2022年 · 第60卷第03期

Trauma is the main cause of ischemic necrosis of talus, and alcohol consumption, rheumatic diseases, etc. can also cause talus necrosis. For early talus avascular necrosis caused by talus osteochondral injury, bone marrow stimulation and talus osteochondral transplantation can achieve good curative effects^［1］。 For patients with extensive ischemic necrosis of the talus surface and end-stage ankle osteoarthritis, ankle fusion or total ankle replacement (TAR) are mostly chosen clinically, both of which can relieve the pain of patients^［2］However, ankle fusion will cause patients to lose ankle function, and TAR requires a large number of osteotomies. For patients with relatively normal distal tibia, this procedure destroys the relatively normal anatomy, and a large number of bone defects during secondary revision are very difficult problems. For some young patients with extensive ischemic necrosis of talus, the articular surface of distal tibia degenerates mildly. At present, there is a lack of an effective method to treat large area necrosis of talus dome. In recent years, medical bionics has developed rapidly^{［3, 4, 5］}Under the guidance of structural bionics, functional bionics and biomechanical bionics, the foot and ankle surgery department of our hospital independently designed and developed a three-dimensional printed talus surface prosthesis, which was successfully applied to 2 patients with extensive ischemic necrosis of the talus surface. The early follow-up clinical and imaging results are satisfactory. The R&D design and clinical efficacy are reported as follows.

The incidence of reflux esophagitis after proximal gastrectomy was 9.1% ~35.3%^［1］For a period of time, some surgeons prefer total gastrectomy to avoid postoperative reflux^［2］。 In recent years, with the increasing incidence of upper gastric cancer^{［3, 4, 5］}The concept of function-preserving surgery is gradually becoming popular^［6］The indication for proximal gastrectomy tends to relax^［4，7］Improved reconstruction methods aimed at improving reflux after proximal gastrectomy, represented by tubular stomach, interposed jejunum and dual-channel surgery, are emerging. In the middle of the 20th century, some scholars conducted animal experiments to improve reflux by making gastric muscle flap tunnels to reconstruct the cardia^［8］The double muscle flap-esophagogastric anastomosis technique (Kamikawa method) reported by Japanese scholar Professor Yasuaki Kamikawa is the most influential clinical application. This procedure can significantly reduce the incidence of postoperative hiccup and reflux esophagitis^［9］However, its operation is complicated, the operation time is long, and there is a certain incidence of postoperative anastomotic stenosis^［10］The popularization and application are restricted to a certain extent. The total operative time of laparoscopic proximal gastrectomy and double muscle flap anastomosis reported in previous literature was 205~404 min^{［11, 12, 13, 14, 15］}The anastomosis time is 100-149 min^［16］。 At present, some attempts to reduce the difficulty of surgery and shorten the operation time are under way^［17］。 Based on the tunnel principle, our team performed an improved "arch bridge" reconstruction of esophageal residual stomach on the basis of muscle flap anastomosis, in order to reduce the difficulty of operation and shorten the operation time. The application results are reported as follows.

The patient was a 56-year-old male who was admitted to the hospital on 1 December 2014 due to "physical examination revealed liver occupying space for 7 d". The patient was examined in another hospital 7 days before admission. Ultrasound examination found that the right lobe of the liver occupied space, and there was no discomfort such as abdominal pain and distension. He went to our hospital for further diagnosis and treatment. The patient had chronic hepatitis B for more than 20 years and liver cirrhosis for 6 years. He regularly took lamivudine (1 tablet/d) and adefovir dipivoxil (1 tablet/d) for antiviral treatment, and his condition was controlled generally. In May 2014, hematemesis and melena occurred. Considering esophagogastric varices with bleeding, endoscopic ligation of esophageal varices was performed in a local hospital. Admission physical examination: Chronic liver disease, flat and soft abdomen, no tenderness and rebound pain in the whole abdomen, no obvious mass, no subcostal liver, and splenomegaly. Laboratory tests: HbsAg (+), HbcAb (+), HBV-DNA below detection limit. Alpha-fetoprotein was 2.1 μ g/L, CA125 was 62.6 U/ml, and CA19-9 was 116.0 U/ml. CT of the upper abdomen showed that the proportion of the liver lobe was out of balance, and a low-density shadow with a maximum diameter of about 22 mm could be seen near the diaphragmatic roof in the right lobe of the liver. The enhancement scan was significantly enhanced in the arterial phase, and the enhancement amplitude was weakened in the portal vein phase. Combined with the patient's history of hepatitis B, laboratory tests and imaging results, the preliminary diagnosis was: primary liver cancer of segment 7 of the liver (Chinese liver cancer stage Ia); post-hepatitis cirrhosis; Hypersplenism; Child-Pugh Grade B (9 points). After department discussion, ultrasound-guided radiofrequency treatment of liver tumor was performed on 8 December 2014. After discharge, the patient continued antiviral therapy and received prophylactic hepatic arterial embolization chemotherapy (oxaliplatin 100 mg, oxaliplatin 50 mg + lipiodol 3 ml) 1 month after discharge. Regular review did not indicate recurrence or metastasis of the tumor.

The patient, a 50-year-old male, was admitted to the hospital on 15 October 2018 due to "upper abdominal discomfort for more than 1 month". More than a month ago, the patient developed dull pain in the upper abdomen, accompanied by abdominal distension, which was intermittent and not severe in nature. It was fixed in the right upper abdomen and examined in an external hospital. The test results showed "hepatitis B small three positives" and abdominal ultrasound showed "liver occupation". Laboratory tests after admission: total bilirubin 22.5 μ mol/L, direct bilirubin 10.8 μ mol/L, albumin 38.3 g/L, prothrombin time 14.7 s, alpha-fetoprotein>1 210 μ g/L, indocyanine green 15 min retention rate 11.3%. The results of dynamic enhanced MRI showed (Figure 1): multiple nodules and masses in the right lobe of the liver, the largest of which was 148 mm ×113 mm ×102 mm; Filling defect of the right branch of the portal vein, considering tumor thrombus; Liver cirrhosis. Admission diagnosis: primary liver cancer, portal vein tumor thrombus type II, Barcelona clinical liver cancer stage C, Chinese liver cancer stage IIIA; The Eastern Cancer Collaborative Group behavioral status score was 0; Child-Pugh Grade A (6 points); Hepatitis B; Compensatory phase of liver cirrhosis. According to the consultation of the multidisciplinary team (MDT), the patient has massive hepatocellular carcinoma with multiple satellite foci, combined with right portal vein tumor thrombus; According to the Chinese Society of Clinical Oncology (CSCO) Guidelines for Diagnosis and Treatment of Primary Liver Cancer 2020^［1］Stage IIIA is not an absolute contraindication for surgical resection. Considering that the mass is confined to the right hemiliver and the tumor thrombus is confined to the right branch, it is expected that the lesion can be completely resected and the tumor thrombus can be removed during the operation. The patient was assessed to have mild cirrhosis before the operation, and sufficient functional remaining liver volume can be retained after the operation, so surgical treatment was decided. Right hemihepatectomy combined with portal vein tumor thrombus removal combined with cholecystectomy was performed on 24 Oct 2018. The postoperative pathology revealed: moderately poorly differentiated hepatocellular carcinoma, invasion of the capsule and vascular tumor thrombus (+). The patient recovered well after surgery and was discharged 2 weeks after surgery and received oral antiviral therapy with entecavir 0.5 mg/d.