Nonoperative management of gastrointestinal malignancies in era of neoadjuvant treatment

Cancers derived from the gastrointestinal(GI)tract are often treated with radical surgery to achieve a cure.However,recent advances in the management of GI cancers involve the use of a combination of neoadjuvant radiation and chemotherapy followed by surgical intervention to achieve improved local control and cure.Interestingly,a small proportion of patients with highly sensitive tumors achieved a pathological complete response(pCR)(no residual tumor cells in the resected specimen)to neoadjuvant chemoradiation therapy(nCRT).The desire for organ preservation and avoidance of surgical morbidity brings the idea of a nonoperative management(NOM)strategy.Because of the different nature of tumor biology,GI cancers present diverse responses to nCRT,ranging from high sensitivity(anal cancer)to low sensitivity(gastric/esophageal cancer).There is an increasing attention to NOM of localized GI cancers;however,without the use of biomarkers/imaging parameters to select such patients,NOM will remain a challenge.Therefore,this review intends to summarize some of the recent updates from the aspect of current nCRT regimens,criteria for patient selection and active surveillance schedules.We also hope to review significant sequelae of radical surgery and the complications of nCRT to clarify the directions for optimization of nCRT and NOM for oncologic outcomes and quality of life.

Pancreatic duct disruption and nonoperative management: the SEALANTS approach

Pancreatic-duct disruption (PDD) can be difficult to manage, with diverse etiologies and sequelae in a heterogeneous population. Common etiologies include pancreatitis, iatrogenic injury, and trauma. Sequelae of PDD include pseudocyst, pancreatic ascites,

Low serum albumin may predict poor efficacy in patients with perforated peptic ulcer treated nonoperatively

BACKGROUND Nonoperative management(NOM)is a promising therapeutic modality for patients with perforated peptic ulcer(PPU).However,the risk factors for poor efficacy and adverse events of NOM are a concern.AIM To investigate the factors predictive of poor efficacy and adverse events in patients with PPU treated by NOM.METHODS This retrospective case-control study enrolled 272 patients who were diagnosed with PPU and initially managed nonoperatively from January 2014 to December 2018.Of these 272 patients,50 converted to emergency surgery due to a lack of improvement(surgical group)and 222 patients were included in the NOM group.The clinical data of these patients were collected.Baseline patient characteristics and adverse outcomes were compared between the two groups.Logistic regression analysis and receiver operating characteristic curve analyses were conducted to investigate the factors predictive of poor efficacy of NOM and adverse outcomes in patients with PPU.RESULTS Adverse outcomes were observed in 71 patients(32.0%).Multivariate analyses revealed that low serum albumin level was an independent predictor for poor efficacy of NOM and adverse outcomes in patients with PPU.CONCLUSION Low serum albumin level may be used as an indicator to help predict the poor efficacy of NOM and adverse outcomes,and can be used for risk stratification in patients with PPU.

NonOperative Management of Blunt Solid Abdominal Organ Injury in Calabar, Nigeria

Background: Over the past several years, nonoperative management has been increasingly recommended for the care of selected blunt abdominal trauma patients with solid organ injuries. Objective: To evaluate the pattern and outcome of blunt abdominal trauma using haemodynamic stability and ultrasonography in the selection of patients for nonoperative management in a facility without computed tomogram. Methods: Patients admitted with blunt abdominal trauma between February 2005 and January 2010 were prospectively studied. Haemodynamic stability and sonography formed the basis for selecting patients for nonoperative management. Results: In total, 58 patients suffered blunt abdominal trauma and 19(33%) patients were successfully managed nonoperatively suffered blunt solid abdominal organ injuries. Road traffic accidents inflicted 17(89%) patients while 2(11%) patients sustained sports injury (football). The spleen was the commonest solid organ injured 12(60%), while the liver and kidney were injured in 6(30%) and 2(10%) respectively. Associated injuries were fractured left femur recorded in 3(16%) patients and fractured rib in a patient (5%). Conclusion: Nonoperative treatment is a safe and effective method in the management of haemodynamically stable patient with blunt solid abdominal organ injury. This translated to a reduction in hospital stay, absence of the risk of blood transfusion as well as attendant morbidity and mortality associated with laparotomy. Establishment of trauma system, provision of diagnostic and monitoring facilities, good roads, and education on road safety is recommended for improved outcome.

Follow-up strategy for early detection of delayed pseudoaneurysms in patients with blunt traumatic spleen injury: A single-center retrospective study

BACKGROUND The spleen is the most commonly injured solid organ in blunt abdominal trauma,and splenic pseudoaneurysm rupture is associated with a high risk of mortality.Nonoperative management has become the standard treatment for hemodynam-ically stable patients with splenic injuries.On the other hand,delayed splenic pseudoaneurysms can develop in any patient,and at present,there are no known risk factors that may reliably predict their occurrence.Furthermore,there is a lack of consensus regarding the most appropriate strategies for monitoring and mana-ging splenic injuries,especially lower-grade(I-III).AIM To determine the predictors of pseudo-aneurysm formation following splenic injury and develop follow-up strategies for early detection of pseudoaneurysms.METHODS We retrospectively analyzed patients who visited the Level I Trauma Center bet-ween January 2013 and December 2022 and were diagnosed with spleen injuries after blunt abdominal trauma.RESULTS Using the American Association for the Surgery of Trauma spleen injury scale,the splenic injuries were categorized into the following order based on severity:Grade I(n=57,17.6%),grade II(n=114,35.3%),grade III(n=89,27.6%),grade IV(n=50,15.5%),and grade V(n=13,4.0%).Of a total of 323 patients,35 underwent splenectomy and 126 underwent angioembolization.19 underwent delayed angioembolization,and 5 under-went both initial and delayed angioem-bolization.In 14 patients who had undergone delayed angioembolization,no extravasation or pseudoaneurysm was observed on the initial computed tomography scan.There are no particular patient-related risk factors for the formation of a delayed splenic pseudoaneurysm,which can occur even in a grade I spleen injury or even 21 days after the injury.The mean detection time for a delayed pseudoaneurysm was 6.26±5.4(1-21,median:6,inter-quartile range:2-9)days.CONCLUSION We recommend regular follow-up computed tomography scans,including an arterial and portal venous phase,at least 1 week and 1 month after injury in any grade of blunt traumatic spleen injury for the timely detection of delayed pseudoaneurysms.

Distal radial fractures——Operative versus nonoperative treatment

There is some evidence to suggest superior results of surgical treatment that includes open reduction internal fixation (ORIF) or percutaneous pin fixation (not including Kapandji pinning) to stabilize fracture fragments and improve functional ability compared with conservative treatment. However, larger studies with longer follow up are needed to verify these results.

Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy

Shoulder pain is a common musculoskeletal complaint,and rotator cuff(RC)pathologies are one of the main causes.The RC undergoes various tendinopathic and avascular changes during the aging process.Other degenerative changes affecting its healing potential make it an appealing target for biological agents.Platelet-rich plasma(PRP)has demonstrated the potential to deliver a high concentration of several growth factors and anti-inflammatory mediators,and its clinical use is mainly supported by experiments that demonstrated its positive effect on muscle,ligaments,and tendinous cells.This review aimed to specify the role of PRP and its future applications in RC tendinopathies based on the current clinical evidence.Due to the different characteristics and conflicting outcomes,clinicians should use PRP with moderate expectations until more consistent evidence is available.However,it is reasonable to consider PRP in patients with contraindications to corticosteroid injections or those with risk factors for inadequate healing.Its autologous origin makes it a safe treatment,and its characteristics make it a promising option for treating RC tendinopathy,but the efficacy has yet to be established.

经皮椎体成形术与非手术疗法治疗骨质疏松性椎体压缩骨折疗效比较的Meta分析

目的:系统评价经皮椎体成形术(percutaneous vertebroplasty,PVP)和非手术疗法治疗骨质疏松性椎体压缩骨折(osteoporotic vertebral compression fracture,OVCF)的临床疗效。方法:应用计算机检索中国知网、万方数据库、维普网、PubMed、Embase、Cochrane Library、Medline中比较PVP和非手术疗法治疗OVCF临床疗效的随机对照试验,检索时限均为建库至2022年1月。同时通过人工检索纳入文献的参考文献进行补充。手术组干预措施为PVP,非手术组干预措施为固定制动、物理治疗、口服镇痛药等非手术疗法。由2名研究人员独立筛选文献、提取数据并评价纳入研究的偏倚风险后,采用RevMan5.3软件进行Meta分析。结果:共纳入8项随机对照试验,涉及748例患者,手术组380例、非手术组368例。Meta分析结果显示,手术组治疗后的腰背部疼痛视觉模拟量表(visual analogue scale,VAS)评分低于非手术组[MD=-1.62,95%CI(-1.91,-1.32),P=0.000],其中治疗后1个月内、治疗后1~3个月和治疗后3个月以上,手术组的腰背部疼痛VAS评分均低于非手术组[MD=-1.78,95%CI(-2.63,-0.93),P=0.000;MD=-1.71,95%CI(-2.11,-1.31),P=0.000;MD=-1.29,95%CI(-1.69,-0.88),P=0.000]。手术组治疗后的欧洲骨质疏松基金会生活质量问卷(quality of life questionnaire of the European Foundation for Osteoporosis,QUALEFFO)评分低于非手术组[MD=-5.62,95%CI(-8.94,-2.30),P=0.001],其中治疗后1个月内手术组的QUALEFFO评分低于非手术组[MD=-6.25,95%CI(-11.69,-0.81),P=0.000];治疗后1~3个月和治疗后3个月以上,2组QUALEFFO评分的差异均无统计学意义[MD=-6.49,95%CI(-15.32,2.33),P=0.150;MD=-3.48,95%CI(-9.64,2.68),P=0.270]。基于治疗后疼痛VAS评分进行发表偏倚分析,Egger’s检验显示纳入的研究不存在发表偏倚(治疗后1个月内:P=0.452;治疗后1~3个月:P=0.633;治疗后3个月以上:P=0.532)。结论:PVP治疗OVCF的临床疗效优于非手术疗法。

离子型和非离子型含碘造影剂过敏反应的预防及处理原则

探讨离子型和非离子型造影剂过敏反应的预防和处理原则。对比国内外有关造影剂过敏试验的相关文献。依据美国和欧洲指南,提出造影剂过敏反应的预防和处理办法。建议使用造影剂前用该造影剂原液进行过敏试验;积极做好造影剂过敏反应的预防和处理,保障患者的生命安全。

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast followthrough and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.

603例胸部穿透伤的诊断与治疗分析

目的：总结胸部穿透伤的诊断方法和治疗经验。方法回顾性分析该院2003～2013年收治的603例穿透性胸部损伤患者的临床资料，包括损伤情况、诊断方法和治疗方式等。结果伤口部位：左前胸壁151例，左后胸134例，右前胸137例，右后胸108例，双侧胸部22例；颈根部35例，上腹部16例。C T检查453例，阳性率96．03％；X线片检查252例，阳性率71．03％；彩色超声检查93例，阳性率62．37％。手术治疗192例，其中，剖胸手术166例，胸腔镜下手术26例；非手术治疗411例。出现并发症76例，死亡20例，治愈583例，治愈率96．68％。结论胸部穿透伤应用多层螺旋C T检查能快捷明确诊断；剖胸手术切口选择应以方便处理胸内最严重、最致命伤为原则。

304例非手术食管癌T分期与生存期相关性分析

目的:探讨非手术治疗食管癌T分期与生存期的相关性。方法:对304例非手术治疗食管癌CT资料按照改良T分期标准进行分期。采用Wilcoxon检验分析T分期与生存期关系。结果:T1、T2、T3、T4中位生存期分别为53.0个月、30.6个月、17.5个月、15.7个月;经统计学检验,T1:T3,P=0.036,T1:T4,P=0.029;T2:T3,P=0.006,T2:T4,P=0.001,T1、T2期组生存率与T3、T4组比较有非常显著性差异,但T1与T2、T3与T4两两比较,T1:T2,P=0.289,T3:T4,P=0.438,无显著性差异。结论:T分期对评价及判断非手术食管癌预后有重要的临床价值,T3、T4期食管癌生存期明显较T1、T2缩短。

重症急性胰腺炎早期非手术治疗的再认识

目的 :探讨重症急性胰腺炎的早期治疗方法。方法 :对 80例急性重症胰腺炎资料分别采用早期手术治疗和早期非手术治疗的两种方法进行回顾分析 ,并对病死率及主要并发症进行总结。结果 :1992年 1月～ 1994年 12月的 2 9例患者经早期手术治疗 ,病死率和并发症发生率分别为 5 5 .2 %和 93.1% ,1995年 1月～ 2 0 0 0年 12月的 5 1例经早期非手术治疗 ,病死率和并发症发生率分别为 2 3.5 %和 5 1.0 %。两组比较差异有显著性 (P <0 .0 1)。结论 :对急性重症胰腺炎患者采用早期非手术治疗能降低病死率和并发症发生率。

加减葛根汤联合针刺治疗神经根型颈椎病的效果及安全性评价

目的观察加减葛根汤联合针刺治疗神经根型颈椎病(CSN)的疗效及安全性,阐述中药联合针刺疗法在CSN治疗中的临床意义。方法将72例神经根型颈椎病患者按照就诊顺序随机分成对照组和观察组,每组36例。对照组予加减葛根汤(葛根、防风、羌活、桑枝、当归、黄芪、白芍、茯苓、姜黄、蜈蚣)治疗,每日1剂,早晚各1次分服,7 d为1个疗程;治疗组采用加减葛根汤联合针刺(夹脊、风池、大椎、天柱、百劳、大杼、天宗、风门、肩外俞、肩井、手三里)治疗,常规刺法,每次20 min,每日1次,7 d为1个疗程。2个疗程后,计算2组治疗总有效率,比较治疗前后2组VAS、NDI变化,评价其安全性。结果治疗组总有效率为(91.7%,33/36)优于对照组(80.6%,29/36)(P<0.05)。2组VAS、NDI均较治疗前降低,且治疗组改善更为明显(P<0.05)。结论加减葛根汤联合针刺治疗神经根型颈椎病,可以明显改善患者颈痛等症状,具有较好的短期疗效,且安全性较高。

手术与非手术治疗跟骨骨折的疗效比较

[目的]探讨手术与非手术治疗跟骨骨折的疗效，便于临床选择跟骨骨折的治疗方法。[方法]总结2001年1月～2005年8月间手术治疗的跟骨骨折38例（42足），骨折类型：按Essex—Lopresti分类方法：Ⅰ型，舌形骨折6足，Ⅱ型，压缩骨折28足，Ⅲ型，严重粉碎骨折8足，手术方式均为钢板内固定（AO跟骨钢板，国产仿AO跟骨钢板），手术入路均为外侧“L”形扩大入路，术后不用石膏固定，2～3d后即行不负重功能锻炼，6～8周后逐渐负重锻炼。并与40例（42足）采用非手术方法（手法复位石膏固定、骨牵引后石膏固定）治疗的患者进行比较，所有病例随访10～36个月，平均17个月。[结果]按Maryland足部评分系统评价，并以每足为基数，手术治疗组：优良率93％，其中Ⅰ型骨折优良率为100％，Ⅱ型骨折优良率为96％，Ⅲ型骨折优良率为75％。非手术治疗组：优良率67％，其中Ⅰ型骨折优良率为92％，Ⅱ型骨折优良率为77％，Ⅲ型骨折无优良患者。[结论]跟骨骨折治疗的关键是尽可能恢复跟距、跟骰关节面的平整和跟骨的正常解剖形态。对跟骨Essex—Lopresti分类Ⅱ型和Ⅲ型骨折者，应积极采用开放复位内固定治疗，并应恰当地选择手术入路，掌握正确地骨折复位方法和术后处理。对跟骨骨折治疗方式的选择应据患者的个体状况、骨折类型等综合考虑才能达到最佳效果。

髋臼骨折的非手术疗法

报告16例髋臼骨折非手术治疗的结果,71％的病例疗效满意,不满意者为负重顶受累和头臼关系不对应的移位骨折。分析了治疗成败的原因,对非手术疗法在髋臼骨折中的作用、地位与适应证进行了讨论。

118例腰椎间盘突出症的手术和非手术治疗对比

目的 :探讨腰椎间盘突出症的手术及非手术治疗的适应证。方法 :回顾性分析 118例确诊的腰椎间盘突出症患者分为 2组。A组 (手术组 ) 6 8例确诊后 1周进行手术治疗 ,术后 1周行腰背肌功能锻炼。B组 (非手术组 ) 5 0例采用卧硬板床休息、骨盆牵引、理疗、β 七叶皂甙钠静滴 ,疼痛缓解后进行腰背肌功能锻炼。平均随访 2 .1年。结果 :手术组治愈率为 94.1% ,非手术组治愈率为 90 .0 % ,两组比较经x2 检验无显著性差异 (P >0 .0 5 )。结论 :并非所有的腰椎间盘突出症都需要手术治疗 。

超声造影在腹部实质脏器外伤非手术治疗中的作用

目的:探讨超声造影在腹部实质脏器外伤非手术治疗中的作用。材料和方法:对67例血流动力学稳定的腹部外伤患者,进行常规超声与超声造影监测随访。结果:非手术治疗成功率61例(91%),4例中转手术治愈,2例死亡。超声造影发现肝外伤性动脉瘤1例,脾外伤性动脉瘤2例。非手术治疗成功组血流动力学持续稳定,损伤区逐渐缩小。中转手术组血流动力学不稳定,超声发现腹水进行性增加。超声造影显示实质内无增强区范围增大。结论:超声造影对腹部外伤的诊断和伤情监测具有重要的价值。

颈椎力学评价指标在非手术疗法治疗神经根型颈椎病疗效评价中的应用

目的:探讨颈椎力学评价指标在非手术疗法治疗神经根型颈椎病疗效评价中的应用价值。方法:2016年10月至2017年6月,采用手法等非手术疗法治疗神经根型颈椎病患者46例。男26例、女20例,年龄(48.91±9.77)岁,体质量指数(24.57±2.99)kg·m^(-2),病程(2.32±1.97)月。病变节段,单节段11例、2节段16例、3节段10例、4节段7例、5节段2例。分别在治疗前和治疗结束后,采用颈椎功能障碍指数(neck disability index,NDI)评分量表对患者颈椎功能进行临床评价;采用DAVID脊柱智能康复系统测定患者颈椎关节活动度、颈椎关节活动协调性、颈部肌群最大等长肌力矩和颈部肌群协调性,对患者颈椎进行力学评价。计算NDI及颈椎力学评价各项指标治疗前后的差值(治疗后-治疗前),分析临床评价指标变化与颈椎力学评价指标变化之间的相关性。结果:(1)临床评价与颈椎力学评价结果。46例患者均顺利完成治疗。治疗结束后,患者颈椎NDI较治疗前降低[(34.32±13.11)%,(18.21±10.65)%,t=-11.041,P=0.000];颈椎前屈、后伸、左右侧屈、左右旋6个方向的关节活动度均较治疗前增加[(39.67°±14.04°),(48.11°±10.76°),t=4.362,P=0.000;(46.76°±12.71°),(57.48°±11.22°),t=5.523,P=0.000;(33.13°±10.58°),(40.00°±11.68°),t=4.428,P=0.000;(35.70°±8.32°),(42.80°±39.55°),t=4.356,P=0.000;(51.17°±12.93°),(56.54°±11.11°),t=3.304,P=0.002;(51.28°±11.25°),(55.63°±10.95°),t=2.715,P=0.009];颈椎关节屈伸活动协调性较治疗前改善,但侧屈和旋转活动协调性与治疗前相比,差异无统计学意义[(1.37±0.87),(0.85±0.20),t=-3.775,P=0.000;(1.15±0.36),(1.10±0.17),t=-1.074,P=0.291;(1.05±0.33),(0.99±0.14),t=-1.202,P=0.211];颈部肌群后伸、前屈及左右侧屈最大等长肌力矩均较治疗前增加[(1.00±0.00)N·m^(-1),(1.00±1.00)N·m^(-1),Z=-2.312,P=0.021;(2.00±6.25)N·m^(-1),(5.00±11.00)N·m^(-1),Z=-3.545,P=0.000;(1.00±1.25)N·m^(-1),(2.00±5.00)N·m^(-1),Z=-3.903,P=0.000;(1.00±2.00)N·m^(-1),(2.00±5.00)N·m^(-1),Z=-2.465,P=0.014];颈部肌群屈伸力量协调性较治疗前改善,而侧屈力量协调性与治疗前相比,差异无统计学意义[(2.00±5.00),(3.50±5.00),Z=-2.043,P=0.041;(1.00±0.62),(1.00±0.04),Z=-1.725,P=0.085]。(2)临床评价指标变化与颈椎力学评价指标变化的相关性分析结果。治疗前后患者NDI的差值与治疗前后颈部肌群前屈、后伸最大等长肌力矩的差值呈负相关(r=-0.455,P=0.002;r=-0.334,P=0.024),即颈部肌群前屈、后伸最大等长肌力矩增加越多,NDI降低越多;与治疗前后颈部肌群屈伸力量协调性的差值呈正相关(r=0.344,P=0.020),即颈部肌群屈伸力量协调性改善越多,NDI降低越多;与其他颈椎力学评价指标治疗前后的差值均无相关性。结论:在非手术疗法治疗神经根型颈椎病的疗效评价中应用颈椎力学评价指标,有利于疗效评价的客观化和精确化。