Volume 33,Issue 4,2024 Table of Contents

1 Guidelines for the diagnosis and treatment of primary liver cancer (2024 edition)

Department of Medical Administration , National Health Commission of the People's Republic of China

2024, 33(4):475-530. DOI: 10.7659/j.issn.1005-6947.2024.04.001

[Abstract](691) [HTML](565) [PDF 2.54 M](3731)

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In April 2024, the "Guidelines for the diagnosis and treatment of primary liver cancer (2024 edition)" were officially released. The guidelines were developed by experts and scholars from various disciplines in the field of liver cancer across the country under the leadership of the Department of Medical Administration of the National Health Commission of the People's Republic of China and with guidance from the Expert Committee on the Compilation of Guidelines for the Diagnosis and Treatment of Primary Liver Cancer, the National Cancer Center, and the Liver Cancer Quality Control Expert Committee of the National Cancer Quality Control Center. The main updates in the "Guidelines for the diagnosis and treatment of primary liver cancer (2024 edition)" include: updates to surgical treatment methods and concepts; objective evaluation of the value of local ablation; revitalization of vascular intervention therapy; further exploration and optimization of radiotherapy; and significant breakthroughs in systemic treatment. As a normative guidance document for primary liver cancer, the guidelines keep pace with the times, timely reflecting new developments and concepts in the field of liver cancer diagnosis and treatment, which will effectively drive the elevation of standardized diagnosis and treatment levels for liver cancer in China, enhanced the influence of our country in this field within the academic community, and hold high guiding significance for the future global standardization of liver cancer diagnosis and treatment.

2 Current development status of surgical resection and reconstruction methods for proximal gastric cancer

HAN Fanghai , XIE Yequan

2024, 33(4):531-538. DOI: 10.7659/j.issn.1005-6947.2024.04.002

[Abstract](192) [HTML](216) [PDF 2.84 M](807)

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Gastric cancer is a common malignant tumor, and in recent years, the incidence of proximal gastric cancer and gastroesophageal junction adenocarcinoma has significantly increased. Multiple studies have shown that for proximal gastric cancer or gastroesophageal junction adenocarcinoma, when the tumor diameter is ≤4 cm, regardless of the depth of infiltration, the likelihood of lymph node metastasis to the No. 4, No. 5 and No. 6 groups is very low. For early proximal gastric cancer and gastroesophageal junction adenocarcinoma, proximal gastrectomy has a comparable 5-year overall survival rate to total gastrectomy. Proximal gastrectomy has advantages in preserving remnant stomach and pyloric function after operation, as well as improving the nutritional status of patients. Various reconstruction procedures are available for postoperative reflux esophagitis after proximal gastrectomy. Among them, double seromuscular flap technique has good anti-reflux effects, significantly reducing the occurrence of food residue and improving the postoperative survival quality of patients, meeting the requirements of modern gastric cancer surgery for individualization, precision, functional preservation, and quality improvement.

3 Perioperative management protocol for the prophylaxis of venous thromboembolism in extremely obese patients

DONG Wenpei , HOU Dongsheng , WANG Rui , YANG Dongchao , SONG Zhicheng , YANG Jianjun , GU Yan

2024, 33(4):539-544. DOI: 10.7659/j.issn.1005-6947.2024.04.003

[Abstract](166) [HTML](148) [PDF 629.56 K](836)

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Venous thromboembolism (VTE) is one of the common complications after bariatric/metabolic surgery, and extremely obese patients have a higher risk of VTE occurrence. Here, the authors conducted a review and analysis of relevant guidelines and literature from both domestic and international sources, incorporated with the clinical experience of their center, to organize and summarize perioperative VTE prevention and management protocols for extremely obese patients, with the aim of providing guidance for the prevention and treatment of VTE.

4 Perioperative management process for patients with extreme obesity and obstructive sleep apnea undergoing metabolic and bariatric surgery

ZHU Dongzi , WANG Wenyue , WANG Bing , YANG Chengcan

2024, 33(4):545-552. DOI: 10.7659/j.issn.1005-6947.2024.04.004

[Abstract](237) [HTML](177) [PDF 648.12 K](995)

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Among obese patients, especially among those with extreme obesity (body mass index ≥50 kg/m²) who are scheduled for metabolic and bariatric surgery (MBS), obstructive sleep apnea (OSA) is one of the most common and s critical comorbidities, with a prevalence ranging from 35.0% to 93.6% in the bariatric population. MBS is the only treatment method capable of providing long-term effective relief for extreme obesity while alleviating OSA symptoms. However, OSA significantly increases the perioperative respiratory and cardiovascular complications and mortality rates associated with MBS. To reduce perioperative risks associated with MBS, key measures for the perioperative management of OSA involve timely and accurate diagnosis and assessment based on a multidisciplinary team (MDT) collaboration. This includes integrating OSA diagnosis, treatment, and monitoring into the perioperative management process of MBS, standardizing personalized precision treatment. This article, drawing on relevant literature and clinical experience from the authors' institution, introduces the perioperative management process for extreme obesity complicated by OSA, covering preoperative, intraoperative, and postoperative aspects, so as to provide clues and insights for the precise assessment of the most effective and safe treatment options.

5 The treatment of anastomosis-related complications after low rectal cancer surgery and the key points of using modified Bacon procedure for redo sphincter-preserving surgery

XU Xiaojia , WANG Xin , HUANG Ping

2024, 33(4):553-560. DOI: 10.7659/j.issn.1005-6947.2024.04.005

[Abstract](151) [HTML](266) [PDF 950.30 K](680)

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With the development of endoscopic technology, the emergence of staplers, and the improvement of surgical concepts, the surgical operation for rectal cancer has become increasingly sophisticated. The anal preservation rate has increased year by year, and the anastomotic position of rectal cancer has also become lower and lower. However, the incidence of anastomosis-related complications has not decreased significantly. As one of the most severe and common complications following rectal cancer surgery, anastomotic leakage, and anastomotic stenosis not only prolong the patients' hospital stay, increase their economic burden, and affect their quality of life, but may even reduce their survival rates. Numerous scholars have conducted extensive and in-depth research on anastomosis-related complications in recent years. However, there is no unified standard for treating anastomosis-related complications in China. Based on relevant literature, this article elaborates on the issues related to anastomotic leakage and stenosis, including definitions, influencing factors, and treatment. At the same time, it introduces the key points and challenges in adopting the modified Bacon procedure for redo sphincter-preserving surgery in patients with anastomotic leakage and anastomotic stenosis, so as to provide a reference for clinical treatment.

6 Clinical analysis of impact of anastomotic leakage on short- and long-term anal function in patients after intersphincteric resection for low rectal cancer

ZHANG Lina , ZHAO Yong , JIANG Honghong , CAO Yu , ZHAO Yujuan , ZHUO Guangzuan , ZHANG Bin , YIN Shuhui , WANG Mei , DING Jianhua

2024, 33(4):561-568. DOI: 10.7659/j.issn.1005-6947.2024.04.006

[Abstract](185) [HTML](192) [PDF 726.72 K](546)

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Background and Aims Intersphincteric resection (ISR) has been proven to achieve good oncological outcomes as an ultimate sphincter-preserving surgery for ultra-low rectal cancer. Due to its maximal preservation of the anus and avoidance of permanent stoma, ISR has gradually become an important option for sphincter-preserving surgery for low rectal cancer. However, ISR involves partial or complete resection of the internal anal sphincter, inevitably leading to a decrease in postoperative anal function. Anastomotic leakage is one of the most common complications after ISR and may have an adverse effect on postoperative anal function. However, there is no thorough study on the specific effect of anastomotic leakage on anal function in patients after ISR. Therefore, this study was performed to investigate the impact of anastomotic leakage on short- and long-term anal function in patients after ISR.Methods The clinical and follow-up data of 236 patients undergoing ISR with a diverting loop ileostomy from June 2011 to January 2022 in the PLA Rocket Force Characteristic Medical Center were retrospectively collected. The general clinical data between patients who developed anastomotic leakage and those who did not were compared. Differences in the Wexner incontinence score (WIS) and low anterior resection syndrome (LARS) score, as well as differences in various parameters of anorectal manometry at 6 months and 2 years after ileostomy reversal, were compared between patients with and without anastomotic leakage.Results Among the 236 patients, 41 cases (17.4%) developed anastomotic leakage, and 23 (9.7%) ultimately did not undergo ileostomy reversal. Comparison of general clinical data between patients with and without anastomotic leakage showed that patients with anastomotic fistula had a higher BMI (27 kg/m² vs. 25 kg/m²), a higher incidence of diabetes (29.3% vs. 15.9%), longer operative time (222 min vs. 200 min), and a significantly higher proportion of ileostomy non-reversal (34.1% vs. 4.6%), all of which were statistically significant (all P<0.05). A total of 149 patients completed anal function questionnaires at 6 months and 2 years after ileostomy reversal, of whom 20 (13.4%) had anastomotic leakage and 129 (86.6%) did not. At 6 months after closure, the WIS score (12 vs. 9) and LARS score (34 vs. 29) of patients with anastomotic leakage were higher than those without (both P<0.05); however, at 2 years after closure, there were no statistically significant differences in WIS score (8.5 vs. 8) and LARS score (28.5 vs. 32) between the two groups of patients (both P>0.05). A total of 53 patients completed rectal manometry examinations at 6 months and 2 years after ileostomy closure, of whom 11 (20.8%) had anastomotic leakage and 42 (79.2%) did not. At 6 months after closure, the maximum squeeze pressure of the anal canal in patients with anastomotic leakage was higher than that in patients without (P<0.05), while other parameters including resting pressure of the anal canal, length of the high-pressure zone of the anal canal, and maximum tolerable volume showed no statistical differences between the two groups of patients (all P>0.05); at 2 years after closure, there were no statistical differences in all parameters of anorectal manometry between the two groups of patients (all P>0.05).Conclusion The occurrence of anastomotic leakage increases the risk of permanent stoma after ISR. For patients who have restored intestinal continuity, anastomotic leakage has a negative impact on early anal function, but may not have a significant impact on long-term anal function.

7 Efficacy and safety of laparoscopic versus transanal endoscopic-assisted dual-scope combination redo coloanal anastomosis: a single-center report of 51 cases

ZHOU Zuolin , HUANG Binjie , HE Yanjiong , LIU Duo , LI Jiamin , ZHOU Wenbin , ZHU Miaomiao , HUANG Xiaoyan , QIN Qiyuan , CAI Jian , MA Tenghui

2024, 33(4):569-577. DOI: 10.7659/j.issn.1005-6947.2024.04.007

[Abstract](259) [HTML](182) [PDF 795.38 K](559)

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Background and Aims Redo coloanal anastomosis after rectal resection can restore intestinal continuity in most patients with rectal anastomotic failure or local tumor recurrence, avoiding permanent enterostomy. However, this surgery is challenging and associated with a high incidence of surgical complications. The choice of surgical approach is crucial for reducing the difficulty of the procedure, ensuring surgical safety, and reducing postoperative complications. Therefore, this study summarized the experience of performing laparoscopic and transanal endoscopic-assisted dual-scope combination redo coloanal anastomosis over 8 years at a single center to provide an evidence-based reference for clinical practice.Methods The clinical data of 51 patients undergoing redo coloanal anastomosis in Division of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University between October 2015 and August 2023 were retrospectively collected. Among them, 24 cases underwent transanal endoscopic-assisted dual-scope combination redo coloanal anastomosis (the dual-scope combination group), and 27 cases underwent laparoscopic r redo coloanal anastomosis (the laparoscopic group). Intraoperative and postoperative conditions of all patients were analyzed, and differences in relevant clinical variables between the dual-scope combination group and the laparoscopic group were compared.Results All 51 patients successfully underwent redo coloanal anastomosis. Methods of digestive tract reconstruction included Bacon operation in 30 cases, Dixon operation in 5 cases, Parks operation in 15 cases, and intersphincteric resection in 1 case. Among the 51 patients, 30 underwent pull-through resection with two-stage coloanal anastomosis, 5 underwent pull-through resection with single anastomosis, 3 underwent pull-through resection with double anastomosis, and 13 underwent one-stage manual anastomosis. Among them, 42 patients had an enterostomy before surgery, 6 underwent prophylactic enterostomy after surgery, and 3 did not undergo prophylactic enterostomy after surgery. The total operative time for the entire group was 296 (251-349) min, and the intraoperative blood loss was 100 (50-200) mL. There was no statistical difference in the operative time and intraoperative blood loss between the dual-scope combination and laparoscopic groups (both P>0.05). A total of 24 specimens were obtained transanally during the operation, with 5 in the laparoscopic group and 19 in the dual-scope combination group, showing a statistically significant difference (P<0.05). The postoperative hospital stay for the entire group was 17 (11-23.5) d. There was no statistical difference in the postoperative hospital stay between the dual-scope combination and laparoscopic groups ( both P>0.05). However, the time to postoperative gas passage and oral intake in the dual-scope combination group was shorter than in the laparoscopic group (both P<0.05). There were no patients in the entire group who were transferred to the ICU for treatment after surgery or died during hospitalization. Pathological examination of specimens from 9 patients with local tumor recurrence after surgery showed no tumor at the specimen margin. Sixteen patients in the entire group experienced complications (9 cases of Clavien-Dindo grade Ⅱ and 7 cases of grade Ⅲ or above), including 4 cases in the dual-scope combination group (16.67%) and 12 cases in the laparoscopic group (44.44%), with a statistically significant difference (χ²=4.554, P=0.033).Conclusion The choice of surgical approach and method for redo coloanal anastomosis should be based on the type of initial anastomotic failure, the distance of the lesion from the anus, the patient's overall condition, and the level of medical care in the hospital to develop individualized treatment plans. Compared with simple laparoscopic redo coloanal anastomosis, transanal endoscopic-assisted dual-scope combination redo coloanal anastomosis has the advantages of faster postoperative recovery and a lower incidence of postoperative complications. Moreover, further follow-up is needed to evaluate the differences in enterostomy reversal rate, long-term anal function, and quality of life after redo coloanal anastomosis by the two surgical methods.

8 Visualization analysis of current status and hotspots of clinical application of robot-assisted colorectal surgery based on CiteSpace

LI Zheng , YI Bo , WANG Guohui , MO Xiaoye

2024, 33(4):578-591. DOI: 10.7659/j.issn.1005-6947.2024.04.008

[Abstract](230) [HTML](111) [PDF 2.82 M](515)

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Background and Aims Colorectal cancer is a common malignant tumor in clinical practice, and its surgical treatment has become one of the research hotspots in the field of surgery in recent years. Robot-assisted surgery, representing the most advanced surgical technology, has rapidly developed in the field of colorectal surgery, and an increasing number of scholars have begun to focus on its application and research in this field. Using CiteSpace software, this study conducted a visual analysis of recent literature on robot-assisted colorectal surgery to explore the development process and evolution of diagnosis and treatment methods of robotic surgery in colorectal surgery worldwide, analyze the research hotspots and trends, identify current hot topics, and determine potential new research directions, so as to provide new clues and ideas for subsequent research.Methods Relevant Chinese and English literature on robot-assisted colorectal surgery in the Web of Science Core Collection (WoSCC) database and the China National Knowledge Infrastructure (CNKI) database between January 1, 1999 and September 30, 2023 were retrieved. CiteSpace 5.8.R3 software was used to analyze the publication countries, prolific institutions, authors, and collaboration relationships in this field. Clustering, burst detection, timeline, and time zone analyses were performed on keywords to draw visual knowledge maps.Results A total of 3 135 articles were included, with 2 760 from the WoSCC database and 375 from the CNKI database. The analysis showed that the number of publications in this field has been increasing year by year, especially after 2011, with a significant increase, reaching its peak in 2021. Currently, the leading countries in publications were the United States (758 articles), Italy (253 articles), and China (173 articles). The top three foreign institutions in terms of publications were Yonsei University in Republic of Korea (76 articles), Korean University (53 articles), and Mayo Clinic in the United States (41 articles). The leading Chinese institutions in terms of publications were Zhongshan Hospital Affiliated to Fudan University (11 articles), Tongji Medical College Affiliated Union Hospital of Huazhong University of Science and Technology (6 articles), the First Affiliated Hospital of Nanchang University (6 articles), and the General Hospital of Shenyang Military Region (6 articles). The top three foreign authors came from Republic of Korea, with most authors forming a wide cooperation network. The top three Chinese authors were from Zhongshan Hospital Affiliated to Fudan University, Gansu Provincial People's Hospital, and Jiangsu Province Hospital of Traditional Chinese Medicine, with most authors belonging to independent research teams and only a few having collaborative relationships. Keyword analysis results show that the foreign development trends mainly focused on colorectal cancer-related liver resection, postoperative survival rate, surgical risk factors, and postoperative survival quality, while domestic trends included new applications of surgery, the operation system of the da Vinci robot, and the compilation of expert consensus and monographs; foreign hotspots and trends were concentrated on clinical randomized controlled trials and open labels, while domestic hotspots focused on surgical techniques, robot operation systems, and integration with other technologies.Conclusion Robot-assisted colorectal surgery is one of the hot topics in the research of minimally invasive surgery. Compared with the international level, research and clinical application of robot surgery in China are relatively lagging, mainly manifested in late start time, few high-quality papers, low citation frequency, and low degree of cooperation with other countries or institutions. Conducting randomized controlled trials, reducing perioperative risks, and improving postoperative patient survival rates and quality of life are the research hotspots and frontiers of robot-assisted colorectal surgery.

9 Bioinformatics analysis of the relationship between MLH1 protein and tumor microflora characteristics in proximal sporadic colon cancer

JIANG Ping , ZHU Anchao , LIU Yingying , LI Zongmin , LIU Yuyan , SHAN Jingjun , HE Ying

2024, 33(4):592-602. DOI: 10.7659/j.issn.1005-6947.2024.04.009

[Abstract](174) [HTML](149) [PDF 1.77 M](658)

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Background and Aims Mutations in the mutL homolog 1 (MLH1) gene can lead to inactivation of the DNA mismatch repair (MMR) system, increasing the risk of colorectal cancer. Additionally, growing evidence suggests that alterations in the composition and function of the intestinal microbiota are closely associated with the occurrence and development of colorectal cancer. However, the relationship between MLH1 protein expression and the intestinal microbiota remains unclear. Therefore, this study aimed to explore the potential relationship between them by analyzing the differences in the microbial composition of tumor tissues between patients with proximal sporadic colon cancer (SCC) and different MLH1 protein phenotypes in Northeast China.Methods Tumor tissue samples and clinical data were collected from 407 patients with proximal SCC treated in Harbin First Hospital and Heilongjiang Provincial Hospital between 2020 and 2021. Immunohistochemistry was used to screen for cases with MLH1 protein deficiency (deficiency group) and intact MLH1 protein (control group). Microbial DNA extracted from the intestinal tumor tissues was analyzed using 16S rRNA gene sequencing technology for bioinformatics analysis. The relationship between clinicopathologic features and the diversity of specific taxa and microbial diversity was analyzed.Results A total of 20 cases were screened in the deficiency group, and 18 cases were screened in the control group. Preliminary analysis of clinical data showed that the larger the tumor, the higher the risk of MLH1 protein deficiency (P<0.05). The α-diversity of the microbial community within tumor tissues under different MLH1 statuses showed no statistically significant differences except for the Shannon index (P=0.042). Other diversity indices had no significant difference (all P>0.05). The β-diversity analysis of microbial communities at the phylum level showed no significant differences between the two groups (P=0.076). At the genus level, β-diversity analysis showed that the differences between the two groups were greater than those within the groups (P=0.04). A comparison of the abundance of bacterial genera revealed that the abundance of the genus Coprococcus spp may promote MLH1 protein deficiency (adjusted P<0.01). However, there were no significant differences in the Shannon diversity index between various clinicopathologic variables or key species with different abundances (all P>0.05).Conclusion The MLH1 protein phenotype of proximal SCC patients is closely related to the composition and diversity of the intestinal microbiota. Moreover, Coprococcus spp was identified as a potential key species associated with MLH1 protein loss in this population, providing a new perspective for future research, prevention, and treatment of this disease.

10 Establishment and validation of a risk prediction model for delayed neurocognitive recovery after laparoscopic colorectal cancer surgery

LUO Ning , YE Chunyan , LIU Xingyang , WANG Lu , WANG E , LI Longyan

2024, 33(4):603-611. DOI: 10.7659/j.issn.1005-6947.2024.04.010

[Abstract](184) [HTML](112) [PDF 839.43 K](560)

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Background and Aims The incidence rate of delayed neurocognitive recovery (DNR) following laparoscopic surgery for colorectal cancer is high and significantly affects patient recovery. Therefore, this study was performed to analyze the risk factors for postoperative DNR following laparoscopic surgery for colorectal cancer and to construct a risk prediction model, in order to provide evidence-based guidance for the prevention and treatment of postoperative DNR.Methods The clinical data of 227 patients with colorectal cancer who underwent laparoscopic surgery with intraoperative monitoring of regional cerebral tissue oxygen saturation (rScO₂) in Xiangya Hospital, Central South University, from March 2018 to July 2020 were retrospectively analyzed. Common and potential factors for postoperative DNR were selected as analysis variables. Univariate and multivariate analyses were performed to determine the predictive factors of the model and construct a risk prediction model. The predictive performance of the model was evaluated using receiver operating characteristic (ROC) curves, the fit between the model and data was assessed using calibration curves, and nomograms were plotted. Additionally, 30 patients meeting the inclusion and exclusion criteria from January 2021 to July 2021 were selected for external validation of the prediction model.Results The incidence rate of postoperative DNR in the modeling group was 15.4% (35/227). Multivariate analysis showed that age, years of education, comorbid diabetes, and lowest intraoperative rScO₂ were independent influencing factors for postoperative DNR (all P<0.05). Based on this, a risk prediction model for postoperative DNR following laparoscopic surgery for colorectal cancer was constructed, with an area under the ROC curve of 0.757 (95% CI=0.676-0.839, P<0.001). The calibration curve demonstrated good model fit according to the Hosmer-Lemeshow test (P=0.516), and the external validation C-index was 0.617.Conclusion The risk prediction model for postoperative DNR associated with rScO₂ monitoring can be used for individualized assessment of patients undergoing laparoscopic colorectal cancer surgery, and provide a clinical basis for the prevention of postoperative DNR.

11 Expression of FBXO43 in gastric cancer and its biological function and mechanisms of action

YANG Juan , LIU Chunmei , WU Han , ZHAO Lu , LU Shanshan

2024, 33(4):612-623. DOI: 10.7659/j.issn.1005-6947.2024.04.011

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Background and Aims F-box protein (FBP) family member F-box only protein 43 (FBXO43) is highly expressed in digestive system tumors such as liver cancer and colorectal cancer, promoting malignant progression of tumors. Research has shown that FBXO43 promotes the degradation of p53, exerting oncogenic functions. Therefore, this study was conducted to further explore the expression of FBXO43 in gastric cancer and its role and related mechanisms in the malignant progression of gastric cancer.Methods Based on online databases such as TCGA, GTEx, and Kaplan-Meier Plotter, the expression of FBXO43 in gastric cancer tissues and its correlation with the prognosis of gastric cancer patients were analyzed. Western blot and qPCR were used to detect the expression levels of FBXO43 in gastric cancer cells and normal gastric mucosal epithelial cells. Immunohistochemical staining was performed to detect the protein levels of FBXO43 in gastric cancer and adjacent tissues. Specific small interfering RNA molecules targeting FBXO43 and p53 (siFBXO43 and sip53) were transfected into HGC27 and MGC803 cells to knock down the expression of FBXO43 and p53 alone or simultaneously. Cell Counting Kit-8 (CCK8) assay, colony formation assay, Transwell invasion and migration assays were used to detect the effects of FBXO43 knockdown on the proliferation, invasion, and migration abilities of gastric cancer cells. Co-immunoprecipitation (Co-IP) was used to detect the interaction between FBXO43 and p53, as well as the total ubiquitination level of p53 after FBXO43 knockdown.Results TCGA and GTEx data showed that the expression level of FBXO43 was significantly upregulated in gastric cancer (both P<0.05). Kaplan-Meier Plotter data showed that high expression of FBXO43 was significantly associated with shortened overall survival (HR=1.39, 95% CI=1.09-1.78, P=0.007 6), progression-free survival (HR=1.35, 95% CI=1.04-1.76, P=0.023), and post-progression survival (HR=1.6, 95% CI=1.18-2.17, P=0.002 1) of gastric cancer patients. Western blot, qPCR, and immunohistochemistry results showed that FBXO43 was upregulated in gastric cancer cells and tissues, and the protein level of FBXO43 was significantly associated with tumor size, distant metastasis, and TNM stage of gastric cancer patients (all P<0.05). CCK8 assay, colony formation assay, Transwell invasion, and migration assays showed that knockdown of FBXO43 expression significantly inhibited the proliferation, invasion, and migration abilities of gastric cancer cells (all P<0.05). Knockdown of FBXO43 expression upregulated the protein level of p53. Co-IP results showed that FBXO43 and p53 could co-immunoprecipitate with each other, and knockdown of FBXO43 significantly increased the total ubiquitination level of p53. Functional experiments showed that simultaneous knockdown of p53 antagonized the inhibitory effects of FBXO43 knockdown on the proliferation, invasion, and migration abilities of gastric cancer cells, restoring the malignant phenotype of gastric cancer cells in vitro (all P<0.05).Conclusion FBXO43 is highly expressed in gastric cancer and is closely associated with poor prognosis in gastric cancer patients. The mechanism of action of FBXO43 may involve interaction with p53, promoting p53 ubiquitination and degradation, thereby promoting the malignant progression of gastric cancer. FBXO43 is expected to become a therapeutic target for gastric cancer.

12 Feasibility and preliminary efficacy analysis of modified double tract reconstruction for digestive tract reconstruction after proximal gastrectomy

BI Zhibin , LI Yingying , HAN Ming , WU Jian , LI Wenbin , LIAN Changhong

2024, 33(4):624-633. DOI: 10.7659/j.issn.1005-6947.2024.04.012

[Abstract](256) [HTML](153) [PDF 1.00 M](597)

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Background and Aims Gastric cancer is a common malignant tumor of the digestive tract in China, and surgery remains a crucial method for its treatment. Proximal gastrectomy (PG) is an option for early upper gastric cancer, including adenocarcinoma of the esophagogastric junction. Numerous studies have confirmed the oncological safety and functional benefits of PG in the treatment of early upper gastric cancer, and its overall survival rate is equivalent to that of total gastrectomy with improvements in maintaining physiological function and quality of life. However, due to the problems such as reliable prevention of reflux, anastomotic stenosis, and technical difficulties, there is still no widely used ideal anastomotic method after PG. Therefore, optimizing digestive tract reconstruction after PG is necessary. Here, the authors report the feasibility and preliminary efficacy analysis of modified double-tract reconstruction (DTR) applied in the reconstruction of the digestive tract after PG to evaluate the clinical application value of this new anastomotic approach.Methods The clinicopathologic data of 46 patients with adenocarcinoma of the esophagogastric junction or upper gastric tumors who underwent laparoscopic PG in two hospitals from June 2019 to December 2022 were retrospectively collected (35 cases in Heji Hospital affiliated to Changzhi Medical College and 11 cases in Heping Hospital affiliated to Changzhi Medical College). Among them, 21 cases underwent modified DTR (observation group), and 25 cases underwent traditional jejunal interposition DTR (control group). Surgical safety and efficacy were compared between the two groups.Results There were no statistically significant differences in baseline data between the two groups (all P>0.05). There were no statistically significant differences between the two groups in terms of total operative time, intraoperative blood loss, number of lymph nodes dissected, time to abdominal drainage tube removal, length of postoperative hospital stays, and total hospitalization costs (all P>0.05). In the observation group compared with the control group, the time to first postoperative anal gas passage (58 h vs. 72 h, P=0.035) and postoperative diet resumption (6 d vs. 8 d, P<0.001) were shorter, but the time for digestive tract reconstruction was longer (65.29 min vs. 58.95 min, P=0.005). There were no significant differences between the two groups in postoperative pulmonary infection, pleural effusion, wound infection, intestinal obstruction, or Clavien-Dindo classification of postoperative complications (all P>0.05). There were no occurrences of anastomotic leakage or stenosis in either group. The incidence of reflux esophagitis in the observation group was 4.8% (1/21), compared to 8.0% (2/25) in the control group, with no statistically significant difference (χ²=0.196, P=0.658), and all cases were graded as grade A according to the Los Angeles classification. At 6 months after operation, the albumin level in the control group was lower than that in the observation group (37.1 g/L vs. 42.7 g/L, P=0.001), while there were no significant differences in other nutritional indicators (body mass index, hemoglobin, total protein) between the two groups (all P>0.05). Gastrointestinal imaging at 6 months after operation showed decreased peristalsis in 4 cases (19%) of the observation group and 9 cases (36%) of the control group, with no statistically significant difference (χ²=1.358, P=0.327).Conclusion Modified DTR after PG is safe and feasible. Compared with jejunal interposition DTR, the former has a longer digestive tract reconstruction time but faster postoperative recovery of gastrointestinal function, better short-term nutritional status, and does not increase the risk of postoperative complications.

13 Misdiagnosis of hepatic cavernous hemangioma combined with nodular regenerative hyperplasia as hepatocellular carcinoma and cirrhosis: a case report and literature review

MEI Hongzhang , CAI Lijun , LI Yueying , YANG Chunxiu , XIAO Shuyuan

2024, 33(4):634-641. DOI: 10.7659/j.issn.1005-6947.2024.04.013

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Background and Aims Hepatic cavernous hemangioma is the most common type of benign liver tumor. Despite the maturity of diagnostic procedures for this disease through imaging examinations, there is still a risk of misdiagnosis as hepatocellular carcinoma in cases of rare disease combinations. This article aims to provide experience and lessons for future clinical work by reviewing a case of liver transplantation diagnosed postoperatively as cavernous hemangioma combined with nodular regenerative hyperplasia, analyzing the key difficulties in the diagnosis and treatment process, reviewing the clinicopathologic characteristics of cavernous hemangioma and nodular regenerative hyperplasia, as well as their differential points from hepatocellular carcinoma and liver cirrhosis.Methods The clinical history, imaging features, and histopathological diagnosis of one liver transplant patient admitted to Zhongnan Hospital of Wuhan University hospital were retrospectively analyzed, and the diagnosis and treatment process of this case were summarized in combination with the characteristics of hepatic cavernous hemangioma and nodular regenerative hyperplasia in domestic and foreign literature.Results The patient was a 71-year-old male admitted for ascites and a space-occupying lesion in the right lobe of the liver. Imaging examinations suggested liver cirrhosis, ascites, and a space-occupying lesion in the right lobe of the liver. Abdominal CT scan and enhancement diagnosed liver cirrhosis combined with hepatocellular carcinoma. After comprehensive consultation and sufficient communication with the patient, liver transplantation was performed. Intraoperative examination and postoperative gross examination revealed diffuse nodular changes in the liver with a space-occupying lesion in the right lobe of the liver. Histologically, the former was nodular regenerative hyperplasia, while the space-occupying lesion was cavernous hemangioma.Conclusion Generally, hepatic cavernous hemangioma does not present difficulties in imaging diagnosis. However, cavernous hemangioma can still be misdiagnosed as hepatocellular carcinoma in a diffuse nodular background. Nodular regenerative hyperplasia is a rare and heterogeneous benign liver lesion with clinical features very similar to liver cirrhosis, and differentiation from the latter depends on pathological diagnosis. Even though authoritative guidelines propose that hepatocellular carcinoma can be diagnosed with imaging alone in the background of liver cirrhosis, in particular scenarios, a pre-transplantation biopsy is still required to confirm the diagnosis.

14 Research progress of fatty acid metabolism-related enzymes in gastric cancer

JIN Huimin , ZHOU Yunlan , WANG Yizhou , CHEN Yujie , LI Dongdong , CHEN Lei

2024, 33(4):642-648. DOI: 10.7659/j.issn.1005-6947.2024.04.014

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Abnormal lipid metabolism plays an important role in the initiation and progression of tumors, as well as in their resistance to drug therapy and metastasis. Fatty acid metabolism is the main component of lipid metabolism, and some key enzymes in this metabolic process have become the focus of research. Here, the authors address four fatty acid metabolism-related enzymes (fatty acid synthetase, sterol regulatory element-binding protein 1, carnitine palmitoyltransferase 1, and CD36) in terms of their roles in the occurrence and development of gastric cancer as well as their potential significance in the diagnosis, treatment and prognosis evaluation of gastric cancer

15 Application and research progress of endoscopic techniques in the diagnosis and treatment of gastroesophageal reflux disease

WANG Yongkang , MAIMAITI·Yisireyili , KELIMU·Abudureyimu

2024, 33(4):649-655. DOI: 10.7659/j.issn.1005-6947.2024.04.015

[Abstract](221) [HTML](177) [PDF 667.35 K](638)

Abstract:
Gastroesophageal reflux disease (GERD) is one of the common digestive disorders affecting millions of people worldwide. In recent years, there have been rapid advancements in GERD endoscopic treatment techniques, such as transoral endoscopic cardiac constriction, endoscopic anti-reflux mucosal resection, and endoscopic radiofrequency ablation, which have been continuously applied and improved. Here, the authors introduce specific endoscopic devices and procedures developed for GERD treatment and summarize the relevant advancements in the endoscopic treatment of GERD.

16 China Journal of General Surgery, 2024, 33(4):656-662.

赵志红，刘蕊，王青霞，JAMIL Mehwish，李乾

2024, 33(4):656-662. DOI: 10.7659/j.issn.1005-6947.2024.04.016

[Abstract](238) [HTML](278) [PDF 1.10 M](746)

Abstract:
背景与目的 以内镜下黏膜切除术（EMR）和内镜下黏膜下层剥离术（ESD）为主的内镜下切除手术已成为目前治疗早期结直肠癌的主要方式。然而，在临床实践中，大多数早期结直肠癌患者，无论内镜治疗后标本病理提示是否为治愈性切除，后续仍追加了外科手术。本研究通过比较早期结直肠癌患者行内镜下治愈性或非治愈性切除治疗后的肿瘤残留情况，分析内镜治疗后追加外科手术的必要性，以期为医生临床决策提供参考。方法回顾性收集2016年5月—2023年7月中南大学湘雅医院收治的行内镜下治疗手术后追加外科根治性切除术的早期结直肠癌患者病例资料。根据内镜切除后标本送检的病理结果将患者分为治愈性切除组（无肿瘤残留且无脉管神经侵犯）和非治愈性切除组［有肿瘤残留和（或）有脉管神经侵犯］，分析两组患者的临床基本资料、病理特征和肿瘤残留情况的差异。结果在接受内镜下切除治疗后追加外科手术的82例早期结直肠癌患者中，治愈性切除组53例，非治愈性切除组29例。两组患者在性别、年龄、症状、息肉部位、息肉形状、息肉大小、病理类型、浸润深度、追加外科手术间隔时间等基线数据方面均无统计学差异（均P>0.05）。外科手术标本病理结果显示，4例患者有肿瘤残留，其中治愈性切除组2例（3.77%，2/53）、非治愈性切除组2例（6.90%，2/29）。内镜下治愈性或非治愈性切除与有无肿瘤残留差异无统计学意义（χ²=0.008，P=0.927）。结论 EMR、ESD可为早期结直肠癌患者带来良好的切除效果。无论内镜下是否为治愈性切除，均需综合患者自身特点、内镜标本病理资料以及内镜医生的处理方式，个体化分析追加外科手术的必要性。其次，无论是否追加外科手术，均需建议患者保持定期规律的内镜随访。

17 China Journal of General Surgery, 2024, 33(4):663-668.

庄培涛，袁明友，王萌萌，类成刚

2024, 33(4):663-668. DOI: 10.7659/j.issn.1005-6947.2024.04.017

[Abstract](147) [HTML](178) [PDF 693.17 K](593)

Abstract:
背景与目的 阑尾切除术后切口感染与腹腔残余感染发生率较高，合理选用抗菌药物，提高抗感染效率非常必要。因此，本研究分析急性阑尾炎患者脓液标本病原菌分布特点及耐药率变迁情况，为临床合理选用抗菌药物提供依据。方法回顾分析2012年1月—2022年1月在青岛市第八人民医院普通外科行阑尾切除手术的753例急性阑尾炎患者的临床资料。在行阑尾切除术中将抽取的脓液或阑尾腔咽拭子置入无菌培养管，并送至检验科细菌培养室，对脓液进行细菌培养、鉴定和药物敏感性试验。按照患者就诊时间分为两组，近期组（427例）的收治时间为2017年1月─2022年1月，早期组（326例）的收治时间为2012年1月─2017年1月，对比两组患者的病原菌分布及常见细菌的耐药率变化趋势。采用WHO细菌监测网提供的WHONET软件对药物敏感性试验结果进行分析。结果全组753例患者，共培养出病原菌879株，其中革兰阳性菌66株（7.5%），革兰阴性菌813株（92.5%）。革兰阳性菌中前2位为屎肠球菌（18.2%，12/66）、鸟肠球菌（18.2%，12/66）；革兰阴性菌中前3位为大肠埃希菌（71.7%，583/813）、肺炎克雷伯菌肺炎亚种（8.9%，72/813）、铜绿假单胞菌（6.3%，51/813）。2012─2022年急性阑尾炎患者脓液中革兰阳性菌（近期组 vs. 早期组：9.3% vs. 5.0%）与革兰阴性菌（近期组vs.早期组：90.7% vs. 95.0%）的比例无明显变化。革兰阳性菌以肠球菌属（59.1%，39/66）为主，革兰阴性菌以大肠埃希菌（71.7%，583/813）为主。两组各种主要菌株比例变化不明显。在两组耐药率变迁分析中，革兰阳性菌对红霉素的耐药率有下降趋势，革兰阴性菌对头孢吡肟、头孢替坦、头孢他啶、头孢曲松、庆大霉素、妥布霉素、复方磺胺甲恶唑、氨曲南、头孢呋辛、替卡西林/克拉维酸等抗菌药物的耐药率下降明显，另外大肠埃希菌对氨苄西林的耐药性有所下降。结论急性阑尾炎患者脓液以革兰阴性菌为主，尤以大肠埃希菌比例最大，近10年各种主要细菌构成比无明显变化，革兰阴性细菌对抗生素耐药性有下降趋势，但仍不能放松根据药物敏感性试验结果进行个体化用药，以防止细菌耐药性增高。

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Volume 33,Issue 4,2024 Table of Contents

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