Management of deep sacral and ischial pressure injuries with free-style local perforator flaps: A D+P+DPD model.

BACKGROUND: Previous reports on the treatment of sacral and ischial pressure injuries have not provided clear algorithms for surgical therapies. The objective of this study was to establish a reconstruction algorithm to guide the selection of an ideal free-style perforator flap that can be tailored to the defect in question. METHODS: We used 23 perforator flaps to reconstruct 14 sacral and 8 ischial defects in 22 patients over 5 years. A reconstruction algorithm system was developed based on the anatomical features of the perforator vessels (diameter, D; pulsatility [++∼+++], P) and their position in the skin island (DPD) (ie, D+P+DPD). A perforator-based propeller flap was applied as the first-line choice; if this plan was not feasible, we applied an altered V-Y advancement model or another second-choice technique. RESULTS: All flaps survived, and only 1 patient experienced partial wound dehiscence, which healed by secondary intention. After an average follow-up period of 11.2 months, no patient experienced recurrence or infection. CONCLUSIONS: Free-style perforator flap selection is determined by pressure injury and the desired advantage of a specific approach. The use of free-style perforator-based propeller flaps allows a surgeon to transfer healthy tissue into the defect, shifts the suture line away from the bony prominence, and preserves additional future donor sites. In cases where unexpected variations are encountered, the V-Y advancement model or another technique can be used. The simplified surgical algorithm (D+P+DPD) can provide versatility and reliability, achieve a durable, natural esthetic outcome, and minimize injuries to future donor sites.

Clinical significance of the advanced lung cancer inflammation index in gastrointestinal cancer patients: a systematic review and meta-analysis.

Background: The advanced lung cancer inflammation index (ALI) has been identified as a scientific and clinical priority in multiple malignancies. The aim of this study is to investigate the value of the ALI before treatment in evaluating postoperative complications (POCs) and survival outcomes in patients with gastrointestinal (GI) cancer. Methods: Electronic databases including PubMed, Embase and Web of Science were comprehensively reviewed up to June 2022. The endpoints were POCs and survival outcomes. Subgroup analyses and sensitivity analyses were also performed. Results: Eleven studies including 4417 participants were included. A significant heterogeneity in the ALI cut-off value among studies was observed. Patients in the low ALI group showed increased incidence of POCs (OR=2.02; 95%CI:1.60-2.57; P<0.001; I2 = 0%). In addition, a low ALI was also significantly associated with worse overall survival (HR=1.96; 95%CI: 1.58-2.43; P<0.001; I2 = 64%), which remained consistent in all subgroups based on country, sample size, tumor site, tumor stage, selection method and Newcastle Ottawa Scale score. Moreover, patients in the low ALI group had an obviously decreased disease-free survival compared to these in the high ALI group (HR=1.47; 95%CI: 1.28-1.68; P<0.001; I2 = 0%). Conclusion: Based on existing evidence, the ALI could act as a valuable predictor of POCs and long-term outcomes in patients with GI cancer. However, the heterogeneity in the ALI cut-off value among studies should be considered when interpreting these findings.

Comparisons of perioperative and long-term outcomes of laparoscopic versus open gastrectomy for advanced gastric cancer after neoadjuvant therapy: an updated pooled analysis of eighteen studies.

BACKGROUND: Outcomes of laparoscopic surgery in advanced gastric cancer patients who received neoadjuvant therapy represent a controversial issue. We performed an updated meta-analysis to evaluate the perioperative and long-term survival outcomes of laparoscopic gastrectomy (LG) versus conventional open gastrectomy (OG) in this subset of patients. METHODS: Electronic databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure were comprehensively searched up to May 2023. The short-term and long-term outcomes of LG versus OG in advanced gastric cancer patients undergoing neoadjuvant therapy were evaluated. Effect sizes with 95% confidence intervals were always assessed using random-effects model. The prospective protocol was registered with PROSPERO (CRD42022359126). RESULTS: Eighteen studies (2 randomized controlled trials and 16 cohort studies) involving 2096 patients were included. In total, 933 patients were treated with LG and 1163 patients were treated with OG. In perioperative outcomes, LG was associated with less estimated blood loss (MD = - 65.15; P < 0.0001), faster time to flatus (MD = - 0.56; P < 0.0001) and liquid intake (MD = - 0.42; P = 0.02), reduced hospital stay (MD = - 2.26; P < 0.0001), lower overall complication rate (OR = 0.70; P = 0.002) and lower minor complication rate (OR = 0.69; P = 0.006), while longer operative time (MD = 25.98; P < 0.0001). There were no significant differences between the two groups in terms of proximal margin, distal margin, R1/R2 resection rate, retrieved lymph nodes, time to remove gastric tube and drainage tube, major complications and other specific complications. In survival outcomes, LG and OG were not significantly different in overall survival, disease-free survival and recurrence-free survival. CONCLUSION: LG can be a safe and feasible technique for the treatment of advanced gastric cancer patients receiving neoadjuvant therapy. However, more high-quality randomized controlled trials are still needed to further validate the results of our study.

Prophylactic drainage versus non-drainage following gastric cancer surgery: a meta-analysis of randomized controlled trials and observational studies.

BACKGROUND: The role of prophylactic drainage (PD) in gastrectomy for gastric cancer (GC) is not well-established. The purpose of this study is to compare the perioperative outcomes between the PD and non-drainage (ND) in GC patients undergoing gastrectomy. METHODS: A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure was performed up to December 2022. All eligible randomized controlled trials (RCTs) and observational studies were included and meta-analyzed separately. The registration number of this protocol is PROSPERO CRD42022371102. RESULTS: Overall, 7 RCTs (783 patients) and 14 observational studies (4359 patients) were ultimately included. Data from RCTs indicated that patients in the ND group had a lower total complications rate (OR = 0.68; 95%CI:0.47-0.98; P = 0.04; I2 = 0%), earlier time to soft diet (MD = - 0.27; 95%CI: - 0.55 to 0.00; P = 0.05; I2 = 0%) and shorter length of hospital stay (MD = - 0.98; 95%CI: - 1.71 to - 0.26; P = 0.007; I2 = 40%). While other outcomes including anastomotic leakage, duodenal stump leakage, pancreatic leakage, intra-abdominal abscess, surgical-site infection, pulmonary infection, need for additional drainage, reoperation rate, readmission rate, and mortality were not significantly different between the two groups. Meta-analyses on observational studies showed good agreement with the pooled results from RCTs, with higher statistical power. CONCLUSION: The present meta-analysis suggests that routine use of PD may not be necessary and even harmful in GC patients following gastrectomy. However, well-designed RCTs with risk-stratified randomization are still needed to validate the results of our study.

A modified perforator-based stepladder V-Y advancement flap in the Achilles tendon area for coverage of larger posterior heel defects.

BACKGROUND: Posterior heel defect coverage is challenging because of the paucity of suitable flaps. The traditional local stepladder V-Y advancement flap is recommended only for small defects because of the lack of an axial pedicle. This study reports our experience of using the perforator-based stepladder V-Y advancement flaps in a larger posterior heel defect repair. METHODS: Twenty-two patients with posterior heel defects were treated with modified perforator-based stepladder V-Y advancement flaps in the Achilles tendon area for 11 years. Sixteen males and six females aged 3-74 years underwent surgery. The defect size, perforator characteristics, flap size, flap movement, sural nerve, lesser saphenous vein, deep fascia, flap survival, and outcome quality were analyzed. RESULTS: The perforators were found to predominate within two 2-cm intervals: 0-2 cm and 4-6 cm proximal to the tip of the lateral malleolus. Twenty-one perforator-based flaps healed uneventfully, and only one developed tip necrosis on the lower edge, which healed by secondary intention. The maximum distance of distal movement was 5.0 cm for the modified flap in contrast to 2.5 cm for the traditional flap. All flaps allowed adequate and durable reconstruction to be achieved, with excellent contouring after 2-28 months of follow-up. CONCLUSIONS: The perforator-based stepladder V-Y advancement flap resulted in good outcomes for larger posterior heel defects compared with conventional transfer methods. The flap is a reliable, well-vascularized, sensate, and pliable local flap option that uses similar tissue from adjacent skin for defect repair and creates an internal gliding surface for the Achilles tendon.

Detection of asymptomatic recurrence following curative surgery improves survival in patients with gastric cancer: A systematic review and meta-analysis.

Background: To date, there is no evidence that intensive follow-up provides survival benefit in gastric cancer patients undergoing curative gastrectomy. The aim of this study is to investigate the efficacy of detection of asymptomatic recurrence using intensive surveillance strategy in long-term survival after curative gastric cancer surgery. Methods: A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library and China National Knowledge Infrastructure, Clinical Trials Registry and Google Scholar was performed up to April 2022. The primary outcomes were survival outcomes: overall survival, recurrence-free survival and post-recurrence survival. The secondary endpoints were clinicopathological features, recurrence patterns and treatment after recurrence. The registration number of this protocol is PROSPERO CRD42022327370. Results: A total of 11 studies including 1898 participants were included. In the pooled analysis, the detection of asymptomatic recurrence was significantly associated with an improved overall survival compared to patients showing symptoms of recurrence (HR=0.67; 95%CI: 0.57-0.79; P<0.001), which was primarily driven by the prolongation of post-recurrence survival (HR=0.51; 95%CI: 0.42-0.61; P<0.001), since there was no significant difference observed in recurrence-free survival (HR=1.12; 95%CI: 0.81-1.55; P=0.48) between the two groups. Meanwhile, male sex and advanced T stage were more frequently observed in the symptomatic recurrence group. Furthermore, patients in the symptomatic recurrence group had a higher proportion of peritoneal relapse but lower proportion of distant lymph node metastasis. Additionally, patients in the symptomatic recurrence group were less likely to receive surgery treatment and post-recurrence chemotherapy. Conclusion: The detection of asymptomatic recurrence using intensive follow-up was associated with an appreciable improvement in overall survival. However, more robust data from high-quality studies are still required to verify this issue. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327370, identifier CRD42022327370.

Preoperative assessment of complicated appendicitis through stress reaction and clinical manifestations.

This study assessed the severity of the disease through the preoperative clinical manifestations and inflammatory reaction indicators of acute appendicitis, and established a score table to predict complicated appendicitis (CA).The clinical data of 238 patients with acute appendicitis in our hospital were retrospectively analyzed, which included 18 patients with acute simple appendicitis (7.6%), 170 patients with acute purulent appendicitis (72.0%), and 48 patients with acute gangrene and perforation (20.3%). The clinical manifestations and inflammatory reaction indicators were analyzed by univariate logistic regression. Multivariate logistic regression analysis was performed to screen out the independent risk factors of CA. The ß coefficients of independent risk factors entering the multivariate model were assigned by rounding, and the total score was the sum of values of all factors. Finally, verification and analysis were performed for the predictive model, and the operating characteristic curve (ROC) curve was drawn. Then, the area under the curve (AUC) was compared with the THRIVE scale, and the Hosmer-Lemeshow method was used to evaluate whether the model fitted well.The multivariate logistic regression analysis of independent risk factors was performed, and the values were rounded to the variable assignment based on the ß coefficient values. The plotted ROC and AUC was calculated as 0.857 (P < .001). Using the Hosmer-Lemeshow method, the X-value was 12.430, suggesting that the prediction model fitted well.The scoring system can quickly determine whether this is a CA, allowing for an earlier and correct diagnosis and treatment. Furthermore, the scoring system was convenient, economical, and affordable. Moreover, it is easy to popularized and promote.

Mechanism research of Bu-Shen-Huo-Xue formula against renal fibrosis in rats with 5/6 nephrectomy via E-cadherin, α-SMA, and TGF-ß1
.

OBJECTIVE: Renal fibrosis generally results in renal failure during the end stage of chronic renal diseases. There are many cell factors including E-cadherin, α-SMA, and TGF-ß1 influencing deposition of extracellular matrix and leading to renal fibrosis. As the most important and widely-used therapy for various diseases in China for thousands of years, traditional Chinese medicine (TCM) provides a novel treatment for renal fibrosis. For clinical application, we explore the effect of Bu-Shen-Huo-Xue formula (BSHX), a traditional Chinese herbal formula, on E-cadherin and α-SMA in rats with 5/6 nephrectomy. MATERIALS AND METHODS: Sprague-Dawley rats were subjected to 5/6 nephrectomy to induce chronic renal failure (CRF); they were divided into three groups including a CRF control group, a BSHX group, and a Cozaar group, and compared with a normal control group. After 8 weeks of therapy with the respective drug, E-cadherin, α-SMA, and TGF were detected by immunohistochemistry assays in renal tissues. RESULTS: As the immunohistochemistry assays indicated, BSHX could significantly enhance the expression of E-cadherin and depress the levels of α-SMA and TGF-ß1 expression in rats' renal tissues with 5/6 nephrectomy. CONCLUSION: BSHX can effectively relieve the renal fibrosis in rats with 5/6 nephrectomy via the change of cell factor levels including enhancement of the expression of E-cadherin and depression of the levels of α-SMA and TGF-ß1 expression.
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Protective Effects of Bu-Shen-Huo-Xue Formula against 5/6 Nephrectomy-Induced Chronic Renal Failure in Rats.

Chronic renal failure (CRF) is a serious disease related to increasing incidence and prevalence as well as decline in quality of life. Bu-Shen-Huo-Xue formula (BSHX), one of traditional herbal formulations, has been clinically employed to treat CRF for decades, but the mechanisms involved have not been investigated. In the present study, we investigated the effects of BSHX on some closely related parameters in 5/6 nephrectomy CRF rats. Rats with CRF were divided into five groups, namely, one control group, one enalapril group, and three BSHX treatment groups (0.25, 0.5, and 1 g/kg·d). The rats subjected to sham operation were used as a normal control. After eight weeks of treatment, BSHX significantly decreased the levels of Scr and BUN, downregulated the mRNA expression levels of TGF-ß 1, CTGF, NF-κB, TNF-α, and OPN, upregulated the mRNA expression of PPARγ, and reduced in situ expression of fibronectin and laminins. Histological findings also showed significant amelioration of the damaged renal tissue. BSHX protects 5/6 nephrectomy rats against chronic renal failure probably via regulating the expression of TNF-α, NF-κB, TGF-ß 1, CTGF, PPARγ, OPN, fibronectin, and laminins and is useful for therapy of CRF.

Prevalence and determinants of parathyroid dysfunction in elderly patients on hemodialysis.

BACKGROUND: The goal of this study was to investigate underlying factors of parathyroid dysfunction in elderly patients undergoing maintenance hemodialysis. METHODS: A total of 286 patients on maintenance hemodialysis were included. Hemoglobin, serum creatinine (Scr), blood urea nitrogen (BUN), serum calcium, serum phosphorus (P), intact parathyroid hormone (iPTH), and serum albumin (Alb) were measured and analyzed both before and after dialysis. RESULTS: A higher incidence of low iPTH level (<150 pg/l) was observed in the elderly group than that in the non-elderly group (55.8 vs. 36.7%, p < 0.05). Elderly patients had a shorter dialysis duration, lighter dry weight, lower concentrations of BUN, Scr, P, iPTH, Alb and standard protein nitrogen present rate (nPNA) compared to that of non-elderly group patients (p < 0.05). CONCLUSIONS: Low iPTH level occurs more frequently in elderly hemodialysis patients. Furthermore, age, serum P, serum Alb and nPNA were independently associated with a low iPTH level.

[Clinical research of the sentinel lymph node in patients with early gastric cancer].

OBJECTIVE: To assess the value of carbon nanoparticles which mapping sentinel lymph node (SLN) and predict the status of lymph node metastasis status in the early gastric cancer (EGC), and to explore the SLN distribution. METHODS: Forty five patients with EGC, who underwent surgical treatment, were enrolled. At the completion of exploratory laparotomy, 1 mL solution of carbon nanoparticles was injected subserosally in the gastric wall 4-6 sites around the primary tumor during surgery in all patients. The first stained lymph nodes were defined as the SLN. Postoperative SLN and dissection of the lymph node was sent for histopathological examination. RESULTS: Carbon nanoparticles were applied in 45 EGC patients for mapping SLN and 43 cases (95.6%) were observed with positive stain. 53 pieces of SLN were detected, average (1.23 +/- 0.53) pieces for one person. 11 of the 43 patients (25.6%) developed lymph node metastasis, through the SLN histopathological examination, 3 cases (7.0%) were false negative, the accuracy and sensitivity of the prediction of regional lymph node metastasis status was 93.0% and 72.7%, respectively. The false negative and negative predictive value was 27.3% and 91.4%. There were significant differences between the mucosal cancer group and submucous cancer group in the diameter of tumor (P = 0.042) and the rate of lymph node metastasis (P = 0.001). There were no significant differences between the two groups in the accuracy and sensitivity (P > 0.05). In 36 cases of gastric cancer patients, 23 SLN positive cases (63.9%) were detected in third group. CONCLUSIONS: The dyeing rate, accuracy and sensitivity of carbon nanoparticles mapping SLN for EGC were high. Carbon nanoparticles mapping SLN can more accurately predict perigastric lymph node metastasis status in patients with EGC.

[Clinicopathological characteristics and surgical treatment of duodenal gastrointestinal stromal tumor].

OBJECTIVE: To investigate the clinicopathological characteristics and surgical treatment of duodenal gastrointestinal stromal tumor (GIST). METHODS: Clinicopathological data of 25 cases with duodenal GIST from January 2007 to July 2011 in West China hospital were retrospectively analyzed. RESULTS: All the patients were identified by pathological examination without specific symptoms. Tumors were located in the bulb area in 2 cases, descending portion in 11 cases, transverse portion in 8 cases, and ascending portion in 4 cases. Two cases were at very low risk, 7 at low risk, 6 at intermediate risk, and 10 at high risk. All the patients received surgical resection, including 11 pancreaticoduodenectomies, 10 local tumor resections, 2 duodenal segmental resections, and 2 distal subtotal gastrectomies. Eighteen patients were followed up from 16 to 39 months and 3 patients recurred 18, 30, and 35 months after operation respectively. CONCLUSIONS: Duodenal GIST exhibits no distinct clinical characteristics. Complete removal of the tumor is the main choice of treatment.

[Application of the gastric tube in surgical treatment of esophagogastric junction adenocarcinoma].

OBJECTIVE: To evaluate the outcome of gastric tube anastomosis after intraperitoneal gastrectomy in the patients with types II and III adenocarcinoma of the esophagogastric junction (AEG). From October 2009 to December 2010, 74 patients with diagnosis of type II or type III AEG were divided groups. Traditional anastomosis of gastric remnant with esophagus was performed to 38 patients in group, while new anastomosis of gastric tube with esophagus was performed to 34 patients in gastric tube RESULTS: There were no statistically significant differences in baseline data, clinical and pathological characteristics between the two groups (P > 0.05). For the postoperative complications, 12 (31.6%) patients in traditional and 4 (11.8%) patients in gastric tube group occurred gastroesophageal reflux symptoms (P = 0.043). 9 patients in traditional group and 2 (5.9%) patients in gastric tube group were diagnosed as reflux esophagitis postoperative endoscopic examination (P = 0.036). CONCLUSION: The anastomosis of gastric tube with the after proximal gastrectomy could reduce the incidence of gastroesophageal reflux.

[Clinical outcomes of surgical patients with types II and III adenocarcinoma of esophagogastric junction].

OBJECTIVE: To investigate the clinical pathological characteristics, choice of surgical therapy and postoprative complications of patients with types II and III adenocarcinoma of esophagogastric junction (AEG). METHODS: Clinical data of 112 patients with types II and III AEG who underwent intraperiteanal operations from January 2008 to July 2010 were reviewed. Amongst the patients, 77 suffered from type II AEG and 35 suffered from type III AEG; 72 underwent proximal gastrectomy and 40 underwent total gastrectomy. RESULTS: The patients with type II and type III AEG shared some common characteristics, such as advanced tumor TNM stage and lymphatic metastasis. There was a significant difference in choice of surgical approaches between the two groups of patients (P < 0.05), with 57 type II AEG patients (74.0%) and 15 type III AEG patients (42.9%) undergoing proximal gastrectomy respectively. Operational time and incidence of postoperative complications differed between proximal gastrectomy and total gastrectomy (P < 0.05). Total gastrectomy lasted longer [(304.12 +/- 23.12) min] than proximal gastrectomy [(275.76 +/- 27.02) min]. Proximal gastrectomy provoked 20.8% (15 patients) heartburn and/or acid regurgitation and 12.5% (9 cases) reflux esophagitis. Fifteen patients (37.5%) with total gastrectomy had more than 5 meals a day. CONCLUSION: Intraperiteanal operations are recommended for patients with types IT and Ili AEG. The choice of proximal gastrectomy or total gastrectomy depends on the location and size of the tumor, both being followed with some complications.

Gastric tube reconstruction reduces postoperative gastroesophageal reflux in adenocarcinoma of esophagogastric junction.

BACKGROUND: The anastomosis of gastric remnant to esophagus after proximal gastrectomy is the traditional surgical treatment procedure for patients with types II and III adenocarcinoma of esophagogastric junction. However, the postoperative complications such as gastroesophageal reflux are frequent. AIMS: To assess the outcome of the intraperitoneal anastomosis of the reconstructed gastric tube to esophagus after proximal gastrectomy for types II and III adenocarcinoma of esophagogastric junction. METHODS: Seventy-six consecutive patients with preoperative diagnosis of type II or type III adenocarcinoma of esophagogastric junction were recruited. Forty-one patients had the traditional anastomosis of gastric remnant to esophagus and 35 patients underwent an anastomosis of esophagus to a gastric tube that was constructed from the gastric remnant after proximal gastrectomy. RESULTS: Twenty-three (56.1%) versus 12 (28.6%) patients (p = 0.016) complained various discomforts and/or were diagnosed with complications in the traditional group and gastric tube group, respectively, although there were no significant differences between the two groups in demographic data and pathological characteristics. Fourteen (34.1%) versus five (14.3%) patients (p = 0.046) complained of heartburn or acid regurgitation and nine (22.0%) versus two (5.7%) patients (p = 0.045) were confirmed reflux esophagitis in the traditional group and the gastric tube group, respectively. CONCLUSIONS: The intraperitoneal anastomosis of the reconstructed gastric tube to esophagus demonstrates less complaints of gastroesophageal reflux and reflux esophagitis than the traditional anastomosis of gastric remnant to esophagus in the surgical treatment of types II and III adenocarcinoma of esophagogastric junction in 1-year follow-up.