Exosomes are a subpopulation of extracellular vesicles ranging in size from 30 to 150 nm. They contain a variety of biological molecules including proteins, lipids, and genetic materials by which they can act as mediators of cell-to-cell communication. Increasing studies on exosomes have elucidate the mechanism of communication between immune cells. Mast cells are found to release exosomes in both resting and activated states, but the quantity, contents and functions of the exosomes are significantly different in different states. Mast cell-derived exosomes are involved in the maturation and antigen presentation of dendritic cells, and mediate the activation of T lymphocytes and the polarization of macrophages. These results provide new insights into the role of exosomes in mast cell function and immune regulation.

Objective To investigate the development of rehabilitation medical resources in Jiangsu during Thirteenth Five-year Plan.Methods The electronic questionnaire was issued uniformly to the medical and health institutions in 13 prefecture-level cities in Jiangsu Province through the Health Commission system, to survey the rehabilitation medical resources data from 2015 to 2019.Results Compared with those in 2015, the secondary and above general hospitals with rehabilitation medicine departments increased 3.42 percentage points and community-level medical and healthcare institutions providing rehabilitation medical services increased 5.67 percentage points at the end of 2019; while, the authorized beds increased 127 and actual beds increased 142 in the rehabilitation department per million population; the early rehabilitation intervention increased 4 326 person-times per million population; there were 91 more rehabilitation professionals per million population, including 25 rehabilitation physicians, 31 rehabilitation therapists, 29 rehabilitation nurses and six other rehabilitation practitioners; the practitioners with associate senior titles and above increased 1.65 percentage points, and those with master-degree or above increased 1.27 percentage points.Conclusion The allocation of various rehabilitation resources has been improved in Jiangsu province during Thirteenth Five-year Plan.

Objective:To study the technical and essential steps in laparoscopic selective devascularization with paraesophageal veins-preservation.Methods:To retrospectively analyze the clinical data of 13 cirrhotic patients who underwent laparoscopic selective pericardial devascularization for portal hypertension at the Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital from January 2019 to March 2020. There were 9 males and 4 females with age ranging from 41 to 83 years (median 51 years). The operative time, intraoperative blood loss, postoperative complications and follow-up data were analyzed.Results:All the 13 patients completed theoperation, no patient stopped the operation or transferred to laparotomy. The operation time was (170±32) min.The intraoperative bleeding was (160±30) ml. The postoperative hospital stay was (6.1±1.1) days. There were no complications, including pancreatic leakage and intra-abdominal infection. On follow-up which ranged from 1 to 15 months, one patient developed portal vein thrombosis, no upper gastrointestinal rebleeding.Conclusions:Preservation of esophageal veins in laparoscopic selective devascularization is an accurate surgery which requires close teamwork and rich experience in laparoscopic surgery. The preservation of the main trunk of the gastric coronary vein and integrity of the esophageal veins are the keys to the surgery which is safe and feasible.

Objective:To study the causes of hemorrhage after laparoscopic pancreaticoduodenectomy (LPD) and to develop countermeasures in its prevention.Methods:The clinical data of 215 patients who underwent LPD at the Department of Hepatobiliary and Pancreatic Surgery of Zhejiang Provincial People's Hospital from December 2013 to May 2020 were reviewed. The patients’ clinical data including gender, age, comorbidities and postoperative complications such as bleeding, pancreatic fistula, biliary fistula and intraperitoneal infection were studied, with the aims to analyze the causes, clinical manifestations and treatment results of post-pancreaticoduodenectomy hemorrhage (PPH) after LPD.Results:Of 215 patients, there were 132 males and 83 females, aged (60.7±10.3) years. PPH occurred in 20 patients, incidence rate was 9.30%(20/215). Early hemorrhage was mainly caused by inadequate hemostasis or loosening of vascular clips, while delayed hemorrhage was mainly caused by gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instruments or pseudoaneurysms. Among the 20 patients, 6 patients had early hemorrhage and 14 delayed hemorrhage. There was 1 patient with grade A, 10 with grade B and 9 with grade C hemorrhage. Thirteen patients developed pancreatic fistula, 1 biliary fistula, and 2 intraperitoneal infection. One patient responded well to conservative treatment. Hemostasis was successfully achieved by gastroscopy ( n=1) and interventional therapy ( n=7). Eleven patients required laparotomy for hemostasis. In this study, 14 of 20 patients survivied PPH and 6 patients died. The mortality rate was 30% (6 of 20 patients with PPH). Conclusions:Early hemorrhage was caused by inadequate hemostasis or loosening vascular clips, while delayed hemorrhage was related to gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instrument or pseudoaneurysm. Careful hemostasis, adequate protection of blood vessels, and accurate anastomosis should be performed in LPD. DSA angiography should be used for arterial hemorrhage which progressed very rapidly. Interventional therapy including embolism and stenting were means to control arterial bleeding in PPH. Decisive surgical exploration when interventional therapy failed was important in reducing the mortality rate of these patients.

Objective To explore the efficacy ofTiaogan-Bushen-Xiaoji recipe (TGBSXJ Recipe) on overall survival and progression free survival (PFS) in patients with advanced breast cancer.Methods A total of 105 patients with advanced breast cancer, who received the first-line treatment, were divided into two groups, 56 cases in the control group and 49 in the experimental group. The control group received standard therapy according to guidelines, including chemotherapy, targeted therapy, endocrine therapy and treatment of bisphosphonates.The experimental group received the treatment of TGBSXJ Recipe besides the standard therapy. The overall survival (OS), progression-free survival (PFS) and Karnofsky (KPS) of the patients in two groups were observed and compared. The treatment ended with the sighs of the observation ending, the second progress for the disease or death.Results The overall survival of the experimental group was significantly higher than that of the control group [OS: 58.2(50.7-65.8)/monthsvs. 43.8(30.6-51.6)/months,P=0.040]. The PFS of the experimental group was significantly higher than the control group [PFS: 30.7(23.8-37.7)/monthsvs. 15.2(11.3-19.1)/months,P=0.001]. The KPS of the experimental group was significantly higher than the control group (88.6 ± 10.0vs. 80.5 ± 19.0,t=2.654). The PFS of the triple negative breast cancer (TNBC) in the experimental group was significantly higher than control group [(25.1(12.1-38.0)/monthsvs. 9.9(4.7-15.0)/months,P=0.038].Conclusions The TGBSXJ recipe could extend the OS and PFS and improve the life quality of the patients with advanced breast cancer. In this study, no severe adverse effects had been found in the experimental group.

Objective To analyze the initial experience of total laparoscopic radical resection for patients with Bismuth type Ⅲa hilar cholangiocarcinoma.Methods A retrospective study was conducted to analyze the clinical data of three patients with Bismuth type Ⅲa hilar cholangiocarcinomatotal who underwent laparoscopic radical resection in Zhejiang Provincial People's Hospital from February to May in 2017.Results The three patients all underwent the operations successfully.The operation time ranged from 490.0 to 580.0 min.The intraoperative blood loss ranged from 300.0 ml to 1 200.0 ml.There was no severe perioperatire complication or death.One patient developed biliary leakage which responded to drainage without reoperation.Another patient developed pleural effusion treated with minimal invasive drainage.The length of postoperative hospital stay ranged from 10.0 to 18.0 days.Histopathology showed two patients with well-differentiated adenocarcinomas and one patient with poorly differentiated adenocarcinoma.The number of lymph nodes harvested ranged from 8 ～ 13.Two patients had no regional lymph node metastasis and one patient had regional lymph node metastasis (1/13).The hilar bile duct resection margins of the three patients were all negative.There was no evidence of tumor recurrence on following up for 7 ～ 10 months.Conclusions It was safe and feasible to carry out total laparoscopic radical resection in selected patients with Bismuth type Ⅲa hilar cholangiocarcinoma.More patients and longer follow-up are required to study the long term oncological results.

Objective To investigate the value of laparoscopic total pancreastectomy for the treatment of noncancerous pancreatic lesions.Methods Clinical data of 3 cases of noncancerous pancreatic lesions undergoing laparoscopic total pancreatectomy in Zhejiang Provincial People's Hospital were reviewed retrospectively.Results One patient underwent laparoscopic total pancreatectomy,one patient underwent laparoscopic resection with robotic reconstruction and one did laparoscopic resection with open reconstruction.All were spleen preserving surgery.The operation time was 310 (280-350) minutes,estimated blood loss was 483 ml(250-700)ml and postoperative hospital stay was 27 (14-38) days.One patient had postoperative bile leakage.Insulin was used to control blood glucose level in all postoperative cases.As showed by pathology there were intraductal papillary mucinous neoplasms in two patients and multiple neurocndocrine tumor in one patient.Conclusion Laparoscopic total pancreatectomy is safe and minimally invasive for the treatment of noncancerous pancreatic diseases.

Objective To evaluate the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) on recurrence after hepatectomy for AFP negative hepatocellular carcinoma (HCC).Methods Clinical data of 68 AFP negative HCC patients undergoing radical hepatectomy from September 2010 to January 2013 were analyzed retrospectively.According to preoperative NLR,patients were divided into low NLR group (NLR ＜ 2.78) and high NLR group (NLR ≥ 2.78),respectively.Univariate analysis was performed to assess for a significant difference in clinicopathological characteristics influencing disease-free suvival after hepatectomy.A multivariate analysis was performed by Cox regression for variables significant on univariate analysis.Kaplan-Meier method was used to assess disease-free survival rate.Results The overall 1,2,and 3-year disease-free survival rate was 79.7％,37.5％,and 18.2％ respectively.The disease-free survival of high NLR group was significantly lower than the low NLR group (1,2,and 3-year overall survival were 70.3％,35.1％,and 13.5％ vs 85.2％,40.7％,and 18.5％,respectively,P =0.042).Preoperative NLR ≥2.78,tumor size (＞ 5 cm),microvascular invasion and liver cirrhosis were risk factors of poor disease-free survival.Cox regression analysis revealed that all of these four factors were independent predictors of poorer disease-free survival.Conclusions Preoperative NLR≥2.78 was one of independent adverse predictors for disease-free survival in AFP negative HCC patients after hepatectomy.

Objective To analyze our experience on laparoscopic and Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection and reconstruction,and to expand the indications of surgery for patients with pancreatic cancer.Methods From December 2013 to January 2016,67 patients underwent laparoscopic and Da Vinci robotic pancreaticoduodenectomy in our department.The resection was combined with major vein resection in 5 patients.We retrospectively analyzed the clinical data of these patients who had laproscopic or Da Vinci robotic pancreaticoduodenectomy with major vascular resection and reconstruction.Results The mean operation time was 378 (360 ～ 480) minutes,and the mean estimated blood loss was 360 (120 ～450) ml.4 patients underwent laparoscopic wedge-resection of PV/SMV without interruption of blood flow.After pancreaticoduodenectomy using the superior mesentery artery first approach,one patient underwent resection of a segment of portal vein and superior mesenteric vein followed by an end to end anastomosis using the Da Vinci robotic system.The total blood flow occlusion time was 35 minutes.Intraoperative frozen section biopsy and postoperative pathological results were chronic pancreatitis with pancreatic cancer in all these patients.The veins were invaded by tumor in 3 patients.In the remaining 2 patients,the vascular wall showed chronic inflammation.All the surgical resection margins were tumor negative.Postoperative complications included one patient with bile leakage,one patient with upper gastrointestinal bleeding and one patient with a grade A pancreatic fistula (PF).The patient with upper gastrointestinal bleeding was managed successfully using hemostatic treatment under gastroscopy,and the other patients all recovered well after conservative therapy.There was no death in this study.The mean postoperative hospitalization stay was 14 (9 ～35) days.Conclusions Laparoscopic or Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection is safe and feasible in selected patients with pancreatic cancer.However,surgeons need to be experienced at both open pancreaticoduodenectomy combined with vascular resection and at standard laparoscopic pancreaticoduodenectomy.