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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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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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??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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??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.     

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目的 提高局部进展期胰腺癌的根治性切除率并改善其预后。方法 对1997～2003年26例单纯侵犯门静脉(PV)和(或)肠系膜上静脉(SMV)的局部进展期胰腺癌施行受侵PV及SMV在内的整块联合切除术。结果 16例(61．5％)获根治性切除，10例获姑息切除。围手术期并发症8例(30．7％)，死亡1例(3．8％)。获根治性切除的16例中，术后1、3、5年生存率分别是68．8％(n=11)、26．7％(n=4)和6．3％(n=1)，但姑息切除者术后平均生存仅5．6个月。结论 对于局部进展期胰腺癌，选择合适的病例施行受侵PV及SMV联合切除是安全可行的，获根治性切除者预后显著改善。     

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脾脏切除术是一种开展比较广泛的手术，它用于治疗脾脏疾病至今已有400余年的历史；部分脾切除术用于治疗脾脏外伤亦有200余年历史。如何实施规范的全脾切除及部分脾切除是保障手术成功、减少术后并发症的关键。本文介绍一下两种术式规范操作技术要点。     

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??Pancreaticoduodenectomy combined with vascular resection of portal vein and/or superior mesenteric vein: A report of 4 patients OUYANG Liu, YAO Jian, JIN Gang, et al. Department of Pancreatic Surgery, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai 200433, China
Corresponding author: HU Xian-gui, E-mail: xianguihu@yahoo.com.cn
Abstract Objective To discuss the operative strategy of pancreaticoduodenectomy combined with vascular resection of portal vein (PV) and/or superior mesenteric vein (SMV). Methods The clinical data of 4 patients with pancreatic neck tumor encasing the PV and/or SMV received pancreaticoduodenectomy (PD) combined with vascular resection between December 1, 2015 and January 15, 2016 at the Department of Pancreatic Surgery of Changhai Hospital Affiliated to the Second Military Medical University were analyzed retrospectively. The patients received pylorus-preserving pancreaticoduodenectomy??PPPD??combined with PV resection??pancreaticoduodenectomy??PD?? with prior PV-SMV shunting??PD combined with SMV resection and PPPD combined with SMV resection, respectively. Results The duration of surgery ranged from 206 to 263 min??with an average of 242 min; the length of the resected vein ranged from 20 to 35 mm, with an average of 27 mm; the duration of vascular occlusion ranged from 20 to 25 min??with an average of 22 min; artificial blood vessel was not used in all of patients; intraoperative blood loss ranged from 700 to 1700 mL??with an average of 1025mL??and intraoperative blood transfusion ranged from 800 to 1800 mL??with an average of 1100 mL. The pathology diagnosis of the 4 patients was pancreatic ductal adenocarcinoma, and the maximal diameter of the tumor ranged from 2.5 to 5.0 cm, with an average of 3.9cm. One of them had delayed gastric emptying, and the gastric tube was removed at postoperative day 15. One of them had bilioenteric anastomosis edema with partial obstruction and pancreatic fistula grade A, and all of them recovered well. The total hospitalization cost ranged from 46 694.3 to 146 991.0 yuan, with an average of 80 214.3 yuan. The postoperative length of hospital stay ranged from 10 to 27 days??with an average of 20 days. All the patients discharged home smoothly. Conclusion The preoperative and intraoperative evaluation is very important for PD combined with vascular resection of PV and/or SMV. It is very important to dissect the invaded blood vessels before resection to insure the blood vessels can be reconstructed safely. It is safe and effective to resect and reconstruct the PV and/or SMV in situ before the resection of the tumor.     

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??Applications and values of combined excision of extra-hepatic bile duct in curative resection of gallbladder carcinoma YIN Xiao-yu. Department of Pancreatobiliary Surgery, the First Affiliated Hospital,Sun Yat-Sen University, Guangzhou 510080,China
Abstract Curative resection remains as the only hope of cure for gallbladder carcinoma. For gallbladder carcinoma invading the extra-hepatic bile duct, combined excision of extra-hepatic bile duct should be undertaken for achievement of curative resection of tumor. However, for gallbladder carcinoma without invasion of extra-hepatic bile duct, there exist controversies about applications and values of combined excision of extra-hepatic bile duct. Combined excision of extra-hepatic bile duct is helpful in clearance of regional lymph nodes, and clearance of some potentially hidden cancer cells. However, it increases the operative risk and postoperative complication incidence. Furthermore, its survival benefits have not been well-documented.     

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自1935年Whipple报告了胰十二指肠切除术(PD)以来，该术式已成为治疗胰头、壶腹周围恶性肿瘤及少数良性疾病的标准术式。PD切除脏器多，手术创伤大，并发症多，至今仍可称为腹部外科最复杂的手术之一。60余年中，外科医生对其进行了许多的改进，减少了并发症的发生，使总体手术死亡率降至5％以下。     

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目的探讨外翻式颈动脉内膜切除术在预防脑缺血性“中风”的临床应用价值方法总结1999～2003年42例接受这一手术的病人的临床资料，分析其动脉阻断时间及术后并发症的发生情况结果手术均获成功，颈动脉平均阻断时间为16min，明显低于常规术式，术后并发症较少，结论外翻式颈动脉内膜切除术具有阻断时间短，再狭窄率低等优点，但对操作者的熟练程度及病人局部的情况具备较高要求。     

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现代影像技术的临床普及应用 ,大大提高了肝脏外科疾病的诊断准确率、手术切除率和术后疗效。术前对肝脏影像仔细地分析 ,结合临床资料和经验 ,可以帮助外科医生更准确、合理地选择最佳治疗方案 ,更安全地进行手术治疗。1　影像学检查对肝肿瘤治疗方式选择的价值1 1　影像学帮助选择最合适的治疗方案　手术切除是肝脏恶性肿瘤可能获得治愈的首选治疗方法。临床经验告诉我们 ,不适合手术切除的病例 ,勉强施行了肝切除术 ,反而会加速病情恶化 ,缩短病人生存期。在对病人全身常规检查的前提下 ,影像学表现即是决定最佳治疗方式的关键。术前常规…