Autoimmune pancreatitis (AIP)is a special type of chronic pancreatitis that originates from an autoimmune -mediated mecha-nism.AIP has unique radiological,serological,and histopathological features,often accompanied by peripancreatic lesions.AIP may be easily confused with pancreatic cancer and cholangiocarcinoma.It is necessary to diagnose AIP while integrating a variety of clinical indica-tors.Steroid therapy should be performed for patients diagnosed with AIP,and surgical treatment can be selected if necessary.

Pancreatic cancer is one of the digestive malignant tumors with the worst prognosis and has an overall 5 -year survival rate as low as 5%.Even though radical resection is performed,the 5 -year survival rate is only about 20%.Recurrence and metastasis are the most important influencing factors for the postoperative survival of patients with pancreatic cancer.Lymph node metastasis is an important feature of pancreatic cancer,and the extent of lymph node dissection has always been a hot topic in radical surgery for pancreatic cancer.This arti-cle summarizes the history and current status of the extent of lymph node dissection in pancreatic cancer and points out that standardized lymph node dissection is a key factor for improving patients′prognosis after pancreatic cancer surgery.

Ampullary tumors mainly manifest as obstructive jaundice and ampullary mass in clinical practice and are difficult to be identified in early stage due to a complex structure of the anatomical site,a deep location,and hidden symptoms.Sometimes a qualitative diagnosis cannot be made.Based on the experience in the treatment of ampullary tumors for many years in our center,this article summarizes the features of ampullary tumors from the aspects of clinical manifestations,diagnosis,treatment,and prognosis,especially the issues regarding imaging evaluation of ampullary tumors,selection of surgical procedure,and prognosis.An early diagnosis is the key to the treatment of ampullary tumors,and early identification and treatment of lesions have great impacts on patients' prognosis.Accurate preoperative imaging evaluation,a professional diagnosis and treatment team,accurate preoperative and intraoperative pathological analysis,and implementation of reasonable therapeutic strategy are the key to patients' recovery.

Objective To investigate the expression of TLR2 and HIF-1α in pancreatic cancer and explore the relationship between TLR2 or HIF-1α protein and the clinical or pathological changes in pancreatic cancer. Methods The mRNA of TLR2 and HIF-1α in 30 cases of pancreatic cancer and its adjacent tissues were detected with real-time PCR and with immunohistochemical methods in 65 cases of pancreatic cancer and 38 cases of corresponding adjacent tissues. The relationship between TLR2 or HIF-1α and pathologic features of pancreatic cancer was analyzed. The correlation between TLR2 and HIF-1α in pancreatic cancer was also assessed. Kaplan-Meier method was used to assess the impact of TLR2 or HIF1αexpression on survival. Results The relative quantification of TLR2 mRNA and HIF-1α mRNA in pancreatic cancer tissues was 0.84±0.17 and 0.87±0.11, respectively, which was significantly higher than that in adjacent tissues 0.70±0.13 and 0.68±0.13 respectively,P＜0.05. The protein expression of TLR2 and HIF-1α in pancreatic cancer tissues was 63. 10% and 70.8%, respectively, significantly higher than that in adjacent tissues (34.20% and 36.8%, respectively). There was no significant correlation between the expression of TLR2 or HIF-1α protein and the age, gender, tumor location, the degree of differentiation in patients with pancreatic cancer (P＞0.05). However, there was significant correlation between the expression of TLR2 or HIF-1α protein and tumor size, lymph node metastasis, venous invasion and clinical staging. TLR2 and HIF-1α had a significant impact on survival. Conclusion TLR2 and HIF-1α overexpressed in pancreatic cancer and TLR2 signaling pathway may promote development of the pancreatic cancer with HIF-1α together.

Objective To investigate the expression and clinical significance of toll-like receptor 9 (TLR9) and hypoxia inducible factor 1 α (HIF-1 α) in pancreatic cancer.Methods The real-time RT-PCR technique,western blot method and immunohistochemical method were used to examine the expressions of TLR9 and HIF-1α in 30 samples of pancreatic cancer,para-cancerous tissues,and 10 samples of normal pancreatic tissues.The relationship between TLR9 and HIF-1 α was determined,and the correlations between their expressions and clinicopathological parameters were measured,and the impact on survival was detected.Results The levels of TLR9 mRNA and HIF-1 α mRNA expression in human pancreatic cancer tissues was 2.32(1.41～3.22) and 2.26 (1.62～ 2.89) folds as many as that in normal tissues.The levels of TLR9 mRNA and HIF-1α mRNA expression in para-cancerous tissues were 1.23 (1.18 ～ 1.28) and 1.36 (1.17 ～1.55) folds as many as that in normal tissues.The expressions in human pancreatic cancer tissues were significantly higher than those in para-cancerous tissues (t =2.642,P =0.023 ; t =4.076,P =0.001).The positive rates of TLR9 and HIF 1α protein were 73.3％ (22/30) and 70.0％ (21/30),and the corresponding values were 33.3％ (10/30) and 36.7％ (11/30) in para-cancerous tissues,while the corresponding values were 20％ (2/10) and 10％ (1/10) in normal tissues,which showed a decreasing trend (x2 =13.99,P =0.001 ;x2 =13.15,P =0.001).The expressions of TLR9 mRNA in human pancreatic cancer tissues was positively associated with HIF 1 α mRNA (r =0.537,P =0.003).The expressions of TLR9 protein was also positively associated with HIF 1α protein (r =0.511,P =0.001).The expressions of TLR9 and HIF 1α were positively correlated with the degree of tumor differentiation,TNM staging and lymph node metastasis,but were negatively correlated with the survival.Conclusions TLR9 and HIF-1α are over-expressed in pancreatic cancer and they are associated with malignant biological behavior and poor prognosis.

Objective To investigate risk factors for early postoperative complications after pancreaticoduodenectomy(PD).Methods Clinical data of 221 patients undergoing PD in our hospital between September 2005 and January 2009 were collected and reviewed retrospectively,the risk factors in relation to early postoperative complications were analyzed with SPSS 15.0 software.Results The incidence of early postoperative complications was 17.6％.Univariate analysis showed that age ( ≥65 years),preoperative total serum bilirubin level ( ≥ 171 μmol/L),preoperative serum albumin level ( ≤30 g/L),intraoperative blood transfusion ( ≥ 1000 ml),operation time ( ≥5 h) were the relative risk factors,Logistic regression analysis revealed that age (≥ 65 years),preoperative serum albumin level ( ≤30 g/L),intraoperative blood transfusion ( ≥ 1000 ml),operation time ( ≥5 h) were the independent risk factors for early complications.Conclusions The risk of postoperative complications after PD is still high,so the dicision to perform a PD should be strictly balanced against its risk.For older or poor risk patients,preoperative management should be enhanced.The set up of surgical team may help standardize operation procedures control intraoperative bleeding,therefore decrease the incidence of postoperative complications after PD.

Objective To explore the method how PDX1 gene modified mesenchymal stem cells (MSCs) from human umbilical cord can be differentiated into islet β-like cells in vitro. Methods Recombined adenovirus vectors inserted with PDX1 (Adxsi-CMV-PDX1) was transfected into MSCs and multiple cytokines was combined to induce differentiation. The expressions of PDX1, insulin, ngn3, glut2,NKX6.1 were examined by RT-PCR and immunofluorescence staining. The levels of insulin and C peptide secretion were examined by chemiluminescence immunoassay. Flow cytometry was used to determine the positive rate of insulin cells. Results After Adxsi-CMV-PDX1 transfection and cytokines induction, MSCs were transformed from short spindle shape to long spindle shape and aggregated into islet-like cell clusters.Dithizone staining of these cells showed bright red color. PDX1, ngn3, NKX6.1, insulin, glut 2 mRNA were expressed in cells 17d after induction. Insulin and C peptide were expressed in cytoplasm. The levels of insulin and C peptide in cell culture supernatant were (473.1 ± 51.5)mU/L and (1.61 ± 0.41)ng/ml; the levels of insulin and C peptide secretion were (964.4 ± 68.1) mU/L, (3.72 ± 1.52) ng/mL, respectively, with 25 mmol/L glucose stimulation for one hour. Insulin (+) cells rate (11.6 ± 4.8) %. Conclusions Adxsi-CMV-PDX1 combined with cytokines can induce MSCs from human umbilical cord to differentiate into islet β-like cells.They can secret insulin and C peptide, and have the sensitivity to the stimulation of glucose.

Objective To construct the eukaryotic plasmid expression vector mediated short hairpin RNA(shRNA) interference targeting TLR4 gene,and transfect it into pancreatic adenocarcinoma cell line PANC1,then screen stably transfected clonal cell line.Methods Three shRNA interference expression plasmid vectors targeting the TLR4 gene were constructed,named TLR4-1,TLR4-2,TLR4-3.The shRNA plasmid with highest inhibitory efficiency was selected and transfected into PANC1 cells with liposome.The silencing efficiency and transfection efficiency of TLR4-shRNA was assayed with real-time quantitative PCR and flow cytometry analysis.Monoclonal cell with stable transfection of TLR4-shRNA were selected by geneticin 418 (C418) and limiting dilution analysis.Results Transient transfection efficiency of PANC1 was (46.72 ±5.06) ％.TLR4 mRNA expressions were 0.025 ± 0.004,0.027 ± 0.003,0.019 ± 0.006in cells transfected with TLR4-1,TLR4-2,TLR4-3,respectively,which were significantly lower than that in untransfected group (0.061 ±0.018) and negative control group (0.057 ±0.015,P ＜0.05).The transfection efficiency of TLR4-3 vector in stably transfected clones [(82.79 ±8.16)％] was significantly higher than that of transient transfection (P =0.001 ).The expression of TLR4 mRNA was decreased to 0.010 ± 0.002,which was significantly lower than that of transient transfection ( P =0.001 ).The expression of TLR4 protein was (0.54±0.32) ％,which was significantly lower than that of untransfected cells [( 87.42 ± 5.00 ) ％] and that of negative control [(82.9±5.00)％,P =0.000].Conclusions Stable transfection PANC1 cell lines with TLR4 gene silencing are successfully identified.

Objective To investigate the efficacy of a modified duodenum-preserving pancreatic head resection (DPPHR) for the treatment of chronic pancreatitis.Methods The clinical data of 109 patients with chronic pancreatitis who received modified DPPHR at the Union Hospital of Huazhong University of Science and Technology from January 2004 to June 2013 were retrospectively analyzed.Of the 109 patients,66 were with mass in the head of the pancreas,29 were with calcification of the head of the pancreas,14 were with atrophy of the head of the pancreas and stones in the main pancreatic duct.The level of glucose of 56 patients were normal,34 patients had glucose tolerance abnormalities and 19 were complicated with diabetes mellitus.Modified DPPHR was carried out after confirming the diagnosis of chronic pancreatitis and excluding the malignancies by frozen pathological examination.The head of the pancreas was completely resected.The posterior pancreaticoduodenal aortic arch running parallel to the duodenum was preserved to guarantee the blood supply to the remaining duodenum.A thin sheet of the pancreatic tissue behind the intrapancreatic common bile duct and between the common bile duct and the duodenum was preserved to guarantee the blood supply to the common bile duct.The gastrointestinal tract was reconstructed with an anastomosis of the distal pancreas and the jejunum and an end-to-en anastomosis of the proximal jejunum and the distal jejunum.Patients were followed up via out-patient examination to learn the frequency of abdominal pain,analgesics usage and the endocrine function.The pain scale,life quality and endocrine function were evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30),Gastrointestinal Quality of Life Index (GLQI) questionnaire,and oral glucose tolerance test (OGTT),respectively.Patients were followed up till January 2014.The measurement data and the count data were analyzed using the t test and the chi-square test,respectively.Results No patients died during the operation.The operation time,volume of blood loss and blood transfusion were (3.5 ± 0.7) hours,(360 ± 125) mL and (260 ±220) mL,respectively.After the operation,5 patients were complicated with pancreatic leakage,5 with bile leakage,2 with duodenal fistula and 1 with peritoneal bleeding,and all the patients were cured after conservative treatment.Four patients were complicated with abdominal abscess,1 patient of whom was treated by conservative treatment,and the remaining 3 patients were cured by drainage guided by B sonography.The duration of hospital stay was 13.8 days (range,10.0-32.0 days).The median time of follow-up was 18.0 months (range,3.0-24.0 months).A total of 102 patients were followed up for more than 9 months.At postoperative month 9,the ratio of patients with abdominal pain was decreased from 78.90％ (86/109) to 18.63％ (19/102),and the ratio of patients administered analgesics was decreased from 76.47％ (78/102) to 12.75％ (13/102),with significant difference between the indexes before and after operation (x2=76.57,74.31,P ＜ 0.05).The score of the EORTC QLQ-C30 was decreased from 58 ±36 before operation to 15 ±4 after operation,with significant difference (t =11.39,P ＜ 0.05).The score of GLQI was increased from 69 ± 8 before operation to 87 ± 15 after operation,with significant difference (t =20.05,P ＜ 0.05).The patient with diabetes mellitus was cured,and no newly onset of diabetes was found.Two patients received reoperation because of recurrence of stones in the distal pancreatic duct and pancreatogenic portal hypertension.Conclusion Modified DPPHR is effective for the treatment of chronic pancreatitis with low incidence of postoperative complications.

Objective To evaluate the dynamic changes in CD4 + CD25 high regulatory T cells (Treg), Foxp3, IL-10, IFN-γand IL-4, in peripheral blood of severe acute pancreatitis(SAP) patients and the clinical significance. Methods From August 2008 to June 2009, 42 hospitalized SAP cases were divided by stage according to the course of disease: phase Ⅰ (the period of SIRS) ;phase Ⅱ (the period in which SIRS ends); phase Ⅲ ( the period during which complication related infection developes). Results were compared with those of hospitalized 38 mild acute pancreatitis(MAP) cases during the same period.Treg and Foxp3 were measured by flow cytometry, the levels of IFN-γ、IL-4 and IL-10 were detected by enzyme-linked immunosorbent assay( ELISA), and the relationships between these indicators were analyzed using Pearson correlation analysis test. Results The percentages of Treg and levels of IL-4 increased in phase Ⅰ SAP(Treg: 1.37% ± 1.12% ;IL-4:22.92 ±4. 17) ,soared in phase Ⅱ (Treg:3.12% ± 1.21%;IL-4:35.42 ± 12. 50) ,culminated in phase Ⅲ( Treg:4. 47% ± 1.04%; IL-4:76. 04 ± 14. 58 ); IFN-γ level was the highest in phase Ⅰ SAP(978.57 ±213.29), decreased in phase Ⅱ (571.43 ± 157. 14) ,and the lowest in phase Ⅲ ( 357. 14 ± 150.00 ); The differences were statistically significant between the three periods(P＜0.05). All that in these three periods were higher than that in MAP controls(P ＜0.05).Pearson correlation analysis test showed that quantities of Treg were negatively proportional to the levels of IFN-γ( r = - 0.895, P ＜ 0.01 ), and positively proportional to the levels of IL-4 ( r = 0.813, P ＜ 0.01 ).Conclusions By suppressing IFN-γand promoting IL-4 ,Treg may protect patients against damage resulting from excessive inflammatory response.