��ǻ����ʮ��ָ���г���������300���ٴ�����

??Results of 300 consecutive laparoscopic pancreaticoduodenectomies: Experience of single institution LIU Xue-qing?? XING Zhong-qiang??QIN Jian-zhang??et al. Department of Hepatobiliary, the Second Hospital of Hebei Medical University, Hebei 050000, China
Corresponding author??LIU Jian-hua??E-mail??ljh@medmail.com.cn
Abstract Objective To summarize clinical experience on large series of laparoscopic pancreaticoduodenectomies (LPD) in Department of Hepatobiliary, the Second Hospital of Hebei Medical University. Methods The clinical data of 300 consecutive patients undergoing LPD operated by same surgical team from November 2013 to October 2017 was analyzed retrospectively.The study included 184 males and 116 females with mean age of??59.5±9.6?? years and 31 patients over 70 years??age ranging from 27 to 81 years??old. The patients’ mean BMI was??23.2±3.3???? ranging from 16.2 to 34.8. The preoperative complications comprised hypertension??n=82???? diabetes??n=34???? coronary disease??n=14??. A total of 17 patients had previous upper abdominal surgery history. Results Out of data from all 300 consecutive patients??the mean operating time was 6.7??2.5-12.0??h?? the mean intraoperative blood loss was 500??100-3000??mL??and the postoperative hospital stay was 17??6-89??d. Out of data of last 100 cases?? the mean operating time was??395.2±62.9??min?? the mean intraoperative blood loss was??408.2±287.9?? mL??and the postoperaive hospital stay was??14.5±6.9??d. Postoperative complications occurred in 95 patients??31.7%????including bile leakage??n=12??4%???? delayed gastric emptying??n=12??4%???? pulmonary infection??n=18??6%???? pancreatic fistula??total??n=25?? grade B??n=17??5.7%?? grade C??n=8??2.6%???? postoperative bleeding??total??n=28?? GI bleeding??n=7??2.3%?? intraperitoneal hemorrhage??n=21??7%??. There were 13 deaths in perioperative period. The final pathological results revealed malignancies in 258 patients??86%???? including ampullary adenocarcinoma in 41 patients?? common bile duct cancer in 78 patients?? duodenal papillary adenocarcinoma in 69 patients?? pancreatic ductal adenocarcinoma in 69 patients?? and 1 pancreatic adenosquamous carcinoma. The mean size of tumor was 3.3cm with lymph node harvest of 12??2-60?? and R0 resection rate of 96%. Conclusion LPD is safe, effective and feasible for surgeons experienced in laparoscopic surgery. The procedure would be carried out more commonly in a standardized approach for individual patient in the near future.     

��ǻ����ʮ��ָ���г�����ͻ��λ���������о�

??Applied anatomy of the blood supply of the uncinate process in laparoscopic pancreatoduodenectomy WANG Wei*??JIANG Chong-yi??CHEN Yin-tao??et al. *Department of General Surgery??Pancreato-Biliary Clinical Center??Minimally Invasive Surgery Center??Huadong Hospital??Fudan University??Shanghai 200040??China
Corresponding author??WANG Wei??E-mail??hdwangwei@fudan.edu.cn
Abstract Objective To investigate the origin and distribution of arteries in the uncinate process, and provide precious anatomy structure of the blood supply of the uncinate process for laparoscopic pancreatoduodenectomy (LPD). Methods Twelve cases of cadaver specimen fixed with formaldehyde and 1 cases of fresh casting mold specimen of pancreatic vessels allied with pancreatic duct were studied for the blood supply of the uncinate process of pancreas in Department of Anatomy, Shanghai Medical College of Fudan University. The distribution of dorsal pancreatic artery (DPA) of 12 cases of LPD performed between January 2014 and December 2014 in Pancreato-Biliary Clinical Center??Huadong Hospital??Fudan University were also observed in operations. Results ??1??The right branch of DPA distributes to the uncinate process. (2) From ventral aspect, the right branch of the DPA was divided into two smaller branches at four o’clock. And those two branches anastomosed with each other at eight o’clock??which formed a closed arterial loop in the uncinate process. The arterial loop communicated with the common hepatic artery and the pancreaticoduodenal arterial arcade by hub-and-spoke arterial anastomosis. (3) In 12 cases of LPD??4 cases (66.7%) of DPA originated from the splenic artery and 2 cases (33.3%) from superior mesenteric artery. Conclusion The uncinate process is supplied by the pancreaticoduodenal arterial arcade and the right branch of DPA, and they communicate with each other by hub-and-spoke arterial anastomosis in the uncinate process. In order to decrease the risk of bleeding in LPD procedure??the surgeons should pay attention to the right branch of DPA and the anastomosed branches from the uncinate process arterial circle.     

��ǻ����ʮ��ָ���г����ؼ�����

??The technique and tips of laparoscopic pancreaticoduodenectomy HONG De-fei. Department of Hepatobiliary and Pancreatic Surgery??Minimally Invasive Surgery??Zhejiang Provincial People’s Hospital??Hangzhou 310014??China
Abstract Laparoscopic pancreaticoduodenectomy is eventually gaining momentum after 10 years’ development of laparoscopic surgical skills and endoscopic surgical devices. Some large volume minimal invasive pancreatic surgery centers have proved that LPD had same short and long-term outcomes compared with OPD??and shown some minimal invasive benefits than traditional OPD. In our country??less than 10 surgical centers have experience of more than 100 cases of LPD??most of the traditional large volume pancreatic centers are not interested in performing LPD. However, most of the surgeons who perform LPD are in small volume pancreatic centers with potential high risks of postoperative mortality and morbidity. To reduce the risks of LPD during the learning curve period??it is important to standardize the surgical procedure and perioperative treatment of these patients.     

��ʮ��ָ���г���������·̽��������

??Evaluation of surgical approaches of pancreaticoduodenectomy JIN Gang??ZHENG Kai-lian. Department of HBP Surgery??Changhai Hospital??the Second Military Medical University??Shanghai 200433??China
Corresponding author: JIN Gang, E-mail??jingang@sohu.com
Abstract In the past ten years??some new techniques of the pancreatoduodenectomy(PD)?? which is represented by the artery- first approach and no-touch technique??has a certain help to improve the R0 resection rate and reduce the risk during operation. The choice of surgical approach should be based on individual comprehensive consideration of patients, tumor location, vascular invasion, and technical experience of the surgeons. The PD surgical approaches included standard approach, no-touch technique, below the transverse mesocolon approach, early ligation of the efferent arteries of the head of pancreas, artery first approach, uncinate process first approach etc. Traditional approach PD is still the foundation and standard. For the large pancreatic surgery centers and experienced pancreatic surgeons, they should use the different approaches properly to improve the R0 resection rate and to reduce the operation risk.     

��ǻ����ʮ��ָ���г������ɹؼ�����

??Several critical problems in laparoscopic pancreaticoduodenectomy ZHANG Jian-sheng??WANG Wen-bin??LIU Jian-hua. Department of Hepatobiliary Surgery??the Second Hospital of Hebei Medical University??Shijiazhuang 050017??China
Corresponding author??LIU Jian-hua??E-mail: dr.ljh@outlook.com.
Abstract In the last few decades??the safety and feasibility of laparoscopic pancreaticoduodenectomy(LPD) have been established and reported by multiple researchers. Compared with open surgery??the advantages of LPD include not only small incisions but a more precise surgical procedure. As the most challenging laparoscopic surgery??LPD still need to be developed and popularized. There are only a few clinical institutions regularly performing this operation and prospective multi-intitutional RCT of large sample remains lacking. Underthe prerequisite of sufficient experiences in open pancreaticoduodenectomy??OPD?? and professional skills of laparoscopic manipulation??after a relatively long learning curve??LPD could be regularly carried out. The standards of professional technique include GI tract reconstruction with pancreaticojejunostomy??lymphadenectomy combined with total mesopancreases excision and major vein segmental resection and reconstruction. At present??the indications for LPD are quite similar to open surgery at high-volume centers. However??given the extraordinary difficulty of this operation??surgeons should gradually perform LPD and select patients according to their own learning curve and technical conditions.     

ERCP������������β�г���������8������

??Clinical application of endoscopic retrograde cholangiopancreatography in the treatment of pancreatic fistula after distal pancreatectomy: A report of 8 cases WU Wen-guang*??ZHANG Wen-jie??GU Jun??et al. *Department of General Surgery??Institute of Biliary Tract Disease??Xinhua Hospital??Affiliated to Shanghai Jiao Tong University School of Medicine??Shanghai 200092??China
Corresponding author??WANG Xue-feng??E-mail??wxxfd@live.cn
Abstract Objective To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of pancreatic fistula after distal pancreatectomy. Methods A retrospective review of 8 cases with ongoing symptoms related to the pancreatic fistula after distal pancreatectomy was conducted from November 2010 to February 2014 at Department of General Surgery and Laboratory of General Surgery??Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Results ERCP was performed and demonstrated clear extravasation of contrast from the main pancreas duct at the site of pancreas transection in all eight cases. Pancreatic duct stents were placed in all patients at a median time of 15.8 days (range??9-26 days)postoperation and the pancreatic fistula resolved in all patients after a median duration of 16.0 days(range??12-25 days) from the index ERCP. Pancreatic duct stent were removed in all patients three months after discharge??and no patient has developed recurrent pancreatic fistula after stent removal. There was no episodes of pancreatitis??perforation??or other complications associated with pancreatic duct stent placement or removal. Conclusion ERCP with pancreatic duct stent may have a beneficial role in the management of patients with pancreatic fistula after distal pancreatectomy and the approach should be considered in patients not responsive to traditional management strategies.     

��ǻ����Ƣ�г���������ΧѪ���������������θ�������ž�����ѹ37������

目的探讨腹腔镜下脾切除加贲门周围血管离断术(LSPD)联合术中胃镜治疗门静脉高压的临床效果。方法回顾性分析2011年1月至2013年7月华中科技大学同济医学院附属协和医院肝胆外科收治的37例行LSPD联合术中胃镜治疗肝硬化门静脉高压并上消化道出血的病人的临床资料,分析术中出血量、手术时间、住院时间和术后并发症发生率。结果 36例在腹腔镜下完成,1例因胃底静脉瘤破裂出血中转开腹。术毕胃镜检查23例存在残余曲张食管静脉,均行曲张静脉套扎;2例存在胃底曲张静脉,行组织胶注射。手术时间180~450 min,平均(265.2±42.5)min。术中失血100~850 m L,平均(342.0±146.5)m L。术后发生胸腔积液10例,门静脉血栓l例;难治性腹水l例,无术中及围手术期死亡。术后住院5~11 d,平均(6.5±2.0)d。随访3~29个月,6例失访,31例获得随访,无再出血发生。结论 LSPD是一种安全、微创、可行的手术方式,联合术中胃镜可减少术后近期再出血。     

��ǻ����ʮ��ָ���г���Ӧ�ü�������

??Application and evaluation of laparoscopic pancreaticoduodenectomy SUN Yue-Ming??MIAO Yi. Minimally Invasive Surgery?? First Affiliated Hospital of Nanjing Medical University, Nanjing 210029??China
Corresponding author??SUN Yue-Ming??E-mail??jssym@vip.sina.com
Abstract Laparoscopic pacreaticoduodenectomy(LPD) LPD is a feasible and risky operation. It’s necessary for LPD that they must be experienced open surgeon meanwhile skilled laparoscopic surgeon. Early, suitable location, smaller tumor and the thin cases are the ided conditions of early surgery It’s dangerous being popularize in noncodition hospital.     

��ǻ�������г���������·��537���ٴ��ܽ�

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中行胆囊壶腹入路预防胆道损伤的临床意义。方法 2008年7月至2011年3月北京军区总医院肝胆外科应用腹腔镜胆囊壶腹入路法行胆囊切除术537例,对其临床资料进行分析。结果以壶腹部与胆囊管移行区为解剖学标志,顺利显露胆囊壶腹部、胆囊管、胆总管及胆囊动脉,均成功进行了经腹腔镜胆囊切除手术,未发生血管及胆管损伤。结论在腹腔镜胆囊切除术中,采用壶腹入路法,胆囊壶腹部与胆囊管移行区是关键解剖学标志,该区域的完整、精准显露,是成功进行腹腔镜胆囊切除术的保证,可有效避免术中胆道损伤。     

�����ϸ���ָ����ž��������Ķ������г�������——������·ɽ�������

??Surgical Modifications on the Conventional ALPPS LAU Wan Yee??LAU Stephanie H.Y. Faculty of Medicine, the Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.
Corresponding author: Lau W.Y?? E-mail: josephlau@cuhk.edu.hk
Abstract Since the introduction of ALPPS, this operation has created a lot of controversies in the international surgical scene. Some surgeons have rapidly adopted this procedure as within a short time, ALPPS can convert a locally unresectable and non-curable liver cancer to become resectable and curable. Others objected this procedure because it has high morbidity and mortality rates.To improve on the indications of ALPPS, and at the same time, to reduce the operative morbidity and mortality rates, surgeons around the world started to make minor and major modifications of ALPPS. Up to now, when the future liver remnant is inadequate, there are only two ways to induce the future liver remnant to hypertrophy to an adequate size to allow resectional surgery:- ALPPS and the traditional two-stage operation (stage one portal vein embolization or ligation, stage 2 partial hepatectomy). These two operations have their own merits and demerits and the authors tried to compare these procedures based on previously reported data and evidences.     

��ͷ����·��ǻ�������������г���7������

??Analysis of 7 cases of laparoscopic anatomical left hemihepatectomy from the head side LI Jian-wei, ZHENG Shu-guo, WANG Xiao-jun,et al. Institute of Hepatobiliary Surgery, Southwest Hospital, the Third Military Medical University , Chongqing 400038, China
Corresponding author:ZHENG Shu-guo,E-mail:shuguozh@163.com
Abstract Objective To investigate the feasibility of laparoscopic anatomical left hemihepatectomy from the head side. Methods The clinical data of 7 cases who underwent laparoscopic anatomical left hemihepatectomy from the head side in Southwest Hospital of the Third Military Medical University between January 2014 and December 2016 were reviewed retrospectively. Results There were 3 male and 4 female patients, aged 47~72 years old. Before operation, 5 cases diagnosed as left hepatolithiasis, and 2 as hepatocellular carcinoma in left lobe. All cases underwent laparoscopic anatomical left hemihepatectomy from the head side successfully. The operation time was 180??160-230??minutes??estimated blood loss was 200??100-350??mL. There was no such severe complications such as hemorrhage and biliary fistula . One case had delayed gastric emptying. Postoperative hospital stay was 4-26 days. Conclusion Laparoscopic anatomical left hemihepatectomy from the head side may be safe and feasible to perform.     

��ǻ���������θ����г�����������·������

??Surgical approaches and techniques of laparoscopic hepatectomy for segments ??, ?? LIANG Xiao, CAI Xiu-jun. Department of General Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou 310016, China
Corresponding author: CAI Xiu-jun, E-mail??cxjzu@hotmail.com
Abstract For those located in the special parts of the liver (??, ?? segment), due to the difficulty of visual field exposure, surgical equipment is difficult to reach,bleeding is not easy to control and other reasons, its resection is still in the exploratory stage in laparoscopic hepatectomy. The choice of surgical approach and the establishment of the operating space are the basis of the successful laparoscopic ?? and ?? segment resection;The precise location of the tumor and the mastery of the plane of liver resection are the key points of laparoscopic ?? and ?? hepatectomy;To select a reasonable blood flow control technique in laparoscopic liver resection is a safe way to complete the operation successfully.     

��ǻ����ʮ��ָ���г���ѧϰ���߷�������251�����棩

??Analysis of learning curve for laparoscopic pancreaticoduodenectomy: A report of 251 cases ZHANG Jian-sheng??LI Qiu-sheng??LIU Jian-hua??et al. Department of Hepatobiliary Surgery??the Second Hospital of Hebei Medical University??Shijiazhuang 050000??China
Corresponding author??LIU Jian-hua??E-mail: ljh@medmail.com.cn
Abstract Objective To analyze the learning curve and perioperative results of laparoscopic pancreaticoduodenectomy??LPD??. Methods Retrospective review of 251 patients undergoing LPD in the Second Hospital Attached to Hebei Medical University from November 2013 to July 2017 was performed. According to the break-through of corresponding technical milestones??the learning curve for LPD was grouped into three phases: initial period including 19 cases from first attempt to total mesopancreases excision??TMpE????progressive period involving 99 cases between implementing TMpE and first LPD with major vascular resection and reconstruction??and professional period containing 133 cases after LPD with major vascular resection and reconstruction. The learning curve and technical milestone of LPD was analyzed according to the compare of surgical related indexes and perioperative results. Results Out of 251 patients??TMpE was performed in 96 cases??LPD with major vascular resection and reconstruction in 8 cases??and total pancreas resection in 5 cases. Among the patients??postoperative complications occurred in 61(24.3%) patients with Grade B/C pancreatic fistula in 22??8.8%?? patients. Mortality happened to 10??4.0%?? patients with 4 in progressive period and 6 in professionalperiod. In the initial period, operative time and blood loss was ??565.5±43.4??min and ??650.0±447.9??mL, respectively. The postoperative hospital stay was??24.2±11.5d??and 4 patients developed postoperative complications. No statistical differences were detected between patients in progressive period and professional period in age, sex and body mass index (BMI). Meanwhile??significant differences were observed from progressive to professional period in operative time [(459.3±87.4) min versus (409.5±78.4)min, P=0.003], blood loss [(451.6±329.7) mL versus (413.1±304.1) mL, P=0.006] and postoperative hospital stay[(18.4±7.8)d versus(13.9±8.5)d, P=0.001]. It also found differences but without statistical significance in laparotomy conversion (4.5% versus 7.1%, P=0.402), postoperative morbidity (27.3% versus 22.6%, P=0.409), Grade B/C pancreatic fistula (11.2% versus 7.0%, P=0.244) and perioperative mortality (4.5% versus 4.0%, P=0.861). Conclusion Technical milestones of LPD learning curve include adaptation of laparoscopic view??suture and anastomosis skills??achievement of TMpE??major vascular resection and reconstruction experience. With extended experience in open pancreaticoduodenectomy??adaption of laparoscopic view??and certain skills in suture technique??LPD could be accomplished completely after 20 tentative cases. LPD with vascular resection and reconstruction could be attempted after 100 LPDs with breaking through the technical milestone of TMpE. It is a sign of profession to implement LPD with majorvascular resection and reconstruction.     

�ϲ���Ӳ���ΰ��и�ǻ�����г���������

??Surgical techniques of laparoscopic hepatectomy for hepatocellular carcinoma and cirrhosis ZENG Yong-yi??ZHANG Xiang. Liver Disease Center??the First Affiliated Hospital of Fujian Medical University??Fuzhou 350005??China
Corresponding author??ZENG Yong-yi??E-mail??lamp1973
@medmail.com.cn
Abstract Patients with liver cancer in China are often combined with varying degrees of liver cirrhosis, which results in additional surgical risks and technical barriers in every aspect of laparoscopic hepatectomy. Appropriate patient selection, reasonable trocar placement??sensitive identification and accurate localization of the cancer??correct resection plane??selective hepatic blood inflow control??precise parenchyma transection??actively preventing haemorrhage are the key techniques of successful laparoscopic hepatectomy for patients with hepatocellular carcinoma and cirrhosis??     

�����г��¸��ھ޴�ȱ��10���������

腹壁浸润性肿瘤常侵犯腹壁全层组织甚至腹腔内脏器 ,对其进行规范性切除后 ,会导致腹壁全层的巨大缺损 ,难以用周围组织对拢缝合。作者自 1994年以来 ,采用带血管蒂大网膜瓣移植代替缺损的腹膜 ,加涤纶布或聚丙烯网片修补腹壁缺损的方法 ,获得满意的疗效。现报告如下。1　临床资料　　本组共 10例 ,男 2例 ,女 8例。年龄 2 1～ 5 4岁 ,平均37 5岁。既往有手术和 (或 )妊娠史者 7例。临床表现主要因发现腹壁渐进性生长的肿块 1～ 11个月 ,不伴或伴轻度的疼痛。肿块位于右侧腹壁 4例 ,脐周及中下腹壁 4例 ,左侧腹壁 2例 ,均行规范性手术切除。…     

��ȷ����θ���������г����������ؽ���

重建术是消化道手术一个永恒的课题。胃肠道手术的消化道重建方式(下称重建术)一直是一个重要的、引人关注的并不断改进的问题。在手术的“黎明”时期，主要考虑重建后近期不梗阻、不漏等安全问题。随着对消化器官功能的深入了解，术后诸多并发症的发生，许多精确检测方法的问世，以及癌症病期的前移，对手术的要求由安全性、根治性逐渐过渡到要求良好的生活质量。     

����������12���������

我院自 1986年 1月至 2 0 0 2年 1月共收治经病理证实的胃肠结核病人 12例。本文对其诊治情况进行总结分析。报道如下。1　临床资料本组 12例中男 2例 ,女 10例。年龄 11～ 64岁 ,平均3 5岁。临床表现 :表现为慢性腹痛者 7例 ,腹部包块 6例 ,排便习惯改变 5例 ,幽门不全梗阻 2例 ,伴消瘦、贫血、便血者2例。辅助检查 :9例做血沉检查 ,8例增快。 12例全部做胸透检查 ,其中 5例拍过胸片 ,3例肺部有结核钙化灶 ,但无明显结核病史。 7例行钡餐或钡剂灌肠透视 ,均有阳性发现 ,如幽门不全梗阻、粘膜破坏、肠腔狭窄、肠管畸形或充盈缺损、肠壁僵硬…     

������������1������

病人男,59岁。因"反复脐周疼痛10年加重2个月"于2011-06-10入院。病人无畏寒发热、无恶心呕吐、无皮肤巩膜黄染。CT平扫检查见胰腺头部体积、密度不均匀,中央见低密度区;增强扫描病灶早期强化不明显,中央不强化,坏死明显(图1、2)。查体未见异常,肿瘤标记物均正常。