机器人辅助腹腔镜根治性膀胱切除术的预后风险因素

目的探讨机器人辅助腹腔镜根治性膀胱切除术(RARC)后的预后风险因素。方法回顾性分析南京鼓楼医院2014年12月至2018年12月收治的224例行RARC患者的临床和随访资料,男193例,女31例。平均年龄68(36~92)岁。7例(3.1%)接受新辅助化疗。125例(55.8%)美国麻醉医师协会(ASA)评分>2分。平均体质指数23.4(15.4~35.5)kg/m2。所有患者均行RARC。使用Kaplan-Meier法绘制无复发生存率(RFS)、癌症特异性生存率(CSS)和总生存率(OS)曲线。使用Cox比例风险回归模型评估RARC患者生存结局与围手术期和病理因素的相关性。结果本组224例手术,中位手术时间380(160~670)min。中位术中估计失血量为350(100~1900)ml,72例(32.1%)术中输血。术后T分期分别为≤T1期82例,T2期64例,T3期57例,T4期21例。淋巴结转移49例(21.9%),手术切缘阳性12例(5.4%),伴淋巴脉管侵犯(LVI)82例(36.6%)。术后辅助化疗41例(18.3%)。中位随访时间24(11~60)个月。5年累积OS、RFS和CSS分别为57.15%、48.84%和59.60%。单因素Cox回归分析结果显示T分期(HR=5.764,95%CI 1.926~17.249,P=0.002;HR=4.086,95%CI 1.611~10.364,P=0.003;HR=9.391,95%CI 2.118~41.637,P=0.003)、N分期(HR=6.446,95%CI 3.438~12.087,P<0.001;HR=5.661,95%CI 3.086~10.385,P<0.001;HR=5.980,95%CI 2.982~11.992,P<0.001)、LVI(HR=3.319,95%CI 2.008~5.486,P<0.001;HR=2.894,95%CI 1.782~4.701,P<0.001;HR=3.471,95%CI 2.017~5.974,P<0.001)、ASA评分(HR=2.888,95%CI 1.619~5.150,P<0.001;HR=1.765,95%CI 1.060~2.940,P=0.029;HR=2.612,95%CI 1.424~4.792,P=0.002)、体质指数(HR=0.886,95%CI 0.819~0.957,P=0.002;HR=0.885,95%CI 0.819~0.955,P=0.002;HR=0.862,95%CI 0.792~0.938,P=0.001)、年龄(HR=1.580,95%CI 1.250~1.997,P<0.001;HR=1.362,95%CI 1.088~1.705,P=0.007;HR=1.530,95%CI 1.190~1.968,P=0.001)和术中输血(HR=1.899,95%CI 1.160~3.108,P=0.011;HR=2.218,95%CI 1.371~3.587,P=0.001;HR=2.227,95%CI 1.312~3.782,P=0.003)是OS、RFS和CSS的显著预测因素。多因素Cox回归分析结果显示,T分期(HR=4.506,95%CI 1.433~14.175,P=0.01;HR=3.159,95%CI 1.180~8.454,P=0.022;HR=7.810,95%CI 1.674~36.444,P=0.009),N分期(HR=6.096,95%CI 2.981~12.467,P<0.001;HR=5.368,95%CI 2.683~10.740,P<0.001;HR=5.539,95%CI 2.497~12.288,P<0.001)和ASA评分(HR=6.180,95%CI 2.371~16.110,P<0.001;HR=2.702,95%CI 1.175~6.215,P=0.019;HR=6.471,95%CI 2.290~18.286,P<0.001)分别是OS、RFS和CSS的独立预测因素,辅助化疗(HR=0.434,95%CI 0.202~0.930,P=0.032)是OS的独立预测因素。结论T分期、N分期和ASA评分是RARC术后患者OS、RFS和CSS的独立预测因素,辅助化疗是OS的独立预测因素。     

非手术指征颈动脉斑块患者缺血性脑卒中的危险因素分析

目的:探讨颈动脉狭窄≤50%的颈动脉斑块患者的MRI斑块特征及临床因素与发生缺血性脑卒中的关系。方法:选取2014年9月—2016年2月超声筛选颈动脉狭窄≤50%的颈动脉斑块患者43例,所有患者行核磁共振黑血成像检查,分析MRI斑块特征及其他危险因素与缺血性脑卒中的关系。结果:43例患者的颈动脉斑块狭窄程度5%～50%,随访时间1.9～19.4个月。随访期间发现脑梗死患者共4例。单因素与多因素Logistic回归分析结果显示,仅MRI的斑块内出血与缺血性脑卒中的发生有明显关系(OR=297.797,95%CI=2.638～33620,P=0.018),而其他斑块特征及临床因素均无明显关系(均P0.05)。Kaplan-Meier生存分析显示,有斑块内出血者较无斑块内出血者的中位无脑卒中时间明显缩短(14.3个月vs. 18.6个月,P=0.001);有冠心病者较无冠心病者的中位无脑卒中时间也明显缩短(12.1个月vs. 18.7个月,P=0.029);Cox回归分析显示,斑块内出血(HR=18.2,95%CI=2.7～123.3,P=0.003)及冠心病(HR=27.4,95%CI=1.6～464.3,P=0.022)是缺血性脑卒中发生的独立危险因素。结论:在颈动脉狭窄≤50%的颈动脉斑块患者中,斑块内出血与冠心病是缺血性卒中的发生密切相关。     

C反应蛋白与血清白蛋白的比值与下肢动脉硬化闭塞症患者股腘支架置入术后再狭窄的相关性研究

目的探讨炎症指标C反应蛋白与白蛋白的比值(CAR)与下肢动脉硬化闭塞症(LEASO)行股腘支架置入术后再狭窄的相关性。方法回顾性收集2020年6月至2022年12月南京大学医学院附属鼓楼医院血管外科收治的95例LEASO患者的临床资料。男性67例, 女性28例, 年龄(73.1±9.4)岁(范围:51～92岁)。根据复查的CT血管造影结果判断是否发生支架内再狭窄, 将患者分为再狭窄组(n=61)和通畅组(n=34)。采用独立样本t检验、Mann-WhitneyU检验、χ2检验对两组患者的一般资料、术前检查结果和手术情况等进行比较, 采用多因素Cox回归分析LEASO患者行股腘动脉支架术后再狭窄的危险因素。绘制CAR的受试者工作特征曲线, 计算曲线下面积(AUC), 评估CAR对支架术后再狭窄的预测价值。结果与通畅组相比, 支架内再狭窄组患者主髂钙化分级、支架数量、支架长度、C反应蛋白、CAR水平均高于通畅组, 血清白蛋白水平低于通畅组, 差异有统计学意义(P值均<0.05)。多因素Cox回归分析结果显示, 术前CAR水平较高与踝肱指数较低是支架内再狭窄的独立危险因素。CAR预测支...     

输尿管结石行输尿管镜下碎石术后并发输尿管狭窄的危险因素分析

目的探讨输尿管镜下治疗输尿管结石术后并发输尿管狭窄的危险因素。方法以2014年1月至2015年12月间来我院就诊的708例行输尿管镜下碎石的输尿管结石患者的临床资料为基础,分析造成术后输尿管狭窄的危险因素。结果术后共发现输尿管狭窄患者36例(5.1%)。导致输尿管狭窄发生的危险因素依次为:嵌顿结石(OR=3.61,95%CI=2.12~6.08,P0.001)、多发结石(OR=3.22,95%CI=1.01~5.77,P0.001)、大结石(OR=2.41,95%CI=1.14~4.18,P0.001)、钬激光手术(OR=1.36,95%CI=1.02~3.93,P=0.031),长病程(OR=1.12,95%CI=1.02~3.42,P=0.038)。结论对于嵌钝性结石、多发结石、结石较大及行钬激光碎石者,应注意手术操作对输尿管的损伤,积极防治输尿管狭窄的发生。     

机器人辅助腹腔镜根治性前列腺切除术后尿控恢复的影响因素

目的评估机器人辅助腹腔镜根治性前列腺切除术(RARP)后1～24个月的尿控率,并探讨术后尿控恢复的影响因素。方法回顾性分析2014年10月至2019年9月期间305例确诊为前列腺癌并由单一术者行RARP患者的临床资料。评估RARP术后1、3、6、12、24个月的尿控率,并采用Cox比例风险回归模型分析RARP术后尿控恢复的影响因素。结果 RARP术后1、3、6、12、24个月的尿控率分别为22%、44%、72%、89%和89%,术后12和24个月尿控率之间的差异无统计学意义(P=1.000)。单因素Cox回归分析显示经尿道前列腺电切术(TURP)手术史(HR=0.69,95%CI:0.51～0.93,P=0.014)、糖尿病(HR=0.66,95%CI:0.47～0.93,P=0.017)、高血压(HR=0.73,95%CI:0.57～0.96,P=0.021)能够显著延迟RARP术后的尿控恢复;多因素Cox回归分析表明TURP(HR=0.68,95%CI:0.51～0.92,P=0.012)和糖尿病(HR=0.66,95%CI:0.47～0.92,P=0.015)是RARP术后尿控恢复的独立危险因素。结论 RARP术后的尿控恢复在12个月时达到稳定状态,TURP手术史和糖尿病是影响RARP术后尿控恢复的独立危险因素。     

经皮肝穿刺置入胆管支架对胃癌术后复发致胆管梗阻的治疗价值

目的探讨经皮肝穿刺胆管支架置入术(percutaneous transhepatic biliary stent,PTBS)治疗胃癌术后复发致梗阻性黄疸的疗效,分析影响支架通畅时间的危险因素。方法 2008年1月~2013年12月对31例胃癌术后复发致胆道梗阻行PTBS,观察手术成功率、临床症状缓解率、并发症发生情况、支架通畅时间和患者生存时间,分析影响支架通畅时间的危险因素。结果 31例成功行PTBS,27例(87.1%)临床症状缓解,术前总胆红素(150.5±59.8)μmol/L,术后1周下降至(61.8±32.4)μmol/L(t=14.440,P=0.000)。支架中位通畅时间250.9 d(95%CI:205.5~296.4 d),中位生存时间251.9 d(95%CI:222.6~281.2 d),12例(44.4%)支架堵塞,未发生其他严重并发症。支架置入术后1周血清总胆红素水平(β=-1.746,95%CI:0.038~0.808,P=0.026)、术后是否化疗(β=-1.692,95%CI:0.039~0.870,P=0.033)是支架通畅时间的影响因素。结论对于胃癌术后复发致胆管恶性梗阻行PTBS安全有效,支架置入术后血清总胆红素水平下降、术后化疗是支架通畅时间的保护因素。     

基于SEER数据库的甲状腺髓样癌预后因素分析

目的:探讨甲状腺髓样癌(MTC)患者预后的影响因素。方法:通过SEER*Stat软件收集SEER数据库中2010—2014年病理明确诊断为MTC的602例患者资料。采用aplan-Meier法与Log-rank检验分析患者的生存率,用单变量与多变量Cox回归模型分析影响患者生存的危险因素。结果:602例患者的平均生存时间为(54.914±1.209)个月,1、3年生存率分别为96.9%、90.8%。单变量分析显示,诊断年龄(χ~2=33.232,P0.001)、性别(χ~2=4.030,P0.045)、原发灶大小(χ~2=37.06,P0.001)、病灶数目(χ~2=6.786,P=0.009)、临床分期(χ~2=116.467,P0.001)、原发肿瘤分期(χ~2=72.482,P0.001)、区域淋巴结受累(χ~2=14.803,P0.001)、远处转移(χ~2=94.976,P0.001)、手术情况(χ~2=80.536,P0.001)以及检出淋巴结阳性数(χ~2=18.700,P0.001)与患者生存时间有关。多变量Cox分析表明,诊断年龄(HR=2.777,95%CI=1.800~4.285,P0.001)、原发肿瘤分期(HR=1.675,95%CI=1.289~2.176,P0.001)及远处转移(HR=5.401,95%CI=2.720~10.725,P0.001)是影响MTC患者预后的独立危险因素。结论:诊断年龄、原发肿瘤分期及远处转移等临床病理参数是预测甲状腺髓样癌患者生存情况的独立指标。     

尿道端端吻合术后狭窄复发的危险因素分析

目的分析尿道狭窄患者行尿道端端吻合术(excision and primary anastomotic urethroplasty,EPA)后狭窄复发的危险因素。方法回顾性分析2017年1月至2018年12月上海交通大学附属第六人民医院收治的209例尿道狭窄患者的临床资料。年龄42.1(5~78)岁。肥胖(体质指数>28 kg/m2)25例(12.0%)。既往有糖尿病史12例(5.7%),术前3个月吸烟史103例(49.3%)。术前未行尿道扩张127例(60.8%),尿道扩张1~2次42例(20.1%),尿道扩张≥3次40例(19.1%)。术前有尿道内切开术史56例(26.8%)。术前无尿道成形术史157例(75.1%),尿道成形术1次38例(18.2%),尿道成形术≥2次14例(6.7%)。术前行膀胱造瘘201例(96.2%),未行膀胱造瘘8例(3.8%)。后尿道狭窄183例,球部尿道狭窄26例。狭窄时间35.1(1~360)个月。狭窄段长度(3.19±0.65)cm。病因为外伤190例,医源性损伤12例,炎性狭窄2例,其他5例。患者均行EPA治疗,69例(33.0%)术中行耻骨下缘切除。术后复发标准:拔除导尿管后出现排尿困难,经尿道镜或尿道造影检查提示手术部位尿道狭窄。对可能导致狭窄复发的因素采用Cox比例风险回归模型进行单因素和多因素分析。结果本组209例术后随访18.8(3~32)个月。31例(14.8%)出现狭窄复发,复发时间(5.3±5.6)个月。单因素分析结果显示,狭窄时间(HR=1.007,P<0.001),狭窄段长度(HR=5.334,P<0.001),尿道内切开术史(HR=2.901,P=0.003),尿道扩张≥3次(HR=6.214,P<0.001),尿道成形术1次、≥2次(HR=4.175,P=0.001、HR=9.885,P<0.001),术前3个月吸烟史(HR=2.605,P=0.016),膀胱造瘘(HR=0.231,P=0.006),耻骨下缘切除(HR=6.603,P<0.001)与狭窄复发有相关性。多因素分析结果显示狭窄段长度(HR=4.911,P<0.001),尿道成形术1次、≥2次(HR=2.387,P=0.045、HR=3.688,P=0.015),术前3个月吸烟史(HR=2.730,P=0.030)是狭窄复发的独立危险因素。结论EPA术后尿道狭窄复发多集中在术后6个月内,患者尿道狭段窄长度、尿道成形术史、术前3个月吸烟史是狭窄复发的独立危险因素。     

脑血管狭窄行支架植入术围术期缺血性卒中的危险因素

目的探讨经皮穿刺脑血管腔内球囊扩张/支架植入术(percutaneous transluminal angioplasty and stenting,PTAS)围术期缺血性卒中的危险因素。方法选择医院颅内、外血管狭窄行PTAS的患者416例,男334例,女82例,年龄40~85岁,ASAⅠ~Ⅲ级。收集围术期缺血性卒中的发病率、人口学、既往史、神经系统及围术期血流动力学因素与临床结局的关系,回顾性探讨围术期缺血性卒中的危险因素。结果颅外血管狭窄行PTAS的328例患者中,10例(3.0%)发生围术期缺血性卒中。颅内血管狭窄行PTAS的88例患者中,6例(6.8%)发生围术期缺血性卒中。颅外血管PTAS围术期脑卒中的危险因素包括术前合并未治疗的颅内血管狭窄(OR=9.44,95%CI2.36~37.71,P=0.001)和术中SBP最低值90 mm Hg(OR=9.13,95%CI 1.35~61.76,P=0.023)。颅内血管PTAS围术期脑卒中的危险因素包括术前合并未治疗的颅内血管狭窄(OR=44.81,95%CI 1.99~1 011.84,P=0.017)、年龄增高(OR=1.25,95%CI 1.04~1.51,P=0.021)和存在钙化斑块(OR=11.02,95%CI 1.11~109.25,P=0.040)。结论在经皮穿刺脑血管腔内球囊扩张/支架植入术中,颅外血管PTAS围术期缺血性卒中的独立危险因素是术前合并未治疗的颅内血管狭窄和术中SBP最低值90mm Hg,颅内血管PTAS围术期卒中的独立危险因素是年龄增高、存在钙化斑块以及术前合并未治疗的颅内血管狭窄。     

非肌层浸润性膀胱癌并糖尿病患者的预后及其意义

目的:探讨非肌层浸润性膀胱癌(non-muscle-invasive bladder cancer,NMIBC)合并糖尿病患者的预后及意义。方法:回顾性分析我院2012年1月~2013年12月经病理检查回报为NMIBC的200例患者临床资料,将患者分为糖尿病组(41例)和非糖尿病组(159例)。所有患者均为首发尿路上皮癌。运用Kaplan-Meier法单因素分析各临床病理特点对患者无复发生存期(recurrence-free survival,RFS)和无进展生存期(progressionfree survival,PFS)的影响,并用Log-rank检验比较生存曲线,运用Cox回归模型多因素分析糖尿病与NMIBC之间的关系,并评估影响其RFS和PFS的预后因素。结果:200例NMIBC患者平均随访14.2(4~40)个月,糖尿病组和非糖尿病组肿瘤复发率分别为34.1%(14/41)和28.3%(45/159),中位无复发生存时间分别为12.0个月(4~38个月)和14.7个月(5~40个月),肿瘤进展率分别为9.8%(4/41)和6.9%(11/159),糖尿病组较非糖尿病组肿瘤复发率高(χ2=4.875,P=0.027),无复发生存时间短(P0.001),而进展率的差异无统计学意义(P=0.770)。Cox多因素生存分析显示糖尿病(P0.001,HR=2.731)、肿瘤大小(P=0.012,HR=2.344)和NMIBC更高的复发风险相关,而灌注药物(P0.001,HR=0.110)会显著降低NMIBC的复发风险。结论:糖尿病是NMIBC患者RFS的独立危险因素,患有糖尿病的NMBIC患者术后复发率更高。     

Intraoperative assessement of coronary flow and coronary vascular resistance during coronary bypass surgery

The measurement of coronary graft flow rates is a well-established method of assessing graft function intraoperatively. In order further to understand the dynamics of graft function, the resistance to the flow was considered a desirable measurement intraoperatively. The coronary vascular resistance (CVR) was estimated by applying the Poiseuille-Hagen equation. The CVR was estimated at zero cardiac work (during cardioplegic arrest) using fixed perfusion flow rates and estimating the pressures produced. After going off cardiopulmonary bypass (CPB), the bypass graft flow (F) was estimated by a standard ultrasound Doppler technique. The perfusion pressure over the perfused coronary graft was then determined and the CVR in the working heart ascertained. The CVR was studied in 178 vein grafts in 59 patients undergoing coronary bypass surgery. The mean CVR in the cardioplegic heart (c-CVR) varied from 0.81 to 2.3 mmHg/ml/min for various coronary artery diameters and was significantly higher in small diameter arteries compared with larger arteries (p < 0.0002). Consequently significant high flows were found in the large vessels compared with the smaller ones (p < 0.0001). The mean c-CVR during cardioplegia of 1.57 +/- 0.06 increased significantly to 1.75 +/- 0.07 mmHg/ml/min after the procedure (p-CVR) and was attributed to the dynamic resistance of the working heart. The post-CPB graft flow was significantly and negatively correlated to the c-CVR of the arrested heart. The measurement of coronary vascular resistance reveals coronary beds at potential high risk for inadequate perfusion. Such areas are usually fed by small vessels with low flows. The working heart, in turn, increases the coronary resistance following cardioplegia during the surgical procedure.     

Giant coronary artery aneurysm with coronary arteriovenous fistula draining into the coronary sinus

A 77-year-old patient suffering from a giant right coronary artery aneurysm with coronary arteriovenous fistula was admitted to our hospital. The fistula could not be documented preoperatively by computed tomography or coronary angiography but was documented intraoperatively by transesophageal echocardiography (TEE). However, TEE was unable to visualize the draining site of the fistula. Direct palpation by the surgeon ultimately confirmed that the fistula was draining into the coronary sinus. The fistula was closed and the volume of the aneurysm reduced by partial resection. The postoperative course of the patient was uneventful. Giant aneurysms occasionally displace cardiac structures. In such cases, combined imaging technologies, including TEE, may be needed for precise assessment of the giant aneurysm and fistula.     

Acute coronary angiography after coronary artery bypass grafting

Objectives Coronary angiography is the golden standard when myocardial ischemia after CABG occurs. We summarize our experience of acute coronary angiography after CABG. Design All 4446 patients (mean age 68?±?9 years, 22% women) who underwent CABG 2007 to 2012 were included in this retrospective observational study. Incidence, indications, findings, measures of acute angiography after CABG was assessed. Outcome variables were compared between patients who underwent angiography and those who did not. Results Eighty-seven patients (2%) underwent acute coronary angiography. Patients undergoing angiography had ECG changes (92%), echocardiographic alterations (48%), hemodynamic instability (28%), angina (15%), and/or arrhythmia (13%). Positive findings were detected in 69% of the cases. Only ECG changes as indication for angiography had a moderate association with positive findings, but the precision increased if other sign(s) of ischemia were present. Thirty-day mortality (7% versus 2%, p?=?0.002) was higher and long-term-cumulative survival lower (77% versus 87% at five years, p?=?0.043) in angiography patients. Conclusions Acute angiography is a rare event after CABG. Postoperative myocardial ischemia leading to acute coronary angiography is associated with increased short-term and long-term mortality.     

Tortuous right coronary artery to coronary sinus fistula

We are reporting the successful surgical treatment of a 23-year-old female with a giant right coronary artery to coronary sinus fistula. This woman had complaints of chest pain and dyspnea on exertion for few months. Transthoracic echocardiography (TTE) showed a large tortuous right coronary artery and a dilated coronary sinus. Preoperative multi-detector computed tomography (MDCT) coronary angiography and cardiac catheterization confirmed the diagnosis of a right coronary artery to coronary sinus fistula. The patient underwent surgical closure of the fistula and division of the communication between the right coronary artery and the coronary sinus with the use of cardiopulmonary bypass. The patient was discharged home on postoperative day 5 and at one-year follow-up is symptom-free.     

Off-pump coronary artery bypass grafting using graft to coronary shunt for acute coronary syndrome

We developed graft to coronary shunt during off-pump anastomosis. Proximal anastomosis of saphenous vein graft (SVG) was done formerly, and vinyl chloride tube, 5 cm long and 2 mm in diameter, was inserted into SVG. Another end was inserted into coronary artery, and continuous suture around the tube was performed before removing the tube. This technique is fit to use for the anastomosis between SVG and #3. Because the tube is easily inserted into those parts without injury of intima, and distal right coronary artery needs enough blood supply. After the revascularization of left anterior descending artery and #3, the heart can be displaced to expose circumflex artery. We adopted this technique to 3 patients with acute coronary syndrome (ACS). Though this technique is not adopted for the patients having stenosis on #4, we conclude that SVG to coronary shunt could be a important part of the strategies of off-pump coronary artery bypass grafting (OPCAB) for ACS patients.