Efficacy of transanal hand-sewn reinforcement in low rectal stapled anastomosis in preventing anastomotic leak after transanal total mesorectal excision / 中华胃肠外科杂志

Objective: To explore the efficacy and feasibility of transanal hand-sewn reinforcement of low stapled anastomosis in preventing anastomotic leak after transanal total mesorectal excision (taTME). Methods: A descriptive cohort study was conducted. Clinical data of 51 patients with rectal cancer who underwent taTME with transanal hand-sewn reinforcement of low stapled anastomosis at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to December 2020 were retrospectively collected. Inclusion criteria: (1) age >18 years old; (2) rectal cancer confirmed by preoperative pathology; (3) distance from tumor to anal verge ≤ 8 cm according to pelvic MR; (4) the lesion was evaluated to be resectable before operation; (5) with or without neoadjuvant chemotherapy and radiotherapy; (6) taTME, end-to-end stapled anastomosis, and reinforcement in the anastomosis with absorbable thread intermittently were performed, and the distance between anastomosis and anal verge was ≤ 5 cm. Exclusion criteria: (1) previous history of colorectal cancer surgery; (2) emergency surgery due to intestinal obstruction, bleeding or perforation; (3) patients with local recurrence or distant metastasis; (4) the period of postoperative follow-up less than 3 months. The procedure of transanal hand-sewn reinforcement was as follows: firstly, no sign of bleeding was confirmed after checking the anastomosis. Then, the anastomosis was reinforced by suturing the muscle layer of rectum intermittently in a figure-of-eight manner using 3-0 single Vicryl. The entry site of the next suture was close next to the exit site of the last one. Any weak point of the anastomosis could also be reinforced according to the specimen from the circular stapler. The primary outcome were the incidence of anastomotic leak, methods of the secondary operation, anastomotic infection, anastomotic stricture, and conditions of Intraoperative and postoperative. Results: All the 51 enrolled patients completed surgery successfully without any conversion to open surgery. The median operative time was 169 (109-337) minutes, and the median intraoperative blood loss was 50 (10-600) ml. The median postoperative hospital stay was 8 (5-16) days. The mssorectum was complete and distal resection margin was negative in all patients. Postive circumferential resection margin was observed in 1 patients (2.0%). Twelve (23.5%) patients underwent prophylactic ileostomy. One patient developed anastomosis stricture which was cured by digital dilatation of the anastomosis. ISREC grade C anastomotic leak was observed in 3 (5.9%) male patients, of whom 2 cases did not received prophylactic ileostomy during the operation, and were cured by a second operation with the ileostomy and anastomotic repair. The other one healed by transanal repair of the anastomosis and anti-infection therapy. One (2.0%) patient suffered from perianal infection and healed by sitz bath and anti-infection therapy. No death was reported within 30 days after operation. Conclusion: Transanal hand-sewn reinforcement in low rectal stapled anastomosis in preventing anastomotic leak after taTME is safe and feasible.

Incidence and mortality risk factors of acute kidney injury in critical ill pregnancies: a single center retrospective analysis / 中华危重病急救医学

Objective To evaluate the incidence and mortality risk factors of pregnancy-related acute kidney injury (PR-AKI) in intensive care unit (ICU). Methods A retrospective analysis was conducted. Critically ill pregnancies admitted to ICU of Shandong University Affiliated Provincial Hospital from January 1st, 2012 to December 31st, 2016 were enrolled. Based on the Kidney Disease: Improving Global Outcomes (KDIGO)-acute kidney injury (AKI) criteria, patients were divided into two groups: PR-AKI group and non-PR-AKI group. Clinical characteristics and laboratory data of two groups were compared. Risk factors of incidence and mortality of PR-AKI patients were analyzed, and the receiver operating characteristic (ROC) curve was drawn to evaluate the value of these risk factors in predicting mortality of PR-AKI patients in ICU. Results ①A total of 219 pregnancies in ICU were included in the analysis, 85 cases (38.8％) were diagnosed with PR-AKI, with 29.4％ in AKI stage 1, 27.1％ in AKI stage 2 and 43.5％ in AKI stage 3. ②Nineteen of 219 critically ill pregnancies died in ICU, the total ICU mortality was 8.7％. The mortality of PR-AKI group was higher than non-PR-AKI group (16.5％ vs. 3.7％, P = 0.003). The mortality was worsened with increasing severity of AKI (4.0％ for AKI stage 1, 4.3％ for AKI stage 2, 32.4％ for AKI stage 3). ③Acute fatty liver of pregnancy (AFLP) and lactate (Lac) were the independent risk factors for PR-AKI [AFLP: odds ratio (OR) = 6.081, 95％ confidence interval (95％CI) was 1.587-23.308, P = 0.008; Lac: OR = 1.460, 95％CI was 1.078-1.977, P = 0.014]. ④ Age, Lac, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) and sequential organ failure assessment (SOFA) were the independent risk factors associated with the mortality of PR-AKI patients in ICU (age: OR = 1.130, 95％CI was 1.022-1.249, P = 0.017; Lac: OR = 1.198, 95％CI was 1.009-2.421, P = 0.039; APACHEⅡ: OR = 1.211, 95％CI was 1.102-1.330, P < 0.001; SOFA: OR = 1.411, 95％CI was 1.193-1.669, P < 0.001). ⑤ ROC curve analysis showed that age, Lac, APACHEⅡscore and SOFA score all had good predictive values for in-hospital mortality among PR-AKI patients in ICU, the cut-off value was 29 years old, 3.8 mmol/L, 16 and 8, respectively, and the AUC was 0.751, 0.757, 0.892 and 0.919, respectively (all P < 0.01). Conclusions The incidence and mortality of PR-AKI of critically ill pregnancies in ICU are high. Increased age, Lac, APACHEⅡ score and SOFA score are independent risk factors associated with the mortality of PR-AKI patients in ICU, and have good predictive values for prognosis.

Incidence and mortality risk factors of acute kidney injury in critical ill pregnancies: a single center retrospective analysis / 中华危重病急救医学

Objective@#To evaluate the incidence and mortality risk factors of pregnancy-related acute kidney injury (PR-AKI) in intensive care unit (ICU).@*Methods@#A retrospective analysis was conducted. Critically ill pregnancies admitted to ICU of Shandong University Affiliated Provincial Hospital from January 1st, 2012 to December 31st, 2016 were enrolled. Based on the Kidney Disease: Improving Global Outcomes (KDIGO)-acute kidney injury (AKI) criteria, patients were divided into two groups: PR-AKI group and non-PR-AKI group. Clinical characteristics and laboratory data of two groups were compared. Risk factors of incidence and mortality of PR-AKI patients were analyzed, and the receiver operating characteristic (ROC) curve was drawn to evaluate the value of these risk factors in predicting mortality of PR-AKI patients in ICU.@*Results@#①A total of 219 pregnancies in ICU were included in the analysis, 85 cases (38.8%) were diagnosed with PR-AKI, with 29.4% in AKI stage 1, 27.1% in AKI stage 2 and 43.5% in AKI stage 3. ②Nineteen of 219 critically ill pregnancies died in ICU, the total ICU mortality was 8.7%. The mortality of PR-AKI group was higher than non-PR-AKI group (16.5% vs. 3.7%, P = 0.003). The mortality was worsened with increasing severity of AKI (4.0% for AKI stage 1, 4.3% for AKI stage 2, 32.4% for AKI stage 3). ③Acute fatty liver of pregnancy (AFLP) and lactate (Lac) were the independent risk factors for PR-AKI [AFLP: odds ratio (OR) = 6.081, 95% confidence interval (95%CI) was 1.587-23.308, P = 0.008; Lac: OR = 1.460, 95%CI was 1.078-1.977, P = 0.014]. ④ Age, Lac, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) and sequential organ failure assessment (SOFA) were the independent risk factors associated with the mortality of PR-AKI patients in ICU (age: OR = 1.130, 95%CI was 1.022-1.249, P = 0.017; Lac: OR = 1.198, 95%CI was 1.009-2.421, P = 0.039; APACHEⅡ: OR = 1.211, 95%CI was 1.102-1.330, P < 0.001; SOFA: OR = 1.411, 95%CI was 1.193-1.669, P < 0.001). ⑤ ROC curve analysis showed that age, Lac, APACHEⅡscore and SOFA score all had good predictive values for in-hospital mortality among PR-AKI patients in ICU, the cut-off value was 29 years old, 3.8 mmol/L, 16 and 8, respectively, and the AUC was 0.751, 0.757, 0.892 and 0.919, respectively (all P < 0.01).@*Conclusions@#The incidence and mortality of PR-AKI of critically ill pregnancies in ICU are high. Increased age, Lac, APACHEⅡ score and SOFA score are independent risk factors associated with the mortality of PR-AKI patients in ICU, and have good predictive values for prognosis.

SARM: a novel Toll-like receptor adaptor, is functionally conserved from arthropod to human.

Sterile-alpha and Armadillo motif containing protein (SARM) was recently identified as the fifth member of the Toll-like receptor (TLR) adaptor family. Whilst the Caenorhabditis elegans SARM homologue, TIR-1, is crucial for efficient immune responses against bacterial infections, human SARM was demonstrated to function as a specific inhibitor of TRIF-dependent TLR signaling. The opposing role of SARM in C. elegans and human is intriguing, prompting us to seek clarification on the enigmatic function of SARM in an ancient species which relies solely on innate immunity for survival. Here, we report the discovery of a primitive but functional SARM (CrSARM) in the immune defense of a "living fossil", the horseshoe crab, Carcinoscorpius rotundicauda. CrSARM shares numerous signature motifs and displays significant homology with vertebrate and invertebrate SARM homologues. CrSARM downregulates TRIF-dependent TLR signaling suggesting the conservation of SARM function from horseshoe crab to human. During infection by Pseudomonas aeruginosa, CrSARM is rapidly upregulated within 3h and strongly repressed at 6h, coinciding with the timing of bacterial clearance, thus demonstrating its dynamic role in innate immunity. Furthermore, yeast-two-hybrid screening revealed several potential interaction partners of CrSARM implying the role of SARM in downregulating TLR signaling events. Altogether, our study shows that, although C. elegans SARM upregulates immune signaling, its disparate role as a suppressor of TLR signaling, specifically via TRIF and not MyD88, is well-conserved from horseshoe crab to human.