Objective:To analyze the apply effect of radiofrequency ablation assisted associating liver partition and portal vein ligation for staged hepatectomy (RALPPS) in liver cancer patients with insufficient future liver remnant (FLR).Methods:The data of 29 patients who underwent RALPPS in the First Affiliated Hospital of the Army Military Medical University from June 2014 to July 2020 were analyzed, including 25 males and 4 females, aged (46.6±9.9) years. The patients were divided into the second stage group (completed the second stage operation, n=18) and the first stage group (completed only the first stage operation, n=11) according to whether they had successfully completed the second stage operation. FLR, percentage of FLR in standard liver volume (percentage of FLR), growth rate of FLR, liver function after operation, operation time and radiofrequency ablation time of first stage operation, surgical complications were compared between the two groups. Results:The percentage of FLR before the first stage operation was (30.0±7.0)% in 29 patients, and the second stage operation was completed in 18 patients (62.1%). After the first stage operation, the aspartate aminotransferase and alanine aminotransferase in the second stage group were 519.0 (362.9, 696.0) U/L and 391.8 (297.2, 591.1) U/L, which were better than those of the first stage group 931.0 (711.7, 1131.9) U/L and 851.3 (426.6, 888.0) U/L (both P<0.05). There was no significant difference between the two groups in FLR and percentage of FLR before the first stage operation, duration time, amount of bleeding and time of radiofrequency ablation of the first stage operation (all P>0.05). In the second stage group, the interval between two operations was (21.6±6.7) days, the FLR before the second stage operation was (623.2±101.8) cm 3, the FLR percentage was (49.0±7.0)%, and the FLR growth rate was (19.0±5.0)%. In the first stage group, there were 11 patients (100.0%) who developed complication after first stage operation, induding 7 patients (63.6%) with complication above Clavien-Dindo grade Ⅲb. In the second stage group, 18 patients (100.0%) developed complication after the first stage operation. There were no complication above grade Ⅲb. The causes of 11 patients who did not completed secondary surgery included poor liver function and insufficient FLR in 4 patients, tumor progression in 6 patients, and death in 1 patient. Conclusion:RALPPS is a therapeutic option for liver cancer patients with insufficient FLR, and the therapeutic effect is reasonable.

Objective To establish a scientific and rational narrative medical curriculum standards for clinical medicine postgraduates to improve their medical humanistic quality.Methods On the basis of literature review and group discussion,the standards of narrative medical curriculum for postgraduates majoring in clinical medicine were preliminarily constructed,and the Delphi method was used to evaluate and screen the indicators.An expert consultation questionnaire was drawn up for 40 selected experts to finalize the curriculum standards for narrative medicine.The small-scale teaching practice was carried out in postgraduates of the Department of Hepatobiliary Surgery in Southwest Hospital of Chongqing,and the problems in the process of teaching implementation were collected.Results Experts' opinions tended to be consistent after two rounds of consultation.Finally,the study confirmed a theoretical and practical narrative medical curriculum which consisted of introducing narrative medicine theory,reading narrative medicine related books,watching the medical narrative film and television works,and writing the narrative medical records.Through the small-scale teaching practice,we collected a variety of problems,for which,we sorted out and analyzed,and finally put forward the improvement scheme.Conclusion The narrative medical curriculum for clinical medicine postgraduates is reasonable,which can lay the foundation for the promotion of clinical medical postgraduates' medical humanistic quality and doctor-patient communication ability,and accelerate the popularization of narrative medicine idea in our country.

Objective To study the feasibility and safety of simultaneous super-selective hepatic arterial and portal vein embolization for staged hepatectomy (ASAPS) in the treatment of patients with hepatocellular carcinoma (HCC) and cirrhosis.Methods The clinical data of 8 patients with HCC who underwent ASAPS at the First Affiliated Hospital of the Army Medical University from December 2016 to January 2018 were retrospectively analyzed.All the patients,including 7 males and 1 female with an average age of 44.3± 9.2,were diagnosed to have cirrhosis with insufficient volume of future liver remnant (FLR).Portal vein embolization (PVE) and super-selective hepatic arterial embolization (SHAE) were performed simultaneously.The patients were then closely monitored for the volumes of FLR.Once the FLR achieved the target volume,a second staged resectional surgery would be performed.The postoperative major complications,laboratory tests and patient long-term survival were studied.Results The ratio of FLR to the average standard liver volume (SLV) increased from (28.5±5) ％ to (49.6±7.3) ％ following the first-stage procedure.All the patients underwent liver resection successfully.The average second-stage operation time was 342.6±92.8 min,and the intraoperative blood loss was 743.8±432.1 ml.Both the postoperative serum alanine amin otransferase (ALT) and aspartate aminotransferase (AST) levels were elevated remarkably and then droppedto the near normal levels.All the patients were discharged home without any severe complications.Among them,3 patients relapsed early in the postoperative period,5 survived without recurrence,and 3 survived for over 1 year.Conclusions The first-stage surgery of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) using ASAPS was minimally invasive.The volume growth rate of the FLR after ASAPS was comparable to that of the conventional first stage of ALPPS.In conclusion,ASAPS is a promising alternative to the traditional ALPPS as the first-line treatment of patients with insufficient FLR.

Objective To investigate practical effects of task based learning (TBL), case based learning (CBL) and problem based learning (PBL) integrated teaching method in clinical novitiate of hepatobiliary disease and pancreatopathy. Methods Total of 64 students majored in seven-year clinical practice were divided into TBL+CBL, TBL+PBL, PBL+CBL and TBL+CBL+PBL groups, using a cluster stratified random sampling method, with 16 students in each group. The students were taught with the same basic theoretical knowledge, followed by different course of the combination of TBL, CBL and PBL. In the TBL + CBL + PBL group, the typical patient data were sent to the students before the class, and at the same time, the catalogues of the reference materials and the preview questions were also provided for them. In the course of teaching, the results of the students' information and the answers to the preview questions were first carried out, and then the task test was carried out in the form of collective consultation, and then the students focused on the answers and tests . The theoretical difficulties and blind spots of the theory and the correction of mistakes, deficiency, the breakdown of the case after the end of the expla-nation, and the mistakes and shortcomings of the students' knowledge were discussed in class. The practical effects were evaluated by theory test, teaching and self-acceptance assessment. The data were analyzed by variance analysis, t test and Chi square test. Results Average scores of students in the TBL+PBL , TBL+PBL, PBL+CBL and TBL+PBL+CBL group were (75.313±8.260), (74.875±9.818), (77.125±9.667) and (82.000±6.491), respectively. Average scores of students in the TBL+PBL+CBL group are signifi-cantly higher than the TBL+PBL (t=0.217, P=0.016) and TBL+PBL (t=0.059, P=0.022) groups, while there was no difference with those of PBL+CBL groups (t=0.049, P=0.106). However, Tests grades of 4 students which were poor performance in TBL+CBL+PBL group were significantly higher than those of 4 students with poor performance in PBL+CBL groups (t=0.356, P=0.000). In addition, students in TBL+CBL+PBL group more greatly enhanced learning interest and initiative, and improved their comprehensive analysis ability than students in TBL+CBL ( x2 and P value: 5.565, 0.018; 5.109, 0.024; 4.167, 0.041), TBL+PBL ( x2 and P value:7.127, 0.008;5.367, 0.021;5.565, 0.018) and PBL+CBL ( x2 and p value:4.167, 0.041;5.000, 0.025; 8.866, 0.003). Conclusion TBL, CBL and PBL integrated teaching method can improve students' mastery of theoretical knowledge, and especially can help poor students to improve their academic perfor-mance and interest.

Gadolinium ethoxybenzyl dimeglumine (Gd-EOB-DTPA),a newly applicable hepatocyte-specific contrast agent,can provide both dynamic and hepatobiliary images and has been rapidly accepted by clinicians for the diagnosis of liver lesions and preoperative evaluation.Gd-EOB-DTPA can fulfill hepatic perfusion imaging,detection and characterization of focal liver lesions,evaluation of liver function,and predict biological behaviors of hepatocellular carcinoma (HCC) within the same examination in a relatively short time window.A large number of domestic and foreign studies have confirmed that hepatobiliaryspecific enhanced magnetic resonance imaging (MRI) was significantly superior to MRI scan,enhanced CT and ultrasound in diagnosing HCC.With the help of the advanced imaging techniques,surgeons can accurately diagnose and assess the situation of patients to implement individualized treatment plans,and therefore these will promote the development of precision hepatic surgery.

Hepatocellular carcinoma (HCC) is still one of common malignant cancers worldwide, with increasing incidence and mortality rates. Early diagnosis and effective treatment for HCC remain to be explored. This article introduces the research advances in the early specific diagnosis and effective therapies for HCC in 2016, such as molecular markers in the specific diagnosis and targeted therapy for HCC, main therapeutic regimens, robot-assisted liver resection, and no-touch radiofrequency ablation.

Colorectal cancer is a kind of common malignant tumor,the incidence of which appears to increase with the developments of social economy and change of life style.Liver metastasis occurred in about 50％ of patients with colorectal cancer,as an important cause of death.In recent years,radiofrequency ablation (RFA) has been used clinically to damage the hepatic metastatic carcinoma.With the characteristics of accuracy,micro-invasive trauma and repeatability,RFA has been extensively used as an effective local treatment.This paper discusses the indications of RFA for colorectal liver metastasis (CRLM),current status of RFA in unresectable and resectable CRLM,application of RFA in combine therapy for CRLM.

Objective To investigate the risk factors resulting in the perioperative liver failure and death for the HBV-associated hepatocellular carcinoma (HCC) patients with or without cirrhosis.Methods The method of retrospective case-control study was performed.The clinicopathological data of 1 083 HCC patients with positive HBsAg who received curative liver resection at the Southwest Hospital from January 2008 to December 2012 were collected.According to the absence or presence of cirrhosis,the HCC patients with positive HBsAg were divided into the 2 groups,including the cirrhosis group (633 patients) and the non-cirrhosis group (450patients).The intraoperative conditions (operation time,volume of intraoperative blood loss,rate of blood transfusion,rate of pringle maneuver) and postoperative conditions (incidence of perioperative complications,duration of postoperative hospital stay,perioperative mortality) of HCC patients were observed.The gender,age,alanine transaminase (ALT),aspartate transaminase (AST),albumin (Alb),total bilirubin (TBil),platelet (PLT),Child-Pugh classification,operation time,volume of intraoperative blood loss,blood transfusion,pringle maneuver,extent of liver resection,number of tumors,tumor diameter,tumor thrombus and liver cirrhosis were enrolled and prognostic factors resulting in perioperative liver failure and death for the HCC patients were explored.Measurement data with skewed distribution were presented as M (range) and comparison between the 2 groups was analyzed using Mann-Whitney U test.Count data were presented as counts (percentage) and comparison between the 2 groups was analyzed using chi-square test or Fisher exact probability.Univariate analysis was performed by chi-square test and multivariate analysis was performed by Logistic regression model (forward).Results (1) The intraoperative conditions:the volume of intraoperative blood loss were 500 mL (range,30-7 000 mL) in the cirrhosis group and 400 mL (range,50-8 000 mL) in the non-cirrhosis group,with a statistically significant difference between the 2 groups (Z =-2.209,P ＜ 0.05).The operation time,rate of blood transfusion and rate of pringle maneuver were 250 minutes (range,82-715 minutes),29.86％ (189/633),62.24％ (394/633) in the cirrhosis group and 242 minutes (range,85-738 minutes),27.11％ (122/450),66.67％ (300/450) in the non-cirrhosis group,respectively,with no statistical differences between the 2 groups (Z =-1.212,x2 =0.969,2.236,P ＞0.05).(2) The postoperative conditions:the incidence of perioperative complications was 30.49％(193/633) in the cirrhosis group and 21.11％ (95/450) in the non-cirrhosis group,with a statistically significant difference between the 2 groups (x2 =11.851,P ＜ 0.05).The incidence of lung infection,abdominal infection and liver failure were 6.48％ (41/633),2.69％ (17/633),5.53％ (35/633) in the cirrhosis group and 3.56％ (16/450),0.89％ (4/450),1.33％ (6/450) in the non-cirrhosis group,respectively,with statistically significant differences between the 2 groups (x2 =4.502,4.465,12.713,P ＜ 0.05).The duration of postoperative hospital stay was 15 days (range,0-70 days) in the cirrhosis group and 14 days (range,0-71 days) in the non-cirrhosis group,with a statistically significant difference between the 2 groups (Z =-3.448,P ＜ 0.05).The perioperative mortality was 5.85％ (37/633) in the cirrhosis group and 2.44％ (11/450) in the non-cirrhosis group,with a statistically significant difference between the 2 groups (x2=7.181,P ＜ 0.05).(3)Results of risk factors affecting perioperative liver failure:①results of univariate analysis showed that age,AST,Alb,Child-Pugh classification,operation time,volume of intraoperative blood loss,blood transfusion,extent of liver resection,tumor diameter,liver cirrhosis with positive HBsAg were associated with perioperative liver failure in HCC patients (x2=5.013,7.979,8.855,16.968,14.148,9.764,18.511,11.749,5.534,12.713,P＜0.05);age,AST,Alb,Child-Pugh classification,operation time,blood transfusion,extent of liver resection and tumor diameter were associated with perioperative liver failure in the cirrhosis group (x2=5.877,5.380,11.087,13.672,8.849,13.170,12.418,5.805,P ＜ 0.05);volume of intraoperative blood loss was associated with perioperative liver failure in the non-cirrhosis group (P ＜ 0.05).②Results of multivariate analysis showed that age≥60 years,Child-Pugh class B,operation time ＞ 360 minutes,blood transfusion,extent of liver resection ≥3 segments and liver cirrhosis were independent risk factors affecting perioperative liver failure in HCC patients with positive HBsAg [OR =2.285,2.716,2.315,2.159,2.459,4.322;95％ confidence interval (CI):1.081-4.831,1.100-6.706,1.064-5.038,1.068-4.362,1.264-9.786,1.763-10.598,P＜0.05];Alb ＜38 g/L,Child-Pugh class B,blood transfusion and extent of liver resection ≥ 3 segments were independent risk factors affecting perioperative liver failure in the cirrhosis group (OR =2.231,2.857,2.186,2.927,95％ CI:1.038-4.795,1.095-7.451,1.045-4.576,1.426-6.008,P ＜ 0.05);volume of intraoperative blood loss ＞ 1 200 mL was an independent risk factor affecting perioperative liver failure in the non-cirrhosis group (OR =15.077,95％CI:2.695-84.353,P ＜ 0.05).(4) Risk factors affecting perioperative death:①results of univariate analysis showed that gender,Alb,TBil,Child-Pugh classification,blood transfusion,extent of liver resection,tumor diameter,tumor thrombus and liver cirrhosis were associated with perioperative death in HCC patients with positive H BsAg (x2=4.462,8.783,4.212,4.869,7.189,11.745,6.837,4.323,7.181,P ＜0.05);Alb,extent of liver resection and tumor diameter were associated with perioperative death in the cirrhosis group (x2=12.173,12.793,10.981,P ＜ 0.05);blood transfusion and tumor thrombus were associated with perioperative death in the non-cirrhosis group (x2 =5.836,6.417,P ＜ 0.05).② Results of multivariate analysis showed that Alb ＜38 g/L,extent of liver resection ≥ 3 segments and liver cirrhosis were independent risk factors affecting perioperative death in HCC patients with positive HBsAg (OR =2.560,2.657,2.567,95％ CI:1.382-4.742,1.471-4.800,1.283-5.134,P ＜ 0.05);Alb ＜ 38 g/L,extent of liver resection ≥ 3 segments and tumor diameter≥5 cm were independent risk factors affecting perioperative death in the cirrhosis group (OR =3.003,2.533,3.060,95％ CI:1.495-6.034,1.251-5.128,1.135-8.251,P＜0.05);blood transfusion and tumor thrombus were independent risk factors affecting perioperative death in the non-cirrhosis group (OR =3.755,4.036,95％ CI:1.047-13.467,1.126-14.469,P ＜ 0.05).Conclusions Liver cirrhosis is an independent risk factor for perioperative liver failure and death in HCC patients with positive HBsAg.The risk of perioperative liver failure and death in HCC patients with cirrhosis is significantly higher than that in HCC patients without cirrhosis,and there is a difference in the risk factors for perioperative liver failure and death.

Objective To systematically compare the clinical efficacy of hepatectomy via anterior approach and the conventional approach for the treatment of giant liver cancer.Methods The database including Cochrane library,PubMed,Web of Knowledge,EMBASE,China National Knowledge Infrastructure (CNKI),Chinese Medical Current Contents(CMCC),Wanfang database were searched with the key words of原发性肝癌,转移性肝癌,手术,肝切除术,前入路,绕肝提拉法,传统入路,hepatocellular carcinoma,metastatic liver cancer,HCC,surgery,liver resection,hepatectomy,hepatic resection,anterior approach,conventional approach and liver hanging maneuver between the database establishment and December 2013.Chinese and English literatures on major hepatectomy via anterior approach and conventional approach for the treatment of giant liver cancer were retrieved,and data were analyzed by 2 independent researchers.Meta analysis was carried out using the software of Review Manager 5.1.2.The count data were analyzed using the odds ratio (OR).The quantitative data were analyzed by the weighted mean difference (WMD),and were presented by 95％ confidence interval (95％ CI).Results Thirteen literatures with 1 287 giant liver cancer patients were retrieved,including 603 patients receiving hepatectomy via anterior approach and 684 via conventional approach.Three literatures were enrolled in the randomly controlled studies,one had high risk of bias and the other 2 had low risk of bias.Ten literatures were enrolled in the non-randomly controlled studies with the mean score of 7 (range,5-9).The results of Meta analysis showed that hepatectomy via anterior approach could reduce the volume of intraoperative blood loss (MD =-349.39,95％ CI:-636.90--61.81,P ＜ 0.05),the blood transmission rate (OR =0.41,95％ CI:0.24-0.72,P ＜ 0.05),the operation time (MD =-40.81,95 ％ CI:-57.81--23.80,P ＜ 0.05),the mean time of hospital stay (MD =-4.52,95 ％ CI:-8.36--0.69,P ＜ 0.05) and the postoperative mortality and incidence of postoperative complications (OR =0.32,0.68,95 ％ CI:0.16-0.62,0.53-0.88,P ＜ 0.05) when compared with the conventional approach,further more,hepatectomy via the anterior approach could reduce the postoperative recurrence of giant liver cancer and had higher overall 1-and 3-year survival rates (OR =0.45,2.72,4.47,95％ CI:0.29-0.69,1.59-4.66,2.61-7.63,P ＜ 0.05).Conclusion The safety of hepatectomy via anterior approach is similar to that of the conventional approach,while the short-and long-term efficacy are superior to those of the conventional approach.