Objective To provide a series of surgical approaches for treatment of bone lesions in ankle and foot. Methods Based on the anatomic investigations,vascularized cuboid bone,medial cuneiform bone,navicular bone and lateral part of calcaneum bone grafting were designed for repaired bone lesions in the area of ankle and foot,and applied to 55 clinic cases. Results Forty-eight cases among them were followed up from 1 year to 10 years,4 years and 6 month in average,the results were satisfactory. Conclusion The designed four types of vascularized tarsal bone flaps are easy and reliable for dissection because of their superficial pedicle.

OBJECTIVETo investigate the morphological features of the perforator from the first plantar metatarsal artery, so as to provide anatomic basis for the reconstruction of soft-tissue defects of the forefoot.

METHODSThe first metatarsophalangeal joint was chosen as the landmark on 30 human cadaveric feet prefused with red latex. The following contents were observed under surgical magnifier: (1)The origin, courses,branches,distribution of the perforator of the first plantar metatarsal artery; (2)The anastomoses among the perforator of the first plantar metatarsal artery and other arteries on the medial aspect of the foot. Simulated operation was performed on one fresh specimen.

RESULTSThe perforator of the first plantar metatarsal artery passed through the space between the tendon, the abductor hallucis and the first metatarsal bone, and its entry point into the deep fascia was located (2. 3 ± 0.7 ) cm proximal to the first metatarsophalangeal joint. The perforator anastomosed with either the medial tarsal artery, the medial anterior malleolus artery or the branch of the medial plantar artery on the superior margin of the abductor hallucis, forming a longitudinal arterial chain,through which small branches were given off to the skin of the medial aspect of the foot. The perforator was( 1. 1 ± 0.2) mm in diameter and(3.2 ± 0.2) cm in length.

CONCLUSIONThe flap based on the perforator of the first plantar metatarsal artery can be harvested as an axial flap to repair the defects of soft tissue on the forefoot.

Anatomic Landmarks ; anatomy & histology ; Arteries ; anatomy & histology ; Cadaver ; Foot ; Foot Injuries ; surgery ; Humans ; Metatarsal Bones ; blood supply ; Metatarsophalangeal Joint ; anatomy & histology ; Muscle, Skeletal ; anatomy & histology ; Perforator Flap ; blood supply ; Reconstructive Surgical Procedures

Objective: To summarize our clinical experience and management of an anomalous proximal bile duct joining the cystic duct in laparoscopic cholecystectomy (LC). Methods: A retrospective study was conducted on 8 patients who had an anomalous right anterior bile duct joining the cystic duct who were treated at the Hunan Provincial People's Hospital from March 2003 to January 2019. Results: All the 8 patients were diagnosed to have gallstones cholecystitis on preoperative CT, MRI and abdominal ultrasound. There were no suggestions of an anomalous bile duct. A total of 6 patients underwent reoperation after LC due to abdominal pain and biliary peritonitis. These 6 patients were treated with drainage and T-tube insertion. In the other 2 patients, the anomalous bile duct opening which joined the cystic duct were detected during LC. There was one patient converted to open laparotomy with preservation of the cystic duct and underwent common bile duct T-tube drainage. The other patients continued with laparoscopic surgery. The cystic duct was partially resected with removal of gallbladder, followed by common bile duct drainage. The average follow-up period was 3.4 years and the results were satisfactory. Conclusions Biliary duct anomaly is the main cause of iatrogenic proximal bile duct injury during laparoscopic cholecystectomy. It is not uncommon to have the anomaly of insertion of right anterior segmental bile duct to the cystic duct. To avoid iatrogenic biliary tract injury, careful preoperative study of X-ray films, accurate identification of the intraoperative gallbladder triangle anatomical structures. Strict adherence to carry out the three-word procedure of " discrimination, cut, identify" will help to reduce the incidence of biliary tract complications in laparoscopic cholecystectomy.

Objective To investigate the clinical effects of laparoscopic pancreaticoduodenectomy (LPD) for distal cholangiocarcinoma.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 37 patients who underwent LPD for distal cholangiocarcinoma in the Hunan Provincial People's Hospital between January 2013 and November 2016 were collected.LPD for distal cholangiocarcinoma was performed using the "en-block" procedure.According to the principle of "one axis,two planes and four zones",anatomy used posterior approach,anterior approach and medial approach,lymph node dissection was performed from carotid sheath outside,and en bloc specimens were resected.Observation indicators:(1) surgical and postoperative recovery situations;(2) postoperative pathological examination;(3) follow-up and survival situations.Follow-up using outpatient examination was performed to detect the patients' recurrence-free survival up to November 2017.Measurement data with normal distribution were represented as (x)±s.The survival curve and rate were drawn and calculated by the Kaplan-Meier method.Results (1) Surgical and postoperative recovery situations:all the 37 patients underwent successful LPD,without conversion to open surgery and perioperative death.The operation time,volume of blood loss and case with intraoperative blood transfusion were (326 ± 55) minutes,(176± 39)mL and 1,respectively.The time to initial exsufflation and time for diet intake were respectively (4.5± 1.6)days and (5.3±2.7)days.Of 37 patients,14 had postoperative complications,including 8 with pancreatic fistula (6 with biochemical fistula and 2 with grade B pancreatic fistula),1 with biliary fistula,3 with postoperative bleeding (2 with intra-abdominal bleeding and 1 with gastrointestinal anastomosis bleeding),2 with delayed gastric emptying (grage A),2 with intra-abdominal infection and 2 with pulmonary infection;the same patients can merge multiple complications.Three patients were in Clavien-Dindo classification ≥ Ⅲ.One patient received reoperation and other patients were improved by symptomatic treatment.Duration of hospital stay of 37 patients was 13.5 days (range,8.0-33.0 days).Eight patients underwent adjuvant chemotherapy of 4-6 cycles by taking orally tegafur or gemcitabine with cisplatin.(2) Postoperative pathological examination:tumor diameter and pancreatic duct diameter of 37 patients were (2.1±1.1)cm and (2.5±1.2) mm,respectively.Of 37 patients,9,13 and 15 were respectively detected in high-differentiated,moderate-differentiated and lowdifferentiated adenocarcinoma.Surgical margins:35 patients received R0 resection and 2 received R1 resection.Number of lymph node dissected,cases with lymph node metastasis and number of positive lymph nodes were respectively 18.5±4.9,16 and 1.7± 1.4.Analysis of lymph node metastasis location showed that the positive rates in 8a,12,13,14 and 17 groups lymph nodes were respectively 5.4％ (2/37),18.9％ (7/37),21.6％ (8/37),8.1％ (3/37) and 10.8％ (4/37);Perineural invasion (PNI),lymphovascular invasion (LVI),pancreatic invasion and duodenal invasion were identified in 14,9,16 and 6 patients,respectively.TNM stage:stage 0,Ⅰ A,Ⅰ B,ⅡA and Ⅱ B were respectively detected in 1,3,5,12 and 16 patients.(3) Follow-up situation:of 37 patients,36 were followed up for 6-45 months,with a median time of 26 months.The median recurrence-free survival time,1-and 3-year recurrence-free survival rates were respectively 28 months,80.6％ and 42.2％.Conclusion LPD is safe and effective for distal cholangiocarcinoma,and "en-block" resection not only helps to optimize the process of LPD for distal cholangiocarcinoma,but also has a significant effect on R0 resection and lymph node dissection.

Objective To investigate the diagnosis, treatments for primary hepatic neuroendocrine neoplasm (NEN) and the efficacy.Methods Clinical data of 10 patients with primary hepatic NEN admitted in Hunan People's Hospital from March 2013 to December 2015 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. There were 3 males and 7 females, aged 21-65 years old and the median age was 45 years old. According to the WHO classification for digestive system tumor 2010 version, there were 6 cases of neuroendocrine tumor (NET) G2, and 4 cases of neuroendocrine carcinoma (NEC). The clinical data, imaging characteristics, treatment, tumor pathological characteristics and prognosis of the patients were analyzed.Results Right upper abdominal pain was observed in 5 cases, right upper abdominal mass in 1 case, asthenia and anorexia1 in 1 case, and the remaining 3 cases were found with tumor when receiving routine physical examination. For imaging finding, 8 cases were diagnosed as isolated liver mass, and 2 were found with multiple masses in the liver. All of the 10 patients were confirmed by pathological examination, of which 3 were diagnosed by biopsy before operation, and 7 were confirmed with pathology after operation. 6 cases underwent radical resection, 1 case received microwave ablation, 1 underwent liver resection and intravenous chemotherapy pump implantation, 1 received chemotherapy alone and 1 abandoned treatment. To the submission date of this article, 6 cases survived without recurrence, 1 case suffered recurrence 1 month after operation with multiple lymph node metastases in the peritoneum and remained alive. 2 cases died, 1 of which died of no treatment after biopsy, 1 died of multiple distant metastases after 1 period of chemotherapy, and 1 lost follow-up.Conclusions There is no specific clinical manifestations of hepatic NEN. It should be confirmed by pathological examination. Surgical resection is the first choice for treatment. For patients with unresectable mass, TACE, microwave ablation and chemotherapy can be applied.

Objective:To explore the risk factors for overall complications after laparoscopic pancreaticoduodenectomy(LPD) and to establish postoperative pancreatic fistula prediction model for LPD.Methods:The clinical data of 176 patients undergoing LPD from Jan 2014 to Mar 2018 were retrospectively analyzed.Results:One died within 30 days. Five patients underwent reoperation. Seventy-three patients (41%) had complications including pancreatic fistula in 30 cases(17.0%), postoperative hemorrhage in 16 (9.1%); bile leakage in 10 (5.7%); abdominal infection in 6 (3.4%); wound infection in 4 (2.2%); pulmonary infection in 4 (2.2%); gastric emptying disorder in 3 (1.7%). Age, intraoperative blood loss, diabetes mellitus were risk factors for overall postoperative complications of LPD(all P<0.05); Age, male gender, pancreatic duct diameter, pancreas texture, lesion size were risk factors for pancreatic fistula after LPD(all P<0.05). Conclusions:Age, intraoperative blood loss, diabetes mellitus were risk factors for overall postoperative complications of LPD; Age, male gender, pancreatic duct diameter, pancreas texture, and lesion size were risk factors for pancreatic fistula after LPD.