2017年 · 第55卷第01期

In the past half century, with the development and progress of medical and health undertakings in China, the field of general surgery, which is the foundation of surgery, has also made remarkable achievements. In terms of the number of doctors, the number of beds, the volume of operations, and even the surgical technique, China's general surgery field has reached the world advanced level; In recent years, related academic activities have been unprecedentedly active, and the number of participants and the level of conferences have increased significantly. However, throughout the century of development of surgery in the world, from the advent of the first Whipple operation to the implementation of the first liver transplantation, until the first proposal of the gastric cancer convention and cholangiocarcinoma classification, and then to the emergence and improvement of robot-assisted surgical system, these major events of epoch-making significance lack Chinese people. Behind the many achievements in the field of general surgery in China, we should clearly realize that there is still a certain gap between the general surgery in China and the world-class level. This is mainly reflected in two aspects: First, talent training, that is, we have not yet reached the world-class in terms of leading talents, physician team and system mechanism; On the other hand, there is international influence, that is, the international influence of our academic organizations, scientific research results and disease guidelines still needs to be improved.

PatientFemale, 38 years old, was admitted to hospital on June 22, 2012 due to "distension and pain in the right upper abdomen for more than 1 month, aggravated for 3 days". One month ago, the patient had persistent distension and pain in the right upper abdomen without obvious trigger, which could be relieved after anal exhaustion. There was no nausea and vomiting, and no anorexia. Gastroscopy in the local hospital revealed "chronic superficial gastritis". Then he came to our hospital for treatment, and the B-ultrasound examination showed "huge gas-containing space in the abdomen (mainly the right upper abdomen); right hydronephrosis (considering the compression of the mass)". There is no significant weight loss recently, and he has been in good health and has a history of cesarean section. Admission physical examination: conscious, no anemia, painful appearance, asymmetric abdominal swelling, obvious right side, collapse left side, no gastrointestinal pattern and peristaltic wave, an old surgical scar can be seen on the lower abdominal wall, and a huge mass can be palpable on the right abdomen up to the level of the xiphoid process down to the anterior superior iliac crest. Percussion showed drum sound, tenderness was not obvious, no rebound pain, no muscle tension, normal intestinal sound, no sound of air passing through water, and no abnormalities were found in digital rectal examination. Auxiliary examination after admission: blood routine, stool routine and occult blood examination, liver and kidney function and other biochemical examination results showed no abnormalities. An upright X-ray of the abdomen showed a huge air-liquid plane shadow of the right upper abdominal cavity. Double contrast angiography of the colon showed compression and displacement of the colon, and no contrast medium entered the cyst cavity (Figure 1)。 After the examination, the patient's abdominal distension and pain were significantly aggravated, and the abdominal swelling was significantly larger than before. The patient was instructed to massage the abdomen at the chest and knees. After a large amount of gas was discharged from the anus, the pain was significantly relieved, and the right abdominal mass was reduced. Enterography showed a huge cystic gas-occupying foci on the right side of the abdomen, no contrast medium entered, and no obvious organic lesions in the small intestine. Abdominal CT examination showed a huge gas-like round shadow in the right abdominal cavity, which was closely related to the intestinal tube, and macroenterosis was possible; Compression of the right kidney with mild pelvic dilatation and hydrops; Small amount of pelvic effusion (Figure 2)。 Abdominal MRI examination showed a huge cystic mass in the abdominal cavity, considering huge diverticulum, food residue, combined with the possibility of left posterior superior wall polyps or adenomas, duplicate deformities and others to be discharged; Small cyst of the left kidney. Preoperative diagnosis: huge abdominal occupancy and duplication of colon and intestine.

Question 8What is your experience in preventing anastomotic leakage?

At present, there are many medicines and technologies. For a disease, there is no longer only one choice of examination and treatment in clinic. More clinical decisions may change from informed consent of patients to informed choice. Informed choice is increasingly considered to be the best way to make appropriate medical treatment. This seemingly ideal diagnosis and treatment decision is attractive, but in fact it confuses doctors around the world.

In today's abundance of medical measures, how to choose treatment in the dazzling world is a question, and who should make medical decisions-the patient, the patient's family, or together with the doctor-is also a question. Today, we will only discuss the latter issue. Because, logically speaking, the latter problem is more basic, and it is also a problem often encountered in clinical practice at present. For the sake of discussion, I'll start by telling a story.