Objective To compare the effect of treating cricopharyngeal achalasia in stroke survivors using transnasal or transoral balloon dilatation.Methods Thirty stroke survivors with cricopharyngeal achalasia were randomly divided into a transnasal and a transoral balloon dilatation group (group N and group O),each of 15.Both groups were given routine swallowing rehabilitation training as well as the transnasal or transoral balloon dilatation.Their heart rate was monitored during the dilatation.Nasal bleeding,mucous membrane swelling and pain were also observed.Their swallowing function was evaluated using the Fujishima Ichiro swallowing efficacy score (FISE) and videofluoroscopy (VFSS) before and after the intervention.Results After the treatment,the average FISE and VFSS scores of both groups had improved significantly comnpared to before the treatment but there were no significant differences between the groups.During the treatment,the average heart rate of group O increased significantly less than that of group N.The treatment acceptance of group O was 98.2％,significantly higher than that of group N (80.1％).One case of mucosal bleeding was observed in group O,and laryngeal edema occurred significantly less often than in group N (9 cases vs.7).The average pain score was also significantly lower in group O.Conclusions Balloon dilatation facilitates swallowing among stroke survivors with cricopharyngeal achalasia.The transoral approach can help to reduce the occurrence of complications such as mucosal bleeding,laryngeal edema and pain,and has better patient acceptance.

Objective:To investigate the predictive effect of adjusted Utrecht staging criteria on efficacy of mammalian target of rapamycin (mTOR) inhibitors in patients with tuberous sclerosis-associated renal angiomyolipoma (TSC-AML).Methods:In this study, 39 adult patients with TSC-AML who attended the Peking Union Medical College Hospital from December, 2014 to December, 2020 were retrospectively analyzed, and were divided into 4 groups based on Utrecht staging criteria: Group 1, Utrecht staging ≤ stage 5, all AMLs <5 cm( n=6); Group 2, stage 6 with at least one AML ≥5 cm and normal renal anatomy( n=14); Group 3, stage 6 with at least one AML ≥5 cm and recognizable renal anatomy( n=10); Group 4, stage with at least one AML ≥5 cm and unrecognizable renal anatomy ( n=9). The mean age of patients in the 4 groups were 27.33±7.84, 28.64±12.36, 31.10±5.88 and 29.11±7.15 ( P=0.869). No statistic difference in gender was found among the different groups ( P=0.233). The mean maximum diameters of AML in the four groups were (3.54±0.52)cm, (8.11±2.08)cm, (11.58±4.60)cm and (17.08±3.61)cm, respectively( P<0.01). The mean levels of creatinine were (80.17±16.01)μmol/L, (76.36±18.72)μmol/L, (76.10±27.61)μmol/L and (71.89±18.66)μmol/L in the four groups( P=0.900). The numbers of patients with positive urine protein were 2, 3, 8 and 2 ( P=0.023). All the patients took Everolimus 10mg orally per day for at least 3 months. Differences in maximum AML shrinkage rate, creatinine level, severity of urine protein and microscopic hematuria were compared between the groups. Results:As AML severity increased, the shrinkage rates decreased significantly in turn [Group 1: (76.06±13.16)%, Group 2: (64.92±16.33)%, Group 3: (55.30±20.49)%, Group 4: (43.73±20.61)%, P=0.009]. After treatment, creatinine levels increased in all groups[Group 1: (8.50±7.61)μmol/L, Group 2: (5.71±8.54)μmol/L, Group 3: (7.70±7.18)μmol/L, Group 4: (6.11±7.04)μmol/L], but there was no significant difference among groups (P=0.856). Moreover the increase in urine protein worsened with the degree of severity (Group 1∶3, Group 2∶4, Group 3∶6, Group 4∶9, P=0.014). Conclusions:The adjusted Utrecht staging criteria could predict the maximum AML shrinkage rate and urine protein increase in TSC-AML patients with treatment of mTOR inhibitors.

Objective:To explore the feasibility of deep learning technology for renal artery recognition in retroperitoneal laparoscopic renal surgery videos.Methods:From January 2020 to July 2021, the video data of 87 cases of laparoscopic retroperitoneal nephrectomy, including radical nephrectomy, partial nephrectomy, and hemiurorectomy, were retrospectively analyzed. Two urological surgeons screened video clips containing renal arteries. After frame extraction, annotation, review, and proofreading, the labeled targets were divided into training set and test set by the random number table in a ratio of 4∶1. The training set was used to train the neural network model. The test set was used to test the ability of the neural network to identify the renal artery in scenes with different difficulties, which was uniformly transmitted to the YOLOv3 convolutional neural network model for training. According to the opinion of two senior doctors, the test set was divided into high, medium, and low discrimination of renal artery and surrounding tissue. High identification means a clean renal artery and a large exposed area. For middle recognition degree, the renal artery had a certain degree of blood immersion, and the exposed area was medium. Low identification means that the exposed area of the renal artery was small, often located at the edge of the lens, and the blood immersion was severe, which may lead to lens blurring. In the surgical video, the annotator annotated the renal artery truth box frame by frame. After normalization and preprocessing, all images were input into the neural network model for training. The neural network output the renal artery prediction box, and if the overlap ratio (IOU) with the true value box was higher than the set threshold, it was judged that the prediction was correct. The neural network test results of the test set were recorded, and the sensitivity and accuracy were calculated according to IOU.Results:In the training set, 1 149 targets of 13 videos had high recognition degree, 1 891 targets of 17 videos had medium recognition degree, and 349 targets of 18 videos had low recognition degree. In the test set, 267 targets in 9 videos had high recognition degree, 519 targets in 11 videos had medium recognition degree, and 349 targets in 18 videos had low recognition degree. When the IOU threshold was 0.1, the sensitivity and accuracy were 52.78% and 82.50%, respectively. When the IOU threshold was 0.5, the sensitivity and accuracy were 37.80% and 59.10%, respectively. When the IOU threshold was 0.1, the sensitivity and accuracy of high, medium and low recognition groups were 89.14% and 87.82%, 45.86% and 78.03%, 32.95%, and 76.67%, respectively. The frame rate of the YOLOv3 algorithm in real-time surgery video was ≥15 frames/second. The false detection rate and missed detection rate of neural network for renal artery identification in laparoscopic renal surgery video were 47.22% and 17.49%, respectively (IOU=0.1). The leading causes of false detection were similar tissue and reflective light. The main reasons for missed detection were image blurring, blood dipping, dark light, fascia interference, or instrument occlusion, etc.Conclusions:Deep learning-based renal artery recognition technology is feasible. It may assist the surgeon in quickly identifying and protecting the renal artery during the operation and improving the safety of surgery.

Objective:To investigate the effects of preoperative mammalian target of rapamycin(mTOR )inhibitor on partial nephrectomy for renal angiomyolipoma associated with tuberous sclerosis complex (TSC-RAML).Methods:A retrospective analysis was conducted on clinical data from 13 patients who were diagnosed with TSC-RAML and treated at Peking Union Medical College Hospital between August 2019 and July 2022. This cohort included 4 males and 9 females, with ages ranging from 22 to 66 years. All patients underwent partial nephrectomy, with 2 patients requiring two-stage surgeries due to bilateral RAMLs, resulting in a total of 15 surgeries being performed. Preoperative mTOR inhibitors, specifically everolimus (10 mg/d) or sirolimus (2 mg/d), were administered orally for at least 3 months prior to 7 of the surgeries. The effects of mTOR inhibitors on tumor size, tumor computed tomography attenuation value (CT value), and tumor CT enhancement were evaluated. The comparison of surgery-related clinical parameters was conducted between patients who received preoperative mTOR inhibitors and those who did not to assess the influences of mTOR inhibitors on surgery.Results:Compared to the baseline tumor, there was a significant reduction in tumor diameter after mTOR treatment [(6.4±3.1) cm vs. (8.7±3.9)cm], as well as in the CT value in both the unenhanced phase[(-18.63±48.73)HU vs. (-2.13±51.58)HU] and corticomedullary phase[(13.25±64.01)HU vs. (47.25±66.99)HU]. Additionally, tumor CT enhancement also decreased as compared with that before treatment [(31.88±18.20)HU vs. (49.38±20.63)HU]. Patients who received preoperative mTOR inhibitor showed a trend towards shorter operative time for removing per milliliter of tumor compared to those without preoperative mTOR inhibitor [1.06(0.18, 2.40) min/ml vs. 1.98(0.39, 5.03) min/ml] and so was the renal artery clamping time [0.17(0.03, 0.79) min/ml vs. 0.34(0.10, 1.71) min/ml]. Additionally, the amount of intraoperative bleeding for removing per milliliter of tumor was lower in patients with preoperative mTOR inhibitors compared to those without [0.72(0.19, 0.88) ml/ml vs. 1.69(0.59, 4.54) ml/ml].Conclusions:The administration of mTOR inhibitors before partial nephrectomy in patients with TSC-RAM have the potential to reduce tumor size and blood supply, as well as operative time, renal artery clamping time and intraoperative bleeding, which might contribute to surgery safety and preservation of renal function.