Malignant obstructive jaundice is caused by direct invasion or compression of the biliary tract by malignant tumors of the bile duct, pancreas and other systems. Patients are often accompanied by symptoms such as malnutrition, low immune function, and organ damage. The treatments of active preoperative biliary drainage and reasonable reinfusion combined with enteral nutrition can help improve the safety of patients during the perioperative period, reduce postoperative complications, and improve the life quality of patients. This article reviewed the research progress of preoperative biliary drainage, bile recycling methods and precautions in patients with malignant obstructive jaundice, aiming to provide reference for clinical diagnosis and treatment practice.

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目的:基于转化生长因子-β(TGF-β)/Smad信号通路探讨白参和黑参水煎液对心肌肥厚大鼠的保护作用及机制.方法:高效液相色谱法和苯酚-硫酸法测定两种水煎液中人参皂苷和人参多糖含量;异丙肾上腺素(ISO)皮下注射制备心肌肥厚大鼠模型,观察对心肌肥厚大鼠体质量、心重指数的影响;超声心动图评价心肌肥厚大鼠心功能;HE、Masson染色评价心肌肥厚大鼠心肌形态及纤维化程度;检测血清中血管紧张素Ⅱ(AngⅡ)、醛固酮(ALD)、脑钠肽(BNP)和羟脯氨酸(HYP)水平,并采用灰色关联度分析方法分析两种水煎液中皂苷和多糖与血清生化指标的关系;Western Blot检测TGF-β/Smad信号通路相关蛋白表达水平.结果:白参水煎液中10种皂苷总量高于黑参水煎液,而多糖含量则趋势相反;两种水煎液均可提高心肌肥厚大鼠体质量增长速度,降低心重指数(P＜0.05);改善心功能(P＜0.01,P＜0.05);改善心肌组织形态结构,降低心肌纤维化程度;降低血清中AngⅡ、ALD、BNP和HYP含量(P＜0.01,P＜0.05);灰色关联度分析结果表明人参皂苷(R)-Rh1对ALD和BNP贡献度最大,人参皂苷Rg2对Ang Ⅱ和HYP贡献度最大;两种水煎液均可抑制TGF-β 1、Smad4和TIMP1蛋白表达水平(P＜0.01,P＜0.05),增加Smad7和MMP9蛋白表达(P＜0.01,P＜0.05).结论:两种水煎液可能通过抑制RAAS系统激活,阻断TGF-β/Smad信号通路,降低心肌组织纤维化程度,对ISO诱导的心肌肥厚大鼠起到保护作用,黑参效果优于白参.

Oxidative stress is an important pathogenic mechanism in degenerative diseases such as Alzheimer’s disease. Although ginsenoside compound K (CK) is protective against neuronal oxidative damage, the underlying mechanism remains to be understood. In this study, the protective effects of ginsenoside CK against oxidative stress damage induced by hydrogen peroxide in HT22 cells were investigated with 1H nuclear magnetic resonance (1H-NMR)-based metabolomics. The optimal CK concentration for decreasing oxidative stress damage in nerves was determined with MTT assays. CK (8 μM) significantly increased the HT22 cell survival rate after the model was established. Cell lysates were subjected to 1H-NMR metabolomics, western blotting, and ATP assays for verification. Metabolic perturbation occurred in HT22 cells in the model group but not the control group. Twenty biomarkers were identified and used to analyze metabolic pathways. CK reversed metabolic changes in HT22 cells by altering taurine, glutamate, glycine, and glutathione metabolism. Subsequently, CK increased ATP content and the expression of components of the PI3K/AKT signaling pathway in HT22 cells. These findings demonstrated that CK prevents oxidative stress damage and protects nerves by regulating energy-metabolism pathways, such as those of taurine, glutamate, and other amino acids, thus providing a rationale for the use of CK in Alzheimer’s disease treatment.

重症急性胰腺炎(severe acute pancreatitis, SAP)是具有病情发展迅猛、进展快、病死率高等特点的常见外科急腹症。随着SAP研究的不断深入，治疗理念不断更新，合理的外科干预始终是降低重症急性胰腺炎患者病死率的关键，原则是既要避免外科干预不足又要避免干预的过度。本文对SAP外科干预时机及指征、外科干预方式的选择作一综述。

肝脏外科在近现代发展中经历了楔形肝切除、规则肝叶切除、不规则局部切除、解剖性肝段切除以及精准肝切除的过程,其中腹腔镜循肝中静脉下腔静脉精准右半肝切除术被认为是更符合解剖性肝切除、精准肝切除要求的手术方式,其目标是实现彻底清除目标病灶、安全完成右半肝切除、患者预后及生存质量最优化.本文对腹腔镜循肝中静脉下腔静脉精准右半肝切除术的临床应用作一综述.

Objective:To study the causes of hemorrhage after laparoscopic pancreaticoduodenectomy (LPD) and to develop countermeasures in its prevention.Methods:The clinical data of 215 patients who underwent LPD at the Department of Hepatobiliary and Pancreatic Surgery of Zhejiang Provincial People's Hospital from December 2013 to May 2020 were reviewed. The patients’ clinical data including gender, age, comorbidities and postoperative complications such as bleeding, pancreatic fistula, biliary fistula and intraperitoneal infection were studied, with the aims to analyze the causes, clinical manifestations and treatment results of post-pancreaticoduodenectomy hemorrhage (PPH) after LPD.Results:Of 215 patients, there were 132 males and 83 females, aged (60.7±10.3) years. PPH occurred in 20 patients, incidence rate was 9.30%(20/215). Early hemorrhage was mainly caused by inadequate hemostasis or loosening of vascular clips, while delayed hemorrhage was mainly caused by gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instruments or pseudoaneurysms. Among the 20 patients, 6 patients had early hemorrhage and 14 delayed hemorrhage. There was 1 patient with grade A, 10 with grade B and 9 with grade C hemorrhage. Thirteen patients developed pancreatic fistula, 1 biliary fistula, and 2 intraperitoneal infection. One patient responded well to conservative treatment. Hemostasis was successfully achieved by gastroscopy ( n=1) and interventional therapy ( n=7). Eleven patients required laparotomy for hemostasis. In this study, 14 of 20 patients survivied PPH and 6 patients died. The mortality rate was 30% (6 of 20 patients with PPH). Conclusions:Early hemorrhage was caused by inadequate hemostasis or loosening vascular clips, while delayed hemorrhage was related to gastrointestinal fistula with vascular erosion, arterial injury by intraoperative energy instrument or pseudoaneurysm. Careful hemostasis, adequate protection of blood vessels, and accurate anastomosis should be performed in LPD. DSA angiography should be used for arterial hemorrhage which progressed very rapidly. Interventional therapy including embolism and stenting were means to control arterial bleeding in PPH. Decisive surgical exploration when interventional therapy failed was important in reducing the mortality rate of these patients.

Objective:To study the technical and essential steps in laparoscopic selective devascularization with paraesophageal veins-preservation.Methods:To retrospectively analyze the clinical data of 13 cirrhotic patients who underwent laparoscopic selective pericardial devascularization for portal hypertension at the Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital from January 2019 to March 2020. There were 9 males and 4 females with age ranging from 41 to 83 years (median 51 years). The operative time, intraoperative blood loss, postoperative complications and follow-up data were analyzed.Results:All the 13 patients completed theoperation, no patient stopped the operation or transferred to laparotomy. The operation time was (170±32) min.The intraoperative bleeding was (160±30) ml. The postoperative hospital stay was (6.1±1.1) days. There were no complications, including pancreatic leakage and intra-abdominal infection. On follow-up which ranged from 1 to 15 months, one patient developed portal vein thrombosis, no upper gastrointestinal rebleeding.Conclusions:Preservation of esophageal veins in laparoscopic selective devascularization is an accurate surgery which requires close teamwork and rich experience in laparoscopic surgery. The preservation of the main trunk of the gastric coronary vein and integrity of the esophageal veins are the keys to the surgery which is safe and feasible.

目前肝脏肿瘤的主要治疗方式为外科手术切除，而能否在术中实现精准定位肿瘤、界定切缘是影响术后恢复的主要因素。吲哚菁绿(indocyanine green，ICG)荧光显像技术自2009年由Ishizawa首次应用于肝肿瘤切除术以来，在肝脏肿瘤的分型、识别、定界等方面表现出独特优势，显著提高肿瘤切除率、减少术后并发症。但其仍存在探测深度有限、假阳性等缺陷，尤其是对肝硬化患者的使用规范还需进一步研究。本文就ICG荧光显像技术在肝脏肿瘤诊治中的应用进展作一综述。

目的 了解智慧医疗实施现状,掌握影响就诊者使用移动医疗的各个因素,总结移动医疗实施过程中遇到的问题,并基此提出合理的对策与建议,从而使智慧医疗发展的更好,更快更有效地达到利民惠民的目的.方法 本文采用问卷和访谈相结合的方法,并且以问卷调查为主.结果 社区卫生服务机构在智慧医疗宣传力度上仍有不足,但智慧医疗发展情况较乐观,大学本科生智慧医疗使用情况较高,目前智慧医疗APP存在同类产品太多无从选择、相关法规政策没跟上等问题.结论 移动医疗建设有待高,居民对其满意度较低.政府应加大宣传力度,各级医院积极配合;引导居民就医习惯,转变医生服务观念;积极建设移动医疗,缩小与实地医院就诊的差距;将医疗保险与移动医疗有机结合.