Current surgical treatment for bile duct cancer

Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy （PD）, plus extrahepatic bile duct resection and regional lyrnphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD （hepatopancreatoduodenectomy） has been applied to selected patients with widespread tumors. Preoperative biliary drainage （BD） followed by portal vein embolization （PVE） enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.

Cholangiocarcinoma:A 7-year experience at a single center in Greece

AIM： To evaluate survival rate and clinical outcome of cholangiocarcinoma. METHODS： The medical records of 34 patients with cholangiocarcinoma, seen at a single hospital between the years 1999-2006, were retrospectively reviewed. RESULTS： Thirty-four patients with a median age of 75 years were included. Seventeen （50%） had painless jaundice at presentation. Sixteen （47.1%） were perihilar, 15 （44.1%） extrahepatic and three （8.8%） intrahepatic. Endoscopic retrograde cholangiography （ERCP） and/or magnetic resonance cholangiography （MRCP） were used for the diagnosis. Pathologic confirmation was obtained in seven and positive cytological examination in three. Thirteen patients had co-morbidities （38.2%）. Four cases were managed with complete surgical resection. All the rest of the cases （30） were characterized as non-resectable due to advanced stage of the disease. Palliative biliary drainage was performed in 26/30 （86.6%）. The mean follow-up was 32 mo （95% CI, 20-43 too）. Overall median survival was 8.7 mo （95% CI, 2-16 mo）. The probability of 1-year, 2-year and 3-year survival was 46%, 20% and 7%, respectively. The survival was slightly longer in patients who underwent resection compared to those who did not, but this difference failed to reach statistical significance. Patients who underwent biliary drainage had an advantage in survival compared to those who did not （probability of survival 53% vs 0% at 1 year, respectively, P = 0.038）. CONCLUSION： Patients with cholangiocarcinoma were usually elderly with co-morbidities and/oradvanced disease at presentation. Even though a slight amelioration in survival with palliative biliary drainage was observed, patients had dismal outcome without resection of the tumor.

Is prophylactic placement of drains necessary after subtotal gastrectomy?

AIM： To determine the evidence-based values of prophylactic drainage in gastric cancer surgery. METHODS： One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups. RESULTS： No significant differences were observed between the drain group and no-drain group in terms of operating time （171 ± 42 rain vs 156 ± 39 rain）, number of post-operative days until passage of flatus （3.7 ± 0.5 d vs 3.5 ± 1.0 d）, number of post-operative days until initiation of soft diet （4.9±0.7 d vs 4.8±0.8 d）, length of post-operative hospital stay （9.3±2.2 d vs 8.4±2.4 d）, mortality rate （5.4% vs 3.8%）, and overall postoperative complication rate （21.4% vs 19.2%）. CONCLUSION： Prophylactic drainage placement is not necessary afer subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.

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.

Effect of preoperative limited fluid resuscitation to the patients with traumatic shock

Objective： To investigate the effect of preoperative limited fluid resuscitation on the patients with traumatic shock. Methods： Eighty-nine patients with multiple injuries complicating with shock were treated in Changhai Hospital Between January 2002 to October 2005 and were divided into 3 groups according to the preoperative levels of systolic blood pressure （SBP）. SBP of group A and group B were about 70 and 80 mmHg, respectively; and the SBP of group C was over 90 mmHg. Results, （1） There was no significant difference in age, gender, and injury severity score （ISS）, initiated resuscitation time and initiated operation time among the 3 groups. Preoperatively, there was significant difference in the amount of fluid resuscitation and infused erythrocyte suspension among group A, B and C （1687 ± 96 ml, 2096 ± 87 ml, 2976±93 ml, P〈0. 05; and 294±110 ml, 404±113 ml, 798±230 ml, P〈0. 05）. （2） The hemoglobin level in group C （94±45 g/L） was lower than that in group A （110±22 g/L） and group B （103±24 g/L） （P〈0.05）. However, there was no significant difference in the level of hemoglobin between group A and B. （3） There was no significant difference in the incidence of acute renal failure （ARF） among the 3 groups. The incidence of acute respiratory distress syndrome （ARDS） of group C （31.2%） was higher than that of group A （16.7%） and group B （18.2%） （P〈0.05）. The mortality of group C （34.4%） was higher than that of group A （12. 5% ） and group B （12. 1% ） （P〈0.05）. Conclusion： Preoperative limited resuscitation applied on patients with traumatic shock can reduce blood loss, incidence of ARDS and mortality.

Surgical palliation of unresectable pancreatic head cancer in elderly patients

AIM: To determine if surgical biliary bypass would provide improved quality of residual life and safe palliation in elderly patients with unresectable pancreatic head cancer. METHODS: Nineteen patients, 65 years of age or older, were managed with surgical biliary bypass (Group A). These patients were compared with 19 patients under 65 years of age who were managed with surgical biliary bypass (Group B). In addition, the results for group A were compared with those obtained from 17 patients, 65 years of age or older (Group C), who received percutaneous transhepatic biliary drainage to evaluate the quality of residual life. RESULTS: Five patients (26.0%) in Group A had complications, including one intraabdominal abscess, one pulmonary atelectasis, and three wound infections. One death (5.3%) occurred on postoperative day 3. With respect to morbidity, mortality, and postoperative hospitalization, no statistically significant difference was noted between Groups A and B. The number of readmissions and the rate of recurrent jaundice were lower in Group A than in Group C, to a statistically significant degree (P = 0.019, P = 0.029, respectively). The median hospital-free survival period and themedian overall survival were also signifi cantly longer in Group A (P = 0.001 and P < 0.001, respectively). CONCLUSION: Surgical palliation does not increase the morbidity or mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head cancer.

Safe Distance for Inspection of 1 000 kV UHVAC Lines with Helicopter

Helicopter inspection of ultra high voltage （UHV） transmission lines has unmatched advantages compared to manual work due to the inspection angle and high-tech equipment on board, especially in detailed inspections of tower heads and defect-detections in virtue of infrared/ultraviolet techniques. This paper deals with some key technical problems in the inspections of i 000 kV UHVAC lines with a helicopter, such as the safe distance of live-line working, electromagnetic field intensity and flight control. Based on the study results, a set of UHV line inspection methods was worked out and applied to the inspection of live UHV lines.

The effect of Shen-Fu on gastrointestinal tract injury and its potential mechanism during cardio-pulmonary bypass in patients undergoing cardiac surgery

Objective: To investigate the effect of Shen-Fu (SF) injection on gastrointestinal tract injury and its potential mechanism.Methods: Thirty-eight patients undergoing elective open heart surgery were assigned to Group C (control group, n = 18) and Group SF (n = 20) randomly. In Group SF, the patients received intravenous injection of SF (0.5 ml/kg) at the beginning of the surgery followed by a continuous infusion of 100 ml SF (1.0 ml/kg) solution diluted by saline at a rate of 0.004 ml · Kg-1 · min-1 with a Grasby pump. The control group was injected with normal saline in the same volume. Gastric intramucosal pH (pHi), activity of blood diamine oxidase ( DAO ), and concentrations of blood LPS and IL-6 were measured before CPB ( S0) and 1 h ( S1 ) and 2 h ( S2) after aortic declamping, respectively.Results: In Group C, pHi value was significantly lower at S1 and S2 than at S0 ( mean P <0.01) and blood DAO and concentrations of LPS and IL-6 were significantly higher at S1 and S2 than at S0 ( meanP < 0.01). In Group SF, pHi was obviously lower at S1 and S2 than at S0(P< 0.05) but LPS and IL-6 levels and DAO were higher at S, (mean P<0.05). Blood DAO and LPS level demonstrated significant negative correlations with pHi ( mean P < 0.01) while LPS concentration showed a positive correlation with blood DAO (P < 0.01) and IL-6 concentration (P < 0.05). At S1 and S2 after aortic declamping, the levels of pHi were higher in Group SF than in Group C (mean P <0.01 ) but DAO and LPS and IL-6 levels were significantly lower in Group SF than in Group C ( P <0.01).Conclusions: SF has a protective effect on gastrointestinal tract and can reduce inflammatory actions.

Comparing twist-drill drainage with burr hole drainage for chronic subdural hematoma

Objective： of chronic subdural hematoma The surgical management （CSDH） is still a controversial issue, and a standard therapy has not been established because of the unclear pathogenic mechanisms in CSDH. The intention of this paper is to find a simple and efficient surgical procedure for CSDH. Methods： A retrospective study of 448 patients with CSDH by surgical treatment during 2005 to 2009 was conducted in order to compare the efficiency between two diferent primary surgical methods, i.e. twist-drill drainage without irrigation in Group A （n-178） and one burr-hole with irrigation in Group B （n=270）. The results were statistically analyzed. Results： The reoperation rates in Group A and Group B were 7.9% and 11.9% respectively. The good outcome rate was 88.8% and 73.5%, the complicatiGn was 7.9% and 20.7% in Group A and Group B, respectively. Conclusions： The burr-hole drainage with irrigation of the hematoma cavity is not beneficial to the outcome and prognosis. Irrigation is not important in the surgical treatmerit for CSDH. Thus in initial treatment, twist-drill drainage without irrigation of the hematoma cavity is recommended because it is relatively safe, time-saving and cost-effective.