The main impacting factors on implementing clinical pathway were analyzed by applying fishbone diagram.The factors include policy factors,organizational factors and personal factors.It was suggested to improve the trial work of implementing clinical pathway management by reforming the medical care payment system,putting the clinical pathway management into the evaluation system,building up medical information system,putting more efforts on promotion and enhancing cooperation among related departments.

Objective To evaluate the safety and short‐term efficacy of delta‐shaped anastomosis in the Billroth‐I reconstruc‐tion of totally laparoscopic distal gastric cancer radical operation (TLDG) .Methods The clinical data in 35 patients with TLDG Delta anastomosis(TLDG group) and 35 patients with laparoscopic assisted distal gastric cancer radical operation (LADG) extraper‐itoneal anastomosis (LADG group) in the gastroenterology department of our hospital from January to December 2014 were ana‐lyzed retrospectively .The intraoperative bleeding volume ,operative time ,gastroenterological function recovery time ,hospitalization duration ,postoperative pathological examination results and hospitalization total cost were compared between the two groups .Re‐sults Seventy cases successfully completed the operation without the cases of conversion to laparotomy and death .The TLDG group had no anastomotic leakage ,bleeding and stenosis after operation ;while the LADG group had 1 case of gastroparesis ,1 case of anastomotic bleeding and 2 cases of anastomotic leakage .The introperative bleeding volume ,tumor size ,number of lymph nodes dissection and distant and proximal incisal margin distance had no statistically significant differences between the two groups (P>0 .05);the operation time ,digestive tract reconstruction time ,first exhaustion time ,time taking liquid diet and postoperative hospital stay time in the TLDG group were significantly shorter than those in LADG group (P< 0 .05) ,but the hospitalization cost was higher than that in the LADG group ,the differences were statistically significant (P<0 .05) .Conclusion The delta‐shaped anasto‐mosis technique is safe and feasible for using in LADG ,moreover has better short‐term effect .

Objective To explore a new surgical procedure for phallic reconstruction. Methods Since Dec 2003 to Nov 2006,4 patients with penile loss were reconstructed by transferring a deep in-ferior epigastric perforator(DIEP)flap with implanting the 12th costal cartilage. Results All of the flaDs survived successfully.With the follow-up from 5 months to 3 years,the appearance oi the neope-nis and donor-site scar was satisfactory. No one developed fistula or urethral stenosls, All patients were reported the return of erogenous sensibility of the neopenis leading to orgasm and achmving Pene-tration during sexual intercourse. Conclusions This new procedure may provide an esthetlcaIlY ac-ceDtable and functional neophallus.It might be a new alternative in penile reconstruction.

Objective To investigate the safety,feasibility and effectiveness of early oral feeding after colorectal surgery. Methods A randomized controlled trial enrolled 47 patients undergoing elective open colorectal surgery from May 2007 to November 2007. The patients were randomized into group of early oral feeding (experimental group) or group of traditional oral feeding(control group). Postoperative course, gastrointestinal function, and complications were evaluated. Results No statistically significant differences were found in clinical characteristics including age, types of procedures, times of surgery or comorbidity between the two groups. There was no perioperative mortality in the two groups. Stoma1 leak occurred and progressed to abdominal abscess in one case in the control group. Passage of flatus and defecation after operation was earlier in experimental group than in control group(1.9 ± 0. 6 d vs. 2. 8 ± 0. 9 d,P <0. 01). Length of postoperative intravenous infusion was shorter in the experimental group (3. 8 ± 0. 9 d vs. 4. 8 ± 1.2 d,P < 0. 01). Length of postoperative stay was also shorter (9.0 ± 3.2 d vs. 10. 0 ± 3. 3 d, P = 0. 27) and the rate of abdominal distension was lower in experimental group(27% vs. 44%, P = 0. 23). The rate of nausea and vomiting was higher in the experimental group(31% vs. 20% ,P =0. 35), the differences were of no significance. Reinsertion of nasogastric tube due to nausea and vomiting and reoperation was necessary in 2 patients in the experimental group and control group respectively. There were 3 patients complaining fever postoperatively in the control group. Conclusions Early oral feeding after colorectal surgery is safe and feasible, and it can promote postoperative recovery effectively.

AIM: To explore the histocompatibility of pinealocyte microencapsules in vivo. METHODS: The pineal glands of neonatal rats were removed under operating microscope and pinealocytes were isolated through collagenase and trypsin digestion. Pinealocytes were cultured for one week in vitro and collected immediately after digesting was encapsulated in APA microencapsules. The cells and empty capsules were transplanted into abdominal cavity or intermuscular space respectively and retrieved at the 15th or 30th day after operation. Morphological observation, HE staining, cell counting, and HPLC technique were used to analyze the shape, proliferation and function, the degree of inflammation fibrosis of retrieved microencapsules. RESULTS: The retrieve rate of cell capsule from abdominal cavity was about 85 % . The retrieved capsules had integrated profile mostly although some were damaged. The amount of macrophages attached to capsule wall and the thickness of wall increased gradually following the period of transplantation. However, the retrieve rate, wall thickness had no difference between retrieved cell and empty capsules at the same time. Secretion ability of pinealocytes in capsule retrieved at 15th day after operation decreased rapidly and those retrieved at 30th day after operation lossed secretion function. CONCLUSION: APA microencapsules had histocompatibility relatively in vivo and protected pinealocytes in capsule from immunologic rejection of the host. The survival time was about 20 days. During this period cells in capsule maintained activity and MT secretion ability.

Objective To elucidate the mutations of NPHS1 gene in children with sporadic steroid-resistant nephrotic syndrome (SRNS) in Southern Chinese Han ethnic group.Methods Peripheral blood samples were collected for genetic analysis from 40 patients with sporadic SRNS and 50 healthy volunteers as control.Genomic DNA was isolated from peripheral blood leucocytes.Twenty-nine exons and exon-intron boundaries of the NPHS1 gene were amplified by polymerase chain reaction.Mutational analysis was performed by DNA sequencing directly.Results Seven variants,928G＞A(D310N),2677A＞G (T893A),2869G＞C (V957L),IVS8+30C＞T,IVS21+14G＞A,IVS25-23C＞T and *142T＞C,of NPHS1 gene were found in 6 of 40 children with sporadic SRNS,whereas they were not found in 50 healthy controls.2677A ＞G,IVS8 +30C ＞T,IVS21 +14G＞A,IVS25-23C ＞T and *142T＞C were novel.Moreover,thirteen already reported NPHS1 polymorphisms,294C＞T,349G＞A,IVS3+15C＞T,IVS3+61A＞G,803G＞A,IVS8+68A＞G,1339G ＞A,1802G ＞C,2223C ＞T,2289C ＞T,IVS24 +36C ＞T,3315G＞A and IVS27 +45C ＞T,were detected in some patients and controls. Conclusions NPHS1 mutations in 6 of 40 children with sporadic SRNS in Southern Chinese Han ethnic group (15％) are detected.NPHS1 mutations are existed in Southern Chinese children,so it is necessary to perform the mutation analysis of NPHS1 gene in those children patients.

Objective To investigate the anatomy of the superficial epigastric artery perforator flap , and to provide anatomical basis for harvesting flap .Methods Of 27 SD rats, 7 were used for gross anatomy observation and anatomic characteristics and 20 rats for lead oxide-gelatin injection followed by computer picture processing , measurements and the related parameters recording .Results The superficial epigastric artery originated from femoral artery , and gave off its first branch when passed through the superficial fascia .The trunk branched into a lateral perforator and a medial perforator , which anastomosed with thoracodorsal artery and lateral thoracic artery , respectively .The average external diameter of superficial epigastric artery was (0.46 ±0.02)mm at its starting point,and(0.46 ±0.02)mm at the superficial fascia level . The nutritive area of superficial epigastric artery was (18.37 ±3.67) cm2 .The anastomosed area with thoracodorsal artery and lateral thoracic artery was(5.34 ±0.86)cm and(6.28 ±0.29)cm, respectively, away from the horizontal line through axillary,and (4.38 ±0.38)cm and(2.04 ±0.33)cm, respectively, away from the ventral median line.Conclusion The position and external diameter of superficial epigastric artery are constant , and the superficial epigastric artery perforator flap is a ideal flap model for research on free flap transplantation , flap supercharging , and hemodynamics .

Objective To build a multi‐level hierarchical structure model of the influencing factors for hierarchical medical system ,to identify the role relationship between all the factors and transmission pathways ,and to recommend on developing China′s hierarchical medical system . Methods Thirty influencing factors were identified in a screening based on literature review for the hierarchical medical system .On such basis ,16 influencing factors were identified by three health policy experts ,which affect operations of the current system .Interpretative structural modeling was called into play in the end to analyze the hierarchy relationship between various influencing factors and the conduction loops .Results There exist among the 16 factors a 3‐level hierarchical structureand two conduction loops .The factor directly limiting the hierarchical medical system is two‐way referral,and most internal core drivers arehuman resources development and governance mechanism.By means of self‐growth and external constraints ,they exert their influence on the operation of hierarchical medical system .Conclusions There are interactive hierarchical effects among the factors ,merging into three node elements of functional role,inter‐entity relationshipand patient participation.

Objective To study the clinical effect of total parathyroidectomy (TPTX) on treatment of secondary hyperparathyroidism (SHPT) in patients with chronic renal failure.Methods 24 patients undergoing TPTX in Mianyang Central Hospital from Jan.2014 to Nov.2016 were retrospectively analyzed.The preoperative,postoperative and follow-up intact parathyroid hormone (iPTH),serum calcium,serum phosphorus and calciumphosphorus product were statistically analyzed.The postoperative complications and recurrence were observed.Results For preoperative,1 week after operation,3 months after operation,6 months after operation,12 months after operation,24 months after operation and 36 months after operation,the mean values of iPTH were (1771.7± 244.5) pg/ml,(70.2±18.2) pg/ml,(106.5±35.3) pg/ml,(114.3±31.3) pg/ml,(122.1±27.8) pg/ml,(128.1±12.5) pg/ml and (113.8±24.9) pg/ml.The mean values of serum calcium were (2.6±0.4) mmol/L,(1.9±0.4) mmol/L,(2.1±0.3) mmol/L,(2.1±0.2) mmol/L,(1.8±0.2) mmol/L,(1.8±0.2) mmol/L and (1.8±0.3) mmol/L.The mean values of serum phosphorus were (2.1±0.7) mmol/L,(1.4±0.6) mmol/L,(1.3±0.4) mmol/L,(1.4±0.3) mmol/L,(1.3±0.3) mmol/L,(1.5±0.2) mmol/L and (1.4±0.4) mmol/L.The mean values of calcium-phosphorus product were (61.9±17.0) mg2/dl2,(34.6±19.4) mg2/dl2,(37.4±14.4) mg2/dl2,(40.4±12.3) mg2/dl2,(29.2±5.3) mg2/dl2,(35.0 ±7.1) mg2/dl2 and (32.4 ± 11.3) mg2/dl2,respectively.Compared with those before operation,postoperative iPTH,serum calcium,serum phosphorus and calcium-phosphorus product decreased significantly at 1 week after operation,3 months after operation,6 months after operation,12 months after operation,24 months after operation and 36 months after operation,and the differences had statistical significance (all P＜0.05).Temporary injury of recurrent laryngeal nerve was found in one patient (4.2％).Early postoperative hypocalcemia rate was 91.7％ (22/24).No recurrence developed after operation.Conclusion TPTX is safe and effective in treatment of SHPT in patients with chronic renal failure,with low recurrence rate and satisfactory treatment outcome.

OBJECTIVE：To investigate the s ynergy between centralized drug volume-based purchasing （called“volume- based purchasing”for short ）and medical insurance negotiation policy. METHODS ：From the aspects of economic and social benefits ， the synergy of volume-based purchasing and medical insurance negotiation was analyzed by using the methods of literature analysis，policy interpretation and interview. The corresponding suggestions were put forward for the problems of the supply and use of drugs. RESULTS & CONCLUSIONS ：The synergy of volume-based purchasing and medical insurance negotiation in terms of economic benefits include medical insurance fund management optimization to improve fund utilization efficiency improvement ； medical insurance fund payment optimization to reduce transaction cost ；network promotion of medical security information platform to reduce the cost of information exchange. The synergy of volume-based purchasing and medical insurance negotiation in terms of social benefits includes relevant index assessment of drug quality evaluation to improve drug quality evaluation system ； medical service level improvement to form compound medical insurance payment mode under total budget management ；enterprise supervision driven by market to reduce the pressure of government supervision. The relevant departments should continue to strengthen the comprehensive management of medical institutions to reduce the phenomenon of irrational drug use ；strengthen policy convergence ，avoid the poor implementation of medical insurance drug adjustment policy ，so that the policy dividend of volume-based purchasing and medical insurance negotiation can benefit the people more through system reform ，optimal allocation of funds ，etc.