目的 探讨肾上腺神经纤维瘤(adrenal neurofibroma,ANF)的临床特征,提高对其的认识及诊治技术.方法 分析我院收治的1例病理证实为ANF患者的临床资料、诊治过程及随访结果,并结合已发表的国内外相关文献进行复习总结.结果 本例患者术前相关肾上腺激素水平检查均正常,增强CT发现右侧肾上腺占位性病变,考虑良性肿瘤性病变.行后腹腔镜手术完整切除肾上腺肿物及少部分右肾上腺.术后病理示:灰黄灰红组织一块,大小6.5 cm×5.5 cm×4.0 cm;可见包膜,切面呈多结节状,灰白实性质软,局部结节质硬,可见少许肾上腺组织;光镜所见梭形细胞肿瘤及神经纤维末梢,间质黏液样变,未见异常核分裂及细胞异型性;结合免疫组化,符合ANF.术后1个月复查,肾上腺相关激素水平均正常,无复发和转移.结论 ANF为良性肿瘤,临床症状、体征缺乏特异性,术前实验室和影像检查并不能确诊,诊断依赖组织病理学检查.腹腔镜完整切除肿瘤是治疗的关键,腹膜后途径具有更大优势,大多数预后良好,但需密切观察及随访.

目的 探讨微创Ivor-Lewis食管切除术(minimally invasive Ivor-Lewis esophagectomy,MI-ILE)治疗食管胃结合部腺癌的可行性.方法 回顾性分析2018年1月～2019年6月MI-ILE治疗食管胃结合部腺癌48例资料.SiewertⅠ型11例,Ⅱ型31例,Ⅲ型6例.病灶距门齿距离(38.8±2.5)cm.结果 手术时间(250.8±42.0)min,术中出血(120.3±67.0)ml.均行R0切除.27例术前新辅助治疗,26例(96％)术后病理显示部分缓解.清扫淋巴结(28.6±10.6)枚,36例淋巴结转移(8.0±5.0)枚.术后吻合口漏2例(4％),1例手术治疗,1例保守治疗,均痊愈.术后住院日(9.7±3.2)d.平均随访14个月(5～22个月),肿瘤均无复发,无死亡.结论 MI-ILE治疗食管胃结合部腺癌可以保证满意的上下切缘和足够的淋巴结清扫范围,手术安全可靠.

目的 探讨微创Ivor-Lewis食管切除术(minimally invasive Ivor-Lewis esophagectomy,MI-ILE)与Sweet手术治疗Siewert Ⅱ型食管胃结合部腺癌(adenocarcinoma of esophagogastric junction,AEG)的疗效.方法 选择2017年12月～2019年3月Siewert Ⅱ型AEG 82例,按照前瞻性非随机方法分为2组,行MI-ILE手术41例,Sweet手术41例,2组术前一般资料差异无显著性(P>0.05).比较2组手术指标、术后并发症及短期生存和复发率.结果 MI-ILE组手术时间长于Sweet组[(244.0±39.5)min vs.(186.9±24.8)min,t=7.840,P=0.000],但术中出血量少[(88.9±34.1)ml vs.(107.7±42.4)ml,t=-2.211,P=0.030],术后第1天胸腔引流量少[(205.9±73.3)ml vs.(287.7±126.3)ml,t=-3.587,P=0.001],胸腔引流时间短[(6.2±2.2)d vs.(8.8±2.8)d,t=-4.666,P=0.000],术后排气早[(3.0±1.0)d vs.(3.7±1.3)d,t=-2.739,P=0.008],术后住院时间短[(9.2±3.2)d vs.(11.2±2.6)d,t=-2.982,P=0.004].MI-ILE组清扫淋巴结(28.6±10.0)枚,其中胸腔清扫(7.2±4.4)枚,腹腔清扫(21.4±8.9)枚,均高于Sweet组的(22.2±7.3)、(4.8±4.0)、(17.4±7.3)枚(P均<0.05).2组胸腔、腹腔淋巴结转移数目差异无显著性(P>0.05).随访1年,2组均无死亡;MI-ILE复发1例(2.5％),Sweet组复发3例(7.3％)(χ2=1.051,P=0.305).结论 MI-ILE治疗Siewert Ⅱ型AEG安全、可行,与Sweet手术比较,不增加风险,近期疗效满意.

Objective To evaluate the value of hand assisted laparoscopic radical resection for distal gastric cancer. Methods The clinical data of 80 patients with advanced gastric cancer from August 2015 to December 2017 were retrospectively analyzed. Among them, 30 patients underwent hand-assisted laparoscopic surgery, 25 patients underwent open surgery, and 25 patients underwent laparoscopic assisted surgery. The operative time, bleeding volume, number of recected lymph nodes, time to postoperative exhaust, postoperative complications, length of hospitalization, hospitalization expenses, length of incision and so on were compared among the three groups. The data were analyzed with SPSS 21.0 software. Measurement data are expressed as mean±standard deviation. ANOVA was used to compare measurement data, and the chi square test or Fisher exact test was used to compare count data. P<0.05 indicated that the difference was statistically significant. Results There was no significant difference in the number of recected lymph nodes, postoperative hospitalization expenses, or postoperative complications among the three groups (P>0.05). The hand-assisted laparoscopic surgery group, laparoscopy assisted surgery group, and open surgery group had significantly different operative time [(186.30±15.27) min vs (230.80±17.06) min vs (183.36±16.03) min] , intraoperative bleeding volume [(93.33±46.86) mL vs (98.80±55.10) mL vs (246.80±92.90) mL] , time to postoperative exhaust [(2.3±0.6) d vs (2.42±0.44) d vs (3.04±0.56) d] , length of stay [(8.90±1.19) d vs (9.40±1.44) d vs (10.92±1.73) d] , and incision length [(7.97±0.49) cm vs (8.04±0.61) cm vs (24.04±2.11) cm] (P<0.001 for all). The length of incision, blood loss, time to postoperative exhaust, and hospital stay were significantly lower in the hand-assisted laparoscopic operation group and laparoscopically assisted operation group than in the open operation group (P<0.001). The operative time was significantly shorter in the hand-assisted laparoscopic surgery group and laparotomy group than in the laparoscopically assisted operation group (P<0.001). Conclusion Hand assisted laparoscopic distal gastrectomy is safe and feasible, can achieve the radical effect of open surgery for tumor resection and lymph node dissection, and does not increase the economic burden of patients. Hand assisted laparoscopic surgery has the advantages of less intraoperative bleeding, faster postoperative recovery, and shorter operative time than laparoscopic assisted surgery. Key words: Hand assisted laparoscopy; Laparoscopy assisted; Traditional laparotomy; Advanced gastric cancer

患者女性,53岁,主因腰背部胀痛1个月于2016年3月就诊于河北医科大学第二医院门诊,体格检查无阳性体征。腹部超声显示可疑脾占位性病变,CT显示脾占位性病变,考虑脾淋巴管瘤(图1)。患者既往于2009年9月因“下腹部不适2个月”于河北医科大学第二医院行CT检查,发现盆腔肿物,住院治疗；在全身麻醉下行传统开腹手术探查,发现肿物来源于卵巢,遂按卵巢肿瘤手术原则,行子宫、双附件、大网膜及阑尾切除术；术后病理回报为卵巢黏液性囊腺瘤,术后恢复良好。术后每3个月复查CA19-9,CA19-9水平一直波动在200 U/ml左右,但近6个月来CA19-9水平呈上升趋势；2016年3月复查CA19-9,CA19-9为672.90 U/ml。为明确脾占位性质,决定再次手术治疗,但患者既往有手术史,腹腔情况复杂,传统腹腔镜手术操作风险大,遂决定行改良手助腹腔镜脾切除术。