Objective To investigate the diagnosis and surgical management of adult choledochal cyst.Methods The clinical data of 58 adult patients with congenital choledochal cyst who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 1997 to December 2010 were retrospectively analyzed.All patients were diangosed by the B ultrasonography,computed tomography (CT),Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). Surgical procedures were selected according to the diagnosis and Todani classification.All data were analyzed using the t test or chi-square test.Results The accurate rates of B sonography,CT,MRCP and ERCP were 78％ (45/58),92％ (23/25),9/9 and 5/5,respectively.Forty-one patients underwent complete excision of the cyst + hepaticojejunostomy (2 patients were converted from laparotomy due to abdominal adhesions),2 underwent resection of the cyst and involed hepatic segments + hepaticojejunostomy,8 underwent laparoscopic excision of the cyst + hepaticojejunostomy,1 underwent left hemihepatectomy,3 underwent pancreaticoduodenectomy ( including partial hepatectomy in 1 patient),2 underwent common bile duct exploration + cholecystectomy due to acute obstructive suppurative cholangitis,1 underwent external drainage of choledochal cyst due to advanced malignance.The mean operation time and postoperative duration of hospital stay of patients who received open and laparoscopic excision of the cyst and hepaticojejunostomy were (235 ± 70) minutes,(320 ± 50) minutes,and ( 10.0 ± 2.3 ) days,( 12.6 ±6.6) days,respectively,with significant differences between the 2 groups (t =3.157,2.162,P ＜ 0.05).The postoperative morbidities of patients who received open and laparoscopic excision of the cyst and hepaticojejunostomy were 18％ (7/39) and 3/8,respectively,with no significant difference (x2 =1.515,P ＞ 0.05 ).Canceration of the choledochal cyst was observed in 6 patients( 10％ ).No perioperative mortality was observed,and the operative complication rate was 24％ (14/58).The duration of the follow up ranged from 1 to 15 years,no severe long-term complications were observed in patients with benign lesions.Four of the 6 patients with malignancy died in 1 year after operation,the other 2 patients survived for 3 years and 5 years,respectively.Conclusions Abdominal B ultrasonography should be the first choice for diagnosing adult congenital choledochal cyst,while MRCP is the gold standard.Surgical intervention should be timely considered once diagnosed. Complete excision of the cyst combined with Roux-en-Y hepaticojejunostomy is the first choice of treatment.

Objective To investigate the clinical features, diagnosis and treatment of malignant pancreatic endocrine tumor. Methods The clinical data of 38 patients with malignant pancreatic endocrine tumor who had been admitted to First Affiliated Hospital of Nanjing Medical University from January 1969 to December 2008 were analyzed retrospectively. Of all patients, 6 were with insulinoma, 23 with pancreatic polypeptide tumor, 4 with glucagonoma and 5 with pancreatic carcinoid. Results All patients except 1 with insulinoma were found with pancreatic lesion by imaging examination. The resection rate was 87% (33/38). Pathological examination found 7 patients with liver metastasis, 5 with lymph node metastasis, 1 with tumor thrombus in vessels and lymphatic vessels, and 28 with local invasion. Twenty-four patients were followed up, and neither recurrence nor metastasis was found except 1 patient with insulinoma who received reoperation for local recurrence and 1 patient with pancreatic carcinoid who received radiofrequency ablation for liver metastasis. Conclusions The diagnosis of pancreatic endocrine tumor mainly depends on imaging examination. The malignancy of pancreatic endocrine tumor is determined after the comprehensive analysis of preoperative imaging findings, intraoperative examination, post-operative pathological examination and the data obtained during follow-up. The malignant pancreatic endocrine tumor should be managed actively by resection because of its relatively low malignancy, high operative resectability and relatively good prognosis.

Objective To investigate the efficacy and safety of hypertonie saline enhanced radiofrequency ablation (RFA) in the treatment of liver cancer. Methods The clinical data of 42 patients with primary liver cancer (n = 28) or metastatic liver eancer (n = 14) who had been admitted to First Affiliated Hospital of Nanjing Medical University from September 2001 to December 2007 were collected. Forty-eight lesions were detected with a diameter ranging from 1.2 cm to 7.5 cm. RFA electrode and 20G needle were pricked into the target lesion under the guidance of B ultrasound or computed tomography (CT) through percutaneoas puncture or open approaches. An amount of 5-10 ml hypertonie saline was infused through the needle at regular intervals during RFA. All patients were followed up for 3-79 months. Contrast-enhanced ultrasound and CT scanning were performed postoperatively to determine the efficacy of RFA. The levels of alpha-fetoprotein (AFP) before and after treatment were compared using t test, and the survival of the patients were analyzed using a Kaplan-Meier survival curve. Results The AFP expression changed to negative in 14 out of the 18 AFP-positive patients, with statistical difference (t =7.703, P <0.05). The complete necrosis rate of tumors was 94% (45/48), and the necrosis rate of tumors with diameter of ≤4.0 cm reached 100% (35/35). The incidence of complication was 5% (2/42). No perioperative mortality occurred. The 1-, 2-, 3-year survival rates were 91%, 85% and 70%, respectively. Conclusions Hypertonic saline enhanced RFA in the treatment of liver cancer was proved to be safe and effective.

Objective:To study the expression and clinical significance of neuron-specific enolase,chromogranin and synaptophysin in islet cell tumors.Methods:Twenty-one paraffin-embedded specimens with islet tumors and 3 cases cholangiocarcinoma and tissue nearby the tumor were recruited from Jan 1988 to Jun 2001.The S-P method was used for the detection of chromogranin,synaptophysin and neuron-specific enolase.Results:There were positive expressions of neuron-specific enolase,chromogranin and synaptophysin in 19,15 and 18 cases respectively,while negative results were observed in 3 cases of cholangiocarcinoma and the para-cancer tissue.Conclusion:CG,SYN and NSE may be specific tumor markers of islet cell tumors and combined detection can help to enhance the sensitivity.

Objective To investigate the therapeutic effect of ehlorpromazine in rats with acute necrotizing pancreatitis (ANP). Methods 120 healthy female SD rats were randomly divided into three groups: normal control group (NC group, n=30); acute necrotizing pancreatitis group (ANP group, n=45) and chlorpromazine treatment group (CPZ group, n=45). ANP was induced by the injection of 5% sodium taurocholate (1 ml/kg) into pancreatic duct, NC group were injected with same amount of saline. 0.4% chlorpromazine (0.25 ml/100 g) was intraperitoneally administered in CPZ group at 0 h, 24 h, 48 h after ANP was established. Same amount of normal saline was given to ANP group and NC group in the same way and at the same time points. The rats were sacrificed at 24, 48, 72 h after ANP was induced. The blood samples were collected for analysis of serum amylase (AMY), phospholipase A2 (PLA2), interleukin-6 (IL-6). Pancreas was harvested for evaluation of pathologic changes. Results The pathologic changes in ANP group were compatible with pathologic changes of ANP. The pathologic scores in CPZ group was 3.57±0.73 at 72 hours after ANP induced, which was significantly lower than 13.29±1.03 in ANP group. The serum amylase and PLA2 levels in CPZ group at 72 hours after ANP induced were (1658.0±277.0) U/L and ( 12.26±1.40) ng/ml respectively, the corresponding values of ANP group were (3666.7±1233.0) U/L and (16.81±1.13)ng/ml, respectively. The difference was statistically significantly (P＜0.01). The serum IL-6 levels of CPZ group at 24,48 72 hours were (116.27±14.49) pg/ml, (75.35±6.17) pg/ml, (82.75± 8.86) pg/ml respectively, the corresponding values of CPZ group were (160.88±27.19) pg/ml, (111.77± 19.10)pg/ml, (125.51±30.71) pg/ml respectively. There was a significant difference between the two groups (P＜0.01). Conclusions Chlorpromazine may have a therapeutic effect on ANP.

Objective To summarize the experience in the diagnosis and treatment of solid pseudopapillary tumors of the pancreas. Methods Ten consecutive patients who underwent surgery with pathologically confirmed solid pseudopapillary tumors of the pancreas between October 2005 and December 2008 were retrospectively reviewed. Results All of the 10 patients were female and the median age at diagnosis was 24 years (range, 11 -39 years). Abdominal discomfort or pain were the most common presenting symptoms. 4 patients had palpable abdominal mass at physical examination. The tumors appeared on ultrasonography and/or CT, MRI as solid or cystic masses. The preoperative serum biochemical parameters and tumor markers level were within the normal range. All the patients underwent surgical treatment. The tumors were located in the head/neck (n = 6) or the distal part (n = 4) of the pancreas. The surgical procedures included enucleation (n=3) , distal pancreatectomy (n=3 , two with preservation of the spleen, one combined with splenectomy, distal gastrectomy and partial colectomy) , segmental pancreatectomy with pancreaticojejunostomy (n=3) and pancreaticoduodenectomy (n = 1). Pancreatic fistula (n = 2) was observed postoperatively and resolved with conservative treatment. The median resected tumor size was 5. 9 cm. All patients were alive and remained recurrence and metastasis free after a median followk-up of 19. 2 months (range, 8～42 months). Conclusions Solid pseudopapillary tumor of the pancreas was rare neoplasm occurred predominantly in young women with low malignant potential. Aggressive resection should be attempted and could result in excellent prognosis.

Objective:To compare the short-term outcomes and long-term survivals of radical antegrade modular pancreatosplenectomy(RAMPS) and conventional distal pancreatectomy(CDP).Methods:A total of consecutive 304 patients including 176 male patients and 128 female patients who underwent RAMPS or CDP at Pancreas Center, the First Affiliated Hospital with Nanjing Medical University from May 2013 to June 2019 were retrospectively analyzed. The median age was 64.1 years old (range:39 to 85 years old). There were 101 patients underwent RAMPS and 203 patients underwent CDP. Measurement data with skewed distribution were presented as ( M( Q R)) and comparison between groups was evaluated with the Wilcoxon rank sum test. Count data were analyzed using the χ 2 test or Fisher exact probability. Survival analyses were performed by the Kaplan-Meier method after a one to one propensity score matching(PSM) conducted to balance several variables. Results:An eighty-one to eighty-one patients were enrolled after PSM. The overall morbidity was 32.1%(26/81)and there were no in-hospital mortalities in RAMPS. The median operative time was 225(95)minutes in RAMPS, not significantly longer as compared with CDP(210(130)minutes, P=0.916). The median greatest tumor diameter in RAMPS was 4.0(2.3)cm, not significantly larger as compared with CDP(4.5(2.2)cm, P=0.520).There were 34.6%(28/81)patients who presented with T4 tumors by 8 th AJCC TNM staging system in RAMPS, which was not significantly different as compared with CDP(39.5%, χ 2=0.574, P=0.902). The median number of examined lymph nodes was 9(9), not significantly greater in RAMPS as compared with CDP(10(11), P=0.992). The rate of negative posterior margins using 1 mm rule in RAMPS was 70.3%(52/74), significantly higher as compared with CDP(53.6%(30/56), χ 2=3.817, P=0.044). The overall R0 resection rate was 44.6% (33/74) in RAMPS and 37.5% (21/56) in CDP, which was not significantly different(χ 2=0.663, P=0.474). The median overall survival was 16.5 months for RAMPS, 25.2 months for CDP, and there was no statistical difference between two groups( P=0.981). The median overall survival was 16.0 months for patients with preoperative CA19-9≥300 U/ml who underwent RAMPS, 10.1 months for patients who underwent CDP, without significant difference( P=0.082). Conclusions:RAMPS can improve the rate of negative posterior margins by 1 mm rule and probably increase R0 resection rate and the harvest of lymph nodes. RAMPS may be beneficial to some patients with preoperative CA19-9≥300 U/ml.

Objective:To investigate the clinical efficacy of distal pancreatectomy with celiac axis resection(DP-CAR).Methods:A total of 89 consecutive patients (50 males and 39 females) who were diagnosed with pancreatic body cancer and underwent DP-CAR in Pancreas Center,First Affiliated Hospital of Nanjing Medical University between September 2013 and June 2022 were retrospectively reviewed. There were 50 males and 39 females,with age( M(IQR)) of 63(12) years(range:43 to 81 years). Perioperative parameters,pathology results and follow-up data of these patients were analyzed, χ2 or Fisher′s test for categorical data while the Wilcoxon test for quantitative data. Survival results were estimated by the Kaplan-Meier survival method. Results:Among 89 cases,cases combined with portal vein-superior mesenteric vein or organ resection accounted for 22.5% (20/89) and 42.7% (38/89),respectively. The operative time,blood loss and postoperative hospital stay were 270 (110) minutes,300 (300) ml and 13 (10) days,respectively. The overall morbidity rate was 67.4% (60/89) while the major morbidity was 11.2% (10/89). The increase rate in transient liver enzymes was 42.7% (38/89),3.4% (3/89) for liver failure,53.9% (48/89) for clinically relevant postoperative pancreatic fistula,1.1% (1/89) for bile leak,3.4% (3/89) for chylous leak of grade B and C,11.2% (10/89) for abdominal infection,9.0% (8/89) for postoperative hemorrhage of grade B and C,4.5% (4/89) for delayed gastric emptying,6.7% (6/89) for deep vein thrombosis,3.4% (3/89) for reoperation,4.5% (4/89)for hospital mortality,7.9% (7/89) for 90-day mortality. The pathological type was pancreatic cancer for all 89 cases and pancreatic ductal adenocarcinoma made up 92.1% (82/89). The tumor size was 4.8(2.0) cm, ranging from 1.5 to 12.0 cm. The number of lymph nodes harvested was 14 (13)(range:2 to 33),with a positive lymph node rate of 13.0% (24.0%). The resection R0 rate was 30.0% (24/80) and the R1 (<1 mm) rate was 58.8% (47/80). The median overall survival time was 21.3 months (95% CI: 15.6 to 24.3) and the median disease-free survival time was 19.1 months (95% CI: 11.7 to 25.1). The overall survival at 1-year and 2-year were 69.60% and 39.52%. The median survival time of 58 patients with adjuvant chemotherapy was 24.3 months (95% CI: 17.8 to 32.3) while that of 13 patients without any kind of adjuvant therapy was 8.4 months (95% CI: 7.3 to 22.3). Seven patients accepted neoadjuvant chemotherapy and there was no significant morbidity among them,with a resection rate of R0 of 5/7. Conclusion:DP-CAR is safe and feasible for selective cases,which could be more valuable in improving long-term survival when combined with (neo) adjuvant therapy.

Objective:To investigate the clinical efficacy of distal pancreatectomy with celiac axis resection(DP-CAR).Methods:A total of 89 consecutive patients (50 males and 39 females) who were diagnosed with pancreatic body cancer and underwent DP-CAR in Pancreas Center,First Affiliated Hospital of Nanjing Medical University between September 2013 and June 2022 were retrospectively reviewed. There were 50 males and 39 females,with age( M(IQR)) of 63(12) years(range:43 to 81 years). Perioperative parameters,pathology results and follow-up data of these patients were analyzed, χ2 or Fisher′s test for categorical data while the Wilcoxon test for quantitative data. Survival results were estimated by the Kaplan-Meier survival method. Results:Among 89 cases,cases combined with portal vein-superior mesenteric vein or organ resection accounted for 22.5% (20/89) and 42.7% (38/89),respectively. The operative time,blood loss and postoperative hospital stay were 270 (110) minutes,300 (300) ml and 13 (10) days,respectively. The overall morbidity rate was 67.4% (60/89) while the major morbidity was 11.2% (10/89). The increase rate in transient liver enzymes was 42.7% (38/89),3.4% (3/89) for liver failure,53.9% (48/89) for clinically relevant postoperative pancreatic fistula,1.1% (1/89) for bile leak,3.4% (3/89) for chylous leak of grade B and C,11.2% (10/89) for abdominal infection,9.0% (8/89) for postoperative hemorrhage of grade B and C,4.5% (4/89) for delayed gastric emptying,6.7% (6/89) for deep vein thrombosis,3.4% (3/89) for reoperation,4.5% (4/89)for hospital mortality,7.9% (7/89) for 90-day mortality. The pathological type was pancreatic cancer for all 89 cases and pancreatic ductal adenocarcinoma made up 92.1% (82/89). The tumor size was 4.8(2.0) cm, ranging from 1.5 to 12.0 cm. The number of lymph nodes harvested was 14 (13)(range:2 to 33),with a positive lymph node rate of 13.0% (24.0%). The resection R0 rate was 30.0% (24/80) and the R1 (<1 mm) rate was 58.8% (47/80). The median overall survival time was 21.3 months (95% CI: 15.6 to 24.3) and the median disease-free survival time was 19.1 months (95% CI: 11.7 to 25.1). The overall survival at 1-year and 2-year were 69.60% and 39.52%. The median survival time of 58 patients with adjuvant chemotherapy was 24.3 months (95% CI: 17.8 to 32.3) while that of 13 patients without any kind of adjuvant therapy was 8.4 months (95% CI: 7.3 to 22.3). Seven patients accepted neoadjuvant chemotherapy and there was no significant morbidity among them,with a resection rate of R0 of 5/7. Conclusion:DP-CAR is safe and feasible for selective cases,which could be more valuable in improving long-term survival when combined with (neo) adjuvant therapy.

Objective:To compare the short-term outcomes and long-term survivals of radical antegrade modular pancreatosplenectomy(RAMPS) and conventional distal pancreatectomy(CDP).Methods:A total of consecutive 304 patients including 176 male patients and 128 female patients who underwent RAMPS or CDP at Pancreas Center, the First Affiliated Hospital with Nanjing Medical University from May 2013 to June 2019 were retrospectively analyzed. The median age was 64.1 years old (range:39 to 85 years old). There were 101 patients underwent RAMPS and 203 patients underwent CDP. Measurement data with skewed distribution were presented as ( M( Q R)) and comparison between groups was evaluated with the Wilcoxon rank sum test. Count data were analyzed using the χ 2 test or Fisher exact probability. Survival analyses were performed by the Kaplan-Meier method after a one to one propensity score matching(PSM) conducted to balance several variables. Results:An eighty-one to eighty-one patients were enrolled after PSM. The overall morbidity was 32.1%(26/81)and there were no in-hospital mortalities in RAMPS. The median operative time was 225(95)minutes in RAMPS, not significantly longer as compared with CDP(210(130)minutes, P=0.916). The median greatest tumor diameter in RAMPS was 4.0(2.3)cm, not significantly larger as compared with CDP(4.5(2.2)cm, P=0.520).There were 34.6%(28/81)patients who presented with T4 tumors by 8 th AJCC TNM staging system in RAMPS, which was not significantly different as compared with CDP(39.5%, χ 2=0.574, P=0.902). The median number of examined lymph nodes was 9(9), not significantly greater in RAMPS as compared with CDP(10(11), P=0.992). The rate of negative posterior margins using 1 mm rule in RAMPS was 70.3%(52/74), significantly higher as compared with CDP(53.6%(30/56), χ 2=3.817, P=0.044). The overall R0 resection rate was 44.6% (33/74) in RAMPS and 37.5% (21/56) in CDP, which was not significantly different(χ 2=0.663, P=0.474). The median overall survival was 16.5 months for RAMPS, 25.2 months for CDP, and there was no statistical difference between two groups( P=0.981). The median overall survival was 16.0 months for patients with preoperative CA19-9≥300 U/ml who underwent RAMPS, 10.1 months for patients who underwent CDP, without significant difference( P=0.082). Conclusions:RAMPS can improve the rate of negative posterior margins by 1 mm rule and probably increase R0 resection rate and the harvest of lymph nodes. RAMPS may be beneficial to some patients with preoperative CA19-9≥300 U/ml.