A 50-year-old male patient was scheduled to undergo epiglottic mass resection under general anesthesia due to an epiglottic cyst. Before anesthesia induction, the patient received dexamethasone, methylprednisolone, midazolam, and ondansetron by intravenous injectionin sequence. After 2 minutes, the patient complained of palpitations, abdominal spasmodic pain, cyanosis of the lips, and patchy changes in the skin on the chest and body. The electrocardiogram monitor showed a heart rate of 175 beats per minute, but his cuff blood pressure cannot be measured. His blood oxygen saturation was 0.76, and he did not respond to the call afterwards. Oxygen through a face mask and pressure ventilation, intravenous injection of 20 mg of esmolol twice were given immediately. The patient′s consciousness recovered, the heart rate gradually decreased to 60 beats per minute (sinus rhythm), and the blood pressure increased to 74/50 mmHg. Continuous IV pumping of norepinephrine 8 μg/min was given. After 25 minutes, the patient′s bedside electrocardiogram showed atrial fibrillation with ventricular differential conduction, myocardial injury or acute myocardial infarction, and QT interval prolongation. Then intravenous injection of furosemide 40 mg was given, his above symptoms were improved,his blood pressure recovered to 110-120/70 mmHg, blood oxygen saturation was 1.00, the skin spots on his chest and body disappeared, and his abdominal pain was alleviated. Anesthesiologists and pharmacists evaluated the patient′s adverse reactions and considered that there was a high possibility of type I Kounis syndrome caused by the combination of glucocorticoids, midazolam, and ondansetron.

A 50-year-old male patient was scheduled to undergo epiglottic mass resection under general anesthesia due to an epiglottic cyst. Before anesthesia induction, the patient received dexamethasone, methylprednisolone, midazolam, and ondansetron by intravenous injectionin sequence. After 2 minutes, the patient complained of palpitations, abdominal spasmodic pain, cyanosis of the lips, and patchy changes in the skin on the chest and body. The electrocardiogram monitor showed a heart rate of 175 beats per minute, but his cuff blood pressure cannot be measured. His blood oxygen saturation was 0.76, and he did not respond to the call afterwards. Oxygen through a face mask and pressure ventilation, intravenous injection of 20 mg of esmolol twice were given immediately. The patient′s consciousness recovered, the heart rate gradually decreased to 60 beats per minute (sinus rhythm), and the blood pressure increased to 74/50 mmHg. Continuous IV pumping of norepinephrine 8 μg/min was given. After 25 minutes, the patient′s bedside electrocardiogram showed atrial fibrillation with ventricular differential conduction, myocardial injury or acute myocardial infarction, and QT interval prolongation. Then intravenous injection of furosemide 40 mg was given, his above symptoms were improved,his blood pressure recovered to 110-120/70 mmHg, blood oxygen saturation was 1.00, the skin spots on his chest and body disappeared, and his abdominal pain was alleviated. Anesthesiologists and pharmacists evaluated the patient′s adverse reactions and considered that there was a high possibility of type I Kounis syndrome caused by the combination of glucocorticoids, midazolam, and ondansetron.

Objective:To evaluate the relationship between intestinal microbiota heterogeneity and acquired myasthenia in septic mice.Methods:Eighty SPF healthy male C57BL/6 mice, weighing 18-20 g, aged 6-8 weeks, were included. Forty mice were selected to prepare a sepsis model by intraperitoneal injection of lipopolysaccharide (LPS) 10 mg/kg. Sepsis-sensitive mice (state of dying or even death within 24 h after developing the model) and sepsis-resistant mice (survival for 7 days and recovery) were screened. The feces from donor mice were collected to make fecal bacteria fluid. Forty mice were selected and divided into 4 groups ( n=10 each) by the random number table method: control group (C group), antibiotic group (ABX group), resistant group (Res group), and sensitive group (Sen group). Group C received no treatment. In ABX group, compound antibiotics were given by intragastric gavage once a day for 5 consecutive days. In Res group, the fecal solution from sepsis-resistant mice 150 μl was given by gavage once a day for 3 consecutive days starting from 5 days after gavage administration of compound antibiotics, and then LPS 15 mg/kg was intraperitoneally injected. In Sen group, the fecal solution from sepsis-sensitive mice was given by gavage for 3 days (using the same method as previously described in Res group) starting from 5 days after gavage administration of compound antibiotics, and then LPS 15 mg/kg was intraperitoneally injected. The severity of sepsis was assessed and scored at 24 h after developing the model. The four limb grip strength was measured after fecal bacteria transplantation and at 24 h after developing the sepsis model. The Compound Muscle Action Potential (CMAP) of the gastrocnemius was measured at 24 h after developing the sepsis model. Then blood samples were collected for determination of the levels of interleukin-1 (IL-1), IL-6 and tumor necrosis factor α (TNF-α) in serum by enzyme-linked immunosorbent assay. The tissues of anterior tibial muscle and gastrocnemius muscle were obtained for determination of the expression of muscle-specific ring finger protein 1 (MuRF-1) and muscle atrophy box F protein (MAFbx) by Western blot. The diameter and cross-sectional area of gastrocnemius muscle fibers were measured after HE staining. The feces of mice were collected at 3 days after fecal bacteria transplantation, and DNA was extracted from mouse fecal samples for 16S rDNA sequencing and untargeted metabolomics analysis. Results:Compared with C group, the score for severity of sepsis was significantly increased, the four limb grip strength was decreased after developing the sepsis model, the serum IL-6 concentration was increased, and the diameter and cross-sectional area of gastnemius muscle fibers were decreased ( P<0.05), and no statistically significant changes were found in the other parameters in Res group, and no statistically significant changes were found in the indexes mentioned above in ABX group ( P>0.05). Compared with C group and Res group, the score for severity of sepsis was significantly increased, the four limb grip strength was decreased, the latency of CMAP was prolonged, and the amplitude of CMAP was decreased, the serum concentrations of IL-1, IL-6 and TNF-α were increased, the diameter and cross-sectional area of gastrocnemius muscle fibers were decreased, and the expression of MuRF-1 and MAFbx in anterior tibial muscle was up-regulated after developing the sepsis model in Sen group ( P<0.05). 16S rDNA sequencing of intestinal flora: Compared with Sen group, no significant change was found in Chao1 index, Good-coverage index and Simpson index in Res group ( P>0.05), Shannon index was increased ( P<0.05), and no significant change was found in β diversity in Res group ( P>0.05). LDA analysis showed that f_Akkermarisiaceae, o_Verrucomicrobiales, g_Akmansia, c_Verrucomicrobiae and p_Verrucomicrobiota were significantly enriched in Sen group, and g_Enterococcus and f_Enterococcaceae were significantly enriched in Res group ( P<0.05). Nontargeted metabolic analysis: The metabolite profiles in Res group and Sen group suggested that the model was well developed (R2Y>Q2Y). Compared with Sen group, 90 metabolites was significantly up-regulated and 88 down-regulated, significantly up-regulated metabolic substances including vitamin K1, gamma-tocopherol, and taurine in Res group ( P<0.05). The differential metabolite KEGG enrichment pathway included 2-oxocarboxylic acid metabolism and ubiquinone and other terpenoid-quinone biosynthesis ( P<0.05). Conclusions:Intestinal flora heterogeneity may be involved in the pathogenesis of acquired myasthenia in septic mice.

OBJECTIVE: To explore the role of endoplasmic reticulum ryanodine receptor 1 (RyR1) expression and phosphorylation in sepsis- induced diaphragm dysfunction. METHODS: Thirty SPF male SD rats were randomized equally into 5 groups, including a sham-operated group, 3 sepsis model groups observed at 6, 12, or 24 h following cecal ligation and perforation (CLP; CLP-6h, CLP-12h, and CLP-24h groups, respectively), and a CLP-24h group with a single intraperitoneal injection of KN- 93 immediately after the operation (CLP-24h+KN-93 group). At the indicated time points, diaphragm samples were collected for measurement of compound muscle action potential (CMAP), fatigue index of the isolated diaphragm and fitted frequencycontraction curves. The protein expression levels of CaMK Ⅱ, RyR1 and P-RyR1 in the diaphragm were detected using Western blotting. RESULTS: In the rat models of sepsis, the amplitude of diaphragm CMAP decreased and its duration increased with time following CLP, and the changes were the most obvious at 24 h and significantly attenuated by KN-93 treatment (P < 0.05). The diaphragm fatigue index increased progressively following CLP (P < 0.05) irrespective of KN- 93 treatment (P>0.05). The frequency-contraction curve of the diaphragm muscle decreased progressively following CLP, and was significantly lower in CLP-24 h group than in CLP-24 h+KN-93 group (P < 0.05). Compared with that in the sham-operated group, RyR1 expression level in the diaphragm was significantly lowered at 24 h (P < 0.05) but not at 6 or 12 following CLP, irrespective of KN-93 treatment; The expression level of P-RyR1 increased gradually with time after CLP, and was significantly lowered by KN-93 treatment at 24 h following CLP (P < 0.05). The expression level of CaMKⅡ increased significantly at 24 h following CLP, and was obviously lowered by KN-93 treatment (P < 0.05). CONCLUSION Sepsis causes diaphragmatic dysfunction by enhancing CaMK Ⅱ expression and RyR1 receptor phosphorylation in the endoplasmic reticulum of the diaphragm.
Rats ; Male ; Animals ; Diaphragm/metabolism* ; Ryanodine Receptor Calcium Release Channel/metabolism* ; Rats, Sprague-Dawley ; Phosphorylation ; Muscle Contraction/physiology* ; Endoplasmic Reticulum ; Sepsis/metabolism*

Objective:To explore the diagnostic value of laparoscopy in the postoperative recurrence of peritoneal metastasis in gastric cancer, and to investigate the efficacy of bidirectional intraperitoneal and systemic (BIPS) chemotherapy for the recurrence.Methods:The descriptive case series study was conducted. Case inclusion criteria: (1) gastric cancer patients without synchronous distant metastasis received D2 radical gastrectomy; (2) postoperative adjuvant chemotherapy was administered; (3) no other distant metastasis except recurrence of peritoneal metastasis; (4) age of 18-75 years; (5) Eastern Cooperative Oncology Group (ECOG) performance-status score≤2; (6) pretreatment evaluation suggested that surgery and chemotherapy could be tolerated. Eight consecutive gastric cancer patients with postoperative recurrence of peritoneal metastasis who met the above criteria at Department of Gastrointestinal Surgery of Ruijin Hospital from September 2015 to September 2016 were enrolled into the study. There were 6 males and 2 females with the median age of 52 (38-68) years. They received laparoscopy or laparotomy first, and then were evaluated with reference to the Sugarbaker peritoneal cancer index (PCI) and the peritoneal metastasis classification of gastric cancer developed by the Japanese Gastric Cancer Research Association. A peritoneal access port was implanted in the subcutaneous space of the lower abdomen and the patients received chemotherapy for 21 days as a course of treatment. All the patients received intraperitoneal 20 mg/m 2 of paclitaxel (PTX) via implanted subcutaneous peritoneal access ports and intravenous 50 mg/m 2 of PTX at day 1 and day 8, meanwhile 80 mg/m 2 of Tigio was orally administered per day for 14 consecutive days, followed by 7 days of interval. Follow-up ended on December 15, 2019. Results:Of these 8 patients with recurrence of peritoneal metastasis after gastric cancer surgery, 1 case underwent laparotomy and loop stoma of terminal ileum because of complete colonic obstruction, and the remaining 7 cases underwent laparoscopy successfully and the recurrence of peritoneal metastasis was clearly diagnosed. Two patients with ovarian metastasis underwent laparoscopic bilateral adnexectomy. The median follow-up time was 17.5 (1.5 to 39.0) months, the median number of BIPS chemotherapy course was 11 (1 to 30), and the median survival time (MST) after BIPS chemotherapy was 17.0 months. The major adverse reaction in BIPS treatment was mainly myelosuppression, of which grade 3/4 leukopenia and neutropenia developed in 1 and 2 cases respectively. No BIPS-related death occurred. The MST of gastric cancer after radical gastrectomy was 40.0 months.Conclusions:Laparoscopy is a safe and feasible method for diagnosing the recurrence of peritoneal metastasis of gastric cancer. BIPS chemotherapy is effective and safe for its treatment and deserves further study.

Objective:To explore the diagnostic value of laparoscopy in the postoperative recurrence of peritoneal metastasis in gastric cancer, and to investigate the efficacy of bidirectional intraperitoneal and systemic (BIPS) chemotherapy for the recurrence.Methods:The descriptive case series study was conducted. Case inclusion criteria: (1) gastric cancer patients without synchronous distant metastasis received D2 radical gastrectomy; (2) postoperative adjuvant chemotherapy was administered; (3) no other distant metastasis except recurrence of peritoneal metastasis; (4) age of 18-75 years; (5) Eastern Cooperative Oncology Group (ECOG) performance-status score≤2; (6) pretreatment evaluation suggested that surgery and chemotherapy could be tolerated. Eight consecutive gastric cancer patients with postoperative recurrence of peritoneal metastasis who met the above criteria at Department of Gastrointestinal Surgery of Ruijin Hospital from September 2015 to September 2016 were enrolled into the study. There were 6 males and 2 females with the median age of 52 (38-68) years. They received laparoscopy or laparotomy first, and then were evaluated with reference to the Sugarbaker peritoneal cancer index (PCI) and the peritoneal metastasis classification of gastric cancer developed by the Japanese Gastric Cancer Research Association. A peritoneal access port was implanted in the subcutaneous space of the lower abdomen and the patients received chemotherapy for 21 days as a course of treatment. All the patients received intraperitoneal 20 mg/m 2 of paclitaxel (PTX) via implanted subcutaneous peritoneal access ports and intravenous 50 mg/m 2 of PTX at day 1 and day 8, meanwhile 80 mg/m 2 of Tigio was orally administered per day for 14 consecutive days, followed by 7 days of interval. Follow-up ended on December 15, 2019. Results:Of these 8 patients with recurrence of peritoneal metastasis after gastric cancer surgery, 1 case underwent laparotomy and loop stoma of terminal ileum because of complete colonic obstruction, and the remaining 7 cases underwent laparoscopy successfully and the recurrence of peritoneal metastasis was clearly diagnosed. Two patients with ovarian metastasis underwent laparoscopic bilateral adnexectomy. The median follow-up time was 17.5 (1.5 to 39.0) months, the median number of BIPS chemotherapy course was 11 (1 to 30), and the median survival time (MST) after BIPS chemotherapy was 17.0 months. The major adverse reaction in BIPS treatment was mainly myelosuppression, of which grade 3/4 leukopenia and neutropenia developed in 1 and 2 cases respectively. No BIPS-related death occurred. The MST of gastric cancer after radical gastrectomy was 40.0 months.Conclusions:Laparoscopy is a safe and feasible method for diagnosing the recurrence of peritoneal metastasis of gastric cancer. BIPS chemotherapy is effective and safe for its treatment and deserves further study.

Objective: To investigate the differences of clinicopathological features, diagnosis, treatment and prognosis between patients with extra-gastrointestinal stromal tumors (EGIST) and duodenal gastrointestinal stromal tumors (DGIST). Methods: A retrospective case - control study was performed. Case inclusion criteria: (1) tumor confirmed by histology and pathology; (2) primary tumor locating in the extra - gastrointestinal tract or duodenum; (3) without other synchronous tumors; (4) complete clinical and pathological data. Clinical data of 20 EGIST patients and 32 DGIST patients from March 2011 to September 2016 at Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine were retrospectively collected and analyzed. The observational parameters included clinicopathological characteristics, treatment and prognosis conditions. Continuous data of abnormal distribution were expressed as median (range) and compared using the Mann-Whitney U-test. Survival curves were drawn by the Kaplan-Meier method and compared with the Log-rank test. Results: Of the 20 EGIST patients, 8 were males and 12 were females with age of 61.0 (30.0 to 86.0) years and of the 32 DGIST patients, 12 were males and 20 were females with age of 55.5 (27.0 to 70.0) years. Compared with DGIST patients, EGIST patients were older (U=188.000, P=0.012], had larger tumor size [10.0 (3.0 to 29.0) cm vs. 4.0 (1.5 to 10.0) cm, U=98.500, P<0.001] and higher ratio of high risk classification [85.0% (17/20) vs. 12.5% (4/32), χ²=26.870, P<0.001]. Among the 20 EGIST patients, 5 were diagnosed with distal metastasis and received imatinib (400 mg/d), and the other 15 patients underwent radical resection who were included in survival analysis. All the 32 DGIST patients underwent radical resection. The median follow-up of whole group was 43 (14 to 76) months. The 3-year recurrence/metastasis-free survival rate of 15 cases undergoing radical resection in the EGIST group was 85.6%, which was lower than that of the DGIST group (88.6%), and the difference was not statistically significant (P=0.745). There was no significant difference in the 3-year overall survival rate between the EGIST group (92.9%) and the DGIST group (100%) (P=0.271). Conclusions As compared to DGIST, EGIST mostly occurs in those with older age, larger tumor size and higher risk grade. The prognosis of EGIST patients after radical resection is similar to that of DGIST patients.

Objective To investigate the differences of clinicopathological features, diagnosis, treatment and prognosis between patients with extra?gastrointestinal stromal tumors (EGIST) and duodenal gastrointestinal stromal tumors (DGIST). Methods A retrospective case?control study was performed. Case inclusion criteria: (1) tumor confirmed by histology and pathology; (2) primary tumor locating in the extra?gastrointestinal tract or duodenum; (3) without other synchronous tumors; (4) complete clinical and pathological data. Clinical data of 20 EGIST patients and 32 DGIST patients from March 2011 to September 2016 at Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine were retrospectively collected and analyzed. The observational parameters included clinicopathological characteristics, treatment and prognosis conditions. Continuous data of abnormal distribution were expressed as median (range) and compared using the Mann?Whitney U?test. Survival curves were drawn by the Kaplan?Meier method and compared with the Log?rank test. Results Of the 20 EGIST patients, 8 were males and 12 were females with age of 61.0 (30.0 to 86.0) years and of the 32 DGIST patients, 12 were males and 20 were females with age of 55.5 (27.0 to 70.0) years. Compared with DGIST patients, EGIST patients were older (U=188.000, P=0.012], had larger tumor size [10.0 (3.0 to 29.0) cm vs. 4.0 (1.5 to 10.0) cm, U=98.500, P<0.001] and higher ratio of high risk classification [85.0% (17/20) vs. 12.5% (4/32), χ2=26.870, P<0.001]. Among the 20 EGIST patients, 5 were diagnosed with distal metastasis and received imatinib (400 mg/d), and the other 15 patients underwent radical resection who were included in survival analysis. All the 32 DGIST patients underwent radical resection. The median follow?up of whole group was 43 (14 to 76) months. The 3?year recurrence/metastasis?free survival rate of 15 cases undergoing radical resection in the EGIST group was 85.6%, which was lower than that of the DGIST group (88.6%), and the difference was not statistically significant (P=0.745). There was no significant difference in the 3?year overall survival rate between the EGIST group (92.9%) and the DGIST group (100%) (P=0.271). Conclusions As compared to DGIST, EGIST mostly occurs in those with older age, larger tumor size and higher risk grade. The prognosis of EGIST patients after radical resection is similar to that of DGIST patients.

Objective To investigate the differences of clinicopathological features, diagnosis, treatment and prognosis between patients with extra?gastrointestinal stromal tumors (EGIST) and duodenal gastrointestinal stromal tumors (DGIST). Methods A retrospective case?control study was performed. Case inclusion criteria: (1) tumor confirmed by histology and pathology; (2) primary tumor locating in the extra?gastrointestinal tract or duodenum; (3) without other synchronous tumors; (4) complete clinical and pathological data. Clinical data of 20 EGIST patients and 32 DGIST patients from March 2011 to September 2016 at Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine were retrospectively collected and analyzed. The observational parameters included clinicopathological characteristics, treatment and prognosis conditions. Continuous data of abnormal distribution were expressed as median (range) and compared using the Mann?Whitney U?test. Survival curves were drawn by the Kaplan?Meier method and compared with the Log?rank test. Results Of the 20 EGIST patients, 8 were males and 12 were females with age of 61.0 (30.0 to 86.0) years and of the 32 DGIST patients, 12 were males and 20 were females with age of 55.5 (27.0 to 70.0) years. Compared with DGIST patients, EGIST patients were older (U=188.000, P=0.012], had larger tumor size [10.0 (3.0 to 29.0) cm vs. 4.0 (1.5 to 10.0) cm, U=98.500, P<0.001] and higher ratio of high risk classification [85.0% (17/20) vs. 12.5% (4/32), χ2=26.870, P<0.001]. Among the 20 EGIST patients, 5 were diagnosed with distal metastasis and received imatinib (400 mg/d), and the other 15 patients underwent radical resection who were included in survival analysis. All the 32 DGIST patients underwent radical resection. The median follow?up of whole group was 43 (14 to 76) months. The 3?year recurrence/metastasis?free survival rate of 15 cases undergoing radical resection in the EGIST group was 85.6%, which was lower than that of the DGIST group (88.6%), and the difference was not statistically significant (P=0.745). There was no significant difference in the 3?year overall survival rate between the EGIST group (92.9%) and the DGIST group (100%) (P=0.271). Conclusions As compared to DGIST, EGIST mostly occurs in those with older age, larger tumor size and higher risk grade. The prognosis of EGIST patients after radical resection is similar to that of DGIST patients.

OBJECTIVETo investigate the clinicopathological features and postoperative short-term complications in the elderly gastric cancer patients.

METHODSClinical data of 270 elderly patients with gastric cancer who underwent gastrectomy in Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine between July 2012 and June 2014 were analyzed retrospectively. Among 270 patients, 220 were 70 to 79 years old( old group) and 50 were ≥80 years old(oldest group). The clinicopathological features were compared between the two groups. Perioperative factors were analyzed to determine if they are associated with postoperative complications. Multivariate logistic regression model was performed.

RESULTSBefore operation, most elderly patients (n=161, 59.6%) had 2 or more than 2 comorbidities, including hypertension (n=154, 57.0%), anaemia (n=126, 46.7%), diabetes (n=53, 19.6%), arhythmia (n=52, 19.3%), cardiovascular disease(n=33, 12.2%), and chronic pulmonary disease(n=28, 10.4%). Elderly gastric cancers were more likely to locate at the lower third of the stomach (n=116, 43.0%). The pathological type was mainly the poorly differentiated carcinoma (n=152, 56.3%), and stage III was more common in TNM staging(n=138, 51.1%). As compared to the old group, the oldest group had more preoperative comorbid diseases(P=0.048), more previous surgery(P=0.029), more preoperative transfusion (P=0.019), more combined cholecystectomy (P=0.007) and feeding jejunostomy (P=0.037), but less tumor invasion of nerves(P=0.045). No significant differences in other clinicopathological parameters were found between the two groups (all P>0.05). A total of 121 (44.8%) patients presented postoperative complications, including severe complication in 30 cases(11.1%) and death in 4 cases(1.5%). Forty-seven patients(17.4%) presented operation-associated complications, including infection in 28 cases(10.4%) and leakage in 21 cases(7.8%). One hundred and seven(39.6%) patients presented non-operation-associated complications, including pneumonia in 48 cases(17.8%), hypertension in 23 cases(8.5%), and arhythmia in 17 cases(6.3%). Postoperative morbidities of Clavien-Dindo class II complication and non-operation-associated complication were higher in the oldest group compared with old group(P<0.05), while other postoperative complications were compared between the two groups, only urinary tract infection was significantly different(P<0.05). Univariate analysis showed that postoperative complications were significantly associated with age(χ(2)=7.308, P=0.007), number of comorbid diseases (χ(2)=10.872, P=0.001), cardiovascular disease (χ(2)=9.412, P=0.002), hypertension (χ(2)=4.934, P=0.026) and preoperative transfusion (χ(2)=3.911, P=0.048). Multivariate analysis showed that only the number of comorbid diseases was an independent risk factor for postoperative complications(OR=2.810, 95% CI: 1.710 to 4.616, P=0.000).

CONCLUSIONNon-operation-associated postoperative complications are more likely to occur in the elderly patients due to more comorbid diseases. Perioperative intensive care should be carried out for the elderly gastric cancer patients with comorbid diseases in order to improve surgical safety and efficacy.

Aged ; Aged, 80 and over ; China ; Comorbidity ; Gastrectomy ; adverse effects ; Humans ; Hypertension ; complications ; Logistic Models ; Multivariate Analysis ; Neoplasm Staging ; Postoperative Complications ; Retrospective Studies ; Risk Factors ; Stomach Neoplasms ; complications ; surgery