Application of self-expanding polyurethane foam in the model of fatal hemorrhage / 中华急诊医学杂志

Objective:To evaluate the hemostatic effect of self-expanding polyurethane foam in an animal model of fatal hepatic trauma and hemorrhage.Methods:The fatal liver trauma hemorrhage model with swine was established. Then the damage-controlled resuscitation was performed. Thirty minutes after injury, the experimental animals were randomly divided into the gauze packing group (GP), foam packing group (FP) and blank control group (BC). The survival time, vital signs, the bleeding volume, coagulation function and other lab indicators were recorded for 48 h. Liver histopathological examination was performed after death or execution.Results:All the three groups had severe hemorrhagic shock after modeling. The 48-h survival rate of the FP group and the GP group was significantly higher than that of the BC group (6/6 vs 4/6 vs 0/6). The average survival time of the FP group was not statistically different from that of the GP group [48 h vs (44.58±5.53) h, P>0.05], and was significantly longer than that of the BC group [48 h vs (1.64±0.17) h, P<0.01]. The bleeding volume of the FP group was significantly less than the GP group and BC group [(19.2±7.3) g/kg vs (41.3±8.6) g/kg, (51.5±7.3) g/kg, both P<0.01]. Compared with the GP group and the BC group, the cardiac output of the FP group was significantly improved [(5.00±0.53) L/min vs (4.13±0.41) L/min, (2.38±0.48) L/min, both P<0.05]. The coagulation function, liver and kidney function and blood lactate level of the FP group and the GP group were better than those of the BC group; the intra-abdominal pressure of the FP group was significantly higher than that in the GP group [(18.83±3.25) cmH 2O vs (3.83±1.47) cmH 2O, P<0.05]. There was no abnormal increased in intra-abdominal pressure in the BC group. According to the histopathology examination, there was no obvious secondary damage in the FP group. Conclusions:The application of self-expanding polyurethane foam for intraperitoneal packing to stop bleeding can effectively reduce the amount of bleeding in the fatal liver trauma hemorrhage model, effectively maintain vital signs, and improve the short-term survival rate.

Relative factors of transmural intestinal necrosis in acute superior mesenteric vein thrombosis / 中华外科杂志

Objective@#To examine the relative factors of transmural intestinal necrosis(TIN) during multidisciplinary stepwise management facilitating the decision making in patients with acute superior mesenteric vein thrombosis (ASMVT).@*Methods@#Clinical data of patients with ASMVT admitted to Department of General Surgery, Jinling Hospital from January 2009 to June 2017 were reviewed retrospectively. There were 52 males and 37 females, aging (45.9±12.6) years (range: 20 to 69 years). According to the postoperative pathological results and follow-up, the patients were divided into TIN group (n=31) and non-TIN group(n=58, including 18 cases of intestinal stricture). The related factors were compared between ASMVT patients with TIN and patients without TIN by univariate analysis using t test, U test and χ2 test accordingly, and factors with statistically significance were subsequently submitted to binary Logistic regression analysis. The predictive value and cut-off point of factors were evaluated by receiver operator characteristic(ROC) curve and area under the curve.@*Results@#In univariate analysis, smoking, hypertension, peritonitis, white blood cell count,haemoglobin, international normalized ratio, blood albumin, thrombosis of superior mesenteric branches vein, free intraperitoneal fluid, decrease of bowel wall enhancement and pneumatosis intestinalis were TIN risk factors (all P<0.05). According to the binary Logistic regression analysis, white blood cell count (OR=1.093, 95%CI: 1.010 to 1.182, P=0.027), thrombosis of the superior mesenteric branches vein (OR=11.519, 95%CI: 1.906 to 69.615, P=0.008), pneumatosis intestinalis (OR=11.140, 95%CI: 2.360 to 52.585, P=0.002) were independent relative factors of TIN in patients with AMI, and the area under the ROC curve of the above factors and predictive model was 0.759 (95%CI: 0.647 to 0.871), 0.745 (95%CI: 0.641 to 0.848), 0.737 (95%CI: 0.621 to 0.854), 0.909 (95%CI: 0.847 to 0.971), respectively. The cutoff value of white blood cell count was 18.1×109/L.@*Conclusion@#White blood cell levels, superior mesenteric vein branch thrombosis and pneumatosis intestinalis are independent predictors of TIN in ASMVT.

Regulatory mechanism of gastric stem cells and their application research in establishment of gastric organoids / 中华消化外科杂志

Gastric stem cells are adult stem cells found in the gastric tissues,which possess high self-renewal capability,proliferation rate and multiple differentiation capability.They can regenerate all the gastric mucosa epithelial cells.Gastric stem cells play an important role in the self-renewal and injury repair,making epithelium of gastric mucosa in the dynamic balance and maintaining the integrity of gastric mucosa.With the constant deepening of stem cell research,the application of gastric stem cells provides a new means for the study of gastric physiology and diseases.Since the first report by Barker in 2010,gastric organoids have soon become a model of interest and are highly desirable as tools for studying gastric diseases.As an optimal experimental model,gastric organoids are superior to animal model and conventional cell culture.Gastric organoids are comprised of all major types of gastric epithelial cells,represent the architecture and function remarkably similar to those of the gastric epithelium,faithfully recapitulating the functional gastric epithelium ex vivo.Especially gastric organoids derived from the human body,which allow the investigation of the function of human stomach in the ex vivo setting.In this review,research progresses of gastric stem cells and their application in establishment of gastric organoids are summarized.

Gut microbiota and its implications in small bowel transplantation / 医学前沿

The gut microbiota is mainly composed of a diverse population of commensal bacterial species and plays a pivotal role in the maintenance of intestinal homeostasis, immune modulation and metabolism. The influence of the gut microbiota on solid organ transplantation has recently been recognized. In fact, several studies indicated that acute and chronic allograft rejection in small bowel transplantation (SBT) is closely associated with the alterations in microbial patterns in the gut. In this review, we focused on the recent findings regarding alterations in the microbiota following SBTand the potential roles of these alterations in the development of acute and chronic allograft rejection. We also reviewed important advances with respect to the interplays between the microbiota and host immune systems in SBT. Furthermore, we explored the potential of the gut microbiota as a microbial marker and/or therapeutic target for the predication and intervention of allograft rejection and chronic dysfunction. Given that current research on the gut microbiota has become increasingly sophisticated and comprehensive, large cohort studies employing metagenomic analysis and multivariate linkage should be designed for the characterization of host-microbe interaction and causality between microbiota alterations and clinical outcomes in SBT. The findings are expected to provide valuable insights into the role of gut microbiota in the development of allograft rejection and other transplant-related complications and introduce novel therapeutic targets and treatment approaches in clinical practice.

Treatment of 21 cases of chronic radiation intestinal injury by staging ileostomy and closure operation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To summarize the application of staged ileostomy and closure operation combined with nutritional support therapy in the treatment of chronic radiation intestinal injury(CRII).</p><p><b>METHODS</b>Clinical data of patients with definite radiation history and pathological diagnosis of CRII receiving treatment at Department of General Surgery, Jinling Hospital from January 2012 to December 2016 were retrospectively analyzed. Patients who were diagnosed with tumor recurrence during operation or by postoperative pathology were excluded. Patients undergoing stageI( ileostomy and stageII( closure operation combined with nutrition support therapy were enrolled to the cohort. Detailed scheme of stage I( ileostomy and therapeutic time were determined by clinical symptoms and nutritional status. While performing ileostomy, the removal of intestinal lesions depended on range and degree of intestinal injury. Nutritional support therapy and other symptom-relieving therapy were offered after surgery. Timing for stageII( closure operation was decided according to nutritional status of patients. Lesions of remaining intestine were determined during operation, then necessary intestinal resection and closure operation were performed. Adhesion classification of radiation intestinal injury (total five levels) proposed by our center was adopted to evaluate the level and range of intestinal lesions. Level 0 indicated no adhesion between injured intestinal loop and surrounding organs; level 1 indicated that the adhesion and fibrosis were limited to right pelvis; level 2 indicated that the adhesion included all pelvis and the adhesion was severe and difficult to divide; level 3 was the forward extension of level 2 adhesion, which was between injured intestinal loop and anterior pelvic wall; level 4 was the upward extension of level 3 adhesion, which was between injured intestinal loop and anterior abdominal wall. Clavien-Dindo classification (lower level means milder symptom) and complication comprehensive index(CCI, lower CCI means milder symptom) calculated by on-line program (http:∕∕www.assessurgery. com) were applied to estimate postoperative complications. Resected intestinal length, adhesion classification of radiation intestinal injury, postoperative complications and time to total enteral nutritional (TEN) of both surgeries and nutritional status (body mass index and serum albumin) were compared between stageI( ileostomy and stageII( closure operation.</p><p><b>RESULTS</b>Twenty-one patients were enrolled in the research with 2 males and 19 females. Primary tumor included 14 cervical cancers, 3 rectal cancers, 1 endometrial cancer, 1 ovarian carcinoma, 1 seminoma and 1 mixed germ cell tumor. Median interval between the end of radiation and radiation intestinal injury was 7(2 to 91) months and median interval between the incidence of radiation intestinal injury and ileostomy was 5(<1 to 75) months. Operative indications for ileostomy were obstruction in 14 cases (66.7%), intestinal internal fistula in 1 case (4.8%), intestinal outer fistula in 2 cases (9.5%), radiation proctitis in 3 cases (14.3%) and acute intestinal perforation in 1 case (4.8%). Average age of patients undergoing stageI( ileostomy was 48 (18 to 60) years with BMI (17.0±2.7) kg/m and serum albumin (36.8±5.2) g/L. Patients undergoing stageII( closure operation had significantly higher BMI [(18.4±2.0) kg/m, t=-2.747, P=0.013] and higher serum albumin [(40.8±3.6) g/L, t=-3.505, P=0.002]. Average interval between stageI( ileostomy and stageII( closure surgery was (197±77) days. Resected intestinal length of stageI( ileostomy was which was significantly longer than that of stageII( closure surgery [(74.0±56.1) cm vs. (15.5±10.4) cm, t=4.547, P= 0.000]. Abdominal adhesion classification of stageII( ileostomy plus closure operation was significantly better as compared to stage I( ileostomy(Z=-3.347, P=0.001). Morbidity of postoperative complications in stageI( ileostomy was 52.4% (11/21), which decreased to 19.0% (4/21) in stageII( operation with significant difference (χ²=5.081, P=0.024). Postoperative complication Clavien-Dindo classification and CCI scores in stageII( operation were significantly lower than those in stageI( operation (P=0.006 and P=0.002). Till June 2017, 17 of 21 patients(81.0%) were followed-up for (28±18) months. Except for 2 cases of relapse, 15 patients recovered to normal diet.</p><p><b>CONCLUSIONS</b>Application of staged ileostomy and closure operation combined with nutritional support therapy to CRII is in accordance with the principle of injury control surgery. Furthermore, this staged approach is safe and effective, can reduce the morbidity and the severity of complications, and can also be helpful to decide the margin for intestinal resection.</p>

The application of intestinal stomas in mesenteric ischemia / 中华外科杂志

Objective@#To evaluate the application of intestinal stomas in mesenteric ischemia (MI) according to the concept of damage control surgery.@*Methods@#Clinical data of 59 MI patients received intestinal stomas at Jinling Hospital, Nanjing University School of Medicine from January 2010 to June 2017 were analyzed retrospectively. There were 41 male and 18 female patients aging of (51±14) years (ranging from 20 to 86 years). All the patients were divided to two groups according to the degree of bowel ischemia: acute MI group (AMI, bowel necrosis, n=43) and chronic MI group (CMI, bowel stricture, n=16). The medium time from onset to consult of AMI was 7(12) days (M(QR)) and the time of CMI was 80(51) days. After the resection of irreversible ischemic intestine, ostomy was carried out for all 59 patients. Patients received oral anticoagulation, enteral nutrition and succus entericus reinfusion therapy for about 6 months after discharge. Then definite surgery to restore digestive tract was preferred.@*Results@#In AMI group, APACHEⅡ score in admission was (16±3). The length of infarcted intestine resected was (160±95) cm, normal bowel left was (220±106) cm. Twelve patients had complications during first post-operation period including sepsis (n=8), acute renal failure (n=4), acute respiratory distress syndrome (n=4), short bowel syndrome (n=4). 30-day mortality was 18.6%. Total 30 patients received operation to restore the continuity of intestinal tract after 202(42) days and APACHEⅡ score was 4±2. Two patients suffered from sepsis and were cured after anti-infection. In CMI group, APACHEⅡ score was 16±3 and NRS2002 score was more than 3. The length of infarcted intestine resected was (43±33) cm. All patients had restored the continuity of intestinal tract after 176 (47) days. No major complications occurred during the first and second post-operation period.@*Conclusions@#According to damage control surgery, after early revascularization, patients with acute intestinal necrosis should be treated with infarcted bowel resection and stomas. Besides, second operation to restore the continuity of intestinal tract should be conducted after nutritional support for 6 months. Patients with ischemic enteropathy who cannot be corrected with severe malnutrition should achieve stomas during first operation.

Diagnosis and treatment of mesenteric venous thrombosis secondary to long-term ischemic enteropathy / 中华消化外科杂志

Objective To explore the diagnosis and treatment of mesenteric venous thrombosis secondary to long-term ischemic enteropathy.Methods The retrospective cross-sectional study was conducted.The clinical data of 36 patients with mesenteric venous thrombosis secondary to long-term ischemic enteropathy who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2009 to June 2017 were collected.Diagnostic methods:history inquiry,physical examination,laboratory test and image finding.Treatment methods:parenteral nutrition support,selective stage 1 bowel resection with anastomosis or stage 1 bowel resection and colostomy,definitive stage 2 operation for recovering digestive tract.Anticoagulation therapy was performed.Observation indicators:(1) clinical characteristics;(2) treatment;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to December 2017.Measurement data with skewed distribution were described as M (P25,P75) and M (range).Results (1) Clinical characteristics:① the main clinical manifestations:34,33,27,20,17 and 14 patients showed respectively discomfort after meal,abdominal pain,abdominal distension,nausea with vomiting,stop of analis exhaust and defecation and weight loss of different degree,and the worst patient lost 20 kg within 1 month.The clinical manifestations of 30 patients were more than 3.② The score of acute physiology and chronic health evaluation (APACHE)Ⅱ in 36 patients was 4 (2,6).③ Laboratory test:total protein (TP),albumin and prealbumin were 55.8 g/L (45.2 g/L,59.1 g/L),30.6 g/L (27.3 g/L,37.5 g/L) and 100.0 g/L (86.0 g/L,132.0 g/L),respectively,showing a decreased trend.④ Imaging finding:enhanced scans of abdominal CT showed the portal cavernous in 16 patients,the absence of main trunk of superior mesenteric vein with extensive collaterals in 12 patients,and dovelopment of portal vein and main trunk of superior mesenteric vein in 8 patients.One patients had intestinal edema and stenosis.X-ray contrast examination of digestive tract showed intestinal stenosis with mucosal erosion in 28 patients and complete intestinal obstruction in 8 patients.(2) Treatment:of 36 patients,24 underwent stage 1 bowel resection with anastomosis and other 12 received stage 1 bowel resection and colostomy (11 undergoing definitive stage 2 operation for recovering digestive tract and 1 refusing stage 2 operation due to advanced age).The length of resected bowel was 30 cm (15 cm,80 cm).One patient with stage 1 bowel resection with anastomosis was complicated with small bowel fistula,and was cured by conservative treatment.There was no complication in other patients.(3) Follow-up:all 36 patients were followed up for 3-10 months,with a median time of 6 months.During the follow-up,7 patients were complicated with secondary portal hypertension,5 of 7 were improved by symptomatic treatment,and 2 died of severe digestive tract bleeding;other patients had no related complications.Conclusions The discomfort after meal and bowel obstruction are the main clinical manifestations of mesenteric venous thrombosis secondary to long-term ischemic enteropathy.The abdominal CT with X-ray contrast examination benefits to diagnosis of patients with poor nutrition status and mild infection.The main strategy includes early surgical resection and postoperative anticoagulation therapy after bleeding risk evaluation.

Influential factors of surgical treatment for ischemic enteropatby secondary to portal venous system thrombosis / 中华普通外科杂志

Objective To investigate the influential factors of surgical treatment for ischemic enteropathy secondary to portal venous system thrombosis (PVST).Methods Clinical data of 27 patients with ischemic enteropathy secondary to PVST admitted in our department from January 2009 to Jun 2016 were analyzed retrospectively.These patients were divided into two groups according to different surgical procedures:ischemic bowel resection with primary anastomosis or ostomy.Results There were significant differences between the groups in albumin and prealbumin level (t =3.585,4.194,P ＜0.05).There were also significant differences for BMI and body fat (t =2.325,2.430,P ＜ 0.05).The average time from the onset PVST to ischemic enteropathy was 20 d.Conclusion There should be awareness of ischemic enteropathy.Intestinal resection and anticoagulation therapy is necessary.The choice of surgical procedures depends on the preoperative nutrition level (albumin,prealbumin).

Clinical analysis of persistent inflammation-immunosuppression-catabolism syndrome in patients with severe acute pancreatitis / 医学研究生学报

Objective Up to the present time, no reports are seen at home or abroad on the clinical characteristics of severe acute pancreatitis (SAP) with persistent inflammation-immunosuppression-catabolism syndrome (PICS), and few studies have been conducted on the risk factors for PICS.This article summarizes the clinical characteristics of PICS in SAP patients and presents a multivariate regression analysis of its risk factors.Methods This is a retrospective study on the clinical data about 214 cases of SAP treated for over 14 days in the Surgical Intensive Care Unit (SICU) from January 1, 2014 to December 31, 2015.According to the diagnostic criteria of PICS, we divided the SAP patients into a PICS group (n=149) and a non-PICS group (n=65).We compared the systemic and pancreatitis-specific complications and mortality rates in the SICU and at 12 months after discharge.We also performed a multivariate regression analysis on the risk factors of PICS.Results The incidence rates of biliary SAP and multiple-organ dysfunction syndrome (MODS) were significantly higher in the PICS (44.3% and 93.3%) than in the non-PICS group (29.2% and 55.4%) (P=0.038).The results of multivariate regression analysis showed that the risk factors for PICS included obesity (OR=2.3;95% CI: 1.0-5.2), biliary causes (OR=4.2;95% CI: 1.4-13.0), and MODS (OR=4.4;95% CI: 1.3-14.4).The survival rate at 12 months after discharge was remarkably lower in the PICS than in the non-PICS group (88.5% vs 98.2%, P=0.036).Conclusion The incidence rate of PICS is high in SAP patients.Obesity, biliary causes and MODS are independent risk factors for PICS.The complication of PICS may be an important indicator of the poor prognosis of SAP.

Clinical efficacy of laparoscopic surgery for pelvic radiation induced enteritis / 中华消化外科杂志

Objective To investigate the clinical efficacy of laparoscopic surgery for pelvic radiation induced enteritis (PRIE).Methods The retrospective cross-sectional study was conducted The clinical data of 66 patients with PRIE who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2012 to December 2015 were collected.Laparoscopic surgery will be applied to patients based on patients' clinical manifestations after completing relative examinations.Observation indicators:(1) surgical situations:surgical method,conversion to open surgery,reoperation,surgical incision length,grade of abdominal adhesions,surgical time,volume of intraoperative blood loss,duration of postoperative hospital stay;(2) occurrence of surgical complications;(3) follow-up situations.Follow-up using telephone interview was performed to detect patients' survival and recurrence of PRIE up to April 2016.Measurement data with normal distribution were represented as x±s.Results (1) Surgical situations:① of 59 patients with small intestinal obstruction,11underwent laparoscopic small intestinal resection or enterostomy,including 2 with conversion to open surgery due to dense adhesions,1 due to uncertainty of tumor recurrence and 1 due to intestinal canal dilatation affected vision;48 underwent laparoscopic resection of ileocecum,including 1 1 with conversion to open surgery due to dense adhesions,2 due to iliac vessels injury and 4 due to injuries of sigmoid colon,rectum and bladder.Four patients with colonic obstruction and proctitis underwent laparoscopic colostomy,without conversion to open surgery.One patient received conversional open surgery and underwent intestinal resection of internal fistula + exclusion of rectal stump due to intestine-rectum fistula induced dense adhesions.One patient with anal atresia underwent laparoscope-assisted resection of pelvic tissues and rectal stump.One patient with localized peritonitis underwent laparoscope-assisted ileostomy.② Among 66 patients,4 received reoperations,including 2 with cervical cancer and 2 with rectal cancer,reoperations of 4 patients were respectively caused by intestine-rectum fistula,rectovaginal fistula,anastomotic fistula and ostomy + stoma reversion.Of 4 patients with reoperations,1 received conversion to open surgery due to dense adhesions and then underwent intestinal resection of internal fistula+exclusion of rectal stump,1 with rectovaginal fistula underwent laparoscopic colostomy,1 with anastomotic fistula underwent resection and anastomosis of small intestine due to dense adhesions and 1 underwent laparoscopic ileostomy and stoma reversion.③ Sixty-six patients received 70 operations,including 46 laparoscopic surgeries and 24 conversion to open surgeries.Surgical incision length and average length were respectively 3.0-6.0 cm,4.0 cm in 46 laparoscopic surgeries and 8.0-25.0 cm,15.5 cm in 24 conversion to open surgeries.Grade 0,1,2 and 3 of abdominal adhesions were detected respectively in 7,13,13,13 laparoscopic surgeries and in 1,1,12,10 conversion to open surgeries.Operation time,volume of intraoperative blood loss and duration of postoperative hospital stay were respectively (128±50) minutes,(108±56) mL,(30± 15)days in 46 laparoscopic surgeries and (173±44) minutes,(222± 105) mL,(38± 19) days in 24 conversion to open surgeries.(2) Occurrence of surgical complications:1 patient was complicated with bladder injury in 46 laparoscopic surgeries,and 2,4 and 2 patients in 24 conversion to open surgeries were respectively complicated with bladder injury,colorectal injury and injury of right iliac vessels,they received intraoperative symptomatic treatment.Two,3,3,6 and 1 patients were respectively complicated with pleural effusion,wound infection or dehiscence,venous catheter infection,anastomotic fistula and cholestatic cholecystitis after 46 laparoscopic surgeries.One,5,1,4,2 and 1 were respectively complicated with pleural effusion,wound infection or dehiscence,venous catheter infection,anastomotic fistula,cholestatic cholecystitis and abdominal wall hemorrhage after 24 conversion to open surgeries.They were improved by symptomatic treatment.(3) Follow-up situations:all the 66 patients were followed up for 4-50 months,with a median time of 26 months.During the follow-up,3 patients died of intraperitoneal infection,short bowel syndrome and pulmonary infection,and 3 patients had PRIE.Conclusion The appropriate surgical method is selected based on clinical manifestations of patients,and laparoscopic surgery is safe and feasible for PRIE.

Influence of gastric acid suppression on the structure and diversity of the jejunal microbiota in a rat model / 肠外与肠内营养

Objective:To investigate the dynamic changes of the luminal microbiota in the jejunum following administration of proton pump inhibitors (PPIs) in a rat model.Methods:Rats were randomized into six groups (n =6 each group).A group of rats were sacrificed just after anesthesia as normal control (0 d) and,other five groups were continuously administered with omeprazole (10 mg/kg twice daily,intraperitoneally) and were euthanized at 5,9,14,21,28 days following the treatment,respectively.Total DNA in the luminal contents of jejunum was extracted and was used for polymerase chain reaction (PCR) amplification with the primer set targeted the hypervariable V3 region of 16S ribosomal RNA genes.Subsequently,the amplicons were separated by denaturing gradient gel electrophoresis (DGGE).After the gels were stained and photographed,the bands were cut out and sequenced to determine the closest bacterial relatives with the BLAST.The DGGE profiles were analyzed to evaluate the shifts of the microbiota composition and diversity following treatments.Results:Changes of the jejunal microbiotas in rats were observed at 5 and 9 days post PPI administration,as characterized by outgrowth of Streptococcus pneumonia,Clostridium saccharolyticum and Lactococcus garvieae compared to those of the controls (0 d).With time extension of PPI treatment,the mictobiotas significantly shifted toward dysbiotic state,in which the opportunistic pathogens,including Ertterococcus faecalis and Clostridium difficile,were strikingly expanded,especially 21 days later.However,the commensals such as Lactobacillus reuteri and Weissella koreensis were markedly declined in PPI-treated animals compared with the controls.The similarity of the jejunal microbiotas between PPI-treated animals and controls was markedly reduced following PPI treatment,reaching (56.1 ± 16.7) ％ at 28 days.Conclusion:Our data demonstrate that the gastric acid suppression could induce shifts of the jejuna microbiota in a rat model.More importantly,long-term use (＞ 14 d) of PPI could lead to the dysbiosis of the jejunal microbiota,which might be related causally to increased susceptibility to enteric infection.

Ultrasonic features of acute acalculous cholecystitis developing at different stages of acute pancreatitis / 医学研究生学报

Objective Acute pancreatitis exhibits different clinical and ultrasonic features in patients complicated with acute acalculous cholecystitis ( AAC) at different stages .The aim of this study was to analyze the ultrasonic characteristics of acute pancreati-tis complicated with AAC at different stages . Methods We retrospectively analyzed the clinical data about 41 cases of acute pancrea-titis with moderate to severe AAC .According to whether AAC developed within or after 2 weeks of the onset of acute pancreatitis , we divided the patients into an early-stage group (n=18) and a late-stage group (n=23).We recorded the gallbladder size, gallbladder wall thickness , fluid around the gallbladder , biliary sludge deposition and the Murphy′s sign by ultrasonography , obtained AAC-related clinical and laboratory data concerning body temperature , Murphy′s sign, WBC count and C-reactive protein level , and analyzed the ultrasonic features of AAC at different stages in the acute pancreatitis patients. Results All the patients experienced a fever of >38.5℃, 38.89%with chills in the early onset group and 47.83%in the late onset group .Increases were observed in patients of the early-and late-stage groups in the WBC count ( 94.44%vs 82.61%) , the C-reactive protein level ( 100%vs 91.30%) , and the fluid volume around the gallbladder (94.44%vs 60.86%, P<0.05), but incidence rate of gallbladder wall thickening was significantly lower in the former than in the latter group (11.11%vs 78.26%, P<0.01). Conclusion AAC developing at different stages of acute pancreatitis has different ultrasonic features , with higher incidence rates of fluid around the gallbladder in the early stage and gallbladder wall thickening in the late stage.

Interdisciplinary research of medical post-doctor / 医学研究生学报

Interdisciplinary research is one of the focus of sci-entific method discussion .In recent years a large number of interdiscipli-nary methods or engaged in interdisciplinary research and collaboration between scientists have won the Nobel prize , once again proved this point.Its profound, interdisciplinary research in the field of medicine it-self also embodies a new paradigm of modern medical science and explo-ration the cross disciplinary research applied to medical postdoctoral training work, aims to cultivate a group of clinicians is an excellent ex-perimental research and know the innovative medical amphibious expert.With the development of modern medicine and the current actual situation , the development of a single subject is far from enough .This article from the interdisciplinary talents cultivation idea or-igin, development of surgery and anatomy , informatics, imaging, such as the development of other disciplines and the close connection between the hot research in twenty-first century To expound the progress of medicine , the need for mutual cooperation between families , and by their respective areas of strengths together to carry out interdisciplinary research .

Application of three-dimensional visualization in pancreatic tumor: a pilot study / 中华外科杂志

Objective@#To study the value of three-dimensional(3D) visualization in the diagnosis and surgical treatment for pancreatic tumor.@*Methods@#From June to September 2016, 26 patients with pancreatic tumors in Jinling Hospital, Medical School of Nanjing University were involved. The study included 26 patients(8 females and 18 males) with mean age of (57±12)years (ranging from 23 to 77 years). And there were 20 malignant tumors and 6 benign tumors. All of them were examined with abdominal thin slice CT scanning and the CT images were imported into 3D visualization system for 3D visualization. The main elements examined by 3D visualization included tumor shape, size, and location; distribution and morphology of the peripancreatic lymph node; the relationships among neoplasms, organs and blood vessels.@*Results@#Among the 26 patients, there were 21 cases with pancreatic cancer, of which 15 cases successfully underwent standard pancreatectomy. All patients were operated underwent accurate assessment. The 3D model demonstrated the origination and bifurcations of blood vessels, and the relationships among neoplasms, organs and blood vessels efficiently. The 3D technique could facilitate to evaluate response of neiadjuvant chemotherapy in the pancreatic cancer patients (n=5).3D reconstruction could detect the lymph-node metastases accurately (n=12) in patients with pancreatic cancer. 3D reconstruction were applied to evaluate the the size and range of tumor on 5 cases.@*Conclusions@#3D reconstruction allows stereoscopic identification of the spatial relationships between physiologic and pathologic structures.The 3D technique could facilitate to evaluate distribution and morphology of the peripancreatic lymph node, and to evaluate the relationships among neoplasms, organs and blood vessels.

Gradient treatment of acute superior mesenteric venous thrombosis: clinical analysis of 68 cases / 中华外科杂志

Objective@#To investigate the effect of Gradient treatment for acute superior mesenteric venous thrombosis (ASMVT).@*Methods@#Clinic data of 68 patients of ASMVT admitted in Department of General Surgery, Jinling Hospital, Medical School of Nanjing University from January 2009 to December 2014 were analyzed retrospectively. There were 50 male and 18 female patients with a mean age of (45±12) years. These patients were conducted by the stepwise treatment model (endovascular treatment-damage control surgery-surgical intensive care-intestinal rehabilitation treatment). Clinical outcomes and complications were compared during the follow-up period. Differences about bowel resection length of endovascular treatment and surgical procedures were evaluated with t test.@*Results@#In the 68 cases, 24 cases were cured simply by endovascular treatment, 19 cases received surgical procedures alone (group surgery). Twenty-five patients received endovascular treatment combined with surgical procedures (group combined), including 6 cases temporary abdominal closure. The overall mortality rate was 2.9% (2/68) during hospitalization. The range of bowel resection of group combined significantly reduced compared with group surgery ((92±14) cm vs. (162±27) cm, t=-2.377, P=0.022). During 1-year follow-up period, 4 cases suffered from short bowel syndrome, whom underwent surgery alone.@*Conclusions@#Early diagnosis and treatment is the key to treatment of ASMVT, the rapid improvement of intestinal ischemia is particularly important for prognosis. Combination therapy significantly save more residual small intestine and avoid short bowel syndrome. The selection of early gradient treatment can significantly reduce the mortality and improve the prognosis of ASMVT patients.

Developing the PLA critical care medicine is critical for advancing the level of battle wound treatment in the new era / 解放军医学杂志

Critical care medicine is an emerging unique specialty developed from the later 20th century,since then,it has been enriched with theoretical and practical experiences and becomes the most active subject in the field of clinical medicine.Critical care medicine of the PLA has attained significant achievements in the treatment and research of severe trauma,sepsis,severe heat stroke,multiple organ failure and severe acute pancreatitis.Besides,it stands in the leading position in the organ function maintenance of critically ill patients,continuous hemofiltration and nutrition support in China.Furthermore,critical care medicine plays an important role in the rescue of critically ill patients,medical support and disaster relief.As the relationship between battle wound rescue system and critical care medicine has been increasingly close,transition in the form of war in the new period brings new tasks to battle wound treatment constantly.Combined with the characteristics of information-oriented war condition in the future,developing the PLA critical care medicine and advancing the level of battle wound treatment in the new period point out the direction for the future work of critical care medicine.

Clinical value of human acellular dermal matrix in reconstruction of giant complex abdominal wall defects after open abdomen / 中华消化外科杂志

Objective To explore the clinical value of human acellular dermal matrix (HADM) in giant complex abdominal wall reconstruction (GCAWR) after open abdomen.Methods The retrospective crosssectional study was conducted.The clinical data of 6 patients with severe trauma who were admitted to the Nanjing General Hospital of Nanjing Military Command of Nanjing University School of Medicine between January 2013 and January 2014 were collected.After open abdomen,fascia of the abdominal wall was fully freed using the component separation,and abdominal wall defects were reconstructed using HADM in the rectus abdominis anterior sheath and peritoneal layers bridge-type suture.Observation indicators:(1) intra-and post-operative situations:operation time,volume of intraoperative blood loss,removal time of postoperative drainage-tube,postoperative complications,duration of hospital stay and hospital expenses;(2) follow-up situations:recurrence of abdominal wall hernia at postoperative year 2.Follow-up using outpatient examination and telephone interview was performed to detect the recurrence of abdominal wall hernia up to April 2016.Measurement data with normal distribution were represented as ~±s.Results (1) Intra-and post-operative situations:6 patients underwent successful surgery.Operation time,volume of intraoperative blood loss and removal time of postoperative drainage-tube were respectively (77±9)minutes,(225±57)mL and (8±3)days.Two patients with postoperative seroma were cured by conservative treatment.One patient with postoperative anastomotic leakage received continuously irrigation and drainage,and leakage was stopped using the biomedical fibrin glue.There was no abdominal bulge of the 6 patients in hospital.Duration of hospital stay and hospital expenses were respectively (10±3) days and (12±7) × 104 yuan.(2) Follow-up situations:6 patients were followed up for 14-28 months,with a median time of 23 months.Two patients had relaxation and bulge of HADM in peritoneal layer at postoperative 2 years,without bulge of HADM in the rectus abdominis anterior sheath layer.There were no occurrence of abdominal wall hernia,chronic pain,paraesthesia,swelling in the local area and other adverse reaction.Conclusion Using of HADM in the rectus abdominis anterior sheath and peritoneal layers bridge-type suture is safe and feasible for GCAWR,with good short-term outcomes.

Effect of postoperative hyperglycemia on clinical outcome of gastrointestinal fistula patients undergoing gastrointestinal reconstruction / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of hyperglycemia within postoperative 48 hours on gastrointestinal (GI) fistula patients without preoperative diagnosis of diabetes undergoing selective GI reconstruction.</p><p><b>METHODS</b>Clinical data of GI fistula patients with age of 18 to 70 years and without diffuse peritonitis and systemic infection undergoing definitive GI reconstruction at Intestinal Fistula Center of Jinling Hospital from September 2012 to December 2015 were retrospectively analyzed. According to the highest blood glucose (BG) value detected within postoperative 48 hours, patients were divided into normoglycemia (BG<6.9 mmol/L), mild hyperglycemia (6.9 to 11.4 mmol/L) and severe hyperglycemia (BG≥11.5 mmol/L) groups. Clinical manifestations were compared among three groups. Effects of postoperative hyperglycemia on associated parameters, including postoperative surgical site infection, anastomotic leakage, intestinal nutrition recovery, hospital stay and hospitalization cost were investigated.</p><p><b>RESULTS</b>A total of 314 patients were enrolled, of whom postoperative gastric fistula occurred in 6 cases, small intestinal fistula in 95 cases, ileocolonic anastomotic fistula in 116, and colorectal fistula in 97 cases. One hundred and ninety-three (61.5%) patients experienced hyperglycemia, including 148 cases of mild hyperglycemia group and 45 cases of severe hyperglycemia group, the other 121 cases were of normoglycemia group. There were no significant differences in gender, BMI, ratio of smoking, ratio of alcohol user and primary diseases among 3 groups (all P>0.05). Older patients were vulnerable to postoperative hyperglycemia and patients who developed hyperglycemia were also prone to have increased ASA score (all P=0.000). Hyperglycemia patients had significantly higher ratio of postoperative ileocolonic anastomotic fistula (mild hyperglycemia group: 40.5%, 60/148; severe hyperglycemia group: 44.4%, 20/45) than normoglycemia cases (29.8%,36/121). Compared to normoglycemia group, ratio of intra-operative transfusion case was higher (P=0.001), operative time was longer (P=0.026), ratio of number of anastomosis >2 was higher (P=0.001), ratio of receiving laparoscopic-assisted operation was lower (P=0.005), ratio of postoperative surgical site infection was higher (P=0.006), incidence of anastomotic leakage was higher (P=0.004), ratio of re-operation was higher (P=0.004), intestinal nutrition recovery time was longer (P=0.001), ICU stay was longer (P=0.001), total hospitalization time was longer (P=0.000) and hospitalization cost was more expensive (P=0.000) in both two hyperglycemia groups. Multivariate regression analysis showed that mild hyperglycemia and severe hyperglycemia were independent risk factors to predict surgical site infection (OR=1.99, 95%CI: 1.12 to 3.54, P=0.019; OR=3.02, 95%CI: 1.36 to 6.70, P=0.007) and anastomotic leakage (OR=7.59, 95%CI: 1.68 to 34.34, P=0.009; OR=13.4, 95%CI: 2.50 to 71.65, P=0.002). Multivariate linear regression analysis indicated that intestinal recovery time of normoglycemia group was 2 days shorter and 3 days shorter, and hospitalization time of normoglycemia group was 2 days shorter and 10 days shorter as compared with mild hyperglycemia and severe hyperglycemia group, respectively.</p><p><b>CONCLUSIONS</b>Elevated postoperative BG is common in GI fistula patients receiving selective GI reconstruction. Postoperative hyperglycemia is significantly associated with surgical site infection, anastomotic leakage and prolonged intestinal recovery. BG control treatment should be recommended for those patients with postoperative hyperglycemia.</p>

Susceptibility genes and serum markers of intestinal fibrosis in Crohn disease / 中华胃肠外科杂志

Crohn disease (CD) is a chronic inflammatory disease which progressively affects the digestive tract with unknown etiology. During the disease course, intestinal fibrosis will gradually develop in many CD patients and results in irreversible fibrosis stricture, causing refractory abdominal pain and even intestinal obstruction, and necessitating one or more surgical interventions. Thus far the exact etiology of CD remains unknown. It is believed that genetic, environmental and immunologic factors are involved, which may also predict the development of intestinal fibrosis. Recent studies have found the association of mutations in genes, such as NOD2, ATG16L1, CX3CR1, IL-23R and MMP3 with the fibrogenic phenotype of CD. In addition, serum extracellular matrix molecules, growth factors, miRNAs and microbial antibodies have also been linked to the fibrogenesis in CD patients, however the results of researches were divergent. Therefore it is of significance to explore noninvasive markers of intestinal fibrosis with high sensitivity and specificity, and the high-throughput proteomic technique may be an approach that deserves further investigation. Screening the high-risk patients for the fibrostenotic phenotype of CD by susceptibility genes, and early detection of intestinal fibrosis using noninvasive serum markers, will help improve the treatment outcomes and reduce the surgical rates. The article aims at summarizing the current susceptibility genes and serum markers of intestinal fibrosis in CD.

Effects of perioperative intestinal microecological treatment on postoperative complications and gastrointestinal function in patients with refractory functional constipation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effects of perioperative intestinal microecological treatment on postoperative complications and gastrointestinal function in patients with refractory functional constipation by nonrandomized controlled trial.</p><p><b>METHODS</b>A total of 198 patients with refractory functional constipation who underwent Jinling procedure in our department from 2014 to 2015 were prospectively enrolled, and were divided into conventional treatment group (n=100, routine intestinal preparation was used before operation; probiotics and prebiotics were applied if diarrhea or abdominal distention occurred after operation) and microecological treatment group (n=98, routine perioperative management was applied; probiotics, prebiotics and enteral nutrition were administered since 2 weeks before operation; probiotics and prebiotics were given again when exhaust and defecation recovered after operation). The general clinical data, postoperative complications, gastrointestinal quality of life index (GIQLI), Wexner constipation score, the incidence of abdominal distension and diarrhea during follow-up were collected.</p><p><b>RESULTS</b>The baseline information was not significantly different between two groups (all P>0.05) as well as the morbidity of postoperative complication [27.6% (27/98) vs 37.0% (37/100), P=0.155]. Compared with conventional treatment group, microecological treatment group had obviously lower incidence of enteritis [2.0%(2/98) vs. 9.0% (9/100), P=0.034] and shorter postoperative hospital stay [(7.2±3.1) d vs. (9.8±3.6) d, P=0.040]. The incidences of diarrhea and abdominal distension in microecological treatment group were obviously lower than those in conventional treatment group [30.9% (29/94) vs. 46.9% (45/96), P=0.024; 44.7%(42/94) vs. 60.4%(58/96), P=0.030] at postoperative 1-month. Compared with conventional treatment group, microecological treatment group had obviously higher GIQLI (52.36 vs. 43.55, P=0.026) at postoperative 1-month. At postoperative 12-month, the incidences of diarrhea and abdominal distension decreased obviously in both two groups but without significant differences [diarrhea: 3.4% (3/89) vs. 3.3%(3/90), P=0.989; abdominal distention: 6.7% (6/89) vs. 5.6% (5/90), P=0.742]. GIQLI and Wexner score were improved but without significant differences as well (all P>0.05).</p><p><b>CONCLUSION</b>Perioperative intestinal microecological treatment can obviously reduce the incidences of postoperative enteritis, early abdominal distension and early diarrhea, improve the postoperative early GIQLI, and shorten postoperative hospital stay.</p>