A 20-year-old male patient presented to the Department of Dermatology of Peking Union Medical College Hospital with complaints of an 8-year history of facial scarring, swelling of the lower limbs, and a 4-year history of scalp thickening. Physical examination showed thickening furrowing wrinkling of the skin on the face and behind the ears, ciliary body hirsutism, blepharoptosis, and cutis verticis gyrate. Both lower limbs were swollen, especially the knees and ankles. The skin of the palms and soles of the feet was keratinized and thickened. Laboratory examination using bone and joint X-ray showed periostosis of the proximal middle phalanges and metacarpals of both hands, distal ulna and radius, tibia and fibula, distal femurs, and metatarsals.Genetic testing revealed two variants in SLCO2A1, c.1658T > A and c.96+4A > C.Through multidisciplinary consultation, we confirmed the diagnosis of pachydermoperiostosis.

Objective To investigate the expression of serum homeobox C9(HOXC9)in patients with hepatocellular carcinoma(HCC)and its prognostic value.Methods A total of 79 patients with HCC(HCC group)and 72 patients with benign liver disease(benign liver disease group)were selected as the study ob-jects from the Affiliated Lianyungang Oriental Hospital of Kangda College of Nanjing Medical University from March 2020 to February 2021.Another 75 healthy subjects in the same period were selected in a hospital as healthy control group.The serum HOXC9 level was detected by enzyme-linked immunosorbent assay and the serum alpha-fetoprotein(AFP)level was detected by chemiluminescence assay.The relationship between serum HOXC9 level and clinicopathological features of HCC patients was analyzed,and Kaplan-Meier survival curve was used to analyze the relationship between serum HOXC9 level and HCC prognosis,and the receiver operating characteristic curve was drawn to analyze the diagnostic efficacy.Results The levels of HOXC9 and AFP in HCC group were significantly higher than those in benign liver disease group and healthy control group,and the difference was statistically significant(P＜0.05).HOXC9 positive group was correlated with tumor differentiation,TNM stage,vascular invasion and lymph node metastasis(x2=4.521,3.526,2.758,3.787,all P＜0.05).The 3-year survival rate was 64.71％(44/68)in the HOXC9 positive group and 81.82％(9/11)in the HOXC9 negative group.Kaplan-Meier survival curve analysis showed that the 3-year survival rate of HOXC9 positive group was lower than that of HOXC9 negative group,and the prognosis of HOXC9 positive group was worse,the difference was statistically significant(x2=5.367,P＜0.05).Cox multivariate analysis showed that multiple lesions,vascular infiltration,TNM stage Ⅲ-Ⅳ stage and HOXC9≥100 mAU/mL were independent risk factors for poor prognosis in HCC patients.The area under the curve of HOXC9 and AFP combined detection was 0.946(95％CI:0.876-0.979),which was significantly higher than that of single detection,and the differences were statistically significant(Z=0.871,0.511,P＜0.05).Conclu-sion The detection of serum HOXC9 level is helpful to evaluate the prognosis of HCC patients,and can be used as a biomarker for the prognosis of HCC patients.

Gastric cancer is a prevalent malignancy of the digestive system, and traditional laparoscopic radical gastrectomy remains a crucial treatment modality. However, the abdominal wound associated with specimen removal during this procedure conflicts with contemporary concept of minimally invasive surgery. Natural orifice specimen extraction surgery (NOSES) is an emerging minimally invasive surgical technique that has gained increasing utilization in patients with gastrointestinal tumors, owing to its benefits of reduced wound, accelerated postoperative recovery, and diminished postoperative pain. In recent years, the extensive application of NOSES technology for colorectal cancer in China has provided theoretical support for the minimally invasive treatment of gastric cancer. With the standardization of community health examinations in China, the incidence of early gastric cancer diagnoses is expected to rise, making NOSES surgery the likely future trend in the surgical treatment for early gastric cancer. However, this area remains under-explored both domestically and internationally. This paper aims to synthesize prior literature and review the historical development, current research status, advantages and disadvantages, technical challenges, and future directions of completely laparoscopic radical treatment of distal gastric cancer utilizing NOSES.

Gastric cancer is a prevalent malignancy of the digestive system, and traditional laparoscopic radical gastrectomy remains a crucial treatment modality. However, the abdominal wound associated with specimen removal during this procedure conflicts with contemporary concept of minimally invasive surgery. Natural orifice specimen extraction surgery (NOSES) is an emerging minimally invasive surgical technique that has gained increasing utilization in patients with gastrointestinal tumors, owing to its benefits of reduced wound, accelerated postoperative recovery, and diminished postoperative pain. In recent years, the extensive application of NOSES technology for colorectal cancer in China has provided theoretical support for the minimally invasive treatment of gastric cancer. With the standardization of community health examinations in China, the incidence of early gastric cancer diagnoses is expected to rise, making NOSES surgery the likely future trend in the surgical treatment for early gastric cancer. However, this area remains under-explored both domestically and internationally. This paper aims to synthesize prior literature and review the historical development, current research status, advantages and disadvantages, technical challenges, and future directions of completely laparoscopic radical treatment of distal gastric cancer utilizing NOSES.

OBJECTIVETo compare the short-term outcomes between robotic and laparoscopic radical total gastrectomy in gastric cancer patients with BMI index ≥24 kg/m.

METHODClinical data of 93 gastric cancer patients who underwent robotic and laparoscopic radical total gastrectomy at PLA General Hospital from April 2016 to April 2017 were retrospectively analyzed. The retrospective cohort study was adopted.

INCLUSION CRITERIApreoperatively definite diagnosis of primary gastric cancer by endoscopy and biopsy; preoperative BMI ≥24 kg/m; no previous abdominal surgery; no previous chemotherapy and radiotherapy; no distant metastasis or invasion into adjacent organs before operation or during operation; receiving radical gastrectomy; Roux-en-Y reconstruction of digestive tract in open procedure. According to approaches of minimally invasive surgery, 24 patients underwent robotic surgery and 69 underwent laparoscopic surgery. The intraoperative parameters (overall operative time, pneumoperitoneal time, open procedure time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes and metastatic lymph nodes) and postoperative parameters (drainage in the first postoperative day, the first defecation time, morbidity of postoperative complication and hospital stay) were compared between two groups. Correlation of the above parameters were analyzed.

RESULTSOf 93 patients, 77 were male and 16 female with an average age of (60.0±10.6) years. The average BMI was (26.8±1.3) kg/m in whole patients, (26.9±1.6) kg/m in robotic group and (26.8±1.7) kg/m in laparoscopic group. No significant differences in age, gender, BMI, preoperative ASA class, postoperative pathological findings and clinical classification were observed between two groups, which made short-term parameters between two groups comparable. The robotic group had a significantly longer overall operative time [(301.2±68.9) minutes vs. (247.3±59.6) minutes, P=0.000], longer open procedure time [(141.5±26.3) minutes vs. (92.5±36.7) minutes, P=0.029] and higher cost than laparoscopy group[(17.5×10 ± 9.7×10) yuan vs. (10.0×10 ± 2.3×10) yuan, P=0.001]. Pneumoperitoneal operative time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes, number of harvested metastatic lymph nodes and postoperative short-term efficacy were similar between the two groups (all P>0.05). In robotic group, pneumoperitoneal operative time was positively correlated with overall operative time (r=0.708, P=0.010); total cost was positively correlated with postoperative hospital stay (r=0.493, P=0.000) and open procedure time was negatively correlated with the first defecation time (r=-0.962, P=0.038). In laparoscopy group, total cost was positively correlated with overall operative time (r=0.411, P=0.046), drainage volume in the first postoperative day was positively correlated with the number of total dissected lymph node (r=0.540, P=0.006), postoperative hospital stay was positively correlated with intraoperative blood loss (r=0.574, P=0.003), total cost was positively correlated with intraoperative blood loss and hospital stay (r=0.609, P=0.002; r=0.865, P=0.000), drainage volume in the first postoperative day was positively correlated with BMI (r=0.533, P=0.007).

CONCLUSIONFor gastric cancer patients with BMI ≥24 kg/m, robotic radical total gastrectomy is associated with longer operative time and higher cost, but is less vulnerable to the change of BMI and more in favor of the realization of enhanced recovery after surgery (ERAS) than laparoscopic radical total gastectomy.

Aged ; Body Mass Index ; Female ; Gastrectomy ; methods ; Humans ; Laparoscopy ; Length of Stay ; Male ; Middle Aged ; Operative Time ; Retrospective Studies ; Robotic Surgical Procedures ; Stomach Neoplasms ; surgery ; Treatment Outcome

Objective To study the clinical efficacy of Bikini incision minimally invasive total hip arthroplasty on elder patients with femoral head necrosis and its effect on bleeding.Methods Seventy-six elder patients with femoral head necrosis in Sanmenxia Central Hospital from January 2015 to December 2016 were randomly divided into the study group(38 cases)and the control group(38 cases).The patients in the study group were treated with Bikini incision minimally invasive total hip arthroplasty by anterior approach,while the control group underwent total hip arthroplasty by anterolateral approach.Harris score and WOMAC score were used to evaluate the clinical function of hip joint.The operation time,length of incision,intraoperative blood loss, blood transfusion,hospitalization time,hemoglobin level at 72 h after surgery,the first ambulation time,the lower limb length discrepancy,postoperative complication were recorded and compared between two groups.Results The Harris scores at 1,2,4 months after operation in the two groups were significantly improved(P<0.05), while WOMAC scores of patients at 1,2,4 months after operation were significantly lower than those before treatment(P<0.05).However,there were no significant differences at different time between the groups(P>0.05).The hospitalization time and the first ambulation time in the study group were significantly shorter than those in the control group((6.1±2.8)d vs.(7.9±3.2)d,P=0.011;(5.3±1.5)d vs.(6.4±1.7)d,P=0.004).After 4 months of treatment,the lower limb length discrepancy in the study group was less than that of the control group((6.5 ± 2.3)mm vs.(10.4 ± 3.5)mm,P<0.01).In addition,there were no significant differences between two groups in the operation time,length of incision,complication occurrence,intraoperative blood loss and blood transfusion(P>0.05).Conclusion Treating femoral head necrosis with Bikini incision minimally invasive total hip arthroplasty can achieve favorable effectiveness,with no increase in intraoperative blood loss and rapid recovery of postoperative joint function,but further follow-up is needed.

Objective To investigate the clinical values of CA199 ,CA242 and DKK1 in diagnosing pancreatic cancer (PCA). Methods The serum levels of CA199 ,CA242 and DKK1 were measured with ECLIA and ELISA method in 112 patients with PCA ,58 patients with benign pancreatic disease and 62 individuals undergoing physical examination.The Kruskal-Wallis single fac-tor analysis of variance (ANOVA) and Mann-Whitney rank-sum test were adopted to conduct the statistical comparison.The ROC curve was drawn by using the Logistic regression model and the area under curve (AUCROC ) was calculated.Results The levels of serum CA199 ,CA242 and DKK1 in the patients with pancreatic cancer were significantly higher than those in the benign pancreatic disease group and healthy normal control group ,the difference was statistically significant ( H=76.30 ,61.2 ,47.60 ,P<0.05);the sensitivities of CA199 ,CA242 and DKK1 for diagnosing pancreatic cancer were 76.7% ,69.6% and 85.7% respectively ;the speci-ficities were 95.0% ,96.7% and 92.5% respectively ;the accuracies were 86.2% ,83.6% and 89.2% respectively.The sensitivity , specificity and accuracy of combined detection of CA 199 ,CA242 and DKK1 by the Logistic regression equation P= 1/[1 +e-(-4.163+0.21X1+0.156X2+0.342X3) ] were 94.4% ,90.8% and 92.2% respectively ;AUC of CA199 ,CA242 ,DKK1 and pre-1 were 0.736 , 0.862 ,0.886 and 0.949 ,respectively.Conclusion Serum CA199 ,CA242 and DKK1 levels have an important value in the diagnosis of pancreatic cancer ,and their combined detection could significantly improve the sensitivity and accuracy of pancreatic cancer diag-nosis.

Objective To investigate the consensus and controversies on the delineation of radiotherapy target volume for patients with locally advanced non-small cell lung cancer (LA-NSCLC).Methods Questionnaires including 15 questions on the delineation of radiotherapy target volume of NSCLC were sent to 12 radiation departments in China in November 2015.A patient with LA-NSCLC was selected by Fudan University Shanghai Cancer Center, and simulation CT images and medical history data were sent to the 12 radiation departments.Twelve radiation oncologists from the 12 radiation departments showed and explained the delineation of radiotherapy target volume of their own, and the patient was discussed by all experts in the sixth multidisciplinary summit forum of precise radiotherapy and chemotherapy for tumor and lung cancer.Results All receivers of the questionnaire answered the questions.The standard lung window width/level for the delineation of lung cancer was 800-1600/-600 to-750 HU, and the mediastinum window was 350-400/20-40 HU.Respiratory movement was measured by stimulator, 4D-CT, and stimulator+4D-CT with 2-5 mm expansion based on experience.The primary clinical target volume (CTV) was defined as gross target volume (GTV) plus 5-6 mm for squamous carcinoma/5-8 mm for adenocarcinoma.The metastatic lesion of mediastinal lymph nodes was delineated as 5 mm plus primary lesion in 6 departments and as primary lesion in another 6 departments.Of the 12 departments, 10 applied 5 mm of set-up error, 1 applied 3 mm, and 1 applied 4-6 mm.For V20 of the lungs, 10 departments defined it as<30%, 1 as<35%, and 1 as 28%.Nine departments defined the radiation dose of concurrent chemoradiotherapy (CCRT) for LA-NSCLC as 60 Gy in 30 fractions, 62.7 Gy in 33 fractions in 1 department, 50-60 Gy in 25-30 fractions in 1 department, and 60-70 Gy in 25-30 fractions in 1 department.For the delineation of target volume for the LA-NSCLC patient treated with CCRT, the primary planning target volume (PTV) was defined as GTV plus organ movement (IGTV) and set-up error (GTV→IGTV→PTV) in 3 departments, as CTV plus organ movement (ITV) and set-up error (GTV→CTV→ITV→PTV) in 8 departments, and as CTV plus set-up error/IGTV plus 5-6 mm for squamous carcinoma/5-8 mm for adenocarcinoma (CTV) and set-up error (GTV→CTV→PTV/GTV→IGTV→CTV→PTV) in 1 department.For the delineation of PTV in the mediastinal lymph node, GTV→IGTV→PTV was performed in 3 departments, GTV→CTV→ITV→PTV in 8 departments, and GTV→CTV→PTV in 1 department.For 10%-100% patients with LA-NSCLC, the radiation field needed to be replanned when 38-50 Gy was completed.There was no unified standard for the optimal standardized uptake value (SUV) of positron emission tomography (PET)-computed tomography (CT) simulation and delineation.Seven departments had applied magnetic resonance imaging (MRI) simulation and 10 departments had applied stereotactic body radiation therapy (SBRT) for the treatment of early-stage NSCLC.For the delineation of PTV for early-stage NSCLC (T1-2N0M0), GTV→IGTV→PTV was performed in 5 departments, IGTV→PTV in 3 departments, and GTV→CTV→ITV→PTV in 2 departments.In all the 12 departments, peripheral early-stage NSCLC was given 6.0-12.5 Gy/fraction, 3-12 fractions and central early-stage NSCLC was given 4.6-10.0 Gy/fraction, 5-10 fractions.The results of discussion on the delineation of target volume for the patient were as follows:respiratory movements should be measured by 4D-CT or simulator;the lung window width/level is 1600/-600 HU and the mediastinal window width/level is 400/20 HU;the primary controversy is whether the involved-field irradiation or elective nodal irradiation should be used for the delineation of CTVnd in the mediastinal lymph node.Conclusions Basic consensus is reached for the delineation of target volume in LANSCLC in these aspects:lung window width/level, respiratory movements and set-up error, primary lesion delineation, the radiation dose in CCRT, and the optimal time for replanning the radiation field.There are controversies on the optimal SUV in the delineation of target volume based on PET-CT simulation, the optimal dose fractionation in SBRT for early-stage NSCLC, and the delineation of CTVnd.

Objective To discuss the clinical value of new- utility anal vacuum tube in preventing anastomotic fistula after colorectal cancer anterior resection. Methods Ninety-six patients having underwent the colorectal cancer anterior resection were divided into new-utility anal vacuum tube group and normal anal vacuum tube group by random digits table method with 48 cases each. The complication, anus exhaust time and postoperative drainage volume were compared between 2 groups. Results The incidences of tube defluxion, proctalgia, anus skin damage, bed sheet pollution and anastomotic fistula in new-utility anal vacuum tube group were significantly lower than those in normal anal vacuum tube group: 6.25% (3/48) vs. 31.25% (15/48), 10.42% (5/48) vs. 41.67% (20/48), 0 vs. 25.00%(12/48), 6.25%(3/48) vs. 60.42%(29/48), 2.08%(1/48) vs. 12.50%(6/48), the anus exhaust time was significantly shorter than that in normal anal vacuum tube group:(44.1 ± 8.9) h vs. (48.9 ± 9.6) h, the postoperative drainage volumes form the first day to fifth day were significantly more than those in normal anal vacuum tube group: (31.2 ± 15.1) ml vs. (15.6 ± 8.2) ml, (25.3 ± 13.2) ml vs. (15.8 ± 6.5) ml, (15.6 ± 9.1) ml vs. (10.3 ± 4.5) ml, (104.3 ± 38.2) ml vs. (90.6 ± 12.3) ml and (93.7 ± 32.5) ml vs. (80.7 ± 18.9) ml, and there were statistical differences (P<0.01 or <0.05). The patients in new-utility anal vacuum tube group had different symptoms, but patients could tolerate. Conclusions The new-utility anal vacuum tube can reduce the incidence of anastomotic fistula, and be safe and reliable, which is worthy of wide application.

Objective To detect the serum levels of 25‐hydroxy vitamin D[25‐(OH)D] ,homocysteine(HCY) andβ2‐microglob‐ulin(β2‐MG) in the patients with type 2 diabetes mellitus (T2DM ) and to investigate the relationship between serum HCY and β2‐MG with 25‐(OH)D and its clinical significance .Methods A total of 139 cases of T2DM were selected anddivided into 3 groups , the normal albuminuria group for [urinary albumin to creatinine ratio (UACR)< 30 mg/gCr ,45 cases] ,microalbuminuria group (UACR ≥ 30 mg/gCr and < 300 mg/gCr ,48 cases) and massive proteinuria group (UACR ≥ 300 mg/gCr ,46 cases) according to the urinary albumin to creatinine ratio (UACR) .Other 45 individuals undergoing the physical examination were selected as the con‐trol group .The serum 25‐(OH)D level was measured by electrochemiluminescence .Serum HCY level was determined by the enzy‐matic method .Serum β2‐MG level was measured by the latex enhanced immune turbidity method .At the same time ,the biochemical indicators of FBG ,HbA1C ,serum calcium and phosphorus were measured .Results The serum 25‐(OH)D level was decreased with the increase of urinary albumin in the DM patients .And the serum 25‐(OH)D level in the microalbuminuria group and the massive proteinuria group was significantly decreased compared with the normal albuminuria group and the control group ,the difference was statistically significant(P<0 .01) .The serum HCY and β2‐MG levels in the microalbuminuria group and the massive proteinuria group were significantly increased compared with the healthy control group ,the difference was statistically significant (P<0 .05) . Conclusion The serum 25‐(OH)D level is decreased with the increase of urinary albumin in the diabetic patients .The serum HCY andβ2‐MG levels are increased with the increase of urinary albumin and serum 25‐(OH)D level is negatively correlated with the HCY andβ2‐MG levels .