加速康复外科理念在行腹腔镜膀胱根治性切除术患者围术期中应用的临床观察#br#

目的探讨加速康复外科（ERAS）理念在腹腔镜膀胱根治性切除中应用的有效性和安全性。 方法收集2015年6月至2017年6月潍坊市人民医院收治的58例膀胱癌患者,分为传统组（n=28）和ERAS组（n=30）。比较两组患者的手术时间、手术出血量、术后排气时间、术后重度疼痛的发生数、麻醉苏醒时间、盆腔引流时间、术后住院天数以及术后并发症的发生情况。 结果ERAS组和传统组手术时间分别为（1722±379）min和（1873±218）min;术中出血量分别为（1597±465）ml 和（1771±469）ml,差异均无统计学意义（P＞005）。ERAS组和传统组麻醉苏醒时间分别为（254±54）min和（417±98）min;术后排气时间分别为（16±07）d和（22±07）d;盆腔引流时间分别为（25±11）d和（50±16）d;术后住院天数分比为（76±14）d和（110±18）d;术后疼痛VAS评分＞7分发生率分别为100％（3／30）和429％（12／28）;两组差异均有统计学意义（P＜005）。ERAS组1例刀口液化,1例发生肾结石;传统组2例肠梗阻,1例发生坠积性肺炎,1例发生肾结石。两组患者中均无尿瘘患者。 结论加速康复外科理念在腹腔镜下膀胱根治性切除术患者中的临床应用是安全、有效的,可加速患者的术后康复,值得临床推广应用。     

加速康复外科理念在行腹腔镜膀胱根治性切除术患者围术期中应用的临床观察#br#

目的探讨加速康复外科（ERAS）理念在腹腔镜膀胱根治性切除中应用的有效性和安全性。 方法收集2015年6月至2017年6月潍坊市人民医院收治的58例膀胱癌患者,分为传统组（n=28）和ERAS组（n=30）。比较两组患者的手术时间、手术出血量、术后排气时间、术后重度疼痛的发生数、麻醉苏醒时间、盆腔引流时间、术后住院天数以及术后并发症的发生情况。 结果ERAS组和传统组手术时间分别为（1722±379）min和（1873±218）min;术中出血量分别为（1597±465）ml 和（1771±469）ml,差异均无统计学意义（P＞005）。ERAS组和传统组麻醉苏醒时间分别为（254±54）min和（417±98）min;术后排气时间分别为（16±07）d和（22±07）d;盆腔引流时间分别为（25±11）d和（50±16）d;术后住院天数分比为（76±14）d和（110±18）d;术后疼痛VAS评分＞7分发生率分别为100％（3／30）和429％（12／28）;两组差异均有统计学意义（P＜005）。ERAS组1例刀口液化,1例发生肾结石;传统组2例肠梗阻,1例发生坠积性肺炎,1例发生肾结石。两组患者中均无尿瘘患者。 结论加速康复外科理念在腹腔镜下膀胱根治性切除术患者中的临床应用是安全、有效的,可加速患者的术后康复,值得临床推广应用。     

中心静脉置管应用植入式输液港1例患者的护理

植入式静脉输液港又称植入式中央静脉导管系统。是通过皮下植入的港体连接导管而建立的中心静脉通道,是一种完全植入体内的闭合的静脉系统,主要是由供穿刺的注射座和静脉导管组成。作为隧道型CVC(经皮穿刺置入中心静脉导管)的替代产品,于1983年正式在欧洲市场上推出,由介入放射科医生植入。该系统应用无损伤针经皮肤刺入封闭的注射座,形成输液通路,可用于所有的静脉输液治     

#br# 体素内不相干运动扩散加权成像鉴别早期#br# 鼻咽癌与鼻咽良性增生的价值#br#

目的探讨体素内不相干运动扩散加权成像(IVIM DWI)在早期鼻咽癌(NPC)与鼻咽部良性增生鉴别中的价值。方法选取2018年5月至2019年5月在中山市中医院行MRI检查并进行IVIM DWI成像的早期NPC患者(n=46)和鼻咽部良性增生患者(n=43)作为研究对象,所有患者均经病理组织学检查证实,记录所有患者的真实扩散系数(D)、灌注分数(f)、灌注相关扩散系数(D*)、表观扩散系数(ADC),比较两组各参数之间的差异;绘制ROC曲线并计算曲线下面积(AUC),评估各参数诊断性能。结果与鼻咽良性增生组相比,早期NPC组的D、ADC0～1 000、ADC300～1 000较低[(067±005)×10-3 mm2/s vs. (090±011)×10-3 mm2/s、(065±009)×10-3 mm2/s vs. (100±015)×10-3 mm2/s、 (059±005)×10-3 mm2/s vs. (076±010)×10-3 mm2/s](P<0001),而早期NPC组的D*则高于鼻咽良性增生组[(3287±480)×10-3 mm2/s vs. (2187±521)×10-3 mm2/s](P<0001);两组之间f的差异无统计学意义(P=0216)。D和ADC300～1 000的AUC分别为0985和0988,D<075×10-3 mm2／s鉴别早期NPC与鼻咽良性增生的灵敏度、特异度和准确度最高(100％、975％和969％)。结论IVMI DWI在鉴别早期NPC和鼻咽良性增生中具有一定的价值,其中D和ADC300～1 000鉴别诊断性能最佳。     

腹腔镜腹会阴联合切除术中腹膜外隧道式乙状结肠造口的疗效分析

目的探讨腹膜外隧道式乙状结肠造口术在低位直肠癌腹腔镜腹会阴联合切除术后的临床疗效。方法选取在2014年3月1日至2015年10月31日间中国医学科学院肿瘤医院行低位直肠癌行腹腔镜腹会阴联合切除术的71例患者,采用随机数余数分组法,随机分为腹膜外隧道式乙状结肠造口组(研究组35例)和传统经腹膜乙状结肠造口组(对照组36例),分析不同造口方法对手术时间、术后排气时间、术后住院时间、造口旁疝等并发症的影响。结果研究组患者完成造口操作所需时间为(13.4±1.7)min,对照组患者为(21.4±2.6)min,两组比较差异有统计学意义(P<0.001)。研究组患者术后恢复排气时间为(63.4±13.3)h,对照组患者为(43.0±15.0)h,两组比较差异有统计学意义(P<0.001)。研究组患者术后住院时间为(5.9±1.0)d,对照组患者为(6.4±1.0)d,两组比较差异有统计学意义(P=0.030)。随访期间,研究组患者未有造口旁疝的发生,对照组患者出现4例造口旁疝,两组比较差异有统计学意义(P=0.042)。结论腹膜外隧道式乙状结肠造口术不仅可以缩短手术时间,还可以减少术后住院时间及造口旁疝等并发症发生率,值得临床推广。     

两种不同观察孔位置在腹腔镜直肠癌根治术中的应用效果#br# #br#

目的比较右侧和中央两种不同观察孔位置在腹腔镜直肠癌根治术中对肠系膜下动脉根部淋巴结清扫显露的临床效果。 方法回顾性分析2017年1月至2017年5月于上海中医药大学附属曙光医院胃肠外科行腹腔镜直肠癌根治术的25例患者的临床资料，清扫肠系膜下动脉淋巴结时分别采用右侧观察孔（右上Trocar）和中央观察孔（脐上Trocar）显露，其中右侧观察孔组13例，中央观察孔组12例。对比两组手术视野、总手术时间、实际淋巴结清扫时间（即自系膜切开至D3淋巴结清扫完成的时间）、术中出血量、淋巴结清扫数目、中转开腹率及术后早期并发症发生率，两组手术均由同组医师完成。 结果右侧观察孔较中央观察孔更易于显露肠系膜下动脉及神经走行，手术均无中转，右侧观察孔和中央观察孔两组患者实际淋巴结清扫时间分别为（280±59）min 和（331±61）min，差异有统计学意义（P=0045）；总手术时间分别为（1403±167）min 和（1464±169）min，术中出血量分别为（596±176）ml 和（633±144）ml，淋巴结清扫数目分别为（184±38）枚和（162±31）枚，术后住院时间分别为（82±22）天 和（83±21）天，术后早期并发症发生率分别为77％（1/13）和167％（2/12），以上差异均无统计学意义（P＞005）。 结论在腹腔镜直肠癌根治术中，右侧观察孔较中央观察孔更有利于手术野的显露，在肠系膜下动脉根部淋巴结清扫、分支血管保留及神经保护中具有优势。     

全自动与半自动活检针在CT引导经皮肺穿刺活检中的临床应用#br#

目的比较全自动式和半自动式两种活检针在CT引导下肺穿刺活检术的临床应用。 方法回顾2015年3月至2016年10月于本院进行CT引导下经皮肺穿刺活检术患者242例,其中157例使用全自动活检针（全自动组）,余85例使用半自动活检针（半自动组）,比较两组的穿刺成功率、充足标本率、诊断效能（准确率、敏感性和特异性）及常见并发症的发生率。 结果两组的穿刺成功率均为1000％,全自动组的充足标本率为1000％（157／157）,高于半自动组的953％（81／85）,差异有统计学意义（P＜005）;全自动组的特异度和准确率分别为917％（22／24）和981％（154／157）,均高于半自动组的700％（7／10）和准确率为926％（74／81）,差异有统计学意义（P＜005）,但全自动组和半自动组的敏感度为992％（132／133）和944％（67／71）,差异无统计学意义（P＞005）。全自动组针道出血的发生率为338％,高于半自动组的212％（P＜005）,两组气胸、血胸、痰中带血、穿刺相关感染、空气栓塞和和胸膜反应发生率的差异无统计学意义（P＞005）。 结论CT引导经皮肺肿物穿刺活检术操作中,两种活检针各有优缺点,仅适用范围不同,全自动活检针充足标本率、诊断准确率和特异性更高,并发症可控,半自动活检针针道出血风险小。     

全自动与半自动活检针在CT引导经皮肺穿刺活检中的临床应用#br#

目的比较全自动式和半自动式两种活检针在CT引导下肺穿刺活检术的临床应用。 方法回顾2015年3月至2016年10月于本院进行CT引导下经皮肺穿刺活检术患者242例,其中157例使用全自动活检针（全自动组）,余85例使用半自动活检针（半自动组）,比较两组的穿刺成功率、充足标本率、诊断效能（准确率、敏感性和特异性）及常见并发症的发生率。 结果两组的穿刺成功率均为1000％,全自动组的充足标本率为1000％（157／157）,高于半自动组的953％（81／85）,差异有统计学意义（P＜005）;全自动组的特异度和准确率分别为917％（22／24）和981％（154／157）,均高于半自动组的700％（7／10）和准确率为926％（74／81）,差异有统计学意义（P＜005）,但全自动组和半自动组的敏感度为992％（132／133）和944％（67／71）,差异无统计学意义（P＞005）。全自动组针道出血的发生率为338％,高于半自动组的212％（P＜005）,两组气胸、血胸、痰中带血、穿刺相关感染、空气栓塞和和胸膜反应发生率的差异无统计学意义（P＞005）。 结论CT引导经皮肺肿物穿刺活检术操作中,两种活检针各有优缺点,仅适用范围不同,全自动活检针充足标本率、诊断准确率和特异性更高,并发症可控,半自动活检针针道出血风险小。     

彩色多普勒引导下完全埋入式静脉输液港颈内静脉植入术的有效性和安全性

目的:探讨彩色多普勒引导下完全埋入式静脉输液港（venous port access,VPA）颈内静脉植入术在地市级医院应用的安全性和有效性。方法:收集2018年02月至2020年02月期间渭南市第二医院需行静脉港植入术的肿瘤患者102例,根据颈内静脉穿刺方法分为彩色多普勒超声引导组（可视组,共51例）或传统盲法（盲穿组,共51例）,对比分析两组患者的一次穿刺成功率、患者满意度及术后并发症的差异。结果:可视组患者的手术时间为(29.88±3.63)min,显著短于盲穿组的(36.16±6.64)min（P＜0.05）;一次性穿刺成功率评估结果显示,可视组为98.04%(50/51),明显高于盲穿组84.31%(43/51);可视组和盲穿组的出血量分别为(6.25±1.64)mL和(10.00±3.48)mL,差异有统计学意义（P＜0.05）;可视组动脉误穿率为0%(0/51),低于盲穿组的3.92%(2/51);可视组术后并发症发生率为1.96%(1/51),显著低于盲穿组的15.69%(8/51)（P＜0.05）,可视组的满意度明显高于盲穿组。结论:在彩色多普勒超声引导下的静脉输液港植入手术,其一次穿刺成功率高,术后并发症少,且操作简单、方便,值得地市级医院推广应用。     

植入式静脉输液港注射座外露的临床处理方法探讨

正完全植入式静脉输液港(totally implantable venous access ports,TIVAP)是一种可植入皮下并可长期留置的封闭式静脉输液装置,主要包括供穿刺的注射座和静脉导管两部分。目前普遍开展的TIVAP多是以颈内静脉或锁骨下静脉为入路的胸壁输液港,但合并胸壁皮肤破损感染或胸部放射治疗的患者不适合植入胸壁输液港,此时以手臂贵要静脉、肱静脉、头静脉等作为入路植入导管的手臂输液港可以作为一种新的选择。研究显示,与其他中心静脉通道相比,输液港置管成功率高,完全植于体内并发症发生率低,已成为国内多     

超声联合DSA引导下单切口经腋静脉输液港植入术的临床应用

目的 探讨超声联合数字减影血管造影技术（DSA）引导下行单切口经腋静脉（AV）入路植入输液港（TIVAP）在临床应用中的可行性及安全性。方法 回顾性分析在福建省肿瘤医院就诊并接受超声联合DSA引导下行单切口经AV入路TIVAP植入术的240例患者临床资料。记录手术相关信息,包括AV宽度、AV穿刺成功率、植入成功率、超声引导穿刺时间、手术时间及术中、术后并发症等。结果 240例患者均成功植入TIVAP,植入成功率100%。229例患者于超声联合DSA引导下行单切口经AV穿刺植入TIVAP,AV穿刺成功率95.42%（229/240）,11例因AV穿刺失败,改超声联合DSA引导下经同侧颈内静脉（IJV）穿刺植入TIVAP。240例患者术前超声探查定位下测得拟穿刺段AV平均宽度为（7.56±1.26）mm,其中AV 1次穿刺成功195例,2次穿刺成功26例,3次穿刺成功8例,成功率分别为81.25%、10.83%、3.34%;超声引导下平均穿刺时间（0.85±0.52）min,手术平均时间（25.9±4.8）min。术中并发症发生率为1.67%（4/240）,未发生血胸、血气胸及严重致死性并发症;TIVAP留置期间相关并发症发生率为2.92%（7/240）,未见导管相关血流感染、导管相关静脉血栓、导管断裂/移位、夹闭综合征、药物外渗等并发症发生。结论 超声联合DSA引导下行单切口经AV植入TIVAP术是一种可行且安全的植入方式,具有较高的成功率、较短的手术时长和较低的并发症风险,可作为TIVAP植入方式的另一种选择。     

Efficacy and safety of ultrasound-guided totally implantable venous access ports via the right innominate vein in adult patients with cancer: Single-centre experience and protocol

BackgroundTotally implantable venous access ports (TIVAPs) are widely used and are an essential tool in the efficient delivery of chemotherapy. This study aimed to evaluate the feasibility and safety of implantation of ultrasound (US)-guided TIVAPs via the right innominate vein (INV) for adult patients with cancer.MethodsThis study retrospectively reviewed the medical records of 283 adult patients with cancer who underwent US-guided INV puncture for TIVAPs between September 2015 and September 2017. It also analysed the technical success rate, operation time, and short-term and long-term surgical complications.ResultsTechnical success was achieved in all patients (100%). The mean operation time was 28.31 ± 7.31 min (range: 23–39 min), and the puncture success rate for the first attempt was 99.30% (281/283). Minor complications included artery puncture during the operation in one patient, but no pneumothorax was encountered. The mean TIVAP time was 304.16 ± 42.54 days (range: 38–502 days). The rate of postoperative complications was 2.83% (8/283), including poor healing of the incision in one patient, catheter-related infections in three patients, port thrombosis in one patient, and fibrin sheath formation in three patients; no catheter malposition, pinch-off syndrome, catheter fracture, or other serious complications were observed.ConclusionsTIVAPs are widely employed for chemotherapy. The present study found that the novel approach of using US-guided INV puncture to implant TIVAPs in adult patients with cancer is both short-termly feasible and safe for long-term central venous access.     

Clinical outcome of totally implantable subcutaneous infusion port--comparison with home parenteral nutrition and chemotherapy

We investigated long-term clinical findings in a total of 107 cases with a subcutaneous infusion port. Some 109 patients were implanted with a subcutaneous infusion port at our institution from 1994 to 2003. The patients' ages ranged from 1 to 93 years (average 58.1 years). Implantation failed in 2 patients because it was impossible to insert the guide wire into the central vein and because of mediastinal hematoma due to injury to the central vein from the dilator. 32 patients had complications after catheter system exchange, 17 suffered port infection, 9 had obstruction of the catheter system, and 3 developed ulcerations from the port system. Two cases were given subcutaneous injection due to port system breakage, and one case experienced pain from the port puncture needle. The use of a totally implantable subcutaneous infusion port is widespread for chemotherapy access or home parenteral nutrition in patients with malignancy or malnutrition. This catheter system is useful for improvement of patient's quality of life. However, once complications occur, patient's condition might become worse. Appropriate measures must be taken when complications occur.     

Outcome of cephalic vein cut-down approach: A safe and feasible approach for totally implantable venous access device placement

This study aimed to evaluate the safety and feasibility of the venous access via the cephalic vein cut-down (CVCD) approach for totally implantable venous access device (TIVAD) placements. A total of 79 patients who received TIVAD for the treatment of unresectable or recurrent colorectal carcinomas were recruited. The operation time and the complications were evaluated. Results showed the TIVAD placement via the CVCD approach was successful in 74 patients. A total of 5 patients required conversion to a percutaneous puncture approach. The mean operation time was 34.7 min. No intraoperative or postoperative complications were observed. Therefore, the CVCD approach is a safe and feasible method for TIVAD placement.     

实体瘤化疗患者植入式静脉输液港治疗的相关感染并发症及危险因素分析

目的:对实体瘤化疗患者行植入式静脉输液港治疗的临床感染并发症及感染率进行分析,探究引起患者相关感染并发症的危险因素。方法:纳入2016年1月至2018年6月在我院介入科接受数字减影血管造影（DSA）引导植入式静脉输液港（IVAP）治疗的实体瘤化疗患者495例进行研究,对患者植入IVAP治疗期的病情进展情况、相关感染并发症及感染率进行回顾性分析,并将可能引起感染并发症的危险因素进行单/多因素分析。结果:495例入组患者中因故拔除IVAP 269例（54.34%）,输液港使用时间约为（335±210）d;持续使用IVAP患者226例（45.66%）,输液港使用时间约为（368±334）d。39例（7.88%）出现IVAP相关感染,其中早期感染并发症8例（20.51%）,晚期感染并发症31例（79.49%）。单因素分析结果显示,穿刺点、化疗方案是显著引起相关感染并发症的初始因素,组间差异具有统计学意义（P＜0.05）。多因素分析结果显示,化疗方案是引起相关感染并发症的危险因素（P＜0.05）。结论:化疗方案是实体瘤化疗患者行植入式静脉输液港治疗期引起相关感染并发症的独立危险因素。     

完全埋入式输注系统在胸部恶性肿瘤患者中的应用

目的:探讨完全埋入式输注系统作为胸部恶性肿瘤患者长期静脉输液通路的可行性。方法:2009 年12月-2012年5月,共50例胸部恶性肿瘤患者行埋入式输注系统置入术。局麻或全麻下行锁骨下静脉或颈内静脉穿刺术,采用经导丝植入技术置入导管。观察围手术期和置入术后的并发症。结果:手术成功率为98%。所有病人未发生严重并发症。出现相关并发症的病人共6例,1例误穿锁骨下动脉;2例导丝进入颈内静脉,经重置后成功;2例输注系统堵塞,通过活动上肢或推动皮下注射座后复通;1例出现注射座部位泄露,手术取出。有35例因治疗结束按计划取出输注系统。结论:完全埋入式输注系统是胸部恶性肿瘤患者有效和安全的输液途径。采用经导丝植入技术和置管深度计算公式可以保证手术的安全性并达到预期的效果。     

Surgical technique for totally implantable access ports (TIAP) needs improvement: a multivariate analysis of 400 patients

BACKGROUND: The objective of this study was to analyze factors that may have an impact on the failure rate of the surgical implantation technique for totally implantable access ports (TIAP) and to assess whether morbidity rates differ between a primarily successful surgical and a secondary Seldinger approach. METHODS: Four hundred consecutive patients receiving a primary TIAP in local anesthesia were included into this retrospective cohort study. A logistic regression-model was used to evaluate reasons for failure of the TIAP method. RESULTS: Three hundred eighteen (79.5%) patients had a successful TIAP procedure, 82 patients were intraoperatively converted to a Seldinger technique. Reasons for failure were: correct positioning impossible n = 54, no or only an undersized vessel for insertion available n = 17, other reasons n = 11. Logistic regression analysis did not reveal any significant factor for failure of the primary surgical approach. In the group with primarily successful TIAP, 8 of 318 patients (3%) developed complications compared to 7 of 82 patients (9%) converted to a Seldinger technique. CONCLUSION: Failure of the surgical approach for implanting totally implantable access ports is related to insertion and positioning. Conversion to a Seldinger technique results in a higher complication rate. A modified approach for surgical port placement should be considered in order to reduce complications.     

Use of totally implantable central venous access port via the basilic vein in patients with thoracic malignancies

Background  For patients with a thoracic malignancy whose peripheral veins are not suitable for blood access for chemotherapy, we evaluated a totally implantable central venous access port, in which the port is implanted in the ulnar side of the arm and the catheter is introduced via the basilic vein into the superior vena cava (TIAP-BV). Methods  Twenty-five patients (21 with lung cancer, 2 with malignant pleural mesothelioma, and 2 with thymoma) receiving TIAP-BV were included. Indications, surgical complications, and long-term complications were analyzed. Results  Indications for TIAP-BV were: chemotherapy (17 patients) and chemotherapy with parenteral nutrition (8 patients). The following surgical complications occurred: arrhythmia due to misplacement of the tip of catheter (1 patient); intraoperative conversion from the left to right arm (2 patients); and hematoma at the implantation site (1 patient). Short-term problems were: death 1 week after implantation without the use of TIAP-BV (2 patients). Long-term complications were: skin ulcer at the port site (1 patient); early removal of TIAP-BV because of port site infection (1 patient); catheter occlusion (1 patient); and venous thrombosis of basilic vein (2 patients). In the 22 patients who did not die early or have the device withdrawn early, the median duration of TIAP-BV use was 7 months (range, 1 to 20 months) without any break to the port system, leakage of drugs, or catheter-related infections. Conclusion  TIAP-BV can be employed for long-term use for chemotherapy and parenteral nutrition. However, a patient’s expected prognosis and infectious disease status at the time of implantation surgery should be considered before the surgery proceeds.     

An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases.

AIM: The aim of the present study was to report our experience of totally implantable central venous access devices (TICVAD) implantation using two techniques and attempt to define the better technique. MATERIALS AND METHODS: From January 1998 to September 2003, 1131 patients were reviewed and divided into two groups with implantation by cephalic vein cut-down (group A) done by general surgeons and subclavian vein puncture with the Seldinger technique (group B) done by vascular surgeons. The operative time, early and late complications of these two groups were compared. Data were analysed by Student's t-test. RESULTS: The average of operative time was 43 min in group A (35-70 min) and 40 min in group B (35-60 min) (P>0.05). No post-operative pneumothorax, hemothorax and fragmentation occurred in group A; the incidence of peri-operative complication was higher in group B. The overall and early complications of group A were significantly lower than that of group B (P<0.0001). CONCLUSION: This retrospective study showed that the cephalic vein cut-down approach for TICVAD placement avoided the risks of pneumothorax, hemothorax and catheter fragmentation.