2016年 · 第31卷第07期

Since Reich first performed laparoscopic hepatectomy (LH) in 1991, laparoscopic hepatectomy has been widely popularized and applied, ranging from local resection to enlarged hemihepatectomy, and even the acquisition of donor liver by living donor liver transplantation, with lesions involving various benign and malignant tumors of the liver and intrahepatic bile duct stones. Although the number of LH surgery cases has increased explosively, most of the current literature reports that LH is mainly limited to simple peripheral parts of the liver. The international consensus of laparoscopic liver resection in Louisville, USA in 2008 and Morioka, Japan in 2014 also regards single benign and malignant tumors with a tumor diameter of ≤5 cm and located in the peripheral liver segment (Ⅱ, Ⅲ, Ⅳb, Ⅴ, VI) as the recommended surgical indication for LH. Laparoscopic left external lobe and left hemihepatectomy have even become the standard surgical procedures for LH. However, the lesions of the right posterior upper liver segment (VII, VIII, IVa) and the caudate lobe (Ⅰ) of the liver have always been considered unsuitable for laparoscopic surgical resection because of their deep location, complex anatomical relationship, poor visual field and difficult operation^[1]。

Primary hepatocellular carcinoma (hepatocellular carcinoma for short) is highly malignant, and vascular invasion can occur in the early stage, among which portal vein system is common^[1,2]While invasion of hepatic vein, inferior vena cava and even right atrium is relatively rare. At present, there are different reports on the incidence of liver cancer complicated with inferior vena cava tumor thrombosis^[1,3,4,5,6]。 Because liver cancer with inferior vena cava tumor thrombus is advanced, and the tumor is prone to distant metastasis, the surgical efficacy is poor. In addition, squeezing the inferior vena cava during tumor separation during operation can easily lead to the tumor thrombus falling off, causing pulmonary embolism, cardiac tamponade and other fatal complications, there are risks during operation and certain technical difficulties. In the past, scholars have considered that active surgical methods should not be adopted in the treatment of liver cancer patients with inferior vena cava tumor thrombosis^[7,8]。 With the development of imaging techniques and surgical techniques, recent data show that long-term survival can be achieved after complete resection of tumor thrombus and liver tumors^[2]。 Yamanaka et al.^[9]In a group of 22 patients with liver cancer and hepatic vein tumor thrombus who underwent surgical treatment, 4 patients had hepatic vein tumor thrombus entering the inferior vena cava, 1 patient had tumor thrombus entering the right atrium, and 1 patient with inferior vena cava tumor thrombus had survived for 15 years. 2013 Wang et al.^[10]By comparing 25 cases of hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus undergoing surgical treatment with 31 cases of hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus undergoing non-surgical treatment, it is concluded that the average survival time of patients undergoing surgical treatment is far longer than that of non-surgical patients. According to the current clinical examination methods, there is no difficulty in diagnosing the size, location, length and obstruction degree of tumor thrombus in inferior vena cava before operation. In addition to Doppler ultrasound, CT, MRI and other examinations, magnetic resonance angiography (MRA) and vena cava angiography can visually show the condition of tumor thrombus, which is very beneficial for the selection of surgical procedure, estimation of surgical difficulty, possible difficulties and preparation of countermeasures. In recent years, it is believed that if no local or distant metastasis is found, radical resection of liver cancer and then removal of hepatic vein tumor thrombus and removal of inferior vena cava tumor thrombus will have a good prognosis. On the contrary, if no active surgical treatment is found, patients will soon die or systemic metastasis will occur^[11,12]。

Severe abdominal infection is a common critical disease in surgery, and it is easy to complicate with fungal double infection after surgery. From March 2010 to October 2014, the Fifth Affiliated Hospital of Sun Yat-sen University administered adjuvant immunotherapy to 88 patients with severe abdominal infection admitted to ICU to reduce the incidence of fungal secondary infection and improve the cure rate. The report is now as follows.

pancreaticoduodenectomy (PD) is the main surgical procedure for the treatment of pancreatic and periampullary diseases, and pancreatic fistula is the main complication after PD and the main cause of postoperative death. This study retrospectively analyzed the clinical data of 87 patients treated with PD in our department since January 2013, and further discussed the penetrating intermittent pancreatojejunostomy^[1]The clinical value of.

The treatment of lumbar hernias is mainly surgical repair. lumbar hernia needs a large free space when performing tension-free repair, and fixation is also a difficult problem when using materials for repair. There are few relevant literature reports at home and abroad^[1]。 From August 2011 to October 2015, the First Affiliated Hospital of the People's Liberation Army General Hospital applied self-adhesive patch to repair 7 cases of lumbar hernia by Sublay method, which are reported below.

In this study, the expression of EGFR, PI3KP110 α and PI3KP110 β in gastric cancer and normal gastric mucosa was detected by immunohistochemistry, and the relationship between the expression of EGFR and the expression of PI3KP110 α and PI3KP110 β was analyzed. The significance of the expression of EGFR, PI3KP110 α and PI3KP110 β on the prognosis of gastric cancer patients was evaluated.

mesenteric panniculitis (MP) is a rare chronic nonspecific inflammatory response and fibrotic lesion involving mesenteric adipose tissue^[1]Its symptoms are complex and diverse, and it lacks specific clinical and imaging manifestations, so the disease is easily misdiagnosed and missed. This study intends to make a comprehensive analysis of 2 cases diagnosed in our hospital, aiming at improving clinicians' understanding of mesenteric panniculitis and improving the level of diagnosis and treatment of this disease.

Andersson et al.^[1]Suspected appendicitis was assessed by classifying patients into low-risk, medium-risk, and high-risk based on the appendicitis inflammatory response (AIR) score. Patients with suspected appendicitis admitted to our department were retrospectively analyzed, and risk stratification based on AIR score was used to assess whether it could be safely used for clinical decision-making of suspected appendicitis, optimizing imaging diagnosis and reducing the rate of negative exploration.

A 46-year-old woman underwent thoracic and upper abdominal CT during radical thyroidectomy for papillary thyroid carcinoma in the thyroid surgery department, which showed that the spleen occupied space, multiple intrahepatic cysts, small hemangioma in the right posterior lobe of the liver, cyst and hamartoma in the left kidney. Combined with the patient's history of thyroid malignant tumor, considering the spleen occupation, Da Vinci robot-assisted laparoscopic splenectomy was performed after perfect examination. Postoperative pathology: A gray-yellow-gray-red nodule with a size of about 9.5 cm ×6.5 cm ×5.5 cm was seen at the lower pole of the spleen (Figure 1)。 In the gray-yellow gray-red substance of the section, gray-white cords can be seen interspersed and separated in the center of the tumor. Significant proliferative fibrous tissue surrounding each hemangiomatous nodule was observed under pathological microscope. The nodules vary in size, and some nodules are clearly bounded (Figure 2)。 The nodule consists of a cleft-like or irregularly expanding sinus-like vessel space located in the central region and a target ring-like tightly arranged fusiform and oval cells around it (Figure 3)。 The pathological diagnosis was sclerosing hemangiomatous nodular transformation of the spleen. There were no complications such as hemorrhage, thrombus and infection, and no abnormalities were found after 9 months of follow-up.

The patient was a 63-year-old male. He was admitted to the Department of Hepatobiliary Surgery of our hospital on June 5, 2015 due to "physical examination found that the liver occupied 2 days". No previous history of hepatitis, denied history of blood transfusion; Anemia and any history of iron use were denied. Has a habit of smoking (20 cigarettes/d) and drinking (250-300 ml/d, more than 20 years). Physical examination of abdomen showed no obvious positive signs. Blood routine showed mild anemia; Biochemistry: AST 41.5 U/L, GGT 300.9 U/L, total bilirubin 26.0 μ mol/L, direct bilirubin 9.0 μ mol/L, total bile acid 28.3 μ mol/L, the rest were normal; Hepatitis markers were all negative; Digestive tract tumor markers were all normal. Blood glucose: 6.57 mmol/L. CT showed increased hepatic parenchymal density (Figure 1), the S6 segment of the liver occupied space, and the enhancement showed the manifestation of "fast in and fast out"; Subcapsular space occupied at the junction of S2 and 3, with marginal enhancement in the arterial phase, enlarged enhancement in the portal phase, and isodensity in the peripheral enhancement area in the delayed phase, while the low density range in the arterial phase decreased. Gd-EOB-DTPA enhanced MRI showed diffuse reduction of T2WI hepatic parenchymal signal (FIG. 2A), in-phase signal (Figure 2B) significantly lower than the reverse phase, consider hepatic hemochromatosis; S6 lesions were significantly enhanced in the arterial phase and showed a slightly higher signal in the portal phase (Figure 2C), in the hepatocyte phase (delay of 20 min), the liver showed diffuse signal reduction, and the liver S6 lesion showed slightly low signal; The enhancement method of left lobe lesion is the same as CT. Combined with CT/MRI, S6 lesions, HCC was considered; The left lobe lesion is considered as a malignant tumor, and intrahepatic cholangiocarcinoma (ICC) is possible. Surgical exploration was performed on June 10, 2015: the liver was reddish-brown, the surface was covered with sclerotic nodules, and the liver lobes were not atrophied. A hard mass with a diameter of about 2.5 cm was observed at the liver margin at the junction of S2 and 3; Liver S6 palpable a hard mass with a diameter of about 4 cm occupying space. Rapid pathological return of biopsy: liver S2, 3 occupied: intrahepatic cholangiocarcinoma, liver S6 occupied: HCC. Anatomical liver S6 resection + S2, 3 resection + regional lymph node dissection (D2) was performed. Postoperative pathology: Liver S6: HCC, moderately-highly differentiated, sorghum type; Liver 2, 3: cholangiocarcinoma, well differentiated; The peripheral liver showed mild steatosis and cholestasis (G2, S2) with intracellular pigmentation, positive iron staining (Figure 3)。 Postoperative examination: serum ferritin: 2 509.5 ng/ml, serum iron 5.5 μ mol/L. Blood was drawn 10 days after surgery for HFE gene of hereditary hemochromatosis type 1: negative, and no mutation of disease-causing gene was detected. Combined with medical history, HFE-related hereditary hemochromatosis was excluded, and secondary hemochromatosis caused by long-term alcohol consumption was considered. Because the symptoms were not obvious, and the damage to liver, heart and pancreas function was not obvious, no bleeding treatment was performed, and oral iron chelating agent was ordered for follow-up.

A 42-year-old female was admitted to hospital with epigastric pain for more than 3 years, aggravated for 2 months and fever. Physical examination: T: 39.5 ℃; P: 104 times/min; R: 19 times/min; BP: 129/75 mmHg, conscious, exhausted constitution, acute painful face, no yellowing stain of skin and sclera, slightly swollen abdomen, obvious tenderness around the umbilicus and upper abdomen, abdominal muscle tension, no rebound pain, no mass, and normal intestinal sounds. Laboratory tests: HB: 102 g/L; RBC: 3.78×10¹²/L; WBC: 17.53×10⁹/L; N: 88.0%; L: 8.9%; PLT: 123×10⁹/L. Albumin 20 g/L; No abnormalities were observed in AFP. Abdominal color ultrasound: The volume of the left lobe of the liver increased, and the hypoechoic areas of 4.8 cm ×4.3 cm and 3.0 cm ×2.9 cm were detected in the right anterior lobe of the liver, respectively. Emergency total abdominal CT: Large patches of low-density shadows were seen in S4 and S8 segments of the liver, with the maximum size of 11.9 cm ×6.0 cm, unclear boundary and irregular shape, and stripe calcification was seen inside. After admission to hospital with anti-infection, symptomatic and supportive treatment, the patient did not see significant improvement in abdominal pain and high fever, and underwent emergency exploratory laparotomy. During the operation, a pus cavity was explored between the left inner lobe and the right anterior lobe of the liver, and the pus was extracted by puncture with syringe. The abscess was incised at the puncture point, and about 150 ml of pus was aspirated. A fish bone of about 5.0 cm was touched in the abscess cavity (Figure 1), place a drainage tube, close the abdomen and close it. Compared with preoperative CT examination, the abscess was obviously absorbed and reduced (Figure 2)。 The patient recovered well and was discharged on day 12.

A 64-year-old male was admitted mainly for "melena for 2 months". Physical examination: deep tenderness in the upper abdomen, no rebound pain and muscle tension in the whole abdomen. There is a hard mass about 2 cm ×2 cm in size at the dorsal finger web between the 1st and 2nd toes of the left foot. There is uneven melanin deposition on the surface of the mass and the surrounding skin, the local skin temperature is not high, the boundary between the mass and the surrounding tissues is still clear, the mobility is poor, and there is no tenderness when touched. Follow-up to the medical history, the patient complained that there was a black mole about 0.5 cm in diameter on the back of his left foot since childhood, and the surface skin did not bulge. In the past 2 years, the black mole gradually increased and bulged on the skin surface. Without treatment, seeFigure 1。 Enhanced CT examination of the abdomen: thickening of the lateral wall of the great curvature of the stomach (locally nodular), seeFigure 2。 Gastroscopy: Multiple bulges of varying sizes were seen in the body of the stomach, the bulb of the duodenum and the descending part, with a maximum of about 3.0 cm ×3.5 cm, without pedicle, and a black necrotic object was seen attached to the center of the bulge, seeFigure 3。 Endoscopic diagnosis: multiple bulging lesions of the stomach and duodenum. Biopsy pathology: malignant tumor of gastric body and descending duodenum, considered malignant melanoma, seeFigure 4。 Immunohistochemical examination: S-100, HMB-45 and Melan-A all (+). Combined with the medical history of the dorsal foot, the patient was diagnosed as gastroduodenal metastatic malignant melanoma. The patient abandoned treatment for his own reasons.

hepatocellular carcinoma (HCC) accounts for more than half of the global HCC in China. Ranked 3rd^[1]。 For unresectable HCC, transcatheter arterial chemoembolization (TACE) is the preferred adjuvant treatment.