Objective To explore the technical process and clinical application of laparoscopic combined upper midline incision minimally invasive liver transplantation. Methods A retrospective analysis was conducted on 30 cases of laparoscopic combined upper midline incision minimally invasive liver transplantation. The cases were divided into cirrhosis group (15 cases) and liver failure group (15 cases) based on the primary disease. The surgical and postoperative conditions of the two groups were compared. Results All patients successfully underwent laparoscopic "clockwise" liver resection, with no cases of passive conversion to open surgery or intolerance to pneumoperitoneum. In 6 cases, the right lobe was relatively large, and the right hepatic ligaments could not be completely mobilized. One case required an additional reverse "L" incision during open surgery. All patients successfully completed the liver transplantation, with no major intraoperative bleeding, cardiovascular events, or other occurrences in the 30 patients. The model for end-stage liver disease (MELD) score in the cirrhosis group was lower than that in the liver failure group (P<0.001). There were no statistically significant differences between the two groups in terms of age, surgical time, blood loss, anhepatic phase, or cold ischemia time (all P>0.05). During the perioperative period, there was 1 case of hepatic artery embolism, 1 case of portal vein anastomotic stenosis, no complications of hepatic vein and inferior vena cava, and 3 cases of biliary anastomotic stenosis, all of which occurred in the liver failure group. Conclusions In strictly selected cases, the minimally invasive liver transplantation technique combining laparoscopic hepatectomy with upper midline incision for graft implantation has the advantages of smaller incisions, less bleeding, relatively easier operation, and faster postoperative recovery, which is worthy of clinical promotion and application.

Objective:To investigate the safety and therapeutic effect of split liver transplantation (SLT) in clinical application.Methods:This is a retrospective case-series study. The clinical data of 203 consecutive SLT, 79 living donor liver transplantation (LDLT) and 1 298 whole liver transplantation (WLT) performed at the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to July 2023 were retrospectively analyzed. Two hundred and three SLT liver grafts were obtained from 109 donors. One hundred and twenty-seven grafts were generated by in vitro splitting and 76 grafts were generated by in vivo splitting. There were 90 adult recipients and 113 pediatric recipients. According to time, SLT patients were divided into two groups: the early SLT group (40 cases, from July 2014 to December 2017) and the mature SLT technology group (163 cases, from January 2018 to July 2023). The survival of each group was analyzed and the main factors affecting the survival rate of SLT were analyzed. The Kaplan-Meier method and Log-rank test were used for survival analysis.Results:The cumulative survival rates at 1-, 3-, and 5-year were 74.58%, 71.47%, and 71.47% in the early SLT group, and 88.03%, 87.23%, and 87.23% in the mature SLT group, respectively. Survival rates in the mature SLT group were significantly higher than those in the early SLT group ( χ2=5.560, P=0.018). The cumulative survival rates at 1-, 3- and 5-year were 93.41%, 93.41%, 89.95% in the LDLT group and 87.38%, 81.98%, 77.04% in the WLT group, respectively. There was no significant difference among the mature SLT group, the LDLT group and the WLT group ( χ2=4.016, P=0.134). Abdominal hemorrhage, infection, primary liver graft nonfunction,and portal vein thrombosis were the main causes of early postoperative death. Conclusion:SLT can achieve results comparable to those of WLT and LDLT in mature technology liver transplant centers, but it needs to go through a certain time learning curve.

Objective:To investigate the safety and therapeutic effect of split liver transplantation (SLT) in clinical application.Methods:This is a retrospective case-series study. The clinical data of 203 consecutive SLT, 79 living donor liver transplantation (LDLT) and 1 298 whole liver transplantation (WLT) performed at the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to July 2023 were retrospectively analyzed. Two hundred and three SLT liver grafts were obtained from 109 donors. One hundred and twenty-seven grafts were generated by in vitro splitting and 76 grafts were generated by in vivo splitting. There were 90 adult recipients and 113 pediatric recipients. According to time, SLT patients were divided into two groups: the early SLT group (40 cases, from July 2014 to December 2017) and the mature SLT technology group (163 cases, from January 2018 to July 2023). The survival of each group was analyzed and the main factors affecting the survival rate of SLT were analyzed. The Kaplan-Meier method and Log-rank test were used for survival analysis.Results:The cumulative survival rates at 1-, 3-, and 5-year were 74.58%, 71.47%, and 71.47% in the early SLT group, and 88.03%, 87.23%, and 87.23% in the mature SLT group, respectively. Survival rates in the mature SLT group were significantly higher than those in the early SLT group ( χ2=5.560, P=0.018). The cumulative survival rates at 1-, 3- and 5-year were 93.41%, 93.41%, 89.95% in the LDLT group and 87.38%, 81.98%, 77.04% in the WLT group, respectively. There was no significant difference among the mature SLT group, the LDLT group and the WLT group ( χ2=4.016, P=0.134). Abdominal hemorrhage, infection, primary liver graft nonfunction,and portal vein thrombosis were the main causes of early postoperative death. Conclusion:SLT can achieve results comparable to those of WLT and LDLT in mature technology liver transplant centers, but it needs to go through a certain time learning curve.

Objective:To investigate the anatomic classification and reconstruction of right intrahepatic bile duct in the donor liver of split liver transplantation (SLT).Methods:The retrospective and descriptive study was constructed. The clinical data of 85 patients who underwent SLT in the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to January 2022 were collected. There were 65 males and 20 females, aged 45(range, 1-82)years. Observation indicators: (1) surgical conditions; (2) anatomy of right intrahepatic bile duct; (3) bile duct reconstruction; (4) postoperative biliary complications; (5) follow-up. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range) or M( Q1, Q3).Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Results:(1) Surgical conditions. Of the 85 donor livers, 11 donor livers were split between the left and right hemilivers, and 74 donor livers were split between the classic right trilobe and left lateral lobe. The cold ischemia time of 85 donor livers was 291(273, 354)minutes, and the operation time, anhepatic phase time and volume of intraoperative blood transfusion of 85 recipients were (497±97)minutes, 51(40, 80)minutes and 8(7, 12)U. (2) Anatomy of right intrahepatic bile duct. Of the 85 donor livers, there were 47 donor livers with classic bile duct anatomical model (type 1), of the ratio as 55.3%(47/85), and 38 donor livers with anatomical variants, of the ratio as 44.7%(38/85). Of the 38 donor livers with anatomical variants, 7 donor livers were type 2, 16 donor livers were type 3a, 2 donor livers were type 3b, 2 donor livers were type 3c, 1 donor liver was type 4, 3 donor livers were type 5a, 4 donor livers were type 5b, 3 donor livers were type 6. For bile duct splitting patterns of the 85 donor livers, 84 donor livers were split with the main trunk of common hepatic duct preserving in the right hemiliver or right trilobe, and 1 donor liver were treated with complete left and right hemiliver splitting to preserve the main trunk of the common hepatic duct in the left hemiliver and the right hemiliver in the right hepatic duct (type 1 bile duct anatomical model). There were 84 donor livers with only one bile duct opening, and 1 donor liver with two bile duct openings (type 3c bile duct anatomical model). (3) Bile duct reconstruction. Of the 85 recipients, there were 69 recipients with common bile duct end-to-end anastomosis to common bile duct of donor liver (38 donor livers with type 1 bile duct anatomical model, 5 donor livers with type 2 bile duct anatomical model, 14 donor livers with type 3a bile duct anatomical model, 2 donor livers with type 3b bile duct anatomical model, 1 donor liver with type 4 bile duct anatomical model, 3 donor livers with type 5a bile duct anatomical model, 4 donor livers with type 5b bile duct anatomical model, 2 donor livers with type 6 bile duct anatomical model), 11 recipients with jejunum anastomosis to common bile duct of donor liver (7 donor livers with type 1 bile duct anatomical model, 2 donor livers with type 2 bile duct anatomical model, 1 donor liver with type 3c bile duct anatomical model, 1 donor liver with type 6 bile duct anatomical model), 3 recipients with jejunum anastomosis to common hepatic duct of donor liver (1 donor liver with type 1 bile duct anatomical model, 2 donor livers with type 3a bile duct anatomical model), 1 recipient with jejunum anastomosis to right hepatic duct of donor liver (type 1 bile duct anatomical model), 1 recipient with common hepatic duct end-to-end anastomosis to right posterior branch of donor liver combined with jejunum of the recipient Roux-en-y anastomosis to common hepatic duct of donor liver (type 3c bile duct anatomical model). (4) Postoperative biliary complications. Of the 85 recipients, 6 cases had postoperative biliary complications, with an incidence of 7.1% (6/85). Of the 6 recipients with postoperative biliary complications, there were 5 recipients with donor liver with type 1 bile duct anatomical model, including 3 cases undergoing postoperative biliary stricture with biliary leakage and 2 cases undergoing postoperative biliary anastomotic stricture, 1 recipient with donor liver with type 3b bile duct anatomical model and undergoing postoperative biliary anastomotic stricture and bile leakage in the liver section. Cases with biliary complications were 5 in the 47 recipients with donor liver with classic bile duct anatomical model and 1 in the 38 recipients with donor liver with anato-mical variants, showing no significant difference between them ( P>0.05). (5) Follow-up. There were 83 recipients receiving followed up for 52(12,96)months. During the follow-up period, 2 recipients died due to non-biliary complication factors (1 donor liver with type 1 bile duct anatomical model and 1 donor liver with 3a bile duct anatomical model). Conclusion:The anatomical classification of right intrahepatic bile duct of donor liver in SLT is mainly classical bile duct anatomical model, and the bile duct reconstruction scheme is mainly common bile duct of donor liver end-to-end anasto-mosis to common bile duct of recipient.

[Objective]Childhood trauma(CT)is considered one of the major risk factors for developing major depres-sive disorder(MDD)in adulthood.However,the neural basis of MDD patients with CT(CT-MDD)remains poorly under-stood.Therefore,the objective of our study is to explore the resting-state global brain functional connectivity(FC)in CT-MDD.[Methods]A total of 34 CT-MDD and 34 healthy controls performed resting-state fMRI.Whole-brain voxel-level degree centrality(DC)analysis was performed,and the brain regions with significant differences between the two groups were selected as region of interest(ROI)for further estimating the global brain FC.Subsequently,correlation analysis was performed between DC values,FC values in abnormal brain areas and clinical characteristics.[Results]The CT-MDD group showed increased DC value of the right middle frontal gyrus(MFG)compared with the healthy controls.Seed-based FC revealed that the CT-MDD group showed increased connections between the left precuneus and the right MFG or the right medial prefrontal cortex,relative to healthy controls(threshold at P<0.05).Additionally,the DC value of the right MFG was correlated with the severity of CT.[Conclusion]Our results show the increased FC between the left precuneus and the ROI(right MFG)as well as the right medial prefrontal cortex,which are two important brain regions within the de-fault mode network(DMN),and might suggest increased synchronism between the cognitive executive networks and DMN in CT-MDD.These findings may provide insights into the pathophysiological mechanisms underlying CT-MDD.

Objective:To understand the use of post-exposure prophylaxis (PEP) and analyze related factors among men who have sex with men (MSM) in Qingdao, and provide a reference for the AIDS prevention and control in this population.Methods:A cross-sectional survey conducted from April 2022 to February 2023. Relying on MSM social groups in Qingdao, a snowball sampling method was applied to recruit research subjects who met the inclusion criteria of age ≥18 years old, having had homosexual anal or oral sex in the past six months, and HIV-negative or infection status unknown. The sample size was estimated at 566. Data on demographic characteristics, sexual behavior characteristics, PEP use, and others of the research subjects was collected through on-site questionnaires. The logistic regression model was used to analyze the factors associated with using PEP.Results:A total of 811 participants were recruited, mainly aged 25-34 (53.6%, 435/811), unmarried (74.7%, 606/811), with an average monthly income of ≥5 000 yuan (52.2%, 423/811), and having lived in Qingdao for ≥10 years (75.6%, 613/811). The proportion of those who knew the HIV status of their sexual partners in the last six months was 67.1% (544/811), and those with HIV-positive partners were 3.6% (29/811). In the last six months, the proportion of participants who had group sex (86.4%, 701/811), unprotected anal sex (98.2%, 796/811), and use of club drugs (80.3%, 651/811) was high. Moreover, 28.4% (230/811) had used PEP. The multivariate logistic regression analysis showed that the factors related to the use of PEP included divorced or widowed (a OR=5.46,95% CI:1.96-15.17), average monthly income ≥5 000 yuan (a OR=2.04,95% CI:1.44-2.89), same-sex sexual orientation (a OR=0.40,95% CI:0.22-0.71), having HIV-positive sexual partners in the last six months (a OR=2.54,95% CI:1.13-5.71) and having been tested for HIV ≥3 times in the last six months (a OR=1.46,95% CI:1.04-2.06). Conclusions:The prevalence of risk behaviors among MSM in Qingdao was high, and the use of PEP was low. In the future, it is essential to increase HIV/AIDS prevention education among MSM, promote MSM to know the HIV status of their sexual partners, and reduce the prevalence of risk behaviors among this population. Additionally, explore medical insurance reimbursement plans for PEP to reduce utilization costs and promote the use of PEP by MSM after HIV exposure occurs as soon as possible.

Objective:To explore the value of serum procalcitonin (PCT) and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score on predicting prognosis of elderly patients with sepsis.Methods:A retrospective cohort study, patients with sepsis who admitted to the department of emergency and the department of geriatric medicine of Peking University Third Hospital from March 2020 to June 2021 were enrolled. Patients' demographics, routine laboratory examinations, APACHE Ⅱ score that within 24 hours of admission were obtained from their electronic medical records. The prognosis during the hospitalization and one year after discharge were collected, retrospectively. Univariate and multivariate analysis of prognostic factors were performed. And Kaplan-Meier survival curves were used to examine overall survival.Results:A total of 116 elderly patients met inclusion criteria, 55 were alive and 61 were died. On univariate analysis, clinical variables such as lactic acid [Lac, hazard ratio ( HR) = 1.16, 95% confidence interval (95% CI) was 1.07-1.26, P < 0.001], PCT ( HR = 1.02, 95% CI was 1.01-1.04, P < 0.001), alanine aminotransferase (ALT, HR = 1.00, 95% CI was 1.00-1.00, P = 0.143), aspartate aminotransferase (AST, HR = 1.00, 95% CI was 1.00-1.01, P = 0.014), lactate dehydrogenase (LDH, HR = 1.00, 95% CI was 1.00-1.00, P < 0.001), hydroxybutyrate dehydrogenase (HBDH, HR = 1.00, 95% CI was 1.00-1.00, P = 0.001), creatine kinase (CK, HR = 1.00, 95% CI was 1.00-1.00, P = 0.002), MB isoenzyme of creatine kinase (CK-MB, HR = 1.01, 95% CI was 1.01-1.02, P < 0.001), Na ( HR = 1.02, 95% CI was 0.99-1.05, P = 0.183), blood urea nitrogen (BUN, HR = 1.02, 95% CI was 0.99-1.05, P = 0.139), fibrinogen (FIB, HR = 0.85, 95% CI was 0.71-1.02, P = 0.078), neutrophil ratio (NEU%, HR = 0.99, 95% CI was 0.97-1.00, P = 0.114), platelet count (PLT, HR = 1.00, 95% CI was 0.99-1.00, P = 0.108) and total bile acid (TBA, HR = 1.01, 95% CI was 1.00-1.02, P = 0.096) shown to be associated with poor prognosis. On multivariable analysis, level of PCT was an important factor influencing the outcome of sepsis ( HR = 1.03, 95% CI was 1.01-1.05, P = 0.002). Kaplan-Meier survival curve showed that there was no significant difference with respect to the overall survival between the two groups, with patients of PCT ≤ 0.25 μg/L and PCT > 0.25 μg/L ( P = 0.220). It also showed that the overall survival rate in patients with high APACHE Ⅱ score (> 27 points) was significantly lower than that in patients with low APACHE Ⅱ score (≤ 27 points, P = 0.015). Conclusion:Serum PCT level is valuable prognostic factors of elderly patients with sepsis, and higher APACHE Ⅱ score (> 27 points) indicates a poor prognosis.

Objective:To understand and analyze the incidence of HIV infection in club drug abusers among men who have sex with men (MSM) in Qingdao and provide a reference for the prevention and intervention of this population.Methods:From March 2017 to July 2022, club drug abusers among MSM who are HIV-negative were recruited by snowball sampling of MSM social organizations in Qingdao, a prospective cohort was established, and a follow-up survey was conducted every six months, with the sample size estimated to be 436. The survey contents included demographic characteristics, sexual characteristics, AIDS knowledge awareness, club drug abuse, HIV testing, and other information. HIV infection was the outcome-dependent variable, and the interval between the recruitment into the cohort and the HIV infection was the time-dependent variable. Cox proportional hazards regression analysis was conducted to identify the related factors for HIV infection.Results:A total of 987 participants of club drug abusers among MSM were recruited during the baseline survey and 826 eligible participants were enrolled in this cohort. A total of 46 HIV infection cases were found, and the cumulative follow-up time was 1 960.68 person-years. The incidence of HIV infection was 2.35/100 person-years. The multivariate Cox regression analysis showed that <30 (a HR=3.04, 95% CI: 1.62-5.71) non-Shandong residents (a HR=2.29,95% CI:1.20-4.39) found their partners through offline (a HR=4.62,95% CI:2.05-10.41), homosexual sexual partners >4 (a HR=3.06,95% CI:1.59-5.88), condom broken during sex (a HR=2.24,95% CI:1.21-4.17) and hemorrhage sexual intercourse (a HR=2.56,95% CI:1.31-5.03) were significantly associated with HIV infection in this cohort. Conclusions:The incidence of HIV infection in club drug abusers among MSM in Qingdao is generally low, but knowledge and practice have separated, and the risk of HIV infection is high. The related factors of HIV infection included younger age, non-Shandong residents, finding their partners offline, multiple sexual partners, condom break during sex, and hemorrhage sexual intercourse; HIV-related behavioral intervention should be strengthened.

Objective To introduce the simplified "All in one" hepatic vein reconstruction in right split liver transplantation, and to investigate the clinical indications, surgical procedures and clinical prognosis of this technique. Methods Clinical data of 2 recipients undergoing right split liver transplantation were retrospectively analyzed, and the simplified "All in one" hepatic vein reconstruction of right liver lobe was summarized and analyzed. In 2 cases, the right liver lobe was split in vivo. In case 1, the liver parenchyma was split until the first and second porta hepatis, and then the liver was obtained by whole-liver perfusion after cutting off the right hepatic duct, and the hepatic blood vessels were isolated ex vivo. In case 2, the left liver lobe was obtained during splitting in vivo and the right liver lobe was obtained after perfusion in vivo. During donor liver splitting in two cases, the common trunk of the middle hepatic vein was maintained in the left liver lobe, the S5 and S8 hepatic veins of the right liver lobe were reconstructed by the same donor iliac artery, and directly anastomosed with the gap between the left and middle hepatic veins of the inferior vena cava, thus reconstructing the integrity of the posterior inferior vena cava. Results The simplified "All in one" right hepatic vein reconstruction was adopted. The anhepatic phase of two recipients undergoing liver transplantation was 41 and 36 min. After the liver was incised open, the blood flow of the donor liver was normal, the iliac artery bypass was fully filled, liver congestion or swelling was not observed, and liver function was properly recovered after surgery. Two recipients were subject to postoperative follow-up for 23 and 10 months, respectively, No complications related to hepatic venous outflow tracts were noted, such as hepatic vein and inferior vena cava. Conclusions "All in one" hepatic vein reconstruction may simplify the procedures of hepatic venous outflow tract reconstruction, shorten the anhepatic phase and reduce the incidence of postoperative hepatic vein complications in complete right liver split transplantation.

Objective To investigate the anatomical classification of left intrahepatic bile duct (LHD) and the pattern of bile duct reconstruction during pediatric split liver transplantation and their relationship with postoperative biliary complications. Methods Clinical data of 75 pediatric recipients undergoing split liver transplantation were analyzed retrospectively. Before splitting the donor liver, iopromide injection was used for retrograde cholangiography through the common bile duct. According to the patterns of intrahepatic bile ducts in the second, third and fourth segments, the anatomical classification of LHD of the donor liver was determined. The biliary reconstruction regimens for different classification types of LHD were summarized. The incidence and treatment of biliary complications after pediatric split liver transplantation were analyzed. Results Among 75 donor livers, the anatomical classification of LHD included 57 cases (76%) of type Ⅰ, 9 cases (12%) of type Ⅱ, 4 cases (5%) of type Ⅲ and 5 cases (7%) of type Ⅳ LHD, respectively. Among 75 pediatric recipients, 69 cases (53 cases of type Ⅰ, 8 type Ⅱ, 4 type Ⅲ and 4 type Ⅳ) underwent the left hepatic duct-jejunum Roux-en-Y anastomosis, 1 case received common bile duct-jejunum Roux-en-Y anastomosis (type Ⅳ), and 5 cases underwent the left hepatic duct-common bile duct end-to-end anastomosis (4 cases of type Ⅰ and 1 type Ⅱ). Postoperative biliary complications occurred in 6 cases (8%), including 3 cases of biliary anastomotic stenosis, 2 cases of biliary anastomotic leakage and 1 case of bile leakage on the hepatic resection surface. Among 6 recipients, 4 cases were classified as type Ⅰ and 2 cases of type Ⅲ LHD. No significant difference was observed in the incidence of biliary complications between typical type and anatomical variant type of LHD (all P > 0.05). Among 3 recipients with biliary anastomotic stenosis, 2 cases underwent percutaneous transhepatic cholangial and drainage (PTCD) and 1 case repeatedly received biliary-intestinal anastomosis. Two cases of biliary anastomotic leakage underwent PTCD and 1 case of bile leakage on the hepatic resection surface received local drainage. All 6 children survived after treatment. Conclusions Anatomical variation of LHD can be observed in 24% of donor livers, and type Ⅱ accounts for the highest proportion of 12%. Prior to donor liver splitting, routine cholangiography and fine biliary anastomosis may effectively lower the incidence of biliary complications. The incidence of postoperative biliary complications is not significantly associated with the anatomical classification of LHD.