2018年 · 第33卷第03期

In recent 20 years, endovascular reconstruction of aortic branch vessels has been a hot topic in endovascular aortic repair techniques. Although the endovascular reconstruction techniques of branch vessels in different parts have some commonalities, each has its own characteristics. Different from the endovascular reconstruction of other branches: the supraaortic arch branches supply the brain, while the brain tissue is poorly tolerant to ischemia; The huge curvature of the aortic arch and hypertensive blood flow pose a great challenge to the endovascular reconstruction branch. Correct understanding of the anatomical characteristics of aortic arch and branches, technical methods and equipment characteristics of endovascular reconstruction branches will help to objectively evaluate the endovascular aortic arch repair technology and its future development trend.

delayed gastric emptying (DGE) is one of the main complications after pancreaticoduodenectomy (PD). Although the occurrence of DGE is a non-fatal complication for patients, it significantly prolongs the hospital stay, increases the hospitalization cost and reduces the quality of life of patients. In this study, the clinical data of 285 patients undergoing pancreaticoduodenectomy were retrospectively analyzed, and the risk factors of DGE were analyzed, which provided a theoretical basis for reducing the occurrence of DGE after PD.

In recent years, with the in-depth research on tumor biology and the development of surgical techniques, in order to preserve the storage and digestive function of the stomach, reduce the syndrome after gastrectomy, and improve the postoperative quality of life of patients, pylorus preserving pancreatoduodenectomy (PPPD) has gradually been popularized and applied to the treatment of periampullary tumors, and has become an important surgical method. We treated 31 cases of periampullary tumors with uncinate process-first PPPD from January 2012 to June 2015, with satisfactory results, which are reported below.

Since Huscher's first laparoscopic thyroidectomy in 1997, the good cosmetic results have been recognized by most surgeons and patients. The full areolar approach we adopted for laparoscopic thyroid surgery has a concealed incision, which has a better cosmetic effect than the thoracic-mammary approach, and can explore both thyroid glands simultaneously. At present, the endoscopic indication has been extended to some cases of thyroid malignancy. The choice of laparoscopic thyroidectomy is currently recognized and accepted in low-risk thyroid cancer patients^[1]。 The aim of this study was to compare the efficacy of laparoscopic and open thyroid surgery with complete areolar approach for micropapillary thyroid carcinoma.

Non-functional parathyroid cysts are rare in clinic, lack of characteristic clinical manifestations, and have a high misdiagnosis rate. They need to be distinguished from thyroid or other cystic neck masses. Nine patients with non-functional parathyroid cysts were treated in our hospital from 1995 to 2016, and the reports are as follows.

The gallbladder in patients with portal hypertension is called a "difficult gallbladder" by some surgeons^[1]The early stage of laparoscopic surgery is defined as a contraindication to surgery. In recent years, with the progress of laparoscopic technology, laparoscopic cholecystectomy (LC) has become the "gold standard" for the treatment of benign diseases of gallbladder, and this contraindication has gradually been broken through. We performed LC on 20 patients with gallstones complicated with portal hypertension, and the surgical treatment results were satisfactory, which are reported below.

Our team used "double-needle pancreaticojejunostomy" to perform pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy (LPD), which improved the quality of pancreaticojejunostomy, which is reported below.

A 49-year-old male was admitted to the hospital with epigastric pain for more than 3 months and aggravated for 1 week. The patient had repeated upper abdominal pain without obvious trigger 3 months ago, mainly under the xiphoid process and around the umbilicus, with occasional abdominal distension. The abdominal pain was worse than before 1 week ago, accompanied by loss of appetite. Physical examination: There was no yellowing stain on the skin and mucosa, and mild tenderness in the middle and upper Color ultrasound: hypoechoic nodules in the body of the pancreas, with clear boundaries and not obvious blood flow signals. Abdominal enhanced CT: abnormal enhanced nodular shadow of rich blood supply to the body of the pancreas, obviously enhanced in the arterial phase (Figure 1), the venous phase decreased (Figure 2), suggesting the possibility of vasculogenic tumors. CEA 5.21 ng/ml (normal 0-5 ng/ml). Laparoscopic middle pancreatectomy was performed. During the operation, the tumor was located in the body of the pancreas. After the specimen was removed, a dark red nodule of about 0.7 cm ×0.5 cm was seen in the body of the pancreas. Postoperative pathology showed pancreatic hemangioma.

A 54-year-old female was admitted to the hospital for 1 d after abdominal pain examination revealed a foreign body in the abdomen. I was diagnosed with "schizophrenia" after head trauma 20 years ago. I usually have difficulty communicating and can't recall when and why foreign bodies entered my body. Physical examination: positive for subxiphoid tenderness and negative for Yu. Abdominal CT: Strip-shaped high-density shadow of the head of the pancreas with radial artifacts at the margins. After reconstruction, a pin was clearly shown, passing through the pancreatic head through the pancreas, the tip of the needle had reached behind the superior mesenteric vein, very close to the inferior vena cava, and significant adhesion and compression were visible at the superior mesenteric vein (Figure 1)。 Robot-assisted laparoscopic foreign body removal from the head of the pancreas under general anesthesia. Exploration showed tight intestinal adhesion in front of the pancreas. The ultrasonic scalpel carefully breaks down the adhesions, cuts the greater omentum at the upper margin of the transverse colon, incises the gastrocolic ligament, opens the small omentum, and reveals the whole front of the pancreas. The superior mesenteric vein was found in the peritoneum after incision of the lower margin of the pancreas, and a posterior pancreatic tunnel was established from bottom to top. The posterior segment of the pancreas of the superior mesenteric vein was completely free. Adhesion wrapping was seen near the lower margin of the pancreatic head behind the gastric antrum, and the pin tail was revealed after separation. The bipolar forceps lightly touched the tail of the needle, and it was seen that the direction of the needle tract penetrated from the pancreatic head to the rear of the superior mesenteric vein. Adhesion of the needle tip to the wall of the superior mesenteric vein. Carefully decompose the surrounding adhesions, and slowly pull out the needle tail of the oval forceps. Because it is difficult to pull out, the pancreatic head is partially incised and the foreign body is completely pulled out (Figure 2，Figure 3), and then the incision of the pancreatic head was intermittently sutured with Prolene thread. One drainage tube was placed in the surgical area. On the first postoperative day, about 10ml of light blood fluid and 186 U/L of blood amylase were drained from the peritoneal drainage tube. There was no drainage fluid in the posterior abdominal drainage tube, so the tube was withdrawn intermittently and extubated and discharged on the 10th day.

The patient was a 59-year-old female. He was admitted to hospital for more than 1 year because of the discovery of a right breast mass. In 2006, due to left eyelid ptosis, myasthenia gravis and thymoma were diagnosed, and thymoma resection was performed in the Second Hospital of Zhejiang University. After recurrence in 2012, thymoma resection was performed in Shanghai Chest Hospital. In the past 1 year, the mass increased slowly without obvious discomfort. Physical examination: A 1.5 cm ×1 cm mass can be seen at the outer upper part of the right breast near the edge of the breast gland, which is hard in quality, with clear boundaries and movable. B-ultrasound: A hypoechoic area with a size of 14 mm ×6 mm was detected at 11~12 points in the right breast (Figure 1), CDFI showed no obvious blood flow signal in it. Bilateral lobular hyperplasia of mammary glands, right mammary nodule, BI-RADS class 3. Admission diagnosis: right breast fibroadenoma, postoperative thymoma, right breast cancer. The patient underwent radical mastectomy for right breast cancer + sentinel lymph node biopsy under general anesthesia on August 5, 2016. Postoperative pathology: (Right side) breast metastatic thymoma (type B2) with "sentinel" lymph node reactive hyperplasia (4 cases) (Figure 2)。 Immunohistochemical staining: TDT (+), CD5 (+), CK20 (-), Ki67 (T cells 80% +), E-Cad (+), CDla (+), CD99 (+), CK19 (+), ER (-), PR (-), CerbB-2 (0), GCDFP-15 (-). Radiotherapy and chemotherapy were received postoperatively, and no recurrence and distant metastasis were found at follow-up so far.

The 68-year-old male was admitted to the emergency department on May 24, 2016 due to sudden abdominal pain 3 days ago and progressive aggravation. During the course of the disease, there was no obvious nausea or vomiting, and dark red bloody stool was discharged. Previous history of atrial fibrillation without systemic treatment. Admission physical examination: Total abdominal tenderness, accompanied by rebound pain and muscle tension, mainly in the left middle abdomen, with weak intestinal sounds. Enhanced CT: The superior mesenteric artery was embolized near the root, with extremely low distal enhancement, thickened intestinal tube of the left abdominal small intestine, exudation of its mesenteric membrane, dilation and effusion of some small intestines and colons, high density of intestinal lumen contents, and no filling defect of the superior mesenteric vein. Clinical diagnosis: superior mesenteric artery embolism, diffuse peritonitis, atrial fibrillation. Emergency exploratory laparotomy under general anesthesia showed intraoperative blood effusion in the peritoneal cavity, poor pulsation of the mesangial vessels, local gangrene perforation of the intestinal canal about 80 cm away from the Trigger's ligament (Figure 1), small intestine, ascending colon, right 1/3 transverse colon intestinal tube color dark red (Figure 2)。 The root of the superior mesenteric artery was blocked with a non-invasive vascular clip, and the wall of the superior mesenteric artery was longitudinally incised about 1.5 cm below the bifurcation of the long artery. A large number of thrombus was removed from the lumen of the superior mesenteric artery and its branch arteries with large and small types of thrombectomy balloon catheters (Figure 3), the arterial incision was continuously sutured with a 6-0 vascular suture. Blood supply to the small intestine from 10 cm to 110 cm from the ileocecal region was not recovered. Part of the small intestine was removed and anastomosed end-to-end. After that, the anastomosis and the distal 15 cm intestinal tube were lifted and externalized through the left abdominal wall incision, and the postoperative intestinal blood supply status was observed. Anticoagulant therapy with low molecular weight heparin was given postoperatively. Half months after the operation, the patient had nausea and vomiting after eating. Considering the stenosis and obstruction of the external intestine, conservative treatment was ineffective, and the external jejunal drainage through the proximal end of the external small intestine and the placement of the distal small intestine nutrition tube were performed (Figure 4)。 On July 17th, the patient developed abdominal pain and fever, and the second-stage enhanced CT of total abdomen showed that distal intestinal fistula and abdominal abscess were not excluded. On July 22nd, the patient underwent small intestine reduction, partial small intestine resection, and abdominal abscess incision and drainage. The patient recovered well after surgery and was discharged on August 12. Oral anticoagulation with rivaroxaban after discharge. The patient was followed up for 1 year, and his nutritional status was good, his diet was normal, and his exhaustion and defecation were acceptable.

A 54-year-old male was seen for "hematochezia for 2 months". Report of colonoscopy and pathological examination in an external hospital: rectal adenocarcinoma 4 cm from anus. Rectal MRI showed rectal mass occupation with extramural invasion, T3N1 (Figure 1)。 No distant metastasis. Neoadjuvant radiotherapy and chemotherapy (50 GY/25F with concurrent oral capecitabine 1 500 mg twice/d) were preceded. 2 courses of XELOX systemic chemotherapy were received after the end of radiotherapy and chemotherapy. Combined laparoscopic abdominoperineal resection was performed in March 2014. Postoperative pathological report: A small amount of adenocarcinoma residual in the rectal intestinal wall, with inflammatory cell infiltration, interstitial fibrosis, consistent with the changes after radiotherapy and chemotherapy, lymph nodes (0/5), infiltration of the whole intestinal wall, resection margin (-), intravascular tumor thrombus (+), nerve invasion (-). Pathological stage: T3N0M0. Postoperatively, he received 2 courses of XELOX and was changed to oral capecitabine due to intolerance. Chemotherapy was discontinued due to intolerance after 2 courses of chemotherapy. In July 2015, chest CT examination revealed metastases in the upper and lower lobes of the left lung (Figure 2), left lung mass resection was performed, postoperative pathological report: lung metastasis of rectal cancer (Figure 3)。 In December 2015, a routine follow-up chest CT examination revealed a solid nodule in the middle of the right thyroid. Ultrasound examination showed that a hypoechoic area was detectable in the middle of the right thyroid gland, with a size of 29 mm ×14 mm, unclear boundary, irregular shape and inobvious internal blood flow; The left lobe probed into a hypoechoic area with a size of 11 mm ×9 mm, with clear boundaries and regular morphology. Fine needle biopsy was performed on the right thyroid nodule, and the pathological report showed cancer cells with necrosis, possibly papillary carcinoma. Right lobectomy and partial left lobectomy were performed in January 2016. Pathological examination confirmed that the right lobe nodule was thyroid metastasis from rectal cancer (Figure 4)。

The patient, a 53-year-old female, was admitted to the hospital for 2 weeks due to the finding of a pancreatic mass. Previous history of diabetes mellitus for 2 years. Upper abdominal CT: Massive soft tissue low-density shadows can be seen in the pancreatic head area, with unclear boundaries; A small cystic low-density shadow about 0.5 cm in size was seen in the left kidney area (Figure 1)。 Enhanced CT: The pancreatic head lesions showed uneven and obvious enhancement, the enhancement gradually subsided in the portal vein phase and the equilibrium phase, and the blood vessels were surrounded; There was no significant enhancement in the three stages of small cystic low-density lesions in the left kidney area (Figure 2，Figure 3)。 Consider: malignant tumor of the pancreas, small cyst of the left kidney. Blood glucose 11.33 mmol/L. CA-199 12 210 U/L, CEA 1.17 ng/ml, AFP 2.9 ng/ml. After perfect preoperative preparation and surgical exploration, the lymph nodes behind the head and pancreas of the common bile duct were obviously enlarged and soft in texture. There was a tumor in the head and neck of the pancreas with a size of about 10.0 cm ×6.0 cm ×4.0 cm, and a mass in the body and tail with a size of 2.5 cm ×1.5 cm ×1.5 cm and 2.0 cm ×1.5 cm ×1.5 cm, respectively. It was homogeneous and tough, and the surface showed multiple hemispherical protuberances of varying sizes (Figure 3)。 Rapid pathological examination of abdominal lymph nodes revealed reactive lymph node hyperplasia. Total pancreas, spleen, cholecystectomy, jejunostomy, common bile duct incision and exploration T-tube drainage were performed. Postoperative pathology (Figure 4): Well differentiated clear cell carcinoma of the pancreas with moderately differentiated sub-carcinoma formation (about 3 cm from the host carcinoma), combined with immunohistochemical results, the sub-carcinoma has neuroendocrine. There was no cancer in the lymph nodes, spleen congestion, no metastatic cancer, chronic cholecystitis, no metastatic cancer, and no metastatic cancer in the lymph nodes near the neck of the gallbladder. Immunohistochemistry: CEA (−), H-CK (−), L-CK (−), Pan-CK (+), HMB-45 (−), S-100 (−), SYN (+), CgA (+), NSE (−). Postoperative patients had good blood glucose control. The patient recovered and was discharged 74 days after surgery. Patients were regularly reviewed in outpatient clinic for 3 years after surgery, and their blood glucose was well controlled, and no tumor metastasis was seen. The patient died more than 3 years and 1 month after surgery, and the specific cause of death was unknown.

Thoracic aortic disease is characterized by high morbidity and mortality^[1,2]。 thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for thoracic aortic disease^[2]。 However, the indications of this surgical treatment method are relatively narrow, and it is difficult to manage the lesions involving some branch arteries of the aortic arch. With the continuous development of medical technology and the improvement of endovascular instruments, the technique of reconstruction of supra-arch branch vessels has also been developed. The commonly used techniques include: de-branching technique, parallel stent technique such as chimney, branch stent and fenestration technique^[1,2,3,4,5]Etc. Different methods have their disadvantages, such as changing normal hemodynamics, increasing the incidence of endoleakage, or immature techniques. In situ fenestration technique, theoretically speaking, does not change the anatomical structure and hemodynamics, and is an ideal method for reconstruction of supraarchal branches. With the improvement of tools, materials and methods, in situ fenestration technique is more and more applied to complex TEVAR, which expands the indications of TEVAR, and its safety and efficacy have also been verified. In this paper, we evaluate the safety and effectiveness of in situ fenestration technique in the treatment of aortic arch and thoracic aorta diseases with TEVAR in recent years.

obstructive sleep apnea (OSA) is a chronic sleep apnea disease in which sleep apnea occurs due to obstruction of the upper respiratory tract for some reasons, accompanied by hypoxia, snoring, daytime drowsiness and other symptoms. OSA is a common disease. Studies have found that the incidence of OSA is 24% to 26% in men and 17% to 28% in women among people aged 30 to 70^[1]。 OSA is closely related to cardiovascular and cerebrovascular diseases. apnea hypopnea index (AHI) in patients with severe OSA<The relative risk (RR) of cardiovascular disease was 1.79 (1.47-1.96), and the RR of fatal and non-fatal coronary artery disease was 1.21 (0.75-1.96). The RR for fatal and non-fatal stroke was 2.15 (1.42-3.24); The RR of all-cause death was 1.92 (1.38-2.69)^[2]。 The pathophysiological change of aortic dissection (AD) is a tear of the intima of the aorta, causing part of the blood flow to leave the main channel (true lumen) and enter the secondary channel (false lumen) located between the intima and media. Under the action of blood pressure, the blood flow into the rupture tears separate the layers of the aorta and develops distally and/or proximally. Can cause poor perfusion of vital organs or rupture of the aortic wall due to weakness^[3]。 The admission rate of AD in China is 2/100,000; The estimated annual incidence rate is 2.8/100,000; There were more males than females (3.7 vs 1.5). The mean age was (58.9 ± 13.4) years. The in-hospital mortality rate was 13.9%. Estimated incidence Italy 4.7/100,000; UK 6/100,000^[4]。 The relationship between obstructive apnea and aortic dissection is reviewed as follows.

enhanced recovery after surgery (ERAS) is a series of perioperative optimization management measures based on evidence-based medicine to achieve the goal of accelerating recovery^[1]。 Since it was proposed by Danish surgeon Kehlet in 1997, ERAS has been carried out in orthopedics, cardiothoracic surgery, breast surgery, gastrointestinal surgery and other surgical fields^[2,3]。 Internationally, ERAS guidelines or expert consensus for elective colorectal surgery, gastrectomy, pelvic surgery and pancreaticoduodenal surgery have been successively published^[4,5,6,7]。