Pancreaticoduodenectomy (PD) is the procedure for treating adenocarcinoma in periampullary region.This involves resection of multiple organs and complex reconstructions.The modern surgery has witnessed the dramatic improvement in outcomes after PD.Mortality has dropped to less than 4％,however,the complication rate remains high,making this procedure still a big challenge for most surgeons. PD is so complicated that even small mistakes could jeopardize the whole procedure and outcomes.With experiences of over 1000 PDs,we discuss the challenges of this procedure and strategies to deal with them.

The da Vinci robotic surgical system assisted colorectal radical resection has been widely applied in many countries and regions.The advantages of the da Vinci robotic surgical system include stable and distinct stereoscopic vision,short learning curve,convenient operation and feasibility of remote manipulation,while its disadvantages are expensive cost,lack of tremor and prolonged operation time.The advantage of da Vinci robotic surgical system is not distinct when compared with traditional laparoscope in radical resection of colorectal cancer.With the accumulation of clinical data and the update of the system,the prospect of da Vinci robotic surgical system assisted colorectal radical resection is promising.

BACKGROUND:Lumbar disc herniation is a clinical syndrome of lumbar pain and radiated pain of the lower limb induced by biochemical changes after intervertebral disc degeneration. Transforaminal endoscopic spine system (TESSYS) and Yeung endoscopic spine system (YESS) are commonly used in the clinic, but their effects are different.
OBJECTIVE:To compare the curative effect of TESSYS and YESS in treatment of lumbar disc herniation. METHODS:Fol ow-up data of 134 cases of lumbar disc herniation were retrospectively analyzed. They were assigned to TESSYS group (n=76) and YESS group (n=58). Intraoperative condition, pain at various time points after repair, and lumbar function changes were compared between the two groups.
RESULTS AND CONCLUSION:(1) No significant difference in Visual Analogue Scale and Oswestry Disability Index scores was detected between the two groups before repair (P>0.05). At 1, 3, and 6 months after repair and during final fol ow-up, above scores were significantly decreased in both groups (P<0.05). Above scores were significantly lower in the TESSYS group than in the YESS group at various time points after repair (P<0.05). (2) No significant difference in Japanese Orthopedic Association score was found between the two groups before repair (P>0.05). Japanese Orthopedic Association score was greater in the TESSYS group than in the YESS group at 1, 3 and 6 months fol owing repair and during final fol ow-up (P<0.05). (3) The excel ent and good rate was significantly greater in the TESSYS group than in the YESS group during final fol ow-up (P<0.05). (4) Operation time and incision length were significantly shorter in the TESSYS group than in the YESS group. No significant difference in the amount of bleeding was detectable between the two groups (P>0.05). Results suggest that TESSYS for lumbar disc herniation was characterized by smal trauma, mild pain and good recovery of function.

Objective To investigate the prevalence of gastroeaophageat reflux disease(GERD)in the end stage renal disease patients(ESRD)with maintenance hemodialysis and the pathogenetic factors of GERD.Methods 60 cases who had heart burn and acid regurgitation symptoms were enrolled,31 cases of them were ESRD patients with maintenance hemodialysis,29 patients who were renal diseases free as control group.GERD was diagnosed by three methods:endoscopy,24h esophageal pH monitoring,endoscopic esophageal biopsy.GERD was established if any of these tests was positive.HP infection and serum gastrin were assessed too.Results (1)The prevalences of GERD in two groups were 83.9%,79.3% respectively and had no significant difference(P＞0.05).(2)The prevalence of HP infection in the ESRD group was significantly lower than control group(19 4% vs 51.7%,P＜0.05).(3)The concentration of serum gastrin in the ESRD group and control group was(102.61±30.80)ng/ml and (83.41±20.61)ng/ml,two group had significant difference(P＜0.05).Conclusion The prevalence of GERD inthe ESRD patients was higher than expected,and was correlated with absence of HP infection and hypergastinemia.

Objective To comparatively investigate the characteristics of bone metabolism in forelimb malformation WHBE rabbits based on the OPG/RANK/RANKL system.Methods Healthy male 2-2.5-month old WHBE rabbit ( HWR) , Healthy Japanese rabbit ( HJR) and forelimb malformation WHBE rabbit ( FMWR) were used in this study and divided into 3 groups, HWR, HJR and FMWR groups, with 10 rabbits in each group.The shape of forelimb and mean gray value observed from X-ray film were examined, and the bone tissue micro-morphology was analyzed using HE staining.Re-al-time fluorescence quantitative PCR was used to determine the expression of osteoprotegerin ( OPG) and receptor activator of NF-KB ligand ( RANKL) mRNA.The expressions of OPG, receptor activator of NF-KB ( RANK) and RANKL protein in serum and bone tissue were assayed by enzyme-linked immunoassay ( ELISA) and immunohistochemistry, respectively. Results Compared with the HWR and HJR groups, rabbits in the FMWR group appeared abnormal in toutuous forelimb and thinner bone cortex.The mean gray values of X-ray in the FMWR group were lower than that in the HWR group ( P<0.05).There were significant differences between the FMWR and healthy rabbits (HWR and HJR) in the following pa-rameters:RANKL mRNA expression and RANKL/OPG mRNA ratio in the liver(P<0.05, P<0.01), serum protein expression of RANK and RANKL and RANKL/OPG ratio (P<0.05, P<0.01), and positive index of expression of RANKL protein and RANKL/OPG ratio in the bone tissue(P<0.05, P<0.01).Furthermore, the gene expression lev-els of OPG and RANKL of HWR were significantly higher than that of HJR(P<0.05, P<0.01).Conclusions The FMWR show some abnormal symptoms in bone metabolism as well as decrease of bone quality and histological changes of bone micro-structure, due to the significant increase of RANKL/OPG ratio of FMWR.The breed differences between WHBE and Japanese rabbits in RANKL mRNA expression level may be one of factors inducing limb malformation in the WHBE rabbits.

Objective To explore the impact of executive function intervention on the executive functioning of elderly patients with cerebral infarction,and to seek the best way to improve executive function in such patients.Methods Eighty elderly patients with cerebral infarction were randomly divided into an intervention group and a control group.A series of executive function interventions were administered to those in the intervention group with no intervention in the control group.The two groups were given the same conventional medication.The Behavioral Assessment of the Dysexecutive Syndrome (BADS) was taken before the intervention,then 3 months and 6 months after recruitment.Results In the intervention group the average score and the total standard score had increased significantly after 3 months except for the action program test and the modified six elements test.Both indicators were still significantly increased from the baseline afar 6 months except for the modified six elements test.The average score and the total standard score had increased significantly between 3 months and 6 months except on the key search test.Both the time determination test and the total standard score had statistically significant average differences.The control group showed no significant differences.After 3 months,the average scores and the total test standard scores in the intervention group were signifieantiy higher than those in control group except on the action program test.The rules conversion card test,the time determination test and the total standard score difference all showed statistically significant differences between the groups.After 6 months the intervention group's scores remained significantly higher than those of the control group except on the action program test.Conclusions Executive function interventions are effective in delaying the progress and improving the prognosis of executive dysfunction in elderly patients with cerebral infarction,and the therapy has persistent effects.

Objective To observe the curative effect of refractory ascites with ascitic ultrafiltration and reinfusion into abdominal cavity.Methods Thirty-seven patients diganosed as refractory ascites were given ultrafiltration and reinfusion into abdominal cavity.The following parameters were detected respectively:24h urine volume,abdomen circumference,heart rate,blood pressure,serum electrolytes,serum albumin,total serum bilirubin.Results After treatment,the 24h urine volume increased and abdomen circumference decreasd significantly (P ＜ 0.01 ).There was no significant difference in heart rate,blood pressure,serum electrolytes,serum albumin and total serum bilirubin before and after treatment (P ＞0.05).Conclusion Ascitic ultrafiltration and reinfusion into abdominal cavity has some effects on refractory ascites.

Objective To approach work pressure and its influencing factors in general surgical nurses. Methods 105 general surgical nurses were selected from 8 hospitals with stratification clus-tering randomization methods. The job stressor inventory,- personality scale, coping styles questionnaire and general state of health questionnaire were used to carry out investigation and the results underwent analysis. Results The main stressors came from the factor of workload and time allocation, then from nursing specialty and job. Working time more than 10 years, undergraduate degree or above, work shift, neuroticism, wrapping, avoidance, letting off were risk factors of work pressure in general surgical nurses. Age more than 40 years old, nurse and associate director, exotrophy, planning to solve the ques-tions, seeking social support, rational coping were protective factors of work pressure for nurses. Con-clusions The overall pressure level of general surgical nurses was moderate. We should cultivate favourable personality of nurses and positive coping styles in combination with their demography char-acters to prevent work pressure.

BACKGROUND: Calcium sulfate (CS) is a good bone conduction material due to its good biocompatibility and degradability. However, simple CS lacks of osteoinductive capability, so it can not satisfy clinical requirements.OBJECTIVE: To verify the potential ofCS/bone matrix gelatin (BMG) composite biomaterial in the repair of segmental bone defects.DESIGN, TIME AND SETTING: An in vivo multi-dimensional observation was performed in the Laboratory Animal Center, Nanfang Hospital, Southern Medical University between December 2004 and April 2006.MATERIALS: Twenty-one healthy adult New Zealand rabbits, weighing 2.5-3.5 kg, were included. The segmental ulnar defects of 15 mm were created bilaterally. CS and BMG were self-prepared.METHODS: CS and BMG were composited at 2:1 and then implanted into 15-mm rabbit ulnar bone defect. The present study consisted of 3 groups: CS/BMG group, defects were filled with CS/BMG; CS group, defects were filled with CS; and blank control group, untreated control defects.MAIN OUTCOME MEASURES: At weeks 4, 8, and 12 post-surgery, repair of bone defect was observed by gross observation, radiographic, histomorphological and tetracycline tracing analysis.RESULTS: Surgical incisions all primarily healed. No inflammatory or foreign reaction was found around all the defects. Both CS/BMG and CS were almost completely absorbed at week 8 post-surgery. In the CS/BMG group, newly formed bone was found throughout the defects after 4 weeks; all defects were repaired with a well-organized trabecular pattern and a thit neocortex after 12 weeks. In the CS group, mass of new bone tissue formed at the periphery of the defect at week 4 post-surgery, but the development of new bone in the center of defect was latter compared with the CS/BMG group: at 12 weeks, all defects were bridged by newly formed bone tissue with little adjacent medullary bone. In the blank control group, slight new bone was found at the periphery of the defect region, and the defects were filled with fibrous tissue.CONCLUSION: CS/BMG composite is totally bioresorbable and biocompatible. The composite can repair bone defects effectively as a bone graft substitute.

Objective To explore the immunoregulatory and lethal effects of natural killer T lymphocytes(NKTs) in vitro .Meth‐ods The mixed lymphocyte cultured(MLC) system was established ,in which the B16F10‐luc‐G5 cells were set as target cells ,the total lymphocyte cells were set as effector cells .(1)In the experiment on immunoregulatory effects ,NKT lymphocytes or CD4+CD25+ T lymphocytes were set as regulating cells ,there was three groups ,including the NKT group ,CD4+CD25+ T group and pure target cell control group .Otherewise ,the 1640 blank control group was set by only adding RPMI1640 solution .(2)In the ex‐periment on antitumor effects ,the NKT or natural killer(NK) lymphocytes were set as killer cells ,there was three groups ,inclu‐ding the NKT group ,NK group and pure target cell control group .Mixed culturing 24 ,48 and 72 hours ,the bioluminescence of target cells in MCL system was detected by using the in vivo imaging system .Results (1)In the experiment on immunoregulatory effects ,there were statistically significant differences in measured average photon numbers between NKT group ,CD4+ CD25+ T group and the two control groups(P<0 .05) .The statistically significant differences were also found in the NKT group between 24 hours and 72 hours (P<0 .05) .(2)In the experiment on antitumor effects ,there were statistically significant differences in meas‐ured average photon numbers ,when the NKT group and NK group were compared to the pure target cell control group(P<0 .05) . After culturing 24 and 72 hours ,statistically significant differences were found between NKT group and NK group(P<0 .05) .Con‐clusion The NKT cells could inhibit the lethal effects of lymphocyte cells on target cells ,and the inhibitory effects are changed by the length of culturing .Compared with the CD4+CD25+ T lymphocytes ,NKT lymphocytes have strongger regulatory effects .Addi‐tionally ,the NKT cells have lethal effects on target cells ,which might be weaker than that of NK cells .