Volume 30,Issue 8,2021 Table of Contents

1 Comparison of clinical efficacy of laparoscopic primary closure of the common bile duct and endoscopic stone extraction for secondary choledocholithiasis

ZHANG Jinghong , SHANG Haitao , LIU Junjian , CHEN Shuai , XU Yan , LI Zhonglian

2021, 30(8):877-885. DOI: 10.7659/j.issn.1005-6947.2021.08.001

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Background and Aims Laparoscopic common bile duct exploration and endoscopic choledochectomy are still controversial in the treatment of secondary choledocholithiasis, but reports in the literature tend to be a single-stage treatment strategy of primary closure following laparoscopic common bile duct exploration combined with cholecystectomy. Therefore, this study was conducted to compare the clinical efficacy of primary suture of laparoscopic common bile duct and endoscopic stone extraction in the treatment of secondary choledocholithiasis.Methods The clinical data of 183 patients with secondary choledocholithiasis treated in the Second Department of Hepatopancreatobiliary Surgery of Tianjin Nankai Hospital from January 2019 to February 2020 were retrospectively analyzed. Of the patients, 60 cases underwent laparoscopic common bile duct exploration with primary closure plus cholecystectomy (primary closure group), and 123 cases underwent endoscopic retrograde cholangiopancreatography/endoscopic lithotomy plus laparoscopic cholecystectomy (endoscopic stone extraction group). The two groups of patients were matched using 1∶1 propensity score matching (PSM), with a total of 59 pairs successfully matched. The surgical efficacy, postoperative complications, length of hospitalization and other clinical variables after matching were compared between the two groups, and the influencing factors for length of postoperative hospital stay and associated postoperative complications were also analyzed.Results Before PSM, there was a statistical difference in sex between the two groups (P=0.007). After PSM, all differences in the baseline data of the two groups had no statistical significance (all P>0.05). The overall incidence of postoperative complication in endoscopic stone extraction group was higher than that in primary closure group (P<0.05), which was mainly due to the higher incidence rate of postoperative hyperamylasemia in the former (20.3% vs. 0). There were no statistical differences in the incidence rates of other specific complications between the two groups (all P>0.05). The length of postoperative hospital stay was shorter and the hospitalization cost was lower in primary closure group than those in endoscopic stone extraction group (both P<0.05). The old age (OR=0.396, 95% CI=0.182-0.864, P=0.020), hyperamylasemia (OR=0.057, 95% CI=0.007-0.468, P=0.008) and endoscopic stone extraction (OR=0.084, 95% CI=0.040-0.179, P=0.000) were risk factors for prolonged postoperative hospital stay, and the surgical method was an influencing factor for postoperative hyperamylasemia (P<0.05). Followed up was conducted for at least 1 year in the two groups of patients, and no stone recurrence and biliary stenosis occurred.Conclusion Compared with endoscopic stone removal, the primary closure of the laparoscopic common bile duct for the treatment of secondary common bile duct stones has the advantages of shorter hospital stay and lower cost, with no damage to the normal physiological structure of the sphincter of Oddi.

2 Application of ureteral catheter in minimally invasive treatment of concomitant gallbladder and common bile duct stones combined with papillary stenosis

LUO Cong , ZHOU Huabo , CHEN Anping , ZENG Qiantao , YAN Chaocheng

2021, 30(8):886-893. DOI: 10.7659/j.issn.1005-6947.2021.08.002

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Background and Aims The staged endoscopic sphincterotomy (EST) plus laparoscopic cholecys-tectomy (LC) is the common treatment method for concomitant gallbladder and common bile duct stones combined with papillary stenosis. However, for large stone or multiple stones, the clearance rate of staged endoscopic stone extraction is lower than that of laparoscopic operation. For the purpose of achieving a high clearance rate of choledocholithiasis with simultaneous treatment of papillary stenosis, and reducing the injury of the anterior wall of the common bile duct by traditional surgery with primary closure of the common bile duct, this study was conducted to investigate the feasibility and clinical value of the one-stage procedure of LC plus laparoscopic transcystic common bile duct exploration (LTCBDE) and EST with primary closure of the common bile duct under the guidance of the ureteral catheter in the treatment of concomitant gallbladder and common bile duct stones combined with papillary stenosis.Methods The clinical data of patients with gallbladder and common bile duct stones combined with papillary stenosis treated by minimally invasive surgery in Chengdu Second People's Hospital from January 2018 to January 2020 were collected. A total of 78 patients meeting the criteria were enrolled, including 40 patients undergoing one-stage procedure of LC+LTCBDE+EST with primary closure of the common bile duct under the guidance of ureteral catheter (observation group) and 38 patients undergoing staged procedures of EST followed by LC (control group), The perioperative clinical data of the two groups of patients were compared.Results The preoperative general data were comparable between the two groups of patients. After operation, no bile leakage occurred in both groups, acute pancreatitis occurred in none of the cases in observation group but occurred in 3 cases (7.9%) in control group. The operative time and length of postoperative hospital stay were shorter and the level of postoperative blood amylase was lower in observation group than those in control group (all P<0.05), while there were no significant differences in terms of intraoperative blood loss, postoperative liver function parameters and nasobiliary drainage time between the two groups (all P>0.05). A total of 62 patients in both groups were followed up for one month to 8 months, with a median follow-up time of 6 months, and in all of them, no repeated abdominal pain and repeated bouts of jaundice occurred, and no biliary stricture and retained or recurrent stones were found.Conclusion Synchronous LC+LCBDE+EST with primary closure under the guidance of the ureteral catheter in the treatment of gallbladder and common bile duct stones combined with papillary stenosis is safe and feasible, and it makes operation more accurate, which can reduce the surgical trauma and complications to a certain extent, and thereby accelerate the postoperative recovery of the patients.

3 Efficacy analysis of emergency laparoscopic transcystic common bile duct exploration

JIANG You , LU Jun , GE Qiang , LI Liang

2021, 30(8):894-901. DOI: 10.7659/j.issn.1005-6947.2021.08.003

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Background and Aims Laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be safe and effective in elective surgery, but its efficacy in emergency surgery has not been established. Therefore, this study was conducted to evaluate the safety and feasibility of emergency LTCBDE in the treatment of patients with cholecystolithiasis complicated with choledocholithiasis.Methods The clinical data of 87 patients with gallbladder stones and concomitant common bile duct stones who underwent LTCBDE in Hefei Second People's Hospital from January 2016 to October 2020 were retrospectively analyzed. Of the patients, 37 cases underwent emergency LTCBDE (emergency group), and 50 cases underwent elective LTCBDE (elective group). The general baseline data, and perioperative variables and follow-up results between the two groups of patients were compared.Results There were no significant differences in baseline data between the two groups of patients (all P>0.05). No open conversion was needed in both groups, and laparoscopic surgery was successfully performed in all cases. Of the 87 patients, LTCBDE was successfully completed in 72 case, and 15 cases were converted to conventional laparoscopic common bile duct exploration with primary closure after failure of LTCBDE. LTCBDE was successfully completed in 29 cases (78.4%) in emergency group and 43 cases (86.0%) in elective group, respectively, and there was no statistical difference in exploration success rate between the two groups (P=0.352). In emergency group compared with elective group, the operative time was prolonged (P=0.015) and intraoperative blood loss was increased (P=0.014), while all other perioperative variables showed no statistical difference (all P>0.05). Complications occurred in 6 patients in the two groups, including 4 cases in emergency group (2 cases of bile leakage, 1 case of abdominal fluid collections and 1 case of retained stones) and 2 cases in elective group (2 cases of bile leakage). There were no significant differences in the overall incidence of complications and incidence of each specific complication between the two groups (all P>0.05).Conclusion Emergency LTCBDE has the comparable efficacy to elective LTCBDE. On the premise of appropriate selection of patients, emergency LTCBDE is safe and effective in the treatment of patients with gallbladder stones and concomitant common bile duct stones.

4 Analysis of influencing factors for postoperative complications in patients with hepatitis B virus-cirrhosis undergoing laparoscopic cholecystectomy

FENG Huaguo , FENG Yi , GONG Jianping , DAI Guohua , LI Bin , LU Ling

2021, 30(8):902-908. DOI: 10.7659/j.issn.1005-6947.2021.08.004

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Background and Aims A thorough preoperative assessment of risk factors for complications in patients with hepatitis B virus (HBV)-cirrhosis undergoing laparoscopic cholecystectomy (LC) is of great clinical significance. Therefore, this study was conducted to investigate the risk factors for complications in patients with HBV-cirrhosis after LC for concomitant gallbladder stones.Methods The clinical data of 188 patients with HBV-cirrhosis and gallbladder stones who underwent LC from January 2016 to January 2020 were collected for retrospective analysis. The patients were divided into complication group and non-complication group according to whether there were postoperative complications. Univariate analysis and multivariate Logistic regression analysis were performed on the perioperative variables of the two groups of patients to determine the influencing factors for postoperative complications.Results Of the patients, postoperative complications occurred in 36 cases, and the overall incidence rate was 19.2%, in which, the incidence rates for Clavien-Dindo I, II and III (IIIa、IIIb) complications were 9.6% (18/188), 5.3% (10/188) and 4.3% (8/188), respectively, and no Clavien-Dindo IV or V complications occurred. The results of statistical analysis showed that there were significant differences in antiviral therapy, the presence of ascites, portal hypertension or hypersplenism, model for end-stage liver disease (MELD) score, operative time and intraoperative blood loss between complication group and non-complication group (all P<0.05). Logistic regression analysis showed that MELD score greater than 10 was an independent risk factor (OR=2.775, P=0.032), while antiviral therapy was an independent protective factor (OR=0.527, P=0.027).Conclusion LC is relatively safe for patients with HBV-cirrhosis. For these patients, antiviral therapy should be recommended before operation, and liver protection treatment should be aggressively administered to reduce the MELD score before operation in those with MELD score greater than 10.

5 Aurora-B promoting the proliferation of cholangiocarcinoma cells by inducing phosphorylation of centrosome protein U

DUAN Xiaohui , SHEN Yao , HUANG Jingbo , LIU Yahui , MAO Xianhai

2021, 30(8):909-916. DOI: 10.7659/j.issn.1005-6947.2021.08.005

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Background and Aims The mitotic kinase Aurora-B is considered to be a proto-oncogene of cholangiocarcinoma. The action of centrosome protein U (CENPU) in mitosis is governed by phosphorylation regulation of Aurora-B kinase. The previous study conducted by the authors’ group has identified CENPU in cholangiocarcinoma and confirmed that the expression level of CENPU is significantly higher in cholangiocarcinoma tissue than that in its corresponding adjacent tissue. So, it is speculated that Aurora-B probably participates the tumor biological process of cholangiocarcinoma through regulation of the CENPU phosphorylation. Therefore, this study was performed to investigate the relationship between Aurora-B and CENPU and their effects in cholangiocarcinoma.Methods The expressions of Aurora-B and CENPU as well as the phosphorylated CENPU (p-CENPU) in 10 pairs of specimens of cholangiocarcinoma and para-carcinoma tissue were determined by immunohistochemical staining. The expressions of Aurora-B and CENPU and their correlation in cholangiocarcinoma were analyzed in TCGA database. The cholangiocarcinoma QBC939 cells with Aurora-B gene knockout were constructed, and then, the expressions of CENPU and p-CENPU were determined by Western blot analysis and the proliferative activity was detected by CCK8 assay. QBC939 cells with mutated phosphorylation site of CENPU were constructed, in which, the changes in expressions of Aurora-B, CENPU and p-CENPU as well as the proliferation activity were observed.Results The results of immunohistochemical staining showed that positive expression rates of Aurora-B and CENPU in cholangiocarcinoma tissue were 22.61% and 12.34%, respectively, but nearly none of them expressed in adjacent tissue. Meanwhile, the expression level of p-CENPU in cholangiocarcinoma tissue was remarkably higher than that in adjacent tissue. TCGA data showed that both expressions of Aurora-B and CENPU were up-regulated in cholangiocarcinoma (both P<0.05), and there was a positive correlation between the expressions of Aurora-B and CENPU (r=0.7322, P<0.05). In QBC939 cells after knockdown of Aurora-B expression, there was no significant change in CENPU expression, but the p-CENPU expression was down-regulated, and the proliferation activity was significantly decreased (P<0.05). In QBC939 cells after mutating the phosphorylation site of CENPU or adding Aurora-B inhibitor, Aurora-B expression showed no change in the former, but was significantly reduced in the latter, and in both conditions, the CENPU expressions showed no changes, but the p-CENPU expressions were decreased; after mutating the phosphorylation site of CENPU, the proliferation activity of QBC939 cells mediated by Aurora-B was significantly lower than that of the wild-type (P<0.05).Conclusion CENPU is the phosphorylation substrate of Aurora-B in cholangiocarcinoma cells. Aurora-B promotes the proliferation of cholangiocarcinoma cells probably by phosphorylation of CENPU.

6 Expression of miR-200a-3p in gallbladder cancer and its effects and mechanism of action

KONG Xianghai , HU Min , WANG Dile , WANG Lili , HE Tao

2021, 30(8):917-925. DOI: 10.7659/j.issn.1005-6947.2021.08.006

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Background and Aims MiR-200a-3p participates in the regulation of biological processes in a variety of tumors, but it exerts different effects in different tumors (oncogene or tumor suppressor). At present, its role in gallbladder cancer is still unclear. Therefore, this study was conducted to investigate the expression of miR-200a-3p in gallbladder cancer as well as its effects on biological behaviors of gallbladder cancer cells and the mechanism.Methods The expressions of miR-200a-3p in 32 specimens of gallbladder cancer tissue and adjacent tissue as well as in different gallbladder cancer cell lines (GBC-SD, SGC-996, and NOZ) and normal human gallbladder epithelial cell line HGBEC were determined by qRT-PCR method. The GBC-SD and NOZ cell lines were transfected with miR-200a-3p-mimics (miR-200a-3p overexpression group), miR-200a-3p-inhibitors (miR-200a-3p silencing group) and scramble sequences (negative control group) respectively using Lipofectamine? 3000 kit. The proliferation and invasion abilities of the cells were examined by MTT assay and Transwell assay. The downstream target genes of miR-200a-3p were predicted using MiRBD/Targetscan7.2/starBase2.0/miRtarbase website, and were verified by Luciferase experiment. The protein expressions of the target genes and the molecules (E-cadherin and vimentin) associated with epithelial-to-mesenchymal transition (EMT) in above three groups of cells were measured by Western blot analysis.Results The results of qRT-PCR showed that the expression level of miR-200a-3p in gallbladder cancer tissue was lower than that in adjacent tissue, and the expression levels of miR-200a-3p in all gallbladder cancer cell lines were lower than that in normal human gallbladder epithelial cell line HGBEC (all P<0.05). In GBC-SD and NOZ cell lines after transfection, the expressions of miR-200a-3p were significantly increased and the proliferative and invasion abilities were significantly decreased in miR-200a-3p overexpression groups of both cell lines, while the expressions of miR-200a-3p were significantly decreased and the proliferative and invasion abilities were significantly increased in miR-200a-3p silencing groups of both cell lines compared with their respective negative control groups (all P<0.05). Online website prediction showed that there were potential binding sites between miR-200a-3p and Notch2. Luciferase verification experiments showed that miR-200a-3p caused markedly decreased luciferase activity in Notch2 wild-type plasmid pmirGLO-Notch2-3'UT WT, but exerted no effect on the luciferase activity of Notch2 mutant plasmid pmirGLO-Notch2-3'UTR MUT. The results of Western blot analysis showed the E-cadherin protein expressions were increased and the protein expressions of vimentin and Notch2 were decreased in miR-200a-3p overexpression groups of both cell lines, while the opposite changes in the three proteins were observed in miR-200a-3p silencing groups of both cell lines compared with their respective negative control groups (all P<0.05).Conclusion The expression of miR-200a-3p is decreased in gallbladder cancer, and it may play a tumor suppressor role in gallbladder cancer, and the mechanism may be probably associated with its down-regulating Notch2 and thereby inhibiting the EMT process.

7 Expression and action of miR-574-5p in hepatocellular carcinoma and its association with prognosis

LI Qian , GUO Qinghao

2021, 30(8):926-933. DOI: 10.7659/j.issn.1005-6947.2021.08.007

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Background and Aims Previous studies demonstrated that miR-574-5p is closely associated with the prognosis of a variety of tumors. However, the relationship between miR-574-5p and hepatocellular carcinoma (HCC) has not been reported yet. Therefore, this study was designed to investigate the expression of miR-574-5p in HCC and its relationship with prognosis of the patients.Methods The expressions of miR-574-5p in 130 paired specimens of HCC and adjacent tissue as well as in HCC cell lines (HepG2 and MHCC-97H) and normal hepatic cell line (L-02) were detected by qRT-PCR method. After the optimal cut-off value of miR-574-5p expression level was determined from the survival data of the patients using X-tile software, the relations of miR-574-5p expression with the clinicopathologic factors and postoperative survival rates of the patients were analyzed. The influencing factors for the prognosis of HCC patients were determined. The target genes of miR-574-5p were predicted by TargetScan, and then were verified by dual-luciferase reporter assay and confirmed by Western blot analysis.Results The expression levels of miR-574-5p were significantly increased in HCC tissue than that in adjacent tissue, and increased in HCC cell lines than that in normal hepatic cell line (all P<0.05). The expression of miR-574-5p was significantly associated with TNM stage (P=0.002) and degree of differentiation (P=0.000). Both overall survival rate and tumor-free survival rate were significantly lower in patients with high miR-574-5p expression than those in patients with low miR-574-5p expression (both P<0.01). The results of univariate and multivariate analysis showed that high miR-574-5p expression (HR=4.101, 95% CI=1.348-8.968, P=0.03), stage III-IV (HR=5.403, 95% CI=1.266-13.860, P=0.02) and moderate/poor differentiation (HR=3.655, 95% CI=2.165-6.984, P=0.00) were independent risk factors for overall survival of HCC patients, and high miR-574-5p expression (HR=7.168, 95% CI=1.144-18.260, P=0.01) and stage III-IV (HR=7.436, 95% CI=1.123-20.916, P=0.00) were independent risk factors for disease-free survival of HCC patients. Targetscan software analysis showed that there was a direct binding site between FOG2 and miR-574-5p, and dual luciferase reporter gene assay showed that FOG2 was the target gene of miR-574-5p. Western blot analysis showed that the protein expression level of FOG2 in HCC tissue was lower than that in adjacent tissue, and Pearson correlation analysis showed that the miR-574-5p expression was negatively correlated with the protein expression of FOG2 in HCC tissue (r=-0.499, P<0.05).Conclusion The expression of miR-574-5p is generally increased in HCC. High miR-574-5p expression can be considered as a molecular marker for poor prognosis of HCC patients. MiR-574-5p may probably exert a tumor-promoting action through down-regulating its target gene FOG2.

8 Expressions of m6A methylation regulators and their prognostic value in thyroid cancer

WANG Wenlong , SHEN Cong , SUN Botao , BAI Ning , LI Xinying , CHEN Jiaxin , PENG E'min

2021, 30(8):934-941. DOI: 10.7659/j.issn.1005-6947.2021.08.008

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Background and Aims The incidence of thyroid carcinoma has been steadily increasing and the molecular mechanism underlying the tumorigenesis is still unclear. Thus, exploring the underlying mechanism is of great importance for improving the prognosis of PTC patients. Studies demonstrated that m6A methylation regulators are widely involved in the occurrence and development of cancers and have superior prognostic value. Therefore, this study was conducted to investigate the expressions of m6A methylation regulators in thyroid cancer and construct a prognostic risk model for thyroid cancer based on m6A methylation regulators using bioinformatics approaches.Methods The gene expression profiles of m6A RNA methylation regulators and the corresponding clinical information were downloaded from The Cancer Genome Atlas (TCGA). The differential expressions of 20 m6A methylation regulators between tumor and normal tissues were analyzed by Wilcoxon test. The thyroid cancer patients were divided into two clusters by consensus clustering, and the differences in clinicopathologic factors and overall survival rate between the two clusters of patients were compared. Subsequently, the risk model was constructed by Lasso Cox regression analysis and its predictive value was evaluated by the area under the ROC (AUC).Results There were 19 m6A methylation regulators that showed significantly different expressions between thyroid cancer and normal tissues (all P<0.05), in which, the HNRNPC, IGF2BP2, FMR1 were remarkably upregulated, while the remaining were down-regulated in thyroid cancer tissue. The clustering analysis showed that the overall survival of cluster 1 was poorer than that of cluster 2 (P<0.05), while the incidence of cervical lymph node metastasis was significantly higher than that of cluster 2 (P<0.01). A prognostic risk model was constructed based on 4 genes (IGF2BP2, RBM15, YTHDF1 and YTHDF3) that were screened by Lasso Cox regression analysis, in which, the high-risk patients had a worse prognosis than that of low-risk patients (P=0.007). The ROC analysis indicated a reliable prediction performance of the model for patients with thyroid cancer (AUC=0.731).Conclusion There are differential expressions in m6A methylation regulators in thyroid cancer, and the constructed prognostic risk model based on the hub m6A methylation regulators in thyroid cancer has better predictive ability, which will provide certain recommendations for clinical decision-making.

9 Clinical value of surgical resection for hilar type intrahepatic cholangiocarcinoma

GUO Junwu , DAI Binghua , ZHU Hengmei , SUI Chengjun , XIE Feng , GENG Li , YANG Jiamei

2021, 30(8):942-948. DOI: 10.7659/j.issn.1005-6947.2021.08.009

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Background and Aims Hilar type intrahepatic cholangiocarcinoma (HICC) is characterized by strong invasion capability and pathophysiological complexity. Surgical resection is the preferred treatment, but the R₀ resection rate remains low and the prognosis is poor. This study was conducted to assess the clinical value of surgical treatment of HICC by analyzing the outcomes of HICC patients treated by surgery.Methods The clinical and pathological data of 98 patients who underwent surgery for HICC in Eastern Hepatobiliary Surgery Hospital from November 2011 to June 2016 were retrospectively analyzed. Of the patients, 67 cases underwent radical surgery, and 31 cases were subjected to palliative surgery that included R₁ resection in 3 cases and R₂ resection in 28 cases. In patients undergoing radical surgery, hilar vascular invasion (HVI) occurred in 32 cases, and HVI did not occur in 35 cases.Results In the entire group of patients, the overall 1-, 3-, and 5-year survival rates were 46.5%, 11.7%, and 5.8%, respectively, with a median overall survival（mOS）of 12.0 months. Patients receiving radical surgery had a better prognosis than those undergoing palliative surgery (mOS: 14.0 months vs. 7.0 months, P=0.004). Patients without HVI showed a better prognosis compared with those with HVI (mOS: 21.0 months vs. 9.0 months, P=0.002) as well as those undergoing palliative surgery group (mOS: 21.0 months vs. 7.0 months, P<0.001). There was no difference in prognosis between patients with HVI undergoing radical surgery and those undergoing palliative surgery (mOS: 9.0 months vs. 7.0 months, P=0.192). Results of multivariate Cox analysis showed that HVI and high CA19-9 level were independent risk factors for the prognosis of HICC patients after radical surgery. Comparison between patients with and without HVI found that the patients with age > 60 years and tumor diameter ≥ 5 cm had a higher rate of HVI (both P<0.05).Conclusion The resection rate of HICC is low and the prognosis is poor. HVI and high CA19-9 level are risk factors for the prognosis of HICC patients after radical resection. Surgery offers no survival benefit to those with HVI.

10 Influence of preoperative improvement of ICGR₁₅ on postoperative complications and short-term liver function in patients after hepatectomy for liver cancer

YU Wei , HUANG Changshan , WANG Qian , HUANG Tao , DING Yuechao , MA Chao

2021, 30(8):949-954. DOI: 10.7659/j.issn.1005-6947.2021.08.010

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Background and Aims Liver function decompensation is the main cause for the increased mortality in patients after liver resection. So, effective preoperative liver function assessment is of great importance. Indocyanine green retention rate at 15 minutes (ICGR₁₅) is a simple and accurate test to evaluate preoperative liver function and is widely used in clinical practice. ICGR₁₅ <20% is essential to major hepatectomy (≥3 segments). Patients with ICGR₁₅ value ranging from 20% to 30% are frequently encountered in clinical practice, and their ICGR₁₅ can be improved after symptomatic management such as hepatoprotective treatment. Whether the major hepatectomy can be safely performed in these patients remains controversial. Therefore, this study was to evaluate the effectiveness of preoperative ICGR₁₅ improvement on complications and liver function in patients after hepatectomy for liver cancer.Methods Form May 2015 to October 2017, 32 liver cancer patients whose ICGR₁₅values were between 20% and 30% on admission and were improved to less than 20% after symptomatic treatment before operation (observation group), and the other 45 liver cancer patients with the ICGR₁₅<20% on admission (control group) were selected. All patients underwent open liver cancer resection (≥3 segments). The intra- and postoperative variables, and the total bilirubin (TBIL), aspartate aminotransferase (AST), albumin (Alb), and prothrombin time (PT) as well as the ECOG physical status scores were compared between the two groups of patients.Results Between the two groups of patients, except the ICGR₁₅ values on admission that were significantly different (P<0.05), all other preoperative general data and biochemical indexes showed no statistical difference (all P>0.05). There were no statistical differences in liver resection scopes and other intraoperative variables between the two groups of patients (all P>0.05). No perioperative death occurred in both groups, and the incidence rates of postoperative complications were 37.5% (12/32) in observation group and 31.1% (14/45) in control group, which had no statistical difference (P>0.05). The length of hospital stay and time to drainage tube removal were prolonged in observation group compared with control group (both P<0.05). The levels of TBIL at hospital discharge or 1 month, and 3 and 6 months after operation were all significantly higher in observation group than those in control group (all P<0.05). The levels of ALB and ECOG scores at hospital discharge or 1 month after operation were all significantly lower in observation group than those in control group (all P<0.05), but both variables showed no significant differences between the two groups later (all P>0.05). There were no significant differences in the remaining biochemical indexes between the two groups at each time point from the time of hospital discharge to 6 months after operation (all P>0.05).Conclusions Patients with the preoperative ICGR₁₅ between 20% to 30% can tolerate major hepatectomy safely after improvement of ICGR₁₅ to less than 20% by hepatoprotective treatment, without increase of postoperative complications. Although the TBIL level is relatively high during a short period after operation, it does not exert harmful effect on patients' quality of life. However, the long-term results of the patients still need further observations.

11 Establishment of diagnosis model for thyroid cancer based on plasma circulating cell-free DNA and ultrasound characteristic of thyroid nodules and its verification

YU Youlin , SHEN Xiongshan , HU Chaohua , YU Junlin , LU Ting , YANG Feng , ZHANG Wenjie , ZHANG Xiaoli , LIU Hanzhong , TAO Yichao

2021, 30(8):955-963. DOI: 10.7659/j.issn.1005-6947.2021.08.011

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Objective Studies have demonstrated that the circulating cell-free DNA (cfDNA) may be a potential biomarker for diagnosis of thyroid cancer. Therefore, this study was performed to investigate the value of a scoring model established by plasma circulating cfDNA and changes in ultrasound characteristics of the thyroid nodules in differential diagnosis between benign and malignant thyroid nodules.Methods Two hundred and forty patients with thyroid nodules (132 cases of thyroid cancer and 108 cases of benign thyroid nodules) admitted from June 2018 to October 2020 were enrolled for this study. They were randomly divided into the modeling group and validation group using a 1∶1 ratio. The plasma cfDNAs were extracted from the 240 patients by blood DNA extraction kit, and the DNA concentrations were further detected by qRT-PCR. Thyroid ultrasound was performed in all patients. The scoring model was constructed based on the cfDNA concentration and thyroid ultrasound characteristics, and then, its sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of thyroid cancer were analyzed. The effectiveness of the model was evaluated in the validation group.Results The cfDNA concentration in patients with thyroid cancer was significantly higher than that in patients with benign nodules (P<0.001). The results of univariate analysis showed that there were significant differences in cfDNA concentration and ultrasound imaging features that included the aspect ratio, internal echo, integrity of the capsule, calcification and cystic lesions between patients with malignant and benign nodules (all P<0.05). The results of multivariate Logistic regression analysis showed that cfDNA≥56.84 ng/mL, and thyroid ultrasound presenting the aspect ratio ≥1, incomplete capsule, hypoechoic, calcification, and non-cystic lesions were independent risk factors for diagnosis of thyroid cancer (all P<0.05). According to the standard regression coefficients of above variables, a scoring model was established. The area under the ROC curve (AUC) of the model for diagnosis of thyroid cancer was 0.958 (95% CI=0.926-0.989), and its optimal cut-off value was 5.5, with a diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of 85.5%, 89.7%, 89.8%, and 85.2%, respectively, which were all superior to those of the predictive power of each single variable. The validation results showed that the AUC was 0.902 (95% CI=0.848-0.957) in validation group.Conclusion The scoring model based on plasm cfDNA and ultrasound features of the thyroid nodules has high predictive value for diagnosis of thyroid cancer, and it provides a reference for the differential diagnosis of thyroid benign and malignant nodules. Clinical intervention should be aggressively performed when the score of a thyroid nodule ≥5.5.

12 Research progress on postoperative recurrence factors of choledocholithiasis

HUANG Yao , YI Jianfeng , ZHOU Wence

2021, 30(8):964-970. DOI: 10.7659/j.issn.1005-6947.2021.08.012

[Abstract](956) [HTML](966) [PDF 634.60 K](2013)

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Choledocholithiasis is one of the most common benign surgical diseases. With the progress of science and technology, the development of medical techniques and the improvement of hospital hardware facilities, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) have become the main treatment methods for choledocholithiasis, with the clinical advantages of less trauma and rapid recovery. However, data from multicenter clinical trials showed that the postoperative recurrence rate of common bile duct stones is 4%-24%. Therefore, the postoperative recurrence of common bile duct stones is a challenge to be faced and an urgent problem to be solved for surgeons. The formation of choledocholithiasis is a complex process of the interactions between genetic and environmental factors, and its specific mechanism has not been fully clarified. The mechanism of postoperative recurrence and related factors have also become the challenges and hotspots of clinical research. Through literature review and extraction, the authors present the mechanism and research progress of postoperative recurrence of common bile duct stones from the three dimensionalities: duodenal papillary sphincter function, biliary microecology and biliary anatomy, so as to provide new strategies and research directions for preventing postoperative recurrence of choledocholithiasis.

13 Progress in clinical application of lymph node dissection in radical surgery for biliary malignant tumors

XIONG Shifeng , ZOU Hao

2021, 30(8):971-978. DOI: 10.7659/j.issn.1005-6947.2021.08.013

[Abstract](767) [HTML](733) [PDF 695.65 K](1352)

Abstract:
Malignant tumors of the bile duct have a high degree of malignancy and present atypical clinical symptoms, which results in the poor overall prognosis. Surgical treatment is still the best treatment modality at present. Biliary malignant tumors have a high potential for lymph node and distant metastasis, which may lead to the loss of opportunity of surgery to patients and the dismal prognosis. In order to reduce tumor recurrence, lymph node dissection is often needed in surgery. However, the scope and number of lymph node dissection for biliary malignant tumors have not been unified in relevant guidelines at home and abroad. Therefore, the authors address the clinical application progress of lymph node dissection in radical resection of biliary malignant tumors based on review of relevant guidelines and literature at home and abroad.

14 Research progress of indocyanine green fluorescent navigation technique in laparoscopic hepatobiliary and pancreatic surgery

YANG Wenwen , TIAN Hongwei , LEI Caining , SONG Shaoming , JIN Chuanwei , JING Wutang , GONG Shiyi , GUO Tiankang

2021, 30(8):979-986. DOI: 10.7659/j.issn.1005-6947.2021.08.014

[Abstract](729) [HTML](1195) [PDF 742.46 K](1493)

Abstract:
In recent years, with the increasingly wide application of indocyanine green (ICG) fluorescence navigation technique in various medical fields, it has grown more mature, especially its development in laparoscopic hepatobiliary and pancreatic surgery. The application of ICG in liver surgery mainly includes defining the boundaries of liver tumor lesions, discovering small lesions, detecting residual lesions at the resection margin, real-time marking of liver segments and surgical liver planes, which is beneficial to reduce the risk of surgery and improve the R₀ resection rate; in biliary tract surgery mainly involves the resection of the intrahepatic cholangiocarcinoma and gallbladder, identifying intraoperative bile leakage, avoiding bile duct damage, and reducing the incidence of postoperative complications. ICG imaging combined with laparoscopic pancreaticoduodenectomy (LPD) can accurately determine the anatomical positional relationship between pancreatic tumors and blood vessels, and locate lymph node metastasis during surgery, providing surgeons with beneficial real-time visual information. Here, the authors summarize the application of ICG combined with laparoscopic techenique in hepatobiliary and pancreatic surgery.

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Volume 30,Issue 8,2021 Table of Contents

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