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Objective:To evaluate trans-artery pressure perfusion autologous transfusion for laparoscopic splenectomy and pericardial devascularization (LSPD).Methods:The clinical data of patients with laparoscopic splenectomy in Zhejiang Provincial People′s Hospital in recent 3 years were reviewed. The therapeutic effects of 30 LSPD cases with trans-artery pressure perfusion (observation group) and 30 radical LSPD cases (control group) were compared and analyzed.Results:There was no significant difference in age, sex, preoperative liver function grade and spleen volume between the two groups ( P>0.05). All 60 patients completed laparoscopic splenectomy without conversion to laparotomy or death. There was no significant difference in liver function, operation time and intraoperative bleeding between the observation group and the control group ( P>0.05), and there was also no significant difference in blood transfusion, postoperative complications and hospital stay ( P>0.05). The hemoglobin level in the observation group was significantly higher than that in the control group ( P<0.05). Conclusions:Laparoscopic splenectomy and pericardial devascularization with trans-artery pressure perfusion autologous transfusion can increase post-operative hemoglobin value effectively.
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In order to facilitate the treatment strategies for biliary tract injury, hilar cholangiocarcinoma, bile duct tumor thrombus, cholangiocellular carcinoma and bile duct cystic dilatation, many classifications have been made, even more than 10 types for one disease. Each type is represented by numbers or English alphabet, which are not only confusing but also difficult to remember. The Academician Mengchao Wu divided the liver into five sections and four segments base on its anatomy, this classification is very direct and visual, thus had been using till now. In order to overcome those complicated problems, it is considered to develop a new classification based on actual anatomic location similar to that for liver cancer, which is easy to remember and to directly determine the treatment strategy. All kinds of classifications have their own characteristics and advantages and disadvantages. This practical classifications avoid the complexity and may be useful for clinicians.
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Objective To analyze the clinical value of repeat ultrasonography and MRCP in patients who presented with acute abdomen caused by a single common bile duct stone after the pain had subsided.Methods The clinical data of 46 patients who were diagnosed to have a single common bile duct stone and presented with acute abdomen admitted to the Department of Hepatobiliary and Pancreatic Surgery and Minimally Invasive Surgery in Zhejiang Provincial People's Hospital were retrospectively studied.The patients were treated with anti-infection,antispasmodic and choleretic drugs with other conservative symptomatic and supportive therapy.Ultrasound and MRCP examinations were carried out before and after conservative treatment of the acute abdominal pain.Results 26 (56.5％) patients with a single stone in the common bile duct passed the stone spontaneously.Of these patients,11 patients were discharged home and were treated conservatively,15 patients underwent LC,and 20 (43.5％) patients still had choledocholithiasis.Of these 20 patients,12 underwent ERCP + EST,followed by LC;while the remaining 8 patients had a history of cholecystectomy,6 and 2 patients underwent ERCP + EST and LCBDE,respectively.Conclusion A single common bile duct stone in patients who presented with acute abdomen may pass the stone spontaneously as shown in this study using ultrasound and MRCP examinations.
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Objective To explore the feasibility and safety of laparoscopic right hemihepatectomy (LRH) via anterior approach for larger tumors in the right lobe of the liver.Methods A retrospective study was conducted based on the clinical data of ten consecutive patients with large right liver cancer undergoing LRH through anterior approach and thirty-seven patients undergoing open hemihepatectomy by anterior approach in recent 6 years.Results Between the two groups there were no significant difference in gender,average age,the mean tumor size,preoperative liver reserve function,cut margin and intraoperative blood transfusion.The LRH group had less average intraoperative blood loss [(408 ± 158)ml vs.(520 ± 153)ml,t =2.047,P =0.046] and shorter postoperative hospital stay [(11.5 ±2.8)d vs.(16.2 ±4.6) d,t=3.091,P=0.003],longer operation time [(302 ±38)min vs.(251±55)min,t=2.732,P=0.009].There was no perioperative death and no significant difference in complications (20.0％ vs.35.1％,x2 =0.812,P =0.367) and similar median survival time (36 mon vs.29 mon,x2 =1.266,P =0.261).Conclusions LRH via anterior approach for larger tumors in the right lobe of the liver is safe and feasible.
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Objective To summarize the experience of diagnosis and treatment for peripancreatic pseudoanemysms.Methods The clinical data of 12 patients with peripancreatic pseudoaneurysm were analyzed retrospectively.Out of 12 patients,6 presented with abdominal or alimentary tract bleeding because of pseudoaneurysm rupture.Possible etiology included chronic pancreatitis (6 cases),severe acute pancreatitis (3 cases),postpancreatoduedenectomy (3 cases),developed after transarterial chemoembolisition for hepatic carcinoma (1 case) and 1 without any definitive cause.Results Interventional radiology as first therapeutic procedure was carried out in 10 patients including 9 endovascular coil embolizations and 1 stent graft placement for pseudoaneurysm from branch of SMA,and bleeding was controlled successfully in 5 patients with pseudoaneurysm rupture.2 patients underwent laparotomy as initial therapy.Three patients underwent surgeries after a failed embolisation,another underwent laparotomy and peritoneal lavage and drainage for pancreaticoenteric anastomotic leak complicated with abdominal infection.2 SAP patients underwent ultrasound guided drainage for peripancreatic abscess.2 after PD patients died,with mortality of 16.7％ (2/12).Conclusions Peripancreatic pseudoaneurysm carried a high and an unpredictable risk of rupture that warranted prompt interventional treatment or surgery.
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Objective To explore the feasibility and safety of total laparoscopic radical resection for a patient of Bismuth type Ⅲ a hilar cholangiocarcinoma.Methods This patient underwent right hemihepatectomy combined caudate lobectomy,radical regional lymphadenectomy and Roux-en-Y hepaticojejunostomy under total laparoscopic techniques.Preoperatively the volume of future liver remnant estimated by CT scan was 46％,and indocyanine green retention rate at 15 min (ICG R15) was 6.0％.Results The total laparoscopic surgery was carried out successfully with operation time of 540 min and intraoperative blood loss 300 ml,without blood transfusion.The results of pathological examination showed well-differentiated adenocarcinoma of hilar bile duct with negative tumor margins and no regional lymph node metastasis(0/13).The postoperative recovery was uneventful with hospital stay time of 10 days and without any complications.Conclusion At experienced hands,total laparoscopic radical resection of Bismuth type Ⅲ a hilar cholangiocarcinoma is feasible and safe for selected patients.
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Objective To investigate the value of laparoscopic total pancreastectomy for the treatment of noncancerous pancreatic lesions.Methods Clinical data of 3 cases of noncancerous pancreatic lesions undergoing laparoscopic total pancreatectomy in Zhejiang Provincial People's Hospital were reviewed retrospectively.Results One patient underwent laparoscopic total pancreatectomy,one patient underwent laparoscopic resection with robotic reconstruction and one did laparoscopic resection with open reconstruction.All were spleen preserving surgery.The operation time was 310 (280-350) minutes,estimated blood loss was 483 ml(250-700)ml and postoperative hospital stay was 27 (14-38) days.One patient had postoperative bile leakage.Insulin was used to control blood glucose level in all postoperative cases.As showed by pathology there were intraductal papillary mucinous neoplasms in two patients and multiple neurocndocrine tumor in one patient.Conclusion Laparoscopic total pancreatectomy is safe and minimally invasive for the treatment of noncancerous pancreatic diseases.
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Objective To discuss the surgical treatment of intraductal papillary mucinous neoplasms of the pancreas (IPMN).Methods The clinical data of 42 IPMN cases undergoing surgical treatment in our hospital during the past 4 years were analyzed retrospectively.Results Routine CT or MRI examination was made in 42 cases,ERCP in 6 cases,ultrasonic endoscopy in 12 cases,fine needle biopsy by endoscopic ultrasonography in 4 cases.There were 12 cases of the main duct IPMN,24 cases of branch duct IPMN,6 cases of mixed IPMN.Pancreatoduodenectomy was performed in 24 cases;6 cases underuent laparoscopic central pancreatectomy;10 cases did distal pancreatectomy,2 cases did total pancreatectomy.Postoperative pathology revealed that the malignant transformation rate of main pancreatic duct type was 66.7％,that of BD-IPMN was 12.5％ and 66.7％ of Mix-IPMN.The postoperative complication rate was 26.2％.All cases were followed up for 1 month to 4 years,with no tumor recurrence.Conclusions Imaging examination combined with endoscopic ultrasonography is the main method for clinical diagnosis of IPMN.The malignant transformation rate of MD-IPMN and Mix-IPMN is high.Most of the BD-IPMN is hyperplasia and adenoma.
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Objective@#To analyze the efficacy of branches portal vein embolization (TBPVE) combined with transcatheter arterial chemoembolization (TACE) on liver neoplasms.@*Methods@#From August 2016 to May 2017, there were 13 patients including 11 males and 2 females with primary hepatocellular carcinoma who underwent TBPVE+ TACE , among whom there were 11 cases with a history of HBV infection.Average age of the 13 patients was (60.8±6.2)years. The live function of all patients were Child-Pugh A classification.The CT or MRI images of each patient was reconstructed and the standard liver volume(SLV) before TBPVE+ TACE was (1 181.2±49.3)ml, estimated future liver remnant(FLR) was (326.1±72.1)ml and FLR/SLV was (27.6±6.0)%.The puncture site for TBPVE was determined by the three-dimensional reconstruction of portal vein.CT scan or MRI, AFP and liver function test were repeated after one and two weeks after TBPVE+ TACE.FLR and FLR/SLV were calculated respectively.Hepatectomy would be performed if the patients agreed.The postoperative complications were analyzed.@*Results@#On the 7thday after TBPVE+ TACE, the FLR/SLV was(42.6±8.0)% and the FLR increasement was(56.0±24.6)%.The level of AFP decreased from(87.9±81.8)μg/L to (29.7±20.9)μg/L.On the 14thday after TBPVE+ TACE, the FLR/SLV was(45.8±6.2)% and the FLR increasement was(71.8±29.0)%.Four patients underwent surgery which including 2 right hepatectomies and 2 right trisegmentectomies in 2 weeks after TBPVE+ TACE.Nine patients were performed with targeting intratumoral lactic acidosis TACE (TILA-TACE). No severe complication occurred in all patients.@*Conclusions@#TBPVE could induce a rapid growth of the liver remnant but still with the concern of inducing the growth of neoplasms at the same time.To combine TACE in TBPVE therapy not also can the growth of neoplasms be prevented but also inducing its shrinking.This method might be a new mode for the treatment of hepatocellular carcinoma.
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Objective@#To investigate the role of "Hong′s single-stitch duct to mucosa pancreaticojejunostomy(HSDMP)" in laparoscopic pancreaticoduodenectomy (LPD).@*Methods@#The clinical data including perioperative and short-term outcomes of 51 cases of LPD with HSDMP which performed in Zhejiang Provincial People′s Hospital(33 cases) and Frist Clinical Hospital of Jilin University(18 cases) between April and October 2016 were reviewed retrospectively. There were 31 male patients and 20 female patients. The mean age was(59±11)years. Body mass index (BMI) was 18 to 28 kg/m2 and the average BMI was (23.2±4.4)kg/m2. Preoperative diagnosis: 18 cases with pancreatic mass, 26 cases with peri-ampullary tumor, 3 cases with intra-ductal papillary mucinous neoplasms, 2 cases with duodenal carcinoma, 2 cases with serous cystadenoma.@*Results@#Fifty-one patients accepted LPD using HSDMP. One patient underwent LPD combined with resection of superior mesentery vein. The mean operation time was (307±69)minutes, the mean diameter of pancreatic duct for reconstruction was (3.1±1.1)mm.The mean operation time for HSDMP was (34±5) minutes, the estimated blood loss was (170±127)ml. Twelve cases(23.5%) had pancreatic fistula according to International Study Group definition, including 9 cases(17.6%) of grade A and 3 cases (5.9%) of grade B. Five cases(9.8%) had delayed gastric empty, 5 cases(9.8%) had bile leakage and 2 cases(3.9%) had pulmonary infection postoperative.All these complications were treated by non-surgical strategies. One patient(2.0%) suffered from postoperative intra-abdominal bleeding and recovered after reoperation. Pathologic results showed pancreatic ductal adenocarcinomas in 20 cases(39.2%), non-pancreatic original peri-ampullary tumors in 23 cases(45.1%), intra-ductal papillary mucinous neoplasms in 3 cases(5.9%), duodenal carcinoma in 2 cases(3.9%), serous cystadenoma in 2 cases(3.9%) and neuroendocrine tumors in one case(2.0%).@*Conclusions@#HSDMP could not only reduce the incidence of clinical pancreatic fistula, but also save operation time. It is a feasible and safe method for pancreaticojejunostomy.
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Objective To investigate the effects of miRNAs-107 (miR-107) on pancreatic cancer proliferation,senescence and invasion.Methods MiR-107 expression levels in 3 pancreatic cancer cell lines PANC-1,ASPC-1,BXPC-3 and normal pancreatic HTERT-HPNE cells were studied by quantitative reverse transcription-polymerase chain reaction (qRT-PCR).PANC-1 cells were transfected with 50 nmol/L anti-miR-107 or negative control using Lipofectamine 2000.After transfection,the miR-107 expression was measured by qRT-PCR.Cell proliferation was tested by methylthiazol tetrazolium (MTT) assay.Cell senescence was detected by β-galactosidase staining.The expression levels of PCNA,P16INK4A and MMP2 were measured by qRT-PCR.Results Compared with the HTERT-HPNE cells,the expression level of miR-107 in 3 pancreatic cancer cell lines was significantly increased (P ＜ 0.01).After transfected with 50 nmol/L anti-miR-107,cell proliferation was inhibited,and cell senescence were increased in PANC-1 cells (P ＜ 0.05),and there was no obvious change in cell invasion.Compared with the HTERT-HPNE cells,after transfected with anti-miR-107,the PCNA expression was significantly decreased and P16INK4A was significantly increased,but expression of M MP2 didn't change significantly.Conclusions These results demonstrate that miR-107 promotes the proliferation and escapes cell senescence in PANC-1 cells by targeting PCNA and P16INK4A.But it has no obvious effects on cell invasion.Therefore,it may be a new target for the biologic therapy for pancreatic cancer.
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Objective To investigates the role of duodenum and bile duct preserving pancreatic head resection (DBPPHR) in treatment of benign or low-grade malignant diseases located in the head of pancreas.Methods The clinical data of 31 patients who underwent DBPPHR between April 2012 to May 2016 in Zhejiang Provincial People's Hospital and Zhangzhou Municipal Hospital of Fujian Province were analyzed retrospectively.Results Of the 31 patients,4 patients underwent laparoscopic DBPPHR.One patient in the open group was converted to pancreaticoduodenectomy.For the open group,the mean operation time was (165.3 ±63.6) min;the mean estimated blood loss was (258.1 ± 156.9) ml;and the mean postoperative stay was (11.7 ± 6.3) days.The postoperative complications included 1 reoperation due to postoperative bleeding,1 bile leakage and 13 patients developed grade A pancreatic fistula (48.2％).For the laparoscopic group,the mean operation time was 350.0 (280.0 ～ 450.0) min;the mean estimated blood loss was 425.0 (250.0 ～600.0) ml;and the mean postoperative stay was 14 days.Three patients developed postoperative pancreatic fistula (grade A).The pathological diagnosis were:12 patients with pancreatolithiasis,8 patients with serous cystadenoma,4 patients with branched intraductal papillary mucinous neoplasm,5 patients with neuroendocrine tumor and 2 patients with mucinous cystadenoma.The follow-up period was 1 ～ 48 month,and there was no patient with diabetes or diarrhea.Conclusions DBPPHR was safe and efficacious.It is less invasive to treat benign or low-grade malignant diseases located in the head of pancreas.
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Objective To analyze our experience on laparoscopic and Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection and reconstruction,and to expand the indications of surgery for patients with pancreatic cancer.Methods From December 2013 to January 2016,67 patients underwent laparoscopic and Da Vinci robotic pancreaticoduodenectomy in our department.The resection was combined with major vein resection in 5 patients.We retrospectively analyzed the clinical data of these patients who had laproscopic or Da Vinci robotic pancreaticoduodenectomy with major vascular resection and reconstruction.Results The mean operation time was 378 (360 ～ 480) minutes,and the mean estimated blood loss was 360 (120 ～450) ml.4 patients underwent laparoscopic wedge-resection of PV/SMV without interruption of blood flow.After pancreaticoduodenectomy using the superior mesentery artery first approach,one patient underwent resection of a segment of portal vein and superior mesenteric vein followed by an end to end anastomosis using the Da Vinci robotic system.The total blood flow occlusion time was 35 minutes.Intraoperative frozen section biopsy and postoperative pathological results were chronic pancreatitis with pancreatic cancer in all these patients.The veins were invaded by tumor in 3 patients.In the remaining 2 patients,the vascular wall showed chronic inflammation.All the surgical resection margins were tumor negative.Postoperative complications included one patient with bile leakage,one patient with upper gastrointestinal bleeding and one patient with a grade A pancreatic fistula (PF).The patient with upper gastrointestinal bleeding was managed successfully using hemostatic treatment under gastroscopy,and the other patients all recovered well after conservative therapy.There was no death in this study.The mean postoperative hospitalization stay was 14 (9 ～35) days.Conclusions Laparoscopic or Da Vinci robotic radical pancreaticoduodenectomy combined with major vascular resection is safe and feasible in selected patients with pancreatic cancer.However,surgeons need to be experienced at both open pancreaticoduodenectomy combined with vascular resection and at standard laparoscopic pancreaticoduodenectomy.
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Objective To evaluate the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) on recurrence after hepatectomy for AFP negative hepatocellular carcinoma (HCC).Methods Clinical data of 68 AFP negative HCC patients undergoing radical hepatectomy from September 2010 to January 2013 were analyzed retrospectively.According to preoperative NLR,patients were divided into low NLR group (NLR ＜ 2.78) and high NLR group (NLR ≥ 2.78),respectively.Univariate analysis was performed to assess for a significant difference in clinicopathological characteristics influencing disease-free suvival after hepatectomy.A multivariate analysis was performed by Cox regression for variables significant on univariate analysis.Kaplan-Meier method was used to assess disease-free survival rate.Results The overall 1,2,and 3-year disease-free survival rate was 79.7％,37.5％,and 18.2％ respectively.The disease-free survival of high NLR group was significantly lower than the low NLR group (1,2,and 3-year overall survival were 70.3％,35.1％,and 13.5％ vs 85.2％,40.7％,and 18.5％,respectively,P =0.042).Preoperative NLR ≥2.78,tumor size (＞ 5 cm),microvascular invasion and liver cirrhosis were risk factors of poor disease-free survival.Cox regression analysis revealed that all of these four factors were independent predictors of poorer disease-free survival.Conclusions Preoperative NLR≥2.78 was one of independent adverse predictors for disease-free survival in AFP negative HCC patients after hepatectomy.
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From the first Laparoscopic pancreaticoduodenectomy (LPD) in 1994 to the first Da Vinci robotic pancreaticoduodenectomy(RPD) in 2003, minimally invasive pancreaticoduodenectomy has achieved a breakthrough after 20-year exploration and development.It is a well-established procedure for periampullary carcinomas in some specialized centers now.Some outstanding reports including large clinical trials more than 100 cases of L/RPD in a single center and review analysis about the short and long outcomes between L/RPD and open PD for large cases have been published.For the sake of increasing popularity and acceptance of L/RPD, it is very important for researchers to update the current status of L/RPD and summarize experience and development.
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Objective To evaluate ultrasound-guided methylene blue dyeing for radical liver segmental resection.Methods Liver segmental resection with uhrasound-guide methylene blue dyeing (UMD-SR) was performed in 16 cases, results were compared with 16 conventional liver segmental resection (CSR) retrospectively.Results All the operations under uhrasound-guided methylene blue dyeing were successfully carried out, among them, reverse dyeing was used in cases with segment Ⅳ, Ⅴ, Ⅷ resection.The blood loss in UMD-SR group was much less than CSR group(t =3.011 ,P =0.009) , at the cost of a longer operation time (t =5.423,P =0.000 07).There was no difference in the mortality and morbidity rates between two groups.Tumor recurrence rate was 6.25％ in UMD-SR group and 18.75％ in CSR group (x2 =0.133,P =0.285).Conclusions Ultrasound-guided methylene blue dyeing liver segmental resection can reduce the blood loss during operation, improve the safety of hepatectomy in case of hepatic carcinoma.
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Objective To explore the treatment of primary hepatic neuroendocrine tumors (PHNET).Methods The therapeutic treatments of 9 PHNET patients from January 2003 to January 2010 in 3 hospitals were retrospective analyzed and followed up.Results Diagnosis of PHNET was confirmed immunohistochemically and by excluding extrahepatic primary sites.The survival is significantly dependent on tumor resectability.One patient received only radiotherapy and one with only chemotherapy,one with radiofrequency ablation.Six patients received R0 resection,one received postoperative radiotherapy,one with TACE perioperatively and internal radiotherapy.Two patients were lost to follow up 3 patients died and 4 were alive.Intrahepatic recurrence was found in 1 patient and metastasis to bone in 2 patients.Survival time ranged from 11 days to 66 months.Conclusions PHNET is an extremely rare entity with difficulty in early diagnosis.Curative liver resection integrated with transarterial chemoembolization or radiotherapy is considered to be an effective modality.
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Objective To evaluate the concept of artery first and total mesopancreatic excision in radical resection of pancreatic head carcinoma through both anterior and posterior approaches.Method The anterior approach was to identify the superior mesenteric artery (SMA) and the posterior approach to confirm the possibility of negative margin at the origin of SMA,on the posterio-lateral vascular wall of superior mesenteric vein (SMV) and the supposed posterior of the mesopancreas.The resection scope were with the celiac trunk and common hepatic artery as the upper boarder,the SMA as the left boarder,the inferior mesenteric vein (IMA) level as the lower boarder,to achieve a complete mesopancreatic excision,namely the en bloc resection of all the involved nerve,the lymph tissue and vascular tissue along the right side of the axial composed by SMA and celiac trunk.Results Of the 15 patients,11 had radical Whipple procedure,among which 2 had a combining SMV resection and reconstruction.1 case suffered from delayed gastric emptying and 2 cases from bile leakage.There was no mortality.The postoperative pathology reported carcinoma in all 11 cases,with duodenum and low bile duct involved in 4 cases,with the duodenum involved in 6 cases,no surrounding tissue involvement was identified in 1 case.Nerve involvement was found in 7 (7/11),vascular involvement in 10 (10/11),and lymphnode metastasis was (2.5 ± 3.8/12.9 ± 4.9).Conclusions The radical resection of pancreatic head carcinoma using the concept of artery first and the total mesopancreatic excision is helpful for an early evaluation of the possibility of radical resection and guarantees negative margins.
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ObjectiveTo evaluate the feasibility,effectiveness and safety of laparoscopic splenectomy combined with pericardial devascularization for the treatment of portal hypertension in cirrhotic patients. MethodsIn this study 16 cases underwent initial totally laparoscopic splenectomy and paraesophagogastric devascularization,with 10 cases undergoing upfront open surgery as controls by one treatment group.Clinical data including operative time,intraoperative blood loss,post-operative complications and hospitalization were compared between the two groups.ResultsIn the laparoscopic group the procedure was successfully performed in 12 cases.4 cases were converted to open surgery.The operative time in laparoscopic group and the open group was respectively (315 ± 77 ) min and (291± 31) min (P =0.384).The mean intro-operative blood loss was (409 ±216) ml and (980 ±402) ml (P ＜0.01).The post-operative stay was ( 10 ± 3 ) d and ( 17 ± 8 ) d ( P ＜ 0.01).Differences in post-operative complication rate between the two groups was not statistically significant ( 17％ vs.30％,P =0.525 ).ConclusionsLaparoscopic splenectomy and pericardial devascularization is feasible,effective and safe for cirrhotic patients with portal hypertension,it has the advantage of less intra-operative blood loss,less pain and shorter hospitalization than open surgery.
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Radical resection is still the only possible cure for gallbladder cancer nowadays. Rational procedures vary according to different TNM stages, locations and biological behavior of tumor. Diagnostic laparoscopic exploration offers the opportunity to identify peritoneal metastasis which may be negative on preoperative radiological findings. Besides, this can also minimize trauma to abdomen. Therefore, laparoscopic exploration is suggested in cases highly suspected of peritoneal metastasis. For incidental gallbladder cancer, radical surgery should be performed because of positive margin of cystic duct, inadequate trocar management or advanced tumor stages. Timing for reoperation is still controversial. Most scholars recommended that it should be proceed within two months after the first surgery.