To investigate the differences in postoperative short-term complications and long-term prognosis of pancreatic cancer(PC) patients after total pancreatectomy(TP) and pancreaticoduodenectomy(PD).

Pancreatic ductal adenocarcinoma (PDAC) has poor prognosis due to limited therapeutic options. This study examines the roles of genome-wide association study identified PDAC-associated genes as therapeutic targets. We have identified HNF4G gene whose silencing most effectively repressed PDAC cell invasiveness. HNF4G overexpression is induced by the deficiency of transcriptional factor and tumor suppressor SMAD4. Increased HNF4G are correlated with SMAD4 deficiency in PDAC tumor samples and associated with metastasis and poor survival time in xenograft animal model and in patients with PDAC (log-rank P = 0.036; HR = 1.60, 95% CI = 1.03-2.47). We have found that Metformin suppresses HNF4G activity via AMPK-mediated phosphorylation-coupled ubiquitination degradation and inhibits in vitro invasion and in vivo metastasis of PDAC cells with SMAD4 deficiency. Furthermore, Metformin treatment significantly improve clinical outcomes and survival in patients with SMAD4-deficient PDAC (log-rank P = 0.022; HR = 0.31, 95% CI = 0.14-0.68) but not in patients with SMAD4-normal PDAC. Pathway analysis shows that HNF4G may act in PDAC through the cell-cell junction pathway. These results indicate that SMAD4 deficiency-induced overexpression of HNF4G plays a critical oncogenic role in PDAC progression and metastasis but may form a druggable target for Metformin treatment.

Objective:To summarize the atypical manifestations and treatment strategies of serous microcystic neoplasm of the pancreas.Methods:Review the case data of 11 cases of pancreatic serous microcystic adenoma with atypical preoperative clinical imaging findings admitted to Peking Union Medical College Hospital from July 2008 to October 2019, and summarize their clinical manifestations, CT/MRI features, and preoperative clinical diagnosis, surgical methods, postoperative conditions.Results:The median age of the 11 patients was 50 (46-66) years old, 7 females, and 4 males. There were 8 cases with back pain and 6 cases with weight loss. The preoperative imaging examination found that the lesion was located in the head and neck in 8 cases, with pancreaticobiliary duct dilatation in 7 cases, suspected vascular invasion in 3 cases, and pancreatic parenchymal atrophy in 2 cases, 3 cases showed rich blood supply and solid space, and 2 cases were connected to the pancreatic duct. Preoperative diagnosis of pancreatic malignant tumors accounted for 4 cases, neuroendocrine tumors in 3 cases, solid pseudopapillary tumors in 3 cases, and intraductal papillary mucinous tumors in 1 case. All patients underwent surgical treatment, 3 cases of distal pancreatectomy (2 cases of using Kimura method to protect the spleen), 3 cases of pancreaticoduodenectomy, 1 case of total pancreatectomy, 2 cases of pancreatic head resection with duodenum preservation, 2 cases of local resection. All patients had no early postoperative deaths. There were 2 cases of grade B pancreatic fistula, 2 cases of biochemical leakage, 1 case of postoperative abdominal hemorrhage, and 2 cases of delayed gastric emptying, all of which were cured after active treatment. The median postoperative hospital stay was 18 (7-63) days.Conclusions:Pancreatic serous microcystic neoplasm could be accompanied by atypical features such as pancreatic/bile duct dilation, parenchyma atrophy, or even present vessel invasion. Understanding the atypical clinic and image features would help improving differential diagnosis and treatment. For those with invasive features, surgical exploration should be recommended.

Objective To investigate the imaging anatomy and clinical significance of the inferior pancreaticoduodenal veins (IPDVs).Methods The retrospective and descriptive study was conducted.The clinicopathological data of 42 patients with pancreatic head ductal adenocarcinoma who were admitted to Peking Union Medical College Hospital from January to June 2018 were collected.There were 24 males and 18 females,aged from 41 to 78 years,with an average age of 61 years.Patients received preoperative contrast-enhanced computed tomography (CT) examination with 1 mm slice thickness,and underwent corresponding surgery according to the preoperative evaluation.Observation indicators:(1) results of preoperative CT examination;(2) surgical situations.Normality of measurement data was analyzed using Shapiro-Wilk test.Measurement data with skewed distribution were described as M (QR) or M (range),and comparison between groups was analyzed by the Mann-Whitney U test.Count data were described as absolute number or percentage,and comparison between groups was analyzed by the chi-square test.Results (1) Results of preoperative CT examination:42 patients received preoperative contrast-enhanced CT examination with 1 mm slice thickness.① The first jejunal venous trunk was identified in all the 42 patients.The first jejunal venous trunk crossed dorsal to the superior mesenteric artery (SMA) in 34 patients and ventral to the SMA in 8 patients.② Of 42 patients,2 showed no IPDV,and 40 showed IPDV including 23 with 1 IPDV,13 with 2 IPDVs,3 with 3 IPDVs,and 1 with 4 IPDVs.A total of 62 IPDVs were identified in the 42 patients,with an average IPDV number of 1 (range,0-4).There were 43 IPDVs drained into first or second jejunal venous trunks and 19 IPDVs drained into superior mesenteric vein (SMV).③ Of 42 patients,type Ⅰ IPDV was identified in 32 patients including 20 with 1 IPDV drained into jejunal venous trunk at dorsal side of SMA,7 with 2 IPDVs drained into jejunal venous trunk at dorsal side of SMA,2 with 3 IPDVs drained into jejunal venous trunk at dorsal side of SMA,and 3 with 1 IPDV drained into jejunal venous trunk at ventral side of SMA,and non-type Ⅰ IPDV was identified in 10 patients;type Ⅱ IPDV was identified in 18 patients including 17 with 1 IPDV drained into SMV and 1 with 2 IPDVs drained into SMV,and non-type Ⅱ IPDV was identified in 24 patients.Some patients can simultaneously had type Ⅰ and type Ⅱ IPDV.(2) Surgical situations:42 patients underwent pancreatoduodenectomy,14 of which underwent laparoscopic surgery and 28 underwent open surgery.There were 5 cases with SMV or portal vein reconstruction,and 18 with intraoperative blood transfusion.All the 42 patients were diagnosed as pancreatic ductal adenocarcinoma by postoperative pathological examination,including 30 of R0 resection and 12 of R1 resection.The volume of intraoperative blood loss,cases with intraoperative blood transfusion,cases with R0 and R1 resection (situation of surgical margin),cases with SMV or portal vein reconstruction were 650 mL(853 mL),15,20,12,4 in the 32 patients with type Ⅰ IPDV,aod 475 mL (480 mL),3,10,0,1 in the 10 patients with non-type Ⅰ IPDV;there were significant differences in the volume of intraoperative blood loss and situation of surgical margin (Z=94.000,x2=5.250,P＜ 0.05).There was no significant difference in the cases with intraoperative blood transfusion,cases with SMV or portal vein reconstruction between patients with type Ⅰ and non-type Ⅰ IPDV (x2 =0.045,0.886,P＞0.05).Conclusions IPDVs can be distinguished on the contrast-enhanced CT with slice thickness,and classified as IPDVs drained into SMV or jejunal venous trunk.It is necessary to carefully deal with IPDVs drained into jejunal venous trunk in the pancreaticoduodenectomy due to its more volume of intraoperative blood loss and lower R0 resection rate.

Objective: To explore the treatment technique, occurrence and development patterns of such radiation injuries as in a major radiological accident in which a victim suffered mild bone marrow radiation sickness combined grade degree Ⅲ acute radiation induced skin injury, based on his dose estimation, clinical manifestations and disease treatments. Methods: History inquiry in detail, earlier physical dose estimation and biological dose estimation were conducted in conjunction with analyzing the chromosome aberration of peripheral blood lymphocytes. The physical dose was estimated by Monte Carlo method.The systematic laboratory and imaging examination was performed to evaluate the condition. The comprehensive analysis was conducted to determine the diagnosis and treatment plan. Results: At 3d after the exposure, "Ren" felt mild pain and discomfortable on the skin of the right index finger. The body of the right hand index finger was covered with blister at 21 d after exposure.The estimation of biological dose was 0.43 Gy (95%CI: 0.31-0.58 Gy), and the physical dose was estimated to be 36-164 Gy for each part of the right hand finger. The hematopoietic system, immune system and endocrine system were normal. The liver function index value was transiently increased. The liver damage resulted from the use of antibiotic-induced combined with the patient′s past medical history and admission examination result, and the relevant antibiotics were discontinued. The liver function returned to normal after liver protection treatment. At 22 d after irradiation, a right finger incision and decompression surgery were performed. The stem cells were extracted and implanted into the right index finger. After 59 days of hospitalization, there was no obvious discomfort in the body, and the right index finger recovered well, as well as the pain significantly relieved, and the knuckle activity was basically normal. Conclusions The patient with excessive radiation and grade Ⅲ acute radiation skin injury was successfully treated, and local application of autologous adipose-derived stem cell transplantation achieved good result .

Objective To investigate the effects of Shenfu injection on early post-operative cognitive dysfunction (POCD) and brain derived neurotrophic factor (BDNF) in patients with burns. Methods Fifty-six patients with burns and ready to receive surgical treatment of scars admitted to Affiliated Hospital of Southwest Medical University from July 2015 to January 2017 were enrolled, and they were divided into a control group and a Shenfu group by random number table, 28 cases in each group. The regimen of anesthesia induction before operation and anesthesia maintenance in the operation in two groups was the same, and the patients in Shenfu group received intravenous drip of Shenfu injection 40 mL at 0.5 hour before surgery. The Mini-mental State Examination Scale (MMSE) was used to evaluate the cognitive function after surgery, and MMSE score reduction of > 2 scores was recognized as cognitive impairment after operation;patient's pain degree was evaluated by using visual analogue scale (VAS); the levels of serum BDNF were detected by the enzyme-linked immunosorbent assay (ELISA) at 0.5 hour before operation, immediately after operation, and 12 hours, 1 day, 3 days after operation. Results The MMSE scores were significantly decreased in the two groups after surgery, but decreasing degree of the MMSE scores in Shenfu group were significantly slower than those of the control group (1 day after surgery was 22.8±2.9 vs. 20.5±3.2, 3 days after surgery was 25.6±3.1 vs. 23.2±3.0, both P < 0.05). The incidence of POCD in the Shenfu group was significantly lower than that of the control group [7.1% (2/28) vs. 42.9% (12/28), P < 0.05]. The VAS scores were significantly higher in the two groups after surgery, but there was no significant difference between the two groups at each time point (all P > 0.05). The serum BDNF levels were significantly increased in two groups at immediate post-operation and 12 hours after surgery compared with those 1 day before operation, in addition, the BDNF level in Shenfu group was obviously higher than that in the control group (mg/L: 13.5±4.2 vs. 9.9±3.3, 11.4±3.5 vs. 9.1±3.2, both P < 0.05), the serum BDNF levels in two groups returned to their preoperative levels on 1 day and 3 days after surgery (all P > 0.05). Conclusion The Shenfu injection can reduce the incidence of early POCD in patients with large area burns and its mechanism may be related to the increase of BNDF expression.

Objective To investigate a dose response curve based on a genetic workstation with automatic analysis system of dicentric chromosome assay (DCA) for establishing a high speed dose estimation method.Methods Peripheral blood from three healthy volunteers was irradiated in vitro using 60Co γ-rays,and then lymphocytes were cultured and fixed on slides using the standard protocol for DCA.Dicentric chromosome in metaphase cells was analyzed automatically with the genetic workstation and confirmed manually,and the dose response curve of automated dicentric chromosome was fitted.Dicentric chromosome of another peripheral blood sample irradiated with different doses was manually analyzed to verify the accuracy of the above automated DCA.Results The yield of automated DCA was well fitted by an equation Y =0.018 06D2 + 0.012 79D + 0.000 489 1 with a correlation coefficient R2 =0.961.The biological dose of radiation could be accurately estimated by this dose response curve within a few minutes.Conclusions We had successfully established a new dosimetry method by analyzing dicentric chromesome automatically,which can save a lot of manual analysis time and hence has important significance for emergency rescue in nuclear accidents.

Objective: To discuss the impact of updated definition and classification system of pancreatic fistula published in 2016 on the postoperative classification of pancreatic fistula. Methods: Retrospective analysis was made on patients who underwent pancreatic surgery at ward 1 in Department of General Surgery, Peking Union Medical College Hospital from January 2015 to December 2016.A total of 408 patients were included in this retrospective study, male/female was 184/224, aged from 9 to 81 years with mean age of 51.6 years.One hundred and fifty-two cases were performed pancreaticoduodenectomy, 125 cases for distal pancreatectomy, 43 cases for spleen preservation distal pancreatectomy, 61 cases for partital pancreatectomy or enucleation, 8 cases for middle pancreatectomy, 6 cases for pancreaticojejunostomy and 13 cases for other procedures.Clinical data including postoperative drainage fluid volume, amylase concentration, duration of hospitalization and drainage were obtained, revaluated and re-analyzed, classified grounded on 2005 edition and 2016 edition, respectively.t-test was adopted for data analysis. Results: According to the previous standards, the incident rate of pancreatic fistula was 57.4%, and the incident rate of B-level plus C-level pancreatic fistula was 35.8%, which decreased to 13.7% based on 2016 edition.Nine patients who received percutaneous puncture or endoscopic drainage was regraded from C-level to B-level. The average duration of postoperative hospitalization of patients without pancreatic fistula was (12.5±6.0)days, demonstrating no significant difference compared to (14.1±7.7)days, duration of postoperative hospitalization of A-level(under 2005 edition of criteria) pancreatic fistula group(t=1.66, P=0.09) and (12.4±6.1)days, duration of postoperative hospitalization of biochemical leakage group(t=0.14, P=0.89). Nevertheless, there was statistical significant difference between the average postoperative duration of hospitalization(30.7±16.9) days of B-level(under 2016 criteria) pancreatic fistula patients and pancreatic fistula-free patients as well as the biochemical leakage group patients (t=7.10, 7.13; both P<0.01). Conclusions Based on the new diagnostic criteria, the incidence of postoperative pancreatic fistula decreased dramatically.New classification system downgraded part of cases graded C-level pancreatic fistula to B-level and some B-level to biochemical fistula.The new diagnostic classification and criteria facilitated clinical practice, accomplished better conformity to clinical reality and potentially enacted clinical outcome.

Objective To observe the effect of ketamine at low dose on inflammatory mediators during one lung ventilation and postoperative depression-like mood in patients with esophageal cancer radical surgery. Methods 60 patients who underwent esophageal cancer radical surgery were randomly divided into ketamine group(K)and control group(C). The patients in group K was injected with ketamine at a dose of 0.5 mg/kg at the time of anesthesia induction,then continuous infused with ketamine at a dose of 0.25 mg/(kg · h)for 30 minutes. Patients in group C:saline was given .Then concentrations of TNF-α,IL-6,IL-10 and PHQ-9 scores at different time points were evaluated. Results The PHQ-9 scores of the patients in K group at the 5 d after operation was significantly lower than that at the 1d before operation(P<0.05);The PHQ-9 scores in group K were decreased ob-viously than that those in group C(P<0.05). The concentration of serum TNF-α,IL-6 and IL-10 were significantly increased after T1 time of the two groups(P<0.05);Compared with group C,there was no statistical difference in the levels of TNF-α,IL-6 and IL-10 in group K at T2 and T3 time(P<0.05).Conclusion Low dose ketamine has no obvious effect on the concentration of blood TNF-α,IL-6 and IL -10 during one lung ventilation in patients with esophageal cancer radical surgery ,but it may alleviate postoperative depression-like mood.

Objective To use three different methods in attempt to estimate the biological dose of the patient partially exposed to 192Ir source at5.7 accident in Nanjing,so as to provide dosimetric information for clinical remedy of exposed patients in the emergency of a nuclear accident.Methods Peripheral blood samples were collected on days 5 after exposure.The biological dose was estimated by the yields of dicentrics plus rings ( dic + r),cytokinesis-block micronuclei (CBMN) assay and nucleoplasmic bridge plus FHC (NPB + FHC).The homogeneity of radiation exposure was examined by Poisson distribution of dicentrics.Results By using three different methods,the whole body equivalent dose was dic + r estimated to be 1.51 Gy (95％ CI 1.40-1.61),1.47 Gy (95％ CI 1.36-1.60) by CBMN and 1.30 Gy (95％ CI 1.00-1.60) by NPB + FHC,respectively.A non-poisson distribution was also detected,suggesting partial body radiation exposure.Conclusions The estimated whole body equivalent dose ot a non-uniform radiation exposure was consistent with clinical diagnosis,suggesting that the yields ofdic + r,CBMN,as well as NPB + FHC,are efficient approaches to the estimation of biological doses.