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??The Effect of Dudenum-Decending Method on Biliary Duct Reoperation in Patients with Repeated Biliary Operation LI Ke-zhou, LUO Zhu-lin, YAN Hong-tao, et al.PLA General Surgery Center, Chengdu Military General Hospital, Chengdu610083,China.
Corresponding author??LI Ke-zhou, E-mail??kzlchina@yahoo.com
Abstract Objective Here we introduce our expierance on searching biliary duct in some difficult condition in biliary reoperation. Methods The data of 2457 cases with reoperation on biliary tract after repeated biliary operations over the past 10 years was analyzed. Duodenum-decending method was used in 31 cases when failed with conventional method. The duodenal bulb was freed and decended to expose the relatively normal posterior duodenal part of extra hepatical biliary duct, the duct was freed and incised upward to the hepatic porta,then accomplied with succeded operation manuver. Results The cases operated with duodenum-drop method accounted for 1.16 percent (31/2457) of the patients during the same period. All the 31 cases were found extra hepatical duct successfully by this method, with operation time of 3~5mins (average 4.5 min), and blood loss of 1.5~2.0ml (average 1.8ml). There were no significant difference in abdominal drainage and gastrointestinal function recovery between duodenum-drop method group and conventional method group. Conclusion Separating and finding the bile duct is sometimes very difficult in biliary reoperation. Duodenum-drop method is feasable and with high success rate,which can be used as a useful complement to other conventional methods.     

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??Clinical efficacy of laparoscopic liver resection in treatment of recurrent hepatolithiasis in patients with history of multiple biliary tract surgery LI Wei-nan, LI Qiang, XU Jian, et al. Department of Hepatobiliary Surgery, Affiliated Hospital of North Sichuan Medical University; Hepatobiliary and Pancreatic Intestinal Institute, North Sichuan Medical University, Nanchong 637000, China
Corresponding author??LI Jing-dong, E-mail:lijingdong358@126.com
Abstract Objective To investigate the clinical efficacy of laparoscopic liver resection in treatment of recurrent hepatolithiasis in patients with history of multiple biliary tract surgery. Methods The clinical data were collected from Affiliated Hospital of North Sichuan Medical University between May 2015 and May 2017. All patients had two or more history of biliary tract surgery. Results Among the 12 cases, 8 cases received exploration of the bile duct+hepatic segmentectomy (lobectomy)+T-tube drainage, 2 case received exploration of the common bile duct+hepatic segmentectomy (lobectomy)+hilar bile duct plastic surgery, 2 cases received exploration of the common bile duct and choledochoscope through the bilioenteric anastomosis Roux-Y jejunal loop. The mean operation was 285(238—348) min and the intraoperative blood loss was 484(396—627) mL. Four patients were conducted blood transfusion treatment, and the blood transfusion amount about 356??200—800??mL. The portal triad clamping were used in the patients. In 12 patients, duodenal plasma muscular injury in 1 case, transverse muscular injury in 1 case, the transverse colon full-thickness injury in 1 case, stomach plasma muscular injury in 3 cases. The anal exhaust time was (1.6±0.8) d and the ostoperative hospital stay was (9.6±4.2) d in the 12 patients; 7 cases of postoperative complications, the area of effusion in 2 cases, abdominal cavity effusion in 3 cases, bleeding in 1 case, bile leakage in 2 cases, the residual stone in 3 cases (1 case of the area at the same time merge effusion and peritonealeffusion, 1 case with residual stone and bleeding, 1 case of merger and residual stone, 1 case of abdominal cavity effusion combined the art district effusion and bile leakage).All complications were cured by symptomatic improvement. There was no surgery patients in perioperative period. During the follow-up, it could be completely asymptomatic in 9 cases. Three cases had occasional mild cholangitis sometimes. The "T" tube indwelling off after 2 months in a case of residual stones patients, and put the catheter in sinus tract immediately. Three patients with residual stones were cured after remove residual stones with electron choledochoscope with 1 to 3 times. Conclusion Based on evaluating patients’ condition sufficiently, the rich experience of laparoscopic hepatectomy and the experience of diagnosis and treatment of a variety of difficult condition in hepatolith disease, clinical curative effect is feasible and reliable in the recurrent hepatolith patients with the history of multiple biliary surgery to use laparoscopic liver resection.     

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??Discussion in the diagnosis and treatment of medullary thyroid cancer CHEN Xi. Department of Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine??Shanghai 200025??China
Abstract Medullary thyroid cancer (MTC) originates from parafollicular C cells of the thyroid gland, and accounts for about 4% of thyroid cancer cases. MTC presents as part of an autosomal dominant inherited disorder related to multiple endocrine tumor type 2 (MEN-2) in about 20%??25% of cases, including MEN-2a, MEN-2b and family MTC, and as a sporadic tumor in the remainder. Calcitonin is a specific tumor marker of MTC, which indicates the tumor onset, residue and recurrence. Calcitonin doubling-time is related to the prognosis. The only possible to cure MTC is total thyroidectomy and lymph node dissection, and the prophylactic surgery benefits the MEN-2 related patients.     

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目的：探讨肝胆管结石手术时机的选择对术后并发症及其治疗效果的影响。方法：回顾性分析1992～2002年因肝胆管结石行手术治疗457例的胆管炎发作史，再手术史，手术方式，术后并发症及结石残留等情况。结果：457例中急症期内行手术治疗213例，出现术后并发症47例(22．1％)，死亡3例，术后结石残留率37．3％；择期行手术治疗244例，出现术后并发症31例(12．7％)，死亡2例，术后结石残留率21．7％。结论：严格掌握肝胆管结石手术时机，避免急症期内被动手术和减少再次手术率，可减少术后并发症和残留结石发生，提高治疗效果。     

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凡手术中结石未能取尽 ,术后短期内又出现术前症状 ,术后造影发现有结石者为残余结石。若术中和术后检查胆管内已无结石 ,以后又出现类似术前的症状 ,经检查证实有结石者称为复发结石。目前一般以手术后至出现症状证实有结石的间隔时间长短来区分 ,术后 1年以内发现结石者为残余结石 ,1年或 1年以上者为复发结石。1　合理选择检查方法1 1　通过引流管检查1 1 1　经Ｔ管或胆道引流管的胆道造影　通过胆道引流管 (包括Ｕ形管、胆道支架管、胆道造口管等 )造影可了解术后肝内外胆管的结构有无病变、结石等 ,与术前造影比较能对预后准确估计 ,如…     

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??Diagnosis and treatment of hepatolithiasis combined with biliary infection ZENG Yong-yi??HUANG Xin-hui. Liver Center??the First Affiliated Hospital of Fujian Medical University??Fuzhou350005??China
Corresponding author??ZENG Yong-yi??E-mail:lamp1973@medmail.com.cn
Abstract Hepatolithiasis combined with biliary infection is a common disease of biliary surgery. However??the reasonable??standardized??completely treatment is still a problem. Surgeons should make clinical diagnosis according to clinical manifestations??laboratory tests and imaging examinations??assess the severity of the disease accurately and perform appropriate treatment plan. For mild acute cholangitis??anti-infection and supporting treatment is often effective??and operation should be done later when the inflammation was controlled. Moderate acute cholangitis may receive conservative treatment firstly under strict observation??and biliary decompression should be performed immediately when the condition deterioraed. However??for severe acute cholangitis??anti-infective and support treatment is usually ineffective??and decompression and drainage of biliary duct should be performed as soon as possible. The bile drainage methods include endoscopic drainage??PTBD??and surgery. The complete operation should be performed when the biliary inflammation has been controlled. Operation methods include resection of liver segment/lobe??plastic operation of the stricture and reconstruction of bile duct. For chronic biliary infection??besides complete operation of biliary stones??the liver lesion should be resected at the same time.     

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??Surgical stress and organs injury in hepatobiliary surgery WANG Jie, SUN Jian. Department of Hepatobiliopancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou510120, China
Corresponding author:WANG Jie,E-mail: sumsjw@163.com
Abstract With advances in hepatobiliary surgery technology, dangers caused by the surgery itself has been significantly reduced, but the impairment caused by surgical stress and excessive surgical stress is becoming prominent issue affecting the treatment and recovery of patients. The reduction of surgical stress response through a variety of perioperative control measures has become an important part of clinical practice in hepatobiliary surgery. But the mechanism of surgical stress is not yet fully understood, and there are still many gaps and controversy in the treatment of excessive stress, therefore, more basic and clinical researchs are needed to demonstrate and explore this issue.     

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??Implementation of enhanced recovery protocols after hepatobiliary and pancreatic surgery BAI Xue-li, LI Guo-gang, LIANG Ting-bo.Department of HBP Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009,China
Corresponding author:LIANG Ting-bo,E-mail:liangtingbo@zju.edu.cn
Abstract Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. Its primary aim is to decrease surgery-related stress, complications, and hospital stay, and also to facilitate recovery. The ERAS pathway has been widely applied and approved to be efficient in gastrointestinal surgery, colorectal surgery, thoracic surgery, urology, orthopedics, and gynecology. However, it’s not adapted as a standard of care in hepatobiliary and pancreatic (HBP) surgery patients in China. Most HBP surgeons in China worried that it may put the patients in danger owing to the complexity of surgery procedure and the high incidence of perioperative complications in HBP surgery. In fact, our experiences and other’s studies indicated to the contrary that the ERAS pathway is not only applicable but also very useful in HBP surgery, especially in patients who underwent longer operation and more severe injuries.     

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??Controversy and consensus on the clinical application of three-dimensional visualization technology in hepatobiliary surgery FAN Ying-fang, FANG Chi-hua. First Department of Hepatobiliary Surgery, Zhujiang Hospital of Southern Medical University, Guangdong 510282,China
Corresponding author: FANG Chi-hua,E-mail:fangch_dr@126.com
Abstract Three dimensional visualization technology has become an important technology for preoperative diagnosis and assessment, operative planning, intraoperative guidance and postoperative evaluation, which has greatly promoted the precise diagnosis and treatment level of hepatobiliary surgery diseases. There are differences between three dimensional visualization technology and post-processing technology of CT and MRI in both image reconstruction and image display. Using the three dimensional reformation technology, the post-processing software of CT and MRI recombines the original two dimensional images into three dimensional images without the preprocessing of the original data. These reformation technologies including multiplanar reformation (MPR), curved planar reformation (CPR), vloume rendering technique (VRT ) or volume reformation??VR??, multiplanar volume reconstruction(MPVR), surface shade display(SSD),and virtual endoscopy(VE). On the other hand, using the technologies including image pre processing, image segmentation, surface rendering or volume rendering, three dimensional visualization technology reconstructs the original two dimensional images (CT or MRI) into three dimensional images and displays these images by visualization technology. Due to the image distortion generated from the further dealing of original two-dimensional image both in three dimensional visualization technology and in post-processing software of CT or MRI, three dimensional visualization technology has no advantages in qualitative diagnosis,however,it is better than post-processing software of CT and MRI in terms of location diagnosis,preoperative planning, improving the the success rate and prognosis of surgery.Surgeons should choose the appropriate three dimensional visualization software on the basis of clinical needs. Three dimensional visualization technology is a new model for the diagnosis and treatment of dieases, which will become an indispensable part of precision surgery in the future.     

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目的 研究近年来原发性肝胆和结石的手术治疗方式及治疗效果。方法 回顾性分析近10年来手术治疗原发性肝胆管结石504例的临床表现、治疗方法及疗效。结果 504例中行肝切除治疗280例（占55．8％）。全组术后残石率为34．6％,肝切除组和非肝切除手术组之间残石率差异显著,有统计学意义（21．7％vs53．7％,P＜0．01）,围手术期并发症差异无统计学意义（5．7％vs2．5％,P＝0．09）,随访疗效优良者比例肝切除组优于非肝切除手术组（86％vs80％）,但差别无统计学意义（P＝0．236）。结论 原发性肝胆管结石的手术治疗可采取多种方式,不同范围的肝叶切除治疗区域性肝内胆管结石,其效果优于单纯胆肠吻合和胆道外引流。各种措施的综合运用有助于减少术后残石。     

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目的 探讨肝胆管结石合并胆管癌的诊治经验。方法 总结1981～2002年第三军医大学西南医院收治的48例肝胆管结石合并胆管癌病人的临床资料。结果 术前CT检查诊断正确率为80％(28／35)。其中60．7％为肝内病变；超声检查诊断率为57．8％(26／45)，其肝门病变的诊断正确率为53.8％。根治性手术13例，病理诊断为胆管腺癌及黏液癌。随访22例，根治组平均存活25个月，姑息治疗组平均存活12个月。结论 胆管癌的发生与肝胆管结石有关；伴有结石的胆管癌疗效较差，应重视胆管结石的早期根治性治疗，以防止胆管癌的发生；姑息性手术可提高生活质量。     

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??Diagnosis and treatment of hepatolithiasis complicated with intrahepatic bile duct carcinoma ZHANG Yong-jie, LIU Jian. Eastern Hepatobiliary Surgical Hospital, the Second Military Medical University, Shanghai 200438,China
Corresponding author??ZHANG Yong-jie,E-mail??yjoy005@sina.com
Abstract Hepatolithiasis is an established risk factor for intrahepatic cholangiocarcinoma??ICC??. In cases of hepatolithiasis combined ICC, there is no specific symptom other than the clinical manifestations of hepatolithiasis, leading to inadequate diagnosis and delayed treatment. Detection of ICC in hepatolithiasis is dependent on both serological examination and imaging modalities. Once the diagnosis of hepatolithiasis combining ICC is confirmed, comprehensive treatment based on surgical resection is advocated.     

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感染始终是困扰外科医生并挥之不去的阴影。在新世纪开始之际 ,就外科感染问题回顾过去 ,认清现状 ,展望未来 ,是很有必要的。1　外科感染诊治的进展在诊断方面 ,除影像学 (如ＣＴ引导下穿刺诊断胰腺坏死感染 )、病理学 (如组织活检诊断深部真菌感染 )、毒素检测 (如用酶联免疫吸附法检测粪便滤液中Ａ毒素诊断难辨梭菌性肠炎 )、免疫学 (如检测血中或脑脊液中隐球菌或曲霉菌抗原诊断系统性真菌感染 )等以外 ,更突出的是微生物学诊断的进步。厌氧菌培养技术的开发与普及极大地提高了人们对厌氧菌感染的认识和治疗水平。采用选择性培养基能显…     

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目的 探讨肝硬化病人实施肝胆手术的危险性。方法 将1997～2002年收治的100例胆道结石手术病人按是否合并肝硬化分为两组，对比分析术后并发症发生情况。结果 肝硬化组43例病人中15例术后出现了一种或数种并发症，发生率高达34，9％(15／43)，且主要发生在肝功能Child B～C级、肝储备功能差的病人中(13／15)。手术死亡率9．3％(4／43)，3例死于肝衰，1例死于消化道出血，对照组并发症发生率仅为10．5％，无死亡。结论 对失代偿的肝硬化病人而言，即便是接受一个简单的胆道手术，都可能是高风险的。肝功能分级的不同是影响其预后的关键因素。     

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??Selection and evaluation of different imaging technology for hepatolithiasis REN Ke??ZHANG Xin. Department of Radiology?? the First Hospital of China Medical University??Shenyang110001??China
Corresponding author??REN Ke??E-mail??renke815@sina.com
Abstract Color ultrasound is a common examination method??suitable for the screening of stones. CT plain scan can diagnose high density stones??difficult to find isodense stones.Enhanced CT can find most stones of hepatic bile duct and the complications??such as liver abscess and intrahepatic cholangiocarcinoma.Plain MRI can display the stones in bile duct and the dilation of the distal duct.It’s helpful to find the abnormal signal in liver.Enhanced MRI can find intrahepatic lesions??such as liver abscess and intrahepatic cholangiocarcinoma??and also has some diagnosis value for the inflammation and tumor of bile duct. MRCP can display the biliary tree and the obstruction site??while have to combine with enhanced CT or MRI in the diagnosis of common hepatic duct and common bile duct lesions.     

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下肢静脉疾病与先天性血管疾病在临床表现上有诸多相似之处 ,容易混淆。本文将着重介绍下肢静脉疾病 (单纯性大隐静脉曲张、深静脉血栓形成后综合征 )与先天性血管畸形 (先天性动静脉瘘、先天性静脉畸形骨肥大综合征 )的各自病因、病理特点及检查手段。1　病因学鉴别按血流动力学变化 ,可将下肢静脉疾病分为两大类型 :(1)血液倒流性病变 :均由瓣膜本身的病变引起。主要包括原发性深静脉瓣膜功能不全、单纯性大隐静脉曲张、深静脉血栓形成后完全再通型 (管道再通 ,但瓣膜已破坏 )、先天性深静脉无瓣症等。约占下肢静脉病的 70 %。 (2 )回流障…