[Analysis of influencing factors on surgical outcome and exploration of technical principles during pancreaticojejunostomy]

Pancreaticojejunostomy is the most common anastomosis following pancreaticoduodenectomy and middle pancreatectomy. The detailed surgical technics of pancreaticojejunostomy vary dramatically, but none of them can achieve zero fistula rate. In recent years,with the development of new surgical concept,application of new surgical technology, high-tech materials and instruments,the incidence of pancreatic fistula has decreased. At the same time,researches on investigating the risk factors of pancreaticojejunostomy are gradually deepening. Based on years of surgical experience on pancreaticojejunostomy and current literatures, this paper analyzes the factors affecting the effect of pancreaticojejunostomy, such as the patient's basic physical state,pancreatic texture and diameter of the pancreatic duct,pathology and course of the disease,surgical technology and perioperative management,and summarizes six technical principles for pancreaticojejunostomy to be shared with surgical comrades:appropriate tension,protection of blood supply,hermetic closure of pancreatic section,accurate connection of pancreatic duct and intestinal mucosa,individualization,learning and accumulation of experience.

[A comparative study of breast cancer mass screening and opportunistic screening in Chinese women]

Objective: To compare the population characteristics, the positive rate of screening, the detection rate of breast cancer, early diagnosis rate and the cost between the mass screening group and opportunistic screening group of breast cancer. Methods: This study is a prospective multicenter cohort study conducted from January 1, 2014 to December 31, 2016. The participants were enrolled for mass screening or opportunistic screening of breast cancer. After completing the questionnaire, all the participants received breast physical examination and breast ultrasound examination every year for 3 rounds by year. The participants' characteristics and screening results of the two groups were compared by χ² test, Fisher exact test or Wilcoxon rank-sum test. Results: A total of 20 080 subjects were enrolled. In the mass screening group, 9 434 (100%), 8 111 (85.98%) and 3 940 (41.76%) cases completed the 3 rounds of screening, and 10 646 (100%), 6 209 (58.32%) and 2 988 (28.07%) cases in the opportunistic screening group, respectively. In the opportunistic screening group, the proportions of less than 3 months lactation (1 275/9 796 vs. 1 061/8 860, χ²=4.597, P=0.032), non-fertility (850/10 646 vs. 574/9 434, χ²=27.400, P<0.01), abortion history (6 384/10 646 vs. 5 062/9 434, χ²=81.232, P<0.01), postmenopausal (2 776/10 646 vs. 2 217/9 434, χ²=17.757, P<0.01), long-term oral contraceptives(>6 months) (171/10 646 vs. 77/9 434, χ²=25.593, P<0.01) and family history of breast cancer in first-degree relatives (464/10 646 vs. 236/9 434, χ²=51.257, P<0.01) were significantly higher than those in mass screening group. The positive rate of screening (514/10 646 vs. 128/9 434, χ²=194.736, P<0.01), the detection rate of breast cancer (158/10 646 vs. 13/9 434, χ²=107.374, P<0.01), and positive rate of biopsy (158/452 vs. 13/87, χ²=13.491, P<0.01) in the opportunistic screening group were significantly higher than those of the mass screening group. The early diagnosis rate of the mass screening group was significantly higher than the opportunistic screening group (10/12 vs. 66/141, χ²=5.902, P=0.015). The average cost for detecting each breast cancer case of the mass screening group was 215 038 CNY, which was 13.6 times of the opportunistic screening group (15 799 CNY/case). In the opportunistic screening group, the positive rate of biopsy in primary hospitals was significantly lower than that in large-volume hospitals (79/267 vs. 79/185, χ²=8.267, P=0.004), but there was no significant difference in the mass screening group (6/37 vs. 7/50, χ²=0.082, P=0.774). Conclusions: Breast cancer screening can improve early detection rate. Compared with the mass screening mode, the opportunistic screening mode has the advantages of higher proportion of high-risk factors, higher positive rate of screening, higher detection rate of breast cancer, higher positive rate of biopsy, and lower cost of screening. However, the early diagnosis rate of breast cancer of opportunistic screening is lower than that of mass screening. The positive rate of opportunistic screening in primary hospitals is lower than that of large-volume hospitals. The two screening modes have their own advantages and should be chosen according to local conditions of different regions in China.

[Four-steps surgery for infected pancreatic necrosis based on "Step-up" strategy: a retrospective study]

Objective: To examine the effect of the "four-steps" treatment on infectious pancreatic necrosis(IPN). Methods: The data of 207 patients who were diagnosed with IPN from January 2013 to December 2017 at Department of Pancreaticobiliary Surgery, the First Affiliated Hospital of Harbin Medical University were analyzed retrospectively. Among 207 patients, 132(63.8%) were males and 75(36.2%) were females. The median age was 45 years old (range: 19 to 80 years old). One hundred and fifty-eight patients(76.3%) suffered severe acute pancreatitis and 49 patients(23.7%) suffered moderately severe acute pancreatitis. Percutaneous catheter drainage(PCD) was performed on all the patients(Step 1). Patients received "four-steps" minimally invasive treatment strategy in step-up group(173 patients). The following steps after PCD were mini-incision access pancreatic necrosectomy(MIAPN) (Step 2), sinus tract endoscopic debridement and(or) PCD for residual infections(Step 3) and finally conventional open pancreatic necrosectomy(OPN) (Step 4). Patients(34 cases) received conventional open pancreatic necrosectomy after invalided PCD in OPN group. The perioperative parameters and prognosis were compared between Step-up group and OPN group. Normally distributed quantitative variables were analyzed by t-test, non-normally distributed quantitative variables were analyzed by Wilcoxon chi-square test and categorical variables were analyzed by χ(2) test or Fisher exact test, respectively. Results: The basic characteristics of the two groups of patients were similar, but the referral rate of patients and the rate of preoperative 3 days organ failure in the OPN group were significantly higher than those of step-up group patients(47.1% vs. 28.9%, χ(2)=4.313, P=0.038; 26.5% vs. 9.2%, χ(2)=2.819, P=0.011). The frequency of PCD and the number of PCD tube (root) were less than those in the step-up group(1(1) vs. 2(1), Z=-3.373, P=0.018; 2(1) vs. 3(2), Z=-2.208, P=0.027). Compared with the OPN group, the interval time from onset to surgery and the MIAPN operation time were significantly shorter in the step-up group(29(15) days vs. 36(17)days, Z=-0.567, P=0.008; 58(27)minutes vs. 90(56)minutes, Z=-3.908, P<0.01); postoperative mortality was lower(5.8% vs.17.6%, χ(2)=4.070, P=0.044); the overall incidence of postoperative complications was reduced(23.1% vs. 55.9%, χ(2)=14.960, P<0.01) and the incidence of new-onset organ failure was decreased after operation in the step-up group(37.5% vs.47.4%, χ(2)=7.133, P=0.007). The incidence of local abdominal complications (pancreatic fistula, intra-abdominal hemorrhage, gastrointestinal fistula) showed no significant difference between the two groups (P>0.05). Fewer patients required ICU treatment after operation in the step-up group compared with OPN group(22.0% vs. 44.1%, χ(2)=6.204, P=0.013). Patients in the Step-up group has shorter hospital stay than patients in OPN group (46(13) days vs. 52(13)days, Z=-1.993, P=0.046). Conclusions: The clinical effects of "four-steps" exhibited the superiority of minimally invasive treatment of IPN.And MIAPN is a simple, safe and effective procedure to remove pancreatic necrotic tissue and decrease complications.

[Clinical analysis of 382 immediately breast reconstruction after mastectomy in Beijing City, Tianjin City and Hebei Province from 2012 to 2016]

Objective: To summarize the status of immediate breast reconstruction (IBR) after mastectomy in Beijing City, Tianjin City and Hebei Province. Methods: A retrospective analysis was made on the data of 382 cases with breast cancer who were treated and followed up successfully with immediate breast reconstruction after mastectomy from January 2012 to December 2016 in Beijing City, Tianjin City and Hebei Province. Clinic data of the followed-up 382 cases (all female, age (38.5±4.2) years (range: 24 to 70 years)), including general information, tumor information, sugery methods, and treatments after surgery were collected. The survival status, metastasis,complications and prognosis were followed up. Cosmetic effcet was evalated by Harris method, and life quality by Functional Assessment of Cancer Therapy-Breast scale (FACT-B). χ(2) test was used to compare the difference between year 2012 and year 2013 to 2016. Bonferroni method was used to correct the inspection level, which was 0.05/10=0.005. The trend of IBR rate (ratio of IBR to modified radical mastectomy) from 2013 to 2016 was analyzed by trend χ(2) test. Results: There was 46 cases in stage 0, 152 cases in stage Ⅰ, 165 cases in stage Ⅱ, 19 cases in stage Ⅲ. Twenty-five cases was treated by neoadjuvant chemotherapy, 231 by chemotherapy and 35 by radiotherapy. The proportion of implant reconstruction was 48.7% (186/382), more than expanded of 21.5% (82/382), with latissimus dorsi of 12.0% (46/382), TRAM of 8.9% (34/382), DIEP of 2.1% (8/382), and latissimus plus implant of 6.8% (26/382). According to the Harris standard, the excellent and good rate of the cosmetic effect of the reconstructed breast was 93.7%. The score of FACT-B was 108.20±16.9 (range: 67 to 144) 1 year postoperatively. Compared with 2012, the IBR rate was significant increased, till 2015, the IBR rate was 153/10 000 cases (χ(2)=47.028, P=0.000). Conclusions: There is a significant increase on IBR rate in Beijing City, Tianjin City and Hebei province by year. Most of cases received IBR is stage Ⅰ to Ⅱ. Implant reconstruction is the main reconstructive method. Postoperative cosmetic effects and quality of life are both meet patients' demon.

[Non-technical skills for surgeons]

The rapid development of professional technology not only brings great benefits to patients, but also reveals the problem of non-technical skills. Technical competence is not enough to avoid the occurrence of adverse medical events or to get optimal post-operative outcomes. The development of technology is endless, we are desperately in need of non-technical skills, such as situation awareness, decision making, communication and teamwork, leadership. The only way we could achieve in the assistance of the perfect surgical operation with the combination of excellent surgical techniques and solid non-technical skills, and therefore relieve the patients as much as possible.

[Effect of non-diabetic postoperative hyperglycemia on complications after pancreaticoduodenectomy]

Objective: To examine the association of hyperglycemia and postoperative complications in non-diabetic patients underwent pancreaticoduodenectomy(PD). Methods: The clinical data of 209 non-diabetic patients who underwent PD from January 2012 to June 2018 at Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University and met the inclusion criteria were retrospectively analyzed. According to the diagnostic criteria of postoperative hyperglycemia, the patients were divided into postoperative hyperglycemia group (167 cases, 79.9%) and control group(42 cases, 20.1%). The propensity score matching(PSM) method was used to eliminate the difference between groups(caliper value=0.02; 38 cases in control group including 30 males and 8 females with age of 59.0 years;38 cases in postoperative hyperglycemia group including 32 males and 6 females with age of 61.0 years;37 cases of pancreatic head carcinoma,30 cases of periampullary carcinoma and 9 cases of benign diseases). A comparative analysis was applied for preoperative data, surgical related indicators and postoperative complication rates.The receiver operating characteristic(ROC) curve was used to calculate the area under the curve(AUC) of blood glucose values on postoperative day 1,3 and 5(POD1, POD3, POD5), to determine the high-risk blood glucose cutoff value of complications and to evaluate its sensitivity and specificity for the prediction of postoperative complications. Results: Univariate analysis showed that the differences in gender, body mass index, preoperative blood glucose, and serum urea nitrogen levels were statistically significant before PSM.There was no significant difference in the preoperative data between the two groups after PSM. Compared with the control group, the incidence of postoperative pancreatic fistula (31.6% vs. 5.3%), abdominal infection(29.0% vs. 7.9%) and Clavien-Dindo Ⅲ-Ⅴ complications(31.6% vs.7.9%) were statistically different(χ(2)=7.092,P=0.008; χ(2)=4.290,P=0.038; χ(2)=5.316,P=0.021), respectively. According to the AUC on POD3,the blood glucose value ≥8.860 mmol/L was an independent risk factor for pancreatic fistula with sensitivity of 58.3% and specificity of 76.9%,the blood glucose value ≥9.130 mmol/L was an independent risk factor for abdominal infection with sensitivity of 54.5% and specificity of 81.5% and the blood glucose value ≥7.685 mmol/L was independent risk factor of Clavien-Dindo Ⅲ-Ⅴ complications with sensitivity of 75.0% and specificity of 57.7%. Conclusions: Postoperative hyperglycemia in non-diabetic patients is associated with postoperative pancreatic fistula, abdominal infection, and Clavien-Dindo Ⅲ-Ⅴ complications.According to the early postoperative blood glucose value,the occurrence of postoperative pancreatic fistula, abdominal infection and Clavien-Dindo Ⅲ- Ⅴ complications can be effectively predicted.

Development and validation of a preoperative prediction model for follicular thyroid carcinoma

OBJECTIVE

The low pre- and intraoperative diagnostic rates in follicular thyroid carcinoma (FTC) often lead to inadequate surgical resection and necessitate further completion surgery. Therefore, the preoperative prediction of FTC in thyroid nodules is essential. DESIGN AND PATIENT: Patients were categorized into two data sets: the modelling data set, which included 3649 patients admitted to our centre between January 2014 and December 2016, and the validation data set, which included 1253 patients admitted between January and December 2017. Patient data from the FTC and non-FTC groups were initially included in a modelling data set to establish a preoperative prediction model. This model was subsequently employed in a validation data set for external validation of the predictive value. The positivity rate for FTC predicted by the model was compared with that of the intraoperative frozen sections.

RESULTS

The preoperative serum thyroglobulin level, nodule diameter, calcification status, solidity and blood supply were selected as predictors for the model. The regression equation was as follows: Y = 0.010 × (thyroglobulin level) + 0.556 × (nodule diameter) + 0.675 × (calcification status) + 2.355 × (nodule component) + 1.072*(blood flow) - 9.787. The model positively predicted FTC at values of Y ≥ -4.11. The accuracy, sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the prediction model were 89.2%, 90.2%, 87.7%, 39.2 and 0.11, respectively. External validation of the model demonstrated acceptable results. The positive prediction rate of the model was 90.7% (78/86), which was significantly higher than that of the intraoperative frozen sections (10.5% [9/86]; P < 0.0001).

CONCLUSIONS

We successfully established and validated a simple and reliable preoperative prediction model for FTC using the preoperative thyroglobulin level and ultrasonographic features of the thyroid nodules. This model may improve the preoperative evaluation of FTC in clinical settings and facilitate the development of a reasonable surgical programme for FTC.

Clinicopathologic risk factors for right paraesophageal lymph node metastasis in patients with papillary thyroid carcinoma

OBJECTIVES

To investigate risk factors associated with right paraesophageal lymph node (RPELN) metastasis in patients with papillary thyroid carcinoma (PTC) and to determine the indications for right lymph node dissection.

METHODS

Clinicopathologic data from 829 patients (104 men and 725 women) with PTC, operated on by the same thyroid surgery team at the First Affiliated Hospital of Harbin Medical University from January 2013 to May 2017, were analyzed. Overall, 309 patients underwent total thyroidectomy with bilateral lymph node dissection, 488 underwent right thyroid lobe and isthmic resection with right central compartment lymph node dissection, and 32 underwent near-total thyroidectomy (ipsilateral thyroid lobectomy with contralateral near-total lobectomy) with bilateral lymph node dissection.

RESULTS

The overall rate of central compartment lymph node metastasis was 43.5% (361/829), with right central compartment lymph node and RPELN metastasis rates of 35.5% (294/829) and 19.1% (158/829), respectively. Tumor size, number, invasion, and location, lymph node metastasis, right central compartment lymph node metastasis, and right lateral compartment lymph node metastasis were associated with RPELN in the univariate analysis, whereas age and sex were not. Multivariate analysis identified tumors with a diameter ≥ 1 cm, multiple tumors, tumors located in the right lobe, right central compartment lymph node metastasis, and right lateral compartment lymph node metastasis as independent risk factors for RPELN metastasis.

CONCLUSIONS

Lymph node dissection, including RPELN dissection, should be performed for patients with PTC with a tumor diameter ≥ 1 cm, multiple tumors, right-lobe tumors, right central compartment lymph node metastasis, or suspected lateral compartment lymph node metastasis.

[Rethinking on ethics and principle of surgery]

Surgery is an important part of medicine, it has undergone huge changes in recent decades in China.The concepts of damage control surgery, minimally invasive surgery, and enhanced recovery after surgery are all new with the date, laparoscopic surgery, robotic surgery, natural orifice transluminalendoscopic surgery are not new words to all of us. Surgical operations are becoming more and more specialized, surgical technique is becoming more and more mature, and surgeons are becoming more and more specialized. Medical ethical issues, as the common language of surgeons and basic principle of surgery, should be recognized and understood more stronger than ever, which will enable surgeons to retrieve original intention of surgery. This paper takes this as starting point and explore the common principles of surgery, aims to arouse some mutual encouragement to growing youth surgeons.

Variation of nanoparticle fraction and compositions in two-stage double peaks aging precipitation of Al-Zn-Mg alloy

Atom probe tomography (APT) coupling high-resolution transmission electron microscopy (HRTEM) was used to analyze the fraction and compositions of different nanoparticles in two-stage double peaks aging process of Al-Zn-Mg alloy. Al content is found to be closely related to the size of nanoparticles and it can be greater than ~ 50.0 at. % in the nanoparticle with the equivalent radius under ~ 3.0 nm. Correspondingly, Al content of the nanoparticle, with the equivalent radius over ~ 5.0 nm, is measured under ~ 40.0 at. %. Evolution from Guinier-Preston (G.P.) zone to η phase is a growing process where Mg and Zn atoms enter the nanoparticle, therefore rejecting Al atoms. G.P. zones can take up a number fraction of ~ 85.0 and ~ 22.7% of nanoparticles in the first and second peak-aged samples, respectively, and even in the over-aged (T73) sample, they can still be found. As aging time increases, fraction of η' phases monotonically rises to the peak value (~ 54.5%) in the second peak-aged state and then drops, which is significant for the second hardness peak and directly proves their function as the transitional medium. In T73 state, ~ 63.3% nanoparticles compose of η phases, which were measured to still contain ~ 10.2 to ~ 36.4 at. % Al atoms.

Measurement of Ti-6Al-4V alloy ignition temperature by reflectivity detection

Fires resulting from titanium combustion are complex and violent processes which can instantly burn a titanium alloy once ignited. The occurrence of titanium combustion is a disaster for aircraft. Accurate measurement of the ignition temperature of titanium alloys is of significance in preventing such fires and in investigating combustion-resistance properties. In this study, monochromatic temperature and emissivity measurement methods based on reflectivity detection were used to determine the ignition temperature of a titanium alloy. Experiments were carried out using a titanium burning apparatus. The temperatures of titanium in the oxidation stage before ignition and in the combustion stage during the ignition process were measured using wavelengths of 1050 nm and 940 nm, respectively. Experimental results showed that the ignition temperature of the titanium alloy could be measured by reflectivity detection and that measurement precision during thermal oxidation (500-900 °C) was ±1 °C. The temperature of the ignition process ranged between 1653 and 1857 °C, and the ignition temperature was around 1680 °C.

[Prognostic factors of postoperative delayed gastric emptying after pancreaticoduodenectomy: a predictive model]

Objective: To study the prognostic factors of delayed gastric emptying(DGE) after pancreaticoduodenectomy(PD) and construct a prognostic predictive model for clinical application. Methods: Clinic data of 401 consecutive patients who underwent PD between January 2012 and July 2016 in the First Affiliated Hospital of Harbin Medical University were retrospectively collected and analyzed. The patients were randomly selected to modeling group(n=299) and validation group(n=102) at a ratio of 3∶1. The data of modeling group were subjected to univariate and multivariate analysis for prognostic factors and to construct a prognostic predictive model of DGE after PD. The data of validation group were applied to test the prognostic predictive model. Results: DGE after PD occurred in 35 of 299 patients(11.7%) in the modeling group. The multivariate analysis of the modeling group showed that upper abdominal operation history(χ(2)=6.533, P=0.011), diabetes mellitus(χ(2)=17.872, P=0.000), preoperative hemoglobin <90 g/L(χ(2)=14.608, P=0.000) and pylorus-preserving pancreaticoduodenectomy(PPPD)(χ(2)=8.811, P=0.003) were associated with DGE after PD independently. A prognostic predictive model of DGE after PD was constructed based on these factors and successfully tested. The area under the receiver operating characteristic(ROC) curve was 0.761(95%CI: 0.666-0.856) of the modeling group and 0.750(95% CI: 0.577-0.923) of the validation group. Conclusions: Upper abdominal operation history, diabetes mellitus, preoperative hemoglobin<90 g/L and PPPD are associated with DGE after PD independently. The preoperative assessment of a patient's prognostic for DGE after PD is feasible. The model is a valid tool to take precautions against DGE after PD.

[Clinical experience on the employment of the staged step-up approach in the treatment of local complications secondary to severe acute pancreatitis]

Objective: To explore the experience and prognostic factors associated with the employment of the step-up approach in the treatment of local complications secondary to severe acute pancreatitis (SAP). Methods: The clinical data of 279 patients admitted to the Department of Pancreatic and Biliary Surgery, First Affiliated Hospital of Harbin Medical University from January 2011 to December 2015, whose local complications secondary to SAP were treated in a staged step-up framework, were retrospectively analyzed.For patients with documented or suspected infected pancreatic necrosis or gastrointestinal tract obstruction, some non-surgical interventions were initialed with the aim of postponing the timing of surgery to the forth week from the onset of SAP.The first-step intervention was a percutaneous catheter drainage (PCD) under the guidance of ultrasound. A minimal access retroperitoneal pancreatic necrosectomy, representing the second-step intervention, was conducted when PCD had failed. Finally, an open necrosectomy (the third-step intervention) was immediately resorted to when all of previous minimal invasive interventions had failed.Normally distributed quantitative variables were analyzed by t-test, non-normally distributed quantitative variables were analyzed by Wilcoxon chi-square test and categorical variables were analyzed by χ² test or Fisher's exact test.A multivariable Logistic regression analytic model was established to figure out the prognostic factors that were independently associated with the requirement of debridement in addition to drainage procedure during the staged step-up framework of patients with local complications secondary to SAP. Results: The initial interventions in this series were performed at 12 d (9-22 d) from the on-set of SAP and 104 cases (37.3%) were cured with ultrasound guided PCD alone.There were 152 cases (54.5%) cured by debridement in addition to PCD with the time interval of 30 d (25 to 44 d) since the on-set of the disease.The overall incidence of postoperative complications was 22.6% (63 cases) and in-hospital mortality was 8.2% (23 cases) in the present series.Multiple organ failures(MOF)(P<0.01, OR=3.15), heterogeneous collections (P<0.01, OR=2.40) and tertiary transfer (P=0.03, OR=1.80) were verified as the prognostic factors that were independently associated with the requirement of debridement in addition to PCD during the staged step-up framework of patients with local complications secondary to SAP. Conclusions: The staged step-up framework is a promising innovation that complies well with the era of minimal invasive surgery and is optimally suitable for the surgical interventions against SAP.MOF, heterogeneous collections and tertiary transfer are the prognostic factors that are independently associated with the requirement of debridement in addition to PCD during the staged step-up framework of patients with local complications secondary to SAP.

EF24 inhibits tumor growth and metastasis via suppressing NF-kappaB dependent pathways in human cholangiocarcinoma

A synthetic monoketone analog of curcumin, termed 3, 5-bis (2-flurobenzylidene) piperidin-4-one (EF24), has been reported to inhibit the growth of a variety of cancer cells both in vitro and in vivo. However, whether EF24 has anticancer effects on cholangiocarcinoma (CCA) cells and the mechanisms remain to be investigated. The aim of our study was to evaluate the molecular mechanisms underlying the anticancer effects of EF24 on CCA tumor growth and metastasis. Cell proliferation, apoptosis, migration, invasion, tumorigenesis and metastasis were examined. EF24 exhibited time- and dose-dependent inhibitory effects on HuCCT-1, TFK-1 and HuH28 human CCA cell lines. EF24 inhibited CCA cell proliferation, migration, and induced G2/M phase arrest. EF24 induced cell apoptosis along with negative regulation of NF-κB- X-linked inhibitor of apoptosis protein (XIAP) signaling pathway. XIAP inhibition by lentivirus mediated RNA interference enhanced EF24-induced apoptosis, while XIAP overexpression reduced it in CCA cells. In vivo, EF24 significantly suppressed the growth of CCA tumor xenografts and tumor metastasis while displaying low toxicity levels. Our findings indicate that EF24 is a potent antitumor agent that inhibits tumor growth and metastasis by inhibiting NF-κB dependent signaling pathways. EF24 may represent a novel approach for CCA treatment.

Precision medicine for hepatocellular carcinoma: Perspectives and obstacles

Hepatocellular carcinoma (HCC) is one of the most common cancers in China. HCC patients have a poor prognosis due to the lack of effective drugs. The marketing of sorafenib in 2007 has terminated the history that there is no effective drug for HCC. Unfortunately, sorafenib prolongs the survival of advanced HCC patients by only 2-3 mo, and remains the unique systemic drug as no alternative effective agents have been demonstrated to be superior to sorafenib in treating HCC. Precision medicine, a novel concept and medicinal model, has recently emerged and been spreading globally, with the development of gene sequencing techniques, bioinformatics, big data and so on. Detecting, analyzing, verifying and utilizing the specific tumor biomarkers with the advanced technology have made it possible to apply "personalized and precision therapy" in the treatment of advanced HCC. In the present article we summarize the recent progress of HCC therapy under the guidance of precision medicine, and analyze the major obstacles for its clinical application, with an aim to provide some new clues for clinicians and researchers engaged in the clinical and basic research of HCC.

[The clinical analysis of a step-up approach for severe acute pancreatitis: report of 121 cases]

OBJECTIVE

To investigate the feasibility and clinical value of the step-up approach for severe acute pancreatitis (SAP).

METHODS

Clinical data of 121 SAP patients admitted between January 2002 and December 2011 were retrospectively analyzed. Fifty-eight patients (37 males and 21 females, aged from 20 to 72 years, mean 47.6 years) in the group of direct open necrosectomy from January 2002 to December 2006 were performed laparotomy through removal of all necrotic tissue. Sixty-three patients (42 males and 21 females, aged from 19 to 78 years, mean 46.2 years) of step-up approach from January 2007 to December 2011 underwent percutaneous catheter drainage through retroperitoneum or omental bursa guided by B-type ultrasonography for the first therapy, and then, according to the pathogenetic condition, if necessary, followed by a small incisional necrosectomy along the drainage tube. The two groups were compared for the rates of postoperative complications, death, transfusion and length of stay, medical costs.

RESULTS

The rates of total postoperative complications, organ dysfunction, alimentary tract fistula and incisional hernia in step-up approach group were significantly lower than those of direct open necrosectomy group (31.7% vs. 62.1%, 14.3% vs. 37.5%, 6.3% vs. 19.0%, 9.5% vs. 29.3%; χ(2) = 4.43 to 11.17, P = 0.001 to 0.035). The other complications had no significant differences between the two groups (P > 0.05). Patients in step-up approach group had a lower rates of transfusion (44.4% vs. 70.7%, χ(2) = 8.488, P = 0.004), fewer medical costs of transfusion and hospital stay, compared with those in direct open necrosectomy group ((2525 ± 4573) yuan vs. (4770 ± 6867) yuan, t = 2.131, P = 0.035; (171 213 ± 50 917) yuan vs. (237 874 ± 67 832) yuan, t = 2.496, P = 0.014). There were no significant differences of length of stay and mortality between two groups (P > 0.05).

CONCLUSION

Step-up approach for SAP which can reduce the rates of postoperative complications, transfusion and medical costs has significant feasibility and great clinical value.

Precise hepatectomy guided by minimally invasive surgery: a novel strategy for liver resection

Liver resection has been established currently as an effective and standard treatment for patients suffering from both benign and malignant hepatobiliary diseases. Although substantial improvement in perioperative mortality rate and morbidity resulting from appropriate candidates selection, advanced surgical techniques and enhanced perioperative care, hepatectomy is still burdened by about 5% mortality rate and some lethal postoperative complications, especially postoperative liver insufficiency and failure. Various approaches have been advocated to minimize stress and insult on patients due to operative procedures. It becomes important to preserve remnant hepatic function as much as possible to improve the outcome of hepatectomy. Minimally invasive concept and fast track surgery are crucial breakthrough in the natural history of surgery and have been employed in liver resection. To safely and accurately perform hepatic resection, owing to our experiences with recent advances in surgical techniques and perioperative administration for liver resection, a novel strategy, "precise hepatectomy" originating from minimally invasive surgery has been developed, which includes precise preoperative planning, sophisticated intraoperative techniques and careful postoperative management. This strategy is characteristic by involvement of minimally invasive concept in overall therapy, from preoperative assessment to postoperative care, optimization of a series of advanced techniques and proper employment of surgical instruments in light of actual individual information. However, further prospective studies, especially randomized controlled trials in high volume centers, remain essential to compare the safety and therapeutic efficacies between precise hepatectomy and conventional surgical procedures.

Matrine inhibits breast cancer growth via miR-21/PTEN/Akt pathway in MCF-7 cells

BACKGROUND

Matrine is one of the major alkaloids extracted from Sophora flavescens and has been used clinically for breast cancer with notable therapeutic efficacy in China. However, the mechanisms are still largely unknown.

METHODS

Cell viability was analyzed by MTT assay. After MCF-7 cells were treated with matrine for 48h, apoptosis was detected by flow cytometry, TUNEL assay and transmission electron microscopy, and the cell cycle distribution was also analyzed by flow cytometry. Further, the expression of PTEN, pAkt, Akt, pBad, Bad, p21(/WAF1/CIP1), and p27(/KIP1) was determined by Western blot. Changes of miR-21 level were quantified by real-time RT-PCR. After miR-21 was transfected in MCF-7 cells, PTEN protein level was measured by Western blot.

RESULTS

Matrine inhibited MCF-7 cell growth in a concentration-and time-dependent manner, by inducing apoptosis and cell cycle arrest at G(1)/S phase. Matrine up-regulated PTEN by downregulating miR-21 which in turn dephosphorylated Akt, resulting in accumulation of Bad, p21(/WAF1/CIP1) and p27(/KIP1).

CONCLUSION

Our study unraveled, for the first time, the ability of matrine to suppress breast cancer growth and elucidated the miR-21/PTEN/Akt pathway as a signaling mechanism for the anti-cancer action of matrine. Our findings also reinforce the notion that miRNAs can act as mediators of the therapeutic efficacy of natural medicines.

Expression and prognostic value of ING3 in human primary hepatocellular carcinoma

The tumor-suppressor ING3 has been shown to be involved in tumor transcriptional regulation, apoptosis and the cell cycle. Some studies have demonstrated that ING3 is dysregulated in several types of cancers. However, the expression and function of ING3 in human hepatocellular carcinoma (HCC) remains unclear. The aim of this study is to investigate ING3 expression in hepatic tumors and its clinical relevance in hepatic cancer. The expression of ING3 protein was examined in 120 dissected HCC tissues and 47 liver tissues adjacent to the tumor by immunohistochemical assays and confirmed by Western blot analysis in 20 paired frozen tumor and non-tumor liver tissues. The relationship between ING3 staining and clinico-pathological characteristics of HCC was further analyzed. The mRNA expression of ING3 in the dissected tissues was also analyzed by reverse transcriptase polymerase chain reaction (RT-PCR) and realtime PCR. Both mRNA and protein concentrations of ING3 were found to be downregulated in the majority of HCC tumors in comparison with matched non-tumor hepatic tissues. Analysis of the relationship between ING3 staining and clinico-pathological characteristics of HCC showed that the low expression of ING3 protein is correlated with more aggressive behavior of the tumor. Kaplan–Meier curves demonstrated that patients with a low expression of ING3 have a significantly increased risk of shortened survival time. In addition, multivariate analysis suggested that the level of ING3 expression may be an independent prognostic factor. Our findings indicate that ING3 may be an important marker for human hepatocellular carcinoma progression and prognosis, as well as a potential therapeutic target.

Nuclear factor-κB-dependent epithelial to mesenchymal transition induced by HIF-1α activation in pancreatic cancer cells under hypoxic conditions

BACKGROUND

Epithelial to mesenchymal transition (EMT) induced by hypoxia is one of the critical causes of treatment failure in different types of human cancers. NF-κB is closely involved in the progression of EMT. Compared with HIF-1α, the correlation between NF-κB and EMT during hypoxia has been less studied, and although the phenomenon was observed in the past, the molecular mechanisms involved remained unclear.

METHODOLOGY/PRINCIPAL FINDINGS

Here, we report that hypoxia or overexpression of hypoxia-inducible factor-1α (HIF-1α) promotes EMT in pancreatic cancer cells. On molecular or pharmacologic inhibition of NF-κB, hypoxic cells regained expression of E-cadherin, lost expression of N-cadherin, and attenuated their highly invasive and drug-resistant phenotype. Introducing a pcDNA3.0/HIF-1α into pancreatic cancer cells under normoxic conditions heightened NF-κB activity, phenocopying EMT effects produced by hypoxia. Conversely, inhibiting the heightened NF-κB activity in this setting attenuated the EMT phenotype.

CONCLUSIONS/SIGNIFICANCE

These results suggest that hypoxia or overexpression of HIF-1α induces the EMT that is largely dependent on NF-κB in pancreatic cancer cells.

Tetraethylammonium enhances the rectal and colonic motility in rats and human in vitro

Hirschsprung's disease is the congenital absence of generating the peristaltic contractions transmitting from the proximal colon to rectum. We previously have found that tetraethylammonium (TEA), the nonselective Ca(2+)-activated K(+) channel blocker, increases the maximal contractile force and the amplitude of the contraction in rat duodenum. The present study is to test the effect of TEA on motility of colon and rectum from rats and Hirschsprung's disease patients in vitro, in order to find an alternative method to improve the syndrome of Hirschsprung's disease. The rectal and colonic motility was recorded by a tension transducer connected to a biology function experiment system. Histology was analyzed with standard hematoxylin and eosin staining. TEA (1, 3, and 5 mM) significantly increased the amplitude and frequency of contractility of colon and rectum from rats in longitudinal and circular direction. TEA at 5 and 15 mM concentrations showed no effect on histology of colon and rectum from rats that were administered locally with TEA into colon lumen from anus for 10 days. TEA at 15 mM increased the amplitude and frequency of contractions of the colon and rectum from Hirschsprung's disease patients. Our data showed that TEA increased the contractility of colon and rectum from rats and Hirschsprung's disease patients in vitro, suggesting that local administration of TEA in colon or rectum lumen might be an alternative method to ameliorate the syndrome of Hirschsprung's disease patients who are not cured completely by surgery or not suitable for surgery.

Dihydroartemisinin inhibits angiogenesis in pancreatic cancer by targeting the NF-κB pathway

PURPOSE

Dihydroartemisinin (DHA) has recently shown antitumor activity in human pancreatic cancer cells. However, its effect on antiangiogenic activity in pancreatic cancer is unknown, and the mechanism is unclear. This study was aimed to investigate whether DHA would inhibit angiogenesis in human pancreatic cancer.

METHODS

Cell viability and proliferation, tube formation of human umbilical vein endothelial cells (HUVECs), nuclear factor (NF)-κB DNA-binding activity, expressions of vascular endothelial growth factor (VEGF), interleukin (IL)-8, cyclooxygenase (COX)-2, and matrix metalloproteinase (MMP)-9 were examined in vitro. The effect of DHA on antiangiogenic activity in pancreatic cancer was also assessed using BxPC-3 xenografts subcutaneously established in BALB/c nude mice.

RESULTS

DHA inhibited cell proliferation and tube formation of HUVECs in a time- and dose-dependent manner and also reduced cell viability in pancreatic cancer cells. DHA significantly inhibited NF-κB DNA-binding activity, so as to tremendously decrease the expression of NF-κB-targeted proangiogenic gene products: VEGF, IL-8, COX-2, and MMP-9 in vitro. In vivo studies, DHA remarkably reduced tumor volume, decreased microvessel density, and down-regulated the expression of NF-κB-related proangiogenic gene products.

CONCLUSIONS

Inhibition of NF-κB activation is one of the mechanisms that DHA inhibits angiogenesis in human pancreatic cancer. We also suggest that DHA could be developed as a novel agent against pancreatic cancer.

microRNA expression alteration after arsenic trioxide treatment in HepG-2 cells

BACKGROUND AND AIM

More and more microRNA (miRNA) are found to be involved in tumor genesis and progress. Arsenic trioxide has been an effective chemotherapeutic drug in cancer therapy for many years. In this study, we aimed to find the miRNA involved in the mechanisms of arsenic trioxide treatment in cancer therapy.

METHODS

We detected the expression profile of miRNA by miRNA microarray and quantitative real-time polymerase chain reaction. Cell viability assay, flow cytometry analysis, prediction of miRNA targets, Western blot analysis and luciferase reporter assay were carried out to determine the role of one selected miRNA, namely mir-29a, in affecting the biological behaviors of HepG-2 cells.

RESULTS

Among the 677 human miRNA in the microarray, five miRNA were upregulated and four were downregulated in HepG-2 cells treated with arsenic trioxide compared to their controls. If only changes above two folds were considered, four miRNA were identified, namely miR-24, miR-29a, miR-30a and miR-210, which were all upregulated. Among them, miR-29a showed a positive therapeutic effect in liver cancer cells by inhibiting cell growth and inducing cell apoptosis, and PPM1D was confirmed to be the target gene of miR-29a. Furthermore, a synergy effect was detected between miR-29a and arsenic trioxide.

CONCLUSIONS

Arsenic trioxide altered miRNA expression profile in HepG-2 cells. Among the altered miRNA, miR-29a seemed to take a role in the mechanism of arsenic trioxide in liver cancer therapy. The synergy effect between miR-29a and arsenic trioxide may offer this drug a new chance in cancer therapy by decreasing its dose and toxic side-effects.

Novel therapeutic strategies targeting the hypoxic microenvironment of tumors

Hypoxic microenvironment is closely related to tumorigenesis, progression, metastasis and prognosis and has become a hot topic in cancer research. This article discusses investigations seeking novel therapies targeting the hypoxic microenvironment of tumors, including hypoxic conversion of non-toxic pro-drugs to cytotoxic drugs, and regulation of upstream and downstream genes of hypoxia-inducible factors (HIFs). Additionally, the article reviews our serial studies on tumor hypoxia, including blockade of HIF-1α expression or overexpression of von Hippel-Lindau to enhance the efficacy of immunotherapy, anti-angiogenic therapy, chemotherapy and transarterial embolization to combat malignancies.

Expression and prognostic value of Id protein family in human breast carcinoma

Inhibitors of DNA binding/inhibitors of differentiation (Id) protein family (Id-1, -2, -3 and -4) of helix-loop-helix proteins have been shown to be involved in carcinogenesis and are regarded as prognostic markers in several types of human cancers. However, the roles of Id proteins during breast carcinoma progression remain unclear. The objective was to study the effects of Id proteins in breast cancer. The expression of Id-1, Id-2, Id-3 and Id-4 proteins was examined in 122 dissected female human breast carcinoma tissues and 22 normal female breast specimens by immunohistochemical assay and the relationship between Id staining and clinical pathological characteristics of breast cancer was also analyzed. The over-expressed Id-1 and down-regulated Id-4 proteins were found both correlated with poorer differentiation and more aggressive behavior of the tumor. Id-1 protein could be termed as a negative prognostic marker while Id-4 protein as a positive marker for patients with breast carcinoma. Although the differentially expressed Id-2 and -3 may be correlated with some clinical parameters, they could not be used as independent prognostic factors in human breast cancer.

Second renormalization of tensor-network states

We propose a second renormalization group method to handle the tensor-network states or models. This method dramatically reduces the truncation error of the tensor renormalization group. It allows physical quantities of classical tensor-network models or tensor-network ground states of quantum systems to be accurately and efficiently determined.

Arsenic trioxide inhibits metastatic potential of mouse hepatoma H22 cells in vitro and in vivo

BACKGROUND

It has been pointed out that only low-dose arsenic trioxide (ATO) presents therapeutic benefits outweighing the toxic side effects. Low-dose ATO can effectively alleviate acute promyelocytic leukemia (APL). However, it is quite challenging in treating solid tumors. The purpose of this study was to investigate the effect of ATO at low concentrations on the metastatic potential of mouse hepatoma H(22) cells and the anti-metastatic mechanism of ATO.

METHODS

The metastatic potential of H(22) cells was evaluated by adhesion, migration and invasion assays after exposure to a low dose of ATO in vitro. The mouse lung metastatic model induced by injection of H(22) cells via the tail vein was adopted for the evaluation of metastatic potential. Different proteins in the lysate of H(22) cells exposed to ATO at different concentrations were investigated by surface-enhanced laser desorption and ionization time-of-flight mass spectrometry (SELDI-TOF-MS). Finally, Western blotting analyses were made to detect the expression pattern of MMP-2 and nm23-M1 proteins.

RESULTS

Significant cell death started at ATO concentrations above 2 micromol/L. The growth and adhesion potential of H(22) cells was inhibited in a time- and dose-dependent manner, and the migration and invasion potential of H(22) cells was inhibited in a dose-dependent manner while ATO concentration was below 2 micromol/L. Mice injected with ATO at a dose of 0.5 mg/kg had fewer lung metastases. However, mice injected with ATO at a dose of 2 mg/kg or 4 mg/kg had a high mortality rate and more liver injuries. A total of 15 different protein peaks were identified between the lysate of H(22) cells treated with ATO and controls. Two proteins that peaked at m/z 5302 and 17207 coincided with MMP-2 (fragment) and nm23-M1, respectively. Western blotting analyses demonstrated that MMP-2 and MMP-2 fragments were down-regulated and nm23-M1 was up-regulated in H(22) cells treated with 2 micromol/L ATO for 48 hours.

CONCLUSIONS

ATO at a low dose inhibits the metastatic potential of mouse hepatoma H(22) cells in vitro and in vivo, and involves down-regulation of MMP-2 and up-regulation of nm23-M1.

[The effect of hyperbaric oxygen on acute pancreatitis through downregulating hypoxia-inducible factor.]

OBJECTIVE

To observe the therapeutic effect of hyperbaric oxygen (HBO) on acute pancreatitis (AP) by downregulating hypoxia-inducible factor (HIF).

METHODS

Forty Wistar rats were randomly divided into 4 groups (n = 10): sham group, AP group, normo-oxygen group (NP) and HBO group. At 4 hours after taurocholate-induced AP, the rats of NP group and HBO group were respectively treated with oxygen or HBO for 90 min. Several parameters were measured to evaluate oxygen stress after treatment including oxygen saturation (SaO2), partial pressure of oxygen (PO2), pH, and serum LDH. Pancreatic tissues were subjected to histopathological analysis, immunostained, and homogenized for Western blotted analysis of HIF-1alpha and VEGF, and measuring myeloperoxidase activity. The serum TNF-alpha and pancreatic histopathological scores were evaluated the severity of AP.

RESULTS

It was proved by immunohistochemisty that HIF in acinar cell and polymorphonuclear leukocytes (PMNs) was activated and transferred from cytoplasm into nucleus in AP group, NP group, and HBO group, following upregulation of VEGF. HBO therapy elevated blood SaO2 (99.6% +/- 0.7% vs. 87.7% +/- 1.8% or 91.2% +/- 2.5%, P < 0.05) and PaO2 [(369.1 +/- 67.6) mm Hg (1 mm Hg = 0.133 kPa) vs. (86.6 +/- 5.6) mm Hg or (99.9 +/- 4.0) mm Hg, P < 0.05]. HBO therapy attenuated the severity of AP through inhibiting AP-induced upregulation of HIF-1alpha and VEGF, as evidenced by reducing histopathological scores (12.40 +/- 1.21 vs. 16.45 +/- 1.10 or 16.38 +/- 1.10, P < 0.05), dry/wet weight ratio of pancreatic tissues, and myeloperoxidase activity.

CONCLUSIONS

HIF-1alpha plays a key role in the pathogenesis of AP. HBO therapy attenuates the severity of AP through downregulating the expression of HIF-1alpha.

[Effects of early goal-directed fluid therapy on intra-abdominal hypertension and multiple organ dysfunction in patients with severe acute pancreatitis.]

OBJECTIVE

To observe the effects of early goal-directed fluid therapy with hydroxyethyl starch 130/0.4 on intra-abdominal hypertension (IAH), multiple organ dysfunction and fluid balance in severe acute pancreatitis (SAP) patients.

METHODS

According to the criteria of selection and exclusion, 120 SAP patients within 72 hours after the symptom occurred from 4 study sites were recruited. They were given standard medication according to "the guideline of diagnosis and treatment of SAP in China" in SICU or PICU. The patients were randomly divided into two groups with crystalloid (control group) and colloid plus crystalloid resuscitation (research group). The objective of fluid therapy was to keep steady hemodynamics for 8 days. IAP was measured three times daily by means of urinary bladder transduction. Function of liver, renal and lung were detected daily. APACHE II score and fluid balance were calculated daily.

RESULTS

Total 120 cases were recruited into research group (n = 59) and control group (n = 61). The demography and baseline data were comparable. IAP was lower in research group than that in control group at day 4 and day 5 (P < 0.05). There was no significant difference in APACHE II scores between two groups pre- and after admission. The decline of daily IAP to baseline (DeltaIAP) in research group was significantly higher than in research group from day 2 to day 8(P < 0.05), whilst the decline of daily APACHE II score to baseline (DeltaAPACHE II score) in research group were significantly higher from day 4 to day 8 (P < 0.05). Negative fluid balance emerged much earlier in the research group (P = 0.036). Percentage of patients with negative fluid balance within 8 days was significantly higher in research group than that in control group (94.9% vs. 62.3%). The amount of positive fluid balance was significantly lower in research group (P = 0.039). IAP correlated significantly with APACHE II score (r(2) = 0.322, P = 0.000). PaO2/FiO2 was significantly higer in research group at day 4 and day 8.

CONCLUSIONS

It is very important to pay close attention to IAP in early fluid therapy of SAP patients. Early goal-directed fluid therapy with HES130/0.4 shortens the duration of positive fluid balance, decreases the amount of positive fluid balance, reduces APACHE II score, relieves IAH, and improves PaO2/FiO2.

Portal hypertension resulted from paroxysmal nocturnal hemoglobinuria: a case report and review of literature

Paroxysmal nocturnal hemoglobinuria is a rare intravascular hemolytic anemia, and thrombosis is the leading cause of mortality rate. The hepatic veins is the common site where Budd-Chiari syndrome usually occurs. We confronted a patient who simultaneously happened to have portal vein and superior mesenteric vein thrombosis leading to prehepatic portal hypertension and upper gastrointestinal bleeding. Percutaneous thrombolysis is an efficacious treatment.

Density matrix renormalization group numerical study of the kagome antiferromagnet

We numerically study the spin-1/2 antiferromagnetic Heisenberg model on the kagome lattice using the density-matrix renormalization group method. We find that the ground state is a magnetically disordered spin liquid, characterized by an exponential decay of spin-spin correlation function in real space and a magnetic structure factor showing system-size independent peaks at commensurate magnetic wave vectors. We obtain a spin triplet excitation gap DeltaE(S=1)=0.055+/-0.005 by extrapolation based on the large size results, and confirm the presence of gapless singlet excitations. The physical nature of such an exotic spin liquid is also discussed.

Accurate determination of tensor network state of quantum lattice models in two dimensions

We have proposed a novel numerical method to calculate accurately physical quantities of the ground state using the tensor network wave function in two dimensions. The tensor network wave function is determined by an iterative projection approach which uses the Trotter-Suzuki decomposition formula of quantum operators and the singular value decomposition of matrix. The norm of the wave function and the expectation value of a physical observable are evaluated by a coarse-grain tensor renormalization group approach. Our method allows a tensor network wave function with a high bond degree of freedom (such as D=8) to be handled accurately and efficiently in the thermodynamic limit. For the Heisenberg model on a honeycomb lattice, our results for the ground state energy and the staggered magnetization agree well with those obtained by the quantum Monte Carlo and other approaches.

[Clinical study of the method of hepatic vascular occlusion during resection of liver carcinoma]

OBJECTIVE

To evaluate the optimal method for hepatic vascular occlusion during resection of liver carcinoma.

METHODS

One hundred and twenty-four patients with liver carcinoma were divided into four groups of hepatectomy with total hepatic inflow occlusion (group A, 51 cases), selective hepatic inflow occlusion (group B, 38 cases), selective exclusion of hepatic inflow and outflow (group C, 24 cases) and total hemi-hepatic vascular exclusion (group D, 11 cases). The time of operation and hepatic vascular occlusion, intraoperative blood loss and transfusion, postoperative liver function, complications and mortality were compared among the four groups.

RESULTS

There were no significant difference among the four groups statistically in preoperative basic states (P > 0.05). The duration of operation was prolonged significantly in group C and D than that of group A, but intra-operative blood loss and transfusion requirements were decreased significantly in group C and D versus group A and B (P < 0.05). There was no significant difference among the four groups regarding ischemia time, postoperative complications and mortality (P > 0.05). The level of postoperative alanine aminotransferase was higher in group A than other three groups (P < 0.05). The postoperative total bilirubin increased significantly in group A contrast to group B (P < 0.05).

CONCLUSIONS

Each hepatic vascular occlusion technique has its place in liver resection. The size and location of tumor, preoperative liver function, underlying liver disease, cardiovascular and cerebral vessels status, and most important the experience and capability to weigh the merits and demerits of the surgeon should be taken into account to select the most appropriate occlusion method.

Gastric cancer cell lines induced by trichostatin A

AIM: To explore the effect of trichostatin A (TSA) on apoptosis and acetylated histone H3 levels in gastric cancer cell lines BGC-823 and SGC-7901.

METHODS: The effect of TSA on growth inhibition and apoptosis was examined by MTT, fluorescence microscopy and PI single-labeled flow cytometry. The acetylated histone H3 level was detected by Western blot.

RESULTS: TSA induced apoptosis in gastric cancer cell lines BGC-823 and SGC-7901 was in a dose and time-dependent manner. Apoptotic cells varied significantly between TSA treated groups (37.5 ng/mL 72 h for BGC-823 cell line and 75 ng/mL 72 h for SGC-7901 cell line) and control group (0.85 ± 0.14 vs 1.14 ± 0.07, P = 0.02; 0.94 ± 0.07 vs 1.15 ± 0.06, P = 0.02). Morphologic changes of apoptosis, including nuclear chromatin condensation and fluorescence strength, were observed under fluorescence microscopy. TSA treatment in BGC-823 and SGC-7901 cell lines obviously induced cell apoptosis, which was demonstrated by the increased percentage of sub-G1 phase cells, the reduction of G1-phase cells and the increase of apoptosis rates in flow cytometric analysis. The result of Western blot showed that the expression of acetylated histone H3 increased in BGC-823 and SGC-7901 TSA treatment groups as compared with the control group.

CONCLUSION: TSA can induce cell apoptosis in BGC-823 and SGC-7901 cell lines. The expression of acetylated histone H3 might be correlated with apoptosis.

[Influence of artificial pneumoperitoneal media on colon carcinoma cell proliferation in vitro]

OBJECTIVE

To evaluate the influence of different pneumoperitoneal media on colon carcinoma LS-174T cell proliferation in vitro.

METHODS

The artificial pneumoperitoneum was established. The proliferation of LS-174T cells was detected by MTT assay and soft agar clone formation assay. Expression of HIF-1alpha and VEGF was examined by immunohistochemistry. Apoptosis of LS-174T cells was analyzed by AO/EB double fluorescein stain and flow cytometry.

RESULTS

The growth speed and proliferating capacity of LS-174T cells in CO(2) pneumoperitoneum group[A:0.37 +/- 0.02,formation (32.8 +/- 3.6)%] were significantly higher than those in control group [A:0.33 +/- 0.01,formation (28.4 +/- 2.3)%] and He group [A:0.30 +/- 0.01,formation (23.5 +/- 2.7)%], meanwhile the He group was the lowest (P<0.01). Positive expression of HIF-1alpha and VEGF in CO(2) and He artificial pneumoperitoneum up-regulated significantly as compared to control group(P<0.01), meanwhile the above expression was higher in CO(2) group (P<0.01). The G(0 )/G(1) ratio in CO(2) group was the lowest as compared to control group and He group (P<0.01), and G(0 )/G(1) ratio in He group was higher than that of control group(P<0.01). Aapoptosis rate in He group was the highest as compared with the other two groups(P<0.01).

CONCLUSION

CO(2) pneumoperitoneum has stronger effect on the proliferation of colon carcinoma cell LS-174T as compared to He pneumoperitoneum in vitro.

Intraoperative ultrasound: a minimally invasive application in liver neoplasm surgery

AIM: To investigate the application of intraopera-tive ultrasound to surgery for liver neoplasms.

METHODS: Intraoperative ultrasound was used to scan 78 patients with liver neoplasms. The results of intraoperative ultrasound were compared with those of preoperative ultrasound and computed tomography (CT)/enhanced CT.

RESULTS: Of 65 patients suffering from liver cancer, intraoperative ultrasound determined all cases, whereas preoperative ultrasound and CT/enhanced CT missed 10 and 6 cases, respectively. For diagnostic accuracy of liver hemangioma, intraoperative ultrasound was better than preoperative ultrasound and CT/enhanced CT (92.31% vs 69.23% and 76.92%, respectively). For small-sized foci with diameters ≤ 1.0 cm, intraoperative ultrasound had a statistically significant better detection rate than preoperative ultrasound or CT/enhanced CT (90.48% vs 59.52% and 69.05%, respectively, both P < 0.05). Intraoperative ultrasound could also better ascertain lesions with diameters bigger. The detection rate was 96.36%, which was significantly higher than that of preoperative ultrasound (74.55%, P < 0.05). The operative style was changed in 22 patients and all lesions were removed after intraoperative ultrasound scans that then determined the resection line and pathway. No residual cancer cells were found at the cutting edge.

CONCLUSION: Compared with preoperative ultrasound and CT/enhanced CT, intraoperative ultrasound is accurate in its diagnosis of quality and localization of liver neoplasms. Thus intraoperative ultrasound, a minimally invasive concept, enhances the security of surgery and the degree of thoroughness for patients with liver tumors.

Multiple littoral cell angioma of the spleen: a case report and review of the literature

BACKGROUND

Littoral cell angioma (LCA) is a rare benign vascular tumor of the spleen with characteristic histomorphologic features. It is a unique splenic tumor which may present with abdominal pain or as an incidental finding.

CASE REPORT

In this case report, we present the case of a 34-year-old woman with multiple splenic LCA. Initially, the patient presented with abdominal pain, weakness and fatigue. After a diagnostic abdominal ultrasound, multiple hemangiomas were observed in the spleen. Computed tomography scans confirmed splenomegaly with multiple round and hyperdense lesions. The patient subsequently underwent splenectomy. Postoperative histological and immunohistochemical profiles confirmed the diagnosis of LCA.

CONCLUSION

LCA is a unique splenic tumor diagnosed in patients with abdominal pain or as an incidental finding. Only a few case reports of this tumor have been published, and those accounts are inconsistent. In the present paper, we report on a case and conduct a literature review.

Current status on treatment for spontaneous rupture of primary hepatocellular carcinoma

The rupture of tumor with intraperitoneal hemorrhage is one of the life-threatening complications of primary hepatocellular carcinoma (HCC). It is relatively intractable to deal with this syndrome which occurs urgently with high mortality rate and risk of rebleeding during the process of clinical management. Before the 1980s, the treatment of hepatocellular carcinoma rupture is mainly focused on the field of the conservative therapy and surgical methods. As the interventional therapy develops, transarterial embolization (TAE) has become an effective way in controlling bleeding from ruptured hepatocellular carcinoma in acute phase. In recent years, some overseas scholars have successfully cured ruptured hepatocellular carcinoma through radiofrequency ablation (RFA) and bio-immunotherapy. In this paper, we summarized the treatments for the spontaneous rupture of primary hepatocellular carcinoma.

[Changes of immunocytes in livers of chronic hepatitis C patients treated with IFN alpha-2b and ribavirin]

OBJECTIVE

To investigate the immunocytodynamic changes in the livers of chronic hepatitis C patients treated with IFN alpha-2b and ribavirin and to find new bases for an effective immune regulation therapy.

METHODS

Forty-two chronic hepatitis C patients were treated with combined IFN alpha-2b and ribavirin and their peripheral blood and liver tissues were collected before the treatment for analyses. After the treatment, peripheral blood and liver tissue specimens were obtained from only 11 patients. All the specimens were exposed to three monoclonal antibody fluorescence dyes, and the CD45+ cells with triple colors were analyzed using flow cytometry.

RESULTS

Compared to the control groups, the positive rates of CD56+, CD57+, CD161+ cells in the livers of those with chronic hepatitis C sharply decreased (Probability value less than 0.01), and CD56+T cells had decreased mildly; CD28 from the CD56+T cells decreased mildly, but the expression of CD152 increased (P<0.05); the positive rates of CD83+CD1a+ cells had decreased mildly, and the positive rates of CD80+CD11c+ and the CD86+CD11c+ cells significantly decreased (P<0.01). After the treatment, the CD56+, CD161+, CD56+T, CD161+T, CD80+CD11c+, CD86+CD11c+ cells in the responding group increased.

CONCLUSION

Combined interferon alpha-2b and ribavirin treatment can improve the suppressed cell immunity function.

Ten-year experience with living related donated splenic transplantation for the treatment of hemophilia A

AIM

Six cases of hemophilia A treated with living related donated splenic transplantation (LRDST) were performed over 10 years.

METHODS

We reviewed the six consecutive cases of LRDST from 1992 to 2002. Three patients received whole spleen allografts and the other three, partial spleen allografts. All allografts were transplanted to the extraperitoneal space in the right iliac fossa by an end-to-end anastomosis between the splenic artery and the internal iliac artery and an end-to-side anastomosis between the splenic vein and the external (or common) iliac vein. After the operation, a combined regimen with cyclosporine, azathioprine, anti-lymphocyte globulin, OKT3, was administered to suppress the immune reaction.

RESULTS

The functional period of the allografts varied between 30 days to 4 years. Patient factor-VIII (F-VIII) levels rose from less than 5% before operation to 15% to 56% postoperatively. One patient died from central nervous system complications. Another lost his graft because exogenous F-VIII was not supplemented in timely fashion at the onset of rejection. And the third could no longer afford the expensive immunosuppressive drugs at 2 years after the operation and eventually lost the spleen. The remaining three patients presently have regained self-support, among whom one has survived for 4 years.

CONCLUSION

Though the sample pool is relatively small, our clinical observations tend to confirm LRDST as a feasible, effective treatment for hemophilia A.

Clone culture of human interleukin-10 gene modified L02 hepatocytes and selection of cell strain with most interleukin-10 expression

AIM: To clone and culture human interleukin-10 (IL-10) gene modified L02 hepatocytes and select the cell strain highly expressing IL-10.

METHODS: With preparation of previously constructed and purified eukaryotic expression plasmid vector pchIL-10, L02 hepatocytes were transfected and then the positive clones were selected with the help of G418 pressure. Enzyme-linked immunosorbent assay (ELISA) was used to detect the expression of human IL-10 in the cells strain.

RESULTS: Sequencing and restriction endonuclease digestion confirmed that eukaryotic expression plasmid vector pchIL-10 was constructed successfully, and electrophoresis show a band of 540 bp. hIL-10 gene was highly expressed in L02 hepatocytes and the highest expression level was 69.875 ng/10⁶ cell per hour.

CONCLUSION: Human interleukin-10 (IL-10) gene modified L02 hepatocytes can highly expresses hIl-10, which may be used in the antifibrotic or cirrhotic treatment.

Microencapsulating hepatocytes

BACKGROUND

Because standardization of the cell microencapsulation procedure has not yet been achieved, we performed hepatocyte microencapsulation using alginate (ALG)-poly-l-lysine (PLL)-ALG (APA) polymer.

METHODS

Hepatocytes were microencapsulated using a binozzle air-jet droplet generator. Our study aims were to: (1) clarify how ALG concentration affects the quality of ALG beads; (2) determine how the PLL concentration affects the quality of microcapsules (MCs); (3) ascertain the influence of liquefaction time by sodium citrate (SC) on the quality of the MCs; (4) and clarify how temperature and solution pH, respectively, affect the viability of the hepatocytes inside the MCs.

RESULTS

The concentration of ALG must be > or = 3% (w/v) to generate droplets with satisfactory homogeneity in size and roundness (P < .01). The total quantity of PLL molecules is the essential component for MCs (P < .01). As our results show, the numeric ratio of PLL (milligrams) to MCs (milliliters) is roughly 25:1. SC incubation for 8 minutes resulted in the proper thickness of the MC wall; however, the time varied according to the size of the MCs (P < .05). Temperature and pH, although both difficult to control, exerted great influences on cell viability: 4 degrees C and pH 7.2 were found to be optimal by this study (P < .05).

CONCLUSIONS

Concentrations of ALG and PLL exerted decisive effects on the quality and strength of MCs. Higher concentrations were suggested. Because temperature and pH greatly affected cell viability, they must be properly monitored.

Construction of an adeno-associated viral vector serotype 2/1 containing human interleukin-10 and its expression in donor liver

AIM: To construct an adeno-associated viral vector serotype 2/1 (AAV2/1) containing human interleukin-10 (hIL-10) gene and to observe its expression in donor liver.

METHODS: hIL-10cDNA amplified by reverse transcription polymerase chain reaction (RT-PCR) from human peripheral blood mononuclear cells was cloned into vector pMD18-T. After confirming the sequence, hIL-10cDNA was isolated and inserted into eukaryotic expression vector pSNAV. The recombinant plasmid pSNAV-hIL-10 was transfected into BHK21 cells. BHK21 cells which contained ITR-hIL-10-ITR were obtained by G418 screening. Then the cells were transfected with rHSV/r2c1 containing rep2-cap1 gene. The cells were cultured and purified to obtain rAAV2/1-hIL-10. The expression of hIL-10 gene was detected after this vector was transfer into donor liver in vivo.

RESULTS: The sequence of cloned hIL-10cDNA was identical with that published on GenBank. A new adeno-associated virus vector containing hIL-10cDNA was constructed. And the transcription and expression of hIL-10 were detected in donor liver for 24 weeks. hIL-10 was significantly expressed in test group than that in empty and rAAV2/1-GFP controls 24 wk after transferred (219.15±45.83 ng/L vs 40.02, 38.64 ng/L, P<0.05).

CONCLUSION: The adeno-associated viral vector serotype 2/1 of hIL-10 is successfully established, which provides the basis for applying IL-10 in clinical organ transplantation.

Role of individually staged nutritional support in the management of severe acute pancreatitis

BACKGROUND

Severe acute pancreatitis (SAP) as a common acute abdomen due to complicated causes is characterized by lots of morbidities, difficult treatment, and high mortality. This study was designed to investigate the role of individually staged nutritional support (ISNS) in the treatment of SAP.

METHODS

One hundred patients with SAP admitted to our hospital from January 1997 to October 2002 were randomly divided into total parenteral nutrition group (TPN group, 50 patients) and individually staged nutrition group (individualized group, 50 patients), between which the therapeutic outcome and the incidence of complications were carefully analyzed.

RESULTS

Compared with the TPN group, the individualized group had less complications (62 vs 94 patients) including incubation related complications (2% vs 16%), superinfections (8% vs 30%), hepatic functional insufficiency (4% vs 24%) and intra-peritoneal infections (4% vs 12%), in addition to a sooner restoring of oral nutrition (18.5 vs 24.8 days, P<0.05), a shorter hospital stay (24.5 vs 30.2 days) and a lower hospital cost (4.1 vs 5.8 10,000 yuan, P<0.05).

CONCLUSION

ISNS, which provides SAP patients with sufficient energy and nutrients according to their true pathological status, is an ideal nutrition planning with lowered incidence of complications, shortened hospital stay and lightened financial burden.

Microencapsulated hepatocytes and islets as in vivo bioartificial liver support system

AIM: To confirm the xenotransplantation of microencapsulated hepatocytes and islets as a temporary bioartificial liver support system for mice with acute liver failure (ALF).

METHODS: Mice were rendered ALF by a single intra-peritoneal injection of D-galactosamine (D-gal) and their tail blood was sampled to examine differences in blood ALT, albumin (ALB), total bilirubin (TB) and glucose (GLU) between 4 experimental groups. Rat hepatocytes and islets were collected and microencapsulated referring to both Sun’s and Fritschy’s methods. Mice were grouped into control group (CG), free hepatocyte group (FHG), microencapsulated hepatocyte group (MHG) and microencapsulated hepatocyte plus islet group (HIG). Tissue samples were subjected to microscopic and electron microscopic (EM) examinations.

RESULTS: The highest survival was observed in HIG, surprisingly at 100% (16/16), while the lowest was in CG at 12.5% (2/16), with inter-group statistical difference P < 0.05. ALT levels revealed no statistical difference between groups but the ALB level of HIG descended by the slightest margin {q = (0.54, 0.24, 1.33), P < 0.05} at the time when it reached the lowest point in all groups. TB of HIG returned to normal reference range (NRR) statistically sooner than that of others after a fierce elevation. No statistical inter-group difference was observed in GLU levels. Fusion between hepatocytes and beta cells was demonstrated giving rise to theoretical assumptions.

CONCLUSION: Hepatocytes to be microencapsulated together with islets should be a preferred in vivo hepatic functional supporting system, which can dramatically prolong survival and improve living status.

Liver regional continuous chemotherapy: Use of femoral or subclavian artery for percutaneous implantation of catheter-port systems

AIM: To evaluate the feasibility and safety of the intraarterial chemotherapy of the liver cancer by an interventional method, catheter-port system.

METHODS: Thirty-two catheter-port systems were implanted percutaneously via the femoral artery or subclavian artery. Chemotherapies were performed 0-5 d after the implantation of the catheter-port systems. The mean interval between two sequent chemotherapies was 4 wk. The occurrence of side effects of the implantation was examined clinically.

RESULTS: Implantation of the catheter-port was successful in all patients. Mean patency period was 210 d. One occlusion (3.1%) of the catheter was observed. Displacement of the catheter was observed in one case (3.1%). One patient rated a hematoma in the chest wall as important. Mild hematoma was reported in 8 cases (25%). In 3 of 32 cases (9.4%), mild pain was reported initially, and dysesthesia was reported in seven (21.9%). No patient rated overall discomfort as mild, severe, or important.

CONCLUSION: Percutaneous placement is feasible and safe for liver regional continuous chemotherapy. Compared with surgical placement, the overall complication rate is comparable or less.