Objective To evaluate the effect of infiltration anesthesia at Calot's triangle on postoperative analgesia in the patients undergoing laparoscopic cholecystectomy.Methods One hundred and forty patients,aged 18-64 yr,with 18 kg/m2 ≤ body mass index ≤ 31 kg/m2,of ASA physical status Ⅰ or Ⅱ,scheduled for elective laparoscopic cholecystectomy,were randomly divided into 2 groups (n =70 each):control group (group A) and infiltration anesthesia at Calot's triangle group (group B).In group B,1％ ropivacaine 10 ml was injected into Calot's triangle before dissection of the gallbladder,while the equal volume of normal saline was injected into Calot's triangle in group A.The patients in both groups received patient-controlled intravenous analgesia (PCIA) for 48 h starting from 10 min before the end of surgery.The VAS score was maintained below 4 during PCIA.When VAS score ≥ 4,lasting for more than 30 min,tramadol 1.5 mg/kg was injected intravenously.The consumption of physic liquor for PCIA,and requirement for tramadol were recorded.The incidence of puncture-related damage to Calot's triangle and local anesthetic intoxication and adverse effects such as nausea and vomiting within 48 h after surgery were also recorded.The first postoperative flatus time was recorded.Results Compared with group A,the consumption of physic liquor for PCIA,requirement for tramadol,and consumption of tramadol were significantly reduced,and no significant change was found in the incidence of nausea and vomiting and the first postoperative flatus time in group B.No puncture-related damage to Calot's triangle occurred in A and B groups.There was no local anesthetic intoxication in group B.Conclusion Infiltration anesthesia at Calot's triangle can optimize postoperative analgesia in the patients undergoing laparoscopic cholecystectomy.

Objective To evaluate the value of 2D ultrasound and elastic strain ratio (SR) in diagnosis of thyroid nodule by fine needle aspiration (FNA).Methods 196 thyroid nodules were analyzed retrospectively with 2D ultrasound,elastography and FNA results,pathology results as the golden standard.A receiver operating characteristic (ROC) curve was used to identify the best cut-off point of SR.The Logistic regression analysis was used to evaluate the variables effectiveness on age,nodule echo,calcification and SR.Tried to discuss how to use SR before or after US-FNA in diagnosis of thyroid nodule.Results The SR of the malignant nodules group was significantly different from the benign nodules group,and the best cut-off point was 0.5 with sensitivity 91.7％,specificity 90.2 ％ and accuracy 90.8 ％.The Logistic analysis results were SR,age,echo,calcification according to the odds ratio.SR can screened nodules without puncture necessary before FNA,and increase the FNA sensitivity,specificity and accuracy after FNA.Conclusions SR has good application value in diagnosis thyroid malignant tumor.SR can reduce unnecessary FNA and make a supplementary diagnosis of FNA.

BACKGROUND:Knowledge of retropedtoneal space communications might influence catheter placement,and understanding the normal anatomy of the retroperitoneal space is a prerequisite for predicting the distribution of inflammation or other fluid collections in this region. Until recent years,the media/ attachment of the posterior renal fascia remained controversial. The multiple detector spiral CT can show the abdominal anatomic details. So,using the multiple-detector spiral CT to study the anatomy of posterior renal fascia has clinical significance. OBJECTIVE:To describe the medial attachment of the posterior renal fascia by using multiple-detector spiral CT. DESIGN,TIME AND SETTING:A retrospective case analysis was performed at Department of Radiology,Affiliated Hospital of Weifang Medical College between June 2003 and November 2007. PARTICIPANTS:A total of 52 patients with retropedtoneal inflammatory diseases were retrospectively reviewed through analysis of their CT data. METHODS:Toshiba Akuilion 16-detector spiral CT was employed for scanning. Of the 52 patients,15 were proved by clinical and laboratory findings and 37 were proved by surgery and pathology. Among the 52 patients,17 suffered from appendicitis,1 from ureteritis,2 from abscesses in the perirenal space,3 from abscesses in the posterior pararenal space,and 29 from pancreatltis. MAIN OUTCOME MEASURES:Medial attachment of the bilateral posterior renal fascia. RESULTS:At the level of the upper pole of kidney,the posterior renal fascia fused with the fascia of the ipsilateral quadratus lumborum muscle. Forty-six patients manifested the attachment site of the left posterior renal fascia transforming from the quadratus lumborum muscle fasciae to the psoas major muscle fascia at the level of the lower pole of kidney or the infrarenal space. Fifty patients showed the attachment site of the right posterior renal fascia transforming from the quadratus lumborum muscle fascia to the psoas major muscle fascia at the level of the lower pole of kidney or the infrarenal space. CONCLUSION:The posterior renal fascia attachment site is not the same all the time. At different levels,the attachment site of the posterior renal fascia is distinct.

BackgroundWhether the peeling of the inner limiting membrane (ILMP) increase the closure rate of idiopathic macular hole is still in controversy.Some ophthalmologist recommend vitrectomy combined with inner limiting membrane peeling for the treatment of idiopathic macular hole.However,the removal of ILMP is difficult because of its similar appearance to adjacent tissues.Objective This study was to investigate the efficacy of triamcinolone acetonide(TA) and indocyanine green(ICG) double staining-assisted vitrectomy combined with ILM peeling during the surgery.Methods A consecutive case- observational study was designed.The standardized vitrectomy was performed in 25 eye of 23 cases with IMH.During the vitrectomy,TA and ICG were injected into posterior pole vitreous to visualize and assist the ILM peeling.The dying effectiveness was observed,and the closure rate of macular hole,visual acuity,intraocular pressure and complications were evaluated after surgery.Written informed consent was obtained from each patient prior to operation.Results Posterior vitreous cortex and ILM were visible and the residual vitreous and cortex were removed clearly after dying of TA and ICG in all the 25 eyes.During the following-up duration of 3-8 months,the completely anatomical reattachment of the macular area was in 22 eyes ( 88.0％ ) and partially reattachment in 3 eyes( 12.0％ ).The best corrected vision was 0.07-0.60 in all of the operated eyes 2 months after surgery.Conclusions TA and ICG- assisted vitrectomy combined with ILM peeling appears to be a safe and effective method for IMH repair.

Objective To evaluate the value of elastic strain ratio (SR) in ultrasound guided fine needle aspiration (US-FNA) of thyroid nodule.Methods A total of 222 thyroid nodules from 216 patients were reviewed and analyzed by Logistic regression of clinical data,2D ultrasound,and SR.The odds ratios of variables in the equation were compared to assess various variables,especially of SR in the diagnosis.The sensitivity,specificity,and accuracy of the SR method,US-FNA method,and combined method were calculated.Results Three statistically significant features finally entered the Logistic regression model,followed by SR,echo,and age according to the odds ratio.The sensitivity,specificity,and accuracy of the SR method,US-FNA method and combined method were 85.4％,82.1％,83.3％ ; 91.5％,82.1％,85.6％ ; 97.6％,94.3％,95.5％ respectively.Conclusions SR＜0.5 is the most important risk factor in differential diagnosis of thyroid malignant nodules from benign nodules.SR raises the sensitivity,specificity,and accuracy of US-FNA method and plays an important role in diagnosing thyroid nodules via US-FNA.

The formative assessment system has been applied to the internship education for the clinical anesthesia with the aim to improve students' initiative and to evaluate their outcomes more compre-hensively. The students' performance in the shift exchange, case discussion, raising question, solving question at the time points of after the preclinical train, one month and 3 months into the anesthesia internship, and after the completion of internship, and their capability in preoperative patient assessment, condition report, clinical practice, review writing have been evaluated to determine the educational quality and to instruct the improvement of educational approach. Assess process takes into account both the individuality and the gen-eral character of the students and feedbacks the evaluation result to improve the practice teaching The im-plementation of the evaluation can promote students' autonomous learning and comprehensively evaluate students' practice process.

Objective To investigate the effects of dendritic cells (DCs)loading alpha-Galactosylce-ramide (α-GalCer)combined with tumor specific cytotoxic T lymphocytes (CTLs)on the growth of transplanted Heps hepatoma in mice.Methods We induced the augmentation of the DC cells and T lymphocyte derived from the mice bone marrow,and enabled them to be specific CTLs.DC cells loaded α-GalCer in vitro.First we established a Heps liver cancer xenograft model,then divided the model mice into 4 groups by random number table method (n =9):control group (intravenous injection with physiological saline),CTL group,DC loadingα-Galcer group and DC loading α-Galcer combined with CTLs group.After 2 weeks of intervention,we extrac-ted the tumor tissue,weighed the tumor and calculated the inhibition rate of tumor.The expressions of Bax/Bcl-2 cells in groups of transplanted tumor tissues were detected using immunohistochemistry and Western blotting. Results The average tumor weight of CTL group,DC loading α-GalCer group and combined treatment group were (1 .07 ±0.1 5)g,(1 .1 1 ±0.1 7)g,(0.79 ±0.1 4)g,respectively.All of them were lower than that of control group (1 .69 ±0.23)g,with significant differences (t =1 4.1 76,P =0.023;t =1 2.351 ,P =0.034;t =1 8.672,P =0.000).The average tumor weight of combined treatment group was lower than those of the CTL group and DC loading α-GalCer group,with significant differences (t =1 5.236,P =0.01 2;t =1 1 .1 76, P =0.037).Compared to the CTL group (36.69%)and DC loading α-GalCer group (34.32%),the com-bined treatment group had a higher tumor inhibition rate (53.25%;P =0.034,P =0.021 ).Immunohisto-chemical assay showed that the numbers of Bax-positive cells in CTL group,DC loading α-GalCer group and combined treatment group were 35.83 ±0.75,33.67 ±0.82,41 .1 7 ±1 .1 7 respectively,and compared with the control group (21 .67 ±2.1 6),the differences were statistically significant (t =-1 3.789,P =0.002;t =-1 5.1 1 6,P =0.001 ;t =-1 7.452,P =0.000).The numbers of Bax-positive cells in combined treatment group were different with CTL group and DC loading α-GalCer group (t =-7.730,P =0.009;t =-5.872, P =0.01 1 ).The numbers of Bcl-2-positive cells in CTL group,DC loading α-GalCer group and combined treatment group were 30.83 ±0.75,31 .67 ±1 .03,25.00 ±0.89,and compared with the control group (38.67 ±1 .21 ),the differences were statistically significant (t =9.234,P =0.007;t =1 1 .738,P =0.003;t =20.608,P =0.000).The numbers of Bcl-2-positive cells in combined treatment group were different with CTL group and DC loading α-GalCer group (t =1 1 .952,P =0.003;t =1 2.223,P =0.002).Western blot-ting test results showed that the expression levels of Bax in CTL group,DC loading α-GalCer group and com-bined treatment group were 0.46 ±0.01 ,0.42 ±0.03,0.55 ±0.01 ,and compared with the control group (0.31 ±0.02),the differences were statistically significant (t =1 .035,P =0.032;t =1 .1 24,P =0.027;t =1 .425,P =0.01 0).The expression level of Bax in combined treatment group was different with CTL group and DC loading α-GalCer group (t =1 .305,P =0.01 3;t =1 .421 ,P =0.01 0).The positive expressions of Bcl-2 in CTL group,DC loading α-GalCer group and combined treatment group were 0.34 ±0.03,0.33 ± 0.02,0.24 ±0.01 ,and compared with the control group (0.46 ±0.01 ),the differences were statistically sig-nificant (t =-1 .1 23,P =0.025;t =-1 .061 ,P =0.031 ;t =1 .278,P =0.01 4);the positive expression level of Bcl-2 in combined treatment group was different with CTL group and DC loading α-GalCer group (t =1 .1 60,P =0.021 ;t =1 .21 9,P =0.01 5).Conclusion It has synergistic killing effect on transplanted Heps hepatoma in mice using DC loading α-GalCer combined with the tumor specific CTL.

Laparoscopic surgery develops fast in China in recent years,and it is widely applied in different fields in the digestive surgery and satisfactory results are achieved.However,uniformed training,technique standard and quality control standard are missing in the education of laparoscopic surgery in China.Fundamentals of laparoscopic surgery (FLS) program is developed by the Society of American Gastrointestinal and Endoscopic Surgeons in 2004.It is composed of congenital assessment and manual skills assessment.Twelve surgeons from China have taken FLS examination in April of 2014,and they introduced the content,features of FLS examination,some thoughts and inspirations on the training of laparoscopic surgery in China in this article.

Objective To explore the safety and effectiveness of percutaneous vertebrophasty(PVP)in the treatment of the metastatic tumor involved axis.Methods Ten patients(8 male,2 female)with osteolytic metastases involved axis were treated with PVPs.The anterolateral approach with fluoroscopy guidance was selected in 9 cases,while the posterolateral approach with CT guidance was selected in 1 case.Results Successful unilateral-paracentesis for PVP were achieved in all patients without intervention related complications such as bleeding and symptomatic polymethylmethacrylate(PMMA)leakage.CT scan taken following PVP showed that over 70% of the osteolytic metastatic area was well filled with PMMA in all cases.Varying degrees of pain relief were observed(CR in 7 cases,PR in 3 cases)within 7 days.All patients could support their heads without brackets.During a 3 to 24 months follow up after the procedures,No aggravated pain was found in the group.Two patients died in 4 months,3 Patients died in 8 to 11 months 4 patients died in 13 to 15 months,and 1 patient still was alive after 24 months.Conclusion Anterolateral or posterolateral approach to Aixs in PVP is safe and effective in treating osteolytic metastatic tumors.

Objective To investigate the features of intravertebral vacuum phenomenon (IVP)in vertebral compression fractures (VCFs). Methods Two hundred and nine patients with VCFs underwent percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP). The biopsies and the images of X-ray, CT, MRI of VCFs were obtained. The consistency between IVP and osteonecrosis on histology and the positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and Youden index of IVP for diagnosing local osteonecrosis in VCFs were analyzed. Fisher exact probability test was used to analyze the coherence between IVP and osteonecrosis. Results Histological examination revealed 146(69.9%) osteoporoses, 10 (4.8%) osteonecroses with osteoporoses, 53 (25.4%) neoplasms. Prior to surgery,10 cases of IVP were found. Plain radiograph showed horizontally oriented lucent cleft in the vertebral body;CT further confirmed the location of gas;T_1-weighted MR image appeared hypointensity,while the signal intensity of T_2-weighted MR image differed, depending on the duration of recumbency. Nine of 10 patients with IVP showed osteonecrosis on histology, while 9 of 10 patients with osteonecrosis contained IVP. The association of osteonecrosis on histology and the IVP was statistically significant(P <0.01). The PPV, NPV, sensitivity, specificity, and Youden index for diagnosing local osteonecrosis was 90% (9/10), 99.5% (198/199), 90.0% (9/10), 99.5% (198/199), and 0.9, respectively. Conclusion The IVP is stongly suggestive of local osteonecrosis in vertebral compression fracture.