Objective To investigate the diagnosis/misdiagnosis reason/treatment of residual gallbladder stone with choledocholithiasis.Methods The clinical data of 34 patients with residual gallbladder,16 cases of them suffered from choledocholithiasis additionally were retrospective analyzed.Results 14 cases were treated by residual cholecystectomy +choledochotomy +T -tube drainage,2 cases were were treated by choledochotomy + T -tube drainage.Preoperative misdiagnosis of residual gallstones rate was 56.3% (9 /16 ),7 cases were found residual gallstones during operation.The other 2 cases were misdiagnosed residual gallstones.The rate of intraoperative and postoperative misdiagnosis was 12.5% (2 /16 ).18 cases with residual gallstones,16 cases underwent residual cholecystectomy,2 cases who were suspected with choledocholithiasis underwent residual cholecystectomy +choledo-chotomy,T -tube drainage.18 cases had no preoperative and postoperative misdiagnosis.Conclusion The clinical symptom of residual gallbladder stone with choledocholithiasis was similar to residual gallstones,often characterized by upper abdominal pain,fever,chills,jaundice,abdominal distension and other symptoms.It is difficult for preoperative imageological diagnosis that less than 3 cm residual gallbladder and small stones.When choledocholithiasis at the same time,needing more intraoperative careful dissect cystic duct and common bile duct,completes the cystic duct and common bile duct exploration,reducing misdiagnose residual gallstones.

Except common histologic type,some special histological types and clinico-pathological features of gastric cancer,such as neuroendocrine carcinoma,hepatoid adenocarcinoma,lymphoepithelioma-like gastric carcinoma and hereditary diffuse gastric cancer,etc,because of there special diagnosis and treatment measures and prognosis,should be taken into account in our clinical work.This article reviews the clinical progress of diagnosis,treatment and prognosis of the four special kinds of gastric cancer mentioned above.

Objective To investigate the application of improving prolene hernia system(PHS) tensionfree repair for inguinal hernia under ultrasound-guided local nerve block anesthesia.Methods Retrospective analysis the clinical data of 40 patients with improving prolene hernia system(PHS) tension-free repair for inguinal hernia under ultrasound-guided local nerve block anesthesia from January 2013 to January 2014 in Gulou Hospital of Nanjing University.Results In group of ultrasound-guided local nerve block anesthesia , the average anesthesia time was (8.9 ± 1.5) min, the time to get out of bed was (5.6 ± 1.1) h, the length of stay was (2.9 ± 0.7) d,There were (12.4 4± 2.2) min, (10.2 ± 1.6) h and (3.7 ±± 0.7) d in general anesthesia group, and significant difference(P ＜0.05), the average operation time of two groups were (22.6 ± 2.0) min, (22.1 ± 2.4) min,the average duration of postoperative analgesia was (6.4 ± 1.6) h, (6.1 4± 1.5) h, and no significant difference (P ＞ 0.05).Conclusions Improving prolene hernia system(PHS) tension-free repair for inguinal hernia under ultrasound-guided local nerve block anesthesia is simple , easy and safe to be performed with mild pain, faster recovery and less bleeding.It is worthy of popularization and application.

Objective:To introduce a 2-stage treatment protocol for the management of temporomandibular joint ankylosis with sec-ondary deformities in adults.Methods:24 adult patients (9 males and 15 female)(30 joints)at the average age of 26.1 years un-derwent TMJ reconstruction as the initial surgery,followed by orthodontic treatment and correction of secondary deformities as the sec-ond surgery.Clinical outcome was assessed based on maximal incisal opening,radiography and medical photography.Results:Skele-tal deformities were significantly improved in all patients,satisfactory occlusion was achieved with the orthodontic treatment,average maximal incisal opening increased from 3.4 mm to 32.5 mm(P <0.05).Conclusion:The 2-stage treatment protocol is an effective approach for management of TMJ ankylosis with secondary deformities in adult patients.

OBJECTIVETo study the clinicopathological features and prognosis of multifocal gastric cancer.

METHODSClinicopathological data of 30 cases with multifocal gastric cancer from January 2003 to March 2014 in our department were retrospectively analyzed. Random selection of 100 cases of single focal gastric cancer patients admitted in the same period was used as control group. Clinicopathological features and prognosis were compared between two groups.

RESULTSSix(20.0%) multifocal gastric cancer patients had 3 or more focuses with different differentiation degrees at the same time. The age of multifocal gastric cancer patients was younger than that of single focal gastric cancer [(56.8±16.4) year vs. (63.3±10.8) year, P<0.05]. The TNM stage of multifocal gastric cancer was mainly stage I((73.3%, 22/30), and the TNM stage of single focal gastric cancer was mainly stage III((64.0%, 64/100). As compared to single focal gastric cancer group, multifocal gastric cancer group had smaller tumors, lower ratio of nerve invasion and lymphatic vascular invasion(all P<0.01). Five-year survival rate was higher in multifocal gastric cancer group as compared to single focal gastric cancer group(76.0% vs. 48.8%, P<0.05). The prognosis of multifocal gastric cancer patients was associated with tumor size, nerve invasion, vascular invasion, depth of tumor invasion, lymphatic metastasis and TNM staging(all P<0.05), which was similar to single focal gastric cancer patients. Differences of 5-year survival rate under various clinicopathological conditions were not significant between two groups(all P>0.05).

CONCLUSIONMultifocal gastric cancer patients have earlier staging tumor and overall advantage as compared to those with single focal gastric cancer.

Objective To study the clinicopathological features and prognosis of multifocal gastric cancer. Methods Clinicopathological data of 30 cases with multifocal gastric cancer from January 2003 to March 2014 in our department were retrospectively analyzed. Random selection of 100 cases of single focal gastric cancer patients admitted in the same period was used as control group. Clinicopathological features and prognosis were compared between two groups. Results Six(20.0%) multifocal gastric cancer patients had 3 or more focuses with different differentiation degrees at the same time. The age of multifocal gastric cancer patients was younger than that of single focal gastric cancer [(56.8±16.4) year vs. (63.3±10.8) year, P<0.05]. The TNM stage of multifocal gastric cancer was mainly stageⅠ(73.3%, 22/30), and the TNM stage of single focal gastric cancer was mainly stage Ⅲ (64.0%, 64/100). As compared to single focal gastric cancer group, multifocal gastric cancer group had smaller tumors, lower ratio of nerve invasion and lymphatic vascular invasion (all P<0.01). Five-year survival rate was higher in multifocal gastric cancer group as compared to single focal gastric cancer group (76.0% vs. 48.8%, P<0.05). The prognosis of multifocal gastric cancer patients was associated with tumor size, nerve invasion, vascular invasion, depth of tumor invasion, lymphatic metastasis and TNM staging (all P<0.05), which was similar to single focal gastric cancer patients. Differences of 5-year survival rate under various clinicopathological conditions were not significant between two groups (all P>0.05). Conclusion Multifocal gastric cancer patients have earlier staging tumor and overall advantage as compared to those with single focal gastric cancer.

Objective To study the clinicopathological features and prognosis of multifocal gastric cancer. Methods Clinicopathological data of 30 cases with multifocal gastric cancer from January 2003 to March 2014 in our department were retrospectively analyzed. Random selection of 100 cases of single focal gastric cancer patients admitted in the same period was used as control group. Clinicopathological features and prognosis were compared between two groups. Results Six(20.0%) multifocal gastric cancer patients had 3 or more focuses with different differentiation degrees at the same time. The age of multifocal gastric cancer patients was younger than that of single focal gastric cancer [(56.8±16.4) year vs. (63.3±10.8) year, P<0.05]. The TNM stage of multifocal gastric cancer was mainly stageⅠ(73.3%, 22/30), and the TNM stage of single focal gastric cancer was mainly stage Ⅲ (64.0%, 64/100). As compared to single focal gastric cancer group, multifocal gastric cancer group had smaller tumors, lower ratio of nerve invasion and lymphatic vascular invasion (all P<0.01). Five-year survival rate was higher in multifocal gastric cancer group as compared to single focal gastric cancer group (76.0% vs. 48.8%, P<0.05). The prognosis of multifocal gastric cancer patients was associated with tumor size, nerve invasion, vascular invasion, depth of tumor invasion, lymphatic metastasis and TNM staging (all P<0.05), which was similar to single focal gastric cancer patients. Differences of 5-year survival rate under various clinicopathological conditions were not significant between two groups (all P>0.05). Conclusion Multifocal gastric cancer patients have earlier staging tumor and overall advantage as compared to those with single focal gastric cancer.

Objective To investigate the pathogenesis of paraquat (PQ) induced acute lung injury through Toll like receptor 3 (Toll-like receptor-3, TLR3), TLR induced nuclear transcription factors (Nuclear Factor-kappa B, NF-κB) and its downstream pro-inflammatory factors TNF-a, IL-1β, IL-6. Methods The acute lung injury model of mice and the acute injury model of type II alveolar epithelial cells (A549) induced by PQ were established. The PQ mediated pathological changes of lung tissue, the cell count and cytospin of bronchoalveolar lavage fluid (BALF) were evaluated, and the pro-inflammatory factors in the lung tissue of mice were determined by ELISA the viability of A549 cells mediated by PQ was detected by CCK8 assay, and the mRNA expression and protein level of TLR3, Phospho-NF-kBp65, tumor necrosis factor-alpha (TNF-a), interleukin-1 beta (IL-1β) and interleukin-6 (IL-6) in the lung tissues and A549 cells were observed by Real-time PCR and Western-blotting. In control group, the mice received normal saline (NS) instead of PQ. Results Compared with the control group, the mice in PQ group showed difficulty breathing, decreased activity, reduced food intake, and weight lost. The total number of BALF cells in the PQ group was significantly increased [NS: (0.018 8±0.102 1) × 105 vs. PQ: (0.237 4±0.121 7) ×105,t=9.804,P＜0.01] with macrophage [NS: (0.162 8±0.086 5) × 105 vs. PQ: (1.063 3± 0.343 3) × 105,t=8.043,P＜0.01],lymphocyte [NS: (0.006 6±0.005 2) × 105 vs. PQ: (0.171 2±0.099 1) × 105, t=5.243,P＜O.Ol] and neutrophils [NS: (0.000 04±0.000 1) × 105 vs. PQ: (0.901 9±0.652 5) × 105, t=4370, P＜0.01]. In PQ group, the appearance and volume of lung tissue increased with hyperemia and edema. HE slices showed inflammatory cell infiltration and pulmonary interstitial hemorrhage. Moreover, the expressions of TNF-a, IL-1β, IL-6 in BALF of PQ group was significantly higher than those of the control group by the ELISA assay [TNF-a: NS: (2.782 1 ± 3.521 5) vs. PQ: ( 7.512 6±3.459 8) pg/mL,t=3.030, P＜0.05; IL-1β: NS: (22.687 5±14.229 3) vs. PQ: (163.100 4±81.118 3) pg/mL,t=5.391,P＜0.01 ; IL-6: NS: (1.653 3±0.442 7) vs. PQ: (648.565 6 ± 422.606 1) pg/mL, t=4.841,P＜0.01]. CCK8 results indicated that the viability of A549 cells decreased by 25.3％ and 36.4％ at 24h after 200～400 μmol/L PQ treatment (all P＜0.05). The mRNA expressions of TNF-a, IL-1p, IL-6 in the lung tissue and A549 cells in PQ group were higher than those in the control group as well (all P＜ 0.05). Furthermore, Western-blotting results revealed that the protein levels of TLR3 and Phospho-NF-κBp65 in the lung and A549 cells mediated by PQ were significantly higher than those in the control group (all P＜ 0.05). Conclusions PQ may induce acute lung injury by up-regulation of the expressions of inflammatory factors TNF-a, IL-1β, IL-6 through the TLR3/NF-κB signaling pathway.

OBJECTIVETo investigate the safety and clinical significance of pelvic floor reconstruction in extralevator abdominoperineal excision(ELAPE) for advanced low rectal cancer.

METHODSThe clinical efficacy was retrospectively analyzed in 30 patients with low rectal cancer who underwent ELAPE from January 2013 to December 2016 in Nanjing Drum Tower Hospital, the affiliated Hospital of Nanjing University Medical School. There were 21 male patients and 9 female, with an average age of 61.7 years old. We used 13*15 cm Biodesign biologic meshes(Cook, China) for the reconstruction and the procedure involved soaking in saline solution for 5 minutes and fixation of the mesh to the cut edges of the levators by non-absorbable 2-0 sutures. A perineal drain was used and was removed when drainage was minimal. Potassium permanganate was used for hip bath after removing the stitches. The surgical procedure, postoperative complications, prognosis and follow-up of all these patients were documented.

RESULTSThe operations of all patients were completed successfully. ELAPE could remove more para cancer tissues in the distant rectum. There was no rectum perforation, and the circumferential resection margins of all specimens were proved to be negative. During the follow-up of 21 months, only 2 patients suffered incision infection and healed uneventfully after strengthening the dressing. No one developed perineal breakdown, bulge or intestinal obstruction, as well as local recurrence and pelvic floor hernia. There was also no complication related to mesh. The average hospitalization time was 10 days (9-15 days).

CONCLUSIONSThe ELAPE could render a low occurrence of intraoperative perforations and circumferential resection margins. Reconstruction of pelvic floor with biologic meshmight lower the complication incidences associated with the perineal region.

Objective:To comprehensively investigate the biomechanical properties of the temporomandibular joint (TMJ) disc and to perfect the mechanical testing system of the TMJ disc by conducting tests of compression, tension, cyclic compression, cyclic tension, creep and friction.Methods:Fifteen fresh goat heads (weighing 2.5-3.0 kg) were purchased from the market. They were all ordinary goats (9-12 months old, body weighing 18-21 kg) regardless of gender. Bilateral articular discs (a total of 30) were dissected within 30 minutes after execution. According to the national standard for mechanical testing of viscoelastic materials, fresh TMJ disc specimens of goat were prepared and tests were carried out in physiological conditions. The universal mechanical testing machine was utilized to test biomechanical properties of TMJ discs.Results:The compressive modulus of TMJ discs was (8.41±2.12) MPa and the tensile modulus was (9.54± 3.26) MPa. The mechanical characteristics would be irreversibly altered once the load exceeded the physiological range. In addition, it underwent apparent creep relaxation under continuous strain (0.5 MPa or 3.0 MPa) and the surface friction coefficient of the TMJ discs (0.015+0.011) was much lower than that of general viscoelastic materials.Conclusions:The TMJ disc was a bio-viscoelastic structure with excellent tensile and compressive properties and its surface was extremely smooth in wet conditions.