Nengwen Ke

Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy.

Surgical reconstruction following pancreaticoduodenectomy (PD) is associated with significant morbidity and mortality. Because of great variability in definitions of specific complications, it remains unclear whether there is a difference in complication rates following the two commonest types of reconstruction, pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ). Published consensus definitions for postoperative pancreatic fistula (POPF) have led to a series of randomized clinical trials (RCTs) uniquely placed to address this question.

The Protective Mechanism of Ligustrazine Against Renal Ischemia/Reperfusion Injury

BACKGROUND Ischemia/reperfusion (I/R) injury is unavoidable in renal transplantation, and represents an additional risk factor for the late renal allograft failure. Our study focused on the effects of ligustrazine on oxidative stress, apoptosis, neutrophils recruitment, the expression of proinflammatory mediators and adhesion molecules caused by renal I/R injury. MATERIALS AND METHODS Renal warm I/R was induced in male C57BL/6 mice by clamping the left renal artery and vein non-traumatically. Group I was sham-operated animals; group II, nontreated animals; and group III, ligustrazine-treated animals (80 mg/kg, i.p. 30 min before I/R). Mice were sacrificed 4 and 24h post reperfusion. The effects of ligustrazine on oxidative stress, neutrophils recruitment, proinflammatory mediators, and adhesion molecules caused by renal I/R injury were assayed. RESULTS Ligustrazine pretreatment attenuated dramatically the injuries in mice kidneys caused by warm I/R (histological scores of untreated versus treated, 4.2 ± 0.4 versus 0.9 ± 0.3; P<0.01). Administration of ligustrazine significantly reduced myeloperoxidase (MPO) activity by 38.6% and decreased malondialdehye (MDA) level by 19.2%, while superoxide dismutase (SOD) activity increased by 39.6% (P<0.01), suggesting an effective reduction of oxidative stress following ligustrazine treatment. Moreover, ligustrazine also inhibited cell apoptosis, abrogated neutrophils recruitment, and suppressed the over expression of TNF-α and ICAM-1. CONCLUSIONS In conclusion, ligustrazine protects murine kidney from warm ischemia/reperfusion injury, probably via reducing oxidative stress, inhibiting cell apoptosis, decreasing neutrophils infiltration, and suppressing the overexpression of TNF-α and ICAM-1 levels.

Systematic review and meta‐analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy

Postoperative pancreatic leakage after pancreaticoduodenectomy is often serious. Although some studies have suggested that stenting the anastomosis can reduce the incidence of this complication, the value of stenting in the setting of pancreaticoduodenectomy remains unclear.

Hydroxyethyl starch resuscitation reduces the risk of intra-abdominal hypertension in severe acute pancreatitis.

Objectives: This study aimed to address whether hydroxyethyl starch (HES) is beneficial for intra-abdominal pressure (IAP) in severe acute pancreatitis (SAP) in early stages. Methods: Forty-one patients with SAP were randomized to HES group (n = 20) and the Ringers lactate (RL) group (n = 21). The groups received 6% HES 130/0.4 for 8 days and RL solution without colloid, respectively. The primary end point was the IAP. The secondary end points were fluid balance, major organ complications, the Acute Physiology and Chronic Heath Evaluation II score, and the serum levels of C-reactive protein, interleukin-6, and interleukin-8. Results: The characteristics of baseline data were similar in the 2 groups. In the HES group, the IAP was significantly lower in 2 to 7 days, and fewer patients received mechanical ventilation (15.0% vs 47.6%). A negative fluid balance was observed earlier in the HES group than in the RL group (2.5 ± 2.2 vs 4.0 ± 2.5 days). Conclusions: Fluid resuscitation with HES in the early stages of SAP can decrease the risk of intra-abdominal hypertension and reduce the use of mechanical ventilation.

Laparoscopic vs open total gastrectomy for gastric cancer: a meta-analysis.

AIM To conduct a meta-analysis comparing laparoscopic total gastrectomy (LTG) with open total gastrectomy (OTG) for the treatment of gastric cancer. METHODS Major databases such as Medline (PubMed), Embase, Academic Search Premier (EBSCO), Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched for studies comparing LTG and OTG from January 1994 to May 2013. Evaluated endpoints were operative, postoperative and oncological outcomes. Operative outcomes included operative time and intraoperative blood loss. Postoperative recovery included time to first flatus, time to first oral intake, hospital stay and analgesics use. Postoperative complications comprised morbidity, anastomotic leakage, anastomotic stenosis, ileus, bleeding, abdominal abscess, wound problems and mortality. Oncological outcomes included positive resection margins, number of retrieved lymph nodes, and proximal and distal resection margins. The pooled effect was calculated using either a fixed effects or a random effects model. RESULTS Fifteen non-randomized comparative studies with 2022 patients were included (LTG - 811, OTG - 1211). Both groups had similar short-term oncological outcomes, analgesic use (WMD -0.09; 95%CI: -2.39-2.20; P = 0.94) and mortality (OR = 0.74; 95%CI: 0.24-2.31; P = 0.61). However, LTG was associated with a lower intraoperative blood loss (WMD -201.19 mL; 95%CI: -296.50--105.87 mL; P < 0.0001) and overall complication rate (OR = 0.73; 95%CI: 0.57-0.92; P = 0.009); fewer wound-related complications (OR = 0.39; 95%CI: 0.21-0.72; P = 0.002); a quicker recovery of gastrointestinal motility with shorter time to first flatus (WMD -0.82; 95%CI: -1.18--0.45; P < 0.0001) and oral intake (WMD -1.30; 95%CI: -1.84--0.75; P < 0.00001); and a shorter hospital stay (WMD -3.55; 95%CI: -5.13--1.96; P < 0.0001), albeit with a longer operation time (WMD 48.25 min; 95%CI: 31.15-65.35; P < 0.00001), as compared with OTG. CONCLUSION LTG is safe and effective, and may offer some advantages over OTG in the treatment of gastric cancer.

Is laparoscopic approach for pancreatic insulinomas safe? Results of a systematic review and meta-analysis.

BACKGROUND No consensus exists as to whether laparoscopic treatment for pancreatic insulinomas (PIs) is safe and feasible. The aim of this meta-analysis was to assess the feasibility, safety, and potential benefits of laparoscopic approach (LA) for PIs. The abovementioned approach is also compared with open surgery. METHODS A systematic literature search (MEDLINE, EMBASE, Cochrane Library, Science Citation Index, and Ovid journals) was performed to identify relevant articles. Articles that compare the use of LA and open approach to treat PI published on or before April 30, 2013, were included in the meta-analysis. The evaluated end points were operative outcomes, postoperative recovery, and postoperative complications. RESULTS Seven observational clinical studies that recruited a total of 452 patients were included. The rates of conversion from LA to open surgery ranged from 0%-41.3%. The meta-analysis revealed that LA for PIs is associated with reduced length of hospital stay (weighted mean difference, -5.64; 95% confidence interval [CI], -7.11 to -4.16; P < 0.00001). No significant difference was observed between LA and open surgery in terms of operation time (weighted mean difference, 2.57; 95% CI, -10.91 to 16.05; P = 0.71), postoperative mortality, overall morbidity (odds ratio [OR], 0.64; 95% CI, 0.35-1.17; P = 0.14], incidence of pancreatic fistula (OR, 0.86; 95% CI, 0.51-1.44; P = 0.56), and recurrence of hyperglycemia (OR, 1.81; 95% CI, 0.41-7.95; P = 0.43). CONCLUSIONS Laparoscopic treatment for PIs is a safe and feasible approach associated with reduction in length of hospital stay and comparable rates of postoperative complications in relation with open surgery.

TNM staging of pancreatic neuroendocrine tumors: an observational analysis and comparison by both AJCC and ENETS systems from 1 single institution.

AbstractWe aimed to analyze the clinical characteristics and compare the surgical outcome of pancreatic neuroendocrine tumors (p-NETs) using the 2 tumor-node-metastasis (TNM) systems by both the American Joint Committee on Cancer (AJCC) Staging Manual (seventh edition) and the European Neuroendocrine Tumor Society (ENETS). Moreover, we sought to validate the prognostic value of the new AJCC criterion.Data of 145 consecutive patients who were all surgically treated and histologically diagnosed as p-NETs from January 2002 to June 2013 in our single institution were retrospectively collected and analyzed.The 5-year overall survival (OS) rates for AJCC classifications of stages I, II, III, and IV were 79.5%, 63.1%, 15.0%, and NA, respectively, (P < 0.005). As for the ENETS system, the OS rates at 5 years for stages I, II, III, and IV were 75.5%, 72.7%, 29.0%, and NA, respectively, (P < 0.005). Both criteria present no statistically notable difference between stage I and stage II (P > 0.05) but between stage I and stages III and IV (P < 0.05), as well as those between stage II and stages III and IV (P < 0.05). Difference between stage III and IV by ENETS was significant (P = 0.031), whereas that by the AJCC was not (P = 0.144). Whats more, the AJCC Staging Manual (seventh edition) was statistically significant in both uni- and multivariate analyses by Cox regression (P < 0.005 and P = 0.025, respectively).Our study indicated that the ENETS TNM staging system might be superior to the AJCC Staging Manual (seventh edition) for the clinical practice of p-NETs. Together with tumor grade and radical resection, the new AJCC system was also validated to be an independent predictor for p-NETs.

Survival Analyses for Patients With Surgically Resected Pancreatic Neuroendocrine Tumors by World Health Organization 2010 Grading Classifications and American Joint Committee on Cancer 2010 Staging Systems.

AbstractIn 2010, World Health Organization (WHO) reclassified pancreatic neuroendocrine tumors (p-NETs) into 4 main groups: neuroendocrine tumor G1 (NET G1), neuroendocrine tumor G2 (NET G2), neuroendocrine carcinoma G3 (NEC G3), mixed adeno and neuroendocrine carcinoma (MANEC). Clinical value of these newly updated WHO grading criteria has not been rigorously validated. The authors aimed to evaluate the clinical consistency of the new 2010 grading classifications by WHO and the 2010 tumor-node metastasis staging systems by American Joint Committee on Cancer (AJCC) on survivals for patients with surgically resected p-NETs. Moreover, the authors would validate the prognostic value of both criteria for p-NETs.The authors retrospectively collected the clinicopathologic data of 120 eligible patients who were all surgically treated and histopathologically diagnosed as p-NETs from January 2004 to February 2014 in our single institution.The new WHO criteria were assigned to 4 stratified groups with a respective distribution of 62, 35, 17, and 6 patients. Patients with NET G1 or NET G2 obtained a statistically better survival compared with those with NEC G3 or MANEC (P < 0.001). Survivals of NET G1 was also better than those of NET G2 (P = 0.023), whereas difference of survivals between NEC G3 and MANEC present no obvious significance (P = 0.071). The AJCC 2010 staging systems were respectively defined in 61, 36, 12, and 11 patients for each stage. Differences of survivals of stage I with stage III and IV were significant (P < 0.001), as well as those of stage II with III and IV (P < 0.001); whereas comparisons of stage I with stage II and stage III with IV were not statistically significant (P = 0.129, P = 0.286; respectively). Together with radical resection, these 2 systems were both significant in univariate and multivariate analysis (P < 0.05).The newly updated WHO 2010 grading classifications and the AJCC 2010 staging systems could consistently reflect the clinical outcome of patients with surgically resected p-NETs. Meanwhile, both criteria could be independent predictors for survival analysis of p-NETs.

Expression of NKG2D and Its Ligand in Mouse Heart Allografts May Have a Role in Acute Rejection

BACKGROUND Ligands for the natural killer cell-activating receptor NKG2D, such as retinoic acid early inducible (Rae-1), minor histocompatibility antigen H60 (mouse), and major histocompatibility complex class I chain-related (human) may be expressed by tissues in response to stress. Because NKG2D-ligand engagement may induce natural killer cell activation and provide T-cell costimulation, we examined whether this interaction between innate and adaptive immunity occurred during heart transplant rejection. METHODS Hearts from BALB/c mice were heterotopically transplanted into C57BL/6 mice without immunosupression. Grafts were harvested at 1, 3, and 5 days after transplantation. Rae-1, H60, and NKG2D mRNA were analyzed by RT-PCR, and the proteins were detected by immunohistochemistry. RESULTS Compared with no expression in naïve BALB/c mice hearts, Rae-1 mRNA levels in heart allografts were detected from days three to five postoperative, H60 on day five, and NKG2D on day three but prominently on day five postoperative. Immunohistochemical assay showed that compared with rare expression in syngeneic cardiac grafts, there were significant protein expressions of Rae-1 and NKG2D in heart allografts from days three to five postoperative and of H60 on day 5 postoperative. CONCLUSION This study reported significant mRNA and protein expression of Rae-1, H60, and NKG2D during acute cardiac allograft rejection. The simultaneous and significant expression of NKG2D and its ligands indicated that interactions with innate immunity may promote acute rejection. The results also suggested that Rae-1 and H60 may be new targets to amelioate this immune response.

Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy.

BACKGROUND Postoperative pancreatic fistula (POPF) has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy (PD). Both patient-derived and technical factors contribute to pancreatic anastomotic failure. The continuous suture duct-to-mucosa pancreaticojejunostomy (PJ) described previously is associated with a low rate of POPF. The aim of the present study was to observe whether the new technique would effectively reduce the POPF rate in comparison with conventional interrupted suture duct-to-mucosa PJ. METHODS Data on 255 consecutive patients, who underwent the two methods of PJ after standard PD by one group of surgeons between 2006 and 2013, were collected retrospectively from a prospective database. The primary end point was the POPF rate. The risk factors of POPF were investigated by using univariate and multivariate analyses. RESULTS A total of 120 patients received continuous suture PJ and 135 underwent interrupted suture PJ. Rate of POPF for the entire cohort was 12.5%. There were 9 fistulas (7.5%) in the continuous anastomosis group and 23 fistulas (17%) in the interrupted anastomosis group (P = 0.022). The rates of major complications (Clavien grades 3-5) were less in the continuous anastomosis group (5%) compared with the interrupted anastomosis group (13.3%) (P = 0.023). The greatest risk factor for a POPF was pancreatic duct diameter: POPF developed in only 3 patients (3.6%) with large pancreatic ducts (≥ 3 mm) and in 29 patients (16.9%) with small pancreatic ducts (<3 mm). There were four postoperative (in-hospital) deaths (both in the interrupted anastomosis group); two of which had POPF as the proximate cause of death, followed by bleeding and sepsis. CONCLUSIONS The continuous suture duct-to-mucosa PJ effectively reduces the POPF rate after PD in comparison with interrupted anastomosis. The results confirm increased POPF rates in patients with pancreatic duct diameter <3 mm compared with pancreatic duct diameter ≥ 3 mm.