Objective To introduce the standard procedure of Cattell Braasch maneuver and evaluate the complication and clinical value of this maneuver as a important exploration method in the surgery of pancreatic tumors. Method The clinical data of 13 cases of pancreatic tumors explored by Cattell Braanch maneuver before undergoing tumor resection were analyzed. Results Among these 13 cases there were 6 cases of tumors of the head (the pancreatic adeuocarcinoma in 4 cases, solid pseudo-papillary tumor and endocrine tumor in one each cases) and 7 cases of tumor of the body and tail of the pancreas (adenocarcinoma in 4 cases, solid pseudo-papillary tumor in 1 case, endocrine tumor in 2 cases) Pancreaticoduodenectomy was performed in 6 cases, including segmental resection of the tumor invading the superior mesenteric vein( SMV )with length varying from 3 to 7 cm and direct end-to-end reanastomosis in 3 cases. Distal pancreatectomy plus spleuectomy was performed in the other 7 cases, including the case in which extended tumor resection demanded left nephrectomy. Operations lasted from 2. 5 hrs to 11 hrs, in which only 10 ～ 15 mins were needed for Cattell Braasch maneuver . The blood lose was from 300 ml to 1000 ml. There were neither mortality nor severe complications in these series. Conclusion Cattell Braasch maneuver facilitates the exploration and tumor resection in patients suffering from pancreatic neoplasms especially malignances with better view of the operation field,it helps to avoid incidental iatrogenic injury, and also to the nongraft PV/SMV end-to-end anastomosis after the resection of tumor invaded segment.

Objective To explore the feasibility of a novel incisionless laparoscopic technique in the treatment of colorectal tumor, and evaluate the preliminary clinical result of this technique. Methods The clinical data of 12 consecutive resected specimens of high located rectal or sigmoid tumor removed by traditional laparoscopic surgery were analyzed to probe the indication of this technique and the first 2 cases received incisionless laparoscopic anterior resection. Postoperative follow up was made to evaluate the clinical feasibilities. Results Among 12 explanted fresh specimens there were 1 adenoma and 3 adenocarcinoma cases in which the key steps of the new technique were successfully demonstrated. In two cases, the bowel above the tumor was cut and the distal end was inverted and pulled through the anus laparoscopically, the tumor along with the bowel resected, the stump pushed hack, and intralumen sigmoidproctostomy fashioned. In these two patients, one of sigmoid cancer and one of large rectal adenoma with focal canceration, the mean operation time was 200 min, mean blood lose was 50 ml, mean bowel function recovery time was 1.5 days. After 13 and 15 respective months fullow up there was no complications nor tumor recurrence. Conclusions Ineisionless laparoscopic surgery, while in line with tumor free principles, has the advantage of safety, cost-effectiveness and being cosmetic in selected cases.

Objective:To discuss the role of incision for short-term outcomes of simultaneous resection in synchronous colorec-tal liver metastases (sCRLM). Methods:We reviewed the data of 37 patients who underwent simultaneous resection between January 2009 and December 2014 in our department and compared the short-term outcomes between Mercedes and midline incisions. Results:Mercedes and midline incisions were used in 19 and 18 patients, respectively. The two groups showed similarities in patient characteris-tics, major hepatectomy, surgery time, blood loss, and hilar block time. The midline group comprised more rectal cancer patients (P<0.001). The two groups did not differ significantly in complication incidence (47.4%vs. 16.7%, P=0.08) and postoperative stay time (22.1 ± 9.5 d vs. 17.2 ± 6.7 d, P=0.08). At body mass index (BMI)<25, the complication incidence (P=0.046) and postoperative stay time (P=0.051) were lower in the midline group than in the Mercedes group. Conclusion:Midline incision provided similar exposure in simultaneous resection for sCRLM and was better than Mercedes incision in rectal cancer patients. Patients with midline incision may attain better short-term outcomes if BMI is<25.

ObjectiveTo evaluate the clinical effecacy and safety of transurethral enucleation of submucosal bladder leiomyoma.MethodsAnalyze retrospectively the clinical data of 6 patients (2 male,4 female) of submucosal bladder leiomyoma. The mean age was 59 years (range 32- 78). The clinical manifestations included dysuresia in 3 cases, irritative bladder in 1 case, gross hematuria in 1 caes, and no clinical symptoms in 1 case. The mean course was 23 months (range 1 week-4 years). All the bladder tumors were indicated by ultrasonography, CT scan and cystoscopy, while 4 cases of bladder filling defects were showed by intravenous urogram. Before the tranaurethral enucleation of the bladder tumor, a deep needle biopsy and pathological examination were carried out to confirm the diagnosis of bladder leiomyoma. For the relatively small lateral leiomyomas, holium laser enucleation was carried out, while for the big ones, resectoscope enucleation was used to remove the mass. Biopsys were performed after complete removal of the tumor.ResultsTransurethral enucleation of 6 cases of submucosal bladder tumors were successful without any postoperative complication. All patients regained normal urination, and lower urinary tract irritation was relieved obviously and hematuria disappeared. No tumor recurrence or metastasis was found during the follow-up of 4 to 158 months.ConclusionsCystoscopy and transurethral biopsy are the most important methods for the diagnosis of submucosal bladder leiomyoma. The transurethral enucleation is a feasible and safe surgical technique for such patients with excellent results.

Objective: To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: A cross-sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture-level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing "watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of "watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher′s exact test for categorical variables. Results: Forty-eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3-year disease-free survival of patients with ypCR in their own hospitals. Fifty-five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over-treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%,70/77) and DWI-MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well-differentiated adenocarcinoma (68.8%, 53/77). Sixty-six surgeons (85.7%) believed that long-term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine + oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty-one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty-four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non-metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty-two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus-preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty-nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty-six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow-up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty-one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty-six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR. Conclusions Chinese surgeons seem to have inadequate knowledge of non-operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non-operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.

Objective To analyze the influencing factors and benchmark value of anesthesia cost in GB25 group in CHS-DRG Group Division Strategy(1.0),and explore the cost control strategy for surgical patients.Methods The data of 152 GB25 cases in sample hospitals were analyzed statistically.Through single factor analysis and multiple stepwise regression analysis,the influencing factors of anesthesia expenses were analyzed,and the evaluation system of hospital anesthesia expenses was built according to the payment standard of GB25 group and the average level of the city.Results Univariate analysis showed that there was significant difference in the influence of laparoscopic surgery or not,operation duration and anesthesiologist on anesthesia cost(P＜0.05);Stepwise regression further analysis showed that the length of operation and the anesthesiologist were the main influencing factors of anesthesia costs.Early warning shall be given when the anesthetic cost is greater than the median in the hospital,and rewards shall be given when the anesthetic cost is less than the average level in the city.Conclusion Hospitals should pay attention to standardize the diagnosis and treatment process,shorten the operation time,and reduce the anesthesia cost.At the same time,they should actively promote the clinical pathway management,and establish and improve the internal assessment mechanism of DRG.

OBJECTIVE To provide a reference for the standardized treatment of chronic obstructive pulmonary disease （COPD） and the adjustment of therapeutic drugs for COPD in the national essential medicine list. METHODS Relevant clinical experts， pharmaceutical experts and medical insurance experts were invited to sort out the COPD treatment drugs involved in the domestic and foreign COPD clinical guidelines， the national essential medicine list， the WHO standard list of essential medicine， the national medical insurance catalogue， and comparatively analyzed the COPD treatment drugs. RESULTS & CONCLUSIONS Compared with domestic clinical guidelines， foreign clinical guidelines included an additional COPD triple preparation， while involving fewer types of expectorants and antioxidants； there were only 12 kinds of COPD treatment drugs included in the WHO standard list of essential medicine， while there were 18 kinds in the national essential medicine list in China， and more theophylline drugs， expectorants and antioxidants were included. In addition， 15 kinds of COPD treatment drugs were found in both the national clinical guidelines and the national medical insurance catalogue， but not in the national essential medicine list， including terbutaline， levalbuterol hydrochloride， salmeterol， formoterol， indacaterol， beclometasone， mometasone furoate， salbutamol ipratropium， glycopyrronium formoterol， umeclidinium vilanterol， indacaterol glycopyrronium， beclometasone formoterol， budesonide/glycopyrrolate/formoterol fumarate， fluticasone furoate/vilanterol/umeclidinium， and fudosteine， which were mainly long-acting beta 2-agonists and COPD triple preparations. These drugs had certain evidence-based medicine evidence， their efficacy and economy had certain advantages， and their impact on the budget of the medical insurance fund was controllable. Therefore， it is suggested that the aforementioned drugs should be included in the essential medicines list in the subsequent update.

BACKGROUNDThe management of Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) is controversial due to the early recurrence after curative hepatectomy, and many variables were related to the prognosis. The purpose of this study was to predict the tumor recurrence in early postoperative period of the patients with BCLC stage B HCC.

METHODSFrom January 2004 to January 2012, 104 patients with BCLC stage B HCC underwent hepatectomy. Clinicopathological factors and follow-up data were statistically analyzed to establish a predicting scoring system.

RESULTSThe overall survival rates for one, three, and five years were 69.2%, 52.7%, and 42.3%, and the disease-free survival rates for one, three, and five years were 52.9%, 47.3%, and 37.5%, respectively. The multiple factors analysis showed that the micro-vessel invasion, lymph nodes metastasis, multiple lesions, and the high expression of HMGB1 were independent factors (P < 0.05). A scoring system was established to predict the early recurrence within one year after the surgery for BCLC stage B HCC, according to the analysis results with a specificity of 85.1% and a sensitivity of 80.3%.

CONCLUSIONVariant clinicopathological factors were associated with early postoperative recurrence for BCLC stage B HCC and recurrence early after hepatectomy was more likely in patients with a higher score of the scoring system.

Carcinoma, Hepatocellular ; metabolism ; pathology ; surgery ; Disease-Free Survival ; Female ; HMGA1a Protein ; metabolism ; Hepatectomy ; Humans ; Liver Neoplasms ; metabolism ; pathology ; surgery ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; Treatment Outcome

OBJECTIVETo explore the applicable value of transanal total mesorectal excision (taTME) in male low rectal cancer patients with narrow pelvis-"difficult pelvis", which remains difficult for both open and laparoscopic sphincter-saving operations.

METHODSClinical data of male low rectal cancer patients diagnosed by pathology undergoing taTME between June 2016 and January 2018 at Peking University Cancer Hospital were collected. A retrospective cohort study was performed. Patients were selected according to the following criteria: (1) low rectal cancer, the distance between inferior margin of tumor and anal verge ≤5 cm; (2) the distance between two sciatic tubercles <5 cm; (3) body mass index (BMI) >25 kg/m; (4) tumor horizontal diameter ≤4 cm. Operation time, intraoperative blood loss, postoperative hospital stay, postoperative complications and anal function were analyzed.

RESULTSA total of 20 patients were included in this study. All the patients received preoperative neoadjuvant chemoradiation and hybrid transabdominal and transanal surgery. The median BMI was 27.7(26.2-36.4) kg/m; the median distance between two sciatic tubercles was 92.5 (78-100) mm; the median distance between the inferior margin of tumor to the anal verge was 4 (2-5) cm; the median operation time was 302 (215-402) min; the median intraoperative blood loss was 100 (50-200) ml; the median postoperative hospital stay was 9 (5-15) d. Postoperative complications occurred in 5 patients (25%), including 3 pelvic infection, 1 intestinal obstruction, 1 anastomotic leakage receiving sigmoid colostomy. There was no perioperative death. Sphincter-preservation rate was 100%. Nineteen patients received anal manometry 1 month after operation with normal resting pressure (41.5±8.6) mmHg and squeeze pressure (121.0±11.6) mmHg. All the patients were followed up to March 2018, and the median follow-up time was 4.5 months. Only 1 patient had supraclavicular lymph node metastasis and no local recurrence was found.

CONCLUSIONSThe safety of transanal total mesorectal excision for male patients with low rectal cancer and difficult pelvis is acceptable. TaTME is helpful to preserve the anal sphincter.

Adult ; Anal Canal ; surgery ; Humans ; Laparoscopy ; Male ; Neoplasm Recurrence, Local ; Pelvis ; surgery ; Postoperative Complications ; Rectal Neoplasms ; surgery ; Retrospective Studies ; Treatment Outcome ; Universities