The incidence of pancreatic cancer has steadily risen in the past decades. Radical resection is still the best option for treatment of pancreatic cancer. Great progress has been achieved in pancreatic surgery;the mortality and morbidity have decreased dramatically, but long term survival after resection is still dismal. Standard pancreaticoduodenectomy is recommended now for pancreatic head cancer. Extended lymphadenectomy could not improve the prognosis of pancreatic cancer patients. Total pancreatectomy is suitable for some IPMNs patients, rather than a routine for pancreatic cancer patients. The current status and future of surgical treatment for pancreatic cancer will be summarized here.

Objective To investigate the outcome of intraductual papillary mucious neoplasms (IPMN) of the pancreas after surgical resection. Method Clinical data of 76 patients with intraductal papillary neoplasms of the pancreas undergoing surgical resection at Zhongshan Hospital, Fudan University between January 1999 and December 2008 were retrospectively analyzed. Results Among the 76 patients,49 were male, 37 were female. 32 had noninvasive IPMNs, including adenomas( n = 16), borderline tumors (n =6 ), carcinomas in situ (n = 10 ). 44 had invasive IPMNs. Lesions were present in the head in 63 cases, in the body or tail in 10, in the whole pancreas in 3. There were significant difference in age,jaundice, weight loss, asymptomatic cases and CA199 value between noninvasive and invasive IPMNs.Three patients underwent total pancreatectomy, 59 patients underwent pancreaticoduodenectomy, 4 patients underwent pancreaticoduodenectomy with portal vein resection and reconstruction, six patients underwent distal pancreatectomy, two patients each underwent central pancreatectomy or enucleation. The overall postoperative morbidity rate were 28.9%, there was no operative mortality. Positive pancreatic margin was identified in seven patients of noninvasive neoplasms, among thoee one developed recurrence after 67 months. The five-year survival rate for patients with noninvasive and invasive neolpasms was 100% and 35% ,respectively. Size and lymph node metastasis were significant prognostic factors after surgical resection of the invasive IPMNs. Conclusions Surgical resection provides a favorable outcome for patients with noninvasive IPMNs. In contrast, invasive IPMNs was associated with a poor survival. Early resection is essential for improving survival. Long-term follow-up is necessary for all patients with IPMNs after resection.

Objective To identify difference between intraductal papillary mucinous neoplasms (IPMN) and pancreatic common ductal adenocarcinoma. Methods Between March 2003 and June 2006, 29 patients with pathological diagnosis of IPMN and 46 patients with pancreatic adenocarcinoma in Zhongshan Hospital were retrospectively reviewed. Clinical, biochemical, and histopathologic factors were retrospectively analyzed. Prognosis between two groups were compared by log-rank test.Results The proportion with no symptom visit in IPMN was obviously higher than in pancreatic cancer. Twenty-one of 29 specimens were malignant in IPMN. Stage of the malignant IPMN was significantly earlier than that of the pancreatic adenocarcinoma (P=0.017). Intrapancreatic neural invasion was more common in pancreatic adenocarcinoma than in malignant IPMN (P=0.005). The survival curve of the malignant IPMN was significantly better than that of the pancreatic adenocarcinoma (P=0.014). Conclusion IPMN with less aggressive bionomics can be diagnosed and treated in an earlier stage. So its prognosis is better than that of pancreatic ductal adenocarcinoma. Prognosis of malignant IPMN which is more invasive than stage Ⅱ B is simular to that of common pancreatic cancer. However, this conclusion should be further investigated.

Objectives: To investigate the role of glutamine on splanchnic blood flow in SAP rats and underling mechanism. Methods: 32 rats were randomized divided into 2 groups:glutamine group(Gln group, n =16) and SAP group ( n =16).Jejunotomy was performed. Gln group received glutamine.SAP group received saline.All groups were subdivided into 2 groups.8 normal rats were used as the controls.At 12,24hours after the induction of SAP,8 rats in each group were sacrificed.Plasma glutamine concentrations were measured by HPLC.The regional pancreatic microvascular blood flow was measured by Dopplar ultrasound,the blood flow of portal vein,spleen artery and superior mesenteric artery was also measured. Results: Enterally administered Gln was well tolerated by the rats.There was an increase in plasma Gln levels after Gln supplementation on Gln group.The regional pancreatic microvascular blood flow decreased significantly in SAP group( P

Objective To investigate the clinical characteristics and surgical outcomes of pancreatic acinar cell carcinoma (PACC).Methods The clinical and follow up data of PACC patients treated with surgery in Zhongshan Hospital of Fudan University between 1999 and 2012 were analyzed retrospectively.Results A total of 16 PACC were identified including 13 male and 3 female patients.The age of the patients ranged from 38 to 71 with an average of 57 years old.Six patients presented as abdominal pain,while low back pain in 3 patients,abdominal distention in 2 patients,emaciation in 2 patients,jaundice in 2 patients and melena in 1 patient.Elevated CA19-9 level was observed in 8 patients and 2 patients had elevated serum CEA.The tumors were located in the uncinate process in 1 patient,head in 9,body and tail in 6.The superior mesenteric vein was invaded in 2 cases and 1 patient had hepatic artery invasion.The tumor invaded both the celiac trunk and splenic artery in 1 patient.One patient had just undergone intra-operative needle aspiration biopsy due to unresectable tumor.All the other 15 patients underwent surgical excision with R0 resection.Among the 10 patients received pancreaticoduodenectomy,2 had superior mesenteric vein resection and replacement and 1 had hepatic artery resection.Five patients underwent distal pancreatectomy without spleen preservation.The mean size of these tumors was 5.7 cm × 4.6 cm,12 cases had a surrounding envelope,while lymphatic metastasis was observed in 8 cases.The follow up data of 15 patients were collected and the median postoperative survival was 21 months,and the survival rate of 1,3,5 year was 71.4％,28.6％,7.1％.Conclusions Pre-operative diagnosis of PACC is extremely difficult due to lack of specific clinical features and lab tests.Surgery is the first line treatment for PACC,and the prognosis of PACC is better than that of pancreatic ductal adenocarcinoma.

Objective To analyse the factors that have effects on patients' procalcitonin (PCT)level after gastic surgery and to evaluate PCT as a parameter for detection of infectious complications.Methods A total of 153 patients undergoing gastric surgery were included in the study between Jul 2011 and Jan 2013.Temperature and routine blood samples for determining PCT level,neutrophil ratio,white blood cell count were obtained on postoperative days (POD) 1,3,7.Predictive values for each of the markers were examined.Results Postoperative complication,preoperative infection and surgery type affected the PCT level of patients on POD 1.Meanwhile,the independent factor that had influence on PCT level on POD 3 and 7 was postoperative complication.After excluding those patients with preoperative infection,patients with infectious complication exhibited significantly higher PCT levels (t =2.92,P ＜0.01,t =5.34,P ＜0.01,t =4.03,P ＜0.05) on POD 1,3,7 respectively),neutrophil ratio (on POD 3 and 7) and WBC count (on POD 3) than did those without complication.According to receiver operating characteristic analysis,PCT showed the highest AUC on POD 1,7 (AUC =0.89 and 0.87 respectively).In the patients without complication,the mean PCT value was (0.47 ± 0.97),(0.36 ± 0.50),(0.23 ± 0.24) ng/ml on POD 1,3,7 respectively.The PCT level declined 55％ from POD 1 to POD 3 and from POD 3 to POD 7.Conclusions The serum PCT level of patients without any complication showed a decreasing trend while PCT level of those with infectious complications increased significantly.Continuous monitoring PCT level could serve as a diagnostic tool for the early identification of infectious complication after gastric surgery.

Objective To compare the short-term efficacy of pylorus-preserving pancreaticoduodenectomy (PPPD) and standard pancreaticoduodenectomy (SPD) for the treatment of periampullary carcinoma.Methods The clinical data of 85 patients with periampullary carcinoma who were admitted to the Zhongshan Hospital of Fudan University from October 2010 to October 2012 were retrospectively analyzed.Forty-four patients who underwent PPPD were divided into the PPPD group and 41 patients who underwent SPD were divided into the SPD group.The pancreatic fistula(Grade B and above), biliary fistula, blood loss, intra-abdominal infection, delayed gastric emptying (DGE) and prognosis were analyzed.Patients were followed up by telephone interview and outpatient examination once every 3 months within postoperative 1 year and once every 6 months within postoperative 2-3 years till October 2014.Count data were analyzed using the chi-square test, measurement data with normal distribution were presented as M(Qn) and comparison was analyzed using the Mann-Whitney U test.The survival curve was drawn by the Kaplan-Meier method, and survival rate was analyzed using the Log rank test.Results The operation time was 195 minutes (180 minutes, 240 minutes) in the PPPD group and 210 minutes (180 minutes,300 minutes) in the SPD group, with a significant difference (Z =-2.090, P ＜ 0.05).The volume of intraoperative blood loss, intraoperative blood transfusion and duration of postoperative hospital stay were 200 mL(113 mL,288 mL), 0 mL(0 mL, 0 mL) and 17 days(12 days, 24 days) in the PPPD group, and 200 mL(150 mL, 325 mL),0 mL(0 mL, 400 mL) and 16 days(12 days, 30 days) in the SPD group respectively, with no significant differences between the 2 groups (Z =-1.185,-1.780,-0.533, P ＞0.05).There was no perioperative death and incidence of overall complication was 42.4％ (36/85) with pancreatic fistula, intra-abdominal infection and DGE as the top 3 common postoperative complications.The incidence of DGE was 20.5％ (9/44) in the PPPD group,which was significantly different from 4.9％ (2/41) in the SPD group (x2=4.571, P ＜ 0.05).The incidence of pancreatic fistula, biliary fistula, intra-abdominal infection, postoperative bleeding and 2 or more complications were 20.5 ％ (9/44), 2.3 ％ (1/44), 15.9％ (7/44), 4.5 ％ (2/44), 25.0％ (11/44) in the PPPD group, and 14.6％ (6/41), 4.9％ (2/41), 19.5％ (8/41), 7.3％ (3/41), 14.6％ (6/41) in the SPD group, respectively, showing no significant difference between the 2 groups (x2=0.495, 0.423, 0.295, 0.190, 1.425, P ＞ 0.05).Eighty-five patients were followed up for 6-47 months with a median time of 31 months, and postoperative overall 1-and 3-year survival rates were 95.3％ and 75.5％, respectively.The 1-and 3-year survival rates were 97.7％ and 78.9％ in the PPPD group, and 92.7％ and 71.7％ in the SPD group, respectively, with no significant difference in 3-year survival rate (x2=0.690, P ＞0.05).The 3-year overall survival rate was 80.5％ in patients without lymph node involvement (LNI) compared with 54.9％ in patients with LNI, showing a significant difference (x2=4.290, P ＜ 0.05).Conclusions Both PPPD and SPD have good short-term efficacy for periampullary carcinoma.There is no significant difference between PPPD and SPD concerning short-term survival rate of periampullary carcinoma.PPPD has shorter operation time, but has a higher postoperative DGE incidence.LNI is a significant prognostic factor for short-term survival of periampullary carcinoma.PPPD is not recommended while the lymph nodes are involved.

Objective To promote the diagnostic accuracy of intrapancreatic accessory spleen (IPAS).Methods The clinical data of 10 cases of IPAS admitted in Fudan University Zhongshan Hospital from Apr 2005 to Dec 2013 were retrospectively analyzed.Results There were ten cases of IPAS confirmed pathologically.Only 1 of the ten cases was diagnosed correctly and definitely with IPAS preoperatively.The other 9 cases were misdiagnosed with benign or malignant pancreatic tumors,including nonfunctional neuroendocrine neoplasms in 5 cases,pancreatic neuroendocrine cancers in 3 and pancreatic intraductal adenocarcinoma in one.All the nine misdiagnosed patients has no specific symptoms or laboratory indexes.All the IPASs located in the tail of the pancreas with the mean diameter (1.3 ±0.2) cm(0.8-2.5 cm).7 cases of IPAS show strikingly similar dynamic enhancement to the spleen on the CT scans and/or MRI.Accessory spleen around the splenic hilum was found in five cases.Conclusions Morphological study plays an important role in the diagnosis and IPAS carries parallel dynamic enhancement to the spleen on CT scans and/or MRI.IPAS should be considered as a differential diagnosis while the lesion is no more than 2.5 cm in diameter and when other accessory spleens were shown around the splenic hilum.

Objective To evaluate the early postoperative complications of pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) following pylorus preserving pancreaticoduodenectomy (PPPD).Methods Clinical data of 97 patients undergoing PPPD,in Zhongshan Hospital,Fudan University from June 2011 to October 2012,were retrospectively analyed.Digestive tract continuity was established respectively by PG(n-45) or PJ(n =52) after PPPD.Results The demographic characteristics of both group were not significantly different.In the two groups,there were not statistically significant difference in those postoperative complications such as biliary fistula,introabdominal infection,bleeding,and the rc-admission rate.The rate of pancreatic fistula in PJ group was significantly higher than that in the PG group (28.85％ vs.6.67％,P =0.033).However,in PG group the incidence of delayed gastric emptying was significantly higher than that in the PJ group (22.22％ vs.5.77％,P =0.018),and the average length of stay was significantly longer than that in PJ group (19.28 ± 11.04 vs.15.09 ± 6.21 ; P =0.034).In PJ group,one patient died of pancreatic fistula and ensuing surgical site infection and intra-abdominal hemorrhage,there was no mortality in PG group.Conclusions After PPPD,PG and PJ are both safe ways of digestive tract reconstruction.But compared to PJ,PG can decreas the rate of pancreatic fistula but may increase the risk of postoperative delayed gastric emptying,and prolong postoperative hospital stay.

Objective To explore the safety and feasibility of single-incision laparoscopic cholecystectomy without using titanium-clips. Methods Data of 1016 patients(group A) undergoing single-incision laparoscopic cholecystectomy without using titanium-clips were compared to that of 874 patients(group B)undergoing two-port laparoscopic cholecystectomy without using titanium-clips by t test and chi square test for operating time,operative hemorrhage,the length of postoperative hospital stay and postoperative pain.Results In group A,1001 cases were successfully operated on with single-incision laparoscopic cholecystectomy,with conversion to classic four-port laparoscopic cholecystectomy in 15 cases,while 874 cases in group B were operated on with two-port laparoscopic cholecystectomy.There were no bile leakage,biliary tract injury or death in both groups.There were no difference in operating time[(34.5 ±5.2) min vs (32.0±7.4)min,t=0.063,P=0.526],the length of postoperative hospital stay[(3.1±0.8)d vs(3.2±0.7)d,t=1.073,P=0.326]and operative hemorrhage[(56.5±17.8)ml vs (55.2±15.9)ml,t=0.812,P=0.425](P>0.05) between the two groups,but the postoperative pain was less severe in Group A than that in group B (P=0.000<0.05). Conclusions The single-incision laparoscopic cholecystectomy is feasible,safe,less traumatic and more cosmetic.