2015年 · 第30卷第10期

1994 Japan Kitano et al.^[1]Laparoscopic gastric cancer surgery was reported for the first time. Because of its minimally invasive advantages, such as light postoperative pain, quick recovery, short hospital stay and low complication rate, it has been gradually carried out at home and abroad, and has achieved good short-term and long-term results. The technology has also been matured and gradually accepted by surgeons^{[2,3,4,5,6,7,8]}。 Although the history of laparoscopic gastric cancer surgery in China is only more than 10 years, it has developed very rapidly, and the number of units and reported cases has gradually increased. However, due to the short development time and uneven technical level, the clinical efficacy is seriously affected. At present, there are some problems in laparoscopic gastric cancer surgery, such as indications, surgical operation standards, insufficient research of evidence-based medicine, and few clinical applications of 3D laparoscopic and robotic gastric cancer surgery, which need to be further explored and solved.

A 21-year-old female was admitted mainly for intermittent abdominal pain for 1 month, aggravated with diarrhea for 1 d. After admission, the patient developed severe abdominal pain, diarrhea, and dark stool color. Abdominal CT showed local target signs in the right lower abdomen, thickened intestinal wall, and the terminal ileum was inserted into the distal intestinal tube (Figure 1)。 Intussusception was diagnosed. The patient's stool was jam-like and occult blood was positive, so he was operated. During the operation, the terminal ileum was inserted into the ascending colon about 25 cm, and multiple white nodules, 0.8-3.0 cm in diameter and tough in texture, were found in the ileum about 20 cm from the ileocecal valve after the inserted ileum was also inserted. Intraoperative frozen pathology reported spindle cell tumor. Partial ileal, cecal and partial ascending colonectomy and end-to-end ileal and ascending colonostomy were performed. The surgical specimens were scattered with dozens of gray-white nodules of varying sizes, with a diameter of 0.3 to 3.0 cm. Postoperative pathological report: ileal neurofibromatosis (Figure 2)。 Immunohistochemical staining showed: S-100 (+).

The patient was a 32-year-old male. He was admitted to hospital for 1 year due to repeated perianal swelling, pain and ulcer. Physical examination at admission: at 6 o'clock perianal at the lithotomy position, a rupture was visible at 3 cm from the anal margin, and the cord could be reached from the rupture to the anal margin at 6 o'clock at the lithotomy position. Digital rectal examination: at 6 points at the lithotomy position, the anal canal can reach a depression, the rectum does not reach the tumor, and the finger cuff is stained with blood (-). Blood routine: WBC 4.6×10⁹/L, HGB 156×10⁹/L, PLT 251×10⁹/L. Liver function : ALT 25 U/L, AST 22 U/L, TP 73 g/L, ALB 44 g/L; Renal function : BUN 5.3 mmol/L, CREA 73.90 μ mol/L; Blood glucose: 4.8 mmol/L. 3D ultrasound examination of anus: A cord-shaped hypoechoic, about 3.0 cm ×0.3 cm in size, can be seen at 6 o'clock at the lithotomy position, and the internal opening is located at the level of the tooth line in the middle of the anal canal at 6 o'clock at the lithotomy position. Diagnosis: trans-sphincter anal fistula. Sacral anesthesia was used for the operation. The patient was recumbent on the left side with Karl Storz video assistance (anal fistuloscope set). The internal orifice of anal fistula was accurately positioned under direct vision, the fistula was completely destroyed by electrocautery, the internal orifice was closed with a stapler, and the anastomosis was reinforced around the rectal anastomosis. After operation, diet was controlled for 3 days, and antibiotics were used for prophylaxis for 3 days. The wound healed 30 days after surgery, and 3D ultrasound examination of anus was performed again. The original fistula misshaped and the healing scar was visible. The postoperative pain score was 1 point (the state with the least clinical pain).

The patient, a 64-year-old male, was admitted for 3 and a half years due to the discovery of an abdominal mass. The patient found an abdominal mass 3 and a half years ago, with slight abdominal distension, chest tightness and shortness of breath, which was obvious after lying down. Surgical treatment was performed in the local hospital, and the postoperative recovery was good. The pathological report was retroperitoneal lipofibroma. Reexamination at 3 months after operation showed that the tumor recurred, the tumor gradually increased, and obvious abdominal distension appeared, which was obvious after eating. Weight loss of about 15 kg in the past 1 year. Physical examination: Abdominal swelling, an old surgical scar about 15 cm long was seen at the left rectus abdominis muscle. A mass about 15 cm ×20 cm in size was palpable in the left upper abdomen, which was soft, without tenderness and good mobility. Pathological diagnosis: retroperitoneal fibrolipoma. Abdominal CT: considered as retroperitoneal giant liposarcoma with compression of pancreas, left kidney, adrenal gland, intestine, portal vein and inferior vena cava, partially displaced (Figure 1)。 Urinary excretion angiography: the morphology and function of both kidneys were roughly normal. Left kidney displacement. Bilateral ureteral catheters were placed preoperatively for intraoperative marking. Exploratory laparotomy was performed on November 4, 2013. One tumor was visible in the abdominal cavity, which was tough and separated. Each tumor had an intact envelope, and the adhesion between them was tight, about 40 cm ×40 cm ×30 cm in size. The root of the tumor was located in the left lower abdomen, and it was tightly adhered to the splenic flexure of the colon, spleen, sigmoid colon, left kidney and ureter, and the left kidney and ureter were displaced to the upper right. Retroperitoneal mass was diagnosed intraoperatively and resection of retroperitoneal mass was performed. The edge of the tumor was carefully separated from the adhesions of sigmoid colon, splenic flexure of colon, spleen, left kidney and ureter, and left peritoneum, and gradually separated deeper. The bilateral ureters were carefully identified by bilateral ureteral catheters, and the bilateral kidneys and ureters were preserved. The size of the resected tumor specimen is about 40 cm ×40 cm ×30 cm, and the weight is about 11 kg (Figure 2)。 Postoperative pathological report: well-differentiated liposarcoma, considered from malignant transformation of lipoma (Figure 3)。 Symptomatic treatment was given after operation, and he recovered well. He was discharged from hospital 14 days after operation.

A 53-year-old female complained of recurrent epigastric discomfort for more than 3 months. Gastroscopy showed two submucosal lesions at the esophagogastric junction (EGJ) (Figure 1)。 Endoscopic ultrasound revealed two hypoechoic masses in EGJ, located in the muscle propria layer, with sizes of 0.5 mm ×0.5 mm and 2.1 mm ×1.1 mm, respectively (Figure 2)。 Multiple tumors of EGJ muscularis propria were diagnosed and treated by endoscopic surgery. After endoscopic redetermination of the lesion location, an incision was made in the left wall of the esophagus 5 cm away from the tumor body, and a mixture of 0.4% indigo rouge and physiological saline was injected submucosally. The mucosa was longitudinally incised 2 cm with a Hook knife, and the submucosal tissue at the incision was preliminarily separated. The submucosal layer was gradually separated with a Hook knife, and a longitudinal tunnel was formed between the submucosal layer and the muscular layer (FIG. 3A), separated to the esophagogastric junction, revealing the tumor (FIG. 3B)。 The muscle propria layer was separated around the tumor with Hook knife, and two tumors were separated from the muscle propria layer, respectively, and the tumor specimens were taken out by tunnel (Figure 3C)。 To treat the hemorrhagic focus in the tunnel, the mucosal incision was completed with a metal clip under direct endoscopic vision (Figure 3D)。 The pathological diagnosis of the resected specimen was EGJ stromal tumor. The patient received intravenous nutritional support and prophylactic antibiotics within 72 hours after operation, and oral feeding after 72 hours, and recovered well after operation.

The patient was a 57-year-old male. The main cause was "nearly 2 months after rectal cancer surgery, prophylactic ileostomy intestinal segment prolapse with cessation of exhaustion and defecation for 2 days". The patient visited our hospital more than 2 months ago due to the change of defecation habit. Colonoscopy showed that the lower edge of the tumor was 6cm away from the anal edge, and the size was about 3 cm ×4 cm; Biopsy: well differentiated adenocarcinoma. Pelvic MRI: The left lateral wall of the middle rectum is high signal, with clear boundaries and local breakthrough of the muscle layer. No obvious enlarged lymph nodes were observed at the periintestinal, superior rectal artery and inferior mesenteric artery. CT of thorax and abdomen did not reveal distant metastases such as liver and lung. Preoperative diagnosis: cT2N0M0. Laparoscopic assisted low anterior resection of rectal cancer + prophylactic ileostomy was performed. The abdominal wall was incised through the rectus abdominis muscle on the right side of the umbilicus, and the ileum could be raised by 2 to 3 fingers, about 15 cm from the ileocecal valve, and a double-cavity stoma was performed. The operation was smooth. Postoperative pathological results: Invasive moderately differentiated adenocarcinoma, about 2.5 cm ×1.5 cm ×1.0 cm in size, invaded the submucosa, no vascular tumor thrombus, 0/13 peri-intestinal and mesangial peri-vascular lymph nodes, and no residual cancer was found at the broken end. Postoperative pathological stage: pT1bN0. The patient did not receive adjuvant treatment after surgery. After operation, general food was taken, and the ileostomy exhausted and defecated smoothly.

The patient was a 43-year-old female. He was admitted to hospital because of "high fever, abdominal pain with bloody stool for more than 2 months, aggravated for 10 days". Physical examination: The superficial lymph nodes of the whole body were not palpable and swollen, and there were no ulcers in the mouth and perineum. Soft abdomen, no tenderness. Emergency colonoscopy: multiple round or oval ulcers scattered at the terminal ileum and the whole colon (Figure 1)。 Pathological examination: Chronic inflammation and edema of mucosa, neutrophil infiltration and inflammatory granulation tissue. There were no obvious signs of tuberculosis infection on lung CT, T-spot test (-), inflammatory bowel disease combination (-). Fecal occult blood: occult blood (+). Hemoglobin 100 g/L at admission, conservative treatment, transfusion of homotypic red blood cells 5.5 U, HGB decreased to 39 g/L, blood pressure 76/58 mmHg, heart rate 120 beats/min. Transferred to gastrointestinal surgery. Emergency laparoscopic exploration showed that the whole abdominal cavity was pale and swollen, and the local exudation of pale yellow clear fluid was performed. Total colonectomy and terminal ileal resection, small intestine and rectal anastomosis, and prophylactic ileostomy were performed. Postoperative anatomical specimens found that the whole colon, terminal ileum and upper rectum were mostly dispersed in superficial ulcers. After operation, high fever persisted for 10 days, and the highest body temperature was 40 ℃. The effect of anti-infective treatment such as melopenem and vancomycin was poor, but the body temperature returned to normal after hormone treatment. Postoperative pathological examination: Chronic multiple superficial ulcers of the colon, the morphology conforms to ulcerative colitis. Consultation of Pathology Department, Beijing Friendship Hospital: Microscopic findings: A large number of small to medium large lymphoid cells diffusely infiltrated in the mucosal layer and submucosal layer, with insignificant atypia, mixed with a large number of plasma cells, eosinophils, histiocytes, etc. EBER in situ hybridization: positive (the number of positive cells is about 50/HPF) (Figure 2)。 Diagnosis: Epstein-Barr virus-associated T-cell lymphoproliferative disorder of (colon), group II (borderline). Consultation of the Department of Pathology, Peking University Third Hospital: multiple ulcers with lymphocyte infiltration (colon wall) (Note: no diagnostic basis for lymphoma was obtained). One month after discharge, multiple superficial ulcers in the stomal ileum were found. After continuing antiviral therapy for 3 months, intestinal ulcers were significantly reduced after re-examination of colonoscopy (Figure 3), hemoglobin 114 g/L, weight gain 10 kg. Half a year later, Epstein-Barr virus (real-time PCR) 3.27E +0.6 copies/ml was performed, and ileostomy reduction was performed.

A 58-year-old male was admitted to the hospital because the pancreas occupied space on physical examination. Blood routine and biochemical examination showed no obvious abnormality, tumor indexes (CA125, CA199, CA242, CEA and CA724) were all normal, fasting blood glucose was 7.1 mmol/L before operation, and enhanced CT (Figure 1，Figure 2) and MRCP showed that there were multiple cystic low-density foci in the uncinate process of pancreas and the tail of pancreas, with clear boundaries, mainly in the uncinate process, and internal separation was visible. The foci were closely related to the main pancreatic duct, and the pancreatic duct was dilated. Intraductal papillary myxoma of pancreas diagnosed preoperatively (intraductal papillary mucinous neoplasm, IPMN). Pancreatectomy with robotic preservation of the middle segment of the pancreas was decided after discussion by the Pancreatic Multidisciplinary Comprehensive Treatment Group. Intraoperative exploration revealed a mass of about 4 cm in diameter in the uncinate process of the pancreas, which was soft and had no obvious adhesion to the surrounding tissues. Another cystic mass of about 1.2 cm in diameter could be found at the lower edge of the pancreas body, and no obvious swelling of the surrounding lymph nodes was found (Figure 3，Figure 4)。 Robot-assisted pancreaticoduodenectomy + body-tail pancreatectomy (Kimura method to preserve the spleen) was performed. During the operation, the distal residual surface of the pancreas was sutured to close the main pancreatic duct stump with Prolene6-0 line, and the pancreatic stump was continuously sutured with Prolene3-0 line. The proximal end of the pancreas and the jejunum were anastomosed from mucosa to mucosa end-to-side, and the biliary-enterostomy was performed 10 cm away from the pancreatic-enterostomy. The gastrointestinal anastomosis was performed with full-thickness + seromuscular layer double-layer suture. Intraoperative bleeding was approximately 100 ml without transfusion. The postoperative pathology was IPMN. The gastric tube was removed on the 5th postoperative day, liquid diet started on the 7th postoperative day, the parastomal drainage tube of biliary enterostomy was removed on the 8th day, and the parastomal drainage tube of pancreatic enterostomy was removed on the 13th postoperative day. The amylase of the pancreatic residual drainage fluid was measured at 5 632 U/L on the 13th postoperative day, and the patient was flushed. On the 31st postoperative day, the effusion in the tail of the pancreas was punctured and drained under CT guidance, and the posterior drainage was smooth and the extubation was smooth. The highest postoperative blood glucose was 19.2 mmol/L on the 7th postoperative day, and the blood glucose was well controlled after subcutaneous insulin injection. At present, the patient is 6 months postoperatively, the tumor has no recurrence, and the blood glucose is well controlled by insulin.

In this study, immunohistochemical methods were used to detect CFTR-associated protein 70 (CAP70) and platelet-derived growth factor receptor β (PDGFR-β) The expression of CAP70 and PDGFR-β in gastric carcinoma and normal gastric tissues was investigated, and the relationship between CAP70 and PDGFR-β and the occurrence, development and prognosis of gastric carcinoma was analyzed.

Our previous study found that zinc finger protein 139 (ZNF139) was increased in gastric cancer, which was related to gastric cancer metastasis and multidrug resistance (MDR)^[1]。 In this study, a nude mouse gastric cancer orthotopic transplantation model was taken as the research object, and the effect of ZNF139 gene inhibition on tumor proliferation was clearly determined, and its mechanism was discussed.

Patients with esophageal obstruction who cannot eat need nutritional supplements, and there is no good clinical solution at present. According to the patient's condition, we combined the advantages of our own interventional technology, used the double fixation of gastric wall and avulsion support sleeve cannula technology, and performed percutaneous gastrostomy to supplement nutrition in this type of patients under the guidance of CT, which successfully solved the nutritional problem of patients with esophageal obstruction who can't eat. The report is as follows.

With the wide application of laparoscopic technique in hepatobiliary surgery, more and more surgeons believe that "T" tube drainage after common bile duct incision and lithotomy can no longer match the "minimally invasive" concept of laparoscopic technique. Therefore, in recent years, it has been reported that many scholars have performed laparoscopic bile duct exploration and primary suture (LBEPS) and achieved ideal results^[1]。 However, in addition to strict selection of cases, whether there can be a means to assist in evaluating the safety of primary suture of common bile duct has always been a problem that has puzzled scholars. We treated 165 patients with gallbladder stones combined with common bile duct stones. Through the analysis of common bile duct pressure measurement after primary suture, we explored the clinical significance of common bile duct pressure measurement in guiding primary suture.

With the development of laparoscopic surgery, history of open liver and biliary surgery is no longer a contraindication for laparoscopic re-hepatobiliary surgery^[1,2,3]。 We have accumulated some experience by performing laparoscopic lobectomy for left intrahepatic bile duct stones and common bile duct stones in 11 patients with previous history of open biliary surgery, which is now reported below.

The pathological causes and clinical manifestations of large intestinal perforation are different, and the positive rate of imaging features is low, so the diagnosis is difficult. Abdominal infection caused by large intestinal perforation is often combined with toxic shock, etc. The surgical risk is high, and if not handled properly, it can lead to adverse consequences. Surgery is an effective method to treat large intestinal perforation. There are many choices of surgical methods, and different surgical methods directly affect the prognosis of patients. From January 2000 to November 2014, 48 patients with large intestinal perforation were treated in our hospital. The treatment experience is reported as follows.

Rectal stromal tumor is a rare gastrointestinal stromal tumor, which is mainly treated by surgery. For patients with no shrinking or huge tumors after drug treatment and located below 5 cm from the anus, abdominoperineal combined radical resection is mostly used, but postoperative permanent enterostomy affects the quality of life of patients. We used local resection through the posterior anal sphincter approach to achieve the effect of R0 resection and preservation of anal function in the treatment of the above rectal stromal tumor.

The occurrence of ischemic stroke is closely related to the severity of carotid artery stenosis. Plaque instability caused by carotid plaque inflammatory activity and intracranial hemodynamic abnormalities in patients with carotid artery stenosis are also important risk factors for ischemic stroke. For different individuals, evaluating the potential stroke risk on the basis of effective evaluation of the severity of carotid artery stenosis will be of great significance for the determination of clinical treatment plan and the evaluation of prognosis and efficacy of patients. A total of 102 patients with different degrees of carotid artery stenosis were admitted to Daqing Oilfield General Hospital in Heilongjiang Province from June 2012 to September 2014. cerebrovascular reserve (CVR) and serum high sensitivity C-reactive protein (hs-CRP) were detected, in order to provide some basis for predicting the risk of ischemic stroke in patients with carotid artery stenosis.

At present, interventional therapy has become a routine treatment for lower extremity arteriosclerosis obliterans^[1]However, interventional therapy has no obvious advantage for postoperative primary patency rate, especially the high incidence of restenosis after long-segment occlusion^[2]。 From January 2004 to January 2013, Quzhou People's Hospital of Zhejiang Province treated 384 patients with long-segment occlusion of lower extremity arteriosclerosis diagnosed for the first time. Anticoagulation combined with anti-platelet aggregation and double anti-platelet aggregation were administered, which are reported as follows.

primary retroperitoneal myxoid liposarcoma (PRMLS) is a rare low-grade malignant tumor, mostly with occult growth, and the onset location is located behind the peritoneum, with a large gap and hidden space. Most patients lack specific symptoms and signs in the early stage, and the tumor is often large at the time of consultation, and it compresses and invades the surrounding organs and tissues, which brings great difficulties to surgical treatment. Its preoperative diagnosis mainly depends on imaging. Because preoperative puncture biopsy may cause tumor dissemination and metastasis, it is not used clinically. Complete surgical resection remains the standard treatment for PRMLS. The effects of adjuvant radiotherapy and chemotherapy and molecular targeted therapy before and after surgery still need to be confirmed by further clinical studies.

Breast cancer is one of the most common malignant tumors in women. The incidence of breast cancer in China has jumped to the first place among female malignant tumors. Up to now, axillary lymph node dissection (ALND) is the gold standard for surgical treatment of patients with clinical axillary lymph node positive breast cancer, but intraoperative damage to the lymphatic duct system draining to the axillary limb is also the main cause of postoperative upper limb edema^[1]。 In recent years, axillay reverse lymphatic mapping (ARM) technology has become a research hotspot in preventing upper limb edema after breast cancer surgery, which is expected to bring good news to breast cancer patients.