2017年 · 第32卷第09期

Pancreatic cancer is one of the common malignant tumors of the digestive tract. In recent years, its morbidity and mortality are on the rise worldwide. The onset of pancreatic cancer is insidious, the early diagnosis is difficult, the prognosis is extremely poor, and the 5-year survival rate is only about 6%^[1]； At the same time, in addition to blood supply and lymphatic tract metastasis, there is often retroperitoneal nerve invasion. When the diagnosis is clear, nearly 2/3 of patients are advanced, and the surgical resection rate is only 15% ~20%^[2]So can row R₀Resection has become an important factor affecting the long-term survival of patients with pancreatic cancer. At present, pancreatic cancer is the fourth leading cause of death from malignant tumors, and the median survival time of unoperated pancreatic cancer patients is about 3 to 6 months; However, after surgical resection combined with multidisciplinary adjuvant therapy, the median survival time can be as high as 34 months, and the 5-year survival rate can also reach 20% ~25%^[3]。 The anatomical position of the pancreas is located in the core area where important blood vessels in the abdominal cavity intersect. Locally advanced or advanced pancreatic cancer often involves peripheral blood vessels, such as portal vein (PV), superior mesenteric vein (SMV), superior mesenteric artery, celiac trunk and hepatic artery. Therefore, the vascular invasion of pancreatic cancer often brings great challenges to radical surgery. pancreaticoduodenectomy with vascular resection (PDVR) has experienced silence from early exploration to middle stage. Since the new century, with the maturity of surgical technology and the development of anesthesia, intensive care and other disciplines, PDVR for pancreatic cancer with vascular invasion, which is called "borderline resectable", has aroused renewed interest and controversy in academic circles^[4]。 In view of the hot issues discussed in the academic circles, this paper expounds the research progress and technical details of PDVR combined with our own experience, hoping to be a reference for surgeons in this field.

Luminal breast cancer is the most common subtype of breast cancer. Although the prognosis is relatively good, recurrence and metastasis still seriously threaten women's health. Ki-67 is the main indicator to judge the proliferation activity of breast cancer cells, while progesterone receptor (PR) has the function of regulating the growth and differentiation of breast cancer. PR deficiency may be one of the factors of malignant proliferation and hormone therapy resistance^[1]。 In recent years, Ki-67 and PR have gradually become hot indicators of prognosis and classification of breast cancer, but they are still controversial^[1,2,3]。 The expression and prognostic significance of Ki-67 and PR in Luminal breast cancer were retrospectively analyzed in this paper, which provided some theoretical basis for individualized treatment of this type of breast cancer.

Breast cancer is one of the malignant tumors with the highest incidence in women, and the incidence rate ranks first among female malignant tumors. triple negative breast cancer (TNBC) accounts for 10% to 20% of breast cancers. Female patients with TNBC are more likely to develop cancer recurrence and disease progression. pre-treatment neutrophil to lymphocyte ratio (PNLR) can be used as a simple parameter to assess systemic inflammation and immune status in tumor patients. The purpose of this paper was to investigate the relationship between PNLR and clinicopathological features of breast cancer in patients with TNBC, and the influence on disease-free survival (DFS) and overall survival (OS) in patients with triple negative breast cancer.

Patients with deep vein thrombosis of the lower extremities were found to have iliac vein stenosis after transcatheter contact thrombolysis. The stent treatment showed good results in both medium and long-term patency rate and symptom improvement^[1]。 However, the effect of stent placement on deep venous valve function still needs to be further explored. Our center has conducted a preliminary study, which is reported below.

The reason why complex anal fistula occurs repeatedly and does not heal for a long time after surgery is because of the persistence of infected anal glands and internal mouth. In this study, 38 cases of complex anal fistula were treated with anatomical fistula resection and rectal mucosal flap closure, and the preliminary results were obtained, which are reported as follows.

isolated dissection of superior mesenteric artery (IDSMA) refers to simple superior mesenteric artery dissection without aortic dissection. It is a rare superior mesenteric artery disease in clinic. Patients' clinical symptoms are inconsistent with physical signs, which can easily lead to misdiagnosis and even serious complications such as intestinal necrosis and hemorrhagic shock. With the widespread application of computed tomography angiography (CTA), more and more patients with abdominal pain or vomiting, abdominal distension and melena are diagnosed with IDSMA early, which is called symptomatic isolated dissection of superior mesenteric artery (SIDSMA). In this paper, the clinical data of 17 patients with SIDSMA were retrospectively analyzed to study their clinical characteristics, treatment strategies and therapeutic effects.

Hepatolithiasis is a common disease in hepatobiliary surgery, accounting for about 15% ~30% of all cholelithiasis. Hepatic lobectomy is one of the main methods to treat this disease, and the curative effect is definite. Clinically, left hemihepatectomy is the common surgical procedure^[1]。 Bile leakage is one of the common complications after hepatectomy, the incidence rate is about 3.6% ~12%. Improper management may lead to diffuse peritonitis, subphrenic abscess and even liver failure^[2]。 We treated 37 cases of hepatolithiasis with the anterior approach left hemihepatectomy with the preservation of the main trunk of the left hepatic duct, and the results were satisfactory.

Insufficient future liver remnant (FLR) is one of the most important factors leading to the loss of surgical resection in patients with advanced liver cancer. Although traditional portal vein embolization (PVE) /portal vein ligation (PVL) can effectively promote remaining liver hyperplasia, patients need to wait at least 4 to 8 weeks. Excessive waiting time increases the risk of disease progression, resulting in 30% to 40% of patients losing the chance of radical resection. Two-step hepatectomy combined with liver separation and portal vein ligation emerging in recent years (associating liver partition and portal vein ligation for staged hepatectomy, ALPPS) It can quickly promote the proliferation of the remaining liver, but patients undergoing ALPPS usually have to undergo two major operations in a short time, which is huge in trauma, and the incidence of postoperative complications and mortality are as high as 25% ~40% and 10% ~20%, respectively^[1,2,3,4]。 At present, minimally invasive primary surgery is considered to be the key to reduce the trauma of ALPPS. We performed secondary hepatectomy combined with portal vein embolization and temporary hepatic artery occlusion (associating portal vein embolization and temporary hepatic artery occlusion for staged hepatectomy, APTAS) A case of giant primary liver cancer complicated with cirrhosis with insufficient FLR was treated. The first attempt to replace the liver separation in traditional surgical procedures by total endovascular intervention was made, and good results were achieved, which are reported below.

Since the concept of enhanced recovery after surgery (ERAS) was put forward in 1997, it has been applied in colorectal, orthopedic, urological, gynecological and other disciplines^[1,2]However, pancreatic surgery is invasive and risky, and the incidence of postoperative complications and mortality remain high. Moreover, pancreatic diseases have low incidence and scattered patient distribution, so ERAS is rarely used in pancreatic surgery at home and abroad. Combined with a case of pancreaticoduodenectomy with ERAS concept, the experience of ERAS in pancreatic surgery in our center is summarized and analyzed.

In recent years, due to the rapid improvement of imaging diagnosis technology, the detection rate of pancreatic duct stones in chronic pancreatitis is increasing rapidly. At the same time, because of the improvement of laparoscopic surgical technique and the popularization of minimally invasive surgical concept, we treated 13 patients with chronic pancreatitis with pancreatic duct stones who were difficult or failed after endoscopic retrograde cholangiopancreatography (ERCP) evaluation with ERCP combined with laparoscopic pancreatoduct jejunostomy, which is reported below.

Calcification is an important sign of mammography. Suspected malignant calcification requires surgical biopsy to confirm the diagnosis and guide the treatment. If the calcification does not form a mass, it cannot be felt by palpation, and the abnormal echo shadow cannot be detected by ultrasound, there will be certain difficulties in localization biopsy. Theoretically, lines are drawn on the breast according to the calcification positions of two different phases, and the intersection of the two lines is the calcification point. However, in practice, there are often deviations. By comparing the similarities and differences between the position of the lesion on the molybdenum target and the actual position of the breast, the displacement law of the lesion under the compression of the molybdenum target splint was studied.

Remote video consultation is mainly used for patient diagnosis and difficult discussion^[1]It has played a very good role in promoting the diagnosis and treatment of diseases^[2]。 But it has not been really applied to the field of surgery. The main reasons are the risk, timeliness, flexibility and uncertainty of surgery^[3]。 Therefore, the surgical consultation still relies on the chief surgeon to attend the operation in person. Our center explores the feasibility of surgical remote video consultation using the advances of modern remote video and the characteristics of intracavitary minimally invasive surgery, which is reported below.

A 28-year-old male was admitted with "left epigastric pain for 5 d". Physical examination: tenderness in the left upper abdomen. Magnetic resonance cholangiopancreatography: multiple stones in the pancreatic duct with obvious dilatation of the pancreatic duct in the body and tail of the pancreas (Figure 1)。 Open pancreatolithotomy + lateral pancreaticojejunostomy were performed. Intraoperative exploration showed that the stones were located in the pancreatic duct of the branch of the pancreatic head and the main pancreatic duct of the pancreatic body and tail. The larger ones were about 4 cm ×1.5 cm ×1 cm, and the main pancreatic duct was significantly dilated (Figure 2)。 Because the stones in the branch pancreatic duct of the pancreatic head are deep, there is a possibility of damaging the common bile duct and pancreatic blood vessels, and considering that the stones are located in the branch pancreatic duct and do not affect the patency of pancreatic juice in the main pancreatic duct, most of the stones are removed according to the preoperative imaging suggestion and the sectional surface is sutured immediately. Fifteen days later, the patient developed bloody stool at night, which was large in volume and hemorrhagic shock. Emergency investigation of Hb 46 g/L, considering postoperative gastrointestinal bleeding, exploration showed no obvious blood accumulation in the abdominal cavity, opening the anterior wall of the intestinal tube at the pancreaticojejunostomy, showing a large number of blood clots, after removing all the clots, the bleeding point was caused by the loosening of the suture at the incision of the pancreatic duct of the original pancreatic head branch, and the 3-0 prolene thread was tightly sutured (Figure 3), and a T-tube was placed in the pancreatic duct to lead out from the abdominal wall, and the abdomen was closed after no bleeding was found. Three weeks later, dark red liquid was drawn out of the patient's T-tube in the early morning, with a volume of about 200 ml. Considering rebleeding of the pancreas, enhanced CT of the upper abdomen: pseudoaneurysm of the uncinate process of the pancreas (Figure 4)。 Angiography showed that the bleeding site was the transverse pancreatic artery in the head of the pancreas. Because of the thinness of this blood vessel, the 1.8 F microcatheter was used to superselectively enter the transverse pancreatic artery. After embolization, the blood flow in the proximal transverse pancreatic artery of the contrast pseudoaneurysm was stagnated, and no pseudoaneurysm development was observed. There has been no bleeding since two years of follow-up.

A 59-year-old female underwent radical mastectomy 8 years ago. The postoperative pathological report was "invasive ductal carcinoma of the breast, lymph nodes (37/37)". Upper abdominal discomfort with intermittent pain with diarrhea 2 months ago. Gastroscopy: Diffuse multiple nodular changes in gastric fundus, gastric body, gastric angle and gastric antrum mucosa, with erosion and shallow ulcer on the surface, about 0.2~0.8 cm in diameter; Multiple ulcers were scattered in the bulb and upper curvature of the duodenum, 0.2-0.3 cm in diameter, covered with thin white coating, and the peripheral mucosa was congested and edema. Colonoscopy showed: irregular ulcer surface and several polypoid protuberances were scattered about 10 cm from the ileocecal valve; Dozens of polypoid protuberances were scattered in the whole large intestine, with depression and erosion at the head end, about 0.5~1.5 cm in size (Figure 1，Figure 2，Figure 3)。 Tissue specimens were clamped at all lesions under microscope, and pathological sections of stomach and duodenum specimens showed malignant tumors; Immunohistochemical staining showed CK (AE1/AE3) (−), CK7 (+), CD20 (−), CDX2 (−), Syn (−), CgA (−), CD56 (−), Ki-67 (positive rate 10%), ER (strong +), PR (−), HER-2 (1+), GATA3 (+), E-Cadherin (+). Pathology of colon specimens: round tumor cell nests were seen in mucosal stroma; ER (+) (Figure 4), PR (−), GATA3 (+), Mammaglobin (+), CD56 (−). Carcinoembryonic antigen (34.08 ng/ml) was significantly elevated; CT examination of chest and total abdomen showed no abnormalities. The patient was diagnosed as "gastric, duodenal and colonic metastases of breast cancer", and the patient was discharged without further diagnosis and treatment.

The patient, male, 58 years old, was admitted for "hematochezia for 1 d". There were no obvious abnormalities in blood tumor markers after admission, and no abnormalities were found in gastroscopy, colonoscopy and capsule endoscopy. Internal hemorrhoids with hemorrhage were considered and relieved after conservative treatment. On abdominal enhanced CT, a cystic occupied space in the tail of the pancreas was found, and the density in the capsule was uniform. The CT value was about 17 HU, and the size was 4.9 cm ×5.0 cm. Abdominal enhanced MRI showed long T1 and long T2 signals in the tail of the pancreas, thin and uniform wall thickness, about 3 mm, and uniform intracapsular signals. DWI sequence showed stratified changes, and the capsular wall was significantly enhanced after enhancement. The spleen is not large and strengthens evenly (Figure 1)。 Spleen-sparing pancreatectomy was performed under general anesthesia considering the possibility of neurogenic tumor. During the operation, the texture of the pancreas was soft, and the solid mass was palpable in the tail of the pancreas, with a size of about 4.9 cm ×5.0 cm. It was hard and tough, with clear borders, and was closely related to the lower pole of the spleen. No swollen lymph was palpable around it. Intraoperative frozen pathology revealed cystic lesions (pancreatic tail tumor), frozen sections only showed lined cubic epithelium in small areas, and angioproliferative lesions in cyst wall area. The postoperative paraffin pathological report was (pancreatic tail tumor) considered to be accessory splenic tissue with cyst formation, the cyst wall was obviously fibrotic and partially calcified, and pancreatic tissue was visible around it (Figure 2)。 The patient was discharged smoothly without postoperative pancreatic fistula, bleeding and other complications.

A 67-year-old female was admitted to the hospital due to "recurrent dull upper abdominal pain and discomfort for 5 years, accompanied by nausea and vomiting for 1 d". Physical examination: epigastric tenderness, no rebound pain, no palpable abdominal mass, bowel sounds 3 times/min. Laboratory tests: Hb 95 g/L, hypersensitive CRP 7.89 mg/L, serum amylase 215.14 U/L, CEA 2.66 ng/ml, CA19-9 3.12 U/ml. Abdominal X-ray plain film showed: the intestinal lumen of the right abdomen was dilated, and there was a small level of gas and liquid in the local area. Abdominal CT showed irregular low-density shadows in the running area of the descending duodenum to the proximal jejunum (CT value-64~ -138 HU) (Figure 1)。 MRI showed that the running area from the descending duodenum to the proximal jejunum was rich in lipid occupation, with high signal in T1WI and T2WI, and low signal in the sequence after lipid suppression. Preoperative diagnosis: Duodenal lipoma, incomplete intestinal obstruction. Exploratory laparotomy was performed, which showed obvious edema of the duodenal wall and obvious dilatation of the intestinal lumen. The soft mass-like thickened tissue in the intestinal lumen was touched from 5 cm below the papilla in the descending duodenum to the beginning of the jejunum. When the duodenal wall was incised, multiple, lobulated yellow lipoma-like tissues of varying sizes protruding from the submucosa to the intestinal lumen, almost completely obstructing the intestinal lumen. Complete resection of the diseased intestinal segment about 18 cm (Figure 2), the broken end was anastomosed in a first stage, and gastrojejunostomy + T-tube drainage of the common bile duct was performed. Postoperative pathological examination showed that there were 21 duodenal multiple lipomas, the size ranged from 1.3 cm ×1.3 cm ×1.0 cm to 11 cm ×5 cm ×4 cm, and the tumor was located in the submucosa (Figure 3)。

Patient, female, 61 years old. Because of the physical examination found a pancreatic head mass, pancreatic head cancer was admitted to hospital. CT plain scan of irregular low-density mass shadow of pancreatic head (Figure 1), the border is still clear, the density is uniform, and the arterial and venous phases are enhanced followed by mild to moderate enhancement. The patient underwent pancreaticoduodenectomy under general anesthesia. During the operation, the mass on the head of the pancreas was hard, with poor borders and movable. Pathology: Solid mass of the head of the pancreas, 4 cm ×4 cm ×3 cm, gray-yellow and gray-white, soft in texture, with clear boundaries. Under the microscope, the border of the tumor was clearly visible, and the intact fibrous capsule was visible. No infiltration or destruction of surrounding normal tissues was observed, and there was no bleeding or necrosis. The tumor cells are spindle-shaped short bundles, distributed in cell-rich areas (AntoniA area) and cell-loose areas (AntoniA area) (Figure 2)。 The cytoplasm is abundant, light stained eosinophilic, without heterotype and necrosis. Immunohistochemistry: S100 (Figure 3), Sox10 (Figure 4) positive expression, SMA, desmin, caldesmon, DOG1, CD34, CD117, GFAP, EMA, CK all negative. The Ki-67 index is about 5%. Pathological diagnosis: schwannoma (head of the pancreas). Follow-up for half a year, recovery was good, no recurrence.

deep venous thrombosis (DVT) is a disorder of venous return caused by abnormal blood coagulation in deep veins, which often occurs in lower limbs. Thrombus shedding can cause pulmonary embolism (PE). DVT and PE are collectively referred to as venous thromboembolism (VTE), which are manifestations of the same disease at different stages. The main adverse consequences of DVT are PE and post thrombotic syndrome (PTS), which can significantly affect the quality of life of patients and even lead to death. Therefore, in order to improve the diagnosis and treatment level of DVT in China, and guide and standardize the diagnosis and treatment of DVT in hospitals at all levels, this guide is specially formulated.