2018年 · 第98卷第01期

In November 1915, Chinese Medical Journal was officially published. Dr. Wu Liande, the founder and first editor-in-chief of this journal, clearly pointed out in Volume 1, No. 1: "Those with weak spirit cannot seek the country, and those with weak courage cannot strive for strength". We should "make medical science progressively prosperous and health perfect day by day."^[1]。 As a conference journal of the Chinese Medical Association, for more than 100 years, through the unremitting efforts of several generations, the Chinese Medical Journal has always adhered to the purpose of spreading medical academic ideas, adhered to the principle of high-quality and high-standard article selection and publication, adhered to the national health needs as the guide, insisted on serving readers and medical scientific and technological personnel, continuously promoted international medical science and technology exchanges, and continuously promoted the development of Chinese medical science and technology. It has formed the characteristics of running a journal with strong scientific nature, high authority, great influence and wide coverage, and published a number of important original documents that are milestones in the history of Chinese medical development, witnessing the magnificent journey of Chinese medical and health workers to strengthen the country with medicine and protect people's health with science and technology^[2,3,4]。

Craniopharyngioma is a common histologically benign intracranial tumor^[1]。 Because the volume of the cranial cavity is relatively fixed, if the tumor is removed without surgical treatment, its space-occupying and compressive effects often lead to the dysfunction of the central nervous system and endocrine system of patients, which is life-threatening. Therefore, surgical treatment is the most commonly used and effective method for the treatment of craniopharyngioma in clinic. With the improvement of surgical skills of neurosurgeons and the improvement of various surgical instruments, experienced doctors have been able to completely remove tumors, so that patients can survive tumor-free for a long time. However, on the whole, there is still a tendency at home and abroad to not pursue long-term tumor-free survival, but only to prolong survival time. Almost all treatment methods for benign and malignant tumors, such as total tumor resection, subtotal tumor resection and radiotherapy and chemotherapy, are used for the treatment of craniopharyngioma. Different medical institutions have different strategies for treating craniopharyngioma, and a considerable proportion of doctors still adopt conservative treatment (radiotherapy, internal irradiation therapy and chemotherapy) strategies. In some neurosurgical centers, due to their rich clinical experience, the total resection rate of craniopharyngioma is more than 80%, and the surgical mortality rate is about 2%^[2,3,4,5]。 This suggests that neurosurgeons should be more responsible, and the treatment of craniopharyngioma should aim at total tumor resection and prevention of recurrence.

With the advancement of microneurosurgical techniques and the deepening of understanding of the origin and growth pattern of craniopharyngioma, radical surgical resection has become possible. A large number of cases have been reported, and the overall survival rates of patients with craniopharyngioma reached more than 90% and 80% at 5 and 10 years after surgery, respectively. Therefore, the current focus on the prognosis of craniopharyngioma patients is not only to improve the survival rate, but also to improve the quality of life of patients. It is reported in the literature that the incidence of hypopituitarism in patients with craniopharyngioma is 68% ~100% on the growth hormone axis, 60% ~80% on the gonadal axis, and 55% ~88% on the corticotropic hormone axis; The thyroid hormone axis is 39%-85%; Posterior pituitary dysfunction was 25% ~86%^[1,2,3,4]。 The level of endocrine function after surgical treatment of craniopharyngioma is the basic factor that determines the quality of life of patients. Under high-quality endocrine replacement therapy, not only can they survive for a long time, but some patients can continue to grow and develop, and even retain fertility. However, the differences in tumor types and treatment levels lead to huge and complicated individual differences in endocrine status. The application of various hormones in patients with hypothalamic-hypopituitary function of craniopharyngioma is still very irregular, and the interaction between hormones is difficult to grasp. Therefore, in order to improve the long-term quality of life of patients with craniopharyngioma, it is particularly necessary to formulate a long-term endocrine therapy expert consensus.

The perioperative management of craniopharyngioma is complicated, and the occurrence of various postoperative complications is the most important factor leading to early postoperative death of craniopharyngioma, and also an important factor affecting the neurological function and quality of life of patients^[1]。 Usually, neurosurgeons have insufficient knowledge and experience in the monitoring and treatment of postoperative internal environment and organ function, while intensive care doctors and even neurointensive care doctors lack understanding of the pathogenesis, anatomical basis and surgical factors of postoperative pathophysiological changes of craniopharyngioma, so there are certain difficulties in the perioperative management of craniopharyngioma. Therefore, the Pediatric Neurosurgery Group of the Neurosurgery Branch of the Chinese Medical Association, together with experts in neurosurgery, neurocritical care, critical care medicine and endocrinology, jointly formulated the Chinese Expert Consensus on Perioperative Management of Craniopharyngioma (2017) (hereinafter referred to as the Consensus), in order to improve the level of perioperative treatment of craniopharyngioma and improve the prognosis of patients.

connective tissue disease (CTD), including systemic lupus erythematosus (SLE), primary Sjogren's syndrome (PSS), etc., is a systemic disease in which the body's immune system produces an immune response to its own muscles, joints, skin and other connective tissues and causes damage to multi-system functions, including the central and peripheral nervous systems^[1]。 The incidence of peripheral neuropathy (PN) associated with CTD varies greatly in previous literature reports, ranging from 1.5% to 45% for SLE and 7.5% to 45% for PSS^[2,3]。 At present, it is believed that the main mechanism of PN is that CTD can induce inflammatory reaction of small vessels, leading to inflammatory occlusion of small vessels, thus causing peripheral nerve dystrophy and functional impairment. Other special causes such as rheumatoid arthritis and sarcoidosis, such as multiple nodules, can also cause the occurrence of PN^[1]。 In order to better understand the clinical and electrophysiological characteristics of CTD-related PN, this study retrospectively analyzed the clinical data of 13 patients with CTD-related PN, and summarized their clinical and electrophysiological characteristics.

A 48-year-old male was admitted to the Department of Gastroenterology of Peking Union Medical College Hospital for "repeated abdominal pain and melena for more than 6 years". In August 2011, I developed lower abdominal cramps without trigger, with visual analogue scale (VAS) of 5 to 6 points, accompanied by abdominal distension, nausea, and thin strips of melena, 1 to 2 times/d, with a volume of about 300 ml, which relieved spontaneously after 3 to 4 days, and then attacked once every 2 months without diagnosis and treatment. In April 2012, abdominal pain worsened with post-activity fatigue. In the first hospitalization in our hospital, the hemoglobin was checked at 90 g/L (iron 4 indicated iron deficiency anemia), and the occult blood in the stool was continuously positive. Erythrocyte sedimentation rate, high-sensitivity C-reactive protein and lactate dehydrogenase were normal. Tuberculin test, lymphocyte culture plus interferon assay (T-SPOT.TB), cytomegalovirus DNA and fecal pathogen culture were all negative. Anti-nuclear antibody, anti-extractable nuclear antigen antibody and anti-neutrophil cytoplasmic antibody were all negative. No obvious abnormalities were found in gastroscopy, colonoscopy and small intestine air barium double angiography. Abdominopelvic enhanced CT + small intestine reconstruction: Group 3 had localized thickening of distal small intestine with abnormal enhancement of mucosal surface, about 2.5 cm long, rough serosal surface and slightly narrow intestinal lumen; There were more mesenteric vascular shadows, multiple small lymph nodes on the mesenteric side, multiple lymph nodes at the mesenteric root, retroperitoneal and bilateral inguinal areas. Capsule endoscopy showed large exudation of jejunum (small intestine of groups 2 and 3), mild mucosal edema, active bleeding, seemingly mucosal bulge, surface ulcer, covered with white coating; Another ulcer was seen in the jejunum, covered with white coating, and there was no congestion and edema in the surrounding mucosa; The end of the ileum is scattered with multiple small protuberances with a white surface. Transoral enteroscopy showed multiple mucosal erosion and worm-like ulcers from the horizontal part of the duodenum to the middle of the jejunum, some of which were covered with thin white coating, some of which had a little red bleeding on the surface, and there was no obvious congestion and edema in the mucosa around the lesion. There were no abnormalities in the interlesional mucosa (Figure 1)。 The pathology of mucosal biopsy of jejunal ulcer showed chronic inflammation of small intestinal mucosa, high hyperplasia of lymphoid tissue, CD20 (+), CD3 (+). Clinically, Crohn's disease is not excluded, and Podesian 1 g is administered orally 4 times/d. After discharge, abdominal pain and melena were still intermittently attacked, but the frequency of attacks was reduced to once every 3 months. The monitoring of occult blood in stool was intermittently positive, and the hemoglobin was normal. In October 2013, the abdominopelvic enhanced CT + small intestine reconstruction was reviewed: the distal lesions of small intestine in group 3 were reduced compared with the previous. Since September 2015, the frequency of abdominal pain and melena attacks increased to once every 1 to 2 months, and there was no follow-up. At the beginning of March 2017, the patient suffered from sudden severe abdominal pain around the umbilical cord, accompanied by nausea, vomiting of stomach contents, and cessation of exhaustion and defecation. He went to the emergency department of our hospital for an upright abdominal plain film showing intestinal obstruction. Fasting water, gastrointestinal decompression, etc., abdominal pain is relieved, and spontaneous defecation is restored. Past history and family history are no different. Personal history: Smoking for more than 10 years, 4~5 cigarettes/d, and quit smoking for more than 7 years. Physical examination at admission: body temperature 36.5 ℃, pulse 78 beats/min, breathing 20 beats/min, blood pressure 118/71 mmHg (1 mmHg =0.133 kPa), clear breathing sounds in both lungs, no murmur in each valve area of the heart, flat abdomen, no gastrointestinal pattern and peristaltic wave, soft abdomen, deep tenderness in the right lower abdomen, no rebound pain, no mass, and intestinal sounds 5 times/min.

A 58-year-old female was diagnosed with "hyperthyroidism (hyperthyroidism)" in May 2003, with fatigue, intermittent tremor in both hands, and poor drug control. On March 12, 2017, free triiodothyronine (FT3) 14.4 pmol/L (reference value: 3.1~6.8 pmol/L, the same below), free thyroxine (FT4) 102.0 pmol/L (12.0~21.9 pmol/L), thyroid stimulating hormone (TSH) were detected.<0.005 mU/L (0.27-4.2 mU/L); Liver function examination showed: γ-glutamyl transpeptidase (GGT) 85.04 U/L (7-45 U/L), and iodine-131 was treated on March 20, 2017. On March 25, 2017, nausea, vomiting and diarrhea occurred without obvious trigger, and then chest tightness and chest pain gradually appeared, located in the precordial area, radiating to the shoulders and back, accompanied by sweating. For further diagnosis and treatment, I went to the emergency department of Cangzhou People's Hospital affiliated to Southern Medical University. Three items of myocardium were examined: creatine kinase isoenzyme (CK-MB) 82.00 μ g/L (0-2.03 μ g/L), myoglobin (Myo) 483.8 μ g/L (0-61.5 μ g/L), and troponin I (cTnI) 39.400 μ g/L (0-0.034 μ g/L); Glucose:>36.89 mmol/L, the patient's family refused to undergo emergency percutaneous coronary intervention (PCI), and was immediately admitted to the CCU ward of our department with "acute coronary syndrome". Previous history of "type 2 diabetes" for 7 years, self-complaint of blood sugar control, denial of bad habits of tobacco and alcohol, other medical history is not special.

A 49-year-old female was admitted to the hospital on December 8, 2016 with the main complaint of "chest tightness and asthma after left lower lung cancer operation for 1 week". One week before admission, the patient underwent "anatomical radical resection of left lower lobe adenocarcinoma" under general anesthesia with double lumen tracheal intubation in a local hospital due to left lower lung adenocarcinoma. The surgical records showed that the patient's lung fissure was well developed. After awakening from anesthesia, he complained of chest tightness and asthma. After treatment with cephalosporin antibiotics (specificity unknown), the symptoms were not significantly relieved after anti-infection, phlegm-resolving and bronchodilating drugs. After coming to our hospital, in order to rule out the possibility of pulmonary artery embolism, pulmonary artery CT angiography (CTA) was examined. The results showed that the main trunk of the left pulmonary artery was visible, but the branches of the arteries were not visible. The main pulmonary artery, the main trunk and all branches of the right pulmonary artery showed good results. There was no obvious stenosis and dilation of the lumen, and no clear filling defect was found in the lumen. Soft tissue density and gas density shadows were seen in the left chest cavity and lung. Bronchoscopy showed that severe mucosal congestion and edema could be seen from the end of the left main bronchus to the stump of the left upper lobe and left lower lobe, and a large amount of bloody secretion could be seen in the bronchial lumen of the left upper lobe to obstruct the lumen. After washing, the left upper lobe bronchial lumen was narrowed, and the left lower lobe bronchial stump was occluded (Figure 1)。 Thoracic ultrasonography showed no obvious effusion in bilateral pleural cavities. Arterial blood gas analysis at 4 L/min oxygen inhalation by nasal catheter showed: partial pressure of arterial oxygen 70.10 mmHg (1 mmHg =0.133 kPa), partial pressure of arterial carbon dioxide 50.8 mmHg and pH 7.40. Blood routine results: Red blood cell count 26.1×10⁹/L, neutrophil percentage 90.2%, red blood cell count 2.81×10¹²/L, hemoglobin 86 g/L. D-dimer 1.34 mg/L. Procalcitonin 0.325 μ g/L, erythrocyte sedimentation rate 115.00 mm/1 h, C-reactive protein 88.00 mg/L. Based on the examination results, considering the possibility of pulmonary torsion, the patient was in critical condition, and exploratory thoracotomy was performed in the emergency department on the second day after admission. Intraoperative observations: There was no obvious adhesion in the left pleural cavity, there was more bloody effusion, some of which were organized, purulent coating was formed on the top of the chest, and the pericardium and mediastinal pleura were congested, edema and thickened. The upper lobe of the left lung was transposed clockwise by 270 degrees with the hilar structure as the midline. Except for the tongue segment located on the outside of the thoracic aorta, the texture was slightly soft, and other parts of the upper lobe of the left lung were congested, swollen and consolidated, which was black-purple. The lower lobe bronchial stump healed well. Intraoperatively, it was considered that infarct-like changes had occurred in the upper lobe of the left lung, so it was resected, with a size of approximately 20 cm ×12 cm ×8 cm. The lung tissue was incised with a sharp knife, and old blood and a small amount of purulent secretion exudated in the cross section. Postoperative pathological results showed extensive lung tissue infarction with suppurative inflammation. The patient recovered well after surgery and was discharged smoothly.

A 67-year-old male was admitted to the Department of General Surgery of Shuyang County People's Hospital on August 6, 2017 due to the discovery of "a mass in the left lower back for 3 months and recent enlargement". One year ago, the patient went to Jiangsu Cancer Hospital due to discomfort after eating. After gastroscopy, the pathological diagnosis was gastric cardia adenocarcinoma. Preoperative tumor markers were detected: carcinoembryonic antigen (CEA) was elevated to 19.49 μ g/L, and carbohydrate antigen 125 (CA-125), carbohydrate antigen 199 (CA-199), carbohydrate antigen 153 (CA-153) and alpha-fetoprotein (AFP) were all normal. Surgical resection was performed on July 27, 2016. During the operation, the tumor was found to be located in the gastric cardia, invading the diaphragm and pancreas, adhering to the omentum, and there was no ascites. Surgical resection of the stomach was performed, and anastomosis under the gastric arch was performed. The postoperative pathological diagnosis was gastric cardia ulcer type mucinous adenocarcinoma, 5.0 cm ×5.0 cm ×2.5 cm in size, infiltrating the full thickness and extraserous adipose tissue, invading the nerve, tumor thrombus was found in the vessel, and adjacent lymph nodes metastasized (2/9). No cancer metastasis was found in 1 paraarterial lymph node of the left gastric artery and 1 inferior pulmonary ligament lymph node. Postoperatively, CEA decreased to normal by laboratory tumor markers, and he was treated with oxaliplatin 200 mg, tegafur regimen 0.4 mg, and doxorubicin 60 mg for 3 cycles of chemotherapy. Due to IV° bone marrow suppression, he was intolerable, and the treatment was not continued thereafter. Three months ago, I accidentally discovered a lump the size of a "pigeon egg" in my left low back. I sometimes had dull pain and discomfort, but I didn't pay attention to it. Recently, the lump increased significantly, so I came to the hospital for treatment. Physical examination: A raised mass 5.0 cm ×3.0 cm in size was palpated subcutaneously on the left lower back, with tenderness, hard texture, unclear boundary and poor mobility. B-ultrasound examination showed that a hypoechoic mass with a size of 4.72 cm ×2.41 cm was seen subcutaneously on the left lower back (Figure 1)。 Clinical diagnosis: fibroma or epidermal cyst of left low back. The mass was resected under local anesthesia, and the mass was located between muscles, hard in texture, unclear in boundary with surrounding tissues, and poor mobility. After operation, the mass was removed and sent for pathological examination after blunt-sharp combination and separation along the edge of the mass.

Peripheral tissue generally includes skin, subcutaneous tissue, muscle, etc. In the process of shock development, in order to ensure the blood perfusion of important organs such as heart and brain, peripheral tissue perfusion will be sacrificed at the earliest and resuscitated at the last. In recent years, the value of peripheral tissue perfusion in shock resuscitation has been paid more and more attention^[1]。 This paper summarizes the application and progress of peripheral tissue perfusion in shock resuscitation.

The most important indications for lung transplantation are idiopathic pulmonary interstitial fibrosis, chronic obstructive pulmonary disease, bronchiectasis, tuberculosis and pulmonary hypertension. According to the 2016 report of the International Heart and Lung Transplant Association (ISHLT), 55,795 lung transplantations have been completed worldwide. The survival rates of 3 months, 1 year, 3 years, 5 years and 10 years after lung transplantation are 89%, 80%, 65%, 54% and 32% respectively^[1]。 At present, the shortage of donor lungs is the biggest difficulty faced by lung transplantation. Organ donation in China is in the initial stage. Many potential donor lungs often lack adequate maintenance, and barotrauma, pulmonary edema and pulmonary infection often occur, which leads to the degradation of donor lung quality, resulting in donation failure. Or the quality of the donor lung is average, and it is used clinically as a marginal donor lung, which increases the risk of postoperative primary graft loss, acute lung injury, chronic rejection, etc.