Objective To approach the hemodynamic effects of combined spinal-epidural anesthesia in 65 years or older patients. Methods In a prospective study, 60 American Society of Anesthesiologists Ⅱ～Ⅲ patients (aged 65 yr or older), undergoing elective TKR surgery were randomLy assigned to either CSE an-esthesia (CSEA, n=30) or epidurai anesthesia alone (CEA, n=30). The age, sex, duration of surgery, blood loss, fluid infusion during the surgery and main complications were recorded. Hemodynamic measure-ments included invasive or non-invasive mean arterial blood pressure (MAP), heart rate (HR) before an-aesthesiaufe, 15 wins after anaesthesia and the end of surgery. Our primary endpoint (outcome) was the number of hypotension and bradycardic episodes (defined as MAP<70 mmHg and HR<50 beats per mi-nute). Cases of blood bandage were also recorded. Results There was no significant difference between two groups in the age, sex, duration of surgery, blood loss, fluid infusion and main complications. Using univariate analysis, we found no significant differences between the groups in regards to MAP, HR during the perioperative period. The incidence of hypotension was similar in both groups (7 patients in CSEA and 6 in CEA group, P=0.704), as of bradycardia (3 patients in CSE, 5 in epidural, P=0.754). The inci-dance of blood bandage pain of CSE group was higher than CSEA group. Conclusion Combined spinal-epi-dural anesthesia and epidural anesthesia alone during TKB surgery are associated with the same incidence of hypotension with statistically and clinically similar hemodynamic responses.

Objective Investgate the anesthetic management of patients with brachiocephaliic arteritis.Methods Review and analysis the clinic data of eleven cases of brachiocephaliic arteritis.Results The process of anesthesia is smooth,and haemodynamics is stable during peri-operation.Two patients was dead of MODS.Conclusion The keys of anesthstic management of brachiocephaliic arteritis are maintaining the haemodynamics steady and the blood supply to the brain,and the protection of the brain function.

Objective To evaluate the feasibility and clinical significance of radical nephrectomy with en bloc resection of involved adjacent organs.Methods Totally,24 cases of renal cancer invading adjacent structures underwent radical nephrectomy with en bloc resection of involved adjacent organs.Among the 24 cases,left radical nephrectomy with en bloc resection of splenic flexure and descending colon was performed in 7,partial resection of corpus and cauda pancreatis and spleen in 5,solitary splenectomy in 3;right radical nephrectomy with en bloc resection of hepatic flexure of the colon in 4,partial hepatectomy of right lobe and end-piece in 4,duodenectomy of pars descendens in 1.Of these cases,partial resection of the psoas muscle was performed in 5,and partial resection of mesocolon in 7.Postoperatively,9 cases received immunotherapy.Results There was no intraoperative mortality or severe posuoperative complication.Follow-up of 3-240 months was available in 21 cases.The follow-up showed that 1-,3-,5-and 8-year survival rates were 90.5%(19/21),42.9%(9/21),33.3%(7/21) and 19.0%(4/21),respectively.Conclusions Radical nephrectomy remains the treatment of choice in organ-confined stage of renal carcinoma.With careful selection,radical nephrectomy with en bloc resection of adjacent structures is technically feasible.It can obtain the radical excisional effect.Based on our experience,the operation is relatively safe.Complete surgical extirpation can lead to prolonged disease-free survival.It may also offer beneficial foundation for the subsequent systematic therapy.

Objective To summarize the methods of diagnosis and results of surgical treatment of pancreatic insulinoma. Methods The clinical data of 137 patients with insulinoma treated in our hospital during the past twenty-six years were reviewed retrospectively.Results There were 77 males and 60 females. All of them were characterized by the Whipple′s triad. The sensitivity of ultrasonography, CT and MRI for localization was 35.1%, 67.9% and 58.1% respectively. One hundred and tweenty-six patients underwent operation. Of them, 102 cases had tumor enucleation, 4 cases had pancreaticoduodenectomy, 16 cases had distal panreatectomy, and the other 4 cases had only laparotomy. Of the 122 patients, who underwent resection, the tumor was benign in 118(96.7%) and malignant in 4(3.3%). The diameter of the tumor was less than 2cm in 86.9% of cases. In 98.4% of cases the tumors were single and in 1.6% of cases were multiple. 13.1% of the tumors located in the head, 46.7% in the body, and 40.2% in the tail.Conclusions Whipple′s triad and the measurement of fasting glucose, IRI, IGR, C-peptide, and proinsulin levels contribute to the diagnosis of insulinoma. However, the preoperative tumor localization is still difficult. Tumor enucleation is the technique of choice when feasible. Patients in whom tumor localization is unsuccessful at operation should be carefully evaluated to be certain of the diagnosis, and in general should not undergo blind resection.

Objective To observe the relationship of awake bispectral index (BISawake) and the postoperative cognitive dysfunction (POCD). Methods 100 patients aged 60~75 years with ASA status Ⅰ~Ⅱ, underwent elective lower abdominal surgery with intravenous anesthesia (propofol, remifentanyl and rocuronium). The BIS was adjusted in 40~60 during the surgery. Their cognitive function was assessed with the neuropsychological test battery commended by International study of postoperative cognitive dysfunction (ISPOCD). Results 8 patients withdrew for unwilling or serious complications. The BISawake was more than 65 in 68 patients (group A), and less than 65 in 24 patients (group B). The difference of the verbal learning immediate and delayed of Hopkins Verbal Learning Test-Revised was more in the group B than in the group A. Conclusion Lower BISawake may be associated with the decline of postoperative cognitive function.

Postoperative pancreatic leakage remains a persistent problem after pancreaticoduodenectomy.For patients with a soft and nonfibrotic pancreas,double binding continuous hemstitch suture is an optimal method for anastomosis.From January 2011 to June 2012,92 cases of periampullary carcinoma with a soft pancreas underwent pancreaticoduodenectomy,and then a modified technique of pancreaticogastrostomy was performed with 2 continuous hemstitch sutures placed in the mucosal and seromuscular layers of the posterior gastric wall,respectively.The median time for pancreaticogastrostomy was 12 minutes,and only 15 patients had postoperative complications.Two patients developed pancreatic leakage(1 grade A and 1 grade B)postoperatively.Pancreaticogastrostomy with double binding continuous hemstitch sutures is a simple and safe reconstruction procedure for patients with a soft and fragile pancreas who received pancreaticoduodenectomy.

Objective To investigate the clinical characteristics and surgical treatment of gastrointestinal stromal tumors (GIST) of the duodenum.Methods The clinical data of 39 patients with duodenal GISTs from 1992 to 2010 were analysed retrospectively.Results The most common symptoms of duodenal GISTs were alimentary tract hemorrhage,occuring in 18 cases of the 39 cases (46％).Clinical diagnosis established by CT in 22 cases (69％).Duodenoscopy performed in 18 cases established the definite diagnosis of GIST in 15 (83％).Duodenal GISTs were most commonly located in the descending portion of the duodenum in 27/39 cases (69％).All 39 cases received surgical treatment,with R0 resection in 34 cases,including partial resection of the duodenum in 47％ (16/34),pancreaticodenectomy in 35％(12/34),segmental resection of the duodenum in 3 cases,subtotal gastrectomy in 3 cases; One died perioperatively and postoperative complications developed in 9 cases,which were cured by conservative therapy.The 1,3,5 year survival rate was 90％,72％,41％ for those receiving R0 resection.Conclusions The abdominal CT scan with contrast and duodenoscopy are helpful to establish the diagnosis of duodenal GISTs.Surgical procedures depend on the size and site of the lesion for R0 resection.To decrease postoperative recurrence and prolong survival adjuvant therapy with Imatinib is necessary.

Objective To investigate the left ventricular (LV) performance in patients with essential hypertension(EH) by global performance index (GPI) based on three-dimensional speckle tracking imaging (3D-STI).Methods A total of 164 EH patients were enrolled and divided into four subgroups according to LV configuration:LV normal group (LVN,n =67),concentric cardiac remodeling group (CCR,n =49),concentric cardiac hypertrophy group (CCH,n =28) and eccentric cardiac hypertrophy group (ECH,n =20).Thirty age and sex matched healthy volunteers were enrolled as controls.3D-STI was performed to assess LV 3D global strain and LV torsion,then LV systolic dyssynchrony index (SDI) and global performance index (GPI) were calculated.Global strain parameters were investigated among the groups,and correlations with GPI were studied.Results GPI,global longitudinal strain(GLS),global area strain(GAS),global radial strain(GRS) and global 3D strain(G3DS) in EH groups were respectively lower than those in the normal controls,and there were statistical differences among the respective parameters (P ＜0.05,respectively).SDI in group CCH and ECH were significantly higher than that in normal controls (P ＜ 0.05,respectively).In multivariate stepwise regression analysis,GAS was the most influential to GPI.Conclusions GPI based on 3D-STI may accurately reflect LV performance in patients with EH,and has potential applications in clinical practice.

Objective To explore the CT manifestations of non-functional islet cell tumor(NFICT)Methods The findings of plain and enhancement CT scanning from 17 cases with NFICT,which were confirmed by the surgeries and pathological sections,were analyzed retrospectively.Ninty ml of non-ioniodine contrast reagent with 3ml/s injection flow rate was employed as the enhancer for measuring the arteriovenous double phase CT value of the pancreas and tumor.Results Tumors were found in all the cases who received CT scan.Compared with pancreatic substance in the CT plain scan,tumors with low density were found in 2 cases,tumors with mixed low density in 11 cases and tumors with isodensity in 4 cases.Local calcification in tumor was found in 5 cases.Various degrees of strengthening were showed in 17 cases with enhancement scanning.Obvious enhancement in arterial phase presented in 5 cases,moderate enhancement in 6 cases and slight enhancement in 6 cases.Conclusions CT plain scan of NFICT shows that the tumor margins are clear and some tumors have calcification.All tumors in the CT enhancement scanning show various degrees of enhancement,the persistent enhancement from arterial phase to portal vein phase is the characteristic manifestation of NFICT.

Objective To summarize our experience in the prevention and treatment of accessory hepatic duct injury during operation on biliary tract.Methods The clinical data of 26 cases with accessory hepatic duct were retrospectively reviewed.Results Of 26 cases,the accessory hepatic duct were type I in 38.5%(10/26),and no complications including bile leakage,biliary infection and obstructive jaundice developed after division and ligation of the accessory hepatic duct;26.9%(7/26) were type II,among which,the accessory hepatic duct were injured in 3 cases,but no case developecl complications after relevant treatment;23.0%(6/26) were type III,among which,injury of accessory bile duct occurred in 2 cases.Of them,1 case developed bile leakage and was cured by reoperation.7.7%(2/26) were type IV and 3.9%(1/26) was type V.The cases of type IV and V were not damaged.Conclusions To prevent injury of accessory hepatic duct,pre-and intra-operation identification of the condition is very important,and especially by intraoperative cholangiography.Different types of accessory hepatic duct injury should be treated by different approaches. Accessory hepatic duct of type I might be cut and ligated.Type II accessory bile duct which(enters) the cystic duct and should be protected,but,if damaged,different methods of treatment are used,(depending) on the caliber of accessory hepatic duct.Type III and IV also should be protected,but,when damaged,the accessory hepatic duct should be repaired or performed an internal draining.