2018年 · 第33卷第05期

Intrahepatic and extrahepatic bile duct stones and gallbladder stones are common and frequent diseases of biliary system in China, and their incidence is regional and high^[1]。 At present, laparoscopic common bile duct exploration (LCBDE) is one of the main surgical methods for the treatment of common bile duct stones. However, LCBDE often requires the placement of T-tubes to prevent postoperative bile leakage, which leads to the decline of patients' quality of life in the near future after operation. Although the primary suture of LCBDE common bile duct accelerates the postoperative recovery, the incidence of bile leakage is as high as more than 10%. Especially in the early stage of LCBDE, the incidence of this complication can be as high as 17.1%, which makes this procedure difficult to be widely carried out in surgery^[2]。 In order to solve the problem of bile leakage after primary suture of LCBDE common bile duct, we developed gastroscopy combined with choledochoscopy transabdominal nasal bile duct placement on the basis of laparoscopic combined with endoscopic retrograde cholangio-pancreatography (ERCP) nasal bile duct placement. Compared with other techniques, this procedure has low technical requirements and good reliability, and can be widely carried out in surgical departments of municipal and county hospitals, so it has excellent popularization value.

Spontaneous cholecystal fistula is a rare complication of gallstones, including cholecystoduodenal fistula, cholecystocholedochal fistula, cholecystocolic fistula, cholecystogastric fistula, etc. The most common one is cholecystoduodenal fistula, and cholecystogastric fistula rarely occurs due to large gastric mobility and thick gastric wall, with atypical clinical symptoms and difficult to diagnose before operation. Two cases of gallbladder gastric fistula were reported, one of them was chronic cholecystitis complicated with gastric antrum diverticular fistula, and one was gallbladder gastric antrum fistula.

gallbladder polyps (PG) are classified into non-neoplastic polyps (cholesterol polyps, inflammatory polyps, adenomyosis, etc.) and neoplastic polyps (adenoma, leiomyoma, neurofibroma, etc.). The malignant rate of adenomatous polyps was 20% ~38.9%^[1,2,3]。 Ultrasound and CT are valuable in differentiating the nature of gallbladder polyps. The imaging data and pathological diagnosis of 37 patients with neoplastic polyps of the gallbladder admitted to us were retrospectively analyzed and are now reported as follows.

It was found that the autophagy level of gastric cancer cells was increased, and it was closely related to the degree of malignancy^[1]Administration of autophagy inhibitors can inhibit the proliferation, invasion and metastasis of gastric cancer cells, promote apoptosis, and increase their sensitivity to chemotherapy drugs^[2]。 In this study, the effects of NVP-BEZ235 on the proliferation, apoptosis and autophagy of gastric cancer cells were determined, and whether it has a synergistic effect with autophagy inhibitors was investigated.

transanal endoscopic microsurgery (TEM) has the advantages of good exposure, less trauma, clear intraoperative visual field, high complete tumor resection rate and few postoperative complications. This study retrospectively analyzed the clinical data of 20 patients with T1 rectal cancer who underwent TEM surgery, which is now reported below.

The traditional pancreatogastric anastomosis is complicated, and the rate of pancreatic fistula is high, about 15%^[1]。 In order to simplify pancreatogastrostomy and reduce the rate of postoperative pancreatic fistula, Peng Shuyou et al. created type I binding pancreatogastrostomy (BPG) in 2008, and type II binding pancreatogastrostomy in 2009. A large sample retrospective study showed that type Ⅱ BPG and conventional pancreatogastric anastomosis were not only easy to operate, but also significantly reduced the incidence of pancreatic fistula^[2,3]。 In order to facilitate laparoscopic or robotic reconstruction using bundled pancreatogastric anastomosis, Hong Defei et al. further simplified type Ⅱ BPG and created type Ⅲ bundled pancreatogastric anastomosis (Hong's BPG)^[4]。 In this study, the safety and simplicity of Hong's BPG were evaluated by a randomized controlled animal study of Hong's strapped pancreatogastric anastomosis versus traditional pancreatogastric anastomosis.

The patient was a 35-year-old woman, pregnant 4 and delivering 2. She had been menopausal for 35 days. She developed paroxysmal pain in the right upper abdomen without trigger with radiation to the right shoulder for 2 days and was admitted to the hospital. In 2003 and 2012, cesarean sections were performed for one girl and one boy, respectively, and no contraceptive measures were used during the subsequent period. Physical examination: clear consciousness, normal response, moderate nutrition, blood pressure 108/80 mmHg, pulse 82 beats/min, no abnormal auscultation on cardiopulmonary examination, flat abdomen, obvious tenderness in right upper abdomen with muscle guard, no rebound pain, no tenderness in McDonald's point, negative mobile voicing, and normal intestinal sounds. 10 ml of non-coagulated blood was withdrawn from posterior fornix puncture, and urine pregnancy test: weak positive. Blood routine: white blood cells 11.4×10⁹/L, β-human chorionic gonadotropin (β-HCG) 186.14 mIU/ml. B-ultrasound examination showed: (1) Abnormal echo mass at the top of the right liver and diaphragm, with an uneven high echo mass with a range of about 91 mm ×37 mm, and a clear boundary. (2) Moderate volume of peritoneal effusion, uterine size: 63 mm ×59 mm, smooth contour, endometrium thickness about 8.4 mm, no obvious gestational sac echo in uterine cavity (Figure 1)。 CT showed a mixed low density mass on the diaphragmatic surface of the right lobe of the liver, about 90 mm in diameter (Figure 2)。 Diagnosis: Hepatic ectopic pregnancy. Exploratory laparotomy under general anesthesia. During the operation, a large number of blood clots were found on the apical and diaphragmatic surfaces of the hepatic septum, and a mass of about 50 mm ×40 mm was palpated. The mass was removed, and bleeding from the base was seen. Suture was performed to stop bleeding, and the abdominal cavity was cleaned. There was no obvious active bleeding. The operation was smooth, with intraoperative bleeding of 200 ml, no blood transfusion, negative pressure drainage under the diaphragm and under the pelvic cavity, pathology showed: liver pregnancy (Figure 3)。 On the 5th postoperative day, β-HCG was 15.73 mIU/ml, and he was cured and discharged on the 8th postoperative day, and was ordered to follow up in the outpatient clinic.

A 60-year-old female was admitted to the hospital on July 3, 2017 due to "right upper abdominal pain with chills and fever for 1 week". Twice abdominal surgery due to "choledochal cyst" in the past 20 years ago. Physical examination: There was no yellowing staining of the skin and mucosa, and the right upper abdomen touched a hard mass of about 10 cm ×10 cm with poor mobility, without tenderness, and positive tenderness in the middle and upper abdomen. Abdominal CT examination showed that the intrahepatic and extrahepatic bile ducts were significantly dilated and accumulated with fluid, gas accumulation and diffuse multiple stones (FIG. 1A)； MRCP showed cystic dilatation of intrahepatic and extrahepatic bile ducts with multiple stones, and huge extrahepatic bile duct stones (FIG. 1B)。 Blood cell analysis: white blood cells 14.0×10⁹/L, neutrophils 94.8%; Blood biochemistry : ALT 29.6 IU/L, AST 35.8 IU/L, TBIL 3.4 μ mol/L. Admission diagnosis: anastomotic stones after choledochal cyst resection, intrahepatic and extrahepatic bile duct stones, acute cholangitis. After admission, after anti-infection and supportive treatment, surgical exploration found that the gallbladder was absent. The original operation was transverse anterior colonic biliary enterostomy with thin anastomotic intestinal wall. The anastomotic intestinal wall was incised, and a huge stone with a size of about 17 cm ×12 cm ×10 cm was removed (Figure 2)； The residual common hepatic duct is about 1.5 cm long, the wall is rough, and the left and right hepatic ducts are about 3 cm in diameter, forming an internal fistula with the hepatic flexure of the colon. Choledochoscopy to explore and remove the bile duct stones at the upper end of the anastomosis; After free the original anastomosis, the bile duct was transected about 1 cm proximal to it, and cholangioplasty was performed (Figure 3)。 The intestinal tube of the original anastomosis was resected, the common hepatic duct was anastomosed with the normal intestinal tube distal to the original bilioenterostomy, and the right hemicolectomy was performed, and the T tube was placed in the bilioenterostomy. No residual stones were found by T-tube angiography at 3 weeks after operation, and the T-tube was removed. No recurrence of calculi has been found since six months of follow-up with oral ursodeoxycholic acid.

Hepatectomy is still the first choice for most benign and malignant liver tumors. In 1888, Langenbuch successfully performed the first elective liver resection in the world, which marked the birth of liver surgery^[1]In 1899, 76 cases of hepatectomy were reported in the literature, and the mortality rate was 14.9%^[2]。 Hepatic surgery has developed a topic of "bleeding" and "hemostasis". The average volume of bleeding during hepatectomy has increased from about 5 000 ml in the 1980s to about 500 ml today, or even less^[3,4]。 The significant reduction of bleeding during hepatectomy is closely related to the overall development of liver surgery. We summarize the following issues of accurate liver anatomy, improvement of hepatic blood flow occlusion technique, development of liver parenchyma dissection technique, control of central venous pressure, and management of liver section.

Gaucher disease (GD), or glucocerebrosidosis, is a familial glucose and lipid metabolism disease, which is chromosomal recessive inheritance and is the most common lysosomal deposition disease. Gaucher disease is caused by the defect of the gene encoding β-glucocerebrum sidase (GBA) in vivo. The lack of this enzyme causes its substrate glucocerebroside to deposit in large quantities in the mononuclear-macrophage system of the liver, spleen, bone and central nervous system, interfering with normal cell apoptosis and causing disease; Very few are due to the lack of sphingolipid-activated protein C, which cannot activate GBA properly and make it function^[1]。

Colorectal cancer is a common malignant tumor of digestive tract in China, and its incidence is increasing year by year. colorectal liver metastases (CRLM) are one of the main factors that affect the prognosis of colorectal cancer, and their metastatic pathways include direct metastasis, lymphatic metastasis and hematogenous metastasis. The liver as the main target organ for hematogenous metastasis of colorectal cancer^[1]About 50% to 60% of colorectal cancer patients have intrahepatic metastases^[2,3,4]And the distribution of hepatic metastases of left and right colorectal cancer in the liver is not consistent. In recent years, with the development of medical diagnosis and treatment technology and the improvement of medical technology, the long-term treatment effect of patients with colorectal cancer liver metastasis has not been improved significantly, which may be related to the missed diagnosis of patients with intrahepatic micrometastasis or occult liver metastasis^[5]。 At present, there has been controversy about the distribution of liver metastases of colorectal cancer in the liver. Some scholars think that there is more right liver than left liver, while others think that there is no difference in the distribution of left and right hemihepatic. Scholars at home and abroad have also conducted many discussions and studies, but have not come up with a clear mechanism that can explain this phenomenon well, but have only formed several theories. Therefore, in-depth research on the distribution mechanism of liver metastasis of colorectal cancer in the liver is not only of guiding significance for early clinical detection of primary tumor, but also of guiding significance for the diagnosis of liver metastasis in patients with confirmed primary tumor, especially when it is difficult to characterize small lesions in the liver. This article briefly reviews several theories about the distribution of liver metastases of colorectal cancer in the liver as follows.

Malignant tumors are an important cause of human death. About 8.2 million patients die from malignant tumors worldwide every year, of which 90% die from multiple organ metastases of tumors^[1,2]。 Once malignant tumor metastasizes, it significantly affects the prognosis, and the 5-year survival rate of patients after operation also decreases. The invasion and metastasis of malignant tumor are the main causes of postoperative recurrence and death^[2]。 This paper summarizes the role and function of endothelial cells in the study of tumor metastasis, and provides ideas for the clinical treatment of tumor and the development of targeted drugs.