Objective To explore the value of lipoprotein-associated phospholipase A2(Lp-PLA2)in the diagnostic grading and prog-nostic assessment of pneumonia-associated acute respiratory distress syndrome(p-ARDS).Methods The study was a prospective ob-servational study.Fifty-seven patients with p-ARDS admitted to the ICU ward of Tianjin Hospital from January 2022 to August 2023 were included as the research subjects.Twenty-six pneumonia patients admitted to the general respiratory ward during the same period and 10 healthy individuals undergoing medical examinations were selected as the control group.Their serum samples were collected,and the samples from p-ARDS and pneumonia patients were obtained within 24 hours of admission.The levels of serum Lp-PLA2,in-terleukin 6(IL-6),and IL-8 were detected using the Luminex? multiplex test kit.The baseline data and laboratory test results,inclu-ding routine blood parameters,biochemical markers,C-reactive protein(CRP),procalcitonin(PCT),and D-dimer at admission,were collected from the patients with p-ARDS or pneumonia.The levels of serum Lp-PLA2 were compared by grouping based on clinical diagnosis,severity of ARDS,and clinical outcomes on day 28 after admission.The diagnostic and prognostic value of serum Lp-PLA2 in p-ARDS was evaluated by plotting the receiver operating characteristic(ROC)curve,Spearman correlation analysis,and Logistic regression analysis.Results The levels of serum Lp-PLA2 in the p-ARDS group([233.67±83.49]ng/mL)were significantly higher than that in the pneumonia group([150.86±39.48]ng/mL,P＜0.05),while those in the pneumonia group were significantly higher than that in the healthy control group([150.86±39.48]ng/mL vs[92.07±12.89]ng/mL,P＜0.05).The analysis results of the ROC curve showed that serum Lp-PLA2 had a better ability to distinguish p-ARDS from pneumonia than indicators such as IL-6,IL-8,CRP,and PCT,with an area under the ROC curve(AUCROC)of 0.781(95％CI:0.685-0.878).The diagnostic value of serum Lp-PLA2 combined with D-dimer was higher,with an AUCROC of 0.897(95％CI:0.832-0.963).Subgroup analysis found that as lung inju-ry worsened,the levels of serum Lp-PLA2 increased,and that serum Lp-PLA2 levels were negatively correlated with the PaO2/FiO2 ra-tio in p-ARDS patients(r=-0.549)and positively correlated with the sequential organ failure assessment(SOFA)scores at admission(r=0.412).The levels of serum Lp-PLA2 in the death group of p-ARDS were significantly higher than that in the survival group([314.5±43.1]ng/mL vs[174.9±48.9]ng/mL,P＜0.001).Logistic regression analysis showed that after adjusting for the SOFA score,serum Lp-PLA2 was independently associated with the mortality risk on day 28 after admission(OR=1.099,95％CI:1.026-1.178,P=0.007).Similar results were obtained after adjusting for IL-8 or the PaO2/FiO2 ratio.Conclusion Serum Lp-PLA2 may be used as a biomarker to aid in the diagnostic grading and prognostic assessment of p-ARDS.

Objective:To explore the clinical efficacy and safety of different surgical procedures of Mayo level Ⅳ inferior vena cava tumor thrombus(IVC-TT).Methods:The clinical and pathological data of 36 patients with Mayo level Ⅳ tumor thrombus were collected in three large clinical centers in China, including 18 cases in PLA General Hospital, 7 cases in Nanfang Hospital, and 11 cases in Renji Hospital. There were 25 males and 11 females.The median age was 56.5 years (53-67 years old). The average body mass index was 24.18±2.55 kg/m 2. The average diameter of renal tumors was 8.24±3.25 cm. The average length of inferior vena cava tumor thrombus was 12.89±2.50 cm. Mayo level Ⅳ tumor thrombus were divided into level Ⅳa and level Ⅳb (301 classification) based on the criterion of whether the proximal end of the thrombus has invaded the right atrium. Among them, level Ⅳa patients underwent robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass(CPB-free group, 6 cases). Level Ⅳb patients underwent robot-assisted inferior vena cava thrombectomy with cardiopulmonary bypass(CPB group, 12 cases) or cardiopulmonary bypass with deep hypothermic circulatory arrest assisted inferior vena cava thrombectomy(CPB/DHCA group, 18 cases). The baseline data of the three groups of patients were comparable. The perioperative results and long-term survival data after surgery were compared with different surgical methods for grade Ⅳcancer thrombosis. Results:All operations were successfully completed. Compared with the CPB group, the CPB-free group had a shorter first portal blocking time[17.5(15-36)min vs. 36.5(12-102)min, P=0.044], less intraoperative bleeding [2 350(1 000-3 000)ml vs. 3 500 (1 500-12 000)ml, P=0.043] and a lower allogeneic blood transfusion [1 250(500-2 000)ml vs. 2 185(700-5 800)ml, P=0.049]. Compared with the CPB/DHCA group, the CPB-free group had an advantage in reducing intraoperative allogeneic blood transfusion [1 250(500-2 000)ml vs. 2 700(1 200-10 000)ml, P=0.003]. There were no significant differences between groups in terms of duration of surgery and postoperative hospital stay. Among the 36 patients in this group, 23(64%) developed major complications (level Ⅲ or above), including 9 (25%) grade Ⅲ, 12 (33%) grade Ⅳ, and 2 (6%) grade Ⅴ. The CPB-free group had a relatively low complication rate of grade Ⅳ or above [ 17% (1/6) vs.42% (5/12) vs.44% (8/18)]. There were no statistical differences in median progression-free survival (16.4 vs.12.3 vs.18.0 months, P=0.695) and overall survival (30.1 vs.30.2 vs.37.7 months, P=0.674) between the groups. Conclusions:Robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass has the advantages of short ischemia time of organs, less intraoperative bleeding, and low incidence of major complications, which can be used as a safe and feasible surgical strategy for selected level Ⅳ tumor thrombus.

Objective:To clarify the anatomical characteristics and adjacent relationship of the superior segment of the inferior vena cava during laparoscopic surgery.Methods:In December 2018, two frozen and two fresh adult cadavers were dissected. The chest of the frozen cadavers was opened along the bilateral midline of the clavicle, the anterior pericardial wall was opened, and the superior vena cava and the inferior vena cava was dissected. The abdominal cavity was opened along the midline of the abdomen, the left and right hepatic lobes were turned over, the inferior vena cava and the second hilum of the posterior segment of the liver were exposed, and the hiatus of the inferior vena cava was opened and entered the pericardium.The anatomical characteristics and adjacent relationship of the superior segment of the inferior vena cava were observed, and the length of the superior segment of the inferior vena cava was measured. The fresh frozen cadaver patients underwent laparoscopic surgery.Five 12 mm trocars were placed at the side of umbilicus, right rectus abdominis about 4 cm from umbilicus, midline of abdomen about 6 cm above umbilicus, right axillary front about 2 cm below inferior edge of liver, left midline of clavicle about 2 cm below inferior edge of liver. Laparoscopic-assisted turning of the left and right hepatic lobes, exposing the posterior inferior vena cava and the second hilum of the liver, opening of the vena cava hiatus into the pericardium.The anatomical characteristics and adjacent relationship of the upper diaphragmatic segment of the inferior vena cava were observed.Results:In two autopsies, the inferior vena cava entered the chest through the cava sulcus of the liver and the phrenic foramen cava, and then through the fibrous pericardium into the right atrium. The length from the diaphragm of inferior vena cava to the right atrium was 1.67 cm, 2.57 cm. In laparoscopic operation, the diaphragm entrance of the posterior segment of the liver inferior vena cava, the second hepatic portal and the inferior vena cava could be well exposed.The diaphragm could be opened along the hole of the vena cava with a relatively non vascular anatomical layer of adipose tissue.There was a large anatomical gap between the pericardium and the right atrium, and the inferior vena cava, the superior vena cava and the right atrium could be well exposed, and the whole diaphragm could be completely and continuously exposed from the bottom to the inferior vena cava at the entrance segment of the right atrium.Conclusions:There was a relatively avascular anatomical layer beside the inferior vena cava. During laparoscopic operation, opening the diaphragm through the abdominal cavity could safely enter the pericardium and expose the inferior vena cava, the superior vena cava and the right atrium, which provides a possibility for the removal of Mayo Ⅳ grade inferior vena cava tumor thrombus through this approach.

Objective:To evaluate the efficacy of holographic image technology in robot-assisted laparoscopic radical prostatectomy (RARP).Methods:The clinical data of 34 patients with prostate cancer who underwent RARP in our hospital during October 2020 and December 2020 was analyzed retrospectively. The average age of the patients was 67.8 (52-78) years. The mean BMI was 25.8 (18.0-32.3) kg/m 2. The median level of PSA before surgery was 13.4 (2-149) ng/ml. Median prostate volume was 31.7 (9.5-159.1) ml. EAU risk groups for biochemical recurrence of localised and locally advanced prostate cancer were list as below: 5 cases of low-risk, 7 cases of medium-risk, 22 cases of high-risk. There were 9, 16, 9 cases with the ASA score of 1, 2, 3 point, respectively. Preoperative Gleason score of 34 patients were list as below: 9 cases in score ≤6 group, 15 cases in score=7 group, 10 cases in score ≥8 group. For clinical stage before the surgery, 13 cases ≤T 2a stage, 1 case in T 2b stage, 20 cases ≥T 2c stage. The engineers established holographic images of 34 patients based on multiparametric magnetic resonance imaging (mpMRI) and the reports before the operation. Surgeons can obtain the size and location of tumors, surrounding neurovascular bundles visually by revolving, assembling, disassembling and concealing images, which was helpful for pre-surgery planning. By manipulating the holographic images extracorporeally, surgeons can discriminate Internal sphincter of urinary bladder and vesicoprostatic muscle, neurovascular bundles, membranous part, seminal vesicle easily, which improves the operation accuracy. Results:All 34 cases underwent operation successfully without transferring to open surgery. The median operative time was 157.5 (95-276) min with an estimated blood loss of 50 (20-300) ml. The median drainage removal time was 2 d and median hospitalization time was 3.5 d, respectively. The catheters were removed within an average time of 20.5 d. For postoperative Gleason score, there were 2 cases in score ≤6 group, 16 cases in score =7 group, 8 cases in score ≥8 group and 8 cases can’t make a score. For clinical stage after the surgery, 10 cases were ≤T 2a stage, 1 case was T 2b stage, 23 cases were ≥cT 2c stage. 22 cases underwent pelvic lymph node dissection, including a patient with right iliac fossa lymph node metastasis. There were 2 cases with positive surgical margin and 3 cases with Clavien-DindoⅠcomplications. The rate of 1-month and 3-month urinary continence were 47.1% and79.4%, respectively, 8 cases recovered erectile function after 3 month. Conclusions:Holographic image technology can promote cancer dissection completely, achieve urinary continence early and reduce perioperative complications tremendously. The technology is the "intraoperative security" for the accurate surgical treatment of prostate cancer.

Objective:To explore the feasibility and safty of robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy in treatment of Ⅳa grade tumor thrombus without cardiopulmonary bypass and thoracotomy.Methods:The clinical data of 4 patients with renal cell carcinoma and Ⅳa grade tumor thrombus by robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy from January 2013 to June 2019 were retrospectively analyzed. The median age was 53.5 (53-70) years. The average body mass index was 23.25 (20.7-26.3) kg/m 2. The tumors were located on the right side in 2 cases. The average maximum diameter of the tumor was 8.1 (3.6-11.2) cm.Preoperative tumor thrombus of all patients was classified as Ⅳa. The average preoperative length of tumor thrombus in vena cava was 12.3 (11.8-18.0) cm. All the operations were performed under multidisciplinary cooperation of urology, hepatobiliary, cardiovascular, ultrasound and anesthesiologist team. Surgical procedure: Robot assisted liver mobilization was used to expose the inferior vena cava. Under the guidance of intraoperative ultrasound, the central tendon and pericardium of diaphragm were dissected until the inferior vena cava and right atrium in the superior pericardium were exposed. The first porta hepatis and inferior vena cava were blocked in turn.The vena cava thrombectomy and inferior vena cava reconstruction were performed. Results:All the operations were completed without conversion. The median operation time was 553.5 (338-642) minutes, and the median time of the first porta hepatis occlusion was 18.1 (14-32)minutes. The median blood loss was 1 900(1 000-2 600)ml. All patients were transferred to ICU after operation. The median length of stay in ICU was 7(4-8) days, and the median time of indwelling drainage tube was 8(4-12) days. The average postoperative hospital stay was 13(11-20) days. There were 1 case of grade Ⅱ and 3 cases of grade Ⅲ complications (Clavien classification). One case had paroxysmal supraventricular tachycardia, one case had lymphatic fistula, one case had pleural effusion with atelectasis, and one case had hepatic and renal insufficiency and lymphatic fistula. The complications were improved after treatment. There was no perioperative death.Conclusions:Robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy is an alternative method for the treatment of Ⅳa grade inferior vena cava tumor thrombus. Using this method, Ⅳa grade tumor thrombus can be treated without cardiopulmonary bypass and thoracotomy, with controllable complications and zero perioperative mortality.

Objective To evaluate the role of 2B-containing NMDA receptors(NR2B)in sevoflu-rane anesthesia-induced cognitive dysfunction in aged rats.Methods Thirty-two healthy male Sprague-Dawley rats,aged 18 months,weighing 570-630 g,were divided into 4 groups(n＝8 each)using a ran-dom number table method: control group(group C),sevoflurane anesthesia group(group S),sevoflurane anesthesia plus NR2B specific inhibitor Ro 25-6981 group(group S+RO)and Ro 25-6981 group(group RO).S and S+RO groups inhaled 3％sevoflurane for 4 h.Ro 25-6981 1 mg/kg was intraperitoneally injec-ted at 15 min before inhaling sevoflurane in group S+RO.Morris water maze test was performed at 2 days af-ter the end of anesthesia to assess cognitive function.The rats were then sacrificed,and hippocampal tis-sues were obtained for determination of the expression and phosphorylation of ERK1/2 by Western blot.Results Compared with group C,the escape latency was significantly prolonged,the frequency of crossing the original platform was reduced,the time of staying at the original platform quadrant was shortened,and the phosphorylation of ERK1/2 was decreased in group S(P＜0.05),and no significant change was found in the escape latency in S+RO and RO groups(P>0.05).Compared with group S,the escape latency was significantly shortened,the frequency of crossing the original platform was increased,the time of staying at the original platform quadrant was prolonged,and the phosphorylation of ERK1/2 was increased in group S+RO(P＜0.05).There was no significant difference in ERK1/2 expression among the four groups(P>0.05).Conclusion The mechanism by which sevoflurane anesthesia induces cognitive dysfunction is re-lated to up-regulating the expression of NR2B and inhibiting the activity of ERK1/2 in aged rats.

Objective To explore the feasibility of robot-assisted laparoscopic inferior vena cava (IVC) thrombectomy in treating renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava thrombus.Methods From November 2014 to January 2017,5 cases of renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava tumor thrombus were treated with robot-assisted surgery.There were 4 males and 1 female with the median age of 59 years (range 54-71 years).Four cases had the renal tumor on the right side and one on the left side.The mean tumor size was 6.8 cm (range 5-9 cm) with 3 cases of T3b and 2 cases of T3c.There were 4 cases of level Ⅲ and 1 case of level Ⅳ inferior vena cava thrombus with the median length of 9 cm (range 7-11 cm).The surgical procedure for Mayo level Ⅲ inferior vena cava thrombus included mobilization of both left and right robes of liver,subsequently controlling the suprahepatic infradiaphramatic IVC and first porta hepatis simultaneously.The surgical procedure for Mayo level Ⅳ inferior vena cava thrombus included cardiopulmonary bypass by multi-disciplinary cooperation among urologists,hepatobiliary and cardiovascular surgeons.The procedures included live mobilization,control of the superior vena cava and first porta hepatis and remove thrombus in the atrium and IVC respectively.Results All operations were completed successfully.The median operative time was 440 min (320-630 min).The blood recovery device was used and the intraoperative estimated blood loss was 2 500 ml (500-6 000 ml) and all cases required intraoperative blood transfusion.The median time of intraoperative occlusion of IVC was 35 min (25-50 min).All patients were transferred to the intensive care unit for median of 4 days (2-8 days) after surgery.The median time to remove the postoperative drainage tube was 9 days (7-12 days).Postoperative pathological diagnosis revealed 5 cases of clear cell carcinoma.Postoperative renal dysfunction occurred in 3 patients and liver dysfunction occurred in 2 patients who improved after medical therapy.During median 19.6 months (12-48 months) of follow-up,1 patient died and 1 patient progressed.Conclusions Despite the high risk of surgery,robot-assisted laparoscopic IVC thrombectomy for renal tumor with Mayo level Ⅲ-Ⅳ thrombus is feasible for experienced surgeons in selected patients.However,the oncological outcomes need further investigation.

Objective: To evaluate the role of 2B-containing NMDA receptors (NR2B) in sevoflurane anesthesia-induced cognitive dysfunction in aged rats. Methods: Thirty-two healthy male Sprague-Dawley rats, aged 18 months, weighing 570-630 g, were divided into 4 groups (n=8 each) using a random number table method: control group (group C), sevoflurane anesthesia group (group S), sevoflurane anesthesia plus NR2B specific inhibitor Ro 25-6981 group (group S+ RO) and Ro 25-6981 group (group RO). S and S+ RO groups inhaled 3% sevoflurane for 4 h. Ro 25-6981 1 mg/kg was intraperitoneally injected at 15 min before inhaling sevoflurane in group S+ RO.Morris water maze test was performed at 2 days after the end of anesthesia to assess cognitive function.The rats were then sacrificed, and hippocampal tissues were obtained for determination of the expression and phosphorylation of ERK1/2 by Western blot. Results: Compared with group C, the escape latency was significantly prolonged, the frequency of crossing the original platform was reduced, the time of staying at the original platform quadrant was shortened, and the phosphorylation of ERK1/2 was decreased in group S (P<0.05), and no significant change was found in the escape latency in S+ RO and RO groups (P>0.05). Compared with group S, the escape latency was significantly shortened, the frequency of crossing the original platform was increased, the time of staying at the original platform quadrant was prolonged, and the phosphorylation of ERK1/2 was increased in group S+ RO(P<0.05). There was no significant difference in ERK1/2 expression among the four groups (P>0.05). Conclusion The mechanism by which sevoflurane anesthesia induces cognitive dysfunction is related to up-regulating the expression of NR2B and inhibiting the activity of ERK1/2 in aged rats.

Objective To investigate the therapeutic effects of presurgical TMT on the heights and levels of inferior vena cava(IVC)thrombi,and to assess its impact on surgical strategy.Methods We retrospectively reviewed data of 18 patients with renal cell carcinoma(RCC)involving IVC tumor thrombi who were treated at our hospital with presurgical TMT followed by an IVC thrombectomy.Data from 18 patients(16 men and 2 women)were included in the analysis.The median age was 53.5 years(range:33-75 years),and the mean BMI was 24.7kg/m2(rrange:18.1 -30.4 kg/m2).4 cases of tumors located in the left kidney,14 cases were right.The changes in heights and levels of the IVC thrombi were compared using computed tomography or magnetic resonance imaging.The IVC tumor thrombus level was evaluated according to the Mayo classification.Results The tumor thrombus levels before TMT were stage Ⅰ in 1 patient,Ⅱ in 1 2 patients,Ⅲ in 4 patients,and Ⅳ in 1 patient.The presurgical TMT was sorafenib in 6 patients(33.3%),sunitinib in 9(50.0%),and axitinib in 3(16.7%).After a median of 2 treatment cycles(range:1-6 cycles),three patients experienced grade 3 adverse events.One patient stopped treatment after 6 weeks owing to intolerable skin reactions and difficulty walking.The tumor thrombus height decreased measurably in 11 patients(61.1%).The thrombus height remained stable in 5 patients(27.8%)and was enlarged in 2(11.1%).The median reduction of tumor thrombus height was -0.53 cm (range:-4.23 to 1.21 cm).The median change in the maximum diameter of the thrombus was -0.30 cm (range:-1.23 to 0.29 cm).Down-staging of the thrombus level occurred in 4 patients(22.2%);the surgical strategy was modified in 3 patients(level≥Ⅲ)to avoid cardiopulmonary bypass and complicated liver mobilization under robot-assisted laparoscopy.Conclusions Our data suggest a limited influence of presurgical TMT,with a positive benefit in RCC patients with level Ⅲ and Ⅳ thrombus.Thrombus-level regression may potentially alter the surgical strategy,especially robotic surgery.Additionally,preoperative targeted therapy did not significantly increase perioperative mortality and risk of serious complications.

Objective To investigate the expression of the long non-coding RNA (IncRNA) H19 in the serum of patients with acute pancreatitis and its clinical significance.Methods A total of 82 patients who were diagnosed with acute pancreatitis in Emergency Department and Department of General Surgery in Shenyang Emergency Center from January 2013 to December 2015 were enrolled,and 20 healthy subjects were enrolled as normal controls.Peripheral blood samples were collected from the patients with acute pancreatitis and healthy subjects,the serum was separated,and RNA was extracted.Real-time PCR was used to measure the expression of lncRNA H19,and the correlation between the expression of H19 and other clinical and pathological parameters was analyzed.The t-test was used for comparison of continuous data between groups,and the chi-square test was used for comparison of categorical data between groups.The receiver operating characteristic (ROC) curve was used to evaluate the value of lncRNA H19 in the diagnosis of acute pancreatitis.Results The acute pancreatitis group had a significantly higher H19 expression level in serum than the healthy control group (t =2.364,P =0.020).The severe acute pancreatitis group had higher expression of lncRNA H19 than the mild acute pancreatitis group (t =2.111,P =0.037),and the patients with a Balthazar CT grade above grade C had significantly higher relative expression of lncRNA H19 than those with CT grade ≤ C (t =2.312,P =0.022).The ROC curve showed that H19 measurement helped with the diagnosis of acute pancreatitis with an area under the ROC curve of 0.752 (95％ CI:0.636-0.867,P ＜ 0.01).Conclusion Patients with acute pancreatitis have increased expression of IncRNA H19 in serum,and therefore,H19 has certain clinical significance in the diagnosis of acute pancreatitis and the evaluation of disease severity.