残胃癌临床特点及诊治

随着诊治水平的提高,残胃癌的诊出率逐年升高,其不同于传统胃癌的临床特点和发病危险因素引起越来越多临床医生的关注。由于早期表现不典型,残胃癌的早期诊断一般不易实现,需要借助针对既往有胃大部切除术史的患者进行常规随访达到早期发现残胃癌的目的。在初次手术中,患者的解剖结构发生改变,残胃与周围组织的粘连及淋巴回流的改变为残胃癌的手术带来更多需要考虑和关注的重点和难点。本文通过复习文献,从残胃癌的定义、临床特点、发病相关因素及相关诊治、预后等方面对残胃癌这一疾病进行简要概述,以提高临床对残胃癌及诊治原则的认识。     

Bile duct schwannoma developed in the remnant choledochal cyst—a case associated with total agenesis of the dorsal pancreas

A 59-year-old Japanese woman was referred to our hospital due to upper abdominal pain. At the age of 44, she was diagnosed with a congenital choledochal cyst, Todani's type Ic. She then underwent bypass operation with end-to-side choledochojejunostomy with Roux-en-Y technique as well as cholecystectomy. Magnetic resonance cholangiopancreatography revealed an 'oval' shaped cystic lesion with a maximal diameter of 25 mm, which had been 'spindle' shaped with a maximal diameter of 18 mm, 15 years ago. It also showed an anomalous pancreaticobiliary ductal union. In addition, a complete absence of the dorsal primordia of pancreas was revealed by magnetic resonance image and computed tomography scan. The patient underwent the surgical exploration for the resection of the 'oval' shaped cystic lesion. Haematoxylin and eosin staining of the thin section of the resected cyst showed a compact spindle cell pattern which was compatible with schwannoma, Antoni type A, which was confirmed by immunocytochemical technique. We present a very interesting case showing choledochal cyst, anomalous pancreaticobiliary ductal union, total agenesis of the dorsal pancreas and late-development of bile duct schwannoma in the remnant choledochal cyst.     

腹腔镜胆囊切除术后残余胆囊结石的外科处理

目的探讨腹腔镜胆囊切除术后残余胆囊结石的治疗和预防方法。方法回顾分析16例腹腔镜胆囊切除术后残余胆囊结石患者的诊治经过。结果结合彩超、MRCP、ERCP等检查方法均可确定诊断,通过开腹或腹腔镜下残余胆囊切除术,术后患者临床症状均有效缓解,无严重并发症。结论对于残余胆囊应该重视初次手术中的预防。腹腔镜下残余胆囊切除术安全可靠。当合并胆总管结石时,可联合内镜和腹腔镜分次治疗。术中胆道造影或胆道镜检查可增加手术安全。     

残胃癌外科治疗临床分析及再认识

目的分析残胃癌的外科治疗及其临床病理特征,对当前残胃癌外科治疗进行再认识。方法回顾性总结我院2004年1月至2011年3月期间经内镜和病理学检查诊断为残胃癌并行外科治疗的26例患者的临床资料,其中首次疾病为良性的残胃癌(RGCB)者14例,胃癌根治术后残胃癌(RGCC)者12例,对其临床发病、HP感染、手术方式、组织病理学特点及预后因素进行分析。结果 RGCB距第1次胃切除术后的发病时间为15～44年(中位时间为26.3年),RGCC距第1次胃切除术后的发病时间为1~10.5年(中位时间为4.0年),两者间差异有统计学意义(P<0.05)。病理检测残胃癌的HP感染率为73.1%(19/26),其中RGCB的HP感染率为71.4%(10/14),RGCC的HP感染率为75.0%(9/12),两者间差异无统计学意义(P>0.05)。26例患者均再次进行了手术治疗,其残胃癌手术根治率为46.2%(12/26),其中RGCB根治切除率为57.1%(8/14),RGCC根治切除率为33.3%(4/12),两者间差异无统计学意义(P>0.05)。在行根治性切除的12例患者中胃周淋巴结转移以小弯淋巴结转移率最高(83.3%,10/12),其次为空肠系膜淋巴结(33.3%,4/12)和脾门淋巴结(33.3%,4/12)。26例残胃癌术后病理分期:Ⅰ期3例,Ⅱ期2例,Ⅲ期14例,Ⅳ期7例。18例手术切除者术后病理报告提示有13例(72.2%)发生淋巴结转移;明确肿瘤侵犯胰腺或横结肠或脾脏者13例(50.0%);8例有腹膜转移(30.8%),其中RGCB的腹膜转移率为14.3%(2/14),明显低于RGCC的腹膜转移率(50.0%,6/12),P<0.05。全组病例累积1年总体生存率为54.5%,3年生存率为38.5%,生存时间为2～61个月(中位生存时间12个月)。生存分析结果表明,肿瘤的病理分期与是否接受根治性手术为残胃癌患者生存的影响因素(P<0.01),而患者年龄、性别、第1次疾病、病理分化程度以及HP感染均不是影响预后的相关因素(P>0.05);是否接受根治性手术为影响生存的独立预后因素(P<0.05)。结论早期诊断和根治手术是改善残胃癌患者预后的关键因素,腹腔镜探查可减少不必要的外科手术创伤。胃癌术后残胃癌与良性疾病后残胃癌在临床特点上不同,临床处理仍需区别对待。     

兔保留与切除残迹前交叉韧带重建生物力学的比较

目的比较兔保留与切除残迹前交叉韧带（ACL）重建的生物力学差异,探讨保留残迹的意义。方法新西兰兔10只,体重（2．66±0．32）kg。切断双侧ACL,右侧股骨与胫骨端各保留残迹2mm,左侧完全切除两端残迹。切取跟腱制备移植物,对应ACL印迹解剖位分别建立胫骨与股骨隧道,重建双侧ACL。于术后8周,行单轴拉力测试。SPSS19．0软件进行数据统计。结果术后8周,保留残迹组的最大载荷（t=2．931,P〈0．05）、屈服载荷（t=2．680,P〈0．05）、刚度（t=5．411,P〈0．05）明显高于切除残迹组,两组之间差异均有统计学意义;保留残迹组拉伸长度显著低于切除残迹组,两组差异有统计学意义（t=-3．872,P〈0．05）。两组损毁模式不同,保留残迹组多表现为移植物关节内断裂,而切除残迹组多表现为移植物自骨隧道拔出。Fisher精确检验表明两组的样本损毁模式有统计学差异（P〈0．05）。结论保留残迹ACL重建的生物力学特征优于切除残迹ACL重建,提示临床采用保留残迹技术重建ACL有可能促进移植物腱-骨愈合和“韧带化”,从而改进治疗效果。     

Appraisal of gastric stump carcinoma and current state of affairs

Gastric stump carcinoma, also known as remnant gastric carcinoma, is a malignancy arising in the remnant stomach following gastrectomy for a benign or malignant condition. Enterogastric reflux and preexisting risk factors in a patient with gastric cancer are the major contributors to the development of gastric stump carcinoma. The occurrence of gastric stump carcinoma is time-dependent and seen earlier in patients operated on for malignant rather than benign diseases. The tumor location is predominantly at the anastomotic site towards the stomach. However, it can occur anywhere in the remnant stomach. The pattern of lymph node involvement and the type of surgery required is distinctly different compared to primary gastric cancer. Gastric stump carcinoma is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. Recent advances in molecular profiling of gastric stump carcinoma have identified distinct molecular subtypes, thereby providing novel therapeutic targets. Also, reports of gastric stump carcinoma following pancreatoduodenectomy and bariatric surgery highlight the need for more research to standardize the diagnosis, staging, and treatment of these tumors. The present review aims to provide an overview of gastric stump carcinoma highlighting the differences in clinicopathological profile and management compared to primary gastric carcinoma.     

缺血再灌注损伤对大鼠肝大部切除后残肝组织TNF α/IL-6/STAT-3信号通路的影响

目的 探讨缺血再灌注损伤对肝大部切除后残肝组织TNF α/IL-6/STAT-3信号通路的影响。 方法 选取健康、清洁级、雄性SD大鼠60只,体重230～280 g,随机分为单纯肝切除组（SH组）和缺血再灌注组（IR组）。将两组大鼠肝左、中叶切除,残肝（右、尾叶）作不同处理：SH组不阻断其血流,IR组阻断血流30min后恢复灌注。术后1、6、12、24、48h时取各组大鼠残肝组织,测定残肝组织TNF α、IL-6水平、CyclinD1、Cdk4、STAT 3 mRNA表达及CyclinD1、Cdk4蛋白表达水平。 结果 与SH组比较,IR组各时点IL 6表达降低,TNF α于1～12h明显升高,24h、48h时CyclinD1、Cdk4、STAT 3 mRNA及CyclinD1、Cdk4蛋白表达水平降低（均P＜0.05）。结论 缺血再灌注损伤下调了肝大部切除后残肝组织TNF α/IL-6 /STAT-3信号通路的表达,最终可能抑制了肝细胞的增殖。     

Three-dimensional remnant pancreatic volume ratio indicates postoperative pancreatic exocrine insufficiency in pancreatic cancer patients after distal pancreatectomy

BackgroundPancreatectomy may cause serious pancreatic exocrine insufficiency (PEI), which can lead to some nutritional problems, including new-onset diabetes mellitus (DM) or non-alcoholic fatty liver disease (NAFLD). Recent studies have reported that remnant pancreatic volume (RPV) significantly influences postoperative PEI. However, the specific correlation between RPV and postoperative PEI remains unclear. Here, we compare various pre-, peri-, and postoperative risk factors in a retrospective cohort to address whether preoperatively measured RPV is a predictor of postoperative PEI in pancreatic cancer patients after distal pancreatectomy (DP).MethodsSixty-one pancreatic cancer patients who underwent DP were retrospectively enrolled. Pancreatic volume was measured using preoperative 3D images, which simulated the actual intraoperative pancreatic parenchymal volume. We obtained the 3D-measured RPV and resected pancreatic volume. We calculated the ratio of the RPV to the total pancreatic volume and then divided the cohort into high- and low-RPV ratio groups based on a cut-off value (>0.35, n = 37 and ≤ 0.35, n = 24). Using multivariate analysis, the RPV ratio as well as pre-, peri- and postoperative PEI risk factors were independently assessed.ResultsThe multivariate analysis revealed that a low RPV ratio (odds ratio [OR], 5.911; p = 0.001), a hard pancreatic texture (OR, 3.313; p = 0.023) and TNM stage III/IV (OR, 3.515; p = 0.031) were strong predictors of the incidence of PEI.ConclusionsThe present study indicates that the RPV ratio is an additional useful predictor of postoperative nutrition status in pancreatic cancer patients.     

L-精氨酸对5/6肾大部切除大鼠残余肾代偿性增生的影响

目的观察１％Ｌ－精氨酸（Ｌ－ａｒｇ）饮食对５／６肾大部切除大鼠（ＳＮｘ）残余肾代偿性增生（ＣＲＧ）的影响。方法实验分组：（１）假手术（ｓｈａｍ）组；（２）ｓｈａｍ＋Ｌ－ａｒｇ组；（３）ＳＮｘ组；（４）ＳＮｘ＋Ｌ－ａｒｇ组。大鼠于术后３０天处死，观察Ｌ－ａｒｇ对残余肾湿重（ＫＷ）、肾重／体重比（ＫＷ／ＢＷ）、ＣＲＧ、残余肾蛋白质、ＤＮＡ含量、细胞增生以及平均肾小球体积（ＶＧ）的影响。结果Ｌ－ａｒｇ明显增加ＫＷ（Ｐ＜０．０５）、ＫＷ／ＢＷ（Ｐ＜０．０５）、ＣＲＧ（Ｐ＜０．０５）以及残余肾蛋白质、ＤＮＡ含量（Ｐ分别＜０．０１，０．００１）。免疫组化显示，残余肾小管、间质增殖细胞核抗原（ＰＣＮＡ）阳性细胞数明显增加（Ｐ＜０．０５）。此外，ＳＮｘ＋Ｌ－ａｒｇ组ＶＧ较ＳＮｘ组增加１６％。结论Ｌ－精氨酸可能刺激残余肾代偿性增生，此为限制Ｌ－精氨酸饮食治疗慢性肾衰提供了理论依据