2017年 · 第32卷第05期

laparoscopic cholecystectomy (LC) is the most commonly used surgical procedure for the treatment of gallbladder diseases. With the development of technology and instruments, it has become a hot spot for surgeons to reduce injury and achieve the perfect combination of minimally invasive and cosmetic^[1]。 In view of this, single-port laparoscopic cholecystectomy was conceived. We retrospectively analyzed the difference between transumbilical single-port laparoscopic cholecystectomy and traditional three-port surgery, and explored the feasibility, safety and cosmetic effect of transumbilical single-port laparoscopic cholecystectomy.

Persimmon stone intestinal obstruction refers to the mechanical intestinal obstruction caused by one or more persimmon stones entering the intestine and being imprisoned in the intestinal lumen. It mostly occurs at the end of the ileum and causes small intestinal obstruction. Conservative treatment is poor and often requires surgical treatment. In this study, 68 cases of persimmon stone intestinal obstruction were performed with laparoscopic assistance, and the results were satisfactory, which are reported below.

percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) are endoscopically mediated gastrointestinal fistula techniques, which are minimally invasive, easy to operate, safe, effective and inexpensive enteral nutrition methods. The clinical data of 39 patients undergoing PEG and PEJ were retrospectively analyzed in this study and are reported below.

catheter directed thrombolysis (CDT) is an effective treatment for acute deep venous thrombosis (DVT) of lower limbs, and has been widely used in clinical practice^[1]。 Yantai Yuhuangding Hospital affiliated to Qingdao University used the method of measuring the pressure gradient difference between iliac vein and inferior vena cava to assess the degree of iliac vein stenosis and guide the treatment of 16 patients with acute left lower limb DVT from June to December, 2015. The report is now as follows.

Spleen complication is a rare complication of acute pancreatitis. Foreign scholars report that its incidence rate is 1% ~5%^[1]Six patients with acute pancreatitis and spleen complications were admitted to our hospital from 2010 to 2015. The summary report is as follows.

acinar cell carcinoma of pancreas (ACCP) is a rare malignant exocrine tumor, accounting for about 1% of pancreatic tumors^[1]。 High rate of preoperative misdiagnosis because of rare and lack of specific clinical manifestations^[1,2]。 The CT and clinical data of 5 cases of ACCP confirmed by pathology were collected and analyzed retrospectively in order to improve the diagnosis and treatment level.

The patient was a 61-year-old male. The skin of the right ankle was ulcerated, pigmented, and the ulcer was recurring for 15 years. He was admitted to the hospital on August 14, 2015 after another ulceration in the boot area of his right foot for 2 months. Eighteen years ago, I had a history of scald and bed rest, and swelling of my right lower limb appeared after moving on the ground. Admission diagnosis of "right lower extremity deep vein post-thrombosis syndrome", right lower extremity deep vein antegrade angiography through right popliteal vein puncture showed: right femoral vein and right external iliac vein stenosis. Balloon stenting of right iliac vein and femoral vein was performed. Anticoagulation treatment was not performed on time after discharge. After reexamination 1 month later, bilateral iliac vein ultrasound showed: "right iliac vein stent thrombosis", and D-dimer was checked: 0.44 mg/L. He was readmitted. AngioJet Ultra thrombus aspiration system (Boston Scientific) was administered. After successful puncture through the right popliteal vein during the operation, angiography showed that the right iliac vein was stented with thrombosis caused by occlusion (Figure 1), AngioJet Ultra thrombus aspiration systemFigure 2)。

A 10-year-old child was admitted to hospital for more than 1 month due to repeated abdominal pain after trauma, accompanied by nausea and vomiting. Physical examination: The left epigastric bulge can be palpable with a mass of about 18 cm ×10 cm ×15 cm in size, which is tough in texture, without tenderness, with clear boundaries and poor mobility. Abdominal ultrasound, abdominal CT and MRCP all revealed a pancreatic pseudocyst, single, approximately 17.3 cm ×10.1 cm ×13.8 cm in size, located above the tail of the pancreatic body, with mature cyst wall, compressed pancreatic duct and not communicating with the cyst cavity (Figure 1)。 Gastroscopy revealed chronic non-atrophic gastritis with bile reflux and bulge of gastric fundus (extracavitary compression). Endoscopic ultrasound-guided fine needle puncture was performed, the cystic fluid amylase was>52 000 U/L, and no cancer cells were found in the cystic fluid smear. Full-thickness gastric wall incision and catheter drainage under the guidance of endoscopic ultrasound: Under the guidance of endoscopic ultrasound, the posterior wall of gastric antrum with no obvious blood flow and close contact with the cyst wall was selected as the puncture point, and a COOK 19G puncture needle was inserted into the cyst cavity, and a yellow zebra guide wire was inserted. After the puncture needle was withdrawn, the puncture tract was expanded with an expansion bougie, the whole thickness of gastric wall and cyst wall was incised with a COOK cyst incision knife along the guide wire (the size of the incision of gastric wall was about 1 cm ×1 cm). A thin light brown cyst fluid overflowed into the gastric cavity, and a COOK dilatation balloon FS-BDB (dilatation outer diameter 10 mm and length 40 mm) was inserted along the guide wire for continuous expansion for 3 min. After the end of the endoscope was inserted into the cystic cavity along the gastric wall incision and the cystic fluid was aspirated as much as possible, a 10F double pigtail stent was placed and a nasal drainage tube was placed. A large amount of thin coffee-colored cystic fluid overflowed into the gastric cavity and was aspirated. The operation was smooth. After operation, acid production, hemostasis, anti-infection and nasojejunal nutrition tube were treated with nutritional support. After treatment, the patient's left upper abdominal mass was significantly smaller than before, and the abdominal CT cyst was significantly smaller after re-examination. The nasal cyst drainage tube and double pigtail stent were removed under endoscope 9 days after operation. The leak size at the original gastric wall incision was about 1 cm ×1 cm. The end of the endoscopic lens was extended into the cyst cavity through the leak opening to absorb the residual cyst fluid. The cyst cavity was fully cleaned with normal saline. After the foreign body forceps were passed through the endoscopic biopsy tract, the absorbable dura mater (spinal) patch was clamped into the gastric cavity to seal the leak (Figure 2)。 After 3 days, the reexamination of gastroscopy showed that the patch was in place at the leakage, and the leakage was approximately closed. The nasojejunal nutrition tube was removed. The child was discharged 14 days after surgery and was followed up for nearly 2 years without recurrence or complication.

The patient was a 70-year-old male. Four years ago, I saw a doctor for left low back pain and weight loss; CT examination showed: left retroperitoneal occupied space. The left adrenal gland was diagnosed as occupying space, and left adrenalectomy was performed. Pathology: Left adrenal cortical adenocarcinoma with necrosis and hemorrhage, size 13 cm ×13 cm ×9 cm, intact capsule, gray-white, gray-red section, soft texture, obvious atypical tumor cells, nuclear division>5/50HPF, IHC: CAM5.2 (partial +), CD10 (-), CgA (-), NSE (weakly positive), Syn (+), Vimentin (partial +), Inhibin-α (partial + +), EMA (-), CK8/18 (+). There was no follow-up after surgery. One month ago, the left upper abdomen had dull pain and weight loss. Physical examination showed that a lump was palpable in the left upper abdomen, about 10 cm ×10 cm, hard and fixed, without tenderness; B-ultrasound showed that the spleen occupied space, and CT showed that the spleen was malignant (Figure 1), considering left adrenal tumor metastasis in combination with medical history; The spleen was diagnosed as occupying space, and exploratory laparotomy was performed. Intraoperative results showed that the spleen was tough, the lymph nodes parasplenic artery were not obviously enlarged, the tail of the pancreas was compressed, the anterior capsule of the left kidney and the mesangium of the upper level of the colon and spleen were adhered to the tumor, and the abdominopelvic peritoneum did not have obvious tumor metastasis and dissemination nodules. The surgical protocol was adjusted: spleen + pancreatic body and tail + splenic area of colon + left partial nephrectomy. Postoperative pathology: metastatic adrenocortical adenocarcinoma of the spleen, 14 cm ×9 cm (Figure 2), gray-yellow, soft in texture, partially necrotic, a small amount of renal tissue and pancreatic tissue can be seen on the surface of the spleen, about 4 cm ×3 cm and 5 cm ×4.5 cm, respectively. The tumor involved part of the renal capsule and pancreatic capsule, but not the parenchyma (Figure 3)。

A 41-year-old male was seen in our hospital mainly for "distension and pain in the right upper abdomen for more than 2 months". Past health, denied history of hepatitis, hypertension and diabetes, denied history of drug allergy. Physical examination: The whole abdomen is soft, and a substantial mass can be palpable at the right subcostal edge of the liver and under the xiphoid process, which is hard in texture and has no tenderness. Laboratory tests showed no obvious abnormalities. Abdominal CT examination of the right lobe of the liver showed a solitary circular mass with uneven density, with clear boundaries and a size of 7.5 cm ×7.0 cm (FIG. 1A)； The enhanced CT arterial phase showed partial enhancement (FIG. 1B)。 Hepatic segment S5 resection + cholecystectomy was performed under general anesthesia. The whole operation went smoothly, with intraoperative bleeding of about 300 ml. The cutting edge of the specimen was gray-white, soft and tough. Pathological examination (FIG. 2A): The spindle-shaped tumor cells were diffusely distributed and swirled. In the dense area of tumor cells, mitotic images are more common, 5~8/10 HP. Focal necrosis was observed between tumor cells. immunohistochemistry (Figure 2B): Vimentin (+), CD34 (+), bcl-2 (+), CD31 (+), SMA (+), Ki-67 (30% +), CD99 were diffusely weakly positive; CK, EMA, Glypican, CK7, S100, Dog-1, HMB45, Melan-A, CK19, CK5/6, CD117 And CD68 were both negative. Postoperative pathological diagnosis: malignant solitary fibrous tumor (liver) (solitary fibrous tumor, SFT). One month after surgery, our hospital underwent routine chemoembolization. No other special treatment was performed, and no tumor recurrence and metastasis were found after 6 months of imaging follow-up.

The patient, male, 64 years old, was admitted to hospital for half a month due to repeated upper abdominal distension and pain, without nausea and vomiting. Hepatitis and other special medical history were denied. Specialist physical examination: mild tenderness in the right upper abdomen, but nothing special. Laboratory tests: There were no abnormalities in blood routine, biochemistry and tumor markers (Figure 1，Figure 2)。 Abdominal MRI showed a mixed density mass in the right lobe, about 10.58 cm ×10.62 cm ×11.08 cm in size. The solid part of the enhanced scan showed mild to moderate uneven enhancement in the arterial phase, and gradually obviously enhanced in the later stage, mostly tending to be benign, and malignant was not excluded. The preoperative diagnosis of liver occupied space was proposed. An anatomical right hemihepatectomy was performed. Intraoperative exploration shows that the right lobe occupies a space of about 10 cm ×10 cm ×11 cm, and the boundary is still clear. When the mass was incised, pale yellow fluid flowed out, the incision surface was white, and some areas were cystic. Evacuated pathological examination, the result showed: liver mesenchymal hamartoma (mesenchymal hamartoma of the liver, MHL) (Figure 3)。 Immunohistochemistry : SMA (+), CD99 (−), CD34 (+), VIM (+), bcl-2 (+). The patient recovered well 8 days after surgery and was discharged.

The patient was a 45-year-old male. Physical examination found that the right liver occupied space for 5 months, without symptoms of right upper abdominal discomfort, fever, and yellowing of the skin and sclera. Specialist examination showed no positive signs. Upper abdominal enhanced CT showed irregular low-density lesions in the right anterior lobe of the liver, irregular rosette-like enhancement in the arterial phase, and more obvious rosette-like enhancement in the venous phase and delayed phase, which seemed to be caused by the fusion of multiple lesions. The maximum transverse diameter area was about 5.2 cm ×4.8 cm, and multiple spotty lower-density shadows were seen inside (Figure 1), considering space-occupying lesions in the right lobe of the liver. Laboratory tests: There were no abnormalities in blood routine, liver and kidney function and tumor markers. Cardiorespiratory function can. Preliminary diagnosis: right liver mass occupying, malignant tumor? Elective partial hepatectomy was performed. Surgical exploration showed that a mass of 5 cm ×4 cm ×4 cm was seen at the junction of the V and VIII segments of the right liver, which was tough in texture, with clear borders, small gallbladder and not thick wall. The liver capsule was incised 2 cm along the edge of the liver mass with ultrasonic scalpel, and the tumor was completely removed. Hepatic hilar was occluded for 20 min. The operation went smoothly. The postoperative pathological results showed that a wedge-shaped liver lobe specimen was resected, and the gross specimen: 5 cm ×4 cm ×4 cm gray-yellow ductile nodule (Figure 2), immediately adjacent to the liver capsule. The nodules were all degenerative necrosis, and a few surrounding liver tissues showed chronic hepatitis changes, and hepatocyte steatoid degeneration (Figure 3)。 Pathological diagnosis: solitary hepatic necrosis nodule (solitary necrotic nodule of the liver, SNNL).

A 77-year-old female was presented on 2 June 2009 for "intermittent claudication of right lower limb for 8 months". Physical examination: The right popliteal artery can pulse, but the femoral artery and dorsal pedis artery are not reached. computed tomography angiography (CTA) of the arteries of both lower limbs showed that the right superficial femoral artery gradually tapered to the knee joint and disappeared. The internal iliac artery migrated to the lateral femur through the piriformis muscle, and continued to the popliteal artery after the femur to the popliteal fossa. The transitional artery showed local aneurysm-like changes, and the distal popliteal artery showed arteriosclerotic occlusion (Figure 1)。 Follow-up to the medical history, the patient complained that a pulsatile mass in his right hip was discovered 8 months ago. Admission physical examination: A pulsatile mass of 6 cm ×4 cm size can be palpable on the lateral side of the right hip, with clear boundaries. The patient is considered to have a rare persistent sciatic artery (PSA) combined with ischial aneurysm in the lower extremities. After the diagnosis of arteriography under local anesthesia on June 15, 2009 (FIG. 2A), selected Bard Company 10 mm diameter and 100 mm length covered stent to perform endovascular isolation, the operation was smooth, the postoperative tumor isolation was satisfactory (Figure 2B), right popliteal artery blood flow was not affected. The pulsatile mass of the right hip disappeared after operation, and the symptoms of intermittent claudication of the right lower limb were relieved. Six months after operation, CTA examination showed no stenosis, smooth blood flow in lower extremities, and no recurrence of aneurysm. The stent was patent for continuous follow-up. The patient died of cirrhosis and liver failure on 25 Jan 2013.

unsuspected/unexpected incidental gallbladder carcinoma (UGC) is a disease in which benign gallbladder diseases, such as gallbladder polyps, gallbladder stones, acute and chronic cholecystitis, are diagnosed by preoperative examination, and pathologically confirmed as gallbladder cancer during or after operation. UGC in and after laparoscopic cholecystectomy (LC) is about 0.2% to 2.1%^[1]In recent years, with the extensive development of LC, the rate of UGC is increasing year by year, accounting for about 50% to 58% of patients with gallbladder cancer^[2]。 The overall 5-year survival rate of gallbladder cancer is less than 5%. If the diagnosis of gallbladder cancer is timely and the staging operation is appropriate, the 5-year survival rate of early patients can reach 75%^[3]。 T1 and T2 stages account for the vast majority of UGC, and there are many chances of radical resection, and the prognosis of patients is better^[4]。 At present, there is some controversy about the choice of treatment plan for each stage of UGC in clinical work. This article will review the options for treatment of UGC.

Cholecystectomy is an effective measure for the treatment of acute cholecystitis, but in some patients, the triangular structure of the gallbladder is blurred due to incarceration of gallbladder neck stones, which is difficult to separate by operation, easy to bleed, and easy to occur extrahepatic biliary tract injury. Moreover, for specific patients, surgical anesthesia is a great threat. percutaneous transhepatic gallbladder drainage (PTGBD) was first proposed by Radder in 1980, and has since been widely used in severe cholecystitis to drain bile in a minimally invasive way and eliminate symptoms.

With the development of interventional techniques, intra-arterial stenting has been widely used in the treatment of lower extremity arteriosclerosis obliterans. However, the existence of metal stents as permanent foreign bodies in blood vessels causing restenosis and late thrombosis is still a difficult problem to solve at present. Due to the continuous development of degradable materials, the application of bioresorbable scaffolds (BRS) in coronary heart disease has accumulated more experience. At the same time, people want to implant this method to the treatment of peripheral arterial disease (PAD). This article summarizes the current basis for the use of BRS in the treatment of lower extremity arterial diseases, and briefly introduces the existing challenges and expected developments.