Objective:To evaluate the efficacy and safety of balloon-assisted enteroscopy (BAE) in the follow-up treatment of small intestinal polyps in patients with Peutz-Jeghers syndrome (PJS).Methods:From February 2005 to September 2019, the clinical data of patients with PJS who visited Air Force Medical Center many times and underwent BAE for small intestinal polyps surveillance and treatment were collected. The number of follow-up treatment times under BAE, operation-related complications and conservative theragy or surgical treatment were observed. Spearman rank correlation analysis was used to analyze the correlation between follow-up treatment times under BAE and the number and maximum diameter of small intestinal polyps.Results:A total of 165 PJS patients were enrolled, including 98 males and 67 females, and the mean age of first visit was (22.5±9.4) years. A total of 664 BAE operations were performed in the 165 PJS patients. The number of BAE operations and the number of follow-up treatments for each patient were 4.0±1.8 and 2.8±1.1, respectively. There were 26, 52, 35, 28, 12, 4, 2, 2, 2 and 2 patients who underwent 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 BAE operations, respectively. There were 165, 76, 30, 12, 4 and 4 patients who received 2, 3, 4, 5, 6 and 7 follow-up treatments, respectively. During the first to the fifth times of BAE follow-up treatment, the numbers of small bowel polyps resected under BAE of each patient were 7.0 (2.0, 11.0), 4.0 (2.0, 10.0), 3.0 (1.0, 8.5), 5.5 (1.8 , 10.3) and 3.0 (2.0, 6.8), respectively; and the maximum diameters of resected small intestinal polyps were 4.5 cm(3.0 cm, 6.0 cm), 3.0 cm(1.5 cm, 4.0 cm), 2.0 cm (1.5 cm, 3.0 cm), 3.0 cm(2.5 cm, 4.0 cm) and 2.5 cm(1.5 cm, 4.0) cm, respectively. The results of Spearman rank correlation analysis indicated that the number of follow-up treatment under BAE was negatively correlated with the number and maximum diameter of resected small intestinal polyps ( r s=-0.141, P=0.003; r s=-0.400, P<0.01). The total incidence of operation-related complications of small intestinal polyps resection under BAE was 3.2% (21/664), and 61.9%(13/21)of the complications were cured by conservative therapy. During the follow-up period, there were 26 cases of PJS complicated with intestinal intussusception, of which 20 cases (76.9%, 20/26) disappeared after BAE resection of small intestinal polyps. A total of 13 patients received surgery for intussusception (6 cases) or large polyps blocking the intestinal lumen (7cases). Conclusions:BAE is safe and effective in the follow-up treatment of small intestinal polyps in PJS. It can reduce the number and maximum diameter of small intestinal polyps, prevent and treat the complications related to small intestinal polyps, and effectively reduced surgical treatments.

Objective To compare the outcomes of giant hepatic hemangioma undergoing enucleation and hepatectomy and to summarize our experience of surgical management of liver hemangioma.Methods A retrospective study was conducted in patients undergoing giant hepatic hemangioma resection (lager than 10 cm in size) in General Hospital of PLA,during 2006 through 2014.Patients were divided into two groups according to the types of operation.Results Of 145 patients with giant liver hemangioma,81 underwent enucleation and 64 had hepatectomy.The differences of tumor size (12.0 cm vs.15.5 cm,u =3.68,P ＜0.01),time of operation (210 min vs.280 min,u =3.89,P ＜ 0.01) and the ratio of inflow control (81.5％ vs.56.3％,x2 =10.91,P ＜ 0.01) of enucleation and hepatectomy was significant.The difference of intraoperative blood loss (500 ml vs.800 ml,u =1.85,P =0.07) and the postoperative morbidity (8.6％ vs.7.8％,x2=0.03,P =0.86) was not statistically significant.There was no inhospital mortality in both groups.Conclusions Both of enucleation and hepatectomy are effective operative approaches for giant liver hemangioma,patients with liver hemangioma should be prudently chosen for surgery,and the operation type should be individualized with the guidance of precision liver surgery.

Humans ; Liver Cirrhosis ; diagnosis

Objective To explore the relationship between diameter of liver hemangioma and operation risk.Methods The clinical data of 362 patients with liver hemangioma who were admitted to the PLA General Hospital from January 2006 to January 2014 were retrospectively analyzed.All patients were divided into the 3 groups according to diameter of gross specimen,217 with tumor diameter≥5 cm and ≤ 10 cm in the large hemangioma group,119 with tumor diameter ＞ 10 cm and ≤20 cm in the giant hemangioma group and 26 with tumor diameter≥20 cm in the extremely large hemangioma group.The operation method included open surgery and laparoscopic surgery.Hepatectomy and enucleation of liver hemangioma were major operation procedures.The operation time,volume of intraoperative blood loss,number of patients with intraoperative blood transfusion,number of patients with postoperative complications and duration of hospital stay were evaluated.Count data were analyzed using the chi-square test.Measurement data with normal distribution were presented as (x) ± s,and comparison among groups was analyzed using the ANOVA.Skewed distribution data were described as M (P25,P75),comparison among groups was analyzed by Kruskal-wallis test and pairwise comparison was done by the MannWhitney U test.Results All patients underwent operation successfully without perioperative death,including 315 receiving open surgery (175 in the large hemangioma group,114 in the giant hemangioma group and 26 in the extremely large hemangioma group) and 47 receiving laparoscopic surgery (42 in the large hemangioma group and 5 in the giant hemangioma group).The operation time,volume of intraoperative blood loss,number of patients with blood transfusion,number of patients with postoperative complications and duration of hospital stay were 160 minutes (125 minutes,205 minutes),300 mL (100 mL,500 mL),31,5 and 8 days (7 days,9 days) in the large hemangioma group,220 minutes (175 minutes,275 minutes),500 mL (300 mL,1 000mL),36,5 and 9 days (8 days,10 days) in the giant hemangioma group,330 minutes (280 minutes,420 minutes),1 975 mL (800 mL,4 000mL),20,7 and 11 days (9 days,13 days) in the extremely large hemangioma group,respectively,with significant differences (x2 =84.24,80.94,53.65,31.54,47.67,P ＜ 0.05).The operation time,volume of intraoperative blood loss,number of patients with intraoperative blood transfusion and duration of hospital stay were compared,showing significant differences between large hemangioma group and giant hemangioma group (Z =6.39,6.51,x2 =11.29,Z =4.73,P ＜ 0.05),with significant differences between large hemangioma group and extremely large hemangioma group and between giant hemangioma group and extremely large hemangioma group (Z =7.28,6.91,x2=51.22,Z =5.57,P ＜ 0.05;Z =5.33,4.86,x2=17.69,Z =3.5 1,P ＜ 0.05).Seventeen patients had postoperative complications with an incidence of 4.70％ (17/362),intra-abdominal hemorrhage were detected in 7 patients,perihepatic effusion in 4 patients,pleural effusion in 3 patients,bile leakage in 2 patients and fat liquefaction of abdominal incision in 1 patient.There was no significant difference in the number of patients with postoperative complications between large hemangioma group and giant hemangioma group (x2 =0.41,P ＞ 0.05).There were significant differences in the number of patients with postoperative complications between large hemangioma group and extremely large hemangioma group and between giant hemangioma group and extremely large hemangioma group (x2 =24.96,11.67,P ＜ 0.05).Conclusions Diameber of liver hemangioma is associated with operation time,volume of intraoperative blood loss,number of patients with intraoperative blood transfusion,number of patients with postoperative complications and duration of hospital stay,and there is a high risk in the surgical treatment of patients with liver hemangioma diameter≥20 cm.

Objective To compare the physical examination results of nephroptosis in the second stage and the final stage, to find the underlying reasons, and to explore better ways to detect nephroptosis.Methods A total of 1334 subjects participated in both the second stage and final stage of PLA air force medical selection of flying cadets, and physical examination results of both stages were compared.Results All the subjects recruited denied a history of abdominal pain or recurrent urinary tract infection, and urine tests were normal.The positive rate of nephroptosis in the second stage was 10.2%, compared to 5.5% in the final stage.The difference of physical examination results in the two stages was significant, and so was that of disqualification rates.Conclusion Results of physical examination of nephroptosis in the second stage are different from those in the final stage.It′s necessary to find better ways of detection of nephroptosis.

Objective To investigate the effect of different medical standards for the urinary system on the enlistment of pilots between PLAAF and USAF , and offer support to amendment .Methods Data on pilots′final enlistment between 2012 and 2015 were analyzed , and results of physical examinations of the urinary system were compared according to differ -ent medical standards .Results One hundred and twenty teenagers enrolled in this examination were disqualifiied due to defects of the urinary system while 97 applicants were qualified after comprehensive assessment of the urinary system .The main problems with the urinary system that affected results of pilots′enlistment were nephroptosia , renal cyst , microscopic hematuria , renal calcified foci and calculus .Conclusion Medical standards for the urinary system are different between PLAAF and USAF, especially those for nephroptosia , renal cyst and microscopic hematuria .The medical standards directo-ry about the urinary system approved by USAF can serve as a reference during our revision of current medical enlistment standards.

Objective To compare the clinical utility of alpha-fetoprotein (AFP) and des-gammacarboxyprothrombin (DCP) in diagnosing hepatocellular carcinoma (HCC) in patients with a hepatic mass.Methods From January 2015 to May 2015,141 patients were diagnosed to have a liver tumor after imaging examinations in the Hepatobiliary Surgical General Hospital of PLA,Beijing,China.Preoperative AFP and DCP were measured using commercial assay kits.The reference standard was either pathologic or clinical diagnosis of HCC.The performance of AFP and DCP in diagnosing HCC was determined using receiver operating characteristic curve analysis.Results Of 141 patients,98 were diagnosed to have HCC and 43 without.The levels of AFP were significantly higher in patients with HCC than those without [80.0(3.9-1 375.0) μg/L vs.2.1 (1.6-3.2) μg/L,Z =6.98,P ＜ 0.01].Similar results were observed in the levels of DCP [141.5 (24.0-978.0) AU/L vs.19.0 (14.0-25.5) AU/L,Z =5.18,P ＜ 0.01].Receiver operating curves (ROC) indicated the cut-off value with the best sensitivity and specificity was 3.6 μg/L for AFP and 35 AU/L for DCP.The difference in the area under ROC between AFP and DCP was not statistically significant (0.87 vs.0.78,Z =1.72,P =0.085).The sensitivity and specificity for detection of HCC in patients with a hepatic mass were 56.1％ and 95.4％ for AFP ＞ or =20 μg/L,69.4％ and 83.7％ for DCP ＞ or =40 AU/L,respectively.The level of AFP was associated with DCP in patients with HCC (x2 =9.12,P ＜ 0.01,r =0.292) and parallel testing of AFP and DCP gave an optimal sensitivity of 79.6％ with a specificity of 81.4％ in diagnosing HCC.Conclusions DCP is a useful biomarker and it gave an equal performance as AFP in diagnosing HCC in patients with a liver mass in this study.Parallel testing of AFP and DCP effectively increased the diagnostic sensitivity.Although the biomarkers only marginally improved the diagnostic results,it could be useful in diagnosing HCC in individuals who had atypical imaging results.

Objective:To evaluate the value of blood urea nitrogen (BUN)/creatinine (Cr) ratio for guiding the access route of double balloon enteroscopy (DBE) for small intestinal bleeding.Methods:The clinical information was collected from 105 patients who underwent DBE for suspected small intestinal bleeding at Air Force Medical Center from January 2015 to October 2019. Patients were divided into the elevated BUN/Cr group ( n=52) and the normal BUN/Cr group ( n=53), with a cut-off value of 81. Comparison was made for the detection rate of lesions between the oral route and anal route separately in the two groups using Chi-square test. Results:Among the 105 patients with suspected small intestinal bleeding, definite causes of bleeding were identified in 79 patients by DBE, and the overall lesion detection rate was 75.24% (79/105). In the elevated BUN/Cr group, the overall lesion detection rate was 76.92% (40/52), among which 79.49% (31/39) was through oral and 47.37% (9/19) through anal enteroscopy. In the normal BUN/Cr group, the overall lesion detection rate was 73.58% (39/53), and 63.64% (21/33) was transoral and 51.43% (18/35) transanal. The lesion detection rate of transoral enteroscopy in the elevated group was significantly higher than that in the normal group ( χ2=6.576, P=0.010). There was no significant difference in the lesion detection rate of transanal enteroscopy between the two groups ( χ2=2.230, P=0.135). Conclusion:For patients with active small intestinal bleeding (active bleeding within 48 hours), the BUN/Cr ratio higher than 81 may indicate that DBE should be performed firstly via oral route.

Objective:To investigate the efficacy of double balloon enteroscopy (DBE) in the treatment of bleeding from small intestinal vascular lesion and risk factors of bleeding recurrence .Methods:From April 2013 to May 2020, at Air Force Medical Center, the clinical data of 65 patients with confirmed or suspected bleeding from small intestinal vascular lesion were retrospectively analyzed. The patients were divided into DBE treatment group (patients of Yano classification 1a and 1b received argon plasma coagulation, and patients of Yano classification 2 and 3 accepted combination of titanium clip and submucosal injection of lauromacrogol sclerosing agent) and non-DBE treatment group (traditional treatments such as stopping anticoagulant or antiplatelet drugs, blood transfusion, and iron supplementation). The bleeding recurrence of patients with single small intestinal vascular lesion between DBE treatment group and non-DBE treatment group, and patients with single or mulitiple vascular lesion of DBE treatment group were compared. Univariate analysis was used to analyze the clinical data of patients with or without recurrent bleeding. Multivariate logistic regression model was used to analyze the independent risk factors and protective factors of recurrent bleeding in small intestinal vascular lesion. Independent sample t test, chi-square test and Fisher exact probability method were used for statistical analysis. Results:Forty-four (25 of single vascular lesion and 19 of multiple vascular lesion) patients were diagnosed with small intestinal vascular lesions and received DBE treatment (DBE treatment group). Twenty-one patients with single vascular lesion accepted traditional treatment (non-DBE treatment group). The recurrent rate of bleeding in patients with single vascular lesion of DBE treatment group was lower than that in patients with single vascular lesion of non-DBE treatment group and patients with multiple vascular lesion of DBE treatment group (24.0%, 6/25 vs. 71.4%, 15/21 and 12/19), and the differences were statistically significant ( χ2=10.348 and 6.848, P=0.001 and 0.009). The results of univariate analysis showed that the proportion of blood transfusion, hypertension, complicated with valvular heart disease and DBE treatment in patients with rebleeding or not rebleeding from small intestinal vascular lesion was different with statistically significant (69.7%(23/33) vs. 37.5%(12/32), 51.5%(17/33) vs. 18.8%(6/32), 42.4%(14/33) vs. 12.5%(4/32) and 54.5%(18/33) vs. 81.2%(26/32), χ2=6.777, 7.628, 7.265, and 5.298, all P<0.05). The results of multivariate logistic regression analysis indicated that blood transfusion during the course of disease (odds ratien ( OR)=3.736, 95% confidence interval ( CI) 1.082 to 12.898, P=0.037) and complication with valvular heart disease ( OR=4.916, 95% CI 1.107 to 21.829, P=0.036) were independent risk factors of bleeding recurrence in patients with small intestinal vascular lesions. DBE treatment was the protective factor of bleeding recurrence in patients with small intestinal vascular lesion ( OR=0.214, 95% CI 0.057 to 0.808, P=0.023). Conclusions:DBE is effective in the treatment of small intestinal vascular lesion bleeding, especially for single vascular lesion. Blood transfusion during disease course and complication with valvular heart disease are independent risk factors for bleeding recurrence in patients with small intestinal vascular lesion.

Objective:To analyze the relationship between STK11 mutation and the cumulative risk of intussusception in patients with Peutz-Jeghers syndrome (PJS). Methods:From December 2017 to June 2019, the clinical data of 167 patients with PJS in Air Force Medical Center were collected, including gender, age, family history, age of first intussusception and results of gene test. Kaplan-Meier was used to analyze the cumulative risk of intussusception in patients with different mutation types. Wilcoxon rank sum test and log-rank test were used for statistical analysis.Results:Among 167 patients, 89.8% patients (150/167) had S TK11 mutation, and 50.7% of the mutation sites were found in exons 1, exon 4 and exon 5. And 70.6% patients (118/167) developed intussusception. The median age of patients with intussusception for the first time was 15 years (ranged from 2 to 52 years). Among 118 PJS patients with intussusception, 53 patients had family history and 65 patients had no family history; 70 cases were male and 48 cases were female. There were no statistically significant differences in the cumulative risk of intussusception between PJS patients with and without family history, and between male and female PJS patients (both P>0.05). There were 107 cases (90.7%) with STK11 mutation ( STK11 mutation group) and 11 cases (9.3%) without STK11 mutation ( STK11 non-mutation group). The median age of first intussusception of STK11 gene mutation group was younger than that of STK11 non-mutation group, and the difference was statistically significant ( Z=-2.108, P=0.035). In STK11 mutation group, 29 cases (27.1%) were nonsense mutations (nonsense mutation group), 23 cases (21.5%) were frameshift mutations (frameshift mutation group), 21 cases (19.6%) were missense mutations (missense mutation group), 26 cases (24.3%) were splicing mutations (splicing mutation group) and 8 cases (7.5%) of other mutations. There were statistically significant differences in the cumulative risk of intussusception between the STK11 mutation group and the STK11 non-mutation group, the STK11 splicing mutation group and the STK11 non-mutation group, STK11 missense mutation group and the STK11 non-mutation group ( χ2=5.570, 10.167 and 6.653, all P<0.05). There were no statistically significant differences in the cumulative risk of intussusception between STK11 nonsense mutation group and STK11 non-mutation group, between STK11 frame-shift mutation group and STK11 non-mutation group, among groups with different mutation types of STK11 gene (all P>0.05). Conclusions:The younger the age of first intussusception in PJS patients with STK11 mutation, the higher the cumulative risk. The mutation type of STK11 gene has potential value for the risk assessment of intussusception in PJS patients.