Persistent Fistula for Treatment of a Failed Periprosthetic Joint Infection: Relic From the Past or a Viable Salvage Procedure?

BackgroundNew treatment algorithms for periprosthetic joint infections (PJIs) show high success rates in achieving permanent infection eradication with some degree of failure. Different salvage procedures are described, but there is no evidence for persistent fistula (PF). The purpose of this study was to analyze PF as a salvage procedure in patients with therapy-resistant PJIs.MethodsThis retrospective analysis included all patients treated with PF (2005-2018) in a maximum care center with PJI (knee or hip). The baseline parameters (age, sex, BMI) and other data (number of surgeries, pathogen spectrum, American Society of Anesthesiologists classification) were recorded. The function was documented using the Harris Hip Score, the Knee Society Score, and the quality of life using the SF-36 Health Survey.ResultsA total of 159 patients were included (80 ± 12 years) and subdivided into four groups: hip (n = 66), knee (n = 13), Girdlestone resection arthroplasty (n = 50), knee arthrodesis (n = 27). Patients stayed 111 ± 87 days in the hospital, underwent six operations and three revisions after establishing PF. The mean American Society of Anesthesiologists score was 2.7. The BMI was 31 ± 3 kg/m² (P = .1). The follow-up was 2.8 ± 0.5 years including 27 patients. The Harris Hip Score and Knee Society Score were 38 and 34, respectively. SF-36 showed no significant difference.ConclusionThe study showed poor outcomes regarding quality of life and the function of the infected joint. Therefore, the indication for establishing a PF in the treatment of PJI must be assessed very critically. PF is only an option for multimorbid patients with a limited life expectancy.     

术前NLR、LMR、PNI值对胰十二指肠切除术后胰瘘发生的预测价值

目的:探讨术前预后营养指数(PNI)、中性粒细胞/淋巴细胞比值(NLR)、血小板/淋巴细胞比值(PLR)、淋巴细胞/单核细胞比值(LMR)对患者因壶腹周围癌而行胰头十二指肠切除术后发生胰瘘的预测价值。方法:回顾性分析中国医科大学附属盛京医院收治的140例手术切除治疗的壶腹周围癌病例资料。采用受试者工作特征曲线(ROC)、多因素回归分析确定术前NLR、PLR、LMR、PNI对术后胰瘘的预测价值。结果:共筛选出30例术后临床胰瘘(B级瘘和C级瘘)患者,累积发生率为21.43%(30/140)，其中C级瘘为8例，发生率为5.71%(8/140)。术前NLR、PLR、LMR、PNI预测术后胰瘘的最佳截断值分别为3.49、150.79、2.48、44.8。进一步行多因素回归分析得出术前合并糖尿病、NLR≥3.49、LMR<2.48及PNI<44.8是胰头十二指肠切除术后并发胰瘘的独立危险因素(P＜0.05)。术前高NLR(≥3.49)、低PNI(<44.8)的患者术后发生严重的C级胰瘘的可能更大(P＜0.05)。应用胰瘘风险评分系统(FRS)对患者进行分层,其中21例处于高风险层次，进一步分析得到处于高风险层次的患者当同时合并术前高NLR、低PNI与低LMR中多项不良因素时，术后胰瘘的发生率可显著升高(78.57%,P=0.016)。结论:术前高NLR、低LMR、低PNI对胰头十二指肠切除术后患者并发胰瘘具有一定的预测价值；术前NLR、PNI水平与胰瘘的严重程度等级(B级瘘、C级瘘)具有相关性；处于FRS评分高风险层次的PD患者，当同时合并术前高NLR、低PNI与低LMR中多项时，术后发生胰瘘的风险增高。     

胰十二指肠切除术后胰瘘的影响因素研究进展

胰十二指肠切除术(Pancreaticoduodenectomy,PD)是治疗壶腹周围恶性肿瘤、癌前病变和部分良性疾病的标准术式。PD手术切除范围广,吻合口多,手术并发症较多。近年来,PD手术死亡率已经由最初的大于50%下降到目前的小于5%,手术并发症发生率也显著下降。PD术后主要并发症有胰瘘、出血、腹腔感染、胆瘘、乳糜瘘、术后胃排空障碍等。其中,胰瘘是导致PD术后早期死亡的主要原因。本文就影响PD术后胰瘘的全身因素、局部因素和手术相关因素进行综述,为降低PD术后胰瘘发生率提供临床可操作性。     

Natural history and management of spinal cord arteriovenous shunts in pregnancy: A monocentric series of 10 consecutive cases with emphasis on endovascular treatment

PurposeIntradural spinal cord arteriovenous shunts (IDSCAVS) are rare and constitute a challenging situation if symptoms occur during pregnancy. We present a series of ten such cases referred to our center: five cervical, four thoracic and one lumbar.MethodsWe retrospectively reviewed our global series of 215 IDSCAVSs between 2002 and March 2020 and found ten patients who had presented during pregnancy. Clinical, radiological and therapeutic data were studied.ResultsSeven shunts were AVM type niduses and three were micro AV-fistulae. All were associated with pial venous reflux and six hemorrhagic cases had pseudo aneurysms. Symptoms occurred mainly during the third trimester, 80% of patients presented with hemorrhage and spinal cord dysfunction. We embolized seven patients and proposed surgery in one, always after delivery: all recovered well. One woman declined treatment; one other was operated in emergency but did not improve. Mean follow-up was 3.9 years (0.5...19 years).ConclusionsDespite this small group of patients, our initial experience of IDSCAVSs diagnosed during pregnancy indicates that embolization is an effective management strategy if performed after delivery and a recovery period. Results indicate that IDSCAVSs seem to have a low risk of early rebleedings after the ictal event and may be closely followed up until delivery. The results obtained show good clinical outcome without long-term rebleeds. Women with known IDSCAVSs should not be discouraged from becoming pregnant, however it seems wise to embolize them before pregnancy in order to offer protection against risks during pregnancy.     

复合手术治疗复杂硬脑膜动静脉瘘近中期效果

目的探讨复合手术治疗复杂硬脑膜动静脉瘘(DAVF)的近中期临床效果。方法回顾性分析2017年1月至2018年12月南方医科大学南方医院收治的20例DAVF患者临床资料,其中符合纳入标准的8例接受复合手术治疗。术后定期随访复查头颅CT/MRI和DSA评估瘘口闭合情况,评估神经功能、改良Rankin量表(mRS)评分变化。结果术中即刻造影显示瘘口完全闭塞7例(7/8),近完全闭塞1例(1/8)。术后2周1例因突发肺栓塞死亡。随访3~24个月,复查CT/MRI和DSA显示7例恢复良好,均无新发神经功能障碍,既往严重临床症状得到改善,mRS评分下降至2~3分。结论复合手术治疗静脉窦闭塞或多"共同通道"的复杂DAVF,可提供明确的治疗入路,通过一次全面手术使瘘口彻底永久性闭合,术后近中期临床预后较好。     

术前减轻黄疸对壶腹部癌行Whipple手术治疗效果的影响

目的:探讨术前减轻黄疸对壶腹部癌患者行Whipple手术治疗效果的影响。方法:回顾性分析2012年1月—2018年7月45例在Whipple手术术前行减轻黄疸治疗的壶腹部癌患者(减轻黄疸组)的临床资料,与同期34例行Whipple手术术前未行减轻黄疸治疗的壶腹部癌患者(未减轻黄疸组)的临床资料进行比较。比较两组患者术前、术中情况(手术时间、出血量、输血量)和术后并发症的差异。结果:减轻黄疸组患者治疗后总胆红素(TBil)、结合胆红素(DBil)、谷丙转氨酶(ALT)与治疗前比较差异有统计学意义(P<0.05)。两组R 0切除率比较差异无统计学意义(P>0.05)。减轻黄疸组手术时间、术中出血量、术中输血量优于未减轻黄疸组,差异均有统计学意义(P<0.05)。减轻黄疸组术后并发症发生率、胰漏发生率和胆漏发生率少于未减轻黄疸组,差异均有统计学意义(P<0.05)。结论:壶腹部癌患者行Whipple手术术前彻底减轻黄疸,可以缩短手术时间,减少术中出血量和术后并发症的发生。     

糖尿病肛瘘lncRNA芯片分析及CNC图搭建＊

目的 研究糖尿病肛瘘创面特异表达LncRNA与mRNA基因功能之间调控网络。方法 用基因芯片技术对糖尿病肛瘘创面和普通肛瘘创面组织中差异性表达的LncRNA及mRNA进行基因表达谱检测，筛选的标准为2倍差异及P < 0.05,再进行差异表达分析，然后对差异表达的mRNAs进行KEGG通路分析及Pathway Map展示，挑选出显著mRNA指标，将这些显著mRNA指标进行q-PCR验证，得到有意义的阳性指标，再将阳性指标与差异LncRNA交集得出LncRNA-mRNA共表达网络，并基于LncRNA-mRNA共表达网络挑选出不同LncRNA进行功能验证。结果 将芯片标准化后分析差异表达的长链非编码RNA和mRNA，发现上调差异有502个，下调差异有1204个；mRNA分析发现上调差异621个，下调差异505个，KEGG通路分析发现上调和下调的通路均有10条；通过分别对上调、下调最明显的通路进行Pathway Map展示，挑选出显著mRNA指标8个：BMP2、IFNB1、IL6、IL18、PIK3CB、SMAD7、SMAD9、β-actin，分别将其进行q-PCR验证，得到有意义的阳性指标个5个：BMP2、IL6、IL18、PIK3CB、SMAD7，将5个阳性指标和差异LncRNA交集得出LncRNA-mRNA共表达网络，并基于LncRNA-mRNA共表达网络挑选出不同LncRNA进行功能验证。结论 挑选出的20个LncRNA（NR_125383、T323486、ENST00000582334、TCONS_00018312、ENST00000418393、TCONS_00017190、TCONS_00019532、ENST00000601559、ENST00000566575、NR_109882、NR_026913、T301537、NR_109774、ENST00000415536、ENST00000610000、ENST00000412485、ENST00000573220、T175957、ENST00000580756、TCONS_00014747）所调控的mRNA居于LncRNA-mRNA共表达网络，其在各个领域当中均有不同程度的报道，为后续的功能和机制研究提供了方向和重点，为加速慢性难愈合和创面愈合的研究提供了新的思路，为开发促愈药物提供基础研究借鉴。