Precision medicine significantly promotes the diagnosis and treatment of various diseases,which also induces the revolution of evidence-based clinical practice guidelines,as well as multimodality therapy for hepatocellular carcinoma (HCC).In the application of the concept of precision medicine and evidence-based medicine,surgeons will concretize the precise surgery,establish an improved multimodality therapy for HCC,and ultimately achieve the goal of overall benefit.This is also a new task of surgeons in the precision medicine era.

Compared with the regeneration ability of normal liver,that of liver with cirrhosis is so weak that its reserve function is insufficient,resulting in a great increase of chance of liver failure after partial hepatectomy,and limiting the development of major hepatectomy.It has been demonstrated that the hepatocytes of cirrhosis still possess the suppressed ability of regeneration.The morphological structures as well as physiological functions of regenerated hepatocytes are not complete.The important mechanisms leading to the impairment of regeneration ability include pathophysiologic changes such as excessive deposition of extracellular matrix and the capillarization,the imbalance of energy metabolism of hepatocytes and disruptive secretion of sinus endothelial cells and so on.The clinical observation is that many factors can stimulate the regeneration of liver with cirrhosis,including radiofrequency ablation,partial hepatectomy,associated liver partition and portal vein ligation for staged hepatectomy,splenectomy,drugs,cell transplantation,tokines et al.It is of great significance to promote the regeneration ability of liver with cirrhosis associated with various approaches reasonably for enhancing the security of partial hepatectomy and treatment of end-stage liver diseases.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is used for patients with advanced hepatocellular carcinoma who cannot tolerate major hepatectomy due to an insufficient future liver remnant,but the morbidity and mortality rate in the perioperative period are still high.Available studies indicate that damage control surgery variations such as laparoscopic procedure and associating radiofrequency/microwave ablation/liver tourniquet and portal vein ligation could improve the morbidity and mortality associated with ALPPS,as could portal vein embolization.However,randomized controlled trials are needed to determine benefits in technical variations.

Various bile duct injuries caused bile leakage or biliary obstruction and severe secondary long-term complications which threaten patients' survival.At present, confirmative surgeries to reconstruct bile flow into gastrointestinal tract remains as a major resort to treat bile duct injury.Successful reconstruction mainly depends on experienced surgeons armed with precisely biliary surgical technology.Surgical repair should be based on cautious preoperative assessment and identification of bile duct injury.The basic principle of reconstruction includes that anastomosis is performed on the healthy bile duct with sufficient blood supply and without inflammation, ischemia and scar.The core of reconstruction includes the exposure of proximal and distal bile ducts and preparation of materials for repair and anastomosis.The definite goal of this surgery is to build up an unobstructed biliary drainage, tension-free mucosa with sufficient blood supply for mucosa anastomosis.

Objective To investigate the feasibility of spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy for the treatment of pancreatic cystic tumor of body and tail.Methods The clinical data of a female patient with pancreatic cystic tumor of body and tail who was admitted to the Sun Yat-Sen Memorial Hospital of the Sun Yat-Sen University in March 2013 were retrospectively analyzed.Spleen-and splenic vesselspreserving laparoscopic distal pancreatectomy was determined as the optimal therapeutic method according to the physical examination and the results of computered tomography scan.Laparoscopic or open operation combined with distal pancreatectomy and splenectomy would be carried out as a candidate choice once it is hard to separate the splenic artery and vein from distal pancreas or to control the serious vessels hemorrhage.The patient was followed up by outpatient examination every 1 to 3 months up to March 2015.Results Spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy was finished successfully.The operation time and volume of intraoperative blood loss were 192 minutes and 50 mL,respectively.The patient took out-of-bed for activity at postoperative day 1 without complications.The multiple severe microcystic pancreatic adenoma was confirmed by postoperative pathological examination,with a maximum diameter of 3.5cm.The leakage tube was removed at postoperative day 5.The levels of serum amylase at postoperative day 1,3,5 were normal.The patient was discharged at postoperative day 8 and got regular follow-up without bleeding,pancreatic fistula,infection and a symptom of epigastric pain or discomfort.Conclusion Spleen-and splenic vessels-preserving laparoscopic distal pancreatectomy has advantages of less traumas,faster postoperative recovery and a preservation of normal splenic function,deserving clinical application.

Objective To discuss the application of endoscopic techniques in the treatment of calculus of intrahepatic or extrahepatic duct. Methods Laparoscopy in conjunction with duodenoscopy or cholangioscopy was adopted in 96 cases of calculus of intrahepatic or extrahepatic duct, including 72 cases of cholecystolithiasis complicated by choledocholithiasis, 16 cases of simple choledocholithiasis and 8 cases of left intrahepatic duct calculus complicated by choledocholithiasis. The surgical procedures included laparoscopic cholecystectomy (LC) combined with EST (37 cases), LC combined with cholangioscopic exploration (54 cases), and laparoscopic left hepatic lobectomy combined with cholangioscopic exploration (5 cases). Results Postoperative re-examination revealed no residual calculus in 93 out of 96 patients. Small amounts of biliary leakage occurred in 4 patients and healed spontaneously within a mean time of 10 days. No other severe complications took place. A conversion to open surgery was required in 3 patients, 2 of which were high bile duct stricture and 1 of which were severe portal adhesion. Conclusions Endoscopy in the treatment of calculus of intrahepatic or extrahepatic duct is feasible. Proper application of multiple endoscopic techniques is a safe, effective and minimally invasive means for the treatment of cholelithiasis.

Objective To compare the effects between epidural and general anesthesia for laparoscopic cholecystectomy. Methods A total of 500 cases scheduled for laparoscopic cholecystectomy (LC) were randomly divided into the epidural anesthesia group (Group E, n=250) and the general anesthesia group (Group G, n=250). Results (1) Hemodynamic parameters: in both groups the cardiac output (CO) decreased significantly after CO 2 pneumoperitoneum ( P 0 05), without significant differences between the two groups; the central venous pressure (CVP) was transiently elevated after pneumoperitoneum ( P 0 05), with significant differences between the two groups ( P 0 05), without significant differences between the two groups. (2) Ventilative parameters: the mean airway pressure (P AWM ) and the peak airway pressure (P peak ) were remarkably elevated during the course of pneumoperitoneum in the Group G ( P

0.05).Conclusions Epidural anesthesia and lower pneumoperitoneum pressure(8 mm Hg) can completely meet with demands of most LC operations,and have the advantages of safety,economy and minimal invasion.

Objective To evaluate the effect of clonidine as an adjuvant of PCEA with morphine and ropivacaine in patients with essential hypertension and it' s effects on hemodynamics and plasma concentrations of endothelin-1 ( ET-1) and calcium gene-related peptide ( CGRP) . Methods Sixty ASAⅠ - Ⅱ patients of both sexes (24 males, 36 females) with a history of essential hypertension for 1-2 years were included in this study. The patients ranged in age from 45-72 yrs and in body weight 55-70 kg and were scheduled for elective pelvic surgery under combined general-epidural anesthesia. An epidural catheter was placed at T12-L1 or L1-2 interspace before induction of general anesthesia. Anesthesia was induced with fentanyl 4 ?g ? kg-1 , propofol 2 mg?kg-1 and vecuronium 0.1 mg?kg-1 and maintained with isoflurane and epidural analgesia. The patients received PCEA after operation. The PCEA regimen included a loading dose of 5 ml followed by background infusion at 2 ml?h-1 with an 1 ml bolus dose and a 15 min lockout interval. The PCEA solution contained morphine 2 mg + ropivacaine 75 mg in group A (n = 20); clonidine 150 ?g + morphine 2 mg + ropivacaine 75 mg in group B ( n = 20) ; clonidine 300 ?g + morphine 2 mg + ropivacaine 75 mg in group C ( n = 20) in 60 ml of normal saline. BP, HR, VAS pain score (0 = no pain, 10 worst pain) and Ramsay sedation score (1 = wide awake, 5-6 over sedated) were recorded one day before operation (T0), before induction of anesthesia (T1 ), 0, 5, 15, 30, 60 min, 2, 4, 8, 20, 24 h (T2-11 ) after PCEA was commenced. Blood samples were taken before induction of anesthesia (baseline) and 6 and 24 h after operation for determination of plasma concentrations of ET-1 and CGRP. The total number of button pressing (D1) and the number of actual delivery of bolus dose (D2) and the consumption of PCEA solution were also recorded. Results VAS pain score was significantly higher in group A than that in group B and C ( P

Objective To compare the effects of laparoscopic hepatectomy (LH) versus conventional laparotomy hepatectomy (CLH) on cellular immunity. Methods Fifteen ASA Ⅱ-Ⅲ patients aged 34-61 yrs, weighing 48-75 kg undergoing laparoscopic hepatectomy (LH) were studied. Another 15 patients aged 33-64 yrs, weighing 46-73 kg undergoing conventional laparotomy hepatectomy (CLH) served as control. The preoperative liver function was rated as Child classification A in both groups. The patients were premedicated with phenobarbital 0.1 g and atropine 0.5 mg i.m. . Anesthesia was induced with fenlanyl 4 ?g?kg-1, propofol 1.5 mg?kg-1 and succinylcholine 2 mg?kg-1. After tracheal intubation the patients were mechanically ventilated and PETCO2 was maintained at 35-45 mm Hg. Anesthesia was maintained with inhalation of isoflurane (MAC 1.0?0.31) and 60% N2O in O2 and intermittent i.v. boluses of vecuronium. The patients received after operation patient-controlled epidural analgesia (PCEA) with 0.125% ropivacaine and morphine 0.05 ?g?kg-1?min-1. Radial artery and right internal jugular vein were cannulated for BP and CVP monitoring. Peripheral venous blood samples were taken before operation and on the 1 st and 3rd postoperative day for determination of CD3+ , CD4+ , CD8+ T cells (by flow cytometry) and IL-6, TNF-?concentrations (ELBA) . Results CD3+ , CD4+ and CD8+ counts were significantly decreased while IL-6 and TNF-?levels were significantly increased on the 1st postoperative day compared with the baseline values before operation in both groups but there was no significant difference between the two groups. On the 3rd postoperative day CD3+ , CD4+ and CD8+ counts and IL-6, TNF-?levels returned to preoperative level in group LH while in group CLH CD3+ , CD4+ , CD8+ remained low and IL-6, TNF-?levels remained high.Conclusion The results suggest that LH exerts less effects on immune function than conventional laparotomy technique.