2018年 · 第33卷第06期

Pancreatic cancer is one of the most malignant tumors of the digestive system, with a 5-year survival rate of less than 5% and a median survival time of less than 6 months. At present, radical surgical resection is the only possible cure for pancreatic cancer, but the 5-year survival rate is only 15% ~25%^[1]The main reason is the recurrence and metastasis of postoperative tumors. With the improvement of perioperative management and surgical technology, surgeons have also begun to change from the pursuit of improving the surgical resection rate of pancreatic cancer to the pursuit of improving the R0 resection rate of pancreatic cancer.

nonthrombotic iliac venous compression syndrome (NIVCS) is the early and middle stage of iliac venous compression syndrome (IVCS), which mostly presents with a series of chronic venous insufficiency (CVI) symptoms. If the missed diagnosis occurs and the lower limb varicose vein operation is simply performed, the postoperative recurrence is easier, and even the acute deep vein thrombosis (DVT) of the lower limb is induced^[1]。 At present, the most commonly used traditional digital anterograde venography (DAV) often cannot clearly show the iliac vein, and the diagnostic accuracy of NIVCS is not high. Since May 2014, the Department of Vascular Surgery of our hospital has adopted stepping digital subtraction venography (SDSV) to perform preoperative examination of CVI patients. Compared with the results of DAV examination of CVI patients in the Department of Vascular Surgery of the Ninth People's Hospital of Shanghai Jiaotong University at the same time, it was found that SDSV can significantly improve the positive detection rate of moderate to severe NIVCS. The results of the study are reported below.

Due to the presence of sternal stem and clavicle, there are blind spots in the dissection of central and IV lymph nodes, which may not be completely dissected, while the oral vestibular approach cannot dissect the upper lymph nodes in zone II or even zone III. Since June 2015, our hospital has performed radical thyroidectomy through total areolar approach and oral vestibular approach to explore the feasibility of combining the two with laparoscopic radical thyroidectomy. The summary report is as follows.

acute biliary pancreatitis (ABP) refers to pancreatitis caused by biliary system diseases, accounting for more than 60% of the total pancreatitis in China, including acute gallstone pancreatitis (AGP) caused by gallbladder stones, intrahepatic bile duct stones and common bile duct stones, as well as acute non-gallstone biliary pancreatitis such as biliary roundworm, parapapillary diverticulum, Oddi sphincter spasm, nipple stenosis, duodenal papillitis, and abnormal biliary-pancreatic confluence^[1]。 In recent years, with the deepening understanding of the etiology and pathogenesis of ABP and the development of minimally invasive techniques, endoscopic sphincterotomy (EST), endoscopic papillary balloon dilation (EPBD) and lithotomy have become effective methods for ABP treatment^[2]。 We successfully treated 72 patients with ABP by performing endoscopic biliopancreatic duct papillary sphincter incision and drainage (biliopancreatic shunt), which is reported below.

Obturator hernia refers to the herniation of abdominal contents or extraperitoneal fat via the obturator of the pelvic floor. It is more common in elderly and thin patients^[1]。 Its morbidity is low, the clinical manifestations are atypical in the early stage of the disease, and the first-line clinicians are inexperienced, which often leads to delays in treatment, and the postoperative mortality rate is as high as 13% ~40%. This article retrospectively analyzed the clinical data of 5 patients with obturator hernia, summarized their onset characteristics and surgical treatment experience, and now reported as follows.

In recent years, with the widespread use of broad-spectrum antimicrobial drugs, nosocomial infections caused by conditional pathogenic bacteria Klebsiella pneumoniae and Klebsiella acidogenes have become increasingly prominent^[1]It seriously threatens the life safety of patients and causes great concern from clinicians. This study retrospectively analyzed the distribution and drug resistance of 1,201 strains of Klebsiella isolated from various clinical departments of Hangzhou Cancer Hospital from January 2015 to September 2017, and provided a basis for the prevention and treatment of Klebsiella infection in this area. The summary report is as follows.

The incidence of biliary perforation in infants and young children with acute abdomen is low, and the clinical symptoms lack specificity, resulting in high misdiagnosis rate. It is common in biliary tract malformation-spontaneous perforation caused by choledochal cyst, and some idiopathic biliary tract perforations without biliary tract malformation. We analyzed 13 children with different modes of biliary perforation to explore the causes, early diagnosis and treatment of the disease.

Bariatric metabolic surgery originated in 1950s and has experienced more than 60 years of development. Weight loss surgery has also gone through several generations of changes, from the initial "first generation dyspepsia" surgery to mixed surgery, and then to simple restrictive surgery, among which laparoscopic sleeve gastrectomy is one of the mainstream weight loss surgery. However, there are few reports on the application of enhanced recovery after surgery (ERAS) in bariatric metabolic surgery in China. Combined with our practice of ERAS in a case of laparoscopic sleeve gastrectomy, we summarize and analyze our center's experience in applying ERAS in bariatric metabolic surgery.

primary hepatic carcinoid tumor (PHCT) refers to a carcinoid tumor originating from the liver, which is an extremely rare slow-growing epithelial cell tumor^[1]PHCT is also called neuroendocrine tumor because it shows neuroendocrine function in structure and biochemistry. Most of them are low-grade malignancy, and the literature is mostly case report. We retrospectively analyzed the clinical data of 52 patients with reported and confirmed PHCT at home and abroad.

Patient, female, 43 years old. Admitted due to sudden upper abdominal pain with vomiting for 2 d. Previous history of extracorporeal lithotripsy for ureteral calculi and hypertension, other medical history is denied. Physical examination: Pulse: 103 beats/min, blood pressure 145/106 mmHg. Acute painful face, tenderness in the upper abdomen, no rebound pain, attenuation of auscultation bowel sounds, about 2 times/min. Blood routine: WBC: 12.8×10⁹/L, hemoglobin: 85 g/L, amylase: 498 U/L. After admission, dark red non-coagulated bloody fluid was extracted by abdominal puncture, and abdominal enhanced CT + CTA was urgently examined: acute pancreatitis complicated with peripancreatic effusion, peritoneal effusion and cholecystitis; High-density shadow in front of the descending duodenum, considering encapsulated hemorrhage; Bilateral pleural effusion; Circular high-density shadow in the main portal vein area, considering aneurysm rupture and bleeding and local wrapping and compression of the main portal vein; Thrombosis of the main portal vein, superior mesenteric vein, and proximal end of splenic vein (Figure 1)。 Angiography: stenosis of the initial part of the celiac trunk, and a dumbbell-shaped pseudoaneurysm of about 0.7 cm ×0.8 cm is visible at 4.5 cm of the initial part of the superior mesenteric artery, which is considered to be a pseudoaneurysm of the branch vessel of the superior mesenteric artery (inferior pancreaticoduodenal artery) (Figure 2), and peritoneal angiography + arterial embolization was performed under local anesthesia. After operation, anti-infection, acid inhibition, enzyme inhibition and anticoagulation treatment were given. Half months after the operation, enhanced CT examination showed that the circular huge high-density shadow in the main trunk area of the original portal vein was narrower than before, and its density was significantly lower than before. The filling defect in the splenic vein was less absorbed and narrower in scope than before. No obvious filling defect was found in the superior mesenteric vein; The swelling of the pancreas was less than before.

A 72-year-old female was admitted to hospital for more than 2 years due to the discovery of progressive enlargement of head mass. The patient had previously discovered a right goiter tumor in 2000 (Figure 1), the local hospital checked that the thyroid function was normal, and no treatment was done. Physical examination: The left temporo-occipital mass has a smooth surface and palpable arterial pulsation, while the right neck can palpable multiple gravel-like masses, which are hard in texture and have poor mobility when touched. CT of the head showed bone destruction of the left temporo-occipital bone, local soft tissue mass with clear boundary, and the mass showed uneven enhancement after injection of contrast medium, with obvious edge enhancement (Figure 2)。 Cranial vascular CTA: A round-like high-density shadow was seen in the left temporo-occipital region, communicating with the left external carotid artery (Figure 3)。 Color ultrasound of the neck: A strong echoic mass about 2.1 cm ×1.7 cm in size was found in the right thyroid gland. Clinical diagnosis: temporo-occipital soft tissue tumor (metastasis?); Thyroid tumors. Temporo-occipital tumor resection + right thyroidectomy were performed. The size of the temporo-occipital tumor resection was about 18 cm ×13 cm, with abundant blood supply and soft texture, and the occipital bone was osteolytically destroyed. Pathology: The tumor cells showed flake-like and glandular tubular infiltrative growth, and the glandular cavity was filled with red-stained colloid; The tumor cells are round, the nucleus is medium-sized, and there is no obvious atypia (Figure 4)； Pathological diagnosis: Temporo-occipital metastatic follicular carcinoma of the thyroid. Pathology of the resected right lobe of the thyroid gland: thyroid follicular carcinoma.

The patient, a 53-year-old female, was admitted to hospital due to intermittent chest tightness and shortness of breath after activity for 1 year, aggravated by half a month. Color ultrasound of neck thyroid and normal thyroid function; Electrocardiogram: sinus bradycardia, complete right bundle branch block; Cardiac ultrasound (Figure 1): A substantial round mass in the right ventricle and occupies most of the right ventricular cavity. The internal echo is slightly stronger and the boundary is clear, 43.6 mm ×46.8 mm. There is a pedicle connected to the right ventricular surface of the interventricular septum near the apex. Diagnosis: The right ventricle occupies space, and the possibility of benign tumor is high. Extraction of cardiac mass under general anesthesia and cardiopulmonary bypass (Figure 2)。 Postoperative histopathological examination showed that it was consistent with thyroid tissue changes (Figure 3)。 The cardiac color ultrasound and thyroid function of the patients were normal 3 months after discharge.

Case 1: A 50-year-old female was admitted to the hospital because of "a mass found in the left upper abdomen for more than 1 month". Physical examination: A mass can be palpable in the left upper abdomen, with soft texture, no tenderness and rebound pain. Abdominal CT showed: cystic mass in the left abdominal cavity, about 11.8 cm ×10.2 cm ×9.1 cm in size, its internal density was not uniform, the cystic part was not enhanced on enhanced scan, the cystic wall showed annular progressive enhancement, and the boundary between the mass and the tail of the pancreas body and the splenic flexure of the colon was not clear (Figure 1)。 Abdominal MRI showed a mass in the tail of the pancreas, with uneven hyperintensity in T1WI and T2WI, and signs of exudation in the periphery. The preoperative diagnosis was a stromal tumor or pseudocyst of colonic origin. Intraoperative exploration showed that there was a cystic-solid mass at the mesangium of the splenic flexure of the colon, with a size of about 11.0 cm ×10.0 cm ×9.0 cm. The boundary between the tumor and the pancreas and the splenic hilum was acceptable, and it adhered to the adjacent colon. Splenectomy of the colon + transverse colostomy were performed. Pathological diagnosis: mesenteric inflammatory myofibroblastic tumor (Figure 2)。 Immunohistochemical staining results showed: CD117 (−), Dog-1 (−), CD31 (+), ALK (−), SMA (2+), Desmin (2+). After 1 year follow-up, there was no recurrence and metastasis.

pancreatoduodenectomy (PD) is the standard surgical procedure for benign and malignant diseases of the pancreas and periampulla. Although the mortality rate decreases to about 5% with the improvement of clinical technology and nursing level, the postoperative complications are still as high as 30% ~65%^[1]。 Postoperative complications of PD, including hemorrhage, pancreatic fistula, biliary fistula and gastric emptying disorder, are the main causes of increased mortality, and also the bottleneck of improving PD safety, which seriously affects surgical safety and postoperative efficacy. The prevention and treatment of pancreatic fistula is the difficulty and focus at present. In order to prevent and reduce the occurrence of postoperative pancreatic impotence, scholars at home and abroad have carried out a lot of research and improvement on pancreatic stump and digestive tract reconstruction. At present, pancreatic stump-digestive tract anastomosis mainly includes pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ), and the controversy about which of these two procedures is superior or inferior has been a hot topic in international surgical circles for many years, which puzzles clinical surgeons. Over the past 30 years, many scholars have re-conducted scientific meta-analysis or prospective studies on these issues, and the results of multiple large sample prospective clinical randomized studies have also been reported^[2,3]。 This article summarizes the latest reports and research results, and summarizes the safety and related progress of the two surgical procedures.

Pancreatic cancer is a highly malignant digestive tract tumor, which has the characteristics of hidden onset, rapid progression and very poor prognosis. The 5-year survival rate is only 7%^[1]。 Most patients were seen with tumors that had progressed locally or metastasized distantly, losing the opportunity for radical surgery^[2]。 The current mainstream view is that new-onset diabetes may be an early clinical manifestation of pancreatic cancer^[3,4]。 Therefore, screening for pancreatic cancer-associated diabetes mellitus (PCDM) can achieve the goal of early detection of pancreatic cancer by taking newly-onset diabetes patients as high-risk groups. In this paper, the research progress of the mechanism of pancreatic cancer-associated diabetes and its potential molecular markers in recent years is reviewed.

In the past few decades of cancer drug therapy research, traditional drugs often have shortcomings such as easy degradation, low uptake rate and poor targeting. How to effectively transport them through suitable carriers is still an urgent problem to be solved. Nano-scale carriers such as viruses, liposomes and polymers have been discovered and used continuously, but their targeting and controllability have not reached a satisfactory degree. Compared with viruses and liposomes, exosomes derived from cells themselves have overcome the application obstacles of existing carriers because of their strong targeting, low toxicity and low immunogenicity, so that they have the potential to become a new type of drug carrier that can be used in clinic. At present, exosomes have successfully transported drugs such as small interfering RNA, microRNA and paclitaxel to target cells. Rapid clearance rate and low productivity are potential factors that limit its clinical application, but the targeted modification of exosomes and the application of mimics effectively solve the problems of clearance rate, yield and targeting. In this paper, the research progress of exosomes as drug carriers in tumor treatment is reviewed, which is reported as follows.