Objective:To investigate the treatment and prognosis of patients of G3 non-functional pancreatic neuroendocrine tumors (pNETs) with proliferation index of Ki-67 <55%.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 15 G3 non-functional pNETs patients with proliferation index of Ki-67<55% who were admitted to Zhongshan Hospital of Fudan University from April 2014 to April 2020 were collected. There were 11 males and 4 females, aged (58±10)years. All patients underwent radical resection of the primary lesion. Obser-vation indicators: (1) treatment; (2) postoperative pathological characteristics; (3) follow-up. Measure-ment data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers. The Pearson correlation analysis was used to verify the correlation between variables. Kaplan-Meier method was used to draw survival curve and calculate survival rate. Log-Rank test was used for survival analysis. Results:(1) Treatment. All 15 G3 nonfunctional pNETs patients underwent radical resection of the primary lesion of pancreas, including 5 cases receiving pancreati-coduodenectomy, 10 cases receiving distal pancreatectomy with splenectomy. There were 5 patients with simultaneous liver oligometastasis who underwent combined segmental (lobectomy) hepatectomy. All 15 patients had negative tumor margin, and the operation time and volume of intraoperative blood loss of 15 patients was 120(90,210)minutes and 200(50,300)mL, respectively. None of patient had complications ≥Ⅲ grade of the Clavien-Dindo classification during the postoperative 30 days. Of the 15 patients, there were 5 cases receiving comprehensive treatment based on CAPTEM chemo-therapy (temozolomide combined with capecitabine), 2 cases receiving local interventional therapy, 2 cases receiving CAPTEM chemotherapy, 1 case receiving local interventional therapy combined with molecular targeted therapy, 1 case receiving local interventional therapy combined with long acting somatostatin therapy, 1 cases receiving long acting somatostatin therapy combined with molecular targeted therapy, and 3 cases without postoperative treatment. (2) Postoperative patholo-gical characteristics. The tumor diameter of 15 patients was 3.3(range, 0.5-6.0)cm. There were 2 cases with tumor diameter <2 cm, 13 cases with tumor diameter ≥2 cm. The number of lymph nodes dissected and number of lymph nodes metastatic was 6(4, 10) and 2(1,3) in 15 patients, respectively, including 12 cases with positive lymph node metastasis. Of the 15 patients, there were 5 cases with tumor invasion of adjacent organ, 5 cases with simultaneous liver metastasis, 8 cases with perineural invasion and 8 cases with vascular invasion. There were 3, 7, and 5 patients with stage Ⅱ, stage Ⅲ, and stage Ⅳ of pathological TNM staging, respectively. The proliferation index of Ki-67 and mitotic count was 32%±9% and (11±9)/10 high power field in the primary lesion of 15 patients, respectively, and there was no correlation between proliferation index of Ki-67 and mitotic count ( P>0.05). (3) Follow-up. All 15 patients were followed up after surgery for (55±24)months. The median survival time of 15 patients was 78(range, 43-113)months, with 1-, 3-, 5-year overall survival rate as 100%, 92%, 62%, respectively. During the follow up, 9 of the 15 patients underwent tumor recurrence, with the recurrence time as 20(14, 44)months. There were 8 patients died of tumor recurrence or metastasis. The median survival time was 86(range, 51-120)months in 5 patients receiving comprehensive treatment based on CAPTEM chemotherapy, versus 53(range, 45-60)months in 10 patients receiving other postoperative adjuvant therapy or without postoperative treatment, showing a significant difference between them ( χ2=4.21, P<0.05). Conclusion:The prognosis of patients of G3 nonfunctional pNETs with proliferation index of Ki-67<55% undergoing radical resection combined with postoperative comprehensive treatment based on CAPTEM chemotherapy in better than that of patients receiving other postoperative adjuvant therapy or without posto-perative treatment.

Pancreaticoduodenectomy (PD) is a major operation of abdominal surgery, with high risk, complex operation, more complications and high mortality. Pancreatic fistula is the main cause of death after PD. Due to its complexity and obstinacy, pancreatic fistula has become the top challenge of pancreatic surgery. The authors review the relevant literature and summarize the prevention and management of pancreatic fistula after PD, such as the optimization strategies for pancreatic anastomosis, the use of external stents, prophylactic drains in surgical field, the applica-tion of somatostatin and its analogues, and whole-course nutrition management, based on the precise and comprehensive opinion, in order to provide reference for improving the prevention and treatment of pancreatic fistula after PD.

Pancreatic neuroendocrine neoplasms (pNENs) is one of the gastrointestinal malignancies of significantly heterogeneous, pathologically classified into well differentiated pancreatic neuro-endocrine tumors (pNETs) and poorly differentiated pancreatic neuroendocrine carcinomas. The prognosis and treatment response of pNETs are primely determined by tumor-intrinsic biolo-gical behavior. Accordingly, surgeons need to operate debulking surgery for low-risk patients, as well as implement adjuvant therapies for those at high-risk of relapse and metastasis after curative resection. Notably, as to two distinct subtypes of patients who suffer primary tumor with diameter less than 2 cm and functional pNETs, oncological benefits and functionally symptomatic control should be considered when formulating surgical strategies. In recent years, advances in next-generation sequencing and organoid technologies have provided practical tools for revealing the gene mutations and tumor microenvironment of pNETs. The four signalling pathways, including mTOR signalling, histone modification, altered telomere length and DNA damage repair pathways, are related to the occurrence and development of pNETs and can be used for the personalization precision therapy of pNETs and guiding the development of new drugs. Empirical therapy and clinical trial studies of pNETs are a continuum of contradictions. Therefore, clinicians need to summarize the rules in treatment and develop disciplines in the summary. Based on relevant literatures, the authors explore the hot issues related to pNENs in recent years, in order to provide reference for the diagnosis and treatment of this disease.

Objective:To investigate the clinical effect of the repair and reconstruction of severe foot trauma by microsurgical methods.Methods:Patients with severe foot trauma were admitted to Xinhua Hospital (Chongming), Affiliated with Shanghai Jiao Tong University School of Medicine, and Taizhou Hospital, Affiliated with Wenzhou Medical University in Zhejiang Province from November 2008 to October 2019. All patients were treated with orthotopic replantation using microsurgical anastomosis in emergency and precise microsurgical reconstruction in the second stage. A retrospective analysis of the clinical effect of the reconstructed appearance and function was performed. The evaluation and surgical design were carried out according to the characteristics of the injury site, range, plane, degree, etc., and adequate debridement and orthotopic replantation of residual tissue was performed under the microscope in emergency. Then regular follow-up was conducted to evaluate the postoperative efficacy, the degree of foot swelling, and the observation of foot activity and function.Results:A total of 23 patients with severe foot trauma were enrolled, including 15 males and 8 females, aged from 17 to 69 years old, with an average of 38.5 years old. Among them were the left foot in 10 cases and the right foot in 13 cases. 15 of the 23 patients survived orthotopic replantation. 2 cases of medial plantar skin necrosis were treated by skin graft in the second stage, 1 case of heel skin necrosis and 2 cases of anterior plantar skin necrosis with infection were repaired by flaps, and 3 cases of dorsal skin necrosis with infection combined with bone defect were repaired by flaps or osteocutaneous flap. After the operation, 23 patients were followed up for 6 to 48 months, with an average of 18.5 months. The wounds were completely healed, the color and elasticity were close to the surrounding normal skin, and there was no apparent swelling deformity on foot. The sensory function of the foot was all restored to grades S3-S4, with a small scar, and they walked freely without noticeable limping. The efficacy was evaluated according to a survival situation, color elasticity, appearance and morphology, donor scar, skin sensation, infection control, and patient recognition. 16 cases were satisfied with the outcomes, and 7 reported moderate. Skin swelling rating in the early stage was 1st degree in 3 cases, 2nd degree in 10 cases, 3rd degree in 8 cases, 4th degree in 2 cases; in the later stage was 1st degree in 15 cases, 2nd degree in 6 cases, 3rd degree in 2 cases. Foot function is assessed by the degree of postoperative pain, function of flexion and extension, degree of deformity, and walking ability, which is excellent in 3 cases, good in 13 cases, general in 7 cases, with a reasonable rate of about 69.6%(16/23).Conclusions:The microsurgical technique is one of the most effective methods to repair and reconstruct the function and appearance of the foot with severe trauma for now.

Objective:To investigate the clinical effect of the repair and reconstruction of severe foot trauma by microsurgical methods.Methods:Patients with severe foot trauma were admitted to Xinhua Hospital (Chongming), Affiliated with Shanghai Jiao Tong University School of Medicine, and Taizhou Hospital, Affiliated with Wenzhou Medical University in Zhejiang Province from November 2008 to October 2019. All patients were treated with orthotopic replantation using microsurgical anastomosis in emergency and precise microsurgical reconstruction in the second stage. A retrospective analysis of the clinical effect of the reconstructed appearance and function was performed. The evaluation and surgical design were carried out according to the characteristics of the injury site, range, plane, degree, etc., and adequate debridement and orthotopic replantation of residual tissue was performed under the microscope in emergency. Then regular follow-up was conducted to evaluate the postoperative efficacy, the degree of foot swelling, and the observation of foot activity and function.Results:A total of 23 patients with severe foot trauma were enrolled, including 15 males and 8 females, aged from 17 to 69 years old, with an average of 38.5 years old. Among them were the left foot in 10 cases and the right foot in 13 cases. 15 of the 23 patients survived orthotopic replantation. 2 cases of medial plantar skin necrosis were treated by skin graft in the second stage, 1 case of heel skin necrosis and 2 cases of anterior plantar skin necrosis with infection were repaired by flaps, and 3 cases of dorsal skin necrosis with infection combined with bone defect were repaired by flaps or osteocutaneous flap. After the operation, 23 patients were followed up for 6 to 48 months, with an average of 18.5 months. The wounds were completely healed, the color and elasticity were close to the surrounding normal skin, and there was no apparent swelling deformity on foot. The sensory function of the foot was all restored to grades S3-S4, with a small scar, and they walked freely without noticeable limping. The efficacy was evaluated according to a survival situation, color elasticity, appearance and morphology, donor scar, skin sensation, infection control, and patient recognition. 16 cases were satisfied with the outcomes, and 7 reported moderate. Skin swelling rating in the early stage was 1st degree in 3 cases, 2nd degree in 10 cases, 3rd degree in 8 cases, 4th degree in 2 cases; in the later stage was 1st degree in 15 cases, 2nd degree in 6 cases, 3rd degree in 2 cases. Foot function is assessed by the degree of postoperative pain, function of flexion and extension, degree of deformity, and walking ability, which is excellent in 3 cases, good in 13 cases, general in 7 cases, with a reasonable rate of about 69.6%(16/23).Conclusions:The microsurgical technique is one of the most effective methods to repair and reconstruct the function and appearance of the foot with severe trauma for now.

Objective:To investigate the surgical technique and the clinical effects of direct posterior approach (DPA) with the fixation of percutaneous tunnel screw and plate for acetabular posterior comminuted fractures.Methods:Thirty-six cases with acetabular posterior comminuted fractures treated by this technique from January 2016 to July 2020 were retrospectively analyzed in this study. There were 28 males and 8 female, aged 42.0±12.1 (range 19-64) years. According to Letournel-Judet classification, there were 28 cases of transverse associated with posterior wall fractures, 6 cases of posterior column with posterior wall fractures and 2 cases of T shape with posterior wall fractures. DPA was adopted in prone position. The anterior and posterior column fractures of the acetabulum were reduced under direct vision and then fixed with percutaneous tunnel screw. Further, the posterior wall fractures of the acetabulum were reduced and fixed with plate and screws. The operation duration, intraoperative blood loss, incision length, fracture union time, fracture reduction quality, postoperative complications and hip function were recorded.Results:The incision was 9.8±1.2 (range 8-12) cm. The operation duration was 102.9±21.4 (range 65-145) min. Intraoperative bleeding was 214.0±116.9 (range 100-640) ml. Postoperative X-ray and CT examinations showed perfect reduction. All the patients were followed up for 20.9±9.2 (range 10-38) months. The fracture healing time was 4.6±1.0 (range 3-6) months. There was no patient with damaged superior gluteal nerve and blood vessel. There were 2 cases of femoral head cystic changes without pain in walking, 1 case of postoperative infection and bacteremia who was cured at 1 month after debridement and anti-infection treatment, 1 case of sciatic nerve injury but recovered at 3 months after operation, and 1 case of heterotopic ossification at 3 months after surgery without affecting hip motion. According to the Matta's criteria, the reduction quality of the acetabular fracture was rated as excellent in 28 cases, good in 6 cases, fair in 2 cases. According to the modified Merle D'Aubigné and Postel scoring system, hip joint function was excellent in 24 cases, good in 10 cases and fair in 2 cases.Conclusion:DPA approach can directly reduce acetabular posterior comminuted fractures through a minimal incision. Combined with the technique of percutaneous tunnel screw, it displays great advantages of less trauma and with good clinical effects.

Objective:To explore the surgical technique and efficacy of pure retroperitoneoscopic extravesical standardized seeable (P.R.E.S.S.) technique for bladder cuff excision (BCE).Methods:Ninety five patients with UTUC from five domestic centers (30 cases from Changzheng Hospital, 21 cases from Peking University First Hospital, 20 cases from Yuhuangding Hospital, 21 cases from Dalian Medical University affiliated No.2 Hospital and 3 cases from General Hospital of Eastern Theater Command)between August 2017 and December 2020 were retrospectively analyzed. There were 57 males and 38 females with a mean age of (67.7±10.0) years and median tumor size of 3.0 cm. All patients underwent pure retroperitoneoscopic radical nephroureterectomy with a single surgical position and four (36 cases) or five (59 cases) trocar layout according to the surgeon’s prefer habit and experience. The demographics of the two groups were the age of [(66.3±11.2)years vs. (68.6±9.1)years], male/female ratio of (25/11 cases vs. 32/27 cases), body mass index of [(25.0± 3.0)kg/m 2 vs. (24.8±3.4)kg/m 2], tumor maximum diameter of [2.8(1.6, 3.5)cm vs. 3.0(2.0, 4.0)cm], left/right side tumor of(19/17 cases vs. 34/25 cases), T 1-2/T 3-4/Tis stage of(25/10/4 cases vs. 49/10/0 cases), and multifocal tumors of(3 cases vs. 2 cases), and the difference was not statistically significant( P>0.05). On the other hand, the differences of hydronephrosis of the operated kidney(13 cases vs. 39 cases, P=0.004), and tumor location (in renal pelvis or calyx or upper/middle/lower ureter being 23/9/4 cases vs. 35/4/20 cases, P=0.005), were statistically significant. The umbilical artery cord was used as anatomical landmark in the process of P. R.E.S.S. bladder cuff excision. The pelvic floor and extraperitoneal space around the ureter were expanded, the bladder wall was opened to form pneumovesicum, and a sufficient bladder cuff resection and exact bladder cuff closure was performed. Perioperative outcomes and follow-up data were analyzed, and the clinical outcomes between the four and five trocars were compared to evaluate the impact of trocar layout on the surgical outcomes. Results:There were 91(95.8%) cases successfully undergoing P. R.E.S.S. BCE technique, with one case converted to open BCE due to bleeding and three cases converted to distal ureter Hem-o-lok clipping because of poor exposure. Median operative time was 180(125, 230)min, and estimated blood loss was 100(50, 100)ml. The overall complication rate was 10.5%(10/95), including 2 cases(2.1%) of intraoperative bleeding, with 1 case treated by transfusion (400 ml), the other case converted to open surgery without transfusion. There were 8 cases of postoperative complications(8.4%), including 7 cases of Clavien-Dindo grade Ⅱ(3 cases of secondary hemorrhage, one case for each of drug allergy, acute renal insufficiency, blood creatinine increased to 490 μmol/L, or lung infection with lymphatic leakage), 1 case of grade Ⅲa(intestinal obstruction treated with insertion of the intestinal obstruction catheter under local anesthesia), and all these patients were discharged smoothly. The difference between the four and five trocars was not statistically significant in the following variables, including the rate of surgical conversion(8.3% vs. 1.7%), estimated intraoperative blood loss(100 ml vs. 60 ml), ratio of intraoperative lymph node dissection (25.0% vs.20.3%), P. R.E.S.S. bladder cuff excision success rate(91.7% vs.98.3%), the incidence of intraoperative and postoperative complications (13.8% vs.8.5%), pT 1-2/pT 3-4/pTis stage(22/11/3 cases vs.37/19/3 cases) and the proportion of recurrence or metastasis(8.3% vs.3.4%)(all P>0.05). However, the differences in the operation time(190 min vs.170 min, P=0.011)and postoperative hospital stay(5 d vs.6 d, P=0.005) were statistically significant. Conclusions:P. R.E.S.S. bladder cuff resection technique is safe and feasible during the procedure of pure retroperitoneoscopic radical nephroureterectomy by a single surgical position and facilitates seeable adequate bladder cuff excision by establishing an enlarged pelvic lateral extraperitoneal space and pneumovesicum. Five-trocar technique is more suitable for patients with lower ureteral tumors but may be associated with a longer postoperative hospital stay compared with the four-trocar technique.

Objective:To analyze the reflux parameters of patients with gastroesophageal reflux disease (GERD) in upright position, supine position and at 2 h after meals, and to explore the cut-off value, sensitivity and specificity of the reflux parameters in different positions and at 2 h after meals in GERD diagnosis.Methods:From January 2016 to July 2020, 200 GERD patients (GERD group) and 61 non-GERD patients (control group) who visited Huazhong University of Science and Technology Union Shenzhen Hospital (Former Nanshan District People′s Hospital), were selected. All the patients of the two groups received gastroesophageal reflux disease questionnaire (GERDQ), upper gastrointestinal endoscopy, esophageal high resolution manometry and 24 h esophageal pH combined impedance monitoring. T test, non-parametric test and chi-square test were used to compare the related parameters in upright position, supine position and at 2 h after meals between two groups and within each group. Receiver oparative characteristic (ROC) curves of reflux parameters in upright position, supine position and 2 h after meals were drawn to determine the cut-off value, sensitivity and specificity in GERD diagnosis. Results:The proportion of patients with acid reflux in supine position of the control group was higher than that of the GERD group (41.0%, 25/61 vs. 8.50%, 17/200), and the difference was statistically significant ( χ2=36.53, P<0.01). In the control group, the acid reflux time in upright position, number of acid reflux, acid exposure time (AET), longest reflux time and number of weak acid reflux were more than those of in supine position in the same group (6.00 min(2.00 min, 13.50 min) vs. 0.00 min(0.00 min, 1.50 min), 16.00(8.00, 27.00) vs. 1.00(0.00, 3.00), 0.90%(0.33%, 1.88%) vs. 0.00%(0.00%, 0.30%), 2.00 min(1.00 min, 4.00 min) vs. 0.00 min(0.00 min, 1.00 min), 7.00(3.00, 11.00) vs. 1.00(0.00, 2.00), respectively) and the differences were statistically significant ( Z=5.43, 6.61, 5.06, 3.58 and 6.24, all P<0.01). In the GERD group, the acid reflux time, number of acid reflux, AET, longest reflux time and number of weak acid reflux in upright position were higher than those in supine position (51.00 min, (31.00 min, 86.75 min) vs. 8.00 min(1.00 min, 42.00 min), 60.00(48.00, 83.75) vs.6.00(2.00, 19.50), 7.30%(3.90%, 12.10%) vs. 1.50%(0.20%, 6.50%), 7.00 min(4.00, 12.00 min) vs. 4.00 min(1.00 min, 17.00 min), 1.00(0.00, 3.00) vs. 0.00(0.00, 2.00), 7.00(3.00, 12.00) vs. 0.00(0.00, 1.00), respectively) and the differences were statistically significant ( Z=7.92, 11.22, 6.90, 2.56, 5.11 and 11.76, all P<0.05). The acid reflux time, number of acid reflux, AET, longest reflux time and number of weak acid reflux at 2 h postprandial were 3.00 min(2.00 min, 9.00 min), 10.00(5.00, 18.00), 0.90%(0.40%, 1.98%), 1.00 min(0.00 min, 3.00 min), 4.00(1.50, 8.50)and 28.50 min(15.00 min, 54.75 min), 35.00(24.00, 52.00), 8.30%(4.32%, 15.83%), 6.00 min(3.00 min, 11.00 min), 4.00(2.00, 7.25), in the control and GERD groups, respectively, which were significantly higher than those in supine position in the same group ( Z=4.30, 6.33, 5.50, 3.40, 5.71 and 3.76, 9.21, 5.76, 1.97, 10.46, all P<0.05). Among 200 GERD patients, 125 patients had symptoms recorded during the 24 h esophageal pH combined impedance monitoring, the incidence of reflux symptoms in upright position was higher than that in supine position (89.6%, 112/125 vs. 65.6%, 82/125), and the difference was statistically significant ( χ2=20.71, P<0.01). The results of ROC curve analysis showed that the accuracy of acid reflux time in upright position in GERD prediction was the highest, with AUC value of 0.94 and cut-off value of 24.5 min, and the sensitivity and specificity in GERD diagnosis were 81.50% and 95.08%, respectively. The prediction accuracy of acid reflux times in upright position and AET in upright position for GERD was secondary, AUC value both were 0.93 and the cut-off value of the acid reflux number in upright position was 39.5, and the sensitivity and specificity in GERD diagnosis were 84.00% and 95.08%, respectively. The cut-off value of AET in upright position was 2.75%, the sensitivity and specificity in GERD diagnosis were 85.00% and 93.33%, respectively. The AUC value, cut-off value, sensitivity and specificity of AET at 2 h postprandial were 0.91, 4.60%, and 73.49% and 95.00%, respectively. Conclusions:Both GERD patients and non-GERD patients have more reflux in upright position, especially within 2 h after meals. The diagnostic values of acid reflux time in upright position, number of acid reflux, AET and AET 2 h after meals for GERD is high, and the AUC values are all >0.90, which can be used as a more comprehensive basis for the analysis and diagnosis of GERD.

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in the world, and the new cases of HCC in China account for more than half of the global cases every year. High incidence mortality and limited treatment methods are the main challen-ges for HCC prevention and treatment in China. Immunotherapy has brought new treatment options and hope of prolonging the survival to patients with advanced HCC. Data from the IMbrave 150 study published in the New England Journal of Medicine in May 2020 showed that the median overall survival of all patients was 19.2 months, and the median overall survival of the Chinese subgroup was 24.0 months, which suggested significant efficacy in prolongating patient survival and controlling tumor. Interven-tional therapy has been playing an important role in the treatment of HCC, and more and more clinical studies have adopted systematic therapy combined with interventional therapy. Interven-tional therapy and systematic therapy have synergistic efficacy which lead to significant clinical efficacy. The authors introduce the diagnosis and treatment of an advanced HCC patient undergoing interventional therapy combined with bevacizumab plus attilizumab treatment, which lead to signifi-cant clinical efficacy of tumor controlling.

Objective To investigate the extraction methods for active components from oral ulcer film and optimize the determination methods of active components dexamethasone sodium phosphate and metronazole. Methods Different extraction solvents(methanol, water and 70% methanol aqueous) were applied to extract the active components dexamethasone sodium phosphate and metronazole from oral ulcer film, which contents were quantified by a HPLC method. Results the extraction solvent water had the best efficacy and more simpler compared to the other two solvents. Clotriazole showed a good linear relationship within 5.014 5-200.5800 μg/ml (r=0.999 8), and the average extraction recovery was (104.23±0.63)%, and for dexamethasone sodium phosphate, a good linear relationship was obtained in the range of 0.482-16.328 μg/ml (r=0.9999), and the average extraction recovery was (103.97±1.02)%. Conclusion The water extraction method established in this study was simple and efficient, which showed features of simplicity, accuracy and repeatable.