2016年 · 第31卷第11期

Intrahepatic bile duct stones are still one of the main problems that often need to be faced in the clinical practice of hepatobiliary surgery so far, and the specific treatment strategies, methods, curative effects, existing problems and how to ensure the safety of treatment of bilateral intrahepatic bile duct stones may all become practical challenges in the treatment process. The etiology of intrahepatic bile duct stones is unknown; Patients with bilateral calculi have great differences in the specific range of calculus distribution, whether there is coexistence of hepatic hilar or intrahepatic bile duct stenosis, the frequency and degree of biliary tract infection, whether there are symptoms of liver hypertrophy and atrophy syndrome, whether they have undergone surgery and the number and mode of surgery in the past, whether there has been biliary cirrhosis and portal hypertension, whether there is intrahepatic bile duct cancer, and the patient's general condition and whether there are other concomitant diseases. How to reasonably apply the basic principle of "removing lesions, relieving obstruction and smooth drainage" to the treatment of such complex and difficult cases on the premise of ensuring safety is a realistic problem worthy of attention and in-depth research. In the past literature, there are few comprehensive discussions on the diagnosis and treatment strategies and specific methods of bilateral intrahepatic bile duct calculi. According to my own practical experience, the author makes a preliminary discussion on the relevant clinical problems.

hepatocellular carcinoma (HCC) is the second leading cause of tumor-related death in China^[1]。 Chronic hepatitis B virus (HBV) is the most important cause of HCC in China. ground glass hepatocytes (GGHs) can be seen under light microscope in the liver tissues of chronic HBV patients in about 2/3 cases^[2]。 Recent studies have shown that GGHs, especially type II GGHs, are considered to be precancerous lesions of HBV-associated CC^[3]The relationship between the two has become a research hotspot at home and abroad. In this study, the expression of type Ⅱ GGHs in HBV-associated HCC tissues was detected by immunohistochemistry, and its relationship with clinicopathological parameters was analyzed.

The risk of acute appendicitis is 7% ~8%, and the incidence is 0.9‰ ~1‰^[1]It is not uncommon to have acute and critical conditions such as septic shock and intestinal obstruction secondary to missed diagnosis. Therefore, acute appendicitis is still considered a high-risk disease^[2]。 During their time as chief resident, the authors found that abdominal CT was able to significantly improve the accuracy of the diagnosis of acute appendicitis in adults, combined with the symptoms and signs of patients.

gastric submucocal tumors (GSMTs) are a large class of digestive tract tumors that originate below the mucosal layer. They are benign and common, including: leiomyoma, stromal tumor, neurogenic tumor, lipoma, etc., and tend to occur in the middle and upper part of the stomach, but less common in the cardia. Surgical resection is the only means of radical treatment^[1,2]。 In this study, the simple operation system of gastric cavity was established under the guidance of laparoscopy, and the submucosal mass resection of gastric cavity and cardia was performed. Good clinical results were obtained, which are reported below.

Rectal cancer is a common tumor of digestive tract in China. Radical abdominoperineal combined rectal cancer (Miles) is the standard surgical procedure for ultralow rectal cancer and anal canal cancer^[1]。 Traditional sigmoidostomy has great differences in stoma quality and many postoperative complications^[2,3,4]。 We visualized 8 cases of rapid extraperitoneal colostomy under laparoscopy and achieved good clinical results, which are reported below.

Pancreatic cancer is the worst prognostic tumor of the digestive tract, and the surgical resection rate is only about 20%^[1]Even if surgically resected, patients still die from local recurrence or distant metastases such as liver and lung. Two cases of pancreatic cancer after resection were recently treated in our department. There was no local recurrence but only isolated abdominal wall metastasis, which was relatively rare. It is reported in conjunction with the literature below.

peripheral arterial disease PAD refers to stenosis or occlusive disease of blood vessels in the limbs due to arteriosclerosis. Severe limb ischemia can often lead to severe intermittent claudication (claudication distance<100 m), resting pain, limb ulcers or gangrene, and even amputation. Inferior genicular artery occlusive diseases are mostly TASC grade D lesions, and endovascular treatment is difficult. Some people advocate endovascular treatment of inferior genicular artery occlusive disease according to Jenali classification and angiosome zoning theory of inferior genicular artery outflow tract^[1,2]。 The treatment experience of 65 patients with inferior knee artery lesions in our hospital from August 2012 to January 2015 is reviewed and summarized as follows.

The incidence of small intestine stromal tumors (SIST) accounts for 31% of all gastrointestinal stromal tumors^[1]。 The risk degree of SIST is related to tumor size, number of mitosis and tumor rupture^[2]。 This case of giant SIST with tumor rupture and bleeding was admitted to the emergency department. After complete resection of small intestine tumor, imatinib mesylate was not selected for adjuvant preventive treatment due to economic problems. According to the microsatellite sequence instability detection results, an individualized treatment plan was selected for microsatellite stability, and certain results were obtained. The report is as follows.

Endovascular stent implantation is the preferred treatment for iliac vein compression syndrome (IVCS), which has the characteristics of less trauma, quick recovery, less complications and high long-term patency^[1,2]However, there are still a few patients with deep vein thrombosis of the lower limbs after operation, resulting in different degrees of postthrombotic syndrome. The Second Affiliated Hospital of Suzhou University and Jiangyin Hospital of Traditional Chinese Medicine treated 259 patients with non-thrombotic IVCS and 9 cases of secondary deep vein thrombosis of lower limbs from January 2012 to January 2015. The reports are as follows.

Increasingly, surgeons tend to repair the entire musculopubic foramen on the affected side, that is, preperitoneal repair, in patients with inguinal hernia open or laparoscopically. We summarized 4 cases of intraoperative preperitoneal space active hemorrhage and 2 cases of postoperative preperitoneal space hematoma formation in the Department of General Surgery of the First Affiliated Hospital of Suzhou University, the Department of General Surgery of the Second Affiliated Hospital of Jiaxing University School of Medicine and the Department of Hernia and Abdominal Wall Surgery of the Second Affiliated Hospital of Zhejiang University School of Medicine from July 2007 to November 2015. The lessons learned are shared as follows.

A 34-year-old male was admitted with "epigastric pain for 1 d". The patient had sudden knife-like pain in the upper abdomen 1 day ago, which was paroxysmal, accompanied by abdominal distension and fever. Physical examination: T 38.6 ℃, abdominal muscle tension, total abdominal tenderness (+), lower abdominal rebound pain (+). Auxiliary test: C-reactive protein 46 mg/L, WBC 15.9×10⁹/L, N 0.83. Abdominal CT examination revealed digestive tract perforation (Figure 1)。 Then an emergency exploratory laparotomy was performed, and about 200 ml of purulent fluid was found in the right paracolonic sulcus. The cecum was located under the liver, and the appendix was located under the cecum. It was about 0.8 cm ×9 cm long, with congestion on the surface and no purulent coating. The small intestine was edema in the subhepatic part of the right upper abdomen, and the surface was covered with a large amount of purulent coating. The small intestine partially repeated deformity about 60 cm away from the ileocecal region showed a "T"-shaped change, about 8 cm long, and there was a diverticulum about 2 cm in the deformed intestinal segment with perforation (Figure 2)。 The purulent coating was absorbed, the deformed intestinal segment and surrounding adhesions were separated, and the deformed intestinal segment and diverticulectomy + end-to-end intestinal anastomosis were performed. Postoperative pathological report: intestinal duplication malformation with Meckel's diverticulum and gastric mucosa ectopia, local intestinal wall necrosis, focal perforation with acute peritonitis; Acute inflammation of the intestinal wall at both ends with acute inflammation of the serous membrane.

A 20-year-old female suffered from abdominal pain with fever for 10 d. 10 days ago, there was no obvious trigger for pain in the right upper abdomen, accompanied by nausea, vomiting and fever, and the highest body temperature reached 38.6 ℃. Previous history: Surgical treatment for mucinous and serous papillary cystadenoma of left ovary 1 month ago. Physical examination: body temperature: 37.5 ℃, pulse: 98 beats/min, breathing: 20 beats/min, blood pressure: 97/68 mmHg. The skin and sclera of the whole body were yellow stained, a transverse surgical scar about 8 cm long was visible in the lower abdomen, tenderness in the right upper abdomen, no rebound pain and muscle tension, positive mobile voiced sound, normal intestinal sound, and abdominal puncture was non-coagulation. Laboratory tests: Blood routine: RBC: 2.77×10⁹/L, HGB: 82 g/L, HCT: 0.236, WBC: 13.62×10⁹/L, NEUT%: 76.8%, PLT: 304×10¹²/L. Liver function: ALT: 165 IU/L, AST: 411 IU/L, ALP: 155 IU/L, GGT: 155 IU/L, ALB: 30.1 g/L, G: 25 g/L, TBIL: 40.3 μ mol/L, DBIL: 15.4 μ mol/L. Four items of preoperative infection were normal. Tumor markers: AFP: 2.56 ng/ml, CEA: 0.27 ng/ml, CA19-9: 10.32 U/ml, CA125: 155.5 U/ml (reference<35 U/ml). Abdominal ultrasound showed that there were multiple flaky medium echo and anechoic areas in the right lobe of the liver, with clear boundaries and irregular shapes. One of them was about 7 cm ×8 cm, and liquid dark areas could be detected in the abdominal cavity. The maximum anteroposterior diameter of the measured area was: left abdomen 5 cm, right abdomen 5 cm, and spleen periphery 3 cm. A liquid dark area can be detected in the pelvic cavity, and the maximum anteroposterior diameter of the measurement area is 6 cm. CT: The outer edge of the liver is smooth, its size, shape and proportion of each lobe are normal, a slightly higher density shadow with a diameter of 8.0 cm can be seen at the top of the liver, and a low density shadow can be seen around it, without obvious enhancement. Several slightly lower density shadows can be seen around it, with unclear boundaries. A sac-like liquid density shadow can be seen under the capsule of the right lobe of the liver, and a strip-like slightly higher density shadow can be seen inside. No enlarged lymph nodes were seen in the abdominal cavity and retroperitoneum; pelvic effusion; Postoperative changes of "ovarian adenoma": multiple intrahepatic lesions, metastasis and rupture, abdominal and pelvic effusion (Figure 1)。

The patient, a 70-year-old female, was admitted to hospital due to "distension and discomfort in the right upper abdomen for more than 2 months" and had no previous history of hepatitis and cirrhosis. Physical examination: No yellowing staining of the skin and sclera, no swelling of superficial lymph nodes, no abnormalities in the heart and lungs, flat and soft abdomen, no tenderness, no percussion pain in the liver area, and no reach to the liver and spleen under the costs. Laboratory tests: There were no obvious abnormalities in blood, urine routine and liver and kidney function. Hepatitis B surface antibody (HBsAb): 3.87 IU/L, hepatitis B core antibody (HBcAb) was positive, hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and hepatitis B e antibody (HBeAb) were all negative; Hepatitis C antibody (HCV) and hepatitis C virus core antigen (HCV-cAg) were all negative, and carbohydrate antigen 19-9 (CA19-9), carbohydrate antigen 125 (CA125), carbohydrate antigen 153 (CA153), α-fetoprotein (AFP) and carcino-embryonic antigen (CEA) were not abnormal. CT examination showed that the liver occupied multiple places, with large lesions in the anterior lobe of the liver, considering the possibility of primary liver cancer, and other lesions to be excluded. Clinical preliminary diagnosis considers the possibility of right hepatocellular carcinoma (Figure 1，Figure 2)。

The patient was a 51-year-old female. Recurrent right upper abdominal distension and pain for more than 1 year, aggravated with fever for 1 week and admitted to hospital. Admission physical examination: T: 36 ℃, P: 99 times/min, R: 22 times/min, BP: 120/90 mmHg. Chronic disease, no yellowing staining of the skin and sclera, flat abdomen, no varicose veins of the abdominal wall, soft abdomen, tenderness in the right upper abdomen, no rebound pain, no palpable abnormal mass, moving voiced sound (-). Laboratory tests; Liver function showed: glutamyltransferase 272 U/L, total bilirubin 22.1 μ mol/L, direct bilirubin 7.7 μ mol/L, indirect bilirubin 14.4 μ mol/L; HBsAg (+); Tumor scale: Malignant tumor specific growth factor was measured at 79.18 U/ml, and no abnormalities were found in CEA and AFP. B-US showed that a mixed structure of cystic solids was detected in the right anterior lobe of the liver, mainly liquid, about 7.2 cm ×5.8 cm in size, and seemed to communicate with the common bile duct. Dilation of the left and right intrahepatic bile ducts. MRI + MRCP showed that an irregular lobulated long T1 and long T2 were the main signal shadows in the VIII segment of the liver, and multiple soft tissue signal shadows and partitions were seen in it, with a size of about 6.5 cm ×6.2 cm ×6.1 cm, which was considered as a possible cystadenoma. The cervical duct of the gallbladder is tortuous, and the intrahepatic and extrahepatic bile ducts are dilated (Figure 1)。 CT showed that a massive cystic-solid focus was seen in the VIII segment of the liver, mainly cystic, with clear borders and irregular borders, and a separation was seen inside, with a size of about 5.46 cm ×4.90 cm, which was considered a cystadenoma. Dilation of intrahepatic and extrahepatic bile ducts and enlargement of the gallbladder (Figure 2)。 Duodenoscopic nipple dilatation + ERCP showed no obvious abnormalities in the bile duct (Figure 3)。 After admission, symptomatic and supportive treatment was given. On the 13th day, liver V and VIII resection + cholecystectomy + cholangiography and exploration were performed. Intraoperative angiography showed that the tumor was communicated with the biliary tract (Figure 4), intraoperative choledochoscopic tissue frozen revealed: intrahepatic bile duct papillary tumor (carcinoma in situ), liver V and VIII resection was performed, and intraoperative syringe can extract mucoid fluid from the tumor. After operation, a cystic area of about 5 cm ×4 cm in size can be seen with naked eye along the specimen, and several nodules of different sizes can be seen in the cyst wall. Postoperative pathology: intrahepatic bile duct papillary tumor (including severe atypical hyperplasia and carcinoma in situ); Immunohistochemistry: CK low (+), CK19 (+), CEA (−), Ki-67 (~30%), VIM (+); Special dyeing: Silver dyeing (+) (Figure 5)。 He recovered well and was discharged on the 15th postoperative day.

A 77-year-old male was admitted to the Department of Hepatobiliary Surgery of our hospital on April 2, 2015 due to "abdominal pain with fever for 7 h". Admission physical examination: clear, soft spirit, cooperative physical examination, no yellowing staining of skin and mucosa, and no yellowing staining of sclera. The neck was soft, the trachea was centered, and the cardiopulmonary examination showed no abnormalities. Specialist examination: flat abdomen, soft abdominal wall, accessible tenderness and rebound pain in the middle and upper abdomen, no palpable mass, no subcostal reach of liver and spleen, and mobile voiced sound (-). The intestinal sound was normal, and there was no edema in both lower limbs. Auxiliary examination: Emergency blood routine in our hospital showed: WBC: 21.36×10⁹/L, N: 0.875, RBC: 4.84×10¹²/L, HgB: 150 g/L. CRP: 52.6 mg/L. Emergency abdominal CT showed multiple common bile duct stones with intrahepatic and extrahepatic bile duct dilatation, and a small amount of intrahepatic bile duct stones; Bladder stones (Figure 1)。 Admission diagnosis: common bile duct stones intrahepatic bile duct stones cholelithiasis (postoperative) bladder stones. The patient underwent cholecystectomy 15 years ago for "gallbladder stones" and biliary tract surgery 13 years ago for "cholelithiasis". The patient was admitted to the gastrointestinal surgery department of our hospital on December 13, 2014 for "chronic liver abscess". The abdominal CT showed: chronic liver abscess in the medial segment of the left liver (Figure 2)。 After giving Shupu deep needle combined with metronidazole injection anti-infective treatment, the patient was informed that the abscess was multi-chambered, difficult to drain, and needed surgical treatment. The patient and his family refused to operate and was automatically discharged. Yu had no history of other diseases.

The patient, a 73-year-old man, had no obvious complaint symptoms. The main reason was that there were space-occupying lesions near the pancreas found by abdominal color ultrasound during physical examination. No abdominal mass was palpable during physical examination, and there were no obvious symptoms of portal hypertension. After completing abdominal enhanced CT examination, the results showed extrahepatic portal vein aneurysm, the tumor body was larger,>6 cm (Figure 1)。 After further diagnosis and treatment in our department, there were indications for surgery, no absolute contraindications for surgery, and surgical treatment was performed. The middle incision of the abdomen was taken, and the abdomen was entered layer by layer, revealing the portal vein and the tumor body. It can be seen that the tumor body is located in the main trunk of the portal vein, which is basal type, and the tumor body is about 7 cm (Figure 2), no obvious thrombosis was observed, the superior mesenteric vein and splenic vein were not involved, the portal vein tumor was blocked by lateral wall occlusion forceps, the tumor was surgically removed, and portal vein reconstruction was performed (Figure 3)。 The patient recovered smoothly after operation, and the pathology showed atrophy of media smooth muscle (Figure 4)。 After discharge, the patient regularly received oral warfarin anticoagulation therapy, and was reviewed in the outpatient clinic. After one year, the drug was stopped, and no obvious tumor continued to grow in the reexamination.

The patient was a 68-year-old female. He was admitted to the hospital with "upper abdominal discomfort for 1 week". Physical examination showed no obvious abnormalities. Blood routine and liver function are within the normal range. Blood urea nitrogen was 8.66 mmol/L, blood creatinine was 331 μ mol/L, and glomerular filtration rate was 75.19 ml/min. alpha-fetoprotein 739.60 ng/ml, HbsAg (+), HbeAb (+), HbcAb (+), HCV-Ab (-). Abdominal CT: The surface of the liver was uneven, and irregular mass shadows were seen in the right lobe of the liver (IV, V, VIII segments), with a size of 7.7 cm ×6.7 cm, uneven enhancement in the arterial phase, and low density necrosis was seen in the center (Figure 1), portal vein and delayed scan contrast medium withdrawal; Both kidneys were atrophied, and the transplanted kidney was visible in the left iliac fossa (Figure 2)。 The patient underwent the first allogeneic kidney transplantation 28 years ago due to uremia and the second kidney transplantation 20 years ago due to transplanted kidney failure. He is now orally taking cyclosporine 3 tablets/d, azathioprine 1 tablet/d and prednisone 1.5 tablets/d. Hypertension for more than 20 years, oral benazepril 1 tablet/d, blood pressure control is stable. Chronic hepatitis B for 20 years, now oral entecavir 1 tablet/d. After perfect preoperative examination and adequate preoperative evaluation, middle hepatectomy was performed under general anesthesia. The operation time was 4 h, and intraoperative bleeding was 400 ml, blood transfusion was 2 U, and plasma was 400 ml. Postoperative pathology: Highly-moderately differentiated hepatocellular carcinoma of the liver, about 10 cm ×9 cm ×7.5 cm in size, with intravascular tumor thrombus and clear liver resection margin. He was discharged from the hospital without complications at 9 days after surgery. Interventional therapy was performed at 1 and 3 months after operation, respectively. There were no new lesions, and no abnormal increase in AFP was found in re-examination.

LLR has developed rapidly since the first laparoscopic liver resection (LLR) was reported in 1991, followed by the LLR global conferences held in 2008 and 2014, respectively^[1,2]However, the development of LLR, especially laparoscopy major hepatectomy (LMH), is limited to a few specialized centers, and the promotion of this technology still has a long way to go. We compare the short-term and long-term outcomes of LLR with conventional open liver resection (OLR), the development and technical improvement of LMH, robotic-assisted liver resection (RALR), laparoscopic living donor hepatectomy (LLDH), and laparoscopic two-step hepatectomy with liver dissection and portal vein ligation (associating liver partition and portal vein ligation for staged hepatectomy, ALPPS) The development and current situation are described separately.

Lower extremity arteriosclerosis obliterans (ASO) is a common vascular disease in the elderly^[1]。 The prevalence rate among people over 70 years old in European and American countries is 18.59%^[2]The prevalence rate of people over 60 years old in China is 16.42%^[3]。 Although endovascular interventional therapy and bypass surgery have also achieved certain clinical results, nearly 1/3 of patients still develop vascular restenosis and occlusion several years after treatment, and eventually develop critical limb ischemia (CLI), of which 16% of patients are forced to amputate^[4]。 In recent years, the relationship between stem cells and angiogenesis and their role in therapeutic angiogenesis has attracted much attention. Studies have shown that induced pluripotent stem cells (iPSCs) can induce differentiation into vascular cells (endothelial cells (ECs), smooth muscle cells (SMCs), pericytes, etc.), promote angiogenesis and establishment of effective collateral circulation in ischemic regions, and help to improve blood supply and function of tissues. It is expected to be a new approach for clinical treatment of limb ischemia^[5,6,7,8]。 At present, the positive role of iPSCs in therapeutic angiogenesis has been validated in quasi-clinical ischemic heart injury models, and the research on angiogenesis in ischemic model mice has been gradually carried out^[9,10]。