2015年 · 第30卷第12期

Long-term good vascular access is the lifeline of patients undergoing maintenance hemodialysis, and the function of vascular access is an important factor affecting the dialysis effect and long-term survival rate of patients. At present, in China, autologous arteriovenous fistula has always been the first choice for long-term dialysis patients. For some patients with deep superficial veins, how to maximize the use of autologous vascular resources and provide them with better use efficiency and longer-lasting vascular access, clinicians have different reports, and their curative effects vary^[1,2]。 From September 2012 to December 2014, Guizhou Cancer Hospital identified uremic patients with poor superficial vein system of autologous arteriovenous fistula in the forearm and upper arm through clinical vascular assessment and color vascular Doppler ultrasound screening of limbs. 30 cases of superficial fistula vein placement were performed, and good clinical results were achieved, which are reported below.

Anastomotic hemorrhage is one of the dangerous complications after radical resection of colorectal cancer. It can be life-threatening if it is not discovered in time or treated improperly. The incidence rate is 0.5% ~9.6%, and the incidence rate is higher after rectal cancer surgery^[1]。 In this paper, the possible causes of anastomotic hemorrhage after radical resection of right colon cancer were retrospectively analyzed, and the intraoperative preventive methods and the best postoperative treatment methods were summarized.

Surgical incision infection accounts for 12% ~16% of nosocomial infections, so reducing surgical incision infection is one of the important links to reduce iatrogenic infection. We retrospectively analyzed the clinical data of 70 patients who underwent exploratory biliary tract surgery through the original incision for recurrent biliary calculi, which are now reported below.

Hashimoto's thyroiditis (HT), also known as chronic lymphocytic thyroiditis, is an autoimmune disease, often combined with papillary thyroid cancer (PTC). The relationship between these two diseases is a hot research topic at present^[1]。 At present, there are few studies on the regularity and characteristics of lymph node metastasis in PTC patients with HT. We conducted a retrospective study of 243 patients with PTC in an attempt to inform the extent and extent of cervical lymph node dissection in such patients.

laparoscopic appendectomy (LA) is the most widely used laparoscopic surgery in clinical practice. However, patients with appendicitis such as appendix perforation, gangrene or severe underlying diseases are often encountered in clinical work. For this type of complicated and difficult appendicitis (CA), traditional open appendectomy (OA) is still recommended in clinical practice. Our clinical data on complicated and difficult appendicitis compared with LA and OA for safety and clinical efficacy.

The uremic stage of chronic renal insufficiency is an irreversible stage of kidney disease. "Dialysis" has become an indispensable way to maintain survival. The establishment of autologous arteriovenous fistula (AVF) is often the first choice in clinical practice. However, for patients with poor autologous arteriovenous condition or failure after many fistulas, arteriovenous grafts (AVG) can be established by artificial blood vessel bridging to maintain dialysis treatment. From January 2012 to December 2013, 39 cases of AVG were established by artificial blood vessels with a diameter of 4 to 6 mm in our department, and 37 cases (94.9%) were successfully used. The average dialysis was 2.5 times per week. Follow-up for 12 to 24 months has achieved good results, which are reported as follows.

Compared with other types of breast cancer, triple-negative breast cancer (TNBC) has the characteristics of strong invasiveness, easy visceral metastasis and poor prognosis. Due to the lack of endocrine and specific targeted therapy, the current treatment methods mainly rely on chemotherapy. There are few studies on the expression of P53 and vascular endothelial growth factor (VEGF) in triple negative breast cancer. This study analyzed the expression of P53 and VEGF in triple negative breast cancer by immunohistochemistry to understand their relationship with clinicopathological features and prognosis of triple negative breast cancer.

Lower extremity arteriosclerosis obliterans is a chronic occlusive disease of lower extremity arteries caused by atherosclerotic lesions. percutaneous transluminal angioplasty (PTA) has good short-term efficacy, but it is prone to in-stent restenosis. The restenosis rate of superficial femoral artery (SFA) is as high as 30% ~80% at 6 months after operation^[1]At the same time, the treatment of in-stent restenosis is difficult, and the long-term effect of PTA again is not good. This article retrospectively analyzed and compared the effects of 12 patients (group A) treated with SilverHawk plaque resection system and 15 patients (group B) treated with PTA for restenosis after superficial femoral artery stenting between September 2012 and May 2014 in Sanming First Hospital Affiliated to Fujian Medical University, which are reported below.

For advanced gastric carcinoma (AGC), D2 or D3 surgery cannot be uniformly selected, and individualized lymph node dissection should be performed according to the degree of lymph node metastasis. In order to perform scientific and rational individualized lymph node dissection, we propose secondary sentinel lymph node^[1]secondary sentinel lymph node (SSLN) and individualized lymph node dissection for AGC guided by SSLN theory are reported below.

A 52-year-old male patient. He was admitted to the hospital on 20 September 2013 because he found that the neck mass was gradually increasing. There was no local redness, heat, tenderness and other discomfort in the tumor, which gradually increased and continued to grow symmetrically around the neck, resulting in a weight gain of more than 30 pounds. At the same time, there was a sense of pressure in the neck, and the turning of the head was limited, without pain, hoarseness, breathing and dysphagia. I have been drinking for 35 years, about 1~2 pounds a day. No history of liver disease. There is no similar disorder in the family. Physical examination: the neck mass grew around the neck for one week, prominent on both sides of the neck, the surface skin was intact, no redness and swelling, the swollen substance was soft, the boundary was unclear, and there was no tenderness (Figure 1), multiple fat pad tissues throughout the body. Magnetic resonance imaging MRI occipital fat deposition (Figure 2), initial diagnosis: Madelung's disease. Surgical resection was performed under general anesthesia. During the operation, a tumor was seen on the back of the neck, about 30 cm ×20 cm, with soft texture and unclear boundary. The adipose tissue showed diffuse proliferation without obvious envelope, the incision surface was yellow, the boundary with the surrounding tissue was unclear, and the subcutaneous adipose tissue continued. Intraoperative freezing showed adipose tissue, so the neck mass was completely removed according to the original plan. Postoperative pathology (Figure 3): Lipomatosis, local accumulation of muscle.

Case 1 was a 34-year-old female. He was admitted to hospital on September 6, 2010 due to "edema of both lower limbs, gradually aggravated for 3 months". Total hysterectomy + left adnexectomy + pelvic mass resection was performed 18 months ago. Physical examination at admission: superficial varicose veins of the abdominal wall and no concave edema of the lower limbs. B-ultrasound: solid filling in the whole course of inferior vena cava and right hepatic vein, thrombosis; CT: space-occupying lesions in inferior vena cava and right atrium (FIG. 1A)； MR: pelvic cavity, left internal iliac vein, common iliac vein, inferior vena cava nodular mass shadows. Inferior vena cava angiography was performed after admission, which showed the full course of inferior vena cava and right atrial filling defects. The proposed surgery is ureteral intubation, pelvic mass resection, and non-stop cardiopulmonary bypass inferior vena cava mass resection. Intraoperative observations: the tumor grows along the pelvic internal vein plexus, beaded, tough in texture, closely related to the surrounding tissues, and extends upward along the left ovarian vein. The left ovarian vein was resected first, and the left internal iliac artery and vein were ligated at the same time. The tumor in the pelvic cavity was thoroughly cleared, and the bleeding volume reached 4 000 ml. The inferior vena cava tumor had to be changed to stage II. Twelve days later, the combined thoracoabdominal incision (the median of the chest and the outside of the right rectus abdominis muscle) was performed, and cardiopulmonary bypass was established by constant jumping, and the superior vena cava and ascending aorta of the right atrial appendage were cannulated (FIG. 1B)。 The retroperitoneal free inferior vena cava was incised above the iliac vein bifurcation, and the bleeding was recovered by cardiopulmonary bypass. Use the endometrial stripper to penetrate deep into the left and right iliac veins to separate the tumor body, drag the distal end of the tumor body out, and then use the endometrial stripper to penetrate deep into the proximal end of the inferior cavity to separate the adhesion between the tumor and the vein wall. The entrance of the inferior vena cava of the right atrium was incised, and the bleeding was also recovered by extracorporeal circulation. The tip of the tumor was pulled out with a finger, and then pulled upward, and the whole tumor was dragged out from the inferior vena cava, and the tumor was completely removed (Figure 1C)。 The patient recovered well after operation, and pathology showed: intravascular leiomyoma. There was no recurrence after 4 years of follow-up.

Case 1 was a 52-year-old male. Severe chest pain for 2 h was admitted on 3 Apr 2013. The enhanced CT diagnosis was "multiple penetrating ulcers of the aorta". He has suffered from coronary heart disease and hypertension for many years. After admission, the symptoms were relieved by conservative treatment. One month later, CT reexamination showed that the ulcer increased and deepened. Surgical procedures under general anesthesia: (1) Angiography of the left dominant vertebral artery. (2) Three catheter guidewires were sent through bilateral brachial artery and left carotid artery puncture, of which the left subclavian artery catheter was sent to the aortic valve, angiography and measurement, and the right brachial artery catheter guidewire and the left common carotid artery catheter guidewire were sent to the descending main. (3) Cook TBE42-81 stent was implanted into the ascending main through right femoral artery incision, and the position of the two ulcers in the ascending main was defined by right anterior oblique angiography, and the stent was positioned by left anterior oblique angiography. (4) Controlled Hypotension, SBP<90 mmHg, after release of the ascending main stent, angiography confirmed disappearance of the ascending main ulcer and patency of the supraarchal branches. (5) Shenzhen Lifetime XJZDZ 40160 stent was sent to the descending part of the arch through the femoral artery to block the left subclavian artery. (6) EV3 10 mm ×60 mm chimney stent was fed through the left subclavian artery route, and the aneurysms and ulcers in the descending part of the contrast arch disappeared. (7) There was no abnormality in intracranial circulation confirmed by angiography. (8) Shenzhen Lifetime XJZDZ34080 stent was delivered through the femoral artery to block the ulcer above the celiac trunk. (9) Suture the incision. After more than 12 months of follow-up, the ulcer disappeared with enhanced CT scan, and there was no endoleak (Figure 1)。

Case 1 was a 54-year-old male. On April 29, 2014, the patient was admitted to the hospital. Six years ago, the patient was diagnosed with aortic dissection due to acute thoracic and dorsal tear-like pain. The patient underwent endovascular repair of aortic dissection in the emergency department. The patient was in good general condition after operation, and there were no positive signs on physical examination. Reexamination of CT large angiography showed: changes after aortic dissection stent operation and celiac artery stenosis. Aortic angiography showed that the celiac trunk and true cavity were supplied with blood, and the blood flow was smooth. The patient had no obvious abdominal pain, upper abdominal vascular murmur and weight loss symptoms. The patient found celiac artery stenosis, typical fishhook-like changes and poststenotic dilatation during postoperative CT review (Figure 1), and was diagnosed as celiac artery compression syndrome (CACS). Considering that the patient had no obvious self-conscious symptoms, no treatment was performed. Follow-up for 9 months, the patient had no abdominal discomfort symptoms.

In a 63-year-old male, a left axillary mass was found for 1 week. Physical examination: A mass with a diameter of about 5 cm can be palpable in the left axilla, which is fused into a mass, with unclear boundaries, can be pushed, no tenderness, less smooth surface, no ulcers and depressions in the skin, no redness and swelling, no mass palpable in the left supraclavicle and right axilla, and no edema in the left upper limb. There were no positive signs in the abdomen. Laboratory tests showed: serum CEA 270 ng/ml, AFP 2.05 ng/ml, CA19-9 21.46 U/ml, albumin 42 g/L. Auxiliary examination: B-ultrasound examination showed multiple lymph nodes swollen in the left axillary area, but lymphoma was not excluded. Chest CT examination showed multiple soft tissue nodules in the left axilla, partially fused, with lower density, the largest about 23 mm in diameter, and multiple swollen lymph nodes in the left axilla (Figure 1)。 Surgical resection was performed. Intraoperative pathological examination of the resected specimens showed: grayish-yellow and grayish-red tissue, the size was 6 cm ×5 cm ×2 cm, and swollen lymph nodes could be palpable within it, the large one was 4 cm in diameter and the small one was 1.5 cm in diameter. A poorly differentiated carcinoma (adenocarcinoma) can be seen in the lymph nodes (left axilla). Immunohistochemical staining showed: CK7 (+ +), CK20 (−), CK5/6 (−), TTF-1 (−), CD3 (−), PAX-5 (−). Abdominal CT examination showed uneven thickening of the gastric wall in the gastric antrum, local annular stenosis, acceptable peripheral space, and rounded soft tissue nodules with rough edges were seen at the mesenteric root below the head of the pancreas. Considered gastric antrum cancer (Figure 2)。 Gastric cancer was confirmed by gastroscopy. Exploratory laparotomy and palliative gastric cancer surgery (Bi II). Postoperative pathological report: (gastric antrum) moderately differentiated adenocarcinoma (bulge type, size 7 cm ×3 cm), invading the serosa, not involving the upper and lower surgical margins, no cancer metastasis was found in the lymph nodes and omentum tissues of small curvature (0/6) and large curvature (0/2), groups 7, 8, 9 (0/1) and 12 (0/2).

A 25-year-old female was admitted to the hospital on 6 February 2006 with recurrent abdominal distension for 1 year and aggravation for 6 months. No trauma, cirrhosis, tuberculosis. Physical examination showed abdominal distension, liquid wave tremor positive, albumin 27.6 g/L, tuberculin test and acid-fast staining negative, tumor index negative, hepatitis B negative. Abdominal puncture showed yellow-white chyle ascites, positive chyle test, positive Sudan red III staining, and no tumor cells. CT showed massive ascites and diffuse lesions of the spleen; Radionuclide imaging showed no abnormalities in abdominal lymphatic pathway. Fourteen days after admission, laparoscopic exploration revealed a large number of dilated lymphatic vessels and lymphatic blisters in serosa and mesentery of small intestine. Sudan Red Ⅲ test showed that ascites stained red after eating for 6~10 h. There was no discomfort in the autologous intravenous reinfusion of ascites. Lower extremity venography showed good function of bilateral saphenofemoral valves. Twenty-one days after admission, the patient underwent exploratory laparotomy under general anesthesia, which showed a large amount of chyloascites in the abdominal cavity, and a large number of dilated lymphatic vessels and lymphatic vesicles in the spleen, mesenteric membrane and serosa of small intestine (FIG. 1A)。 Six hours before surgery, the patient took Sudan Red III and underwent lymphangiography, but no lymphatic fistula was found. Intraoperative pathology showed splenic lymphangioma, mesenteric hyperplasia of lymphoid tissue and dilated lymphatic vessels, considering the primary small intestinal lymphangiectasia. In view of the preoperative imaging examination revealing diffuse lesions of the spleen, extensive intestinal segments of the lesions and a large number of lymphoid blisters on the surface of the spleen during the operation, splenectomy + left great saphenous vein inversion peritoneal-femoral vein bypass was performed (FIG. 1B)。 In order to avoid twisting and compression of the bridge vein, an artificial blood vessel with a shunt vein jacket and ring is used (Figure 1C)。 Patients' symptoms were relieved after surgery; After 8 years of follow-up, the general condition was good and there was no recurrence of massive chyloascites.