In 2009,the World Health Organization included snakebite on the list of neglected tropical diseases,acknowledging it as a common occupational hazard for farmers,plantation workers,and others,causing tens of thousands of deaths and chronic physical disabilities every year.This guideline aims to provide practical information to help clinical professionals evaluate and treat snakebite victims.These recommendations are based on clinical experience and clinical research evidence.This guideline focuses on the following topics:snake venom,clinical manifestations,auxiliary examination,diagnosis,treatments,and prevention.

Background/Aims: Enteroenteric intussusception in Peutz-Jeghers syndrome (EI-PJS) is traditionally treated by surgery. However, enteroscopic treatment is a minimally invasive approach worth attempting. We aimed to develop a risk scoring system to facilitate decision-making in the treatment of EI-PJS. Methods: This was a single-center case-control study, including 80 patients diagnosed with PJS and coexisting intussusception between January 2015 and January 2021 in Air Force Medical Center. We performed logistic regression analysis to identify independent risk factors and allocated different points to each subcategory of risk factors; the total score of individuals ranged from 0 to 9 points. Then, we constructed a risk stratification system based on the possibility of requiring surgery: 0–3 points for “low-risk,” 4–6 points for “moderate-risk,” and 7–9 points for “high-risk.” Results: Sixty-one patients (76.25%) were successfully treated with enteroscopy. Sixteen patients (20.0%) failed enteroscopic treatment and subsequently underwent surgery, and three patients (3.75%) received surgery directly. Abdominal pain, the diameter of the responsible polyp, and the length of intussusception were independent risk factors for predicting the possibility of requiring surgery. According to the risk scoring system, the incidence rates of surgery were 4.44% in the low-risk tier, 30.43% in the moderate-risk tier, and 83.33% in the high-risk tier. From low- to high-risk tiers, the trend of increasing risk was significant (p<0.001). Conclusions We developed a risk scoring system based on abdominal pain, diameter of the responsible polyps, and length of intussusception. It can preoperatively stratify patients according to the risk of requiring surgery for EI-PJS to facilitate treatment decision-making.

Purpose: This study was performed to analyze the rule of confluence of the caudate lobe bile duct (CLD) into the left hepatic duct (LHD) and to discuss the protective strategy during left hemihepatectomy. Methods: MRI of 400 patients and T-tube angiography images of 100 patients were collected, and the imaging rules of the confluence of the CLD into the LHD were summarized. The clinical data of 33 patients who underwent left hemihepatectomy using the protective strategy were analyzed. Results: MRI and T-tube angiography images showed that the length from the confluence point of the CLD into the LHD to the confluence of the left and right hepatic ducts was 1.19 ± 0.40 cm and 1.26 ± 0.39 cm, respectively. The average angle between the longitudinal axis of the 2 bile ducts was 68.27° ± 22.59° and 66.58 ± 22.88°, respectively. Coronal and cross-sectional images showed that inflow from the foot side to the cranial side was noted in 79.8% and 82.0% of patients, respectively, and inflow from the dorsal to the ventral side was observed in 84.5% and 88.0%, respectively. Based on these imaging rules, the safe transection length and plane were summarized, and the CLD was effectively protected in 33 cases of left hemihepatectomy. Conclusion In left hemihepatectomy, the LHD should be transected at least 1.5 cm away from the confluence of the left and right hepatic ducts, and the plane of transection should be oblique to the dorsal side at an angle of 45° with the LHD, these parameters represent an effective strategy to protect the CLD.

Objective:To investigate the anatomy of lateral maxillocervical boot-shaped perforator fasciocutaneous flap and its clinical effect on repairing soft tissue defect of zygomatic-temporal region.Methods:(1)From December 2017 to December 2020, five fresh adult cadaver specimens were infused with gelatin lead oxidate and underwent one-time arteriography.The X-ray image was imported into Mimics 17.0 software, divided and colored based on the head and face anatomy, and the distribution and anastomosis of the arteries involved in the lateral maxillocervical boot-shaped perforator fasciocutaneous flap were observed.The head and neck samples of another 5 (10 sides) fresh adult cadavers were infused with red latex artery to establish the surgical model, and then dissected layer by layer to investigate the blood supply and the source of perforating artery of this flap.(2) The patients with zygomatic-temporal lesions were treated in the Department of Plastic Surgery, the First Affiliated Hospital of Anhui Medical University.They were treated with the lateral maxillocervical boot-shaped perforator fasciocutaneous flap to repair the wound left after lesion resection. The survival of the flap and the healing of the incision were observed after surgery and the appearance and sensation of donor and recipient sites as well as tumor recurrence were followed up.Results:(1) The pedicle of the lateral maxillocervical boot-shaped perforator fasciocutaneous flap is mainly nourished by the superficial temporal artery and its perforator.The average diameter of the maximum three perforations is (0.44±0.04) mm, (0.90±0.08) mm, (0.73±0.05) mm.The fascial vascular network and subdermal vascular network formed by perforating arteries from superficial temporal artery and branching arteries from facial artery at different layers are the anatomical basis for ensuring blood supply of lateral maxillocervical boot-shaped perforator fasciocutaneous flap. (2) A total of 12 patients with zygomatic-temporal lesions were treated clinically, including 8 males and 4 females aged 42-79 years, including 2 cases of senile sebaceous keratosis, 3 cases of squamous cell carcinoma, 1 case of skin ulcer and 6 cases of basal cell carcinoma. The range of defect after resection of the lesions was 4 cm×3 cm-9 cm×8 cm. The flap area was 5 cm×3 cm-11 cm×9 cm, the flap pedicle width was 2-3 cm, length was 2-4 cm, After surgery, the blood supply of the flap was good without necrosis, the wound were covered by first treatment. After 6-18 months of follow-up, the donor and recipient areas presented natural appearance, no swelling, no paresthesia and facial paralysis, and no recurrence of cancer.Conclusions:The lateral maxillocervical boot-shaped perforator fasciocutaneous flap pedicled with perforating branch of superficial temporal artery has reliable blood supply. Using this flap to repair large soft tissue defects in zygomatic-temporal region has the advantages of simple operation, similar color and texture, and good appearance.

Objective:To investigate the method and clinical effect of horn-shaped perforator flaps with multiple blood supply for reconstructing massive facial defects caused by various reasons.Methods:A retrospective review was performed on patients with massive facial defects in the Department of Plastic Surgery of First Affiliated Hospital of Anhui Medical University from June 2015 to July 2020. The Doppler ultrasound was used to localize the facial source artery and perforators preoperatively. During the operation, the flap was designed according to the defect size, the elasticity of around skin, the length from the distal end of the defect to the location of the selected perforator, and the Langer’s line of the face. The length of the proximal part of the flap was approximately equal to the defect width, and the length of the flap was about 3 to 3.5 times longer than the defect width. An incision was made along the distal part of the flap. The flap dissection proceeded in a proximal to distal fashion superficial to the superficial musculoaponeurotic system, until forming a large perforator flap. A small number of fibrous around the perforator were retained, and the flap was rotated and advanced to reconstruct the defect without any tension. The donor site was closed directly. Wound healing, scar formation, tumor recurrence, and tumor metastasis were followed postoperatively.Results:A total of nine cases were enrolled, with four male patients and five female patients. The mean age of the patients was 58 years, ranging from 35 to 81 years. The size of the flap ranged from 10.0 cm × 6.0 cm to 14.0 cm × 7.0 cm. All flaps survived, and the wound healed primarily. After 3 to 24 months of follow-up, no recurrence of tumor, obvious scar, flap bloated, facial deformity, or other complications were observed. The patients was satisfied with the aesthetic subunit structure and function.Conclusions:The horn-shaped perforator flap with multiple blood supply is simple in design, easy in decision, reliable in blood supply, and consistent in color and texture with the original tissue. The incision scar can be hidden in the Langer’s line with a satisfying appearance, which is suitable for aged patients with sagging facial skin.

Objective:To investigate the clinical effect of local perforator advancement flap in repairing mid-face soft tissue defects and its correlation with the three-dimensional configuration of the skin ligament.Methods:(1) Tweleve fresh adult cadaver specimens, including seven males and five females, aged 54-87 years old, were selected. After dehydration and degreasing of the cadaver head with acetone, plasticized and sliced with a fully transparent ultra-thin layer of epoxy resin, using a Leica MZ8 stereo microscope and a Leica DFC295 digital camera to observe and analyze the prepared slices and observe the differences in the three-dimensional structural characteristics of the cutaneous ligaments in different parts of the mid-face (cheek, nose, orbital eyelid). (2) A retrospective study was conducted with the data of mid-face soft tissue defects admitted to the Department of Plastic Surgery of the First Affiliated Hospital of Anhui Medical University from January 2015 to October 2021. All patients were repaired with local perforator advancement flaps. The Pearson bivariate correlation test was used to analyze the correlation among flap advancement distance, flap area, flap aspect ratio, and defect size. The Kruskal-Wallis test was used to analyze the differences in flap size and aspect ratio in different parts of the mid-face. The measurement data were described by Mean±SD or M( Q1, Q3). Results:(1) Anatomical studies have shown that the running direction of the facial skin ligaments is the same as that of the expressive muscles, and their three-dimensional structures at the upper eyelid and the nasal and facial corners of the upper nasal alar are different. The upper eyelid skin ligaments run along the eyelid, while the upper nasal cutaneous ligaments run down the nose alar. (2) The clinical study included 18 patients, including eight males and ten females, aged (64.6±23.4) years old. All flaps survived uneventfully. The average flap size was 10.6(8.0, 18.0) cm 2, and the average advancing distance was 2.8(2.0, 4.0) cm. Statistical analysis showed a correlation between the flap advancement distance, the flap incision area ( r=-0.71, P=0.022), and the flap aspect ratio ( r=-0.58, P=0.012). There was no correlation with the defect area ( r=-0.23, P=0.365); the aspect ratios of the cheek, nose, and orbital lid flaps were 2.1(1.9, 2.3), 2.0(1.6, 3.5), 3.5(3.0, 4.0), and the differences were statistically significant ( H=6.59, P=0.037). Conclusions:The local perforator advancement flap is an ideal method for repairing mid-face soft tissue defects. The differences in the construction of the skin ligaments in different parts of the mid-face will affect the ease of advancement of the flaps and other characteristics in each part, which may be the reasons for affecting the aspect ratio of the flap design.

Objective:To investigate the anatomy of lateral maxillocervical boot-shaped perforator fasciocutaneous flap and its clinical effect on repairing soft tissue defect of zygomatic-temporal region.Methods:(1)From December 2017 to December 2020, five fresh adult cadaver specimens were infused with gelatin lead oxidate and underwent one-time arteriography.The X-ray image was imported into Mimics 17.0 software, divided and colored based on the head and face anatomy, and the distribution and anastomosis of the arteries involved in the lateral maxillocervical boot-shaped perforator fasciocutaneous flap were observed.The head and neck samples of another 5 (10 sides) fresh adult cadavers were infused with red latex artery to establish the surgical model, and then dissected layer by layer to investigate the blood supply and the source of perforating artery of this flap.(2) The patients with zygomatic-temporal lesions were treated in the Department of Plastic Surgery, the First Affiliated Hospital of Anhui Medical University.They were treated with the lateral maxillocervical boot-shaped perforator fasciocutaneous flap to repair the wound left after lesion resection. The survival of the flap and the healing of the incision were observed after surgery and the appearance and sensation of donor and recipient sites as well as tumor recurrence were followed up.Results:(1) The pedicle of the lateral maxillocervical boot-shaped perforator fasciocutaneous flap is mainly nourished by the superficial temporal artery and its perforator.The average diameter of the maximum three perforations is (0.44±0.04) mm, (0.90±0.08) mm, (0.73±0.05) mm.The fascial vascular network and subdermal vascular network formed by perforating arteries from superficial temporal artery and branching arteries from facial artery at different layers are the anatomical basis for ensuring blood supply of lateral maxillocervical boot-shaped perforator fasciocutaneous flap. (2) A total of 12 patients with zygomatic-temporal lesions were treated clinically, including 8 males and 4 females aged 42-79 years, including 2 cases of senile sebaceous keratosis, 3 cases of squamous cell carcinoma, 1 case of skin ulcer and 6 cases of basal cell carcinoma. The range of defect after resection of the lesions was 4 cm×3 cm-9 cm×8 cm. The flap area was 5 cm×3 cm-11 cm×9 cm, the flap pedicle width was 2-3 cm, length was 2-4 cm, After surgery, the blood supply of the flap was good without necrosis, the wound were covered by first treatment. After 6-18 months of follow-up, the donor and recipient areas presented natural appearance, no swelling, no paresthesia and facial paralysis, and no recurrence of cancer.Conclusions:The lateral maxillocervical boot-shaped perforator fasciocutaneous flap pedicled with perforating branch of superficial temporal artery has reliable blood supply. Using this flap to repair large soft tissue defects in zygomatic-temporal region has the advantages of simple operation, similar color and texture, and good appearance.

Objective:To investigate the method and clinical effect of horn-shaped perforator flaps with multiple blood supply for reconstructing massive facial defects caused by various reasons.Methods:A retrospective review was performed on patients with massive facial defects in the Department of Plastic Surgery of First Affiliated Hospital of Anhui Medical University from June 2015 to July 2020. The Doppler ultrasound was used to localize the facial source artery and perforators preoperatively. During the operation, the flap was designed according to the defect size, the elasticity of around skin, the length from the distal end of the defect to the location of the selected perforator, and the Langer’s line of the face. The length of the proximal part of the flap was approximately equal to the defect width, and the length of the flap was about 3 to 3.5 times longer than the defect width. An incision was made along the distal part of the flap. The flap dissection proceeded in a proximal to distal fashion superficial to the superficial musculoaponeurotic system, until forming a large perforator flap. A small number of fibrous around the perforator were retained, and the flap was rotated and advanced to reconstruct the defect without any tension. The donor site was closed directly. Wound healing, scar formation, tumor recurrence, and tumor metastasis were followed postoperatively.Results:A total of nine cases were enrolled, with four male patients and five female patients. The mean age of the patients was 58 years, ranging from 35 to 81 years. The size of the flap ranged from 10.0 cm × 6.0 cm to 14.0 cm × 7.0 cm. All flaps survived, and the wound healed primarily. After 3 to 24 months of follow-up, no recurrence of tumor, obvious scar, flap bloated, facial deformity, or other complications were observed. The patients was satisfied with the aesthetic subunit structure and function.Conclusions:The horn-shaped perforator flap with multiple blood supply is simple in design, easy in decision, reliable in blood supply, and consistent in color and texture with the original tissue. The incision scar can be hidden in the Langer’s line with a satisfying appearance, which is suitable for aged patients with sagging facial skin.

Objective:To investigate the clinical effect of local perforator advancement flap in repairing mid-face soft tissue defects and its correlation with the three-dimensional configuration of the skin ligament.Methods:(1) Tweleve fresh adult cadaver specimens, including seven males and five females, aged 54-87 years old, were selected. After dehydration and degreasing of the cadaver head with acetone, plasticized and sliced with a fully transparent ultra-thin layer of epoxy resin, using a Leica MZ8 stereo microscope and a Leica DFC295 digital camera to observe and analyze the prepared slices and observe the differences in the three-dimensional structural characteristics of the cutaneous ligaments in different parts of the mid-face (cheek, nose, orbital eyelid). (2) A retrospective study was conducted with the data of mid-face soft tissue defects admitted to the Department of Plastic Surgery of the First Affiliated Hospital of Anhui Medical University from January 2015 to October 2021. All patients were repaired with local perforator advancement flaps. The Pearson bivariate correlation test was used to analyze the correlation among flap advancement distance, flap area, flap aspect ratio, and defect size. The Kruskal-Wallis test was used to analyze the differences in flap size and aspect ratio in different parts of the mid-face. The measurement data were described by Mean±SD or M( Q1, Q3). Results:(1) Anatomical studies have shown that the running direction of the facial skin ligaments is the same as that of the expressive muscles, and their three-dimensional structures at the upper eyelid and the nasal and facial corners of the upper nasal alar are different. The upper eyelid skin ligaments run along the eyelid, while the upper nasal cutaneous ligaments run down the nose alar. (2) The clinical study included 18 patients, including eight males and ten females, aged (64.6±23.4) years old. All flaps survived uneventfully. The average flap size was 10.6(8.0, 18.0) cm 2, and the average advancing distance was 2.8(2.0, 4.0) cm. Statistical analysis showed a correlation between the flap advancement distance, the flap incision area ( r=-0.71, P=0.022), and the flap aspect ratio ( r=-0.58, P=0.012). There was no correlation with the defect area ( r=-0.23, P=0.365); the aspect ratios of the cheek, nose, and orbital lid flaps were 2.1(1.9, 2.3), 2.0(1.6, 3.5), 3.5(3.0, 4.0), and the differences were statistically significant ( H=6.59, P=0.037). Conclusions:The local perforator advancement flap is an ideal method for repairing mid-face soft tissue defects. The differences in the construction of the skin ligaments in different parts of the mid-face will affect the ease of advancement of the flaps and other characteristics in each part, which may be the reasons for affecting the aspect ratio of the flap design.

Objective:This paper introduces four surgical methods and effects of one-stage repair for defect in nasal wing because of tumor resection and other reasons.Methods:Totally 41 cases of nasal wing defects caused by various reasons admitted to the First Affiliated Hospital of Anhui Medical University from June 2015 to June 2018 were analyzed retrospectively, including 22 male patients and 19 female patients, age ranged from 15 to 93 years, with an average of 45 years. All patients were treated and repaired with the nasolabial horn-shaped perforated pedicle flaps(20 cases), the lateral nasal artery horn-shaped perforated pedicle flaps(10 cases), the nasolabial sulcus island flaps based on nasal basal perforator vessel(6 cases) and the supralabial-nasolabial horn-shaped perforated pedicle flaps(5 cases).Results:All the flaps that were used in 41 patients were transplanted successfully, size ranged from 0.5 cm×1.5 cm-4.0 cm×4.0 cm. The defects on the nasal wing were completely repaired, and the wounds healed in one stage. All patients underwent postoperative follow-up for a period of 4 months to 1 year. Postoperative results indicate that the patients’ alae shapes of the nose were good, the functions were not significantly affected, and no recurrences were found in the cancer cases.Conclusions:The nasolabial horn-shaped perforated pedicle flap can be used for lager defects of the the nasal wing, and the lateral nasal artery horn-shaped perforated pedicle flap can be used for the minor defects. In addition, the nasolabial sulcus island flap based on nasal basal perforator vessel can be used when the facial skin tension is greater. Finally, the supralabial-nasolabial horn-shaped perforated pedicle flap is suitable when the defect is near the nasolabial sulcus. All patients can obtain better aesthetic results when the flap is selected according to the actual situation and reasonably.