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。

Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer:A 9-year review

BACKGROUND Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide.About 5%-10%of patients are diagnosed with locally advanced rectal cancer(LARC)on presentation.For LARC invading into other structures(i.e.T4b),multivisceral resection(MVR)and/or pelvic ex-enteration(PE)remains the only potential curative surgical treatment.MVR and/or PE is a major and complex surgery with high post-operative morbidity.Minimally invasive surgery(MIS)has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies,but there is little evi-dence on its use in MVR,especially so for robotic MVR.This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023.Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR,or stage 4 disease with resectable systemic metastases.Pa-tients who underwent curative MVR for locally recurrent rectal cancer,or me-tachronous rectal cancer were also included.Exclusion criteria were patients with systemic metastases with non-resectable disease.All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery.Complex sur-gery was defined based on technical difficulty of surgery(i.e.total PE,bladder-sparing prostatectomy,pelvic lymph node dissection or need for flap creation).Our primary outcomes were the margin status,and complication rates.Cate-gorical values were described as percentages and analysed by the chi-square test.Continuous variables were expressed as median(range)and analysed by Mann-Whitney U test.Cumulative overall survival(OS)and recurrence-free survival(RFS)were analysed using Kaplan-Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.RESULTS A total of 46 patients were included in this study[open MVR(oMVR):12(26.1%),miMVR:36(73.9%)].Patients’American Society of Anesthesiologists score,body mass index and co-morbidities were comparable between oMVR and miMVR.There is an increasing trend towards robotic MVR from 2015 to 2023.MiMVR was associated with lower estimated blood loss(EBL)(median 450 vs 1200 mL,P=0.008),major morbidity(14.7%vs 50.0%,P=0.014),post-operative intra-abdominal collections(11.8%vs 50.0%,P=0.006),post-operative ileus(32.4%vs 66.7%,P=0.04)and surgical site infection(11.8%vs 50.0%,P=0.006)compared with oMVR.Length of stay was also shorter for miMVR compared with oMVR(median 10 vs 30 d,P=0.001).Oncological outcomes-R0 resection,recurrence,OS and RFS were comparable between miMVR and oMVR.There was no 30-d mortality.More patients underwent robotic compared with laparoscopic MVR for complex cases(robotic 57.1%vs laparoscopic 7.7%,P=0.004).The operating time was longer for robotic compared with laparoscopic MVR[robotic:602(400-900)min,laparoscopic:Median 455(275-675)min,P<0.001].Incidence of R0 resection was similar(laparoscopic:84.6%vs robotic:76.2%,P=0.555).Overall complication rates,major morbidity rates and 30-d readmission rates were similar between la-paroscopic and robotic MVR.Interestingly,3-year OS(robotic 83.1%vs 58.6%,P=0.008)and RFS(robotic 72.9%vs 34.3%,P=0.002)was superior for robotic compared with laparoscopic MVR.CONCLUSION MiMVR had lower post-operative complications compared to oMVR.Robotic MVR was also safe,with acceptable post-operative complication rates.Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

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。

Robotic versus laparoscopic surgery for sporadic benign insulinoma:Short-and long-term outcomes

Background:Minimally invasive surgery is the optimal treatment for insulinoma.The present study aimed to compare short-and long-term outcomes of laparoscopic and robotic surgery for sporadic benign insulinoma.Methods:A retrospective analysis of patients who underwent laparoscopic or robotic surgery for insulinoma at our center between September 2007 and December 2019 was conducted.The demographic,perioperative and postoperative follow-up results were compared between the laparoscopic and robotic groups.Results:A total of 85 patients were enrolled,including 36 with laparoscopic approach and 49 with robotic approach.Enucleation was the preferred surgical procedure.Fifty-nine patients(69.4%)underwent enucleation;among them,26 and 33 patients underwent laparoscopic and robotic surgery,respectively.Robotic enucleation had a lower conversion rate to laparotomy(0 vs.19.2%,P=0.013),shorter operative time(102.0 vs.145.5 min,P=0.008)and shorter postoperative hospital stay(6.0 vs.8.5 d,P=0.002)than laparoscopic enucleation.There were no differences between the groups in terms of intraoperative blood loss,the rates of postoperative pancreatic fistula and complications.After a median follow-up of 65 months,two patients in the laparoscopic group developed a functional recurrence and none of the patients in the robotic group had a recurrence.Conclusions:Robotic enucleation can reduce the conversion rate to laparotomy and shorten operative time,which might lead to a reduction in postoperative hospital stay.

Non-anatomical liver resection for hepatocellular carcinoma:the SegSubTe classification to overcome the problem of heterogeneity

Background:The superiority of anatomical resection(AR)vs.non-anatomical resection(NAR)in the surgical management of hepatocellular carcinoma(HCC)is debated.ARs are well-defined procedures,whereas the lack of NAR standardization results in heterogeneous outcomes.This study aimed to introduce the SegSubTe classification for NAR detailing the appropriateness of the level of surgical section of the Glissonean pedicles feeding the tumor.Methods:A single-center retrospective analysis of pre-and postoperative imaging of consecutive patients treated with NAR for single HCC between 2012 and 2020 was conducted.The quality of surgery was assessed classifying the type of vascular supply and the level of surgical section(segmental,subsegmental or terminal next to the tumor)of vascular pedicles feeding the HCCs;then,the population was divided in“SegSubTe-IN”or“SegSubTe-OUT”groups,and the tumor recurrence and survival were analyzed.Results:Ninety-seven patients who underwent NAR were included;76%were SegSubTe-IN and 24%were SegSubTe-OUT.Total disease recurrence,local recurrence and cut-edge recurrence in the SegSubTe-IN vs.SegSubTe-OUT groups were 50%vs.83%(P=0.006),20%vs.52%(P=0.003)and 16%vs.39%(P=0.020),respectively.SegSubTe-OUT odds ratio for local recurrence was 4.1 at univariate regression analysis.One-,three-,and five-year disease-free survival rates in the SegSubTe-IN vs.SegSubTe-OUT groups were 81%,58%and 35%vs.46%,21%and 11%,respectively(P<0.001).Conclusions:The SegSubTe classification is a useful tool to stratify and standardize NAR for HCC,aiming at improving long-term oncological outcomes and reducing the heterogeneity of quality of NAR for HCC.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography(SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76(90%) procedures and clinical success rate of 30/34(88%) patients. Mild adverse event rate was 8/76(11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30(80%) procedures( P = 0.194 vs. biliary SBEERCP) and clinical success rate of 11/17(65%) patients( P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30(20%)( P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Wettability,reactivity,and interface structure in Mg/Ni system

The sessile drop method was applied to the experimental investigation of the wetting and spreading behaviors of liquid Mg drops on pure Ni substrates.For comparison,the experiments were performed in two variants:(1)using the Capillary Purification(CP)procedure,which allows the non-contact heating and squeezing of a pure oxide-free Mg drop;(2)by classical Contact Heating(CH)procedure.The high-temperature tests were performed under isothermal conditions(CP:760℃for 30 s;CH:715℃for 300 s)using Ar+5 wt%H_(2) atmosphere.During the sessile drop tests,images of the Mg/Ni couples were recorded by CCD cameras(57 fps),which were then applied to calculate the contact angles of metal/substrate couples.Scanning and transmission electron microscopy analyses,both coupled with energy-dispersive X-ray spectroscopy,were used for detailed structural characterization of the solidified couples.It was found that an oxide-free Mg drop obtained by the CP procedure showed a wetting phenomenon on the Ni substrate(an average contact angleθ<90°in<1 s),followed by fast spreading and good wetting over the Ni substrate(θ_((CP))~20°in 5 s)to form a final contact angle ofθ_(f(CP))~18°.In contrast,a different wetting behavior was observed for the CH procedure,where the unavoidable primary oxide film on the Mg surface blocked the spreading of liquid Mg showing apparently non-wetting behavior after 300 s contact at the test temperature.However,in both cases,the deep craters formed in the Ni substrates under the Mg drops and significant change in the structure of initially pure Mg drops to Mg-Ni alloys suggest a strong dissolution of Ni in liquid Mg and apparent values of the final contact angles measured for the Mg/Ni system.

Multi-Objective Optimization of the Ultrasonic Scalpel Rod and Tip with Improved Performance:Vibration Frequency,Amplitude,and Service Life

Ultrasonic scalpel design for minimally invasive surgical procedures is mainly focused on optimizing cutting performance.However,an important issue is the low fatigue life of traditional ultrasonic scalpels,which affects their long-term reliability and effectiveness and creates hidden dangers for surgery.In this study,a multi-objective optimal design for the cutting performance and fatigue life of ultrasonic scalpels was proposed using finite element analysis and fatigue simulation.The optimal design parameters of resonance frequency and amplitude were determined.By setting the transition fillet and keeping the gain structure away from the node position to enable the scalpel to have a high service life with excellent cutting performance.The frequency modulation method of setting the vibration node bosses at the node position and setting the vibration antinode grooves at the antinode position was compared.Then,the mechanism of the influence of various design elements,such as tip,shank,node position,and antinode position,on the resonance frequency,amplitude,and fatigue life of the ultrasonic scalpel was analyzed,and the optimal design principles of the ultrasonic scalpel were obtained.The proposed ultrasonic scalpel design was confirmed by simulations,impedance measurements,and liver tissue cutting experiments,demonstrating its feasibility and enhanced performance.This research introduces innovative design strategies to improve the fatigue life and performance of ultrasonic scalpels to address an important issue in minimally invasive surgery.

Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study

BACKGROUND Glucagon-like peptide-1 receptor agonists(GLP-1 RA)are effective in diabetes and obesity,reducing hyperglycemia by increasing insulin release and delaying gastric emptying.However,they can cause gastroparesis,raising concerns about aspiration during procedures.Recent guidelines advise discontinuing GLP-1 RA before surgery to reduce the risk of pulmonary aspiration.AIM To evaluate the effect of GLP-1 RAs on gastric residual contents during endosco-pic procedures.METHODS A retrospective chart review at BronxCare Health System,New York,from January 2019 to October 2023,assessed gastric residue and aspiration in GLP-1 RA patients undergoing endoscopic procedures.Two groups were compared based on dietary status before the procedure.Data included demographics,symptoms of gastroparesis,opiate use,hemoglobin A1c,GLP-1 agonist indication,endo-scopic details,and aspiration occurrence.IBM SPSS was used for analysis,cal-culating means,standard deviations,and applying Pearson’s chi-square and t-tests for associations,with P<0.05 as being significant.RESULTS During the study,306 patients were included,with 41.2%on a clear liquid/low residue diet and 58.8%on a regular diet before endoscopy.Most patients(63.1%)were male,with a mean age of 60±12 years.The majority(85.6%)were on GLP-1 RAs for diabetes,and 10.1%reported digestive symptoms before endoscopy.Among those on a clear liquid diet,1.5%had residual food at endoscopy compared to 10%on a regular diet,which was statistically significant(P=0.03).Out of 31 patients with digestive symptoms,13%had residual food,all from the regular diet group(P=0.130).No complications were reported during or after the procedures.CONCLUSION The study reflects a significant rise in GLP-1 RA use for diabetes and obesity.A 24-hour liquid diet seems safe for endoscopic procedures without aspiration.Patients with upper gastrointestinal symptoms might have a higher residual food risk,though not statistically significant.Further research is needed to assess risks based on diabetes duration,gastroparesis,and GLP-1 RA dosing,aiming to minimize interruptions in therapy during procedures.

Efficacy and safety of remimazolam in bronchoscopic sedation:A meta-analysis

BACKGROUND Remimazolam is a new benzodiazepine used for procedural sedation and general anesthesia.Several studies have used remimazolam for bendable bronchoscopy.AIM To assess the safety and efficacy of remimazolam for sedation in patients undergoing bendable bronchoscopy by performing a meta-analysis of randomized controlled trials(RCTs).METHODS We searched the EMBASE,PubMed,Cochrane Library,and Web of Science databases for RCTs on bendable bronchoscopic procedural sedation with remimazolam vs conventional sedatives(CS).RESULTS Five studies with 1080 cases were included.Remimazolam had the same sedation success rate compared with CS[relative risk(RR):1.35,95%CI:0.60-3.05,P=0.474,I2=99.6%].However,remimazolam was associated with a lower incidence of hypotension(RR:0.61;95%CI:0.40-0.95,P=0.027;I2=65.1%)and a lower incidence of respiratory depression(RR:0.50,95%CI:0.33-0.77,P=0.002,I2=42.3%).A subgroup analysis showed a higher success rate of sedation with remimazolam than midazolam(RR:2.45,95%CI:1.76-3.42,P<0.001).Compared with propofol,the incidence of hypotension(RR:0.45,95%CI:0.32-0.64,P<0.001,I2=0.0%),respiratory depression(RR:0.48,95%CI:0.30-0.76,P=0.002,I2=78.4%),hypoxemia(RR:0.36,95%CI:0.15-0.87,P=0.023),and injection pain(RR:0.04,95%CI:0.01-0.28,P=0.001)were lower.CONCLUSION Remimazolam is safe and effective during bronchoscopy.The sedation success rate was similar to that in the CS group.However,remimazolam has a higher safety profile,with fewer inhibitory effects on respiration and circulation.

Associative Tasks Computing Offloading Scheme in Internet of Medical Things with Deep Reinforcement Learning

The Internet of Medical Things(Io MT) is regarded as a critical technology for intelligent healthcare in the foreseeable 6G era. Nevertheless, due to the limited computing power capability of edge devices and task-related coupling relationships, Io MT faces unprecedented challenges. Considering the associative connections among tasks, this paper proposes a computing offloading policy for multiple-user devices(UDs) considering device-to-device(D2D) communication and a multi-access edge computing(MEC)technique under the scenario of Io MT. Specifically,to minimize the total delay and energy consumption concerning the requirement of Io MT, we first analyze and model the detailed local execution, MEC execution, D2D execution, and associated tasks offloading exchange model. Consequently, the associated tasks’ offloading scheme of multi-UDs is formulated as a mixed-integer nonconvex optimization problem. Considering the advantages of deep reinforcement learning(DRL) in processing tasks related to coupling relationships, a Double DQN based associative tasks computing offloading(DDATO) algorithm is then proposed to obtain the optimal solution, which can make the best offloading decision under the condition that tasks of UDs are associative. Furthermore, to reduce the complexity of the DDATO algorithm, the cacheaided procedure is intentionally introduced before the data training process. This avoids redundant offloading and computing procedures concerning tasks that previously have already been cached by other UDs. In addition, we use a dynamic ε-greedy strategy in the action selection section of the algorithm, thus preventing the algorithm from falling into a locally optimal solution. Simulation results demonstrate that compared with other existing methods for associative task models concerning different structures in the Io MT network, the proposed algorithm can lower the total cost more effectively and efficiently while also providing a tradeoff between delay and energy consumption tolerance.

Reconstruction of cervical necrotizing fasciitis defect with the modified keystone flap technique:Two case reports

BACKGROUND Cervical necrotizing fasciitis(CNF)is a rare,aggressive form of deep neck space infection with significant morbidity and mortality rates.Serial surgical debridement acts as the cornerstone of CNF treatment;however,it often results in defects requiring complex reconstructions.CASE SUMMARY We report two cases in which the keystone flap(KF)was used for CNF defect coverage:Case 1,an 85-year-old patient with CNF in the anterior neck,and Case 2,a 54-year-old patient with CNF in the posterior neck.Both patients received empirical intravenous antibiotic therapy and underwent serial debridement,enabling adequate wound preparation and stabilization.The final defect size measured 5.5 cm×12 cm in Case 1 and 6 cm×11 cm in Case 2.For defect coverage,we employed an 8 cm×19 cm type II KF based on perforators from the superior thyroid artery in Case 1 and a 9 cm×18 cm type II KF based on perforators from the transverse cervical artery in Case 2.Both flaps showed complete survival.No postoperative complications occurred in both cases,and favorable outcomes were observed at 7-and 6-month follow-ups in case 1 and 2,respectively.CONCLUSION We effectively treated CNF-associated defects using the KF technique;KF is viable for covering CNF defects in carefully selected cases.

Minimally invasive pelvic exenteration for primary or recurrent locally advanced rectal cancer:A glimpse into the future

Surgeons have grappled with the treatment of recurrent and T4b locally advanced rectal cancer(LARC)for many years.Their main objectives are to increase the overall survival and quality of life of the patients and to mitigate postoperative complications.Currently,pelvic exenteration(PE)with or without neoadjuvant treatment is a curative treatment when negative resection margins are achieved.The traditional open approach has been favored by many surgeons.However,the technological advancements in minimally invasive surgery have radically changed the surgical options.Recent studies have demonstrated promising results in postoperative complications and oncological outcomes after robotic or laparoscopic PE.A recent retrospective study entitled“Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer:A 9-year review”was published in the World Journal of Gastrointestinal Surgery.As we read this article with great interest,we decided to delve into the latest data regarding the benefits and risks of minimally invasive PE for LARC.Currently,the small number of suitable patients,limited surgeon experience,and steep learning curve are hindering the establishment of minimally invasive PE.

Minimally invasive multivisceral resection in rectal cancer:Preparation or Precipitation?

Rectal cancer is a malignant neoplasm that constitutes a significant public health challenge due to its high incidence and associated mortality.In this editorial,we comment on the article by Chan et al.In recent years,there has been progress in the development of new treatments for initial and metastatic rectal cancer due to introduction of techniques of innovative and minimally-invasive surgery(MIS)such as laparoscopy and robotic surgery.However,only a few studies have ana-lyzed the feasibility,safety,and results of MIS in relation to open surgery,thereby highlighting the promising and superior results of MIS in functional and oncolo-gical terms.The findings were corroborated by the comparative study of Chan et al which evaluated the feasibility and safety of minimally invasive multivisceral resection(miMVR).A comparison of postoperative outcomes between open MVR and miMVR showed that miMVR presented less blood loss,fewer postoperative complications,and less morbidity.This editorial article is focused specifically on analysis of the characteristics of new minimally-invasive surgical techniques in rectal cancer,particularly in advanced stages.The importance of future research is emphasized by progress in knowledge,training,and clinical practice in the appli-cation of these surgical procedures for the treatment of advanced colorectal cancer.

Structural Characteristics and Influencing Factors of Carbon Emission Spatial Association Network:A Case Study of Yangtze River Delta City Cluster,China

City cluster is an effective platform for encouraging regionally coordinated development.Coordinated reduction of carbon emissions within city cluster via the spatial association network between cities can help coordinate the regional carbon emission management,realize sustainable development,and assist China in achieving the carbon peaking and carbon neutrality goals.This paper applies the improved gravity model and social network analysis(SNA)to the study of spatial correlation of carbon emissions in city clusters and analyzes the structural characteristics of the spatial correlation network of carbon emissions in the Yangtze River Delta(YRD)city cluster in China and its influencing factors.The results demonstrate that:1)the spatial association of carbon emissions in the YRD city cluster exhibits a typical and complex multi-threaded network structure.The network association number and density show an upward trend,indicating closer spatial association between cities,but their values remain generally low.Meanwhile,the network hierarchy and network efficiency show a downward trend but remain high.2)The spatial association network of carbon emissions in the YRD city cluster shows an obvious‘core-edge’distribution pattern.The network is centered around Shanghai,Suzhou and Wuxi,all of which play the role of‘bridges’,while cities such as Zhoushan,Ma'anshan,Tongling and other cities characterized by the remote location,single transportation mode or lower economic level are positioned at the edge of the network.3)Geographic proximity,varying levels of economic development,different industrial structures,degrees of urbanization,levels of technological innovation,energy intensities and environmental regulation are important influencing factors on the spatial association of within the YRD city cluster.Finally,policy implications are provided from four aspects:government macro-control and market mechanism guidance,structural characteristics of the‘core-edge’network,reconfiguration and optimization of the spatial layout of the YRD city cluster,and the application of advanced technologies.

Endoscopic clipping of gastrojejunostomy leakage following Whipple procedure: A case report

BACKGROUND Currently,perioperative complications of classic Whipple surgery occur at a rate of approximately 40%.Common complications include delayed gastric emptying,pancreatic fistula,and bile leakage,whereas gastrojejunostomy(GJ)leakage is rare.CASE SUMMARY This case report will assess the management of a GJ leak in a 71-year-old male patient following the Whipple procedure.After surgery,the patient was trans-ferred to the clinic after four days of intensive care,where vacuum therapy was used to handle a developing subcutaneous collection.The patient,who had bile in the drains and incision during follow-up,underwent endoscopic examination on the 21st day after the operation.An opening of approximately 4 mm was observed in the GJ anastomosis during endoscopy.Five titanium clips were used to close the openings.The drainage of bile decreased to less than 50 mL on the first day after the procedure,and the patient's oral intake was opened.CONCLUSION Current literature reports a GJ leakage rate of 0.54%following Whipple surgery,with clinical findings lasting on average between 4-34 days.Surgery was the main form of therapy for this case,with a success rate of 84%,and percutaneous drai-nage was also utilized as a treatment option.This case report is the first to docu-ment endoscopic treatment of GJ leaks following the classic Whipple procedure.

Emergence of the stromal vascular fraction and secretome in regenerative medicine

Recently,we read a mini-review published by Jeyaraman et al.The article explored the optimal methods for isolating mesenchymal stromal cells from adipose tissue-derived stromal vascular fraction(SVF).Key factors include tissue source,processing techniques,cell viability assessment,and the advantages/disadvantages of autologous vs allogeneic use.The authors emphasized the need for standardized protocols for SVF isolation,ethical and regulatory standards for cell-based therapy,and safety to advance mesenchymal stromal cell-based therapies in human patients.This manuscript shares our perspective on SVF isolation in canines.We discussed future directions to potentiate effective regenerative medicine therapeutics in human and veterinary medicine.

Advancing the predictive accuracy of PNTML in rectal prolapse:An ongoing quest

Fecal incontinence is a common symptom among patients with rectal prolapse.Pudendal nerve terminal motor latency(PNTML)testing can serve as a reference indicator for predicting the outcomes of rectal prolapse surgery,thereby assisting surgeons in formulating more appropriate surgical plans.The direct correlation between preoperative PNTML testing results and postoperative fecal incontinence in patients with rectal prolapse remains a contentious issue,necessitating further clarification.Thus,we analyze the existing publications from both clinical and statistical perspectives to comprehensively evaluate the accuracy of preoperative PNTML testing in rectal prolapse and provide some feasible statistical solutions.

Airway management of a patient with linear immunoglobulin A bullous dermatosis:A case report

BACKGROUND There is limited literature on managing the airway of patients with linear immunoglobulin A(IgA)bullous dermatosis,a rare mucocutaneous disorder that leads to the development of friable bullae.Careful clinical decision making is necessary when there is a risk of bleeding into the airway,and a multidisciplinary team approach may lead to decreased patient morbidity during these high-risk scenarios,especially when confronted with an unusual cause for bleeding.CASE SUMMARY A 45-year-old African American female presented to our ambulatory surgical center for right corneal transplantation due to corneal perforation after blunt trauma in the setting of cicatricial conjunctivitis and diffuse corneal neovascularization from linear IgA bullous dermatosis.The diagnosis of IgA dermatosis was recent,and the patient had been lost to follow-up.The severity of the disease and extent of airway involvement was unknown at the time of the surgery.Significant airway bleeding was noticed upon intubation and the otorhinolaryngology team had to be called to the operating room.The patient required transfer to the intensive care unit where a multidisciplinary team was involved in her case.The patient was extubated on postoperative day 4.CONCLUSION A multidisciplinary approach to treating this disease is the best course of action before a surgical procedure.In our case,key communication between the surgery,anesthesia,and dermatology teams led to the quick and safe treatment of our patient’s disease.Ambulatory surgery should not be considered for these cases unless they are in full remission and there is no mucous membrane involvement.