手术切除联合术中氩氦刀冷冻和无水乙醇注射治疗结直肠癌多发性肝转移

目的探讨手术切除联合术中氩氦刀冷冻和无水乙醇注射治疗结直肠癌多发性肝转移的疗效与安全性。方法回顾性分析2005年1月至2010年12月间在广州医学院附属肿瘤医院胃肠肿瘤外科接受手术切除联合术中B超引导下氩氦刀冷冻消融和无水乙醇注射的23例无法完全切除的结直肠癌多发性肝转移患者的临床和随访资料。结果本组23例患者男15例,女8例．年龄34-69（平均52．2）岁。23例患者均顺利完成治疗,98个肝转移灶中,经手术切除45个,经氩氦刀联合无水乙醇注射处理53个。肝转移灶手术时间27-96min．术中出血量50～450ml。无围手术期死亡病例：术后出现少量胸腔积液和肌红蛋白尿各1例。所有患者均接受了8～70（中位时间34）个月的术后随访,1、3、5年总体生存率分别为83．2％、45．5％和37．6％。结论对于无法完全切除的结直肠癌多发性肝转移,采用手术切除联合术中氩氦刀冷冻和无水乙醇注射治疗安全有效。     

经皮穿刺氩氦刀冷冻治疗肝癌56例临床分析

目的　探讨氩氦刀冷冻治疗肝脏恶性肿瘤的临床意义。方法　 2 0 0 1年 7月～ 2 0 0 2年6月 5 6例肝脏恶性肿瘤在B型超声引导下行经皮穿刺氩氦刀冷冻治疗。术后患者定期复查血清肿瘤标记物、B型超声检查及CT或MRI。结果　患者肝功能ChildA级 5 0例 ,ChildB级 5例 ,ChildC级 1例。原发性肝癌 4 6例 ,转移性肝癌 10例。小肝癌 (直径≤ 5cm)甲胎蛋白阳性者治疗后转阴占80 % ,甲胎蛋白阴性者治疗后CT或MRI复查病灶完全坏死达 6 1.5 %。转移性肝癌治疗后瘤标降至正常或CT、MRI提示病灶完全坏死者占 6 0 %。结论　氩氦刀冷冻治疗肝脏恶性肿瘤是一种微创、安全、疗效可靠的新方法。对于不适宜行手术治疗的肝脏恶性肿瘤患者是一种有效的微创外科治疗方法。     

经皮穿刺氩氦刀冷冻联合肝动脉栓塞化疗治疗肝脏恶性肿瘤(附34例临床报告)

目的　探讨氩氦刀冷冻毁损联合肝动脉栓塞化疗 (TACE)介入治疗肝脏恶性肿瘤的适应证、疗效及临床意义。方法　 2 0 0 1年 7月至 2 0 0 2年 6月 34例肝脏恶性肿瘤病人先行TACE治疗 ,术后 7～ 4 5d后在B超或B超CT联合引导下行经皮穿刺氩氦刀冷冻毁损治疗肝脏肿瘤术。术后病人定期复查血清肿瘤标记物、B超检查及CT或MRI扫描。结果　病人肝功能ChildA级 32例 ,ChildB级 2例 ,ChildC级 0例。原发性肝癌 2 8例 ,转移性肝癌 6例。在随访期 (3～ 15个月 )内 ,4 1 1% (14 /34)的病人血清肿瘤标记物降至正常或 (和 )CT、MRI提示病灶完全坏死者。 4 4 1% (15 / 34)的病人血清肿瘤标记物明显下降或CT、MRI提示病灶明显缩小。结论　氩氦刀冷冻联合TACE治疗肝脏恶性肿瘤是一种微创、安全、疗效可靠的新方法。对于不适宜行手术治疗的肝脏恶性肿瘤病人是一种有效的综合治疗方法。     

氩氦刀靶向冷冻术治疗中晚期恶性实体瘤106例临床分析

目的研究氩氦刀靶向冷冻术治疗中晚期恶性实体瘤的疗效和安全性。方法我院自2001年4月-2003年12月利用氩氦刀为106例失去手术根治时机的恶性实体瘤患者实施冷冻切除术。结果106例患者经氩氦刀靶向冷冻术治疗后1个月，生活质量有所改善，Karnofsky评分为60～90分，平均70分。CT检查肿瘤出现坏死。术后3个月复查CT肿瘤明显缩小。术中、术后不良反应轻。生存期有所延长。结论氩氦刀靶向冷冻术为不能手术切除的中晚期恶性实体瘤患者提供了一种较好的治疗方法。     

术中氩氦刀治疗晚期胰腺癌

目的 探讨术中氩靶向冷冻治疗系统（即氩氦刀）治疗晚期胰腺癌的安全性及疗效。方法 2001-2002年期间8例晚期胰腺癌使用了术中氩氦刀治疗。结果 8例晚期胰腺癌病人中，平均生存期为8．6个月，1例目前仍然存活。5例腹痛病人，3例完全缓解，2例部分缓解；1例腰背痛病人，疼痛部分缓解。结论 术中氩氦刀治疗尽管不能明显延长晚期胰腺癌病人的平均生存期，但能明显缓解病人的疼痛，提高病人的生活质量，仍不失为一种有效的晚期胰腺癌的姑息治疗方法。     

氩氦刀冷冻消融治疗恶性肾肿瘤23例分析

目的探讨氩氦刀冷冻消融治疗恶性肾肿瘤的临床疗效。方法应用氩氦刀冷冻消融治疗恶性。肾肿瘤患者23例。CT引导下经皮肾穿刺9例,后腹腔镜下9例,开放手术5例。结果术后第1、6个月复查CT或MRI,肾肿瘤冷冻区域呈梗死、无信号增强、逐渐消散等演变过程。23例均未见出血、皮肤冻伤、感染、穿刺道种植转移等严重并发症。随访1．5～48个月,平均28．5个月。21例健康存活,未发现远处转移和复发;死亡2例。开放手术治疗者5例,其中左肾平滑肌肉瘤1例于术后1．5个月因肿瘤广泛转移死亡;CT引导下治疗患者,1例肿瘤直径为8cm者术后10个月因脑血管意外死亡。结论氩氦刀冷冻治疗恶性肾肿瘤技术可靠、创伤小、安全性高,是治疗孤立肾肾肿瘤或无法手术肾肿瘤的一种有效的新手段,对于小的肾肿瘤采用后腹腔镜下氩氦刀冷冻消融治疗是一种值得尝试的新方法。     

CT评价单纯氩氦刀冷冻术联合放疗粒子治疗非小细胞肺癌的疗效

目的探讨CT评价单纯氩氦刀冷冻术及联合^125I粒子植入治疗非小细胞肺癌（NSCLC）疗效的价值。方法应用单纯氩氦刀冷冻术（A组,22例）及氩氦刀冷冻术联合^125I粒子植入（B组,20例）治疗NSCLC患者共42例。以胸部CT扫描动态观察治疗前、后病灶的变化,包括治疗时的冰球覆盖率、治疗后肿瘤的大小、密度并进行临床疗效评价。结果42例均置刀成功。CT显示两组低密度冰球的平均覆盖率均大于80％。两组中直径3～5cm与〉5cm病灶的疗效差异均有统计学意义（P均〈0．05）。A、B组在术后1、3、6、12个月有效率分别为63．64％（14／22）和65．00％（13／20）、72．73％（16／22）和75．00%（15／20）、54．55％（12／22）和85．00％（17／20）、59．09％（13／22）和80．00％（16／20）。结论氩氦刀冷冻术能有效治疗失去手术机会的NSCLC;联合^125I粒子植入能有效地控制残余肿瘤,进一步提高有效率;CT可准确定位、追踪复查评价治疗效果。     

肝脏移植在治疗肝脏恶性肿瘤中的作用

目的 探讨我国目前原位肝脏移植在治疗肝脏恶性肿瘤中的作用以及围手术期的处理，进一步提高肝脏移植治疗肝脏恶性肿瘤的疗效。方法 18例肝脏恶性肿瘤肝脏移植病人术后采用全身化疗复发转移灶采用手术切除或介入化疗。结果 肝脏移植术后甲胎蛋白短期内降为正常者6例，虽有下降但未降至正常者2例。术后肝癌肝内复发4例次，肺转移3例次，骨转移1例次，肿瘤复发多在术后6－12个月。结论 （1）小肝癌、胆管细胞癌可行肝脏移植，中晚期肝癌行肝脏移植需综合考虑；（2）肿瘤复发转移灶采用手术切除或介入化疗。     

超声引导细刀头氩氦刀靶向冷冻治疗肝癌

目的探讨细刀头氩氦刀靶向冷冻毁损治疗肝癌的疗效。方法在超声引导下采用Cryo—Hit氩氦刀对27例肝癌经皮或开腹靶向冷冻治疗，其中原发性肝癌10例，复发性肝癌11例，转移性肝癌6例。结果27例冷冻治疗后无肝破裂、出血、胆漏等并发症发生。12例术前AFP值增高者（36．5—1200μg／L），术后AFP下降（8．0—254μg／L），其中6例恢复正常。3例术前CEA值升高，术后均下降，其中2例降至正常。术后随访1—3个月，59．2％（16／27）的病人CT或MR检查提示病灶完全坏死，25．9％（7／27）的病人CT或MR提示病灶有不同程度缩小，但仍见活动病灶。结论超声引导细刀头氩氦刀靶向冷冻治疗肝癌是安全、有效、操作简便，远期疗效还有待进一步观察。     

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目的 总结原发性腹膜后肿瘤(primary retroperitoneal tumor,PRT)的诊疗方法.方法 回顾性分析东南大学附属徐州医院1995年6月至2005年6月收治的60例PRT病人的临床资料.结果 60例病人肿瘤直径(13.5±6.5)cm,均经手术治疗,且经病理证实.其中16例良性肿瘤完整切除14例(87.5%);42例恶性肿瘤完整切除28例(66.7%);2例间质细胞潜在恶性肿瘤行完整切除,恶性肿瘤切除后切缘予以氩氦刀消融术20例.良、恶性肿瘤3年存活率分别为88.3%和21.6%.结论 完整切除肿瘤是治疗的关键和影响预后的重要因素.氩氦刀冷冻切缘有助于获得肿瘤的阴性切缘,改善预后.PRT的预后与手术的彻底性和病理类型相关.影像学检查对诊断有重要意义.     

累及多肝门的巨大肝肿瘤切除术(附22例报告)

目的 探讨累及多肝门的巨大肝肿瘤切除的安全性、可行性及手术方法。方法 总结1996年4月至2003年4月间我科收治的累及多肝门的巨大肝肿瘤22例，肿瘤平均直径12．9cm（8～23cm）。肿瘤同时累及第1和第3肝门者9例，同时侵及第2、3肝门者8例，累及1、2、3肝门者5例。肝肿瘤包括：原发性肝细胞癌14例，胆管细胞癌1例，肝血管瘤4例，肝母细胞瘤3例。癌灶有完整包膜12例（55．5％），无完整包膜10例（45．5Voo）。对肝肿瘤所施手术方法、并发症防治等进行分析。结果 全部病例均手术切除，无手术死亡，术中平均出血量1480ml（450～4200m1），12例施行第1肝门阻断，10例采用了肝门区域选择性血管阻断，手术时间平均195min。术后无严重并发症，均治愈出院。本组22例病人经1～8年随访，术后存活时间最长已达8年，1年生存率为90．9％（20／22）。结论 对于累及多肝门的巨大肝肿瘤，只要正确把握手术指征，熟练掌握切肝技术，手术切除是安全的、可行的最佳治疗手段。     

规则性肝段切除术治疗肝内胆管结石病

目的 总结采用肝段切除术治疗肝内胆管结石病的经验。方法 回顾性分析1975年1月至1998年12月间采用肝段切除术治疗514例肝内胆管结石的临床资料及远期疗效。结果 肝内胆管结石的分布：左外叶64例、左肝叶176例、右前叶10例、右后叶24例、右肝叶31例、双侧肝叶209例。合并症：合并有显著肝段或肝叶萎缩者280例，肝脓肿17例，胆瘘7例，胆管癌8例。265例有1-5次胆道手术史。手术方法：根据肝内结石的分布决定肝段或联合肝段切除的范围，其中S2－3切除284例、切除98例、切除26例、切除37例、双侧肝叶部分切除23例。附加术式包括经肝门胆管切开取石217例，经肝实质肝内胆管切开取石11例，胆管空肠Roux-en-Y吻合296例。术后并发症有胆漏15例（2.9%）、膈下感染23例(4.5%)、腹腔脓肿2例（0.4%）和肝衰3例（0.6%）等。11例（2.1%）术后死于肝衰竭。随访10个月到25年，75.9%症状消失，14.5%偶而有轻度胆管炎发作，9.6%仍反复发作严重胆道感染。49例手术效果差的主要原因是肝脏切除范围不够兖分而遗留病变的肝胆管。结论 规则性肝叶切除术是清除病灶的最有效手段。     

肝切除治疗原发性肝癌自发性破裂出血

目的: 探讨肝切除治疗原发性肝癌自发性破裂的疗效。方法:回顾性分析1988年以来采用肝切除术治疗肝癌破裂15例的临床资料。结果:全组15例，男12例，女3例；平均年龄48岁。8例行急症肝切除，2例手术止血后40d行二期手术，5例保守治疗40d行择期手术。右肝叶部分切除术8例，中肝切除术1例，左肝外叶切除术2例，左肝内叶切除术2例，左半肝切除术1例，右肝肿瘤切除1例、左肝肿瘤术后综合治疗1例。肝功能Child B级中1例术后5d死于肝衰竭，手术死亡率6.7%，14例生存者12例获得随访，中位生存时间18个月。1，3，5年生存率为58.3%，25.0%，16.7%。其中1例无瘤生存6年2个月。结论:肝切除是治疗肝癌破裂的最好方法，当有可能时应争取施行。肝切除治疗肝癌破裂可能使患者获得长时间生存。     

Hepatic resection for metastatic colon and rectal cancer. An evaluation of preoperative and postoperative factors.

Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate.     

Stapler Hepatectomy is a Safe Dissection Technique: Analysis of 300 Patients

Background In many surgical procedures, stapling devices have been introduced for safety and to reduce the overall operative time. Their use for transection of hepatic parenchyma is not well established. Thus, the feasibility of stapler hepatectomy and a risk analysis of surgical morbidity based on intraoperative data have been prospectively assessed on a routine clinical basis. Materials and Methods From October 1, 2001, to January 31, 2005, a total of 416 patients underwent liver resection in our department. During this period endo GIA vascular staplers were used for parenchymal transection in 300 cases of primary (22%) and metastatic (57%) liver cancer, benign diseases (adenoma, focal nodular hyperplasia [FNH], cysts) (14%), gallbladder carcinoma (2%), and other tumors (5%). There were 193 (64%) major resections (i.e., removal of three segments or more) and 107 minor hepatic resections. Additional extrahepatic resections were performed in 44 (15%) patients. Results Median values for operative time and intraoperative hemorrhage were 210 minutes and 700 ml, respectively. Further, transfusion of RBC and FFP was needed in 17% and 11% of patients, respectively. A postoperative ICU stay for >2 days was required in 18% of patients. The median postoperative hospital stay was 10 days (IQR 8–14 days). The most frequent surgical complications were bile leak (8%), wound infection (3%), and pneumothorax (2%). In 7% of cases after stapler hepatectomy a relaparotomy was necessary. Treated medical complications were pleural effusion (7%), renal insufficiency (5%), and cardiac insufficiency (3%). Risk assessment revealed that both operative time and indication for resection had significant impact on surgical morbidity. Mortality (4%) and morbidity (33%) were comparable to other high-volume centers performing conventional liver resection techniques. Conclusion In conclusion, stapler hepatectomy can be used in a routine clinical setting with a low incidence of surgical complications.     

Complete hepatic resection of metastases from leiohyosarcoma prolongs survival

Although liver resection has been shown to prolong survival in selected patients with metastases from colorectal cancer, the benefit for other metastatic tumors is unproved. To determine whether hepatic resection has a role in the management of metastatic leiomyosarcoma, medical records from 11 consecutive patients who underwent resection of isolated metastases from leiomyosarcoma between 1984 and 1995 were reviewed. All liver resections were for leiomyosarcomas originating in the viscera (n = 6) or retroperitoneum (n = 5). The average disease-free interval was 16 months. Five of 11 primary tumors were classified as low grade, whereas six were high grade. Hepatic resections included lobectomy or extended lobectomy (n = 4), segmentectomy and/or wedge resection (n = 5), and complex resection (n = 2). There were no operative deaths. Median survival of all patients after liver resection was 39 months. Patients who underwent complete resection of hepatic metastases (n = 6) had a significantly longer survival than those who had incomplete resections (n = 5) (P = 0.03, log-rank test). Furthermore, five of six patients who underwent complete resection are alive after hepatectomy with a median follow-up of 53 months. Therefore, in selected patients with isolated liver metastases from visceral and retroperitoneal leiomyosarcomas, complete resection of hepatic metastases results in prolonged survival. Presented in part at the Fiftieth Annual Cancer Symposium of the Society of Surgical Oncology, Chicago, Ill., March 20–23, 1997.     

Abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases

OBJECTIVE: The aim of this study was to determine whether abdominal drainage is beneficial after elective hepatic resection in patients with underlying chronic liver diseases. SUMMARY BACKGROUND DATA: Traditionally, in patients with chronic liver diseases, an abdominal drainage catheter is routinely inserted after hepatic resection to drain ascitic fluid and to detect postoperative hemorrhage and bile leakage. However, the benefits of this surgical practice have not been evaluated prospectively. PATIENTS AND METHODS: Between January 1999 and March 2002, 104 patients who had underlying chronic liver diseases were prospectively randomized to have either closed suction abdominal drainage (drainage group, n = 52) or no drainage (nondrainage group, n = 52) after elective hepatic resection. The operative outcomes of the 2 groups of patients were compared. RESULTS: Fifty-seven (55%) patients had major hepatic resection with resection of 3 Coiunaud's segments or more. Sixty-nine (66%) patients had liver cirrhosis and 35 (34%) had chronic hepatitis. Demographic, surgical, and pathologic details were similar between both groups. The primary indication for hepatic resection was hepatocellular carcinoma (n = 100, 96%). There was no difference in hospital mortality between the 2 groups of patients (drainage group, 6% vs. nondrainage group, 2%; P = 0.618). However, there was a significantly higher overall operative morbidity in the drainage group (73% vs. 38%, P < 0.001). This was related to a significantly higher incidence of wound complications in the drainage group compared with the nondrainage group (62% vs. 21%, P < 0.001). In addition, a trend toward a higher incidence of septic complications in the drainage group was observed (33% vs. 17%, P = 0.07). The mean (+/- standard error of mean) postoperative hospital stay of the drainage group was 19.0 +/- 2.2 days, which was significantly longer than that of the nondrainage group (12.5 +/- 1.1 days, P = 0.005). With a median follow-up of 15 months, none of the 51 patients with hepatocellular carcinoma in the drainage group developed metastasis at the drain sites. On multivariate analysis, abdominal drainage, underlying liver cirrhosis, major hepatic resection, and intraoperative blood loss of >1.5L were independent and significant factors associated with postoperative morbidity. CONCLUSION: Routine abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases.     

选择性左肝动脉结扎在腹腔镜肝切除术中的应用

目的:探讨选择性左肝动脉结扎用于腹腔镜肝切除术的可行性。方法:回顾分析2008年10月至2009年7月我院为19例左肝内外胆管结石、血管瘤患者行腹腔镜肝切除术中行选择性左肝动脉结扎的临床资料。结果:19例手术均获成功,术中出血20~200ml,平均80ml,手术时间90~420min,平均240min,术后住院4~9d,平均5.9d,术后病理示无恶变,无肝脏衰竭、出血、胆漏及膈下脓肿等并发症发生。结论:腹腔镜左肝切除术中选择性左肝动脉结扎术能减少术中出血,安全可行。     

Hepatic resection in 128 patients: a 24-year experience

The records of 128 patients who underwent hepatic resection at the Cleveland Clinic Foundation between 1960 and 1984 were reviewed. Sixty patients (47%) had major resections and 68 patients (53%) had wedge or segmental resections. One hundred five patients had malignant tumors; 29 were primary liver tumors and 78 were metastatic (61 from a colorectal primary). Twenty-three patients had benign hepatic tumors. The overall operative mortality rate was 7% (7.6% for malignant tumors and 4.3% for benign lesions). Survival rate after resection of a hepatocellular carcinoma (22 patients) at 3, 5, and 10 years was 50%, 33%, and 12%. Survival rate after resection of colorectal metastases at 3, 5, and 10 years was 44%, 28%, and 21%. Overall survival was better for patients who were less than 56 years of age (p = 0.003) and for patients with no tumor at the line of resection (p less than 0.001). In patients with colorectal metastases, survival after wedge or segmental resection was better than after a major anatomic resection (p = 0.004). In these patients, the number or size of the metastases, the time interval between resection of the primary tumor and of the hepatic metastases, and/or the presence of mesenteric lymph node metastases were not significant. Most patients with primary malignant tumors require major hepatic resection. Patients with benign tumors and metastatic colorectal carcinomas require resection only to the extent that the tumor is sufficiently encompassed.     

Hepatic resection for incidentaloma

The study goal was to review a single-center experience in hepatic resection for patients who presented with incidental liver tumors. With recent advances in diagnostic imaging techniques, incidental finding of liver tumors, or "incidentalomas," is increasing in asymptomatic and healthy individuals. However, little information is available in the literature regarding the underlying pathology and operative outcomes after hepatic resection. Between January 1989 and December 2002, 1011 patients underwent hepatic resection for liver tumors; of these patients, 107 (11%) were asymptomatic individuals who presented with incidentalomas. Incidentalomas were first detected on percutaneous ultrasonography (n = 83), computed tomography (n = 23), or magnetic resonance imaging (n = 1). Fifteen (14%) patients had preoperative aspiration for cytology or biopsy for histology, and the results correlated with the final pathology in 12 patients. Fifty-six (52%) patients underwent major hepatic resection with resection of three or more Coiunaud’s segments. Median postoperative hospital stay was 8 days (range, 3–66 days). The operative mortality rate was 1%, and the operative morbidity rate was 21%. Histologic examination of the resected specimen revealed malignant liver tumors in 62 (58%) patients, including hepatocellular carcinoma (HCC) (n = 48), cholangiocarcinoma (n = 8), lymphoma (n = 2), cystadenocarcinoma (n = 2), carcinoid tumor (n = 1), and malignant fibrous histiocytoma (n = 1). Benign pathologies were found in 45 (42%) patients, including focal nodular hyperplasia (n = 17), hemangioma (n = 12), angiomyolipoma (n = 5), cirrhotic regenerative nodule (n = 4), hepatic adenoma (n = 2), and others (n = 5). On multivariate analysis, male sex, age of greater than 50 years, and tumor size of greater than 4 cm were the independent predictive factors for malignant diseases. On retrospective analysis, 48 patients with HCC who presented with incidentalomas had signi.cantly better survival outcomes after hepatic resection than did 646 patients with HCC who presented otherwise during the same study period. Hepatic resection for patients with incidentalomas is associated with a low operative mortality and acceptable morbidity. The diagnosis of malignant disease, especially HCC, should be considered in male patients older than 50 years who present with large hepatic lesions. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, LA, May 15–19, 2004 (poster of distinction). Supported by the Sun C.Y. Research Foundation for Hepatobiliary and Pancreatic Surgery of the University of Hong Kong.