胰腺癌(pancreatic cancer)是一种高度恶性的肿瘤,因起病隐匿,早期常无明显的症状及体征,常难被临床医生发现,且在大多数患者确诊时,往往早已发现远处脏器的转移,因而错失了最好手术时间,且常规化疗、放疗效果不佳,导致其预后极差.胰腺癌肿瘤微环境(tumor microenvironment,TME)包含癌症细胞、免疫细胞、基质细胞、细胞外基质以及其中的多种可溶性分子.并且在胰腺癌的细胞外基质中存在一些结合点,可以与微环境中的细胞因子进行相互结合,通过调节微小血管生成,抑制化疗药物和促进肿瘤转移等方式,使得肿瘤微环境朝着有利于癌症细胞生长的方向发展.随着肿瘤相关微环境研究的不断进展,转化生长因子β诱导蛋白(βig-H3)作为一种细胞外基质蛋白,其在肿瘤组织中发挥的作用受到了研究者们的广泛关注.本文拟对近年来在βig-H3的结构功能、其在胰腺癌中的表达作用以及参与胰腺癌免疫抑制机制等方面的相关研究进展进行综述.

分析高海拔地区1例老年男性胆囊结石穿孔十二指肠瘘患者的诊疗经过，对胆囊十二指肠瘘的病因和诊断及预防等方面进行归纳总结。该患者慢性胆囊炎合并胆囊多发结石数年，现急性发作后致十二指肠球部穿孔，后形成肠瘘导致胆石性肠梗阻，内科治疗无效后，成功开腹手术取出结石。

胰腺导管腺癌恶性程度高,起病隐匿,病情进展快,在早期无明显的腹部表现及体征.多数患者就诊时已发展为中晚期,并常伴远处脏器转移,因此手术治疗、放化疗及药物靶向治疗效果通常不佳.近年来研究表明,转化生长因子β(TGFβ)与肿瘤的发生、发展密不可分,在肿瘤细胞的增殖、侵袭、迁移和血管的生成等进程中发挥关键性的调节作用.尽管TGFβ信号能够利用SMAD介导的细胞周期阻滞起到强大的肿瘤抑制作用,但是TGFβ信号也可以通过增强上皮-间质转化、纤维化和免疫逃逸来加速胰腺癌的发生.本文所述胰腺癌均特指为胰腺导管腺癌,旨在对TGFβ在其信号传导中的作用及其相关因子和免疫反应等方面关系的研究予以综述,为今后胰腺癌的靶向治疗提供理论依据.

ObjectiveTo investigate the postoperative complications of ex vivo liver resection combined with autologous liver transplantation in the treatment of end-stage hepatic alveolar echinococcosis at high altitude and related prevention and treatment strategies. MethodsSurgical data and follow-up data were collected from 11 patients with end-stage hepatic alveolar echinococcosis who underwent autologous liver transplantation in Qinghai People’s Hospital from January 2013 to March 2019, and intraoperative and postoperative conditions were analyzed. ResultsAll 11 patients underwent autologous liver transplantation successfully, without intraoperative death, among whom 2(18.18%) underwent hemi-extracorporeal hepatectomy and 9 (81.82%) underwent total extracorporeal hepatectomy. For the reconstruction of the retrohepatic inferior vena cava, 2 patients (18.18%) underwent reconstruction with the autologous great saphenous vein, 4 patients (36.36%) underwent reconstruction with artificial vessels, and the autologous retrohepatic inferior vena cava was preserved in 5 patients (45.45%). For biliary reconstruction, 8 patients (72.73%) underwent choledochoenterostomy and 3 (27.27%) underwent choledochocholedochostomy. The main postoperative complications of the 11 patients included bleeding in 2 patients (18.18%), bile leakage and abdominal infection in 4 patients (36.36%), bilioenteric anastomotic stenosis in 1 patient (9.09%), thrombus in 2 patients (1818%), pulmonary infection and pleural effusion in 2 patients (18.18%), and echinococcosis recurrence in 1 patient (9.09%). Of all 11 patients, 2 (18.18%) died during the perioperative period, and the other 9 patients (81.82%) were improved and discharged. Conclusion Bleeding, biliary complications, and infection are the main causes of death in patients undergoing autologous liver transplantation at high altitude. An accurate understanding of surgical indication, careful multidisciplinary evaluation before surgery, superb operation during surgery, standardized surgical procedures, and fine perioperative management are the key to reducing perioperative mortality, avoiding and reducing postoperative complications, and achieving good long-term survival in patients undergoing autologous liver transplantation.

近年来，胰腺癌的治疗并未取得良好的收效，全基因组测序及诊断的微解剖技术使我们发现胰腺癌的分子分型的多样性，诊疗策略均无法套用其他肿瘤的模式，但可以肯定的是由于胰腺癌肿瘤组织和间质的部分独立性发展及相互联系制约，使得肿瘤相关的微血管以及肿瘤微环境亦有其独特性，肿瘤微环境更像是一个微生态，干预微血管的生理可以使肿瘤、微环境的特性发生改变，机械性的过渡干预或者不适时的干预则会干扰了机体自身对肿瘤的免疫。目前针对胰腺癌微血管的生理特性的认识较前有所提高，但其对肿瘤发生、发展及转移的影响机制仍需要进一步研究。

目的 探讨手术室量化评估干预策略对胃肠道肿瘤手术患者应激反应和术后康复的影响.方法 选择200例行胃肠道肿瘤手术患者,采用随机数字表法分为观察组100例和对照组100例.对照组患者接受常规干预,观察组患者接受手术室量化评估干预.采用焦虑自评量表(SAS)和抑郁自评量表(SDS)评估两组患者的心理应激状态,并比较两组患者手术前后的心理应激状态评分及躯体应激反应指标[血清内皮素(ET)、一氧化氮(NO)、C反应蛋白(CRP)、白细胞介素-6(IL-6)]水平、手术时间、术后康复效果及护理满意度.结果 术后,观察组患者的SAS、SDS评分及ET、NO、CRP、IL-6水平均低于对照组(P﹤0.05);手术时间及术后首次排气时间、首次排便时间、首次下床时间、总住院时间均明显短于对照组(P﹤0.01);观察组患者及医师对手术室护理工作的满意度均明显高于对照组(P﹤0.01).结论 与常规干预比较,对胃肠道肿瘤患者实施手术室量化评估干预,可改善护理质量,减轻患者的心理应激状态和躯体应激反应,有利于患者术后康复,值得临床推广.

目的:探讨肝切除手术治疗肝包虫病的疗效及对患者预后和肝功能的影响.方法:选取2015年2月-2018年5月期间我院收治的肝包虫病患者103例为研究对象,所有患者根据手术方式的不同分为A组(n=51,行外膜内完整外囊摘除术)和B组(n=52,行肝切除手术),比较两组患者围术期临床指标、肝功能指标、并发症发生情况,随访半年,记录两组患者随访期间死亡及原位复发情况.结果:B组术中出血量少于A组,手术时间、术后拔管时间以及住院时间均短于A组,组间比较差异有统计学意义(P＜0.05).与术前比较,两组患者术后3d、术后7d谷丙转氨酶、胆红素以及谷草转氨酶均升高,但B组低于A组(P＜0.05);与术前比较,两组患者术后3d、术后7d白蛋白降低,但B组高于A组(P＜0.05);与术后3d比较,两组患者术后7d谷丙转氨酶、胆红素以及谷草转氨酶均降低,白蛋白升高(P＜0.05).B组术后并发症总发生率为7.69％(4/52),低于A组的23.52％(12/51),组间比较差异有统计学意义(P＜0.05).两组随访期间无患者死亡,原位复发率比较差异均无统计学意义(P＞0.05).结论:肝切除手术治疗肝包虫病患者安全有效,可减少术中出血量,促进患者术后康复,减轻手术对肝功能的影响,且术后复发率较低,患者预后较好.

Objective: To evaluate the therapeutic evaluation of four different surgical treatments for postoperative biliary leakage in patients with hepatic hydatid disease. Methods: A total of 103 cases of hepatic hydatid disease, who were admitted to Qinghai Provincial People's Hospital from December 2015 to June 2017, were selected and divided into group A (undergoing endocystectomy, n=26), group B (undergoing complete cystectomy, n=28), group C (external capsule for subtotal resection, n=25) and group D (undergoing partial hepatectomy, n=24) according to different surgical methods. The operation time, intraoperative blood loss, postoperative tube time and hospitalization time were compared among the four groups. The incidence and complications of bile leakage after operation in the four groups were compared and analyzed. Results: There were significant differences in the operation time, intraoperative blood loss, postoperative tube time and hospitalization time among the four groups (P＜0.05). The operation time and the amount of bleeding during operation in group A were significantly less than those in group B, C and D; the operation time and the amount of bleeding in group B and group C were significantly less than those in group D (P＜0.05). The postoperative tube time of group A was significantly more than that of group B, C and D; the postoperative tube time of group D was significantly more than that of group B and group C (P＜0.05). The hospitalization time of group D was significantly more than that of group A, B and C; the hospitalization time of group A was more than that of group B and group C (P＜0.05). The incidence of postoperative bile leakage in group A was significantly higher than that in group B, C and D (P＜0.05). There were no statistically significant differences in the incidence of diaphragmatic infection and pleural effusion among the four groups (P＞0.05). The incidence of residual cavity infection and residual cavity effusion in group A was higher than that in group B, C and D (P＜0.05). The incidence of postoperative liver function impairment in group D was significantly higher than that in group A, B and C (P＜0.05). Conclusion: Surgical treatment is the main way to treat hepatic hydatid disease, each of the four operation methods has advantages and disadvantages, and the most suitable surgical method should be selected according to the actual situation of the patient.

Objectives To establish rats with SAP model at high altitude area by animal experiments in the case of zero intervention and observe the expression of TNF-α in damaged liver at different times.This study aim to clarify the relationship between hepatic lesion and the expression of TNF-α from the perspective of cytokines in high altitude hypoxia.This study would provide the basis for the mechanism study of diagnosis and treatment of severe acute pancreatitis.Methods The rats with SAP model was established by sodium taurocholate retrograde injection.The content of the ALT and AST in serum will be measured by centrifugation.The tissue microarray was made by the method of Immunohistochemistry.The content of TNF-α in liver was measured.The content of the ALT,AST of SAP rat were measured in different altitude.The correlation between the expression of TNF-α and altitude will be verified.Results The expression of ALT,AST and TNF-αincreased with time in the same altitude after the rat hepatic lesion.The expression of ALT,AST and TNF-aincreased with altitude at the same time after the rat hepatic lesion but the control group.Conclusion The hepatic lesion of SAP rat aggravated with time and the hepatic lesion of SAP rat aggravated with altitude.The expression of TNF-α in SAP rat increased with time and the expression of TNF-α in SAP rat increased with altitude.

目的 发现西宁地区胆总管结石并发胰腺炎的临床特点,提高预见性的诊疗水平.方法 收集2011年1月至2014年12月间就诊于青海省人民医院的胆总管结石患者457例,其中合并急性胰腺炎患者198例,设为试验组;单纯胆管结石患者259例,设为对照组.统计试验组与对照组患者年龄、性别与体重指数,入院3 d内的生化、凝血功能、全血细胞分析、血气分析、腹部核磁或CT等结果,分析合并胆囊结石与胆管炎的情况以及胰腺炎与糖尿病病史对患者的影响.采用多因素分析法对影响胆总管结石患者并发胰腺炎的因素进行统计分析.结果 试验组与对照组患者在年龄(P=0.143)、性别(P=0.065)、体重指数(P=0.071)、C-反应蛋白(P=0.208)、结石直径(P=0.600)、与糖尿病病史(P=0.306)各方面无明显差异(均P>0.05).与对照组相比,试验组胆总管直径明显偏大(P=0.004),合并胆囊结石(χ2=15.847,P<0.001)及胆管炎(χ2=63.820,P<0.001)的病例明显更多,具有胰腺炎病史(χ2=15.925,P=0.015)者更多;且γ-谷氨酰基转移酶含量更高(P<0.001)、氧分压更低(P<0.001).多因素分析结果表明,胆总管直径、合并胆囊结石、合并胆管炎、胰腺炎病史、γ-谷氨酰基转移酶、氧分压对胆总管结石患者并发胰腺炎有明显影响,且各因素的影响程度从大到小依次为合并胆管炎、合并胆囊结石、有胰腺炎病史、氧分压、胆总管直径以及γ-谷氨酰基转移酶.结论 西宁地区胆总管结石并发胰腺炎的临床特点为:γ-谷氨酰基转移酶升高、胆总管直径增加、氧分压降低、易发胆囊结石与胆管炎,具有胰腺炎病史.根据上述临床特点有助于对胆总管结石并发胰腺炎进行预见性治疗.

急性重症胰腺炎属于普通外科疾病中起病较急而且发展较快的急重症之一，同时伴发其他的疾病较多，病死率也较高，对患者的身心健康造成了严重的影响，甚至威胁着患者的生命安全。目前治疗急性重症胰腺炎患者的原则是及时诊断及时给予有效的治疗，减少患者的病死率。

急性胰腺炎(AP)是一种发病率和死亡率较高的暴发性疾病.最常见的致病因素是胆结石和酗酒,大多患者由于并发症的出现需长期住院治疗和进入重症监护室(ICU)治疗.通常情况下,急性胰腺炎的初始治疗包括禁食疗法(NPO)、镇痛药的使用和充足的静脉补液.对于几天内不能接受正常食物的病人来讲,营养支持是必需的；有大量的科学证据表明肠内营养优于全肠外营养(TPN).肠内营养保护肠道黏膜完整性并防止细菌在肠道内过度生长.肠内营养明显减少了感染的风险、降低了手术干预的需要,并缩短了住院的时间.