Volume 92  ·   Issue 21  ·  2012

At present, lymph node (N) stage is one of the most commonly used clinical staging systems for malignant solid tumors. It is generally believed that lymph node status is one of the most important factors in survival and prognosis of most patients with malignant solid tumors. In recent years, surgeons have proposed various lymph node dissection procedures for tumor patients. However, in order to achieve better survival advantage, there are still controversies about how many lymph nodes should be removed and how to design the resection range. With the advancement of imaging diagnosis technology of metastatic lymph nodes, the accuracy of detecting positive lymph nodes before and even during operation has been greatly improved, and the advantages of minimally invasive interventional therapy in controlling metastatic lymph nodes have also been highlighted.

After more than half a century of development, the treatment of many diseases is facing strong competition from many related disciplines. For example, the treatment of vascular diseases has been distributed in vascular surgery, interventional department, thoracic and cardiac surgery, cardiology, brain surgery, etc.; The treatment of tumor is distributed in oncology department, radiotherapy department, surgery department, internal medicine department, interventional department, etc. With the continuous development of all disciplines, they are also widely absorbing the advanced theories and technologies obtained by medical progress, which makes all kinds of treatment technologies make great progress in the direction of minimally invasive.

Objective To evaluate the feasibility and efficacy of endovascular treatment for different types of carotid cavernous fistula (CCF) via the approach of internal carotid artery ( ICA ) or inferior petrosal sinus (IPS).Methods From April 2005 to June 2010,28 CCF patients underwent endovascular treatment at our institution.There were 13 males and 15 females with a mean age of 39 years (range:21 -71 ).According to the Barrow's classification,they were classified into type A (n =21 ),type B (n =2) and type D (n =5).Patients of type A underwent detachable balloon embolization of ipsilateral cavernous sinus or stent-graft placement via the ICA approach.Patients of types B and D received detachable coil plus n-BCA (n-butyl-2-cyanoacrylate) embolization of ipsilateral cavernous sinus via the IPS approach.The technical results,complications and therapeutic outcomes were reviewed.Results Detachable balloons (number:1 -4) were used in 16 patients of type A.Angiography at immediate postembolization showed a complete occlusion of fistula in 15 patients and a small residual fistula ( ＜20％ ) in 1 patient.Five patients of type A received stent-graft placement.One stent was placed in 4 patients and 2 stents in 1 patient.Complete fistula closures with preserved ICA were documented on immediate angiogram in 3 patients whereas a large residual flow ( ＞ 50％ ) persisted in 1.The fistula was completely occluded after 3 detachable balloons were deployed in affected cavernous sinus through a gap between stent and vascular wall.Both fistula and ICA were occluded in 1 patient after stenting.No cerebral infarction was observed due to the adequate collateral blood flow from contralateral ICA.Complete closures of affected cavernous sinus were achieved in 6 patients of types B and D while residual flow ( ＜ 50％ ) persisted in 1.The number of detachable coils for each embolization ranged from 3 to 8 ( mean:6.0).The volume of n-BCA mixture varied from 1.0 to 2.1 ml (mean:1.3 ).The mean duration of n-BCA injection was 65 s (range:45 -90).Clinical symptoms were completely relieved in 26 patients.During the mean follow-up period of 30 months (range:12 -60),no recurrence of clinical symptoms was observed.No thrombosis or stenosis was found in the lumina of stents.Conclusion Detachable balloon embolization is the preferential treatment for direct CCF.Detachable coil plus n-BCA embolization of cavernous sinus via the IPS approach is an efficient and safe treatment for indirect CCF.

Objective To evaluate the predictive value of serum beta 2-microglobulin level for recurrent stenosis or occlusion in patient undergoing percutaneous transluminal angioplasty ( PTA ) for lower limb ischemia.Methods Between March 2009 and October 2010,81 patients were admitted with a diagnosis of lower limb ischemia.Among them,54 patients had a mean age of 64 ± 12 years.The baseline characteristics,stenting and post-procedure events were collected. And the serum level of beta 2-microglobulin was measured by dynamic timing nephelometry assay.Recurrent stenosis or occlusions were confirmed with color Doppler ultrasonography or CTA imaging. Cox regression univariate analysis was performed with variables with P value ＜ 0.20 to investigate the independent predictors of recurrent stenosis or occlusions.Receiver-operating characteristics curves (ROC) were constructed to evaluate the sensitivity and specificity of this model.Results The baseline characteristics were evenly distributed in two groups.Twenty-three patients (42.5％ ) were found to have recurrent stenosis or occlusions.The cumulative primary patency was 85％,69％ and 34％ at Month 6,12 and 24 respectively. The serum levels of beta 2-microglobulin decreased during a follow-up period of 3 months and then increased gradually in patients with recurrent stenosis or occlusion.Cox regression analysis identified the serum level of beta 2-microglobulin as an independent predictor of recurrent stenosis or occlusion ( Odds Ratio =1.459,95％ CI 1.199 - 1.777,P =0.000).The area under the curve (AUG) of the serum level of beta 2-microglobulin was 0.952 for recurrent stenosis or occlusion.And the sensitivity was 95.7％ and the specificity 77.4％ on a cut-off value 3.2 mg/L.Conclusion With a cut-off value 3.2 mg/L,the serum level of beta 2-microglobulin may be useful for the prediction of recurrent stenosis or occlusion in patients after lower limb PTA.

Objective To evaluate the feasibility and efficacy of urokinase infusion therapy via a transradial approach for transcatheter superior mesenteric artery ( SMA ) in patients with acute extensive portal and superior mesenteric venous thrombosis.Methods During a period of 8 years,47 patients with acute extensive thrombosis of portal vein (PV) and superior mesenteric veins (SMV) received urokinase infusion therapy by transcatheter selective SMA via radial artery.Their mean age was 44 ± 13 years (range:19-65).Through radial sheath,a 5F catheter was placed into SMA and subsequently the infusion of urokinase was given for 5-11 days ( mean:7.1 ± 2.5 ).Adequate anticoagulation was initiated during treatment,throughout hospitalization and post-discharge.Follow-up contrast-enhanced computed tomography (CT) was performed in each patient every 3 days and before the removal of infusion catheter.Termination of urokinase infusion therapy was decided on the basis of clinical and radiographic findings. Results Technical success was achieved in all patients.Two patients had worsening abdominal pain,developed the signs of peritonitis at 24 hours after interventional treatment and underwent eventual laparotomy with the resection of necrotic bowel.Substantial clinical improvement was observed in 45 (95.7％) of them after the procedure.Minor complications at the radial puncture site were observed in 7 patients ( 14.9％ ) and infusion therapy continued. Follow-up CT scans at pre-discharge demonstrated a nearly complete disappearance of PV-SMV thrombosis in 29 patients ( 64.4％ ) and partial recanalization of PV-SMV thrombosis in 16 patients(35.6％ ).They were discharged at 9-20 days ( mean:12 ±6) post-admission.The mean post-discharge duration of follow-up was 48 ± 20 months. Recurrent episodes of PV and SMV thrombosis were observed in 2(4.4％ )patients at 6 months and 5 years respectively post-discharge and they were treated successfully with urokinase infusion.Conclusion The transcatheter SMA urokinase infusion therapy via a transradial approach for plus anticoagulation is both safe and effective for the management of patients with acute extensive PV-SMV thrombosis.

Posterior circulation stroke accounts for about 20% of all strokes. Different from anterior circulation, posterior circulation only depends on one basilar artery, which supplies blood to the brainstem, most of the occipital lobe, cerebellum and part of the thalamus. Clinically, basilar artery occlusion (BAO) has various manifestations, including transient ischemic attack (TIA), minor stroke, acute brainstem lesions and coma. Although the treatment of stroke is gradually increasing in recent years, the high mortality and disability rate of posterior circulation stroke as high as 80% still endanger people's life and health.

Objective To explore the involvement characteristics and influencing factors of anxiety and depression in patients after percutaneous coronary intervention (PCI). Methods A total of 396 patients undergoing PCI were investigated between January 2009 and December 2010.All of them completed the Hospital Anxiety and Depression Scale (HADS) before discharge and at 12 months post-PCI. We evaluated the involvement characteristics and used Logistic regression to analyze the influencing factors of mood changes.Results The relevant factors of post-PCI anxiety were gender ( P =0.003 ),age ( P =0.004) and acute myocardial infarction ( P =0.009 ) while depression was associated with acute myocardial infarction ( P ＜ 0.001 ).A 12-month follow-up study showed that anxiety remained stable in 76.3％ of patients while depression in 79.5％. Multi-factor analysis showed that factors of presence of adverse cardiovascular events ( OR:1.323,95％ CI:1.026-1.705,P =0.031 ),Seattle angina score ( OR:0.870,95％ CI:0.772-0.981,P =0.023 ) and anxiety scores at pre-discharge ( OR:1.228,95％ CI:1.053-1.432,P =0.009) were correlated with the deterioration degree of depression.And the factor associated with the deterioration of depression was the scores before discharge ( OR:1.287,95％ CI:1.072 ～ 1.545,P =0.007 ).Conclusion The levels of anxiety and depression remain stable in the majority of PCI patients at Month 12 post-PCI. Perioperative communication and effective control of postoperative cardiovascular events may ease a patient's negative emotions and improve their living quality.

Objective To explore the feasibility and value of intra-operative contrast-enhanced ultrasound in different pathological grades of glioma.Methods A total of 46 patients with glioma were selected to undergo the contrast-enhanced ultrasound.They were divided into 3 groups according to their pathological grades.Results All 46 tumors were hyperechoic after examinations and the borders became much more distinct. Different level of tumors had their representative ultrasonic findings. Conclusions Intraoperative contrast-enhanced ultrasound is quite useful for determining the position and border of tumors.And it is also excellent in detecting the residual tumor tissues post-operatively. And it can improve the resection accuracy and operative precision,especially for Grade Ⅳ glioma with internal necrosis,cyst and surrounding brain edema.

Objective To explore the clinical efficacies of displaced intra-calcaneal fractures with operative treatment.Methods From January 2005 to December 2010,103 calcaneal patients (92 males,11 females) were recruited.The mean age was 45.8 years old ( range:23 - 65 ).All received operative treatment.They included left calcaneal fractures (n =51 ),right calcaneal fractures (n =40) and bilateral calcaneal fractures (n =12 ).All patients were of closed fractures.According to the Sanders classification,there were type Ⅱ ( n =15 ),type Ⅲ ( n =75 ) and type Ⅳ ( n =13 ).A modified lateral approach with profiled plate fixation was adopted for all.Partial weight-bearing occurred at 6 weeks and full weight-bearing at 12 weeks.Function assessment was made with the American Orthopedic Foot and Ankle Society anklehindfoot scale (AOFAS).Results The mean follow-up period was 18 months ( range:6 -30) and the mean healing duration 12 weeks (range:8 - 15 ).Two cases had incision dehiscence.After the removal of plate,the skin healed.Eight cases were associated with subtalus arthritis and painful walking.Three cases of caved calcaneal surface appeared after weight-bearing.According to the AOFAS foot score,the outcomes were excellent ( n =83 ),good ( n =13 ),fair ( n =5 ) and poor ( n =2 ).And the excellent and good rate was 93.2％.Conclusion With a modified lateral approach,displaced intra-calcaneal fracture may be treated with a satisfactory clinical efficacy.But an orthopedic surgeon should master skillful surgical techniques.

Objective To evaluate the clinical effectiveness of subintirnal angioplasty in treating chronic arterial occlusive disease of lower extremity.Methods Eligible studies concerning treatment by subintimal angioplasty in patients with arterial occlusive disease of lower extremity were identified from electronic database,cross-reference search and relative articles.The study quality and data extraction of all relevant articles were assessed by three independent reviewers.The study endpoints were technical success,primary patency,limb salvage,and complications. Results A total of 352 studies were selected for comprehensive review.Fourteen studies including a total of 2350 patients matched the selection criteria.According to whether selective using of re-entery catheter were used or not,the technical success rates were 96.4％ and 87％ ( P ＜0.01 ).Limb salvage rate was 90.5％ and 81.5％ at 6 and 12 months respectively.Depending on whether preoperative use of anti-platelet drug,primary patency rate was 91％ and 68.5％ at 6 months respectively ( P ＜ 0.01 ). The complication rate was 8.25％ without serious complications.Conclusion This Meta-analysis suggests that subintimal angioplasty is a safe and effective method in treating chronic arterial occlusive disease of lower extremity with high technical success rate and limb salvage,and low serious complications.Selective using of re-entry devices and preoperative anti-platelet drug can improve the technical success rate and primary patency rate significantly. Despite the high rate of technical and clinical success of the procedure,randomized contrast trials and long-term follow-up results are required to confirm the efficacy of these results.

Objective To evaluate the correlation of spinal sagittal imbalance and life quality.Methods Radiographic analysis for 48 consecutive symptomatic patients with spinal sagittal imbalance was performed with posteroanterior and lateral standing radiographs.There were 12 males and 36 females with an average age of ( 66.2 ± 8.5 ) yrs.The measurement parameters included C7PL,thoracic kyphosis ( TK),thoracolumbar kyphosis (TLK),lumbar lordosis (LL),pelvic tilt (PT),pelvic incidence (PI) and sacral slope (SS).Life quality was assessed with SF-36 questionnaire.Pearman's method was employed to analyze the correlation.Results Mean C7PL was (44.7±22.5) mm,TK (26.1 ±13.1)°,TLK (11.9±10.3)°,LL(23.5±18.2)°,PT (32.1±13.4)°,PI (57.4±10.9)° andSS (22.5 ±11.5)°.C7PL had a significant correlation with physical functioning ( r =- 0.428,P ＜ 0.01 ) and general health ( r =- 0.428,P ＜ 0.01 ).PI had a significant correlation with bodily pain ( r =- 0.374,P ＜ 0.01 ),vitality (r=-0.303,P＜0.01),social functioning (r=-0.309,P＜0.01) and role emotional (r=-0.429,P ＜ 0.05 ).TK had a significant correlation with physical functioning ( r =- 0.292,P ＜ 0.05 ) and general health (r =-0.389,P ＜ 0.01 ).LL had a significant correlation with physical functioning ( r =0,428,P ＜0.01),general health (r =0.340,P＜0.05) and vitality (r =0.373,P＜0.01).PT had significant correlation with vitality (r =-0.385,P＜0.01) and social functioning (r=-0.417,P＜0.05).No significant collation existed between TLK,SS and SF-36 categories.Conclusion C7PL,TK,LL,PI and PT are significant parameters correlating with quality of life.PI is the most important one affecting bodily pain.TK,LL and C7PL are the main parameters affecting general health.PI,PT and LL affect vitality the most.Correcting these parameters while treating sagittal imbalance is important for a better life quality.

Objective To explore the clinical efficacies of skipping two-level transpedicular wedge osteotomy in the correction of severe kyphotic deformity in ankylosing spondylitis (AS).Methods From January 2003 to December 2009,a total of 38 consecutive patients with AS and severe kyphosis ( chin-brow vertical angle (CBVA) or global thoraco-lumbar kyphosis angle (TLKA) over 70°) undergoing skipping two-level transpedicular wedge osteotomy at the Department of Orthopedics of Chinese PLA General Hospital were reviewed retrospectively.There were 32 males and 6 females with an average age of 38.0 years ( range:22-65).The preoperative parameters of TLKA,T11-L2 kyphotic angle,L1-S1 lordosic angle,sagittal imbalance and CBVA were obtained from the total spine radiography or computed tomography and clinical lateral photograph. According to the characteristic curves and normal spinal alignment,their profiles of osteotomy location and angle were determined and confirmed by computer simulations. Improvement in postoperative parameters was observed and treatment satisfaction evaluated Results The average operating duration was 309 minutes and the average volume of blood loss was 2050 ml.The parameters of TLKA,T11-L2 kyphotic angle and L1-S1 lordosic angle improved from 101.0° ±21.3°,45.2° ± 13.6°,-28.2° ±23.3° at preoperation to 26.0° ± 12.1°,2.8° ± 11.6°,28.9° ± 13.3° postoperation respectively (P ＜0.01).CBVA improved from 79.4° ± 15.9° to 13.6 ° ± 10.9° (P ＜0.01).The sagittal imbalance distance improved from (49 ± 13 ) to ( 15 ±7) cm ( P ＜0.01 ).All patients could walk with orthophoria and lie horizontally postoperatively.The average follow-up was 32 months (range:24 ～ 78 months).Fusion of osteotomy was achieved in all patients and there was no event of loss of correction or implant failure.The SRS-22 average score improved from 1.8 to 4.2.Conclusion For severe kyphosis in AS,skipping two-level transpedicular wedge osteotomy is a satisfactory and reliable approach for the correction of kyphotic deformity and it may improve appearance and function significantly.

Objective To assess the value of fetal chromosomal abnormality screening by a maternal serum test plus fetal nasal bone length in second trimester ( parallel test).Methods From January 2009 to December 2010,fetal nasal bone was measured at 19-22 weeks gestation in 6173 unselected cases.Karyotyping was performed in cases with a high risk for maternal serum test and/or abnormal fetal nasal bone length.All cases were followed-up postnatally.Results Nasal bone was assessed successfully in 5607 cases (90.83％ ).Normally it is increases with gestational age.The detection rate of chromosomal abnormality was 69.64％ by maternal serum test,79.76％ by maternal serum test plus hypoplastic nasal bone and 83.93％ by maternal serum test plus shortened nasal bone.Conclusion Fetal nasal bone hypoplasia is closely correlated with chromosomal abnormality.And sonographic evaluation of nasal bone may be a useful tool for screening chromosomal abnormality.The combination of maternal serum test and fetal nasal bone length will boost the detection rate of chromosomal abnormality.

Objective To evaluate the clinical value of VarioGuide in stereotactic brain biopsy.Methods Fifteen patients with brain lesions underwent frameless stereotactic brain biopsy guided by VarioGuide and multimodal neuronavigation.Intraoperative magnetic resonance imaging (iMRI) was used to confirm the accuracy of biopsy. And the VarioGuide-related adverse events,operative duration,surgical outcomes and postoperative complications were recorded respectively.Results In all patients,VarioGuide and multimodal neuronavigation were successfully integrated into the biopsy procedure. No VarioGuiderelated adverse events were reported.The mean operative duration was (65 ± 8) min.The biopsy accuracy was confirmed by iMRI in all cases.And the postoperative histological diagnostic rate was 100％.No mortality and morbidity occurred postoperatively.Conclusion The combined approach of VarioGuide and multimodal neuronavigation is accurate,safe and efficient.It may improve the histological diagnostic rate without postoperative neurological deficits in stereotactic brain biopsy.

Objective To analyze the mutation of CX32 gene and related clinical features in Chinese Han patients with Charcot-Marie-Tooth (CMT) disease.Methods Thirty-four CMT families,from 2004 to 2011 at Departments of Neurology,Xiangya Hospital,Third Xiangya Hospital and National Key Laboratory of Medical Genetics,were selected for CX32 mutation screening after the exclusion of the PMP22 duplication and male-to-male transmission.Mutation analysis was carried out by polymerase chain reaction (PCR) plus direct sequencing.Analyses of clinical,electrophysiological and pathological features in 11 patients from 6 CMTX1 families were performed by 2 neurologists.Results Five CX32 gene mutations were detected in 6 CMT families:c.37G ＞ A,c.65G ＞ A,c.246C ＞ G,c.256A ＞ G and c.533A ＞ G.Among them,c.246C ＞ G and c.533A ＞ G were firstly reported.The clinical manifestations included progressive distal muscle atrophy and weakness,areflexia,sensory abnormalities and pes vacus. Nerve conduction velocity ranged from 21.7 to 49.3 m/s.Both demyelination and axonal degeneration were detected in nerve biopsy.Conclusions CMT1X has a frequency of around 9％ in our study.The male patients tend to have more serious clinical features and their electrophysiological and pathological changes are intermediate.CX32 mutation analysis helps to confirm the genetic diagnosis of CMT so as to provide genetic counseling and reproductive guidance and elucidate its pathogenesis.

In recent years, oxidative stress and apoptosis have been a hot topic in the study of the pathogenesis of diabetic peripheral neuropathy (DPN). Mitochondria, as the regulatory center of apoptosis and organelles derived from reactive oxygen radicals (ROS), may be closely related to the pathogenesis of DPN. Launch-related protein-1 (Drp-1) is a member of Dynamin superfamily and one of the executive molecules mediating mitochondrial division.

Cerebral hyperperfusion syndrome (CHS) is a group of syndromes caused by increased cerebral blood flow after surgery. At present, there are three widely recognized diagnostic criteria: ipsilateral temporal, frontal and retroorbital pain with or without nausea and vomiting, ipsilateral focal seizure or neurological dysfunction after recanalization of intracerebral stenosis or occlusion; Imaging examination showed that the distribution area of recanalized vessels was hyperperfused and the mean blood flow of middle cerebral artery (MCA) was increased; Head CT or MRI confirmed no ischemic infarction.

The pathogenesis of autoimmune diseases is the result of the interaction of environmental and genetic factors. The exact etiology of autoimmune diseases is still unknown, but there is sufficient evidence that genetic factors play an important role in the pathogenesis of autoimmune diseases. Besides human major histocompatibility complex (HLA) as the main genetic susceptibility factor, other non-HLA genes also play an important role, such as cytotoxic T lymphocyte associated antigen 4 (CTLA4) site and protein tyrosine phosphatase non-receptor type 22 (PTPN22).

A 44-year-old male was admitted to the Cancer Intervention Department of Tianjin Medical University Affiliated Cancer Hospital in January 2004 due to distension and pain in the right upper abdomen for 1 week. The CT examination of the upper abdomen showed a mass in the right lobe of the liver about 8.0 cm ×9.0 cm ×11.5 cm, and liver cirrhosis. The patient had a history of hepatitis B for more than 10 years. Liver function : ALT 249 U/L, AST 148 U/L, ALB 32.3, TBIL 13.5 μ mol/L, DBIL 5.5 μ mol/L; T cell subsets: CD3 65.6%, CD4 41.4%, CD8 23.3%, NK 10.2%. There was no obvious abnormality in ECG chest radiogram. The clinical diagnosis was as follows: (1) Primary liver cancer BCLC stage: C, Child grade: A, PS: 1.