Objective To summarize the experience in diagnosis and treatment of intraductal papillary mucinous neoplasm(IPMN) of the pancreas and identify potential preoperative factors predicting invasiveness of intraductal papillary mucinous neoplasm of the pancreas. Methods From September 2003 to July 2010,27 patients underwent pancreatic resection for IPMN. All cases were divided into invasive and noninvasive groups. Preoperative medical records were reviewed retrospectively between the two groups. Results Pathological results revealed 15 cases of invasive IPMN and 12 noninvasive cases. The incidence of obstructive jaundice, tumor size and serum total bilirubin values were significantly different between the two groups. The other factors including sex ratio, age, incidence of abdominal pain or back pain, diarrhea, weight loss, new onset diabetes, serum CEA, CA19-9 values showed no statistical difference. Conclusion Serum total bilirubin≥22.2μmol/L and tumor size≥3 cm could be predicting factors of invasive IPMN.

Objective To compare the anesthetic effect of interscalene joint axillary brachial plexus block guided by nerve stimulator or conventional paresthesia in elderly patients with upper extremity surgery.Methods Sixty cases of ASA grade Ⅱ-Ⅲ elderly patients with upper extremity surgery were divided into two groups by random number table.Nerve stimulator group (30 cases) received interscalene joint axillary brachial plexus block guided by nerve stimulator.Paresthesia group (30 cases) received interscalene joint axillary brachial plexus block guided by conventional paresthesia.Both groups used the same local anesthetic:0.375％ ropivacaine,the dosage was 0.4 ml/kg.Anesthetic dose between interscalene and axillary in two groups in half.The operating time,block onset time,duration of analgesia,anesthetic effect [used by visual analogue scale (VAS) scores] and adverse reaction in two groups were observed and recorded.Results The operating time and block onset time in nerve stimulator group were significantly shorter than those in paresthesia group[(5.2 ± 1.7) min vs.(8.6 ± 2.2) min and (19.4 ± 3.2) min vs.(29.0 ± 3.9) min],VAS scores was lower than that in paresthesia group [(0.7 ± 0.4) scores vs.(2.3 ± 0.8) scores],there were significant differences (P ＜ 0.01).There was no significant difference in duration of analgesia between two groups [(12.4 ± 3.6) h vs.(13.1 ± 3.8) h,P ＞0.05].Nerve stimulator group without adverse reactions.Paresthesia group had 5 cases of adverse reactions,including local hematoma in 2 cases,laryngeal recurrent nerve paralysis in 1 case,horner syndrome in 2 cases.Conclusion Interscalene joint axillary brachial plexus block guided by nerve stimulator in elderly patients is accurate positioning,high success rate,good anaesthesia effect,less adverse reaction,and worth promoting in clinical.

Objective To evaluate the feasibility of using single lumen tube intubation technique in bronchial intubation with Robertshaw double-lumen tube .Methods 80 patients with ASA Ⅰ - Ⅱ level who need to accept bronchial intubation were ran-domly divided into two groups .Group A(n=40) accepted bronchial intubation using single lumen tube intubation technique .Group B(n=40) accepted bronchial intubation using traditional intubation technique .The single success rates and intubation complication rates were observed .Results The single success rates of group A was obviously higher than group B (P< 0 .05) ,the intubation complication rates of group A was lower than group B ,but with no statistical significance(P>0 .05) .Conclusion The single suc-cess rates of single lumen tube intubation technique in bronchial intubation with Robertshaw double-lumen tube is higher than tradi-tional intubation technique ,at the same time ,the complication rate of intubation is low ,safe and feasible .

Objective To investigate the feasibility of Narcotrend-guided application of small dose of dexmedetomidine ( DEX) for sedation during combined spinal-epidural anesthesia for elderly patients. Methods Fifty cases of ASA II or Ⅲelderly patients were randomly divided into treatment group and control group (25 patients of each group). After combined spinal-epidural anesthesia, both groups received continuous intravenous infusion of DEX, at 0. 4 μg·kg-1 in 10 min, and then the rate was lowered to 0. 4 μg·kg-1 per hour. For the treatment group, infusion rate was adjusted to reach a Narcotrend Index (NTI) of 75-85, and for the control group, infusion rate was adjusted to reach an OAA/S score of level 3-4. MAP, HR, RR, SpO2 , NTI and OAA/S score were recorded at the beginning of DEX treatment ( t0 ) , 10 min ( t1 ) , 20 min ( t2 ) , 30 min ( t3 ) , and 60 min ( t4 ) after the beginning of DEX treatment, and at the end of surgery ( t5 ) . The incidence rates of adverse events including bradycardia, hypotension, low oxygenation, and respiratory depression were also recorded. The patients were followed up until 24 h after surgery to record loss of memory about the surgical events. Results In comparison with t0 , NTI and MAP of both groups significantly decreased at t1-t5(P<0. 01). Comparison between the two groups showed no difference in MAP at each time point, and NTI of treatment group was higher than that of control group at t2-t5(P<0. 05). In comparison with t0, OAA/S of both groups significantly decreased at t1-t5(for t1, P<0. 05;for t2-t5, P<0. 01). Comparison between the two groups showed no difference in OAA/S at each time point (P>0. 05). Follow-up at 24 h after surgery observed total amnesia in 72. 0% of DEX group patients and in 76. 0% of the control group, without significant difference (P>0. 05). Conclusion Sedating elderly patients undergoing spinal-epidural anesthesia with DEX under the guidance of Narcotrend is safe and feasible, and the patients can be sedated properly.

ObjectiveTo explore the psychological training methods on improving the mental adaptation and performance of recruits.MethodsAccording to army's squad establishment,372 recruits were randomly extracted and divided into intervention group (182) and control group (190).A series of special group psychological trainings,such as Warm barracks,Friendly Care,Self-awareness,Interpersonal communication,etc,was applied to the recruits of the intervention group through the squad leaders given psychological training.The effect was assessed with Psychosocial Stress Survey For Groups (PSSG),General Maladjustment Scale (GM),Social Support Rating Scale (SSRS),General Self-Efficacy Scale (GSES),Wallace Slef-Concept Scale (WSCS) and Examined Performance.ResultsThe scores of negative emotion was [(3.89±2.01) score vs (2.56±1.65) score ],negative copy was [(3.96±2.52) score vs (2.97±1.78)score],total stress was [(46.36±21.74)score vs (33.71±17.56) score],maladjustment was [(11.26±5.04)score vs (9.10±4.53)score] in the intervention group,which was significantly reduced than those in the control group(P＜0.01).But the scores of positive emotion was [(3.70±1.62) score vs (4.16±1.84) score],positive copy was [(5.21±1.94) score vs (6.93±2.17) score ],subjective support was [(21.37±3.59)score vs (22.56±3.53)score] and support utilization was [(7.03±2.16) score vs (8.92±2.44) score],self-concept was [(74.33±15.72) score vs (80.65±13.98) score],self-efficacy was [(2.44±0.56) score vs (2.91.±0.52) score ] and the examination performance was [(pull-up:(5.12±3.77) times vs (12.09±4.52) times; sit-up:(30.82±9.54) times/3 min vs (70.20±16.83) times/3min; push-up:(21.32±9.73)times/2 min vs (61.75±17.62)times/2 min; Running 3000 meters:(14.17±1.14) s vs (12.82±0.32) s; standing grade throw:(26.68±4.62) mvs (35.38±8.44) m ],which was significantly improved (P＜0.01 or P＜0.05).ConclusionsComprehensive group psychological training implemented by Squad leader could effectively improve the ability of adaptation of recruits and promote the performance.

Objective:To evaluate the clinical efficacy of transanal total mesorectal excision (taTME) on transanal endoscopic microsurgery (TEM) platform in the treatment of middle and low rectal cancer.Methods:The retrospective and descriptive study was conducted. The clinico-pathological data of 28 patients with middle and low rectal cancer who underwent taTME on TEM platform in the Peking Union Medical College Hospital of Chinese Academy of Medical Science from October 2014 to October 2017 were collected. There were 21 males and 7 females, aged 59 years (51 years, 68 years). Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up was conducted using outpatient examination or telephone interview to detect post-operative defecation function and survival of patients up to October 2020. Patients underwent physical examination, examination of tumor markers including carcinoembryonic antigen and CA19-9, colonoscopy, rectal magnetic resonance imaging, thoracoabdominal and pelvic enhanced computed tomography (CT) and (or) PET-CT examination during the follow-up. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were represented as M( P25,P75) or M (range), and comparison between groups was analyzed using the non parameter Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Surgical and postoperative situations: 28 patients underwent successful surgery, without intra-operative conversion to laparotomy. Of 28 patients, 24 cases underwent colorectal anastomosis and 4 cases underwent colon-anal anastomosis. Twenty-six cases underwent primary protective enterostomy and 2 cases didn't undergo primary protective enterostomy. The operation time of 28 patients was (182±37)minutes and the volume of intraoperative blood loss was 40mL(30 mL, 55 mL). One patient with intraoperative presacral hemorrhage received compression hemostasis. Eleven patients had postoperative complications, including 4 cases with anastomotic leakage, 2 cases with alteration of intestinal flora, 2 cases with paralytic ileus, 2 cases with urinary retention, 2 cases with urinary infection, 1 case with prolapse necrosis of small intestinal stoma, 1 case with anal hemorrhage, 1 case with rectovaginal fistula, 1 case with pelvic infection; some patients had multiple complications. Three patients had non-planned reoperation. One case without primary protective enterostomy had anastomotic leakage at postoperative 3 days, and was improved after emergency transversostomy. One case had prolapse necrosis of small intestinal stoma at postoperative 3 days and was improved after emergency enterostomy and reconstruction. One case with anal hemorrhage was stopped hemorrhage under anoscopy. Patients with other complications were cured after conservative treatments. The duration of postoperative hospital stay of 28 patients was 8 days(7 days, 9 days). Results of pathological examination in 28 patients showed 16 cases of moderately differentiated adenocarcinoma, 3 cases of moderately to highly differentiated adenocarcinoma, 5 cases of highly differentiated adenocarcinoma, 1 case of mucinous adenocarcinoma, 3 cases of pathological complete response. TNM staging of 28 patients showed 3 cases in stage T0N0, 4 cases in stage T1N0, 6 cases in stage T2N0, 4 cases in stage T2N1, 7 cases in stage T3N0, 3 cases in stage T3N1, 1 case in stage T4N1. The distance from tumor to distal margin was (2.2±1.7)cm. The surgical specimens of 28 patients showed negative for proximal, distal and circumferential margins. The number of lymph node dissection was 15±7. The complete rate of total mesorectal excision was 100%(28/28). Eleven of 28 patients underwent neoadjuvant therapy and 17 patients didn't receive neoadjuvant therapy. The tumor diameter, distance from tumor to anal margin, operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 2 cm(1 cm, 4 cm), 5 cm(4 cm, 6 cm), (187±25)minutes, 45 mL(38 mL, 53 mL), 8 days(7 days, 12 days) for patients with neoadjuvant therapy, respectively, versus 3 cm(2 cm, 4 cm), 5 cm(4 cm, 6 cm), (177±35)minutes, 40 mL(30 mL, 60 mL), 8 days(7 days, 8 days) for patients without neoadjuvant therapy, showing no significant difference between the two groups ( Z=-1.127, -0.293, t=0.590, Z=-0.790, -0.876, P>0.05). (2) Follow-up: 23 of 28 patients were followed up for (44±14)months. Of the 23 patients,11 cases were classified as grade A of Williams score for defecation function at postoperative 6 months, 8 cases were classified as grade B and 4 cases were classified as grade C. Eighteen of 23 patients with follow-up had disease-free survival, 1 of whom didn't undergo stoma closure due to anastomotic stenosis at postoperative 6 months. Three patients had distant metastasis, including 1 case with parastomal implantation metastasis, 1 case with sacral metastasis, 1 case with pulmonary metastasis. Two patients died, 1 case of whom died of urinary obstruction and 1 case with mucinous adenocarcinoma died at postoperative 24 months. Conclusion:TaTME based on TEM platform is feasible for middle and low rectal cancer, which has the advantages of preserving anus and negative circumferential margin.

OBJECTIVETo investigate the safety and feasibility of the posterior transsphincteric approach for rectovaginal fistulas repair.

METHODData of 23 cases of rectovaginal fistulas treated by the transsphincteric approach in the Peking Union Medical College Hospital, from April 1994 to May 2014 were reviewed. The success rate of this surgical procedure and the postoperative complications were analyzed.

RESULTSThe procedure of the transsphincteric approach for the repair of rectovaginal fistulas was performed successfully in all 23 cases. Three patients(13%) suffered surgical wound infection, which healed after regular dressing changes. In 19 cases, the fistulas were successfully repaired with an initial healing rate of 82.6%. The surgical repair failed to accomplish initial healing in 3 cases(13%). No complications including rectocutaneous fistula or anal sphincter malfunction occurred in these patients.

CONCLUSIONThe transsphincteric approach for the repair of rectovaginal fistulas is a safe and feasible procedure with a good success rate.

Objective: The aim of the current study is to compare the short-term clinical outcomes between Billroth-I reconstruction using an overlap method and delta-shaped anastomosis in totally laparoscopic distal gastrectomy (TLDG). Method: A retrospective cohort study was performed. The following inclusion criteria were applied: (1) Preoperative gastroscopy and CT confirmed that the tumor is located in the antrum of the stomach, and the biopsy suggested adenocarcinoma; (2) Chest, abdomen and pelvis enhanced CT showed no evidence of distant metastasis; (3) Preoperative gastric reconstruction CT or endoscopic ultrasonography suggested that the clinical stage of the tumor is stage I-III. (4) During the operation, the tumor position was confirmed to be located in the antrum of the stomach by nanocarbon injection or gastroscope; (5) Complete laparoscopic radical gastrectomy for distal gastrectomy, and the gastrointestinal reconstruction was performed by delta-shaped anastomosis or overlap anastomosis. And the following exclusion criteria were applied: (1) History of gastric surgery; (2) Patients who cannot tolerate laparoscopic surgery because of comorbidities. Finally, data on 43 consecutive patients who underwent TLDG with Billroth-I reconstruction between January 2016 and November 2018 in Peking Union Medical College Hospital were retrospectively reviewed. Patients were divided into those who underwent Billroth-I reconstruction using an overlap method (n=20) or using delta-shaped anastomosis (n=23). The demographic and clinical characteristics and perioperative data of the two groups were analyzed. Measurement data that conformed to the normal distribution were expressed as the mean ± s, and differences between groups were compared using Student′s t-test; comparisons between the counting data groups were performed using the χ² test or the continuously corrected χ² test. Results: The demographic and clinical characteristics were similar between the delta-shaped group and the overlap group (P>0.05). There was no significant difference between groups regarding operation time [(185.9±22.8) minutes vs. (184.0±25.8) minutes, t=0.260, P=0.796], blood loss [(50.9±36.0) ml vs. (47.0±30.8) ml, t=0.375, P=0.709], number of stapler reloads used for anastomosis (5.1±0.3 vs. 5.2±0.6, t=-0.465, P=0.651), time to flatus [(3.3±0.9) days vs. (3.6±0.9) days, t=-1.067, P=0.292) and postoperative hospitalization [(8.8±3.1) days vs. (10.4±3.8) days,t=-1.494, P=0.143]. As for the delta-shaped group and the overlap group, the anastomotic leakage rate was 4.3% (1/23) and 0 (χ²=0.000, P=1.000), respectively. The incidence of anastomotic bleeding was 4.3% (1/23) and 5.0% (1/20) (χ²=0.000, P=1.000), while the incidence of intra-abdominal hemorrhage was 4.3% (1/23) and 0 (χ²=0.000, P=1.000). The incidence of gastric emptying disorders was 4.3% (1/23) and 30.0% (6/20), respectively (χ²=3.454, P=0.063). All complications were cured after conservative treatment or symptomatic treatment. Conclusion The overlap method for Billroth-I reconstruction is safe and feasible.

Objective: To examine the anatomical relationships of tributaries to superior mesenteric artery and vein in surgical procedures. Methods: A prospectively designed observational trial, registried to Chinese Clinical Trial Registry, ChiCTR 1800014610, was conducted in Department of General Surgery, Peking Union Medical College Hospital from July 2016 to Decmeber 2018 to record the relationships of ileocolic artery and vein, right colic artery and vein, middle colic artery and vein, and combinations to assemble Henle′s trunk, during the laparoscopic operation of radical right colectomy for right colon malignancies. The length of middle colic artery, length of Henle′s trunk, and distance from Henle′s trunk to the inferior margin of pancreatic head to duodenum were measured during operation. A total of 100 patients, 52 male and 48 female, with right colon cancer, who underwent radical right colectomy, were enrolled in present study from July 2016 to December 2018, with age of (61.0±12.3) years (range: 31 to 82 years), and body mass index of (23.3±3.5) kg/m² (range: 16.0 to 34.2 kg/m²). Results: The ileocolic artery and vein presented as rates of 97.0% (97/100, 95%CI: 91.5% to 99.4%, the same below) and 98.0% (98/100, 93.0% to 99.8%), respectively. The ileocolic vein ran ventrally in 51 of 97 patients (52.6%, 42.7% to 62.5%). The right colic artery, which raised from superior mesenteric artery directly, was found in 42 of 100 patients (42.0%, 32.3% to 51.7%); and the right colic vein drained directly into superior mesenteric vein in 19 of 100 patients (19.0%, 11.3% to 26.7%). The presence of middle colic artery and vein were 95.0% (95/100, 90.7% to 99.3%) and 90.0% (90/100, 84.1% to 95.9%) respectively. The average length of middle colic artery, from its origin to bifurcation into right and left branches, was (2.6±1.6) cm (range: 0.1 to 7.2 cm). All the dissected middle colic vein drained into superior mesenteric vein (87.8% (79/90), 81.0% to 94.6%) and Henle′s trunk (12.2% (11/90), 5.4% to 19.0%). Henle′s trunk was found in 93 of 100 patients (93.0%, 88.0% to 98.0%), with average length of (1.0±0.6) cm (range: 0.1 to 2.4 cm). The distance between Henle′s trunk to the inferior margin of pancreatic head was (2.7±0.7) cm (range: 1.3 to 4.5 cm). More than half of the Henle′s trunk were composed of 3 tributaries (54.8% (53/93), 40.8% to 61.2%). The most frequently discovered tributaries to form Henle′s trunk were right gastroepiploic vein (98.0% (98/100), 93.0% to 99.8%), superior right colic vein (82.0% (82/100), 74.5% to 89.5%), and superior anterior pancreaticoduodenal vein (78.0% (78/100), 69.9% to 86.1%). In present study, the right branch of middle colic vessels was often found to run closely with Henle′s trunk, veins drained from small intestine could be found to run over superior mesenteric artery to converge into superior mesenteric vein. There were 2 incidences, injuries to Henle′s trunk and middle colic vein, happened during the operation, which were overcomed by bipolar coagulation and dividing the vessels. Conclusions Ileocolic vessels and middle colic vessels could be used as landmarks for laparoscopic surgery based on their constant anatomical existence. In contrast, the chances are rare for the presence of right colic artery or right colic vein. Nearly half of the Henle′s trunk was consisted of right gastroepiploic vein, superior right colic vein and superior anterior pancreaticoduodenal vein. Exceptional cautions should be made for the variations of the Henle′s trunk during the operation.

Some patients with rectal cancer can achieve clinical complete response (cCR) after neoadjuvant chemoradiotherapy. The watch and wait strategy for cCR patients can achieve similar curative effects as radical surgery, avoid surgical complications, and significantly improve the quality of life of patients, which is attracting increasing attention. Although the existing research results support that the watch and wait strategy is safe and feasible, there is still a lack of high-level evidence-based medicine evidence. There are still many issues in the implementation of the watch and wait strategy that need to be further clarified, including long-term oncology efficacy, cCR diagnosis and evaluation criteria, appropriate patient selection, follow-up strategies during the observation period, and treatment methods for local tumor regeneration. This article will explain the above problems based on the results of the existing literature and the clinical experience of our center.