2019年 · 第34卷第03期

Loyal female, 75 years old, mainly due to intermittent right upper abdominal distension and pain accompanied by nausea for more than 1 month. He had chronic bronchitis for more than 20 years and varicose veins in both lower limbs for more than 10 years. Physical examination: Pulse 105 beats/min, respiratory rate 24 beats/min. The respiratory sounds of both lungs were weak, no dry or wet rales were heard, the heart rhythm was uniform, no murmur was heard in the auscultation area of each valve, the abdomen was flat and soft, the right upper abdomen was positive for tenderness, no rebound pain, the Murphy sign was negative, no mass was palpable, and there was no obvious swelling of both lower limbs. Emergency abdominal color ultrasound: single cyst in the right lobe of the liver, chronic cholecystitis. Then he was admitted to hospital with "acute attack of chronic cholecystitis". After admission, the abdominal pain symptoms were not significantly relieved after the treatment of diet ban, fluid rehydration and anti-infection. Period blood routine : WBC 4.8×10⁹/L, neutrophils 63.4%; Arterial blood gas analysis: PO₂48.9 mmHg, PCO₂36.3 mmHg. Coagulation series : D-D3 175 ng/ml, FIB 1.53 g/L. Chest CT: Inflammatory lesions in the posterior and lower lobes of the right upper lobe, right pleural effusion, and bilateral pleural thickening. The heart is enlarged, the pericardium is thickened, and the pulmonary artery is widened. Cardiac color ultrasound: right atrium and right ventricle enlargement, tricuspid valve insufficiency (mild-moderate), PAP 49 mmHg. After asking about the medical history, the patient complained that his right calf had felt swelling and discomfort. Thoracic CTPA showed multiple pulmonary embolism in both lungs (Figure 1）； Pulmonary hypertension, right pleural effusion, incomplete dilation of the lower lobe of the right lung, lower limb vein color ultrasound: right small saphenous vein thrombosis, both calves intermuscular vein, perforating vein thrombosis (Figure 2）。 He was diagnosed as pulmonary embolism and was given anticoagulation (low molecular weight heparin) and blood circulation activation. The patient's abdominal pain was significantly better than before and he was discharged. Oral warfarin anticoagulation was administered regularly outside the hospital, and there were no symptoms such as lower limb swelling, chest stiffness and air tightness.

A 66-year-old male was admitted to the hospital for "dull pain in middle and upper abdomen for 2 months". The patient had middle and upper abdominal pain without obvious trigger and prodromal symptoms 2 months ago, showing persistent dull pain. No white clay-like stools, no progressive emaciation. Physical examination: Mild tenderness in the middle and upper abdomen, no obvious mass palpable. Abdominal CT: A first-density closed shadow was seen in the body of the pancreas, and the boundary with the stomach body was unclear (FIG. 1A)。 Abdominal MR: A slightly longer T1 and slightly longer T2 signal shadow with a size of about 60 mm ×56 mm was observed in the gastric and pancreatic spaces (FIG. 1B), after enhancement, the mass can be seen to be supplied by the left gastric artery, and the internal enhancement of the mass is uneven, and the cystic necrotic area can be seen, showing mild delayed enhancement (Figure 1C), the boundary between the lesion and the pancreas is unclear. Laboratory tests: Squamous cell carcinoma associated antigen 6.60 ng/ml, cytokeratin 24.6 ng/ml. Clinical diagnosis: cancer of the pancreas and invasion of the stomach. Body and tail of pancreas + celiac trunk + spleen + proximal stomach + left adrenalectomy were performed. Postoperative pathology: Typical squamous cell carcinoma infiltration with different degrees of keratinization was observed in pancreatic tissue (Figure 1D), showing typical keratinized beads, clear intercellular bridges and necrosis, large nuclei in some areas, obvious atypia, thick chromatin, easy to see nuclear division, rich cytoplasm, red staining. Typical squamous cell carcinoma tissue involvement was seen from the submucosa to the serosa layer of the stomach. Pathological diagnosis: Differentiated squamous cell carcinoma in the body of the pancreas. The cancerous tissue invaded the adjacent stomach wall tissue. There was no cancer involvement in the stomach, pancreas and bile duct, and no cancer metastasis in lymph nodes. There was no recurrence and metastasis of tumor at 6 months after surgery.

A 56-year-old male was admitted to the hospital due to yellow staining of the skin and sclera and yellow urine for 2 weeks. Cholecystectomy for gallbladder polyps 22 years ago; Left nephrectomy for clear cell carcinoma of the left kidney 12 years ago. Physical examination: Skin and sclera were yellow stained, and there were no positive signs. CA199 27.98 U/ml, AFP, CEA and CA125 were normal. Abdominal CT: A round, low-density mass shadow about 3.1 cm ×3.6 cm in size was seen on the head of the pancreas, with uneven enhancement after enhancement (Figure 1)； Changes after gallbladder and left nephrectomy. Imaging diagnosis: multiple neuroendocrine tumors of the pancreas. Pancreaticoduodenectomy was performed. Postoperative pathology: metastatic clear cell carcinoma of the pancreas involving duodenal serosa and muscle layer (FIG. 2A), lymph nodes: 0/15; immunohistochemistry: CD10 (+) (Figure 2B), Pax-8 (+), NSE (+), CK (partial +), CD56, CEA, CgA, RCC, Syn, TTF-1 and Vim (-). There were no complications such as pancreatic fistula and hemorrhage after operation, and he recovered and was discharged on the 8th postoperative day. No radiotherapy or chemotherapy was given after operation, and no recurrence and metastasis were observed after 5 months of follow-up.

The patient was an 80-year-old male. Admitted for "irreducible mass in right inguinal area during forced urination for 3 d". In the past, a bilateral reversible mass in the inguinal area was discovered 40 years ago, and dysuria was diagnosed as "bladder stone" 3 months ago. Physical examination: body temperature 36.5 ℃, BMI 14.8 kg/m²。 There were no positive signs in the abdomen, and a 3 cm ×3 cm mass was seen inside and below the right inguinal ligament, which was tough in texture and had poor mobility, so it could not be recovered; The mass on the medial side of the left groin and above the outside of the pubic tubercle disappeared when lying down. WBC 4.9×10⁹/L, neutrophils 79.4%, CRP 0.6 mg/L. CT: A round-like density-increased focus in the right inguinal area, connected to the abdominal intestine, with shadow of the surrounding fluid density (Figure 1)。 B-ultrasound: right inguinal canal mass, with a small amount of intestinal echo detected at the upper end (Figure 2)。 Admission diagnosis: right femoral hernia, left direct inguinal hernia, bladder stones. Transurethral cystoscopic lithotripsy was performed because there were no signs of strangulation or obstruction in the incarcerated hernia. He returned to hospital half a month after the operation and underwent bilateral hernia repair under epidural anesthesia. During the operation, the right hernia sac was seen running below the inguinal ligament, protruding from the femoral ring, and the hernia sac wall was annular thickened peritoneum. When the hernia sac was opened, yellow effusion was ejected and the tail of the appendix was close to the hernia sac wall, and the distal end was congested and edema (Figure 3)。 Appendectomy was performed, and the femoral annulus was closed by McVay method after wound disinfection, and a negative pressure drainage tube was placed. Tension-free repair of hernia ring filling was performed on the left side. Pathology: Chronic appendicitis. The incision healed in stage I, and there was no recurrence after 3 months follow-up.

The patient was a 58-year-old female. He was admitted to hospital on December 28, 2017 due to cold and numbness in his left lower limb for more than 1 month. The patient experienced cold and numbness in the left lower limb without obvious trigger about 1 month ago. After visiting the local hospital, he was diagnosed with lower limb ischemia, and given symptomatic treatment such as improving circulation, but no obvious improvement was seen. The patient and his family came to our hospital for further diagnosis and treatment. No previous trauma. Physical examination: There was no tenderness in both lower limbs, the skin temperature of the left lower limb was slightly lower, the skin color was pale, the pulsation of the left femoral artery was weak, and the pulsation of the left popliteal artery, dorsal foot and posterior tibial artery was not reached. Color ultrasound of lower limb arteries: arteriosclerosis of both lower limbs, occlusion of the lower segment of superficial femoral artery of left lower limb, and occlusion of the middle and lower segments of anterior tibial artery of left lower limb. Lower extremity artery CTA: The left internal iliac artery was significantly thicker than the external iliac artery; Patent left ischiatic artery (Figure 1), left iliac artery, common femoral artery and proximal superficial femoral artery dysplasia (Figure 2), the ischial artery continues downward to communicate with the popliteal artery (Figure 3）。 After admission, the patient was given symptomatic treatment such as improving circulation and dilating blood vessels, and the symptoms of lower limbs were significantly improved. The patient refused surgery and was given regular follow-up.

A 66-year-old male was admitted to the hospital mainly because of "loss of appetite for 20 days". "Radical gastrectomy (total gastrectomy, esophagojejunal Roux-en-Y anastomosis)" was performed 2 months ago. Gastroscopy revealed that postoperative changes of gastric cancer showed no anastomotic stenosis or fluid retention. Enhanced CT of the whole abdomen showed that the local intestinal arrangement of the left upper abdomen was irregular, some intestinal walls were slightly thickened, the intestinal tubes were slightly dilated, and gas accumulated. Physical examination: The texture of the abdomen is slightly tough, the upper abdomen is mild tender, there is no rebound pain and muscle tension, and the intestinal sounds are active. Laboratory tests : Hb 104 g/L, WBC 4.44×10⁹/L, serum high-sensitivity C-reactive protein 4.9 mg/L, serum procalcitonin 0.66 ng/ml, serum albumin 29 g/L, and serum total protein 52 g/L. Abdominal standing X-ray: Colonic contrast agent residual, no free gas under the double diaphragm. No intestinal lumen dilatation and abnormal gas-liquid plane were observed, and a large amount of contrast medium was found in the colon. After admission, they were treated with fasting, water, gastrointestinal decompression, glycerol enema and parenteral nutrition support. The patient still experienced nausea and vomiting. The vomit was a dilute watery substance, accompanied by fever, and the maximum body temperature was 39.1℃. Emergency examination of total abdominal enhanced CT showed that the left middle abdominal small intestine was intussuscepted with upper level small intestine obstruction (Figure 1)。 An urgent laparotomy showed severe adhesions in the abdominal cavity, separated the adhesions between the intestinal tube and the mesangium, and the jejunum was inserted into the distal intestinal tube about 10 cm from the enterointestinal anastomosis, resulting in obvious dilatation of the proximal intestinal tube. The intussuscepted intestinal tube is returned, and the part of the intestinal tube is adhered into an inverted "U" shape (Figure 2)。 Considering the intestinal adhesion as the initiating factor of intussusception, the adhesion was separated. The patient recovered smoothly after operation and was followed up for half a year without recurrence of intussusception.

enhanced recovery after surgery (ERAS) refers to the adoption of a series of optimized management measures with evidence-based medical evidence during the perioperative period to reduce the traumatic stress of patients, thereby reducing complications, shortening hospital stay, reducing the risk of readmission and death, and reducing medical expenses^[1]。 nonsteroidal anti-inflammatory drugs (NSAIDs) play an important role in the perioperative period of ERAS. NSAIDs have definite analgesia, inflammation inhibition, stress reduction and other effects, and have no adverse reactions such as opioid addiction, nausea and vomiting, and respiratory depression. At present, multimodal analgesia regimens based on NSAIDs and frugal opioids have become the mainstream trend in ERAS pain management^[2,3,4,5]。 A survey on the current situation of perioperative pain treatment and management in China found that, on the one hand, the concept of multimodal analgesia needs to be further popularized, and the use rate of NSAIDs and nerve block needs to be improved^[6]。 However, on the other hand, with the increasingly widespread application of NSAIDs in the surgical field, the irrational use of such drugs (such as over-indication, over-dose, over-course of treatment, and irregular combination medication) has become increasingly prominent, and its potential adverse reactions and safety events have attracted much attention^[7,8]。 At present, practicing accelerated rehabilitation surgery and optimizing perioperative management is one of the hot directions in the surgical field. How to scientifically and standardize the application of NSAIDs is also particularly important. In view of the lack of unified and standardized standards for the use of NSAIDs in the perioperative period in China, the Expert Committee of Accelerated Rehabilitation Surgery of the Medical Management Center of the National Health Commission, together with the Expert Committee of Clinical Pharmacists of Zhejiang Medical Physicians Association and the Hospital Pharmacy Professional Committee of Zhejiang Pharmaceutical Association, took the lead in formulating this consensus based on the latest research progress and best clinical evidence at home and abroad, in order to better promote the rational use of ERAS perioperative drugs in China.