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??Application of vacum-assisted closure in open abdomen with enteroatmospheric fistulae??A report of 45 cases LI Wu-han, ZHAO Yun-zhao, ZHAO Ri-sheng, et al. Research Institute of General Surgery??Clinical School of Medical College of Nanjing University; Department of General Surgery, Nanjing General Hospital of Nanjing Military Command of PLA??Nanjing 210002??China
Corresponding author: ZHAO Yun-zhao, E-mail??yzzhaomd@gmail.com
Abstract Objective To investigate the feasibility and therapeutic efficacy of vacum-assisted closure in open abdomen with enteroatmospheric fistulae. Methods The clinical data of 45 cases of intestinal fistulae and complicated intra-abdominal infection received open abdomen from February 2012 to February 2015 in Department of General Surgery, Nanjing General Hospital of Nanjing Military Command of PLA were analyzed retrospectively. Comparison of the effect of vaccum-assisted closure and polypropylene patch for temporary abdomen closure. Results Application of vaccum-assisted closure in open abdomen with enteroatmospheric fistulae shorten the time from opening abdomen to skin grafting, the length of stay in ICU and hospital significantly, and increased the rate of primary fascial closure. Conclusion Vaccum-assisted closure is an effective treatment for open abdomen with enteroatmospheric fistulae.     

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??Pathogen distribution and drug resistance in patients with intro-abdominal infection??A report of 310 cases DAI Xiao-ming*??SHI Kun??WU Xiang-dong??et al. *Intensive Care Unit??the First Affiliated Hospital of Dalian Medical University??Dalian 116011??China
Corresponding author??TAN Guang??E-mail??tanguang009@sina.com
Abstract Objective To investigate the distributions and antimicrobial resistances of the bacteria in abdominal drainage fluid in intro-abdominal infection??IAI??. Methods The abdominal drainage fluid specimen of 310 cases of IAI admitted from January 2012 to December 2014 in the First Affiliated Hospital of Dalian Medical University was collected. The bacterial distributions and antimicrobial resistances were analyzed. Results A total of 578 clinical isolates were collected??of which gram-negative organiams, gram-positive cocci and fungi accounted for 65.2% ??377 strains????27.0% ??156 strains??and 7.8% ??45 strains?? respectively. The top five most prevalent isolated pathogens were escherichia coli??19.6%????klebsiella pneumonia??11.4%??, acinetobacter baumannii??10.2%????enterococcus faecium??8.1%????pseudomonas aeruginosa??7.3%??. The resistance rate of E. faecium to most antibiotics was higher than that of E. faecalis. The resistance rates of E.faecium and E. faecalis against to ampicillin, ciprofloxacin, levofloxacin and erythromycin were all above 80%??and the sensitive rates of sulfamethoxazole and chloromycetin against staphylococcus were above 90%. No strain was found resistant to vancomycin or linezolid. The prevalence of ESBLs in enterobacteriaceae was above 55%, and the sensitive rates were higher in carbapenems, amikacin and β-Lactamase inhibitors, but severely resistant to the third generation cephalosporin. The prevalence rate of carbapenem-resistant enterobacteriaceae (CRE) was increasing year by year. The resistance rates of minocycline and cefperrazone-sulbactam against acinetobacter baumannii were 11.9% and 37.3%??which of other antimicrobial drugs were above 60%??of carbapenem was above 70%??of ceftriaxone and cefotaxime above 80%, of gentamicin above 90%. The sensitive rates of carbapenem??ceftazidime??cefepime??piperacillin sodium and tazobactam sodium??amikacin against pseudomonas aeruginosa were higher than those against acinetobacter baumannii. Conclusion The enterobacteriaceae and non-fermentative bacterias are the chief bacteria in IAI. Multi-drug resistant bacteria is serious??and the resistance rate is increasing year by year. Extensive and dynamical monitoring of pathogens resistance should be performed and rational use of antibiotics are advocated.     

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??Surgical strategies of duodenal gastrointestinal stromal tumor??A report of 34 cases WU Xiao-yan, LIU Gang, LIU Jian, et al. Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
Corresponding author: LIU Tong, E-mail: liutonga@126.com
Abstract Objective To explore the clinical features and selective surgical procedures for duodenal gastrointestinal stromal tumor (GIST). Methods The clinical pathological data and follow-up data of 34 cases of duodenal GIST performed surgery from January 2009 to December 2014 in Tianjin Medical University General Hospital were analyzed retrospectively. All the cases were performed surgical resection??including 8 cases of pancreaticoduodenectomy (PD) and 26 cases of limited resection (LR). Related clinical information between PD and LR groups were compared by statistical analysis. Results There was no statistical difference in intraoperative blood loss, tumor size, complication incidence, postoperative recurrence free survival and tumor risk classification between PD and LR group. LR was significantly associated with a shorter operation time and a shorter hospital stay compared to PD [??185±102??min vs.??420±135??min????24±15??d vs.??33±16??d]. The choice for PD depends on the tumor margin away from the position of duodenal papilla and involvement of the pancreas. Conclusion Operative procedure of duodenal GIST depends on the tumor margin away from the duodenal papilla and involvement of the pancreas. If the tumor margin is greater than 2 cm away from duodenal papilla and without pancreatic invasion, LR would be the preferred choice of operative procedure.     

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原发于十二指肠的肿瘤较为少见，而十二指肠平滑肌瘤则更为罕见。现结合我院近年来经手术与病理所证实的3例十二指肠平滑肌瘤引起的上消化道出血报告如下，并进行分析讨论。     

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目的 探讨血管疾病所致急腹症的诊断和治疗。方法 对1997年6月至2002年8月间经治的15例血管源性急腹症的临床资料进行回顾性分析。结果 以中老年病人为多见，常并存心脏、血管疾病。临床表现差异较大，容易漏诊、误诊。平均确诊时间11h，手术治疗11例，非手术治疗4例，死亡2例，致残l例。结论 重视病史的全面采集，坚持正规的体格检查程序，严密观察病情，正确的临床逻辑思维，恰当的辅助检查，是早期诊断和成功治疗该病的关键。     

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??Clinical features and diagnosis of parathyroid adenoma with cystic degeneration??A report of 8 cases ZHAO Hai-ying, CUI Yong, ZHOU Yong, et al. Department of General Surgery, Affiliated Shengjing Hospital, China Medical University??Shenyang 110004, China
Corresponding author??LIU Jin-gang, E-mail??liujg@sj-hospital.org
Abstract Objective To evaluate the clinical features and diagnosis of parathyroid adenoma with cystic degeneration. Methods The clinical data of 8 cases of parathyroid adenoma with cystic degeneration and 50 cases of parathyroid adenoma without cystic degeneration performed surgery and identified by pathology between January 2003 and August 2012 in Department of General Surgery, Affiliated Shengjing Hospital of China Medical University were analyzed retrospectively. The serum calcium, serum parathyroid hormone (PTH), parathyroid crisis, lesion size and diagnosis methods between cystic degeneration group and no cystic degeneration group were compared and analyzed. Results There was no difference in serum calcium, serum PTH and incidence of parathyroid crisis between two groups. The mean largest diameter of lesion in cystic degeneration group was ??37.1±13.8??mm, in no cystic degeneration group it was ??23.6±11.4??mm, there was statistical difference between two groups (P??0.01). In all parathyroid adenomas, the sensitivity, accuracy, positive predictive value in ultrasonography, CT and MIBI scintigraphy was 82.1%, 79.3%, 95.8%; 66.7%, 66.7%, 100.0%; 71.4%, 68.2% and 93.8% respectively. There was no statistical difference among the three groups. The sensitivity of ultrasonography in cystic degeneration group was 37.5%, lower than it in no cystic degeneration group (89.6%), there was statistical difference between two groups (P??0.01). Conclusion In both parathyroid adenoma with cystic degeneration group and no cystic degeneration group, the clinical feature is the same. There is no difference in serum calcium and serum PTH, and cystic degeneration does not increase the incidence of parathyroid crisis, while size is larger in cystic degeneration group. When cystic degeneration happened, the misdiagnosis increases, it should use both ultrasonography and MIBI scintigraphy for the diagnosis.     

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??Diagnosis and treatment of acute intestinal obstruction from single center??A report of 267 cases ZHU Li-jing, HAN Xu, QIN Xin-yu, et al. Department of General Surgery, Zhongshan Hospital Fudan University; Research Institute of General Surgery of Fudan University, Shanghai 200032, China
Corresponding author: LOU Wen-hui, E-mail:wenhuilou@aliyun.com
Abstract Objective To analyze the clinical spectrum, diagnosis and treatment of acute intestinal obstruction in Zhongshan Hospital Fudan University. Methods The clinical data of 267 cases of acute intestinal obstruction admitted from January 1, 2011 to December 31, 2012 in Department of General Surgery, Zhongshan Hospital Fudan University were analyzed retrospectively. Results There were 267 cases diagnosed with acute intestinal obstruction including 141 cases (52.8%) of adhesive intestinal obstruction and some other causes followed by colon tumor (49 cases, 18.4%), rectal tumor (17 cases, 6.4%), all types of hernia (10 cases, 3.7%), peritonitis (7 cases, 2.6%), intestinal obstruction by gallstone, meconium and persimmon bezoar (7 cases, 2.6%), and other rare causes (36 cases, 13.5%). The top three kinds of previous surgery leading to adhesive intestinal obstruction were listed as followed: 46 cases (32.6%) of colorectal tumor resection, 28 cases (19.9%) of subtotal gastrectomy or total gastrectomy, 21 cases (14.9%) of appendectomy. Of 141 cases of adhesive intestinal obstruction, 82 cases (58.2%) were required surgical intervention eventually, and the remaining 55 cases (39.0%) were received conservative treatments and recovered. Conclusion Adhesive intestinal obstruction is the leading cause of acute intestinal obstruction in the cases from Zhongshan Hospital Fudan University. Resection of colorectal cancer is the most common cause of adhesive intestinal obstruction. More than half cases of all adhesive intestinal obstruction need reoperation.     

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腹部切口骨化是指腹部手术后瘢痕内骨组织形成 ,为骨化性肌炎的一个亚型 ,临床罕见。英文文献中迄今报道80余例 ,国内至今仅有 3例报道。我院曾发现 3例。现报告如下。1　病历简介　　例 1 男性 ,5 3岁。因胃癌于 1980年行根治性胃大部切除术。术中取上腹正中切口 ,术后切口一期愈合。术后 8个月于腹部瘢痕上部触及坚硬之条索状肿物。 1个月后 (术后9个月 ) ,以“胃癌切口种植”的诊断再次手术。术中发现原切口皮下有一约 10ｃｍ× 0 5ｃｍ肿物 ,与剑突相连 ,有类似骨膜、骨皮质及骨松质的结构。术后病理检查示 :脂肪结缔组织、部分纤维化…     

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目的 探讨联合血管重建胰十二指肠切除术的适应证和方法。方法 回顾自1994年4月至2001年3月多家协作医院42例联合血管重建胰十二指肠切除术的经验。42例行胰十二指肠切除，其中1例胰头癌累及结肠肝曲合并右半结肠切除。全组均联合肠系膜上静脉门静脉（SMVPV）切除，其中合并肠系膜上动脉（SMA）和肝动脉（HA）切除重建者分别为4例和2例。1例胰头癌因与下腔静脉前壁粘连紧密不能分开则合并下腔静脉前壁部分切除修复。结果 围手术期死亡3例（7.1%）。无胆胰瘘及人工血管感染并发症，病理检查结果：胰腺神经内分泌恶性肿瘤1例，其余均为腺癌，切除血管内膜和胰腺切缘均无肿瘤浸润。失访2例。随访时间3－87个月，7例死于术后7个月至3年，其中6例为合并SMA、HA切除重建者，存活超过3年19例，超过5年6例。其余病例尚在随访中。结论 在选择适宜的病例中施行联合切除血管的胰头癌根治术可提高其切除订，延长病人存活时间。     

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??Evaluation on outcomes and reliability of treatment options for splenic arterial steal syndrome after orthotopic liver transplantation:A report of 5 patients ZOU Wei-long*, ZHANG Wei, REN Xiu-yun, et al. *Department of Liver Transplant and Hepatopancreatobiliary Surgery, the General Hospital of Chinese People’s Armed Police Force, Beijing 100039, China
Corresponding author: SHEN Zhong-yang, E-mail: wlzouah@sina.com
Abstract Objective To evaluate the clinical outcomes and reliability of treatment options based on diagnostic timing for splenic artery steal syndrome (SASS) in recipients underwent orthotopic liver transplantation (OLT), and to compare splenic artery coil-embolization (SAE) with other options by efficacy and reliability. Methods The incidence and clinical manifestation of SASS in 191 consecutive patients performed OLT between January 2004 and December 2013 in the General Hospital of Chinese People’s Armed Police Force were analyzed retrospectively. Those patients were suffered from liver cirrhosis combined with splenomegaly, with the ratio of pre-OLT splenic artery (SA) diameter to common hepatic artery (SA/CHA) diameter ≥1.5, but intra-OLT peak systolic velocity (PSV)≥30 cm/s. SAE, re-anastomosis HA to aorta (HTA, SA or abdominal aorta), splenic artery ligation (SAL) or splenectomy (SPT) were performed to cope with SASS depending on occurring time and aftermath of SASS. SAE with other treatments were compared by clinical outcomes and reliability. Results A total of 17 cases out of 191 patients (8.90%) were identified as SASS, and the overwhelming majority of whom (16/17, 94.11%) were detected in 15d early after OLT. The sluggish and dim PSV of the patency hepatic artery increased immediately in the mean PSV from 16.55±2.97 cm/s to 39.34±7.67 cm/s (P??0.001), and resistivity index (RI) of HA rehabilitated to reasonable level(0.5~0.8) after SAE, without any related complication detected. A total of 12 patients with hepatic artery thrombosis secondary to SASS were performed embolectomy or thrombolysis followed by HTA (4 patients), SA ligation (SAL, 3 patients), or splenectomy (SPT, 5 patients), while 3 of them developed requiring re-OLT. All the patients obtained satisfactory results by the salvage strategies, except 2 out of 12 patients died from liver failure. Conclusion SASS is a severe complication after OLT. As an effective salvage intervention to prevent from devastating consequence, coil-emblization of SA shortly after early diagnosis is deserved to be introduced for satisfactory results and reasonable safety.     

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目的 探讨藏毛疾病的诊断和治疗方法。方法 回顾分析1991-2001年收治的10例藏毛疾病病人的临床资料。结果 10例藏毛疾病中藏毛窦9例，藏毛囊肿1例。10例病人均反复发作骶尾部感染，仅2例在瘘口内发现毛发，1例发现尾骨缺损。10例均经手术治疗，术后病理为异物性肉芽肿，随访时间1～11年，均无复发。结论 藏毛疾病容易误诊，术前应进行全面评估，彻底手术切除是预防复发的关键。     

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在施行胆道手术 ,采用胆道探条进行胆总管远端探查时可造成其末端部位的穿通伤 ,如术时未能即时发现这种特殊类型的胆道损伤 (ＤＣＰＤ) ,在术后可发生腹膜后间隙严重感染等致死性恶果。术文报道 2例的诊治经过并讨论与之有关的临床问题。1　病例介绍　　例 1 女 ,6 3岁。因胆道结石行胆囊切除及胆总管探查。术时发现胆总管直径 1 2ｃｍ ,用 3号硬质探条无阻地进入“十二指肠” ,当在胆总管内将Ｔ管安置完毕 ,常规经该管向胆总管内注水时 ,十二指肠降部外侧腹膜后间隙出现水肿 ,其内侧与胰腺之间连续渗水。分析穿通伤定位于邻近壶腹部的胆总…     

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??Diagnosis and treatment of the pancreatitis as an initial manifestation of primary hyperparathyroidism?? A report of 6 cases HE Liang*, ZHANG Hao, ZHANG Ping, et al. *Department of General Surgery, the First Affiliated Hospital of China Medical University, Shenyang 110001, China
Corresponding author: ZHANG Hao??E-mail: haozhang@mail.cmu.edu.cn
Abstract Objective To evaluate the clinical characteristics, diagnosis and treatment of the pancreatitis as an initial manifestation of primary hyperparathyroidism (PHPT). Methods The clinical data of 6 cases of the pancreatitis as an initial manifestation of PHPT admitted from February 2009 to March 2013 in Department of General Surgery, the First Hospital of China Medical University were reviewed retrospectively for the diagnosis and treatment strategies. Results Of 6 patients with PHPT, 4 patients complicated with acute pancreatitis and 2 patients complicated with chronic pancreatitis. Four patients with acute pancreatitis presented rapid progression. The serum calcium concentration was higher than 3.5mmol/L and the typical hypercalcemia crisis appeared in 4 patients. Resection of parathyroid adenoma was performed in 3 patients. Two patients were cured and 1 died of drug-induced liver failure. The other one without operation died of hypercalcemia crisis. Two chronic pancreatitis patients with pancreatolithiasis showed mild symptoms. Although the serum calcium concentration was higher than 3.5mmol/L, no hypercalcemia crisis appeared. They were cured after the resection of parathyroid adenoma. One of them presented recurrent pancreatitis during the follow-up period and one patient had no recurrence. Conclusion PHPT should be suspected highly when pancreatitis appeared without common causes, especially combined with normal or elevated serum calcium concentration. Surgery is considered as the most direct and effective way to treat PHPT and could alleviate the symptom of pancreatitis and improve survival rate.     

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目的 探讨胰腺损伤的诊断和治疗方法。方法 回顾性分析1983～2002年收治的65例胰腺损伤的临床资料。结果 胰腺损伤Ⅰ级7例，Ⅱ级24例，Ⅲ级19例，Ⅳ级10例，Ⅴ级5例。单纯胰腺损伤13例(20．0％)，合并其他器官损伤52例(80．0％)。术前诊断为胰腺损伤的仅12例(18．5％)。65例均行手术治疗，治愈56例(86．2％)，死亡9例(13．8％)。结论 胰腺损伤早期诊断困难，应高度警惕。对怀疑或诊断为胰腺损伤者，应尽早手术探查，并根据损伤的部位及严重程度，选择合理的手术方式。     

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??Transient rise of postoperative bilirubin for hilar cholangiocarcinoma: A report of 175 cases GAN Wei*??YU Wen-long??QIAO Liang??et al. *1st Department of Biliary Surgery, Eastern Hepatobiliary Surgery Hospital??the Second Military Medical University, Shanghai 200438??China
Corresponding author??ZHANG Yong-jie??E-mail??yjoy005@sina.com
Abstract Objective To explore the change rule of postoperative bilirubin for hilar cholangiocarcinoma??and analysis the influence factors of postoperative serum bilirubin elevation. Methods The clinical data of 175 cases of hilar cholangiocarcinoma admitted from January 2009 to December 2012 in Eastern Hepatobiliary Surgery Hospictal were analyzed retropectively. All the cases were divided into groupA (105 cases of bilirubin declined gradually) and group B (70 cases of bilirubin rising trasiently). The influence factors of postoperative serum bilirubin elevation were analyzed by t-test chi-square test Fisher exact probability test and Keplan-Meier method. Results The postoperative serum bilirubin gradually declined to the normal range in 2 weeks in group A??whereas it reached a peak at the first 4-5 days then declined gradually in group B and still can not return to normal range in two weeks. According to the single factor analysis, blood transfusion, hepatectomy, hepatic liver cirrhosis or not, CA19-9, ALP, preoperative biliary drainage and GGT had statistical differences between two groups??P<0.05??. Multivariate Logistic analysis showed that ALP??OR=0.996??95%CI 0.993-0.998??, CA19-9??OR=2.434??95%CI 1.177-5.037??, blood transfusion (OR=2.274, 95%CI 1.088-4.753), hepatectomy(OR=5.842??95%CI 1.473-23.171?? and hepatic liver cirrhosis??OR=2.690??95%CI 1.192-6.070??were the independent risk factors for the changes of postoperative bilirubin. The hospital stays [(25.1±1.2)d vs. (38.7±2.0)d??t=-5.820] and postoperative complications incidence??9.5% vs. 38.0%, χ2=22.948??had statistical differences??P<0.05??. There was no statistical difference in the prognosis between two groups (median survival time:30 months vs. 26 months, χ2=0.562??P=0.453). Conclusion ALP, CA19-9, the blood transfusion, hepatectomy and liver cirrhosis were the independent influence factors for the transient rise of postoperative bilirubin. The transient rise of post operative bilirubin may increase the risk of postoperative complications,extend hospital stays??but not shorter the life expectancy.     

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??Diagnosis and treatment of parathyroid carcinoma??A report of 30 cases CHEN Hai-zhen, XUE Song, CHEN Xi, et al. Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine??Shanghai200025, China
Corresponding auther: CHEN Xi, E-mail: chz11011@rjh.com.cn
Abstract Objective To evaluate the diagnosis and surgical treatment of parathyroid carcinoma (PC). Methods The clinical data of 30 cases of PC admitted from January 2000 to December 2013 in Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine were analyzed retrospectively. Results There were 10 men and 20 women, which accounted for 8.22% of cases of primary hyperparathyroidism (PHPT)??Thirty cases were all treated by operation and 8 cases developed recurrence in 1-11 years postoperatively. The initial operation was closely related with the prognosis. Conclusion The preoperative and intraoperative diagnosis of PC should be combined with clinical manifestations, imaging data, laboratory data and intraoperative exploration, etc. PC cases should be performed pathological parathyroid resection plus homolateral total thyroid resection. For PC cases performed pathological parathyroid resection or plus homolateral partial thyroid resection in the initial operation, supplementary operation should be taken in 2-3 weeks after initial operation.     

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??Influential factors of multiple operations in abdominal surgery: A report of 162 cases XU Dong-sheng??SUN Bei??JIANG Hong-chi??et al. Department of General Surgery??the First Affiliated Hospital of Harbin Medical University??Harbin 150001??China
Corresponding author??JIANG Hong-chi??E-mail??jianghc@vip.163.com
Abstract Objective To investigate the influential factors of multiple operations in abdominal surgery. Methods The clinical data of 162 cases of multiple operations (more than 3 times) performed in Department of General Surgery, First Affiliated Hospital of Harbin Medical University between January 1998 and December 2012 were analyzed retrospectively. Results Bile duct and gallbladder diseases ranked the first in multiple operations (27.16%)??followed by colon and rectum (19.75%), stomach (15.43%), appendix (11.73%), pancreas (9.88%) and liver (7.41%). Multiple operations were performed mainly by associate chief surgeons (48.15%)??secondly by chief surgeons (26.54%)??only 25.31% by attending doctors. The first- or second-operations performed in other hospitals account for 82.1%. Selective operations ??64.81%??were still the majority of multiple operations. Iatrogenic factors were the main reasons (85.80%). The cure rate could achieve 67.28%. The incidence of medical dispute was 69.14%. Conclusion Iatrogenic factors cause the complicated disease to some extent. Enhancing basic knowledge, following basic principle and strengthening responsibility, humanistic care and specialized training for surgeons??are critical to prevent multiple operations in abdominal surgery.     

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目的 总结运用腹腔镜与十二指肠镜、胆道镜联合，微创治疗内镜取石失败的胆管结石病人的治疗经验。方法 从1998年4月至2002年5月，运用三镜联合的手术方式（术前内镜下经鼻胆管引流，腹腔镜胆总管探查术，术中胆道镜），对251例胆总管结石病人进行微创治疗。结果 240例手术均获成功，11例中转开腹、无残余结石及严重并发症。术后住院时间明显缩短，操作熟练后手术时间也短于开腹手术。194例随访半年以上未见远期并发症。结论 三镜联合胆总管探查术对于有较高内镜、腹腔镜技术的医疗单位是切实可行和安全可靠的。十二指肠镜、胆道镜及腹腔镜的联合应用优势明显，可基本取代开腹胆总管探查术。