Objective:To examine the clinical value of rapid detection of drug-resistant bacteria by immunochromatography and the effects of rapid detection on the prognosis of patients with severe intra-abdominal infection complicated by carbapenem-resistant Enterobacteriaceae (CRE) bloodstream infection.Methods:This was a retrospective cohort study. We analyzed clinical data of 73 patients with severe abdominal infections with sepsis or septic shock complicated by CRE bloodstream infection admitted to the general surgery department of Jinling Hospital between February 2022 and February 2023. Patients were divided into a colloidal gold immunochromatographic assay (GICA) group (17 patients) and conventional testing group (56 patients) based on whether a GICA for CRE had been performed on the patients' first blood culture sample during the diagnosis and treatment process. There were no statistically significant differences between the GICA and conventional testing groups in age ([55.9±17.3] vs. [47.6±16.4] years), sex ([16 men vs. one woman ] vs. [41 men vs. 15 women]), median Charlson comorbidity index (3.0[2.0,4.0] vs. 3.0[2.0, 4.8]), septic shock (10 vs. 39), or acute kidney injury (8 vs. 40) (all P>0.05). Both groups routinely underwent traditional bacterial identification and drug susceptibility testing. Additionally, patients in the GICA group were tested directly for positive blood cultures using a GICA carbapenemase test kit. The main outcomes were mortality rates on Days 28 and 90 after the first identification of CRE bloodstream infection in both groups. We also compared the microbial clearance rate, duration of hospitalization and intensive care unit stay, and time from onset of CRE bloodstream infection to initiation of targeted and appropriate antibiotics between the two groups. Results:The rate of microbial clearance of bloodstream infection was significantly greater in the GICA group than in the conventional testing group (15/17 vs. 34/56 [60.7%], χ 2=4.476, P=0.034), whereas the 28-day mortality tended to be lower in the GICA than conventional testing group [5/17 vs. 44.6% [25/56], χ 2=1.250, P=0.264). The 90-day mortality (8/17 vs. 53.6% [30/56], χ 2=0.222, P=0.638), median duration of hospitalization (37.0 [18.0, 46.5] days vs. 45.5 [32.2, 64.8] days, Z=-1.867, P=0.062), and median duration of intensive care unit stay (18.0 [6.5, 35.0] days vs. 32.0 [5.0, 51.8] days, Z=-1.251, P=0.209). The median time between the onset of bloodstream infection and administration of antibiotics was 49.0 (38.0, 69.0) hours in the GICA group, which is significantly shorter than the 163.0 (111.8, 190.0) hours in the conventional testing group ( Z=-5.731, P<0.001). The median time between the onset of bloodstream infection and administration of appropriate antibiotics was 40.0 (34.0, 80.0) hours in the GICA group, which is shorter than in the conventional testing group (68.0 [38.2, 118.8]) hours; however, this difference is not statistically significant ( Z=-1.686, P=0.093). Conclusions:GICA can provide information on carbapenemase- producing pathogens faster than traditional drug sensitivity testing, enabling early administration of the optimal antibiotics. The strategy of 'carbapenemase detection first' for managing bacterial infection has the potential to improve prognosis of patients and reduce mortality rate.

Objective:The purpose of this study was to analyze the course and outcome of patients with combined entero-atmospheric fistulas in open abdomen treatment.Methods:In this retrospective observational study, we collected data on 214 patients with open abdomen complicated by entero-atmospheric fistulas admitted to Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School from January 2012 to January 2021. We collected their basic characteristics, aetiology, treatment plan, and prognosis, including the durations of hospitalization and open treatment, time to resumption of enteral nutrition, duration and prognosis of definitive surgery, and overall prognosis.Results:Of the 214 patients with open abdomen complicated with entero–enteral fistulas, 23 (10.7%) died (11 of multiple organ failure caused by abdominal infection, five of abdominal cavity bleeding, four of pulmonary infection, one of airway bleeding, one of necrotizing fasciitis, and one of traumatic brain injury). The remaining 191 underwent definitive surgery at our hospital. The patients who underwent definitive surgery were predominantly male (156 patients, 81.7%); their age was (46.5±2.5) years. Trauma and gastrointestinal tumors (120 cases, 62.8%) predominated among the primary causes. The reasons for abdominal opening were, in order, severe abdominal infection (137 cases, 71.7%, damage control surgery (29 cases, 15.2%), and abdominal hypertension (25 cases, 13.1%). Temporary abdominal closure measures were used to classify the participants into a skin-only suture group (104 cases) and a skin-implant group (87 cases). Compared with the skin-implant group, in the skin-suture-only group the proportion of male patients was lower (74.7% [65/87] vs. 87.5% [91/104], χ 2=5.176, P=0.023), the mean age was older ([48.3±2.0] years vs. [45.0±1.9] years, t=-11.671, P<0.001), there were fewer patients with trauma (32.2% [28 /87] vs. 58.7% [61/104), χ 2=13.337, P<0.001), intensive care stays were shorter ([8.9±1.0] days vs. [12.7±1.6] days, t=19.281, P<0.001), total length of stay was shorter ([29.3±2.0] days vs. [31.9±2.0] days, t=9.021, P<0.001), there was a higher percentage of colonic fistulas (18.4% [16/87] vs. 8.7% [9/104], χ 2=3.948, P=0.047), but fewer multiple fistulas (11.5% [10/87] vs. 34.6% [36/104], χ 2=14.440, P<0.001). As to fistula management, a higher percentage of fistula sealing methods using 3D-printed intestinal stents were implemented in the skin-only suture group (60.9% [53/87] versus 43.3% [45/104], χ 2=5.907, P=0.015). Compared with the implant group, the skin-only suture group had a shorter mean time to performing provisional closure ( [9.5±0.8] days vs. [16.0±0.6] days, t=66.023, P<0.001), shorter intervals to definitive surgery ( [165.0±10.7] days vs. [198.9±8.3] days, t=26.644, P<0.001), and less use of biopatches (56.3% [49/87) vs. 71.2% [74/104], χ 2=4.545, P=0.033). Conclusions:Open abdomen complicated with entero-enteral fistulas is more common in male, and is often caused by trauma and gastrointestinal tumor. Severe intra-abdominal infection is the major cause of open abdomen, and most fistulae involves the small intestine. Collection and retraction of intestinal fluid and 3D-printed entero-enteral fistula stent sealing followed by implantation and skin-only suturing is an effective means of managing entero-enteral fistulas complicating open abdominal cavity. Earlier closure of the abdominal cavity with skin-only sutures can shorten the time to definitive surgery and reduce the rate of utilization of biopatches.

Objective:To examine the clinical value of rapid detection of drug-resistant bacteria by immunochromatography and the effects of rapid detection on the prognosis of patients with severe intra-abdominal infection complicated by carbapenem-resistant Enterobacteriaceae (CRE) bloodstream infection.Methods:This was a retrospective cohort study. We analyzed clinical data of 73 patients with severe abdominal infections with sepsis or septic shock complicated by CRE bloodstream infection admitted to the general surgery department of Jinling Hospital between February 2022 and February 2023. Patients were divided into a colloidal gold immunochromatographic assay (GICA) group (17 patients) and conventional testing group (56 patients) based on whether a GICA for CRE had been performed on the patients' first blood culture sample during the diagnosis and treatment process. There were no statistically significant differences between the GICA and conventional testing groups in age ([55.9±17.3] vs. [47.6±16.4] years), sex ([16 men vs. one woman ] vs. [41 men vs. 15 women]), median Charlson comorbidity index (3.0[2.0,4.0] vs. 3.0[2.0, 4.8]), septic shock (10 vs. 39), or acute kidney injury (8 vs. 40) (all P>0.05). Both groups routinely underwent traditional bacterial identification and drug susceptibility testing. Additionally, patients in the GICA group were tested directly for positive blood cultures using a GICA carbapenemase test kit. The main outcomes were mortality rates on Days 28 and 90 after the first identification of CRE bloodstream infection in both groups. We also compared the microbial clearance rate, duration of hospitalization and intensive care unit stay, and time from onset of CRE bloodstream infection to initiation of targeted and appropriate antibiotics between the two groups. Results:The rate of microbial clearance of bloodstream infection was significantly greater in the GICA group than in the conventional testing group (15/17 vs. 34/56 [60.7%], χ 2=4.476, P=0.034), whereas the 28-day mortality tended to be lower in the GICA than conventional testing group [5/17 vs. 44.6% [25/56], χ 2=1.250, P=0.264). The 90-day mortality (8/17 vs. 53.6% [30/56], χ 2=0.222, P=0.638), median duration of hospitalization (37.0 [18.0, 46.5] days vs. 45.5 [32.2, 64.8] days, Z=-1.867, P=0.062), and median duration of intensive care unit stay (18.0 [6.5, 35.0] days vs. 32.0 [5.0, 51.8] days, Z=-1.251, P=0.209). The median time between the onset of bloodstream infection and administration of antibiotics was 49.0 (38.0, 69.0) hours in the GICA group, which is significantly shorter than the 163.0 (111.8, 190.0) hours in the conventional testing group ( Z=-5.731, P<0.001). The median time between the onset of bloodstream infection and administration of appropriate antibiotics was 40.0 (34.0, 80.0) hours in the GICA group, which is shorter than in the conventional testing group (68.0 [38.2, 118.8]) hours; however, this difference is not statistically significant ( Z=-1.686, P=0.093). Conclusions:GICA can provide information on carbapenemase- producing pathogens faster than traditional drug sensitivity testing, enabling early administration of the optimal antibiotics. The strategy of 'carbapenemase detection first' for managing bacterial infection has the potential to improve prognosis of patients and reduce mortality rate.

Objective:The purpose of this study was to analyze the course and outcome of patients with combined entero-atmospheric fistulas in open abdomen treatment.Methods:In this retrospective observational study, we collected data on 214 patients with open abdomen complicated by entero-atmospheric fistulas admitted to Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School from January 2012 to January 2021. We collected their basic characteristics, aetiology, treatment plan, and prognosis, including the durations of hospitalization and open treatment, time to resumption of enteral nutrition, duration and prognosis of definitive surgery, and overall prognosis.Results:Of the 214 patients with open abdomen complicated with entero–enteral fistulas, 23 (10.7%) died (11 of multiple organ failure caused by abdominal infection, five of abdominal cavity bleeding, four of pulmonary infection, one of airway bleeding, one of necrotizing fasciitis, and one of traumatic brain injury). The remaining 191 underwent definitive surgery at our hospital. The patients who underwent definitive surgery were predominantly male (156 patients, 81.7%); their age was (46.5±2.5) years. Trauma and gastrointestinal tumors (120 cases, 62.8%) predominated among the primary causes. The reasons for abdominal opening were, in order, severe abdominal infection (137 cases, 71.7%, damage control surgery (29 cases, 15.2%), and abdominal hypertension (25 cases, 13.1%). Temporary abdominal closure measures were used to classify the participants into a skin-only suture group (104 cases) and a skin-implant group (87 cases). Compared with the skin-implant group, in the skin-suture-only group the proportion of male patients was lower (74.7% [65/87] vs. 87.5% [91/104], χ 2=5.176, P=0.023), the mean age was older ([48.3±2.0] years vs. [45.0±1.9] years, t=-11.671, P<0.001), there were fewer patients with trauma (32.2% [28 /87] vs. 58.7% [61/104), χ 2=13.337, P<0.001), intensive care stays were shorter ([8.9±1.0] days vs. [12.7±1.6] days, t=19.281, P<0.001), total length of stay was shorter ([29.3±2.0] days vs. [31.9±2.0] days, t=9.021, P<0.001), there was a higher percentage of colonic fistulas (18.4% [16/87] vs. 8.7% [9/104], χ 2=3.948, P=0.047), but fewer multiple fistulas (11.5% [10/87] vs. 34.6% [36/104], χ 2=14.440, P<0.001). As to fistula management, a higher percentage of fistula sealing methods using 3D-printed intestinal stents were implemented in the skin-only suture group (60.9% [53/87] versus 43.3% [45/104], χ 2=5.907, P=0.015). Compared with the implant group, the skin-only suture group had a shorter mean time to performing provisional closure ( [9.5±0.8] days vs. [16.0±0.6] days, t=66.023, P<0.001), shorter intervals to definitive surgery ( [165.0±10.7] days vs. [198.9±8.3] days, t=26.644, P<0.001), and less use of biopatches (56.3% [49/87) vs. 71.2% [74/104], χ 2=4.545, P=0.033). Conclusions:Open abdomen complicated with entero-enteral fistulas is more common in male, and is often caused by trauma and gastrointestinal tumor. Severe intra-abdominal infection is the major cause of open abdomen, and most fistulae involves the small intestine. Collection and retraction of intestinal fluid and 3D-printed entero-enteral fistula stent sealing followed by implantation and skin-only suturing is an effective means of managing entero-enteral fistulas complicating open abdominal cavity. Earlier closure of the abdominal cavity with skin-only sutures can shorten the time to definitive surgery and reduce the rate of utilization of biopatches.

Objective:This study aims to reveal the special immune infiltrating environment and possible immune escape mechanism of giant cell tumor of bone through single-cell sequencing data.Methods:The fresh samples obtained from 4 patients with primary giant cell tumor of bone from January 2018 to December 2021 were collected, and single-cell transcriptome sequencing was performed on the 10X platform to explore the characteristics and immune environment of giant cell tumor of bone by using t-distributed stochastic neighbor embedding ( t-SNE). The main cell types and signal pathways of immune cell regulation and function in giant cell tumor of bone were observed by cell communication analysis. Results:Cell clustering, the definition of basic cell types, the classification of immune cells, and the mutual regulatory relationship between cell types were analyzed for 35 643 single-cell data from 4 giant cell tumor samples of bone. It was found that giant cell tumor of bone was composed of 9 basic cell types, in which the immune cells were mainly CD8 + T cells (51%) and the non-immune cells were mainly fibroblast like spindle stromal cells (74%). The immune infiltration of giant cell tumor of bone is dominated by cytotoxic CD8 + T cells and lacks exhausted CD8 + T cells. CD4 + T cells are characterized by high expression of immune checkpoint genes CTLA4 and TIGIT. In giant cell tumor of bone, immune cells mainly act on multinucleated osteoclast like giant cells through PARs and CCL signaling pathways, but not stromal cells. Conclusion:This study defined the main cell types of giant cell tumor of bone through single cell sequencing data, and further revealed the composition characteristics of its immune infiltration, and found that the target of its immune cells was mainly multinuclear osteoclast like giant cells, which provided effective information for further understanding the occurrence and development of giant cell tumor of bone.

Objective:To investigate the clinical value of cephalosporin combined with morinidazole in the prevention of surgical site infection (SSI) for gastrointestinal fistula.Methods:The retrospective cohort study was conducted. The clinicopathological data of 107 patients with gastrointestinal fistula who undergoing selective digestive tract reconstruction surgery in General Hospital of Eastern Theater Command from January to December 2017 were collected. There were 76 males and 31 females, aged from 18 to 79 years, with a median age of 46 years. Of 107 patients, 43 cases receiving cephalosporin for prevention of SSI were allocated into cephalosporin monotherapy group, 64 cases receiving cephalosporin combined with morinidazole were allocated into combination therapy group, respectively. Observation indicators: (1) incidence of SSI; (2) stratification; (3) pathogen culture results of SSI; (4) adverse drug reaction; (5) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect other complications of patients. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Incidence of SSI: 29 of 107 patients had postoperative SSI, including 15 cases with superficial SSI, 7 cases with deep SSI, and 7 cases with organ/space SSI. There were 18 cases of cephalosporin monotherapy group with SSI, including 7 cases with superficial SSI, 5 cases with deep SSI, and 6 cases with organ/space SSI. The above indicators were 11, 8, 2, 1 of combination therapy group, respectively. There was a significant difference in the overall SSI between the two groups ( χ2=7.925, P<0.05). There was also a significant difference in the organ/space SSI between the two groups ( P<0.05). There was no significant difference in the superficial SSI between the two groups ( χ2=0.305, P>0.05). There was no significant difference in the deep SSI between the two groups ( P>0.05). (2) Stratification: there were 10 cases and 33 cases with type Ⅱ incision and type Ⅲ incision in the 43 cases of cephalosporin monotherapy therapy group, respectively. The above indicators were 11 and 53 in the combination group, respectively. For the type Ⅱ incision, 1 patient of cephalosporin monotherapy group had SSI, and 2 cases of combination therapy group had SSI, showing no significant difference between the two groups ( P>0.05). For the type Ⅲ incision, 17 patient of cephalosporin monotherapy group had SSI, and 9 cases of combina-tion therapy group had SSI, showing a significant difference between the two groups ( χ2=11.499, P<0.05). (3) Pathogen culture results of SSI: of 29 patients with SSI, 21 were positive for bacterial culture, including 12 cases with single bacterial infection, 9 cases with mixed infection of multi-bacteria. A total of 33 strains were cultured. (4) Adverse drug reaction: there was no adverse drug reaction in the 107 patients. (5) Follow-up: 107 patients were followed up for 30 days after surgery. No complication occurred in the 107 patients. Conclusion:Cephalosporin combined with morini-dazole can be used to prevent the SSI for patients with gastrointestinal fistula.

Objective:To investigate the safety and feasibility of transgluteal percutaneous drainage using double catheterization cannula in the treatment of deep pelvic abscess.Methods:A retrospective analysis of the clinical data of patients who underwent transgluteal percutaneous drainage using double catheterization cannula with deep pelvic abscesses admitted to the Jinling Hospital from May 2017 to September 2020 was conducted. Seven patients were enrolled, including 5 males and 2 females, who aged 26-74 (median 53.0) years old, and all of them had digestive fistula. One male patient was punctured again due to the tube falling off, and a total of 7 patients underwent 8 times of transgluteal percutaneous drainage, all under the guidance of CT. The puncture and drainage steps of the double catheterization cannula group are as follows: (1) Locate the puncture point under CT in the lateral position; (2) Place the trocar into the abscess cavity; (3) Confirm that the trocar is located in the abscess cavity under CT; (4) Pull out the inner core and insert into the double catheterization cannula through the operating hole; (5) Confirmthat the double catheterization cannula is located in the abscess cavity under CT; (6) The double catheterization cannula is properly fixed to prevent it from falling off. The white blood cells, C-reactive protein (CRP), procalcitonin, and interleukin-6 (IL-6) of all patients before the drainage and 1 days, 3 days, and 5 days after the drainage were collected, as well as the bacterial culture results of the drainage fluid. The changes of various infection biomarkers before and after the drainage were compared.Results:All 7 patients were cured. No complications such as hemorrhage and severe pain were observed. The average time with drainage tube was 60.8 (18-126) days. Five patients finally underwent gastrointestinal reconstruction surgery due to gastrointestinal fistula. The median serum interleukin-6 of patients before drainage, 1 day, 3 days and 5 days after drainage were 181.6 (113.0, 405.4) μg/L, 122.2 (55.8, 226.0) μg/L, 59.2 (29.0,203.5) μg/L and 64.1 (30.0,88.4) μg/L, respectively.The level of serum interleukin-6 at 3 days and 5 days after drainage was significantly lower than before drainage ( F=3.586, P=0.026). Although the white blood cell count, C-reactive protein, and procalcitonin decreased gradually after drainage compared with before drainage, the difference was not statistically significant (all P>0.05). Conclusion:Transgluteal percutaneous drainage with double catheterization cannula is simple and effective, and can be used for the treatment of deep pelvic abscess.

Objective:To investigate the safety and feasibility of transgluteal percutaneous drainage using double catheterization cannula in the treatment of deep pelvic abscess.Methods:A retrospective analysis of the clinical data of patients who underwent transgluteal percutaneous drainage using double catheterization cannula with deep pelvic abscesses admitted to the Jinling Hospital from May 2017 to September 2020 was conducted. Seven patients were enrolled, including 5 males and 2 females, who aged 26-74 (median 53.0) years old, and all of them had digestive fistula. One male patient was punctured again due to the tube falling off, and a total of 7 patients underwent 8 times of transgluteal percutaneous drainage, all under the guidance of CT. The puncture and drainage steps of the double catheterization cannula group are as follows: (1) Locate the puncture point under CT in the lateral position; (2) Place the trocar into the abscess cavity; (3) Confirm that the trocar is located in the abscess cavity under CT; (4) Pull out the inner core and insert into the double catheterization cannula through the operating hole; (5) Confirmthat the double catheterization cannula is located in the abscess cavity under CT; (6) The double catheterization cannula is properly fixed to prevent it from falling off. The white blood cells, C-reactive protein (CRP), procalcitonin, and interleukin-6 (IL-6) of all patients before the drainage and 1 days, 3 days, and 5 days after the drainage were collected, as well as the bacterial culture results of the drainage fluid. The changes of various infection biomarkers before and after the drainage were compared.Results:All 7 patients were cured. No complications such as hemorrhage and severe pain were observed. The average time with drainage tube was 60.8 (18-126) days. Five patients finally underwent gastrointestinal reconstruction surgery due to gastrointestinal fistula. The median serum interleukin-6 of patients before drainage, 1 day, 3 days and 5 days after drainage were 181.6 (113.0, 405.4) μg/L, 122.2 (55.8, 226.0) μg/L, 59.2 (29.0,203.5) μg/L and 64.1 (30.0,88.4) μg/L, respectively.The level of serum interleukin-6 at 3 days and 5 days after drainage was significantly lower than before drainage ( F=3.586, P=0.026). Although the white blood cell count, C-reactive protein, and procalcitonin decreased gradually after drainage compared with before drainage, the difference was not statistically significant (all P>0.05). Conclusion:Transgluteal percutaneous drainage with double catheterization cannula is simple and effective, and can be used for the treatment of deep pelvic abscess.

Malignant peripheral nerve sheath tumor (MPNST) is a rare invasive soft tissue sarcoma that originates from peripheral nerve branches and peripheral nerve sheaths. Early radical surgery is an effective treatment for MPNST. Since it is insensitive to radiotherapy and chemotherapy, the disease manifests a rapid progression, poor prognosis and high mortality. In recent years, the translational researches on the driving factors and therapeutic targets of MPNST have been rapidly developed, including the pathways of NF1-Ras, Raf-MEK-ERK, PI3K-AKT-mTOR, Wnt signaling, and abnormal expressions of apoptotic proteins, the general loss of polycomb repressive complex 2 (PRC2), upregulation of the HDAC family, abnormal expressions of receptor tyrosine kinases, expressions of programmed cell death ligand (PD-L1), aurora kinase and various microRNAs.This review summarizes the current translational researches on potential therapeutic targets of MPNST, and the clinical trials which provide helpful information for MPNST targeted therapy.