2017年 · 第32卷第02期

The spleen was once considered a "garbage organ" together with the appendix. However, today, the function of the spleen is increasingly recognized by us, and the veil of the spleen deep under the costal arch is gradually uncovered. In 1911, Kocher, a great surgical pioneer, thought that splenectomy was not harmful to the body, and Morris and Bullock raised the problem of sepsis after splenectomy in 1919, thus opening the debate between "preserving the spleen" and "excising the spleen". 100 years have passed, and with the increasing understanding of spleen function in academic circles, preserving the spleen as much as possible on the premise of safety has become the choice in most cases. In 1549, Zaccaelli successfully performed the first splenectomy, and in 1991, Delaitre and Maignien successfully completed the first laparoscopic splenectomy. There are more and more cases of partial splenectomy, and robotic splenectomy is gradually reported. Spleen surgery has undergone great changes in technical level. With the advancement of basic and clinical research, splenic surgery has now become an important branch of surgery.

epithelioid haemangioendothelioma (EHE) is a rare low-grade malignant vascular tumor^[1]It mostly occurs in superficial or deep soft tissues, and can also be located in organs such as lungs, bones, brain and small intestine. Primary hepatic EHE is very rare, its clinical manifestations are not characteristic, and it is easy to be misdiagnosed^[2]。 The clinical data of two patients with hepatic epithelioid hemangioendothelioma admitted to us are reported below.

deep venous thrombosis (DVT) of lower limbs is a common disease in vascular surgery. It has been reported in the literature that iliac vein stenosis is more than 70% after thrombolysis in DVT^[1]Kunshan First Hospital and the Second Affiliated Hospital of Soochow University treated 62 patients with lower limb DVT with iliac vein stenosis or occlusion from January 2011 to January 2014. The deep vein patency rate and symptom improvement in the middle term were observed whether the patients were stented or not, which are now reported as follows.

The proliferation of intimal or smooth muscle cells after arterial revascularization of lower limbs in diabetic patients will lead to a higher rate of vascular restenosis or occlusion than in non-diabetic patients^[1]。 The treatment of reocclusion after lower limb artificial blood vessel bypass grafting in diabetic patients is very difficult. If blood supply cannot be restored in time, they will face amputation. Catheter thrombolysis is mostly used in the treatment of acute lower extremity arterial ischemia, and there are few reports on its application in the treatment of bypass vessel reocclusion. From February 2010 to May 2014, Tianjin People's Hospital performed simple catheter thrombolysis combined with interventional therapy in 43 diabetic patients with femoral-popliteal artificial vessel reocclusion compared with the combined interventional therapy after thrombectomy. The efficacy and safety were compared as follows.

At present, the diagnostic criteria of thromboangiitis obliterans (TAO) mostly adopt Shionoya, Sasaki and Olin criteria, but the diagnostic criteria are mainly based on clinical manifestations, and only a few studies describe the characteristics of laboratory tests. However, accurate diagnosis is very important for reducing TAO amputation rate. This paper aims to investigate the application value of analyzing mean platelet volume (MPV) in the diagnosis of TAO patients.

Before the invention of percutaneous endo-scopic gastrostomy (PEG), surgical procedures were commonly used to perform gastrostomy (SG). PEG is a minimally invasive surgery, which has the advantages of not requiring general anesthesia, less invasive, and short tube feeding time. This study compares the clinical efficacy of PEG and SG.

In this study, the expression of circular RNA circ_001947, micro-RNAMIR-30c-1-3p and ADAM19mRNA in colorectal cancer (CRC) was detected, and the correlation between circ_001947 and miR-30c-1-3p, miR-30c-1-3p and ADAM19mRNA was analyzed. The correlation between circ_001947 and miR-30c-1-3p, miR-30c-1-3p and ADAM19mRNA expression was discussed, which provided some theoretical basis for further research on the significance of circ_001947, miR-30c-1-3p and ADAM19mRNA in the diagnosis and prognosis of CRC.

Tension-free repair with repair materials has become the main surgical treatment for abdominal wall hernia^[1]。 Although various measures were taken to prevent infection during the perioperative period, there were still a few patients with complications such as incision infection and rejection reaction, with the incidence rate reported in the literature ranging from 2.88% to 4.37%^[2]。 A total of 410 patients with abdominal wall hernia were treated in our hospital from January 2010 to October 2015, and 10 cases had incision infection and rejection reaction, accounting for 2.44% of the total. After treatment, satisfactory results were achieved, which are reported as follows.

Studies have shown that about 9% to 33% of lactating women have suffered from acute mastitis, and 5% to 11% of them eventually develop breast abscesses^[1]。 The traditional incision and drainage has obvious adverse reactions such as scar, pain and lactation arrest. This study evaluated the therapeutic effect of liposuction combined with continuous closed lavage in the treatment of breast abscess during lactation by selecting ultrasound-guided puncture and pus aspiration as a control.

Case 1: A 57-year-old male experienced a sensation of foreign body in the pharynx for 8 months. Gastroscopy showed bulging lesions of the duodenal bulb, and pathological biopsy showed chronic inflammation of the mucosa with glandular hyperplasia. Ultrasonic gastroscopy showed that there was a medium echo lesion in the bulb bulb of the duodenum, which was located in the lamina propria and submucosa of the mucosa of the tube wall. The internal echo was mainly homogeneous medium echo, and a cystic echo area was visible in it, with a section length diameter of 13.5 mm. After gastroscopic treatment, a slightly hemispherical wide basal bulge about 1.5 cm in size was seen on the anterior wall side of the duodenal bulb near the great curvature of pylorus, with a smooth surface (Figure 1), endoscopic mucosal resection was performed to remove the lesion. Postoperative pathological report: Brunner gland hamartoma of the duodenum.

The patient, 64-year-old female, was admitted for "physical examination revealed intraabdominal space occupation for 3 d". The patient found "cystic occupation between spleen and stomach" during the physical examination in the unit 3 days before admission. The patient was prosecuted for having injured the left upper abdomen due to a car accident in the past, but there was no abnormality in the physical examination at that time, no special treatment, and no special history, personal history and family history. Physical examination: the abdominal wall was flat, no obvious gastrointestinal pattern and peristaltic wave, no scar, no abnormal pulsation, no superficial varicose veins of the abdominal wall, soft abdomen, no tenderness and rebound pain in the whole abdomen, no mass in the whole abdomen, no subcostal palpation of liver and spleen, Murphy sign (-). Both kidneys were untouched. Moving voiced sound (-), percussion pain in bilateral renal area (-). The intestinal sound was moderate, and there was no sound of gas passing through water, no sound of vibrating water and blood vessel murmur. Abdominal CT examination suggests (Figure 1): Irregular low-density shadows can be seen between the spleen and stomach, about 15.3 cm ×9.0 cm in size, with clear boundary, CT value about 17-22 HU, separated density shadows can be seen within it, and mild enhancement can be seen after injection of contrast agent. No abnormalities were found in laboratory auxiliary tests. After improving all examinations and preoperative preparation, "exploratory laparotomy" was performed under general anesthesia. During the operation, it was found that the pancreas was normal in shape, with a cystic occupying space in the upper left side of the abdominal cavity, between the liver, spleen and diaphragm, and the capsule was intact, yellow in color, irregular in shape, soft in texture, closely related to the spleen and no adhesion to the pancreas. "Intra-abdominal tumor combined with splenectomy" was performed. Pathological diagnosis: (spleen) mucinous cystadenocarcinoma (low-grade malignancy, size: 12 cm ×6 cm ×4 cm), invading the splenic capsule (Figure 2)。 Immunohistochemistry: Cancer cells showed CK7 (+), CK20 (+), CAM5.2 (+), Ki67 index 10%, PR (-), ER (-), CA125 (-), CEA focal (+), MC (+), CR (+), CDX2 (-), villin (-) supporting the above diagnosis. Symptomatic treatment was given after surgery, and the patient recovered well. He was discharged from hospital on the 8th day after surgery, and was followed up regularly. It has been 2 years since then, and no tumor recurrence was found in re-examination.

A 50-year-old female was found to have liver space-occupying lesions for more than 12 years, without symptoms such as upper abdominal discomfort, and denied hepatitis and other special medical history. Specialist physical examination: the whole abdomen was flat and soft, and no positive signs were palpable. Laboratory tests: There were no abnormalities in blood routine, biochemistry and tumor markers. Abdominal CT showed that multiple rounded slightly low-density masses were seen in the liver, the larger one was located in the left inner lobe of the liver, about 7.5 cm ×7.1 cm ×6.6 cm in size, and the internal density was not uniform. The margin of the arterial phase was patchy enhanced, the enhancement range from the portal phase to the venous phase gradually extended to the center, and the delayed phase was isodensity. Multiple patchy low-density shadows were seen in the mass, and hemangioma was mostly considered (Figure 1)。 The preoperative diagnosis was: hemangioma of the liver. Intraoperative exploration of macroscopic findings: tumor was seen, about 7.1 cm ×6.3 cm ×5.2 cm, with clear boundary, located at the junction of S4 and S5. An anatomical liver segment S5+ S4 resection was performed. During the operation, the tumor had obvious envelope surrounding, without obvious signs of invasive growth, but the envelope was fragile and easily ruptured. Focal necrosis, yellow fat-like tissue and thrombosis of different sizes were found in the tumor, and the characteristic structure of typical cavernous hemangioma was not found. Postoperative examination showed: liver angiomyolipoma, immunohistochemical results CD34 (±), Hepa (-), SMA (+), HMB-45 (+), Melan-A (+) (Figure 2)。 The patient was cured and discharged 10 days after surgery.

A 65-year-old female was admitted to our hospital for diagnosis and treatment for more than 2 years due to intermittent pain in the right upper abdomen. In the past two years, the patient had intermittent distension and pain in the upper abdomen without obvious inducement, good spirit and appetite, normal urine and defecation, and no obvious weight loss. There is no special history of hepatitis or tuberculosis in the past. The pain in the upper abdomen was significantly worsened in the last month, with body temperature at admission of 36.6 ℃, heart rate of 91 beats/min, breathing of 22 beats/min, blood pressure of 117/80 mmHg, cardiopulmonary (-). Physical examination: tenderness in the right upper abdomen, no mass palpable. There were no abnormalities in blood cell analysis; The liver function showed that alanine aminotransferase (ALT) was 151 U/L, aspartate transaminase (AST) was 89 U/L, alkaline phosphatase (ALP) was 556 U/L, and total bilirubin (TBIL) was 26.9 μ mol/L. There were no obvious abnormalities in tumor markers. Color ultrasound of liver, gallbladder, pancreas and spleen showed: cholecystitis, gallbladder wall thickening, gallbladder stone sonographic MRI (Figure 1) showed: cholecystitis, gallbladder neck and gallbladder cervical canal occupying space, enhancing late artery enhancement, delayed stage obvious enhancement of gallbladder mucosal layer and serous layer (gallbladder CA possible) hilar bile duct stenosis. Check abdominal CT (Figure 2) shows: (1) gallbladder neck mass, uneven enhancement in the arterial phase after enhancement, and CA in the gallbladder neck is more considered; (2) The wall of the common bile duct is thickened, considering the invasion of gallbladder cancer, and the main portal vein is compressed and narrowed. Gallbladder carcinoma was considered preliminarily. After discussion, radical cure of gallbladder carcinoma + common bile duct resection and choleenterostomy were proposed. Intraoperative exploration: The gallbladder wall was irregularly thickened and hardened, and the gallbladder triangle and the first hepatic hilum were seriously adhered, which was hard to touch. The duodenum, transverse colon and gastric pylorus are tightly adhered to the wall of the gallbladder. The adhesion was gradually separated, and a hard mass was touched in the ampulla of the gallbladder, and the boundary with the surrounding area was unclear. After exploration, ampullary carcinoma of gallbladder and invasion of common bile duct, gastric antrum, duodenum, transverse colon and pancreas were preliminarily considered according to biological characteristics. Partial hepatectomy + pancreaticoduodenectomy is proposed. The hepatoduodenal ligament was dissected, and the lymph nodes were frozen during operation. No malignant cell metastasis was observed. The tissue of the gallbladder wall was continued to be frozen intraoperatively, and the pathological examination showed xanthogranuloma. Cholecystectomy was performed. The gallbladder wall was 1 cm thick and decayed, with milky white thin pus in the cystic cavity. The lining of the gallbladder is smooth. The gallbladder was sent for medical examination. The pathological findings revealed xanthogranulomatous cholecystitis (Figure 3)。 The patient had no abnormalities after surgery and was cured and discharged.

Case 1, a 45-year-old male, was admitted to the hospital due to "yellow staining of the skin and sclera for 14 days". Physical examination: Skin and sclera were yellow stained, and no positive signs were found. Auxiliary tests: aspartate aminotransferase: 96.5 U/L, alanine aminotransferase: 244.8 U/L, total bilirubin: 39.3 μ mol/L, direct bilirubin: 16.5 μ mol/L, indirect bilirubin: 22.8 μ mol/L. Tumor markers : CA199>800 U/ml, CA242: 237 U/ml, CA724: 33.92 U/ml. Abdominal three-phase enhanced CT and magnetic resonance cholangiopancreatography (MRCP) (Figure 1，Figure 2) suggest: the biliary duct occupies space lesions in the hilar region, the intrahepatic and extrahepatic bile ducts are slightly dilated, and the common bile duct is widened, reaching 1.1 cm at the widest point. The patient had increased CA199 and CA242, normal alpha-fetoprotein, and was a middle-aged man, so the possibility of cholangiocarcinoma could not be ruled out. Preliminary diagnosis: space-occupying lesion of the bile duct. Preoperatively, according to the imaging data, the tumor was mainly located in the left hemihepatic, so elective left hemihepatectomy was planned. During the operation, the tumor was located in the first hepatic portal, light brown, cystic-solid, about 4 cm ×3 cm in size. Careful dissection of the structure of the hepatic portal region showed that the tumor originated from the right hepatic duct, convexed towards the left lobe of the liver, compressed the left hepatic duct, and presented a large cystic small nodule type (Figure 3), performed right hemihepatectomy. A choledochoscope was placed through the incision of the common bile duct, and the wall of the common bile duct was found to be good, without bulge or thickening. The left hepatic duct was explored, and the wall of the biliary duct was suspected to be slightly thicker, so part of the left hepatic duct was removed, and the common bile duct was ligated at the upper end of the common bile duct pancreas, and the left hepatic duct-jejunum Roux-en-Y anastomosis was performed. When the tumor was dissected, it was found that the tumor was mixed with cyst and solid, and jelly-like material was seen in the cyst. The postoperative pathological report was: mucinous papillary tumor of the hilar bile duct with associated invasive carcinoma (Figure 4), the left hepatic duct margin and common bile duct margin were negative. The patient recovered well after surgery.

sphincter of Oddi dysfunction (SOD) is a disease involving the sphincter of Oddi (SO) Benign, acalculous lesions of. According to whether the symptoms are intermittent biliary abdominal pain or recurrent pancreatitis, SOD can be divided into biliary and pancreatic types. Biliary SOD is more common in patients after cholecystectomy. According to the sphincter of Oddi manometry (SOM), SOD can also be divided into SO stenosis, which is SO fibrosis or hypertrophy caused by inflammatory reaction, and SO dysfunction^[1]。 However, it is sometimes difficult to distinguish between the two clinically. Although the criteria for the diagnosis and treatment of SOD have been published, there are still many points of debate.

The prostaglandin family is formed by arachidonic acid through the action of cyclooxygenase (COX), which is involved in many physiological processes such as platelet agglutination, vasodilation and contraction, local inflammatory response and leukocyte-endothelial cell adhesion^[1]。 Prostaglandin family plays an important role in the process from the formation of vascular lipid streaks to the rupture of atherosclerotic plaques caused by local inflammatory response, and may be an important mechanism for its regulation of the occurrence and development of various vascular diseases^[2]。 Under the action of COX, arachidonic acid produces unstable prostaglandin G2 and prostaglandin H2, which produce Prostacyclin (PGI) through the action of Prostacyclin synthase (PGIS) in platelets, endothelial cells and vascular smooth muscle cell microsomes₂)； COX simultaneously mediates the production of multiple inflammatory mediators^[3]。 In some specific circumstances, PGIS in endothelial cells may act directly on Thromboxane (TXA₂) Precursors produce PGI₂^[3]。 It suggests that COX may be an ideal anti-inflammatory therapeutic target for vascular diseases, COX inhibitors and PGI₂Become the focus of discussion on the pathophysiological processes of vascular diseases, the benefits of patients in clinical applications, and the potential risks.