Objective:To discuss the method and clinical outcomes in reconstruction of soft tissue defects on palmar side of thumbs and fingers by transfer of combined full-thickness skin grafting with a great toe fibular flap carrying partial subcutaneous fascial flap.Methods:From December 2019 to December 2023, 11 patients with soft tissue defects on the palmar side of thumbs and fingers were treated in the Department of Hand Surgery Ward One, the Longgang Orthopaedics Hospital of Shenzhen. The patients were 7 males and 4 females, aged 16-55 years old with 26 years old in average. Fibular great toe flaps carrying partial fascial subcutaneous flap were employed. The soft tissue defects of thumbs and fingers were 4.0 cm×3.0 cm-6.0 cm×4.0 cm in size. Fibular great toe flaps carrying partial fascial subcutaneous tissue flap were harvested for reconstruction of the soft tissue defects in palmar digits. The sizes of flaps were 4.0 cm×1.5 cm-6.0 cm×2.0 cm, and the extended area by subcutaneous tissue flap was 4.0 cm×1.5 cm-6.0 cm×2.0 cm. Eight medial foot skins and 3 medial calf skins were applied. All donor sites were directly sutured. All patients were included in the scheduled postoperative follow-up by regular visis of outpatient clinic, and by video and telephone to observe the appearance, function and healing of the flaps and donor sites.Results:All 11 flaps survived, including 1 that had partial necrosis, and healed after dressing changes. The follow-up ranged from 6 to 18 months, with an average of 9 months. Good shape, texture and elasticity of the flaps were achieved. The grasping, pinching and holding functions of digits were all good. According to the British Medical Research Council (BMRC) sensory recovery criteria, the sensation of the flap was recovered to S 3+, with 6 skin graft areas recovered to S 3 and 5 recovered to S 3+. Eight patients had no cold intolerance but 3 had mild cold intolerance with Cold Intolerance Symptom Severity (CISS) scores of 4, 12 and 36, respectively. According to the Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, 10 patients were in excellent and 1 in good. Linear scars were left at the donor sites. The Vancouver Scar Scale (VSS) score at the final follow-up was 2.42 points±0.75 points. The scars were flat or less than 1-2 mm above the skin with the colour close to that of the surrounding normal skin with good softness and without itchiness or pain. Conclusion:The combination of a fibular flap of the great toe with a fasciocutaneous flap and a full-thickness skin graft for reconstruction of the soft tissue defects on the palmar side of the thumbs and fingers can avoid skin grafting from a donor site hence reduce a damage to the donor site. It can be applied as an alternative surgical procedure.

Gallbladder carcinoma is a common malignant tumor of the biliary system characterized by poor specificity of early symptoms， a high degree of malignancy， and rapid progression， and it is difficult to make an early diagnosis. Gallstones and gallbladder polyps are considered the most common risk factors for gallbladder carcinoma. Ultrasound is the preferred examination， while CT， MRI， and PET also have their own advantages. There is a lack of radical treatment methods for gallbladder carcinoma， and surgical operation remains the preferred treatment method for gallbladder carcinoma； however， due to the rapid progression of this disease， most patients have lost the opportunity for surgery at the time of diagnosis. A combination of various treatment modalities， such as radiochemotherapy， targeted therapy， and immunotherapy， has improved the prognosis of patients to a certain extent， but with an unsatisfactory long-term therapeutic effect. Therefore， it is of particular importance to give priority to prevention rather than treatment and emphasize early identification and treatment.

Objective:To explore the practical value of general anesthesia with non-intubated spontaneous breathing in uniportal thoracoscopic surgery in elderly patients.Methods:Clinical data of 86 elderly patients undergone uniportal thoracoscopy surgery during hospitalization at our hospital between March 2020 and December 2021 were retrospectively reviewed and analyzed.Based on the anesthesia intubation method, they were divided into a non-intubated spontaneous breathing video-assisted thoracic surgery group(NI-VATS group)and a one-lung ventilation video-assisted thoracic surgery group(OLV-VATS group), with 43 cases in each group.Data were compared on the inflammatory indexes, preparation time for anesthesia, time to awakening after anesthesia, intraoperative lung collapse score, mediastinal flutter score, time to postoperative feeding, digestive tract complications, sore throat, postoperative pulmonary atelectasis, and hospitalization time.Results:Compared with the OLV-VATS group, the NI-VATS group had a shorter anesthesia preparation time [(19.8±2.6)min vs.(32.3±4.5)min, t=-15.77, P<0.001]and a shorter time to awakening [(6.8±2.1)min vs.(11.9±2.9)min, t=-9.485, P<0.001], slightly poorer operating field during surgery, an unfavorable lung collapse score [(2.5±0.7) vs.(1.8±0.7) t=4.704, P<0.001], worse mediastinal flutter [(2.1±0.6) vs.(1.3±0.5), t=6.514, P<0.001]. Lower procalcitonin(PCT)[(0.189±0.130)μg/L vs.(0.264±0.123)μg/L, t=-2.744, P=0.007), a shorter time to postoperative feeding [(3.4±1.0)h vs.(5.5±1.0)h, t=-9.55, P<0.001], and lower rates of digestive tract reactions(4.7% vs.20.9%, χ2=5.108, P=0.024)and throat pain(4.7% vs.23.3%, χ2=6.198, P=0.013), and a shorter length of hospital stay [(3.8±0.3)d vs.(4.9±0.8)d, t=-7.266, P<0.001]. Conclusions:For the elderly patients undergoing uniportal thoracoscopic surgery, non-intubated spontaneous breathing may somewhat obstruct the operating field, but it can shorten the time of anesthesia and the time to awakening, does not increase complications from anesthesia and surgery, favors rapid postoperative recovery for patients and therefore should be promoted.

Objective:To investigate the technique and clinical effect of repairing 2 soft tissue defects on the same finger with a pedicled tandem flap of the first dorsal metatarsal artery and the second toe tibial artery.Methods:From March, 2018 to May, 2020, 8 patients, which were 5 males and 3 females, with 2 soft tissue defects in the same finger, were repaired with the first dorsal metatarsal artery flap in series with the second toe tibial flap. The causes of injury: 4 by crush, 2 by heavy object, and 2 by thermal press. There were 4 defects on index fingers, 2 on middle fingers and 2 on ring fingers. The defects ranged from 2.0 cm×2.5 cm to 2.5 cm×3.0 cm. All defects had exposed bone or tendon at varying degrees and 3 with phalanx fractures. Three patients underwent emergency surgery, the other 5 had sub-emergency surgery which were performed 3 to 5 days after the injury. The size of the flaps was 2.0 cm×2.5 cm to 3.0 cm×3.5 cm. The donor sites were sutured directly in 3 patients and 5 patients received skin grafting. The regular follow-up was performed. The survival of flaps, character, feeling and Total active motion(TAM), recovery of the foot donor area and complications were observed.Results:The operation time ranged from 2.0 to 5.5 hours, with an average of 3.5 hours. No vascular crisis occurred and all flaps survived after the surgery. All patients entered follow-up for 3-20 months, with an average of 8 months. The flaps had a good plump appearance, soft texture, good elasticity, and with a high similarity to the surrounding skin. The TPD of the flaps was 6-15 mm, with an average of 8 mm. The fingers had good flexion and extension functions. The incision in the donor site of the foot healed by first intention. The walking, running and jumping were normal without pain or discomfort.Conclusion:The first dorsal metatarsal artery-second toe tibial artery tandem flap has been used to repair 2 soft tissue defects in same finger. It simplifies the revascularisation of the flap together with exact surgical curative effect.

Objective To discuss the clinical effect of transplantation of slice nail bed flap of great toe with vascular anastomosis in repair of partial nail-bed and soft tissue defect at fingers.Methods From January,2015 to March,2018,16 cases (16 fingers) of partial nail-bed defect at fingers were repaired with transplantation of slice nail bed flap of great toe with vascular anastomosis.All cases were combined with palmar soft tissue defect at distal segment fingers.The area of nail bed defects were from 0.8 cr×0.5 cm to 1.2 cm×1.0 cm.The area of soft tissue defects were from 1.2 cm×1.0 cm to 2.5 cm×1.5 cm.The average time from injury to operation was 3.6 hours after injuries (ranging from 1 hour to 8 hours).The area of slice nail bed flap incised during operation were from 2.5 cm×1.2 cm to 3.2 cm×1.8 cm,and the donor site was sutured directly.All patients were followed-up regularly for nail appearance,function and donor healing.Among them,11 cases were followed-up by clinic,4 cases by WeChat,and telephone follow-up was performed in 1 case.Results The nail-bed flap after transplantation survived successfully.The followed-up time were from 6 to 18 months,the average time was 9 months.Longitudinal spine and rough appearance occurred in 1 case.Others were flat,smooth,complete attachment of nail body and nail bed.The flaps had good appearance,texture and elasticity at 6 months after surgery,and two-point discrimination was 6-12 mm(average,8 mm).The toenails at donor sites grew well.No walk-associated pain after long-term following-up.Six months after surgery,according to standard for efficacy evaluation of nail regeneration,12 cases were excellent,3 cases were good and 1 case was acceptable.Conclusion Transplantation of slice nail bed flap of great toe with vascular anastomosis in repair of partial nail-bed and soft tissue defect at fingers is one of the effective methods for repairing nail-bed defect at fingers.

Objective To investigate the surgical methods and clinical effect of repairing the thumb tip defects in infants by applying the reversed first dorsal metacarpal radial artery island flaps along with anatomosing of nerves and veins.Methods Twenty-one cases with soft tissue defects of thumb tips caused by trauma were admitted from August,2015 to August,2017.The first dorsal metacarpal radial island artery flaps were transplanted reversely to repair the defects along with the anatomosis of nerves and veins.Among all the cases,the range of defect area was 2.0 cm×1.8 cm-3.0 cm×2.5 cm.The area range of the flap harvested during the surgery was 2.2 cm×2.0 cm-3.2 cm×2.7 cm.The regular post-operative followed-up was performed.Results All flaps survival after the surgeries,and the wounds were I-staged healing.All cases were followed-up by 3-18 months,and the average time was 7 months.The appearance and quality of the flaps were good.The range of motion of the metacarpophalangeal joints and interphalangeal joints was normal.According to the Upper Extremity Functional Evaluation Tentative Criteria set up by Hand Surgery Branch of Chinese Medical Association,14 cases were excellent,5 case was good,and 2 cases were fair.Conclusion The surgery of using the first dorsal metacarpal radial reversed island artery flap to repair the defect of thumb tip in infant,along with the anatomosis of nerve and vein,is a good method in repairing the defects due to its ease of operation,achievement of plump of finger tip and good recovery of appearance and sensation after the surgery.

Objective To explore the clinical effect of using hallux-nail flap with the distal part of phalanx combined with iliac bone for reconstruction of thumb with Ⅲ degree defect.Methods From June,2011 to June,2016,7 patients with thumb Ⅲ degree defect were treated with the hallux-nail flaps with distal phalanx combined with iliac bone to reconstruct thumbs.According to the thumb defect indexing method reported by Cheng Guoliang,the type 1 of thumb Ⅲ degree defect was 4 cases,and the type 2 of Ⅲ degree defect was 3 cases.The donor site was covered with skin grafting in 1 case,free superficial iliac artery graft in 5 cases and free peroneal artery perforator flap in 1 case.All patients kept the number and length of donor toes.Regular follow-up was performed after operation to observe the function,shape,feeling of finger reconstruction,the survival condition of flaps or skin graft in donor site,etc.It was also observed if the pain by walking actually exists in the long-term effect.Results All of the reconstructed thumbs survived.One patient suffered the necrotic in the donor site repaired by superficial iliac artery flap,which was successfully covered with the skin graft.All patients were followed-up from 3 months to 18 months (mean,8 months).The reconstructed thumb with smooth nail had fine textile and good elasticity,good flexion and extension function of the palm,fingers and the metacarpophalangeal joint.The donor sites recovered with fine texture,and there were no difficulties in walking and running and no complaint about the pain and discomfort.According to the Trial Criteria of Upper Limb Functional Evaluation of Chinese Medical Association Hand Surgery Society,5 cases resulted in excellent,and 2 cases resulted in good.Conclusion The hallux-nail flap with the distal phalanx combined with iliac bone is an excellent option to reconstruct thumb with Ⅲ degree defect with the outcome of good function and appearance.The trauma of the donor site is small and the number and length of the toes are remained.The clinical effect is good.

Objective To discuss the clinical effect of partial nail-bed flap at second toe with blood-vessel anastomosed in repair of different types of nail-bed defects at finger.Methods From July,2010 to July,2015,25 cases of partial nail-bed flap at second toe with blood-vessel anastomosed were treated,including 14 males and 11 females,with an age range from 18 to 45 years old (average 25 years old).Eleven cases at index finger,6 cases at middle finger,5 cases at ring finger and 3 cases at little finger.According to the classification of nail bed defect site,9 cases at lateral,5 cases at nail root and 11 cases at distal.All cases were combined skin and soft tissue defect.The area of defects were from 1.1 cm × 2.0 cm to 2.5 cm × 3.2 cm.The time from injury to admission were from 1 hour and 12 minutes to 3 hours and 12 minutes,the average time was 2.1 hours.The area of incised nail flap during operation were from 1.2 cm × 2.2 cm to 2.6 cm × 3.5 cm.The donor site was sutured directly or repaired with free skin graft.The toe length in all cases were retained.The nail shape,nail gloss,fine function of finger such as pinch,grip,grasp and restoration of the donor toes were compared in the follow-up.All patients were followed-up at regllar intervals.Results The nail-bed flap after transplantation and skin graft at donor site survived successfully,and primary healing of the wounds occured in all cases.The follow-up time were from 6 to 26 months(average 9 months).Longitudinal spine or transverse groove occurred in 3 cases at the nail-bed boundary between toe and finger,nail thickened and distal tilted occurred in 1 case,flat,smooth,no deformity nail and glossy deck occurred in others.The flap had good appearance,texture and elasticity.Two-point discrimination was 5-9 mm,averageal of 6 mm.The donor toe had no shortening and no pain after long-term following.According to effectiveness standard for fingernail regeneration:19 cases were excellent and 6 cases were good.Conclusion Partial nail-bed flap at second toe wih bloodvessel anastomosed in repairing nail-bed defects at finger,nail appearance is realistic and function recovered well postoperatively.

Objective To study the clinical features and prognostic risk factors of patients with autoimmune hepatitis-related hepatocellular carcinoma (AIH-HCC).Methods We reviewed the clinical data of 40 patients with AIH-HCC who were treated at the 302 Hospital between May 1,2008 and April 30,2013,and analyzed the clinical characteristics and prognostic risk factors of these patients.Results These patients were diagnosed to have HCC at a mean ± SD of 55.1 ± 13.5 years (range 28-76 years).The median duration from the time of confirmed cirrhosis to a diagnosis of HCC was 49.2 ± 44.5 months (range 3-194 months).The median survival of the AIH-HCC patients was 16.0 ±4.0 months (range 1-44 months),and the 1-year survival rate was 54.0％.Univariate analysis showed AFP,tumor size,tumor number were related to prognosis (P ＜ 0.05) ; while gender,age,IAIHG score,category,history of blood transfusion,alcohol-drinking and smoking did not significantly affect the patients' survival (P ＞ 0.05).Multivariate regression analysis showed AFP and tumor number were independent prognostic factors.Most of these patients received transcatheter arterial chemoembolization(TACE),however the survival rate of those patients who received hepatectomy was significantly higher than those who received TACE or accepted conservative treatment.Conclusion Liver cirrhosis in AIH is the sine qua non for HCC development,which subsequently occurs at a rate of 1.65％ per year.Patients who had AFP-negativity or a single tumor had a better prognosis.Surgical treatment prolonged survival.

A common pathophysiological changes caused by liver cirrhosis indudes damage of liver function and portal hypertension,and upper gastrointestinal hemorrhage caused by portal hypertension is the main cause of death in patients with liver cirrhosis.Therefore,the main purpose of portal hypertension treatment should be prevention and control of esophagus and fundus of stomach variceal bleeding.However,upper gastrointestinal bleeding can not be completely cured no matter by medication or endoscopic treatment,devascularization or shunt.Although liver transplantation is the best treatment method for portal hypertension,the application of liver transplantation is limited by the source of donor and medical condition.Devascularization is effective to treat upper gastrointestinal hemorrhage caused by portal hypertension,while disputes exist on the surgical indications,timing and procedure selection.