2018年 · 第33卷第08期

fast track surgery or enhanced recovery after surgery (ERAS) is defined as: based on evidence-based medical evidence; Multidisciplinary collaboration in surgery, anesthesia, nursing and nutrition; Through optimizing the clinical path of perioperative management, to reduce the physiological and psychological trauma stress of surgical patients, reduce postoperative complications, shorten the hospital stay, and accelerate the recovery of patients^[1]。 This optimized clinical pathway includes the complete treatment process before hospitalization (home), before surgery, during surgery, after surgery, and after discharge (home). ERAS is a new concept and treatment model of modern medicine. Its core is to emphasize patient-centered service, evidence-based medicine as the basis, and multidisciplinary cooperation and participation to achieve comprehensive optimization of clinical pathways and processes. It has achieved a win-win situation for society, hospitals, patients and medical staff, and produced important social and economic benefits. Through more than 20 years of clinical research and promotion, accelerated rehabilitation surgery is forming a new discipline focusing on optimized perioperative management: accelerated rehabilitation surgery.

Adding special nutrients and intestinal probiotics on the basis of traditional enteral nutrition, the special nutrients have immunopharmacological effects, not only provide energy of the body, but also regulate the immune response of the body, use the biological antagonism of probiotics in the intestinal tract, reduce the growth of intestinal pathogenic bacteria, improve the intestinal environment, and maintain the barrier function of digestive tract. We used combined immunomicroecological enteral nutrition for accelerated rehabilitation surgery of colorectal cancer patients to observe the clinical efficacy of immunomicroecological enteral nutrition therapy in patients.

Hepatectomy is an important method to treat some benign and malignant liver diseases. With the rapid increase of average life expectancy in recent years, the proportion of liver resection in the elderly is increasing^[1]。 Accelerated rehabilitation surgery has been widely used in colorectal surgery, gynecological surgery and other fields and has achieved good results^[2]。 In order to understand the clinical effect and safety of the concept of accelerated rehabilitation in the perioperative period of elderly patients with hepatectomy, we conducted a study on elective elderly patients undergoing hepatectomy, which is reported below.

In recent years, the number of patients with small diameter choledocholithiasis combined with duodenal papillary stenosis has been increasing year by year^[1]。 Due to long-term poor bile drainage, recurrent cholangitis, ampullary stones irritating the duct wall, diaphragm injury and inflammation caused by biliary stone drainage, and fibrosis and hyperplasia of the duct wall^[2]etc., which can often cause inflammatory and fibrous membranous (or annular) stenosis of the common bile duct^[3]。 Duodenal papillotomy (EST) is mainly used in most hospitals at home and abroad for the management of choledocholithiasis combined with nipple stenosis. However, due to the incision of Oddi sphincter, the function of the nipple can be damaged and a series of digestive complications can be caused. In choledocholithotomy, the liver puncture catheter dilates the nipple step by step, which not only solves the bile duct stones and nipple stenosis, but also effectively avoids the function damage of nipple^[4]。 The report is now as follows.

after a long-term deliberation and discussion in the transplantation community, since 2015, donation after citizen's death (DCD) organs have become the main organ source. Compared with adult organ donation, the probability of successful donation in children is relatively higher. At present, this work is in its infancy in the whole country^[1,2,3]We carried out relevant work during the pilot period of organ donation after the death of early citizens, and successively completed 3 adult transplantations of children's donor livers. The summary report is as follows.

Infant chyloabdomen is rare in clinic, and congenital cases are even rarer. If this disease is not diagnosed and treated in time, it can lead to death due to complications. This study retrospectively analyzed 6 children with congenital chyloabdomen, and their diagnosis and treatment experience are reported below.

Endovascular stenting in the treatment of iliac vein stenosis has the characteristics of less trauma, quick recovery, less complications and high long-term patency^[1]However, a few patients will have secondary deep vein thrombosis of the contralateral lower extremities after surgery. From January 2015 to December 2016, 246 patients with iliac vein stenosis were treated with iliac vein stent placement in the Department of Vascular Surgery of the Second Affiliated Hospital of Suzhou University, and 4 cases developed contralateral lower extremity deep vein thrombosis. The retrospective analysis is as follows.

Temporary enterostomy is one of the important surgical methods to treat severe colorectal injury and obstructive colorectal diseases and save patients' lives. After the original condition is satisfactorily controlled, the enterostomy readmission is the key step for the patient to bid farewell to the enterostomy disease state and recover completely^[1,2,3]。 However, it has been found in clinical practice that enterostomy reduction is by no means a simple operation, because it can be complicated by complications such as anastomotic fistula, intestinal obstruction, incision infection, abdominal infection and incision hernia^[1,2,3,4]。 Therefore, it is of great clinical significance to reduce the surgical accidents and postoperative complications of enterostomy reduction.

papillary thyroid carcinoma (PTC) is the most common endocrine malignancy^[1]。 More and more evidence shows that miRNA plays an important role in the development of PTC. Many studies have shown that let-7a is specifically low expressed in a variety of tumors^[2]However, its expression in PTC tissues and its correlation with clinicopathological features are rarely studied at present. This study investigated the expression of miRNA let-7a in PTC tissues and its clinical significance, and provided experimental basis for early diagnosis and treatment of PTC.

Case 1, a 51-year-old male, was seen for the main reason that "a mass on the right side of the neck was found for more than 40 years". The patient complained of accidental discovery of a neck mass, which was about 0.5 cm ×0.6 cm in size at the initial stage, soft and painless, and had an acceptable range of mobility. In the past year, the mass increased compared with before, about 1.8 cm ×1.5 cm, and there was no chest tightness, shortness of breath, dysphagia and hoarseness. Specialist examination: A tumor of about 2 cm ×1 cm size can be palpable in the supraclavicular fossa on the right side of the neck near the right side. There is no redness, swelling, ulceration, desquamation and other manifestations on the surface of the tumor. The boundary is still clear, the mobility is poor, the texture is tough, accompanied by tenderness, and no swollen lymph nodes are palpable in the neck. Color ultrasound examination showed that a cystoid mass with a size of about 2.4 cm ×1.1 cm ×2.6 cm could be seen subcutaneously in the neck mass, which seemed to be fused with multiple pieces, with sound transmission, and punctate blood flow signals could be seen around it. Plain CT scan and enhanced contrast imaging of the neck showed that the right subepithelial cystic lesion of the clavicle near the horizontal entrance of the right thorax showed low density nodules, the cyst wall was annular enhancement, and the boundary with the adjacent sternocleidomastoid muscle was unclear. The neck mass was resected under general anesthesia. During the operation, the mass was located on the deep surface of the platysma muscle, with a size of 1.5 cm ×2.0 cm, a round shape and a soft texture. It adhered to the sternocleidomastoid muscle outside, and the separation reached the hyoid bone without adhesion. The mass was completely removed, and yellow viscous fluid was visible during incision. Postoperative pathological report: cyst of bronchogenic origin with chronic inflammatory cell infiltration of local parietal cells with foam cell aggregation.

The 69-year-old female was admitted to the Department of Hepatobiliary and Pancreatic Surgery of our hospital on June 16, 2017 due to "right upper abdominal pain with skin sclera yellowing for more than 20 days". Physical examination on admission: clear consciousness, soft spirit, obvious yellowing of skin and sclera, soft neck, centered trachea, and no swelling of thyroid gland. Superficial lymph nodes throughout the body were unpalpable. Cardiopulmonary examination showed no abnormalities. Specialist physical examination: the abdomen was flat, the abdominal wall veins were not varicose, and no gastrointestinal pattern and peristaltic waves were seen. Soft abdominal wall, tenderness in right upper abdomen, no rebound pain, unpalpable mass, unpalpable liver and spleen subcostal, unpalpable gallbladder, no tenderness in gallbladder area, negative Murphy sign. The boundary of liver voice was in the normal range, there was no percussion pain in the liver and kidney areas, and the mobile voice was negative. Intestinal sounds were 5 times/min, no vascular murmur was heard, and there was no edema in both lower limbs. Auxiliary examination: Biochemical examination showed: total bilirubin 222 μ mol/L, direct bilirubin 182 μ mol/L, indirect bilirubin 40 μ mol/L, total protein 71.8 g/L, albumin 34.2 g/L, globulin 37.6 g/L, albumin ratio 0.9, alanine aminotransferase 214 U/L, aspartate aminotransferase 133 U/L, alkaline phosphatase 262 U/L, γ-glutamyltransferase 920 U/L. Blood routine showed: white blood cells 13.85×10⁹/L, neutrophil percentage 0.754, erythrocytes 4.47×10¹²/L, hemoglobin 130 g/L, platelets 259×10⁹/L. CA19-9: 773.7 kU/L, CA12-5: 17.3 kU/L, CEA: 0.7 kU/L, CA15-3: 5.3 kU/L; CT enhancement showed: intrahepatic bile duct and common bile duct dilation, chronic liver disease changes; Large spleen; Left liver cyst; MRCP showed: cystic dilatation of the middle and upper segments of the common bile duct and the common hepatic duct, considering bile duct cyst; Mild dilatation of intrahepatic bile duct (Figure 1，Figure 2)； Small nodules in the posterior lower right lobe of the liver and the external upper left lobe of the liver, considering cysts or hemangiomas. Abdominal B-ultrasound: fatty liver, intrahepatic and extrahepatic bile duct dilatation. Admission diagnosis: "obstructive jaundice, common bile duct dilatation, hepatobiliary duct dilatation, hypertension, diabetes", active preoperative preparation, operated under general anesthesia on June 22, 2017, during the operation: the common bile duct can be seen with a mass of about 4 cm ×2.5 cm ×2.5 cm size, which is hard in texture, and there is white bile in the bile duct above the mass; The liver manifests as cirrhosis. Bile duct mass resection, cholecystectomy, common hepatic duct jejunostomy were performed. The anatomical specimens showed that a separated cyst with a size of about 4 cm ×2.5 cm ×2.5 cm was seen on the anterior wall of the common bile duct, which compressed the common bile duct and caused its occlusion, and the mucosa of the bile duct was congested and edema was obvious (Figure 3)。 Postoperative microscopic pathology: fibrous cyst wall tissue, lined with monolayer cubic or columnar epithelium, epithelium without abnormality, combined with clinical, consistent with peribiliary cyst (Figure 4)。

Liver cancer is one of the most frequent malignant tumors in China^[1]At present, open hepatectomy is the main treatment for liver cancer. Open hepatectomy has the characteristics of long operation time, large trauma and strong stress response, which often leads to severe postoperative pain, seriously affects the postoperative rehabilitation of patients and prolongs the hospital stay. The concept of enhanced recovery after surgery (ERAS) provides the possibility to solve the above problems. ERAS aims to reduce surgical stress, pain and related complications as much as possible and promote postoperative recovery through multidisciplinary cooperation and application of management strategies based on evidence-based medicine. In the implementation process, it is essential to achieve optimal analgesia through multimodal analgesia (MMA) and reduced use and dependence on opioids.

short bowel syndrome (SBS) refers to the syndrome that after extensive resection of the small intestine, the remaining functional intestine cannot maintain the nutritional needs of patients or children's growth needs, and occurs mainly diarrhea, acid-base, water-electrolyte disorders, and various nutrient absorption and metabolism disorders. At present, nutritional support, intestinal rehabilitation and surgical treatment are mainly used, but the curative effect is not certain. The survival treatment of patients still depends on the length, location and functional status of the remaining small intestine^[1]。

Acute cholangitis is a common acute abdomen in general surgery, and the common etiologies are common bile duct stones and ampullary tumors. Acute cholangitis has an acute onset and a high mortality rate, which reaches 2.7% ~10% after 2000. The mortality rate of severe cholangitis patients can reach 20% ~30%^[1,2]Charcot's triad is the classic clinical manifestation, and severe patients can be accompanied by shock and changes in consciousness. At present, the generally recognized treatment principle is early bile duct decompression. Common treatment methods include conventional surgical bile duct decompression (laparotomy or laparoscopy), oral retrograde duodenal papillotomy and placement of nasobiliary duct, and percutaneous hepatobiliary puncture. This paper reviews the literature reports and clinical studies at home and abroad in the past ten years. The etiology, diagnosis, treatment and prognosis of acute cholangitis were discussed.

A 63-year-old male was admitted for "10 d intrahepatic occupation found on physical examination". Physical examination: There were no yellowing stains, bleeding spots and spider nevus on the skin and mucosa of the whole body. Auxiliary examination: Hepatitis B two-and-a-half: HBcAb (+), Child-Pugh grade A. Upper abdominal CT: Liver S8 slightly lower density mass, the nature of which is to be determined, and the possibility of primary liver cancer is not excluded. Contrast-enhanced ultrasound: hepatic S8 lesions. Pathology of puncture biopsy of liver tumors: high suspicion of liver cancer. MDT in our department discussed that the diagnosis of hepatocellular carcinoma is highly likely, the patient's general condition and liver function are good, there are no contraindications for surgery, and surgical treatment is feasible. Intraoperative exploration: A tumor with a size of about 4 cm ×5 cm was palpable in the S8 segment of the liver, which was hard in texture and closely related to the right and middle hepatic veins. Consider that if right hemihepatectomy is performed, the remaining liver volume is insufficient; If local resection, the risk of bleeding is high, so it was decided to perform local resection of liver S8 mass after left hemihepatectomy. Intraoperatively, Habib ablation was used to cut the liver boundary, combined with electroknife to cut the liver to stop hemorrhage. Intraoperative hilar was blocked once (15 min), and intraoperative bleeding was 400 ml without blood transfusion. Postoperative pathological diagnosis of hepatocellular carcinoma, beam-cable type. On the first postoperative day, the patient's AST was 435 mmol/L and ALT was 350 mmol/L. The patient was given monoammonium glycyrrhizinate, cysteine and sodium chloride injection (200 ml/d) intravenously. The patient's AST and ALT gradually decreased, and it decreased to AST 40 mmol/L and ALT 50 mmol/L on the seventh postoperative day. At the same time, the patient was given adenosylmethionine supplementation, acid suppression, fluid rehydration, analgesia and other treatments. The patient recovered well without complications. Hematuria routine, renal function and electrolytes were normal after re-examination, and he was successfully discharged on the eighth day after operation.