2018年 · 第33卷第10期

The literature reported that the complication rate of radical gastrectomy in Asia was 20% and the mortality rate was 1%, including local complications related to surgical procedures and systemic complications caused by tumor invasion and underlying diseases^[1]Among them, the more serious complications failed after conservative treatment require surgical intervention^[2]。 In this study, 17 patients undergoing unplanned secondary surgery after laparoscopic radical gastrectomy were retrospectively analyzed. The relevant perioperative data were summarized, and the related influencing factors and prevention and treatment strategies were discussed.

Medical practice at home and abroad proves that timely and effective communication between doctors, nurses and patients is the key link to ensure medical safety^[1]。 In this study, the concept of enhanced recovery after surgery (ERAS) was implemented in the perioperative period of gastric cancer patients, which significantly accelerated the recovery speed of patients with good results. The results are reported below.

transanal endoscopic microsurgery (TEM) has obvious advantages over traditional open surgery. The TEM revealed clearly and ensured sufficient margin distance, which not only allowed full-thickness resection, but also partial mesorectal tissue resection. At present, many scholars have reported the experience of applying it to the treatment of T1 and T2 rectal cancer without lymphatic metastasis, but there is still some controversy. This study analyzed the treatment of 30 patients with rectal cancer with local resection by TEM, and achieved satisfactory results, which are reported below.

In this study, the clinical data of 128 patients with acute appendicitis and periappendicular abscess were retrospectively analyzed, and the clinical data, some inflammatory indexes and plasma fibrinogen results of patients were compared. In order to understand the risk factors of appendix adhesion and periappendicular abscess formation, and to provide preliminary basis for surgical evaluation of acute appendicitis patients.

neuroendocrine neoplasm (NEN) is a group of tumors originating from the diffuse endocrine system, originating from stem cells and having neuroendocrine markers, capable of producing bioactive amines and/or polypeptide hormones, among which gastric neuroendocrine tumors (g-NEN) are relatively rare in the whole gastrointestinal NEN. This study retrospectively analyzed the clinical data of 6 patients with g-NEN, which are reported below.

Traumatic splenic rupture is the most common closed abdominal injury, accounting for about 25% of closed abdominal trauma^[1]。 2006 Dissanaike et al.^[2]The first case of emergency laparoscopic splenectomy was reported. In recent years, with the development of laparoscopic technique, the surgical approach tends to be diversified, but there is a lack of uniform operation norms and procedures^[3]。 We have completed several cases of emergency laparoscopic splenectomy or partial splenectomy and have accumulated some clinical experience. In order to further standardize laparoscopic splenectomy or partial splenectomy to better guide clinical treatment, programmed laparoscopic splenectomy or partial splenectomy is proposed for the diagnosis and treatment of traumatic splenic rupture, and good results have been achieved. The summary report is as follows.

laparoscopic cholecystectomy (LC), as a standard procedure for the treatment of benign diseases of the gallbladder, has been popularized in hospitals at all levels. According to the concept of enhanced recovery after surgery (ERAS), LC should not only promote early recovery and shorten hospital stay, but also reduce the incidence of postoperative complications and readmission rate. Expert Consensus of Accelerating Rehabilitation Surgery Combined with Biliary Tract Surgery (2016 Edition)^[1]We diagnosed and treated 419 cases of benign diseases of the gallbladder, performed perioperative management by ERAS procedure of biliary tract surgery, treated the Calot triangle by critical view of safety (CVS) technique, and completed laparoscopic cholecystectomy with satisfactory results, which are reported below.

Placenta previa occurring in another pregnancy after cesarean section is called dangerous placenta previa, often combined with placental implantation, which can lead to obstetric hemorrhage. With the development of interventional radiology, the abdominal aortic balloon is used to reduce intraoperative bleeding, and good clinical results have been achieved^[1]。 Since June 2013, balloon implantation of abdominal aorta was carried out in our hospital. Up to December 2017, a total of 721 cases were placed with balloons, of which 22 cases developed right iliofemoral artery thrombosis. We review the clinical data of our patients to explore how to reduce the incidence of thrombosis, which is now reported below.

From 2012 to 2017, the author treated a total of 13 children with intestinal obstruction caused by accidentally eating "water-fed balls", and all of them were cured and discharged after surgical treatment. The experience of diagnosis and treatment is summarized as follows.

A 45-year-old female suffered from dull upper abdominal pain and discomfort without obvious trigger 6 months ago, which was intermittent and had nothing to do with eating and posture. There was no radiating pain in the lower back, sometimes acid reflux and belching. CT examination showed diffuse thickening of the gastric wall in the gastric antrum to 3.7 cm (Figure 1)。 Gastroscopy showed irregular bulge of the gastric antrum and ulcer formation on the mucosal surface. The pathological diagnosis of biopsy was inflammation with dysplasia of gastric mucosal epithelium. Gastric tumor resection, distal part of the stomach and part of the duodenum were removed, and the surrounding lymph nodes were dissected. Gross pathological examination showed a 5 cm ×4 cm bulge on the large curved side of the gastric antrum, rough mucosal surface, stomach wall thickness of 1~4 cm, no obvious boundary, and shallow ulcer formation on the surface. The cut surface was gray-white, brittle, delicate and edematous. A polypoid bulge of 1.2 cm was observed at the proximal end of the duodenum broken (Figure 2), the cut surface is off-white, and the texture is slightly tough. Under light microscope, the tumor tissue was diffusely distributed in the stomach wall, and was composed of fibroblasts and fibroblasts (Figure 3), and focal eosinophilic collagen fibers, various inflammatory cells and histiocytes infiltrate the interstitium. The pathological diagnosis was duodenal adenoma (Figure 4) and inflammatory myofibroblastoma of the gastric antrum, with low-to high-grade intraepithelial neoplasia of the surrounding mucosal gland epithelium and reactive hyperplasia of the lymph nodes of the gastric antrum.

A 2-year-old female developed abdominal pain and distension without obvious trigger 3 days ago, abdominal pain did not relieve due to change of body position, nausea and vomiting of stomach contents, accompanied by stopping defecation and exhaustion from the anus, fever, and the highest body temperature was 39.6 ℃. Abdominal CT showed: huge irregular abnormal density in the abdominal cavity, the density was relatively uniform, and multiple strip separations were seen in the abdominal cavity (Figure 1), the boundary is clear, and the adjacent organs are obviously compressed. Routine blood tests: neutrophils were elevated. Radical tumor resection was performed. Gross examination: 1 irregular mass with a total volume of 28 cm ×18 cm ×6 cm, with a smooth surface, cystic multilocular section, spongiform, containing pale yellow liquid, and a wall thickness of 0.1~0.3 cm. Light microscope: The diseased tissue is composed of a large number of lumens of different sizes and thicknesses, lined with a single layer of flat epithelial cells without anomaly, containing a large amount of lymphatic fluid, and the wall of the tube is smooth muscle and adipose tissue (Figure 2), there is multifocal lymphocyte infiltration in the interstitium, and some blood vessels are dilated and congested. Immunohistochemical staining: D2-40 (+), CK (+), Vimentin (+), CD34 (vascular +), SMA (smooth muscle +), CR (-), MC (-), S-100 (-), Ki-67 (<5%＋)。 Pathological diagnosis: cavernous lymphangioma of the greater omentum.

A 19-year-old male was admitted to the hospital for "5 years of discovery of a painless perianal mass". Perianal ultrasound examination before admission showed: substantial perianal space occupation and abundant internal blood flow, and the diagnosis was hemangioma. Physical examination: A multi-nodular mass was palpable in the right ischial anal fossa, which was tough, elastic and smooth on the surface (Figure 1)。 Digital rectal examination was normal. Pelvic MRI showed that the right buttock showed an irregular mass about 4.4 cm ×3.2 cm in size subcutaneously, with low signal in T1WI and iso-and high mixed signal in T2WI, with obvious enhancement, and was diagnosed as hemangioma (Figure 2)。 Local resection of the tumor was performed. Pathological examination showed one mass of 4.0 cm ×2.5 cm ×1.5 cm, with 9 nodular tissues, 0.3~0.8 cm in diameter, and the section surface was gray-yellow. Under light microscope, the tumor was mainly in dense area (Antoni A), and rarely in loose area (Antoni B). The tumor cells were arrayed in cluster and palisade shape, and the nucleus was long fusiform, showing Verocay bodies (Figure 3)。 Nuclear abnormalities and mitotic images were not observed. The tissue around the nodule is fibrous connective tissue. Immunohistochemical staining showed that the tumor cells were negative for Vimentin (+), S100 (+), CD56 (+), Ki-67 (+3%), Desmin, SMA, CD34 and CD68. Diagnosis: plexiform schwannoma (PS).

The patient, a 30-year-old female, was admitted to hospital for "repeated upper abdominal discomfort with melena for more than 1 month". The patient had undergone "right scapular hemangioma surgery" when he was 8 years old, and the hemangioma was still gradually increasing after operation. Physical examination: severe anemia appearance, right scapula, right axilla and upper arm saw vascular distension, multiple papillary protrusions, soft, compressible (Figure 1)。 Routine blood tests : Hb 32 g/L, PLT 75×10¹²/L. Gastroscopy showed that the fundus fornix was 1.5 cm ×1.5 cm bulge, bayberry-shaped, with clear borders. Colonoscopy revealed a large amount of dark red blood in the whole colon cavity. The angiography of celiac artery, superior and inferior mesenteric artery showed no vascular rich lesions. Exploratory laparotomy was performed, and multiple grape-shaped or coral-shaped hemangiomas near the external lobe of the left liver and the gallbladder bed of the right liver were found during the operation (Figure 2), multiple gray-white cavernous hemangioma changes in the spleen, one hemangioma with a diameter of 1.5 cm in the fundus of the stomach, and one hemangioma with a diameter of 6 mm at the end of the ileum 15 cm from the ileocecal valve. Local resection of gastric hemangioma and ileal hemangioma; The hemangioma near the left external lobe of the liver and the gallbladder bed of the right liver was locally sutured, and 6 ml of absolute ethanol was injected locally. Postoperative pathological report: (stomach, ileum, liver) capillary hemangioma changes, consistent with blue rubber bullous nevus syndrome. Reexamination of Hb 67 g/L showed that melena was still defecated. In March 2004, he was readmitted to the hospital because of "intermittent blood in the stool, which was aggravated for half a month". Routine blood test: Hb 45 g/L, considering recurrence of blue rubber bullous nevus syndrome. Exploratory laparotomy revealed old intestinal hemorrhage 50 cm away from Trigger's ligament, and 11 hemangiomas with a diameter of about 2 to 4 cm could be palpable under the mucosa of jejunum and ileum, which were completely resected along the tumor body. A hemangioma of about 3 cm ×3.5 cm was seen retroperitoneally in front of the inferior vena cava, and the bleeding was completely stopped by absolute ethanol injection. Pathological report: Multiple submucosal hemangiomatous changes in the small intestine, combined with clinical manifestations consistent with blue rubber bullous nevus syndrome. Four months after surgery, he was readmitted to hospital for "melena". Physical examination: anemia appearance, right shoulder hemangioma enlarged and increased compared with before. Routine blood test: Hb 29.5 g/L. Laparotomy was performed, and a blue blood nevus about 4.3 cm ×4.5 cm in size was found in the ileum 20 cm away from the ileocecal region. After ileectomy, end-to-end anastomosis was performed. The pathological examination was consistent with the intestinal lesions of the blue rubber bullous nevus syndrome. The patient was followed up in July 2017. The patient did not complain of special discomfort and took propranolol intermittently after surgery. Physical examination: There were no signs of anemia, and multiple hemangiomas were seen on the back (Figure 3)。

A 50-year-old female was admitted to the hospital for 1 week after abdominal ultrasound revealed that the liver occupied space. The patient had no abdominal pain, abdominal distension, nausea, vomiting and other discomfort. Physical examination at admission showed that there were no obvious abnormal signs of heart, lung and abdomen. Hepatitis B surface antigen positive AFP: 2.2 ng/ml, CA19-9: 6.6 U/ml, CEA: 1.1 nmol/ml, ALB: 43 g/L, ALT: 12 U/L, AST: 6 U/L, TBiL: 16 μ mol/L, DBiL: 8 μ mol/L; IBiL: 1.9 μ mol/L. CT showed a huge uneven and slightly lower density mass shadow in the right liver, with obvious uneven enhancement in the enhanced arterial phase and decline in the venous phase. Considering the possibility of liver malignant tumor, please combine it with clinical (Figure 1,Figure 2,Figure 3)。 MRI suggests that there is a huge space-occupying lesion of the right liver, blood supply to the hepatic artery, obvious uneven enhancement of the enhanced artery phase, and decrease in the venous phase. Consider the possibility of primary liver cancer, please combine it with clinical practice. Considering that CT and MRI showed positive hepatitis B surface antigen, although AFP and CA19-9 were in the normal range, the diagnosis of primary liver cancer was considered after discussion. Liver cancer resection was performed under general anesthesia. It was found that it was located in the lower segment of the posterior lobe of the right liver, adhered tightly to the transverse colon, invaded the liver flexure of the colon, and the mass had no obvious boundary and was tough in texture. It looked like the liver lesion was liver cancer with colon invasion. It was prepared to perform resection of the posterior lobe of the right liver together with the mass and the right hemicolon. However, considering that there was no pathological evidence of the mass, the mass was carefully incised, and the wound seemed to be fish-like. A small part of the tissue was taken and frozen. Freezing during the operation suggested benign lesions, but no evidence of malignant tumor was found. In order to prevent missed diagnosis, two more freezing sessions were performed, but no malignant tumor lesions were found. Then it was decided to perform only the right posterior lobe of the liver together with the mass resection.

Due to the objective reasons such as the inobvious clinical symptoms of early gastric cancer, the proportion of early gastric cancer in the diagnosed gastric cancer is low at present, and most patients who come to hospital have developed lymph node metastasis. Foreign studies have found that 65% of gastric cancers in the United States are stages T3 and T4, and most patients have lymph node metastasis at the time of consultation. Even if they are diagnosed with early gastric cancer, the lymph node metastasis rate reaches 5.7% ~29.0%, and lymph node metastasis is one of the important factors affecting the prognosis of gastric cancer patients^[1]。 According to the treatment guidelines for gastric cancer at home and abroad, lymph node metastasis is very important for the selection of surgical procedure (mainly the range of lymph node dissection) and whether adjuvant chemotherapy is needed (mainly for T1 patients).

perivascular adipose tissue (PVAT) refers to the adipose tissue surrounding a vascular structure. PVAT has long been considered merely a type of adipose tissue that protects and supports blood vessels^[1]。 However, recent studies have shown that PVAT can also secrete a large number of active cytokines, chemokines and hormones, such as leptin, adiponectin, resistin and vasoactive substances, so as to exert anti-inflammatory effects and inhibit the development of atherosclerosis^[2]。 Under pathological conditions, such as obesity, infection and other factors can lead to abnormal function of PVAT. PVAT releases inflammatory factors to promote inflammatory response and cause atherosclerosis^[3]。 It can be seen that PVAT is a functional vascular tissue layer, which plays different roles under physiological and pathological conditions.

ulcerative colitis (UC) is a diffuse chronic non-specific inflammatory lesion that occurs in the colorectal mucosa and submucosa. Its clinical characteristics are persistent or recurrent mucus, pus and bloody stool, abdominal pain, tenesmus and so on, accompanied by systemic symptoms of varying degrees. At present, there are three recognized pathways of colorectal cancer: adenoma-adenocarcinoma pathway, De novo pathway and inflammation-carcinogenesis pathway. colitis-associated cancer (CAC) is a serious complication of UC, and its carcinogenesis pattern occurs through inflammation-carcinogenesis pathway. Epidemiological data suggest that disturbances of intestinal flora can lead to the occurrence of many diseases. Some studies believe that intestinal flora disorder plays a central role in the pathogenesis of inflammatory bowel disease (IBD), which mainly causes disease by inducing abnormal immune response in intestinal mucosa; In addition, some studies have confirmed that some intestinal bacteria play an important role in colorectal cancer^[1]。 In recent years, the influence of intestinal flora changes on CAC has also become a hot research topic in this field. In this paper, the relationship between UC carcinogenesis and intestinal flora is reviewed.

The patient was an elderly male, 66 years old. He was admitted to hospital because of "liver space-occupying lesions found in physical examination for 2 years". Percutaneous hepatic arteriography and hepatic artery embolization were performed 2 years ago. Physical examination: There was no yellowing stain on the skin of the whole body, liver palms were visible on both hands, the abdomen was flat, and the abdominal wall was soft without tenderness, rebound pain and mass. The liver, spleen and gallbladder were not palpable under the costs. Negative for Moufe's sign and negative for mobile voicing. The intestinal sound was normal, 4 times/min, and no water vibration sound and vascular murmur were heard. Liver function was examined after admission: AST 29 U/L, ALT 33 U/L, hepatitis B major triple positive, alpha-fetoprotein 25.46 ng/ml, blood routine and coagulation did not show obvious abnormalities. Abdominal CT plain scan + enhancement: multiple nodules in liver S4, 5, 6 and 8, considering the possibility of liver cancer. The previous patient underwent MR of the upper abdomen on May 24, 2016: multiple lesions in the right lobe of the liver, considering the possibility of multinodular liver cancer, cirrhosis, multiple small cysts in the left lobe and S7 segment of the liver, and mild chronic cholecystitis. Multiple cysts in both kidneys. After discussion in our department, the patient had been hospitalized for "liver occupation" in the past. At that time, no pathology was taken, and the nature of the tumor could not be clarified. After admission to our department, relevant examinations were performed and combined with the imaging manifestations and clinical symptoms of the patient, considering the possibility of hepatocellular carcinoma, the patient's cardiopulmonary function was good, and relevant contraindications were excluded. Ultrasound-guided fine needle puncture was performed to improve the pathology and radiofrequency ablation. On the first day after surgery, the patient was given symptomatic treatment such as glutathione injection (3.6 g/d) to protect the liver and entecavir (0.5 mg/d) to improve immunity. Blood biochemistry and liver function were monitored, and the changes of disease were paid close attention to. On the second postoperative day, ALT 586 U/L and AST 381 U/L were added with monoammonium glycyrrhizinate cysteine sodium chloride injection (200 ml/d) intravenously, and liver function was closely monitored. ALT 322 U/L and AST 90 U/L on postoperative day 3, ALT 167 U/L and AST 41 U/L on postoperative day 5. After active treatment, the patient's liver function recovered well and was successfully discharged on the 5th day after operation. It is recommended that the liver function be re-examined in outpatient clinic after 1 week.