Objective:A microsurgical simulation training device based on real clinical scenes was designed and its effectiveness was tested.Methods:From January 1, 2020 to January 1, 2023, postgraduate students in the Plastic and Reconstructive Surgery Department of the First Medical Center of PLA General Hospital and the Plastic Surgery Hospital of Chinese Academy of Medical Sciences were enrolled in this prospective study. The simulation training device consists of four parts: (1)Blood perfusion system, which is used to simulate living animal blood vessels.(2)The inner baffling rod system, which is used to simulate the operation in deep cavity.(3) The exterior baffling rod system, which is used to simulate the operation in difficult positions.(4) A pulsating platform system is used to simulate microsurgery under the influence of respiratory movement. Preliminary verification of the effect of the simulated training device was as follows: Surgeons with no experience in microsurgery were completely randomized assigned to the control group (traditional microsurgery training group) and the experimental group (training group using the simulated training device). After 4 weeks of microsurgical training, the trainees were assigned to perform two surgical skill assessments, the first using a live animal model for end-to-end anastomosis of rat tail arteries, and the second assessment using end-to-end anastomosis of free latissimus dorsi flap arteries in a real case. The performance of the two groups was compared by using operation time and microsurgical GRS score scale including four items of dexterity, visuospatial ability, operative flow and judgment. Chi-squared test was used to analyze gender between the two groups. GRS scores between the two groups were compared by the Mann-Whitney U test. Participants’ ageand operation time between the two groups was compared by independent t-test. P<0.05 was considered statistically significant. Results:A total of 18 trainees were enrolled, including 10 in the control group, 6 males and 4 females, with an average age of (27.80±1.87) years. There were 8 subjects in the experimental group, 4 males and 4 females, with an average age of (28.10±1.56) years old. There were no significant differences in age, gender and other baseline characteristics between the two groups ( P>0.05). There was no significant difference in GRS score and operation time between the control group and the experimental group ( P> 0.05) in the first assessment. However, in the second assessment of real cases, the GRS score of the experimental group was significantly higher than that of the control group(14.25 vs. 5.70), and the operation duration of the experimental group was also shorter than that of the control group, and the difference was statistically significant[(100.37±24.65 ) min vs. (105.60±22.84) min] ( P<0.05). Conclusion:Compared with traditional microsurgery training methods, using microsurgery training devices based on clinical real scenes can effectively shorten the learning curve and enable trainees to master complex micromanipulation skills more quickly.

Objective:A microsurgical simulation training device based on real clinical scenes was designed and its effectiveness was tested.Methods:From January 1, 2020 to January 1, 2023, postgraduate students in the Plastic and Reconstructive Surgery Department of the First Medical Center of PLA General Hospital and the Plastic Surgery Hospital of Chinese Academy of Medical Sciences were enrolled in this prospective study. The simulation training device consists of four parts: (1)Blood perfusion system, which is used to simulate living animal blood vessels.(2)The inner baffling rod system, which is used to simulate the operation in deep cavity.(3) The exterior baffling rod system, which is used to simulate the operation in difficult positions.(4) A pulsating platform system is used to simulate microsurgery under the influence of respiratory movement. Preliminary verification of the effect of the simulated training device was as follows: Surgeons with no experience in microsurgery were completely randomized assigned to the control group (traditional microsurgery training group) and the experimental group (training group using the simulated training device). After 4 weeks of microsurgical training, the trainees were assigned to perform two surgical skill assessments, the first using a live animal model for end-to-end anastomosis of rat tail arteries, and the second assessment using end-to-end anastomosis of free latissimus dorsi flap arteries in a real case. The performance of the two groups was compared by using operation time and microsurgical GRS score scale including four items of dexterity, visuospatial ability, operative flow and judgment. Chi-squared test was used to analyze gender between the two groups. GRS scores between the two groups were compared by the Mann-Whitney U test. Participants’ ageand operation time between the two groups was compared by independent t-test. P<0.05 was considered statistically significant. Results:A total of 18 trainees were enrolled, including 10 in the control group, 6 males and 4 females, with an average age of (27.80±1.87) years. There were 8 subjects in the experimental group, 4 males and 4 females, with an average age of (28.10±1.56) years old. There were no significant differences in age, gender and other baseline characteristics between the two groups ( P>0.05). There was no significant difference in GRS score and operation time between the control group and the experimental group ( P> 0.05) in the first assessment. However, in the second assessment of real cases, the GRS score of the experimental group was significantly higher than that of the control group(14.25 vs. 5.70), and the operation duration of the experimental group was also shorter than that of the control group, and the difference was statistically significant[(100.37±24.65 ) min vs. (105.60±22.84) min] ( P<0.05). Conclusion:Compared with traditional microsurgery training methods, using microsurgery training devices based on clinical real scenes can effectively shorten the learning curve and enable trainees to master complex micromanipulation skills more quickly.

Objective:To investigate the genomic profiles and immune microenvironment of olfactory neuroblastoma (ONB).Methods:Nineteen ONB cases diagnosed in the Beijing Tongren Hospital from May 2018 to October 2022 were divided into low-grade and high-grade groups according to the Hyams grading system, including 7 low-grade and 12 high-grade ONB. Whole exome sequencing and multiplex immunofluorescence analyses were performed on tissue samples of these ONB.Results:A total of 929 nonsynonymous alterations were identified in 18 of the 19 ONB (18/19) cases. The most commonly altered cancer-related genes were CTNNB1 (3/19) and ZNRF3 (3/19). The most mutated oncogenic pathways were the WNT and RAS pathways. The median tumor mutation burden (TMB) was 0.45/Mb, ranging from 0 to 3.25. The median tumor neoantigen load (TNB) was 9.39 neoantigens/Mb, ranging from 0 to 38.30. The median allelic mutation tumor heterogeneity (MATH) score was 16.95, ranging from 3.05 to 117.47. Only one of the 19 cases expressed PD-L1 (composite positive score, CPS>1) in the tumor cells. The median percentage of CD8 + tumor-infiltrating lymphocyte (TIL) in the tumor region was 1.08%. No significant differences were observed between the low-and high-grade groups for mutant genes, mutant pathways, TMB, TNB, MATH, PD-L1 expression levels, or CD8 + TILs percentage( P>0.05). However, the low-grade group showed significantly more CD68 + macrophages in both the tumor and total region than the high-grade group. Notably, CD68 +CD163 - macrophages accounted for an average of 80.52% of CD68 + macrophages. Conclusions:CTNNB1 and ZNRF3 are the most commonly altered cancer-related genes. The low expression of PD-L1 and the low percentage of CD8 + TIL indicate that ONB might not be sensitive to immunotherapy. The percentage of M1-type macrophages in low-grade ONB is significantly higher than that in high-grade ONB, suggesting that M1-type macrophages may be involved in the progression of ONB from low-grade to high-grade.

Objective:To investigate the clinical features and therapeutic efficacy of patients with hereditary leiomyomatosis and renal cell carcinoma(RCC) syndrome-associated RCC (HLRCC-RCC) in China.Methods:The clinical data of 119 HLRCC-RCC patients with fumarate hydratase (FH) germline mutation confirmed by genetic diagnosis from 15 medical centers nationwide from January 2008 to December 2021 were retrospectively analyzed. Among them, 73 were male and 46 were female. The median age was 38(13, 74) years. The median tumor diameter was 6.5 (1.0, 20.5) cm. There were 38 cases (31.9%) in stage Ⅰ-Ⅱand 81 cases (68.1%) in stage Ⅲ-Ⅳ. In this group, only 11 of 119 HLRCC-RCC patients presented with skin smooth muscle tumors, and 44 of 46 female HLRCC-RCC patients had a history of uterine fibroids. The pathological characteristics, treatment methods, prognosis and survival of the patients were summarized.Results:A total of 86 patients underwent surgical treatment, including 70 cases of radical nephrectomy, 5 cases of partial nephrectomy, and 11 cases of reductive nephrectomy. The other 33 patients with newly diagnosed metastasis underwent renal puncture biopsy. The results of genetic testing showed that 94 patients had FH gene point mutation, 18 had FH gene insertion/deletion mutation, 4 had FH gene splicing mutation, 2 had FH gene large fragment deletion and 1 had FH gene copy number mutation. Immunohistochemical staining showed strong 2-succinocysteine (2-SC) positive and FH negative in 113 patients. A total of 102 patients received systematic treatment, including 44 newly diagnosed patients with metastasis and 58 patients with postoperative metastasis. Among them, 33 patients were treated with tyrosine kinase inhibitor (TKI) combined with immune checkpoint inhibitor (ICI), 8 patients were treated with bevacizumab combined with erlotinib, and 61 patients were treated with TKI monotherapy. Survival analysis showed that the median progression-free survival (PFS) of TKI combined with ICI was 18 (5, 38) months, and the median overall survival (OS) was not reached. The median PFS and OS were 12 (5, 14) months and 30 (10, 32) months in the bevacizumab combined with erlotinib treatment group, respectively. The median PFS and OS were 10 (3, 64) months and 44 (10, 74) months in the TKI monotherapy group, respectively. PFS ( P=0.009) and OS ( P=0.006) in TKI combined with ICI group were better than those in bevacizumab combined with erlotinib group. The median PFS ( P=0.003) and median OS ( P=0.028) in TKI combined with ICI group were better than those in TKI monotherapy group. Conclusions:HLRCC-RCC is rare but has a high degree of malignancy, poor prognosis and familial genetic characteristics. Immunohistochemical staining with strong positive 2-SC and negative FH can provide an important basis for clinical diagnosis. Genetic detection of FH gene germ line mutation can confirm the diagnosis. The preliminary study results confirmed that TKI combined with ICI had a good clinical effect, but it needs to be confirmed by the results of a large sample multi-center randomized controlled clinical study.

【Objective】 To compare the value of CT pulmonary angiography (CTPA) and echocardiography in predicting the degree pulmonary hypertension (PH). 【Methods】 Fifty-four patients in our hospital who underwent right heart catheterization, CTPA and echocardiography for suspected or confirmed PH from November 2013 to April 2021 were retrospectively recruited. Pulmonary artery systolic pressure (PASP) and mean pulmonary artery pressure (PAMP) were measured by right heart catheterization. According to PAMP, the patients were divided into non-PH group and mild, moderate, and severe PH groups. The three-dimensional model of the pulmonary artery was obtained by computer-aided segmentation, and the best fitting circle diameter (Dfit), inscribed circle diameter (Dmin), circumscribed circle diameter (Dmax), hydraulic diameter (Dh), cross-sectional area (Area), circumference (Scf), and the largest area and largest short diameter of the right ventricle were measured. Echocardiography was used to estimate PASP. The differences in the above parameters between different PH groups were compared, the correlations of the above parameters with PASP and PAMP were analyzed, and statistically significant indicators were included to establish three predictive models of PAMP (Model 1: CTPA pulmonary artery; Model 2: CTPA pulmonary artery+CTPA right ventricle; Model 3: CTPA pulmonary artery+CTPA right ventricle+echocardiography), and receiver operating characteristic (ROC) curves were used to compare the diagnostic performance of the three models. 【Results】 Some parameters of main pulmonary artery (Dfit, Dmin, Dmax, Dh, Area, Scf), right pulmonary artery (Dmax, Dh, Area, Scf), left pulmonary artery (Dfit), and right ventricular short diameter increased with the increase of PAMP (P<0.05). Dfit, Dmin, Dh, and area of main pulmonary artery, right pulmonary artery and left pulmonary artery were positively correlated with PASP and PAMP (P<0.05). Right ventricular short diameter and right ventricular maximum area were positively correlated with PASP (P<0.05), and right ventricular short diameter was positively correlated with PAMP (P<0.05). The estimated value of pulmonary artery systolic blood pressure in echocardiography was positively correlated with PASP and PAMP (P<0.05). Model 1, Model 2 and Model 3 could all be used to identify mild PH and moderate PH, among which Model 3 had the best performance in identifying non-PH and mild PH, moderate PH and severe PH. 【Conclusion】 CTPA and echocardiography are helpful in assessing the degree of PH, and the combination of the two has better accuracy in distinguishing non-PH from mild PH, moderate and severe PH.

Objective:To investigate the risk factors of restenosis after dilation of anastomotic stenosis in patients with esophageal cancer surgery.Methods:Clinical data of 997 patients who underwent endoscopic dilation due to anastomotic stenosis after esophageal cancer radical surgery in the Affiliated Huai′an First Hospital of Nanjing Medical University from June 2015 to July 2021, were retrospectively analyzed. There were 486 cases receiving single dilation (single dilation group) and 511 cases receiving more than two dilations (multiple dilation group). The risk factors of restenosis were explored using univariate and multivariate logistic regression analysis.Results:There were 682 males and 315 females with a median age of 65 years, the median distance between the stenosis and incisor was 20 (20, 22) cm, the median stenosis diameter was 4 (3, 5) mm, and the median stenosis diameter after dilation was 11 (11, 13) mm. Univariate analysis showed that there were significant differences in the distance of the stenosis and incisor ( Z=-2.303, P<0.05), stenosis diameter ( Z=-4.637, P<0.05) and stenosis diameter after dilation ( Z=-5.773, P<0.05) between single and multiple dilation groups. Stratified multivariate logistic regression showed that for male patients, risk of multiple dilations dropped by approximately 3% for every 1-mm increase in the distance between the stenosis and incisor ( OR=0.97, 95% CI:0.93-1.00, P=0.047); the risk of multiple dilations decreased by about 15%, for every 1-mm increase in stenosis diameter ( OR=0.85, 95% CI:0.76-0.94, P=0.004); the risk of multiple dilations decreased by about 13% for every 1-mm increase in stenosis diameter after dilation ( OR=0.87, 95% CI:0.78-0.96, P=0.007). For females patients under 60 years old, the risk of multiple dilations decreased by about 31%, for every 1-mm increase in stenosis diameter after dilation ( OR=0.69, 95% CI:0.47-0.98, P=0.049); for female patients≥60 years old, the risk decreased by about 5%, for every 1-year increase in age ( OR=0.95, 95% CI:0.91-1.00, P=0.037), risk of multiple dilations dropped by 17%( OR=0.83, 95% CI:0.70-0.99, P=0.039) for every 1 mm increase in stenosis diameter after dilation. Stratified smooth curve fitting indicated that the distance between the stenosis and incisor≤23 mm, stenosis diameter≤4.5 mm, stenosis diameter after dilation≤12 mm were risk factors for multiple dilations. Conclusions:The study indicates that patients with the distance between the stenosis and incisor≤23 mm, stenosis diameter≤4.5 mm, stenosis diameter after dilation≤12 mm may need multiple dilations; and the first dilation should expand the stenosis diameter to 12 mm or above as far as possible to reduce the risk of restenosis in patients receiving esophageal cancer radical surgery.

Objective    To analyze the risk factors for esophagogastric anastomotic leakage (EGAL) after esophageal cancer surgery, and to establish a risk prediction model for early prevention and treatment. Methods    Clinical data of patients undergoing esophagectomy in our hospital from January 2013 to October 2020 were retrospectively analyzed. The independent risk factors for postoperative EGAL were analyzed by univariate and multivariate logistic regression analyses, and a clinical nomogram prediction model was established. According to whether EGAL occurred after operation, the patients were divided into an anastomotic fistula group and a non-anastomotic fistula group. Results    A total of 303 patiens were enrolled, including 267 males and 36 females with a mean age of 62.30±7.36 years. The incidence rate of postoperative EGAL was 15.2% (46/303). The multivariate logistic regression analysis showed that high blood pressure, chronic bronchitis, peptic ulcer, operation way, the number of lymph node dissected, anastomotic way, the number of intraoperative chest drainage tube, tumor location, no-supplementing albumin in the first three days after operation, postoperative pulmonary infection, postoperative use of bronchoscope were the independent risk factors for EGAL after esophageal cancer surgery (P<0.05). A prognostic nomogram model was established based on these factors with the area under the receiver operating characteristic curve of 0.954 (95%CI 0.924-0.975), indicating a high predictive  value. Conclusion    The clinical prediction model based on 11 perioperative risk factors in the study has a good evaluation efficacy and can promote the early detection, diagnosis and treatment of EGAL.

Objective:To confirm the reuse of mismatched regenerated motor axons of brachial plexus and explore the effect of target organs on their regeneration in a rat model.Methods:This study was carried out between January 2021 and December 2021 at the research laboratory of the Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, the First Affiliated Hospital of Sun Yat-sen University. Animals were randomly assigned into 2 groups, as a regeneration group (RGen) with 5 subgroups and a reuse group (RUs) with 3 subgroups. There were 6 rats per subgroup with 42 rats in total. It was observed that in the groups of RGen1-4, after the transection and suture of the musculocutaneous nerve, the motor axons of the proximal end could accurately grow into the distal corresponding endoneural tube. It was also observed that in the mismatched regenerated group, motor axons were the axons that grew into the endoneurial tube of the lateral forearm cutaneous nerve (LFCN), and other non-target organ contacts were made to the regenerated nerves after mismatch. It was specifically further divided into RGen1, the group without an organ for nerve to make contact with; RGen2, the group with skin as the target organ with nerves contact by neurorrhaphy; RGen3, the group with skin as the target organ with originally reserved natural nerve contact; RGen4, the group with muscle as the target organ with nerves contact by neurorrhaphy and RGen5, a control group. After 8 weeks, the positive area (PA), mean density (MD) and integral optical density (IOD) were measured, with AChE and ChAT fluorescence staining of the medial branch of LFCN, to evaluate the regenerated nerves after mismatch. Of the RUs group, firstly, the innervating branches of the flexor carpi radialis (FCR) were dissected and exposed, then further assigned according to initially innervated FCR (RUs1), contacted with regenerated nerves after mismatch (RUs2) and denervated (RUs3), respectively. After 8 weeks, compound muscle action potential (CMAP) and wet weight ratio of FCR were taken. Masson staining of FCR was also performed to evaluate muscle reinnervation by the regenerated nerves after mismatch. Data analysis with One-Way ANOVA and Bonferroni 0.05 indicated a statistically significant difference.Results:In the RGen groups, after AChE staining, the PA, MD and IOD of RGen3 and RGen4 were higher than that of RGen1 and RGen5, and PA of RGen4 were higher than that of RGen2, with a statistically significant difference ( P<0.05). After ChAT staining, the values of PA and IOD of RGen3 and RGen4 were higher than that of RGen1 and RGen5, and PA of RGen4 were higher than that of RGen2, with a statistically significant difference ( P<0.05). In the RUs, electrophysiological assessment showed that no CMAP was observed in RUs3, there was no significant difference in Latency of RUs1 and RUs2. The difference was statistically significant ( P<0.05). Wet weight rate of muscle of RUs1 (98.91%±3.86%) was higher than that of RUs3 (86.67%±4.68%) with a statistically significant difference ( P<0.01), but no significant difference when compared with RU2 (92.74%±3.88%). Masson staining showed that the CVF value of RUs2 (8.61%±1.16%) was significantly higher than that of RUs1 (3.17%±0.76%), and statistic significantly lower than that of RUs3 (16.44%±2.26%)( P<0.01). Conclusion:Target organ contact can promote the regenerated nerves after mismatched regeneration, and the muscle target organs exhibit greater facilitation than the cutaneous target organs. Besides, regenerated nerves after mismatch can establish effective innervation with muscle target organs, comfirming their effective reuse.

Exogenous lipoid pneumonia is an inflammatory response to the lungs caused by inhaled lipid substances, which is prone to secondary bacterial infection, resulting in the formation of local abscesses, which can be life-threatening in severe cases. This paper reports a case of a 55-year-old patient with diesel aspiration, secondary to Klebsiella pneumoniae (ESBL positive) and Candida glabrata infection resulting in lung abscess formation. He was treated with a variety of antibacterial drugs for anti-infection, non-invasive ventilator ventilation, bronchoalveolar lavage, glucocorticoids, phlegm and other medical treatments. Finally, he underwent middle lobectomy for improvement and was discharged from the hospital, and he recovered well with regular follow-up.

Exogenous lipoid pneumonia is an inflammatory response to the lungs caused by inhaled lipid substances, which is prone to secondary bacterial infection, resulting in the formation of local abscesses, which can be life-threatening in severe cases. This paper reports a case of a 55-year-old patient with diesel aspiration, secondary to Klebsiella pneumoniae (ESBL positive) and Candida glabrata infection resulting in lung abscess formation. He was treated with a variety of antibacterial drugs for anti-infection, non-invasive ventilator ventilation, bronchoalveolar lavage, glucocorticoids, phlegm and other medical treatments. Finally, he underwent middle lobectomy for improvement and was discharged from the hospital, and he recovered well with regular follow-up.