Clinical efficacy of ex vivo liver resection and autotransplantation for liver complex space-occupying lesions / 中华消化外科杂志

Objective:To investigate the clinical efficacy of ex vivo liver resection and autotransplantation (ELRA) for liver complex space-occupying lesions.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 50 patients with liver complex space-occupying lesions who underwent ELRA in the First Hospital Affiliated to Army Medical University between June 2009 and May 2017 were collected. There were 36 males and 14 females, aged from 13 to 69 years, with a median age of 51 years. All patients underwent ELRA. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was conducted by outpatient examination or telephone interview. Patients were followed up according to the individual follow-up plan in the first 6 months after discharge, and then once every 3 to 6 months to detect tumor recurrence and survival up to May 2019. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were represented as M (range). Count data were expressed as absolute numbers or percentages. The Kaplan-Meier method was used to calculate survival rates and draw survival curves, and Log-rank test was used for survival analysis. Results:(1) Surgical situations: all the 50 patients underwent ELRA successfully, and postoperative pathological examination showed the R 0 resection rate was 100%(50/50). The operation time of the 50 patients were (630±186)minutes, of which 9 patients with liver benign occupation had the operation time of (684±168)minutes and 41 patients with liver malignant tumor had the operation time of (618±190)minutes. The operation time of temporary reconstruction of inferior vena cava and portacaval shunt, time of anhepatic phase, volume of intraoperative blood loss of the 50 patients were (35±9)minutes, (256±71)minutes, 2 000 mL(range, 400-10 000 mL), respectively. The remnant liver mass to standard liver mass ratio of the 50 patients was 65%±16%, of which 9 patients with liver benign occupation had the remnant liver mass to standard liver mass ratio of 63%±14% and 41 patients with liver malignant tumor had the remnant liver mass to standard liver mass ratio of 65%±17%. Of the 50 patients, 35 had vascular invasion (7 cases with liver benign occupation, 28 cases with liver malignant tumor), of which 24 (6 cases with liver benign occupation, 18 cases with liver malignant tumor) underwent in vitro vascular reconstruction, 12 (5 cases with liver benign occupation, 7 cases with liver malignant tumor) had bile duct invasion and underwent choledochojejunostomy due to the inability of the common bile duct to anastomose the ends. Two cases with liver metastasis of gastric cancer, one case with liver metastasis of colon cancer and one case with liver metastasis of pancreatic cancer underwent radical gastrectomy, radical resection of colon cancer, and pancreaticoduodenectomy, respectively. (2) Postoperative situations: the duration of postoperative hospital stay of the 50 patients were 25 days (range, 11-169 days). Of the 50 patients, 12 had pleural effusion who were treated with pleural puncture drainage, 10 had bile leakage who were treated with abdominal puncture drainage, 3 had bile duct anastomotic leakage who were treated with endoscopic nasobiliary drainage or biliary stent implantation, 6 underwent reoperation among which 4 underwent exploratory laparotomy due to abdominal hemorrhage, 1 underwent portal vein reconstruction due to abdominal hemorrhage combined with portal vein thrombosis, and 1 underwent salvage liver transplantation due to liver failure. Nine of the 50 patients died within 90 days after surgery, all of whom had liver malignant tumor. Among them, 3 died of multi-organ dysfunction syndrome caused by severe infection, 3 died of acute liver failure, 2 died of abdominal hemorrhage and 1 died pulmonary embolism. (3) Follow-up: all the 50 patients were followed up for 1 to 119 months. The overall survival time, 1-, 3-, 5-year overall and tumor-free survival rates of the 50 patients after operation were 17 months (range, 1-119 months), 68.0%, 45.9%, 41.1% and 41.9%, 33.4%, 30.8%, respectively. The overall survival time, 1-, 3-, 5-year overall and tumor-free survival rates of the 9 patients who with liver benign occupation after operation were 68 months (range, 10-114 months), 88.9%, 88.9%, 88.9% and 88.9%, 88.9%, 88.9%, respectively. The overall survival time, 1-, 3-, 5-year overall and tumor-free survival rates of the 41 patients who with liver malignant tumor after operation were 15 months (range, 1-119 months), 63.4%, 36.6%, 31.0% and 31.5%, 21.0%, 18.0%, respectively. There were significant differences in the overall and tumor-free survival rates between patients who with liver benign occupation and patients who with liver malignant tumor ( χ2=7.626, 11.766, P<0.05). Conclusions:ELRA can be applied in the treatment of liver complex space-occupying lesions. The selection criteria of patients with liver malignant tumor should be more rigorous to reduce perioperative mortality.

A survey study on major surgeon′s mental trauma caused by iatrogenic biliary injury during laparoscopic cholecystectomy / 中华消化外科杂志

Objective:To conduct a survey on major surgeon′s mental trauma caused by iatrogenic biliary injury (IBI) during laparoscopic cholecystectomy (LC), and explore its influencing factors.Methods:The retrospective cross-sectional survey was conducted. Surgeons who have registered in Chinese College of Surgeons of Chinese Medical Doctor Association and Chinese Surgical Society of Chinese Medical Association were recruited to participate as respondents between December 1, 2018 and January 1, 2019. The survey was conducted by the questionnaires of influencing factors for surgeon′s mental trauma caused by IBI during LC. The questionnaires were distributed to participants via WeChat on the Wenjuanxin platform. Observation indicators: (1) results of questionnaire survey; (2) analysis of influencing factors for severe mental trauma of major surgeons caused by IBI during LC. Measurement data with normal distribution were expressed as Mean± SD, and count data were expressed as absolute numbers or percentages. The chi-square test was used for univariate analysis. Factors with P<0.10 in the univariate analysis were included in multivariate analysis, and Logistic regression model was used for multivariate analysis. Results:(1) Results of questionnaire survey. A total of 606 questionnaires were retrieved. ① Basic information of major surgeons: of the 606 major surgeons, there were 596 males and 10 females, aged (41±7)years, with a range from 18 to 62 years. Of the 606 major surgeons, 59.24%(359/606) came from non-teaching hospitals, and 64.03%(388/606) encounted the most impressive case of IBI during LC when they were in the primary or intermediate professional title. For 76.24%(462/606) of the major surgeons, the first case of IBI during LC was the most impressive case, and 69.80%(423/606) believed that careful operation during LC could avoid IBI. ② Patient information: of the patients with the most impressive IBI during LC in each major surgeon′s memory, there were 400 females and 206 males. The proportion of patients younger than 35 years old, in 35-65 years old and older than 65 years old was 9.57%(58/606), 65.51%(397/606), and 24.92%(151/606), respectively. ③ IBI related information: 57.43%(348/606) of the major surgeons indicated that they could receive help from senior surgeons in time for the occurrence of IBI during LC, and 78.88%(478/606) of the major surgeons invited senior surgeons to participate in the initial repair. For the most impressive case of IBI during LC, 66.83%(405/606) of the primary repair surgeries were performed during LC, 11.06%(67/606) were performed within postoperative 3 days and 22.11%(134/606) were performed after 3 days. The main repair methods included local repair, bile duct to end anastomosis, and bilioenteric anastomosis, accounting for 24.92%(151/606), 30.20%(183/606), 33.17%(201/606), respectively. The proportion of patients requiring partial hepatectomy, with perioperative death, and requiring multiple repair was 2.48%(15/606), 2.15%(13/606), and 9.24%(56/606), respectively. ④ Subsequent processing on major surgeons: after the occurrence of IBI during LC, 64.85%(393/606) of the major surgeons gained the understanding of patients and their families, 35.15%(213/606) of the major surgeons were involved in medical disputes, 15.68%(95/606) of the major surgeons received administrative punishment from the hospital. About the compensation, 14.36%(87/606) of the major surgeons had to pay for the compensation by themselves, and only 6.77%(41/606) of the major surgeons had medical liability insurance. There were 9.24%(56/606) of the major surgeons invloved in violent conflicts during the medical disputes. ⑤ Psychology-related information of major surgeons: of the 606 major surgeons, 544 had mental trauma including 279 with severe mental trauma. After the occurrence of IBI during LC, 82.01%(497/606) of the major surgeons experienced anxiety and/or depression for more than one month; 63.37%(384/606) of the major surgeons expected to avoid LC or showed tension during LC; 44.72%(271/606) of the major surgeons had a physiological response when recalling the case; 36.14%(219/606) of the major surgeons initiated the idea of not being a surgeon; 6.44%(39/606) of the major surgeons asked psychologists for help; and 5.61%(34/606) of the major surgeons had taken psychiatric drugs such as antianxiety and anti-depression drugs for more than one month. (2) Analysis of influencing factors for severe mental trauma of major surgeons caused by IBI during LC. Results of univariate analysis showed that the hospital type of the major surgeons, participation of senior surgeons in the repair, surgical method of the primary repair, IBI requiring repeated repair, medical disputes, administrative punishment from the hospital, compensation paid by the major surgeon, having medical liability insurance, violent conflicts in medical disputes were related factors for severe mental trauma of the major surgeons caused by IBI during LC ( χ2=7.688, 3.932, 19.764, 13.837, 61.488, 24.904, 30.976, 5.344, 26.285, P<0.05) . Results of multivariate analysis showed that the surgical method of the primary repair, IBI requiring repeated repair, medical disputes, administrative punishment from the hospital, compensation paid by the major surgeon, violent conflicts in medical disputes were independent risk factors for severe mental trauma caused by IBI during LC of the major surgeons ( odds ratios=1.203, 2.198, 2.922, 1.830, 2.405, 2.171, 95% confidence interval: 1.033-1.402, 1.143-4.226, 1.944-4.391, 1.083-3.093, 1.076-5.375, 1.002-4.702, P<0.05). Having medical liability insurance was an independent protective factor for severe mental trauma of the major surgeons caused by IBI during LC ( odds ratios=0.336, 95% confidence interval: 0.126-0.896, P<0.05). Conclusions:Most surgeons in China are troubled by IBI during LC, and nearly half of them suffer from severe mental trauma. Surgical method of the primary repair, IBI requiring repeated repair, medical disputes, administartive punishment from the hospital, compensation paid by the major surgeon, and violent conflicts in medical disputes are independent risk factors for severe mental trauma of major surgeons caused by IBI during LC. Having medical liability insurance is an independent protective factor for severe mental trauma of major surgeons caused by IBI during LC.

A preliminary study on the narrative medical curriculum for clinical medicine postgraduates / 中华医学教育探索杂志

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.

Analysis of therapeutic effect and prognosis of pancreatectomy, pancreatic duct drainage and combined procedures for pancreatic ductal stones / 中华胰腺病杂志

Objective To analyze the curative effect and prognosis of pancreatic ductal stone treated by pancreatectomy,pancreatic duct drainage or combined procedures.Methods The clinical data of 296 pancreatic ductal stone patients who received surgical treatment in First Affiliated Hospital of the Army Medical University between January 2008 and June 2017 were retrospectively analyzed.The cases were divided into pancreatectomy group (162 cases),pancreatic duct drainage group (104 cases) and combined procedures group (30 cases) according to their surgical procedures.The clinical characteristics and short-term and longterm outcomes of surgical treatment between the three groups were analyzed.Kaplan-Meier method was used to estimate the survival rate of no recurrence of pain after operation.Log-rank test and Cox-proportional hazard model were used to analyze the influencing factors on the recurrent pain free survival after surgery.Results The ratio of male patients was highest in pancreatectomy group,and the incidence of pancreatic exocrine insufficiency was highest in pancreatic duct drainage group.Of 296 patients,Ⅰ type pancreatic stone was most in pancreatectomy group and combined procedures group (80.2％,70.0％),and Ⅲ type pancreatic stone was most in pancreatic duct drainage group (46.2％).Medium size pancreatic stone was most in pancreatectomy group (52.5％),and medium and large size pancreatic stone was most in pancreatic duct drainage group (80.8％).Obvious pancreatic atrophy was most in pancreatic duct drainage group.Pancreatic head swelling,bile ductal dilation or compression,combined with pancreatic or surrounding organ complications were most in pancreatectomy,and all the differences were statistically significant (all P ＜ 0.05).In the short-term effect,the overall rate of pain relief was 99.3％,and there was no statistical difference among three groups.Pancreatic duct drainage group was superior to the other two groups in terms of operative time,bleeding volume,postoperative hospitalization days and postoperative complications (all P ＜0.05),but the total incidence of residual stones after operation in drainage group (64.8％) was higher than that in the other two groups,and the difference was statistically significant (all P ＜ 0.05).In the long-term effect,there were no significant differences in pain recurrence,stone recurrence reoperation,postoperative pancreatic function,body weight and quality of life recovery among the three groups.The 1-year,3-year and 5-year no recurrent pain after operation was 89.0％,79.2％ and 68.9％,respectively.Univariate and multivariate analysis showed that the course of CP ≥5 years(HR =2.113,95％ CI 1.160-3.848,P=0.014) and postoperative long-term alcohol consumption (HR =1.971,95％ CI 1.073-3.620,P =0.029) were independent risk factors affecting pain recurrence after surgery.Conclusions Surgery is still an important means for the treatment of pancreatic ductal stone.The short-term and long-term effect of pancreatectomy,pancreatic duct drainage and combined procedures for pancreatic ductal stones are definitely effective.However,none of the three methods can prevent the continued loss of pancreatic function in some patients.According to the preoperative clinical features,surgery strategy should be formulated individually,and the postoperative health guidance and follow-up should be emphasized,which can help to improve the prognosis of the patients with pancreatic ductal stones.

Clinical application of combined hepatic artery resection and reconstruction in surgical treatment for hilar cholangiocarcinoma / 中华外科杂志

Objective@#To clarify whether the surgical treatment for hilar cholangiocarcinoma combined with artery reconstruction is optimistic to the patients with hilar cholangiocarcinoma with hepatic artery invasion.@*Methods@#There were 384 patients who received treatment in the First Affiliated Hospital to Army Medical University from January 2008 to January 2016 analyzed retrospectively. There were 27 patients underwent palliative operation, 245 patients underwent radical operation, radical resection account for 63.8%. Patients were divided into four groups according to different operation method: routine radical resection group(n=174), portal vein reconstruction group (n=47), hepatic artery reconstruction group (n=24), palliative group(n=27). General information of patients who underwent radical operation treatment was analyzed by chi-square test and analysis of variance. The period of operation time, blood loss, the length of hospital stay and hospitalization expenses of the radical operation patients were analyzed by one-way ANOVA. Comparison among groups was analyzed by LSD-t test.@*Results@#The follow-up ended up in June first, 2016. Each of patients followed for 6 to 60 months, the median follow-up period was 24 months. 1-, 3-, and 5-year survival rates were 81.3%, 44.9% and 13.5% of routine radical operation group, and were 83.0%, 44.7% and 15.1% of portal vein reconstruction group, and were 70.8%, 27.7% and 6.9% of hepatic artery reconstruction group, respectively. And 1-, 3-, and 5-year survival rates of hepatic artery reconstruction group was lower than routine radical group and portal vein reconstruction group significantly (P<0.05). However, the rate of postoperative complications of the hepatic artery reconstruction group and the routine radical operation group and the portal vein reconstruction group were 62.5%(15/24), 55.3%(96/174) and 51.5%(24/47), respectively. There was no significant difference among them (P>0.05). The data shows that the ratio of lymphatic metastasis in hepatic artery reconstruction group (70.8%) is much higher than them in routine radical operation group (20.1%) and portal vein reconstruction group (19.1%) significantly (P<0.05). The presented data also indicate that hepatic artery resection prolongs survival time comparing with patients undergoing palliative therapy for hilar cholangiocarcinoma. Cox regression analysis indicate that hepatic artery resection and reconstruction is a protective factor compare with palliative therapy (RR=0.38, 95%CI: 0.22-0.67). The significant reason for shorter survival time is a positive correlation between hepatic artery invasion and lymph node metastasis.@*Conclusion@#Hepatic artery resection and reconstruction has beneficial impact on oncologic long-term outcome in patients with advanced stage hilar cholangiocarcinoma.

Risk factors analysis of pancreatic ductal stones combined with malignant tumor beside stones / 中华消化外科杂志

Objective To investigate the risk factors of pancreatic ductal stones (PDS) combined with malignant tumor beside stones.Methods The retrospective case control study was conducted.The clinicopathological data of 190 patients with PDS who underwent surgical treatment at the First Affiliated Hospital of Army Medical University (Third Military Medical University) between January 2008 and June 2017 were collected.Of 190 patients,175 and 15 were detected PDS complicated with chronic pancreatitis and malignant tumor beside stones respectively.Observation indicators:(1) risk factors analysis of PDS combined with malignant tumor beside stones;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was done to detect treatment of patients who had PDS combined with malignant tumor beside stones and postoperative survival up to December 2017.Univariate analysis was done by chi-square test,Fisher exact probability or rank sum test,and multivariate analysis was done using Logistic regression model.The survival curve was drawn and survival rate was calculated by Kaplan-Meier method.Results (1) Risk factors analysis of PDS combined with malignant tumor beside stones:results of univariate analysis showed that increased serum tumor markers,diameter of PDS,common bile duct dilation or compression,pancreatic parenchymatous atrophy were related factors affecting PDS combined with malignant tumor beside stones (x2 =12.501,Z =-2.508,x2 =12.230,5.863,P＜0.05).Results of multivariate analysis showed that increased serum tumor markers,common bile duct dilation or compression,pancreatic parenchymatous atrophy were independent risk factors affecting PDS combined with malignant tumor beside stones (odds ratio:5.482,8.062,4.993,95％ confidence interval:1.556-19.313,1.620-40.107,1.188-20.977,P＜0.05).(2) Follow-up and survival situations:162 of 190 patients were followed up for 2-111 months with a median time of 20 months,including 149 of PDS complicated with chronic pancreatitis and 13 of PDS combined with malignant tumor beside stones.During the follow-up,the 1-,3-,5-year overall survival rates after operation were 46.7％,6.7％ and 0 in 13 patients of PDS combined with malignant tumor beside stones,and 3 patients received postoperative chemotherapy.The 1-,3-,5-year overall survival rates of the 149 patients who had PDS combined with chronic pancreatitis were 97.0％,93.5％,91.6％.Conclusion Increased serum tumor markers,common bile duct dilation or compression,pancreatic parenchymatous atrophy are independent risk factors affecting PDS combined with malignant tumor beside stones.

Clinical application of combined vascular resection and reconstruction in surgical treatment of hilar cholangiocarcinoma / 临床肝胆病杂志

The surgical treatment of hilar cholangiocarcinoma is one of the most challenging routine surgeries in the field of hepatobiliary surgery, and vascular invasion is an important reason for the low rate of radical resection in hilar cholangiocarcinoma. Currently, it is universally acknowledged that resection and reconstruction of the portal vein invaded is a key factor in improving R0 resection rate and long-term survival rate in patients with hilar cholangiocarcinoma. However, whether to perform resection and reconstruction after invasion of hepatic artery is still controversial. With reference to published literature and clinical practice in our center, this article introduces the application and prospects of combined vascular resection and reconstruction in the surgical treatment of hilar cholangiocarcinoma and points out that with the development of computer-assisted surgery and summarization of more and more case data, indications and long-term efficacy of combined vascular resection and reconstruction in the treatment of hilar cholangiocarcinoma await further investigation and research.

Da Vinci robot-assisted laparoscopic pancreaticoduodenectomy combined with portal vein resection and artificial vascular graft and reconstruction / 中华消化外科杂志

Objective To explore the application value of Da Vinci robot-assisted laparoscopic pancreaticoduodenectomy combined with portal vein (PV) resection and artificial vascular graft and reconstruction.Methods The retrospective descriptive study was adopted.The clinical data of 1 patient with cancer of pancreatic head combined with biliary and duodenal obstructions who was admitted to the Southwest Hospital of the Third Military Medical University in November 2015 were collected.Da Vinci robot-assisted laparoscopic pancreaticoduodenectomy combined with PV resection and artificial vascular graft and reconstruction were applied to the patient due to intraoperative tumor extensive invasion to the PV and angiogenesis around the tumor.The operation time,volume of intraoperative blood loss and transfusion,time of postoperative drainage-tube removal,postoperative complications,result of postoperative pathological examination,duration of postoperative hospital stay and results of follow-up were observed.The follow-up of outpatient examination and telephone interview was performed to detect the survival of the patient up to February 2016.Results The patient underwent successful Da Vinci robot-assisted laparoscopic pancreaticoduodenectomy combined with PV resection and artificial vascular graft and reconstruction.The length of intraoperative excisional PV,operation time,volume of intraoperative blood loss,volume of red blood cell suspension and blood plasma infusions were 3 cm,670 minutes,600 mL,400 mL and 200 mL,respectively.The patient got out-off-bed activity at postoperative day 1 and fluid diet intake after gastric-tube removal at postoperative day 3,and drainage-tube was removed at postoperative day 8.No postoperative complication was detected.The patient had unblocked main PV without obvious stenosis and filling defect by computer tomography rescanning.Adenosquamous carcinoma of the pancreatic head was confirmed by postoperative pathological examination.There were negative resection margins from the proximal and distal duodenum to the pancreas.The patient was discharged from hospital at postoperative day 12 and followed up for 3 months,with a good survival.Conclusions Da Vinci robot-assisted laparoscopic pancreaticoduodenectomy combined with PV resection and artificial vascular graft and reconstruction are safe and feasible in the treatment of the cancer of pancreatic head combined with biliary and duodenal obstructions,with a good short-term outcome.

Clinical efficacy of surgical treatment for hilar cholangiocarcinoma: a report of 207 cases / 中华消化外科杂志

Objective To investigate the efficacy of different radical surgical procedures for the treatment of hilar cholangiocarcinoma.Methods The clinical data of 207 patients with hilar cholangiocarcinoma who were treated at the Southwest Hospital from June 2007 to June 2012 were retrospectively analyzed.Local resection or hemihepatectomy combined with caudate lobectomy was applied to patients with Bismuth type Ⅰ hilar cholangiocarcinoma; dumbbell type radical resection was applied to patients with Bismuth type Ⅱ hilar cholangiocarcinoma or some patients with type Ⅲ a,Ⅲ b and Ⅳ hilar cholangiocarcinoma; hemihepatectomy or extended hemihepatectomy combined with caudate lobectomy was applied to patients with Bismuth type Ⅲ a,Ⅲ b and Ⅳ hilar cholangiocarcinoma.The patients were followed up every 3 months postoperatively till December 2012.All data were analyzed using the chi-square test or Fisher exact probability test,the survival curve was drawn by Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results Of the 207 patients,124 received radical resection,including 14 received local resection,23 received dumbbell type resection,87 received lobectomy + caudate lobectomy,49 received palliative resection; 34 received biliary drainage.Four patients died perioperatively.The incidences of complications of dumbbell type radical resection,left hemihepatectomy + caudate lobectomy,right hemihepatectomy + caudate lobectomy were 21.7％ (5/23),46.6％ (27/58) and 48.3％ (14/29),respectively.The incidence of complications after dumbbell type radical resection was significantly lower than left hemihepatectomy + caudate lobectomy and right hemihepatectomy + caudate lobectomy (x2 =4.42,3.90,P ＜ 0.05).One hundred and seventy patients were followed up.The median survival time of the 112 patients who received radical radical resection was 26.5 months,and the 1-,3-,5-year survival rates were 75.9％ (85/112),42.9％ (24/56) and 28.9％ (11/38),respectively.The median survival time of the 38 patients who received palliative resection was 8.5 months,and the 1-,3-year survival rates were 31.6％ (12/38) and 0.The survival time of 20 patients who received biliary drainage was 4.0 months,and the l-year survival rate was 0.The survival rate of patients who received radical resection was significantly higher than those who received palliative resection (x2=65.32,P ＜ 0.05).There was a significant difference in the survival rate between patients who received surgical treatment and those who received biliary drainage (x2=99.97,P ＜ 0.05).Of the 112 patients who received radical resection,the median survival time of 10 patients who received local resection of tumor was 47.0 months,the 1-year survival rate was 10/10,and 4 patients survived at the end of the follow-up; the median survival time of 23 patients who received dumbbell type radical resection was 32.0 months,and the 1-,3-year survival rates were 95.7％ (22/23) and 7/15,and the survival time of 6 patients was longer than 5 years; the median survival time of 54 patients who received left hemihepatectomy or extended left hemihepatectomy + caudate lobectomy was 27.6 months,and the 1-,3-year survival rates were 42.1％ (24/57) and 38.7％ (12/32),and the survival time of 9 patients was longer than 5 years,3 patients survived at the end of the follow-up ; the median survival time of 25 patients who received right hemihepatectomy or extended right hemihepatectomy + caudate lobectomy was 28.3 months,and the 1-,3-year survival rates were 45.8％ (11/24) and 6/15,and the survival time of 6 patients was longer than 5 years,2 patients survived at the end of follow-up.The median survival time of 35 patients (patients with Bismuth type Ⅰ,Ⅱ hilar cholangiocarcinoma and Bismuth Ⅲ a and Ⅲ b hilar cholangiocarcinoma which did not invade the secondary bile duct) who received hemihepatectomy + caudate lobectomy was 32.0 months,and the 1-,3-,5-year survival rates were 91.4％ (32/35),45.8％ (11/24) and 5/16,which were not different from the survival rate of patients who received dumbbell type radical resection (x2 =0.17,P ＞ 0.05).The 5-year survival rate of patients with lymph node metastasis was 4/19,which was significantly lower than 30.4％ (7/23) of patients without lymph node metastasis (x2 =23.40,P ＜ 0.05).Conclusion Joint lobectomy and standardized lymph node dissection could help to improve the efficacy of surgical treatment for patients with hilar cholangiocarcinoma.

Dumbbell type radical resection for hilar cholangiocarcinoma / 中华消化外科杂志

Surgical resection is considered to be the most effective therapy for hilar cholangiocarcinoma.Inadequate excision range is the main reason for recurrence after surgery.Extended radical resection provides better long-term survival,however,it may also increase the risk of liver failure because of the extensive hepatic resection.In present study,we showed a new operation which could excise enough length of bile ducts and avoid large volume hepatic tissue resection.The excision extension includes:segment Ⅰ,Ⅳb and partial Ⅳ,left,right and furcation of hepatic duct,extrahepatic ducts,skeletonization of hilar vessels,and dissection of at least second station lymph nodes.As the tissue resected resembles a dumbbell,this surgical technique is named dumbbell type radical resection.The operative indications include:(1) hilar cholangiocarcinoma,Bithmuth Ⅱ and Bithmuth Ⅲ with tumor limited in left or right hepatic ducts ; (2) Without portal invasion; (3) Without third station lymph node metastasis; (4) Without liver or distant organ metastasis.Twenty-three patients had undergone this operation sucessfully.Most patients have high total bilirubin levels (more than 300 μmol/L) and have not received percutaneous transhepatic cholangial drainage or biliary drainage.The average operation time was 355 minutes,and average volume of blood loss during operation was 350 ml.The total survival rate was 65.2％.One-year tumour free survival rate was 95.7％ (22/23),and three-year tumor free survival rate was 7/15.The results indicated that dumbbell type radical resection was feasible for hilar cholangiocarcinoam of Bismuth Ⅱ and Bismuth Ⅲ with tumor limited in left or right hepatic ducts.

Clinical significance of combined vascular resection and reconstruction in pancreaticoduodenectomy for pancreatic cancer / 中华消化外科杂志

Objective To investigate the significance of combined vascular resection and reconstruction in surgery for pancreatic cancer.Methods The clinical data of 231 patients with pancreatic canccr who received pancreaticoduodenectomy at the Southwest Hospital from January 2006 to December 2011 were retrospectively analyzed.All the patients were divided into the combined vascular resection and reconstruction group (97patients) and non-vascular resection and reconstruction group (134 patients).Effects of operation,results of pathological examination,prognosis and lymph node metastasis on the prognosis of the patients in the 2 groups were compared.Two independent samples t test was used to analyze the measurement data,and the count data were analyzed using the chi-square test.The survival curve was drawn by the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results The operation time and intraoperative volume of blood loss were (554 ± 136)minutes and (1110 ± 939)rnl in the combined vascular resection and reconstruction group,and (445 ±106)minutes and (623 ±349)ml in the non-vascular resection and reconstruction group,with significant difference between the 2 groups (t =6.552,4.873,P ＜ 0.05).The mortality,morbidity and positive rate of lymph node metastasis of were 8.2％ (8/97),20.6％ (20/97) and 32.0％ (31/97) in the combined vascular resection and reconstruction group and 3.0％ (4/134),8.2％ (11 / 134) and 16.4％ (22/134) in the non-vascular resection and reconstruction group.There was no significant difference in the mortality between the 2 groups (x2=3.164,P ＞ 0.05),while significant differences in the morbidity and positive rate of lymph node metastasis were detected between the 2 groups (x2 =7.458,7.687,P ＜ 0.05).A total of 223 patients were followed up till September 2012,53 patients were with lymph node metastasis,and their median survival time was 8.4 months (range,6.9-10.0 months) ; 170 patients were with negative lymph node metastasis,and their median survival time was 18.6 months (range,15.8-21.5 months),which was significantly longer than that of patients with positive lymph node metastasis (x2=17.045,P ＜ 0.05).Of the 53 patients with lymph node metastasis,31 were in the combined vascular resection and reconstruction group,and their median survival time was 8.5 months (range,6.3-10.7 months) ; 22 were in the non-vascular resection and reconstruction group,and their median survival time was 8.3 months (range,6.1-10.5 months),with no significant difference between the 2 groups (x2 =0.022,P ＞ 0.05).Of the 178 patients with negative lymph node metastasis,64 were in the combined vascular resection and reconstruction group,and their median survival time was 13.2 months (range,9.2-17.1 months) ; 106 were in the non-vascular resection and reconstruction group,and their median survival time was 21.7 months (range,18.1-25.3 months),with significant difference between the 2 groups (x2 =11.908,P ＜ 0.05).Conclusions Although pancreaticoduodenectomy combined with vascular resection and reconstruction increases the incidence of postoperative complications,it could achieve the complete removal of tumors without significantly increasing the mortality rate.For patients with lymph node metastasis,pancreaticoduodenectomy combined with vascular resection and reconstruction has no influence on the postoperative survival time,while it might have influence on the patients without lymph node metastasis.

Clinical value of different imaging techniques in the diagnosis of periampullary carcinoma / 中华消化外科杂志

Periampullary carcinoma is a rare malignant tumor of digestive system,and its accurate diagnosis is still difficult.From January 2007 to July 2012,12 patients with periampullary carcinoma had been admitted to the Southwest Hospital of Third Military Medical University,and the imaging data were retrospectively analyzed.The results of ultrasonography revealed that all tumors were hypoechoic.The tumor displayed hyperenhancement in 3 patients,isoenhancement in 1 patient,hypoenhancement in 8 patients during the arterial phase on contrastenhanced ultrasonography (CEUS),while the tumor displayed hypoenhancement in all patients during the venous phase.Magnetic resonance imaging (MRI) plain scanning showed duodenal papilla enlargement in 1 patient,ampullary tissue mass signal in 2 patients,tissue mass signal at distal common bile duct in 2 patients,the rest 7 patients did not show tissue mass signal.Lower biliary obstruction was the common manifestation of the 12 patients on magnetic resonance cholangiopancreatography (MRCP),intrahepatic and extrahepatic bile vine-like expansion in 4 patients,double duct sign in 2 patients,the bottom of common bile duct with filling defect in 2 patients and it revealed beak-like narrow in 1 patient.CEUS,MRI and MRCP could both play an important role as conventional methods in diagnosing periampullary carcinoma.

Efficacy of laparoscopic hepatectomy for regional hepatolithiasis / 中华消化外科杂志

ObjectiveTo investigate the efficacy of laparoscopic hepatectomy for regional hepatolithiasis.MethodsThe clinical data of 81 patients with regional hepatolithiasis who received laparoscopic hepatectomy at the Southwest Hospital from March 2007 to March 2011 were retrospectively analyzed.Based on the classification of the Guideline for the diagnosis and treatment of hepatolithiasis 2007 version and indications for open surgery,hepatic lobes with calculi,biliary stricture or dilated bile ducts were resected laparoscopically after preoperative examination.Bile ducts of the remnant hepatic lobes were explored using fiber choledochoscope or electronic choledochoscope for the prevention of residual stones. Results Laparoscopic hepatectomy was successfully performed on 72 patients,and the other 9 patients were converted to open surgery. Left lateral lobectomy ( segments Ⅱ,Ⅲ ) was performed on 20 patients,left hemihepatectomy ( segments Ⅱ,Ⅲ,Ⅳ ) on 30 patients,right posterior lobectomy ( segments Ⅵ,Ⅶ ) on 11 patients,right anterior lobectomy ( segments Ⅴ,Ⅷ ) on 6patients,right hemihepateetomy (segments Ⅴ,Ⅵ,Ⅶ,Ⅷ ) on 9 patients,hepatic Ⅲ segmentectomy on 2 patients and hepatic Ⅵ segmentectomy on 3 patients.Gallbladders were resected,and intermittent portal triad clamping was performed on 15 patients.Hepateetomy combined with biliary exploration and stone removal was performed on 57 patients.The mean operation time and operative blood loss were (328 ± 80)minutes and (451 ±288) ml,respectively.No operative mortality was observed.Sixteen patients had postoperative complications,including pulmonary infection in 2 patients,pleural effusion in 4 patients,encapsulated effusion in the resection margin in 6 patients,abdominal infection and abscess in 2 patients and wound infection in 2 patients.Of the 16patients with complications,9 were cured by medicine,6 by pleural or abdominal drainage and 1 by wound debridement.The mean duration of hospital stay was ( 13 + 6)days.The intraoperative stone clearance rate was 96％ (69/72),and the residual stone in 3 patients were removed by choledochoscopy.Sixty-nine patients were followed up for 7-55 months,7 patients had symptoms of cholangitis and 2 patients had common bile duct stone recurrence.ConclusionsLaparoscopie hepatectomy is sate and effective for regional hepatolithiasis.Accurate positioning of the stones and lesions pre- and intra-operatively,reasonable designing of the parenchymal transection plane,and anatomical liver resection are the key points for achiving good therapeutic effects.

Exploring the new strategy of training and education for hepatobiliary robotic surgeons / 中华医学教育探索杂志

Robotic surgery is a major trend of mini-invasive surgery,which is still in its infancy in China.The training and education of robotic surgeons is a problem to be solved imperatively.In our clinical practice,we explored the new strategy of training and education for hepatobiliary robotic surgeons by assimilating the essence of traditional surgery education and by drawing lessons from the successful training of robotic surgery in foreign countries.Satisfactory teaching effect was obtaincd.

Application of radiofrequency ablation in liver resection for hepatic cancer / 中华消化外科杂志

Objective To compare the effects of radiofrequency ablation and clamp crushing resection on intraoperative blood loss and postoperative complications.Methods The clinical data of 130 patients with hepatic cancer who were admitted to the Southwest Hospital from January 2011 to June 2012 were retrospectively analyzed.Sixty-five patients who received radiofrequency ablation were in the radiofrequency ablation group; the clinical data of 65 hepatic cancer patients with similar tumor size,position and Child-Pugh scores who received traditional clamp crushing resection were selected from the data base,and they were in the clamp crushing resection group.The intra-and postoperative clinical data of the 2 groups were statistically analyzed.The measurement data were presented in the format of median plus range,and were analyzed using the analysis of variance; the enumeration data were analyzed using chi-square test,when the number of patients was under 10,the Fisher exact probability was used for analysis.Results The time for liver resection and hepatic inflow occlusion in the radiofrequency ablation group were 28 minutes (range,12-55 minutes) and 10 minutes (range,0-15 minutes),which were significantly shorter than 45 minutes (range,25-92 minutes) and 15 minutes (range,10-32 minutes) in the clamp crushing resection group (F =10.35,9.05,P ＜0.05).The volumes of intraoperative blood loss and blood transfusion were 150 ml (range,50-350 ml) and 0 ml in the radiofrequency ablation group,which were significantly lesser than 450 ml (range,250-2500 ml) and 550 ml (range,0-2000 ml) in the clamp crushing resection group (F =15.86,P ＜ 0.05).The number of patients who did not receive blood transfusion in the radiofrequency ablation group was 65,which was significantly greater than 48 in the clamp crushing resection group (x2 =19.58,P ＜ 0.05).The levels of aspartic transaminase (AST) and total bilirubin (TBil) at postoperative day 3 and 7,prothrombin time (PT) at postoperative day 3,Clavien classification of surgical complications,duration of hospital stay were 302 U/L (range,89-823 U/L),54 U/L (range,16-325 U/L),37 μmol/L(range,18-112 μmol/L),24 μmol/L (range,9-66 μmol/L),15 s (range,11-20 s),22％ (14/65),12 days (range,8-36 days) in the radiofrequency ablation group,and 253 U/L (range,63-876 U/L),62 U/L(range,22-376 U/L),41 μmol/L (range,19-105 μmol/L),25 μmol/L (range,11-59 μmol/L),14 s (range,11-21 s),26％ (17/65) and 13 days (range,9-35 days) in the clamp crushing resection group.There were no significant differences in the 7 indexes between the radiofrequency ablation group and the clamp crushing resection group (F=2.59,1.93,3.96,1.58,2.35,x2 =0.381,F=1.58,P＞0.05).The incidence of complications of the radiofrequency ablation group was 17％ (11/65),which was significantly lower than 52％ (34/65) of the clamp crushing resection group (x2 =17.38,P ＜ 0.05).The number of patients who had postoperative bleeding in the radiofrequency ablation group was 2,which was significantly lesser than 22 patients in the clamp crushing resection group.Eight patients in the radiofrequency ablation group had encapsulated effusion,and 5 of them need drainage.Two patients in the clamp crushing resection group had hepatic insufficiency.Two patients in the radiofrequency ablation group had hemoglobinuria.Conclusion Compared with clamp crushing resection,radiofrequency ablation has advantages of less blood loss and safer manipulation.

Pancreaticoduodenectomy combined with portal vein and superior mesenteric vein resection and reconstruction / 中华消化外科杂志

The majority of the pancreatic cancer was diagnosed at advanced stage.The tumor may invade portal vein and/or superior mesenteric vein.Moore et al.firstly reported pancreaticoduodenectomy combined with portal vein and superior mesenteric vein resection and reconstruction in 1951.This procedure has improved the resection rate of pancreatic cancer.A 72-year-old man suffered from pancreatic cancer was admitted to the Southwest Hospital in September 2011.Because the tumor invaded the confluence of portal vein and superior mesenteric vein,thus the patient underwent a pancreaticoduodenectomy combined with portal vein and superior mesenteric vein resection and reconstruction.The patient recovered smoothly without any complication,and he had a normal liver function and CA19-9 value,and no local and remote metastasis was detected during the follow-up.

Radical resection of pancreatic cancer combined with vascular resection and reconstruction / 中华消化外科杂志

Most of the pancreatic cancer was diagnosed at advanced stages and the resection rate was only 10％-20％.Vascular invasion was a common event in the pathogenesis of pancreatic cancer.However,in the traditional view,vascular invasion is a contraindication of pancreatic resection.With the development of surgical techniques and perioperative management,radical resection of pancreatic cancer with vascular resection and reconstruction was performed in some large centers.Preliminary results suggested that this procedure could increase the resection rate and 5-year survival to 26％-46％ and 20％ respectively,without increasing morbidity and mortality.Radical resection of pancreatic cancer with vascular resection and reconstruction was a safe and effective method for the surgical treatment of advanced pancreatic cancer,which should be performed by experienced pancreatic surgeons.

The new technology of enhanced radiofrequency ablation is safe and effective for treating giant hepatic hemangioma / 中华肝脏病杂志

<p><b>OBJECTIVE</b>To determine the safety and efficacy of the enhanced radiofrequency ablation (RFA) new technology for treatment of giant hepatic hemangiomas.</p><p><b>METHODS</b>From August 2010 to September 2011, 30 patients with giant hepatic hemangiomas (average diameter: 7.7+/-1.9 cm, range: 5.0 to 12.8 cm) were treated with enhanced RFA. The original lesion diameter, enhanced radiofrequency duration, and cases of RFA-induced burning were recorded. Cases requiring a second RFA treatment were also recorded. Correlation analysis was carried out to determine the association of enhanced RFA with adverse events and change in lesion diameter.</p><p><b>RESULTS</b>The rate of completely destroyed lesions by enhanced RFA was 70.96%, and the total rate of reduced lesions was 87.1%. No severe adverse events occurred. The duration of enhanced radiofrequency correlated positively with the original lesion diameter (r=0.687, P less than 0.01). The enhanced RFA treatment significantly reduced the average lesion diameter (follow-up: 6.2+/-1.8 cm; t=6.417, P less than 0.01).</p><p><b>CONCLUSION</b>The new minimally-invasive technology of enhanced radiofrequency ablation is effective and safe for treating giant hepatic hemangiomas and produces an obvious, short-term curative effect.</p>

Deletion and mutation analysis of hepatocyte mtDNA damage in patients with obstructive jaundice / 中华肝胆外科杂志

Objective To lay the foundation for analyzing the mechanism of liver cell injury caused by mtDNA deletion and mutation in patients with obstructive jaundice. Methods 30 patients were randomly selected as obstructive jaundice group (case group) and 10 patients as control group according to the strict condition. Author makes use of the methods of PCR amplification of the entire human mitochondrial genome in 17 mismatch-specific overlapping fragments and gene sequencing results to Preliminary estimate the localizathion of hepatocyte mtDNA damage in patients with obstructive jaundice. Result Deletions and length of partial liver cells were 8429-9591 of about 1. 1 kb, 16024-60 of about 0. 6 kb, 1889-3031 of about 1. 1 kb and 4977bps common deletion and the high mutation rate of some bases in D-loop region. Conclusion There are multiple mtDNA deletions and multiple point mutations in patients with obstructive jaundice

Comparative study of the teaching modes based on problem-based learning and lecture-based learning in clinical practice of hepatobiliary surgery / 中华医学教育探索杂志

Objective To investigate the effect of the teaching modes based on problem-based learning (PBL) and lecture-based learning (LBL) in clinical practice of hepatobiliary surgery.Methods 166 5-year program students were divided into 2 groups:PBL group (n=83)and LBL group (n=83).The performance in interrogation,physical examination,medical records and theoretical tests were analyzed.Results PBL group had better performance in all the above aspects compared to LBL group (P<0.05).Conclusions The teaching mode based on PBL is a good method,which Can inspire the students and improve their ability to solve problems in clinical practice of hepatobiliary surgery.