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??Some questions of diagnosis and treatment in gallbladder carcinoma QUAN Zhi-wei. Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
Abstract Gallbladder carcinoma has been considered the malignancy with dismal prognosis due to its propensity for early dissemination and delayed diagnosis at an advanced tumor stage, and the improved survival could be obtained by the early and precise diagnosis. Surgical radical resection with tumor-free margins provides the only method for long-term survival. Scientific tumor staging system could not only indicate the tumor stage but also do favor for the choice of operation and prediction of prognosis. Unnecessary laparotomy could be avoided by routinely staging laparoscopy. More attention should be paid to the radical resection of incidental gallbladder carcinoma and comprehensive treatment of advanced gallbladder carcinoma. With the development of clinical and basic research of gallbladder carcinoma, comprehensive and standardized treatment, as well as the establishment of professional team on biliary tract carcinoma surgery should also be emphasized.     

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先天性胆管扩张症(congenital biliary dilatation,CBD)常并发结石、胆管炎,具有较高的癌变率,因此需要特别关注。目前,对CBD的病因仍未明确,涉及到胆胰结合部畸形、感染、神经、基因及遗传等因素。CBD的临床分型在Todani分型的基础上仍有不断的变更和补充。治疗的关键是完全切除囊肿,尤其是Ⅰ型和Ⅳ型的囊肿,但对ⅣA型的治疗仍有不同意见。在手术治疗中,有时仍会遇到各种各样需要解决的困难。     

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腹膜后肿瘤 (除了恶性淋巴瘤 )对放疗和化疗不甚敏感 ,手术切除是其最主要的治疗手段。但对那些肿瘤巨大、血供丰富、基底广 ,与重要脏器或重要血管紧密粘连 ,或多次手术后复发的病例 ,手术颇为复杂 ,运用传统的手术方法 ,难度高 ,易发生术中大出血或邻近器官副损伤。　　近年来 ,我们运用刮吸解剖法成功地完成了一系列高难度的手术 ,如肝尾叶切除、高位胆管损伤的修复等。现将典型病例的经验介绍如下。1　病例介绍　　例 1.男性 ,5 6岁。因反复发作高血压 ,ＣＴ和磁共振成像 (ＭＲＩ)示肝后下腔静脉后巨大占位病变。运用彭氏多功能手术解剖…     

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??The issues and use of anticoagulation in the perioperative period CHEN Zhong, YANG Yao-guo. Department of Vascular Surgery, Beijing Anzhen Hospital , Capital Medical University, Beijing 100029, China
Corresponding author: CHEN Zhong, E-mail: chenzhong8658@vip.sina.com
Abstract It is an important issue of prevention of thrombosis in the perioperative period, which could make a successful surgery and smooth recovery. Anticoagulant therapy is a very important methods, but different surgery requires different anticoagulation methods. It needs to know all kinds of surgery on the anticoagulant strength requirements. The use of anticoagulant drugs needs according to the patient's age,general condition, disease status, the results of monitoring indicators, type of surgery and different times of operation,which strives to achieve a reasonable individualized anticoagulant therapy.     

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在复杂手术结束前 ,多需放置空肠导管进行术后治疗[1] 。我们在总结前人经验的基础上 ,研制成一种可经鼻自行进入空肠的导管—液囊空肠导管。现介绍如下。1　液囊空肠导管结构与用法导管长 12 0 0～ 145 0ｍｍ ,用标有刻度的医用硅胶管制成 ,外径 3 0ｍｍ ,内径 1 8～ 2 0ｍｍ。利用特制的胃管作载体 ,两者合而为一组成。用法 :同下胃管一样 ,经鼻孔插入至胃腔。从液囊开口端注入 2～ 3ｍＬ液体 ,使导管前端膨胀成为球状的液囊 ,从嵌入胃管的槽中弹出 ,胃管与空肠导管自行分离 (图 1)。导管进入空肠的方法根据病人情况决定 :( 1)胃肠动力正…     

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??Matters of concern about surgical treatment of thyroid nodules WU Yi. Department of Head and Neck Surgery??Fudan Universiry Cancer Center??Fudan Universiry Thyroid Tumor Research Centre??Shanghai 200032, China
Abstract Thyroid nodule is a quite common disease. The indication for its surgery should be measured discreetly??and the patients should not be overly inspected or treated. To avoid unnecessary the second operation??the surgeons should choose a proper surgical extent and post operational substitutional thyroxin dosage. For the retrosternal goiter??appropriate surgical route should be weighed. Last but not least??since the endoscopic surgery has been applied in thyroid nodules more and more frequently??a unified standard should be established to restrict it.     

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??Some concerns with surgical treatment of secondary liver cancer JIANG Hong-chi. Center of Hepatic-splenic Surgery of Heilongjiang Province, Digestive Disease Hospital of 1st Hospital, Harbin Medical University, Harbin 150001??China
Abstract Metastatic liver cancer has not yet been considered as an hopeless one at the last stage of cancer now. Some of them have potential possibility to undergo hepatic resection and get ideal postoperative outcomes and even five years survival. For the sake of long term survival, multidisciplinary treatment should be carried out. However hepatic resection is hopefully first therapy choice. As indication for liver resection and the number of the patients undergoing liver resection for metastatic liver cancer successfully and fantastically expand, objective measures to assess the risk of preoperative morbidity and mortality are needed in order to make surgical procedure dramatically in effectiveness and safety because postoperative morbidity can lead to prolonged hospital stays, increased need for resource expenditure, great medical costs, move over possibly even worse long-term survival.     

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??Anterior plane of rectal mobilization in total mosorectal excision LIN Mou-bin*, YIN Lu, CHEN Wei-guo, et al. *Department of Surgery, Ruijin Hospital, Medical School of Shanghai Jiaotong University , Shanghai 200025,China. Corresponding author: Yin Lu, E-mail:yindalu@yahoo.com.cn Abstract Objective To clarify the appropriate anterior plane in total mesorectal excision. Methods 24 pelvises harvested from embalmed cadavers were studied by dissection in Shanghai Jiaotong University School of Medicine. Results The appearance of Denonvilliers’ fascia varies considerably. Denonvilliers’ fascia was more closely applied to the seminal vesicles than the rectum. Denonvilliers’ fascia ends at the pelvic plexus, and in some cases, the communicating branches of bilateral pelvic plexuses run in front of Denonvilliers’ fascia. Conclusion In circumstances in which the anterior circumferential margin is not threatened, the appropriate anterior plane is behind Denonvilliers’ fascia for reliable preservation of autonomic nerves.     

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目的 探讨累及肠系膜上静脉（SMV）的胰腺钩突部癌手术切除时,联合SMV、门静脉（PV）切除的手术方法、操作要点,以提高切除率。方法 总结1990年1月至2000年6月手术切除累及SMV的胰腺钩突部癌8例,合并PV、SMV切除、重建的经验。其中5例切除静脉干长度为2．0－4．2cm,直接对端吻合,3例行受浸润血管侧壁切除修补术。结果 1例术后3天肝功能衰竭死亡;1例未行脾静脉与SVM吻合者,术后出现乳糜样腹水,经治疗40天痊愈,术后存活20个月;5例术后生存13－29个月;1例术后已3个月,无癌肿复发。结论 胰腺钩突部癌的门静脉浸润不是根治手术禁忌证;联合PV、SMV切除可提高根治手术切除率。     

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??Total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy YANG Wei-ping, SHAO Tang-lei,CHEN Wei-gou, et al.Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China. Corresponding author:SHAO Tang-lei,E-mail:shaotl_03@hotmail.com Abstract Objective To evaluate the safety of total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy. Methods Thirty-four cases of subtotal bilateral thyroidectomy because of benign thyroid disease were performed total or near-total bilateral thyroidectomy because of the recurrence of nodules between June 1995 and June 2008 at Ruijin Hospital of Shanghai Jiaotong University School of Medicine. The clinical data of all the cases were analyzed. Results Partial fibers of right recurrent laryngeal nerves were cut at their entrance to the larynges in 2 cases.But the mobility of the vocal cord return to normal and the hoarseness were disappeared 6 months after operation. Hypocalcaemia was occurred in 6 cases.The hypocalcaemia disappeared by calcium supplementing through oral or/and intravenously in 5 of 6 cases 2 weeks after operation. But the righr superior parathyroid was cut inadvertently in one thyroid papillary cancer case, and the case underwent parathyroid autotransplantation. Hypocalcaemia was alleviated gradually 1 year after operation in the case. The levels of calcaemia and PTH were still under the normal until 14 months after operation. Conclusion If choosing the right way to expose the remnant gland and being familiar with the anatomical position of bilateral recurrent laryngeal nerves and parathyroids, it is safety to perform total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy.     

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目的　比较吻合器痔切除术和常规痔切除术后肛门温度觉的差异。方法　利用自制的肛门温度觉测量仪测量经肛门镜下吻合器痔切除术 (PPH)和常规痔切除手术前后肛门可感觉的最小温度变化值 (minimumde tectabletemperaturechange ,MDTC)的变化。术前、术后肛门镜检查痔核大小及出血情况。切除标本病理检查。结果　PPH手术后 10例病人痔核明显缩小 ,出血停止。病理检查标本中未见有肌肉组织及痔组织。肛管的MDTC值均较术前降低 ,肛管下部和中部MDTC值下降明显 (P <0 0 5 ) ,肛管上部最显著 (P <0 0 1)。常规痔切除手术后 10例病人的MDTC值均较术前增高 ,肛管上部、中部和下部MDTC值均升高明显。痔核消失 ,出血停止。病理检查标本中无肌肉组织 ,但有痔组织。结论　PPH手术可保护肛垫 ,使痔病人术后肛门感觉改善 ,控便功能加强。     

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当结直肠癌确诊并发现伴有同时性肝转移时,原发灶和转移灶手术时机的选择尚存争议。学术界传统观点是首先切除结直肠癌原发灶,然后再分期切除肝转移灶,但是近年来原发灶和转移灶同期切除的理念得到迅速发展,在一些特殊病例,甚至还会选择先切除肝转移灶,再切除原发灶的"逆向策略"。因此,当前结直肠癌伴同时性肝转移的外科治疗仍缺乏统一的规范,尚需高级别循证医学证据来支持。对于每例结直肠癌肝转移病人,需经过多学科查房讨论,制定个体化的综合治疗方案。     

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??Some noteworthy issues about surgery for colon cancer WAN De-sen. Sun Yat-sen University Cancer Center, Guangzhou 510080??China
Abstract Based on the fact that surgical outcome for colon cancer is not promising due to a high recurrence or metastasis rate, and that acute bowel obstruction is often presented in patients with colon cancer, a surgical resection for colon cancer requires strictly stick to the tumor-free principle for cancer surgery to avoid iatrogenic tumor spread during operation, as well as the common principles of general surgery. Some noteworthy issues about colectomy for cancer, including resection area, detection and resection of liver metastasis, prevention and management of peritoneal carcinomatosis, resection and anastomosis for obstructing bowel, and intra-operative chemotherapy should be emphasized on.     

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目前,腹腔镜下食管裂孔疝修补、胃底折叠术治疗食管裂孔疝及胃食管反流病取得很好的疗效,有共识也有争议。食管裂孔疝的诊治过程中应关注食管裂孔疝的诊断、手术方法选择、手术适应证选择等问题,不断总结临床经验,降低并发症发生率,以促进腹腔镜食管裂孔疝诊治的进一步规范化,取得更好的治疗效果。     

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??Analysis of the effectiveness of ultrasound-guided thermal ablation in initial treatment of primary thyroid tumor: A report of two cases and retrospective analysis of the previous literature MA Ben*??WANG Yu??JI Qing-hai??et al. *Department of Head and Neck Surgery??Fudan University Shanghai Cancer Center??Shanghai 200032??China
Corresponding author??WANG Yu??E-mail??neck130@hotmail.com
Abstract Objectives To investigate the effectiveness of ultrasound-guided thermal ablation in treatment of primary thyroid cancer. Methods We retrospectively analyzed two cases with suspicious thyroid cancer by ultrasound-guided fine needle aspiration biopsy who accepted surgery after undergoing thermal ablation at Fudan University Shanghai Cancer Center in October and November 2015??and performed a pooled analysis on the two cases and the other similar cases selected from the previous studies. Results The primary tumors of the two cases after treatment of thermal ablation were confirmed to be remnant by surgery??and respectively PTC and MTC by histological pathology. Conclusion Our findings suggest that there is not enough evidence for the effectiveness of the thermal ablation procedure in treatment of primary thyroid cancer.