Objective:To investigate the treatment and prognosis of patients of G3 non-functional pancreatic neuroendocrine tumors (pNETs) with proliferation index of Ki-67 <55%.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 15 G3 non-functional pNETs patients with proliferation index of Ki-67<55% who were admitted to Zhongshan Hospital of Fudan University from April 2014 to April 2020 were collected. There were 11 males and 4 females, aged (58±10)years. All patients underwent radical resection of the primary lesion. Obser-vation indicators: (1) treatment; (2) postoperative pathological characteristics; (3) follow-up. Measure-ment data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers. The Pearson correlation analysis was used to verify the correlation between variables. Kaplan-Meier method was used to draw survival curve and calculate survival rate. Log-Rank test was used for survival analysis. Results:(1) Treatment. All 15 G3 nonfunctional pNETs patients underwent radical resection of the primary lesion of pancreas, including 5 cases receiving pancreati-coduodenectomy, 10 cases receiving distal pancreatectomy with splenectomy. There were 5 patients with simultaneous liver oligometastasis who underwent combined segmental (lobectomy) hepatectomy. All 15 patients had negative tumor margin, and the operation time and volume of intraoperative blood loss of 15 patients was 120(90,210)minutes and 200(50,300)mL, respectively. None of patient had complications ≥Ⅲ grade of the Clavien-Dindo classification during the postoperative 30 days. Of the 15 patients, there were 5 cases receiving comprehensive treatment based on CAPTEM chemo-therapy (temozolomide combined with capecitabine), 2 cases receiving local interventional therapy, 2 cases receiving CAPTEM chemotherapy, 1 case receiving local interventional therapy combined with molecular targeted therapy, 1 case receiving local interventional therapy combined with long acting somatostatin therapy, 1 cases receiving long acting somatostatin therapy combined with molecular targeted therapy, and 3 cases without postoperative treatment. (2) Postoperative patholo-gical characteristics. The tumor diameter of 15 patients was 3.3(range, 0.5-6.0)cm. There were 2 cases with tumor diameter <2 cm, 13 cases with tumor diameter ≥2 cm. The number of lymph nodes dissected and number of lymph nodes metastatic was 6(4, 10) and 2(1,3) in 15 patients, respectively, including 12 cases with positive lymph node metastasis. Of the 15 patients, there were 5 cases with tumor invasion of adjacent organ, 5 cases with simultaneous liver metastasis, 8 cases with perineural invasion and 8 cases with vascular invasion. There were 3, 7, and 5 patients with stage Ⅱ, stage Ⅲ, and stage Ⅳ of pathological TNM staging, respectively. The proliferation index of Ki-67 and mitotic count was 32%±9% and (11±9)/10 high power field in the primary lesion of 15 patients, respectively, and there was no correlation between proliferation index of Ki-67 and mitotic count ( P>0.05). (3) Follow-up. All 15 patients were followed up after surgery for (55±24)months. The median survival time of 15 patients was 78(range, 43-113)months, with 1-, 3-, 5-year overall survival rate as 100%, 92%, 62%, respectively. During the follow up, 9 of the 15 patients underwent tumor recurrence, with the recurrence time as 20(14, 44)months. There were 8 patients died of tumor recurrence or metastasis. The median survival time was 86(range, 51-120)months in 5 patients receiving comprehensive treatment based on CAPTEM chemotherapy, versus 53(range, 45-60)months in 10 patients receiving other postoperative adjuvant therapy or without postoperative treatment, showing a significant difference between them ( χ2=4.21, P<0.05). Conclusion:The prognosis of patients of G3 nonfunctional pNETs with proliferation index of Ki-67<55% undergoing radical resection combined with postoperative comprehensive treatment based on CAPTEM chemotherapy in better than that of patients receiving other postoperative adjuvant therapy or without posto-perative treatment.

Objectives:To evaluate the role of pancreas multidisciplinary team(MDT) clinic in the diagnosis of pancreatic diseases,patient compliance with MDT advice,and the impact of MDT on the postoperative survival of patients with pancreatic cancer.Methods:The study included 927 patients(554 males,373 females,aged (58.1±13.3)years (range: 15 to 89 years)) that had visited the pancreas MDT clinic of Zhongshan Hospital from May 2015 to December 2021,and 677 patients(396 males, 281 females, aged (63.6±8.9)years(range: 32 to 95 years)) who underwent radical surgery and with pathologically confirmed pancreatic adenocarcinoma from January 2012 to December 2020,of whom 79 patients had attended the pancreas MDT. The clinical and pathological data were collected and analyzed retrospectively. Diseases were classified in accordance with 2010 WHO classification of tumors of the digestive system and usual clinical practices. The Kaplan-Meier method was used for drawing the survival curve and calculating the survival rate. The univariate analysis was done by Log-rank test and the multivariate analysis was done by COX proportional hazards model. Survival rates were compared using χ 2 test. Results:Among the 927 patients that had visited the MDT clinic,233 patients(25.1%) were referred due to undetermined diagnosis. A direct diagnosis was made in 109 cases (46.8%,109/233) by the MDT clinic, of which 98 were consistent with the final diagnosis,resulting in an accuracy of 89.9%(98/109). The direct diagnosis rate in the recent years(36.6%(41/112),from June 2019 to December 2021) decreased compared to that in the previous years(56.2%(68/121),from May 2015 to May 2019),yet the accuracy in the recent years(90.2%,37/41) was basically the same as before (89.7%,61/68). The rate of compliance of the entire cohort was 71.5%(663/927), with the compliance rate in the recent two and a half years(81.4%,338/415) remarkably higher than that in the previous four years(63.4%,325/512). Patients with pancreatic cancer that attended the MDT exhibited a trend toward longer median postoperative survival than patients that did not attend the MDT,but the difference was not statistically significant(35.2 months vs.30.2 months, P>0.05). The 1-year and 3-year survival rates of patients that attended the MDT were significanly higher than patients that did not attend the MDT(88.6% vs. 78.4%, P<0.05;32.9% vs. 21.9%, P<0.05,respectively),but the 5-year survival rate was not statistically different(7.6% vs. 4.8%, P>0.05). Conclusions:The pancreas MDT clinic is an accurate and convenient way to diagnose intractable pancreatic diseases,and in the recent years the patients′ compliance rate with MDT advice has increased. Pancreatic cancer patients that have attended the MDT have higher 1-year and 3-year postoperative survival rates,but the long-term survival benefits of MDT still needs to be proved by clinical studies on a larger scale.

Objectives:To evaluate the role of pancreas multidisciplinary team(MDT) clinic in the diagnosis of pancreatic diseases,patient compliance with MDT advice,and the impact of MDT on the postoperative survival of patients with pancreatic cancer.Methods:The study included 927 patients(554 males,373 females,aged (58.1±13.3)years (range: 15 to 89 years)) that had visited the pancreas MDT clinic of Zhongshan Hospital from May 2015 to December 2021,and 677 patients(396 males, 281 females, aged (63.6±8.9)years(range: 32 to 95 years)) who underwent radical surgery and with pathologically confirmed pancreatic adenocarcinoma from January 2012 to December 2020,of whom 79 patients had attended the pancreas MDT. The clinical and pathological data were collected and analyzed retrospectively. Diseases were classified in accordance with 2010 WHO classification of tumors of the digestive system and usual clinical practices. The Kaplan-Meier method was used for drawing the survival curve and calculating the survival rate. The univariate analysis was done by Log-rank test and the multivariate analysis was done by COX proportional hazards model. Survival rates were compared using χ 2 test. Results:Among the 927 patients that had visited the MDT clinic,233 patients(25.1%) were referred due to undetermined diagnosis. A direct diagnosis was made in 109 cases (46.8%,109/233) by the MDT clinic, of which 98 were consistent with the final diagnosis,resulting in an accuracy of 89.9%(98/109). The direct diagnosis rate in the recent years(36.6%(41/112),from June 2019 to December 2021) decreased compared to that in the previous years(56.2%(68/121),from May 2015 to May 2019),yet the accuracy in the recent years(90.2%,37/41) was basically the same as before (89.7%,61/68). The rate of compliance of the entire cohort was 71.5%(663/927), with the compliance rate in the recent two and a half years(81.4%,338/415) remarkably higher than that in the previous four years(63.4%,325/512). Patients with pancreatic cancer that attended the MDT exhibited a trend toward longer median postoperative survival than patients that did not attend the MDT,but the difference was not statistically significant(35.2 months vs.30.2 months, P>0.05). The 1-year and 3-year survival rates of patients that attended the MDT were significanly higher than patients that did not attend the MDT(88.6% vs. 78.4%, P<0.05;32.9% vs. 21.9%, P<0.05,respectively),but the 5-year survival rate was not statistically different(7.6% vs. 4.8%, P>0.05). Conclusions:The pancreas MDT clinic is an accurate and convenient way to diagnose intractable pancreatic diseases,and in the recent years the patients′ compliance rate with MDT advice has increased. Pancreatic cancer patients that have attended the MDT have higher 1-year and 3-year postoperative survival rates,but the long-term survival benefits of MDT still needs to be proved by clinical studies on a larger scale.

Objective: To explore preoperative predictive markers for invasive malignancy in intraductal papillary mucinous neoplasm(IPMN). Methods: The retrospective case-controlled study was adopted.Seventy-nine patients who underwent surgery and with pathologically confirmed IPMN from January 2005 to December 2014 at Department of Pancreatic Surgery, Zhongshan Hospital Fudan University were enrolled.Forty-six patients were male and 33 were female,with an average age of (62.9±8.9)years (range:37-82 years).Tumor sites:56 tumors were located at the head of the pancreas,22 were located at the body and tail of the pancreas,and 1 was located across the whole pancreas.Surgical procedures: 51 patients underwent pancreaticoduodenectomy, 22 patients underwent distal pancreatectomy, 4 patients underwent segmental pancreatectomy and 2 patients underwent total pancreatectomy.IPMNs were classified into non-invasive lesions and invasive carcinomas according to the histopathological findings of the tumor.Thirty-two tumors were non-invasive lesions and 47 were invasive carcinomas.The preoperative findings were compared between patients with non-invasive IPMN and patients with invasive carcinoma by univariate analysis using t test and χ² test accordingly,and factors with statistically significance were subsequently submitted to multivariate analysis. Results: Univariate analysis showed that tumor size(P=0.022), carcinoembryonic antigen(P=0.012), CA19-9(P=0.011), lymphocytes(P=0.034), neutrophil-to-lymphocyte ratio(P=0.010)and platelet-to-lymphocyte ratio(PLR)(P=0.004)were predictive markers with statistical significance.Multivariate analysis showed that CA19-9(P=0.012)and PLR(P=0.025) were independent predictive markers for invasive malignancy in IPMN.The area under curve of the combination factor of CA19-9 and PLR(0.864) was larger than that of CA19-9(0.806) or PLR(0.685) alone, and all the authentic indicators of the combination factor were better than those of each alone. Conclusions CA19-9 and PLR are independent predictive markers for invasive malignancy in IPMN.The combination of CA19-9 and PLR has improved efficacy than each alone.

Objective To analyze the difference among the 3 guidehnes used to make surgical decision for branch duct intraductal papillary mucinous neoplasm (BD-IPMN),then the guidelines were combined with neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) respectively for further analysis.Methods Clinical data of 51 appropriate BD-IPMN patients who underwent surgical resection from January 2008 to December 2015 was retrospectively analyzed.Results The significant difference was exist in the consensus for followup criterion (P ＜ 0.05).The preoperative NLR and PLR were helpful for the differential diagnosis between malignant and benign BD-IPMN,because the receiver operating characteristic curve (ROC) of NLR and PLR for prediction were 0.686 and 0.692,and the best boundary values were 2.64,92.56 respectively.The consensus combined with PLR could improve the specificity and positive predictive value (PPV),besides,the specificity and PPV could achieve 70.3％,54.2％ respectively while the sensitivity (92.9％) still remained at an ideal level after international consensus guideline combined with PLR.Conclusions NLR ≥ 2.64 and PLR ≥ 92.56 were predictive markers for the presence of BD-IPMN associated invasive tumor.The addition of PLR as a criterion to the international consensus guideline improved the accuracy of international consensus guidelines in estimating invasive BD-IPMN.

Objective To compare the short-term efficacy of pylorus-preserving pancreaticoduodenectomy (PPPD) and standard pancreaticoduodenectomy (SPD) for the treatment of periampullary carcinoma.Methods The clinical data of 85 patients with periampullary carcinoma who were admitted to the Zhongshan Hospital of Fudan University from October 2010 to October 2012 were retrospectively analyzed.Forty-four patients who underwent PPPD were divided into the PPPD group and 41 patients who underwent SPD were divided into the SPD group.The pancreatic fistula(Grade B and above), biliary fistula, blood loss, intra-abdominal infection, delayed gastric emptying (DGE) and prognosis were analyzed.Patients were followed up by telephone interview and outpatient examination once every 3 months within postoperative 1 year and once every 6 months within postoperative 2-3 years till October 2014.Count data were analyzed using the chi-square test, measurement data with normal distribution were presented as M(Qn) and comparison was analyzed using the Mann-Whitney U test.The survival curve was drawn by the Kaplan-Meier method, and survival rate was analyzed using the Log rank test.Results The operation time was 195 minutes (180 minutes, 240 minutes) in the PPPD group and 210 minutes (180 minutes,300 minutes) in the SPD group, with a significant difference (Z =-2.090, P ＜ 0.05).The volume of intraoperative blood loss, intraoperative blood transfusion and duration of postoperative hospital stay were 200 mL(113 mL,288 mL), 0 mL(0 mL, 0 mL) and 17 days(12 days, 24 days) in the PPPD group, and 200 mL(150 mL, 325 mL),0 mL(0 mL, 400 mL) and 16 days(12 days, 30 days) in the SPD group respectively, with no significant differences between the 2 groups (Z =-1.185,-1.780,-0.533, P ＞0.05).There was no perioperative death and incidence of overall complication was 42.4％ (36/85) with pancreatic fistula, intra-abdominal infection and DGE as the top 3 common postoperative complications.The incidence of DGE was 20.5％ (9/44) in the PPPD group,which was significantly different from 4.9％ (2/41) in the SPD group (x2=4.571, P ＜ 0.05).The incidence of pancreatic fistula, biliary fistula, intra-abdominal infection, postoperative bleeding and 2 or more complications were 20.5 ％ (9/44), 2.3 ％ (1/44), 15.9％ (7/44), 4.5 ％ (2/44), 25.0％ (11/44) in the PPPD group, and 14.6％ (6/41), 4.9％ (2/41), 19.5％ (8/41), 7.3％ (3/41), 14.6％ (6/41) in the SPD group, respectively, showing no significant difference between the 2 groups (x2=0.495, 0.423, 0.295, 0.190, 1.425, P ＞ 0.05).Eighty-five patients were followed up for 6-47 months with a median time of 31 months, and postoperative overall 1-and 3-year survival rates were 95.3％ and 75.5％, respectively.The 1-and 3-year survival rates were 97.7％ and 78.9％ in the PPPD group, and 92.7％ and 71.7％ in the SPD group, respectively, with no significant difference in 3-year survival rate (x2=0.690, P ＞0.05).The 3-year overall survival rate was 80.5％ in patients without lymph node involvement (LNI) compared with 54.9％ in patients with LNI, showing a significant difference (x2=4.290, P ＜ 0.05).Conclusions Both PPPD and SPD have good short-term efficacy for periampullary carcinoma.There is no significant difference between PPPD and SPD concerning short-term survival rate of periampullary carcinoma.PPPD has shorter operation time, but has a higher postoperative DGE incidence.LNI is a significant prognostic factor for short-term survival of periampullary carcinoma.PPPD is not recommended while the lymph nodes are involved.

Objective To investigate the risk factors of delayed gastric emptying after pancreaticoduodenectomy (PD) for periampullary carcinoma.Methods The clinical data of 96 periampullary carcinoma patients who received PD with or without pylorus preservation at Zhongshan Hospital Fudan University from October 2010 to September 2013 were retrospectively analyzed.The risk factors associated with delayed gastric emptying were analyzed.The univariate and multivariate analysis were done using the chi-square test and Logistic regression model respectively.Results A total of 17 patients had postoperative delayed gastric emptying, with the incidence of 18％.The results of univariate showed that female sex, pancreatogastrostomy, increased intraoperative blood loss and transfusions and postoperative abdominal infection were risk factors of delayed gastric emptying (x2 =4.512, 6.412, 6.245, 6.695, 6.816, all P ＜ 0.05).The results of multivariate analysis revealed that only pancreatogastrostomy and postoperative abdominal infection were independent risk factors of delayed gastric emptying (OR =4.031 and 5.281).Conclusions Pancreatogastrostomy and postoperative abdominal infection indicate a higher incidence of delayed gastric emptying after pancreaticodudenectomy for periampullary carcinoma.

Objective To investigate the clinical characteristics and surgical outcomes of pancreatic acinar cell carcinoma (PACC).Methods The clinical and follow up data of PACC patients treated with surgery in Zhongshan Hospital of Fudan University between 1999 and 2012 were analyzed retrospectively.Results A total of 16 PACC were identified including 13 male and 3 female patients.The age of the patients ranged from 38 to 71 with an average of 57 years old.Six patients presented as abdominal pain,while low back pain in 3 patients,abdominal distention in 2 patients,emaciation in 2 patients,jaundice in 2 patients and melena in 1 patient.Elevated CA19-9 level was observed in 8 patients and 2 patients had elevated serum CEA.The tumors were located in the uncinate process in 1 patient,head in 9,body and tail in 6.The superior mesenteric vein was invaded in 2 cases and 1 patient had hepatic artery invasion.The tumor invaded both the celiac trunk and splenic artery in 1 patient.One patient had just undergone intra-operative needle aspiration biopsy due to unresectable tumor.All the other 15 patients underwent surgical excision with R0 resection.Among the 10 patients received pancreaticoduodenectomy,2 had superior mesenteric vein resection and replacement and 1 had hepatic artery resection.Five patients underwent distal pancreatectomy without spleen preservation.The mean size of these tumors was 5.7 cm × 4.6 cm,12 cases had a surrounding envelope,while lymphatic metastasis was observed in 8 cases.The follow up data of 15 patients were collected and the median postoperative survival was 21 months,and the survival rate of 1,3,5 year was 71.4％,28.6％,7.1％.Conclusions Pre-operative diagnosis of PACC is extremely difficult due to lack of specific clinical features and lab tests.Surgery is the first line treatment for PACC,and the prognosis of PACC is better than that of pancreatic ductal adenocarcinoma.

Objective To evaluate the early postoperative complications of pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) following pylorus preserving pancreaticoduodenectomy (PPPD).Methods Clinical data of 97 patients undergoing PPPD,in Zhongshan Hospital,Fudan University from June 2011 to October 2012,were retrospectively analyed.Digestive tract continuity was established respectively by PG(n-45) or PJ(n =52) after PPPD.Results The demographic characteristics of both group were not significantly different.In the two groups,there were not statistically significant difference in those postoperative complications such as biliary fistula,introabdominal infection,bleeding,and the rc-admission rate.The rate of pancreatic fistula in PJ group was significantly higher than that in the PG group (28.85％ vs.6.67％,P =0.033).However,in PG group the incidence of delayed gastric emptying was significantly higher than that in the PJ group (22.22％ vs.5.77％,P =0.018),and the average length of stay was significantly longer than that in PJ group (19.28 ± 11.04 vs.15.09 ± 6.21 ; P =0.034).In PJ group,one patient died of pancreatic fistula and ensuing surgical site infection and intra-abdominal hemorrhage,there was no mortality in PG group.Conclusions After PPPD,PG and PJ are both safe ways of digestive tract reconstruction.But compared to PJ,PG can decreas the rate of pancreatic fistula but may increase the risk of postoperative delayed gastric emptying,and prolong postoperative hospital stay.

Objective To promote the diagnostic accuracy of intrapancreatic accessory spleen (IPAS).Methods The clinical data of 10 cases of IPAS admitted in Fudan University Zhongshan Hospital from Apr 2005 to Dec 2013 were retrospectively analyzed.Results There were ten cases of IPAS confirmed pathologically.Only 1 of the ten cases was diagnosed correctly and definitely with IPAS preoperatively.The other 9 cases were misdiagnosed with benign or malignant pancreatic tumors,including nonfunctional neuroendocrine neoplasms in 5 cases,pancreatic neuroendocrine cancers in 3 and pancreatic intraductal adenocarcinoma in one.All the nine misdiagnosed patients has no specific symptoms or laboratory indexes.All the IPASs located in the tail of the pancreas with the mean diameter (1.3 ±0.2) cm(0.8-2.5 cm).7 cases of IPAS show strikingly similar dynamic enhancement to the spleen on the CT scans and/or MRI.Accessory spleen around the splenic hilum was found in five cases.Conclusions Morphological study plays an important role in the diagnosis and IPAS carries parallel dynamic enhancement to the spleen on CT scans and/or MRI.IPAS should be considered as a differential diagnosis while the lesion is no more than 2.5 cm in diameter and when other accessory spleens were shown around the splenic hilum.