如何有组织、成系统、熟练灵活地综合运用烧伤理论知识及实践技能进行烧伤急救,是目前烧伤教学的难点.VR技术具有浸没感、交互性、多感知性等优点,已广泛应用于医学教育.该文结合烧伤教学的现状及VR技术的优势,探讨VR技术在烧伤临床教学中的应用前景.

目的 探讨腹腔镜下倒刺线行吻合口全层连续缝合加固对中低位直肠癌术后吻合口漏的预防作用.方法 针对吻合口漏易发因素设计了一整套手术方案,除了保护血供、改进吻合方式以及消除张力外,重点进行吻合口全层连续缝合加固,力求避免临时性末端回肠造口转流.结果 用上述方法对78例中低位直肠癌患者采用了吻合口缝合加固,术后均未发生吻合口漏.结论 吻合口缝合加固法可有效预防中低位直肠癌吻合口漏的发生.

Enhanced recovery after surgery (ERAS) represents a multimodal approach to improve the outcomes of medical treatment and care. Colorectal surgery initiates a series of physiological and psychological stress processes in the body, inducing transient insulin resistance. Insulin resistance is a central metabolic response to surgery and it has been shown to increase morbidity and mortality after surgery. Thus its early detection and remedy would directly lead to great improvement of outcomes. Preoperative intake of oral carbohydrates for ERAS has resulted in attenuating the development of postoperative insulin resistance and being one of the important methods of preoperative metabolic regulation in colorectal surgery.

Objective To explore the feasibility and safety of laparoscopic resection for rectal stromal tumor.Methods Sixteen (10 male and 6 female) patients underwent laparascopic resection of rectal stromal tumor in our department from May 2013 to Dec.2016,and the tumor diameter of all patients was less than 5 cm.The patients with the distance of more than 5 cm from the lower margin of the tumor to the anal verge received laparoscopic anterior resection of the rectal carcinoma (Dixon),the patients with the distance of less than 5 cm and more than 3 cm received laparoscopic local resection,and the patients with the distance of less than 3 cm,whose tumor boundary with the surrounding tissue were unclear,received laparoscopic abdominal perineal resection (Miles).Results The rectal stromal tumors of 16 cases were successfully removed under laparoscope without conversion to laparotomy,and no post-operative complications such as perforation,bleeding,obstruction or anastomotic leakage occurred.Of 16 cases,12 underwent laparoscopic anterior resection of the rectal carcinoma (Dixon),3 underwent laparoscopie local resection,and 1 underwent laparoscopic perineal resection (Miles).The average operation time was (103.0±23.8) min,the average hospital stay was (7.0 ± 1.2) days,and the average volume of intra-operative bleeding was (14 ± 4.1) mL.The pathological findings were confirmed as stromal tumor with negative margin.There was no recurrence during the followup of 8 to 40 months.Two cases with the tumor transferring to the liver eventually died of liver metastasis.Conclusion Laparoscopic resection of rectal stromal tumors is safe and feasible,with less trauma,shorter hospitalization time and quicker post-operative recovery.

目前,结肠直肠癌仍以外科治疗为主,并朝着功能最佳化、创伤最小化的方向发展. 1991年,Jacobs等[1]率先完成腹腔镜结肠切除术以来, 各项循证医学证据已证明腹腔镜结肠直肠癌手术可取得与开腹手术相似的肿瘤学疗效, 且病人所受的手术创伤小,康复速度快,并发症发生少,安全可行,成为外科医师首选的手术方式[2-5],推荐为结肠直肠癌的标准手术方式[6].

Gastric cancer is a common malignant tumor and ranks the third in China .In recent years,laparoscopic radical operation has been the important procedure for rapid rehabilitation after removal of gastric cancer , which reduces the incision and eleminates postoperative pain .The patient we described suffered from early gastric cancer located in the stomach angle .Radical distal gastric resection was performed with laparoscopy and Delta anastomosis was used for the reconstruction of the digestive tract .The operation lasted for 100 minutes with a 2.5 cm incision under the navel level .The patient ambulated 24 hours after surgery and was discharged 7 days after operation .This sdudy showed that laparoscopic radical gastrectomy is beneficial to patient ’ s postoperative recovery .

目的：探讨腹腔镜辅助下超低位直肠癌ISR手术的疗效及相关的治疗体会。方法选择2011年7月至2013年5月，在本院实施腹腔镜辅助下内括约肌切除术的20例超低位直肠癌患者进行回顾性分析。结果所有患者手术顺利，无中转开腹及改行Miles术者，患者的手术时间为（152.5±12.5）分钟，术中出血量为（60±15）毫升；术后肠道功能恢复时间为（2.5±1.5）天；术后住院时间为（12.5±4.5）天；术后共出现1例（5%）吻合口瘘、1例（5%）血栓性外痔、2例（10%）吻合口狭窄；所有病人的末端回肠造口均在（8±2）月内还纳；造口还纳术后1、3、6、12月分别对患者的肛门功能进行评估，发现随着时间推移，肛门功能总体恢复良好。结论腹腔镜辅助下内括约肌切除术是一种安全、可行的手术方式，只要病人条件符合，均可尝试行该手术。

Background Preoperative oral carbohydrate (OCH) improves postoperative insulin resistance (PIR) and insulin sensitivity. However, the exact mechanisms involved in the improvement of PIR with respect to preoperative OCH are still not clear. The aim of this study was to investigate the involvement of preoperative OCH and PI3K/AKT/mTOR pathway in reducing PIR in rats. Material/Methods Forty male Sprague-Dawley rats were randomly assigned to PreOp, glucose, saline, and fasting groups. Rats in the PreOp, glucose, and saline groups received OCH, 5% glucose solution, and saline, respectively. Rats in the fasting group did not receive anything but were fasted 3 h before surgery. Blood glucose, insulin and leucine levels, and insulin resistance, secretion, and sensitivity indexes were measured before and after surgery. mRNA and protein (total and phosphorylated) levels of mTOR, IRS-1, PI3K, PKB/AKT, and GlUT4 were measured using real-time polymerase chain reaction and Western blot in skeletal muscles. Results In the PIR experiment, blood glucose, serum insulin, insulin resistance, and serum leucine levels were all significantly lower in the PreOp group than in the other 3 groups (P<0.05) after surgery. HOMA-ISI were higher in the PreOp group vs the other 3 groups after surgery (P<0.05), and HOMA-β in the PreOp group was higher than that in the other 3 groups at 30 and 120 min after surgery. Additionally, post-operative phosphorylated IRS-1, PI3K, and AKT protein levels were significantly higher in the PreOp group than in the other 3 groups (P<0.05), but no significant differences were observed in their respective protein levels (P>0.05). Conclusions OCH decreases postoperative insulin resistance and improves postoperative insulin sensitivity in skeletal muscles through the PI3K/AKT/mTOR pathway.

目的：探讨乙状结肠憩室穿孔的诊断与治疗。方法选择上海长征医院自2013年1月至2014年6月共收治的2例乙状结肠憩室穿孔患者进行回顾性分析。结果2例患者术前均未明确诊断，术中经探查证实，根据病情采取不同手术方式均获得成功。结论乙状结肠憩室在国内是一种罕见的疾病，易误诊，在临床工作中需充分重视，综合多种检查以明确，并根据患者的实际情况制定合适的治疗方案。

目的 探讨腹腔镜器下完成经肛微创手术治疗直肠肿瘤的可行性及疗效.方法 我院2012年6月至12月14例适合于局部切除的直肠良性肿瘤、类癌病例选择腹腔镜下经肛微创治疗.手术方法以肛管扩张器、手套联合切口保护套建立腹腔镜操作通路,使用腹腔镜/结肠镜作为照明和充气设备,超声刀完成直肠黏膜下切除或全层切除,全层切除创面采用可吸收线缝合.结果 14例患者手术过程顺利,无围手术期并发症.手术时间30 ～ 70 min,其中建立操作入路平均花费15 min.切除的肿瘤直径1.5 ～3.8cm,大体观和病理检查证实均为R0切除.随访6～12个月无复发及远期并发症.结论 使用腹腔镜器械设备完成经肛微创手术治疗直肠肿瘤安全有效,但该术式部分操作细节仍需改进.

目的：探讨分析胃肠外科临床实践教学对转化医学理念结合病例讨论模式实践可行性。方法：选取2010-2013年我院普通外科实习医师共60名，拆信封法随机将其分成实验组（30名）和对照组（30名），给予实验组学生采取转化医学理念结合病例讨论临床实践教学模式，给予对照组传统教学法。观察对比两组学生考试成绩和分析相关问卷调查指标。结果：实验组学生平均成绩为82.252分，对照组学生平均成绩为73.151分，实验组学生平均成绩高于对照组，两组差异对比具有明显统计学意义（P＜0.05）。实验组30名学生中，有26名学生认为能增加探索临床问题的兴趣，占86.66%，有24名学生认为能提升从临床实践中提炼科研思路的能力，占80%。有25名学生认为能促进独立思考和自主学习，占83%，有22名学生认为能增加学习的深度和广度，占73%。与对照班学生17/30，56.67%、13/30，43.3%、15/30，50%，12/30，占40%调查比例相比，两组差异对比具有明显统计学意义（P＜0.05）。结论：转化医学理念结合病历讨论教学模式克服了传统教学模式的不足，适合当前临床实践教学所需，同时也适应现代医学教学的要求，教学效果明显，值得在胃肠外科临床教学中应用和推广。

随着我国医疗事业的不断深化改革，普通外科临床规培生在教学过程中，教学方法正在不断地进行着改革，很多院校不断积极的探索新的教学手段和教学方法。在外科临床教学过程中TBL教学法一直是广大教育者普遍关注的一个热点领域。但是教学过程中，一种教学方法尤其自身的优点和缺陷，在教学中教师应该对教学方法的优点和缺点明确的进行辨别，将缺点降低到最小程度，最大程度上保证教学的效果。本文主要对TBL教学法在普外科临床规培生教学中的优点和存在问题进行了探讨，希望本次研究对更好的开展TBL教学有一定的帮助。

社会的发展和医学模式的转变给乳腺癌治疗领域增添了美学的新内容，社会经济水平促进乳癌疾病研究深入，手术治疗耐受程度从最大治疗变为最小有效治疗已成为患者的形体美需求，传统乳腺癌治疗片面强调的唯手术论实际上忽视患者这一需求。本文通过介绍医学美学对于乳癌治疗临床教学的必要性和其实践运用，以达到促进医学生了解医学美学常识、增加审美意识、培养美学素质的作用，来完善和加强医学生的医学美学教育，来为现代医学领域提供高素质乳腺外科专业人才。

The objective of this study was to establish and validate the diagnostic value of the new established N-glycan markers in gastric cancer(GC).In total,244 individuals were enrolled,including 80 patients with GC,25 patients with gastric ulcer(GU),and 139 healthy controls.Serum N-glycan profiling was analyzed by DNA sequencer-assisted/flurophore-assisted carbohydrate electrophoresis(DSA-FACE).Routine tumor markers were measured by clinical immunoassay using standard methods and matched reagents.New established diagnostic model was constructed with logistic step-wise regression and receiver operating characteristic curve(ROC) analysis.Different N-glycan profil patterns emerged in the three groups.We quantified and statistically compared these peaks among the 3 different groups.At least 9 N-glycan structures(peaks) were identified in all samples.Compared with the other two groups,in the GC group,Peaks 5 and 9 were elevated,whereas Peaks 2,3,6,7 and 8,which all contian the core-α-1,6-fucosylated biantennary,were decreased.Furthermore,these N-glycans were decreased with progression of gastric cancer.The diagnostic model GCglycoB was constructed to differentiate GC from GU.Compared with the combination of standard markers for GC,the sensitivity and accuracy of GCglycoB improved 20% and 26.70% respectively.The current results indicate that the N-glycan markers-based diagnostic models may be a new valuable alternative for diagnosis of GC.The mechanism for decrease of core-fucosylated glycans need to be further researched.

Objective: Comparison of insulin resistance and that of early rehabilitation were respectively made between laparoscopic(LCR) and open(OCR) resection for colorectal cancer in order to explore the clinical significance.Methods: 60 patients with colorectal cancer were divided into 2 groups: LCR Group and OCR Group.Each group has 30 patients.We compared the HOMA and early rehabilitation before and after operation.Results: Comparison within each group: before and after operation,insulin resistance index and insulin sensitive index were significantly different(P0.05).There was no significant difference in insulin secretion index(P0.05).Comparison between groups: before operation,there were no significant differences in insulin resistance index,insulin secretion index and insulin sensitive index(P0.05).After operation,insulin resistance index and insulin sensitive index were significantly different(P0.05).There was no significant difference in insulin secretion index(P0.05).Anal exhaust,time of activities and average length of stay after operation were significantly different(P0.01).Conclusion: Degree of Insulin resistance after laparoscopic resection for colorectal cancer is smaller than that of open(OCR) resection,and it is more conductive to early rehabilitation of patients.

Objective To investigate the expressions of reversion inducing cysteine rich protein with Kazal motifs (RECK), matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-2 (MMP-9) genes and their clinical significance in colon cancer. Methods Reverse transcription polymerase chain reaction (RT-PCR) was used to determine the expression of RECK genes, MMP-2 genes and MMP-9 genes in 40 colon cancer tissues and adjacent normal tissues. Results The expression of RECK in colon cancer was significantly lower than that in the adjacent normal tissues (0.46±0.16 vs 0.88± 0.08, P0.01), while the expression levels of MMP-2 and MMP-9 in colon cancer specimens were significantly higher (0.41±0.13 vs 0.14±0.13, 0.28±0.11 vs 0.12±0.06, P0.01). The expression of RECK genes was negatively correlated with the expressions of MMP-2 and MMP-9 in colon cancer(r=-0.918, P0.01; r=-0.855, P0.01). The expressions of MMP-2 and MMP-9 closely correlated with lymphatic metastasis and TNM staging while the expression of RECK closely correlated with cancer differentiation, lymphatic metastasis, distant metastasis and TNM staging. Conclusions RECK gene may suppress the expressions of MMP-2 and MMP-2 genes in colon cancer. RECK, MMP-2 and MMP-9 may serve as the markers for the comprehensive diagnosis and estimation of metastasis and TNM staging of colon cancer.