Abstract Background Hemorrhagic chronic radiation proctitis (CRP) is the most common and stubborn complication after pelvic radiation therapy. Understanding the high-risk factors, exploring a method to predict it, and then formulating a reasonable radiotherapy plan are the keys to preventing hemorrhagic CRP. The aim of this study was to retrospectively identify potential risk factors for hemorrhagic CRP and establish a nomogram to predict the onset of hemorrhagic CRP. Methods In this retrospective study, we considered patients who received pelvic radiotherapy for cervical carcinoma from March 2014 to December 2021 at Chongqing University Cancer Hospital (Chongqing, China). Logistic regression analysis was performed to determine the factors and then a nomogram model was established. To evaluate the performance of the model, metrics such as the area under the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis were used. Results A total of 221 patients were included.125 patients diagnosed with hemorrhagic CRP by colonoscopy. The median time of diagnosis of hemorrhagic CRP was 14.45 months after pelvic radiotherapy. Age (≥ 54 years old), weight (< 52 kg) and total radiation dose (≥ 72 Gy) were identified as risk factors and then a nomogram was established to predict the onset of hemorrhagic CRP. The area under the ROC curve (AUC) values of the nomogram were 0.741 and 0.74 in the training and the validation cohort, respectively. To investigate the clinical utility of the model,decision curves and clinical impact curves were further performed. The results showed that the model was beneficial over a wide probability range from 0.25 to 0.85. and 0.74 in the training and the validation set, respectively. Conclusion In this study, we constructed and developed a nomogram for hemorrhagic CRP. The calibration curves, ROC curve analysis, and decision curves showed that the nomogram was reliable for clinical application. It may provide some evidence for radiologist to make a reasonable radiotherapy plan to preventing hemorrhagic CRP. Trial registration retrospectively registered.
Objective: Liver cancer is the third leading cause of cancer mortality in China. This study assesses the cost-effectiveness of sorafenib, lenvatinib, and FOLFOX4 in the treatment of advanced hepatocellular carcinoma (HCC) to inform clinical decision-making.Material and Methods: We used a Markov model to simulate the progression of HCC and calculate Quality-Adjusted Life Years (QALYs) and Incremental Cost-Effectiveness Ratios (ICERs) under two scenarios. Costs were obtained from the Yaozhi Network, while transition probabilities and utilities were derived from the REFLECT, EACH, and CELESTIAL clinical trials. One-way sensitivity analysis and probabilistic sensitivity analysis were conducted to evaluate model robustness and parameter uncertainty.Results: In Scenario A, using market-listed prices, sorafenib, and lenvatinib were found to be more cost-effective than FOLFOX4, with ICERs of $11,635.28 and $1,499.93 per QALY, respectively, both below the cost-effectiveness threshold. In Scenario B, with centralized procurement prices, sorafenib had a negative ICER of -$7,351.26 per QALY, indicating cost savings with improved outcomes, while lenvatinib had an ICER of $2,685.99 per QALY. Sensitivity analysis revealed that drug costs, utilities of disease progression, and discount rates were key determinants of ICER values.Conclusion: Sorafenib and lenvatinib are significantly more cost-effective compared to FOLFOX4, particularly under centralized procurement pricing. These results support the inclusion of these treatments in public health policy to enhance healthcare outcomes and optimize resource allocation, thereby improving the economic and quality-of-life metrics for patients with HCC.
Objective
To explore the application value of multimodal image fusion technology in the diagnosis and treatment of intrahepatic cholangiocarcinoma (ICC).
Methods
The retrospective descriptive study was conducted. The clinicopathological data of 11 patients with ICC who were admitted to Zhujiang Hospital of Southern Medical University between January and September 2018 were collected. There were 5 males and 6 females, aged (55±12)years, with a range from 30 to 74 years. The data of contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with gadoxetate disodium (Gd-EOB-DTPA) of the upper abdomen were respectively collected, and three-dimensional (3D) model of liver was constructed based on CT-MRI fusion images. The preoperative evaluation and surgical planning were carried out based on the different modal imaging examination technologies. The indocyanine green (ICG) molecular fluorescence imaging system and augmented reality navigation system were used to guide hepatectomy. Observation indicators: (1) preoperative evaluation; (2) intraoperative situations; (3) comparison between surgical planning based on the different model imaging technologies and actual surgical method; (4) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to November 2018. Measurement data with normal distribution were represented as Mean±SD, measurement data with skewed distribution were represented as M (range). Count data were described as absolute number or percentage and comparisons were analyzed using the paired chi-square test.
Results
(1) Preoperative evaluation: the proportions of grade 3 and above branch vessels of the portal vein and hepatic vein system and tumor margin by enhanced CT examination and enhanced MRI examination were respectively 11/11, 4/11 and 5/11, 11/11, with statistically significant differences in above indicators (χ2=4.16, 5.14, P<0.05). The enhanced CT showed 11 liver cancer lesions and enhanced MRI showed 13 lesions (including 2 lesions not demonstrated by enhanced CT, with a maximum diameter ≤10 mm). The 3D model of liver based on CT-MRI fusion image: location, number, infiltrating range (tumor boundary), intrahepatic vascular distribution, variation and its spatial relationship with lesions could be stereoscopically, intuitively and comprehensively displayed. (2) Intraoperative situations: of 11 patients, 11 lesions were explored with naked eyes; 13 lesions were detected by ICG molecular fluorescence imaging system, including 2 lesions showing low uptake lesions in liver and gallbladder specific period by preoperative MRI examinations and intrahepatic metastasis cancer by pathologic examination. Of 11 patients, 6 had naked-eye ischemia boundaries around related vessels of hepatic portal ligation; 10 with anatomical hepatectomy had hepatic segments or hemihepatic boundary by ICG molecular fluorescence imaging system, including 2 using positive staining and 8 using anti-staining. Among 11 patients, 3 (1 combined with local resection of hepatic segment Ⅷ metastases), 2, 2, 1, 1, 1 and 1 underwent respectively left hepatectomy, left lateral lobectomy of liver, right hepatectomy, extended right hepatectomy, right lobectomy of liver, resection of partial hepatic segment Ⅷ and mesohepatectomy. Seven of 11 patients received regional lymph node dissection and 4 received simple lymph node biopsy. Of 11 patients, 1 diagnosed as with bile leakage of liver section underwent suture and ligation treatment with 4-0 Prolene; 10 didn′t occurred bile leakage. The surgical margin of 11 patients was negative. The operation time, volume of intraoperative blood loss and duration of hospital stay were (240±118)minutes, (275±249)mL and (13±8)days, respectively. There was no blood transfusion in the perioperative period. (3) Comparison between surgical planning based on the different model imaging technologies and actual surgical method: surgical planning of 3D model based on CT, MRI and CT-MRI fusion image in 6, 9 and 11 patients was respectively consistent with actual surgical method. (4) Follow-up: 11 patients were followed up for 2-10 months, with a median time of 6 months. Three patients had postoperative complications, 2 of which were found in Clavien-DindoⅠ and Ⅱ, including 1 with pleural effusion + peritoneal effusion and 1 with pleural effusion, they were improved after conservative treatment; 1 with complication of Clavien-Dindo Ⅲ (postoperative intra-abdominal bleeding) was improved by selective arterial embolization using percutaneous femoral artery puncture. There was no postoperative bile leakage, hepatic failure and death.
Conclusion
Multimodal image fusion technique is helpful to optimize the preoperative surgical planning, which can assist the recognition of important vessels and real-time navigation of hepatectomy during operation, and improve the safety of operation.
Key words:
Biliary tract neoplasms; Intrahepatic cholangiocarcinoma; Multimodal image fusion technology; Three-dimensional visualization; Preoperative planning; Intraoperative navigation
To evaluate whether continuous hemihepatic inflow occlusion (HHO) during hepatectomy can be safer than and be as effective as intermittent total hepatic inflow occlusion (THO) in reducing blood loss.Eighty patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under THO (n=40) or HHO (n=40). THO was performed with periods of 20 minutes of occlusion and 5 minutes of releasing, while HHO was performed with continuous occlusion. The surface area of liver transection, amount of blood loss, measurements of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and postoperative evolution were recorded.The two groups were similar at entry in terms of preoperative liver function and in the proportion of patients experiencing major hepatectomy. The total ischemic time of the two groups was similar (p=0.37), but the operative time in the THO group was longer than in the HHO group (p=0.02). No significant difference was found between the HHO and THO group in blood loss during liver parenchyma transection (p=0.14), the elevations of ALT and AST on the first postoperative day (ALT: p=0.12; AST: p=0.66) and postoperative morbidity (p=0.35).On the basis of our findings, if it is feasible, continuous HHO is recommended for complex liver resection.
Objective
To investigate the clinical efficacy of three-dimensional visualization technique (3DVT) combined with enhanced recovery after surgery (ERAS) in the treatment of hepatolithiasis.
Methods
The retrospective cohort study was conducted. The clinicopathological data of 64 patients with hepatolithiasis who were admitted to Zhujiang Hospital of Southern Medical University from November 2015 to August 2018 were collected. There were 17 males and 47 females, aged from 30 to 82 years, with a median age of 55 years. Of the 64 patients, 23 who completed preoperative assessment and planning using 3DVT, and furthermore received ERAS for perioperative management were divided into 3DVT + ERAS group, and 41 who received preoperative assessment merely under the guidance of 3DVT, combined with conventional perioperative management were divided into 3DVT + conventional group. Observation indicators: (1) preoperative CT and 3DVT assessment; (2) perioperative conditions; (3) follow-up. The follow-up was conducted by outpatient service, e-mail or telephone interview to detect the postoperative recurrence of hepatolithiasis up to March 2019. The measurement data with normal distribution were expressed as Mean±SD, and the t test was used for comparison between groups. The measurement data with skewed distribution were expressed as M (P25, P75), and the Mann-Whitney U test was used for comparison between groups. The count data were expressed as absolute numbers or percentages, and the comparison between groups was performed using the chi-square test or Fisher exact probability.
Results
(1) Preoperative CT and 3DVT assessment: 23 patients in the 3DVT + ERAS group underwent preoperative CT examination and 3DVT assessment, the consistency between CT results and intraoperative findings was 91.3%(21/23), and the consistency between 3DVT results and intraoperative findings was 95.7%(22/23). Fourty-one patients in the 3DVT + conventional group underwent preoperative CT examination and 3DVT assessment, the consistency between CT results and intraoperative findings was 90.2%(37/41), and the consistency between 3DVT results and intraoperative findings was 95.1%(39/41). (2) Perioperative conditions: the volume of intraoperative blood loss, duration of postoperative hospital stay, postoperative total bilirubin, postoperative direct bilirubin, postoperative albumin, postoperative alanine aminotransferase, postoperative aspartate aminotransferase and postoperative hemoglobin were 50 mL (10 mL, 100 mL), 8 days (7 days, 9 days), 12 μmol/L (9 μmol/L, 16 μmol/L), 6 μmol/L (4 μmol/L, 8 μmol/L), (37±4)g/L, 44 U/L (18 U/L, 85 U/L), 32 U/L (20 U/L, 65 U/L), (117±18)g/L in the 3DVT + ERAS group, and 100 mL (50 mL, 300 mL), 13 days (10 days, 16 days), 17 μmol/L (12 μmol/L, 33 μmol/L), 11 μmol/L (7 μmol/L, 21 μmol/L), (29±6)g/L, 78 U/L (43 U/L, 122 U/L), 121 U/L (72 U/L, 176 U/L), (106±13)g/L in the 3DVT + conventional group, respectively; there were significant differences between two groups (Z=-3.084, -4.827, -2.953, -3.632, t=5.261, Z=-2.960, -4.625, t=2.773, P<0.05). Two patients had pulmonary infection and 2 had pleural effusion in the 3DVT + ERAS group, and all the 4 patients were cured after treatment. One case of biliary fistula, 4 cases of pulmonary infection and 5 cases of pleural effusion occurred in the 3DVT + conventional group, and these patients were cured by adequate abdominal drainage, antibiotic therapy and thoracocentesis, respectively. There was no perioperative death in either group. (3) Follow-up: 64 patients were followed up for 6-36 months, with a median time of 23 months. During the follow-up, no recurrent hepatolithiasis in the 3DVT + ERAS group, and 1 case of recurrent hepatolithiasis was confirmed by ultrasound in the 3DVT + conventional group. No cholangiocarcinoma occurred in either group.
Conclusion
The combination of 3DVT and ERAS is effective, safe and feasible in the management of hepatolithiasis, which can accelerate the postoperative recovery of liver function, thus enhancing perioperative recovery and improving the prognosis of patients simultaneously.
Key words:
Hepatolithiasis; Three-dimensional visualization; Enhanced recovery after surgery; Efficacy; Diagnosis; Management
To study a new treatment to repair large perforation of nasal septum with medical titanium membrane and local padicled mucoperiosteum flap.The bottom mucoperiosteum of nasal cavity around the perforation of nasal septum were separated from the bone surface except with the margin part of perforation. Then the distal part of mucoperiosteum flap was incised and turn over to cover the perforation, free edge of the flap was sutured to secure immobilization. Finally, the Titanium membrane was cut to the right size to tuck into subperiosteal pocket around the perforation, and was sutured to the mucoperiosteal for added immobilization.The perforations of nasal septum in 11 patients were closed satisfactorily. Perforation of nasal septum did not recur and the follow-up time ranged from half a year to 1 year.Titanium membrane is easy of application, and has good tissue tolerance. In our study, it is a good material to repair large perforation of nasal septum.
To investigate the anatomy of right portal vein based on three-dimensional (3D) visualization technology and provide a morphological basis for computer-assisted individualized liver segmentation and anatomical hepatectomy.Liver CT data of 83 cases were segmented and reconstructed using the medical image three-dimensional visualization system (MI-3DVS), and 3D classifications of the right portal vein were established according to its branch number, direction and distribution. Individualized liver segmentation was performed based on the 3D typing results.The reconstructed portal vein models were capable of visualizing the fourth-order portal branches. Generally, the third-order right portal branches were classified into P5, P6, P7 and P8 branches. According to the 3D distribution of the branches, P5 branches were classified into types A, B, C, D, and E [in 16 (19.3%), 5 (6%), 30 (36.1%), 7(8.5%), and 25 (30.1%) cases, respectively], P8 branches into types A, B, C, and D [in 29 (34.9%), 29 (34.9%), 10 (12.1%), and 15 (18.1%) cases, respectively], P6 branches into types A, B, C, and D [in 35 (42.2%), 12 (14.5%), 33 (39.7%), and 3 (3.6%) cases, respectively], and P7 branches into types A, B, C, D, E, and F [in 27 (32.5%), 11(33.3%), 27 (32.5%), 4(4.8%), 12 (14.5%), and 2 (2.4%) cases, respectively]. Individualized liver segmentation was achieved based on liver segments supplied by the third-order portal branches.3D classifications of the complex and highly variant anatomy of third-order right portal vein and individualized liver segmentation based on this classification before the operation facilitates successful performance of anatomical hepatectomy.
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