Objective To investigate the clinical relevance of hepatic artery variation during the procedure of duodenopancreatectomy. Methods Data of 100 patients who underwent duodenopancreatectomy were retrospectively reviewed, and the anatomy of hepatic artery variation was evaluated, then the types of variation and specific intra-operative managements were recorded. Results Through pre-operative celiac artery and superior mesenteric artery DSA and duodenohepatic ligament skeletonization during operation, 16 cases were found to have hepatic artery variation, and 14 (14%) patients had alternative hepatic artery, among them there were 10 cases of alternative right hepatic artery (10%) , 8 cases originated from superior mesenteric artery, 2 cases originated from gastroduodenal artery. 4(4%) patients had alternative left hepatic artery, 3 of them originated from left gastric artery, 1 originated from right hepatic artery. The diameter of variant artery was 0.3 -0.6 cm with a mean of 0. 47 cm. All the variant arteries were reserved in operation. 1 patient had a variant hepatic artery located in the posterior of hepatoduodenal ligament parallel with portal vein, and the diameter of this variant artery was 0. 4 cm, the variant artery was reserved. 1 patient had a variant hepatic artery towards right hepatic lobe which originated from the direction of pancreatic head, and the diameter of this variant artery was 0.2 cm, the artery was dissected 1 h after artery occlusion. Conclusions Whether variant blood vessel need to be reserved shall be judged according to blood vessel diameter, the changes of liver in the course of variant artery occlusion and suggestions from blood vessel surgeon.

Objective To investigate the feasibility and safety of spleen-preserving distal pancreatetomy outside abdominal cavity. Methods We used the method of spleen-preserving distal pancreatetomy outside abdominal cavity for 6 patients of benign diseases of distal pancreas who were admitted in Gulou Hospital from December 2005 to December 2008. Results All patients underwent the operation successfully. The mean operation time was 180 minutes, the blood loss was 100～300 ml with a mean of 200ml. No patients needed blood transfusion. The mean post-operative hospital stay time was (14±5 ) days. One patient developed pancreatic fistula and was cured with non-operative management, there was no other complications. All patients were followed up from 3 to 24 months, and the results were excellent. Conclusions Spleen-preserving distal pancreatetomy outside abdominal cavity is safe and feasible, which may avoid the unnecessary splenectomy.

Objective To explore clinical efficacy and safety of intraoperative localization of occult insu -linoma by using step-by-step occlusion of the pancreas .Methods 22 cases of occult insulinoma patients admit-ted from Mar.2003 to May 2013 were given intraoperative localization by adopting the technology of step -by-step occlusion of the pancreas .Results All the 22 patients were successfully completed the segmental resection of pancreas.The average operation time was(120 ±50)min, and the average intraoperative blood loss was (100 ± 80)ml.No blood transfusion was needed.Blood glucose rose rapidly when insulinoma was located within the scope of occlusion, blood glucose remained unchanged when insulinoma was beyond the scope of occlusion ,and blood glucose dropped swiftly when insulinoma was on the point of occlusion .Two patients had postoperative short-term pancreatic fistula and they were cured by conservative treatment .No other complications occurred .The average hospitalization time was(12 ±5)d.The result was good during the followed up of 8 to 24 months.Con-clusion The technique of step-by-step occlusion of the pancreas for localization of occult insulinoma is effective supplement for conventional methods , worthy of promotion .

Objective: To observe the effect of ω-3 fish oil emulsion on the experimental severe acute pancreatitis(SAP)through the morphologic alteration of pancreas,the level of serum amylase(AMS)and the functions of liver and kidney,and explore its possible mechanism. Methods: Rat model of SAP was produced by injecting 5% Sodium Cholate(1 ml/kg)into the biliopancreatic duct.Male Sprague-Dawley rats were randomly divided into 4 groups: normal group(n=6),fish oil emulsion treatment group(FOG,n=18),soybean oil emulsion treatment group(SOG,n=18) and normal sodium treatment group(NSG,n=18).Then fish oil emulsion(FO,10 ml/kg);soybean oil emulsion(SO,10 ml/kg)and normal sodium(NS,10 ml/kg)were intravenously injected respectively 120 minutes.The pancreatitis were confirmed by levels of serum AMS and histopathologic score.ALT,AST,BUN and Cr were tested 24 hours after the treatments.Expressions of IL-1β and IL-10 were tested by ELISA.The activated NF-kappa B was examined in the pancreases. Results: Lower level of serum AMS(P<0.05)and lower histopathology score(P<0.05) appeared in FOG.Compared with NS,FO decreased the levels of serum ALT and BUN significantly (P<0.05).FO significantly attenuated the expression of IL-1β (P<0.05).FO downregulated the activity of NF-kappa B efficiently.Conclusions: By down-regulating the levels of IL-1β together with up-regulating the level of IL-10,FO reduces inflammatory damage at the beginning of AP.

ObjectiveTo study the situation of neural invasion in pancreatic cancer and investigate its related clinical factors. Methods The neural invasion in 73 cases of pancreatic cancer patients was retrospective analysed. The correlation between neural invasion and clinicopathological parameters,and survival rate was investigated.Results In 73 cases of pancreatic cancer,neural invasion occurred in 38(52.1％) patients,among whom intra-pancreatic neural invasion rate was 15.8％ (n =6) ; and both intrapancreatic and external pancreatic plexus invasion rate was 84.2％ ( n =32).Neural invasion was not related with gender,age,and pathological type,degree of differentiation,tumor size and lymph node metastasis (P ＞ 0.05 ).But the presence of abdominal pain,vascular invasion,the expression of EGFR and VEGF in tumor tissue was significantly related with neural invasion (P ＜0.01 ).The median survival of patients in neural invasion group was 8 months,which were significantly shorter than that of in patients without neural invasion (13 months,x2 =4.69,P =0.030).Conclusions Neural invasion has a high incidence in pancreatic cancer,and it can cause obvious abdominal pain.And it is related with vascular invasion and the expression of EGFR and VEGF in tumor tissue.Neural invasion is one of the factors affecting the survival rate.

Objective To investigate the clinical features of non- functioning pancreatic neuroendocrine tumors and to summarize experiences in the diagnosis and treatment. Methods The clinical pathology and follow-up data of 20 patients with non-functioning pancreatic neuroendocrine tumors treated in Nanjing Drum Tower Hospital Affiliated to Medical School of Nanjing University, from January 2008 to February 2018 were retrospectively analyzed. Results Among the 20 patients, 9 patients (9/20) were asymptomatic, and the tumor was found unexpectedly by physical examination. Eleven patients (11/20) with symptoms were admitted to the hospital due to non-specific gastrointestinal symptoms or compression symptoms caused by tumor space occupying. None of the patients had endocrine disorders. There were nineteen patients who received surgical treatment. According to the grading system, there were 7 patients (7/19) with G1, and 12 patients (12/19) with G2 . Among the 14 patients with diameter of tumor greater than 2 cm, there are 4 patients (4/14) with lymph node metastasis, and 4 patients (4/14) with liver metastasis. Five patients with diameter of tumor less than or equal to 2 cm had no distant metastasis. Conclusions NF-pNETs is often with nonspecific symptoms. Imaging examination is an important diagnostic method. Operation is the primary therapy for NF-pNETs. Because most of the small NF-pNETs with no symptoms are benign and grow slowly, and the metastatic rate is very low. It is important to weigh the pros and cons of surgical treatment for these patients.

OBJECTIVETo compare the accuracy of CT and MR including diffusion-weighted imaging(DWI) in preoperative diagnosis and T staging of gastric cancer.

METHODSForty-one patients with gastric cancers proved by gastroscopy biopsy from November 2011 to August 2012 were prospectively enrolled. They underwent contrast enhanced CT and MR imaging (including DWI, T2 weighted and dynamic enhanced imaging) preoperatively. Two radiologists interpreted CT and MR images for detecting and staging each patient independently. With the reference of post-operative histopathological findings, T staging accuracy of CT and MR imaging was calculated and compared. Inter-observer agreement was also evaluated.

RESULTSOverall T staging accuracy in MR including DWI was significantly higher than that in CT imaging(87.8% vs. 65.9%, P=0.004). MR had a better inter-observer agreement than CT(Kappa=0.813, 0.603, respectively).

CONCLUSIONMR including DWI can improve preoperative T staging accuracy of gastric cancer significantly, which deserves recommendation for clinical application.

OBJECTIVETo explore the preoperative diagnostic value of MR diffusion weighted imaging (DWI) for metastatic lymph nodes in patients with gastric cancer.

METHODSBetween December 2011 and December 2012, 52 gastric cancer patients(34 men, 18 women) underwent preoperative MR DWI. The apparent diffusion coefficient(ADC) and short diameter of lymph nodes were measured and compared with the postoperative histopathological findings. Diagnostic value of ADC and short diameter for metastatic lymph nodes in patients with gastric cancer was investigated by receiver characteristic curve(ROC) analysis.

RESULTSA total of 180 metastatic and 57 non-metastatic lymph nodes were detected as hyperintense on DWI obtained from 52 patients. The ADC of metastatic lymph nodes [(1.059±0.196)×10(-3) mm(2)/s] was significantly lower than that of non-metastatic nodes [(1.402±0.285)×10(-3) mm(2)/s, P<0.001]. With ADC threshold of 1.189×10(-3) mm(2)/s, the sensitivity, specificity and area under the curve(AUC) were 78.9%, 72.8% and 0.840, respectively. The overall diagnostic accuracy of preoperative N staging of ADC was 75%(39/52). The short diameter of metastatic lymph nodes [(8.08±3.99) mm] was significantly longer than that of non-metastatic lymph nodes [(6.75±2.70) mm, P=0.005]. With short diameter threshold of 5.05 mm, the sensitivity, specificity and AUC were 88.3%, 29.8% and 0.602, respectively. The overall diagnostic accuracy of short diameter in preoperative N staging was 67.3%(35/52).

CONCLUSIONSMR DWI is a useful technique in diagnosing metastatic lymph nodes in patients with gastric cancer. ADC value and short diameter can be used as diagnostic criterion for the diagnosis of preoperative N staging.

Objective:To investigate the influencing factors for pancreatic endocrine and exocrine insufficiency after pancreaticoduodenectomy.Methods:The retrospective case-control study was conducted. The clinicopathological data of 168 patients who underwent pancreaticoduodenectomy in the Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from January 2016 to December 2017 were collected. There were 96 males and 72 females, aged (64±13)years, with a range from 38 to 75 years. Of the 168 patients, 36 had pancreatic endocrine insufficiency while 8 had pancreatic exocrine insufficiency preoperatively. All patients underwent pancreaticoduodenectomy. Observation indications: (1) surgical situations and follow-up; (2) analysis of influencing factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy; (3) analysis of influencing factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy. Follow-up using out-patient examination and telephone interview was performed to detect postoperative condition of blood glucose control, diet and nutrition, tumor recurrence and metastasis up to June 2018. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Univariate analysis was conducted using the chi-square test. Multivariate analysis was conducted using the Logistic regression model. Results:(1) Surgical situations and follow-up: all the 168 patients underwent pancreaticoduodenectomy successfully and recovered well after operation. All patients were followed up for 6 months. The level of fasting and postprandial blood glucose of the 168 patients after surgery were 7 mmol/L(range, 5-9 mmol/L) and 10 mmol/L(range, 7-14 mmol/L), respectively. The defecation frequency was (2.4±1.2)times per day. No tumor recurrence or metastasis occurred in either patient. One hundred and thirty-two of the 168 patients were included in the study excepting patients with pancreatic endocrine insufficiency before operation. At postoperative 6 months, 47 patients developed pancreatic endocrine insufficiency, with an incidence of 35.61%(47/132). One hundred and sixty of the 168 patients were included in the study excepting patients with pancreatic exocrine insufficiency before operation. At postoperative 6 months, 68 patients had pancreatic exocrine insufficiency, with an incidence rate of 42.50%(68/160). (2) Analysis of influencing factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy. Results of univariate analysis showed that gender, metabolic syndrome, chronic pancreatitis, excision point, and postoperative chemotherapy were the related factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy ( χ2=5.300, 6.270, 4.473, 4.392, 5.397, P<0.05). Results of multivariate analysis revealed that male and metabolic syndrome were independent risk factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy [ hazard ratio ( HR)=5.252, 5.364, 95% confidence interval ( CI): 1.362-6.382, 1.891-12.592, P<0.05)]. (3) Analysis of risk factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy. Results of univariate analysis showed that body mass index (BMI), chronic pancreatitis, total bilirubin, excision point, postoperative pancreatic fistula as grade B or C, and pancreatic fibrosis were related factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy ( χ2=1.691, 4.910, 7.763, 5.605, 4.663, 7.700, P<0.05). Results of multivariate analysis showed that BMI<18.5 kg/m 2, chronic pancreatitis, total bilirubin ≥171 μmol/L were independent risk factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy ( HR=3.695, 5.231, 7.623, 95% CI: 1.232-7.324, 2.161-6.893, 1.562-5.235, P<0.05). Conclusions:Male and metabolic syndrome are risk factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy. BMI<18.5 kg/m 2, chronic pancreatitis, and total bilirubin ≥171 μmol/L are risk factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy.

Objective:To review our clinical experience on total pancreatectomy in treatment of pancreatic diseases.Methods:The clinical data of 25 patients with pancreatic diseases who underwent total pancreatectomy at Nanjing Drum Tower Hospital from February 2016 to October 2019 were retrospectively analyzed. The data on general information, surgical methods, postoperative complications, changes in postoperative pancreatic endocrine and exocrine functions and quality of life were analyzed.Results:There were 16 males and 9 females, aged (60.9±9.4) years. Planned selective surgery was carried out in 16 patients while unplanned operations in 9 patients. There were 15 patients with pancreatic neoplasms with 4 patients who received neoadjuvant or conversion therapy, 6 patients with intraductal papillary mucinous neoplasms, 3 patients with chronic pancreatitis and 1 patient with pancreatic neuroendocrine carcinoma. The total postoperative complication rate was 36% (9/25). One patient died in the perioperative period, and one patient underwent a second operation. After 6 months of operation, 2 of 24 patients had died. The remaining patients had a fasting blood sugar of (8.9±1.6) mmol/L, with an insulin dosage of (30.7±10.6) U/d. The average dosage of trypsin was (1.1±0.3) g/d. The quality of life score reached or exceeded the preoperative levels.Conclusions:Total pancreatectomy was safe and feasible for some pancreatic diseases. For patients with pancreatic cancer, its long-term oncological outcomes need further studies.