Table of Content

20 August 2023, Volume 23 Issue 04

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Original Articles and Clinical Research

Constructing and validating an online predictive model of severe postoperative complication for hepatocellular carcinoma

HUANG Gui-zhong, LIN Qiao-hong, YIN Peng-fei, ZHANG Jian-long

2023, 23(04):  289-293.  DOI: 10.3969/j.issn.1009-976X.2023.04.001

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Objective To construct and validate an online predictive model of severe postoperative complications for hepatocellular carcinoma （HCC）. Methods The clinical data of 347 HCC patients who underwent resection from December 2009 to December 2017 in Sun Yat-sen Memorial Hospital of Sun Yat-sen University were retrospectively analyzed. The significantly independent factors of severe postoperative complications were identified according to the logistic regression analysis, and then an online model was constructed. A concordance index （C-index） and calibration curve were used to validate the performance and clinical utility of the model. Results A total of 39 cases had severe complications after hepatectomy and the mean postoperative hospital stay was 19±10 days. Multivariate regression analysis suggested that concomitant disease, smoking/drinking, preoperative serum ALT and GGT levels, surgery time, and the number of tumors were risk factors for severe complications （P<0.05）. Based on the results of the multi-factor analysis, an online prediction model was developed. After internal verification, the C-index of the developed model was 0.845. Conclusion Severe postoperative complications tend to increase the risk of perioperative mortality for HCC. Clinicians can figure out those patients at high risk of severe postoperative complications more efficiently by using the constructed model, which can effectively shorten postoperative hospital stay and improve short-term outcomes.

Real-world analysis of mFOLFOX systemic chemotherapy combined with immunotherapy and targeted therapy for unresectable hepatocellular carcinoma

LUO Xuan, LONG Yin, HUANG Zi-qi, HE Xiao-dong, HUANG Jue, LIAO Jian-guo, ZHANG Lei

2023, 23(04):  294-301.  DOI: 10.3969/j.issn.1009-976X.2023.04.002

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Objective To evaluate the real-world efficacy and safety of mFOLFOX systemic chemotherapy combined with immunotherapy and targeted therapy for unresectable hepatocellular carcinoma （uHCC）. Method The real-world data of 51 patients with uHCC treated by mFOLFOX combined with immunotherapy and targeted therapy in the Hepatobiliary Department of Sun Yat-sen Memorial Hospital from July 2022 to July 2023 were retrospective collected and analyzed. Results According to the preliminary statistics, the objective response rate （ORR） and disease control rate （DCR） under the mRECIST standard were 47.1% and 96.1% respectively; Among them, 21 cases （41.2%） successfully underwent conversion surgery, and 5 cases achieved pCR （23.8%） after surgery. Logistic regression analysis showed that the number of tumors was an independent influencing factor for achieving conversion （OR=11.6, 95% CI：1.28~105.41, P=0.029）, while treatment timing may be an independent clinical factor affecting remission, but there was no statistically significant difference （P=0.054）. The average follow-up time was 6.76 months, and the median OS and PFS were not achieved. The overall incidence of treatment related adverse events （TRAE） was 92.1% and the incidence of level 3~4 TRAE is 33.3%. Conclusion mFOLFOX systemic chemotherapy combined with immunotherapy and targeted therapy can be safely and effectively applied to the treatment of unresectable hepatocellular carcinoma, with a considerable conversion surgery rate.

Spermidine inhibits colon cancer and enhances the sensitivity to 5-Fu

LIN Zhi-rong, YANG Hao-jie, WANG Pei, CHEN Jia-ning

2023, 23(04):  302-308.  DOI: 10.3969/j.issn.1009-976X.2023.04.003

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Objective To investigate the effects of spermidine （SPD） on the proliferation, migration, invasion and apoptosis of colon cancer cells and the change of the sensitivity of HCT15 and SW620 to 5-Fu. Methods CCK-8, clonal formation assay, transwell migration and invasion assay, flow cytometry used to detect apoptosis, and subcutaneous tumor transplantation experiments in nude mice were performed to investigate the effects of SPD on the proliferation, migration and invasion ability and apoptosis of HCT15 and SW620 cells（KRAS mutant）, and the changes of the sensitivity of HCT15 and SW620 to 5-Fu. Results The IC₅₀ of HCT15 treated by SPD was 15.75±1.55 μM, and that of SW620 treated by SPD was 7.11±0.37 μM. The IC₅₀ of HT29 treated by SPD was 76.17±10.02 μM, and that of SW48 treated by SPD was 64.40±5.61 μM. The number of clones formed in HCT15 and SW620 treated by SPD at 5 μM was lower than that in control group, and it was not found that the number of cell clones formed by SPD treatment of HT29 and SW48 was less than that of control group. The number of HCT15 and SW620 cells passing through transwell cells after SPD treatment was significantly reduced compared with the control group. The apoptosis rates of HCT15 and SW620 treated with SPD at 20 μM were higher than those of the control group. Combined SPD and 5-Fu treatment of HCT15 and SW620 cells had lower IC₅₀ than 5-Fu treatment of HCT15 and SW620 cells alone. Treatment of HCT15 and SW620 cells with a combination of 5 μM SPD and 5 μM 5-Fu resulted in fewer cell clones than treatment of HCT15 and SW620 cells with 5-Fu alone. The apoptosis rates of HCT15 and SW620 cells treated with 1 μM SPD combined with 5 μM 5-Fu were higher than that treated with 5-Fu alone. Subcutaneous tumor transplantation in nude mice showed that the tumor volume of SPD treatment group was smaller than that of placebo group, and the tumor volume of SPD combined with 5-Fu treatment group was smaller than that of 5-Fu treatment group alone.ALT, AST and Cr levels were not found to be higher in the treatment group than in the placebo group. Conclusion SPD can inhibit the proliferation, migration and invasion of HCT15 and SW620 cells, promote the apoptosis of HCT15 and SW620 cells, enhance the sensitivity of HCT15 and SW620 to 5-Fu, inhibit the growth of subcutaneous transplantation tumors of SW620 and enhance the anti-tumor effect of 5-Fu, which has certain safety.

Development and validation of a clinical prediction model for predicting postoperative complications after radical resection of colon cancer

LIU Xiao-qing, ZHANG Yu-chao, WANG Cheng-li

2023, 23(04):  309-314.  DOI: 10.3969/j.issn.1009-976X.2023.04.004

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Objective The aim of this study was to develop and validate a nomogram for predicting postoperative complications after radical resection of colon cancer. Methods Retrospective analysis was conducted based on the relevant data of patients who underwent radical resection of colon cancer at Sun Yat-sen Memorial Hospital of Sun Yat-sen University from January 2019 to June 2021 which was extracted from the electronic medical record system. The main outcome variables of the study were postoperative complications. Cases that meet the inclusion criteria were randomly divided into a model training cohort and an internal validation cohort in a ratio of 7∶3. Firstly, the LASSO regression was used to screen potential influencing factors with non-zero regression coefficients. Then, multiple factor stepwise regression was performed on the selected potential risk factors ad select variables with P<0.05 to further construct a prediction model and visualize it using nomogram. The discriminability, calibration, and clinical application value of the model were evaluated through receiver operating characteristic curve （ROC curve）, calibration curve, and decision curve analysis （DCA）. Results The final prediction model included four variables： age, duration of surgery, postoperative admission to ICU, and preoperative D-dimer level. The area under the operating characteristic curve （AUC） of the training set and the validation set were 0.791 and 0.889, respectively. The calibration curve and DCA curve indicate that the model has good calibration and clinical practicality. Conclusion We have developed and validated a new predictive model for postoperative complications after radical resection of colon cancer, which only has 4 predictive factors but has good predictive performance. This new tool may help reduce postoperative complications and accelerate patient recovery.

Study on enhanced recovery after surgery in gastrointestinal surgery

SONG Shun-xin, GUO Shuo-hao

2023, 23(04):  315-319.  DOI: 10.3969/j.issn.1009-976X.2023.04.005

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Objective To explore the postoperative outcome of enhanced recovery after surgery （ERAS） protocol on patients in gastrointestinal surgery. Methods A total of 110 patients underwent radical resection of gastric cancer and colorectal cancer in our hospital from January 2021 to June 2022 were included in the study, and were randomized into two groups with 51 in each group. The patients treated by the traditional clinical pathway were the control group, and those treated with ERAS protocol were assigned ERAS group. Inclusion criteria： All patients completed radical resection of gastric cancer and colorectal cancer and were cured and discharged from hospital with complete clinical data. The compliance of patients in ERAS group was more than 80%. The levels of blood routine, insulin resistance index, cortisol, C-reactive protein （CRP） before and 7 d after surgery were recorded The abdominal pain and abdominal distension scores were recorded, and the postoperative clinical indicators were recorded in detail to observe the occurrence of postoperative complications. Results Before surgery, the levels of hemoglobin, serum albumin, insulin resistance index, cortisol and CRP in the two groups were not statistically significant （P>0.05）. Compared with the control group, hemoglobin and serum albumin in ERAS group were increased, and the levels of insulin resistance index, cortisol, CRP were decreased, the differences between two groups were statistically significant （P<0.05）. The NRS of patients in the ERAS group was significantly lower than that in the control group, and the difference was statistically significant （P<0.05）. There were one case of anastomotic leakage and two cases of urinary tract infection in ERAS group, and the complication rate was 5.45 %, and two cases of anastomotic leakage, three cases of urinary tract infection, two cases of pulmonary infection and three cases of incision infection in the control group with complication rate 18.18 %. The difference between the two groups was statistically significant （P<0.05）. Conclusion In this study, ERAS protocol promoted the recovery of patients and reduced the incidence of complications in patients with gastric cancer and colorectal cancer.

Changes of immune indexes and related factors of SSI in HIV patients during limited period orthopedic surgery

YE Jun-jie, HU Bo-yong

2023, 23(04):  320-325.  DOI: 10.3969/j.issn.1009-976X.2023.04.006

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Objective To observe the changes of immune indexes in HIV patients during limited period orthopedic surgery and analyze the related factors of surgical site infection （SSI） after surgery. Methods from January 2019 to January 2020, 37 patients diagnosed as HIV infection before operation in our hospital and required orthopaedic surgery within the time limit were selected for standardized orthopaedic surgery during the perioperative period. The basic data and immune index changes of patients during the perioperative period were collected, and the fluctuation of immune index changes was analyzed. 9 patients with SSI （24.3%） were included in the infection group, 28 patients （75.7%） without SSI were included in the control group, and the related factors of postoperative SSI were analyzed. Results Among the 37 patients, 12 were newly found HIV infected patients and 25 previously diagnosed HIV patients, of which 16 were not treated with anti retroviral therapy （ART）. One way ANOVA showed that there were significant differences in operation mode, operation time, blood loss, CD4 in 3 days after operation, CD4 in 7 days after operation, CD4 in 14 days after operation, viral load 14 days after operation, Preoperative HCT and HGB, HCT and HGB in 3 days after operation, HCT and HGB in 7 days after operation, HCT and HGB in 14 days after operation, ALB in 7 days after operation and ALB in 14 days after operation between the two groups （P<0.05）. Further Stepwise regression analysis showed that the operation mode had a significant positive impact on the occurrence of SSI （P<0.05）, and HCT in 3 days after operation and CD4 in 14 days after operation had a significant negative impact on the occurrence of SSI （P<0.05）. Conclusion The occurrence of SSI after orthopaedic surgery in HIV patients is affected by many factors, but it is not related to the preoperative viral load and CD4 level, but closely related to the size of surgical trauma, the viral load and CD4 fluctuation during the perioperative period.

Correlation between mechanical changes and malunion after supracondylar fracture of the humerus

FENG Ting, ZENG Jun, LI Jun, CHEN Yun-hui, DU Tao

2023, 23(04):  326-331.  DOI: 10.3969/j.issn.1009-976X.2023.04.007

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Objective To study the correlation of mechanical changes after supracondylar fracture of the humerus. Methods Fifty-four children with supracondylar fracture of the humerus who were treated in our hospital from 2019 to 2022 were selected. All patients underwent closed reduction and Kirschner wire fixation and were followed up for 6 months. The children with valgus and tebitus varus at 6 months of follow-up were assigned to malunion group （n=10）, and those without cubitus valgus and cubitus varus were divided into normal healing group （n=44）. anteversion angles of capitulum humerus , Baumann angle, carrying angle and torsion angle of distal humerus were measured in two groups and compared between the two groups before operation, after reduction and at 6 months of follow-up. Logistic regression analysis was used to analyze the mechanical factors affecting the malunion of elbow joint. Results The preoperative Baumann angles, distal humeral torsion angles, and carrying angles were significantly higher in the malunion group than in the normal healing group, and the differences were all statistically significant （P<0.05）. After reduction, the anteversion angles of capitulum humerus, Baumann angle and distal humeral torsion angles in the malunion group were significantly higher than those in the normal healing group, and the differences were statistically significant （P<0.05）. Spearman correlation analysis showed that Baumann angles were negatively correlated with distal humeral torsion angles and carrying angles before operation in both groups; after reduction, the anteversion angles of capitulum humeri, Baumann angles, distal humeral torsion angles and carrying angles were significantly negatively correlated with the carrying angle in both groups; at a follow-up of 6 months, there was a significant negative correlation between Baumann angle and carrier angle in both groups. Multivariate logistic regression analysis showed that anteversion angles of capitulum humerus after reduction, Bauman angle before operation and after reduction, carrying angle at 6-months of follow-up, and distal humeral torsion angles before operation were all factors influencing the malunion of children with supracondylar fracture of the humerus. Conclusion The present study showed that anteversion angles of capitulum humerus after reduction, Bauman angles before operation and after reduction, carrying angles at 6-months of follow-up, and distal humerus torsion angles before operation were related to the malunion of children with supracondylar fracture of humerus.

Predictive factors of diabetic foot amputation for community medical center

ZULIPIYA Nuermaimaiti, GULIJIANAITI Maimaituxun, MAIJIMI Simayi, AIERXIATI Yibulayin

2023, 23(04):  332-336.  DOI: 10.3969/j.issn.1009-976X.2023.04.008

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Objective To analyze risk factors for amputation using information on diabetic foot（DF） at community clinics for early detection of high-risk DF at the grassroots levels and early specialist treatment. develop cost-effective and extendible method for early detection and treatment, this study evaluated risk factors for diabetic foot （DF） amputation using easily accessed data from community medical centers. Methods A total of 403 DF patients admitted to First People′s Hospital of Kashi Prefecture between Jan 2018 and Jan 2021 were enrolled. They were divided into amputation and non-amputation group according to treatment and prognosis. Multivariate cox regression and K-M method were performed to analyze the factors influencing （major） amputation. Results The significant differences were showed on duration of diabetes mellitus （DM）, DF surgery history, blood glucose management, smoking, fever, Wagner grade, ankle brachial index （ABI）, hemoglobin （HB） between two groups （P<0.05）. The multivariate cox regression showed that DM>10 years （HR=2.439, 95%CI： 1.180-5.050, P=0.016）, DF surgery history （HR=2.403, 95%CI： 1.540-3.745, P<0.001）, uncontrolled blood glucose （HR=1.879, 95%CI： 1.259-2.898, P=0.002）, smoking （HR=1.644, 95%CI：1.085-2.487, P=0.019）, Wagner grade 3~5 （HR=1.980, 95%CI： 1.314-2.985）, P=0.001] and hypo-HB （HR=1.027, 95%CI： 1.011-1.044, P=0.001） were risk factors of amputation. Additionally, DM>18years （HR=2.544, 95%CI： 1.055-7.874, P=0.037） and DF surgery history （HR=2.525, 95%CI： 1.757-4.608, P=0.034） were risk factors of major amputation. Conclusion DF patients from community medical centers with long DM duration, DF surgery history, uncontrolled blood glucose, smoking, Wagner grade 3-5, hypo-HB and ABI<0.9 should be given more attention to prevent probable amputation.

Case Report

Recurrent pericardial effusion from primary cardiac angiosarcoma leading to delayed diagnosis： a case report and literature review

LIU Cong-yong, ZHANG Lu, JIANG Hui-qi, GAO Min-nan, LI Jing-wen, SHI Zhan-yue, YANG Yan-qi, ZHENG Jun-meng

2023, 23(04):  337-342.  DOI: 10.3969/j.issn.1009-976X.2023.04.009

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Primary cardiac angiosarcoma is very rare disease with very poor prognosis due to its high mortality, late diagnosis, and lack of effective treatment. Early diagnosis may relieve patient′s symptoms and prolong survival. This article presented the case of a 38 year-old male patient with recurrent persistent pericardial effusion for three months as the first symptom from primary cardiac angiosarcoma which leading to delayed diagnosis and treatment. As soon as the clinical diagnosis of localized right atrial angiosarcoma without metastasis was made, the surgical resection was performed and the right atrium was reconstructed with a bovine pericardium patch. Postoperative pathological examination confirmed the preoperative clinical diagnosis being moderate differentiated primary right atrial angiosarcoma. The patient received chemotherapy with Duopafei （Docetaxel from Qilu Pharmaceutical Co., Ltd.） for three cycles. Lung metastasis and local recurrence were found 4 months after operation, and the patient died 3 months later. For patients with recurrent or unexplained pericardial effusion, echocardiography, cardiac CTA and MR imaging techniques are recommended for early detection and diagnosis of primary cardiac angiosarcoma.

Adenoid cystic carcinoma of breast： two cases and review of literature

WU Xiao-yong, YAN Xue-min, ZHANG Jia-yi, WEN Jin-xu, ZHU Jia, WANG Yue-xin

2023, 23(04):  343-346.  DOI: 10.3969/j.issn.1009-976X.2023.04.010

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Objective To report two rate cases of adenoid cystic carcinoma of the breast （ACCb）. Methods Clinical data of 2 patients diagnosed with ACCb admitted to Hebei Provincial People′s Hospital in 2018 and 2020 were retrospectively analyzed. Results The ages of the two patients were 78 and 56 years old respectively, follow-ups were 39 and 12 months respectively. No recurrence and metastasis were found. Conclusion ACCb is a rare triple-negative breast cancer, its imaging and signs are untypical, and it is easy to be misdiagnosed. The diagnosis of adenoid cystic carcinoma mainly depends on cell morphology and immunohistochemistry. However, adenoid cystic carcinoma is a type of triple negative breast cancer with a relatively good prognosis.

Review

Research progress of hepatic arterial infusion chemotherapy with FOLFOX regimen

QIAN Jun-lin, TANG Hong-tao, LIN Wei, HU Ze-min

2023, 23(04):  347-352.  DOI: 10.3969/j.issn.1009-976X.2023.04.011

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Hepatic arterial infusion chemotherapy （HAIC） is one of the important treatments for hepatocellular carcinoma. In recent years, through continuous exploration, Chinese scholars have innovatively applied the oxaliplatin-based FOLFOX regimen to perfusion chemotherapy for hepatocellular carcinoma, and FOLFOX-HAIC and its combination regimen have achieved encouraging results in the treatment of intermediate to advanced hepatocellular carcinoma, which has received increasing attention. This paper summarizes and analyzes the results reported in the relevant domestic and international literature, and reviews the development history, clinical applications, research progress and current problem of FOLFOX-HAIC.

Risk factors for stone recurrence after LCBDE and ERCP for common bile duct stones

LI Peng-cheng, YU Han-xiang, TUO Hong-fang, WEN Jun-ye, WANG Chao-chao

2023, 23(04):  353-359.  DOI: 10.3969/j.issn.1009-976X.2023.04.012

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Common bile duct stones are one of the most common benign diseases in hepatobiliary surgery and are mostly treated surgically, with a recurrence rate of 4%-25% after surgery. In recent years, the recurrence rate has been on the rise. Therefore, preventing the recurrence of common bile duct stones after surgery and understanding their risk factors becomes a problem that clinicians must address. Endoscopic retrograde cholangiopancreatography （ERCP） and laparoscopic common bile duct exploration （LCBDE） have become the most common surgical treatment for common bile duct stones. The two procedures have similarities and differences in the risk factors for stone recurrence. And the causes of stone recurrence are not due to a single factor, but to a combination of factors. This paper aims to investigate how to minimize the probability of stone recurrence from the surgeon′s point of view and provide a reference for clinicians by synthesizing the differences in risk factors for stone recurrence after two types of surgery at home and abroad.

Strategies and advances in the combined surgical management of perianal lesions in Crohn′s disease

YAO Xiao, GAO Jin-bo

2023, 23(04):  360-367.  DOI: 10.3969/j.issn.1009-976X.2023.04.013

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Perianal fistulizing Crohn′s disease （PFCD） remains one of the greatest challenges in inflammatory bowel disease. Despite the development of new treatments, such as the introduction of newer biologics, including the most promising field of bone marrow mesenchymal stem cells, the most effective cure is still lacking. Surgery remains the predominant approach to PFCD and each treatment option is individualized according to the different patients. The endoscopic and surgical techniques, experienced surgeons, and multidisciplinary collaboration holds promisea brighter future for patients.