Volume 101 ·  Issue 29 ·  2021

Neck is an important and complex region of the human body. Once injury occurs, it often leads to a high mortality rate and complication rate, among which vascular injury and massive hemorrhage are the main causes. However, due to the particularity of neck structure, there is a lack of effective control methods for cervical vascular hemorrhage, and there is still no consensus on the diagnosis and treatment of cervical vascular hemorrhage. Combined with the newest researches, this paper tries to explore and summarize the experience of the new classification and management principle of vascular massive hemorrhage.

The application of day surgery on thoracic surgery is just started, and the innovation of surgical robots and their application on thoracic surgery bring new opportunities to the development of thoracic day surgery. However, the clinical practice of robot-assisted thoracic day surgery (RTDS) in China still has challenges and disagreements. Based on the experience of domestic experts in the field of RTDS clinical practice, this review discussed several key points of RTDS, including the future direction of RTDS, adjusting the indications according to their own conditions for the institutions carrying out RTDS, the robot-assisted advantage of RTDS being brought into play during the operation, and the perfect post-discharge follow-up mechanism being an important guarantee for the safe development of RTDS, to promote the application progress of RTDS in China.

Stereotactic electroencephalogram-guided radiofrequency thermocoagulation damage (SEEG RF-TC) is a minimally invasive treatment for drug-refractory epilepsy, which has been gradually developed at home and abroad in recent years. In order to further standardize the application of this clinical treatment, well-known domestic experts in this field were invited to discuss, and a consensus of Chinese experts was formed on the indications, contraindications, treatment plans, safety and effectiveness of this treatment. The consensus is that SEEG RF-TC indications should be divided into two categories, one of which is for the purpose of treatment, and the other is mainly for the purpose of locating the epileptogenic focus and taking into account the treatment. The electrode design scheme should also be specifically designed according to the purpose of surgery. Its safety is good, and it is effective for localized epileptogenic foci such as hypothalamic hamartoma and ectopic nodules of paraventricular gray matter, and it is also effective for other types of focal epilepsy such as hippocampal sclerosis and focal cortical dysplasia (FCD), or it can play the purpose of predicting the efficacy of surgical resection.

To summarize the classification and clinical treatment experience of cervical massive hemorrhage in multiple centers.

From April 2012 to October 2020, clinical data of 42 patients with cervical massive hemorrhage were retrospectively analyzed, including 27 cases from Shanghai Changzheng Hospital, 7 cases from Hunan Provincial People′s Hospital, 4 cases from Longkou People′s Hospital and 4 cases from Laizhou People′s Hospital. According to bleeding position (P), bleeding vessel (V), cerebral blood supply (C), and the presence or absence of associated injury (A), 42 patients were classified as "PVCA", and summarize the methods of pre-hospital emergency and in-hospital treatment based on the "ABC" treatment principles: airway rebuild (A), effective arterial hemostasis and bleeding stop (B), and cerebral blood flow reconstruction within the time window (C).

Within the 42 cases of cervical massive hemorrhage, there were 3 cases of type P1 (below cricoid cartilage), 28 cases of type P2 (cricoid cartilage-mandibular angle), 11 cases of type P3 (mandibular angle-skull base); 22 cases of type V1 (arterial hemorrhage), 11 cases of type V2 (main venous hemorrhage), 7 cases of type V3 (simple superficial vein or small artery hemorrhage), 2 cases of type V4 (mixed arteriovenous hemorrhage); 5 cases of type C0 (no symptoms of cerebral ischemia and neurological dysfunction), 33 cases of type C1 (transient cerebral ischemia without sensory disturbance), 4 cases of type C2 (symptoms of cerebral ischemia and neurological dysfunction); 39 cases of type A0 (no other system damage was involved) and 3 cases of type A1 (combined with other system damage). All 42 patients received operations, 25 patients received open surgery of vascular reconstruction+hematoma/foreign body removal (7 cases of vascular ligation, 14 cases of direct suture repair, 4 cases of vascular interposition), 17 patients received hybrid surgery (carotid angiography+covered stent repair+hematoma/foreign body removal). The surgical technique success rate the was 100%. All the hemorrhagic shock was corrected, hematoma compression was relieved, and the symptoms of cephalic ischemia were improved. There were 4 cases of local cranial nerve injury, 1 case of incision hematoma and 6 cases of postoperative hyper perfusion. During the average 14.3 months follow-up, there was no operation related myocardial infarction, stroke or death, no re-rupture or re-dissection, and 50% asymptomatic restenosis was found in 1 case one year after received covered stent endovascular repair.

Based on the "PVCA" classification and "ABC" treatment principle, it is safe and effective to rescue cervical massive hemorrhage.

To investigate the emergency management process of ruptured abdominal aortic aneurysm (RAAA), and analyze the perioperative mortality factors of different surgical methods.

The emergency data and hospitalization data of 91 patients with ruptured abdominal aortic aneurysm in Xiangya Hospital of Central South University from June 2010 to June 2019 were retrospectively analyzed.Twelve of the patients died preoperatively due to excessive blood loss, and the remaining 79 patients were hospitalized for open surgery (OSR) or endovascular repair (EVAR).The differences in age, time to hospital arrival, emergency preparation time, first creatinine value, emergency infusion volume, preoperative drop in blood pressure, preoperative use of vasoactive drugs and iliac artery involvement were compared between preoperative death group (n=12) and preoperative survival group (n=79), OSR group (n=50) and EVAR group (n=29), postoperative death group (n=23) and postoperative survival group (n=56).

Seventy-nine patients received open surgery or endovascular repair, and 23 died after operation. Age, time to hospital arrival, first creatinine value and emergency infusion volume were (77±11) years, (18±5)h, (469±150) μmol/L, (4 140±1 743) ml in the preoperative death group and (70±10) years, (12±8) h, (228±174) μmol/L, (1 358±1 211) ml in the preoperative survival group, respectively, and the differences were statistically significant (allP<0.05). There were no significant differences in preoperative data, intraoperative treatment and postoperative perioperative mortality between the open surgery group and the endovascular repair group (allP>0.05). The intraoperative blood loss, operation time and aortic occlusion rate in the endovascular repair group were 100 (50, 175) ml, (3.2±0.9) h, 13.8%, respectively, which were better than that in the open surgery group 1700 (600, 3425) ml, (5.2±1.1) h, 100%. The differences were statistically significant (allP<0.05). Age, emergency preparation time, first creatinine value, emergency infusion volume, blood pressure decline rate and vasoactive drug utilization rate in the death group were (77±8) years, (4.1±1.7) h, (456±172) μmol/L, (2 024±1 687) ml, 100%, 100%, respectively, and (68±10) years, (2.7±2.2) h, (135±26) μmol/L, (1 085±825) ml, 21.4%, 12.5% in the survival group, respectively. The differences were statistically significant (allP<0.05).

Age, emergency preparation time, first creatinine value, emergency infusion volume, decreased blood pressure and use of vasoactive drugs are all associated with perioperative death in patients with ruptured abdominal aortic aneurysm. EVAR surgery is a better choice if conditions exist.

Propose a new risk classification system for blunt thoracic aortic injury and explore its treatment strategies.

After the retrospective analysis of clinical data from 68 patients with blunt thoracic aortic injury in the First Affiliated Hospital of Zhengzhou University from November 2016 to October 2020, there were 56 males and 12 females, among these patients, the median age was 45(21-69). According to the degree of aortic injury and the combined injury, the patients were scored for aortic injury, and the risk of the patients were graded into following three types: low-risk group (score ≤ 2 points) 12 cases, intermediate-risk group (3 points ≤ score ≤ 5 points) 41 cases, high-risk group (score ≥ 6 points) 15 cases. Analyzing the effects of treatments received by patients in different grades on the prognosis. Patients were followed up through hospitalization or outpatient clinics at 1, 3, 6, 12 months after surgery and every year thereafter.

Of the 68 patients, 21 received non-surgical treatment and 47 received surgical repair, including 6 open surgery and 41 thoracic aortic endovascular repair. There were 16 cases of emergency operation and 31 cases of delayed operation. Twelve low-risk patients were treated with non-surgical treatment, and only 1 patient died of lung infection, with a mortality rate of 8.3% (1/12). There were 8 deaths in 41 moderate-risk patients, with a mortality rate of 19.5% (8/41), and the aortic-related mortality rate was 9.8% (4/41), and the operative mortality rate was 10.8% (4/37). The total mortality of 15 high-risk patients was 40% (6/15), and the aortic-related mortality rate was 30.0% (5/15), and the mortality rate of surgical patients was 10% (1/10). During the follow-up period of 5 to 52 months, no deaths occurred outside the hospital. According to the risk grading, there were significant differences in the aortic-related mortality of each grade (χ²=7.840, P=0.020). During the follow-up of 5-52 months, 1 case had type Ⅰ endoleak, 1 case of cerebral infarction, and 1 case of acute renal failure.

According to the patient′s degree of aortic injury and combined injury, the risk classification helps to choose the appropriate treatment.

To analyze the feasibility of anterior occipitocervical fusion biomechanical characteristic of craniovertebral reconstruction by anterior occipital condyle screw plate system.

Six cervical vertebra specimens including 4 males and 2 females were enrolled, whose mean age of death was (49.3±7.5) years. The normal models were established by soft tissue dissection, and the instability models were established by destroy bone and ligament structure including, anterior arch of the atlas, part of the lateral mass of the atlas, the odontoid process, the odontoid apical ligament, the pterygoid ligament, the transverse ligament of the atlas the joint capsule. The clivus screw fixation models were established by anterior clivus screw fixation, and then those models were performed by anterior occipital condyle screw fixation. All four groups were loaded with a 1.5 N·m continuous pure force in flexion-extension, lateral bending, and axial rotation. Then measured the range of motion of specimen C₀-C₁ and C₀-C₂. And the pull-out force test was conducted to compare the effects of unicortical and bicortical fixation on the pull-out force of screws.

In the C₀-C₁ segment, the range of motion in flexion-extension (forward and posterior), lateral bending and axial rotation in the clivus group was 6.46°±0.85°, 5.14°±0.76°, 2.73°±0.36°, 1.12°±0.41°, respectively; and it was 5.92°±0.90°, 4.16°±1.06°, 2.86°±0.50°, 1.05°±0.27°, respectively in the occipital condyle group. As for C₀-C₂ segment, the range of motion in the clivus group was 9.55°±1.99°, 10.46°±2.03°, 6.90°±1.29°, 13.51°±1.37°, respectively; and it was 8.14°±1.38°, 9.53°±1.55°, 4.75°±1.06°, 7.90°±1.68°, respectively, in the occipital condyle group. The ranges of motion in the occipital condyle group were significantly lower than clivus group (all P<0.05). The maximum pull out force by bicortical fixation was significantly better than unicortical fixation ((439±33) N vs (408±28) N,P<0.05).

The anterior occipital condyle screw plate system provides better stability especially in anti-bending and anti-rotation than the anterior clival screw fixation.

To explore the preliminary clinical efficacy and safety of calerizumab combined with apatinib in the treatment of patients with middle-advanced liver cancer whose disease has progressed after drug-eluting beads-transcatheter arterial chemoembolization (D-TACE).

A retrospective analysis of 23 patients with advanced liver cancer after D-TACE who were treated with carrelizumab combined with apatinib from April 2019 to July 2020 at Lianyungang First People′s Hospital was carried out. There were 15 males and 8 females with a mean age of (62±9) years. The clinical efficacy was evaluated according to the modified Response Evaluation Criteria in Solid Tumors (mRECRST), and treatment-related adverse events were analyzed after treatment.

All the patients received D-TACE therapy with an average of (2.6±1.0) times, TACE-refractory tumor was observed in 7 patients, and distant metastasis was seen in 6 patients. The objective response rates after combined treatment of 1 month and 3 months were 47.8% and 60.9%, respectively. Disease control rate (DCR) was 73.9% and 78.3%, respectively; median progression-free survival (mPFS) was 126 days. Among 18 patients with alpha fatoprotein (AFP)>200 μg/L, the values before and after treatment of 2 months was (497±117) μg/L and (80±19) μg/L, respectively (P<0.05). Among 9 patients of vascular endothelial growth factor (VEGF)>142.2 ng/L, the values before and after treatment of 2 months was (154±51) ng/L and (57±19) ng/L, respectively (P<0.05). The incidence of treatment-related adverse events was 87.0% (20/23). All adverse reactions did not exceed grade 3 and could be controlled by symptomatic supportive treatment or reducing the dose of apatinib,and the serum aspartate aminotransferase (AST) level after treatment of 3 months[(77±33) U/L] was higher than that before treatment [(45±26) U/L] (P<0.05).

For patients with advanced liver cancer after D-TACE, the treatment of carrelizumab combined with apatinib is effective and the adverse reactions are controllable.

To investigate the seasonal changes of benign paroxysmal positional vertigo (BPPV) onset, and explore the relationship between vascular risk factors and the seasonal patterns of BPPV.

Data of 3 886 patients subjected to vestibular function examination and diagnosed with BPPV who underwent manipulation or instrumental repositioning from January 1, 2016 to December 31, 2019 in the Department of Neurology, Beijing Tiantan Hospital were retrospectively analyzed. Demographic information and medical history of the patients were recorded. Weather temperature data of Beijing were obtained and monthly averages were calculated. The relationship between the BPPV onset and temperature and seasonality was investigated. Meanwhile, the influence of vascular risk factors on the seasonal patterns of BPPV was determined.

BPPV is more common in women (n=2 667). The male to female ratio of patients was approximately 1∶2, with a mean age of (55±13) years. The cases of BPPV in spring (March-May), summer (June-August), autumn (September-November) and winter (December-February) were 1 000 (25.7%), 911 (23.4%), 808 (20.8%) and 1 167 (30.0%), respectively. The peak incidence of BPPV occurred in December (n=491) and the lowest occurred in September (n=251). The number of BPPV cases diagnosed monthly was inversely correlated with mean temperature (R²=0.317; P<0.001). Patients with ≥2 vascular risk factors were at higher risk of developing BPPV in spring or winter than those without risk factors (OR=1.32, 95%CI: 1.13-1.53,P<0.001). Proportion of onset in spring or winter increased with each additional risk factor (P trend<0.001).

BPPV often occurs in the months with low temperature (spring and winter) and the number of cases is inversely correlated with temperature. Compared with those with no vascular risk factors, patients with more vascular risk factors are more likely to develop BPPV in spring and winter.

To explore the application value of single-port laparoscopic and thoracoscopic McKeown esophagectomy for esophageal cancer.

A retrospective study was conducted to collect clinical data of 34 patients with esophageal cancer who were admitted to the Department of Thoracic Surgery, the First Affiliated Hospital of Fujian Medical University, from August to November 2020. All of them, 24 males and 10 females aged from 43 to 75 with an average of (62±4) years, underwent single-port laparoscopic and thoracoscopic McKeown esophagectomy.In the thoracic part, esophageal separation and mediastinal lymph node dissection were performed with conventional 4-ports thoracoscopy in the left lateral-prone position. In the abdominal part, gastric separation and lymph node dissection were accomplished with single-port laparoscopic retrograde three-step gastric separation: firstly, the lesser omentum was dissociated, the left liver lobe was suspended with purse-string needle and thread, after that the left gastric blood vessel and lymph node was dissected; secondly, the esophageal hiatus was separated, and the gastric cardia was cut off; finally, the spleen and stomach ligaments were dissociated to complete these steps. The operation time,volume of intraoperative blood loss, time for out-of-bed activities, time of postoperative drainage tube removal,volume of thoracic drainage fluid, short-term postoperative commplications,the postoperative pathological diagnoses, the time of their discharge from hospital and results of follow-up were observed.

All patients underwent successfully single-port laparoscopic and thoracoscopic esophagectomy without any conversion to open surgery; the operative time of the patients was 194-285 (240±21)min, including 53-105(60±13)min for the thoracic part and 40-73(49±7)min for the abdominal part. The volume of intraoperative blood loss was 15-110(60±20) ml. The numbers of mediastinal lymph node dissected and abdominal lymph nodes harvested were 10-25(13±3), 6-16(9±3)respectively. The 34 patients resumed out-of-bed activities on the 2nd to 3rd day after the operation. The thoracic closed drainage tube and left cervical drainage were removed 2 days after the operation. The thoracic Abel drainage tube was removed 5 days after the operation. The total volume of postoperative thoracic drainage fluid was 100-500(300±100)ml. No obvious sign of anastomotic leakage, anastomotic stenosis, chylothorax or gastric emptying disorder was found after the operation. Eight cases were complicated with temporal hoarseness, and 4 patients with pneumonia which was cured by antibiotics. The mean postoperative hospital stay was 8 days(6, 8), and patients were discharged after they could take a routine semi-liquid diet. The postoperative pathological diagnoses of all patients were squamous cell carcinoma, and the postoperative pathological stage was T1-3N0-1M0. Thirty-four patients were followed up for 60 (40, 75) days after the operation. During the follow-up period, no complication or death occurred. In addition, neither recurrence nor metastasis was observed.

Single-port laparoscopic and thoracoscopic McKeown esophagectomy for esophageal carcinoma is safe and feasible, with good short-term efficacy. Therefore we consider it an alternative minimally invasive surgery for esophageal cancer.

To investigate the efficacy of an etoposide-containing regimen in the treatment of adult-onset Still′s disease related hemophagocytic syndrome(AOSD-HLH).

This study adopted the method of retrospective analysis to collect clinical data of 43 AOSD-HLH patients, including the clinical characteristics, laboratory indexes, treatment regimen and prognosis. There were 7 males and 36 females, aged 24-40 years, with a median age of 30. All of them were diagnosed and treated in Beijing Friendship Hospital of Capital Medical University from December 2014 to December 2019. According to whether or not etoposide (VP-16) was included in the initial therapy, patients were divided into group 1 (VP-16 was not administrated in the initial treatment, n=31) and group 2 (the initial treatment included etoposide, n=12). Patients in group 1 who did not respond to the initial treatment were retreated with VP-16-containing regimen, and the effect of initial treatment was compared between the 2 groups. Similarly, according to whether the VP-16-containing regimen was applied or not, patients achieving remission of HLH were divided into group a (not applied, n=6) and group b (applied, n=33), and the laboratory indicators of the two groups were compared.

The overall response rate (ORR, 6/31 vs 11/12) and complete response rate (CRR, 1/31 vs 5/12) of patients in group 1 were significantly lower than those in group 2 (both P<0.05). Patients in group 1 who did not respond to the initial treatment were retreated with a VP-16-containing regimen, and we found that the ORR reached 22/24. Among patients in remission, the natural killer cell activity [16.3(14.2, 17.5)% vs 13.1(12.2, 13.8)%] and granulocyte counts [5.6(3.4, 9.3) ×10⁹/L vs 3.9(2.3, 4.7) ×10⁹/L] of patients was significantly higher in group B than that in group A(both P<0.05). There was no statistically significant difference in haemoglobin [103.0 (97.0, 109.5) g/L vs 91.5 (70.0, 118.0) g/L] and platelet counts [(212.2±74.2)×10⁹/L vs (226.0±114.9)×10⁹/L] between the two groups(both P>0.05).

The remission status of HLH has an impact on the prognosis of patients. The use of VP-16 in initial treatment can significantly increase the ORR and CRR of AOSD-HLH patients. The application of VP-16 does not cause bone marrow suppression.

To investigate the feasibility, efficacy and safety of semiconductor laser in situ fenestration of type A aortic dissection during thoracic endovascular aortic repair.

The clinical data of 68 patients with type A aortic dissection treated by semiconductor laser in situ fenestration from June 2016 to January 2020 in Department of Vascular Surgery, Shanghai Ninth People′s Hospital Affiliated to Shanghai Jiaotong University were analyzed retrospectively. Of the patients, 45 were male, 23 were female, the mean age was (52±14) years. The technical success rate and complication rates were assessed.

The technical success rate of 68 patients was 92.6% (63/68), only 5 patients failed due to the complex aortic arch type, 3 patients underwent chimney stent implantation, 2 patients underwent artificial vessel bypass. During the perioperative period, 1 patient died due to severe pulmonary infection, 4 patients developed neurological symptoms such as cerebral infarction after surgery, and the remaining patients had no related complications. Postoperative CTA follow-up indicated that the primary intercalation rupture was completely closed, and the main and branch stents were patency, 8 (8.8%) type Ⅰ leakage were occurred.

It showed that in situ semiconductor laser fenestration is a feasible, effective and safe method to treat type A aortic dissection.

Data of 189 patients with first-ever cardioembolic stroke (CES) hospitalized in the Second People′s Hospital of Changzhou from June 2014 to September 2019 were retrospectively analyzed. The neuoimaging markers of chronic small vessel disease (cSVDm) were evaluated and their total burden (0-3 points) was calculated. At 90 d after onset, 65 patients had poor prognosis. Regression analysis showed that the total cSVDm burden score was an independent riskfactor for the poor prognosis(OR=1.754, 95%CI:1.137-2.707, P=0.011).

This paper reports a clinically rare case of epithelioid leiomyosarcoma (BLMS) of the bladder in infants. The clinical manifestations of the child were macroscopic hematuria, and no obvious abnormalities were found on physical examination. Imaging examination showed that the bladder was solid occupying space. After symptomatic supportive treatment, bladder occupying space resection and cystostomy were performed, and the pathological diagnosis was BLMS.

The morbidity and mortality of colorectal cancer (CRC) in China are increasing year by year, and immune checkpoint inhibitor therapy brings new options to CRC patients. At present, the beneficiary population of immunotherapy is limited to the highly microsatellite-unstable (MSI-H) CRC population. In the existing immunotherapy, whether it is anti-programmed death ligand 1 (PD-L1) monoclonal antibody used alone or in combination with anti-cytotoxic T lymphocyte-associated antigen 4 (CTLA4) immune point inhibitor, there is no obvious efficacy for the microsatellite-stable (MSS) CRC population. Binding sialic acid immunoglobulin-type lectin-15 (Siglec-15) is normally expressed only on certain myeloid cells, but its expression is widely upregulated in human cancer cells and tumor-infiltrating myeloid cells. The latest research shows that Siglec-15 is expected to become a new target for current immunotherapy tumor patients, which can bring new hope for immunotherapy for MSS CRC patients who are ineffective in anti-PD-L1 treatment. The purpose of this article is to explain the latest research progress of Siglec-15 itself in tumor and the recent research status of CRC immunotherapy, and to elaborate the research of Siglec-15 in CRC immunotherapy, in order to provide reference information for CRC immunotherapy.

Although the endovascular treatment of traumatic arterial injuries is increasingly common, the effects after repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries have been rarely reported. This study summarized the characteristics and effects of endovascular repair and open surgery in the treatment of traumatic SFA and PA injuries.

While abdominal trauma remains the leading cause of morbidity and death from mesenteric vascular injury (MVI), large-scale multicenter studies on the prognosis of patients with MVI have not been reported. The study aimed to investigate the factors associated with the prognosis of patients with MVI.

traumatic popliteal vascular injuries (TPVI) have the highest risk of amputation among all peripheral vascular injuries (14% ~25%). It is of great value to predict the risk of amputation in patients with TPVI by using effective preoperative assessment tools. The common problem with the existing limb injury severity score (MESS score), nerve injury, ischemia, soft tissue injury, bone injury, shock, and patient age score (NISSA score), limb salvage index, predicted salvage index, and Hanover Fracture Scale is the small study sample size (all<50 patients), insufficient prediction accuracy. This study aimed to provide a simplified and accurate traumatic popliteal injury score (POPSAVEIT scoring system) for preoperative amputation risk stratification in patients with TPVI.

penetrating cervical carotid artery injury (PCCAI) is a rare but high-risk trauma with a high fatality rate. Even after effective treatment, complications such as stroke often occur. The study compares the characteristics of PCCAI in military and civilian settings and provides clues and evidence for subsequent disposal.