Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1).MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2).ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way.ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.     

乳房血供及乳房缩小术的研究进展

目的总结近年来乳房血供及乳房缩小术式的研究进展。方法广泛查阅近年来有关乳房神经分布、血供、乳房缩小术式的发展和术后哺乳功能等情况的国内外文献，并结合临床经验进行分析总结。结果随着对乳房腺体及乳头乳晕复合体的神经分布与血供的解剖研究，乳房缩小术已形成了多种手术方式，各有优缺点，适应证亦不同。通过辅助检查技术的应用，术后乳头、乳晕坏死等严重并发症发生率明显降低；通过对切口与蒂部位置的选择、保留蒂部腺体量的程度、辅助吸脂技术的应用和缝合技术方面的改进，减轻了术后切口瘢痕，更好地保留了乳头乳晕感觉，获得了更为满意的乳房形态。行乳房缩小术后部分分娩患者具有一定哺乳功能。结论乳房缩小术需根据患者特点采用个性化手术方式。在如何更好地保留乳头、乳晕感觉，获得良好而持久的乳房形态，生育期妇女术后哺乳功能保留等方面有待进一步研究。     

External Iliac Artery Dissection During Renal Transplantation: A Case Report and Literature Review

Iliac artery dissection in the setting of renal transplant is a rare but potentially catastrophic event that may result in loss of kidney and lower extremity perfusion. We report a right external iliac artery dissection in a 45-year-old man with end-stage renal disease, diabetes, and hypertension who underwent a renal transplant at our institution. An external iliac artery dissection was diagnosed intraoperatively after completion of the arterial anastomosis given the mottled appearance of the kidney and loss of Doppler signal. The dissection was repaired via open endarterectomy, intimal tacking, bovine patching, and re-anastomosis of the kidney to a proximal site on the external iliac artery. To date, 23 cases of transplant-related iliac artery dissection have been described in the literature. Predisposing risk factors include atherosclerosis and hypertension combined with trauma from vascular clamps or suturing. There is a slight male predominance. Only one group utilized an open endarterectomy approach similar to ours, whereas others used synthetic vascular grafts (12 of 23), endovascular stents (4 of 23), donor iliac artery grafts (4 of 23), or saphenous vein grafts (2 of 23). In the absence of long-term outcomes data, the optimal repair mechanism is yet to be established.     

黄芪多糖对毒胡萝卜素诱导人结肠癌系HT29细胞内质网应激的影响

目的探讨黄芪多糖(Astragalus polysaccharides,AP)对毒胡萝卜素内酯(Thapsigargin,Tg)诱导人结肠癌系HT29细胞发生内质网应激(Endoplasmic Reticulum Stress,ERS)时内质网结构变化及相关分子GRP78和CHOP的影响。方法常规培养HT29细胞后,将细胞分为4组:①空白细胞组(Control组):细胞不做任何药物处理;②细胞模型组(Model组):采用1μmol/L Tg诱导HT29细胞建立ERS模型;③黄芪多糖低浓度组(AP-L组);④黄芪多糖高浓度组(AP-H组)。CCK8法检测黄芪多糖对HT29细胞活性,透射电镜观察内质网结构变化,Real-time PCR法检测ERS时GRP78、CHOP mRNA表达情况。结果黄芪多糖浓度分别为1、10μg/mL,且分别作用HT29细胞12、24、36、48 h时,细胞存活率随着浓度的增加而增加,说明对细胞无明显毒副作用。透射电镜观察Control组内质网结构呈网膜状结构,网膜腔不扩张;Model组内质网形态迥异,大小不一,呈空泡状改变,部分可见融合成簇现象;AP-L组内质网网膜腔扩张程度减轻,空泡体积减小和数量减少;AP-H组内质网形态基本恢复正常,呈网膜状结构,可见数量较少,形态较小的空泡状结构。Real-time PCR法检测结果:与Control组相比,Model组HT29细胞GRP78、CHOP mRNA表达明显增加(P<0.05);与Model组比较,AP-L组和AP-H组HT29细胞GRP78、CHOP mRNA表达均减少(P<0.05);与AP-L组比较,AP-H组HT29细胞GRP78、CHOP mRNA表达减少(P<0.05)。结论黄芪多糖能够抑制Tg诱导HT29细胞发生ERS,其机制可能与降低GRP78和CHOP的表达、减轻内质网应激有关。     

SDF-1α/CXCR4 信号通路在轴向应力刺激促进骨再生中的作用研究

目的通过轴向应力刺激促进骨再生，观察基质细胞衍生因子 1α/趋化因子 CXC 亚族受体 4（stromal cell-derived factor 1α/cysteine X cysteine receptor 4，SDF-1α/CXCR4）信号通路变化，探讨轴向应力刺激促进骨再生的机制。方法取 72 只雄性新西兰大白兔，于右后肢胫骨近端内侧制备直径 8 mm 圆形皮质骨缺损并脱蛋白松质骨支架修复模型，随机分为 3 组（n=24）。A 组腹腔注射 PBS，B 组术肢给予应力刺激治疗+腹腔注射 PBS，C 组术肢给予应力刺激治疗+腹腔注射 CXCR4 拮抗剂（AMD3100）。术后 2、4、8、12 周，摄 X 线片并采用 Lane-Sandhu X 线评分标准评价骨愈合情况，取标本行 HE 染色观察新生骨组织及支架降解，免疫组织化学染色观察 VEGF、CXCR4 表达水平；4、8 周取标本 Western blot 检测 SDF-1α 及 CXCR4 蛋白表达水平；12 周行 Micro-CT 检查，计算新生骨体积及新生骨密度。 结果X 线片检查示，除术后 2 周各组骨缺损区及支架无明显变化外，4、8 及 12 周时 B 组骨愈合评分均高于 A、C 组（P<0.05）。12 周时 Micro-CT 扫描可见 B 组骨缺损修复、髓腔再通，新生骨体积及骨密度均高于 A、C 组（P<0.05）。HE 染色显示，术后 4 周开始 B 组骨再生及支架降解均明显快于 A、C 组。免疫组织化学染色示，各组 VEGF 及 CXCR4 阳性表达均在 4 周达峰值；各时间点 B 组 VEGF 及 CXCR4 表达量均显著高于 A、C 组（P<0.05）。Western blot 检测显示，4、8 周时 B 组 SDF-1α 与 CXCR4 表达量均显著高于 A、C 组（P<0.05）。 结论轴向应力刺激促进骨再生可能与其促进骨缺损区组织高表达 SDF-1α，激活与其下游调控 BMSCs 募集的 CXCR4 信号有关。     

Molecular mechanisms involved in the protective actions of Selective Estrogen Receptor Modulators in brain cells

Synthetic selective modulators of the estrogen receptors (SERMs) have shown to protect neurons and glial cells against toxic insults. Among the most relevant beneficial effects attributed to these compounds are the regulation of inflammation, attenuation of astrogliosis and microglial activation, prevention of excitotoxicity and as a consequence the reduction of neuronal cell death. Under pathological conditions, the mechanism of action of the SERMs involves the activation of estrogen receptors (ERs) and G protein-coupled receptor for estrogens (GRP30). These receptors trigger neuroprotective responses such as increasing the expression of antioxidants and the activation of kinase-mediated survival signaling pathways. Despite the advances in the knowledge of the pathways activated by the SERMs, their mechanism of action is still not entirely clear, and there are several controversies. In this review, we focused on the molecular pathways activated by SERMs in brain cells, mainly astrocytes, as a response to treatment with raloxifene and tamoxifen.     

3D 打印金属假体在关节外科的临床应用

目的总结 3D 打印金属假体在关节外科的应用进展。方法广泛查阅相关文献，总结 3D 打印金属假体治疗关节外科疾病的疗效，包括假体稳定性、术后并发症、骨长入等假体移植中的关键性问题。结果3D 打印金属假体具有良好的匹配度，可精确重建并恢复关节功能，节省手术时间，早中期随访患者满意度较高，在关节外科的应用取得了良好进展。结论3D 打印技术可制造任意形状的个性化微孔结构假体，很好地解决了传统假体存在的特殊患者关节匹配度较差的问题，在骨科领域有巨大应用潜力。     

Role of Endoplasmic Reticulum Stress in Rheumatoid Arthritis Pathogenesis

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by abnormal proliferation of synoviocytes, leukocyte infiltration, and angiogenesis. The endoplasmic reticulum (ER) is the site of biosynthesis for all secreted and membrane proteins. The accumulation of unfolded proteins in the ER leads to a condition known as ER stress. Failure of the ER''s adaptive capacity results in abnormal activation of the unfolded protein response. Recently, we have demonstrated that ER stress-associated gene signatures are highly expressed in RA synovium and synovial cells. Mice with Grp78 haploinsufficiency exhibit the suppression of experimentally induced arthritis, suggesting that the ER chaperone GRP78 is crucial for RA pathogenesis. Moreover, increasing evidence has suggested that GRP78 participates in antibody generation, T cell proliferation, and pro-inflammatory cytokine production, and is therefore one of the potential therapeutic targets for RA. In this review, we discuss the putative, pathophysiological roles of ER stress and GRP78 in RA pathogenesis.     

后交叉韧带重建中转角效应：力学机制与临床改良

目的总结后交叉韧带（posterior cruciate ligament，PCL）重建中转角效应的研究进展。方法查阅近年来国内外 PCL 重建中转角效应相关研究，并进行总结。结果研究表明转角效应是导致 PCL 重建术后移植物松弛的主要原因。目前临床上主要通过改变骨隧道固定方式、改变骨隧道方位以及挤压螺钉辅助固定、保留韧带残端、打磨骨隧道口骨质等方式来减小该效应，但缺乏长期临床随访结果。结论针对转角效应的改进方法仍存在较大争议，需要更深入的基础研究，进一步探索重建后 PCL 磨损机制。