Volume 104 · Issue 35 · 2024

Endoscopic therapy has gone through three stages of development: intraluminal treatment, endoscopic tunneling technology, and endoscopic super minimally invasive surgery (ESMIS). Compared to the drawbacks of traditional surgical methods"organ resection and anatomical reconstruction", super minimally invasive surgery (SMIS) emphasizes the surgical concept of"curing diseases while preserving organs and functions". SMIS conducts treatment through four channels: natural cavity channel, tunnel channel, puncture channel, and multi cavity channel. It offers dozens of surgical methods for diagnosing and treating gastrointestinal diseases. At present, relatively sound implementation principles for ESMIS treatment have been established to ensure the safety and effectiveness of surgery, and to continuously expand other diagnostic and therapeutic fields.

With the development of medicine, surgery has also experienced the development and evolution from traditional surgery to minimally invasive surgery, and then to super minimally invasive surgery (SMIS). Meanwhile, reducing surgical trauma and preserving and reconstructing nerve function have gradually become new goals of modern vestibular schwannoma (VS) resection surgery. The surgery of VS can be divided into hearing-preserving surgery (retrosigmoid approach and middle fossa approach) and non-hearing-preserving surgery (traditional translabyrinthine approach), according to whether the patient has practical hearing before operation. Improving the hearing preservation rate of hearing-preserving surgery and reconstructing the hearing of patients with non-hearing-preserving surgery are major challenges and hotspots. The traditional translabyrinthine approach has the highest proportion in the Department of Otolaryngology-Head and Neck Surgery, with the advantages of high facial nerve preservation rate and few intracranial complications. However, due to the resection of the cochlear nerve and labyrinth, the cochlea develops fibrosis, and patients lose the opportunity to reconstruct hearing through cochlear implantation. The new modified translabyrinthine approach can preserve the cochlear nerve and effectively reduce cochlear fibrosis, providing an opportunity for cochlear implantation to reconstruct the hearing. This is another important breakthrough in vestibular schwannoma surgery.

The treatment mode for patients with low rectal cancer (LRC) is still mainly surgical treatment. With the advancement of medical technology, the current surgical mode is more inclined towards super minimally invasive surgery (SMIS) that preserves organs and functions. SMIS belongs to organ preservation surgery, including non-full thickness and full-thickness resection under digestive endoscopy, laparoscopic or robotic full-thickness resection, and transanal minimally invasive surgery, which can cover all stages of TNM staging. The paper elaborates on the importance of preoperative accurate diagnosis and risk stratification in selecting appropriate SMIS methods, the new progress of imaging technology in accurately predicting lymph node metastasis, providing preoperative TNM staging and risk stratification, and guiding SMIS treatment. Finally, the paper introduces the SMIS surgical options for the treatment of LRC that have been developed and are currently in the clinical research stage, with the aim of maximizing the quality of life for LRC patients.

Alzheimer′s disease is the most prevalent neurodegenerative disorder leading to cognitive impairment, but its progression is subtle and the early recognition is difficult. With advancements in disease-modifying therapies, the need for precise early diagnosis of Alzheimer′s disease is increasingly pressing. Fluid biomarkers of Alzheimer′s disease, detectable in bodily fluid samples, are intricately associated with the disease.It can be used for screening, diagnosis, staging, prediction of disease progression, and clinical trials, playing an increasingly critical role in clinical practice.. This guideline systematically reviews and evaluates the spectrum of fluid biomarkers for Alzheimer′s disease, propose standardized protocols for sample collection and processing, and delineates the application standards of fluid biomarkers in disease screening, diagnosis, staging, prognosis of disease progression, and clinical trials. A total of 24 recommendations have been formulated. The publication of this guideline aims to standardize the application of fluid biomarkers in clinical practice, thereby advancing research in Alzheimer′s disease fluid biomarkers.

Autogenous bone has always been the gold-standard bone graft material. As such, it is the primary choice for bony grafts. Autogenous bone grafting has been performed for hundreds of years, and more than 2 million cases of autogenous bone transplantation are performed each year worldwide. It has become the most commonly used surgical method in orthopedics. Numerous studies have suggested methods to select the appropriate donor area, standardize the surgical procedure, and reduce donor site complications, but clinical standards and guidelines remain to be established. To better guide the clinical practice of physicians in China, the Trauma Orthopedic Branch of the Chinese Orthopedic Association, the External Fixation and Limb Reconstruction Branch of the Chinese Orthopedic Association, and the Microsurgery Branch of the Beijing Orthopedic Association developed the "Clinical practice guideline for autogenous bone grafting in China (2024 edition)" based on current medical evidence. This guideline systematically evaluates recent domestically and internationally published literature and medical research evidence in the field of autologous bone grafting in the Chinese population. The guideline was produced with the aim of standardizing the indications and techniques for autogenous bone transplantation, as well as preventing complications at the harvesting site of autologous bone, in the Chinese population.

To explore the application value of the domestic precision ®single-port robotic system in nephron sparing surgery.

The clinical data of patients with renal masses underwent nephron sparing surgery using the domestic precision ®single-port robotic system at the PLA General Hospital, Gulou Hospital Affiliated to Nanjing University School of Medicine, Zhongnan Hospital of Wuhan University and the First Affiliated Hospital of Nanchang University from September to November 2023 were retrospectively included. Perioperative clinical data, pathological examination results, and postoperative complications were summarized.

A total of 12 patients were included, including 8 males and 4 females, with 26-75 (56±16) years. Body mass index (BMI) was (25.1±2.7) kg/m². There were 6 cases on the left side and 6 case on the right side. The surgical approach was transabdominal in 9 cases and retroperitoneal in 3 case. The maximum diameter of the lesions was (2.7±0.7) cm, the warm ischemia time [M (Q₁, Q₃)] was 19 (15, 26) minutes, the surgical time was 180 (149, 216) minutes, and the intraoperative blood loss was 50 (28, 100) ml. Postoperative visual analogue scale (VAS) was (2.9±1.5) points. Postoperative pathology revealed malignant renal clear cell carcinoma in 9 cases, with nuclear grading of 3 cases for Grade 1, 3 cases for Grade 2, and 3 cases for Grade 3. Eight cases of pathological TNM staging were pT1aN0M0 and 1 case was pT3aN0M0, with no cancer at the resection margin. Three cases showed benign renal vascular smooth muscle lipoma. There were no postoperative blood transfusions and no complications such as fever, urine leakage and poor wound healing.

The prliminary experience reveals that the domestic precision ®single-port laparoscopic robotic system has good clinical application value in urological nephron sparing surgery.

To investigate the efficacy of Da Vinci robotic transanal minimally invasive surgery (R-TAMIS) for rectal neoplasms.

The patients of rectal neoplasms who underwent R-TAMIS and were regularly followed up at the First Medical Center of Chinese PLA General Hospital from January 2021 to January 2024 were retropectively selected. Follow-up visits were conducted at 1, 2, and 4 weeks postoperatively, and then every 3 months until January 20, 2024. The perioperative situation, postoperative histopathological results, and follow-up status of the patients were observed.

A total of 17 patients were included, including 10 males and 7 females, aged 35-80 (59±13) years. Eleven patients underwent surgery using the da Vinci® Si robot, while 6 patients underwent surgery using the da Vinci® Xi robot. The height of the resected tumor from the anal verge [M (Q_1,Q₃)] was 3.5 (3.0, 3.8) cm. The total operative time was 55.0 (50.0, 55.0) minutes, the platform installation time was 32.5 (30.0, 35.0) minutes. The actual surgical operation time was 22.5 (20.0, 27.5) minutes. Intraoperative blood loss was 9.2 (5.0, 10.0) ml. The postoperative hospital stay was 3.2 (3.0, 3.8) days. The total treatment cost was (29 447±4 765) yuan. Two patients who achieved clinical complete remission after neoadjuvant chemoradiotherapy experienced incision dehiscence one week postoperatively, which was resolved after four weeks of rectal irrigation therapy. All surgical specimens were intact, and all resection margins were negative. A total of 44(31,73) weeks were followed up, without local recurrence or distant metastasis.

Da Vinci robotic transanal minimally invasive local resection may be a safe and feasible treatment option for rectal neoplasms.

To investigate the safety and efficacy of a varicose vein sealant kit in the treatment of great saphenous vein dysfunction.

It was a randomized controlled trial. A total of 180 patients with great saphenous vein dysfunction were enrolled prospectively, and scheduled for surgical treatment in 9 hospitals, including the Second Affiliated Hospital of Naval Medical University, Shanghai Oriental Hospital Affiliated to Tongji University, Xuanwu Hospital Capital Medical University, the First Hospital of Hebei Medical University, Ganzhou People′s Hospital, Shanxi Bethune Hospital, the Second Affiliated Hospital of Zhejiang University School of Medicine, the Fourth Affiliated Hospital of Zhejiang University School of Medicine, and Zhongshan Hospital Affiliated to Xiamen University, from June to October 2022. Using a random number table method, the subjects were divided into an experimental group and a control group, with 90 cases in each group. The patients of experimental group received treatment with varicose vein sealant kit, while the patients of control group received radiofrequency ablation. The main outcome measure was the complete closure rate of the great saphenous vein in both groups of patients 3 months after surgery. The secondary outcome measures were the complete closure rate of the great saphenous vein in both groups of patients immediately after surgery and 6 months after surgery, the operation time for closing the main trunk of the great saphenous vein, pain score, venous clinical severity score (VCSS), Aberdeen varicose veins questionnaire (AVVQ) at different times before and after surgery, and the incidence of complications in both groups of patients. The non inferiority threshold for the two treatment methods is set at "-10.00%".

A total of 177 patients were ultimately enrolled. There were 89 cases in the experimental group, including 38 males and 51 females, with a median age [M (Q₁, Q₃)] of 59.7(49.6, 66.7) years, and 88 cases in the control group, including 30 males and 58 females, with a median age of 57.2(46.9, 65.9) years. A total of 174 patients completed a 3-month follow-up, and 167 patients completed a 6-month follow-up. The closure time of the main saphenous vein in the experimental group was (22.1±11.1) min, which was longer than the control group, which was (18.7±9.8) min (P=0.031). The complete closure rate of the great saphenous vein immediately after surgery in both the experimental group and the control group was 100%. The complete closure rates of the great saphenous vein at 3 months after surgery were 98.8% (85/86) and 98.9% (87/88), respectively. The lower limit of the 95%CI for the difference between the two groups was -3.19%, which was greater than the non-inferiority threshold of -10.00% (non-inferiority P<0.001). The complete closure rates of the great saphenous vein at 6 months after surgery were 97.6% (81/83) and 100% (84/84), the lower limit of the 95%CI for the difference between the two groups was -5.71%, which was greater than the non-inferiority threshold of -10.00% (non-inferiority P<0.001). The immediate pain scores after complete anesthesia awakening of the experimental group and the control group were both 1.0 (0, 2.0), with no statistically significant difference (P=0.365). The incidence of bruising in the experimental group and the control group one week after surgery was 61.2% (52/85) and 67.1% (57/85), respectively, with no statistically significant difference (P=0.181). There was no statistically significant difference in VCSS and AVVQ scores between groups before surgery and at 1, 3, and 6 months after surgery (all P>0.05). There was no statistically significant difference in the incidence of complications such as deep vein thrombosis, phlebitis, pain, and subcutaneous hematoma in the lower limbs 3 months after surgery (all P>0.05).

The varicose vein sealant kit is safe and effective in treating great saphenous vein dysfunction, and can achieve a complete closure rate of great saphenous vein that is not inferior to traditional radiofrequency ablation.

To analyze the clinical characteristics of appendiceal orifice polyps and the effect of endoscopic super minimally invasive treatment. A retrospective analysis was conducted on the general situation (age and sex), the classification of appendiceal orifice polyps, the treatment method under endoscope, postoperative pathology and postoperative complications in patients who underwent resection of appendiceal orifice polyps at the Peking University First Hospital and the First Medical Center of the PLA General Hospital from January 1, 2022, to December 31, 2023. A total of 47 patients were included, consisting of 28 males and 19 females, with 35-86 (61±12) years. Appendiceal orifice polyps were classified into four types: type 0 (14 cases), type 1 (15 cases), type 2 (12 cases), and type 3 (6 cases). Among the endoscopic morphologies, 22 cases were granular laterally spreading tumors. Endoscopic mucosal dissection was performed in 37 cases. Postoperative appendiceal stent placement was performed in 1 case. The pathological types of polyps included adenoma in 15 cases, high-grade intraepithelial neoplasia in 10 cases, intramucosal carcinoma in 4 cases, submucosal carcinoma in 5 cases, inflammatory polyps in 1 cases, and sessile serrated lesion in 12 cases. Curative resection was performed in 44 cases. There were no postoperative complications such as bleeding, perforation, or acute appendicitis. The pathology of appendiceal polyps is mostly precancerous lesions, and the treatment scheme of endoscopic super minimally invasive resection is both safe and effective.

Clinical data of 1 494 patients with hematological diseases who were scheduled to receive allogeneic hematopoietic stem cell transplantation and received the anti-human-leukocyte-antigen (HLA) antibody test for the first time at the First Affiliated Hospital of Soochow University from 2016 to 2018 was collected to analyze the positive rates and distribution characteristics of different types of pre-existing anti-HLA antibodies in patients with different hematological diseases. Among 1 494 patients with hematological diseases, there were 849 males and 645 females, aged [31 (17, 45)] years, and included 577 cases of acute myeloid leukemia (AML), 373 cases of acute lymphocytic leukemia (ALL), 234 cases of aplastic anemia (AA), 175 cases of myelodysplastic syndrome (MDS), and 135 cases of other diseases. The total positive rate of pre-existing anti-HLA antibodies was 25.1% (375/1 494), among which the positive rates of anti-HLA class Ⅰ, anti-HLA class Ⅱ, and anti-HLA class Ⅰ+Ⅱ antibodies were 11.2% (168/1 494), 4.9% (73/1 494), and 9.0% (134/1 494), respectively.The total positive rates of pre-existing anti-HLA antibodies in patients with MDS、AA、AML、ALL and other diseases were 40.6% (71/175), 30.8% (72/234), 26.2% (151/577), 12.3% (46/373), and 25.9% (35/135), respectively, with statistically significant difference (P<0.001). The positive rates of anti-HLA class Ⅰ, anti-HLA class Ⅱ, and anti-HLA class Ⅰ+Ⅱ antibodies in patients with different hematological diseases showed statistically significant differences (all P<0.001). Given the varying positive rates and distribution characteristics of pre-existing anti-HLA antibodies among patients with different hematological diseases, anti-HLA antibody test should be performed before receiving hematopoietic stem cell transplantation.

The patient, a 54-year-old male, was admitted to the Department of General Surgery of the First Hospital of Lanzhou University on March 29, 2023 because of "gastric mucosal lesions found for more than 2 weeks". The patient's out-of-hospital physical examination and gastroscopy results showed high-grade intraepithelial neoplasia of the mucosa. After admission, the relevant examinations were completed, and after excluding the contraindications for surgery, endoscopic submucosal dissection (ESD) was performed. Endoscopy showed a depressed lesion in the middle segment of the small curved side of the stomach body, about 0.6 cm. Postoperative pathology showed high-grade intraepithelial neoplasia of the glandular epithelium and local carcinoma. Early gastric cancer was diagnosed. According to the radical evaluation system (eCura evaluation system), it was non-curative resection, followed by full-thickness resection of local tissue of the stomach wall + D1+ lymph node dissection. Postoperative pathology showed mild atypical hyperplasia of the surrounding glandular epithelium, and no abnormal lymph nodes were found. The surgical method of this case followed the super minimally invasive concept, and the patient recovered well after operation, and there were no special abnormalities in all examination indexes. Three months after discharge, the patient recovered well without recurrence or metastasis. This operation has high clinical value for the treatment of early gastric cancer.

Two middle-aged female patients with abdominal pain were presented to the Affiliated Hospital of Southwest Medical University and consumed persimmons before admission. After admission, total abdominal CT and gastroscopy revealed the formation of huge stones in the stomach (Case 1 had 2 huge stomach stones, the maximum was about 5 cm ×6 cm; Case 2 had 1 huge stomach stones, about 5 cm ×4 cm), and the diagnosis of giant gastrolithiasis was clear. Due to the huge and hard texture of the stones, the conventional snare failed to remove the stones successfully. Our team designed a new simple endoscope composed of yellow zebra guide wire and snare sleeve, which is hard enough to adjust the size and width of the snare according to demand. Finally, after successful lithotripsy under digestive endoscopic super minimally invasive surgery, part of the lithotripsy was removed through a lithotripsy net basket; The rest of the stones remained in the stomach, and after a few days the residual stones were discharged with the feces. After operation, symptomatic treatment such as acid suppression, gastric mucosa protection and nutritional support were given. After reexamination and endoscopy, there was no residual lithotripsy, and he was successfully discharged. Both patients were followed up 1 week after discharge, and there were no complications such as intestinal obstruction.

With the development of digestive endoscopy technology, the treatment of biliary and pancreatic diseases is transitioning from traditional surgery to super minimally invasive surgery (SMIS) mode. The application of oral choledochoscopy and endoscopic ultrasound (EUS) and other technologies is increasingly mature, which lays the foundation for the extensive development of SMIS. These technologies are widely used in the treatment of diseases such as bile duct stones, gallbladder stones, peripancreatic effusion and pancreaticobiliary system tumors. In addition, the protection of duodenal papillary sphincter function is also an important goal of SMIS surgery. This article reviews the application of these techniques in patients with biliary and pancreatic diseases, evaluates their clinical effects, and explores future development directions.

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder commonly seen in children, characterized by social interaction disorders, communication difficulties, and repetitive behaviors. In recent years, a series of studies on the relationship between ASD and intestinal flora imbalance have been conducted, and it has been found that the difference in intestinal flora composition between normal developing individuals and ASD patients is more significant. This article reviews the characteristics of intestinal flora in ASD patients and discusses the effects of intestinal flora imbalance in ASD patients on the microglia-mediated immune system, as well as the effects of intestinal flora metabolites on the central nervous system via the microbial-intestinal-brain axis, thereby increasing the susceptibility to ASD disease. In addition, based on the intervention strategy of intestinal flora on ASD, the research progress of fecal bacteria transplantation in the intervention and treatment of ASD is mainly discussed, which provides new ideas for early intervention and treatment of ASD.

The patient, a 73-year-old man, went to Hubei Provincial Corps Hospital of the Armed Police for "dull pain in the upper abdomen for more than 10 days". More than 10 days before admission, there was no obvious trigger for paroxysmal epigastric dull pain, which was obvious at night, without nausea, vomiting, diarrhea and melena. Previous history of cholecystectomy and coronary heart disease; No special family history. The whole body examination is nothing special. Perfect gastroscopy showed multiple bulges of different sizes and punctate black changes in the mucosa of the stomach fundus, gastric body, gastric antrum and duodenum. The center of the bulge was black, the surrounding mucosa was swollen and the surface was smooth, the largest of which was near the duodenal papilla (about 1.2 cm ×1.5 cm) (Figures 1 and 2); colonoscopy showed multiple polyps in the colon, but no black lesions were found. Gastroscopy pathology: (gastric body) mucosa lamina propria showed small focal pigmentation (Figure 3). Immunohistochemistry: HMB45 (+), Ki-67 (+, 40%), Melan-A (+), S-100 (+), SOX10 (+). Whole body PET/CT showed: multiple lymph nodes or nodules in the thoracic, abdominal and pelvic cavities with increased metabolism; Localized thickening and increased metabolism of the stomach body and wall; Multiple metabolic increases throughout the body. The final diagnosis was primary gastroduodenal malignant melanoma stage IV (TxN₂M₁）。 After 8 months of systemic chemotherapy and immunotherapy, the patient died due to deterioration of his condition. Primary upper gastrointestinal malignant melanoma is extremely rare and has no specific clinical manifestations, so it is difficult to diagnose, and because of its strong aggressiveness, lack of effective treatment, and poor prognosis.

A 56-year-old male went to Shiyan People's Hospital for "pain in the right lower abdomen for more than 10 days". The pain is paroxysmal swelling and pain, which does not radiate to other parts. Physical examination showed flat abdomen, no palpable intestinal type, tension of abdominal muscles in the right lower abdomen, tenderness and rebound pain at McMaher's point, and no abnormal mass palpable. Blood routine showed white blood cells 8.44×10⁹g/L, neutrophil ratio 63.2%; Ultrasound examination showed a cystic mass with a range of 7.8 cm ×3.3 cm between the right lower abdomen and intestine, with clear boundaries and poor intracapsular sound transmission, showing "onion skin"-like changes; Ultrasound cross-sectional scanning showed thickening of the intestinal wall, no obvious blood flow signal, and no obvious fluid accumulation around it (Figures 1 and 2). The patient underwent laparoscopic cecectomy, during which an appendix with a length of 8 cm and a diameter of 0.8 to 3.5 cm was removed. The partial lumen of the appendix is dilated, the wall thickness is 0.2~0.5 cm, the serous surface is gray-red and congested, the incision surface contains a large amount of mucoid matter, and the appendix is slightly adhered to the mesenteric root of the small intestine. Pelvic and abdominal exploration did not reveal significant nodules or enlarged lymph nodes. The pathological findings showed a low-grade mucinous tumor of the appendix with stage pT3. One year later, there was no obvious abnormality in ultrasound reexamination in the outside hospital. When a mass in the right lower abdomen is found clinically, the possibility of mucinous tumor of the appendix should be considered and puncture should be avoided to reduce the risk of metastasis of abdominal implants. The treatment principle is to remove the appendix tumor tissue as much as possible. During the operation, attention should be paid to avoid appendix perforation and tumor implantation. If necessary, laparoscopic surgery should be converted to open surgery.