Objective: To investigate the feasibility and safety of stent-assisted percutaneous endoscopic necrosectomy (SAPEN) in the treatment of infected pancreatic necrosis (IPN). Methods: The patients with severe acute pancreatitis (SAP) who received the treatment of SAPEN for IPN were sequentially included from January 2018 to September 2018 in the Eastern Theater General Hospital of People′s Liberation Army. The demographic and clinical data were analyzed. The mortality and incidence of major organ dysfunctions were used as the primary observation endpoints. Results: A total of 40 IPN patients were enrolled including 27 men and 13 women. The percutaneous covered stent placement procedures were successful in all cases; the median number of SAPEN operations was 1 (range 1-3), and no operation-related complications occurred. 32 patients were successfully cured by SAPEN, and the treatment effective rate was 80.0%. 5 patients (12.5%) required further open surgery after SAPEN. 12 patients developed new important organ dysfunction and 6 patients eventually died. Conclusions SAPEN was an effective and feasible minimally invasive method for the treatment of IPN, but its technical advantages still need to be further validated in large scale studies.

Objective: To explore the predictive value of acute gastrointestinal injury(AGI) grading system in assessing the severity, infectious pancreatic necrosis and death of patients with moderate severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP). Methods: The clinical data of 344 patients with MSAP or SAP admitted in Changhai Hospital Affiliated to Navy Medical University from June 2011 to June 2015 were collected. ROC curve was used and the area under ROC curve (AUC) was calculated. The predictive value of AGI grade for the severity, infectous pancreatic necrosis and death was compared with those of different clinical scores(APACHEⅡ score, MCTSI and Marshal score). Results: Of 344 patients, 81 patients were classified into high AGI grade group (Grade Ⅲ, Ⅳ), while 263 patients were in low AGI grade group(Grade Ⅰ, Ⅱ). The mortality and the number of patients with organ failure were obviously higher in high AGI grade group than those in low AGI grade group (25/81 vs 0/263, 36/45 vs 32/231), and the difference was statistically significant (all PCI 0.916-0.972) and0.779(95% CI 0.723-0.836), respectively, which was higher than those of APACHEⅡ and Marshall score. Conclusions AGI grading system can be applied to better assess the severity of acute pancreatitis, and its predictive value for death and infectious pancreatic necrosis was higher than that of APACHEⅡ, MCTSI and Marshall score.

Objective: To establish a visualized nomogram with early predictive value for the severity of first-onset acute pancreatitis (AP). Methods: 706 cases of first-onset AP patients admitted to the First Affiliated Hospital of Wenzhou Medical University within 72 hours from January 2013 to January 2016 were collected. According to the revised Atlanta classification of AP in 2012, AP patients was divided into non-severe pancreatitis (NSAP, also called mild acute pancreatitis and moderately severe acute pancreatitis) group and severe acute pancreatitis (SAP) group. The demographic data (age, body mass index and admission time, etc) and laboratory tests (serum amylase, blood sugar, albumin, white blood cells, creatinine, urea nitrogen) were collected and statistically analyzed. Logistic univariate and multivariant regression analysis were performed based on the relevant clinical indicators. The statistically significant indicators were used to obtain regression equations. The R-language software was used to obtain the visualized nomogram via LR model, which was further validated by ROC curve analysis. Results: In univariate logistic regression analysis, the OR (95% CI) values of blood glucose, creatinine at admission and 24 h after admission, urea nitrogen at admission and 24 h after admission, white blood cell, albumin in NSAP group and SAP group were 1.132(1.080-1.186), 1.019(1.013-1.025), 1.026(1.020-1.033), 1.066(1.035-1.099), 1.333(1.241-1.432), 1.083(1.032-1.136), and 0.853(0.811-0.889), and all the differences were statistically significant (all P values <0.05). Multivariate logistic regression analysis showed that the regression equation of the LR model was Y=-2.657-0.116×albumin(g/L)+ 0.082×white blood cell(×10⁹/L)+ 0.118× glycemia(mmol/L)+ 0.022× 24 h after admission creatinine (μmol/L). A total score of more than 60 points on the nomogram predicted the possibility of SAP. If the total score exceeded 130, the possibility of SAP may be up to 14% or more. Furthermore, the ROC curve analysis confirmed that the sensitivity and specificity of LR model established in this study for predicting of SAP were superior to those of urea nitrogen, creatinine and BISAP score alone by AUC, respectively. Conclusions This nomogram may be a useful clinical tool for predicting the severity of the first-onset acute pancreatitis.

Objective: To investigate the influence of Brucine on cell apoptosis of pancreatic cancer CFPAC-1 cells and the possible mechanism. Methods: Brucine in different concentrations were used to treat CFPAC-1 cells. Cell proliferation was determined by MTT assay and cell apoptosis was determined by flow cytometer assay. Mitochondrial membrane potential was examined by JC-1 staining. The protein expression of Bax and Bcl-2 was measured by Western Blot. Results: The growth inhibition rates of CFPAC-1 cells after being treated with 0 (control group), 0.4 and 0.8 mmol/L Brucine for 24, 48 and 72 h were 0, (30.23±0.55)%, (40.61±0.15)%, (46.98±1.27)% and(50.17±0.75)%, (61.23±0.91)%, (70.32±0.40)%, increasing with a concentration- and time-dependent increase, which was higher than that in control group; and the differences between either two groups at different time points were statistically significant (P<0.05). CFPAC-1 cell apoptosis rate after being treated with 0, 0.4 and 0.8 mmol/L Brucine for 48 h was (2.92±0.46)%, (4.64±1.31)% and (13.09±0.65)%, which increased gradually with the increased drug concentration. The apoptotic rate in 0.8 mmol/L treatment group was obviously higher than that in control group, and the difference was statistically significant (P<0.05). With the increase of the drug concentration, the red fluorescence gradually decreased, and the green fluorescence gradually increased, indicating that the mitochondrial membrane potential was severely damaged and thus decreased. The protein expression of Bcl-2 in CFPAC-1 cells were(0.92±0.12), (0.67±0.14)and(0.35±0.14)mmol/L, and the expression of Bax in CFPAC-1 cells were(0.56±0.12), (0.85±0.10)and(1.15±0.12)mmol/L. With the increase of brucine concentration, the expression of Bcl-2 was significantly reduced while the expression of Bax was significantly increased; and the difference was statistically significant (P<0.05). Conclusions Brucine can effectively induce the apoptosis of human pancreatic cancer CFPAC-1 cells through mitochondrial apoptotic pathway by up-regulating the expression of Bax and down-regulating the expression of Bcl-2.

Objective: To elucidate the mechanism of melatonin combined with cisplatin in promoting cell apoptosis of rat pancreatic cancer AR42J cells. Methods: Rat pancreatic cancer AR42J cells were divided into control group, 1 mmol/L cisplatin treated group (cisplatin group), 1 mmol/L melatonin treated group (melatonin group), 1 mmol/L cisplatin combined with 1 mmol/L melatonin treated group (combined group), 1 μmol/L cisplatin combined with melatonin treated group after 1 μmol/L PBN pretreatment for an hour (PBN+ combined group) and 1 μmol/L cisplatin combined with melatonin treated group after PBN solvent pretreatment for an hour (solvent+ combined group). MTT and annexin V-FITC/PI were used to detect the cell proliferation rate and cell apoptosis rate, respectively. The protein expression of caspase-3 was detected by Western blot. DCFH-DA was used to detect the level of ROS. ROS level and caspase-3 expression in AR42J cells pretreated with ROS antagonist PBN for 24 hours were detected. Results: The cell proliferation rate of control group, cisplatin group, melatonin group and combination group after 24-hour culture was (96.29±3.49)%, (81.38±6.01)%, (80.72±3.68)% and (42.26±6.35)%, respectively. The cell apoptosis rate was (16.42±4.15)%, (56.47±9.06)%, (52.94±6.57)% and (87.36±6.48)%, respectively. The percentage of ROS positive cells was (1.33±1.53)%, (46.67±7.64)%, (45.67±5.13)% and (83.33±7.64)%, respectively. The expression of cspase-3 was 100%, (150.64±7.70)%, (147.00±7.27)% and (190.04±5.07)%, respectively. The cell proliferation rate of cisplatin group and melatonin group was significantly lower than that of the control group. The apoptotic rate, the proportion of ROS positive cells and the expression of caspase-3 were significantly higher than those in control group. The changes in the combined group were more obvious than those in the single drug treatment group, and the differences were all statistically significant (all Pvalues <0.05). The percentage of ROS positive AR42J cells [(45.24±4.64)% vs (84.90±6.13)%)] induced by melatonin combined with cisplatin could be significantly reversed by PBN pretreatment for 1 hour, and the expression of caspase-3 in AR42J cells could be down regulated (124.92±9.72 vs 184.69±7.76) with statistically significant difference (all P values<0.05). Conclusions Melatonin combined with cisplatin may promote cell apoptosis of pancreatic cancer AR42J cells through ROS/caspase-3 pathway.

Objective: To discuss the imaging features of solid-cystic pancreatic neuroendocrine tumors (PNEN). Methods: CT and MRI data of 38 pathologically diagnosed solid-cystic PNEN admitted in Changhai Hospital affiliated with Navy Medical University were retrospectively analyzed. The tumor location, major axis, shape, boundary, solid and cystic proportion, enhancement pattern, condition of cholangiopancreatic duct, vascular invasion, lymph nodes and organs metastasis were recorded, and the imaging features of PNEN were analyzed and summarized. Results: Of 38 PNEN patients, only one case had two lesions including one solid lesion and one solid-cystic lesion, and 37 cases had only one solid cystic lesion including 6 with mainly cystic component and 31 with solid-cystic mixture. 22 of 38 lesions were located in head or neck of pancreas, and 16 were in body or tail of pancreas. The minimum of major axis was 1.1 cm, and the maximum was 13.3 cm, and the average was 5.5 cm. There were 23 round-like tumors, 2 oval tumors, and 13 irregular lesions; 25 lesions with clear margin, 13 with unclear margin. CT scan detected iso- to hypodense lesions, and speckled, nodular, cambered or eggshell calcification in 10 cases. The lesions were mainly manifested as low signal in T₁WI, which were as inhomogeneous high signal and fluid high signal in T₂WI. The solid component of all the lesions was strengthened at different degree after enhancement. 25 lesions showed obvious enhancement that was higher than that of normal pancreatic parenchyma. 13 lesions had no significant contrast enhancement that was similar to or lower than pancreatic parenchyma. 8 patients had mild dilations of main pancreatic duct and 1 case had mild dilation of common bile duct and intrahepatic bile duct. 5 cases were associated with the atrophy of pancreatic parenchyma with different degrees. 5 cases had adjacent organ infiltration, 3 cases had liver metastases and 3 cases had lymph node metastasis, 1 case had celiac axis, splenic artery and superior mesenteric vein invasion. 6 cases were associated with pancreatogenous portal hypertension. Conclusions Solid-cystic pancreatic neuroendocrine tumors can be easily misdiagnosed as other tumors of pancreas. Analyzing imaging characteristics and clinical data can be expected to improve diagnostic accuracy.

Objective: To investigate the application and surgical experience of total laparoscopic pancreaticoduodenectomy (TLPD) in treating children with solid pseudopapillary neoplasm (SPN) of pancreas. Methods: Clinical data 4 children with SPN who underwent TLPD in Jilin University First Hospital from April 2017 to June 2018 were retrospectively analyzed. Results: Among the 4 children, a case was male and 3 cases were female. Their age ranged from 9 to 14 year-old, the height ranged from 1.2 to 1.7 meters, and body weight ranged from 30 to75 kg. All patients complained of upper abdominal pain, one child had nausea and vomiting, and one child had abdominal mass. All patients underwent abdominal enhanced CT scan before operation, which showed a mass-like low-density shadow or mixed density shadow in the pancreatic head, with slightly uneven enhancement or no obvious enhancement. All 4 patients underwent TLPD, and the operation was successful without conversion to open surgery. The duration of operation time ranged from 250 to 365 minutes, the intraoperative blood loss ranged from 80 to 120 ml, the tumor size ranged from 4 to 8 cm, and the hospital stay ranged from 10 to 22 days. One patient developed grade B pancreatic fistula after surgery and was cured after conservative treatment. Pathological examinations of all patients confirmed the diagnosis of pancreatic SPN. All patients were followed up until February 2019, and no significant discomfort was observed and no recurrence or metastasis was found. Conclusions TLPD was safe and feasible in children in relatively large pancreatic surgery centers with extensive laparotomy and TLPD experience.

Objective: To investigate the imaging characteristics and the cause for the misdiagnosis and mistreatment of epidermoid cyst in intrapancreatic accessory spleen (ECIPAS) in order to improve the accuracy of preoperative diagnosis. Methods: The clinical and imaging data of 8 patients with ECIPAS confirmed by pathology in Zhejiang Provincial People′s Hospital between June 2008 and February 2018 were collected. The reason for doctor visit included CA19-9 elevation (n=1) and pancreatic occupying mass (n=9) during physical examination and no obvious symptoms were reported. CT and MRI imaging features, diagnosis and treatment were analyzed. Results: The lesions in 8 cases of ECIPAS were all located in the tail of the pancreas and were cystic and solid. The lesions in 3 cases were mainly cystic and the cystic wall was linear, whose CT density, MRI signal and enhancement pattern cannot be compared with those of the spleen. Solid components can be seen in 5 cases, and the CT density or MR signal of the solid part was similar to that of the spleen. After enhancement, the solid part at the artery stage was uniformly enhanced and the enhancement degree was higher than that of the pancreas. Similar to the spleen, it was uniformly enhanced at the portal vein stage and the enhancement degree of the spleen was consistent. All 8 patients were diagnosed with pancreatic neoplastic lesions before surgery, and 1 patient had pancreatic fistula and peripancreatic necrosis after surgery. Postoperative pathology confirmed the diagnosis of ECIPAS. Conclusions Improving the radiologists and clinicians′ cognition of the imaging manifestations of ECIPAS can improve the accuracy of preoperative diagnosis and avoid unnecessary surgery due to misdiagnosis.

Objective: To investigate the characteristics of histogram analysis and differences of apparent diffusion coefficient (ADC) for normal pancreas with different diffusion gradients of diffusion weighted imaging (DWI) at 3.0T. Methods: Three unidirectional diffusion gradients (X, Y or Z direction) and three orthogonal diffusion gradient DWI data of 21 volunteers with normal pancreas were retrospectively analyzed. The histogram parameters of mean ADC, percentile, skewness, peak and the like were measured based on home-made DWI post-processing software, and the differences on histogram parameters obtained from 4 different diffusion gradients were compared by using Kruskal Wallis test. Results: There was no significant difference on the mean ADC, skewness, percentile and the like for normal pancreas among 3 unidirectional diffusion gradients and tri-orthogonal diffusion gradient DWIs, but there was significant difference on the mean kurtosis value (X: 3.16±1.44, Y: 4.72±2.26, Z: 4.47±2.1, tri-orthogonal: 3.69±1.82; χ² =-9.84, P=0.02). Further analyses results showed that the ADC kurtosis of normal pancreas obtained from X-directional diffusion gradient DWI was significantly smaller than that of the direction of Y or Z, and the difference was statistically significant (P<0.05). Conclusions The ADC kurtosis of normal pancreas is related to the direction of diffusion gradient in DWI, and the ADC kurtosis of normal pancreas obtained by X-direction diffusion gradient is the smallest.

Objective:To investigate the technical key points and clinical effects of laparoscopic surgery using the subgastric approach for infected pancreatic necrosis (IPN).Methods:From October 2020 to October 2021, The clinical data of 6 patients with IPN after severe acute pancreatitis (SAP) undergoing laparoscopic surgery using the subgastric approach at First Hospital and Second Hospital of Hebei Medical University was retrospectively analyzed. Parameters in this report included the operation time, estimated blood loss, and the patient's vital signs, inflammatory marker CRP, and WBC before operation and postoperative 24 h, 3 d, and 1 w, and postoperative complications including pancreatic leakage, organ failure, bleeding, and abdominal infection and incision infection. Follow-up after surgery was completed in outpatient checkups and long-term complications were recorded.Results:There were 4 male and 2 female patients. The median age of the 6 patients was 50 (43.5, 56.5) years. Laparoscopic debridement surgery using the subgastric approach was successfully completed in all the patients and no reoperation was needed. The median operation time was 65 (52.5, 85) min; the median estimated blood loss was 20 (25, 37.5) ml. Median APACHEⅡ score one day before surgery was 11.5 (10.25, 12.75) and the median MCTSI score at initial admission was 8 (7, 8). The inflammatory parameters including CRP, WBC, and neutrophil count on postoperative day 3 and 1w were significantly lower than those before surgery, and all the differences were statistically significant (all P value <0.05). One patient had a postoperative pancreatic fistula and was alleviated after ERCP with pancreatic stent implantation. Another patient had a incision infection after surgery and recovered after complete surgical drainage of the abdominal wall incision. No patients had complications such as heart, lung, and kidney failure, abdominal hemorrhage and infection. During the follow-up, 5 of 6 patients had no newly-occurred diabetes, except one patient who had diabetes before the operation. None of the 6 patients had recurrent IPN. Conclusions:Laparoscopic surgery using the subgastric approach for infected IPN in lesser omental sac is safe and feasible.