2018年 · 第56卷第07期

Living donor liver transplantation can solve the problem of donor liver shortage, especially for pediatric patients, and receiving donor liver from the left lateral lobe of adults can meet the demand. Since 1988 Raia et al.^[1]Since the completion of the first living donor liver transplantation (LDLT), LDLT has become the most important surgical method for pediatric liver transplantation. How to ensure the safety of donors during living donor liver transplantation and minimize the physiological and psychological damage to donors has become a hot spot in recent research in the field of liver transplantation. Laparoscopic left lateral lobe donor liver acquisition operation has less trauma, fast recovery and accurate local anatomy, and is expected to become the standard procedure for left lateral lobe acquisition. From October 2016 to January 2018, the general surgery department of our hospital completed a total of 20 laparoscopic left lateral lobe donor liver acquisition operations. All donors and recipients recovered well after the operation, among which 8 patients were treated with left hepatic vein preferential approach (LHVPA). The clinical data are reported as follows.

The patient was a 20-year-old female. Because of the "left breast mass for 2 years, gradually increasing with skin color change for half a year", I was seen in our hospital on July 5, 2017. Physical examination: bilateral breasts were well developed, no abnormalities were found in the right breast, and the margins of the glands in the upper quadrant of the left breast were partially raised near the axillary, where the skin became thinner, dark in color and light brown pigmentation. Here, a mass with a size of 3.0 cm ×2.5 cm ×1.0 cm can be reached under the epidermis, with irregular shape, small lobular nodules on the surface, uneven soft and hard texture, most of which are hard. When exposed to light, it appears as a milky white translucent blister shape through the surface skin, and the boundary with the surrounding tissues is clear, and the subcutaneous blood vessels are not dilated. Both axillary lymph nodes were not swollen. No skin nodules and caffeine spots were seen elsewhere throughout the body. Cardiopulmonary and abdominal examinations showed no abnormalities. The patient had no family history of tumor. There were no other clinical manifestations that could be considered for neurofibromatosis. The outpatient was admitted to the hospital with "suspicious subcutaneous lymphangioma of the left breast". After admission, double breast ultrasound imaging examination was performed. The results showed that a first-class hypoechoic area could be seen in the subcutaneous soft tissue layer (fat layer) 8 cm away from the nipple in the upper quadrant of the left breast at 2~3 o'clock, mainly hypoechoic, about 2.9 cm ×1.0 cm in size, with parallel growth, irregular shape, unclear boundary, no obvious envelope, and punctate blood flow signal could be seen in it; BI-RADS Class 4a (Figure 1)。 Mammography was not performed considering the young age of the patient. The patient had no abnormalities in laboratory tests after admission and underwent left breast mass resection including superficial skin under local anesthesia on 31 Jul 2017. During the operation, a crescent-shaped transverse incision was taken, and the tumor was found in the subcutaneous fat, milky white, enveloped, irregular in shape, like the root of Phalaenopsis, and partially coiled into a cluster, with a fine root penetrating deep into the breast tissue, which was translucent under light (Figure 2,Figure 3,Figure 4)。 The mass was completely removed, and the connected breast tissue was removed in size of approximately 1.5 cm ×1.5 cm ×1.0 cm. The results of postoperative pathological examination showed spindle cell tumor and schwannoma of the left breast. Immunohistochemistry showed: S-100 (+), SMA (-), Vimentin (+), Ki-67 (+5%), CD34 (-), AE1/AE3 (-) (Figure 5,Figure 6,Figure 7,Figure 8)。 The patient recovered smoothly after operation and was followed up for more than 6 months without any abnormalities.

The foundation of American medical treatment is evidence-based medicine, while the clinical behavior of Chinese physicians is rich in more empirical color. When discussing problems with American physicians during ward rounds, outpatient visits, or surgery, it is data that is heard the most. Western doctors and patients have always lived in a "data" environment, so patients are more likely to accept and choose data. In the outpatient clinic, I saw a patient write down the postoperative bleeding rate, pancreatic fistula incidence and biliary fistula incidence mentioned by Professor Kendrick, calculate his own probability of complications, and further discuss the benefits and risks of surgery with the doctor. When dealing with clinical problems, data and literature are their dependence. Once I saw Professor Kendrick breaking the pancreas with a straight-line cutting closure. He could not only tell the precise time required for each step, but also tell the source, complication rate and advantage, etc.