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从微创外科的角度讲 ,腹腔镜手术技术最适合于那些传统的开腹手术给腹壁带来的创伤远远大于腹腔内创伤的手术。许多情况下肠梗阻的手术只是“一剪之劳”。因此 ,腹腔镜小肠梗阻手术是最能体现微创技术优越性的手术之一。1　手术的适应证及禁忌证腹腔镜小肠梗阻手术的适应证、禁忌证与传统的开腹手术没有根本的区别 ,只是由于手术操作技术的不同而受到一定的限制。一般而言 ,腹腔镜肠梗阻手术的适应证要比开腹手术更加严格 ,禁忌证的范围则要大些。随着手术经验的积累、技术的提高 ,这些适应证和禁忌证的范围也会发生变化[1,2 ] 。1 1　适…     

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Ｃｒｏｈｎ病 (ＣＤ)是一原因不明的节段性慢性炎性肠病 ,可发生于消化道的任何部位 ,其中回盲部占 4 1%～ 5 5 % ,小肠占 30 %～ 4 0 % ,结肠占 14 %～ 2 6 %。ＣＤ在我国的发病率较低 ,约为 (6～ 10 ) / 10万人 ,欧美国家约为 (5 0～10 0 ) / 10万人。ＣＤ是慢性反复发作性终身疾病 ,不论是内科或外科治疗都不能治愈。但临床治疗上仍以内科药物治疗为主[1] ,70 %的病人在病程中至少接受一次手术治疗。通过手术治疗 ,可以消除或缓解症状 ,改善病情 ,从而提高病人的生活质量。因此 ,在适当的情况选择外科治疗是一种迅速、安全 ,也是最有效的…     

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??Surgical treatment of the infra-renal aortic dissection aneurysm WANG Li-xin, FU Wei-guo, GUO Da-qiao, et al. Institute of Vascular Surgery??Zhongshan Hospital??Fudan University, Shanghai 200032??China Corresponding author: FU Wei-guo, E-mail??fu.weiguo@ zs-hospital.sh.cn Abstract Objective To analyze the treatment method choice and efficacy of infra-renal aortic dissection aneurysm (IRADA). Methods The medical records of all patients with IRADA (n= 15) who were treated from January 2004 to July 2009 at Zhongshan Hospital of Fudan University were reviewed retrospectively. The diagnosis was confirmed by CTA or MRA preoperation. Of them, two patients were treated by open surgery with graft replacement (traditional surgery group, TSG); seven patients received endovascular theapy (endovascular therapy group, ETG); six patients were given endovascular therapy combined with open surgery (hybrid treatment group, HTG). The patients were followed up in the 1st, 3rd, 6th month, 1 year later and every 1 year mostly with CTA. Results TSG: The operation time was 3.6h and 2.8h respectively. The blood loss volume was 500mL and 800mL. The two patients were followed up for 1 month and 24 months. CTA check showed that the configuration was satisfied. ETG: The mean operation time was??1.6±0.5??h. The mean blood loss volume was??30±20??mL. The mean follow time was??32±18??months. Minor endoleak was found in one patient in 6 month. No complication was detected in other patients. HTG: The mean operation time was??2.4±0.8??h. The mean blood loss volume was??80±30??mL. The mean follow time was??38±16??months. Moderate anastomosis stenosis of femoral to femoral bapass was observed. Conclusion IRADA could be treated by endovascular therapy and hybrid method effectively. They are less invasive, less operations time needed and recover sooner than TSG.     

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目的：探讨直肠全系膜切除在预防直肠癌术后肿瘤局部复发中的作用以及同该操作相关的一些问题。方法：对1998年8月以来共75例直肠癌术中行全直肠系膜切除的疗效和并发症等进行分析。结果：全组无手术死亡，术后吻合口漏4例，发生率为10％(4／40)；吻合口狭窄2例，发生率为3．3％(2／21)；会阴切口感染2例，发生率为14．3％(2／14)；术后肿瘤局部复发1例，复发率为1．3％。结论：直肠癌术中全直肠系膜切除能有效预防和降低直肠癌术后的局部复发率，但该操作给病人带来的不利因素也不容忽视。     

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目的 探讨胃癌手术后复发因素及其再手术的适应证。方法 回顾性分析1974－1998年胃癌术后复发病人进行再次手术治疗48例的临床资料，并对手术方法、要后并发症、病死率及术后病理结果进行了分析。结果 术后生存5年以上7例，3年以上8例，2听以上6例，1年以上9例，1年内死亡者12例。单纯探查者6例分别于3－6个月内死亡。结论 对胃癌术后复发者，再手术能否切除病灶主要取决于复发方式，凡证实吻合口或残胃复发者，即使侵及邻近脏器，无远处转移，且心肺功能可以耐受手术者，均应再次手术。     

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??Abdominoperineal resection??Historical review and present situation WANG Lin??GU Jin. Tumor Hospital of Peking University, Beijing100142, China
Corresponding author: GU Jin, E-mail??zlgujin@126.com
Abstract Abdominoperineal resection (APR) is the procedure of choice for treatment of rectal adenocarcinomas arising in the distal rectum or anal canal. APR involves removal of the entire rectum, mesorectum, anal canal, levator muscle, and portions of the ischiorectal fat and perineal skin. The aim of APR is to obtain negative circumferential resection margins (CRM). Surgical dissection for an APR candidate should be planned preoperatively by high-quality imaging and thorough physical examination. It must be accomplished with strict attention to tumor size and location, circumferential margin, distal margin, and invasion of the levator muscle and adjacent organs. Recent publications have emphasized the importance of resecting the levator muscles in continuity with the distal rectum. The re-visitation of the surgical planes, as described in the original Miles procedure, is now often referred to as “cylindrical APR” or “extra-levator APR, ELAPE”, as opposed to “conventional” or “standard” APR. Three variations of standard APR can be described based on plane of dissection in the perineal phase: 1. Intra-levator APR, which is equivalent to the conventional APR described in the last decade; 2.Extra-levator APR, which is equivalent to the cylindrical or extra-levator APR; 3.Ischiorectal APR, which is with wide perineal resection and equivalent to the original Miles APR described in the early 20th century. In selected cases, an APR with multi-visceral resection—such as seminal vesiculectomy or prostatectomy in male patients, or partial vaginectomy in female patients—can preserve urinary function without compromising the principles of en-bloc R0 resection.     

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肠梗阻的分类方法较多 ,有机械性、动力性和血运性 ;单纯性和绞窄性 ;完全性和不完全性 ;急性和慢性等。按梗阻部位分高位小肠梗阻、低位小肠梗阻和结直肠梗阻。高位肠梗阻通常是指十二指肠和空肠近端梗阻 ,低位是指回肠末端和结直肠梗阻。由于回肠梗阻在诊治方面同属于小肠梗阻。因此 ,本文综合国内外报道主要对结直肠梗阻的诊治情况进行论述。1　临床特点1 1　病因大肠梗阻占肠梗阻的 2 0 % [1] ,以机械性肠梗阻多见。麻痹性者可见于一些假性结肠梗阻 ,病变多限于盲肠、升结肠和横结肠 ,发生原因较多 ,约 5 0 %的病人发生在外科手术后和…     

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目的 总结和分析残胃癌的临床诊治特点。方法 回顾性分析1996年2月至2003年11月收治的14例残胃癌病人。结果 手术切除率为78．6％,根治切除率57．1％,5年生存率21．4％;根治性切除者的2年生存率达87．5％。结论 根治性外科治疗及病期是决定残胃癌预后的关键。     

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??Challenge of diagnosis and treatment in pancreatic tumors ZHAO Yu-pei??ZHANG Tai-ping??CAO Zhe. Department of General Surgery??Peking Union Medical College Hospital??Chinese Academy of Medical Sciences??Beijing 100730??China
Corresponding author??ZHAO Yu-pei??E-mail??zhao8028@263.net
Abstract Pancreatic tumor is one of the most challenging diseases in surgery. During the past decades??pancreatic surgery in China has achieved great development through the efforts of several generations of pancreatic surgeons. But in the new period??there are still many challenges in the diagnosis and therapy in pancreatic tumors. For instance, the mechanism of occurrence and development is still unclear, the prognosis of pancreatic tumors is still poor. Some new concepts of management in pancreatic tumors has evolved, and raise the new challenges. In order to promote the development of pancreas surgery in China, we should build the multi-center and multidisciplinary clinical research platform for pancreatic tumors. To standardize the multidisciplinary diagnosis and treatment, popularize the standardized workflow of pancreatic tumors. At the same time, it is also very important to train the clinical quality and scientific research thinking in young doctors.     

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甲状腺微小癌(thyroid microcarcinoma，TMC)是指肿瘤直径≤1．0cm的甲状腺癌结节。根据尸解研究，人群中其病死率较高，约超过10％的非甲状腺癌死亡病人患有TMC，且无性别和年龄的差别。Bramley等总结了世界各地尸解报告，微小癌的发现率为1．5％～35．5％。然而，大多数微小癌病灶可能几乎没有临床意义，这些病灶可在病人身上无症状存留终生。     

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??Resection of adjacent viscera for complex retroperitoneal tumor WANG Ya-nong. Department of Gastric and Soft Tissue Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
Abstract Retroperitoneal tumors, especially highly malignant retroperitoneal soft tissue sarcomas and recurrent tumors, often involve adjacent viscera by infiltrative pattern or by expansive pattern. Extended surgery with resection of adjacent viscera is recommended to control local recurrence and improve survival. Resectability should be carefully evaluated preoperatively by computed tomography scan and at surgical exploration. The frontline aggressive surgical approach and the way of en bloc resection have many advantages such as clear anatomic approach, high success rate of R0 resection, less concomitant damage of organ, and less bleeding in the operation.     

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原发性肝癌(以下简称肝癌)是我国常见的恶性肿瘤之一，恶性度高，预后差，在各种恶性肿瘤中，其病死率现已居第二位，而发病率则呈上升趋势。近年来，以手术为主的系统、序贯治疗成为学者们的共识，但如何掌握各种治疗方法的适应证，以提高肝癌治疗的整体效果则是一个有待商讨的问题。     

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目的 介绍用肝门区域血管阻断法切除最大径１０～３０ｃｍ,且经病理证实的肝细胞癌９６例的经验。复发的相关因素和疗效。方法 用肝门务砭解剖法游离阻断相应血管如肝右叶或右叶多亚役切除阻断肝动脉（ＨＡ）和门静脉（ＰＶ）右支（５４例次）,中叶切除阻断睡ＰＶ右前支和ＨＡ和ＰＶ左内支（１０例次）、左叶切除阻断ＨＡ和ＰＶ左支（１１例次）,左外段切除阻断ＨＡ和ＰＶ左外支（１５例次）。结果 （１）手术死亡率３．１％;     

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目的分析重症加强治疗病房呼吸机相关性肺炎(VAP)的病原菌分布特点及变迁。方法对中国医科大学附属第一医院重症加强治疗病房(ICU)2003年1月至2006年12月间VAP病人的痰培养病原菌及药敏结果进行回顾性分析。结果4年中ICU中VAP发生率为19.1%。铜绿假单胞菌为最常见菌,洋葱伯克霍尔德菌、鲍曼不动杆菌、嗜麦芽窄食单胞菌4年中均排在前6位。金黄色葡萄球菌在2003-2005年间逐年增加,2006年有所下降;脑膜败血黄杆菌在2005、2006年分离率明显下降;近两年肺炎克雷伯杆菌的分离率增加。2004年铜绿假单胞菌对多种抗生素耐药率高(均在75%以上)。4年中对亚胺培南的耐药率均超过40%。鲍曼不动杆菌对亚胺培南和左氧氟沙星耐药率较低,嗜麦芽窄食单胞菌对复方磺胺甲恶唑、环丙沙星和左氧氟沙星耐药率较低。分离出的金黄色葡萄球菌中,耐甲氧西林金黄色葡萄球菌(MRSA)所占比例高。结论铜绿假单胞菌、洋葱伯克霍尔德菌、鲍曼不动杆菌、嗜麦芽窄食单胞菌等非发酵菌仍为VAP主要致病菌。4年中VAP致病菌的分布特点和耐药性发生了改变。     

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??Combined multiple organ resection in the treatment of gastric stump carcinoma HE Yu-long. Department of Gastroenteropancreatic Surgery, the First Affiliated Hospital,Sun Yet-san University,Gastric Cancer Center of Sun Yat-sen University, Guangzhou 510080,China Abstract Combined multiple organ resection for gastric stump carcinoma (GSC) is associated with high morbidity and mortality. It is necessary to select patients carefully. Good preoperative preparation need to be done, and the risk of operation should be weighed against the benefit of surgery. After the communication with the patient, it should propose an surgery plan thoughtfully. During the operation, the surgical techniques should be fine and ordered. It should observe and handle the complication in time in order to improve the pronosis of patient.     

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目的　探讨经腹行左侧内脏大神经切断术对顽固性上腹痛的临床治疗效果。方法　 1998年 10月至2 0 0 0年 4月共为 37例难治性上腹及腰背痛病人经腹行左侧内脏大神经切断术 ,其中 32例为胰源性疾病 ,余 5例为邻近器官肿瘤。结果　手术前病人疼痛平均为 (9 47± 0 5 5 )分 ,术后平均为 (1 5 3± 1 0 6 )分 ,差异明显 (P <0 0 1)。病人术后住院期间全部无需止痛药物 ,术后随访无疼痛再发。结论　经腹行左侧内脏大神经切断术治疗难治性腹痛 ,疗效确切 ,操作简单 ,并发症少。对于上腹部腹膜后肿瘤引起的难治性疼痛也可以应用此术式治疗。     

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目的　探讨区域性胰腺切除术围手术期液体的正、负平衡及治疗特点。方法　 2 0 0 0～ 2 0 0 2年 ,对 16 5例病人采用术前水化使血液轻度稀释 ,术日和术后第 1天以红细胞压积 (HCT)、中心静脉压 (CVP)和尿量为指标 ,等量补充血液 ,足量输入平衡液 ,不用血管加压药 ,术后第 2～ 3天慎用小剂量利尿剂 ,注意负平衡的出现。结果　平均每例术日输液 (84 89.0 1± 174 3.17)mL ,术后第 1天输液 (4 372 .2 7± 96 7.18)mL。尿量从术后第 1～ 3天逐渐增加。术日和术后第 1天正平衡量分别为 (2 5 6 2 .73± 786 .99)mL和 (14 15 .98± 5 79.11)mL。术后第 2天 10 7例出现负平衡 ,第 3天 14 7例 ,负平衡量达 (14 90 .84± 2 97.4 3)mL。未出现负平衡者中 ,12例发生与液体治疗无关的严重并发症 ,2例死亡。结论　该方案完全适于区域性胰腺切除术围手术期的液体治疗 ,术后第 2～ 3天出现液体负平衡 ,否则预示发生严重并发症的可能。