Background and Aims:Laparoscopic transcystic bile duct exploration(LTCBDE)has become the preferred method for treating secondary bile duct stones due to its advantages of minimal trauma,fast recovery,and low complication rates.However,challenges remain in the dilation of the cystic duct,the insertion of the choledochoscope,and the exploration of the common hepatic duct and intrahepatic bile ducts.This study was performed to explore the clinical application and effectiveness of the programmed modified LTCBDE in the treatment of gallbladder stones combined with common bile duct stones.Methods:A retrospective analysis was conducted on the clinical data of 248 patients who underwent programmed modified LTCBDE at the Affiliated Suzhou Ninth Hospital of Soochow University from January 2018 to January 2024.The surgical strategies and treatment outcomes were summarized.Data from 913 patients who underwent laparoscopic common bile duct exploration(LCBDE)during the same period were also collected to compare surgical outcomes and postoperative complications between the two groups.Results:Through programmed surgical steps,the innovative"diaphragm"incision technique,and improved bile duct probe application,244 patients(98.4%)successfully underwent LTCBDE,while 4 patients were converted to LCBDE due to failure to insert a 4.9 mm choledochoscope through the cystic duct.After operation,1 patient(0.4%)had residual bile duct stones,which were successfully removed through T-tube tract stone extraction(this patient was converted to LCBDE during the procedure).Additionally,1 case of bile leakage and 1 case of abdominal infection(each 0.4%)occurred,both of which resolved with conservative treatment.No cases of intra-abdominal bleeding,bile duct stenosis,or bile duct injury were reported.The average operative time in the programmed modified LTCBDE group was comparable to that of the LCBDE group(85.2 min vs.88.0 min,P=0.398),but the postoperative hospital stay was significantly shorter(6.2 d vs.8.3 d,P<0.001),and the incidence of complications was lower(1.6%vs.4.7%,P=0.044).Conclusion:The programmed modified LTCBDE is a standardized,safe,and effective procedure with a low complication rate.It is worthy of further clinical promotion and application.

Background and Aims:Laparoscopic transcystic bile duct exploration(LTCBDE)has become the preferred method for treating secondary bile duct stones due to its advantages of minimal trauma,fast recovery,and low complication rates.However,challenges remain in the dilation of the cystic duct,the insertion of the choledochoscope,and the exploration of the common hepatic duct and intrahepatic bile ducts.This study was performed to explore the clinical application and effectiveness of the programmed modified LTCBDE in the treatment of gallbladder stones combined with common bile duct stones.Methods:A retrospective analysis was conducted on the clinical data of 248 patients who underwent programmed modified LTCBDE at the Affiliated Suzhou Ninth Hospital of Soochow University from January 2018 to January 2024.The surgical strategies and treatment outcomes were summarized.Data from 913 patients who underwent laparoscopic common bile duct exploration(LCBDE)during the same period were also collected to compare surgical outcomes and postoperative complications between the two groups.Results:Through programmed surgical steps,the innovative"diaphragm"incision technique,and improved bile duct probe application,244 patients(98.4%)successfully underwent LTCBDE,while 4 patients were converted to LCBDE due to failure to insert a 4.9 mm choledochoscope through the cystic duct.After operation,1 patient(0.4%)had residual bile duct stones,which were successfully removed through T-tube tract stone extraction(this patient was converted to LCBDE during the procedure).Additionally,1 case of bile leakage and 1 case of abdominal infection(each 0.4%)occurred,both of which resolved with conservative treatment.No cases of intra-abdominal bleeding,bile duct stenosis,or bile duct injury were reported.The average operative time in the programmed modified LTCBDE group was comparable to that of the LCBDE group(85.2 min vs.88.0 min,P=0.398),but the postoperative hospital stay was significantly shorter(6.2 d vs.8.3 d,P<0.001),and the incidence of complications was lower(1.6%vs.4.7%,P=0.044).Conclusion:The programmed modified LTCBDE is a standardized,safe,and effective procedure with a low complication rate.It is worthy of further clinical promotion and application.

Objective:To evaluate the effects of comprehensive reform of clinical education on cultivating the clinical thinking ability of medical students in internal medicine.Methods:A total of 44 clinical interns on medicine rotation were included in this study and divided into experimental group and control group, and a series of measures for clinical teaching reform, which included undergraduate tutorial system, team-based learning (TBL) mode, combination of electronic medical record and handwritten medical record, as well as formative assessment, were applied to fully promote clinical thinking ability of medical students. SPSS 17.0 software was used to compare the scores of final academic tests of rotation and competition of medical record writing between the control and the experiment groups. Self-designed questionnaires on undergraduate tutors and clinical interns were applied to comprehensively evaluate the effects of this education reform.Results:Independent-sample t tests showed there were statistically significant difference ( P<0.01) in the scores of final academic tests of rotation and competition of medical record writing between the two groups, and the mean score of the experiment group was higher than that of the control group. Questionnaire survey showed that tutors and clinical interns both fully affirmed the positive effects of the education reform on cultivating clinical thinking ability of medical students in internal medicine. Conclusion:Application of comprehensive education reform in clinical teaching of internal medicine, which based on introduction of undergraduate tutorial system and TBL mode, could effectively promote the clinical thinking ability of medical students and the teaching quality.

Objective To investigate the effect of remote ischemic preconditioning on nuclear factor erythroid-2 related factor 2 (Nrf2) signaling in the liver of aged rats after warm ischemia reperfusion injury.Methods A 70％ hepatic warm ischemia-reperfusion model was established in aged rats (15-16 months old) (1 hour after ischemia and 2 hours after reperfusion).12 male Sprague-Dawley rats were divided into two groups:pretreatment group and control group.The level of serum alanine aminotransferase (ALT) was detected after operation and the liver tissues were harvested for the determination of malondialdehyde (MDA) content and the activity of antioxidant enzyme-superoxide dismutase (SOD).The pathological changes of liver were observed.The change of Nrf2 protein expression in liver tissue was examined by Western blot.Results Serum ALT and MDA in the pretreatment group were significantly lower than those in the control group.The liver pathological damage of pretreatment group rats were lighter than the control group (P ＜ 0.05).Compared with the control group,the Nrf2 protein expression and the activity of SOD increased in the liver of pretreatment group (P ＜ 0.05).Conclusions Remote ischemic preconditioning can reduce 70％ hepatic ischemia-reperfusion injury in aged rats,and its mechanism may be related to its activation of Nrf2 signaling pathway.

AIM: To observe the effects of polysaccharides-2b from mudan cortex of Paeonia Suffruticosa Andr on glycocylation hemoglobion(GHb),blood glucose(BG),superoxide dismutase(SOD),the content of malonaldehyde(MDA) in serum and blood rheology of diabetic rats. METHODS: Diabetic rats were induced by associating streptozotocin(STZ) with freund's adjuvant complete(CFA),and then the diabetic rats were divided randomly into five groups: model group,polysaccharides-2b lower dose group(30 mg/kg),middle dose group(60 mg/kg),high dose group(120 mg/kg),positive group.Normal group was established additionally.PSM2b was perfused into stomach in diabatic rats for 60 days.The blood glucose was measured on the 10 th,30 th and 60 th days.The rehologic indexes,GHb,SOD and MDA were measured on the 60 th days. RESULTS: Compared with model group,every administrative group of PSM2b were able to apparently reduce high blood glucose and GHb(P