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Objective:To investigate the risk factors for anastomotic leakage after laparo-scopic lower anterior resection (LAR) of rectal cancer, and the application value of its risk assess-ment scoring model.Methods:The retrospective case-control study was conducted. The clinico-pathological data of 539 patients who underwent laparoscopic LAR of rectal cancer in 13 medical centers, including 248 cases in Renji Hospital of Shanghai Jiaotong University School of Medicine, 35 cases in Ningbo First Hospital, 35 cases in Changzhou Second People's Hospital, 32 cases in the First People's Hospital of Nantong, 32 cases in Linyi People's Hospital, 31 cases in Changzhou Wujin People's Hospital, 28 cases in Jiading District Hospital of Traditional Chinese Medicine, 27 cases in the First Hospital of Taizhou, 26 cases in Shanghai Pudong Gongli Hospital, 21 cases in the People's Hospital of Rugao, 11 cases in Central Hospital of Fengxian District, 7 cases in Ningbo Hangzhou Bay Hospital and 6 cases in Jiangsu jianhu People's Hospital, from January 2016 to November 2020 were collected. There were 157 males and 382 females, aged (62.7±0.5)years. Observation indicators: (1) follow-up; (2) risk factors for anastomotic leakage after laparoscopic LAR; (3) establishment of risk assessment scoring model for anastomotic leakage after laparoscopic LAR. Follow-up was conducted by outpatient examination or telephone interview. Patients were followed up at 1 week after discharge or 1 month after the operation to detect the anastomotic leakage. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Univariate analysis was conducted using the chi-square test and multivariate analysis was conducted usong the Logistic regression model. The area under curve of receiver operating characteristic curve was used to estimate the efficiency of detecton methods. The maximum value of the Youden index was defined as the best cut-off value. Results:(1) Follow-up: 539 patients were followed up at postoperative 1 week and 1 month. During the follow-up, 79 patient had anastomotic leakage, with an incidence of 14.66%(79/539). Of the 79 patients, 39 cases were cured after conservative treatment, 40 cases were cured after reoperation (ileostomy or colostomy). (2) Risk factors for anastomotic leakage after laparoscopic LAR. Results of univariate analysis showed that sex, age, body mass index, smoking and/or drinking, tumor diameter, diabetes mellitus, hemoglobin, albumin, grade of American Society of Anesthesio-logists (ASA), neoadjuvant chemoradiotherapy, distance from anastomotic level to dentate line, the number of pelvic stapler, reinforced anastomosis, volume of intraoperative blood loss, placement of decompression tube, preservation of left colic artery, operation time and professional doctors were related factors for anastomotic leakage after laparoscopic LAR ( χ2=14.060, 4.387, 5.039, 4.094, 17.488, 33.485, 25.066, 28.959, 34.973, 34.207, 22.076, 13.208, 16.440, 17.708, 17.260, 4.573, 5.919, 5.389, P<0.05). Results of multivariate analysis showed that male, tumor diameter ≥3.5 cm, diabetes mellitus, hemoglobin <90 g/L, albumin <30 g/L, grade of ASA ≥Ⅲ, neoadjuvant chemoradiotherapy, distance from anastomotic level to dentate line <1 cm, the number of pelvic stapler ≥3, non-reinforced anastomosis, volume of intraoperative blood loss ≥100 mL and no placement of decom-pression tube were independent risk factors for anastomotic leakage after laparoscopic LAR ( odds ratio=2.864,3.043,12.556,7.178,8.425,12.895,8.987,4.002,3.084,4.393,3.266,3.224,95% confidence interval as 1.279?6.411, 1.404?6.594, 4.469?35.274, 2.648?19.459, 2.471?28.733, 4.027?41.289, 3.702?21.777, 1.746?9.171, 1.365?6.966, 1.914?10.083, 1.434?7.441, 1.321?7.867, P<0.05). (3) Establishment of risk assessment scoring model for anastomotic leakage after laparoscopic LAR. based on the results of univariate analysis, clinicopathological factors with χ2>20, χ2>10 and ≤20 or χ2≤10 were defined as scoring of 3, 2, 1, respectively. The cumulative clinicopatho-logical factors scoring ≥6 was defined as an effective evaluating indicator for postoperative anastomotic leakage. The risk assessment scoring model (6-321) for anastomotic leakage after laparoscopic LAR was established. The cumulative value ≥6 indicated high incidence of anastomotic leakage, and the cumulative value <6 indicated low incidence of anastomotic leakage. Conclusions:Male, tumor diameter ≥3.5 cm, diabetes mellitus, hemoglobin <90 g/L, albumin <30 g/L, grade of ASA ≥Ⅲ, neo-adjuvant chemoradiotherapy, distance from anastomotic level to dentate line <1 cm, the number of pelvic stapler ≥3, non-reinforced anastomosis, volume of intraoperative blood loss ≥100 mL and no placement of decompression tube are independent risk factors for anastomotic leakage after laparoscopic LAR. The risk assessment scoring model (6-321) is established according to the above results.The cumulative value ≥6 indicates high incidence of anastomotic leakage and the cumulative value <6 indicates low incidence of anastomotic leakage.
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<p><b>OBJECTIVE</b>To summarize the treatment status of gastric gastrointestinal stromal tumor (GIST) in Shandong province,by analyzing the clinicopathological features and prognostic factors.</p><p><b>METHODS</b>Clinicopathological and follow-up data of 1 165 patients with gastric GIST between January 2000 and December 2013 from 23 tertiary referral hospitals in Shandong Province were collected to establish a database. The risk stratification of all cases was performed according to the National Institutes of Health(NIH) criteria proposed in 2008. Kaplan-Meier method was used to calculate the survival rate. Log-rank test and Cox regression model were used for univariate and multivariate prognostic analyses.</p><p><b>RESULTS</b>Among 1 165 cases of gastric GIST, 557 were male and 608 were female. The median age of onset was 60 (range 15-89) years. Primary tumors were located in the gastric fundus and cardia in 623 cases(53.5%), gastric body in 346 cases(29.7%), gastric antrum in 196 cases(16.8%). All the cases underwent resection of tumors, including endoscopic resection (n=106), local resection (n=589), subtotal gastrectomy(n=399), and total gastrectomy(n=72). Based on the NIH risk stratification, there were 256 cases (22.0%) at very low risk, 435 (37.3%) at low risk, 251 cases (21.5%) at intermediate risk, and 223 cases (19.1%) at high risk. A total of 1 116 cases(95.8%) were followed up and the median follow-up period was 40 (range, 1-60) months. During the period, 337 patients relapsed and the median time to recurrence was 34 (range 1-60) months. The 1-, 3-, and 5-year survival rates were 98.6%, 86.1% and 73.4%, respectively. The 5-year survival rates of patients at very low, low, intermediate, and high risk were 93.1%, 85.8%, 63.0% and 42.3% respectively, with a statistically significant difference (P=0.000). Multivariate analysis showed that primary tumor site (RR=0.580, 95%CI:0.402-0.835), tumor size (RR=0.450, 95%CI:0.266-0.760), intraoperative tumor rupture(RR=0.557, 95%CI:0.336-0.924), risk classification (RR=0.309, 95%CI:0.164-0.580) and the use of imatinib after surgery (RR=1.993, 95%CI:1.350-2.922) were independent prognostic factors.</p><p><b>CONCLUSIONS</b>The choice of surgical procedure for gastric GIST patients should be based on tumor size. All the routine procedures including endoscopic resection, local excision, subtotal gastrectomy and total gastrectomy can obtain satisfactory curative outcomes. NIH classification has a high value for the prediction of prognosis. Primary tumor site, tumor size, intraoperative tumor rupture, risk stratification and postoperative use of imatinib are independent prognostic factors in gastric GIST patients.</p>
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Objective An ideal small bowel transplantation model is the prerequisite and guarantee of small bowel transplan-tation-related researches.The aim of this study is to establish a pig model of orthotopic segmental small bowel transplantation by modifi-cation of blood vessel reconstruction and surgical techniques. Methods Twenty healthy pigs were equally assigned as donors and re-cipients.The superior mesenteric vessels were freed and the distal ileum harvested as grafts.After irrigation and preservation, the small bowel was transplanted by end-to-end anastomosis of the superior mesenteric arteries and veins, and then the small bowel was re-constructed simultaneously to restore intestinal continuity, with the proximal part of the graft brought out as a stoma for the purpose of graft monitoring. Results Transplantation was successfully performed in 9 of the 10 cases, with a success rate of 90%.The donor operations averaged 100 min, recipient operations 172 min, warm ischemia 1.3 min, cold ischemia 96 min, and vascular anastomosis 27.6 min.No postoperative anastomosis fistula occurred in any of the cases. Conclusion The pig model of orthotopic segmental small bowel transplantation is ideal for small bowel transplantation-related researches.
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Objective To investigat the changes of hemodynamics and arterial blood gas during the establishment of ECMO model and provide an ideal platform for the study of the mechanism of DCD protection using ECMO, a porcine model of controlled donors of cardiac death (CDCD) with extracorporeal support was established in the paper. Methods Eight domestic crossbred pigs were anes-thetized, atracurium (1mg/kg) and heparin (150~200 U/kg) was administered and the ventilator was discontinued while the animal was under deep anesthesia to kill the animal.Meanwhile, blood was drained from the left jugular vein catheter into the ECMO circuit and re-turned into the left femoral artery to establish the porcine model of CDCD with extracorporeal support . The average blood press and arterial blood gas were ministered at normal, cardiac arrest and ECMO supporting 1 h, 3 h and 5 h. Results The model of CDCD with extra-corporeal support was established successfully.Two animals restored the beating of the heart and the high doses of potassium chloride were given untill cardiac arrest during extracorporeal support.Blood gases throughout the apneic time showed a severe hypoxemia and acidosis, pH and PaO2 reduced to 7.09 ±0.24 and 5.3 ±0.93mmHg respective-ly, which can be improved during extracorporeal support.MAP and PaO2 were maintained over 300mmHg and 65mmHg respectively. Conclusion A new porcine model of controlled donors of cardiacdeath with extracorporeal support has been successfully established and showed to be feasible for related pathophysiological research work.
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Objective To evaluate the effect of extracorporeal membranous oxygenation (ECMO) on the small bowel preservation in a porcine model of controlled donors after cardiac death (CDCD).Method The domestic crossbred donor pigs were anesthetized and ventilated with 100％ oxyger.An intravenous cannula was placed through iliac arteries and jugular vein,and connected to ECMO system.The ECMO was performed to infuse abdominal organs when cardiac death was declared.Pathology,electron microscope,energy metabolism and cell apoptosis level of intestinal mucosa were evaluated before operation,in cardiac death and at the end of extracorporeal support,respectively.Result The normothermic extracorporeal support could quickly restore graft blood supply and oxygenation.One-h extracorporeal support could improve the energy status in intestine of donation after cardiac death (DCD).The histologic damage and apoptosis of 1-h extracorporeal support had no significant difference with those before operation and in cardiac death (P＞0.05).With the extension of extracorporeal support,the intestinal mucosa damage degree was gradually increased,and the content of adenosine triphosphate in intestinal mucosa reduced gradually.Conclusion The normothermic extracorporeal support for 1 h in DCD is beneficial for improving the viability of small bowel.However,the integrity of intestinal mucosa is destroyed gradually as extracorporeal supporting time over,which may be initiated by the activation of intestinal epithelial apoptosis.
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Objective:The effect and side effect of the dose-adjusted EPOCH regimen were evaluated perspectively for the pre-liminarily diagnosed angioimmunoblastic T-cell lymphoma. Methods: Nine cases of untreated angioimmunoblastic T-cell lymphoma were diagnosed and enrolled in our department from September 2008 to September 2012. All patients received dose-adjusted EPOCH regimen as first-line chemotherapy. Results: The median age of 9 patients was 54 years. The male-to-female ratio was 2∶1. About 88.9%of all patients were at Ann Arbor stageⅢ/Ⅳ, and 77.8%presented with B symptoms. Anemia was found in 66.7%of 9 patients, and lactate dehydrogenase elevated in 55.6%of patients. After an average of 4.7 cycles of chemotherapy of dose-adjusted EPOCH regi-men, the complete remission rate was 22.2%, and the total response rate was 66.7%. With a median follow-up of 20 months, the 4-year progression-free survival rate was 11.1%, and the overall survival rate was 33.3%. The median survival time was 19 months. The most common adverse events of EPOCH chemotherapy were hematologic toxicity. Grades 3-4 neutropenia and thrombocytopenia were re-ported in 77.8%and 33.3%of patients. Febrile neutropenia was observed in 44.4%of patients. Non-treatment-related mortality was al-so noted. Conclusion: The results of our research showed no clear benefit of treating preliminarily diagnosed angioimmunoblastic T-cell lymphoma with dose-adjusted EPOCH regimen. The main adverse events were hematologic toxicity and could be tolerated.
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Cancer stem cells are defined as the unique subpopulation in the tumors that possess the abili-ty to initiate tumor growth and sustain self-renewal as well as metastatic potential.Accumulating evidences in recent years strongly indicate the existence of cancer stem cells in solid tumors of a wide variety of organs.In recent years,many cancer stem cells have been found,including leukemia,breast cancer,brain ttunor,liv-er cancer,colon carcinoma,etc.In this review,we will discuss the conception and origin of the gastric cancer stem cells,and their role in the development of multi-drug resistance.
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Objective: To investigate the surgical methods and outcomes of the enlarged translabyrinthine approach in the removal of large acoustic neuromas. Methods: A large mastoidectomy involved complete exposure of the sigmoid sinus, the dura behind the sinus for at least 1 cm, the superior petrosal sinus and the middle fossa dura. The jugular bulb was exposed and pressed downwards if necessary. The internal auditory meatus was skeletonized and uncovered for at least 270°.The debulking of the tumor began inside the anterior and inferior poles in order to find the brainstem and the facial nerve root as early as possible, and then the dissection of the nerve was done medially to laterally. Intraoperative facial nerve monitoring and postoperative CT and MRI were done in all cases. Results: Total removal was achieved in all 18 patients with tumors larger than 3 cm (mean size: 4.2 cm). There were no deaths or other complications such as intracranial infection and persistent cerebrospinal fluid leakage. There were no obvious cerebral sequelae. The facial nerve was preserved both anatomically and functionally in 14 cases, with Grade Ⅰ or Ⅱ in 8 cases, Grade Ⅲ or Ⅳ in 6 cases. Nerve interruption occurred in 4 patients who all had severe facial palsy or nerve interruption before operation. Sixteen patients resumed work within 1-3 months. Conclusion: Total removal of large acoustic neuroma could be acomplished via the translabyrinthine approach, with good preservation of facial nerve function and minimum incidence of morbidity.
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Objective To obtain more detailed microsurgical anatomical data and multi-slice helical CT scanning of cochlear aqueduct for the translabyrithine approach. Methods Twenty cadaver heads(40 sides)fixed with formalin were dissected under a microscope ,and cochlear aqueducts were found and measured. Five cadaver heads(10 sides) were scanned by multi-slice helical CT. Results The width of external aperture of cochlear aqueduct was (2.64?0.82)mm. The length of cochlear aqueduct was (8.40?1.35)mm. The distance between cochlear aqueduct and cranial nerves Ⅸ, Ⅹ, Ⅺ, and that between the inferior petrosal sinus was(1.08?0.36 )mm,(2.71?0.63)mm,(4.52?1.25)mm, (1.14?0.46)mm, respectively. The distance between external aperture of cochlear aqueduct and the inferior margin of internal acoustic meatus aperture was (5.53?0.93)mm. The otic capsule segment of cochlear aqueduct could not be demonstrated on the coronal section. The petrosal portion could be demonstrated by both coronal and axial scannings. Conclusion The axial scanning was useful for detecting cochlear aqueduct. Cochlear aqueduct could be regarded as one of the landmarks in translabyrithine approach for cerebellopontile angle operation.