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 value of uncinate process first for pancreaticoduodenectomy (PD).MethodsThe clinical data of 19 patients admitted from December 2010 to March 2011,who underwent uncinate process first for PD were studied.ResultsAmong the 19 patients,there were 5 cases of periampullary adenocarcinoma,11 cases of pancreatic cancer,1 case of duodenum aggressive fibromatosis,1 case of main pancreatic duct type IPMN,1 case of SPN.During operation,3 patients (21％) were found to have abnormal or aberrant right hepatic artery.Among the 11 patients with pancreatic cancer,there are Peripancreatic lymph node(3 ～7) metastasis,in 7 cases,and nerve invasion occurred in 8 cases.All the N16 lymph nodes,pancreatic stump,bile duct margin,duodenum and retroperitoneal margin were negative,and all the cases were subjected to R0 resection.The median time for the portal vein blocking was 16 minutes.The average operation time was 4h and there was no major bleeding occurred,and the mean blood loss was 600 ml.No intractable diarrhea occurred post-operatively. Conclusions Uncinate process first for PD offers a comfortable,safe,accurate and controllable method to resect pancreatic head.

Objective To describe a novel technical modification of the uncinate process first approach with a retrograde dissection of the pancreatic head.Methods The authors described the surgical technique,and reported their preliminary experience.The surgical data,postoperative outcomes and pathological results of patients who were submitted to PD/PP PD (20 patients) and TP (3 patients) for pancreatic neoplasm using “the uncinate process first” technique between December 2010and May 2011 were reviewed.Retrograde resection of the pancreatic head was performed starting with the uncinate process after division of the first jejunal loop.The transection of the pancreas was the last operative step of the resection.The technical aspects and possible advantages of this procedure were discussed.Results The authors used this technique successfully in 23 patients.In 3 patients with a replaced or accessory RHA,the arteries were all successfully preserved.In another patient with a replaced HCA,the artery was also successfully preserved.In 1 patient with adenocarcinoma which involved the SMV,en-bloc vascular resection was carried out.Additionally,the authors used this technique on 3 patients with IPMN-2 and SPPN-1 to carry out total pancreatectomy.The uncinate process first was performed on 23 patients without any intraoperative and postoperative complication and massive bleeding.No patient required blood transfusion.The surgical margins,including retroperitoneal marginswere negative.Conclusions The “uncinate process first” approach can be used as an alternative approach in modern pancreatic surgery.Further studies are required to evaluate this procedure regarding operative parameters and postoperative outcomes when compared with the standard resectional procedure.

Objective To summarize the experience in the diagnosis and treatment of solid pseudopapillary tumors of the pancreas. Methods Ten consecutive patients who underwent surgery with pathologically confirmed solid pseudopapillary tumors of the pancreas between October 2005 and December 2008 were retrospectively reviewed. Results All of the 10 patients were female and the median age at diagnosis was 24 years (range, 11 -39 years). Abdominal discomfort or pain were the most common presenting symptoms. 4 patients had palpable abdominal mass at physical examination. The tumors appeared on ultrasonography and/or CT, MRI as solid or cystic masses. The preoperative serum biochemical parameters and tumor markers level were within the normal range. All the patients underwent surgical treatment. The tumors were located in the head/neck (n = 6) or the distal part (n = 4) of the pancreas. The surgical procedures included enucleation (n=3) , distal pancreatectomy (n=3 , two with preservation of the spleen, one combined with splenectomy, distal gastrectomy and partial colectomy) , segmental pancreatectomy with pancreaticojejunostomy (n=3) and pancreaticoduodenectomy (n = 1). Pancreatic fistula (n = 2) was observed postoperatively and resolved with conservative treatment. The median resected tumor size was 5. 9 cm. All patients were alive and remained recurrence and metastasis free after a median followk-up of 19. 2 months (range, 8～42 months). Conclusions Solid pseudopapillary tumor of the pancreas was rare neoplasm occurred predominantly in young women with low malignant potential. Aggressive resection should be attempted and could result in excellent prognosis.

Objective:To observe and evaluate the clinical efficacy and safety of albumin-bound paclitaxel as first-line treatment for patients with advanced pancreatic cancer in China, and to explore the prognosis-related molecules in pancreatic cancer based on next-generation sequencing (NGS) of tumor tissues.Methods:From December 2018 to December 2020, patients with locally advanced or metastatic pancreatic cancer were recruited to accept albumin-bound paclitaxel as first-line treatment in the oncology departments of 24 hospitals in East China. The primary endpoints were overall survival (OS) and treatment related adverse events, and the secondary endpoint was progression-free survival (PFS). Adverse effects were graded using Common Terminology Criteria for Adverse Events 5.0 (CTCAE 5.0). NGS sequencing on the primary or metastatic tissue samples of pancreatic cancer obtained through surgical resection or biopsy was performed.Results:This study recruited 229 patients, including 70 patients with locally advanced pancreatic cancer (LAPC) and 159 patients with metastatic pancreatic cancer (mPC). The disease control rate was 79.9% and the objective response rate is 36.3%.The common adverse effects during treatment were anaemia (159 cases), leucopenia (170 cases), neutropenia (169 cases), increased aminotransferases (110 cases), and thrombocytopenia (95 cases), and the incidence of grade 3-4 neutropenia is 12.2% (28/229). The median follow-up time was 21.2 months (95% CI: 18.5-23.1 months). The median PFS (mPFS) was 5.3 months (95% CI: 4.37-4.07 months) and the median OS (mOS) was 11.2 months (95% CI: 9.5-12.9 months). The mPFS of patients with LAPC was 7.4 months (95% CI: 6.6-11.2 months), and their mOS was 15.5 months (95% CI: 12.6-NA months). The mPFS of patients with mPC was 3.9 months (95% CI: 3.4-5.1 months), and their mOS was 9.3 months (95% CI: 8.0-10.8 months). Multivariate Cox regression analysis showed that clinical stage ( HR=1.47, 95% CI: 1.06-2.04), primary tumor site ( HR=0.64, 95% CI: 0.48-0.86), Eastern Cooperative Oncology Group Performance Status (ECOG PS) score ( HR=2.66, 95% CI: 1.53-4.65), and whether to combine radiotherapy ( HR=0.65, 95% CI: 0.42-1.00) were independent influencing factors for the PFS of these patients. The primary tumor site ( HR=0.68, 95% CI: 0.48-0.95), ECOG score ( HR=5.82, 95% CI: 3.14-10.82), and whether to combine radiotherapy ( HR=0.58, 95% CI: 0.35-0.96) were independent influencing factors of the OS of these patients. The most frequent gene mutations in these advanced stage pancreatic patients were KRAS (89.66%), TP53 (77.01%), CDKN2A (32.18%), and SMAD4 (21.84%) by NGS of tumor tissues from 87 pancreatic cancer patients with sufficient specimens. Further analysis revealed that mutations in CDKN2B, PTEN, FGF6, and RBBP8 genes were significantly associated with an increased risk of death ( P＜0.05). Conclusion:Albumin-bound paclitaxel as first-line treatment demonstrated feasible anti-tumor efficacy and manageable safety for patients with advanced pancreatic cancer in China.

ObjectiveThe biosynthetic pathways of benzylisoquinoline alkaloids（BIAs） in Nelumbo nucifera are of great theoretical and economic value. In this paper， N. nucifera O-methyltransferase（NnOMT） and N. nucifera N-methyltransferase（NnNMT） gene families were identified and analyzed by bioinformatics in order to facilitate the biosynthetic pathway of BIAs in N. nucifera. MethodBased on the whole genome of N. nucifera， UniPort and National Center for Biotechnology Information（NCBI） databases were used to identify the NnOMT and NnNMT gene families of N. nucifera， and analyze their physicochemical properties and subcellular localization， then TBtools， MEME， MEGA 11.0， FigTree 1.4.4 and other tools were used to analyze the phylogeny， sequence characteristics， gene structure， functional annotation and cis-acting elements of NnOMT and NnNMT genes identified in the previous stage. ResultA total of 61 NnOMT and NnNMT genes were identified in this paper， the number of amino acids encoded by these genes ranged from 168 aa to 580 aa， the isoelectric point ranged from 4.76 to 9.16， and the relative molecular weight ranged from 18 699.52 Da to 64 934.53 Da， most of which showed acidic and mostly hydrophilic proteins. There were 10 conserved motifs， Kyoto Encyclopedia of Genes and Genomes（KEGG） analysis enriched a total of 12 pathways， including metabolism， biosynthesis of phenylpropane and isoquinoline alkaloids， etc. And Visualization of Gene Ontology（GO） enrichment results showed that 61 NnOMT and NnNMT genes were annotated to 32 items， which included 16 molecular functions［such as reduced nicotinamide adenine dinucleotide（NADH） activity and exopeptidase activity］ and 16 biological processes（such as metabolic process of carbon tetrachloride， anaerobic carbon tetrachloride metabolic process and responses to exogenous biological stimuli）. There were a variety of cis-acting elements in the promoter regions of NnOMT and NnNMT genes， mainly promoter and enhancer regions element， light responsive element and methyl jasmonate responsive element. ConclusionIn this study， a comprehensive bioinformatics analysis of 61 NnOMT and NnNMT genes is carried out based on the genome data of N. nucifera， which lays a foundation for research on the gene structure and function of NnOMT and NnNMT gene families， and provides a reference for biosynthetic pathway elucidation of BIAs in N. nucifera.