2018年 · 第33卷第07期

The main objective of the treatment of portal hypertension is to control and prevent its most serious and dangerous complication, namely esophageal and gastric variceal bleeding. Although liver transplantation is the most effective radical method, in view of many social and economic constraints and shortage of donors in China, traditional treatment methods still play a leading role for a long time. To this end, we interpreted the "Consensus on Diagnosis and Treatment of Esophageal and Gastric Variceal Rupture and Bleeding" formulated by the Portal Hypertension Group of the Surgical Branch of the Chinese Medical Association in 2015^[1]In 2016, the Hepatology Branch of Chinese Medical Association, the Gastroenterology Branch of Chinese Medical Association and the Endoscopy Branch of Chinese Medical Association jointly formulated the Guidelines for the Prevention and Treatment of Esophagogastric Variceal Bleeding in Cirrhosis and Portal Hypertension.^[2]"Expert Consensus on Tranjugular Intrahepatic Portosystemic Shunt" formulated by the Interventional Group of the Radiology Branch of the Chinese Medical Association in 2017^[3]and the 2017 American Society of Hepatology (AASLD) and the American Society of Gastroenterological Endoscopy (ASGE) portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis and management: 2016 practice guidance by the American Association for the Study of Liver Disesaes^[4]The following standardized requirements are put forward for the treatment of portal hypertension.

At present, laparoscopic radical resection of rectal cancer has been proved safe and feasible^[1]Patient complications and mortality during hospitalization are important components of the short-term prognosis of laparoscopic rectal cancer surgery. This study retrospectively analyzed the complications of 549 patients with laparoscopic rectal cancer during hospitalization, and explored the complications and their risk factors in patients undergoing laparoscopic rectal cancer surgery during hospitalization.

enhanced recovery after surgery (ERAS) takes a variety of optimization measures during the perioperative period to reduce the stress response caused by physical and psychological trauma of patients and achieve the goal of rapid recovery. In recent years, ERAS has been widely used in the field of gastrointestinal surgery^[1,2]。 In this study, the clinical data of 235 elderly patients with gastric cancer were retrospectively analyzed to explore the clinical value of ERAS in radical total gastrectomy in elderly patients with gastric cancer.

Laparoscopic splenectomy is currently the most effective treatment for hereditary spherocytosis (HS)^[1]However, long-term hemolysis of HS is easy to form pigmented gallbladder stones or common bile duct stones, and some patients see a doctor with "cholelithiasis" as the main symptom. We treated 4 patients with hereditary spherocytosis complicated with common bile duct stones, all of which were treated with combined laparoscopic surgery, and the curative effect was good, which is reported below.

At present, the technique of laparoscopic cholecystectomy (LC) is becoming more and more mature, and the surgical complications are significantly reduced. However, even in elective surgery, accidental rupture of gallbladder and bile spillage contamination of abdominal cavity still occur from time to time. Experience has advocated abdominal irrigation and indwelling drainage tube if necessary. Whether it conforms to the concept of enhanced recovery after surgery (ERAS) still needs to be further confirmed. We analyzed the feasibility of accidental rupture of gallbladder without abdominal irrigation during elective laparoscopic cholecystectomy through a prospective controlled study.

laparoscopic pancreaticoduodenectomy (LPD) has complicated operations, high technical requirements and high risk of complications, and there is no unified standard for the specific procedure of enhanced recovery after surgery (ERAS) in LPD. Since the establishment of ERAS ward in 2012, our department has applied ERAS concept to more than 180 cases of LPD. This article summarizes some experience of our department on the management of perioperative ERAS in LPD patients by introducing the individualized implementation of ERAS strategy in a patient with distal cholangiocarcinoma.

Recurrence and metastasis are one of the most significant biological characteristics of gastric cancer, and they are also the main factors that affect the survival of patients after radical gastrectomy, especially the vast majority of patients with recurrent and metastatic gastric cancer die in a short time. A patient with gastric cancer after surgery was admitted to our hospital with extensive intra-abdominal recurrence and metastasis complicated with intestinal obstruction. Complete tumor remission was obtained by double-cavity transverse colostomy and SOX chemotherapy, which is reported below in combination with literature analysis.

It is still unclear whether NHE-1 and V-ATPase expression have a synergistic effect and correlation in the development of gastric cancer. Therefore, immunohistochemical staining was used to detect the expression levels of NHE-1 and V-ATPase in primary gastric cancer tissues, and the relationship between simultaneous overexpression of NHE-1 and V-ATPase and clinicopathological features of gastric cancer, as well as the correlation between the expression of NHE-1 and V-ATPase in primary gastric cancer tissues were analyzed.

Met is a member of the tyrosine kinase growth factor receptor family, and is a receptor of hepatocyte growth factor, a promoter of tumor progression. Met regulates multiple downstream signaling pathways to promote tumor cell motility and invasion^[1]。 Studies have shown that multiple miRNAs that can regulate Met are abnormally expressed in tumors and participate in the occurrence and progression of tumors. By analyzing the expression level of miRNA in colorectal cancer, this study aims to create conditions for studying the molecular pathway of Met in colorectal cancer and molecular targets for diagnosis and treatment of colorectal cancer.

Regulatory T cells (Treg) play an immunosuppressive role in tumor-specific T cell response and play an important role in tumor immune tolerance^[1]。 There are three kinds of CD4+ Foxp3+ T cells with different phenotypes and functions, FrⅠ: CD45RA + Foxp310 resting Treg cells (rTreg); FR II: CD45RA-Foxp3hi activated Treg cells (aTreg); FrⅢ: CD45RA-Foxp3lo non-inhibitory functional T cells (non-Treg)^[2]。 This study investigated the clinical significance of the expression of Treg cells and their subsets in peripheral blood and tumor tissues of patients with gastric cancer.

A 23-year-old woman was admitted for "recurrent right lower abdominal pain for 4 years and recurrent for 1 d". Physical examination showed slight abdominal swelling, McMaher's point tenderness (+), rebound pain (+), mobile voicing (-), no intestinal pattern and peristaltic wave. Laboratory Test: WBC 10.57×10⁹/L, N 0.926. Abdominal B-ultrasound showed: sausage-like echo in the right lower abdomen. Admission diagnosis "acute attack of chronic appendicitis", emergency appendectomy. During the operation, it was found that the appendix was located in the inferior position of the cecum, about 8 cm long and 1.5 cm thick, with congestion and edema on the surface, covered with purulent coating, a fecal stone was seen imprisoned in the appendix cavity, and 20 ml of pus was aspirated in the abdominal cavity. Pathological report: massive neutrophil infiltration in the whole thickness of the appendix and mesangium. A mass was found in the appendix cavity, 0.7 cm ×0.7 cm in size. The tumor cells were polygonal and spindle-shaped, with abundant cytoplasm, granules and vacuoles were visible, and the nucleus was small, without atypia (Figure 1)。 Immunohistochemical staining results: S-100 protein (+), NSE (+), SMA (-), CD34 (+), CD68 (+). Pathological diagnosis: (1) granulosa cell tumor of appendix; (2) Acute suppurative appendicitis and peripheral inflammation. No metastasis and recurrence were observed within 6 months of follow-up.

A 51-year-old male was admitted to the hospital in March 2017 due to "repeated right lower abdominal pain for 3 years with anal stopping defecation for 5 days". In 2014, the patient underwent colonoscopy in an outside hospital due to "abdominal pain", which showed that the intestinal lumen of the ascending colon was narrowed 90 cm away from the anus, with nodular changes. Pathological examination showed "granulomatous inflammation". "Ileocecal tuberculosis" was diagnosed in another hospital, and the patient felt that the abdominal pain improved after anti-tuberculosis treatment. Physical examination: slightly swollen abdomen, tenderness in the right lower abdomen, no rebound pain, muscle tension. T-cell test positive for tuberculosis infection. Colonoscopy showed that annular scar stenosis was visible in the ascending colon, and the intestinal lumen was about 0.3 cm in diameter, which could not be passed by colonoscopy. Abdominal CT examination showed: (1) the ascending colon and small intestine walls were unevenly thickened and stiff, and the intestinal lumen was obviously dilated, accompanied by fluid accumulation and a little gas accumulation, considering intestinal obstruction; (2) In the cecal cavity, a cord-like object can be seen free in the intestinal cavity, and its root is located in the cecal wall (Figure 1)。 Laparoscopic intestinal adhesiolysis, right hemicolectomy, and ileotransverse colonostomy were performed. During the operation, ulcer-type lesions were found in the initial segment of ascending colon, with obvious thickening of the local intestinal wall, redness and swelling of the serous surface, and multiple dense adhesions to the right lower abdominal wall. There is a cord-like tissue in the cecal cavity, about 4.5 cm long and 0.4 cm in diameter, with free distal end and root located in the wall of the cecum (Figure 2)。 Postoperative pathology showed focal atrophy of the intestinal mucosa of ascending colon, more lymph node infiltration and focal foam cell aggregation. See also polypoid bulge, hyperplastic smooth muscle under light microscope, covered with columnar epithelial adenomatous hyperplasia, chronic appendicitis (Figure 3)。 0/15 of the lymph nodes submitted for examination were reactive hyperplasia.

A 74-year-old female was admitted with "melena for 1 month, aggravated for 10 days". Physical examination: Light tenderness in the left lower abdomen. Routine blood test: Hb 75 g/L. There were no abnormalities in CT examination of the whole abdomen. After admission, gastrocolonoscopy, capsule endoscopy and mesenteric angiography were not able to determine the cause. Because the patient's gastrointestinal bleeding continued to worsen, exploratory laparotomy was performed in the emergency department. Intraoperatively, a small intestinal mass with hemorrhage approximately 140 cm from Treitz's ligament, approximately 2.5 cm in diameter, penetrated the whole thickness of the small intestine. Intraoperative enteroscopy revealed multiple small intestinal tumors combined with bleeding from 30 to 140 cm from the Treitz ligament (Figure 1)。 Surgical removal of small intestinal masses. Postoperative pathological examination showed that the tumor cells were diffusely arranged, with fissures and lacunae, and the lacunae were lined with cells, showing shoe spike-like (Figure 2)。 Immunohistochemical staining results: CK (+), Vim (+) (Figure 3), CD31 (partial +), F8 (focus +), CK7 (focus +), Ki67 (10% +), EMA, CD34 negative. Multiple epithelioid angiosarcoma of the small intestine was diagnosed postoperatively. The patient recovered well after operation and was followed up for 3 months. No recurrence and metastasis were found.

The patient is a 53-year-old male, Han nationality, who has been engaged in the catering industry in Ganzi County, Sichuan Province for many years. One week before admission, persistent distension and pain in the right middle and upper abdomen began to appear without obvious inducement, without relief after rest, accompanied by nausea and vomiting, no fear of cold and fever, no acid reflux belching, no diarrhea and melena, no yellow urine, and no yellow staining of the skin and sclera. The patient then went to the People's Hospital of Ganzi County, Sichuan Province for treatment. Color ultrasound in the local hospital showed hepatic hydatidosis. For further treatment, the patient came to our hospital and was admitted to the hospital on March 30, 2017. Physical examination: No yellowing staining of the skin sclera, normal jugular vein, negative hepatic jugular reflux sign, swelling of the right upper abdomen of the abdomen, no superficial varicose veins of the abdominal wall, no abnormal peristaltic waves, soft abdomen, tenderness in the right upper abdomen, no rebound pain and muscle tension, no palpable mass, percussion pain in the liver area, and no moving voiced sound. Cranial CT: No abnormal changes were observed in the cranium. Abdominal CT (plain scan + enhanced): A mass-like mixed density shadow with a size of about 9.7 cm ×9.1 cm was seen in the medial segment of the left lobe of the liver, mainly low density, and a punctate high density shadow was seen in the interior. The enhanced scan showed no obvious enhancement in the arterial phase, but annular enhancement in the venous phase. MRI (plain scan + enhancement): A mass of about 9.7 cm ×9.7 cm mixed signal shadow was seen in the medial segment of the left lobe of the liver, with punctate calcification, unclear boundary, and uneven enhancement in the enhancement scan (Figure 1)。 Carefully read the film before surgery to determine whether the occupied space invades the right hepatic vein or the left hepatic vein, and evaluate the liver volume. Scattered lesions in the left lateral lobe of the liver were seen during the operation, and frozen: benign lesions (parasitic infection with granulomatous inflammation), after free liver and the first, second and third hepatic hilum, anatomical left third hepatectomy was performed according to the location of the occupied space during the operation and preoperative imaging evaluation. During the operation, the initial part of the right hepatic vein was eroded, and the hepatic vein was repaired after local resection. The surgery went smoothly and the space was completely removed. Postoperative pathology: Hepatic echinococcal cyst, cyst wall fibrous tissue hyperplasia, vitreous degeneration, necrosis with granulomatous inflammation, peripheral liver parenchyma compression atrophy with cholestasis and degeneration, mixed inflammatory cell infiltration in portal area. The patient received albendazole 1 100 mg/d orally after surgery. After 6 months, there was no recurrence on outpatient CT.

With the rise of total mesorectal resection and complete mesorectal resection in the field of colorectal tumor surgery, people have begun to pay attention to and research on mesenteric. In fact, as early as the Renaissance, Leonardo da Vinci described its existence as "continuous mesangial folds closing toward the center". For hundreds of years, the mesentery was left out, and it was considered a discrete structure used to connect and fix the intestinal tube to the posterior wall of the abdominal cavity, with little research value. Recently, a series of studies have found that the mesenteric membrane is a fan-shaped organ with a continuous structure^[1], participated in the pathophysiological processes of numerous diseases and formed a mesangial-based diagnostic and therapeutic strategy, which even has the potential to change the surgical modalities of certain abdominal diseases, such as colorectal tumors and Crohn's disease.

Normal wound healing includes three stages: inflammation, proliferation and remodeling. It is a physiological process that requires the participation of multiple cells. After wound formation, macrophages migrate to the injury site and exert antibacterial and necrotic tissue clearing effects through phagocytosis and secretion of inflammatory factors, and promote angiogenesis and inflammation regression^[1]。 In the early stage of wound healing, keratinocytes recruit neutrophils to the site of injury by secreting interleukin-8 to participate in the inflammatory response, and then reepithelialize the wound through proliferation and migration^[2]。 Under normal physiological conditions, endothelial cells can undergo mesenchymal transformation, secrete collagen, and promote wound tissue remodeling and fibrosis. However, excessive endothelial mesenchymal transformation will lead to excessive aggregation of fiber components and local sclerosis^[3,4]。 neutrophil extracellular traps (NETs) are a network-like structure composed of free DNA, histones, antimicrobial peptides and various granzymes released by neutrophils^[5]。 NETs can restrict, capture and kill pathogens and prevent infection. However, the excessive formation of NETs can also cause tissue damage, which can participate in the occurrence of many diseases, such as transfusion-related acute lung injury, venous thrombosis, autoimmune diseases, etc^[6,7,8]。 Increased production of NETs in wound tissue of diabetic patients, studies show^[9]。 peptidylarginine deiminase 4 (PAD4) can depolymerize DNA and histones, and is the core enzyme of neutrophils to produce NETs. The wound healing rate of diabetic mice with PAD4 knockout was 30% ~40% higher than that of control diabetic mice, suggesting that the generation of NETs could lead to delay of diabetic wound healing^[10]。 At present, it has been found that NETs can directly damage the normal physiological functions of macrophages, keratinocytes and endothelial cells in wounds, and affect tissue repair and angiogenesis at all stages of wound healing. This may be an important reason for the delay of wound healing in diabetic patients caused by NETs. This article reviews the possible mechanisms of delayed diabetic wound healing caused by NETs.