2018年 · 第33卷第12期

Carotid artery stenosis is closely related to ischemic stroke. At least about 20% ~30% of ischemic strokes are related to atherosclerotic carotid artery stenosis^[1]。 Studies show that asymptomatic patients with>60% carotid stenosis have a 2.4% risk of stroke in the first year^[2]The risk of ischemic stroke in the first year is 19% in 70% to 79% of symptomatic patients with carotid artery stenosis, while the risk of stroke in the first year is as high as 33% in patients with carotid artery stenosis ≥90%^[3]。 According to the 2018 China Stroke Prevention and Treatment Project Work Report released by the National Stroke Prevention and Treatment Committee, the current situation of stroke prevention and treatment in China is very severe. The number of people over 40 years old in China who have suffered from stroke is 12.42 million, and the trend of younger stroke patients is obvious. 70% of the surviving patients have varying degrees of disability, which causes a serious economic burden on society and families, and is the most important influencing factor for returning to poverty due to illness. Worldwide, stroke has become the second leading cause of death^[4]It is the first cause of death among nationals in our country. According to the "2015 China Stroke Prevention and Treatment Project Work Report" released by the National Stroke Prevention and Treatment Committee, the incidence of stroke in China continues to grow, with a growth rate of 13.19%, and the incidence of high-risk groups even reaches 14.01%. At present, only 6% of carotid artery stenosis diseases in China have been treated in time and effectively. Therefore, it is very important to further strengthen the diagnosis and standardized treatment of carotid artery stenosis for the prevention of stroke.

The incidence of brachiocephalic artery injury is not high, among which carotid artery and subclavian artery injury are more common. Once injured, it will lead to massive bleeding, dangerous disease, and even death in severe cases. From January 2014 to May 2018, 7 patients with brachiocephalic trunk artery injury were treated by vascular surgery in our hospital, which are now reported as follows.

gallbladder carcinoma (GBC) is mostly advanced at the time of consultation. The surgical resection rate of GBC is still very low, and the comprehensive treatment effect such as radiotherapy, chemotherapy and biological therapy is not obvious, and the overall prognosis is extremely pessimistic^[1]。 Radical surgical resection remains the only possible cure for patients with GBC. However, the application of extended radical gallbladder carcinoma combined with multiple organ resection in the treatment of stage T4 GBC is still controversial^[2]。 We performed extended radical resection combined with multiple organ resection in 4 patients with stage T4 GBC, and achieved good therapeutic results, which are reported below.

After endovascular repair of abdominal aortic aneurysm or iliac aneurysm, the gap between the distal end of the covered stent and the wall of the iliac artery can be used to retrograde ascending into the residual tumor cavity or false cavity through catheter or guide wire to treat type II endoleak after EVAR^[1]。 We used this technique to treat 1 case of type II and type III endoleak after EVAR, and also successfully treated 1 case of intraoperative accident of EVAR. The summary report is as follows.

In this study, the application of enhanced recovery after surgery (ERAS) in patients undergoing gastric sleeve resection was used to investigate the effects of ERAS on the inflammatory response and immune function changes of the body after gastric sleeve resection.

In recent years, it has been found that microRNA (microRNA) plays an important role in the regulation of gastric cancer^[1]。 This study investigated the relationship between miR-150 and epithelial mesenchymal transformationin (EMT) in gastric cancer, which provided ideas for clarifying the mechanism of invasion and migration of gastric cancer and finding new therapeutic methods.

In recent years, endovascular aneurysm repair (EVAR) has become more and more popular in China, and some infected abdominal aortic aneurysms have also been treated with EVAR. However, the main problem is that the infection after EVAR is not well controlled or the infection recurs again. According to literature reports, the incidence of stent-type artificial vessel graft infection after endovascular surgery is about 0.4% ~1%, and the mortality rate is extremely high if left untreated (63.3%)^[1]。 At present, vacuum-assisted wound closure (VAC) is widely used in abdominal surgery^[2]and has been successfully used to treat infection after lower limb artificial blood vessel bypass surgery^[3]。 The application of VAC has shown good drainage and healing promotion, but there are no reports of application to aortic graft infection. The Department of Vascular Surgery of Peking University People's Hospital successfully applied extracorporeal fenestration combined with debridement + VAC drainage to treat a case of abdominal aortic vascular graft infection after EVAR. After six months of follow-up, the patient recovered well, and the infection did not relapse. The report is as follows.

Covered stent strangling may occur when reconstructing the internal iliac artery with parallel stent technique in abdominal aortic aneurysm. We successfully managed one case, and the experience is summarized below.

A 65-year-old male was admitted to the hospital for "abdominal pain accompanied by yellowing of the skin and mucosa of the whole body for 3 d". Chest X-ray: dextrocardiac (Figure 1)。 Preoperative MRI: cholangiocarcinoma; Complete visceral transposition of thorax and abdomen (Figure 2)。 CA19-9: 178.0 U/ml; Direct bilirubin: 190.0 μ mol/L, total bilirubin: 226.1 μ mol/L. Laparoscopic pancreaticoduodenectomy was performed after perfect preoperative preparation. Take 5 cm below the umbilicus to establish an observation hole, and implant 2 Trocar on the left and right sides of the abdomen respectively. Exploration of abdominal cavity: total visceral inversion, liver showed cholestatic changes, and no obvious metastatic lesions were found in abdominal cavity and pelvic cavity. The large and small curved blood vessels of the stomach were freed, the body of the stomach was transected by the closure device, about 50% of the distal stomach was removed, the hepatoduodenal ligament was dissected, the right stomach and the gastroduodenal artery were clipped and severed, the hepatoduodenal ligament and the swollen lymph nodes around the hepatic artery were removed, and the main portal vein trunk was separated at the upper margin of the pancreas. The jejunum was cut by the closure device 15 cm away from the Treitz ligament, the proximal jejunum was freely removed, the Traitz ligament was separated, the third and fourth parts of the duodenum were dissected, and the second part of the duodenum and the rear of the pancreatic head were gradually freed along the pylorus, and the third part of the duodenum was penetrated. Dissect the main portal vein along the superior mesenteric vein, separate the posterior space of the pancreatic neck, cut the pancreatic neck, free the pancreatic stump about 2 cm, separate the space between the pancreatic head and uncinate process and the superior mesenteric artery and vein, and clip the thick blood vessels at the same time. The gallbladder was removed, the common hepatic duct was cut, the median incision of the upper abdomen was 6 cm, and the specimen was removed after the incision was protected. Child's digestive tract reconstruction was performed, and the jejunum broken end was lifted through the Treitz ligament hole, and the mesangial side was approximately 15 cm from the jejunal stump, and the end-to-side anastomosis of the bile duct and jejunum was performed. The pancreatic duct was placed into a drainage tube, and the mesangial side of the jejunum was anastomosed with the residual pancreatic duct mucosa-mucosa at a distance of about 5 cm from the jejunal stump, and then the seromuscular layer of the jejunum was intermittently sutured with the pancreas. Finally, jejunal-gastric posterior wall closure anastomosis was performed approximately 40 cm away from the bilioenterostomy, and full-thickness suture was intermittently performed. Three drainage tubes were placed around the biliary intestine and pancreatic intestine anastomosis. The bleeding was about 500 ml at 7 hours when the surgery was shared. The patient recovered well after surgery. Pathology: Pancreatic head mass pancreatitis.

The patient was a 28-year-old male. He was admitted to the hospital because he found that the anterior superior mediastinum occupied half a month. The patient's thyroid B-ultrasound showed no obvious abnormality; Chest CT showed a nodular shadow on the left side of the ascending aorta, which was significantly enhanced and about 1.7 cm long, except for parathyroid adenoma, and the density in the thymic area was slightly increased (Figure 1)。 PET-CT showed a nodular shadow in the mediastinum with a slight uptake of imaging agent, about 1.2 cm ×0.8 cm in size, which was considered as a benign lesion. Blood calcium 3.0 mmol/L; Blood phosphorus 0.7 mmol/L; Blood parathyroid hormone was 524.0 pg/ml. Clinical diagnosis: mediastinal ectopic parathyroid adenoma. Left thoracoscopic mediastinal mass resection was performed on the 3rd day of admission (Figure 2,Figure 3)。 Parathyroid adenoma was confirmed by postoperative pathology. Blood calcium on the postoperative day was 2.6 mmol/L; Blood parathyroid hormone 12.4 pg/ml. The serum calcium was 2.3 mmol/L and the serum parathyroid hormone was 24.0 pg/ml at 6 months after surgery.

A 50-year-old male was admitted for a sudden left neck mass with pain for 4 h. The mass was gradually enlarged, without dyspnea, and there was a history of hypertension, and no history of trauma or surgery. Physical examination: The trachea was deviated to the right, and a pulsatile mass of about 4 cm ×3 cm could be palpable in the left neck without tremor. Carotid CTA showed left common carotid artery pseudoaneurysm (Figure 1)。 Laboratory Test: WBC 7.39×10⁹/L, neutrophils 49.9%, C-reactive protein 2.32 mg/L, human immunodeficiency virus antibody (negative), Treponema pallidum specific antibody (negative), vasculitis antibody spectrum and antinuclear antibody spectrum were normal. Endovascular stent-covered isolation of left common cervical pseudoaneurysm under emergency local anesthesia. The right femoral artery was punctured under local anesthesia in supine position, and left common carotid arteriography was performed (Figure 2), the size of the pseudoaneurysm was about 3.5 cm ×3 cm, the arterial rupture was 1.5 cm from the bifurcation, the diameter was 2.5 mm, the diameter of the common carotid artery was 7.5 mm, and the internal and external carotid arteries were normal. Gore 9 mm ×50 mm Viabahn stent (diameter magnification 20%) was selected. The distal end of the stent was positioned at the bifurcation of the common carotid artery. After the stent was released, the pseudoaneurysm was completely isolated by angiography. After operation, aspirin 100 mg/d and Plavix 75 mg/d were given anti-platelet. After six months, aspirin 100 mg/d was taken for life. The patient had no neurological dysfunction. After 5 months of follow-up, the left neck mass disappeared, and the three-dimensional reconstruction of carotid artery CTA showed that the stent was patent (Figure 3), the hematoma is completely absorbed.

A 50-year-old female was admitted due to intermittent upper abdominal distension for 2 months and nausea for 1 month. Physical examination: there was no yellowing stain on the skin and sclera and no bleeding spots; The abdomen was flat, with mild tenderness in the middle and upper abdomen, no rebound pain, muscle tension, no percussion pain in the liver area, about 4 transverse fingers under the xiphoid process, and there were no positive signs. Abdominal enhanced CT showed multiple hemangiomas of the liver and giant hemangioma of the left lobe of the liver, with the longest diameter 21.25 cm ×11.90 cm (Figure 1)。 The patient did not undergo surgery and required minimally invasive treatment, so transcatheter arterial embolization (TAE) combined with microwave ablation (MWA) was proposed. After TAE (Figure 2), percutaneous MWA under CT guidance under local anesthesia. Intraoperative ablation was performed with the margin and then the center (Figure 3), the single-point ablation time was 5 min, and a total of 10 needles were ablated. During the operation, the patient developed upper abdominal distension, which was relieved after reducing the ablation power. Operation time 100 min. After operation, the patient was given fluid rehydration, alkalized urine with sodium bicarbonate, diuresis and hepatoprotective treatment. The patient did not show abdominal pain, fever and jaundice. Laboratory test: WBC: 8.62×10⁹/L NEUT: 89.4%, NEUT#: 7.71×10⁹/L, HGB: 126 g/L, PLT: 162×10⁹/L; ALT: 46.32 IU/L, AST: 78.11 IU/L, TBIL: 21.37 μ mol/L, SCr: 64.66 μ mol/L, BUN: 4.99 mmol/L, Electrolytes are normal. ALT, AST and total bilirubin decreased to normal range on the 3rd day after operation, and he was discharged safely. CT was re-examined 6 months after operation (Figure 4)。

A 49-year-old female was admitted with "upper abdominal discomfort for 5 years". The patient underwent right hemicolectomy for colon cancer 10 years ago, pathological mucinous adenocarcinoma without chemotherapy, and hysterectomy for cervical cancer 6 years ago. Five years ago, CT examination of inferior vena cava metastasis was found due to abdominal discomfort, and then chemotherapy, gamma knife treatment, radiation seed implantation and other palliative treatments were performed in turn. Since last year, abdominal distension and back pain have worsened, accompanied by anemia. Abdominal enhanced CT (Figure 1): Localized cystic protrusion was seen in the posterior wall of the horizontal part of the duodenum, which was connected to the duodenum. The irregular soft tissue of the cyst wall was thickened, and the enhancement was uneven. The upper right ureter was involved, and the upper ureter and the right renal pelvis were dilated and effused. The inferior vena cava was obviously compressed, and filling defects were seen at the level of the flat renal hilum. PET-CT: Hypermetabolic mixed-density mass adjacent to the inferior vena cava, considered metastatic cancer. After excluding surgical contraindications, metastatic cancer + pancreaticoduodenum + right kidney + inferior renal vena cava + right common iliac artery resection and reconstruction were performed (Figure 2)。 The middle incision of the upper abdomen was taken. After entering the abdomen, it was found that the tumor was located in the retroperitoneal boundary and invaded the inferior vena cava, right ureter and duodenum. The stomach body was transected by cutting and closing device on the distal side of the stomach, and the hemorrhage was carefully stopped in the proximal section and embedded in gastric serosa. Lift the transverse colon to expose the mesocolic root (because the patient has a history of right hemicolon surgery in the past), suture the arteries at the upper and lower edges of the pre-cut line of the pancreas neck with No.4 silk thread through the pancreatic parenchyma, and use this to tract, clamp a long blood vessel curved forceps on its right side, and cut the pancreas between the right side of the traction line on the left side of the curved forceps. Retrograde resection of the gallbladder. Transect the common bile duct above the duodenum. The pancreatic head and uncinate process were removed, the jejunum was transversed at the distal side of Treitz ligament, and the proximal jejunum was double-layered sutured. Blunt and sharp separation, free right renal artery and vein and ureter, cut, ligate and suture the renal artery and vein, cut and ligate the ureter. Exploration of the inferior vena cava shows a tumor thrombus in the inferior vena cava, the proximal end is located in the plane of the renal vein, the inferior vena cava is blocked above the level of the renal vein, the intraluminal tumor thrombus is pushed downward, the inferior vena cava is cut by a straight-line closure in the plane below the renal vein, and the inferior vena cava containing the tumor is free until the left and right common iliac veins, and the bilateral common iliac veins are ligated and disconnected. During the process of dissociation, it is found that the root of the right iliac artery is narrowed, so the stenotic segment is removed and the right iliac artery is replanted in the left common iliac artery. Digestive tract reconstruction: Lateral jejunopancreatic duct anastomosis was performed, and the pancreatic duct cannula was placed in the jejunum to wrap the pancreatic section with jejunal serosa around the anastomosis. Lateral anastomosis of jejunum and common bile duct was performed at the minimum tension about 10 cm away from this anastomosis. End-to-side anastomosis was performed between the large curvature of the stump and the jejunum about 50 cm from the bilioenterostomy. The patient recovered well after surgery and was successfully discharged after 5 days. Postoperative pathology: mucinous adenocarcinoma of the abdominal cavity (of intestinal origin).

A 51-year-old male was diagnosed with aortic dissection of DeBakey type Ⅲb (FIG. 1A) underwent endovascular isolation of thoracic aortic dissection on August 31, 2016. He had a history of hypertension for 10 years and had poor blood pressure control. Intraoperative angiography showed that the primary dissection was about 4 cm away from the left margin of the left subclavian artery, and the pressure was controlled to 90/60 mmHg. A 30 mm diameter covered stent (30 mm ×30 mm ×150 mm, Medtronic Company) was positioned at the distal end of the left subclavian artery and released downward to cover the descending aorta. The angiography showed that the stent was in good shape, the left subclavian artery showed positive blood flow, and there was no endoleak at the proximal end of the stent. The operation was successfully completed at about 11: 30 am. The intraoperative iodixanol (100 ml: 32 gI) dosage was 120 ml. At about 13 o'clock postoperatively, the patient in the anesthesia and resuscitation room complained of blurred vision in both eyes, which gradually worsened. The anesthesiology department considered that the patient had not been resuscitated after general anesthesia. By 13:20, the patient complained of only light sensing. Cranial MRI + DWI in emergency department: new punctate infarction of left temporal lobe and right parietal lobe; MRA: No abnormalities in bilateral carotid and vertebral artery systems (FIG. 1B，Figure 1C)。 Neurology and ophthalmology consultation: The new punctate infarction found by imaging examination cannot explain the symptoms of binocular vision decrease, and cortical blindness may be. Then he was treated with mannitol, dexamethasone, atorvastatin, edaravone and oxiracetam. At 16: 20 pm, the family complained that the patient's vision had recovered. Physical examination: light reflection was sensitive, and both eyes could distinguish the finger index in front of the eyes, and the rest was normal. The symptomatic treatment was continued according to the original regimen, and the patient's visual acuity was completely recovered the next day, and the duration of cortical blindness was about 10 h. Since the follow-up, the patient's visual acuity was normal and there was no visual field defect.

perihilar cholangiocarcinoma (PHC), also known as Klatskin tumor, accounts for more than half of cholangiocarcinomas. It occurs in the common hepatic duct above the opening of the cystic duct and at the beginning of the right and left secondary hepatic ducts^[1]。 Without intervention therapy, the prognosis of PHC patients is extremely poor, with a median survival of less than 6 months, while the median survival can reach 19 to 39 months by resection of affected intrahepatic and extrahepatic bile ducts or ipsilateral liver tissue^[2]。 Although surgical treatment provides long-term survival opportunities for patients with PHC, the morbidity and mortality of complications after hepatectomy for PHC remain statistically high, ranging from 43% to 81% and 1.4% to 12%, respectively^[3]。 post-hepatectomy liver failure (PHLF) is the most common complication. It is very important to explore its risk factors and take corresponding treatment measures to reduce its incidence and related mortality.

A 63-year-old male underwent MRI in a local hospital 4 months ago, showing a lesion in the inner left lobe of the liver, which was considered malignant, and probably cholangiocarcinoma. After that, he underwent 5 chemotherapy sessions in a local hospital. One month ago, CT in the local hospital showed cholangiocarcinoma, low-density focus in the left lobe of the liver, the lesion involved the portal area and upper common bile duct, and adjacent peritoneal omentum metastasis. The patient came to our hospital and refused to undergo percutaneous transhepatic cholangial drainage (PTCD), hoping for endoscopic drainage treatment. He planned to be admitted to the hospital after 4 months of confirmed malignant bile duct tumor and 1 week of abnormal liver function. The previous medical history is not special. Physical examination: Mild jaundice, unpalpable subcostal liver, negative Murphy sign. Auxiliary examination on the day of admission: total bilirubin 15.8 μ mol/L, direct bilirubin 8.1 μ mol/L, ALT 113 U/L, AST 43 U/L, AKP 252 U/L, γ-GT 488 U/L, AFP 1.7 ng/ml, CEA 221.8 ng/ml, CA199 67.5 U/ml, CA125 121.7 U/ml, CA153 56 U/ml, CA724 5.2 U/ml. On the afternoon of admission, endoscopy revealed obstruction of the upper common bile duct of the patient. After repeated attempts, the endoscope could not pass through the obstruction segment. Endoscopic retrograde stenting was unsuccessful, and the guide wire successfully entered the pancreatic duct. An indwelling pancreatic duct stent was placed. Fluoroscopy showed good position. Postoperatively, liquid rehydration, acid suppression, anti-inflammatory and liver protection (monoammonium glycyrrhizinate, cysteine and sodium chloride injection 200 ml/d intravenous drip) were treated, and blood biochemistry and liver function were monitored at the same time, and the changes of disease were paid close attention to. Liver function was re-examined on the first postoperative day: ALT 98 U/L, AST 35 U/L, total bilirubin 15.1 μ mol/L and direct bilirubin 8.2 μ mol/L. Communicate with the patient that there is no possibility of endoscopic treatment at present, and be discharged. After discharge, the patient still came to our hospital for emergency rehydration. On the second day after operation, the liver function was re-examined: ALT 98 U/L, AST 35 U/L, total bilirubin 15.1 μ mol/L and direct bilirubin 8.2 μ mol/L, and the original regimen was continued. Liver function after 4 d: ALT 76 U/L, AST 31 U/L. After 7 days, the blood routine, renal function and electrolytes were all normal, and the liver function was reexamined: ALT 49 U/L, AST 27 U/L, AKP decreased to 178 U/L, and γ-GT decreased to 242 U/L. ALT and AST all dropped to the normal range. Later, the use of hepatoprotective drugs was stopped, and the condition was stable. The patient returned to the local hospital for continued treatment.

The patient, male, 69 years old, underwent radical resection of ascending colon cancer in the colorectal surgery department of our hospital on March 20, 2016. Postoperative pathology: ulcer type poorly differentiated adenocarcinoma of ascending colon, penetrating the whole thickness to the extra-serous membrane, with vascular invasion and no nerve recidive. No cancer was seen at the upper and lower resection margins. There was no metastasis in the peri-intestinal lymph nodes (0/15). The lymph nodes of the inferior mesenteric root had no metastasis (0/5). Postoperatively, chemotherapy with mFOLFOX6 regimen (oxaliplatin 150 mg, intravenous drip, day 1, continuous intravenous pumping of fluorouracil 3.5 g for 48 h, intravenous push of fluorouracil 0.5 g, day 1; 8 cycles of chemotherapy) was performed smoothly. The gastrointestinal tumor markers and thoracic and abdominal CT were reviewed every 3 months after operation to monitor the recurrence and metastasis after operation. The patient was admitted to our department after multiple metastases in both lungs were found during regular re-examination on February 26, 2018. The admission diagnosis was: multiple metastases in both lungs after poorly differentiated adenocarcinoma of ascending colon operation, stage IV, KPS score: 80 points. After discussion with the MDT team, the patient was assessed as unresectable metastatic colon adenocarcinoma, and the treatment goal was to shrink the tumor and control the disease. Objective: To prolong the survival period and improve the quality of life of patients. Therapeutic strategy: Comprehensive therapy based on systemic systemic therapy (chemotherapy combined with targeting). Targeted drugs were not used for economic reasons. Then the first-line FOLFIRI regimen (irinotecan 240 mg, intravenous drip, day 1, continuous intravenous pumping of fluorouracil 3.5 g for 48 h, intravenous injection of fluorouracil 0.5 g, day 1) was given for 4 cycles of chemotherapy, and the process went smoothly. After 4 cycles of chemotherapy, the reexamination showed abnormal liver function. Liver function: ALT 88 U/L, AST 96 U/L, and bilirubin was normal. CT showed that multiple metastases in both lungs increased significantly after ascending colon cancer surgery. The patient had no prior history of hepatitis, no fatty liver, and did not drink alcohol. Chemotherapy was suspended, and liver function returned to normal after 7 days of hepatoprotective treatment with "reduced glutathione and isoglycoside magnesium oxalate". In order to control the disease, the patient was given a second-line mFOLFOX6 regimen of chemotherapy for 1 cycle on the basis of liver protection. The patient experienced abnormal liver function again. Liver function: ALT 208 U/L, AST 196 U/L, and bilirubin was normal. And symptoms of fatigue, anorexia and loss of appetite occur, and drug-induced liver injury is considered. The hepatoprotective treatment plan was changed, and "monoammonium glycyrrhizinate cysteine sodium chloride injection 200 ml, intravenous drip, once/d" was given. After 3 days, reexamination of liver function showed: ALT 178 U/L, AST 166 U/L, 7 days later: ALT 68 U/L, AST 86 U/L, bilirubin was normal, and symptoms disappeared. After 14 days: ALT 38 U/L, AST 45 U/L, no obvious adverse reactions. The patient has been given monoammonium glycyrrhizinate cysteine sodium chloride injection for liver protection during the follow-up chemotherapy. No abnormal liver function occurred after 5 cycles of chemotherapy continued with the original regimen. After re-examination, the condition was stable, and the oral capecitabine was maintained, and no abnormal liver function occurred during the regular monitoring.