Frey与Beger手术治疗慢性胰腺炎的临床疗效分析

目的 比较Frey与Beger手术治疗慢性胰腺炎的临床疗效.方法 回顾性分析四川大学华西医院1999年1月至2009年6月收治的行Beger(38例)及Frey(32例)手术治疗的慢性胰腺炎患者的临床资料,并对术后疼痛及胰腺的内外分泌功能状况进行比较.结果 Frey及Beger组围手术期并发症发生率分别为12.5%和7.9%(P=0.52);总疼痛缓解率为96.8%和94.7%(P=0.57);术后糖尿病发生率分别为12.5%和21%(x2=0.90,P=0.34),脂肪泻发生率分别为12.5%和18.6%(x2=0.15,P=0.70).结论 Frey及Beger手术可同等有效的改善慢性胰腺炎患者的症状,围手术期并发症、术后疼痛缓解率及内外分泌功能状况无显著差异,手术方式的选择应建立在对患者个体化治疗的基础上.     

慢性胰头肿块型胰腺炎合并胰管结石的外科治疗疗效比较

目的比较不同外科方法治疗慢性胰头肿块型胰腺炎合并胰管结石的疗效。方法回顾性分析哈尔滨医科大学附属第一医院胰胆外科2004年1月至2011年1月期间收治的、并经病理学检查确诊的19例慢性胰头肿块型胰腺炎合并胰管结石患者的临床资料,根据术式不同,分为Beger组(n=9)和Frey组(n=10)。结果Beger组患者的手术时间、术中失血量、总并发症发生率、B级胰瘘发生比例、腹腔感染发生比例、胃排空障碍发生比例、总住院时间及住院费用均长于(高于)Frey组(P0.05)。术后2组患者均无围手术期死亡,无C级胰瘘发生,腹痛及黄疸全部缓解。术后18例获访,随访率为94.7%。随访时间5~12年、(8.6±2.5)年。2组患者术后5年疼痛缓解比例均为7/9,2组比较差异无统计学意义(P0.05)。随访期间,新发糖尿病2例(Beger组和Frey组各1例),新发脂肪泻2例(Beger组和Frey组各1例),2组新发糖尿病及脂肪泻比例比较差异均无统计学意义(P0.05)。随访期间无死亡、胰管结石复发、癌变及再次手术病例。结论对于慢性胰头肿块性胰腺炎合并胰管结石患者,采用Frey术与Beger术的效果相当,但Frey术的术后恢复优于Beger术。     

外科手术治疗胰管结石46例分析

目的 探讨外科手术在胰管结石治疗中的价值.方法 回顾性分析2008年1月至2013年12月间安徽医科大学第一附属医院普外科手术治疗46例胰管结石的临床资料.结果 46例胰管结石患者中上腹痛42例,脂肪泻4例,合并糖尿病6例,血、尿淀粉酶升高4例,CA19-9升高9例,胰腺癌5例,急性胰腺炎病史4例.所有患者术前均经影像学检查确诊为胰管结石.结石分布于胰头部21例,胰体(尾)部17例,充满型全胰管结石8例.7例患者为单发结石,28例为2 ～3枚,11例为3枚以上.21例患者的结石最大直径＞1.0cm,25例的结石最大直径≤1.0cm.手术方式:33例患者行胰管切开取石+胰管空肠侧侧吻合术,8例行胰十二指肠切除术,5例行胰体尾联合脾脏切除术.6例患者术后出现并发症,并发症发生率13.0％ (6/46).全组无死亡病例.术后残石率为6.5％ (3/46).39例获得随访,随访率为87.5％ (39/46),随访时间为3～57个月.疼痛缓解率为85.7％ (36/42),结石复发率为4.3％ (2/46).结论 外科手术是治疗胰管结石的重要方式;根据患者胰管结石的具体情况采用个体化手术治疗是取得良好疗效的关键.     

胰腺中段切除术治疗胰腺颈体部良性肿瘤和交界性肿瘤的临床效果分析

目的:研究胰腺中段切除术(CP)在胰腺外科中的应用及临床意义。方法:采用回顾性描述性研究方法,对青岛大学附属医院肝胆外科2007年2月—2017年12月39例行CP患者的临床资料进行分析。6例胰腺中段肿瘤在达芬奇机器人辅助系统下完成。消化道重建采用胰空肠吻合或胰胃吻合。观察所有患者的治疗情况,包括术前影像学资料,手术情况与围手术期相关指标。采用门诊和电话方式进行随访,内容包括空腹血糖水平、消瘦、厌食、腹泻等症状以及预后。结果:(1)39例患者成功行CP,术后发生胰瘘20例(51.28%)。其中生化瘘19例(48.72%),均经非手术治疗治愈;B级瘘1例(2.56%),经CT引导下穿刺引流后治愈;无C级瘘出现。39例患者术后并发症均经对症支持治疗后好转,无死亡病例。(2)39例患者均获得术后随访,平均随访时间31个月(4～72个月)。术后血糖水平(4.26～11.79mmol/L,7.10±1.81 mmol/L)与术前(3.37～13.36 mmol/L,6.49±2.50 mmol/L)比较,差异无统计学意义(t=1.231,P0.05)。术后无新发糖尿病患者。39例患者均未出现厌食、脂肪泻及体质量下降改变等情况。结论:CP是一种治疗胰腺颈体部良性肿瘤和交界性肿瘤的有效方法,可较好地保存术后胰腺的内、外分泌功能,提高患者的生活质量。     

慢性胰腺炎患者行Frey术后的生活质量

目的探索Frey术治疗慢性胰腺炎患者的疗效,并评估术后患者的疼痛情况和生活质量。方法回顾性分析2010年1月至2015年1月期间于华西医院接受Frey术的81例慢性胰腺炎患者的临床资料,术前和术后采用Izbicki疼痛评分系统和欧洲癌症研究与治疗组织生活质量调查问卷(EORTC-QLQ-C30)评分系统对患者的疼痛和生活质量进行问卷调查。结果本组患者的手术时间为(252±70)min(180~430 min),术中出血量为(220±142)m L(100~550 m L),术后住院时间为(14.1±4.9)d(8~36 d)。术后发生胃排空障碍4例,吻合口出血1例,切口感染或脂肪液化6例,腹腔感染、腹腔积液4例,胰瘘3例。术后所有患者均获访,随访时间4~60个月,中位数为28个月。随访期间,新发糖尿病11例,新发脂肪泻10例。在疼痛方面,与术前比较,术后患者的疼痛频率得分、疼痛VAS得分、口服止痛药得分、失去劳动能力得分及疼痛总得分均降低(P0.001)。与术前比较,术后患者的躯体功能得分、角色功能得分、情绪功能得分及社交功能得分均升高(P0.001);症状项目中乏力、疼痛、食欲情况及体质量下降得分均降低(P0.050);术后的总体生活质量得分高于术前(P0.001)。结论总体来说,Frey术可以明显缓解慢性胰腺炎患者的疼痛症状,提高患者的生活质量。     

微血管减压手术治疗原发性三叉神经痛围术期的护理体会

目的总结微血管减压手术治疗原发性三叉神经痛围术期的护理体会。方法对38例接受微血管减压术治疗的三叉神经痛患者实施围手术期护理。回顾性分析患者的临床资料。结果本组29例患者疼痛完全缓解,7例明显缓解且能药物控制,2例无效。总缓解率为94.74(36/38)%。术后出现1例脑脊液漏,经对症处理后痊愈。2例面部麻木或感觉减退者均在3个月内恢复。未发生颅内出血、感染等其他严重并发症。36例患者随访6个月,1例(2.77%)患者疼痛复发。结论对接受微血管减压术治疗的三叉神经痛患者,加强围手术期护理,可有效减少并发症发生率,提高手术疗效,降低术后复发率。     

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目的探讨4种保留器官功能胰腺切除术的适应证、并发症及治疗效果。方法回顾性总结1990年1月至2012年3月中国医科大学附属第一医院普通外科施行的76例保留器官功能胰腺切除术的临床资料,其中男21例,女55例。年龄15～75岁。除胰腺壶腹癌及胰腺外伤各1例外,其余均为胰腺良性或低度恶性病变。76例中,行保留幽门的胰十二指肠切除术(PPPD)8例、保留十二指肠的胰头切除术(DPPHR)14例、中段胰腺切除术(CP)14例、保留脾脏的远侧胰腺切除术(SPDP)40例。结果无手术死亡。发生手术并发症13例(17.1%),其中胰瘘11例(14.5%),胆瘘1例(1.3%),术后胰肠吻合口出血1例(1.3%)。8例行PPPD的病人中,1例发生胰瘘。14例行DPPHR的病人中,发生胰瘘2例、胆瘘1例。行CP的14例病人中,2例发生胰瘘,1例术后合并胰肠吻合口出血者行手术治疗后治愈。40例行SPDP的病人中6例发生胰瘘,未发生迟发性脾梗死、脾脓肿或血小板升高。结论保留器官功能的胰腺切除术可明显减轻手术创伤、保留器官功能、降低手术并发症发生率,疗效与传统术式相似,应作为胰腺良性或低度恶性病变的首选术式。     

慢性胰腺炎胰管多发结石手术治疗临床分析（附17例报告）

目的 探讨慢性胰腺炎胰管多发结石的手术治疗方法及效果.方法 回顾性分析2000年1月至2013年12月14年间经手术治疗的17例慢性胰腺炎胰管多发结石病人的临床资料.其中3例胰头肿块合并胰头部胰管结石,5例胰体结石,8例胰尾结石,1例全胰管结石.结石数量4～31枚.2例行胰十二指肠切除术,10例行胰管空肠Roux-y吻合术,5例行胰尾切除术.其中4例同时行脾切除术.结果 17例均完成手术,无手术死亡及胰漏.术后出现胸腔积液2例,切口裂开1例.获随访13例,时间1～7年,复查CT,1例胰体结石复发.术前腹痛12例术后8例（66.7％）疼痛完全消失,3例疼痛部分缓解,1例术后未戒酒,慢性胰腺炎未控制,顽固性疼痛需止痛药物治疗.术前血糖升高10例,术后8例血糖恢复正常,2例仍需胰岛素控制.术前脂肪泻6例,有4例痊愈,2例仍服胰酶制剂.结论 外科手术是治疗多发胰管结石的有效方法.     

中段胰腺切除术在胰腺实性假乳头状瘤治疗中的应用及疗效分析

目的 为中段胰腺切除术在胰腺实性假乳头状瘤治疗中的合理应用提供一定依据。方法 回顾性分析2010年1月至2015年12月在海军军医大学附属长海医院接受胰腺手术的患者临床病例资料,筛选病理结果为实性假乳头状瘤且肿瘤位于胰腺颈部或近体部的病例。根据手术方案分为中段胰腺切除术组（central pancreatectomy,CP）和远端胰腺切除术组（distal pancreatectomy,DP）,比较两组患者的术中情况、术后并发症发生率及复发率情况。结果 共37例患者入组,其中CP组12例,DP组25例。两组在手术时间[（119.92±29.56）min vs（100.92±27.91）min,t=1.902,P=0.065]、术中失血量[（291.67±178.16）mL vs（330.00±277.26）mL,t=-0.436,P=0.666]）、住院时间[（14.5±4.3）d vs（13.24±4.9）d,t=0.759,P=0.451）等方面差异均无统计学意义。在术后并发症方面,两组胰瘘、出血、腹腔感染、胃排空障碍发生率均无统计学差异（P＞0.05）;在术后内发泌功能不全（新发糖尿病）（9.1% vs 28.6%,P=0.374）、外分泌功能不全（0 vs 14.3%,P=0.534）方面两组虽存在差异,但也无统计学意义。两组均无围手术期死亡病例,随访期内无复发病例。结论 与传统术式DP治疗胰颈部或近体部胰腺实性假乳头状瘤相比,CP手术未增加术后并发症发生率,且在一定程度上降低了发生外分泌功能不全的风险,选用适宜的残端处理方法可有效控制CP手术后的胰瘘发生率。     

保留器官功能的胰腺切除术28例临床分析

目的 探讨保留器官功能的胰腺切除术式在治疗胰腺良性及低度恶性肿瘤中的疗效.方法 回顾性分析2005年5月至2011年6月施行的28例保留器官功能的胰腺切除术患者的临床资料.结果 28例患者行保留十二指肠的胰头切除术7例,中段胰腺切除术9例,行保留脾脏的胰体尾切除术5例,行胰腺肿块局部切除术7例.行保留十二指肠胰头切除术的7例患者术后并发胰瘘1例.行中段胰腺切除术的9例患者术后并发胰瘘1例.行胰腺肿块的局部切除术7例患者中切口脂肪液化2例,均经保守治疗而愈.患者均获得随访,随访时间半年到6年,均无肿瘤复发,无新发糖尿病,脂肪泻及胰腺假性囊肿形成.结论 保留器官功能的胰腺切除术治疗胰腺良性或者低度恶性的肿瘤临床疗效确切,且可明显降低手术创伤.     

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目的改善慢性胰腺炎的治疗效果？方法回顾性分析1985～2000年收治的58例慢性胰腺炎病人的治疗效果。结果33例接受非手术治疗的病人多数有效，但多有复发。经手术治疗的25例病人效果明显好于非手术治疗组。结论对胰头包块型慢性胰腺炎、梗阻型慢性胰腺炎、假性胰腺囊肿应手术治疗；对病变弥漫且无胰管梗阻者，应采取内科治疗，若药物难以控制，可采用胰腺去神经术；对合并胆石的慢性胰腺炎，应积极进行手术处理。     

Change of external and internal secretory pancreatic function in pancreatitis

In 49 patients with an acute pancreatitis and 91 - with chronic pancreatitis were studied external and internal secretory pancreatic function in remote terms after the treatment. In 48 (52.7%) patients, suffering chronic pancreatitis, the investigated indexes were studied in dynamic before and after the operation. There was established the disorders of external secretory pancreatic function in an acute pancreatitis of severe stage and noninfected pancreonecrosis in patients, to whom direct operative pancreatic interventions were not performed. Indications for conduction of internal drainage of the pancreatic ducts, taking into account data of preoperative instrumental examination and initial activity of fecal elastase-1, were substantiated. The advantages of Beger and Frey operations, in comparison with resecting procedures, were proved because of lesser occurrence of the pancreatic functions disorders.     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated. Methods After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct. Results ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far. Conclusions ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

胰腺癌血清相关蛋白质分子的差异表达

目的 利用双向差异凝胶电泳(2D-DIGE)的方法建立胰腺癌、慢性胰腺炎和正常对照人群外周血清的差异蛋白质双向凝胶电泳图谱并分析差异蛋白质点.方法 双向差异凝胶电泳分离20例胰腺癌患者、10例慢性胰腺炎患者和20例正常对照组人群外周血清蛋白,比较不同血清中蛋白质表达的差异.结果 成功建立胰腺癌、慢性胰腺炎和正常人之间的外周血清蛋白质双向差异凝胶电泳图谱,软件分析共发现了168个明显差异表达的蛋白质点,其中在胰腺癌组与正常对照组的比较中有22个蛋白质点在胰腺癌血清中表达上调,29个蛋白质点下调;在胰腺癌组和慢性胰腺炎组的比较中有24个蛋白质点在胰腺癌血清中表达上调,54个表达下调;在慢性胰腺炎组和正常对照组的比较中有20个蛋白质点表达上调,19个蛋白质点表达下调.结论 双向差异凝胶电泳是快速有效的分离蛋白质新的方法,得到的双向差异凝胶电泳图谱以及显著表达差异的蛋白质点为质谱鉴定提供了实验基础.

Abstract：

Objective To analyze and compare the proteomes expressed by human pancreatic carcinoma, chronic pancreatitis and normal control groups. Methods Differencial expression of the proteomes in peripheral serum was analyzed by fluorescence 2-D difference gel electrophoresis (2D-DIGE). Results 2D-DIGE protein maps in 20 patients with pancreatic cancer, 10 patients with chronic pancreatitis and 20 normal controls were analyzed and 168 spots were identified by gel-analysis software. Between pancreatic cancer group and normal control group 22 protein spots were up-regulated and 29 spots down-regulated; 24 spots were up-regulated and 54 spots down-expressed between pancreatic cancer group and chronic pancreatitis group; 20 spots were up-regulated and 19 spots down-regulated between chronic pancreatitis group and normal control group. Conclusion 2D-DIGE was a rapid and efficient method to separate proteins. 2D-DIGE protein maps and different protein spots would provide an exprimental basis for the phase of mass spectrometry.     

Extrahepatic portal hypertension in chronic pancreatitis: an old problem revisited

OBJECTIVE: To evaluate the impact of concomitant nonhepatic portal hypertension in chronic pancreatitis on immediate and long-term outcome after major pancreatic surgery. METHODS: A total of 154 patients (96 male, 58 female) with a history of pancreatitis of at least 12 months, severe incapacitating pain, and radiologic evidence of pancreatic head enlargement was evaluated. One hundred thirty-five patients underwent duodenum-preserving resections of the pancreatic head according to Beger or Frey, and 19 patients underwent pancreatoduodenectomy without (classical Whipple) or with pyloric preservation (PPPD) in cases of suspected malignancy. Outcome parameters included operative time and blood loss, early and late complications and death, recurrent pancreatitis, professional rehabilitation, and alterations in portal venous flow. Median follow-up in this prospective study was 51 months. RESULTS: Patients with portal hypertension required significantly more blood transfusions and had longer operative times than their counterparts. The overall postoperative complication rate was significantly higher in this subgroup. Restoration of postoperative portal venous blood flow was complete after Beger, Whipple, and PPPD procedures but was little affected by Frey procedures. There was no evidence of variceal hemorrhage during the observation period in all operative groups. CONCLUSIONS: Concomitant extrahepatic portal hypertension entails a substantial risk in pancreatic surgery for chronic pancreatitis. When surgery is considered in a symptomatic patient, surgical strategy is determined more by pancreatic morphology than by the intent to restore portal blood flow.     

Extent of Pancreatic Fibrosis as a Determinant of Symptom Resolution After the Frey Procedure: A Clinico-pathologic Analysis

Objective

The aim of this study was to evaluate the association of histopathologic features of chronic pancreatitis and pain relief after the Frey procedure.

Design

We retrospectively analyzed 35 patients who underwent the Frey procedure for chronic pancreatitis over a 5-year period (November 2005 to February 2011).

Setting

Thirty-five patients with varied etiologies of chronic pancreatitis and persistent symptoms were referred to a multi-disciplinary pancreatitis clinic where a consensus decision to recommend surgery was established. The Frey procedure was then performed.

Main outcome measures

We compared symptomatic outcomes with the degree of pancreatic fibrosis, duct dilatation, and presence of pancreatic duct stones based on a blinded evaluation of resected pancreatic tissue.

Results

Symptom resolution was associated with severe or extensive (>75 %) fibrosis and absence of symptom resolution was associated with mild or minimal (<25 %) fibrosis (chi-squared, p value?<?0.05). Symptom resolution was associated with pancreatic duct >4 mm and absence of symptom resolution was associated with pancreatic duct ≤4 mm (chi-squared, p value?<?0.05). There was no difference in outcomes for patients with and without pancreatic duct stones.

Conclusion

Symptom resolution after the Frey procedure is more likely in the setting of severe or extensive fibrosis due to chronic pancreatitis.     

Chronic pancreatitis: A surgical disease? Role of the Frey procedure

Although medical treatment and endoscopic interven-tions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Al-though pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complica-tion and pancreatic exocrine or/and endocrine dysfunc-tion rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to ana-lyze its outcome. Because of its hybrid nature, combin-ing both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical proce-dure performed for chronic pancreatitis.     

Long-term Outcome After Resection for Chronic Pancreatitis in 224 Patients

Introduction Organ complications like biliary or duodenal stenosis as well as intractable pain are current indications for surgery in patients with chronic pancreatitis (CP). We present here our experience with pancreatic resection for CP and focus on the long-term outcome after surgery regarding pain, exocrine/endocrine pancreatic function, and the control of organ complications in 224 patients with a median postoperative follow-up period of 56 months. Methods During 11 years 272 pancreatic resections were performed in our institution for CP. Perioperative mortality was 1%. Follow-up data using at least standardized questionnaires were available in 224 patients. The types of resection in these 224 patients were Whipple (9%), pylorus-preserving pancreato-duodenectomy (PD) (PPPD; 40%), duodenum-preserving pancreatic head resection (DPPHR; 41%, 50 Frey, 42 Beger), distal (9%) and two central pancreatic resections. Eighty-six of the patients were part of a randomized study comparing PPPD and DPPHR. The perioperative and follow-up (f/up) data were prospectively documented. Exocrine insufficiency was regarded as the presence of steatorrhea and/or the need for oral enzyme supplementation. Multivariate analysis was performed using binary logistic regression. Results Perioperative surgical morbidity was 28% and did not differ between the types of resection. At last f/up 87% of the patients were pain-free (60%) or had pain less frequently than once per week (27%). Thirteen percent had frequent pain, at least once per week (no difference between the operative procedures). A concomitant exocrine insufficiency and former postoperative surgical complications were the strongest independent risk factors for pain and frequent pain at follow-up. At the last f/up 65% had exocrine insufficiency, half of them developed it during the postoperative course. The presence of regional or generalized portal hypertension, a low preoperative body mass index, and a longer preoperative duration of CP were independent risk factors for exocrine insufficiency. Thirty-seven percent of the patients without preoperative diabetes developed de novo diabetes during f/up (no risk factor identified). Both, exocrine and endocrine insufficiencies were independent of the type of surgery. Median weight gain was 2 kg and higher in patients with preoperative malnutrition and in patients without abdominal pain. After PPPD, 8% of the patients had peptic jejunal ulcers, whereas 4% presented with biliary complications after DPPHR. Late mortality was analyzed in 233 patients. Survival rates after pancreatic resection for CP were 86% after 5 years and 65% after 10 years. Conclusions Pancreatic resection leads to adequate pain control in the majority of patients with CP. Long-term outcome does not depend on the type of surgical procedure but is in part influenced by severe preoperative CP and by postoperative surgical complications (regarding pain). A few patients develop procedure-related late complications. Late mortality is high, probably because of the high comorbidity (alcohol, smoking) in many of these patients.     

胰管结石性慢性胰腺炎的临床特点与外科治疗

目的探讨胰管结石性慢性胰腺炎的临床特点及外科术式选择与疗效。方法回顾性分析我院外科1983年1月至2006年12月间收治并手术治疗的31例胰管结石性慢性胰腺炎患者的临床资料、手术方式和疗效。结果胰管结石性慢性胰腺炎患者多见于酗酒所致的酒精性胰腺炎,腹痛为最突出临床表现,胰腺内外分泌功能减退较为常见。B超及CT为最常用的检查手段,对胰管结石的诊断准确率分别达到96.8%（30/31）和100%（26/26）,患者多同时存在胰腺萎缩及钙化、胰管扩张等。31例患者共接受32例次手术,胰管取石＋括约肌成形术2例,胰尾空肠吻合3例,改良Puestow术13例,Whipple手术9例,Frey手术5例。手术效果满意。结论胰管结石性慢性胰腺炎临床表现复杂,病因以酒精性为主,腹部B超和CT检查多可明确诊断。手术治疗是缓解症状的主要治疗手段,外科治疗应采用个体化原则。