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Objective:To study the risk factors and microbial spectrum for infectious complications for patients with biliary tract cancer after major hepatectomy with cholangiojejunostomy.Methods:Enrolled into this study were 78 consecutive patients (57 patients with perihilar cholangiocarcinoma, 17 with intrahepatic cholangiocarcinoma and 4 with gallbladder cancer), who underwent major hepatectomy with cholangiojejunostomy at Nanjing Drum Tower Hospital between September 2010 and March 2019. The clinical data were reviewed using multivariate analysis to find independent risk factors for postoperative infectious complications. Microorganisms isolated from bile and infected sites were determined to study the microbial spectrum.Results:A total of 45(57.7%) patients suffered from postoperative infectious complications. Male sex ( OR=7.765, 95% CI=1.895-31.815, P<0.05) was the independent risk factor, whereas increased preope-rative red blood cell (RBC) ( OR=0.151, 95% CI=0.038-0.592, optimal cut-off value=3.7×10 12/L) and increased total cholesterol (TC) on postoperative day (POD) 1 ( OR=0.227, 95% CI=0.083-0.626, optimal cut-off value=3.5 mmol/L) were protective factors (both P<0.05). The area under the receiver operating characteristic (ROC) curve was 0.805 (95% CI=0.707-0.902, P<0.05). 205 and 230 microorganisms were cultured respectively from 286 and 681 specimens which were collected from pre-/intraoperative bile and potentially infected sites. Staphylococcus, enterococcus, acinetobacter, klebsiella and pseudomonas were the most common pathogens on bile culture. The first 5 most frequently isolated microorganisms from the infected sites were enterococcus, staphylococcus, klebsiella, candida and xanthomonas. Sixteen (61.5%) of 26 patients had at least one pathogen being isolated from the infected sites with the pathogen being previously isolated in bile culture. Conclusions:Male sex were independent risk factors of infectious complications. Increased preoperative RBC and inreased TC on POD were proteetive factors. For patients without a positive bile culture, a third-generation cephalosporin can be considered as a prophylactic antibiotic. It is important to identify high-risk patients and monitor perioperative pathogens actively to prevent and to cure postoperative infectious complications.
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Objective To evaluate the prognostic value of pathological characteristics of microvascular invasion (MVI) in patients with hepatocellular carcinoma (HCC).Methods 289 consecutive HCC patients who underwent curative hepatectomy at Nanjing Drum Tower Hospital from January 2007 to December 2015 were retrospectively studied.These patients were divided into three groups:the no-MVI group (n =176),the low-MVI group (the number of invaded microvessels ≤ 5 and the distance of invasion ≤ 1 cm,n =53) and the high-MVI group (the number of invaded microvessels ＞ 5 or the distance of invasion ＞ 1 cm,n =60).The clinical and pathological data and the survival outcomes of these HCC patients were analyzed.We further compared the prognosis among the three groups.Results Kaplan-Meier survival indicated that the number of invaded microvessels ＞ 5 and the distance of invasion ＞ 1 cm were associated with cumulative and recurrence-free survival rates of HCC patients.The cumulative and recurrence-free survival rates of the high-MVI group were significantly poorer than those of the low-MVI and the no-MVI groups.Multivariate analysis showed ICG-R15 (HR =1.049,95％ CI:1.002 ～ 1.097),tumor size (HR =1.138,95％ CI:1.043 ～ 1.241),and high-MVI (HR =3.245,95％ CI:1.946 ～ 5.413) were independent risk factors for cumulative survival.Tumor size (HR =1.117,95％ CI:1.050 ～ 1.188),and high-MVI (HR =2.222,95％ CI:1.540 ～ 3.205) were independent risk factors for recurrence-free survival.The prognosis of the no-MVI and low-MVI groups were significantly better than the high-MVI group (P ＜ 0.05).The recurrence rates of the low-MVI and no-MVI groups (49.4％ and 67.9％) were significantly lower than the high-MVI group (80.0％,P ＜ 0.05).Conclusions The risk classification of MVI based on histopathological features was valuable in predicting prognosis of HCC patients.We could use the risk classification of MVI to establish a follow-up and individualized treatment plan for HCC patients.
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Objeetive To compare the clinical value of early enteral nutrition (EEN) and combined enteral nutrition (EN) and parenteral nutrition (PN) in patients with hepatocellular carcinoma (HCC) after precise hepatectomy.Methods The prospective study was conducted.The clinical data of 60 HCC patients who underwent precise hepatectomy in the Affiliated Drum Tower Hospital of Nanjing University Medical School between January 2013 and December 2014 were collected.All patients were allocated into the EN group and combined EN+PN group by random number table method.Patients in the EN group and combined EN+PN group respectively received EEN and early combined EN+PN at 24 hours postoperatively for 7 days,total nutrient intakes between groups were consistent,with an average daily intake of nitrogen-feeding of 0.2 g/(kg · d) and an average daily intake of nonprotein calories of 25 kcal/(kg · d).Observation indicators:(1) comparison of nutritional indexes between groups;(2) comparison of liver function between groups;(3) comparison of postoperative conditions between groups.Measurement data with normal distribution were represented as-x±s.Comparisons at the same time between groups were respectively analyzed using the group-design t test.Comparisons of count data were analyzed using the chi-square test.Ordinal data were analyzed by the nonparametric test.Comparison of repeated measurement data were done using the repeated measures ANOVA.Results Sixty patients were screened for eligibility,and 30 in each group.(1) Comparison of nutritional indexes between groups:levels of albumin (Alb),globulin,prealbumin and hemoglobin (Hb) and lymph nodes count in the EN group were respectively (41±4)g/L,(28±4) g/L,(188±37) mg/L,(139± 17) g/L,(1.6±0.6) × 109/L before operation and (32±4) g/L,(23±5)g/L,(114±41)mg/L,(121±19)g/L,(1.1±0.7) ×109/L at 1 day postoperative1y and (34±5)g/L,(26±4) g/L,(169± 41) mg/L,(113 ± 16) g/L,(1.9 ± 1.1) × 109/L at 8 days postoperatively,with statistically significant differences in above indexes (F=2.23,4.45,8.96,5.21,2.18,P＜0.05).There were statistically significant differences in above indexes between pre-operation and 1 day postoperatively (t =9.79,8.53,9.81,4.56,5.77,P＜0.05) and between 1 and 8 days postoperatively (t =5.55,6.31,4.69,3.99,8.26,P＜0.05).There were statistically significant differences in levels of Alb,globulin,prealbumin and Hb between pre-operation and 8 days postoperatively (t=3.48,5.12,6.37,8.20,P＜0.05) and no statistically significant difference in lymph nodes count (t =2.48,P＞0.05).Levels of Alb,globulin,prealbumin and Hb and lymph nodes count in the combined EN+PN group were respectively (42±4)g/L,(28±6)g/L,(188±29)g/L,(142±16)g/L,(1.6±0.6)×109/L before operation and (31±5)g/L,(20±5) g/L,(96±31) g/L,(124± 16) g/L,(0.9±0.4) × 109/L at 1 day postoperatively and (34±4)g/L,(24±4)g/L,(143±18)g/L,(115±18)g/L,(1.4±0.7)×109/L at 8 days postoperatively,with statistically significant differences in above indexes (F=3.21,7.35,4.36,7.78,3.19,P＜0.05).There were statistically significant differences in above indexes between pre-operation and 1 day postoperatively (t =11.95,5.38,9.91,4.84,6.22,P＜0.05) and between 1 and 8 days postoperatively (t =9.45,7.66,4.98,3.15,4.79,P＜ 0.05).There were statistically significant differences in levels of Alb,globulin,prealbumin and Hb between pre-operation and 8 days postoperatively (t=9.31,8.44,6.57,5.25,P＜0.05).There were no statistically significant difference in lymph nodes count (t =3.11,P＞ 0.05) and in changing trends of Alb,globulin,prealbumin,Hb and lymph nodes count (F=8.54,3.83,7.21,6.33,3.91,P＞0.05).Levels of prealbumin at 8 days postoperatively were statistically different between groups (t =3.00,P＜0.05).(2) Comparison of liver function between groups:levels of alanine transaminase (ALT),aspartate transaminase (AST),alkaline phosphatase (ALP),glutamyl-transpeptidase (GGT),total bilirubin (TBil),direct bilirubin (DBil) and C-reactive protein (CRP) in the EN group were respectively (44±37)U/L,(44±30) U/L,(90± 29) U/L,(85 ± 49) U/L,(15.7± 5.4) μmol/L,(4.6± 2.3) μmol/L,(4.5 ± 3.2) mg/L before operation and (411±375)U/L,(379±323)U/L,(68±26)U/L,(55±49)U/L,(20.3±10.7)μmol/L,(7.8±5.5) μmol/L,(47.9± 30.6) mg/L at 1 day postoperatively and (107± 58) U/L,(43± 21) U/L,(100± 42) U/L,(111±71)U/L,(19.7±10.6) μmol/L,(8.8±5.9) μmol/L,(28.3±23.0) mg/L at 8 days postoperatively,with statistically significant differences in above indexes among pre-operation,1 and 8 days postoperatively (F=5.48,9.44,1.73,5.03,8.42,6.09,6.69,P＜0.05) and between pre-operation and 1 day postoperatively (t=5.12,5.36,5.35,0.45,2.88,3.82,6.95,P＜ 0.05).There were statistically significant differences in levels of ALT,TBil,DBil and CRP between pre-operation and 8 days postoperatively (t =6.71,4.14,5.96,6.33,P＜0.05) and in levels of ALT,AST,ALP,GGT and CRP between 1 and 8 days postoperatively (t =6.23,5.55,3.14,3.56,4.99,P＜0.05).There were no statistically significant difference in levels of AST,ALP and GGT (t =0.13,0.98,1.11,P＞0.05) and in levels of TBil and DBil (t =0.08,0.23,P＞0.05).Levels of ALT,AST,ALP,GGT,TBil,DBil and CRP in the combined EN+PN group were respectively (41±38) U/L,(43±25) U/L,(100±89) U/L,(106±46) U/L,(17.9±9.8) μmol/L,(6.2±3.6) μmol/L,(3.7±2.3)mg/L before operation and (462±409)U/L,(494±162)U/L,(73±53)U/L,(75±57)U/L,(28.1±18.8)μmol/L,(9.1±6.1) μmol/L,(40.7±26.2) mg/L at 1 day postoperatively and (90±47) U/L,(42± 16) U/L,(95±40) U/L,(110±66) U/L,(22.5± 14.5) μmol/L,(8.2±8.1) μmol/L,(26.9±24.6) mg/L at 8 days postoperatively,with statistically significant differences in above indexes among pre-operation,1 and 8 days postoperatively (F=5.96,3.73,6.94,3.88,7.97,4.14,5.25,P＜0.05) and between before operation and 1 day postoperatively (t=5.72,4.96,3.95,0.88,2.83,4.13,6.11,P＜0.05).There were statistically significant differences in levels of ALT and CRP between pre-operation and 8 days postoperatively (t =4.22,6.77,P＜0.05) and in levels of ALT,AST,ALP and GGT between 1 and 8 days postoperatively (t=7.01,5.21,4.38,6.15,P＜0.05).There were no statistically significant difference in levels of AST,ALP,GGT,TBil and DBil (t =0.29,1.65,1.92,0.33,P＞0.05) and in levels of TBil,DBil and CRP (t =0.09,0.37,0.58,P＞0.05).There was no statistically significant difference in changing trends of ALT,AST,ALP,GGT,TBil,DBil and CRP of 2 groups (F=7.18,2.23,3.94,5.88,4.72,2.17,6.53,P＞0.05) and in above indexes among pre-operation,1 and at 8 days postoperatively (t=0.27,0.42,0.91,0.12,0.96,0.24,0.59,0.32,0.49,1.27,0.88,0.07,1.07,1.45,0.23,1.11,0.88,0.32,0.35,0.93,0.21,P＞0.05).(3) Comparison of postoperative conditions between groups:times of initial defecation were respectively (3.2± 1.0) days and (4.2± 1.2) days in the EN group and combined EN +PN group,showing a statistically significant difference (t =3.21,P＜ 0.05).Conclusion EEN and combined EN+PN are safe and feasible in HCC patients after precise hepatectomy,and also can improve liver function recovery,but EEN has advantages of promoting protein synthesis and gastrointestinal function recovery.
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Objective To investigate the correlation between immediate postoperative platelet count with liver failure after partial hepatectomy in patients with hepatocellular carcinoma.Methods The clinical data of 71 patients with hepatocellular carcinoma who underwent liver resection at the Hepatopancreatobiliary Surgery Department of Nanjing Drum Tower Hospital from July 2013 to August 2015 were retrospectively analyzed.The clinical diagnosis was confirmed by pathology of the resected specimens.Based on postoperative platelet count within 2 h,the patients were divided into the low platelet count (PLT ＜ 100 × 109/L) group (n =24,33.8％) and the normal platelet count (PLT ≥ 100 × 109/L) group (n =47,66.2％).The correlations between immediate postoperative platelet count with serum indexes including serum alanine aminotransferase (ALT),aspartate aminotransferase (AST),total bilirubin (TBil) and direct bilirubin (DBil) were analyzed,and the incidences of posthepatectomy liver failure was also evaluated in these two groups.Results There was no re-operation and perioperative death in this study.Among the 71 patients,25 patients (35.2％) developed postoperative complications (grade Ⅰ to Ⅲ),and 8 patients (11.3％) suffered from postoperative liver failure (grade A).When compared with the normal platelet count group,the low platelet count group had significantly increased risks of postoperative liver failure (29.2％ vs 2.1％,X2 =11.618,P ＜ 0.05),increased postoperative peaks of ALT,AST,TBil and DBil levels [(462.5 ±135.7)U/L vs (307.9 ± 192.6) U/L,(440.0 ± 163.3) U/L vs (265.8 ± 155.8) U/L,(29.5 ±9.1) μmol/L vs (17.9 ±8.8) μ mol/L,t =3.507,4.385,5.129,P ＜0.05,respectively] and longer normalization time of liver function.Multiple Logistic regression analyses revealed that an immediate postoperative low platelet count was an independent risk factor of posthepatectomy liver failure.Conclusions The platelet count was associated with the incidence of postoperative liver failure after partial liver resection in patients with hepatocellular carcinoma.Patients with an immediate postoperative low platelet count suffered from a high incidence of posthepatectomy liver failure and delayed liver function recovery.
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BACKGROUND: To discuss the feasibility of allogeneic freeze-drying radiation sterilization bone sheet applying in the prevention of post-laminectomy adhesion as an ideal biological material for filling and repairing bone defect. OBJECTIVE: To observe the preventive effect of allogeneic freeze-drying radiation sterilization bone sheet on the postlaminectomy adhesion and restenosis.DESIGN: Follow-up survey on cases.SETTINGS: Department of Orthopedics, Union Hospital, Tongji Medical School of Huazhong University of Science and Technology; Shanxi Medical Tissues of China Institute for Radiation Protection PARTICIPANTS: From March 2003 to June 2005, 58 patients with segmental lumbar spinal stenosis (LSS) were selected from Department of Orthopedics, Union Hospital, Tongji Medical School of Huazhong University of Science and Technology, including 34 males and 24 females, aged 30-78 years, including 25 cases of simple LSS and 33 combined LSS; and including 36 cases in L4-5 and 33 cases in L5, S1 segments. All the patients were similar in age, gender and healthy conditions.METHODS: The segmental whole laminectomies were performed in 58 patients with prolapse of lumbar intervertebral or LSS, and allogeneic freeze-drying radiation sterilization bone sheet in "H" shape was used to cover the vertebral laminae. According to the follow-up standard of lumbar spine operation recommended by the Orthopaedics Branch of Chinese Medical Association, all patients were followed up to evaluate their clinical symptoms, absorption of implanted bone as well as CT and MRI presentations.MAIN OUTCOME MEASURES: Improvements of clinical symptoms;Absorption of bone sheet in lumbar spinal canal.RESULTS: Totally 58 LSS patients were involved in the result analysis.In postoperative 0.5-year follow-up period, 17 of 21 patients showed excellent curative effects while other 4 patients showed fine effects. In postoperative 1-year follow-up period for 23 patients, CT and MRI results demonstrated that the spinal canal had been extended obviously. There was no tilt or displacement of the femoral sheet or compression of the spinal cord. As for 14 patients who were followed up for 1.5 years, CT results displayed that there was no rejective reaction observed in this study. The edgeof the allograft was inosculated with connective lamina of vertebra, and the shape of lumber spinal was good.CONCLUSION: Allogeneic freeze-drying radiation sterilization bone sheet is an ideal dressing material for epidural laminoplasty. The imaging results of patients in postoperative 1.5-year follow-up indicate that it can effectively reduce the post-laminectomy adhesion formation and prevent recurrence of post-laminectomy spinal restenosis, so as to apply on the segmental vertebral plate dressing.
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Objective To study the retrieved human allografts pathologically in order to probe into the histological changes of implanted allograft. Methods The specimens were retrieved from seven cases between February 2003 and March 2004, and the allografts had been in situ from two to 16 months. Of seven cases, four were diagnosed primarily as malignant fibrohistocytoma of proximal humerus, osteosarcoma of femoral shaft, bone giant cell tumor of distal femur and bone giant cell tumor of proximal tibia each, which were treated with wide resection of tumor and massive allograft transplantation and internal fixation of plate or inter-locking nail; two were open comminuted fracture of distal femur, treated with massive allograft transplantation and internal fixation, underwent autograft bone transplantation because of united massive allograft, had a punch biopsy of allografts for observation; one was tibial open fracture being fixated with inter-locking nail and small segment allograft transplantation, sustained infection at two weeks after primary operation and underwent debriment, removal of internal fixation and external fixation. Results Of seven cases, five were found with bone absorption radiographically, and were classified into three types:1)sever bone absorption; 2)bone absorption associated with sinus and effusion of the wound; 3)bone absorption accompanied by pyogenic infection. The later condition was caused by bacterial infection without a relationship of allograft. And the former two conditions could be classified into two subtypes: 1)osteoclastic absorption, which was followed by new bone formation; 2)inflammatory absorption, which was found with infiltration by round inflammatory cell, preponderantly lymphocytes, and mononuclear phagocytes with few osteoclasts, osteoblasts or new bone formations. Moreover, in sever bone absorption, vascular lesions such as vasculitis, swelling of endothelial cells or proliferation changes in the vessels, and obliteration of the arteries. Conclusion An intensive infiltration accompanied by vascular lesions may be the evidences of histological changes suggestive of an immune reaction directed against the grafts, and the failure of the clinical outcomes.