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s / Pancreatology 16 (2016) S1eS63 S32 Conclusion: Repeated FNA or serum CA19-9 levels were helpful in improving the diagnosis.

s / Pancreatology 16 (2016) S1eS63 S35 Introduction: Pancreatic ductal adenocarcinoma (PDAC) is still one of the poorest prognoses cancers, lacking understanding. In PDAC, abnormal activity of Hedgehog (HH) pathway, inflammation(Nuclear factor-kappa B, NF-kB) and K-ras mutation were all involved in. Exploring the interaction of the three elements of PDAC is quite critical to uncover the mechanism of PDAC. Methods: K-ras gene-type, protein expression of Shh and nuclear protein expression of Gli1 and NF-kB of 32 PDAC tissues were detected, the correlation of the three factors were also analyzed. SW1990 were transfected with Gli1 cDNA;SW1990, Panc-1and BxPC-3 were treated with Shh, using untreated group as control, then we examined expression of Shh, Gli1 and NF-kB, cell proliferation and apoptosis changes; K-ras downstream p-/t-ERK1/2 and p-/t-AKT1 expression, as well as Ras activity were tested to estimate K-ras activation. And, the correlation between HH pathway and NF-kB in different K-ras gene-type cells were analyzed separately. Then K-ras expression was knocked-down by si-Kras, experiments above were done again. At last, mutant K-ras cDNA was transfected into K-ras wild-type cells, Shh, Gli1 and NF-kB mRNA expression changes were detected after Shh stimulation. Results: Positive correlation of HH pathway and NF-kB was significant in K-ras mutant PDAC tissues. In K-ras mutant PDAC cells, HH activation could promote NF-kB activation, accelerate cell proliferation, and inhibit apoptosis, up-regulate p-ERK1/2 and p-AKT1, and increase active-Ras expression. When K-ras expression was down-regulated by si-Kras, all the effects above were all weakened. But in wild-type K-ras cells, little significant change happened under such circumstances. But when they transfectedwithmutant K-ras cDNA, themRNA expression of Shh, Gli1 and NF-kB were all increased significantly by Shh stimulation. Conclusions: HH pathway induced NF-kB activation was based on mutant K-ras gene-type in PDAC, and K-ras activity change is the critical molecular mechanism behind them.

To study the changes in blood volume and hormones controlling sodium and water homeostasis after infusions of 0.9% saline, Gelofusine (4% succinylated gelatin in 0.7% saline, weight-average molecular weight 30 kD), and Voluven (6% hydroxyethyl starch in 0.9% saline, weight-average molecular weight 130 kD) in healthy volunteers.Randomized, three-way crossover study.University teaching hospital.Ten healthy adult male volunteers.Volunteers received 1-L infusions of 0.9% saline, Gelofusine, and Voluven over 1 hr on three occasions. Body weight, hematocrit, serum biochemistry, and plasma concentrations of vasopressin, aldosterone, brain natriuretic peptide, and total renin were measured before infusion and hourly thereafter for 6 hrs. Changes in body water, blood volume, and extravascular fluid volume were calculated.Although changes in body weight (total body water) after the infusions were similar, blood volume expansion by the two colloids was significantly greater than that produced by 0.9% saline (p.01). At the end of infusions, 68%, 21%, and 16% of the infused volumes of 0.9% saline, Gelofusine, and Voluven, respectively, had escaped from the intravascular space to the extravascular space. Over the 6 hrs, the magnitude and duration of blood volume expansion by the two colloids were similar (p = .70). There were no significant differences in urinary volume, osmolality, and sodium content after the three infusions. Hormonal changes were similar after the three infusions, with the increase in natriuretic peptide being transient. The reduction in aldosterone and total renin concentrations was more sustained.The effects of Gelofusine and Voluven were similar despite the 100 kD difference in weight-average molecular weight. Excretion of an acute fluid load containing sodium and chloride may be dependent on a sustained suppression of the renin-angiotensin-aldosterone system rather than on natriuretic peptides.

Meckel's diverticulum is the most common congenital anomaly of the small intestine. Common complications related to a Meckel's diverticulum include haemorrhage, intestinal obstruction and inflammation. Gangrene due to axial torsion and enteroliths of a Meckel's diverticulum are the rarest complications that have been reported in the literature. We report a case of gangrene due to axial torsion of giant Meckel's diverticulum with multiple stones in its lumen.

A 75 year old gentleman who presented with an incarcerated paraumibilical hernia was found intraoperatively to have small bowel perforation due to a piece of china with a synchronous asymptomatic sigmoid carcinoma.

A 60-year-old man without comorbidity underwent a totally extraperitoneal repair of bilateral inguinal hernias under general anesthesia. Forty minutes after the procedure he developed a slow, shallow respiratory pattern with a respiratory rate of 5/min and a self-limiting grand mal seizure lasting 30 seconds. Arterial blood gas analysis indicated significant hypercarbia and acidosis. The total dose of morphine administered was 20 mg intravenously. Naloxone was administered and the respiratory rate improved. The patient was discharged after 24 hours after making a good recovery and has had no further seizures a year after surgery. Although hypercarbia is a well-known complication of laparoscopic surgery when CO2 is used for insufflation, this, to the best of our knowledge, is the first reported case of a patient sustaining a grand mal seizure resulting from CO2 narcosis after laparoscopic surgery. The possible mechanisms are discussed.

s / Pancreatology 15 (2015) S1eS141 S115 Results: Both underwent a surgical intervention with curative intention: the first, after preoperative biliary dreinage was candidate to a Whipple resection, the second to a distal pancreatectomy. After laparotomy, both patients showed palpable hepatic metastases radiologically not evident at preoperative imaging. The first patient was surgically derived and in both cases liver biopsy confirmed a PDAC and a palliative chemotherapy was programmed. Conclusion: This is the first report of EOPC both schizophrenic and in an advanced stage possibly reflecting an underlining predisposition. Clinical/radiological assessments should be performed, especially in young schizophrenics with suggestive symptoms, to avoid the missing of early cancer diagnosis.

AIM: To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage. METHODS: Relevant comparative randomized and non-randomized studies were systemically searched based on specific inclusion and exclusion criteria. Postoperative outcomes were compared between patients with and those without routine drainage. Pooled odds ratios (OR) with 95%CI were calculated using either fixed effects or random effects models. RESULTS: One randomized controlled trial and four non-randomized comparative studies recruiting 1728 patients were analyzed. Patients without prophylactic drainage after PD had significantly higher mortality (OR = 2.32, 95%CI: 1.11-4.85; P = 0.02), despite the fact that they were associated with fewer overall complications (OR = 0.62, 95%CI: 0.48-0.82; P = 0.00), major complications (OR = 0.75, 95%CI: 0.60-0.93; P = 0.01) and readmissions (OR = 0.77, 95%CI: 0.60-0.98; P = 0.04). There were no significant differences in the rates of pancreatic fistula, intra-abdominal abscesses, postpancreatectomy hemorrhage, biliary fistula, delayed gastric emptying, reoperation or radiologic-guided drains between the two groups. CONCLUSION: Indiscriminate abandonment of intra-abdominal drainage following PD is associated with greater mortality, but lower complication rates. Future randomized trials should compare routine vs selective drainage.

AIM: To investigate the differences in outcome following pylorus preserving pancreaticoduodenectomy (PPPD) and subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). METHODS: Major databases including PubMed (Medline), EMBASE and Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched for comparative studies between patients with PPPD and SSPPD published between January 1978 and July 2014. Studies were selected based on specific inclusion and exclusion criteria. The primary outcome was delayed gastric emptying (DGE). Secondary outcomes included operation time, intraoperative blood loss, pancreatic fistula, postoperative hemorrhage, intraabdominal abscess, wound infection, time to starting liquid diet, time to starting solid diet, period of nasogastric intubation, reinsertion of nasogastric tube, mortality and hospital stay. The pooled odds ratios (OR) or weighted mean difference (WMD) with 95% confidence intervals (95%CI) were calculated using either a fixed-effects or random-effects model. RESULTS: Eight comparative studies recruiting 650 patients were analyzed, which include two RCTs, one non-randomized prospective and 5 retrospective trial designs. Patients undergoing SSPPD experienced significantly lower rates of DGE (OR = 2.75; 95%CI: 1.75-4.30, P < 0.00001) and a shorter period of nasogastric intubation (OR = 2.68; 95%CI: 0.77-4.58, P < 0.00001), with a tendency towards shorter time to liquid (WMD = 2.97, 95%CI: -0.46-7.83; P = 0.09) and solid diets (WMD = 3.69, 95%CI: -0.46-7.83; P = 0.08) as well as shorter inpatient stay (WMD = 3.92, 95%CI: -0.37-8.22; P = 0.07), although these latter three did not reach statistical significance. PPPD, however, was associated with less intraoperative blood loss than SSPPD [WMD = -217.70, 95%CI: -429.77-(-5.63); P = 0.04]. There were no differences in other parameters between the two approaches, including operative time (WMD = -5.30, 95%CI: -43.44-32.84; P = 0.79), pancreatic fistula (OR = 0.91; 95%CI: 0.56-1.49; P = 0.70), postoperative hemorrhage (OR = 0.51; 95%CI: 0.15-1.74; P = 0.29), intraabdominal abscess (OR = 1.05; 95%CI: 0.54-2.05; P = 0.89), wound infection (OR = 0.88; 95%CI: 0.39-1.97; P = 0.75), reinsertion of nasogastric tube (OR = 1.90; 95%CI: 0.91-3.97; P = 0.09) and mortality (OR = 0.31; 95%CI: 0.05-2.01; P = 0.22). CONCLUSION: SSPPD may improve intraoperative and short-term postoperative outcomes compared to PPPD, especially DGE. However, these findings need to be further ascertained by well-designed randomized controlled trials.

Summary Background The provision of perioperative immune modulating enteral feeds after major surgery may result in reduced infective complications, but meta-analyses have not demonstrated a survival advantage. The aim of this study was to determine whether early postoperative immune modulating jejunostomy feeding results in reduced infective complications in patients undergoing resectional surgery for upper gastrointestinal cancer. Methods A total of 120 patients undergoing resection for cancers of the pancreas, oesophagus and stomach were randomized in a double-blind manner to receive jejunostomy feeding with an immune modulating diet (Stresson—Group A) or an isonitrogenous, isocaloric feed (1250 Calories and 75 g protein/l—Nutrison High Protein—Group B) for 10–15 days. Feeding was commenced 4 h postoperatively and continued for 20 h/day. The target volume (ml/h) was 25 on day 0, 50 on day 1, and 75 thereafter. Outcome measures included complications, hospital stay and mortality. Results A total of 108 patients (54 in each group) were analysed. Feed delivery, although less than targeted, was similar in both groups. There were 6 (11%) deaths in each group. Median (IQR) postoperative hospital stay was 14.5 (12–23) days in Group A and 17.5 (13–23) days in Group B ( P = 0.48 ). A total of 24 (44%) patients in each group had infective complications ( P = 1.0 ). A total of 21 (39%) patients in Group A and 28 (52%) in Group B had non-infective complications ( P = 0.18 ). Jejunostomy-related complications occurred in 26 (48%) patients in Group A and 30 (56%) in Group B ( P = 0.3 ). Conclusion Early postoperative feeding with an immune modulating diet conferred no outcome advantage when compared with a standard feed.

intake and helicobacter pylori infection. The presence of thrombi in the smalland medium-sized vessels surrounding the necrotic ulcer on histologic examination suggested PAN. The presence of microaneurysms in both renal arteries on MR angiography corroborated this evidence. It is difficult to come to a diagnosis preoperatively because it is not a common cause of upper GI bleeding. It should be considered in the differential diagnosis in patients with massive upper GI bleeding, with endoscopy showing giant ulcers.

Both anthropometric and functional measurements have been used in nutritional assessment and monitoring. Hand dynamometry is a predictor of surgical outcome and peak expiratory flow rate has been used as an index of respiratory muscle function. This study aims to measure in normal subjects the relationship between anthropometric measurements, voluntary muscle strength by hand grip dynamometry and respiratory muscle function by peak expiratory flow rate.Ninety-eight subjects (46 male, 52 female) with a mean age of 45.9 years were studied. Hand grip strength was measured in the dominant and non-dominant hands with a portable strain-gauge dynamometer. Peak expiratory flow rate was measured using a mini-Wright peak flow meter. Three readings were taken, each 1 min apart, and the average recorded. Midarm muscle circumference (MAMC) was derived from triceps skin fold thickness and midarm circumference (MAC) using standard anthropometric techniques. Statistical relationships were measured with Pearson's coefficient of correlation.In both sexes there was significant correlation between hand grip strength in the dominant and non-dominant hands and peak expiratory flow rate (P0.001). In men, there was a positive correlation between MAMC, hand grip strength (P0.001) and peak expiratory flow rate (P0.001). In women muscle function correlated with height (P0.001) but not MAMC (P0.05).In normal subjects bedside tests of skeletal and respiratory muscle function correlated with each other in both sexes, and with muscle mass in men but not in women.

Summary Background & Aims : The optimal testing position for hand grip strength, which is a useful functional measure of nutritional status, is open to debate. We therefore examined the systematic difference between different postures in order to establish a methodology that is clinically relevant, easy to perform and reproducible. Methods : Grip strength was measured in the dominant and non-dominant hands with a strain gauge dynamometer in three positions: lying at 30° in bed with elbows supported, seated in an armchair with elbows supported and in a chair with elbows unsupported. The average of three readings made in each position, each 1min apart, was recorded. Results : 55 normally nourished subjects (26 male) were studied. Mean (95% CI) grip strengths measured in the dominant hand with the subject in bed, sitting in an armchair and sitting in a chair were 45.7 (42.3–49.2), 46.3 (42.9–49.8) and 48.5 (45.4–51.7)kg, respectively for males. Corresponding values for females were 29.4 (27.0–31.8), 29.3 (26.8–31.9) and 31.6 (28.8–34.3)kg. There was no significant difference (Student t -paired test) between measurements made in bed and on an armchair ( P = 0.49 ), but the measurements made in a chair were significantly higher than those made in bed ( P = 0.001 ) and in an armchair ( P = 0.004 ). No statistical difference was present, comparing the three separate measurements in each position (Student t -paired test). Conclusions : Measurement of grip strength using hand dynamometry is reproducible and consistent. As all patients are not able to sit in a chair with elbows unsupported, in clinical practice it is more practicable to perform hand dynamometry with the elbows supported in a bed or armchair.

AIM: To investigate the effect of preoperative biliary drainage (PBD) in jaundiced patients with hilar cholangiocarcinoma (HCCA) undergoing major liver resections. METHODS: An observational study was carried out by reviewing a prospectively maintained database of HCCA patients who underwent major liver resection for curative therapy from January 2002 to December 2012. Patients were divided into two groups based on whether PBD was performed: a drained group and an undrained group. Patient baseline characteristics, preoperative factors, perioperative and short-term postoperative outcomes were compared between the two groups. Risk factors for postoperative complications were also analyzed by logistic regression test with calculating OR and 95%CI. RESULTS: In total, 78 jaundiced patients with HCCA underwent major liver resection: 32 had PBD prior to operation while 46 did not have PBD. The two groups were comparable with respect to age, sex, body mass index and co-morbidities. Furthermore, there was no significant difference in the total bilirubin (TBIL) levels between the drained group and the undrained group at admission (294.2 ± 135.7 vs 254.0 ± 63.5, P = 0.126). PBD significantly improved liver function, reducing not only the bilirubin levels but also other liver enzymes. The preoperative TBIL level was significantly lower in the drained group as compared to the undrained group (108.1 ± 60.6 vs 265.7 ± 69.1, P = 0.000). The rate of overall postoperative complications (53.1% vs 58.7%, P = 0.626), reoperation rate (6.3% vs 6.5%, P = 1.000), postoperative hospital stay (16.5 vs 15.0, P = 0.221) and mortality (9.4% vs 4.3%, P = 0.673) were similar between the two groups. In addition, there was no significant difference in infectious complications (40.6% vs 23.9%, P = 0.116) and noninfectious complications (31.3% vs 47.8%, P = 0.143) between the two groups. Univariate and multivariate analyses revealed that preoperative TBIL > 170 μmol/L (OR = 13.690, 95%CI: 1.275-147.028, P = 0.031), Bismuth-Corlette classification (OR = 0.013, 95%CI: 0.001-0.166, P = 0.001) and extended liver resection (OR = 14.010, 95%CI: 1.130-173.646, P = 0.040) were independent risk factors for postoperative complications. CONCLUSION: Overall postoperative morbidity and mortality rates after major liver resection are not improved by PBD in HCCA patients with jaundice. Preoperative TBIL > 170 μmol/L, Bismuth-Corlette classification and extended liver resection are independent risk factors linked to postoperative complications.

AIM: To conduct a meta-analysis to compare Roux-en-Y (R-Y) gastrojejunostomy with gastroduodenal Billroth I (B-I) anastomosis after distal gastrectomy (DG) for gastric cancer. METHODS: A literature search was performed to identify studies comparing R-Y with B-I after DG for gastric cancer from January 1990 to November 2012 in Medline, Embase, Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials in The Cochrane Library. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed or random effects model. Operative outcomes such as operation time, intraoperative blood loss and postoperative outcomes such as anastomotic leakage and stricture, bile reflux, remnant gastritis, reflux esophagitis, dumping symptoms, delayed gastric emptying and hospital stay were the main outcomes assessed. Meta-analyses were performed using RevMan 5.0 software (Cochrane library). RESULTS: Four randomized controlled trials (RCTs) and 9 non-randomized observational clinical studies (OCS) involving 478 and 1402 patients respectively were included. Meta-analysis of RCTs revealed that R-Y reconstruction was associated with a reduced bile reflux (OR 0.04, 95%CI: 0.01, 0.14; P < 0.00 001) and remnant gastritis (OR 0.43, 95%CI: 0.28, 0.66; P = 0.0001), however needing a longer operation time (WMD 40.02, 95%CI: 13.93, 66.11; P = 0.003). Meta-analysis of OCS also revealed R-Y reconstruction had a lower incidence of bile reflux (OR 0.21, 95%CI: 0.08, 0.54; P = 0.001), remnant gastritis (OR 0.18, 95%CI: 0.11, 0.29; P < 0.00 001) and reflux esophagitis (OR 0.48, 95%CI: 0.26, 0.89; P = 0.02). However, this reconstruction method was found to be associated with a longer operation time (WMD 31.30, 95%CI: 12.99, 49.60; P = 0.0008). CONCLUSION: This systematic review point towards some clinical advantages that are rendered by R-Y compared to B-I reconstruction post DG. However there is a need for further adequately powered, well-designed RCTs comparing the same.

s / Pancreatology 13 (2013) e1–e20 e9 Conclusion: When combined histopathological and molecular criteria define 2 clinically relevant phenotypes of adenocarcinoma of the ampulla of Vater that potentially represent 2 distinct diseases with significant implications for current therapeutic strategies, better interpretation of past clinical trials, and facilitate future trial design. Take-home message: When combined histopathological and molecular criteria define 2 clinically relevant phenotypes of adenocarcinoma of the ampulla of Vater that potentially represent 2 distinct diseases with significant implications for current therapeutic strategies. Abstract previously presented? no () Any disclosures? no ()

Gangrene of the breast, although rare, has been reported following anticoagulant treatment, trauma, and infection. Two cases of breast gangrene due to puerperal sepsis have been reported. We report a case of right breast gangrene as a complication of puerperal sepsis in a female patient.

BackgroundBetter pre-operative risk stratification may improve patient selection for pancreatic resection in pancreatic cancer. C-reactive protein (CRP) and the neutrophil–lymphocyte ratio (NLR) have demonstrated prognostic value in some cancers. The role of CRP and NLR in predicting outcome in pancreatic cancer after curative resection is not well established.MethodsAn electronic search of MEDLINE, EMBASE and CINAHL was performed to identify studies assessing survival in patients after pancreatic cancer resection with high or low pre-operative CRP or NLR. Systematic review was undertaken using the PRISMA protocol.ResultsIn total, 327 studies were identified with 10 reporting on survival outcomes after a pancreatic resection in patients with high or low CRP, NLR or both. All but one paper showed a trend of lower inflammatory markers in patients with longer survival. Three studies from six showed low CRP to be independently associated with increased survival and two studies of eight showed the same for NLR. All studies were retrospective cohort studies of low to moderate quality.DiscussionInflammatory markers might prove useful guides to the management of resectable pancreatic cancer but, given the poor quality of evidence, further longitudinal studies are required before incorporating pre-operative inflammatory markers into clinical decision making.

Background Periodontitis is described as a group of inflammatory diseases of the gingiva and supporting structures of the periodontium. The accumulation of plaque bacteria, which include putative periodontal pathogens, is known to initiate the disease but the host immune response is the major contributing factor for destruction of periodontal tissues. Proteins that bind to heparin heparin-binding protein (HBPs) play important roles in health and disease and interact with each other via networks known as ‘heparin interactomes’. This study aimed at evaluating published datasets of HBPs and its role in periodontitis. Methods To elucidate the role of HBPs in periodontitis, bioinformatics analyses of published data was used. In silico analyses of published datasets were used to construct a putative HBPs interactome using an online database resource, ‘STRING’ (Search Tool for the Retrieval of Interacting Genes). Results PubMed searches identified 249 genes that were up regulated and 146 genes that were down regulated in periodontal disease, compared with periodontal disease-free gingival samples. In silico analyses using published datasets revealed 25 up-regulated and 23 down-regulated HBPs in periodontitis. Of these HBPs; chemokines, such as CXCL12 was up regulated where as some of the matrixmetalloproteinases (MMPs; MMP-2 and MMP9) were up-regulated while MMP-14 was down regulated. Conclusions The results indicate that HBP analyses will provide multiple targets for the biological mechanisms underlying periodontal disease (such as MMPs, cytokines and chemokines) that will have important clinical implications in the future drug design and management of periodontal disease. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-1857-1) contains supplementary material, which is available to authorized users.