For the high rate of relapse and metastasis,the 5-year survival rate in Pancreatic cancer patients is low.Surgery still is a effective treatment in pancreatic cancer.With the deep understanding of the disease,the operation of pancreatic cancer has been improved.In recent years,with the rapid development of laparoscopic techniques,minimally invasive surgery is also applied to the treatment of pancreatic cancer.This review summarizes some pancreatic cancer surgical operations developed in recent years.

Objective To investigate the effects of improved end-to-end invagination pancreaticojejunostomy on the occurrence of pancreatic fistula after pancreaticoduodenectomy.Methods The clinical data of 396 patients who received pancreaticoduodenectomy at the Cancer Hospital of Shandong Province from January 2001 to January 2011 were retrospectively analyzed.All patients were divided into the improved group(235 patients)and traditional group(161 patients)according to different anastomotic methods.All the operations were done by the same surgical group,and the digestive tract was reconstructed by the Child method.Patients in the improved group received improved end-to-end invagination pancreaticojejunostomy,and patients in the traditional group received traditional end-to-end anastomosis.The volume of operative bleeding,operation time,incidence of pancreatic fistula and duration of hospital stay of the 2 groups were compared.All data were analyzed using the t test,chisquare test or Fisher exact probability.Results The operative blood loss,operation time and duration of hospital stay were(383 ±56)ml,(7.2 ± 1.0)hours,(21 ±3)days in the improved group,and(381 ±39)ml,(7.0 ± 0.5)hours,(22 ± 5)days in the traditional group,with no significant difference between the 2 groups(t =0.388,1.680,-1.835,P ＞ 0.05).No operative death was detected in the 2 groups,and the overall incidence of pancreatic fistula was 7.6％(30/396).The incidence of pancreatic fistula of the improved group was 0(0/235),which was significantly lower than 18.6％(30/161)of the traditional group(P ＜ 0.05).Patients complicated with pancreatic fistula in the traditional group were cured by drainage,somatostatin administration and parenteral nutrition.Conclusion Improved end-to-end invagination pancreaticojejunostomy can significantly reduce the incidence of pancreatic fistula after pancreaticoduodenectomy.

Objective To study the results of laparotomy and Cool-tip radiofrequency ablation to treat large liver tumors.Methods Laparotomy and Cool-tip radiofrequency ablation were carried out on 64 patients with large hepatic cancer.To destroy the tumor completely,for tumors of 3.0～4.0 cm in diameter,7 ablations were required; for 4.0～5.0 cm in diameter 15 ablations; for 5.0～6.0 cm in diameter 19 ablations; for 6.0～7.0 cm in diameter 40 ablations.Result The complete necrosis rate of laparotomy and radiofrequency ablation was 93.75％ (60/64).The short-term results were good.Conclusions Laparotomy and Cool-tip multipoint overlapping radiofrequency ablation for large liver tumors (tumor diameter＞3 cm) could result in a high complete necrosis rate and a low complication rate.It is a good radical treatment for unresectable and large liver cancer.

Objective To investigate the relationship between ischemic time and thrombus types in patients with ST-segment elevation myocardial infarction (STEMI).Methods Eighty-two STEMI patients undergone emergency percutaneous coronary intervention (PCI) and coronary thrombus aspiration (CTA) from Sep.2012 to Apr.2016 were included and divided into 3 groups according to the ischemic time:≤4 hours (n=36),4-7 hours (n=30) and ＞7 hours (n=16).Visible aspirated thrombi were collected and separated into erythrocyte-rich type,platelet/fibrin-rich type and combined type thrombi by HE dying.The percentage difference of the 3 types thrombi was compared among the 3 groups.Results The percentage of platelet/fibrinrich type,erythrocyte-rich type and combined type thrombi in the 3 groups were as follows:in ≤4h group:61.1％(22/36),8.3％(3/36) and 30.6％(11/36),P=0.019;in 4-7h group:23.3％(7/30),10.0％(3/30) and 66.7％(20/30),P=0.012;and in ＞7h group:43.8％(7/16),12.5％(2/16) and 43.8％(7/16),P=0.913.For platelet/fibrin-rich type thrombi,the percentages in 3 periods were 61.1％(22/36),19.4％(7/36) and 19.4％(7/36),P=0.009;For combined type thrombi,the percentages in 3 periods were 28.9％(11/38),52.6％(20/38) and 18.4％(7/38),P=0.013;For erythrocyte-rich type thrombi,the percentages in 3 periods were 37.5％(3/8),37.5％(3/8) and 25.0％(2/8),P=0.895.Conclusions The types of intracoronary aspirated thrombi differ from various periods.Ischemia time may be an important predicted factor.

Objective To examine the influence of gender difference on the reperfusion delay in patients with ST-elevation myocardial infarction (STEMI).Methods A total of consecutive 325 patients with STEMI were analyzed admitted in the 306 Hospital of PLA from Jan.2011 to Dec.2015.Patients were divided into two groups:male group (n=268) and female group (n=57).The clinical data and the time intervals including symptom onset to first medical contact (So-to-FMC),transfer delay (FMC-to-D),FMC to balloon dilatation (FMC-to-B),activation delay and door to balloon (D-to-B) time were compared between different gender groups,and the prognosis was observed.Results The overall median of pre-hospital delay was 125 minutes.The median of prehospital delay time (male 119.5min vs.female 160.0min) and So-to-FMC time (male 69.5min vs.female 100.0min) were longer in female than in male patients,but no statistical difference existed (P＞0.05) between the two groups in pre-hospital delay,So-to-FMC,FMC-to-B,D-to-B and total ischemia time.Compared with male patients,female patients were more likely to have additional comorbidities,such as hypertension and diabetes mellitus,and lower rate of smoking (P＜0.05).However,the incidence of major adverse cardiac and cerebrovascular events (MACCE) showed no significant difference between female and male patients at 30-day (male 5.22％ vs.female 5.26％) and I-year (male 10.82％ vs.female 8.77％) follow-up (P＞0.05).Conclusion The influence of gender on reperfusion delay is gradually weakening.

Hepatocellular carcinoma (HCC) owns the high morbidity and mortality rates. Surgical resection is still the major pathway for the longer survival of HCC patients. Postoperative recurrence and metastasis have become the key impairment of prognosis of HCC patients. The relationship between tumor recurrence and surgical manner underwent by HCC patients is complicated and multiple factors are included. When the liver tumor was pressured during operation, tumor cells could be squeezed into blood flow via the broken vessels, which resulted in tumor metastasis. Besides, ischemia-reperfusion injury induced by Pringle maneuver during the liver blood blockade resulted in the immune destruction of liver and induced tumor recurrence.The destruction of physical barriers consisted of interstitial cells and normal liver cells was also a key factor for tumor recurrence. This paper summarizes the possible relationship between postoperative recurrence and surgical manner in HCC patients to provide the preventive suggestions for the postoperative recurrence of HCC patients.

Hepatocellular carcinoma (HCC) owns the high morbidity and mortality rates. Surgical resection is still the major pathway for the longer survival of HCC patients. Postoperative recurrence and metastasis have become the key impairment of prognosis of HCC patients. The relationship between tumor recurrence and surgical manner underwent by HCC patients is complicated and multiple factors are included. When the liver tumor was pressured during operation, tumor cells could be squeezed into blood flow via the broken vessels, which resulted in tumor metastasis. Besides, ischemia-reperfusion injury induced by Pringle maneuver during the liver blood blockade resulted in the immune destruction of liver and induced tumor recurrence.The destruction of physical barriers consisted of interstitial cells and normal liver cells was also a key factor for tumor recurrence. This paper summarizes the possible relationship between postoperative recurrence and surgical manner in HCC patients to provide the preventive suggestions for the postoperative recurrence of HCC patients.

Objective: To investigate the impact of symptom onset to first medical contact (SO-to-FMC)time on the prognosis of patients with acute ST-segment elevation myocardial infarction(STEMI). Methods: The clinical data of 341 consecutive STEMI patients, who were hospitalized to our hospital and received primary percutaneous coronary intervention(PCI) from August 2011 to April 2016, were retrospectively analyzed. The patients were divided into ≤90 min group (201 cases) and >90 min group (140 cases) according to the SO-to-FMC time. The treatment time, mortality and incidence of major adverse cardiac and cerebro-vascular events(MACCE) were analyzed. The risk factor of 1-year mortality after PCI and 1-year incidence of MACCE during the post-discharge follow-up period were analyzed by binary logistic regression analysis. The predictor of 4.5-year mortality after PCI was analyzed by multivariate Cox regression analysis. Methods The door to balloon time (104(88, 125) min vs. 111(92, 144)min, P=0.023), first medical contact to balloon time(146(119, 197) min vs. 177(125, 237)min, P=0.005), and symptom onset-to-balloon time(200(170, 257) min vs. 338(270, 474)min, P<0.001)were all significantly shorter in the ≤90 min group than in>90 min group. The 30-day mortality (2.99% (6/201) vs. 7.86%(11/140), P=0.042), 1-year mortality (2.89 (5/173) vs. 9.57(11/115), P=0.015), 1-year incidence of MACCE during the post-discharge follow-up period(1.16%(2/173) vs. 6.96%(8/115), P=0.021), and 4.5-year cumulative mortality(3.00% vs. 11.20%, P=0.007) after PCI were significantly lower in the ≤90 min group than in the >90 min group. Moreover, the 4.5-year incidence with free of MACCE (97.20% vs. 88.80%, P=0.025) during the post-discharge follow-up period was significantly higher in the ≤90 min group than in the >90 min group. In-hospital mortality was similar between the two groups (2.49%(5/201) vs. 6.43%(9/140), P=0.071). Results: The door to balloon time (104(88, 125) min vs. 111(92, 144)min, P=0.023) , first medical contact to balloon time(146(119, 197) min vs. 177(125, 237)min, P=0.005), and symptom onset-to-balloon time(200(170, 257) min vs. 338(270, 474)min, P<0.001) were all significantly shorter in the ≤90 min group than in >90 min group. The 30-day mortality(2.99% (6/201) vs. 7.86%(11/140), P=0.042), 1-year mortality (2.89(5/173) vs. 9.57(11/115), P=0.015), 1-year incidence of MACCE during the post-discharge follow-up period (1.16%(2/173) vs. 6.96%(8/115), P=0.021), and 4.5-year cumulative mortality (3.00% vs. 11.20%, P=0.007) after PCI were significantly lower in the ≤90 min group than in the >90 min group. Moreover, the 4.5-year incidence with free of MACCE (97.20% vs. 88.80%, P=0.025) during the post-discharge follow-up period was significantly higher in the ≤90 min group than in the >90 min group. In-hospital mortality was similar between the two groups (2.49%(5/201) vs. 6.43%(9/140), P=0.071). Results of binary logistic regression analysis showed that the SO-to-FMC time >90 min was the risk factor of 1-year mortality(OR=2.90, 95%CI 1.22-6.92, P=0.016) and 1-year incidence of MACCE (OR=5.19, 95%CI 1.21-22.20, P=0.026) during the post-discharge follow-up period. Multivariate Cox regression analysis demonstrated that the SO-to-FMC time >90 min was the risk factor of 4.5-year mortality after PCI in patients with STEMI (HR=2.88, 95%CI 1.10-7.53, P=0.031). Conclusion Shorting the SO-to-FMC time can significantly reduce the treatment time of STEMI patients, short and long-term mortalities and the incidence of MACCE, and improve the prognosis of patients with STEMI.

Objective To explore the mechanisms of mesenchymal stem cell-derived extracellu-lar vesicles(MSC-EVs)in improvement of renal injury in rats with diabetic nephropathy(DN)by reg-ulating mammalian target of rapamycin(mTOR)/p70 ribosome protein S6 kinase(S6K1)/coiled-coil myosin-like Bcl-2-interacting protein(Beclin 1)pathway.Methods The model of SD rats with DN was established by a method of high-fat diet combined with intraperitoneal injection of streptozotocin,and they were randomly divided into model group,MSC-EVs group,and MSC-EVs+MHY1485(mTOR activator)group,with 12 rats in each group.Another 12 SD rats were normally fed for 6 weeks and then intraperitoneally injected with an equal dose of sodium citrate solution as controls.After grouping with MSC-EVs and MHY1485,blood glucose and levels of renal function indicators[blood urea nitrogen(BUN),serum creatinine(Scr),and urinary microalbumin(UmALB)]in rats were detected.HE staining was used to detect the pathological morphology of renal tissue in rats of each group;immunohistochemistry was used to detect the expression of mTOR/S6K1/Beclin 1 pathway related proteins in the renal tissues of rats in each group;the Western blot was used to de-tect the mTOR/S6K1/Beclin 1 pathway and autophagy-related protein expression in the renal tissues of rats in each group.Results Compared with the control group,the renal tissue morphology of rats in the model group were impaired,and the blood glucose,BUN,Scr,UmALB,relative positive ex-pressions of p-mTOR and p-S6K1,p-mTOR/mTOR,p-S6K1/S6K1 increased significantly(P＜0.05),while microtubule associated protein 1A/1B light chain 3(LC3)Ⅱ/LC3 Ⅰ,expression of Beclin 1 protein,and relative positive expression of Beclin 1 significantly reduced(P＜0.05);compared with the model group,the MSC-EVs group had less impairment in the renal tissue mor-phology,and the blood glucose,BUN,Scr,UmALB,relative positive expressions of p-mTOR and p-S6K1,p-mTOR/mTOR,and p-S6K1/S6K1 decreased significantly(P＜0.05),while expression of LC3 Ⅱ/LC3 Ⅰ,Beclin 1 protein,and relative positive expression of Beclin 1 increased signifi-cantly(P＜0.05);compared with the MSC-EVs group,the impairment of the renal tissue morphol-ogy was worse in the MSC-EVs+MHY1485 group,and the blood glucose,BUN,Scr,UmALB,rel-ative positive expressions of p-mTOR and p-S6K1,expression of p-mTOR/mTOR,and p-S6K1/S6K1 increased significantly(P＜0.05),while the expression of LC3Ⅱ/LC3Ⅰ,Beclin 1 protein,and rela-tive positive expression of Beclin 1 decreased significantly(P＜0.05).Conclusion MSC-EVs can enhance autophagy,reduce levels of blood glucose,Scr,BUN and urinary protein in rats with DN,alleviate renal tissue damage,and the mechanism may be achieved by inhibiting the activation of the mTOR/S6K1/Beclin 1 pathway.

An estimate of about 50% of new liver cancer cases worldwide occur in China every year.Surgical resection is still the major treatment choice for longer survival of patients with hepatocellular carcinoma. Blocking hepatic blood flow and reducing intraoperative bleeding ensure the success of the operation. Anatomic separation of hepatic hilar region is the precondition of hepatic inflow occlusion. The hepatic hilar plate system involves a thick layer of connective tissue covering the hepatic inflow ducts of hepatic hilar region. The descending part of hilar plate assists in reducing the anatomical difficulty of the hepatic hilar region. The "forth porta hepatis" that is hidden in the hepatic hilar plate system involves the accumulation area of "short hepatic portal veins" .The communicating branch vessels between the hepatic inflow vessels form the anatomical basis in reducing the indocyanine green fluorescence stain effect.The relatively fixed position of the hepatic portal plate is considered as a positioning marker for accurate liver resection. The intrahepatic Glisson sheath is connected with thick connective tissue of the hepatic portal panel system, and is regarded as the physical barrier in limiting the proliferation and hypertrophy of hepatocytes and continuation of hepatic portal panel system in the liver.This paper summarizes the anatomy and application of hepatic hilar plate system during hepatobiliary surgery.