2019 Vol. 10, No. 4

Specialist Forom
Abstract:
The history of surgery is, to a certain extent, a history of the game between surgeons and surgical complications. The initial invention of aseptic techniques, anesthesiology, and antibiotics significantly reduced the incidence of surgical complications, which made modern surgery completed the conversion from "high mortality" to "high success rate". From a medical point of view, advances in medical technology, surgical treatment strategies, and treatment concepts have played a key role in reducing surgical complications. In terms of education, the standardized training system for residents, i.e. the "Three Basics and Three Restrictions", is not only an important cornerstone for becoming an excellent surgeon, but also an important guarantee for the quality of surgery and patient safety. From the perspective of management, the concept of "multidisciplinary team", the establishment of a medical safety system, and optimization of surgical procedures effectively reduce the incidence of surgical complications. In short, our surgeons must always attach great importance to the occurrence and prevention of surgical complications. Change our minds, lay emphasis on prevention, and strive to reduce the incidence of surgical complications to a lower level.
Abstract:
As an organ-preservation procedure, laparoscopic central pancreatectomy has been performed routinely in large pancreatic centers. Due to the limitation of indications, the complexion of the operation, and higher incidence of complications, there are few publications with more than 100 cases of central pancreatectomy reported by a single center. The current article reviews the history, indications and contraindications, short- and long-term complications, and laparoscopic techniques of central pancreatectomy.
Abstract:
With the development of laparoscopic techniques, more and more gynecological operations are performed under the laparoscope. Intestinal injury is one of the complications of gynecological laparoscopic surgery with a relatively low incidence. Some of the cases are difficult to be identified during surgery, and a delayed diagnosis can bring about serious consequences. Intestinal injury can be divided into mechanical injury and thermal injury. Adhesions in the pelvic and abdominal cavity are the main risk factors for intestinal injury in laparoscopic surgery. Pelvic and abdominal surgery and inflammatory disease can lead to pelvic-abdominal tissue adhesion. The surgeon's experience also affects the incidence of intestinal injury. Early identification of intestinal injury, as well as proper and timely treatment is critical to reducing the morbidity and mortality. The key to treating an intestinal injury is to restore the anatomy of the intestinal wall and avoid the appearance of intestinal leakage.
Guidelines and Consensuses
Abstract:
Glioma is the most common primary brain tumor in adults, among which glioblastoma (GBM) is the most malignant. At present, the therapeutic regimen for patients with glioma mainly includes surgery, radiotherapy, and chemotherapy. However, the treatment strategy for elderly patients with GBM often varies because of their characteristics. A systematic and comprehensive assessment before the operation will be helpful to summarize clinical characteristics of elderly patients with GBM, and can provide clinicians with more comprehensive clinical information in order to evaluate the patient's tolerance to surgery and predict the prognosis. Based on a systematic review of the latest research, this expert consensus summarizes the most widely used and studied tools of preoperative assessment of glioma, and initially establishes a preoperative evaluation system for elderly patients with glioma in China.
Original Contribution
Abstract:
  Objective  The aim of this study was to explore the causes of postoperative rebleeding after abdominal surgery and the timing of intervention, so as to optimize the treatment plan.  Methods  The clinical data of patients with abdominal bleeding after abdominal surgery from January 2013 to December 2018 were retrospectively collected in Peking Union Medical College Hospital. The causes of bleeding, treatment plan, and prognosis were analyzed.  Results  A total of 61 patients with postoperative hemorrhage after abdominal surgery who met the inclusion and exclusion criteria were enrolled in this study, including 49 males and 12 females. Among them, most patients had pancreaticoduodenectomy (50.8%, 31/61), followed by liver surgery (16.39%, 10/61) and gastric surgery (14.8%, 9/61). The causes of bleeding were identified in 56 patients, including 24 cases of wound bleeding and/or arteriolar active bleeding (42.9%, 24/56) and 11 cases of anastomotic bleeding (19.6%, 11/56). After hemorrhage, most patients (65.6%, 40/61) underwent surgical hemostasis, with a success rate of 87.50%; hemostasis by interventional embolization was adopted in the other patients(24.6%, 15/61), with a success rate of 26.7%(P > 0.01). Successful hemostasis was achieved in 55 cases. Five cases died, and one gave up treatment.  Conclusions  Major abdominal surgery increases hemorrhage risk. Hemostasis of surgery may be superior to that of interventional embolization.
Abstract:
  Objective  The aim of this study was to investigate the incidence and the possible risk factors for myocardial injury in critical care patients after abdominal surgery.  Methods  A retrospective study of critical care patients after abdominal surgery from January 2017 to January 2019 in Peking University People's Hospital was carried out. General clinical data and myocardial injury after abdominal surgery were analyzed. The clinical data including medical history, intraoperative conditions (operational time, emergency surgery, intraoperative hemorrhage, and intraoperative hypotension, etc), and postoperative conditions (modified oxygenation index, blood lactic acid, acute kidney injury, vasopressor drugs used within 24h after operation) were observed. According to whether myocardial injury occurred after abdominal surgery, patients were divided into the myocardial injury group and the non-myocardial injury group. Risk factors for myocardial injury after abdominal surgery were analyzed using Logistic regression.  Results  The incidence of myocardial injury for critical care patients after abdominal surgery was 17.2%(138/803), while the incidence of acute myocardial infarction was only 0.9%(7/803). There were 7 risk factors correlated with myocardial injury after abdominal surgery in critical patients by univariate analysis, including previous chronic kidney disease, operational time, emergency surgery, intraoperative hypotension, vasopressor drugs used within 24 h after operation, APACHE Ⅱ scores, and postoperative acute kidney injury; the independent risk factors for myocardial injury in these patients by Logistic regression analysis included emergency surgery (OR=3.14, 95% CI:1.76-5.60, P < 0.001), administration of vasopressor drugs within 24 h after the operation(OR=2.26, 95% CI:1.23-4.15, P=0.008), high APACHEⅡ scores(OR= 1.05, 95% CI:1.01-1.09, P=0.008), and postoperative acute kidney injury(OR=3.18, 95% CI:1.78-5.69, P < 0.001).  Conclusions  The incidence of myocardial injury in critical care patients after abdominal surgery is high. Emergency surgery, administration of vasopressor drugs within 24 h after the operation, high APACHEⅡ scores, and postoperative acute kidney injury are the independent risk factors associated with myocardial injury in critical care patients after abdominal surgery.
Abstract:
  Objective  The aim of this study was to investigate the safety and feasibility of transperineal template-guided prostate biopsy (TTPSB).  Methods  Clinical data of patients with suspected prostate cancer who were admitted for prostate biopsy in the Department of Urology at the Northern Jiangsu People's Hospital from March 2017 to May 2018 were retrospectively collected and analyzed. All patients were divided into two groups, TTPSB group and traditional transperineal template-guided prostate biopsy (TTPB) group, according to the prostate shape and size, pubic condition, and patient intention. The complications including bleeding, infection, urinary retention, urinary function, and erectile function after prostate biopsy were compared between the two groups.  Results  A total of 385 patients meeting the inclusive and exclusive criteria were enrolled in this study. There were 204 patients in the TTPSB group with mean of (23.7±5.8) cores (range from 11 to 47 cores) and 181 patients in the TTPB group with mean of (12.3±4.3) cores (range from 5 to 12 cores); the baseline information was matched between the two groups. The incidence of moderate hematuria in the TTPSB group was higher than that in the TTPB group [19.6% (40/216) vs. 11.6% (21/181), P < 0.05]; there was no statistical difference in the incidence of the other complications (all P > 0.05). The International Prostate Symptom Score (IPSS) of the two groups were increased at the 1st and 4th week after the biopsy compared with the baseline before the biopsy [TTPSB group: 15.8±6.9 and 12.6±7.5 vs. 10.2±6.8; TTPB group: 16.2±6.7 and 13.2±7.1 vs. 10.7±7.2, all P < 0.05], and returned to the baseline level at the 12th week after the biopsy (TTPSB group: 11.3±6.5; TTPB group: 11.9±6.8, both P > 0.05). The International Index Erectile Function (IIEF-5) score of the two groups were decreased at the 1st month after biopsy compared with the baseline [TTPSB group: 18.4±4.3 vs. 19.5±4.6; TTPB group: 18.8±4.8 vs. 19.9±4.5, both P < 0.05]; while there was no significant difference between the baseline and the 3rd and 6th month after the biopsy (TTPSB group: 18.9± 4.4 and 19.3±4.2; TTPB group: 19.3±4.2 and 19.7±4.3, all P < 0.05).  Conclusions  Compared with traditonal TTPB, the complications of TTPSB are nearly the same. TTPSB is a safe procedure.
Abstract:
  Objective  The aim of this study was to discuss the preoperative medicine treatment and adjustment for catecholamine-induced cardiomyopathy in patients with pheochromocytoma/paraganglioma to ensure the safety of operation.  Methods  The clinical information of patients with catecholamine-induced cardiomyopathy in pheochromocytoma/paraganglioma who underwent surgery in the Department of Urology at Peking Union Medical College Hospital from January 2007 to January 2019 was retrospectively collected and reviewed, including the clinical features, echocardiographic results, therapeutic strategies for catecholamine-induced cardiomyopathy, urinary catecholamine and its metabolites, and the cardiac function. The correlation between norepinephrine level and severity of catecholamine-induced cardiomyopathy was evaluated. Normal distribution quantitative data were expressed by mean±SD and analyzed by t test. The difference was statistically significant with P < 0.05.  Results  Seventeen patients meeting the inclusive and exclusive criteria were enrolled in this study. All patients had mild to moderate heart failure. The left ventricular ejection fraction (LVEF) before and after the medication was (42.58±7.35)% and (56.0±7.09)% respectively (t=0.507, P=0.038).The LVEF of patients with catecholamine-induced cardiomyopathy in the high norepinephrine group and low norepinephrine group were (43.11±5.79)% and (42.0±9.19)% (t=0.015, P=0.973), and after treatment, (55.2±5.21)% and (56.87±9.07)% (t=-0.145, P=0.732) respectively.  Conclusions  Medicine might improve the cardiac function of patients with catecholamine-induced cardiomyopathy in pheochromocytoma/paraganglioma. Norepinephrine level is not correlated with the severity of catecholamine-induced cardiomyopathy.
Abstract:
  Objective  The aim of this study was to observe the mRNA expression of DNA methyl-transferase(DNMT) and methyl-CpG binding protein(MeCP) in the peripheral blood mononuclear cells from GPP patients, and to explore the potential role of DNA methylation in the pathogenesis of GPP.  Methods  Clinical data of 9 GPP patients admitted or hospitalized at the Department of Dermatology of Peking Union Medical College Hospital from December 2015 to December 2016 were retrospectively collected. Ten healthy people who underwent a physical examination in the same hospital during the same period were randomly selected as the control group; their age and gender were matched with those of GPP patients. Peripheral blood mononuclear cells were isolated from 10 ml blood of the elbow median vein using density gradient centrifugation. Total RNA was extracted from peripheral blood mononuclear cells by Trizol method; mRNA expression levels of DNMT1, DNMT3a, DNMT3b, MBD1, MBD2, MBD3, MBD4, and MeCP2 were detected by real-time PCR. The correlation of age and GPP severity with the expression level of these mRNAs was observed and analyzed.  Results  Compared with the healthy subjects, the relative expressions of DNMT3a, DNMT3b, MBD1, MBD2, and MBD4 mRNA in peripheral blood mononuclear cells from GPP patients were higher than those from the healthy controls [DNMT3a:0.000 17(0.000 06, 0.001 15) vs. 0.000 03(0.000 02, 0.000 04), DNMT3b 0.000 04± 0.000 02 vs. 0.000 02±0.000 01, MBD1 0.001 01±0.000 45 vs. 0.000 46±0.000 15, MBD2 0.002 61±0.000 39 vs. 0.001 85±0.000 52; and MBD4 0.004 29±0.001 60 vs. 0.001 57±0.000 55, all P < 0.05]. There was no correlation between age and GPP severity with the mRNA expression of the above factors (all P > 0.05).  Conclusions  Methylation related regulatory genes are abnormally expressed in GPP patients, and do not correlate with age or the disease severity.
2019, 10(4): 364-366. doi: 10.3969/j.issn.1674-9081.2019.04.010
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2019, 10(4): 367-369. doi: 10.3969/j.issn.1674-9081.2019.04.011
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2019, 10(4): 419-422. doi: 10.3969/j.issn.1674-9081.2019.04.021
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Abstract:
Reviews
Abstract:
Periprosthetic joint infection is one of the severe complications after total hip and knee arthroplasty. Once happened, it would bring great psychological burden and economic pressure on the patients. Current methods of treatment include one-stage revision, two-stage revision and debridement with prosthesis retention. In this paper, we discussed the indication, success rate and risk factors of debridement with prosthesis retention.
Abstract:
With the improvement of medicine and surgical instruments, robotic surgery has been increasingly applied as a new minimally invasive surgical approach to gynecology field.Compared with conventional laparotomy and laparoscopic surgery, it has advantages of clear three-dimensional vision, a 360° rotating arm to simulate the flexibility of human wrist, more precise operation, short learning curve, and so on.
Abstract:
Photoacoustic imaging(PAI) is a state of the art biomedical imaging technique with the potential of wide application. Based on the photoacoustic effect, PAI combines the advantage of optical imaging as high contrast and spectroscopic specificity with the advantage of ultrasonography as high spatial resolution and deep penetration. This paper introduced the latest progress in PAI, which contains the fundamentals of photoacoustic imaging, the improvement in detecting modes of images, and the most promising clinical applications. The limitation of PAI has also been discussed.
Complicated and Rare Disease
Abstract:
Familial hypercholesterolemia (FH) is a serious hereditary metabolic disease. It is clinically divided into homozygous and heterozygous.The incidence of homozygous FH(HoFH) is 1/(160 000-1 000 000) and considered as a rare disease. HoFH is characterized by very high levels of low density lipoprotein cholesterol, multi-sited yellow tumors, and atherosclerosis cardiovascular disease. Without prompt diagnosis and early treatment, myocardial infarction and even death can occur in adolescence. In recent years, the international community has paid more and more attention to the early diagnosis and treatment of FH, and issued a number of guidelines and consensus on FH. China has also developed a screening and diagnostic standard suitable for Chinese people in combination with national conditions, which provides bases for better treatment of FH. This article reviewed HoFH's existing diagnostic criteria, differential diagnostic screening, and treatment methods, to improve physicians' understanding of the disease.
Abstract:
Pulmonary large-cell neuroendocrine carcinoma (LCNEC), first reported in 1991, is a rare pulmonary epithelial malignancy. It was not until 2004 that LCNEC was officially classified pathologically as the bronchopulmonary neuroendocrine tumor. Most of the patients are elderly male smokers. Their clinical manifestations are not specific. They may have respiratory tract-related symptoms. Paraneoplastic syndrome is rare. CT usually shows peripheral nodules, including lobulation, burr, and pleural traction. LCNEC was reported as a highly aggressive malignancy, with lymph node metastasis occurring in about 60%-80% of patients and distant metastasis in about 40% of patients, similar to the degree of malignancy of small cell lung cancer. Surgery combined with postoperative adjuvant therapy is the main treatment for stage Ⅰ, Ⅱ, and Ⅲa patients. PE regimen is recommended for chemotherapy. Metastasis and recurrence may be the main causes of poor prognosis. Tumor-driven genes and targeted drug therapy need further study.
Clinical Research and Evidence Based Medicine
Abstract:
Clinical Epidemiology (CE) is an essential course of medicine that involves the application of methods established by Modern Epidemiology and Statistics to investigate the etiology, prophylaxis, diagnosis, treatment, and prognosis of diseases-inflicted subjects from individuals to populations. Evidence-Based Medicine (EBM) requires healthcare providers to make shared-decisions for the patient's best interest through extensively searching, explicitly appraising, and judiciously applying evidence in the light of the physician's expertise and the patient's values and preferences. David Sackett, who is from McMaster University, and his successor, Gordon Guyatt, have become the iconic figures of founding, improving and spreading CE/EBM globally. In 1980s David Sackett tutored the first generation of physician-methodologists from China, and they, in turn, introduced the core concepts of CE, i.e., the design, measurement and evaluation of clinical research, into their own homeland. Thanks to their effort, China embraced EBM in parallel with the world in the 1990s. Over the past three decades, we have witnessed the infancy, childhood, adolescence, and mature adulthood of CE and EBM in China and have benefited tremendously from therein. Today, the task to strengthen CE and EBM in China becomes even imminent in the era of building Healthy China.
Clinical Practice Guidelines
Abstract:
As the most important guiding documents in the medical practice, clinical practice guidelines and expert consensuses have received more and more attention in recent years. However, partial domestic experts also have understanding biases on guidelines and consensus. Thus, we analyzed and compared guidelines and consensuses on their definition, status, development, connection, and difference. Combined with the example, we introduced good practice statement along with its formation conditions. Finally, we proposed five recommendations on how to improve the quality of clinical practice guidelines and expert consensus in China.
Clinical Boibank
Abstract:
Since 2009, especially with the discovery of biomarkers and disciplines of translational medicine, the development of Biobank in China has grown incredibly fast. However, we are still facing many challenges nowadays, and the most significant one is that we have not yet fully understood why, what and how we should build biobanks. The heterogeneity of goal setting for the development of Biobank highlights the challenge we need to solve in order to develop with synergy for achieving a greater value with cooperation. This challenge has turned out to result in poor integration of resources for larger research. This article believes that it is critical to have a strategic harmonization first before we can cooperate to improve the development of Biobank. To articulate it, we begin our discussion with a terminology of the industry of software development-"refactoring". Refactoring is a controlled technique improving the design of an existing code base: to avoid multiple small mistakes ahead for greater achievements with the minimal risk and cost before a system is finished. Refactoring is very applicable for us to rethink the way to design and cooperatively develop Biobanks. That would help us with: refactoring the deign of Biobank development; refactoring the strategy and methods; refactoring Biobank management. The entry point is to reconcile the difference between our desire and feasibility across Biobanks. The article will focus on articulating five elements of the Biobank development: the initial intention for goal setting, to rethink the way to develop, clinical annotation, quality assurance/quality control application, integration and sharing. In a summary, we need to set up a strategy for the development of Biobank in harmony and pave the way for the standardization of Biobanks. The goal is to build quality resource across Biobanks, to achieve quality research on the strategic discovery of biomarkers, and to improve healthcare with the research achievements based on Biobanks.
Breast Cancer
Abstract:
With a nationwide increase in elderly population, an increased number of breast cancer diagnosed in older women is expected. Nowadays, targeted therapy is an important systemic treatment for human epidermal growth factor 2 (HER-2) positive breast cancer, which has been playing an important role in the treatment for breast cancer. It is controversial whether trastuzumab should be used for targeted therapy in elderly Her-2 positive breast cancer patients with moderate risk and no cardiac disease. Current evidence suggests that patients aged 60-70 years old with a moderate risk of Her-2 positive breast cancer may benefit from trastuzumab with an acceptable and reversible risk of heart events. Yet there is no enough evidence for elderly patients beyond 70 years old. Therefore, we should balance the benefit and risk when considering targeted therapy for elderly patients with breast cancer. Management of breast cancer in the elderly should take the will of the patients, the physical condition, and comorbidities in to consideration. Anthracycline-based chemotherapy should not be used together with targeted therapy. It is necessary to monitor cardiac function and deal with heart events timely.
Clinical Case Analysis
Abstract:
A case of atypical malignant mesothelioma involving both pleura and peritoneum was reported. The aim of this article was to strengthen clinicians' understanding of the atypical performance of malignant mesothelioma by illustrating the characteristics of its clinical and pathological manifestations and by reviewing related literature.
History of Medicine
Abstract:
Choriocarcinoma is a highly invasive malignant gynecological carcinoma. Widespread metastases can occur by bloodstream in the early stage. Before 1960s, due to the lack of effective treatments, its mortality rate was above 90%. Since 1949, under the leadership of Academician SONG Hong-zhao, Peking Union Medical College Hospital has conducted a series of research on the pathogenesis, development, diagnosis and treatment of choriocarcinoma, and has achieved groundbreaking results. His team members are continuing to make unremitting efforts. Their work plays an important role in enhancing the research level in this field. Now, the overall cure rate of choriocarcinoma is over 90%. At present, China has maintained the cutting edge of this field. Efforts by Peking Union Medical College Hospital has been recognized by their overseas counterparts and written into the international guidelines of Choriocarcinoma.