经直肠标本取出的3D腹腔镜直肠前切除术治疗高龄直肠癌近期疗效分析

目的 分析经直肠标本取出的3D腹腔镜直肠前切除术治疗高龄直肠癌的近期疗效和安全可行性。方法 回顾性分析同济大学附属东方医院自2016年1月至2019年7月接受3D腹腔镜直肠前切除术的高龄组患者的临床资料,比较结直肠癌经自然腔道取标本手术（natural orifice specimen extraction surgery, NOSES）组和小切口手术（小切口手术组）患者手术、术后并发症及术后恢复等情况。结果 2组在肿瘤距下切缘距离、淋巴结清扫数、淋巴结阳性率、回肠造口率及术后第1天疼痛评分差异无统计学意义;但NOSES组的手术时间、术中出血量、术后肛门排气、进食、住院时间、并发症及术后第3天疼痛评分均明显优于小切口组（P＜0.05）。结论 NOSES腹腔镜直肠前切除术治疗高龄直肠癌的近期疗效与小切口组无差异,但术后恢复较快,并发症发生率低,值得临床推广。     

两步翻出直肠法在低位直肠癌NOSES中的应用7例

目的介绍7例腹腔镜低位直肠癌根治经自然腔道取标本手术(NOSES)中,采用两步翻出直肠法取出直肠标本。方法回顾分析吉林大学第一医院2017年8月至2018年3月收治的采取两步翻出直肠法完成根治切除肿瘤的低位直肠癌患者7例,记录肿瘤大小(最大直径)、手术时间、术中出血量、清扫淋巴结数目、术后排气时间等近期疗效指标。具体翻出手术操作方法:当直肠的正常肠管部分被翻出体外时,立刻停止继续翻出操作,切开直肠顶端并用取物钳从该切口伸入被翻转的肠腔把系膜拉出体外;然后就可以很容易继续翻出剩余的带有肿瘤的直肠。结果本组7例患者均从肛门顺利拖出标本,切除后完成吻合,顺利完成了低位直肠癌的自然腔道取标本手术(NOSES),肿瘤直径3.1~5.2cm,手术时间为110~153min,出血量50~110ml,清扫淋巴结数目为13~25枚,术后肛门排气时间2~4d,术后进食流质时间3d,术后均无并发症发生。结论两步翻出直肠法在低位直肠癌NOSES中能降低直肠翻出难度,增加安全性,准确判定切缘,取得良好的近期疗效。     

两步翻出直肠法在低位直肠癌经自然腔道取标本 手术中的应用(附39例报告)

目的：比较腹腔镜低位直肠癌根治经自然腔道取标本手术（NOSES）中两步翻出直肠法和传统一步翻出直肠法的围手术期及近期疗效。方法：回顾性分析63例行腹腔镜低位直肠癌NOSES患者的临床资料,其中39例患者采用两步翻出直肠法取出直肠标本（两步翻出直肠法组）,24例患者采用传统一步翻出直肠法（传统一步翻出直肠法组）,并结合文献复习观察两步翻出直肠法在低位直肠癌经自然腔道取标本手术中应用的可行性。结果：记录2组患者肿瘤最大直径、翻出成功率、肿瘤破碎率、手术时间、术中出血量、术后首次排气时间、吻合口漏发生率和短期随访结果。两步翻出直肠法组39例标本均从肛门顺利翻出,切除后完成吻合,顺利完成低位直肠癌NOSES,而传统一步翻出直肠法组24例中有3例翻出失败,2组翻出成功率比较差异有统计学意义（P=0.024）;翻出后两步翻出直肠法组患者肿瘤破碎率低于传统一步翻出直肠法组（P=0.004）,两步翻出直肠法组患者手术时间少于传统一步翻出直肠法组（t=4.266,P<0.01）。2组患者肿瘤最大直径（t=-0.406,P=0.686）、术中出血量（t=-1.247,P=0.217）、术后首次排气时间（t=-0.144,P=0.886）和术后吻合口漏发生率（P=1.000）比较差异均无统计学意义。随访3~24个月,两步翻出直肠法组和传统一步翻出直肠法组患者直肠癌复发率（P=0.140）及肿瘤转移率（P=0.360）比较差异无统计学意义。结论：两步翻出直肠法在低位直肠癌NOSES中能降低直肠翻出难度,减少手术时间,获得良好的近期疗效。     

经自然腔道取出标本的腹腔镜直肠癌根治术16例效果观察

目的探讨经自然腔道取出标本腹腔镜直肠癌根治术的可行性与疗效。方法回顾性分析16例经自然腔道取出标本腹腔镜直肠癌根治术患者的临床资料,对手术的可行性、安全性、根治性等进行评价。结果16例手术均获成功,无中转术式,无严重术中术后并发症,无手术相关死亡。手术平均时间为156（90-210）min,平均失血量147（50～350）ml,术后平均留置导尿时间10（7～15）d,平均住院日14（10-21）d。所有患者3个月后排便控便功能均良好。平均清扫淋巴结13（8-21）枚,11例低位直肠癌平均远切缘1.7（1-4）cm,无切缘阳性病例。结论经自然腔道取出标本腹腔镜直肠癌根治术安全可行,同时具有腹部创口最小化、降低直肠低位横断的难度等优点。     

术前骨盆出口横径测量用于评估腹腔镜低位直肠癌NOSES的临床价值

目的 探讨骨盆出口横径等临床病理因素对腹腔镜低位直肠癌经直肠取标本手术的影响,探索低位直肠（natural orifice specimen extraction surgery, NOSES）NOSES选择的独立预测因子。方法 本研究回顾性纳入于2017年3~8月在同济大学附属东方医院胃肠肛肠外科接受全腹腔镜低位直肠癌经直肠取标本病例（NOSES组）及同期取出困难而改行腹腔镜辅助低位直肠手术病例（小切口组）的临床病理资料,通过单因素及多因素Logistic回归分析NOSES术式选择的相关影响因素及其独立预测因子。结果 NOSES组骨盆口横径显著小于小切口组（P=0.0188）,单因素分析结果显示NOSES手术与女性患者（P=0.035）、BMI（P=0.006）、肿瘤位置（P=0.005）、肿瘤横断面最大直径（P=0.004）、隆起型肿瘤（P=0.017）、LNC（P=0.041）、T分期（P=0.011）及骨盆出口横径（P=0.020）特征显著相关,而与患者年龄（P=0.935）、术前CEA水平（P=0.304）、分化程度（P=0.853）、N分期（P=0.326）和TNM分期（P=0.169）相关性不显著。多因素分析结果显示骨盆出口横径、BMI、肿瘤距肛缘距离及肿瘤横断面最大直径是NOSES的独立相关和预测因子,其中以骨盆出口横径（OR： 0.13,95%CI： 0.03~0.52,P=0.004）的相关程度最密切。结论 本研究结果均提示低位直肠癌经直肠取标本NOSES术式是多因素相关的,而骨盆出口横径等局部因素对NOSES术式的选择的临床参考价值可能更大。     

较大直肠癌NOSES与传统腹腔镜手术的临床资料比较

目的 探讨较大直肠癌经自然腔道取标本手术(natural orifice specimen extraction surgery, NOSES)成功患者的临床特征。方法 回顾性地将11例较大直肠癌NOSES病例及64例较大直肠癌传统腹腔镜手术病例纳入研究。收集患者临床资料,包括年龄、性别、体质量指数（body mass index, BMI）、肿瘤梗阻、肿瘤距肛缘距离、腹部手术史、手术方式、肿瘤病理结果、盆腔MRI测量的最大肿瘤直径和直肠系膜厚度。2组患者临床因素的差异使用卡方检验进行分析。结果 较大直肠癌NOSES病例中,6例进行了双吻合器拖出式经直肠取标本手术(transrectal extraction of specimen-double stapling anastomosis, TRES-DSA),4例进行了单吻合器拖出式经直肠取标本手术(transrectal extraction of specimen-single stapling anastomosis, TRES-SSA),1例进行了翻出式经直肠取标本手术(transanal endorectal eversion and transection, TEET)。NOSES组与传统腹腔镜手术组的性别(P=0.657),年龄(P=0.416),腹部手术史(P=0.936),肿瘤梗阻(P=0.136),病理分期(P=0.138)和直肠系膜厚度（前后径： P=0.603;左右径P=0.352）差异无统计学意义。相对于传统腹腔镜手术组,NOSES组的BMI更低(P=0.007),肿瘤位置更低(P=0.002)。2组患者的生存(P=0.727)和复发(P=0.855)情况差异无统计学意义。结论 相对于传统腹腔镜手术患者,较大直肠癌NOSES成功患者有更低的BMI和更低的肿瘤位置。术前综合评估BMI和肿瘤位置有助于选择合适的较大直肠癌病例进行NOSES。     

经阴道NOTES在妇科手术中的临床应用进展

经自然腔道内镜手术（natural orifice transluminal endoscopic surgery,NOTES）是指不经体表切口,利用内镜通过人体自然孔道进入体内进行手术,女性具有阴道这一天然通道,绝大多数NOTES通过经阴道途径完成。经阴道NOTES可应用于卵巢及输卵管手术、子宫肌瘤剔除术、子宫切除手术、恶性肿瘤手术及盆底手术。具有体表无瘢痕、对机体干扰少、标本易取出、减轻术者疲劳、手术安全性提高等优势。但也存在子宫直肠凹陷状态判断困难,操作空间有限、学习曲线长等问题。经阴道NOTES是安全可行的,未来应用前景广阔。     

基层医院开展腹腔镜下结直肠癌NOSES术式的临床体会

目的 探讨腹腔镜下结直肠癌根治性切除经自然腔道取标本术式的临床应用价值及个人体会。方法 对26例结直肠癌患者行腹腔镜下结直肠癌根治性切除,经完全腔镜下切除标本吻合,或经肛门切除吻合,或经肛门翻出切除吻合,经自然腔道取出标本治疗进行回顾分析。结果 26例手术均成功,平均手术时间180min,平均术中出血50m L,术后平均胃肠蠕动恢复时间为20.5h,平均住院时间为10d,无明显严重并发症。结论 腹腔镜下结直肠癌NOSES术式安全可行,无腹部辅助切口,美观、损伤小、恢复快,费用与传统腹腔镜手术无差异,深受病患及家属欢迎,值得推广应用。     

经脐入路内镜手术的现状与展望

随着微创外科技术的发展,腹壁无瘢痕手术（Scarless Surgery）成为人们研究新的热点。其基本人路是经自然腔道手术（Natural Orifice Transluminal Endoscopic Surgery,NOTES）和经脐入路内镜手术（Transumbilical Endoscopic Surgery,TUES）。NOTES系通过自然腔道（胃、结直肠或阴道）的切口将软性内镜置入腹腔进行手术。从而达到腹壁无瘢痕、术后疼痛更轻、更加微创、更加美观的效果。     

经自然腔道取出标本手术联合加速康复外科理念治疗乙状结肠及直肠上段癌86例

目的:对于乙状结肠及直肠上段癌的患者实行经自然腔道取出标本手术联合加速康复外科理念治疗,分析其临床效果。方法:将86乙状结肠及直肠上段癌的患者平均分为两组实施不同的治疗,分别给予经自然腔道取出标本手术联合加速康复外科理念治疗(研究组)和经腹腔镜联合加速康复外科理念治疗(对照组),分析患者的住院时间和首次排气时间。结果:研究组患者住院时间、首次排气时间均短于对照组,组间数据对比差异明显P0.05。结论:乙状结肠及直肠上段癌对患者的生活有较大的影响,实施经自然腔道取出标本手术联合加速康复外科理念治疗显著提高了患者的护理效果,促进患者的恢复,值得临床推广。     

APPLICATION OF LORNOXICAM TO PATIENT-CONTROLLED ANALGESIA IN PATIENTS UNDERGOING ABDOMINAL SURGERIES

FOR anesthesiologis s ,treatingpostoperativepainhas alwaysbeen a problem.Althoughopioidshave been provedtobe effective,theirsideeffectscouldnotbeignored.With thedevelopmentofscienceand pharmacology,many drugs with aspectsof satisfactoryanalgesicefficacyand couldbe welltoleratedby patientshave been developed.And lornoxicamisone of them, which isa non-steroidalanti-inflammatorydrug (NSAID ), with analgesic, anti-infl-ammatory,andantipyreticproperties.Itseliminationhalf-time(3 to 5 hours) isle…     

Dr.Zhang Ren''''s Experience in the Acupuncture Treatment of Different Diseases with the Same Therapeutic Principle

Dr.Zhang Ren,the chief physician,is the chairman of Shanghai Acupuncture and Moxibustion Association.Having been engaged in medicine for about 40 years,he is experienced in treating various intractable diseases.In his long years of clinical practice,he advocates taking the TCM differentiation as the basis to seek for the acupuncture method for treatment of modern intractable diseases.The author of this essay had the fortune to follow Dr.Zhang in study.The following is a summary of Dr.Zhang's experience in the acupuncture treatment for different intractable diseases with the same therapeutic principle.     

Luo Lingjie''''s Experience in Treating Chronic Nephropathy

In treating chronic nephropathy,Luo Lingjie,a chief physician,pays attention to regulating the balance between yin and yang,treating infection if present,and removing pathogenic factors.He prescribes gentle drugs and uses carefully strongly warming-tonifying ones,emphasizes the importance of persuading the patient to persist in treatment with medication and nurse one's health for recuperation,and is good at combined use of TCM and western medicine therapy and brings the merits of various therapies into full play,with obvious theraoeutic effects.     

Acupuncture Combined with Spinal Tui Na for Treatment of Primary Dysmenorrhea in 30 Cases

Objective: To observe the therapeutic effects in acupunture treatment of primary dysmenorrhea combined with spinal Tui Na, and study its mechanism. Methods: Thirty cases of the treatment group were treated by acupuncture combined with spinal Tui Na, and thirty cases in the control group were treated by routine acupuncture. Results: The total effective rate was 93.3% in the treatment group, and 73.3% in the control group, with a significant difference between the two groups (P<0.05). Conclusions: Acupuncture combined with spinal Tui Na has good prospects for treatment of primary dysmenorrhea.     

猪肺磷脂注射液联合经鼻持续气道正压通气对呼吸衰竭早产儿的临床疗效及肌酸激酶同工酶活性的影响

目的 探讨猪肺磷脂注射液联合经鼻持续气道正压通气(NCPAP)对呼吸衰竭早产儿的临床疗效及肌酸激酶同工酶活性(CK-MB)的影响.方法 选取呼吸衰竭早产儿80例,分为观察组和对照组各40例.对照组采用NCPAP给氧治疗,观察组给予NCPAP给氧联合猪肺磷脂气管内给药.观察两组患儿治疗前及治疗12h、24 h后PaO2、PaCO2、血氧饱和度(SaO2)、pH的变化情况,检测治疗前及治疗5d后血清CK-MB水平;评估两组患儿的临床治疗效果.结果 两组患儿PaO2、PaCO2、SaO2、pH比较,差异均有统计学意义(P＜0.05),其中观察组治疗后的PaO2、SaO2、pH均高于对照组,PaCO2则低于对照组.两组的PaO2、SaO2、pH均随观察时间延长而升高(P＜0.05),PaCO2均随观察时间的延长而降低(P＜0.05).观察组治疗有效率为87.5％,显著高于对照组的70.0％ (P ＜0.05).治疗5d后两组患儿血清CK-MB水平均较前降低(P＜0.05),且观察组明显低于对照组(P＜0.05).结论 猪肺磷脂注射液气管内给药联合NCPAP可以显著降低呼吸衰竭早产儿CK-MB的含量,提高治疗有效率,起到很好的呼吸循环支持作用.     

Survey and practice of reporting quality of randomized controlled clinical trials on traditional Chinese medicine

Evidence obtained from randomized controlled trials （RCTs） has been generally accepted as the gold standard in the evaluation of clinical effectiveness. Readers need to understand the trial design, implementation, results, analysis and interpretation, so as to fully Jnderstand the results of RCTs. Thus, the investigators of RCTs have to report these items in a complete, accurate and clear manner. Since 1998, we have conducted several evaluations on the reporting quality of RCTs published in Chinese journals on traditional Chinese medicine （TCM） and results have shown that there is an urgent need for higher quality RCTs on TCM.     

TCM Treatment of Ankylosing Spondylitis by Tonifying the Kidney and Strengthening the Governor Vessel

Ankylosing spondylitis is a chronic and progressive disorder with inflammation mainly involving the central axis joints. It mainly affects the cervical spine and the lumbosacral area, with the pathogenesis closely related to the kidney and the Governor Vessel (GV). TCM holds that the syndrome is deficiency in origin and excess in superficiality, which is due to insufficiency of the kidney, deficiency of GV, and blocking of the channels with the invasion of exogenous evil, leading to poor circulation of qi and blood and malnutrition of the bones, muscles and joints. The TCM method of tonifying the kidney and strengthening GV to regulate circulation of qi and blood and check the arthralgia pain should be adopted, with the Kidney-Tonifying and GV Strengthening Decoction (益肾强督汤) prescribed.     

IMPROVING P-gp EXPRESSION IN HUMAN MONONUCLEAR CELLS IN VITRO TRANSFECTED BY MULTIDRUG RESISTANCE-1 mRNA

CHEMOTHERAPY playsa greatrolein the treat- ment of malignanttumors,especiallyingynecolo- gicalones.But inanticancerchemotherapy,leuko-cytopeniaisfrequentlytheprimarydose-limitingsideeffect factor.Moreover,cancersarefrequentlychemoresistantbe-causeof overexpressionof P-glycoprotein(P-gp), which isencodedby multidrugresistancegene (MDR1 ) and detectableinup to50% ofhuman cancersand renderscellsresistancetoanticancerdrugs.The safetyand potentialtherapeuticbenefitof mdr1 gene transferredto h…