[Application of digital medical technology in hepatopancreatobiliary surgery:20 years' retrospective review and prospect].

Digital medicine has played a vital role in promoting the development of hepatobiliary and pancreatic surgery of China.The multidisciplinary integration of medical science and technology innovates research and development,and practice in clinical diagnosis and treatment.Digital medicine has enabled within 20 years,development from digital virtual human,three-dimensional visualization,molecular fluorescence imaging to artificial intelligence.There are four important stages of the development in China's digital medical technology:digital medicine 1.0 (2002 to 2004,digital virtual human) on digital human anatomy, digital medicine 2.0(2004 to 2014,three-dimensional(3D) visualization and 3D printing) on 3D diagnosis and treatment of complex hepatobiliary and pancreatic diseases, digital medicine 3.0(2014 to 2019,molecular fluorescence imaging) on precision navigation of tumor boundaries and micro tumors using indocyanine green molecular imaging, and digital medicine 4.0(2019 to present,digital artificial intelligence) on augmented reality-based and mixed reality-based 3D abdominal navigation hepatectomy and photoacoustic imaging of tumors.Over the past 20 years' course of development,Chinese researchers have made countless and remarkable achievements in digital medicine through continuous efforts and innovation. In the future,cutting-edge technologies such as artificial intelligence on deep machine learning,multi-mode image real-time fusion navigation surgery,photoacoustic imaging and targeted molecular probe technology will promote the development of digital medicine 4.0 in a coordinated manner,leading to the advent of digital medicine 5.0.

[From digital virtual human, three-dimensional visualization to digital intelligence in liver surgery].

Digital intelligent hepatobiliary surgery has evolved over decades.It has experienced an evolution course from digital virtual human technology to the establishment of a quality-controlled and homogeneous three-dimensional visualization system for precision diagnosis and treatment of diseases, from three-dimensional visualization to the clinical transformation of digital intelligent technology and changes in the diagnosis and treatment model, from empirical diagnosis of diseases to the application of deep learning for the intelligent diagnosis and treatment of diseases, from empirical surgery to real-time multi-modal image guidance during surgery, and from the morphological diagnosis of tumors to accurate diagnosis from molecular imaging.During the whole process, only through continuous innovation in research, theory and technology can the "life" of digital intelligent surgery be endowed with new vitality.In the future, the definition of tumor boundary from the molecular and cellular levels and the early diagnosis and treatment of liver tumor through the functional visualization of key molecules will have significant clinical value for changing the prognosis of liver cancer.In addition, in order to realize intelligent navigation for hepatectomy and break through the technical bottleneck, it is of great clinical significance to develop an intelligent robot real-time navigation hepatectomy system with automatic navigation technology, machine learning intelligent planning technology and multimodal image fusion technology.This provides unprecedented opportunities and challenges for the development of digital intelligent hepatobiliary surgery.

[Construction and application of the core technology system of digital intelligent diagnostic and treatment for hepato-biliary-pancreatic diseases].

Digital intelligent diagnostic and treatment technology is a novel technology which is based by combining modern medicine with digitalized and intelligent high-tech to form a multidisciplinary and multi-knowledge domain. This technology plays an important role in areas including precision diagnosis, preoperative planning and surgical navigation. Its core technologies are: (1) quality control research on high-quality CT imaging data acquisition; (2) quality control and homogenization research on three-dimensional (3D) reconstruction; (3) high-quality 3D printed physical models; (4) virtual reality 3D simulation platform; (5) molecular fluorescence imaging to define tumor boundaries; (6) non-rigid registration multi-mode image fusion surgical navigation system; (7) image feature extraction and prediction model establishment. The workflow of this system includes: First, CT data acquisition and 3D visualization of hepatobiliary and pancreatic diseases; followed by individualized vascular assessment, liver volume calculation and surgical planning using the 3D model; then virtual simulation surgery, 3D printing, virtual reality technology and molecular fluorescence imaging accordance to the required specific conditions. Preoperative radiomics are used to predict the risk of complications and long-term follow-up results. Intraoperative multi-modal fusion image navigation and its consistency are evaluated with the findings in actual surgery and preoperative planning. This technology, hopefully, will bring in novel strategies and approaches in the diagnosis and treatment of hepatobiliary and pancreatic diseases.

[The clinical application of three dimention printing technology].

In recent years, the three-dimentional(3D)printing technology is gradually applied in medicine.Now, the 3D printing has already play an important role in medical education, surgical device development, prosthesis implantation and so on.There are still many challenges and difficulties in the clinical overall application of 3D printing for some time, but it also contains a huge application prospect.Once with appropriate applications of this technology, it will be a major breakthrough in iatrical history once more.

The urogenital-hypogastric sheath: an anatomical observation on the relationship between the inferomedial extension of renal fascia and the hypogastric nerves.

PURPOSE: The study aimed to perform an anatomical observation on the inferomedial extension of the renal fascia (RF) to the pelvis and explore its relationship with the hypogastric nerves (HGNs). METHODS: Gross anatomy was performed on 12 formalin-fixed and 12 fresh cadavers. Sectional anatomy was performed on four formalin-fixed cadavers. RESULTS: Different from the traditional concept, both the anterior and posterior RF included the outer and inner layer with different inferomedial extensions. The multiple layers of RF extended downward to form a sandwich-like and compound fascia sheath with potential and expandable spaces which was named as "the urogenital-hypogastric sheath." Below the level of the origin of the inferior mesenteric artery, the bilateral urogenital-hypogastric sheath communicated with the counterpart in front of the great vessels in the midline and the superior hypogastric plexus ran into the urogenital-hypogastric sheath which carried the HGNs, ureters, and genital vessels downward to their terminations in the pelvis. In the retrorectal space, the urogenital-hypogastric sheath surrounded the fascia propria of the rectum posterolaterally as a layer of coat containing HGNs. CONCLUSION: The multiple layers of RF with different extensions are the anatomical basis of the formation of the urogenital-hypogastric sheath. As a special fascial structure in the retroperitoneal space and the pelvis, emphasis on its formation and morphology may be helpful for not only unifying the controversies about the relationship between the pelvic fascia and HGNs but also improving the intraoperative preservation of the HGNs by dissecting in the correct surgical plane.

Three dimensional reconstruction of the pancreas based on the virtual Chinese human--female number 1.

OBJECTIVE: To study the three dimensional (3D) reconstruction and 3D visualisation of the pancreas and create anatomy of the digitalised visual pancreas so as to construct a concrete basis for virtual operation and surgical operation on pancreas. METHODS: The digital imaging data of pancreas, duodenum, common bile duct, arteries, and veins were obtained from the virtual Chinese human--female 1 (VCH-F1). The image data were investigated and 380 images ascertained of pancreas picked up from images numbers 2617 to 2996. Finally, the images from number 2574 to 3017 were adopted to segment and processed using ACDSee and Photoshop so as to reconstruct 3D pancreas digitally. The data of pancreatic surfaces were transformed into Visualization Toolkit (VTK). The GUI program written with VC+ was used to display this VTK file and realise 3D visualisation of the pancreas. RESULTS: 3D reconstruction and visualisation of the pancreas and the peri-pancreatic structures (the duodenum, the common bile duct,the inferior vena cava, the portal vein vessels, the aorta, the coeliac trunk vessels) was successful. The 3D and visualised pancreas manifested itself with its complete structure as well as its adjacency to other tissues. CONCLUSION: The 3D reconstruction and 3D visualisation of the pancreas based on the digital data of VCH-F1 produces a digitally visualised pancreas, which promises a novel method for virtual operation on the pancreas, clinical operation on the pancreas, and anatomy of 3D visualised pancreas.

[Overview of Chinese digital medicine].

Digital medicine is a newly developed interdiscipline, which is based on the rapid development of medical imaging technology and other advanced technologies in information science, such as computer and internet etc. To let academic world comprehend the history, status, mission, and prospect of this new branch of science, this comment primarily review the major events related to the booming process in Chinese digital medicine, the published milestone works, and dominating applied technology.

Behavior of axons, Schwann cells and perineurial cells in nerve regeneration within transplanted nerve grafts: effects of anti-laminin and anti-fibronectin antisera.

Wistar rats (close cloned strain) were used to investigate the effect of endogenous laminin and fibronectin on axons, Schwann cells and perineurial cells in the regenerating peripheral nervous system (PNS). Sciatic nerve grafts obtained from donor rats were frozen, thawed and treated with rabbit anti-rat laminin or anti-fibronectin antiserum. Control grafts were treated with normal rabbit serum alone. One cm long portions of the sciatic nerve of the recipient rats were replaced with grafts. At 15 days after transplantation the number of regenerated axons in the laminin- and fibronectin-depleted grafts was half of that in the control. The growing axons in the laminin-depleted grafts did not recognize the basal lamina scaffolds (BLS) remaining in the basal lamina tubes, while in the control and fibronectin-depleted grafts 90% or more of axons grew inside the BLS. Elongation of axons always preceded migration of Schwann cells with the latter subsequently adhering to and wrapping around the former. Perineurium-forming fibroblastic cells recognized the combination of axons and Schwann cells and formed perineurial fasciculi around them. These fibroblastic cells did not recognize empty BLS but responded to them only when fibronectin was depleted. Macrophages sometimes closely faced the naked axons which elongated outside the BLS. These results suggest that in the early stages of nerve regeneration endogenous laminin and fibronectin not only regulate the growth of regenerating nerve fibers, but also exert a positive influence on perineurial cells and macrophages, both of which play important roles in nerve tissue injury and repair.

Nerves accompanying the vertebral artery and their clinical relevance.

In elucidating the morphologic basis of cervical spondylosis, the nerves accompanying the vertebral artery were studied under an operative microscope and by means of Karnovsky's histochemical method for acetylcholinesterase (AChE). The results show that the nerves arising from the cervical part of the sympathetic trunk and the cervical nerves anastomose with each other around the artery, and are distributed to the vertebral artery and the cervical spine. The nerves accompanying the vertebral artery show different degrees of AChE activity, and may be compressed or stimulated as a result of disease of Luschka's joint and the other degenerated structures, based on their anatomic relationship.

Acetylcholinesterase: a histochemical identification of motor and sensory fascicles in human peripheral nerve and its use during operation.

To evaluate the precision of acetylcholinesterase histochemical identification of motor and sensory fascicles, this study presents a systematic observation of human peripheral nerves by Karnovsky and Roots' histochemical method. The results indicate that either of the enzymatic activities of myelinated and unmyelinated fibers was different between motor and sensory fascicles. Fifty-seven percent of the myelinated fibers showed enzymatic activity in the motor fascicles, while none of the myelinated fibers in the sensory fascicles showed enzymatic activity. The unmyelinated fibers showing enzymatic activity in the sensory fascicles were far denser than those in the motor fascicles. Our study demonstrated that the unmyelinated fibers were sympathetic postganglionic unmyelinated fibers. From these results it is concluded that the motor and sensory fascicles may be identified not only according to the enzymatic activities of the myelinated fibers, but also according to the enzymatic activities of the sympathetic postganglionic unmyelinated fibers. An improved histochemical method was suggested for its applicability as a method of intraoperative nerve fascicle identification. Simulated experiments were done on the radial nerves and the median nerves in human cadavers. This improved histochemical process can be completed within 50 minutes and can be used in intraoperative nerve fascicle identification.

Applied anatomy of the anterolateral femoral flap.

A study of the source of the blood supply to the anterolateral femoral flap was carried out on 42 lower limbs of adult cadavers (among them 35 cadavers with injection of red latex and 1 with india ink into the arteries and 6 vascular cast specimens), and the surface locations of the vascular pedicle were detected on 50 healthy adults. It was found that the descending branch of the lateral circumflex femoral vessel was an ideal axial vessel. There are constant perforating branches of the myocutaneous artery or cutaneous branches from the intermuscular space to the anterolateral femoral skin. The area extends about 12 x 30 cm. Within the flap, the anterior branch of the anterolateral cutaneous nerve of the high is located. This flap has been widely used for free transplantation in China since 1983 with satisfactory results.

Microsurgical anatomy in China.

This is a general review on the recent advances made in China of microsurgical anatomy. In recent years, more than 300 research papers and a number of monographs on microsurgical anatomy have been published in China. In the research of skin and musculocutaneous flaps, much applied anatomical data about more than 30 new donor areas have been collected and the investigations on the patterns of the blood supply of the flaps are instructively significant to clinical practice. New donor areas have also been introduced for scapular, radial, tibial and other bone flaps, and the range of indications for using the periosteal and cartilaginous flaps has been broadened. On the basis of the technique of superficial lymphaticovenous anastomosis, new information for deep typhaticovenous anastomosis has been provided by clinical anatomists. Through experimental research, the anatomists pointed out that lymphatic vessels with contracting ability should be selected for anastomosis in order to enhance the long term effect of the operation. The successful experiment of bridging the peripheral nerve gap with skeletal muscle, which has been clinically used, has opened up a hopeful prospect for solving the problem of the unavailability of autogenous nerve donors. The identification of nerve fascicles in the nerve trunk provides a morphological basis for the selection of different suture patterns. In addition, much research work has been done on the tranplantation of the suprarenal gland, pancreas, parathyroid gland, testis, kidney of foetus and other small organs.

Experimental study of lymphatic contractility and its clinical importance.

Lymphatic contractility in rats was studied, and changes in lymphatic contractility were recorded under the influence of various factors. We suggest that this contraction is not only the essential driving force in lymph drainage, but also that it plays an important role in the effect resulting from external forces. It was proved that there are alpha- and beta-receptors on the smooth muscle of the lymphatics. Under the control of neurohumoral factors, alpha and beta receptors regulate the lymphatic motion coordinately. We recommend that the lymphatics that still have contractile function be selected for lymphaticovenous anastomoses or other microlymphatic operations for treating lymphedema. Diluted epinephrine is dropped onto the local lymphatic to identify its contractile function.

Spinal manipulation in China.

BACKGROUND: Although there is a long history of the use spinal manipulation in China, little has been formally written on this topic. OBJECTIVE: To discuss the history and status of Chinese spinal manipulation. DISCUSSION: This article describes the history of Chinese spinal manipulation as revealed through past formal textbook publications on this topic, along with journal articles describing both the basic science foundation and clinical applications of such manipulation. In addition, the current status of Chinese spinal manipulation is described. CONCLUSION: There is a long history of the use of spinal manipulation throughout China, though some basic problems of application remain. Current research may help to resolve these problems.

[Applied anatomy of the paraumbilical flap with the lateral anterior branch of the thoracic nerve].

OBJECTIVE: To provide the anatomical basis for the free paraumbilical flap with sensory nerve. METHODS: The morphology, branch and distribution of the inferior epigastric artery and inferior intercostal nerve were dissected and measured in 20 adult cadaver specimens. RESULTS: The diameter of inferior epigastric artery at the original point was (2.3 +/- 0.3) mm, and that of its accompanying vein was (3.6 +/- 0.4) mm. The anterial branch of inferior intercostal nerves transversed through their corresponding intercostal spaces of axilla anterior line and ran out of the superficial fascia at the midclavicular line. The lateral anterior branch of the eighth to tenth intercostal nerves ran out of superficial fascia in the range of 0-7 cm above umbilicus and innervated the paraumbilical flap. CONCLUSION: It is possible to design sensory paraumbilical flap with the lateral anterior branch of the eighth to tenth intercostal nerve.

Experimental study of lymphatic contractility in lymphedema and its clinical significance.

Fifty-four rats that had been used as models for lymphedema were divided into nine groups to observe the changes of lymphatic contractility in pathologic conditions at varying postoperative days. The changes of the lymphatic contractility were divided into three stages in this paper: In the first stage, the lymphatic contractility was impaired by high intralymphatic pressure, but the morphology of its wall was normal and it could recover its function if the pressure was decreased. In the second stage, the blocked lymphatic lost its contractile function partially or completely because its wall thickened and fibrosed, but the newborn lymphatics possessed contraction function and could be anastomosed. In the third stage, most lymphatics had lost their contractile function because of severe fibrosis. The fibrosis of the tissue even blocked the growth of the newborn lymphatics. In this stage, therefore, it was unsuitable to do a lymphatic-venous anastomosis. It can be concluded from the experiment that lymphatic contractility should be considered before performing a lymphatic-venous anastomosis. The lymphatic that still has contractile function should be selected for lymphatic-venous anastomosis.