Objective:To analyze the clinical efficacy of laparoscopic common bile duct exploration and stone removal via the cystic duct with a flexible ureteroscope.Methods:The clinical data of 96 patients with cholecystolithiasis and choledocholithiasis who were admitted to the Department of Hepatobiliary Surgery, the Third Hospital of Nanchang from September 2021 to November 2024 were retrospectively analyzed. There were 49 male and 47 female patients, aged (59.2±13.9) years. The 96 patients were randomly divided into two groups according to the surgical methods: the flexible ureteroscope group ( n=48) and the choledochotomy group ( n=48), patients who underwent laparoscopic cholecystectomy plus flexible ureteroscope for common bile duct exploration and stone removal via the cystic duct were included in the flexible ureteroscope group; patients who underwent laparoscopic cholecystectomy plus choledocholithotomy and T-tube drainage placement were included in the choledochotomy group. Clinical data including operation time, intraoperative blood loss, postoperative intestinal function recovery time, abdominal drainage tube removal time, postoperative hospital stay and postoperative complications were compared between the two groups. Results:Compared with the choledochotomy group, the operation time [150 (120, 176) min vs. 197 (165, 240) min], intraoperative blood loss [20 (10, 30) ml vs. 30 (20, 50) ml], postoperative intestinal function recovery time [2 (1, 2) d vs. 3 (2, 4) d], abdominal drainage tube removal time [6 (4, 7) d vs. 7 (6, 8) d], and postoperative hospital stay [8 (6, 9) d vs. 16 (13, 17) d] in the flexible ureteroscope group were all reduced, and the differences were statistically significant (all P<0.05). The incidence of postoperative complications in the choledochotomy group was 10.4% (5/48), compared with 2.1% (1/48) in the flexible ureteroscope group. There was no statistically significant difference ( χ2=1.60, P=0.206). Conclusion:Compared with laparoscopic choledocholithotomy plus T-tube drainage, laparoscopic common bile duct exploration and stone removal via the cystic duct with a flexible ureteroscope can shorten the hospital stay of patients with choledocholithiasis, offering a minimally invasive, safe and effective treatment method.

Objective:To analyze the clinical efficacy and learning curve of robotic-assisted Warshaw procedure using the da Vinci system.Methods:Clinical data of 91 consecutive patients with pancreatic body and tail lesions undergoing robotic-assisted Warshaw procedure at Qingdao University Affiliated Hospital from October 2021 to April 2023 were retrospectively analyzed, including 21 males and 70 females, aged (50.2±14.3) years. Patient characteristics, operative time, and intraoperative blood loss were recorded. The learning curve was constructed using cumulative sum (CUSUM) analysis, with case number on the x-axis and CUSUM values on the y-axis. Linear fitting was performed, and the model with the highest determination coefficient was selected as the optimal fitting model. The learning process was divided into two phases based on the inflection point of the CUSUM learning curve: the learning phase and the proficiency phase. Perioperative outcomes were compared between these two phases.Results:All 91 procedures were successfully completed using the da Vinci robotic system with R0 resection margins. There were no perioperative mortalities or reoperations due to postoperative splenic infarction. The operative time was (227.84±76.68) min. The optimal fitting equation for the CUSUM learning curve was: CUSUM=0.005 640X 3-1.501X 2+ 92.59X-183.1. The CUSUM learning curve showed an inflection point at case 39, dividing the learning process into the learning phase (cases 1-39) and proficiency phase (cases 40-91). Compared to the learning phase, the proficiency phase demonstrated significantly shorter operative time [(203.0±75.6) min vs. (260.9±65.5) min], less intraoperative blood loss [50.0 (20.0, 50.0) ml vs. 100.0 (50.0, 100.0) ml], and reduced postoperative drainage duration [(8.7±2.4) d vs. (10.8±3.2) d] (all P<0.05). Conclusion:The robotic-assisted Warshaw procedure feasible for patients with pancreatic body and tail lesions. Surgeons require approximately 39 cases to complete the learning curve and achieve proficiency in this procedure.

Objective:To analyze the efficacy and safety of splenic artery occlusion combined with microwave ablation (MWA) in the treatment of hepatocellular carcinoma (HCC) complicated with liver cirrhosis and hypersplenism.Methods:Clinical data of 24 patients with HCC complicated with cirrhosis and secondary hypersplenism admitted to Airport Hospital of Tianjin Cancer Hospital from August 2023 to May 2024 were retrospectively analyzed, including 13 males and 11 females, aged (57.4±7.8) years. All patients were treated with splenic artery occlusion combined with MWA of spleen. Spleen volume measured by MRI before and after MWA, blood routine changes and postoperative complications (fever, bleeding, pain, renal failure and thrombosis) were analyzed.Results:The splenic volume of 24 patients measured by MRI before MWA was 692.4 (504.7, 1023.7) cm 3, and decreased to 225.0 (186.4, 285.6) cm 3 after treatment for 60 days ( Z=-3.23, P=0.001). The red blood cell counts were comparable before and after microwave ablation. The white blood cell count before MWA was 4.3 (3.2, 5.3)×10 9/L, which increased to 11.0 (8.6, 15.8)×10 9/L three days after treatment, and to 5.0 (3.3, 6.1)×10 9/L 90 days after treatment ( Z=-4.70, -0.34, P<0.001, P=0.732). The platelet count of the patients was 47.0 (39.0, 67.0)×10 9/L before MWA, which increased to 155.0 (120.3, 214.3)×10 9/L seven days after Treatment, and to 77.0 (63.0, 125.0)×10 9/L 90 days after treatment ( Z=-5.29, -2.51, P<0.001, P=0.012). None of the patients had obvious bleeding and no death occured. One patient (4.2%) developed renal failure, one patient (4.2%) had splenic venous thrombosis, 4 patients (16.7%) had pain of different degrees, and 5 patients (20.8%) had low fever. Conclusion:Splenic artery occlusion combined with MWA in the treatment of HCC complicated with liver cirrhosis and hypersplenism can significantly reduce spleen volume and increase platelet level with acceptable complications.

Objective:To analyze the APR triangle formed when the right hepatic vein (RHV) passed through the right anterior hepatic pedicle (RAHP) and the right posterior hepatic pedicle (RPHP) by 3D visualization technique.Methods:Clinical data of 100 subjects undergoing liver contrast-enhanced CT scan in the Second Affiliated Hospital of Harbin Medical University from September 2019 to September 2022 were retrospectively analyzed, including 57 males and 43 females, aged (53.2±13.0) years. The CT data were imported into a system for 3D image reconstruction of the liver. The intrahepatic vascular structure was observed, including the portal vein, APR triangle, the angle between the RAHP and RPHP, the distance between RHV and the vertex of angle when it crosses the angle plane of the RAHP and RPHP, the structure and branches of the right posterior branch of portal vein, and the number of branches into the APR triangle from the main trunk of the right anterior and right posterior portal vein.Results:The main type of portal vein was type A (the main portal vein was divided into left and right branches, and the right branch was further divided into right anterior branch and right posterior branch), in 86 cases (86.0%). The APR triangle was observed in 81 cases (81.0%), and the distance between the right hepatic vein and the vertex of the right anterior and right posterior hepatic pedicle was (1.70±0.36) cm, 1.00-2.00 cm was 82.7%(61/81). The angle between right anterior and right posterior hepatic pedicle was 45°-90° in 77 cases (77.0%, 77/100). In 100 subjects, the main branch of the right posterior portal vein accounted for 42.0% (42/100) of typeⅠ (bifurcation type) and 53.0% (arch type) of type Ⅱ (53/100). In 16 cases (19.8%, 16/81), the main right anterior portal vein branched into the APR triangle, with a total of 22 branches. In 9 cases (11.1%, 9/81), the main branch of the right posterior portal vein (branching type) branched into the triangle, with a total of 11 branches. There were 33 cases (40.7%, 33/81) of right posterior portal vein (arch type) main branch branching into the triangle, a total of 41 branches.Conclusion:The APR triangle, composed of the RAHP, RPHP and RHV, has an objective anatomical basis and is affected by the variants of portal vein and RHV. It is more common for the RHV to be within 1.00-2.00 cm of the vertex of the angle between the RAHP and RPHP, and the main trunk of the right anterior and right posterior branches of portal vein are less divided into the triangle, so it is relatively safe to dissect within this area.

Objective:To evaluate the feasibility of " two-stitch" fashion in laparoscopic pancreaticojejunostomy (PJ) for patients with fine pancreatic duct (<3 mm).Methods:Clinical data of 32 patients with pancreatic duct diameter <3 mm undergoing laparoscopic PJ using the " two-stitch" fashion between Apr 2021 and Jun 2024 were retrospectively analyzed, including 20 males and 12 females, aged (61.2±23.7) years. Among the patients, there were 23 (71.9%) patients of periampullary tumor and 9 (28.1%) of central pancreatic tumor. 23 (71.9%) patients underwent laparoscopic pancreatoduodenectomy (LPD) and nine (28.1%) underwent laparoscopic central pancreatectomy (LCP). All patients underwent the " two-stitch" fashion of laparoscopic PJ (one stitch each on the ventral and dorsal sides of pancreas for duct-to-mucosal anastomosis). The operation time, PJ time, postoperative hospital stay, postoperative complications (pancreatic fistula, gallbladder leakage, abdominal cavity infection, etc) and mortality were recorded.Result:All patients underwent the " two stitch" laparoscopic PJ successfully, 23(71.9%) patients underwent laparoscopic pancreatoduodenectomy (LPD) and nine (28.1%) underwent laparoscopic central pancreatectomy (LCP). The operation time was (279.3±115.8) min, the PJ time was (31.9±12.2) min, and the postoperative hospital stay was (13.4±8.3) d. Grade B pancreatic fistula occurred in six cases (18.8%, four of LPD and two of LCP), delayed gastric emptying in one case of LPD (3.1%), abdominal infection in three cases (9.4%, two of LPD and one of LCP), biliary fistula in two cases (6.3%, LPD). There were no grade C pancreatic fistula. All patients with postoperative complications were managed with conservative treatment.Conclusion:Laparoscopic " two stitch" PJ for patients with fine pancreatic duct (<3 mm) is safe and feasible.

Objective:To construct the gemcitabine resistant cell lines of human pancreatic cancer cell line (PANC1) and mouse pancreatic cancer cell line (PANC02), and to investigate their biological behavior changes.Methods:Gemcitabine-resistant cell lines PANC1-GR of human pancreatic cancer and PANC02-GR of mouse pancreatic cancer were induced by concentration gradient increment method. Cell count assay (CCK-8), flow cytometry, cell scratch assay and Transwell assay were used to detect the drug resistance, proliferation, cell cycle, migration and invasion of the four groups of cell lines. The drug-resistant cells were also compared with the parent cells.Results:The resistance indices of PANC1-GR and PANC02-GR were 153.3 and 185.4, respectively. The results of CCK-8 showed that with the increase of gemcitabine concentration, the proliferation of resistant cells changed significantly compared with parental cells, the population doubling time of PANC1-GR was significantly shorter than that of PANC1 (1.5±0.1) d vs (2.4±0.2) d ( t=8.00, P<0.001). The proportion of cells in S and G2/M phase increased, and the proportion of cells in G0/G1 phase decreased. The cell scratch and Transwell experiments indicated that the 24h mobility of PANC1-GR and PANC02-GR was higher than that of parent cells (47.6±2.4)% vs (28.7±6.3)% and (53.6±3.2)% vs (30.1±1.4)%, the number of individual field (200 times magnification) penetrating membrane cells was also higher than that of parent cells (269.7±30.9) vs (62.7±10.1) and (172.0±30.8) vs (36.3±4.9), with statistical significance (all P<0.05). Conclusion:Concentration gradient increment method can successfully establish gemcitabine-resistant pancreatic cancer cell lines, which have stronger proliferation, migration and invasiveness, and can be used to study the mechanism of drug resistance in pancreatic cancer.

Objective:To analyze the expression of heat shock protein 90α (HSP90α) in pancreatic cancer tissues and its potential diagnostic value for pancreatic cancer.Methods:A retrospective study was conducted on surgical specimens and clinical data from 99 patients with pancreatic cancer who were treated at Qingdao Municipal Hospital from January 2018 to May 2023, including 58 males and 41 females, with the age of (63.5±23.5) years. Among them, 44 patients (44.4%) were used for pathological examination and prognostic analysis, while 55 patients (55.6%) were tested for plasma HSP90α levels to evaluate its diagnostic efficacy for pancreatic cancer. Blood samples from 119 healthy individuals undergoing routine physical examinations at the same hospital during the same period were collected, including 74 males and 45 females, with the age of (50.5±25.5) years, and plasma HSP90α levels were measured. Immunohistochemistry (IHC) was performed to detect the expression of HSP90α in cancerous and adjacent non-cancerous tissues. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic performance of HSP90α, carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and carbohydrate antigen 125 (CA125) for pancreatic cancer. Survival analysis was conducted using the Kaplan-Meier method, and the log-rank test was used to compare survival rates. The correlation between HSP90α positive expression in cancer tissues and mutant p53 positive expression was analyzed using Spearman correlation analysis.Results:Immunohistochemical analysis showed that the positive expression rate of HSP90α in pancreatic cancer tissues was 81.8%(36/44), higher than that in adjacent non-cancerous tissues 13.6%(6/44)( χ2=19.82, P<0.01). HSP90α positive expression in pancreatic cancer tissues was positively correlated with mutant p53 positive expression (correlation coefficient was 0.57, P<0.001). The median plasma HSP90α level in the pancreatic cancer group ( n=55) was 83.30 (48.30, 212.00) μg/L, which was significantly higher than that in the normal control group ( n=119), with a median of 37.00 (29.20, 43.50) μg/L, showing a statistically significant difference ( Z=-7.34, P<0.001). The area under the ROC curve (AUC) for plasma HSP90α in diagnosing pancreatic cancer was 0.85 (95% CI: 0.77-0.92), with an optimal cutoff value of 53.52 μg/L, yielding a sensitivity of 69.1% (38/55) and a specificity of 98.3% (117/119). The AUC for HSP90α in diagnosing pancreatic cancer was higher than that of CEA, CA19-9, and CA125. In the immunohistochemical analysis of cancer tissues, the one-year cumulative survival rate of the HSP90α-negative group ( n=8) was 87.5%, which was significantly higher than that of the HSP90α-positive group ( n=36), which was 18.8%( χ2=12.74, P<0.001). Conclusions:HSP90α is highly expressed in pancreatic cancer tissues, which is positively correlated with mutant p53 positive expression. Patients with positive HSP90α expression have a poorer prognosis. HSP90α demonstrates good diagnostic performance for pancreatic cancer and holds potential for clinical application.

Objective:To evaluate the safety and feasibility of double-port laparoscopic cholecystectomy (LC) combined with transcystic common bile duct (CBD) exploration using ultrafine choledochoscopy on patients with gallbladder stones and common bile duct stones.Methods:Clinical data of 35 patients undergoing double-port LC combined with transcystic CBD exploration using ultrafine choledochoscopy in Anhui No.2 Provincial People’s Hospital from December 2021 to June 2024 were retrospectively analyzed, including 8 males and 27 females, aged (45.8±18.1) years. In all patients, the diameter of the gallbladder duct was greater than 3 mm, the maximum diameter of the stones was less than 10 mm, and the number of stones was less than 5, and the gallbladder ducts were normal. Magnetic resonance cholangiopancreatography (MRCP) was used to measure the diameter of CBD, the number and the maximum diameter of stones. The operative time, intraoperative blood loss, postoperative anal exhaust time, postoperative hospital stay and complications (including abdominal infection, biliary tract infection, bile leakage, bleeding, etc.) of all patients were analyzed. The incidence of bile duct stenosis, residual stone or stone recurrence were followed up by telephone or outpatient review.Results:MRCP measurement indicated that the common bile duct diameter of patients was (8.1±1.3) mm. Single CBD stone occurred in 27 cases (77.1%, 27/35), and the mean maximum diameter of CBD stones was (3.9±1.3) mm. All patients successfully underwent the procedure. The operative time was (80.1±10.9) min, the intraoperative blood loss was (25.5±10.2) ml, the recovery time of postoperative anal exhaust was (17.3±4.7) h, and the postoperative hospital stay was (2.5±0.6) d. There were no complications such as abdominal and biliary tract infection, bile leakage and bleeding. All patients were followed up for 1-30 months, with a median follow-up time of 12 months. No biliary stricture, residual stones or recurrence occured during the follow-ups.Conclusion:In selected cases, double-port LC combined with transcystic CBD exploration using ultrafine choledochoscopy could be safe and feasible, with less trauma, quick recovery and short operative time.

Objective:To establish and validate a nomogram for postoperative disease progression (including recurrence, metastasis, and death) in patients with primary liver cancer (PLC) based on quantitative CT measurements of relevant indicators.Methods:Clinical data of 290 patients with PLC admitted to Zhongshan Hospital Affiliated to Fudan University and Kunshan Hospital Affiliated to Jiangsu University from January 2016 to December 2021 were retrospectively collected, including 177 males and 113 females, aged (60.3±11.9) years. Two hundred and three patients admitted to Zhongshan Hospital Affiliated to Fudan University were used as the training set, and 87 patients admitted to Kunshan Hospital Affiliated to Jiangsu University were used as the validation set. The patient's condition of ascites , tumor length, number of lesions, tumor differentiation degree, relevant indicators of quantitative CT detection (including decreased muscle mass and increased intra-abdominal fat area), prognosis and other clinical data were recorded. The influencing factors of postoperative disease progression was analyzed through multiple logistic regression in the training set, and the nomogram model was constructed based on the results of multiple factor analysis. The predictive performance of the model was evaluated using receiver operating characteristic (ROC) curves and calibration curves. The clinical applicability of predictive models was evaluated using the decision curve analysis.Results:The results of multiple logistic regression analysis showed that the increase in maximum tumor diameter ( OR=1.519, 95% CI: 1.251-1.843), multiple lesions ( OR=3.193, 95% CI: 1.493-6.830), low tumor differentiation ( OR=5.604, 95% CI: 2.442-12.863), ascites ( OR=3.321, 95% CI: 1.166-9.463), portal vein tumor thrombus ( OR=3.990, 95% CI: 1.681-9.474), decreased muscle mass ( OR=2.173, 95% CI: 1.051-4.492) and increased intra-abdominal fat area ( OR=2.634, 95% CI: 1.276-5.438) were independent risk factors for postoperative disease progression in patients with PLC (all P<0.05). A nomogram was constructed based on the above variables, and the area under the ROC curve for predicting postoperative disease progression in patients with PLC in the training set and validation set was 0.862 (95% CI: 0.810-0.914) and 0.879 (95% CI: 0.806-0.953), respectively. The calibration curve and ideal curve fit well, indicating that the predicted situation was basically consistent with the actual situation. Decision curve analysis showed that the column chart model had a high clinical net benefit and good clinical prediction effectiveness. Conclusion:The nomogram constructed based on the maximum diameter of the tumor, the number of lesions, the degree of tumor differentiation, ascites, portal vein tumor thrombus, decreased muscle mass, and increased intra-abdominal fat area has good predictive power for postoperative disease progression in patients with PLC.

Objective:To analyze the effect of rapid division of left Glisson pedicle and Arantius tube plane in laparoscopic anatomical left hemihepatectomy (LALH).Methods:Clinical data of 25 patients (15 with intrahepatic bile duct calculus and 10 with liver tumor) undergoing LALH in the Department of Hepatobiliary and Pancreatic Surgery, Jiangyin Hospital Affiliated to Nantong University from June 2020 to November 2024 were retrospectively analyzed, including 14 males and 11 females, aged (66.6±11.9) years. Among the patients, 15 received LALH with rapid division of left Glisson pedicle and Arantius tube plane in " one-clamp" fashion, and the others received LALH after traditional dissection of left Glisson pedicle. Age, sex, body mass index, time of left Glisson pedicle dissection, whether the MHV exposure, the time of liver transection, whether MHV and its important branches or bile duct injury occurred, intraoperative blood loss, the incidence of postoperative biliary leakage, the time of abdominal drainage remove, the hospital stay, and alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, albumin 3 days after postoperative were compared between the groups.Results:The times of left Glisson pedicle dissection in the new-fasion and traditional group were (6.1±1.6) min and (13.8±3.0) min, and the time of liver transection was (24.9±3.5) min and (33.4±3.3) min, respectively ( t=-8.34, 6.08, P<0.001 for both). After division of left Glisson pedicle, the MHV was well exposed in 14 cases of new-fashion group and none of traditional group ( P<0.001). All the patients successfully completed the operation without conversion to laparotomy. Intraoperative blood loss, incidence of postoperative bile leakage, time of peritoneal drainage tube removal, postoperative hospital stay, AST, ALT, total bilirubin and albumin 3 days after surgery between the two groups were no significant differences (all P>0.05). Conclusion:LALH using the rapid division of left Glisson pedicle and Arantius tube plane in " one-clamp" fashion could be safe and feasible, the time of left Glisson pedicle and liver transection was short.