目的与手段:公共管理中的双重正当性分析

根据"脏手"与国家理性学说,公共管理活动对正当目的的诉求常常意味着要采用不正当的手段。但对目的正当性的片面追求无法避免目的本身被扭曲,从而使得公共管理失去目的与手段的双重正当性,它还可能导致公共管理者与被管理者争抢同一道德制高点的伦理困境。现代公共管理必须追求目的与手段的双重正当性,其理论基础是一种立宪的国家理性,而其实践选择则是行政法治。

政治哲学视阈中的道德两难

政治生活中的道德两难具有内在价值和现实意义。它不仅有助于缓解不同诉求之间的冲突,弥合管理者的人格分裂,而且能对公共权力构成必要的约束,减少社会制度本身的缺陷所带来的负面影响。

Surgical Resection of Right or Total Caudate Lobe of the Liver Including the Paracaval Portion

Objective To explore the method for and experience of the right or total caudate lobectomies including the paracaval portion. Methods The right posterior approach was employed for right caudate lobectomy and the left lateral approach for total caudate lobectomy. Prior to liver parenchymal transection, dissection was made to separate the caudate lobe and the tumor from the retrohepatic inferior vena cava (IVC). The transection was carried out by forceps and finger fracture with or without some kind of hepatic vascular occlusion. Results A total of 7 right and 6 total caudate lobectomies were performed, all including resection of the paracaval portion. There were no operative deaths or severe complications. The mean intraoperative blood loss was 896 ml (range: 250–2 000 ml). Among the 13 hepatectomies, 10 were done under portal triad clamping with a mean clamp time of 25 min (range: 10–83 min). There was a mean postoperative hospital stay of 12 days (range: 9–22 days). Conclusion Athough deeply located and in close proximity to the trunk of the main hepatic veins and the portal pedicle, the caudate lobe including paracaval portion can be safely resected either alone or combined with liver resection. Key words hepatectomy - liver neoplasms - inferior vena cava-surgery

Efficacy of multislice computed tomography for gastroenteric and hepatic surgeries

AIM: To determine the efficacy of multislice CT for gastroenteric and hepatic surgery.METHODS: Dual-phase helical computed tomography was performed in 50 of 51 patients who underwent gastroenteric and hepatic surgeries. Twenty-eight, eighteen and four patients suffering from colorectal cancer, gastric cancer,and liver cancer respectively underwent colorectal surgery (laparoscopic surgery: 6 cases), gastrectomy, and hepatectomy. Three-dimensional computed tomography imaging of the inferior mesenteric artery, celiac artery and hepatic artery was performed. And in the follow-up examination of postoperative patients, multiplanar reconstruction image was made in case of need.RESULTS: Scans in 50 patients were technically satisfactory and included in the analysis. Depiction of major visceral arteries, which were important for surgery and other treatments, could be done in all patients.Preoperative visualization of the left colic artery and sigmoidal arteries, the celiac artery and its branches, and hepatic artery was very useful to lymph node dissection,the planning of a reservoir and hepatectomy. And multiplanar reconstruction image was helpful to diagnosis for the postoperative follow-up of patients.CONCLUSION: Three-dimensional volume rendering or multiplanar reconstruction imaging performed by multislice computed tomography was very useful for gastroenteric and hepatic surgeries.

Factors that influence outcome in non-invasive and invasive treatment in polycystic liver disease patients

AIM: To evaluate the factors that influence outcome of both non-invasive and invasive treatment of polycystic liver disease. METHODS: Analysis of clinical files of patients with complete follow-up from July 1986 to June 2006. RESULTS: Forty-one patients (male, 7; female, 34), 47.8 ± 11.9 years age, and 5.7 ± 6.7 years follow-up, were studied. Alkaline phosphatase (AP) elevation (15% of patients) was associated with the requirement of invasive treatment (IT, P = 0.005). IT rate was higher in symptomatic than non-symptomatic patients (65.4% vs 14.3%, P = 0.002), and in women taking hormonal replacement therapy (HRT) (P = 0.001). Cysts complications (CC) were more frequent (22%) in the symptomatic patients group (P = 0.023). Patients with body mass index (BMI) > 25 (59%) had a trend to complications after IT (P = 0.075). Abdominal pain was the most common symptom (56%) and indication for IT (78%). Nineteen patients (46%) required a first IT: 12 open fenestration (OF), 4 laparoscopic fenestration (LF) and 3 fenestration with hepatic resection (FHR). Three required a second IT, and one required a third procedure. Complications due to first IT were found in 32% (OF 16.7%, LF 25%, FHR 66.7%), and in thesecond IT in 66.7% (OF 100%). Follow-up mortality rate was 0. CONCLUSION: Presence of symptoms, elevated AP, and CC are associated with IT requirement. HRT is associated with presence of symptoms and IT requirement. Patients with BMI > 25 have a trend be susceptible to IT complications. The proportions of complications are higher in FHR and second IT groups. RS is more frequent after OF.

Current treatment for colorectal liver metastases

Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver,with five-year survival rates up to 58% in selected cases.However,only a minority are resectable at the time of diagnosis.Continuous research in this field aims at increasing the percentage of patients eligible for resection,refining the indications and contraindications for surgery,and improving overall survival.The use of surgical innovations,such as staged resection,portal vein embolization,and repeat resection has allowed higher resection rates in patients with bilobar disease.The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection.Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates.Current management of colorectal liver metastases requires a multidisciplinary approach,which should be individualized in each case.

Anomalous origin of left pulmonary artery branch from the aorta with Fallot's tetralogy:one case report

We report the case of a ten-year-old boy who had often presented with respiratory distress since born. Chest X-ray showed an enlarged right ventricle. Echocardiography demonstrated characteristic features of Fallot＇s tetralogy and the left pulmonary artery could not be visualized. However, cardiac catheterization disclosed that the left pulmonary artery had an anomalous origin in the ascending aorta. The patient underwent total surgical correction of the defects. Nine days later, he was discharged. We present the results of a literature review of the incidence, physiopathological, clinical, diagnostic, and surgical characteristics of this rare disease.

Risk-adjustment in hepatobiliarypancreatic surgery

AIM: The present study evaluates the performance of the POSSUM, the American Society of Anesthetists (ASA), APACHE and Childs classification in predicting mortality and morbidity in hepatopancreaticobiliary (HPB) surgery. We describe especially the limitations and advantages of risk in stratifying the patients. METHODS: We investigated 177 randomly chosen patients undergoing elective complex HPB surgery in a single institution with a total of 71 pre-operative and intra-operative risk factors. Primary endpoint was in-hospital mortality and morbidity. Ordered logistic regression analysis was used to identify individual predictors of operative morbidity and mortality. RESULTS: The operative mortality in the series was 3.95%. This compared well with the p-POSSUM and APACHE predicted mortality of 4.31% and 4.29% respectively. Postoperative complications amounted to 45% with 24 (13.6%) patients having a major adverse event. On multrvariate analysis the pre-operative POSSUM physiological score (OR = 1.18, P = 0.009) was superior in predicting complications compared to the ASA (P= 0.108), APACHE (P= 0.117) or Childs classification (P= 0.136). In addition, serum sodium, creatinine, international normalized ratio (INR), pulse rate, and intra-operative blood loss were independent risk factors. A combination of the POSSUM variables and INR offered the optimal combination of risk factors for risk prognostication in HPB surgery. CONCLUSION: Morbidity for elective HPB surgery can be accurately predicted and applied in everyday surgical practice as an adjunct in the process of informed consent and for effective allocation of resources for intensive and high-dependency care facilities.

Percutaneous cryosurgery for the treatment of hepatic colorectal metastases

AIM:To determine the safety and efficacy of efficacy of percutaneous cryosurgery for treatment of patients with hepatic colorectal metastases. METHODS: Three hundred and twenty-six patients with non-resectable hepatic colorectal metastases underwent percutaneous cryosurgery under the guidance of ultrasound or CT. Follow-up was 1 mo after cryosurgery and then every 4 mo thereafter by assessment of tumor markers, liver ultrasonography, and abdominal CT. For lesions suspicious of recurrence, a liver biopsy was performed and subsequent repeat cryosurgery was given if histology was positive for cancer. RESULTS: All patients underwent a total of 526 procedures of cryosurgery. There were 151 patients who underwent repeat procedures of cryosurgery for recurrent tumors in the liver and extrahepatic places. At 3 mo after cryosurgery, carcinoembryonic antigen (CEA) levels in 197 (77.5%) patients who had elevated markers before cryosurgery decreased to normal range. Among 280 patients who received CT following-up, cryotreated lesions showed complete response (CR) in 41 patients (14.6%), partial response (PR) in 115 patients (41.1%), stable disease (SD) in 68 patients (24.3%) and progressive disease (PD) in 56 patients (20%). The recurrence rate was 47.2% during a median follow-up of 32 mo (range, 7-61). Sixty one percent of the recurrences were seen in liver only and 13.9% in liver and extrahepatic areas. The recurrence rate at cryotreated site was only 6.4% for all cases. During a median follow-up of 36 mo (7-62 mo), the median survival of all patient was 29 mo (range 3-62 mo). Overall survival was 78%, 62%, 41%, 34% and 23% at 1, 2, 3, 4 and 5 years, respectively, after the treatment. Patients with tumor size less than 3 cm, tumor in right lobe of liver, lower CEA levels (< 100 ng/dL) and post- cryosurgery TACE had higher survival rate. There wasno significant difference in terms of survival based on the number of tumors, pre-cryosurgery chemotherapy and the timing of the development of metastases (synchronous vs metachronous). Patients who underwent 2-3 procedures of cryosurgery had increased survival compared to patients who received cryosurgery once only. There was no intra-cryosurgery mortality. Main adverse effects, such as hepatic bleeding, cryoshock, biliary fistula, liver failure, renal insufficiency and liver abscess were only observed in 0.3%-1.5% of patients. CONCLUSION:Percutaneous cryosurgery was a safe modality for hepatic colorectal metastases. Rather than an alternative to resection, this technique should be regarded as a complement to hepatectomy and as an additional means of achieving tumor eradication when total excision is not possible.

Risk factors for prolonged intensive care unit stays in patients after cardiac surgery with cardiopulmonary bypass:A retrospective observational study

Objectives:Patients after cardiac surgery with cardiopulmonary bypass(CPB)require a stay in the ICU postoperatively.This study aimed to investigate the incidence of prolonged length of stay(LOS)in the ICU after cardiac surgery with CPB and identify associated risk factors.Methods:The current investigation was an observational,retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017.Data were obtained from the hospital database.Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.Results:Of 395 patients,137(34.7%)had a prolonged ICU LOS(>72.0 h),and the median ICU LOS was 50.9 h.Several variables were found associated with prolonged ICU LOS:duration of CPB,prolonged mechanical ventilation and non-invasive assisted ventilation use,PaO2/FiO2 ratios within 6 h after surgery,type of surgery,red blood cell infusion during surgery,postoperative atrial arrhythmia,postoperative ventricular arrhythmia(all P<0.05).Conclusions:These findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS,enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.

Role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy

AIM:To evaluate the role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy. METHODS:The medical records of thirteen patients with pyogenic liver abscess who underwent surgical treatment between January 1995 and December 2002 were retrospectively reviewed to determine the clinical presentation, indication and nature of surgery, and out-come of surgery. RESULTS:The patients were predominantly women (10/13) with a mean age of 65 ± 17 years. Their main presenting symptoms were abdominal pain (100%) and fever (77%). The aetiologies included biliary (n = 6), cryptogenic (n = 3), portal (n = 2), and trauma (n = 2). Seven patients underwent percutaneous drainage as the initial treatment. Of these, three patients developed peritonitis secondary to peritoneal spillage. Another four patients failed to respond because of multilocula-tion. Salvage surgery was required in these patients. Six patients proceeded to straight laparotomy:two had marked sepsis and multiloculated abscess that precluded percutaneous drainage, and four presented with perito-nitis of uncertain pathology. Surgical procedures included deroofment and drainage (n = 9), liver resection (n = 3), peritoneal lavage (n = 2), cholecystectomy (n = 4), and exploration of common bile duct (n = 2). One patient required reoperation because of bleeding. Three patients required further percutaneous drainage after surgery. The overall mortality was 46%. Four patients died of multiorgan failure and two patients died of pulmonary embolism. CONCLUSION:Surgical treatment of pyogenic liver ab-scess is occasionally needed when percutaneous drainage has failed due to various reasons. Mortality rate in this group of patients has remained high.

Anesthesia Management at Fuwai Hospital:Practice,Evidence and Outcomes

Fuwai Hospital was established in 1956 and the Anesthesia Department of Fuwai Hospital was one of the earliest anesthesia departments then in China.Under the leadership of several department directors and with the concerted efforts of all generations of colleagues,the Anesthesia Department of Fuwai Hospital has dramatically transformed,upgraded and modernized.For more than six decades,the Anesthesia Department has been providing high-quality peri-operative anesthesia care for cardiovascular surgeries,conducting innovative experimental and clinical researches,and offering comprehensive training on cardiovascular anesthesiology for professionals across China.Currently,Fuwai Hospital is the National Center for Cardiovascular Diseases of China and one of the largest cardiovascular centers in the world.The present review introduces the Anesthesia Department of Fuwai Hospital,summarizes its current practice of anesthesia management,the outcomes of cardiovascular surgeries at Fuwai Hospital,accumulates relevant evidence,and provides prospects for future development of cardiovascular anesthesiology.

Current preventive treatment for recurrence after curative hepatectomy for liver metastases of colorectal carcinoma: A literature review of randomized control trials

To review the preventive approaches for recurrence after curative resection of hepatic metastases from colorectal carcinoma, we have summarized all available publications reporting randomized control trials (RCTs) covered in PubMed. The treatment approaches presented above include adjuvant intrahepatic arterial infusion chemotherapy, systemic chemotherapy, neoadjuvant chemotherapy, and immunotherapy. Although no standard treatment has been established, several approaches present promising results, which are both effective and tolerable in post-hepatectomy patients. Intrahepatic arterial infusion chemotherapy should be regarded as effective and tolerable and it increases overall survival (OS) and disease free survival (DFS) of patients, while 5-fluorouracil-based systemic chemotherapy has not shown any significant survival benefit. Fortunately chemotherapy combined with hepatic arterial infusion and intravenous infusion has shown OS and DFS benefit in many researches. Few neoadjuvant RCT studies have been conducted to evaluate its effect on prolonging survivals although many retrospective studies and case reports are published in which unresectable colorectal liver metastases are downstaged and made resectable with neoadjuvant chemotherapy. Liver resection supplemented with immunotherapy is associated with optimal results; however, it is also questioned by others. In conclusion, several adjuvant approaches have been studied for their efficacy on recurrence after hepatectomy for liver metastases from colorectal cancer (CRC), but multi-centric RCT is still needed for further evaluation on their efficacy and systemic or local toxicities. In addition, new adjuvant treatment should be investigated to provide more effective and tolerable methods for the patients with resectable hepatic metastases from CRC.

Low preoperative platelet counts predict a high mortality after partial hepatectomy in patients with hepatocellular carcinoma

AIM： To assess the validity of our selection criteria for hepatectomy procedures based on indocyanine green disappearance rate （KICG）, and to unveil the factors affecting posthepatectomy mortality in patients with hepatocellular carcinoma （HCC）. METHODS： A retrospective analysis of 198 consecutive patients with HCC who underwent partial hepatectomies in the past 14 years was conducted. The selection criteria for hepatectomy procedures during the study period were KICG≥0.12 for hemihepatectomy, KICG≥0.10 for bisegmentectomy, KCG≥0.08 for monosegmentectomy, and KICG≥ 0.06 for nonanatomic hepatectomy. The hepatectomies were categorized into three types： major hepatectomy （hemihepatectomy or a more extensive procedure）, bisegmentectomy, and limited hepatectomy. Univariate （Fishers exact test） and multivariate （the logistic regression model） analyses were used. RESULTS： Postoperative mortality was 5% after major hepatectomy, 3% after bisegmentectomy, and 3% after limited hepatectomy. The bhree percentages were comparable （P = 0.876）. The platelet count of ≤ 10× 10^4/μL was the strongest independent factor for postoperative mortality on univariate （P = 0.001） and multivariate （risk ratio, 12.5; P= 0.029） analyses. No patient with a platelet count of 〉7.3× 10^4/μL died of postoperative morbidity, whereas 25% （6/24 patients） of patients with a platelet count of ≤7.3×10^4/μL died （P〈0.001）. CONCLUSION： The selection criteria for hepatectomy procedures based on KICG are generally considered valid, because of the acceptable morbidity and mortality with these criteria. The preoperative platelet count independently affects morbidity and mortality after hepatectomy, suggesting that a combination of KICG and platelet count would further reduce postoperative mortality.

Transcatheter aortic valve replacement in elderly patients

Aortic stenosis is the most common native valve disease, affecting up to 5% of the elderly population. Surgical aortic valve replacement reduces symptoms and improves survival, and is the definitive therapy in patients with symptomatic severe aortic stenosis. However, despite the good results of classic surgery, risk is markedly increased in elderly patients with co-morbidities. Transcatheter aortic valve replacement （TAVR） allows implantation of a prosthetic heart valve within the diseased native aortic valve without the need for open heart surgery and cardiopulmonary bypass, offering a new therapeutic option to elderly patients considered at high surgical risk or with contraindications to surgery. To date, several multicenter registries and a randomized trial have confirmed the safety and efficacy of TAVR in those patients. In this chapter, we review the background and clinical applications of TAVR in elderly patients.

RISK OF PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY UNDERGOING NONCARDIAC SURGERY

Objective To determine the risk of noncardiac surgery in patients with hypertrophic cardiomyopathy.Methods We reviewed the medical records of all patients who were diagnosed as hypertrophic cardiomyopathy at Peking Union Medical College Hospital from January 1998 to August 2006 and identified 24 patients who subsequently underwent noncardiac surgery.Results There were no intraoperative cardiac events.Postoperative cardiac events were identified in 3 patients including 1 death due to acute myocardial infarction and 2 episodes of transient hypotension.Conclusions The risk of anesthesia and noncardiac surgery is low in patients with hypertrophic cardiomyopathy.During the perioperative period,beta-blockers and/or calcium channel blockers should be given;vasodilator and inotropic agents should be avoided due to the side effects on hemodynamics.

Intrahepatic biliary cystadenoma:Is there really an almost exclusively female predominance?

Biliary cystic tumors,such as cystadenomas and cystadenocarcinomas,are rare cystic tumors of the liver,accounting for less than 5% of all intrahepatic cysts of biliary origin.Biliary cystadenomas have been known to occur predominantly in women (> 85%),and 38%-44% of biliary cystadenocarcinomas have occurred in males.We wrote this letter to comment on a brief article (World J Gasteroenterol 2011 January 21;17(3):361-365) regarding a case of intrahepatic biliary cystic neoplasm treated with surgery.The adenoma-carcinoma sequence is the possible mechanism of carcinogenesis.If the carcinogenesis of biliary cystadenocarcinoma occurs in the adenoma-carcinoma sequence,we believe that the male-to-female ratio of cystadenoma should be higher than the incidence rate that has been reported to date.

Dose requirements of continuous infusion of rocuronium and atracurium throughout orthotopic liver transplantation in humans

Objective： To compare the dose requirements of continuous infusion of rocuronium and atracurium throughout orthotopic liver transplantation （OLT） in humans. Methods： Twenty male patients undergoing liver transplantation were randomly assigned to two comparable groups of 10 patients each to receive a continuous infusion of rocuronium or atracurium under intravenous balanced anesthesia. The response of adductor pollicis to train-of-four （TOF） stimulation of unlar nerve was monitored. The infusion rates of rocuronium and atracurium were adjusted to maintain Tl/Tc ratio of 2%-10%. The total dose of each drug given during each of the three phases of OLT was recorded. Results： Rocuronium requirement, which were （0.468±0.167）mg/（kg·h） during the paleohepatic phase, decreased significantly during the anhepatic phase to （0.303±0.134）mg/（kg·h） and returned to the initial values at the neohepatic period （（0.429±0.130） mg/（kg·h））; whereas atracuruim requirements remained unchanged during orthotopic liver transplantation. Conclusions： This study showed that the exclusion of the liver from the circulation results in the significantly reduced requirement of rocuronium while the requirement of atracurium was not changed, which suggests that the liver is of major importance in the clearance of rocuronium. A continuous infusion of atracurium with constant rate can provide stable neuromuscular blockade during the three stages of OLT.

Multi-disciplinary treatment for cholangiocellular carcinoma

Cholangiocarcinoma(CC)is rare malignant tumors composed of cells that resemble those of the biliary tract.It is notoriously difficult to diagnose,and is associated with a high mortality.Traditionally,CC is divided into intrahepatic and extraheaptic disease according to its location within the biliary tree.Intrahepatic cholangiocellular carcinoma(IH-CCC)or peripheral cholangiocellular carcinoma(CCC)appears within the second bifurcation of hepatic bile duct,and is the second most common primary liver cancer following hepatocellular carcinoma(HCC),IH-CCC or peripheral CCC often presents with advanced clinical features,and the cause for this cancer rise is still unclear.MRI,CT and PET provide useful diagnostic information in those patients.Surgical resection is the only chance for cure,with results depending on selected patients and careful surgical technique.Liver transplantation could offer long-term survival in selected patients when combined with chemotherapy.Chemotherapy,radiation therapy or combination therapies remain as the only treatment for inoperable patients.However,these are uniformly ineffective in patients' survival.

Identification of expressed genes in regenerating rat liver in 0-4-8-12 h short interval successive partial hepatectomy

AIM: To identify the genes differentially expressed in the regenerating rat liver of 0-4-8-12 h short interval successive partial hepatectomy (SISPH) and to analyze their expression profiles.METHODS: Five hundred and fifty-one elements screened from subtractive cDNA libraries were made into a cDNA microarray (cDNA chip). Extensive gene expression analysis following 0-4-8-12 h SISPH was conducted by microarray.RESULTS: One hundred and eighty-three elements were selected, which were either up- or down-regulated more than 2-fold at one or more time points after SISPH. Cluster analysis and generalization analysis showed that there were five distinct temporal patterns of gene expression.Eighty-six genes were unreported, associated with liver regeneration (LR).CONCLUSION: Microarray analysis shows that the down regulated genes are much more than the up-regulated ones in SISPH; the numbers of genes expressed consistently are fewer than that expressed immediately; the genes expressed in high abundance are much fewer than that increased 2-5-fold. The comparison of SISPH with partial hepatectomy (PH) shows that the expression trends of most genes in SISPH and in PH are similar,but the expression of 43 genes is specifically altered in SISPH.