[A retrospective study of postoperative adjuvant therapy following immunotherapy combined with targeted therapy and sequential curative surgical procedures for initially unresectable hepatocellular carcinoma].

Objective: To report the clinical efficacy of adjuvant therapy based on pathological results following immunotherapy combined with targeted therapy and sequential curative surgical procedures in patients with initially unresectable hepatocellular carcinoma. Methods: This is a retrospective case series study. Data from 100 patients who underwent adjuvant therapy based on pathological results following immunotherapy combined with targeted therapy and sequential curative surgical procedures with long-term survival were collected from December 2018 to December 2022 at the Faculty of Hepato-Pancreato-Biliary Surgery, First Medical Center, Chinese People's Liberation Army General Hospital. According to inclusion and exclusion criteria, 47 cases were included, among which patients who met the discontinuation criteria and maintained a drug-free tumor-free status. Thirty-nine male and eight female patients were included, with an age of (54.2±18.8)years(range:38 to 73 years) at initial diagnosis. At the time of initial diagnosis, 43 cases (91.5%) were classified as Barcelona Clinic Liver Cancer stage C. Survival curves were made using Kaplan Meier method. Results: Forty-seven patients underwent R0 resection, all achieved a drug-free tumor-free state through postoperative adjuvant therapy based on pathological examination results. Thirty-six patients(76.6%) maintained a drug-free tumor-free survival status for more than 6 months,28 patients(59.6%) for more than 12 months,and 8 patients(17.0%) for more than 24 months. The longest drug-free tumor-free survival in this cohort reached 48 months. The median follow-up time in this study was 32 months. After diagnosis, the overall survival rates at 1- and 3- years were 97.7%(95%CI:93.4% to 100%) and 90.7%(95%CI:82.5% to 99.8%). The postoperative recurrence-free survival rates at 1- and 3- years were 91.0%(95%CI:83.0% to 99.8%) and 71.3%(95%CI:58.7% to 86.5%). Conclusions: The adjuvant therapy based on pathological results following immunotherapy combined with targeted therapy and sequential curative surgical approach provides long-term survival benefits for patients with initially unresectable hepatocellular carcinoma. Standardized adjuvant therapy maybe sustain long-term tumor-free status,and achieve drug-free tumor-free survival.

Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach.

BACKGROUND: Various minimally invasive approaches have been described for infected necrotizing pancreatitis. This article describes a modified minimal-access retroperitoneal pancreatic necrosectomy (MARPN) procedure assisted by gas insufflation. METHODS: This retrospective, observational study documented patients who had undergone a step-up MARPN between 1 January 2010 and 31 December 2016. A minimum follow-up of 1 year was required for inclusion. The step-up approach involved percutaneous catheter drainage followed by the modified MARPN and necrosectomy. If more than one access site was needed it was categorized as complex MARPN. RESULTS: Of 212 patients with infected necrotizing pancreatitis, 164 (77·4 per cent) underwent a step-up approach. The median number of percutaneous catheter drains and MARPN procedures was 3 (range 1-7) and 1 (1-6) respectively. Ninety patients (54·9 per cent) underwent complex MARPN. For residual necrosis after MARPN, three patients (1·8 per cent) underwent sinus tract gastroscopy, and 11 (6·7 per cent) had sinography combined with a tube change. However, operations in 13 patients (7·9 per cent) required conversion to open surgery. Postoperative complications developed in 103 patients (62·8 per cent). The mortality rate was 6·1 per cent (10 deaths). CONCLUSION: A step-up approach using a modified MARPN for infected necrotizing pancreatitis is a reasonable option.

ANTECEDENTES: Los procedimientos mínimamente invasivos se han convertido en los más frecuentes para el tratamiento de necrosis pancreáticas infectadas. El objetivo de este estudio fue presentar un procedimiento de necrosectomía pancreática retroperitoneal de acceso mínimo (minimal-access retroperitoneal pancreatic necrosectomy, MARPN) modificado y asistido mediante insuflación de gases, así como evaluar su seguridad y eficacia. MÉTODOS: Se realizó un análisis retrospectivo y observacional de los datos de un hospital desde el 1 de enero de 2010 hasta el 31 de diciembre de 2016. Se incluyeron en el análisis todos los pacientes en los que realizó un abordaje por etapas, que consistía en el drenaje percutáneo mediante la colocación de un catéter seguido de un procedimiento MARPN modificado, en los que se dispusiese de un seguimiento postoperatorio mínimo de 1 año. El MARPN en el lado derecho y la necrosectomía realizada a través de más de un acceso se clasificaron como MARPN complejo. Se evaluaron los resultados radiológicos y quirúrgicos. RESULTADOS: De 212 pacientes con necrosis pancreática infectada, en 164 (77,4%) se realizó un abordaje por etapas. La mediana del número de drenajes percutáneos y procedimientos MARPN fue 3 (rango, 1-7) y 1 (rango, 1-6), respectivamente. En 90 pacientes (54,9%) se realizó un MARPN complejo. Para la exéresis de necrosis residual después de un MARPN, en 3 pacientes (1,8%) se realizó mediante gastroscopia y en 11 pacientes (6,7%) con un recambio de drenaje bajo control radiológico. En 13 pacientes (7,9%) fue necesaria la reconversión a cirugía abierta. Hubo complicaciones postoperatorias en 103 pacientes (62,8%). La tasa de mortalidad fue del 6,1% (n = 10). CONCLUSIÓN: El abordaje por etapas con un MARPN modificado es seguro y efectivo en el tratamiento de la necrosis pancreática infectada.

Assessment of the effect of the Aquamantys® system on local recurrence after hepatectomy for hepatocellular carcinoma through propensity score matching.

OBJECTIVE: To assess the effect of the intraoperative application of the Aquamantys® system to treat the hepatic resection margin on local and overall recurrence of HCC. METHODS: We retrospectively analyzed 101 patients admitted from November 2016 to June 2018 who underwent hepatectomy using the Aquamantys® as hemostatic device, who were matched with 101 patients (control group) using conventional hemostatic devices through PSM. Univariate and multivariate analyses of recurrence-free survival (RFS) and local recurrence-free survival (LRFS) were performed using the Cox proportional hazard model. RESULTS: There were no significant differences in baseline data and surgical procedures between the two groups. The Aquamantys® group showed less blood loss (P = 0.005) and a lower blood transfusion rate (P = 0.036), while the incidences of postoperative complications of the two groups showed no difference (P = 0.266). OS rates of the Aquamantys® group and the control group were 82.6% and 84.2%, respectively (P = 0. 446), and RFS rates were 65.5% and 58.2%, respectively (P = 0.153), with no significant differences. The Aquamantys® group and the control group had two cases and 11 cases of local recurrence, respectively, with LRFS rates of 98% and 87.9%, respectively, in the follow-up period, corresponding to a significant difference (P = 0.011). Multivariate analysis showed that microvascular invasion (MVI), tumor diameter > 5 cm, and the control group were independent risk factors for LRFS. CONCLUSION: Our results indicate that application of the Aquamantys® system in hepatectomy can reduce local recurrence, but it can neither reduce overall recurrence nor improve OS.

[The clinical characteristics and surgical treatment strategy of acute gangrenous cholecystitis after biliary tract stenting].

Objective: To analysis of the possible cause and surgical diagnosis and treatment strategies of acute gangrenous cholecystitis (AGC) after biliary stent drainage. Methods: The clinical data of 273 patients who received biliary stent drainage in Beijing Chaoyang Hospital from January 2015 to March 2016 were analyzed retrospectively. Among them, 22 patients who underwent surgical treatment were divided into two groups: 9 cases of AGC group and 13 cases of non-AGC group. The risk factors of AGC and surgical approach were analyzed. Result: All 22 patients underwent laparoscopic surgery. In AGC group, 1 patient with toxic shock died of multiple organ viscera function failure caused by infection, and 1 patient with gallbladder triangle inflammatory adhesion suffered from biliary leakage. The postoperative pathology of 2 patients was acute gangrenous cholecystitis. Non-AGC group had no death, bile duct injury and bleeding, with postoperative pathology of chronic cholecystitis. Patients were followed up for 2 month to restore well, without biliary calculi residual. Operation time, intraoperative blood loss, hospitalization days and hospitalization expenses of AGC group were higher than those of non-AGC group. Conclusion: The advocated AGC after biliary stent drainage should actively surgery after early diagnosis and endoscopic therapy should not be repeated. Laparoscopic surgery is a safe and effective treatment for AGC after carotid stenting.

[Analysis of the influence of gender on the clinicopathological features and prognosis of pancreatic cystic neoplasms].

Objective: To compare the clinicopathological features and prognosis of pancreatic cystic neoplasms (PCN) between male and female patients. Methods: A total of 325 patients with histological confirmed PCN from January 2010 to October 2015 were enrolled. The clinicopathological features, laboratory examination, imaging features, treatment and prognosis were analyzed. Results: Of the 325 patients diagnosed as PCN, 104 were male and 221 were female. The average age of male patients was significantly higher than that of female patients (55.0±12.7 vs 47.9±13.4 years, P<0.001), however, the average tumor size of male patients was smaller than that of female patients (3.9±2.7 vs 4.9±3.0 cm, P=0.004). The location of PCN in male patients was predominantly located at pancreatic head and neck, and majority of male patients were mucinous cystic neoplasms. 1-year, 3-year and 5-year survival rates of patients with PCN were 98.5%, 92.6%, and 87.5%, respectively. 1-year, 3-year and 5-year survival rates of male patients were 97.8%, 84.9%, and 77.8%, however, those of female patients were 98.8%, 96.5%, and 92.2%, respectively. Female patients had better prognosis than male patients (χ2=5.543, P=0.019). Elevated CA19-9 (χ2=3.843, P=0.050), perineuronal invasion (χ2=6.250, P=0.012) and lymph node metastasis (χ2=4.529, P=0.033) were important prognostic factors for malignant mucinous cystic neoplasm. Conclusions: Male patients had low incidence of PCN, and were more common for mucinous cystic neoplasm. The long-term outcome of malignant PCN was poor. Even with complete resection, male patients still had worse prognosis. Close follow-up is recommended especially for male patients.

[Experience of minimal-access video-assisted retroperitoneal debridement in treatment of infected pancreatic necrosis].

Objective: To explore the experience of minimal-access video-assisted retroperitoneal debridement in treatment of infected pancreatic necrosis(IPN). Methods: A retrospective review was performed on 12 patients with IPN who underwent minimal-access video-assisted retroperitoneal debridement between June 2008 and June 2013 in People's Liberation Army General Hospital and First Affiliated Hospital of People's Liberation Army General Hospital, respectively.There were 10 male patients and 2 female patients aging from 33 to 55 years with mean age of(43±8)years.Pancreas infective necrosis, the serious complications of severe acute pancreatitis occurred in all of the patients among which there were 2 patients with infection after percutaneous catheter drainage(PCD)in early phase of disease, and 12 patients with spontaneous during the late phase. The technical strategies of the minimally invasive treatment mainly included PCD, minimal-access video-assisted retroperitoneal debridement, and irrigation. Results: Ten patients received PCD and the median time from onset of acute necrotizing pancreatitis to PCD was mean of 24 days(range 8-86 days). Minimal-access video-assisted retroperitoneal debridement was performed after 18 days(range 3-29 days) after PCD.Three patients died after surgery.Five patients had hemorrhage complication and 3 had colonic fistula.Pancreatic fistula occurred in 2 patients. Conclusions: The technique of minimal-access video-assisted retroperitoneal debridement has advantage and some minor disadvantage.Delayed minimal-access video-assisted retroperitoneal debridement is recommended.

Low metallothionein 1M expression association with poor hepatocellular carcinoma prognosis after curative resection.

According to the typical clinical characteristics of hepatocellular carcinoma (HCC), recurrence and prognosis can differ dramatically between patients. Using RNA sequencing, we identified differential expression of the gene metallothionein 1M (MT1M) by comparing early-recurrence HCC (N = 11), no-recurrence HCC (N = 10), and normal liver tissues (N = 5). Reverse transcription-polymerase chain reaction was employed to test MT1M expression levels in 92 HCC tissue samples from a cohort of patients with whom contact was established for post-operative follow-up. Low MT1M expression correlated with high alpha-fetoprotein levels (P = 0.017) and tumor recurrence within 24 months after surgery (P = 0.029). Recurrence rates in high- and low-MT1M groups were significantly different (MT1M cutoff point = 0.066; P = 0.008). Moreover, the disease-free survival time of patients in the former was longer than that of those in the latter (median of 20.39 vs 14.35 months, respectively; P = 0.002). Among early-stage HCC patients (Barcelona Clinic Liver Cancer stage 0/A), those with reduced MT1M expression exhibited higher recurrence rates (37.5 vs 12.1%; P = 0.023). Low MT1M expression is associated with poor HCC prognosis following curative resection, and this also applies to the early stage of this disease.

[Significance of three-dimensional reconstruction as a method of preoperative planning of laparoscopic radiofrequency ablation].

OBJECTIVE: To discuss the significance of three-dimensional reconstruction as a method of preoperative planning of laparoscopic radiofrequency ablation(LRFA). METHODS: Thirty-two cases of LRFA admitted from January 2014 to December 2015 in Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital were analyzed(3D-LRFA group). Three-dimensional(3D) reconstruction were taken as a method of preoperative planning in 3D-LRFA group.Other 64 LRFA cases were paired over the same period without three-dimensional reconstruction before the operation (LRFA group). Hepatobiliary system contrast enhanced CT scan of 3D-RFA patients were taken by multi-slice spiral computed tomography(MSCT), and the DICOM data were processed by IQQA(®)-Liver and IQQA(®)-guide to make 3D reconstruction.Using 3D reconstruction model, diameter and scope of tumor were measured, suitable size (length and radiofrequency length) and number of RFA electrode were chosen, scope and effect of radiofrequency were simulated, reasonable needle track(s) was planed, position and angle of laparoscopic ultrasound (LUS) probe was designed and LUS image was simulated.Data of operation and recovery were collected and analyzed. Data between two sets of measurement data were compared with t test or rank sum test, and count data with χ(2) test or Fisher exact probability test.Tumor recurrence rate was analyzed with the Kaplan-Meier survival curve and Log-rank (Mantel-Cox) test. RESULTS: Compared with LRFA group ((216.8±66.2) minutes, (389.1±183.4) s), 3D-LRFA group ((173.3±59.4) minutes, (242.2±90.8) s) has shorter operation time(t=-3.138, P=0.002) and shorter mean puncture time(t=-2.340, P=0.021). There was no significant difference of blood loss(P=0.170), ablation rate (P=0.871) and incidence of complications(P=1.000). Compared with LRFA group ((6.3±3.9)days, (330±102)U/L, (167±64)ng/L), 3D-LRFA group ((4.3±3.1) days, (285±102) U/L, (139±43) ng/L) had shorter post-operative stay(t=-2.527, P=0.016), less post-operation ALT changes (t=-2.038, P=0.048) and post-operative TNF-α changes(t=-2.233, P=0.027). Disease-free survival between two groups was significantly different (χ(2)=4.049, P=0.046). Disease-free survival of 12 months survival rates were 77.6% and 65.7% in 3D-LRFA group and LRFA group, respectively.The median disease-free survival was 16.0 months in LRFA group and over 24.0 months in 3D-LRFA group. CONCLUSIONS: Three-dimensional model of liver reconstruction based on image information is a powerful tool in liver surgery planning.It helps to simulate tumor location and vital tubular structure, make plan for interventional treatment, and therefore mean puncture time and operation time is shortened, influence on liver function is reduced, hospital stay is decreased and DFS is prolonged.

[Analysis of disease spectrum of biliary surgery among 30 years in a single center].

OBJECTIVE: To explore the changing trend and clinical significance of disease spectrum of biliary surgery among 30 years in PLA General Hospital. METHODS: We retrospectively analyzed the clinical data of 21 189 consecutive patients with biliary diseases in PLA General Hospital between January 1985 and December 2014 according to the inclusion criteria. Taking 5 years as a research group, all patients were divided into 6 groups, and then the 30 years of the disease spectrum of biliary surgery was described. RESULTS: (1) From January 1985 to December 2014, the PLA General Hospital performed 21 189 cases of patients with biliary surgery diseases, including 9 460 cases of male, 11 729 cases of female (female∶male=1.24∶1). The average age was 52.1±13.5 years old (6-98 years). (2) Of the all cases, the most patients was cholelithiasis, accounting for 65.26%, and gallbladder stones accounting for 53.61%. The following disease was cholangiocarcinoma, accounting for 12.79%, and hilar cholangiocarcinoma accounting for 5.95%. (3) From the perspective of disease spectrum changing trend, the proportion of patients with cholelithiasis were decreased gradually, from 74.9% to 65.2%, while the proportion of patients with cholangiocarcinoma showed a gradual upward trend, rising from 6% to 14% (P<0.05); and the proportion of bile duct cystic dilatation and gallbladder carcinoma shared a gradual increase(P<0.05), however, the variation of proportion of gallbladder polyps and biliary stricture were not statistically significant (P>0.05). (4) In patients with cholelithiasis, the proportion of patients with gallbladder stones increased gradually from 71.9% to 82%, while the proportion of patients with bile duct stones decreased gradually from 28.1% to 18%. There was no statistical significance in the proportion of different types of cholangiocarcinoma patients (P>0.05) (40% of the patients with hilar cholangiocarcinoma, 25% of the intrahepatic cholangiocarcinoma, and 35% of the extrahepatic cholangiocarcinoma). CONCLUSION: With the time changing, the disease spectrum of biliary surgery has also changed. The proportion of patients with cholelithiasis, especially the patients with bile duct stones, was declining gradually, and the proportion of patients with cholangiocarcinoma was increasing gradually.

Effect of CYP3A5 gene polymorphisms on tacrolimus concentration/dosage ratio in adult liver transplant patients.

We examined the influence of the cytochrome P450 3A5 (CYP3A5) genes in both donors and recipients on the concentration-dosage ratio (C/D) of tacrolimus in Chinese liver transplant patients. Fifty-one adult liver transplant patients who received tacrolimus were included in this study. The CYP3A5 polymorphism in donors and recipients was determined at the time of transplantation, and tacrolimus-based immunosuppressive therapy was started based on each patient's genetic constitution. The relationship between the C/D of tacrolimus for 3 months after surgery and the CYP3A5 genotype was analyzed. A stepwise regression model was used to analyze the relationship between C/D of tacrolimus and genotype, time course, age, and liver weight in liver transplant patients. Three months after liver transplantation, C/D was both affected by the CYP3A5 genotype of both the donors and the recipients. The C/D of tacrolimus in patients with the CYP3A5*1 allele or carrying CYP3A5*1 allele in the liver was lower than that in CYP3A5*3/*3 patients with the CYP3A5*3/*3 genotype in the liver (P < 0.01). The CYP3A5*1 genotype in donors as well as in patients both contributes to interindividual variation in the C/D of tacrolimus in adult liver transplantation.

Obesity is independently associated with infection in hospitalised patients with end-stage liver disease.

BACKGROUND: Infection is the most common cause of mortality in end-stage liver disease (ESLD). The impact of obesity on infection risk in ESLD is not established. AIM: To characterise the impact of obesity on infection risk in ESLD. METHODS: We evaluated the association between infection and obesity in patients with ESLD. Patients grouped as non-obese, obesity class I-II and obesity class III were studied using the Nationwide Inpatient Sample. Validated diagnostic code based algorithms were utilised to determine weight category and infections, including bacteraemia, skin/soft tissue infection, urinary tract infection (UTI), pneumonia/respiratory infection, Clostridium difficile infection (CDI) and spontaneous bacterial peritonitis (SBP). Risk factors for infection and mortality were assessed using multivariable logistic regression analysis. RESULTS: Of 115 465 patients identified, 100 957 (87.5%) were non-obese and 14 508 (12.5%) were obese, with 9489 (8.2%) as obesity class I-II and 5019 (4.3%) as obesity class III. 37 117 patients (32.1%) had an infection diagnosis. Infection was most prevalent among obesity class III (44.0%), followed by obesity class I-II (38.9%) and then non-obese (31.9%). In multivariable modelling, class III obesity (OR = 1.41; 95% CI 1.32-1.51; P < 0.001), and class I-II obesity (OR = 1.08; 95% CI 1.01-1.15; P = 0.026) were associated with infection. Compared to non-obese patients, obese individuals had greater prevalence of bacteraemia, UTI, and skin/soft tissue infection as compared to non-obese patients. CONCLUSIONS: Obesity is newly identified to be independently associated with infection in end-stage liver disease. The distribution of infection sites varies based on weight category.

Benefits of minimizing immunosuppressive dosage according to cytochrome P450 3A5 genotype in liver transplant patients: findings from a single-center study.

We evaluated the clinical efficacy of tailoring tacrolimus dosage to cytochrome P450 (CYP) 3A5 genotype in liver transplant patients. One hundred patients who received tacrolimus-based therapy were included in the retrospective study in which the relationship between the tacrolimus blood trough concentration/dosage ratio and the CYP3A5 genotype of both donors and recipients was determined. Subsequently, 106 patients were continuously enrolled in a prospective study and followed-up for 6 months; the relationship between tacrolimus dosage and CYP3A5 genotype was also determined. Rates of acute rejection, hepatotoxicity, renal toxicity, neurotoxicity, hypertension, and hyperglycemia were compared between the groups. During the 6 months following liver transplantation, the mean tacrolimus concentration/dosage ratio among patients who did not have the CYP3A5*1 genotype and who received a transplant from a donor with the same genotype (24/100, 24% of patients) was higher than that among patients who did have the CYP3A5*1 genotype and/or had a donor with the same genotype (76/100, 76% of patients). In the second part of the study, the tacrolimus dosage was tailored to CYP3A5 genotype and 24 patients (22.64%) received a lower dose. There was an obvious decrease in acute rejection, hepatotoxicity, renal toxicity, neurotoxicity, hypertension, hyperglycemia, and Pneumocystis carinii infection among the latter group. A lower tacrolimus dose was suitable for about 25% of the liver transplant patients, as these patients did not have the CYP3A5*1 genotype and received a transplant from a donor with the same genotype. Tailoring the tacrolimus dosage according to the CYP3A5 genotype could reduce rejection and adverse effects.

Model for End-Stage Liver Disease (MELD) score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients.

BACKGROUND: Acute-on-chronic liver failure (ACLF) is a severe clinical entity and liver transplantation is the only definitive therapy to salvage these patients. However, the timing of liver transplant for these patients remains unclear. METHODS: Seventy-eight patients undergoing liver transplantation because of hepatitis B ACLF were retrospectively analyzed from June 2004 to December 2010. The areas under the receiver operating characteristic curve (AUC) of Model for End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) score for the post-transplantation outcomes were calculated. RESULTS: The median age was 44 years (range, 25-64 years), serum bilirubin 418.53 µmol/L (range, 112.90-971.40 µmol/L), INR 3.177 (range, 1.470-9.850), and creatinine 70.84 µmol/L (range, 12.39-844.1 µmol/L); the median MELD score was 32 (range, 21-53) and CTP score 12 (8-15). The AUCs of MELD and CTP scores for 3-month mortality were 0.581 (95% confidence interval [CI], 0.421-0.742; sensitivity, 87.5%; specificity, 32.8%) and 0.547 (95% CI, 0.401-0.693; sensitivity, 75%; specificity, 41%), respectively. Meanwhile, there were no significant differences in hospital mortality (P = .252) or morbidity (P = .338) between the patients with MELD score ≥30 and those <30. CONCLUSIONS: MELD score had no predictive ability for the outcomes of patients with hepatitis B ACLF after orthotopic liver transplantation.

Clinical application of total parenteral nutrition in patients with peritoneal carcinomatosis.

Cancer patients with terminal stage peritoneal carcinomatosis are often unable to eat, rendering total parenteral nutrition (TPN) as the only option to avoid starvation. In this retrospective study, we reviewed the medical records of 46 patients with peritoneal carcinomatosis and compared them to the records of 51 patients who had gastrointestinal malignancy without evidence of peritoneal carcinomatosis. The factors evaluated include demographic data, cause of primary malignancy, ascites formation, anthropometric measurements, laboratory tests, and outcome measurements as well as factors associated with greater than 90-day survival. In-hospital mortality was observed in 31 of the 46 patients with peritoneal carcinomatosis, with a median survival time of 40 days (4-148 days) for all 46 patients. The median duration of TPN administration in the peritoneal carcinomatosis group was 24.1 ± 27.4 days (3-68 days). Severe infection related to TPN application was seen in 5/46 (10.7%) patients with peritoneal carcinomatosis and 6/51 (9.8%) patients without peritoneal carcinomatosis. The length of survival varied widely among terminal patients with peritoneal carcinomatosis. The average survival time in peritoneal carcinomatosis patients receiving TPN was short, indicating that the nutrition support of TPN was relatively suboptimal. Ascites was not a prognostic factor for peritoneal carcinomatosis, while body mass index was a predictor for 90-day survival.

Tubular stomach or whole stomach for esophagectomy through cervico-thoraco-abdominal approach: a comparative clinical study on anastomotic leakage.

BACKGROUND: Esophagectomy through cervico-thoraco-abdominal approach is a useful surgical technique in treating patients with esophageal cancer. However, the cervical reconstruction is also known to have a high rate of anastomotic leakage, as well as anastomotic stricture, intrathoracic stomach syndrome, reflux esophagitis and other complications, thereby influencing postoperative recovery and quality of life. AIMS: The objective of this study was to investigate whether tubular stomach is superior to whole stomach in reducing anastomotic leakage for esophageal reconstruction through the cervico-thoraco-abdominal (3-field) approach. METHODS: A total of 850 patients undergoing the 3-field esophagectomy were retrospectively included in this study and divided into a tubular stomach reconstruction group (Group A, n=453) and a whole stomach reconstruction group (Group B, n=397). All patients underwent esophagectomy through right thorax, left cervical part, abdominal triple incisions and done in esophageal reconstruction by hand-sewn two-layer anastomosis. RESULTS: Results revealed that in comparison with whole stomach, esophageal reconstruction with tubular stomach had a lower incidence of anastomotic leakage (5.5 vs. 9.3%, P<0.05), less manifestation of intrathoracic syndrome (3.3 vs. 9.8%, P<0.001) and less occurence of reflux esophagitis (5.1 vs. 11.1%, P<0.01). However, for the incidence of anastomotic stricture, there was no significant difference between the two groups (9.3 vs. 9.8%). CONCLUSIONS: This observation study suggests that for esophageal cancer patients undergoing the 3-field esophagectomy tubular stomach is better than whole stomach for esophageal reconstruction as reflected by a reduced postoperative anastomotic leakage, intrathoracic syndrome and reflux esophagitis.

Human leucocyte antigen-Bw4 and Gag-specific T cell responses are associated with slow disease progression in HIV-1B-infected anti-retroviral therapy-naive Chinese.

In China, the majority of human immunodeficiency virus (HIV) infections are predominately subtype B. It is important to characterize the HIV-1 subtype B-specific and its T cell response within the Chinese population, with the aim of identifying protective correlates of immunity to control HIV-1 infections. In this study, we performed a comprehensive analysis looking into the magnitude/strength of T cell responses directed at the Gag protein of the HIV-1 subtype B, one of the most conserved HIV-1 proteins. The study group consisted of anti-retroviral native and chronic HIV-1 subtype B-infected individuals. We used enzyme-linked immunospot (ELISPOT) assay to quantify the total T cell responses to HIV-1 Gag at the single peptide level. Twenty-eight (38%) peptides were recognized in 24 (82·8%) individuals. The p24 was identified as the most frequently recognized subunit protein with the greatest T cell response in the test, which correlated positively with CD4(+) T cell count and inversely with viral load (VL). At the level of the human leucocyte antigen (HLA) supertypes, we detected the highest levels and a significant correlation with both the CD4(+) T cell count and the VL with Gag T cell responses in Bw4/Bw4. These findings demonstrate that (i) the HIV-1B Gag p24-specific immune responses play an important role in controlling viral replication and slowing clinical progression; and (ii) HLA-Bw4/Bw4 allele has stronger T cell responses, which is associated with slow clinical progression in Chinese HIV patients.

Obesity-dependent metabolic signatures associated with nonalcoholic fatty liver disease progression.

Our understanding of the mechanisms by which nonalcoholic fatty liver disease (NAFLD) progresses from simple steatosis to steatohepatitis (NASH) is still very limited. Despite the growing number of studies linking the disease with altered serum metabolite levels, an obstacle to the development of metabolome-based NAFLD predictors has been the lack of large cohort data from biopsy-proven patients matched for key metabolic features such as obesity. We studied 467 biopsied individuals with normal liver histology (n=90) or diagnosed with NAFLD (steatosis, n=246; NASH, n=131), randomly divided into estimation (80% of all patients) and validation (20% of all patients) groups. Qualitative determinations of 540 serum metabolite variables were performed using ultraperformance liquid chromatography coupled to mass spectrometry (UPLC-MS). The metabolic profile was dependent on patient body-mass index (BMI), suggesting that the NAFLD pathogenesis mechanism may be quite different depending on an individual's level of obesity. A BMI-stratified multivariate model based on the NAFLD serum metabolic profile was used to separate patients with and without NASH. The area under the receiver operating characteristic curve was 0.87 in the estimation and 0.85 in the validation group. The cutoff (0.54) corresponding to maximum average diagnostic accuracy (0.82) predicted NASH with a sensitivity of 0.71 and a specificity of 0.92 (negative/positive predictive values=0.82/0.84). The present data, indicating that a BMI-dependent serum metabolic profile may be able to reliably distinguish NASH from steatosis patients, have significant implications for the development of NASH biomarkers and potential novel targets for therapeutic intervention.

Correlation between expression of S100A4 and VEGF-C, and lymph node metastasis and prognosis in gastric carcinoma.

This semiquantitative immunohistochemical study investigated the clinical significance of S100A4 and vascular endothelial growth factor C (VEGF-C) protein expression in gastric carcinoma. Correlations between S100A4 and VEGF-C immunoreactivity and clinicopathological characteristics were evaluated using 108 gastric carcinoma specimens and 20 specimens of tissue adjacent to gastric carcinoma. S100A4 and VEGF-C expression in carcinoma was higher than that in adjacent tissues. S100A4 expression was significantly related to tumour size and lymph node metastasis, whereas VEGF-C expression was associated with invasion depth, lymph node metastasis and tumour, node, metastasis (TNM) stage. A significant correlation was found between S100A4 and VEGF-C expression. Patients expressing S100A4 or VEGF-C showed no significant reduction in 5-year survival rate compared with those not expressing these proteins. Sex, age, tumour size, invasion depth, lymph node involvement, TNM stage, S100A4 expression and VEGF-C expression had a common effect on carcinoma prognosis but none was an independent prognostic factor.

Beneficial response to gabapentin portraying with interval change of brain SPECT imaging in a case with failed back surgery syndrome.

WHAT IS KNOWN AND OBJECTIVE: Failed back surgery syndrome (FBSS) is a well-recognized consequence of surgery of the lumbar spine. Here, we present a case with FBSS associated neuropathic pain. CASE SUMMARY: During hospital stay, the patient was stabilized with gabapentin 200 mg twice a day and this was titrated to a dose of 1200 mg per day over the period of 1 week. The treatment produced a substantial reduction in his episodic pain. We assessed regional cerebral blood flow (rCBF) by using brain single photon emission computed tomography (SPECT) scans, which were performed before and after gabapentin treatment 1 week later. The examination of the first SPECT showed decreased uptake in left fronto-temporal-parietal region. The latter one showed much improvement of the above areas. WHAT IS NEW AND CONCLUSION: The gabapentin has beneficial effect in the FBSS associated neuropathic pain. Besides, this case suggests the association between rCBF and pain associated with FBSS, as well as the association of gabapentin and altered blood flow of brain cortex.

Methylprednisolone worsening neuropathic pain in non-traumatic thoracic myelopathy.

Methylprednisolone (MP) is the only neuroprotective medication currently in widespread use for the treatment of spinal cord injury. Increasingly, published studies challenge its clinical effects in view of its serious side-effects including wound infection, pneumonia, sepsis and steroid myopathy. Most cases with spontaneous spinal epidural haematoma (SSEH) need emergency evacuation, and typically show good neurologic recovery. Some patients with SSEH given preoperative or postoperative MP within hours of the onset of symptoms, and have had good motor recovery, although no mention was made of sensory function. Severe, intractable neuropathic pain has not been reported in patients with SSEH. We present a case of SSEH treated with a high-dose MP 16 h after onset of symptoms. Surgical decompression was performed 1 h after MP treatment. Motor recovery was good; however, intractable neuropathic pain developed 5 weeks postoperatively. We discuss the factors contributing to intractable pain. We speculate that the severe, intractable pain might be due to misuse of large-dose steroids in this case of non-traumatic spinal myelopathy, and not because of the injury per se.