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 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 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 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.

Objective To explore the clinical charateristics,diagnosis and treatment of solid pseudopapillary tumors of the pancreas (SPTP).Methods 40 SPTP cases admitted in the First Hospital of China Medical University from 2004 to 2014 were analyzed retrospectively.Results Among 40 cases,male to female ratio was 1 ∶ 7 with the average age of 33.8 years.Major clinical manifestations included abdominal pain or discomfort and palpable abdominal masses.CT and MRI accuracy for detecting the location of tumors was better than B Ultrasonic.Surgical procedure included spleen preserving distal pancreatectomy in 15 cases,distal pancreatectomy with splenectomy in 9 cases,tumor enucleation in 11 cases,pancreaticoduodenectomy in 3 cases,duodenum preserving pancreas head resection in 2 cases.30 postoperative cases were followed-up with the mean follow-up time of 58.4 months and were all doing well.Conclusions SPTP is a tumor with low-grade malignant potentiality.Cystic and solid tumors of the pancreas found among young women are highly suspected as SPTP.Surgery is the main method of treatment and the prognosis is good.

Objective To investigate the risk factors of pulmonary metastasis and prognosis of patients with rectal cancer after anterior resection of rectal cancer.Methods The retrospective case-control study was adopted.The clinical data of 421 patients with rectal cancer who underwent anterior resection at the First Hospital of China Medical University from August 2010 to December 2014 were collected.The patients were followed up by outpatient examination and telephone interview once three months in the first postoperative year,once half a year in the second postoperative year,and then once a year.The follow-up included satuses of pulmonary metastasis and survival of patients after anterior resection of rectal cancer.The end point of follow-up was death of the patients or 31 December,2014.The risk factors of pulmonary metastasis and prognosis in patients after anterior resection of rectal cancer were analyzed.Measurement data with normal distribution were presented as x-± s and measurement data with skewed distribution were presented as M(range).The pulmonary metastasis rate/curve and survival rate/curve were calculated and drawn by the Kaplan-Meier method.The comparisons of pulmonary metastasis rate and survival rate were done using the Log-rank test.The univariate analysis was done using the chi-square test and Log-rank test.The multivariate analysis was done by Logistic regression model and COX regression model.Results Of the 421patients,389 patients were successfully followed up with a median time of 34 months (range,11-53 months) and a follow-up rate of 92.40％ (389/421).Ninety-four,168 and 127 patients were detected in Ⅰ,Ⅱ and Ⅲ stages of TNM stage.There were 29 patients diagnosed with postoperative pulmonary metastasis with the diagnosis time of (21 ± 9) months.The 3-year cumulative incidence of pulmonary metastasis after anterior resection of rectal cancer was 2.2％ in patients of Ⅰ stage,3.0％ in patients of Ⅱ stage and 17.4％ in patients of Ⅲ stage,showing significantly increase trend as the increase of the TNM stage (x2=19.927,P ＜ 0.05).The 29 patients with pulmonary metastasis did not receive chemoradiotherapy including 6 patients receiving pulmonary metastatic nodule recection.Nineteen patients were survived and 10 patients were dead.The survival time of patients diagnosed with pulmonary metastasis was (13 ±9)months and the 3-year cumulative survival rate was 75.7％,whereas the survival time of patients without postoperative pulmonary metastasis was (35 ±9)months and the 3-year cumulative survival rate was 94.3％,showing significant difference between the 2 kinds of patients (x2 =25.219,P ＜ 0.05).The univariate analysis showed that the preoperative carcinoembryonic antigen (CEA) level,degree of tumor differentiation,depth of invasion and lymph node metastasis were risk factors affecting pulmonary metastasis after anterior resection of rectal cancer (x2=4.745,7.250,5.379,18.796,P ＜ 0.05),and the multivariate analysis showed that lymph node metastasis was an independent risk factor affecting postoperative pulmonary metastasis [OR =4.167,95％ confidence interval (CI):1.608-10.801,P ＜ 0.05].The univariate analysis showed that the preoperative CEA level,distribution and number of pulmonary metastatic nodule and lymph node metastasis were risk factors affecting the prognosis of patients with pulmonary metastasis after anterior resection of rectal cancer (x2=13.793,7.246,6.284,4.076,P ＜ 0.05),and the multivariate analysis showed that the preoperative CEA level ＞ 5 μg/L was an independent risk factor affecting the prognosis of patients (HR =13.489,95 ％ CI:1.407-129.297,P ＜ 0.05).Conclusions Pulmonary metastasis after anterior resection of rectal cancer is common.Lymph node metastasis is a high risk factor affecting postoperative pulmonary metastasis,and preoperative CEA level ＞ 5 μg/L is an independent risk factor affecting the prognosis of patients with postoperative pulmonary metastasis.

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.

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.