This paper summarized nursing experience of one patient with diffuse esophageal spasm(DES) undergoing peroral endoscopic myotomy (POEM).Key points of nursing included:preoperative training of use of medical bedpan;respiratory functional exercises;postoperative management of body position,nursing of gastrointestinal decompression,management of refined diet and prevention and nursing of complications.The patient recovered well and no complication occurred.The patient was discharged on the eighth day after surgery.

Objective To investigate the expression of insulin-like growth factor Ⅱ mRNA binding protein 3 (IMP3) in non-muscle invasive bladder cancer and its relationship with the tumor recurrence and progression.Methods IMP3 protein expression was detected by immunohistochemistry in 130 cases of nonmuscle invasive bladder cancer specimens who underwent transurethral resection the first time at Beijing Chao-Yang hospital,from October 2010 to October 2013.Besides,we analyzed 20 cases of muscle-invasive samples and 20 benign tissues adjacent to cancer as control.The 130 patients were followed up by telephone and other methods.According to the UICC-TNM standard.Survival analysis was calculated by using the Kaplan-Meier method,and the difference in survival curves was analyzed by using the log-rank test.For multiple analyses,The Cox proportional hazards regression model was used.Results The positive expression rate of IMP3 in 130 patients with non-muscle invasive bladder cancer was 59.2％ (77/130),of which 30.0％ (39/130) was weak expression,29.2％ (38/130) was strong.However there was 80.0％ (16/20) in muscle-invasive specimens,of which 20.0％ (4/20) was weak,60.0％ (12/20) was strong (P =0.011).IMP3 was not detected in all benign tissues adjacent to cancer (P ＜0.001).All the 130 patients were followed-up for 5 to 69 mnonths,45 cases experienced disease recurrence,20 patients had progressed and 12 cases died.IMP3 expression was significantly related to higher tumor stage (P ＜ 0.001),high tumor grade (P =0.014),and tumor recurrence (P =0.003).Kaplan-Meier plots and log-rank tests showed that patients with IMP3-positive tumors had a lower disease-free survival (P =0.002) and progression-free survival rate (P =0.010) than those with IMP3-negative tumors.In the multivariable Cox analysis,we found that IMP3 protein was an independent predictor of disease-free survival (P =0.010) in non-muscle invasive urothelial carcinoma of bladder.Conclusions IMP3 was not expressed in benign tissue adjacent to cancer,whereas highly expressed in bladder cancer,and high IMP3 expression is an independent prognostic factor in NMIBC that can identify the patients with a high potential to relapse.

Objective:To explore the feasibility and superiority of retropubic extraperitoneal laparosco-pic simple prostatectomy with prostatic urethra preservation to treat large volume benign prostatic hyperplasia(BPH).Methods:From January 2006 to August 2009,laparoscopic simple prostatectomy with prostatic urethra preservation was performed in 45 patients with symptomatic BPH,and the age of patients was 70.5?7.2(range 47 to 83) years old.The transrectal ultrasound(TRUS) revealed BPH and calculated prostatic gland weight was 126.1?52.4(range 62 to 365) g.There were 3 cases presented with bladder calculus and 1 case presented with bladder diverticulum.The technique included retropubic extraperitoneal space produced by balloon dilation,five trocars in a reverted U shape placed,transverse prostatic capsular incision made,subcapsular plane developed,prostatic adenoma removed while prostatic urethra preserved as well as prostatic capsule sutured.Demographic,perioperative and outcome data were recorded.Results:No patient required conversion to open surgery.The mean operative time was 123.9?51.3(range 37 to 270) minutes and the estimated blood loss was 230.6?194.5(range 50 to 800) mL.Blood transfusion was not necessary in this group of patients.Bladdder irrigation was not needed except for the initial 2 cases and the average Foley catheter duration was 7.5?3.5(range 2 to 14) days.Significant improvement was noted in the maximum flow rate,the International Prostate Score Symptoms(IPSS) and the quality of life questionnaires(QOL) three months after surgery.The erectile function was preserved in all patients who were potent before surgery and the ejaculation maintained antegrade.No urinary incontinence was reported by patients.Conclusion:Laparoscopic simple prostatectomy with prostatic urethra preservation for large benign prostatic hyperplasia is feasible and reproducible.Postoperative bladder irrigation can be avoided and antegrade ejaculation is preserved.The patients have a shorter hospital stay and early return to normal activity.

Objective:To explore risk factors for positive surgical margin (PSM) after laparoscopic radical prostatectomy (LRP) in high risk prostate cancer (PCa) patients with and without neoadjuvant hormornal therapy (NHT).Methods:The clinicopathological data of 202 high risk patients who underwent LRP from January 2012 to July 2020 was retrospectively analyzed. There were 111 cases performed in Beijing Chaoyang Hospital and 91 cases in National Cancer Center. Mean age was(67.7±6.5)years, mean BMI was (25.65±3.21)kg/m 2. Median highest preoperative PSA was 20.97(11.00, 34.40)ng/ml, median preoperative prostate volume was 32.88(23.33, 46.20)ml. Among all 202 high risk PCa patients, 97 did not receive NHT(non-NHT group) and 105 received NHT(NHT group). There were significant statistical difference in term of highest PSA, preoperative prostate volume between NHT and non-NHT groups ( P<0.05), while there was no significant difference in term of age or BMI between the two groups. Among NHT patients, 80 cases accepted complete androgen blockade therapy with median course of 3 months; 3 cases accepted simple castration therapy with median course of 3 months; 22 cases accepted simple anti-androgen therapy with median course of 1 month. Risk factors for PSM after LRP in NHT and non-NHT groups were respectively explored, including age, BMI, hypertension, diabetes, history of pelvic surgery, highest PSA before puncture, ISUP before puncture, preoperative prostate volume, ISUP after LRP, postoperative pathological stage T, pathological lymph node involvement, vessel carcinoma embolus, etc. Results:PSM rate was 50.5%(49/97) and 24.8% (26/105) in non-NHT and NHT, respectively. The apex was the most common location of PSM in non-NHT group(35.1%, 34/97), while the fundus was the most common location of PSM in NHT group(14.3%, 15/105). Multiple logistic regression revealed that postoperative pathological stage T was the only independent factors affecting the PSM for high risk patients without NHT ( OR=3.814, 95% CI 1.302-11.173, P=0.015), while postoperative pathological stage T, pathological lymph node involvement, and vessel carcinoma embolus were independent risk factors affecting PSM for high risk patients with NHT ( OR=18.434, 95% CI 4.976-68.297, P<0.001; OR=7.181, 95% CI 2.089-24.689, P =0.002; OR=3.545, 95% CI 1.109-11.327, P=0.033). Conclusions:Postoperative pathological stage T was independent risk factors affecting PSM for all high risk PCa patients no matter with or without NHT, while pathological lymph node involvement, and vessel carcinoma embolus were also independent risk factors affecting PSM for high risk PCa patients with NHT.

Objective To discuss the coverage of finger soft tissue defect with dorsal proximal digit fasciocutaneous flap on the middle and distal digit.Methods From May,2013 to December,2014,8 cases with soft tissue defects at 8 fingers were treated with dorsal proximal digit fasciocutaneous flap.The flap sizes ranged from 2.5 cm × 2.0 cm to 3.5 cm × 3.0 cm.The donor site were closed straightly.Results Eight flaps of 8 fingers survived.All the wounds at the donor sites healed well.Eight fingers in 8 cases were followed up for 6-12 months.The color,texture and contour of the flaps were satisfied.The two-point discrimination distances were 8-10 mm.Conclusion The skin defect in the middle and distal digit can be satisfied covered with dorsal proximal digit fasciocutaneous flap.This flap is a simple,reliable and safe management for digit defect and can be performed in the primary hospital.To ensure the surviving of the flap,ensure the surviving of the flap,the awareness of the anatomy of the flap should be known well.The limits of its reconstruction of sensation and coverage size exit in its application.

Objective:To evaluate the value of 68Ga-labeled prostate-specific membrane antigen( 68Ga-PSMA PET/CT)in the diagnosis of prostate cancer(PCa) and determination of the strategy on neurovascular bundle(NVB)preservation and lymphadenectomy before surgery. Methods:We retrospectively analyzed the clinical data of 46 patients with newly diagnosed PCa who underwent 68Ga-PSMA PET/CT from June 2018 to October 2019. The median age was 66.50 (60.00, 69.25) years old and the median PSA was 15.97(8.58, 33.10)ng/ml. Forty-one patients were diagnosed PCa and 5 were diagnosed with benign prostatic hyperplasia or prostatitis by 68Ga-PSMA PET/CT, 6 were diagnosed with lymph nodes metastasis. Forty patients underwent mpMRI, 33 were diagnosed PCa, and 6 were diagnosed with lymph nodes metastasis. Seventeen patients underwent 11C-choline PET/CT, 12 were diagnosed PCa, and 4 were diagnosed with lymph nodes metastasis. Among the 41 patients which were diagnosed PCa by 68Ga-PSMA PET/CT, 26 were confirmed with PCa by needling biopsy, 12 did not undergo the needling biopsy and 3 had negative biopsy; 22 were in the high-risk group, and 19 were in the low- and medium-risk group. All 41 patients underwent radical prostatectomy. The strategy of NVB preservation was determined by the position of the PCa reported by 68Ga-PSMA PET/CT. If the tumor was close to the unilateral prostate capsule, the healthy part of the NVB would be preserved. And if the tumor was limited in the prostate gland, bilateral NVB would be preserved. The NVB was preserved in 16 cases(6 cases unilateral and 10 cases bilateral). In addition to routine lymph node dissection for patients in the high-risk group, lymph node dissection was also performed on patients with 68Ga-PSMA PET/CT that showed positive lymph nodes in the low- and medium-risk groups. The paired chi-square or Fisher exact test was used to compare the sensitivity and specificity of 68Ga-PSMA PET/CT, mpMRI, and 11C-choline PET/CT for lesion detection. Spearman analysis was used to examine the correlation between the SUV max, Gleason score, and the PSA value before treatment. Results:Forty-one patients undergoing radical resection were diagnosed PCa by postoperative pathology, and no cancer tissue was observed at the surgical margin; the median Gleason score was 8(7, 9); 20 cases (48.8%) had a pathological stage ≤pT 2c; 21 cases (51.2%)≥pT 3; 7 cases were N+ (11 positive lymph nodes). Seven cases (17.1%) had complications of Clavien-Dindo ≤ grade 2 within 30 days after surgery, and there was no complication above grade 3 after surgery. The median follow-up time of the 41 patients was 16(12, 20). The rate of urinary control was 46.3%, 95.1%, and 100% after 1 month, 6 months, and 12 months follow-up respectively. Among the five patients that did not undergo surgery, the PSA value of 4 decreased after antibiotic treatment, and biopsy was performed in 1 case without PSA decreasing, and no carcinoma was found. The sensitivity of 68Ga-PSMA PET/CT on the primary PCa was 100%(41/41), which was significantly better than that of 11C-choline(80%, 12/15, P=0.016)and mpMRI (83.7%, 31/37, P=0.009), while no statistical significance was observed between the specificity of 68Ga-PSMA PET/CT (5/5)and 11C-choline PET/CT(2/2, P=1.000), 68Ga-PSMA PET/CT and mpMRI(1/3, P=0.107). Of the 41 patients that were diagnosed with PCa, the sensitivity of 68Ga-PSMA PET/CT to lymph nodes metastases(71.4%, 5/7) had a significant difference with that of mpMRI(16.7, 1/6, P=0.016), but no statistical difference with 11C-choline (75%, 3/4, P=1.000). Analysis of the relationship between SUV max of 68Ga-PSMA PET/CT, Gleason score, and PSA value before treatment revealed that the SUV max of 68Ga-PSMA PET/CT in patients with Gleason score ≥8 and <8 score were 19.60(9.58, 24.38) and 8.55 (5.18, 12.88); SUV max of patients with PSA values ≥20 ng/ml and <20 ng/ml before treatment were 19.40 (13.00, 23.50) and 8.40 (5.35, 13.95), respectively, the differences were statistically significant (all P<0.05). Conclusions:68Ga-PSMA PET/CT had high sensitivity and specificity for the diagnosis of primary prostate cancer lesions, but the sensitivity for the diagnosis of lymph node metastasis was not enough to guide the preoperative decision of whether to remove the lymph node and the scope of the removal. However, the treatment strategy of whether to retain NVB could be formulated according to the tumor location displayed by 68Ga-PSMA PET/CT before surgery.

Objective To evaluate the supercutaneous fixation with locking plate for treatment of open metacarpal fractures.Methods From March 2015 to November 2016,16 open metacarpal fractures were treated with supercutaneous locking plate after emergency debridement at Department of Hand Surgery,The Second Affiliated Hospital to Wenzhou Medical University.They were 11 men and 5 women,from 20 to 67 years of age (average,37.5 years).There were 2 cases of the 1st metacarpal fracture,6 ones of the 2ed metacarpal fracture,one of the 3rd metacarpal fracture,2 ones of the 4th metacarpal fracture and 5 ones of the 5th metacarpal fracture.All fractures were open injury.By the Gustilo-Anderson classification,there were 9 cases of type Ⅱ and 7 ones of type Ⅲ A.Functional rehabilitation was encouraged immediately after operation.The outcomes were evaluated at the 4th and 24th weeks postoperatively according to the Total Angle of Motion (TAM) for digital joints recommended by the Hand Surgery Society,Chinese Medical Association.Results The mean operation time was 46.8 minutes (from 35 to 108 minutes).All cases were followed up for an average of 9.8 months (from 7 to 25 months).All fractures healed without breakage or loosening of the supercutaneous locking plate after an average of 6.2 weeks(from 4.3 to 7.8 weeks).Nail tract infection occurred in 3 cases.According to the TAM at the 4th week postoperatively,5 cases were rated as excellent,8 as good,2 as fair and one as poor;according to the TAM at the 24th week postoperatively,11 cases were rated as excellent,4 as good and one as fair.Conclusion For open metacarpal fractures with severe contamination or soft tissue injury,supercutaneous locking plate fixation can achieve fine clinical outcomes.

Objective To discuss surgical tips and techniques of laparoscopic radical cystectomy in the female.Methods We retrospectively reviewed 29 females who underwent laparoscopic radical cystectomy between Feb.2008 and Mar.2017.The median age was 64 years (range 37-83 years),and the median BMI was 24.7 kg/m2 (range 12.1-31.2 kg/m2),and the median CCI was 3 (range 2-9).No distant metastasis was identified by bone scans,chest X-ray and sonography.Preoperative pathology were non-muscular infiltrating bladder cancer in 19 patients and muscular infiltrating bladder cancer in 10 patients by cystoscopic biopsy.Surgical method:under general anesthesia,the patients were placed in lithotomy position.A 5-port transperitoneal approach was used.Under laparoscopy,the suspensorium ligament of ovary was dissected and cut at lateral to the fimbriae of uterine tube,then the ureter was divided and umbilical artery was managed.The broad ligament of uterus was divided.Afterwards,the Douglas'pouch was opened and the fornix of vagina was cut transversely.Then,the endopelvic fascia was divided.The bladder was excised with the female reproductive organs together.If the female reproductive organs were decided to preserve,the dissection was performed along the space between bladder and uterus or vagina.Frozen section of urethra end andthe distal ureter were then obtained.The resected tissues were removed through the vagina,and then vagina was closed.Urinary diversion consisted of orthotopic ileal neobladder in 9 patients,ileal conduit in 14 patients,ureterostomy in 4 patients.All urinary tracts were removed for two cases due to renal function loss before surgery.Results Mean total operative time was 315 mins (ranged from180 mins to 420 mins).Estimated blood loss was 299 ml (ranged from 10 ml to 1 500 ml).Complications occurred in 2 cases.One patient had both vaginal infection and incomplete intestinal obstructionand the other had vaginal infection alone.No patients died in perioperative period.At a median follow up of 36.8 months (ranged from 2 to 110 months),24 patients (82.8％)were alive without recurrences,1 (3.4％) had metastasis in lymph nodes and 4 (13.8％) died.Conclusions Laparoscopic radical cystectomy in the female is technically feasible.Knowing female pelvic anatomy and grasping the techniques conduce to optimize the tips of the surgery and reduce complications.

Objective To compare perioperative outcomes and complications between intracorporeal and extracorporeal orthotopic ileal neobladder after laparoscopic radical cystectomy (LRC) from one center.Methods We retrospectively analysis patients' clinical and follow-up data who underwent laparoscopic radical cystectomy (LRC) in our hospital from January 2011 to May 2017,of whom 25 cases underwent intracorporeal orthotopic ileal neobladder (ICIN) and 20 cases underwent extracorporeal orthotopic ileal neobladder (ECIN).The patients' characteristics,perioperative data,postoperative pathological results,postoperative complications and oncologic outcomes were compared and analyzed.The mean age of ECIN group was (59.9 ± 10.5)years,mean BMI was (24.7 ±3.3)kg/m2,the ASA level was less than Ⅱ in 19 cases and level Ⅲ in 1 case,the mean preoperative CCI was 4.5 ± 1.6,3 patients got preoperative neoadjuvant chemotherapy.The mean age of ICIN group was (59.0 ± 9.8) years,mean BMI was (25.3 ±4.3)kg/m2,the ASA level was less than Ⅱ in 25 cases and no level Ⅲ,mean preoperative CCI was 4.0 ±1.3,3 patients got preoperative neoadjuvant chemotherapy.There was no statistical difference between the two groups in patients' characteristics.All operations were performed under general anesthesia.After LRC was accomplished,an additional 12 mm trocar was placed 1 cm crania to the pubic symphysis for EndoGIA in ICIN group.An ileal segment 60 cm long was isolated 25 cm proximal to the ileocecum.The continuity of the small bowel was restored with side to side anastomosis.The proximal 10 cm was moved to the distal end of the ileal segment for the right isoperistaltic afferent limb,and the remaining proximal 10 cm ileal segment was reserved for the left isoperistaltic afferent limb.Then,the remaining length of the 40 cm ileal segment was detubularized along its antimesenteric border.The anterior wall of the neobladder was folded forward and the free edges were sutured to achieve a spherical configuration.After single J ureteric stents were inserted into the ureters,the urethra and ureters were sutured with neobladder successively.For ECIN,the ileal segment is removed via a midline laparotomy below the umbilicus 5-10 cm.The construction method of neobladder was the same with ICIN group.Results All 45 cases were successfully operated.There was no statistical difference between ICIN group and ECIN group in operation time [(374.2 ± 74.6) min vs.(360.3 ±83.6)min,P =0.557] and extraction time of pelvic drainage tube[(12.5 ±5.9)d vs.(11.8 ±4.5)d,P =0.686].Patients in the ICIN group had less intraoperative blood loss [(186.0 ± 140.3)ml vs.(272.0 ±110.7) ml,P =0.030],shorter oral intake time [(4.2 ± 2.2) d vs.(6.1 ± 1.6) d,P =0.002],shorter postoperative hospital stay [(13.7 ± 4.2) d vs.(19.9 + 7.6) d,P =0.001].There was no significant difference in the early postoperative complications (P =0.345).The median follow-up time of ICIN group and ECIN group were 30 months and 52.5 months,respectively.The day-time and night-time continence rate were 97.4％ and 86.8％ respectively in the first year after surgery without significant difference.A total of 6 patients suffered distant metastasis,of whom 4 patients suffered multiple metastases,1 case bone metastases and 1 case pelvic lymph node metastasis.Seven patients died,five of whom died of tumor recurrence or metastasis.There was no statistical difference between the two groups in cancer specific survival rates (P =0.644) and recurrence free survival rates (P =0.981).Conclusions Comparing with extracorporeal orthotopic ileal neobladder,intracorporeal orthotopic ileal neobladder has advantages of less blood loss and faster intestinal function recovery,without significantly increased operative time and complications.No significant difference was found in the function of neobladder and oncological outcomes.Randomized controlled trial with large sample and long-term follow-up is needed to verify the advantages of intracorporeal neobladder construction.

Purpose: Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease, and Th17 cells are key factors in the pathogenesis of human inflammatory conditions, such as RA. Catalpol (CAT), a component in Rehmanniae Radix (RR), has been found to regulate human immunity. However, the effects of CAT on Th17 cell differentiation and improvement of RA are not clear. Materials and Methods: Collagen-induced arthritis (CIA) mice were constructed to detect the effects of CAT on arthritis and Th17 cells. The effect of CAT on Th17 differentiation was evaluated with let-7g-5p transfection experiments. Flow cytometry was used to detect the proportion of Th17 cells after CAT treatment. Levels of interleukin-17 and RORγt were assessed by qRT-PCR and enzyme-linked immunosorbent assay. The expression of signal transducer and activator of transcription 3 (STAT3) was determined by qRT-PCR and Western blot. Results: We found that the proportion of Th17 cells was negatively associated with let-7g-5p expression in CIA mice. In in vitro experiments, CAT suppressed traditional differentiation of Th17 cells. Simultaneously, CAT significantly decreased Tregs-to-Th17 cells transdifferentiation. Our results demonstrated that CAT inhibited Tregs-to-Th17 cells transdifferentiation by up-regulating let-7g-5p and that the suppressive effect of CAT on traditional differentiation of Th17 cells is not related with let-7-5p. Conclusion Our data indicate that CAT may be a potential modulator of Tregs-to-Th17 cells transdifferentiation by up-regulating let-7g-5p to reduce the expression of STAT3. These results provide new directions for research into RA treatment.