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orthopedic paper V

Treatment of femoral neck fracture with closed nailing

Report of 45 cases

Abstract

The paper discusses treating 45 cases of traumatic femoral neck fractures using closed reduction and percutaneous triangular pinning. Follow-up conducted over 1-3 years showed delayed healing in one case and avascular necrosis of the femoral head in two cases. The rest of the patients were able to walk without crutches within 3-6 months. The treatment method is characterized by minimal trauma, quick recovery, safety, broad indications, and the preservation of anatomical structures.

Keywords: Closed Reduction, Femoral Neck Fracture, Triangular Pin

Introduction

Femoral neck fractures are clinically common, especially among the elderly. To date, there is still no standardized treatment method, making the search for a safe, effective, and easily disseminated approach a long-standing goal in the field of orthopedics. Since Smith-Petersen first introduced the use of triangular nails for internal fixation in 1931, there have been notable achievements in shortening the duration of treatment, reducing complications related to bed rest, and lowering disability rates, among other aspects. However, the method of open nailing has its disadvantages, such as causing significant trauma, further damaging the periosteum and blood supply, and increasing the risk of infection. On the other hand, closed reduction and percutaneous nailing, including recent developments like compression screws or cannulated screws, have become much simpler and more feasible with the continuous improvement of radiological equipment, technical advancements, innovative tools, and accumulated experience. The text concludes by stating that the authors have recently conducted this type of surgery and have followed up on 45 cases, which will be reported.

Clinical Data

All 45 cases are fresh fractures. There are 30 males and 15 females. Ages range from 40 to 81 years, with an average age of 62. There are 32 cases on the left side and 13 on the right. Six are of the eversion type, while the rest are inversion. There are 34 intracapsular cases (7 subcapital and 27 in the neck) and 11 extracapsular ones (at the base of the neck). Fourteen patients were admitted immediately after the injury. All received early surgery, and the rest underwent surgery within a week. For those with successful nailing, postoperative movement was unrestricted, and they could move around and sit up with assistance. Otherwise, patients received lower limb traction for 2-3 weeks or wore a rotational support shoe. Afterward, they could move with crutches. No surgical infections were reported in any cases.

Follow-Up Results: All cases were followed up for 1-3 years. Three months post-op, 90% (40/45) of patients had bone union, pain-free hips, and could walk without limping, using crutches. In two cases with subcapital fractures, X-rays six months post-op showed localized cystic changes and collapse within the femoral head, but walking was still possible, and slight repair was observed after a year. One case had poor repositioning and resulted in mild limping, while another case had insufficient implant insertion. One year post-op, 25 cases had the nails removed.

Surgical Indications

Apart from non-displaced impacted fractures that do not require special treatment, and comminuted fractures where nailing is expected to be ineffective, this surgical procedure can be applied to all types of fractures.

Surgical Method

For patients admitted within 24 hours of the fracture, who have no specific contraindications for surgery, traction is not pre-arranged and surgery is carried out as soon as possible. At this point, tissue reaction is mild, and muscle elasticity is reversible, making reduction easier. Otherwise, preoperative skeletal traction is applied for 48-72 hours to correct fracture displacement. The proposed reduction plan is determined based on factors such as the direction of the fracture line, the shear force, blood supply to the head, and muscle action.

Epidural blockade anesthesia is usually used to achieve muscle relaxation, facilitate reduction, and make surgery painless. Alternatively, local anesthesia can also be used.

The patient lies supine on the X-ray diagnostic table for reduction using Whitman's method. The principle of "first separation, then joining" is followed. Initially, the leg is slightly externally rotated and adducted to loosen the fracture surface, making it easier to apply traction and correct shortening. The fluoroscope is used to confirm anatomical alignment and to tighten the fracture line. The affected limb is kept in 15° internal rotation to counteract the natural forward tilt, facilitating horizontal needle insertion. A lead marker is used to mark the intersection point between the inguinal ligament and the femoral artery at the surface projection of the center of the femoral head.

A guide needle is inserted 3 cm below the greater trochanter, following aseptic requirements. When it reaches the bone, its closest point, i.e., the tangential point on the outer edge of the femur, is probed to prevent sliding forward or backward. It is inserted horizontally at approximately a 130° angle, using the distance between the insertion point and the target for comparison to reduce X-ray exposure for the surgeon. Skilled surgeons can achieve this almost every time on their first try. A Kirschner wire is inserted transversely from the upper part through the femoral head to the acetabulum to prevent head rotation. Note: This wire should not interfere with the guide wire and should maintain a triangular nail width distance.

A 2 cm incision is made at the skin entry point of the guide wire to reach the bone cortex. A self-made cortical opener (triangular nail with a serrated progressive step) is used to pierce the cortex and pre-make a tunnel. After confirming that the guide wire has not moved, a suitable triangular nail is chosen based on its scale. The nail is carefully driven in to prevent misalignment, jamming, or breaching the head edge. The guide wire and Kirschner wire are then removed. A self-made small round steel tube is used to embed and tighten the fracture surface. The incision is sutured in one layer, followed by compression bandaging. Surgery is then completed.

Discussion

The hip joint is surrounded by abundant muscle tissue and is very strong. Additionally, the shaft and head are not aligned, making it easy for shear stress to cause shortening and dislocation after a femoral neck fracture. The joint also tends to rotate easily within the socket, causing deformities that affect the range of motion in the joint later on. These anatomical and pathological factors often lead to poor outcomes with conservative treatments. Therefore, timely reduction and effective internal fixation, which help maintain proper alignment and allow the patient to get out of bed as soon as possible, are crucial.

Clinical data shows that closed nailing treatment for femoral neck fractures has several advantages: minimal trauma, simplicity, effective fixation, fast recovery, and cost-effectiveness. It not only allows the patient to get up quickly but also retains the patient’s own femoral head, without damaging the anatomy of the hip joint, and largely restores pre-injury function. In our study, functional recovery was achieved in 90% of cases (40/45).

Radiological equipment and technical details are two key elements in this surgical method. Advanced radiological facilities make the procedure even more convenient. The technique focuses on restoring physiological angles and preventing inward and outward rotation of the hip. Accurate needle placement and tight bone fracture contact are essential. With these in place, the patient can move in bed shortly after surgery, aiding overall recovery.

Considering the complex anatomy and mechanics of the hip joint, surgeons must understand the fundamental theories and master the pathology of fractures. Improvements in equipment, traction methods, and positioning can further refine the surgical procedure. Recent years have seen advancements like pressure screws for better insertion, traction frames for effective traction and stable positioning during surgery, and cortical openers for accurate cortical bone chipping, which significantly simplify the surgical process and improve medical outcomes.

Regarding bone non-union and head necrosis, the general rate is between 15%-25%. It's observed that necrosis is generally determined at the time of fracture but only manifests later. Factors such as the degree of dislocation, location of the fracture, timing, and method of reduction, as well as weight-bearing time on the affected limb, are relevant. Preventing iatrogenic re-injury is crucial. Even if this treatment fails due to poor reduction, needle error, or other complications, salvage methods like osteotomy or artificial femoral head replacement are still available.

References 

1. Liu Shijie, Chinese journal of surgery 1980 18: 125 
2. Ouyang Jia, Chinese journal of surgery 1978 16: 123 
3. Wu Zuyao, Chinese journal of surgery 1959 7: 135 
4. Wang Yongchang, Chinese journal of surgery 1982 20:289

This article was originally published in the 1994 supplemental issue of the Journal of Southern Anhui Medical College, pages 37-38
Nanling Hospital, Li Mingjie,Zhang Jianmin, Xu jianzhong
Sept. 1, 1988

from 闭式穿钉治疗股骨颈骨折45例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

orthopedic paper IV

Lipoma under soft spinal membrane complicated with high paraplegia

Introduction

Intraspinal tumors predominantly consist of extramedullary tumors, accounting for 85% of the cases. However, subdural lipomas are exceedingly rare. Due to their proximity to the spinal cord, the pathological changes and clinical symptoms often get confused with intramedullary tumors. Nevertheless, as benign lesions, their surgical treatment and prognosis differ significantly. We report a case admitted to our hospital who has fully recovered after six months post-surgery.

Case Presentation

The patient is a 39-year-old married male farmer from our county, admitted on March 28, 1979, with case number 1340. He experienced numbness and weakness in both lower limbs accompanied by sharp, band-like pain on the right side of the chest for six months. He had difficulty with bowel and bladder control and was unable to walk or stand for two months. Paralysis had ascended to the level of the nipples, accompanied by breathing difficulties for two weeks.

Clinical Examination

Superficial sensation below the second rib was virtually absent, more so on the right side. Partial sharp pain remained on the left side. Abdominal and cremasteric reflexes were absent. The muscle strength in both lower limbs was graded 8-4, and there were no ankle clonus. Tenderness was observed upon percussion of the spinous processes of the upper thoracic vertebrae, but no deformity was noted. Thoracic spine X-rays were negative. Queckenstedt's test showed complete obstruction of the subarachnoid space. CSF analysis: Pandy's test positive, cell count 10/mm³, and positive for Froin's sign. Paralysis index was 2-4 (sensory 2, motor 1, sphincter 1).

Preoperative Diagnosis

Cervicothoracic intraspinal tumor with paralysis, extramedullary type.

Surgery

On April 4, intraspinal exploration was performed under local anesthesia. Via a posterior midline approach, the laminae of thoracic vertebrae 7-12 were excised. The dura was opened between cervical 6 and thoracic 5. Although fat distribution seemed uniform in the epidural space, a 35x20x12 cm fatty, yellow, soft protrusion was discovered on the dorsolateral aspect of the spinal cord at T1:T2, causing 50% compression. The lesion was partially excised (80%) to avoid spinal cord injury, tagged, and sent for pathology. The surgical field was irrigated. The dura was left open to decompress, and the soft tissues were sutured without drainage.

Postoperative Recovery

Within 48 hours post-surgery, the patient reported a burning sensation in both lower limbs. Gradually, motor and sensory functions improved. On postoperative day 19, the urinary catheter was removed, and the patient could urinate voluntarily and turn himself over. He was discharged after 36 days without any complications.

Pathological Report

The protrusion was identified as "fatty tissue," pathology number 4724.

Six-Month Follow-Up

Six months postoperatively, the patient can walk with crutches, has completely regained sensation, has normal bowel movements, and has normal urinary flow. His appetite is good, nutrition is well-maintained, and he can engage in weaving and other handcrafts.

Discussion

Intraspinal tumors that reside underneath the soft dura mater are, for the most part, growths that overlay the spinal cord. These growths create a space-occupying pressure that leads to spinal canal obstruction, a mechanism distinct from intramedullary tumors that directly damage the spinal cord. While the former mostly consists of benign abnormalities, the latter are primarily malignant. However, both can cause early-onset paraplegia due to their close relationship with the spinal cord, and both can advance rapidly. In this case, the "lipoma" is a benign growth that, within a short span of six months, caused severe obstruction of the spinal canal.

In the case of intramedullary malignant tumors, such as gliomas, paraplegia appears early and is often complete. Benign growths close to the spinal cord usually cause more severe paralysis on the side where the growth is present, commonly known as Brown-Séquard syndrome. This case exhibited varying degrees of paralysis on both sides, with early-onset "intercostal neuralgia" on the right side, which correlates with the intraoperative finding of the growth leaning to the right. Additionally, bladder and rectal functions were not completely impaired.

Clinically, progressive paraplegia accompanied by evidence of obstruction in Queckenstedt's test indicates the need for early surgical intervention to relieve the pressure. Even if the abnormality is benign, prolonged pressure can cause irreversible damage to the spinal cord. Relaxing paralysis, even if it lasts for several weeks, is hard to reverse. In our case, timely surgical decompression yielded good results.

Based on clinical symptoms, the level of paralysis, and tests like Queckenstedt's and spinal angiography, it is possible to understand and locate the spinal canal obstruction. Intraoperatively, the effectiveness of decompression can be judged by the return of pulsations in the spinal cord. When the growth cannot be completely removed, it's crucial to leave the dura mater open as a decompressive measure.

Soft dura mater lipomas are soft, benign tissues. They don't cause localized fatty absorption on the hard dura and show no localized elevation or hardening, making them hard to detect from outside the dura mater. When the dura is cut open, these growths can be clearly identified: a yellow growth overlaying the spinal cord with increased, abnormal vascular distribution, flattening the spinal cord due to pressure.

Conclusion

This paper reports a rare case of a lipoma underneath the soft dura mater, leading to high-level paraplegia. It analyzes the case from a pathological and clinical perspective, comparing it with intramedullary tumors. It suggests that surgical intervention should be performed as early as possible. However, it's not necessary to "completely" remove the tumor; spinal decompression is crucial.

This article was presented at the Second Sessiong of Third Annual Surgical Conference in Anhui Province and originally published in "Nanling Medicine" 1979；1:68.
Nanling Hospital, Li Mingjie

from 软脊膜下脂肪瘤并发高位截瘫

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

orthopedic paper III

Surgical analysis of surgical paraplegia

Report of 14 cases

Abstract: The article reviews the surgical treatments and long-term follow-ups of 14 patients who experienced paraplegia due to surgical causes over the last 13 years. The outcomes were 10 cases recovered, 3 cases improved, and 1 case deceased. The article details the causes, pathology, and surgical methods, followed by discussions.

Causes Classification:

• Spinal Fractures: 7 cases
• Spinal Tuberculosis: 5 cases
• Intradural Tumors: 2 cases

Spinal Fractures: Particularly in "complete transverse fractures" (refers to fractures affecting the vertebral body, arch, and intervertebral ligaments), dislocations are common. If it happens in the cervical-thoracic section, it often results in spinal cord contusions or compressions, causing paraplegia. Among them, 4 cases had spinal cord destruction observed during surgery, presenting as a mushy substance. No surgical methods could reverse the paraplegia. Apart from one case, which resulted in breathing difficulty and lung infection, leading to death one month post-injury, the rest could generally live for years with disabilities, even capable of manual labor.

Spinal Tuberculosis: Especially in the thoracic section, due to the relatively narrow spinal canal and the inability for abscess to drain, it easily results in spinal cord compression and subsequent paraplegia. All 5 cases were in the lower thoracic section, 4 were vertebral tuberculosis, and 1 was arch tuberculosis. After surgical lesion removal, all recovered. The paper strongly recommends applying thoracic lesion removal and anterior intervertebral bone grafting in suitable cases, which not only increases the effectiveness but also significantly shortens the treatment period.

Intradural Tumors: Generally benign and located extramedullary. Surgery to remove or decompress shows good results. Both cases in this group were extramedullary benign tumors; one was completely removed, and one was mostly removed along with dural decompression, both achieving full recovery. However, surgery should be extremely cautious for malignant tumors to avoid accidental injuries and uncontrolled bleeding.

Overview

Spinal cord dysfunction due to injury or compression can result in varying degrees of paraplegia, which can have serious consequences for the patient. If managed appropriately, the majority of cases can be salvaged. Between 1968 and 1981, the author encountered 14 such cases, all of which underwent surgery, received a definitive diagnosis, and were given corresponding treatments. The outcomes were 10 cases fully recovered, 8 cases improved, and 1 case deceased. This paper introduces and analyzes the causes, pathology, surgical interventions, and prognoses of this patient group.

1. Classification of Causes

2. Degree of Paralysis

3. Choice of Anesthesia and Surgical Approach

4. Surgical Methods

5. Pathological Changes and Prognosis

Regarding Spinal Fractures Accompanied by Paralysis

Spinal fractures can appear at various segments of the spine due to different points of external force. However, because the spinal cord terminates at the lower edge of the first lumbar vertebra, below which is the cauda equina comprised of nerve fibers, its injuries are generally not complete. The spinal cord, on the other hand, is very delicate and easily damaged. As a result, the incidence of paralysis accompanying cervical and thoracic spinal fractures is high, and the prognosis is often poor.

The treatment objectives for these patients are:

1. To explore the spinal cord, ascertain the pathological changes, and attempt to relieve compression or additionally take decompression measures, aiming to restore the vertebral canal's openness and make a prognosis.
2. Under direct surgical view, to reset the fracture, take care to avoid repeated injuries, and apply strong internal fixation to restore the stability and supportive force of the spinal column.

For these purposes, although the work involves both orthopedics and neurosurgery, neither can be neglected. This is because the recovery of spinal cord function is a matter of life and death, while the recovery of spinal column stability is related to regaining labor capability. Both are often handled concurrently in clinical practice.

1. Case Presentation

2. Typical Case Introductions

Case 1: Male, 36 years old, had a complete transverse fracture and dislocation at the 9th thoracic vertebra. Palpation revealed spinal cord compression without destruction. Under direct vision, fracture reduction and decompression were performed, followed by internal fixation with spinal steel plates. Fourteen days post-surgery, the patient regained urinary function, lower limb muscle strength improved to Grade III, and sensation was restored. Discharged one month after surgery, the patient could walk with crutches in three months and gradually regained full mobility and working capacity. One year later, the steel plate was removed, and the patient was fully recovered.

Case 2: Cervical vertebrae 4 and 5 were shattered, and high-level paralysis was observed. Surgical exploration confirmed spinal cord destruction. Only cranial traction was applied. The patient died one month after surgery due to respiratory failure, lung infection, and bedsores leading to systemic collapse.

Case 3: Male, 42 years old, had a complete fracture at the 8th thoracic vertebra along with paralysis. During surgery, the spinal cord was found to have a mushy appearance. Spinal steel plates were used for internal fixation. Paralysis was not reversed; the muscles in the lower limbs atrophied, while the upper limbs developed. The patient relied entirely on crutches for mobility and had a reflexive bladder but could perform weaving work. He died five years later due to diabetes.

3. Discussion

Spinal fractures accompanied by paralysis pose significant risks. Aside from spinal shock that can recover over time, a few cases arise from vertebral compression causing the rear edge to move backward, compressing the anterior part of the spinal cord. This is often exacerbated by hematomas and reactive edema of the spinal cord. More commonly, the vertebral bodies and their attachments are injured or dislocated in a single plane, causing a "complete transverse fracture of the spine," which disrupts the normal anatomy of the spine. This leads to bone or bone fragments easily damaging and severing the delicate substance of the spinal cord, resulting in function loss that is difficult to recover.

Osterholm believes that once the spinal cord is mechanically compressed, local catecholamine levels increase, causing vascular constriction and blood supply obstruction in the affected area, thus accelerating the development of paralysis or making it irreversible. Based on this theory, it is strongly advised to undertake emergency surgical decompression to avoid missing the treatment window. However, there have been reports of paralysis recovery following delayed surgery. For cases where the spinal cord is already damaged, the goal is merely to explore and avoid further iatrogenic injuries while preserving any remaining spinal function. Allem points out that the spinal cord usually dissolves within 24 to 48 hours after severe injury, which is related to the intrinsic autolytic process within the spinal cord. Therefore, surgery is best performed within 24 hours for patients with partial spinal damage.

According to our long-term follow-up observations, the prognosis primarily depends on the degree of pathological changes in the spinal cord. Recovery is rare for patients with a destroyed spinal cord, as in cases 2, 3, 4, and possibly 7. On the other hand, for those with compressed spinal cords, effective decompression can often lead to full recovery, as in cases 1, 5, and 6.

Studies have shown that displacements greater than 1 cm in the thoracic vertebrae above T12 with complete paralysis often indicate severe spinal cord injury, with little hope for recovery. Displacements less than 1 cm usually indicate mild spinal cord injury with better chances of recovery. However, it should be noted that spinal fractures often have an automatic recoil effect, making the actual displacement greater than what X-rays may show. Overall, the surgical group has a 50% higher recovery rate than the conservative treatment group.

4. Conclusion

Traumatic paralysis can lead to different outcomes. Aside from cases of high-level paralysis which can result in short-term death due to severe complications, paralysis caused by compression can often be reversed through decompression. However, recovery from spinal contusions is less likely. Through surgical repositioning and internal fixation to stabilize the spine, patients can still survive for a prolonged period. It's important to note that there's no clear boundary between "compression" and "contusion," as both can coexist. Moreover, what is observed visually may not be entirely accurate. Those with contusions can still hope to maintain some residual spinal function, while those suffering from compression may also experience worsening paralysis due to edema or localized ischemia. Therefore, individuals suspected of having spinal cord damage should be treated as if they are "compressed" for maximum salvaging.

Regarding Spinal Tuberculosis Complicated by Paralysis

Spinal fractures can appear at various segments of the spine due to different points of external force. However, because the spinal cord terminates at the lower edge of the first lumbar vertebra, below which is the cauda equina comprised of nerve fibers, its injuries are generally not complete. The spinal cord, on the other hand, is very delicate and easily damaged. As a result, the incidence of paralysis accompanying cervical and thoracic spinal fractures is high, and the prognosis is often poor.

Spinal tuberculosis is usually found in the vertebral bodies, with the appendages rarely affected, accounting for about 1%. Obstruction caused by tubercular matter in the spinal canal can lead to paralysis, often in the thoracic region where the spinal canal is relatively narrow.

The likelihood of thoracic vertebrae tuberculosis leading to paralysis is high, and conservative treatment not only prolongs bed rest but also offers minimal chances of recovery. The complications of paralysis are pressing and demand urgent attention. Thus, early surgery, after appropriate preparation, has become the modern consensus. Under the protection of anti-tuberculosis treatment, complete lesion removal to clear the spinal canal, coupled with bone graft fusion to stabilize the diseased spinal area, can achieve good results and prevent recurrence. All five cases in this group were cured through surgery.

1. Case Presentation

2. Typical Case Studies

1. Case 1: Male, 35 years old, tuberculosis of the 8th and 9th thoracic vertebrae accompanied by paralysis. After three weeks of anti-tuberculosis preparation, a staged, lateralized surgical plan was carried out. Initially, the lesion on the right side was removed under spinal anesthesia, extracting a large amount of pus, necrotic bone, and tubercular granuloma. Post-surgery, the paralysis showed signs of recovery, but urinary catheterization could not be removed. One month later, a second surgery was planned to remove the lesion on the opposite side and perform spinal fusion. However, the patient experienced a high fever (41°C) and convulsions under general anesthesia, forcing the surgery to be halted. The patient then refused further surgeries and was discharged for home care. Twenty days after returning home, the urinary catheter fell out on its own, and the patient began to urinate independently. Three months later, he was able to walk with crutches and returned to light work after six months. A year after the surgery, the patient carried his ill mother for 40 miles to the hospital, astonishing the surgeons!

2. Case 3: Male, 36 years old, tuberculosis of the 7th thoracic vertebra arch, accompanied by paralysis. Four months after total laminectomy, he was able to walk, and a year later, he also returned to work. This case had a spinal angiogram showing pseudolocation due to arachnoid adhesions; the lesion was located during surgery and confirmed pathologically post-removal.

3. Case 5: Female, 29 years old, worker, tuberculosis of the 8th and 9th thoracic vertebrae. The vertebrae had collapsed, causing kyphosis, accompanied by proliferative pulmonary tuberculosis and a healed dislocation of the right hip due to tuberculosis. She was frail and weighed only 42 kilograms. During her pre-surgical hospital stay, her paralysis worsened, and she showed uncontrollable symptoms of sepsis. Surgery was performed under endotracheal ether anesthesia. The lesion was removed through the right thorax in one go, 2.5 diseased vertebrae were excised, and anterior decompression was performed. Tubercular material was scraped out from within a 10 cm section of the spinal canal, revealing a pulsating dura mater. Two rib sections were implanted between the vertebrae. The surgical field was flushed, and the thoracic cavity closed as per routine. The patient had no postoperative complications, the paralysis was quickly relieved, and the body also recovered smoothly. She was able to walk after four months in bed and returned to textile work after a year. X-ray follow-up showed successful bone graft fusion, disappearance of paravertebral abscess shadows, and slightly blunted costal angles.

3. Discussion

Spinal tuberculosis is a specific infection characterized by the presence of tubercular granuloma, caseous material, and pus both inside and outside the spinal canal, especially around the spinal cord. In the narrow thoracic spine, the pus doesn't easily drain, and along with necrotic bone or intervertebral disc tissue, this leads to spinal canal obstruction and consequent paralysis. Tuberculosis sepsis at this stage can affect multiple organs, making the situation far more complex and difficult to manage compared to paralysis caused solely by mechanical compression.

The posterior approach for staged, lateralized lesion removal has been a standard procedure to date. Not only does it eliminate the lesion and break the "tuberculosis barrier," aiding in lesion healing, but it also allows for spinal decompression. This is particularly effective for the recovery of concurrent paralysis, as demonstrated in Case 1. However, the method carries a certain degree of uncertainty. The surgery is performed deep within the body where visibility is limited, requiring reliance on experience to achieve "relative completeness." There's also the risk of accidentally damaging blood vessels, the spinal cord, or internal organs. According to domestic reports, the surgical success rate is 61.6%.

In contrast, the anterior thoracic approach allows for a thorough and effective lesion removal under direct vision. It also removes destructive tubercular material from the spinal canal and relieves spinal cord compression. Combined with reliable anterior decompression of the spinal canal, it significantly aids in the recovery from paralysis. Performing anterior intervertebral bone grafting also promotes compression fusion and helps restore spinal stability. This approach not only avoids the pain and economic burden of multiple surgeries but also significantly increases the cure rate and shortens the treatment duration, as seen in Cases 4 and 5.

In cases of spinal accessory tuberculosis, which has a lower incidence rate and generally better prognosis due to abundant peripheral muscles and good blood circulation, lesions are usually absorbed naturally. However, paralysis can still occur in the thoracic section. Laminectomy for spinal decompression and lesion removal is relatively convenient if it doesn't compromise the small facet joints, as in Case 3.

4. Summary

In cases of traumatic paralysis, except for high-level paralysis, which often leads to early death due to severe complications, paralysis caused by compression often shows a good recovery rate once decompressed. On the other hand, recovery is generally more difficult in spinal cord contusions. However, surgical repositioning and internal fixation to stabilize the spine can still lead to prolonged survival.

It’s important to note that the terms "compression" and "contusion" are not strictly separate and often coexist. What is observed with the naked eye isn't always entirely accurate. Therefore, in cases identified as "contusion," the hope lies in maintaining the remaining functional portions of the spinal cord. For those identified as "compression," secondary spinal cord degeneration can occur due to edema or local ischemia, making the paralysis worse.

Hence, for patients suspected of having substantial spinal cord damage, treatment should be approached as if the spinal cord is "compressed" in order to maximize the chances of recovery.

Regarding Spinal Tuberculosis and Resulting Paralysis

Spinal tuberculosis predominantly affects the vertebral bodies, while appendages of the spine are less commonly involved, accounting for about 1%. When tuberculous material fills the spinal canal and causes an obstruction, it can result in paralysis, most commonly in the thoracic region due to the relative narrowness of the spinal canal there.

The likelihood of paralysis is quite high in cases of thoracic spinal tuberculosis. Conservative treatment doesn't yield significant improvement; not only does it require prolonged bed rest, but the chance of complete recovery is also extremely low. Complications from the resulting paralysis can be aggressive and need immediate attention. Therefore, the modern consensus leans towards early surgical intervention after adequate preparation.

Under the cover of anti-tuberculosis treatment, thorough removal of the lesion to unblock the spinal canal is recommended. Additionally, bone graft fusion to stabilize the affected spinal area can achieve good results and prevent recurrence. All five cases in this group were completely cured after surgical intervention.

1. Case Presentation

2. Case Studies Summary

1. Case 1: Male, 35 years old, affected at T8-T9

   • After three weeks of anti-tuberculosis treatment, he underwent staged, unilateral surgery to remove the lesion on the right side. Postoperative evaluation showed some recovery of paralysis, but a catheter for urination was still necessary.
   • A second surgery for the opposite side was planned, but had to be stopped due to high fever and seizures under anesthesia. The patient opted out of additional surgeries and was discharged. After returning home, he started to urinate on his own within 20 days, and six months later, he was able to perform light work. Astonishingly, a year after the surgery, he even carried his sick mother 40 miles to the hospital.

2. Case 3: Male, 36 years old, affected at T7

   • Four months after undergoing decompression of the entire vertebral arch, he could walk. A year later, he resumed work.
   • Spinal angiography was performed, revealing false localization due to arachnoid adhesions. The lesion was identified and removed during the surgery and confirmed through pathology.

3. Case 5: Female, 29 years old, worker, affected at T8-T9

   • Also suffering from proliferative pulmonary tuberculosis and a healed form of tuberculosis in the right hip, she weighed only 42 kg.
   • During the preoperative preparation period, her paralysis worsened and septicemia symptoms could not be controlled. She underwent surgery, including removal of 2.5 affected vertebrae and spinal decompression.
   • After the surgery, she experienced no complications, her paralysis was quickly resolved, and she returned to her textile work within a year. Radiography confirmed bone graft fusion and the disappearance of paravertebral abscesses.

Discussion Summary

1. Complex Nature of Spinal Tuberculosis

   • The disease involves a unique type of infection where tuberculous granuloma, caseous material, and pus accumulate both inside and outside the spinal canal. This is more problematic in the thoracic spine, which is relatively narrow. Along with necrotic tissue and bone, this leads to spinal canal obstruction and paralysis. In addition, systemic symptoms due to tuberculosis further complicate the condition.

2. Surgical Approaches

   • The standard surgical procedure involves staged, unilateral lesion removal via a posterior approach. This not only clears the lesion but also breaks the "tubercular barrier," aiding in healing. It's also effective in relieving paralysis, as in Case 1. However, the procedure is risky due to its "blind" nature.
   • The anterior approach via the chest allows for a more effective and safer removal of the lesion under direct vision. It also offers the opportunity for reliable spinal decompression, aiding in the recovery of paralysis. Coupled with anterior interbody bone grafting, it enhances spinal stability.

3. Rate of Success and Adaptation

   • Studies have shown a 61.6% success rate for the posterior approach. The anterior approach not only minimizes the pain and economic burden of multiple surgeries but also significantly improves the cure rate and shortens the treatment period. The authors are leaning towards adopting this approach, as in Case 4 and Case 5.

4. Attachments of the Spine

   • Tuberculosis of the spinal attachments is rare and generally has a good prognosis due to good blood circulation and muscle mass around it. Even in the thoracic spine, where paralysis can occur, laminectomy and lesion removal without destroying the facet joints can achieve good results, as shown in Case 3.

Regarding Spinal Canal Tumors Complicated with Paralysis

1. Types of Tumors

   • Most commonly found are meningiomas in the extradural intrathecal space.
   • Gliomas and ependymomas are usually present within the spinal cord.
   • Subarachnoid lipomas are relatively rare.

2. Mechanism of Paralysis

   • The tumor creates a space-occupying lesion, putting pressure on the spinal cord.
   • As the tumor grows, the paralysis progressively worsens.
   • Non-surgical decompression or shunting is usually not effective in reversing this condition, highlighting the need for attention to these cases [7].

3. Differential Diagnosis

   • It's crucial to distinguish these tumors from other conditions causing paralysis, such as transverse myelitis, and subarachnoid hemorrhage to avoid unnecessary surgery and complication.

1. Case Presentation

Case 1: A neurofibroma located at the T10 spinal segment was completely excised. The Queckenstedt's test showed partial obstruction. The patient recovered in 2 months. Straightforward and effective, like a clean piece of code.

Case 2: This one's a bit more complex. A subdural lipoma at C7 T1 caused complete obstruction. About 70% of the tumor was removed and the dura was decompressed. It took 6 months for the patient to recover, but hey, they did recover!

Discussion

Clinical Confirmation

Both cases were diagnosed through clinical neuro-localization, confirmed during surgery. It's like finding a bug in a specific part of the code—difficult but not impossible.

Pre-operative Uncertainty

It was hard to nail down the pathology before surgery, but both cases improved post-operation. The first case was easier to handle with complete tumor excision since the neurofibroma was outside the spinal cord. The second case required a more cautious approach: the benign lipoma was intimately adhered to the spinal cord, so only partial removal was attempted. They also decompressed the dura to relieve pressure.

The Root Cause

The root cause of spinal cord paralysis due to tumors is essentially mechanical compression within the spinal canal. Similar to an overloaded server, the only solution is to alleviate the congestion. Various diagnostic tests like cerebrospinal fluid dynamics and chemical examination can help confirm this.

Diagnostic Methods

Spinal angiography can theoretically localize the lesion, but like any sophisticated AI model, there can be false positives or negatives. Clinicians must consider errors, adhesions, vascular anomalies, and other factors.

Importance of Pre-op Assessment

Efforts must be made to understand whether the tumor is inside or outside the spinal cord, benign or malignant, as this influences both the surgical complexity and prognosis. It's like optimizing an algorithm—you need to know the variables affecting the output.

Urgent Action

If the diagnosis is unclear, it's better to operate sooner rather than later. First, most spinal tumors are benign and easier to treat. Second, even if it's malignant, at least you can relieve the pressure. But caution is crucial; surgeries aren't risk-free. Third, surgical and pathological examinations can confirm the diagnosis, allowing for appropriate management.

Summary

Long-Term Observations

The study recaps 14 cases of paralysis due to surgical causes over a 13-year span. It's like looking back at 13 years of software updates—some work wonders, some need patching. Various treatment methods were evaluated and outcomes of individual cases were discussed.

Outcomes

Of the 14 cases, there were no surgical mortalities. Ten fully recovered; one with a high cervical injury died shortly after surgery; one case is too recent for assessment; two more lived for 5 and 3 years post-operation but eventually died due to complications like diabetes and intestinal obstruction, making it unclear if their paralysis contributed to their deaths.

Tuberculosis and Benign Spinal Tumors

100% effective treatment was shown here. It's like finding that perfect algorithm you've been dreaming about. Treatment for thoracic spine tuberculosis-induced paralysis has significantly advanced, reducing treatment time and increasing the chances of successful outcomes. So, we're overcoming historical fears.

Key Takeaways

For traumatic spinal paralysis, the severity of the spinal injury is the key determinant for outcomes—just like how the root cause of a bug determines how messy the debugging is going to be.

References

1. Guo Shi Fu et al.: "Preliminary Observations on Pathological Changes After Spinal Injury and Different Treatments (Animal Experiments)," Bone Supplement: 4:176, 1979
2. Xu Shao Ting: "Early Treatment of Earthquake-Induced Spinal Fractures and Spinal Injuries," Orthopedics Supplement: 4:146, 1980
3. Guo Ju Ling et al.: "Preliminary Summary of Treatment for Earthquake-Induced Paralysis," Orthopedics Supplement: 1:28, 1978
4. Fang Xian Zhi et al.: "Lesion Removal Therapy for Tuberculosis of the Joints and Bones," P: 58 (People’s Health Publishing House) 1957
5. Fan Bing Zhe: "Thoracic Lesion Removal Surgery for Thoracic Tuberculosis," Chinese Journal of Surgery: 7:20, 1959
6. Wang Zhi Xian: "Thoracic Cavity Lesion Removal Surgery for Spinal Tuberculosis," Chinese Journal of Surgery: 7:271, 1959
7. Zeng Guang Yi et al.: "Spinal Tumors," Chinese Journal of Surgery: 10:(6)374, 1962
8. Wu Ying Kai et al. (Trans.): "Soviet War Medical Experience, Selected Translations in Surgery," Volume 11, People’s Health Publishing House: 1956

This article was originally originally published in the proceedings of the Second Orthopedic Academic Conference in Anhui Province; initial draft was written in January 1981 and later revised in September 1981
Nanling Hospital, Li Mingjie

Note: This article has been reviewed by Dr. Yuan Sizhong from the Orthopedic Department of Wuhu District Hospital, to whom we extend our special thanks.

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

orthopedic paper II

Transpedicular tuberculosis complicated with paraplegia

A Case Report

Abstract: Spinal appendage tuberculosis accounts for only 1% of spinal tuberculosis. It is prone to paraplegia in the thoracic section and is easily misdiagnosed. We encountered a case misdiagnosed as spinal cord tumor preoperatively but confirmed as vertebral arch tuberculosis after surgery. After a three-year follow-up, the patient has now fully recovered. Reports on this type of case are rare in China, and we now present our findings.

Case Description

Vertebral appendage tuberculosis accounts for only 1% of spinal tuberculosis and is prone to cause paraplegia in the thoracic segment, easily leading to misdiagnosis [1]. Our hospital encountered one such case, initially misdiagnosed as spinal tumor preoperatively. The postoperative pathology confirmed it to be vertebral arch tuberculosis. After a three-year follow-up, the patient has now recovered completely. Such case reports are rare domestically, and we present it as follows:

The patient, Wu XX, is a 36-year-old married male farmer from Nanling. Medical Record Number: 1928.

He had lumbar back pain for three years, unstable walking for one year, paraplegia for three months, and difficulty with bowel and bladder functions. Admitted to the hospital on April 27, 1976. Examination: Both lower limbs exhibited spastic paraplegia, muscle atrophy, 0-grade muscle strength, and numbness at the T10 level. Knee reflexes were hyperactive, and ankle clonus was present. The paraplegia index was 5 (sensory 2, motor 2, sphincter 1). There was no postural deformity of the thoracic vertebrae, but T4-T10 were tender upon percussion. Queckenstedt's test indicated partial obstruction. The cerebrospinal fluid was yellow, and the protein level was elevated (Pandy's test+). Spinal angiography on May 3rd showed an irregular filling defect on the right side of T11, and a small amount of contrast medium ascended through the narrow passage. Thoracolumbar spine X-ray did not show any specific positive signs. Clinical impression: Extramedullary spinal tumor around T10. Under endotracheal ether anesthesia, exploratory surgery of the spinal cord was performed on May 5, 1976. The posterior midline approach was used, and the lamina of T7-T12 were completely removed without affecting the facet joints. During the operation, Queckenstedt's test still indicated obstruction. Therefore, the dura mater was incised to explore the spinal cord, but no lesion was found. However, granulation tissue was found compressing the spinal cord near the facet joint of the T7 lamina on the right side, which was then scraped off. A thin catheter was used to explore the subarachnoid space, confirming it to be unobstructed. The spinal cord resumed pulsation at this time. During the operation, some adhesions of the arachnoid membrane were seen, but no definitive bone destruction of the vertebral arch was observed. The pathological report confirmed "tuberculosis". Pathology number: 2476 (PLA 127 Hospital). Forty-eight hours postoperatively, the lower limbs had voluntary movement, muscle strength was at level 3, ankle clonus disappeared, sensory function partially recovered, and subsequently gradually improved. The incision healed on time, and the patient could urinate and defecate on his own 20 days postoperatively. He was discharged on May 28 for recuperation and continued anti-tuberculosis treatment, staying in the hospital for 31 days.

Follow-up: Four months postoperatively, the patient started walking with a crutch, abandoned it five months later, and began working a year later. He can now work at 90% efficiency and can walk 20-30 miles. His general condition is normal. Examination: There is partial stiffness of the surgical segment of the spine, so bending and lifting are slightly affected. Re-examination of the X-ray on August 14, 1979, showed no bone destruction or other mutations. Residual contrast medium and absence of lower thoracic spinous processes and lamina were observed.

Discussion:

1. For cases with spastic paraplegia, clinicians naturally consider space-occupying compression of the spinal cord. However, the diagnosis is often difficult for rare conditions like vertebral arch tuberculosis.

2. Compared to the vertebral body, the vertebral arch has a richer blood supply and is surrounded by more muscles. If paralysis occurs, surgery is essential. This case report demonstrated good prognosis after the operation.

3. If surgical exploration and total laminectomy do not damage the articular processes, there is no need to worry about spinal stability.

4. Iodine contrast imaging is often misleading due to various factors such as membrane adhesions and vascular abnormalities. This case also shows that the iodine contrast agent can remain in the body for years after the operation without causing nerve pain.

5. This disease is sometimes difficult to differentiate from intraspinal tuberculosis. Both can cause obstruction in the subarachnoid space leading to paraplegia. However, the latter usually has more severe symptoms, often accompanied by other foci of tuberculosis (e.g., pulmonary tuberculosis, pleuritis), and the prognosis is generally more serious.

Conclusion

This paper reports a clinical case of thoracic vertebral arch tuberculosis complicated by paraplegia, along with diagnosis, treatment, and prognosis. In light of the existing literature, we conclude the following:

1. Vertebral arch tuberculosis has a low incidence rate but a high rate of misdiagnosis.

2. When located in the thoracic section, the rate of complicating paraplegia is high.

3. Surgical treatment yields good results.

4. Issues related to myelography and the stability of the spine after extensive laminectomy are discussed.

References

[1] Tianjin Orthopedic Hospital, Clinical Orthopedics Tuberculosis Edition, P253, People's Health Publishing House, 1974

[2] Wang Guisheng et al, Surgical Treatment of Spinal Tuberculosis Complicated by Paraplegia, Chinese Journal of Surgery, 10:365, 1962

[3] Zeng Guangyi et al, Spinal Tumors, Chinese Journal of Surgery, 10: (6)374, 1962

[4] Yang Weiming et al, Intraspinal Tuberculosis, Chinese Journal of Surgery, 14: (3)165, 1966

南陵县医院外科 李名杰原载省骨科年会交流后《芜湖医药》1980；7:47 

This article was originally presented at the Provincial Orthopedic Annual Meeting, later published in "Wuhu Medicine," 1980; 7:47
Nanling Hospital, Department of Surgery, Li Mingjie

from 椎弓结核并发截瘫手术一例报告

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

orthopedic paper I

A surgical treatment of spinal tuberculosis

Report of Three Cases

Spinal tuberculosis accounts for 47.28% of all bone and joint tuberculosis and is commonly seen in clinical settings (1). Conservative treatment, even with the advent of anti-tuberculosis drugs, often takes many years and is difficult to cure. Surgical treatment, although significantly improved, usually requires 2-3 major surgeries, costing time and money and causing additional pain. A one-time surgical cure is, therefore, ideal. This paper reports on one case each of cervical, thoracic, and lumbar spinal tuberculosis that were treated with a single planned surgery at our hospital in the years 1975 and 1976.

Case Presentation

Case One

Male, 18 years old, a farmer from Fanchang County. Case number: 12179.

He has experienced neck pain for a year and limited movement for half a year. He has had a fever, neck swelling, and difficulty swallowing for two weeks. He cannot eat or drink, speak, and has had breathing difficulties for four days. X Hospital diagnosed him with tuberculosis of the 3rd and 4th cervical vertebrae and a large abscess behind the pharynx, compressing the trachea and esophagus, following a puncture that drained white, thin pus. He was admitted to our hospital as an emergency case on October 26, 1975. Examination: His neck is immobile, and there is fullness and fluctuation below the jaw. He breathes through his mouth, does not speak, sweats profusely, and is dehydrated but not cyanotic. No other special findings. Quick fluid replacement of 1000cc was done, and emergency surgery was performed two hours after admission under local anesthesia. Through the left anterolateral approach of the neck, 600cc of pus was drained, and the pus cavity wall was scraped off. The cervical vertebrae's periosteum was cut open along the midline, and a pus plug at the lower edge of the 3rd cervical vertebra was removed under direct vision. A 0.5x0.6 cm bone hole was visible. The external opening was enlarged, and tuberculous granulation tissue, cheesy material, and granular fragments were carefully scraped off. The pus cavity was flushed. No bone grafting was done as the intervertebral space had already disappeared and fused naturally. Gentamycin and streptomycin were placed, and rubber pieces were used for drainage. The surgery went smoothly. After the surgery, his breathing stabilized, he could eat and speak. His neck was immobilized postoperatively, and anti-tuberculosis treatment was administered. Sutures were removed on the sixth day, and the incision healed. He was discharged after ten days. A total of 60 grams of streptomycin was injected, and rimifon was taken for half a year. He resumed light labor two months after surgery and full labor a year later. Follow-up after three and a half years showed everything to be normal; his neck movement was unimpeded. An X-ray on August 14, 1979, showed bony fusion of the 3rd and 4th cervical vertebrae, with no necrotic bone, abscess, or bone destruction (X-ray number 2090).

Case Two

Male, 23 years old, from Nanling, a farmer. Case number: 2875.

Admitted to the hospital on May 31, 1976, due to tuberculosis of the 9th and 10th thoracic vertebrae and an adjacent abscess. After pre-operative preparation and ensuring no contraindications to surgery, the procedure was performed under endotracheal ether anesthesia on June 19, 1976. The approach was through the 9th intercostal space on the right side. The mediastinal pleura was incised to enter the thorax and reach the abscess on the vertebrae. The pus was aspirated, and after dealing with the two intercostal veins, the exposure was expanded. Direct vision to the opposite lesion up to the rib-transverse process joint was achieved. Tuberculous granulation tissue, cheesy material, necrotic intervertebral discs, and dead bone were scraped off and flushed. Bone grooves were chiseled above and below the diseased vertebrae, and four rib grafts were implanted tightly. Antibiotics were placed and the area was sutured meticulously. The thoracic cavity was thoroughly rinsed, closed, and a drain was put in place. The post-operative recovery was smooth. The thoracic tube was removed after 26 hours, and a thorax radiograph after 72 hours showed a sharp costophrenic angle. On the fifth post-operative day, the patient's temperature returned to normal, and he was discharged on June 29, 1976, after a 29-day hospital stay. He was advised bed rest for four months and anti-tuberculosis treatment for nine months. Follow-up: The patient started moving around one month after surgery and gradually resumed light work, but developed kyphosis. A year later, he returned to regular labor. Three years post-surgery, an X-ray showed no abscess shadow or dead bone adjacent to the vertebrae. The 9th and 10th thoracic vertebrae had fused, but the bone grafts were absorbed. The 10th vertebra had collapsed, leading to a hump (X-ray number 2104).

Case Three

Male, 50 years old, married, a farmer from Nanling. Case number: 1462.

He suffered from tuberculosis of the 2nd and 3rd lumbar vertebrae, which led to a psoas abscess. He had already been administered 20 grams of streptomycin. He was admitted to the hospital on August 8, 1976. On August 9, 1976, under spinal anesthesia, he underwent lesion removal and anterior bone grafting via a left lumbar incision. The 12th rib was removed and set aside for later use. After extraperitoneal dissection, the lumbar muscle was incised to access the abscess. Subsequently, two lumbar transverse vessels nearby were safely dealt with. This allowed for an expanded exposure and clearing of the abscess from the opposite lumbar muscle. Granulation tissue from the abscess wall was fully scraped off. Immediate pressing with a hot saline-soaked gauze for 5 minutes was done to minimize extensive bleeding. The exposure to the bony hole in the vertebrae was expanded, and necrotic bone, intervertebral disc, and substantial tuberculous tissue were thoroughly removed. After cleaning, the site was deemed satisfactory. A bone groove was chiseled between the affected vertebrae and the removed 12th rib was embedded, completing the lesion removal and anterior bone grafting in one go. Post-operative recovery was smooth, and the incision healed without complications. He was discharged on March 24, 1978, after a 21-day hospital stay. He was advised bed rest for four months and resumed work half a year later. Currently, he works at 90% of his capacity, can walk 50 kilometers without discomfort, and is in good mental and physical health. Three years post-surgery, an examination on August 15, 1979, revealed no palpable masses in both lumbar muscles, no tenderness upon percussion on the spine, and good spinal mobility. A thorax X-ray showed the upper right lung tuberculosis in the absorption and recovery phase. Lumbar X-ray revealed bony fusion from L1 to L4 with no signs of dead bone or abscess (X-ray number 2101).

Discussion

(1) The treatment of spinal tuberculosis has undergone a long evolutionary process. From prolonged bed rest, full-body anti-tuberculosis treatment to palliative abscess incision; from abscess scraping, fistula shortening surgery to radical lesion removal with fusion surgery, and even recently, there has been an attempt to resolve the issue with one operation. However, because of the complex anatomical relationships of the spine and the difficulty of exposure, the high surgical risk hinders a "complete clearance". Thus, curing this type of disease with one surgery has not yet become widespread. By improving external and internal exposure, making complete clearance possible, we went through the three cases mentioned, all of which were cured within half a year, showing superiority compared to other treatment schemes.

(2) In the surgical treatment of spinal tuberculosis, in addition to clearing the abscess and vertebral lesions, the "tuberculosis barrier" is also broken, allowing anti-tuberculosis drugs to reach the lesion, significantly increasing the cure rate compared to conservative treatment alone [3]. During the same period, our hospital treated five other cases, including two cases of thoracic spine tuberculosis with paralysis. These cases underwent one-sided lesion clearance or simple fusion surgery and were all cured, though it took about a year. The cases in this study were cured more quickly due to more thorough clearance.

(3) Treatment of spinal tuberculosis requires both lesion recovery and the restoration of the spine's support and stability, making bone graft fusion an essential part of treatment. Posterior grafting faces tensile stress, which is not conducive to graft growth; anterior grafting, however, is under compressive forces, favoring graft growth. It can be done simultaneously with lesion clearance, using autologous grafts from the external exposure site. Embedding the graft is more effective than covering or filling, providing both temporary and permanent support, making it more reasonable. Still, thorough lesion clearance without mixed infection is a prerequisite, or the graft is easily absorbed or necrosed [3]. Cases two and three in this study had no mixed infections, and the clearances were "satisfactory", hence they underwent anterior grafting.

Bone grafting between vertebrae is susceptible to displacement and absorption due to pressure, so it's imperative to ensure the patient is on bed rest for more than three months. Rural patients often are unwilling to be hospitalized for extended periods. If they move prematurely at home, it can lead to graft failure. In case two, the patient got out of bed just one-month post-op, leading to graft displacement, absorption, vertebral collapse, and a hunched back. In contrast, case three followed medical advice and achieved the expected results, serving as a valuable lesson.

(4) Cervical spine tuberculosis with a retropharyngeal abscess can cause compressive symptoms, leading to difficulties in swallowing, speech, and even breathing, constituting an emergency situation. Given its convenient surgical approach, the operation can be carried out under local anesthesia, with minimal blood loss and damage, making the procedure relatively straightforward. Moreover, the abscess stretches the surrounding tissue, exposing a broad area in front of the diseased vertebra. By adhering to the "midline incision" principle [1], the vertebral lesion can be thoroughly removed under direct vision. Given the rich blood supply in the neck, rapid absorption of the lesion, and strong repair capability, satisfactory outcomes can be easily achieved, as seen in Case 1. Whether to graft, apply traction, or fixate depends on the stability of the affected vertebrae. However, precautions must be taken to prevent cervical cord trauma and avoid serious accidents like high-level paralysis (① Avoid using a bone chisel; ② Do not go beyond the posterior longitudinal ligament during removal).

(5) For thoracic spine tuberculosis, especially between the 3rd to 10th vertebrae, if conditions permit, the thoracic approach can be used to clear lesions on both sides and perform anterior grafting in a single operation. This is preferred by patients and also saves bed space. Although there's the inconvenience of thoracotomy and the risk of infection, it's still considered safe under modern anesthesia, asepsis, and the use of antibiotics. Case 2 was discharged 10 days after the operation for recuperation.

(6) The lumbar spine is deeply situated, surrounded by numerous vital structures, making it hard to expose and the surgery more invasive. Thoroughly removing the lesion isn’t easy, and typically, 2-3 operations are needed. However, given the patient's physical condition, with special handling of the lumbar vessels [1], following the sub-periosteal dissection, the diseased vertebrae can be safely and extensively exposed, facilitating the thorough removal of the lesion.

Regarding the clearance of the contralateral lumbar abscess: by compressing the contralateral lumbar region and directly viewing the source of the pus, and then through the broadened internal exposure, using curettes of various curvatures, one can navigate and scrape away the abscess. If necessary, an incision can be made at a safe location on the contralateral side, guided by the curette, to "meet up" and clear out the abscess. It’s essential to note that all vital organs are located outside the lumbar muscles, so "intramuscular" abscess scraping is generally safe. Still, care should be taken to avoid vascular and nerve damage [9]. On this basis, anterior grafting can also be expected to cure, significantly shortening the treatment duration, as seen in Case 3.

Conclusion

Through the clinical practice of the author's three cases, the clinical process and the 3-4 year follow-up results of cervical, thoracic, and lumbar spine tuberculosis being cured with a single surgery are described. Among them, Case 1 was an emergency, while Cases 2 and 3 both involved anterior grafting. It is pointed out that the key lies in proper exposure and thorough removal. Combined with a review of the literature, some technical measures are proposed, and a preliminary discussion on the treatment of spinal tuberculosis is presented.

References

① Tianjin Hospital Orthopedics, Clinical Orthopedics Tuberculosis Volume, P183 People's Health Publishing House 1974

② Fang Xianzhi: Bone and Joint Tuberculosis Lesion Removal Therapy, People's Health Publishing House 1960

③ Guo Juling: The role and issues of anterior grafting in the treatment of spinal tuberculosis, Chinese Journal of Surgery 11:12, 1963

④ Liu Zhong: Thoracic vertebrae tuberculosis lesion removal through the thoracic cavity, Chinese Journal of Surgery 8:531, 1960

⑤ Fan Bingzhe: Open chest procedure for thoracic vertebral tuberculosis lesion removal, Chinese Journal of Surgery 7:20, 1959

⑥ Wang Zhixian: Thoracic surgery for thoracic lesion removal through the chest, Chinese Journal of Surgery:271, 1959

⑦ Luo Xianzheng: Preliminary report on thoracic extrapleural spinal tuberculosis lesion removal, Chinese Journal of Surgery 12:1144, 1964

⑧ Tian Chengrui: Some insights into the lesion removal therapy for spinal tuberculosis, Tianjin Medical Orthopedics Supplement 2:76:1678

⑨ Yu Peili and others: Injury to the external iliac artery during lumbar vertebrae tuberculosis lesion scraping surgery (Clinical case discussion), Chinese Journal of Surgery 11:936, 1963.

This article was originally published in the Proceedings of First Anhui Province Orthopedic Symposium in 1979.
Nanling Hospital Orthopedics, Li Mingjie

from 脊椎结核的一次手术治疗

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XIX

Several improvement measures of circumcision

Introduction

This paper outlines several innovative methods aimed at improving the effectiveness and safety of circumcision surgeries. The techniques include local venous anesthesia of the foreskin, bloodless surgery through arterial blockage, and the use of human hair as a suturing material.

1. Local Venous Anesthesia of the Foreskin

Procedure:

A rubber band is tied around the base of the penis to block venous return, causing the superficial veins of the penis to engorge. A fine needle is used to puncture the subcutaneous vein on the distal side of the penis, and 2 ml of 2% lidocaine is injected after aspirating stagnant blood.

Advantages:

• Provides complete anesthesia.
• Eliminates the risk of foreskin edema due to local anesthesia, thereby ensuring a more accurate resection line.

2. Bloodless Surgery via Blood Supply Blockage

Procedure:

The rubber band at the base of the penis is tightened, blocking the dorsal artery and creating a blood-free surgical field. This facilitates precise and complete cutting of the foreskin. Visible ends of severed blood vessels are first ligated, and then the tourniquet is released, ensuring complete hemostasis.

Advantages:

• Creates a clear, blood-free surgical field.
• Allows for precise cutting and complete hemostasis, aiding the surgical process.

3. Utilizing Human Hair for Suturing

Procedure:

Several strands of long female hair are cut and sterilized by soaking in a disinfectant solution for 5 minutes, followed by a saline rinse. The sterilized hair is then used as suture material.

Advantages:

• Enables flexible suturing of both the inner and outer layers of the foreskin, ensuring a tight and accurate anastomosis.
• Eliminates the need for the conventional 8-point suturing method, reducing contamination and facilitating healing.
• Postoperative suture removal is not necessary as the hair naturally breaks and falls off within 7–10 days.

Results:

In a series of 30 cases using these techniques, there were no incidents of wound dehiscence or infection, and all cases achieved Grade I healing.

These improved circumcision techniques offer multiple benefits, including enhanced anesthesia, a cleaner surgical field, and easier postoperative care.

（论文刊于《交通医学》90;4（3）：66）???

Originally published in "Transportation Medicine Journal" 90; 4(3):66 by Li Mingjie, Changhang Hospital, 1979; 1:70

from 包皮环切术的几点改进

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XIIX

Subcutaneous heterotopic pancreas of the abdominal wall

A Case Report

Introduction

Heterotopic pancreas is typically documented to occur only in internal organs, most commonly beneath the mucosa of the digestive tract. Clinically, it is rare to encounter. To date, there have been no reported cases of heterotopic pancreas located subcutaneously in the abdominal wall. We treated a case in our hospital, which was pathologically confirmed post-surgical resection. We present the report below.

Case Presentation

The patient is a 41-year-old male teacher admitted to our hospital on March 24, 1979, with the medical record number 794.

Approximately one year prior, he had a mass removed from his left lower abdomen at Hospital X. The pathological report identified the mass as a "desmoid tumor." Ten months post-surgery, a recurrent mass the size of a fingertip appeared at the same site, which was asymptomatic. In the past week, the mass suddenly enlarged to the size of an egg and became tender to touch.

On examination, the patient's general condition was normal, with no swollen superficial lymph nodes. A 5 cm oblique surgical scar was observed in the left lower abdomen. Below the scar, a 5x4x3 cm nodular, soft mass was palpable, with limited mobility and mild tenderness. There was no erythema or warmth. The white blood cell count was 5600/mm³, with 58% neutrophils and 42% lymphocytes.

Surgery was performed under local anesthesia immediately upon admission. The mass was located subcutaneously and above the muscle fascia. The boundary was ill-defined, and there was no capsule. The mass was lobulated and yellow in color. A sharp dissection was performed to excise the mass, followed by 24-hour subcutaneous drainage. The incision healed primarily, and the patient was discharged after a 9-day hospital stay. The pathological report confirmed "Heterotopic Pancreas in the Abdominal Wall's Fibrous Tissue" (Pathology No. 4686).

Postoperative Follow-Up

One week after discharge, the patient experienced subcutaneous swelling, pain, and fluctuation, although there was no redness or fever. Antibiotic treatment was administered by the local community hospital, leading to gradual resolution of the symptoms without the need for fluid aspiration. The patient returned to normal within a month.

Originally published in "Nanling Medical Journal" by Li Mingjie & He Jinxian, Department of Surgery, Nanling County Hospital, 1979; 1:70

from 腹壁皮下异位胰腺一例报告

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XIIIX

Abdominal trauma

Literature Review 

Introduction

Abdominal trauma, encompassing injuries to both the abdominal wall and internal viscera, is a prevalent medical issue. While the severity of the injury is undoubtedly a significant factor, early diagnosis and appropriate treatment are equally crucial. However, healthcare providers often encounter specific challenges and pitfalls, such as:

Common Pitfalls in Diagnosis and Treatment

1. Unknown Medical History: The inability to obtain a valuable medical history due to patient coma or overlooked minor trauma.

2. Subtle Early Symptoms: Lack of apparent signs in the immediate aftermath of the injury, making diagnosis challenging.

3. Delayed Visceral Rupture: Instances of late-onset rupture that go unnoticed during the initial evaluation.

4. Distracting Injuries: Concomitant severe injuries, such as cerebral or thoracic trauma, that divert attention away from abdominal injuries.

5. Misdiagnosis Due to Spinal Involvement: Abdominal signs resulting from lower thoracic spine and chest injuries that may be mistaken for abdominal trauma.

6. Conservative Approach: An overly cautious attitude, especially when the abdominal wall appears intact, can lead to missed diagnoses and lost opportunities for timely intervention.

Pathogenesis

abdominal trauma refers to injuries to the abdominal wall or internal organs, or both, caused by external force.

Mechanisms of Injury

1. Direct Impact: Blunt force trauma to the abdomen.

2. Indirect Impact: Falls from heights, seismic shocks, and other indirect forces.

3. Non-penetrating Injury: Injuries resulting from vehicular accidents.

4. Penetrating Injury: Wounds from knives, guns, or explosions.

Categories of Abdominal Viscera

1. Solid Organs: Liver, spleen, kidney, pancreas.

2. Cavitary Organs: Stomach, intestines, bladder, gall bladder.

3. Structural Components: Mesentery, peritoneum, nerves, blood vessels.

Risks and Complications

The main risk of trauma to solid organs and stent structures is hemorrhage; the main risk for hollow organ trauma is the infection caused by the contents overflowing into the abdominal cavity, leading to peritonitis.

In fact, any visceral trauma can result in fatal hemorrhage. Liver and spleen injuries, in particular, can lead to long-term, persistent, and recurrent bleeding. This is because the blood vessel walls of these organs are thin, and the organs themselves are fragile and lack elasticity. Therefore, effective vessel constriction and blood clot formation may not occur. Moreover, once bleeding stops, due to the rich blood supply to these organs, a rise in blood pressure can wash away the hemostatic clot, leading to recurrent bleeding.

The likelihood of hollow organ injury is related to the amount of contents it holds (those with a full stomach are more susceptible to injury); it is related to the degree of fixation (the distal and proximal ends of the small intestine, and the hepatic and splenic flexures of the colon are vulnerable); and it is related to pre-existing conditions (those with prior illnesses are more susceptible to injury).

The nature of substances that irritate the peritoneum determines its pathological changes and abdominal signs:

1. Gastrointestinal bacteria increase from top to bottom, such as in the case of fecal peritonitis due to colon injury, which has a very strong infectious nature.

2. The chemical irritability of the gastrointestinal tract decreases from top to bottom, such as in the case of chemical peritonitis caused by perforations in the stomach or duodenum, which can be very severe.

3. Bile and urine may or may not contain bacteria, but they are chemical mixtures that can lead to peritonitis, albeit a bit later in time.

4. Blood without bacteria causes minimal irritation to the peritoneum, so the reaction to hemorrhagic peritonitis is usually mild.

5. Gas irritation of the peritoneum can also produce symptoms.

Regardless of the nature of the material that spills into the abdominal cavity, it often follows its natural drainage route with the peritoneal exudate it produces, leading to the paracolic gutter and the pelvic floor, resulting in intestinal paralysis and abdominal distension.

Symptoms and Signs

1. Fainting or Shock:

   • Abdominal wall contusions are rare, but visceral injuries are common. Substantial visceral organ rupture can cause massive bleeding and can be extremely dangerous. Damage to major blood vessels can be immediately fatal and beyond rescue. Peritonitis due to the perforation of hollow organs leads to toxic shock.

2. Abdominal Pain:

   • Contusions to the abdominal wall are localized and minor; visceral injuries are extensive and persistent.

3. Abdominal Distension:

   • Progressive worsening is a sign of internal bleeding and peritonitis, with inhibited abdominal breathing. However, attention must also be paid to intestinal motility inhibition caused by retroperitoneal injuries and hematomas that stimulate the abdominal plexus.

4. Abdominal Tenderness:

   • Point muscle guarding, tenderness, and rebound tenderness can often indicate the site of injury in the early stages. In the later stages, it becomes generalized and is often corroborative evidence of visceral injury.

5. Nausea and Vomiting:

   • Reflexive in the early stages and due to backflow in the later stages.

6. Liver Dullness Boundary:

   • Abdominal gas distension can cause it to shrink, and a free air layer can make it disappear. After liver rupture, the dullness boundary expands.

7. Shifting Dullness:

   • Often a significant basis for abdominal hemorrhage or effusion.

8. Intestinal Motility:

   • Reflexively weakened in the early stages, leading to an "inactive abdomen" caused by inflammation in the later stages.

Diagnosis

The central issues in diagnosing abdominal trauma are to clarify:

1. Is it a simple abdominal wall injury, or is there also visceral injury?
2. Which organ(s) are injured, and is it a single or multiple injuries?
3. What is the volume and rate of internal bleeding, and has it stopped or is it ongoing?

A detailed medical history should be obtained, including the magnitude and direction of the force, posture at the time of injury, and subsequent reactions such as sudden sharp pain, fainting, and vomiting. Physical examination should include evaluation of muscle guarding, the scope of tenderness, dullness and tympanic areas, and their changes. Body temperature, pulse, respiration, blood pressure, blood and urine tests, X-rays, and ultrasound should be measured. The use of analgesics like morphine should be avoided during observation, except when a diagnosis has been confirmed and surgery is planned. If necessary, exploratory laparotomy should be performed; it's better to act than to miss the opportunity, even if no significant findings are obtained.

1. Blood Count: An elevated white blood cell count in the early stage is a physiological response to trauma. Some believe that internal bleeding can produce a large amount of hematopoietic stimulants, leading to an elevated white blood cell count when absorbed by the peritoneum. Peritonitis naturally causes elevated white blood cells and a left shift in neutrophils. Internal bleeding presents as anemia.

2. Hematuria: A strong basis for urological injuries and an effective indicator for monitoring the outcome of the injury.

3. X-Ray: Free air under the diaphragm is generally considered to have only a 50% positive rate, and attention should be paid to it. Comparison of the diaphragmatic height and movement on both sides can aid in the diagnosis of liver and spleen injuries.

4. Abdominal Paracentesis: Highly valuable. The characteristics and state of the extracted fluid can often confirm the diagnosis. Because a positive result requires more than 200 ml of fluid in the abdominal cavity, some use lavage to increase the positivity rate. If unsuccessful, change the needle direction and depth or reattempt after an interval. Besides macroscopic observation, amylase quantification and smear tests can be done on the puncture fluid. The presence of multiple types of bacteria without pus cells or the presence of parasitic eggs supports the hypothesis of accidental intestinal entry.

5. Rectal Examination and Posterior Fornix Puncture in Married Women: These can be included as routine examinations to help with early diagnosis.

Management and Treatment

1. Shock Management: For patients in shock, use a slight incline position and elevate both legs (to facilitate breathing and venous return). Measures like warming, fluid resuscitation, blood transfusion, oxygen administration, and antibiotics are essential. Given the peritoneum's strong anti-infective ability, fatalities due to infection are far less common than those due to shock or bleeding. Therefore, establishing an open vein and rapidly restoring effective blood volume is of utmost importance.

2. Surgical Intervention: Surgery for abdominal injuries should ideally be performed within 6 hours. If anti-shock measures are ineffective, forced surgery should be performed to eliminate the source of the problem as one of the life-saving measures.

3. Surgical Incision: The location of the incision is determined based on the estimated site of injury. The principle is to make the incision as close and convenient as possible to the affected area. A midline vertical incision is generally used, as it allows for quick entry and is easily extendable. Before closing the abdomen, it's crucial to thoroughly wash and aspirate the abdominal cavity. For contamination with bile, pancreas, feces, or urine, drainage should be implemented.

Specific Injuries and Treatments

1. Spleen Rupture: Standard procedure is removal. Some recent studies advocate for repair in minor injuries to preserve spleen function. Autotransfusion of the patient's own blood can be done without anticoagulants, saving resources and avoiding citrate toxicity.

2. Small Intestine Rupture: Repairs or resection and anastomosis are the go-to approaches. Externalization of the intestine is less preferred.

3. Liver Injury:

   • Type of Injury: Most liver injuries involve a laceration of the liver tissue, which largely remains intact due to the resiliency of its blood vessels.
   • Surgical Interventions: During surgery, the focus is on debridement and individual ligation of severed blood and bile ducts. Further harm to the liver should be avoided. Full-layer mattress sutures are generally used, and the omentum is often laid over the sutured area. Sometimes, omentum or muscle can be used for packing. Gauze packing should be avoided.
   • Limited Crush Injuries: For localized crush injuries, partial hepatectomy is recommended.
   • Control of Bleeding: If there is profuse bleeding during surgery, temporary occlusion of the hepatic portal can control it (up to 15 minutes at room temperature is allowed). If bleeding can't be controlled, ligation of the hepatic artery often works immediately.
   • Post-Operative Considerations: Adequate drainage below the liver is crucial, often with the additional step of controlled decompression of the common bile duct.

   Suturing and Complications:

   • Suture Material: Both intestinal thread and silk thread are acceptable, although the author believes that No. 4 silk thread is preferable.
   • Tightness of Ligations: Ligations should not be too tight; they should be just tight enough to control bleeding. Over-tightening can lead to complications like hepatic necrosis, delayed bleeding, or bile leakage.
   • Anecdotal Experience: The author recounts a case of postoperative massive biliary bleeding on Day 21, which required another surgery to ligate the intrinsic hepatic artery.

   Blood Transfusion:

   • Caution with Bile-Contaminated Blood: Normally, blood contaminated with bile should not be transfused back. However, an anecdotal case saw 1500 mL transfused without adverse effects in a rural setting. It's generally considered safe to transfuse one's own blood back if there are no injuries to the extrahepatic biliary tract.

4. Colon Injury: Early repair is recommended; late-stage injuries may require externalization and later resection and anastomosis.

5. Mesenteric Tear: Repair and hemostasis are essential. If blood supply to the intestines is compromised, resection may be needed.

6. Pancreatic Injury: Small tears can be sutured, and the pancreatic duct can be ligated if damaged. For injuries to the head of the pancreas, reimplantation is necessary to establish a new pancreatic-intestinal pathway.

7. Stomach and Duodenal Injuries: Repair is standard. Special attention should be given to retroperitoneal injuries of the duodenum.

8. Extrahepatic Biliary Tract Injury: Repair, fistula creation, and external drainage are options.

9. Kidney Injury: Generally conservative treatment under close observation is sufficient due to the kidney's high regenerative capacity.

   10. Extrarenal Urinary Tract Injury: Injuries to the ureter are rare. Bladder injuries are more common and often associated with pelvic fractures. Repair, fistula creation, and drainage are usual treatments.

   11. Diaphragm Injury: More commonly seen on the left side, resulting in diaphragmatic hernia and bleeding. High mortality rates necessitate early thoracic repair.

   
   12. Retroperitoneal Major Vascular Injury: Repair is generally performed unless immediate intervention is not possible. For injuries to the inferior vena cava below the renal veins, ligation is an option.

   • General Treatment: Unless the injury is too severe to be managed emergently, the usual approach is to repair the damaged vessel.
   • Below the Level of the Renal Vein: Injuries to the inferior vena cava below the level of the renal veins can generally be managed by ligation and cutting off the damaged segment.
   • Above the Level of the Renal Vein: For injuries to the inferior vena cava above the level of the renal veins, if repair is not possible, some advocate for ligation. However, this necessitates the removal of the right kidney. The left kidney can rely on collateral circulation (e.g., adrenal vein) and should be unaffected. However, this approach could lead to insufficient venous return to the heart.

   Discussion

   Early Diagnosis:

   Determining whether the injury is confined to the abdominal wall or involves internal organs is crucial for making timely decisions about surgical intervention and life-saving measures. A simple contusion of the abdominal wall can also lead to symptoms like abdominal pain, muscular guarding, and localized tenderness due to muscle bruising and bleeding, which can irritate the peritoneum. These symptoms may even be accompanied by nausea and vomiting. On the other hand, early signs of internal organ damage can be subtle due to minimal initial bleeding and leakage, which may be diluted by intraperitoneal fluid. This makes it easy to confuse the two types of injuries.

   Abdominal Wall Contusion:

   In cases of abdominal wall contusion, the abdominal pain is usually mild, muscular guarding is localized, and there may be subcutaneous bruising and soft tissue swelling. Generally, systemic disturbance is minimal, and shock is unlikely.

   Solid Organ Rupture:

   For solid organs, except for the liver and gallbladder, the symptoms of peritoneal irritation are generally less severe compared to hollow organ injuries. While pain may be felt throughout the abdomen, it is most prominent in the area where the damaged organ is located.  The following points can assist in the diagnosis:

   1. Indicators of Internal Bleeding: After trauma to the lower chest and upper abdominal area, there may be signs of internal bleeding, such as an increased pulse rate, a drop in blood pressure, progressive anemia, and the absence of abdominal breathing.

   2. Pain Radiating from the Ribcage: Abdominal pain may be most pronounced in the costal margins and may radiate to the shoulders, back, and waist.

   3. Persistent Upper Abdominal Pain: After the injury, pain in the upper abdomen persists and may be accompanied by localized tenderness, muscular guarding, abdominal distension, and reduced bowel sounds.

   4. Changes in Liver or Spleen Percussion: On X-ray, there may be an enlargement of the liver or spleen shadow, elevation and reduced movement of the diaphragm on the injured side, and disappearance of the psoas muscle shadow.

   5. Presence of Fixed or Shifting Dullness: During abdominal paracentesis, non-clotting dark red blood may be observed. This is due to defibrinated blood, which is also associated with the action of fibrinolysin.

Diagnosis of Hollow Organ Perforation:

Perforation of hollow organs often leads to peritonitis at an early stage, characterized by severe abdominal pain that makes early detection easier. The following points can assist in diagnosis:

1. Severe Abdominal Pain Lasting Over 4 Hours: This is accompanied by:

   • Nausea and bilious vomiting
   • Increased pulse rate
   • Fixed tenderness upon palpation
   • An expanding area of muscular guarding
   • Elevated white blood cell count with a leftward shift in differential
   • Weakened or absent abdominal breathing

2. Anemia Not Prominent but Rapid Pulse and Restlessness: Even if anemia is not obvious, a fast pulse rate and symptoms of restlessness or agitation may be present.

3. Disappearance of Liver Dullness: An X-ray may show the presence of free air under the diaphragm, indicating perforation.

4. Abdominal Paracentesis Shows Turbid Fluid: Microscopic examination confirms the presence of pathogens, indicating infection.

Early Diagnosis and Treatment:

For patients with multiple injuries, if there is even one reliable indicator, early exploratory laparotomy is advised.

Conditions for Conservative Treatment:

1. Injury is confined to the abdominal wall.
2. Although there's internal bleeding, it has stopped and there are no signs of hollow organ perforation; vital signs remain stable.
3. General condition is still good one or two days post-injury, and any internal infection is localized.
4. Mild kidney injuries where the hematuria gradually decreases and pain subsides.

Anesthesia:

Complete anesthesia is required to relax the abdominal muscles, facilitating exploration and cleaning of the abdominal cavity. Our majority of cases have safely and satisfactorily used continuous epidural anesthesia, but it should be administered in small, slow doses. Note that the required dosage for these patients is generally less than for typical patients.

Exploration:

Pay attention to the existence of compound injuries to avoid overlooking any. Check retroperitoneal organs like the duodenum, colon, and the bare area of the liver. The omentum often points to the location of the pathology.

Suggested Order of Exploration:

Spleen, liver, pancreas, diaphragm, base of the stomach, bile ducts, duodenum, mesentery, omentum, small intestine (from the jejunum to the ileocecal region), large intestine (note the hepatic and splenic flexures), retroperitoneal organs like kidneys and major blood vessels, and pelvic organs.

Drainage:

The decision to drain is based on the timing of the injury, the degree of infection, and the quantity and quality of the intra-abdominal fluid. For early abdominal contamination, thorough washing is the main approach, supplemented by drainage. Drainage is necessary for liver, gallbladder, pancreas, and intestinal injuries.

Prognosis:

Early death is usually due to severe compound injuries, traumatic shock, and major bleeding. Late death often occurs from generalized peritonitis, toxic shock, and water and electrolyte imbalances. The cure rate for surgical cases can reach around 90%.

References:

1. Huang Jiaqi, "Surgery," People's Health Publishing House, P: 497, 1964.
2. Gao Xianming, "Abdominal Trauma," Journal of Surgery, 6: 468, 1951.
3. Jiang Kegou, "Diagnosis and Treatment of Abdominal Trauma," Journal of Surgery, 6: 376, 1951.
4. Huang Wen, "Clinical Analysis of 98 Cases of Abdominal Contusion," Chinese Journal of Surgery, 4: 370, 1960.
5. Gong Songnan, "Closed Abdominal Injury (with analysis of 220 cases)," Chinese Journal of Surgery, 15: (2) 96, 1977.

Originally published in "Nanling Medical Journal" by Li Mingjie, Department of Surgery, Nanling County Hospital, 1979; 59-63.

from 腹部创伤

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XVI

A case of plastic tube foreign body in the bladder

Patient Information

• Gender: Male
• Age: 20
• Occupation: Farmer
• Hospital Admission Number: 16318

History

On April 5, 1990, out of curiosity and playfulness, the patient self-inserted a 35-cm hollow plastic tube designed for hair-tying into his bladder via the urethra and was unable to remove it. He subsequently developed symptoms of lower urinary tract irritation, including frequent urination, urgency, and painful urination. Local hospital urine tests revealed pyuria (++), but a plain film of the bladder was reported as negative. Due to the concealment of this medical history, treatments for cystitis were ineffective. The patient was admitted to the hospital on December 3, 1990.

Physical Examination

General conditions were normal. Urinalysis showed red blood cells (++) and pyuria (x10). B-mode ultrasound revealed a hyperechoic mass within the bladder. A plain film of the bladder showed a circled mass (Figure 1). The diagnosis was a foreign body in the bladder accompanied by stone formation.

Surgical Intervention

On an unspecified day in December 1990, the patient underwent a cystotomy under continuous epidural anesthesia. A solid foreign body, measuring 2×2.5×3.0 cm and weighing 5.5 grams, was removed (Figure 2). It consisted of five loops of the plastic tube, folded upon themselves, with extensive urine salt deposition.

Insights and Reflections

This case underscores the importance of a detailed medical history for accurate diagnosis. After the operation, we conducted a simulation using a hollow plastic tube similar to the one in the patient's case and found that if the conditions are right and the films are read carefully, the foreign body could indeed be identified. However, in the early stages of this case, the local hospital misinterpreted a bladder plain film as negative and incorrectly treated the patient for cystitis. This not only prolonged the symptoms but also led to the deposition of urine salts around the foreign body, turning it into a calcified mass. Essentially, this became a case of secondary bladder calculus.

Interestingly, because the foreign body served as the core around which salts aggregated, it did not readily cause obstruction during urination. Thus, symptoms like interrupted urine flow or "staccato" urination were absent. Instead, the patient continued to experience pain and symptoms of bladder irritation. The correct diagnosis was eventually made based on the patient’s medical history, B-mode ultrasound, and X-ray examinations.

Given the specific circumstances of this case, attempting to break and remove the stone via the urethra seemed implausible and would likely result in remnants. Complete surgical removal of the mass proved to be the most effective treatment approach.

(1991/10/05), Changhang Hospital, Li Mingjie & Shi Lianghui

from 膀胱内塑料管异物一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XV

Recurrent stones in common bile duct with suture as core 

A report of 6 cases

Introduction

Between 1975 and 1980, we reviewed a group of 70 patients who had undergone reoperations for recurrent cholelithiasis, representing 19% (70/368) of cholelithiasis surgeries during the same period. Of these 70 cases, six had recurrent stones formed around the surgical suture used in their previous operations. This report aims to discuss these specific six cases due to their implications for improving surgical techniques.

Case Summaries

Case 1

• Gender: Male
• Age: 37
• Hospital No.: 1047
• Date of Admission: February 13, 1976
• Medical History: Underwent cholecystectomy, choledocholithotomy, and T-tube external drainage at our hospital a year prior.
• Symptoms: Began experiencing frequent right upper abdominal pain and occasional fever six months after discharge.
• Intraoperative Findings: Discovered a 2cm diameter muddy stone mass formed around a surgical suture in the common bile duct.
• Outcome: Stone removed, T-tube placed, and the patient was discharged 14 days post-op. No recurrence at three-year follow-up.

Case 2

• Gender: Female
• Age: 28
• Hospital No.: 4893
• Date of Admission: October 6, 1977
• Medical History: Had cholecystectomy, left hepatic lobectomy, and T-tube external drainage two years earlier.
• Symptoms: Upper right abdominal pain, fever, and jaundice half a month prior.
• Intraoperative Findings: Two pieces of 7cm and 4cm sutures were found in the common bile duct, around which loose stone masses of 3cm and 2cm in diameter had formed.
• Outcome: Stones removed, patient was hospitalized for 15 days and discharged. However, the patient died a year later due to intrahepatic stones and severe infection, leading to shock.

Case 3

• Gender: Female
• Age: 52
• Hospital No.: 5105
• Date of Admission: October 20, 1977
• Medical History: Cholecystectomy and common bile duct T-tube drainage 14 months ago.
• Symptoms: Recurrence of symptoms 8 months post-op, leading to admission 10 hours after the onset.
• Intraoperative Findings: A 4x3x3 cm sand-mud stone mass was found, with the suture from the previous surgery serving as the core.
• Outcome: The patient died of toxic shock 10 hours post-operation.

Note: Three additional cases had similar intraoperative findings and outcomes. All were successfully treated and had no recurrence after a follow-up period of 1 to 3 years.

Discussion

The recurrence rate of primary hepatobiliary pigmented stones after surgery is high, reaching 19% according to our data. The fundamental cause is metabolic dysfunction in bile composition. However, improper surgical procedures or the retention of foreign objects can also lead to early recurrence of stones. In this report, all six cases of recurrent stones had sutures from previous surgeries as their core. The absence of these sutures could have potentially prevented the recurrence or at least recent postoperative recurrence. Case 3 in our series tragically passed away due to this issue, serving as a serious lesson.

Although we have only identified six such cases, the actual number may be higher. Not every stone removed in reoperations is crushed for examination. Therefore, it is possible that the actual number of such cases is higher. Furthermore, in most reoperations, the original sutures from previous surgeries on the common bile duct were not found. We speculate that once these sutures penetrate into the lumen, the body's natural rejection mechanisms could expel them into the intestine through the common bile duct, thereby averting harm. However, before being expelled into the intestine, could these sutures serve as a nucleus for stone formation or even cause symptoms? This warrants further investigation. It might also be one of the reasons contributing to the so-called "post-cholecystectomy syndrome," another aspect deserving attention. Further systematic endoscopic or radiographic studies are needed to draw scientific conclusions.

In our hospital, the common practice for suturing the common bile duct incision involves using non-absorbable No.0 or No.1 silk threads for full-layer continuous suturing, starting from the upper edge of the incision and moving downwards. While this method ensures tight closure and is time-efficient, it has a downside. During the removal of the T-tube, part of the duct wall is inevitably damaged, exposing the suture to the lumen. This can lead to a natural rejection response, causing the suture to adhere to bile sediments before being fully expelled into the intestine, sometimes leading to symptoms. Therefore, we recommend abandoning this suturing method and instead using thinner sutures for submucosal interrupted sutures to prevent the suture from being exposed to the lumen.

Case 3 demonstrated that even the thicker sutures used for the hepatic section can fall into the lumen, illuminating the body's natural rejection instinct. This is a rare but instructive instance.

Originally published in the Proceedings of the Second Annual Surgical Conference of Anhui Province, 1988; 87; presented at he Yangtze River Full-Line Biliary Surgery Seminar, No. 23. (1987/02/24), Changhang Hospital, Li Mingjie

from 以缝线为核心的总胆管复发结石6例报告

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XIV

Successful primary repair of congenital omphalocele 

A Case Report

Case Presentation

The patient, a male newborn named Shao, was born at home on May 14, 1983. He was brought to the emergency department four hours post-birth due to the presence of an omphalocele, a condition where part of his abdominal organs were protruding out of the abdomen, enclosed in a transparent membranous sac.

Clinical Examination

Upon examination, the infant weighed 3010 grams and had no other associated congenital malformations. The umbilical cord was ligated at a distance of 10 cm. The transparent sac contained portions of the liver, the majority of the stomach, and sections of the small and transverse intestines. There were no signs of strangulation or vascular compromise. The sac was intact and not discolored, and the abdominal wall defect at the umbilicus measured 6 cm (Figures 1 and 2).

Surgical Intervention

The surgery was performed under local anesthesia. The omphalocele sac was excised, and the skin edges were trimmed and dissected laterally. Successful herniation of the protruding organs was achieved, followed by layered suturing (Figure 3). The patient experienced neither respiratory distress nor circulatory complications. He passed gas and stool on the evening following surgery, and sutures were removed as scheduled. The wound healed without complications.

Follow-up

One-and-a-half years post-surgery, the child displayed normal development, stable gait, and no intellectual disabilities. He had begun to recognize and call out to people.

Discussion

Congenital omphalocele is an embryonic developmental disorder resulting from the failure of synchronous development between the abdominal cavity and viscera. Approximately 40% of cases present with additional congenital malformations. The condition is relatively rare, occurring in 1 in 7,000 births. The literature contains limited case reports, with one study reporting only 22 instances. Delayed surgical intervention can result in desiccation, necrosis, and rupture of the omphalocele sac, exposing the organs to infection and significantly increasing mortality risk. The surgical approach, either primary or staged repair, depends on the size of the omphalocele and the developmental status of the abdominal cavity. Our case, although categorized as a "giant" omphalocele due to the 6 cm abdominal wall defect and involvement of multiple organs, was successfully managed through primary repair owing to the absence of other deformities and favorable overall development.

References

• She Yaxiong: Pediatric Surgery. 1979; p. 296

Figures: Embryonal Omphalocele

• Figure 1: External appearance of the omphalocele with a 6 cm abdominal wall defect at the umbilical pedicle.

• Figure 2: Organs involved in the omphalocele: liver, stomach, small intestine, and transverse colon.

• Figure 3: Appearance following successful primary repair.

1988/04/01
Changhang Hospital, Li Mingjie

from 先天性脐膨出一期修补成功一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XII

Adult retroperitoneal teratoma infection complicated with chronic purulent fistula 

A Case Report

Introduction

A 53-year-old female patient presented with a history of left waist swelling, pain, fever, and pus discharge that occurred 12 years ago and reportedly "self-healed" within a few months. Six years prior to the current consultation, she developed an abscess on the medial aspect of her left thigh, which was incised to create a fistula but never fully healed.

Clinical Examination

Upon examination, the patient appeared to be suffering from chronic consumptive anemia. She had purulent fistulas in both the right lumbar and left femoral regions, discharging yellowish fluid and some pus. Radiographic evaluations showed no abnormalities in the spine, pelvis, or hip joints. However, the shadow of the left psoas muscle appeared indistinct. No evidence of an intestinal fistula was found through contrast studies. A 4.5 cm irregular residual barium shadow was noted near the second and third lumbar vertebrae, appearing potato-like. Biopsy of the fistula tissue revealed inflammatory granulation.

Surgical Findings

Immediate surgical exploration was carried out, confirming that the fistula tract led into the left psoas muscle. Upon injecting methylene blue into the fistula and subsequently incising the muscle, thin pus was drained. The abscess cavity was spindle-shaped, measuring approximately 20x5x4 cm. Tracking the cavity upwards led to the discovery of a 6x5x4 cm encapsulated mass near the second and third lumbar vertebrae. The mass was easily excised. It was adherent to and penetrated the psoas major muscle. The intramuscular abscess was fully incised, its inner wall scraped clean of granulation tissue, washed, and hemostasis was achieved through compression.

Pathological Diagnosis

The pathological examination confirmed a benign cystic teratoma complicated by infection, leading to the formation of a left psoas muscle abscess and an external fistula.

This article was originally published in Journal of Transportation Medicine,1993；Vol.7, fourth (368)
Changhang Hospital, Li Mingjie

from 成人腹膜后畸胎瘤感染并发慢性脓瘘1例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XIII

Ingested lighter as a foreign body in the stomach

A Case Report

Case presentation

A 22-year-old male, generally in good health, intentionally ingested a wire resistance lighter two months prior to admission. He manually forced the object through his pharynx, facilitating its smooth passage into the stomach without experiencing obstruction, bleeding, or esophageal injury. Despite consuming a large quantity of leeks that evening, the foreign body was not naturally expelled and he experienced no immediate discomfort. One month later, he began experiencing abdominal pain on an empty stomach, which was alleviated by eating. An abdominal X-ray at our institution confirmed the object's retention in the stomach. Surgical intervention was deferred until two months later, given the absence of acute symptoms.

Clinical Examination

Upon physical examination, the patient appeared generally well, with no upper abdominal tenderness. Abdominal X-ray and B-type ultrasonic gastric perfusion examination confirmed the presence of the foreign body within the stomach.

Surgical Procedure

On July 4, 1991, under epidural anesthesia, a 3.5 cm gastric incision was made. The gastric mucosa appeared slightly congested, but there were no signs of ulceration or hyperplasia. The foreign object, not adhered to the gastric wall, was successfully retrieved under direct visualization and the stomach was subsequently repaired. The postoperative course was uneventful, with sutures removed on day seven.

Pathological Findings

The retrieved foreign body was identified as a wire resistance lighter, measuring 7x3x1.5 cm and weighing 18 grams. It was composed of a blend of plastic and metal. Erosion was evident on its metal shell, and part of the plastic had been stripped away.

Discussion

The smooth passage of a rigid foreign body with a 3 cm transverse diameter through the pharynx and esophagus without injury is notable. However, the object remained in the stomach for an extended period, unable to pass through the pylorus. Stomach acid had corroded both the metal and plastic components of the lighter, although it remained largely intact due to its composite nature. Endoscopic retrieval was considered but deemed risky due to the potential for iatrogenic injury. Surgical removal proved to be a safe and effective approach, with a favorable prognosis confirmed at a three-month follow-up.

1991/10/15
Changhang Hospital, Li Mingjie & Wang Yisheng

from 胃内打火机异物一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper XI

Misdiagnosis of subacute perforated peritonitis in gastric malignant lymphoma 

A Case Report

Case Presentation

A 71-year-old female patient, with the medical record number 13520, experienced intermittent periumbilical abdominal pain for 10 days, without accompanying diarrhea, hematochezia, or fever. She was admitted to the Affiliated Hospital of Anhui Medical University on March 22, 1987, with severe colic in the right lower abdomen and vomiting lasting for two days. She was initially suspected to have appendiceal perforation.

Clinical Examination

Upon admission, the patient had a temperature of 35.5°C, a pulse rate of 84 beats/min, and a blood pressure of 120/80 mmHg. She appeared acutely dehydrated with general nutrition. No lymphadenopathy or jaundice was observed. Physical examination revealed tenderness and rebound tenderness throughout the abdomen, especially in the right lower quadrant. Laboratory tests showed decreased hemoglobin levels (9 g/mm3), RBC count of 3.8 million/mm3, and a WBC count of 19,700/mm3 with 91% neutrophils and 9% lymphocytes. Urine amylase was 16 units/Winsler.

Surgical Findings

The patient underwent emergency surgery on the day of admission for suspected acute appendicitis with peritonitis. During the procedure, a small amount of intra-abdominal exudate was found, but no obvious purulent fluid was observed. The appendix, gallbladder, liver, spleen, and pancreas appeared normal. However, a 5x6 cm mass was discovered on the anterior wall of the gastric antrum, with a soft texture and focal necrosis at its center.

Histopathology and Postoperative Care

Histopathological examination confirmed the diagnosis of malignant lymphoma of the gastric antrum. The patient was discharged after 12 days of hospitalization and showed no signs of recurrence during the one-year follow-up.

Discussion

Gastric malignant lymphoma accounts for 80% of gastric sarcomas and often presents with insidious and non-specific symptoms, making preoperative diagnosis challenging—only 10% are accurately diagnosed before surgery. These tumors may result in peritonitis due to necrosis and exudation, often misleadingly presenting as appendicitis.

For patients with a prolonged history of symptoms but no localized inflammatory mass, the possibility of this rare condition should be considered. Excision of sufficient gastric tissue and omentum generally leads to a more favorable prognosis than gastric cancer, with a 5-year survival rate up to 50%. In this case, the patient remained symptom-free at the one-year follow-up.

References

Waltar LJ, et al. Cancer Management. New York, 1977; p.269.

This article was originally published in Proceedings of First Health Conference of the Yangtze River Shipping Company,1988；4:1
Changhang Hospital, Li Mingjie

from 胃恶性淋巴瘤亚急性穿孔腹膜炎误诊一例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper IX

Several special problems in diagnosis and treatment of biliary tract surgery

Abstract

In the realm of biliary surgery, unique anatomical deviations and pathological transformations often necessitate unconventional approaches to achieve therapeutic success and minimize unintended harm. This article delves into the surgical procedures and outcomes of a curated selection of cases from a pool of 456 biliary surgeries. Through a retrospective evaluation, this study seeks to enhance both the diagnostic and therapeutic strategies for managing biliary disorders.

Traditional approaches to biliary surgery, well-versed among surgeons, have been progressively refined to better manage conditions like intrahepatic stones and biliary strictures [1]. However, the nature of challenges that arise during such procedures can be incredibly diverse, and not all can be addressed through standard methodologies or by adhering to a one-size-fits-all surgical protocol. The eventual outcome of the intervention holds significant implications for patient prognosis. This study delves into an array of unique challenges encountered in a collection of 456 biliary surgical cases [2]. It aims to shed light on their pathological underpinnings, surgical strategies employed, and the resulting clinical outcomes, serving as a repository of insights and lessons for future reference.

Case Introduction

Case 1:

The patient is a 42-year-old female farmer, medical record No. 13317, who has been experiencing recurrent right upper abdominal colic for eight years. B-ultrasound indicated the presence of gallstones and stones at the left hepatic margin. She underwent surgery in our hospital on December 2, 1986. The surgical findings aligned with the B-ultrasound report. Intraoperative cholangiography displayed normal and unobstructed grade 1 to 3 biliary ducts but failed to reveal clusters of stones on the lower margin of the liver's left outer lobe. The surgical approach included a cholecystectomy and a partial hepatectomy for stone removal, capped off with sub-hepatic drainage. Bile duct exploration and drainage were not performed, and the patient recovered smoothly without the need for a blood transfusion. She was discharged 12 days post-surgery, fully recovered.

Key Takeaways

The insights from this case underscore the utility of combining B-ultrasound and intraoperative cholangiography for a more nuanced understanding of the pathology, thereby aiding in the selection of the most appropriate surgical technique. The chosen procedure in this case was minimally invasive and effectively addressed the lesion.

While pre-operative examinations like PTC and ERCP are invaluable, their absence can make it challenging to fully comprehend the intrahepatic bile duct conditions, even when bile duct exploration is performed during the surgery, including choledochoscopy. Intraoperative cholangiography delivers direct imaging of the biliary tree, thus providing valuable guidance and mitigating some of the operative uncertainties.

In this specific case, however, the intrahepatic stones weren't visualized in the cholangiography. This could have been due to the patient's positioning during the imaging or perhaps due to obstruction caused by a narrow biliary tract. Thankfully, the diagnosis was confirmed through liver surface palpation, emphasizing the need for a comprehensive evaluation in similar cases.

Case 2:

The patient is a 64-year-old male worker, medical record No. 12928. He was diagnosed with the pentalogy of ACST and underwent emergency surgery in our hospital on April 18, 1986. During the operation, the common bile duct was opened and a pigmented gallstone with a diameter of 2 cm was removed. Microscopic analysis of the bile revealed pus cells, and a culture indicated the presence of E. coli. The gallbladder was found to be atrophic, measuring 3 cm in diameter, and containing 23 mixed stones along with some white mucus. The cystic duct was occluded. Remarkably, the gallbladder had an internal fistula of 0.3 cm with the common hepatic duct, which was patent. To simplify the procedure, separate choledochotomy and cholecystostomy were performed. Angiography on the 19th day post-operation showed normal intrahepatic and extrahepatic bile and pancreatic ducts, and the gallbladder-common hepatic duct fistula was also patent. The patient recovered well and had no symptoms upon a 10-month follow-up.

Key Experience

This was a high-risk case that required immediate surgical intervention, primarily focused on relieving biliary obstruction and draining infectious materials. The operation was straightforward, but the condition of the gallbladder—non-functioning and a disease focal point—posed a dilemma: to remove or not to remove.

The authors argue that the presence of a patent internal fistula would ensure proper drainage, essentially serving as a biliary diverticulum. This is considered harmless, especially given the emergency nature of the surgery and the complexities of the local anatomy that could potentially lead to additional complications, such as stenosis of the main bile duct or biliary leakage. Therefore, opting not to remove the gallbladder was deemed appropriate. Although the gallbladder could have been repaired, the recent inflammation and edema were inhibitory to proper drainage. As a safety precaution, a cholecystostomy was performed instead.

Case 3:

The patient is a 64-year-old female teacher, with medical record No. 4417. She was diagnosed with gallstones based on her medical history and B-ultrasound. A cholecystectomy was performed on October 16, 1984. During the surgery, 23 cholesterol gallstones were discovered in the gallbladder. The common bile duct, measuring 0.7 cm, appeared normal upon inspection and matched the B-ultrasound report. Since there was no history of jaundice, the common bile duct was neither explored nor puncture-confirmed. While removing the gallbladder, a cystic duct of 0.3 cm was found, which gradually tapered and extended away from the hepatic pedicle. The duct was ligated, and attention was then turned to the gallbladder artery. After 75 minutes, the surgery was successfully completed with no postoperative bile leakage and grade A incision healing. However, on the third postoperative day, progressive jaundice was observed. Serum bilirubin levels rose to 8.8 mg% on the 20th postoperative day, suggesting obstructive jaundice.

A follow-up B-ultrasound revealed generalized dilation of both intra and extrahepatic bile ducts, with the common bile duct measuring 1.1 cm in diameter. The patient refused further tests like PTC, and a second surgery was conducted on November 9, 1984. Despite exhaustive efforts, the common bile duct was not located, and no ligated end of the bile duct was found to be enlarged. The surgery lasted six hours, and due to the length of the procedure, no additional enterohepatic drainage was attempted. A catheter was placed for external drainage from the left intrahepatic bile duct, with postoperative bile discharge measuring 150 ml per day. Unfortunately, the jaundice did not resolve significantly. A follow-up after two months showed the intrahepatic bile ducts had thinned and become branch-like. A subsequent surgery on February 10, 1985, resulted in multiple organ failure, and the patient passed away on the fifth postoperative day.

Key Experience

This case underscores the complexity and unpredictability often encountered in biliary tract surgeries. Even when initial surgeries seem successful, complications like postoperative jaundice can emerge. Multiple interventions may not always resolve the issue, emphasizing the importance of thorough preoperative evaluations and planning. The case also draws attention to the limitations of relying solely on imaging for diagnosis, particularly when surgical intervention is involved. Furthermore, the case reiterates the need for cautious decision-making, especially when surgeries stretch on for extended periods, as excessive duration can elevate the risks of complications and unfavorable outcomes.

Discussion

1. Anomalies in Extrahepatic Biliary Tract

Extrahepatic biliary variations can occur in up to 85% of cases, but the rare variation observed in this case has not been previously reported. The absence of a typical common hepatic duct and common bile duct was noted. Instead, a 0.2 cm duct entering the upper left corner of the gallbladder functioned as the common hepatic duct, and an extended 0.3 cm cystic duct served as the common bile duct. When the gallbladder was removed due to gallstones, the extrahepatic biliary tract was inadvertently damaged. Mistakes in pre- and post-operative B-ultrasound measurements, confusing the common bile duct with the portal vein, also contributed to this issue. Therefore, in such anomalies, exploration of the common bile duct is crucial, and the relationships among the three bile ducts should be thoroughly understood to avoid unnecessary damage.

2. Importance of Preoperative Testing

For surgical jaundice, it is crucial to conduct preoperative PTC and/or ERCP to obtain a clear image of both the intra- and extrahepatic bile ducts. This aids in the surgical planning. In this case, had a high-level biliary obstruction been diagnosed earlier, a lifesaving enterohepatic internal drainage could have been performed during the second surgery. However, repeated delays and long-term obstructive jaundice led to significant liver and multi-organ damage, rendering subsequent surgeries difficult and ultimately futile. This serves as a critical lesson.

3. Limitations of B-scan Ultrasonography

While B-scan ultrasonography is a relatively new and non-invasive diagnostic method, its diagnostic accuracy is 94% for gallstones and 64% for common bile duct stones. However, the modality is often prone to errors due to interference from intestinal gas and large blood vessels. Thus, clinicians should exercise caution when relying solely on B-ultrasonography for diagnosis. In this case, the two B-ultrasound images of the common bile duct were clearly incorrect, significantly contributing to the repeated diagnostic delays.

References

1. Li Mingjie: "Choledocho-Intestinal Drainage." Proceedings of Symposium on Biliary Tract Surgery, Ministry of Transportation, 37, 1987.
2. Li Mingjie: "Left Lateral Hepatectomy for Intrahepatic Calculi." Domestic Medical Abstracts, 1980; #161.
3. Wang Yu: "Journal of Practical Surgery," 1984; 4(5): 235.
4. Chief Editor of China Medical University: "Regional Anatomy." Beijing People's Publishing House, 1979; 142.
5. Liu Guoli: "Chinese Journal of Surgery," 1984; 22: 669.

This article was originally published in Proceedings of the Second Academic Conference on Health Care Along the Yangtze Riverthe (27), Dec. 1988；27
Changhang Hospital, Li Mingjie

from 胆道手术中几个特殊问题的诊治体会

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper VIII

Biliary enteric drainage

Literature Review and Clinical Analysis

Abstract

Between 1974 and 1980, a comprehensive review was conducted on 441 biliary duct surgical procedures, which included 81 instances (18%) of Internal Biliary-Intestinal Drainage (IDBI). This subset featured 61 cases of choledochoduodenostomy, 15 of Oddi's sphincterotomy, 2 hepatocholangiojejunostomies in the Roux-en-Y configuration, 2 Brown-type choledochojejunostomies, and one instance of U-type biliary-intestinal bridging.

The patients in this cohort generally experienced good health post-surgery, with no significant symptoms or signs of reflux. However, two exceptions were noted: one patient died due to an infection in the U-bridge, and another experienced recurrent cholelithiasis following a Finster's technique procedure, necessitating re-operation.

This paper places particular emphasis on the issue of postoperative reflux in the application of IDBI for treating biliary tract obstructions and cholelithiasis. Advances in diagnostic and therapeutic techniques, including ultrasound, CT scans, endoscopy, percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP), have considerably evolved the landscape of biliary tract disorder management.

Keywords:

Internal Biliary-Intestinal Drainage, Sump Pool Syndrome, Cholelithiasis

Introduction

Over the past six decades, advancements in various diagnostic techniques—particularly in Bus, PTC, ERCP, and CT—alongside animal clinical trials and in-depth research into biliary pathophysiology, have led to a renewed understanding of Biliary Enteric Drainage (BID). While the topic remains a subject of ongoing debate, it is clear that the field is moving along a path of increasing maturity and depth.

The concept of duodenal papillotomy has evolved significantly since its initial proposal in 1884. Despite a century of continuous exploration and advancement, a standardized surgical procedure for Biliary Enteric Drainage (BID) has yet to be established. The selection of surgical indications and technical nuances often depends on a myriad of factors—ranging from the specific clinical condition and the surgeon's individual expertise to the available equipment.

For the purposes of this study, we have reviewed a sample set comprising 441 cases of biliary surgery conducted in the Nanling region between 1974 and 1980. This data has been analyzed in conjunction with existing literature to provide a comprehensive review of BID.

Applications of Biliary-Enteric Internal Drainage (BID)

1. Restoring Normal Bile Flow

In cases where the bile-intestinal pathway is interrupted or narrowed due to tumors or injuries, BID aims to restore normal bile flow. This involves creating an artificial channel as an alternative route for bile to pass through.

2. Post-Surgical Bile Flow Management

After surgical corrections for conditions such as intrahepatic and extrahepatic bile duct stones or bile duct stenosis, BID is employed as a preventive measure. The objective is to maintain smooth bile flow, thereby preventing complications like bile stasis, recurrent infections, and further formation of stones.

On "Reflux Infections" and "Blind Bag Syndrome"

Concerns About Reflux

All Biliary-Enteric Internal Drainage (BID) procedures inherently disrupt the physiological function of the sphincter of Oddi, effectively eliminating the natural "valve" mechanism between the biliary and intestinal tracts. While the general flow direction of bile into the intestine is facilitated by factors like gravity, pressure, and peristaltic action, there are scenarios—such as a full stomach, intestinal reverse peristalsis, or posture changes—that can result in reflux from the intestine to the biliary system. This can consequently lead to infections and form a "blind bag" or "dump pool" in the residual bile ducts, causing symptoms and pathological changes of cholangitis.

Madden's Animal Experiment

In a well-known animal study by Madden in 1970, gallbladder-colon anastomosis was performed on dogs without intestinal preparation. Of 131 cases monitored with barium radiography, only one dog showed symptoms of cholangitis due to anastomotic stenosis; the rest were asymptomatic. Madden concluded that a wide and open anastomosis would not result in cholangitis. He even shifted the terminology from "ascending infection" to "descending infection," although he did not perform pathological examinations.

Follow-Up Studies

Twelve years later, a similar experiment was conducted in China by Qian Li in 1982 [1]. Pathological examinations were conducted 34-105 days post-surgery. Though all 10 dogs were asymptomatic before being sacrificed, histological studies revealed cholecystitis, cholangitis, pericholangitis, and even focal hepatocyte necrosis. This unveiled the clinical "illusion" in Madden's study, suggesting that such pathological inflammation could become clinically significant if the experiment were prolonged or if immune resistance were lowered.

However, Qian Li himself later stated in 1980 that "reflux is not a concern as long as the anastomotic opening is large enough to allow bidirectional flow; symptoms will not occur" [2]. He attributed this mainly to the bipedal nature of humans, contrasting them with the quadrupedal dogs used in the experiments. Although the potential for cholangitis exists, actual occurrences are minimal [3]. This is supported by data from eight different case groups, both within China and internationally.

In this cohort of 441 secondary biliary surgeries, 81 cases involved Biliary-Intestinal Drainage (Bid), making up 18% of the cases [4]. The procedures included:

• 56 choledochoduodenal side-to-side anastomoses, of which 21 were secondary surgeries, one was a tertiary surgery, and 5 were end-to-side anastomoses.
• 2 Roux-Y hepaticojejunostomies
• 15 sphincterotomies of the Oddi sphincter, with six of these being secondary surgeries and one being a tertiary surgery.
• 2 Brown's cholangiojejunostomies
• 1 U-tube choledocho-intestinal bridging surgery

In this group, there were no instances of severe ascending infections post-Bid. However, one case of choledochoduodenal side-to-side anastomosis required a subsequent surgery due to a "test tube phenomenon," which was confirmed to be due to intrahepatic calculi falling two years post-operation [4].

Extensive practice has shown that as long as the Bid (Biliary-Intestinal Drainage) anastomotic site is wide, concerns about reflux are generally not a deterrent for surgeons. However, unfortunate cases do arise where, 2-3 years post-surgery, symptoms develop due to anastomotic narrowing caused by inflammatory proliferation. This has led to a variety of surgical innovations aimed at preventing anastomotic constriction and eradicating reflux. These innovations include the elongation of drainage intestinal tubes—sometimes up to 60 cm [5]. For targeted drainage, two parallel artificial intussusceptions are created on an open intestinal loop. These intussusceptions, along with parallel segments of bile and intestinal input loops, are then sealed to form a true Y-shaped, rather than T-shaped, anastomosis [6-10].

In light of the specific pathology of hepatolithiasis, it's recommended to perform a significant dissection of the extrahepatic bile duct and potentially extend it to the left and right hepatic ducts. This facilitates stone removal and stenosis alleviation, followed by a large-caliber side-to-side gallbladder-intestinal anastomosis, known as the Longmire-type operation, effectively preventing long-term postoperative stenosis. To eliminate the "blind pouch," a posterior duodenal foramen low choledochoduodenostomy is performed [2]. For physiological conformity and to reduce the incidence of gastrointestinal ulcers, a jejunal interposition is done to restore natural bile flow. To further facilitate future stone removal and biliary tract clearance, a subcutaneous blind loop (SB-jicd) is added [9].

Factors Related to the Efficacy of Bid (Biliary-Intestinal Drainage)

1. Incomplete Cure of Primary Disease

Bid serves the purpose of clearing bile flow but does not act as a substitute for treating the underlying primary disease. The surgery aims to completely remove gallstones, Ascaris lumbricoides, and manage primary lesions or complications in the liver, gallbladder, and pancreas. Despite initial optimism that intrahepatic stones would naturally pass through internal drainage, clinical evidence proves otherwise. In instances where intrahepatic calculi "collapse," they may obstruct the anastomotic site, causing symptoms. When biliary constriction above the anastomotic site is not corrected or eliminated, bile-intestinal reflux becomes difficult to manage, leading to challenging infections. In cases of malignancy, the focus is either on curative or palliative surgical approaches. For congenital choledochal cysts, removal of the cyst followed by Bid is advisable to prevent the cyst wall from becoming inflamed or malignantly transformed.

In the early stages, due to the Finster procedure's ease of operation and good short-term outcomes, there was a tendency to overuse it, accounting for 70% of Bid cases in this study group. Diagnostic capabilities at the time, such as imaging and direct cholangiography, were not as advanced, leading to an incomplete understanding of the pathology. This often resulted in neglecting the treatment of intrahepatic lesions and bile duct stenosis, subsequently causing a high reoperation rate of 13.2%, and in some cases, three or four subsequent surgeries. However, with the advent of Percutaneous Transhepatic Cholangiography (PTC), the use of Bus Ultrasound (BUS), and an improved understanding of the disease, surgical techniques advanced, leading to better outcomes.

2. Choice of Timing for Surgery

It is generally advised against performing emergency primary drainage (Bid). This recommendation is based on multiple factors. First, emergency surgeries for acute or severe conditions should not be complicated due to the immediate need for treatment. Second, the short time frame makes it challenging to gain a comprehensive understanding of the condition, thus complicating the decision for the optimal surgical approach. Lastly, performing Bid during the stage of inflammatory edema could reduce its safety and increase the likelihood of long-term restenosis.

However, there's a school of thought advocating for completing Bid in a single stage, thanks to advancements in diagnostic technologies. With the use of Bus, PTC, ERCP, CT, and choledochoscopy, a more accurate understanding of the condition is possible, allowing for more informed surgical choices. This avoids complications related to anatomical disarray, adhesions, and accessory injuries in case of a second surgery, thus minimizing the patient's physical and financial burdens.

In summary, the choice of surgical approach should be made after comprehensive consideration of several factors: the local anatomical conditions, the patient's overall ability to endure surgery, and both the short-term and long-term needs dictated by the disease condition.

3. Issues with Technology Implementation

The approach to biliary-enteric anastomosis has evolved significantly. Initially, the focus was solely on ensuring free bile flow. However, with time and lessons learned from clinical experience—sometimes at a cost—there's now a shift towards understanding the postoperative physiological and pathological changes in the body. This is considered a valuable progress in the field.

Technical Precautions and Best Practices

1. Preventing Anastomotic Stenosis: It's crucial to create a spacious channel for bile flow and to avoid performing this surgery during periods of inflammation.

2. Understanding Blood Supply: Given that the blood supply to the extrahepatic bile ducts is axially distributed, excessive separation of the bile ducts should be avoided to prevent ischemic stenosis caused by surgical trauma.

3. Suture Techniques: Leakage of bile between different layers of bile duct tissues can hinder tissue healing. Therefore, suturing should be done in a tension-free manner to prevent this.

4. Optimizing Duct Length: The non-functioning segment of the bile duct should be kept as short as possible to minimize the formation of blind pouches.

5. After Bid: Post-Bid, the regulatory function of the sphincter of Oddi is lost, leading to decreased pressure in the bile ducts. In this condition, the gallbladder merely serves as a diverticulum. Given that the cystic duct is small and convoluted, ongoing gallbladder inflammation and stone formation are almost inevitable. Therefore, it's recommended to remove the gallbladder when performing Bid.

4. Selection of Surgical Procedures and Principles of Joint Observation

With the abundance of Bid surgical procedures, how do we choose among them? In addition to considering patient conditions, pathology, available equipment, technical conditions, and the physician's personal experience, several principles and requirements are emphasized:

1. Biliary flow should be physiological: The surgery should aim to avoid disrupting the natural physiology and pH of the digestive system to minimize the risk of gastrointestinal ulcers.
2. Shorten the non-functioning bile duct segment: The non-functioning parts of the bile duct should be minimized to avoid complications.
3. Fewer short-term symptoms: The surgical method should have fewer immediate complications.
4. Low risk of restenosis: The surgery should minimize the risk of the internal drainage becoming narrow again.
5. Minimal "ascending infection": The chosen method should minimize the risk of infection moving upward in the system.
6. Complexity and safety of the operation: The surgical method should balance complexity against safety.
7. Favorable for monitoring and re-examination: Post-operative follow-up should be facilitated by the surgical method chosen.

Based on the aforementioned principles, the best surgical approach is chosen depending on the patient's condition.

1. SB-jicd: This method is generally the first choice for cases with multiple intrahepatic and extrahepatic stones to avoid the need for multiple surgeries.
2. Jied: For non-stone-related benign obstructions in the biliary tract, the Jied procedure is advisable to restore physiological conditions.
3. Finster Surgery: For older patients with severe diseases, the Finster operation may be suitable.  If conditions allow, this can be an alternative approach.
4. Oddi Sphincterotomy or Plasty: For obstructions in the far end of the common bile duct or stenosis at the outlet, these procedures may be performed.
5. Roux-en-Y Biliary Bypass: This method reduces the neutralizing effect of bile on gastric acid within the duodenum. There are claims that this could lead to an ulcer rate as high as 52%, although clinical observations put it at around 10%. Pappa-Lardo recommends an additional procedure (possibly a specific type of cut or incision, as the term "迷切" is not entirely clear, 建议此术附加迷切) to be included in the surgery. This suggestion, however, hasn't garnered much attention in China, where the surgical method in question is still widely used. One speculation for this could be that gastric acid levels are generally lower in the Chinese population compared to Western countries.

6. Endoscopic Sphincterotomy (ES): This surgical technique avoids the need for open abdominal surgery and represents a recent advancement in foreign countries. However, it hasn't gained widespread adoption in China yet, possibly due to limited experience with the procedure.

Comments on Several Commonly Used Surgical Procedures

I. Sphincterotomy and plasty of Oddi

In the case of Oddi sphincterotomy and plasty, the surgical procedure theoretically aligns with the natural flow of bile and eliminates the presence of a 'blind bag,' making natural stone expulsion possible. In this particular study, 15 cases were performed, accounting for 20% of all biliary-intestinal diversion (Bid) procedures. Post-operative ascending infections were observed in two cases, which were controlled using antibiotics.

Due to advancements in endoscopic technology, especially abroad, there's a shift towards duodenal endoscopic sphincterotomy (ES). This method avoids the need for a laparotomy and has a high stone-removal rate of 85-90%. However, the complication rate is also noted to be 28%.

When an incision of 10mm is made in the Oddi sphincter, it relieves muscle spasms but doesn't entirely remove the functionality of the distal bile duct sphincter. This makes it prone to restenosis, making it difficult to achieve the desired long-term outcome.

In terms of the distal sphincter, a more extended cut could result in complete severing of the ampullary and most of the common bile duct sphincter. The consequences of such cuts need to be weighed carefully, particularly in terms of potential for bile reflux and ascending infections.

Considering that the function of the distal sphincter of the bile duct comprises three components—the Oddi muscle, the inner wall sphincter of the bile duct, and the partial function of the circular muscle in the duodenum—if an incision of 1.5 cm is made, it would sever the entire ampulla and a large portion of the common bile duct sphincter. If the incision extends to 2.5-3 cm, all three components would be severed, essentially resulting in a low-position choledochoduodenostomy. Any incision of these various lengths must be done cautiously to prevent damage to the pancreatic duct. Moreover, due to the pressure equilibrium between the bile and intestinal tracts, reflux from the intestine to the bile duct is almost inevitable. This could easily lead to ascending infections. Additionally, there's the issue that a dilated common bile duct greater than 20 cm can still form a funnel-shaped narrow segment post-surgery.

Choi, in 1982, proposed a re-operative extraperitoneal approach to avoid the difficulties of adhesions and collateral damage encountered when dissecting the original surgical area.

Plasty involves the removal of a wedge-shaped portion of the anterior lateral wall of the common bile duct outlet, followed by suturing. To prevent reflux, a valve was designed.

This operation, when used as an adjunct to other internal drainage procedures, has considerable value in eliminating the 'blind bag.' Four such cases were noted in this study, and in one case, liver stones were no longer present two years post-operation, possibly a supporting case for the long-term efficacy of the procedure.

II. Choledochoduodenostomy

This procedure involves two types of anastomosis: lateral-lateral and terminal-lateral. The operation is simple, straightforward, and safe, with good short-term recovery. Influenced by the "illusion" created by Madden's experiments, this procedure was widely performed in earlier years. Among our group of 81 cases, this technique was applied in 61 cases, making up 75%. However, recent consensus—built upon observations from reoperations, insights from animal experiments, and a deeper understanding of the pathophysiology of the biliary tract—indicates that the appropriateness of this surgery has significantly decreased.

Particularly problematic is the classic Finster's fissure technique, which has several downsides: the anastomosis is narrow, there's a latent risk of retrograde infection and blind-end syndrome, and prolonged exposure to digestive juices can induce chemical cholangitis that leads to mucosal atrophy. This results in goblet cell and fibrous tissue proliferation, making the duct wall thick and hard. Post-anastomotic biliary infections often involve a complex mix of aerobic and anaerobic bacteria, complicating treatment. Sometimes, extreme measures like a B-II partial gastrectomy are required to divert food, or the posterior wall of the blind end needs to be cut open, or a new biliary-intestinal anastomosis has to be constructed.

The procedure is generally not recommended for those with hepatogenic stones that haven't been completely removed or if there's uncorrected bile duct stenosis above the anastomotic site. For gallstones combined with lower common bile duct narrowing, often termed "Western-style gallstones," this procedure can be the best option. It's also a viable choice for elderly or frail patients who can't endure complex surgeries.

To overcome the limitations of this technique, various improved methods have been introduced recently, including post-duodenal choledochoduodenostomy and hollow-end biliary anastomosis. These improvements are theoretically more sound and have shown good results in practice.

III. Biliary-Jejunal Roux-en-y Anastomosis

One issue with this technique is that extending the jejunal loop used for bile drainage to even 60 cm doesn't necessarily eliminate the risk of reflux infection. Directly routing bile into the jejunum disrupts physiological norms. This not only hampers the digestion and absorption of fats but also reduces the suppression of gastric juice secretion in the upper jejunum. For those with high gastric acid levels, the absence of bile to neutralize stomach acid in the duodenum can increase the incidence of ulcer disease. Additionally, an overly long jejunal loop can twist and adhere, causing potential obstructions. Changes in the functionality of this intestinal segment make it difficult to maintain a normal microbiota, giving rise to a condition known as "jejunal blind loop syndrome."

Despite these challenges, this remains one of the most frequently used surgical methods. It allows for tension-free anastomosis with bile ducts at all levels, including the Longmire procedure. This versatility addresses issues like intrahepatic bile duct stenosis and enables the reconstruction or palliative bypass of the biliary-intestinal pathway following substantial resection of malignant liver tumors. Ongoing technical improvements aim to minimize the risk of reflux infection as much as possible.

IV. Intermittent Jejuno-Biliary-Duodenal Anastomosis (Jicd)

This surgical technique evolved from the Roux-en-y procedure. It was first reported by Grassi in 1969 and subsequently introduced in China by Shiweijin in 1982. The method involves interposing a segment of the jejunum between the bile duct and the duodenum, aiming to restore the physiological state of bile flow. This addresses some of the limitations associated with the Roux-Y method. Regarding the length of the interposed segment, Grassi recommended 20 cm, while Huang Zhiqiang advised against excessive length. An artificial nipple is designed at the distal end of the interposed jejunum and is inserted into the wall of the duodenum during anastomosis.[9] Shi Weijin suggests that a 60 cm length could essentially prevent reflux. Technically, attention must be paid to the "peristaltic direction" when placing the interposed intestinal segment. End-to-side anastomosis between the bile duct and jejunum is preferable as it allows for more flexible design of the anastomotic site.

However, the procedure comes with three anastomotic connections, making it more invasive and complex compared to the Roux-Y method, which involves two anastomotic sites, and choledochoduodenostomy, which has just one. This complexity has hindered its widespread adoption. Despite these challenges, the technique is currently being promoted in China due to its advantages. As it has not been in use for a long period, its long-term efficacy and ultimate evaluation still require further clinical validation.

V. Subcutaneous Blind Loop Interposition of Jejuno-Choledochoduodenal Anastomosis (SB-JICD)

This technique evolved from the aforementioned JICD and is specifically designed for cases where multiple intrahepatic stones are difficult to remove completely or where hepatic stones are expected to regenerate. The subcutaneous blind loop is reserved for direct access when needed to remove stones, worms, or facilitate bile drainage. It can also serve as a route for medication administration and postoperative monitoring.

Built upon the foundation of Roux-Y and JICD procedures, this technique involves interposing a segment of jejunum, which is then subcutaneously buried and marked with a silver clip. Corresponding skin surface markings can also be made for easier monitoring and treatment access. A blind loop length of around 10 cm is recommended to minimize the risks associated with "blind loop syndrome."

However, this procedure has not yet gained widespread acceptance. It leaves another option for suitable candidates, but it comes with its own set of challenges. Not only is the surgery complex, but the risk of infection in the blind loop also exists. Furthermore, the procedure may not be as effective in practice as it is in theory, especially for deeper hepatic lesions. Even if a cholangioscope is inserted through this route, it may not necessarily solve the problem.

VI. Others

Other techniques like gallbladder-gastrointestinal anastomosis are generally discarded due to the circuitous and narrow nature of the gallbladder duct, which cannot ensure reliable drainage. These methods are no longer considered viable options, especially in the case of late-stage malignant tumors or critically ill elderly patients. In our early practice, we performed a few gallbladder-stomach and gallbladder-jejunum anastomoses. These techniques played an active role in alleviating symptoms for patients with distal biliary obstruction-induced jaundice, such as those with late-stage pancreatic head cancer.

References:

1. Qian Li: Analysis of the pathogenesis of secondary cholangitis after biliary-intestinal anastomosis and the efficacy of various biliary-intestinal internal drainage procedures. Anthology of Papers on Cholelithiasis, Wenzhou Medical College, 1982.

2. Qian Li: Treatment of Primary Pigment Stones in the Common Bile Duct. Journal of Practical Surgery, 1986; 1:19.

3. Zhang Shengdao: Evaluation of choledochoduodenostomy in the treatment of severe acute cholangitis. Journal of Practical Surgery, 1986; 6(1): 42.

4. Li Mingjie: Hepatectomy for treating intrahepatic gallstones. Domestic Medicine, 1980 #161; Wannan Medical Journal, 1980, 13:51-55.

5. Shi Weijin: Indications and evaluations of JICD and SB-JICD. Journal of Practical Surgery, 1986; 6(1): 44.

6. Tan Yuqian: Evaluation of Roux-Y type cholangiojejunostomy. Journal of Practical Surgery, 1986; 6(1): 44.

7. Zhang HD: An Exploration on the prevention of Reflux in "Y" Type Choledochojejunostomy. Abd 'surg, 1985; 27:34.

8. Kassi M: Improved technique of end-to-side anastomosis of the intestine. SGO, 1974; 138:87.

9. Huang Zhiqiang, et al.: Artificial nipple-type intermittent jejuno-biliary-duodenal anastomosis. Journal of Practical Surgery, 1986; 6(1): 48.

This article was originally published in Proceedings of the Second Annual Surgical Conference of the Third Session in Anhui Province,Sept. 1988；87
Changhang Hospital, Li Mingjie

from 胆肠内引流

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper VII

Hepatobiliary basin-type biliary-enteric drainage

 A Case Report 

A 46-year-old male seaman initially underwent cholecystectomy and common bile duct stone extraction in 1973 for cholecystitis and cholelithiasis. Three months post-discharge, he experienced recurrent episodes of biliary tract infection, characterized by abdominal colic, jaundice, fever, and fatigue, persisting for three years. In 1976, symptomatic relief was achieved through the expulsion of two biliary stones via Chinese herbal medicine. Subsequent B-scan ultrasonography in June and December of 1990 identified choledocholithiasis with a 1.9cm diameter stone. Further imaging in October 1991 confirmed extrahepatic choledocholithiasis accompanied by common bile duct dilatation (2.2cm) and left intrahepatic cholelithiasis with bile duct dilatation. No signs of infection or jaundice were observed, and liver function tests were within normal limits. No surgical contraindications were identified, and elective surgery involving a high-level biliary tract incision, basin-type biliary-intestinal drainage, and focal hepatectomy was planned.

Surgical Procedures

Under the guidance of continuous epidural anesthesia, an L-shaped incision was initiated below the right costal margin. The xiphoid process was subsequently excised, extending the incision toward the right axillary line. Upon abdominal entry, the common bile duct was isolated from the pre-existing surgical scar, revealing a multitude of cast stones and a "residual gallbladder" that was notably large and stone-filled.

The perihepatic ligaments, including the left and right triangular, falciform, and left coronary ligaments, were then dissected to facilitate the downward mobilization of the liver. Palpation of the left hepatic duct revealed a cluster of stones accompanied by fibrosis in segment III of the left lateral lobe. Additional stones were identified at the hepatic duct confluence.

Continuing the dissection, the extrahepatic bile ducts outside the hepatic hilum were isolated. Incisions were made in the porta hepatis and umbilical plates, with blunt dissection used to reach the left and right primary hepatic ducts. A high-level incision was performed on the common hepatic duct up to its bulging part to extract the gallstones. This was immediately followed by a hepatectomy of segment III of the left lateral lobe to eradicate the intrahepatic stones and cystic duct dilatation.

The extracted intrahepatic stones were completely removed via the interface between the left hepatic section and the common hepatic duct, followed by a hydrogen peroxide rinse. Hemostasis was achieved via suturing of the left hepatic section. The "small gallbladder" was then excised, and the common bile duct incision was enlarged to facilitate the removal of the lower segment stones. A No. 7 probe was introduced into the duodenum to repair the common bile duct incision.

Subsequently, the common hepatic duct and primary left and right hepatic ducts were exposed, revealing the openings of the secondary hepatic ducts and caudal lobe bile duct. Stone removal and rinsing were performed following ductal dilatation. The basin's rim was meticulously trimmed to maintain a 2mm edge for optimal anastomosis, with a basin diameter of 3.5cm. Finally, hemostatic suspension was applied.

A segment of the jejunum was transected 15cm distal to its origin. The distal jejuno-colonic segment was then elevated anteriorly and anastomosed to the hepatobiliary basin in an end-to-side fashion, employing a layer of mucosal eversion. Upon inspection, no leaks were identified. Subsequently, an anastomosis was performed between the proximal jejunum and the biliary-enteric loop, 40cm distal to the initial anastomosis.

For drainage, a dual cannula system was employed to establish negative pressure drainage beneath the porta hepatis and the hepatobiliary basin. The intraoperative blood loss was recorded at 300ml, and a blood transfusion of 600ml was administered to maintain hemodynamic stability.

Postoperative Course

Hemostatic triple therapy was administered for three days postoperatively, alongside a gold-standard antimicrobial regimen consisting of gentamicin, ampicillin, and metronidazole. The patient's postoperative body temperature plateaued around 38°C for a duration of two weeks. Bloody abdominal exudate was observed for three days but showed no signs of bile leakage. Drainage tubes were safely removed on the 9th postoperative day, with no ensuing abdominal or incisional infections or jaundice. The patient was declared fit and discharged after three weeks.

A 5-month follow-up indicated no episodes of biliary reflux infection or abdominal symptoms. Digestive functions were observed to be normal, and a subsequent B-scan ultrasonography revealed no residual intrahepatic or extrahepatic calculi.

Discussion

There is currently no standardized surgical approach for treating intrahepatic and extrahepatic bile duct stones. Conventional extrahepatic bile duct surgeries often fail to entirely remove stones, alleviate hepatobiliary strictures, or establish smooth drainage, leading to recurrent symptoms. This often necessitates multiple surgeries and may result in acute obstructive suppurative cholangitis (AOSC) and biliary sepsis, both associated with high mortality rates [1]. In recent years, however, many scholars have advocated for extending surgical interventions into the liver itself, enabling comprehensive stone removal and subsequently improving treatment outcomes [2]. Although these procedures are more invasive, when executed with meticulous surgical techniques and well-planned pre- and post-operative care, they yield satisfactory results.

Primary hepatic ducts (Grade I) can be safely dissected beyond the liver parenchyma, thus facilitating the treatment of secondary hepatic duct (Grade II) stones and strictures. If the quadrate lobe is hypertrophic, some surgeons recommend local resection to improve surgical field visibility and ensure precise choledocho-intestinal anastomosis, thereby enhancing the procedure's safety. However, with adept dissection techniques, the liver can be mobilized and manipulated without necessitating quadrate lobe resection. Our case demonstrated that anastomosis could be conveniently performed without resecting the quadrate lobe.

For diverse intrahepatic stone locations, specific treatments were applied in each case. Superficial liver stones were excised through liver parenchymal incisions followed by hepatic repair. Segmental resections were performed for stones confined to specific lobes accompanied by proximal bile duct dilation. For cast stones, direct incisions were made according to the liver entry route, followed by bile duct repair or T-tube and U-tube drainage. For localized liver stones, "sculptural" hepatectomy was executed to avoid resection of healthy liver tissue. It is crucial to preserve the liver's blood supply and bile drainage routes while employing a combination of surgical techniques.

References

1. Huang Zhiqiang. "10-Year Progress in Surgical Treatment of Hepatolithiasis." Journal of Practical Surgery, 1991; 8.9: 447.

2. Wu, J. et al. "Hepatobiliary Basin-Type Enterohepatic Drainage: An Analysis of 209 Cases." Chinese Journal of Surgery, 1989; 27: 130.

3. Wang Zhesheng, et al. "Treatment of Intrahepatic Biliary Stricture Accompanied by Calculi Using Tongue Resection at the Hepatic Hilus: A Report of 56 Cases." Journal of Practical Surgery, 1991; 8.9494

This article was originally published in Transportation Medicine 1993. 7:91
Changhang Hospital, Li Mingjie, Yang Zonghua Shi Lianghui

from 肝胆管盆式胆肠内引流术一例 

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper VI

Surgical treatment of short bowel syndrome

Study of 2 Cases  

Abstract

Short Bowel Syndrome (SBS) manifests as malnutrition, electrolyte imbalances, and various other complications due to the extensive resection of the small intestine. We present two cases where reverse peristaltic bowel loop anastomosis was performed in the distal small intestine to mitigate the risks of SBS.

Case Studies

Case 1: Male Farmer, 29 Years Old

The patient underwent extensive resection of the lower small intestine due to torsional necrosis, sparing only 3 cm above the ileocecal valve and leaving 80 cm of the jejunum intact. To restore intestinal continuity, the distal 7 cm of the jejunum, along with its mesentery, was inverted and an end-to-end anastomosis was performed. Postoperative observations showed effective reverse peristalsis in the interposed bowel segment. Although the patient experienced frequent bowel movements and mild indigestion, there were no significant nutritional or electrolyte imbalances, negating the need for specialized nutritional interventions. The patient returned to work six months post-surgery and has remained symptom-free for 18 years.

Case 2: Female Peasant, 24 Years Old

The patient presented with segmental enteritis featuring multiple necrotic perforations. A resection of the lower small intestine and a right hemicolectomy were performed, leaving 100 cm of the jejunum. The distal 7 cm of the jejunum was inverted, followed by a jejunum-to-jejunum-to-transverse colon end-to-end anastomosis. The patient successfully recovered from postoperative infection risks. However, she experienced loose stools for three months post-surgery. Nutritional absorption was satisfactory, and she resumed her normal life within a year. X-ray barium examination eight months post-surgery revealed reverse peristalsis at the anastomotic site, with slow barium propulsion. She has remained largely symptom-free for 20 years, except for two instances of abdominal pain.

Both cases highlight the potential of reverse peristaltic bowel loop anastomosis in preventing the onset of SBS. The technique appears to be particularly effective in preserving nutritional absorption and electrolyte balance. It also allows for a reasonable quality of life post-surgery, as evidenced by the patients' ability to return to work and maintain a normal lifestyle over an extended follow-up period.

Discussion

Importance of Intestinal Segmentation in SBS

The onset of Short Bowel Syndrome (SBS) is not solely determined by the length of the intestinal segment removed but also by its specific location. The small intestine demonstrates selective nutrient absorption at different segments—iron and calcium are primarily absorbed in the proximal jejunum, whereas bile salts and vitamin B are absorbed in the distal ileum. The duodenum, proximal jejunum, and distal ileum are considered pivotal for intestinal digestion and absorption. Thus, preserving these key segments and the ileocecal valve during resection can often prevent the development of SBS, even if up to 50% of the middle small intestine is removed.

Physiological Adaptations and Complications

The small intestine has a significant functional reserve, making it relatively tolerant to partial resection. However, extensive resection, particularly of functionally crucial segments, can trigger SBS. Initial symptoms often involve substantial fecal fluid loss and electrolyte imbalances. In some cases, increased gastric secretions can lead to peptic ulcers. Over time, the remaining small intestine may undergo compensatory changes, like villi enlargement and mucosal cell proliferation, to enhance absorption. If these compensatory mechanisms are inadequate, SBS may still develop, necessitating surgical interventions like short bowel anastomosis.

Limitations of Non-Operative Measures

Non-surgical treatments are generally supportive and aim to assist patients through the adaptation and compensatory phases. Our study group had ten other cases without specific short bowel anastomosis; three patients died within two months from severe electrolyte and fluid imbalances, despite aggressive fluid and blood transfusion therapies. The remaining seven underwent a challenging recovery period lasting 1-2 years.

Efficiency of Reverse Peristaltic Bowel Loop Anastomosis

Various techniques for short bowel anastomosis exist, but the reverse peristaltic bowel loop anastomosis has proven to be straightforward, effective, and complication-free, even in emergency scenarios. The optimal length for the interposed loop is between 7-14 cm for adults and less than 8 cm (3 cm for neonates) to prevent physiological intestinal obstruction due to reverse peristalsis. The location of the loop should be carefully considered, aiming for the distal side of the remaining small intestine to maximize its functional efficiency.

Preventative Strategies for SBS

In adults, the length of the small intestine can reach up to 7 meters, but the actual in vivo length is often around 3 meters. During resection, it's generally advised to limit the removal to less than 50% of the intestine. Special attention should be paid to conditions like Peutz-Jegher's disease, which may require multiple surgeries due to recurrent polyps. In such cases, individual polyp excision should be prioritized over extensive resection. Care should also be taken to preserve the ileocecal valve function and avoid indiscriminate incisions.

In summary, a multifaceted approach, considering the anatomical, physiological, and surgical aspects, is essential in both the treatment and prevention of SBS.

This article was originally published in Transportation Medicine 1991. Vol.5, No.1: 41-40
Changhang Hospital, Li Mingjie

from 短肠综合征的外科治疗

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper V

Diagnosis and treatment of closed retroperitoneal duodenal injury  

A Case Report

A 29-year-old male was admitted to our hospital one hour after experiencing a traumatic impact to his right rib area when his bicycle collided with the handle of a parked scooter. He reported immediate severe pain, difficulty breathing, and palpitations.

Initial Examination and Admission

Upon admission, the patient's vitals were as follows: Blood Pressure 15/10 kPa, Temperature 36°C, Pulse 68 beats/min. He appeared alert but in acute pain. Physical examination revealed a shallow abrasion along the clavicular midline of the right costal margin, a slightly tense right upper abdominal muscle, and no obvious tenderness or rebound pain. Abdominal puncture was negative. Laboratory tests indicated Hemoglobin levels at 125 g/L, WBC count at 10.2 x 10^9/L, with 75% neutrophils and 25% lymphocytes. B-ultrasound showed no abnormalities in the liver, spleen, pancreas, or kidneys, and no abdominal fluid was detected. Chest fluoroscopy was also normal.

After 16 hours of hospitalization, the patient experienced increasing right-sided lumbar and testicular pain. Further imaging revealed indistinct fat lines and psoas major muscle shadows on the right side of the abdominal wall, although the right kidney appeared normal. Despite rehydration and anti-inflammatory treatments, the patient's abdominal pain worsened.

Clinical Observations and Diagnosis

Subsequent physical examination showed increased abdominal muscle tension, widespread tenderness, particularly in the lower right quadrant, and rebound pain. Percussion of the right kidney area was painful. Repeat abdominal puncture and lavage were negative. Serum amylase levels were within normal limits, and WBC count was 11.1 x 10^9/L with 84% neutrophils and 16% lymphocytes. Urinalysis was negative. The patient was diagnosed with a closed retroperitoneal duodenal injury and underwent exploratory laparotomy 28 hours post-injury.

Discussion

Diagnostic Challenges and Characteristics

Retroperitoneal duodenal injuries are rare and serious abdominal traumas that often present diagnostic challenges due to their initially subtle symptoms. Characteristic symptoms such as right lumbago and testicular pain may occur as a result of stimulation of the right psoas major muscle and retroperitoneal testicular nerve by duodenal fluid. Additionally, the accumulation of extraintestinal air in the retroperitoneal space can make the outline of the right kidney clearly visible in X-ray examinations. Elevated levels of serum amylase can also indicate the overflow of pancreatic juice. Diagnostic abdominal puncture is a valuable tool for early diagnosis, and some practitioners successfully use intraoperative injection of methylene blue via a stomach tube for diagnosis.

Case Specifics

In this particular case, the patient exhibited symptoms of right lumbago, testicular pain, and signs of peritoneal irritation. Radiological findings revealed indistinct fat lines and psoas major muscle shadows on the right abdominal wall, while the right kidney outline remained clear. These factors led us to suspect a retroperitoneal duodenal injury. Exploratory laparotomy confirmed a retroperitoneal hematoma and diffuse green staining, corroborating our diagnosis.

Surgical Management and Postoperative Care

Despite the delayed surgery occurring 28 hours post-injury and considerable local inflammation, the patient experienced no postoperative complications. The surgical approach included gastrojejunal bypass, common bile duct drainage, and duodenal stump fistulization, supplemented by abdominal double cannula negative-pressure drainage.

Adjuvant Treatments

Postoperatively, we implemented a range of adjuvant treatments aimed at patient recovery. These included continuous gastrointestinal decompression and duodenal fistula to lower duodenal internal pressure and minimize the retention of irritating and inflammatory fluids. We also administered a combination of broad-spectrum antibiotics and provided rehydration to maintain water, electrolyte, and acid-base balance. Active postoperative support was instrumental in the patient's successful recovery.

This article was originally published in Transportation Medicine 1995. Vol.9, No.3
Changhang Hospital, Zhang Qi, Director: Li Mingjie

from 闭合性腹膜后十二指肠损伤诊治体会 

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical paper IV

Surgical treatment of acute gastroduodenal perforation 

Abstract

This study examines 76 cases of acute gastroduodenal perforation, categorized into digestive ulcer perforations (60 cases), perforations due to gastric cancer (10 cases), and traumatic duodenal ruptures (6 cases). Of these, 37 underwent gastrectomy, while 39 received perforation repair. Clinical outcomes favored gastrectomy, which displayed fewer postoperative complications such as re-perforation and bleeding. The study recorded 5 mortalities. The findings suggest that gastrectomy is the preferred surgical intervention for both immediate relief and long-term cure. Even palliative gastrectomy for malignant conditions can alleviate symptoms and improve quality of life. Perforation repair, although life-saving in certain situations, has significant drawbacks. For traumatic duodenal ruptures, post-repair treatment should include Berne-style diverticulization.

1. Clinical Data

The study involved 76 patients, comprising 69 males and 7 females, ranging in age from 14 to 73 years with an average age of 42 years. Among these patients, 32 were diagnosed with duodenal ulcer perforation with an average age of 35 years; 28 had gastric ulcer perforation with an average age of 54 years; 9 had perforations due to gastric cancer with an average age of 58 years; one case was identified as gastric malignant lymphoma aged 73; and 6 cases involved duodenal rupture due to trauma with an average age of 34 years. Concurrent conditions in the cohort included 7 cases of bleeding, 15 cases of shock, and 3 instances of additional visceral injuries among the 6 trauma-induced perforations. Comorbidities included hypertension in 12 cases, coronary artery disease in 8, diabetes in 6, and pulmonary tuberculosis in 4. Among the 18 cases that underwent surgery within 12 hours of perforation, 13 underwent gastrectomy and 5 received perforation repair. Of the 30 cases operated on between 13 and 24 hours post-perforation, 12 had a gastrectomy and 18 had perforation repair. Finally, among the 28 cases (including 6 trauma cases) who were operated on after 24 hours from perforation, 12 underwent gastrectomy.

2. Results

Gastrectomy

A total of 37 patients underwent gastrectomy, all of which were performed using the Billroth-I technique, with no immediate postoperative fatalities. Of the 10 gastrectomies performed for malignant conditions, 7 were palliative resections with survival periods ranging from 6 to 14 months. Three were curative resections, with survival periods ranging from 2 to 5 years; notably, one 73-year-old patient with gastric malignant lymphoma remained alive and symptom-free five years post-curative resection. Among the 23 patients who underwent gastrectomy for perforated peptic ulcers, all but one patient with a pancreatic-origin ulcer—who required three surgeries culminating in a total gastrectomy—were successfully treated. During an 8 to 10-year follow-up, only two cases exhibited mild symptoms of alkaline reflux gastritis but were otherwise healthy.

Perforation Repair

Out of 39 cases that underwent perforation repair, two patients died due to re-perforation or leakage on the fourth postoperative day, while another two experienced postoperative bleeding on the second and fifth days, resulting in one fatality. In cases involving duodenal trauma, two patients underwent simple repair but did not survive. Among the 34 surviving patients, one experienced re-perforation due to active ulceration at 2 years post-surgery and another at 5 years post-surgery. Additionally, 7 patients underwent subsequent gastrectomies due to persistent symptoms.

3. Discussion

Acute perforation of the stomach and duodenum presents an urgent clinical challenge, irrespective of the underlying etiology or disease progression. The immediate concern is the spillage of luminal contents, leading to acute peritonitis and a cascade of pathophysiological changes that require prompt intervention.

3.1 Evaluation of Non-Surgical Treatments

For cases where the perforation is small and quickly sealed by adhesion, symptoms and signs are mild, systemic disturbances are minimal, or high-risk factors such as advanced age and comorbidities are present, non-surgical treatment may be considered. However, most surgeons are reluctant to take this risk for several reasons:

1. A passive and negative mindset is prevalent, demanding rigorous and continuous observation and monitoring. The criteria for transitioning to surgical intervention are difficult to gauge, and the risk of delayed surgery could come at a significant cost.

2. Precise diagnosis in terms of localization and quantification is challenging. It is generally believed that duodenal ulcer perforations may self-seal, while conservative treatment for gastric ulcer perforations tends to be less effective.

3. Perforations due to gastric cancer necessitate further surgical intervention.

4. The underlying condition requires systematic examination and treatment after the acute phase, with at least half of the cases eventually requiring surgery. Additionally, the rate of re-perforation stands at 8.5%.

5. Post-treatment complications such as intra-abdominal abscesses and adhesions are possible.

Given these considerations, the majority of surgeons opt for surgical intervention.

Certainly, opting for surgical intervention carries risks associated with perioperative anesthesia, surgical trauma, and hemodynamic changes. However, the advantages often outweigh these concerns. Open surgery allows for a more accurate assessment of the nature and extent of the pathological changes, the status of intra-abdominal infection, as well as the location and size of the perforation. This enables a more targeted and proactive choice of surgical procedures. Furthermore, advancements in surgical techniques, improved monitoring measures, and the progress in antibiotics contribute to increasingly encouraging surgical outcomes.

3.2 Subtotal or Radical Gastrectomy

Whenever feasible, this should be the treatment of choice, boasting excellent therapeutic outcomes of 90%-95% for perforated ulcer diseases and a surgical mortality rate of less than 1%. It serves both diagnostic and therapeutic purposes. This approach is also suitable for treating perforations caused by gastric cancer. In cases of duodenal trauma followed by diverticulization, gastroenterostomy along with gastric resection is required. Out of the 37 gastrectomies performed in our study group, both short-term and long-term outcomes were favorable, except for cases of advanced gastric cancer where curative resection was not possible. The time elapsed since perforation should not be the sole criterion for selecting the surgical approach; rather, factors like the extent of edema and inflammation at the lesion site, as well as intra-abdominal infection, should also guide the choice. During gastrectomy, the lesion is removed, allowing for anastomosis on healthy tissue. In our group, four cases underwent this procedure 48 hours post-perforation and had smooth postoperative recoveries.

Of course, suturing techniques and comprehensive perioperative management are also crucial factors.

3.3 Perforation Repair

Since its inception by Von Heusner in 1892 and Bennett in 1896, perforation repair remains clinically valuable for life-saving measures even today. The procedure is characterized by its simplicity, minimal invasiveness, and safety, making it indispensable for high-risk patients. However, the technique is not without its drawbacks. Apart from the risks of postoperative bleeding and leakage, 50%–70% of patients ultimately require further surgical intervention or experience symptom recurrence. Illingworth reported that 40% of patients experienced symptom recurrence within one year and 70% within five years following perforation repair. Shi Huang reported that, in a long-term follow-up of 141 cases, 20% experienced bleeding, 9.2% had pyloric stenosis, and 4.7% suffered re-perforation. All five fatalities in our study group underwent this procedure. Moreover, perforation repair for gastric cancer provides only temporary relief and does not alter the disease course, with most patients succumbing to cancer within a year post-surgery.

The authors believe that this procedure should be strictly limited to the following conditions:

1. Severe peritonitis accompanied by shock.
2. Extensive edema around the perforation site, which could hinder the healing of anastomosis following gastrectomy.
3. Lost opportunity for palliative resection of the tumor.
4. Presence of other severe comorbidities or frailty due to advanced age, where any increase in surgical trauma would elevate the mortality risk.

Three technical aspects warrant special attention during perforation repair:

1. Care must be taken to avoid excessive inverting sutures, particularly in the pylorus and duodenum, to prevent iatrogenic stenosis.

2. Effective repair to prevent re-leakage is crucial. The first layer of sutures should be loosely approximated, followed by a second layer of seromuscular sutures for coverage, and then supplemented by an omental patch with an adequate blood supply.

3. In cases of traumatic duodenal rupture, if repair proves challenging, nearby organs such as the stomach, intestine, or gallbladder can be used, or a vascularized patch may be applied for suturing and sealing. However, this must be accompanied by thorough diverticulization to ensure proper drainage [5].  

References

[1] Shen Hongxun. Current Status and Progress in Surgical Treatment of Peptic Ulcers: Transportation Medicine 1991, 5(1): 26~

[2] Berne CT. Duodenal Diverticularization for Duodenal and Pancreatic Injury. Am J Surg. 1974, 127:503~

[3] Rodney Maingot. Abdominal Surgery. Shanghai: Science and Technology Press, 1965, pp. 244-247.

[4] Shi Huang. Simple Repair for Acute Gastric and Duodenal Ulcer Perforation. Chinese Journal of Surgery, 1964, 12:646.

[5] Jiang Kai, Pan Youlan, Li Mingjie.  Diagnosis and Treatment of Closed Retroperitoneal Injury of the Duodenum. Wuhu Medicine, 1997, 3(2): 9~

Li Mingjie
Changhang Hospital, Wuhu, Anhui Province, China
Surgical Department, Zip Code: 241000
Received: June 5, 1995; Revised: October 21, 1997
Originally published in the Chinese Journal of General Surgery, Supplement to Volume 6, December 6, 1997, pp. 22-23.

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】

Surgical paper III

Surgical management study of hepatic injury

Abstract

The incidences of the hepatorrhexis in trauma have markedly increased lately.  In its treatment, there are still some difficulties due to acute massive hemorrhage.  The clinical experiences are presented by the author.  The Pringle technique, hepatorrhaphy, resectional debridement hepatotomy, hepatic artery selected libation and double catheter drainage have been employed.  Postoperative treatment of re-hepatorrhagia, bile leakage or infection is emphatically recommended in emergency cases.

Key Words:
1. Traumatic Hepatorrnexis
2. Resectional Debridement Hepatotomy
3. Double catheter Drinage

May 11, 1990

As technological advancements in production and transportation continue to rise, so too does the incidence of hepatic trauma. These injuries often present as life-threatening conditions with a general mortality rate ranging from 20% to 25%. In a study conducted by McEarrall in 1962, 55% of 200 accidental deaths that occurred while walking were attributed to liver injuries. While modern medicine has made strides in reducing mortality rates through improved rescue technologies and blood transfusion methods, the liver's inherent fragility and thin capsule continue to pose challenges. Complications such as bile leakage and infection can arise in addition to hemorrhaging. The liver's unique anatomy, particularly the complexity surrounding the second porta hepatis, further complicates emergency surgical interventions. Given that the liver is not a paired organ, only partial excision is possible, adding another layer of complexity to its treatment. Despite the high risks associated with hepatic injuries, there remains a lack of uniform treatment standards. This paper reviews 35 clinical cases encountered over the past three decades, alongside a comprehensive literature review, to discuss various aspects of this challenging issue.

Non-Surgical Management of Superficial Hepatic Injuries

Clinical Experience

In our clinical practice, we have encountered three cases of superficial hepatic injuries. Upon surgical exploration, the lacerations were found to be superficial, and active bleeding had ceased. Consequently, suturing was deemed unnecessary; instead, the abdominal cavity was either cleaned or drained. All patients exhibited a stable postoperative course and made full recoveries.

Literature Review and Case Study

Superficial liver injuries that neither affect circulatory dynamics nor present with peritonitis or other complications can often be managed conservatively. Such injuries frequently self-terminate bleeding during the surgical intervention. Minor amounts of hemoptysis and bile leakage in the abdominal cavity are typically reabsorbed spontaneously.

Oldham's study reported 53 pediatric liver trauma cases, with 49 being managed conservatively. One illustrative case involved an 8-year-old boy who fell from a height of one meter. He experienced localized pain in his right hypochondriac region and mild discomfort in the lower right abdomen. Despite these symptoms, he displayed no muscle guarding, maintained normal blood pressure, and had a hemoglobin level of 120 g/L. A diagnostic aspiration of 2 ml of yellow, non-coagulated fluid from his abdomen confirmed liver injury. Hospitalized for three days without significant changes, he was discharged and observed for one month without complications. While the exact grade of liver injury was not surgically confirmed, it was presumed to be mild, and the patient exhibited a natural recovery.

Complications and Lessons Learned from Surgical Repair of Hepatic Injuries

Clinical Experience

During liver repair, the common practice of using mattress sutures may offer temporary hemostasis and wound closure. However, this technique often leads to complications such as necrotic infection and secondary hemorrhage. These adverse outcomes are primarily due to inadequate drainage, wound bed inactivation, autolysis of liver tissue, and bile accumulation.

Case Study

A 13-year-old male fell off the back of a cow, sustaining a transverse rupture in the center of his right liver upon impact with a cliffside. The surgical intervention employed mattress sutures for hemostasis and closed the liver wound, neglecting to perform common bile duct decompression and drainage. Although the patient initially recovered well postoperatively and was discharged after 14 days, he later developed hemobilia, recurrent right upper abdominal colic, hypotension, and anemia. Multiple rounds of blood transfusion and anti-infection measures proved ineffective over a week of conservative treatment. Subsequent surgery involved ligation of the hepatic artery and common bile duct drainage, leading to full recovery. A 10-year follow-up showed favorable growth and no residual sequelae.

Lessons and Recommendations

The key takeaway from this case is the critical need for debridement hepatectomy during the initial operation. This procedure removes necrotic liver tissue, followed by individual vessel ligations. Open drainage techniques, such as double-cannula negative pressure drainage, should be utilized. Alternatively, pedicled omentum can be loosely packed and affixed to the wound, in conjunction with common bile duct decompression and drainage. Implementing these measures can prevent the complications described above. Stone's research corroborates this approach, demonstrating successful hemostasis in 37 cases through the use of pedicled omentum packing in liver injuries.

Management of Large Vessel Injuries in the Second Porta Hepatis Region

Clinical Considerations

For injuries involving large vessels in the second porta hepatis area, it is crucial to provide ample exposure for manual pressure or non-injurious vascular clamping to temporarily halt bleeding. In situ repair of ruptured vessels can also yield successful outcomes. However, the use of Schrock catheter shunts is not universally applicable.

Case Study

A 42-year-old male, employed as a car driver, sustained injuries to the right retrohepatic bare area and a laceration of the inferior vena cava due to a vehicle rollover. A right thoracoabdominal incision was made to mobilize the liver. During wound exploration, profuse bleeding was encountered and temporarily controlled through emergency hand compression. Upon clearing the surgical field, a 0.5 cm tear in the inferior vena cava was discovered. Hemostasis was achieved through vessel repair using Satinsky forceps and continuous everting sutures with fine threads. Subsequently, liver laceration debridement and suturing were performed, leading to a successful outcome.

Clinical Implications

In cases like this, flipping the liver to expose the wound for hemostasis could exacerbate the tearing of already damaged vessels, thereby intensifying bleeding. Rapid blood transfusion would be futile in such situations and could precipitate intraoperative mortality.

Manual Techniques for Hemostasis in Liver Surgery

Practical Approaches

During surgeries involving the left outer lobe of the liver or its surrounding areas, manual pressure or hand kneading can effectively control intraoperative bleeding. Additionally, irregular resections can be safely and conveniently performed.

Abdominal Hematocrit and Transfusion as an Emergency Measure in Liver Rupture

Criteria and Rationale

In the absence of concomitant hollow organ injuries, abdominal hematocrit and transfusion can serve as a feasible and effective emergency measure for managing liver ruptures. This approach is particularly beneficial when immediate external blood sources are unavailable.

Multifaceted Concerns in Liver Injury Management

Beyond Hemorrhage

Liver injuries pose challenges that extend beyond bleeding issues. Given the liver's intricate bile duct system, bile overflow can exacerbate peritonitis through chemical irritation. Furthermore, the liver's portal venous system, which collects blood from the digestive tract, presents a heightened risk for anaerobic infections.

Importance of Intraoperative Measures

Intraoperative drainage and perioperative prophylaxis against anaerobic infections are critical components in minimizing intra-abdominal infections. Earlier, we underestimated and inadequately managed these aspects, leading to secondary infections—a lesson that has since guided our approach.

Discussion

Ease of Diagnosis in Typical Cases

Diagnosing liver injuries is generally straightforward. For closed injuries, the presence of trauma to the right hypochondriac region, or an associated fracture of the right lower rib, coupled with right upper abdominal pain and internal bleeding, usually confirms the diagnosis through positive abdominal puncture tests.

Challenges in Less Obvious Cases

However, diagnostic difficulties arise when intra-abdominal hematoma is less than 200 ml, as abdominal puncture tests often return negative results. Moreover, such low volumes of intra-abdominal bleeding do not typically affect hemodynamics, complicating the diagnosis further. In these instances, abdominal lavage or repeated peritoneal punctures can yield positive results, thereby proving decisive for diagnosis.

Diagnostic Tools and Their Limitations

While visceral angiography and isotope-based liver scans using Selenium-76 and Isotope-198 offer valuable insights, they are not universally applicable. Non-invasive ultrasound and dynamic CT observations are beneficial alternatives. However, the dynamic observation of the hemogram proves to be of the utmost importance in these cases.

(1) Management of Hemorrhagic Shock

In the event of hemorrhagic shock, immediate measures should be taken to establish effective venous access, preferably in the upper limb. Additionally, a central venous pressure catheter should be inserted to ensure accurate monitoring and rapid volume expansion of the effective circulating blood volume. Concurrently, blood supplies should be actively prepared.

If the shock state persists and hemoglobin levels continue to decline, intraperitoneal liver blood transfusion may be performed under stringent conditions. This approach is particularly crucial in cases of massive acute hemorrhage, with increasing numbers of successful interventions reported in recent literature [4, 5].

When surgical intervention becomes necessary, it should be executed promptly alongside blood transfusion and preparation. This strategy aims to maximize the rescue opportunities for patients experiencing hemorrhage at rates exceeding the speed of blood transfusion.

(2) Mortality Rates and Surgical Approaches

(2) Research by Jaejackdavis indicates a 29% mortality rate for liver injuries treated with surgical resection. This rate can surge to 50% when conventional hepatectomies are performed. Consequently, debridement hepatectomies are the preferred surgical approach for liver contusions and lacerations to minimize further trauma.

Best Practices for Liver Surgery

During hepatic suture cutting, it is crucial to ensure adequate blood supply and bile drainage for the preserved liver segments. Failing to do so increases the risk of complications such as necrotic infections and bile leakage. Therefore, the guiding principles for liver trauma surgery include comprehensive debridement, effective hemostasis, prevention of bile leakage, and unobstructed drainage.

(3) Hepatic Artery Ligation: A Risk-Benefit Analysis

In severe liver injuries that are not amenable to hepatectomy or complications involving intra-hepatic vascular and biliary fistulas, selective hepatic artery ligation can offer a reliable hemostatic solution. The rationale behind this is that the portal vein provides 75% of the liver's blood supply and 50% of its oxygen. After ligation of a high-pressure hepatic artery, blood flow from the portal vein is enhanced. Collateral circulation can be established within 10 hours, typically eliminating the risk of liver necrosis. According to the Walt system, this approach can be effective in up to 31% of cases [6].

Postoperative Considerations

Post-ligation, transient spikes in serum markers like lactate dehydrogenase, transaminase, cholelithiasis, and alkaline phosphatase have been observed, but these levels normalize within 7–14 days. However, careful postoperative management is essential, including blood volume and oxygen supplementation, infection prevention, and dietary restrictions to mitigate the liver’s metabolic load. This technique should be used cautiously in patients with liver cirrhosis and liver diseases.

Operational Guidelines

During the procedure, excessive dissection in the porta hepatis region should be avoided to facilitate collateral circulation. Also, the ligation should be as close to the lesion as possible for targeted efficacy, avoiding the ligation of the liver's intrinsic arteries which could compromise the entire liver's blood supply.

(4) The Role of Common Bile Duct Decompression and Drainage

Aside from treating superficial injuries, common bile duct decompression and drainage should be considered a standard adjunctive procedure for managing this condition. This method facilitates bile drainage, mitigates intrahepatic cholestasis and bile leakage, and aids in infection control.

Monitoring and Diagnostic Benefits

The procedure serves as an essential monitoring tool for assessing postoperative liver function recovery and hemobilia (biliary tract bleeding). During the operation, methylene blue can be introduced to inspect for potential leaks in the intrahepatic bile ducts. Postoperatively, this technique can also be employed for angiographic studies.

(5) Hepatic Blood Transfusion in the Context of Massive Blood Loss

The liver has a rich blood supply, making severe injuries prone to extensive bleeding. The complications arising from massive blood transfusions cannot be overlooked. For instance, when transfusion volumes reach up to 4000ml, coagulation mechanisms can be disrupted, leading to uncontrolled bleeding.

Clinical Relevance

To mitigate this, hepatic blood transfusion becomes critically important. Ye [5] reported successful rescue in a case involving the transfusion of 6000ml of hepatic blood.

Theoretical Foundation

The theoretical underpinning is that the liver processes 1500ml of blood per minute and less than 1ml of bile. About 91% of bile is made up of water and inorganic salts, and the rest are trace amounts of substances like cholesterol and cholic acid. Therefore, mixing this with hepatic blood for transfusion poses no harm.

Practical Applications

Animal studies have confirmed the non-toxic nature of bile. Both anaerobic and regular cultures of liver blood from the portal vein have shown negative results, confirming its safety for transfusion.

Implementation Guidelines

For implementation, an abdominal puncture can be performed preoperatively to draw blood. A sterile suction device is then used for filtering and transfusion. If fresh blood is collected instead of pooled blood, anticoagulant measures are necessary. Otherwise, anticoagulants can be omitted, simplifying the process.

(6) Prevention of Postoperative Complications

(6) Loose suturing of the liver trauma is beneficial for drainage. The procedure should ensure that all areas around the liver, particularly the porta hepatis, are adequately drained.

Practical Recommendations

• Drainage Systems: The use of double sets of silicon tube negative pressure suction systems is preferred in the porta hepatis region. This is to prevent complications like infections and bile leakage.

• Pharmacological Measures: Antibiotics should be administered to minimize the risk of postoperative infections.

• Blood Volume: Replenishing blood volume is essential for stabilizing the patient’s condition.

• Liver Protection: Additional measures should be taken to protect the liver post-surgery.

• Oxygen Supply: Oxygen should be administered as part of the postoperative care to ensure optimal recovery.

(7) Treatment of Combined Injuries

(7) When dealing with patients who have sustained multiple injuries, prioritization is key. Special attention must be paid to cerebral and thoracic trauma, as these can be life-threatening.

Practical Recommendations

• Prioritization: Determine the most urgent injuries that need immediate treatment. Usually, head injuries and thoracic injuries take precedence due to their potential severity.

• Simultaneous Treatment: Whenever possible, manage cerebral and thoracic traumas concurrently to maximize the chances of a successful outcome.

• Exploration Post-Laparotomy: After opening the abdominal cavity, careful exploration of other internal organs is crucial. This is to identify and treat any other possible injuries and to prevent any complications like leakage.

• Holistic Approach: By addressing all injuries in a coordinated manner, the success rate of the treatment is likely to improve.

(8) Conservative Treatment of Liver Trauma

The data presented by old ham [1] from Mott Children's Hospital in the U.S. shows that a conservative approach to liver trauma can often be effective. Out of 188 cases of closed abdominal trauma, 53 involved liver injuries. Only four required emergency surgery due to acute hemorrhage. The rest were managed non-operatively, with only three later requiring delayed surgical intervention due to complications from biliary peritonitis. This results in a relatively low surgical intervention rate of 13.2% (7/53).

Key Points to Consider

• CT and Liver Enzyme Monitoring: Any conservative treatment must involve rigorous monitoring, including CT scans and liver enzyme tests (GOT, GPT).

• Hematocrit Levels: It's crucial to maintain hematocrit levels above 30% to ensure effective treatment.

• Medical Support: Excellent medical services and the availability of surgical intervention at any time are necessary.

• Risks: Such a conservative approach does carry risks, including post-transfusion hepatitis and the potential for acquired immunodeficiency syndrome (AIDS).

• Long-term Effects: The impact of abdominal blood on long-term adhesive intestinal obstruction remains inconclusive.

• Clinical Judgement: Based on clinical experience, liver trauma that does not cause hemodynamic changes can be managed conservatively with thorough monitoring and responsible clinical observation.

References

[1] Oidham KT et al. "Blunt liver injure in childhood: Evolution of therapy and current perspective." J Current Surg. 1988;45(1):41

[2] Stone HH et al. "Use of pedicle omentum as an autogenous pack for control of hemorrhage in major injuries of the liver." S.G.O. 1975;141:92

[3] Li, Mingjie. "Left Lateral Hepatectomy for Intrahepatic Gallstones" 国内医学外科分册 1980; 161; 皖南医学 1980;13:51

[4] Lu, Xianding. "Report of 4 Cases of Intra-abdominal Hematocrit and Transfusion Due to Traumatic Liver Rupture" 中华外科杂志 1980; 18(3):211

[5] Ye, Shengdan. "A Case Report of Massive Liver Blood Transfusion for Traumatic Liver Rupture" 实用外科杂志 1986: 6(3):425

[6] Walt HJ. "Discussion of hepatic artery ligation." Surg 1979; 86:536

Contributors

Wuhu Changhang Hospital

• • Li, Mingjie
  • Wang, Yueqin

This article was originally published in "交通医学 (Transportation Medicine)" 1996; 10(1): 60-62. (A paper presented at the Transportation Ministry's 1990 Surgical Academic Symposium).

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】

Surgical paper II

PEUTZ syndrome

A 14-Year Case Study of Three Surgical Interventions Due to Complications

Surgical paper I

Regular resection of left lateral lobe of liver for intrahepatic calculi

Introduction

Intrahepatic calculi, otherwise known as stones within the bile ducts situated above the left and right hepatic ducts, are an often underdiagnosed but significant clinical entity. Over the past five years, our hospital has recorded 368 cases of primary bile duct stones, which constitute 83.4% of the 441 cases of cholelithiasis surgeries performed during the same time frame. Of these, 112 cases were identified as intrahepatic stones, accounting for 30.4% of primary bile duct stone cases. These statistics align closely with domestic literature on the subject [4, 5]. However, it should be noted that the actual incidence is likely higher, given the limitations in diagnostic capabilities. The distribution of intrahepatic stones within the liver is further detailed in Table 1.

Table 1        Distribution of 112 Cases of Intrahepatic Stones

Intrahepatic calculi present a unique challenge in diagnosis and treatment, often leading to misdiagnosis and unsuccessful interventions. Until recently, the condition has been marked by a cycle of recurrent episodes, multiple surgeries, and repeated failures in treatment.

In a concerted effort to enhance the treatment outcomes for intrahepatic calculi, our hospital initiated a new surgical approach. Between 1975 and 1976, we performed resections of the left lateral lobe of the liver in five patients. Following a period of 3 to 4 years of postoperative surveillance, the long-term therapeutic outcomes have been promising. This innovative approach has not only yielded good long-term curative effects but also provided valuable insights that have significantly improved our treatment protocols for intrahepatic calculi.

Clinical Data

The study sample comprised a total of five patients: two males and three females, ranging in age from 21 to 40 years. Among them, two patients presented with residual stones. Intraoperatively, all cases were complicated by choledocholithiasis—stones in the common bile duct. The primary location for the intrahepatic calculi was identified as the left lateral lobe of the liver, where varying degrees of fibrous atrophy were also noted.

Surgical Procedure

All surgeries were performed under general anesthesia with abdominal incisions. Resection of the left lateral lobe was the principal surgical intervention. A "T"-shaped tube was employed for external drainage of the common bile duct, or additional intrahepatic calculi were extracted using a "joining forces" technique.

Postoperative Outcomes

Two cases experienced complications, specifically delayed hemorrhage and abdominal infection. The hospitalization duration for these patients varied between 14 and 72 days. However, all patients recovered fully and were discharged. Postoperative recurrence of choledocholithiasis was noted in two cases, necessitating further surgical intervention supplemented by a choledocho-duodenal lateral anastomosis. Subsequent examinations revealed no presence of intrahepatic bile duct stones.

Long-term Follow-up

All patients were followed for a period of 3 to 4 years postoperatively and showed no signs of recurrence. Overall health status was reported as good. (For a detailed summary of the original medical records, please refer to Table 2). 

Diagnosis of Intrahepatic Calculi

The majority of surgeries for intrahepatic stones are performed to address biliary obstruction. Among the 112 cases in this group, 95 were complicated by common bile duct stones (84.9%). Previously, the removal of extrahepatic stones and restoration of biliary tract patency were considered sufficient for a "cure," supplemented by general treatment. However, this approach failed to account for potential adverse reactions arising from persistent intrahepatic infections. This oversight often resulted in repeated episodes and surgeries.

Diagnostic Methods

1. Intraoperative Indicators: If the common bile duct is expanded by pigment stones or filled with sediment and the gallbladder is clear of stones, this suggests hepatogenic stones, warranting further examination of intrahepatic lesions.

2. Visual and Tactile Examination: The liver's surface may exhibit localized hardness, paleness, and dome-shaped prominence, along with localized atrophy. In contrast, healthy liver tissue may show compensatory hypertrophy.

3. Liver Abscesses: Multiple bile duct-derived liver abscesses often indicate intrahepatic calculi.

4. Angiographic Evidence: "T" angiography may reveal negative shadows, such as a bean-and-pod pattern, suggesting intrahepatic stones.

5. Postoperative "T" Tube Drainage: The presence of sediment-like stone deposition in the drainage bottle indicates a reduction in postoperative intrahepatic stones.

The Role of Left Extrahepatic Lobectomy in Treatment

1. Minimal Surgical Trauma: This procedure inflicts moderate damage on liver function and minor disturbance on the body overall. When executed correctly, it solves most treatment challenges related to intrahepatic stones, ensuring short-term recovery and long-term satisfaction.

2. Complete Elimination: It eradicates lesions and prevents ongoing infections and stone reformation due to poor drainage and bile retention.

3. Alternate Exploration: The surgery allows for the exploration and removal of stones from other hepatic lobes, offering a different vantage point for tackling intrahepatic lesions.

4. Convenience: Compared to intrahepatic cholangiojejunostomy, left lateral lobe hepatectomy is technically easier to perform.

However, it's crucial to note that simpler surgical interventions are more suitable for patients with toxic shock, severe systemic infections, or extremely compromised liver function. Relief of obstruction is better achieved with "T" external drainage.

Surgical Indications

The following cases are considered appropriate candidates for the surgical resection of the left lateral lobe of the liver for treating intrahepatic calculi:

1. Multiple Intrahepatic Stones in the Left Lateral Lobe: Particularly when accompanied by fibrous atrophy, and when other hepatic lobes either have no stones or have stones that can be completely removed by other methods.

2. Calculus in the Outer Lobe with Poor Drainage: Cases where the outer lobe has calculus, along with bile duct stenosis and poor drainage, making it likely that stone regeneration will occur if only the liver parenchyma is cut open for stone removal.

3. Inaccessible Calculus at the Junction: Cases where there is calculus at the junction of the left inner lobe hepatic duct that cannot be removed through other means.

4. Left Lateral Lobe Calculus with Abscess: Cases where an abscess is present along with the calculus in the left lateral lobe.

5. Necessity for Roux-Y Longmire Surgery: Cases where the extrahepatic bile duct cannot be located due to inflammation or adhesion, or is too narrow to be shaped, thereby necessitating a Roux-Y Longmire procedure (anastomosis between the intrahepatic bile duct and jejunum) for drainage.

   Implementation Technique of Regular Left Lateral Lobectomy

   Preoperative Preparations

   • Anesthesia: Continuous epidural anesthesia is recommended.
   • Positioning: Patients should lie on their back with their right side elevated.
   • Incision: A right rectus abdominis longitudinal incision is advised. The xiphoid process is sufficient, and if necessary, the seventh costal arch can also be cut off and exposed through extrapleural enlargement.

   Hemostatic Techniques

   1. Local Blocking Method: After freeing the left lateral lobe, an assistant holds it or presses it against the costal arch, and the surgeon performs resection with minimal blood loss. This was the method used in all 5 cases.
   2. Hepatic Portal Block Method: The hepatoduodenal ligament is freed, and the hepatic artery and portal vein are blocked for 15 minutes, then relaxed for 5 minutes. This can be done safely and repeatedly.
   3. Other Techniques: Liver forceps, rubber bands, and the mattress suture method were not used.

   Surgical Procedures

   1. Ligament Resection: Cut several ligaments like the ligamentum cirrhosae, falciform ligament, left triangular ligament, left coronary ligament, and hepatogastric ligament.
   2. Vein Ligation: Place a needle 1 cm to the left of the second hepatic portal and ligate the left hepatic vein. Be careful not to damage the middle hepatic vein.
   3. Liver Capsule and Parenchyma: Cut the liver capsule 1 cm along the left side of the suspensory ligament and sever the liver parenchyma with a knife handle. The cut should be flat, not in a "V" shape, to avoid damaging the left inner vein.
   4. Vessel Ligation: Each vessel should be ligated individually.
   5. Stone Removal: The hepatic duct and common bile duct are jointly opened to remove the stones, followed by internal and external suturing or drainage.
   6. Final Steps: The mattress suture is limited to not crossing the suspensory ligament. Turn over the suspensory ligament to cover the liver section and fix it. Use subhepatic siphon drainage or negative pressure drainage.

Discussion

Stone Distribution and Diagnosis

The distribution of intrahepatic stones is not random but follows patterns influenced by anatomical and dynamic factors, particularly favoring the left lobe. Direct imaging techniques are ideal but may not always be practical, making clinical judgment during surgery crucial.

Left Lobe Calculus

Calculus in the left lobe often undergoes significant fibrous atrophy, losing much of its function. However, the anatomical boundary of this lobe is well-defined, facilitating a safer and more convenient hepatectomy.

Treatment Efficacy

Left lateral hepatectomy is effective in treating most hepatolithiasis issues. Chinese reports show a success rate of around 90%. There were recurrence cases, but these were not related to the liver, suggesting that more comprehensive internal drainage strategies might prevent such outcomes.

Treatment Goals

The key to treating intrahepatic calculi is to remove the focus, ensure drainage, and prevent new stone formation. Surgery alone may not be sufficient, and a multi-pronged approach involving other treatments may be needed to prevent recurrence.

Infections

Hepatolithiasis often comes with serious infections, which can lead to abdominal infections. Aseptic techniques should be strengthened to mitigate this risk. The use of intraoperative bile duct irrigation should be carefully considered as it can spread infections.

Blood Transfusion

The necessity of blood transfusion is not emphasized; for generally healthy patients, it can often be avoided.

Etiology

The high frequency of intrahepatic stones, particularly bile pigment sediment-like stones, is not yet fully understood. However, it appears to be linked to biliary ascariasis and subsequent infections by Gram-negative bacteria. These factors contribute to the formation of stones with various cores, like parasite cadavers, making it an important subject for preventive medicine.

Summary

The paper summarizes the treatment and follow-up of 5 patients who underwent left lateral lobectomy to address intrahepatic stones. It delves into the surgical indications, the benefits of this particular surgical approach, the techniques employed, and the precautions that should be taken. One of the key takeaways is the recommendation to combine left lateral lobectomy with other methods like "reunion" for stone removal or incisions in the liver parenchyma. Coupled with the establishment of "valveless" internal drainage, this multifaceted approach aims to eliminate infection and prevent the recurrence of stones. The paper concludes that this strategy offers a viable treatment alternative for the complex issue of intrahepatic stones.

References  

1. Qian, Wenzhi.  Preliminary experience in treating hepatolithiasis by intrahepatic cholangiojejunostomy. Chinese Journal of Surgery 18221- 1965
2. Meng, Xianmin. Hepatectomy. Shanghai Science and Technology Press, Shanghai 1965
3. Han, Yongjian. Liver Surgical Anatomy.  Shanghai Science and Technology Press, Shanghai 1963
4. Huang, Zhiqiang. Hepatolithiasis and its treatment. Chinese Journal of Surgery. 91716-1961
5. Ran, Ruitu. Surgical treatment of intrahepatic bile duct stones. Chinese Journal of Surgery, 9:216-1961
6. Zhou, Hongquan.  Discussion on etiology and treatment of hepatolithiasis. Chinese Journal of Surgery 50(8):501-1964

Li Mingjie, Department of Surgery, Nanling County Hospital

This article was published in Journal of Wannan Medical College, Wannan Medicine, 1980, 13:51  and Domestic Medicine Surgery Volume (Part 1), 1981, 39

from 肝左外叶规则性切除治疗肝内结石

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】

In support of application for Deputy Chief Surgeon, 1987

Editor’s Comment: This piece of writing submitted by my father 35 years ago is a review of the achievements and hard work in his first 30 years of medical practice. This stellar and unique report card explains how a doctor in a grass-roots hospital has been tempered into a powerful ‘iron man’, becoming an all-skill expert practicing almost all major medicine areas, extremely rare in a modern society.  In helping compile the collection of his own medical papers and in reviewing the 66-year journey, my father feels extremely grateful and proud. Dad said, his growth depends largely on “one book and two mentors”. This book refers to Maingot's Abdominal Surgery, which is a biblical surgical masterpiece. Dad said: At that time, the price of this book was 10 yuan, which was 25% of my monthly salary. It was a treasure of all my belongings! 

One of the two tutors was Dr. Meixian Min, the surgical authority in Wuhu superior hospital, whose theory, technology, character and demeanor were praised by everyone!  The other is Dr. Jingbin Xu, an authoritative professor of orthopaedics in China. My father studied orthopaedics with him at the 127 Hospital of the People's Liberation Army and became his accomplished disciple. About Dr. Min, Dad recalled two episodes he has cherished most.  Dad said: 

Once, he had me preside over an extremely challenging operation. When I came to the operation table ready for the surgery, he said, "Maybe you can't get off the table successfully. Everything off the table  is mine!"  It means all the aftermath, I do not need to worry about, and he will take care of everything. Who can match this spirit of responsibility! Another thing he said is also very memorable.  Before I moved to Wuhu, I came to see him, he said, "Knowing your recent situation, I suggest that you come to join me, in department of either surgery or orthopedics, better in surgery as it has a wider range and would benefit your further development. As long as your current employerNanling agrees to let you leave, I’ll take care of all logistics on the accepting side, including the health bureau, personnel bureau and hospital authority. Ours will be the Second Affiliated Hospital of Anhui Medical University, the provincial level hospital, which should be beneficial to your future promotion! "  He was very sincere and his favor was out of pure treasuring for talents. Apart from the career relationship as my mentor, there was not much personal relationship between us. Along the journey of practicing surgery, I always turned to him for advice once I came across challengies, and he acted always as my direct supervisor. It was also his key evaluation that helped my smooth promotion to the title Attending Physician.  He was the chief examiner in the promotion committee, and he evaluation was decisive. At that time, he said to me: “you can apply for either surgery or orthopedics for this promotion”.  The implication was that I was qualified for both subjects. That was 1981, not long after the Cultural Revolution. The entire Nanling had only seven people promoted to Attending Physicians, that is, less than half of the applicants made it.  Your mother and I both succeeded in the promotion list, which caused a stir effect in our community. At that time, professional titles were highly respected in the society. With the title of attending physician, one can enjoy all kinds of preferential treatments.

Mingjie Li, a full-time worker, graduated from the medical class of Wuhu Medical School in 1955.  In March 1956, he joined Nanling County Hospital. In 1960, he was sent to study radiology in Wuhu District Hospital for one year, and then returned to the hospital to establish the radiology department.  Since 1961, he has been mainly engaged in clinical surgery (during which he had worked concurrently in radiology for two years).  Since 1968, he has been the principal surgeon of major surgery in the hospital.

In 1973, he took part in an advanced training course in orthopaedics, and studied orthopaedics for more than one year under the guidance of Professor Jingbin Xu, an expert in orthopaedics at the 127 Hospital of the People's Liberation Army and editor of the Chinese Journal of Orthopaedics.  He obtained a certificate for the completion of the course.  Meanwhile, he was selected by the Foreign Affairs Bureau of the province as preparatory personnel for the foreign aid medical team waiting to be sent abroad.  On December 1, 1981, he was promoted to the title of Attending Surgeon. At that time, he served as Director of Nanling Branch of Medical Society.  In August, 1985, he was transferred to Wuhu Changhang Hospital, where he worked as an attending surgeon and orthopedic surgeon.

Since the medical association resumed its activities after the Cultural Revolution, I have participated in, and submitted papers to, the first, second and third annual conferences of orthopaedics and the first and second annual conferences of surgery in Anhui Province.  My papers were printed in the conference proceedings for research exchange.  I have also submitted papers to the first academic conference of obstetrics and gynecology in Anhui Province.  I have been involved in a variety of academic activities at the prefecture, city and county levels.  I have served as a lecturer in the county health school, teaching courses in anatomy, physiology, surgery and orthopedics.  I have been supervizing numerous medical college interns for many years.  I have been studying professional English for more than 10 years.  In 1980, I took part in the correspondence course of "Clinical English Learning" administered by Jiangsu Health Department for one year. Upon graduation, I won the first prize for the National Translation Competition.  I have translated a number of professional papers.  I can read and translate English books and journals, and write English abstracts for my own papers.  I have published numerous papers in medical journals at all levels, and in 1980 I was awarded the title of advanced scientific and technological worker in our county.

In the past two years since I joined Changhang Hospital, according to the limited cases encountered in our hospital, I have performed subtotal thyroidectomy, superficial parotidectomy, radical gastrectomy for gastric cancer, rectal cancer and breast cancer, and numerous cases of gallbladder, biliary tract and intestinal operations.  In addition, I have treated cases with spinal canal decompression, spinal cord exploration, myelography (Amipaque), closed penetration of triangular nail under fluorescence of femoral neck fracture and other osteopathy operations in orthopedics.  All these cases have achieved good results.

Earlier in my career, I served in Nanling County Hospital surgical department for nearly 30 years as a front line   physician of clinical practice. As a principle, all kinds of cases should be solved on the spot. Therefore, my practice covered a wide range, including orthopedics, urology, thoracic surgery, obstetrics and gynecology, ophthalmology and otorhinolaryngology, which are described below.

General surgery:

Surgeries performed include epatectomy, liver repair, ligation of proper hepatic artery, and a large number of biliary surgery and various biliary and intestinal drainage,

Additionally, a comprehensive array of biliary surgeries and assorted drainage techniques for both the biliary system and the intestine have been performed. These techniques include sphincterotomy and plasty of Oddi's sphincter, as well as various forms of anastomosis involving the common bile duct and duodenum. Procedures such as Roux-en-Y jejunostomy and multiple subsequent operations for recurrent hepatolithiasis are also among the interventions undertaken

such as Oddi's sphincterotomy and plasty (括约肌切开、成形术), side-to-side and end-to-end anastomosis of common bile and duodenum and its low hole anastomosis, Roux-y jejunostomy, second, third and fourth operations for recurrent hepatolithiasis. Incision and stone removal of liver parenchyma, intrahepatic bile duct stricture plasty, intrahepatic bile duct bypass, a large number of cases for gastrointestinal surgery, radical gastrectomy for gastric cancer (R1R2), total gastrectomy, radical resection for rectal cancer (Miles Bacon Dixon operation), intestinal obstruction, colon cancer, hernia, hemorrhoids, appendix, etc. A case of Hirschsprung's disease, congenital omphalocele and Pcutz-Jegher Syndrome underwent three operations in 14 years, including hyperthyroidism surgery, radical mastectomy (including super radical mastectomy), splenectomy (including giant brand 含巨牌), splenorenal vein anastomosis, portal azygos disconnection, internal drainage of pancreatic cyst, focus clearance and drainage of abdominal adenitis, PTC and retroperitoneal oxygenation.

Extrathoracic:

Resection of carcinoma in the middle and lower esophagus (including supraarch anastomosis and thoracic roof anastomosis), lung repair, pneumonectomy, septal hernia repair, and closed thoracic drainage.

Urological surgery:

Surgical procedures on the kidney such as removal of the kidney, stripping of lymphatic vessels in the kidney, removal of stones from the kidney through an incision in the renal parenchyma, removal of tumors in the kidney, removal of stones in the ureter and bladder, realignment of the urethra in case of trauma, vasectomy, transplantation of the ureter, removal of one or both testicles, treatment of cancer on the penis, and repair of a congenital defect of the urethra called hypospadias.///Nephrectomy, renal lymphatic stripping, pyelolithotomy, renal parenchyma incision to remove stones (肾实质切开取石), renal embryonic tumor resection, removal of ureteral and vesical urethral calculi, urethral trauma realignment, vasectomy and anastomosis, ureter transplantation, orchiectomy, penis cancer radical cure, hypospadias repair.

Obstetrics and gynecology:

All operations involved, including Cesarean section (classical, lower segment, extraperitoneal surgery), total hysterectomy (abdominal, vaginal), tubal ligation (abdominal, vaginal), vaginal wall repair, uterine isthmus incision to obtain the fetus, induction of labor, fetal debris, ovarian tumor resection, vesicovaginal fistula repair, cervical cancer pelvic cleaning.

Orthopedics:

Manipulation and surgical treatment of limbs’ bone, joint and spinal trauma, including reduction steel plate internal fixation and bone grafting for spinal fracture and dislocation, internal fixation (opening and closing) of femoral neck fracture with three-wing nails, and lesion removal of bone and joint tuberculosis, including surgery for tuberculosis of neck, chest, waist, sacral vertebra, hip, knee, ankle, shoulder, elbow and wrist joint, one-time operation for thoracic vertebra tuberculosis through pre-thoracic approach,  with lesion clearance, spinal canal decompression and anterior bone grafting, spinal cord tumor extraction, lumbar intervertebral disc extraction, myelography (iodine oil and iodine water), bone tumor (benign and malignant) surgery, meningocele repair and some orthopedic operations.

Ophthalmology and ophthalmology:

Tonsillectomy, radical correction of maxillary sinus, turbinectomy, nasal polypectomy, mastoid incision, cataract, artificial pupil, dacryocystectomy, nasolacrimal duct anastomosis, enucleation and strabismus correction, trichiasis, pterygoid excision and burial, etc.

Professional growth and innovation efforts

The original county hospital where I worked for nearly 30 years is a medical center with a population of 500,000 in the mountainous area of southern Anhui, and its surgery has an exclusive market. Although in the early 1960s, when I entered the early clinical stage of surgery, the conditions and my skill level were both very limited, I had to work hard to face all kinds of diseases related to surgery. There were many surgical opportunities and a wide range of operations. Environment trains people, pressure urges them to advance.  I managed to study hard and practice hard, and made rapid progress in practice.

The famous Maingot’s work "Abdominal Surgery" has benefited me a lot with intensive reading and digesting.  At that time, the incidences of intestinal obstruction were widespread, especially in the years of famine.  There were hundreds of such cases in a year, which laid the foundation for me to break through the basic theory of surgery and practice of lower abdominal surgery.  In 1964, I marched into the upper abdomen practice.  On the basis of dozens of stomach and gallbladder operations, I was appointed to lead a team for rural roving medical treatment in the countryside in 1965.  In 100 days, more than 600 operations of various scales were performed, including 121 laparotomy operations, in which 25 were upper abdomen operations, including stomach, gallbladder and uterus operations.  By this time, I had mastered the epidural anesthesia technique in advance, which created favorable conditions for these operations.  In the following year, I was sent to lead a team to set up two medical branches in Yijiang and Hewan successively, serving as business leader and continuing to carry out surgical operations.  In 1968, I was appointed as the head of the major surgery department of our county hospital, in charge of the treatment of all surgical patients. According to statistics, nearly 100 cases of gastric and biliary operations were performed in our hospital every year in that period.  Over the past decades, I have accumulated experience from both positive and negative aspects through a large number of operations, which also involves a process of continuous exploration and innovation.

In 1973, I participated in the restoration and reconstruction of Wuhu District Hospital after the early tubulance of Cultural Revolution.  While studying orthopedics, I also helped to perform numerous surgical operations, under the guidance of the director of surgery. Orthopedic specialty was also systematically studied and mastered.  I learned the most from Director Meixian Min and Professor Jingbin Xu, who were my two mentors in surgery and orthopedics.

Learn to swim in swimming

The recurrence and reoperation of cholelithiasis prompted me to be eager to update my examination methods and operation methods.  Inspired by the literature, I shifted my focus from simply dealing with extrahepatic bile duct problems to paying special attention to the discovery and examination of intrahepatic stones, hence a better understanding of intrahepatic bile duct stenosis.  Shortly after the 1980 Provincial Surgical Annual Meeting, I administered PTC, which dramatically improved the blindness in the past practice.  The operation methods also expanded to hepatectomy and liver incision for stone removal.  Combined with Finster operation plus Oddi sphincterotomy, Roux-en-y operation, posterior duodenal choledochoduodenectomy, hollow anastomosis of distal common bile duct and other internal drainage methods, the curative effect was greatly improved and the re-operation rate was reduced.

In our county, early local schistosomiasis portal hypertension was very common, our treatment ranged from early gastric circle and omentum to liver and kidney, to portal azygos disconnection, and finally to splenorenal venous shunt in 1976.  In order to prevent short bowel syndrome after a large number of bowel resection, I performed intestinal anastomosis with interposition of reverse peristalsis segments, resulting in good effect.

I had frequent on-call visits to the countryside to rescue liver and spleen injuries and ectopic pregnancy.  In order to solve the critical problem of blood source difficulty, my innovative and careful self-blood transfusion approach played a positive role.  For example, in 1969, I was sent 60 miles away to visit a 13-year-old child with rupture of the central liver, which needed to be repaired through the chest.  During the 4-5 hour interval while waiting for the ambulance’s return from the county hospital to bring the anesthesia machine, I practiced rein fusion of up to 1000 ml of abdominal liver blood repeatedly for the first time, and finally won the operation opportunity.  The postoperative recovery was fairly smooth, but 16 days later, the patient was complicated with massive hemobilia, treated with ligation of inherent hepatic artery, also for the first time.  Finally it was cured.  Having followed up to now, all is well with the case.

    Following the experience reported by provincial hospital in the First Annual Meeting of Obstetrics and Gynecology in 1980, I helped the Department of Obstetrics and Gynecology in our hospital to carry out the first 10 cases of extraperitoneal approach cesarean section and gained practical experience.  This became standard operation in our hospital.

After further study in the orthopedics trainee class, I changed the posterior approach of vertebral tuberculosis to the anterior approach for one operation, which greatly shortened the course of treatment, including one-time treatment through chest of thoracic tuberculosis complicated with paraplegia.  At the same time, interbody bone grafting was performed. In addition, lumbar tuberculosis was also treated with a trial operation to remove bilateral abscesses, together with bone grafting.  It was a success.  I also performed cervical tuberculosis surgery. This experience was reported at the first annual meeting of orthopaedics in our province.

Femoral neck fractures are common, complicated to handle and often ineffective. The original open triangular nail fixation led to   damage, easy to cause shock to the elderly, and often requiring blood transfusion.  After learning the experience from the Tianjin peers in 1979, I changed to closed nailing under fluorescence.  The patients had little burden, resulting in less pain, faster recovery and less cost. This experience was reported in the third provincial orthopaedic annual meeting.

I also advanced the spinal cord lipiodol angiography in the past to iodohydrography, which provided the basis for the diagnosis of intervertebral disc surgery, beneficial to the identification and monitoring.

In addition, I assisted the Ear, Nose, and Throat (ENT) department in performing a procedure called subchondral tamponade to help treat a condition called atrophic rhinitis by filling under the mucous membrane of the cartilage nose.  My report of this practice received rave reviews at the first annual meeting of the ENT in the province.

In summary, my professional growing process is primarily through improvement in massive practice and advance in technical pursuit. Long-term independent work facing all sorts of clinical practical cases, short of good conditions and nearby mentors, enables me to have developed the habit of independent thinking and turning to books and literature for help and insights.  Every time when a new operation is carried out, I feel it necessary to collect extensive information and review all relevant knowledge for contingency. This way, although the road has not been easy, the experience accumulated from practice proves to be fairly profound.

Mingle Li, Attending Surgeon, Wuhu Changhang Hospital, 19??

业务自传和工作报告

【李名杰从医66年论文专辑（英语电子版）】

Editor’s Comment: I have always felt that Dad is the modern Hua Tuo created by the times, which is basically unprecedented (except for Hua Tuo himself maybe) in terms of extensiveness in medical practice, the number of patients treated and the long service time.  Dad has been practicing medicine at the grass-roots hospital for more than 60 years (he is still on the job for half a day although he is in his eighties now).  In his long career, Dad has encountered various complicated situations. With his extraordinary intelligence, dedication and ingenuity, Dad demonstrated his expertise and professionalism to the fullest extent.  Dad has been both bold and cautious, knowing how to adapt to local conditions case by case, having saved countless lives with his comprehensive skills.  In a community where more than 300,000 people in the county had access to  only two or three surgeons, there was no clear division between surgery, gynecology, orthopedics and so on.   My dad made himself to be a general practitioner involving all major areas of clinic practice.  As my father said in his memoire, "My surgical life is the longest, with a large number of operations involving a wide range of surgical  areas (general surgery, orthopedics, urology, obstetrics and gynecology, nerves, facial features, chest, etc.)."  This is one piece of his more works written in 2011 covering his amazing undertakings in clinic visits beyond his hospital.  These stories can enlighten young doctors and encourage them to strike for their best. 

My surgical career has lasted for more than 50 years since the early 1960s.  Besides the three hospitals I have served as full time practitioners (Nanling County Hospital, Wuhu Changhang Hospital, and China Railway Bujiadian Hospital), I have been involved in dozens of external hospitals in "guest practice", including hospitals at all levels in Nanling and Wuhu, such as the Fourth Hospital, the Sixth Hospital, Xinwu Hospital, Matang Hospital, Jiangdong Hospital, Clinic at Smelter, etc.  My engagement also includes  on-call house visits, tour medical treatment in rural areas, various on-site surgeries and remote consultation as a visiting doctor.  This achievement is hardly heard of in terms of the number of number of operations and a wide range of subjects involved (general surgery, orthopedics, urology, obstetrics and gynecology, neurology, facial features, chest, etc.).  In fact, the number of operations performed beyond my own hospitals may well exceed the sum of the operations I have practiced in the three hospitals I have served. 

This situation of work overload continued until June, 2007, when my health entered an inflection point, with a red light on.  I was rushed to Wuhan Union Hospital for stomach cancer with massive bleeding, and had a total gastrectomy.   My gallbladder was also removed in the surgery  due to gallstones.  My postoperative recovery was reasonably smooth. Postoperative pathology: gastric Ca, poorly differentiated, involving deep muscle layer, all 18 lymph nodes around the stomach were negative, which can be described as "early stage". The operator said: no radiotherapy or chemotherapy is needed.  With this diagnosis, for the  sake of dealing with the cancer monster, it's a perfect ending, it's all over.  But my health was still hit severely with a long list of consequence.  I suddenly lost 15kg (from 70Kg to 55Kg). Although there were no common complications such as stenosis, reflux, dumping, indigestion, I felt sudden aging effects now that I have no bile and stomach.  Life entered the countdown, and energy and physical strength are much worse.  Physiologically, there is always something occurring of annoying discomfort or minor symptoms one after another.  Fortunately, I still can maintain the lowest level of normal "healthy" daily activity: I have been working in the first half of the day, and from time to time, I still manage to perform operations at the table for 3-4 hours non-stop.  From June to August last year, I made a trip to Silicon Valley, USA, where I visited my two sons and their families,  who both have a PhD background and serve the IT industry.  I endured the 14-hour flight journey fairly well.  So far, it has been more than 4 years since my operation, so I think I was lucky enough to have escaped the cancer.  However, what it left behind is a downhill path in life, and I know my future is limited.  So I need to cherish life more in the remaining time. 

After that incident, besides emergency call for surgery rescue several times, basically I stopped the out-of-hospital consultation practice, but the operations in my hospital have not stopped.  Nevertheless, surgery operations beyond my own hospitals accounts for more than half of my surgical career.  Here, looking back on the external visiting practice or on emergency calls to help rescue in the middle of other’s operations, there are some remarkable episodes worthy sharing.

It is said in the scientific and technological circles that scientific and technological talents should be encouraged to take more external posts or jobs, in order to fully tap the valuable human resources to serve the society.  But the current "practice" following the on-going policy is to stick to one post, in the fixed discipline for fixed jobs, with no felxibility allowed.  However, in today's market economy, it is not uncommon for experts to take advantage of the needs for undertaking multiple external jobs for extra financial benefits,  making visiting experts or guest doctors lose their original glory.  I have experienced the social transformation and different needs of various times in different periods over a much longer time.  In contrast, my guest practice was quite unique. 

During the 29 years (1956-1985) of working for Nanling County Hospital, the expert human resources of the society were extremely scarce, with very few doctors and even fewer surgeons serving a large population.  In fact, for many years there were only two or three surgeons who were counted on to meet the needs for solving the difficult surgery problems in a county with a population of more than 300,000 residents.  That is to say, all the surgical patients in this population basically need to be treated by these two or three people.  Prohibited by the economic and traffic restrictions at the time, there was very little possibility to outflow the patients elsewhere.  Furthermore, in addition to those who manage to come to the hospital, there are many of them who cannot make to the hospital in emergency.  It is inevitable to make numerous house visits, consultations and on-site operations.  Especially after 1968, as the head of our surgery department, I had to make more frequent house visits and all kinds of consultations for diagnosis. 

Here's a fun episode.  At that time, there was only one ambulance in our hospital, driving within 20 miles an hour at its best on those rural sandy roads. Many times, it was only me and our driver heading for an emergency house visit to the rural area.  Over time, although I didn't attend any driving class, I managed to have learned to drive, without a license (at that time, the traffic rules were lax and there were few vehicles on the country road anyway). Over the subsequent few decades, I drove at least 10,000 kilometers to make house calls, with a driving experience of more than 30 years, comparable to a full-time driver.  It is mainly my health and age following my last operation that makes me miss the emerging driving era as a legit licensed driver. 

That was the era of "serving the people", and there was never a personal benefit of house visiting and consultation for any out-of-hospital surgery. When we needed to invite experts from the superior hospital to come for consultation on difficult cases, it was the same.  Their coming to support was counted as a business trip then, only to reimburse their travel expenses.  They needed to leave 20 cents to cover the cost of the meal. In Mao’s era, no matter how famous a doctor is, there was no way of having any extra-salary income. 

1. Rural itinerant medical treatment 

During the last three months for 100 days in 1965, as captain leading a rural itinerant medical team of 5-7 people, I performed 612 operations, major or minor, in Yandun Commune, Nanling.  Among them, 121 people underwent laparotomy, including stomach, intestine, gallbladder, uterus, hernia, hemorrhoids, thyroid, kidney, ureter, bladder, orthopedics, ophthalmology and dentistry.  One afternoon, while there was availability of an anesthesiologist on site, I operated on three consecutive cases of vaginal hysterectomy plus pelvic floor repair and reconstruction.  The high rate of this disease, often third degree uterine prolapse (or pelvic floor hernia), was in fact incurred as side effects of sustained malnutrition from the notorious great famine in 1960 China.  This is unbelievable work efficiency, not to mention that everything was operated on a temporary "operating room" in a remote commune clinic.  That day, operations lasted non-stop until three o'clock in the morning, and more than ten other operations were also performed. 

There is a middle-aged woman who suffered from intestinal perforation of typhoid fever complicated with peritonitis (such infectious diseases were prevalent at that time, but very rare in recent years).  I treated her with intestinal resection.  She was penniless and there was no charge on her treatment.  Furthermore, after she was discharged from hospital, I rode my bike to pay her a house visit in her rural home in Qingyangmu town for the follow-up and condolences, with some donated gifts gathered from physicians ourselves. This was a trend in answering the call from Mao on serving the “poor and lower-middle peasants”.   It also reflects the original holy glory for medical practitioners as "angels in white". 

There was a case of incomplete abortion with massive bleeding, facing a crisis every minute.  I and a midwife rushed to her home at Sanxing Brigade to give an emergency uterus cleaning with rapid fluid replacement, which saved her life. 

Another case of vesicovaginal fistula was repaired by my operation, and discharged with recovery after 12 days.  This success initiated this kind of operations.

2.   First aid visits

Here are a few cases of first aid visits to share. 

That was 1968.  A 13-year-old boy from a remote mountainous village Yashan fell from the back of a cow, and his right liver ruptured, causing massive abdominal bleeding.  I rushed in our ambulance to the Hewan health center where I had to open his chest to complete the operation.  There was a need for blood transfusion.  I had to send the ambulance back to the county town (at that time, this was the one ambulance we had) to fetch the anesthesia machine and a blood donor.  This mountain road was in a very poor condition, about 30 miles away, and it happened to be foggy day in the mountainous area.  It ended up taking more than 4 hours for the return trip.  I simply could not wait any more.  As a last resort, I decided to have the accumulated blood boldly extracted from the patient’s  abdominal cavity for the first time to save the case.  The self-transfused blood amounted to 1700 ml.  Here it also involves a theoretical question whether the blood mixed with bile can be re-transfused safely, which  was debated in the community and also finally affirmed in subsequent literature later on.  The transfusion helped to maintain the hemodynamic operation during the “waiting" time, and enabled the general anesthesia thoracotomy and liver repair surgery on the spot.  The postoperative recovery was fairly "smooth".  But 9 days after the operation, just as he was supposed to be discharged the next day, the complication of intrahepatic biliary tract hemorrhage occurred.  The hemorrhage attack was typical: with a burst of biliary colic, blood pressure came down, a list of symptoms followed: pale face, anemia, shock, and repeated attacks. Conservative treatment failed, so after one day's observation and measures, I decisively transferred this case to the county hospital to perform the proper hepatic artery ligation and external drainage of common bile duct.  The operation was a success. This entire procedure is very typical based on classical operation theory: the hepatic artery tremor was felt during the operation, which showed bleeding.  After ligation, the tremor disappeared immediately, and the common bile duct hemorrhage was delayed and stopped (as noted in the literature). Life was finally saved. This was an absolute "miracle" for the surgical level of a county hospital at that time, and I was pioneering frontier of surgery. 

At that time, our monthly salary was less than 50 yuan.  This case cost more than 1,000 yuan in the entire treatment,  so he was nicknamed as "1,000 yuan".  How can a poor farmer afford this astronomical amount of money?   Fortunately, in the era of Mao's "curing the wounded and saving the dying", the poor lower middle peasants’ medical charges could be simply written off following some logistics, which has been passed from mouth to mouth with approbation in the society. 

Another example is the splenic rupture at Donghe. My colleague and I were called for the urgent house visit.  We performed splenectomy successfully on the spot on a desk of the commune.  The wonder in this case was our use of 800ml abdominal blood for self-transfusion to overcome the problem of no blood source. 

Although it is defibrinated blood, it is without anticoagulation, yet it does not need to be anti-coagulated (thereby solving another difficult problem of no anticoagulants on hand) as it is the self-blood on the spot.  This was a first bold attempt forced out by the emergency in innovation.  Life was saved.  The road paved out, as it is so-called "the times make heroes”.   This innovative practice was later supported and theoretically recognized by the surgery community.  Its efficacy report gradually appeared as legit rescue in the literature. 

There was a difficult labour case at Xinlin, in Fanchang, with intrauterine transverse position of fetus， and uterine aura rupture, too critical to transport to county hospital.  Cesarean section had to be performed on the spot.  An office desk was used as the operating table, a cloth was pulled on the top to block the ash, with disinfectant sprinkled on the ground, I performed the operation with an infusion under local anesthesia, which saved two lives.

3.  Surgical practice during special period of “civil fighting”

During the Cultural Revolution, there was a special period of chaos when the various factions were armed fighting with real fire arms.  Traffic was interrupted, and hospitals were shut down.  Bullets had no eyes, and gunshot wounds ensued.   They had to be operated on the spot to repair the damaged liver and lungs, kidney, intestines and stomach, etc.  At that critical period, I was forced to take the challenge of practicing these urgent surgeries for rescue, like in a war.  Many lives were saved and most of the cases were successful.  It was a special war-like time, so in case of accidents during operations, there was no strict accountability check.  It was also a unique period when my surgery skills advanced rapidly with tons of urgent surgery practice demanded then.  Indeed, practice generates expertise.  

This is an era of serving the people, and all this will not bring economic benefits, nor will we pursue benefits at that time. 

4.  AS guest surgeoN

After joining Wuhu Changhang Hospital in August, 1985, this affiliated staff hospital did not demand a full work load, so I had some extra time to serve as a guest surgeon for other hospitals. 

4.1 I served as surgical consultant for Xinwu District Hospital for three years, until the hospital was restructured and turned private.   Every Saturday morning, I administered an expert clinic.  I was also responsible for managing the patients’ ward.   During that period, all surgical operations were conducted by me, and for almost all daily operations I would be present. Mr Chen, the president of this hospital, suffered from gallstones, and I performed the operation right there in the hospital. 

4.2  The Municipal Tuberculosis Hospital, later named as Municipal Red Cross Hospital (Sixth Hospital), is located in  suburban Yueya Road. This hospital is also responsible for some comprehensive medical treatment for the people in its neighborhood.  However, this is a specialized hospital, and the surgery expertise is zero.  The hospital leader came to me and asked me to take over the surgical work in this hospital. I was at the time also with "excess energy", so I organized a queue of surgical directors of various hospitals from all districts and factories in the city, and requested the director of radiology department of our hospital to be the chief shift supervisor (equivalent to the chief resident).  The day shift and night shift watchmen came from 4 or 5 hospitals.  Where there was a need for operation, I would take my anesthesiologist, Mr. Chen, together with me to the hospital in the hospital car.  In this way, in more than a year, we performed hundreds of operations, involving various areas of surgery, gynecology, orthopedics and urology, related to stomach, gallbladder, appendix, lumbar intervertebral disc, uterus, fracture, etc.  Meanwhile a number of surgical new talents were also trained there.  During this period, a rare case of pyometra was encountered.  In order to clear the focus at one time, hysterectomy was performed for the first stage, and the recovery was smooth.  That was also the first such operation in this hospital. 

4.3 For No 4 Hospital and Municipal Psychiatric Hospital, surgery, orthopaedics, obstetrics and gynecology are not their forte, and there was a lack of related talents.  However, as a hospital, their comprehensive medical care is still indispensable.  Therefore, when they encountered problems in these area, I was the support they relied on.  From time to time, I went on visits to have performed cesarean section, choledocholithiasis and other operations for this hospital. 

4.4  Matang District Hospital, located in the south of the city, is a connecting part of urban and rural areas.  Although it is a class 2 hospital, there is insufficient technical strength and it often calls for diagnosis guidance.  With my anesthesiologist, I served for their surgery emergency rescue.  One case with acute suppurative obstructive cholangitis was treated right there by an emergency operation successfully . 

4.5.  Zheshan Branch, Jiangdongchang Hospital, is a class one hospital in the city, close to Hongmei New Village where I live.  So it is convenient for me to be called for help any time. Basically, I took care of all the surgical matters there, which lasted for many years.  It's my “backyard”, sort of.  Although they all have deputy chief physicians, they still lack the experience and ability to support all the comprehensive surgeries needed independently.  It's a "win-win" and mutually beneficial for me to support them on call.  When my hometown acquaintances and old patients turned to me for treatment, for convenience and economy, I could solve most of their problems there. Hence I have done a lot of operations on the spot.  

My child’s fifth uncle had rectum cancer and came from Hefei to me for help.  I had a radical operation on him in Zheshan.  It took him 7 hours to get through this critical stage because of massive bleeding before sacrum.  He was cured 

A case of thoracic vertebra fracture with high paraplegia from Nanling had my operation of spinal canal exploration and decompression in Zheshan too. I also performed a caesarean section for a doctor in this hospital,.  I also demonstrated vaginal hysterectomy for the training of the surgeons there. 

A large number of routine operations are performed there, often dozens of surgeries in one month.

5. Numerous weekend house calls 

Over time, I have become their perennial consultant in numerous hospitals such as Sanli, Yijiang (the second and third branch hospitals of Nanling), Family Planning Station, Schistosomiasis Station, Hewan, Xuzhen, Chengguan.  Almost every weekend, I was on my way back and forth to help with their operations. 

Lumbar disc herniation and lumbar spinal stenosis are common diseases in orthopedics, which belong to the Level -3 and Level-4 operation of high difficulty.  My confidence in performing such surgeries comes from my many years of clinical experience and my studying orthopedics under Professor Jingbin Xu, the top orthopedic master in China.  Not long before my own serious illness and operation in 2007, I drove out in the morning to Nanling schistosomiasis control station, and performed the operation on three cases within one day.  The key to ensure success is to completely loosen the compressed nerve root and spinal meningeal sac.  The curative effect is then definitive.  That afternoon after three surgeries performed, it was still not too late for me to drive home for dinner.  

There is another case of Wang XX, a young driver and also a family friend of mine, who also suffers from this disease.   She is restless day and night, and cannot move.  Dr. Lin, the president of the Second Hospital of our city (who is my junior fellow), and I performed an operation on him in Zheshan Hospital.  After decompression of the vertebral lamina, he was able to drive a car again three months after the operation.  For more than ten years now, he has had no symptoms and has enjoyed normal activity in work and life.  He has made himself a billionaire today. 

6. Save the performance at operation table any time 

6.1.  Once in a private hospital of Guniushan, Nanling,  they had a surgery on-going but could not find the expected bilateral ureteral stones during the operation.  Their dean gave me an urgent call for rescue and he was waiting outside on the parkway.  I immediately took a taxi, and in less than an hour, I went on the operation table, taking out the bilateral stones and smoothing the urine flow to have saved the surgery. 

6.2. Once there was an urgent case of subacute perforated peritonitis of a transverse colon cancer in Yijiang Hospital.  At three o'clock in the midnight, they called for my help.  I had to get up to rush for a taxi.  It also took me one hour to get onto the operation table, and I stepped down at dawn with the first stage excision and radical cure of the lesion.  It has achieved long-term curative effect, saving the patient as well as the doctor initiating this surgery.  In fact, they are all my disciples and trainees in the past.  Of course, I feel the responsibilities to be on call to help them any time needed, without hesitation.

7.  Tangshan  Earthquake 

In the July 28, 1976 Tangshan Earthquake, the official death toll was 240,000.  On August 3rd, I was called to go to Tangshan for earthquake-related medical treatment and rescue.  Before getting on the bus in Wuhu, the central authorities gave us a telex: the wounded are being transferred to the south so we do not need to go northfor their treatment.  As the appointed team leader, I organized a medical team of 25 people from Fanchang, Jingxian, Nanling counties plus 25 additional logistics security guards.  The task given to me was to receive and treat 100 wounded people.   Of course, all expenses are covered by the state. It is ordered as a serious political task for us to accomplish.  We set up a temporary treatment site beside the railway at a small town Eqiao. Then I led the team to the Nanjing station in a specially assigned emergency train to take over the patients in orthopedics. About three months after our treatment and care, we had completed this glorious task and sent all of them back to their hometown safely.  It is a historical monument. 

Most of these patients involved fractures, peripheral nerve injuries and spinal cord injuries with paraplegia.  There were not many operations, most of the treatments are of rehabilitation.  This large-scale urgent medical activity involves dozens of sites like ours in Wuhu area, whose leaders include authorities of orthopedics like Jingbin Xu, director of the 127 Hospital of the People's Liberation Army, and Naiyi Chou, director of the former Yijishan Hospital (the medical captain who led medical teams to South Yemen twice).   We medical team leaders meet regularly and discuss all clinical problems and measures.  I am both the captain and the backbone of orthopedics, having participated in the entire process of this rare undertaking. 

8.  Remote consultation and diagnosis 

During an online chat,  my son Wei in the U.S  said that he had severe "heartburn" from time to time, as he said, “it comes and goes, but when it strikes, it is unbearable.” His family physician asked him to have a gastroscope and checked his heart, but he never thought he was suffering from biliary colic.   A healthy middle-aged man, with sporadic pains striking and leaving, what could have been the cause?  On this side of the ocean thousands of miles away from him, I remembered that he had mentioned one year earlier that his annual physical exam found gallstones but it was asymptomatic then.  It must be biliary colic kicking in!  But he didn't agree with my suggestion. He was convinced that it had nothing to do with gallstones because the pain was from the heart area.  I am professionally sensitive and experienced, insisting on my diagnosis: this is gallstone colic, and it can be cured by surgery.  He then followed my advice to see his doctor again, reminded him of this possibility, and then had an ultrasonic examination, coming back with a definite diagnosis.  A laparoscopic operation was performed, and it cured him instantly.  He has been amazed by this experience of my remote diagnosis and has enjoyed a healthy life since.

There have been many similar incidents.  One day, our head nurse called me and said that her husband suddenly had severe abdominal pain.  I knew that he had a history of bleeding from gastric ulcer, so I naturally thought that it must be related to perforation complicated with peritonitis.  I told him to go to the hospital immediately and make preoperative preparations, such as taking an abdominal fluoroscopy, checking blood, etc.  At the same time, I went to the emergency department.  Although no "gas layer" was found under the diaphragm, I still went on with a decisive surgery and managed to perform radical gastrectomy for him.  It is more than ten years now, and he has enjoyed a healthy life.

Many of my out-of-hospital practice and visiting operations, and my being so interdisciplinary in medicine, are the special products of my era.  According to today's standards of high specialization, such practice is neither standardized nor rigorous.  Nevertheless, my special skillset has managed to save many lives and cured many diseases.  It is an indelible mark in the career of my medical practice, demonstrating a significant contribution to society. It has made a difference to my patients and hard for them to forget.  In my life, I have had countless sleepless nights, with eating and sleeping in total disorder, but the sense of self-satisfaction in saving lives is more than enough to comfort me with deep pride and joy.   Nothing could have been better, I have no regrets!

More recently, with the rapid development of science and technology, medicine is also making great strides, evolving with each passing day.  In the ascendant, medical instruments and drugs also see revolutionary development, especially striking to me are the new drugs and the orthopedic equipments, such as stapler, occluder and repair mesh, etc.  As I have been on duty all the time, I feel extremely fortunate to have got on this "last bus", although most peers in my generation are now blocked at the door.  However, the currently popular techniques like laparoscopy surgery, minimally invasive technology is still a blind spot for me, due to the equipment requirements beyond my reach. 

In recent years, a large number of new concepts and terms have appeared in medicine, such as translational medicine (TM), targeted therapy (TT), evidence-based medicine (EBM), etc. I keep up with the times, continuously update my knowledge and keep on following up.  Both in theory and clinical practice have been undergoing changes. 

According to the requirements of fine division of labor in modern clinical medicine, in the past five years after my own gastrectomy, I have basically given up other related professional work outside general surgery, such as orthopedics, obstetrics and gynecology and even urology. This, too, is a way to help create bigger room for new talents to be superior to masters, and shows the progress of society.  My professional title is "General Surgery" chief physician, and I will stick to this area for the remaining path of my career, never fall behind in my lifetime and stay young and energetic! 

My eldest granddaughter is a senior with the 8-year medicine practitioner curriculum in Tongji Medical University, Wuhan.  She is expected to follow me to become the next doctor in my family.  Well-educated, standing from a high starting point, she came to my hospital as a trainee and intern during the Spring Festival holidays last year. When she wore a white medicine costume, she looked like a brand-new doctor in the 21st century.  This baton is passed down to her, and I feel that it is a perfect legacy carry-on for my medicine career,  there’s nothing more I could have asked for.  Admittedly, this profession calls for enduring dedication, involving huge risks and hard work.  However, it also provides a platform where the value of life is most experienced and demonstrated!

October 2011

《李家大院》7: 我的外科生涯—-院外集锦

【李名杰从医66年论文专辑（英语电子版）】

In support of Application for Chief Surgeon

Since the resumption of professional journals and academic activities after the Cultural Revolution in 1979, I have published dozens of papers in journals such as Southern Anhui Medicine, Journal of Bengbu Medical College, Lectures of Provincial Medicine, Domestic Medicine (Surgery) and Jiaotong Medicine.  In 1979 and 1980, I participated in the preparation and re-founding of Anhui Orthopedic Society and Surgical Society respectively, and attended the annual meetings (1-6 sessions) of the two societies.  I also participated in many academic activities of surgery in China and the Ministry of Transportation.  

In 1994, I was involved in the planning and organization of a symposium on orthopedics in the Yangtze River Basin area, helping to compile a special issue of Orthopedic Clinic for Journal of Southern Anhui Medical College, Vol-13 supplement, 1994) under the guidance of Professor Jingbin Xu, editor of Chinese Journal of Orthopedics, carrying over 100 published papers, with participants and contributions from all over the country.

In September, 1995, I published two papers at the National Academic Conference on Acute and Severe Surgery (Guilin, 1995), among which "Problems in the Treatment of Liver Trauma" (0190) won the certificate of excellent papers.  I have also published papers in the First International Academic Conference of Chinese Naturopathy (Chengdu, 1991) and Naturopathy (published in Taiwan Province).

1 Professional path and deputy chief physician performance

 (On evolution of several theoretical problems in surgery)

1.1 In the early 1960s, a large number of patients suffered from acute volvulus, ascaris lumbricoides intestinal obstruction and cholelithiasis.  Carrying out a large number of related operations for these cases consolidated my mastering  the basic surgical skills.  In addition, for the treatment of toxic shock in late cases, we practitioners underwent an arduous zigzag path from vasoconstriction and pressure increase to volume expansion and improvement of microcirculation, which proves to be an epoch-making change and progress both theoretically and clinically. 

1.2  In Southern Anhui, there used to be a large number of patients with portal hypertension, hypersplenism and upper gastrointestinal bleeding in the early years of late-stage schistosomiasis and late hepatitis cirrhosis. techniques. The medicine community has also gone through a process of repeated debate and re-evaluation of the choice between shunt and devascularization techniques.  In this regard, as far back as in 1975, I performed splenectomy, splenorenal vein anastomosis and other types of shunt surgeries. Due to the high rate of postoperative embolism, the blood supply to the liver was reduced and hepatic encephalopathy was easily induced.  Later on, I switched to various types of portal-azygous devascularization, and obtained many lessons and various experiences for improvements from the treatment of this difficult problem. 

1.3 Biliary lithiasis still bothers the surgical community. With the development of hepatobiliary surgery and improvement of monitoring methods, surgical procedures for this challenging problem of intrahepatic calculi are constantly updated and improved.  I started the surgery of regular resection of the left lateral lobe of the liver for this disease in 1980 (the paper on five early cases was published in the Annual Meeting of the Provincial Surgery in 1980 and in Journal of Southern Anhui Medicine (80, 13; 51, “Regular resection of the left outer lobe of the liver for the treatment of intrahepatic stones”).  Also starting in 1980, various types of choledocho-intestinal drainage (Finster, Longmire, Roux-en-Y, etc.) were successively performed.  In 1992 and 1995, three cases were treated with intrahepatic bile duct incision, stone removal and plasty, and "basin" biliary and intestinal drainage (The first case was reported in “Communication Medicine”,  93,7; 91, “A case of hepatobiliary basin type biliary enteric drainage”). This work advanced the operation to the treatment of intrahepatic lesions, leading to improved  clinical efficacy. 

1.4 In recent years, the incidence rate of acute pancreatitis has increased. All severe pancreatitis patients in my department were cured by measures such as focus removal, pancreatic bed drainage, intraperitoneal lavage, 5-Fu, somatostatin and other measures to inhibit exocrine, anti-shock and anti-infection. In recent years, one patient was rescued in my department despite the complicated stress ulcer bleeding after operation was performed in another external hospital.  

1.5 On the basis of treatment and operation for various thyroid diseases, hyperthyroidism operation was performed after 1980, and two cases of radical thyroidectomy (neck-mimicking surgery) were performed in 1994. One case was re-operated due to recurrence 3 years after the initial surgery was performed in an external hospital.  No further recurrence was observed during follow-up.  

1.6 In addition, there are surgeries such as excision and anastomosis of cervical aneurysm, thymopharyngeal duct cyst, thyroglossal duct cyst and cystic hygroma resection, etc. 

1.7 Over the past 30 years, more than 1,000 cases of breast cancer, gastric cancer, colon cancer and rectal cancer have been treated, and many of them have survived for a long time.   

1.8  The prevention and treatment of short bowel syndrome after large intestinal resection as a surgical method of interposition of distal reverse peristaltic bowel loops, the observation shows no diarrhea and malnutrition for 21 years. This paper was published in the Journal of Bengbu Medical College (82; 7: 214, PEUTZ Syndrome) and Traffic Medicine (91; 1: 41, “Surgical treatment of short bowel syndrome”).   

1.9 The management of duodenal injury has its particularity and complexity, and its retroperitoneal injury is especially prone to missed diagnosis and misdiagnosis.  The prognosis of patients who underwent surgery more than 24 hours after injury is grim.  In a case report from 1994, following the principle of "rest transformation" of duodenum, I performed a Berne-like operation 28 hours after injury, and the recovery was smooth. My paper was published in Communication Medicine (“Experience in Diagnosis and Treatment of Closed Retroperitoneal Duodenal Injury”, by Mingjie Li). 

1.10  Subdiaphragmatic total gastrectomy, jejunostomy, supradiaphragmatic esophagectomy, thoracic esophagogastrostomy, lobectomy, mediastinal thymoma removal, diaphragmatic hernia repair, etc. which started years ago.

2. Work involving various medicine disciplines 

The two hospitals I have served are both base-level primary hospitals. The "major surgery" department covers general surgery, orthopedics, urology, chest surgery, obstetrics and gynecology, ophthalmology and otorhinolaryngology,  anesthesia, radiation, laboratory test and other related work.  As professional subject leader, I have long been engaged in the work of all of the above areas, outlined below. 

2.1 Orthopedics is one of my key areas, only second to general surgery.  I have performed all major surgeries in this area, and participated in academic activities at all levels, including publication of numerous papers, professional talks and compilation of a special issue on Orthopedics.  My representative operations treating bone injury and bone disease include closed nailing of femoral neck (for the paper, see Orthopedics Clinical 1994, 13:37, Closed nailing treatment of femoral neck fracture in 45 cases), surgical paraplegia (paper in Anhui Province Medical Lectures 1982;, 4:21, Surgical paraplegia analysis of 14 cases), spinal tuberculosis surgery (paper Spinal tuberculosis a surgical therapy in Proceedings of First Provincial Orthopedic Annual Conference, 1979), lumbar disc surgery, spinal cord tumor enucleation, bone tumor removal and orthopedic surgery, etc.    

2.2 Urological surgery: nephrectomy, stripping of renal pedicle lymph nodes, removal of various segments of ureteral calculi and Urethral trauma realignment repair, ureteral transplantation, vasovasostomy, spermatic vein–inferior epigastric vein anastomosis, hypospadias repair, radical resection of bladder cancer and penile cancer, etc. 

2.3 Gynaecology and obstetrics: I founded the department of obstetrics and gynecology of our hospital, having operated Cesarean section (lower segment and extraperitoneal operation), hysterectomy (abdominal type and vaginal type), oophorectomy, repair of vesicovaginal fistula and cervical cancer resection, etc. 

2.4 Ophthalmology and otorhinolaryngolog: parotid gland, tonsil, maxillary sinus, mastoid, cataract, artificial pupil, enucleation, nasolacrimal duct anastomosis, strabismus correction, etc.   

2.5 Anesthesiology: various segments of epidural block, cervical plexus block, brachial plexus block, intubation general anesthesia and intravenous compound anesthesia, etc.    

2.6 Radiology: I founded the department of radiology in 1960, and concurrently served as the head of the department for 2 years (1960-1962).  Very familiar with its routine work and related angiography. 

Environment trains people.  A wide range of issues encountered in the long-term work of grass-roots hospitals enabled me to dabble in many subjects.  The knowledge and skills of these relevant areas complement each other, contributing to and deepening the improvement of my surgical expertise.  Various Level-4 and Level-5 surgeries have been performed to keep placing me at the forefront of contemporary surgery.

3  Continuous innovations and some experience to share 

Over the past 40 years, with high technological development, diagnosis and monitoring methods are constantly updated.  With the change of social life, diseases are also changing. In an aging society, geriatrics takes a prominent position.  Many factors make the clinical work evolve too.  This requires physicians to constantly hunt for scientific and technological information, learn from the experience of others, study hard and embrace the courage for innovation, in order to improve the service quality for our patients. 

3.1 Improvement and innovation 

3.1.1 The key to the control of traumatic infection is complete debridement at the first diagnosis, rather than relying on drainage and antibiotics.  Techniques involve a large quantity of water washing, elimination of foreign objects and inactivating tissues, disinfection, and no suture.  When postoperative inflammatory reaction occurs, apply local wet compress with alcohol, supplemented with with or without antibiotics.  Following this strategy, surgery within 6 hours of trauma is almost completely free from infection. 

3.1.2 Over the past 30 years, based on the experience of over 1,000 cases of gastrectomy I have performed, the preset gastric tube has basically been abandoned except for special needs, and there were no cases of failure.  This requires excellent anastomosis, perfect hemostasis, intraoperative emptying of the residual stomach, and attentive postoperative monitoring. 

3.1.3 For extensive peritonitis, after the nidus and infectious substances are removed, abdominal cavity drainage can be abandoned to reduce postoperative adhesion.  The key for this to work is to wash it thoroughly during the operation.  As the drainage is quickly blocked by fibrin glue in the abdominal cavity and soon stops working, it only increases the pain of the patient. To be sure, however, in cases such as pancreatitis, abdominal abscess, etc., if continuous overflow is expected, double-cannula negative pressure drainage is still required.   

3.1.4  For any surgery, regardless of scale, its success or failure makes a big difference to the health and safety of patients.  As a surgery practitioner, I attach importance to the technical improvement of each and every "small" surgery.  Some of my technical innovations and experience are outlined below. 

For inguinal hernia repair, the focus is the transverse abdominal fascia, the traditional Bassini method should be replaced by the modified Madden procedure, which greatly reduces the pain of postoperative tension suture for patients, and is also conducive to healing, with the recurrence rate  greatly reduced. 

For circumcision, the conventional routine procedure has plagued both doctors and patients with the poor alignment of the inner and outer plates, hematoma, edema, as well as difficulty in stitches removal.  I modified the procedure, using local venous anesthesia to support neat cutting under a tourniquet, with perfect hemostasis, accompanied by careful sutures with human hair or absorbable thread.  The benefits include no pains during the operation, good alignment, fast healing and avoiding stitches. (see my paper published in Jiaotong Medicine 90; 4（3)：66,  Several improvements of circumcision） 

Anal fistula seton therapy or open resection can cause patients to suffer from postoperative pain and a prolonged recovery period post-surgery. I used long-acting anesthesia (with local injection of diluted methylene blue) to ensure the primary resection and suture. Most cases receiving this treatment result in primary healing, with the course of treatment greatly shortened.

3.2 Some General Experiences 

Based on what I have learned from my 40 years of hands-on surgical practice, I feel that in order to be a qualified surgeon, we need not only consolidate the basic knowledge with continuous updating, but also exercise meticulous working methods with a high sense of responsibility, supported by logical thinking and practical orderly working style.  It is very difficult to just follow a unified norm or standard procedure when the real-world surgery scenario involves so many moving parts to be weighed and considered, factors like the ever-changing condition, physical differences, positive and negative effects of drugs, advantages and disadvantages of the techniques in consideration, the reserve function of body organs, the length of the course of the disease, and even the natural environment, mental and material conditions, and so on.  One must be equipped with high adaptation wisdom.  It is not an exaggeration to say that the adaptation ability determines a surgeon’s diagnosis and treatment level and the clinical effects.   

3.2.1 The entire process on the operating table involves struggles between personal fame and the interests of patients.  The so-called following "safety first, and draw the line accordingly” principle is often not a feasible practice.  A competent physician must have the courage to take risks for his patients. It is often the case to be placed in the position in fighting for patients' good chances of rescue that can be missed because of a small mistake in one's thinking.  I have countless memories of such incidents in the past, one of which is as follows.  In the fifth operation of biliary tract, cavernous blood vessels caused by portal hypertension due to biliary cirrhosis were distributed all over the hepatic hilus, and in addition, the inflammation was thickened.  After struggling for 8 full hours of operation, I finally managed to open the biliary duct and save the life of the patient.  This was a victory of perseverance. 

3.2.2  Adjust measures to real world conditions, and keep an open mind to break the routine to save a patient.  The key to life-saving in case of liver and spleen trauma and massive hemorrhage of ectopic pregnancy in the countryside lies in rigorous transfusion of the abdominal blood.  To wait for the blood supply in these scenarios means to wait for death.  I remember a case of liver trauma in which 1700ml of liver blood was transfused locally to support the successful operation.  (See paper Related issues in the treatment of liver trauma (review), in Proceedings of the National Academic Conference on Acute and Major Surgery, 95; 190） 

3.2.3 For difficult surgery and new surgery, one must accumulate the relevant knowledge and operation skills, by reviewing literature, consulting experienced experts for guidance, and visiting and studying surgery scenes, before embarking on the operation, to minimize potential misses or accidents.  In my first case of hepatobiliary-pelvic internal drainage operation, I asked for direct guidance from a professor of surgery. The subsequent two cases were successfully completed all by myself.   

Looking back on my 40 years of career in surgery, I deeply feel that clinical surgery is a combination of science, perseverance, determination, and a sense of responsibility.  It is like a small boat that ups and downs in the forefront of the waves.  Walking on thin ice, one can hit hidden rocks at any time.  The hardships and risks of our career are among the highest in all trades.  Fortunately, I have not failed the society.   Along the journey, there have been countless joys of success, together with many sleepless nights and panic moments.  For the rest of my career years, I am determined to maintain the service spirit of "healing the wounded and rescuing the dying", to complete the journey to the end.   

Appendix 1, Publications
Appendix 2, Relevant Materials and Records of Level III and Level IV surgeries

《李家大院》6: 业务自传和工作报告

【李名杰从医66年论文专辑（英语电子版）】

Before writing my debriefing report in support of my application for Chief Surgeon, let me start with three unforgettable orthopedic cases that I experienced in my medical practice. 

In 1970, my old schoolmate and close friend from junior high school, Mr. Gui from Fanchang No.1 Middle School at that time, brought his son’s case to my attention.  His son, aged 16 then, suffered from cervical vertebra 5 tuberculosis with cold abscess, which severely oppressed esophagus and trachea. He was unable to eat, and had difficulty breathing, with hoarseness, dehydration and hypoxia, in a critical condition.  

They had visited Yijishan Hospital, the largest hospital in Wuhu, but the director there Dr. Chen of the Department of Orthopaedics could not admit this case, saying that a few days before, a similar case, died during the operation.  He made the suggestion for the patient to be sent to the provincial Hospital of Hefei, which required 800 yuan then.   However, Mr. Gui’s monthly salary was only 52 yuan, and he had to support a family of six with this income.  How could he afford it?  Besides, nobody knows whether the chief hospital in Hefei could treat him.  In a hurry, Mr. Gui turned to the No. 127 Army’s Hospital located in the suburb of my town Nanling, to try their luck there.  The corresponding department of the hospital was administered by Dr. Xu Jingbin, the nation-wide orthopedic authority, and this military hospital located in a small place long had a tradition of helping the poor.  Unfortunately, Dr. Xu was on a business trip to Nanjing, and several of his subordinates there were too afraid to accept this high-risk patient.   

Feeling helpless, Mr. Gui came to me in Nanling County Hospital (the two hospitals are only 5 miles apart) to discuss possible rescue plans with me.  I was not sure about how best to treat this condition either.  However, I had studied in No. 127 Hospital, with Dr. Xu as my supervisor, familiar with the personnel there.  I immediately called an ambulance. We went back to No.127 Hospital, found doctors in orthopedics and surgery, and asked them to work together for the treatment of this urgent case.  Mr. Gui as patient’s family and I jointly signed the required paper for willing to take the risk of the operation, and discussed the detailed rules.  However, this plan was still not approved by the hospital.  Instead, the hospital asked me to help them out of this embarrassing predicament, and promised a free car to be used for transferring the patient to big city hospitals in Hefei or Nanjing.  The patient's life was in danger at any time. Far water cannot put out the near fire, so it's not advisable to transfer to hospital far away. 

I decided to take on the challenge myself.  At that time, I thought, at least I could give pus discharge for saving life first, relieving the oppression of esophagus and trachea, and making it possible for hime to eat and breathe.  So the patient was brought back to the county hospital where I worked.  Without even getting off the stretcher, I ordered to first give fluid replacement and antituberculosis.  At this point in the evening, Mr. Gui didn't get any food for a whole day, so he was given dinner at my home.  I could not afford the time to have a dinner.  I took the time to review the related literature and anatomy.  Half an hour later, the patient was sent to the operating room under local anesthesia. After my careful dissection, the patient’s pus cavity was cut to release a large amount of pus.  The patient immediately started making sounds, could sip the water, and breath smoothly, indicating him finally put out of immediate danger. 

The operation continued, exposing the focus of cervical vertebra 5 by anterior approach, I removed the dead bone, scraped off the granulation of tuberculosis, flushed the pus cavity, inserted streptomycin and isoniazid, put the drainage piece in, with suture.  The operation was smooth and very effective.  The fever came down 3 days after operation.  The patient went to get a haircut, ate normally and recovered well. 12 days after the operation, he was discharged from hospital, and his medical expenses were 32 yuan.  He continued anti-tuberculosis treatment for half a year and recovered well.  For more than 40 years now, the patient has been working and living normally, now enjoying a family of his numerous children and grandchildren. 

In addition to the complicated anatomy of the neck, such as dense blood vessels, nerves, thyroid gland, trachea, esophagus, etc., this type of cervical tuberculosis debridement operation is of high difficulty also due to the fragility of the cervical spine and the destruction of tuberculosis.  If there is a slight mistake in the cervical spinal cord, it will lead to being paraplegic at a high level or even death.  It's an orthopedic high risk level 4 operation.  Even in big hospitals, the directors are extremely cautious in treating such cases.  I was still a newcomer in orthopaedics then, but I needed to save lives, knowing that transferring to another hospital at that time was basically a dead end.  The patient was on the verge of an abyss.  But I also had some of my own strength and preparedness for this success.  I had had many years of experience in neck thyroid surgery, familiar with anatomy, and had accumulated specialized knowledge in orthopedics.  This solid foundation finally enabled me successfully complete this rare problem in a grass-roots hospital.  Life threatening symptoms were treated by relieving oppression immediately.  And the disease was cured, with the lesion eradicated.  It proved to be a cure for life.  

Another case, at the end of 1980s, named Xiao Wei, a 14-year-old junior student in Wuhu No.1 Middle School, suffered from right humeral neck tumor.  He had undergone two operations in Yijishan Hospital and Shanghai Zhongshan Hospital respectively.  Now, the disease struck at the right scapula.  The director of orthopaedics in a hospital of our city said, it is malignant tumor recurring and metastasizing, amputation is necessary, and it is challenging to save his life!   The family was in a desperate situation.  The patient’s grandfather, Mr. Wu, was my junior middle school teacher.    Mr.  Wu knew about the case of cervical tuberculosis treated  well by me on Mr. Gui’s son, so he came to me for consultation.  I carefully examined the medical records and the X-ray films before and after, and diagnosed it as a new critical tumor, neither a recurrence nor a metastasis of the original disease.  I personally performed a half-excision of the right scapula in my own hospital, resulting in his full recovery.   More than 20 years have passed, and Xiao Wei has enjoyed good health ever since.  He has become a Dr. Yang in the west later on, and is now a high-end international talent in his field.  From time to time, he and his father still come to visit me with appreciation. 

The third case, in the fall of 1975, a 35-year-old female patient, who had lost 40 kilograms, was admitted to our hospital for tuberculosis of thoracic vertebrae 6 and 7 with paraplegia.  Under general anesthesia, through the chest, the focus was cleared, and the dead bone and the necrotic intervertebral disc were removed.  The tubercle granulation in the spinal canal was 8cm long, which pressed the thoracic spinal cord, resulting in spinal canal obstruction and paraplegia.  After curettage, it could be seen that this segment of spinal cord was throbbing again.  The focus area was thoroughly washed, with antituberculosis drugs added in.     The ribs cut during thoracotomy were trimmed and embedded in the intervertebral defect area, and the anterior bone graft was completed in one single stage. After operation, the patient recovered well and was cured.  The patient’s husband was a blacksmith, who gifted me with  a stainless steel kitchen knife and a spatula of his own craftsmanship, which are still in use in my home today.  In orthopedic surgery, this belongs to the top level-four category.  With thoracic tuberculosis complicated with paraplegia, the cure was one-time lesion clearance and bone grafting through the anterior thoracic approach, definitely having reached the peak in county-level hospitals. 

Such cases have brought me a great sense of pride and accomplishment, and they form the motivation for my lifelong dedication to saving lives and relieving pains for my countless patients.

《李家大院》5: 我的外科生涯

【李名杰从医66年论文专辑（英语电子版）】