2018年 · 第33卷第01期

In the past two decades, the incidence of gastric cancer in western countries has been decreasing continuously, but the incidence and mortality rate of gastric cancer in East Asian countries, such as China, Japan and South Korea, remain high. There are nearly 950,000 new gastric cancer patients in the world, and about 730,000 deaths due to gastric cancer every year. Among them, the incidence rate of gastric cancer in China in 2015 was 67.9/100,000, more than 60% of all gastric cancers in the world, and the mortality rate was as high as 48.9/100,000, ranking among the most common malignant tumors. The second place and the third place for tumor death^[1]。 With the continuous advancement of medical diagnostic and therapeutic techniques, the overall prognosis of gastric cancer patients has improved significantly. However, the local advanced gastric cancer accounts for more than 80% in China, which is obviously different from the present situation of 50% ~60% in Japan and South Korea, which is mainly composed of early gastric cancer, and to some extent affects the clinical application of laparoscopic minimally invasive surgery in China^[2,3]。 The fourth edition of Japanese gastric cancer treatment guidelines in 2014 proposed that laparoscopic radical gastrectomy can benefit gastric cancer patients and can be used as an alternative surgical treatment^[4]。 Two well-known large-scale multicenter prospective randomized controlled studies, JCOG0912 in Japan and KLASS-01 in South Korea, were the first to conduct a series of clinical studies on the long-term efficacy of laparoscopic radical gastrectomy. Although the overall start of laparoscopic gastric cancer surgery in China is slightly late and the regional development is unbalanced, the development speed and application level in recent years have been recognized by international peers. In particular, the Chinese Laparoscopic Gastrointestinal Surgical Study Group (CLASS), which was established in 2009 and includes more than 30 large tertiary hospitals in China, has greatly promoted the development of Laparoscopic gastric cancer surgery in China, and has received wide attention from peers at home and abroad^[5]。 In this paper, the development process of laparoscopic gastric cancer surgery, the opportunities and challenges faced in the future are expounded, and the theoretical reference for laparoscopic minimally invasive treatment of gastric cancer is provided.

At present, there are many treatment options for minimally invasive treatment of gallbladder stones combined with common bile duct stones. We retrospectively analyzed the case data of endoscopic retrograde cannulation of the pancreatic (ERCP) combined with laparoscopic cholecystectomy (LC) in patients with gallbladder stones combined with common bile duct stones in our hospital at different times, and explored the differences in safety and economy between the two methods. the results are reported below.

gastroesophageal reflux disease (GERD) is one of the main causes of benign esophageal stricture due to its unique pathogenesis^[1]。 Laparoscopic fundoplication is a classic procedure for the treatment of GERD. However, for benign esophageal stenosis caused by gastroesophageal reflux, there are few relevant literature reports on whether to perform anti-reflux surgery while treating the stenosis. In this study, 40 patients with benign esophageal stenosis caused by gastroesophageal reflux were collected to investigate the safety and efficacy of interventional therapy combined with laparoscopic anti-reflux surgery.

Since 2009, laparoscopic liver resection has been developed rapidly, and its indications are basically close to open surgery^[1,2]。 However, due to the difficulty of traditional open techniques (organ dissociation, touch, blood vessel separation, blood flow obstruction and parenchymal separation, etc.) in laparoscopic liver resection, there are still bottlenecks in the following aspects: First, the surgical plane is difficult to grasp, second, the intraoperative bleeding is difficult to control, and third, the surgical field is difficult to reveal^[3,4]。 In order to solve these problems, on the basis of the concept of vascular priority in laparoscopic gastrointestinal surgery, we proposed the hepatic vein priority strategy, and achieved good results in practical application. Two typical cases are selected and reported below.

Rectal cancer accounts for 84% of mechanical intestinal obstruction caused by tumor^[1]。 Because of the large number of bacteria in the colorectum, it is difficult to operate, and there are many complications, especially in the elderly patients with rectal cancer and intestinal obstruction. In this study, wrinkle-free anastomosis technique was used to treat elderly patients with high rectal cancer complicated with intestinal obstruction with simultaneous resection and anastomosis, and good clinical results were achieved.

Castleman's disease (CD), also known as vascular lymphoid follicular tissue hyperplasia or giant lymph node hyperplasia, is a chronic lymphoid tissue proliferative disease characterized by unexplained lymph node enlargement. It was first reported as a pathological phenomenon by Castleman et al. in 1954. The author treated 3 patients with retroperitoneal CD from 2010 to 2016. According to their clinical characteristics and therapeutic effects and combined with the literature, the analysis is as follows.

aquaporins (AQPs) are proteins that selectively mediate the transport of free water across cell membranes. Studies have shown that AQPs are widely expressed in the body and are involved in the occurrence, migration and proliferation of some tumors. In this study, the expression of AQP4 and AQP5 in tumor tissues of 182 patients with gastric cancer was retrospectively analyzed, and the relationship between the expression of AQP4 and AQP5 and the clinicopathological characteristics and prognosis of patients with gastric cancer was discussed.

A 40-year-old female complained of "physical examination showed that the pelvic mass gradually increased for more than 10 years". Physical examination: There was no enlargement of superficial lymph nodes in the whole body. Abdominal CT examination showed that a mass shadow was seen in the uterorectal crypt, with a clear boundary, 6.9 cm ×6.2 cm ×5.7 cm in size and uniform density (Figure 1)。 Exploratory laparotomy was performed. During the operation, the tumor was located below the rectal peritoneal reflux, with regular shape, clear boundary and tough texture. It was closely related to the rectum, and the tumor could not be separated and removed. Rectal mass resection was performed. The postoperative pathological results showed a large number of lymphoid tissue hyperplasia and obvious hyperplasia of lymphoid follicular vessels. Immunohistochemical staining results showed that interfollicular lymphocytes CD3 (+), CD5 (+), Bcl-2 (+), intrafollicular lymphocytes CD20 (+), Ki67 (+), vascular endothelium CD34 (+), CD21 and CD23 showed follicular dendritic cell network (Figure 2)。 Pathological diagnosis: Castleman's disease of mesorectal lymph nodes, hyaline vascular type.

A 57-year-old male was admitted to the hospital for "abdominal pain with cessation of anal exhaustion and defecation for 3 days". Physical examination: The abdomen is slightly swollen, visible intestinal type, total abdominal tenderness, no rebound pain, muscle tension, negative mobile voiced sound, and active intestinal sound. Admission diagnosis: intestinal obstruction. Abdominal X-ray plain film suggests: multiple gas and liquid levels. Abdominal CT showed that the local intestine and mesentery of the right lower abdomen showed "vortex" changes, local wall thickening, proximal intestine dilatation, and pelvic effusion (Figure 1)。 An exploratory laparotomy was performed in the emergency department. During the operation, a 16 cm ×12 cm ×8 cm tumor was found in the mesenteric mesentery about 130 cm away from Treitz's ligament. The tumor was close to the intestinal tube, purple-red, with less smooth surface and uneven texture. The intestinal tube at the tumor site entered the pelvic cavity, rotated 360 degrees clockwise along the mesenteric axis, and the proximal intestinal tube of the tumor was significantly dilated. Intraoperative diagnosis: mesenteric hemangioma of small intestine with intestinal volvulus. Intestinal volvulus reduction was performed, and the diseased small intestine was removed (Figure 2)。 Postoperative pathological report: mesenteric cavernous hemangioma (Figure 3)。

An 86-year-old male was admitted for "8 years of bilateral inguinal area tumor with 1 d of aggravation". Physical examination: The patient showed forced upright sitting position, flat abdomen, tenderness in the lower abdomen and mild rebound pain. A mass of about 10 cm ×8 cm in size can be palpable in the left inguinal area, which is soft and non-tender. It can be lowered into the scrotum and returned to the abdominal cavity when lying down. A mass about 7 cm ×9 cm in size can be palpable in the right inguinal area, which is hard in texture, red and swollen on the surface, and the skin temperature is elevated (Figure 1), severe pain refuses to press, does not descend into the scrotum, and cannot be returned to the abdominal cavity when lying down. Laboratory tests: Serum CRP 136.13 mg/L, WBC 18.68×10⁹/L, N 0.81. Color ultrasound of bilateral inguinal area showed that there were more intestinal echoes in bilateral scrotum, peristalsis was seen, extending to bilateral inguinal area, and anechoic area was seen in right inguinal area, with a range of about 33 mm ×73 mm. Preoperative diagnosis: left inguinal hernia, right inguinal strangulated hernia, intestinal necrosis. The right inguinal area was explored in the emergency department, and the hernia cyst was thickened and dark red. The hernia sac was incised, and about 50 ml of yellow pus flowed out. The sac was covered with purulent coating, and the appendix was imprisoned in it (Figure 2)。 The body of the appendix is suppurative and gangrenous, the inner annulus is enlarged, and the root of the appendix is found. The appendix is removed by conventional methods. The stump is embedded in the end of the cecum, and the cecum is also accommodated. Distilled water is repeatedly rinsed until it is clear. The right inguinal hernia was repaired by Shouldice method, and the rubber drainage strip was placed and closed layer by layer. According to the principle of aseptic operation, the unincarcerated left inguinal hernia will not be treated temporarily, and the second stage operation will be repaid after the disease is improved. After operation, the patient was infected with suppuration in the incision, and after removing some sutures, he was open for drainage. After 2 weeks, he was discharged.

A 64-year-old male underwent laparoscopic-assisted distal gastrectomy plus D for "gastric cancer"₂Lymphadenectomy, anterior colon residual stomach posterior wall-jejunostomy with 29#tubular stapler, input haptics to the large curvature of the stomach, 12 cm long. The gastric tube was removed 3 days after surgery, liquid diet was entered, enteral nutrition preparation was pumped through nasointestinal tube, and semi-liquid diet was entered 7 days after surgery. The patient developed abdominal distension 9 d after surgery. Upper gastrointestinal angiography 10 d after surgery showed that there was more fluid retention in the stomach. The contrast medium slowly entered the input loop through the anastomosis, but no contrast medium entered the output loop, and the stomach contracted weakly, seeFigure 1。 Then the contrast medium was injected through the nasointestinal tube, and there was no obstruction in the distal small intestine. Gastrointestinal decompression, warm saline gastric lavage, somatostatin and erythromycin were given. Gastroscopy at 19 days after operation showed that the anastomosis was mild edema, and it could enter the input loop smoothly. The output loop seemed to be angled at the gastric opening, which made it difficult to enter the gastroscopy. During the examination, the nasointestinal tube was removed from the output haptics and failed to be replaced. On 29 days after operation, a thinner diameter and rigid nasobiliary duct was inserted into the output loop through gastroscope, and enteral nutrition was given through the nasobiliary duct. At 42 days after surgery, the contrast medium could only enter the input loop but not the output loop. Then, 44 days after operation, a super-hard and super-slippery interventional guidewire was inserted into the jejunum through the nasobiliary duct under X-ray fluoroscopy, and a 6F long sheath was inserted along the guidewire. The obstruction location was determined by angiography. The stent pusher was replaced, and the stent was pushed into and through the obstruction section along the guidewire, and the stent was released. The proximal end was anchored to the residual gastric cavity and the distal end was anchored to the distal jejunum of the anastomosis. Then, the nasointestinal tube was placed in the distal jejunum through the guidewire. The self-expanding stent is woven from nickel-titanium alloy wire, segmented, fully coated, 18 mm in diameter and 80 mm in length. The gastrointestinal decompression outflow was significantly reduced on the same day after stent placement. The contrast examination 3 days later showed that the stent had been expanded, the contrast medium could enter the output loop smoothly, and a small amount of contrast medium entered the input loop, seeFigure 2。 Gastrointestinal decompression was stopped after 4 days, diet was gradually resumed after 5 days, and discharged 10 days after surgery. Follow-up for 3 months, the patient tolerated ordinary diet without special discomfort.

cytological examination of peritoneal lavage fluid (PLC) is an important method for detecting free cancer cells in the peritoneal cavity at present. It has important guiding significance for predicting peritoneal recurrence and metastasis and prognosis of gastric cancer patients. However, PLC also has certain limitations-its sensitivity is low. Leake et al.^[1]The results showed that the accuracy and specificity of PLC in predicting the risk of peritoneal recurrence and metastasis could reach 73% ~91.9% and 86.4% ~100%, respectively, but the sensitivity ranged from 11.1% ~80%. In view of the low sensitivity of PLC, a highly sensitive molecular biology gene detection technology, reverse transcriptase-polymerase chain reaction (RT-PCR), has been applied to detect a very small number of free cancer cells in the abdominal cavity. PCR technique is more sensitive than PLC, and related studies have shown that PCR detection results of peritoneal lavage fluid are related to peritoneal recurrence and metastasis and prognosis of gastric cancer patients. In this paper, the research progress of molecular marker gene detection in patients with gastric cancer is reviewed.

Since the emergence of endovascular therapy technology in the late 1960s, the treatment of vascular diseases has experienced several "revolutions"^[1,2]。 Advances in material science and the development of endovascular devices are undoubtedly the most important factors to promote the development of endovascular therapy, and bioabsorbable materials are one of the most promising^[3,4,5,6]It is absorbable, without permanent foreign body retention, and reduces adverse events; It can also be used as a carrier for therapeutic agents. We present a review on the development and application of bioabsorbable materials in endovascular therapy.