Objective To evaluate the efficacy and safety of the damage-controlling surgery for the elderly patients with obstructive biliary diseases. Methods 278 elderly patients with obstructive biliary diseases were divided into the damage-controlling surgery group and definite surgery group.The obstructive biliary diseases were divided into the benign obstructive group and the malignant obstructive group. The complication rate and mortality between the 2 groups were analyzed and compared. Results One hundred and eighteen elderly patients were treated by damage-contolling surgery, its complication rate was 9.32 % and the mortality was 0 %. One hundred and sixty elderly patients,were treated by definite surgery, its complication rate was 24.38%, the mortality was 6.88%. There were significant differences in complication rate and mortality between the damage-controlling surgery group and the definite surgery group (all P＜0.01). The complication rate of the benign obstructive diseases group treated by damage-controlling surgery was 17.3%, the mortality was 0%. The complication rate of the benign obstructive diseases group treated by definite surgery was 16.3%, the mortality was 4.34%. There was no significant difference in the complication rate and mortality between the 2 groups (all P＞0.05). The complication rate and mortality of the malignant obstructive biliary diseases group treated by damage-controlling surgery were 4.45% and 0% respectively, and were 35.29% and 10.29% by definite surgery, there were significant differences in the complication rate and mortality between the 2 groups (P＜0.01 and P＜0.05). Conclusions Damage-controlling surgery may decrease the complication rate and mortality of the elderly patients with obstructive biliary diseases, and improve the operation safety of the elderly patients.

Objective To investigate bile leakage prevention in laparoscopic common bile duct (CBD) choledochoscopic exploration through micro-incision approach at the cystic duct-CBD junction.Methods From August 2007 to February 2015,a total of 147 cases undergoing laparoscopic CBD choledochoscopic exploration through micro-incision approach at the cystic duct-CBD junction were included in this study.From August 2007 to November 2012,57 patients were treated with laparoseopic CBD exploration (control group).From November 2012 to February 2015,90 patients were with optimized suture method of CBD (study group).The outcomes of patients in two groups were compared,including procedure time (PT),postoperative hospitalization time (PHT),and postoperative complications.Results In control group,the bile leakage rate was 5.3％,compared to 1.1％ in study group.There were significant differences in postoperative hospitalization time(t =1.98,P =0.0007) and hile leakage rate (x2 =139.5,P =0.04)between the two groups.Conclusions The prophylaxis measurements during operation are important to prevent bile leakage in laparoscopic CBD choledochoscopic exploration through micro-incision approach,including strict indications for micro-incision operation,proper expertise for laparoscopic cholecystectomy and laparoscopic suturing,choledochoscopic exploration,and suturing the whole layer of CBD wall,and carefully checking the suturing spot in case of bile leakage.T-tube placement is recommended while bile leakage is suspected.

Objective To investigate the management of pseudomyxoma peritonei originated in the appendix.Methods The clinical data of 51 patients with pseudomyxoma peritonei originated in the appendix who were admitted to the Beijing Hospital from 1970 to 2010 were retrospectively analyzed.The results of operation,reoperation,adjuvant treatment and follow-up were analyzed.The time from pseudomyxoma peritonei recurrence to the reoperation between patients who did or did not receive chemotherapy was compared by two tailed t test.Results Of the 51 patients,48 received operation,and the operation time was (135 ± 72 )minutes.Tumor recurrence was observed in 34 patients,and 16 of them received cytoreduction procedure,and 33 cytoreduction procedures were performed in total.The median time of follow-up was 49.7 months (range,3-132 months).The disease-specific survival was observed in 25 patients and disease-free survival in 16 patients.Four patients died of tumor recurrence or progression.The results of postoperative pathological examination confirmed that 19 patients were with benign disseminated peritoneal adenomucinosis (DPAM),26 were with malignant peritoneal mucinous carcinomatosis (PMCA) and 6 were with intermediate subtype (PMCA-1).The 3-,5- and 10-year survival rates were 75％ (38/51),55％ (28/51) and 22％ ( 11/51 ),respectively.The survival time and reoperation time interval for patients who received postoperative chemotherapy were ( 21 ± 4) months and ( 10 ± 6 ) months,which were longer than (19 ±7 )months and (7 ±4)months of those who did not receive postoperative chemotherapy (t =1.027,0.361,P ＞ 0.05).The median survival time of patients with benign DPAM,PMCA-1 and malignant PMCA were 96,63,23 months,respectively.The tumor recurrence interval for patients with benign DPAM and those with malignant PMCA were ( 15 ± 5 ) months and (7 ± 4) months,with significant difference ( t =2.193,P ＜ 0.05 ).Conclusions An active cytoreduction surgery is feasible for patients with pseudomyxoma peritonei originated in the appendix in improving survival.Repeated cytoreduction is a treatment of strategy to prolong the recurrence time and improve the prognosis of selected patients.

Objective To evaluate the intraoperative advantage and postoperative outcomes of threedimensional laparoscopic common bile duct (CBD) choledochoscopic exploration by micro-incision made at the cystic duct-CBD junction (LCBDEM) for gall stones and choledocholithiasis.Methods From January 2014 to December 2015,31 patients were operated under 3D LCBDEM (study group) and 37 patients under 2D LCBDEM (control group).The outcomes of patients in two groups were compared,including total procedure time (TPT),modified procedure time(MPT),suturing time(ST) and the wrong grasping per 100grasps(WG)of the LCBDEM.8 surgeons experienced in 3D LCBDEM were asked to fill in a subjective questionnaire.Results In control group,the TPT,MPT,ST and WG were (148 ± 47) min,(108 ± 42)min,(20 ±3)min and (19 ±4)per 100 grasps,respectively.In study group,the TPT,MPT,ST and WG were (148 ± 46) min,(9 1 ± 25) min,(1 8 ± 3) min and (8 ± 2) per 100 grasps,respectively.There were significant differences in MPT (t =-2.026,P ＜ 0.05),ST (t =-2.239,P ＜ 0.05) and WG (Z=-7.062,P ＜ 0.001).In subjective questionnaire survey,3D laparoscopy has advantages over 2D laparoscopy in visual and operation experience.But 3D laparoscopy made eyes more easily tired and dizzy.31 aparoscopy was inferior to 2D laparoscopy in spinning the camera around to get optimal field of vision.Conclusions 3D LCBDEM shortens procedure time and suturing time,increases operating accuracy and safety by providing high definition stereovision.

Objective To explore the advantages of the technique of bile duct mini-incision (BDM) for stone removal in choledocholithiasis,and to further clarify the indications for T tube insertion during surgery.Methods 85 BDM operations were performed.The use of MRCP (Magnetic resonance cholangiopancreatography),Advantage Workstation AW4.2 0.7sdc software,choledochoscopic imaging system and illustrations were used to study the applicability of the BDM technique in stone removal.Results The width of common bile duct (CBD) was usually over 8 mm in the patients with choledocholithiasis,and the width was related to the number and size of the stones.In the patients who had a CBD width of over 11mm (n 16),the MRCP stone imaging area (MRCP-SIA) was significantly larger when compared with that [(148±67)mm2 vs.(47±31)mm2,P＜0.05] in the patients (n=14) with CBD width of less than 11 mm.T tube insertion for secondary choledochoscopic examination should be performed when the stones were non drifting,multiple,and closely related to the lower part of CBD indicating difficulty in complete stone removal.Conclusions Unnecessary T tube insertion could be avoided by the BDM technique for stone removal which was especially suitable for patients with early diagnosis of choledocholithiasis.T tube insertion should only be performed in patients with difficulty in complete stone removal and in other complicated situations.

Objective To study the effect of inosine monophosphate dehydrogenase inhibitor (IMPDHI) on maturation, migration, endocytosis and allostimulatory properties of human peripheral myeloid dendritic cell (MDC). Methods PBMC from healthy donors were isolated. MDC were cocultured with PBMC and exposed to mycophenolic acid (MPA) for 48 h. The expression of co-stimulatory and adhesion molecules as well as chemokine receptors on MDC was analyzed by flow cytometry. In separate experiments,MDC were cultured with or without MPA, and their endocytosis function was estimated by means of FITC dextran uptake. MDC migration experiments were performed in Transwell chambers. Inflammatory chemo kines were added to the lower chambers and MDC numbers were analyzed by flow cytometry. MPA treated (48 h) BDCA-1 + DC served as stimulator cells in MLR. Allogenic healthy CD4 T responder cells were labeled with fluorescent dye CFSE and measured by flow cytometry. Results Maturation: compared to the control group, the expression of CD40, CD62L, HLA-DR, CD54, CD80, CD83 and CD86 on MDC in study group were significantly down-regulated ( P ＜ 0.05 ). Chemokine receptor and migration: compared to control group, the expression of CCR1 on MDC in study group was up-regulated significantly (17.02 ±3.23 vs 30.63 ± 9.13, P ＜ 0.05 ), the expression of CCR3 ( 10.26 ± 2.25 vs 5.81 ± 0.97, P ＜ 0.05 ) and CCR7(9.56 ± 1.84 vs 5.18 ±0.60, P ＜0. 05) on MDC were down-regulated significantly in the study group.MDC in study group showed enchanced migratory response to inflammatory chemokine CCL2, CCL3, CCL4,CCL7, CXCL12 (P＜0.05). Endocytotic capacity: the capacity of endocytosis in study group was signifi cantly higher than that in control group( P ＜ 0.05 ). Llostimulatory capacity: MPA-treated MDC exhibited a markedly reduced ability to stimulate allogenic CD4+ T cell proliferation. Conclusion Treatment of MDC with MPA exhibited an immature phenotype, a propensity to migrate in response to inflammatory chemokines, increased endocytotic capacity and impaired allogenic ability of MDC.

Objective To explore the effect of age on clinical postoperative outcomes of elderly patients with colorectal cancer undergoing surgical treatment. Methods The clinical data of 1249 patients from January 1999 to December 2007 were analyzed retrospectively, and patients were divided into two groups according to age; the study group (≥75 years, n=312) and the control group (<75 years, n=937). Results (1) The average age was significantly higher in study group than in control group (t=33.09,P<0.05), and the rates of malnutrition risk, co-morbidity, tumor in right colon and local Iymphonodus metastasis were significantly higher in study group than in control group (x2=47.33, 130.75, 21.24 and 45.33, P<0.05). ( 2 ) The rates of preoperative surgical complications, bowel obstruction and emergency operation were significantly higher in study group than in control group (x2 =26.81, 34.14 and 10.72, P<0.05) . The rate of resection was significantly lower in study group than in control group (x2 =9.732, P<0.05). (3) The overall incidences of postoperative complications, general complications and mortality of perioperative period were significantly higher in study group than in control group (x2= 19.38, 20.75 and 10.11,P<0.05). (4) The two-year survival and five-year survival were significantly lower in study group than in control group (x2=11.91 and 27.17, P<0.05), but there were no significant differences in the cancer-specific two-year survival and five-year survival between the both groups. Conclusions Preoperative complications and co-morbidities, local tumor metastasis and postoperative nonsurgical complications adversely affect the postoperative outcomes for elderly patients with colorectal cancer.

Objective Common bile duct stones are common in elderly patients.The laparoscopic transcystic approach with micro-incision of the cystic duct confluence in common bile duct exploration (LTM-CBDE) is a modified laparoscopic transcystic approach.This study evaluated the safety and efficacy of LTM-CBDE in the elderly (≥65 years) patients with choledocholithiasis and compared the results in the elderly with those in younger patients.Methods In this retrospective analysis,128 patients underwent LTM-CBDE from March 2007 to December 2013.The patients were divided into two groups:aged ≥65 years (n=50,the elderly group) versus aged ＜65 years (n=78,the younger group).The preoperative morbidity rate,American Society of Anesthesiologists (ASA) score,previous abdominal operations,operation time,postoperative hospital stay,open conversion rate,postoperative complication rate,residual stone rate,recurrence rate and mortality rate were compared between the both groups.Results The preoperative morbidity (41 vs.28) and ASA score (2.5± 0.7 vs.1.8±0.6) were higher in the elderly group than in he younger group (x2=26.063,t=-6.030,P =0.000,in both).No significant differences in previous abdominal operations,operation time,postoperative hospital stay,open conversion rate,postoperative complication rate,residual stone rate,recurrence rate and mortality rate (P＞0.05) were found between the two groups from March 2007 to December 2013.Conclusions LTM-CBDE is a safe and effective treatment procedure for elderly patients with choledocholithiasis.For LTM-CBDE-suitable patients,we recommend LTM-CBDE as the treatment of choice.

Objective To explore the theory of curriculum contents for gerontological nurse practitioner training which is suitable for the situation of our country. Method Delphi technique was used in this research to build content indicators of gerontological nurse practitioner training curricu-lum, and calculate the variation coefficient. Results The theory training curriculum includes founda-tions of gerontological nursing, geriatric syndrome, facilitating physiological balance and general gero-tological care modules and 41 core indexs. Every coefficient of variation is less than 20 percent [(4.35±0.71), (4.63±0.57), (4.55±0.57), (4.67±0.55)]. The mean values of the importance (4.54± 0.622) and general characteristics are more than four. Conclusion The content setting of the geron-tological nurse practitioner training theory course not only highlights the training characteristics of the geriatric care, but also has comprehensive and systematic content, reflects humanistic care spirit and pays attention to developing nurses’clinical practice ability. Therefore, it is worthy of reference and promotion.

ObjectiveTo study the feasibility and technique in liver transplantation (LT) in an adult with situs inversus (SI) and reviewed the medical literature on this subject.MethodsA 45-year-old male with complete SI,suffered from progressive hepatic failure secondary to hepatolithiasis,obstructive jaundice,portal hypertension and liver cirrhosis.He underwent liver transplantation in July 2004.His anatomy was studied by preoperative CT scan and three-dimensional liver reconstruction imaging and angiography.LT was performed using the modified piggyback technique.The donor right liver was rotated 45 degree to the left,making the donor left liver pointing to the left paracolic sulcus and the donor right liver was in the recipient hepatic fossa.The donor suprahepatic vena cava was anastomosed end-to-side to the recipient vena cava,and the infrahepatic vena cava was closed by oversewing.ResultThe patient recovered uneventfully.His liver function was stable during a follow-up of 75 months.ConclusionLT in patients with SI is safe and feasible.Exact determination of the anatomy,comprehensive preoperative planning,and good technique in liver transplantation play important roles in LT for patients with SI.