目的:分享肝移植术后新发结直肠癌腹腔镜手术的体会。方法:介绍2010年6月至2018年6月期间，海军军医大学附属长征医院肛肠外科收治的原位肝移植术后4例出现新发结直肠癌患者的腹腔镜下行根治术的治疗情况。结果:4例患者（结肠癌3例、直肠癌1例）根据病情及主观意愿接受腹腔镜下结直肠癌根治术。术后2例患者死亡，另2例患者术后存活>10个月。结论:腹腔镜术式可有效减少对手术创伤，减少出血和不良反应的风险，值得在临床上进行广泛应用。手术操作应严格规范无瘤操作的规程，避免术后肿瘤复发转移或不良反应的风险。

目的 探讨十二指肠胃肠道间质瘤(GIST)局部切除手术和消化道重建方式,并总结临床经验.方法 收集2010年1月至2018年1月于我院肛肠外科接受局部切除治疗的29例十二指肠GIST患者的临床资料.分析患者局部切除手术和消化道重建方式,并结合临床病理参数及随访资料探讨不同术式的临床疗效和适用范围.结果 29例十二指肠GIST患者中,24例(82.8％)位于十二指肠球部和降部,5例(17.2％)位于水平部和升部.19例行单纯楔形切除+一期吻合(16例开腹手术、3例腹腔镜手术),7例行开腹区段切除术+毕Ⅱ式胃空肠吻合+Roux-en-Y式吻合,2例行开腹楔形切除术+Roux-en-Y式十二指肠空肠吻合,1例行开腹区段切除术+侧-侧十二指肠空肠吻合.术后病理示所有患者肿瘤切缘均为阴性(R0).术后发生吻合口瘘2例,肠梗阻3例.随访期间所有患者均无局部复发.结论 局部切除手术是治疗十二指肠GIST的合理选择之一,疗效可靠.

"糖友"患胆结石是普通人群的2～3倍 糖尿病和胆囊结石之间存在非常密切的关系.据统计,约有三分之一的糖尿病患者可能中招.有数据表明,糖尿病人群患胆囊结石的概率为非糖尿病人群的2～3倍.原因之一是血糖控制不佳,特别是2型糖尿病患者,大多存在血脂异常,再加上肥胖及高胰岛素血症等,体内的胰岛素不能有效地抑制脂肪分解,脂肪代谢紊乱,导致肝内胆固醇合成增加,最终形成结石.

Objective:To construct recombinant adenovirus vector Ad5-CCL20,and detect the expression of CCL20 after Ad5-CCL20 transfected colon cancer cells CT-26.Methods:Genes encoding CCL20 was obtained from original plasmid double-digested with EcoR I/Sal I enzymes.The CCL20 DNA segments were linked into pDC316 to recombine shuttle plasmid pDC316-CCL20.After genome sequencing,we take shuttle plasmid pDC316-CCL20 and plasmid backbone pBHGIox_E1,3Cre co-transfecting 293T cells in mediation of liposome.The constructed recombinant adenovirus vector was named Ad5-CCL20.Lastly,after Ad5-CCL20 transfected CT-26 cells in vitro,the expression of CCL20 at different time points (12h,24h,36h and48h)was detected by Western blot and Elisa.Then,Culture supernatant was added into iDC and mDC to evaluate the chemotactic activity of CCL20.Results:The recombinant adenovirus Ad5-CCL20 were successfully constructed.The expression of CCL20 was detected by Western blot and Elisa.The level of CCL20 expression was increased with prolonged incubation of the infected CT-26 cells.Chemotaxis experiments show that the chemokine CCL20 had chemotactic activity to the iDC and mDC,but more obviouly for iDC (P＜0.05).Conclusion:The construction and obtain of recombinant adenovirus vector Ad5-CCL20 provide a new method for developing tumor immunotherapy.

目的:探讨重组腺病毒Ad5-CCL20联合热疗对结肠癌CT-26细胞小鼠移植瘤的抑制作用.方法:将Ad5-CCL20转染CT-26细胞,采用ELSA法和趋化实验分别检测CT-26细胞中CCL20的表达及其对DC的趋化作用.Western blot-ting检测热激结肠癌CT-26细胞中HSP70、GP96的表达.用热激后细胞蛋白(Heat组)对DC进行诱导,并设对照组(Control组)和阴性对照组(Unheat组),流式细胞术检测DC的表型.建立CT-26细胞移植瘤模型,设Ad5-CCL20/Heat、Heat、Ad5-CCIL20、Ad5-GFP和Control组,观察各组荷瘤小鼠肿瘤生长和生存时间;采用ELISAPOT法和LDH法分别检测脾组织T淋巴细胞分泌IFN-y的能力和对CT-26细胞的CTL杀伤活性,免疫组化法检测肿瘤组织DC浸润情况.结果:Ad5-CCL20转染CT-26细胞后可高表达CCL20,且对iDC、mDC都具有趋化活性,对iDC更为明显(P＜0.05).CT-26细胞热激后可高表达诱导型HSPT0和GP96.与Control、Unheat组相比,Heat组细胞蛋白诱导后DC的CD80、CD86、CCR6和MHC-Ⅱ的表达率明显升高(均P＜0.01).与Control、Ad5-GFP、Ad5-CCL20组和Heat组相比,联合治疗组荷瘤小鼠的肿瘤抑制最为明显(均P＜0.01),生存时间明显延长(均P ＜0.05).联合治疗后的荷瘤小鼠脾组织T淋巴细胞的CTL活性要明显高于另外四组(均P＜0.05),其瘤组织中CD11c+ DC的阳性率也明显增高(均P＜0.05).结论:重组腺病毒Ad5-CCL20联合热疗可召募并促进DC成熟和抗原提呈,明显抑制肿瘤生长,并延长荷瘤小鼠的生存期,提示其对结肠癌有潜在的治疗作用.

Objective: To study the relationship between epithelial-mesenchymal transition (EMT) phenotype of circulating tumor cells (CTCs) and liver metastasis of pancreatic cancer.Methods: The patients who were found without liver metastasis by preoperative imaging examination but confirmed with pancreatic cancer by postoperative pathological diagnosis were recruited in this study from January 2010 to December 2013 in Department of General Surgery, Changzheng Hospital, Second Military Medical University. All patients were followed up for 1 year after surgical operation, then divided into liver metastasis group and non-liver metastasis group according to whether the patient had liver metastasis or not during the follow-up. In each group, 50 patients were randomly selected. The peripheral blood samples from all patients were collected before surgery, and at the same time, the peripheral blood samples from 10 healthy volunteers were collected as the control. Then the CTCs were enriched and isolated from peripheral blood samples using immunomagnetic method, and identified by immunofluorescence method with carbamoyl-phosphate synthetase 1 (CPS1) antibody. The expressions of EMT markers Snail and Vimentin in blood samples were detected by immunofluorescence method. The relationships between these EMT markers and liver metastasis of pancreatic cancer were analyzed by univariate and multivariate analyses.Results: CPS1, Snail and Vimentin were not expressed in blood samples from 10 healthy volunteers. In peripheral blood samples from 50 pancreatic cancer patients with liver metastasis, the positive expression rates of Snail and Vimentin were 82% (41) and 72% (36), respectively; while in non-liver metastasis group, the positive expression rates of Snail and Vimentin were 20% (10) and 12% (6), respectively. The positive expression rates of Snail and Vimentin in liver metastasis group were higher than those in non-liver metastasis group (χ2 = 38.455, P 37 kU/L, tumor diameter ≥ 4 cm, pancreatic head tumors, vascular invasion, and positive expressions of Snail and Vimentin were correlated with liver metastasis of pancreatic cancer (all P 37 kU/L (β = 3.411, P < 0.01) and positive expressions of Snail (β = 2.882, P < 0.01) and Vimentin (β = 3.361, P < 0.01) were independent risk factors for liver metastasis of pancreatic cancer.Conclusion: CTCs-EMT phenotype markers Snail and Vimentin in peripheral blood may be closely related to liver metastasis of pancreatic cancer. DOI:10.3781/j.issn.1000-7431.2015.33.221

Colorectal cancer is one of the most common malignant tumors of digestive tract.The liver is a frequent site of metastatic colorectal disease. Only less than 20% of colorectal liver metastases (CRLM ) can be surgically resected, so that the liver metastases is one of the important causes of death in patients withCRLM. For this reason, a lot of the “guidelines for diagnosis and treatment” and “criterion” for CRLM were formulated at home and abroad. Because of the uneven medical levels in various hospitals of China, it is dififcult to completely follow the “guidelines” and “criterion” in treatment of CRLM. Therefore, this article summarizes therapeutic measures suitable for majority of doctors in treatment of CRLM including surgery, neoadjuvant chemotherapy and adjuvant chemotherapy, local treatment and multi-disciplinary treatment.

现已证实,基因研究有助于阐明能够促进胰腺癌(pancreatic cancer,PC)发生、发展的一些关键基因和分子通路.早期研究发现,在胰腺上皮内瘤样变(PanINs)进展过程中,随着组织异型程度的增加,相应的发生KRAS基因激活,CDKN2A基因、TP53基因及SMAD4基因失活,并可导致多个重要的细胞过程和信号转导通路发生改变 而在导管内乳头状黏液性瘤(IPMNs)和黏液性囊性瘤(MCNs)进展过程中,也发生了相应的基因突变.最近,全基因组外显子测序技术揭示了由癌前病变进展而来的胰腺癌基因图谱,这些研究对发展形成新的个体化治疗方法有所帮助.本文从胰腺三种癌前病变形态学变化、各自的基因突变事件以及胰腺癌前病变中部分信号通路和调控过程与基因突变的关系等方面作一综述.

Objective To analyze the differential expression and clinical significance of mucin 4 ( MUC4) in pancreatic in-traepithelial neoplasias (PanINs) and pancreatic ductal adenocarcinoma (PDAC). Methods We collected 85 cases of paraffin of pancreatic tissue specimens from Affiliated Changzheng Hospital of the Second Military Medical University from 2009-03-01 to 2011-12-31. Immunohistochemical SP method was used to examine the expression of MUC4 in 48 normal pancreatic duct (NP) tissues, 17 Pan-INs tissues and 20 PDAC tissues. The correlation of MUC4 expression with clinicopathological characteristics and prognosis of PDAC patients was analyzed. Results MUC4 was not expressed in NP;MUC4 expression gradually increased with the progression of pancre-atic tissue. The positive expression rates of MUC4 in NP, PanIN-1, PanIN-2, PanIN-3 and PDAC were 0, 17. 4%, 52. 6%, 84. 6%and 90. 0%, respectively; The immunohistochemical scores of MUC4 expression in NP, PanIN-1, PanIN-2, PanIN-3 and PDAC groups were 0, 1. 30±0. 89, 2. 58±1. 76, 4. 54±1. 64 and 7. 68±2. 34, with statistic significance among groups (P<0. 001). The ex-pression level of MUC4 was associated with neural invasion ( P=0. 028) , lymph node metastasis ( P=0. 020) and CA19-9 level ( P=0. 028) in PDAC. The median overall survival(OS) of PDAC patients was 17. 0 months(95%CI:14. 809-19. 191 months);The median OS of MUC4 high expression group ( immunohistochemical score≥8. 8) and low expression group ( immunohistochemical score <8. 8) were 13. 0 months ( 95%CI:7. 456-18. 544 months) and 20. 0 months ( 95%CI:15. 521-24. 479 months) , with statistic significance ( P=0. 003) . Conclusion MUC4 perhaps participates in the PDAC occurrence and development. MUC4 expression may be an early event in the evolution of PDAC. MUC4 high expression probably affects both invasion and metastasis of PDAC, and probably predicts poor prognosis.

Pancreatic cancer is a malignant with very poor prognosis.Although methods and technologies of diagnosis and treatment in connection with pancreatic cancer have made great progresses,the prognoses of patients with pancreatic cancer still have not a significant upgrade,which are closely related with the degree of malignancy of pancreatic cancer cells.Earlier studies have shown that normal pancreatic cells need to have a total of six capabilities,which are intimate connection with the degree of malignancy of pancreatic cancer cells,during the process of deterioration.A variety of immunohistochemical markers that correlate with prognosis of pancreatic cancer involve in the process of pancreatic cells obtaining these six capabilities.

腹腔镜手术已成为外科手术中常见的一种方式,甚至已成为某些手术的标准.一台腹腔镜手术成功与否,不仅需要主刀医生精湛的技术和一助医生密切的合作,也需要持镜助手默契的配合.而目前在临床中,大部分持镜助手是年轻的住院医生或研究生,甚至实习生,而他们几乎均未进行专业的持镜培训,这极大影响了腹腔镜手术的进程.因此,本文从腹腔镜手术术前、术中、术后三方面对持镜助手的配合要求做一简要论述.

The application of standardized patients in CBL of colorectal surgery has the advantages of being repeated,standardization,visualization,which is in favor for improving students' clinical skills,communication techniques and broken concept.CBL with case as the guide can help students better understand and grasp the basic clinical knowledge,promote the integration of theory with practice,improve the analysis and solve the practical problems of clinical ability.

OBJECTIVE: To construct an expression plasmid of siRNA against CD133 gene and to investigate its biological behavioral effect on human colon carcinoma cell line HT-29.METHODS: we inhibited the CD133 expression using the siRNA method.Expression levels of CD133 mRNA and protein from HT-29 after transfection were examined by RT-PCR and Western blot respectively.Changes of the cell growth activity in response to transfected plasmid were evaluated by MTT assay.The migration ability of transfected HT-29 cells were measured quantitatively by Transwell migration assays.RESULTS: After CD133 siRNA transfeetion into HT-29 cells,compared with that in control groups,the level mRNA of CD133 in cancer cells transfected with CD133 siRNA was inhibited in a concentration and time dependent manner and the CD133 protein concentration decreased significandy.The growth of HT-29 cells was significantly inhibited than those in control groups(P0.05).CD133 siRNA significandy inhibited invasion of HT-29 cells to matrigel(P0.05).CONCLUSION: Silencing CD133 gene by the siRNA technology can actively suppress the expression of CD133 gene,and then inhibit the growth and invasion of HT-29 cell.

Knowledge process outsourcing as a knowledge-intensive industry is closely related with intellectual property.This paper analyzes the authorized agent for intellectual property in knowledge process outsourcing,and proposes the authorization model of intellectual property in the knowledge process outsourcing industry and the criteria for the selection of the model.The paper gives a detailed analysis of the authorization model of intellectual property of Evalueserve Business Consulting Corporation in China,which is a knowledge process outsourcing enterprise investigated by us.

From the perspective of knowledge management and based on the TRM drawing process,this paper analyzes the categories of knowledge and the knowledge flow in TRM,and then constructs a model of knowledge flow.From the angles of knowledge acquisition,knowledge integration and knowledge innovation,the paper also expatiates on the knowledge management activities in TRM drawing process and discusses the methods of optimizing the knowledge management process and improving the quality of knowledge management in TRM.

目的 以MNU灌肠方式建立大鼠原位结肠癌及远处转移模型,实时观察大鼠结肠癌的发生、发展及转移过程.方法 应用MNU(N-甲基-N-亚硝基脲)对SD大鼠进行灌肠,观察大鼠摄食、活动、排便等临床表现及成瘤时间、肿瘤生长、转移情况,分别于8、12、16周进行解剖,观察结肠原位肿瘤的生长及远处转移情况,通过病理分析,综合评价该模型.结果 实验大鼠未发生死亡,灌肠8周后,大鼠即可出现大便性状改变、便血、淋巴结肿大等临床症状,灌肠后12周后,75%的SD大鼠发生了结肠癌,并同时发生了多处淋巴结转移,16周后大鼠结肠原位肿瘤诱导成功率达到91.7%,病理学证实了原位结肠癌及远处淋巴结转移.结论 MNU能够通过灌肠方式有效地在SD大鼠上诱导出结肠癌及远处转移,诱导过程方便有效,贴近结肠癌的自然发生、发展过程,该模型淋巴结转移成功率较高,为结直肠癌原位生长及淋巴道转移机制,寻找新的治疗方案以及抗转移治疗等提供了理想的动物模型.

Objective:The aim of this study was to evaluate the safety and efficacy of hand-assisted laparoscopic distal pancreatectomy(HLDP) and compare it with open distal pancreatectomy(open-DP).Methods:Twenty-four patients who underwent distal pancreatectomy(HLDP,10 patients;open-DP,14 patients) between Sep.2002 and Dec.2009 in department of general surgery of Shanghai Changzheng Hospital were enrolled in this study.Their clinical data were compared.Results:The incision for HLDP group[(4.8±0.8)cm] was significantly shorter than that in the open-DP group[(14.4±2.6)cm](P0.001).Blood loss in the HLDP group [(116.0±64.8) ml] was significantly less than that in the open-DP group [(328.6±314.8)ml](P=0.048).And,none of the patients in the HLDP group received conversions.The average time of first passage of flatus[(2.8±0.6)d vs.(3.9±0.7)d;P=0.002],time of oral intake[(3.7±0.7)d vs.(4.7±0.8)d;P=0.001] and hospital stay [(9.5±4.2)d vs.(12.7±2.7)d;P=0.033)] in the HLDP group were significantly shorter than those in the open-DP group.The operative time and the incidence of postoperative complications in HLDP and open-DP groups were not significantly different.Conclusions:HLDP for distal pancreatic neoplasms is safe and feasible.The procedure appears to be mini-invasive and rapid,and it is accompanied by an accelerated recovery.

胆囊黏液腺癌是一种少见疾病,临床上缺乏特异性表现,上海长征医院普外科自1995年1月至2009年8月年共收治150例胆囊癌,其中黏液型胆囊腺癌分泌果冻样黏液性胶状物质阻塞胆管引起黄疸3例,现报道如下.

军事医学首先遇到的是武器伤害问题.因此,加强武器特别是高技术武器伤害的教学及科研,已成为军队医学院校极其迫切的任务.我们遵循信息化教学设计的基本原则,以"任务驱动"和"问题解决"作为学习和研究活动的主线.在2004年从以下4个模块着手建构了现代战伤的信息化教学平台,实施至今,取得了较好的效果.

患者,男,34岁.因左上腹部胀痛不适4个月于2008年10月28日入院.患者4个月前出现反复左上腹坠胀不适,伴轻度疼痛,近两个月出现右侧腰背部胀痛.伴右肩背部束带感.外院B超、CT检查提示"脾脏占位,肝脏多发结节"(见图1).人院查体:全身浅表淋巴结未及肿大,皮肤巩膜无黄染.腹平软,无压痛,脾脏肋下2 cm,质韧,轻度压痛.