Volume 32,Issue 2,2023 Table of Contents

1 Efficacy comparison of biliary drainage stenting and T-tube drainage after laparoscopic common bile duct exploration: a Meta-analysis

XU Jian , HE Xiangkun , SUN Chao , YU Feng

2023, 32(2):161-170. DOI: 10.7659/j.issn.1005-6947.2023.02.001

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Background and Aims Laparoscopic common bile duct exploration (LCBDE) is the most commonly used surgical procedure for the treatment of common bile duct stones, but the methods for suture of the common bile duct after LCBDE remain controversial. Biliary drainage stenting (BDS) is a suture technique of the common bile duct and has been widely used in recent years. Compared with the traditional T-tube drainage, BDS has the advantages of primary closure and avoidance of the long-term placement of T-tube after surgery. Therefore, this study was conducted to evaluate the clinical application value of BDS by comparing the clinical efficacy of BDS and T-tube drainage following LCBDE through a Meta-analysis.Methods The clinical studies comparing BDS and T-tube drainage following LCBDE were collected by searching several national and international literature databases. The retrieval time was set from January 1, 2010 to January 1, 2022. The outcome variables included operative time, blood loss, time to anal gas passage, time to abdominal drainage tube removal, length of hospitalization and incidence rates of bile leakage and overall complications. Meta-analysis was performed using Revman 5.4 software.Results A total of 11 studies meeting the inclusion criteria were selected, including 5 randomized controlled trials and 6 retrospective cohort studies, involving 1 140 patients, with 561 cases in BDS group and 579 cases in T-tube drainage group. The results of Meta-analyses showed that there was no significant difference in operative time (WMD=-4.60, 95% CI=-10.01-0.81, P=0.10) and blood loss (WMD=-0.66, 95% CI=-2.12-0.79, P=0.37) between the two groups, but BDS group was superior to control group in terms of time to postoperative gas passage (WMD=-8.99， 95% CI=-13.60--4.39， P=0.000 1), incidence rates of bile leakage (OR=0.37, 95% CI=0.17-0.78, P=0.009) and overall complications (OR=0.41, 95% CI=0.23-0.73, P=0.002), time to abdominal drainage tube removal (WMD=-1.33, 95% CI=-2.47--0.19, P=0.02) and length of hospital stay (WMD=-3.79, 95% CI=-5.24- -2.35, P<0.000 01).Conclusion For indicated patients with common bile duct stones, BDS suture after LCBDE can accelerate the postoperative recovery and reduce the complications associated with suture of the common bile duct. So, it is a safe procedure with certain clinical application value.

2 Propensity score matching comparison of sequential laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage and urgent LC for grade Ⅱ acute cholecystitis

ZHAN Feng , ZHANG Kai , CHENG Baoliang , ZHANG Yun , JIANG Chao

2023, 32(2):171-180. DOI: 10.7659/j.issn.1005-6947.2023.02.002

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Background and Aims Acute cholecystitis (AC) is a frequently encountered disease in the general surgical practice. Laparoscopic cholecystectomy (LC) is currently recognized as the "gold-standard" treatment for AC. The severity of AC is recommended to be classified as grade I (mild), Ⅱ (moderate) and Ⅲ (severe) by the Tokyo guidelines 2018 (TG18), and the choice of surgical procedure varies according to the grade of disease. In clinical practice, the consensus has been achieved on the treatment of grade Ⅰ and Ⅲ AC. However, the treatment strategy for grade Ⅱ AC is still controversial, which depends more on the surgeon's experience and the admitting medical provider. The intraoperative conditions are complicated in patients with grade Ⅱ AC, for which inappropriate LC surgery may cause higher incidence of complications, such as bile leakage, abdominal abscess, and even bile duct injury. Percutaneous transhepatic gallbladder drainage (PTGBD) can effectively relieve the inflammation of the gallbladder, gallbladder wall edema and adhesions around the gallbladder, and also provide a "time window" for elective surgery. Therefore, this study was performed to evaluate the application value of sequential LC after PTGBD in the treatment of grade Ⅱ AC.Methods The clinical data of 205 patients classified as grade Ⅱ AC according to TG18 classification in Yixing Hospital Affiliated to Jiangsu University from October 2017 to October 2022 were analyzed retrospectively. Of the patients, 42 cases underwent PTGBD followed by elective LC (PTGBD+LC group) and 163 cases underwent urgent LC (LC group). The two groups of patients were matched using propensity score matching (PSM) at a 1∶1 ratio. After match, the differences in clinical indexes such as ICU admission rate, operative time, intraoperative blood loss, intraoperative drainage rate, open conversion rate, bile duct injury rate, length of hospital stay, total hospitalization cost and surgical complications were compared between the two groups of patients.Results No puncture-related complications occurred in the 42 patients who received PTGBD. Only one patient had catheter slippage and underwent catheter re-insertion. All the 42 patients received a questionnaire survey on the quality of life during indwelling catheterization, and the results showed that 39 patients (92.8%) tolerated the treatment. There were 38 patients in each group after match, with balanced and comparable baseline data. There was no perioperative death in both groups. In PTGBD+LC group, the operative time was shorter (64.4 min vs. 84.4 min), intraoperative blood loss was less (21.9 mL vs. 47.6 mL), length of hospital stay after LC was shorter (3.4 d vs. 5.3 d), and overall incidence of postoperative complications was lower (5.3% vs. 23.7%), but the total hospitalization cost was higher (29 239 yuan vs. 22 150 yuan) than those in LC group, and all differences had statistical significance (all P<0.05). There were no significant differences in rates of open conversion (0 vs. 13.2%), bile duct injury (0 vs. 5.3%), intraoperative drainage (92.1% vs. 100%) and postoperative ICU admission (0 vs. 5.3%) between the two groups (P>0.05).Conclusion Sequential LC after PTGBD in the treatment of TG18 grade Ⅱ AC increases the total medical cost, but significantly reduce the difficulty of surgery and the incidence of surgical-related complications. So, it is still suitable for individualized application in clinical practice.

3 Application of a new self-shedding biliary stent in laparoscopic common bile duct exploration (with video)

YANG Xianwei , YANG Gang , DONG Dinghui , LIU Xuemin , LI Yu

2023, 32(2):181-189. DOI: 10.7659/j.issn.1005-6947.2023.02.003

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Background and Aims Laparoscopic common bile duct exploration (LCBDE) is a traditional method for treating common bile duct stones. Intraoperative biliary stent implantation may reduce the risk of postoperative bile leakage but may give rise to prolonged retention or premature shedding of the stent. This study investigated the safety and effectiveness of implantation of a new type of self-shedding biliary stent in LCBDE for cholecystolithiasis with choledocholithiasis.Methods The clinical data of patients with concomitant cholecystolithiasis and choledocholithiasis treated in the First Affiliated Hospital of Xi'an Jiaotong University from June 2019 to December 2020 were retrospectively analyzed. Patients receiving LCBDE plus biliary stent implantation were selected as the observation group, and those undergoing LCBDE with primary closure were set as the control group. The stent used was 5 Fr in diameter and 5 cm in length, with a length scale marked in the main body, its anti-skid side wings opened toward the direction of the head to prevent the premature detachment or prolonged retention of the stent, and a spiral tail left outside the duodenal papilla for being pulled out under the drive of digestive tract fluid. The stent placement method was advancing the choledochoscope to the end of the common bile duct, endoscopically inserting a 0.035" guidewire through the duodenal papilla, using the outer sheath of the stone basket as a pusher to push the stent into the bile duct over the guide wire, pushing the stent while retrieving the choledochoscope when the 1-cm mark of the stent body passed through the inner orifice of the papilla, and removing the guidewire to complete the placement of the stent under the direct vision when the end of the stent completely disengages from the lens. The general data of patients, preoperative blood test results, the number and maximum diameter of common bile duct stones, the time for intraoperative biliary stent implantation, operative time, postoperative complications, and length of postoperative hospital stay were compared between the two groups, and the rate of stent shedding in observation group was recorded.Results Forty-three patients in the observation group and 52 patients in the control group were included. The general preoperative data, blood routine test, liver function parameters, common bile duct diameter and size of bile duct stones were comparable between the two groups (all P>0.05). The median time for stent implantation in observation group was 14 (10-20) min, but there was no significant difference in overall operative time between the two groups [125 (55-210) min vs. 116 (50-200) min, P>0.05]. In control group, there were 2 cases of mild bile leakage (<50 mL/d) after operation, which was improved after prolonging the abdominal drainage time. No bile leakage was observed in observation group, but there was no significant difference in the incidence of bile leakage between the two groups (P>0.05). Hyperamylasemia was observed in both groups, which caused no obvious clinical symptoms and was cured with conservative treatment. Its incidence rates showed no significant difference between the two groups (11.6% vs. 3.8%, P>0.05). There was no significant difference in the overall incidence of postoperative complications between the two groups (16.3% vs. 9.6%, P>0.05). The median time of abdominal drainage and length of postoperative hospital stay was significantly shorter in observation group than those in control group [1 (1-3) d vs. 2 (1-5) d; 2 (2-6) d vs. 3 (2-8) d, both P<0.05]. In observation group, the abdominal X-ray showed that the stents were all in place on postoperative day 2, the rate of stent detachment was 88.4% after two weeks, and all stents fell off one month after the operation.Conclusion Using the new type of self-shedding biliary stent in LCBDE is safe and effective, and it can reduce the time of abdominal drainage and length of postoperative hospitalization.

4 Application of preoperative lymphocyte to C-reactive protein ratio in predicting postoperative recurrence of gallbladder cancer and its clinical value

CHENG Yang , CHEN Xiaobin , WEI Zhihong , CHEN Jianwei , PENG Xiangyu , XIE Yunjun , YANG Fang

2023, 32(2):190-199. DOI: 10.7659/j.issn.1005-6947.2023.02.004

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Background and Aims Systemic inflammation is closely associated with the development of most malignant tumors. Studies of inflammation-related scores provide valid predictive information for improving the risk stratification and prognosis of patients with cancer. However, the studies to evaluate the relationship between inflammation scores and the risk of postoperative relapse in patients with gallbladder cancer (GBC) are limited. Therefore, this study was conducted to investigate the relationship between preoperative lymphocyte to C-reactive protein (CRP) ratio (LCR) and postoperative recurrence in GBC patients and establish a nomogram model to predict the risk of postoperative recurrence of GBC.Methods The clinical data of 103 patients with GBC who received surgical treatment from May 2009 to December 2021 in the No. 900 Hospital, Joint Logistics Support Force of the Chinese People's Liberation Army were retrospectively analyzed. A receiver operating characteristic curve (ROC) of LCR for predicting postoperative recurrence was drawn, and the optimal cut-off value was determined. Based on the cut-off value, the patients were divided into high LCR group and low LCR group. The differences in clinicopathologic characteristics between the two groups of patients were analyzed, and the risk factors for postoperative recurrence were determined. According to the regression coefficient of risk factors, the corresponding nomogram prediction model of postoperative recurrence in GBC patients was created and validated by calibration curve and consistency index. Survival curves were drawn by the Kaplan-Meier method, and the differences in overall survival (OS) and recurrence-free survival (RFS) between two groups of patients were compared by Log-rank test.Results The area under the ROC curve of preoperative LCR for predicting postoperative recurrence in GBC patients was 0.681 (95% CI=0.560-0.802, P<0.05) and the cut-off value was 0.275. Results of the univariate analysis showed differences in T stage, lymphnode metastasis, surgical procedure, combined hepatectomy or not, combined choledochotomy or not, surgical margin, CA19-9, CEA, CA125 and LCR between the two groups (all P<0.05). Multivariate Logistic analysis showed that T stage, CA19-9 and LCR were independent risk factors for postoperative recurrence in GBC patients (all P<0.05). The C-index of the nomogram established by integrating the risk factors was 0.736, and the calibration curve indicated that the probability of recurrence predicted by the nomogram was in good agreement with the actual observation. The Kaplan-Meier survival curve showed that the OS and RFS of patients in the high LCR group were significantly higher than those of patents in the low LCR group (both P<0.001).Conclusion LCR can be used as a new indicator for predicting the postoperative recurrence of GBC patients. The higher the preoperative peripheral blood LCR, the lower the risk of recurrence in patients. The nomogram prediction model constructed on this basis will help clinicians provide better information on individualized treatment and follow-up strategies for GBC patients.

5 Clinical characteristics and surgical prognosis of synchronous double primary hepatocellular carcinoma and intrahepatic cholangiocarcinoma

GAO Yuan , LI Hucheng , SHAO Yanling , YAN Jin , CAO Li

2023, 32(2):200-210. DOI: 10.7659/j.issn.1005-6947.2023.02.005

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Background and Aims Synchronous double primary hepatocellular carcinoma and intrahepatic cholangiocarcinoma (sdpHCC-ICC) is extremely rare. Here, the authors report the diagnosis and treatment process of 9 cases of sdpHCC-ICC, and investigate the clinical characteristics and post-operative prognosis of this condition, so as to raise clinical awareness.Methods The clinical data of 9 patients with sdpHCC-ICC (as confirmed by postoperative pathology) treated in the Fifth Medical Center of Chinese PLA General Hospital between January 2016 and December 2022 were retrospectively collected. The clinical manifestations, pathogenesis, imaging features, pathological characteristics, treatment strategy, and prognosis were evaluated.Results All patients were male with a history of chronic hepatitis, including 8 patients infected with hepatitis B, 7 patients with long-term alcohol consumption, 2 patients with elevated hepatocellular carcinoma and intrahepatic cholangiocarcinoma markers. Preoperative imaging examinations failed to make the correct diagnosis in all patients. All patients received surgical treatment and were identified as sdpHCC-ICC by postoperative pathological diagnosis. The intrahepatic lesions in 6 patients simultaneously expressed CD34. The postoperative follow-up was conducted for 2 to 58 months, relapse occurred in 2 patients on 6 and 20 months after operation, respectively, and no relapse occurred in the other 7 patients as of this manuscript writing.Conclusion The tumor cells of sdpHCC-ICC have different origins, which can be a monoclonal or multiclonal origin. Long-term alcohol consumption may be one of the risk factors. Surgical resection is still an effective treatment. The tumor stage of the intrahepatic cholangiocarcinoma components is one of the main factors affecting the prognosis of surgery. Lymph node dissection should be included in the surgical plan. Transcatheter arterial chemoembolization is effective for HCC components.

6 Analysis of the clinical and on biliary microflora features in patients with cholelithiasis and Oddi sphincter dysfunction

HOU Xiaofan , ZHAO Zhanxue , WU Jindu , ZHANG Hao , HUO Zheng , LI Xiao , LI Chenrui , ZHAO Dongyu , LIU Linxun

2023, 32(2):211-220. DOI: 10.7659/j.issn.1005-6947.2023.02.006

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Background and Aims Studies have indicated that gallstone disease (GSD) is related to the alterations of the bile duct microbiome. However, the bile duct microbiome changes caused by abnormal function of the sphincter of Oddi (SO) that serves as the barrier between the intestinal tract and biliary tract are not fully known. Therefore, this study investigated the differences in clinical features and bile tract microbiotas between GSD patients with concomitant SO dysfunction (SOD) and GSD patients with normal SO function.Methods Fourteen patients with cholecystolithiasis and choledocholithiasis undergoing an emergency operation from 2019 to 2021 in Qinghai Provincial People's Hospital were prospectively recruited. Of the patients, 7 cases presented with SOD (SOD group), and 7 cases had normal SO function (normal SO group) according to the value of the SO pressure determined during operation. All patients' bile specimens were obtained before and three months after the operation. The 16S rRNA genes were extracted from the collected samples, and amplicon sequencing was performed. Then, the amplicon sequencing data of the 16S rRNA genes were analyzed using QIIME 2 microbiome bioinformatics platform.Results The preoperative white blood count in patients of the SOD group was significantly higher than that of the normal SO group (P<0.05). At the same time, the parameters of other laboratory tests and the general conditions showed no significant difference between the two groups of patients (all P>0.05). Different bile duct microbiotas were observed in all patients. The microbial abundance was highest in the postoperative samples from the SOD group, followed by postoperative samples from the normal SO group, preoperative samples from the SOD group, and preoperative samples from the normal SO group, successively. The distributions of species of the microbiota of the four groups of bile samples from the two groups were different from each other, and the bacterial communities involved in GSD patients with SOD were predominantly of Escherichia, Clostridium, and Enterococcus versus GSD patients with normal SO function.Conclusion GSD patients with SOD have a higher inflammatory burden and significantly increased microbial abundance. They present increased species of bacteria associated with cholelithiasis compared with GSD patients with normal SO function, which may more likely cause biliary tract infection and recurrent stones.

7 Effects of pristimerin on biological behavior and the sensitivity to gemcitabine chemotherapy in hepatocellular carcinoma cells

YU Bin , YU Yong , SHI Lei , YUAN Junjian

2023, 32(2):221-230. DOI: 10.7659/j.issn.1005-6947.2023.02.007

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Background and Aims Studies have demonstrated that pristimerin (PT) can regulate the proliferation, apoptosis, migration and angiogenesis of cancer cells through multiple mechanisms. However, its role in hepatocellular carcinoma (HCC) has been less studied. Therefore, this study was conducted to investigate the effect of PT on the biological behavior of HCC cultured in vitro and its impact on the sensitivity of HCC cells to gemcitabine (GEM) chemotherapy, as well as the mechanism.Methods The inhibitory effects of PT and GEM on the proliferation of HCC cell lines (Huh7, SMMC-7721 and HepG2) were detected by CCK-8 assay. The suitable HCC cell line and drug concentrations were selected for subsequent experiments according to the results of CCK-8 assay. HCC cells were exposed to GEM (GEM group), PT (PT group), GEM plus PT (GEM+PT group) or Wnt/β-catenin signaling pathway inhibitor FH535 (FH535 group), respectively, using the purely cultured cells as the control group. Then, the apoptosis, colony formation, migration, invasion and the mRNA expressions of c-myc, cyclin D1 and surviving were detected by flow cytometry, plate cloning test, cell scratch assay, Transwell test and qRT-PCR, respectively. At the same time, Western blot technology was used to detect the protein expressions of β-catenin, GSK-3β, p-GSK-3β, vimentin (Vim), E-cadherin (E-cad) and cleaved caspase 3 (C-caspase-3).Results The proliferation rates of Huh7, SMMC-7721 and HepG2 cells were significantly decreased after exposure to both PT and GEM, with a concentration-dependent manner (all P<0.05). The Huh7 cells were chosen as the study object, and the treatment concentrations of PT, GEM and FH535 used were 2.0 μmol/L, 20 μmol/L and 20 μmol/L, respectively. Compared with control group, the apoptosis rate, the relative protein expressions of E-cad and C-caspase-3 were increased, the number of colony formation, scratch healing rate, the number of invasive cells, the relative mRNA expressions of c-myc, cyclin D1, survivin and protein expressions of β-catenin, p-GSK-3β and Vim were decreased in GEM group, PT group, GEM+PT group (all P<0.05). The above changes in Huh7 cells were increased successively in order of GEM group, PT group, GEM+PT group and FH535 groups (all P<0.05).Conclusion PT has significant inhibitory effect on the malignant biological behavior of HCC cells, and can enhance the sensitivity of HCC cells to GEM. The mechanism may be related to its inhibition of the activation of Wnt/β-catenin pathway.

8 Mechanism of miR-650 targeting PRDX2 to regulate oxidative stress in gastric cancer cells with Helicobacter pylori infection

WANG Yongqi , HE Donglei , LIANG Yuexiang , LIU Lijie

2023, 32(2):231-238. DOI: 10.7659/j.issn.1005-6947.2023.02.008

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Background and Aims The colonization of Helicobacter pylori (HP) in the human stomach is a recognized risk factor for the occurrence of gastric cancer. Study also found that the oxidative stress is significantly changed in gastric cancer cells after HP infection, while the mechanism is not entirely elucidated. Therefore, this study was conducted to investigate the potential mechanism and role of HP-induced oxidative stress in gastric cancer cells.Methods In gastric cancer SNU-1 cells after HP infection, the changes in production of reactive oxygen species (ROS) and proliferation ability were detected by DCF-DA fluorescence and CCK-8 assay. The key genes inducing oxidative stress in SNU-1 cells after HP infection were identified by high-throughput sequencing and siRNA screening, and then the key upstream miRNAs causing oxidative stress in SNU-1 cells were identified using miRDB online analysis tools and luciferase reporter assay, in combination with gain- and loss-of-function experiments for validation.Results In SNU-1 cells after HP infection, the ROS level was increased and the proliferation ability was enhanced, but these changes were abolished by simultaneous treatment with the ROS inhibitor acetylcysteine (all P>0.05). The results of siRNA screening found that the ROS level was increased and the proliferation ability was enhanced in SNU-1 cells with HP infection after peroxiredoxin 2 (PRDX2) knock-down and the opposite changes were found after PRDX2 overexpression (all P<0.05). Meanwhile, Western blot validation showed that PRDX2 was down-regulated in SNU-1 cells after HP infection. The promoter activity of PRDX2 in SNU-1 cells did not change after HP infection (P>0.05), but the mRNA level of PRDX2 was decreased (P<0.05). Results of analysis showed that the expression level of miR-650 in SNU-1 cells with HP infection was increased (P<0.05), and miR-650 targeted at the 3' non-coding region of the PRDX2 mRNA. Results of validation showed that the PRDX2 expression was down-regulated, the ROS level was increased and the proliferation ability was enhanced in SNU-1 cells after overexpression of miR-650, and the opposite changes were seen after miR-650 knockdown (all P<0.05); the proliferation ability had no significant change in SNU-1 cells with HP infection and simultaneous miR-650 knockdown or simultaneous PRDX2 overexpression (both P>0.05).Conclusion The mechanism and action of HP infection in gastric cancer cells is possibly that it up-relates the expression of miR-650, and the latter suppresses the mRNA and protein expressions of PRDX2 by binding its 3' non-coding region, and then causes the increase of ROS level, thereby promotes the proliferation of gastric cancer cells.

9 Report of a multicenter retrospective analysis of abdominal wall aggressive fibromatosis in Hunan province

SUN Zefang , ZHAO Yuguo , CAO Chao , ZHANG Zhuo , JIANG Caijian , LU Yizhan , HUANG Chenggang , HUANG Jinsong , JIANG Xungui , WEI Yuanshui , MO Yabing , ZOU Bin , ZHOU Xin , XU Dayong , XIONG Guozuo , LUO Pengfei , TAN Hongbo , LIU Siyu , TANG Wubin , LI Feng , LI Tao , ZHANG Tao , LI Jiarong , CHEN Lu , ZHOU Jianping , REN Feng , ZHU Liyong , HUANG Gengwen

2023, 32(2):239-245. DOI: 10.7659/j.issn.1005-6947.2023.02.009

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Background and Aims Aggressive fibromatosis (AF) is a rare clonal myofibroblast proliferative disease derived from deep soft tissues. This study aims to analyze and summarize the case characteristics and clinicopathologic features of patients with abdominal wall AF admitted to 21 medical centers in Hunan province, to enhance the current knowledge and investigate the factors associated with the recurrence of abdominal wall AF.Methods The clinical data and follow-up results of 148 patients with abdominal wall AF recruited consecutively from 21 medical centers in Hunan province between January 1, 2010 and September 30, 2022 were reviewed. The general characteristics, treatment method, risk factors for postoperative recurrence, and prognosis of patients were analyzed.Results Among 148 patients with abdominal wall AF, 15 cases (10.1%) were males, and 133 cases (89.9%) were females with a median age of 31 (3-72) years old; there were 142 cases (95.9%) with primary disease and 6 cases (4.1%) with recurrent disease; 71 cases (48.0%) had a history of abdominal surgery. Among the female patients, 111 cases (83.5%) had a history of pregnancy, and 57 cases (42.9%) had a history of cesarean section. All patients were confirmed with AF by postoperative pathological examination. Pathological diagnosis obtained by fine needle puncture before surgery in 16 patients (10.8%), which in 8 cases (50.0%) were consistent with the postoperative results. Immunohistochemical staining was performed in 100 patients (67.6%). Among them, 32 cases (32.0%) had Ki-67 >5%, 56 cases (56.0%) had β-catenin (+), and 42 patients (42.0%) had vimentin (+). All 148 patients with AF underwent radical resection of abdominal wall tumors. Among them, 72 cases underwent abdominal wall repair by direct suture after tumor resection, 72 cases underwent mesh implant for abdominal wall strengthening, and 4 cases underwent abdominal wall reconstruction with a musculocutaneous flap or pedicled tensor fascia lata musculocutaneous flap. Follow-up was obtained through telephone calls and clinic visits in 127 patients (85.8%), and the median follow-up time was 3.6 (0.9-12.3) years. During follow-up, recurrence occurred in 11 patients (11/127, 8.7%), including three re-recurrent cases. Recurrent AF and positive surgical margins were risk factors for postoperative recurrence (both P<0.05). Postoperative wound infection and wound dehiscence or incisional hernia were observed in none of them, and no tumor metastasis or death occurred.Conclusions Abdominal wall AF predominantly affects young female adults with a pregnancy history. There is a certain recurrence rate after radical resection. Surgeons should strive to achieve negative surgical margins, especially for those with recurrent AF, for whom specialized care with an individualized treatment plan from an experienced hernia and abdominal wall surgery center is recommended.

10 Analysis of influencing factors for bile leakage after hepatectomy

MI Xingyu , MO Lei , SU Wenxin , YANG Hanrui , XIAO Liang , ZHOU Ledu

2023, 32(2):246-253. DOI: 10.7659/j.issn.1005-6947.2023.02.010

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Background and Aims Bile leakage is a common complication after hepatectomy, which will cause prolonged hospital stay and delayed removal of the abdominal drainage tube, thereby increasing the suffering and economic costs of patients. Severe bile leakage can lead to abdominal infection, sepsis, and even death. This study aims to investigate the factors associated with postoperative bile leakage through retrospective analysis to reduce the incidence of postoperative bile leakage in clinical practice.Methods The general information and clinical data of patients undergoing hepatectomy in Xiangya Hospital of Central South University from January 1, 2020 to October 1, 2022 were collected retrospectively. The influencing factors for postoperative bile leakage were determined by univariate and multivariate Logistic analyses.Results A total of 1 845 patients who underwent hepatectomy were finally included. Of the patients, bile leakage occurred in 59 cases (3.2%), which was classified as grade A in 36 cases, grade B in 20 cases and grade C in 3 cases. The results of univariate analysis indicated that previous history of hepatectomy (χ²=9.337, P=0.002), diagnosis of malignant tumor (χ²=10.849, P=0.001), anatomical hepatectomy (χ²=8.015, P=0.005), operative time (t=4.613, P<0.001), blood loss (t=4.274, P<0.001), blood transfusion or not (χ²=5.129, P=0.024) and the use of fibrin glue (χ²=10.289, P=0.001) were related to postoperative bile leakage. The results of Logistic analysis showed that previous history of hepatectomy was an independent risk factor (P=0.003), while anatomical hepatectomy (P=0.006) and the use of fibrin glue during the operation (P=0.002) were independent protective factors for postoperative bile leakage. Conversion therapy was associated with postoperative bile leakage in patients with primary liver cancer (χ²=74.594, P<0.001), and only transcatheter arterial chemoembolization (TACE), among the local treatments, was an independent risk factor for postoperative bile leakage (P<0.001).Conclusion For patients with a previous history of hepatectomy or who have received conversion therapy, mainly containing TACE, preoperative planning is essential, and more caution should be taken during the operation. Anatomical hepatectomy and intraoperative use of fibrin glue can help reduce the occurrence of bile leakage.

11 Clinical observation of efficacy of brief mindfulness-based body scan in control of intraoperative hypertension and pain in patients undergoing radiofrequency ablation for liver cancer under local anesthesia

PENG Jing , XIAO Liang , QU Yingjun , LI Lan , LIU Xin , XIE Yanhui

2023, 32(2):254-260. DOI: 10.7659/j.issn.1005-6947.2023.02.011

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Background and Aims During the radiofrequency ablation (RAF) treatment under local anesthesia for liver cancer, anxiety and stress are inevitable reactions in patients, which will make the patients more sensitive to pain, and thereby lead to increased blood pressure and decreased tolerance, even forced discontinuation of treatment. Therefore, maintaining the stability of vital signs and relieving pain are the guarantees of the successful implementation of RAF under local anesthesia for patients with liver cancer. Conventionally, antihypertensive and analgesic medications are often used to relieve the above symptoms in clinical practice. Still, these drugs possess inherent side effects and increase the patients' economic burden. Mindfulness-based stress reduction (MBSR) therapy has been proven to positively impact the control of various adverse emotions and chronic pain. However, its value in the treatment of liver cancer is rarely reported. Therefore, this study was conducted to investigate the efficacy of a brief mindfulness-based body scan (BMBS) in controlling intraoperative hypertension and pain in patients receiving RAF under local anesthesia for liver cancer and provide data support for its clinical application.Methods The data of 67 patients who underwent RAF for liver cancer from January 2018 to June 2019 in the Department of Liver Surgery, Xiangya Hospital, Central South University, were retrospectively analyzed. Of the patients, 32 cases received BMBS only without administering antihypertensive drugs throughout RAF (BMBS group), and the other 35 cases received sublingual administration of amlodipine sublingual amlodipine tablets to control the blood pressure and keep it around the normal level (control group). All patients underwent blood pressure measurement 4 times before and after RAF (10 min before the initiation of BMBS or oral administration of antihypertensive drugs, immediately before the initiation of BMBS or oral administration of antihypertensive medications, at the initiation of RAF, and the completion of RAF). The baseline characteristics and efficacy evaluation variables, such as changes in blood pressure, the frequency of analgesic drug use, and scores for pain assessment during the RAF process, were compared between the two groups.Results There were no significant differences in the baseline conditions between the two groups of patients (all P>0.05). The results of the intra-group comparison showed that the systolic and diastolic pressure were significantly reduced in both the BMBS group and control group after the complementary treatment (all P<0.05), The results of the inter-group comparison showed that there were no significant differences in both systolic pressure and diastolic pressure at each predefined time point between the two groups (all P>0.05). The number of analgesic requirements and pain scores was significantly lower in the BMBS group than that in the control group (P=0.044, P=0.003).Conclusion As a simple MBSR method, BMBS has a good control effect on intraoperative hypertension and pain in patients with liver cancer undergoing RAF under local anesthesia and has a reasonable prospect of clinical application. Since its implementation depends on professional training of medical staff in psychological intervention, it is necessary to strengthen the training in this aspect in the future so that it can provide benefits to more patients.

12 Lymph node dissection in radical resection of intrahepatic cholangiocarcinoma: controversies and progress

ZHAO Zekun , WEI Fengxian , WANG Jianxiong , ZHOU Zhiming , MA Shangxian , XU Xiaodong

2023, 32(2):261-268. DOI: 10.7659/j.issn.1005-6947.2023.02.012

[Abstract](1123) [HTML](743) [PDF 706.52 K](1146)

Abstract:
Intrahepatic cholangiocarcinoma (ICC) is a highly aggressive primary liver malignant tumor with insidious onset, atypical early symptoms, and poor prognosis. Radical surgical resection is the only effective treatment for ICC. Lymph node metastasis (LNM) is one of the most important risk factors affecting the prognosis of patients with ICC. Most guidelines suggest routine lymph node dissection (LND) during radical resection of ICC. However, the extent of LND in radical ICC resection and its prognostic value is still controversial. Therefore, the authors review the research progress on the controversies and problems of LND in radical ICC resection combined with the existing research results at home and abroad to provide a reference for the clinical treatment of ICC.

13 Current status and strategies of multidisciplinary diagnosis and treatment of intrahepatic cholangiocarcinoma

LIU Sulai , LIU Pei , SONG Yinghui , YU Zhangtao , PENG Chuang

2023, 32(2):269-278. DOI: 10.7659/j.issn.1005-6947.2023.02.013

[Abstract](804) [HTML](890) [PDF 822.14 K](1230)

Abstract:
Intrahepatic cholangiocarcinoma (ICC) is a highly aggressive malignant tumor arising from the epithelial cells of the second-order or more proximal bile ducts. ICC usually has no early warning signs, so most patients are diagnosed at an advanced stage and have no chance of radical surgery. With the introduction and widespread implementation of multidisciplinary diagnosis and treatment model for ICC, the disease control effect and survival time of patients have been improved, but the prognosis is still unfavorable. In the current surgery-based multidisciplinary diagnosis and treatment approach, attention should be focused on the mid- and long-term benefits to patients, and take this as the end goal throughout the whole process of treatment. Given the diversity of treatment options and the complexity of the disease, all treatment strategies recommend creating individualized management plans based on multidisciplinary discussion, and that the diagnosis and treatment should be conducted at or directed by a highly specialized hepatobiliary and pancreatic center. Here, the authors emphatically describe the development status and strategies of multidisciplinary diagnosis and treatment of ICC.

14 Research progress of gut microbiome in hepatobiliary and pancreatic malignancies

LIU Keliang , WANG Xiaohui , LI Sirou , LI Jinghua

2023, 32(2):279-286. DOI: 10.7659/j.issn.1005-6947.2023.02.014

[Abstract](772) [HTML](513) [PDF 744.08 K](1297)

Abstract:
In recent years, studies have demonstrated that the gut microbiome may play an important role in hepatobiliary and pancreatic malignancies. In this article, the authors address the association of the gut microbiome with hepatocellular carcinoma, cholangiocarcinoma and pancreatic cancer, and the research progress of the gut microbiome in the treatment of hepatobiliary and pancreatic malignancies, so as to discuss the application value of the gut microbiome in clinical treatment of hepatobiliary and pancreatic malignancies.

15 Research advances in drug therapy of cholangiocarcinoma

YOU Junqi , XIA Haoming , HUANG Ziyue , CHEN Jiali , XU Yi , CUI Yunfu

2023, 32(2):287-295. DOI: 10.7659/j.issn.1005-6947.2023.02.015

[Abstract](847) [HTML](1394) [PDF 837.22 K](1263)

Abstract:
Cholangiocarcinoma (CCA) is a malignant tumor originating from the biliary system. Although surgery is the recognized radical treatment for CCA, the treatment results are not satisfactory due to the special anatomical characteristics of the biliary system and the high aggressiveness of the disease. Drug therapy has become an option for patients with advanced CCA to achieve a better outcome. Drug treatment mainly includes chemotherapy, targeted therapy and immunotherapy. At present, two important therapeutic targets, the fibroblast growth factor receptor and isocitrate dehydrogenase 1, have been found in studies, and the targeted therapeutic drugs against them generally showed positive effects in clinical trials. Although CCA generally expresses PD-1/PD-L1, it is not sensitive to immune checkpoint inhibitors, and the efficacy can be improved by combining other immunotherapy drugs. Traditional chemotherapy has the most stable efficacy for CCA compared with emerging targeted therapies and immunotherapies. The National Comprehensive Cancer Network guidelines recommend cisplatin plus gemcitabine as the first-line chemotherapy regimen for patients with advanced unresectable CCA or CCA presenting with metastatic symptoms. Recent advances in these drugs will significantly improve the survival benefits of CCA patients.

16 Strategy for etiological diagnosis and treatment choice of benign biliary stricture

WU Lili , YUE Jinquan , LIU Zhiheng , AI Runyao , PENG Chengjiang , ZHONG Xingwei

2023, 32(2):296-308. DOI: 10.7659/j.issn.1005-6947.2023.02.016

[Abstract](712) [HTML](991) [PDF 882.02 K](1232)

Abstract:
Benign biliary stricture (BBS) is one of the main complications of hepatopancreatobiliary diseases and surgical procedures. The use of appropriate diagnostic methods and strategies to identify the cause of biliary stricture, can not only avoid the missed diagnosis of malignant biliary stricture with benign manifestations, but also avoid unnecessary surgical exploration in benign diseases, and has become a key element in the diagnosis and treatment of biliary stricture. Among numerous treatment methods for different causes, how to select and make a reasonable treatment strategy is also a problem faced by hepatopancreatobiliary surgeons. The etiological causes of BBS mainly include iatrogenic, infectious, inflammatory, obstructive, ischemic and autoimmune factors. In terms of diagnosis, CT, MRI and other imaging examinations are the first choice for finding biliary stricture and preliminarily determining the benign or malignant nature of the lesion. The etiological diagnosis of BBS can be made by combining the history, clinical manifestations and laboratory findings with the comprehensive evaluation of the collaborative multidisciplinary team including hepatobiliary surgeons, radiologists and pathologists. In terms of treatment, endoscopic retrograde cholangiopancreatography (ERCP) is still the first-line treatment for BBS; in the cases with anatomical changes or various reasons that cause the failure of endoscope to enter the biliary tract through the duodenal papilla, percutaneous transhepatic biliary drainage (PTBD) can be used for solution; for refractory BBS, surgery is considered as the final option; emerging techniques such as magnetic compression anastomosis, intraductal radiofrequency ablation and biodegradable stents have promising application prospects, but more research data are needed to evaluate the efficacy and safety.

17 China Journal of General Surgery, 2023, 32(2):309-316.

任庆旗，林泽伟，熊沛，尹耀新，刘吉奎

2023, 32(2):309-316. DOI: 10.7659/j.issn.1005-6947.2023.02.017

[Abstract](740) [HTML](778) [PDF 1.60 M](1067)

Abstract:
背景与目的 肝包膜下血肿（SHH）是内镜逆行胰胆管造影（ERCP）术后罕见并发症之一，总体病死率可达7.5%，临床医师需引起足够重视。本文报告1例ERCP术后SHH患者的诊治过程，结合既往文献分析病例特点，以期为SHH病因探索及后续SHH术中及术后诊疗提供借鉴。方法回顾性分析北京大学深圳医院肝胆胰外科收治的1例ERCP术后SHH患者的临床资料，结合前期文献资料进行复习和总结。结果患者为32岁女性，肝功能检查提示总胆红素（TBIL）133.1 μmol/L、结合胆红素（DBIL）75.0 μmol/L，MRI检查提示胆总管近壶腹部结石伴以上肝内外胆管扩张，予以行ERCP+Oddi括约肌扩张+胆道取石+鼻胆管外引流术，术后15 h患者出现右上腹疼痛伴有肩痛，予以止痛处理后缓解，术后18 h出现心率增快，复查血常规提示血红蛋白进行性降低，急诊CT检查提示肝脏包膜下弧形高密度影，考虑血肿可能；ERCP术后腹腔、盆腔积血积液。予急诊行选择性肝动脉造影+经皮动脉栓塞术，术后患者血红蛋白逐步升高至正常，于动脉栓塞术后2周出院。出院后3 d患者再发右上腹疼痛，急诊CT提示SHH较前范围增大，再次行选择性肝动脉造影+经皮动脉栓塞术，术后患者血红蛋白逐步升高至正常，于再次手术后16 d出院。术后随访患者无不适，影像学复查见血肿进行性缩小，予继续随访。结论 ERCP术中导丝损伤致SHH临床罕见，文献报道对其病因有广泛共识，但缺乏直接证据。该病例术中透视片可见沿导丝、导管走行对应肝脏包膜下术中显影，可视为导丝损伤胆管、肝实质致SHH的直接证据。ERCP患者术中应留意透视图片有无造影剂外渗及异常积聚，对于术后腹痛患者，要高度警惕SHH的可能，以期早期识别及干预。

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Volume 32,Issue 2,2023 Table of Contents

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