Chronic refractory wound (CRW) is one of the most challengeable issues in clinic due to complex pathogenesis, long course of disease and poor prognosis. Experts need to conduct systematic summary for the diagnosis and treatment of CRW due to complex pathogenesis and poor prognosis, and standard guidelines for the diagnosis and treatment of CRW should be created. The Guideline forthe diagnosis and treatment of chronic refractory wounds in orthopedic trauma patients ( version 2023) was created by the expert group organized by the Chinese Association of Orthopedic Surgeons, Chinese Orthopedic Association, Chinese Society of Traumatology, and Trauma Orthopedics and Multiple Traumatology Group of Emergency Resuscitation Committee of Chinese Medical Doctor Association after the clinical problems were chosen based on demand-driven principles and principles of evidence-based medicine. The guideline systematically elaborated CRW from aspects of the epidemiology, diagnosis, treatment, postoperative management, complication prevention and comorbidity management, and rehabilitation and health education, and 9 recommendations were finally proposed to provide a reliable clinical reference for the diagnosis and treatment of CRW.

Objective:To evaluate the efficacy of total laparoscopic surgery vs. open surgery for hilar cholangiocarcinoma. Methods:The clinical data of 45 patients undergoing laparoscopic radical resection of hilar cholangiocarcinoma and 42 patients by open surgery from Mar 2017 to Mar 2021 were retrospectively analyzed.Results:There was no significant difference in demographics, Bismuth classification and excision extension between the two groups (all P>0.05). The laparoscopic surgery used longer time ( t=-1.366, P<0.05). The intraoperative blood loss, number of lymph node dissection and postoperative hospital stay favored laparoscopic method( t=0.043, t=0.026, t=-1.852, P<0.05). R 0 radical resection rate，postoperative complications were also in favor of laparoscopic surgery ( χ2=3.216, χ2=2.566, all P<0.05). There was no significant difference in postoperative pathology and in hospital expenses (all P>0.05). The 1- and 3-year survival rate of the laparoscopic group was superior (all P<0.05). Conclusions:In spite of longer operational time，patients in laparoscopic hilar cholangiocarcinoma radical resection group have shorter postoperative in hospital stay and longer postoperative survival time.

Traumatic rib fractures are the most common injury in thoracic trauma. Previously，the patients with traumatic rib fractures were mostly treated non-surgically，of which 50%，especially those combined with flail chest presented chronic pain or chest wall deformities and over 30% had long-term disabilities，being unable to retain a full-time job. In the past two decades，thanks to the development of internal fixation material technology，the surgical treatment of rib fractures has achieved good outcomes. However，there are still some problems in clinical treatment，including inconsistency in surgical treatment and quality control in medical services. The current consensuses on the management of regional traumatic rib fractures published at home and abroad mainly focus on the guidance of the overall treatment decisions and plans，and relevant clinical guidelines abroad lacks progress in surgical treatment of rib fractures in recent years. Therefore，the Chinese Society of Traumatology affiliated to Chinese Medical Association and Chinese College of Trauma Surgeons affiliated to Chinese Medical Doctor Association，in conjunction with national multidisciplinary experts，formulate the Chinese Consensus for Surgical Treatment of Traumatic Rib Fractures（2021）following the principle of evidence-based medicine，scientific nature and practicality. This expert consensus puts forward some clear，applicable，and graded recommendations from aspects of preoperative imaging evaluation，surgical indications，timing of surgery，surgical methods，rib fracture sites for surgical fixation，internal fixation methods and material selections，treatment of combined injuries in rib fractures，in order to provide references for surgical treatment of traumatic rib fractures.

Objective:To compare the embedding anastomosis with the intermittent eversion anastomosis on the pancreatic fistula rates after laparoscopic pancreaticoduodenectomy (LPD).Methods:The clinical data of 116 patients who underwent LPD at the Center Hospital of Xianyang City affiliated to Xi' an Jiaotong University Health Science Center from March 2016 to March 2020 were retrospectively studied. According to the method of pancreaticojejunostomy used, these patients were divided into the following two groups: the embedding anastomosis group ( n=55) and the intermittent eversion anastomosis group ( n=61). The duration of pancreaticojejunostomy, bilioenterostomy and gastrointestinal anastomoses, and the amounts of intraoperative blood loss and postoperative complication rates were compared between the two groups. Results:Of 116 patients in this study, there were 67 males and 49 females, with a median age of 61.5 years. No perioperative death occurred in the 2 groups. The operation time, digestive tract reconstruction time and pancreaticojejunostomy time in the embedded anastomosis group were (260±20), (65±15) and (35±15) min, respectively, which were significantly lower than those in the intermittent eversion anastomosis group (305±25), (81±25) and (45±12) min, (all P<0.05). The grade A and B pancreatic fistula rates in the embedded anastomosis group were 27.3%(15/55) and 21.8%(12/55), respectively, which were significantly higher than those in the intermittent eversion anastomosis group [8.2%(5/61) and 6.6%(4/61)], (all P<0.05). The postoperative hospital stay in the intermittent eversion anastomosis group (10.3±1.1) d was significantly lower than that in the embedding anastomosis group [(15.2±3.2) d, P<0.05]. Conclusion:In LPD, when compared with embedded pancreaticojejunostomy, intermittent eversion pancreaticojejunostomy reduced the postoperative pancreatic fistula rate and shortened the postoperative hospital stay.

Objective:To explore the application effect of 3D printing technology in comprehensive reconstruction of thumb and finger.Methods:From January, 2018 to January, 2020, 67 patients with 84 thumbs and fingers defects were selected, which were 37 thumbs and 47 fingers, and 45 of I-III degree and 39 of IV-VI degree. The method of operation was comprehensive reconstruction of thumbs and fingers assisted by 3D printing technology. The patient's hands and feet were scanned with CT and 3D modeling, and the 1∶1 model was derived. The skin model and bone model of thumb and finger defect were printed. Put the skin model on the great toes, and design the shape of the nail flap to be cut. Then the flap was spread in the groin area to design the perforating branch flap of the superficial circumflex iliac artery. The interphalangeal joint or metatarsophalangeal joint of the second toe was cut off according to the skeleton model (when the length of the bone joint was not enough, the iliac bone strip was taken to be connected in series). The effect of operation was observed in outpatient.Results:All of the 84 thumbs and fingers survived and were followed-up for 3 to 24 months. The appearance of the reconstructed thumbs and fingers was similar to that of the normal ones, with good texture and elasticity. The nail was smooth and glossy. The sensory recovery was S 3+, and the TPD was 4-6 mm. According to the Evaluation Standard of Finger Replantation and Reconstruction of Hand Surgery Society of Chinese Medical Association, 70 thumbs and fingers were excellent and 14 thumbs and fingers were good. In 64 thumbs and fingers, all toes were preserved in the donor area, and the color and texture of the flap were satisfactory, which did not affect walking, running and jumping, and had no walking pain. Conclusion:With the help of 3D printing technology, the tissues can be cut more accurately during the thumb and finger comprehensive reconstruction, which not only improves the beauty of reconstructed thumbs and fingers, but also avoids unnecessary trauma and improves the satisfaction of patients.

Objective:To study the impact of traditional versus artery first approach in laparoscopic pancreaticoduodenectomy (LPD).Methods:The clinical data of 58 patients who underwent laparoscopic pancreaticoduodenectomy using the two different approaches from February 2016 to August 2018 at the Xianyang Central Hospital affiliated to Xi'an Jiaotong University Medical Department were retrospectively analyzed.Results:All 58 patients successfully underwent the complete laparoscopic Whipple operation using the Child digestive tract reconstruction and anastomosis. There was no conversion to laparotomy. The average operation times for the conventional approach group (35 cases) was (302.0±20.0) min and the digestive tract reconstruction time was (36.0±15.0) min. The intraoperative blood loss was (365.0±150.0) ml. Negative pathological resection margins on intraoperative frozen section examination were achieved in 33 patients. Early postoperative complications happened in 6 patients which included grade A pancreatic fistula in 3 patients (1 patient complicated with biliary fistula and 1 patient complicated with gastric emptying disorder), and grade B pancreatic fistula in 2 patients who were complicated with abdominal hemorrhage, successfully treated by conservative treatment. Postoperative pathological examination showed that 32 patients (91.4%) had R 0 resection and 3 patients (8.6%) had R 1 resection. The number of lymph node dissection was (7.5±5.5). On the other hand, the average operation time of the artery first access group (23 cases) was (355.0±25.0) min, and the reconstruction time of digestive tract was (41.0±12.0) min. The amount of bleeding was (410.0±200.0) ml. During the operation, 22 patients had negative resection margins shown on pathological frozen sections. Early postoperative complications occurred in 3 patients, including 1 patient with grade A pancreatic fistula which was complicated with gastric emptying disorder, and 2 patients with grade B pancreatic fistulas which were complicated with abdominal hemorrhage. The patients were successfully managed by conservative treatment. Postoperative pathological examination showed that 22 patients (95.7%) had R 0 resection and 1 patient (4.3%) R 1 resection. The number of lymph node dissection was (6.8±4.2). Conclusion:The LPD surgical approach was selected according to the general conditions of patients, locations of tumors, relationship of tumors with blood vessels, and technical skills of surgeons with the aims to achieve adequate lesion clearance, organ protection, damage control, and safety and efficiency of minimally invasive surgery.

Objective To compare the efficacies of laparoscopic versus open splenectomy plus portaazygous devascularization in the treatment of patients with portal hypertension with recurrent upper gastrointestinal bleeding.Methods The clinical data of patients who underwent laparoscopic (n =60) versus open (n =52) splenectomy plus open portaazygous devascularization in the Department of Hepatobiliary Surgery,the Center Hospital of Xianyang City,Xi'an Jiaotong University Health Science Center from March 2014 to February 2017 were retrospectively analyzed.Results There was no perioperative death in the 2 groups.The amounts of intraoperative bleeding,the durations of the operation,the time of first flatus passed after operation and the duration of postoperative hospitalization were compared,and the differences were significantly different (t =3.288,2.533,3.325,2.823,P ＜ 0.05).There was no significant difference in the total hospitalization expenses (t =0.651,P ＞0.05).The incidence of postoperative complications was significantly higher in the open surgery group (x2 =7.622,P ＜ 0.05).At 1-month after surgery,color doppler flow imaging (CDFI) showed no significant difference on the portal blood flow between the two groups (t =0.625,P ＞ 0.05).On gastroscopy,the esophageal and gastric varices were significantly improved,and there was no significant difference between the two groups (x2 =0.718,P ＞ 0.05).Liver function was better in the laparoscopic group than the open group (x2 =3.765,P ＜ 0.05).Comparison of the rebleeding rates and the incidences of hepatic encephalopathy for the two groups at 1 year after operation showed significantly better outcomes for the laparoscopic group (x2 =2.351,1.245,P ＜ 0.05).The 1-year and 3-year survival rates after operation (x2 =0.218,0.361,P ＞ 0.05) were not significantly different.Conclusion Compared with laparotomy,laparoscopic splenectomy plus portaazygous devascularization had the advantages of less trauma,better short-term and long-term efficacies.

Objective To investigate the therapeutic effect of total laparoscopic vs open surgery for gallbladder carcinoma.Methods Clinical data of 51 cases of laparoscopic surgery and 41 cases of open operation for gallbladder cancer from Mar 2012 to Dec 2016 were analyzed retrospectively.Results There were no perioperative death in both groups.The blood loss during operation,operative time,the first anal exhaust after operation and the hospital stay were in favour of laparoscopic procedure (t =2.756,2.325,1.362,2.252,P ＜ 0.05).There was no significant difference in total hospitalization expenses (t =0.655,P ＞ 0.05),the short-term postoperative complications were in favor for laparoscopic surgery (x2 =5.522,P ＜ 0.05).The 1,3,5-year survival rates of laparoscopic group and laparotomy group were comparable (x2 =0.356,0.428,0.388,P ＞0.05).Conclusion Laparoscopic radical surgery for gallbladder cancer is safe,feasible and less traumatic than open surgery,with long term survival comparable to open surgery.

Objective To investigate the effect of percutaneous transhepatic gallbladder drainage(PTGBD) on different American Society of Anesthesiologists(ASA) grading of laparoscopic cholecystectomy in patients with acute cholecystitis. Methods The 324 patients with acute cholecystitis undeigoing laparoscopic cholecystectomy who were hospitalized in Department of Hepatobiliary Surgery, Xianyang Central Hospital from March 2010 to December 2014 were enrolled in the retrospective analysis. According to the history of the patients with or without PTGBD before laparoscopic cholecystectomy, all patients were divided into 2 groups. One hundred and eighty four patients who underwent directly laparoscopic cholecystectomy were the control group, and the other 140 patients who underwent PTGBD + elective laparoscopic cholecystectomy were the study group. The rates of conversion to laparotomy, total days of hospitalization, hospitalization days after cholecystectomy incidence, postoperative complications incidence, postoperative drainage were compared between two groups. The difference of clinical data between the two groups were compared under different ASA classification. Measurement data were expressed as ((x)±s) and t-test were used for comparison between groups. Count data were compared by X2 test. Results The rate of intraoperative laparotomy was 23.6％(33/140) in the study group and 20.7％(38/184) in the control group; the mean length of hospital stay was (7.3 ±3.3) days in the study group and (6.8 ±2.3) days in the control group; the postoperative complication rate was 2.8％(4/140) in the study group and 0.5％(1/184) in the control group; the abdominal cavity drainage rate was 80.0％(112/140) in the study group and 73.9％(136/184) in the control group; intraoperative laparotomy rate, postoperative hospital stay, postoperative complications incidence, and abdominal cavity drainage rate between the two groups had no significant difference(P> 0.05). The total length of hospital stay was(17.6 ±4.4) days in the study group and(10.6 ±3.0) days in the control group, and there was a statistically significant difference between the two groups(P <0.001). According to the subgroup analysis by ASA classification, the two groups of ASA-I patients in the experimental group were significantly higher than the control group in the temperature, C reactive protein and the total number of days of hospitalization, and the difference was statistically significant(P< 0.05). The two groups of ASA-Ⅱ patients in the experimental group were significantly higher than those of the control group in age, white blood cell count, C reactive protein and total hospitalization days, and the difference was statistically significant(P<0.05). In ASA-Ⅲ patients, the rate of intraoperative laparotomy was 28.3％ (13/46) in the study group and 32.1％ (9/28) in the control group; the mean hospital stay after surgery was(10.8 ± 3.7) days in the study group and(11.2±4.8) days in the control group; The total length of hospital stay was (19.7 ±7.2) days in the study group and (16.8 ± 8.6) days in the control group; the rate of intraoperative laparotomy, the mean length of hospital stay and postoperative hospital stay in the two groups of ASA-Ⅲ patients had no statistically significant difference(P>0.05). Conclusions PTGBD has different effects on laparoscopic cholecystectomy in patients with different ASA grading of acute cholecystitis. PTGBD combined with laparoscopic cholecystectomy is a safe and effective method that can turn emergent operation intoselective operation. It is worthy of extensive application.

Objective To investigate the clinical efficacy and influencing factors of arterial switch operation (ASO) in the treatment of complete transposition of great arteries (TGA).Methods Totally 156 children with TGA who underwent ASO surgery from January 2005 to December 2011 were selected as the subjects.The clinical curative effect and prognosis of all patients were observed,and the relationship be tween clinical features and prognosis was analyzed.Results Totally 156 cases of TGA children were successfully completed the operation,and 29 patients died during the 5 year follow-up period,the mortality rate was 18.59％.Univariate analysis showed that the death in children with TGA after ASO was closely related to coronary artery abnormality,cardiopulmonary bypass time,aortic occlusion time,postoperative low cardiac output syndrome and reoperation (P ＜ 0.05).Multivariate logistic regression analysis showed that coronary artery abnormalities,and low cardiac output syndrome were independent outcome factors leading to postoperative death in patients.Conclusions The postoperative death of ASO in TGA children is closely related to the incidence of coronary artery abnormalities,the time of cardiopulmonary bypass,the time of oc clusion of aorta and the occurrence of postoperative low cardiac output syndrome,which should be pay attention to and take relevant measures.