手术联合腹腔热化疗及免疫疗法治疗腹膜恶性间皮瘤11例

目的:探讨减瘤手术联合术后腹腔热灌注化疗或免疫治疗等综合治疗方法对腹膜恶性间皮瘤的治疗效果.方法:腹膜恶性间皮瘤17例分为3组:联合治疗组(减瘤手术 术后腹腔热化疗或联合DC免疫治疗,n=11),单独全身化疗组(n=4)和未治疗组(n=2).回顾性分析其临床资料及治疗经过,所有患者全部随访,观察生存期.结果:17例均经组织病理学确诊,其中小细胞型2例,上皮型5例,弥漫浸润型4例,未明确分型6例.随访时间5-67(平均35)mo,中位生存期32.5 mo,其中联合治疗生存期约35.5 mo,单独全身化疗生存期约11.3 mo,未治疗者生存期约4.5 mo.联合治疗组患者生存期较其他两组延长.结论:腹水细胞学检查、剖腹探查及腹腔镜活检为腹膜恶性间皮瘤的主要诊断方法.采用减瘤手术治疗联合术后腹腔热灌注化疗或免疫治疗等综合治疗,可以提高患者生存期.     

Determination of peritoneal glucose kinetics in rats: implications for the peritoneal implantation of closed-loop insulin delivery systems

Summary Peritoneal glucose kinetics were evaluated in the anaesthetized rat, to assess whether the peritoneal cavity would be a suitable site for the implantation of membrane-protected islets of Langerhans (bioartificial pancreas) or the glucose sensor of an artificial B cell. Glucose was measured in peritoneal fluid samples aspirated by needle puncture. Basal peritoneal and blood glucose concentrations were identical in 16 h fasted (n=4) and non fasted (n=3) animals. After 10 min of an i.v. glucose infusion (n=15) the increment in peritoneal glucose concentration was 63±3% of the increment in blood glucose concentration and both values were significantly correlated (r=0.92; p<0.001). After 10 min of glucose clamping (12.6±0.8 mmol/l), the increment in peritoneal glucose concentration was 69±3% (n=5; p<0.05) of the increment in blood glucose concentration. In three additional experiments it was 93±3% of the increment in blood glucose concentration (NS), after 30 min of glucose clamping (8.0±0.5 mmol/l). Peritoneal glucose concentration monitored by a glucose sensor: (a) followed blood glucose sluggishly during a glucose clamp (n=5), confirming the data shown above, (b) followed blood glucose with a 5 min delay and reached the same plateau after the intravenous injection of 1U insulin (n=3; NS). We conclude that peritoneal glucose reflects blood glucose at basal state and during variations of glycaemia, nevertheless, presenting heterogeneous kinetics. These kinetics might be appropriate for a bioartificial pancreas but not for an in vivo calibration procedure, of a peritoneally implanted glucose sensor.     

糖尿病与非糖尿病病人腹膜透析初始时的临床状况比较分析

目的　对比分析糖尿病与非糖尿病终末期肾病 (ESRD)病人在腹膜透析 (CAPD)初始时的临床状况 ,初步探讨糖尿病ESRD病人适当的透析时机。方法　入选了 6 7例接受CAPD治疗的年龄 5 0岁以上ESRD患者 ,其中糖尿病组 2 7例 ,非糖尿病组 4 0例。分别对患者的残肾功能、营养状况、合并症情况、活动能力进行评估。结果　与非糖尿病组相比 ,糖尿病组CAPD病人开始透析时的血肌酐质量浓度、血浆白蛋白及握力检测明显低于非糖尿病组 ,而肌酐清除率及营养不良发生率均明显高于非糖尿病组 ;糖尿病组的合并症指数评估明显高于非糖尿病组 ,活动能力明显低于非糖尿病组。统计学检验差异均具有显著性。结论　糖尿病病人透析时机选择应根据病人的残肾功能、临床症状、合并症情况和营养状态综合考虑 ,应及时开始CAPD治疗。     

继发性甲状旁腺功能亢进症术后低钙血症相关因素分析

目的 探讨继发性甲状旁腺功能亢进症（SHPT）患者术后发生低钙血症的相关因素。方法 回顾性分析62例接受了双侧甲状旁腺全切除术+前臂甲状旁腺自体移植术的SHPT患者的临床资料,包括性别、年龄、透析类型、透析时间、体质量、术前术后生化指标等。采用多因素Logistic回归分析模型分析术后发生低钙血症的独立危险因素。结果 所有患者术中切除甲状旁腺后15 min 甲状旁腺激素（PTH）水平均下降80%以上,术后24 h PTH水平降至20 ~ 30 pg/ml;血钙水平于术后24 h明显下降,48 h降至低值。多因素Logistic回归分析结果显示透析方式（OR = 0.173,P = 0.038）、术前PTH水平（OR = 1.003,P < 0.001）、术前肌酐水平（OR = 1.004,P = 0.001）是术后低钙血症的独立影响因素。结论 腹透透析方式、术前PTH水平偏高、术前肌酐水平偏低是甲状旁腺全切除术+前臂甲状旁腺自体移植术后出现低钙血症的独立危险因素。     

清醒镇静麻醉用于腹膜透析置管术的有效性及安全性的临床研究

目的探讨清醒镇静(conscious sedation,CS)麻醉在腹膜透析(peritoneal dialysis,PD)置管术中的有效性和安全性。方法选取2017年1月~2020年5月在北京大学国际医院使用手术切开法行腹膜透析置管术的患者,根据麻醉方式不同分成2组:传统组(A组):术前30min肌肉注射盐酸哌替啶和盐酸异丙嗪,联合局部浸润麻醉。改良组(B组):手术开始时静脉使用芬太尼(B1)、舒芬太尼(B2)或瑞芬太尼(B3)联合局部浸润麻醉。比较两组患者的临床基线资料,手术过程中血压、心率,术中、术后疼痛以及不良反应。结果共94例患者纳入本研究,其中A组53例,B组41例。2组的人口学资料及相关的化验检查无差异,美国麻醉协会(american society of anesthesiologists,ASA)麻醉风险分级评估为IV级的高危风险患者比例分别占58.5%和68.3%(P=0.330)。B组患者术中疼痛比例明显低于A组患者(17%比39.6%,P=0.018);术后疼痛比例、静息疼痛评分及活动时疼痛评分无显著差异。A组有5例(9.4%)不良反应,其中3例出现了胃肠道反应,1例发生了低血压和1例出现意识障碍,B组有2例(4.8%)的患者出现不良反应均是胃肠道反应,但2组总不良反应发生率无显著差异(P=0.395)。进一步分析,在B1、B2和B3组患者使用不同的药物镇痛效果及不良反应无差异(P>0.05)。结论行腹膜透析置管术的患者存在麻醉高风险,采用清醒镇静麻醉能达到更好的镇痛效果,且安全性好,体现了舒适化医疗的理念。     

弥漫型恶性腹膜间皮瘤的MDCT征象分析及其鉴别诊断

目的 探讨多排螺旋CT(MDCT)对弥漫型恶性腹膜间皮瘤(MPM)诊断,以及与结核性腹膜炎、腹膜转移癌鉴别诊断的价值.方法 回顾性分析10例经病理证实的弥漫型MPM(组1)、14例结核性腹膜炎(组2)及17例腹膜转移癌(组3)的MDCT资料,对照分析3组病例的发病年龄,病变分布,腹膜、大网膜、肠系膜改变的形态学特点,腹部淋巴结、脏器转移及腹腔积液等MDCT表现. 结果 弥漫型MPM组与结核性腹膜炎组在腹膜、大网膜、肠系膜的形态学改变上差异有统计学意义(P＜0.05);弥漫型MPM组与腹膜转移癌在腹部淋巴结、脏器转移上的差异有统计学意义(P＜0.05).结论 弥漫型MPM MDCT表现为腹膜、大网膜、肠系膜不规则增厚并明显强化,可呈结节状或团块状;结合其形态学特点,有无脏器转移、淋巴结肿大和临床资料等可与结核性腹膜炎及腹膜转移癌鉴别.     

Limitations of peritoneal lavage with antiseptics in prevention of recurrent colorectal cancer caused by tumor-cell seeding

PURPOSE: Exfoliated or soiled free malignant cells have serious consequences in patients undergoing gastrointestinal cancer surgery. The present study evaluates the toxicity and efficacy of cytotoxic agents in the prevention of cell seeding and tumor growth in the peritoneal cavity in an experimental model. METHODS: Mtln3 adenocarcinoma cell viability was testedin vitro using the trypan blue exclusion test after incubation with povidone-iodine or chlorhexidine.In vivo, Fischer rats were inoculated with 10⁵ or 10⁶ cells followed by peritoneal lavage with physiological saline, chlorhexidine 0.02 percent, providone-iodine low molecular weight 1 percent or povidone-iodine high molecular weight 1 and 2 percent in different quantities and incubation times. RESULTS: Chlorhexidine 0.02 percent and povidone-iodine low molecular weight 1 percent or high molecular weight 2 percent, killed over 98 percent of 10⁵ or 10⁶ tumor cellsin vitro. Povidone-iodine low molecular weight 1 percent and high molecular weight 2 percent were toxic and lethal when 5 ml were applied in the peritoneal cavity three times for five minutes. Chlorhexidine 0.02 percent applied after inoculation of 10⁵ or 10⁶ cells, reduced the tumor development only to 70 and 80 percent. Application of 5 ml povidone-iodine 1 percent low molecular weightor high molecular weight, three times for one and five minutes, after inoculation of 10⁶ cells did not change the tumor take. However, inhibition of Mtln3 cells to form metastases was observed. When povidone-iodine low molecular weight 1 percent was used three times for one minute after 10⁵ tumor cells were soiled, no toxicity was observed and the tumor take was reduced to 30 percent (P<0.05). CONCLUSIONS: Povidone-iodine toxicity proved to be a major issuein vivo. However, povidone-iodine low molecular weight 1 percent was safe when used for short periods and very effective when a limited number of tumor cells was inoculated. The use of cytotoxic agents to prevent recurrent disease caused by tumor cell seeding in patients seems to make sense only when the inoculum size of exfoliated or soiled cancer cells is limited.     

Combined suicide and cytokine gene therapy for peritoneal carcinomatosis

BACKGROUND: Gene therapy is a novel approach for the treatment of cancers, and tumours disseminated in the peritoneal cavity are suitable for in situ delivery of a therapeutic gene. AIMS: The efficacy of a therapy combining a suicide gene (herpes simplex virus type I thymidine kinase (HSV-TK)) and cytokine genes was investigated in a model of peritoneal carcinomatosis induced by colon carcinoma cells in syngeneic rats. MATERIAL AND METHODS: Pre-established macroscopic tumours in BDIX rats were treated by intraperitoneal injections of retrovirus producing cells (FLYA13 TK, FLYA13 granulocyte macrophage-colony stimulating factor (GM-CSF), FLYA13 interleukin 12 (IL-12)) and ganciclovir (GCV). RESULTS: TK/GCV treated animals showed a slight increase in survival time (72 days) compared with the control group (63 days) while the association of cytokine and TK/GCV gene therapy resulted in significantly improved survival, with a large proportion of animals remaining tumour free on day 480 (60% and 40% for TK/GCV/GM-CSF and TK/GCV/IL-12 treated animals, respectively). Histological analysis of treated animals showed that the remaining tumour nodes were infiltrated by mononuclear cells but no major differences were observed between the various treatments. Immunohistochemical analysis revealed that lymphoid CD4(+) and CD8(+) T cells as well as macrophages accumulated outside untreated tumour nodes while CD8(+) and CD25(+) activated T cells and macrophages heavily infiltrated the tumours after the different treatments. CONCLUSIONS: Our data indicate that combined suicide and cytokine gene therapy is a powerful approach for the treatment of macroscopic peritoneal carcinomatosis.     

Chronic Kidney Disease-Mineral Bone Disorder in the Elderly Peritoneal Dialysis Patient

♦ Purpose:

The purpose of this paper was to review the literature concerning the treatment of chronic kidney disease-mineral bone disorder (CKD-MBD) in the elderly peritoneal dialysis (PD) patient.

♦ Results:

Chronic kidney disease-mineral bone disorder is a major problem in the elderly PD patient, with its associated increased fracture risk, vascular calcification, and accelerated mortality fracture risk. Peritoneal dialysis, however, bears a lower risk than hemodialysis (HD). The approach to CKD-MBD prophylaxis and treatment in the elderly PD patient is similar to other CKD patients, with some important differences. Avoidance of hypercalcemia, hyperphosphatemia, and hyperparathyroidism is important, as in other CKD groups, and is generally easier to attain. Calcium-free phosphate binders are recommended for normocalcemic and hypercalcemic patients. Normalization of vitamin D levels to > 75 nmol/L (> 30 pg/L) and low-dose active vitamin D therapy is recommended for all patients. Hyperparathryoidism is to be avoided by using active vitamin D and cinacalcet. Particular attention should be paid to treating protein malnutrition. Fracture prophylaxis (exercise, use of walkers, dwelling modifications) are important. Hypomagnesemia is common in PD and can be treated with magnesium supplements. Vitamin K deficiency is also common and has been identified as a cause of vascular calcification. Accordingly, warfarin treatment for this age group is problematic.

♦ Conclusion:

While treatment principles are similar to other dialysis patient groups, physicians should be aware of the special problems of the elderly group.