OBJECTIVE To investigate the reasons and preventive measures of recurrent laryngeal nerve injury during operation in patients with benign thyroid neoplasm. METHODS The clinical data of 2243 cases with benign thyroid neoplasm were reviewed. The relations among different neoplasm regions, different procedures and injury of recurrent laryngeal nerve were analyzed. RESULTS Injury incidence of recurrent laryngeal nerve in this study was 3.0 %. In cases with nodular goiter on the dorsum of thyroid and recurrent laryngeal nerve exposed during operation, injury incidence of recurrent laryngeal nerve was 1.0 %. And there was no recurrent laryngeal nerve injury in cases with nodular goiter on other region of the thyroid. In cases used locality protection during operation, injury incidence of recurrent laryngeal nerve was 7.6 % when benign lesions on the dorsum of thyroid and was 0.17 % when benign lesions on other region of the thyroid. CONCLUSION In cases with nodular goiter or adenoma on the dorsum of thyroid, exposing recurrent laryngeal nerve is necessary during operation and in cases with benign lesions on other region of thyroid, locality protection is useful. There are three major routes for recurrent laryngeal nerve exposure.

Objective To investigate the clinical characteristics and surgical treatment of gastrointestinal stromal tumors (GIST) of the duodenum.Methods The clinical data of 39 patients with duodenal GISTs from 1992 to 2010 were analysed retrospectively.Results The most common symptoms of duodenal GISTs were alimentary tract hemorrhage,occuring in 18 cases of the 39 cases (46％).Clinical diagnosis established by CT in 22 cases (69％).Duodenoscopy performed in 18 cases established the definite diagnosis of GIST in 15 (83％).Duodenal GISTs were most commonly located in the descending portion of the duodenum in 27/39 cases (69％).All 39 cases received surgical treatment,with R0 resection in 34 cases,including partial resection of the duodenum in 47％ (16/34),pancreaticodenectomy in 35％(12/34),segmental resection of the duodenum in 3 cases,subtotal gastrectomy in 3 cases; One died perioperatively and postoperative complications developed in 9 cases,which were cured by conservative therapy.The 1,3,5 year survival rate was 90％,72％,41％ for those receiving R0 resection.Conclusions The abdominal CT scan with contrast and duodenoscopy are helpful to establish the diagnosis of duodenal GISTs.Surgical procedures depend on the size and site of the lesion for R0 resection.To decrease postoperative recurrence and prolong survival adjuvant therapy with Imatinib is necessary.

Objective To study the methylation status of the promoter region of several tumor suppressor genes in p53-Bax mitochondrial apoptosis pathway and its role in cholangiocarcinoma. Methods The hypermethylation of the promoter region of tumor suppressors death-associated protein kinase (DAPK), p14, and target of methylation-associoted silencing-1 (TMS1/ASC) were detected by methylation-specific PCR. P53 gene status (exon 5-8 ) were examined by automated sequencing. The relationship between gene mutations and the biological behaviors of cholangiocarcinoma was analyzed. Results Methylation existed in at least one promoter region of tumor suppressor gene in the tumor tissues of 24 patients (66. 7% ). The frequencies of tumor suppressor gene methylation in cholangiocarcinoma were: p14 24%, DAPK 30. 6%, and TMS1/ASC 36. 1%. The frequencies of tumor suppressor gene methylation in the adjacent tissues were: TMS1/ASC 8.3% and DAPK 5.6%. DNA sequencing showed p53 gene mutation was found in 22 of 36 patients (61.1% ), and p53 gene mutation combined with the methylation of tumor suppressor was found in 14 (38.9%) patients, which was significantly correlated with pathologic biology, invasion, and differentiation ( P ＜ 0.05 ). The 1-year, 2-year, and 3-year survival rates were significantly higher in tumor-suppressing genes methylation group ( n = 4) (70%, 43 %, and 28%, respectively)than those in p53 gene mutation group (n = 14) (28%, 5%, and 0%, respectively) (χ2 =9. 060, P =0.03).Conclusions Promoter hypermethylation of p53-Bax mitochondrial apoptosis pathway is a common epigenetic event in cholangiocarcinoma. Although the methylations of TMS1/ASC and DAPK genes in the adjacent tissues are relatively low, they may be informative for the early detection of cholangiocarcinoma. P53 gene mutation combined with the methylation of tumor suppressor may be related with the pathologic biology of cholangiocarcinoma, making the latter trend to be with high malignancy and poor prognosis.

Objective To investigate the risk factors of pulmonary metastasis and prognosis of patients with rectal cancer after anterior resection of rectal cancer.Methods The retrospective case-control study was adopted.The clinical data of 421 patients with rectal cancer who underwent anterior resection at the First Hospital of China Medical University from August 2010 to December 2014 were collected.The patients were followed up by outpatient examination and telephone interview once three months in the first postoperative year,once half a year in the second postoperative year,and then once a year.The follow-up included satuses of pulmonary metastasis and survival of patients after anterior resection of rectal cancer.The end point of follow-up was death of the patients or 31 December,2014.The risk factors of pulmonary metastasis and prognosis in patients after anterior resection of rectal cancer were analyzed.Measurement data with normal distribution were presented as x-± s and measurement data with skewed distribution were presented as M(range).The pulmonary metastasis rate/curve and survival rate/curve were calculated and drawn by the Kaplan-Meier method.The comparisons of pulmonary metastasis rate and survival rate were done using the Log-rank test.The univariate analysis was done using the chi-square test and Log-rank test.The multivariate analysis was done by Logistic regression model and COX regression model.Results Of the 421patients,389 patients were successfully followed up with a median time of 34 months (range,11-53 months) and a follow-up rate of 92.40％ (389/421).Ninety-four,168 and 127 patients were detected in Ⅰ,Ⅱ and Ⅲ stages of TNM stage.There were 29 patients diagnosed with postoperative pulmonary metastasis with the diagnosis time of (21 ± 9) months.The 3-year cumulative incidence of pulmonary metastasis after anterior resection of rectal cancer was 2.2％ in patients of Ⅰ stage,3.0％ in patients of Ⅱ stage and 17.4％ in patients of Ⅲ stage,showing significantly increase trend as the increase of the TNM stage (x2=19.927,P ＜ 0.05).The 29 patients with pulmonary metastasis did not receive chemoradiotherapy including 6 patients receiving pulmonary metastatic nodule recection.Nineteen patients were survived and 10 patients were dead.The survival time of patients diagnosed with pulmonary metastasis was (13 ±9)months and the 3-year cumulative survival rate was 75.7％,whereas the survival time of patients without postoperative pulmonary metastasis was (35 ±9)months and the 3-year cumulative survival rate was 94.3％,showing significant difference between the 2 kinds of patients (x2 =25.219,P ＜ 0.05).The univariate analysis showed that the preoperative carcinoembryonic antigen (CEA) level,degree of tumor differentiation,depth of invasion and lymph node metastasis were risk factors affecting pulmonary metastasis after anterior resection of rectal cancer (x2=4.745,7.250,5.379,18.796,P ＜ 0.05),and the multivariate analysis showed that lymph node metastasis was an independent risk factor affecting postoperative pulmonary metastasis [OR =4.167,95％ confidence interval (CI):1.608-10.801,P ＜ 0.05].The univariate analysis showed that the preoperative CEA level,distribution and number of pulmonary metastatic nodule and lymph node metastasis were risk factors affecting the prognosis of patients with pulmonary metastasis after anterior resection of rectal cancer (x2=13.793,7.246,6.284,4.076,P ＜ 0.05),and the multivariate analysis showed that the preoperative CEA level ＞ 5 μg/L was an independent risk factor affecting the prognosis of patients (HR =13.489,95 ％ CI:1.407-129.297,P ＜ 0.05).Conclusions Pulmonary metastasis after anterior resection of rectal cancer is common.Lymph node metastasis is a high risk factor affecting postoperative pulmonary metastasis,and preoperative CEA level ＞ 5 μg/L is an independent risk factor affecting the prognosis of patients with postoperative pulmonary metastasis.

Objective To summarize the diagnosis and treatment of localized malignant peritoneal mesothelioma(LMPM). Methods A total of 68 cases of LMPM were analyzed retrospectively,including 65 patients in the literature concerning LMPM published in Chinese medical journals be-fore October 2014 plus 3 cases of LMPM admitted in The First Hospital of China Medical University in the same period. Results Among the 68 cas-es,30 cases were male,38 cases were female,with a male to female ratio of 1:1.27. Mean age was 57.6 years. Major clinical manifestations includ-ed abdominal pain or discomfort(76.9%)and palpable abdominal masses(58.5%). Patients(41.7%)had the history of exposure to asbestos. Among the 48 cases(92.3%)that underwent CT examination,ascites was found in 16 cases,and hepatic metastasis was found in 11 cases. Most of the tumors were epithelial type(76.7%),with a mean diameter of 12.2 cm. The main therapeutic strategy was combination therapy of cytoreductive surgery with intraperitoneal hyperthemic chemotherapy. Conclusion LMPM is a rare malignant tumor that occurs predominantly in old people. Symptoms and imaging examinations are untypical. The diagnosis is dependent on pathological examination. Combining several laboratory tests could help the diagnosis. Combination therapy of cytoreductive surgery with intraperitoneal hyperthemic chemotherapy provides an adequate and efficient treatment for LMPM.

Objective To explore the clinical charateristics,diagnosis and treatment of solid pseudopapillary tumors of the pancreas (SPTP).Methods 40 SPTP cases admitted in the First Hospital of China Medical University from 2004 to 2014 were analyzed retrospectively.Results Among 40 cases,male to female ratio was 1 ∶ 7 with the average age of 33.8 years.Major clinical manifestations included abdominal pain or discomfort and palpable abdominal masses.CT and MRI accuracy for detecting the location of tumors was better than B Ultrasonic.Surgical procedure included spleen preserving distal pancreatectomy in 15 cases,distal pancreatectomy with splenectomy in 9 cases,tumor enucleation in 11 cases,pancreaticoduodenectomy in 3 cases,duodenum preserving pancreas head resection in 2 cases.30 postoperative cases were followed-up with the mean follow-up time of 58.4 months and were all doing well.Conclusions SPTP is a tumor with low-grade malignant potentiality.Cystic and solid tumors of the pancreas found among young women are highly suspected as SPTP.Surgery is the main method of treatment and the prognosis is good.

Objective To explore the CT manifestations of non-functional islet cell tumor(NFICT)Methods The findings of plain and enhancement CT scanning from 17 cases with NFICT,which were confirmed by the surgeries and pathological sections,were analyzed retrospectively.Ninty ml of non-ioniodine contrast reagent with 3ml/s injection flow rate was employed as the enhancer for measuring the arteriovenous double phase CT value of the pancreas and tumor.Results Tumors were found in all the cases who received CT scan.Compared with pancreatic substance in the CT plain scan,tumors with low density were found in 2 cases,tumors with mixed low density in 11 cases and tumors with isodensity in 4 cases.Local calcification in tumor was found in 5 cases.Various degrees of strengthening were showed in 17 cases with enhancement scanning.Obvious enhancement in arterial phase presented in 5 cases,moderate enhancement in 6 cases and slight enhancement in 6 cases.Conclusions CT plain scan of NFICT shows that the tumor margins are clear and some tumors have calcification.All tumors in the CT enhancement scanning show various degrees of enhancement,the persistent enhancement from arterial phase to portal vein phase is the characteristic manifestation of NFICT.

Objective To evaluate the diagnostic value of US, ECT, CT and MRI in primary hyperparathyroidism (PHPT). Methods Data of 34 PHPT patients with diagnosis confirmed by postoperative pathology were retrospectively reviewed from January 1, 1990, through March 31, 2004. Results The preoperative diagnosis in 22 out of 25 cases (88%) undergoing preoperative ultrasonography of the neck with a positive result was verified by intraoperative findings. For 99m Tc-MIBI, CT and MRI, the positive results were 95%, 69% and 100% respectively. Conclusion Ultrasonography and 99m Tc-MIBI should be considered as the first choice for preoperative loci localization in patients with PHPT. Ultrasonography and 99m Tc-MIBI in combination is more sensitive and accurate for the localization of PHPT.

Objective To summarize our experience in the prevention and treatment of accessory hepatic duct injury during operation on biliary tract.Methods The clinical data of 26 cases with accessory hepatic duct were retrospectively reviewed.Results Of 26 cases,the accessory hepatic duct were type I in 38.5%(10/26),and no complications including bile leakage,biliary infection and obstructive jaundice developed after division and ligation of the accessory hepatic duct;26.9%(7/26) were type II,among which,the accessory hepatic duct were injured in 3 cases,but no case developecl complications after relevant treatment;23.0%(6/26) were type III,among which,injury of accessory bile duct occurred in 2 cases.Of them,1 case developed bile leakage and was cured by reoperation.7.7%(2/26) were type IV and 3.9%(1/26) was type V.The cases of type IV and V were not damaged.Conclusions To prevent injury of accessory hepatic duct,pre-and intra-operation identification of the condition is very important,and especially by intraoperative cholangiography.Different types of accessory hepatic duct injury should be treated by different approaches. Accessory hepatic duct of type I might be cut and ligated.Type II accessory bile duct which(enters) the cystic duct and should be protected,but,if damaged,different methods of treatment are used,(depending) on the caliber of accessory hepatic duct.Type III and IV also should be protected,but,when damaged,the accessory hepatic duct should be repaired or performed an internal draining.

Objective To explore the diagnosis and treatment of primary hyperparathyroidism (PHPT). Methods Clinical data of 35 cases of PHPT were retrospectively analyzed. Results 23 out of 26 cases (88.5%) undergoing preoperative ultrasonography with a positive result were verified by intraoperative (findings). For ECT, the positive rate was 21 out of 23 cases (95.5%). Unilateral neck explorations (UNE) was performed in 27 cases of parathyroidoma. Two cases of parathyroid hyperplasia were treated by UNE and the other two cases by bilateral neck exploration (BNE). The procedure for 3 cases of parathyroid carcinoma was the same as that for papillary thyroid carcinoma. Unilateral resection of thyroid and parathyroid was done in a case of parathyroidoma with malignant change. Emergency excision of parathyroidoma, after (emergency) medical management, was performed in a patient with parathyroid storm, and the symptoms (subsided) postoperatively. All cases developed hypocalcemia in various degrees after surgery, but the symptoms were relieved with the use of calcium gluconate. Conclusions PHPT could be diagnosed according to (co-elevated) calcemia and PTH. Ultrasonography and ECT should be considered as the methods of first choice for preoperative localization. UNE of parathyroidoma could be feasible if accurate image localizations are (available). Radionuclear guided parathyroid resection could be performed in the patients with ectopic parathyroid disease or lesions without accurate localization. Aggressive surgical exploration after medical control of (symptoms) is the first choice of treatment when parathyroid storm is diagnosed.