2016年 · 第31卷第12期

At the beginning of 2012, then-Argentine President Cristina was diagnosed with thyroid cancer and underwent surgery, but postoperative pathology showed that the tumor was benign. This has aroused widespread concern about the correctness of preoperative diagnosis of thyroid cancer. At present, fine-needle aspiration (FNA) is the gold standard for preoperative diagnosis of thyroid cancer, but a considerable number of patients cannot be correctly diagnosed by FNA alone. In recent years, the combination of molecular detection of thyroid cancer related genes and FNA can significantly improve the accuracy of preoperative cytological diagnosis of thyroid cancer, which has brought revolutionary breakthroughs in pathological diagnosis, treatment and prognosis evaluation of thyroid diseases. On the other hand, whether papillary thyroid microcarcinoma (PTMC) can mostly be treated without surgery has also caused many controversies.

Biliary stent is an effective method for the treatment of malignant obstructive jaundice, especially in patients with common bile duct obstruction. At present, there are many clinical reports on stent treatment of malignant common bile duct obstruction, and the technique of biliary stent is relatively mature, and it has been widely used in clinical practice^[1,2,3,4]。 However, for patients with middle and lower common bile duct obstruction, biliary stents are mostly placed across the duodenal papilla, that is, the lower end of the stent crosses the duodenal papilla into the duodenum. Transduodenal papilla stent placement has the following complications: stent displacement, occlusion, biliary tract infection, pancreatitis, etc., especially biliary tract infection caused by intestinal bacteria upstream, which leads to repeated hospitalization of patients and brings great pain and financial burden to patients^[5,6,7]。 At present, there are few reports on the way the stent is placed not across the duodenal papilla^[8]。

deep vein thrombosis (DVT) is one of the common diseases in vascular surgery, with an incidence of about 1.2‰^[1]。 At present, catheter directed thrombolysis (CDT) has become the first choice for the treatment of acute lower limb DVT, and urokinase is the main thrombolytic drug for CDT in the treatment of acute lower limb DVT. The literature reports on the usage, dosage and thrombolytic time of urokinase during CDT are very controversial, and there is no uniform standard so far. From July 2009 to July 2015, 130 patients with DVT were treated with CDT in the Department of Vascular Surgery of the Second People's Hospital of Fuyang City, Anhui Province. The dose of urokinase, thrombolytic efficiency and related complications are reported below.

Male breast malignancies account for less than 1% of all breast malignancies, and about 0.1% of male malignancies. Its incidence continues to increase, and its mortality rate (18.2%) is similar to that of female breast cancer (17.2%)^[1]。 We conducted a clinical analysis of 31 cases of male breast malignant tumors in our hospital from 2003 to 2014, and now summarized and reported as follows.

There are few clinical reports of acute severe cholecystitis in patients with cerebrovascular accident recovery. However, because most patients are unconscious and bedridden for a long time, they are prone to acute cholecystitis, and they are often severe when found, so the treatment is difficult, which is easy to cause serious consequences and even death. The clinical data of 10 patients with acute severe cholecystitis in the recovery period of cerebrovascular accident were retrospectively analyzed.

Early hemorrhage after radical gastrectomy refers to hemorrhage within 24 hours after surgery, and delayed hemorrhage refers to hemorrhage occurring 7 days after surgery. When early bleeding occurs, it is easier to cause concern because the patient is still in hospital; However, delayed hemorrhage mostly occurs after patients are discharged from hospital. Although the incidence rate is not high, the mortality rate is high, which needs enough attention. This study analyzed the clinical data of patients with delayed hemorrhage after gastric cancer surgery, analyzed its causes, clinical manifestations and treatment, and proposed preventive measures, which are reported below.

Hybridization refers to the combination of traditional surgical techniques and endovascular techniques to give full play to their respective advantages. In recent years, the application in patients with chronic lower limb ischemia has achieved good curative effect^[1]。 The First Affiliated Hospital of Fujian Medical University and the Second Affiliated Hospital of Suzhou University used hybrid revascularization technology to treat 25 cases of acute lower limb ischemia from May 2010 to June 2015, and achieved good results, which are reported as follows.

Pancreaticoduodenectomy is one of the most complicated procedures in abdominal surgery and a landmark procedure that reflects the growth of surgeons with complicated procedures and a high incidence of postoperative complications. The safety and feasibility of laparoscopic pancreaticoduodenectomy (LPD) have been controversial, but with the development of laparoscopic technology, especially the mature development of laparoscopic radical gastrectomy and laparoscopic spleen-preserving pancreatectomy, LPD has been paid more and more attention. A total of 10 cases of LPD were performed in our hospital from May 2014 to October 2015, and the reports are as follows.

Pancreaticoduodenectomy is the main surgical method for the treatment of ampullary tumors, pancreaticojejunostomy is the difficulty of this operation, and postoperative pancreaticfistulas (POPF) is one of its serious complications^[1,2]。 How to improve pancreaticojejunostomy and reduce the incidence of pancreatic leakage is a problem that surgeons are constantly exploring. From March 2012 to September 2014, 51 patients with ampullary tumors who underwent pancreaticoduodenectomy were treated with pancreaticojejunostomy and traditional pancreaticojejunostomy (pancreaticojejunostomy or sleeved pancreaticojejunostomy) for pancreaticojejunostomy and comparison. It was found that pancreaticojejunostomy with pancreaticojejunostomy had obvious advantages and achieved good clinical efficacy, which is reported below.

The rapid rise of the incidence of breast cancer makes people pay more and more attention to breast health care, and the widespread application of breast color ultrasound examination has found many unpalpable sub-centimeter breast lesions. For small lesions of Breast Imaging Reporting and Data System (BI-RADS) category 4 and 5, the conventional treatment method is to percutaneous biopsy guided by ultrasound first, and then the treatment plan is decided according to the pathological results. Regular follow-up is recommended for benign lesions, and further surgical resection is recommended for malignant lesions. We have been using the Mammotome Elite wireless handheld vacuum-assisted breast biopsy rotary resection device for unpalpable sub-centimeter breast lesions since 2014, with satisfactory results. The preliminary results are reported below.

The patient, a 65-year-old female, was admitted to the hospital on March 6, 2015, mainly due to chills in both lower limbs and pain after activity for 1 year, with a limp distance of about 100 meters. Arterial color ultrasound examination revealed stenosis and occlusion of superficial femoral arteries in both lower limbs. Past history: 12 years of diabetes; 10-year history of hypertension; History of gallbladder stones 2 years. No history of smoking or drinking. Rutherford Grade 4, TASC Grade D. Preoperative digital subtraction angiography (DSA) revealed bilateral superficial femoral artery occlusive lesions, with severe left side and poor vascular condition below the knee. Preoperative DSA (Figure 1) Treatment process: The patient was in supine position, the right femoral artery was punctured, and the mountain climbed into the left common femoral artery. The V18 guide wire attempted to occlude the superficial femoral artery unsuccessfully, and the middle and distal segment was dissected, making it difficult to return to the true cavity. Select popliteal artery puncture (Figure 2): (1) The P3 segment of the popliteal artery was successfully punctured by needle insertion from between the left tibiofibular heads guided by radiation; (2) the two-way guide wires intersect, establish a track, and perform balloon dilation of superficial femoral artery antegrade; (3) Apply 4-40 PTA balloon to dilate and iron to stop bleeding, and apply external pressure bandage. The operation took 3 h and 130 ml of Nuctech-Parker contrast medium was applied. The patient was discharged from the hospital on the third day after operation without discomfort and claudication symptoms were relieved.

A 24-year-old male was admitted to hospital for 6 years after thyroid surgery, 25 days after skull metastasis cancer surgery, and 15 days after re-examination found goiter tumor. The patient underwent right subtotal thyroidectomy at the local hospital 6 years ago, and the pathological results reported nodular goiter. 25 days ago, CT found "right skull occupied space" in the external hospital (Figure 1) Right skull mass resection + dural repair + titanium plate implantation were performed. Pathology: Bone metastatic tumor, considering thyroid follicular carcinoma metastasis; Immunohistochemistry: CK20 (-), CK7 (+), Ki-67 (+5%), Tg (+), Villin (-), TTF (+) (Figure 2，Figure 3)。 Physical examination of this admission: A tumor can be palpable in the right lobe of the thyroid gland, about 4 cm ×3 cm, with clear boundary and tough texture, which can move up and down with swallowing. Neck ultrasound: A mixed nodule was seen in the right lobe of the thyroid gland; Several nodular echoes were seen in the left lobe of the thyroid gland. PET-CT: Postoperative changes of thyroid gland and right skull, and no obvious abnormalities were found in PET-CT of the rest of the body. Goiter resection was performed, and the larger nodule in the right lobe of the thyroid gland was located in the lower part, hard in texture, without intact capsule, and serious adhesion to the surrounding muscle tissue. The nodule in the left lobe of the thyroid gland is located in the lower part, tough in texture, cystic, and the capsule is intact. Multiple enlarged lymph nodes were seen around the thyroid gland, and bilateral total thyroidectomy and central lymph node dissection were performed. Intraoperative pathology: Bilateral thyroid nodular goiter with metastasis in the lymph nodes (central region) (2/16). Postoperative pathological report: right thyroid follicular carcinoma, left thyroid papillary microcarcinoma, central lymph node metastasis (2/17), considering the origin of thyroid follicular carcinoma (Figure 4,Figure 5,Figure 6)。 Postoperative supplementary endocrine suppression therapy and¹³¹I treatment.

A 37-year-old female was seen in a local hospital for 1 d of persistent epigastric pain and had a history of long-term alcohol consumption. The patient experienced nausea and vomiting during the course of the disease, and abdominal CT showed full pancreas with a large amount of exudation around it. Blood amylase 673 U/L. The clinical diagnosis was acute pancreatitis. No improvement was seen after 3 weeks of conventional treatment, so he was transferred to our hospital. Abdominal CT in our hospital showed encapsulated effusion on the liver surface, with a size of about 12.5 cm ×8.9 cm. The shape of the pancreas is irregular, the parenchyma becomes smaller, and stripe-like high-density shadows and multiple cystic density shadows of different sizes are seen around it, about 0.5 cm ×7.2 cm, which is considered to be pancreatitis with pseudocyst formation. The gastric antrum, duodenum and the lower end of the common bile duct around the cyst were compressed and narrowed, and the proximal segment of the common bile duct was dilated, about 2.0 cm. Serum amylase 857 U/L. The clinical diagnosis was acute pancreatitis, pancreatic pseudocyst and peritoneal effusion. Gastrointestinal decompression, intravenous nutritional support, anti-inflammatory and enzyme inhibition treatment were given. Parallel ultrasound-guided puncture and drainage of perihepatic encapsulated effusion and pancreatic cyst were performed. After puncture, fever and abdominal distension were relieved, and nasointestinal tubes were placed in place, and enteral nutrition was given gradually. One week after being transferred to our hospital, the patient suddenly became apathetic, unresponsive, able to respond to calls but difficult to make instructions, followed by shallow coma, extraocular muscle paralysis, inadequate movement of both eyeballs accompanied by nystagmus, inability to close both upper eyelids, but blinking, low muscle tone of the limbs, and weakened tendon reflex of the limbs. The neurological consultation recommended head MRI examination, which showed multiple symmetrical patchy abnormal signals in the posterior midbrain (superior and inferior colliculus), upper cerebellum, bilateral frontal lobes and bilateral thalamus, and T1WI showed a slightly low signal (FIG. 1A), T2WI showed a slightly higher signal (FIG. 1B), T2WI FLAIR High signal (Figure 1C), DWI showed a slightly higher signal (Figure 1D)。 Wernicke Encephalopathy (WE) was diagnosed. Then intramuscular injection of vitamin B₁Treatment, 300 mg/time, once/d, after 24 hours, the spirit was still acceptable, the mind was slightly clearer than before, and 2 to 3 words could be spoken when communicating with him, and the response was slightly more flexible than before. Both upper eyelids could be closed, and the remaining symptoms were the same as before. One month later, the patients were followed up with ataxia and retardation, and other symptoms disappeared.

A 50-year-old female was admitted for 1 month due to a mass found in her abdomen with intermittent abdominal distension. The patient found a mass in the left upper abdomen 1 month ago, and the mass gradually increased, accompanied by intermittent abdominal distension, obstruction of stool and loss of appetite. Weight loss of 5 kg in 1 month. Previous history of cholecystectomy. Physical examination: A mass can be seen in the left upper abdomen, a 5 cm long surgical scar can be seen in the right upper abdomen, and a mass about 15 cm ×20 cm in size can be palpable in the left upper abdomen, which is hard in texture and has poor mobility. Abdominal ultrasound: The pelvic and abdominal cavity occupies a large mixed type of mass, considering the possibility that the lesion originates from the pancreas. Abdominal CT: Malignant tumor of left adrenal origin, after breakthrough, the peritoneum enters the abdominal cavity and grows with adrenal lymph node metastasis, cortical cancer is likely, the left kidney is compressed and moved downward, and the spleen is moved forward (Figure 1)。 Preoperative diagnosis: retroperitoneal malignancy. Blood routine: hemoglobin 76 g/L, white blood cells 15.51×10⁹/L, albumin 22 g/L, tumor markers normal. Laparotomy was performed under general anesthesia after preoperative albumin supplementation and blood transfusion. Adhesion between stomach and tumor was found during operation, and two tumors were found after separation. The larger tumor was closely related to the body and tail of pancreas, and the tumor was seriously adhered to the spleen. Enlarged lymph nodes were seen in many places in the omentum. Another tumor was located in the left adrenal gland, and there was an obvious gap with the tumor at the tail of pancreas. It was decided to perform body and tail of pancreas + left adrenalectomy + splenectomy, and the operation was successful. The size of pancreatic tumor was 21 cm ×16 cm ×7 cm, and the size of left adrenal tumor was 11 cm ×8 cm ×4 cm. Postoperative pathology: Malignant tumor of pancreatic body and adrenal soft tissue, tending to malignant fibrous histiocytoma (Figure 2Immunohistochemistry: EMA +, CK-, CEA-, SMA-, S-100-, desmin-, SYN-, MSA-, CK19-, Vim +, CD68+, Ki-67 (3+), P53 (3+), CD20-, CK +, CK8+, CA125-, Ki-67 (90% +), P53+, EGFR +, villin (+). He recovered well and was discharged on the 8th postoperative day.

thyroid stimulating hormone (TSH) inhibition therapy, as a guideline recommended treatment for differentiated thyroid cancer after surgery, has gradually developed into a routine, rational and individualized treatment plan, and has been recognized by clinicians. The risk of recurrence and metastasis of differentiated thyroid cancer was effectively reduced by taking sufficient amounts of thyroxine to control TSH at or below the low limit of normal^[1,2]But at the same time, it also leads to the patient's physical function in a state of subclinical hyperthyroidism for a long time. Long-term follow-up shows that subclinical hyperthyroidism can lead to many adverse reactions, such as the occurrence of cardiovascular-related events and increased risk of death, drug-induced secondary osteoporosis, metabolic and blood chemical changes, menstrual disorders, and some patients may also develop mild psychiatric symptoms and signs^[3,4,5,6]。 The research progress of sex hormone therapy in patients with long-term TSH inhibition therapy is summarized as follows.

thyroid microcarcinoma (TMC) generally refers to thyroid cancer with a tumor diameter ≤1 cm. In recent years, the proportion of thyroid cancer is increasing, up to 70% in some areas, and it is the main part of the rapid growth of thyroid cancer^[1]。 At present, the histological types of TMC are almost all papillary thyroid carcinoma (PTC), that is, papillary thyroid microcarcinoma (PTMC), so the research around PTMC has become a hot spot in the field of thyroid cancer^[1]。 Most PTMCs have a good prognosis, even the same as that of the normal population; However, a small number of PTMC patients are prone to extrathyroid invasion and lymph node metastasis, resulting in poor prognosis^[2]If such PTMC subtypes are not thoroughly treated, the risk of recurrence can be as high as 20% to 30%, and repeated recurrence can also cause dedifferentiation and ultimately affect the prognosis. Therefore, it is urgent to carry out accurate risk assessment and early warning of PTMC before clinical treatment, in order to achieve accurate individualized treatment. Although there is still a lack of clinical risk assessment methods for PTMC system at home and abroad, many scholars have carried out risk assessment research to varying degrees in the clinical characteristics, imaging features, pathomorphological manifestations and current popular molecular markers of PTMC.

Delphian lymph node (DLN), also known as Delphian lymph node or prelaryngeal lymph node, has been studied in pharyngeal cancer in the past. It is an important marker of poor prognosis independent of pharyngeal cancer, and can predict extensive lymph node metastasis, increased recurrence rate and increased mortality^[1]。 DLN is rarely studied in thyroid cancer and is often overlooked when performing central cervical lymph node dissection. In this paper, the research progress of DLN in thyroid cancer in recent years was reviewed, hoping to attract the attention of clinicians and improve the therapeutic effect of thyroid cancer.