病例讨论|以上消化道大出血为首要表现的胰腺神经内分泌肿瘤

2019-11-19 不详 消化科空间

患者男,65岁,因"反复呕血伴黑便2个月余,加重3 d"于2018年6月21日转诊至上海长征医院胰胆外科。患者于2018年4月底无明显诱因出现一次呕血,5月3日当天1012呕血5次,外院查胃镜提示胃底静脉曲张,红色征(+),可见渗血,胃体中部占位性病变。急查腹部CT平扫检查提示胰腺占位。患者于外院抗感染、补液、止血对症治疗数天后,于2018年5月7日转院至上级三甲医院。

胰腺神经内分泌肿瘤(pancreatic neuroendocrine neoplasm,pNEN)中有40%~50%的患者首诊时已出现远处转移,其中以肝转移最常见。G1和G2级pNEN即使出现远处转移,因发展速度慢,生物学行为较好,预后优于胰腺癌,故建议选择更加积极的手术策略,并联合生物治疗和靶向治疗等多种治疗方法,文献报道其5年总生存率为62.4%,10年总生存率为33.8%。少数pNEN患者首诊临床表现为肿瘤导致的消化道出血或梗阻,上海长征医院胰胆外科曾收治1例以上消化道大出血为首发表现并伴有肝脏多发转移的pNEN患者,经多学科讨论后行手术治疗,预后良好。
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一、病例介绍

患者男,65岁,因"反复呕血伴黑便2个月余,加重3 d"于2018年6月21日转诊至上海长征医院胰胆外科。患者于2018年4月底无明显诱因出现一次呕血,5月3日当天1012呕血5次,外院查镜提示底静脉曲张,红色征(+),可见渗血,胃体中部占位性病变。急查腹部CT平扫检查提示胰腺占位。患者于外院抗感染、补液、止血对症治疗数天后,于2018年5月7日转院至上级三甲医院。

2018年5月8至18日完善上腹部增强CT、胃镜、正电子发射型计算机断层显像(PET-CT)检查后考虑为胰腺恶性肿瘤侵犯胃体、脾脏伴肝脏多发转移,胰源性门静脉高压,胃底静脉曲张出血。

2018年5月25日行腹腔镜探查,术中见肝脏表面转移灶2枚,胃大弯侧肿块与大网膜粘连紧密,胃底周围血管明显曲张成团,胰尾部肿瘤侵犯脾脏,考虑为胰腺癌伴肝转移,仅行肝左叶转移灶和胰腺肿瘤活组织检查。

2018年5月26日患者再次大量呕血,5月27日行胃镜下食管静脉曲张套扎术(EVL),结扎6处。患者于2018年6月18日再次呕血,对症处理,未见缓解,6月21日转入上海长征医院胰胆外科治疗。

入院时患者一般情况差,有少量黑便,长期禁食状态,无皮肤、巩膜黄染,无发热、寒战,小便正常,体质量尚稳定。既往有多囊肝、多囊肾病史,其余无特殊。

入院后体格检查:体温36.3 ℃,脉搏78次/min,呼吸18次/min,血压139/74 mmHg,精神差,重度贫血貌,全身皮肤、巩膜无黄染,锁骨上淋巴结未及,全腹无压痛和反跳痛,全腹未扪及明显包块,肠鸣音正常。

1.临床检查

2018年6月21日入院后复查血常规示红细胞计数为1.76×1012/L,血红蛋白为49 g/L,白细胞计数为6.2×109/L,中性粒细胞占比为0.699,血小板计数为127×109/L;肝肾功能示TBil为14.8 μmol/L,白蛋白为31 g/L,ALT为24 U/L,AST为13 U/L,血肌酐为96 μmol/L;查电解质示钾离子浓度为3.68 mmol/L,钠离子浓度为131 mmol/L。查凝血功能示PT为12.9 s,部分凝血活酶时间为28.4 s,纤维蛋白原为1.85 g/L,D-二聚体为2 670 μg/L,纤维蛋白原降解产物为7.1 mg/L。肿瘤标志物CA125为40.45 U/mL,癌胚抗原、CA19-9、糖类抗原724、甲胎蛋白、糖类抗原15-3均正常。

经输血、补液支持治疗后,2018年6月22日复查血常规示红细胞计数为2.38×1012/L,血红蛋白为68 g/L。并于当日在全身麻醉下行急诊胰体尾脾切除+近端胃切除+肝脏肿瘤减瘤术。

术后第15天复查血常规示红细胞计数为3.38×1012/L,血红蛋白为100 g/L,白细胞计数为8.2×109/L,中性粒细胞占比为0.765,血小板计数为534×109/L;肝肾功能示TBil为17.1 μmol/L,白蛋白为42 g/L,ALT为21 U/L,AST为19 U/L,GGT为28 U/L,血肌酐为101 μmol/L;电解质示钾离子浓度为4.62 mmol/L,钠离子浓度为134 mmol/L。

影像学检查(外院):2018年5月8日上腹部增强CT检查示胃底、胃体静脉曲张;胰尾、胃体、脾脏内见软组织密度影,形态不规则,最大截面位于脾脏内,大小约75 mm×57 mm,增强后边缘强化较明显,考虑胰腺来源恶性肿瘤可能性大,胃体和脾脏受累,网膜转移可能;增强后动脉期肝实质内见多发明显强化结节,肝脏多发转移可能;肝实质内见多发、大小不等囊肿;肝内外胆管未见结石和扩张;胰腺头、颈、体部形态、大小正常,其内未见异常密度灶,胰管未见扩张;腹腔、腹膜后未见肿大淋巴结;两侧肾脏体积增大,肾实质内见多发、大小不等囊肿,最大者约63 mm×56 mm,两侧肾盂、肾盏和上段输尿管未见扩张积液(图1)。

5月9日胃镜检查示胃底大量蓝色曲张静脉,红色征(+),胃体后壁见息肉样隆起,大小约2.5 cm×2.0 cm,表面见扩张毛细血管,少量渗血,周围见蓝色曲张静脉(图2);5月27日复查胃镜见曲张静脉无活动性出血,部分曲张静脉表面有血痂附着,予EVL结扎(图3)。

5月18日PET-CT检查示胰尾、胃体和脾脏处肿块,伴氟脱氧葡萄糖(FDG)摄取增高,标准摄取值(SUV)最大值为40.35,延迟后51.77,考虑为恶性病变;肝内多发稍低密度灶,SUV最大值为43.44,糖代谢增高,考虑为转移;肝多发囊性灶;双肾多发囊性灶;腹膜后未见放射性异常浓聚影(图4)。

2018年6月1日腹腔镜探查病灶活组织病理检查示(胰尾)神经内分泌肿瘤,G2级;(肝肿物)肝组织内见神经内分泌肿瘤浸润,G2级;免疫组织化学检查结果示角蛋白阳性,细胞角蛋白8阳性,突触素阳性,CD56阳性,嗜铬素阴性,Ki-67为5%(+),肝细胞阴性,细胞角蛋白7、胃泌素、胰高血糖素、胰岛素和生长抑素均为阴性。


图1. 2018年5月8日患者上腹部增强计算机断层扫描检查结果 
A 胃底、胃体静脉曲张(箭头所示);B 胰尾、胃体、脾脏内软组织密度,形态不规则,增强后边缘强化较明显,胃体和脾脏受累(箭头所示);C 增强扫描肝实质内见多发明显强化结节,提示肝脏多发转移(箭头所示);D 腹腔动脉和肠系膜上动脉未受肿瘤侵犯(箭头所示)


图2. 2018年5月9日胃镜下表现 
A 胃体后壁见息肉样隆起,表面见扩张毛细血管,见少量渗血,周围见蓝色曲张静脉;  B 胃底大量蓝色曲张静脉,红色征(+)


图3. 2018年5月27日胃镜下表现 
A 胃体后壁息肉样隆起,曲张静脉无活动性出血;  B 胃底部分曲张静脉表面有血痂附着; C 胃体曲张静脉套扎后表现; D胃底曲张静脉套扎后表现


图4. 2018年5月18日正电子发射计算机断层显像检查
胰尾、胃体和脾脏见软组织密度肿块,伴氟脱氧葡萄糖摄取增高,左肝转移灶伴氟脱氧葡萄糖摄取亦增高

2.临床诊断

①胰源性门静脉高压伴上消化道出血,重度贫血,低蛋白血症,低钠血症,凝血功能异常;
②无功能性pNEN,侵犯脾脏、胃底,伴肝脏多发转移,G2级(Ki-67为5%,+);
③多囊肝;
④多囊肾;
高血压

3.治疗

2018年6月21日患者转入上海长征医院胰胆外科后,立即予抗感染、抑酸、抑制胰液分泌、保肝、止血、输血、补充白蛋白、补液等对症支持治疗,经多学科讨论后,决定于6月22日行急诊手术治疗。

术中探查示胃底和胃大弯侧可见明显曲张静脉,多囊肝表现,肝内可触及多发、大小不等的质硬结节,较大者直径约2 cm,位于左内叶下缘,边界清晰。于胰尾部和脾脏可及范围约8 cm×5 cm质中肿块,肿瘤累及胃底和近端胃大弯侧。双侧肾脏体积明显增大,呈多囊肾表现,肾周脂肪囊和肾前筋膜菲薄。

遂决定行胰体尾脾切除+近端胃切除+肝脏肿瘤减瘤术。术中先游离并切断胰体,再结扎切断脾静脉,然后依次切断胃体和食管下段。沿脾静脉后方间隙游离胰体尾,游离并结扎切断脾动脉,游离脾脏和胃底,完整移除胰体尾、脾和近端胃标本。楔形完整切除左肝肿瘤。手术创面严密止血。于小网膜囊经胰腺断端留置双套管,于胰腺断端经脾窝留置单腔引流管。

手术用时210 min,术中出血1200 mL,术中输红细胞悬液8 U,血浆1600 mL,冷沉淀40 U。术后加强生命体征监测,继续予抗感染、抑酸、抑制胰液分泌、保肝、止血、输血、补充白蛋白、补液、营养支持等对症支持治疗。

术后3 d内,患者一般情况可,神志清,精神差,生命体征平稳,尿量正常,腹腔引流液呈淡血性,每日引流量为100~200 mL,引流液淀粉酶均正常。血红蛋白、血小板、白蛋白稳步回升,肝功能无明显异常,肾功能正常,凝血功能趋于正常。

术后第4天拔除胃管,第5天流质饮食,第9天低脂半流质饮食。术后第11天复查上腹部CT示腹腔无明显积液,右侧腹腔双套管冲洗改为腹腔单管引流。术后第14天拔除左侧腹腔引流管。术后第17天拔除右侧腹腔引流管,并于当日顺利出院。

出院后继续予胰酶肠溶胶囊补充胰酶,泮托拉唑抑酸,阿司匹林抗血小板聚集,多潘立酮促进胃肠蠕动治疗,继续加强营养。出院后1个月,开始行长效生长抑素类似物治疗(深部肌内注射醋酸奥曲肽微球30 mg/次,治疗28 d);每3~6个月复查上腹部增强MRI,每6个月至1年复查68Ga-生长抑素受体显像(SRS)。截至2019年5月,患者无新发转移灶,原有肝转移灶无明显变化,评估为稳定。

二、多学科讨论

胰胆外科侍力刚主治医师:患者为老年男性,以突发上消化道出血起病,外院胃镜和CT检查提示胰源性门静脉高压,胰腺来源可能性大,考虑为pNEN伴肝脏多发转移。但PET-CT检查示肿瘤部位FDG摄取增高,胰腺癌可能性大。外院行腹腔镜探查,见胰尾部肿瘤侵犯脾脏并有多发肝转移性结节,考虑为胰腺癌伴肝转移,即行肝左叶转移灶和胰腺肿瘤活组织检查,并于胃镜下套扎可能出血的曲张静脉,拟行化学治疗。病理检查结果提示为G2级神经内分泌肿瘤(Ki-67为5%,+),相比胰腺导管腺癌恶性程度较低,拟先行长效生长抑素类似物治疗。然而,患者内科止血治疗无效,再次呕血,并逐渐加重,重度贫血,如不能有效控制上消化道出血,患者将有生命危险。

影像科王俭主任医师:该患者增强CT检查表现为胰体尾部实性占位,边界不清,动脉期轻度强化,侵犯脾脏和胃壁,胃底和胃体部静脉曲张明显,肝脏内多发占位,动脉期强化,倾向pNEN伴肝脏转移;PET-CT检查示病灶糖代谢均增高,说明肿瘤生长活跃,呈侵袭性生长。然而,病理检查报告提示为G2级,Ki-67仅为5%(+)。国外已有多篇文献报道,不论肿瘤分级高低,均有可能18F-FDG代谢阳性,也可能SRS阳性,因此,不能根据PET-CT、SRS是否阳性预测肿瘤分级,而需要根据病理结果分级。另外,评价pNEN全身肿瘤转移负荷,需要完善68Ga-SRS检查,有助于发现其他检查无法发现的转移灶。

肿瘤科焦晓栋副主任医师:患者无激素分泌相关症状,可以确诊为无功能性pNEN伴肝脏多发转移,G2级(Ki-67为5%,+)。从PET-CT的表现上看存在3处肝转移灶,弥漫分布于肝脏左右叶中,属于肝转移Ⅲ型。依据欧洲神经内分泌肿瘤学会(ENETS)2016年指南,首选的治疗方案是系统治疗,对于肿瘤Ki-67<10%的患者,可予长效生长抑素类似物治疗;肿瘤进展后,再改用舒尼替尼、依维莫司靶向治疗或CAPTEM方案(卡培他滨+替莫唑胺)化学治疗;同时,由于pNEN的肝转移灶动脉血供丰富,可联合行经肝动脉栓塞术治疗,可有效降低肝内肿瘤负荷。

消化内科曾欣副主任医师:患者属于胰腺肿瘤侵犯脾静脉引起的胰源性门静脉高压和上消化道出血。胰源性门静脉高压是指由于胰腺疾病及其并发症致使脾静脉受压、扭曲、管壁炎性增厚或管内堵塞,脾静脉血栓形成,影响脾静脉回流,导致脾静脉压力增高,最终脾脏肿大和脾胃区静脉压增高,其区别于肝硬化门静脉高压的特征是胃底和胃大弯侧曲张血管明显,食管下段静脉曲张不明显。对于胃底曲张静脉破裂出血,内镜下曲张血管套扎往往效果不佳,最好选用硬化剂注射或组织黏合剂。患者内镜套扎曲张血管止血无效,可以考虑外科手术行脾切除和(或)原发灶切除,控制出血。

胰胆外科陈丹磊副主任医师:患者具备手术指征:①胰源性门静脉高压并发上消化道出血;②输血、补液等保守治疗和行EVL止血无效;③随时可能再次大出血,危及生命,需要急诊手术止血。此外,患者虽病情较重,但仍具备接受手术治疗的机会:①胰尾肿瘤并无腹腔干、肠系膜上动脉侵犯,原发灶可完整切除;②患者生命体征尚平稳,肝肾功能无明显异常,凝血指标PT和部分凝血活酶时间尚无异常;③经积极输血、补液治疗,血红蛋白较前提升明显。可急诊行胰体尾脾脏切除+近端胃切除术。

胰胆外科刘安安副主任医师:胰体尾脾切除+近端胃切除术中操作的主要风险在于胃底、胃体大量曲张血管易出血。应对措施为先切断胰腺,再处理胃;处理血管时,先结扎切断胃左动脉,再切断脾动脉,按照由右至左、由下向上的次序进行。围手术期应充分考虑到术中和术后因大量出血和大量输血造成的凝血功能障碍,进而导致创面广泛渗血的可能。应对措施为大量备血,补充冷沉淀、凝血酶原复合物和纤维蛋白原,防止弥散性血管内凝血。同时大量输血易并发低钙血症、高钾血症、急性呼吸窘迫综合征等,需监测电解质变化。术后胰瘘、吻合口瘘、腹腔积液、腹腔感染、胃排空障碍、尿瘘、胸腔积液等外科并发症亦要密切观察,积极处置,并注意预防深静脉血栓。

胰胆外科邵成浩主任:对于pNEN伴肝转移合理的治疗策略为:①术前活组织检查确定肿瘤的增殖活性;②明确肝转移的类型,以及有无肝外转移;③评估肿瘤负荷,以及可能达到的减瘤程度。如同时满足肿瘤分级G1或G2级(Ki-67≤20%),肝转移为Ⅰ型(简单型,累及单叶或局限)或Ⅱ型(复杂型,累及双叶),且无肝外转移,肝转移灶减瘤可达到至少70%时,可以考虑行原发灶切除+肝转移灶减瘤术治疗。

对于局部进展期pNEN导致梗阻或出血时,需更加激进的手术策略。①对于引起消化道梗阻者,行原发灶切除或短路手术;②对于胆道梗阻者,行胰十二指肠切除术、胆道支架置入术或胆肠吻合术;③对于十二指肠受侵犯出血者,行胰十二指肠切除术;④对于结肠受侵犯出血者,行联合部分结肠切除的胰腺切除术;⑤对于胰源性门静脉高压致胃底静脉出血者,则行脾切除和(或)原发灶切除术。该患者虽然为肝转移Ⅲ型,但其伴有胰源性门静脉高压、上消化道出血,且内科治疗效果不佳,因此,外科手术指征明确,需急诊行胰体尾脾脏切除+近端胃切除术,控制出血。前期该患者上消化道出血量较大,贫血较严重,围手术期要注意积极备血和凝血药物的应用,以纠正贫血和凝血功能。

三、结语

对于pNEN伴肝转移的患者,需明确肿瘤分级,充分评估其转移负荷,进而采取积极的系统治疗、局部治疗、外科手术或综合治疗。对于因肿瘤局部进展导致的梗阻或出血,应采取更积极的手术策略。本例pNEN伴肝转移患者,以上消化道大出血为首发表现,起病急,病情重,无法接受系统治疗控制肿瘤进展,如不能及时控制反复的消化道大出血,则有生命危险。上海长征医院胰胆外科在充分的术前评估基础上,积极进行术前准备,果断采取手术治疗策略,术后加强围手术期管理,使患者转危为安并获得了接受系统治疗控制肿瘤的机会。

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    2020-05-04 gwc392
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  7. [GetPortalCommentsPageByObjectIdResponse(id=1682578, encodeId=083516825e8e8, content=<a href='/topic/show?id=d4d031e8074' target=_blank style='color:#2F92EE;'>#分泌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31780, encryptionId=d4d031e8074, topicName=分泌)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0da227938338, createdName=gwc392, createdTime=Mon May 04 03:20:00 CST 2020, time=2020-05-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2071131, encodeId=3ce320e11314f, content=<a href='/topic/show?id=8f67199861f' target=_blank style='color:#2F92EE;'>#上消化道大出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19986, encryptionId=8f67199861f, topicName=上消化道大出血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f378286, createdName=shalley66, createdTime=Thu Sep 10 11:20:00 CST 2020, time=2020-09-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1723083, encodeId=dca91e2308372, content=<a href='/topic/show?id=0cc01998259' target=_blank style='color:#2F92EE;'>#上消化道#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19982, encryptionId=0cc01998259, topicName=上消化道)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b81833366357, createdName=zchen, createdTime=Thu Mar 26 20:20:00 CST 2020, time=2020-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1953758, encodeId=8a141953e5822, content=<a href='/topic/show?id=9bdbe41946e' target=_blank style='color:#2F92EE;'>#神经内分泌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74194, encryptionId=9bdbe41946e, topicName=神经内分泌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Tue Sep 22 11:20:00 CST 2020, time=2020-09-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1986300, encodeId=84de19863003b, content=<a href='/topic/show?id=7454e07856a' target=_blank style='color:#2F92EE;'>#病例讨论#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70785, encryptionId=7454e07856a, topicName=病例讨论)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4cea26, createdName=yxch36, createdTime=Sun Jun 21 15:20:00 CST 2020, time=2020-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1763508, encodeId=74711e6350819, content=<a href='/topic/show?id=3fc83035361' target=_blank style='color:#2F92EE;'>#内分泌肿瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30353, encryptionId=3fc83035361, topicName=内分泌肿瘤)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=763a37536718, createdName=1249898am27暂无昵称, createdTime=Wed Oct 07 00:20:00 CST 2020, time=2020-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2066872, encodeId=bfa620668e2f9, content=<a href='/topic/show?id=1adc65e70ef' target=_blank style='color:#2F92EE;'>#消化道大出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65770, encryptionId=1adc65e70ef, topicName=消化道大出血)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLGtr9t89oicQdQSIeKmOQic1weIWfibJ7H24XnT8ic9wiaUMTnXByenuwicOj8Jib42ibHXNptnuiaKthhiaVw/132, createdBy=ac342500190, createdName=ms7524819409032184, createdTime=Wed Dec 11 15:20:00 CST 2019, time=2019-12-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1316171, encodeId=f49f13161e1dc, content=<a href='/topic/show?id=7a1c4360e6e' target=_blank style='color:#2F92EE;'>#大出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43607, encryptionId=7a1c4360e6e, topicName=大出血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aad0444, createdName=cmsvly, createdTime=Thu Nov 21 05:20:00 CST 2019, time=2019-11-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1464637, encodeId=c885146463ea0, content=<a href='/topic/show?id=32e765e6591' target=_blank style='color:#2F92EE;'>#消化道#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65765, encryptionId=32e765e6591, topicName=消化道)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b6e6676048, createdName=changhe715, createdTime=Thu Nov 21 05:20:00 CST 2019, time=2019-11-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1553012, encodeId=cc421553012e8, content=<a href='/topic/show?id=a46c839869c' target=_blank style='color:#2F92EE;'>#胰腺神经内分泌肿瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83986, encryptionId=a46c839869c, topicName=胰腺神经内分泌肿瘤)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f99714344271, createdName=jiafufeng@yaho, createdTime=Thu Nov 21 05:20:00 CST 2019, time=2019-11-21, status=1, ipAttribution=)]
  8. [GetPortalCommentsPageByObjectIdResponse(id=1682578, encodeId=083516825e8e8, content=<a href='/topic/show?id=d4d031e8074' target=_blank style='color:#2F92EE;'>#分泌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=31780, encryptionId=d4d031e8074, topicName=分泌)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0da227938338, createdName=gwc392, createdTime=Mon May 04 03:20:00 CST 2020, time=2020-05-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2071131, encodeId=3ce320e11314f, content=<a href='/topic/show?id=8f67199861f' target=_blank style='color:#2F92EE;'>#上消化道大出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19986, encryptionId=8f67199861f, topicName=上消化道大出血)], attachment=null, authenticateStatus=null, createdAvatar=, 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objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30353, encryptionId=3fc83035361, topicName=内分泌肿瘤)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=763a37536718, createdName=1249898am27暂无昵称, createdTime=Wed Oct 07 00:20:00 CST 2020, time=2020-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2066872, encodeId=bfa620668e2f9, content=<a href='/topic/show?id=1adc65e70ef' target=_blank style='color:#2F92EE;'>#消化道大出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65770, encryptionId=1adc65e70ef, topicName=消化道大出血)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLGtr9t89oicQdQSIeKmOQic1weIWfibJ7H24XnT8ic9wiaUMTnXByenuwicOj8Jib42ibHXNptnuiaKthhiaVw/132, createdBy=ac342500190, createdName=ms7524819409032184, createdTime=Wed Dec 11 15:20:00 CST 2019, time=2019-12-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1316171, encodeId=f49f13161e1dc, content=<a href='/topic/show?id=7a1c4360e6e' target=_blank style='color:#2F92EE;'>#大出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43607, encryptionId=7a1c4360e6e, topicName=大出血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=aad0444, createdName=cmsvly, createdTime=Thu Nov 21 05:20:00 CST 2019, time=2019-11-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1464637, encodeId=c885146463ea0, content=<a href='/topic/show?id=32e765e6591' target=_blank style='color:#2F92EE;'>#消化道#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65765, encryptionId=32e765e6591, topicName=消化道)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7b6e6676048, createdName=changhe715, createdTime=Thu Nov 21 05:20:00 CST 2019, time=2019-11-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1553012, encodeId=cc421553012e8, content=<a href='/topic/show?id=a46c839869c' target=_blank style='color:#2F92EE;'>#胰腺神经内分泌肿瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83986, encryptionId=a46c839869c, topicName=胰腺神经内分泌肿瘤)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f99714344271, createdName=jiafufeng@yaho, createdTime=Thu Nov 21 05:20:00 CST 2019, time=2019-11-21, status=1, ipAttribution=)]
    2019-11-21 cmsvly
  9. 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  10. 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