The introduction of stapling instruments and improved understanding of pathology has resulted in a greater proportion of low rectal cancer patients undergoing sphincter-preserving resection.A variety of alternative techniques have been proposed to avoid a permanent stoma,including abdominal pull through,abdominal trans-sphincteric resection and intersphincteric resection.However,these damages always inflicted on the anal sphincters with poor functional results.More recently,the anterior perineal plane for ultra-low anterior resection of the rectum (APPEAR) technique was developed which approaches the anurectum via an anterior transperineal approach and exploits an anatomic space within the pelvic floor musculature termed “rectal no-man's laud”.The ability to access this segment of distal rectum by the perineal approach may determine whether a sphincter-saving resection can be performed for a proportion of patients who would otherwise require a permanent stoma.We performed laparoscopic APPEAR for a 46-year old woman with low rectal cancer with satisfactory results.

Objective To investigate the prognostic value of procalcitonin (PCT) and C-reactive protein (CRP) combined with sequential organ failure assessment (SOFA) score in elderly patients with sepsis induced by pulmonary infection. Methods A retrospective study was conducted. The elderly patients aged over 60 years old with sepsis induced by pulmonary infection admitted to Guangdong Provincial Hospital of Chinese Medicine from October 2015 to December 2018 were enrolled. The PCT, CRP and SOFA scores of patients within 24 hours after admission and 28-day prognosis were recorded. The patients were divided into groups according to the severity of the disease and 28-day prognosis. The differences in above parameters among all the groups were compared. Receiver operator characteristic (ROC) curve was drawn to analyze the prognostic value of the above indicators in elderly patients with sepsis induced by pulmonary infection alone or in combination. Results A total of 265 patients were enrolled in the study. According to the severity of the disease, the patients were divided into sepsis group (n = 194) and septic shock group (n = 71). According to the 28-day prognosis, the patients were divided into survival group (n = 186) and non-survival group (n = 79). Compared with the sepsis group, the PCT, CRP and SOFA scores of patients in the septic shock group were significantly increased [PCT (μg/L): 6.16 (1.94, 19.60) vs. 1.56 (0.34, 7.32), CRP (mg/L): 128.90 (54.93, 198.70) vs. 91.45 (30.15, 175.30), SOFA score: 9.0 (7.0, 12.0) vs. 4.0 (3.0, 5.0)] with significant differences (all P < 0.05). Compared with the survival group, the PCT, CRP and SOFA scores of sepsis patients in the non-survival group were significantly increased [PCT (μg/L): 4.80 (1.06, 19.60) vs. 1.82 (0.34, 7.24), CRP (mg/L): 135.20 (58.10, 225.50) vs. 91.45 (31.50, 172.53), SOFA score: 7.0 (4.0, 11.0) vs. 4.0 (3.0, 6.0)] with significant differences (all P < 0.01). ROC curve analysis showed that the area under the ROC curve (AUC) of PCT, CRP, SOFA score and CRP+PCT+SOFA score was 0.641, 0.607, 0.697, and 0.712, indicating that above parameters had certain predictive value for 28-day prognosis of elderly patients with sepsis induced by pulmonary infection, and the combined predictive value of them was the greatest with the sensitivity of 55.1% and the specificity of 80.1%. Conclusion PCT, CRP and SOFA score are commonly used to evaluate the prognosis of the elderly patients with sepsis induced by pulmonary infection, and the combination of them has higher evaluation value.

Objective:To explore the efficacy of distracting external fixator for tibiofibular fractures combined with osteofascial compartment syndrome.Methods:A retrospective case-control study was conducted to analyze the clinical data of 62 patients with tibiofibular fractures combined with osteofascial compartment syndrome admitted to Air Force Hospital from Eastern Theater of PLA from March 2009 to March 2019, including 47 males and 15 females, aged 20-78 years［（47.1±13.4）years］. There were 30 patients with tibia shaft fractures, 17 with tibia plateau fractures and 15 with tibia distal fractures. The fractures were classified as type 4A in 18 patients, type 4B in 24 and type 4C in 20 according to AO/OT classification. Distracting external fixation was performed for 30 patients（Group A）and calcaneal tuberosity traction for 32 patients（Group B）. Levels of alanine aminotransferase（ALT）, urea nitrogen（BUN）, creatine kinase（CK）and lactate dehydrogenase（LDH）of the injured limb were compared between the two groups during traction. Additionally, the fasciotomy rate, time of damage control treatment（observation interval from trauma to stage II definitive surgery）, time of stage II definitive surgery, internal fixation modalities of stage II definitive surgery, rate of needle tract infection and rate of non-planned secondary surgery were compared between the two groups. The limb function was assessed using Johner-Wruhs scoring system at the last follow-up.Results:All patients were followed up for 12-22 months［（15.1±2.7）months］. Level of CK in Group A was 315.6（140.0, 531.5）U/L, significantly lower than that in Group B［465.5（277.0, 1240.5）U/L］（ P<0.05）. The two groups revealed no statistical differences in levels of BUN, CK and LDH（ P>0.05）. The fasciotomy rate in Group A［40%（12/30）］was higher than that in Group B［34%（11/32）］, but the difference was statistically insignificant（ P>0.05）. The time of stage II definitive surgery in Group A was（68.5±17.1）minutes, significantly lower than that in Group B［（89.0±15.1）minutes］（ P<0.05）. The rate of non-planned secondary surgery in Group A［3%（1/30）］was lower than that in Group B［25%（8/32）］（ P<0.05）. There were no statistically significant differences in time of damage control treatment, internal fixation modalities of stage II definitive surgery and rate of needle infection between the two groups（ P>0.05）. According to Johner-Wruhs scoring system, the function in Group A were excellent in 17 patients, good in 5, fair in 2 and poor in 6 at the last follow-up, with the excellent rate of 73%. However, the difference was not statistically significant when compared to Group B: excellent in 13 patients, good in 3, fair in 7 and poor in 9, with the excellent rate of 50%（ P>0.05）. Conclusion:Compared with calcaneal tuberosity traction, the distracting external fixation of tibiofibular fractures combined with osteofascial compartment syndrome can attenuate soft tissue damage during the traction and shorten the time of stage II definitive surgery by maintaining intraoperative fracture reduction.

Osteofacial compartment syndrome (OCS) is one of the serious complications in traumatic orthopedics. If not treated in time, OCS may result in irreversible damage to nerve and muscle,even amputation or death in serious condition. 5P presents to be the classic clinical diagnosis of OCS, but it is highly subjective and cannot timely and accurately judge the progression of the disease. Intracompartment pressure manometry is the main auxiliary method for the diagnosis of OCS. Although there are many manometry methods, there is still no authoritative pressure threshold as the diagnosis standard. Clinicians often aggressively perform fasciotomy to avoid serious complications, leading to unnecessary fasciotomy. The authors retrospectively reviewed the data of patients with OCS treated at Air Force Hospital of Eastern Theater of PLA from March 2010 to March 2020 and found that some patients with OCS had gradual alleviation of clinical symptoms after appropriate conservative treatments such as brace releasing, limb stabilization and swelling subsidence, with no need of fasciotomy. However, the symptoms of some patients progressively aggravated after the above-mentioned traditional treatments and timely fasciotomy was required. The authors graded the severity of OCS and proposed for the first time the OCS grading criteria according to quantitative clinical results and quantitative indicators such as ratio of mean blood flow velocity of bilateral arteries and pulse wave changes, aiming to take corresponding intervention measures for patients with different OCS classifications, carry out more precise treatment and avoid unnecessary fasciotomy.

Objective:To explore the protective effect and mechanism of improved St. Thomas solution on canine skeletal muscle ischemia-reperfusion injury (IRI).Methods:Between March 2021 and September 2021, in the experimental operating room at the Air Force Hospital of the PLA Eastern Theater Command, 16 Beagles were randomly divided into control group, IRI group, IRI+NS group, and improved St. Thomas group, 4 in each group. The canine skeletal muscle IRI model was established, and the canine vital signs were monitored by pre-perfusion with improved St. Thomas perfusate [potassium chloride (KCl), magnesium sulfate (MgSO 4), and NaHCO 3 (pH adjusted)]. The pathological damage of canine skeletal muscle was explored by hematoxylin eosin (HE) staining, electron microscope detection and tissue wet/dry weight ratio, and blood vessel density. Hypoxia performances were detected by labeling blood vessels and hypoxia-inducible factor-1α (HIF-1α). The IRI model of L6 rat myoblasts was established, and the components of St. Thomas perfusion solution were pre incubated to explore the effect on the inhibition of cell proliferation. And by detecting reduced nicotinamide adenine dinucleotide phosphate (NADPH), F2 isoprostane (F2-isoprostane), interleukin 1β(IL-1β), tumour necrosis factor alpha (TNF-α), myeloperoxide enzyme (MPO), glutathione peroxidase (GSH-Px), etc. to explore its protective mechanism. Statistical software SPSS 23.0 was used for statistical analysis, A P<0.05 was set as statistically significant. Results:In the improved St. Thomas group, the vital signs of the dogs were relatively stable, the amount of maintained dopamine was less, the histopathological structure of the gastrocnemius muscle tended to be intact, the swelling of tissue cells and mitochondria was significantly relieved, and the tissue wet/dry weight ratio was less than that in the IRI group ( P=0.046). Pre-incubated with therapeutic doses of MgSO 4 or NaHCO 3, the proliferation rate of L6 cells was higher than that of IRI group ( P<0.01, P=0.005), NADPH ( P=0.004, P=0.001), F2-isoprostane ( P<0.01, P=0.01), IL-1β ( P=0.02, P=0.015), TNF-α ( P<0.01, P<0.01), MPO ( P<0.01, P<0.01) were all lower than those in the IRI group, except GSH-Px that was higher than what in the IRI group ( P<0.01). Conclusion:Pre-perfusion of the improved St. Thomas solution can stabilise the vital signs of dogs in a short period of time. The solution can improve the state of skeletal muscle cells, improve tissue hypoxia, and reduce the damage of skeletal muscle tissue cells through anti-inflammatory and anti-oxidative stress.

Objective To quantitatively judge the degree of tibial bone healing using the finite element wall thickness analysis method, so as to provide an intuitive diagnostic basis for clinical judgment of tibial union and delayed bone healing. Methods After three-dimensional (3D) modeling for the affected and healthy limb side of 48 patients, the maximum wall thickness (MWT) was calculated, and the ratio (B value) was used as a quantitative index of bone healing. When both BMWT2 and BMWT1 were greater than 0.9, bone healing could be judged. When BMWT2 was between 0.9 and 0.7, bone union was judged to be poor, and there was no significant increase in this value after regular reexamination. When BMWT3 was above 0.9 while both BMWT1 and BMWT2 were smaller than 0.7, it could be judged as internal fixation failure, which should be replaced during the second operation. The clinical diagnosis was revised twice, and the final clinical healing results were observed. Results Clinical diagnosis analysis and finite element wall thickness analysis were carried out in 48 patients during each review period, and 21 cases of delayed bone healing and 27 cases of bone nonunion were judged clinically. Among them, 2 cases were judged to be ineffective, and bone grafting intervention was adopted to replace the internal fixation, 12 cases were judged to be still effective, and all cases were finally healed by surgical intervention of bone grafting alone. By Bowker test, P=0.094 was obtained, indicating that the wall thickness analysis method was consistent with the clinical diagnosis. Conclusions The wall thickness analysis method can be used to quantitatively analyze the degree of bone healing at fracture end and realize the rapid calculation of bone healing degree. The case results in this study show that the finite element wall thickness analysis method is superior to the simple clinical diagnosis method, and has better differential diagnostic significance for early diagnosis of poor bone healing.