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.

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 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 Endovascular stenting or combined stenting and Guglielmi detachable coils packing for the treatment of intracranial fusiform and wide necked aneurysms were reported to access the feasibility of the procedures.Methods The coronary stents were implanted across the neck of 3 vertebral fusiform aneurysms and 6 wide necked aneurysms. Microcatheters were introduced into the aneurysm sacs through stent mesh, and finally GDCs were used to embolize the aneurysms. Results The stents were precisely deployed resulting in total occlusion of 7 cases with more than 90% occlusion in 2 cases. All patients recovered well with patency of the parent arteries.Conclusions Endovascular therapy with combined stent implantation and microcoil placement maybe a valid alteration for the treatment of intracranial fusiform or wide necked aneurysms.

Objective To analyze the causes, prevention and treatment of repture druing procedure for intracranial aneurysm embolization with GDC.Methods All the seven patients were embolized. Six patients were ruptured during the procedure and continuously embolized until the bleeding was halted. Another one was identified by post procedure CT. Results Four patients recovered unevent fully with one only suffering from mild deficit. Another 2 patients died of hyper intracranial pressure within one week. Conclusions Rupture during procedure of intracranial aneurysm embolization with GDC may be related to manipulation, properties of the parent artery and arneurysm. Continuous embolization with GDC will provide favorable prognosis for the patients.

Objective To evaluate the endovascular embolization treatment of large and giant ophthalmic aneurysms. Methods Three aneurysms were embolized with coils only and 5 aneurysms were treated with stent placement togather with subsequent coiling. Results In the 3 aneurysms treated only with GDC, total embolization was achieved in 1 and partial embolization in 2. In the stent placement and coiling case, 4 aneurysms were densely packed and another one was partially packed. Conclusions Combined stenting and coiling is effective and safe for the treatment of large and giant ophthalmic artery aneurysm with the preservation of parent artery.

Objective To evaluate three dimensional digital subtraction angiography (3D DSA) in endovascular treatment of carotid stenosis. Methods In 138 patient with ischemic stroke, the shape and stenosis of carotid artery, the feasibility of endovascular treatment and the choice of the stent were analyzed by 2D DSA and 3D DSA. Results Comparing with 2D DSA,3D DSA could clearly depict the carotid artery in shape and stenosis with correct figuring of the feasibility for endovascular treatment and choice of the stent. Conclusions 3D DSA shows the major importance in endovascular treatment of carotid stenosis providing more valuable informations than 2D DSA.

Objective To evaluate the safety and short term outcome of stent assisted angioplasty for extracranial carotid stenosis. Methods From October 2000 to September 2002, 93 cases of extracranial carotid stenosis, including 86 cases of carotid bifurcation stenoses, 4 of extracranial internal carotid stenoses, 2 of common carotid stenoses and 1 of functional external carotid stenosis, were treated by self expandable stent placement and angioplasty. Results Stent placement and angioplasty were successfully administered in all the 93 patients. The average stenosis rate was reduced from (79.5?14.6)% before treatment to (11.2?7.8)% after stent assisted angioplasty. There were only 1 case of TIA (1.1%) and 1 case of minor stroke (1.1%) during the operation, without mortality or major stroke. No cerebral ischemic attach occurred in the 91 patients during clinical follow up for a period of 3 25 months with an average of 7.9 months. Twenty nine patients were angiographically followed up 6 months after treatment with only one asymptomatic restenosis (3.4%). Conclusions Endovascular stent assisted angioplasty for extracranial stenosis is safe and effective with considerable good short term outcome.

90%) and 1 incompletely (