2020年 · 第58卷第02期

PatientMale, 72 years old. The patient went to the emergency department of Bethune First Hospital of Jilin University on August 20, 2019 due to sudden upper abdominal pain. The patient was admitted to the local hospital in July 2019 for acute right upper abdominal pain. He was diagnosed with gallstones with cholecystitis. He underwent laparoscopic cholecystectomy (LC) in the local hospital and was discharged on the 4th day after operation. Admission physical examination: body temperature 37.8 ℃, heart rate 95 beats/min, 18 breaths/min, blood pressure 95/70 mmHg (1 mmHg =0.133 kPa). The first LC puncture hole scars were seen below the xiphoid process in the abdomen, 1.0 cm above the umbilicus and 2.0 cm below the midline of the right clavicle; Tenderness in the right upper abdomen, no rebound pain, and no obvious mass in the abdomen; No previous special medical history. Emergency examination of blood biochemistry: white blood cell count 15.16×10⁹/L, hemoglobin 76 g/L, prothrombin time 17.8 s, prothrombin activity 51%, international normalized ratio 1.55, creatinine 243.9 μ mol/L, K⁺5.72 mmol/L, AST 14 435 U/L, ALT 4 195.3 U/L, total bilirubin 33.2 μ mol/L, cholinesterase 1 773 U/L, albumin 25.6 g/L, whole blood ammonia determination 45 μ mol/L. Troponin I 0.261 μ g/L, myoglobin 429.9 μ g/L, B-type natriuretic peptide precursor 2 030 ng/L, D-dimer 23.14 mg/L. The results of emergency upper abdominal ultrasonography showed that a 131 mm ×34 mm hematoma was seen under the capsule of the right lobe of the liver, with free effusion in the abdominal cavity, and the depth reached 117 mm; Ultrasound-guided abdominocentesis to withdraw old bloody fluid. Initial diagnosis: intraabdominal hemorrhage, hemorrhagic shock. Then, an abdominal drainage tube was placed, and 900 ml of dark red bloody liquid was intermittently drained within 24 hours. At the same time, fluid rehydration and blood transfusion were given. Blood routine and liver function indexes were monitored intermittently 24 hours after operation. Hemoglobin was 97~106 g/L, which tended to be stable, AST was 1 342 U/L, and ALT was 869 U/L, which was significantly lower than that at admission. An enhanced CT scan of the whole abdomen was performed on August 22, which showed a hematoma with a maximum diameter of 5.8 cm under the liver capsule (FIG. 1A）； In the hepatic artery stage, the right hepatic artery travels to the gallbladder area, and a cystic protrusion can be seen, with a basal portion of about 0.6 cm and a maximum diameter of about 1.4 cm (FIG. 1B), considering the possibility of pseudoaneurysm. Three-dimensional Visualization System of Abdominal Medical Image^[1]Three-dimensional reconstruction CT images showed that the pseudoaneurysm was located in the neck of the gallbladder bed, at the branch of the right hepatic artery, about 1.5 cm in size, and was not closely related to the portal vein (Figure 2）。 Abdominal vascular ultrasonography showed that the artery in the hepatic hilar region showed tumor-like dilatation, 1.5 cm ×1.7 cm in size, and the blood flow in it was detectable, showing an arterial spectrum, with a peak value of 208 cm/s.

PatientA 77-year-old male was admitted to the hospital on 25 October 2018 due to "intermittent upper abdominal distension and pain for 2 days". The patient developed upper abdominal distension and pain without obvious trigger 2 days ago, with intermittent attacks, accompanied by abdominal distension, nausea and vomiting. The vomit was stomach content, no chills or fever, yellow urine and normal stool color. Nothing special in the past. Physical examination at admission: vital signs were stable, acute disease appearance, skin and sclera were yellowed, and body shape was thin. Upper abdominal tenderness, rebound pain, no muscle tension, negative Murphy sign, abdominal percussion as drum sound, no abdominal mass palpable. Laboratory tests: (1) urinalysis: bilirubin (+); (2) Blood analysis: white blood cell count 14.32×10⁹/L, neutrophil percentage 94%; (3) Liver function: total bilirubin 79.4 μ mol/L, direct bilirubin 44.4 μ mol/L, ALT 143.5 U/L, AST 118.5 U/L; (4) Tumor markers are normal. The results of ultrasound and abdominal CT examination showed that the middle and upper segments of intrahepatic bile duct and common bile duct were dilated with stones, the gallbladder was significantly enlarged, and the gallbladder was small. magnetic resonance cholangiopancreatography (MRCP) findings: filling defect in the hilar bile duct, suspected membranous stenosis of the lower common hepatic duct (Figure 1）。 After 1 week of anti-infection, liver protection and acid suppression treatment, the liver function was re-examined: total bilirubin 28.2 μ mol/L, direct bilirubin 11.9 μ mol/L, ALT 60.8 U/L and AST 43.2 U/L; Blood analysis was roughly normal. Abdominal pain symptoms were significantly reduced. Preoperative diagnosis: (1) choledocholithiasis with acute cholangitis; (2) Gallbladder stones with acute cholecystitis; (3) Common hepatic duct stenosis. Laparoscopic cholecystectomy + exploration of the common bile duct is proposed.

In the 1980s, Professor Slamon's team atScienceA paper investigating the relationship between human epidermal growth factor receptor 2 (HER2), a proto-oncogene, and breast cancer was published in the paper. It was proposed that HER2 is an independent prognostic factor for breast cancer different from tumor size, lymph node status and hormone receptor status. Patients with HER2 amplification have a high risk of recurrence and metastasis and poor prognosis^[1]。 The presence of trastuzumab alters the prognosis of HER2-positive breast cancer. The results of several early large-scale clinical studies have confirmed that chemotherapy combined with 1-year trastuzumab for postoperative adjuvant therapy in patients with HER2-positive early breast cancer can improve disease-free survival (DFS) and overall survival time of such patients^[2,3,4,5]。 The AJCC 8th Breast Cancer Staging System is the first to propose a prognostic staging system combining histological grading, hormone receptor status and HER2 status on the basis of traditional anatomical TNM staging. In this prognostic staging system, HER2 positivity is defined as a benign prognostic factor for breast cancer, but only if anti-HER2 therapy is necessary^[6]。 However, a proportion of patients still experienced recurrence and metastasis after 1 year of standard trastuzumab therapy^[7]； Although new anti-HER2 drugs are continuously being developed and marketed, the consequent adverse reactions such as cardiotoxicity and economic burden are also problems that cannot be ignored.

total mesorectal excision (TME) proposed by Professor Heald in 1982 is an important milestone in the treatment of rectal cancer. This technique emphasizes sharp dissociation in the avascular area between the rectal visceral layer and the parietal fascia, ensuring the integrity of the mesorectum and effectively reducing the recurrence rate; At the same time, dissociation along the anatomical space reduces pelvic nerve damage. With the improvement of surgical techniques and the development of minimally invasive techniques for rectal cancer, pelvic neuroprotection has been paid more and more attention. In 1991, Professor Hojo of Japan confirmed that the protection of pelvic nerves contributes to the preservation of bladder and reproductive function, and put forward the concept of pelvic autonomic nerve protection, and proposed surgical grading. On the premise of ensuring TME, he emphasized the role of protecting pelvic nerves^[1]。 This article expounds the anatomical problems related to nerve injury sites and surgical precautions in low rectal cancer surgery.

The paper "Experimental study on bridging peripheral nerves in rats by chitin biological cannula with small gap" published in our journal, volume 43, issue 20, pages 1344~1347, 2005Figure 2Should be the figure below and is hereby corrected.