Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis

Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes.This systematic-review and meta-analysis design is based on the “PICO” process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery.The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%–91.7% and 80%–94% for LE, in contrast to 92.3%–94.3% and 94.4%–97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09–1.45) and DSS (HR: 1.19; 95%CI, 1.01–1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50–4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15–0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present.In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.     

局部浸润麻醉应用于拇外翻术后镇痛的可行性研究

目的：探讨罗哌卡因联合复方倍他米松局部浸润麻醉在拇外翻术后镇痛中的临床疗效及不良反应。方法：自2019年9月至2020年12月手术治疗拇外翻患者48例,根据术后不同镇痛方式分为联合局部浸润组和静脉镇痛泵组。联合局部浸润组24例,男2例,女22例;年龄21~78（58.3±7.7）岁;行软组织松解加Chevron截骨15例,行跖趾关节融合9例;术后即刻应用罗哌卡因联合复方倍他米松混合稀释液20 ml局部浸润麻醉1次。镇痛静脉镇痛泵组24例,男3例,女21例;年龄23~81（56.8±8.3）岁;行软组织松解加Chevron截骨17例,跖趾关节融合7例;术后即刻静脉镇痛泵进行镇痛,设置基础流量为2 ml/h,自控剂量为0.5 ml,锁定时间15 min。记录患者术后12、24、48、72 h疼痛视觉模拟评分（visual analogue scale,VAS）,同时记录术后24 h换药时VAS,记录术后0~12 h、12~24 h、24~48 h药品不良反应发生情况,并记录拆线后刀口愈合情况。结果：所有患者获得随访,时间14~17（14.60±0.92） d。术后联合局部浸润组与静脉镇痛泵组12、24、48 h VAS比较差异有统计学意义（P<0.05）。术后两组72 h VAS比较差异无统计学意义（P>0.05）。两组术后0~12 h发生药品不良反应例数比较差异无统计学意义（P>0.05）;术后12~24 h发生药品不良反应例数比较差异有统计学意义（P<0.05）;术后24~48 h两组均未发生麻醉药品不良反应。拆线后两组刀口愈合等级比较差异无统计学意义（P>0.05）。结论：与静脉镇痛泵镇痛相比,罗哌卡因联合复方倍他米松的局部浸润麻醉在不增加麻醉药品不良反应的情况下,可显著降低患者拇外翻术后伤口疼痛,且不增加刀口感染风险。     

Efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia: A meta-analysis with trial sequential analysis of 23 randomised controlled trials

To further identify the real efficacy and safety of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia, we conducted this meta-analysis. The systematic search strategy was performed using PubMed, Embase, Cochrane Library, and Chinese databases. As a result, a total of 23 RCTs (1445 patients) were included. Patients receiving dexmedetomidine combined with local anaesthetics had a lower rescue analgesia rate [risk ratio (RR): 0.48; 95% confidence interval (CI): 0.36-0.65] and lower rescue analgesic consumption [weighted mean difference (WMD): −10.80 mg; 95%CI: −13.28 to −8.31 mg] than patients receiving local anaesthetics alone. The dexmedetomidine-related adverse reactions included bradycardia (RR: 1.33; 95%CI: 0.32-5.56) and hypotension (RR: 3.00; 95%CI: 0.49-18.42). In addition, the time to first analgesic request (WMD: 296.16 minutes; 95%CI: 165.69 minutes ~ 426.63 minutes), incidence of postoperative nausea and vomiting (PONV) and pain scores at 4 hours postoperatively were also significantly lower in patients receiving dexmedetomidine combined with local anaesthetics. This meta-analysis demonstrated that the use of dexmedetomidine as an adjuvant to wound infiltration is effective for reducing the rescue analgesia rate, rescue analgesic consumption and PONV. In addition, limited evidence shows that dexmedetomidine can prolong postoperative analgesia for approximately 5 hours. Further investigations on dexmedetomidine-related adverse reactions and the dose–response effect of dexmedetomidine in wound infiltration are warranted.     

面向能力差距的陆军战场搜救体系论证研究

目的:基于面向能力差距的论证理念,开展陆军战场搜救体系(装备体系和非装备体系)的论证研究。方法:通过比较陆军战场搜救能力需求和现有战场搜救能力,分析能力差距。综合考虑能力需求贡献度和能力开发迫切度,定量评估能力差距并定性规范化描述。构建陆军战场搜救体系能力差距矩阵,分析装备体系和非装备体系内容。从成熟度、风险、时间、费用和效能5个方面,采用专家打分法评估装备体系。非装备体系采用头脑风暴法评估。结果:面向陆军战场搜救体系的能力差距,分析得出陆军战场搜救体系的内容,确定了陆军战场搜救体系的发展方向。结论:面向能力差距的论证理念具有较好的可行性,论证结果可信度较高,为提高陆军战场搜救体系论证工作的科学性和规范性提供了支撑。     

Continuous blockade of the lumbar plexus after knee surgery: a comparison of the plasma concentrations and analgesic effect of bupivacaine 0.250% and 0.125%

In 20 patients a continuous block of the lumbar plexus was administered after knee-joint surgery, and the analgesic effect of two different concentrations of bupivacaine was compared. The same volume of bupivacaine was given to both groups of patients: a bolus dose of 0.4 ml/kg, 0.5% or 0.25%, followed by infusion of 0.14 ml/kg/h, 0.25% or 0.125%, respectively, via a catheter placed in the neurovascular fascial sheath of the femoral nerve according to the "3-in-1 block" technique. The median morphine consumption during the first 16 h postoperatively was 6.0 mg when bupivacaine 0.5/0.25% was used and 9.5 mg when 0.25/0.125% was used. This difference is not significant. The visual analogue pain scores were also similar in the two groups (P greater than 0.05). All plasma concentrations were below 4 micrograms/ml, the highest concentration measured being 3.6 micrograms/ml. It is concluded that when used for a continuous block of the lumbar plexus after knee-joint surgery, bupivacaine in a concentration of 0.125% offers the same pain relief as a concentration of 0.25%, and the risk of toxic reactions is reduced.     

多区域浸润麻醉减轻腹腔镜胆囊切除术后早期症状

目的探讨躯体、内脏局部浸润麻醉对择期腹腔镜胆囊切除术后疼痛、恶心症状的影响.方法随机将50例病人分为对照组和实验组,在门静脉周围和腹膜内分别浸润生理盐水66ml和罗吡卡因66ml;术后3h记录疼痛和恶心的程度、部位及所补充的哌替啶用量.结果罗吡卡因局部浸润可减轻术后3h的切口疼痛和恶心症状,但对腹内和肩部疼痛无明显效果;且术后3h所补充的哌替啶的用量显著减少.结论躯体、内脏局部浸润麻醉可减轻术后3h的切口疼痛、恶心及哌替啶用量.     

成人高分级脑胶质瘤术后放疗设野的探讨

目的：探讨用局部扩大野的设野方法照射成人高分级脑胶质瘤的可行性。方法：经术后病理证实为Ⅲ～Ⅳ级星形细胞瘤５３例,分为实验组（Ａ组,２５例）和对照组（Ｂ组,２８例）,放疗采用常规分割,总剂量ＤＴ５０～６５Ｇｙ,设野方法：Ａ组用局部扩大野,Ｂ组用全脑加局部照射野。随访其放疗后生存期及１、３年生存率,复发率。并行统计学处理。结果：Ａ、Ｂ组的中位生存期分别是１４个月,１５．５个月,１,３年生存率分别是８０     

鼻咽癌放疗后局部复发和纤维化的增强CT鉴别诊断价值

目的探讨鼻咽癌放疗后出现块影时,ＣＴ检查对鉴别肿瘤局部复发和放射性纤维化的价值。方法收集１５９例经ＣＴ检查的鼻咽癌,其中放疗后局部复发（ＲＴ）３７例,放射性纤维化（ＲＦ）５４例,以６８例未经放疗的鼻咽癌（ＰＴ）作对比。使用ＥＬＳｃｉｎｔｓｐｒｉｎｔ２０００型ＣＴ机,测量放疗后出现的块影平扫和强化的ＣＴ值,用统计学的方差分析法处理增强前后的ＣＴ值差异。结果ＲＴ组平扫ＣＴ值为５０．４０±８．１０Ｈｕ,增强为７３．７４±７．３７Ｈｕ;ＲＦ组平扫为４８．６２±１０．１５Ｈｕ,增强为５６．７４±８．６９Ｈｕ;对照组（ＰＴ）病变区平扫为４８．３２±９．２０Ｈｕ,增强为７２．３８±７．７５Ｈｕ。测量表明ＲＴ组有明显强化,ＲＴ组与ＲＦ组强化后ＣＴ值差异有非常显著性（Ｐ＜０．０１）。结论鼻咽癌放疗后出现块影时,ＣＴ增强扫描可作为鉴别诊断的重要方法。     

Posterior approach to the lumbar plexus combined with a sciatic nerve block using lidocaine

A combination of lumbar plexus block, by a posterior technique, and sciatic nerve block can be a useful technique for outpatient anaesthesia. The purpose of this study was to examine the clinical characteristics of these blocks using lidocaine and to measure the serum lidocaine concentrations. Forty-five patients, undergoing lower extremity surgery, were studied. Sciatic nerve and lumbar plexus blocks were made with lidocaine, 680 mg with adrenaline 0.3 mg. For each patient the following data were collected: weight, age, sex, site of surgery, time to perform each block, needle depth, speed of onset of the sensory and motor blocks in the territories of the sciatic, femoral, obturator and lateral cutaneous (sensory) nerves and postoperative analgesic requirements. Lidocaine serum concentrations were measured in ten of these patients at 0, 2, 5, 10, 30, 60, 90 and 120 min after the second block. Analgesia was complete in 88% (40/45) of the patients. The remaining five patients needed analgesics (fentanyl 150 μg or less). Despite the high dose of lidocaine, the serum concentrations were within safe limits (mean ± SD) (C_MAX = 3.66 ± 2.21 μg · ml^?1). Only one patient had a serum concentration > 5 μg · ml^?1 (C_MAX = 9.54 μg · ml^?1). This was associated with a contra-lateral extension of the block. We conclude that this combination of blocks is a valuable alternative for unilateral lower extremity anaesthesia. However, clinicians must be aware of the implications of a contra-lateral extension of the block.