Colorectal cancer (CRC) is one of the most common malignant tumors in China, ranking second in morbidity and fourth in mortality. Metastasis and recurrence are the leading causes of patient death, and the peritoneum is a frequent site of metastasis in CRC, second only to liver and lung metastases. However, the prognosis of peritoneal metastasis is much worse than hepatic and pulmonary metastasis. CRC peritoneal metastasis is challenging early diagnosis, presents with severe symptoms, and has a poor prognosis. It is crucial to emphasize standardized diagnosis and treatment for CRC peritoneal metastasis to improve patients' outcome and enhance their quality of life. This consensus, based on evidence-based medical evidence, revised the "Chinese Expert Consensus on the Diagnosis and Treatment of Colorectal Cancer Peritoneal Metastasis (2022 edition)" and reached a preliminary consensus on the definition, diagnosis, treatment, and prevention of CRC peritoneal metastasis, with the aim of guiding and standardizing the diagnosis and treatment of CRC peritoneal metastasis, developing reasonable and effective comprehensive treatment plans, prolonging survival time and improving quality of life for CRC peritoneal metastasis patients, thereby raising the overall level of diagnosis and treatment for CRC in China.
In recent years, the diagnosis and treatment of groin hernia have become more mature, and personalized treatment plans for different groin hernias have become more standardized. On the basis of the Guidelines for diagnosis and treatment on the adult groin hernia (2018 edition), more than 70 experts and scholars in China have discussed the consultation and modified the content of diagnosis and treatment of groin hernia in children and adolescents, diagnosis and treatment of scrotal hernia, management of hernia related complications, and postoperative education and follow-up in this new edition, combined with evidence-based medical evaluation standards. The relevant medical institutions and peers in China are requested to carry out the actual clinical reference.
Incisional hernia is a type of iatrogenic disease, and its clinical treatment is complicated. In recent years, there have been new advances in the diagnosis, surgical methods, and materials science of incisional hernias. On the basis of the Guidelines for diagnosis and treatment of abdominal wall incisional hernia (2018 edition), more than 70 experts and scholars over the country have discussed the consultation and modified the issues such as complex abdominal wall conditions, loss of domain, principles of incisional hernia treatment, techniques of abdominal wall hernia defects closure, perioperative management, and follow-up in this new edition, combined with evidence-based medical evaluation standards. The relevant medical institutions and peers in China are requested to carry out the actual clinical reference.
Background: Minimally invasive surgeries are increasingly central to modern medicine, particularly in liver transplantation. These techniques, which offer reduced trauma, precise operations, minimal bleeding, and swift recovery, are, however, unevenly adopted across China. Only a limited number of centers routinely perform minimally invasive donor hepatectomies, indicating a significant imbalance in the development and application of these advanced procedures. Additionally, there lacks a set of standardized guidelines that are tailored to meet China's unique healthcare challenges and conditions. Methods: In August 2023, the Branch of Organ Transplant of Chinese Medical Association and the Branch of Organ Transplant Physicians of Chinese Medical Doctor Association convened a group of national liver transplantation experts to establish a guideline development committee. This committee conducted a thorough review of relevant literature, evaluated existing guidelines and consensus, and assessed factors such as the evidence base, patient preferences, and the cost-effectiveness of interventions within China. After multiple rounds of discussions, both online and offline, the committee finalized the guidelines. Results: This collaborative effort led to the creation of the "Chinese guidelines for minimally invasive donor hepatectomy in living donor liver transplantation (2024 edition)". These guidelines address crucial aspects such as the safety and advantages of minimally invasive surgery for living donor liver transplantation, donor selection criteria, anesthesia strategies, surgical technical details, and learning curves associated with these procedures, resulting in a comprehensive set of 26 recommendations. Conclusions: The formulation of these guidelines represents a significant advancement towards standardizing minimally invasive liver transplantation surgeries in China. They are designed to enhance outcomes for both donors and recipients by synthesizing expert consensus with contemporary research and clinical practices. Moreover, they serve as a crucial reference for surgeons and medical institutions, promoting the refinement and adoption of minimally invasive surgical techniques in liver transplantation.
Morbid obesity and its accompanying diseases have become one of the most serious public health problems warranting global effort and bariatric and metabolic surgery is still the most effective method for long-term weight control. Among all bariatric and metabolic procedures, sleeve gastrectomy is currently the most widely used, but it is not a perfect procedure. One of the most serious issues that this surgical procedure faces is the possibility of worsening existing or developing de novo gastroesophageal reflux disease after surgery. Moreover, there is currently a lack of high-level clinical trial evidence on the diagnosis and treatment of gastroesophageal reflux disease in patients undergoing sleeve gastrectomy. Therefore, initiated by four domestic bariatric and metabolic surgery centers, 41 experts with rich experience in bariatric and metabolic surgery and diagnosis and treatment of gastroesophageal reflux disease from China, Japan, and South Korea reached a consensus on the diagnosis and treatment of gastroesophageal reflux disease in sleeve gastrectomy patients using the Delphi method. There are a total of 59 consultation questions in this consensus, of which 44 have reached a consensus. We hope that this consensus can not only serve as a reference for clinical diagnosis and treatment, but also provide more possible directions for future high-quality clinical research.
Objective To analysis the predictive factrors for pathologic complete response(pCR)and prognosis after neoadjuvant therapy of locally advanced gastric cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 662 patients with locally advanced gastric cancer who underwent neoadjuvant therapy in 12 medical centers,including Fudan University Shanghai Cancer Center,et al,from January 2018 to October 2023 were collected.There were 493 males and 169 females,aged 63(range,24-82)years.After neoadjuvant therapy,there were 331 patients with pCR and 331 patients without pCR.Observation indicators:(1)clinical characteristics of pCR and non-pCR patients after neoadjuvant therapy;(2)predictive factors for pCR after neoadjuvant therapy;(3)prognosis after neoadjuvant therapy;(4)prognostic factors analysis after neoadjuvant therapy.Measurement data with skewed distribution were represented as M(range),and comparison between groups was analyzed using the nonparameter rank sum test.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test.Logistic regression model was used to identify predictive factors for pCR.The Kaplan-Meier method was used to plot the survival curveand calculate the survival rate.The survival analysis was conducted using the Log-Rank test.The COX proportional risk regression model was used for univariate and multivariate analyses.Results(1)Clinical characteristics of pCR and non-pCR patients after neoadjuvant therapy.There were significant differences in the serum oncolo-gical indicators,tumor diameter,signet ring cell carcinoma,surgical procedures,neoadjuvant therapy pattern,postoperative N staging between pCR and non-pCR patients(P＜0.05).(2)Predictive factors for pCR after neoadjuvant therapy.Logistic regression analysis showed that serum oncological indi-cators,signet ring cell carcinoma and neoadjuvant therapy pattern were independent predictive factors for pCR after neoadjuvant therapy in locally advanced gastric cancer[odds ratio=0.479,0.290,1.451,95％confidence interval(CI)as 0.333-0.691,0.146-0.576,1.199-1.756,P＜0.05].(3)Prognosis after neoadjuvant therapy.All the 662 patients were followed up for 21.0(range,0.7-109.0)months.The overall survival rates were 88.2％and 69.8％for pCR and non-pCR patients,showing a significant difference between them(hazard ratio=0.351,95％CI as 0.228-0.431,P＜0.05).The disease-free survival rates were 87.3％and 61.9％for pCR and non-pCR patients,showing a significant difference between them(hazard ratio=0.285,95％CI as 0.226-0.416,P＜0.05).Further analysis:among the patients with negative lymph node metastasis after surgery,the overall survival rates were 90.4％and 69.8％for pCR and non-pCR patients,showing a significant difference between them(hazard ratio=0.292,95％CI as 0.237-0.475,P＜0.05).The disease-free survival rates were 87.7％and 58.3％for pCR and non-pCR patients,showing a significant difference between them(hazard ratio=0.279,95％CI as 0.232-0.431,P＜0.05).Among the patients with positive lymph node metastasis,the overall survival rates were 74.4％and 69.8％for pCR and non-pCR patients,showing no significant difference between them(hazard ratio=0.671,95％CI as 0.404-1.231,P＞0.05).The disease-free survival rates were 71.8％and 61.9％for pCR and non-pCR patients,showing no significant difference between them(hazard ratio=0.628,95％CI as 0.403-1.122,P＞0.05).Of pCR patients after neoadjuvant therapy,the overall survival rates were 87.8％and 89.7％for patients with and without postoperative adju-vant therapy,showing no significant difference between them(hazard ratio=0.710,95％CI as 0.268-1.693,P＞0.05).The disease-free survival rates were 85.9％and 88.2％for patients with and without postoperative adjuvant therapy,showing no significant difference between them(hazard ratio=0.919,95％CI as 0.417-2.010,P＞0.05).(4)Prognostic factors analysis after neoadjuvant therapy.Results of multivariate analysis showed that tumor diameter,postoperative N staging,pCR status were inde-pendent influencing factors for overall survival time after neoadjuvant therapy in locally advanced gastric cancer(hazard ratio=1.476,2.691,0.621,95％CI as 1.042-2.092,1.730-3.965,0.406-0.948,P＜0.05).Serum oncological indicators,tumor diameter neoadjuvant therapy pattern,postoperative N staging,pCR status were independent influencing factors for disease-free survival time after neo-adjuvant therapy in locally advanced gastric cancer(hazard ratio=1.477,1.474,0.780,2.182,0.472,95％CI as 1.080-2.020,1.069-2.030,0.635-0.958,1.509-3.154,0.316-0.704,P＜0.05).Conclusions Serum oncological indicators,signet ring cell carcinoma,and neoadjuvant therapy pattern are inde-pendent predictive factors for pCR after neoadjuvant therapy in locally advanced gastric cancer.The locally advanced gastric cancer patients with pCR after neoadjuvant therapy have better prognosis than patients with non-pCR.The survival benefits are more prevalent in pCR patients with negative lymph node metastasis after surgery,while the benefits in pCR patients with positive lymph node metastasis after surgery are comparable to non-pCR patients.Aadjuvant therapy after surgery may not improve the prognosis of pCR patients after neoadjuvant therapy.The pCR status is an indepen-dent influencing factor for overall survival and disease-free survival time after neoadjuvant therapy in locally advanced gastric cancer.
一、概述 根据中国国家癌症中心发布的数据,2022年全国原发性肝癌发病人数36.77万,位列各种癌症新发病人数第4位(肺、结直肠、甲状腺、肝),发病率位列第5位(肺、女性乳腺、甲状腺、结直肠、肝);2022年因原发性肝癌死亡人数31.65万,死亡人数和死亡率均位列第2位(肺、肝)[1-2].原发性肝癌主要包括肝细胞癌(hepatocellular carcinoma,HCC)、肝内胆管癌(intrahepatic cholangiocarcinoma,ICC)和混合型肝细胞癌-胆管癌(combined hepatocellular-cholangiocarcinoma,cHCC-CCA)3 种不同病理学类型,三者在发病机制、生物学行为、病理组织学、治疗方法以及预后等方面差异较大,其中HCC占75％～85％、ICC占10％～15％[3-4].本指南中的"肝癌"仅指HCC.
The increasing aging population in China leads to an increase in the number of elderly patients undergoing surgical procedures. Elderly patients are characterized with conditions such as multiple comorbidities, high nutritional risk, frailty, decreased organ function, etc. Nutritional support is one of the most significant elements in the perioperative period of elderly surgical patients. Currently, there is a lack of guidelines or expert consensus on nutritional support. To promote the standardized development of clinical work in this field, the Geriatric Surgery Professional Committee of the Chinese Research Hospital Association gathered experts and formulated relevant recommendations for perioperative nutritional therapy for elderly surgical patients based on existing research evidence. This consensus included several parts: preoperative nutritional assessment, indications, goals, ingredients and approaches of perioperative nutritional support, nutritional complications and management, nutritional intervention for surgical complications, and nutritional follow-up. It is expected to provide valuable suggestions for standardizing nutritional support for elderly surgical patients.
Objective:To investigate the short-term efficacy and safety of Donafenib as postoperative adjuvant therapy for patients with high risk of recurrence after radical resection of hepatocellular carcinoma (HCC).Methods:The propensity score matching (PSM) and retrospective cohort study was conducted. The clinicopathological data of 157 HCC patients with high risk of recurrence after radical resection who were admitted to 6 medical centers, including The First Affiliated Hospital of Nanjing Medical University et al, from June 2021 to February 2023 were collected. There were 128 males and 29 females, aged (59±10)years. Of 157 patients, 101 cases undergoing Donafenib as postoperative adjuvant therapy were divided into the the Donafenib group, and 56 cases under-going no systemic postoperative adjuvant therapy were divided into the control group. Observation indicators: (1) PSM and comparison of general data of patients between the two groups after matching; (2) postoperative treatment; (3) follow-up and survival of patients; (4) analysis of risk factors affecting recurrence-free survival of patients. PSM was done based on the principle of optimal perfect matching, with the clamp value of 0.5, and the Donafenib group and the control group were matched at a ratio of 1.25∶1. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers and/or percentages, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data between groups was conducted using the Kruskal-Wallis H test. The Kaplan-Meier method was used to calculate survival rates and draw survival curves, and the Log-Rank test was used for survival analysis. The COX proportional hazard model was used for univariate and multivariate analyses. Results:(1) PSM and comparison of general data of patients between the two groups after matching. Of 157 patients, 126 cases were successfully matched, including 70 cases in the Donafenib group and 56 cases in the control group, respectively. The elimination of tumor number confounding bias ensured comparability between the two groups after PSM. (2) Postoperative treatment. After PSM, of 70 patients in the Donafenib group, there were 23 cases receiving Donafenib monotherapy, 26 cases combined with transcatheter arterial chemoembolization (TACE), 14 cases combined with immunotherapy, and 7 cases combined with TACE+immunotherapy. Of 56 patients in the control group, there were 37 cases receiving postoperative follow-up alone and 19 cases combined with TACE. (3) Follow-up and survival of patients. All 157 patients were followed up, and the follow-up time of the 101 patients in Donafenib group and the 56 patients in control group were 10.1(range, 6.3-14.6)months and 22.2(range, 15.1-25.5)months, respectively. During the follow-up period, 70 patients in the Donafenib group experienced treatment-related adverse reactions, inclu-ding 8 cases of grade 3 adverse reactions, 23 cases of grade 2 and 39 cases of grade 1 adverse reactions, respectively. After PSM, the postoperative 12-, 18-month recurrence-free survival rates were 83.7%, 83.7% in the 70 patients of Donafenib group and 67.8%, 58.9% in the 56 patients of control group, respectively, showing a significant difference in the postoperative recurrence-free survival time between the two groups ( hazard ratio=0.395, 95% confidence interval as 0.176-0.888, P<0.05). (4) Analysis of risk factors affecting recurrence free survival of patients. Results of multivariate ana-lysis showed that microvascular invasion, vascular thrombus, clinical stage as ⅢA were independent risk factors affecting recurrence-free survival in patients with high risk of recurrence after radical resection of HCC ( hazard ratio=2.181, 2.612, 2.612, 95% confidence interval as 1.028-4.629, 1.128-6.047, 1.128-6.047, P<0.05), Donafenib as postoperative adjuvant therapy was an independent protective factor affecting recurrence-free survival in patients with high risk of recurrence after radical resection of HCC ( hazard ratio=0.457, 95% confidence interval as 0.227-0.920, P<0.05). Results of further analysis showed that after PSM, there were significant differences in the postoperative recurrence-free survival time in patients with different clinical factors, including male, age ≥60 years, tumor diameter >5 cm, positive microvascular invasion, positive hepatitis B virus infection, alpha fetoprotein <200 μg/L, between the Donafenib group and the control group ( hazard ratio=0.283, 0.202, 0.174, 0.345, 0.273, 0.180, 95% confidence interval as 0.114-0.707, 0.044-0.937, 0.038-0.794, 0.128-0.929, 0.091-0.819, 0.052-0.620, P<0.05). Conclusion:Donafenib as postoperative adjuvant therapy can effectively reduce the short-term recurrence rate in patients with high risk of recurrence after radical resection of HCC, with good safety and tolerance.
The standardization of surgical treatment has become indispensable in the overall outcome of esophageal cancer care in China, but there is a notable deficiency of clinical guidelines regarding esophageal surgery. The Chinese National Cancer Center organized esophageal surgery experts from the Chinese Association of Thoracic Surgeons (CATS), Chinese Society for Thoracic and Cardiovascular Surgery (CSTCVS), and Chinese Society for Disease of the Esophagus (CSDE) to develop and establish the Chinese Guidelines on Perioperative Management of Resectable Esophageal Cancer (2023 edition). This guideline comprehensively covers all aspects of surgical treatment for esophageal cancer, including conceptual clarification, preoperative diagnosis, clinical staging, indications for surgery, multidisciplinary comprehensive treatment, surgical treatment modalities, and perioperative management. A total of 39 critical clinical questions are categorized into six domains above. This guideline follows the globally accepted approach for developing recommendations and takes into account the most recent research evidence as well as China's unique national circumstances. Its main aim is to serve as a comprehensive resource for standardizing the diagnosis and surgical treatment of esophageal cancer in China, with the ultimate goal of substantially improving the overall outcomes.
Immune checkpoint inhibitors (ICIs)-based immunotherapy combined with other treatment for hepatocellular carcinoma (HCC) has achieved significant efficacy in clinical research and practice, and has become the most commonly used and mainstay therapy for the treatment of unresectable HCC. In order to help clinicians administrating immunotherapy drugs and regimens rationally, effectively and safely, we organized a multidisciplinary expert team to adopt the "Delphi" consensus formation method, and finally revised and completed the "Multidisciplinary Expert Consensus on Combination Therapy Based on the Immunotherapy for Hepatocellular Carcinoma (2023 Edition)" on the basis of the 2021 version. This consensus mainly focuses on the principles and methods of clinical application of combination therapy based on the Immunotherapy, aiming to summarize the recommendations for clinical application based on the latest research and expert experience, and provide application guidance for clinicians.
目的 构建基于术前增强CT检查的联合影像组学模型,预测肝细胞癌微血管侵犯(MVI)状态,对影像组学模型进行生物学解释.方法 采用回顾性队列研究方法.收集癌症基因组图谱数据库建库至2023年1月纳入的424例肝细胞癌患者的mRNA数据,癌症图像档案馆数据库建库至2023年1月纳入的39例肝细胞癌患者和甘肃省人民医院2020年1月至2023年1月收治53例肝细胞癌患者的临床病理资料.92例肝细胞癌患者通过随机数字表法按7∶3分为训练集64例和测试集28例.分析动脉期及门静脉期CT检查图像及临床资料.使用3Dslicer软件(5.0.3版本)进行动脉期和门静脉期图像配准和三维感兴趣区勾画.使用开源软件FAE(0.5.5版本)对原始图像进行预处理并提取特征.通过最小绝对收缩和选择算子等方法筛选特征,构建影像组学模型并计算影像组学评分(R-score),通过Logistic回归整合临床参数、影像学特征及R-score构建列线图.通过加权基因共表达网络分析和相关性分析获取影像组学模型相关的基因模块并进行富集分析.观察指标:(1)不同MVI性质患者的临床特征比较.(2)MVI风险模型的建立.(3)MVI风险模型的评估.(4)基因模块聚类.(5)特征相关基因模块功能富集.正态分布的计量资料以(x)±s表示,组间比较采用独立样本t检验,偏态分布的计量资料以M(范围)表示,组间比较采用Mann-Whitney U检验,计数资料比较采用x2检验.采用组内和组间相关系数(ICC)评估影像组学特征提取的观察者间的一致性.ICC＞0.75表示特征提取的一致性良好.单因素和多因素分析采用Logistic回归模型.绘制受试者工作特征曲线,以曲线下面积(AUC)、决策曲线、校准曲线评估模型的诊断效能及临床实用性.结果 (1)不同MVI性质患者的临床特征比较.92例肝细胞癌患者中,MVI阳性47例,MVI阴性45例,两者肝炎、肿瘤长径、瘤周增强、瘤内动脉、假包膜及瘤周不光滑比较,差异均有统计学意义(x2=5.308,9.977,47.370,32.368,21.105,31.711,P＜0.05).(2)MVI风险模型的建立.在动脉期及门静脉期的瘤内和瘤周分别提取了1 781个特征,经过特征降维后,从动脉期及门静脉期中确定8个影像组学特征构建联合模型.多因素分析结果显示:瘤周增强、瘤内动脉、假包膜、瘤周不光滑及R-score是肝细胞癌患者MVI的独立危险因素[风险比=0.049,0.017,0.017,0.021,2.539,95％可信区间(CI)为 0.005～0.446,0.001～0.435,0.001～0.518,0.001～0.473,1.220～3.283].纳入瘤周增强、瘤内动脉、假包膜、瘤周不光滑及R-score构建列线图模型.(3)MVI风险模型的评估.R-score在训练集和测试集中AUC分别为0.923(95％CI为0.887～0.944)和0.918(95％CI为0.894～0.945);联合R-score及影像学特征构建的列线图在训练集和测试集中AUC分别为0.973(95％CI为0.954～0.988)和0.962(95％CI为0.942～0.987).决策曲线显示:列线图的临床效益优于R-score.校准曲线显示:列线图和R-score预测状态与实际观察结果间一致性良好.(4)基因模块聚类.经加权基因共表达网络分析后获取8个基因模块.(5)特征相关基因模块功能富集.4个基因模块与影像组学特征显著相关.预测MVI的影像组学特征可能与细胞周期、中性粒细胞外陷阱形成及PPAR信号通路有关.结论 基于术前增强CT检查的联合影像组学模型可以预测肝细胞癌MVI状态.通过获取影像组学特征相关的mRNA基因表达谱,为影像组学模型提供了生物学解释.
腹腔感染是ICU和住院患者第二大感染性疾病,病死率高达20％～30％.医学的进步并没有改善腹腔感染患者预后,且日益严峻的细菌耐药形势可能导致腹腔感染患者预后恶化.腹腔感染可导致肠道菌群失调,而肠道菌群失调反过来又可加重腹腔感染.肠道微生态制剂可调节肠道菌群,是腹腔感染潜在的治疗措施.笔者回顾腹腔感染时肠道菌群的变化、肠道菌群对腹腔感染预后的影响及肠道微生态制剂在腹腔感染中的作用,旨在为临床应用提供参考.
目的 探讨术前淋巴细胞与单核细胞比值(LMR)-血小板与淋巴细胞比值(PLR)评分模型对胰腺导管腺癌(PDAC)根治术后预后的预测价值.方法 采用回顾性队列研究方法.收集2015年1月至2019年12月兰州大学第二医院收治的116例PDAC患者的临床病理资料;男73例,女43例;年龄为61.5(29.0～75.0)岁.患者均行胰腺癌根治术.观察指标:(1)LMR、PLR的最佳截断值.(2)不同术前LMR-PLR评分患者的临床病理特征.(3)随访和生存情况.(4)PDAC患者预后的影响因素分析.(5)列线图预测模型构建及验证.偏态分布的计量资料以M(范围)表示.计数资料以绝对数表示,组间比较采用x2检验.等级资料比较采用Mann-Whitney U检验.采用Graphpad prism 8绘制生存曲线,Kaplan-Meier法计算生存率,Log-Rank检验进行生存分析.单因素和多因素分析采用COX比例风险回归模型.采用X-tile软件确定LMR、PLR的最佳截断值.根据多因素分析结果构建列线图预测模型,绘制受试者工作特征(ROC)曲线,以曲线下面积(AUC)评价列线图预测模型的区分度.以校准曲线评价列线图预测模型的一致性.以决策曲线评价临床获益度.结果 (1)LMR、PLR的最佳截断值.LMR、PLR的最佳截断值分别为1.9和156.3.(2)不同术前LMR-PLR评分患者的临床病理特征.术前LMR-PLR评分为0、1、2分患者分别为11、42、63例.上述3者CA125(＜12.4 U/mL)、脉管侵犯、术后化疗分别为1、8、24例,9、27、27例,3、26、43例,不同LMR-PLR评分患者上述指标比较,差异均有统计学意义(x2=6.73、8.37、6.68,P＜0.05).(3)随访和生存情况.116例患者均获得随访,随访时间为39(2～86)个月.116例PDAC患者术后1、2、3生存率分别为50.9％、37.9％、19.3％,生存时间为13(1～85)个月.LMR-PLR评分为0、1、2分患者生存时间分别为3(1～9)个月、7(2～56)个月、26(2～85)个月,3者生存情况比较,差异有统计学意义(x2=48.78,P＜0.05).(4)PDAC患者预后的影响因素分析.多因素分析结果显示:癌胚抗原、CA19-9、LMR-PLR评分、肿瘤长径是PADC患者预后的独立影响因素[风险比=1.61,1.88,0.27,1.87,95％可信区间(CI)为1.02～2.54,1.18～3.00,0.19～0.39,1.13～3.09,P＜0.05].(5)列线图预测模型构建及验证.纳入癌胚抗原、CA19-9、LMR-PLR评分、肿瘤长径构建列线图预测模型.绘制ROC曲线预测患者1、2、3年生存率的AUC分别为0.86(95％CI为0.79～0.93,P＜0.05)、0.86(95％CI为0.79～0.92,P＜0.05)、0.87(95％CI为0.78～0.95,P＜0.05).校准曲线结果显示:列线图预测模型的预测生存率和实际生存率一致性较好(一致性指数为0.74).决策曲线结果显示:在风险阈值为0.12～0.85,列线图预测模型预测性能优于单一因素的预测性能.结论 癌胚抗原、CA19-9、LMR-PLR评分、肿瘤长径是PDAC患者根治术后预后的独立影响因素,其列线图预测模型可预测患者术后生存率.预测生存率和实际生存率一致性较好.在风险阈值为0.12～0.85,列线图预测模型预测性能优于单一因素预测性能.
目的 探讨肌少症对食管胃结合部腺癌患者生命质量的影响.方法 采用回顾性队列研究方法.收集2019年1月至2022年12月河南省人民医院收治的109例食管胃结合部腺癌患者的临床病理资料;男63例,女46例;年龄为(63±11)岁.患者均行3D腹腔镜辅助下根治性全胃切除+D2淋巴结清扫术.手术前3 d内,使用多频生物电阻抗人体成分分析仪获取患者骨骼肌含量.观察指标:(1)肌少症和非肌少症患者临床特征.(2)肌少症和非肌少症患者术中和术后情况.(3)食管胃结合部腺癌患者术后发生严重并发症的影响因素分析.(4)肌少症和非肌少症患者术前和术后生命质量评分.正态分布的计量资料以(x)±s表示,组间比较采用t检验;偏态分布的计量资料以M(Q1,Q3)表示,组间比较采用Mann-WhitneyU检验.计数资料以绝对数或百分比表示,组间比较采用x2检验.等级资料比较采用Mann-Whitney U非参数检验.重复测量资料采用重复测量方差分析,并用球形检验其方差.单因素分析采用Logistic回归模型,多因素分析采用Logistic逐步回归模型.结果 (1)肌少症和非肌少症患者临床特征.109例食管胃结合部腺癌患者中,肌少症42例,非肌少症67例.肌少症患者体质量指数、第1秒用力呼气容积(FEV1)、FEV1/用力肺活量(FVC)分别为(20.3±2.3)kg/m2、92％±9％、79％±11％;非肌少症患者上述指标分别为(24.4±2.7)kg/m2、97％±9％、85％±11％,两者上述指标比较,差异均有统计学意义(t=8.07,2.46,2.77,P＜0.05).(2)肌少症和非肌少症患者术中和术后情况.肌少症患者术中出血量、术后首次肛门排气时间、术后住院时间、术后并发症分别为208(192,231)mL、(3.4±0.9)d、(11.4±3.2)d、26例;非肌少症患者上述指标分别为195(150,215)mL、(2.8±0.7)d、(9.9±1.6)d、14例,两者上述指标比较,差异均有统计学意义(Z=-2.14,t=3.25、3.38,x2=18.69,P＜0.05).(3)食管胃结合部腺癌患者术后发生严重并发症的影响因素分析.多因素结果显示:肌少症和BMI降低是食管胃结合部腺癌患者术后发生严重并发症的独立危险因素(优势比=2.04,1.98,95％可信区间为1.24～3.36,1.09～3.60,P＜0.05).(4)肌少症和非肌少症患者术前和术后生命质量评分.肌少症和非肌少症患者术前、术后2周、术后4周、术后8周躯体功能、角色功能、社会功能以及整体评分多变量检验结果显示:两者上述指标的时间效应、组间效应、交互效应比较,差异均有统计学意义(P＜0.05).单独效应结果显示:两者上述指标组间效应比较,差异均有统计学意义(P＜0.05).结论 术前肌少症增加食管胃结合部腺癌患者术后发生严重并发症的风险,降低患者术后生命质量.
基于外科膜解剖理论以及腹腔感染状态下膜结构异常,笔者团队创新性提出腹腔感染分区理念,对分区的定义、内容和意义作简要阐述,引起学术界广泛共鸣.针对分区中特殊的D区,笔者团队结合临床实践以及回顾相关文献综述,对若干关键诊断与治疗难点问题进行深入研究和探讨,旨在为腹腔感染科学规划诊断与治疗策略,制订完善诊断与治疗体系提供理论基础.
手术是治疗外科疾病的主要手段,但对机体是一次创伤应激,引起机体代谢变化和营养受损,加上原发外科疾病以及基础疾病的影响,外科患者在术前、术中、术后以及出院后的不同阶段常存在不同程度的代谢变化和营养不良.任一阶段的代谢变化和营养受损都将相互影响,最终降低患者的外科治疗效果,影响短期和长期临床结局.营养治疗的理念和技术近几十年获得迅猛发展,临床应用极大提高了疾病救治成功率.全面推进全程营养管理在外科中的应用,将营养筛查-评估-干预贯穿于术前、术中、术后以及出院后整个疾病治疗和康复过程,可发挥营养治疗的最大疗效,加速术后康复,改善患者预后.笔者结合临床实践与文献资料,探讨全程营养管理的重要性和必要性、首要任务、关键措施、最后保障.
目的 探讨肌少症对食管鳞癌围手术期临床结局的影响.方法 采用回顾性病例对照研究方法.收集2020年1月至2021年12月南京医科大学附属淮安第一人民医院收治的1 148例食管鳞癌患者的临床病理资料;男789例,女359例;年龄为(67±7)岁.所有患者行胸腹腔镜联合食管癌根治术.观察指标:(1)食管鳞癌患者并发肌少症情况.(2)食管鳞癌并发肌少症患者与食管鳞癌非肌少症患者的一般资料比较.(3)食管鳞癌并发肌少症患者与食管鳞癌非肌少症患者的临床结局比较.(4)食管鳞癌患者并发肌少症的影响因素分析.正态分布的计量资料以(x)±s表示,组间比较采用t检验;计数资料以绝对数表示,组间比较采用x2检验;等级资料采用Mann-Whitney U检验.单因素分析采用Logistic回归分析,多因素分析采用Logistic逐步回归向后模型.结果 (1)食管鳞癌患者并发肌少症情况.1 148例食管鳞癌患者中,469例并发肌少症,679例非肌少症,肌少症发生率为40.854％(469/1 148).469例并发肌少症患者中,男313例,女156例;年龄＜65岁、≥65岁且＜70岁、≥70岁且＜75岁、≥75岁分别为125、145、106、93例.(2)食管鳞癌并发肌少症患者与食管鳞癌非肌少症患者的一般资料比较.469例食管鳞癌并发肌少症患者的年龄,肿瘤长径,体质量指数,T分期(T1期、T2期、T3期),术前白蛋白,术前血清前白蛋白,腰大肌指数,腰大肌密度分别为(68±7)岁,(3.3±1.5)cm,(22.4±2.9)kg/m2,100、105、264例、(43±4)g/L,(193±38)mg/dL.(3.9±0.8)cm2/m2,(48±8)HU;679例食管鳞癌非肌少症患者上述指标分别为(66±7)岁,(3.2±1.4)cm,(23.8±3.0)kg/m2,173、170、336例,(44± 4)g/L,(206±37)mg/dL,(6.0±2.2)cm2/m2,(50±7)HU,两者上述指标比较,差异均有统计学意义(t=5.74、2.11、7.57,Z=-2.93,t=2.25、5.52、20.36、4.18,P＜0.05).(3)食管鳞癌并发肌少症患者与食管鳞癌非肌少症患者的临床结局比较.469例食管鳞癌并发肌少症患者的术后住院时间、术后住院时间＞30 d、肺炎、急性呼吸衰竭、吻合口瘘、心律失常例数分别为(17±9)d、32例、158例、39例、33例、103例,679例食管鳞癌非肌少症患者上述指标分别为(15±6)d、15例、102例、18例、19例、85例,两者上述指标比较,差异均有统计学意义(t=4.89,x2=15.04、55.17、18.86、11.52、18.06,P＜0.05).(4)食管鳞癌患者并发肌少症的影响因素分析.多因素分析结果显示:年龄≥65岁是食管鳞癌患者并发肌少症的独立危险因素(优势比=1.64,95％可信区间为1.26～2.14,P＜0.05);术前血清前白蛋白≥200mg/dL、腰大肌密度≥48 HU和体质量指数＞24 kg/m2是食管鳞癌患者并发肌少症的独立保护因素(优势比=0.64、0.72、0.53,95％可信区间为0.50～0.82、0.56～0.92、0.41～0.69,P＜0.05).结论 年龄≥65岁是食管鳞癌患者并发肌少症的独立危险因素,而术前血清前白蛋白≥200 mg/dL、腰大肌密度≥48 HU和体质量指数＞24 kg/m2是食管鳞癌患者并发肌少症的独立保护因素.与食管鳞癌非肌少症患者比较,食管鳞癌并发肌少症患者术后更易发生肺炎、急性呼吸衰竭、吻合口瘘、心律失常等并发症,且术后住院时间更长.
目的 探讨半离体自体小肠移植(IATx)用于肠系膜根部区域肿瘤伴血管侵犯患者的临床价值.方法 采用回顾性描述性研究方法.收集2021年9月至2022年12月四川省医学科学院·四川省人民医院收治的6例行半离体IATx患者的临床病理资料;男4例,女2例;年龄为(47±21)岁.观察指标:(1)手术情况.(2)术后情况.(3)随访情况.正态分布的计量资料以(x)±s表示.计数资料以绝对数表示.结果 (1)手术情况.6例患者顺利完成半离体IATxo6例患者手术时间为(10.2±2.1)h、热缺血时间为(2.3±1.6)min、冷缺血时间为(49.2±15.6)min、术中输血量为(707±263)mLo6例患者中,3例术中行冷冻威斯康星大学保存液(UW液)灌注,3例术中未行UW液灌注.(2)术后情况.6例患者术后病理学检查结果显示:4例为胰腺导管腺癌,1例为胆管腺癌,1例为肠系膜纤维瘤病.6例患者手术切缘均为阴性,术后住院时间为(19±4)d.6例患者术后均未出现胃肠道出血及吻合口瘘,自体移植肠道功能良好.6例患者围手术期无死亡,出院后无需静脉补液.(3)随访情况.6例患者均获得随访,随访时间为(12±5)个月.6例患者中,仅1例肠系膜纤维瘤病患者术后第7个月复发,其余5例患者无复发、转移.6例患者中,4例出现慢性腹泻,口服罗哌丁胺、双歧杆菌及胰酶胶囊后症状缓解.6例患者均生存.结论 半离体IATx用于治疗肠系膜根部区域肿瘤伴血管侵犯患者安全、可行,近期疗效良好.
目的 探讨不同喂养不耐受变化轨迹外科危重症患者预后及影响因素.方法 采用回顾性队列研究方法.收集2018年3月至2019年7月中国重症营养临床研究小组-NEED数据库中69家医学中心收治的354例外科危重症患者的临床资料;男247例,女107例;年龄为58(46,68)岁.根据354例患者喂养不耐受变化轨迹模型,分为无喂养不耐受、喂养不耐受下降、喂养不耐受持续分别为164、49、141例.观察指标:(1)不同喂养不耐受变化轨迹患者一般情况.(2)不同喂养不耐受变化轨迹患者营养治疗情况.(3)不同喂养不耐受变化轨迹患者生存情况.(4)外科危重症患者预后影响因素分析.正态分布的计量资料以(x)±s表示,组间比较采用单因素方差分析;偏态分布的计量资料以M(Q1,Q3)表示,组间比较采用Kruskal-Wallis秩和检验.计数资料以绝对数或百分比表示,组间比较采用x2检验.等级资料比较采用Kruskal-Wallis秩和检验.两两比较采用Bonferroni校正.根据Stata17.0统计软件中Traj插件构建组基轨迹模型,最佳轨迹模型采用贝叶斯信息准则、平均后验概率参数评价.采用Kaplan-Meier法绘制生存曲线并计算生存率,Log-Rank检验进行生存分析.采用COX比例风险回归模型进行单因素和多因素分析.结果 (1)不同喂养不耐受变化轨迹患者一般情况.354例外科危重症患者中,行肠内营养治疗257例、行肠内营养+肠外营养治疗97例,急性生理与慢性健康(APACHE Ⅱ)评分为17(13,21)分,序贯性器官功能衰竭(SOFA)评分为6(5,8)分,改良危重症营养风险(mNUTRIC)评分为4(2,5)分,合并症数量为2(1,3)个,急性胃肠损伤分级为Ⅰ级、Ⅱ级、Ⅲ级分别为293、55、6例,行机械通气、连续肾替代治疗、血管活性药物使用分别为224、17、61例.354例患者喂养不耐受发生率呈先上升后下降趋势,第3天发生率达峰值为25.42％(90/354),7d内发生率为53.67％(190/354)o 354例外科危重症患者中,无喂养不耐受、喂养不耐受下降、喂养不耐受持续患者APACHE Ⅱ评分,mNUTRIC评分,合并症数量,急性胃肠损伤分级,机械通气分别为16(12,20)分、17(14,25)分、18(13,22)分,3(2,5)分、4(3,6)分、4(3,5)分,2(1,2)个、2(2,3)个、2(2,3)个,Ⅰ级(152例、27例、114例)、Ⅱ～Ⅲ级(12例、22例、27例),95、39、90例,三者上述指标比较,差异均有统计学意义(H=6.14、13.11、28.05,x2=37.96、7.65,P＜0.05);进一步分析,与无喂养不耐受患者比较,喂养不耐受下降、喂养不耐受持续患者均有更高的合并症数量和急性胃肠损伤分级(Z=60.32、54.69,x2=39.72、9.52,P＜0.05);与无喂养不耐受患者比较,喂养不耐受下降患者有更高的mNUTRIC评分和机械通气比例(Z=53.41,x2=7.59,P＜0.05).(2)不同喂养不耐受变化轨迹患者营养治疗情况.无喂养不耐受患者促胃动力药物使用,幽门后喂养分别为36例,13例,喂养不耐受下降患者上述指标分别为25例,10例,喂养不耐受持续患者上述指标分别为46例,19例,三者上述指标比较,差异均有统计学意义(x2=15.76,6.20,P＜0.05).进一步分析,与无喂养不耐受患者比较,喂养不耐受下降患者有更高的促胃动力药物使用和幽门后喂养比例(x2=15.60,6.10,P＜0.05).(3)不同喂养不耐受变化轨迹患者生存情况.无喂养不耐受、喂养不耐受下降、喂养不耐受持续患者28 d总生存率分别为96.96％、95.92％、87.94％,三者比较,差异有统计学意义(x2=10.39,P＜0.05);进一步分析,无喂养不耐受与喂养不耐受持续患者比较,差异有统计学意义(x2=9.19,P＜0.05).(4)外科危重症患者预后影响因素分析.多因素分析结果显示:喂养不耐受持续是外科危重症患者28 d死亡的独立危险因素(风险比=3.92,95％可信区间为1.43～10.79,P＜0.05).结论 与无喂养不耐受患者比较,喂养不耐受持续的外科危重症患者28 d总生存率下降,喂养不耐受持续是外科危重症患者28 d死亡的独立危险因素.
