The level of urinary albumin is a critical indicator for the early diagnosis and management of chronic kidney disease (CKD). However, existing methods for detecting albumin are not conducive to point-of-care testing due to the complexity of reagent addition and incubation processes. This study presents a smartphone-integrated handheld automated biochemical analyzer (sHABA) designed for point-of-care testing of urinary albumin. The sHABA features a pre-loaded, disposable reagent cassette with reagents for the albumin assay arranged in the order of their addition within a hose. The smartphone-integrated analyzer can drive the reagents following a preset program, to enable automatic sequential addition. The sHABA has a detection limit for albumin of 5.9 mg/L and a linear detection range from 7 to 450 mg/L. The consistency of albumin level detection in 931 urine samples using sHABA with clinical tests indicates good sensitivity (95.78%) and specificity (90.16%). This research advances the field by providing an automated detection method for albumin in a portable device, allowing even untrained individuals to monitor CKD in real time at the patient's bedside. In the context of promoting tiered diagnosis and treatment, the sHABA has the potential to become an essential tool for the early diagnosis and comprehensive management of CKD and other chronic conditions.

Existing traditional Chinese medicine (TCM)-related databases are still insufficient in data standardization, integrity and precision, and need to be updated urgently. Herein, an Encyclopedia of Traditional Chinese Medicine version 2.0 (ETCM v2.0, http://www.tcmip.cn/ETCM2/front/#/) was constructed as the latest curated database hosting 48,442 TCM formulas recorded by ancient Chinese medical books, 9872 Chinese patent drugs, 2079 Chinese medicinal materials and 38,298 ingredients. To facilitate the mechanistic research and new drug discovery, we improved the target identification method based on a two-dimensional ligand similarity search module, which provides the confirmed and/or potential targets of each ingredient, as well as their binding activities. Importantly, five TCM formulas/Chinese patent drugs/herbs/ingredients with the highest Jaccard similarity scores to the submitted drugs are offered in ETCM v2.0, which may be of significance to identify prescriptions/herbs/ingredients with similar clinical efficacy, to summarize the rules of prescription use, and to find alternative drugs for endangered Chinese medicinal materials. Moreover, ETCM v2.0 provides an enhanced JavaScript-based network visualization tool for creating, modifying and exploring multi-scale biological networks. ETCM v2.0 may be a major data warehouse for the quality marker identification of TCMs, the TCM-derived drug discovery and repurposing, and the pharmacological mechanism investigation of TCMs against various human diseases.

Objective:To investigate the reliability and repeatability of 3 classification systems for coronal fractures of distal humerus.Methods:Included were the imaging data (X-ray and CT scan) of the 64 patients with distal humeral coronal fracture who had been admitted to the outpatient and emergency departments of Beijing Jishuitan Hospital from January, 2015 to December, 2021. Four orthopedic surgeons (1 chief surgeon, 1 associate chief surgeon, 1 attending surgeon, and 1 resident surgeon) served as observers who classified the fractures by their imaging data respectively according to the Bryan-Morrey, Ring and Dubberley classifications. Four weeks later when the imaging data of 64 patients were renumbered, the 4 orthopedic surgeons performed the same classifications again. Inter-observer and intra-observer Kappa values were calculated for the 3 classifications. Landis and Koch Kappa's Benchmark Scale was used to interpret the results.Results:Interobserver confidence: The average agreement of the Bryan-Morrey classification was 75.0%, and its Kappa value was 0.546, indicating moderate agreement. The average consistency of Ring classification was 74.7%, and its Kappa value was 0.702, indicating high consistency. The average consistency of Dubberley classification was 84.1%, and its Kappa value was 0.785, indicating high consistency. Intra-observer repeatability: The average consistency of Bryan-Morrey classification was 89.9% and its Kappa value was 0.824 for the same observer. The average consistency of Ring classification was 91.0%, and its Kappa value was 0.884. The average consistency of Dubberley classification was 91.8%, and its Kappa value was 0.888.Conclusions:The 3 classification systems for distal humeral coronal fractures all demonstrate high reproducibility. As the Dubberley classification system is relatively more reliable, it has a certain guiding value for the treatment of coronal fractures of the distal humerus. However, in clinical practice, an optimal surgical strategy should take into account various factors that may affect fracture typing.

Objective:To compare the differences in the prevalence of mild micro-hepatic encephalopathy (MHE) among patients with cirrhosis by using the psychometric hepatic encephalopathy score (PHES) and the Stroop smartphone application (Encephal App) test.Methods:This prospective, multi-center, real-world study was initiated by the National Clinical Medical Research Center for Infectious Diseases and the Portal Hypertension Alliance and registered with International ClinicalTrials.gov (NCT05140837). 354 cases of cirrhosis were enrolled in 19 hospitals across the country. PHES (including digital connection tests A and B, digital symbol tests, trajectory drawing tests, and serial management tests) and the Stroop test were conducted in all of them. PHES was differentiated using standard diagnostic criteria established by the two studies in China and South Korea. The Stroop test was evaluated based on the criteria of the research and development team. The impact of different diagnostic standards or methods on the incidence of MHE in patients with cirrhosis was analyzed. Data between groups were differentiated using the t-test, Mann-Whitney U test, and χ2 test. A kappa test was used to compare the consistency between groups. Results:After PHES, the prevalence of MHE among 354 cases of cirrhosis was 78.53% and 15.25%, respectively, based on Chinese research standards and Korean research normal value standards. However, the prevalence of MHE was 56.78% based on the Stroop test, and the differences in pairwise comparisons among the three groups were statistically significant (kappa = -0.064, P < 0.001). Stratified analysis revealed that the MHE prevalence in three groups of patients with Child-Pugh classes A, B, and C was 74.14%, 83.33%, and 88.24%, respectively, according to the normal value standards of Chinese researchers, while the MHE prevalence rates in three groups of patients with Child-Pugh classes A, B, and C were 8.29%, 23.53%, and 38.24%, respectively, according to the normal value standards of Korean researchers. Furthermore, the prevalence rates of MHE in the three groups of patients with Child-Pugh grades A, B, and C were 52.68%, 58.82%, and 73.53%, respectively, according to the Stroop test standard. However, among the results of each diagnostic standard, the prevalence of MHE showed an increasing trend with an increasing Child-Pugh grade. Further comparison demonstrated that the scores obtained by the number connection test A and the number symbol test were consistent according to the normal value standards of the two studies in China and South Korea ( Z = -0.982, -1.702; P = 0.326, 0.089), while the other three sub-tests had significant differences ( P < 0.001). Conclusion:The prevalence rate of MHE in the cirrhotic population is high, but the prevalence of MHE obtained by using different diagnostic criteria or methods varies greatly. Therefore, in line with the current changes in demographics and disease spectrum, it is necessary to enroll a larger sample size of a healthy population as a control. Moreover, the establishment of more reliable diagnostic scoring criteria will serve as a basis for obtaining accurate MHE incidence and formulating diagnosis and treatment strategies in cirrhotic populations.

Objective:To investigate the analgesic effect of intravenous anesthesia induction combined with anterior quadratus lumborum block (AQLB)and related hemodynamic changes in patients undergoing laparoscopic retroperitoneal partial nephrectomy (RPN).Methods:A total of 116 patients undergoing elective laparoscopic partial nephrectomy for renal tumors in Jinhua Central Hospital from August 2021 to February 2022 were randomly divided into two groups with 58 cases in each group. Patients in control group received intravenous anesthesia , while those in study group received intravenous anesthesia induction with AQLB. The analgesic effect was evaluated at 1, 6, 12, 24, and 48 h after the operation. The hemodynamics were monitored at the time of entering the operating room (T 0), 3 min after induction of anesthesia (T 1), at the beginning of the operation (T 2), after the operation (T 3), and leaving the operating room (T 4). Microcirculation was assessed at 1, 6, 12, 24, and 48 h after operation. Cognitive function was assessed 30min before anesthesia, 6 h, 24 h, and 72 h after operation. Results:At 1, 6, 12, 24 and 48 h after operation, the visual analogue scale (VAS) of the resting (quiet state) pain in the study group were 3.2±1.2, 2.6±0.3,2.0±0.4, 1.5±0.4 and 0.8±0.2, which were significantly lower than those in control group (4.0±1.7, 3.4±0.7, 2.9±0.5, 1.7±0.5 and 1.2±0.3) ( t=2.93, P=0.004; t=8.00, P<0.001; t=10.07, P<0.001; t=2.38, P=0.019; t=8.45, P<0.001). There was no significant difference in heart rate and mean arterial pressure (MAP) at T 0 between two groups ; no significant difference in the heart rate at T 1, T 2, T 3 and T 4. There were significant differences in MAP levels at T 1, T 2, T 3 and T 4 between study group [(80.0±8.0)mmHg (1 mmHg=0.133 kPa), (84.4±8.4)mmHg, (80.4±5.7)mmHg, (86.4±4.7)mmHg and control group (77.1±7.5)mmHg, (88.0±8.6)mmHg, (83.0±7.7)mmHg, (92.2±6.2) mmHg; t=2.01, P=0.046; t=2.28, P=0.024; t=2.07, P=0.041; t=5.68, P<0.001]. At 6, 12, 24 and 48 h after operation, the morphological scores of tube loops in the study group were 1.0±0.2, 0.8±0.2, 0.7±0.1 and 0.7±0.1, which were lower than those in the control group (1.1 ±0.2, 0.9±0.2, 0.8±0.2 and 0.8±0.1; t=2.69, P=0.008; t=2.69, P=0.008; t=3.41, P=0.001; t=5.39 , P < 0.001). The blood flow status scores of the study group were 1.1±0.2, 0.9±0.2, 0.8±0.2 and 0.6±0.1, which were lower than those of the control group (1.2±0.2, 1.0±0.2, 0.9±0.2 and 0.7±0.1; t=2.69, P=0.008; t=2.69, P=0.008; t=2.69, P=0.008; t=5.39, P<0.001). The cognitive function scores of the study group and the control group were 24.4±1.0, 27.1±0.9 and 23.5±0.9, 26.7±0.9 at 6 h and 24 h after operation ( t=5.10, P<0.001; t=2.39, P=0.018); while there were no significant at 72 h after operation between two groups (28.2±0.9 vs. 28.1±0.8, t=0.63, P=0.529). Conclusion:Intravenous anesthesia induction combined with anterior quadratus lumborum block has a good analgesic effect in patients undergoing RPN, with stable hemodynamics and microcirculation, and not affecting cognitive function of patients.

Objective:To analyze the clinical phenotype and molecular pathogenesis of nine patients with hereditary factor Ⅴ (FⅤ) deficiency.Methods:Nine patients with hereditary FⅤ deficiency who were admitted to the Institute of Hematology and Blood Diseases Hospital from April 1999 to September 2019 were analyzed. The activated partial thromboplastin time, prothrombin time, and FⅤ procoagulant activity (FⅤ∶C) were measured for phenotypic diagnosis. High-throughput sequencing was employed for the F5 gene mutation screening, Sanger sequencing was adopted to confirm candidate variants and parental carrying status, Swiss-model was used for three-dimensional structure analysis, and ClustalX v.2.1 was used for homologous analysis.Results:The FⅤ∶C of the nine patients ranged from 0.1 to 10.6. Among them, eight had a hemorrhage history, with kin/mucosal bleeding as the most common symptom (three cases, 37.5%) , whereas one case had no bleeding symptom. There were five homozygotes and four compound heterozygotes. A total of 12 pathogenic or likely pathogenic mutations were detected, of which c.6100C>A/p.Pro2034Thr, c.6575T>C/p.Phe2192Ser, c.1600_1601delinsTG/p. Gln534*, c.4713C>A/p.Tyr1571*, and c.952+5G>C were reported for the first time.Conclusion:The newly discovered gene mutations enriched the F5 gene mutation spectrum associated with hereditary FⅤ deficiency. High-throughput sequencing could be an effective method to detect F5 gene mutations.

Objective To investigate the risk factors of perioperative complications of laparoscopic radical distal gastrectomy and influence of body shape on the short-term therapeutic effects.Methods The retrospective case-control study was conducted.The clinicopathological data of 506 patients (328 males and 178 females,average age 60 years with the range of 24-85 years) who underwent laparoscopic radical distal gastrectomy+D2 lymph nodes dissection in the 8 clinical centers between March 2016 and November 2018 were collected,including 143 in the First Affiliated Hospital of Xiamen University,66 in the Affiliated Hospital of Qinghai University,66 in the Second Affiliated Hospital of Wenzhou Medical University,64 in the Zhongshan Hospital of Xiamen University,54 in the Affiliated Hangzhou First people's Hospital of Zhejiang University School of Medicine,48 in the Zhangzhou Affiliated Hospital of Fujian Medical University,35 in the Affiliated Quanzhou First Hospital of Fujian Medical University,30 in the Second Affiliated Hospital of Xiamen Medical College.The maximum thickness of subcutaneous fat at the level of umbilicus (USCF),the maximum vertical distance between the anterior abdominal skin and the back skin at the level of the umbilicus (UAPD),the maximum horizontal distance between the anterior abdominal skin and the back skin at the level of the umbilicus (UTD),the maximum verticaldistance between the anterior abdominal skin and the back skin at the level of the xiphoid bone (XAPD),the maximum horizontal distance between the.anterior abdominal skin and the back skin at the level of the xiphoid bone (XTD),the distance between the anterior abdominal skin and the root of celiac artery (CAD) and the maximum horizontal distance at a right angle to CAD (CATD) were measured using preoperative imaging examinations.Observation indicators:(1) intraoperative and postoperative situations;(2) follow-up situations;(3) risk factors analysis of perioperative complications;(4) influence of body shape related indexes on intraoperative situations and postoperative recovery:① Pearson univariate correlation analysis,② liner regression model analysis.Followup using outpatient examination and telephone interview was performed to detect the postoperative survival and tumor recurrence or metastasis up to December 2018.Measurement data with normal distribution were represented as Mean±SD.Measurement data with skewed distribution were described as M (range).Comparisons of count data were analyzed using the chi-square test.Comparisons of ordinal data were analyzed by Mann-Whitney U nonparametric test.Risk factors of perioperative complications of laparoscopic distal gastrectomy were analyzed by Logistic regression model.Influence of body shape related indexes on intraoperative situations and postoperative recovery was analyzed by Pearson univariate correlation analysis and liner regression model.Results (1) Intraoperative and postoperative situations:all the 506 patients underwent successful laparoscopic distal gastrectomy,including 103 with Billroth Ⅰ anastomosis,140 with Billroth Ⅱ anastomosis,201 with Billroth Ⅱ + Braun anastomosis,62 with Roux-en-Y anastomosis.The operation time,volume of intraoperative blood loss,number of lymph nodes dissected,time to postoperative anal exsufflation,time for initial fluid diet intake,time for initial semi-fluid diet intake and duration of postoperative hospital stay were (233±44)minutes,(102±86)mL,34±13,(3.6±1.5)days,(5.8±3.3)days,(8.3±3.8)days,(12.2±5.7)days respectively in the 506 patients.Of 506 patients,196 were defined as pathological stage Ⅰ,122 were defined as pathological stage Ⅱ and 188 were defined as pathological stage Ⅲ postoperatively.Of 506 patients,93 had 106 times of perioperative complications,including 33 times of pulmonary and upper respiratory infection,12 times of incisional infection,11 times of anastomotic leakage,11 times of abdominal infection,8 times of intestinal obstruction,8 times of gastroplegia,6 times of abdominal hemorrhage,5 times of bacteremia,3 times of anastomotic hemorrhage,3 times of lymph fluid leakage,2 times of pancreatic leakage,1 time of urinary infection,1 time of anatomotic stenosis,1 time of deep venous thrombosis and 1 time of pulmonary embolism;the same patient can merge multiple complications.Eleven patients were in the Clavien-Dindo classification ≥ Ⅲ.(2) Follow-up situations:465 of 506 patients were followed up for 1-32 months with a median time of 12 months.During the follow-up,451 had postoperative survival and 38 had tumor recurrence or metastasis.(3) Risk factors analysis of perioperative complications.① Results of univariate analysis showed that age,body mass index (BMI),preoperative hemoglobin,preoperative serum albumin and XAPD were related factors affecting perioperative complications of laparoscopic distal gastrectomy (x2 =10.289,7.427,5.269,5.481,4.285,P＜ 0.05).② Results of multivariate analysis showed that age,BMI,preoperative serum albumin were independent related factors affecting perioperative complications of laparoscopic distal gastrectomy (odds ratio =1.033,1.118,0.937,95％ interval confidence:1.011-1.057,1.025-1.219,0.887-0.990,P＜0.05).(4) Influence of body shape related indexes on intraoperative situations and postoperative recovery.① Results of Pearson univariate correlation analysis showed correlations between UAPD,XAPD,CAD,CATD and volume of intraoperative blood loss (r=0.107,0.169,0.179,0.106,P＜0.05),between UAPD,XAPD,CAD and the number of lymph nodes dissected (r=-0.137,-0.143,-0.173,P＜0.05),between USCF,XAPD and time to postoperative anal exsufflation (r =0.122,0.109,P＜0.05),between USCF,XAPD,CAD and time for initial fluid diet intake (r=0.132,0.108,0.132,P＜0.05),between USCF,XAPD and duration of postoperative hospital stay (r=0.116,0.100,P＜0.05).② Results of liner regression model analysis showed a positive correlation between CAD and volume of intraoperative blood loss (r =6.776),a negative correlation between CAD and the number of lymph nodes dissected (r =-0.841),with statistically significant differences (t =2.410,-1.992,P＜ 0.05);a positive correlation between USCF and time to postoperative anal exsufflation (r=0.170),between USCF and time for initial fluid diet intake (r=0.365),between USCF and duration of postoperative hospital stay (r=0.636) respectively,with statisticallysignificant differences (t =2.188,1.981,2.107,P＜ 0.05).Conclusions Abdominal shape can influence intraoperative situations and postoperative recovery of laparoscopic distal gastrectomy,but cannot increase risks ofperioperative complications.Age,BMI and preoperative serum albumin are independent related factors affecting perioperative complications of laparoscopic distal gastrectomy.

Objective To observe the improving effect of Hypericum Perforatum L Extracts (HPLES)on depression induced by chronic unpredictable mild stress in mice. Methods The depression model was established by the method of chronic unpredictable mild stress. Fifty depression model mice were divided into model control group,fluoxetine hydrochloride group (2. 6 mg / kg),Hypericum perforatum ex-tract low,medium and high (0. 2 g / kg,0. 4 g / kg,0. 8 g / kg) dose groups according to the random num-ber table method. Another 10 normal mice matched with body weight were taken as the normal control group. The mice in normal control group and the model control group were given pure water by gavage every day,and the mice in other groups were given corresponding solution by gavage for 4 weeks. In addition to the normal control group,the mice in other groups continued to undergo chronic unpredictable mild stress during gavage. The sugar water preference test and forced swimming test were performed after the last administration. Blood samples were collected from the posterior orbital venous plexus,and the levels of dopamine (DA) and brain-derived neurotrophic factor (BDNF) were measured by Elisa. The hippocampal tissues of mice were exam-ined by HE staining. Results Compared with the normal control group,the body mass of mice in the model control group decreased significantly at the first,second,third and fourth weeks ( t=2. 739,4. 162,4. 082, 3. 957;all P<0. 05). At the first,second,third and fourth weeks,the body mass of mice in the low,middle and high dose group of Hypericum perforatum extract were not significantly different from those in the model control group (all P>0. 05). Compared with the normal control group,the sugar water preference index of mice in the model control group was significantly reduced((61. 3± 4. 5)%,(52. 6± 5. 2)%; t=2. 721,P<0. 05),the swimming immobility time was prolonged(( 44. 3± 20. 00) s,(101. 8± 50. 8) s;t=2. 939,P<0. 05),the difference were statistically significant. Compared with the model control group,the sugar water preference index of mice in the low,middle and high dose group of Hypericum perforatum extract increased ((61. 8±4. 7)%,(65. 2±4. 1)%,(62. 6±5. 6)%,t=-3. 005,5. 073,-2. 928,all P<0. 05),the swimming immobility time decreased ((47. 2±17. 9) s,(54. 8±50. 3) s,(61. 3±44. 2) s; t=2. 803,1. 921,1. 903,all P<0. 05). The results of Elisa showed that compared with the normal control group,the levels of serum DA and BDNF of mice in the model control group were significantly lower (t=3. 031,8. 507,all P<0. 05); com-pared with the model control group,the levels of serum DA of mice in the low dose and high dose group of Hypericum perforatum were significantly higher (t=5. 025,3. 414,P<0. 05),and the serum BDNF of mice in the high dose group of Hypericum perforatum was also significantly higher (t=6. 098,P<0. 05),the differ-ence was statistically significant. HE staining showed that compared with the normal control group,the neu-rons in CA3 area of hippocampus in the model control group mice were seriously damaged,suggesting the es-tablishment of the mouse model. Compared with the model control group,the atrophy and degeneration of hippocampal CA3 cells in the three dose groups were significantly reduced. The atrophy and deformation of hippocampal CA3 neurons in the low,middle and high dose groups of Hypericum perforatum extract were re-lieved. Conclusion HPLES have obvious improving and antidepressant effects on the depression model mice induced by chronic unpredictable stress. The above effects may be related to the improvement of serum DA,DBNF level and reduce neuronal damage in CA3 area.

Objective: To observe the improving effect of Hypericum Perforatum L Extracts (HPLES)on depression induced by chronic unpredictable mild stress in mice. Methods: The depression model was established by the method of chronic unpredictable mild stress. Fifty depression model mice were divided into model control group, fluoxetine hydrochloride group (2.6 mg / kg), Hypericum perforatum extract low, medium and high (0.2 g / kg, 0.4 g / kg, 0.8 g / kg) dose groups according to the random number table method. Another 10 normal mice matched with body weight were taken as the normal control group. The mice in normal control group and the model control group were given pure water by gavage every day, and the mice in other groups were given corresponding solution by gavage for 4 weeks. In addition to the normal control group, the mice in other groups continued to undergo chronic unpredictable mild stress during gavage.The sugar water preference test and forced swimming test were performed after the last administration. Blood samples were collected from the posterior orbital venous plexus, and the levels of dopamine (DA) and brain-derived neurotrophic factor (BDNF) were measured by Elisa. The hippocampal tissues of mice were examined by HE staining. Results: Compared with the normal control group, the body mass of mice in the model control group decreased significantly at the first, second, third and fourth weeks (t=2.739, 4.162, 4.082, 3.957; all P<0.05). At the first, second, third and fourth weeks, the body mass of mice in the low, middle and high dose group of Hypericum perforatum extract were not significantly different from those in the model control group (all P>0.05). Compared with the normal control group, the sugar water preference index of mice in the model control group was significantly reduced((61.3±4.5)%, (52.6±5.2)%; t=2.721, P<0.05), the swimming immobility time was prolonged((44.3±20.00) s, (101.8±50.8) s; t=2.939, P<0.05), the difference were statistically significant. Compared with the model control group, the sugar water preference index of mice in the low, middle and high dose group of Hypericum perforatum extract increased((61.8±4.7)%, (65.2±4.1)%, (62.6±5.6)%, t=-3.005, 5.073, -2.928, all P<0.05), the swimming immobility time decreased ((47.2±17.9) s, (54.8±50.3) s, (61.3±44.2) s; t=2.803, 1.921, 1.903, all P<0.05). The results of Elisa showed that compared with the normal control group, the levels of serum DA and BDNF of mice in the model control group were significantly lower (t=3.031, 8.507, all P<0.05); compared with the model control group, the levels of serum DA of mice in the low dose and high dose group of Hypericum perforatum were significantly higher (t=5.025, 3.414, P<0.05), and the serum BDNF of mice in the high dose group of Hypericum perforatum was also significantly higher (t=6.098, P<0.05), the difference was statistically significant. HE staining showed that compared with the normal control group, the neurons in CA3 area of hippocampus in the model control group mice were seriously damaged, suggesting the establishment of the mouse model. Compared with the model control group, the atrophy and degeneration of hippocampal CA3 cells in the three dose groups were significantly reduced. The atrophy and deformation of hippocampal CA3 neurons in the low, middle and high dose groups of Hypericum perforatum extract were relieved. Conclusion HPLES have obvious improving and antidepressant effects on the depression model mice induced by chronic unpredictable stress.The above effects may be related to the improvement of serum DA, DBNF level and reduce neuronal damage in CA3 area.

Objective To investigate the short-term clinical effects of selecting duodenal transection timing on laparoscopic-assisted distal gastrectomy (LADG).Methods The retrospective cohort study was conducted.The clinicopathological data of 239 gastric cancer (GC) patients undergoing LADG in the 5 medical centers between March 2016 and March 2018 were collected,including 104 in the First Affiliated Hospital of Xiamen University,45 in Zhangzhou Affiliated Hospital of Fujian Medical University,35 in Quanzhou Affiliated Hospital of Fujian Medical University,30 in the Second Affiliated Hospital of Xiamen Medical College,25 in Zhongshan Hospital of Xiamen University.Of 239 patients undergoing LADG + D2 lymph node dissection,107 receiving duodenal transection and then lymph node dissection in the upper region of pancreas after lymph node dissection in the lower region of pylorus and 132 receiving lymph node dissection in the upper region of pancreas and then duodenal transection were respectively divided into anterior approach group and posterior approach group.Sixty-four,8,16,14 and 5 patients in the anterior approach group and 40,37,19,16 and 20 patients in the posterior group respectively came from the First Affiliated Hospital of Xiamen University,Zhangzhou Affiliated Hospital of Fujian Medical University,Quanzhou Affiliated Hospital of Fujian Medical University,Second Affiliated Hospital of Xiamen Medical College and Zhongshan Hospital of Xiamen University.Observation indicators:(1) surgical and postoperative situations;(2) postoperative complications;(3) stratified analyses of surgical and postoperative situations in patients with different TNM staging,body mass index (BMI) and maximum tumor dimension;(4) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival and tumor recurrence or metastasis up to April 2018.Measurement data with normal distribution were represented as (-x)±s,and comparison between groups was analyzed using the independent-samples t test.Measurement data with skewed distribution were described as M (Q),and comparison between groups was analyzed using the nonparametric test.Comparisons of count data were analyzed using chi-square test or Fisher exact probability.Comparison of ordinal data was done by the rank-sum test.Results (1) Surgical and postoperative situations:all the patients underwent successful operation,without perioperative death.Number of lymph node dissection in the upper region of pylorus in the anterior and posterior approach groups were respectively 3.9±2.6 and 3.0±2.5,with a statistically significant difference between groups (t=2.778,P＜0.05).Cases with Billroth Ⅰ,Billroth Ⅱ,Billroth Ⅱ +Bruan and Roux-en-Y of digestive tract reconstruction,operation time,dissected times of lymph nodes in greater curvature of stomach,lower region of pylorus,upper region of pancreas and lesser curvature of stomach,cases with visible port vein,volume of intraoperative blood loss,number of overall lymph node dissection,numbers of lymph node dissection in greater curvature of stomach,lower region of pylorus,upper region of pancreas and lesser curvature of stomach,time to postoperative anal exsufflation,time for postoperative fluid diet intake,time for postoperative semi-fluid diet intake,intraperitoneal drainage-tube removal time and duration of postoperative hospital stay were respectively 16,32,47,12,(233.0±41.0)minutes,(14.6±5.4)tninutes,(21.9±6.3)nminutes,(32.7±6.8) minutes,(7.4±2.9)minutes,74,(87±73)mL,35.0±10.0,8.5±4.1,4.8±4.2,13.3±5.2,4.3± 3.3,(4.1±2.6)days,(5.4±2.8) days,(7.9± 3.5) days,(8.9± 2.9) days,(11.7± 4.5) days in the anterior approach group and 17,47,61,7,(243.0±44.0) minutes,(15.7±5.2) minutes,(23.1±8.0) minutes,(34.2±7.1) minutes,(7.9±2.8)minutes,79,(93±57)mL,33.0±10.0,8.1±4.8,5.3±4.9,12.5±5.6,3.8±2.4,(3.8±3.3)days,(5.0±3.6)days,(7.5±4.0) days,(8.5±3.8)days,(11.3±5.7) days in the posterior approach group,with no statistically significant difference between groups (x2 =3.431,t =-1.836,-1.546,-1.324,-1.634,-1.228,x2=2.552,t=-0.684,1.630,0.797,-0.871,1.148,1.314,0.954,0.951,0.884,1.065,0.694,P＞0.05).(2) Postoperative complications:cases with overall complications,anastomotic leakage,anastomotic stenosis,anastomotic bleeding,pancreatic fistula,postoperative gastroparesis,intra-abdominal hemorrhage,incision infection,pneumonia,intra-abdominal infection,bacteremia,intestinal obstruction,endolymphatic leakage,Clavien-Dindo grade Ⅰ,Ⅱ,Ⅲa,Ⅲb and Ⅳa of postoperative complications were respectively 15,1,1,1,0,3,1,2,3,0,1,3,0,3,9,1,2,0 in the anterior approach group and 25,3,0,1,2,2,2,5,7,3,2,3,1,6,14,1,2,2 in the posterior approach group,with no statistically significant difference between groups (x2=1.027,0.643,0.022,0.479,0.161,0.765,0.921,0.161,0.063,Z=-1.055,P＞0.05).Patients in 2 groups with complications were cured by symptomatic treatment.(3) Stratified analyses of surgical and postoperative situations in patients with different TNM staging,BMI and maximum tumor dimension:operation time,dissected times of lymph nodes in upper region of pancreas,cases with visible port vein,number of overall lymph node dissection,numbers of lymph node dissection in upper region of pylorus and upper region of pancreas were respectively (236.0±41.0)minutes,(33.9±6.2) minutes,32,36.0±12.0,3.8±3.0,13.4±5.5 in patients of the anterior approach group with Ⅲ stage of TNM staging and (253.0± 45.0) minutes,(36.5 ±7.0) minutes,29,31.0±t9.0,2.5±2.0,11.4±4.6 in patients of the posterior approach group with Ⅲ stage of TNM staging,with statistically significant differences between groups (t =-1.988,-2.066,x2 =4.686,t =2.472,2.757,2.016,P＜0.05).Numbers of overall lymph node dissection and number of lymph node dissection in upper region of pylorus were respectively 37.0± 12.0,3.6±3.1 in patients of the anterior approach group with BMI ≥ 25 kg/m2 and 30.0±7.0,2.0± 1.3 in patients of the posterior approach group with BMI ≥ 25 kg/m2,with statistically significant differences between groups (t =2.211,2.205,P＜0.05).Volume of intraoperative blood loss and number of lymph node dissection in upper region of pylorus were respectively (80±45) mL,4.0±2.6 in patients of the anterior approach group with maximum tumor dimension ≥ 3.3 cm and (110±67)mL,2.8± 1.8 in patients of the posterior approach group with maximum tumor dimension ≥ 3.3 cm,with statistically significant differences between groups (t =-2.320,2.589,P ＜ 0.05).(4) Follow-up and survival:of 239 patients,202 were followed up for 2-24 months,with a median time of 12 months,including 89 in the anterior approach group and 113 in the posterior approach group.During the follow-up,cases with overall survival,tumor recurrence and metastasis were respectively 85,3,8 in the anterior approach group and 109,3,11 in the posterior approach group,with no statistically significant difference between groups (x2=0.032,0.089,0.119,P＞0.05).Conclusions Both of anterior approach and posterior approach are safe and feasible in LADG,with equivalent short-term efficacies.The anterior approach in LADG has an advantage of the lymph node dissection in the upper region of pylorus compared with posterior approach,and it also is better for patients with later tumor staging,higher BMI and bigger tumor.