Evaluation of clinical pharmacists participating in the perioperative nutritional management of pancreaticoduode-nectomy / 中国药房

OBJECTIVE To explore the role of clinical pharmacists participating in the standardized perioperative nutritional management process for pancreaticoduodenectomy （PD） on improving postoperative recovery in patients. METHODS The clinical data of 100 patients undergoing PD in the Department of Biliary and Pancreatic Surgery， Drum Tower Hospital Affiliated to Nanjing University School of Medicine from November 2019 to February 2021 were analyzed retrospectively. According to the different perioperative nutrition management plans， they were divided into clinical pharmacist intervention group （n＝51， clinical pharmacists intervened according to the standardized nutrition management process） and control group （n＝49， clinical pharmacists only performed preoperative nutrition evaluation， and clinical physicians took nutrition support according to the patient’s condition）. The differences in postoperative recovery index， economic evaluation index， hospitalization length， postoperative complications， and postoperative enteral nutrition support route were compared between 2 groups. RESULTS The time of postoperative diet， the first postoperative ventilation， the first postoperative defecation， and postoperative drainage time of abdominal drain were significantly earlier in the clinical pharmacist intervention group than in the control group （P＜0.05）； the hospitalization cost， medication cost， nutritional support cost， parenteral nutrition cost， albumin preparation cost， and the length of postoperative hospitalization were significantly lower/shorter in the clinical pharmacist intervention group than in the control group （P＜0.05）； there was no statistically significant difference in the incidence of postoperative complications between the two groups （P＞0.05）； there was statistically significant difference in the perioperative enteral nutrition support pathways between two groups （P＜0.05）. CONCLUSIONS Clinical pharmacists’ participation in perioperative nutritional management for PD can significantly reduce hospitalization costs and nutritional support costs， improve patients’ perioperative nutritional status， and shorten hospital stays. wanglina668@163.com

The chemical constituents and hypoglycemic activity of alcoholic extract of sea buckthorn leaves / 药学学报

The purpose of this research is to identify the chemical constituents of sea buckthorn leaves extract (SBLE) and explore its hypoglycemic biological activity. SBLE was prepared by hot reflux extraction with 65% ethanol, and its chemical composition was analyzed by ultra-high-performance liquid chromatography-photodiode array-mass spectrometry/mass spectrometry (UHPLC-PDA-MS/MS) system. The animal experiments were compliant with ethical principles for animal use and had been approved by the Animal Experiment Ethics Committee of Jinan University. Mice were injected with streptozocin (STZ) to establish a hyperglycemic animal model, and SBLE (1.5 g·kg-1) was administered by gavage for 5 weeks. The fasting blood glucose (FBG) and oral glucose tolerance were detected. Normal mice were given SBLE (1.5 g·kg-1) by intragastric administration for 10 days, and blood was collected from the tail vein to detect the changes in blood glucose within 120 min after sucrose or starch loading. The mucous membrane of the small intestine of mice was taken to detect the activity of α-glucosidase (AG), and the activity of yeast-derived AG incubated with SBLE was evaluated. The glucose uptake by Caco-2 cells treated with SBLE was detected by fluorescence microscopy and cytometry, and the gene expression of sodium-dependent glucose transporter 1 (SGLT1) and glucose transporter 2 (GLUT2) in Caco-2 cells were detected by real-time quantitative PCR (qPCR). A total of 18 compounds were identified, mainly including tannins and flavonoids. SBLE reduced FBG and increased oral glucose tolerance in STZ hyperglycemic mice. SBLE effectively inhibited the increase of blood glucose caused by starch intake in normal mice. SBLE exerted good inhibitory activity on yeast-derived AG (IC50 = 16.94 μg·mL-1) and small intestinal mucosa AG with an inhibition rate of 15.48%. SBLE (25-100 μg·mL-1) dose-dependently inhibited glucose uptake by Caco-2 cells, and SBLE significantly reduced the mRNA level of SGLT1 without changing the expression of GLUT2. In conclusion, the UHPLC characteristic fingerprint of SBLE is established with 18 chemical components identified by mass spectrometry, and SBLE exerts hypoglycemic effect by inhibiting the activity of AG and the absorption of glucose by intestinal epithelial cells.

Clinical efficacy of radical resection of pancreatic cancer after neoadjuvant conversion therapy / 中华消化外科杂志

Objective:To investigate the clinical efficacy of radical resection of pancreatic cancer after neoadjuvant conversion therapy.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 23 patients who underwent radical resection of pancreatic cancer after neoadjuvant conversion therapy in Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School from January 2019 to May 2022 were collected. There were 17 males and 6 females, aged 58(range, 33-73)years. After neoadjuvant conversion therapy, the three-dimensional (3D) visualization was used to evaluate and classify tumor vascular invasion, and surgical plan was planned and implemented. Observation indicators: (1) situations of neoadjuvant conversion therapy; (2) surgical situations; (3) postoperative histopathological examination; (4) postoperative recovery; (5) follow-up. Measurement data with normal distribution were represen-ted as Mean± SD, and measurement data with skewed distribution were represented as M(range) or M( Q1, Q3). Count data were described as absolute numbers. Results:(1) Situations of neoadjuvant conversion therapy. All 23 patients received the AG combination chemotherapy (albumin-paclitaxel+gemcitabine), including 14 patients combined with stereotactic body radiation therapy. Of the 23 patients, 22 cases achieved partial response, and 1 case showed stable disease. The CA19-9 of the 23 patients was 85.06(29.74,634.5)U/mL and 13.96(9.74,25.02)U/mL before and after neoadjuvant conversion therapy, respectively. (2) Surgical situations. According to the results of preoperative 3D visualization of tumor vascular invasion, 7 of the 23 patients were evaluated as arterial invasion, 8 cases were evaluated as venous invasion, 5 cases were evaluated as arterial and venous invasion, and there were 3 cases showing negative of vascular invasion. Of the 23 patients, 12 cases underwent pancreaticoduodenectomy, 4 cases underwent radical antegrade modular pancreatosplenectomy, 7 cases underwent total pancreaticoduodenectomy. For vascular reconstruction, there were 10 patients without vascular reconstruction, and there were 13 patients undergoing artificial vascular vein reconstruction. The operation time and volume of intraoperative blood loss of the 23 patients was (524±171)minutes and 1 000(400,1 600)mL, respectively. (3) Postoperative histopathological exami-nation. Results of postoperative histopathological examination in 23 patients showed that there were 2 cases with moderate-well differentiated tumor, 10 cases with moderate differentiated tumor, 7 cases with moderate-poorly differentiated tumor, 2 cases with poorly differentiated tumor, and 2 cases negative of tumor. The number of lymph node dissected in 23 patients was 16±7. There were 5 cases with lymph node metastasis and 18 cases without lymph node metastasis. There were 17 cases with nerve invasion and 6 cases without nerve invasion. All 23 patients were negative of vascular invasion. Of the 23 patients, there were 21 cases with R 0 resection and 2 cases with R 1 resection. For pathological TNM staging, there were 2 cases with 0 stage, 13 cases with Ⅰ stage, 7 cases with Ⅱ stage, and 1 case with Ⅳ stage. For postoperative pathological scoring, there were 2 cases achieved 0 point (complete pathological remission), 16 cases achieved 2 points (partial remission), and 5 cases achieved 3 points (no significant effect). (4) Postoperative recovery. The postoperative duration of hospital stay of 23 patients was 19(14,31)days. There were 17 of 23 patients underwent postoperative complications, including 11 cases with Clavien-Dindo Ⅱ stage complications, 3 cases with Clavien-Dindo Ⅲa stage complications, 1 case with Clavien-Dindo Ⅲb stage complication, 1 case with Clavien-Dindo Ⅳ stage complication, and 1 case with Clavien-Dindo Ⅴ stage complica-tion. (5) Follow-up. There were 22 patients underwent follow-up, with follow-up time as 12(9,23)months. There were 9 patients underwent postoperative recurrence and metastasis, with recurrence and metastasis time as 7.8(range, 6.0-12.0)months. During the follow-up, 15 of the 22 patients survived. Conclusion:Radical resection of pancreatic cancer after neoadjuvant conversion therapy is feasible.

Surgical efficacy and prognosis influencing factors of hilar cholangiocarcinoma based on multi-disciplinary diagnosis and treatment / 中华消化外科杂志

Objective:To investigate the surgical efficacy and prognosis influencing factors of hilar cholangiocarcinoma based on multidisciplinary diagnosis and treatment.Methods:The retrospective cohort study was conducted. The clinicopathological data of 91 patients with hilar cholangiocarcinoma who underwent surgery in Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from April 2004 to April 2021 were collected. There were 59 males and 32 females, aged (61±10)years. Patients who were admitted from April 2004 to March 2014 underwent traditional surgical diagnosis and treatment, and patients who were admitted from April 2014 to April 2021 underwent multidisciplinary diagnosis and treatment. Observation indica-tors: (1) surgical situations; (2) postoperative situations; (3) postoperative pathological examina-tions; (4) postoperative prognosis analysis; (5) influencing factors of postoperative prognosis. Follow-up was conducted using telephone interview and outpatient examination. Patients were followed up once every 6 months after surgery to detect survival. The follow-up was up to April 2023. Measure-ment data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Comparison of ordinal data was conducted using the rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Kaplan-Meier method was used to draw survival curve and calculate survival rate. The Log-Rank test was used for survival analysis. Univariate and multivariate analyses were conducted using the COX proportional hazard model. Results:(1) Surgical situations. Of the 91 patients, there were 65 cases receiving hemi- or expanded hemi-hepatectomy, 13 cases receiving tri-hepatectomy, 9 cases receiving partial hepatectomy, 4 cases receiving extrahepatic bile duct resection. There were 24 cases receiving combined vein resection and reconstruction, 8 cases receiving combined pancreaticoduodenectomy, 6 cases receiving com-bined hepatic artery resection and reconstruction, including 24 cases receiving extended radical surgery (tri-hepatectomy, hepatic artery resection and reconstruction, hepatopancreaticoduodenec-tomy). The operation time, volume of intraoperative blood loss and intraoperative blood transfusion rate of 91 patients was (590±124)minutes, 800(range, 500?1 200)mL and 75.8%(69/91), respectively. Of the 91 patients, cases receiving extended radical surgery, the volume of intraoperative blood loss were 4, 650(range, 300?1 000)mL in the 31 patients who were admitted from April 2004 to March 2014, versus 20, 875 (range, 500?1 375)mL in the 60 patients who were admitted from April 2014 to April 2021, showing significant differences between them ( χ2=4.39, Z=0.31, P<0.05). (2) Post-operative situations. The postoperative duration of hospital stay and cases with postoperative infectious complications were (27±17)days and 50 in the 91 patients. Cases with abdominal infection, cases with infection of incision, cases with bacteremia and cases with pulmonary infection were 43, 7, 5, 8 in the 91 patients. One patient might have multiple infectious complications. Cases with bile leakage, cases with delayed gastric emptying, cases with chylous leakage, cases with liver failure, cases with pancreatic fistula, cases with intraperitoneal hemorrhage, cases with reoperation, cases dead during the postoperative 90 days were 30, 9, 9, 6, 5, 3, 6, 3 in the 91 patients. Cases with abdominal infection was 10 in the 31 patients who were admitted from April 2004 to March 2014, versus 33 in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( χ2=4.24, P<0.05). Cases dead during the postoperative 90 days was 3 in the 31 patients who were admitted from April 2004 to March 2014, versus 0 in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( P<0.05). (3) Post-operative pathological examinations. Of the 91 patients, cases with Bismuth type as type Ⅰ?Ⅱ, type Ⅲ, type Ⅳ, cases with T staging as Tis stage, T1 stage, T2a?2b stage, T3 stage, T4 stage, cases with N staging as N0 stage, N1 stage, N2 stage, cases with M staging as M0 stage, M1 stage, cases with TNM staging as 0 stage, Ⅰ stage, Ⅱ stage, Ⅲ stage, ⅣA stage, ⅣB stage, cases with R 0 radical resection, cases with R 1 or R 2 resection were 15, 46, 30, 1, 9, 25, 30, 26, 49, 36, 6, 85, 6, 1, 7, 13, 58, 6, 6, 63, 28. Cases with R 0 radical resection, cases with R 1 or R 2 resection were 15, 16 in the 31 patients who were admitted from April 2004 to March 2014, versus 48, 12 in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( χ2=9.59, P<0.05). (4) Postoperative prognosis analysis. Of the 91 patients, 3 cases who died within 90 days after surgery were excluded, and the 5-year overall survival rate and median overall survival time of the rest of 88 cases were 44.7% and 55 months. The 5-year overall survival rate was 33.5% in the 28 patients who were admitted from April 2004 to March 2014, versus 50.4% in the 60 patients who were admitted from April 2014 to April 2021, showing a significant difference between them ( χ2=5.31, P<0.05). Results of further analysis showed that the corresponding 5-year overall survival rate of cases without lymph node metastasis was 43.8% in the 16 patients who were admitted from April 2004 to March 2014, versus 61.6% in the 31 patients who were admitted from April 2014 to April 2021. There was a significant difference in the 5-year overall survival rate between these patients without lymph node metastasis ( χ2=3.98, P<0.05). The corresponding 5-year overall survival rate of cases with lymph node metastasis was 18.5% in the 12 patients who were admitted from April 2004 to March 2014, versus 37.7% in the 29 patients who were admitted from April 2014 to April 2021. There was no significant difference in the 5-year overall survival rate between these patients with lymph node metastasis ( χ2=2.25, P>0.05). (5) Influencing factors of postoperative prognosis. Results of multivariate analysis showed that poorly differentiated tumor and R 1 or R 2 resection were inde-pendent risk factors influencing prognosis after surgical treatment of hilar cholangiocarcinoma ( hazard ratio=2.62, 2.71, 95% confidence interval as 1.30?5.29, 1.30?5.69, P<0.05). Conclusions:Compared with traditional surgical diagnosis and treatment, treatment of hilar cholangiocarcinoma based on multidisciplinary diagnosis and treatment can expand surgical indications, reduce proportion of dead patients within 90 days after surgery, improve proportation of radical resection and long-term survival rate. Poorly differentiated tumor and R 1 or R 2 resection are independent risk factors influencing prognosis after surgical treatment of hilar cholangiocarcinoma.

New progress in the diagnosis and treatment of biliary tract tumors / 国际外科学杂志

Biliary tract cancers (BTC) is a type of digestive tract malignant tumors that originate from biliary epithelial cells, is characterized by strong occult and highly invasive, and has a high mortality rate. Early detection and diagnosis are considered to be the key to obtaining radical surgical treatment. R0 resection is an effective measure to benefit patients with BTC. However, most of the patients present with local progression or associated distant metastasis, making it impossible to undergo radical surgical treatment. With existing diagnosis and treatment methods, the 5-year survival rate of patients is still very low. Therefore, how to improve the level of diagnosis and treatment of BTC, prolong survival, and improve the quality of life has become an urgent problem to be solved. In view of the characteristics of BTC and the continuous deepening of clinical pathological molecular research, adjuvant therapy, precisely targeted therapy, immunotherapy, and comprehensive treatment are currently considered to be standardized diagnosis and treatment models and research directions beyond surgery. Therefore, this article systematically analyzes the current research progress of BTC both domestically and internationally, aiming to provide strategies for the diagnosis and treatment of patients with BTC.

Interactive scalp acupuncture for hemiplegic upper extremity motor dysfunction in patients with ischemic stroke: a randomized controlled trial / 中国针灸

OBJECTIVE@#To compare the curative effect between interactive scalp acupuncture and traditional scalp acupuncture on hemiplegic upper extremity motor dysfunction in the patients with ischemic stroke.@*METHODS@#Seventy cases of hemiplegic upper extremity motor dysfunction of ischemic stroke were randomly divided into an interactive scalp acupuncture group (35 cases, 1 case breaked off) and a traditional scalp acupuncture group (35 cases, 1 case dropped off). The patients of the two groups received the secondary prevention medication and routine rehabilitation therapy. Besides, in the interactive scalp acupuncture group, the upper extremity occupational therapy was operated during the needle retaining of scalp acupuncture; and in the traditional scalp acupuncture group, the upper extremity occupational therapy was delivered after the completion of scalp acupuncture. The same points were selected in the two groups such as Fuxiang head area, Fuxiang upper-limb-shoulder point, Fuxiang upper-limb-elbow point and Fuxiang upper-limb-wrist point. The needles were inserted perpendicularly by flying-needle technique and manipulated by triple technique of gentle twisting, heavy pressure and vibrating. The needles were retained for 30 min. Based on the degree of the upper extremity motor impairment, the regimen of the upper extremity occupational therapy was formulated individually and one treatment took 30 min. In the two groups, the therapies were delivered once daily, 5 times a week, lasting 4 weeks. Before and after treatment, the scores of Fugl-Meyer assessment of upper extremity (FMA-UE), Wolf motor function test (WMFT), the modified Barthel index (MBI) and the modified Ashworth scale (MAS) grade in the two groups were observed before and after treatment.@*RESULTS@#After treatment, the scores of FMA-UE, WMFT and MBI were higher than those before treatment (P<0.01), and MAS grade was improved (P<0.05) in the two groups. The scores of FMA-UE, WMFT and MBI in the interactive scalp acupuncture group were higher than those in the traditional scalp acupuncture group (P<0.01, P<0.05), and there was no statistical significance in the difference of MAS grade between the two groups (P>0.05).@*CONCLUSION@#The interactive scalp acupuncture can effectively improve the motor function of the hemiplegic upper extremities and the activities of daily living in the patients with ischemic stroke and its efficacy is better than traditional scalp acupuncture. But these two types of scalp acupuncture obtain the similar effect on spasticity.

Risk factors of newly developed nonalcoholic fatty liver disease after pancreaticoduodenectomy / 中华外科杂志

Objective: To identify the risk factors of newly developed nonalcoholic fatty liver disease(NAFLD) after pancreaticoduodenectomy(PD). Methods: The clinical data of 130 patients who had undergone PD at Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Medical School of Nanjing University from June 2018 to December 2020 were collected retrospectively. There were 74 males and 56 females, with age(M(IQR)) of 62(16) years (range: 22 to 84 years). Twenty-nine patients who developed NAFLD were divided into NAFLD group and 101 patients who did not suffer NAFLD were divided into no NAFLD group. Observation indications included:(1)preoperative demographics,intraoperative and postoperative characteristics; (2)the risk factors of newly developed NAFLD after PD. Count data were analyzed using χ2 test or Fisher's exact test. Measurement data were analyzed by student t test or Mann-Whitney U test. Multivariate analysis was performed using Logistic regression model with a stepwise forward approach. Results: All 130 patients successfully underwent PD and 29 cases(22.3%) developed NAFLD in 6 months after PD. The results of univariate analysis showed that gender,diabetic mellitus,the level of triglyceride preoperatively,and pancreatic ductal adenocarcinoma were the related factors of the development of NAFLD after PD(t=-2.655, χ²=4.563,U=-2.192,χ²=7.044;all P<0.05).Multivariate analysis revealed that gender,body mass index and pancreatic ductal adenocarcinoma were independent risk factors for the development of NAFLD after PD(OR=2.849,1.214,4.165,all P<0.05). Conclusion: Gender, body mass index and pancreatic ductal adenocarcinoma were independent risk factors for the development of NAFLD after PD.

Application value of pancreatoduodenectomy with preservation of the gastric tube / 中华消化外科杂志

Objective:To investigate the application value of pancreatoduodenectomy (PD) with preservation of the gastric tube.Methods:The retrospective and descriptive study was conducted. The clinicopathological date of 3 male patients who underwent PD with preservation of the gastric tube for the treatment of periampullary tumor in Nanjing Drum Tower Hospital affiliated to Nanjing University Medical School from May 2018 to November 2019 were collected. The 3 patients were aged from 66 to 77 years, with a median age of 76 years. All 3 patients with surgical history of radical resection of esophageal tumors and tubular gastric surgery underwent PD with preservation of the gastric tube. Observation indications: (1) preoperative three-dimensional (3D) reconstruction; (2) surgical and postoperative situations; (3) follow-up. Follow-up using outpatient exa-mination or telephone interview was conducted to detect survival of patients and tumor metastasis and recurrence up to April 2021. Measurement date with skewed distribution were expressed as M(range).Count date were expressed as absolute numbers. Results:(1) Preoperative 3D recons-truction: results of preoperative 3D reconstruction for the 3 patients showed none of patients with vascular variation. (2) Surgical and postoperative situations: 3 patients underwent PD with preserva-tion of the gastric tube successfully. The operation time and the volume of intraoperative blood loss were 402 minutes(range, 345?480 minutes) and 330 mL(range, 300?400 mL) for the 3 patients. Of 3 patients, 1 case had postoperative grade B pancreatic fistula and 1 case had chylous leakage, respectively, who were improved after conservative treatment. There was no perioperative death. The duration of postoperative hospital stay was 18 days(range, 15?20 days) for the 3 patients. Results of postoperative histopathological examination for the 3 patients showed that 1 case with pancreatic cancer as T2N0M0 stage, 1 case with ampulla carcinoma as T2N0M0 stage and 1 case with intraductal papillary mucinous neoplasms of the pancreas. (3) Follow-up: 3 patients were followed up for 12 to 18 months, with a median follow-up time of 16 months. Results of abdominal enhanced computed tomography examination at postoperative 14 month for the 3 patients showed that the right gastroepiploic artery and vein around the pancreas were unobstructed. Of 3 patients, 1 case with pancreatic cancer who did not receive chemotherapy died at postoperative 14 months due to tumor recurrence and metastasis. There was no recurrence and metastasis in the other two cases.Conclusion:PD with preservation of the gastric tube is safe and feasible, which can be used for patients with periampullary lesions who underwent radical resection of esophageal tumors and tubular gastric surgery in the past.

Application of accurate endoscopic retrograde cholangiopancreatography drainage to preoperative jaundice reduction for hilar cholangiocarcinoma / 中华消化内镜杂志

Objective:To investigate the application of accurate endoscopic retrograde cholangiopancreatography (ERCP)drainage guided by IQQA ?-Liver CT(an image interpretation and analysis system)to preoperative jaundice reduction for hilar cholangiocarcinoma. Methods:Data of 12 patients with hilar cholangiocarcinoma who planned to receive surgical treatment in the hepatobiliary surgery department of Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from May 2017 to December 2018 were reviewed. All patients were treated with ERCP drainage before surgery. The procedure success rate, postoperative drainage volume and postoperative complications of the patients were analyzed.Results:ERCP was successful in all patients, and the median daily volume of endoscopic nasobiliary drainage was 675 mL(400-1 500 mL). Only 1 patient developed postoperative cholangitis, and another patient developed postoperative mild pancreatitis. The mean serum total bilirubin was 173.3±62.8 μmol/L in the patients before ERCP, which decreased to 35.6±13.9 μmol/L before surgery.Conclusion:Accurate ERCP drainage can effectively reduce the serum bilirubin level in patients with hilar cholangiocarcinoma and reduce the incidence of cholangitis after the procedure, creating favorable conditions for subsequent surgical operations.

Logistic regression analyses for preoperative assessment of liver functional reserve based on virtual touch tissues quantification and fibrosis-4 / 中华肝胆外科杂志

Objective:To investigate the effect of logistic regression model based on virtual touch tissues quantification (VTQ) and fibrosis index based on four factors (FIB-4) in assessing impaired liver reserve function (LFR) in hepatic surgery patients before surgical resection.Methods:From January 2016 to October 2018, 173 patients including 135 males and 38 females with the mean age of 58.6 years old, scheduled for potential hepatectomy in Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, were enrolled in our retrospective study. According to indocyanine green retention test at 15 minutes (ICG R15), the patients were divided into two groups, LFR-impaired group ( n=11, ICG R15≥20%) and control group ( n=162, ICG R15 < 20%). VTQ, FIB-4, platelet count and other parameters were compared between two groups. The multivariate logistic regression model was used to establish a risk model to access the impaired LFR. Receiver operating characteristic (ROC) curve was used to analyze the efficacy of each parameter in LFR-impaired. Results:The platelet count in LFR-impaired group was lower than that in control group, VTQ and FIB-4 were higher than that in control group (all P<0.05). Logistic regression showed that VTQ ( OR=4.382, 95% CI: 1.380-13.918)) and FIB-4 ( OR=2.112, 95% CI: 1.342-3.325) were risk factors for LFR-impaired. The final prediction model of LFR-impaired group was Logit (P)=-6.185+ 0.748×FIB-4+ 1.477×VTQ. The cut-off point (sensitivity, specificity, accuracy) of logistic model, FIB-4 and VTQ were 0.098 (72.8%, 90.1%, 89.0%), 0.990 (90.9%, 79.0%, 79.8%) and 1.8 m/s (81.8%, 77.8%, 78.0%), respectively. The specificity, accuracy of logistic model was higher than FIB-4 or VTQ. Conclusions:Logistic regression model based on VTQ and FIB-4 may improve the specificity and accuracy in the diagnosis of significant LFR impairment. VTQ can further assist clinicians in preoperative evaluation of LFR.

Risk factor analysis for pancreatic fistula after pancreaticoduodenectomy for Vater′s ampullary carcinoma / 中华胰腺病杂志

Objective:To identify the risk factors of clinically relevant pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) for Vater′s ampullary carcinoma.Methods:The clinical data of 93 Vater's ampullary carcinoma patients who had undergone PD in Nanjing Drum Tower Hospital from January 2018 to December 2020 was retrospectively analyzed. According to the occurrence of CR-POPF, all patients were divided into the CR-POPF group and no CR-POPF group. Univariate analysis and multivariate analysis by logistic regression model were performed for perioperative risk factors of CR-POPF to identify the independent risk factors for CR-POPF after PD for Vater's ampullary carcinoma.Results:44 patients developed CR-POPF and the rate of CR-POPF was 47.3%(44/93). The most frequently detected microorganisms from abdominal drain fluid after operation were Klebsiella pneumoniae (25.8%), Enterococcus faecalis (19.4%), Enterobacter cloacae (11.8%) and Enterococcus faecium (10.7%). The results of univariate analysis showed that operation time, C-reactive protein (CRP) on postoperative day (POD)1, Klebsiella pneumoniae, Enterococcus faecalis and Enterococcus faecium in the abdominal drainage were statistically different between the two groups (all P value <0.05). Multivariate analysis revealed that CRP on POD1 ( OR 1.029, 95% CI 1.003-1.055, P=0.026), Klebsiella pneumoniae( OR 8.671, 95% CI 2.366-31.772, P=0.001), Enterococcus faecalis( OR 10.497, 95% CI 2.306-41.776, P=0.002) and Enterococcus faecium ( OR 22.580, 95% CI 2.303-221.403, P=0.007) in the abdominal drainage were independent risk factors for the development of CR-POPF after PD for Vater′s ampullary carcinoma. Conclusions:CRP on POD1, Klebsiella pneumoniae, Enterococcus faecalis and Enterococcus faecium in the drain samples were independent risk factors for the development of CR-POPF after PD for Vater′s ampullary carcinoma.

Comparative study of simultaneous three scopes surgery and staged two scopes surgery in the treatment of choledocholithiasis with cholecystolithiasis / 国际外科学杂志

Objective:To compare the clinical efficacy of the Simultaneous three scopes combined surgery [laparoscopic cholecystectomy(LC)+ choledochoscopy exploration + choledochectomy and removal of the common bile duct + primary suture of the common bile duct + endoscopic guided nasobiliary duct placement] and staged two scopes surgery[endoscopic retrograde cholangiopancreatography (ERCP) combined with LC] in the treatment of choledocholithiasis and cholecystolithiasis.Methods:From January 2018 to June 2020, we retrospectively analyzed the clinical data of 83 patients with choledocholithiasis and choledocholithiasis, who underwent minimally invasive treatment in our center. According to the different surgical procedures, the patients were divided into three-mirror group ( n=42) and two-mirror group ( n=41). All patients in the three-mirror group underwent three-scopy combined surgery. The patients in two-mirror group received endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC). In this study we compared the relevant clinical indicators of the two groups, in terms of the operation time, intraoperative blood loss, one-time stone clearance rate, postoperative exhaust time, postoperative defecation time, total hospitalization cost, incidence of postoperative acute pancreatitis, postoperative stone recurrence rate, incidence of postoperative cholangitis, and incidence of postoperative biliary fistula, total hospitalization time, postoperative bile duct stricture rate. Use SPSS 26.0 software to statistically analyze various indexes such as intraoperative, postoperative, follow-up, etc. Normally distributed measurement data were described by the mean±standard deviation ( Mean± SD), the comparison between groups was by t test, and measurement data with skewed distribution were destribed as M( P25, P75), Pairwise comparisons were analyzed using nonparametric test. The comparison of count data between groups was by the chi-square test. Results:No death was observed in both two groups. The operation time, intraoperative blood loss, one-time stone clearance rate, postoperative exhaust time, and postoperative defecation time of the three-mirror groupwere (167.98±47.37) min, 50(50, 100) mL, 100%(42/42), (2.10±0.76) days, 3(3, 4) days, the two-mirror group were (143.80±34.47) min, 50(50, 50) mL, 85.4%(35/41), (1.53±0.99) days and 2(1, 3) days. Compared with the two groups, the three-mirror group was higher than the two-mirror group, and the difference was statistically significant ( P<0.05). The total hospitalization expenses, postoperative acute pancreatitis incidence, and postoperative calculus recurrence rate in the three-mirror group were (3.46±0.77) ten thousand yuan, 0(0/42), 2.38%(1/42), the two-mirror group were (4.22±1.50) ten thousand yuan, 9.8%(4/41), 19.5%(8/41). Compared with the two groups, the three-mirror group was lower than the two-mirror group, and the difference was statistically significant ( P<0.05). No postoperative cholangitis or biliary fistula occurred in the two groups. There was no statistically significant difference in the total hospital stay and incidence of postoperative bile duct stenosis between the two groups ( P>0.05). Conclusions:For choledocholithiasis combined with cholecystolithiasis patients, simultaneous three-scopes combined surgery and elective LC after ERCP are safe and effective, and each has its own advantages. It should be selected reasonably according to the patient′s condition and combined with the technical advantages of the treatment team.

Risk factors and microbial spectrum for infectious complications for patients with biliary tract cancer after major hepatectomy with cholangiojejunostomy / 中华肝胆外科杂志

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.

Selection of preoperative biliary drainage of perihilar cholangiocarcinoma / 国际外科学杂志

Preoperative biliary drainage (PBD) has become an essential part of perioperative management for perihilar cholangiocarcinoma. However, it is controversial about the indication of PBD. There are three main PBD methods, including percutaneous transhepatic biliary drainage, endoscopic nasobiliary drainage and endoscopic biliary stenting. At present, different centers have different preferences on PBD, and the controversies mainly focus on the followings: the relationship between percutaneous transhepatic biliary drainage and seeding metastasis; the success rate, tolerance and pancreatitis risk of endoscopic nasobiliary drainage; as an internal drainage, the merits and demerits of endoscopic biliary stenting. Additionally, whether PBD could increase the incidence of postoperative infections is still ambiguous. This review summarizes the recent scenario about the above-mentioned controversies to provide references for clinical decision-making.

CTimagingfeaturesanddifferentialdiagnosisofhilarcholangiocarcinomawithdifferentgrossclassification / 实用放射学杂志

Objective TodiscusstheCTimagingfeaturesanddifferentialdiagnosisofhilarcholangiocarcinomawithdifferent grossclassifications.Methods 83casesofperihilardiseasesconfirmedbyhistopathologywereanalyzedretrospectivelybytworadiologists. CTimagingfeaturesandenhancementpatternsinhilarcholangiocarcinomawithdifferentgrossclassificationsandotherperihilarbenign diseaseswerecomparedtoseeiftherewasasignificantdifference.Results Ofall,15caseswithintraductalgrowinghilarcholangiocarcinoma, theaxialdiametersweresignificantlylargerthanperihilarbenigndiseases,andallofthem werewash-inandwash-outpatternof enhancement.38caseswereperiductalinfiltratinghilarcholangiocarcinomawithsignificantlyshorterlongitudinallength,mostlywith biliarystricture,bileductthicknessandsoftrattandistantbiliarydilatation.Mostofthem werewash-inandwash-outpatternof enhancement.30casesweremass-forminglesions.Hilarmass-forminglesionsweremostlyhilarcholangiocarcinoma,andtheenhancement patternswerepersistentandprogressiveenhancements.Conclusion Differentgrossclassificationsofhilarcholangiocarcinomahave differentCTfeatures,includingthesize,morphology,indirectsignsandenhancementpatterns,whichcanbeusedtodistinguishwith thehilarbenignlesions.

Retrospective study on the risk factors related to intraabdominal infection after anatomical hepatectomy / 中华普通外科杂志

Objective@#To assess the incidence and related risk factors of postoperative intraabdominal infection in patients undergoing anatomical hepatectomy.@*Methods@#The clinical data from 122 patients who underwent anatomical major hepatectomy in our institution were retrospectively analyzed. The electronic medical data were retrieved for further analysis including the amount of crystalloid and colloid fluid infused, intraoperative estimated blood loss, volume of blood transfusion, the dosage of vasoactive drugs, postoperative liver function, inflammation index, the incidence of intraabdominal infection and the length of hospital stay (LOS).@*Results@#Patients were divided into infection group (n=39) and non- infection group (n=83). Intraabdominal infection was correlated with preoperative cirrhosis, the elevated direct bilirubin and alanine aminotransferase, the duration of operation, bilioenteric anastomosis or cholangiotomy, the infusion volume of colloid and crystalloid fluid, transfusion volume, direct bilirubin level on the POD 1(post-operation on day 1) (P<0.05); Multivariate analysis showed the incidence of intraabdominal infection was highly correlated with the amount of intraoperative colloid fluid bilioenteric anastomosis(P<0.05).@*Conclusions@#Intraoperative infused volume of synthetic colloid, along with bilioenteric anastomosis are independent risk factors for postoperative intraabdominal infection.

Retrospective study on the risk factors related to intraabdominal infection after anatomical hepatectomy / 中华普通外科杂志

Objective To assess the incidence and related risk factors of postoperative intraabdominal infection in patients undergoing anatomical hepatectomy.Methods The clinical data from 122 patients who underwent anatomical major hepatectomy in our institution were retrospectively analyzed.The electronic medical data were retrieved for further analysis including the amount of crystalloid and colloid fluid infused,intraoperative estimated blood loss,volume of blood transfusion,the dosage of vasoactive drugs,postoperative liver function,inflammation index,the incidence of intraabdominal infection and the length of hospital stay (LOS).Results Patients were divided into infection group (n =39) and non-infection group (n =83).Intraabdominal infection was correlated with preoperative cirrhosis,the elevated direct bilirubin and alanine aminotransferase,the duration of operation,bilioenteric anastomosis or cholangiotomy,the infusion volume of colloid and crystalloid fluid,transfusion volume,direct bilirubin level on the POD 1 (post-operation on day 1) (P ＜ 0.05);Multivariate analysis showed the incidence of intraabdominal infection was highly correlated with the amount of intraoperative colloid fluid bilioenteric anastomosis(P ＜ 0.05).Conclusions Intraoperative infused volume of synthetic colloid,along with bilioenteric anastomosis are independent risk factors for postoperative intraabdominal infection.

Mechanism of Paris Forrestii (Takht.) H. Li-Suppressing the Proliferation of Acute Myeloid Leukemia Cell Lines / 中国实验血液学杂志

OBJECTIVE@#To investigate the mechanism of Paris forrestii (Takht.) H. Li (PCT3)-suppressing the proliferation of HL-60, K562, KG-1 and HT-93 cells.@*METHODS@#cute myeloid leukemia cell lines such as HL-60, K562, KG-1 and HT-93 were treated with Paris forrestii (Takht.) H. Li (PCT3) for 24, 48, and 72 h, and MTT assay was employed to determine the cells proliferation. Meanwhile, the apoptosis of K562, HL-60, KG-1 and HT-93 cells were detected by flow cytometry after PCT3 (Control, 4 μg/ml, 8 μg/ml) treated for 24 h and the Western blot was performed to detect the expression of PARP,Caspase-3, MCL-1, BAX, BCL-2, P53, and P27. GAPDH was used as an internal loading control.@*RESULTS@#MTT assay showed that Paris forrestii (Takht.) H. Li (PCT3) significantly inhibited the proliferation of HL-60, K562, KG-1 and HT-93 cells in concentration and time-dependent manners. Compared with the control group, the leukemia cell viabilities were significantly suppressed (r =0.9436; r =0.8623; r =0.9922; r =0.8918). Paris forrestii (Takht.) H. Li (PCT3) induced apoptosis of leukemia cells in a concentration dependent manner, compared with the control group (P＜0.05 or P＜0.01). Western blot revealed that PARP, a major enzyme in DNA damage repair, and Caspase-3 another one of the major executive apoptotic enzymes were cleaved in cell lines examined, and this cleavage was concentration dependent. Anti-apoptotic proteins such as MCL-1 and BCL-2 were down regulated by Paris forrestii (Takht.) H. Li (PCT3), and Pro-apoptotic protein BAX was upregulated. And the protein of tumor suppressor gene P53 and its downstream signaling protein P27 increased.@*CONCLUSION@#Paris forrestii (Takht.) H. Li (PCT3) can inhibit the proliferation of leukemia cells by activating endogenous apoptosis pathway, and provide a potential new drug selection for clinical treatment of AML leukemia.

Application of three-dimensional visualization technology in preoperative assessment for hepatocellular carcinoma / 中华普通外科杂志

Objective To explore the value of medical three-dimensional visualization technology in preoperative precise assessment for hepatocellular carcinoma (HCC).Methods The clinical data of 24 HCC patients were analyzed retrospectively from Jan 2015 to Dec 2016 in our department.Thin-layer 320-slice CT scaning was performed and data stored in the form of DICOM.Three dimensional reconstruction and simulated hepatectomy were conducted,and correlation test analysis was performed.Results The volume of simulated resected liver was (565 ± 296)ml,while the actual liver resection volume was(523 ± 252)ml.There was no significant difference between the predicted and the actual values (t =1.734,P ＞ 0.05).The actual liver resection volume was positively correlated with the predicted liver resection volume (r =0.920,P ＜ 0.05).The stimulated resection margin was (1.2 ± 0.6)cm,while the actual resected tumor margin was (1.0 ± 0.5) cm.There was no significant difference between the predicted and the actual values (t =1.853,P ＞0.05).The actual margin was positively correlated with the predicted one (r =0.956,P ＜ 0.05).Conclusion The three-dimensional visualization technology has a certain degree of clinical value in the preoperative evaluation of HCC.

Saponins from Paris forrestii(Takht.)H.Li displays potent activity against acute myeloid leukemia by suppressing RNF6/AKT/mTOR signaling pathway / 中国药理学与毒理学杂志

Acute myeloid leukemia (AML) is a heterogeneous disease characterized by the accu-mulation of immature myeloid progenitor cells in the bone marrow,compromising of normal hematopoi-esis and ultimately resulting in bone marrow failure. Chemotherapy is the mainstay treatment for all AML patients,however,drug resistance and clinical relapse limits its efficacy.The 5-year survival rate of AML patients is only 26.6%.Survival rates are even lower among patients ages 65 to 74 years (5.3%)and 75 years or older(1.6%).Therefore,exploring novel therapeutic agents is urgent for improving the outcome of patients with AML. Saponins are amphipathic glycosides found in traditional Chinese medicines. In the present study, we isolated a panel of saponins from Paris forrestii (Takht.) H. Li, a unique plant found in Tibet and Yunnan provinces, China. By examining their activities in suppressing acute myeloid leukemia cell proliferation, total saponins from Paris forrestii (TSPf) displayed more potent activity than individual ones.TSPf induced more than 40% AML cell apoptosis within 24 h and decreased the viability of all leukemia cell lines. TSPf-induced apoptosis was confirmed by both Annexin V staining and caspase-3 activation.TSPf downregulated pro-survival proteins Mcl-1,Bcl-xL and Bcl-2,but upreg-ulated the expression of tumor suppressor proteins p53,p27,Bax and Beclin 1.The AKT/mTOR signaling pathway is frequently over activated in various AML cells,and TSPf was found to suppress the activa-tion of both AKT and mTOR,but had no effects on their total protein expression.This was further con-firmed by the inactivation of 4EBP-1 and p70S6K,two typical downstream signal molecules in the AKT/mTOR pathway. More specifically, TSPf-inactivated AKT/mTOR signaling was found to be associated with downregulated RNF6, a recently identified oncogene in AML. RNF6 activated AKT/mTOR, and consistently, knockdown of RNF6 led to inactivation of the AKT/mTOR pathway. Furthermore, TSPf suppressed the growth of AML xenografts in nude mice models. Oral administration of 100 mg·kg-1 body weight almost fully suppressed tumor growth within 14 d, without gross toxicity. This study thus demonstrated that TSPf displays potent anti-AML activity by suppressing the RNF6/AKT/mTOR pathway. Given its low toxicity,TSPf could be developed for the treatment of AML.