Background:Mandibular angle osteotomy (MAO) is widely performed in East Asian patients seeking lower-face contouring. Although numerous osteotomy designs and adjunctive technologies have been described, practical guidance for selecting an appropriate technique according to mandibular morphology, surgical endpoints, and surgeon experience remains limited. Methods:A narrative review was conducted using a systematic literature search of PubMed and Embase up to December 30, 2025. Studies related to MAO techniques, anatomical classification, aesthetic assessment, adjunctive procedures, emerging technologies, complications, and long-term remodeling were reviewed. Results:MAO techniques differ mainly in the starting point, endpoint, and trajectory of the osteotomy line. Long curved osteotomy remains a commonly used approach for prominent mandibular angles, whereas ABC osteotomy, U-shaped osteotomy, V-line osteotomy, mandibular outer cortex reduction, mandibular body osteotomy, genioplasty, and partial masseter muscle resection may be selected according to specific skeletal and soft-tissue features. Surgical endpoints should include not only skeletal reduction but also frontal width, lateral contour, mandibular border smoothness, symmetry, soft-tissue support, neurosensory safety, patient satisfaction, and long-term remodeling. Digital planning, osteotomy templates, navigation, and endoscopic assistance may improve accuracy and safety, especially in anatomically complex cases. Conclusion:MAO should be planned as an individualized lower-face contouring procedure rather than a uniform reduction technique. A morphology-based decision-making framework may help clarify indications, optimize surgical endpoints, reduce complications, and improve long-term aesthetic outcomes. Future studies should emphasize standardized outcome measures, patient-reported outcomes, and long-term three-dimensional assessment. Level of evidence:V.

Post-operative treatment of bone tumors faces a critical clinical dilemma: the need to simultaneously inhibit the tumor while promoting bone regeneration. For this purpose, a multifunctional borate bioactive glass (B-BG) with dynamic pH was designed. In vitro studies indicated, within 2 days, a significant increase in pH up to ∼8.3 was generated to inhibit tumor cells. In the meantime, the increase of surrounding pH generated the formation of apatite-like minerals on the glass surface due to higher supersaturation with respect to hydroxyapatite, thus slow down the degradation rate of B-BG to generate the second stage, a moderate pH range between 7.5 and 8.0, thus increasing the expression of angiogenic genes in HUVECs at 2 days to 2 weeks, and then osteogenic genes in hADSCs after 2 weeks. Such results were further confirmed by implanting B-BG in a mouse CDX osteosarcoma model, a rabbit tumor metastatic model, and a rabbit femoral condyle defect model. The intelligence of such composition indicates the ability to spontaneously meet the surrounding environment respectively tumor inhibition and bone formation. In summary, multifunctional borate bioactive glass (B-BG) may provide a promising strategy for the treatment of bone tumors and the repair of bone defects.

OBJECTIVES:To evaluate the effectiveness of deep learning (DL) in medical imaging for improving clinical procedures related to the mandibular third molar (MM3). METHODS:Our systematic search included databases such as PubMed, EMBASE, Web of Science, and the Cochrane Library, up to April 10, 2024. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to assess the potential bias and clinical relevance of the studies. To examine the interaction between MM3 and the inferior alveolar nerve (IAN), we conducted a meta-analysis using a bivariate mixed-effects model to compare the performance of DL methods with that of human experts. RESULTS:In this comprehensive review, a total of 33 scholarly works involving 45,029 imaging instances were analyzed. Among these, 15 studies specifically focused on evaluating the performance of DL methods in identifying the spatial relationship between MM3 and IAN. The aggregated results showed that DL achieved a diagnostic sensitivity of 0.89 (95% CI, 0.85-0.93) and a specificity of 0.88 (95% CI, 0.80-0.93). In parallel, a comparative meta-analysis that included assessments from 16 clinical experts revealed slightly lower sensitivity (0.76; 95% CI, 0.65-0.85) and specificity (0.86; 95% CI, 0.70-0.94). Additionally, the review explored the utility of DL in predictive modeling of MM3 eruption, assessing the complexity of extraction procedures, and identifying MM3 characteristics. The 18 studies in this area demonstrated diagnostic sensitivity ranging from 0.80 to 0.94 and specificity from 0.75 to 0.97, collectively highlighting the strong prognostic capabilities of DL in these clinical applications. CONCLUSIONS:DL has demonstrated remarkable efficacy, especially in precisely identifying the anatomical connections between MM3 and IAN. Moreover, DL excels in identifying, categorizing, and assessing the complexity associated with MM3 extractions. This study confirms the substantial value of DL, particularly when utilized through image-based methods, in improving clinical management strategies for MM3. The creation of intelligent diagnostic tools using oral panoramic radiographs (OPGs) is strongly encouraged to assist physicians, especially those with limited clinical experience, in enhancing their diagnostic accuracy. These advancements in DL applications are expected to significantly improve the accuracy and efficiency of clinical diagnoses in oral and maxillofacial surgeries.

This meta-analysis compares the accuracy of mandible-first and maxilla-first approaches in bimaxillary orthognathic surgery to improve clinical decision-making. A systematic search was performed in PubMed, Web of Science, Embase, and Cochrane databases up to August 2024. The analysis included randomized controlled trials and cohort studies with a minimum of 10 patients. Data extraction followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and pooled effect estimates for continuous outcomes were calculated using weighted mean difference (WMD) with 95% CIs. Heterogeneity was assessed using Cochran I 2 and Q statistics, with a random-effect model applied when I 2 exceeded 50%. Seven studies involving 316 patients were included. The analysis showed no significant differences in vertical (WMD: -0.05, 95% CI: -0.57 to 0.48, P = 0.86), transverse (WMD: -0.17, 95% CI: -0.43 to 0.09, P = 0.21), and sagittal (WMD: -0.41, 95% CI: -0.98 to 0.15, P = 0.15) surgical errors between the two approaches. Rotational surgical errors were also similar, including pitch (WMD: 0.07, 95% CI: -0.11 to 0.25, P = 0.29), roll (WMD: 0.01, 95% CI: -0.18 to 0.25, P = 0.69), and yaw (WMD: 0.12, 95% CI: -0.56 to 0.81, P = 0.72). The findings suggest that there is no significant difference in surgical accuracy between mandible-first and maxilla-first approaches. Therefore, the choice of sequence should be based on patient-specific factors rather than a presumed advantage of one method over the other. Further research, including large-scale randomized controlled trials, is needed to confirm these results and evaluate long-term outcomes.

The study aims to evaluate the global research landscape of facial bone contouring to identify current hotspots and future research directions. Data were extracted from Web of Science Core Collection and analyzed using VOSviewer, CiteSpace, and ArcGIS for bibliometric visualization, including annual publication trends, journals, authors, institutions, countries, and keywords. This bibliometric analysis examined 936 publications (2005-2025), showing consistent growth in publications. Journal of Craniofacial Surgery contributed the highest publication volume, while Journal of Oral and Maxillofacial Surgery exhibited the highest citation impact per article. China led in publication volume, followed by the US and South Korea. The top 5 research institutions were concentrated in China and South Korea, with Chinese Academy of Medical Sciences and Peking Union Medical College ranking first. Among authors, Gui Lai is the most productive, whereas Hu Jing received the highest citations per article. Keyword timezone analysis revealed 3 distinct research phases: technical foundation (2005-2011), technical refinement (2012-2017), and digitalization and interdisciplinary integration (2018-present). Facial bone contouring has become an increasingly popular area in plastic surgery. Bibliometric analysis reveals China, the US, and South Korea as the predominant contributors to this field. Current research hotspots include digital surgical techniques and facial gender-affirming surgery, while future directions should emphasize long-term outcome studies, international multicenter collaborations, and the integration of artificial intelligence with advanced biomaterials to drive innovation in surgical techniques and outcomes.

Impaired efferocytosis in diabetic wounds contributes to apoptotic cell accumulation, chronic inflammation, and poor healing outcomes. In this study, a multi-hierarchical hydrogel designed to facilitate cellular debridement and initiate a healing process in diabetic wounds is proposed. A reactive oxygen species (ROS)/glucose-responsive hydrogel conjugated with chemokine aptamers is developed that encapsulated mannose-modified lipid nanoparticles (mLNPs) loaded with ADAM17 siRNA (A disintegrin and metalloproteinase 17). This hydrogel enhanced macrophage recruitment by enriching endogenous chemokines. Additionally, it responded to the pathological microenvironment, enabling the dynamic release of mLNPs for targeted siRNA delivery to macrophages. Treatment with ADAM17 siR@mLNPs significantly enhanced macrophage efferocytosis through the MerTK-Rac1 pathway and glycolytic reprogramming, thereby initiating the resolution of inflammation and tissue repair. Finally, in animal models of diabetic wounds, this therapy reduced the apoptotic burden and improved wound healing. In conclusion, macrophage-targeted efferocytosis-reactivation therapy is a promising strategy for the treatment of diabetic wounds.

BACKGROUND:Tissue engineering based on whole-organ perfusion decellularization has successfully generated small-animal organs, including the heart and limbs. Herein, we aimed to use angiosome-guided perfusion decellularization to develop an acellular fasciocutaneous flap matrix with an intact vascular network. METHODS:Abdominal flaps of rats were harvested, and the vascular pedicle (iliac artery and vein) was dissected and injected with methylene blue to identify the angiosome region and determine the flap dimension for harvesting. To decellularize flaps, the iliac artery was perfused sequentially with 1% sodium dodecyl sulfate (SDS), deionized water, and 1% Triton-X100. Gross morphology, histology, and DNA quantity of flaps were then obtained. Flaps were also subjected to glycosaminoglycan (GAG) and hydroxyproline content assays and computed tomography angiography. RESULTS:Histological assessment indicated that cellular content was completely removed in all flap layers following a 10-hour perfusion in SDS. DNA quantification confirmed 81% DNA removal. Based on biochemical assays, decellularized flaps had hydroxyproline content comparable with that of native flaps, although significantly fewer GAGs (p = 0.0019). Histology and computed tomography angiography illustrated the integrity and perfusability of the vascular system. CONCLUSION:The proposed angiosome-guided perfusion decellularization protocol could effectively remove cellular content from rat fasciocutaneous flaps and preserve the integrity of innate vascular networks.

Large full-thickness skin lesions have been one of the most challenging clinical problems in plastic surgery repair and reconstruction. To achieve in situ skin regeneration and perfect clinical outcomes, we must address two significant obstacles: angiogenesis deficiency and inflammatory dysfunction. Recently, black phosphorus has shown great promise in wound healing. However, few studies have explored the bio-effects of BP to promote in situ skin regeneration based on its nanoproperties. Here, to investigate whether black phosphorus nanosheets have positive bio-effects on in situ skin repair, we verified black phosphorus nanosheets' positive effects on angiogenic and anti-inflammatory abilities in vitro. Next, the in vivo evaluation performed on the rat large full-thickness excisional wound splinting model more comprehensively showed that the positive bio-effects of black phosphorus nanosheets are multilevel in wound healing, which can effectively enhance anti-inflammatory ability, angiogenesis, collagen deposition, and skin re-epithelialization. Then, multiomics analysis was performed to explore further the mechanism of black phosphorus nanosheets' regulation of endothelial cells in depth. Molecular mechanistically, black phosphorus nanosheets activated the JAK-STAT-OAS signaling pathway to promote cellular function and mitochondrial energy metabolism in endothelial cells. This study can provide a theoretical basis for applying two-dimensional black phosphorus nanosheets as nanomedicine to achieve in situ tissue regeneration in complex human pathological microenvironments, guiding the subsequent optimization of black phosphorus.

Nanotechnology and nanomaterials have swiftly influenced wound healing, propelling the development of wound-healing nanomaterials. Therefore, it’s crucial to gather essential information about prominent researches in this domain. Moreover, identifying primary directions and related frontiers in wound healing and nanomaterials is paramount. This will enhance our comprehension of the current research landscape and foster progress in this field. Retrieved from the Web of Science core database, a total of 838 relevant studies published from 2013 to 2022 were analyzed through bibliometric visualization tools such as CiteSpace, VOSviewer, and Bibliometrics Online Analysis Platform. The annual study count has been rising steadily, primary contributors to this field include China, India, and the United States. The author with the highest output is Zangeneh, Akram, while Grumezescu, Alexandru Mihai garners the most citations. Chinese Academy of Sciences emerges as the leading institution, with Nanomaterials as the predominant journal. The keyword “antibacterial” signals prevailing and forthcoming trends in this domain. This study presents the first scientometric study and bibliometric visualization for wound healing-related nanomaterials, shedding light on research hotspots and trends. Over the course of the decade from 2013 to 2022, enthusiasm for nanomaterials in wound healing research has surged, auguring well for upcoming investigations.

Objective To develop a real and comprehensive all-elements surgical simulation teaching for clinical skills training, and observe the differences between this method and the traditional standardized training. Methods All interns were randomly divided into experimental group (all-elements surgical simulated surgery training group) and control group (traditional standardized training teaching group). The control group was trained according to the operating procedures in traditional textbooks, while the experimental group was trained according to the All-elements Surgical Simulated Surgery Tutorial compiled by the subject group. After the training was completed, the students took basic surgical skills assessment, and questionnaires was issued to investigate how they felt about the course. Results A total of 80 interns were included, with 40 each in the test and control groups. In the examination of surgical clinical skills, the scores of students in the experimental group were higher than those in the control group, including disinfection and drape, incision and suture, ligation and hemostasis, dressing and suture removal, debridement, abscess incision, thoracic drainage extraction. The differences between the two groups were statistically significant (all P < 0.01). In the questionnaire for feedback of teaching effect, the scores of students in the experimental group were higher than those in the control group, including self-operation ability, clinical self-thinking ability, self-learning efficiency, teaching methods acceptance, and the differences between the groups were statistically significant (all P < 0.05). Conclusions Compared with the traditional standardized training, the all-elements operation training can significantly improve the operation skill of interns. At the same time, interns have better acceptance and satisfaction with the new training method.

Osteosarcoma (OS) is a rare primary malignant bone tumor in adolescents and children with a poor prognosis. The identification of prognostic genes lags far behind advancements in treatment. In this study, we identified differential genes using mRNA microarray analysis of five paired OS tissues. Hub genes, gene set enrichment analysis, and pathway analysis were performed to gain insight into the pathway alterations of OS. Prognostic genes were screened using the Therapeutically Applicable Research to Generate Effective Treatments (TARGET) dataset, then overlapped with the differential gene dataset. The carboxypeptidase E (CPE) gene, found to be an independent risk factor, was further validated using RT-PCR and Gene Expression Omnibus (GEO) datasets. Additionally, we explored the specific expression of CPE in OS tissues by reanalyzing single-cell genomics. Interestingly, CPE was found to be co-expressed with osteoblast lineage cell clusters that expressed RUNX2, SP7, SPP1, and IBSP marker genes in OS. These results suggest that CPE could serve as a prognostic factor in osteoblastic OS and should be further investigated as a potential therapeutic target.

Osteosarcoma is the most common malignant bone tumor, tending to be aggressive and recurrent. The therapeutic development for treating osteosarcoma has been largely hampered by the lack of effective and specific targets. Using kinome-wide CRISPR-Cas9 knockout screens, we systematically revealed a cohort of kinases essential for the survival and growth of human osteosarcoma cells, in which Polo-like kinase 1 (PLK1) appeared as a specific prominent hit. PLK1 knockout substantially inhibited proliferation of osteosarcoma cells in vitro and the tumor growth of osteosarcoma xenograft in vivo. Volasertib, a potent experimental PLK1 inhibitor, can effectively inhibit the growth of the osteosarcoma cell lines in vitro. It can also disrupt the development of tumors in the patient-derived xenograft (PDX) models in vivo. Furthermore, we confirmed that the mode of action (MoA) of volasertib is primarily mediated by the cell-cycle arrest and apoptosis triggered by DNA damage. As PLK1 inhibitors are entering phase III clinical trials, our findings provide important insights into the efficacy and MoA of the relevant therapeutic approach for combating osteosarcoma.

Colorectal cancer (CRC) is a common gastrointestinal malignancy, and recurrence and metastasis contribute considerably to its high mortality. It is well known that the epithelial-mesenchymal transition (EMT) accelerates the rate of cancer cell dissemination and migration, thus promoting cancer metastasis. Targeted therapy is a common modality for cancer treatment, and it can play a role in inhibiting cancer progression. In this study, bioinformatics was used to search for genes associated with the prognosis of CRC. First, differential analysis was performed on colon and rectal cancer samples to obtain 2,840 and 3,177 differentially expressed genes (DEGs), respectively. A Venn diagram was then used to identify 262 overlapping genes from the two groups of DEGs and EMT-related genes. The overlapping genes were subjected to batch survival analysis and batch expression analysis successively, and nine genes were obtained whose high expression in CRC led to a poor prognosis. The least absolute shrinkage and selection operator (LASSO) prognostic model was then constructed to obtain the risk score formula. A nomogram was constructed to seek prognostic independent factors to obtain CDKN2A. Finally, CCK-8 assay, flow cytometry and western blotting assays were performed to analyze the cellular biological function of CDKN2A. The results showed that knockdown of CDKN2A expression inhibited HT-29 cell proliferation, promoted apoptosis and cell cycle progression, and affected the EMT process in CRC.

Objective:To evaluate the clinical efficacy of transanal total mesorectal excision (taTME) on transanal endoscopic microsurgery (TEM) platform in the treatment of middle and low rectal cancer.Methods:The retrospective and descriptive study was conducted. The clinico-pathological data of 28 patients with middle and low rectal cancer who underwent taTME on TEM platform in the Peking Union Medical College Hospital of Chinese Academy of Medical Science from October 2014 to October 2017 were collected. There were 21 males and 7 females, aged 59 years (51 years, 68 years). Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up was conducted using outpatient examination or telephone interview to detect post-operative defecation function and survival of patients up to October 2020. Patients underwent physical examination, examination of tumor markers including carcinoembryonic antigen and CA19-9, colonoscopy, rectal magnetic resonance imaging, thoracoabdominal and pelvic enhanced computed tomography (CT) and (or) PET-CT examination during the follow-up. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were represented as M( P25,P75) or M (range), and comparison between groups was analyzed using the non parameter Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Surgical and postoperative situations: 28 patients underwent successful surgery, without intra-operative conversion to laparotomy. Of 28 patients, 24 cases underwent colorectal anastomosis and 4 cases underwent colon-anal anastomosis. Twenty-six cases underwent primary protective enterostomy and 2 cases didn't undergo primary protective enterostomy. The operation time of 28 patients was (182±37)minutes and the volume of intraoperative blood loss was 40mL(30 mL, 55 mL). One patient with intraoperative presacral hemorrhage received compression hemostasis. Eleven patients had postoperative complications, including 4 cases with anastomotic leakage, 2 cases with alteration of intestinal flora, 2 cases with paralytic ileus, 2 cases with urinary retention, 2 cases with urinary infection, 1 case with prolapse necrosis of small intestinal stoma, 1 case with anal hemorrhage, 1 case with rectovaginal fistula, 1 case with pelvic infection; some patients had multiple complications. Three patients had non-planned reoperation. One case without primary protective enterostomy had anastomotic leakage at postoperative 3 days, and was improved after emergency transversostomy. One case had prolapse necrosis of small intestinal stoma at postoperative 3 days and was improved after emergency enterostomy and reconstruction. One case with anal hemorrhage was stopped hemorrhage under anoscopy. Patients with other complications were cured after conservative treatments. The duration of postoperative hospital stay of 28 patients was 8 days(7 days, 9 days). Results of pathological examination in 28 patients showed 16 cases of moderately differentiated adenocarcinoma, 3 cases of moderately to highly differentiated adenocarcinoma, 5 cases of highly differentiated adenocarcinoma, 1 case of mucinous adenocarcinoma, 3 cases of pathological complete response. TNM staging of 28 patients showed 3 cases in stage T0N0, 4 cases in stage T1N0, 6 cases in stage T2N0, 4 cases in stage T2N1, 7 cases in stage T3N0, 3 cases in stage T3N1, 1 case in stage T4N1. The distance from tumor to distal margin was (2.2±1.7)cm. The surgical specimens of 28 patients showed negative for proximal, distal and circumferential margins. The number of lymph node dissection was 15±7. The complete rate of total mesorectal excision was 100%(28/28). Eleven of 28 patients underwent neoadjuvant therapy and 17 patients didn't receive neoadjuvant therapy. The tumor diameter, distance from tumor to anal margin, operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 2 cm(1 cm, 4 cm), 5 cm(4 cm, 6 cm), (187±25)minutes, 45 mL(38 mL, 53 mL), 8 days(7 days, 12 days) for patients with neoadjuvant therapy, respectively, versus 3 cm(2 cm, 4 cm), 5 cm(4 cm, 6 cm), (177±35)minutes, 40 mL(30 mL, 60 mL), 8 days(7 days, 8 days) for patients without neoadjuvant therapy, showing no significant difference between the two groups ( Z=-1.127, -0.293, t=0.590, Z=-0.790, -0.876, P>0.05). (2) Follow-up: 23 of 28 patients were followed up for (44±14)months. Of the 23 patients,11 cases were classified as grade A of Williams score for defecation function at postoperative 6 months, 8 cases were classified as grade B and 4 cases were classified as grade C. Eighteen of 23 patients with follow-up had disease-free survival, 1 of whom didn't undergo stoma closure due to anastomotic stenosis at postoperative 6 months. Three patients had distant metastasis, including 1 case with parastomal implantation metastasis, 1 case with sacral metastasis, 1 case with pulmonary metastasis. Two patients died, 1 case of whom died of urinary obstruction and 1 case with mucinous adenocarcinoma died at postoperative 24 months. Conclusion:TaTME based on TEM platform is feasible for middle and low rectal cancer, which has the advantages of preserving anus and negative circumferential margin.

Objective To investigate the teaching needs of clinical skills and scientific research skills in standardized training of surgical residents and to crient teaching remodeling. Methods A self-filling questionnaire survey was conducted in July 2018. Surgical residents of Peking Union Medical College Hospital, who are at the second and the third year of training, were gathered to sit in separate in classrooms. The filling methods and matters needing attention were explained uniformly. The trainees filled in the form of “back-to-back” by themselves. Totally 85 questionnaires were collected and 83 questionnaires were valid. This paper mainly investigates the training needs of clinical diagnosis and treatment, operation skills and scientific research skills. Results The demand of clinical skills is mostly manifested in the diagnosis and treatment of common surgical diseases and surgical teaching. The most demanded surgical teaching was “hand-holding” and acting as a assistant or master knife. The main requirements of scientific research skills are data collection, statistical methods (Meta analysis), scientific research design and project establishment, tender writing and bidding, and paper writing and publication. Conclusions The needs of surgical residents reflect their deficiencies in the diagnosis and treatment of common diseases, operation skill and research capacity. For this reason, the Surgical Teaching Group has put forward such reform schemes as “tutorial system” “animal model” “all-factor simulated surgery” “more scientific research training courses” and so on.

内镜治疗直肠癌具有创伤小、并发症发生率低等优势,已成为早期直肠癌治疗的重要方式之一.然而,由于术前影像学评估存在局限性,且内镜切除无法清扫淋巴结,使得内镜治疗相较于传统根治术的局部复发率更高.因此,正确把握内镜治疗的适应证十分重要.对于内镜切除后病理学检查证实肿瘤残留、高复发风险pT1期直肠癌或pT2期以上进展期直肠癌,及时行补救性治疗可以有效降低复发率与转移发生率,改善病人预后.补救性根治术可清扫区域淋巴结,完整切除直肠系膜,根治效果佳,但手术时机争议较大,早期手术的术中穿孔风险高,易造成肿瘤播散;补救性放化疗对于高复发风险pT1期病人的治疗效果与补救性根治术相当且创伤小,但有关研究相对较少,而放化疗的敏感度评价也较困难.补救性根治术已推行多年,治疗效果确切,仍应视为补救性治疗的“金标准”,但应把握适宜的手术时机、全面评估术中穿孔风险.对于保肛意愿强烈、拒绝根治手术或者不可耐受根治手术的病人,在充分告知复发风险后可选择补救性放化疗,但术后应密切随访.

目的 探讨经肛门内镜显微手术(TEM)局部切除早期直肠癌后续治疗方式的选择.方法 回顾性分析北京协和医院于2013-2019年间收治的105例经TEM切除直肠癌病人资料,所有病人均在知情同意后接受TEM.结果 105例病人经术前检查[直肠腔内超声和(或)直肠MRI]评估为cT1期且除外淋巴结转移,经病理学活检报告为腺瘤局部癌变或者直肠腺癌,均通过TEM完成直肠癌的局部扩大切除.105例病人术后36例行补救性根治性手术,29例行补救性放化疗,40例仅随访观察.105病人术后接受平均40(12～69)个月随访.随访期间,13例(12.4％)局部复发,2例(1.9％)远处转移,3例(2.9％)死亡.单因素分析结果显示,T分期(P=0.003)、是否R0切除(P＜0.01)和术后处理策略(P=0.036)是复发及死亡预测因子.在多因素分析中,T分期(HR 7.36,95％CI1.82～29.85,P=0.005)、是否R0切除(HR 20.82,95％CI 2.71～159.64,P=0.003)及术后处理策略(HR 0.57,95％CI0.08～0.38,P=0.003)与复发及死亡密切相关.结论 TEM局部切除pT1期直肠癌安全、有效.而对于pT2期或未达R0切除直肠癌病人术后复发风险高,后续积极采取根治术或辅助放化疗的补救性治疗可提高病人预后.

Transanal endoscopic microsurgery (TEM) is widely used in the treatment of local rectal lesions and helps avoid radical surgery. This study evaluated the management and outcome in a long-term followed cohort of patients with localized rectal GIST underwent TEM with alternative neodajuvant imatinib (nIM). A retrospective cohort study was undertaken of patients identified from a case database at Department of General Surgery, Peking Union Medical College Hospital (PUMCH) over a continuous period, from January 2006 to December 2017. Over 12 years, 42 patients presented with a primary rectal GIST in PUMCH. Median age was 49 (range 27–77) years. Neoadjuvant imatinib (nIM) therapy was used in 16 patients, significantly reducing mean tumor size from 4.41 to 2.46 cm (p < 0.001) and mitotic index (p = 0.041). All of these patients underwent TEM with no tumor rupture, nIM therapy enabled sphincter-preserving surgery to be undertaken in 16 (16/42) patients who would otherwise have required abdominoperineal resection or pelvic exenteration for tumor clearance and all patients (42/42) achieve R0 resection and negative margin. Imatinib was also used as postoperative adjuvant treatment in 15 patients with high-risk GIST. Median follow-up was 77 (range 14–144) and overall survival is 100%. In 42 patients, Local recurrence (LR) occurred in 3 of 42 patients and 1 of 42 patients developed distant metastasis (DM) in 112 months after TEM. In the univariate analysis, mitotic index (p = 0.028), NIH risk categories (p = 0.047) were predictive feature of local relapse. The application of nIM significantly decreased tumor size in large localized rectal GIST, which permitted TEM to preserve sphincter. The TEM procedure with alternative neoadjuvant imatinib therapy is a practicable treatment for patients with rectal GIST to preserve anus and have satisfied anal function.

目的 探讨经肛门内镜显微手术(TEM)治疗直肠腺瘤癌变的临床应用价值.方法 回顾性分析2010年8月至2018年9月于本院接受TEM治疗且术后病理诊断为直肠腺瘤癌变的124例患者的临床资料,纳入病例的人口学特点、病变特征、手术情况、术后恢复及随访情况进行统计分析.结果 124例患者均成功实施TEM术,其中男性56名,女性68名;平均年龄(55.67±10.13)岁;平均手术时间(70.26±24.51)min,平均术中出血量(23.92±2.53)mL,平均肿瘤直径(2.72±1.13)cm;术后并发症发生率为13.71％,其中Clavien-DindoⅠ级12例,Ⅱ级3例,Ⅲ级2例.所有肿瘤均获完整切除,切缘均阴性,术后病理pTis期59例,pT1期65例.根据术后病理分期分两组进行比较,pT1期患者年龄高于pTis期患者,差异有统计学意义(P<0.05);pT1期患者肿瘤直径大于pTis期患者,差异有统计学意义(P<0.05);pT1期患者癌变腺瘤具有绒毛成分者为87.69％,高于pTis期患者的69.49％,差异有统计学意义(P<0.05);术前直肠腔内超声检查与术后病理诊断符合率高于肠镜与术后病理诊断符合率(59.82％vs.35.48％),差异有统计学意义(P<0.05).术后共113例患者获得随访,平均随访(63.97±10.23)个月,均未发现肿瘤复发或远处转移.结论 TEM治疗直肠腺瘤癌变微创,疗效确切,并发症少,可推荐作为一种安全有效的治疗方式.高龄、肿瘤直径大、绒毛成分多可能是直肠腺瘤癌变及进展的高危因素,临床应予以重视.术前直肠腔内超声检查对于提高诊断准确率十分重要.术后应根据患者病理分期与是否具有高复发风险因素等制定个体化随访方案,保证治疗效果.

痔是肛肠外科常见疾病,约占我国肛肠疾病总人数的63.5％.便血是痔最主要的症状之一,便秘、用力排便等原因均可以引起痔出血.痔长期出血可以引起贫血症状,还可导致肛周皮肤瘙痒、湿疹及感染等.当患者出现反复便血、出血量较大而保守治疗无效时,需及时进行外科手术止血.痔合并出血的不同外科治疗方式的临床效果、并发症及复发情况各异,目前临床上对该类患者施行手术的时机、手术方式的选择等问题仍存在争议.根据患者自身情况,选择疗效确切、安全可行的个体化手术方式是解决这一问题的关键,如此方能真正有助于降低痔的复发率,改善患者生活质量.