大肠癌术后早期肠梗阻的临床特点和治疗

目的：探讨大肠癌术后早期肠梗阻的诊断与治疗。方法：回顾分析在肠癌手术412例术后早期肠梗阻29例的临床资料。结果：20例经手术探查发现以机械性梗阻占多数（18/20)，手术治愈18例；死亡2例，死亡原因均为延误手术时机造成；非手术治愈9例。结论：大肠癌术后早期肠梗阻虽有梗阻症状，但由于术后诸多因素的影响，大多缺乏典型机械性肠梗阻的临床表现。处理中先进行适当时间的非手术治疗，无缓解者再手术。     

Endometrial carcinoma: Does the addition of intracavitary vault caesium to external beam therapy postoperatively result in improved control or increased morbidity?

A retrospective analysis of treatment for endometrial carcinoma is reported here. From 1987 to 1989, 138 patients were referred to the oncology department following total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. Forty-seven patients were not prescribed postoperative radiotherapy; 31 had Stage I well differentiated adenocarcinoma with minimal myometrial invasion, while the remaining 16 patients were considered unfit for postoperative radiotherapy. There were no instances of local relapse amongst the 31 patients with minimal myometrial invasion.The remaining 91 patients all received external beam irradiation to the pelvis and, according to the preference of the individual therapist, 51 were prescribed additional intracavitary vault caesium-137. Patients receiving postoperative radiotherapy were analysed according to whether or not they received additional intracavitary vault caesium. The two groups were also analysed for incidence of vaginal vault recurrence and treatment related morbidity.In the group receiving additional intracavitary treatment more patients had Stage II or III disease (P<0.05), and had greater depth of myometrial invasion (P<0.05). Vaginal vault recurrence was not observed in patients receiving intracavitary therapy in addition to external beam therapy. Four patients (10%) receiving external beam therapy alone developed vaginal vault recurrence.The incidence of Kottmeier-Perez grade 2 or 3 bowel toxicity following treatment was significantly higher in those patients receiving combined treatment (18% vs. 2.5%; P<0.03). There was also a higher incidence of vaginal stenosis in the group receiving both external beam and intracavitary therapy (21% vs. 3%; P<0.05). There was only one instance of grade 2 bladder toxicity in the external beam and intracavitary treatment group and none in the external beam therapy alone group.In conclusion, postoperative radiotherapy for Stages I-III endometrial carcinoma was carried out in a non-randomized manner by two regimens; either external beam therapy alone or external beam therapy with additional intracavitary vaginal caesium. The combined therapy gave significantly better local control but resulted in significantly more late bowel and vaginal morbidity.     

局部性尤文肉瘤综合治疗临床分析

目的　探讨局部性尤文肉瘤的综合治疗效果。方法　收集经综合治疗的 2 5例尤文肉瘤患者的临床资料 ,采用Kaplan Meier法进行分析、Logrank法检验 ,分析治疗方式和化疗周期对疗效的影响。结果　综合治疗局部性尤文肉瘤的有效率为 92 % (2 3 /2 5 )。治疗结束后病灶完全消退组患者的 1、3、5年生存率 (10 0 %、93 .8%和 81.3 % )明显高于病灶未完全消退组 (10 0 %、75 .0 %和 5 0 .0 % ) (均P <0 .0 5 )。行 6个周期化疗的患者 1、3、5年生存率 (10 0 %、93 .8%和 66.7% )高于 3个周期者 (88.9%、77.8%和 5 5 .6% ) (均P <0 .0 1)。局部采用手术或放疗对疗效无明显影响 (P >0 .0 5 )。结论　经综合治疗 ,局部性尤文肉瘤病灶完全消退者生存期明显延长 ,化疗周期的次数是影响疗效的重要因素。     

进展期霍奇金病经化疗达完全缓解后,巩固放疗的Meta分析

目的 应用Meta分析的方法评价进展期霍奇金病经化疗达完全缓解后巩固放疗的作用。材料和方法 在MEDLINE、CBMdisc数据库检索进展期霍奇金病化疗达完全缓解行巩固性放疗或不行巩固性放疗的前瞻性随机对照研究。对入选研究的总生存、无事件生存优势比进行Meta分析。结果 4项研究入选，以α=0．05为检验水准，巩固性放疗组与对照组(不作巩固性放疗)相比，5年总生存优势比=1．18，P=0．46；5年无事件生存优势比=1．05．P=0．83：巩固性侵犯野放疗组与对照组相比，5年总生存优势比=0．96，P=0．87。结论 进展期霍奇金病经化疗达到完全缓解后，巩固性放疗对总生存及无事件生存均无益处。     

放疗化疗联合治疗局部晚期非小细胞肺癌43例

目的 探讨以顺铂为主的化疗方案加放疗对局部晚期非小细胞肺癌的疗效。方法 86例局部晚期非小细胞肺癌患随机分为治疗组及对照组各43例，放疗方案以CAP、EP、MVP或MOP，每人至少化疗两个周期，化疗后10～14天放射治疗，放疗采用^60Co外照射。结果 治疗组有效率83．7％，中位生存期14．5个月，对照组有效率67．4％，中位生存期10个月，两组不良反应为骨髓抑制、胃肠道反应。结论 以顺铂为主的化疗方案加放疗治疗局部晚期非小细胞肺癌的疗效较高，可提高肿瘤的局部控制率和延长生存期。     

Endoscopic sealing of infected bronchus stump fistulae with fibrin following lung resections

Summary Bronchus stump insufficiency following lung resection, with an average incidence of 4%, is a serious complication which carries a mortality of up to 90%. Operative transthoracic approaches have been largely unsatisfactory because of the high operative risk and rapidly spreading infection. In an experimental study on 18 pigs, endoscopic occlusion of infected bronchus stump fistulae was achieved with fibrin sealant (1 ml, 500 units/ml thrombin, 3500 units/ml aprotinin) applied via a flexible bronchoscope. During autopsy, all bronchus stump fistulae were found to have healed after the second postoperative week. Transitory local abscesses of the pleura could be prevented by high-dose systemic antibiotic therapy for 5 postoperative days but not by antibiotics added to the fibrin sealant. This endoscopic method has already been performed successfully in 3 clinical cases; additional sclerotherapy with (2–3 ml Ethoxysclerol applied around the fistula orifice was carried out before fibrin sealing to stimulate fibrosis. Endoscopic controls demonstrated fistula closure by granulation tissue after 2 weeks. This procedure could become the method of choice for infected postoperative fistulae of the bronchus stump and should be attempted in any case before operative approaches are considered.     

Zum Einfluß von Operationszeitpunkt und Kliniksorganisation auf die postoperativen Komplikationen

Zusammenfassung Über ein Jahr wurden 1082 allgemeinchirurgische Planeingriffe prospektiv konsekutiv erfaßt und ihre Komplikationen mit einem Score bewertet. EinflußgröBen und die Komplikationsraten, die unter Umständen von der Kliniks-organisation abhängig sind, sollten analysiert werden. Es fand sich eine Beziehung zwischen Komplikationen und Wochentag, Operationsdauer sowie der Abweichung der tatsächlich benötigten von der geplanten Operationszeit. Mit höherer Auslastung der Operationssäle pro Arbeitstag stiegen die Komplikationsraten ebenfalls an.Keinen Einfluß auf die Komplikationsraten hatten Operationsbeginn und-monat sowie die monatliche Auslastung der Säle. Ob das Wetter einen Einfluß auf die Komplikationsraten nahm, konnte nicht entschieden werden: so fanden sich im Sommer- höhere Komplikationsraten als im Winterhalbjahr, jedoch war der Score von der Höhe der Außentemperatur und der Luftfeuchtigkeit unabhängig.

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The influence of time of operation and hospital organization on postoperative complication rates

Summary During a 1-year period 1082 general surgical interventions were prospectively documented and their complication rates evaluated by a score system. Factors responsible for the complication rates and possibly depending on hospital organization should be analysed. The complication rates were influenced by the selection of the weekday, the length of operation time and the extent of discrepancy between planned and required operation time. Furthermore, the complication rates paralleled the extent of utilization of the operation theatre during a workday. The complication rates werenot affected by the beginning of operation and the operation month as well as the monthly utilization of the operation theatres. Whether the weather did influence the complication rates could not be decided: higher complication rates were found in the summer as compared to the winter period, but the complication score was independent of the level of the outside temperature and humidity.

     

1142例胃癌切除术围手术期死亡因素分析

目的研究影响胃癌围手术期死亡的主要因素,为指导选择合理的切除范围和手术方式提供依据。方法回顾1989年1月至2004年3月胃癌手术后1142例患者的临床资料,按照不同年代分为3组,第1组:1989年1月至1994年1月,405例;第2组:1994年2月至1999年1月,377例;第3组:1999年2月至2004年3月,360例。比较3组间的围手术期死亡率,采用Logistic多因素回归分析研究影响手术死亡率的危险因素。结果全组患者术后并发症发生率和死亡率分别为11.2%(128/1142)和3.6%(41/1142)。第1、2、3组的术后并发症发生率依次为13.1%、10.1%和10.3%;3组比较,P>0.05。3组手术死亡率依次为4.7%、3.4%和2.5%,3组比较,P>0.05。术后最常见的并发症是吻合口瘘(24.2%,31/128),影响手术死亡的主要因素为临床Ⅳ期、姑息性切除术、联合脏器切除及术前合并症的存在(P<0.05)。Logistic多元回归分析显示淋巴结的清除范围和手术方式不是影响手术死亡的主要因素(P>0.05)。结论胃癌晚期患者手术死亡率高,对胃癌Ⅳ期患者行姑息性切除手术时应避免施行不必要的淋巴结清除及联合脏器切除术。     

Significance of beaten copper appearance on skull radiographs in children with isolated sagittal synostosis

Aims and Objectives The significance of beaten copper appearance (BCA) on skull radiographs in children following surgery for isolated sagittal craniosynostosis has not been studied. This study was designed to look for any correlation between BCA and symptoms suggestive of intracranial hypertension in this group of patients. Materials and Methods Forty-eight consecutive children, who were operated for isolated sagittal synostosis from1987 to 2000 and had postoperative skull radiographs, were included. Patients were divided into: (a) BCA group (n = 20), consisting of children who had beaten copper appearance on skull radiographs at last follow up, and (b) Non-BCA group (n = 28), consisting of children who did not have this finding. Records were reviewed to look for symptoms suggestive of intracranial hypertension, such as headache, head banging, and irritability. Results Median age at surgery was 4.8 months for BCA group and 4 months for the non-BCA group. Follow up ranged from 4 to 156 months with a mean of 36.2 months. Total of 28.6% (n = 6) of the children with follow up radiographs done at ≤18 months of age had BCA. The incidence of BCA increased to 83.3% in children with skull radiographs performed after 48 months of age. In 18 (90%) children, the BCA was ‘diffuse’ with 5 (25%) children having the maximum possible score of 8. In the BCA group, 45% (n = 9) had symptoms compared to 10.7% (n = 3) in the control group (p = 0.0068). Conclusions This study suggests a significant number of children with BCA on radiographs develop symptoms suggestive of raised ICP following surgical treatment in infancy and prolonged follow up may be warranted in this group of patients.     

应用MRCP对63例肝移植术后胆道并发症的临床分析

目的评价MRCP在诊断原位肝移植术后胆道并发症中的临床应用价值。方法分析63例肝移植术后怀疑有胆道并发症患者的MRCP图像,并与手术、胆道造影、临床随访证实结果进行对照。所有病例均在高场强1.5T磁共振上进行。MRCP采用两种不同的成像方法:厚层块T2加权成像和薄层块多层T2加权成像。结果MRCP诊断移植术后胆道并发症的敏感性为95.3%(41/43),阳性预测值97.6(41/42),假阴性率为4.54%(2/44),假阳性率为2.27%(1/44)。总诊断准确率为95.2%(60/63)。MRCP作为唯一的诊断方法能为96.8%(61/63)的患者提供特异性诊断结果,仅2例患者需要ERCP和PTHC检查3.2%(2/63)。直接胆道造影作为一项治疗手段应用于22.2%(14/63)的患者中。结论MRCP是评价肝移植术后胆道并发症的有效影像学方法。