目的:研究内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)治疗胆总管巨大结石,分析先乳头球囊扩张再机械碎石与先碎石再乳头球囊扩张两组对取石效率及术后并发症发生的影响.方法:对2021年1月至2022年1月期间,于我院行ERCP取石治疗的40例胆总管巨大结石病人进行前瞻性研究.采用随机数字表法将病人随机分为先碎后扩组和先扩后碎组,每组各20例.比较两组的取石时间、取石效率(cm3/min)、结石残留率及术后胰腺炎发生率等参数的差异.结果:所有病人均通过一次ERCP完成取石.两组病人的结石最大径、结石单发或多发、结石总体积(cm3)、取石时间、操作时间差异均无统计学意义.先碎后扩组的取石效率高于先扩后碎组[(0.91±0.58)(cm3/min)比(0.51±0.17)(cm3/min),P=0.048],而器械出入乳头口次数少于先扩后碎组[(4.9±1.7)次比(7.9±2.2)次,P=0.021].两组术后结石残留率和ERCP术后胰腺炎发生率差异无统计学意义.先碎后扩组术后24 h淀粉酶水平[(196±158)U/L比(332±265)U/L,P=0.02]和高淀粉酶血症发生病例(2例比8例,P=0.028)显著低于先扩后碎组.两组均未出现重症胰腺炎、胃肠道出血、十二指肠穿孔等严重并发症.结论:ERCP治疗困难胆总管结石时采用先机械碎石后乳头球囊扩张的顺序可提高取石效率,减少取石器械出入乳头次数,并降低术后高淀粉酶血症的发生率.

目的 探讨内镜治疗结直肠癌根治术后吻合口漏疗效的影响因素.方法 回顾性分析2015年1月—2020年12月71例行内镜辅助治疗结直肠癌根治术后吻合口漏患者的临床资料,包括性别、年龄、术前血红蛋白水平、糖化血红蛋白、血清白蛋白水平、肿瘤位置、肿瘤分期、有无新辅助化疗史、吻合口漏发生时间、内镜治疗时间、漏口大小、内镜治疗方式、术后症状缓解情况、引流液量、住院时间等.将患者按治疗效果分为完全缓解组和部分缓解组,比较2组各项指标的差异.结果 71例患者中,42例内镜治疗后吻合口漏完全缓解,治疗有效率为59.15％;29例内镜治疗后漏口未完全闭合;吻合口漏治疗有效者的治疗后3 d平均引流液量少于吻合口漏未完全闭合者,差异有统计学意义(P＜0.01).完全缓解组与部分缓解组患者糖化血红蛋白水平、漏口大小、确诊吻合口漏至接受内镜治疗的时间比较,差异有统计学意义(P＜0.05或P＜0.01).多因素分析发现,确诊吻合口漏至接受内镜治疗时间、漏口大小、糖化血红蛋白水平是疗效的独立影响因素(P＜0.05或P＜0.01).结论 确诊吻合口漏至接受内镜治疗时间、漏口大小、糖化血红蛋白水平是内镜辅助治疗结直肠癌根治术后吻合口漏疗效的独立影响因素.当发生结直肠癌吻合口漏时,应积极控制血糖及糖化血红蛋白水平,行早期内镜治疗,并根据漏口大小选择合适的方式,从而使患者获得最大的临床受益.

Objective:To report pediatric endoscopic retrograde cholangiopancreatography (ERCP) intubation techniques and to analyze the influencing factors of pediatric ERCP in China.Methods:Retrospective analysis was performed on 90 cases of pediatric and adult ERCP operations respectively at Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2016 to June 2020. The anatomic data, intubation time, and endoscopic intubation measures were reviewed. The anatomic differences in duodenal papilla between the children and adults were analyzed to find the factors affecting ERCP intubation time in children.Results:There were 88 cases of successful infantile intubation with the success rate of 97.8%, and 90 cases of successful adult intubation with the success rate of 100.0%. The intubation time in the pediatric group was 187±67 s, and that in the adult group was 247±86 s with significant difference ( t=5.220, P<0.001). The duodenal diameter of pediatric patients was 3.38±1.57 cm, and that of adult patients was 5.94±1.87 cm with significant difference ( t=9.832, P<0.001). The horizontal distance from the duodenal bulb to the papilla in pediatric patients was 2.44±1.15 cm, which was significantly shorter than 4.22±1.43 cm in adult patients ( t=9.077, P<0.001). Most duodenal papillae in children were hemispherical [flat 26.1% (23/88), hemispherical 51.1% (45/88), cylindrical 22.7% (20/88)], while most of those in the adult patients were cylindrical [flat 9.1% (8/88), hemispherical 23.9% (21/88), cylindrical 67.0% (59/88)]. The factors influencing the intubation time of ERCP in children by univariate analysis included the shape of duodenal papilla, duodenal papilla hardness, visual region, distance from junction of duodenal bulb and descending part to duodenal papilla, distance from duodenal papilla to endoscope, and degree of incising. Conclusion:Shorter and stiffer duodenal papillae in children with normal papilla orientation are associated with shorter intubation time. These indicators are favorable factors for intubation.

Objective:To study the relationship between gastric fundus size and postoperative gastroparesis and to find effective ways to prevent postoperative gastroparesis in high-risk patients.Methods:We retrospectively reviewed the clinical data of 276 gastric cancer patients undergoing radical gastrectomy from 2015 to 2016. The gastric fundus volume/total gastric volume (FV/TV) ratio was measured by computed tomography (CT) and comparative study between the gastroparesis group and the non-gastroparesis group was carried out in terms of postoperative gastroparesis. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive performance. Single-factor and multiple-factor analyses were performed to filter clinically significant predictive factors of gastroparesis. Then, we increased the sample size to 304 patients whose FV/TV ratio was >19.4%. The different surgical methods and perioperative management of these patients were analysed. The chi-square test and logistic regression analysis were performed to identify effective independent factors for preventing gastroparesis.Results:The FV/TV ratio in the gastroparesis group was significantly higher than that in the non-gastroparesis group ( P<0.05). A cut-off value of 19.4% was selected by ROC curve analysis, at which the FV/TV ratio had a sensitivity of 76.2% and a specificity of 53.7%. In 304 patients in the second retrospective study, the incidence of gastroparesis was 9.2%. Gastroparesis was significantly reduced in patients with residual gastric size <1/3 ( P<0.05) and early postoperative gastrointestinal decompression ( P<0.05). Conclusions:The FV/TV ratio can effectively predict the risk of postoperative gastroparesis preoperatively. Small residual stomach and early postoperative gastrointestinal decompression are effective measures to prevent gastroparesis in high-risk patients.

间置阑尾重建术后并发症，特别是远期并发症相对罕见，本文报道了1例胆总管囊肿切除＋间置阑尾重建胆道术后病例，患者胆道重建术后26年胆管结石形成，拟行经内镜逆行胰胆管造影术诊治，术中造影提示间置阑尾狭窄段过长，考虑内镜下取石困难，予鼻胆管置入引流，术后建议患者择期行常规手术治疗。

胃-十二指肠梗阻合并胆道梗阻是进展期转移性肿瘤累及十二指肠及胆总管所致，此类病灶因无法手术切除常常选择内镜下姑息治疗，而放置自膨胀金属支架是解除解剖梗阻有效的姑息治疗手段。根据十二指肠梗阻部位与十二指肠大乳头的位置关系，可将梗阻分为3类，其相对应的最佳放置支架的方法有所不同。临床上胃-十二指肠梗阻与胆道梗阻发生顺序的差异也会影响支架的放置策略。本文归纳近期文献，对上述不同情况下支架的放置提供临床参考。

吻合口瘘是消化道手术术后较为严重的并发症之一.目前内镜下治疗吻合口瘘正逐步发展,与传统外科手术相比,具有安全、微创、低治疗成本等诸多优势.治疗方式包括内镜下空肠营养管置入术、金属夹闭合术、支架封堵术、组织胶封堵术、缝合术、真空辅助闭合治疗等.其相关的特点涉及:置入空肠营养管可以有效改善患者的营养状况;经内镜钳道内镜夹联合尼龙绳圈套器治疗直径＜1.0 em的吻合口瘘具有优势;外置内镜夹适用于瘘口较大、张力较大的吻合口瘘;内镜支架可以直接覆盖整个瘘口,早期控制渗漏,对于有腔道狭窄风险的患者有较高收益,但可能出现支架移位、移除困难等情况;组织胶联合内镜夹或支架有助于提高瘘口封堵成功率;内镜下缝合术用于预防支架移位安全有效;内镜下真空辅助闭合治疗能充分引流瘘口周围炎性环境,对于继发纵膈炎或胸腔内炎症的吻合口瘘患者具有更好的适用性.内镜微创治疗吻合口瘘避免了再次手术,可作为部分患者的优先治疗方式之一.

Objective: To investigate the feasibility and effectiveness of endoscopicretrograde cholangio-pancreatography(ERCP)in the management of long-term complications after pancreaticoduodenectomy. Methods: From January 2009 to July 2018, the clinical data of 62 patients with biliary or pancreatic long-term complications after pancreatoduodenectomy were reviewed at Department of General Surgery, and the corresponding ERCP were carried out in the multi-disciplinary cooperation.There were 39 males and 24 females.The age was 56.5 years(aging from 13 to 76 years). The time of treatment was 3 months to 20 years after pancreatoduodenectomy.The long-term biliopancreatic complications after pancreatoduodenectomy included 51 cases of biliary calculi, 42 cases of bilioenteric anastomotic stenosis with proximal bile duct dilatation, and 11 cases of pancreaticointestinal anastomosis stenosis with distal pancreatic duct dilatation.All patients received conventional duodenoscopy or single-balloon enteroscopy assisted ERCP under general anesthesia. Results: A total of 95 ERCP were performed in 62 patients, averaging 1.5 times per case.The long-term complications of cholangiopancreatic after pancreatoduodenectomy(ERCP indications) included 56 times of bile duct stones(58.9%), 45 times of bilioenteric anastomatic stricture(47.4%), 11 times of recurrent pancreatitis(11.6%), 6 cases(6.3%) of bilioenteric anastomatic foreign body, 3 times of intrahepatic bile duct stenosis(3.2%). Among the 95 times, 82 times(86.3%) achieved endoscopic endoscopy, 76 times(80.0%) were diagnosed successfully, and 72 times(75.8%) were successfully treated with ERCP.Small intestinal perforation occurred in 1 patient undergoing duodenoscopy, and then healed by surgical repair. Conclusion: Multi-disciplinary collaboration of ERCP is safe and effective in the treatment of long-term complications after pancreaticoduodenectomy, but the long-term effect still needs further clinical follow-up.

目的 探讨早期胃癌临床病理特征及多层螺旋CT(MSCT)在早期胃癌术前TNM分期中的价值.方法 单因素分析104例早期胃癌(黏膜内癌和黏膜下癌)患者的临床病理特征,并行MSCT术前TNM分期,与术后病理检查结果进行对照.结果黏膜内癌和黏膜下癌两组患者在pN分期上差异显著(P=0.0014),而在诸如年龄、性别、肿瘤位置、肿瘤最大径、胃切除类型、切除淋巴结数量、大体分型、肿瘤分化、淋巴管浸润、静脉浸润、神经浸润等临床病理特征上,两组患者无显著差异(P<0.05).MSCT对早期胃癌T分期准确率为84.62％(88/104);N分期准确率为77.89％(81/104),其中对pN0、pN1、pN2和pN3期判断的准确率分别为80.46％(70/87)、63.64％(7/11)、75％(3/4)和50％(1/2);TNM分期的准确率为83.65％(87/104),其中Ⅰ、Ⅱ、Ⅲ和Ⅳ期分期准确率分别为85.15％(86/101)、100％(1/1)、100％(0/0)和0％(0/2).结论 黏膜内癌和黏膜下癌患者在pN分期上存在明显差异. MSCT动态增强扫描对早期胃癌术前TNM分期具有重要的临床价值.

Objective:To analyze the clinicopathological factors affecting the prognosis of patients with Siewert typeⅡ/Ⅲ adenocarcinoma of esophagogastric junction (AEG), and the effect of different surgical methods on the quality of life.Methods:The clinical records of patients who were diagnosed with SiewertⅡ/Ⅲ AEG and received surgery from 2004 to 2015 were retrospectively analyzed.The patients followed up for at least 2 years were selected to perform survival analysis.The relationship between clinical pathological factors and prognosis of patients with Siewert Ⅱ/Ⅲ AEG was compared.The status of health-related quality of life at least 1 year after proximal gastrectomy (PG) or total gastrectomy (TG) was evaluated by a questionnaire.Results:A total of 325 patients with AEG were enrolled, including 157 patients with typeⅡAEG (48.3%) and 168 with type Ⅲ AEG (51.7%).The patients with type Ⅲ AEG were likely to have larger tumors, lower differentiation, more lymph node metastasis, and poorer prognosis (all P<0.05).The univariate analysis showed that tumor size, differentiation degree, tumor location, resection range, R0 resection, vessel and nerve invasive status, and TNM stage were the long-term prognostic factors in 284 patients who were followed up for at least 2 years.Correlation analysis showed that the positive rate of lymph node metastasis was negatively correlated with overall survival time (r=-0.520, P<0.001).In patients with typeⅡAEG, there was no significant difference in the 5-year survival rate and survival time between the PG group and the TG group (P>0.05).In patients with type Ⅲ AEG, the 5 year survival rate of the TG group was significantly lower than that of the PG group (P<0.05).The multivariate analysis indicated that T/N stage was an independent prognostic risk factor in typeⅡAEG patients, while TNM stage was an independent prognostic factor in type Ⅲ AEG patients.Multivariate prognostic analysis revealed that T/N stage was a risk factor for prognosis in patients with type Ⅱ AEG, while TNM staging was an independent risk factor for long-term survival in type Ⅲ AEG patients.Moreover, 55 patients completed questionnaires.The survey showed that the patients in the PG group suffered from more serious postoperative reflux as compared with the TG group (P<0.05), but there was no significant difference in other psychical functions and symptoms between the two groups.Conclusions:The patients with type Ⅲ AEG have large tumors, low differentiation, multiple lymph node metastasis and poor prognosis.Therefore, total gastrectomy may be feasible for these patients to ensure R0 resection and thorough cleaning.But for the patients with typeⅡAEG, PG and TG treatment did not affect long-term prognostic survival.

The application of precision surgery and minimally invasive techniques has become the general trend of biliary surgery in minimal invasive era. Concomitantly,endoscopy plays a pivotal, irreplaceable role. Endoscopic retrograde cholangiopancreatography (ERCP)-based duodenoscopy, choledochoscopy, multiple endoscopes, endoscopic ultrasonography and intraductal ultrasonography have been effective and widely used in the diagnosis and treatment of biliary tract diseases. However, it can not be ignored currently is that in the process of application and generalization of endoscopic technology, there exist some problems such as lacking of available industry standards, operating procedures are not enough, malfunctioning physician training system. Biliary surgeons should strictly master the operation indication and pay fully consideration to the reasonable and standard application of endoscopic technique in the diagnosis and treatment of biliary tract diseases.

Objective To investigate the application of endoscopic retrograde cholangiopancreatography (ERCP) in pancreatic duct injury. Methods Fourteen patients with pancreatic duct injury who were diagnosed and treated with ERCP in Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine between August 2006 and February 2014 were retrospectively analyzed. Among them, 9 were males and 6 were females, aged 6-77 years old with a median age of 58 years old. Six patients were diagnosed with closed pancreatic injury. Eight cases were complicated with pancreatic fistula after surgery, 3 of whom underwent distal pancreatectomy and 5 underwent distal pancreatectomy combined with splenectomy. The informed consents of all patients were obtained and the local ethical committee approval was received. Patients diagnosed with closed pancreatic injury underwent ERCP. According to the imaging result and American Association for the Surgery of Trauma (AAST) classification, therapeutic measures such as endoscopic retrograde pancreatic drainage (ERPD), and endoscopic retrograde biliary drainage (ERBD) + ERPD were performed. Patients with pancreatic fistula after surgery received ERCP for diagnosis and drainage therapy. The recovery status and incidence of ERCP-related complications after ERCP diagnosis and treatment were observed. Results Six cases were confirmed with closed pancreatic injury by ERCP. According to the AAST classification, 4 cases with grade Ⅲ injury underwent ERPD, and 2 with grade IV injury underwent ERBD + ERPD. Eight cases with pancreatic fistula after surgery were all found with pancreatic duct injury by ERCP and then underwent ERPD. The median healing time of pancreatic fistula after surgery was 16(12-25)d. No severe complication was observed during the treatment of ERCP. All patients were recovered and discharged after ERCP treatment. Biliary and pancreatic duct stents were removed 3 months after discharge. Conclusions ERCP has the advantages of safty and minimally invasion for the diagnosis and treatment of pancreatic duct injury.

It is highly desirable to develop a rapid and simple method to detect pathogens. Combining nanomaterials with electrochemical techniques is an efficient way for pathogen detection. Herein, a novel 3D Ag nanoflower was prepared via a biomineralization method by using bovine serum albumin (BSA) as a template. It was adopted as a sensing interface to construct an electrochemical bacteria immunosensor for the rapid detection of foodborne pathogens Escherichia coli ( E. coli ) O157:H7. Bacterial antibody was immobilized onto the surface of Ag nanoflowers through covalent conjugation. Electrochemical impedance spectroscopy (EIS) was used to detect and validate the resistance changes, where [Fe(CN) 6 ] 3−/4− acted as the redox probe. A linear relation between R et and E. coli concentration was obtained in the E. coli concentration range of 3.0 × 10 2 –3.0 × 10 8 cfu mL −1 . The as-prepared biosensor gave rise to an obvious response to E. coli but had no distinct response to Cronobacter sakazakii , methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus albus , Lactobacillus easei , and Shigella flexneri , revealing a high selectivity for the detection of the pathogens down to 100 cfu mL −1 in a short time. We believe that this BSA-conjugated 3D Ag nanoflowers could be used as a powerful interface material with good conductivity and biocompatibility for improving pathogen detection and treatment in the field of medicine, environment, and food safety.

上消化道手术后病人的经内镜逆行性胰胆管造影（endoscopic retrograde cholangio-pancreatography,ERCP）的操作难度明显高于正常解剖结构的病人,而全胃切除Roux-en-Y重建术后的ERCP操作难度更高,成功率更低,大部分病人不得不接受创伤更大、风险更高的常规再次手术。本文应用十二指肠镜下球囊造影引导进镜法来完成全胃切除Roux-en-Y重建术后ERCP诊断和治疗。现报告如下。1资料与方法1.1临床资料回顾性分析2012年8月至2014年9月上海交通大学医学院附属新华医院普外科收治的8例全胃切

Long non-coding RNA (lncRNA) metastasis-associated lung adenocarcinoma transcript 1 (Malat1) functions as an oncogene in many types of human cancer. In this study, we show that Malat1 is overexpressed in gallbladder cancer (GBC) tissue and cells. The high Malat1 levels correlated positively with tumor size and lymphatic metastasis, and correlated negatively with overall survival. We also show that Malat1 functions as a competing endogenous RNA (ceRNA) for miR-206. Because miR-206 directly suppresses expression of ANXA2 and KRAS, which are thought to promote GBC progression, Malat1 binding of miR-206 in GBC tissue and cells has an oncogenic effect. Conversely, Malat1 knockdown inhibits proliferation and invasion by GBC cells while increasing apoptosis. In vivo, silencing Malat1 decreases tumor volume. These results suggest Malat1 could potentially serve as a therapeutic target and prognostic marker for GBC.

ERCP已经成为胆胰管疾病重要的诊治手段，选择性胆管插管是ERCP关键步骤。文献报道选择性胆管插管成功率一般在90％，在选择性插管15 min后仍有10％左右的患者插管失败，即所谓的困难插管，需行十二指肠乳头肌开窗术等方法才能成功进行胆管插管［1］。但是否每例患者均需常规插管时间15 min以后方可选择十二指肠乳头肌开窗术，选择性胆管插管过程中如何进行适时的乳头肌开窗尚无定论。本研究旨在探讨有经验ERCP 医师选择十二指肠乳头肌开窗在胆管插管过程中的合理运用时机。

Objective To explore the clinicopathological characters of T2 gastric cancer and the value of MSCT in the preop‐erative TNM staging of T2 gastric cancer .Methods A total of 93 patients with T2 gastric cancer were included in our study and un‐derwent preoperative MSCT staging ,who were confirmed by pathologic results .Then the results were compared with those of path‐ologic TNM staging .Also the clinicopathological features of the T2 gastric cancer were analyzed .Results There were no statistical‐ly significant differences in the clinicopathological characters among T2a and T2b patients (P>0 .05) .Comparing with pathologic TNM stage ,the T staging accuracy of MSCT was 91 .40% (85/93) ,the N staging accuracies of CT was 66 .67% (62/93) ,in which , 68 .18% (30/44) ,65 .00% (26/40) ,60 .00% (3/5) and 75 .00% (3/4) were for pN0 ,pN1 ,pN2 and pN3 .And the TNM staging ac‐curacies of CT was 67 .74% (63/93) ,in which ,68 .18% (30/44) ,64 .10% (25/39) ,60 .00% (3/5) and 100% (5/5) were for stageⅠ ,Ⅱ ,Ⅲ and Ⅳ .Conclusion There are no significant different on clinicopathology features among T2a and T2b patients .MSCT can clearly determine the preoperative TNM staging of T2 gastric cancer .

Objective To analyze the clinical characteristics and operation risk of gastric cancer patients of different ages. Methods The data of 463 gastric cancer patients undergoing radical gastrectomy between January 2012 and June 2014 were analyzed retrospectively. The patients were divided into 3 groups:younger than 65 years old group,65-80 years old group and older than 80 years old group,explore whether there are differences between the clinical and pathological data of these 3 groups. Results There was no significant difference in the constituent ratio of male and female,operative method,pathological characteristics and postoperative complications (P>0.05) between the three groups. Patients in older than 80 years old group have more preoperative complications compared with the other two groups (P<0.05). Conclusion Although elderly patients have more preoperative complications,the surgical risk is not increased.

Human cytomegalovirus infects the majority of humanity which may lead to severe morbidity and mortality in newborns and immunocompromised adults. Humoral and cellular immunity are critical for controlling CMV infection. HCMV envelope glycoprotein complexes (gC I, II, III) represent major antigenic targets of antiviral immune responses. The gCIII complex is comprised of three glycoproteins, gH, gL, and gO. In the present study, DNA vaccines expressing the murine cytomegalovirus homologs of the gH, gL, and gO proteins were evaluated for protection against lethal MCMV infection in the mouse model. The results demonstrated that gH, gL, or gO single gene immunization could not yet offer good protection, whereas co-vaccination strategy apparently showed effects superior to separate immunization. Twice immunization with gH/gL/gO pDNAs could provide mice complete protection against lethal salivary gland-derived MCMV (SG-MCMV) challenge, while thrice immunization with pgH/pgL, pgH/pgO or pgL/pgO could not provide full protection. Co-vaccination with gH, gL and gO pDNAs elicited robust neutralizing antibody and cellular immune responses. Moreover, full protection was also achieved by simply passive immunization with anti-gH/gL/gO sera. These data demonstrated that gCIII complex antigens had fine immunogenicity and might be a promising candidate for the development of HCMV vaccines.

We selected the conserved sequence in the stalk region of influenza virus hemagglutinin (HA) trimmer, the long alpha helix (LAH), as the vaccine candidate sequence, and inserted it into the major immunodominant region (MIR) of hepatitis B virus core protein (HBc), and, by using the E. coli expression system, we prepared a recombinant protein vaccine LAH-HBc in the form of virus-like particles (VLP). Intranasal immunization of mice with this LAH-HBc VLP plus cholera toxin B subunit with 0.2% of cholera toxin (CTB*) adjuvant could effectively elicit humoral and cellular immune responses and protect mice against a lethal challenge of homologous influenza viruses (A/Puerto Rico/8/1934 (PR8) (H1N1)). In addition, passage of the immune sera containing specific antibodies to naïve mice rendered them resistant against a lethal homologous challenge. Immunization with LAH-HBc VLP vaccine plus CTB* adjuvant could also fully protect mice against a lethal challenge of the 2009 pandemic H1N1 influenza virus or the avian H9N2 virus and could partially protect mice against a lethal challenge of the avian H5N1 influenza virus. This study demonstrated that the LAH-HBc VLP vaccine based on a conserved sequence of the HA trimmer stalk region is a promising candidate vaccine for developing a universal influenza vaccine against multiple influenza viruses infections.