TRANSECTION OF METAL STENTS USING ARGON PLASMA COAGULATION

Background: Placement of self‐expandable metallic stents has become the preferred palliative treatment for patients with unresectable malignant biliary obstruction. Metallic stents provide longer patency compared with plastic stents. Distal malposition or migration of metallic stents sometimes occurs, but it is often difficult to remove them. We evaluated the efficacy and safety of argon plasma coagulation (APC), and the optimum conditions for cutting metallic stents (Wallstent). Methods: We wrapped porcine small intestines around a metallic Wallstent with and without silicon lining membrane (Permulume®), leaving the distal portion unwrapped to resemble the protrusion of the biliary metallic stent from the ampulla of Vater. APC irradiation was applied to the metallic stent at 1 cm from the edge of the wrapped small intestine at 30, 60 and 99 watts (W) for 3 or 6 s. Results: Metallic Wallstent with the silicone‐based membrane Permalume® was cut at 30 W power, whereas more than 60 W power was required to cut the bare metallic wire. The irradiation of APC (flow rate at 2.0 L/min) at 30 W to the covered metallic stent transected the metallic mesh stent not only under dry but also under wet conditions (moisturized stent). Irradiation of APC caused no gross damage to the small intestines irrespective of the power applied and duration of irradiation. Conclusions: Our results suggest that APC is efficacious and safe for endoscopic sectioning of wire mesh stents at low power (30 W) without gross damage to the surrounding pancreaticobiliary tissues.     

Enteral Stents for Malignancy: A Report of 46 Consecutive Cases over 10 years,with Critical Review of Complications

Background  Current management of malignant gastric outlet obstruction (GOO) includes surgical diversion or enteral stent placement for unresectable cancer. We analyzed the long-term results, predictive factors of outcomes, and complications associated with enteral stents with focus on their management. Methods  Between 1997 and 2007, 46 patients with malignant GOO underwent placement of self-expandable metal stents (SEMS) for palliation. Patients were captured prospectively after 2001 and followed until complication or death. Patency, management of complications, and long-term survival were analyzed. Results  Forty-six patients had a mean survival of 152 ± 235 days and a mean SEMS patency rate of 111 ± 220 days. SEMS patency rates of 98%, 74%, and 57% at 1, 3, and 6 months were seen. Thirteen patients presented with obstruction and included two SEMS migration, two early occlusion, one fracture, four malignant ingrowth, and four with delayed clinical failure. Interventions included seven endoscopic revisions with three SEMS replacements. Six had percutaneous endoscopic gastrostomy with jejunal arm placed. Two patients eventually underwent surgical bypass. Two patients required surgery for complications including delayed duodenal perforation and aortoenteric fistula. Conclusions  SEMS effectively palliate gastric outlet obstructions that result from upper gastrointestinal malignancies. Their benefits offset potential complications or malfunctions, when a pluridisciplinary approach is adopted. Presented at Digestive Disease Week/SSAT, May 2008, San Diego, California.     

结肠镜联合腹腔镜治疗左半结肠癌梗阻的临床研究

目的 评价结肠镜辅助下术前经肛门置管减压,以及在腹腔镜下左半结肠癌一期切除、吻合的疗效,探讨左半结肠癌伴肠梗阻的治疗选择.方法 2004年12月至2007年8月治疗11例左半结肠癌伴肠梗阻:(1)在结肠镜辅助和x线指引下经肛门将肠梗阻导管置入梗阻部位的近端肠管进行减压,观察患者症状缓解情况、肠鸣音、腹围、腹腔内压力、腹平片等的变化,评价肠梗阻的治疗效果;(2)肠梗阻缓解后,经常规术前准备后行择期腹腔镜左半结肠癌一期切除、吻合.结果 (1)置管减压5～14 d后,11例患者的肠梗阻症状均有缓解,避免了急诊手术;(2)11例患者均接受腹腔镜下一期切除、吻合手术;(3)11例患者均未出现吻合口漏、切口感染、腹腔内感染等手术并发症;(4)平均随访15.2个月:局部复发率为9%(1/11),切口或穿刺孔种植率为0(0/11),无瘤生存率为91%(10/11).结论 结肠镜辅助术前减压,联合腹腔镜一期切除吻合治疗左半结肠癌肠梗阻安全有效,此法可能成为治疗左半结肠癌的最合理的治疗策略.     

咽喉镜直视下气管插管术抢救上呼吸道急性梗阻的方法及护理体会

目的　推荐采用咽喉镜直视下气管插管术 ,以及时有效地清除上呼吸道阻塞物 ,提高抢救成功率 ,减少并发症。方法　在咽喉镜直视下用长镊子或粗吸管清除呕吐物、血块或痰液 ,然后行气管插管术。结果　本文 34例中解除呼吸道梗阻 32例 ,占 94 % ;而传统的经鼻或口腔抽吸术有效率为 58% ,两者经 χ2 检验 ,差异性非常显著 ( χ2 =8.91,P <0 .0 0 5)。结论　该方法具有方便、快捷、准确、安全的优点 ,避免了传统方法的诸多弊端 ,但对部位较深的下呼吸道梗阻疗效较差     

中医辨证分期治疗视网膜静脉阻塞86例

目的:观察应用中医辨证分期治疗视网膜静脉阻塞的临床疗效.方法:对86例视网膜静脉阻塞患者初期应用生蒲黄汤加减、中期应用通窍活血汤加减、后期应用驻景丸加减治疗.结果:显效32例,有效40例,无效14例.结论:中医辨证分期治疗可以有效的治疗视网膜静脉阻塞.     

Vascular alterations in the canine kidney following obstruction of the urinary tract

Summary Changes in the vasculature of the canine kidney following four weeks obstruction of the ureter via double ligature is described on the basis of SEM investigation. Three significant alterations were observed: 1) A two-thirds reduction in the depth of the renal cortex as compared to controls. 2) Rarification of the entire cortical capillary bed. 3) Reduction in both the number and diameter of the glomeruli. The rarification of the post-glomerular capillaries is interpreted to be a pressure atrophy, whereas the reduction in the number of renal glomeruli and the concommitant diminuation of their capillary loops is thought to represent a functional atrophy.     

Long-term Efficacy of Percutaneous Transhepatic Choledochoscopic Y AG Laser Therapy for Malignant Biliary Obstruction

Abstract: The long-term effect of percutaneous transhepatic choledochoscopic YAG laser therapy for malignant biliary tract obstruction was evaluated. Ten consecutive patients underwent laser therapy to alleviate the obstruction. All patients were followed up for 8 months or more (range: 8–33 month, average: 15). Cholangiography was performed when re-elevation of the alkaline phosphatase level was observed during the regular checkup. Choledochoscopy was performed when any sign of recurrence was observed on cholangiography. Sufficient re-opening of the bile duct was obtained in every case, without complications. Indwelling of the internal drainage tube was perfomed in 5 patients, the remaining 5 having “tube free” internal drainage. Five patients showed no rise in alkaline phosphatase levels during their 8- to-13 month follow-up period. Re-elevation of the alkaline phosphatase level was observed 9 times in 5 patients, mostly from internal drainage tube occlusion. The cholangiogram performed on each occasion revealed a patent bile duct without any sign of recurrence (6/9), slight narrowing (2/9) or tumorous obstruction (1/9). Cholangitis was complicated 6 times in 3 patients, mostly from internal drainage tube occlusion. Choledochoscopy was performed in the 3 patients suspected of tumor recurrence on cholangiogram. In 2 of them, no signs of recurrence were noted endoscopically or histologically, but the tumor was revealed to have recurred only at the part previously treated, in the remaining. Thus, choledochoscopic I'AG laser therapy can locally control the malignant biliary tract obstruction for a long period of time. “tube free” internal drainage may serve as a means to prevent cholangitis, which is one of the complications frequently occurring with conventional stent therapy.     

经胃管注入泛影葡胺治疗术后早期炎性肠梗阻

目的　探讨 76 %泛影葡胺在术后早期炎性肠梗阻治疗中的作用。方法　对 2 3例术后早期炎性肠梗阻患者经胃管分 3次间歇注入 76 %泛影葡胺 ,每次 6 0ml。结果　 16例患者在首次注入泛影葡胺后 4 8h开始有肠梗阻缓解征象 ,4～ 7d内痊愈 ,占 6 9.5 %。 7例患者 3次注入泛影葡胺后无效 ,继续保守治疗 ,13～ 19d内痊愈 ,占 30 .5 %。结论　经胃管注入高渗透压的 76 %泛影葡胺治疗术后早期炎性肠梗阻是一种简便、安全、有效的治疗措施 ,值得进一步探讨     

降纤酶治疗视网膜动脉阻塞的临床研究

目的观察降纤酶治疗视网膜动脉阻塞的疗效及血液流变学变化。方法视网膜动脉阻塞患者49例，分为2组：治疗组25例，应用降纤酶治疗；对照组24例，应用低分子右旋糖酐治疗；其它治疗方法相同。2组治疗前后均分别检查视力及眼底变化以判断疗效，同时检查血液流变学变化。结果治疗组显效率为72．0％，总有效率为88．0％，对照组显效率为20．8％，总有效率为58．3％，2组相比有显著差异（P〈0．01，P〈0．05）。治疗组治疗后纤维蛋白原、血浆黏度、全血黏度下降明显，与治疗前及对照组相比差异显著（P〈0．01，P〈0．05）。结论降纤酶能改善血液流变，降低纤维蛋白原，改善血液循环，治疗视网膜动脉阻塞的疗效显著。