2017年 · 第32卷第03期

Since 1997 Hüscher et al.^[1]Since the success of laparoscopic thyroid lobectomy was the first to be performed, the development of laparoscopic thyroid surgery has been 19 years. With the rapid development of laparoscopic technology and the progress of thyroid surgery, various surgical methods and approaches emerge one after another. According to whether it is inflated or not, it can be divided into inflatable and non-inflatable endoscopic surgery; According to the role of intraoperative endoscopy, it can be divided into laparoscopic assisted surgery and complete laparoscopic surgery. Complete laparoscopic surgery is divided into subclavicular approach, axillary approach, axillary areolar approach, thoracic mammary approach, complete areolar approach, retroauricular approach, transoral approach, etc. according to its approach, and gradually realizes the crossing from a small incision in the front of the neck, no scar in the neck (i.e., skin incision outside the neck), to no scar on the body surface. The development of endoscopic system also makes 3D endoscopy, robotic endoscopic surgery, etc. possible. Its surgical indications have gradually expanded, covering various diseases in the field of thyroid surgery, such as benign thyroid nodules, hyperthyroidism, retrosternal goiter, thyroid cancer (including central and lateral cervical lymph node dissection), hyperparathyroidism, parathyroid mass, etc. It has maturely served as the successor of traditional open thyroid surgery in terms of curative effect, trauma and complication rate.

Chylothorax and chylothorax are serious complications after lateral cervical lymph node dissection. The incidence rate is about 4.5% ~8.3%^[1]。 Chylous fluid accumulation can easily lead to incision infection, affect incision healing, and at the same time, it can also lead to electrolyte disorder and massive protein loss, resulting in nutritional disorders and reduced immunity. Large amounts of chyle fluid accumulate in the chest cavity can cause breathing difficulties^[2]。 We summarized the experience of managing chylous leakage after central region lymph node dissection to provide reference for guiding clinical treatment.

Laparoscopic total extra-peritoneal hernia repair (TEP) is a minimally invasive laparoscopic technique to repair the musculopubic foramen with a patch from the extraperitoneal space on the basis of tension-free repair. The operation of TEP is difficult, and the establishment of extraperitoneal space is the key of TEP. However, it is difficult to dissociate the extraperitoneal space and establish the operation skills, so it is necessary to master the correct anatomical plane^[1]。 Due to its automatic adhesion characteristics, if self-fixing patches are used during TEP, it is quite difficult to lay them in the limited extraperitoneal space, which often leads to insufficient deployment of the patches, local deformation, and insufficient local coverage area, resulting in failure of operation or postoperative recurrence. We analyzed TEP cases performed by the same operator from May 2015 to May 2016 to explore a reasonable and standardized patch placement method and the best operation method for using self-fixing patches during TEP surgery.

Laparoscopic right hemihepatectomy has gradually matured, but the technique of laparoscopic separation of the retrohepatic tunnel is still immature. For giant liver cancer of the right liver, laparoscopic resection of the right liver is difficult, and there are few reports in the literature. We use our own patent (patent number: ZL201420838598.7) long sleeve hand aid to perform long sleeve operating hole assisted laparoscopic surgery^[1]Right liver cancer surgery, fingers separated from top to bottom to establish retrohepatic tunnel^[2]Five cases of large liver cancer and giant liver cancer of the right liver were completed, which are reported below.

deep venous thrombosis (DVT) of the lower extremities is the most common disease in vascular surgery, which is at risk of causing fatal pulmonary embolism and may leave behind severe post-thrombotic syndrome^[1,2]Therefore, timely and effective treatment is of decisive significance to reduce DVT mortality. The anterior tibial vein belongs to the deep vein system of the lower limbs, which usually merges into the popliteal vein at the popliteal fossa, and is one of the approaches for the treatment of deep vein thrombosis of the lower limbs^[3]Is an ideal thrombolytic pathway for catheterization. From December 2013 to December 2015, Xuzhou Central Hospital of Jiangsu Province performed thrombolytic therapy through anterior tibial vein catheter in patients with acute lower limbs. The report is as follows.

arteriosclerosis obliterans (ASO) refers to the lesion involving ASO at the opening of the common femoral artery (CFA), the profunda femoral artery (PFA), and the superficial femoral artery (SFA). Due to the special location, whether the stent covers the PFA opening during interventional therapy is still controversial^[1,2]。 The First People's Hospital of Suzhou and the Second Affiliated Hospital of Suzhou University treated 38 patients with this type of ASO with self-expanding bare stent covering PFA opening from January 2010 to January 2014, and obtained good short-term and medium-term results, which are reported as follows.

Since the first application of the inferior vena cava filter (IVCF) in the 1960s, IVCF has gradually evolved from permanent to recyclable. The use of recyclable IVCF has gradually exceeded that of permanent IVCF. With the recognition of IVCF complications, it has become a consensus that IVCF should be removed as soon as the indication for IVCF placement is lifted^[1]。 From January 1, 2007 to December 31, 2015, IVCF was placed in 425 patients in Changzhou Second People's Hospital affiliated to Nanjing Medical University, which is reported as follows.

We retrospectively analyzed the clinical data of 16 patients with Bismuth type Ⅲ and Ⅳ hilar cholangiocarcinoma (HCCA), and explored the application value of three-dimensional reconstruction technique in the preoperative resectability assessment and surgical planning of Bismuth type Ⅲ and Ⅳ HCCA.

With the continuous development of endovascular technology, endovascular therapy (EVT) has become the first choice for the treatment of iliac artery sclerosis obliterans. From December 2012 to December 2015, 20 patients with long segment iliac artery occlusive lesions were performed in Ganzhou People's Hospital. The lesions were classified in accordance with the treatment guidelines of transAtlantic inter-Society consensus (TASC) II^[1]Type D lower extremity arteriosclerosis obliterans (PAD) lesions are reported below.

Studies have shown that the phospholipid inositol 3 kinase/protein kinase B/mammalian rapamycin target protein pathway (phosphninositide 3-kinase/protein kinase B/the mammalian target of Rapamycin, PI3K/Akt/mTOR) It is activated in a variety of tumors and is closely related to the proliferation, anti-apoptosis, angiogenesis and drug resistance of tumor cells^[1]。 As a downstream signaling molecule of PI3K/Akt/mTOR, mTOR is activated by phosphorylated Akt to generate p-mTOR. In this study, the expression of mTOR and p-mTOR in gastric cancer tissues was detected by immunohistochemistry to investigate the relationship between the positive expression of mTOR and p-mTOR and clinicopathology and prognosis of gastric cancer patients.

The carcinoembryonic antigen related adhesive molecular (CEACAM) family members are highly glycosylated proteins belonging to the immunoglobulin gene superfamily, which are overexpressed in many kinds of tumors^[1,2,3]。 In this study, the expression of CEACAM5 in gastric cancer tissues was detected, and its clinicopathological significance was expounded, so as to provide evidence for early diagnosis, recurrence and prognosis of gastric cancer.

Case 1: A 31-year-old female was admitted to hospital with severe abdominal pain accompanied by intermittent exhaustion and decreased defecation for more than 10 days and aggravated for 1 day. Physical examination: flat and soft abdomen, tenderness in the middle and upper abdomen, no rebound pain and muscle tension, and active intestinal sounds. Abdominal CT examination showed that the left upper abdominal colon was dilated and gas accumulated, and the middle and lower abdominal small intestine was gas accumulated, with scattered small air and liquid levels visible inside, which was considered as small intestinal insufficiency obstruction. Given intermittent enema, anti-infection, acid suppression, fluid rehydration and symptomatic supportive treatment, the patient exhausted and defecated, but still had intermittent severe abdominal pain. Laboratory tests: Positive urinary porphyrochologen qualitative test. Considered as intermittent porphyria.

A patient, 80 years old, was admitted to the hospital for 9 months with the discovery of a reversible mass in the left inguinal area. The patient found a reversible mass in the left inguinal area 9 months before admission, which was obvious when standing. After lying down, it could be recovered by itself. After that, the mass gradually increased and could enter the scrotum. Deny the history of frequent nausea and vomiting, constipation and diarrhea, increased nocturia, chronic cough, etc. The patient underwent open prostatectomy 8 years ago and Lichtenstein repair for "left indirect inguinal hernia" 1 year ago. Physical examination: Old surgical scar can be seen in the middle of the lower abdomen, and there is no obvious defect when touched. The reversible mass in the left inguinal area protrudes when standing, and can be recovered by itself after lying down. The mass can enter the scrotum, and the mass still protrudes when pressing the inner ring. After admission, the patient was diagnosed with "recurrent left inguinal hernia", and CT scan of the lower abdomen showed a hernial mass protruding in the lower abdominal wall (Figure 1), into the left scrotum (Figure 2)。 The operation was entered through the original left inguinal hernia repair incision, and the original left inguinal hernia repair was found to heal well without defects. The left muscle layer defect of the original prostate surgical incision was 5 cm ×4 cm. The hernia contents protruded through the defect and went down into the left scrotum. Then the hernia sac was closed, the muscle defect was sutured, and a patch was placed in the preperitoneal space of the original prostate surgical incision defect. Intraoperative diagnosis: suprapubic incisional hernia, after left inguinal hernia repair. Because the original inguinal hernia incision was selected for the surgical incision, it was difficult to expose the surgical field.

Case 1, male, 62 years old, was admitted to the Department of Gastroenterology of our hospital for 5 months due to recurrent abdominal pain with mucus, pus and blood. The stool is unformed loose stool with blood and white pus in the stool. Admitted with "ulcerative colitis". Previously, appendectomy was performed in an external hospital 30 years ago, and tension-free hernioplasty of left inguinal hernia with hernia ring filling was performed in a local hospital 5 years ago. Physical examination at admission: deep tenderness in the left lower abdomen. Abdominal enhanced CT showed thickening of the sigmoid colon wall, thickening and uneven enhancement of the middle sigmoid colon wall, and local intestinal lumen became narrow. Colonoscopy revealed: sigmoid colon foreign body, visible net plug (Figure 1)； Sigmoid fistula. Pathological report: Chronic inflammatory changes in mucosal tissue of sigmoid colon, with a small amount of inflammatory granulation tissue. Please consider the invasion of the net plug into the sigmoid colon after consultation in our department, transfer to our department for exploratory laparotomy + implant removal, inform the necessity of the operation and related risks, and the family will give up the operation and be discharged after full consideration.

A 63-year-old woman was admitted to the hospital for 2 months after a progressive enlargement of the right breast mass was found. Previously healthy, menopausal. In May 2015, he underwent endoscopic extended resection of malignant melanoma of left nasal mucosa due to malignant melanoma of left nasal mucosa. After operation, radiotherapy, chemotherapy and immunotherapy were given according to the standard, and the whole body was re-examined every 3 months after operation, and all showed that it was normal. A swollen lymph node of about 1.3 cm ×1.3 cm in the right axillary was found on mammography at the 8th month after surgery (Figure 1)； At the 10th postoperative month, the patient found a 20 mm mass on the lateral side of the right breast, which was painless. However, the mass grew rapidly and increased to 70 mm within 2 months. Specialist examination: A 70 mm ×50 mm size mass was palpable at 9 o'clock on the lateral side of the right breast and 5 cm away from the nipple. It was hard in texture, with poor borders, poor movement, slight adhesion to the skin, no tenderness, and no discharge when squeezing the nipple. No swollen lymph nodes were palpable in the right axilla and above and below the clavicle; There were no abnormalities in the left breast. Breast color ultrasound, MRI (Figure 2), chest CT and mammography all showed irregular mass in the right outer mammary quadrant and an enlarged lymph node in the right axilla; Hollow needle aspiration biopsy of breast mass revealed malignant melanoma, considered metastatic in combination with medical history. After the consent of the patient and family, the right breast mass enlarged resection + mammoplasty + right axillary lymph node dissection were performed. Postoperative pathology: Malignant melanoma, no nerve and vascular invasion, no skin involvement, tumor cell metastasis in 1/18 lymph nodes in right axillary region, no malignant components were found in skin margin, pericavity margin, and tumor bed section; Immunohistochemistry: HMB45 (+ + +) (FIG. 3A), Melan-A (+ + +) (FIG. 3B), S-100 moiety (+ +), ER (-), CK (-), HER2 (-). One month after surgery, the right breast and axilla were treated with low-dose radiotherapy and maintenance therapy with temozolomide + endu regimen.

A 53-year-old male developed severe abdominal pain after a meal 3 months ago, and an enhanced CT of the upper abdomen in a local hospital showed isolated superior mesenteric artery dissection (Figure 1), percutaneous transluminal angioplasty of superior mesenteric artery under local anesthesia the next day. During the operation, the true cavity was severely narrowed, the guide wire could not pass, and the operation was not completed. After conservative treatment, repeated symptoms, accompanied by fever, came to Changhai Hospital for treatment. Previous smokers with a history of hypertension. Physical examination: low fever, tenderness in the middle and upper abdomen, no rebound pain, and weak intestinal sounds. Intestinal obstruction revealed by abdominal orthostatic radiography. Multiple blood cultures of fungal D glucan (+), after conservative treatment such as antifungal anticoagulation, the patient's body temperature was stable for 3 days, and the blood culture was negative. After one week of admission, surgical exploration showed that the jejunoileum peristalsis was good, the blood supply was normal, the pulsation of the initial part of the superior mesenteric artery disappeared, and the inferior mesenteric artery was well compensated. Approximately 15 cm from the Treitz ligament, the distal end is about 60 cm long, the jejunointestinal lumen is atresia, and the proximal intestinal tube is dilated. Then the occluded intestine was removed and the proximal and distal end anastomosis was performed. The mesenteric blood supply was confirmed to be normal again, and the superior mesenteric artery dissection was not treated with special treatment. The patient returned to exhaust on the 3rd postoperative day, no obvious abdominal pain was seen after eating, and was discharged on the 7th postoperative day. Pathological report: Segmental hemorrhagic infarction with localized intestinal serosal surface fibrin exuditis (Figure 2)。

the 2015 edition of ATA guidelines for the management of adult thyroid nodules and differentiated thyroid cancer clearly states that all thyroid surgeries should identify the recurrent laryngeal nerve directly and protect the external branch of the superior laryngeal nerve (EBSLN). Although there are increasing reports focusing on intraoperative neuromonitoring (IONM), it remains uncertain whether it is beneficial to protect sound function. This article reviews the anatomy of the superior laryngeal nerve and the application of IONM.

Pancreatic cancer is a very deadly solid tumor^[1]With high degree of malignancy, rapid development and poor prognosis^[2,3]。 Surgery is still the only way to cure pancreatic cancer, and it is also the best way to improve the survival rate of pancreatic cancer patients. However, 80% ~90% of patients with pancreatic cancer have lost the opportunity of surgery when diagnosed, mainly due to local invasion or distant metastasis, among which hematogenous metastasis to the liver is the most common. Generally speaking, surgical resection for liver metastasis of pancreatic cancer is not recommended, and comprehensive treatment of chemotherapy and radiotherapy is mostly used. However, the emergence of new chemotherapy regimens and drugs has prolonged the survival time of some patients with pancreatic cancer with liver metastasis, and also made some surgeons see the possibility of treating patients with pancreatic cancer with metastasis through effective chemotherapy combined with surgical resection. In recent years, there have been many literature reports that for some pancreatic cancer complicated with liver metastasis, surgical treatment seems to improve the long-term survival and prognosis of patients. Although most of these studies are case reports or a few cases, they show that with the progress of pancreatic cancer chemotherapy, some patients with liver metastasis of pancreatic cancer who have lost the opportunity of radical surgery may be resected at the same time or in stages after preoperative or postoperative chemotherapy. This article reviews the literature on surgical treatment of patients with liver metastasis of pancreatic cancer in recent years to clarify the role and future development trend of surgical treatment in patients with pancreatic cancer with liver metastasis.

enhanced recovery after surgery (ERAS) refers to the use of a series of perioperative management measures with evidence-based medical evidence to reduce or reduce the patient's traumatic stress and achieve rapid recovery^[1]。 Perioperative pain management is an important part of ERAS. At present, multimodal analgesia composed of a variety of analgesics and technical means has become the mainstream trend. Among them, non-steroidal anti-inflammatory drugs are playing an increasingly important role in perioperative pain management of ERAS because they have definite preventive analgesia, inhibit inflammation, reduce stress, and have no adverse reactions such as opioid addiction, nausea, vomiting and respiratory depression.