Objective:To evaluate the feasibility and safety of a fascial space priority approach to total pelvic exenteration (TPE) in patients with pelvic malignancy.Methods:This was a descriptive case series. Relevant clinical data of patients who had undergone TPE via a fascial space priority approach at Tianjin Union Medical Center from September 2017 to March 2025 were retrospectively collected. All operations had been performed via a fascial space priority approach, the guiding principle of which is separating the avascular pelvic spaces first and then transecting the vessels and nerves of the pelvic organs. That is, the avascular planes around all the pelvic organs are dissected first, after which the relevant vessels and nerves are fully dissected and transected, followed by en bloc resection of pelvic organs distally or via perineal approach. The variables studied included relevant surgical parameters, postoperative pathological findings, complications (classified according to the Clavien-Dindo criteria); recurrence-free survival (RFS), overall survival, and tumor-specific survival. Results:The study cohort comprised 41 patients, including 30 (73.2%) with primary tumors and 11 (26.8%) with recurrent tumors. Open TPE was performed on five patients (12.2%) and laparoscopic TPE on the remaining 36 (87.8%). All procedures were successfully completed with a fascial space priority approach and there were no intraoperative deaths. R0 resection was achieved in 34 patients (82.9%) and R1 resection in seven (17.1%). The operation time was 500 (265-740) min, and the amount of bleeding 200 (10-3,500) mL. Twelve patients (29.3%) developed postoperative complications, two of which were Clavien-Dindo Grade III complications. One of these patients required re-operation to manage a pelvic hematoma 29 days after the primary TPE. No active bleeding was observed during the re-operation. Another patient underwent interventional angiography for an episode of postoperative bleeding; this showed a pseudoaneurysm of the internal iliac artery that was successfully treated by interventional embolization via the internal iliac artery. Five days after undergoing a primary TPE with bladder preservation, a third patient was found to have a urinary fistula and underwent laparoscopic bladder resection with percutaneous ureterostomy. The median duration of follow-up was 18 (1-90) months. The 5-year RFS and overall survival were 46.7% and 52.2%, respectively, whereas the 5-year tumor-specific survival was 67.8%. Univariate Cox regression analysis identified a positive surgical margin ( P < 0.001), lateral pelvic sidewall invasion ( P=0.014), and vascular invasion ( P=0.004) as significantly associated with RFS, whereas multivariate analysis identified only a positive surgical margin (HR: 21.93, 95% CI: 3.78-127.42, P<0.001) as an independent predictor of RFS. Conclusions:It is safe and feasible to perform TPE with a fascial space priority approach on patients with pelvic malignancy. Positive surgical margins are significantly associated with RFS.

Objective:To evaluate the feasibility and safety of a fascial space priority approach to total pelvic exenteration (TPE) in patients with pelvic malignancy.Methods:This was a descriptive case series. Relevant clinical data of patients who had undergone TPE via a fascial space priority approach at Tianjin Union Medical Center from September 2017 to March 2025 were retrospectively collected. All operations had been performed via a fascial space priority approach, the guiding principle of which is separating the avascular pelvic spaces first and then transecting the vessels and nerves of the pelvic organs. That is, the avascular planes around all the pelvic organs are dissected first, after which the relevant vessels and nerves are fully dissected and transected, followed by en bloc resection of pelvic organs distally or via perineal approach. The variables studied included relevant surgical parameters, postoperative pathological findings, complications (classified according to the Clavien-Dindo criteria); recurrence-free survival (RFS), overall survival, and tumor-specific survival. Results:The study cohort comprised 41 patients, including 30 (73.2%) with primary tumors and 11 (26.8%) with recurrent tumors. Open TPE was performed on five patients (12.2%) and laparoscopic TPE on the remaining 36 (87.8%). All procedures were successfully completed with a fascial space priority approach and there were no intraoperative deaths. R0 resection was achieved in 34 patients (82.9%) and R1 resection in seven (17.1%). The operation time was 500 (265-740) min, and the amount of bleeding 200 (10-3,500) mL. Twelve patients (29.3%) developed postoperative complications, two of which were Clavien-Dindo Grade III complications. One of these patients required re-operation to manage a pelvic hematoma 29 days after the primary TPE. No active bleeding was observed during the re-operation. Another patient underwent interventional angiography for an episode of postoperative bleeding; this showed a pseudoaneurysm of the internal iliac artery that was successfully treated by interventional embolization via the internal iliac artery. Five days after undergoing a primary TPE with bladder preservation, a third patient was found to have a urinary fistula and underwent laparoscopic bladder resection with percutaneous ureterostomy. The median duration of follow-up was 18 (1-90) months. The 5-year RFS and overall survival were 46.7% and 52.2%, respectively, whereas the 5-year tumor-specific survival was 67.8%. Univariate Cox regression analysis identified a positive surgical margin ( P < 0.001), lateral pelvic sidewall invasion ( P=0.014), and vascular invasion ( P=0.004) as significantly associated with RFS, whereas multivariate analysis identified only a positive surgical margin (HR: 21.93, 95% CI: 3.78-127.42, P<0.001) as an independent predictor of RFS. Conclusions:It is safe and feasible to perform TPE with a fascial space priority approach on patients with pelvic malignancy. Positive surgical margins are significantly associated with RFS.

At present, there are still some problems in the standardized residency training. Some standardized training bases often regard the resident trainees as ordinary practitioners, and devote their time and energy to the daily medical procedural work without giving enough training and teaching, ignoring the basic skills training of resident trainees. Therefore, this study constructed an active knowledge push system based on business scenarios. The system mainly includes three parts: sensitive operation identification layer, knowledge index layer and resource push layer in order to cultivate the norms of diagnosis and treatment of standardized training students and reasonably solve the problem of inconvenient resource acquisition in clinical work. Through the preliminary application, it was found that the system has effectively improved the mini-clinical evaluation exercise (Mini-CEX) score of the trainees and achieved good results.

Previously, we proposed a new perspective of triptolide (TP)-associated hepatotoxicity: liver hypersensitivity upon lipopolysaccharide (LPS) stimulation. However, the mechanisms for TP/LPS-induced hepatotoxicity remained elusive. The present study aimed to clarify the role of LPS in TP/LPS-induced hepatotoxicity and the mechanism by which TP induces liver hypersensitivity upon LPS stimulation. TNF- inhibitor, etanercept, was injected intraperitoneally into mice to investigate whether induction of TNF- by LPS participated in the liver injury induced by TP/LPS co-treatment. Mice and hepatocytes pretreated with TP were stimulated with recombinant TNF- to assess the function of TNF- in TP/LPS co-treatment. Additionally, time-dependent NF-B activation and NF-B-mediated pro-survival signals were measured and . Finally, overexpression of cellular FLICE-inhibitory protein (FLIP), the most potent NF-B-mediated pro-survival protein, was measured and to assess its function in TP/LPS-induced hepatotoxicity. Etanercept counteracted the toxic reactions induced by TP/LPS. TP-treatment sensitized mice and hepatocytes to TNF-, revealing the role of TNF- in TP/LPS-induced hepatotoxicity. Mechanistic studies revealed that TP inhibited NF-B dependent pro-survival signals, especially FLIP, induced by LPS/TNF-. Moreover, overexpression of FLIP alleviated TP/LPS-induced hepatotoxicity and TP/TNF--induced apoptosis . Mice and hepatocytes treated with TP were sensitive to TNF-, which was released from LPS-stimulated immune cells. These and other results show that the TP-induced inhibition of NF-B-dependent transcriptional activity and FLIP production are responsible for liver hypersensitivity.