2017年 · 第32卷第10期

Early oral enteral nutrition can improve short-term clinical outcomes in patients with colorectal cancer after surgery without increasing the incidence of postoperative complications^[1]。 The purpose of this study was to investigate the safety of early postoperative oral intake of enteral nutrition preparations in patients with gastric cancer and its effect on short-term clinical outcome, nutritional status and immune function of patients.

In recent years, the surgical plan based on the intraoperative monitoring of portal vein blood flow is a hot research topic in portal hypertension surgery. This study received good results in the treatment of portal hypertension through an individualized surgical protocol of intraoperative portal vein combined with dynamic manometry, which is reported below.

triple-negative breast cancer (TNBC) refers to the type of breast cancer molecules lacking the expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2), accounting for about 15% to 20% of breast cancer. Its onset age is young, clinical stage is high, recurrence and metastasis rate is high, and it belongs to a class of molecular classification with poor prognosis. We combined body mass index (BMI) and waist-hip ratio (WHR) to explore the significance of obesity in the prognosis of TNBC.

A 52-year-old female was admitted to the hospital due to "upper abdominal tightness with upper abdominal distension and anorexia for more than 1 month". Six years ago, I had a history of "retroperitoneal tumor resection", and postoperative pathological examination showed: left upper abdominal retroperitoneal accessory neuroma (pheochromocytoma). Has a history of diabetes and hypertension in the past, and his blood sugar and blood pressure control are acceptable. On September 17, 2015, he underwent "left upper lingual segment resection" in a foreign hospital. Postoperative pathological report: neuroendocrine tumor (atypical carcinoid). The external hospital considered it as "pulmonary metastasis of retroperitoneal tumor", and no further surgical treatment was done. Physical examination on admission: BP: 114/68 mmHg, no mass palpable in the abdomen, no tenderness, and obvious skin hair on both calves. Abdominal enhanced CT revealed that there was a solid mass with abundant blood supply in the left retroperitoneal area, between the lower margin of the spleen and the left kidney (Figure 1)。 CTA examination showed that the tumor had abundant blood supply (Figure 2)。 Chest CT scan showed nodules in the lingual segment of the left upper lobe and the posterior segment of the right upper lobe (Figure 3), considering the possibility of lung metastatic tumors. Laboratory tests showed that serum CEA, CA19-9, CA125, CA153, aldosterone, cortisol and catecholamines were normal. Retroperitoneal tumor resection was performed. Postoperative pathological examination revealed retroperitoneal accessory neuroma. Two months later, the right upper lobe tumor was resected again, and the pathological examination showed atypical carcinoid tumor. There was no radiotherapy or chemotherapy after operation, and the follow-up was 9 months so far. The general condition was good, the preoperative symptoms disappeared, the skin and body hair of the calf disappeared, and no complications occurred. No recurrent or metastatic lesions were found in retroperitoneal and both lungs on imaging.

autogenou arteriovenous fistula (AVF) is the preferred vascular access for long-term hemodialysis (HD) patients^[1]。 Autologous AVF is superior to graft bypass and long-term central venous intubation^[2,3,4]。 Some patients underwent dialysis after routine AVF surgery for many years. Due to repeated punctures, the original standard AVF (anastomosis of the distal radial artery of the forearm and the cephalic vein) lost its function due to complications such as thrombosis, stenosis or hemangioma, or because the radial artery and ulnar artery of the forearm were too thin, the operation was not easy to succeed and effective blood flow could not be established. The patient's own obesity caused the forearm fat to be too thick, and the puncture was not easy to succeed. When the patient's distal arterial blood flow is poor and the lumen of the distal vein is thick and unobstructed, transposition is necessary in this case. During the transposition process, the vein is superficialized, which is not only beneficial to vascular puncture, but also effectively utilizes vascular resources. We performed nearly 180° transposition of the forearm vein (cephalic vein or essential vein) and brachial artery anastomosis to establish unconventional high AVF in 20 cases, with good results, which are reported below.

Complex pelvic retroperitoneal tumors are difficult to operate through abdomen and sacrum alone due to their large size and low location. Combined with laparoscopic technique, abdominal trauma can be effectively reduced. In this study, 5 patients with complex pelvic tumors underwent laparoscopic transabdominal and transacral combined pelvic tumor resection, which was less invasive, safe and reliable, and is reported below.

Hemorrhage is one of the common complications of laparoscopic cholecystectomy (LC). The most common site of hemorrhage is the gallbladder artery, but a few (10%) of the right hepatic artery^[1]Located behind the gallbladder bed, once injured, it can lead to massive hemorrhage in the right liver. The hemorrhage is hidden and the amount of hemorrhage is large, which is very difficult to deal with. We analyzed the diagnosis and treatment of 2 cases of massive right intrahepatic hemorrhage and huge subcapsular hematoma after LC operation, and the reports are as follows.

At present, the CDX (cell-line-derived xenograft) model constructed by inoculating human tumor cell lines into immunodeficient mice has been widely used to detect the efficacy of preclinical anticancer drugs. However, the CDX model has many shortcomings, such as the limited number of tumor cell lines that can be used for modeling, low transplantation success rate, high feeding conditions of nude mice, etc. Moreover, the model cannot simulate the effect of immune response on tumors. In this study, a human gastric cancer transplanted tumor model was successfully constructed in normal immunized mice based on microcarrier composite human gastric cancer MKN28 cells, and the pathological characteristics of the transplanted tumor were discussed.

A 59-year-old male was admitted to the hospital with "gallstones with chronic cholecystitis" because of "gallstones found for more than 5 years, repeated right upper abdominal pain for more than 2 years, aggravated for 5 days". Physical examination: the abdomen was flat and soft, without palpable mass, tenderness in the right upper abdomen, no rebound pain and muscle tension. B-ultrasound examination showed: multiple cysts in the liver; Multiple gallbladder stones; Cyst in the right kidney. Upper abdominal MR plain scan + MRCP showed: multiple liver cysts; Cyst of both kidneys; Multiple calculi of the gallbladder with chronic cholecystitis. Laparoscopic cholecystectomy was performed. Intraoperative exploration showed that the liver was reddish-brown, the gallbladder volume was about 8 cm ×4 cm ×4 cm, and there was no congestion and edema in the cyst wall. A mass about 1.5 cm ×1.0 cm in size was seen in the serous layer of the small curvature of the stomach (Figure 1)。 After completion of laparoscopic cholecystectomy, the mass was completely removed laparoscopically with an ultrasonic scalpel along 1.5 cm of the mass margin, and the stomach wall was sutured intermittently. Pathological report of intraoperative rapid frozen section: small cells in the stomach wall have nest-like hyperplasia, cells are atypical, and some areas are rich in blood vessels. Postoperative pathological report: Glomus tumor of gastric wall (Figure 2)。 Immunohistochemical staining results: Vim (+), SMA (+), Desmin (-), CK broad spectrum (-), Syn (+), CgA (-), CD56 (-), CD34 (vascular +), CD117 (-), Dog-1 (-), Ki-67 (<1% +), P53 (5% +). Special staining results: PAS (+).

A 51-year-old male was admitted to the hospital because of "gastric fundus mass for 1 week" found on physical examination. Ultrasound gastroscopy revealed: bulging erosive gastritis, bulging lesions of the fundus of the stomach (considering stromal tumor). Partial gastrectomy was performed. Postoperative pathological report: Submucosal and muscular spindle cell tumors of (gastric fundus), considering gastrointestinal stromal tumors. Tumor size approx. 3.5 cm ×3 cm ×3 cm. There was no tumor invasion in the vessel and no tumor invasion in the nerve fiber bundle. No tumor involvement was observed at both surgical margins (approximately 3 cm and 3.2 cm from the tumor, respectively). No enlarged lymph nodes were observed around the stomach. Immunohistochemical staining: CD117 (−), CD34 (Vessel +), S-100 (+ + +), SMA (Focus +), Desmin (−), DOG-1 (−), Ki-67 (~8% +). Cell rich nerve sheath tumor of the gastric fundus was diagnosed (Figure 1)。

A 30-year-old male was admitted with "left epigastric pain for 3 d, aggravated for 15 h". Physical examination: No abnormalities were found. Blood routine: WBC 16.41×10⁹/L, neutrophils 14.06×10⁹/L. Enhanced abdominal CT: No obvious abnormalities and accessory renal arteries were found. Two days after admission, he developed difficulty in urination and defecation, numbness in both lower limbs, banding sensation below the xiphoid process, muscle strength of both lower limbs grade I, and positive Pap sign. Consider the possibility of spinal cord compression. MRI plain scan showed that a fusiform mixed signal shadow, about 3.4 cm ×1.3 cm ×1.7 cm in size, was observed in the dorsal extramedullary subdural of the spinal cord at the level of the vertebral body of T6-7. T1WI showed isolow signal, T2WI showed isolow signal, T2 lipid pressure showed high and low mixed signal, and the adjacent thoracic cord showed compression changes (Figure 1)。 Considered as intraspinal spinal cord tumor. Emergency surgical exploration showed that the tumor tissue was mainly located in the extramedullary subdural mater in the spinal canal at the level of T6-7 vertebral body. It was brittle, yellow-white, rich in blood supply and clear in boundary. One spinal nerve passed through the tumor, and the spinal cord was thinly compressed and displaced to the right front. The tumor adhered to peripheral nerves and spinal cord seriously. Carefully separate and remove the tumor and the diseased nerve together. Pathological report: schwannoma with extensive hemorrhage (Figure 2)。 After 3 days after operation, the abdominal pain disappeared, the muscle strength of left lower limb was grade IV, the muscle strength of right lower limb was grade III, and the Pap sign was negative.

A 69-year-old male was admitted with "dysphagia for 1 month". He had a subtotal gastrectomy for "gastric ulcer" 30 years ago. Physical examination: No positive signs in the abdomen. Laboratory test: Hb 113 g/L, serum tumor markers AFP, CEA, CA125 and CA199 were all normal. Gastroscopy revealed residual gastric cancer (type B-I), after subtotal gastrectomy (type Bi II). Pathological report: malignant tumor of residual stomach. Total abdominal CT showed that the large curved side of the stomach body occupied space, protruding into the gastric cavity, and malignant space occupation may be (Figure 1)。 Preliminary diagnosis: stomach cancer. Radical subtotal gastrectomy of residual stomach was performed. Postoperative pathological report: mixed adenoneuroendocrine carcinoma (MANEC) of residual stomach, invasion of serosa, bulge type, stomach broken end, intestinal broken end and omentum were not involved in cancer. There were 6 parenteral lymph nodes, and no cancer metastasis was seen (Figure 2)。 Immunohistochemical staining showed that CD56 (2+), Syn (2+) (Figure 3), CgA (2+), CK (3+), EMA (+) (Figure 4)。 The patient recovered well after surgery, and no tumor recurrence or metastasis has been seen so far.

A 20-year-old male was admitted to the hospital for half a month due to the discovery of "retroperitoneal mass". Physical examination: abdominal swelling, soft touch, no abdominal tenderness and rebound pain in the whole abdomen, no muscle tension, left upper abdomen touching an unclear boundary mass, no tenderness. Serum tumor markers were normal. Upper abdominal CT showed that the retroperitoneal area (centered on the upper space area in both kidney areas) occupied a huge space, mainly fat components, and visible patchy soft tissue density shadow and patchy calcification shadow, which was consistent with the changes of teratoma (Figure 1)。 During the operation, the mass was located in the retroperitoneum, and the left and right masses were fat cyst-like tissues, which were lobulated, with intact capsule, adhering to the surrounding tissues, and the size was respectively 25 cm ×18 cm, 15 cm ×10 cm. The left mass adhered to the psoas major muscle, and the medial adhered to the abdominal aortic sheath; The right mass is located between the inferior vena cava and the abdominal aorta. The lower edge of the mass is adhered to the right adrenal gland and renal fat sac, and the upper edge is adjacent to the S5 and 8 segments of the liver. The left and right masses are connected in a dumbbell shape, and the handle of the dumbbell passes in front of the abdominal aorta, between the celiac trunk and the superior mesenteric artery. The handle can palpable bone-like structures, and the texture is hard. Postoperative pathological report: teratoma with secondary malignant transformation, the malignant component is prostatic acinar adenocarcinoma, gleason score 6, diameter 0.5 cm, carcinoma tissue accounts for 5% of prostatic gland volume, prostate tissue range in teratoma 1.5 cm ×1.5 cm (Figure 2)。

A 44-year-old male was admitted for "1 d of melena with 1 vomiting". Has a history of diabetes for 1 year. Half a month ago, I underwent "L4-5 lumbar disc herniation" and took oral "painkillers". The specific medication is unknown. Physical examination: pulse 120 beats/min, blood pressure 96/66 mmHg, localized mild tenderness in upper abdomen, no rebound pain and abdominal muscle tension. Blood routine: WBC 12.19×10⁹/L, RBC 2.43×10¹²/L, Hb: 75 g/L. Blood glucose: 16.46 mmol/L. Gastroscopy: diagnosis of duodenal bulb ulcer with bleeding (Forrest IB). No contrast extravasation was observed on celiac trunk arteriography. Hemostasis with OTSC anastomotic clip: a deep depression of about 1 cm ×1 cm was seen near the pylorus of the gastric antrum, with white coating at the base and no bleeding; On the small curved side of the duodenal bulb, a deep depression of about 1cm ×1cm was seen, with white coating at the base and active bleeding around it. An OTSC anastomotic clip (Model 11/6t) was installed on the outside of the transparent cap at the end of the endoscope, and the ulcer surface of the bulb was completely inhaled into the transparent cap, and then the anastomotic clip was released to clamp the bleeding lesion. 1:10000 epinephrine saline was injected into the mucosa around the lesion. After 5 minutes of observation, no bleeding was observed, the scope was withdrawn to complete the operation. The condition improved on the 5th postoperative day and was discharged. Seven weeks after discharge, the patient was readmitted to the hospital because of "melena relief once". Gastroscopy showed: linear scar near pylorus of the gastric antrum, slight congestion and edema of the surrounding mucosa; There were a large number of dark red blood clots in the duodenal bulb. After rinsing with adrenaline saline, the OTSC anastomosis clip was in place at the original small curve ulcer, and there was no active bleeding. A deep depression of about 8 mm ×8 mm was seen on the large curve side, with exposed basal blood vessels and a little bleeding (Figure 1)。 One OTSC anastomotic clip was applied to clamp the new ulcer bleeding lesion on the large curvature of the bulb (Figure 2)。 After operation, the patient's condition was repeated, and Hb decreased significantly 10 days after operation. After reexamination of gastroscopy, linear scars were seen near the pylorus of the gastric antrum, and the surrounding mucosa was slightly congested and edematic. The OTSC anastomotic clip at the original ulcer on the small curve side of the bulb was in place without active bleeding. The OTSC anastomotic clip at the original ulcer on the large curve side was in place, and a bright red bleeding spot was visible in the center without active bleeding. Epinephrine saline was injected submucosally, and the endoscope was withdrawn after successful hemostasis (Figure 3，Figure 4)。 Four days after endoscopic local injection hemostasis, the patient's condition improved and he was discharged. The patient was followed up for 1 month after discharge, and there was no recurrence.

A 60-year-old female was seen for "melena for 1 week". Occult blood in stool: 4+. Endoscopy: varicose veins of the upper digestive tract. CT showed that the superior mesenteric vein (SMV) showed "double lumen sign". DSA examination showed that the superior mesenteric artery (SMA) and gastroduodenal artery communicated with pseudoaneurysm formed by SMV, and the diagnosis was gastroduodenal artery/SMA-SMV fistula. The cause of gastrointestinal bleeding is related to hypertension of the portal system caused by artery-vein fistula (AVF). Interventional embolization was performed (Figure 1)。 The patient had melena again 3 months after the operation. Angiography confirmed AVF recurrence, and interventional embolization was performed again. After embolization, SMA angiography confirmed that there were still a small number of microarteries communicating with pseudovenous aneurysm and SMV. Due to the small arteries, coil embolization could not be performed, so the operation was ended. CT was re-examined 3 months after the second embolization and confirmed recurrence of AVF. Four months after the second embolization, color ultrasound examination confirmed that the pseudoaneurysm still existed. Considering the limitation of endovascular embolization, the pseudoaneurysm was directly percutaneously punctured under the guidance of color ultrasound, and then embolized with a spring coil and isobutyl cyanoacrylate (NBCA glue) (Figure 2)。 The patient experienced melena again 4 months after the third embolization, and the recurrence of AVF was confirmed by color ultrasound. Surgical treatment was performed, the pseudoaneurysm was removed intraoperatively, and the SMV was repaired. After 1 year follow-up, the patient did not reappear gastrointestinal bleeding and melena, and endoscopy showed that upper gastrointestinal varices disappeared.

A 47-year-old male was admitted with "pharyngeal pain for 1 month". He had undergone gastroscopy in a local hospital and was diagnosed as "gastric adenocarcinoma" by biopsy pathology. One course of "Oxaliplatin + Tegio" chemotherapy was performed. Radical gastrectomy was performed. During the operation, the mass was explored at the fundus of the cardia and stomach. The surface was rough and uneven, erosive, and easy to bleed. The mass involved the ventral side of the lower esophagus, was hard in texture, without external invasion, and there was no adhesion between the gastric serosa layer and the diaphragm. Two enlarged lymph nodes were seen next to the cardia. Cardiac cancer resection + esophagogastric subarch anastomosis were performed. Postoperative pathological report: There was an ulcer-type mass in the gastric cardia, the size was 4.0 cm ×3.5 cm ×2.0 cm, the section was gray-white, some areas were dark brown, and the texture was hard. The gray-white tissue infiltrated the whole thickness of the gastric wall and involved the esophagus. Under light microscope, the tumor was located under the gastric mucosa and diffusely infiltrated into the gastric wall. The tumor cells were arranged in solid sheet, acinar, glandular or nest shape, and the cell morphology was also diverse, including spindle, round and polygonal cells, rich cytoplasm, eosinophilic staining, obvious nucleoli, and more mitotic images (Figure 1)。 Clear cells can be seen in some areas, and melanin particles are contained in the cytoplasm. Immunohistochemical staining: tumor cells expressed HMB45 (Figure 2), S-100, vimentin positive, does not express CK, CEA, EMA. The pathological diagnosis was malignant melanoma of gastric cardia, which invaded the whole thickness but did not break through the adventitial layer, and the tumor involved the esophagus. Tumor metastasis in gastric paracardial lymph nodes (2/2). Chronic inflammation of lymph nodes in small curvature of stomach, no tumor metastasis (0/1), 1 lymph node in Group 6 and 1 lymph node in Group 8 were dissected, and no tumor metastasis was found. The tumor TNM stage is T₃N₁M₀。 Because the patient had no previous history of nevus removal, no primary lesions were found in other parts of the body, and there was no evidence of metastasis from other organs. The intragastric lesions were single and large, so the diagnosis was primary malignant melanoma of the stomach. The patient did not receive other treatment after surgery and died of multiple metastases in the abdominal cavity after 3 months of follow-up.

The patient was a 44-year-old male. Admitted for "metastatic right lower abdominal pain for 2 d". Physical examination: slightly swollen abdomen, tenderness in the right lower abdomen, mild rebound pain, no muscle tension, no palpable mass, negative mobile voiced sound, and no hyperactivity of intestinal sound. Blood routine: WBC 15.5×10⁹/L, N 0.84. B-ultrasound examination showed that the appendix was unclear and the right lower abdominal omentum was wrapped. The outpatient clinic was treated with "acute appendicitis". Abdominal enhanced CT showed that the right middle and lower abdominal omental vessels were obviously thickened, gathered and twisted spirally along the same axis in the axial position, with blurry edges, accompanied by extensive spotty dense turbid changes of surrounding omental fat, constituting a typical "typhoon cloud map"-like appearance (Figure 1)。 The enhanced CT scan of the above gathered and rotated blood vessels showed mild enhancement. The coronal and sagittal reconstruction images showed that the axis of rotation extended from the lower margin of the transverse colon horizontally down to the entrance of the inguinal canal, and a large amount of turbid adipose tissue was seen in the inguinal canal and scrotum continuous with the omentum in the abdominal cavity (Figure 2)。 CT diagnosis: right inguinal omental hernia with omental torsion and partial omental necrosis. Exploratory laparotomy was performed in the emergency department. During the operation, the torsion of the right middle and lower abdominal omentum was about 1080°, with a range of about 30 cm ×20 cm, with extensive blood stasis and edema, partial bleeding and necrosis, and the lower end of the omentum herniated into the inguinal canal and scrotum with partial adhesion. The contents of the hernia were restored, the torsion and necrosis of the omentum were removed, and the neck of the hernia sac, small intestine and colon were repaired without any abnormalities. The appendix was thickened with congestion and edema, approximately 5.0 cm ×0.9 cm in size, and appendectomy was performed at the same time. Pathological reports: (1) Omental hemorrhage, degeneration and necrosis; (2) Chronic appendicitis.