2016年 · 第31卷第05期

As a classic surgical procedure for the treatment of periampullary tumors, pancreaticoduodenectomy has a history of more than 100 years, and it is very mature in terms of resection steps, scope and digestive tract reconstruction. Especially in the past two decades, with the renewal and development of surgical concept, imaging technology, energy platform, etc., combined vascular resection, combined organ resection, extended radical resection, total mesangial pancreatectomy and other surgical procedures have been widely carried out, but the perioperative mortality rate has decreased greatly with the increase of surgical complexity. At present, it has dropped to below 3% in large-scale pancreatic surgery centers, reflecting the great improvement of surgical safety. However, pancreaticoduodenectomy, as one of the most complicated procedures in abdominal surgery, is still accompanied by a high risk of perioperative complications, with an incidence rate of about 30% ~50%; In addition, as one of the indications of this procedure, although the resection rate of pancreatic head cancer has improved to some extent, the prognosis is still not significantly improved. Therefore, around the classic surgical procedure of pancreaticoduodenectomy, there are still hot issues emerging, reflecting the deepening cognitive process in twists and turns.

With the advancement of laparoscopic technology and the improvement of instruments, laparoscopic body and tail resection of pancreas has gradually become popular in large hospitals in China. Because the spleen and splenic arteries and veins are close to the tail of the pancreas, at present, tumors in the tail of the pancreas are often removed together with the spleen. Spleen is the largest lymphoid organ in human body, which has the functions of hematopoiesis, improving immunity, anti-infection, anti-tumor, immune and endocrine. We performed complete laparoscopic spleen-sparing body-and-tail pancreatectomy in 27 cases of body-and-tail pancreatic tumors from April 2011 to May 2015 with satisfactory results, which are now reported below.

By comparing the short-term efficacy of traditional laparoscopic surgery with laparoscopic combined anal endoscopic surgery for left colon cancer and middle to high rectal cancer, the purpose is to confirm the feasibility and efficacy of the latter surgery.

Intussusception accounts for 15% to 20% of intestinal obstruction, and adult intussusception accounts for about 5% of all intussusceptions^[1]The clinical misdiagnosis rate and mortality rate are relatively high^[2]。 Laparoscopic assisted surgery can quickly determine the etiology, the site of the lesion, the extent and degree of the involvement and intestinal canal, and make an effective surgical plan, which has definite clinical value. From January 2012 to July 2015, a total of 9 cases of adult intussusception were treated with laparoscopic assisted surgery in our hospital, and the clinical results were good, as reported below.

The management of residual incarcerated stones in the common bile duct after biliary tract surgery is still a thorny problem in biliary tract surgery. Although the development of choledochoscopy has provided an ideal method for the treatment of biliary tract stones, loosening and fragmentation are the key to the success of incarcerated stones in the biliary tract. It is difficult to successfully remove stones by net basket under choledochoscopy alone. Making full use of holmium laser technology in urology to carry out lithotripsy first and then remove stone with net basket can increase the success rate of operation. We treated 12 cases of residual common bile duct incarcerated stones after biliary tract surgery with holmium laser lithotripsy under T-tube sinus choledochoscope, and achieved satisfactory results.

The authors summarize the clinical data of 10 patients undergoing emergency surgery for giant stromal tumors of the abdominal cavity, and analyze the prognosis of patients treated with adjuvant therapy with imatinib mesylate after surgery, which are reported below.

The spiral valve structure in the cystic duct not only prevents the stones in the gallbladder from falling into the common bile duct, but also makes small stones remain in the cystic duct, resulting in residual stones in the cystic duct after laparoscopic cholecystectomy (LC), thus causing intractable pain or the formation of small gallbladder after operation. It has been reported in literature that the incidence of cystic duct stones after LC is as high as 11% ~20%^[1,2]。 The surgeon should therefore be aware of this risk^[3]。 In this regard, we changed the clamping action and sequence of the cystic duct during LC surgery, which we called the "semi-incision" technique of the cystic duct. The summary report is as follows.

primary hyperparathymidism (PHPT) caused by ectopic parathyroid lesions accounts for about 10% of PHPT. Ectopic lesions cause certain difficulties in diagnosis and surgical resection. From December 1995 to December 2012, a total of 5 cases of PHPT caused by ectopic parathyroid adenoma were surgically treated in our hospital. The summary report is as follows.

In recent years, the incidence of lower extremity deep vein thrombosis (DVT) is increasing year by year, and there are about 30-60 million patients with DVT every year in developing countries; Lower extremity post-thrombosis syndrome (PTS) is a serious complication of DVT. Studies have shown that about 20% ~50% of DVT patients develop PTS within two years, and about 5% ~10% of them are accompanied by venous ulcer^[1]Despite the continuous progress in the diagnosis and treatment of lower limb DVT, about 30% to 50% of patients will develop PTS within 2 years, and about 10% of patients will have severe PTS. For PTS, there is still a lack of ideal treatment methods, in order to explore the effective treatment of PTS. The clinical data of 30 patients with PTS treated by endovascular therapy in Luoyang Central Hospital affiliated to Zhengzhou University from January to December 2012 are reported below.

Pleural effusion is one of the most common early complications after gastric cancer surgery. When the amount of pleural effusion is large, patients will have symptoms such as low fever, chest tightness and shortness of breath, and more than moderate amount of pleural effusion will lead to lower lung atelectasis and aggravate lung infection. Therefore, it is particularly important to study the related factors of symptomatic pleural effusion in the early postoperative stage of gastric cancer and further summarize the effective preventive measures. The clinical data of 267 patients undergoing gastric cancer surgery were retrospectively analyzed in this study and are now reported below.

With the progress of laparoscopic technology and the improvement of patients' requirements for cosmetic effect, laparoscopic thyroid surgery has become increasingly common, and its characteristics of less trauma and obvious cosmetic effect make up for the deficiency of open surgery. Conventional laparoscopic thyroid surgery requires filling the subcutaneous space with CO₂Gas, which uses air pressure to establish and maintain surgical operating spaces, is often "more than spacious and less stable". From January 2014 to January 2015, we used a self-made "mini-elastic cavity building device", with the suprasternal fossa as the entrance, elastic distraction anterior cervical region flap combined with low pressure (0~3 mmHg) CO₂43 cases of endoscopic thyroid surgery were performed by pneumatic cavity building, and the results were satisfactory.

Patient, female, 43 years old. He was admitted to hospital for 7 years due to the discovery of a right neck mass. The patient recently felt dyspnea, no bone pain and pathological fracture, no discomfort symptoms such as renal colic and hematuria. Physical examination: the trachea moved left, the lower pole of the right lobe of the thyroid gland touched the tumor, no tenderness, tough texture, smooth surface, regular shape, clear boundary, and can move up and down with swallowing action. Thyroid ultrasound: diffuse echogenic abnormalities of the thyroid gland; Larger cystic anechoic (7.1 cm ×3.7 cm) in the right lobe of the thyroid, seeFigure 1。 Laboratory test: serum calcium 2.35 mmol/L (2.05~2.85 mmol/L), serum phosphorus 1.41 mmol/L (0.80~1.6 mmol/L), parathyroid hormone 67.80 pg/ml (14~72 pg/ml), thyroid function test: thyroid peroxidase antibody>1 300.0 IU/ml (0~60 IU/ml), TSH 54.018 mIU/L (0.55~4.78 mIU/L), and no abnormalities were found in other indexes. Clinical diagnosis: goiter (right lobe), Hashimoto's thyroiditis. Goiterectomy was performed. During the operation, bilateral thyroid volume increased, and a cystic mass of 7.0 cm ×3.5 cm ×3.0 cm was seen at the lower pole of the right lobe of the thyroid gland, and the lower boundary could reach the suprasternal fossa. The cystic mass has a thin and transparent wall, a clear boundary with the surrounding tissues, and is easy to peel. The tumor ruptured during the operation and contained a large amount of transparent pale yellow fluid. The cyst wall of the mass was completely removed. Pathology: Parathyroid cyst (Figure 2)。 There were no postoperative manifestations of hypoparathyroidism such as numbness of hands and feet. On the first postoperative day, parathyroid hormone was 19.2 pg/ml (14-72 pg/ml), blood calcium was 2.12 mmol/L (2.05-2.85 mmol/L), and blood phosphorus was 1.30 mmol/L (0.80-1.6 mmol/L). On the 5th postoperative day, parathyroid hormone was 118.80 pg/ml (14-72 pg/ml), blood calcium was 2.17 mmol/L (2.05-2.85 mmol/L), and blood phosphorus was 0.86 mmol/L (0.80-1.6 mmol/L).

The patient, male, 78 years old, was admitted to hospital for more than 4 years due to the discovery of a reducable mass in the left lower abdomen. Four years ago, the patient found a bulging mass in the left lower abdomen when standing or when abdominal pressure increased. At that time, the mass was about 3 cm ×3 cm in size, and the manipulation could be returned by itself. There was no local redness, swelling, tenderness, nausea, vomiting, difficulty in defecation and other digestive tract symptoms, which were not treated. Abdominal wall ultrasound examination performed in our hospital 2 years ago showed that the continuity of the abdominal wall in the left lower abdomen was interrupted, about 0.9 cm. After increasing abdominal pressure, a hypoechoic mass could be detected and protruding from the abdominal wall to the abdominal cavity through the gap, with a size of about 2.1 cm ×1.1 cm. Abdominal wall hernia was considered. The patient had a history of chronic constipation and chronic obstructive pulmonary disease, and no history of abdominal trauma and surgery. Physical examination: The patient was instructed to stand up to increase abdominal pressure, and a protruding mass in the left lower abdomen was visible. The texture was soft to touch, no tenderness, the boundary was still clear, the maneuver could be returned, and the mass disappeared when the patient lay down. Laboratory tests showed no obvious abnormalities. Lower abdominal CT: Local deep fascia of the left lower abdominal wall is discontinuous, and local intra-abdominal fat protrudes outward (Figure 1)。 Surgical treatment under general anesthesia, combined with CT and mass position, a longitudinal incision of the left lower abdominal semilunar line was taken, and the skin was incised subcutaneously. Two small lipomas, about 2 cm ×2 cm in size, were found. The local external abdominal oblique muscle aponeurosis was weak, and the internal abdominal oblique muscle and transverse abdominal muscle were separated in its direction. Extraperitoneal fat hernia with a diameter of 5 cm was seen. The hernia ring was located on the left semilunar line with a maximum diameter of 3 cm, and the hernia contents had been returned to the abdominal cavity. Intraoperative diagnosis: left semilunar hernia. The hernia ring was continuously sutured with 1-0PDS-Ⅱ thread transversely, and there was no local weakness. The PDS-Ⅱ thread was continuously sutured with external oblique aponeurosis, the 2-0 absorbable thread was intermittently sutured subcutaneously, and the 3-0 absorbable thread was continuously sutured intradermally. Postoperative abdominal belt compression bandage, routine symptomatic supportive treatment, the patient recovered well after operation (Figure 2), and was discharged on the 5th postoperative day. There was no recurrence after 3 months of follow-up (Figure 3)。

iliac vein compression syndrome (IVCS), also known as May-Thurner syndrome and Cockett syndrome, mainly manifests as lower limb edema, superficial varicose veins, skin pigmentation or ulcer, etc. IVCS can be classified into 3 different types according to clinical presentation^[1]Namely: asymptomatic type, chronic venous insufficiency type, acute iliofemoral vein thrombosis type. The incidence of asymptomatic IVCS is high, which has been reported in the literature^[2,3]It is said that a higher proportion of patients in the asymptomatic population also have this anatomical compression, but do not exhibit any symptoms of venous hypertension due to low degree of stenosis or good collateral compensation, however about 1/4 of these patients have iliac vein stenosis>50%^[4]； Chronic venous insufficiency type IVCS usually manifests as chronic swelling and pain of the affected limb, which may be accompanied by varicose veins or venous ulcers. This type of lesion is mostly short segment stenosis or occlusion of the proximal common iliac vein; Acute iliofemoral vein thrombosis type IVCS often manifests as sudden swelling and pain of the lower limbs, which occurs in middle-aged female patients and is usually found after the venous thrombosis is cleared. The first two types of IVCS may be collectively referred to as nonthrombotic iliac vein compression lesions (NIVCLs). At present, with the development of diagnosis and treatment technology, some consensus has been reached on the diagnosis and treatment of IVCS at home and abroad, but there are still many controversies, among which the treatment of NIVCLs is the most controversial. This paper mainly discusses the current controversy and consensus of NIVCLs.

Phyloid breast tumor is a kind of rare fibroepithelial tumor, and the incidence rate is about 0.3% ~0.9% of all breast tumors, accounting for 2% ~3% of fibroepithelial tumors. We now review the progress in the diagnosis and treatment of breast phyllodes tumors as follows.