With the rapid development of China's economy,obesity and diabetes have become a serious social problem.Metabolic surgery has grown mature abroad,while it started relatively late in China.There is obvious lack of operative indications,mode and procedure,preventions of complications,perioperative management and follow-up in the early time.To standardize nationwide surgical treatment of diabetes,to make the treatment of type 2 diabetes mellitus (T2DM) patients with the best way,to reduce the incidence of postoperative complications,the domestic famous experts assembled by the Branch of Obesity and Diabetes Surgeons Committee of the Chinese Medical Doctor Association composed the Surgical Treatment Guidance of Obesity and Type 2 Diabetes in China (2014).Metabolic surgery rapidly be popularized across the country.The number of surgery is rising year by year,especially making further standardization of operative indications and modes.Many academic meetings are conveyed to promote the discipline to develop,and provide the communication platform for metabolic surgeons.The future development of metabolic surgery will be accompanied by technological progress,equipment updates,operation excellence and continuous improvement.

With the rapid development of minimally invasive techniques,the emergence of three-dimensional (3D) laparoscope leading minimally invasive surgical accessPrecise Time.In the past 60 years,bariatric surgery provides a large number of clinical evidences to confirm:metabolic and bariatric surgery is lasting and effective for obesity combined with type 2 diabetes mellitus (T2DM),and it is also the best treatment method for T2DM.The author believes that 3D laparoscopic system can help beginners quickly master laparoscopic surgical techniques and shorten the learning curve to master the technical points.Compared with two-dimensional (2D) laparoscopic surgery,3D laparoscopic stereo vision can help experienced bariatric surgeons shorten operation time which is related to surgical procedures.The shorter surgical procedure in laparoscopic sleeve gastrectomy is hardly affecting the operation time.Because gastric bypass surgery is relatively complex,3D laparoscopic techniques which are fully utilized in gastric bypass surgery can effectively shorten the operation time.

In recent decades, human lifestyle has undergone tremendous changes with the development of society,obesity, type 2 diabetes mellitus and related metabolic diseases have been prevalent around the world.In addition to the traditional treatment including diet control, lifestyle modification and drug intervention, bariatric and metabolic disease surgeries have become the significant therapeutic means.In recent years, the international community has made some breakthroughs in the mechanisms of surgical treatment for obesity and metabolic disease, the mechanism that gastrointestinal surgery activates the body to increase energy expenditure and white adipose tissues convert to brown become the new hot spot.In western countries,bariatric surgery has already undergone semicentennial renewal and evolution.Currently, classical metabolic surgery methods basically reach a consensus worldwide, however, along with the changes of the surgery methods, patients who accept early surgical treatments of obesity and metabolic disease or who are not satisfied with the initial surgery can be further remedied through repairing operation.In addition, the rapid development of endoscopic technique provides a new idea for renewal of bariatric surgery.This review focuses on the latest international developments about the mechanisms of metabolic disease surgery and the innovation of operation methods.

Obesity-induced insulin resistance and metabolic syndrome continue to pose an important public health challenge worldwide.Metabolic surgery was developed with the aim of weight reduction.In recent years,authors have witnessed great advancement in metabolic surgery,including the development of new and safe procedures or devices.During the last decade,improvements in glycemic control and decreases in cardiovascular events and mortality after surgery have been consistently reported.Therefore,there is an urgent need to identify the type of patients that may benefit the most from metabolic surgery,morbidly obese or not,and selection criteria must be reviewed and updated based on the current surgical outcomes.This article reviews the history of metabolic surgery and summarizes the new perceptions in obesity treatment.

Gastrectomy ; Gastric Bypass ; Humans

The curative effect of surgical treatment for obesity and type 2 diabetes mellitus has been internationally recognized.In mainland China,the number of the minimally invasive gastric volume reduction surgery has been increased from 110 cases in 2008 to 2000 cases in 2012.While some of the patients suffered from poor curative effects or severe postoperative complications due to lack of unified standard treatment guidelines.Authoritative statistical agencies and the Chinese clinical database has not been formed till now,therefore the specification and promotion of Chinese surgical treatment standards for obesity and type 2 diabetes mellitus is imperative.

ObjectiveTo study the feasibility,safety and efficacy of laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy for adult congenital choledochal cyst.MethodA retrospective study was conducted on 7 adult patients with congenital choledochal cyst who received total laparoscopic cyst excision and Roux-en-y hepaticojejunostomy from May 2008 to February 2011 in the Department of General Surgery of Shengjing Hospital,China Medical University.ResultsAll the laparoscopic surgery was successful.The mean operation time was 210 minutes.The average intraoperative blood loss was 80 ml.All patients were out of bed within the first 24 h after surgery.The mean time to first flatus/bowel motion was 2.4 days.Except 1 patient who had small amount of bile leakage,all patients recovered smoothly without any major postoperative complications.The average hospital stay was 8.1 days.No patients suffered from abdominal pain,fever or jaundice during follow-up from 3 to 30 months.ConclusionTotal laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy was a safe,efficacious,and minimally invasive procedure.

Objective To summarize the clinical characteristics and investigate the prognostic factors of primary duodenal carcinoma.Methods The clinical data of 122 patients with primary duodenal carcinoma who were admitted to the Shengjing Hospital Affiliated to China Medical University from November 2007 to May 2013 were retrospectively analyzed.All the patients received different operations according to the characteristics of tumors.Primary duodenal carcinomas of patients were confirmed by the postoperative pathological diagnosis.All the patients were followed up by outpatient examination, telephone interview and correspondence till November 30,2014.The treatment process, results of imaging examination and laboratory examination and postoperative survival were recorded.The clinical features, diagnostic criteria, therapeutic regimens and prognostic factors were analyzed.The survival rate and survival curve were analyzed and drawn by the Kaplan-Meier method.The univariate analysis was done using the Log-rank test, and multivariate analysis was done using the COX regression model.Results Among the 122 patients with primary duodenal carcinoma, jaundice as the first symptom was detected in 57 patients, abdominal pain and upper abdomen discomfort in 37 patients, gastrointestinal obstruction in 14 patients,anorexia and reduction of body weight in 4 patients, gastrointestinal hemorrhage in 3 patients, diarrhea in 3 patients, pyrexia in 3 patients and abdominal mass in 1 patient.The positive rates of CT examinations, endoscopic examinations, magnetic resonanced cholangio-pancreatography (MRCP), B-ultrasound examinations and upper gastrointestinal contrast examinations were 69.67％ (85/122), 85.56％ (77/90), 79.76％ (67/84), 12.73％ (7/55) and 75.00％ (36/48), respectively.Among the 122 patients, anemia was detected in 48 patients,positive fecal occult blood test in 94 patients, increasing level of CA19-9 in 71 patients, increasing level of CEA in 22 patients and increasing level of AFP in 9 patients.The tumors located at the descending part of duodenum,duodenal bulb and horizontal part of duodenum were detected in patients of 86.07％ (105/122), 7.37 ％ (9/122) and 6.56％ (8/122), respectively.The mean diameter of tumors was 2.3 cm (range, 1.0-15.0cm).All the 122 patients received operation.Pancreaticoduo-denectomy was performed in 100 patients, including combined with jejunostomy in 17 patients, pylorus-preserving pancreatoduodenectomy in 7 patients, segmental resection of duodenum and gastrojejunostomy in 5 patients, local resection of duodenal papilla in 6 patients and palliative gastrojejunostomy in 11 patients.Nineteen patients with complications were cured by symptomatic treatment.Of the 122 patients, adenocarcinoma, carcinoid tumor, lymphoma, small cell carcinoma, intraepithelial neoplasm combined with differentiated rhabdomyoma and with undifferentiated rhabdomyoma were detected in 116, 2, 1, 1,1 and 1 patients, respectively.The Ⅰ , Ⅱ , Ⅲ and Ⅳ stage of tumors were detected in 10, 4, 74 and 34 patients.There were 100 patients without lymph node metastasis, 13 patients with 0 ＜ metastatic lymph node ratio (MLR) ≤0.2, 4 patients with 0.2 ＜ MLR≤0.4 and 5 patients with MLR ＞ 0.4.One-hundred and twelve of 122 patients were followed up for 1-70 months with a median follow-up time of 20 months.The postoperative survival time, a median of survival time, postoperative 3-and 5-year survival rates were 1-70 months, 18 months, 36.6％ and 13.5％ , respectively.The results of univariate analysis showed that the lymph node metastasis, differentiated grade of tumor, MLR and with invasion of pancreas were risk factors affecting the prognosis of patients (x2 =8.465, 57.355, 16.232, 20.112, P ＜ 0.05).The multivariate analysis showed that the low-differentiation of tumor, invasion of pancreas, lymph node metastasis and MLR ＞ 0.4 were independent risk factors affecting the prognosis of patients (RR =3.330, 3.718, 2.623, 95％ confidence interval: 1.861-5.956, 1.292-10.696,1.624-4.236, P ＜ 0.05).Conclusions Most of the primary duodenal carcinomas are located at the descending part of duodenum without specific clinical symptoms in the early stage.The joint usage of assistant examinations can improve the diagnostic rate of primary duodenal carcinoma, and surgery is mainly therapeutic method.The low-differentiation of tumor, MLR ＞ 0.4 and invasion of pancreas are independent risk factors affecting the prognosis of patients.

Objective To evaluate the effect of recominant human growth hormone(rhGH) in the prevention and treatment of endotoxemia(ETM) in murine experimental obstructive jaundice (OJ) Methods Twenty OJ rats received subcutaneously given rhGH of 0 75*!IU/kg daily for 2 weeks (rhGH group). Blood endotoxin(ET) was measured, and intestinal mucosa was observed under electron microscope at 5th week.Results In rhGH group, ET level 〔(0 40?0 02)*!EU/ml〕 was significantly lower than OJ rats〔(0 77?0 03)*!EU/ml, n =20〕 ( t = 6 237, P 0 05). Under electron microscope bowel villi in OJ group were distroyed, epithelial cells were degenerated and necrotic, whereas in rhGH group the ultrastructural pathology was much less evident and similar to that in sham operation rats. Conclusion rhGH has significant effect on protecting the injured mucosa barrier in OJ,and decreases ETM significantly.

Objective To evaluate the therapeutic effectiveness of postoperative hemorrhage of cholejejunal or pancreato - jejunal anastomotic stoma after pancreato - duodenectomy by the way of fibercholedochoscopy. Meth- ods The drainge tube was extracted out of choledochojejunal anastomotic stoma. And fibercholedochoscopy was in- serted in fistula to affirm hemorrhagic position of choledochojejunal or pancreato - jejunal anastomotic stoma. And then local coagulation and microwave solidifying was proceeded with. Local spray of Galla - chineses compound solution was performed for hemostasis. Results We succeeded in hemorrhage of four choledochojejunal and six pancreato - jejunal anastomotic stoma One failed for frequent hemorrhage in pancreato - jejunal anastomotic stoma. Conclu- sion Fibercholedochoscopy is the first selective and effective method in the diagnosis and treatment of postoperative hemorrhoge of pancreato - jejunal or choledochojejunal anastomotic stoma after whipple operation.