2018年 · 第33卷第11期

For the surgical resection of hepatocellular carcinoma (hereinafter referred to as hepatocellular carcinoma), especially open liver resection, whether to choose anatomical or non-anatomical liver resection is still controversial. The author believes that the choice of anatomical or non-anatomical hepatectomy needs comprehensive analysis based on the background of liver disease, lesion site, initial or recurrent tumor, tumor size, classification, stage, patient's age, and technical ability of the operator. The two surgical methods have their own advantages and cannot be replaced by each other.

follicular dendritic cell sarcoma (FDCS) is a relatively rare low-grade malignant tumor, which tends to occur in the cervical and axillary lymph nodes, but can also occur in extranodal organs such as liver, spleen, stomach and colon. Among FDCS, there is a morphological manifestation of inflammatory pseudotumor-like tumor, which is different from other traditional FDCS, Cheuk et al.^[1]It was defined as a new type in 2001, namely, inflammatory pseudotumor-like follicular dendritic cell tumor (IPT-like FDCT). It is a very rare tumor that occurs in the liver and spleen and is associated with Epsterin-Bbrr virus infection^[2]。 This paper reports a case of IPT-like FDCT in the spleen, and analyzes its clinical features in combination with domestic and foreign literatures.

hepatic portal venous gas (HPVG), an ominous clinical marker, was identified in 1955 in neonatal patients with necrotizing enterocolitis^[1]。 HPVG is not an independent disease, but a symptom associated with multiple abdominal diseases, which are clinically rare and have a high mortality rate, and most of them require timely surgical intervention^[2]。 A patient with abdominal compartment syndrome and portal pneumatosis caused by car accident trauma was admitted to Wenling First People's Hospital, and he recovered after active abdominal volume reduction surgery. The report is now as follows.

Case 1: A 15-year-old male was admitted for "15 years of finding a sacrococcygeal mass". The patient had a mass in the sacrococcygeal region since childhood, about 3 cm ×3 cm in size, no local pain, no abnormal sensation in the nerve deformation area, no ulceration, redness and swelling, etc. The mass increases gradually with the age, and it has increased rapidly in the past six months. Physical examination: A mass can be seen about 3 cm away from the anus at 12 o'clock in the chest and knee lying position, like a "tail" (Figure 1), about 6 cm ×2 cm in size, no redness, swelling, no tenderness, tough texture, and acceptable mobility. Color ultrasound examination: consider the possibility of lipoma. CT and MRI examination revealed: cystic-solid lesions in the caudal and anterior sacrococcygeal vertebrae, considering teratoma or epidermoid cyst. Combined laparoscopic abdominosacral approach was performed for sacrococcygeal teratoma resection. Intraoperatively, the tumor was located in the presacral space, about 8 cm ×6 cm in size, with jelly-like substances and hairs inside, and the tumor extended to the sacrococcygeal part to the body surface. Intact free intrapelvic tumor. The patient's body position was changed to prone position, and a circular incision was taken around the body surface mass, and then the free tumor was approached and merged with intraperitoneal operation, and the tumor was completely removed. When the specimen was cut open, it was found that there was hair inside. Postoperative pathological report: sacrococcygeal mature teratoma (Figure 2)。

The concept and path of enhanced recovery after surgery (ERAS) refers to multi-disciplinary cooperation on the basis of evidence-based medicine, and through optimizing traditional perioperative management methods, it can achieve the purpose of reducing stress response, reducing postoperative complications, shortening hospital stay and saving medical expenses. The implementation of ERAS pathway for pancreaticoduodenectomy is controversial due to objective factors such as poor preoperative condition, complicated surgical procedure and high complication rate. Based on the diagnosis and treatment of a patient with pancreatic head cancer who underwent pancreaticoduodenectomy, this paper discusses the safety of ERAS in the perioperative management of pancreaticoduodenectomy.

Ginsenoside Rg 5 is a new type of ginsenoside isolated from ginseng in recent years, which has great potential in clinical application. In this study, we observed the effect of cisplatin combined with cisplatin on the growth of esophageal cancer cells through in vitro experiments, and explored its mechanism, so as to provide theoretical basis for the research and development of new drugs.

Preoperative imaging examination can basically accurately classify and grade hilar cholangiocarcinoma. However, no matter how advanced the imaging examination is, it is difficult to fully evaluate the real situation of hilar cholangiocarcinoma, especially Bismuth type III cholangiocarcinoma. There are often "accidental" findings during surgery, and if improper handling is often caused serious consequences. Two typical cases are reported as follows.

A 68-year-old male was admitted to hospital due to "colon cancer liver metastasis for 1 month". The patient underwent surgical resection for colon cancer 3 years ago. One month ago, abdominal CT showed multiple liver mass occupation, manifesting as "bull eye sign". CA199 was 82.4 U/ml and CEA was 109.8 ng/ml, both of which were increased. He was diagnosed as colon cancer liver metastasis and was treated with TACE. Intraoperative angiography of the celiac trunk and superior mesenteric artery (SMA) showed that the right/left hepatic artery originated from the hepatic proper artery and a vessel originating from the right colonic artery extended into the liver (Figure 1), and intrahepatic tumor staining was observed, and finally it was confirmed that this vessel was the accessory right hepatic artery originating from the right colonic artery. Microcatheter was used for superselection, and TACE treatment was successfully performed.

A 54-year-old male was admitted for 2 months due to abdominal distension and chest tightness. Physical examination: the skin and sclera of the whole body were yellowed, the abdomen was slightly swollen, varicose veins in the right lower abdominal wall, edema and varicose veins in both lower limbs. Color ultrasound: hypoechoic filling defect in the inferior vena cava, extent 10.3 cm ×2.4 cm. The middle hepatic vein was 0.6 cm wide and occluded in a cord shape; The left hepatic vein was unclear; The right hepatic vein was 0.8 cm wide and occluded at the opening; A small amount of ascites. Admission diagnosis: Budd-Chiari syndrome (obstruction of hepatic vein, inferior vena cava with thrombosis). Treatment course: A 5F pigtail catheter was sent to the posterior hepatic segment of the inferior vena cava, and angiography showed that the proximal end of the inferior vena cava was occluded (Figure 1), using a 6F AngioJet mechanical thrombectomy catheter, 100 ml of normal saline +100,000 U of urokinase were sprayed into the thrombus in the spray mode, and then repeatedly aspirated from the distal end to the proximal end of the hepatic vein and inferior vena cava in the aspiration mode for 280 s. The angiography showed that the thrombosis of the hepatic vein and inferior vena cava was significantly reduced compared with the previous (Figure 2)； Thrombolysis was carried out in the lower segment of the inferior vena cava by retaining a pigtail catheter, bolus injection of 10 ml of normal saline +100,000 U of urokinase every 6 hours, and subcutaneous injection of low molecular weight heparin sodium 4 000 U every 12 hours. The patient developed hemoglobinuria on the first day after operation, which improved after symptomatic treatment; On the 5th day, the reexamination and angiography showed that the thrombosis in the hepatic vein and inferior vena cava was reduced compared with the previous one. The 10 mm ×4 cm small balloon dilated the occlusion segment of the inferior vena cava. The angiography showed that the occlusion was partially opened, the blood flow was smooth, and there was still thrombosis in it. The pigtail catheter was kept to the posterior hepatic segment of the inferior vena cava to continue thrombolysis. On the 7th day of thrombolysis, reexamination showed unobstructed blood flow in the posterior hepatic segment of the inferior vena cava, severe stenosis, and a small number of filling defects were found locally. The stenotic segment of the inferior vena cava was dilated by a 26 mm ×4 cm large balloon, and the stenotic segment was obviously retracted by angiography, so a 30 mm ×70 mm stent (Shenyang Yongtong) was placed. Another reexamination showed unobstructed blood flow in the inferior vena cava. Warfarin was administered orally after discharge and maintained INR 2.0 to 3.0. By the 20th postoperative day, the patient lost 5 kg of body weight, and the edema of both lower limbs and the yellowing stain of skin and sclera disappeared. After 8 months, the color ultrasound was re-examined: the inferior vena cava stent was in good position and shape, and the internal blood flow was smooth. String-like occlusion of the middle hepatic vein; The distal end of the left hepatic vein was 0.3 cm wide, and the lumen and blood flow in the proximal segment of the heart were unclear; The right hepatic vein was 0.5 cm wide and the blood flow was unobstructed. CTV: Inferior vena cava blood flow is smooth, and the stent position and shape are good (Figure 3)。 The left and middle veins of the liver were unclear; Blood flow in right hepatic vein is unobstructed (Figure 4)。

The patient was a 46-year-old male. Abdominal pain 18 h, progressive aggravation. The patient experienced dull pain in the middle and upper abdomen without obvious trigger 18 h before admission, and persistent abdominal pain was aggravated with fever. Physical examination: moderate shock, suspected jaundice, mild tenderness in the upper abdomen, peritoneal irritation (-), percussion pain in the liver area, and normal intestinal sounds. Laboratory tests: Blood routine: WBC 5.28×10⁹/L, N 91.7%. Liver function : TBiL 24.5 μ mol/L. Abdominal ultrasound showed dilation of the left intrahepatic bile duct and suspected calculi in the lumen of the bile duct near the hilar. Preliminary diagnosis: infectious toxic shock; Acute severe cholangitis; Left intrahepatic bile duct lithiasis. After PTCD in the emergency department, he was admitted to ICU and was given symptomatic and supportive treatment such as Shupu deep anti-infection, volume expansion and anti-shock. The sedative was discontinued after 10 d, and the patient still did not recover consciousness after 8 h of discontinuation. Physical examination: GCS score 3. The bilateral pupils are equal in size and round, sensitive to light reflection, corneal reflex exists, no gaze, no spontaneous nystagmus, and symmetrical facial lines. The muscle tone of the limbs is not high, tendon reflex can be elicited, pathological reflex (-), meningeal irritation sign (-). CT of the head showed multiple lesions in the cortex-medulla junction area of bilateral cerebral hemispheres, showing slightly higher density shadows, and "acupressure" edema was seen in local lesions (Figure 1) without significant enhancement (Figure 2), considered as a brain abscess caused by sepsis in combination with medical history. The bacteria of blood and bile are cultured as Morgan morgans. Mannitol combined with meropenem + metronidazole + vancomycin combined with anti-infective treatment. After 2 days of treatment, the patient's condition improved rapidly, his consciousness gradually recovered, and the GCS score was 10 points. After combined exercise rehabilitation and acupuncture treatment, the limb activity gradually recovered, and the patient was clinically cured and discharged after 6 weeks. Six months later, the bilateral brain lesions were significantly improved when the head CT was re-examined.Figure 3)。

The patient was a 58-year-old male. In May 2017, a left neck mass was found and visited the stomatology department for 3 months. The mass size was 3 cm ×3 cm, with clear boundaries, mobility and soft texture. Previous medical history: Hepatitis B cirrhosis for 10 years. In September 2016, CT found multiple intrahepatic mass occupation, with a maximum diameter of 62 mm, suspected metastatic nodules in the peritoneal cavity and peritoneum, and serum alpha-fetoprotein (AFP) 4.0 μ g/L. Coarse needle biopsy under ultrasound was performed to diagnose hepatocellular carcinoma pathologically. radiofrequency ablation (RFA) and transcatherter arterial chemoembolization (TACE) were combined for 6 courses because of multiple mass occupation and suspected metastasis^[1]。 Ultrasonography of the left neck mass revealed benign adenoma of the parotid gland (pleomorphic adenoma or adenolymphoma) (Figure 1)。 Fine needle aspiration cytology (FNA) was performed, and the cytopathological examination showed that a large number of eosinophils were composed, with nested and adenoid structures, and the cells differentiated well. Combined with the medical history, it is suggested that metastatic hepatocellular carcinoma or parotid tumor may be possible. Excision of left parotid mass was performed in oral surgery.

Patient 1, a 9-year-old female, was admitted with the complaint of "intermittent abdominal pain for 1 month". Physical examination: The abdomen is flat and soft, and a mass of about 6 cm ×5 cm ×4 cm can be palpable in the left lower abdomen. It is movable, the surface is smooth, there is tenderness, and the bowel sounds are normal. Preoperative color Doppler ultrasound and CT showed a mass in the left lower abdomen and no splenic echo in the splenic fossa. Considering the wandering spleen with torsion, an emergency laparotomy was performed. It was found that the spleen was completely free, the splenic pedicle was about 25 cm long and located in the left lower abdomen. The splenic pedicle was torsed 360° without necrosis. Torsion reduction was performed. The lateral peritoneum was longitudinally incised on the lateral side of the left upper splenic fossa, and the lateral peritoneum was free and enlarged to the retroperitoneum to form a pouch. The peritoneum pouch was incised vertically from the incision to the middle, making the incision a "T" shape. The spleen is placed in the peritoneal pouch, the spleen pedicle passes through the incision to avoid the influence of blood supply by pulling the spleen pedicle, and the pouch is sutured to fix the spleen (Figure 1)。 The postoperative recovery was smooth. After 6 months follow-up, the spleen size and blood supply were normal, and it was located in the peritoneal sac (Figure 2)。

A 51-year-old female was admitted to the emergency department with sudden and persistent right upper abdominal pain for 6 h. Physical examination at admission: flat and soft abdomen, mild tenderness in the right upper abdomen, local muscle guard, no rebound pain, no abdominal mass, Murphy's sign (-), mobile voiced sound (-), and normal intestinal sound. The patient has a history of hypertension for more than 10 years, and he is usually treated with oral drugs, and his blood pressure can be controlled; Interventional surgery for cerebral aneurysm 2 years ago, long-term oral aspirin after surgery. Emergency abdominal CT: (1) gallbladder occupies space with bleeding, which may invade the right lobe of the liver; (2) gallbladder neck stones; (3) A small amount of peritoneal fluid accumulation with a little blood accumulation (Figure 1，Figure 2)。 Emergency ultrasound: There is a slightly hyperechoic area in the gallbladder, the boundary with the liver is unclear, and the change of body position is not obvious, suggesting that the gallbladder occupies space; Stones in the neck of the gallbladder. Admission blood test: red blood cells 4.19×10¹²/L, white blood cells 5.08×10⁹/L, C-reactive protein 12.83 mg/L, neutrophils 90.2%, hemoglobin 112 g/L. Considering that the condition is relatively stable, supportive treatment such as hemostasis, anti-infection, nutritional rehydration, etc. will be given, and the next treatment plan will be decided after complete examination. The patient had sudden palpitation with increased heart rate in the afternoon. Emergency blood test: red blood cells 2.77×10¹²/L, white blood cells 3.64×10⁹/L, C-reactive protein 133.96 mg/L, neutrophils 90.7%, hemoglobin 75 g/L, considering a progressive decrease in hemoglobin, suggesting active hemorrhage in the abdominal cavity. Immediately perform abdominal enhanced CT: (1) gallbladder rupture, accompanied by hemorrhage in the cyst, gallbladder fossa and abdominal cavity; (2) gallbladder neck stones (Figure 3)。 Laparoscopic exploration was performed in the emergency department. A large amount of blood clots and blood were found during the operation, with a volume of about 2 000 ml. The surface of the liver was smooth, no tumor was found, the gallbladder was slightly adhered to the omentum, the size of the gallbladder was about 9 cm ×4 cm ×3 cm, the gallbladder wall was congested and edema, and a rupture of about 1.5 cm in diameter was seen on the right side of the gallbladder body, accompanied by active bleeding. There was no obvious abnormality in the common bile duct, so laparoscopic cholecystectomy was decided. Intraoperative transfusion of 300 ml of red blood cell suspension and 6 units of plasma. Postoperative macroscopic examination specimens showed gallbladder wall thickness edema, obvious congestion, rupture in the body, and one stone in the neck, about 1.2 cm in size. Paraffin pathology suggests: chronic cholecystitis (Figure 4)。 Immunohistochemistry: glandular epithelium CK-p (+), CK8/18 (+), CEA (-), CGA (-), Syn (-), Vin (-).

A 38-year-old male was admitted to the hospital for 9 years because of a spleen mass found on physical examination. In the past 9 years, the patient did not have abdominal pain, unexplained fever and other discomfort. Multiple reexaminations found that the diameter of the spleen mass gradually increased, so he was admitted to the hospital for surgical treatment. Color ultrasound examination of liver, gallbladder, spleen and pancreas was performedFigure 1) suggested that the size of the spleen mass was about 11.8 cm ×7.2 cm, considering the possibility of hemangioma. In addition, there are multiple tumors in the liver, and the possibility of cyst is considered. Upper abdominal CT examination was performed (Figure 2) suggest that the spleen is enlarged, and multiple abnormal density shadows are seen within it, the maximum is about 11.2 cm ×7.8 cm, and the enhancement scan shows progressive mild uneven enhancement. In addition, similar multiple lesions were observed under the capsule of liver S7 and bilateral adrenal glands, which considered the possibility of hemangioma. Laparoscopic splenectomy, combined with postoperative pathology, was diagnosed as splenic sinus bank cell tumor (Figure 3，Figure 4)。 The results of pathological diagnosis and immunohistochemistry were as follows: (Spleen) Multiple lumen-like structures of different sizes were found in the spleen tissue submitted for examination, lined with a single layer of flat or nail-like epithelium, and some endothelial hyperplasia protruded into the lumen to form a papillary structure. There was no obvious abnormality in the cells. The lumen was filled with pale pink matter, and a small number of red blood cells were seen. Immunohistochemistry: Vimt (+), CD31 (+), CD34 (small +), CD8 (-), CD68 (partial +), CD21 (-), Ki-67 (~2% +).

A 43-year-old female was admitted to the hospital due to "intermittent abdominal pain and abdominal distension for more than 1 month, accompanied by cessation of exhaust and defecation for 3 days". Physical examination: flat abdomen, tenderness in the upper abdomen, with mild rebound pain, no muscle tension, positive Murphy's sign, and bowel sounds 4~5 times/min. Abdominal X-ray plain film showed that an arched intestinal shadow with dilated gas accumulation could be seen in the middle and upper abdomen, and a stepped gas-liquid level (Figure 1)。 CT examination showed that the morphology of the local small intestine and adjacent mesentery in the pelvic cavity was abnormal, the upper small intestine was dilated and accumulated gas and fluid, and the local liquid and gas level was visible. Consider pelvic intussusception with small intestinal obstruction, local mesenteric exudation and pelvic effusion. Enhanced CT showed that the morphology of the small intestine and adjacent mesangium in the pelvic cavity was abnormal, and it was inserted into the adjacent intestinal tube, and a circular heterogeneous enhanced tumor shadow was visible locally (Figure 2)。 Initial diagnosis of intussusception, small intestinal tumor not excluded, complete intestinal obstruction. Exploratory laparotomy was performed: during the operation, small intestinal intussusception was seen at 50 cm away from Trigger's ligament. A tumor about 4 cm ×4 cm in size could be palpable at the distal end of the intussusception, which was tough in texture, and the proximal intestinal tube was obviously dilated, accompanied by fluid effusion. The distal intestinal tube was empty. The proximal intussusception tube was returned, and the tumor could be seen to block the intestinal lumen. The small intestinal tumor and corresponding mesangium were removed, and enterectomy and enterostomy were performed. Postoperative diagnosis: intussusception of small intestinal tumor with small intestinal obstruction. Postoperative pathological findings: spindle cell tumor of small intestine, consistent with inflammatory fibrous polyps. Immunohistochemical staining: CD34 small vessels (+), CD117 (-), Dog-1 (-), SMA fraction (+), S100 (-), Ki-67 (15%-20% +) (Figure 3)。

hepatocellular carcinoma (HCC) is one of the major diseases that seriously endanger human life and health. The base of hepatitis B population in China is large, and 50% of new cases of liver cancer in the world occur in China. The situation of diagnosis and treatment of liver cancer is very severe. Patients with liver cancer in China often have a history of hepatitis B cirrhosis, and liver cancer is still prone to recurrence after radical surgical resection or liver transplantation. Studies have shown that microvascular invasion (MVI) is one of the main risk factors for postoperative hepatocellular carcinoma recurrence. China's "Guidelines for Standardized Pathological Diagnosis of Primary Liver Cancer (2015 Edition)" lists MVI as an important index to predict postoperative recurrence of liver cancer, and it is an important pathological indication for clinical anti-postoperative recurrence treatment of liver cancer. So far, there are many studies to predict MVI in liver cancer before surgery, such as inflammatory factors, tumor markers, genomics and imaging examinations. In this paper, the research progress of preoperative imaging in predicting MVI of liver cancer is reviewed.

infrarenal aortic occlusion (IAO) accounts for 3% to 8.5% of patients with aortoiliac artery occlusion disease, and is the most serious type. It is manifested by complete occlusion of the abdominal aorta below the level of renal artery, with or without occlusion of iliac branch. According to the occlusion plane and the distance of renal artery, it can be further divided into distal renal type and proximal renal type^[1]。 Acute IAO is extremely rare and critically ill^[2]It is an emergency of vascular surgery, which is not mainly discussed in this article. Common clinical IAO is mostly chronic occlusion, mainly caused by the accumulation of atherosclerotic plaque, and can also be seen in autoimmune diseases such as Takayasu arteritis. Symptoms from mild to severe may be intermittent claudication, resting pain, tissue ulcers and ischemic necrosis. There is no unanimous opinion on treatment. Traditional views tend to open surgery on the basis of conservative treatment. In 2017, the European Society for Vascular Surgery (ESVS) put forward the vague description that "abdominal main-bifemoral bypass is recommended for patients who can tolerate Surgery, and endovascular treatment can also be an option."^[3]。 We believe that the disease should be considered comprehensively according to the severity of the disease, the patient's own condition, wishes and the technical level of the medical center.

hepatocellular carcinoma (HCC) is the sixth most fatal malignant tumor in the world and ranks second in cancer-related mortality in China^[1]。 Early HCC is difficult to diagnose and has a poor prognosis and high risk of recurrence. Identifying effective, non-invasive and specific biomarkers is therefore an urgent need to provide predictive potential for early identification of HCC. microRNA (miRNA) is a small non-coding RNA, and its abnormal expression is closely related to the development of tumor^[2]。 Dysregulation of exosomal miRNA expression may accelerate disease progression, and exosomal miRNA may affect many aspects of the physiological and pathological state of liver cancer, and is an important molecule with significant functions in HCC. The role of exosomal miRNA in HCC is now summarized as follows.

A 33-year-old male was admitted for 1 week with epigastric pain. Physical examination: mild yellowing of the whole body and sclera, deep tenderness in the right upper abdomen, no rebound pain and muscle tension. Auxiliary examination: hepatitis B and hepatitis C negative. Liver function: AST: 362.61 IU/L, ALT: 587.25 IU/L, total bilirubin: 57.41 μ mol/L, direct bilirubin: 22.83 μ mol/L, indirect bilirubin: 34.58 IU/L. MRCP and CT scan of the biliary tract confirmed the diagnosis of gallbladder stones and common bile duct stones. The patient's general state was acceptable, but the transaminase was significantly elevated, and there was no indication for surgery for the time being. He was given monoammonium glycyrrhizinate cysteine sodium chloride injection (200 ml/d) once a day, intravenous drip, combined with adenosylmethionine treatment. After 1 day of application, liver function: AST: 79.82 IU/L, ALT: 290.89 IU/L, total bilirubin: 37.20 μ mol/L, direct bilirubin: 14.08 μ mol/L, indirect bilirubin: 28.12 μ mol/L; After 4 days of application, liver function was re-examined: AST: 83.91 IU/L, ALT: 201.36 IU/L, total bilirubin: 25.93 μ mol/L, direct bilirubin: 8.33 μ mol/L, indirect bilirubin: 17.60 IU/L. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic nasobiliary drainage (ENBD) were performed to remove common bile duct stones and relieve common bile duct obstruction. After ERCP, the reexamination of liver function on the first day of continued treatment with the same regimen showed: AST: 41.01 IU/L, ALT: 136.79 IU/L, total bilirubin: 19.65 μ mol/L, direct bilirubin: 7.08 μ mol/L, indirect bilirubin: 12.57 IU/L. On the second day after ERCP, the patient's condition was stable and the liver function improved significantly, and laparoscopic cholecystectomy was performed. After cholecystectomy, the treatment was continued in the same regimen. Liver function was reviewed: AST: 52.91 IU/L, ALT: 87.18 IU/L, total bilirubin: 20.31 μ mol/L, direct bilirubin: 8.27 μ mol/L, and indirect bilirubin: 12.04 IU/L. The blood routine, renal function, electrolyte and urine routine were all normal after reexamination. The nasobiliary duct was removed on the second day after cholecystectomy and was successfully discharged from hospital for a total of 11 days of treatment.