Eighty percent of patients with chronic pancreatitis were presented with symptoms of intractable pain.Patients with chronic pancreatitis were at risk of losing the endocrine and exocrine function of the pancreas as the advance of the disease.The main objective of surgical management of chronic pancreatitis includes pain alleviation and pancreatic endocrine and exocrine function improvement.This paper analyzes the strategics of surgical procedure selcction and thc time,indication for surgical intervention.

Objective To compare the efficacies of extended and standard radical pancreatoduodenectomy (RPD) for the treatment of pancreatic cancer in head of pancreas.Methods The clinical data of 96 patients with pancreatic cancer in head of pancreas who were admitted to the West China Hospital of Sichuan University from 2001 to 2011 were retrospectively analyzed.Forty-one patients who received extended RPD were in the extended group and 55 patients who received standard RPD were in the standard group.Blood loss,operation time,hospital stay,surgical complications,severity of complication,1-,3-,5-year survival rate,median survival time,time and location of tumor recurrence and 1-year quality of life of the patients in the 2 groups were compared.All data were analyzed by using rank sum test and analysis of variance.The survival rate was calculated by Kaplan-Meier method and was analyzed by Log-rank test.Results There were no significant differences in the age,diameter and differentiation of the tumor,and number of metastatic lymph nodes between the 2 groups.The operation time,operative blood loss,postoperative hospital stay were 364 minutes (310-650 minutes),680 ml (0-1800 ml) and 13.5 days (10-76 days) in the extended group,which were significantly higher than 315 minutes (260-306 minutes),305 ml (0-1000 ml) and 9.2 days (7-30 days) in the standard group (F=7.15,4.22,3.82,P＜0.05).The incidences of complications in grade 1 and 2 were 5％ (2/41) and 20％ (8/41) in the extended group,which were significantly lower than 25％ ( 14/55 ) and 49％ (27/55) in the standard group ( x2 =5.76,8.87,P ＜ 0.05).The incidence of complications in grade 3a was 41％ ( 17/41 ) in the extended group,which was significantly higher than 7％ (4/55) in the standard group ( x2 =14.10,P ＜ 0.05 ).There were no significant differences in the incidence of complications in grade 3b and 4a between the 2 groups ( x2 =1.44,0.88,P ＞ 0.05 ).There were no significant difference in the 1-,3-,5-year survival rate,median survival time,postoperative quality of life and time of tumor recurrence between the 2 groups ( x2 =0,0.13,0; F =0.49,1.03,t =0.32,P ＞ 0.05 ).Conclusion Standard RPD is optimal for patients with ordinary pancreatic cancer in head of pancreas.Extended RPD could be applied for patients with enlargement of group 16 lymph nodes and could receive R0 resection.

Pancreatic neuroendocrine tumors (P-NETs) are a group of heterogeneous tumors,including functional and nonfunctional ones.With the enhancement of clinicians' awareness about this disease and the improvement of imaging diagnostic techniques,the incidence of P-NETs has obviously increased in the past years.Based on the mitotic counting and Ki-67 positive index,the grading classification is of great value for the diagnosis,treatment and even prognosis of P-NETs.P-NETs are a group of malignant tumors with inert biological behaviors,whose surgical resection rate and long-term survival is much better than those of pancreatic ductal adenocarcinoma.P-NETs have different malignant potentials.Clinicians need to develop a comprehensive treatment plan in combination with the patient's symptoms,tumor grading classification and TNM staging information.Surgery is the only curable way to cure P-NETs.Even if radical resection is not suitable,palliative surgery may alleviate the patients,symptoms,and even prolong their survival time.According to the tumor location,size,quantity,degree of grading,local invasion and distant metastasis,different surgical procedures should be selected.

Objective To investigate the clinical efficacy of pancreaticoduodenectomy with vein resection (PD + VR) via inferior mesenteric vein(IMV) for tumors in the head and neck of pancreas.Methods The clinical data of 62 patients who underwent modified PD + VR for tumors in the head and neck of pancreas at the West China Hospital of Sichuan University between January 2006 to December 2013 were retrospectively analyzed.Twenty-eight patients undergoing Whipple procedure via inferior mesenteric vein were allocated to the WATIMV group,and 34 patients with pancreatic transection as central pancreatectomy undergoing PD + VR were allocated to the c-PD + VR group.The operation time,volume of intraoperative blood loss,rate of patients with intraoperative blood loss ＞ 800 mL,rate of intraoperative blood transfusion,length of vein resection,R1 resection rate,site of positive margin,incidence of complications,classification of complications and duration of postoperative hospital stay were compared between the 2 groups.Patients were followed up via outpatient examination and telephone interview till December 2014.Count data of ratio and proportion were compared by the chi-square test.Measurement data with normal distribution were presented as (x) ± s and analyzed by independent sample t test.Results All the 62 patients underwent operation successfully without perioperative death.The operation time,rate of intraoperative blood transfusion,length of vein resection,incidence of complications,incidence of grade 1,2,3,4,5 complication,duration of postoperative hospital stay were (325 ± 50) minutes,35.7 ％ (10/28),(25 ± 5) mm,46.4％ (13/28),14.3％ (4/28),17.9％ (5/28),14.3％ (4/28),0,0,(15 ± 7) days in the WATIMV group,and (346 ± 97) minutes,58.8％ (20/34),(24 ±5)mm,50.0％ (17/34),14.7％ (5/34),23.5％ (8/34),8.8％ (3/34),0,2.9％ (1/34),(19 ± 11) days in the c-PD + VR group,respectively,showing no significant difference between the 2 groups (t =0.866,x2 =3.283,t =0.647,x2 =0.078,1.883,t =1.666,P ＞ 0.05).The volume of intraoperative blood loss,rate of patients with intraoperative blood loss ＞ 800 mL,R1 resection rate,rate of positive margin in pancreas and retroperitoneal positive margin were (534 ± 277) mL,46.4％ (13/28),3.6％ (1/28),0,3.6％ (1/28) in the WATIMV group,and (796 ± 567) mL,67.6％ (23/34),23.5％ (8/34),8.8％ (3/34),14.7％ (5/34) in the c-PD + VR group,respectively,showing significant differences between the 2 groups (t =2.374,x2 =2.839,4.929,6.507,P ＜ 0.05).Fifty-nine patients were followed up for 15.2 months (range,8.0-23.0 months) with a follow-up rate of 95.2％ (59/62).No patient was complicated with portal vein thrombosis during the follow-up.Conclusion WATIMV is safe and feasible for treatment of tumors in the head and neck of pancreas,helping to improve radical resection rate of carcinoma and operation safety.

Objective To compare biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) with intraductal papillary mucinous neoplasm of the pancreas (P-IPMN).Methods From January 2008 to December 2013,eleven (6.0％) cases of BT-IPMNs were retrospectively identified from a total of 182 biliary tract tumors resected in our institution,while 50 cases underwent surgery for P-IPMN.The mean age of the 11 BT-IPMN cases was 57.3 years (range 40 to 74 years).There were 8 men (73.0％).The mean age of the 50 P-IPMN cases was 57.4 years (range 33 to 85 years).There were 34 men (68.0％).The clinical features,radiologic findings,pathology,surgical strategies,and long-term follow up outcomes between the 2 groups of patients were analyzed.Results There was no significant difference between BT-IPMN and P-IPMN in the following aspects:mean age,sex ratios and clinical presentation [including the most common presenting symptom abdominal pain (73.0％ vs.68.0％),and elevated tumor markers (CEA and CA19-9)].The mean tumor size of BT-IPMN was significantly smaller than P-IPMN (1.7 vs.4.1 cm,P ＜ 0.05).Macroscopically visible mucin was detected in all the 11 patients basing on the original surgical reports.The most common abnormal preoperative imaging findings for BT-IPMN were bile duct dilatation (100％) and intraluminal masses (55.0％).Most cases (82.0％) involved the intrahepatic bile duct and hilum.For tumor clearance,we conducted left hepatectomy in most cases (64.0％).Only one patient underwent biopsy and choledochojejunostomy for multiple tumors involving the extrahepatic,right and left bile ducts.BT-IPMN was likely to have a higher risk of malignancy (55.0％ vs.44.0％) and poorer prognosis (median survival,57 vs.63 months),although there was no significant difference (P ＞ 0.05).The patient without tumor resection died of liver failure 22 months after palliative surgery.Conclusions BT-IPMNs are very rare and they had some similarity with P-IPMN.Complete resection of BT-IPMN is associated with good survival.

Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein (IMV) pathway for resectable pancreatic cancer with superior mesenteric vein (SMV) and / or anterior wall of portal vein (PV) involvements.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected.The tumors of 25 patients were BR-PV type (simplex SMV and / or PV involvements),and tumors of 13 patients were BR-A type (SMV,celiac trunk and / or hcpatic artcry involvements).The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection,the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway.Observation indicators:(1) intraoperative and postoperative situations;(2) results of postoperative pathological examination;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018.Measurement data with skewed distribution were described as M (range).The survival curve was drawn by the Kaplan-Meir method,and Log-rank test was used for survival analysis.Results (1)Intraoperative and postoperative situations:38 patients underwent intraoperative segmental resection of PV and / or SMV,including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis.Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ.There was no intraoperative celiac trunk resection.The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes (range,280-520 minutes) and 530 mL (range,420-650 mL).The incidence of total complications (Clavien-Dindo Ⅲ and above) of 38 patients was 18.4％ (7/38),and some patients were combined with multiple complications,including 6 with pulmonary infection,4 with pancreatic fistula (B and C grade),4 with intra-abdominal infection,3 with delayed gastric emptying,2 with postoperative bleeding and 2 with venous thrombosis.Five patients were cured by postoperative symptomatic treatment,and 2 with postoperative bleeding died of worsened condition after reoperation.The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3％(2/38) and 12 days (range,9-52 days).(2) Results of postoperative pathological examination:the R0 resection rate of 38 patients was 81.6％ (31/38).The R0 resection rate of 25 patients in BR-PV type was 92.0％ (23/25),and resection margin of pancreatic leading edge ＜ 1 mm was in 2 patients without R0 resection;R0 resection rate of 13 patients in BR-A type was 8/13,and resection margin of pancreatic leading edge ＜ 1 mm was in 2 patients and resection margin of SMV ＜ 1 mm was in 4 patients (1 margined with resection margin of multiple sites ＜ 1 mm) of patients without R0 resection.The resection margins of pancreatic trailing edge,venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to 1mm.The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100.0％ (25/25) and 9/13.(3) Follow-up and survival situations:38 patients were followed up for 6-40 months,with a median time of 15 months,and survival time was 18 months (range,6-40 months).The survival time and 1-,2-and 3-year cumulative survival rates were respectively 23 months (range,8-40 months),89.5％,33.1％,22.1％ in 25 patients with BR-PV type and 16 months (range,6-25 months),83.9％,16.8％,0 in 13 patients with BR-A type.The tumor-free survival time and 1-and 2-year cumulative tumor-free survival rates were respectively 15 months (range,5-30 months),63.0％,7.5％ in patients with BR-PV type and 9 months (range,4-18 months),11.5％,0 in patients with BR-A type.Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements,pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV,and increase negative rates of venous and pancreatic resection margins.

Objective To study the postoperative nutritional effects of early orogastric feeding compared with nasoenteric tube enteral nutrition within postoperative 24-48 h in pancreaticoduodenectomy (PD) patients.Methods The clinical data of 87 PD patients from June 2013 to January 2015 in Huaxi Hospital was analyzed retrospectively.Patients were divided into orogastric enteral nutrition group and nasoenteric tube enteral nutrition group.Patients' tolerance,hospital stay,mortality,and major complications associated with PD were compared.Results The average time of bowel function recovery (P ＜0.001) and average hospital stay (P=0.017) in the nasoenteric tube enteral nutrition group were significantly shorter than those in the orogastric enteral nutrition group.The differences of patients' tolerance were not statistically different (P =0.089).The differences of major complications and mortality were not statistically different (P =0.745,P =1.00).Conclusions Nasoenteric tube enteral nutrition in after PD patients improves nitrogen balance,promotes bowel function recovery and makes hospital stay shorter.

Objective To analyze the viability of extended distal pancreatectomy and the associated prognostic factors.Methods The data of 57 patients with pancreatic adenocarcinoma who underwent standard distal pancreatectomy (DP) or extended distal pancreatectomy (EDP) from January 2011 to December 2014 were reviewed retrospectively.Thirty-five patients were performed with DP and 22 with EDP.Operation safety and survival benefit between DP and EDP were compared by t-test or x2 test.Cox regression analysis was used to explore the prognostic indicators.Results Compared to DP group,operation time((255 ±91)min vs.(208 ±80)min)(t =2.066,P =0.044) and ratio of blood transfusion (50.0％ vs.17.1％) (x2 =12.836,P =0.008) were greater in EDP group,respectively.There were no significant differences in amount of intraoperative blood loss and postoperative duration of hospitalization.Delayed gastric emptying was greater in EDP(22.7％ vs.2.9％) (Z =-2.251,P =0.027),while other complications had no differences.Mortality and ratio of relaparotomy also showed no differences.Median survival following DP was 13.1 months compared to 8.2 months following EDP.There was no difference in survival between DP and EDP.According to the results of multivariate analysis,tumor size (RR =1.275,P =0.03) and perioperative blood transfusions(RR =2.673,P =0.04) were independent prognostic factors.Conclusions Though patients with pancreatic adenocarcinoma who undergo EDP have a worse pathologic staging,they will gain a comparable long-term survival to the patients undergo DP.Tumor size and perioperative blood transfusions are independent prognostic factors.

Objective Discuss the surgical options for the chronic pancreatitis on the basis of anatomical morphological changes.Methods A retrospective review of chronic pancreatitis patients in Department of Pancreatic Surgery,West China Hospital,Sichuan University between January 2010 and December 2014 was performed.The data of medical records,image feature,surgical types and records of follow-up were collected.Total 295 patients including 275 male and 20 female aged from 14 to 74 years with median age of 51 years.The clinical symptoms included abdominal pain in 280 cases,jaundice in 3 cases,single hemorrhage in digestive tract,diarrhea or mellitus in 12 cases.The anatomical morphological changes included pancreatic fibrosis and atrophy of the main pancreatic duct lesions in 44 cases (14.9％),inflammatory mass in the pancreatic head in 69 cases (22.4％),sporadic stones with calcification in the pancreatic head in 165 cases(55.9％),hyperplasia mass of pancreatic head and body in 14 cases (4.8％),sporadic stones with calcification in whole branch ducts accompanied with different degree of hyperplasia in whole pancreas in 3 cases (1.0％).The surgical options included longitudinal pancreaticojejunostomy,duodenum-preserving pancreatic head resection,Frey/Frey + distal pancreatectomy,total and subtotal pancreatectomy.All patients were followed-up for 3 to 6 months in the outpatient.A cross-sectional study was carried out by telephone,letters,questionnaire and outpatient from April to June 2016.Results Among 295 patients,267 cases were followed-up for an average time of 40 months(18 to 78 months),28 cases were lost to followed-up(9.5％).Pain remission rate of pancreatic fibrosis and atrophy of the main pancreatic duct lesions patients was 97.0％,of inflammatory mass in the pancreatic head patients was 96.8％,of sporadic stones with calcification in the pancreatic head patients was 96.6％,of hyperplasia mass of pancreatic head and body patients was 12/13,of sporadic stones with calcification in whole branch ducts accompanied with different degree of hyperplasia in whole pancreas patients was 3/3.There were 19 cases(9.6％) with blood glucose rising.Conclusion According to the pathological changes of chronic pancreatitis,the reasonable choice of surgical procedures can be done to maximize the removal of the cause of pain and the preservation of pancreatic tissue.

Objective To analyze the viability of extended distal pancreatectomy and the associated prognostic factors.Methods The data of 57 patients with pancreatic adenocarcinoma who underwent standard distal pancreatectomy (DP) or extended distal pancreatectomy (EDP) from January 2011 to December 2014 were reviewed retrospectively.Thirty-five patients were performed with DP and 22 with EDP.Operation safety and survival benefit between DP and EDP were compared by t-test or x2 test.Cox regression analysis was used to explore the prognostic indicators.Results Compared to DP group,operation time((255 ±91)min vs.(208 ±80)min)(t =2.066,P =0.044) and ratio of blood transfusion (50.0％ vs.17.1％) (x2 =12.836,P =0.008) were greater in EDP group,respectively.There were no significant differences in amount of intraoperative blood loss and postoperative duration of hospitalization.Delayed gastric emptying was greater in EDP(22.7％ vs.2.9％) (Z =-2.251,P =0.027),while other complications had no differences.Mortality and ratio of relaparotomy also showed no differences.Median survival following DP was 13.1 months compared to 8.2 months following EDP.There was no difference in survival between DP and EDP.According to the results of multivariate analysis,tumor size (RR =1.275,P =0.03) and perioperative blood transfusions(RR =2.673,P =0.04) were independent prognostic factors.Conclusions Though patients with pancreatic adenocarcinoma who undergo EDP have a worse pathologic staging,they will gain a comparable long-term survival to the patients undergo DP.Tumor size and perioperative blood transfusions are independent prognostic factors.