重度急性胰腺炎并发胰腺脓肿的诊治进展

2016-06-08 西南医科大学附属医院消化内科 杨凤 彭燕 胃肠病学

胰腺脓肿(pancreatic abscess,PA)是重度急性胰腺炎(severe acute pancreatitis,SAP)最严重的并发症,发生率约为5%,病死率国外为14%~54%,国内为12.2%~25%。通常发生于急性胰腺炎(AP)病程后期(距发病4~6周),多数情况下由局灶性坏死液化继发感染形成。如未及时干预,可导致全身和(或)局部并发症,甚至死亡。本文就SAP并发PA的诊治进

胰腺脓肿(pancreatic abscess,PA)是重度急性胰腺炎(severe acute pancreatitis,SAP)最严重的并发症,发生率约为5%,病死率国外为14%~54%,国内为12.2%~25%。通常发生于急性胰腺炎(AP)病程后期(距发病4~6周),多数情况下由局灶性坏死液化继发感染形成。如未及时干预,可导致全身和(或)局部并发症,甚至死亡。本文就SAP并发PA的诊治进展作一综述。


一、诊断


1. 临床诊断:PA患者的临床表现各异,感染征象是常见的临床表现。SAP患者如出现败血症表现,而无其他原因可寻(尤其是疾病进展至第4~6周),高度提示PA。患者表现为症状和体征发生改变和加剧,如发热、持续性心动过速、呼吸加快、胃肠道症状、肠麻痹、腹痛加剧,白细胞计数升高、肝肾功能异常等。体格检查显示上腹部或全腹压痛,可触及包块,腹部痛性包块是PA 最具价值的诊断体征。


2. 影像学检查:B超可显示PA大小、数目和位置。B超下可见腹部局限性包块,内含液性暗区。Fink等的研究显示,B超对PA的检出率为70%,应作为首选检查。但超声容易受胃肠道内气体的影响,对于胃肠道积气严重、被肠道包绕的脓肿通常不能准确显示。CT分辨率高,不受气体、骨骼的影响,可较好显示各种解剖结构,是安全有效的诊疗技术。增强CT是诊断PA最重要的影像学手段,其可明确病灶部位、大小、与周围邻近脏器的关系,有助于指导引流。增强CT下可见PA位于胰腺内或胰周,呈类圆形或不规则形,脓液密度略低于囊肿,脓腔内见气泡是PA的特征性表现,但出现率仅为30%~50%,增强扫描可见脓肿壁明显强化。


3. 细菌学依据:胰腺和胰周脓液细针穿刺细菌学检查是鉴别有无感染的重要方法,可在B超或CT引导下进行,为诊断提供细菌学依据。罗斌等对32例PA患者的脓液进行细菌培养,最常见的为大肠杆菌,其次为肠球菌和克雷伯氏菌。Petrov等的研究显示最常见的细菌依次为大肠杆菌、克雷伯杆菌和绿脓假单胞菌,并且随着住院时间延长,亦可见革兰阳性菌感染,主要为金黄色葡萄球菌。许志伟等指出PA混合菌感染多于单一病原菌感染,除常见细菌感染外,厌氧菌和真菌的感染率亦不断上升。


二、治疗


1.抗菌药物治疗


关于PA 感染,目前比较认同的是“肠道细菌易位”学说。一旦确认感染,应立即控制感染源并给予抗菌药物治疗。控制感染源可通过手术引流,如内镜超声(EUS)引导下引流或经皮穿刺置管引流(percutaneouscatheter drainage,PCD)。抗菌药物的选择应具备:①脂溶性强,能有效通过血胰屏障;②经验性用药时,选择广谱抗菌药物。然而,随着抗菌药物的广泛使用,目前许多病原体已产生耐药性。Su等的研究发现,在SAP相关感染病原体中,革兰阳性菌株对红霉素和青霉素的耐药性较高,革兰阴性菌株对碳青霉烯类抗菌药物敏感。因此临床治疗上应联合使用抗菌药物,首选碳青霉烯类和三代头孢类。


2.营养支持治疗


SAP的营养支持应达到正氮平衡。营养支持包括两种方式,即完全肠外营养(TPN)和肠内营养(EN)。TPN曾被认为是AP供给营养的标准方式,在供给营养的同时可减少胰液的刺激。但该方法可导致中央静脉导管感染、高血糖、电解质紊乱等不良反应,且长时间TPN可能导致肠道屏障功能受损,促使肠道细菌易位,增加感染风险。2012年Yi等对8项随机对照试验分析发现,与TPN相比,EN组的病死率更低,感染并发症更少,并且能降低器官衰竭和手术的发生率。早期开始EN的优点在于能维持肠黏膜屏障功能,保护肠道有益菌,减少细菌易位和内毒素释放,维持肠道屏障功能的完整性。临床应用最多的是经鼻胃管和鼻空肠管。若EN患者耐受量不足以获得足够的热量支持,应联合肠外和肠内喂养。


3.脓液引流


①手术引流:以往认为SAP并发PA的患者应立即手术治疗。手术的关键是切开脓肿,充分引流。术者应遵循接近病灶和腹膜外路径的原则选择手术切口和路径,进腹后经肝胃、胃结肠韧带、结肠旁沟或肾前间隙探查脓肿,术中应尽量吸除脓液并清除坏死组织,根据脓腔的大小、位置以及残留坏死组织的情况决定引流管大小、数量和放置部位。术后定时行脓腔冲洗,脓液明显减少时可减少冲洗液量和冲洗次数,注意观察引流液性质,并逐渐拔管。亦有部分患者无法彻底引流,需再次手术,此时需进行残腔窦道造影,结合确定再次手术清创路径。


手术治疗是的传统治疗方法,可彻底清除坏死组织和脓液,但手术创伤大,并发症发生率和死亡率较高。并发症主要包括器官衰竭、脏器穿孔、伤口感染、出血、胰瘘、胰腺内外分泌功能不全等,亦可能需二次手术。手术主要适用于内科治疗不能缓解、瘘管形成、脓肿压迫胆总管发生阻塞性黄疸、脾静脉血栓形成和门静脉高压引起出血者。


②PCD:近年来PCD在SAP相关局部并发症的治疗中发挥重要作用。Baudin等的研究显示,CT引导下PCD治疗PA的有效率为64.6%(31/48),其中2例发生非致命性手术相关并发症,对其处理后症状完全缓解,复查CT示脓肿消失。置管后需定期使用抗菌药物、0.9% NaCl冲管,必要时换管,以免脓栓阻塞引流管,引流管留置时间应根据引流情况和CT复查结果评估。


PCD定位准确、创伤小、并发症少,病死率低,可避免危重患者经受手术打击,亦可为再次手术赢取时间。但对于脓肿位置较深的患者,由于穿刺路径较长,PCD仍可导致出血、针道感染、腹膜炎、败血症等并发症。此外,若脓腔内脓液黏稠、内含坏死组织,则PCD 疗效不佳。van Santvoort 等的研究显示,单独使用PCD治疗的成功率仅为33% ~35% 。Prochazka等认为对PA的微创穿刺引流可避免外科手术干预,但并不妨碍后续必要时行外科干预。许元鸿等的研究认为单独PCD不适合作为PA的常规治疗,仅适用于下列两种情况,即危重患者进行暂时性减压和引流,为进一步手术作准备;不含半固体坏死组织的单房性脓肿,尤其单纯性脓肿,且发病时间间隔较长、坏死组织已充分液化的患者。


③EUS引导下引流:内镜下引流胰腺和(或)胰周液体已应用于临床多年,EUS技术的发展扩大了透壁穿刺的适应证,包括未见囊壁隆起和穿刺风险高的液体积聚。将EUS 探头置于胃腔,可多角度显示病变和血管等解剖结构,选取最短且安全的穿刺途径。在进行脓肿穿刺引流术前,应确定脓肿的位置、大小和囊壁厚度,脓肿与胰腺、胃、肠壁的部位及其距离,脓肿与胃壁间的距离应不超过1cm。常用的引流方法包括EUS引导下经胃壁支架置入引流术、EUS引导下经胃鼻脓肿管引流术、EUS引导下经胃支架与鼻脓肿管联合引流术等。Giovannini等的研究中,20例PA患者行EUS引导下治疗并安置鼻脓肿管,17例脓肿位于胰尾,3例脓肿邻近胃壁,治疗后随访2个月,2例复发行手术治疗,其余患者均治疗成功。Lopes等对51 例患者通过EUS引导下行PA胃引流或十二指肠内引流术,随访39周,复发率为17.7%,无患者死亡。


EUS引导下引流术可对PA进行定位,了解其与周围脏器的位置关系,对进针途径进行实时监测,能准确穿刺脓肿、放置透壁支架和鼻脓肿导管,以确保持续冲洗和有效引流,可达到PCD操作难度大、不易处理的部位。未见囊壁隆起、门静脉高压、高出血风险等不良反应,使用其他方法治疗失败、需排除囊性肿瘤的患者均可行EUS 引导下穿刺。但此操作易引起出血、穿孔、感染、引流管脱落、支架易位等并发症,且是否优于手术和影像学引导下PCD治疗,尚缺乏大规模、多中心、随机对照研究证实。


三、结语 


PA形成后无法自行消除,一旦诊断成立,应给予早期通畅引流、抗感染、加强营养支持等治疗,其中通畅引流尤为重要。以往PA的治疗以手术治疗为主,随着微创技术的发展,EUS引导下引流以及PCD为PA的治疗开辟了新途径。对于SAP患者,预防和早期诊断PA成为治疗中的挑战之一,未来仍需进一步研究和探讨。


原始出处:


重度急性胰腺炎并发胰腺脓肿的诊治进展。胃肠病学,2016,21(3):190-192.



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  3. [GetPortalCommentsPageByObjectIdResponse(id=1740451, encodeId=ec861e404519f, content=<a href='/topic/show?id=e0ba916e323' target=_blank style='color:#2F92EE;'>#诊治进展#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91673, encryptionId=e0ba916e323, topicName=诊治进展)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Sat Nov 26 15:29:00 CST 2016, time=2016-11-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1809867, encodeId=784c180986ebf, content=<a href='/topic/show?id=046183998f9' target=_blank style='color:#2F92EE;'>#胰腺脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83998, encryptionId=046183998f9, topicName=胰腺脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1dbc2500219, createdName=huagfeg, createdTime=Fri May 19 04:29:00 CST 2017, time=2017-05-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=147947, encodeId=d11214e947fc, content=写的很笼统,初学者按照文章治疗一定会吃苦头!, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9c231965579, createdName=张俊2101, createdTime=Thu Oct 13 23:44:19 CST 2016, time=2016-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1757714, encodeId=06331e57714dc, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Sun Oct 23 05:29:00 CST 2016, time=2016-10-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1537245, encodeId=e597153e245c9, content=<a href='/topic/show?id=8a988520e74' target=_blank style='color:#2F92EE;'>#脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85207, encryptionId=8a988520e74, topicName=脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d01712842068, createdName=hunizi009, createdTime=Fri Jun 10 01:29:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89055, encodeId=adb689055ba, content=学习了,内容很丰富, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/PiajxSqBRaEJJAFMgSjibMicGVUgkmDBw4svXiccQxZicwjRHNxGPTghAmITxP12Rcmm0yFKfwGwUaiaUwpPUUUTOd2g/0, createdBy=fcd21609070, createdName=hekzn, createdTime=Wed Jun 08 18:06:00 CST 2016, time=2016-06-08, status=1, ipAttribution=)]
    2016-10-13 张俊2101

    写的很笼统,初学者按照文章治疗一定会吃苦头!

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1740451, encodeId=ec861e404519f, content=<a href='/topic/show?id=e0ba916e323' target=_blank style='color:#2F92EE;'>#诊治进展#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91673, encryptionId=e0ba916e323, topicName=诊治进展)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Sat Nov 26 15:29:00 CST 2016, time=2016-11-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1809867, encodeId=784c180986ebf, content=<a href='/topic/show?id=046183998f9' target=_blank style='color:#2F92EE;'>#胰腺脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83998, encryptionId=046183998f9, topicName=胰腺脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1dbc2500219, createdName=huagfeg, createdTime=Fri May 19 04:29:00 CST 2017, time=2017-05-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=147947, encodeId=d11214e947fc, content=写的很笼统,初学者按照文章治疗一定会吃苦头!, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9c231965579, createdName=张俊2101, createdTime=Thu Oct 13 23:44:19 CST 2016, time=2016-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1757714, encodeId=06331e57714dc, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Sun Oct 23 05:29:00 CST 2016, time=2016-10-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1537245, encodeId=e597153e245c9, content=<a href='/topic/show?id=8a988520e74' target=_blank style='color:#2F92EE;'>#脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85207, encryptionId=8a988520e74, topicName=脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d01712842068, createdName=hunizi009, createdTime=Fri Jun 10 01:29:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89055, encodeId=adb689055ba, content=学习了,内容很丰富, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/PiajxSqBRaEJJAFMgSjibMicGVUgkmDBw4svXiccQxZicwjRHNxGPTghAmITxP12Rcmm0yFKfwGwUaiaUwpPUUUTOd2g/0, createdBy=fcd21609070, createdName=hekzn, createdTime=Wed Jun 08 18:06:00 CST 2016, time=2016-06-08, status=1, ipAttribution=)]
    2016-10-23 丁鹏鹏
  5. [GetPortalCommentsPageByObjectIdResponse(id=1740451, encodeId=ec861e404519f, content=<a href='/topic/show?id=e0ba916e323' target=_blank style='color:#2F92EE;'>#诊治进展#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91673, encryptionId=e0ba916e323, topicName=诊治进展)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Sat Nov 26 15:29:00 CST 2016, time=2016-11-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1809867, encodeId=784c180986ebf, content=<a href='/topic/show?id=046183998f9' target=_blank style='color:#2F92EE;'>#胰腺脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83998, encryptionId=046183998f9, topicName=胰腺脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1dbc2500219, createdName=huagfeg, createdTime=Fri May 19 04:29:00 CST 2017, time=2017-05-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=147947, encodeId=d11214e947fc, content=写的很笼统,初学者按照文章治疗一定会吃苦头!, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9c231965579, createdName=张俊2101, createdTime=Thu Oct 13 23:44:19 CST 2016, time=2016-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1757714, encodeId=06331e57714dc, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Sun Oct 23 05:29:00 CST 2016, time=2016-10-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1537245, encodeId=e597153e245c9, content=<a href='/topic/show?id=8a988520e74' target=_blank style='color:#2F92EE;'>#脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85207, encryptionId=8a988520e74, topicName=脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d01712842068, createdName=hunizi009, createdTime=Fri Jun 10 01:29:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89055, encodeId=adb689055ba, content=学习了,内容很丰富, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/PiajxSqBRaEJJAFMgSjibMicGVUgkmDBw4svXiccQxZicwjRHNxGPTghAmITxP12Rcmm0yFKfwGwUaiaUwpPUUUTOd2g/0, createdBy=fcd21609070, createdName=hekzn, createdTime=Wed Jun 08 18:06:00 CST 2016, time=2016-06-08, status=1, ipAttribution=)]
    2016-06-10 hunizi009
  6. [GetPortalCommentsPageByObjectIdResponse(id=1740451, encodeId=ec861e404519f, content=<a href='/topic/show?id=e0ba916e323' target=_blank style='color:#2F92EE;'>#诊治进展#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91673, encryptionId=e0ba916e323, topicName=诊治进展)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=医者仁心, createdTime=Sat Nov 26 15:29:00 CST 2016, time=2016-11-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1809867, encodeId=784c180986ebf, content=<a href='/topic/show?id=046183998f9' target=_blank style='color:#2F92EE;'>#胰腺脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83998, encryptionId=046183998f9, topicName=胰腺脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1dbc2500219, createdName=huagfeg, createdTime=Fri May 19 04:29:00 CST 2017, time=2017-05-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=147947, encodeId=d11214e947fc, content=写的很笼统,初学者按照文章治疗一定会吃苦头!, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9c231965579, createdName=张俊2101, createdTime=Thu Oct 13 23:44:19 CST 2016, time=2016-10-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1757714, encodeId=06331e57714dc, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Sun Oct 23 05:29:00 CST 2016, time=2016-10-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1537245, encodeId=e597153e245c9, content=<a href='/topic/show?id=8a988520e74' target=_blank style='color:#2F92EE;'>#脓肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85207, encryptionId=8a988520e74, topicName=脓肿)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d01712842068, createdName=hunizi009, createdTime=Fri Jun 10 01:29:00 CST 2016, time=2016-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=89055, encodeId=adb689055ba, content=学习了,内容很丰富, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/PiajxSqBRaEJJAFMgSjibMicGVUgkmDBw4svXiccQxZicwjRHNxGPTghAmITxP12Rcmm0yFKfwGwUaiaUwpPUUUTOd2g/0, createdBy=fcd21609070, createdName=hekzn, createdTime=Wed Jun 08 18:06:00 CST 2016, time=2016-06-08, status=1, ipAttribution=)]
    2016-06-08 hekzn

    学习了,内容很丰富

    0