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??Clinical study of enhanced recovery after surgery for pancreatoduodenectomy LI Min??WANG Xin-bo??WANG Si-zhen??et al. Department of General Surgery, Research Institute of General Surgery of PLA??Nanjing General Hospital of Nanjing Military Command of PLA??Nanjing 210002??China
Corresponding author??WANG Xin-bo??E-mail??wxinbo2008@163.com
Abstract Objective To study the safety??feasibility and efficacy of enhanced recovery after surgery (ERAS) for pancreatoduodenectomy (PD) patients. Methods The clinical data of the 281 patients who underwent PD between January 2008 and September 2014 in Nanjing General Hospital of Nanjing Military Command of PLA were analyzed retrospectively. The patients were divided into ERAS (90 patients, treated with ERAS protocol) and conventional groups (191 patients, treated with conventional program) according to different treatments. The intraoperative and postoperative data were compared. Results There was no significant difference in operation time and operative blood loss between two groups (P>0.05). The days of first flatus, first stool and intravenous, length of stay (LOS) and LOS after operation in ERAS group were shorter than those in conventional group (P<0.05). Compared with conventional group, the patients in ERAS group had earlier food intake and drain removal (P<0.05). There was no significant difference in the rates of overall complication, special complication, relaparotomy, readmission and mortality between two groups (P>0.05). Four patients in ERAS group had readmission because of pancreatic fistula grade C (1 patient), delayed gastric emptying (2 patients) and wound infection (1 patient). Meanwhile, the number of readmission in conventional group was five (1 pancreatic fistula grade B, 2 delayed gastric emptying, 1 wound infection, 1 small bowel obstruction). One patient who had pancreatic fistula grade C was treated with percutaneous puncture draining guided by CT. The other readmitted patients were all cured with conservative treatment. Conclusion The ERAS pathway is feasible and safe for PD patients yielding a shorter postoperative LOS. ERAS pathway doesn’t increase morbidity, mortality and the readmission rate.     

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??Statistical tests for surgical clinical research ZHANG Bo-heng.Liver Cancer Institute??Zhongshan Hospital, Fudan University,Shanghai200032??China Abstract A set of questions should be clarified when selecting statistical tests in clinical research, such as aim of study, study design, type of data, distribution of data, and sample size. Misuse of statistical tests will lead to poor quality of research, and even to opposite results. Common statistical tests and experimental designs for surgical clinical research were briefly introduced in this paper. It is followed by demonstrations of research design, features of dependant and independent variables are important to consider when choosing a statistical test. The aim of this paper focuses on how to select the appropriate statistical test for a particular clinical question.     

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??Causes to leading to bias and common bias in clinical researches of surgery LIU Xu-bao.Department of General Surgery, Huaxi Hospital, Sichuan University,Chengdu610041,China Abstract Bias is leading causes to decrease reliability of surgical research. Philosophy of Surgical doctors and clinical character of surgery may be correlated with defect in research design, which is cause of bias. So to avoid bias in research, a series of interventions should be applied, such as to select relatively strict target objectives, to use scientific proposal of design, to adopt reasonable control, and to apply blind observation and objective detections. Conclusion: bias is important factor to decrease research quality of surgery. Only way to abate or avoid bias is use scientific proposal of design in researches.     

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??Early postoperative enteral nutrition compared with parenteral nutrition in patients with liver cirrhosis after hepatectomy LAI Jia-ming*, LIANG Li-jian,HUA Yu-peng, et al. *Department of Hepatobiliar Surgery, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China Corresponding author: LIANG Li-jian, E-mail??LiangLJ@medmail.com.cn Abstract Objective To evaluate the impact of early enteral nutrition over parenteral nutrition in patients with liver cirrhosis after hepatectomy. Methods Thrity -five patients with liver cirrhosis undergoing liver resection were study: EEN group, received early enteral nutrition (n=16); PN group, received parenteral nutrition (n=19). The two groups were received nutritional formulas with isocaloric and isonitrogenous 24 hours after operation, and they were ended at postoperative day 7. The general conditions, liver function tests, clinic complications, clinic nutritional variables on three time point that included preoperative phase, postoperative day 1 (POD 1) and postoperative day 8 (POD8) were observed respectively. Results No significant difference was found in length of hospital stay, liver function,and clinic nutritional variables between the two groups. In the EEN group, the serum prealbumin and albumin level neared the preoperative level on POD8. Nutritional complication rate of EEN group was increased signiflcanly ??but mild than the PN group respectively .The time of gut function recover was shorter than PN group.The costs of nutritional drugs showed a signiflcant decrease in the EEN group. Conclusion Early enteral nutrition is safe, rational and effective in patients with liver cirrhosis after hepatectomy.     

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??The study on treatment and prognosis of local recurrent rectal cancer after anterior resection CHEN Yue, LIU Fang, MENG Qing-kai??et al.Department of Colorectal Surgery, Cancer Hospital of China Medical University; Liaoning Cancer Hospital&Institute, Shenyang 110042, China
Corresponding author??LIU Fang, E-mail:liufang666555@sina.com; MENG Qing-kai, E-mail:mqk1454@sina.com
Abstract Objective To investigate the precise treatment of local recurrenct rectal cancer after anterior resection. Methods The clinical data of 178 patients with local recurrent rectal cancer were retrospectively analyzed and correlations between different treatments and prognosis of patients were analyzed retrospectively. Results Of the 178 patients??the overall survival time was??32.8±1.2??months. The prognosis of patients performed radical resection was better than those performed palliative resection [??40.8±1.4??months vs.??27.5±1.6??months]. There was no significant difference in the survival time between the patients performed radical resection and those performed radical resection after radiotherapy [??41.3±1.5??months vs.??38.6±2.6??months]. There were also no significant differences in the survival time among the patients performed palliative resection?? palliative resection after radiotherapy and colostomy [??27.8±1.6??months vs.??25.8±4.5??months vs.??23.9±4.9??months]. The prognosis of patients performed palliative resection was better than those performed radiotherapy and/or chemotherapy[??27.8±1.6??months vs.??16.4±2.2??months]. However there was no significant difference between palliative resection after radiotherapy and chemotherapy and/or radiotherapy. Conclusion The recurrence of rectal cancer should be treated with radical surgery. If the cancer could not be removed initially?? radiotherapy and chemotherapy should be performed before the radical surgery. Palliative resection should be carefully chosen?? especially for patients who still could not achieve radical resection after radiotherapy, which suggests that the biological behavior of the tumor is poor?? and symptomatic treatment should be chosen.     

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??Clinical outcome between Jinling procedure and total colectomy with ileorectal side-to-side anastomosis for refractory mixed constipation: A prospective controlled trial FENG Xiao-bo??JIANG Jun??DING Wei-wei??et al. Research Institute of General Surgery??Nanjing General Hospital of Nanjing Military Command??Affiliated Jinling Hospital of Nanjing University School of Medicine, Nanjing 210002??China
Corresponding author??JIANG Jun??E-mail??jiangjun6987@163.com
Abstract Objective To compare the morbidity and efficacy between Jinling procedure and total colectomy with ileorectal side-to-side anastomosis in the treatment of refractory mixed constipation. Methods A total of 156 cases of refractory mixed constipation admitted between February 2009 and December 2010 in Nanjing General Hospital of Nanjing Military Command were analyzed. Group A was performed Jinling procedure. Group B was performed laparoscopic assisted total colectomy with ileorectal side-to-side anastomosis. Results Primary outcomes included operation time, first flatus time, Wexner constipation score, gastrointestinal quality of life index (GIQLI), stool frequency, incidence of diarrhea, diarrhea severity, satisfaction, contentment, serum electrolyte level and surgical complications were observed after operation 1 months, 3 months, 6 months, 12 months until 24 months. Postoperative Wexner constipation score and GIQLI both in two Groups were improved significantly compared with preoperative data (P<0.05). Postoperative stool frequency??incidence of diarrhea??contentment??Wexner constipation score??GIQLI and progress of recovery of Group A were superior to Group B (P<0.05). There was no significant difference in postoperative surgical complication between 2 groups (P??0.05). The incidence of adhesive ileus in Group B was higher than Group A significantly. Conclusion Jinling procedure is superior to total colectomy with ileorectal side-to-side anastomosis in clinical outcome for refractory mixed constipation. Patients can get better quality of life and satisfaction besides relieving the constipation.     

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??Laparoscopic-assisted associating liver partition and portal vein ligation for staged hepatectomy for primary liver cancer CAO Jun??ZHANG Hong-wei??ZHANG Lei??et al. Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
Corresponding author??CHEN Ya-jin, E-mail:cyj0509@126.com
Abstract Objective Our aim was to investigate the feasibility of laparoscopic “Associating liver partition and portal vein ligation for staged hepatectomy” (ALPPS) in the treatment of advanced hepatocellular carcinoma. We retrospectively analyzed the clinical data of one patient with a huge right-lobe hepatocellular carcinoma lesion and multiple right-lobe metastases who underwent laparoscopic ALPPS in the Sun Yat-sen Memorial Hospital in August 2013. Methods The first-stage surgery was laparoscopic ligation of the right branch of the portal vein and liver partition. Seven days later, open right hepatic trisegmentectomy was performed as the second-stage surgery. The perioperative indicators were then analyzed. Results The operative time was 205 minutes for the first-stage surgery and 160 minutes for the second-stage surgery. Liver function returned to normal six days after the first-stage surgery and left lateral lobe volume increased 115.9% compared to the preoperative volume. The second-stage open right hepatic trisegmentectomy was then performed safely and liver function returned to normal eight days after the second-stage surgery. Conclusion Laparoscopic ALPPS is an excellent choice for patients with advanced hepatocellular carcinoma and insufficient volume of the future liver remnant.     

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??Totally robotic surgery for rectal cancer with transanal specimen extraction ZHANG Xue-feng, LV Chi, ZHANG Cheng, et al. Department of General Surgery, General Hospital of Shenyang Military Region, Shenyang 110015, China
Corresponding author: LI Jin, E-mail: lvlinger92@gmail.com
Abstract Objective To investigate the clinical experience of transanal specimen extraction with robot-sewn anastomosis technique. Methods The clinical data of 16 cases performed rectal cancer resection by the da Vinci robotic system with transanal specimen extraction and robot-sewn anastomosis technique between July 2012 and December 2012 in General Hospital of Shenyang Military Region were analyzed retrospectively. Results There were 9 males and 7 females with age 46-84 years old??and BMI 18.8-28.8 kg/m2. All the cases??13 cases of rectal cancer, 2 cases of rectal villous tubular adenomas, 1 case of rectal carcinoid tumors?? were performed robotic surgery successfully without intraoperative conversion??The operative time was 160-610 min [mean (220.4±24.5)min]. The blood loss was below 50mL. The time to first flatus was 18-74 hours [mean (27.3±7.5)hours] postoperatively. The postoperative hospital stay was 5-10 days [mean (6.2±2.1)days]. The number of lymph node harvested from the surgical specimen was 2-39 (mean 18.2±7.6)??TNM stage: 2 cases of stage??, 7 cases of stage II, 4 cases of stage ??. All the resection margins were negative??There was no local surgical complication. Conclusion Totally robotic surgery for rectal cancer with transanal specimen extraction is safe and feasible.     

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??Precise right hemihepatectomy for the treatment of hepatocellular carcinoma guided by fusion ICG fluorescence imaging: A clinical analysis of 11 patients YAO Shun-yu??JIA Wei-dong??WANG Run-dong??et al. Department of Hepatic Surgery??Anhui Provincial Hospital Affiliated to Anhui Medical University; Key Laboratory of Hepatopancreatobiliary Surgery of Anhui Province??Hefei 230001??China
Corresponding author??JIA Wei-dong??E-mail??jwd1968@sina.com
Abstract Objective To evaluate the clinical value of fusion indocyanine green (ICG) fluorescence imaging in precise right hemihepatectomy for the treatment of hepatocellular carcinoma??HCC??. Methods The clinical data of 11 patients with HCC who underwent precise right hemihepatectomy guided by fusion ICG fluorescence imaging (IGFI) from July 2017 to December 2017 were retrospectively analyzed. Injecting ICG in right portal vein or peripheral vein in surgery??positive staining or negative staining??attained three-dimensional staining of the half liver for precise right hemihepatectomy. Results Ten of the 11 patients (90.9%) had successful staining who underwent precise right hemihepatectomy guided by FIGFI. The negative stainings were applied to 8 patients??including 1 failed staining??and the positive stainings were applied to 3 patients. ICG fluorescence range of 10 patients in liver surface were consistent with the ischemic line??whose postoperative liver cross-section are clearly demarcation. The mean operation time??blood loss??postoperative hospital stay??cases of blood transfusion??complication rate??postoperative peak volume of ALT and TB and complication rate were 246??150-345??min??241??100-600??mL??10.4??6-15??d??0??4/11??346??114-707??U/L and 47.1??21.5-68.0??μmol/L. Pathology results of all patients are HCC and negative margins??and microvascular invasion occurred in 8 patients. The average follow-up time of 11 patients was 3.9 months (1-7 months) without death??and pulmonary metastasis was found in 1 patient 2 months later after surgery. Conclusion FIGFI can guide the anatomical right hepatectomy in real time?? increase radical rate??accuracy and safety of right hemihepatectomy for the treatment of HCC??and has a promising prospect.     

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??Single-stitch pancreatic duct suture for pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy??A multiple center prospective study HONG De-fei*??LIU Jian-hua??LIU Ya-hui??et al. *Department of General Surgery??Sir Run Run Shaw Hospital??Zhejiang University??Hangzhou 310016??China
Corresponding author??HONG De-fei??E-mail??hongdefei@zju.edu.cn
HONG De-fei, LIU Ya-hui, LIU Jian-hua and LIU Jun are the first authors who contributed equally to the article
Abstract Objective To investigate the role of Single-stitch pancreatic duct suture for pancreaticojejunostomy technique (SSPJ) in laparoscopic pancreaticoduodenectomy ??LPD??. Methods Between April 2016 and March 2018??the clinical data of patients underwent LPD in Sir Run Run Shaw Hospital of Zhejiang University??Frist clinical hospital of Jilin university??Second Affiliated Hospital of Hebei Medical University??Shandong Provincial Hospital??and Zhejiang provincial people’s hospital were collected prospectively. All patients underwent LPD using SSPJ technique. Results All patients underwent laparoscopic procedure. 9 patients (2.2%) conversed to open operation. The mean time for SSPJ was??32.2±7.6??min. The mean operation time was (353.9±104.8) min. The mean estimated blood loss was ??327.2±362.3??mL. Postoperative complications included??42 patients??10.2%?? had Biochemical leak??25 patients??6.1%?? had pancreatic fistula grade B??4 patients??1.0%?? had pancreatic fistula grade C??25 cases??6.1%?? had bile leakage??23 patients ??5.6%??had postoperatively bleeding??22 cases ??5.3%??haddelayed gastric empty??9 cases??2.3%?? had intra-abdominal infection and 11 cases??2.7%?? had pulmonary infection postoperatively. 18 patients need re-operation??7 patients??1.1%??died within 30 days postoperative. The mean postoperative hospital stay is ??18.6±10.6??d. Pathologic results showed pancreatic ductal adenocarcinomas in 121 cases??29.37%????distal bile duct carcinomas in 95 cases(20.06%)??Carcinoma of duodenal papilla in 47cases??11.4%????ampullary tumors in 42 cases??10.2%????duodenal carcinoma in 21 cases??5.1%????solid pseudopapillary tumor of pancreas in 16 cases??3.9%????intra-ductal papillary mucinous neoplasms in 15 cases??3.6%????neuroendocrine tumors in 16??3.9%?? patient and 31 cases with other diagnosis. Conclusion Our results show that SSPJ is a simple??safe and feasible laparoscopic pancreaticojejunostomy technique??which worth to be popularized.     

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??Multi-center clinical analysis of iatrogenic bile duct injury associated with laparoscopic cholecystectomy TIAN Xiao-dong*,ZHANG Yuan-yuan??TANG Zhao-hui??et al. *Department of Surgery,Beijing University First Hospital??Beijing 100034??China
Corresponding author??TANG Zhao-hui??E-mail??tangzhaohui@yahoo.com
Abstract Objective To retrospectively analyze and summarize the current status of diagnosis and treatment of iatrogenic bile duct injury in laparoscopic cholecystectomy (LC) in China. Methods Based on the data from Big Data Platform of YiDuCloud??clinical data of 105 cases of LC related iatrogenic bile duct injury in 16 tertiary hospitals in China from March 2002 to March 2018 was retrospectively collected. Results A total of 105 patients with LC related bile duct injury??including 44 males and 61 females with an average age of 50.0(25~76) years??accounted for 0.104% of patients with laparoscopic cholecystectomy in the same hospitals at the same time. Among them??34 patients ??32.4%?? underwent bile duct repair surgery in the same hospital where the injury occurred??and 71 patients??67.6%?? were transferred from other hospitals. The most common clinical manifestations after bile duct injury were abdominal pain??fever and jaundice. The cure rate was 88.5% in all patients??of which 20% required multiple surgeries??1 patient died with the mortality rate of 0.95%. The results of early surgery ??within 48 hours after injury?? was better than those of late surgery. Patients who failed the first repair surgery in other hospitals had the lowest cure rate??and thereoperation rate was 100%. Conclusion LC related bile duct injury requires individualized surgical treatment according to the comprehensive factors such as the cause??location and extent of the injury.Once occurs??early diagnosis and the definitive first repair surgery by an experienced specialist are essential for the improvement of the prognosis.     

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目的 了解原发性肝癌病人行肝部分切除术后早期腹水形成的原因。方法 通过对69例原发性肝癌病人的临床资料回顾性研究，分析了术前、术中及术后有关指标，探讨其腹水形成的原因。结果 腹水形成的术前因素主要与血清白蛋白、前白蛋白含量、肝功能的Child分级及肝硬化类型等有关；要中与肝门阻断时间术中出血量、术中输血量、右肝韧带的离断等有关；术后主要与腹腔引流管的拔除时间有关。结论 为减少术后早期腹水形成，主要是要前有良好的肝功能储备，尽可能缩短手术时间，减少不必要的分离，尽早拔除腹腔引流管。     

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目的　探讨胰十二指肠切除术后并发症的影响因素及防治方法。方法　在原 196 0～ 1979年报告基础上 ,比较研究 1980～ 1999年 14 2例胰十二指肠切除术后并发症、围手术期病死率及相应时期医疗水平的差异。结果　 196 0～ 1979年和 1980～ 1989年手术并发症发生率分别为 4 2 7%和 4 1 8% (P >0 0 5 ) ;1990～ 1999年为11 5 % (P <0 0 1)。结论　 2 0世纪 90年代起手术并发症大幅度下降 ,与围手术期处理和手术操作的改进有关。掌握适应证和手术操作原则 ,完善围手术期处理 ,是降低胰十二指肠切除术并发症发生率的关键。     

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??Usage of mechanical stapler in digestive tract reconstruction of laparoscopic total gastrectomy MIAO Ru-lin??LI Zi-yu??WANG Yin-kui??et al. Gastrointestinal Cancer Center, Peking University Cancer Hospital &Institute; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing 100142, China
Corresponding author??LI Zi-yu?? E-mail??ligregory@outlook.com
Abstract Objective To evaluate the safety and effectiveness of mechanical staplers in laparoscopic total gastrectomy. Methods The clinical data of gastric adenocarcinoma patients who received laparoscopic-assisted or totally laparoscopic total gastrectomy in Gastrointestinal Cancer Center Ward I of Peking University Cancer Hospital from March 2012 to April 2016 was collected retrospectively. The clinical pathologic characteristics??operative features and postoperative recovery features were compared between patients with linear stapler (LS) and the ones with circular stapler (CS). Logistic regression was used to identify the risk factors of postoperative complications. Results A total of 72 patients were enrolled in the study with 47 patients in the CS group and 25 patients in the LS group. The difference of age??gender??BMI??tumor size??Lauren classification??differentiation grade??and pathologic stage between the two groups were not significant statistically??P??0.05??. The proportion of patients who received preoperative therapy were lower in the LS group (4.0% vs.27.7%??P=0.026). The difference of surgical time and intraoperative blood loss of OS group and LS group were not significant statistically (median surgical time??247min vs. 258min??median intraoperative blood loss??100mL vs. 50mL). There was no statistical difference in the extent of curative??retrieved lymph node number??and proximal margin distance between the two groups. On postoperative recovery??the first liquid diet time was shorter in the LS group (3.5d vs. 5.0d??P=0.030)??but the postoperative hospital stay??first flatus time??first semi-liquid diet time and first abdominal drainage tube removing time were same statistically between the two groups. The rates of postoperative complications were 25.5% and 32.0% in CS group and LS group (P =0.560)??and no risk factor was identified in regression model. Conclusion For laparoscopic total gastrectomy??mechanical staplers are safe. The surgical time??intraoperative blood loss and postoperative risk of linear stapler are comparable to those of circular stapler??and gastrointestinal function recovery may be faster in linear stapler group.     

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全胃切除是胃体癌和累及两个分区以上胃癌的首选术式 ,其手术并发症和术后生存质量与消化道的重建方式有关。自 1995年 10月至 1997年 6月 ,我院为 30例胃癌病人施行根治性全胃切除 ,原位十二指肠、部分空肠翻转代胃消化道重建手术 ,获得满意效果 ,报告如下。1　资料与方法1 1　一般资料30例病人中 ,男 18例 ,女 12例。年龄 2 7～ 72岁 ,中位年龄 5 2岁。肿瘤部位 :ＭＡＣ/ＭＣＡ 1例 ,ＭＣ/ＣＭ 5例 ,ＭＡ/ＡＭ 9例 ,Ｍ 13例 ,胃窦及胃体双原发癌 1例 ,残胃癌1例。组织学类型及分级 :30例中 ,高、中、低分化腺癌分别为 5、8、9例 ,粘液腺癌…     

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??Evaluation of glutamine-enhanced enteral nutritional support by gastro-duodenal route in the patients after total gastrectomy LIU Hua, LING Wei, SHEN Zhi-yong, et al. Department of General Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
Corresponding author??CAO Hui, E-mail: housman111@yahoo.com.cn
Abstract Objective To evaluate glutamine-enhanced enteral nutritional support by gastro-duodenal route in the patients after total gastrectomy. Methods From October 2006 to February 2009, 72 patients receiving total gastrectomy at Department of General Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were selected. They were randomly divided into 3 groups: glutamine-enhanced enteral nutrition (EN+Gln) group, enteral nutrition (EN) group and the control group. The patients received nutrition support within 48 h after operation for 7 days. The occurance of postoperative complication and hospitalization duration were compared. Besides serum total protein, albumin, proalbumin and transferrin were measured 1 day before operation, the 3rd day and the 12th day after operation. And on the 7th day after operation, NK cells, CD4+T and CD8+T cells, IgM and IgG levels in peripheral blood were measured. Results The occurrence of postoperative complication and hospitalization duration in the EN+Gln and EN group were fewer than those in the control group. The postoperative serum level of total protein, albumin, proalbumin and transferrin on the 3rd day after operation of all groups decreased significantly(P<0.05) while those data of EN+Gln and EN group on the 14th day after operation were significantly higher than those of the control group. On the 7th day after operation NK cells, CD4+T cells, IgM and IgG levels of the EN+Gln group increased prominently and significantly higher than those of EN and the control group. Conclusion For the patients receiving total gastrectomy, perioperative glutamine-enhanced nutritional support can improve nutrition and immune status and reduce the incidence of postoperative complication and hospital stay.     

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??Analysis of prognostic predictors affecting hepatectomy combined with postoperative adjuvant TACE in patients with hepatocellular carcinoma??A double-centered propensity-score matching study QU Kai*??GU Jing-xian??CUI Rui-xia??et al. *Department of Hepatobiliary Surgery??the First Affiliated Hospital of Xi'an Jiaotong University??Xi'an 710061??China
Corresponding author??LIU Chang??E-mail??eyrechang@126.com??FAN Hai-ning??E-mail??1486713174@qq.com
Abstract Objective To confirm the clinical effectiveness of postoperative adjuvant transcatheter arterial chemoembolization??TACE?? in HCC patients after liver resection??and further identify the patients who could benefit most from postoperative adjuvant TACE. Methods The clinical data of 593 consecutive patients were retrospectively collected from the First Affiliated Hospital of Xi’an Jiaotong University from January 2005 to December 2016 and the Affiliated Hospital of Qinghai University between January 2011 and June 2017. Propensity score matching (PSM) was used between hepatectomy patients with and without receiving postoperative adjuvant TACE and finally a total of 348 patients were matched. Kaplan-Meier analysis was performed to compare overall survival (OS) and recurrence-free survival (RFS) between the two groups??univariate COX regression and stratified survival analysis were performed to screen and identify survival predictors for postoperative adjuvant TACE patients. Results The Log-rank tests showed both OS and RFS of the patients in postoperative adjuvant TACE group were significantly longer than those in the control group (P<0.05). The identified prognostic predictors by Cox regression and stratified survival analysis included hepatitis B infection??spleen diameter??preoperative serum alpha-fetoprotein (AFP)??TNM stage??tumor size??tumor number. Conclusion Postoperative adjuvant TACE could improve prognosis markedly in HCC patients??particularly in late-stage ones with hepatitis B??portal hypertension??or higher level of preoperative AFP.     

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??Middle hepatic vein-guidedhepatectomy for treatment of hepatocellular carcinoma: A preliminary clinical study JI Gu-wei??WANG Ke??LI Chang-xian??et al. Liver Transplantation Center??the First Affiliated Hospital of Nanjing Medical University??Nanjing 210029??China
Corresponding author??LI Xiang-cheng??E-mail??drxcli@njmu.edu.cn
Abstract Objective To explore the clinical efficacy of middle hepatic vein (MHV)-oriented hepatectomy for treatment of hepatocellular carcinoma (HCC). Methods A retrospective analysis of the clinical and follow-up data of 91 patients??who received radical treatment by hemihepatectomy at Liver Transplantation Center??the First Affiliated Hospital of Nanjing Medical University between June 2006 and June 2015 was conducted. Surgical approaches were divided into MHV-oriented group and conventional group according to full exposure of the MHV on the dissection plane. Early recurrence was defined as tumor recurrence within the first year after surgery. One-to-one propensity score matching (PSM) analysis of the two groups was performed to investigate the clinical efficacy of different surgical approaches. Results Among the 91 patients??left and right hemihepatectomy was performed in 30 and 61 patients. Mean tumor size was 9.9 cm (1.5 to 20.0 cm). Median survival time was 48 months (2 to 127 months). The 1-??3- and 5-year overall survival (OS) rates were 80.1%??58.0%??and 41.8%??respectively. Corresponding disease-free survival (DFS) rates were 57.7%??37.4%??and 30.3%. There was no statistic difference between MHV-oriented group and conventional group in terms of OS and DFS; However??early recurrence rate in conventional group was significantly higher than that in MHV-oriented group. The result was further confirmed by PSM. Multivariate analysis of all patients showed that macrovascular invasion and satellite focus were independent prognostic factors for OS??macrovascular invasion was the independent prognostic factor for DFS??and surgical approach was an independent risk factor for early recurrence after surgery. Conclusion MHV-oriented hepatectomy is associated with decreased early recurrence after radical resection of HCC??However??tumor biology remains the main determinant of overall prognosis.     

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??Comparison of the efficiency between two methods of alimentary tract reconstruction after robot-assisted total gastrectomy for gastric cancer DIAO Yan-qing, WANG Zhi-ming, JIANG Zhi-wei, et al. Research Institute of General Surgery of PLA, Nanjing General Hospital of Nanjing Military Region, Nanjing 210002, China
Corresponding author??JIANG Zhi-wei, E-mail??surgery34@163.com
Abstract Objective To compare the feasibility and difficulty between two methods of alimentary tract reconstruction after robot-assisted total gastrectomy for gastric cancer. Methods From April 2012 to April 2015??57 patients with gastric cancer in Nanjing General Hospital of Nanjing Military Region were enrolled for robot-assisted total gastrectomy and reconstruction of digestive tract??and all the operations were performed by the same surgeons. In 35 patients (group A)??reconstruction of alimentary canal was performed using single needle running by an absorbable suture. In the other 22 patients (group B), it was performed using two needle running by a barbed suture (180 Polyglyconate Absorbable Knotless Wound Closure Device). Several parameters were evaluated and compared in the two groups, such as time of operation, time of anastomosis, length of hospital stay, and the incidence rate of postoperative complications. In addition??the difficulty of anastomosis was assessed by the surgeon. Results All the 57 robot-assisted operations were completed successfully without conversion to open surgery. In group A??the total time of surgery was ??251.3±64.4??min??time of esophagojejunostomy was ??37.8±11.6??min??time of jejunojejunostomy was ??29.4±8.7??min??the time of postoperative hospital were ??5.5±3.7??days. In group B??the total time of surgery was ??192.8±52.9??min??time of esophagojejunostomy was ??18.1±7.9??min??time of jejunojejunostomy was ??14.6±6.3??min??the time of postoperative hospital were ??4.7±4.1?? days. Compared with group A??group B represented reduced difficulty in both operation and cooperation??significantly shorter time of the anastomosis?? surgery and postoperative hospital stay??P??0.05??. Furthermore??in group A there were two patients with anastomotic complications (anastomotic stricture)??but in group B they had declined (2/35 vs.0/22). Conclusion Both two kinds of anastomosis for alimentary canal reconstruction in robotic total gastrectomy are safe and feasible. The use of the barbed suture in totally robotic total gastrectomy would reduce the difficulty of reconstruction of digestive tract and save a lot of time of anastomosis??surgery and postoperative hospital stay.