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Journal: Zhonghua wai ke za zhi [Chinese journal of surgery]

22

Objective: To compare the clinical efficacy of transcystic biliary drainage with nasobiliary drainage during primary closure following laparoscopic choledochotomy. Methods: The clinical data of 106 patients with cholecystolithiasis and choledocholithiasis treated by laparoscopy at Department of General Surgery, Danyang People’s Hospital from May 2014 to June 2017 were analyzed prospectively. The patients were divided into 2 groups by means of random number method: the study group was treated with transcystic biliary drainage, and the control group adopted nasobiliary drainage. The operation time, postoperative drainage volume, postoperative hospital stay and postoperative complications were compared between the 2 groups. Results: All patients in the two groups completed the operation successfully. Compared with nasobiliary drainage, the operation time of transcystic biliary drainage was shortened ((133.9±14.7) minutes vs. (143.3±21.7) minutes, t=-2.617, P<0.05). Postoperative hospital stay ((8.2±1.7) days vs. (7.7±2.5) days), the difference between the two groups was not statistically significant(P>0.05). The quantity of bile drainage was no significant difference in the two groups of patients. There were 1 case of duct obstruction and 2 cases of catheter slippage during transcystic biliary drainage, without causing bile leakage. During nasobiliary drainage, there were 3 cases of catheter obstruction, 1 case of catheter slippage, 2 cases of self extubation, 1 case of bile peritonitis caused by catheter blockage, transferred to laparotomy and T tube drainage. The patients were followed up for 1 month to 17 months, with an average of 8 months. B-ultrasound showed no bile duct stenosis and hepatic function was normal. Conclusions: Transcystic biliary drainage could achieve the same biliary drainage as well as nasobiliary drainage during primary closure following laparoscopic choledochotomy. In addition, transcystic biliary drainage maintain the physiological function of bile duct, it is simple and minimally invasive under certain conditions.

Concepts: Surgery, Statistical significance, Liver, Addition, Hepatology, Bile, Bile duct, Gallstone

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In order to provide the clinical guidelines of acute thoracolumbar injury for the Chinese orthopedic surgeons, the Spine Trauma Group of Chinese Association of Orthopedic Surgeons compiled this guideline. The guideline applies to adult patients with acute (less than 3 weeks) thoracolumbar fracture and(or) dislocation with or without spinal cord, cauda equina or nerve root injuries. The Study Group wrote the guideline by setting up questions, determining search words, screening literatures according to inclusion and exclusion criteria, analyzing the included literatures, confirming evidence levels and then providing recommendations. The guideline include 247 literatures, of which 35 articles were in Chinese and 212 articles were in English. The guidelines set up 20 questions divided into 4 sections: pre-hospital care, diagnosis and evaluation, treatment and prevention of complications, which include 39 recommendations.

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In order to standardize the diagnosis and treatment of early onset scoliosis (EOS) and to improve the quality of care in dealing with the spectrum of multidisciplinary diseases, the EOS treatment guideline task force from the Chinese Association of Orthopedic Surgeons compiled this guideline. The guideline is based on epidemiological data, evidence-based literature and clinical studies, combined with recent technological advances globally. The task force have discussed and reviewed together, revised constantly and finally finalized this paper. Hopefully, the guideline will be refined in clinical practice to further improve the diagnosis and treatment of EOS in China.

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Objective: To explore preoperative predictive markers for invasive malignancy in intraductal papillary mucinous neoplasm(IPMN). Methods: The retrospective case-controlled study was adopted.Seventy-nine patients who underwent surgery and with pathologically confirmed IPMN from January 2005 to December 2014 at Department of Pancreatic Surgery, Zhongshan Hospital Fudan University were enrolled.Forty-six patients were male and 33 were female,with an average age of (62.9±8.9)years (range:37-82 years).Tumor sites:56 tumors were located at the head of the pancreas,22 were located at the body and tail of the pancreas,and 1 was located across the whole pancreas.Surgical procedures: 51 patients underwent pancreaticoduodenectomy, 22 patients underwent distal pancreatectomy, 4 patients underwent segmental pancreatectomy and 2 patients underwent total pancreatectomy.IPMNs were classified into non-invasive lesions and invasive carcinomas according to the histopathological findings of the tumor.Thirty-two tumors were non-invasive lesions and 47 were invasive carcinomas.The preoperative findings were compared between patients with non-invasive IPMN and patients with invasive carcinoma by univariate analysis using t test and χ(2) test accordingly,and factors with statistically significance were subsequently submitted to multivariate analysis. Results: Univariate analysis showed that tumor size(P=0.022), carcinoembryonic antigen(P=0.012), CA19-9(P=0.011), lymphocytes(P=0.034), neutrophil-to-lymphocyte ratio(P=0.010)and platelet-to-lymphocyte ratio(PLR)(P=0.004)were predictive markers with statistical significance.Multivariate analysis showed that CA19-9(P=0.012)and PLR(P=0.025) were independent predictive markers for invasive malignancy in IPMN.The area under curve of the combination factor of CA19-9 and PLR(0.864) was larger than that of CA19-9(0.806) or PLR(0.685) alone, and all the authentic indicators of the combination factor were better than those of each alone. Conclusions: CA19-9 and PLR are independent predictive markers for invasive malignancy in IPMN.The combination of CA19-9 and PLR has improved efficacy than each alone.

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Objective: To investigate the clinical application value of using laminoplasty combine with short-segment pedicle screw fixation in the treatment of cervical spine trauma patients with ossification of posterior longitudinal ligament (OPLL). Methods: Fifty-four cervical spine trauma patients with OPLL from June 2014 to June 2016 were retrospectively analyzed of Department of Spine Surgery, Changzheng Hospital, Naval Military Medical University. There were 31 males and 23 females, aging (68.4±4.3) years (rang: 46 to 82 years). All patients had a history of cervical spine trauma, confirmed by imaging examination of OPLL, and there are signs and symptoms related to cervical spinal cord compression. Eighteen patients underwent one-stage laminoplasty combine with short-segment pedicle screw fixation(group A), and 15 patients underwent posterior cervical laminectomy and pedicle screw fixation (group B). Twenty-one patients underwent posterior laminoplasty (C group). According to the range of OPLL and the compression of the spinal cord, the range of laminoplasty was selected. MRI scan was used to evaluated the compression condition of cervical spine and the injury condition of anterior longitudinal ligament injury and other factors that can cause local instability of the cervical spine. Posterior unilateral pedicle screw fixation (two pedicles) were performed in the instability segment. The neurological function of the patients was assessed by the Japanese Orthopedic Association (JOA) Score before surgery, the second day after surgery, 3 months, 1 year and the last follow-up. The cervical spine X-ray films were used to evaluate cervical curvature, cervical spine activity and internal fixation-related complications. Results: The average follow-up time was 18 months (6-30 months). Satisfactory neurological improvement was achieved in all three groups, and no internal fixation-related complications occurred during follow-up. The range of laminoplasty was 22 cases in 4 segments (C(3)-C(6), C(4)-C(7)) and 17 cases in 5 segments (C(3)-C(7)). Unilateral pedicle screw fixation was performed in 11 patients with C(3-4) fixation and 7 patients with C(4-5) fixation. Cervical curvature was basically the same in the three groups after operation and at the last follow-up. No significant changes in cervical curvature and kyphosis were observed during the follow-up period. The overall cervical mobility (C(2)-C(7)) in group A and group C had no significant difference compared with preoperative (P=0.077). The overall mobility of cervical vertebrae in group B was significantly lower than that before surgery (P=0.013). Conclusions: For cervical spine trauma patients with OPLL, laminoplasty combined short-segment pedicle screw fixation can increase cervical segmental stability while extensive decompression of cervical spinal cord compression. At the same time, to some extent, the complications of postoperative axial symptoms caused by posterior cervical laminectomy and pedicle screw fixation were avoided.

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Objective: To analyze the clinical effects of all-inside arthroscopic treatment for the patients of avulsion fracture of tibial origin withⅠdegree supination and external rotation injury according to the Lauge-Hansen classification. Methods: A retrospective analysis of 34 patients (34 feet) who had underwent all-inside arthroscopic for avulsion fracture of tibial origin with Ⅰ degree supination and external rotation injury from September 2015 to September 2017 in Department of Hand and Foot Microsurgery, Xuzhou Central Hospital. There were 20 males and 14 females, aged (24.7±11.3)years (range:14-43 years). The duration from injury to operation was (4.3±2.5) d (range: 6 h-7 d). The pro-operation visual analogue scale(VAS) of pain was 6.8±1.4(range: 4-8). All the patients were treated with the all-inside arthroscopic procedure by using the anterolateral and near-anterolateral portals and the fractures were fixed with cannulated screws. Main outcome measures included the pain, foot appearance, and patients were scored using the American Orthopaedic Foot & Ankle Society Lesser Toe Metatarsophalangeal-Interphalangeal Scale(AOFAS). Results: Primarily healing of the wound was achieved in all cases without postoperative complications of nerve, vessel and tendon injury. The follow-up period was (16.9±6.6)months(range: 8-24 months). Postoperatively X-ray films showed complete fracture healing at (11.2±2.1)weeks after surgery.At the last follow-up, the ankle movement and appearance were good, and no ankle joint traumatic arthritis were found. The VAS and AOFAS was 0 and 95.7±9.4 respectively. Conclusion: The all-inside arthroscopic treatment of Lauge-Hansen type avulsion fracture of tibial origin with Ⅰ degree supination and external rotation injury is an effective and precise method, with accurately outcomes, precise reduction and minimally postoperative complications.

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Objective: To investigate the influence of different discontinuation time of aspirin and clopidogrel before off-pump coronary artery bypass grafting (OPCABG) on postoperative bleeding and blood products transfusion requirement. Methods: Three hundred and fifty-three coronary artery disease patients who underwent OPCABG from January 2017 to January 2018 at Department of Cardiac Surgery, Zhongshan Hospital, Fudan University were retrospectively analysed. There were 268 males and 85 females, aged (66.0±9.1)years. All patients were divided into three groups: (1) guideline-recommended group: patients who discontinued clopidogrel for >5 days without discontinuing aspirin before surgery; (2) without discontinuing group: patients who discontinued clopidogrel for ≤5 days without discontinuing aspirin before surgery; (3) discontinuing group: patients who discontinued clopidogrel for >5 days with discontinuing aspirin before surgery. Postoperative bleeding recorded as chest tube drainage (CTD) volume and blood products transfusion requirement and perioperative complications were recorded. CTD volumes within 12 hours after surgery between groups were compared by Mann-Whitney U tests, CTD volumes after 12 hours postoperatively were compared by repeated measures analysis of variance and blood products transfusion and complications incidence were compared by χ(2) test or Fisher’s precise test. Results: The 12 hours CTD volumes of guideline-recommended group, without discontinuing group, discontinuing group after surgery were 280(153) ml (M(Q®)), 291(229) ml, 225(161) ml, respectively. There were no significant differences in postoperative 12 hours CTD volumes (P=0.865), red blood cells transfusion incidence (χ(2)=2.626, P=0.149) and fresh frozen plasma (FFP) transfusion incidence (χ(2)=1.258, P=0.324) between guideline-recommended group and without discontinuing group. However, the 12 hours CTD volumes were significantly higher in guideline-recommended group patients compared with disconutinuing group patients (U=5 247, P=0.002). No significant differences were observed in red blood cells (χ(2)=0.182, P=0.757) and FFP (χ(2)=0.083, P=0.839) transfusion rate between these two groups. Repeated measures analysis of variance indicated that when patients began to take antiplatelet drugs (aspirin and clopidogrel) after 12 hours postoperatively, the change of CTD volumes beyond 12 hours after surgery didn’t differ either between guideline-recommended group and without discontinuing group (F=0.019, P=0.941) or between guideline-recommended group and discontinuing group (F=2.447,P=0.113). Besides, the incidence of perioperative arrhythmia was significantly higher in guideline-recommended group patients compared with without discontinuing group patients (4.8% vs. 0, χ(2)=5.073, P=0.038). Conclusions: OPCABG patients who discontinued aspirin before surgery had lower postoperative 12 hours CTD volumes but similar blood products transfusion rate and CTD volumes beyond 12 hours postoperatively compared with patients adhering to the current guideline-recommended protocol. And for patients who discontinued clopidogrel for ≤5 days, postoperative CTD volumes and blood products transfusion requirement were similar but the incidence of perioperative arrhythmia was significantly lower compared with guideline-treated patients.

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Objective: To investigate application value of “point-line-surface-volume” four dimensional holmium laser enucleation of prostate (HoLEP) in the treatment of benign prostatic hyperplasia (BPH). Methods: From December 2016 to November 2017, the clinical data of 60 cases of BPH with the treatment of “Point-line-surface-volume” four dimensional HoLEP at Department of Urology, Peking University Third Hospital were analyzed retrospectively. The age was (73.8±8.0) years (range: 60 to 96 years), body mass index was (23.2±3.6) kg/m(2) (range: 14.9 to 31.1 kg/m(2)), volume of prostate was (64.5±36.9) ml (range: 15.5 to 197.9 ml). All the cases were operated by the same chief surgeon expert in endoscopic surgery. First of all, taking verumontanum as the anchor point, crossing point between the outer 45° line of verumontanum and middle line of the lateral lobe and verumontanum was made as the breakthrough point. The “blasting and paddling” method was used to find prostatic surgery capsule, and the two sides of the capsule plane were connected in front of the verumontanum. Secondly, the plane was maintained by the “fan tunnel” method, and the middle lobe and the lateral lobes were divided at the 5 o'clock and 7 o'clock positions. The glands of the middle lobe were first removed and pushed into the bladder. Then, on the anteroinferior inclined coronal plane through 12 o'clock point right above of verumontanum, the urethral mucosa was cut apart in a semi-curved shape in advance. Bilateral semi-curved incision confluenced above the verumontanum, and extend to the bladder neck to form an inverted Y-shaped groove which completely divided the bilateral lobes. Finally, the bilateral lobes were enucleated respectively, and glands in the bladder were removed by tissue morcellator. Clinical data included operative time, hemoglobin decrease, catheterization duration, postoperative hospital stay, preoperative and postoperative international prostate symptom score and quality of life (QOL) score. The efficiency of enucleation was calculated as prostatic volume divided by enucleation time (not including morcellation time). The efficiency of morcellation was calculated as prostatic volume divided by morcellation time. Paired t-test was used to compare the indexes before and after surgery. Results: All the operations of 60 cases were sumlessful, one of which prostate tissue was removed by conversion to transurethral resection prostate due to malfunction of tissue morcellator. The operative time was (115.2±52.9) minutes (range: 25 to 276 minutes). The enucleation efficiency was (0.81±0.35) ml/minutes (range: 0.17 to 1.58 ml/minutes). The morcellation efficiency was (6.60±4.28) ml/minutes (range: 0.89 to 17.42 ml/minutes). The hemoglobin was decreased by (15.9±12.3) g/L (range:-10 to 57 g/L). Meanwhile, catheterization duration was (5.2±2.9) days (range: 0.8 to 19.8 days), and postoperative hospital stays were (5.0±1.5) days (range: 1.9 to 11.9 days). Preoperative and postoperative IPSS scores (10.92±6.98 vs. 23.37±7.49, t=10.357, P=0.000) and QOL scores (1.75±1.62 vs. 4.53±1.47, t=9.373, P=0.000) were significantly different. Postoperative complications included: 4 cases of fever (greater than 38.5 ℃), 1 case of acute epididymitis, 1 case of bladder mucosal injury, and 1 case of active bleeding need blood transfusion therapy. Conclusion: “Point-line-surface-volume” four dimensional HoLEP is an effective and safe minimally invasive method in the treatment of BPH.

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Objective: To explore the effects of various forms of prostatic apex on positive apical margin rate (PAM) and biochemical recurrence (BCR) after laparoscopic radical prostatectomy. Methods: A retrospective analysis of 309 patients (aging (65±6) years) who were experienced laparoscopic radical prostatectomy from January 2010 to December 2016 at the Department of Urology, First Affiliated Hospital of Fujian Medical University. According to the relationship between prostate apex and membrane urethra at the mid-sagittal plane of preoperative MRI, all patients were classified into 4 categories. There were 31 patients for type 1, apex covering both anterior and posterior aspects of membranous urethra, 139 patients for type 2, apex covering anterior side of membranous urethra, 63 patients for type 3, apex covering posterior aspect of membranous urethra, 76 patients for type 4, apex not covering membranous urethra. PAM and BCR after operation were compared between this four groups respectively. The χ(2) test was used to compare PAM among the 4 types. Logistic regression analysis were undertaken to analyze the factors affecting PAM. Cox’s proportional hazards regression model was undertaken to identify the variables influencing BCR. Results: There was no significant difference in the 4 groups concerning age, body mass index, prostate volume, preoperative prostate-specific antigen (PSA) value, postoperative Gleason score and pathological stage (P>0.05).The median follow-up time was 32 months (ranged from 12 to 60 months).The data showed that the apical type 3 patients has the highest PAM. There was statistical difference among the 4 groups in PAM (χ(2)=15.592, P=0.001). Preoperative level of PSA (OR=20.356, 95% CI: 2.440 to 169.810, P=0.005), postoperative Gleason score (OR=4.113, 95% CI: 1.911 to 8.849, P=0.001), pathological stage (OR=3.422, 95% CI: 1.600 to 7.319, P=0.002) and apical type 3 (OR=6.134, 95% CI: 2.196 to 17.132, P=0.001) were independent relactive factors of PAM. Preoperative level of PSA (HR=1.362, 95% CI: 1.006 to 1.843, P=0.045), postoperative Gleason score (HR=1.920, 95% CI: 1.384 to 2.665, P=0.001), pathological stage (HR=1.476, 95% CI: 1.098 to 1.983, P=0.010), PAM (HR=3.497, 95% CI: 2.407 to 5.081, P=0.001)and apical type 3 (HR=1.828, 95% CI: 1.266 to 2.639, P=0.001) were independent prognosis factors of BCR. Conclusion: Prostate apical type 3 could be a significant independent predictor of PAM, and an independent prognosis factor for BCR.

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Objective: To study the expression of ISYNA1 and association of ISYNA1 with clinicopathological significance in pancreatic ductal adenocarcinoma (PDAC). Methods: Collecting clinical data and specimens of 68 PDAC patients at Department of General Surgery, the First Hospital of China Medical University from March 2008 to December 2017.There were 39 males and 29 females, aged 33 to 81 years(median 59 years).The expression of ISYNA1 in 68 paraffin embedded PDAC specimens was detected by immunohistochemistry,in which 34 had paired non-cancerous pancreatic tissues,the relationship between ISYNA1 expression and clinicopathological parameters was analyzed; and the correlation between ISYNA1 and p53 in 48 PDAC specimens were estimated.qRT-PCR and Western blot were used to examine the expression of ISYNA1 mRNA and protein level in 17 paired fresh PDAC specimens and adjacent non-cancerous pancreatic tissues,respectively.siRNA interference was used to knockdown the expression of p53 in Capan-2,SW1990 and Miapaca-2 cells,and association of p53 with ISYNA1 expression was explored. Statistical methods included Student’s test,χ(2) test, Kaplan-Meier curve, Log-rank test and Pearson analysis, respectively. Results: Immunohistochemistry results showed that the expression of ISYNA1 in PDAC(3.681±2.198)was significantly lower than that in normal pancreatic tissues(6.012±3.428)(t=-3.611,P=0.001).In 17 paired fresh PDAC specimens,ISYNA1 mRNA expression in non-cancerous pancreatic tissues(()ΔC(T): (3.721±2.234)was obviously higher than that in PDAC tissues ()ΔC(T): (5).889±1.607) (t=-4.636,P<0.01), and ISYNA1 protein level in non-cancerous pancreatic tissues(0.815±0.418)was similarly higher than that in PDAC tissues(0.517±0.240)(t=2.948,P=0.009).χ(2) test showed the expression of ISYNA1 was negatively associated with tumor invasion depth(χ(2)=7.534,P=0.030)and vascular invasion(χ(2)=5.048,P=0.043);Pearson analysis showed there was no relationship between ISYNA1 and mutant p53(χ(2)=1.377,P=0.359).In p53 wild-type Capan-2 and SW1990 cells,Knockdown of p53 significantly down regulated ISYNA1 expression, whereas had no effect on ISYNA1 expression in p53 mutant Miapaca-2 cells. Kaplan-Meier survival analysis and Log-Rank test indicated patients with negative ISYNA1 expression had a shorter median survival time and poorer prognosis(χ(2)=4.953, P=0.026). Conclusions: The expression of ISYNA1 in PDAC tissues is significantly decreased,which is associated with the prognosis of PDAC patients,it is only related to wild type p53,and has no relationship with mutant p53.Abnormal expression of ISYNA1 may play an important role in the progression of PDAC.