患者老年男性,因"右侧腹痛3 d"于2020年7月29日入院.3 d前出现右侧腹痛伴发热呕吐,门诊腹部CT发现阑尾增粗,周围脂肪间隙模糊;十二指肠降部肠壁可疑增厚.追问病史发现8年前有类似腹痛史,当时保守治疗.入院后查血常规:白细胞11.8×109/L,中性粒细胞比例87.8％,淋巴细胞8.2％;肿瘤标志物甲胎蛋白、癌胚抗原、CA19-9均正常.十二指肠镜发现降部约2.5 cm×3.0 cm充血隆起,质硬,中间凹陷.活检病理:黏膜慢性炎,局灶区呈腺瘤样增生,小灶腺上皮低级别上皮内瘤变.超声内镜提示降部黏膜隆起,外瘘? 病理:黏膜慢性炎伴局灶呈息肉样增生.8年前患者腹部CT发现急性化脓性阑尾炎,头端积脓.本次增强CT发现阑尾管壁增厚强化,周围脂肪间隙模糊,十二指肠降部肠壁增厚,增强后可见强化.初步诊断:慢性阑尾炎急性发作,阑尾十二指肠瘘? 十二指肠肿瘤? 完善术前准备后行腹腔镜探查,术中见阑尾根部位于距回盲部约2.5 cm处,体部经回盲部后方向上,头端紧邻十二指肠降部,并形成致密粘连(图1) ,沿阑尾浆膜层分离至十二指肠,证实为阑尾十二指肠外瘘,行阑尾切除术,同时切除瘘口及周围部分肠壁送术中冰冻,提示局灶腺上皮轻度非典型增生,未见明确恶性证据.术中与家属沟通后行十二指肠修补术.十二指肠降部肿物考虑系长期阑尾炎症刺激引起,多次病理均未发现恶性证据,因此术中并未切除整个肿物所在的肠壁,术后定期复查十二指肠镜.患者术后恢复良好,随访至今,未诉特殊不适.

Chemerin是脂肪组织和肝脏分泌的一种蛋白质,其与脂肪、血管生成,脂质以及葡萄糖代谢有关,chemerin是促进多种免疫细胞趋化的重要因素,并在几种病理生理过程中起重要作用.Chemerin受体存在于单核细胞/巨噬细胞、T细胞、自然杀伤细胞、树突细胞以及嗜中性粒细胞上,然而,有关chemerin和chemerin受体在消化道肿瘤中的病理生理作用研究较少.越来越多的临床和实验研究发现,在食道癌、胃癌、肝癌、大肠癌在内的许多疾病中,chemerin和chemerin受体受到了干扰.此外,chemerin和chemerin受体已被证明可调节免疫细胞以及与癌症相关的成纤维细胞的增殖、迁移和侵袭.本文重点介绍Chemerin在消化道肿瘤病理生理中的研究进展.

自发性食管破裂是一种罕见疾病,而在肠道准备过程中发生自发性食管破裂更是罕见.该病的死亡率很高,治疗原则是清除污染源,封闭裂口,恢复食管完整性,充分引流,控制感染,加强营养支持,改善身体状况,促进伤口愈合.但关键是避免患者在肠道准备过程中因剧烈呕吐而发生自发性食管破裂,笔者建议小口、多次服用导泻剂.

在大多数国家中,胃癌通常是在疾病的晚期被确诊的.我们总结了目前关于早期胃癌病变的诊断和治疗的科学证据,包括了对这些病变患者筛查、诊断、评估、治疗和随访等主题,并讨论了未来的研究领域. 1 诊断和评估 理论上,胃癌筛查可能会提高早期病变的确诊率,降低病死率.然而,目前仍不清楚何时进行筛查及应对谁进行筛查.尽管有几个因素和条件可能导致胃癌,如先前的胃部手术、胃癌家族史、自身免疫性胃炎、萎缩性/化生性胃炎、遗传和基因条件,但对于其中许多情况,尚未确定明确的筛查指征.

目的 系统性评价肠内营养应用于术前肠道准备对结直肠癌患者腹腔和肠腔脱落癌细胞及预后的影响.方法检索建库至2017年3月中国知网(CNKI)、万方数据库、维普数据库(VIP)、Pubmed、Embase、Medline、Coehrane library、Web of Science有关肠内营养与机械性肠道准备用于结直肠癌患者术前肠道准备的对比研究文献.对肠内营养肠道准备组与机械性肠道准备组患者腹腔脱落癌细胞阳性率、肠腔脱落癌细胞阳性率、局部复发率、远处转移率、3年生存率等数据进行Meta分析.数据分析应用RevMan 5.3软件.结果共4篇随机对照研究文献纳入本研究,444例结直肠癌患者纳入Meta分析,其中肠内营养肠道准备组222例,机械性肠道准备组222例.与机械性肠道准备组比较,肠内营养肠道准备组患者腹腔脱落癌细胞阳性率(OR=0.22,95％CI:0.10～0.51,P<0.05)和肠腔内脱落癌细胞阳性率(OR=0.32,95％CI:0.19～0.54,P<0.05)均降低,但术后局部复发率(OR=0.72,95％CI:0.19～2.01,P>0.05)、远处转移率(OR=1.01,95％CI:0.42～2.42,P>0.05)和3年生存率(OR=1.14,95％CI:0.69～1.86,P>0.05)比较差异均无统计学意义.结论肠内营养应用于结直肠癌患者术前肠道准备可降低腹腔和肠腔脱落癌细胞阳性率,且不影响术后局部复发率、远处转移率和3年生存率.

Multiple primary cancer (MPC), also known as repeated and multiple cancer, is a rare pathological phenomenon. It can be divided into two types. Patients with tumor interval within 6 months are called Synchronous Carcinoma (SC), and more than 6 months are called Metachronous Carcinoma (MC). Here, we report a case of MPC. The abdominal CT showed: a 30 mm * 34 mm round slightly low density shadow on the right kidney and the right wall of the rectum was unevenly thickened. The patient was diagnosed as MPC and treated with radical surgery. This unique case highlights that MPC should be considered if a patient is suspected of having metastatic tumor.

目的:探讨腹腔镜探查联合Lichtenstein或经腹腹膜前疝修补术(transabdominal preperitoneal,TAPP)治疗腹股沟嵌顿疝的手术方法,评估发生绞窄且行肠切除时放置合成补片的安全性.方法:回顾分析2013年9月至2015年12月因腹股沟嵌顿疝就诊且经手术治疗的71例患者的临床资料,其中35例腹腔镜探查后行Lichtenstein手术(Lichtenstein组),36例行TAPP(TAPP组).71例患者中60岁以上占64.8％,男性占78.9％,嵌顿时间平均(17.2±22.6)h;术后随访25～52个月,平均(39.1±8.3)个月.比较两组术后近远期并发症发生率及临床疗效.结果:7例因发生绞窄而行肠切除术.TAPP组住院时间、恢复日常活动时间与工作时间均优于Lichtenstein组,两组差异有统计学意义.两组并发症发生率差异无统计学意义.结论:在腹股沟嵌顿/绞窄疝的治疗中,如腹腔镜下探查判断肠管失活,先于镜下完成肠切除肠吻合术,联合Lichtenstein放置大孔聚丙烯补片是安全、有效的.

Objective To evaluate the adjuvant analgesia effect of the addition of dexamethasone to ropiva-caine in a transversus abdominis plane(TAP)block after inguinal herniorrhaphy. Methods 100 adult male pa-tients who underwent open tension-free inguinal herniorrhaphy from August 2015 to June 2017,randomized into two groups equally. TAP block with ropivacaine with additional dexamethasone was experiment group(group D) and with ropivacaine was control group(group C). Before the operation,all the patients were performed TAP block by the same group of surgeons. Celecoxib(200mg,Q12h,po)was prescribed to all patients in 48 hours after oper-ation. VAS and clinical symptoms were recorded. The sum and time of celecoxib consumption were also recorded af-ter 72 hours postoperatively. The surveys about the Carolinas comfort scale(CCS)of all the patients one week after operation were collected. Results The averaged pain score in 48 hours after operation has no statistical signifi-cance. The occurrence of postoperative nausea and vomiting of group D is lower than group C,neither of them were statistically significant. The averaged CCS of group D was lower than group C;the difference was significant. Con-clusions Compared to single usage of ropivacaine in the single-shot TAP as a preemptive analgesia method for in-guinal herniorrhaphy,adding dexamethasone to ropivacaine didn′t show significance in analgesic intensity after in-guinal herniorrhaphy,though the adjuvant usage of dexamethasone reduced the sum and duration of other analgesic medications and enhanced the comfort of the patients after mesh-used herniorrhaphy.

术后胃瘫综合征(postoperative gastroparesis syn-drome,PGS)是腹部手术后早期常见的并发症.它主要发生在胃十二指肠手术后,也发生在非胃十二指肠手术中,是一种具有胃动力障碍和胃肠道非机械性阻塞特征的功能性疾病[1].PGS 的发病率随着手术的展开和手术时间的延长而增加[2].据报道,胰十二指肠切除术后 PGS 发生率达到 20％～50％,远端胃癌切除术后其发病率约为 4％～5％[3].大多数胃瘫患者单纯使用药物难以治愈,目前胃瘫的治疗都是综合治疗,包括饮食调整,血糖控制,止吐药物,促动力药物和手术干预,如胃电刺激(gastric electrical stimu-lation,GES),肉毒杆菌注射,幽门成形术等[4],但临床疗效不理想.本文对可能引起胃瘫的因素进行非条件 Logistic 回归分析,探讨引起胃瘫的危险因素,为临床诊治提供参考.

Objective:The purpose of this study is to evaluate the incidence of occult contralateral inguinal hernia ( OCH) dur-ing laparoscopic inguinal hernia repairs ( LIHR) ,to mark the risk factors and judge which kind of patients need bilateral inguinal explo -ration.Methods:The results of 174 patients who underwent laparoscopic inguinal hernia repair in Tongde Hospital of Zhejiang Province during the period of 2014-2015 were retrospectively analyzed .160 patients among them underwent bilateral groin exploration .The occur-rence rate of OCH and metachronous contralateral inguinal hernia were calculated respectively .Meanwhile,the incidence of operative complications was also assessed over a period of following-up ranging from 24 to 36 months.Results:There was one case loss of follow-ing-up.15 patients (15/160) who completed bilateral exploration were diagnosed as OCH during operation .6 patients (6/144) under-went unilateral repair ( though they were given bilateral groin exploration and considered contralateral side "healthy") developed a her-nia in median follow-up of 29 months.Operative complications were summarized as follows:two cases of seroma,one case of recurrence, one case of mesh shifting and five cases of chronic pain .In addition,one case was transferred to open surgery .There was no surgical site infection,intestinal injury,vas deferens injury or blood vessels injury .Conclusions:There is higher incidence of OCH reported in the elder/male/the left side/the greater defect of hernia ring .For these patients ,bilateral inguinal exploration is recommended and prophy-lactic bilateral hernia repair is necessary and safe according to the findings of laparoscopic exploration .

Objective To investigate the relationship between reflux esophagitis and bridge loop distance in total gastrectomy with non-isolated Roux-en-Y reconstruction.Methods Twenty-nine patients with gastric cancer treated by total gastrectomy were retrospectively analyzed.The gastrointestinal tract was reconstructed with non-isolated Roux-en-Y correlation and the bridge distance of intraoperative anastomosis was 40cm,50cm or 60cm,respectively.The operation time,intraoperative blood loss,postoperative anal recovery time,postoperative feeding time and postoperative hospital stay were observed and compared.The patients were followed up for 6 months.The gastrointestinal function,nutritional status and acid reflux score were evaluated before and 6 months after operation;the endoscopic esophageal endoscopy score was evaluated at discharge and 1,3 and 6 months after operation.Results There were no significant differences in the operation time,intraoperative blood loss,postoperative anal recovery time,postoperative eating time and postoperative hospital stay (P ＞0.05) among 3 groups.The digestive function and nutritional status were significantly improved after operation in all groups (P＜0.05),the acid reflux score was significantly lower than that before operation (P＜0.05),the endoscopic score were significantly lower than those before discharge (all P＜0.05).There were no significant differences in digestive function,nutritional status and acid reflux score among three groups before operation (P ＞0.05),and no significant difference in endoscopic scores among three groups before and after discharge (P ＞0.05).In 40 cm group the digestive function and nutritional status were significantly better,and the endoscopy scores,acid reflux scores were significantly lower than those in 50 cm and 60 cm groups (all P＜0.05).Conclusion The 40 cm may be the best bridge distance in total gastrectomy with non-isolated Roux-en-Y reconstruction,and the risk of postoperative reflux esophagitis is relatively low.

目的 探讨进展期胃癌患者手术前后癌胚抗原(CEA)及糖链抗原199(CA199)水平变化对其预后的评价作用.方法 收集进展期胃癌患者40例(观察组),另取同期收治的非胃癌患者40例作为对照组,对两组患者治疗前后的血清CEA、CA199水平变化情况进行研究.结果 观察组手术后血清CEA、CA199水平均低于术前(均P＜0.05),对照组治疗前后差异均无统计学意义(均P＞ 0.05).观察组行根治手术患者术后血清CEA、CA199水平明显低于姑息手术患者(均P＜ 0.05).观察组术后血清CEA、CA199阳性率及两者联合检测的阳性率均显著低于手术前(P＜0.05).结论 进展期胃癌患者手术后CEA、CA199水平均显著低于手术前,对患者预后有指导价值.

目的 研究癌相关成纤维细胞中Gal-1表达通过integrin β1促进胃癌细胞侵袭的机制.方法 高表达Gal-1的胃癌CAFs采用原代培养法,通过CAFs与胃癌细胞共培养、siRNA转染、抑制Gal-1/封闭integrin β1表达、细胞侵袭能力实验、侵袭能力影响实验和IHC实验等技术,研究胃癌细胞侵袭迁移能力受胃癌CAFs中Gal-1表达的影响程度及作用机制.分析高表达Gal-1的CAFs对癌细胞迁移能力和侵袭能力的影响,比较Gal-1和integrin β1免疫组化实验结果.结果 CAFs共培养使得胃癌细胞侵袭和迁移能力得到明显提升,Gal-1的表达遭到siRNA抑制后,CAFs对迁移能力和侵袭能力的促进作用得到有效抑制.Gal-1主要在胃癌细胞的间质成纤维细胞中表达,integrin β1主要在胃癌细胞的细胞膜中表达.Gal-1和integrin β1在胃癌中的阳性率分别为56.67％(51/90)、43.33％(39/90),并且其表达与淋巴结转移、远处转移、TNM分期差异具有统计学意义(P＜0.05).结论 CAFs表达Gal-1并通过促进胃癌细胞integrin β1表达的形式提高胃癌细胞的侵袭迁移能力,指明今后胃癌的治疗和相关预后的研究方向,表现出一定的理论研究价值.