2018年 · 第34卷第02期

The incidence and mortality of esophageal cancer rank fifth and fourth among all kinds of malignant tumors in China, respectively^[1]Lymph node metastasis is the main metastatic mode of esophageal cancer, and it is also an important indicator to determine the prognosis of esophageal cancer^[2]。 The anatomy of lymph nodes parararyngeal to recurrent laryngeal nerve is complicated and easy to produce accessory injury. Correct grasp of lymph node metastasis is an important factor in determining the surgical mode and lymph node dissection range of esophageal cancer. This study retrospectively analyzed the clinical data of 138 patients with thoracic esophageal squamous cell carcinoma who underwent three-incision radical esophagectomy for left cervical, right thoracic and upper abdominal cancer in our department from June 2015 to December 2016, and counted the metastasis pattern of left and right recurrent laryngeal nerve lymph node, and analyzed its influencing factors, which are reported as follows.

After more than 100 years of development, esophageal cancer surgery has focused on safety at first to pay more attention to the quality of life of patients now. With the improvement of people's health awareness and the improvement of examination methods, the detection rate of early esophageal cancer continues to increase^[1]。 Due to the early metastasis of lymph nodes in esophageal cancer, it is generally chosen to cut off the vagus nerve trunk to thoroughly dissect the lymph nodes, which may lead to chronic diarrhea, dumping syndrome, delayed gastric emptying, etc. after operation, and affect the prognosis. It has been reported that the preservation of vagus nerve during esophageal extraction or left open thoracic esophagectomy and thoracolaparoscopic resection of esophageal cancer can improve the postoperative quality of life of patients^[2,3,4,5]。

During the European Annual Conference of Cardiology in August 2017, the European Society of Cardiology (ESC) and the European Society of Cardiothoracic Surgery (EACTS) jointly released the 2017 ESC/EACTS Guidelines for the Management of Valvular Heart Diseases, which made specific recommendations for the diagnosis and treatment strategies of common valvular heart diseases. Some of these contents have changed from the previous edition of the European guidelines in 2012, and they are also different from the heart valve guidelines of AHA/ACC in the United States in 2017. Especially in recent years, the rapid development of catheter technology in the treatment of valvular diseases has greatly affected the choice of treatment strategies for valvular heart diseases. This article interprets the updated 2017 European valve guidelines.

In recent years, with the improvement of people's living standard and the enhancement of disease prevention awareness, life expectancy has been significantly prolonged, and cardiac surgeons are facing more and more elderly patients who need cardiac surgery. However, due to the poor organ reserve function and many comorbidities, it is often difficult for clinicians to make surgical decisions. In addition, patients' families have negative attitudes because of fear of surgical risks, which makes a considerable number of elderly cardiac surgery patients face the risk of deterioration of quality of life and death^[1]。 However, the improvement of cardiopulmonary bypass technology and the increase of perioperative management experience make cardiac surgery safer for elderly patients than before, and the mortality and complication rate are decreasing^[2,3]。

Female, 14 months. Pneumonia, enlarged heart shadow for 7 days. A history of repeated upper respiratory tract infections, and no obvious abnormalities were found on multiple echocardiograms in the local hospital. Admission physical examination: blood pressure 101/67 mmHg (14.6/8.9 kPa), coarse breathing sounds in both lungs, more small and medium wet rales, heart rate 126 beats/min, uniform rhythm, and grade 3/VI systolic murmur in the precordial area. The electrocardiogram showed sinus tachycardia, deep Q wave in AVL and V5 leads, and ST-T changes. Echocardiography showed left heart enlargement, left atrial diameter 38 mm, left ventricular end-diastolic diameter 45 mm, end-systolic diameter 36 mm, left ventricular ejection fraction (Simpson's method) 0.40, left ventricular wall thickening rate weakened, endocardial echo enhanced, chordae tendineae echo enhanced; Severe regurgitation was observed at the mitral valve, and the regurgitation volume accounted for about 49% of the left atrial area; The right coronary artery originates from the right coronary sinus with an internal diameter of about 2.8 mm, and the two-dimensional left coronary artery appears to originate from the left coronary sinus of the aorta (Figure 1)； Color Doppler ultrasound showed that the right coronary artery communicated with the left coronary artery in the collateral circulation, and the blood flow from the left coronary artery reversed into the main pulmonary artery (Figure 2、Figure 3)； Spectral Doppler ultrasound showed a turbulent spectrum predominantly diastolic. Echocardiography suggested that the left coronary artery abnormality originated in the pulmonary artery. CT angiography (CTA) showed that the left and right coronary arteries originated from the root of the aorta, the right branch descended along the anterior wall of the right atrioventricular, and the anterior descending and circumflex branches of the left branch ran as usual (Figure 4)。 During the operation, the coronary artery was dilated and tortuous, and the opening of the left coronary artery was located in the right wall of the main pulmonary artery, close to the root of the aorta (Figure 5), and the anterior mitral valve chordae tendineae rupture and prolapse were seen, followed by coronary artery replantation and mitral valvuloplasty.

Female, 5 months and 20 days, weight 10 kg, cough for 1 day, aggravated with wheezing for half a day. Acute laryngitis, laryngeal obstruction (Ⅲ degree), bronchopneumonia and atrial septal defect (Ⅱ) were admitted to the hospital. Physical examination: breathing laborious, obvious "three concave" disease. Anti-infection and antispasmodic symptomatic treatment were given, but the child did not improve, so ventilator assistance was given. During tracheal intubation, intubation was difficult, cardiac CTA and tracheal CT examination showed pulmonary artery sling, and tracheal stenosis (long segment possible) (Figure 1)。