Pancreaticoduodenectomy (PD) is the procedure for treating adenocarcinoma in periampullary region.This involves resection of multiple organs and complex reconstructions.The modern surgery has witnessed the dramatic improvement in outcomes after PD.Mortality has dropped to less than 4％,however,the complication rate remains high,making this procedure still a big challenge for most surgeons. PD is so complicated that even small mistakes could jeopardize the whole procedure and outcomes.With experiences of over 1000 PDs,we discuss the challenges of this procedure and strategies to deal with them.

Objective To research the mechanism of impairment that cholestatic jaundice is treated as- sistly by MMDB. Methods Obstructive jaundice models with SD rats, which were divided into three time points randomly, namely 7,14,21 days,were established. In each time point, there were three groups(each six rats) : sham operation(SO + NS) ; BDL + MMDB; (BDL + NS). The rats were sacrificed at different time point, in order that liver tissue and inferior vena cava blood were taken out. The concentration of serum glutamate transaminase(AST), albumin(ALB), and total bilirubin (TB) were measured with biochemistry; the expression of TLR4mRNA was measured by reverse transcription PCR. Results On the 7th day after BDL, serum TB,AST level in BDL + MMDB and BDL + NS group were upgrade compared with SO group, in which BDL + NS group were more obviously upgrade than BDL + MMDB group(P<0.01). There was differ- ent to compare between BDL + MMDB group and SO group(P <0.01). On the 14th, 21st day after BDL, serum TB, AST coNTents were to last upgrade in BDL + MMDB and BDL + NS group. It was opposite to the SO group(P <0. 01). Conclusion The level of TLR4 could be weaken by MMDB. It may relieve the im- pairment of liver in cholestatic jaundice by LPS.

ObjectiveTo explore the resilience and mental health of recruits during training,and to investigate mutual prediction of resilience between mental health and psychological stress to provide the scientific evidence for the mental health training and psychological selection of recruits.MethodsConnor-Davidson resilience questionnaire ( CD-RISC),symptom checklist ( SCL-90 ),psychological stress self-evaluation test ( PSET),satisfaction with life scale (SWLS),positive and negative affect scale (PANAS) were applied to 650 recruits in 2011 before starting training and after two months of training.Results ① Chinese recruits had good resilience,and the CD scores of pre-and post-test were (61.60 ± 14.36) and (61.41 ± 14.55 ) respectively.②Mental health (SCL-90) of two tests were good in recruits.③ Correlation analysis showed that the same premise of phase correlation,resilience (pre-test) could significantly predict mental health (post-test) ( β =0.070,P ＜ 0.05 ),mental health ( pretest) could not predict resilience (post-test) (β =0.015,P ＞ 0.05 ).Resilience (pre-test) could significantly predict psychological stress (post-test) ( β =0.075,P ＜ 0.05 ),psychological stress (pre-test) could not predict resilience (post-test) (β =0.017,P ＞ 0.05 ).④ Compared with high resilience group,low-resilience group of recruits had higher total score of SCL-90 and psychological stress and less positive emotion,more negative emotion and lower life satisfaction.ConclusionThe recruits training have good resilience.Resilience of recruits have predictive ability to mental health,psychological stress during training.

Objective To investigate the diagnosis and surgical management of adult choledochal cyst.Methods The clinical data of 58 adult patients with congenital choledochal cyst who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 1997 to December 2010 were retrospectively analyzed.All patients were diangosed by the B ultrasonography,computed tomography (CT),Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). Surgical procedures were selected according to the diagnosis and Todani classification.All data were analyzed using the t test or chi-square test.Results The accurate rates of B sonography,CT,MRCP and ERCP were 78％ (45/58),92％ (23/25),9/9 and 5/5,respectively.Forty-one patients underwent complete excision of the cyst + hepaticojejunostomy (2 patients were converted from laparotomy due to abdominal adhesions),2 underwent resection of the cyst and involed hepatic segments + hepaticojejunostomy,8 underwent laparoscopic excision of the cyst + hepaticojejunostomy,1 underwent left hemihepatectomy,3 underwent pancreaticoduodenectomy ( including partial hepatectomy in 1 patient),2 underwent common bile duct exploration + cholecystectomy due to acute obstructive suppurative cholangitis,1 underwent external drainage of choledochal cyst due to advanced malignance.The mean operation time and postoperative duration of hospital stay of patients who received open and laparoscopic excision of the cyst and hepaticojejunostomy were (235 ± 70) minutes,(320 ± 50) minutes,and ( 10.0 ± 2.3 ) days,( 12.6 ±6.6) days,respectively,with significant differences between the 2 groups (t =3.157,2.162,P ＜ 0.05).The postoperative morbidities of patients who received open and laparoscopic excision of the cyst and hepaticojejunostomy were 18％ (7/39) and 3/8,respectively,with no significant difference (x2 =1.515,P ＞ 0.05 ).Canceration of the choledochal cyst was observed in 6 patients( 10％ ).No perioperative mortality was observed,and the operative complication rate was 24％ (14/58).The duration of the follow up ranged from 1 to 15 years,no severe long-term complications were observed in patients with benign lesions.Four of the 6 patients with malignancy died in 1 year after operation,the other 2 patients survived for 3 years and 5 years,respectively.Conclusions Abdominal B ultrasonography should be the first choice for diagnosing adult congenital choledochal cyst,while MRCP is the gold standard.Surgical intervention should be timely considered once diagnosed. Complete excision of the cyst combined with Roux-en-Y hepaticojejunostomy is the first choice of treatment.

ObjectiveTo investigate the effects of protein phosphatase 2A (PP2A) inhibitors on the viability of pancreatic cancer cell line PANC-1 and its mechanism.MethodsPANC-1 cells were treated with PP2A inhibitors Cantharidin or Okadiac acid.The activity degree of NF-κB pathway was tested by Western blot.NF-κB pathway was blocked from all sectors by PP2Acα plamid transfection,NF-κB inhibition of protein kinase α (IKKα) and NF-κB inhibitor α (IκBα) dominant negative mutant and p65 interfering plasmid.Cell viability was determined by MTT.ResultsPP2A inhibitors could induce phosphorylation of IKKα,further phosphorylation of IκBα and degradation and followed by the release of p65 into nucleus.When PP2Acα,IKKα dominant negative mutant and IκBα dominant negative mutant were overexpressed,or p65 was interfered,the inhibition rate of Cantharidin on cell viability decreased (31.85±13.37) ％,(23.48±8.98)％,(22.63±5.81)％ and (20.88±3.24)％respectively,and the inhibition rate of Okadiac acid on cell viability decreased (40.17 ± 11.65)％,(27.34±14.28)％,(24.85±3.39)％ and (27.08±3.81)％ respectively.ConclusionsPP2Ainhibitors play a role in preventing pancreatic cancer through PP2Acα/IKKα/IκBα/p65 pathway.

Objective To retrospectively study the anisotropy of shear wave elastography (SWE)quantitative parameters of breast lesions,and the correlation with histopathology.Methods A total of 281 consecutive women with 281 breast lesions (179 malignant,102 benign) were included,who underwent conventional ultrasound (US) and 2D SWE before surgical excision.Three acquisitions each for transverse and longitudinal planes were obtained,and maximum elasticity (Emax),mean elasticity (Emean),standard deviation (Esd) of the whole lesion and ratio between the elasticity in the mass and the fatty tissue (Eratio)were recorded.Anisotropic difference (AD) and anisotropy factors (AF) were calculated,and correlation with histopathology was analyzed.Results The average Emax,Emean and Esd of transverse planes were significantly higher than those of longitudinal planes.AF showed positive correlation with quantitative elasticity (Emax,Emean,Esd and Eratio) (P =0.000),and was significantly higher in malignant lesions than that in benign besions (P =0.000).AUC of AF was significantly higher than that of AD (P ＜0.001).AF was significantly higher in invasive ductal carcinoma than that in ductal carcinoma in situ.Higher AF was associated with higher histopathological grades of invasive ductal carcinoma (P =0.000),and correlated with ER/PR(+).Conclusions Anisotropy of SWE is an indicator of malignancy of breast lesions,and is of predictive value for prognosis in breast cancer.

AIM:To investigate the safety and effect of femtosecond laser-assisted cataract surgery with Cionni modified capsular tension ring (MCTR) implantation in the management of traumatic lens subluxation.METHODS: Totally 11 patients (11 eyes) with traumatic lens subluxation were divided into three groups according to the severity of lens dislocation, ranging from 90° to 120° (4 eyes), 120° to 180° (5 eyes) and 180° to 270° (2 eyes).The contact LenSx femtosecond laser cataract surgery platform was applied to create the capsulotomy, prepare nuclear fragmentation and make corneal wound creation.Anterior vitrectomy was performed in some patients during the surgery.After capsular retractors insertion and phacoemulsification, the MCTR was inserted to the capsular bag and fixed to the sclera.Finally, the IOL was implanted into the capsular bag.Postoperative visual acuity, intra-and post-operative complications, anterior capsular opening, IOL and MCTR position and intraocular pressure (IOP) were assessed.RESULTS:The duration of follow-up was 2mo.All the operations were completed successfully.Five eyes underwent cataract surgery combined with anterior vitrectomy.Four eyes had been inserted with 2-eyelet MCTR and seven eyes with 1-eyelet MCTR.The best corrected visual acuity (BCVA) after operation was better than 0.5 in 4 eyes, between 0.3 and 0.5 in 3 eyes, between 0.1 and 0.3 in 3 eyes, and less than 0.1 in 1 eye.Compared with preoperative BCVA, the difference was statistically significant (P<0.05).All the IOLs were stably centered and the eyelet of MCTR was fixated steadily between the iris and the anterior capsule.The common intra-and post-operative complications were subconjunctival hemorrhage, incomplete capsulotomy, residual cortex, secondary glaucoma and posterior capsular opacification.CONCLUSION:Femtosecond laser-assisted cataract surgery can improve the success rate of capsulorhexis, and reduce the difficulty of nuclear fragmentation.Femtosecond laser-assisted cataract surgery combined with MCTR implantation is an ideal surgical method for traumatic lens subluxation.

Objective To retrospectively study the quantitative features and diagnostic value of 3-dimensional shear wave elastography (3D-SWE) in breast lesions.Methods A total of 198 consecutive women with 198 breast lesions (125 malignant,73 benign) were included,who underwent conventional ultrasound (US) and 3D-SWE before surgical excision.Quantitative parameters of transverse planes,sagittal planes and coronal planes were calculated,including maximum elasticity (Emax-w),mean elasticity (Emean-w),standard deviation (Esd) of the whole lesion and ratio between the stiffest elasticity (Emean-s)in the lesion and the fatty tissue (Eratio).Area under ROC curve(AUC) for combination of quantitative parameters and US were calculated.Results The AUC,sensitivity and specificity for US were 0.919,88.0％ and 78.1 ％,respectively.In the total 198 lesions,Emax-w,Emean-w,Esd,Eratio and Emean s were significantly lower in coronal planes than those in transverse and sagittal planes (all P ＜0.001).AUC for combination of each quantitative parameter and US were significantly higher than those of US (all P ＜0.05),except Emean-w of transverse plane,while there was no significant difference among the three orthogonal plane (P＞0.05).Sensitivity significantly increased by combining US with Emean-s,Eratio (transverse,sagittal and coronal planes),Emean-w (coronal and sagittal planes) or Esd (coronal and transverse planes) (all P＜0.05).Combination of US and Emean w of coronal plane yielded significantly higher sensitivity than those of transverse and sagittal planes.Conclusions Combination of quantitative features of 3D-SWE and US can significantly increase diagnostic accuracy and sensitivity in breast lesions.Emean-w of coronal plane yields the highest sensitivity.

Objective To investigate the apoptosis induction effect of Cantharidin on pancreatic cancer cell line PANC1 and CFPAC-1 and possible mechanism. Methods PANC1 and CFPAC-1 was treated with Cantharidin. Cell growth was determined by MTT. Apoptosis was measured by flow cytometry. Caspase activity was measured by using enzyme chemical method. Apoptosis-related gene expressions were determined by using RT-PCR and Western blotting. Results Cantharidin significantly inhibited the growth of pancreatic cancer cells PANC1, CFPAC-1 and induced apoptosis in a dose-dependent manner. Seventy-two hours after 10 μmol/L Cantharidin treatment, the inhibitory rates of PANC1, CFPAC-1 were (52.95 ± 6.34)％ and (71.21 ±6.30)％. Twenty-four hours after treatment, the early and later period apoptotic cell of PANC1 was increased from 7.35％ to 24.89％, from 6.36％ to 17.73％. The early and later period apoptotic cell of CFPAC was increased from 6.39％ to 24.70％, from 9.21％ to 12.58％ (P＜0.01). Activity of caspase 8 and caspase 9 in PANC1 cells was (155.8 + 11.5)％ and (194.6 ± 14.7)％ when compared with that of control group. Activity of caspase 8 and caspase 9 in CFPAC- 1 was ( 182.5 ± 24.3 ) ％ and ( 215.8 ± 12.2) ％when compared with that of control group ( P ＜ 0. 01 ). The expression of pro-apoptotic genes, TNF-α,TRAILR1, TRAILR2, Bad, Bak and Bid was elevated, the expression of anti-apoptotic Bcl-2 gene was decreased. Conclusions Cantharidin can induce apoptosis in pancreatic cancer cell lines by activating caspase,up-regulating the expression of pro-apoptotic genes and down-regulating the expression of anti-apoptotic genes.

Objective To investigate the value of ultrasound-guided diffuse optical tomography (US-guided DOT) to predict clinical efficacy of breast cancer neoadjuvant chemotherapy (NAC).Methods Eighty-eight breast cancer patients with 93 lesions were included.Pre-and post-last chemotherapy,the size,total hemoglobin concentration (THC) of each lesion were measured by ultrasonography (US) and US-guided DOT.Based on the guidelines to evaluate the response to treatment in solid tumors,the lesions of treated breast cancer patients were divided into 4 types of responses to NAC:complete response (CR),partial response (PR),stable disease (SD),and progressive disease (PD).Efficient groups include CR and PR groups.Results As expected,no significant difference was found in size and THC for untreated lesions (all P ＞0.05).However,for the treated lesions(P =0.001),THC,pre-vs post-treatment size changes (△Size％) (P =0.002) and THC changes (△THC％) (P ＜0.001) were significantly varied among CR,PR,SD,PD groups.When compared with pre-treated,tumor sizes after treatment were changed significantly in all CR(P ＜0.001),PR(P ＜0.001),SD (P =0.023) and PD (P =0.001),while significant change of THC was only found in CR(P ＜0.001),PR(P ＜0.001) and SD (P =0.002).When △THC％ =23.9％ as the threshold for prediction of NAC efficiency,the area under the curve of ROC was 0.75,and the sensitivity was 73.7％,specificity was 76.5 ％,positive predictive value was 93.3 ％,negative predictive value was 39.4％,accuracy was 74.2％.Conclusions △size％ changes in consistent with △THC％ among the intergroups,but their changes levels are different,the highest change percent appears in CR,gradually decreased in PR,SD groups.△THC％ will contribute to predict preoperative clinical NAC efficacy.