医学笔记︱盘点：低位直肠癌的平常10种手术方式
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz_gif/2fKbYIekAWr4EibHTND6fF8xQqTrx89icH9K3tH3huIXicPvGhcOHvIEdY4pcORAibxjxkL3cVrG3U2l3E0DCoX3sw/0?wx_fmt=gif&tp=webp&wxfrom=5&wx_lazy=1" style="width: 50%; margin-bottom: 20px;"></p><span style="color: black;"><strong style="color: blue;"><span style="color: black;">直</span></strong></span><span style="color: black;">肠癌是近年来发病率较高的一种恶性肿瘤，</span><span style="color: black;"><span style="color: black;">因为</span>特殊的解剖位置和肿瘤生物学的<span style="color: black;">需求</span>，低位直肠癌手术存在<span style="color: black;">必定</span>的难度。与结肠癌和上段直肠癌单<span style="color: black;">1、</span>规范的手术方式不同，<span style="color: black;">探索这一问题的学者较多，形成的手术方式<span style="color: black;">亦</span>多种多样。</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">■</span>会议<span style="color: black;">通告</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 2017年6月9日<span style="color: black;">～</span>11日，山西省医学会胃肠外科学专业委员会成立大会暨中国胃肠外科卓异青年联盟成立大会将在太原市晋祠宾馆国际会议中心召开，<span style="color: black;">期盼</span>全国的各位同道积极参与这一学术盛会。</span></p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> <span style="color: black;"> <span style="color: black;">我国直肠癌的发病特点是以中低位多见（<span style="color: black;">位置于</span>距齿状线7cm 以内，腹膜反折下的癌），约占直肠癌的70%～75%。<span style="color: black;">日前</span>尚<span style="color: black;">没</span>对低位直肠癌的精确定义。男性解剖学肛管长约2cm，女性约1.5 cm。直肠长度12～15 cm，可分为上、中、下3部分。<span style="color: black;">因此呢</span>，低位直肠癌<span style="color: black;">一般</span>被定义为距离肛缘＜5 cm或距离肛管直肠交界处＜3 cm的直肠癌。</span></span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz_jpg/2fKbYIekAWqP083USI53w2NY82botyxsB7Liav2mgFHGw9cA8WoLYon4GXPUT051FoBHrmuIR05IibCtP2fSuiazw/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">直肠的分部</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">低位直肠癌的手术方式<span style="color: black;">重点</span>有10种：</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（1）经肛门的局部切除；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（2）经骶后入路的局部切除；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（3）经肛门全直肠系膜切除（transanal total mesorectal excision，TaTME）；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（4）Hartmann术（肿瘤切除远端封闭，近端造口）；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（5）Dixon术（低位直肠癌前切除术）；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（6）Parks术（结肠-肛管吻合术）；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（7）Bacon术（结肠经肛拖出吻合术）；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（8）括约肌间切除术（intersphincteric resection，ISR）；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（9）Miles术（腹会阴联合切除术，abdomen perineal resection，APR）；</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（10）腹会阴柱状切除术（extralevator abdominoperineal excision，ELAPE）。</span></p><span style="color: black;"><span style="color: black;">1、经肛门局部切除</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 经肛门局部切除<span style="color: black;">重点</span>分直视下经肛门切除和利用肛门内镜显微手术（TEM），<span style="color: black;">重点</span>适用于特定的<span style="color: black;">初期</span>直肠癌，<span style="color: black;">对T、N分期有较严格的限制，直径在3cm内，术前MRI和直肠内超声<span style="color: black;">检测</span><span style="color: black;">评定</span>淋巴结<span style="color: black;">必要</span>为阴性（淋巴结直径＜3 mm）。</span>严格<span style="color: black;">把握</span>适应证，可取得良好的<span style="color: black;">长时间</span>预后。术中仍<span style="color: black;">需求</span>肠壁全层切除，切除边界1 cm以上，肠壁<span style="color: black;">缺失</span>反复冲洗后予以缝合，切除标本须做连续大切片病理学<span style="color: black;">检测</span>，<span style="color: black;">知道</span>环周切缘阴性，否则须追加手术。<span style="color: black;">针对</span>本文探讨的距肛缘5cm的低位直肠癌，充分扩肌后自动拉勾牵开肛门，直视下已能顺利切除缝合，<span style="color: black;">通常</span><span style="color: black;">没</span>须行肛门镜平台的手术。</span></p><span style="color: black;"><span style="color: black;">2、经骶尾部入路直肠癌切除</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 经骶尾入路的直肠癌切除术<span style="color: black;">重点</span>有两种<strong style="color: blue;">：Kraske术</strong>和<strong style="color: blue;">Mason术</strong>，Kraske术不切断肛管括约肌，而Mason术切断肛管括约肌。经骶尾入路的局部切除，术野显露好，切缘易<span style="color: black;">把握</span>，切断的括约肌用粗丝线对合缝合后，不影响肛管括约功能。但有较高的感染和吻合口漏<span style="color: black;">出现</span>率（约20%），术野须充分冲洗，<span style="color: black;">安置</span>有效引流，引流管引出口靠近肛缘，一旦<span style="color: black;">显现</span>漏，可按单纯肛瘘处理。<span style="color: black;">经骶尾入路只适用于T分期在T1以内、MRI和直肠内超声<span style="color: black;">没</span>淋巴结转移的<span style="color: black;">初期</span>低位直肠癌</span>，肿瘤<span style="color: black;">体积</span>不受限制，可行肠段切除吻合。</span></p><span style="color: black;"><span style="color: black;">3、<span style="color: black;">TaTME</span></span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> TaTME是近5年<span style="color: black;">逐步</span>开展并受到结直肠外科<span style="color: black;">大夫</span>广泛关注的一种手术方式。TaTME是完全经肛门，由下往上分离直肠系膜直至肠系膜下动静脉的手术方式，<span style="color: black;">其优点是良好的下切缘和环周切缘，</span><span style="color: black;">适用于腹膜反折下的直肠癌，有学者将其用于距肛缘≤6 cm的直肠癌，尤其适用于<span style="color: black;">肥壮</span>、强壮和骨盆相对狭窄的青壮年男性病人。</span>笔者认为，不要刻意强调完全经肛门切除，腹腔镜辅助下的TaTME更安全，副<span style="color: black;">损害</span>少，且容易清扫肠系膜下动脉根部<span style="color: black;">淋巴结。<span style="color: black;">在左结肠动脉缺如的变异<span style="color: black;">状况</span>下，游离肠系膜下动脉，<span style="color: black;">保存</span>乙状结肠动脉分支以<span style="color: black;">保准</span>近端结肠血供非常<span style="color: black;">要紧</span>。</span>完全经肛门手术完成乙状结肠动脉的<span style="color: black;">保存</span>、仅结扎直肠上动脉并清扫肠系膜下动脉根部淋巴结是</span>极有难度的，几乎<span style="color: black;">不可</span>完美实现。</span></p><span style="color: black;"><span style="color: black;">4、Hartmann术</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> Hartmann术为直肠肿瘤切除后远端封闭、近端造口的手术方式。<span style="color: black;">该手术<span style="color: black;">重点</span>用于<span style="color: black;">不可</span>耐受手术，或已有肛门功能不全的老年病人。</span>分离到足够切缘后，<span style="color: black;">因为</span>是针对低位直肠癌，会阴组<span style="color: black;">大夫</span>经肛门内荷包缝合将肿瘤隔离，充分冲洗残留直肠肛管后，经腹用闭合器离断或经肛门离断，封闭残端。该手术对部分病人可免去肛门切除手术，术后恢复快，远期疗效待商榷。</span></p><span style="color: black;"><span style="color: black;">5、<span style="color: black;">Dixon术</span></span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 随着圆形吻合器的发明和应用，低位肠段吻合的难度大大降低，低位前切除术<span style="color: black;">亦</span>被应用于治疗低位直肠癌。<span style="color: black;">日前</span>，腹腔镜低位直肠前切除术是直肠癌手术中<span style="color: black;">保存</span>肛门控便功能及根治效果最为满意的术式。<span style="color: black;"><span style="color: black;">按照</span>全直肠系膜切除（TME）原则，距离肿瘤2cm的远端切断，<span style="color: black;">保存</span>完整的肛管，若能<span style="color: black;">保存</span>3~4 cm的直肠残端，更能<span style="color: black;">保准</span>肛门排便功能的完整性。</span>应用吻合器的Dixon手术<span style="color: black;">日前</span>仍为首选，其<span style="color: black;">长时间</span>存活率和<span style="color: black;">没</span>病存活率均不亚于Miles术。而<span style="color: black;">针对</span>距离肛缘＜5 cm的肿瘤，须<span style="color: black;">尤其</span><span style="color: black;">重视</span>远切缘<span style="color: black;">是不是</span>足够，如切除在齿状线以下时<span style="color: black;">常常</span><span style="color: black;">不可</span>进行常规吻合，此时<span style="color: black;">能够</span>采用其他吻合技术，如Parks术、Bacon术和ISR。这些不同的吻合方式，严格<span style="color: black;">道理</span>上仍然是低位直肠癌前切除术的延伸或演变。</span></p><span style="color: black;"><span style="color: black;">6、改良Parks术</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 该术式为在腹部手术切除肿瘤后，由会阴组医师从齿状线上方1 cm切断直肠，再行结肠断端全层与齿状线处黏膜及肌层的吻合，吻合口<span style="color: black;">位置于</span>齿状线<span style="color: black;">周边</span>。<span style="color: black;">适用于距齿状线上4～6cm以内<span style="color: black;">没</span>法行Dixon术或吻合器吻合者</span>，但Parks手术<span style="color: black;">引起</span>粪便存储功能锐减，<span style="color: black;">导致</span><span style="color: black;">初期</span>排便功能<span style="color: black;">掌控</span>欠佳。<span style="color: black;">因为</span>Parks术后吻合口漏<span style="color: black;">出现</span>率较高，<span style="color: black;">必须</span>常规进行腹部结肠造口，给病人带来<span style="color: black;">不方便</span>和再次手术的经济<span style="color: black;">包袱</span>，近年来应用在减少。</span></p><span style="color: black;"><span style="color: black;">7、Bacon术</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">该术式的腹部操作与Dixon术<span style="color: black;">类似</span>，<span style="color: black;">通常</span>于结肠内置入小儿<span style="color: black;">麻木</span>螺旋导管作支架，拖出肛门结肠浆肌层与肛管缝合6~8针固定，10d<span style="color: black;">上下</span>自动脱落，但<span style="color: black;">增多</span>了会阴部手术过程，将结肠经腹拖出切除肿瘤<span style="color: black;">而后</span>与肛管吻合，<span style="color: black;">适用于低位直肠癌、直肠阴道瘘、部分放疗后、低位吻合失效和低位吻合口漏再手术的病人</span>。<span style="color: black;">因为</span>该手术<span style="color: black;">必须</span>较长的近端游离肠段，术后肛门括约肌功能不甚满意，控便功能差。将肠管结扎在螺纹导管上的距离应在肛门外2cm，过长可能须二期切除多余肠管，此术式因在<span style="color: black;">身体</span><span style="color: black;">没</span>吻合口，<span style="color: black;">出现</span>漏的机会少，但有部分病人<span style="color: black;">显现</span>肠管回缩。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz_png/2fKbYIekAWpRibiaxvBKuQD49hroAjsnm1LTu3lib5h1ehtyLd9cjEQTMtXcaXP7eEQg9ufiaZAzTTIjfDryVxXp8w/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">改良Bacon术（手术<span style="color: black;">次序</span>：左上→左下→右）</span></p><span style="color: black;"><span style="color: black;">9、括约肌间切除术（ISR<span style="color: black;">）</span></span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 相比较Bacon术和Parks术，ISR的肿瘤位置更低。近年来，<span style="color: black;">ISR<span style="color: black;">逐步</span>用于距齿状线2～5 cm以内的<span style="color: black;">初期</span>直肠癌（T1或部分T2）</span>，能达到肿瘤彻底切除和<span style="color: black;">得到</span>满意的排便<span style="color: black;">掌控</span>功能。该术式是用腹腔镜从腹腔分离直肠到达盆底后，会阴组在肛门直视下从肿瘤下缘足够处切开至肛管内外括约肌之间，随后向上游离达肛提肌处与腹腔镜组会合。该术式<span style="color: black;">保存</span>肛门外括约肌及部分内括约肌，<span style="color: black;">能够</span><span style="color: black;">得到</span>足够的远端切缘，从而达到肿瘤根治及<span style="color: black;">保存</span>肛门（保肛）的目的。适用于距齿状线2～5 cm、未侵犯内括约肌且分化程度高的直肠癌病人。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">有<span style="color: black;">科研</span>证实，腹腔镜ISR是安全可行的，ISR的R0切除率为97.0%，围手术期病死率为0.8%，总并发症<span style="color: black;">出现</span>率为25.8%，局部复发率为6.7%（中位随访时间56个月），5年中位存活率为86.3%、<span style="color: black;">没</span>病存活率为78.6%。其根治效果和<span style="color: black;">长时间</span>预后不亚于Miles术；术后短期内肛门功能<span style="color: black;">显著</span>受损，但6个月后<span style="color: black;">发掘</span>肛门功能<span style="color: black;">逐步</span>恢复，并随时间延长<span style="color: black;">乃至</span>接近术前水平。内括约肌<span style="color: black;">是不是</span>完全切除为影响术后肛门功能的<span style="color: black;">重点</span><span style="color: black;">原因</span>，行全内括约肌切除病人的控便功能较差。</span></p><span style="color: black;"><span style="color: black;">十、</span><span style="color: black;">腹会阴联合切除和柱状切除</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> <span style="color: black;"><strong style="color: blue;">传</strong></span>统直肠癌APR仍是不可保肛的低位直肠癌病人首选的治疗手段，尽管采用了TME技术，但在直肠游离<span style="color: black;">周期</span>，<span style="color: black;">通常</span>随着系膜的缩小，必然<span style="color: black;">引起</span>标本形成狭窄的“腰部”。<span style="color: black;">文献<span style="color: black;">报告</span>狭窄处正是肿瘤残存复发之处</span>，严重影响病人存活率，其术后效果仍<span style="color: black;">无</span>得到<span style="color: black;">显著</span>改善。<span style="color: black;">近年来对T3~T4期低位直肠癌病人<span style="color: black;">逐步</span>推广了ELAPE</span>，标本呈圆柱状，其效果可<span style="color: black;">显著</span>降低环周切缘阳性率以及术后局部复发率。柱状切除的<span style="color: black;">不方便</span>是术中须更换体位，两次消毒铺巾。这两种手术都切除了肛门，病人的<span style="color: black;">存活</span>质量受到影响，<span style="color: black;">因为</span>局部晚期的低位直肠癌常规<span style="color: black;">举荐</span>新辅助放化疗，且可用环周切缘来判断手术质量，故柱状切除似<span style="color: black;">没</span>必要。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（声明：本文摘选自《中国实用外科杂志》）</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz_jpg/2fKbYIekAWr8wV0ibXDawYHIv0ricUNv6PUH1QVKfO38T5jQlug3ibltqN7JvXYOHCI3diawdbibYLujXdWAysA3eZw/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">点个赞再走呗</span><span style="color: black;">（本文左下角）</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">每 日 双 语 新 闻</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">Last month, China’s social networking and messaging app WeChat closed the "tipping" function on its iOS version due to Apple’s restrictions on third-party payment links. Soon after, Apple decided to take 30 percent of "tips" on other social networking apps as commission fees<span style="color: black;">.</span>（4/6/2017）</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz_jpg/2fKbYIekAWpRibiaxvBKuQD49hroAjsnm1tfzjhpzAjEkic63icSibDqT8yD566NbrPbnRrYtYFrV0kBbFicgNctb2pQ/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;">由</strong></span>于苹果限制第三方支付链接，中国社交网络和<span style="color: black;">信息</span>传送app<span style="color: black;">微X</span>于上月关闭了其IOS上的“打赏”功能。不久，苹果决定对其它社交网络app收取30%的“打赏<span style="color: black;">花费</span>”<span style="color: black;">做为</span>佣金<span style="color: black;">花费</span>。（2017-6-4）</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="http://mmbiz.qpic.cn/mmbiz_gif/2fKbYIekAWqdldj1IxjxbrdWgEqe6PAZmIC1ndh04ePLmdvzNxVTVZfbpiayWKGxibrwW7WlulXuoibpQoas0dLRw/0?wx_fmt=gif&tp=webp&wxfrom=5&wx_lazy=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;">支持<span style="color: black;">咱们</span>的医学平台，请</strong></span></strong><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">点赞</span></strong></span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;">过往的君子，可在右下角</strong></span></strong><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;">写</strong></span></strong><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">留言</span></strong></span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">倘若</span>觉得<span style="color: black;">文案</span>不错，欢迎</strong><strong style="color: blue;"><span style="color: black;">转发</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><img src="http://mmbiz.qpic.cn/mmbiz_gif/2fKbYIekAWoJ0j3oJaRUfyOCWDC9YVVP1UJ5KCXfSk9Ql02FwT8LaTJSwp747ONBh22iamcg0J75a1MoBZ05vew/0?wx_fmt=gif&tp=webp&wxfrom=5&wx_lazy=1" style="width: 50%; margin-bottom: 20px;"></span></strong></span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;"><img src="http://mmbiz.qpic.cn/mmbiz_gif/2fKbYIekAWpFGvLXomwZoVtm8Vv1pmMMLTmMuTpVNae2BXBGMgiarw1SKp9E94GAXhYoMIc6ZpNsRCYDriaGXrHQ/0?wx_fmt=gif&tp=webp&wxfrom=5&wx_lazy=1" style="width: 50%; margin-bottom: 20px;"></span></strong></span></strong></p>
楼主果然英明！不得不赞美你一下！ 这篇文章真的让我受益匪浅，外链发布感谢分享！
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