2017年 · 第32卷第06期

Obturator hernia is less common clinically^[1]Its clinical manifestations are mostly atypical, more common in elderly women, and intestinal obstruction is often the main clinical manifestation, with low preoperative diagnosis rate and high mortality rate. Early detection and timely surgery are the only effective means to treat obturator hernia. A total of 9 patients with obturator hernia were treated in the Department of Gastrointestinal Surgery of our hospital from August 2009 to December 2015, and the reports are as follows.

Intestinal obstruction caused by malignant tumors is a common complication in patients with advanced cancer, and most of them are treated with unconditional reoperation. In this study, the use of nasal small intestinal decompression tube to directly drain and decompress the small intestine of this type of patients can relieve the symptoms of intestinal obstruction in a short time. At the same time, enteral nutrition therapy, namely "drainage while eating", has achieved good therapeutic effect, which is reported as follows.

Mammotome Rotary Breast Excision System is an ultrasound-guided vacuum-assisted biopsy device mainly used in breast tumor biopsy produced by Johnson & Johnson^[1]。 Initially, it was mainly used for resection and biopsy of breast tumors, and later it was extended by clinicians for resection of benign breast tumors. Because of its small surgical incision, quick healing and no impact on appearance, it is popular among young patients. There was no significant difference in postoperative complications compared with traditional surgery^[2]However, the residual tumor problem is rarely reported clinically. In this study, we retrospectively analyzed the patients treated in our hospital for this problem.

Colon cancer is more common clinically, and sigmoid colon is the most common site of colon cancer. Its early symptoms are not obvious. With the development of the disease, symptoms such as changes in defecation habits, diarrhea, alternating constipation, blood in the stool and local abdominal pain will appear, and the clinical incidence and mortality rate are high^[1]。 Related studies show^[2,3]The incidence of sigmoid colon adenocarcinoma has gradually increased in recent years, mostly in middle-aged or elderly men, with a male-female ratio of about 2:1, and the cause of the disease is unknown. In this study, a patient with sigmoid adenocarcinoma underwent laparoscopic radical sigmoid colonectomy, and observed the clinical effect of implementing enhanced recovery after surgery (ERAS) during the perioperative period, so as to provide a reference for clinical choice of treatment plan.

The injury of the superior laryngeal nerve, especially the external branch, can lead to relaxation of vocal cords, reduced pitch, inability to make high tones, etc., which affect the quality of life of patients. There are different opinions of scholars at home and abroad on whether the superior laryngeal nerve is routinely exposed during thyroid surgery. We conducted a retrospective study on 761 patients with thyroid cancer who underwent unilateral total thyroidectomy and bilateral total thyroidectomy to analyze the postoperative treble function of patients.

Laparoscopic choledochal exploration and T-tube drainage is one of the common methods for the treatment of extrahepatic choledocholithiasis. However, with the popularization of the concept of precision and minimally invasive surgery, people's constant awareness of the disadvantages of T-tube drainage and the continuous improvement of patients' requirements for quality of life, and the primary suture of the common bile duct after laparoscopic common bile duct exploration and stone removal has become the development direction of the treatment of common bile duct stones because it speeds up the recovery speed and avoids the deficiency of T-tube drainage. We performed laparoscopic common bile duct exploration lithotomy in 87 cases, of which 42 cases underwent primary suture of common bile duct, and achieved satisfactory results, which are reported below.

SiewertⅡ and SiewertⅢ adenocarcinomas of the esophagogastric junction (AEG) are closer to gastric cancer, and the choice of transthoracic or transabdominal hiatus surgery approach is still controversial^[1]。 This study compared the effects of two different surgical approaches on the prognosis of patients with Siewert II and Siewert III AEG.

With the development of endovascular treatment technology in vascular surgery, thoracic endovascular aortic repair (TEVAR), as an alternative therapy to traditional open surgery, is gaining the recognition and acceptance of more and more clinicians because of its minimally invasive and less postoperative complications. The number of catastrophic complications of graft infection after TEVAR is increasing with the extensive development of TEVAR. From October 2008 to April 2016, 120 patients underwent TEVAR surgery in our department due to thoracic aortic dissection/aortic aneurysm. During this period, a total of 2 cases of postoperative graft infection occurred, 1 case occurred during postoperative hospitalization, and 1 case occurred during postoperative follow-up. We summarized the data of these 2 cases of postoperative graft infection and reported it as follows.

A 69-year-old female patient had mild distension and pain in the lower abdomen accompanied by frequent urination and urgency for 3 months. Color ultrasound in the gynecological department of the local hospital showed a mass in the left adnexal area, which was diagnosed as a pelvic retroperitoneal mass during laparoscopy. Admitted to our hospital for further diagnosis and treatment. Pelvic CT: A massive soft tissue shadow paravascular to the left iliac blood vessel in the pelvic cavity, with a clear boundary, about 6.0 cm ×3.8 cm in size, patchy enhancement at the edge of the lesion in the arterial phase, and tortuous and thickened blood vessel shadows around the tumor. Laparoscopic pelvic mass resection was performed. During the operation, a protruding mass in the left adnexal area was seen, located behind the peritoneum, and the peritoneum was opened. The tumor was located between the iliac blood vessels, iliopsoas muscle and ureter, with good mobility, and the tumor was completely removed. The capsule was intact, and the section surface was gray-white, solid and hard. Postoperative pathology: Castleman's disease (hyaline vascular type), seeFigure 1。 Immunohistochemistry Ki-67, CD20, PAX-5, CD3, CD43, Bcl-2, CD5, cyclin D1, CD10 positive, in situ hybridization: EBER (-); The patient recovered well after operation, and the symptoms of frequent urination and urgency basically disappeared.

A 64-year-old female was admitted to hospital because of "a huge pelvic mass found by physical examination for more than 1 month". Physical examination: A tough mass about 10 cm in size can be palpable in the left lower abdomen, with unclear boundaries and no tenderness. CT examination showed that a soft tissue mass was visible on the left side of the pelvic cavity, about 11.0 cm ×9.2 cm in size, with clear and smooth boundaries, uneven density, arcuate calcification at the edge, and uneven moderate enhancement on enhancement scan. CT diagnosis: left pelvic mass, considered as neurogenic tumor, excluding tumor of stromal origin (Figure 1)。 Exploratory laparotomy was performed. The mass was tough, the anterior capsule was smooth, and the posterior side was closely related to the pelvic floor. Complete mass resection was performed. Pathological examination: The nodular tissue was 12 cm ×9 cm ×9 cm in size, the cut surface was gray-yellow, tough in texture, partially gelatinous, and the periphery was encapsulated. Under light microscope, the tumor cells were arranged in bundles or braids, some areas were densely arranged, some areas were sparsely arranged. The cells are spindle-shaped, rich in cytoplasm, the nucleus is rod-shaped, and there is no nuclear division. Interstitial blood vessels proliferate and dilate, and lymphocytes aggregate at the tumor envelope (Figure 2)。 Immunohistochemical staining results showed that: Dog-1 (-), CD117 (-), CD34 (vascular +), SMA (-), Des (-), S100 (3+) (Figure 3), CR (−), CD56 (focal +), Ki-67 (focal 5% +). Diagnosis: pelvic cellular schwannoma.

Patient, female, 66 years old. He was admitted to hospital for 3 days due to the discovery of a left breast mass. Physical examination: A mass about 2 cm ×1.5 cm in size can be palpable in the upper inner part of the left breast 2 cm from the edge of the areola. It is hard in texture, with unclear boundaries, irregular surface, good mobility, and no adhesion to the skin and chest muscles. Breast ultrasound: A hypoechoic mass of about 1.6 cm ×1.0 cm was seen in the left breast, with irregular shape, unclear boundary, uneven internal echo, and unobvious blood flow signal in it. Mammography: Irregular high-density mass shadow was seen in the upper quadrant of the left breast, with blurred edges. Pathology of mass puncture: invasive carcinoma of the breast. Left mastectomy + sentinel lymph node biopsy under general anesthesia. Intraoperative freezing: 0/6 sentinel lymph nodes metastasized. Postoperative pathology: The gray-white matter was hard on the tumor section, and mucous cells, epidermoid cells and intermediate cells were mixed in different proportions in the solid area and the cystic area containing mucus. Mucous cells are abundant, accounting for more than 50% of tumor cells. Mucous cells constitute glandular cavity and cystoid cavity, and there are proliferative mucous cell papillae protruding into them. There are mucus and exfoliated epithelial cells in the capsule. Epidermoid cells are mature, nuclear division is rare, and there are few intermediate cells. Immunohistochemistry: Ki67 (5% positive), P53 (10% positive), ER (10% weak positive), PR (0%), TOPOII (2% positive), HER2 (0), CK7 (+), CK (+), Calponin (-), S100 (-), P63 (+), CK5/6 (+). AB (+). Pathological diagnosis: well differentiated breast mucoepidermoid carcinoma (Figure 1), no vascular tumor thrombus and nerve invasion were seen. The patient was instructed to take letrozole orally for 5 years after surgery. The patient was followed up for 3 months without recurrence.

A 38-year-old female was admitted to the hospital due to the discovery of a mass in her right axilla for 4 years, enlarged with pain for half a year. B-ultrasound: cystic mass in the right axilla with internal septum, with a high possibility of lymphangioma. Mammography: Double breast hyperplasia with left breast calcification, bilateral axillary accessory breast, right axillary accessory breast cyst, possible cystic lymphangioma, BI-RADS grade III. Physical examination: A painless mass with a size of 8 cm ×7 cm can be found under the right axilla, which is soft in texture, good in mobility, and clearly bounded with surrounding tissues. There is no ulcer on the skin surface, no redness and swelling around it, there is nipple formation in the center, and there is no discharge around the nipple when squeezed. No swollen lymph nodes are palpable in the contralateral axilla, and no swollen lymph nodes are palpable on the bilateral clavicules (Figure 1)。 MRI: A sheet-like long T1 and long T2 signal shadow can be seen under the right axillary, and a circular cystic signal shadow with a diameter of about 9.8 cm can be seen under the right axillary. Its anterior edge penetrates deep into the pectoralis major muscle. Its signal is uniform, the edge is clear, and there is an intact capsule. The capsule is obviously enhanced after enhanced scan; A slightly swollen lymph node, about 1.2 cm in diameter, was seen under the right axilla; Several small lymph nodes were seen in the left axillary (Figure 2)。 Right axillary mass resection + axillary lymph node dissection under general anesthesia. During the operation, the size of the tumor was 15 cm ×12 cm ×5 cm, it was cystic, with an intact capsule, and the boundary with the surrounding tissues was obvious. About 300 ml of pale yellow clear liquid was extracted by puncture, and the tumor was completely removed (Figure 3)。 Intraoperative pathology: The puncture fluid of the right axillary mass was pale yellow clear fluid, lymphocytes were seen, but no malignant cells were found. Postoperative pathology: (right axillary) cystic lymphangioma with smooth surface in some areas and a small amount of adipose tissue around it. The section was biatrial, with dark red fluid in one sac and pale yellow chyloid fluid in the other sac. Microscopically: The tumor tissue is composed of cavities of different sizes, lined with flat endothelial tissue, and scattered smooth muscle and lymphocytes can be seen in the wall (Figure 4)。 The patient recovered well after surgery without recurrence.

A 46-year-old male was admitted to the hospital for 4 months due to bloody stool. Physical examination: No enlarged lymph nodes were found on the left clavicle. (Digital anal examination) The rectum is 3 cm away from the anal margin and the mass occupies a circle of the intestinal canal. The surface of the mass is irregular, hard in texture and poor in movement. Tumor markers : CEA 6.53 ng/ml, CA125 8.46 IU/ml, CA19-9 8.53 IU/ml. Abdominal and pelvic CT: abnormal signal foci in the body and tail of the pancreas, lower rectal cancer with multiple lymph nodes around the rectum (Figure 1，Figure 2)。 Colonoscopy: rectal adenocarcinoma. Clinical diagnosis: rectal cancer, mass occupation of the body and tail of the pancreas. Laparotomy showed that there was no ascites and implant nodules in the abdominal and pelvic cavities, the liver and spleen did not occupy space, there was no abnormality in the gastroduodenum and small intestine, the lymph nodes for the abdominal aorta were not swollen, and the rectal tumor could not be palpable through the abdominal cavity; There is a mass at the tail of the pancreas, about 4 cm ×3 cm in size, hard in texture and with good mobility. Transabdominoperineal combined radical resection of rectal cancer + combined splenectomy of body and tail of pancreas were performed. The patient recovered smoothly after surgery. Pathology: poorly differentiated adenocarcinoma of the rectum (Figure 3), infiltrated the whole thickness of the intestinal wall, and no cancer metastasis was seen in mesenteric lymph nodes (0/4); Under the microscope, most areas of pancreatic lobular structure exist, and abnormal cancer cell nests are seen around the lobules and vasculature in the portal area, which are multifocal and jumping distribution. Most cancer cells are located in the vasculature, and the focal area is surrounded by nerve fiber bundles and necrosis. No cancer metastasis was observed in the spleen. Immunohistochemistry showed that the positive index of cancer cells CK20 (+), CEA (+ + +), Villin (+ + +), CDX-2 (+ + +), CK19 (+ +), Syn (-), CgA (-), CD56 (-), P53 (+ + +), Ki-67 was approximately 50% (Figure 3、Figure 4、Figure 5)。 The consultation opinion of the pathology department: Based on the HE morphology and the results of immune enzyme labeling, it is consistent with metastatic poorly differentiated adenocarcinoma. Adjuvant chemotherapy was given with FOLFOX4 regimen after operation. After 18 months follow-up, no tumor recurrence was observed.

The patient was a 52-year-old female. On January 5, 2016, he was admitted to hospital due to "intermittent abdominal pain for 1 month and aggravated for 3 days". Intermittent upper abdominal discomfort without obvious trigger 1 month before admission, aggravated after eating, accompanied by nausea and vomiting. It improved after symptomatic treatment such as anti-inflammatory and acid suppression. Acute attack of abdominal pain 3 days before admission, accompanied by nausea and vomiting, shortness of breath, without chills and high fever. Admission physical examination: T: 38.4 ℃, P: 110 times/min, R: 22 times/min, BP: 145/90 mmHg. Abdominal swelling, no gastrointestinal type and peristaltic wave, no palpable mass, positive total abdominal tenderness and rebound pain, and obvious muscle tension. Intestinal sound (1~2) times/min. Experimental examination showed that white blood cells were 18.4×10⁹/L, neutrophils 91.5%, total bilirubin 41.5 μ mol/L, direct bilirubin 15.6 μ mol/L, indirect bilirubin 25.9 μ mol/L, blood glucose 9.61 mmol/L, PT 53.00%, INR 1.56, APTT 43.6 s, D-dimer>4.0, fibrin degradation products 40.23 μ g/ml, anticoagulase III 48%, brain natriuretic peptide precursor 625 pg/ml, creatine kinase 324.0 U/L, lactate dehydrogenase 368.5 U/L, CKMB 38.4 U/L, hypersensitive C-reactive protein 253.9 mg/L. No obvious abnormalities were found in routine urine and fecal examinations and autoantibody examinations. ECG showed: right ventricular hypertrophy; Abdominal B-ultrasound showed: pelvic and peritoneal effusion; Chest radiograph showed: the texture of both lungs increased, the heart shadow increased, and pulmonary hypertension, which was in line with the manifestation of pulmonary heart disease; Abdominal radiograph showed suspected incomplete intestinal obstruction. 800 ml of pale red liquid was drained by abdominal puncture and sent to the patient for examination. Pulmonary angiography (CTA) showed: (1) multiple pulmonary embolism in the main trunk and branches of bilateral pulmonary arteries; (2) Fibrosis lesions and exudative changes in both lungs; (3) Bilateral pleural hypertrophy and adhesion (Figure 1)。 Surgical treatment: pulmonary artery venography + pulmonary artery thrombectomy + drug thrombolysis. Preoperative diagnosis: (1) Pulmonary embolism and acute pulmonary heart disease; (2) hypertension (Grade II, very high risk); (3) pulmonary embolism; (4) pleural effusion; (5) ascites; (6) Acute peritonitis. Intraoperative angiography showed that the inferior vena cava was well developed, and a guidewire was taped with a pigtail catheter to the pulmonary artery. Angiography showed thrombosis of the right inferior pulmonary artery, and the visualization of both lungs was poor. The catheter and guidewire were exchanged, and the guidewire and catheter were used for mechanical thrombolysis + drug thrombolysis. Ascites routine suggested that there were no malignant tumor cells in the exudate. Color Doppler ultrasound and color Doppler imaging (CDFI) of both lower limbs showed no abnormalities. The procedure was smooth, and the postoperative condition was stable. Anticoagulation, acid suppression and anti-infection treatment were given, and the detection and coagulation time were detected. Reexamination of abdominal B-ultrasound showed ascites with a maximum depth of about 86 mm. Portal CTA showed: (1) superior mesenteric vein, inferior mesenteric vein, splenic vein and main portal vein embolism, multiple small vessel shadows in the hepatic hilar area, considering portal cavernous degeneration; (2) Double lower pulmonary pulmonary embolism (Figure 2，Figure 3)。 Giving symptomatic treatment. The patient's ascites drainage volume was about 1,000 ml in the first 4 days, and then gradually decreased. After 8 days of continuous drainage, the patient's abdominal B-ultrasound showed no obvious effusion and then extubated. After continuing symptomatic treatment for 10 days, the patient's abdominal pain symptoms were significantly relieved. After reexamination of biochemistry and blood routine, no abnormalities were found and he was discharged. He was instructed to continue to take warfarin anticoagulation therapy, and coagulation was found in regular reexamination.

The patient was a 65-year-old male. Previous history of aortic valve replacement surgery. The patient did not undergo any follow-up after surgery until the 37th postoperative month due to pulmonary infection Chest X-ray revealed widening of the aortic shadow and CTA revealed multiple pseudoaneurysms of the ascending aorta (Figure 1)。 Since the patient had no symptoms and no risk factors such as hypertension, follow-up observation was given. MRA was performed at the 81st postoperative month, which confirmed that the pseudoaneurysm was unchanged; However, at the 85th month after surgery, the patient underwent chest CT in the field due to pneumonia and found that one of the pseudoaneurysms was significantly larger than before, so he underwent ascending aortic replacement, and CTA examination was performed 4 months after ascending aortic replacement (Figure 2), confirming that the surgical effect was good and the pseudoaneurysm disappeared.

Pancreatic cancer is a malignant tumor with high incidence and poor prognosis, and the mortality rate ranks fourth among neoplastic diseases. The average survival time of patients was only 6 months, and the 5-year survival rate was 5%. The pathogenesis of pancreatic cancer is hidden, difficult to diagnose early, and easy to occur distant metastasis are all important reasons for its poor prognosis. Therefore, there is an urgent need for more effective diagnosis and treatment methods for early diagnosis and intervention of pancreatic cancer. The discovery of MicroRNA (miRNA) and the validation of multiple molecular pathological signaling pathways involved in the development of pancreatic cancer indicate that miRNA will play a potential but important role in the diagnosis of pancreatic cancer.

Aortic dissection is a life-threatening emergency and the most serious of aortic diseases. The incidence of aortic dissection reported in the literature is (3.0-3.5) /100,000 per year^[1,2,3]。 The onset and complications of aortic dissection are extremely rapid^[4]。 Studies have shown that if aortic dissection is not effectively treated, the hourly mortality rate of patients on the first day of onset is 1% to 2%, and the mortality rate in the first week is about 50%^[5]。 Currently, thoracic endovascular aortic repair (TEVAR) is the main treatment for type B aortic dissection^[6,7]Through research and exploration, the traditional restricted area has gradually become one of the treatments for type A dissection^[8]。 The endovascular graft used in TEVAR needs to be anchored in the aorta at a size slightly larger than the diameter of the aorta, i.e. endovascular graft magnification^[9]。 In order to select the appropriate magnification of endovascular aortic graft, it is necessary to measure the aortic diameter of the graft anchoring area before TEVAR surgery, and then select the appropriate endovascular graft according to the measured results. Measurement of aortic diameter on imaging examinations such as CTA (computed tomography angiography) or MRA (magnetic resonance angiography) is an important part of aortic morphology assessment before TEVAR^[10]。 The measurement of aortic diameter is the benchmark of endovascular graft magnification. Its accuracy is crucial for the selection of endovascular graft, and it also has an important influence on the success or failure of TEVAR surgery and the prognosis. At present, there is no uniform standard for the measurement method of aortic diameter before TEVAR. The current status of arterial diameter measurement before endovascular repair of aortic dissection is summarized as follows.

There are not many auxiliary examination methods that can be used to diagnose non-traumatic acute abdomen in clinic. Usually, in addition to symptoms and signs, the diagnosis of such acute abdomen mainly relies on main examination methods such as imaging and infection indicators. In a few cases, diagnostic abdominal puncture and lavage are performed, and only a few diseases have specific enzymatic detection. In the treatment of acute abdomen, it is often necessary to decide the treatment plan according to the severity of the disease, especially whether to operate. Therefore, from the treatment point of view, non-traumatic acute abdomen can be divided into two categories: one is acute abdomen that does not need surgical treatment, and the other is acute abdomen that needs surgical treatment. For acute abdomen that needs surgical treatment, blood supply disorders are often involved, and the blood supply status of the diseased organs of acute abdomen is indirectly reflected by coagulation indexes such as fibrinogen (Fib) and D-dimer (D-D)^[1,2]It is expected to provide a new test method for judging ischemic necrosis of abdominal lesions in patients with acute abdomen involved in blood supply disorders. This paper reviews the application status, mechanism and prospect of coagulation indexes such as Fib and D-D in acute abdomen with blood supply disorders.