目的 探讨腹腔镜肝切除术中转开放手术危险因素及构建中转开放手术的风险预测模型.方法 回顾性分析2019年6月至2022年5月南方医科大学南方医院肝胆外科收治的938例行腹腔镜肝切除术病人的临床病例信息,依据是否中转开放手术分为腹腔镜组(836例)和中转组(102例),收集所有纳入病人基本信息和临床病例资料,分析两组组间差异及因素,基于多因素分析结果构建中转开放手术列线图预测模型.结果 单因素分析结果显示,在有无腹部手术史、有无血管性介入治疗史、是否首次行肝切除、有无腹腔积液、肝肿瘤最大直径、是否为困难肝段切除、切除范围等,差异具有统计学意义(P＜0.05).多因素分析结果显示,有腹部手术史(OR=1.716,95％CI 为 1.023-2.878)、非首次行肝切除(OR=3.585,95％CI 为 1.705-7.538)、肝肿瘤最大直径≥5cm(OR=2.680,95％CI 为 1.646-4.363)、困难肝段切除(OR=2.953,95％CI为 1.755-4.967)、肝段切除范围≥3 个肝段(OR=1.901,95％CI为1.099-3.290)为腹腔镜肝切除术中转开放手术的独立危险因素(P均＜0.05).依据多因素分析结果,纳入5个独立危险因素变量,构建腹腔镜肝切除术中转开放手术的列线图模型.模型的C-index为0.746(95％CI为 0.692-0.800),Hosmer-Lemeshow拟合优度检验结果P=0.541＞0.05,绘制 ROC 曲线,曲线下面积(AUC)为0.746(95％CI为0.692-0.800,P＜0.001).绘制的临床决策曲线(DCA)结果示在阈值概率范围0.05～0.70内模型具有临床效用.结论 有腹部手术史,非首次行肝切除,肝肿瘤最大直径≥5 cm,困难肝段切除,肝段切除范围≥3个肝段是腹腔镜肝切除术中转开放手术的独立危险因素.基于此构建的列线图模型的校准曲线拟合程度理想,在预测的中转开放手术率与实际的中转开放手术率有较好的一致性,模型具有良好预测能力,但仍有待行外部验证来进一步证实.

目的 评估初始不可切除肝癌经转化治疗后行序贯手术切除的临床疗效和分析其临床特征.方法 回顾性收集并分析南方医科大学南方医院2020年1月至2021年12月期间收治的13例初始不可切除肝癌患者的临床数据.结果 13例患者中,12例为男性患者,1例为女性患者,年龄50.0±12.7岁(23～72岁);Child-Pugh分级标准均为A级;CNLC Stage分级Ib期5例,Ⅱa期2例,Ⅱb期2例,Ⅲa期3例,Ⅲb期1例;ECOG ps评分均≤1分;肝硬化者有6例,无肝硬化者7例;有门脉癌栓者2例,无门脉癌栓者11例;治疗前最大肿瘤直径9.8±2.7 cm,治疗前中位AFP为848.1 ng/mL(IQR:20.0～4638.1 ng/mL);有乙肝者12例,无乙肝者1例.转化治疗方案:TACE+免疫方案治疗的有2例、TACE+靶向+免疫方案治疗的有6例、HAIC+靶向+免疫方案3例及TACE+HAIC+靶向+免疫方案治疗的2例.中位转化时间为3.4月(IQR:2.7～5.5月),转化治疗后术前的肿瘤最大直径为7.1±2.2 cm,转化治疗后术前的中位AFP水平17.2 ng/mL(IQR:4.0～121.6 ng/mL),术前影像学评估(mRECIST)CR 2例,PR 5例,PD 1例,SD 5例,肿瘤学转化7例,外科学转化6例,术前PS评分均≤1分.转化后行手术切除:10例行肝部分切除,3例行半肝切除,经腹腔镜手术6例,开腹手术7例.中位手术时间295.0 min(IQR:230.5～418.0 min),中位术中出血量300 mL(IQR:100～375 mL),术后中位住院天数为10 d(IQR:7～13 d),术后中位拔除引流管的时间为7 d(IQR:5.5～13 d).术后病理结果pCR 6例,pPR有7例,MVI分级M010例,M1有3例,均为<5处脉管内癌栓,其中2例为1处脉管内癌栓,无一例切缘阳性病例.术后出现心衰1例,术后出现肺动脉栓塞1例,术后出现胆漏1例.术后中位随访时间11.9月(IQR:6.3～15.1月),3位患者出现复发,随访期间无一例患者死亡.结论 转化后行序贯手术切除的临床疗效效果肯定,安全性尚可.

Background: This study investigated the incidence of post-hepatectomy hypoalbuminemia and the necessity of Intravenous Albumin (ALB) supplement for hypoalbuminemia after Laparoscopic Hepatectomy (LH). Methods: Nine hundred and eighty patients with Open Hepatectomy (OH) and 198 patients with LH were matched on the propensity score by 2:1. The incidences of postoperative hypoalbuminemia and the usage of ALB injection on different Postoperative Days (POD) were compared. Preventive and risk factors of hypoalbuminemia were screened by logistic regression. Receiver Operator Characteristic (ROC) curve and nomogram were established to predict postoperative hypoalbuminemia. Result: 175 patients of LH and 296 patients of OH were matched. The usage of ALB injection was significantly lower in the LH group than those in the OH group (60.0 vs. 75.3%, P=0.000; 6.71 ± 6.99 vs. 8.62 ± 7.18 g, P=0.005). The incidences of postoperative hypoalbuminemia in the LH group were significantly lower than those in the OH group (62.3 vs. 78.4% (P=0.000) on POD 1, 51.4 vs. 71.6% (P=0.000) on POD 3, 37.1 vs. 51.4% (P=0.003) on POD 5, and 27.4 vs. 39.9% (P=0.006) on POD 7). Preoperative serum ALB level and Serum Alanine Aminotransferase (ALT) level was identified as independent protective and risk factor of hypoalbuminemia after LH, respectively. Preoperative serum ALB level below 42.95 g/L and serum ALT level above 28.50 U/L were identified as the reliable cut-off value to predict postoperative hypoalbuminemia after LH. A nomogram for predicting the probability of hypoalbuminemia after LH was established. Conclusion: LH with a reduced intravenous ALB supplement was still associated with a lower incidence of postoperative hypoalbuminemia.

神经损伤及其修复是当今医学界的研究热点和难点,以往的研究主要集中于关注如何改善神经元再生的局部微环境.近年来越来越多的研究显示,成年后的神经元本身再生能力低下是神经再生困难的核心原因.现已知神经元内部有多个信号通路对神经再生具有抑制作用,充分理解这些信号通路对于今后通过提高神经元自身的再生能力,从而促进神经修复具有重要意义.为此,通过文献复习,对神经元内部与抑制神经再生有关的信号通路进行了综述.