Objective To introduce the standard procedure of Cattell Braasch maneuver and evaluate the complication and clinical value of this maneuver as a important exploration method in the surgery of pancreatic tumors. Method The clinical data of 13 cases of pancreatic tumors explored by Cattell Braanch maneuver before undergoing tumor resection were analyzed. Results Among these 13 cases there were 6 cases of tumors of the head (the pancreatic adeuocarcinoma in 4 cases, solid pseudo-papillary tumor and endocrine tumor in one each cases) and 7 cases of tumor of the body and tail of the pancreas (adenocarcinoma in 4 cases, solid pseudo-papillary tumor in 1 case, endocrine tumor in 2 cases) Pancreaticoduodenectomy was performed in 6 cases, including segmental resection of the tumor invading the superior mesenteric vein( SMV )with length varying from 3 to 7 cm and direct end-to-end reanastomosis in 3 cases. Distal pancreatectomy plus spleuectomy was performed in the other 7 cases, including the case in which extended tumor resection demanded left nephrectomy. Operations lasted from 2. 5 hrs to 11 hrs, in which only 10 ～ 15 mins were needed for Cattell Braasch maneuver . The blood lose was from 300 ml to 1000 ml. There were neither mortality nor severe complications in these series. Conclusion Cattell Braasch maneuver facilitates the exploration and tumor resection in patients suffering from pancreatic neoplasms especially malignances with better view of the operation field,it helps to avoid incidental iatrogenic injury, and also to the nongraft PV/SMV end-to-end anastomosis after the resection of tumor invaded segment.

Objective To explore the feasibility of a novel incisionless laparoscopic technique in the treatment of colorectal tumor, and evaluate the preliminary clinical result of this technique. Methods The clinical data of 12 consecutive resected specimens of high located rectal or sigmoid tumor removed by traditional laparoscopic surgery were analyzed to probe the indication of this technique and the first 2 cases received incisionless laparoscopic anterior resection. Postoperative follow up was made to evaluate the clinical feasibilities. Results Among 12 explanted fresh specimens there were 1 adenoma and 3 adenocarcinoma cases in which the key steps of the new technique were successfully demonstrated. In two cases, the bowel above the tumor was cut and the distal end was inverted and pulled through the anus laparoscopically, the tumor along with the bowel resected, the stump pushed hack, and intralumen sigmoidproctostomy fashioned. In these two patients, one of sigmoid cancer and one of large rectal adenoma with focal canceration, the mean operation time was 200 min, mean blood lose was 50 ml, mean bowel function recovery time was 1.5 days. After 13 and 15 respective months fullow up there was no complications nor tumor recurrence. Conclusions Ineisionless laparoscopic surgery, while in line with tumor free principles, has the advantage of safety, cost-effectiveness and being cosmetic in selected cases.

Objective:To discuss the role of incision for short-term outcomes of simultaneous resection in synchronous colorec-tal liver metastases (sCRLM). Methods:We reviewed the data of 37 patients who underwent simultaneous resection between January 2009 and December 2014 in our department and compared the short-term outcomes between Mercedes and midline incisions. Results:Mercedes and midline incisions were used in 19 and 18 patients, respectively. The two groups showed similarities in patient characteris-tics, major hepatectomy, surgery time, blood loss, and hilar block time. The midline group comprised more rectal cancer patients (P<0.001). The two groups did not differ significantly in complication incidence (47.4%vs. 16.7%, P=0.08) and postoperative stay time (22.1 ± 9.5 d vs. 17.2 ± 6.7 d, P=0.08). At body mass index (BMI)<25, the complication incidence (P=0.046) and postoperative stay time (P=0.051) were lower in the midline group than in the Mercedes group. Conclusion:Midline incision provided similar exposure in simultaneous resection for sCRLM and was better than Mercedes incision in rectal cancer patients. Patients with midline incision may attain better short-term outcomes if BMI is<25.

ObjectiveTo evaluate the clinical effecacy and safety of transurethral enucleation of submucosal bladder leiomyoma.MethodsAnalyze retrospectively the clinical data of 6 patients (2 male,4 female) of submucosal bladder leiomyoma. The mean age was 59 years (range 32- 78). The clinical manifestations included dysuresia in 3 cases, irritative bladder in 1 case, gross hematuria in 1 caes, and no clinical symptoms in 1 case. The mean course was 23 months (range 1 week-4 years). All the bladder tumors were indicated by ultrasonography, CT scan and cystoscopy, while 4 cases of bladder filling defects were showed by intravenous urogram. Before the tranaurethral enucleation of the bladder tumor, a deep needle biopsy and pathological examination were carried out to confirm the diagnosis of bladder leiomyoma. For the relatively small lateral leiomyomas, holium laser enucleation was carried out, while for the big ones, resectoscope enucleation was used to remove the mass. Biopsys were performed after complete removal of the tumor.ResultsTransurethral enucleation of 6 cases of submucosal bladder tumors were successful without any postoperative complication. All patients regained normal urination, and lower urinary tract irritation was relieved obviously and hematuria disappeared. No tumor recurrence or metastasis was found during the follow-up of 4 to 158 months.ConclusionsCystoscopy and transurethral biopsy are the most important methods for the diagnosis of submucosal bladder leiomyoma. The transurethral enucleation is a feasible and safe surgical technique for such patients with excellent results.

Objective To design and produce serial shock tubes and further examine their application to experimental studies on blast injury.Methods Bio-medical engineering technique was used for the design and development of the serial shock tubes. One thousand four hundred and fifty nine animals (757 rats, 105 guinea pigs, 335 rabbits, 240 dogs and 22 sheep) were then used to test the wounding effects of the shock tubes.Results Three types of bio-shock tubes, that is, large-, medium- and small-scale shock tubes were made in our laboratory. The large-scale shock tube is 39 meters long; the inner diameter of the test section is 1 meter; and the maximum overpressure in the driving section is 10.3 MPa. A negative pressure could be formed by means of the reflected rarefactive wave produced by the end plate. The medium-scale shock tube is 34.5 meters long; the maximum overpressure in the driving section is 22 MPa; the test section is designed to be a knockdown, showing 5 basic types with inner diameter of 77 to 600 millimeters, which could be used for researches on overpressure, explosive decompression, underwater explosion, and so on. The small-scale shock tube is 0.5 meter long with the maximum endured overpressure of 68.6 MPa. Results from animal experiments showed that this set of shock tubes could induce various degrees of systemic or local blast injury in large or small animals. Conclusions This set of bio-shock tubes can approximately simulate typical explosive wave produced by nuclear or charge explosion, and inflict various degrees of blast injury characterized by stability and reproducibility. Therefore, they can meet the needs of blast research on large and small animals.

Objective: To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: A cross-sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture-level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing "watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of "watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher′s exact test for categorical variables. Results: Forty-eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3-year disease-free survival of patients with ypCR in their own hospitals. Fifty-five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over-treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%,70/77) and DWI-MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well-differentiated adenocarcinoma (68.8%, 53/77). Sixty-six surgeons (85.7%) believed that long-term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine + oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty-one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty-four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non-metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty-two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus-preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty-nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty-six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow-up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty-one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty-six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR. Conclusions Chinese surgeons seem to have inadequate knowledge of non-operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non-operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.

Objective To analyze the influencing factors and benchmark value of anesthesia cost in GB25 group in CHS-DRG Group Division Strategy(1.0),and explore the cost control strategy for surgical patients.Methods The data of 152 GB25 cases in sample hospitals were analyzed statistically.Through single factor analysis and multiple stepwise regression analysis,the influencing factors of anesthesia expenses were analyzed,and the evaluation system of hospital anesthesia expenses was built according to the payment standard of GB25 group and the average level of the city.Results Univariate analysis showed that there was significant difference in the influence of laparoscopic surgery or not,operation duration and anesthesiologist on anesthesia cost(P＜0.05);Stepwise regression further analysis showed that the length of operation and the anesthesiologist were the main influencing factors of anesthesia costs.Early warning shall be given when the anesthetic cost is greater than the median in the hospital,and rewards shall be given when the anesthetic cost is less than the average level in the city.Conclusion Hospitals should pay attention to standardize the diagnosis and treatment process,shorten the operation time,and reduce the anesthesia cost.At the same time,they should actively promote the clinical pathway management,and establish and improve the internal assessment mechanism of DRG.

OBJECTIVE To provide a reference for the standardized treatment of chronic obstructive pulmonary disease （COPD） and the adjustment of therapeutic drugs for COPD in the national essential medicine list. METHODS Relevant clinical experts， pharmaceutical experts and medical insurance experts were invited to sort out the COPD treatment drugs involved in the domestic and foreign COPD clinical guidelines， the national essential medicine list， the WHO standard list of essential medicine， the national medical insurance catalogue， and comparatively analyzed the COPD treatment drugs. RESULTS & CONCLUSIONS Compared with domestic clinical guidelines， foreign clinical guidelines included an additional COPD triple preparation， while involving fewer types of expectorants and antioxidants； there were only 12 kinds of COPD treatment drugs included in the WHO standard list of essential medicine， while there were 18 kinds in the national essential medicine list in China， and more theophylline drugs， expectorants and antioxidants were included. In addition， 15 kinds of COPD treatment drugs were found in both the national clinical guidelines and the national medical insurance catalogue， but not in the national essential medicine list， including terbutaline， levalbuterol hydrochloride， salmeterol， formoterol， indacaterol， beclometasone， mometasone furoate， salbutamol ipratropium， glycopyrronium formoterol， umeclidinium vilanterol， indacaterol glycopyrronium， beclometasone formoterol， budesonide/glycopyrrolate/formoterol fumarate， fluticasone furoate/vilanterol/umeclidinium， and fudosteine， which were mainly long-acting beta 2-agonists and COPD triple preparations. These drugs had certain evidence-based medicine evidence， their efficacy and economy had certain advantages， and their impact on the budget of the medical insurance fund was controllable. Therefore， it is suggested that the aforementioned drugs should be included in the essential medicines list in the subsequent update.

Objective To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods A cross?sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture?level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing"watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of"watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher′ s exact test for categorical variables. Results Forty?eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3?year disease?free survival of patients with ypCR in their own hospitals. Fifty?five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over?treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%, 70/77) and DWI?MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well?differentiated adenocarcinoma (68.8%, 53/77). Sixty?six surgeons (85.7%) believed that long?term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine+oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty?one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty?four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non?metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty?two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus?preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty?nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty?six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow?up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty?one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty?six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR. Conclusions Chinese surgeons seem to have inadequate knowledge of non?operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non?operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.