食管癌外科治疗中联合腔镜的应用

目的 探讨食管癌根治性切除术中应用联合腔镜的可行性和近期疗效及手术适应证.方法 回顾性分析2009年12月至201 1年8月139例食管癌患者施行联合腔镜食管癌切除术的临床资料.食管癌位于上段者16例,中段107例,下段者16例.手术先用胸腔镜游离胸段食管并清扫淋巴结,再用腹腔镜游离胃行食管胃左颈部吻合.术后病理分期:Ⅰ期25例(Ⅰ a期13例、Ⅰb期12例),Ⅱ期71例,Ⅲ期31例(Ⅲa期16例、Ⅲb期15例),Ⅳ期12例.结果 除4例中转开胸手术,中转率2.9％外,其余全部顺利完成手术.术后出现吻合口瘘6例、心律失常4例和乳糜胸、胃排空障碍各1例,均保守治愈;吻合口狭窄2例扩张治疗后治愈;肺部感染11例,3例气管切开、呼吸机辅助呼吸,其中1例死亡(0.7％);10例声音嘶哑.130例随访1～20个月,10例死亡,其中癌转移6例、肺部感染和精神抑郁各1例、不明原因2例.24例患者1年生存率88.9％.结论 胸、腹腔镜联合行食管癌根治术在技术上足安全可行的,近期疗效满意.不仅适应于早、中期食管癌,而且适用于部分晚期病例.     

胸腹腔镜联合与传统食管癌根治术疗效比较

目的 比较胸腹腔镜联合行食管癌根治术与传统手术食管癌根治术的临床疗效.方法 比较70例接受腔镜联合食管癌根治术与80例接受传统手术食管癌根治术患者的一般情况、病理学资料、术后并发症、复发或转移比例等方面的差异.结果 腔镜联合组手术时间长于传统手术组,但术中出血量、术后胸腔引流液总量及术后吗啡用量少于传统手术组(P ＜0.05或P＜0.01).两组术后住院时间差异无统计学意义(P＞0.05).腔镜联合组切除食管标本长度、肿瘤近端切缘长度长于传统手术组,但前者差异无统计学意义(P＞0.05),后者差异有统计学意义(P＜0.05).两组淋巴结清扫数目及术后并发症和切口种植致局部复发发生率差异均无统计学意义(P＞0.05).腔镜联合组术后反流性胃炎发生率7.1％,传统手术组45.0％,差异有统计学意义(P＜0.01).两组术后同期复发转移率比较差异无统计学意义(P＞0.05).结论 胸腹腔镜联合食管癌根治术具有与传统开胸癌根治术相同的治疗效果,且创伤小,恢复快.     

OrVil吻合技术在全腔镜食管癌根治术中的应用

目的 探讨应用经口钉砧头输送系统(OrVil)吻合技术行全腔镜食管癌根治术的可行性、安全性.方法 回顾性分析2010年12月至2013年3月53例应用OrVil吻合技术行全腔镜食管癌根治术的患者临床资料.男42例,女11例;年龄36 ～ 78岁,平均(59.3±8.6)岁.肿瘤位于胸中段13例,胸下段40例(包括13例食管胃交界腺癌累及食管下段),病变长度(3.7±1.6)cm.其中46例应用OrVil技术行全胸腹腔镜下食管癌切除胃食管右胸内吻合术,7例应用OrVil技术行全腹腔镜下食管胃交界癌切除胃食管吻合术.结果 全组无围手术期死亡,无中转开胸、开腹手术.手术(294.5±46.8)min,术中出血(172.3±102.1)ml;术后(5.2±2.3)天拔胸管,(10.1±4.3)天进食;住院(14.1±6.2)天.全组淋巴结清扫总数(26.5 ±9.9)枚/例,其中胸野清扫淋巴结(10.9±6.6)枚/例,腹野清扫淋巴结(15.1±10.9)枚/例.围术期主要并发症发生率13.2％ (7/53)例,其中吻合口瘘1例,肺部感染6例.按手术时间比较,早期15例与后期15例,手术时间由(307.3±53.7) min缩短至(266.0±24.7) min(P=0.014),术中出血量由(180.0±106.6) ml减少至(142.0±81.3) ml(P=0.281).52例患者平均随访(13.0±7.3)个月,无吻合口狭窄.1例失访.术后总生存率88.5％,死亡6例.结论 应用OrVil吻合技术完成全腔镜食管癌切除消化道重建术是微创、安全、可行的,近期效果良好.     

单孔充气式纵隔镜联合腹腔镜治疗食管癌疗效分析

目的 探讨单孔充气式纵隔镜联合腹腔镜治疗食管癌的效果.方法 回顾性分析2017年1月至2019年12月我院收治的13例食管癌患者的临床资料,其中胸上段2例,胸中段11例.术前分期:0期1例,Ⅰ期4例,ⅡA期2例,ⅡB期3例,ⅢA期3例.所有患者均行单孔充气式纵隔镜联合腹腔镜食管癌根治术.结果 全组患者均顺利完成手术,手...     

胸腹腔镜食管癌根治术的临床效果研究

目的 探讨胸腹腔镜食管癌根治术的临床效果.方法 回顾性分析2019-07—2021-07新乡同盟医院胸外科行食管癌根治术治疗的92例食管癌患者的临床资料.按手术方法分为胸腹腔镜组(腔镜组)和传统开胸组(开胸组),各46例.比较2组患者的基线资料、手术相关指标.统计术后并发症发生率.术前和术后1周时测定患者的第1s用力呼...     

胸、腹腔镜下食管癌根治术与传统开放手术的疗效比较分析

目的:探讨胸、腹腔镜下食管癌根治术的安全性与可行性。方法:2011年6月至2016年6月为80例患者行完全胸、腹腔镜下联合食管癌根治术,选择同期行传统食管癌开放手术的80例患者作为研究对象。比较两组手术相关指标及术后随访情况。结果:胸、腹腔镜联合组手术时间较开放组长,失血量、术后第1天胸腔引流量少于开放组,术后拔管时间、ICU观察时间、住院时间均短于开放组(P0.05)。两组术中淋巴结清扫数量、阳性淋巴结数量、术后并发症发生率、术后随访例数、随访时间、复发或转移、总生存率差异无统计学意义(P0.05)。结论:与传统开放食管癌根治术相比,胸、腹腔镜食管癌根治术能达到相似的疗效,可实现手术的根治性与微创效果。     

全腔镜下Ivor Lewis食管癌根治术钉砧安置的新方法

目的探讨全腔镜下Ivor Lewis食管癌根治术中普通管形吻合器钉砧安置新方法的可行性。方法 2011年6月~2012年10月对20例胸中段食管癌在胸腔镜下安置钉砧到食管残端,以普通管形吻合器行胸膜顶胃食管吻合。结果手术时间平均200 min(150~300 min),术中出血平均180 ml(150~250 ml),清扫淋巴结平均18枚(12~44枚)。未行胸腹部辅助切口,围术期未输血,无手术相关并发症,未发生吻合口漏。术后病理上、下切缘均末见癌累及。患者术后恢复良好,术后平均10 d(8~12 d)出院。20例随访6个月,均未发生手术相关并发症,进食正常。结论利用新方法放置钉砧行胸腹腔镜下Ivor Lewis食管癌根治术可行,近期疗效满意。     

胸、腹腔镜联合Ivor Lewis食管癌根治术

目的探讨胸、腹腔镜联合行Ivor Lewis食管癌根治术的可行性和近期疗效。方法2007年12月,胸腹腔镜联合行Ivor Lewis食管癌根治术1例,腹腔镜经5个trocar游离胃,并制作管状胃。胸腔镜经4个trocar游离胸段食管,切除病灶并打开膈肌,将管状胃提至胸顶使用吻合器吻合。所有手术操作均在镜下完成。结果手术时间330min,术中出血量200ml,病灶彻底切除,切缘阴性。术后病理为高分化鳞癌,T2N0M0。随访3个月,无复发。结论胸、腹腔镜联合行Ivor Lewis食管癌根治术可行,近期疗效满意。     

全腔镜下食管癌根治术(OrVil术式)关键技术改进——附40例报告

目的 探索全腔镜下(胸/腹腔镜下)经口腔置入吻合器底钉座的食管癌根治手术的新方法.方法 40例食管癌患者接受经口置入钉砧头技术(OrVil技术)全腔镜下食管癌根治术.男30例,女10例,年龄42～76岁.胸食管上段癌4例,中段癌29例,下段癌7例.术前均经内镜取得病理,37例为鳞状细胞癌,3例为高级别瘤变;利用钡餐和超声内镜检查获得相对准确的术前分期.结果 术中右下肺静脉破裂出血、吻合口瘘和底钉座滑入食管残端各1例;术后吻合口瘘1例,胸腔出血2例,胸腔积液5例,经正确处理后,均恢复正常.全组患者恢复良好.无手术死亡.1例术后1年死于脑转移.病理分期Ⅰb期和Ⅱ期患者均用GP方案化疗1～4个疗程,Ⅲa期患者术后1个月常规辅助放疗1次,再行GP方案化疗1～4个疗程.远期结果仍在进一步观察中.结论 OrVil技术是一种较为方便的全腔镜下食管癌根治方法,临床医师只要熟练掌握了腔镜操作的基本方法均可施行此技术.     

胸腹腔镜技术在食管癌手术中的应用

目的探讨胸腹腔镜在食管癌手术中应用的可行性及近期疗效。方法 2012年6月至2013年10月四川省人民医院胸外科90例食管癌患者行胸腹腔镜联合食管癌切除术,其中男54例、女36例,年龄47~83岁,平均(63.15±11.10)岁。手术先行胸腔镜游离胸段食管并清扫淋巴结,再腹腔镜游离胃行食管胃左颈部吻合术。记录手术时间、术后胸腔引流管放置时间、平均住院时间、淋巴结清扫枚数、术后并发症等。结果全部无围术期死亡。手术时间260~450 min。术后4~11 d(平均5 d)拔除胸腔闭式引流管,胸腔总引流量为530~4 260 ml。全组共清扫纵隔淋巴结(气管旁、右下肺韧带、食管旁、隆凸下及左右喉返神经链旁)、腹腔淋巴结(贲门旁、胃左动脉旁)及颈部淋巴结1 395枚,平均每例15.5枚,15例(16.7%)发现淋巴结转移。术后发生吻合口瘘7例(7.8%),声音嘶哑5例(5.6%),肺部感染5例(5.6%),乳糜胸2例(2.2%),均经保守治疗后痊愈。术后10~14 d出院。门诊及电话随访82例,随访率91.1%,随访时间1~16个月,患者全部生存,无复发。结论胸腹腔镜联合行食管癌根治术在技术上是安全可行的,近期疗效可靠。     

Histochemical and contractile properties of striated muscles of urethra and levator ani of dogs and sheep

AIMS: To understand their possible importance in long- and short-term control of continence, some properties of the striated muscles of the urethra and pelvic floor (levator ani) of dogs and sheep were investigated, especially fiber types and contractile characteristics. MATERIALS AND METHODS: Striated muscles of urethra and levator ani of 29 male and 6 female dogs and 11 male and 6 female sheep were removed and cut into strips. Some strips were frozen and stained for ATPase at pH 9.4 and 4.3 for fiber typing; others were set up in an organ bath to study contractile responses to nerve stimulation. RESULTS: All muscles contained both type I (slow) and type II fibers, ranging from 97% type II in female greyhound urethra to 60% in female sheep levator ani. For each muscle, there were fewer type II muscles in sheep than in dog. The diameters of the urethral fibers were about 60% of the levator ani in dogs and 34% in sheep. Contraction of the urethral muscle was faster than for levator ani and declined to about 80% of the peak, 500 msec after the beginning of stimulation at 20 Hz. The levator ani contraction rose to a steady level as long as stimulation continued. CONCLUSIONS: Both the levator ani and urethral striated muscles contain slow and fast fiber types. The levator ani muscles are capable of sustained contraction with rapid onset which will produce long-term closure of the urethra. The circular urethral muscle contraction was faster but less well maintained.     

Recognition and management of phaeochromocytoma and paraganglioma

Phaeochromocytomas and paragangliomas (PPGL) are catecholamine-secreting neuroendocrine tumours arising from the chromaffin cells in the adrenal medulla. These tumours may be identified incidentally, as part of a work-up for multiple endocrine neoplasia or following haemodynamic surges during unrelated procedures. Advances in perioperative management and improved management of intraoperative haemodynamic instability have significantly reduced surgical mortality from around 40% to less than 3%. Surgery is the definitive treatment in most cases and laparoscopic resection where possible is associated with improved outcomes. Anaesthetic management of PPGL cases represents a unique haemodynamic challenge both before and after tumour resection. In this article we describe the physiology of these tumours, their diagnosis, preoperative optimization methods, intraoperative anaesthetic management and management of postoperative complications.     

Incorporation and release of85Sr and14C-proline-hydroxyproline in mineral and collagen of bone and incisor teeth of growing rats

The extent to which exchange and reutilization processes of mineral tracers affect skeletal mineral accretion and resorption measurements was evaluated by comparing the rates of appearance and disappearance of⁸⁵Sr and¹⁴C-proline-hydroxyproline in bones and teeth in growing rats for 12 days following simultaneous parenteral injection of these tracers. Expressions for the relative rates of collagen synthesis and breakdown, which unlike mineral metabolism are considered not to be complicated by exchange phenomena, were based on¹⁴C-proline conversion to¹⁴C-hydroxyproline; the specific activity of the latter was determined. Both the mineral and the collagen specific activities reflected the rates and patterns of growth of the samples assayed; rapid growth and a short interval of time between formation and resorption of tissue in themetaphyseal bone which contains the cartilagineous growth plate, slow growth and an interval of time between formation and resorption of tissue indiaphyseal bone and incisor teeth which is longer than the 12 days of the experiment. However, in metaphyseal bone the specific activity collagen/mineral ratio dropped by one half during the 4–12 day interval in contrast to diaphyseal bone and incisor teeth in which no change in this ratio was observed during this period of time. The data indicate that collagen in the metaphyseal growth zone is removed by resorption before it has become fully mineralized, and that exchange is a relatively unimportant factor in the long term kinetics of bone mineral.

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Zusammenfassung Das Ausmaß, bis zu welchem Austausch- und Wiederverwendungsprozesse der mineralen Tracer die Messungen des mineralen Skelett-Auf- und Abbaues beeinflussen können, wurde ausgewertet; zu diesem Zweck wurde die Geschwindigkeit des Auftretens und Verschwindens von⁸⁵Sr und von¹⁴C-Prolin-Hydroxyprolin in Knochen und Zähnen von wachsenden Ratten während der 12 auf die simultane parenterale Injektion dieser Tracer folgenden Tage verglichen.Der Ausdruck für die relative Geschwindigkeit des Kollagen-Auf- und Abbaues, bei welchem im Gegensatz zum Mineralmetabolismus kein Mitwirken des Austauschphänomens vermutet wird, basiert auf der Umwandlung von¹⁴C-Prolin zu¹⁴C-Hydroxyprolin; die spezifische Aktivität des letzteren wurde bestimmt.Aus der spezifischen Aktivität des Minerals sowie jener des Kollagens konnten die Geschwindigkeit und die Art des Wachstums der untersuchten Proben ersehen werden, d.h.schnelles Wachstum und ein kurzes Zeitintervall zwischen Bildung und Resorption des Gewebes imKnochen der Metaphyse, die auch die knorpelige Wachstumsplatte enthält, und andererseitslangsames Wachstum und längeres Zeitintervall (länger als die 12 Tage des Experimentes) zwischen Bildung und Resorption des Gewebes imKnochen der Diaphyse und in den Schneidezähnen. Immerhin fiel die spezifische Aktivität des Kollagen/Mineral-Anteils im Knochen der Metaphyse während dem 4–12tägigen Zeitintervall auf die Hälfte, im Gegensatz zum Knochen der Diaphyse und der Schneidezähne, bei welchen während dieser Zeitspanne kein Unterschied in diesem Verhältnis beobachtet wurde.Diese Ergebnisse zeigen, daß Kollagen in der Wachstumszone der Metaphyse durch Resorption verschwindet, bevor es ganz mineralisiert ist, und daß der Austausch ein relativ unwichtiger Faktor in der Kinetik auf lange Sicht des Knochenminerals ist.

     

Instrumented ligamentotaxis and stabilization of compression and burst fractures of dorsolumbar and mid-lumbar spines

Background:

Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique employing the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra.

Materials and Methods:

The study includes 15 Denis burst and two Denis type D compression fractures between T₁₂ and L₃. The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patients after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in vertebral body height, sagittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated.

Results:

The preoperative and postreduction percentile vertebral heights at, zero (immediate postoperative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at preoperative, and postoperative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively.The preoperative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final followup. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications.

Conclusion:

Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short contoured rod derotation technique and the instrumented stabilization of the fractured spine are found to be effective procedures which contribute to the fractured vertebral body consolidation without recollapse and maintain the motion segment function.     

Physiology and pharmacology of nausea and vomiting

Nausea and vomiting are both very unpleasant experiences. The physiology is poorly understood; however, understanding what we do know is key to tailoring a preventative or therapeutic antiemetic regime. There are two key sites in the central nervous system implicated in the organization of the vomiting reflex: the vomiting centre and the chemoreceptor trigger zone. There are five key neurotransmitters involved in afferent feedback to these areas. These are histamine (H₁ receptors), dopamine (D₂), serotonin (5-HT₃), acetyl choline (muscarinic) and neurokinin (substance P). Postoperative nausea and vomiting will occur in around one-third of elective patients who have no prophylaxis. This can result in many detrimental effects including patient dissatisfaction, unplanned admission and prolonged recovery. It is therefore essential that clinicians understand how they can prevent and treat nausea and vomiting using either a single agent or a combination of antiemetics to target relevant receptors. Commonly used drugs include antihistamines, dopamine antagonists, serotonin antagonists and steroids. More novel agents are being developed such as aprepitant, a neurokinin receptor antagonist, palonosetron, a 5HT₃ receptor antagonist and nabilone, a synthetic cannabinoid.     

Physiology and pharmacology of nausea and vomiting

Nausea and vomiting are both very unpleasant experiences. The physiology is poorly understood; however, understanding what we do know is key to tailoring a preventative or therapeutic antiemetic regime. There are two key sites in the central nervous system implicated in the organization of the vomiting reflex: the vomiting centre and the chemoreceptor trigger zone. There are five key neurotransmitters involved in afferent feedback to these areas. These are histamine (H₁ receptors), dopamine (D₂), serotonin (5-HT₃), acetyl choline (muscarinic) and neurokinin (substance P). Postoperative nausea and vomiting will occur in around one-third of elective patients who have no prophylaxis. This can result in many detrimental effects including patient dissatisfaction, unplanned admission and prolonged recovery. It is therefore essential that clinicians understand how they can prevent and treat nausea and vomiting using either a single agent or a combination of antiemetics to target relevant receptors. Commonly used drugs include antihistamines, dopamine antagonists, serotonin antagonists and steroids. More novel agents are being developed such as aprepitant, a neurokinin receptor antagonist, palonosetron, a 5HT₃ receptor antagonist, and nabilone, a synthetic cannabinoid.     

动静脉穿刺网络课件的开发及其应用

目的:确保护理教学效果,提高教学水平。方法:应用多项信息技术将动静脉穿刺技术制作成教学网络课件,并用于临床教学。结果:该课件在本校园网上运行半年余,2000余人次对其进行访问,受到师生好评。结论:该课件能及时反映动静脉穿刺的最新研究进展及具体操作步骤和使用方法,实现护理教学的直观性和交互性,对护理教学和临床带教指导有一定的借鉴作用。     

Physiology and pharmacology of nausea and vomiting

The physiology of nausea and vomiting is poorly understood. The initiation of vomiting varies and may be due to motion, pregnancy, chemotherapy, gastric irritation or postoperative causes. Once initiated, vomiting occurs in two stages, retching and expulsion. The muscles responsible for this sequence of events are controlled by either a vomiting centre or a central pattern generator, probably in the area postrema and the nearby nucleus tractus solitarius. Drugs which induce vomiting include ipecacuanha, a gastric irritant, and apomorphine, a dopamine-receptor agonist. Opioid drugs also induce vomiting, but opioid antagonists are not useful to treat nausea and vomiting. Anti-emetic drugs consist of a variety of neurotransmitter antagonists and may act in the periphery, the central nervous system or both sites. The most important drugs are antagonists at muscarinic, dopamine D₂, 5-HT₃, histamine H₁ and neurokinin NK₁ receptors. These drugs are discussed with particular attention to post-operative nausea and vomiting (PONV).