Hepatic encephalopathy and malnutrition due to hyperammonemia often interact with each other, forming a vicious circle in patients with cirrhosis. In addition, hepatic encephalopathy and malnutrition have a high incidence in patients with cirrhosis, which seriously affects the quality of life and prognosis. Therefore, identifying whether malnutrition is present in patients with cirrhosis combined with hepatic encephalopathy is crucial for providing appropriate interventions.This article reviews the pathogenesis, nutritional assessment methods, and nutritional management of malnutrition in patients with liver cirrhosis combined with hepatic encephalopathy.

Hepatic encephalopathy and malnutrition due to hyperammonemia often interact with each other, forming a vicious circle in patients with cirrhosis. In addition, hepatic encephalopathy and malnutrition have a high incidence in patients with cirrhosis, which seriously affects the quality of life and prognosis. Therefore, identifying whether malnutrition is present in patients with cirrhosis combined with hepatic encephalopathy is crucial for providing appropriate interventions.This article reviews the pathogenesis, nutritional assessment methods, and nutritional management of malnutrition in patients with liver cirrhosis combined with hepatic encephalopathy.

The polyfoliate perforator flap is a new type of flap that was developed on the basis of the traditional polyfoliate myocutaneous flap, polyfoliate fascial flap and perforator flap. It overturns the traditional idea that the deep fascial vascular network is the fundamental for a survival of the flap, and enables the flaps to achieve the best profile and function of the recipient areas with minimal damage to the donor area. In order to improve the understanding of the polyfoliate perforator flap and further standardise its clinical application, this paper forms a consensus on the definition, classification, indications, operative points and precautions of the polyfoliate perforator flap, so as to provide references in diagnosis and treatment process and practical application for the surgeons.

The polyfoliate perforator flap is a new type of flap that was developed on the basis of the traditional polyfoliate myocutaneous flap, polyfoliate fascial flap and perforator flap. It overturns the traditional idea that the deep fascial vascular network is the fundamental for a survival of the flap, and enables the flaps to achieve the best profile and function of the recipient areas with minimal damage to the donor area. In order to improve the understanding of the polyfoliate perforator flap and further standardise its clinical application, this paper forms a consensus on the definition, classification, indications, operative points and precautions of the polyfoliate perforator flap, so as to provide references in diagnosis and treatment process and practical application for the surgeons.

Objective:To investigate the correlation between paraspinal muscle atrophy, morphological changes of facet joints and adjacent segment disease (ASDis) after lumbar fusion operation.Methods:A retrospective study was conducted among 195 patients who underwent posterior lumbar fusion again for ASDis at this institution from January 2014 to December 2020, including 29 patients with ASDis whose initial surgical fusion segment was L 4,5. According to Roussouly's staging, there were 5 cases of type I, 9 cases of type II, 10 cases of type III, and 5 cases of type IV. Another 29 cases were selected from patients without ASDis after lumbar fusion as a control group. The control group was paired 1∶1 with the ASDis group according to gender, fusion segment, and Roussouly typing of the lumbar spine. The cross-sectional area (CSA) and fat infiltration (FI) of paravertebral muscle, facet joint angle (F-J) and pedicle facet (P-F) angle before the first (second) operation were measured and compared between the two groups. Then logistic regression analysis was used to determine the predictors of ASDis after posterior lumbar fusion. Finally, the receiver operation characteristic (ROC) curve was described, and the area under the curve (AUC) and cut-off point were calculated. At the same time, the paraspinal muscle atrophy before the second operation in ASDis group was measured. Results:The average follow-up time of 98 patients was 59.25±6.38 months (range, 49-73 months). The average body mass index (BMI) of ASDis group was 24.76±3.64 kg/m 2, which was higher than that in control group (22.24±2.92 kg/m 2) ( t=2.481, P=0.041). The average CSA and relative cross-sectional area (rCSA) of paraspinal muscle in ASDis group were 3 214.32± 421.15 mm 2 and 1.69±0.36 respectively, which were less than 3 978.91±459.87 mm 2 and 2.26±0.29 in control group ( t=10.22, P=0.012; t=9.47, P=0.038). The FI degree of paraspinal muscle in ASDis group (21.95%±5.89%) was significantly higher than that in control group (14.64%±7.11%) ( t=7.32, P=0.002). The F-J angle in ASDis group was 35.06°±3.45°, which was less than 38.39°±4.67° in control group ( t=4.76, P=0.027). The P-F angle in ASDis group was 117.39°±8.13°, which was greater than 111.32°±4.78° in control group ( t=5.25, P=0.031). Multivariate logistic regression analysis showed that higher BMI ( OR=1.34, P=0.038), smaller rCSA of paraspinal muscle ( OR=0.02, P=0.017) and higher FI of paraspinal muscle ( OR=1.58, P=0.032) were the risk factors of postoperative ASDis. The ROC curve showed that the AUC of BMI was 0.680 and the cut-off point was 22.58 kg/m 2; The AUC of the FI of paraspinal muscle was 0.716 and the cut-off point was 15.69%; The AUC of rCSA of paraspinal muscle was 0.227 and the cut-off point was 1.92. For ASDis patients, the paraspinal muscle before the second operation had a higher degree of FI (25.47%±6.59% vs. 21.95%±5.89%, t=3.99, P=0.042) and a smaller rCSA (1.52±0.28 vs. 1.69±0.36, t=3.85, P=0.038) than that before the first operation. The difference between the FI degree of paraspinal muscle before the second operation and the first operation was negatively correlated with the occurrence time of ASDis ( r=-0.53, P=0.039) , and the difference of rCSA was positively correlated with the occurrence time of ASDis ( r=0.64, P=0.043) . Conclusion:When BMI >22.58 kg/m 2, FI of paraspinal muscle >15.69%, and rCSA of paraspinal muscle <1.92, it suggests that ASDis is more likely to occur after operation. And the more obvious paraspinal muscle atrophy after the first operation, the earlier ASDis may occur. Morphological changes of facet joints cannot be used as an index to predict the occurrence of ASDis.

In the development of flap surgery, the groin flap was one of the earliest flaps used in repair of soft tissue defect. However, due to its unstable anatomical position and many variations, small vessels and great difficulty in vascular anastomosis, the application of this flap reduced gradually. With the development of microsurgical techniques and the increasing demand of patients for aesthetics in donor site, the groin flap has been still widely used in the repair of soft tissue defect in limb maxillofacial region, and perineal partsin in recent 10 years, due to its advantages of concealed donor site and large area of flap. This article review the historical development of the groin flap, summarize the clinical application of perforator flap, and special types of groin flaps in repair of soft tissue defect in extremities. Hoping to further promote the application and development of groin flap in soft tissue repair.

[Abstract] Objective: To investigate the expression of chemokine-like factor-like MARVEL transmembrane domain-containing family member 6 (CMTM6) in breast cancer tissues and its correlation with clinicopathological features and prognosis of patients. Methods:Atotal of 136 breast cancer tissue chips (purchased from Superchip Company), including 42 pairs of matched cancer and paracancerous tissues, were used for this study. The expression level of CMTM6 in cancer and paracancerous tissues was detected by immunohistochemistry. The comparison of CMTM6 expression between breast cancer and paracancerous tissues was conducted by paired χ2 test. The relationship between CMTM6 expression in breast cancer tissues and the clinicopathological characteristics of patients was analyzed by χ2 test. Kaplan-Meier and Log rank test analyses were used to analyze the relationship between CMTM6 expression and the survival of patients, and Cox model was used to evaluate the effect of different indicators on the prognosis of patients. Results: The expression of CMTM6 in breast cancer tissues was significantly higher than that in paracancerous tissues (P<0.01). The expression of CMTM6 was correlated with pathological type of breast cancer and HER2 positivity (P<0.05). The survival time of patients in CMTM6 high expression group was significantly shorter than that of patients in CMTM6 low expression group (P<0.05). Pathological type (HR=10.374, 95%CI: 3.529-30.497, P<0.01), TNM stage (HR=4.599, 95%CI: 1.784-11.856, P<0.01), triple-negative breast cancer (HR=3.370, 95%CI: 1.055-10.761, P<0.05) and high expression of CMTM6 (HR=0.195, 95%CI: 0.073-0.518, P<0.01) were independent risk factors for prognosis of breast cancer patients. Conclusion: CMTM6 is highly expressed in breast cancer tissues, which can be used as a risk factor for prognosis evaluation of breast cancer patients.

Objective: To explore the effect of enteral nutrition on tumor cell proliferation activity in rectal cancer patients with nutritional risk treated with preoperative neoadjuvant therapy. Methods: Sixty-six rectal cancer patients with nutritional risk treated with preoperative neoadjuvant therapy from January 2016 to January 2018 in the Yongchuan Hospital Affiliated to Chongqing Medical University were selected. The patients were divided into experimental group (enteral nutrition combined with neoadjuvant therapy) and control group (simple adjuvant therapy) according to the random digits table method, with 33 cases in each group. The expressions of proliferating cell nuclear antigen (PCNA) and Ki-67 antigen before and after treatment were detected by immunohistochemical method; the albumin and prealbumin before and after treatment were observed, and the nutrition risk screening 2002 (NRS2002) was evaluated. Results: There were no statistical differences in the expressions of PCNA and Ki-67 antigen before treatment between 2 groups (P>0.05); the expressions of PCNA and Ki-67 antigen after treatment in experimental group were significantly lower than those in control group, and there were statistical differences (P<0.05). There were no statistical differences in the NRS2002 score, albumin and prealbumin before treatment between 2 groups (P>0.05); the NRS2002 score after treatment in experimental group was significantly lower than that in control group: (1.58 ± 0.50) scores vs. (3.65 ± 0.72) scores, the albumin and prealbumin after treatment were significantly higher than those in control group: (35.92 ± 2.77) g/L vs. (31.12 ± 1.76) g/L and (204.58 ± 23.86) mg/L vs. (157.46 ± 18.99) mg/L, and there were statistical differences (P<0.01). Conclusions Enteral nutrition can reduce the proliferation activity of tumor cell in rectal cancer patients with nutritional risk treated with preoperative neoadjuvant therapy, and it can improve the nutritional status of patients.

The main work and achievements of clinical pathway work in China since 2009 were systematically reviewed in the paper. It analyzed the problems existing in the implementation of clinical pathway management in China, and suggested on such management in the future. The suggestions include:deeper understanding, convergence with the payment system reform, strengthened quality control, further informatization,and better performance appraisal system.

Objective To prospectively summary the piercing-out position,direction,length and piercing-in position of perforator,and investigate the feasibility of preoperative design and optimization of the anterolateral thigh flap and its clinical application.Methods All 58 cases of anterolateral thigh flaps were designed and taken from the lateral thigh area from January,2014 to January,2016.Portable Doppler ultrasound was used before an operation to detect the piercing-out position (point P) of perforators.The direction and length (lower subcutaneous segment of perforators) of perforators after leaving piercing-out position were observed during the operation.And the piercing-in positions (point P') on superficial fascia and the dermis were observed.Based on this,we added line B (anterior superior spine-lateral femoral epicondyle) and line C (anterior superior spine-the middle point of superior border of patella) in the lateral and anterior side of original ilium-patella line in the thigh (line A),respectively.Results All perforators found in 58 cases before and during the operations were located on line A or between line A and line B.No perforators were found between line A and line C.Perforators walked toward the anterior medial side after leaving the muscle membrane.The perforator vascular subcutaneous segment (distance between point P and point P') was (2.02±0.23) cm.There was rectus muscle branch in the descending branch of lateral femoral circumflex artery,while no rectus muscle cutaneous branch was seen.20 cases were designed by one-line method,12 cases were designed by two-line method,while 26 cases were designed by three-line method.Conclusion Advanced three-line method is beneficial to detect of the perforators on the anterior thigh lateral region and to reduce the intraoperative injury perforator vessels at the puncture point.Clinical application of the anterior lateral thigh flap is simple and reliable.