Information
Chinese Journal of General Surgery
(Monthly, Established in March 1992)
Responsible Institution
Ministry of Education People's Republic of China
Sponsor
Central South University Xiangya Hospital
Central South University
Editing
Editorial Board of Chinese
Journal of General Surgery
(Zhongguo Putong Waike Zazhi)
Editor-in-Chief
WANG Zhiming
ISSN 1005-6947
CN 43-1213/R

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    Research progress in relationship between gut microbiota and colorectal cancer
    WANG He, SHI Xinlong, LI Jingjing, ZHU Chengzhang, LU Jiyong, WANG Shuai, WANG Tao, DU Binbin, ZHANG Weisheng, YANG Xiongfei
    Chinese Journal of General Surgery    2020, 29 (10): 1261-1269.   DOI: 10.7659/j.issn.1005-6947.2020.10.013
    Abstract318)      PDF(pc) (1117KB)(115)       Save
    The intestinal tract is not only an important place for digestion and absorption of the human body, but also the largest immune organ, which plays an important role in maintaining normal immune defense and other functions of the body. The survival and reproduction of intestinal microorganisms depends on the special micro-ecological environment in the intestinal tract, and they can also complete a variety of metabolic functions that the human body does not possess. Intestinal microorganisms have a great influence on the occurrence and development of human diseases, in which the bacteria in the intestinal tract constitutes the largest proportion with a number more than 100 trillion, directly or indirectly participates in the processes of immune regulation, substance metabolism, digestion and absorption in the human body, and plays an important role in the protection of intestinal mucosa, the maintenance of intestinal homeostasis and the normal function of the body, as well as disease resistance. The microflora colonized in the intestinal tract are closely related, are always relatively independent but interrelated, and their populations and numbers maintain a dynamic balance. Treatments such as surgery, radiotherapy, chemotherapy and fasting, mechanical intestinal preparation or the use of antibiotics can change its composition and function, thus affecting the dynamic balance of gut microbiota, and even lead to flora imbalance. Studies have found that gut microbiota imbalance can directly or indirectly affect the occurrence and development of colorectal cancer through immunomodulatory and inflammatory reactions, genotoxic reactions, metabolites and so on. In recent years, the role of gut microbiota in non-invasive diagnosis, radiotherapy, chemotherapy and immunotherapy of colorectal cancer has been gradually confirmed. In addition, the intake of probiotics and other microbial products through diet regulation and fecal therapy also provide a new idea for the prevention and treatment of colorectal cancer and the related complications. A comprehensive understanding of the relationship between gut microbiota and colorectal cancer can provide a theoretical basis for the biological prevention and treatment of colorectal tumors. Based on the above background, the authors address the relationship between gut microbiota and colorectal neoplasm through reviewing the relevant literature in recent years.
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    Clinical analysis of total laparoscopic-assisted retrieval of wall-penetrating conical filters
    JIA Wei, LIU Jianlong, TIAN Xuan, JIANG Peng, CHENG Zhiyuan, ZHANG Yunxin, LI Jinyong
    Chinese Journal of General Surgery    2020, 29 (6): 671-676.   DOI: 10.7659/j.issn.1005-6947.2020.06.006
    Abstract197)      PDF(pc) (1672KB)(82)       Save
    Background and Aims: Conical filters are commonly used retrievable inferior vena cava filters in recent years. However, the filter tilting and retrieval hook embedded in or penetrating through the caval wall may possibly occur, which cause the failure of filter retrieval by routine interventional method and even the occurrence of severe complications. Therefore, this study was designated to investigate the safety and efficacy of total laparoscopic-assisted removal of conical filter with retrieval hook penetrating the wall of the inferior vena cava, so as to provide the treatment strategies and methods in clinical practice. 
    Methods: The clinical data of 15 patients with implantation of conical inferior vena cava filter admitted from December 2016 to November 2019 were retrospectively analyzed. Of these patients, the average age was (47.7±13.3) years; 12 cases (80%) were males and 3 cases (20%) were females; 12 cases (80%) had a Celect filter implantation, 2 cases (13.3%) had a Denali filter implantation, and one case (6.7%) had an Option filter implantation. All the filters could not be removed by intervention via the jugular vein, and the preoperative CT showed that the hook of the filter penetrated the wall of the inferior vena cava. All patients underwent total laparoscopic-assisted filter removal under general anesthesia.
    Results: Nine patients (60%) underwent laparoscopic surgery through peritoneal approach and 6 patients (40%) through peritoneal approach. the filters in 14 patients (93.3%) were successfully removed by laparoscopic-assisted procedure, and a Celect filter in one patient (6.7%) failed to be removed by laparoscopic surgery, and then was successfully removed by open surgery. The indwelling time was (103.9 ± 70.3) d. During the perioperative period, one patient (6.7%) received blood transfusion due to intraoperative blood loss and one patient (6.7%) had an incision skin infection. The length of postoperative hospital stay was (7.4±2.8) d.
    Conclusion: The laparoscopic-assisted removal of the conical filter with retrieval hook penetrating the wall of the inferior vena cava is safe and effective. It can avoid the complications caused by long-term implantation of the filter. Preoperative CT evaluation can improve the success rate of surgery.
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    Technique and application of laparoscopic anatomical hepatectomy via hepatic parenchymal transection-first approach
    YOU Nan, LI Jing, ZHENG Lu
    Chinese Journal of General Surgery    2020, 29 (7): 775-784.   DOI: 10.7659/j.issn.1005-6947.2020.07.001
    Abstract160)      PDF(pc) (4509KB)(95)       Save
    Laparoscopic anatomical hepatectomy is a difficult and risky procedure, containing a number of technical essentials. The choice of laparoscopic approach is considered to be one of the core techniques. After decades of development, approach selection of laparoscopic anatomical hepatectomy has gradually established a completely new field. Surgical design determines the selection of surgical approach which is variable and not independent. The authors’ team has developed a technique of laparoscopic anatomical hepatectomy with liver parenchymal transection-first approach through repeated practice in clinical settings since the laparoscopic liver surgery was carried out. In accordance with the clinical experience, the technique was found to be simple, fast, safe and effective, which overcomes the challenges of complicated operation and high technical risk of laparoscopic anatomical hepatectomy by the conventional approaches to some extent, and has certain clinical application value in laparoscopic anatomical hepatectomy.
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    Progress in endovascular treatment of aortic arch diseases
    ZHANG Hongpeng, GUO Wei
    Chinese Journal of General Surgery    2020, 29 (12): 1415-1419.   DOI: 10.7659/j.issn.1005-6947.2020.12.001
    Abstract159)      PDF(pc) (1058KB)(70)       Save
    Aortic arch lesions mainly include aneurysm and dissection. Traditional open surgery requires thoracotomy and cardiopulmonary bypass, which is huge traumatic and has a high incidence of complications. Therefore, elderly patients or those with high surgical risks often cannot tolerate the operation. With its minimally invasive and effective advantages, the endovascular technique has become the first choice for the treatment of the descending thoracic aorta aneurysm or type B dissection. However, due to the characteristics of arch lesions near the heart, many important branch vessels, and fast blood flow, endovascular treatment still faces many challenges. At present, some endovascular treatment techniques applied to the aortic arch are off-label use and the long-term efficacy is not clear. The branched endovascular arch repair technique is more in line with the normal anatomical structure and blood flow state of the human body. It usually does not require brain protection measures. Therefore, it is a hot research direction of scholars at home and abroad.
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    Xiangya expert consensus on liver needle biopsy
    Writing Group of the Xiangya Expert Consensus on Liver Needle Biopsy
    Chinese Journal of General Surgery    2021, 30 (1): 1-8.   DOI: 10.7659/j.issn.1005-6947.2021.01.001
    Abstract159)      PDF(pc) (1170KB)(338)       Save
    Liver needle biopsy has been used for a long time as a diagnostic measure for liver disease in several clinical departments such as liver surgery, liver transplantation, infectious disease, and digestive disease. Because it is usually performed by selecting a safe puncture route under the guidance of B-ultrasound or CT, it is safe and its incidence of postoperative massive hemorrhage or bile leakage is not high in most cases. However, there have been clinical reports of death due to liver needle biopsy, and this raised a great concern by clinicians. At present, there are no standards, guidelines or expert consensus on liver needle biopsy in China. Therefore, this expert consensus statement was developed through the organization by the Department of Medical Affairs and Department of Liver Surgery of Xiangya Hospital, Central South University in collaboration with the experts in own hospital from the Department of Hepatopathy, Ultrasound, Interventional Radiology and Pathology, so as to provide a reference for  performing liver needle biopsy in clinical practice.
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    Immune microenvironment and immunotherapy in hepatocellular carcinoma: research progress and development directions
    ZOU Tiantian, QIN Wei, ZHU Ying, LI Tianen, QIN Lunxiu, DONG Qiongzhu
    Chinese Journal of General Surgery    2020, 29 (7): 785-797.   DOI: 10.7659/j.issn.1005-6947.2020.07.002
    Abstract152)      PDF(pc) (618KB)(93)       Save
    The tumor microenvironment in hepatocellular carcinoma (HCC) comprises a variety of cell types that include tumor-associated macrophages, tumor-associated neutrophils, myeloid-derived suppressor cells, cancer-associated fibroblasts and tumor infiltrating lymphocytes, etc., as well as extra-cellular components such as cytokines, growth factors, hormones, extracellular matrix. The immune microenvironment plays important roles in the progression, immune escape and therapeutic response of HCC. In recent years, dramatic advances have been achieved in immunotherapy based on inflammatory microenvironment modulation, and the emergence of immunotherapy provides a promising new strategy for the treatment of HCC. However, low objective response rate, and high adverse reaction and high resistance rates are still noted. Therefore, deep understanding of the role of the microenvironment in the progression of HCC and the exploration of the future development of immunotherapy will improve the response rates of the current treatment approaches, and be of great theoretical value and clinical significance for precise diagnosis and treatment of HCC.
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    Progress in Lynch syndrome associated gastric cancer
    WANG Lingling, LIU Zheng, WANG Xishan
    Chinese Journal of General Surgery    2020, 29 (10): 1243-1250.   DOI: 10.7659/j.issn.1005-6947.2020.10.011
    Abstract145)      PDF(pc) (1081KB)(38)       Save
    Lynch syndrome (LS) is an autosomal inherited disease caused by mutations in DNA mismatch repair (MMR) genes. LS-associated gastric cancer, its incidence ranking first among all LS-associated gastrointestinal tumors, is different from the gastric cancer in general population, and presents the pathological features of microsatellite instability (MSI) and being sensitive to immunotherapy. With the precision of LS molecular detection and the popularization of various diagnostic technologies, LS patients and their families have an increasing demand for LS-associated gastric cancer screening, surveillance, and treatment. However, but their strategies are still unclear, and there are still many controversies. The incidence risk of LS-associated gastric cancer is high in Asian population. China, as one of the Asian countries, should strengthen the identification of LS patients and standardize management measures. Here, the authors review the relevant literature concerning the LS-associated gastric cancer in recent years, so as to provide a basis and reference for fully understanding the LS-associated gastric cancer, optimizing its prevention decision, and improving its diagnosis and treatment.
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    Current status of diagnosis and treatment of abdominal aortic dissection
    WANG Tun, SHU Chang,
    Chinese Journal of General Surgery    2020, 29 (6): 649-653.   DOI: 10.7659/j.issn.1005-6947.2020.06.002
    Abstract135)      PDF(pc) (1044KB)(81)       Save
    Abdominal aortic dissection (AAD) is a rare and severe aortic disease that usually occurs in men and is closely associated with smoking, hypertension and hyperlipidemia. The clinical manifestations are diverse or even absent, which may easily lead to misdiagnosis, missed diagnosis and delayed treatment. Enhanced CT is the first choice for the diagnosis of AAD. Conservative treatment to control the blood pressure and heart rate combined with imaging follow-up is the most common initial treatment. When AAD progresses and has surgical indication, surgery treatment should be performed actively. Endovascular aortic repair (EVAR) is the first surgical choice. Open surgery is often used in patients with anatomic conditions that are not suitable for EVAR. A detailed preoperative evaluation and an appropriate operation plan are essential for the success of EVAR.
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    Establishment of risk prediction model for axillary lymph node metastasis in breast cancer at early age based on clinicopathologic big data
    SONG Wenjing, HE Xin, GONG Pengju, YANG Yan, WEI Lei, ZHANG Jingwei
    Chinese Journal of General Surgery    2020, 29 (11): 1293-1302.   DOI: 10.7659/j.issn.1005-6947.2020.11.002
    Abstract127)      PDF(pc) (1424KB)(48)       Save
    Background and Aims: Over the recent years, the incidence of breast cancer is increasingly shifting to younger population, which is more likely to develop axillary lymph node (ALN) metastasis. Therefore, this study was conducted to determine the influencing factors for ALN metastasis in young breast cancer patients using big-data platform of clinicopathologic information and establish a risk prediction models, so as to provide a reference for the clinical diagnosis and treatment of breast cancer in young adults.  
    Methods: The clinicopathologic data of young patients who were diagnosed with breast cancer and underwent ALN dissection between 2010 and 2015 were selected from the SEER database. The influencing factors for ALN metastasis were determined by univariate and multivariate analysis, and were subsequently visualized by nomogram. The ability of the nomogram to identify patients with different ALN status was quantized using the AUC/C-index. The internal verification of the prediction performance of the nomogram was estimated by bootstrap method (1 000 replicates with a random seed of 12). Furthermore, the data of young patients with newly diagnosed breast cancer from 2015 to 2017 in Zhongnan Hospital of Wuhan University were collected for external validation of the original model. 
    Results: A total of 23 778 young patients with breast cancer was recruited from the SEER database, 39.6% of whom had ALN metastasis. Univariate Logistic regression analysis showed that age, race, location of primary tumor, pathological grade, tumor size, and presence or absence of the chest wall or skin invasion as well as the status of ER, PR and HER-2 were significantly associated with ALN metastasis (all P<0.001). Multivariate Logistic regression analysis showed that age, race, and marital status, laterality, location of primary tumor and grade, tumor size, and presence or absence of the chest wall or skin invasion as well as the status of the ER, PR were independent influencing factors for ALN metastasis (all P<0.05), based on which, the risk prediction model was established. The calibration curve of internal validation indicated a good consistency between the predicted value calculated by the model and the real value (AUC/C-index=0.716). A total of 391 young patients with breast cancer were clinically enrolled as external validation dataset, and 49.9% of them were found to have ALN metastasis at initial diagnosis. The of external validation showed the good predictive ability of the model (AUC/C-index=0.798).
    Conclusion: The risk prediction model developed using the SEER database for ALN metastasis in young patients with breast cancers has good predictive ability, and it can be used as a reference in clinical practice for estimating ALN metastasis of patients.
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    Analysis of values of FRS and a-FRS for predicting pancreatic fistula after different types of pancreatic surgery
    SHEN Jian, SUN Yan, GUO Feng, REN Dianyun, QIN Gengdu, JIN Xin, WU Heshui
    Chinese Journal of General Surgery    2020, 29 (9): 1029-1036.   DOI: 10.7659/j.issn.1005-6947.2020.09.001
    Abstract125)      PDF(pc) (494KB)(88)       Save
    Background and Aims: Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) are common surgical approaches for pancreatic tumors. Postoperative pancreatic fistula (POPF) is one of the most serious complications following pancreatic surgery, if the occurrence of POPF can be reliably predicted that will be of great clinical significance. The fistula risk score (FRS) and alternative fistula risk score (a-FRS) are two widely used prediction models for POPF, and however, the predictive efficiencies of FRS and a-FRS for POPF need further validation. This study was conducted to compare the predictive value of the FRS and a-FRS for POPF following DP and PD, so as to provide the theoretical basis and reference for the selection of the appropriate prediction model in clinical practice. 
    Methods: The clinical data of all patients undergoing pancreatic surgery between 2018 and 2019 in a single center were retrospectively collected, and the enrolled patients after screening for exclusion criteria were used as study subjects. The incidence rates of POPF in the whole group of patients and patients undergoing different surgery types (PD and DP) were counted, and the predictive efficiencies of the two scoring models in predicting POPF for the whole group and different surgery types were compared using area under the ROC curve (AUC).
    Results: A total of 339 patients were included after exclusion of the ineligible cases, with 193 patients undergoing PD and 146 cases undergoing DP. The incidence of POPF was 17.4% in the entire group, and was 18.1% and 16.4% in PD group and DP group, respectively. FRS and a-FRS had a similar predictive ability for POPF in the whole group (AUC: 0.67 vs. 0.65, P=0.412), and the predictive value of FRS for POPF was better than that of a-FRS in PD group (AUC: 0.74 vs. 0.67, P=0.006), but FRS showed no predictive value for POPF in DP group (AUC=0.57, 95% CI=0.44–0.70, P=0.285), while the predictive ability of a-FRS for POPF was better than that of FRS in DP group (AUC: 0.66 vs. 0.57, P=0.048). Moreover, the incidence rates of POPF were increased in either the whole group, PD group or DP group with the increase of the risk grade classified by either FRS or a-FRS. Among the predictive factors of FRS, there were significant differences in intraoperative blood loss and diameter of the main pancreatic duct between DP group and PD group (both P<0.05).
    Conclusion: Both FRS and a-FRS can be used for predicting POPF. However, FRS has a better predictive value than that of a-FRS for POPF following PD, but is unsuitable for POPF following DP, while a-FRS may be helpful for predicting POPF flowing DP. Blood loss and diameter of the main pancreatic duct may be responsible for the poor predictive ability of FRS for POPF following DP. However, these conclusions still need to be further verified due to the limitations of the study. 
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    Prognostic value of the systemic immune-inflammation index in patients with pancreatic cancer: a systematic review and Meta-analysis
    ZHOU Faquan, , CHEN Shi, SUN Hongyu, TANG Lijun
    Chinese Journal of General Surgery    2020, 29 (9): 1076-1083.   DOI: 10.7659/j.issn.1005-6947.2020.09.007
    Abstract122)      PDF(pc) (1210KB)(49)       Save
    Background and Aims: The relationship between systemic immune index (SII) and prognosis in patients with pancreatic cancer is controversial at present, and there are also no large sample multi-center studies to provide confirmation. This study was conducted to systematically explore the prognostic significance of SII in pancreatic cancer by Meta-analysis, so as to provide evidence for improving patients’ prognosis and individualized treatment. 
    Methods: A computer-based searching was conducted in several national and international databases, and the publicly published studies on the relationship between SII and the prognosis of pancreatic cancer were collected. The retrieval time was from inception to March 2020. After literature screening, data extraction and bias risk evaluation by two independent reviewers, Meta-analysis was conducted using Stata 12.0 software.
    Results: Five cohort studies were included involving a total of 3 086 patients. Results of Meta-analysis showed that the overall survival (OS) was shortened (HR=1.26, 95% CI=1.13–1.40, P<0.001) and the cancer-specific survival (CSS) was poor (HR=2.232, 95% CI=1.55–3.48, P<0.001) in pancreatic cancer patients with high SII, while SII had no significant relation with the disease-free survival (DFS) of pancreatic cancer patients (HR=1.27, 95% CI=0.95–1.70, P<0.106). Subgroup analysis found that high SII was associated with shortened OS (HR=1.39, 95% CI=1.14–1.69, P=0.001) when the threshold value of SII was greater than or equal to 600, and was irrelevant to OS (HR=1.22, 95% CI=0.97–1.54, P=0.089) when the threshold value of SII was less than 600. High SII was associated with shorter OS as evidenced by studies from Austria and the United States (HR=1.40, 95% CI=1.07–1.84, P=0.016; HR=1.37, 95% CI=1.02–1.84, P=0.004), but was unrelated to OS as demonstrated by studies from China (HR=1.22, 95% CI=0.97–1.54, P=0.089). High SII was related to the shortened OS in patients undergoing surgical treatment and non-surgical treatment (HR=1.40, 95% CI=1.07–1.84, P=0.004; HR=1.38, 95% CI=1.18–1.61, P<0.001), but was not associated with OS in those undergoing mixed treatment (HR=1.09, 95% CI=0.92–1.29, P=0.303). High SII was connected to shortened OS in patients with either AJCC stage I-III or III-IV disease (HR=1.39, 95% CI=1.14–1.69, P<0.001; HR=1.38, 95% CI=1.14–1.66, P<0.001), and high SII was relevant to shortened OS in patients either before or after treatment (HR=1.39, 95% CI=1.19–1.62, P<0.001; HR=1.37, 95% CI=1.02–1.84, P=0.037). In addition, SII, the neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio had a predictive effect on OS in pancreatic cancer patients, while CA19-9 did not. None of the above 4 factors had predictive effect on DFS, but all had predictive effect on CSS.
    Conclusion: High SII may be an independent risk factor for poor prognosis in pancreatic cancer patients. Limited by the quantity and quality of the studies, the above conclusion needs to be verified by more high-quality studies.
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    Application of liver parenchymal dissection-first method in laparoscopic extra-Glissonian inflow occlusion: a case of anatomical mesohepatectomy
    XIAO Liang, FANG Tongdi, LONG Guo, HU Xi, LI Zengbo, WANG Dong, WANG Zhiming, ZHOU Ledu
    Chinese Journal of General Surgery    2020, 29 (7): 798-805.   DOI: 10.7659/j.issn.1005-6947.2020.07.003
    Abstract118)      PDF(pc) (4280KB)(50)       Save
    Background and Aims: Intraoperative bleeding is the main cause of conversion to laparotomy in anatomical laparoscopic hepatolobectomy (ALH), and effective control of blood inflow to the liver is the key step to achieve successful implementation of ALH. Traditionally, the hepatic inflow occlusion for ALH follows the conception of “Glissonean pedicle-first”, namely, isolation and division of the Glissonean pedicle (specifically, it can be divided into "intra-Glissonian approach" and "extra-Glissonian approach") are performed prior to liver parenchymal transection. However, this method is complicated and time-consuming. In the long-term clinical work, the authors have explored a new technique for hepatic inflow occlusion and named it as the "liver parenchymal dissection-first" (LPDF) method. This method just adjusts the order of operative procedures without expanding the scope of the operation, and it can simplify the hepatic inflow occlusion, and thereby facilitate the promotion and application of ALH. This paper was aimed to introduce a case of laparoscopic anatomical mesohepatectomy with LPDF method and preliminarily summarize the technical characteristics of LPDF. 
    Methods: The clinical data of a patient with hepatocellular carcinoma (HCC) undergoing anatomical laparoscopic mesohepatectomy using LPDF technique in October 2019 were retrospectively analyzed. The HCC lesions in the patient involved the segments 8, 5 and 4b. During the operation, the perihepatic ligaments were dissociated, then the first porta hepatis was blocked, the liver parenchyma was fully dissected along the right side of the falciform ligament and toward the first and second porta hepatis (the left resection line) using ultrasonic scalpel until the exposure of a proper length of the intrahepatic right anterior Glissonean pedicle, which was then ligated and transected. As a result, the demarcation line of the right anterior lobe was appeared (the right resection line), and the right parenchymal resection was performed. Finally, the middle hepatic lobe and the lesions were completely resected after the intersection of the two cutting planes.
    Results: The operative time was 260 min, the amount of intraoperative blood loss was 300 mL, and no blood transfusion was needed. The bowel function was recovered on postoperative day (POD) 3, and the patient was discharged from the hospital on POD 6. There were no complications such as massive intraperitoneal hemorrhage and bile leakage occurred. One month later, a 117 mm×87 mm fluid collection in the operation area was found by color doppler ultrasound, but no fever or abdominal pain was noted, and the number of white blood cells and level of total bilirubin were within the normal ranges. The fluid was gradually absorbed without treatment. 
    Conclusion: LPDF is safe and feasible. It can facilitate the extra-Glissonian inflow occlusion for laparoscopic anatomical mesohepatectomy, and its application value in ALH is worthy of further exploration.
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    Analysis of clinical value of day-case laparoscopic transabdominal preperitoneal repair
    NING Caihong, HUANG Gengwen, LIN Jiayan, SHEN Dingcheng, CAO Xintong, LI Jiarong
    Chinese Journal of General Surgery    2021, 30 (4): 399-405.   DOI: 10.7659/j.issn.1005-6947.2021.04.004
    Abstract117)      PDF(pc) (1091KB)(24)       Save
    Background and Aims: Inguinal hernia repair is one of the most common procedures performed in day surgery units. With the development of modern inguinal hernia surgery and anesthetic techniques, an increasing cases of inguinal hernia surgery can be done in day surgery units. However, there is no a uniform standard for the selection of procedure and anesthetic method in day surgery for inguinal hernia. Laparoscopic transabdominal preperitoneal hernia repair (TAPP), for the advantages such as minimal invasiveness, fast recovery, high patient comfort level and low recurrence rate, has become one of the main methods for clinical treatment of inguinal hernia. This study was conducted to evaluate the effectiveness and safety of day-case laparoscopic TAPP.  
    Methods: The clinical data of the consecutive patients with inguinal hernia undergoing laparoscopic TAPP in Xiangya Hospital of Central South University from January 2016 to January 2021 were retrospectively analyzed, and a total of 785 patients were finally included in this study. All patients were evaluated by the surgeon and anesthesiologist before operation for decision-making on inpatient surgery or day surgery, of whom, 585 cases underwent inpatient surgery and 200 cases received day surgery. The 200 patients undergoing day-case laparoscopic TAPP were specially analyzed. 
    Results: The average age of patients receiving day surgery was younger than that of patients undergoing inpatient surgery, and meanwhile, the proportions of cases with concomitant disease, recurrent hernia or bilateral hernia were less than those of patients undergoing inpatient surgery (all P<0.05). Laparoscopic TAPP was successfully performed in all patients of the two groups. The average length of total hospital stay was 0.5 d, the average postoperative length of stay was 6 h, and the average hospitalization expense (including outpatient examination cost) was 16 185 yuan for patients receiving day surgery, all of which were significantly lower than those for patients undergoing inpatient surgery (all P<0.05). Postoperative urinary retention occurred in one case in patients undergoing day surgery. The median follow-up period was 13 (2–62) months. One case (0.5%) in patients undergoing day surgery and 2 cases (0.3%) in patients undergoing inpatient surgery recurred, and the difference showed no statistical significance (P>0.05), and no long-term inguinal chronic pain, readmission and death were observed in patients of both groups during the follow-up period. 
    Conclusion: Day-case laparoscopic TAPP can significantly reduce the length of hospital stay and hospitalization expenses compared with inpatient operation. It can be safely performed under the premise of reasonable selection of indications, for example, in most of young patients with less complications (American Society of Anesthesiologists grade II or below) and patients with simple inguinal hernia (such as incipient hernia, no incarceration or strangulation, and no relevant history of lower abdominal surgery). 
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    Application of preoperative CT angiography in laparoscopic anterior resection of rectal cancer with accurate low ligation of inferior mesenteric artery and D3 lymphadenectomy
    SHEN Yang, CHENG Yuanguang, WANG Guanlong, MAO Shengdong, HE Lei, WEN Gang
    Chinese Journal of General Surgery    2020, 29 (10): 1157-1164.   DOI: 10.7659/j.issn.1005-6947.2020.10.001
    Abstract114)      PDF(pc) (2752KB)(70)       Save
    Background and Aims: In recent years, more and more studies have found that the preservation of left colonic artery (LCA) in laparoscopic radical resection of rectal cancer can ensure the blood supply of the proximal bowel and reduce the incidence of anastomotic leakage. However, there are several variations in the branches of the inferior mesenteric artery (IMA), the D3 lymph node dissection with LCA preservation will increase the operation difficulty and significantly prolong the operative time. This study was conducted to investigate the feasibility and safety of low ligation with LCA-preserving D3 lymph node dissection under the guidance of preoperative CT angiography (CTA).  
    Methods: The clinical data of 50 patients with rectal cancer undergoing laparoscopic anterior resection with low IMA ligation and D3 lymph node dissection from January 2018 to December 2019 in the Department of Gastroenterology of the Third Affiliated Hospital of Anhui Medical University were retrospectively analyzed. All patients underwent preoperative CTA three-dimensional reconstruction of the lower abdominal vessels for identifying the types of branch vessels of the IMA.
    Results: Of the 50 patients, the proportions of type I, II, III and IV of IMA branches were 48.0% (24/50), 16.0% (8/50), 34.0% (17/50), and 2.0% (1/50), respectively. The length of IMA was 1.6-4.8 cm, with an average of (3.7±0.5) cm. the incidence of Riolan artery arcade absence was 70.0% (35/50). The operation was uneventfully completed in all patients, and no open conversion was required. The time for No.253 lymph node dissection was (18.5±5.8) min on average (ranged from 12-35 min), and the number of No.253 lymph node dissection was 4.5±1.3 on average (ranged from 0-6), in which, positive lymph nodes were identified in 2 cases (4.0%), and both of them were classified a pathological stage IIIC. The total operative time was (130±26) min on average (ranged from 115–190 min), the intraoperative blood loss was (65.8±7.8) mL on average (ranged from 30–150 mL), and the total number of lymph node dissection was 17.6±4.5 on average (range from 10–39). The histological classification of the 50 patients included highly differentiated adenocarcinoma in 10 cases, moderately differentiated adenocarcinoma in 25 cases, and poorly differentiated adenocarcinoma in 15 cases, and the pTNM stage included stage I in 5 cases, stage IIB in 23 cases, stage IIIA in 15 cases a, stage IIIB in 5 cases and stage IIIC in 2 cases. The length of postoperative hospital stay was (12.5±2.3) d on average (ranged from 8–15 d). No anastomotic leakage and other serious complications occurred in all patients after surgery, and one patient had dark red blood in stool after surgery, which was improved after hemostatic therapy. All patients were discharged from hospital after recovery. Followed-up was obtained in all patients for a period of 3–26 months. liver metastases occurred in one of the two patients with positive No.253 lymph node and stage IIIC disease at 14 months after surgery, and no death occurred in the entire group. 
    Conclusion: For all rectal cancer patients, routine abdominal and pelvic CTA three-dimensional reconstruction is recommended before operation. Based on the types of branch vessels of the IMA, laparoscopic anterior rectal resection with accurate low ligation, LCA preservation and D3 lymphadenectomy is safe and feasible.
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    The choice of surgical approach in anatomic laparoscopic hepatectomy
    XIAO Liang, ZHOU Ledu
    Chinese Journal of General Surgery    2021, 30 (1): 9-15.   DOI: 10.7659/j.issn.1005-6947.2021.01.002
    Abstract114)      PDF(pc) (1608KB)(139)       Save
    Anatomic laparoscopic hepatectomy (ALH) is one of the most difficult operations in general surgery. Being restricted by the limited operation space of laparoscopic surgery, the liver, as the largest solid organ in the human body, is difficult to manipulate and expose. In addition, uncontrollable bleeding is likely to occur during the process of liver parenchyma dissection because of the abundant blood supply of the liver and the complex structure of the intrahepatic vessels, which may lead to a forced conversion to open surgery, and therefore cause a long learning curve to achieve the skill for ALH. Although after nearly 30 years of development as well as this operation has been carried out in most large medical institutions in our country, there are few systematic explanations for the selection of individualized surgical approach, which is the premise and basis for successful implementation of ALH. Here, the authors discuss the issues about this topic.
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    Application of biliary flap transposition hilar biliary stricture repair in treatment of hepatolithiasis
    TAN Zhiguo, PENG Chuang, SUN Zengpeng, LIU Jianming, LI Ou, YI Weimin, WU Jinshu
    Chinese Journal of General Surgery    2020, 29 (8): 909-915.   DOI: 10.7659/j.issn.1005-6947.2020.08.001
    Abstract111)      PDF(pc) (2752KB)(56)       Save
    Background and Aims: Hepatolithiasis is a complicated pathological condition, with a high postoperative recurrence rate, requiring repeated operations. In the late course of the disease, biliary cirrhosis and even intrahepatic cholangiocarcinoma may occur, which seriously affect the patients’ quality of life. This study was conducted to investigate the safety and efficacy of biliary flap transposition hilar biliary stricture repair in treatment of hepatolithiasis.  
    Methods: The clinical data of 36 patients with hilar biliary stricture treated in Hunan Provincial People's Hospital from January 1, 2016 to December 31, 2018 were retrospectively analyzed. The clinical variables that included the operative time, intraoperative blood loss, hospitalization time, postoperative complications, and anastomotic restenosis observed. 
    Results: Of the patients, 8 cases had the initial surgery, and the other 28 cases had surgery such as cholecystectomy, and common bile duct exploration once to 4 times previously. All patients underwent hilar biliary stricture repair by biliary flap transposition, and biliary basin Roux-en-Y internal drainage. Meanwhile, 3 cases underwent the right posterior lobe resection, 6 cases underwent the left lateral lobe resection, and 11 cases underwent the quadrate lobe resection. No perioperative death occurred. The average operative time was (256.4±98.2) min, the average intraoperative blood loss was (218.5±68.1) mL, and the average length of hospital stay was (10.3±3.2) d. After operation, residual stones were found in 3 cases (8.3%), mild bile leakage occurred in 1 case, partial intestinal obstruction occurred in 1 case, abdominal fluid collection occurred in 2 cases, and pleural effusion occurred in 2 cases, which were all resolved by conservative treatment, and no complication greater than Clavien-Dindo IIIa was noted. All patients were followed up by outpatient examination and telephone interview. The median follow-up time was 23.6 (12–46) months. Reflux cholangitis occurred in 2 patients, which were spontaneously resolved, and no anastomotic restenosis was found. Stone recurrence was found in 3 cases (8.3%).
    Conclusion: Biliary flap transposition hilar biliary stricture repair is safe and effective for the treatment of hepatolithiasis, and it can be used for reference in clinical paractice.
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    Expression of mismatch repair proteins in rectal cancer and its predictive value for sensitivity of neoadjuvant chemoradiotherapy
    CHENG Kangwen, LI Jia, WANG Guihe, SHU Kuanshan, ZHENG Ming, MA Donghua
    Chinese Journal of General Surgery    2020, 29 (10): 1178-1186.   DOI: 10.7659/j.issn.1005-6947.2020.10.004
    Abstract111)      PDF(pc) (2560KB)(37)       Save
    Background and Aims: Neoadjuvant chemoradiotherapy (nCRT) is the gold standard for the treatment of mid-low locally advanced rectal cancer. Patients achieving pathologic complete remission (pCR) may have a better long-term prognosis. Despite the development of new molecular biology and progress of diagnosis and treatment technologies, there are few potential biomarkers for predicting good pathologic response before nCRT. This study was conducted to investigate the expression of mismatch repair (MMR) proteins in patients with mid-low locally advanced rectal cancer and their relationship with the sensitivity of nCRT.  
    Methods: A total of 162 patients with mid-low locally advanced rectal cancer admitted in Gastrointestinal Surgery Department of Tongling People's Hospital from January 2014 to December 2019 were enrolled. All patients underwent surgery following nCRT. The expressions of MMR proteins (MLH1, MSH2, MSH6 and PMS2) in their initial colonoscopic biopsy samples were detected by immunohistochemical staining. The relations of MMR protein expression status with clinical variables and nCRT efficacy [according to the RECIST 1.1 evaluation criteria and tumor regressive grading (TRG) score], as well as the relations of the TRG score with the clinicopathologic factors and MMR protein expression status were analyzed, and the influential factors for pCR were determined by multivariate Logistic regression model.
    Results: In the 162 patients, deficient MMR (dMMR) was found in 22 cases (13.4%), including MLH1 protein deletion in 17 cases (10.5%), MSH2 protein deletion in 10 cases (6.2%), MSH6 protein deletion in 8 cases (4.9%) and PMS2 protein deletion in 11 cases (6.8%). Histological type, preoperative clinical stage and TRG score were significantly associated with MMR protein expression status (all P<0.05). The effective rate assessed by RECIST 1.1 in dMMR patients was higher than that in patients with proficient MMR (pMMR) (59.1% vs. 36.4%, P=0.043). The sex age, tumor location, differentiation, histological type, CEA level, synchronous chemotherapy regimen and expressions of MLH1, MSH2, MSH6 and PMS2 proteins were irrelevant to TRG score (all P>0.05), while the clinical T stage, clinical N stage, preoperative clinical stage, and the MMR protein expression status (dMMR or pMMR) were related to TRG score (all P<0.05). Logistic multivariate regression analysis revealed that dMMR was an independent influential factor for pCR of the patients (OR=0.327, 95% CI=0.109–0.984, P=0.047). 
    Conclusion: In patients with mid-low locally advanced rectal cancer, the dMMR protein phenotype presented in the tissue of initial colonoscopic biopsy indicates a better nCRT effect, and MMR protein expression status can be used as a predictor of nCRT efficacy for rectal cancer patients.
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    Primary anorectal small-cell carcinoma: a case report and literature review
    CHEN Zhongsheng, LI Lianghe, ZHANG Jiandong, JIANG Dongbin, LIAO Xin, LI Po, ZHAN Wei
    Chinese Journal of General Surgery    2020, 29 (10): 1172-1177.   DOI: 10.7659/j.issn.1005-6947.2020.10.003
    Abstract108)      PDF(pc) (2320KB)(52)       Save
    Background and Aims: Primary anorectal small-cell carcinoma (SCC) is a rare type of cancer, accounting for less than 1% of all anorectal tumors. Compared with common anorectal adenocarcinoma, the clinical symptoms and imaging manifestations of anorectal SCC are not specific, so the diagnosis is difficult, postoperative recurrence and distant metastasis are easy to occur, the prognosis is poor, and the overall mortality is extremely high. Due to the rarity and particularity of anorectal SCC, there are so far few domestic and foreign literature reports available, lack of relevant research data and treatment experience as well as in-depth understanding of its characteristics, and no unified optimal treatment plan, which bring certain troubles to clinical diagnosis and treatment. Here, the authors discuss the diagnosis and treatment modality of anorectal SCC through analyzing the diagnosis and treatment process in a treated case of primary anorectal SCC, so as to provide corresponding clinical experience and new ideas for the diagnosis and treatment of this condition.  
    Methods: The clinical data of one patient with primary anorectal SCC were retrospectively analyzed. The patient's medical history, general condition, imaging examination, pathological tissue morphology and characteristics of immunomarker were analyzed and diagnosed, and corresponding treatment strategies were developed according to its characteristics, combined with review of relevant literature.
    Results: The clinical feature of the patient presented was bloody stool, which was considered as anorectal malignant tumor after imaging examination, and SCC was pathologically suggested after twice colonoscopic biopsies. Then, laparoscopic-assisted Miles surgery was performed, and postoperative pathologic diagnosis was SCC of the anorectal canal. After operation, additional comprehensive treatment compromising pelvic radiotherapy and "cisplatin plus etoposide" EP chemotherapy regimen was applied. Regular reexaminations such as chest CT, total abdominal CT, pelvic MRI, colonoscopy, serum tumor markers showed no tumor recurrence or distant metastasis. The patient has survived with tumor-free status for 13 months by now, and was still in follow-up observation.
    Conclusion: Primary anorectal SCC is a rare disease with low overall survival. The clinical symptoms and imaging manifestations of anorectal SCC are similar to those of common anorectal adenocarcinoma without specificity. Biopsy material is difficult to obtain under colonoscopy, and the diagnosis requires combining the histopathological findings and a variety of immunohistochemical markers. Surgical resection is the most important and effective method for the treatment of locally advanced anorectal SCC. Surgical treatment should be carried out as soon as possible. Postoperative combined treatment with pelvic radiotherapy and "cisplatin plus etoposide" EP chemotherapy regimen can improve the prognosis of patients and prolong their survival time.
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    Construction and analysis of prognostic model for hepatocellular carcinoma based on autophagy-related long non-coding RNAs
    CHEN Sheng, , ZHAO Jisen, LI Jinghua, YANG Jihong, CHENG Shujie
    Chinese Journal of General Surgery    2020, 29 (7): 839-848.   DOI: 10.7659/j.issn.1005-6947.2020.07.008
    Abstract107)      PDF(pc) (3628KB)(28)       Save
    Background and Aims: Hepatocellular carcinoma (HCC) is the most common primary liver cancers, and has a poor prognosis. Dysregulation of autophagy can promote the occurrence and development of HCC. This study was designated to investigate the potential prognostic roles of autophagy-related long non-coding RNAs (lncRNAs) in HCC patients and construct a risk prediction model based on autophagy-related lncRNAs.  
    Methods: The transcriptomic and clinical data of 374 HCC samples and 50 normal control samples in TCGA database were analyzed using bioinformatics approaches, and the list of autophagy-related genes were obtained from HADb. The lncRNAs associated with autophagy genes were screened by Person’s correlation analysis. Three hundred and forty-two HCC samples obtained by selection were randomly assigned to train dataset and validation dataset with a ratio of 70%:30% using caret package in R. The autophagy-related lncRNAs with prognostic significance were identified by Kaplan-Meier method and univariate Cox regression analysis. Then, the autophagy-related lncRNAs with independent prognostic significance were determined by multivariate stepwise regression Cox analysis to construct a prognostic prediction model. After the risk scores were calculated using Cox regression coefficient, the patients were divided into low risk group and high risk group, the relationship between the risk score and clinicopathologic features as well as the overall survival (OS) was analyzed, and then was verified in the validation dataset. 
    Results: A total of 347 lncRNAs were identified as autophagy-related lncRNAs (|R2|>0.3, P<0.001), including 26 lncRNAs with prognostic value for HCC patients. The risk model for predicting the prognosis of the patients was derived from the multivariate stepwise regression Cox analysis based on 12 autophagy-related lncRNAs (CYTOR, DANCR, LINC01138, LUCAT1, Mapkapk5-AS1, NRAV, NRSN2-AS1, LINC01871, LINC00864, LINC02362, TMEM220-AS1 and PSMB8-AS1). The risk scores of the 12- autophagy-related lncRNAs prognostic model was sufficiently associated with tumor grade, tumor stage and T stage (all P<0.05), but irrelevant to the age and sex of the patients (both P>0.05). In this model, the area under curve (AUC) of the time-dependent ROC for the 1, 3 and 5-year overall survival were 0.801, 0.819 and 0.787 in the train dataset, and the AUC of the time-dependent ROC for the 1, 3 and 5-year overall survival were 0.694, 0.733 and 0.746 in the validation dataset. 
    Conclusion: The identified autophagy-related lncRNAs may play critical roles in the oncobioloy of HCC, and the 12- autophagy-related lncRNAs has certain predictive value for the prognosis of HCC.
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    Application of π-shaped esophagojejunostomy in laparoscopic radical total gastrectomy
    YAO Yuan, FANG Ke, ZHANG Zhengjun, LI Guangyao
    Chinese Journal of General Surgery    2020, 29 (10): 1204-1211.   DOI: 10.7659/j.issn.1005-6947.2020.10.007
    Abstract107)      PDF(pc) (1832KB)(44)       Save
    Background and Aims: Laparoscopic radical gastrectomy has become the first choice for surgical treatment of gastric cancer. The surgical procedure mainly comprises radical resection of the tumor and digestive tract reconstruction. Digestive tract reconstruction is a difficult technique during the operation, and especially, the totally laparoscopic esophagojejunostomy is the most difficult procedure to perform, which greatly restricts the clinical development of totally laparoscopic radical total gastrectomy. The π-shaped esophagojejunostomy is a linear anastomosis technique based on a linear cutting closure device, which is reported to simplify the procedure and shorten the operative time. Therefore, this study was conducted to evaluate the application value of π-shaped esophagojejunostomy in totally laparoscopic radical total gastrectomy.  
    Methods: The clinical data of 78 patients with gastric cancer treated in the Department of Gastrointestinal Surgery of Wuhu Second People's Hospital between January 2016 and January 2020 were retrospectively analyzed. All patients underwent total laparoscopic gastrectomy with D2 lymphadenectomy. Of the patients, 40 cases underwent π-shaped esophagojejunostomy (observation group) and 38 cases underwent traditional functional end-to-end esophagojejunostomy (control group) for digestive tract reconstruction. The main intra- and postoperative variables were compared between the two groups of patients. 
    Results: Total gastrectomy, lymphadenectomy and digestive tract reconstruction were uneventfully completed in all patients under totally laparoscopic surgery, none required open conversion and all had a negative esophageal margin. In observation group compared with control group, the total operative time and the operative time for esophagojejunostomy were significantly shortened, and the intraoperative blood loss was significantly decreased (217.4 min vs. 237.9 min; 22.6 min vs. 34.8 min; 64.4 mL vs. 99.2 mL, all P<0.05); the time to first ambulation and the time to first flatus passage after the operation were all significantly shortened (1.5 d vs. 2.3 d; 2.6 d vs. 2.9 d, both P<0.05). Postoperative complications occurred in 3 patients in observation group and 2 patients in control group, and the incidence of postoperative complications had no significant difference between the two groups (P=0.687). There were no significant differences in terms of the length of postoperative hospital stay and the number of resected lymph nodes between the two groups (both P>0.05). Postoperative follow-up was conducted for 3 to 12 months, and the anastomotic stoma was patent in all patients. 
    Conclusion: The application of π-shaped esophagojejunostomy is safe and feasible in totally laparoscopic radical total gastrectomy. Compared with the traditional functional end-to-end esophagojejunostomy, it has the advantages of shorter operative time and esophagojejunostomy time, and faster postoperative recovery. Its short-term efficacy is also satisfactory.
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    Chinese Journal of General Surgery    2020, 29 (8): 1018-1022.   DOI: 10.7659/j.issn.1005-6947.2020.08.015
    Abstract106)      PDF(pc) (1387KB)(68)       Save
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    Proximal landing zone requirements in complex abdominal aortic aneurysms and evaluation of different techniques
    GUO Wei, HE Yuan
    Chinese Journal of General Surgery    2020, 29 (6): 645-648.   DOI: 10.7659/j.issn.1005-6947.2020.06.001
    Abstract105)      PDF(pc) (469KB)(57)       Save
    With the rapid development of endovascular treatment and interventional instruments in recent years, endovascular aneurysm repair has gradually replaced traditional open surgery and has become the preferred method for the treatment of abdominal aortic aneurysms. However, the poor proximal landing zone is still the main factor restricting the application of endovascular aneurysm repair. Here, the authors briefly discuss the proximal landing zone requirements in complex abdominal aortic aneurysms and the relevant clinical evidences by combining the introduction of the "chimney stent-graft", "fenestrated stent" and "multi-branch stent-graft" techniques, so as to provide recommendations for the treatment of complex abdominal aortic aneurysms.
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    Clinical application of computer-based three-dimensional reconstruction in diagnosis and treatment of complicated hepatolithiasis
    YANG Ji, HUANG Qiang, WANG Cheng, XIE Fang, LIN Xiansheng, WANG Cheng, SUN Yi
    Chinese Journal of General Surgery    2020, 29 (8): 916-923.   DOI: 10.7659/j.issn.1005-6947.2020.08.002
    Abstract104)      PDF(pc) (1992KB)(37)       Save
    Background and Aims: The diagnosis and treatment of intrahepatic bile duct stones, especially the stones located in multiple hepatic segments or the complicated hepatolithiasis with a history of multiple biliary tract surgeries, is one of the difficult problems in hepato biliary surgery. How to remove the stones in one step is one of the current research interests. Considering that the computer-based three-dimensional reconstruction visualization technology has been increasingly used in hepatectomy in recent years, this study was designed to investigate the clinical application value of computer-based three-dimensional reconstruction technology in the diagnosis and treatment of complicated intra- and extrahepatic bile duct stones. 
    Methods: The clinical data of patients with hepatolithiasis treated in the Department of Biliary and Pancreatic Surgery of the First Affiliated Hospital of University of Science and Technology of China, who underwent computer-based three-dimensional reconstruction before operation from January 1, 2018to July 31, 2019 were retrospectively analyzed. 
    Results: A total of 19 patients with complicated hepatolithiasis admitted during above period were enrolled. Of the patients, the classification of hepatolithiasis was type I in 9 cases, type II a in 6 cases, type IIb in 3 cases and type IIc in 1 case, 12 cases had concomitant extrahepatic bile duct stones, 1 case was complicated with hepatic space-occupying lesions and 1 case was combined with right hepatic schistosomiasis. The surgical procedures including left hepatectomy performed in 3 cases, right hepatectomy performed in 7 cases, and common bile duct exploration plus drainage performed in 9 cases. The coincidence of preoperative three-dimensional reconstruction with the real intra-operative findings were that the coincidence rate of the running patterns of the portal vein and hepatic artery were 78.95%, the coincidence rates of both stone distribution in bile duct and liver volume were 84.21%, and the total accuracy rate was 73.68%. No residual stones were detected by immediate postoperative cholangiography, and no postoperative cholangitisor bile duct injuries occurred.
    Conclusion: The preoperative computer-based three-dimensional reconstruction technology can accurately describe the distribution of intrahepatic bile duct stones and accurately measure the liver volume. It has important clinical application value in the diagnosis of complex hepatolithiasis and individual planning of surgical procedures, and can help achieve the greatest degree of stone removal in one step.
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    Comparison of operative time and surgeon's subjective assessment in 3D and 2D laparoscopic gastric bypass surgery
    THAPA Dil Momin, WANG Mofei, , , ZHOU Yong, WANG Yong, LIU Jingang
    Chinese Journal of General Surgery    2020, 29 (6): 739-744.   DOI: 10.7659/j.issn.1005-6947.2020.06.015
    Abstract103)      PDF(pc) (1113KB)(39)       Save
    Background and Aims: The prevalence of obesity is growing at alarming rate, and has become a major global health problem. Laparoscopic gastric bypass surgery is the most common type of weight loss surgery. With the development of technology and equipment, 3D laparoscopic system has increasingly entered the field of general surgery. The three-dimensional stereo vision overcomes the shortage of the traditional 2D laparoscopic vision system that lacks the vertical perception and stereo views of the anatomy, and thereby provides a better surgical visual field for the primary surgeon, which allows more procedural accuracy and reduces the surgical difficulty to some extent. However, as a major renovation in laparoscopic technique, there are few reports on application of 3D laparoscopic system in gastric bypass surgery, and its advantages and disadvantages comparing with 2D laparoscopic system are unknown. Therefore, this study was designated to assess the superiority of 3D laparoscopic system in gastric bypass surgery and its application value by a single-center randomized controlled trial. 
    Methods: Between August 2017 and March 2019, 60 patients seeking weight-loss treatment in the 4th Affiliated Hospital of China Medical University were enrolled, and were randomly assigned to two groups, with 30 cases in each group, and then underwent 2D laparoscopic gastric bypass surgery (2D group) and 3D laparoscopic gastric bypass surgery (3D group), respectively. The time for the completion of each surgical procedure (creating the small stomach pouch, gastrojejunostomy, and jejunojejunostomy) and the total operative time were compared between the two groups, and the subjective perceptions in operability and operating comfort of the surgeon under laparoscope were scored by questionnaire survey.
    Results: There were no significant differences in the general data between the two groups of patients before operation (all P>0.05). In 3D group compared with 2D group, except the time for making small stomach pouch which showed no significant difference (P=0.120), the time for gastrojejunostomy (P=0.015) and the time for jejunojejunostomy (P=0.012) as well as the total operative time (P=0.023) were significantly reduced. The subjective scores of the surgeon for accuracy, layering perception and vertical perception and the scores for eye-fatigue sensation and neck-fatigue sensation under 3D laparoscope were all superior to those under 2D laparoscope (all P<0.05).
    Conclusion: Compared with 2D laparoscopic system, 3D laparoscopic system can significantly shorten the operative time and increase the operating comfort of the surgeon in performing gastric bypass surgery. So, it has excellent application prospects.
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    New research progress of autophagy in acute pancreatitis
    ZHOU Jia, MO Mengjun, LIU Sulai, LI Ou, SONG Yinghui, PENG Chuang
    Chinese Journal of General Surgery    2020, 29 (9): 1134-1140.   DOI: 10.7659/j.issn.1005-6947.2020.09.015
    Abstract103)      PDF(pc) (714KB)(49)       Save
    Autophagy is a major catabolic process in which cells remove damaged, defective or useless organelles, long-lived proteins and lipids from the cytoplasm, and recycle their components to meet the nutritional and energy needs of biological metabolism. Acute pancreatitis (AP) is a common critical disease, and its prevalence continues to rise in recent years. Studies have demonstrated that autophagy plays an important role in the pathogenesis of AP, it can cause trypsinogen activation and accumulation of large vacuoles in the pancreatic acinar cells, and induce the release of proinflammatory mediators, and thereby cause inflammatory cell infiltration of the pancreas and systemic inflammatory response. Here, the authors address the molecular mechanism of autophagy and the mechanism of autophagy in the occurrence and development of AP.
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    Construction of prognostic prediction model for gastric cancer based on aggregate data from multiple databases
    ZHOU Xintong, , DANG Shengchun
    Chinese Journal of General Surgery    2020, 29 (10): 1187-1194.   DOI: 10.7659/j.issn.1005-6947.2020.10.005
    Abstract103)      PDF(pc) (1910KB)(47)       Save
    Background and Aims: Long non-coding RNAs (lncRNAs) exert significant influences on the prognosis of gastric cancer patients. This study was designated to construct a lncRNA-based prediction model for accurately evaluating the prognosis of gastric cancer patients through bioinformatics approaches. 
    Methods: The data obtained from The Cancer Genome Atlas (TCGA) and Genotype-Tissue Expression (GTEx) databases were used for constructing the prognosis model (modeling group), while the data from The Gene Expression Omnibus (GEO) database were used for validation (validation group). The differentially expressed lncRNAs were screened using edgeR package in R software. Univariate and multivariate Cox regression were used to evaluate the association between LncRNA and survival time. prognostic model was created through univariate and multivariate Cox regression analyses and the risk score were calculated. The patients were divided into high-risk group and low-risk group according to their risk scores, and the relations of the risk score with clinicopathologic variables and prognosis were analyzed. The results of the modeling group were verified in the sample from validation group.
    Results: A total of 288 differentially expressed lncRNAs were screened, and 28 of them were associated with the prognosis of gastric cancer (all P<0.05). Ten lncRNA biomarkers (MEG3, DNAJC9-AS1, ACTA2-AS1, C15orf54, LINC01210, OVAAL, POU6F2-AS2, ERICH3-AS1, LINC00326 and LINC01526) were identified and used to construct a prognostic model. Both overall survival rate and disease-free survival rate in high-risk group were significantly lower than those in low-risk group (both P<0.01). ROC curve confirmed that the prediction model had certain accuracy (AUC=0.700). The results of univariate and multivariate Cox regression analyses showed that the risk score was an independent prognostic factor (both P<0.001). The risk score had significant relation with T stage (P=0.031) and the degree of tumor differentiation (P=0.044). In validation cohort, the overall survival rate and disease-free survival rate in high-risk group were also lower than those in low-risk group, and the risk score remained an independent prognostic factor (all P<0.05). 
    Conclusion: The constructed 10-lncRNA model has certain value in predicting the prognosis of gastric cancer patients, and the screened differentially expressed lncRNAs also provide the basis for further investigating the molecular mechanism of gastric cancer.
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    Analysis of prognostic value of the lymphocyte-to-monocyte ratio in patients with hepatocellular carcinoma
    SHU Qinghua, ZHANG Nannan, HAN Jianbo, YI Yongxiang, ZHANG Yufeng
    Chinese Journal of General Surgery    2020, 29 (7): 867-876.   DOI: 10.7659/j.issn.1005-6947.2020.07.011
    Abstract102)      PDF(pc) (1219KB)(48)       Save
    Background and Aims: The clinical significance of systemic inflammation assessed with laboratory analysis of blood samples has been validated in variety of cancers. hepatocellular carcinoma (HCC) is an inflammation-driven cancer, and inflammation has been shown to be correlated with poor differentiation, microvascular invasion and micrometastasis. This study was conducted to investigate the prognostic value of the lymphocyte-to-monocyte ratio (LMR) in patients with HCC after hepatectomy. 
    Methods: The clinical data 88 HCC patients undergoing radical hepatectomy in the Affiliated Nanjing Hospital of Nanjing University of Chinese Medicine between January 2012 and December 2016 were retrospectively analyzed. The prognostic predictive power of LMR for HCC was analyzed by ROC curve, which was compared with those of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). The relations of LMR with the clinicopathologic factors as well as the disease-free survival (DFS) and overall survival (OS) of the HCC patients were determined. The risk factors for DFS and OS were determined by Cox regression model.
    Results: The cut-off diagnostic value of LMR determined by ROC was 2.87, and the area under the curve (AUC) was 0.757, and its efficiency in estimating the prognosis of HCC was greater than those of NLR (AUC=0.687) and PLR (AUC=0.583). The patients were divided into low LMR group (LMR ≤2.87) and high LMR group (LMR >2.87) according to the cut-off value of LMR. The number of cases with lesion number >3 in high LMR group was significantly less than that in low LMR group (P=0.048); both DFS and OS in high LMR group were significantly superior than those in low LMR group (both P<0.05); results of stage-stratified comparison (BCLC A/B, BCLC C/D; CNLC I/II, CNLC III/IV) showed that except the DFS had no significant difference between high LMR group and low LMR group among patients classified as CNLC I/II stage group (P=0.132), either DFS or OS in high LMR group were significantly superior than that in low LMR in all other stage groups (all P<0.05). LMR was an independent prognostic factor for DFS (P=0.001), while BCLC stage (P=0.000) and LMR (P=0.000) were independent prognostic factors for OS. In addition, after adjustment for LMR, PLR, and NLR as a continuous variable, only LMR had a prognostic value (P=0.001).
    Conclusion: LMR is an independent prognostic factor for OS and DFS in HCC patients after hepatectomy, and its predictive value is possibly superior to that of NLR or PLR. Using LMR combined HCC stage to grade the risk of patients may probably make a more precise assessment.
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    Chinese Journal of General Surgery    2020, 29 (11): 1399-1403.   DOI: 10.7659/j.issn.1005-6947.2020.11.015
    Abstract99)      PDF(pc) (2856KB)(78)       Save
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    Analysis of clinical characteristics of ischemic colitis: a report of 101 cases
    LONG Zhenpu, YU Yanghua, CHEN Xiaoxioa, HUANG Haosu, PENG Jie
    Chinese Journal of General Surgery    2020, 29 (8): 979-986.   DOI: 10.7659/j.issn.1005-6947.2020.08.009
    Abstract97)      PDF(pc) (1135KB)(37)       Save
    Background and Aims: Ischemic colitis (IC) is a common type of ischemic bowel disease, and is also a condition with difficult clinical diagnosis. The early misdiagnosis rate is high, and some patients will rapidly deteriorate after onset, with high associated mortality. This study was conducted to summarize and analyze the clinical characteristics of IC, so as to provide a reference for the its diagnosis and treatment in clinical practice. 
    Methods: The clinical data of 101 IC patients treated in Xiangya Hospital of Central South University from January 2010 to September 2019 were reviewed. The general features, clinical manifestations, endoscopic findings and outcomes of the patients were analyzed, and the clinical characteristics between different age groups of patients were also compared. 
    Results: All patients had the first onset of IC, of whom, 62 cases (61.4%) were females; age ranges from 45 to 93 years old, with an average age of (63±8.8) years, and with age of 45 to <60 years in 39 cases (middle-age group) and ≥60 years in 62 cases (old-age group). The main symptoms of the patients were hematochezia, lower abdominal pain, nausea and abdominal distension. The main colonoscopic findings were mucosal erythema, edema, vascular pattern abnormalities, erosion and ulceration. Left colon involvement was found in 69 cases (68.3%), right colon involvement was found in 7 cases (6.9%), and extensive colon involvement was in 25 cases (24.8%), respectively. Eighty-one patients (80.2%) underwent abdominal vascular examination, of whom, vascular stenosis or thrombosis formation was detected in 25 cases (30.9%), simple arteriosclerosis was noted in 14 cases (17.3%) and 42 cases (51.8%) showed no obvious abnormity. Most of the patients received conservative medical treatment only, the time for symptom relief was 1 to 35 d, with an average time of (9.5±4.3) d. There were no significant differences in sex composition, location of colon involvement, time for main symptom relief, and total cure rates between old-age group and middle-age group (all P>0.05); the proportions of cases with history of hypertension, coronary heart disease and cerebral vascular disease were higher, and the proportions of cases with stenosis and arteriosclerosis of celiac arteries in old-aged group were higher than those in middle-age group (all P<0.05).
    Conclusion: IC occurs frequently in elderly individuals, with a high prevalence in women. The main symptoms are lower abdominal pain and blood in stool, and the left colon is the most affected location. Timely colonoscopy is helpful for making definite diagnosis of IC. Currently, the main treatment modality for IC is conservative treatment based on internal medicine. Elderly IC patients always have underlying health conditions, with poor abdominal vascular conditions, for whom, correct diagnosis as well as early diagnosis and treatment are important for improving the prognosis.
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    Clinical observation of impacts of different types of thyroid surgery on parathyroid function
    WU Runzhang, YUAN Sheng, LIU Yong, LI Guan, ZHANG Donghai, ZHANG Chaojie
    Chinese Journal of General Surgery    2020, 29 (11): 1357-1363.   DOI: 10.7659/j.issn.1005-6947.2020.11.009
    Abstract96)      PDF(pc) (1366KB)(59)       Save
    Background and Aims: Surgery plays an important role in the treatment of thyroid disease, and hypoparathyroidism is one of the common complications of thyroid surgery. However, different kinds of thyroid pathologies have different indications for different types of thyroid surgery, which may exert different impacts on parathyroid function. This study was conducted to investigate the differential influences of different types of thyroid surgery on parathyroid function and analyze the reasons. 
    Methods: The clinical data of 319 eligible patients who underwent thyroid surgeries from April 2017 to March 2019 were retrospectively analyzed. Of the patients, 111 cases underwent unilateral thyroid lobectomy (unilateral resection group), 107 cases underwent bilateral thyroid lobectomy (bilateral resection group), 71 cases underwent bilateral thyroid lobectomy with central lymph node dissection (bilateral resection plus level VI dissection group), and 30 cases underwent bilateral thyroid lobectomy with central and lateral neck dissection (bilateral resection plus level II–VI dissection group). During the operation, 1-2 points on the capsule around the affected side close to the isthmic region were selected, and 0.1-0.2 mL of nanocarbon suspension was injected at each point. Meticulous capsular dissection technique was adopted in all patients for in-situ preservation of the parathyroid glands. If the parathyroid glands failed to be retained in situ, they were immediately cut into pieces or homogenates and reimplanted into the sternocleidomastoid muscle. The changes in parathyroid hormone (PTH) and blood calcium levels before and after surgery as well as the incidence rates of postoperative hypoparathyroidism and hypocalcemia among groups of patients were observed and compared.
    Results: The preoperative general data and PTH and blood calcium levels showed no significant differences among groups (all P>0.05). After surgery, both PTH and blood calcium levels were significantly decreased in all groups compared with their preoperative levels (all P<0.01), but their decreasing amplitudes were significantly magnified with the expansion of surgical scope, namely unilateral resection group < bilateral resection group < bilateral resection plus level VI dissection group < bilateral resection plus level II–VI dissection group, and all differences had statistical significance (all P<0.05). The incidence rates of hypoparathyroidism and hypocalcemia were likewise increased with the expansion of surgical scope, and in unilateral resection group, bilateral resection group, bilateral resection plus level VI dissection group and bilateral resection plus level II–VI dissection group, the incidence of hypoparathyroidism was 9.9%, 32.7%, 56.3% and 73.3%, and the incidence of hypocalcemia was 0, 1.9%, 19.7% and 50.0%, respectively. Follow-up was conducted for 24 weeks in all patients, and no permanent hypoparathyroidism was noted.
    Conclusion: All kinds of thyroid surgery have certain impacts on the parathyroid function, and the possibility of parathyroid injury and risk of the occurrence of hypoparathyroidism will increase with the expansion of the surgical scope. So, the protective measures for parathyroid glands should be adopted in all thyroid surgeries, with meticulous dissection and reduced interference in the blood supply of the parathyroid glands, and thereby to decrease the incidence of hypoparathyroidism as far as possible.
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    Prediction of target gene of miR-486-5p and bioinformatics analysis of their roles in pancreatic adenocarcinoma
    REN Tianyu, ZHOU Xintong, DANG Shengchun
    Chinese Journal of General Surgery    2020, 29 (6): 715-722.   DOI: 10.7659/j.issn.1005-6947.2020.06.012
    Abstract94)      PDF(pc) (1707KB)(67)       Save
    Background and Aims: Pancreatic cancer is one of the main causes of cancer-related death. It is the most malignant tumor of the digestive system. Its main pathological type is pancreatic adenocarcinoma (PAAD), which has a dismal prognosis. MiR-486-5p plays an important role in different cancers, but there is still no research report on miR-486-5p in PAAD so far. This study was conducted to explore the target genes of miR-486-5p and analyze the expression and significance of its target genes in PAAD by bioinformatics approaches.
    Methods: The correlation between miR-486-5p and the prognosis of PAAD was analyzed using the PROGmiRV2 database. The target genes of miR-486-5p were predicted by combined use of multiple data platforms, and then, the gene ontology (GO) enrichment analysis and Kyoto Gene and Genome Encyclopedia (KEGG) signal pathway analysis were performed for the selected target genes using the DAVID online database. After that, the protein-protein interaction (PPI) network of the target genes was constructed using the STRING database, and visualized using Cytoscape software for to screen the core genes in the PPI network. Finally, the candidate genes were verified and picked up to find the core genes related to the prognosis of PAAD. 
    Results: The overall survival time of PAAD patients with low miR-486-5p expression was shorter than that of PAAD patients with high miR-486-5p expression (P<0.05). A total of 187 target genes were obtained, which were predicted by at least 3 different databases. Go analysis showed that the predicted target genes were mainly involved in the biological processes such as protein stability, protein phosphorylation, positive regulation of RNA polymerase II promoter transcription and negative regulation of apoptosis; KEGG analysis showed that the target genes were mainly involved in FOXO signaling pathway, p53 signal pathway, Ras signaling pathway, and PI3K-Akt signaling pathway. Protein network analysis of potential target genes of miR-486-5p showed that SIRT1, PTEN, SMAD2, CSNK2A1 and SERPINE1 were key target genes in PPI network. Further GEPIA verification revealed that CSNK2A1 and SERPINE1 were significantly up-regulated in PAAD tissues (all P<0.05). The high expressions of these genes were associated with the overall and disease-free survival in patients with PAAD (all P<0.05), and those with high expressions of CSNK2A1 and SERPINE1 had worse prognosis.
    Conclusion: MiR-486-5p acts on the network of multiple signaling pathways in PAAD patients through the regulation of targeted genes, participates in the occurrence and development of PAAD, and affects the prognosis of PAAD patients.
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    Safety and feasibility of laparoscopic retrieval of inferior vena cava filters
    WANG Haidong, LIU Jianlong, ZHU Xiaofei, WANG Hai, LI Guizhong, ZHOU Ning, JIA Wei, JIANG Peng, MAN Libo
    Chinese Journal of General Surgery    2020, 29 (12): 1468-1474.   DOI: 10.7659/j.issn.1005-6947.2020.12.008
    Abstract94)      PDF(pc) (2385KB)(25)       Save
    Background and Aims: Since the authors’ hospital initially conducted laparoscopic retrieval of inferior vena cava (IVC) filters in 2016, a number of cases of this operation have been performed. The aim of this article is to summarize the surgical experience of two approaches (transperitoneal approach and retroperitoneal approach) of laparoscopic retrieval of IVC filters by analyzing the clinical data of 10 patients undergoing this operation, so as to provide a reference for its popularization and promotion. 
    Methods: The clinical data of 10 patients undergoing laparoscopic retrieval of IVC filters during December 2016 and November 2018 were retrospectively analyzed. Among these patients, 7 were males and 3 were females, aged from 24 to 66 years, with an average age of (47±12.5) years. CT findings were that the head of the IVC filter dislocated above the renal vein in 1 case, at the renal vein level in 4 cases, and inferior to renal vein in 5 cases; the head of the IVC filter located close to the anterior or anterior lateral wall of the IVC in 5 cases, posterior lateral wall of the IVC in 4 cases, and in the lumen of the IVC in 1 case. All IVC filters were retrievable filters, including Celect filter used in 9 cases, and Denali filter in 1 case. All filters were inserted in others hospital. Seven patients underwent prophylactic placement of IVC filters due to iliac and lower extremity venous thrombosis, one case underwent prophylactic placement of IVC filters due to multiple traumatic rib and pelvis fractures, and IVC filter placement for 2 patients was in the setting of acute pulmonary embolism due to deep venous thrombosis. All patients were transferred to our hospital after previous endovascular retrieval failure for 1-3 times in other hospitals. All the 10 patients underwent laparoscopic IVC filter retrieval through transperitoneal approach in 6 cases and through retroperitoneal approach in 4 cases. Using a standard 3-port or 4-port technique, the IVC was dissected, the location of filter hook was found according to CT scan, a longitudinal incision in the wall of the IVC over the filter hook was made, and the filter was then retrieved. After operation, the volume and color of drainage were checked carefully. If the 24-h drainage volume was less than 50 mL for transperitoneal approach or less than 20 mL for retroperitoneal approach, the tube could be removed. Patients were given subcutaneous heparin 24 to 48 h after operation depending on surgical drainage for prevention of lower extremity deep venous thrombosis. Patients were started on a liquid diet the following day after operation, then slowly return to a normal diet and were encouraged to ambulate as much as tolerable.
    Results: IVC filter retrieval was successfully performed in 9 cases, and failed in one case. IVC occlusion was performed in one patient for 20 min, and was not required in other patients. the operative time was 150–420 min, with an average time of (253.5±86.7) min, the blood loss was 10–500 mL, with an average of (67.0±152.6) mL, 9 patients did not need a blood transfusion small for amounts of blood loss (10–50 mL), and one patient blood loss of 500 mL was transfused with 4 U of red blood cell suspension. The length of hospital stay was 7-15 d, with an average of (12.3±2.4) d. No operation-related complications occurred in all patients. No deep venous thrombosis recurred during the follow-up period.
    Conclusion: Laparoscopic retrieval of IVC filters is a complex and technically demanding operation. Careful preoperative preparation, rich operative experiences and proficient skills might improve the safety and success rate of the operation. According to CT scan and hook location of each patient, choosing different laparoscopic retrieval technique is important for improving the success rates.
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    Predictive value of preoperative plus postoperative neutrophil-lymphocyte ratio and Glasgow prognostic score for prognosis of gallbladder carcinoma
    ZHU Zhencheng, LUO Kunlun, XIE Weixuan, ZHU Mengjiao, ZHU Qingzhou, BAI Yang, LI Fuli, LIU Weiwei
    Chinese Journal of General Surgery    2020, 29 (8): 947-957.   DOI: 10.7659/j.issn.1005-6947.2020.08.005
    Abstract93)      PDF(pc) (575KB)(32)       Save
    Background and Aims: Gallbladder carcinoma (GBC) is a malignant tumor with a high mortality rate. The lack in quick and effective methods of preoperative diagnosis and prognostic assessment has increased the difficulty of operation and follow-up treatment for GBC. In recent years, the relations of the peripheral blood inflammation-related indicators with tumor prognosis have been extensively studied, but the predictive values are often limited due to the instability of the peripheral blood parameters. The purpose of this study was to investigate the role of the new peripheral blood parameter models preoperative plus postoperative neutrophil-lymphocyte ratio (PP-NLR) and Glasgow prognosis score (GPS) in prognostic assessment of GBC. 
    Methods: The clinical data of 140 patients with GBC treated from January 2005 to December 2015 were retrospectively analyzed. The cut-off values of NLR before and after operation were determined by ROC curve, based which, the NLR value was assigned as 1 if it was increased, or as 0 if not, and the PP-NLR value was defined as the sum of the two assigned values and was 0, 1 and 2, respectively; the preoperative serum albumin <35 g/L and preoperative CRP >10 g/L were assigned as 1 respectively and were assigned as 0 if not, and GPS value was defined as the sum of the two assigned values and was 0, 1 and 2, respectively. The relations of PP-NLR and GPS with the prognosis and clinicopathologic factors of the patients were analyzed by Kaplan-Meier method, Log-rank test and univariate analysis, respectively. The correlations of PP-NLR and GPS with the clinicopathologic factors were determined by Spearman correlation analysis. The independent prognostic factors were determined by multivariate Cox hazard model. 
    Results: The cut-off values of NLR before and after operation determined by ROC curve were 2.51 (sensitivity: 0.961, specificity: 0.788) and 2.38 (sensitivity: 0.745, specificity: 0.712). Survival analysis showed that the survival rates were significantly different among patients with different PP-NLR and GPS levels (all P<0.05), which presented a successive decrease in PP-NLR=1, PP-NLR=2 and PP-NLR=3 group, and was significantly higher in GPS=0 group than those in GPS=1 group or GPS=2 group (both P<0.05), but had no significant difference between GPS=1 group and GPS=2 group (P>0.05). Univariate analysis suggested that both PP-NLR and GPS were related to the radical resection rate, tumor invasion, lymph node or distal metastases, TNM classification and degree of differentiation as well as the inflammatory indexes and tumor markers (all P<0.05). The correlation analysis indicated that PP-NLR and GPS were significantly correlated to the radical resection rate, tumor invasion, lymph node or distal metastases, TNM classification and degree of differentiation (all P<0.05). Univariate analysis demonstrated that both the increased PP-NLR and GPS were significantly associated with low survival rate (both P<0.05), and multivariate analysis revealed that PP-NLR was an independent risk factor affecting the prognosis of the patients (PP-NLR=1: HR=0.357, 95% CI=0.221–0.575, P<0.05; PP-NLR=2: HR=0.357, 95% CI=0.221–0.575, P<0.05). 
    Conclusion: Both PP-NLR and GPS are related to the prognosis of GBC patients, and PP-NLR is an independent prognostic factor, suggesting that peripheral blood parameters PP-NLR and GPS can easily, quickly and effectively assess the prognosis of the patient. In addition, PP-NLR integrates the pre- and postoperative systemic inflammation and immune status, so it is more comprehensive and reliable that that GPS and preoperative or postoperative NLR alone for prediction, and can provide a theoretical basis for follow-up treatment. 
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    Endovascular interventional treatment of intravascular foreign bodies: a report of 4 cases and literature review
    WANG Weiming, SHI Sen, ZENG Hong, ZHANG Lei, LIU Yong
    Chinese Journal of General Surgery    2020, 29 (6): 693-698.   DOI: 10.7659/j.issn.1005-6947.2020.06.009
    Abstract93)      PDF(pc) (2471KB)(42)       Save
    Background and Aims: The occurrence of intravascular foreign bodies is relatively common in clinical practice, especially the intravascular foreign bodies caused by iatrogenic factors. With the increase of number of medical invasive procedures, the occurrence of iatrogenic intravascular foreign bodies is also increasing, which may lead to serious complications in patients. Therefore, the occurrence and development of intravascular foreign bodies as well as their diagnosis and treatment have also attracted attention and discussion from clinicians. Therefore, in order to optimize the diagnosis and treatment of such patients, and ensure the safety of the patients, this study conducted a comprehensive analysis and discussion based on the experience in diagnosis and treatment of intravascular foreign bodies in our department in the past two years, combined with the existing literature reports, so as to provide scientific theoretical basis and experience sharing for the diagnosis and treatment of similar cases in clinical practice. 
    Methods: The clinical data of 4 patients with intravascular foreign bodies diagnosed and treated in our center in the past two years were collected, and the sources and characteristics of foreign bodies, surgical procedures and experience were retrospectively analyzed and sorted out. The existing domestic and foreign literature reports concerning such diseases were retrieved, and then were reviewed and summarized.
    Results: All the 4 patients had iatrogenic intravascular foreign bodies, which in one case was caused by the guide wire detachment during placement of the peripherally inserted central catheter (PICC), in two cases were caused by the fracture of the PICC catheter, and in another case was causes by undesirable detachment of the coils in the abdominal aortic lumen during endovascular embolization for a penetrating aortic ulcer. None of the four patients had clinical manifestations related to foreign bodies. All the foreign bodies were successfully removed by using a single-bent catheter and a gooseneck snare under interventional approach, and the integrity of each foreign body was acceptable. All patients recovered well after operation without any foreign body and operation-related complications.
    Conclusion: In clinical practice, the occurrence of intravascular foreign bodies cannot be completely avoided, especially those caused by iatrogenic factors, and effective preventive measures should be taken. For the already occurred intravascular foreign bodies, timely and effective treatment is extremely important to reduce the risk of serious complications caused by foreign bodies. As the preferred treatment for intravascular foreign bodies, endovascular interventional therapy has the unique advantages of high retrieval rate, low surgical risk and fewer complications, and its efficacy has also been proven. In addition, a variety of appropriate interventional instruments should be selected and experienced surgeons are necessary during endovascular interventional procedures.
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    Analysis of risk factors for early postoperative recurrence of pancreatic ductal adenocarcinoma and application value of neoadjuvant chemotherapy and postoperative adjuvant chemotherapy 
    ZHU Lei, LI Shanshan, GU Hongzhu, WANG Yang
    Chinese Journal of General Surgery    2020, 29 (9): 1084-1090.   DOI: 10.7659/j.issn.1005-6947.2020.09.008
    Abstract93)      PDF(pc) (1066KB)(33)       Save
    Background and Aims: Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant digestive tumor, and the patients may face a risk of early postoperative recurrence (recurrence within postoperative 6 months) even after radical resection. Further, the perioperative risk factors for predicting early recurrence remain unclear so far. This study was designated to investigate the risk factors for early postoperative recurrence of PDAC, and the clinical value of preoperative neoadjuvant chemotherapy (NAC) and postoperative adjuvant chemotherapy (PAC) in preventing early recurrence of PDAC. 
    Methods: The clinical data of 141 patients with PDAC who underwent pancreatectomy in Panjin Liao-Oil Gem Flower Hospital from January 2011 to December 2016 were retrospectively analyzed. Of the patients, 64 cases (47.5%) received NAC and 103 cases (73.0%) received PAC; recurrence occurred in 45 cases and did not occur in 96 cases within postoperative 6 months.
    Results: The results of univariate analysis showed that TNM stage, preoperative CA19-9 level, NAC, postoperative complications, postoperative CA19-9 level and PAC were associated with early postoperative recurrence (all P<0.05). The results of comparative analysis among different treatment methods, the incidence of early local recurrence in patients undergoing NAC (undergoing NAC or NAC+PAC) was lower than those without NAC (undergoing pure surgery or PAC) (partial P<0.05); the incidence of early distant metastasis in patients undergoing PAC (undergoing PAC or PAC+NAC) was lower than those without PAC (undergoing pure surgery or NAC) (all P<0.05). The results of multivariate analysis showed that the advanced TNM stage (III vs. I: HR=1.866, 95% CI=1.148–3.035, P=0.012; III vs. II: HR=1.790, 95% CI=1.044–3.068, P=0.035), postoperative CA19-9 level above 37 IU/mL (HR=1.998, 95% CI=1.200–3.325, P=0.008) and absence of PAC (HR=1.962, 95% CI=1.176–3.273, P=0.010) were independent risk factors for early postoperative recurrence. 
    Conclusion: TNM stage, postoperative CA19-9 level and PAC are important predictor of early recurrence of PDAC. Although PAC is an important preventive measure against the early recurrence, particularly distant metastasis of PDAC, NAC can effectively prevent the early local recurrence of PDAC. So, there is a potential complementary association between the two regimens.
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    Application efficacy of three-dimensional visualization combined with indocyanine green clearance test in operation for patients with liver tumor and comorbid cirrhosis
    PANG Runhua, ZHU Yaqing, WU Jian, HUANG Junhai, CHEN Bin
    Chinese Journal of General Surgery    2021, 30 (1): 71-78.   DOI: 10.7659/j.issn.1005-6947.2021.01.009
    Abstract93)      PDF(pc) (2138KB)(169)       Save
    Background and Aims: Complications and hepatic insufficiency are likely to occur in patients with liver tumor and concomitant liver cirrhosis after hepatectomy due to the always presence of poor liver functional reserve. So, accurate preoperative clinical assessment and precise intraoperative resection scope are of great importance for the outcomes of patients with liver tumor and concomitant liver cirrhosis undergoing hepatectomy. This study was conducted to investigate the efficacy of using three-dimensional visualization technology (3DVT) combined with indocyanine green (ICG) clearance test in operation for patients with liver tumor and cirrhosis. 
    Methods: The clinical data of 57 patients with liver tumor and cirrhosis undergoing hepatectomy with 3DVT plus ICG clearance assessment from May 2019 to March 2020 (observation group), as well as 62 patients with the same conditions undergoing hepatectomy with 3DVT plus traditional Child-Pugh assessment from January 2018 to April 2019 (control group) were retrospectively analyzed. The main clinical variables and the incidence rates of postoperative liver dysfunction and other complications were compared between the two groups of patients. 
    Results: There were no significant differences in the basic data and each inflammatory factor and liver function parameter between the two groups before operation (all P>0.05). The operative time showed no significant difference between the two groups (P>0.05), but the intraoperative blood loss and length of hospital stay were reduced in observation group compared with control group (both P<0.05). In either group, all inflammatory factors and liver function parameters were significantly improved compared to preoperative values, but the improving degrees of them in observation group were significantly superior to those in control group (all P<0.05). The overall incidence rates of postoperative liver dysfunction and complications in observation group were significantly lower than those in control group (both P<0.05). 
    Conclusion: Using 3DVT plus ICG clearance test in operation for patients with liver tumor and concomitant liver cirrhosis is helpful for accurate preoperative judgment of the space structure relations between liver tumor and surrounding tissues, determination of the liver resection volume and residual liver volume, and estimation of the liver functional reserve, and also can reduce the intraoperative blood loss and postoperative traumatic stress reactions of the patients, shorten hospitalization time, and decrease the incidence rates of postoperative complications and hepatic insufficiency. So, it has good application value and is recommended to be used.
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    Emphysematous pancreatitis: a report of three cases and literature review 
    CAO Lijun, ZHANG Pinjie, HU Qiuyuan, CHEN Hu, SUN Yun
    Chinese Journal of General Surgery    2020, 29 (9): 1098-1104.   DOI: 10.7659/j.issn.1005-6947.2020.09.010
    Abstract92)      PDF(pc) (1366KB)(37)       Save
    Background and Aims: Emphysematous pancreatitis (EP) is regarded as a rare form of necrotizing pancreatitis, with a high mortality. However, it has not been definitely classified so far, and also no consensus on its treatment protocol has been reached at home and abroad. Here, the authors summarize the clinical features, pathogenesis, diagnosis and treatment as well as outcomes of 3 cases of EP, so as to provide help for the clinical diagnosis and treatment of this condition in future. 
    Methods: The clinical data of 3 patients admitted and diagnosed with EP were retrospectively analyzed. The relevant literature was reviewed and discussed. 
    Results: Case 1 was a 72-year-old male patient who was admitted due to abdominal pain for 12 h and abdominal CT revealed the signs of acute pancreatitis. The patient developed a high-grade fever on the 5th day of admission, and reexamination abdominal CT on the that day showed pancreatic necrosis and diffuse gas shadows in the peripancreatic region, and then, an emergency peripancreatic necrosectomy was performed. Massive retroperitoneal hemorrhage occurred on the 28th day after operation, and the patient was discharged on that day after failure of conservative treatment and died on the same day. Case 2 was a 70-year-old woman who was admitted for severe abdominal pain for 1 d, and presented with septic shock on admission. CT scan on the admission day showed pancreatitis complicated with gas collections in the retroperitoneal space. Emergency laparoscopic exploration and converted open incision of the pancreatic capsule for decompression plus abdominal drainage was performed. The shock status continued to worsen and multiple organ dysfunction appeared which could not be corrected after operation. The patient was discharged on her own request 4 d after operation and died on the same day. Case 3, 71-year-old man, was hospitalized for abdominal pain for 20 h. CT scan showed acute pancreatitis without retroperitoneal gas. On the 9th day of admission, reexamination CT showed blurred contours of the pancreas and gas collections in the peripancreatic region, and percutaneous catheter drainage (PCD) was performed. On the 25th day of admission, massive retroperitoneal hemorrhage occurred, and interventional embolization was performed. One month after admission, laparotomy necrosectomy plus transverse colostomy was performed, and the patients recovered and was discharged from hospital 30 d after surgery. According the literature, the mortality rate of EP reached 10%–36%, and risk factors associated with mortality have not been well summarized. Generally, fulminant type EP was associated with a poor prognosis and subacute type EP had a relatively benign prognosis.
    Conclusion: EP is a rare and life-threatening necrotizing infection of the pancreas. CT is the first choice for diagnosis of EP. Regardless of whether for the fulminant type or the subacute type EP, active antimicrobial therapy, early percutaneous catheter drainage and other minimally invasive treatment as well as delayed surgery are helpful to improve the prognosis.
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    Chinese Journal of General Surgery    2020, 29 (9): 1151-1156.   DOI: 10.7659/j.issn.1005-6947.2020.09.018
    Abstract92)      PDF(pc) (1095KB)(31)       Save
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    Chinese Journal of General Surgery    2020, 29 (10): 1275-1279.   DOI: 10.7659/j.issn.1005-6947.2020.10.015
    Abstract92)      PDF(pc) (1020KB)(41)       Save
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    Efficacy observation of endarterectomy in treatment of carotid artery stump syndrome
    HU Xintao, WANG Bing, WANG Yue, WU Fei, GUO Peng, WANG Hao, CHEN Jichong
    Chinese Journal of General Surgery    2020, 29 (6): 699-705.   DOI: 10.7659/j.issn.1005-6947.2020.06.010
    Abstract91)      PDF(pc) (2364KB)(39)       Save
    Background and Aims: After the chronic occlusion of unilateral internal carotid artery (ICA), there are 3%-5% of patients will still have symptoms of cerebral ischemia, such as black-outs and dizziness. However, there are few cases of clinically diagnosed this condition in China at present, and the understanding of its operation method is insufficient. Therefore, this study was conducted to preliminarily investigate the safety and efficacy of the endarterectomy of the external carotid artery (ECA), common carotid artery (CCA) or ICA as the main method combined with the occlusion or resection of the residual lumen of the ICA in treatment of the carotid stump syndrome (CSS). 
    Methods: The clinical and follow-up data of 9 patients diagnosed with CSS and treated by endarterectomy from August 2015 to June 2018 were analyzed retrospectively. Of the patients, 6 cases were males and 3 cases females, with an average age of 67.3 years. The changes in clinical symptoms before and after operation were compared. The scorers of the modified Rankin Scale (mRS) before and after operation were recorded.
    Results: All procedures were uneventfully completed in the 9 patients. After operation, the neurological symptoms such as dizziness and limb weakness were relieved and improved, and the frequency of TIA was significantly reduced, but the visual loss in one patient could not be relieved due to the long period of blindness. Two patients (22.2%) had headache, dysphoria and other high perfusion manifestations, which were improved after decompression and dehydration treatment, without serious complications such as cerebral hemorrhage and cerebral infarction; two patients had choking cough when drinking water after operation, but basically recovered one week later. The scores of mRS for all patients were lower than those before procedure (≥1).
    Conclusion: Endarterectomy of the ECA, CCA or ICA as the main method combined with the occlusion or resection of the residual lumen of the ICA is a safe and feasible method for CSS, with satisfactory short-term follow-up results. So, it can be used as a surgical method when the drug treatment fails.
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    Research progress of bromodomain 4 in transcriptional regulation and neoplastic processes and its inhibitors
    YANG Linrui, ZHANG Fenghe
    Chinese Journal of General Surgery    2020, 29 (7): 890-897.   DOI: 10.7659/j.issn.1005-6947.2020.07.014
    Abstract91)      PDF(pc) (1107KB)(29)       Save
    Bromodomain 4 (BRD4), a member of the bromodomain and extraterminal protein family, plays an important role in the physiological activities of normal cells and tumor cells by regulating gene transcription and cell cycle. As a transcriptional and epigenetic regulator, BRD4 gene overexpression, rearrangement and mutation are often associated with a variety of diseases, especially malignant tumors. Here, the authors review and analyze the function of BRD4 and its inhibitors in transcriptional regulation and their interaction with tumor cells, hoping to provide new ideas for relevant clinical treatment.
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    Progress in diagnosis and treatment of infected abdominal aortic aneurysm
    CHEN Xiyang, ZHAO Jichun
    Chinese Journal of General Surgery    2020, 29 (6): 659-663.   DOI: 10.7659/j.issn.1005-6947.2020.06.004
    Abstract91)      PDF(pc) (1086KB)(60)       Save
    Infected abdominal aortic aneurysm (IAAA) is a particularly challenging condition in the field of vascular surgery. It is resulted from the infection of the abdominal aorta directly or indirectly caused by pathogenic microorganism, characterized by rapid development, high risk of rupture, high mortality and poor prognosis. The treatment of IAAA currently is performed by means of endovascular aortic repair or surgical procedure on the basis of full course of antibiotic therapy. Here, the authors address the current experiences and advances in diagnosis and treatment of IAAA in China and abroad, so as to provide reference for optimum individualized therapy of the patients.
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    Breakthrough through accumulation: suggestions and reflections on hierarchical quality management of thyroid cancer clinical database in China
    CHENG Ruochuan, LIU Wen
    Chinese Journal of General Surgery    2020, 29 (11): 1282-1292.   DOI: 10.7659/j.issn.1005-6947.2020.11.001
    Abstract91)      PDF(pc) (1222KB)(32)       Save
    Clinical database construction has made great achievements in clinical research of thyroid tumors. Large database-based clinical studies lead the development and updating of guidelines, and promote the development of clinical practice in thyroid surgery. The thyroid cancer database construction starts relatively late in China. There is still a lack of high-quality evidence-based medicine data on Chinese population for thyroid cancer, as well as reference evidence for clinical guidelines. In recent years, the construction of thyroid tumor clinical database has increasingly developed depending on the evolution of internet technology and a large number of patients in China. However, due to the lack of quality control standards for database construction, and with the improvement of data availability, the risk of authenticity and integrity reduction is greatly increased during the process of various clinical information digitalizing. Based on experience and problems encountered during construction of thyroid tumor clinical database in the authors’ center, the authors present some preliminary ideas and suggestion on graded quality management of thyroid tumor clinical database. The process of database construction and application can be summarized as extracting the original information to convert the data for the final scientific research paper. The information characteristics of database were summarized as a step by step process of data acquisition on a scale of 0 to 3. The quality control of the data depends on the authenticity and availability of the data at the superior adjacent level. With the progressively transcriptions of information data, the data availability gradually increased to the level for scientific research application, while the authenticity gradually decreased. Database quality control is to ensure the authenticity of data as much as possible in the process of improving availability. Improving level-1 data quality is the foundation and key to improve the overall quality of the database, because that is at a higher risk of data loss during database construction. In order to improve the overall quality of the database, this paper shares some thoughts on data quality management from different aspects of medical record, including laboratory examination (level-1A), pathological report (level-1A), ultrasonic report (level-1B), and written record. In addition, we also propose structured level-1 medical record data recommendations. Over the years, clinical research of artificial intelligence diagnosis and disease prediction models based on big data has been carried out in full swing. However, the lack of satisfactory original database is difficult to improve later; the construction of a large database may lead to the embarrassing situation of “getting half the result with twice the effort”. This management problem may be ubiquitous in every specialized field and every national database construction. Therefore, the purpose of this paper is to call for the domestic colleagues pay attention to the quality control of the database and integrate the experiences of database construction from different centers, so as to brainstorm ideas and jointly develop a more reasonable hierarchical management of thyroid tumor clinical database in China.
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    Advances in management of infected abdominal aortic aneurysm
    LIN Changpo, FU Weiguo
    Chinese Journal of General Surgery    2020, 29 (6): 654-658.   DOI: 10.7659/j.issn.1005-6947.2020.06.003
    Abstract90)      PDF(pc) (1130KB)(38)       Save
    Infected abdominal aortic aneurysm (IAAA) is a special type of aneurysm caused by infection of various pathogenic bacteria. IAAA is characterized by acute onset, rapid progression, high risk of aneurysmal rupture and dismal clinical prognosis. So, early diagnosis and treatment of this condition are extremely critical. Diagnosis can be made based on typical medical history, laboratory tests, CTA images, intraoperative findings, positive results of blood culture or tissue culture. After diagnosis, surgical treatment should be performed as soon as possible on the basis of adequate antibiotic therapy. However, there is no agreement on specific antibiotic treatment options and surgical options so far. It is currently recommended to use antibiotics for at least 6 months after surgery. With the development of minimally invasive techniques, the proportion of IAAA treated by endovascular repair has been increasing with favorable short-term results. Endovascular therapy is expected to be the first choice of options for IAAA in the future.
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    Influence of cryptotanshinone on biological behaviors of pancreatic cancer cells and the action mechanism
    HUANG Zhiwei, TAN Peng, , DU Yichao, , SHI Hao, CHEN Hao, QIAN Baolin, LIU Yu, FU Wenguang, , LI Qiu
    Chinese Journal of General Surgery    2020, 29 (9): 1060-1068.   DOI: 10.7659/j.issn.1005-6947.2020.09.005
    Abstract90)      PDF(pc) (5430KB)(48)       Save
    Background and Aims: Pancreatic cancer is a highly malignant tumor of the digestive system. Although the current treatment for pancreatic cancer is constantly evolving, the prognosis of pancreatic cancer patients is still poor. Cryptotanshinone (CPT) is a monomer extracted from Chinese medicinal herb salvia miltiorrhiza with variety of activities, which has been proven to have anti-cancer potential against cervical cancer and prostate cancer, etc. However, its effect on pancreatic cancer is still unclear. This study was conducted to investigate the effect of CPT on the growth and migration of pancreatic cancer cells in vitro and the possible mechanism, so as to provide theoretical and experimental basis for the development of relevant drugs for clinical use. 
    Methods: The human pancreatic cancer BxPC-3 and SW1990 cells were used as study subjects. In these two types of pancreatic cancer cells, the concentration and time effects of CPT on cell viability were determined after treatment with different concentrations (10, 20 and 40 μmol/L) of CPT for different times (0, 1, 2 and 3 d); the changes in abilities of colony formation, migration and invasion after treatment with above concentrations of CPT for 24 h were determined by colony forming assay, scratch wound healing assay and Transwell assay, respectively; the expressions of Akt, phosphorylated Akt (p-AKT), and the epithelial-mesenchymal transition (EMT)-associated proteins vimentin and E-cadherin as well as the cell cycle-related proteins CDK4, cyclin D1 after treatment with 20 μmol/L CPT for different times were determined by Western blot analysis. The cells for control were treated with the vehicle (DMSO) only.
    Results: In the two types of pancreatic cancer cells compared with corresponding control group, the growth abilities were significantly inhibited after CPT treatment, with a concentration- and time-dependent manner (all P<0.05); the degree of wound healing, relative colony formation rate and number of invading cells were significantly reduced, with a concentration-dependent manner (all P<0.05); the protein expressions of Akt, p-Akt, vimentin and E-cadherin, CDK4 and cyclin D1 were all significantly down-regulated, with a time-dependent manner (all P<0.05). 
    Conclusion: CPT can effectively inhibit the growth and migration of pancreatic cancer cells, and the mechanism may be probably associated with its downregulating the expression of Akt and thereby, cause the cell cycle arrest and inhibition of the EMT process of the pancreatic cancer cells.
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    Current status of pancreaticojejunostomy technique for pancreatoduodenectomy and prevention strategies for pancreatic fistula
    DENG Hongyang, WEI Fengxian, XU Xiaodong
    Chinese Journal of General Surgery    2020, 29 (9): 1126-1133.   DOI: 10.7659/j.issn.1005-6947.2020.09.014
    Abstract88)      PDF(pc) (1127KB)(52)       Save
    Pancreatoduodenectomy (PD) is the standard procedure for the treatment of pancreatic head or periampullary malignancies, and some benign diseases as well as precancerous lesions. Pancreaticojejunostomy-associated postoperative pancreatic fistula (POPF) is one of the important causes for the adverse outcomes of the operation, bringing huge pain and economic loss to the patients and their families. Existing studies suggest that POPF may be the result of multiple factors, and pancreaticojejunostomy is one of the independent risk factors and also one of the important factors that can be controlled by surgeons. However, although there have been more than 100 reported pancreaticoenterostomy methods, POPF cannot be avoided and none of them have been fully recognized. So, pancreatic surgeons are keeping looking for a more reliable anastomosis between the pancreas and intestine. Nowadays, scholars at home and abroad have never stopped exploring pancreaticojejunostomy, and they are also making unremitting efforts in developing other measures to prevent pancreatic fistula. Based on the above background, the authors reviews the current situation of pancreaticojejunostomy and POPF prevention strategies, so as to help reduce the harm of POPF.
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    Analysis of indications and clinical value of open pancreatic necrosectomy in treatment of infected pancreatic necrosis
    NING Caihong, ZHU Shuai, SHEN Dingcheng, CAO Xintong, LIN Jiayan, LI Jiarong, JI Liandong, WEI Wei, HUANG Gengwen
    Chinese Journal of General Surgery    2020, 29 (9): 1105-1111.   DOI: 10.7659/j.issn.1005-6947.2020.09.011
    Abstract87)      PDF(pc) (1140KB)(23)       Save
    Background and Aims: With the development of critical care medicine and the update of the surgical concepts and treatment modalities in recent years, the minimally invasive step-up approaches of different types have gradually become the mainstream methods for the treatment of infected pancreatic necrosis (IPN). However, traditional open pancreatic necrosectomy (OPN) still plays an irreplaceable role. This study was conducted to analyze the new characteristics and clinical value of OPN in treatment of IPN in the era of minimally invasive surgery.  
    Methods: A total of 140 consecutive patients with IPN treated in Xiangya Hospital of Central South University from January 2014 to May 2019 were reviewed. Of the patients, 24 cases underwent OPN and 116 cases were treated with purely minimally invasive approach, and the main attention was focused on the clinical characteristics, surgical timing, indications and outcomes of the 24 cases undergoing OPN. In the whole group of IPN patients, the therapeutic principle of delayed surgery was implemented. For those failed to antibiotic treatment, surgical intervention was performed after full encapsulation and liquefaction of the pancreatic necrosis by prolongation of the conservative treatment as maximal as possible at least 3 to 4 weeks after the onset. 
    Results: The indications or reasons for OPN in the 24 patients included no route for PCD in one case (4.2%), aggressively performed OPN in 5 cases (20.8%), uncontrollable infection after minimally invasive surgery in 6 cases (25.0%), serious associated complications in 9 cases (37.5%) and uncontrollable infection after open surgery in other hospitals in 3 cases (12.5%). All patients undergoing OPN were complicated with severe retroperitoneal and bloodstream infections, of whom, 79.2% (19/24) were multidrug-resistant infections, 58.3% (14/24) were bloodstream infections, 29.2% (7/24) were peripancreatic fungal infections, and 4.2% (1/24) were fungal bloodstream infection. Klebsiella pneumoniae was the most common microorganism isolated from the peripancreatic necrosis. In patients undergoing OPN compared with patients undergoing purely minimally invasive surgery, the proportion of cases with severe illness was high (87.5% vs. 63.8%), the average length of ICU stay was prolonged (26.9 d vs. 17.7 d), the average length of hospital stay after intervention was shortened (24.1 d vs. 42.9 d), and the mortality rate was increased (45.8% vs. 20.7%), and all the differences had statistical significance (all P<0.05); no significant differences in other general data, the interval between intervention and onset, and the main postoperative complications (massive bleeding, intestinal fistula and pancreatic fistula) were noted (all P>0.05). The main causes for postoperative death in patients undergoing OPN included septic shock in 5 cases (45.5%) and hemorrhagic shock in 6 cases (54.5%). 
    Conclusion: OPN still plays an irreplaceable role in the treatment of IPN, and sometimes even the only way to save the life of the patients. In the era of minimally invasive surgery, appropriate selection of indications and timing for OPN has great importance in improving the prognosis of the patients with severe acute pancreatitis. 
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    Clinical observation of using modified PCH regimen neoadjuvant therapy in young patients with treatment-naïve locally advanced HER-2 positive breast cancer
    ZHENG Xiangxin, WU Ji, GU Shucheng, JIANG Xiaoling, SHI Xiaohong, YUAN Mu, LU Bolin, QIU Xing, ZHANG Xuxu, BAI Jianyin, YANG Peng, GUAN Xiaoqing
    Chinese Journal of General Surgery    2020, 29 (11): 1311-1318.   DOI: 10.7659/j.issn.1005-6947.2020.11.004
    Abstract87)      PDF(pc) (1202KB)(33)       Save
    Background and Aims: HER-2 positive breast cancer, especially the locally advanced HER-2 positive breast cancer in young patients, PCH regimen (paclitaxel + carboplatin + trastuzumab) is recommended for neoadjuvant therapy. However, the commonly used solvent paclitaxel is prepared with polyoxyethylene castor oil, which may cause the side effects such as allergic reactions, myelosuppression and peripheral neurotoxicity. Therefore, this study was designed to investigate the efficacy and safety of neoadjuvant therapy using the modified PCH regimen (albumin-bound paclitaxel + carboplatin + trastuzumab) in the treatment of young patients with initially diagnosed locally advanced HER-2 positive breast cancer.  
    Methods: Using a prospective protocol, the treatment-na?ve young females (aged from 18 to 40 years) diagnosed with locally advanced HER-2 positive breast cancer in the Department of Breast Surgery of Affiliated Suqian Hospital of Xuzhou Medical university from June 2016 to December 2018 were enrolled. The patients were assigned to two groups by random number table, and then underwent neoadjuvant therapy with PCH regimen (PCH group) or modified PCH regimen (PCH group). In all patients, the treatment responses and adverse reactions were evaluated after 6 cycles of chemotherapy, and then modified radical mastectomy was performed. Trastuzumab treatment was continued for a full year after operation, and the progression-free survival (PFS) and overall survival (OS) of the two groups of patients were compared.
    Results: A total of 62 patients were enrolled, with 30 cases in PCH group and 32 cases in modified PCH group, and the preoperative data between the two groups of patients were comparable. After neoadjuvant therapy, complete clinical response (cCR) was obtained in 6 patients, complete pathological response was achieved in 2 patients, and partial response was found in 22 patients in PCH group, while 14 patients had cCR, 8 patients had pCR and 10 patients had PR in modified PCH group. Both cCR and pCR rates in modified PCH group were significantly higher than those in PCH group (43.8% vs. 20.0%, χ2=3.997, P=0.046; 25.0% vs. 6.7%, χ2=4.098, P=0.043). No treatment-associated death occurred in all patients during chemotherapy. The incidence of neutropenia in modified PCH group was significantly lower than that in PCH group (31.3% vs. 60%, χ2=5.168, P=0.023), while the incidence of peripheral sensory neurotoxicity in modified PCH group was significantly higher than that in PCH group (40.6% vs. 20.0%, χ2=3.997, P=0.046), but all reactions presented as numbness or tingling in hands or feet, and no neurotoxic reaction of 3 to 4 degree occurred in both groups. There were no significant differences between the two groups in other common adverse reactions such as nausea and vomiting, alopecia and rash (all P>0.05). The parameters of cardiac function of the two groups of patients were within the normal range during treatment. The median PFS time and the median OS time were 13.1 months and 35.4 months in modified PCH group, and were 7.8 months and 21.6 months in PCH group, and the difference had statistical significance (χ2=8.302, 8.557, P=0.005, 0.004).
    Conclusion: In young patients with treatment-na?ve locally advanced HER-2 positive breast cancer, using the modified PCH regimen not only increases the cCR rate, but also improves the pCR rate to a certain extent compared with PCH regimen. The short-term efficacy in patients is satisfactory, with relatively mild adverse reactions. So, it is recommended to be used in clinical paractice.
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    Analysis of influencing factors for gut microbiota in patients with hepatocellular carcinoma
    ZHOU Kaifei, WANG Jilong, TENG Yanjuan, CHEN Sixia, MO Xinshao
    Chinese Journal of General Surgery    2020, 29 (7): 877-883.   DOI: 10.7659/j.issn.1005-6947.2020.07.012
    Abstract85)      PDF(pc) (1110KB)(70)       Save
    Background and Aims: Gut microbiota is closely related to the occurrence and development of hepatocellular carcinoma (HCC). This association suggests that gut microbiota balance should also be an important target for the treatment of HCC in addition to the treatment of primary liver diseases. Therefore, this study was aimed to explore the influencing factors for gut microbiota in patients with HCC. 
    Methods: A total of 121 HCC patients were enrolled. Fecal DNA samples of the HCC patients were extracted, and the relative abundance of gut microbiota was analyzed by quantitative real-time PCR. Intestinal dysbacteriosis (ID) was diagnosed by Bifidobacterium/Enterobacteriaceae (B/E) <1. The major factors affecting the gut microbiota in HCC patients were determined by univariate and multiple linear regression analysis .
    Results: The abundance of Bifidobacterium was significantly lower than that of Enterobacteriaceae in patients with HCC [Log5 (6.24±1.30)/g vs. Log5(7.59±1.11)/g, P<0.000]. The incidence of ID was 77.69% (94/121). Multiple linear regression analysis showed that monocyte was the only main influencing factor for Bifidobacterium (P<0.000) and ID (P=0.008); total bilirubin (P=0.011), sex (P=0.027) and fasting blood glucose (P=0.038) were the main influencing factors for Enterobacteriaceae. 
    Conclusion: Monocyte, total bilirubin, sex and fasting blood glucose are possibly important factors affecting the gut microbiota and thereby cause ID in HCC patients. The correlation between these factors and gut microbiota may not only provide the potential targets for modulating gut microbiota in HCC patients, but also give a solid theoretical basis for gut microbiota intervention as a therapeutic strategy for HCC.
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    Anatomical variations and new anatomical classification of the arteries supplying the liver based on multi-slice spiral CT
    WANG Chengyu, , , ZHANG Zhipeng, , , FANG Zhenhao, , , LI Xianchu, , LI Xi, , , YIN Junda, , , DNEG Shengjun, , , YANG Hao, , , LONG Xueying, , WU Wei, ,
    Chinese Journal of General Surgery    2020, 29 (7): 857-866.   DOI: 10.7659/j.issn.1005-6947.2020.07.010
    Abstract85)      PDF(pc) (2055KB)(27)       Save
    Background and Aims: There are many anatomical variations of the arteries supplying the liver. Currently, the anatomical classification methods of the liver arteries are mainly Michels’ classification and Hiatt’s classification. However, new types of anatomical variations have continually been discovered. So, previous classification systems cannot meet the clinical needs. This study was conducted to analyze the anatomical variations of the liver supplying arteries by imaging observation, so as to create an accurate classification method and provide precise scientific information for clinical work. 
    Methods: The imaging data of patients undergoing biphasic contrast-enhanced scanning of abdominal multi-slice spiral CT from January 2019 to March 2019 were reviewed. The patterns of the arteries supplying the liver were observed, the relevant data were recorded and categorical analysis was performed. 
    Results: The CT imaging data of 1 520 patients were selected, including 967 males and 553 females. Of the patients, 1 504 cases (98.95%) met Michels’ classification, and 16 cases (10.53‰) did not meet Michels’ classification; 1 507 cases (99.14%) met Hiatt’s classification, and 13 cases (8.55‰) did not meet Hiatt’s classification. By analyzing the anatomical variations of the arteries supplying the liver from the aspects of the origin of the common hepatic artery (CHA), the origin of the accessory left hepatic artery (ALHA) and the types of the arteries supplying the liver, the authors proposed the seven-type classification (according to the origin of the CHA) and five-type classification (according to the anatomical variation of the left and right liver supplying arteries and the combination of different variations) for classifying the anatomical types of the arteries supplying the liver. In the seven-type classification, 1 471 cases (96.78%) were classified as type I, 25 cases (1.64%) were type II, 7 cases (0.46%) were type III, 5 cases (0.33%) were type IV, 4 cases (0.26%) were type V, 4 cases (0.26%) were type VI, and 4 cases (0.26%) were type VII. In the five-type classification, 1 381 cases (90.86%) were classified as type I, 87 cases (5.72%) were type II, 38 cases (2.50%) were type III, 10 cases (0.66%) were type IV, and 4 cases (0.26%) were type V.
    Conclusion: The new classification methods proposed in this study cover all possible anatomical variations, which simplify the complex situation of taking simultaneously into account the CHA and the hepatic supplying arteries for classification in previous studies. The frameworks of the classifications are clear, consistent with the anatomical reality and clinical cognition, and they can provide theoretical basis and guidance for clinical work.
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