Volume 99 ·  Issue 04 ·  2019

Intracranial and extracranial carotid artery tandem lesions (TCL) are not uncommon in clinical practice. Surgical management is difficult and the surgical procedures are different. Improper management often leads to poor prognosis. One of the main reasons lies in the lack of systematic classification. This paper proposes a new classification of TCL and discusses the guiding significance for the selection of surgical procedures.

Carotid artery stenosis is an important cause of stroke. Surgical treatment of carotid artery stenosis mainly includes carotid intimal plaque resection and carotid stenting. The choice of surgical method for patients with severe carotid artery stenosis (stenosis>70%) has been controversial. Based on our long-term clinical treatment experience, the center continued to subdivide patients with severe carotid artery stenosis into two groups according to the dividing line of 90% stenosis, and detailed the advantages of carotid intimal plaque resection in patients with extremely severe carotid artery stenosis (stenosis>90%).

Percutaneous transhepatic gallbladder drainage (PTGD) is an emergency or remedial treatment for acute, severe and high-risk acute cholecystitis, acute pancreatitis, obstructive jaundice and other diseases. It has the advantages of simple operation, less trauma, remarkable curative effect and less complications. PTGD not only relieves biliary tract diseases and creates surgical opportunities for radical surgery, but also determines whether there are biliary and pancreatic confluence diseases such as bile outflow tract obstruction and occult biliary and pancreatic reflux through gallbladder pressure measurement, bile amylase detection, cholangiography and bile drainage volume, and can differentiate the effect and complications of endoscopic biliary and pancreatic shunt in the treatment of biliary and pancreatic confluence diseases.

To evaluate the safety and efficacy of carotid endarterectomy (CEA) and carotid angioplasty with stenting(CAS) for carotid artery stenosis after radiotherapy.

The clinical data of 73 cases with carotid artery stenosis after radiotherapy from October 2007 to September 2017 were analyzed retrospectively. Among them, 36 cases underwent CEA and 37 cases underwent CAS.

No complications occurred during the perioperative period in both groups. During the follow-up period, transient cerebral ischemia occurred in 1 case in the CEA group. There was no in-stent restenosis or adverse events such as stroke or myocardial infarction. In the CAS group, transient cerebral ischemia occurred in 2 cases, postoperative restenosis occurred in 2 cases, and myocardial infarction occurred in 1 case. The restenosis rate and incidence of adverse events were lower in the CEA group.

Both surgical methods are safe and effective in the treatment of carotid artery stenosis after radiotherapy. CEA surgery can be more beneficial to long-term outcome, and it is supposed to be the preferred surgical method.

To investigate the influence factors of carotid endarterectomy(CEA) improving cognitive function in patients with carotid stenosis.

The clinical data of carotid stenosis patients with cognitive impairment who underwent CEA in Nanjing Drum Tower Hospital and the First People′s Hospital of Lianyungang from December 2011 to July 2017 were retrospectively analyzed. One week before operation, carotid CT angiography and cranial magnetic resonance imaging were performed, and the cognitive function of patients was evaluated with Montreal Cognitive Scale (MoCA). The magnetic resonance imaging and MoCA were reexamined 4 weeks after the procedure. The patients were divided into improved group (COI+) and un-improved group (COI-) according to whether the cognitive function score was improved or not after operation. The general data, carotid artery occlusiontime, surgical site, preoperative carotid calcification score (CS) and the Fazekas score, pre-operative and post-operative cerebral perfusion parameters, like mean transit time(MTT), time to peak(TTP) and arrivetime (T0), and any new infarcts after operation between the two groups were compared.

A total of 70 patients were selected, including 50 patients in group COI+ and 20 patients in group COI-. There were no significant differences in age, gender, hypertension, diabetes mellitus, smoking and drinking habits, as well as in carotid artery occlusiontime and preoperative Fazekas score between the two groups (all P>0.05). The preoperative carotid artery calcification scores of the two groups were 469.75±50.86 and 393.51±77.41, respectively. The changes of pre-and post-operation perfusion parameters between the two groups were statistically significant, with ΔMTT were 7.79±9.51 and 3.03±6.40, ΔTTP were 5.83±8.98 and 1.17±4.77, T0 were 5.89±8.08 and 3.05±5.95, respectively( t=4.844, 2.053, 2.192 and 1.423, respectively, all P<0.05). Proportion of cases with new infarcts after operation(0.38 vs 0.65) or undergoing left CEA (0.66 vs 0.40)between the two groups was statistically different (χ²=4.197 and 9.677, respectively, both P<0.05).

Higher preoperative CS score, undergoing left CEA, significantly improved cerebral perfusion and without new infarct postoperatively, are independent factors contributing to improving cognitive function through CEA operation.

To explore the microsurgical treatment of paraclinoid aneurysms and evaluate its safety and efficacy.

The data of 21 patients with 22 paraclinoid aneurysms receiving craniotomy between Jan. 2010 and Dec. 2017 in Peking University First Hospital were retrospectively analyzed. According to the Barami K classification, 2 aneurysms were type Ⅰa, 6 type Ⅰb,7 typeⅡ,6 type Ⅲa,1 type Ⅳ. Out of the 17 cases of saccular aneurysms, 16 aneurysms were clipped and one aneurysm was trapped following high-flow EC-IC bypass. Out of the 5 cases of blood blister like aneurysms, 2 aneurysms were wrap-clipped, 2 aneurysms were trapped following high-flow EC-IC bypass and 1 aneurysm was trapped following STA-MCA bypass. The patients were reexamined with CT angiography (CTA) or digital subtraction angiography (DSA) and followed up in outpatient or by phone call.

Seventeen patients with 18 paraclinoid aneurysms had received aneurysm clipping. Aneurysmal neck remnant was found in 2 cases, parent artery stenosis was found in 2 cases. In all of the four bypass cases, graft artery patency was confirmed and no recurrence of aneurysm was observed. The obliteration rate of the paraclinoid aneurysm was 91%(20/22). Eight cases with preoperative vision defect had recovered to some extent. New vision defect occurred in two cases. At discharge, 12 patients scored with Glasgow outcome scale 5, 6 patients scored 4, 2 patients scored 3, and one patient scored 1.

Microsurgical treatment for paraclinoid aneurysm is a safe and effective method with high aneurysm obliteration rate and low aneurysm recurrence rate, and is thus a reasonable and effective complementary method for endovascular treatment.

To explore a modified method for constructing a mouse model of instable carotid plaque and provide the mouse model for simulating the development of human instable carotid plaque.

Twenty-four low density lipoprotein receptor deficiency (LDLr-/-), C57BL/6, male mice were randomized into two groups according to computer-generated table, tandem constriction of carotid artery+ high cholesterol diet (tandem surgery group, n=12); sham surgery+ high cholesterol diet(sham surgery group, n=12). After 12 weeks of consecutive feeding, murine carotid artery were collected and analyzed by carotid ultrasound, pathological examination to assess the formation and stability of atherosclerotic plaque.

No statistical difference in body weight and blood lipid level between the two groups was observed (all P>0.05). After surgery, through ultrasound biomicroscopy, obvious stenosis at the two sites of tandem constriction and atherosclerotic plaque between the two sites were observed in tandem surgery group. By pathological examination, no plaque was formed in carotid artery in sham surgery group. The lipid area in the stable plaque of innominate artery in sham surgery group and the plaque of carotid artery in tandem surgery group were (4.8±0.6) ×10⁴,(10.2±1.1)×10⁴ μm ², respectively. The difference was statistically significant between the two groups (t=12.023,P<0.001). In addition, the thickness of fibrous cap in the above groups were (122.4±17.8), (41.3±20.2) μm, respectively. The difference was statistically significant either ( t=9.224, P<0.001). The region of necrotic core were (3.3±0.4)×10⁴,(8.1±0.9)×10⁴ μm ².The difference was statistically significant as well (t=13.456, P<0.001). The percentage of macrophages in innominate artery of sham surgery group and in carotid artery of tandem surgery group were (20.8±5.2)%, (38.6±6.4)%, respectively.The percentage of vascular smooth muscle cells were (32.5±7.3)%,(21.2±5.1)%, respectively (t=6.114,3.585, all P<0.05). The results indicated that the plaque in tandem surgery group had severer inflammatory response.

Through tandem constriction surgery upon carotid artery in LDL-/-mouse, instable carotid atherosclerotic plaque can be induced, which is less time-consuming, replicable and effective.

To explore the application value of mixed-reality (MR) navigation combined with three-dimensional visualization technique in complicated hepatectomy.

A retrospective analysis of the clinical data of fifty patients with complex liver cancer who underwent liver resection in the Department of hepatobiliary surgery of Nantong Tumor Hospital during September 2015 to October 2017 was conducted. These patients were randomly divided into control group and experimental group, including 22 cases in the experimental group, using three-dimensional visualization technique for preoperative assessment, and MR surgery intraoperative navigation technology, and 28 cases in the control group, in which the three-dimensional visualization technique and the MR navigation were not performed. The surgeons of the two groups were the same. The preoperative, intraoperative and postoperative indexes of the two groups were compared and analyzed.

There was no significant difference in preoperative indexes. But in the intraoperative indexes, the operation time [(82.3±10.4) min vs (96.6±22.7) min] and hepatic portal blocking time [(12.2±3.8) min VS (15.8±4.2) min] of the experimental group were significantly shorter than those of the control group, meanwhile, the amount of intraoperative bleeding [(486.4±118.5) ml vs (567.2±142.8) ml] and the volume of intraoperative blood transfusion of [(1.8±0.2) U vs (2.5±0.6) U] were significantly decreased. These differences were statistically significant. In the postoperatively, the total incidence of postoperative complications (4/22 vs 13/28) of the experimental group was lower than that of the control group, and the difference was statistically significant.

In complicated hepatectomy, MR intraoperative navigation combined with three-dimensional visualization technique which used for preoperative assessment can significantly shorten operation time, hepatic portal blocking time, significantly reduce intraoperative blood loss and transfusion volume, and significantly reduce the incidence of postoperative total complications, which is of clinical value.

To study the experience of preoperative evaluation, surgical planning and postoperative treatment of hilar cholangiocarcinoma (HCC) in our center.

The clinical data of 70 patients with HCC who underwent resection at the First Affiliated Hospital of Bengbu Medical College, from January 2011 to December 2017 were analyzed retrospectively. The treatment experience of HCC from the aspects of preoperative evaluation and treatment, surgical methods, postoperative recovery and prognosis were discussed.

The accurate evaluation of HCC by three-dimensional visualization technology was beneficial to the formulation of surgical plan preoperatively. Extended hemihepatectomy or combined resection of caudate lobe or portal vein was effective for type Ⅲ-Ⅳ HCC. The R0 resection rate was 93% (53/57). Postoperative pathology showed that high/middle/low differentiated adenocarcinoma of 21/30/16, adenoma in 2 cases, inflammatory lesion in 1 case. The 1/3/5-year overall survival rates of patients with adenocarcinoma after chemotherapy were 87%(60/69)/47.0%(31/66)/30.2%(19/63) respectively.

HCC patients who under radical surgery after preoperative evaluation and postoperative chemotherapy can obtain a good prognosis. Expanding hepatectomy can improve R0 resection rate and prognosis in patients with type Ⅲ-Ⅳ HCC.

To investigate the efficacy, feasibility and safety of treatment of gallbladder and common bile duct stones treated through cholecystostomy tube.

The clinical data of 17 patients with gallbladder and common bile duct stones treated through cholecystostomy tube from January 2012 to December 2016 was analyzed retrospectively.

Seventeen patients were successfully treated with percutaneous transhepatic gallbladder (PTGD), and 88.2% (15/17) patients had clinical symptom relief. There was no complication happened after PTGD and fistula expansion. All the stones were removed and there was 11.7% (2/17) of gallbladder bleeding, 5.9% (1/17) of pancreatitis, and 5.9% (1/17) of hyperamylasemia after stones extraction. The patients had gone through an average treatment period of 87.8±16.0 days, hospitalization of 5.5±0.6 times and 43.3±4.5 days, cost of 60.0±8.0 thousand, 6.9±0.9 operations, 1.4±0.6 stone extraction operations with the average time of 58.4±21.2 min. The duodenal papillary balloon dilatation rate was 82.4% (14/17).

The treatment through cholecystostomy tube is an effective, safe and feasible technique for gallbladder and common bile duct stones. However, there are many shortcomings such as long treatment cycle, large number of hospitalization and operations, difficult operation and high cost.

To determine the timing and efficacy of entecavir (ETV) therapy in hepatitis B-related acute-on-chronic liver failure (HBV-ACLF) using a new simple scoring system.

A total of 212 patients with HBV-ACLF were treated with ETV 0.5 mg daily besides the routine treatment. The severity of illness was scored by the HBV-ACLF prognostic scoring system. Hepatic failure severity scores, hepatitis B virus DNA (HBV DNA) load, and length of hospital stay were recorded at the time of initiation of treatment, and the time of survival to hospital discharge/end of life.

Patiens were divided into four groups by the admission severity scores according to the percentile table: low score group (score≤ 4), medium-low score group (score: 5-7), medium-high score group (score: 8-11), and high score group (score ≥12). As the scores increased, the mortality rate increased. There were significant differences among different groups (χ²=310.662, P<0.001). There were significant difference of the admission and discharge/death severity scores in the low score group (P=0.003). There were significant differences of the comparison of HBV DNA load at admission and death/discharge using ETV in low-, medium-low, and medium-high score groups (P<0.001). There were no significant differences of HBV DNA load at admission and death/discharge using ETV for dead and survival patients in the medium-low, and medium-high score groups.

The efficacy of ETV in the rescue treatment of HBV-ACLF is related to the severity of ACLF when starting medication. The HBV-ACLF prognostic scoring system can clearly determine the timing and efficacy of ETV treatment of HBV-ACLF.

To explore the efficacy of Jinghuaweikang capsules combined with Quadruple therapy in the treatment of Helicobacter pylori (H.pylori)infection.

Patients who were infected with H.pylori in 7 centers in Gansu Province were recruited in this prospective simple randomized study. All the patients are divided into four groups randomly: patients in Group A1 were treated with esomeprazole (20 mg, twice a day) + pectin bismuth (200 mg, three times a day) + amoxicillin (1 000 mg, twice a day) + clarithromycin (500 mg, twice a day), while Group A2 with Jinghuaweikang capsules(160 mg, three times a day) based on group A2, Group B1 with esomeprazole (20 mg, twice a day) + bismuth pectin (200 mg, three times a day) + amoxicillin (1 000 mg, twice a day) + furazolidone (100 mg, twice a day) and Group B2 with Jinghuaweikang capsules(160 mg, three times a day) based on group B2. The treatment time was 14 days for all 4 groups. In the course of treatment, abdominal pain, acid reflux, abdominal distension, belching, hiccups were observed at the time before treatment, 14 days and 30 days after treatment and were scored. Finally, all patients received ¹³C or ¹⁴C for H.pylori at the time of 30 days after the treatment.

A total of 455 patients were included in 7 hospitals from February 2016 to May 2017 in Gansu province, and there were 189 male patients. Group A1 included 129 cases, group A2 96 cases, group B1 112 cases and group B2 118 cases. The eradication rates that accorded with program data analysis (PP) were A1[46.9%(60/128)], A2[63.8%(60/94)], B1[60.7%(68/112)], B2[68.6%(81/118)] (P<0.004). Compared with group A1, the eradication rate of H.pylori in group B1 and group A2 increased (P<0.001, P=0.032), there was no statistical difference between group B2 and group A2, group B1 and group B2 (P=0.208, P=0.461). According to intentional analysis (ITT), the eradication rates of H.pylori in group A1 were 46.5% (60/129),group A2 were 62.5% (60/96),group B1 were 60.7% (68/112),and group B2 were 68.6% (81/118).The radical rate of A2 was higher than A1 (P=0.017), group B2 was not higher than group B1 (P=0.208), and there was no significant difference among the other groups. The symptoms of abdominal pain, abdominal distention, acid reflux, belching and hiccup in the group A2 and group B2 were improved than those in group A1 and group B1 (P<0.05). No serious adverse reactions occurred in all groups.

Jinghuaweikang capsules can improve the eradication rate of Helicobacter pylori, and improve the symptoms of patients.

To assess the prognostic value of ¹⁸F-FDG PET/CT and its relationship with clinical features in newly diagnosed MM patients.

A total of 123 patients with newly diagnosed MM in Tianjin Medical University Cancer Institute and Hospital from September 2008 to December 2017 were retrospectively reviewed. The overall survival (OS) and progression free survival (PFS) were estimated by Kaplan-Meier analysis and the distribution of OS and PFS were compared using log-rank test. Cox regression was used to identify the independent prognostic factors.

Of all 123 patients, there were 43 patients (35.0%) who had extramedullary diseases (EMD). Compared to the patients without EMD, the PFS (24.5 months vs 37.8 months, P<0.05) and OS (30.1 months vs 51.4 months, P<0.05) of the patients with EMD at diagnosed was significantly inferior. In multivariate analysis, β2-MG≥5.5 mg/L, age≥65, EMD on ¹⁸F-FDG PET/CT and without CR at the ending of treatments were the four factors leading to poor prognosis. According to the above four factors, the patients were regrouped into low risk, medium risk and high risk groups, the significant difference existed (P<0.01) in these groups.

¹⁸F-FDG PET/CT is helpful in predicting the prognosis of newly diagnosed MM patients.

To investigate the relationships between serum cystatin C (Cys C), chemerin levels and subclinical atherosclerosis in type 2 diabetes mellitus (T2DM) patients.

A cross-sectional study was carried out between January 2016 and January 2018, and T2DM patients with carotid intima-media thickness (IMT) less than 1.1 mm were selected as subjects (100 males and 80 females, aged 40-60 years). The brachial-ankle pulse wave velocity (baPWV) ≥ 1 700 cm/s was set as the observation group (subclinical atherosclerosis) and baPWV<1 700 cm/s as the control group (non-subclinical atherosclerosis). Physical and blood examination were performed in both groups. Serum Cys C and chemerin levels were measured and their relationship with subclinical atherosclerosis was analyzed.

There was a statistically significant correlation between serum creatinine (r=0.167, P=0.011) and baPWV in the observation group, but not in the control group (r=0.105, P=0.070). Multiple linear regression analysis showed that age, duration of diabetes, serum creatinine, estimated glomerular filtration rate (eGFR), Cys C and chemerin were independently associated with baPWV, while high sensitive C reactive protein (hsCRP) and glycosylated hemoglobin (HbA1c) were not associated with baPWV. The elevation of serum Cys C (β′=0.393,P=0.003) and chemokine (β′=0.340,P=0.007) were correlative factors for atherosclerosis.

The level of serum Cys C and chemerin is possibly related to the occurrence and development of subclinical atherosclerosis in T2DM patients.

To investigate the value of three-dimensional quantitative analysis (3DQA) and automatic cardiac motion quantification (aCMQ) in evaluating the left ventricular systolic function in patients with different stages of chronic kidney disease (CKD).

A total of 127 cases of CKD patients between June 2016 and December 2017 who were admitted to Department of Nephrology of Wuxi No.2 People′s Hospital were divided into three groups: Group A (44 cases in CKD stage 1 and 2), Group B (38 cases in CKD stage 3) and Group C (45 cases in CKD stage 4 and 5). Another 50 age and sex matched normal controls were selected during the same period. The left ventricular segments and global longitudinal strain (GLS), left ventricular segments and global three-dimensional displacement (3DD) obtained by aCMQ and 3DQA techniques were compared and analyzed.

Compared with the control group, as for the longitudinal strain (LS) of each segment of left ventricular 5 (17 in all) segments in Group A, 10 segments in Group B and all segments in Group C decreased (P<0.05). As for the 3DD of each segment of left ventricular, 6 segments in Group A, 12 segments in Group B and all segments in group C decreased (P<0.05). As for the GLS, there was no statistically significant difference in group A, however, absolute value of GLS in group B and C [(19.82±3.62)%, (16.62±5.48)% vs (21.98±4.32)%] decreased statistically significantly (bothP<0.05). As for the left ventricular global 3DD, the global 3DD of group A, group B and group C [(6.24±0.51) mm, (5.54±0.29) mm, (4.62±0.55) mm vs (7.11±0.51) mm] decreased (all P<0.05).

Three-dimensional quantitative analysis and automatic cardiac motion quantification can detect the abnormality of left ventricular systolic function in patients with chronic kidney disease at an early stage. And the global 3DD of left ventricle of 3DQA is more sensitive than the global longitudinal strain of left ventricle of aCMQ.

Two young men with pananterior hypopituitarism onset in early childhood were not treated with androgen replacement therapy in adolescence and adulthood. The height of the patient in childhood was significantly lower than that of children of the same age, and although the levels of blood growth hormone and insulin-like growth factor 1 were extremely low in adulthood, the patient's height continued to increase, which was significantly higher than the expected height calculated according to genetic factors, and was accompanied by the clinical features of metabolic syndrome. This phenomenon of "growth independent of growth hormone" is rare in clinic, and its mechanism may be related to the long-term deficiency of sex hormones leading to unclosed epiphysis and hyperinsulinemia.

Comrade Gu Fangzhou, a member of the Communist Party of China, former president of Peking Union Medical College, Chinese Academy of Medical Sciences, first-class professor of Peking Union Medical College, and editor-in-chief of the 22nd editorial committee of Chinese Medical Journal of Chinese Medical Association (1990-1994), died in Beijing on January 2, 2019 at the age of 92 due to ineffective treatment.