2018年 · 第33卷第04期

Because of its special anatomical location, left colon cancer can obstruct the intestinal lumen to a certain extent when the tumor progresses, causing closed loop intestinal obstruction, especially in elderly patients, which can lead to serious water-electrolyte balance disorder, and in severe cases, it can threaten the patient's life^[1]。 Emergency surgery is faced with great risks. Intraoperative lavage can achieve the purpose of evacuating the contents of jejunum and reducing the edema of intestinal wall, but there are some problems such as low anastomosis rate in stage I and high incidence of anastomotic leakage^[2]。 In this study, an intestinal obstruction catheter was inserted into the upper segment of the obstruction through colonoscopy, and the obstruction was relieved by adequate lavage and drainage, and the disorder of water and electrolyte balance was corrected, which created favorable conditions for time-limited laparoscopic surgery.

Patients with perforation of ileocecal carcinoma with peripheral abscess (PICPA) have no specific clinical manifestations, their symptoms and signs are very similar to those of periappendicular abscess, and their anatomical location is in the right lower abdomen, which is very easy to lead to misdiagnosis and misdiagnosis, with a misdiagnosis rate as high as 50.7%^[1]。 A case of PICPA is reported, and its clinical characteristics, diagnosis and treatment are summarized.

Rapid recovery surgery^[1], also known as enhanced recovery after surgery (ERAS), is the application of a series of perioperative management methods proven effective by evidence-based medicine to minimize the patient's stress response and organ function damage, especially in abdominal surgery^[2,3]。 At present, there is no relevant application report in dietary management after ERCP. We explored perioperative dietary intervention for ERCP patients, and analyzed and evaluated the effect of the intervention, aiming to explore a set of effective measures to accelerate the rapid postoperative recovery of ERCP patients.

acute mesenteric ischemia (AMI) is a syndrome caused by mesenteric blood supply disorder leading to ischemia and then leading to necrosis of intestinal wall. Early symptoms associated with AMI are often rare and atypical, and are often prompted to clinicians by signs of peritonitis during intestinal infarction with necrosis or perforation. Our hospital admitted a patient with intestinal necrosis caused by extensive thrombosis of the portal vein and mesenteric vein after rectal cancer surgery. The following is reported in combination with the literature review.

hepatic portal venous gas (HPVG) is a rare clinical complication, which was first reported by Wolfe and Evans in 1955. In recent years, many typical cases have been reported, while atypical hepatic portal venous gas is not easy to attract attention. Recently, a patient with atypical portal pneumatosis caused by lower esophageal perforation was admitted to our hospital. The clinical data and imaging findings are reported as follows.

critical limb ischemia (CLI) caused by lower limb vascular disease is a serious threat to limbs and life health, and is a major risk factor for diabetic foot (DF). maggot debridement therapy (MDT) is a biological therapy that has emerged in recent years to treat chronic ulcer of diabetic foot by using live sterile larvae (maggots) of Mercerized Green fly of the family of Drosophila. From January 2016 to May 2017, 8 patients with diabetic foot were treated with endovascular opening of lower extremity arteries and combined with cornworm biological debridement package to treat infected wounds. The retrospective analysis is as follows.

Primary small intestinal tumors are relatively rare, accounting for only 0.6% ~6% of gastrointestinal tumors, especially benign tumors accounting for only about 25%^[1,2]。 Because of its slow onset, long course of disease, atypical symptoms and easy to be ignored, and lack of intuitive and effective examination methods, preoperative diagnosis is very difficult. It is not discovered until secondary symptoms require surgery or other abdominal surgery, or even at autopsy. 85 cases of primary benign tumor of small intestine were analyzed in order to improve the understanding and diagnosis and treatment of this disease.

A 31-year-old female was admitted to hospital for "6 months of pelvic mass, 1 month of anal drop and impurity of defecation". Physical examination: No mass palpable in the abdomen and pelvis. Rectal mucosa is visible at the anal margin. Digital rectal examination: The rectal sphincter is relaxed, and a tough and elastic mass can be palpable on the posterior wall of the rectum. The surface is smooth, the boundary is clear, and the mobility is poor. The lower pole is about 5 cm away from the anal opening, and the upper pole is unpalpable. The patient underwent anoplasty and rectovaginal fistula repair at 6 months due to congenital anal atresia. MRI examination showed abnormal development of double uterus and sacrum with meningocele, and a rounded slightly higher density shadow in the sacrococcygeal region (Figure 1)。 Diagnosis: postoperative congenital anal atresia, postoperative rectovaginal fistula, meningocele, presacral mass, double uterus. Take the sacrococcygeal approach in prone position for surgical treatment^[1]。 The patient recovered well after surgery, anal drop, defecation impurity disappeared, the wound healed in the first stage, there was no defecation abnormality, and the lower limb sensation and activity were normal. Postoperative pathological report: mature teratoma (Figure 2)。 After 6 months follow-up, there was no recurrence.

A 63-year-old male was admitted for "abdominal mass found for 10 d". Physical examination: Abdominal swelling, palpable mass of about 20 cm ×15 cm size, tough in texture, poor mobility, no tenderness. Dynamic enhanced CT scan of the abdomen showed a huge retroperitoneal mixed density mass shadow, the CT value was-8~65 Hu, the largest cross section was about 210 mm ×130 mm, some of which were unclear and infiltrated, moving and surrounding the pancreas and left kidney, and the main intestinal canal was displaced to the right, suspected of liposarcoma (Figure 1)。 Renal dynamic imaging: The left kidney was not developed, and it was considered that the left kidney had no function, the right kidney had normal filtration function, and the right upper urinary tract had poor excretion. Preoperative serum albumin was 30.22 g/L, hemoglobin 114 g/L and carbohydrate antigen 125 62 U/ml. The left abdomen was incised through the rectus abdominis muscle, about 40 cm long. During the operation, the tumor size was about 40 cm ×30 cm ×30 cm, with unclear boundary and poor mobility, reaching the diaphragm and the pubic symphysis. The tumor had severe adhesion to the transverse colon, left kidney and the tail of the pancreas. The tumor wrapped the descending colon and left kidney, and was closely related to the splenic vein, left renal vein and iliac vessels. Retroperitoneal mass resection + descending colonectomy + left nephrectomy were performed. Postoperative pathological report: Malignant mesenchymal tumor, morphologically consistent with mixed liposarcoma with necrosis. Under light microscope, the tumors mainly consist of dedifferentiated liposarcoma, mucinous liposarcoma and pleomorphic liposarcoma, which invade the peripheral renal envelope, parenchyma and some renal pelvic mucosa, and involve part of the serous surface of colon wall. The patient recovered smoothly after surgery, and CT examination 1 month after surgery showed multiple nodules in both lungs, with a high possibility of metastasis; Multiple circular low-density shadows in the liver, with a high possibility of metastasis (Figure 2，Figure 3)。

The patient was a 22-year-old male. He was admitted to the hospital for "upper abdominal distension for more than 1 month, sudden persistent upper abdominal pain with nausea and vomiting for 14 hours". Physical examination: Body temperature 37.5℃, no yellowing stain of skin and sclera, flat and soft abdomen, obvious tenderness in the upper abdomen, no muscle tension, rebound pain, Moh's disease (-), and normal intestinal sounds. Blood routine: WBC 17.5×10⁹/L, N 0.94. Serum total bilirubin 24.3 μ mol/L, direct bilirubin 7.2 μ mol/L, serum amylase 311.1 U/L, urinary amylase 13 167 U/L. Abdominal enhanced CT revealed edematous pancreatitis; The descending duodenal cavity occupies a cystic-like circular space with a diameter of about 2.5 cm, and the cyst wall is enhanced in the arterial phase (Figure 1)。 MRCP showed acute pancreatitis, no dilatation of the biliopancreatic duct, and cystic long T2 signal in the descending duodenum. Gastroscopy revealed that spherical mass in the cavity of the descending duodenum, about 3 cm in diameter, with basal attachment to the medial intestinal wall, normal surface mucosa, and no duodenal papillary opening (Figure 2)。 Two weeks after admission, pancreatitis improved and exploratory laparotomy was performed. The anterior wall incision of the descending part of the duodenum showed a cystic mass attached to the medial wall at the junction of the descending part and the horizontal part, about 3.0 cm in diameter, soft in texture, wide in pedicle, and a papillary opening in the middle communicating with the cystic cavity. It contains pale yellow clear cyst fluid, the cyst wall is about 2 mm thick and the inner wall is rough. The duodenal papilla was opened at the bottom of the cystic cavity without stenosis through exploration of the common bile duct. The cyst wall was removed along the attachment of the cyst to the duodenal wall, the resection margin and the duodenal opening were sutured, and a T-tube was placed in the common bile duct. The postoperative recovery was good. T-tube angiography at the 6th week showed normal intrahepatic and extrahepatic bile ducts, and the T-tube was removed. Postoperative pathological report: The medial and lateral wall of the cyst was covered with mucosa, the lamina propria between them was absent, and the muscle layer was poorly developed. The diagnosis was intraluminal duodenal diverticulum (IDD) (Figure 3)。 After 16 months of follow-up, the patient recovered well.

A 79-year-old male was admitted to the hospital for "intermittent melena for more than 1 month and tarmac for 5 days". Physical examination: Mild tenderness under the xiphoid process, no abdominal mass palpable. Laboratory tests: Positive occult blood in stool, blood routine Hb 57 g/L. Gastroscopy showed that a 4 cm spherical mass was seen on the large curved side of the fundus of the stomach, and ulcer bleeding was seen on the surface. No biopsy was taken because the patient had intermittent bleeding. Upper abdominal CT showed a round high-density shadow in the gastric cavity, about 5.7 cm ×4.5 cm in size, with clear boundaries. Exploratory laparotomy was performed, and a tumor was seen on the large curved side of the gastric fundus, mainly endogenous type, about 6 cm in size. The tumor was lobulated, tough in texture, and the surface was congested and edema. Partial gastrectomy was performed. Postoperative pathological report: The size of the tumor was 6 cm ×5 cm ×4 cm, the tumor cells were round, medium-sized, relatively uniform in size, the nucleus was round, oval, nucleus deviated, the cytoplasm was basophilic, and the growth was diffuse and infiltrating (Figure 1)。 The results of immunohistochemical staining showed that CD38 (+), CD138 (+), MUM-1 (+), λ (+), κ (-), CD3 (-), CD20 (-), BCL-2 (+), BCL-6 (-), Ki-67 (60% +) were consistent with plasmacytoma, and no tumor invasion was observed at the resection margin. Postoperative peripheral blood smear and bone marrow puncture biopsy showed no abnormality, serum protein electrophoresis showed no M band, bone scan was negative. extramedullary plasmacytoma (EMP) was diagnosed excluding bone plasmacytoma and multiple myeloma.

The patient, a 53-year-old male, was admitted to hospital because of "coughing and expectoration for more than 1 month, repeated fever, and the liver was found to occupy space for more than 20 days". The patient developed cough and white sticky sputum about 1 month ago, and repeated fever about 20 days ago. The local primary hospital considered "pneumonia" and gave treatment such as resolving phlegm, relieving cough and anti-infection, but the patient's cough did not improve significantly. Perfect chest CT showed "liver occupation: primary liver cancer possible". He was given "moxifloxacin, meropenem and ornidazole" anti-infective treatment successively. The patient still had fever every afternoon, and the highest body temperature fluctuated between 38.5 and 39 ℃. The body temperature could return to normal after oral non-steroidal anti-inflammatory drugs. Feeling decreased appetite, weight loss of about 7 kg in the last 2 months. The local hospital considered "liver occupation: primary liver cancer?", and for further diagnosis and treatment, the patient was admitted to the Hepatobiliary Hospital of Hunan Provincial People's Hospital on May 17, 2017. Past history: 30 years ago, there was a history of "acute jaundice hepatitis", the details are unknown; I underwent splenectomy due to trauma 15 years ago, and my past history is no different. Physical examination: Body temperature: 38.0 ℃, pulse: 75 beats/min, breathing: 20 beats/min, blood pressure: 122/68 mmHg. No obvious dry and wet rales were heard in the lungs, no obvious yellowing stain was seen in the sclera, the abdomen was flat and soft, no abnormal mass was palpable in the whole abdomen, and the liver area was slightly tapped, and there were no obvious positive signs.

A 35-year-old male complained that "a mass the size of a soybean grain was found in the left anterior position of the anus for 7 years, and the mass was enlarged with ulcer for 1 month". Physical examination: Body temperature 37.5℃, poor spirit, and several swollen lymph nodes can be palpable in bilateral groins. Serum beta₂Microglobulin, C-reactive protein and lactate dehydrogenase were increased, and erythrocyte sedimentation rate was accelerated. Color ultrasound examination showed: bilateral inguinal and left iliac fossa lymph nodes were enlarged, and hypoechoic masses were seen near the abdominal aorta, left common iliac artery, and left external iliac artery, considering lymphatic metastasis. MRI examination showed multiple enlarged and fused lymph nodes in the left clavicular area, retroperitoneal area below both kidneys, pelvic wall and inguinal area, and the apparent diffusion coefficient value of the left retroperitoneal lymph nodes was low, which was consistent with the manifestation of tumor lymph nodes. The bones of both limbs, ribs, spine and pelvis were the same. Bone marrow puncture normal. A gray-red mass on the left side of the anus was seen by naked eye, about 8 cm ×8 cm ×3.5 cm in size, cauliflower-like, ulcerated and brittle on the surface, easy to bleed when touched, and odorous (Figure 1), the cut surface is dark red between gray and white. Pathological examination: Diffuse infiltration of heterosexual hyperplasia round cells under light microscope, some nuclei are hoof-shaped and kidney-shaped, some nuclei are deviated, there are red-stained inclusion bodies, nuclear division can be seen, and interstitial fibrous blood vessels separate them into a nest shape, accompanied by bleeding and necrosis (Figure 2)。 Immunohistochemical staining showed that LCA, MUM-1, CD79a, CD38 and Bcl-6 were all positive. Pathological diagnosis: (perianal) soft tissue plasmacytoma. Extended perianal tumor resection was performed. The intact tumor was removed by surgery, and the residual wound surface was cleaned up to the subcutaneous fat layer. The wound edge was enlarged and resected, and the wound base was injected with 1:1 normal saline plus fluorouracil. The patient did not receive radiotherapy or chemotherapy for economic reasons. After 15 days, the tumor at the surgical mouth recurred, and after 30 days, the tumor proliferated as before operation. Six months later, the patient underwent radiotherapy and chemotherapy due to repeated proliferation of mass at the surgical mouth and inguinal lymph node enlargement and pain, and repeated radiotherapy and chemotherapy to 11 months after surgery. Fourteen months later, X-ray examination revealed multiple bone destruction in the whole body, and multiple myeloma was confirmed by bone marrow puncture smear. The patient died one month after the family gave up treatment.

A 44-year-old female was seen in our hospital for "intermittent left upper abdominal pain for 1 week". Spleen MRI at local hospital revealed spleen mass. No previous history of gastrointestinal disease. Physical examination: Karl physical strength score (KPS) 90, left upper abdominal tenderness, no rebound pain and muscle tension. Serum tumor markers: carcinoembryonic antigen 2.5 ng/ml, alpha-fetoprotein 40.5 ng/ml, remaining blood laboratory tests showed no abnormalities. Spleen MRI showed: space-occupying lesions in the upper pole of the spleen and the splenic hilum area, suspected lymphoma, please combine with other clinical examinations; The lower pole level of the spleen is like a round shadow in its inner anterior area, and the accessory spleen is considered. No abnormalities were found on plain chest CT scan. The nature of the spleen mass of the patient could not be determined, and laparoscopic exploration was performed under general anesthesia on the third day after admission. Intraoperative exploration showed that no mass was found in the liver, pelvic cavity, small intestine and colon, and no metastatic nodules were found in the peritoneum, omentum and mesenteric roots. A tumor was seen in the splenic hilum area, which showed exophytic growth and poor mobility, about 6 cm ×4 cm ×4 cm in size, and was closely related to the blood vessels in the splenic hilum area. "Laparoscopic splenectomy" was performed and sent for pathological examination (Figure 1)。 The patient recovered smoothly without significant postoperative complications. Postoperative pathological report: poorly differentiated adenocarcinoma (spleen) (Figure 2), considered as metastatic high-grade serous carcinoma (it is recommended to check the female reproductive system to further determine the primary focus), infiltrated into the connective tissue of the splenic hilum, invaded the splenic capsule, no cancer was seen at the severed end of the splenic hilum blood vessels, and cancer metastasis was seen in the splenic hilum lymph nodes (1/11). Immunohistochemical staining results: Ki-67 (positive rate 80%), CK (AE1/AE3) (+), CK5/6 (-), CK7 (+), CK20 (-), CDX2 (-), WT3 (+), P53 (+), CEA (-), P16 (+), P40 (-). Combined with the patient's intraoperative exploration and postoperative pathological examination results, the patient underwent gynecological color ultrasound and MRI examination after operation, and no abnormalities were found.

enhanced recovery after surgery (ERAS) has shown a "blowout" development in China in recent years, but the breadth and depth of its application are far from enough. The specific ERAS schemes adopted by related research and application vary widely, and the quality control of important factors that affect ERAS performance, such as whether the core content of ERAS is included, at least the number of ERAS projects that should be adopted, the quality of each ERAS content implementation and patient compliance, not only makes patients unable to fully benefit from ERAS model, but also leads to inconsistent, untrustworthy and even distorted research results. It can be said that the ERAS model lacking quality control standards still focuses on implementing the concept, and it is still in the primary application stage of "difficult to operate", "difficult to evaluate" and "difficult to repeat", which greatly hinders the development and popularization of ERAS.

Intestinal ischemia and hypoxia can cause a series of complications, with poor prognosis and high mortality. ischemia reperfusion injury (IRI) often aggravates the degree and condition of intestinal tissue injury. Studying the mechanism of intestinal ischemia injury and intestinal IRI is very important to prevent and treat intestinal ischemia injury and intestinal IRI. There are many animal models that can be used to study intestinal ischemic injury and intestinal IRI. Each animal model has its own advantages and disadvantages. No animal model can completely simulate human intestinal ischemic injury and intestinal IRI. This paper systematically expounds the characteristics of different animal models and the means of establishing different animal models.