Volume 87  ·   Issue 21  ·  2007

Gastrointestinal surgery is an ancient discipline in the field of surgery. Although it experienced rapid development in the 20th century, many scholars think that gastrointestinal surgery, an ancient branch of general surgery, seems to have stagnated compared with other cutting-edge disciplines. Looking back on the history of medical development, we find that it is very difficult to make an accurate prospect of the development of medical science, because the progress of technology is so fast that even authoritative predictions can go wrong.

Objective to observe the maximum tolerated dose and dose-limiting toxicity of hydroxycamptothecin in HFL regimen (hydroxycamptothecin + fluorouracil/calcium leucovorin) in the treatment of advanced colorectal cancer, to determine the optimal dose of camptothecin, and to observe the efficacy of this regimen. Methods A total of 18 patients with advanced colorectal cancer were enrolled. The camptothecin dose was divided into 6 grades, starting from 4 mg/m2 and climbing upward. Each group was intravenously infused with camptothecin 4, 6, 8, 10, 12, 14 mg/m2 on days 1 to 5. 5 Fluorouracil (5-FU) /calcium leucovorin (LV) (5-FU 425 mg/m2 on days 1 to 5, LV 20 mg/m2 on days 1 to 5) was intravenously injected with camptothecin every 4 weeks. The toxicity and efficacy of this regimen were observed. Results Two patients in 10, 12, 14 mg/m2 groups had grade IV myelosuppression. The main toxicity of HFL regimen was myelosuppression and digestive tract reaction, and the toxicity was dose-related. The dose-limiting toxicity was myelosuppression. The maximum tolerated dose (MTD) of camptothecin in this regimen was 10 mg

Objective to improve the long-term survival of patients with colorectal cancer liver metastasis after hepatectomy. Methods The results and clinicopathological data of 75 patients with colorectal cancer liver metastasis who were hospitalized in Cancer Hospital of China Union Medical University from June 1981 to November 2005 were retrospectively analyzed. Results Among the 75 patients, 43 were males and 32 were females. The primary tumor was located in the colon in 39 cases, the primary tumor was located in the rectum in 36 cases, the simultaneous liver metastasis in 59 cases, and the metachronous liver metastasis in 16 cases. The complication rate was 16% (12/75), and the mortality rate was 1.33% (1/75). The total 1-year, 3-year and 5-year survival rates of the whole group were 86.7%, 35.5% and 22.2%, respectively, and the median survival time was 25 months. The 1-year, 3-year and 5-year survival rates of the tumor-free group were 91.6%, 58.1% and 34.9%, respectively, and the median survival time was 25 months The median survival time was 18 months, and the difference of survival time between the two groups was significant by Log Rank test, P =0.000. Conclusion Hepatectomy can significantly prolong the survival time of colorectal cancer liver metastases, and radical resection with complete resection of all liver metastases and extrahepatic lesions is an important factor affecting prognosis and the fundamental guarantee of improving long-term survival rate.

Objective to evaluate the long-term efficacy of endoscopic submucosal resection (ESMRL) by ligation method in the treatment of rectal carcinoid tumors.Methods From April 2002 to April 2006, 45 patients with rectal carcinoid tumors with diameter ≤2 cm were treated in the endoscopic center of Zhongshan Hospital affiliated to Fudan University. All patients underwent ESMRL, including 20 males and 25 females, aged 19-73 years, with an average age of (58±18) years. Results The radical resection, postoperative complications and long-term efficacy of the patients in this group were analyzed.Results The patients in this group accounted for 1.8% (45/24600) of the patients who underwent colonoscopy in the same period. The distance from the anal margin was 2-15 cm and the diameter was 0.3-2.0 cm, with an average of (1.4±0.3) cm. Endoscopic ultrasound revealed that the lesions of 24 patients (53%) were located only in the submucosal layer (3rd layer) without echo, with no acoustic shadow at the back, intact muscle layer, and the mean lesion diameter was (0.8 ± 0.2) cm. In the other 21 patients (47%), the lesions were located at the same time in the mucosal layer (2nd layer) and the submucosal layer (3rd layer), and the mean lesion diameter was (1.5 ± 0.2) cm. The difference between the two patients was statistically significant (P<0.05). All patients underwent ESMRL, the success rate of operation was 100%, the mean operation time was (25 ± 4) min. 34 patients (75.6%) had arterial hemorrhage at the resection margin after resection, and the hemostatic clip was clamped to stop the hemorrhage or sclerostatic agent was injected to stop the hemorrhage. 7 patients (15.6%) had delayed hemorrhage from 2 to 7 days after surgery, of which 3 cases (43%) were bleeding from the muscle layer at the bottom of the wound, and 4 cases (57%) were bleeding from the resection margin or arterial hemorrhage, which required endoscopic examination to stop the hemorrhage. There were no other complications such as perforation and infection. The negative rate of resection margin was 86.7% (39/45). Another 6 patients could not see the normal submucosal structure around the tumor under microscopic examination, and it was impossible to judge whether the resection margin was involved or not. However, the tumor envelope was intact and the border was clear, and there was no basis for rebiopsy. Follow-up was selected. The average follow-up time was 31 (6-52) months, and the follow-up rate was 100%. There were no metastasis, recurrence and death cases. Conclusion ESMRL is a safe and effective method for the treatment of rectal carcinoid tumors, and it is worth promoting.

Objective to investigate the relationship between single nucleotide polymorphism (SNP) of C-8343G, C-1863T and codon 72 (CGC/CCC, encoding amino acids of arginine R and proline P, R72P, respectively) of TP53 gene and genetic susceptibility to colorectal cancer (CRC) in Chinese population. Methods TaqMan and polymerase chain reaction-restriction fragment length polymorphism were used to detect the genotype distribution and differences of SNP in 345 CRC patients and 670 controls. Results There was no significant difference in the genotype distribution of C-8343G and C-1863T between CRC and control groups (P>0.05). The genotype and allele distribution of R72P in the two groups were statistically significant (P<0.01). Compared with RR homozygotes, the CRC risk of RP homozygotes and PP homozygotes increased to 1.60 times (95% CI =1.17-2.18, P<0.01) and 2.37 times (95% CI =1.61-3.47, P<0.01), respectively. Drinking alcohol could further increase the R72P polymorphism R72P polymorphism increases the risk of CRC in Chinese population, especially alcohol drinkers.

Objective to investigate the value of revised Bethseda criterion in screening hereditary non-polyposis colorectal cancer (HNPCC) and its composition ratio in colorectal carcinoma. Methods A cohort of 110 consecutive patients who underwent surgical treatment from August 2004 to December 2005 was established, and the microsatellite instability (MSI) status was detected by multiplex fluorescence polymerase chain reaction method, and the germline mutations of hMSH2, hMLH1 and hMSH6 were detected in MSI colorectal cancer patients. Results A total of 23 (20.9%) MSI colorectal cancer patients were detected. Among 23 (30.4%) MSI colorectal cancer patients, 7 (30.4%) pathological mutations were found, accounting for 6.4% of all colorectal carcinomas; Among them, there were 3 germline mutations of hMSH6 gene, 3 mutations of hMSH2 gene and 1 mutation of hMLH1 gene.Conclusion According to the revised Bethesda criteria, the detection rate of MSI colorectal cancer and HNPCC was 20.9% and 6.4%; Missense mutations in hMSH2 and hMSH6 are more common in Chinese mismatch repair gene germline mutations.

Objective to summarize the perioperative experience of combined cardiopulmonary transplantation in the treatment of Eisenmanger's syndrome.Methods Two patients with congenital heart disease complicated with Eisenmanger's syndrome.Allotopic combined cardiopulmonary transplantation was performed with modified St. Thomas cardioplegia and modified LPD solution to protect the donor's heart and lung.After carefully removing the patient's heart, lung, thorax and mediastinum to completely stop the hemorrhage, the donor's heart and lung were placed into the donor's cardiopulmonary.The patients were closely monitored after operation.The rejection reaction and infection were actively prevented and treated, and the complications were treated in time.Results All the operations were successful.The tracheal anastomosis stenosis was improved by tracheal sleeve resection. At present, both patients have returned to normal working life.Conclusion Good cardiopulmonary protection, fine surgical operation and correct postoperative management are the keys of successful combined cardiopulmonary transplantation.

Objective to investigate the diagnosis, clinical management and prognosis of fetal polyvesicular kidney. Methods 24 858 pregnant women were diagnosed prenatally by B-ultrasound. Among them, 41 cases had polyvesicular kidney, 35 cases were unilateral, 6 cases were bilateral, and the mean gestational age at the time of detection was 29.8 weeks. 41 cases of fetal polyvesicular kidney were followed up and followed up after birth. Results Among 41 cases, 17 cases were induced labor, 1 case was in complete remission, 3 cases were in partial remission, and 9 cases had no obvious changes. Conclusion Ultrasound can diagnose fetal polyvesicular kidney before birth. The key of fetal polyvesicular kidney management is to evaluate the prognosis of perinatal infants. The natural course of unilateral disease is benign, and part of the disease can resolve spontaneously after birth.

Objective to investigate the clinical, pathological and molecular pathological characteristics of dysferlinopathy. Methods the expressions of dysferlin, α-sarcosan and dystrophin were observed by immunohistochemical staining (IHC) in frozen muscle specimens of 45 patients with clinical pathological diagnosis of limb band muscular dystrophy (LGMD) and Miyoshi myopathy (MM). The contents of dysferlin in muscle tissue were determined by Western blot analysis (WB). Results dysferlin was completely deleted in 5 cases of muscle specimens of 39 patients with LGMD and 6 patients with MM, and the expression of dysferlin in 3 cases was below 15% of the normal control value. These 8 patients were consistent with the diagnosis of dysferlinopathy, including 3 cases with LGMD and 5 cases with MM. The mean age of onset was 18.8 years. Two patients with LGMD were siblings, and one patient with MM was a cousin, which suggested that the disease belonged to autosomal recessive inheritance mode. Serum CK585~21 280 IU/L, mean 6240 IU/L, electromyography showed myogenic lesions and muscle pathology It is easy to be misdiagnosed as inflammatory myopathy. The analysis of the expression of dysferlin by immunohistochemistry and western blot is a necessary means to diagnose this disease and differentiate it from inflammatory myopathy.

Objective to investigate the best surgical method of gastroesophageal junction carcinoma (EGJ carcinoma) and the pattern of lymph node metastasis under Siewert classification. Methods Among 26 patients with EGJ carcinoma, 12 patients underwent two abdominal and thoracic incisions + abdominal and thoracic lymph node dissection (two incisions group), and 14 patients underwent conventional left thoracotomy + enlarged lymph node excision (conventional group). Results (1) The mean number of lymph node dissection groups (7.3 groups and 3.5 groups, respectively, P<0.01) and the mean number of metastatic lymph node detection groups (1.9 groups and 0.9 groups, respectively, P<0.05) were statistically significant. The mean number of abdominal lymph nodes (20.5 and 13.3, respectively, P<0.01) and the number of thoracic lymph nodes (8 and 4.9, respectively, P<0.05) were also statistically significant. The distance between the esophageal margin of the two incision group and the tumor was 5.8 cm more than that of the conventional group; The two incisions did not damage the diaphragm and reduced the influence on the respiratory and circulatory system. (2) Siewert classification: type Ⅰ abdominal cavity metastasis is not serious, type Ⅱ thoracic and abdominal cavity bidirectional metastasis, type Ⅲ abdominal cavity metastasis is mainly, and the lymph node metastasis of the three subtypes is different. Conclusion Two abdominal and thoracic incisions plus abdominal and thoracic lymph node dissection is helpful to improve the radical cure of EGJ cancer and study the metastasis rule of EGJ cancer.

Objective to investigate the effect of transabdominal radical total gastrectomy in the treatment of patients with cardiac carcinoma and analyze the prognostic factors. Methods the clinical data of 56 patients with cardiac carcinoma who underwent transabdominal radical total gastrectomy from April 1993 to March 2002 were retrospectively analyzed. Results the positive rate of lymph node metastasis in 56 patients with cardiac carcinoma was 71.4% (40/56), among them 19 patients underwent para-aortic lymph node dissection, and the positive rate of lymph node metastasis in 16 groups was 31.6% (6/19); The depth of tumor invasion, Borrmann classification, tumor size and esophageal invasion are important factors affecting lymph node metastasis; The incidence of postoperative complications was 21.4% (12/56), and the perioperative mortality was 3.6% (2/56); The 1-year, 3-year and 5-year survival rates were 77.6%, 47.7% and 37.1%, respectively. Univariate analysis showed that lymph node metastasis, tissue type, tumor size, Borrmann classification, invasion depth and esophageal invasion had significant effects on patients' survival. The 5-year survival rate of lymph node metastasis was 63.3% in the negative group and 25.4% in the positive group, and the difference between the two groups was statistically significant (P =0.011). Cox multivariate analysis showed that lymph node metastasis could be an independent factor affecting prognosis (P =0.042). Conclusion Transabdominal radical total gastrectomy is a safe and effective procedure for the treatment of cardia cancer; Lymph node metastasis is an important factor affecting the prognosis of cardia cancer.

Objective to investigate the relationship between the minimum stimulation current used in the positioning of nerve stimulator and the block effect in subclavian brachial plexus block.Methods 188 patients who underwent elective surgery of upper extremity below the elbow were selected and divided into small current group (Group A, n =118 cases) and high current group (Group B, n =70 cases). The coracal process approach proposed by Wilson was used to locate the nerve stimulator.The minimum stimulation current (I) of the two groups was adjusted to 0.1 mA ≤ I<0.3 mA or 0.3 mA ≤ I<0.5 mA respectively, and 30 ml of 0.5% ropivacaine was given when it could trigger distal motor response. The anesthetic block area was recorded 5 min, 10 min, 20 min and 30 min after administration, respectively. The complete disappearance of pain sensation in the cutaneous area of 5 terminal nerves (median nerve, musculocutaneous nerve, radial nerve, ulnar nerve and medial cutaneous nerve of the upper limb) was defined as the successful block 30 min after administration. Results The successful rate of block in group A was 84.7% and that in group B was 67.1%, and the power of component A was significantly higher than that in group B (P<0.05). The analysis of the stratified subgroup showed that among the cases (n =124 cases) that triggered the motor response of the posterior bundle, the successful rate of block in group A (n =86 cases) was 96.5%, and that in group B (n =38 cases) was 78.9%, and the power of component A was significantly higher than that in group B (P<0.05). Conclusion Reducing the minimum stimulation current below 0.3 mA can significantly improve the successful rate of subclavian brachial plexus block, especially when triggering the motor response of the posterior bundle, it can obtain an extremely high successful rate of block (96.5%).

Objective to investigate the relationship between vitamin D receptor (VDR) gene polymorphism and low bone mass and abnormal growth pattern in adolescent idiopathic scoliosis (AIS) patients. Methods 164 female patients with AIS were measured by morphology, and their age, height, weight, arm length, menstrual condition, Cobb angle, Risser sign and other indexes were recorded. Venous blood samples were collected from 122 healthy female adolescents. VDR genotypes in AIS group and normal adolescents were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP), and the distribution of VDR genotypes between the two groups and each subgroup in AIS group was compared. Results The frequency of Bb genotype and B allele in AIS group was significantly higher than that in control group (P<0.01). The frequency of Aa in AIS group with body mass index (BMI) ≥18 kg/m2 was significantly higher than that in BMI<18 kg/m2 group (P<0.05). The frequency of Bb type in groups with BMI<18 kg/m2, arm length<160 cm and menarche age ≥12 years was significantly higher than that in groups with BMI ≥18 kg/m2, arm length ≥160 cm and menarche age<12 years (P<0.05). Conclusion The distribution of BsmI polymorphism in VDR gene may be related to low bone mass and abnormal growth pattern in women with AIS.

Objective to evaluate the inhibitory effect of RNA interference (RNAi) technique on the expression of insulin-like growth factor class Ⅰ receptor (IGF-IR) in human lung cancer A549 cell line and its antitumor effect in vitro and in vitro.Methods IGF-IR specific shRNA was transfected into human lung cancer A549 cell line to detect the expression level of IGF-IR and the expression changes of bcl-2 and caspase-3; The growth inhibition rate of cells cultured in vitro was detected by MTT method; The cell proliferation cycle was detected by flow cytometry; Phosphorylation of Akt and ERK was analyzed by Western blot; Results the inhibition rate of IGF-IR expression was 89.8%, the expression of bcl-2 was 46%±6%, the activation of caspase-3 was 156%±8%, the phosphorylation of Akt and ERK was 20% and 36%±3%, respectively. The viability of tumor cells decreased significantly; Conclusion RNAi can effectively inhibit the expression of IGF-IR in A549 cells, decrease cell proliferation, increase apoptosis and inhibit tumor growth.

Objective to investigate the effects of calcitonin on the proliferation of mouse osteoblasts and the expression of osteoprotectin (OPG) /nuclear factor KB receptor activating factor ligand (RANKL). Methods Thirty mice within 24 hours of birth were removed from the skull under sterile conditions, and the osteoblasts were cultured by enzyme digestion. Different concentrations of calcitonin were added to the culture medium of osteoblasts. Firstly, the effect of calcitonin on the proliferation of osteoblasts was detected by MTT assay, then the expression of OPG/RANKL mRNA was detected by RT-PCR and the secretion of OPG protein was detected by ELISA. Results Calcitonin can promote the proliferation of osteoblasts. Calcitonin can enhance the expression of OPG mRNA in osteoblasts and inhibit the expression of RANKL mRNA in osteoblasts and the secretion of OPG protein. Conclusion Calcitonin can promote the proliferation of osteoblasts and the expression of OPG mRNA in osteoblasts and inhibit the expression of RANKL mRNA in osteoblasts.

Objective to investigate how apoptosis signal can promote cell death after tissue injury. Methods After laser irradiation, the culture solution of porcine cartilage block was collected at different times (3, 6, 9, 12, 24 h), that is, experimental conditioned culture solution (TCM), and the control conditioned culture solution (CCM) was obtained from the cartilage block medium without laser irradiation. The cartilage block was cultured for 28 d, and the progression of the damaged area was evaluated by focal microscope. The isolated chondrocyte monolayer was cultured in TCM, CCM or normal culture solution (NM). The positive control group monolayer cells were irradiated with ultraviolet for 10 min and then cultured in normal culture solution. After 24 h, the cells were collected and stained with fluorescent markers, and analyzed by flow cytometry. Results All the cells cultured by TCM showed positive cysteine proteolytic enzyme (caspase) -3, CMXRos and nitric oxide signal were reduced or lost; The cells cultured by CCM or NM showed caspase-3 negative, CMXRos and nitric oxide signal were intact; Caspase-3 and CMXRos were both positive, and the signal of nitric oxide was decreased or lost in the positive control group, representing the early stage of apoptosis. After different concentrations of TCM (100%, 50%, 25%, 12.5%) and time (0.5, 1, 3, 9, 12 h), all the cells were positive for caspase-3, and the signal of CMXRos and nitric oxide was decreased or lost. Conclusion Laser irradiation of damaged cartilage releases apoptotic factors, which can induce the death of monolayer cells.

A 50-year-old female was admitted to the hospital on June 22, 2006 due to "progressive walking instability for 3 years and dry eyes for 3 months". The main manifestations were unsteady walking, inflexible movement of limbs, stiff expression, unclear speech, urinary incontinence, frequent urination, cold and numbness in the limbs, accompanied by pain in the left knee, muscle soreness in the left lower limb, no tremor, choking and cough after drinking water. She had been diagnosed with "Parkinson's disease" and had poor response to levodopa treatment.

As a complex endocrine tumor, pheochromocytoma has a great influence on hemodynamics. It originates from adrenal medulla, sympathetic ganglia or chromogenic tissues in other parts of the body. Because the tumor secretes a large amount of catecholamines, clinical syndromes mainly include hypertension and metabolic disorders, and its main clinical manifestations are hypertension, headache, palpitations and hyperhidrosis.

Polycystic ovary syndrome (PCOS) accounts for 5% ~10% of women in childbearing years, and is one of the main causes of female infertility. Non-ovulation, early abortion and late pregnancy complications are the main manifestations of decreased fertility in women with PCOS. At present, there are many drugs used to induce ovulation and conception in patients with PCOS, among which clomiphene citrate (clomiphene) is a simple and effective drug that can be administered orally, resist estrogen and promote the release of follicle-stimulating hormone (FSH) from the pituitary gland, thus promoting the development of follicles and ovulation.

Pulmonary hypertension (PAH) is an important problem in cardiac surgery. At present, PAH is treated with drugs such as prostacyclin and nitric oxide to reduce pulmonary artery pressure. Recently, in Circulation (2007, 115: 1275-1284), Hansmann et al., Pediatric Heart Center, Stanford University School of Medicine, USA, published an article titled "PAH is related to insulin resistance (IR), which can be reversed by the activation of peroxisome proliferator-activated receptor (PPAR) -γ", which has made medical practitioners have a new understanding of PAH.