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.

Clinical application of bipolar tweezers-clamp for hepatic parenchymal transection / 中华外科杂志

Objective: To investigate the clinical value of the bipolar tweezers-clamp for the hepatic parenchymal transection in the resection of hepatocellular carcinoma. Methods: From January 2020 to January 2021,63 patients with the hepatocellular carcinoma for hepatectomy at Department of Hepatopancreatobiliary Surgery,Yuebei People's Hospital Affiliated to Shantou University Medical College were analyzed retrospectively.According to the different instruments used in the hepatic parenchymal transection,the patients were divided into bipolar tweezers-clamp group and ultrasonic scalpel group.There were 32 patients in bipolar tweezers-clamp group,with age of (55.5±10.5)years(range:37 to 78 years),including 22 males and 10 females,tumor size was (6.0±3.4)cm(range:2.4 to 13.4 cm). There were 6 patients with portal vein tumor thrombus and 5 patients with portal hypertension. There were 31 patients in ultrasonic scalpel group,with aged(57.8±10.1)years(range:37 to 79 years),including 27males and 4 females,tumor size was(7.9±5.1)cm(range: 2.4 to 21.3 cm),3 patients with portal vein tumor thrombus and 2 patients with portal hypertension. The preoperative baseline data,operation time,blood loss,postoperative liver function and the complications were compared between two groups using t test,χ2 test and Fisher exact probabilityrespectively. Results: The operation was successfully completed in both groups.Compared with the ultrasonic scalpel group,the operation time was significantly shorter((219.3±76.4)minutes vs.(294.0±100.8)minutes,t=-3.322,P=0.002),the blood loss was less((250(475)ml vs. 500(1 050)ml,t=-2.307,P=0.026),the concentrate red blood cells transfusion volume was less(0.92(0.88)U vs. 2.32(4.00)U,Z=-1.987,P=0.047) in the bipolar tweezers-clamp group.The postoperative serum ALB level was higher in the bipolar tweezers-clamp group than that in the ultrasonic scalpel group((33.5±6.1)g/L vs. (29.5±4.2)g/L,t=3.226,P=0.020) on postoperative day 1;((35.7±4.5)g/L vs.(30.1±3.2)g/L,t=5.575,P<0.01) on postoperative day 3;((33.2±3.7)g/L vs. (31.0±4.4)g/L,t=3.020,P=0.004) on postoperative day 7. There was no significant difference in serum ALT,TBIL and PT level between the two groups(all P>0.05).No postoperative bile leakage occurred in both groups.The postoperative complications occurred in 8 cases(25.0%)in the bipolar tweezers-clamp group,including liver failure in one,and in 11 cases(35.5%)in the ultrasonic scalpel group,including liver failure in two(P>0.05). Conclusion: The bipolar tweezers-clamp is a safe and reliable method for the hepatic parenchymal transaction,which is quick and less bleeding during the hepatic resection.

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.

"Total arterial devascularization first" technique for resection of pancreatic head cancer during pancreaticoduodenectomy / 华中科技大学学报（医学）（英德文版）

Integrated resection of the pancreatic head is the most difficult step in radical pancreaticoduodenectomy (RPD) in patients with the portal vein (PV) and superior mesenteric vein (SMV) invasion or oppression by the tumor. This study introduced a new idea and skill named the "total arterial devascularization first" (TADF) technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta (AA) by completely transecting neural and connective tissue between superior mesenteric artery (SMA) and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h (ranging 4.5-8.1 h). The median intraoperative blood loss was 450 mL (ranging 200-900 mL). No intraoperative and postoperative bleeding of pancreatic head region occurred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical approach for RPD.

The role of preoperative TACE on hepatocellular carcinoma located in caudate lobe / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the effect of preoperative transarterial chemoembolization (TACE) on hepatocellular carcinoma located in caudate lobe.</p><p><b>METHODS</b>Totally 29 cases of caudate lobe hepatocellular carcinoma admitted from January 2001 to December 2010 were analyzed retrospectively. Among the 29 patients, 23 were male and the other 6 were female. The median age was 52 years. According to receiving preoperative TACE or not, the 29 cases were divided into two groups: preoperative TACE plus surgery (group A, n = 11) and surgery only (group B, n = 18). The surgical results and long-term survival were compared between two groups.</p><p><b>RESULTS</b>After TACE, the diameter of the tumour reduced by over 33.3% in 3 patients, 10.0% to 33.3% in 6 patients, and less than 10.0% in 2 patients. The duration of surgery and intraoperative blood loss in group A were (298 ± 39) minutes and (1031 ± 310) ml, respectively. The duration of surgery and intraoperative blood loss in group B were (281 ± 54) minutes and (868 ± 403) ml, respectively. No significant difference was found in terms of these two groups (t = 1.006, P = 0.324; t = 1.223, P = 0.232). In addition, 6 cases in group A developed complications and 4 cases in group B did so. Only one patient died because of postoperative complication, and this patient belonged to group A. No significant difference was found between two groups (χ(2) = 0.028, P = 0.868; χ(2) = 0.633, P = 0.426). The 5-year survival rate was 56.8% in group A and 34.9% in group B. The difference did not reach significant difference (P = 0.132).</p><p><b>CONCLUSIONS</b>For hepatocellular carcinoma located in caudate lobe, preoperative TACE does not significantly increase the surgical difficulty and impair the safety. In addition, preoperative TACE has the tendency to provide benefit to long-term survival.</p>

"Total arterial devascularization first" technique for resection of pancreatic head cancer during pancreaticoduodenectomy / 华中科技大学学报（医学）（英德文版）

Integrated resection of the pancreatic head is the most difficult step in radical pancreaticoduodenectomy (RPD) in patients with the portal vein (PV) and superior mesenteric vein (SMV) invasion or oppression by the tumor. This study introduced a new idea and skill named the "total arterial devascularization first" (TADF) technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta (AA) by completely transecting neural and connective tissue between superior mesenteric artery (SMA) and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h (ranging 4.5-8.1 h). The median intraoperative blood loss was 450 mL (ranging 200-900 mL). No intraoperative and postoperative bleeding of pancreatic head region occurred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical approach for RPD.

Intrahepatic biliary cystadenoma presenting with pleural effusion / 中华医学杂志(英文版)

Hepatobiliary cystadenomas are rare cystic neoplasms that often occur in middle aged women. The exact etiology of these tumors is unknown. Diagnosis is often delayed in these cases. However, misdiagnosis and inappropriate treatment may result in unfavorable outcome. We report a case of hepatobiliary cystadenoma with pleural effusion. We also review the literature and discuss the current diagnostic and treatment modalities.

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>

Role of dissection of secondary branches of splenic pedicle in portal hypertension cases undergoing splenectomy / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>It is well known that conventional splenectomy, which requires careful handling and ligation of tissue of the splenic hilum, can easily cause complications such as splenic fever and pancreatic fistula. Here, we use the technique of dissection of the secondary branches of the splenic pedicle to handle the hilum in the portal hypertension patients who are subjected to splenectomy.</p><p><b>METHODS</b>We retrospectively compared and analyzed the complications, postoperative hospital stay, operative time, and occurrence of hemorrhage in 121 patients with portal hypertension undergoing splenectomy and devascularization of the gastric cardia from January 1999 to December 2007. The selected cases consisted of 51 patients undergoing conventional splenectomy and 70 patients undergoing dissection of secondary branches of the splenic pedicle. In addition, we analyzed the relationship between size of the spleen and occurrence of complications.</p><p><b>RESULTS</b>The incidence of pancreatic fistula and splenic fever (0/70 and 9/70) was lower in patients undergoing dissection of secondary branches of the splenic pedicle as compared with that of the conventional group (5/51 and 18/51 respectively). In addition, there was no significant difference in operative time and volume of blood loss between two groups. The spleen thickness of those patients who had pancreatic fistula and splenic fever was significantly greater than those without complications.</p><p><b>CONCLUSIONS</b>These results indicate that dissection of secondary branches of the splenic pedicle in portal hypertension patients undergoing splenectomy can decrease the incidence of splenic fever and pancreatic fistula, and shorten the postoperative hospital stay, especially in the patients with a large spleen. So dissection of secondary branches of the splenic pedicle is a valuable technique for splenectomy.</p>

Ultrasound-guided percutaneous radiofrequency ablation of hepatic malignancies with cool-tip needle / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To investigate the efficacy, indication and complication of radiofrequency ablation (RFA) with cool-tip needle in patients with hepatic malignancies.</p><p><b>METHODS</b>421 patients with hepatic malignancies underwent ultrasound-guided RFA with cool-tip needle under local anaesthesia. The tumor size was from 1.0 to 15 cm in diameter with an average diameter of 4.3 cm.</p><p><b>RESULTS</b>The complete ablation (CA) rate was 91.4% (382/418) in the patients with a tumor < 3 cm, 78.9% (97/123) in those with a tumor of 3 to 5 cm and 37.6% (35/93) in the patients with a tumor > 5 cm. No patient died or changed to celiotomy during the 1121 times of RFA for 634 lesions in 421 patients. No hemorrhage occurred in any of these patients after the RFA treatment. The complications included abdominal pain in 32.3% (136/421), nausea in 9.0% (38/421), fever in 34.9% (147/421) and biliary leakage in 0.2% (1/421) of the patients.</p><p><b>CONCLUSION</b>Ultrasound-guided percutaneous radiofrequency ablation with cool-tip needle is effective and safe in the treatment of liver tumors.</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>

Study on the quality of life after pancreaticoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the quality of life (QOL) of the patients who received pancreaticoduodenectomy (PD) and work out their long term therapy agents.</p><p><b>METHODS</b>QOL of 18 cases who received PD (group PD) and 18 cases received laparoscopic cholecystectomy (LC) (group LC) in the same days was determined by symptoms questionnaire and Chinese version SF-36 QOL questionnaire from Jan 2002 to Dec 2003 in Sir Run Run Shaw Hospital.</p><p><b>RESULTS</b>Compared with group LC, the total QOL score and physical health score of group PD didn't have significant decrease. But the mental health score of group PD was lower than group LC (P < 0.05). Eight different scales of SF-36 questionnaire showed that the score in physical functioning, role-physical, bodily pain, general health, social functioning of group PD was lower than that of group LC. The score in vitality, role-emotional and mental health of group PD was the same as the group LC. According to the symptoms questionnaire, the patient diarrhea and recurrence had obvious influence on PH score. The patient weight loss and unemployment had obvious influence on MH2 score.</p><p><b>CONCLUSIONS</b>The QQL of patients received PD didn't have decreased. Their total score of SF-36 QQL was close to the patients who received LC. But the mental health score of group PD was lower than group LC. Weight loss, unemployment, recurrence and chronic pancreatic diarrhea may be infect the Quality of life after PD.</p>

Isolation of a down-regulated novel gene with lower abundance in gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To clone novel gene from suppression subtraction library established for screening down-regulated genes in gastric carcinoma, and the effects of novel gene on gastric tumorigenicity were analyzed.</p><p><b>METHODS</b>Sequencing results of 860 positive colonies chosen randomly were compared by Blast program in GenBank. Novel gene fragment was amplified by rapid amplification of cDNA ends (RACE). The mRNA expression of novel gene was detected by Northern blot and semi-quantitative PCR in 25 cases of gastric carcinoma tissue and counterpart normal gastric mucosa. The structure and chromosomal location of novel gene were investigated by Bio-message technique.</p><p><b>RESULTS</b>A 233 bp novel gene fragment was screened out from 860 clones and a 802 bp novel gene was obtained by RACE. The novel gene was named as GDDM, registered in the number of AF494508 by GenBank. The mRNA expression of GDDM in gastric carcinoma tissue (4.496+/-0.637) was significantly lower than that in the counterpart normal gastric mucosa (36.919+/-6.290)(P<0.01). Chromosomal location of GDDM gene was at 4q31.</p><p><b>CONCLUSION</b>The cloned novel gene, GDDM, is down-regulated in gastric carcinoma, and it is likely to be involved in gastric tumorigenicity.</p>

Congenital choledochal cysts in adults: twenty-five-year experience / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Choledochal cyst is rare in western countries. The relatively high incidence of coexistent hepatobiliary disease increases the difficulty of the surgical management of choledochal cyst. Here we analyze the diagnosis and treatment of congenital bile duct cyst in 122 Chinese adults.</p><p><b>METHODS</b>The clinical data of 122 patients with congenital choledochal cysts admitted from 1981 to 2006 were analyzed.</p><p><b>RESULTS</b>Clinical symptoms in most cases were nonspecific, resulting in delayed diagnosis. Sixty-one patients (50%) had coexistent pancreatobiliary disease. Among the 122 patients, 119 patients underwent ultrasonic examination; ERCP/MRCP was performed in 63 cases and CT in 102 cases. Abnormal pancreatobiliary duct junction was found in 48 patients. Sixteen patients had malignant lesions in the bile duct, arising in 11 of them from incomplete choledochal cyst that underwent various operations including cystenterostomy or cystojejunostomy. There was significant difference between the patients who underwent incomplete cyst resection and complete cyst resection in malignancy rate of bile duct (Chi square test, P = 0.000; odds ratio, 7.800; 95% confidence interval, 2.450 to 24.836).</p><p><b>CONCLUSIONS</b>ERCP, CT and MRCP had proved their great values in the classification of the disease. Cyst excision with Roux-en-Y hepaticojejunostomy is recommended as the treatment of choice for patients with type I or type IV cysts. For type V cyst (Caroli's disease) with recurrent cholangitis, liver transplantation should be considered.</p>

Laparoscopic hepatectomy by curettage and aspiration: a new technique / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Laparoscopic surgery is advantageous for minimal invasiveness and rapid postoperative recovery. Since the use of laparoscopic hepatectomy in liver resection in the 1990s, it has been performed in a few institutions worldwide. Lack of efficient and safe techniques for liver transaction is the major obstacle preventing from its further development. We developed a new technique for laparoscopic hepatectomy by curettage and aspiration in 1998. In this paper we analyze the clinical outcomes of this technique after 7 years of practice.</p><p><b>METHODS</b>Altogether 59 consecutive patients underwent laparoscopic hepatectomy by curettage and aspiration from August 1998 to January 2005 at our institution. These patients included 33 males and 26 females, with a mean age of 47 years. For liver transection laparoscopic Peng's multifunctional operative dissector (LPMOD) was used. Lesions included malignant liver tumors in 19 patients, benign liver tumors in 17, intrahepatic calculus in 18, and other liver lesions in 5. Procedures included local resections in 30 patients, left lateral segmentectomy in 28, and right hemihepatectomy in 1.</p><p><b>RESULTS</b>Laparoscopic operation was completed in 57 patients. Two patients (3.4%) had the operation converted to laparotomy. The mean operating time was 143 minutes and the mean intraoperative blood loss was 456 ml. The mean length of postoperative hospital stay was 7 days. Complications occurred in 2 patients (3.4%), and there was no perioperative death.</p><p><b>CONCLUSION</b>Laparoscopic hepatectomy by curettage and aspiration is efficient and safe for liver resection.</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>