Objective To explore the effect of the traumatic brain injury on the fracture healing and the related mechanism. Methods 64 12-week-old SD rats were randomly divided into 2 groups: The femoral fracture with a brain injury group and the femoral fracture group. The bone callus was obtained 1, 2, 3 and 4 week after operation respectively, and observed with the HE staining. The vascular endothelial growth factor (VEGF) and VEGF mRNA in the callus were detected with immunohistochemical staining and hybridization in situ. Results The formation and reforming of the callus in group with brain injury were ahead to only fracture. The percentages of the cells positive for VEGF and VEGF mRNA in the callus were more in group with brain injury than in pure fracture group at the same time point (P<0.05). Conclusion Traumatic brain injury can promote the healing of fracture, which is probably related to an increase in the expression of VEGF.

Objective:To investigate the application value of hepatic vein outflow tract reconstruction with ringed polytetrafluoroethylene vascular in right lobe living donor liver trans-plantation.Methods:The retrospective and descriptive study was conducted. The clinicopatho-logical data of 4 donors and 4 recipients undergoing right lobe living donor liver transplantation in Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School and 17 donors and 17 recipients undergoing right lobe living donor liver transplantation in the First Affiliated Hospital with Nanjing Medical University from June 2015 to August 2018 were collected. Of 21 donors, there were 10 males and 11 females, aged from 35 to 57 years, with a median age of 46 years. The median body mass of 21 donors were 64 kg, with a range from 56 to 72 kg. Of 21 recipients, there were 16 males and 5 females, aged from 21 to 68 years, with a median age of 42 years. The median body mass of 21 recipients were 63 kg, with a range from 47 to 77 kg. Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up was conducted by outpatient examination or telephone interview to detect graft function, tumor recurrence, vascular graft complications, patency of vascular graft and survival of recipients up to August 2020. All recipients will be followed up for all their lives. Measurement data with normal distribution were represented as Mean±SD and measurement data with skewed distribution were represented as M (range). Count data were represented as absolute numbers or percentages. The Kaplan-Meier method was used to calculate patency rates of hepatic vein outflow tract and survival rates to draw patency curve and survival curve. Results:(1) Surgical and postoperative situations: the operation time, the weight of donor graft, graft to recipient weight ratio and duration of hospital stay of 21 donors were (367±72)minutes, (557±68)g, 0.89%±0.16% and (10+2)days, respectively. No major complication requiring reoperation or intervention occurred in any of the 21 donors. One donor undergoing mild bile leakage preserved peritoneal drainage for one week. All 21 recipients underwent classic orthotopic liver transplantation successfully. The time of hepatic vein outflow tract reconstruction in donor graft, operation time and time of anhepatic phase of 21 recipients were (24±4)minutes, (326±66)minutes and (42±6)minutes, respectively. The number of reconstructed middle hepatic vein in hepatic segment 5 and 8 were 18 and 15, with the diameter of (6.1±1.3)mm and (7.2±1.2)mm, respectively. The number of reconstructed inferior right hepatic vein were 10, with the diameter of (6.3±1.3)mm. The postoperative treatment time at intensive care unit and duration of hospital stay of 21 recipients were (1.5±0.9)days and (22.6±6.7)days, respectively. Ten of 21 recipients underwent postoperative complications. Five recipients underwent graft dysfunction including the level of alanine aminotransferase and aspartate aminotransferase >1 000 IU/L and the level of bilirubin slightly increasing, combined with increased ascites. Enhanced computed tomography scan showed congestion in the right anterior of graft and thrombosis in the middle hepatic vein of hepatic segment 5 and segment 8. All 5 recipients undergoing graft dysfunction recovered with normal liver function and ascites decreasing after symptomatic treatment including liver protection therapy, anticoagulation and albumin infusion. Two recipients underwent inferior vena cava thrombosis and intractable pleural effusion one month after operation. Vena cava venography examination showed thrombosis in the graft vascular. Of the 2 recipients, one case with collateral circulation formation recovered undergoing balloon dilatation and stent placement combined with anticoagulation therapy of warfarin. The other one case recovered after anticoagulation therapy of warfarin. One recipient undergoing bile leakage and abdominal infection with klebsiella pneumoniae recovered after symptomatic treatment. Two recipients undergoing abdominal infection or pulmonary infection recovered after symptomatic treatment. There was no serious complication or death during perioperative period. (2) Follow-up: all 21 recipients were followed up for 10 to 57 months, with a median follow-up time of 38 months. During the follow-up, no recipient underwent graft dysfunction and 2 recipients had tumor recurrence at postoperative 6 months. Six of the 21 recipients died within 2 years after operation including 3 cases dying of tumor recurrence, 2 cases dying of acute hemorrhage and 1 case dying of liver failure. There was no death caused by vascular graft complica-tions. The postoperative 1, 3, 6-month, and 1-year and 2-year potency rates of hepatic vein outflow tract in 21 recipients were 88.4%, 88.4%, 82.4%, 68.0% and 42.1%, respectively. The 6-month, 1-year and 2-year overall survival rates in 21 recipients were 100%, 94.4%, 71.4%, respectively.Conclusion:Application of hepatic vein outflow tract reconstruction with ringed polytetrafluoroethylene vascular in right lobe living donor liver transplantation is safe and feasible.

Objective:To study the clinical application of a new classification on location of hepatolithiasis in guiding treatment using percutaneous transhepatic choledochoscopic lithotomy (PTCSL).Methods:The clinical data of 85 consecutive patients with preoperatively diagnosed hepatolithiasis who underwent PTCSL at the First Affiliated Hospital of Nanjing Medical University from January 2017 to July 2021 were prospectively collected. There were 27 males and 58 females, aged from 15 to 86(62±14) years. Hepatolithiasis was classified into five types of stone location based on preoperative imagings: type Ⅰ ( n=12) , stones located in central bile duct, including hilar bile duct and common hepatic duct; type Ⅱ ( n=17) in unilateral hepatic duct with multiple branches; type Ⅲ ( n=24) in unilateral hepatic duct with multiple branches plus central bile duct; type Ⅳ ( n=31) in bilateral hepatic ducts with multiple branches; and type Ⅴ ( n=1) in unilateral hepatic duct with a single branch. Fistulation path, number of procedures, number of bile duct fistula, and complications were recorded. The residual stone rate and stone recurrence rate were compared among the five types. The follow-up was performed to analyse prognosis. Results:A total of 99 biliary fistulae were performed, with one single tract created in 74 patients, two tracts in 9 patients, three tracts in 1 patient, and four tracts in 1 patient. The fistulation path was B2 in 12 patients, B3 in 18 patients, B4 in 1 patient, B5 in 4 patients, B6 in 10 patients, B7 in 4 patients, and B8 in 50 patients. Altogether, 151 choledochoscopic lithotomy procedures were performed (1-3 times per patient, mean 1.78 times). For the 9 patients with residual stones (10.6%, 9/85), there were 3 patients with type Ⅱ and 6 patients with type Ⅳ. There were significant differences in the residual stone rates among the 5 types (χ 2=11.13, P=0.025). Stone recurrence developed in 33 (38.8%) patients, including 2 patients with type Ⅰ, 7 patients with type Ⅱ, 10 patients with type Ⅲ and 14 patients with type Ⅳ (χ 2=9.07, P=0.046). The total intraoperative and postoperative complications rates was 28.2% (24/85). The follow-up period was 4-58 months with the median follow-up time of 30 months. Twelve patients died during the follow-up period, including 1 patient who died from postoperative bleeding, 3 cholangiocarcinoma, 7 biliary cirrhosis-related liver failure, and 1 stone-unrelated disease. Conclusion:Type Ⅳ in the location classification of hepatolithiasis based on PTCSL had significantly higher rates of residual stones and stone recurrence. This new classification is helpful for clinicaians to determine the optimal path using a smaller number of fistulation tracts to clear stones. It improved the efficacy of PTCSL in treating hepatolithiasis.

Objective: To assess application of reconstruction of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation (LDLT) in the treatment of hepatocellular carcinoma (HCC) beyond Milan Criteria. Methods: The clinical data of 9 HCC patients who underwent right lobe liver transplantation after reconstruction of retrohepatic inferior vena cava using artificial blood vessel between June 2015 and Nov 2016 at Liver Transplantation Center of the First Affiliated Hospital of Nanjing Medical University were retrospectively analyzed. The liver of the patients was removed with retrohepatic inferior vena cava, and then the right donor graft was implanted by conventional orthotopic liver transplantation. Results: All 9 liver transplantations were performed successfully. The time of reconstruction of hepatic venous outflow of the donor graft was (22.6±3.0) min, anhepatic time was (45.0±7.1) min, and total operation time was (321.9±52.5) min. All patients recovered uneventfully, ICU and hospital stay day were (1.2±0.4) days and (18.4±3.0) days. 2 patients suffered from thrombosis of artificial blood vessel, one recovered after conservative treatment and another was treated by placement of vein stent. No abdominal/pulmonary infection and non-artificial blood vascular complications were found, and none died in perioperative period. Postoperative pathological results showed that all patients were hepatocellular carcinomas and vascular tumor thrombosis was found in 5 cases. All patients were follow up, 1 patient died of pulmonary and brain metastasis 10 months after operation. One patient survived with local recurrence of tumor in liver. The other patients had no tumor recurrence and metastasis. Conclusion Replacement of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation is safe and feasible in the treatment of HCC beyond Milan Criteria, and might improve the resection rate of diseased liver and the prognosis of HCC patients after living donor liver transplantation.