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??Analysis of value of nonpalpable breast lesions by vacuum assisted biopsy JIN Si-li, ZHAO Yi.The Seventh Department of General Surgery, Shengjing Hospital, China Medical Universiry, Shenyang 110004, China
Corresponding author: ZHAO Yi, E-mail: 2597016916@qq.com
Abstract Objective To explore the application of vacuum assisted biopsy (VAB) in nonpalpable breast high-risk lesions. Methods From January 2015 to December 2016, 1641 nonpalpable breast lesions from 518 patients with Encor guided by ultrasound in Shengjing Hospital, China Medical University were analyzed retrospectively. Results Pathological tips show adenosis 610??37.2%??, breast fibroma 163??9.9%??, fibroadenosis 668??40.7%??, mesenchymal cells in active growth 32??2.0%????papillary 25??1.5%????dysplasia 89??5.4%???? mastitis 15??0.9%??, 8 cancer??0.5%?? and others 31??1.9%??. The patients were followed up for 18-24 months??458 (88.4%) cases were followed up successfully. Color Doppler ultrasound was reviewed every 3 months.No recurrence in high-risk patients,no metastasis in malignant patients. Conclusion For nonpalpable breast lesion, the VAB is helpful for the diagnosis and treatment, and is more conductive to the detection of high-risk lesions.     

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??Establishment and value of three-dimensional visualization diagnosis platform in the treatment of hepatolithiasis FANG Chi-hua, FANG Zhao-shan, CAI Wei, et al. The First Department of Hapatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou510282,China
Corresponding author:FANG Chi-hua,E-mail: fangch_dr@126.com
Abstract Objective To study the establishment and value of three-dimensional visualization diagnosis platform in the treatment of hepatolithiasis. Methods The clinical data of 112 consecutive patients with hepatolithiasis between January 2008 and April 2015 in the First Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University were analyzed. (1) In order to acquire submillimeter CT data, each patient underwent the spiral CT epigastric enhancement scanning. Medical image three-dimensional visualization system (MI-3DVS) was used to establish three-dimensional visualization image model. (2) The three-dimensional visualization analysis covered the vascular classification, the classification of clinical diagnosis, liver segments, virtual hepatectomy and liver volume calculation with three-dimensional visualization technology. (3) Preoperative evaluation and surgical planning were performed to select a reasonable plan. (4) The 3D printing of liver might be performed when necessary, which help to perform the precise surgery. (5) Therapeutic effect was evaluated. Results All the patients had a real reconstruction of three-dimensional visualization image model based on CT images. The position and distribution of calculus, location and degree of biliary stricture, vascular anatomic relationships were shown in the three-dimensional visualization image model clearly. The category of hepatic artery, hepatic vein and portal vein were made. The three-dimensional visualization diagnostic classification of hepatolithiasis and liver segments was also performed. The relationships between lesions and vasculature were shown in the 3D printing model of liver. The three-dimensional visualization preoperative evaluation and 3D printing model were in tune with actual operation. The stone residue rate, incidence rate of complications and calculus recurrence rate was less than 3.0%, 5.6% and 2.4% respectively. Conclusion The establishment of three-dimensional visualization diagnosis platform for hepatolithiasis could help to improve the clearance of calculus and decrease postoperative complications. It could provide safe, precise, minimally invasive and efficient therapeutic measures for hepatolithiasis and has a good clinical prospect.     

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??Application of a three-dimensional visualization technology for precise before retroperitoneal tumor surgery (Report of 15 cases) SU Zhao-jie*, LI Wen-gang, CHEN Fu-zhen,et al. *Department of Hepatobiliary Surgery, the ChengGong Affiliated Hospital, Xiamen University,Xiamen 361000,China
Corresponding author:LI Wen-gang,E-mail:LWG11861@163.com
Abstract Objective Explore the value of three-dimensional visualization technology in the precise before retroperitoneal tumor surgery. Methods The clinical data of fifteen patients with retroperitoneal tumor who were admitted to the ChengGong Hospital from March 2011 to December 2013 were retrospectively analyzed. Based on three-dimensional visualization technology, converted the two-dimensional images of CT into three-dimensional images, observed the relationship between tumor and abdominal viscera, major abdominal vascular??measured the volume of tumor and Simulated operation to evaluate the preoperative. Both volumes of the predicted resected tumor and the results of the actual operations tumor resection were calculated, and had a correlation test analysis??Results The tumor tissue, abdominal organs and blood vessel were reconstructed three-dimensionally using the three-dimensional reconstruction software.Twelve of fifteen patients were operated underwent accurate assessment. Assessment of the anatomical situation were broadly consistent with actual situation before operation.The volume of twelve patients simulated resected tumor were ??1117.50±690.35??mL, while the actual operations tumor resection volumes were ??1189.92±737.74??mL. There was no significant different between the predicted and the actual values??t=0.25??P>0.05??. The actual liver resection volume was positively correlated with the predicted liver resection volume (r=0.81, P<0.05). Conclusions The three-dimensional visualization technology has a certain degree of clinical value in the precise before retroperitoneal tumor surgery.     

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目的 探讨肛门镜下吻合器痔切除术（PPH）的临床应用价值。方法 分析重度内痔（Ⅲ度、Ⅳ度内痔）经吻合器切除的诊治资料。结果 经肛门镜下采用33mm吻合器切除重度内痔36例。平均手术时间10min,术后平均.5天,6例术后第2-7天有便血,经保守治疗后好转,12例术后当天无肛门疼痛,随访1-5个月效果良好。结论 经肛门镜下吻合器痔切除术是一种新技术,具有安全,有效、住院时间短和恢复快的优点,有望替代传统的手术治疗方法。     

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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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??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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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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总体而言 ,肝胆管肿瘤合并胆道外科急症的情况在临床上并不常见 ,主要是肿瘤合并结石或肿瘤本身阻塞胆道引起的化脓性感染。65 %～ 80 %的肝内胆管癌合并肝内胆管结石。台湾长庚纪念医院报道[1 ] 10 2例合并结石的肝内胆管癌 ,以急性肝胆管炎症状就诊的病例占 2 /3。Caroli病有 7%～ 10 %继发恶变[2 ] ,这类病人的主要临床表现依然是反复发作的急性肝胆管炎。肝门部和中、下段胆管癌合并胆道外科急症的情形相对少见 ,而在胆囊癌则时常发生 ,因为 80 %～90 %的胆囊癌合并胆囊结石[3] 。我院一组 76例胆囊癌 ,11%首先表现为急性胆囊炎。肝癌…     

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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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目的探讨肝内胆管结石合并胆道出血的诊治方法。方法对1982～1992年收治的32例肝内胆管结石合并胆道出血病人进行回顾性分析。结果32例病人中14例为肝内胆管自发性出血，均采用手术治疗，止血率为100％，随访1年无复发出血，18例为手术后出血，3例经保守治疗治愈，15例经保守治疗无效后采用手术治疗，13例止血成功，2例死亡。结论对肝内胆管结石合并自发性胆道出血应及时手术，在止血同时注意处理原发病变。手术后的胆道出血可先采取非手术治疗，部分病人可取得较好的疗效；非手术治疗无效者，应积极再手术治疗。     

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??Utility of tumor markers and molecular testing technique in diagnosis and management of thyroid microcarcinoma ZHAO Wen-xin??WANG Bo. Department of Thyroid Surgery??Fujian Medical University Union Hospital??Fuzhou 350001??China
Corresponding author??ZHAO Wen-xin??E-mail??Zhaowx@fjmu.edu.cn.
Abstract Thyroid fine needle aspiration is the gold standard for preoperative diagnosis of thyroid carcinoma. There are 25% to 30% cytological indeterminate thyroid nodules??which likely cannot be discriminated due to technical limitations of FNAB. With the significant progress of the pathogenesis of thyroid cancer based upon molecular biology aspects and rapid development of molecular testing techniques??the diagnosis, prognosis and treatment have gotten remarkable improvement. The development of the technologies is expected to make up for the deficiency of FNAB??conductive to assess the preoperative risk stratification??predict the prognosis and then optimize the initial treatment options.     

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1　肝外科技术的发展ＣａｒｌＬａｎｇｅｎｂｕｃｈ(1888)被认为是首先成功施行肝左叶切除的医师 ,但手术后发生肝门处血管出血 ,又做了第二次手术止血 ,病人终归治愈了。这个病例亦提示了肝脏的出血与止血是贯彻着整个肝外科发展的问题。1 1　肝脏的出血与止血肝脏象是一团充满血液的“海绵” ,不管你是如何碰她一下 ,总会流血 ,并且流个不止 ,多少年来 ,外科医生对此已伤透了脑筋。直至 190 8年 ,Ｐｒｉｎｇｌｅ在美国的《外科年鉴杂志》(ＡｎｎａｌｓｏｆＳｕｒｇｅｒｙ)上发表了一篇文章 ,名为“肝外伤止血札记 (ｎｏｔｅｓｏｎｔｈｅａ…     

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目的 注意肝胆管结石合并胆管变异，提高肝内胆管结石的诊断治疗水平。方法 总结2001-2002年来手术治疗的5例肝胆管结石合并无肝右管或肝左管病例的诊断治疗过程和治疗方法。结果 5例病人都是手术中被发现肝胆管结石合并胆管变异，其中4例为无肝右管，1例为无肝左管，均行不同部位的肝切除和胆管空肠吻合，术后无残石，治疗效果良好。结论 对肝胆管结石需警惕合并胆管异常，治疗应争取切除结石并胆管异常的肝叶。     

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肝胆管残留结石仍是当今外科治疗的难题。 1983～1999年 ,我科收治各种类型肝胆管残石 110 0例 ,其中接受再手术 92 0例 ,占 84%。 80 %的病例经过 3个月至 17年的随访 ,残石率 17% ,无残石或反复胆管炎效果优良者占 90 %。现将再手术问题讨论如下。1　肝胆管残留结石的手术时机肝胆管残留结石 ,由于种种原因 ,致使遭受多次胆道手术。我科 92 0例肝胆管残留结石病人 ,平均经历 2 8次手术(2～ 8次 )。对此 ,病人“谈术色变”、医生“望之头痛”。因此 ,对二者都是一个十分严肃而慎重的问题 ,不是所有的肝胆管残留结石 ,都要或都能适于再手术…     

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胆道结石手术因其疾病本身的复杂性及经治医生水平的不同 ,其残余结石的发生率低者可达 2 0 %以下 ,高者可达 90 %。但无论如何 ,术后胆道残余结石仍是肝胆外科最棘手的难题之一。近年来 ,外科医生试图采用部分肝叶切除、肝门胆管成形盆式吻合等手术方式解决肝内胆管结石的问题 ,但效果并不理想 ,而且又出现了一些新的、亟待解决的问题。本文拟从对肝胆管残余结石分析入手 ,重点讨论其非手术疗法。1　肝胆管残余结石分析1 1　胆总管残余结石胆总管残余结石的原因有 :(1)病人病情危重 ,尽快引流结束手术。往往是一些急诊胆道休克的病人如急性…