Prognostic factors of radical gastrectomy for stage Ⅲ gastric cancer and predictive value of metastatic lymph node ratio for prognosis: a report of 995 cases / 中华消化外科杂志

Objective To investigate the prognostic factors of radical gastrectomy for stage Ⅲ gastric cancer and predictive value of metastatic lymph node ratio for prognosis.Methods The retrospective case-control study was conducted.The clinicopathological data of 995 patients with stage Ⅲ gastric cancer who were admitted to the Zhongshan Hospital of Fudan University between January 2003 and December 2014 were collected.There were 690 males and 305 females,aged from 20 to 75 years,with an average age of 61 years.After clinical staging according to results of preoperative accessory examinations,patients with early gastric cancer underwent D1+ lymphadenectomy,patients with advanced gastric cancer underwent D2 lymphadenectomy and patients with serosa invasion underwent D2+ lymphadenectomy.Observation indicators:(1) treatment situations;(2) follow-up and survival situations;(3) prognostic factors analysis after operation;(4) stratified analysis:① stratified analysis of tumor pathological N staging;② stratified analysis of number of lymph node dissected;③ stratified analysis of tumor pathological TNM staging;(5) receiver operating characteristic (ROC) curve.Patients were followed up using outpatient examination and telephone interview to detect postoperative survival up to January 2016.The overall survival time was from the operation data to last follow-up or time of death.Measurement data with normal distribution were represented as Mean±SD.The survival rate and curve were respectively calculated and drawn by the Kaplan-Meier method and Log-rank test was used for survival analysis.The COX proportional hazard model was used for univariate and multivariate analysis.The ROC curve and area under curve (AUC) were used to check the accuracy of number of positive lymph nodes and metastatic lymph node ratio for prognosis.Comparison of the AUC was analyzed by the Z test.Results (1) Treatment situations:of 995 patients underging gastrectomy,677 underwent distal gastrectomy,85 underwent proximal gastrectomy,233 underwent total gastrectomy.There were 117 undergoing D1+ lymphadenectomy and 878 undergoing D2 lymphadenectomy or D2+ lymphadenectomy.The number of lymph node dissected,number of positive lymph nodes,metastatic lymph node ratio were 27± 12,10± 9 and 0.41±0.28,respectively.(2) Follow-up and survival situations:995 patients were followed up for (35± 32)months.During the follow-up,the 1-,3-,5-year overall survival rates were 77.9％,47.8％,36.2％.(3) Prognostic factors analysis after operation:results of univariate analysis showed that sex,tumor histological type,vascular embolus,degree of tumor invasion,tumor pathological N staging,number of lymph node dissected,metastatic lymph node ratio,tumor pathological TNM staging were related factors affecting prognosis of radical gastrectomy for stage Ⅲ gasteric cancer (hazard ratio =0.817,1.486,1.268,2.173,1.957,1.737,3.357,2.169,95％ confidence interval:0.686-0.973,1.059-2.086,1.074-1.497,1.195-3.954,1.480-2.588,1.390-2.170,2.476-4.602,1.740-2.704,P＜0.05).Results of multivariate analysis showed that sex,tumor histological type,tumor pathological N staging,number of lymph node dissected,metastatic lymph node ratio,tumor pathological TNM staging were independent factors affecting prognosis of radical gastrectomy for stage Ⅲ gastric cancer (hazard ratio =0.805,1.476,0.237,1.475,3.811,3.600,95％ confidence interval:0.673-0.963,1.049-2.087,0.083-0.678,1.140-1.909,2.259-6.428,1.317-9.839,P＜0.05).(4) Stratified analysis:of the 995 patients,the postoperative l-,3-,5-year overall survival rates were 93.7％,69.6％,60.5％ in the patients with metastatic lymph node ratio ≤ 0.1,86.9％,60.6％,44.3％ in the patients with 0.1 ＜ metastatic lymph node ratio ≤0.4 and 64.3％,28.9％,21.0％ in the patients with metastatic lymph node ratio ＞ 0.4,showing a statistically significant difference (x2 =121.300,P＜0.05).There were statistically significant differences between patients with metastatic lymph node ratio ≤0.1 and patients with 0.1＜ metastatic lymph node ratio ≤0.4,between patients with metastatic lymph node ratio ≤0.1 and patients with metastatic lymph node ratio ＞0.4 (x2=7.580,65.320,P＜0.05).There was a statistically significant difference between patients with 0.1 ＜ metastatic lymph node ratio ≤0.4 and patients with metastatic lymph node ratio＞0.4 (x2 =80.806,P＜0.05).① Stratified analysis of tumor pathological N staging:the average metastatic lymph node ratio was 0.09 in the 132 stage N1 patients,who were divided into the patients with metastatic lymph node ratio ≤ 0.1 and ＞ 0.1.The postoperative 1-,3-,5-year overall survival rates were 92.2％,68.6％,59.1％ in the 108 patients with metastatic lymph node ratio ≤ 0.1 and 79.2％,32.8％,21.9％ in the 24 patients with metastatic lymph node ratio ＞0.1,respectively,showing a statistically significant difference (x2 =14.499,P＜0.05).The average metastatic lymph node ratio was 0.23 in the 265 stage N2 patients,who were divided into the patients with metastatic lymph node ratio ≤0.2 and ＞0.2.The postoperative 1-,3-,5-year overall survival rates were 92.3％,73.8％,61.0％ in the 138 patients with metastatic lymph node ratio ≤0.2 and 76.5％,40.1％,22.2％ in the 127 patients with metastatic lymph node ratio ＞0.2,respectively,showing a statistically significant difference (x2 =42.536,P＜0.05).The average metastatic lymph node ratio was 0.56 in the 598 stage N3 patients,who were divided into the patients with metastatic lymph node ratio ≤0.4 and ＞0.4.The postoperative 1-,3-,5-year overall survival rates were 88.5％,62.8％,47.0％ in the 194 patients with metastatic lymph node ratio ≤ 0.4 and 64.3％,29.8％,21.0％ in the 404 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2 =51.860,P＜ 0.05).② Stratified analysis of number of lymph node dissected:7 of 117 patients with the number of lymph node dissected ＜ 15 had metastatic lymph node ratio ≤0.1,who were divided into patients with metastatic lymph node ratio ≤0.4 and ＞0.4.The postoperative 1-,3-,5-year overall survival rates were 78.2％,40.0％,28.6％ in the 44 patients with metastatic lymph node ratio ≤0.4 and 78.1％,18.7％,12.9％ in the 73 patients with metastatic lymph node ratio＞0.4,respectively,showing a statistically significant difference (x2 =4.727,P＜0.05).③ Stratified analysis of tumor pathological TNM staging:of 262 patients with stage Ⅲa gastric cancer,the postoperative 1-,3-,5-year overall survival rates were 88.5％,65.0％,54.3％ in the 230 patients with metastatic lymph node ratio ≤0.4 and 77.5％,35.4％,29.5％ in the 32 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2 =6.132,P＜0.05).Of 296 patients with stage Ⅲb gastric cancer,the postoperative 1-,3-,5-year overall survival rates were 84.4％,60.7％,42.7％ in the 200 patients with metastatic lymph node ratio ≤ 0.4 and 59.9％,26.8％,21.7％ in the 96 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2 =23.699,P＜0.05).Of 437 patients with stage Ⅲ c gastric cancer,the postoperative 1-,3-,5-year overall survival rates were 84.7％,59.9％,38.7％ in the 133 patients with metastatic lymph node ratio ≤0.4 and 64.0％,27.9％,18.3％ in the 304 patients with metastatic lymph node ratio ＞0.4,respectively,showing a statistically significant difference (x2=36.215,P＜ 0.05).(5) ROC curve:ROC curves of postoperative overall survival rates in patients with stage Ⅲ gastric cancer were drawn using the number of positive lymph nodes and metastatic lymph node ratio,of which AUC were 0.619 (95％ confidence interval:O.588-0.649) and 0.706 (95％ confidence interval:0.677-0.734),showing a statistically significant difference (Z=8.842,P＜0.05).Conclusions Sex,tumor histological type,tumor pathological N staging,number of lymph node dissected,metastatic lymph node ratio,tumor pathological TNM staging are independent factors affecting prognosis of radical gastrectomy for stage Ⅲ gastric cancer.There is different prognosis of patients with different metastatic lymph node ratios in the subgroup of the same tumor pathological TNM staging,number of lymph node dissected,tumor pathological TNM staging.Compared with tumor pathological N staging,metastatic lymph node ratio has a more accurate predictive value for prognosis.

The expression and clinical significance of S100A9 protein in gastric cancer of intestinal type / 中华普通外科杂志

Objective To investigate the expression and clinical significance of pro-inflammation S100A9 protein in intestinal type gastric cancer.Methods We retrospectively analyzed the clinicopathological materials of the 278 patients who were diagnosed as Lauren classification intestinal gastric cancer and underwent surgical treatment between January and December 2008 at the Department of General Surgery,Zhongshan Hospital Fudan University.Immunohistochemistry was used to analyze the expression of S100A9 protein in tumor tissues and para-tumor tissues.Results High expression of S100A9 protein was associated with the depth of tumor invasion (P =0.013),lymph node metastasis (81.4％,53.9％,47.3％ vs.84.7％,69.3％,60.7％,x2 =4.220,P =0.041) and TNM stage (P =0.010).The overall survival rate of these patients with high expression of S100A9 protein was significantly lower than those with low expression of S100A9 protein.In stage Ⅲ/Ⅳ patients,the overall survival rate of these patients with high expression of S100A9 protein was significantly lower than those with low expression of S100A9 protein.Moreover,for those patients who received postoperative chemotherapy,the prognosis of the patients with high expression of S100A9 protein was poorer than those with low expression.By multivariable analysis,the expression of S100A9 protein was not an independent risk factor for the prognosis of intestinal gastric cancer patients.Conclusions High expression of S100A9 protein in intestinal gastric cancer was associated with poor prognosis.

Strategies for prevention and treatment of postoperative complications of gastric cancer / 中华胃肠外科杂志

Postoperative complications after gastric cancer surgery has their own specificity and complexity, and the strategies for prevention and treatment should be of equal emphasis on both theory and technology. Based on the knowledge and familiarity with different postoperative complications, to efficiently prevent them, it is not only necessary to strengthen the training of acknowledged operative strategy, smooth and precise surgical techniques, but also to address the importance of overall preoperative assessment for patients, to treat the basic diseases, and to improve and correct their general conditions. Combining with the concept and basic protocol of enhanced recovery after surgery (ERAS), it is preferred to work out an individualized perioperative preventing strategy for patients who have high risk factors of specific postoperative complications. After the operation, to guarantee intensive and individual managements for patients, to catch early abnormal signs, then to make early and precise diagnosis, and to do timely response and accurate treatments, including timely and proper re-operations, can improve the efficacy of complications and promote the recovery of patients as soon as possible.

Clinicopathologic characteristics and prognosis analysis of 90 young patients with gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the features of clinicopathology and prognosis in young gastric cancer patients.</p><p><b>METHODS</b>Clinicopathological data of 90 young gastric cancer patients (≤40 years old) who received radical gastrectomy in the Department of General Surgery of Zhongshan Hospital, Fudan University from January 2013 to December 2014 were retrospectively analyzed. Survival data were obtained by follow-up and the last follow-up time was October 2016. Log-rank test and Cox regression model were used to analyze the risk factors of prognosis and these factors included gender, age, tumor size, degree of differentiation, histological type, Lauren pattern, T stage, N stage, vessel carcinoma embolus, clinical symptom, anemic condition, CA19-9 level, et al.</p><p><b>RESULTS</b>The median age of 90 patients was 35 years old, of whom, 20(22.2%) patients were ≤30 years old and 70(77.8%) patients were between 31 and 40 years old. There were 70(77.8%) female patients, 38(42.2%) patients with anemia, 11(12.8%) patients with elevated CA19-9 level and 9(10.0%) patients with family history of gastrointestinal tumors. The mean time of all the patients from presence of symptom to consultation was 8.2 months. Postoperative pathology revealed 65(72.2%) patients with poorly differentiated adenocarcinoma, 6(6.7%) patients with mucinous adenocarcinoma, 9(10%) patients with signet-ring cell carcinoma, and 10(11.1%) patients with papillary-canalicular adencarcinoma. Sixty-nine (76.7%) patients were diagnosed as advanced gastric cancer and 67(74.4%) patients were involved with lymphatic metastasis when they visited our hospital. Univariate analysis showed that gender (P=0.021), tumor size (P=0.001), depth of tumor infiltration (P=0.016), lymphatic metastasis (P=0.000), vessel carcinoma embolus (P=0.001), elevated CA19-9 level (P=0.001), and anemia (0.024) were statistically related with postoperative survival. Multivariate analysis showed that lymphatic metastasis was an independent risk factor of the poor prognosis of young patients (HR:2.774, 95%CI:1.435 to 5.364, P=0.002).</p><p><b>CONCLUSIONS</b>The majority of young gastric cancer cases are female with poorly differentiated adenocarcinoma. Most patients are diagnosed as advanced gastric cancer with lymphatic metastasis when they visit hospital at the first time. The lymphatic metastasis is an independent risk factor of prognosis in young gastric cancer patients.</p>

Surgical treatment of Stanford type A acuteaortic dissection in elderly patients / 西安交通大学学报(医学版)

Objective To review our surgical treatment experience and analyze the surgical methods and efficacy of Stanford type A acute aortic dissection in elderly patients.Methods We recruited 24 patients aged over 60 years with Stanford type A acute aortic dissection treated surgically with deep hypothermic circulatory arrest and selective cerebral perfusion from June 2013 to September 2016.Depending on the patients` conditions, we selected different surgical methods, including Bentall operation in 3 cases, David operation in 1 case, partial aortic arc replacement+Bentall operation in 3 cases, total aortic arch replacement+stented elephant trunk implantation technique+Bentall operation in 12 cases, total aortic arch replacement+stented elephant trunk implantation technique+ascending aorta replacement in 5 cases, and concomitant coronary artery bypass grafting (CABG) in 3 cases.Results Surgical operation was successful in all the 24 patients.The average CPB time of the all patients was (192.9±37.1)min, the aortic cross-clamp time was (120±28.72)min, deep lower temperature of cerebral perfusion time was (36.2±11.3)min, and operation time was (544.8±91.2)min.Soon after the operation, two patients died of multiple organ dysfunction syndrome and renal failure complicated with infection, respectively.Postoperative complications included brain nerve dysfunction in 2 cases;renal insufficiency in 4 cases, which werelater treated with CRRT;pulmonary infection and tracheotomy in 3 cases;dysfunction in lower extremities in 1 case;hyoxemia in 3 cases;and incision infection in 2 cases.All the patients were followed up for 2-38 months, one patient was hospitalized because of hydropericardium and another one died of sudden death with unclear cause.Conclusion Surgical treatment of Stanford type A acute aortic dissection can obviously decrease the mortality and improve the quality of life.Total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta is a classic clinical surgical treatment.Precise diagnosis, suitable surgical treatment and post-operative care are all important factors contributing to patients` recovery.

Endovascular repair of Stanford type B aortic dissection: initial experience in 85 cases / 介入放射学杂志

Objective To explore the technology and curative effect of thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection.Methods The clinical data of 85 patients with Stanford type B aortic dissection,who were admitted to authors' hospital during the period from January 2010 to April 2016 to receive TEVAR,were retrospectively analyzed.Conventional left brachial artery puncture and straight incision of right femoral artery were employed in all 85 patients,and DSA of ascending aorta was performed to find out the position of rupture,the position of the true and false lumens,and their relationship with the vascular openings of important organs.Endovascular covered stent was implanted to seal off the primary rupture;reexamination of ascending aorta angiography was adopted to check the sealing-off condition of the proximal rupture and the changes of blood flow in the aortic branches as well as in the true and false lumens.Results Successful TEVAR was accomplished in 84 patients.One patient died of sudden rupture of aortic dissection during preoperative anaesthesia.The technical success rate was 100％.In 9 patients the covered stent partially overlapped the left subclavian artery,in one patient the left subclavian artery “chimney” stem completely obstructed both the left common carotid artery and the left subclavian artery,and bypass surgery between left common carotid artery and left subclavian artery was carried out in 2 patients.After the treatment,internal leakage of type Ⅰ was detected in 2 patients.No death occurred during hospitalization period.After the surgery the patients were followed up for 3 months to 3 years,and all patients survived.New rupture at the distal site occurred in 2 patients.Conclusion For the treatment of Stanford type B aortic dissection,TEVAR is safe and effective.Strict observance of surgical indications,careful operative manipulation,and strengthening postoperative management after discharge from hospital are the key points to ensure a successful surgery as well as to improve the long-term survival rate.

Clinical efficacy of interventional therapy on children with congenital heart diseases / 中国综合临床

Objective To summarize clinical outcomes of interventional therapy on children with common congenital heart diseases(CHD).Methods A retrospective study was conducted.One hundred and fourteen patients with CHD were selected as our subjects,who underwent catheter interventional therapy in the Second Affiliated Hospital of Zhengzhou University from Jan.2004 and Dec.2012.The size of occluder was chose according to intraoperative echocardiography or cardiac imaging measurements,and occluder was released under assisted monitoring by subtraction angiography or cardiac ultrasound.Results There are all together 112 patients got the therapy successfully,2 cases failed(occluder detachment),and the success rate of operation was 98.2％.After the success of interventional,echocardiography examination showed that 11 cases were with star point across shunt,but the function of the around valve was not affected.One months after operation,echocardiography examination showed star point across shunt of 11 cases were disappeared,and no occluder was shifted as well as no thrombosis formed.Three months after operation,chest radiograph showed pulmonary congestion decreases and heart shadow was shrink.Thirty-eight cases were with three tricuspid regurgitation before operation and 32 cases were without reflux at 3 months after operation,and 6 cases relieved significantly.The patients were followed up for 6 months or 3 years,activity endurance was significantly improved than that before operation.No occluder was shiftand hemolysis and arrhythmia occurred.Meanwhile,No thrombosis or embolism occurred.Conclusion Interventional treatment for children with congenital heart disease is proved as a safe,effective methods and it have broad prospects in clinical application.

A novel histamine receptor: histamine H_4 receptor / 中国药理学通报

HH 4R, a novel histamine receptor, was found in recent years. HH 4R posses unique pharmacological character and special tissue distribution,which has high homology compared with the H 3 receptor.In this article,we review various aspects of HH 4R,such as gene formation, tissue distribution, homologous analysis, signal transduction pathway, histamine ligand affinity,and so on, and preview future study on HH 4R.