背景与目的:局部进展期胰腺癌(LAPC)的治疗方法在不断更新,且随着血管重建技术与自体器官移植技术的进步,血管侵犯的LAPC的手术根治率也极大提高.本文探讨小肠自体移植式扩大胰腺癌根治术的可行性与安全性.方法:回顾性分析中国人民解放军火箭军特色医学中心2022年5月—2023年5月收治的肠系膜根部受侵的2例LAPC患者的临床资料.2例患者均为女性,分别为66岁和58岁,术前影像学检查提示胰腺钩突恶性肿瘤,肿瘤侵犯并包绕肠系膜上动脉(SMA)及空肠动脉分支.2例患者术前一般情况可,均有十二指肠梗阻表现而未实施化疗,术前心、肺、肝、肾功能经评估患者均能耐受手术,实施小肠自体移植式扩大胰腺癌根治术.手术的关键是将小肠连同肿瘤标本一并切除至体外,再迅速移除标本,后遵循"先动脉、后静脉"的顺序进行SMA/肠系膜上静脉(SMV)重建.结果:2例患者的手术均顺利实施,患者1使用脾动脉翻转与SMA进行重建,SMV与门静脉(PV)对端吻合,小肠热缺血时间为24 min,术后病理诊断为胰腺低分化腺癌.患者2使用SMA端端吻合重建,SMV与PV对端吻合,小肠热缺血时间为18 min,术后病理诊断为胰胆管型壶腹癌.2例患者术后恢复均良好,没有出现动静脉血栓,术后住院时间分别为25 d和21 d.截至2023年8月1日,2例患者分别已在门诊随访12个月与2个月,随访期间患者一般情况良好,除患者2血糖控制尚不平稳外,2例均未见复发或转移证据.结论:从对2例病例回顾性分析结果看,对于侵犯肠系膜根部的LAPC患者采用小肠自体移植式的扩大根治术可以安全成功实现,为此类患者提供了一种可以获得解除病痛、增加生存机会的治疗选择.

回顾性分析2015年5月至2020年12月火箭军特色医学中心收治的因复发性肝母细胞瘤施行再次肝切除手术16例患儿的临床资料及随访结果。初次手术的中位年龄为26.5个月（5~87个月），复发距初次手术的中位时间为7个月。再次肝切除时间为（5.0±1.4）h，术中出血量50~3 200 ml。获得R 0切除10例，R 1切除3例；R 2切除3例。围手术期未出现严重并发症和死亡。中位随访时间16个月，患儿总生存率为62.5％。本研究结果表明，再次肝切除术治疗复发性儿童肝母细胞瘤，在技术上是安全可行的，但应注意其适应证，且应联合规范的系统性治疗。

回顾性分析本中心2014年1月至2019年12月完成的7例胰腺癌行“隔离式胰肠引吻”患者的临床资料，7例均顺利行隔离式胰肠引吻，其中胰管内引流5例，胰管外引流2例；术后生化瘘4例（外引流1例）、B级胰瘘2例（外引流1例）、C级胰瘘1例，B级胰瘘经过充分腹腔引流及冲洗引流后好转，C级胰瘘患者术后第11天因腹腔出血接受二次手术治疗。2例胰管外引流病例支撑管分别在术后1和1.5个月拔除。本组无围手术期死亡病例，所有患者均康复出院。本研究显示“隔离式胰肠引吻”式胰肠吻合技术操作相对安全简单，可以作为胰十二指肠切除术后出血时的补救手术，也可以作为一种重要的胰肠吻合方式来应用。

Repeat hepatectomy for adult recurrent hepatocellular carcinoma significantly prolongs the overall survival, but repeat hepatectomy for pediatric recurrent hepatoblastoma (HB) is rarely reported, and the outcomes are warranted to be investigated. All patients between May 2015 and December 2020 with recurrent HB after intended surgical cure were retrospectively evaluated. Clinicopathologic features, surgical details and outcomes were analyzed during a median following-up of 24 months after repeat hepatectomy. Survival analysis was performed using the Kaplan–Meier estimate. A total of 18 patients of recurrent HB undergoing repeat hepatectomy with radical cure intention were included. There were 11 males and 7 females. The median age was 29 months (range 5–87 months) at first hepatectomy, and the median time to the recurrence from the first hepatectomy was 7 months. The operating time of the repeat hepatectomy was 5.0 h (range 3.5–9.0 h) and the mean blood loss was 592 ml (range 50–3200 ml). Radical resection (R0) was achieved in 12 patients (66.7

胰腺癌恶性度高，进展快，根治性手术切除是胰腺癌患者改善预后和获得长期生存的必要条件，手术切除后胰腺癌患者的预后明显优于不可切除患者 ［1］，但临床中能够接受根治性手术的病例仅15%~20% ［2］。按照2021版NCCN 胰腺癌临床实践指南 ［3］和《中国胰腺癌诊治指南（2021）》 ［4］要求，肠系膜上动脉受侵犯周径超过180°属于局部晚期，不推荐进行手术切除。随着外科技术的提高及肿瘤治疗的前沿探索，国外胰腺专科中心在有效新辅助治疗的前提下，对于一部分同时侵犯肠系膜动、静脉的胰腺癌病例，进行了联合动、静脉同时切除重建的尝试 ［5, 6, 7］。我中心自2021年7月以来，尝试针对肠系膜上动、静脉同时受侵犯的病例施行“全胰腺联合肠系膜上动、静脉切除，同种异体血管替代重建门静脉-肠系膜上静脉（或门静脉-肠系膜上静脉端端吻合），脾动脉原位翻转替代肠系膜上动脉重建术”。现将病例资料报告如下。杨尹默教授（北京大学第一医院）：本文报告了3例局部进展期胰腺癌患者的资料，患者均接受全胰腺联合肠系膜上静脉及肠系膜上动脉切除重建。作者详实报告了手术过程，其中脾动脉原位翻转与肠系膜上动脉部分切除后远端重建颇具技术亮点。3例患者1例围手术期死亡，另2例近期预后良好。

回顾性分析3例胰腺癌联合血管切除并重建手术患者的临床资料，术中出血量为4 000～8 000 ml，手术时间480～600 min。1例术后顺利恢复出院，1例术后腹腔出血行介入栓塞止血后顺利出院，1例术后12 d因腹腔出血而死亡，住院时间14～46 d。2例生存患者均未出现胆瘘、肠瘘等并发症。本研究结果提示有计划性包含动静脉切除吻合在内的整体切除对胰腺癌患者是可行的，动脉重建材料及方法可以根据肿瘤侵犯的范围及程度进行不同选择。

回顾性分析火箭军医学特色中心肝胆外科2014年5月至2019年12月14例采用Glisson蒂横断法切除巨大中肝肿瘤患者的资料，均未出现肝功能衰竭，术中出血量400~1 200 ml；术后住院时间9~20 d；围手术期再次手术1例，再手术原因为肝创面出血；术后胆漏3例，经通畅引流后拔除腹腔引流管。本研究结果表明，Glisson蒂横断法在巨大中肝肿瘤切除术中具有临床应用价值。

With the development of fine anatomy,the concept of mesopancreas has been proposed,and total mesopancreatic excision continues to be used in clinical practice.This method has become the best surgical method of pancreatic head cancer.But due to deep position of pancreas and mesopancreas,the surrounding adjacent organs and complexs tructure and other factors,experts are concerned about at the presence or absence of the mesopancreas.So the scope of clinical surgical resection structural reservations are also controversial.This article reviewed the development of embryonic development of the pancreas and the research progress in order to provide theoretical support for the study of the fine anatomy of the pancreas and the precise operation of pancreatic diseases.

Chemotherapy is the best choice for the vast majority of hepatocellular carcinoma patients at late stage, but few effective chemotherapy drugs are available in clinic. Licochalcone A (LicA) is a new chemotherapy drug inducing apoptosis as Bcl-2 inhibitor, but few studies report on LicA-induced autophagy. This study investigated the phenomenon and mechanisms of LicA-induced autophagy looking for a targeted combination drug. Human hepatocellular carcinoma cells (HCCs) were treated with LicA, to detect markers of autophagy and to investigate the mechanisms. In order to investigate the role of reactive oxygen species (ROS) in LicA-induced autophagy, ROS, glutathione (GSH) and O-2(-) were measured in LicA treated HCCs, and antioxidant N-Acetyl-L-cysteine (NAC) was cotreated with LicA in HCCs, then mechanisms of ROS-induced autophagy was investigated in LicA or LicA combined with NAC treated HCCs. Finally, the LicA-induced apoptosis was detected in LicA combined with NAC treated HCCs. We first report that LicA can induce autophagy through ULK1/Atg13 and ROS pathway in HCCs, suppression of LicA-induced ROS through antioxidant NAC can enhance LicA-induced apoptosis, promoting the function of LicA killing HCCs. LicA can activate the ULK1/Atg13 complex which is upstream of autophagy, additionally, LicA also can promote ROS generation, ROS trigger the expression level of TSC1/2 complex, PRAS40, CTMP, PP2A, PDK1 and Rubicon change, these molecules are upstream of autophagy. In conclusion, LicA can induce autophagy through ULK1/Atg13 and ROS pathway in HCCs, LicA combined with NAC can enhance LicA-induced apoptosis. Our results may provide a novel design for clinical hepatocellular carcinoma therapy trials.

Pancreatic cancer rapidly acquires resistance to chemotherapy resulting in its being difficult to treat. Gemcitabine is the current clinical chemotherapy strategy; however, owing to gemcitabine resistance, it is only able to prolong the life of patients with pancreatic cancer for a limited number of months. Understanding the underlying molecular mechanisms of gemcitabine resistance and selecting a suitable combination of agents for the treatment of pancreatic cancer is required. Astaxanthin (ASX) is able to resensitize gemcitabine-resistant human pancreatic cancer cells (GR-HPCCs) to gemcitabine. ASX was identified to upregulate human equilibrative nucleoside transporter 1 (hENT1) and downregulate ribonucleoside diphosphate reductase (RRM) 1 and 2 to enhance gemcitabine-induced cell death in GR-HPCCs treated with gemcitabine, and also downregulates TWIST1 and ZEB1 to inhibit the gemcitabine-induced epithelial-mesenchymal transition (EMT) phenotype in GR-HPCCs and to mediate hENT1, RRM1 and RRM2. Furthermore, ASX acts through the hypoxia-inducible factor 1α/signal transducer and activator of transcription 3 signaling pathway to mediate TWIST1, ZEB1, hENT1, RRM1 and RRM2, regulating the gemcitabine-induced EMT phenotype and gemcitabine-induced cell death. Co-treatment with ASX and gemcitabine in a tumor xenograft model induced by GR-HPCCs supported the in vitro results. The results of the present study provide a novel therapeutic strategy for the treatment of gemcitabine-resistant pancreatic cancer.

Objective To evaluate the application of three-dimensional visualization in diagnosing right he-patic artery variation and formulating corresponding preoperative procedures for patients.Methods A total of 41 patients who had undergone skeletal cleaning of the hepatoduodenal ligament between Apr. 2014 and Apr. 2016 in our hospital were summarized and analyzed. All patients' clinical data of multidetector CT angiography scan-ning was preserved in DICOM format and introduced into 3D reconstruction. The hepatic artery was extracted from the reconstructed 3D model. The origination, bifurcation and three-dimensional anatomical relationship of variant hepatic artery could be observed distinctly. Thereafter, the corresponding preoperative procedures was formulated based on the observed stereo-anatomic relationship. All of these findings were compared in intraop-erative exploration.Results According to three-dimensional visualization, all of the 8 cases with right hepatic artery variant were found. All these founding and preoperative procedures reminded the surgeon pay attention to the right hepatic artery in operation. Compared with the intraoperative exploration, the accuracy of 3D visualiza-tion in diagnosing variant right hepatic artery was 100%, which was helpful in avoiding the misjudge of the vari-ant right hepatic artery in patients with right hepatic artery variation.Conclusion Three-dimensional visualiza-tion can accurately diagnose right hepatic artery variation before preoperation. It maybe contribute to formulating individual preoperative procedures for patients, increasing the success rate of surgical operations and decreasing the occurrence of postoperative complications.

目的 探讨Glisson蒂横断切肝技术是否为一种简便、安全、有效的技术手段.方法 选取2014年4月至2016年8月期间收治的23例明确为中肝癌的患者,并成功用Glisson蒂横断法中肝叶切除术,并做相应临床分析.结果 23例患者应用Glisson蒂横断切除中肝,术后恢复顺利,无术后肝衰竭、出血等并发症出现.结论 该方法是一种简单、安全、快捷有效的切肝技术,尤其对于中肝切除中防止肝门部保留侧肝蒂的作用尤为明显.

目的 探索肝胰十二指肠联合切除(hepatopancreatoduodenectomy,HPD)术对胆囊癌(NevinⅣ)的治疗价值.方法 对19例胆囊癌病人行HPD术,术前酌情行门静脉栓塞(portal vein embolization,PVE),行经皮经肝穿刺胆道引流术(percutaneous transhepatic cholanic drainage,PTCD)减黄;观察术中、术后有无严重并发症及术后生存时间.结果 19例HPD病人未出现术中大出血、死亡等并发症,但1例病人术后出现肺栓塞猝死,1例肝衰竭,1例术后出现严重的肺部感染死亡,其余病人不同程度出现胆瘘及胰瘘等并发症.结论 HPD手术对胆囊癌达到R0切除有较大价值,能明显提高病人生存时间,但术后有严重的并发症及较高的病死率,需谨慎实施.

Objective To review the diagnosis and surgical treatment of pancreatic fistula after pancreatoduodenectomy. Methods The clinical data of 7 patients with pancreatic fistula treated at this hospital from March 2012 to June 2014 after pancreatoduodenectomywere analyzed retrospectively. Results According to the diagnostic criteria and clinical grading system proposed by the International Study Group on Pancreatic Fistula ( ISGPF) in 2005, all the 7 patients were classified into grade C, with pancreatic fistula occurring in postoperative day 6-9.The amount of peritoneal drainage varied from 100 to 2 000 ml , and the amylase level in the drainage ranged from 2 000 IU/L to 9 000IU/L.Fever was found in all the 7 patients, but abdominal distension and abdominal or GI hemorrhage were noted in 6 patients respectively.All patients with postoperative pancreatic fistula were confirmed operatively to suffer from leakage of pancreaticojejunostomy.The original pancreatic-enteric anastomosis was removed and the jejunal stump was closed in 6 patients.In addition, the pancreatic duct stent was implanted with external drainage through the jejunum;the residual pancreas was removed in one patient.All patients underwent continuous abdominal lavage with negative-pressure drainage.Six patients were cured and discharged home, whereas one patient died of postoperative abdominal hemorrhage. Conclusion The ISGPF grading system for pancreatic fistula after pancreatoduodenectomy is of clinical significance.Pancreatic duct stent with external drainage and persistent peritoneal lavage with continuous negative pressure drainage are effective for the treatment of pancreatic fistula after pancreatoduodenectomy.

[目的]评估左肾静脉作为血管重建移植物在联合肠系膜上静脉切除重建胰十二指肠术中的应用.[方法]回顾分析接受联合肠系膜上静脉切除重建的胰十二指肠切除术的7例病例,并使用左肾静脉作为血管重建移植物.[结果]截取的左肾静脉平均长度约(4.8±0.2)cm,手术时间为(290±20)min,失血量为(400±30)ml,肠系膜上静脉阻塞时间为(25±3)min,术后住院疗程为(17±2)d.术后均未发生肾功能不全,术前术后血清肌酐和尿素氮无统计学差异(P＜0.05).术后增强CT及超声提示移植物无血栓形成以及狭窄.[结论]左肾静脉在联合肠系膜上静脉切除重建的胰十二指肠切除术中是一个方便的选择.

OBJECTIVE:To explore and find a new method to treat hilar cholangiocarcinoma with deep jaundice assisted by Da Vinci robot.METHODS:A hilar cholangiocarcinoma patient of type Bismuch-Corlette IIIa was found with deep jaundice (total bilirubin: 635 µmol/L). On the first admission, we performed Da Vinci robotic surgery including drainage of left hepatic duct, dissection of right hepatic vessels (right portal vein and right hepatic artery), and placement of right-hepatic vascular control device. Three weeks later on the second admission when the jaundice disappeared we occluded right-hepatic vascular discontinuously for 6 days and then sustained later. On the third admission after 3 weeks of right-hepatic vascular control, the right hemihepatectomy was performed by Da Vinci robot for the second time.RESULTS:The future liver remnant after the right-hepatic vascular control increased from 35% to 47%. The volume of left lobe increased by 368 mL. When the total bilirubin and liver function were all normal, right hemihepatectomy was performed by Da Vinci robot 10 weeks after the first operation. The removal of atrophic right hepatic lobe with tumor in bile duct was found with no pathologic cancer remaining in the margin. The patient was followed up at our outpatient clinic every 3 months and no tumor recurrence occurs by now (1 y).CONCLUSIONS:Under the Da Vinci robotic surgical system, a programmed treatment can be achieved: first, the hepatic vessels were controlled gradually together with biliary drainage, which results in liver's partial atrophy and compensatory hypertrophy in the other part. Then a radical hepatectomy could be achieved. Such programmed hepatectomy provides a new treatment for patients of hilar cholangiocarcinoma with deep jaundice who have the possibility of radical heptolobectomy.

目的 探讨带血管蒂组织瓣在医源性胆道损伤中的手术方式及效果.方法 对于11例腹腔镜胆囊切除术后胆道损伤的患者,分别使用脐静脉瓣、胃瓣、胆囊瓣、空肠瓣以及圆韧带瓣进行修复.结果 胆道修复术采用脐静脉瓣1例、胃瓣1例、胆囊瓣1例、空肠瓣4例以及圆韧带瓣4例.有1例患者术后出现胆瘘.所有患者于出院后肝功能指标及胆道影像学表现均基本正常.结论 医源性胆道损伤修复手术为围肝门操作的精细手术.带血管蒂组织瓣修复重建术在恢复胆道连续性以及降低术后并发症方面具有很好的效果.

BACKGROUND AND AIM:Sinistral portal hypertension (SPH) is a rare cause of upper gastrointestinal hemorrhage. Besides splenectomy, there is no consensus on the role of sclerotherapy and splenic embolization for bleeding gastric varices (GVs). This retrospective study summarizes our experience in managing GV bleeding from SPH in patients with pancreatic diseases.METHODS:Patients with pancreatic diseases who had bleeding GVs from SPH in two tertiary hospitals were reviewed from January 2001 to December 2011. The etiology, clinical manifestations, diagnostic and therapeutic modalities were analyzed.RESULTS:Twenty-one patients (15.2 %) complicating bleeding GVs among 139 patients with SPH secondary to pancreatic diseases were enrolled. The etiologies were acute pancreatitis in one patient, chronic pancreatitis in seven patients, and pancreatic tumors in 13 patients. Emergent endoscopic sclerotherapy was initially performed in five patients, and succeeded in two patients, while one patient died of massive hemorrhage. Initial transcatheter artery embolization using Gianturco coils was successfully performed in six patients. Splenectomy combined with other surgical procedures was undertaken for 15 patients. The patients undergoing artery embolization or splencetomy achieved hemostasis. The survivors had no recurrent bleeding during a median 72-month follow-up period.CONCLUSIONS:The incidence of bleeding GVs from SPH is relatively rare. Splenic artery embolization could be selected as a first-line choice for bleeding SPH, especially for patients in poor conditions, and sclerotherapy may not be preferentially recommended. Further studies are required to evaluate the optimum treatment algorithm for bleeding GVs from SPH.

原发性肝癌严重威胁着人类的健康,全球每年新增的病例数约为50万,其中54％发生在我国,且患者在3年内复发率高于60％,可见诊治形势十分严峻.肝癌的临床分期系统对于患者的预后评估以及选择何种治疗方案有着极其重要的意义.国内外虽有此类研究的相关内容,但将各种分期的评价及适用范围、发展趋势相结合进行分析的较少.本文对国际上多种常用的分期方案(TNM分期、Child-Pugh分期、Okuda分期、CLIP评分、JIS分期、CUPI指标、CIS记分)进行探讨,论述各种方案间的差异及相互关系,并对未来可能发展方向进行展望.经本文分析多项研究发现:TNM分期更适用于外科病人,Child-Pugh对肝功能受损的患者具有较好的预后价值,而Okuda、CLIP、JIS分期适用于不适合手术治疗的进展期病人,CUPI指数则对慢性乙肝患者有疗效,CIS适用于非手术治疗的患者.随着肿瘤分子生物学技术的进步,肝癌分期有可能上升到分子病理学的水平,肝癌切除的根治程度将划分得更为细致,以反映患者肝癌切除后所处状态的多种可能性,分子指标也将更加客观、敏感,有利于患者早期的诊断与治疗.