Given that ovarian stimulation is vital for assisted reproductive technology (ART) and results in elevated serum estrogen levels, exploring the impact of elevated estrogen exposure on oocytes and embryos is necessary. We investigated the effects of various ovarian stimulation treatments on oocyte and embryo morphology and gene expression using a mouse model and estrogen-treated mouse embryonic stem cells (mESCs). Female C57BL/6J mice were subjected to two types of conventional ovarian stimulation and ovarian hyperstimulation; mice treated with only normal saline served as controls. Hyperstimulation resulted in high serum estrogen levels, enlarged ovaries, an increased number of aberrant oocytes, and decreased embryo formation. The messenger RNA (mRNA)‍-sequencing of oocytes revealed the dysregulated expression of lysine-specific demethylase 6b (Kdm6b), which may be a key factor indicating hyperstimulation-induced aberrant oocytes and embryos. In vitro, Kdm6b expression was downregulated in mESCs treated with high-dose estrogen; treatment with an estrogen receptor antagonist could reverse this downregulated expression level. Furthermore, treatment with high-dose estrogen resulted in the upregulated expression of histone H3 lysine 27 trimethylation (H3K27me3) and phosphorylated H2A histone family member X (γ-H2AX). Notably, knockdown of Kdm6b and high estrogen levels hindered the formation of embryoid bodies, with a concomitant increase in the expression of H3K27me3 and γ-H2AX. Collectively, our findings revealed that hyperstimulation-induced high-dose estrogen could impair the demethylation of H3K27me3 by reducing Kdm6b expression. Accordingly, Kdm6b could be a promising marker for clinically predicting ART outcomes in patients with ovarian hyperstimulation syndrome.
Female ; Mice ; Demethylation/drug effects* ; Embryonic Stem Cells ; Estrogens/administration & dosage* ; Gene Expression/drug effects* ; Histones/metabolism* ; Jumonji Domain-Containing Histone Demethylases/metabolism* ; Mice, Inbred C57BL ; Oocytes ; Ovary/drug effects* ; Reproductive Techniques, Assisted ; Animals

Interferon regulatory factor 4 (IRF4) is a critical transcription factor that governs the differentiation of cluster of differentiation 4⁺ (CD4⁺) T cells. The pathogenesis and progression of psoriasis are primarily attributed to an immune imbalance stemming from the overproduction of interleukin-17A (IL-17A) by T lymphocytes. However, the role of IRF4 in psoriasis remains unexplored. In this study, we found that IRF4 activity is increased in the cutaneous lesions of patients with psoriasis in response to stimulation by IL-23A and IL-1β. This IRF4 elevation heightens its binding to the E1A binding protein p300 (EP300) promoter, triggering the transcription of downstream retinoic acid receptor-related orphan receptor-γt (RORγt) and increasing the secretion of IL-17A, thereby establishing the IL-1β/IL-23A-IRF4-EP300-RORC-IL-17A inflammatory cascade in psoriasis. The alleviation of imiquimod (IMQ)-induced psoriatic-like symptoms was achieved through the creation of a Irf4 ^-/- gene deletion mouse model and pharmacological inhibition using antisense oligonucleotides targeted for Irf4. This amelioration was accompanied by a decreased number of IL-17A-producing CD4⁺ T cells in the skin. The findings of this study suggest that IRF4 plays a crucial role in the promotion of inflammation and exacerbation of IMQ-induced psoriasiform dermatitis. Consequently, IRF4 targeting could be a promising therapeutic strategy.

Background::Sentinel lymph node (SLN) biopsy is gradually accepted as the standard of care in breast cancer patients with down-staged axillary disease after neoadjuvant chemotherapy (NAC). However, it is still difficult to precisely define pre-NAC clinical node-positive (cN1) and post-NAC clinical node-negative (ycN0). This prospective single-center trial was designed to evaluate the feasibility and accuracy of standard targeted axillary dissection (TAD) after NAC in highly selective pre-NAC cN1 patients (not considering ultrasound-based axillary ycN staging).Methods::This prospective trial included patients with initial pre-NAC cT1–3N1M0 invasive breast cancer but with a rigorous definition of cN1 from the Affiliated Cancer Hospital of Zhengzhou University. When NAC was effective (including complete and partial responses) and preoperative axillary palpation was negative, preoperative ultrasound-based axillary staging was not considered, and all patients underwent TAD followed by axillary lymph node (LN) dissection. The detection rate (DR) and false-negative rate (FNR) of TAD were calculated.Results::A total of 82 patients were included, and 77 of them were eligible for data analysis. The DR for TAD was 94.8% (73/77). There were 26 patients with one abnormal LN at the time of diagnosis based on ultrasound, 45 patients with two, and 2 patients with three. One patient had one TAD LN, four patients had two TAD LNs, and 68 patients had three or more TAD LNs. Preoperative axillary palpation yielded negative results for all 73 patients who successfully underwent TAD. Preoperative ultrasound-based ycN0 and ycN+ conditions were detected for 52 and 21 cases, respectively. The FNR was 7.4% (2/27) for standard TAD (≥3 SLNs), which was lower than that of all successful TAD (≥1 SLN; 10.0%, 3/30).Conclusions::In rigorously defined pre-NAC cN1 breast cancer patients, standard TAD is feasible for those with negative axillary palpation after NAC, and FNR is also less than 10%.Registration::chictr.org.cn, ChiCTR2100049093

Objective:To investigate the level of functional fitness of elderly hypertensive patients in the community and to analyze its influencing factors.Methods:A cross-sectional survey was used from November 2021 to September 2022, questionnaire survey and Senior Functional Fitness Test (SFT) were conducted on 189 elderly hypertensive patients in the community by convenience sampling method, multiple linear regression was used to analyze the influencing factors of SFT in elderly hypertensive patients in the community.Results:Totally 189 cases of community-aged hypertensive patients completed the investigation, 88 cases were male and 101 were female. The total SFT score of community-aged hypertensive patients was (58.61 ± 16.07). Single factor analysis showed that there were significant differences in SFT scores among patients with different gender, age and education ( t=-2.57, F=6.24, 7.54, all P<0.05). Multifactorial analysis revealed that age ( t=-5.55), gender ( t=2.63), and literacy ( t=5.69) were influential factors in the total SFT scores of community-dwelling elderly hypertensive patients (all P<0.05). Conclusions:Age, gender, and literacy level are the main factors affecting the total SFT scores of elderly hypertensive patients in the community, and community caregivers should pay close attention to the above elderly hypertensive population.

Objective:To construct and validate the physical fitness age model for community-dwelling elderly people, so as to provide new methods and reference for the health assessment and rehabilitation guidance of the elderly.Methods:From March to September 2021, 794 community-dwelling health people in six districts of Suzhou (Wuzhong District, Gusu District, Xiangcheng District, Wujiang District, Huqiu District and Industrial Park) were selected by multi-stage stratified sampling. Postgraduates who received unified training used unified monitoring tools to assess the physical function and physical fitness of the subjects in the designated community health service centers. Principal component analysis was used to construct a physical fitness age model. According to the scores of Short Physical Performance Battery, people with high physical function and people with low physical function were divided to verify the effectiveness of the model evaluation.Results:A total of four indicators, including 2-min step test, 30 s chair stand test, biceps flexion and lift test, and time up and go test (TUGT) , were finally included to build a physical fitness age model. The model formula was physical fitness age=-0.126×2-min step test-0.612×biceps flexion and lift test-0.625×30 s chair stand test+1.855×TUGT+0.51×age+55.29. The model validation showed that the physical fitness age of the community-dwelling elderly people of the high physical function group was lower than the age, and the difference was statistically significant ( P<0.01) . The physical fitness age of the community-dwelling elderly people of the low physical function group was higher than that of the age, and the difference was also statistically significant ( P<0.01) . The research results were consistent with the research assumptions, suggesting that the model was reasonable and effective. Conclusions:The construction of the physical fitness age model for community-dwelling elderly people can reflect the decline of the elderly's physical function, can be used for the elderly's health assessment and rehabilitation guidance, and can provide evaluation indicators for the elderly to provide community and home medical care services.

Adoptive cell therapy (ACT) is an emerging powerful cancer immunotherapy, which includes a complex process of genetic modification, stimulation and expansion. During these

Objective:To investigate the relationship of osteoporotic vertebral body compression fracture(OVCF)with multifidus muscle and intervertebral disc degeneration in the lower lumbar spine and the lumbar-pelvic parameters in elderly women.Methods:Clinical data of a total of 108 elderly women with osteoporosis were retrospectively analyzed.They were divided into the fracture group(n=56)and the control group(n=52)according to the presence of vertebral body compression fractures.Age, body mass index(BMI)and bone mineral density(BMD)were collected in two groups.The angle of pelvic incidence(PI), angle of pelvic tilt(PT), low lumbar lordosis(LLL)and sacral slope(SS)were measured by the standing lumbar lateral X-ray photography.The degree of degeneration of intervertebral disc L 3-S 1 and multifidus muscle were detected by using the lumbar MRI.These parameters were compared between the two groups. Results:The age, BMI and BMD had no significant difference between the two groups( P>0.05). The degree of intervertebral disc degeneration of L 3-L 4 and L 4-L 5 was statistically significant higher in the fracture group than in the control group( Z=-4.656 and -2.675, P=0.000 and 0.007), while the degree of intervertebral disc degeneration of L 5-S 1 had no statistically significant difference between the two groups( Z=-1.784, P=0.075). There were statistically significant higher multifidus muscle degeneration of L 3-L 4 and L 4-L 5 in the fracture group than in the control group( Z=-3.248 and -4.073, P=0.001 and 0.000), while no significant difference between the two groups in multifidus muscle degeneration of L 5-S 1( Z=-1.096, P=0.282). No statistically significant differences were found in PI, PT, SS and LLL between the two groups( t=1.162, 0.827, -0.082 and -0.677, P=0.248, 0.410, 0.935 and 0.500). Conclusions:The degeneration of intervertebral disc and multifidus muscle of L 3-L 4 and L 4-L 5 is positively correlated with OVCF in elderly women.

Objective:To investigate the risk factors for anastomotic leakage after laparo-scopic lower anterior resection (LAR) of rectal cancer, and the application value of its risk assess-ment scoring model.Methods:The retrospective case-control study was conducted. The clinico-pathological data of 539 patients who underwent laparoscopic LAR of rectal cancer in 13 medical centers, including 248 cases in Renji Hospital of Shanghai Jiaotong University School of Medicine, 35 cases in Ningbo First Hospital, 35 cases in Changzhou Second People's Hospital, 32 cases in the First People's Hospital of Nantong, 32 cases in Linyi People's Hospital, 31 cases in Changzhou Wujin People's Hospital, 28 cases in Jiading District Hospital of Traditional Chinese Medicine, 27 cases in the First Hospital of Taizhou, 26 cases in Shanghai Pudong Gongli Hospital, 21 cases in the People's Hospital of Rugao, 11 cases in Central Hospital of Fengxian District, 7 cases in Ningbo Hangzhou Bay Hospital and 6 cases in Jiangsu jianhu People's Hospital, from January 2016 to November 2020 were collected. There were 157 males and 382 females, aged (62.7±0.5)years. Observation indicators: (1) follow-up; (2) risk factors for anastomotic leakage after laparoscopic LAR; (3) establishment of risk assessment scoring model for anastomotic leakage after laparoscopic LAR. Follow-up was conducted by outpatient examination or telephone interview. Patients were followed up at 1 week after discharge or 1 month after the operation to detect the anastomotic leakage. 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, and comparison between groups was analyzed using the chi-square test. Univariate analysis was conducted using the chi-square test and multivariate analysis was conducted usong the Logistic regression model. The area under curve of receiver operating characteristic curve was used to estimate the efficiency of detecton methods. The maximum value of the Youden index was defined as the best cut-off value. Results:(1) Follow-up: 539 patients were followed up at postoperative 1 week and 1 month. During the follow-up, 79 patient had anastomotic leakage, with an incidence of 14.66%(79/539). Of the 79 patients, 39 cases were cured after conservative treatment, 40 cases were cured after reoperation (ileostomy or colostomy). (2) Risk factors for anastomotic leakage after laparoscopic LAR. Results of univariate analysis showed that sex, age, body mass index, smoking and/or drinking, tumor diameter, diabetes mellitus, hemoglobin, albumin, grade of American Society of Anesthesio-logists (ASA), neoadjuvant chemoradiotherapy, distance from anastomotic level to dentate line, the number of pelvic stapler, reinforced anastomosis, volume of intraoperative blood loss, placement of decompression tube, preservation of left colic artery, operation time and professional doctors were related factors for anastomotic leakage after laparoscopic LAR ( χ2=14.060, 4.387, 5.039, 4.094, 17.488, 33.485, 25.066, 28.959, 34.973, 34.207, 22.076, 13.208, 16.440, 17.708, 17.260, 4.573, 5.919, 5.389, P<0.05). Results of multivariate analysis showed that male, tumor diameter ≥3.5 cm, diabetes mellitus, hemoglobin <90 g/L, albumin <30 g/L, grade of ASA ≥Ⅲ, neoadjuvant chemoradiotherapy, distance from anastomotic level to dentate line <1 cm, the number of pelvic stapler ≥3, non-reinforced anastomosis, volume of intraoperative blood loss ≥100 mL and no placement of decom-pression tube were independent risk factors for anastomotic leakage after laparoscopic LAR ( odds ratio=2.864,3.043,12.556,7.178,8.425,12.895,8.987,4.002,3.084,4.393,3.266,3.224,95% confidence interval as 1.279?6.411, 1.404?6.594, 4.469?35.274, 2.648?19.459, 2.471?28.733, 4.027?41.289, 3.702?21.777, 1.746?9.171, 1.365?6.966, 1.914?10.083, 1.434?7.441, 1.321?7.867, P<0.05). (3) Establishment of risk assessment scoring model for anastomotic leakage after laparoscopic LAR. based on the results of univariate analysis, clinicopathological factors with χ2>20, χ2>10 and ≤20 or χ2≤10 were defined as scoring of 3, 2, 1, respectively. The cumulative clinicopatho-logical factors scoring ≥6 was defined as an effective evaluating indicator for postoperative anastomotic leakage. The risk assessment scoring model (6-321) for anastomotic leakage after laparoscopic LAR was established. The cumulative value ≥6 indicated high incidence of anastomotic leakage, and the cumulative value <6 indicated low incidence of anastomotic leakage. Conclusions:Male, tumor diameter ≥3.5 cm, diabetes mellitus, hemoglobin <90 g/L, albumin <30 g/L, grade of ASA ≥Ⅲ, neo-adjuvant chemoradiotherapy, distance from anastomotic level to dentate line <1 cm, the number of pelvic stapler ≥3, non-reinforced anastomosis, volume of intraoperative blood loss ≥100 mL and no placement of decompression tube are independent risk factors for anastomotic leakage after laparoscopic LAR. The risk assessment scoring model (6-321) is established according to the above results.The cumulative value ≥6 indicates high incidence of anastomotic leakage and the cumulative value <6 indicates low incidence of anastomotic leakage.

Objective:To investigate the application value of three-dimensional visualization technology in management of middle hepatic vein (MHV) processing in associating liver partition and portal vein ligation for staged hepatectomy(ALPPS).Methods:The retrospective and descriptive study was conducted. The clinical data of 40 patients with right massive liver cancer or multiple right liver lesions who underwent ALPPS in the First Affiliated Hospital of Guangxi Medical University from November 2017 to August 2019 were collected. There were 34 males and 6 females, aged (44±9)years, with a range from 26 to 64 years. All patients underwent multi-slice computed tomography (CT) plain and enhanced scan of superior abdominal region before operation, and the data were transmitted to the liver visualization analysis software IQQA system with 1.5 mm thin-layer images to complete the three-dimensional reconstruction of the liver and its blood vessels. Patients were performed ALPPS based on results of three-dimensional reconstruction and intraoperative findings. Observation indicators: (1) results of preoperative three-dimensional reconstruction; (2) surgical situations; (3) follow-up. Follow-up was conducted using outpatient examinations and telephone interview to detect postopeartive survival of patients up to March 2020. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were described as M (range). Count data were represented as absolute numbers. Results:(1) Results of preoperative three-dimensional reconstruction: 40 patients underwent three-dimensional reconstruction successfully, of which 37 clearly showed MHV, tumor location and relationship between them, 3 patients showed unclearly MHV and were classified based on two-dimensional images. Of the 40 patients, 12 had MHV classified as type A, 13 as type B, 9 as type C, and 6 as type D. Three-dimensional reconstruction of vessels showed 22 with umbilical veins and 9 with anterior veins. Of the 40 patients, 35 were predicted to preserve MHV, and 5 were predicted to resect MHV. Total estimated liver volume, tumor volume, and reserved liver volume were (1 012±119)cm 3, 600 cm 3(8-2 055 cm 3), (346±80)cm 3. The ratio of future liver remnant to standard liver volume was 34%±8%. (2) Surgical situations : 40 patients underwent the first-stage ALPPS, including 35 with preservation of MHV and 5 with resection of MHV, which was accorded with preoperative prediction. Thirty-four patients underwent the second-stage ALPPS, and 6 patients had failure to receive the second-stage ALPPS due to undificiency future liver remnant. The operation time and volume of intraoperative blood loss for 40 patients undergoing first-stage ALPPS were (350±79)minutes and 300 mL(range, 100-2 600 mL). Three patients received blood transfusion and no perioperative death occurred. There were 24 patients with grade A heptic insufficiency according to criteria of International StudyGroup of Liver Surgery (ISGLS) and 16 patients with grade B heptic insufficiency after the first-stage ALPPS. Twenty-eight patients had grade Ⅰ complications of Clavien-Dindo classification, including 17 with a small pleural effusion, 10 with a small pleural and abdominal effusion, 1 with hypoproteinemia; 8 patients had grade Ⅱ complications of Clavien-Dindo classification, including 5 with pneumonia, 1 with pneumonia combined with pleural and abdominal effusion, 1 with coagulation disorders, 1 with biliary fistula; 3 patients had grade Ⅲ complications of Clavien-Dindo classification, including 2 with pneumothorax and pneumonia, 1 with pneumothorax, pneumonia and coagulation disorders; 1 patient had grade Ⅳ complications of Clavien-Dindo classification as systemic inflammatory response syndrome. All patients with complications were improved after symptomatic treatment, anti infection, transfusion of fresh frozen plasma or drainage. For the 34 patients undergoing the second-stage ALPPS, the operation time and volume of intraoperative blood loss were (320±83)minutes and 500 mL(range, 200-6 000 mL). Twelve patients received blood transfusion. There were 12 patients with grade A heptic insufficiency according to criteria of ISGLS and 22 with grade B heptic insufficiency after the second-stage ALPPS. Eighteen patients had grade Ⅰ complications of Clavien-Dindo classification, including 11 with a small pleural effusion, 7 with a small pleural and abdominal effusion; 12 patients had grade Ⅱ complications of Clavien-Dindo classification, including 4 with pneumonia, 4 with coagulation disorders, 3 with massive abdominal effusion, 1 with biliary fistula; 3 patients had grade Ⅲ complications of Clavien-Dindo classification, including 1 with pneumothorax and pneumonia, 1 with massive pleural effusion, 1 with obstructive jaundice; 1 patient had grade Ⅳ complications of Clavien-Dindo classification as pneumonia and anemia. All patients with complications were improved after symptomatic treatment, anti infection, transfusion of fresh frozen plasma or drainage. (3) Follow-up: 40 patients were followed up for 2-35 months, with a median follow-up time of 17 months. The 6-month, 1-, and 2-year survival cases were 35, 26, 21 cases. Conclusion:Three-dimensional visualization technology can clearly show the MHV classification and its relationship with tumor location, which has an important guiding significance in the decision-making of MHV management in ALPPS.

Objective To investigate the clinical efficacy of hepatic artery ringed and restriction operation-associating liver partition and portal vein ligation for staged hepatectomy (HARO-ALPPS) in the treatment of giant hepatocellular carcinoma.Methods The retrospective and descriptive study was conducted.Clinical data of a 45-year-old male patient with giant hepatocellular carcinoma who was admitted to the First Affiliated Hospital of Guangxi Medical University in July 2018 were collected.In the first stage operation,right portal vein ligation+ in situ liver partition + right hepatic artery ringed operation was performed on the patient.In the second stage operation,right hemihepatectomy was performed on the patient.Observation indicators:(1) surgical and postoperative situations of the first stage operation;(2) surgical and postoperative situations of the second stage operation;(3) postoperative pathological examination;(4) changes in future liver remnant (FLR) and tumor volume;(5) perioperative hemodynamic changes of right hepatic artery,proper hepatic artery and left hepatic artery;(6) perioperative hemodynamic changes of left-portal vein and main portal vein;(7) follow-up.Follow-up using outpatient examination was performed to detect the prognosis of patients up to February 2019.Count data were described as absolute number.Results (1) Surgical and postoperative situations of the first stage operation:the patient underwent right portal vein ligation+ in situ liver partition+ right hepatic artery ringed operation successfully.The operation time and volume of intraoperative blood loss were 376 minutes and 400 mL.Inflammatory indicators including body temperature,white blood cells (WBC),C-reactive protein,procalcitonin,and liver function indices including total bilirubin (TBil),albumin (Alb),alanine aminotransferase (ALT),aspartate aminotransferase (AST),ascites,indocyanine green retention rate at15 min (ICG R15),score of model for end-stage liver disease (MELD) before the second stage operation were improved after symptomatic supportive treatment.Prothrombin time (PT) was in the normal range after the first stage operation.There was no complication of Clavien-Dindo classification Ⅱ or above.(2) Surgical and postoperative situations of the second stage operation:the patient underwent right hemihepatectomy successfully.The operation time and volume of intraoperative blood loss were 322 minutes and 900 mL.The patient received 300 mL of fresh frozen plasma infusion.Inflammatory indicators including body temperature,C-reactive protein,and liver function indices including Alb,ALT,AST,ascites,were recoved to normal level after symptomatic supportive treatment.WBC,procalcitonin,TBil,and PT were in the normal range.There was no complication of Clavien-Dindo classification Ⅱ or above.(3) Postoperative pathological examination:① Ⅱ stage hepatocellular carcinoma was confirmed,mass-like type,with tissue necrosis and microvascluar invasion.There was no distal metastasis and tumor did not invade liver capsule or surgical margin.Ishak score of surrounding tissues was 3 in the inflammation and 2 in the fibrosis.② Chronic inflammation was detected in the gallbladder mucosa.③ Reactive hyperplasia was found in the 2 lymph nodes of the group 8.④ One in the group 12 lymph nodes showed reactive hyperplasia.Immunohistochemistry showed positive Glypican-3,Hepatocyte,Arginase-1,NM23,weakly positive vascular endothelial growth factor,and negative Ki-67,vascular endothelial cell marker CD34,biliary epithelial marker CK19 and CK 7,tumor suppressor gene P21 and P23.(4) Changes in FLR and tumor volume:FLR was 565 mL and 580 mL at the 5th and 14th day after the first stage operation respectively,accounting for 54％ and 57％ of total liver volume.The FLR to body weight ratio was 0.96 and 0.98,and the growth rate of FLR was 194％ and 202％.Tumor volume was 1 210 mL and 1 297 mL at the 5th and 14th day after the first stage operation respectively.Tumor necrosis volume was 635 mL and 500 mL at the 5th and 14th day after the first stage operation respectively.At the 5th and 14th day after the first stage operation,the liver CT examination showed that HARO was successfully underwent and the blood supply of remnant liver was good.Preoperative CT aothgraphy (CTA) examination showed that the right hepatic tumor had rich arterial blood supply.At the 5th day after the first stage operation,the CTA examination confirmed the ringed site of right hepatic artery,and the blood supply of the tumor gradually decreased.At the 14th day after the first stage operation,CTA examination showed significant decrease in the blood supply of liver tumors.Liver CT examination showed rich supply of the remnant liver and the liver volume of 829 mL at the 7th day after the second stage operation.(5) Perioperative hemodynamic changes of the right hepatic artery,proper hepatic artery and left hepatic artery.① Blood flow of right hepatic artery was 224.3,574.7,827.5,222.7,153.0,282.5,279.1,247.9 and 150.2 mL/min before the first stage operation,before right portal vein ligation,after right portal vein ligation and before right hepatic artery ringed and restriction,after right portal vein ligation and right hepatic artery ringed and restriction,at the 1st,3th,5th and 7th day after the first stage operation.Blood flow of right hepatic artery in the second stage operation was 505.0 mL/min.② Blood flow of proper hepatic artery was 399.7,793.5,830.5,1 075.4,784.7.5,821.2,722.8,467.4 and 555.4 mL/min before the first stage operation,before right portal vein ligation,after right portal vein ligation and before right hepatic artery ringed and restriction,after right portal vein ligation and right hepatic artery ringed and restriction,at the 1st,3th,5th and 7th day after the first stage operation.Blood flow of proper hepatic artery was 505.0,473.3,158.5,627.0,103.8 and 139.8 mL/min before right hepatectomy in the second stage operation,after right hepatectomy,at the 1st,3th and 5th day after the second operation,respectively.③ Blood flow of left hepatic artery was 147.5,13.8,19.4,16.2,62.1,93.9,67.1,30.8 and 106.1 mL/min before the first stage operation,before right portal vein ligation,after right portal vein ligation and before right hepatic artery ringed and restriction,after right portal vein ligation and right hepatic artery ringed and restriction,at the 1st,3th,5th,7th and 10th day after the first stage operation.Blood flow ot left hepatic artery was 52.0,43.2,112.4,103.6,80.7 and 56.1 mL/min before right hepatectomy in the second stage operation,after right hepatectomy,at the 1st,3th and 5th day after the second operation,respectively.(6) Perioperative hemodynamic changes of left-portal vein and main portal vein.① Blood flow of left portal vein was 552.6,181.2,412.2,320.0,1 777.7,1 284.7,749.5 and 484.2 mL/min before the first stage operation,before right portal vein ligation,after right portal vein ligation and right hepatic artery ringed and restriction,at the 1st,3th,5th,7th and 10th day after the first stage operation,respectively.Blood flow of left portal vein was 793.3,979.0,485.2,1 042.5,803.5 and 548.3 mL/min before right hepatectomy in the second stage operation,after right hepatectomy,at the 1st,3th,5th and 7th day after the second operation respectively.② Blood flow of main portal vein was 1 186.0,696.7,833.7,431.7,1 319.1,668.4,890.7,550.8 mL/min before the first stage operation,before right portal vein ligation,after right portal vein ligation and right hepatic artery ringed and restriction,at the 1st,3th,5th,7th and 10th day after the first stage operation,respectively.Blood flow of main portal vein was 846.4,937.4,891.2,1 671.0,2 697.8,and 1 230.0 mL/min before right hepatotectomy in the second stage operation,after right hepatectomy,at the 1st,3th,5th and 7th day after the second stage operation,respectively.(7) Follow up:the patient was followed up for 6 months and survived well,with Child A of liver function and normal alpha fetoprotein level.Liver contrast CT examination showed increase in the remnant liver,good blood supply,and no tumor recurrence.The FLR was 727 mL at the 2 months after operation.Conclusion For patients with giant hepatocellular carcinoma,HARO-ALPPS can be performed to decrease blood supply of tumor,increase tumor necrosis area,and reduce the incidence of intrahepatic arteriovenous fistula,which ensure blood supply of remnant liver hyperplasia.