Objective To assess the effect of three different liver vascular exclusions on prognosis of patients undergoing hemihepatectomy.Methods Clinical data of 216 patients undergoing hemihepatectomy were analyzed retrospectively.Ninety-eight out of 216 patients received Pringle maneuver during hepatectomy in group A,71 patients of selective liver inflow and outflow vascular exclusions in group B,47 patients using liver hanging maneuver combining with selective liver inflow and outflow vascular exclusions were in group C.Results There was no difference in operation time between the three groups ( t =0.72,0.83,and 0.67,P ＞ 0.05 ).The intraoperative blood loss and transfusion in group B and C were less than that in group A (t =3.72,3.83 and 4.11,4.07,P ＜0.05).Serum albumin level on day 1 and day 3 in group B and C were higher than that in group A (t =3.65,3.77,and 3.90,3.74,P ＜0.05 ).Serum total bilirubin level on day 3 and 5 in group B and C were lower than that in group A ( t =4.13,5.01,and 4.09,3.99,P ＜0.05).Serum alanine aminotransferase on day 1,3 and 5 in group B and C were lower than that in group A ( t =5.36,6.14,and 5.70,7.01,and 4.94,3.98,P ＜ 0.05 ).Postoperative complication rate in group A was higher than that in group B and C ( x2 =13.71 and 23.56,P ＜ 0.05 ).The 3-year survival rate of patients with malignant tumor in the three groups were not significantly different (t =2.38,P ＞ 0.05 ).Conclusions Intraoperative blood loss and transfusion and postoperative complication rate can be reduced,and liver injury can be diminished in hemihepatectomy using selective liver inflow and outflow vascular exclusion alone and or in combination with a liver hanging maneuver.

Objective To investigate the pathogen distribution and drug resistance of biliary tract infection in patients with cholelithiasis, and to summarize the clinical experience.Methods160 patients with cholelithiasis were analyzed.The proportion of patients with biliary tract infection was counted.The bile and venous blood were collected and the distribution of pathogens was detected.The patients were also analyzed for the drug resistance.ResultsThe incidence of biliary tract infection was 62.5%, the positive rate of bile culture was 62.5%, and the positive rate of blood test was 37.5% for 160 patients with cholelithiasis.Gram-positive bacteria include Escherichia coli, Enterococcus faecium, Staphylococcus, Gram-negative bacteria, including Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, etc.;Gram-positive bacteria for the large Methicillin and erythromycin resistance is higher, Gram-negative bacteria for ampicillin and levofloxacin higher resistance.ConclusionThe pathogen distribution and drug resistance of biliary tract infection in patients with cholelithiasis are analyzed.The clinical pathogens are widely distributed.At the same time, the pathogens have different resistance to different antimicrobial agents.Therefore, clinical use should be reasonable choice when using antimicrobial agents, With a view to give full play to drug effects.

Intraductal papillary mucinous neoplasm (IPMN) is a kind of epithelial neoplasms of mucin-producing cells arising in the main duct and/or branch ducts of the pancreas,and it is one of the precancerous lesions of the pancreatic cancer.With the development of pathology and radiology,the diagnostic rate of IPMN has been gradually increased and given a new understanding on the pathological characteristics,clinical diagnosis and treatment of IPMN.This review overviewed the classification,diagnosis,management and prognosis of IPMN,aiming to deepen the understanding of IPMN and improve the level of diagnosis and treatment.

Objective To evaluate right hepatic veins exclusion in the prevention of massive bleeding and air embolism during the resection of huge hepatic cavernous hemangioma near the second hepatic portal. Method This is a retrospective study on the clinical data of 12 hepatic hemangioma patients at the Live Surgery Department of Zhejiang Provincial People's Hospital from 2004. 1 to 2010.3. In all patients the huge hepatic cavernous hemangioma was adjoining the second hepatic portal. Block webbing or vascular clamp were used to exclude the right hepatic veins. Among the 11 patients without hepatic cirrhosis Pringle maneuvre was applied in 5 cases and selective hepatic inflow occlusion in 6 cases. Patients with hepatic cirrhosis used hemi-hepatic blood inflow occlusion. Results During the surgery no rupture of right hepatic vein happened. Nine patients used vascular block webbing and 3 patients used vascular clamp.Six patients without cirrhosis used the complete hepatic inflow occlusion and other patients without cirrhosis used hemi-hepatic blood inflow occlusion. Cirrhotic patients used hemi-hepatic blood inflow occlusion. All the operations were successful. Intraoperative blood loss ranged from 200 - 5800 ml, averaging 680 ml. Three patients needed not blood transfusion. There was no right hepatic vein rupture or air embolism. Conclusion Right hepatic veins exclusion is a useful technique to prevent massive bleeding and air embolism caused by the rupture of right hepatic vein during the resection of huge hepatic cavernous hemangioma.

Objective To evaluate the surgical treatment of Nevin′s stage Ⅳ and Ⅴ gallbladder carcinoma. Methods A retrospective analysis was made on 62 cases of Nevin′s stage Ⅳ and Ⅴ gallbladder carcinoma patients undergoing surgical treatment from Jan. 1993 to Dec. 2002. Results There were 17 cases of stage Ⅳ and 45 of stage Ⅴ. Cholecystectomy was performed in 32 cases with a resection rate of 52%, 7 cases received radical resection, 10 extended radical resection and 15 palliative resection. The total surgical morbidity rate was 35.3%. Postoperative 1-, 3-, 5-year survival rate of radical and palliative resection were 61%, 31%, 11% and 27%, 13%, 0 respectively (P

Objective To explore the safety of the left anterior pararenal space approach in laparoscopic distal pancreatectomy with splenic preservation.Methods 30 patients operated between August 2008 and September 2013 were retrospectively reviewed.Results Of the 30 patients,28 underwent laparoscopic distal pancreatectomy with preservation of splenic artery and vein,2 underwent laparoscopic distal pancreatectomy with division of the splenic artery and vein and preservation of the short gastric vessels.All the 30 patients had their operations carried out successfully with an average operative time of (55 ± 38) min,blood loss (100 ± 48) ml and duration of hospitalization 7.8 d.Pancreatic fistula occurred in 2 patients and it healed spontaneously on drainage.Partial splenic infarction occurred in 1 patient.The pathological lesions were serous cystadenoma in 6 patients,mucinous cystadenoma in 6 patients,insulinoma in 5 patients,solid pseudopapillary tumor in 6 patients,chronic pancreatitis presenting as a mass in 3 patients,and pancreatic cyst in 4 patients.Conclusions The left anterior pararenal space approach was safe and efficacious in distal pancreatectomy with splenic preservation.If the pancreatic lesion was big and compressed the splenic artery and vein,laparoscopic distal pancreatectomy with division of the splenic artery and vein and preservation of the short gastric vessels was the procedure of choice.

Objective To study the causes of and management for reoperative surgery in patients of congenital choledochal cyst. Methods The clinical data of 41 patients of congenital choledochal cysts undergoing reoperative surgeries were reviewed. Results There were 32 cases of type Ⅰ , 1 of type Ⅱ ,3 of type Ⅳ, and 5 of type Ⅴ according to Todani classification of congenital choledochal cyst. Thirty patients experienced one previous biliary tract surgery, 8 had a history of 2 surgeries and 3 experienced three times of operations previously. Among the 41 patients, 40 presented bile duct stones, 33 suffered from biliary infections, 7 had hilar hepatic duct strictures, 6 had strictures of previous hepatoenteric anastomosis, 5 had carcinomas arising in cysts. The reoperative surgeries for the 41 patients consisted of excisions of extre-hepatic bile cyst and hepato-jejunal anastomosis by Roux-Y fashion (combining with hepatoduodenal ligament dissection and regional lymphadenectomy for two patients with cholangiocarcinoma) in 32 cases, hepatectomies combined with excisions of choledochal cyst and hepato-jejunal anastomosis in 8 cases, reconstruction of hepatoenteric anastomosis by excision of stenosis in one. All patients were followed up with mean time of 53. 7 ± 32. 1 months, ranging from 3 months to 10 years. Intermittent biliary infection was experienced in 4 cases during follow-up period, and there was no anastomotic stricture and stone recurrence. Conclusion The main causes of reoperation for congenital choledochal cyst patients with a history of previous surgery are complications arising from incorrect surgical procedure and misdiagnosis. Complete excision of extra hepatic bile cyst combined with Roux-en-Y hepatojejunal anastomosis benefits patients who had a failed previous surgery.

Objective To evaluate the result of multiple segmentectomy under selective occlusion of hepatic inflow for complicated intrahepatic cholangiolithiasis. Methods In this study 12 cases of complicated intrahepatic cholangiolithiasis receiving multiple segmentectomy under selective occlusion of hepatic inflow during 2004. 1 - 2010. 10 were reviewed retrospectively. The short-term and long-term outcomes of the patients were analyzed. Results There was no surgical mortality in this group. The segmentectomy performed were Ⅱ + Ⅲ + Ⅴ in 1 case; Ⅱ + Ⅲ + Ⅵ in 2 cases; Ⅱ + Ⅲ + Ⅴ + Ⅵ in 1 case;Ⅱ +Ⅲ+Ⅵ +Ⅶ in4 cases; Ⅱ +Ⅲ +Ⅳ +Ⅵ in 3 cases and Ⅱ + Ⅲ +Ⅳ +Ⅵ +Ⅶ in 1 case. The average intraoperative blood loss was 560 ± 291 ml. Postoperative complications were wound infection in 2 cases, bile leakage in 1 case, abdominal infection in 1 case. There were no liver failure, intrabdominal hemorrhage or hemobilia; stone clearance rate at 10 days after operation was 83% (10/12) and 92%(11/12) at 6 weeks after operation following postoperative choledochoscopic lithotripsy. 92% (11/12) cases were followed-up with the median follow-up period of 31 months. The result was excellent or good in 92% (11/12) cases. Conclusions Multiple segmentectomy was the choice for complicated intrahepatic cholangiolithasis, and the procedure could be safely performed under selective occlusion of the hepatic inflow.

Objective To evaluate hepatic vein exclusion (HVE) outside the liver in the resection of giant hepatic hemangioma near the second hepatic hilum. Methods From January 2003 to December 2009, giant hepatic hemangiomas near the second hepatic hilum were resected in 19 cases. Preoperatively 19 cases were divided into two groups: HVE group (9 cases) and IVE group ( 10 cases). Data regarding the intra-operative and postoperative courses of the patients were analyzed. Results There was no difference between the 2 groups regarding the age, sex and tumor size. No damage of hepatic vein was happened in HVE group. Resection of the hemangioma was applied in all cases of HVE group, and 1 case in IVE group had right hemi-hepatectomy. Hepatic veins rupture occurred in 4 cases in IVE group and 2 cases of them had massive bleeding, while in HVE group hepatic veins rupture occurred in 5 cases but no massive bleeding occurred. Intra-operative blood loss was significantly less in HVE group than IVE group. The serum ALT value in postoperative day 1 and total bilirubin in postoperative day 3 in HVE group was significantly lower than that of the IVE group. The mean drainage volume in HVE group was significantly less than that of the IVE group on postoperative day 1 and day 2. The total cost of patient in HVE group were significant less than in IVE group. Conclusions The use of hepatic vein exclusion reduces the risk in the resection of giant hepatic hemangioma near the second hepatic hilum.

Objective To evaluate the effects of selective hepatic vascular occlusion SHVO) on the prognosis of patients undergoing hepatic resection for huge liver cancer.Methods The clinical data of 49 patients who received huge liver cancer resection at the Zhejiang People's Hospital from January 2005 to January 2010 were retrospectively analyzed.Based on the type of hepatic vascular occlusion,all patients were divided into Pringle's maneuver group (24 patients) and SHVO group (25 patients).The intraoperative condition,postoperative recovery of hepatic and renal function,incidence of complications,survival rate and recurrence rate of liver cancer of the 2 groups were compared.All data were analyzed by using the t test or Fisher exact probability.The survival curve was drawn by using the Kaplan-Meier method and the survival of the 2 groups was compared by using the Log-rank test.Results Hepatectomy was successfully performed on all the patients.Time for blood occlusion were (32 ±19) minutes in the Pringle's maneuver group and (34 ± 22)minutes in the SHVO group,with no significant difference between the 2 groups (t =2.45,P ＞ 0.05).The volume of blood loss of the Pringle's maneuver group was (736 ± 543) ml,which was significantly greater than (273 ± 298) ml of the SHVO group (t =6.87,P ＜0.05).The incidences of hepatic vein rupture were 21％ (5/24) in the Pringle's maneuver group and 24％ (6/25)in the SHVO group,with no significant difference (x2=1.45,P＞0.05).The course of 3 patients was complicated by hepatic vein rupture and hemorrhage and 1 by air embolism in the Pringle's maneuver group,while no hemorrhage or air embolism happened in the SHVO group.Four patients in the Pringle's maneuver group and 3 in the SHVO group were found with vascular invasion,while the resection margins were negative.There was no significant difference in the hepatic function in the 2 groups before operation.The levels of alanine aminotransferase in the SHVO group at postoperative day 1 and 3 were significantly lower than those in the Pringle's maneuver group (t=7.12,6.35,P ＜ 0.05).There was no significant difference in the levels of blood urea nitrogen and creatinine between the 2 groups (P ＞ 0.05).Acute hepatic dysfunction was found in 4 patients in the Pringle's maneuver group,but no patients with acute hepatic dysfunction was found in the SHVO group.The 1-and 3-year tumor-free survival rates were 58％ and 21％ in the Pringle's maneuver group,which were significantly lower than 72％ and 30％ in the SHVO group (x2 =5.32,6.07,P ＜ 0.05).The 5-year tumor-free survival rates were 21％ in the Pringle's maneuver group and 20％ in the SHVO group,with no significant difference between the 2 groups (x2 =1.78,P ＞ 0.05).Conclusion SHVO is safe,feasible and effective to prevent hemorrhage and postoperative acute hepatic dysfunction,and it is also helpful in reducing early-stage tumor recurrence and improving the tumor-free survival rate in patients with huge liver cancer.