Endoscopic diagnosis and management of gallbladder carcinoma in minimally invasive era:New needs,new models

Gallbladder cancer(GBC)is a rare and lethal malignancy;however,it represents the most common type of biliary tract cancer.Patients with GBC are often diagnosed at an advanced stage,thus,unfortunately,losing the opportunity for curative surgical intervention.This situation leads to lower quality of life and higher mortality rates.In recent years,the rapid development of endoscopic equipment and techniques has provided new avenues and possibilities for the early and minimally invasive diagnosis and treatment of GBC.This editorial comments on the article by Pavlidis et al.Building upon their work,we explore the new needs and corresponding models for managing GBC from the endoscopic diagnosis and treatment perspective.

DIAGNOSIS AND TREATMENT OF POLYPOID LESIONS OF THE GALLBLADDER

This article reports 56 pathologically confirmed cases of polypoid lesions of the gallbladder (PLG) that were operated on in our hospital from 1984 to 1995. The patients' ages ranged from 10 to 70 and the mean age was 43. 5, 83.9% were 30～49 years old. Gallstone could be round in 24cases. There were 36 cases of pseudotumor in this group (64.2% ), 20 of true tumor(35. 8% ) and 1of carcinopolypus. The diagnosis rate was elevated with the use or BUS. The patients with complicated gallstone and polyp in the neck of gallbladder should be operated early while asymptom patients could be followed and operated on at sultable stage.

Giant squamous cell carcinoma of the gallbladder: A case report

BACKGROUND Gallbladder cancer is the most common malignant tumor of the biliary tract. The majority of cases are adenocarcinoma. Squamous cell carcinoma is the histological type present in 12% of all neoplasias accounting for approximately 12% of gallbladder neoplasms. It can occur in its pure form reaching 1%-3% of the tumors. Many patients are at an advanced stage when diagnosed and have bad therapeutic efficacy. CASE SUMMARY A 45-year-old male patient presented with left flank pain for 1 year and irradiated to the mesogastric region. He denied fever, vomiting, and any other intestinal changes. He reported a weight loss of 10 kg in a period of 7 mo. He denied alcoholism, smoking, drug use, or prior illness. Computed tomography of the abdomen showed in the gallbladder fossa a voluminous mesogastric heterogeneous collection that had a thick and irregular capsule with liquid and gaseous contents. A predominantly hypoattenuating rounded material with partially calcified margins measuring about 2.0 cm related to gallstone was also emphasized. No lymphadenomegalies or free fluid was observed in the abdominal cavity. Patient underwent laparotomy where a huge tumor was observed affecting the transverse colon and gallbladder. This mass was resected en bloc removing gallbladder and transverse colon together with corresponding mesocolon and regional lymphadenectomy. There were no complications in the postoperative period. Although oncological treatment was performed, the patient died 6 mo after surgery. CONCLUSION Squamous cell carcinoma represents a rare disease. Patients often present with large, bulky tumors with involvement of adjacent organs. In spite of progress in surgical techniques and adjuvant chemotherapy, the prognosis remains poor.

Adjuvant radiotherapy for gallbladder cancer:A dosimetric comparison of conformal radiotherapy and intensity-modulated radiotherapy

AIM: To assess the efficacy and toxicity of conformal radiotherapy (CRT) and compare with intensity-modulated radiotherapy (IMRT) in the treatment of gallbladder cancer. METHODS: Between November 2003 and January 2010, 20 patients with gallbladder cancer were treated with CRT with or without chemotherapy after surgical resection. Preliminary survival data were collected and examined using both Kaplan-Meier and actuarial analysis. Demographic and treatment parameters were collected. All patients were planned to receive 46-56 Gy in 1.8 or 2.0 Gy per fraction. CRT planning was compared with IMRT. RESULTS: The most common reported acute toxicities requiring medication (Radiation Therapy Oncology Group, Radiation Therapy Oncology Group Grade 2) were nausea (10/20 patients) and diarrhea (3/20). There were no treatment-related deaths. Compared with CRT planning, IMRT significantly reduced the volume of right kidney receiving > 20 Gy and the volume of liver receiving > 30 Gy. IMRT has a negligible impact on the volume of left kidney receiving > 20 Gy. The 95% of prescribed dose for a planning tumor volume using either 3D CRT or IMRT planning were 84.0% ± 6.7%, 82.9% ± 6.1%, respectively (P > 0.05). CONCLUSION: IMRT achieves similar excellent target coverage as compared with CRT planning, while reducing the mean liver dose and volume above threshold dose. IMRT offers better sparing of the right kidney compared with CRT planning, with a significantly lower mean dose and volume above threshold dose.

Simple cholecystectomy is an adequate treatment for grade I T1bN0M0 gallbladder carcinoma:Evidence from 528 patients

BACKGROUND T1b gallbladder carcinoma(GBC)is defined as a tumor that invades the perimuscular connective tissue without extension beyond the serosa or into the liver.However,controversy still exists over whether patients with T1b GBC should undergo cholecystectomy alone or radical GBC resection.AIM To explore the optimal surgical approach in patients with T1b gallbladder cancer of different pathological grades.METHODS Patients with T1bN0M0 GBC who underwent surgical treatment between 2000 and 2017 were included in the Surveillance,Epidemiology,and End Results database.The Kaplan-Meier method and log-rank test were used to analyze the overall survival(OS)and disease-specific survival(DSS)of patients with T1b GBC of different pathological grades.Cox regression analysis was used to identify independent predictors of mortality and explore the selection of surgical methods in patients with T1b GBC of different pathological grades and their relationship with prognosis.RESULTS Of the 528 patients diagnosed with T1bN0M0 GBC,346 underwent simple cholecystectomy(SC)(65.5%),131 underwent SC with lymph node resection(SC+LN)(24.8%),and 51 underwent radical cholecystectomy(RC)(9.7%).Without considering the pathological grade,both the OS(P<0.001)and DSS(P=0.003)of T1b GBC patients who underwent SC(10-year OS:27.8%,10-year DSS:55.1%)alone were significantly lower than those of patients who underwent SC+LN(10-year OS:35.5%,10-year DSS:66.3%)or RC(10-year OS:50.3%,10-year DSS:75.9%).Analysis of T1b GBC according to pathological classification revealed no significant difference in OS and DSS between different types of procedures in patients with grade Ⅰ T1b GBC.In patients with grade Ⅱ T1b GBC,obvious survival improvement was observed in the OS(P=0.002)and DSS(P=0.039)of those who underwent SC+LN(10-year OS:34.6%,10-year DSS:61.3%)or RC(10-year OS:50.5%,10-year DSS:78.8%)compared with those who received SC(10-year OS:28.1%,10-year DSS:58.3%).Among patients with grade Ⅲ or Ⅳ T1b GBC,SC+LN(10-year OS:48.5%,10-year DSS:72.2%),and RC(10-year OS:80%,10-year DSS:80%)benefited OS(P=0.005)and DSS(P=0.009)far more than SC(10-year OS:20.1%,10-year DSS:38.1%)alone.CONCLUSION Simple cholecystectomy may be an adequate treatment for grade Ⅰ T1b GBC,whereas more extensive surgery is optimal for grades Ⅱ-Ⅳ T1b GBC.

Contribution of Cytology for the Diagnosis of Gallbladder Carcinoma to Avoid Misdiagnosis in This Commonly Resected Organ

The cytological study of gallbladder bile is a diagnostic tool used very often in the treatment of gallbladder cancer. The diagnosis of gall bladder cancer is done by morphological examinations such as ultrasound, computed tomography in 80% of cases, but in some difficult cases, benign lesions associated with malignant lesions, such as pseudo-tumoral cholecystitis, adenomyosis or adenoma and cancers requiring medical treatment by chemotherapy or radiotherapy, is without the possibility of surgical treatment. Cytology can help resolve a number of difficult situations, such as the presence of an intra-gallbladder lesion in the form of a polyp or nodule. Some studies have reported very interesting results from gallbladder cytology to cancer diagnosis with results up to 85% sensitivity. The purpose of this study is to analyze the contribution of the cytological study of gallbladder bile to the positive diagnosis of gallbladder cancer.

Role of adjuvant chemoradiotherapy and chemotherapy in patients with resected gallbladder carcinoma: a multiinstitutional analysis (KROG 19-04)

Objective:The effectiveness of adjuvant treatments for resected gallbladder carcinoma(GBC)has remained unclear due to lack of randomized controlled trials;thus,the aim of present study was to evaluate the role of adjuvant treatments,including chemoradiotherapy(CRT)and/or chemotherapy(CTx),in patients with resected GBC.Methods:A total of 733 GBC patients who received curative-intent surgical resection were identified in a multi-institutional database.Of 733 patients,372(50.8%)did not receive adjuvant treatment,whereas 215(29.3%)and 146(19.9%)received adjuvant CTx and CRT,respectively.The locoregional recurrence-free survival(LRFS),recurrence-free survival(RFS),and overall survival(OS)of the adjuvant treatment groups were compared according to tumor stage(stage II vs.stage III–IV).Results:In stage II disease(n=381),the 5-year LRFS,RFS,and OS were not significantly different among the no-adjuvant therapy,CTx,and CRT groups,and positive resection margin,presence of perineural invasion,and Nx classification were consistently associated with worse LRFS,RFS,and OS in the multivariate analysis(P<0.05).For stage III–IV(n=352),the CRT group had significantly higher 5-year LRFS,RFS,and OS than the no-adjuvant therapy and CTx groups(67.8%,45.2%,and 56.9%;37.9%,28.8%,and 35.4%;and 45.0%,30.0%,and 45.7%,respectively)(P<0.05).Conclusions:CRT has value as adjuvant treatment for resected GBC with stage III–IV disease.Further study is needed for stage II disease with high-risk features.

Gallbladder neuroendocrine carcinoma diagnosis, treatment and prognosis based on the SEER database: A literature review

BACKGROUND Gallbladder neuroendocrine carcinoma(GB-NEC)has a low incidence rate;therefore,its clinical characteristics,diagnosis,treatment and prognosis are not well explored.AIM To review recent research and analyze corresponding data in the Surveillance Epidemiology and End Results(SEER)database.METHODS Data of GB-NEC(n=287)and gallbladder adenocarcinoma(GB-ADC)(n=19484)patients from 1975 to 2016 were extracted from the SEER database.Survival analysis was performed using Kaplan–Meier and Cox proportional hazards regression.P<0.05 was considered statistically significant.We also reviewed 108 studies retrieved from PubMed and Reference Citation Analysis(https://www.referencecitationanalysis.com/).The keywords used for the search were:"(Carcinoma,Neuroendocrine)AND(Gallbladder Neoplasms)".RESULTS The GB-NEC incidence rate was 1.6%(of all gallbladder carcinomas),male to female ratio was 1:2 and the median survival time was 7 mo.The 1-,2-,3-and 5-year overall survival(OS)was 36.6%,17.8%,13.2%and 7.3%respectively.Serum chromogranin A levels may be a specific tumor marker for the diagnosis of GBNEC.Elevated carcinoembryonic antigen,carbohydrate antigen(CA)-19-9 and CA-125 levels were associated with poor prognosis.Age[hazard ratio(HR)=1.027,95%confidence interval(CI):1.006–1.047,P=0.01]and liver metastasis(HR=3.055,95%CI:1.839–5.075,P<0.001)are independent prognostic risk factors for OS.Patients with advanced GB-NEC treated with surgical resection combined with radiotherapy and/or chemotherapy may have a better prognosis than those treated with surgical resection alone.There was no significant difference in OS between GB-NEC and GB-ADC.CONCLUSION The clinical manifestations and prognosis of GB-NEC are similar to GB-ADC,but the treatment is completely different.Early diagnosis and treatment are the top priorities.

Therapeutic strategies for gastroenteropancreatic neuroendocrine neoplasms: State-of-the-art and future perspectives

Although gastroenteropancreatic neuroendocrine neoplasms(GEP-NENs)have always been considered rare tumors,their incidence has risen over the past few decades.They represent a highly heterogeneous group of neoplasms with several prognostic factors,including disease stage,proliferative index(Ki67),and tumor differentiation.Most of these neoplasms express somatostatin receptors on the cell surface,a feature that has important implications in terms of prognosis,diagnosis,and therapy.Although International Guidelines propose algorithms aimed at guiding therapeutic strategies,GEP-NEN patients are still very different from one another,and the need for personalized treatment continues to increase.Radical surgery is always the best option when feasible;however,up to 80%of cases are metastatic upon diagnosis.Regarding medical treatments,as GEP-NENs are characterized by relatively long overall survival,multiple therapy lines are adopted during the lifetime of these patients,but the optimum sequence to be followed has never been clearly defined.Furthermore,although new molecular markers aimed at predicting the response to therapy,as well as prognostic scores,are currently being studied,their application is still far from being part of daily clinical practice.As they represent a complex disease,with therapeutic protocols that are not completely standardized,GEP-NENs require a multidisciplinary approach.This review will provide an overview of the available therapeutic options for GEP-NENs and attempts to clarify the possible approaches for the management of these patients and to discuss future perspectives in this field.

The transition and current pattern of drug therapy for advanced gastric cancer

Gastric cancer is one of the most common malignant tumors in the world.Its incidence ranks fifth among all malignant tumors worldwide and is the third leading cause of death among cancer patients.Surgery is currently considered to be the only radical treatment.However,the low rate of early diagnosis means that most patients have an advanced-stage disease at diagnosis which lost the chance of surgery.Therefore,the main treatment for advanced gastric cancer includes chemotherapy,targeted therapy,immunotherapy.The purpose of this study is to review the transition and current patterns of drug therapy for advanced gastric cancer and to provide assistance for subsequent clinical studies in advanced gastric cancer.

Successful multimodality treatment of metastatic gallbladder cancer:A case report and review of literature

BACKGROUND Gallbladder cancer is the most common malignant tumor in the biliary system,and it is characterized by high aggressiveness and an extremely poor prognosis.Current treatment for advanced gallbladder cancer remains unsatisfactory.Here,we report a patient with advanced gallbladder cancer who was cured by multidisciplinary treatment.CASE SUMMARY A 73-year-old male presented to our hospital with right abdominal pain for 3 d and was diagnosed with stage IVB gallbladder cancer with multiple liver metastases,peritoneum metastasis,diaphragm metastasis and lymph node metastases.The patient initially received chemotherapy,targeted therapy,125I seed implantation and immunotherapy,as there were no specific indications for radical surgery.During these palliative therapies,the level of tumor markers gradually decreased but remained higher than the normal level,lymph node metastases gradually disappeared,and liver metastasis was gradually limited to the left liver.Finally,the patient received radical surgery with left hepatectomy,radical lymphadenectomy and partial diaphragmatic resection.To date,the patient has survived for more than six years posttreatment,the levels of tumor markers are normal,and imaging examinations show no signs of tumor recurrence.CONCLUSION Currently,the prognosis of advanced gallbladder cancer remains unsatisfactory.A single treatment method is not sufficient for patients with advanced gallbladder cancer.Multidisciplinary individualized treatment is essential and should be utilized for advanced gallbladder cancer patients to further improve prognosis.

Efficacy and safety of endoscopic transpapillary gallbladder drainage in acute cholecystitis:An updated meta-analysis

BACKGROUND Percutaneous transhepatic gallbladder drainage has been the most frequently performed treatment for acute cholecystitis for patients who are not candidates for surgery.Endoscopic transpapillary gallbladder drainage(ETGBD)has evolved into an alternative treatment.There have been numerous retrospective and prospective studies evaluating ETGBD for acute cholecystitis,though results have been variable.AIM To evaluate the efficacy and safety of ETGBD in the treatment of inoperable patients with acute cholecystitis.METHODS We performed a systematic review of major literature databases including PubMed,OVID,Science Direct,Google Scholar(from inception to March 2021)to identify studies reporting technical and clinical success,and post procedure adverse events in ETGBD.Weighted pooled rates were then calculated using fixed effects models for technical and clinical success,and post procedure adverse events,including recurrent cholecystitis.RESULTS We found 21 relevant articles that were then included in the study.In all 1307 patients were identified.The pooled technical success rate was 82.62%[95%confidence interval(CI):80.63-84.52].The pooled clinical success rate was found to be 94.87%(95%CI:93.54-96.05).The pooled overall complication rate was 8.83%(95%CI:7.42-10.34).Pooled rates of post procedure adverse events were bleeding 1.03%(95%CI:0.58-1.62),perforation 0.78%(95%CI:0.39-1.29),peritonitis/bile leak 0.45%(95%CI:0.17-0.87),and pancreatitis 1.98%(95%CI:1.33-2.76).The pooled rates of stent occlusion and migration were 0.39%(95%CI:0.13-0.78)and 1.3%(95%CI:0.75-1.99)respectively.The pooled rate of cholecystitis recurrence following ETGBD was 1.48%(95%CI:0.92-2.16).CONCLUSION Our meta-analysis suggests that ETGBD is a feasible and efficacious treatment for inoperable patients with acute cholecystitis.

Early Gallbladder Cancer: Clinical, Morphological, Therapeutic and Evolutionary Aspects

Introduction: The early cancer of gallbladder is an entity which is not well recognized currently. It is a cancer which does not extend beyond the muscularis layer of the gallbladder and it is characterized in almost of cases by the absence of lymph node and visceral invasion. Patients and Method: We have conducted this retrospective study of all our cases of early gallbladder cancer treated in our surgical unit. We have studied these through clinical, morphological, therapeutical and evolutionary aspects. Results: Of 202 gallbladder carcinoma, 33 cancers were classified as early cancer. 25 were females and 8 were males. The mean age was 56.4 years (41 -?70 years). All patients were free of gallbladder cancer symptoms and all except one had normal CEA and CA19.9. 2 patients had synchronous tumors (one colonic cancer and one rectal cancer). For 16 patients, the diagnosis was done by ultrasonography and 17 by histological examination of the specimen removed for biliary lithiasis. 8 patients had PT1a tumor (confined only to mucosa) and 25 had PT1b tumor (tumor infiltration of the muscular layer). For 19 patients who benefited from extensive lymphadenectomy, only one (5.3%) had lymph node infiltration. 16 patients had a simple cholecystectomy and in two cases, the cholecystectomy was associated with bile duct resection. 17 patients had hepatectomy with extensive lymphadenectomy. 2 patients had a simultaneous right colectomy and abdominoperineal resection and another one benefited from choledocal cyst resection. 3 patients benefited from stone removal from bile duct and two had tumor removal from bile duct (ruptured tumor in the bile duct). 1 patient (3.7%) died in postoperative course (hospital mortality). In the follow-up period, 4 patients died from intercurrent causes. Two patients presented a recurrence at 14 and 36 months and died respectively at 19 and 42 months. One patient presented a bile duct cancer at 66 months. She died at 78 months after palliative treatment. Currently, 22 patients (66.7%) are still alive without recurrence with mean and median survival of 53 and 31 months. Conclusion: Early gallbladder cancer is an entity which must be known by the radiologist and the surgeon. Recognized on time and well treated, early gallbladder cancer can be cured and its prognosis is excellent.

Current status and progress in laparoscopic surgery for gallbladder carcinoma

Gallbladder carcinoma(GBC)is the most common biliary tract malignancy associated with a concealed onset,high invasiveness and poor prognosis.Radical surgery remains the only curative treatment for GBC,and the optimal extent of surgery depends on the tumor stage.Radical resection can be achieved by simple cholecystectomy for Tis and T1a GBC.However,whether simple cholecystectomy or extended cholecystectomy,including regional lymph node dissection and hepatectomy,is the standard surgical extent for T1b GBC remains controversial.Extended cholecystectomy should be performed for T2 and some T3 GBC without distant metastasis.Secondary radical surgery is essential for incidental gallbladder cancer diagnosed after cholecystectomy.For locally advanced GBC,hepatopancreatoduodenectomy may achieve R0 resection and improve long-term survival outcomes,but the extremely high risk of the surgery limits its implementation.Laparoscopic surgery has been widely used in the treatment of gastrointestinal malignancies.GBC was once regarded as a contraindication of laparoscopic surgery.However,with improvements in surgical instruments and skills,studies have shown that laparoscopic surgery will not result in a poorer prognosis for selected patients with GBC compared with open surgery.Moreover,laparoscopic surgery is associated with enhanced recovery after surgery since it is minimally invasive.

Synchronous primary duodenal papillary adenocarcinoma and gallbladder carcinoma:A case report and review of literature

BACKGROUND Synchronous primary cancers(SPCs) have become increasingly frequent over the past decade.However,the coexistence of duodenal papillary and gallbladder cancers is rare,and such cases have not been previously reported in the English literature.Here,we describe an SPC case with duodenal papilla and gallbladder cancers and its diagnosis and successful management.CASE SUMMARY A 68-year-old Chinese man was admitted to our hospital with the chief complaint of dyspepsia for the past month.Contrast-enhanced computed tomography of the abdomen performed at the local hospital revealed dilatation of the bile and pancreatic ducts and a space-occupying lesion in the duodenal papilla.Endoscopy revealed a tumor protruding from the duodenal papilla.Pathological findings for the biopsied tissue revealed tubular villous growth with moderate heterogeneous hyperplasia.Surgical treatment was selected.Macroscopic examination of this surgical specimen revealed a 2-cm papillary tumor and another tumor protruding by 0.5 cm in the gallbladder neck duct.Intraoperative rapid pathology identified adenocarcinoma in the gallbladder neck duct and tubular villous adenoma with high-grade intraepithelial neoplasia and local canceration in the duodenal papilla.After an uneventful postoperative recovery,the patient was discharged without complications.CONCLUSION It is essential for clinicians and pathologists to maintain a high degree of suspicion while evaluating such synchronous cancers.

Glyco-sphingo biology: a novel perspective for potential new treatments in Huntington's disease

Huntington＇s disease （HD） is the most common dominantly inherited neurodegenerative disorder, mainly characterized by the progressive striatal and cortical neurodegeneration and as- sociated motor, cognitive and behavioural disturbances （Zuccato et al., 2010）. The disease-causing mutation is an expansion of a GAG trinucleotide repeat （〉 36 repeats） encoding a polygluta- mine stretch in the N-terminal region ofhuntingtin （Htt） （Zuc- cato et al., 2010）, a ubiquitous protein whose function is still unclear （Zuccato et al., 2010）. Expansion of the polyQ stretch endows mutant Htt （mHtt） with toxic properties, and results in the development of a broad array of undesirable effects in both neuronal and non-neuronal cells （Zuccato et al., 2010）. Among all cellular dysfunctions and biochemical imbalances classically associated with HD, perturbed metabolism of （glyco） sphingolipids appears to play a crucial role in the pathogenesis of the disease. Over the last years, we and other have extensively contributed to these findings （Desplats et al., 2007;

Predicting portal venous anomalies by left-sided gallbladder or rightsided ligamentum teres hepatis: A large scale, propensity scorematched study

BACKGROUND Right-sided ligamentum teres(RSLT)is often associated with portal venous anomalies(PVA)and is regarded as a concerning feature for hepatobiliary intervention.Most studies consider RSLT to be one of the causes of left-sided gallbladder(LGB),leading to the hypothesis that LGB must always be present with RSLT.However,some cases have shown that right-sided gallbladder(RGB)can also be present in livers with RSLT.AIM To highlight the rare variation that RSLT may not come with LGB and to determine whether ligamentum teres(LT)or gallbladder location is reliable to predict PVA.METHODS This study retrospectively assessed 8552 contrast-enhanced abdominal computed tomography examinations from 2018 to 2021[4483 men,4069 women;mean age,59.5±16.2(SD)years].We defined the surrogate outcome as major PVAs.The cases were divided into 4 subgroups according to gallbladder and LT locations.On one hand,we analyzed PVA prevalence by LT locations using gallbladder location as a controlled variable(n=36).On the other hand,we controlled LT location and computed PVA prevalence by gallbladder locations(n=34).Finally,we investigated LT location as an independent factor of PVA by using propensity score matching(PSM)and inverse probability of treatment weighting(IPTW).RESULTS We found 9 cases of RSLT present with RGB.Among the LGB cases,RSLT is associated with significantly higher PVA prevalence than typical LT[80.0%vs 18.2%,P=0.001;OR=18,95%confidence interval(CI):2.92-110.96].When RSLT is present,we found no statistically significant difference in PVA prevalence for RGB and LGB cases(88.9%vs 80.0%,P>0.99).Both PSM and IPTW yielded balanced cohorts in demographics and gallbladder locations.The RSLT group had a significantly higher PVA prevalence after adjusted by PSM(77.3%vs 4.5%,P<0.001;OR=16.27,95%CI:2.25-117.53)and IPTW(82.5%vs 4.7%,P<0.001).CONCLUSION RSLT doesn't consistently coexist with LGB.RSLT can predict PVA independently while the gallbladder location does not serve as a sufficient predictor.

经皮经肝胆囊穿刺引流联合腹腔镜胆囊切除术序贯治疗急性胆囊炎最佳手术时机的临床研究

目的探讨经皮经肝胆囊穿刺引流(PTGBD)联合腹腔镜胆囊切除术(LC)序贯治疗急性胆囊炎的最佳手术时机。方法选取2021年6月至2022年6月于九江市第一人民医院接受PTGBD联合LC序贯治疗的66例急性胆囊炎患者作为研究对象,根据手术时间不同分为对照组与观察组,每组33例。对照组于发病后1周内行PTGBD,观察组于发病1周后行PTGBD,两组均择期行LC序贯治疗。比较两组围手术期指标、治疗前后肝功能指标、炎症因子指标及术后并发症和中转开腹发生率。结果两组住院费用比较差异无统计学意义;观察组术中出血量少于对照组,手术时间、住院时间均短于对照组,差异有统计学意义(P<0.05)。治疗后,观察组冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT、)、γ-谷氨酰基转移酶(γ-GT)水平均低于对照组,差异有统计学意义(P<0.05)。治疗后,观察组C反应蛋白(CRP)、白细胞介素(IL)-6、肿瘤坏死因子-α(TNF-α)水平均低于对照组,差异有统计学意义(P<0.05)。观察组术后并发症及中转开腹发生率均低于对照组,差异有统计学意义(P<0.05)。结论发病1周后行PTGBD联合LC序贯治疗急性胆囊炎,可有效改善患者肝功能,快速降低机体炎症因子水平,且可减少中转开腹及术后并发症的发生,手术风险更低,有助于促进患者术后尽快恢复,值得临床应用推广。

乳腺癌“应激治乳”新理论的构建与临床应用探讨

应激是生物体对内、外源性刺激的一种非特异的适应性反应,有助于维持机体内环境稳态。然而当应激反应的程度超过机体适应阈值,即可诱发多种疾病。乳腺癌发病率和死亡率高居女性恶性肿瘤前列,乳腺病领域首位国医大师林毅教授创立“六郁治乳”理论,认为六郁是乳腺癌发生发展的核心病机,而六郁与机体应激反应系统密切相关,中医药在调整应激稳态平衡领域有特色优势。该文基于中医经典理论、“六郁治乳”理论及现代应激理论,提出“应激治乳”学说,阐释应激因素介导乳腺癌发生发展的病机特性、致病特点、分子机制,提出基于应激稳态调控的核心思想和辨治原则,总结“应激治乳”理论指导下的遣方用药。“应激治乳”理论的构建丰富了中医乳腺癌理论体系,有望为改善乳腺癌患者的临床预后提供新路径。

肝胃不和胃脘痛辨治经验

胃脘痛包括现代医学的各种急慢性胃炎和消化性溃疡,是消化系统常见病、多发病。在中医学藏象学说和病因病机理论中,肝胃不和是导致胃脘痛发作的主要病机之一,若肝的疏泄功能失职,导致气滞、气郁、化火、克脾等皆可直接或间接影响胃之通降,形成肝病及胃或肝胃同病,均可导致胃脘痛。笔者根据肝胃不和的临床表现将肝胃不和病机归纳总结为肝气郁结、胃失和降,肝郁化火、肝胃郁热,肝郁气滞、肝胃阴虚,肝胃气滞、气滞血瘀,肝郁脾虚、胃失和降,胆胃不和、气逆不降,胆胃郁热、痰湿中阻7个证型。现就肝胃不和辨证和治法方药进行梳理分析,以期对临床辨治胃脘痛有一定的借鉴。