Analysis on relative factors of lymph node metastasis and pattern of postoperative locoreginal relapse of esophageal carcinoma

Objective: We aimed to study the relative factors of lymph node metastasis of esophageal carcinoma, and to analyze the distribution rule of lymph node metastasis of post esophagectomy patients for guiding the radiotherapy. Methods: To collect the patients' data (102 cases) in our hospital from 2001 to 2009, who were found lymph node metastasis confirmed by pathologic in a certain period of time after esophageal cancer surgery. The factors affected the lymph node metastasis in esophageal cancer were analysed by single logistic regression and Logistic Regression Method. To analyze the rule of post-operative lymph node metastasis in different regions, according to the lymph node partition, in accordance with paragraphs of esophageal cancer in different groups. Results: Of the 102 patients after esophageal cancer surgery, who were confirmed by pathological examination, 50 cases had positive lymph node metastasis and 52 cases had negative, the lymph node metastasis rate was 49.0%. Lymph node metastasis rates of different depth, length and paragraph of tumor invasion had statistical difference (P < 0.05). The impact on lymph node metastasis rates of the different age and degree of differentiation had no statistical difference (P > 0.05). Multivariate analysis showed that the lesion length, depth of invasion and paragraph of tumor were meaningful factors affecting the lymph node metastasis. Of the 102 patients, 132 sites node metastasis were found by imaging study and histopathology with lower neck and supraclavicular node 59 (44.70%), upper mediastinum node 51 (38.64%), A-P windows node 1 (0.76%), anterior mediastinum node 1 (0.76%), Subcarinal node 5 (3.79%), paraesopha- geal node 3 (2.27%), hilar node 3 (2.27%), abdominal node 9 (6.82%). Conclusion: The length and depth of invasion, and paragraph of esophageal cancer are meaningful factors that affect the lymph node metastasis. The longer of lesion, deeper of infiltration and lower of paragraph, the easier to get independently lymph node metastasis. The postoperative lymph node metastasis was mainly distributed in the lower neck and supraclavicular region and upper mediastinal region, which is the focus of postoperative radiotherapy.

Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss

BACKGROUND Pancreatic adenocarcinoma is currently the fourth leading cause of cancer-related deaths in the United States.In patients with“borderline resectable”disease,current National Comprehensive Cancer Center guidelines recommend the use of neoadjuvant chemoradiation prior to a pancreaticoduodenectomy.Although neoadjuvant radiotherapy may improve negative margin resection rate,it is theorized that its administration increases operative times and complexity.AIM To investigate the association between neoadjuvant radiotherapy and 30-d morbidity and mortality outcomes among patients receiving a pancreaticoduodenectomy for pancreatic adenocarcinoma.METHODS Patients listed in the 2015-2019 National Surgery Quality Improvement Program data set,who received a pancreaticoduodenectomy for pancreatic adenocarcinoma,were divided into two groups based off neoadjuvant radiotherapy status.Multivariable regression was used to determine if there is a significant correlation between neoadjuvant radiotherapy,perioperative blood transfusion status,total operative time,and other perioperative outcomes.RESULTS Of the 11458 patients included in the study,1470(12.8%)underwent neoadjuvant radiotherapy.Patients who received neoadjuvant radiotherapy were significantly more likely to require a perioperative blood transfusion[adjusted odds ratio(aOR)=1.58,95%confidence interval(CI):1.37-1.82;P<0.001]and have longer surgeries(insulin receptor-related receptor=1.14,95%CI:1.11-1.16;P<0.001),while simultaneously having lower rates of organ space infections(aOR=0.80,95%CI:0.66-0.97;P=0.02)and pancreatic fistula formation(aOR=0.50,95%CI:0.40-0.63;P<0.001)compared to those who underwent surgery alone.CONCLUSION Neoadjuvant radiotherapy,while not associated with increased mortality,will impact the complexity of surgical resection in patients with pancreatic adenocarcinoma.

Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

AIM： To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh （CTP） and model for end-stage liver disease （MELD） score to predict that outcome. METHODS： We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint. RESULTS： Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD （12.8 ＋ 3.9 vs 12.6 ＋ 4.7, P = 0.9） or in the mean CTP （7.6 ± 1.2 vs 7.7 ± 1.7, P = 0.8） between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures （MELD： 22.4 ± 8.7 vs 15.2 ± 6.4, P = 0.0007; CTP： 9.9 ± 1.8 vs 8.5 ± 1.8, P = 0.008）. The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them （AUC = 0.755 ± 0.066 for MELD vs AUC = 0.696 ± 0.070 for CTP, P = 0.3）. CONCLUSION： The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.

Operative treatment for separation of distal tibiofibular syndesmosis

Objective： To study the influence of separation of distal tibiofibular syndesmosis on ankle joint and to compare various operative methods so as to find suitable stabilization for separated distal tibiofibular syndesmosis. Methods： From July 1997 to July 2002, we treated 87 patients （64 males and 23 females, aged 18-54 years） with separation of distal tibiofibular syndesmosis, among whom, 79 were combined with fracture of malleolus. Manipulative reduction, internal fixation with cancellous screws and external fixation with plaster support were performed on 37 patients, fixation with plate and screws for fibular fracture and fixation with cancellous screws for distal tibiofibular syndesmosis on 34 patients, and repair of the distal tibiofibular ligaments with tendon of peroneus Iongus, reduction of the separated distal tibiofibuiar syndesmosis, and fixation with cancellous screws on 16 patients. The ankle joint had been dorsiflexed for 30° when the distal tibiofibular syndesmosis was fixed with cancellous screws. And the cancellous screws were taken out at 8-10 weeks after operation. Results： These patients were followed up for at least two years. The curative effects were assessed according to the complaints of the patients and the contour, function and radiogram of the ankle joint： excellent in 55 patients （63 % ）, good in 18 patients （ 21% ）, and fair in 14 patients （16%）. Separation of distal tibiofibular syndesmosis recurred in 2 patients, who underwent a reoperation for repairing the distal tibiofibular ligaments with tendon of peroneus Iongus and recovered. One cancellous screw was broken off. No necrosis developed in the anterior skin of the ankle mortise. Conclusions ： Separation of distal tibiofibular syndesmosis can be treated with various reasonable operations. Repair with tendon of the peroneus Iongus can get excellent outcomes for complete separation of the distal tibiofibular syndesmosis.

低温等离子治疗儿童鼻咽部第二鳃裂囊肿分析

目的探讨儿童鼻咽部第二鳃裂囊肿的临床特征和治疗方式,提高诊治能力。方法回顾性分析河北省儿童医院收治的4例儿童鼻咽部第二鳃裂囊肿的临床资料,包括年龄、性别、症状、影像学资料和治疗过程。总结分析病变部位特点,B超、CT或MRI特征,术后病理结果及治疗方式。结果4例鼻咽部第二鳃裂囊肿患儿均表现为鼻咽侧壁咽鼓管咽口与腭咽弓后上方连线上的囊性肿物,囊壁较厚,影像学检查结果均为囊性病变。4例患儿选择内镜下低温等离子病变切除术,其中2例为内侧囊壁大部分切除术,将囊腔充分敞开,2例为囊肿全部切除术。术后病理提示衬覆纤毛柱状上皮或复层上皮,周围淋巴组织增生。术后随访1.5~3年无复发。结论儿童鼻咽部第二鳃裂囊肿临床罕见,诊断主要依靠病变部位及术后病理结果,内镜下低温等离子切除病变组织是微创、安全、有效的治疗方式。

吸入性烧伤导致的喉气管狭窄疗效分析

目的探讨成年人吸入性烧伤导致喉气管狭窄的外科治疗方法和效果。方法回顾性分析2008年9月~2022年3月就诊于西安交通大学附属红会医院,由吸入性烧伤导致的16例喉气管狭窄患者临床资料,男10例,女6例,年龄17~57岁,平均38.4岁。支撑喉镜下喉剪或激光切除瘢痕并球囊扩张4例;气道前壁加宽喉气管重建术9例,其中肋软骨加宽4例,肌皮瓣2例,甲状软骨翼板3例;气管-气管端端吻合1例,环气管吻合1例,甲状软骨气管吻合1例。结果拔管13例,拔管率81.25%(13/16),失败3例,失败率为18.75%(3/16)。T型硅胶管放置时间为9~24个月,平均12.5个月。随访3个月~10年,所有拔管者均未见复发,进食、呼吸正常。结论对于成年人吸入性烧伤导致的喉气管狭窄患者进行气道重建选择好恰当的手术时机及对应的手术方法,效果满意,T型管放置时间要长。

Operational procedures of auricular point sticking technology

As an external treatment technique of traditional Chinese medicine(TCM),auricular point sticking,which is rooted in holographic biology theory and TCM viscera and meridian theory,is a safe and effective treatment method.This article introduces the technology overview and development process.The auricular point sticking technique for constipation is taken as an example to specify the basic requirements,assessment,operational points,acupoint selection and matters needing attention during the implementation of the auricular acupressure technique,providing a reference for the operating procedures of this technique in the clinical treatment of other diseases such as insomnia,diarrhea,colds,hypertension,headache,and dysmenorrhea.

Automatic Synthesis of Batch Process Operating Procedures

A three-step synthesis strategy for the automatic synthesis of operating procedures in batch processoperations is presented in this paper.The first step is pre-operation which consists of a set of checks that mustbe considered before starting the basic process operation.The second step is operation which is described by a setof basic control instructions.The third step is post-operation described by a set of instructions that must becarried out when the basic process operation is terminated.The three-step synthesis method has been imple-mented as part of a prototype recipe management system.

AP1000 Operation Procedures System and Development

This paper makes a brief introduction on AP1000 operation procedure system, including procedure classification, function and composition. In addition, key points of work flow process and the advantages of AP1000 operation procedures are described, among which the application of CPS （computerized procedure system） on AP1000 operation area and human factor engineering are highlighted. Moreover, based on current situation, this paper offers several suggestions on procedure development for Sanmen AP 1000 nuclear power project, i.e. first, ensure the quality of operation procedures; then determine the way how we are going to use operation procedures in English version; finally realize CPS Chinesization and localization gradually by digesting and absorbing API000 technology.

Monte Carlo Study of 3D Stray Radiation during Interventional Procedures

In interventional medical procedures, other than the highly important issue of optimizing image quality and patient exposure using the primary beam, there remains a continuing need for the study of staff exposure from the scattered radiation. Herein, investigation is made of the 3D stray-radiation distribution, the simulation being made of a realistic interventional scenario through use of the Monte Carlo code Geant4 (version 10.3). The simulation is conducted based on the high definition reference Korean-man (HDRK-man) computational phantom and a GE Infinia 3/8” C-arm machine, focusing on the effect of variation of kVp and field of view (FoV) on the scattered particles’ spatial distribution. With direct measurement of the absorbed dose remaining challenging, not least in respect of the organs at risk, we computed the scatter fractions, defined as the ratio of the air kerma free-in-air to the entrance surface air kerma (ESAK), which are both easily quantifiable. Scatter fraction distributions were simulated for X-ray tube outputs (and half-value layers, HVL) of 60 kVp (2.3 mm Al), 80 kVp (3.2 mm Al) and 120 kVp (4.3 mm Al) and FoV of 15, 20, 25 and 30 cm. The distributions are obtained for different height levels, corresponding to the lens of the eye, and the lung and prostate, all radiosensitive organs. Investigations are made for eight likely locations around the patient. At fixed FoV results reveal an inverse relationship between ESAK and kVp, also that change in kVp from 60 to 80 has a greater effect than from 80 to 120. For change in FoV at fixed kVp, the scatter fraction remains constant. The particular staff locations are found to be optimal in seeking mitigation of dose. Moreover, the combined usage of numerical human model and Monte Carlo simulation can be considered as an added value to the radiation safety research field, especially to the interventional radiology staff and to the patient.

Establishment and implementation of safety check project for invasive procedures outside the operating room

Objective:This study aimed to describe the implementation of the surgical safety check policy and the surgical safety checklist for invasive procedures outside the operating room(OR)and evaluate its effectiveness.Methods:In 2017,to improve the safety of patients who underwent invasive procedures outside of the OR,the hospital quality and safety committee established the surgery safety check committee responsible for developing a new working plan,revise the surgery safety check policy,surgery safety check Keywords:Invasive procedures outside the operating room Safety management Surgical safety checklist Patient safety form,and provide training to the related staff,evaluated their competency,and implemented the updated surgical safety check policy and checklist.The study compared the data of pre-implementation(Apr to Sep 2017)and two post-implementation phases(Apr to Sep 2018,Apr to Sep 2019).It also evaluated the number of completed surgery safety checklist,correct signature,and correct timing of signature.Results:The results showed an increase in the completion rate of the safety checklist after the program implementation from 41.7%(521/1,249)to 90.4%(3,572/3,950),the correct rates of signature from 41.9%(218/521)to 99.0%(4,423/4,465),and the correct timing rates of signature from 34.4%(179/521)to 98.5%(4,401/4,465),with statistical significance(P<0.01).Conclusion:Implementing the updated surgery safety check significantly is a necessary and effective measure to ensure patient safety for those who underwent invasive procedures outside the OR.Implementing surgical safety checks roused up the clinical staff's compliance in performing safety checks,and enhanced team collaboration and communication.

Investigation and analysis of clinical trial research nurse to perform standard operating procedures

Objective： The aim of this study was to investigate the situations and factors that cause nurses not to follow standard operating procedures （SOPs） during the clinical trial process. Methods： Five cases involving patients enrolled in a clinical trial were divided into two groups, pre-SOP training and post-SOP training, to compare and observe the process problems and whether nurses fol- lowed SOPs in clinical trials. The causes of problems were analyzed and corrective measures were proposed. Results： Our results indicate significant improvement in compliance with SOPs after training. There were three occurrences of irregular behavior after training compared with 21 occurrences of irregular behavior before training. Conclusions： The quality of clinical trials can be improved if nurses strictly follow SOPs.

Operating procedures of traditional Chinese medicine breast massage

Traditional Chinese medicine breast massage,also known as breast Tuina or manual expression of breast milk,is a technique of using certain manipulations to act on specific positions or acupoints of the breast to promote blood and lymphatic circulation of breast and facilitate the discharge of stagnant milk.This technique is widely used in China to treat breastfeeding problems such as breast engorgement,mastitis,and postpartum hypogalactia.In this article,we introduce the definition and standardization process of breast massage,elaborate the operating procedures of breast massage in detail,and summarize and discuss the current situation of its clinical application,so as to provide a reference for its wide application and in‑depth research.

术中超声临床应用进展:创新及发展精准外科

术中超声(IOUS)因其便利、可重复性好、成本较低等优势广泛用于外科手术。近年来,随着超声设备不断发展,IOUS对实现精准外科手术越来越重要。本文就IOUS临床应用进展进行述评。

低温等离子射频消融联合下鼻甲骨折外移术治疗阻塞性睡眠呼吸暂停低通气综合征的疗效观察

目的探讨阻塞性睡眠呼吸暂停低通气综合征(OSAHS)患者接受低温等离子射频消融联合下鼻甲骨折外移术后睡眠及经鼻持续气道正压通气(nasal continuous positive airway pressure,nCPAP)治疗耐受性的改善情况。方法选择40例OSAHS合并双侧下鼻甲肥大的患者作为研究对象,均在局麻下接受下鼻甲低温等离子射频消融联合骨折外移术。术前及术后2周分别采用多导睡眠监测(PSG)、鼻阻力仪、autoCPAP呼吸机及视觉模拟量表(VAS)测定睡眠呼吸暂停低通气指数(AHI)、最低血氧饱和度(lowest oxygen saturation,LSaO_(2))、鼻气道阻力及nCPAP治疗耐受性。结果与术前比较,术后2周时患者AHI降低至(35.17±9.72)次/h,LSaO_(2)提高至(83.21±6.58)%,鼻气道阻力降低至(0.55±0.09)kPa·s/cm^(3),VAS评分升高至8.32±1.17,差异比较均有统计学意义(P均<0.05)。结论低温等离子射频消融联合下鼻甲骨折外移术能有效降低OSAHS患者的鼻阻力,提高nCPAP治疗的耐受性,改善OSAHS患者的睡眠情况。

多灶性肝母细胞瘤手术切除的单中心研究

目的探讨多灶性肝母细胞瘤(hepatoblastoma,HB)手术切除治疗的可行性及有效性。方法本研究为回顾性研究,以2014年4月至2022年12月首都医科大学附属北京儿童医院肿瘤外科收治的21例多灶性HB患儿为研究对象,收集患儿临床特征、手术方式及远期预后等资料,并与同期收治的58例中高危单灶性HB患儿进行疗效对比。结果21例多灶性HB患儿中,11例为2个瘤灶,4例为3个瘤灶,1例为5个瘤灶,5例肝内瘤灶超过5个且无法明确计数。21例均接受肿瘤切除手术,其中9例行解剖性肝切除术,11例行不规则肝切除或瘤灶剜除术,1例行联合肝脏离断及门静脉结扎的分次肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)。20例为R0切除,1例为R1切除,术后无一例发生严重并发症。本组多灶性HB患儿接受手术联合化疗的多学科综合治疗后,中位随访时间57个月,18例患儿无瘤生存,3例死亡。本组多灶性HB患儿3年无事件生存率(event-free survival,EFS)为57.58%,3年总生存率(overall survival,OS)为82.00%,局部进展累积发生率(cumulative incidence of local progression,CILP)为38.00%。同期收治的单灶性中高危HB患儿上述指标分别为91.84%、74.96%、20.04%。两组数据对比,差异无统计学意义(P>0.05)。结论多灶性HB经规范外科手术切除辅助术前、术后化疗,可以获得较为满意的预后。

民政部门担任遗产管理人的困境与法律对策研究

遗产管理人是《民法典》规定的新制度,民政部门作为兜底主体担任遗产管理人是我国法律制度上的一项创新。自《民法典》实施以来,各地都在积极探索民政部门担任遗产管理人的做法与经验,但由于缺乏配套性、操作性、实施性的具体规定,导致民政部门工作中产生许多困惑与问题,影响民政部门遗产管理职能的发挥与落地。应当通过制定立法解释,完善司法解释和相关规范性文件,从源头上解决裁判依据问题,进一步明确民政部门在遗产管理实务中独立的法律地位和诉讼主体地位,细化指定遗产管理人确认和启动程序在内的各项具体规则,制定遗产管理人工作操作指引,明确承担遗产管理职能的内设机构、职责、人员、编制和经费,并加快专业人才的培养步伐,使这一新制度能够落地落实,实现《民法典》的立法宗旨。

细胞减灭术联合腹腔热灌注化疗在局部反复复发肾母细胞瘤治疗中的应用

目的观察细胞减灭术(cytoreductive surgery,CRS)联合腹腔热灌注化疗(hyperthermic intraperitoneal chemotherapy,HIPEC)对反复复发肾母细胞瘤的腹腔局部控制情况。方法本研究为回顾性研究,以2019年1月至2022年1月首都医科大学附属北京儿童医院肿瘤外科及北京儿童医院保定医院肿瘤外科收治的6例反复复发的肾母细胞瘤患儿为研究对象,收集患儿基本信息(性别、年龄、发病部位等)、既往治疗经过、治疗方案以及本中心(北京与保定两个病区)手术、热灌注、术后治疗及随访情况。结果6例反复复发的肾母细胞瘤患儿均为单侧病变,5例行根治性瘤肾切除术,1例行保留肾脏肿瘤剥除术。4例直接接受手术,参考COG分期,其中2例为Ⅲ期,行化疗+放疗;2例为Ⅱ期,予以化疗;另2例术前予以化疗,参考SIOP分期,术后诊断为Ⅱ期,术后仅行化疗。初次复发时间最短为术后1.5个月,最长为术后10个月,其中3例为原位复发,2例为腹盆腔单发种植病灶,1例为肠系膜多发病变。在治疗过程中,6例复发部位均位于腹盆腔,未见远处转移,且均接受了手术切除;5例进行了局部放疗;6例术后均采用了强于初次化疗的个体化治疗方案。6例在本中心治疗过程中均接受了细胞减灭术+术中腹腔热灌注化疗,术中、术后均未见危及生命的严重并发症;随访时间为14(2,32)个月,其中4例长期生存,2例死于肿瘤进展。结论局部反复复发的肾母细胞瘤预后差,在化疗的辅助下,CRS+HIPEC可以最大程度杀灭可能残存的肿瘤细胞,更有利于肿瘤局部控制。

单侧肾母细胞瘤新辅助化疗后保留肾单位手术的初步疗效分析

目的探讨新辅助化疗后保留肾单位手术(nephron sparing surgery,NSS)治疗单侧肾母细胞瘤的初步疗效。方法回顾性分析2014年1月至2020年12月复旦大学附属儿科医院收治的7例单侧肾母细胞瘤患儿临床资料,均行新辅助化疗及NSS。收集患儿生存率、肾功能以及肿瘤复发情况,并与同期行根治性肿瘤切除术(radical nephrectomy,RN)的患儿进行疗效比较。结果7例中,男4例、女3例,发病年龄(38.86±18.23)个月,无一例合并肿瘤相关综合征或半侧肢体肥大;肿瘤位于肾脏一极1例,肾脏中央6例。7例经新辅助化疗后,肿瘤体积缩小(66.4±18.6)%。1例肿瘤位于肾脏一极的患儿行部分肾切除术(partial nephrectomy,PN),6例肿瘤位于肾中央的患儿行肿瘤剜除术(tumor enucleation,TE),术后病理检查结果提示镜下肿瘤切缘阳性2例。儿童肿瘤国际协会(International Society for Pediatric Oncology,SIOP)分期:Ⅱ期4例、Ⅲ期3例。随访时间(38.42±10.17)个月,无一例失访或死亡。无瘤生存6例,带瘤生存1例。NSS后出现肿瘤复发2例。NSS后复发率(28.6%)及5年生存率(100%)与同期行RN的患儿复发率(13.3%)和5年生存率(86.9%)相比,差异均无统计学意义(P>0.05)。结论单侧肾母细胞瘤通过合理的术前评估和新辅助化疗,可以增加NSS的机会,并取得与RN相似的治疗效果。

肝细胞癌转化治疗的策略及实践

原发性肝癌因发病隐匿及预后较差,多数初始诊断即为不可切除。近些年,随着靶向治疗、免疫治疗及局部治疗等转化治疗方案的兴起,部分中晚期肝癌患者成功转化并行根治性手术切除,但同时也带来了诸多问题,如潜在转化人群的界定、转化方案的选择、转化后手术切除的必要性及时机、转化手术后辅助治疗的必要性及持续时间等。本文将结合笔者的自身经验,针对肝癌转化治疗中上述问题进行探讨。