Objective:To investigate the effect of anatomic hepatectomy（AR）and non-anatomic hepatectomy（NAR）led by the third liver pedicle on the prognosis of liver cancer patients.Methods:The clinical data of 89 patients with primary liver cancer who underwent hepatectomy from July 2015 to December 2017 were retrospectively analyzed. According to different surgical methods，they were divided into AR group（n=45）and NAR group（n=44）. The data were processed by SPSS 22.0 software. The perioperative indicators and liver zymogram changes of the two groups were expressed as（xˉ±s），and independent t test was used. χ2 or Fisher exact test was used for postoperative complications and positive rate of surgical margin. The postoperative recurrence rate was analyzed by Log-Rank test. P<0.05 was statistically significant.Results:The blood loss and positive rate of surgical margin in AR group were significantly lower than those in NAR group（blood loss：414 ml vs. 973 ml，P<0.01；The positive rate of surgical margin was 0% vs. 10%，P=0.056），and the recurrence rate at 6 and 12 months after surgery was significantly lower than that in the NAR group（6.7% vs. 20.5%，P=0.058；15.6% vs. 40.9%，P=0.008）；The operation time in AR group was significantly longer than that in NAR group（325 min vs. 270 min，P=0.041）. The liver function of AR group was less affected after operation（P<0.01），and the comparison between the two groups was statistically significant. There was no significant difference in the incidence of postoperative serious complications between the two groups（P>0.05）.Conclusion:Compared with non-anatomical hepatectomy，anatomical hepatectomy led by the third hepatic pedicle is a more appropriate surgical method for the treatment of liver cancer，with less intraoperative blood loss，less postoperative liver function impact，and lower postoperative recurrence rate.

原发性肝癌是临床上常见恶性肿瘤之一,其中肝细胞癌(hepatocellular carcinoma,HCC)占90％,其发病率在全球范围内一直呈上升趋势,在全球每年新发和病死的HCC中,中国占比>50％;高居中国肿瘤发病的第3、4位和肿瘤死因的第2、3位 [1],其中66.7％～77.2％的HCC患者死于肝内肿瘤未控 [2].由于HCC起病隐匿、进展迅速、侵袭性高和早期诊断困难,多数确诊时已属中晚期或发生远处转移,大部分患者丧失了最佳手术治疗时机,而高复发率和过早远处转移是治疗HCC的一大困境[3,4].其中,以肺转移最常见,占肝外转移的39.5％～53.8％,HCC肺转移患者预后极差,中位总生存期(median overall survival,mOS)仅为5.9～8.8个月.

目的 总结分析感染坏死性胰腺炎(infected necrotizing pancreatitis,INP)感染坏死灶在CT影像学上的解剖学位置与分布特点,并据此对INP进行临床分型,为INP的外科处理提供参考.方法 选取解放军总医院第一医学中心和第四医学中心2008年6月6日至2014年12月31日INP病例112例,根据INP感染坏死灶CT影像学中位置分为五个区域:胰腺区域、网膜囊区、脾胃间隙区、左侧腹膜后间隙区、右侧腹膜后间隙区;据此分为三型:I型,感染灶位于胰腺区域,局限于胰腺实质组织、胰腺包膜周围脂肪组织、胰腺下沿肠系膜根部脂肪组织.II型,感染灶扩散至胰腺周围,包括网膜囊和脾胃间隙,IIa型感染灶扩散至网膜囊,Ⅱb型感染灶扩散至脾胃间隙,Ⅱc型感染灶同时存在于网膜囊和脾胃间隙.III型,感染灶扩散至侧腹膜后间隙,IIIa型感染灶扩散至左侧腹膜后间隙,IIIb型感染灶扩散至右侧腹膜后间隙,IIIc型感染灶扩散至左、右侧腹膜后间隙.结果 112例INP患者共204个感染灶分别位于胰腺区域42个、网膜囊区43个、脾胃间隙区16个、左侧腹膜后间隙区68个、右侧腹膜后间隙区35个.I型12例(10.7％);II型14例(12.5％),其中IIa型8例,IIb型5例,IIc型1例;III型86例(76.8％),其中IIIa型51例,IIIb型17例,IIIc型18例.结论 INP感染灶沿着胰周间隙,尤其是腹膜后间隙有着特征性扩散分布,根据该特征进行的INP分型,对INP治疗方案的选择和操作步骤的优化有指导作用.

随着对肝脏血管和胆道的解剖结构的深入了解,解剖性肝切除已逐渐得到广泛应用,并从解剖性肝叶切除逐渐精确到解剖性肝段切除.为进一步提高解剖性肝段切除的手术安全性,规范手术流程,本文拟以肝Ⅷ段切除为例,从术前评估的标准化、手术步骤的标准化以及术后管理的标准化等方面对以第三级肝蒂为主导的解剖性肝段切除制定标准化流程,为解剖性肝段切除的手术步骤和围手术期管理提供规范化参考.

Objective:To explore the expression of microRNA-338-3p (miR-338-3p) in hepatocellular carcinoma and its relationship with clinicopathological parameters.Methods:A total of 67 hepatocellular carcinoma tissue samples obtained by surgery from January 2015 to June 2016 in our hospital were selected,and adjacent normal tissue samples matched to each hepatocellular carcinoma tissue sample were selected.The miR-338-3p in tissue samples of the two groups were detected by the real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR),and the relationship between miR-338-3p and clinicopathologic features of hepatocellular carcinoma was analyzed.Results:There were 45 cases (67.16％) ofmiR-338-3p down expression,22 cases (32.85％) of up expression;RT-qPCR results showed that the relative content of miR-338-3p in hepatocellular carcinoma tissues was (0.76± 0.38),lower than (1.23 ± 0.45) in the adjacent normal tissues,the difference was statistically significant (t=-6.259,P=0.000).The expression down-regulation rate of miR-338-3p in hepatocellular carcinoma tissue samples of patients with poorly differentiated,Ⅲ&V stages of TNM,T3&T4 stages of tumor infiltrating depth,lymph node metastasis were higher than those with well differentiated,Ⅰ&Ⅱ stages,T1&T2 stages,without lymph node metastasis,the differences were statistically significant (P＜0.05).The differences of the expression down-regulation rate ofmiR-338-3p in different gender,age,pathological type and tumor size were not statistically significant (P＞0.05).Conclusion:MiR-338-3p expression was low in hepatocellular carcinoma tissues,which may be related to the degree of differentiation,TNM stage,depth of tumor invasion and lymph node metastasis.MiR-338-3p may be involved in the development and progression of hepatocellular carcinoma,and early detection ofmiR-338-3p can be used as an indicator to evaluate hepatocellular carcinoma condition.

Objective To investigate the clinical effect of selective hepatic inflow occlusion on laparoscopic liver resection, and compare with total hepatic blood flow occlusion. Method Selected 62 patients who were subject to laparoscopic liver resection by hepatic inflow occlusion from January 2010 to December 2015 in our hospital, they were devided into two groups by intraoperative blood flow. Control group patients were treated with intermittent total hepatic inflow occlusion, and observation group patients were treated with selective hepatic inflow occlusion. Operation time, amount of bleeding during operation, postoperative hospital day, liver function and postoperative complication rate were compared between the two groups. Result There were no significant differences in amount of bleeding during operation, operation time and postoperative hospital day between the two groups (P > 0.05). The concentration of ALT and AST of observation group were lower than control group on the first, third and seventh postoperative day respectively (P < 0.05), the level of PA was higher than control group (P > 0.05), There were no significant differences in the levels of albumin, total bilirubin and direct bilirubin between the two groups (P > 0.05). There was no significant difference in the incdence of postoperative complications between the two groups (P > 0.05). Conclusion Both of the selective hepatic inflow and total hepatic inflow occlusion can control liver blood flow and decrease bleeding on laparoscopic liver resection. Moreover, the selective hepatic inflow can protect liver function better.

Objective To compare the advantages and disadvantages of ERCP and laparoscopic common bile duct exploration for the treatment of gallbladder stones combined with common bile duct stones.Methods The therapeutic results of 197 cases who underwent ERCP or LCBDE were reviewed retrospectively to find out the advantages and disadvantages of the two operations.Results There are 6 cases operation failure,32 cases acute pancreaitis,1 case duodenum perforation and 3 cases common bile duct stones recurrence in the ERCP group(99 cases).There are no operation failure,8 cases with T-tube drainage,no serious complications and no bile duct stones recurrence in the LCBDE group(98 cases).The hospital stay time and hospital costs of LCBDE group is lower than the ERCP group[(5 ± 2) d vs (3 ± 1) d,(2.23 ± 0.85) Million yuan vs (1.73 ± 0.43) Million yuan].Conclusions The ERCP and LCBDE are effective methods for the treatment of Gallbladder stones combined with common bile duct stones.For most patients,the LCBDE is the first choice method,and for some special patient,ERCP is a good choice.

RNF43 is a novel tumor suppressor protein and known to be expressed in a multitude of tissue and dysregulated in cancers of these organs including ovarian and colorectal tissues. RNF43 expression has been shown to be expressed in mutated forms in several pancreatic cell lines. RNF43, by virtue of being an ubiquitin ligase, has the potential to ubiquitinylate membrane receptors like frizzled that subserves sensing Wnt soluble signals at the cell membrane. Thus, normally, RNF43 downregulates Wnt signaling by removing frizzled receptor from the membrane. In the present study, the expression of the tumor suppressor RNF43 was examined in human patient samples of pancreatic ductal adenocarcinoma (PDAC). Reduced levels of expression of RNF43 in PDAC were demonstrated by Western blotting. We incorporated membrane biotinylation assay to examine the expression of frizzled6 receptor in the membrane and demonstrated that it is significantly increased in PDAC tissues. This may be responsible for enhanced Wnt/beta-catenin signaling and provides the first level of evidence of a possible role of this well-known pathway in pancreatic exocrine carcinogenesis. We have utilized appropriate controls to ensure the true positivity of the findings of the present study. The contribution of Wnt/beta-catenin/RNF43 pathway in pancreatic carcinogenesis may provide for utilization of pharmacologic resources for precision-based approaches to treat pancreatic ductal adenocarcinoma.

Objective To investigate the effect of laparoscopic cholecystectomy (LTCBDE) in treatment of patients with secondary extrahepatic bile duct stones. Methods Eighty-seven cases of our hospital patients with secondary to extrahepatic bile duct stones were randomly divided into the laparoscopic bile duct exploration and T tube drainage surgery (LCBDE) treatment group and the laparoscopic transcystic duct exploration of common bile duct lithotomy (ltcbde) treatment group. The observation focused on the operation time, bleeding volume , postoperative transfusion , postoperative drainage time , postoperative hospitalization time , cost of hospitalization, postoperative recovery time and complications compared clinical efficacies. Results LTCBDE group of patients in operation time (2.1 ± 0.5) was longer than that of the control group (1.6 ± 0.4), (P <0.001), while the bleeding volume, postoperative fluid volume, postoperative drainage time, postoperative hospitalization time, hospitalization expenses and postoperative recovery time were (17.4 ± 5.4), (6 550.4 ± 1 076.9), (3.5. 1.6), (4.1 ± 1.7), (12 243.5 ± 2 379.6), (11.3 ± 3.5) were lower than that of the group LCBDE (22.1 ± 7.5), (8 304.2 ± 1 394.8), (32.9 ± 10.4), (6.4 ± 2.4), (14 098.1 ± 2 897.3), (16.1 ± 5.7) P, respectively (P values were defined as 0.001, 0, 0, 0.015, 0.001, 0 individually); LTCBDE group of patients with bile leakage, acute peritonitis rates were 1/46,1/46,in which those were lower than the corresponding LCBDE in 6/41, 7/41 (P values were 0.033, 0.016, separately). Conclusion According to indications, LTCBD surgery has the advantages of less injury, less cost, less complications and so on. It has important significance to improve the condition of patients with secondary extrahepatic bile duct stones.

Objective To compare the superiority between laparoscopic surgery and laparotomy in treating acute gangrenous cholecystitis. Methods The 84 patients with acute gangrenous cholecystitis were collected from Jan. 2010 to Oct. 2015, which were divided into LC group ( 53 cases ) and OC group (31 cases). The intraoperative and postoperative situations of the two groups were compared. Results All the 84 patients were operated successfully. No difference existed in operation time and costs(P>0. 05), but the difference in amount of intraoperative bleeding[(86. 7 ±12)ml vs (120. 4 ± 18) ml], length of incision [(3. 1 ± 0. 4)cm vs (13. 2 ± 2. 7)cm], pain rating index[(5. 3 ± 2. 1) marks vs (8. 6 ± 1. 9) marks], intestinal function recovery time[(20. 6 ± 6. 5) h vs (34. 5 ± 4. 7) h], wound infection rate (1. 8% vs 12. 9%),hospital stay time[(7. 6 ± 1. 8) d vs (13. 4 ± 4. 8)d] and changes of serum bilirubin level was sta-tistically significant (P<0. 05),The LC group was better than OC group. Conclusions Under the strict selection of operation indications and premise surgery operation, LC in treating acute gangre-nous cholecystitis has short hospitalization time and low cost of hospitalization.

Objective To evaluate the clinical efficacy of modified Chen's biliojejunostomy technique in treating hilar cholangiocarcinoma.Methods The clinical data of the patients with hilar cholangiocarcinoma from January 2011 to June 2014 in the PLA general hospital and its first affiliated hospital were retrospective ly studied,and 17 of them underwent modified biliojejunostomy.There were 10 male and 7 female patients with a mean of 65 years old (range 34 ～82).Cases diagnosed as Bismuth-Corlette Type Ⅱ,Ⅲ a,Ⅲ b and Ⅳ were 2,6,4,and 5,respectively.Results Liver segment Ⅳ were resected from 2 patients,segment Ⅳ + Ⅴ from 7 patients and segment Ⅳ + Ⅴ + Ⅰ from 8 patients.No death was observed during the study period.One patient had mild bile leakage,2 patients had cholangititis,and another patient had biliary intestinal anastomotic bleeding.Three patients received resection and reconstruction of the portal vein.Three right hepatic arteries and 1 anterior branch of right hepatic artery were resected in combination with the tumor because of invasion.All the complications were alleviated under conservative treatment.Twelve cases had been followed up for a median time of 16 months (range 3 ～ 24).Two cases had cholangititis intermittently.One case underwent radiotherapy because of local recurrence in 2 years after the surgery.MRCP and relevant enzymes were within the normal range.Conclusion Modified Chen's biliojejunostomy is a simple,effective and safe method,which can be widely used when there are multiple biliary intestinal anastomoses.

目的:探讨复方利多海浮膏用于治疗混合痔外剥内扎术后肛缘疼痛和水肿的临床疗效.方法:选择2012年7月-2014年12月在我院接受混合痔外剥内扎术治疗的患者70例,随机分为治疗组和对照组,每组各35例.治疗组采用复方利多海浮膏外敷换药治疗,对照组采用黄连膏换药治疗.观察并比较两组患者治疗前后肛缘疼痛和水肿的变化情况.结果:两组患者术前疼痛评分及肛缘水肿得分差异无统计学意义(P＞0.05);治疗组患者治疗后1天、2天、3天、5天的疼痛评分和肛缘水肿得分均显著低于对照组,差异有统计学意义(P＜0.05);治疗组患者治疗总有效率显著优于对照组,差异有统计学意义(P＜0.05).结论:复方利多海浮膏外敷换药用于治疗混合痔外剥内扎术后肛缘疼痛和水肿方面的疗效更好.

AIMTo investigate the feasibility of temporary extracorporeal continuous porta-caval diversion (ECPD) to relieve portal hyperperfusion in "small-for-size" syndrome following massive hepatectomy in pigs.METHODSFourteen pigs underwent 85%-90% liver resection and were then randomly divided into the control group (n = 7) and diversion group (n = 7). In the diversion group, portal venous blood was aspirated through the portal catheter and into a tube connected to a centrifugal pump. After filtration, the blood was returned to the pig through a double-lumen catheter inserted into the internal jugular or subclavian vein. With the conversion pump, portal venous inflow was partially diverted to the inferior vena cava through a catheter inserted via the gastroduodenal vein at 100-130 mL/min. Portal hemodynamics, injury, and regeneration in the liver remnant were compared between the two groups.RESULTSCompared to the control group, porta-caval diversion via ECPD significantly mitigated excessive portal venous flow and portal vein pressure (PVP); the portal vein flow (PVF), hepatic artery flow (HAF), and PVP in the two groups were not significantly different at baseline; however, the PVF (431.8 ± 36.6 vs 238.8 ± 29.3, P < 0.01; 210.3 ± 23.4 vs 122.3 ± 20.6, P < 0.01) and PVP (13.8 ± 2.6 vs 8.7 ± 1.4, P < 0.01; 15.6 ± 2.1 vs 10.1 ± 1.3, P < 0.05) in the control group were significantly higher than those in the diversion group, respectively. The HAF in the control group was significantly lower than that in the diversion group at 2 h and 48 h post hepatectomy, and ECPD significantly attenuated injury to the sinusoidal lining and hepatocytes, increased the regeneration index of the liver remnant, and relieved damage that the liver remnant suffered due to endotoxin and bacterial translocation.CONCLUSIONECPD, which can dynamically modulate portal inflow, can reduce injury to the liver remnant and facilitate liver regeneration, and therefore should replace permanent meso/porta-caval shunts in "small-for-size" syndrome.

目的 评价右半肝阻断技术结合陈氏绕肝双悬吊法在右后叶肝肿瘤切除术中的应用价值.方法 2011年1月至2015年1月,在37例解剖性肝脏右后叶切除术中应用持续右半肝及陈氏绕肝双悬吊法辅助肝切除.右后叶肝肿瘤行右后叶切除时,采取持续右半肝阻断技术并结合陈氏绕肝双悬吊法经下腔静脉右侧放置2根提肝带,离断肝实质的过程中通过牵拉提肝带辅助肝切除.结果 全组共37例肝右后叶肿瘤病人行肝右后叶肿瘤切除术.术中均成功分离出右半肝肝蒂和右后叶肝蒂,游离右肝后均成功放置绕肝提拉带,断肝时行右半肝持续肝门阻断,术中无胆管损伤、肝短静脉、肝右静脉撕裂和大出血等相关操作并发症.肝实质离断时间17～28 min,阻断时间约20～30min,术中出血量60～330 ml.术后第1天丙氨酸转氨酶(ALT) 183～352 U/L,生化指标均在1周内恢复正常,无围手术期死亡.结论 右半肝持续阻断结合陈氏绕肝双悬吊法有助于减少右后叶肝切除术中出血量以及改善手术野,缩短肝实质离断时间,减轻肝脏缺血再灌注损伤,其操作简单、使用安全、适用范围广泛.

Objective: To investigate the hemorrhoid on mucosal fibrotomy(Procedure for Prolapse and Hemorrhoids, PPH) and the anus stapling rectum Resection(Stapled Trans-anal Rectal Resection, STARR) clinical curative effect for the treatment of type outlet obstruction constipation. Methods: 100 cases with constipation who were treated in our hospital from May 2012 to May 2014 were selected and randomly divided into PPH group and STARR group with 50 cases in each group, respectively, for the treatment of PPH and STARR. To observe and compare the two groups before and after treatment in patients with type Longo outlet obstruction constipation score and Wexner constipation severity score. Results: two groups of patients with intraoperative blood loss, there was no statistically significant difference(P0.05); PPH group, operation time, length of hospital stay and cost of treatment in patients with significantly less than STARR group, the difference was statistically significant(P0.05). Two groups of patients, there was no difference in the incidence of complications, no statistical significance(P0.05). Two groups of patients with preoperative Longo grade and Wexner comparison,there was no statistically significant difference(P0.05); Postoperative STARR score lower than that of PPH group, the difference was statistically significant(P0.05). Conclusion: Compared with the anus stapling rectum resection, hemorrhoids mucosa fibrotomy operation simple, easier accepted by patients, worthy of clinical popularization and application.

目的:研究Rouviere沟引导定位对腹腔镜胆囊切除术的应用价值.方法:选择2010年7月至2014年10月在我院进行胆囊切除术的患者300例,根据手术方式不同将患者分为研究组和对照组,每组各150例.研究组患者在Rouviere沟引导下行腹腔镜胆囊切除术,对照组采用传统定位手术.观察并比较两组手术时间、并发症及手术效果.结果:研究组患者Rouviere沟分型为开放型89例(59.33％)、融合型32例(21.33％)、缺失型29例(19.33％),分型的性别构成存在统计学意义(P＜0.05);与对照组比较,研究组手术时间较短、并发症少和中转开腹率低,差异有统计学意义(P＜0.05).两组术后未出现任何病例胆管损伤和手术死亡,手术后恢复较好.结论:Rouviere沟引导定位行腹腔镜胆囊切除术的临床效果较好,值得临床进一步推广应用.

目的:探讨Src激酶特异性抑制剂PP2对人胆管癌QBC939细胞侵袭能力的影响和机制.方法:通过Western Blotting技术检测PP2对人胆管癌QBC939细胞中Src激酶活化的影响;用Transwell小室法观察PP2对QBC939细胞的影响;用RT-PCR和Western Blotting技术检测PP2对QBC939细胞侵袭能力相关分子的作用.结果:实验组p-Src蛋白表达水平明显低于对照组,差异具有统计学意义(P＜0.05);实验组QBC939细胞体外侵袭能力较对照组显著降低,差异具有统计学意义(P＜0.05);与对照组相比,实验组E-cadherin表达显著增强,CD44表达明显减弱,差异具有统计学意义(P＜0.05).结论:PP2通过抑制Src激酶活化,增强E-cadherin表达、减弱CD44表达,抑制人胆管癌QBC939细胞侵袭能力.

目的:探讨单孔腹腔镜辅助整形术(TUES)对急性胆囊炎患者腹壁美观及其肝功能的影响.方法:选取我院急性胆囊炎择期手术患者130例,随机分为观察组和对照组.观察组采用经脐单孔腹腔镜胆囊切除术联合整形术,对照组采用三孔腹腔镜胆囊切除术.观察并比较两组手术时间、术后疼痛评分、切口满意度及肝功能指标的变化情况.结果:与对照组比较,观察组患者手术时间长,术后疼痛评分低,患者对切口美观满意度高,差异具有统计学意义(P＜0.05).两组住院日无显著差异(P＞0.05).两组患者术前ALT、AST和ALP水平无显著差异(P＞0.05).两组患者术后ALT、AST和ALP水平均高于术前,组内比较差异具有统计学意义(P＜0.05).观察组患者术后ALT、AST和ALP水平低于对照组,组间比较差异具有统计学意义(P＜0.05).结论:单孔腹腔镜辅助整形术能够改善急性胆囊炎患者病情,提高腹壁美观效果,而且对肝功能影响较小,值得临床推广.

目的 评价陈氏绕肝提拉法在右半肝切除术中的应用价值.方法 右肝巨大肿瘤行右半肝切除时,采取陈氏绕肝提拉法经下腔静脉右侧放置提肝带,离断肝实质的过程中通过牵拉提肝带辅助肝切除.结果 全组共32例右肝巨大肿瘤患者行右半肝切除术,其中前入路肝切除15例,经典入路17例.术中均成功放置提肝带,放置和牵拉过程中无肝短静脉撕裂和大出血等相关并发症.32例肝切除术的肝实质离断时间约25～45 min,肝门阻断时间约20～32 min,术中出血量300～1 300ml.所有患者无围手术期死亡.结论 陈氏绕肝提拉法有助于右半肝切除术中手术野的显露,缩短肝实质离断时间,减少肝实质离断过程中的出血;且其操作简单、使用安全、适用范围广泛.