Pancreaticoduodenectomy (PD) is the procedure for treating adenocarcinoma in periampullary region.This involves resection of multiple organs and complex reconstructions.The modern surgery has witnessed the dramatic improvement in outcomes after PD.Mortality has dropped to less than 4％,however,the complication rate remains high,making this procedure still a big challenge for most surgeons. PD is so complicated that even small mistakes could jeopardize the whole procedure and outcomes.With experiences of over 1000 PDs,we discuss the challenges of this procedure and strategies to deal with them.

With the advancement of the health reform and development of medical services,and performance evaluation of fine management,have become a major means to regulate medical services, improve quality of medical services, and promote healthy functioning of hospitals. The Hospital Authority worked out the performance evaluation standards for municipal hospitals. Setup of such financial evaluation indices as cost control rate,basic operation and healthcare materials for 10 000 yuan medical revenue,per-capita income and expenditure balance,implementation of fiscal input,and asset turnover.Finance and asset management of municipal public hospitals were subject to a general assessment and comparative analysis. Assessment results were linked to the hospital ’s annual performance bonuses.This enables the financial indicators and assessment to play a key role for hospitals to reduce costs,improve efficiency and strengthen fine management. Hospitals were encouraged to achieve balanced income and expenditure, surpluses, asset efficiency, performance budgeting, cost controls,decent financial operations.

Objective To analyse the failed total hip arthroplasty(THA) and to improve its long term results. Methods Thirty five patients(36 hips) undergone revision THA from November 1996 to April 1999, were grouped according to the different causes of the primary failed THA. Results Statistical analysis failed to show the factors related to the failures. In any one failed case, the causes were usually more then one item. The most common causes of failed surgery found in 24 cases were aseptic loosening and peri prosthetic osteolysis, wear out of acetabulum was seen in 7, malpositioned prostheses in 6 and postoperative dislocation in 3. Infection and fracture of femoral stem happened in 3 and 2 patients respectively. Conclusion THA has been extensively used as an effective procedure for the reconstruction of hip joint. Long term excellent clinical results are related to strict selection of indications, appropriate prosthesis, and finally the experience and surgical technique of the surgeon are also of importance to the final outcome.

Objective To investigate the indication, preoperative evaluation, technical tip, prevention and treatment of complications, effect, and clinical use of the embolization of intracranial aneurysms by using GDCs. Methods From July 1998 to February 2000,93 patients with 118 intracranial aneurysms were embolized using GDCs, including 84 ruptured aneurysms (Hunt-Hess grade, Ⅰ 18 cases, Ⅱ 29 cases, Ⅲ 25 cases, Ⅳ 10 cases, Ⅴ 2 cases). 72 patients were treated at emergency, and 48 patients had CTA examination preoperatively. The operations were completed under the DSA monitoring. Continuous lumbar subarachnoid drainage was instituted and standard 3H treatment was given postoperatively. Results Total occlusion was achieved in 104 aneurysms(88 14%), over 90% in 11aneurysms(9.32%), less than 90% in 3 aneurysms(2 54%), with 3 patients (3/93, 3 23%) died in the cohort. One case rebleeded after 1.5 months and was cured by surgical clipping, 2 patients experienced enlargement of the aneurysmal neck and were reembolized. Following-up was performed from 2 to 22 months, 1 had severe disability, 7 had mild neurological deficit symptoms. Conclusion The results of short-term follow-up suggested that embolization of intracranial aneurysms with GDCs be microtraumatic, safe, effective, and reliable. Partial packing may result in continuous enlargement, rupture, and bleeding, while tight coil packing in aneurysms was reliable. The ruptured aneurysms need emergency embolization, and postoperative continuous lumbar subarachnoid drainage can enhance curative effect significantly.

Objective To report the treatment of intracranial fusiform or wide-necked aneurysms with combined endovascular stenting and Guglielmi detachable coils packing, and to evaluate its indication, technique, outcome, and complications. Methods The coronary stents were implanted across the necks of 5 fusiform aneurysms and 12 wide-necked aneurysms. Microcatheters were introduced into the aneurysmal sac through stent mesh, and GDCs were used to embolize the aneurysms. Results The stents were deployed in 16 cases, and total occlusion was obtained in 13 cases,while more than 90% in 3 cases. One aneurysm was embolized with GDCs alone after the attempt of stenting was failed. All the patients recovered well with patency of the parent arteries. Conclusion Endovascular therapy combined with stent implantation and microcoil placement may be a valid alteration for the treatment of intracranial fusiform or wide-necked aneurysms. Further study was necessary for long-term outcome.

Objective To summarize the technique and efficiency of combined endovascular stenting and Guglielmi detachable coils (GDC) packing for the treatment of intracranial wide-necked bifurcation aneurysms and recanalized aneurysms.Methods The coronary stents were implanted across the necks of 5 intracranial wide-necked aneurysms (two at bifurcation of ICA, one at basilar artery and two recanalized PcoA aneurysms). The porous stents covered the ostia of vital side branches and perforating vessels in three cases. Microcatheters were introduced into the aneurysmal sac through the stent mesh and then followed by GDCs embolizing the aneurysms. Results The stents were deployed in parent artery in all cases. Total occlusion was obtained in 4 cases, while more than 90% in one case with patency of the parent arteries and vital perforating arteries. Follow-up angiography performed in all patients 3-6 months later revealed no intra-stent stenosis. All the patients recovered well except Ⅲ nerve palsy in one patient which diminished 3 months later.Conclusion Endovaseular therapy combined stent implantation and microcoil placement maybe a valid alteration for the treatment of wide-necked bifurcation aneurysms and recanalized aneurysms, which shows promise clinical application in the future. The ostia of vital side branches covered with stents showed no effect on hemodynamics.

Objective Try to find out the feasibility and curative effect of the treatment of DAVF with stenosed drainage vein by implantation of stent.Methods A patient of complicated DAVF with stenosed drainage vein ,stent was implanted in the stenosed drainage vein to improve the function of vien. Results The procedure was successful. The symptom of the patient improved obviously. Cerebral angiography after six month revealed the fine shape and location of the stent. The fistulas of lateral sinus and sigmoid sinus showed no obvious change comparing with the formers.Conclusions The treatment of DAVF with stenosed drainage vein by implantation of stent is feasible. The short term curative effect is satisfactory and the long-term one is still wait for follow-up.

Objective To evaluate the use of three-dimensional (3D) digital subtraction angiography (DSA) in endovascular treatment of carotid stenosis.Methods In 216 patient of ischemic stroke,carotid artery shape,stenosis,the feasibility of endovascular treatment and the choosing of the stent were analyzed at 2D DSA and 3D DSA. Results Comparing with 2D DSA,3D DSA can clearly depicted the carotid artery shape and stenosis.3D DSA can correctly judge the feasibility of endovascular treatment,can correctly choose the stent.Conclusions 3D DSA is very important in endovascular treatment of carotid stenosis.It can provide many valuable information for endovascular treatmen that 2D DSA can not provide.

Objective We analyzed the incidence and treatment of symptomatic vasospasm after early endovascular therapy of ruptured aneurysms by endovascular embolization.Methods 329 patients classified as Hunt-Hess grades Ⅰto Ⅲ were embolized within 72 hours after aneurysm rupture. Symptomatic vasospasm was diagnosed as the onset of delayed neurological deterioration with evidence of angiographic or transcranial Doppler studies. Results Symptomatic vasospasm occurred in 62 patients (18.2%). Both Hunt-Hess grade and Fisher's scale before treatment correlated with the incidence of cerebral vasospasm. Among the 62 patients suffered from symptomatic vasospasm, 41 patients recovered well, 13 were moderately disabled, 6 were severely disabled and 2 patients died. Conclusions The incidence of symptomatic vasospasm was relatively low as compared to conventional open surgery. lumber puncture cerebral spinal fluid drainage may play an important role in reducing the incidence of cerebral vasospasm.