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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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??The anatomical significance and surgical dissection of Denonvilliers' fascia in laparoscopic and robotic total mesorectal excision CHI Pan, WANG Xiao-jie. Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou 350001, China
Corresponding author: CHI Pan, E-mail: cp3169@163.com
Abstract To dissect in the pre-rectal space is a technically difficult procedure during laparoscopic and robotic total mesorectal excision. With the further understanding of surgical membrane anatomy and the relationship between Denonvilliers' fascia and neurovascular bundles ??NVB????surgeons can identify and protect the NVB during dissecting in the pre-rectal space without oncological compromise. The article introduces a surgical technique of an individual dissection of Denonvilliers' fascia. Firstly?? entering the pre-Denonvilliers space by cutting the peritoneum at 1 cm anterior and cranial to the peritoneal reflection. Secondly?? entering the post-Denonvilliers space by a U-shaped cut of the anterior lobe of Denonvilliers' fascia at the inner side of NVB?? and at 0.5 cm away from the bottom of seminal vesicles for males or 5 cm below the peritoneal reflection for females.     

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??Surgical resection of solitary huge hepatocellular carcinoma YANG Lian-yue, FANG Feng, YANG Hao. Department of Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
Corresponding author: YANG Lian-yue, E-mail: lianyueyang@hotmail.com
Abstract Huge hepatocellular carcinoma which holds a large proportion in clinic is a challenge problem for liver surgeons. Solitary huge hepatocellular carcinoma, a subtype of huge hepatocellular carcinoma, has special clinical and biological characters and good outcome after surgical resection. Surgical resection should be the first choice for solitary huge hepatocellular carcinoma, even though operation is extremely difficult due to its huge size. Surgical resection for solitary huge hepatocellular carcinoma is safe and feasible if surgeons are familiar with the operative indications and operation technique, which could improve the effects of surgical resection and decrease the incidence of complications.     

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原发性腹膜后肿瘤是一类起源于腹膜后潜在腔隙内的肿瘤性疾病,并不包括来源于腹膜后脏器的肿瘤和转移性肿瘤[1-2].腹膜后间隙含有大量疏松结缔组织和脂肪组织,其特殊的解剖学结构和特点为肿瘤无症状生长提供了较大空间,部分病人在首次就诊时肿瘤可能已压迫和浸润局部脏器和组织结构,在多次复发的病人中,肿瘤侵犯邻近脏器的情况更为常见.     

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??Efficacy and prognostic factors of repeat hepatic resection for recurrent hepatocellular carcinoma??A report of 175 cases XU Yun*??SHEN Qiang??WANG Neng??et al. *Department of Minimally Invasive Therapy??Hepatobiliary Surgery Hospital??the Second Military Medical University??Shanghai 200438??China
Corresponding author??QIAN Guo-jun??E-mail??qgjs@sina.com
Abstract Objective To investigate the safety, efficacy and prognostic factors for the survival in the patients with recurrent hepatocellular carcinoma (HCC) treated with repeat hepatic resection (RHR). Methods The clinical data of 175 cases of recurrent HCC following resection treated with RHR from January 2007 to December 2011 in Hepatobiliary Surgery Hospital of the Second Military Medical University were analyzed retrospectively. Complication rate, overall survival rates, disease-free survival rates were calculated and prognostic risk factors were analyzed. Results The severe complication rate after RHR was 7.4%. The 1-,3-,5-year overall survival rates and disease-free survival rates were 92%,71%,51% and 75%,43%,36%, respectively. Elderly patient??>65 years old??, primary HCC at Barcelona Clinic Liver Cancer (BCLC) stage B, microvascular invasion, larger size and incomplete capsule were risk factors for overall survival. Conclusion Indications of RHR should be managed strictly. For patients who satisfy the indications, RHR is safe and effective. For elderly patients??>65 years old??, primary HCC at BCLC stage B, microvascular invasion, larger size and incomplete capsule, closer follow-up and auxiliary treatment following RHR should be considered to improve relatively poor prognosis of the category.     

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上消化道重建是胃切除手术中关键操作步骤之一,但上消化道重建术后并发症规范化防治仍存在诸多问题,上消化道重建术后并发症大多数与吻合技术及围手术期处理有关。严重并发症将增加医疗费用,影响病人预后,甚至产生医患纠纷。因此,临床医师应当充分重视上消化道重建术后并发症的防治。     

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目的 研究大肝癌的手术切除和围术期处理技术。方法 回顾性总结分析1990年1月至2000年9月施行肝切除术的114例大肝癌病例。结果 大肝癌手术中输血量及术后并发症发生率均较小肝癌显著高,两两组间肝门阻断时间、术中出血量、术时、住院天数及病死率差异无显著性。1996-2000年所施行的大肝癌手术切除较1990-1995年而言,术中输血量、肝门阻断时间及住院天数均有明显下降。多元回归分析显示术中出血量是决定术后并发症发生率之独立的危险因素。结论 大肝癌的手术切除和围术期处理技术较前已有明显进步。只要术前准确判断肝脏储备功能及术中有效控制出血,大肝癌的切除仍是安全可行的。     

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胃切除术后消化道梗阻并不少见 ,但由于机械性原因引起需要手术治疗者仅占少数。术前恰当的术式选择、必需要考虑以下情况 :(1)上次行胃切除手术的原因 ,是因为良性疾病行胃切除治疗 ,还是因为恶性肿瘤而行手术治疗 ;(2 )上次手术是近端胃切除、远端胃切除或全胃切除或行单纯的胃空肠吻合术 ;(3)胃切除后胃肠重建方式是Ｂ Ⅰ式 ,Ｂ Ⅱ式或Ｒｏｕｘ ｅｎ Ｙ吻合 ;(4 )梗阻的部位 ;(5 )出现梗阻的时间 ;(6 )此次梗阻的性质、原因等。其中最为重要的是胃切除术后消化道梗阻的部位和性质、原因。　　根据梗阻的部位分为输入空肠袢梗阻、吻合口梗…     

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虽然上消化道重建方式多种多样,但目前尚无被公认的最佳重建方式。上消化道重建后,一方面必须控制好并发症的发生率;另一方面要保证病人有满意的营养状态和良好的生存质量。胃癌根治术后的重建方式也是专家们一直讨论和研究的热点,一直受到大家的重视。全胃切除术后,Roux-en-Y吻合是一种简单、并发症少,又能满足功能要求的重建方式。对病期晚、预后差的进展期胃癌病人,Roux-en-Y吻合时不建议附加贮袋,对于良性肿瘤或者早期胃癌,可以附加重建贮袋,以期提高生存质量。远端胃大部切除术后,相对于BillrothⅠ式吻合来说,BillrothⅡ式或Roux-en-Y吻合重建术并发症少、肿瘤复发率低。BillrothⅠ式吻合重建的适用范围较为有限。近端胃大部切除术后,采用食管残胃(管状胃)吻合是较为常见的重建方式。幽门重建的作用还存在一定争议,有待进一步研究。     

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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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??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.     

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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.