2018年 · 第33卷第02期

Bile duct stone is a common type of calculus disease in China, which mainly refers to intrahepatic and extrahepatic bile duct stone. It has the characteristics of high incidence rate, many complications, high risk of recurrence and high reoperation rate^[1]Clinical treatment is difficult. Recurrent intrahepatic and extrahepatic bile duct stones are complicated, and sometimes it is difficult to completely remove the stones by a single surgical method. Some patients need to combine multiple surgical methods to treat the patients^[2]。 In order to analyze the surgical treatment of recurrent intrahepatic and extrahepatic bile duct stones, 98 patients with recurrent intrahepatic and extrahepatic bile duct stones admitted to our hospital were selected for analysis, and the reports are as follows.

Surgical approaches for rectal prolapse can be divided into two categories: transperineal approach and transabdominal approach. Transperineal approach is less invasive, less difficult to operate, and more safe, so its clinical application is more and more common. Altemeier's procedure is one of the representative procedures of transperineal approach for complete rectal prolapse in adults. In this study, 13 cases of complete rectal prolapse in adults were treated with Altemeier's procedure, which is now reported below.

Selective celiac arteriography is of great significance in the diagnosis of gastrointestinal bleeding (GIB). Celiac arteriography can not only diagnose GIB, judge the nature and approximate location of bleeding, but also provide timely and effective minimally invasive treatment for some patients with GIB, avoiding the trauma and risk of surgical treatment. However, selective celiac arteriography for the diagnosis of GIB has a high rate of false negatives. We analyzed the results of arteriography in two patients to explore the application value of microcatheter superselective arteriography to improve the positive rate of arteriography.

splenic artery aneurysm (SAA) has a low incidence, but it is very dangerous and can be life-threatening if it ruptures. SAA is defined as an abnormal dilatation of the splenic artery and>1 cm in diameter, and the arterial wall of the tumor body contains all the arterial layers (i.e. intima, media, adventitia). Because SAA is rarely seen in clinical practice, the treatment strategy of this disease remains controversial.

damage control surgery (DCS) emphasizes the importance of stabilizing the vital signs of patients in the rescue of critically ill patients, so as to win opportunities for further treatment^[1,2]。 At present, this concept has gradually expanded from a surgical technique only suitable for dying patients with traumatic injury to a new concept of surgical treatment for critical patients with non-traumatic diseases^[2,3]。 We applied the concept of injury-controlled surgery to the treatment of 23 patients with massive hemorrhage difficult to control during hepatectomy. The satisfactory results have been obtained, which are reported as follows.

Patient, female, 75 years old. He was admitted to hospital in April 2017 due to "intermittent right upper abdominal pain for 2 months". The history of gastrointestinal disease was denied, ALP 152 U/L, and ALT, AST, ALB, DBIL and TBIL were all within the normal values. CEA 103 ng/ml, remaining AFP, CA19-9, CA125 were not abnormal. CT: The gallbladder is not clear, the wall is irregularly thickened, the mass in the hilar area around the gallbladder is low-density, the density is uneven, the enhancement arterial phase is uneven, and the venous phase is continuous. Gallbladder cancer is considered to invade the hilar area; The wall of the common bile duct is thickened, considering the possibility of invasion of gallbladder cancer; Multiple high-density shadows were seen in the lumen of the common hepatic duct and common bile duct, and calculi were considered (FIG. 1A): Electronic gastroscope: No obvious tumor was seen. Intraoperative exploration revealed that the porcelanized gallbladder was hard, invading the hilar of the liver, and the duodenal ligament could palpable swollen lymph nodes; The bile duct was invaded, the wall was thick, the diameter was widened, about 15 mm, and the stone was palpable inside, and palliative cholecystectomy + bile duct incision and lithotomy + T-tube drainage was performed. Postoperative pathological findings: signet ring cell carcinoma of gallbladder, infiltrating the whole thickness of gallbladder wall, with carcinoma components visible from the cross section (FIG. 1B), recovered smoothly, and was discharged from the hospital after oral Tigeo capsules.

A 21-year-old male was admitted to the hospital on November 4, 2016 due to "liver occupation found on physical examination". The patient was healthy in the past, had no history of hepatitis, and recently developed aversion to greasiness. Physical examination: The abdomen was flat, there was no tenderness and rebound pain in the upper abdomen, and no mass was palpable. The liver and spleen were not palpable under the costs, and Murphy's sign was negative. Post-admission laboratory tests : CEA 0.58 ng/ml, AFP 1.71 ng/ml, CA19-9 8.92 U/ml, ALT 10.4 U/L, AST 11.3 U/L, WBC 5.14×10^9,TAP 209.75 μ m/m²。 Upper abdominal enhanced MRI after admission showed a mass-shaped long T1 signal shadow in the right lobe of the liver, which was significantly enhanced in the arterial and portal phases, and the degree of enhancement was reduced in the delayed phase (Figure 1)。 Consider the possibility of liver cancer. The patient underwent liver segment VIII resection under general anesthesia on Nov. 8, 2016. During the operation, an irregular mass of about 5 cm in diameter of right anterior liver segment VIII was seen, and the tumor and part of liver segment tissue were resected 1 cm away from the tumor edge. Postoperative pathological examination: A piece of liver tissue was submitted for examination, with a size of 6.5 cm ×6 cm ×3.5 cm. A nodular mass was found in the incision, with a range of 5 cm ×3.5 cm, involving the liver capsule immediately adjacent to the broken end of the liver, and the incision surface was gray-yellow and brittle. Microscopically, the lobular structure of liver tissue was lost to normal, the portal area was small, Hepatocyte edema and steatosis were observed, and immunohistochemistry showed that Hepatocyte (+), VEGF (+), EGFR (-), GS (+), HSP70 (+), GPC3 (-), CD31 fraction (+), Arginase-1 (-), AFP (-), Ki-67 were positive<1%。 Consideration of hepatocellular adenoma in combination with immunohistochemistry (Figure 2)。 After follow-up, the patients have survived healthily without recurrence.

The 83-year-old female was seen in the emergency department of our hospital because of "pain and discomfort in the right upper abdomen aggravated for 5 days with fever for 1 day". Suffered from cerebral infarction 2 months ago with limited movement of right limb. Diabetic history for 5 years. Physical examination: vital signs are stable, consciousness is clear, right upper abdomen tenderness, no muscle tension, no rebound pain. Abdominal ultrasound: the contour of the gallbladder is blurred around the gallbladder and in the gallbladder cavity due to gas interference, pneumoperitoneum, peritoneal effusion, and bilateral pleural effusion; Abdominal CT showed: emphysematous cholecystitis, gallbladder stones (Figure 1), liver abscess, peritoneal effusion, bilateral pleural effusion (Figure 2)； WBC: 18.8×10⁹/L, Hb: 142 g/L; PLT: 214×10⁹/L, total protein: 57.0 g/L, albumin: 29.8 g/L, total bilirubin: 69.2 μ mol/L, direct bilirubin: 37.7 μ mol/L, alanine aminotransferase: 136 U/L, glutamyl aminotransferase: 120 U/L, alkaline phosphatase 245 U/L, urea: 21 mmol/L, creatinine: 249 μ mmol/L, blood glucose: 13.9 mmol/L. Diagnosis after admission: acute emphysematous cholecystitis, gallstones, liver abscess, peritoneal effusion, pleural effusion, diabetes mellitus, liver and kidney dysfunction. On the day of admission, B-ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) was performed in the emergency department, and purulent bile and gas were extracted during the operation. Meropenem 1 g was given by intravenous drip at 8h. Results of bile cultures: Clostridium perfringens. He recovered smoothly after PTGD and was hospitalized for 19 d. Laparoscopic cholecystectomy was performed 6 weeks after discharge, and the recovery was smooth.

A 41-year-old male was admitted to the hospital due to "distension and pain in the right upper abdomen for 15 days". Physical examination: mild yellowing of the skin and sclera, soft abdomen, tenderness in the right upper abdomen, not reaching the liver under the costs, and two fingers under the costs of the spleen. Previous history of hepatitis B. Laboratory test: white blood cells 3.00×10⁹/L, hemoglobin 130.0 g/L, platelets 66×10⁹/L; Tumor markers normal; Hepatitis B surface antigen, hepatitis B E antibody and hepatitis B core antibody were positive; Epstein-Barr virus negative. Hepatobiliary enhanced MRI showed (Figure 1): Liver cirrhosis, irregular mass shadow in the right anterior lobe, about 42 mm ×24 mm, with unclear boundary; There was no significant enhancement in the arterial phase, peripheral enhancement in the portal phase, and slightly decreased in the delayed phase. The spleen is enlarged, and the veins around the splenic hilum are dilated and tortuous. No abnormalities were observed in pancreas, kidney and adrenal glands, and no enlarged lymph nodes were observed retroperitoneally. Pathological report of puncture biopsy: Most of the tissues submitted for examination were necrotic tissues, and a very small amount of residual abnormal cell degeneration and necrosis and fibrous tissue proliferation were seen, which tended to be malignant tumors. After hepatic protection treatment, the Child-Pugh score of liver function was reduced to Grade A and liver cancer resection was performed. Postoperative pathological report: lymphoepithelioma-like carcinoma with partial necrosis, 4 cm ×4 cm ×3 cm, without lymph node metastasis. Immunohistochemical staining results: AACT (+), AAT (+), CD34 (+), SMA (-), CD10 (+), CK8/18 (-), AFP (-), Hepatocyte (-), CK7 (+), E-cadherin (-), CD138 (+), CD68 (+), CD38 (local +). The patient underwent regular postoperative review and hepatic artery chemoembolization twice. The reexamination of hepatobiliary enhanced MRI at 17 months postoperatively showed nodules between portal vein and inferior vena cava, with a size of about 25 mm ×47 mm. The enhanced scan showed uneven enhancement, and metastasis was considered. PET-CT showed: soft tissue mass between portal vein and inferior vena cava, mildly active FDG metabolism, considering metastasis; Low density foci in the posterior right lobe of the liver, mildly active FDG metabolism, and possible tumor. The tumor and right liver lesion were reoperatively removed. Postoperative pathological report: metastatic lymphoepithelioma-like carcinoma of hilar lymph node, necrotic nodule of right liver with multinucleated giant cell reaction. After the second operation until August 2017, the patient had received gemcitabine combined with cisplatin chemotherapy for 4 times, and there was no tumor recurrence or metastasis.

A 78-year-old male was admitted to the hospital mainly because CA199 was elevated for 19 days and liver space occupied for 10 days. Physical examination revealed an elevation of CA199 up to 552.1 U/ml 19 days before admission, and abdominal MRI revealed liver space-occupying lesions 10 days before admission. Laparoscopic cholelithotomy was performed 8 years ago for gallstones and gallbladder polyps, and there was no other special medical history. Physical examination showed no positive signs. After admission, the laboratory tests of CA 199 463.7 U/ml and CEA 12.93 ng/ml showed normal alpha-fetoprotein and ferritin, negative hepatitis B surface antigen, and normal direct bilirubin, indirect bilirubin, alanine aminotransferase and aspartate aminotransferase. Ultrasound of liver, gallbladder, pancreas and spleen showed suspicious echoic nodules in the right posterior lobe of the liver. MRI: nodule in the right posterior lobe of the liver, inflammatory change? Neoplastic lesions are not excluded (Figure 1，Figure 2)。 PET-CT: Hypermetabolic nodule shadow in right posterior lobe VII of the liver, considering the possibility of malignant lesion, cholangiocarcinoma (Figure 3)？ After admission, the relevant examinations were completed, and there were no contraindications for surgery, and liver mass resection was performed. During the operation, the right liver and diaphragm were tightly adhered and difficult to separate, which considered the possibility of malignancy. Intraoperative color ultrasound showed a hypoechoic area of about 2.5 cm ×2.0 cm, and two strong echoes of about 0.5 cm were seen in the center. No lesions were found in repeated scans of the remaining liver. According to the principle of tumor-free surgery, the tumor and part of the adhered diaphragm were removed 1 cm from the edge of the tumor. Specimen examined after operation: The tumor was thick-walled fibrous tissue, containing 2 ml of pus and 2 stones, with a diameter of about 0.6 cm (Figure 4)。 The patient recovered well after surgery. CA 199 decreased to 153 U/ml on reexamination 13 d postoperatively. Postoperative pathology: Local liver tissue and diaphragm adhesion fibrosis with abscess formation. Balloon-like degeneration and steatosis of hepatocytes around the liver lobules, massive inflammatory cell infiltration in the portal area, small bile duct and fibrous tissue hyperplasia (Figure 5)。

A 59-year-old female was admitted to hospital mainly for "intermittent epigastric pain with jaundice for more than 1 month and aggravated for 3 days", occasionally with nausea and vomiting, without fever and chills. Complained that his whole body turned yellow once at the age of 15, and was relieved by conservative treatment; At the age of 46, he underwent laparotomy twice due to abdominal pain and jaundice, but no gallbladder was found during the operation. He underwent common bile duct incision and lithotomy and liver cyst surgery, and the two operations were completed by the same doctor. Has a history of cesarean section. Physical examination: soft abdomen, deep tenderness in the upper abdomen, no rebound pain, muscle tension, and negative Murphy's sign. Assay: Alanine aminotransferase (ALT) 391.80 U/L, aspartate aminotransferase (AST) 205.20 U/L, total bilirubin (TBIL) 160.30 μ mol/L, direct bilirubin (DBIL) 100.40 μ mol/L, glutamyl transpeptidase (GGT) 681.90 U/L, alkaline phosphatase (ALP) 307.00 U/L. Abdominal color ultrasound: the extrahepatic bile duct was dilated, 2.9 cm wide, and multiple strong echoes were detected internally, and the gallbladder was unclear; Magnetic resonance cholangiopancreatography (MRCP): gallbladder stones, dilatation of intrahepatic and extrahepatic bile ducts, 2.74 cm at the widest point of the common bile duct.

A 32-year-old female was admitted due to melena for half a month. The amount of melena is about 100 ml/time, 2 times/d, accompanied by upper abdominal fullness, discomfort and fatigue, and no other discomfort symptoms. In the previous year, he was diagnosed with gastric tumor in another hospital due to "discomfort after eating", and underwent laparoscopic gastric tumor resection. Postoperative pathological diagnosis was polypoid lesion. Physical examination: anemic appearance, pale conjunctiva, left upper abdominal tenderness, no rebound pain and muscle tension, liver palpable 10 cm below the costal margin, obvious tenderness, smooth surface, no nodules palpable. Laboratory tests: Blood routine: RBC 1.09×10¹²/L, Hb 22 g/L, PLT 431×10¹²/L; Biochemistry: ALB 22 g/L, no obvious abnormality in the remaining indexes. Occult blood in stool: positive. Imaging examination: Abdominal CT: Multilocular cystic lesions in the liver, uniform enhancement of the cyst wall, right posterior displacement of the inferior vena cava, left anterior displacement of the hepatic hilar structure, mucosal enhancement shadow in the gastric cavity, and edema of the muscular mucosa (Figure 1)。 Electronic gastroscopy: A huge bulging lesion was seen on the large curved side of the stomach body, the surface was congested, the biopsy forceps were still soft when touched, and the remaining mucosa was edema (Figure 2)。 Preoperative diagnosis: (1) gastric mucosal hypertrophy (Menetrier's disease), (2) giant space-occupying cystadenoma of the liver? (3) severe anemia, (4) hypoalbuminemia. Active preoperative preparation to correct anemia and hypoalbuminemia. On March 9, 2017, total gastrectomy, liver tumor resection, and esophagojejunal Roux-Y anastomosis were performed under general anesthesia. Polycystic space-occupying lesions were observed from the first hepatic hilum to the second hepatic hilum during the operation, with a medium size of about 20 cm ×10 cm ×8 cm. The stomach is obviously dilated, occupying the left upper abdomen, and the gastric mass can be palpable from the pylorus of the stomach to the cardia. Postoperative pathology: The gastric mucosal folds showed papillary protrusions with partial gland dilatation, and the morphology was consistent with mucosal fold hypertrophy; (Liver neoplasm) Multilocular cystadenoma of the biliary duct with chronic suppurative inflammation (FIG. 3A，FIG. 3B)。 After operation, all laboratory indexes of the patient remained normal, and he was cured and discharged.

Liver cancer has the second highest tumor-related mortality rate in the world^[1]。 Radical tumor resection can significantly improve the long-term survival rate of patients, and is the most important treatment at present. Increasing tumor resection rate and reducing postoperative complications have a positive effect on improving prognosis, while insufficient future liver remnant (FLR) after hepatectomy can lead to postoperative liver function abnormalities and even liver failure. The application of portal vein embolization (PVE) and portal vein ligation (PVL) in traditional two-stage hepatectomy (TSH) can promote the proliferation of postoperative FLR, but the problems such as failure of second-stage resection and long intermittent tumor progression caused by insufficient postoperative FLR proliferation have not been solved. Two-step hepatectomy with liver dissection and portal vein ligation (associating liver partition and portal vein ligation for staged hepatectomy, ALPPS) It can improve the rate of liver tissue proliferation and secondary resection, and shorten the waiting time for surgery. However, the high morbidity, complication rate and mortality rate after ALPPS have been questioned^[2]。 Therefore, the research hotspots, technical improvements and existing controversies in the application of ALPPS are discussed.

According to incomplete statistics, about 250,000 people in China suffer from liver cancer every year, accounting for more than half of the number of new liver cancer cases in the world every year. How to effectively diagnose and treat liver cancer has become a major problem to improve the level of national happiness. Although the diagnosis and treatment technology has progressed, the current effective treatment for liver cancer is still surgical resection. At present, it is believed that the surgical treatment for patients with very early and early BCLC can achieve good benefits, but the risks of surgical treatment for patients with middle and late BCLC are quite high, and comprehensive treatments such as interventional embolization and radiochemotherapy are preferred^[1]。 However, liver cancer is prone to metastasis and resistance to conventional chemical drugs, which is the bottleneck of liver cancer treatment. With the in-depth research of molecular biology, it has been found that there is a similar tumor metastasis mechanism-epithelial mesenchymal transition (EMT) in pancreatic cancer, breast cancer, colon cancer and other epithelial malignant tumors^[2]。

hepatocellular carcinoma (HCC) ranks second among tumor-related causes of death^[1]China is a major country with hepatitis B virus infection, and liver cancer patients account for 50% of the world's liver cancer patients^[2]。 At present, surgical resection is still the main treatment for early HCC. Considering the degree of cirrhosis caused by hepatitis infection, the size of tumor, the reserve function of the liver, whether there is vascular invasion and metastasis of extrahepatic tissue, etc., less than 30% of patients can undergo surgical treatment^[3]。 Another effective treatment is liver transplantation, but the application of liver transplantation is limited due to expensive surgical cost and shortage of liver donors. At the same time, HCC is generally considered to be poorly effective for systemic chemotherapy, probably due to its high expression of drug resistance genes and poor liver function, which makes it unable to tolerate systemic chemotherapy. Sorafenib, a molecular targeting drug mainly targeting Raf kinase, is currently the only recognized systemic therapeutic drug in the world that is effective for intermediate and advanced HCC^[4]However, it is still not widespread enough in our country because of its expensive. radiofrequency ablation (RFA) has been widely used in clinical practice, and has become the third most important treatment for liver cancer after surgical resection and liver transplantation. However, when the tumor body is>3 cm, there is a higher recurrence rate. In order to compensate for this defect, people will use RFA combined with transcatheter hepatic artery chemoembolization (TACE) treatment, RFA combined with absolute ethanol injection treatment, etc.