门静脉高压症的外科治疗缘何令您困惑

肝硬化门静脉高压症患者，对手术治疗的常识还知之甚少。另外，由于我国门静脉高压症的治疗尚未很好地规范，应该做什么样的手术这一实质性问题，仍然让人困惑。     

肠内营养在维护门静脉高压症术后患者肠道黏膜屏障功能中的作用

目的了解肠内营养在维护门静脉高压症术后患者肠道黏膜屏障功能中的作用和地位。方法40例门静脉高压症手术患者随机进入肠内(EN)或肠外营养(PN)组,术后分别接受肠内外营养,观察两种营养方式对患者内脏蛋白合成能力、肝功能及其储备、胃肠功能、内毒素水平、肠道细菌移位和乳果糖/甘露醇比值等方面的影响。结果两种营养方式均能改善患者的营养状况。EN术后并发症少,在刺激肠道蠕动,减轻内毒素水平,防止肠道菌群移位,维护肠黏膜屏障方面优于PN,且差异显著(P<0.05)。结论EN是维护此部分患者肠道黏膜免疫屏障功能稳定的有效方式。     

An approach to timing selection of emergency operation for acute cholangitis of severe type

This article reports on a retrospective analysis on 121 patients and a prospectivestudy on 21 patients with acute cholangitis of severe type(ACST)for a study on the timing se-lection of emergency operation for ACST.Twenty two clinical,biological,etiologic,pathologicand operative variables were analyzed.Simple regression revealed 11 factors with prognosticsignificance,but multivariate analysis detected only 6 factors with independent significance inpredicting mortality(age,mean blood pressure,generalized peritonitis,serum albumin-globin ra-tio,blood culture,and the number of failed organs and systems).The results indicate that theclinical principles of treatment for ACST should be the combination of medical and surgicaltreatment.Active conservative treatment is practically applicable to the majority of ACST,espe-cially,those with short history and few complication.Prognostic mathematical model of ACSTdoes good for its timing selection of emergency operation.A critical level of 0.40 is determinedto be the discriminant score for emergency bile duct drainage.The model seems to have advan-tages over the traditional method.     

急性胆道感染时肝脏能量代谢改变及其防治的实验研究

本文以肝细胞线粒体呼吸速率(S)、呼吸控制率(RCR)、氧化磷酸化效率(ADP/O)和肝脏ATP含量为指标测定了大鼠急性梗阻性胆管炎(AOC)时线粒体呼吸功能的变化,并观察了异搏停和地塞米松对线粒体损害的防治效果。结果发现,AOC术后6h时线粒体Ⅳ态呼吸速率(S_4)即有明显增强,RCR、ADP/O和肝脏ATP含量明显降低,而异搏停和地塞米松对AOC的治疗组在术后48h内各指标均无明显变化。结果提示,AOC早期即能够引起严重的肝细胞线粒体呼吸功能损害和能量代谢障碍,异搏停和地塞米松能够有效地防治AOC所致的肝细胞线粒体呼吸功能和能量代谢障碍。     

A study of hepatic energy metabolism disturbance and its management in acute obstructive cholangitis in rats

The mitechondrial respiratory rate(S)of hepatocytes,respiratory control ratio(RCR),oxidative phosphorylation effidency(ADP/O),and hepatic ATP level were determined in ratswith acute obstructive cholangitis(AOC)to observe the changes of mitochondrial respiration,andthe therapeutic effects of verapamil and dexamethasone on the changes were assessedIt was found that S especially its state IV was significantly accelerated and RCR,ADP/O,and ATP level of the liver decreased at 6h after AOC,but in those rats treated with verapamilor dexamethasone,no significant changes of these parameters were observed in 48 h period afterAOC.These facts suggest that in the early stage of AOC,severe impairment of the mitochondrialrespiratory function and disturbance of energy metabolism could be present,but verapamil anddexamethasone could effectively prevent these damages from occurring.     

彩超引导下经皮肾微造瘘通道输尿管镜钬激光治疗肾结石效果分析

目的：探讨彩色多普勒超声引导下经皮肾微造瘘通道输尿管镜钬激光取石术治疗肾结石患者的临床疗效。方法选取2011年7月—2012年7月于我院进行彩色多普勒超声引导下经皮肾造瘘通道输尿管镜钬激光碎石取石术的60例肾结石患者,回顾性分析患者的临床资料,观察患者结石的取净效果,探讨彩色多普勒超声引导下建立穿刺通道的优势。结果60例患者在彩色多普勒超声引导下建立理想穿刺通道,一次性取净结石42例,占70%;1周后经穿刺通道或再穿刺取净结石14例,占23.33%。4例多发肾结石患者于术后结石残留3个月后行体外冲击波碎石治疗。联合两次手术总取净结石率达到93.33%。手术时间平均用时96 min,术中无患者输血,所有患者均取石成功,无患者于术中转开放手术。结论于彩色多普勒超声引导下经皮肾微造瘘通道输尿管镜钬激光取石术治疗肾结石患者,手术操作更为安全、简便,临床更易掌握。     

浅述肝癌治疗决策中的系统视角

现阶段,我国肝癌治疗相关领域专业划分越来越细,医生专业范畴和知识面越来越窄.鉴于仅从自身专业视角思考和决策肝癌治疗的倾向愈发明显,学科之间难以形成有效的协作已成为影响肝癌疗效进一步提升的重要原因,肝癌的系统观将可能为进一步提升长期停滞不前的肝癌疗效提供有益帮助.本文从医学本质、临床治疗变迁、肝脏解剖和功能特点、多中心发生规律、病理学、肿瘤免疫学和生物学七个方面阐述肝癌治疗决策中应有的系统观,旨在为拓展医生的肝癌治疗视野和优化临床思维能力提供点滴借鉴.     

自身免疫性胰腺炎误诊误治17例临床分析

Objective To summarize the reasons of mis-diagnosis and mis-treatment of autoimmune pancreatitis (AIP). Methods Clinical data of 17 patients with AIP,who were admitted to the hospital from May 2005 to July 2010 and experienced mis-diagnosis and mis-treatment, were retrospectively analyzed. Results The main clinical manifestations included epigastric pain (13 cases),progressive obstructive jaundice (12 cases), fever (6 cases) and weight loss (9 cases). Fifteen patients had extrapancreatic organ involvemnet, including allergic rhinitis, swelling of lymphoglandulae submaxillares, swelling of submaxillary gland, allergic asthma, rheumatoid arthritis, Sjogren syndrome, diabetes mellitus, primary sclerosing cholangitis and autoimmune hepatitis. Of these 17 cases, 11 cases presented with high serum globulin, 14 cases with high serum IgG, 13 cases with high serum γ-globulin, 13 cases with positive anti-nuclear antibody and 2 cases with positive anti-insulin IgG antibody. The abdominal imaging demonstrated that 15 patients had diffuse enlargement of the pancreas with diffuse or segmental narrowing of main pancreatic duct, narrowing of the intrapancreatic common bile duct, dilation of the proximal biliary duct and gallbladder enlargement. Focal enlargement of the pancreas was found in 2 cases. Thirteen cases were misdiagnosed as pancreatic carcinoma. Among them, 4 cases underwent pancreaticoduodenectomy and 7 cases underwent choledochojejunostomy. Two cases were misdiagnosed as end stage of cancer that lost therapeutic chance. Another 4 cases were misdiagnosed as chronic pancreatitis. Steroid therapy was administered in all patients with satisfactory response. All patients were followed-up for 15 months (ranged from 6 months to 45 months), and recurrence was found in 4 cases. Satisfactory response was found in patients treated with steroid for the second time. No pancreatic cancer was found in these patients in the follow up period. Conclusion The main causes of mis-diagnosis and mis-treatment of AIP may be contributed by difficulty in differentiating AIP from pancreatic carcinoma based on clinical manifestations and inadequate knowledge of AIP as well as insufficient attention to AIP in China.     

腹腔镜胆囊切除术时妥当处理胆囊动脉的原则和技巧

腹腔镜胆囊切除术(Laparoscopic cholecyctectomy,LC)是胆囊结石、急性胆囊炎等胆囊疾病最常用的治疗方式.LC成功与否,有两大关键步骤[1]:一是在准确辨认肝门部胆道结构(包括胆总管、肝总管以及变异肝管)的前提下对胆囊管和胆囊壶腹进行分离、结扎和离断;二是对胆囊动脉进行妥当处理.相比而言,肝门部胆道结构较粗,位置相对固定,容易辨认和分离;而胆囊动脉较细,变异情况更为繁多,更容易损伤,引起出血及其相关并发症.术中胆囊动脉出血是最难以处理的问题,是胆管损伤和中转开腹的最常见原因[2];术后胆囊动脉出血更是能够导致休克和死亡[3-5].     

从学术视角探析现代临床医师的内涵和素质特征

进入21世纪,人们群众的健康需求明显提高,医学模式正在发生着深刻转变,以高效率解决临床问题为着力点的转化医学理念已经建立,并且已付诸实施~([1-4]),这都将对医师的综合素质提出更高要求.