Laparoscopic surgery in hepatobiliary,splenic and pancreatic diseases is being widely used.However,the incidence of postoperative complications is relatively higher due to the complexity of the operative procedures.Surgeons are expected to have familiarity with normal and variant anatomy,as well as a good command of prevention and management of bleeding.Different separation techniques should be used based on the different characteristics of tissues.Moreover,digestive tract reconstruction is the technical bottleneck in laparoscopic hepatobiliary,splenic and pancreatic surgeries,and depending on the team work.Different anastomotic methods should be applied according to patients' condition.Three-dimensional laparoscopy and Da Vinci robot surgical system have greatly promoted the development of complex laparoscopic surgery in hepatobiliary,splenic and pancreatic surgeries.Comprehensive perioperative management and enhanced recovery after surgery are the guarantee of safe and quick postoperative recovery,which also fully embody the advantages of minimally invasive surgery.

Farnesoid X receptor(FXR), a member of the metabolic nuclear receptor superfamily, plays key roles in maintaining bile acid and lipid homeostasis.FXR is highly expressed in the entero-hepatic system where it transcriptionally regulates bile acid metabolism, intestinal barrier function and liver regeneration, etc.Loss or down regulation of FXR expression can lead to a lot of diseases, such as cholecystolithiasis, biliary cirrhosis,primary hepatic carcinoma, colon carcinoma, etc.Activation of FXR may protect against or provide a pharmacological target for these diseases.

Pancreatic adenocarcinoma is a highly malignant tumor and its prognosis is poor. The key factors for cure and prolonged survival are early detection, adequate evaluation of resectability and surgical resection with microscopic tumor clearance. Surgeons should pay attention to standardize operative procedures to increase the R0 resection rate. Whipple specimens should be inked and examined carefully. Postoperative adjuvant radiotherapy and chemotherapy are beneficial in the prevention of local tumor recurrence and distant metastasis. Inter-disciplinary cooperation and multimodality treatment are helpful to improve the prognosis and quality of life of patients with pancreatic cancer.

Pancreatic cancer is highly malignant with a poor prognosis. The resectability and prognosis of early pancreatic cancer are much better than the advanced, so early diagnosis is crucial for saving patients' lives. Because the symptoms of pancreatic cancer are non-specific, most of the patients are misdiagnosed as gastrointestinal or hepatobiliary diseases. Early diagnosis rate of pancreatic cancer can be greatly improved by combined application of tumor marker detection, endoscopic ultrasound, computed tomography, positron emission tomo-graphy, and etc. Early screening of high-risk population has been advocated by the experts, and its value in early diagnosis of pancreatic cancer has been confirmed by relevant studies. The colaboration of multiple pancreatic surgery centers in conducting prospective studies and setting gnidlines for the pancreatic cancer diagnosis, and relevant fundamental reseaches should also be emphasized.

Pancreatic cancer is a highly malignancy of the digestive system, with low early diagnosis rate and poor prognosis. Cancer cachexia, muscle and adipose tissue wasting are important factors affecting surgical complications and long-term prognosis of patients with pancreatic cancer. On one hand, the occurrence and development of pancreatic cancer cachexia are associated with the decrease of food intake. On the other hand, the characteristic of tumor hypermetabolism, many inflammatory factors, fat and protein regulatory factors and many neuroendocrine pathways are also involved in pancreatic cancer cachexia. At present, the understanding of cancer cachexia and tissue wasting is not comprehensive, and the diagnostic methods are not unified. The main screening method is based on body mass index, but it is not applicable to obese patients. The detection of serum cytokines and determination of intramuscular fat content based on the abdominal computed tomography scan also play pivotal roles in the diagnosis of pancreatic cancer cachexia. Perioperative inhibition of tissue wasting can not only reduce surgical complications, but also improve the prognosis of pancreatic cancer patients. However, there is no effective method to completely reverse cancer cachexia. Multidisciplinary treatment is the routine therapy. Surgical treatment to remove the tumor is the fundamental measure to impede the development of cachexia. In addition, strengthening nutritional support, reducing inflammation and stress reaction, reducing the muscle wasting are also important in the treatment of cachexia during the perioperative period. Combined with self experience, the authors comprehensively analyze research advances, summarize the etiology, molecular mechanism, diagnosis and treatment of tissue wasting, in order to investigate tissue wasting and perioperative treatment strategies of pancreatic cancer patients.

Objective To retrospectively study the variation of glucose in patients with insulinomas. Methods The medical records of patients who underwent operations in the last 20 years at Peking Union Medical College Hospital were reviewed retrospectively. Patients who received repeated operations, or just exploratory laparotomy or liver biopsy were excluded. The clinical data were collected and analyzed. Results There were 245 patients, including 103 males and 142 females. The mean age was (42.2+ 14.6) years old. The mean value of preoperative fasting glucose was (1.47+0. 57) mmol/L, and the ratio of insulin to glucose was greater than 0.3 in 87.4% patients. The glucose level rose gradually after removal of the tumor(s). The blood sugar rising more than 1 time over the baseline value at one hour after resection was observed in 79.6% patients. For all the other patients, the glucose level rose to this level in the morning of the first postoperative Day 1. Rebound hyperglycemia was common after operations, and the glucose gradually returned to normal, with a mean level of 5.56 mmol/L at the time when the patients were discharged home. Conclusions Patients with insulinomas had a serum fluctuation in glucose (low→high→normal) during the perioperative period.Intraoperative glucose test combined with ultrasound and frozen section helped to localize and to remove all the lesions. Rebound hyperglycemia after surgery should be treated with insulin pump actively to minimize the incidence of complications.

Obesity, alcohol consumption and metabolic diseases can cause the accumula-tion and infiltration of adipocytes in pancreatic tissues, resulting in pancreatic steatosis (PS). There is little clinical concern about PS, which has not yet attracted the attention of the physicians. How-ever, previous studies have confirmed that PS is associated with the carcinogenesis, development, surgical complications and prognosis of pancreatic cancer (PC). Within the environment of PS, adipocytes, macrophages and other inflammatory cells infiltrate among the acinar cells, aggravating the local inflammation in pancreatic tissue, stimulating the atypical hyperplasia of the pancreatic duct epithelium, and promoting the occurrence of PC. Patients with PS have a significantly higher incidence of PC and are more susceptible to lymph node metastasis, with worse long-term prognosis. The texture of pancreas become soft and fragile under the condition of PS, and the risk of pancreatic fistula and its related complications evidently increase after pancreatic resections. In terms of imaging examinations, it is common to use abdominal computed tomography or magnetic resonance imaging for the diagnosis of PS. In addition, a large number of adipocytes infiltration in pancreatic acinar tissue can confirm the diagnosis of PS histologically. Surgeons should pay more attention to PS, be familiar with its diagnostic criteria and clinical significance, and take active prevention and early intervention to reduce the occurrence of PC. Regard to PC patients complicated with PS, blood glucose, blood pressure and other metabolic diseases should be well controlled during the perioperative period, surgical details should be comprehensively considered to ensure the quality of pancreatojejunostomy and reduce postoperative complications. Combined with self-experience, the author comprehensively analyzes research advances at home and abroad, summarizes the role of PS in the occurrence and development of PC and its important influence on clinical diagnosis and treatment, and explores the perioperative management strategy of PC patients with PS.

Pancreatic neuroendocrine tumors (pNETs) are a highly heterogeneous group of neoplasms, which are predominantly solid and rarely present as cystic lesions. Due to the development and widespread use of cross-sectional imaging, such as CT and MRI examination, the detection rate of asymptomatic cystic pNETs has dramatically risen in the past decade. The etiology of cystic pNETs remains unclear. Despite several proposed hypothesis, the current studies still show contradictory results. Compared with solid pNETs, cystic pNETs are more likely to be non-functional and asymptomatic, and present with indolent biological behavior, such as lower Ki-67 proliferation index and mitotic count, less lymph node involvement and distant organ metastasis. The long-term prognosis of patients with cystic pNETs is also better compared with those with solid pNETs. However, a small part of cystic pNETs have invasive biological behavior. Preoperative diagnosis of this disease is challenging owing to the lack of specific imaging features. Endoscopic ultrasonography combined with fine needle aspiration can significantly improve the sensitivity and specificity in diagnosis of cystic pNETs. For its treatment strategy, all following factors, including clinical symptoms, tumor location, tumor size, degree of cystic component should be considered compre-hensively to individually make decision. Surgical resection is the standard procedure of cystic pNETs. Owing to its indolent behaviors, observation and active surveillance should be considered as an alternative to surgery for patients with non-functional, purely cystic and diameter less than 2 cm cystic pNETs. Combined with their own experience and relative literature, the authors make an investigation on the etiology, clinical characteristics, diagnosis and treatment strategies of cystic pNETs to provide reference for clinical treatment of surgeons.

OBJECTIVETo examine the renal function changes and mechanisms on rats with diabetes through a sleeve gastrectomy operation.

METHODSThirty-six rats were induced diabetes through injection of streptozotocin (STZ), and 30 of these diabetic rats that blood glucose levels at the midrange (blood sugar 17.88-23.65 mmol/L, mean: 20.32 mmol/L) were randomly assigned to the sleeve gastrectomy group, Sham-operation group and control group. The serum creatinine, lipid parameters were measured postoperatively. The 24 h urine volume obtained and urine albumin excretion rate (UAER) was calculated. Serum and urinary creatinine were examined and glomerular filtration rate (GFR) was counted. Kidney sections were stained with periodic acid-Schiff, and then the index of mesangial expansion was determined. The expression of synaptopodin for podocytes was also performed through the immunohistochemical procedure. A one-way ANOVA and t-test were performed to evaluate differences between groups and each other.

RESULTSOnly one rat of SG group died after operation. The GFR ((8.44 ± 2.10) ml · g⁻¹ · d⁻¹), 24 h UAER ((36.04 ± 11.10) mg/d), plasma lipids level (total cholesterol (1.66 ± 0.23) mmol/L, triglycerides (1.25 ± 0.17) mmol/L), kidney weight ((1.61 ± 0.06) g), the index of mesangial expansion ((6.14 ± 1.50)%) and synaptopodin expression ((20.44 ± 2.99)%) were improved in the SG group compared with the sham-operation group ((15.05 ± 3.01) ml · g⁻¹ · d⁻¹, (57.01 ± 11.34) mg/d, (2.15 ± 0.29) mmol/L, (1.65 ± 0.23) mmol/L, (1.93 ± 0.07) g, (11.32 ± 2.09)%, (10.34 ± 1.43)%) and control group ((14.79 ± 2.38) ml · g⁻¹ · d⁻¹, (62.71 ± 16.46) mg/d, (2.23 ± 0.21) mmol/L, (1.59 ± 0.20) mmol/L, (1.91 ± 0.06) g, (10.82 ± 1.79)%, (11.13 ± 2.43)%) (t = 0.781-5.025, all P < 0.05).

CONCLUSIONThe sleeve gastrectomy procedure can improve the renal function in a diabetes rat model may be through protecting the podocytes function and preventing the mesangial expansion of glomeruli.

Animals ; Blood Glucose ; Creatinine ; blood ; urine ; Diabetes Mellitus, Experimental ; physiopathology ; Diabetic Nephropathies ; physiopathology ; surgery ; Gastrectomy ; Glomerular Filtration Rate ; Kidney ; physiopathology ; Kidney Function Tests ; Random Allocation ; Rats

Objective To investigate the clinical features and treatment of solid pseudopapillary neoplasm (SPN) of the pancreas.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 69 patients with SPN of the pancreas who were admitted to the Qilu Hospital of Shandong University from January 2012 to July 2017 were collected.Serum tumor markers detection,enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of abdomen were carried out preoperatively for all the patients,and a part of the patients received endoscopic ultrasonography (EUS).Surgery plans were formulated after completion of examinations.Observation indicators:(1) clinical features;(2) treatment situation;(3) results of pathological examination;(4)follow-up.All the patients were followed up via outpatient examination and telephone interview to detect the survival and tumor recurrence and metastasis till July 2017.Measurement data with normal distribution were presented by (x)±s and were compared by Student's t test.Count data were compared by chi-square test.Results (1) Clinical features:① epidemiologic features:the ratio of male to female was 1∶5.9;patients were aged between 9 and 65 years,including 40 under 30 years and 29 above or equal to 30 years.The onset age was (34± 15)years for male patients and (28 ± 11)years for female patients,respectively,with no statistically significant difference (t=1.364,P＞0.05).Of 69 patients,SPN was located at pancreatic uncinate process in 25 patients,at neck of pancreas in 12 patients,body and tail of pancreas in 32 patients.② Medical history:history of acute or chronic pancreatitis and abdominal trauma were denied by all the 69 patients.③ Clinical manifestation:26 patients had no obvious symptoms and were detected by physical examination;31 patients had discomfort in upper abdomen,nausea and vomiting;other patients were admitted to the hospital because of upper abdominal mass (10 patients),jaundice (1 patient) or nausea,constipation (1 patient).④ Laboratory examination:the levels of preoperative carcinoembryonic antigen (CEA) and CA19-9 were normal.⑤ Imaging examination:plane scan of the CT examination showed round or round-like low-density shadows in the 69 patients,including 51 of cystic solid lesion,13 of solid lesion and 5 of cystic lesion.Complete capsules were observed in 64 patients,blurred boundary between pancreas and adjacent viscera in 5 patients,calcified foci in the pancreatic parenchyma and capsules in 14 patients.Ten patients received MRI examination,and the T1-weighted images showed equal or slightly lower signal,T2-weighted images showed slightly higher signal in the plane scan,and T1-weighted and T2-weighted images of the tumor capsule showed continuous or non-continuous ring-like signal.The results of enhanced scan showed slightly heterogeneous enhancement of the capsule and the parenchyma of the pancreas in the arterial phase,and progressive enhancement in the venous and delayed phase,while the enhancement degree was lower than that of the normal pancreas parenchyma.The parenchyma was cloud-,papillaor mural nodule-like enhanced.Obvious enhancement was observed in capsule while not in the cystic components.The boundaries of the tumors in 5 patients were clear under EUS.Hypo-,iso-and hyperechoic regions were found in the masses,and the masses were confirmed as cyst-solidary type.Obvious calcified foci were found in 1 patient.(2) Treatment outcome:twenty-seven patients received laparoscopic surgery,including tumor expiration in 13 patients,distal pancreatectomy with preservation of spleen in 8 patients,distal pancreatectomy combined with splenectomy in 2 patients,middle pancreatectomy in 2 patients,pancreaticoduodenectomy with preservation of pylorus in 1 patient,pancreatic head resection with preservation of duodenum under the assistance of laparoscopy in 1 patient.Forty-two patients received open surgery,including tumor expiration in 12 patients,distal pancreateetomy with preservation of spleen in 10 patients,distal pancreatectomy combined with spleneetomy in 6 patients,middle pancreatectomy in 5 patients,pancreaticoduodenectomy in 7 patients (with preservation of pylorus in 2 patients) and pancreatic head resection combined with preservation of duodenum in 1 patient.One patient with SPN + hepatic metastasis received distal pancreatectomy+ metastatic foci resection in the lesser omental bursa,and then followed by radiofrequency ablation in the hepatic metastatic foci.Postoperative complications:21 of 69patients had postoperative complications,including 17 intestinal fistulas,2 abdominal bleedings,1 incomplete obstruction,1 pleural effusion + atelectasis,and all of them were cured by symptomatic treatment.(3)Pathological examination:the resection margins of 69 patients were negative.The mean diameter of the tumor was (7±4) cm (21 patients with tumor diameter ＜ 5 cm,and 48 with tumor diameter ≥5 cm).The tumor diameters of 4 in 10 male patients were above or equal to 5 cm,and the number was 44 in 59 female patients,with statistically significant difference (x2 =4.828,P＜0.05).The tumor diameters of 32 in 40 patients who aged under 30 years were above or equal to 5 cm,and the number was 16 in 29 patients who were aged above or equal to 30 years,with statistically significant difference (x2=4.895,P＜0.05).Solid,pseudo-papillary and cystic regions in the SPN tissues were seen under the light microscope.Tumor cells were surrounded the blood vessels and were arranged in the nest or sheet shape in the solid region;blood vessels were surrounded by one or multiple layers of tumor cells in the axis or pseudopapillary shape in the pseudopapillary region;large amount of mucus and clusters of blood cells were seen in the cystic regions.The result of immunohistochemistry showed that the positive rates of α1-antitrypsin,vimentin,β-catenin,progesterone receptor,CD10,synaptophysin and chromogranin A were 100.0％ (39/39),96.6％ (28/29),95.7％ (45/47),94.4％ (51/54),92.5％ (49/53),72.9％ (35/48) and 5.6％ (3/54),respectively.(4) Follow-up:63 of 69 patients were followed up for 1-68 months,with median time of 29 months.No SPN recurrence or metastasis was detected.One patient died of lung cancer at postoperative month 35 and other patients survived well.Conclusions SPN of pancreas is mostly detected in young female patients,and it could be solid or cystic.Abdominal enhanced CT or MRI examination could clarify the diagnosis.EUS-fine needle aspiration examination could provide pathological evidence for definitive diagnosis.Typical cellular morphology and pseudopapillary regions may provide hints for the diagnosis of SPN,and the diagnosis could be clarified when combined with the detection of vimentin,α 1-antitrypsin or other indexes.Complete resection of SPN and ensure negative resection margin are fundamental principles of treatment.