2018年 · 第33卷第09期

severe acute pancreatitis (SAP) is a kind of surgical acute abdomen with acute onset, complex and variable, critical condition and dangerous prognosis. The mortality rate is 8%-39%. The early stage is mostly due to persistent organ failure, and the late stage is mostly due to infectious pancreatic necrosis. SAP can be accompanied by a variety of complications. For local pancreatic complications secondary to infection or compression symptoms, such as digestive tract obstruction, biliary tract obstruction, etc., and complications such as pancreatic fistula, digestive tract fistula, pseudoaneurysm rupture and bleeding, surgical intervention is often required^[1,2]。 Open surgery was used in the past, but SAP patients themselves may have multiple organ failure and other problems, and open surgery can cause a second blow and increase mortality. With the development of minimally invasive techniques and the idea of injury control, a new way has been opened for the treatment of SAP complications. This article will explore the opportunity and technique of minimally invasive intervention in SAP-related complications.

fine needle aspiration biopsy (FNAB) is currently the most effective method to evaluate benign and malignant thyroid nodules, but nearly 40% of them are undiagnosed due to unclear nature or small cell volume that cannot meet the valid diagnostic criteria^[1]。 Previous studies have shown that combined BRAF V600E gene mutation detection can effectively improve the accuracy of FNAB in the diagnosis of papillary thyroid carcinoma (PTC)^[2]。 This study retrospectively analyzed the clinical data of patients with FNAB combined with BRAF V600E gene mutation detection admitted to Guangzhou Yiheyou Clinic from June 2016 to November 2017 to explore its significance in the clinical diagnosis and treatment of thyroid nodules.

rectovaginal fistula (RVF) is a pathological channel composed of epithelial tissue between rectum and vagina. With the popularization of low anus-preserving surgery for rectal cancer, the use of stapler and the combination of preoperative adjuvant radiotherapy, iatrogenic factors are increasing^[1]。 Because the etiology of RVF is complex, and the postoperative infection is easy to occur, the recurrence rate is high, and it is extremely difficult to operate again. Therefore, individualized treatment according to the etiology, fistula location and size can improve the cure rate. This study performed surgical procedures on 25 patients with RVF, all of which were successful. Combined with the literature, the cause of RVF, the timing of surgical treatment and the best surgical method were discussed.

The concept of enhanced recovery after surgery (ERAS) refers to the adoption of a series of optimization measures during the perioperative period to reduce body stress and postoperative complications, and accelerate patient recovery. The concept was first developed in 1997 by Kehlet of the University of Copenhagen, Denmark^[1]Professor proposed that it has been applied in general surgery, orthopedics, urology, thoracic surgery and other disciplines^[2]However, liver resection and liver transplantation are invasive and risky, and most of them are accompanied by cirrhosis. ERAS is rarely used in liver surgery and perioperative period of liver transplantation at home and abroad. autologous liver transplantation (ALT) includes two parts: extracorporeal liver resection and autologous liver transplantation. It was developed by Pichlmayr et al. in 1988^[3]First reported, it is the most complicated liver surgery at present. Combined with a case of autologous liver transplantation with ERAS concept, we summarized and analyzed the experience of using ERAS in liver resection and liver transplantation in our center.

Three-dimensional visualization technology can be used to effectively analyze the relationship between tumor location and liver anatomy, which can perform surgical planning and virtual surgery, and provide effective technical support for precise liver resection^[1]。 The clinical data of 10 patients with primary hepatocellular carcinoma undergoing three-dimensional reconstruction visualization technique in laparoscopic precise hepatectomy were retrospectively analyzed. The report is now as follows.

phelegmasia cerulea dolens (PCD) is a rare and life-threatening serious complication of deep venous thrombosis (DVT) of lower limbs. If it is not treated in time and effectively, it can easily lead to limb gangrene or even death^[1]。 From November 2012 to March 2017, we treated 7 patients with PCD with combined surgery or total endovascular technique, and the results were satisfactory, as reported below.

At present, there are more than 1 million cases of inguinal hernia repair in China every year, and most of the inguinal hernia repair methods are tension-free^[1]。 While pursuing low recurrence rate, low complication, and high comfort by patch repair, we have to face the thorny problem of infection caused by endoplantation^[2]。 surgical site infection (SSI) is a common complication of tension-free inguinal hernia repair, which is very difficult to treat and even requires reoperation, resulting in the failure of inguinal hernia repair, increasing the hospitalization time and hospitalization cost of patients. In this study, we compared the incidence of incision infection in surgical patients who used iodine-containing antibacterial film with ordinary film in surgery, and observed the application value of iodine-containing antibacterial film.

Klebsiella pneumoniae is a common pathogenic bacterium of nosocomial infection, which is more common in pneumonia, urinary tract infection and meningitis. In the past, the pathogenic bacteria of bacterial liver abscess were mostly Escherichia coli and Staphylococcus aureus, and the liver abscess caused by Klebsiella pneumoniae was rarely encountered. The clinical characteristics of 2 cases of liver abscess complicated with suppurative endophthalmitis treated by us are summarized and analyzed.

A 43-year-old female was admitted to hospital for more than 1 month due to yellowing of the skin and sclera with deepening of urine color, accompanied by skin pruritus, abdominal distension and nausea. Physical examination: Severe yellowing staining of skin sclera. Auxiliary examination : ALT: 337 U/L, AST: 342 U/L, ALP: 606 U/L, γ-GT: 301 U/L, DBiL: 105.6 μ mol/L, TBiL: 143.6 μ mol/L. Tumor markers CA19-9 were elevated (99.86 U/ml) and CA50 (59.95 U/ml). CT showed that the soft tissue of the pancreatic head occupied space, and the enhancement was uneven after enhancement. The enhancement degree was lower than that of the surrounding pancreatic parenchyma, and the pancreaticobiliary duct was obviously obstructed and dilated upstream of the lesion. MRI showed that the pancreatic head was enlarged, with a mass-like abnormal signal shadow about 2.5 cm ×2.0 cm in size. T1WI showed isoslightly low signal, T2WI showed isoslightly high signal, with unclear boundary, and DWI showed high signal. After enhancement, the lesion showed mild enhancement (Figure 1)。 After admission, the patient underwent pancreaticoduodenectomy (Child procedure). During the operation, a solid tumor of about 3 cm in diameter on the head of the pancreas was seen. The adhesion to the surrounding tissues, especially the right wall of the portal vein, was dense, and there was no obvious external invasion. Chronic inflammatory changes of the pancreas with dilatation of the main pancreatic duct about 8 mm. The common bile duct is dilated, approximately 2 cm in diameter. Postoperative pathology: Pancreatic head squamous cell carcinoma grade Ⅰ ~ Ⅱ, stomach, duodenum, pancreatic margin, common bile duct margin and all lymph nodes were negative. Immunohistochemistry: 34 β E12 (+), P63 (+), CK7 (-), P53 (+), Ki67 (40% +), CK19 (+), CK20 (-), CEA (-), CgA (-), SYN (-), CD56 (-), TTF1 (-), conforming to grade I to II of squamous cell carcinoma (Figure 2，Figure 3)。 According to the AJCC version 8 pancreatic cancer TNM staging criteria, the patient was T2NOM0, stage IB. The patient recovered well after surgery, and started radiotherapy one month later, and was given Tegio for chemotherapy. The current follow-up is 6 months and the patient survives well.

The patient was a 62-year-old male. He was admitted to hospital for more than 36 h due to persistent pain in his left waist. Prior history of paroxysmal atrial fibrillation for more than 5 years. Physical examination: tenderness in the left middle and lower abdomen (+), percussion pain in the left kidney area (+). Serum creatinine was 88.0 μ mol/L and blood urea nitrogen was 6.47 mmol/L. Enhanced abdominal CT considering left main renal artery embolization; Renal color Doppler ultrasound showed no obvious blood flow signal in left renal artery and left renal parenchyma. Renal arteriography under local anesthesia and AngioJet thromboaspiration. Puncture angiography of the left femoral artery showed that the main trunk of the left renal artery was not developed (Figure 1), the guidewire guided 5F C2 catheter was selected into the left renal artery opening, the super-slippery guidewire was gently twisted through the embolized lesion, and the 5F C2 catheter was followed up. Angiography confirmed that the distal outflow tract was acceptable. A 6F catheter was selected to the embolization site of the left renal artery, and 200,000 units of urokinase was given to thrombolysis for 15 min. Then, the thrombosis was repeatedly aspirated three times. The main trunk of the left renal artery was well developed and no residual stenosis was observed.Figure 2)。 Postoperatively, tirofiban 5 ml/h was continuously pumped through peripheral veins for 72 h; enoxaparin 6 000 IU q 12 h subcutaneously for 1 week; After overlapping with enoxaparin for 3 days, it was changed to oral warfarin, and the INR was controlled within the range of 2.0~3.0. One week after surgery, kidney color Doppler ultrasound showed no obvious abnormalities in kidney size and blood flow; Serum creatinine and urea nitrogen were normal; Renal dynamic radionuclide imaging showed that the glomerular filtration rate of left kidney and right kidney were 15.56 and 60.17 ml/min, respectively. Serum creatinine and urea nitrogen were normal 1 month after operation; Renal dynamic radionuclide imaging showed that the glomerular filtration rate of left kidney and right kidney were 13.93 and 61.37 ml/min, respectively.

The patient, female, 47 years old, was admitted to the hospital on 25 November 2014 due to lower limb weakness with general pain for 3 years. The patient had visited the doctor many times and in many places before, and no specific reason was found. The patient's abdominal color in the outer hospital 2 years ago: double kidney stones; Lung CT: nodular shadow of anterior mediastinal thymus area; Calcium 2.48 mmol/L, alkaline phosphatase (ALP) 209 U/L. Eighteen months ago, the rheumatism and autoimmunity related tests were negative, ALP 513 U/L, HLA-B27 negative. Osteocalcin 6 months ago: 68.67 ng/ml (14-42), PTH 498.6 pg/ml (15-65), 25-hydroxyvitamin D 4.0 ng/ml, calcium 2.58 mmol/L, ionized calcium 1.23 mmol/L (1.10-1.30), bone mineral density T-6.5. Parathyroid examination 16 months ago^99mTc-MIBI (Figure 1): There were no abnormal increased radioactivity areas in the neck, post-sternum and other areas of the whole body. 24 h Urinary calcium normal. PTH 887.4 pg/ml, calcium 2.54 mmol/L and ALP 384 IU/L in outer hospital 5 months ago;^99mTc-MIBI SPECT/CT: Soft tissue density with increased radioactivity distribution in the right anterior of the ascending aorta in the mediastinum (Figure 2)。 Pulmonary CT: nodular shadow in the anterior mediastinal thymic region. Calcium 2.67 mmol/L, ALP 217 U/L, PTH 603.6 pg/ml. Thoracoscopic thymic and mediastinal mass resection was performed with a definite diagnosis of ectopic parathyroid tumor. Pathology: parathyroid adenoma. Calcium on postoperative day 1 1.86 mmol/L, PTH 182.9 pg/ml. The ALP was 205 U/L and the calcium was 2.05 mmol/L at 2 years postoperatively, after which the patient was lost to follow-up.

A 27-year-old male was admitted with epigastric pain for 14 h. The patient had sudden upper abdominal pain without obvious trigger 14 h ago, which continued to worsen, accompanied by back radiation, nausea and vomiting several times, all of which were stomach contents. Upper abdominal CT examination in the local hospital showed acute pancreatitis (AP), so he was transferred to the pancreatic center for further treatment. The patient was diagnosed with fused reticular papilloma at the Institute of Dermatology, Chinese Academy of Medical Sciences 2 months ago. He has been treated with isotretinoin (10 mg bid) orally for nearly 2 months, and the rash improved significantly after treatment. Physical examination six months ago showed no history of diabetes and hyperlipidemia. Physical examination: Slightly swollen abdomen, tenderness in the middle and upper abdomen, obvious on the left side. Dermatological examination: A large area of pale brown maculopapular rash intertwined into a network can be seen on the chest and back. The color of the papules at the edge of the lesion is slightly lighter, and the desquamation is not obvious (Figure 1)。 Blood routine: white blood cells 29.56×10⁹/L, the neutrophil ratio was 91.7%. Blood amylase 1 243.50 IU/L, urinary amylase 1 0726 U/L, blood lipase 1 135 U/L. Albumin 35.2 g/L, ALT 52.0 U/L, AST 42.1 U/L, γ-glutamyl transpeptidase 79.4 U/L, triglycerides 4.73 mmol/L, cholesterol 4.3 mmol/L. Procalcitonin 10.13 ng/ml, CRP>90 mg/L. IgG4 is in the normal range. Abdominal B-ultrasound: the pancreas is full in shape, with a slightly lower echo, considering the possibility of pancreatitis and fatty liver. Abdominal CT after admission showed AP (Figure 2)。 MRCP: There were no obvious abnormalities in intrahepatic and extrahepatic bile ducts. It is considered that this AP episode was caused by isotretinoin. The isotretinoin was discontinued and the patient was treated according to AP routine. The patient recovered and was discharged one week later.

A 61-year-old male was admitted to the hospital for "30 months after radical gastrectomy, gastroscopy revealed a well-differentiated adenocarcinoma of the residual gastric cardia". Physical examination: No positive signs. Total laparoscopic radical resection of residual gastric carcinoma was performed, and the esophagojejunal anastomosis was lateral anastomosis during the operation. Postoperative pathological report: (residual gastric) moderately differentiated adenocarcinoma. The patient resumed intestinal ventilation on the 5th postoperative day, but was accompanied by fever and increased peripheral blood white blood cell count. On the 7th postoperative day, trans-gastrointestinal X-ray revealed 2 fistulas and anastomotic stenosis in the esophagojejunal anastomosis (FIG. 1A), then placed a Leigh drainage tube in the sinus tract formed by the original drainage tube with the assistance of X-rays (FIG. 1B) was rinsed and sucked under negative pressure. Enteral nutrition support was performed through a spiral nasogastric tube with adequate irrigation and drainage (Figure 1C)。 After 1 month of treatment, one fistula healed well, but one fistula healed poorly (FIG. 2A)。 A mushroom-shaped fully covered self-expanding esophageal stent with diameters and lengths of 16 mm and 60 mm, respectively, was placed in the esophagojejunal anastomosis to occlude the unhealed fistula (Figure 2B)。 The drainage fluid became clear immediately after operation. On the 7th day of placement, because the covered stent moved to the distal end of the anastomosis, the position of the stent was adjusted once, and a small amount of drinking water and liquid diet were resumed in the later stage of placement. After 28 days, the digestive tract X-ray was re-examined, the fistula had healed, and the stent was removed (Figure 2C)。

A 26-year-old woman was admitted to the hospital with "gastric fundus mass for 1 week". He has a history of pulmonary tuberculosis for 4 months and is currently treated with isoniazid, rifampicin, ethambutol and pyrazinamide for antituberculosis. CT examination 1 week ago showed that soft tissue density nodules with a diameter of 2.2 cm were seen on the fundus of the stomach, with clear borders. Gastroscopy showed a bulge about 3 cm ×2.5 cm in size on the fundus of the stomach, and a deep ulcer about 0.6 cm ×0.8 cm in size in the center, covered with white coating at the bottom, and congestion and edema in the peripheral mucosa (Figure 1)。 Ultrasonic gastroscopy showed that the lesion was located in the muscularis propria, showing mixed echoic changes with hypoechoic predominance, and the boundary with the submucosa was not clear (Figure 2)。 Histopathological examination under gastroscopy showed granulomatous inflammation of mucosal tissue (fundus). An exploratory laparotomy was performed. During the operation, an ulcer lesion near the cardia of the gastric fundus was seen. The ulcer lesion was compressed inward, and white pus overflowed. Part of the necrotic material from extragastric lesions was taken and sent to frozen sections. Pathological examination showed that the fibrous connective tissue (fundus) was chronically granulomatous inflammation, with large necrosis and langhans giant cells. Necrotic tissue removal and catheter drainage in the lesion area were performed concurrently. Pathological examination showed chronic granulomatous inflammation of fibrous connective tissue with caseous necrosis and langhans giant cells, acid-resistant staining (-) (Figure 3)。 Combined with the medical history, support the diagnosis of fundus tuberculosis and continue the anti-tuberculosis treatment. One month after the operation, gastroscopy showed a 0.4 cm ×0.5 cm depression in the posterior wall of the gastric fundus, with redness in the center and collection of the peripheral mucosa. After the patient was treated with anti-tuberculosis, the ulcer of gastric fundus gradually healed.

infected pancreatic necrosis (IPN) is the most common local complication of severe acute pancreatitis (SAP), and it is also an important cause of death in the later stage of SAP^[1,2,3]。 Since Freeny et al.^[4]Since percutaneous catheter drainage was first reported in 1998, a series of minimally invasive techniques have sprung up. The evolution and progress of this series of techniques are reviewed.

autoimmune pancreatitis (AIP) is a special type of pancreatitis mediated by autoimmunity, with obstructive jaundice and abdominal discomfort as the main clinical manifestations. According to the pathological characteristics, AIP is divided into two types. Type 1 AIP: Lymphoplasma cell sclerosing pancreatitis is characterized by immunoglobulin G4 (IgG4) plasma cell infiltration with periductal fibrosis. In fact, it is a local manifestation of IgG4-related diseases in the pancreas. Besides pancreatic involvement, it can also involve bile duct, lacrimal gland, salivary gland, retroperitoneum, kidney, lung, etc. A large number of lymphocytes, plasma cells and IgG4 (+) cells infiltrate in the affected organs, and it responds well to steroid therapy^[1]。 Type 2 AIP: Idiopathic ductal central pancreatitis is characterized by neutrophil epithelial injury without IgG4 (+) lymphocyte infiltration and is closely related to inflammatory bowel disease^[2]。 Type 1 AIP accounts for the vast majority of Asian AIP patients, and type 2 is relatively rare. This article mainly focuses on type 1 AIP. Clinically, AIP, especially in patients with pancreatic space occupying and painless obstructive jaundice, and localized pancreatic cancer have many similarities in clinical manifestations, serology and imaging, and clinical differentiation is difficult; In addition, AlP is rare, and clinicians often lack attention. It is reported in the literature that nearly 1/3 of AIP patients are misdiagnosed as pancreatic cancer and then undergo pancreatectomy^[3]。 This paper introduces the diagnostic process of type 1 AIP, summarizes the key points of its differential diagnosis from pancreatic cancer, and briefly introduces its treatment and outcome, so as to make clinicians know about AIP and improve the diagnostic accuracy and treatment effect of AlP.

With the aging of China's population and the change of dietary structure, the incidence of peripheral vascular disease has increased sharply. Among the existing hypertensive patients in China, the number of patients with peripheral vascular disease is about 8 million. Among the about 113.9 million Chinese diabetic patients, the number of patients with peripheral arterial disease is more than 20 million^[1]。 Lower extremity arterial ischemic disease accounts for more than 40% of all peripheral vascular diseases, among which femoropopliteal arteriosclerosis obliterans has the highest incidence, which affects the quality of life and even life span of patients. Its treatment has also become an important challenge for clinicians^[2]。 In recent years, endovascular interventional therapy has gradually become the preferred treatment for peripheral vascular diseases with the advantages of less trauma and fast recovery. Intra-arterial stent implantation is one of the main methods for the treatment of arteriosclerotic occlusive disease. The problem of insufficient blood supply to the distal tissues of blood vessels is solved by implanting stents in the stenosis site. However, there are many problems with permanent stents. With the development of material technology, peripheral vascular drug-coated bioabsorbable stents have also been developed, and their development progress is summarized as follows.

Patient, male, 55 years old, found HBsAg positive 20 years ago, hepatitis B five items: HBsAg (+), anti-HBe (+), anti-HBc (+), liver function was normal at that time. Ten years ago, he was diagnosed with abnormal liver function, ALT 270 U/L, and was hospitalized in a local hospital. After more than 20 days, his liver function returned to normal. Later, he did not re-check his liver function because he had no discomfort symptoms. He developed liver discomfort 2 months ago, and was confirmed by B-ultrasound and CT as primary right lobe liver cancer. He underwent local liver cancer resection. Two weeks after operation, the patient developed sclera yellowing, urine yellowing, urine tea-like, and was admitted to the local hospital for 1 week after aggravation. Liver function: albumin 33.6 g/L, globulin 39.8 g/L, AST 97 U/L, ALT 78 U/L, total bilirubin 50.6 μ mol/L, direct bilirubin 11.7 μ mol/L, γ-GT 105 U/L, ALP 171 U/L, given 30 ml of Ganlixin and 10 ml of Shuganning to protect liver and reduce enzyme for 1 week, the patient's symptoms were not relieved, and he showed loss of appetite, nausea, yellow urine and yellow scleral staining. For further diagnosis and treatment, he went to our hospital and was admitted to our department as "postoperative primary liver cancer". Previous diabetes for 5 years without regular treatment; The history of drinking was 20 years, ranging from 2 to 6 taels each time, more frequently, and abstaining from drinking for 2 months. Physical examination: face with chronic liver disease, liver palm and spider nevus, moderate yellowing of skin sclera, suspected positive ascites sign, and no edema in both lower limbs. Blood routine: white blood cells 2.8×10⁹/L, neutrophil ratio 53%, hemoglobin 106.8 g/L, platelets 74×10⁹/L; Normal urine routine; Four items of hemagglutination showed: PTA 57.38%; Blood ammonia: 45 μ mol/L; Biochemistry: AST 297 U/L, ALT 136 U/L, total bilirubin 98.7 μ mol/L, direct bilirubin 33.7 μ mol/L. HBsAg (+), anti-HBe (+), anti-HBc (+), the remainder negative; HBV DNA 7.46×10⁴IU/ml; AFP 315 ng/ml, Yu normal; CT: Liver parenchyma was damaged, gallbladder polyps, and splenomegaly, which was consistent with the postoperative manifestations of liver cancer. No obvious dilatation of intrahepatic and extrahepatic bile ducts was observed. 200 ml of monoammonium glycyrrhizinate cysteine sodium chloride injection was given once a day, combined with adenosylmethionine and antiviral treatment, as well as liver protection, enzyme reduction, yellowing reduction and symptomatic treatment. After 1 week of treatment, the patient's loss of appetite improved. After 2 weeks of treatment, the patient complained of decreased urine yellowness and increased food intake. The biochemistry was reviewed: AST 147 U/L, ALT 135 U/L, total bilirubin 64.9 μ mol/L, direct bilirubin 25.1 μ mol/L, γ-GT 129 U/L, ALP 121 U/L, PTA 60.3%; The same regimen was continued for 4 weeks, and the HBV DNA was re-examined at 8.37×10²IU/ml; PTA 65.2%; Biochemistry: albumin 36.4 g/L, globulin 34.3 g/L, AST 63 U/L, ALT 54 U/L, total bilirubin 41.2 μ mol/L, direct bilirubin 15.3 μ mol/L, γ-GT 74 U/L, ALP 101 U/L, AFP 218 ng/ml; The patient's liver function improved significantly. Continued treatment with the above drugs for 10 days, PTA reexamination was 71.3%; Biochemistry: albumin 35.4 g/L, globulin 28.9 g/L, AST 35 U/L, ALT 44 U/L, total bilirubin 29.2 μ mol/L, direct bilirubin 10.3 μ mol/L, γ-GT 66 U/L, ALP 98 U/L, no discomfort symptoms, fluid infusion was stopped, the patient was discharged from hospital for a total of 38 days of treatment. Two weeks after discharge, PTA was reexamined 73.7%; Biochemistry: albumin 36.3 g/L, globulin 29.9 g/L, AST 27 U/L, ALT 35 U/L, total bilirubin 26.3 μ mol/L, direct bilirubin 9.4 μ mol/L, HBV DNA<20 IU/ml; AFP 139 ng/ml; The patient's condition was stable and there was no rebound.