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Objective: To investigate and compare the clinical outcomes of the arterial pre-occlusion technique(APOT) and the traditional technique in the surgery of locally advanced pancreatic cancer with arterial involvement after conversion therapy. Methods: This is a retrospective cohort study. The clinical data of 145 patients with locally advanced pancreatic cancer with arterial involvement admitted to the Department of Hepato-Biliary-Pancreatic Surgery of the First Hospital Affiliated to Naval Medical University,from January 2020 to December 2022 were retrospectively analyzed. All patients completed neoadjuvant therapy for tumors, and the feasibility of radical surgical treatment was determined by a multidisciplinary collaborative team evaluation before surgery. According to whether the intraoperative artery was pre-occluded, 145 patients were divided into two groups, including 28 cases in the APOT group(16 males, 12 females, aged (59.0±9.4) years), and 117 cases in the routine surgery group(76 males, 41 females, aged (55.1±8.2) years). To ensure comparability of baseline data between the APOT group and the routine surgery group, a 1∶2 match was performed using the propensity score matching method, and the caliper value was 0.006 45. The t -test,the Mann-Whitney U test, χ 2 test or Fisher's exact test were used to compare the data between the two groups,respectively. Results: After matching the propensity score,there were 28 cases in the APOT group and 56 cases in the routine surgery group. There were no significant differences in gender,age,preoperative comorbidities,preoperative body mass index,surgical approaches,chemotherapy regimen,stereotactic body radiation therapy ratio,tumor markers,and type of invaded artery between the two groups (all P >0.05).The arterial occlusion time M (IQR) in the APOT group was 7.0(3.8)minutes(range:3 to 15 minutes),and no ischemic manifestations were observed in the distal target organs that blocked blood vessels after surgery. The operation time was (170.3±57.7)minutes in the APOT group and (235.0±80.2)minutes in the routine surgery group,and the difference was statistically significant ( t =-3.800, P <0.01). The APOT group also experienced less intraoperative blood loss(650(588)ml vs. 800(600)ml; U =1 026.500, P =0.021). No significant differences were found between the groups in combined vein resection and reconstruction,celiac trunk resection,early postoperative complications, readmission rates at 30 days,and postoperative length of stay(all P >0.05). Extra-arterial dissection was performed in all patients,with arterial resection and reconstruction in 3 cases: 2 cases in the APOT group(1 case involving the superior mesenteric artery and 1 case involving the common hepatic artery) and 1 case in the routine group(involving the common hepatic artery). Postoperative abdominal bleeding occurred in 4 cases,with 3 cases in the routine group,1 case in the routine group. The R0 resection rate was 85.7%(24/28) in the APOT group and 80.4%(45/56) in the routine group,without significant differences between the groups( P =0.763). The median overall survival time was 27.6 months for the APOT group and 22.5 months for the routine group,while the median disease-free survival was 11.7 months and 16.8 months,respectively,with no significant differences between the two groups( P =0.532, P =0.927). Conclusion: The arterial pre-occlusion technique can be used for extra-arterial dissection in patients with locally advanced pancreatic cancer involving the arteries,reducing surgery time and intraoperative blood loss.

Objective: To evaluate the performance of the European Evidence-based Guidelines on Pancreatic Cystic Neoplasms (EEGPCN)(2018) and International Association of Pancreatology(IAP) Guideline(Version 2017) in predicting high grade dysplasia/invasive carcinoma-intraductal papillary mucinous neoplasm(HGD/INV-IPMN). Methods: A retrospective analysis of 363 patients,who underwent surgical resection in Changhai Hospital affiliated to Navy Medical University from January 2012 to December 2018 and were pathologically identified as (intraductal papillary mucinous neoplasm, IPMN),was performed. The patients,including 230 males and 133 females,aging (61.7±10.1) years(range:19 to 83 years). The proportion of HGD/INV-IPMN who met with the absolute indication(AI) of EEGPCN and high risk stigma(HRS) of IAP were compared. The binary Logistic regression analysis was used to find the independent risk factors of HGD/INV-IPMN.Eight combinations of risk factors derived from relative indication/worrisome feature or risk factors in this study,were made to evaluate the diagnostic efficacy. The area under curve(AUC) of receiver operating characteristics was used to evaluate the the cutoff value of risk factors(①CA19-9≥37 U/ml,②diameter of main pancreatic duct 5.0-9.9 mm,③enhancing mural nodule<5 mm,④(acute) pancreatiti,⑤ a cyst diameter ≥40 mm,⑤ b cyst diameter ≥30 mm, ⑥thickened or enhancing cyst walls,⑦neutrophile granulocyte to lymphocyte ratio(NLR)≥2, ⑧cyst located in head, uncinate or neck,⑨carcinoembryonic antigen(CEA) ≥5 μg/L) number for predicting HGD/INV-IPMN.The accuracy,sensitivity,specificity,positive predictive value,negative predictive value,true positive,true negative,false positive,false negative,positive likelihood ratio,negative likelihood ratio,Youden index and F1 score were calculated. Results: Ninety-two patients(49.5%) of 186 ones who met AI and 85 patients(48.3%) of 176 ones who met HRS were respectively confirmed as HGD/INV-IPMN. In those patients who were not met AI,tumor location,thickened/enhancing cyst wall,CA19-9 elevated,NLR≥2 and CEA elevated were significantly ( P <0.05) correlated with HGD/INV-IPMN. And tumor location(head/uncinate/neck vs. body/tail, OR =3.284,95% CI :1.268-8.503, P =0.014),thickened/enhancement cyst wall (with vs. without, OR =2.713,95% CI :1.177-6.252, P =0.019),CA19-9(≥37 U/L vs. <37 U/L, OR =5.086,95% CI :2.05-12.62, P <0.01) and NLR(≥2 vs. <2, OR =2.380,95% CI :1.043-5.434, P =0.039) were the independent risk factors of HGD/INV-IPMN. Patients with ≥4 risk factors of 9 in combination Ⅷ(①②③④⑤ b ⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the moderate accuracy(71.0%),moderate sensitivity (62.0%) and moderate specificity (73.0%). Patients with ≥4 risk factors of 9 in Combination Ⅶ(①②③④⑤ a ⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the highest specificity(83.0%) and patients with ≥3 risk factors of 8 in combination Ⅵ(①②③④⑤ b ⑥⑧⑨) were diagnosed as HGD/INV-IPMN with the highest sensitivity(74.0%). The AUC for diagnosis of HGD/INV-IPMN in combination Ⅵ,Ⅶ and Ⅷ were 0.72,0.75 and 0.75,respectively. Older patients and younger patients could respectively refer to combination Ⅶ and combination Ⅵ to improve the management of IPMN. Conclusions: Patients who meet AI of EEGPCN should undertake resection, otherwise the method we explored is recommended. The method of improvement for diagnosis of HGD/INV-IPMN is relatively applicable and efficient for decision-making of surgery, especially for younger patients with decreasing of missed diagnosis and elder patients with decreasing of misdiagnosis.

Objective: To examine the prognostic value of four important driver gene mutations in patients with radical resection of pancreatic cancer. Methods: The clinical data and follow-up data of pancreatic cancer patients undergoing radical pancreatectomy and targeted sequencing from January 2016 to March 2018 at Department of Hepato-Biliary-Pancreatic Surgery, Changhai Hospital were retrospectively analyzed.There were 159 males and 88 females,aged of (60.8±8.7)years(range:33-83 years) and preoperative CA19-9 of (492.4±496.6)kU/L(range: 2-1 200 kU/L). One hundred and fifty nine cases of tumors were located in the head and 88 cases in the body and tail of the pancreas. After univariate analysis of clinical pathological factors (including gender, age, preoperative CA19-9, tumor location, tumor differentiation, pathological T and N stage, Micr. perineural invasion, Micr. lympho -vascular invasion, resection margin), the variable whose P< 0.1 was included in COX regression model with four important driver gene mutations to find which mutation was related to prognosis independently. The number of gene mutations and KRAS subgroups were analyzed by Kaplan-Meier curve. Results: Among 247 patients,the number of KRAS,TP53, SMAD4 and CDKN2A mutations was 212 cases(85.8%), 160 cases(64.8%), 66 cases(26.7%) and 44 cases(17.8%),respectively.KRAS mutation was correlated with the tumor differentiation and pathological T stage (χ(2)=24.570/6.690, P= 0.000/0.035), TP53 mutation was correlated with the tumor differentiation and the resected margin(χ(2)=5.500/4.620, P= 0.019/0.032), and CDKN2A mutation was correlated with gender(χ(2)=16.574, P= 0.000).COX regression model analysis showed that only KRAS mutation was an independent risk factor for disease free survival and overall survival( HR =1.776, 95 %CI : 1.079-2.923, P= 0.024; HR =1.923, 95 %CI : 1.016-3.639, P= 0.045); KRAS(G12D) mutation was associated with shorter OS( P= 0.007). Conclusion: KRAS and its subgroup KRAS(G12D) mutation can be used as a prognostic index for patients with radical resection of pancreatic cancer.

Objective: To analyze the factors which influence the safety and prognosis of aorta replacement combined with coronary artery bypass grafting (CABG) for thoracic aortic aneurysm associated with coronary artery disease., Methods: From May 1982 to October 2002, 67 patients with thoracic aortic aneurysm were admitted, and 24 of them combined with CABG. Of the 24 patients, 9 received descending aorta replacement combined with CABG, and the other 15 received the ascending aorta replacement combined with CABG. The treatment results were compared with the other 43 patients only undergoing the thoracic aortic replacement., Results: The mortality rate of the patients with aorta replacement combined with CABG was 13% (3/24). Though the descending aorta replacement combined with CABG could make the cardiopulmonary bypass time and selective cerebral perfusion time longer, (278 +/- 54) min and (188 +/- 59) min respectively, no significant difference was observed in postoperative complications, 3-year survival rate, 3-year-cardiac-event-free rate compared with the patients only undergoing the thoracic aortic replacement (P > 0.05)., Conclusions: The aorta replacement combined with CABG can be performed safely, and the revascularization for coronary artery disease is useful for preventing occurrence of cardiac events.

In this paper, the results of the papillary myotomy and septal tricuspid valvotomy were studied. The 19 dogs were randomly divided into four groups so as to observe the blood supply, healing course, strength and functions of the anterior papillary muscle. It was confirmed that the traumatic rupture of the papillary muscle should be repaired early. In the clinic 31 patients of ventricular septal defect with tricuspid valve pouch were treated by the approach with septal valvotomy and cone papillary myotomy of tricuspid valve. The successful rate of VSD repair was up to 100%. Therefore, this approach is worthy to be used clinically.

Myocardial hypothermia during extracorporeal circulation is commonly created by perfusion of cool cardioplegic solution into the ascending aorta and burial of ice sludge in the pericardial sac. Measurement of temperature of the atrial and ventricular septums during animal experiment and operations for ASD and VSD showed: (1) The temperature was obviously higher in the atrial septum than ventricular. (2) The atrial and ventricular temperature exceeded 15 degrees C 5 minutes after cardioplegic perfusion. (3) Influence on postoperative heart rate and rhythm was obvious when ventricular temperature raised above 15 degrees C during cardiac arrest, especially when the temperature difference between the atrium and ventricule was above 3 degrees C. But this influence may be decreased by maintaining ventricular temperature below 15 degrees C and temperature gradient less than 3 degrees C with a combination of cardioplegic perfusion, ice sludge in pericardial sac plus constant lavage of intracardiac cavity with saline at 4 degrees C.

Closed mitral commissurotomy was performed in 206 consecutive cases with mitral stenosis from 1965 to 1987. Follow-up study from 8 months to 22 years showed that both early and long term postoperative results were satisfactory for mitral stenosis even in cases combined with mild mitral regurgitation. The long-term survival rate of this group of patients was 95.58% and the average time of maintenance of cardiac function classes I and II was 10.83 +/- 2.11 years. The influence of valvular calcification or high pulmonary arterial pressure on long-term effects was not serious, but preoperative atrial fibrillation or congestive cardiac failure might cause lead to poor results, indicating the benefit of early operation before their development. The peak period of restenosis with rapid decrease in cardiac function was 8-10 years postoperatively, and therefore more attention should be paid in this period to the decision of whether a reoperation is needed.