Application of membrane anatomy in hepatopancreatobiliary and splenic surgery / 中华外科杂志

Understanding of a variety of membranous structures throughout the body,such as the fascia,the serous membrane,is of great importance to surgeons. This is especially valuable in abdominal surgery. With the rise of membrane theory in recent years,membrane anatomy has been widely recognized in the treatment of abdominal tumors,especially of gastrointestinal tumors. In clinical practice. The appropriate choice of intramembranous or extramembranous anatomy is appropriate to achieve precision surgery. Based on the current research results,this article described the application of membrane anatomy in the field of hepatobiliary surgery,pancreatic surgery,and splenic surgery,with the aim of blazed the path from modest beginnings.

Ten-year retrospect of ALPPS in the treatment of hepatocellular carcinoma:an eternal concept with cautious technologic choice / 中华外科杂志

Clinical practice using associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) or its modified procedures in treatment of primary hepatocellular carcinoma(HCC) with insufficient future liver remnant(FLR) in the past 10 years has failed to meet our expectations both in achieving decreased perioperative complications and mortality.The efficacy of ALPPS in improving long-term survival outcome of HCC still remains poor.Due to the trauma of two surgery within a short period,and patients with inadequate FLR are all diagnosed at advanced disease stages,ALPPS can only achieve surgical rather than biological tumor-curability.Previous studies have demonstrated comparable 5-year survival rates between early and advanced stages of HCC who underwent regional treatments.Therefore,tumor biological conversion is the key strategy prior to liver remnant volume conversion in improving treatment outcomes for HCC patients with insufficient FLR.Target therapy,immunotherapy together with locally treatment were expected to improve the conversion efficacy.Looking back at the development of ALPPS for the last decade,the rapid proliferation of FLR should be passed on,while the technology costs high risks and result in poor long-term outcome must be cautiously selected.

Binding pancreatic duct to mucosa anastomosis / 中华外科杂志

<p><b>OBJECTIVE</b>To study the feasibility of binding pancreatic duct to mucosa anastomosis (BDM)-a complementary procedure to both binding pancreaticojejunostomy and binding pancreaticogastrostomy.</p><p><b>METHODS</b>(1) Animal experimental study:gastrostomy and jejunostomy were performed on six adult New Zealand rabbits. The gastrostomy and jejunostomy shared a same stent (rubber urethral catheter, silicone tube or plastic infusion tube). Both ends of the stent were placed in gastric and enteric cavity. Purse-string suture was performed around the stent before the jejunum and the stomach were brought together for fixation by few stitches. And to observe whether the purse-string suture around a plastic tube, rubber tube or silicon tube inserted into jejunum and/or stomach can prevent leaking out of the jejunal or gastric content to cause peritonitis. (2) Clinically 7 patients were performed with BDM anastomosis. The procedure was consisted of five steps: preparation of the pancreatic stump;preparation of the jejunum; preparation of the fixing sutures between the pancreatic stump and the jejunum; implementation of the anastomosis; lastly, fixation of the jejunum beside the pancreas stump. Post-operative periodic examination of the blood amylase and the amylase in the abdominal drainage. Pancreatic fistula was classified in to two categories: parenchymal fistula (pancreatic cut surface fistula) and anastomotic leakage.</p><p><b>RESULTS</b>Animal experiment did not show any leakage around the plastic tube or silicon tube inserted into jejunum and(or) stomach. There was no anastomotic leak in all the patients. There was transient increase of amylase in two cases, but the volume of drainage did not exceed 50 ml/d and the recovery of the patients was not affected.</p><p><b>CONCLUSIONS</b>BDM is a simple, safe and easy procedure to perform. It provides to the surgeons with a new option in different situations to achieve the most ideal surgical result.</p>

A pancreas suture-less type II binding pancreaticogastrostomy / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the feasibility and safety of type II binding pancreaticogastrostomy (BPG) in pancreaticoduodenectomy and mid-segmentectomy of pancreas.</p><p><b>METHODS</b>From November 2008 to May 2009, 26 patients underwent pancreaticoduodenectomy and mid-segmentectomy of pancreas with type II BPG reconstruction, including 13 cases of pancreatic head cancer, 3 cases of duodenal adenocarcinoma, 2 cases of ampullary carcinoma, 4 cases of cholangiocarcinoma, 1 case of bile duct cell severe atypical hyperplasia, and 1 case of stomach cancer. The process of type II BPG was described as the following: after pancreas remnant was mobilized for 2-3 cm, a piece of sero-muscular layer at the posterior gastric wall was excised and then a sero-muscular depth purse-suturing with 3-0 prolene was pre-placed (outer purse-string). Incising anterior gastric wall or opening part of the closed distal gastric stump, the mucosa layer at the sero-muscular defect was incised and then purse-suture at the mucosal tube was pre-placed (inner purse-string). Through the two pre-placed purse-strings, the pancreas remnant was pulled into the gastric lumen and then posterior gastric wall was pushed backward to keep it closely in contact with the retro-peritoneal wall. Thereafter, the outer purse-string was tied (outer binding) and then the inner purse-string was tied (inner binding).</p><p><b>RESULTS</b>All cases underwent BPG of type II. The operative time ranged from 3 to 5.5 hours. The postoperative hospital stay ranged from 6 to 48 days. Postoperative complications included 1 case of ascites, 2 cases of delayed gastric emptying and 1 case of intra-abdominal bleeding. All cases with complications were cured after nonsurgical treatment. No mortality or pancreatic leakage occurred.</p><p><b>CONCLUSIONS</b>Pancreaticogastrostomy is good for accommodating a large pancreas stump. Binding technique is very helpful in minimizing the leak rate of pancreaticogastrostomy. While type I BPG is safe and easy to perform, type II is even safer and easier to be done.</p>

Binding pancreaticogastrostomy / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the value of a new technique of the binding pancreaticogastrostomy (BPG) in pancreaticoduodenectomy.</p><p><b>METHODS</b>From May 2008 to October 2008, 15 patients were performed with BPG, included pancreatic head cancer in 7 cases, duodenal adenocarcinoma in 2 cases,mass-type chronic pancreatitis with pancreatolithiasis in 1 case, ampullary carcinoma in 1 case, gallbladder cancer in 1 case, islet cell tumor in 1 case and cholangiocarcinoma in 2 cases. The main procedures of BPG included: isolating remnant pancreas; slitting partial posterior wall of stomach and preplaced with seromuscular purse-string suture; cutting gastric anterior wall; performing pancreaticogastrostomy (binding of outer seromuscular and inner mucous layer of stomach).</p><p><b>RESULTS</b>The procedures were successful in 15 patients. Postoperative complications included small amount of pleural effusion in 2 cases, delayed gastric emptying in 2 cases and bile leakage in 2 cases. All patients were cured in 2 weeks. No mortality and anastomosis leakage occurred.</p><p><b>CONCLUSION</b>The application of BPG technique can prevent the anastomosis leakage and improve the safety for pancreaticoduodenectomy.</p>

The strategy of isolated complete resection of the caudate lobe of the liver through the anterior liver-splitting approach: a report of 19 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the strategy of isolated complete resection of the caudate lobe of the liver through the anterior liver-splitting approach.</p><p><b>METHODS</b>From January 1995 to June 2006, isolated complete caudate resection of the caudate lobe of the liver through the anterior liver-splitting approach in which accessed the caudate lobe by separation the liver parenchyma along the interlobar plane, was performed on 19 patients with tumors originated in caudate lobe. They were included hepatocellular carcinoma in 13 cases, cholangiocarcinoma in 4 cases and hemangioma in 2 cases, the tumor size range from 4 - 12 cm. The approach to hepatic resection involved routine use of Peng's multifunctional operative dissector, inflow and outflow of hepatic vascular control before hepatic parenchyma transection, low central venous pressure and selective use of liver hanging maneuver, as well as retrograde caudate lobectomy.</p><p><b>RESULTS</b>The operations were successful in 19 patients. Operating time averaged at (296 +/- 55) min. The average amount of blood loss were 1200 ml (ranged from 500 - 3000 ml). Postoperative complications included ascites in 2 cases, pleural effusion in 5 cases and bile leakage in 2 cases. They were cured by drainage. No mortality occurred in the perioperative period.</p><p><b>CONCLUSIONS</b>The application of anterior approach for isolated caudate lobectomy can converse certain kind of caudate lobe tumor from non-resectable to respectable resulting in widening the indication. The intraoperative routine use of Peng's multifunctional operative dissector, application of inflow and outflow of hepatic vascular control, low central venous pressure and selective use of liver hanging maneuver, as well as retrograde caudate lobectomy make the anterior liver-splitting approach for isolated complete caudate lobectomy safer and easier.</p>

Role of pancreatic hilar vascular occlusion in sophisticated pancreaticoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the value of a simple occlusive technique of the triple vessels, ie, portal vein, superior mesenteric vessels and splenic vein, in complicated pancreaticoduodenectomy.</p><p><b>METHODS</b>The technique was fulfilled with a No.8 urethral catheter to encycle the portal vein, superior mesenteric vessels and its near tissue plus pancreatic tail and splenic vein than the neck of pancreas was transected and well exposure superior mesenteric vein and complete transaction of uncinate. From November 2005 to November 2006 the technique was applied to 12 cases of pancreatic malignancy which presented very infiltrated and adhesive to the hilar vascular structure.</p><p><b>RESULTS</b>The 12 cases were accomplished according with this technique. The operating time was (292.4 +/- 36.3) min (270 - 390 min) and the intraoperative blood loss was (833.3 +/- 618.4) ml (300 - 2500 ml). The postoperative complication included one case of lymphatic leakage, two cases of pneumonia, one case of abdominal infection and two cases of wound infection. There was no perioperative mortality. The postoperative hospital stay was 17 d (11 - 29 d).</p><p><b>CONCLUSIONS</b>Use this triple vessels occlusive technique can improve the safety and feasibility in complicated cases of pancreaticoduodenectomy.</p>

Surgical treatment of hepatocellular carcinoma with tumor thrombus in inferior vena cava / 中华外科杂志

<p><b>OBJECTIVE</b>To review the experience for the management of hepatocellular carcinoma with tumor thrombus in inferior vena cava.</p><p><b>METHODS</b>From July 2003 to May 2005, hepatectomy combined with thrombectomy were performed on 7 cases of hepatocellular carcinoma with tumor thrombus in inferior vena cava. In order to remove the tumor thrombus in inferior vena cava, total hepatic vascular exclusion were adopted on all cases to control the blood flow of IVC. According to the position of extension of tumor thrombus, 5 different procedures were adopted in the cases to control the suprahepatic IVC and extract the tumor thrombus out of IVC and atrium. Procedure 1: Median sternotomy, extracorporeal bypass, cardiac arrest, incision on right atrium and IVC were performed on 1 case for thrombectomy. Procedure 2: Median sternotomy, extracorporeal bypass without cardiac arrest, incision on IVC and (or without) incision on right atrium were performed on 2 cases for thrombectomy. Procedure 3: Abdominal approach to control intrapericardial IVC through an incision on diaphragm was performed on 1 case for thrombectomy. Procedure 4: Abdominal approach to control suprahepatic IVC above diaphragm through a small incision made on vena cava foramen for thrombectomy was performed on 1 case. Procedure 5: Abdominal approaches to control suprahepatic IVC below diaphragm for thrombectomy were performed on 2 cases.</p><p><b>RESULTS</b>All operations were successfully performed. The postoperative complications included pleural effusion in 1 case, subphrenic fluid collection in 1 case and wound infection in 1 case. The average survival time of 7 cases was 9.8 month. The longest survival time was 26 months.</p><p><b>CONCLUSION</b>Hepatectomy and thrombectomy can be safely performed on the case of HCC combined with tumor thrombus in IVC. Surgical treatment can relieve the patient from the risk of sudden death caused by heart failure and pulmonary.</p>

Role of anatomic hepatectomy performed under vascular exclusion in management of hepatolithiasis / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the effect of anatomic hepatectomy performed under vascular exclusion in management of hepatolithiasis.</p><p><b>METHODS</b>From May 2002 to March 2005, fifty-three patients with unilateral hepatolithiasis underwent anatomic hepatectomy with exposure and control of inferior vena cava and main trunk of hepatic veins. The hepatic lobes involved by hepatolithiasis were left lateral lobe (S(2), S(3)) in 12 patients, left lobe (S(2), S(3), S(4)) in 26 patients, right posterior lobe (S(6), S(7)) in 8 patients and right lobe (S(5), S(6), S(7), S(8)) in 7 patients. Atrophy of involved hepatic lobes was found in 38 patients. Fourteen patients had experienced more than one operation on biliary tract. Nine patients showed the symptoms of acute cholangitis preoperatively and 4 patients complicated with liver abscess.</p><p><b>RESULTS</b>Vascular exclusion was successfully performed on all patients to control the blood inflow and outflow of liver. The anatomically resected hepatic lobes were left lateral lobe (S(2), S(3)) in 12 patients, left lobe (S(2), S(3), S(4)) in 26 patients, right posterior lobe (S(6), S(7)) in 8 patients and right lobe (S(5), S(6), S(7), S(8)) in 7 patients. Except hepatectomy, the additional procedures performed on the patients were choledocholithotomy in 39 cases, choledocho-jejunostomy in 5 cases. The majority of complications were bile leakage in 3 cases, subphrenic infection in 2 cases, hydrothorax in 5 cases and wound infection in 5 cases.</p><p><b>CONCLUSIONS</b>Anatomic hepatectomy under vascular exclusion is effective treatment to eradicate intrahepatic stone foci in case of unilateral hepatolithiasis, and help to reduce intraoperative blood loss and decrease postoperative complications.</p>

Retrograde caudate lobectomy in 7 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the clinical value and significance of retrograde caudate lobectomy.</p><p><b>METHODS</b>From December 2003 to January 2005, 7 patients underwent retrograde caudate lobectomy in which division and ligation of short hepatic veins were carried out at the final stage of the procedure in stead of at the initial stage.</p><p><b>RESULTS</b>The procedures were carried out smoothly with no operative death in all the 7 cases including isolated complete caudate lobectomy in 4 cases, isolated partial caudate lobectomy in 1 case, combined right half liver resection in 2 case. The average operation time, blood loss and length of stay after operation was (273 +/- 44) min, (1114 +/- 241) ml (800-1500 ml) and 16 days respectively. Complications including pleural effusion and ascites in 1 case respectively were fully recovered. During the follow-up, 1 patient died at 6 months for tumor recurrence in lung and the remaining 6 patients are alive at the follow-up of 5 to 16 months.</p><p><b>CONCLUSIONS</b>Retrograde caudate lobectomy is a new procedure suitable for those caudate neoplasms which are adhering to or infiltrating to IVC or too big to move side by side. The application of this technique can converse certain kind of caudate lobe tumor from non-resectable to resectable resulting in widening the indication.</p>

The effect of hepatic blood inflow occlusion on hepatic cancer treated with diode-laser thermocoagulation / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

<p><b>OBJECTIVE</b>To assess the effect of temporary occlusion of hepatic blood inflow on hepatic cancer treated with diode-laser induced thermocogation (LITT).</p><p><b>METHODS</b>The carcinoma Walker-256 was implanted in 40 SD rat livers. Twelve days later, the animals were randomly divided into 4 groups. Group A received LITT alone; group B received hepatic artery temporary occlusion during LITT; group C received portal vein temporary occlusion during LITT; group D received hepatic artery and portal vein temporary occlusion during LITT. Tumors were exposed to 810 nm diode-laser light at 0.95 watts for 10 min from a scanner tip applicator placed in the tumor. At the same time, the intrahepatic temperature distribution in rats with liver tumors was measured per 2 min during thermocoagulation. Tumor control was examined immediately 7 and 14 d after thermocoagulation.</p><p><b>RESULTS</b>There was significant difference of intrahepatic temperature distribution in rats with liver tumors among the 4 groups (P<0.05) except when group C samples were compared with group D samples at each time point, and group B samples were compared with group C samples at 120 s (P>0.05). Light microscopic examination of the histologic section samples revealed three separate zones: regular hyperthermic coagulation necrosis zone, transition zone and reference zone. Compared with the samples in group A and group B, group C and group D samples had more clear margin among the three zones.</p><p><b>CONCLUSION</b>The hepatic blood inflow occlusion, especially portal vein hepatic blood inflow occlusion, or all hepatic blood inflow occlusion considerably increased the efficacy of LITT in the treatment of liver cancer.</p>

Experimental study of diode-laser induced thermocoagulation on hepatic tissue with scanner fiber tip / 中华外科杂志

<p><b>OBJECTIVE</b>To seek a safe, efficient, and cost-effective technique for local thermo-ablation of hepatic cancer.</p><p><b>METHODS</b>The livers from 16 healthy rabbits were thermocoagulated by diode-laser with scanner fiber tip, 6 w for 10 mins. At the same time, the temperatures were measured at 0, 5 and 10 mm from laser tip. The pre-thermocoagulative liver function was compared with that of 7 days post-thermocoagulation. The pathologic changes were also observed 1 month after laser thermocoagulation.</p><p><b>RESULTS</b>All the rabbits survived and hepatic tissue temperatures at 0, 5, 10 mm from laser tip reached 96.39 degrees C +/- 3.97 degrees C, 60.79 degrees C +/- 6.21 degrees C, 46.10 degrees C +/- 4.58 degrees C respectively after 10 minutes of thermocoagulation. There were no significant differences in liver function parameters between rabbits of pre-laser thermocoagulation and of post-laser thermocoagulation. Thermocoagulated necrosis of liver tissue with surrounding fibrosis in a diameter of 26.0 mm was formed. Light microscopy revealed coagulative necrosis in the center of the coagulated area without surviving hepatic cells.</p><p><b>CONCLUSION</b>The hepatic tissue can be coagulated safely and effectively by diode-laser with scanner fibertip, and such a technique may provide a new method for the treatment of hepatic carcinoma.</p>