腹腔镜联合硬性胆道镜微创保胆取石(息肉)术60例临床分析

目的 探讨联合应用腹腔镜、硬性胆道镜行微创保胆取石(息肉)术治疗胆囊结石(息肉)的适应证、优势、可行性及手术技巧.方法 对2009年4月～2009年12月该科60例采用腹腔镜联合硬性胆道镜微创保胆取石(息肉)术的胆囊结石(息肉)患者病例资料进行回顾分析.结果 60例患者中,54例成功取净结石(息肉),取出结石最大直径约3.2cm,结石数最多52颗.手术时间40～120min,平均75min.术后第2天低脂流质饮食.平均住院时间5 d.无手术中或术后并发症发生.6例患者中转LC.结论 掌握好手术技巧,腹腔镜、硬性胆道镜联合应用微创保胆取石(息肉)术是安全可行的,同时保持了胆管的完整性及胆囊功能,临床上具有良好的应用前景.     

完全腹腔镜保胆取石术和息肉切除术(附68例报告)

目的 探讨完全腹腔镜下保胆取石和取息肉的手术方法 和应用价值.方法 总结2006年3月～2008年8月68例完全腹腔镜下保胆取石和取息肉术的经验,胆石症患者63例,其中单纯胆囊结石51例,行胆囊切开结合胆道镜取石,3-0可吸收线双层缝合胆囊;胆囊颈部结石嵌顿5例,行颈部切开取石成型术,用3-0可吸收线间断全层、单层缝合胆囊颈部,若颈部不扩张为预防狭窄则纵切横缝,针距、边距1.5 mm;胆囊结合并胆总管结石7例,胆囊切开取石后行胆总管切开取石术.胆囊息肉5例,3例胆固醇性息肉用胆道镜取尽息肉;2例为胆囊腺瘤样息肉,行胆囊部分切除术.结果 68例保胆患者手术均获成功,有1例合并胆总管结石的患者因胆总管取石困难中转开腹.胆漏2例,术后每天10 mL,共2 d,术后4 d拔除腹腔引流管.手术时间80～240(109±33)min(包括胆总管切开取石术).术后住院4～10(6.0±0.8)d,所有患者均治愈.获随访患者58例,随访时间1～29个月,结石复发1例,占1.59%.结论 完全腹腔镜下保胆取石和取息肉术对于保留胆囊及胆囊功能具有重要的意义,特别是胆囊部分切除术、胆囊颈部成型术对于治疗胆囊腺瘤样息肉、胆囊颈部结石嵌顿是一种新的保胆术式和方法 .     

硬性输尿管肾镜在微创保胆取石(息肉)术中的运用

目的 探讨输尿管肾镜在微创保胆取石(息肉)术中的运用技巧及运用前景.方法 2007年12月～2009年5月,用WOLF或奥林巴斯输尿管肾镜联合腹腔镜行微创保胆取石(息肉)手术287例.采用气管插管全身麻醉或连续硬脊膜外阻滞麻醉,在腹腔镜监视下于右上腹近胆囊底处腹壁切口1.5-2.0 cm.将胆囊底提出体外切开1.0 cm左右切口,插入F18或F20的peel-away鞘建立经皮胆通道,利用套石篮、气压弹道碎石、灌注泵低压灌注、peel-away鞘推、挤、压,取石钳钳夹等手法.结果 287例患者中283例保胆成功.1例胆囊管内多发结石嵌顿及3例胆囊化脓性炎症而改行胆囊切除.全组无1例并发症发生.随访1～18个月,1例结石复发.结论 利用输尿管肾镜联合腹腔镜行微创保胆取石(息肉)手术与硬胆道镜一样简单易行、安全有效,且能完全清除胆囊结石(息肉).     

硬质胆道镜联合腹腔镜保胆取石治疗胆囊结石、胆囊息肉的78例疗效观察

目的观察硬质胆道镜联合腹腔镜保胆取石治疗胆囊结石、胆囊息肉的临床疗效。方法 48例胆囊结石与30例胆囊息肉患者行硬质胆道镜保留胆囊、取净结石和息肉手术,术后定期复查腹部彩超。结果 78例患者中1例(1.28%)因结石位于胆囊颈且嵌顿中转行胆囊切除,其余均顺利手术;1例(1.28%)术后2月发现胆囊颈内残余结石,行腹腔镜胆囊切除术;胆囊息肉术后病理检查均为良性息肉。结论硬质胆道镜取石、取息肉术方法简单、安全、可行,是保留胆囊功能的有效方法。     

腹腔镜联合电子胆道镜微创保胆取石(息肉)术256例护理配合

目的:探讨腹腔镜联合电子胆道镜微创保胆取石(息肉)术患者的护理配合技巧及效果。方法:对256例胆囊结石(息肉)患者行腹腔镜联合电子胆道镜微创保胆取石(息肉)术,给予精心护理配合。结果:本组13例改行腹腔镜下胆囊切除术(LC),1例因息肉快速病理结果为恶性改行开腹手术,余242例均成功完成保胆取石(息肉)术,手术时间25~120 min,术后切口愈合良好,患者满意手术效果。结论:良好的护理配合是保障腹腔镜联合电子胆道镜微创保胆取石(息肉)术成功的关键。     

硬性胆道镜保胆取石(息肉)80例报告

目的探讨硬性胆道镜微创保胆取石(息肉)的可行性。方法2006年10月～2007年3月,用Wolf硬性胆道镜行保胆取石(息肉)手术80例。喉罩全身麻醉,迷你腹腔镜直视肋缘下小切口抓取胆囊,胆囊底部小切口,应用Wolf硬性胆道镜进行胆囊探查、取石(息肉),直径>0.5cm的结石,用套石网取出,直径<0.5cm的结石以及泥沙样结石用胆囊泥沙样结石吸取箱取出,取石钳从根部摘除胆囊息肉。应用胆囊泥沙样结石吸取箱设备,用推、挤、压、撕、撑、冲6种手法,发现并清除8例55窝胆囊黏膜下结石,3-0肠线间断缝合胆囊底部切口。结果80例硬镜微创保胆取石(息肉)手术顺利,平均手术时间63min,平均住院4d,均治愈出院,无并发症发生。发现并清除8例55窝胆囊黏膜下结石,最少1例1窝,最多1例30窝,发生率10%。结论硬性胆道镜微创保胆取石术是一项新技术,安全、有效。     

硬性胆道镜下胆囊结石(或息肉)保胆手术200例临床研究

目的 探讨胆囊结石及胆囊息肉经硬性胆道镜下微创保胆取石(或息肉)手术的适应证以及预防结石术后复发.方法 采用WOLF新式硬性胆道镜完成保胆取石手术200例.其中2例急性胆囊炎、8例萎缩性胆囊炎均行保胆取石术,利用气压弹道碎石技术13例,45例采取腔内电凝导丝电凝止血.保胆取石术后患者常规服用步长胆石利通片,防止胆汁胆固醇饱和,防止结石复发.结果 200例患者平均手术时间(55±5)min、平均住院时间5 d,其中放置胆囊造瘘管9例.除1例保胆失败最终选择切胆手术、3例保胆取石术后发现胆囊内沉积物外,其余患者均获得近期较为理想的疗效.结论 硬性胆道镜下微创保胆取石(息肉)手术安全、可行、疗效满意.     

腹腔镜联合胆道镜保胆取石术的临床分析

目的:探讨腹腔镜联合胆道镜保胆取石/息肉术的临床疗效及安全性.方法:回顾分析2011年3月-2012年9月采用腹腔镜联合胆道镜成功行保胆取石/息肉术的376例患者的临床资料.结果:手术平均时间(90±12)min,平均住院时间(5±1)d.手术均治愈顺利出院,无胆漏、胆囊及胆管出血、腹腔感染、胆石及息肉残留等并发症的发生.术后随访6～14个月,结石复发3例,复发率1.0％.结论:腹腔镜联合胆道镜保胆取石术应严格掌握适应证.双镜联合取石安全、可行、有效.     

新式保胆取石取息肉术的临床意义

目的:探讨新式保胆取石取息肉术的临床意义.方法:对475例胆囊结石、145例胆囊息肉采取新式保胆取石取息肉术病例进行随访观察,综合各学者研究及术者体会,比较新式保胆手术与传统胆囊切除术、既往保胆手术及腹腔镜胆囊切除术的优缺点.结果:新式保胆取石取息肉术具有手术切口小、损伤轻及结石复发率低等优点,475例胆囊结石经1～4年的随访,结石复发率为1.26%(6/475).结论:新式保胆取石取息肉术可以保留胆囊正常生理功能,减少医源性胆管损伤,并有效地解决结石复发问题,对胆道外科的发展有着现实和长远的意义.     

腹腔镜联合胆道镜微创保胆取石术治疗胆囊结石(附56例病例报告)

目的 探讨腹腔镜联合胆道镜行微创保胆取石术治疗胆囊结石病的适应证、手术方法及临床疗效.方法 回顾分析56例腹腔镜联合胆道镜微创保胆取石术治疗胆囊结石病患者的临床资料.结果 56例病人中,成功行微创保胆取石术54例,2例病人由于慢性炎症较重,中转为腹腔镜胆囊切除术.保胆取石术54例,手术时间30～70min,平均52min,住院时间2～6d,无术中及术后并发症发生,术后随访6～12个月,1例病人复发少量泥沙样结石(1.9%).结论 选择合适病人,联合应用腹腔镜、胆道镜行微创保胆取石术治疗胆囊结石病是可行、有效和安全的.     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.