肛垫悬吊手术在重度痔疮治疗中的效果及并发症发生率研究

本文旨在探讨肛垫悬吊术在治疗重度痔疮中的疗效及其并发症发生率。方法,我们从我院肛肠科筛选出60名接受手术治疗的重度痔疮患者,采用随机分组的方法,将他们分为对照组(30例)和观察组(同样30例),两组分别接受了传统的外剥内扎术和肛垫悬吊手术。结果,观察组术后并发症的发生率显著低于对照组,这一差异具有统计学意义(P<0.05)。此外,观察组在手术后的临床总有效率上也明显优于对照组,这一发现同样具有统计学显著性(P<0.05)。结论,肛垫悬吊术在治疗重度痔疮方面的临床表现出了明显的优点,不仅疗效显著,而且并发症的发生率相对较低。因此,对于重度痔疮的治疗,肛垫悬吊手术可能是一种更为优选的策略。治疗安全性高,值得临床使用。

雷诺昔芬可增加骨密度并降低骨质疏松症的发病率

两个随机试验结果显示,健康绝经后妇女经雷诺昔芬(Raloxifene)治疗5年可保持骨密度(BMD),并可降低骨质疏松症的发病率。雷诺昔芬是选择性雌激素受体调节剂(SERM),用来预防和治疗绝经后妇女的骨质疏松症。与其他通过雌激素受体而起作用的药物如雌激素和他莫昔芬不同,雷诺昔芬不刺激子宫内膜。一项早期的研究结果已显示:使用雷诺昔芬治疗3年可增加BMD。

EUS-guided drainage is more successful in pancreatic pseudocysts compared with abscesses

AIM: To compare the results for endoscopic ultrasound (EUS)-guided drainage of clear fluid pancreatic pseudocysts with the results for abscess drainage. METHODS: All patients referred for endoscopic drainage of a fluid collection were prospectively included. The outcome was recorded. RESULTS: Altogether 26 pseudocysts or abscesses were treated in 25 (6 female) patients. One endoscopist performed the procedures. Non-infected pseudocysts were present in 15 patients and 10 patients had infected fluid collections. The cyst size ranged between 28 cm × 13 cm and 5 cm × 5 cm. The EUS drainage was successful in 94% of the pseudocysts and in 80% of the abscesses (P = 0.04). The complication rate in pseudocysts was 6% and in abscesses was 30% (P = 0.02). Recurrence of a pseudocyst occurred in one patient (4%) after 6 mo; the patient was successfully retreated. CONCLUSION: EUS-guided drainage of pseudocysts is associated with a higher success rate and a lower complication rate compared with abscess drainage.

Prognostic factors for 5-year survival after local excision of rectal cancer

AIM:To evaluate the prognostic factors for 5-year survival after local excision of rectal cancer,and to examine the therapeutic efficacy and surgical indications for this procedure. METHODS:Clinical data,obtained from 106 local rectal cancer excisions performed between January 1980 and December 2005,were retrospectively analyzed.Survival analysis was performed using the Kaplan-Meier method,statistical comparisons were performed using the log-rank test,and multivariate analysis was performed using the Cox proportional hazards model. RESULTS:Transanal,transsacral,and transvaginal excisions were performed in 92,12,and 2 cases, respectively.The rate of complication,local recurrence, and 5-year survival was 6.6%,17.0%,and 86.7%, respectively.Univariate analysis showed that T stage, vascular invasion,and local recurrence were related to the prognosis of the cases(P<0.05).Multivariate analysis showed that T stage[P=0.011,95% confidence interval(CI)=1.194-3.878]and local recurrence(P=0.022,95%CI=1.194-10.160)were the major prognostic factors for 5-year survival of cases after local excision of rectal cancer. CONCLUSION:Local rectal cancer excision is associated with few complications,and suitable for stages Tis and T1 rectal cancer.Prevention of local recurrence,active postoperative follow-up,and administration of salvage therapy are the effective methods to increase the efficacy of local excision of rectal cancer.

Endoscopic submucosal dissection of a rectal carcinoid tumor using grasping type scissors forceps

Endoscopic submucosal dissection （ESD） with a knife is a technically demanding procedure a ssociated with ahigh complication rate. The shortcomings of this meth-od are the inability to fix the knife to the target lesion,and compression of the lesion. These can lead to major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps （GSF）,which can grasp and incise the targeted tissue using electrosurgical current. Colonoscopy on a 55-year-old woman revealed a 10-ram rectal submucosal nodule.The histological diagnosis of the specimen obtained by biopsy was carcinoid tumor. Endoscopic ultrasonog-raphy demonstrated a hypoechoic solid tumor limitedto the submucosa without lymph node involvement. Itwas safely and accurately resected without unexpectedincision by ESD using a GSF. No delayed hemorrhage or perforation occurred. Histological examination confirmed the carcinoid tumor was completely excisedwith negative resection margin.

Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery： a contemporary and practical review

Research to date indicates that the number of coronary artery bypass graft （CABG） surgery patients affected by depression （i.e., major, minor, dysthymia） approximates between 30% and 40% of all cases. A longstanding empirical interest on psychosocial factors in CABG surgery patients highlights an association with increased risk of morbidity in the short and longer term. Recent evidence suggests that both depression and anxiety increase the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood. Though neither depression nor anxiety seem to markedly affect neuropsy- chological dysfunction, depression confers a risk for incident delirium. Following a comprehensive overview of recent literature, practical advice is described for clinicians taking into consideration possible screening aids to improve recognition of anxiety and depression among CABG surgery patients. An overview of contemporary interventions and randomized, controlled trials are described, along with suggestions for future CABG surgery research.

Role of gastrin-peptides in Barrett's and colorectal carcinogenesis

Gastrin is the main hormone responsible for the stimulation of gastric acid secretion;in addition,gastrin and its derivatives exert proliferative and antiapoptotic effects on several cell types.Gastrin synthesis and secretion are increased in certain situations,for example,when proton pump inhibitors are used.The impact of sustained hypergastrinemia is currently being investigated.In vitro experiments and animal models have shown that prolonged hypergastrinemia may be related with higher cancer rates;although,this relationship is less clear in human beings.Higher gastrin levels have been shown to cause hyperplasia of several cell types;yet,the risk for developing cancer seems to be the same in normo-and hypergastrinemic patients.Some tumors also produce their own gastrin,which can act in an autocrine manner promoting tumor growth.Certain cancers are extremely dependent on gastrin to proliferate.Initial research focused only on the effects of amidated gastrins,but there has been an interest in intermediates of gastrin in the last few decades.These intermediates aren't biologically inactive;in fact,they may exert greater effects on proliferation and apoptosis than the completely processed forms.In certain gastrin overproduction states,they are the most abundant gastrin peptides secreted.The purpose of this review is to examine the gastrin biosynthesis process and to summarize the results from different studies evaluating the production,levels,and effects of the main forms of gastrin in different overexpression states and their possible relationship with Barrett's and colorectal carcinogenesis.

Donor safety in adult living donor liver transplantation using the right lobe: Single center experience in China

AIM: To evaluate the safety of donors in adult living donor liver transplantation (LDLT) using the right lobe in a single liver transplantation center in China. METHODS: We investigated retrospectively 52 living donor liver resections performed from October 2003 to July 2006. All patients were evaluated by blood tests and abdominal CT. The mean donor age was 28.2 ± 7.4 years. Residual liver volume was 42.1% ± 4.7%. Mean operative time was 420 ± 76.2 min; mean ICU stay, less than 36 h; mean hospital stay, 16.4 ± 8.6 d; and mean follow-up period, 6 mo. RESULTS: There was no mortality. The overall complication rate was 40% (21 donors). Major complications included biliary leak in two, and pneumonia in 2 donors. Minor complications included mild pleural effusion in 12 donors, transient ascites in 6, mild depression in 4, intra-abdominal collections in 2, and wound infections in 1 donor. Residual liver volume did not affect the complication rate. None required re- operation. Return to pre-donation activity occurred within 5-8 wk. CONCLUSION: Right hemi-hepatectomy can be performed safely with minimal risk in cases of careful donor selection. Major complications occurred in only 7.7% of our series.

Appendiceal mass:Is interval appendicectomy “something of the past” ?

The need for interval appendicectomy (I.A) after successful conservative management of appendiceal mass has recently been questioned.Furthermore,emergency appendicectomy for appendiceal mass is increasingly performed with equal success and safety to that performed in non-mass forming acute appendicitis.There is an increasing volume of evidence-although mostly retrospective-that if traditional conservative management is adopted,there is no need for routine I.A except for a small number of patients who continue to develop recurrent symptoms.On the other hand,the routine adoption of emergency laparoscopic appendicectomy (LA) in patients presenting with appendiceal mass obviates the need for a second admission and an operation for I.A with a considerable complication rate.It also abolishes misdiagnoses and deals promptly with any unexpected ileo-cecal pathology.Moreover,it may prove to be more cost-effective than conservative treatment even without I.A due to a much shorter hospital stay and a shorter period of intravenous antibiotic administration.If emergency LA is to become the standard of care for appendiceal mass,I.A will certainly become 'something' of the past.

Severe acute pancreatitis in the elderly: Etiology and clinical characteristics

AIM: To investigate the etiology and clinical characteristics of severe acute pancreatitis (SAP) in elderly patients (≥ 60 years of age). METHODS: We reviewed retrospectively all the SAP cases treated in Xuanwu Hospital in Beijing between 2000 and 2007. RESULTS: In 169 patients with SAP, 94 were elderly and 16 died. Biliary and idiopathic etiologies were the first two causes that accounted for over 90% of SAP in the elderly. Biliary, hyperlipemic and alcoholic etiologies were the first three causes in the young. The proportion of co- morbidity of cholelithiasis, biliary infection, hypertension and coronary heart disease in the aged was significantly higher than that in their young partners. The scores of APACHE Ⅱ and Ranson were also significantly higher in the elderly except the CT score. Organ failures were more common in the elderly, but the local pancreatic complications were not different between the two groups. Mortality of the aged was correlated with the severity of SAP, multiple co-morbidity and incidence of multiple organ dysfunction syndrome (MODS). MODS was the main cause of death. CONCLUSION: The etiology of SAP in the elderly is quite different from that in the young. Biliary and unknown factors are main causes in the aged. The elderly are subject to major organ failures but there is no difference in the occurrence of local pancreatic complications between the elderly and the young. It is crucial to monitor and improve the functions of major organs so as to prevent MODS in the aged with SAP.

The treatment of relapsing primary nephrotic syndrome in children

Objective: To explore better therapy and reduce the rate of re-relapse of primary nephritic syndrome in children who had been treated with corticosteroids but relapsed. Methods: Eighty relapsers were enrolled from Jan. 1994 to Apr. 2000, who were randomly divided into two groups. The treatment group (n=39) had been treated with tripterysium glucosides for three months,with the control group (n=41) members were treated with cyclophosphmide (CTX) by intermission intravenous pulse, with total dose of CTX not being more than 150 mg/kg. Prednisone, meanwhile, was given to both groups. The total treatment period of prednisone was prolonged by 12-18 months. Results: After following up for 3-7 years, the re-relapse rates of both groups were observed. The re-relapse rate of the treatment group was 28.2% to 29.3% in the CTX-controlled group. The re-relapse rates between two groups were almost similar, and with no observed significant difference (P>0.05). The side effect of tripterysium glucosides was less than that of CTX. Conclusion: For the treatment of relapsing nephritic syndrome in children, the combination of tripterysium glucosides and prolonged corticosteroid therapy is as effective as the regimen of CTX plus prolonged use of prednisone.

Extracorporeal shock wave lithotripsy for pancreatic and large common bile duct stones

Extraction of large pancreatic and common bile duct(CBD)calculi has always challenged the therapeutic endoscopist.Extracorporeal shockwave lithotripsy(ESWL)is an excellent tool for patients with large pancreatic and CBD calculi that are not amenable to routine endotherapy.Pancreatic calculi in the head and body are targeted by ESWL,with an aim to fragment them to<3 mm diameter so that they can be extracted by subsequent endoscopic retrograde cholangio-pancreatography(ERCP).In our experience,complete clearance of the pancreatic duct was achieved in 76% and partial clearance in 17%of 1006 patients.Short-term pain relief with reduction in the number of analgesics ingested was seen in 84%of these patients.For large CBD calculi,a nasobiliary tube is placed to help target the calculi,as well as bathe the calculi in salinea simple maneuver which helps to facilitate fragmenta-tion.The aim is to fragment calculi to<5 mm size and clear the same during ERCP.Complete clearance of the CBD was achieved in 84.4%of and partial clearance in 12.3%of 283 patients.More than 90%of the patients with pancreatic and biliary calculi needed three or fewer sessions of ESWL with 5000 shocks being de-livered at each session.The use of epidural anesthesia helped in reducing patient movement.This,together with the better focus achieved with newer third-gen-eration lithotripters,prevents collateral tissue damage and minimizes the complications.Complications in our experience with nearly 1300 patients were minimal,and no extension of hospital stay was required.Similar rates of clearance of pancreatic and biliary calculi with minimal adverse effects have been reported from the centers where ESWL is performed regularly.In view of its high efficiency,non-invasive nature and low complication rates,ESWL can be offered as the first-line therapy for selected patients with large pancreatic and CBD calculi.

Comparison of Cancer Incidence between China and the USA

Objective The incidence of cancer varies around the globe,especially between less-developed and developed regions.The aim of this study is to explore differences in cancer incidence between China and the USA. Methods Data were obtained from the GLOBOCAN 2008 database.Estimated numbers of new cancer cases in the USA were obtained from the American Cancer Society,while the numbers of cases in China,including those in urban and rural areas,were obtained from 36 cancer registries(2003-2005).Cancer incidence for major sites between China and the USA were analyzed. Results In China,lung cancer was the predominant type of cancer detected in males;in females,breast cancer was the main type of cancer.Gastrointestinal cancers,such as those of the liver,stomach,and esophagus,were more commonly seen in China than in the USA.A significant difference in the incidence of melanoma of the skin was observed between China and the USA.During comparison of differences in the age-standardized rates by world population(ASRWs) of major cancer sites between the two countries,4 sites in males(i.e.,nasopharynx,esophagus,stomach,and liver) and 6 sites in females(i.e.,nasopharynx,esophagus,stomach,liver, gallbladder,and cervix uteri) showed higher cancer incidence rates in China than in the USA. Conclusions Significant differences in cancer incidence sites were found between the two countries.Cancer may be prevented through public education and awareness.Programs to promote cancer prevention in China,especially those of the lung,breast,and gastrointestinal region,must also be implemented.

Impact of medical therapies on inflammatory bowel disease complication rate

Crohn's disease and ulcerative colitis are progressive diseases associated with a high risk of complications over time including strictures,fistulae,perianal complications,surgery,and colorectal cancer.Changing the natural history and avoiding evolution to a disabling disease should be the main goal of treatment.In recent studies,mucosal healing has been associated with longer-term remission and fewer complications.Conventional therapies with immunosuppressive drugs are able to induce mucosal healing in a minority of cases but their impact on disease progression appears modest.Higher rates of mucosal healing can be achieved with anti-tumor necrosis factor therapies that reduce the risk of relapse,surgery and hospitalization,and are associated with perianal fistulae closure.These drugs might be able to change the natural history of the disease mainly when introduced early in the course of the disease.Treatment strategy in inflammatory bowel diseases should thus be tailored according to the risk that each patient could develop disabling disease.

Celiac disease:Prevalence,diagnosis,pathogenesis and treatment

Celiac disease(CD) is one of the most common diseases,resulting from both environmental(gluten) and genetic factors [human leukocyte antigen(HLA) and nonHLA genes].The prevalence of CD has been estimated to approximate 0.5%-1% in different parts of the world.However,the population with diabetes,autoimmune disorder or relatives of CD individuals have even higher risk for the development of CD,at least in part,because of shared HLA typing.Gliadin gains access to the basal surface of the epithelium,and interact directly with the immune system,via both trans-and para-cellular routes.From a diagnostic perspective,symptoms may be viewed as either "typical" or "atypical".In both positive serological screening results suggestive of CD,should lead to small bowel biopsy followed by a favourable clinical and serological response to the gluten-free diet(GFD) to confirm the diagnosis.Positive anti-tissue transglutaminase antibody or antiendomysial antibody during the clinical course helps to confirm the diagnosis of CD because of their over 99% specificities when small bowel villous atrophy is present on biopsy.Currently,the only treatment available for CD individuals is a strict life-long GFD.A greater understanding of the pathogenesis of CD allows alternative future CD treatments to hydrolyse toxic gliadin peptide,prevent toxic gliadin peptide absorption,blockage of selective deamidation of specific glutamine residues by tissue,restore immune tolerance towards gluten,modulation of immune response to dietary gliadin,and restoration of intestinal architecture.

Dose surgical sub-specialization influence survival in patients with colorectal cancer?

AIM:To perform a review of patients with colorectal cancer to a community hospital and to compare the risk-adjusted survival between patients managed in general surgical units versus a colorectal unit. METHODS:The study evaluated all patients with colorectal cancer referred to either general surgical units or a colorectal unit from 1/1996 to 6/2001.These results were compared to a historical control group treated within general surgical units at the same hospital from 1/1989 to 12/1994.A Kaplan- Meier survival analysis compared the overall survivals (all- cause mortality) between the groups.A Cox proportional hazards model was used to determine the influence of a number of independent variables on survival.These variables included age,ASA score,disease stage,emergency surgery, adjuvant chemotherapy and/or radiotherapy,disease location,and surgical unit. RESULTS:There were 974 patients involved in this study. There were no significant differences in the demographic details for thethree groups.Patients in the colorectal group were more likely to have rectal cancer and Stage Ⅰ cancers, and less likely to have Stage Ⅱ cancers.Patients treated in the colorectal group had a significantly higher overall 5-year survival when compared with the general surgical group and the historical control group (56 % versus 45 % and 40 % respectively,P<0.01).Survival regression analysis identified age,ASA score,disease stage,adjuvant chemotherapy,and treatment in a colorectal unit (Hazards ratio:0.67;95 % CI:0.53 to 0.84,P =0.0005),as significant independent predictors of survival. CONCLUSION:The results suggest that there may be a survival advantage for patients with colon and rectal cancers being treated within a specialist colorectal surgical unit.

Medical Foreign Bodies in Urinary Bladder: a Case Report

RETAINED foreign bodies in the urinary tract after surgical or diagnostic procedure, named iatrogenic foreign bodies, are rarely reported, though the estimated incidence was as high as 1/1500 cases.1 Prompt and proper retrieval is required due to potential complications. We report a case of iatrogenic foreign body into the bladder.

An epidemiological study of collagenous colitis in southern Sweden from 2001-2010

AIM： To estimate the incidence of collagenous colitis （CC） in southern Sweden during 2001-2010. METHODS： Cases were identified by searching for CC in the diagnostic registers at the Pathology Departments in the county of Skane. The catchment area comprised the south-west part of the county （394 307 inhabitants in 2010） and is a mixed urban and rural type with limited migration. CC patients that had under- gone colonoscopy during the defined period and were living in this area were included in the study regardless of where in Skane they had been diagnosed. Medical records were scrutinized and uncertain cases were re- assessed to ensure that only newly diagnosed CC cases were included. The diagnosis of CC was based on both clinical and histopathological criteria. The clinical crite-rion was non-bloody watery diarrhoea. The histopatho- logical criteria were a chronic inflammatory infiltrate in the lamina propria, a thickened subepithelial collagen layer ≥10 micrometers （um） and epithelial damage such as flattening and detachment. RESULTS： During the ten year period from 2001-2010, 198 CC patients in the south-west part of the county of Skane in southern Sweden were newly diagnosed. Of these, 146 were women and 52 were men, i.e., a female： male ratio of 2.8：1. The median age at diag- nosis was 71 years （range 28-95/inter-quartile range 59-81）, for women median age was 71 （range 28-95） years and was 73 （range 48-92） years for men. The mean annual incidence was 5.4/105 inhabitants. During the time periods 2001-2005 and 2006-2010, the mean annual incidence rates were 5.4/105 for both periods [95% confidence interval （CI）： 4.3-6.5 in 2001-2005 and 4.4-6.4 in 2006-2010, respectively, and 4.7-6.2 for the whole period]. Although the incidence varied over the years （minimum 3.7 to maximum 6.7/105） no increase or decrease in the incidence could be identi- fied. The odds ratio （OR） for CC in women compared to men was estimated to be 2.8 （95% CI： 2.0-3.7）. The OR for women 65 years of age or above compared to below 65 years of age was 6.9 （95% CI：5.0-9.7）, and for women 65 years of age or above compared to the whole group the OR was 4.7 （95% CI： 3.6-6.0）. The OR for age in general, i.e., above or 65 years of age compared to those younger than 65 was 8.3 （95% CI： 6.2-11.1）. During the last decade incidence figures for CC have also been reported from Calgary, Canada dur- ing 2002-2004 （4.6/105） and from Terrassa, Spain dur- ing 2004-2008 （2.6/105）. Our incidence figures from southern Sweden during 2001-2010 （5.4/10s） as well as the incidence figures presented in the studies during the 1990s （Terrassa, Spain during 1993-1997 （2.3/10s）, OI- msted, United States during 1985-2001 （3.1/10s）, Orebro, Sweden during 1993-1998 （4.9/10s）, and Iceland during 1995-1999 （5.2/10s） are all in line with a north- south gradient, something that has been suggested be- fore both for CC and inflammatory bowel disease.CONCLUSION： The observed incidence of CC is com- parable with previous reports from northern Europe and America. The incidence is stable but the female： male ratio seems to be decreasing.

Is cardiac resynchronisation therapy feasible, safe and beneficial in the very elderly？

Objective To evaluate whether cardiac resynchronisation therapy （CRT） implantation was feasible and safe in octogenarians and the asso- ciation with symptoms. Methods Consecutive patients undergoing CRT implantation were recruited from two UK centers. Patients grouped according to age： 〈 80 ＆ ≥ 80 years. Baseline demographics, complications and outcomes were compared between those groups. Results A total of 439 patients were included in this study, of whom 26% were aged ≥ 80 years. Octogenarians more often received cardiac resynchronization therapy pacemaker in comparison to cardiac resynchronisation therapy-defibrillator. Upgrade from pacemaker was common in both groups （16% 〈 80 years vs. 22% ≥ 80 years, P = NS）. Co-morbidities were similarly common in both groups （overall diabetes： 25%, atrial fibrillation： 23%, hypertension： 45%）. More patient age ≥ 80 years had significant chronic kidney disease （CKD, estimated glomerular filtration rate 〈 45 mL/min per 1.73 m^2, 44% vs. 22%, P 〈 0.01 ）. Overall complication rates （any） were similar in both groups （16% vs. 17%, P = NS）. Both groups demonstrated symptomatic benefit. One-year mortality rates were almost four fold greater in octogenarians as compared with the younger cohort （13.9% vs. 3.7%, P 〈 0.01）. Conclusions CRT appears to be safe in the very elderly despite extensive co-morbidity, and in particular frequent severe CKD. Symptomatic improvement appears to be meaningful. Strategies to increase the appropriate identification of elderly patients with CHF who are potential candidates for CRT are required.