肝切除术治疗区域性肝内胆管结石

目的 探讨肝内区域性胆管结石肝切除术的适应症、方法、效果。方法 对本科2年来14例肝内区域性胆管结石实行肝叶切除术进行系统回顾。结果 肝内胆管结石伴有肝内胆管狭窄、胆管慢性炎症、肝实质受损表现;肝叶切除后,结石清除率达100％,手术后症状很快缓解,围手术期渡过平稳,近期随访无复发。结论 对肝内区域性结石患者采用肝叶或肝段切除是一种有效、安全、彻底的治疗方法;对伴有肝内部分胆管狭窄梗阻的,有胆管炎症状的,有肝组织受损的患者应尽早实施。     

喉部分切除术81例的疗效分析

目的：探讨喉部分切除术的疗效及修复方法。方法：回顾分析1980年1999年施行喉部分切除术81例的临床资料,其中声门上型喉癌22例、声门型喉癌59例。结果：声门上型喉癌3、5年生存率分别为66．7％、63．2％,声门型喉癌3、5年生存率分别为87．2％、80．5％。拔管率声门上型喉癌为77．2％（17／22）,声门型喉癌为93．2％（55／59）。结论：喉部分切除术能保留大部分患者喉的呼吸及发声功能,是根治喉癌的有效术式。     

A Cross-Sectional Study on Novel-Risk Factors Associated with Supraspinatus Tendon Tear

Background and AimSeveral patient-related factors have been identified which are responsible for the development of rotator cuff tears. The purpose of the study was to assess various parameters which can be risk factors for the development of supraspinatus tendon tear.MethodsA total of 100 patients with symptomatic rotator cuff tear, aged > 18 years, of either gender, presenting to the outpatient department were included in this cross-sectional study. Magnetic resonance imaging was done and based on its results; patients were identified for the type of tear. Demographic, clinical, and biochemical factors affecting the tears were assessed using logistic regression analysis.ResultsFactors such as age, gender, pain radiation, night pain, and analgesic intake had significant association with supraspinatus tendon tears.Conclusion“Pain radiation” and “Analgesic intake” were two new parameters found associated with the supraspinatus tendon tears. New parameters that have been assessed as risk factors will help in better understanding of supraspinatus tendon tears.     

ALPPS与采用不同栓塞材料PVE对肝再生及手术切除率影响研究

目的 比较不同栓塞材料的门静脉栓塞术（PVE）与联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）对剩余肝体积（FLR）增长速率的影响,比较各组FLR的增长速率,二期手术切除率、术中数据和术后并发症。方法 采用单中心、前瞻性、非随机对照的对比研究。2014年11月至2019年12月,海军军医大学第三附属医院共126例因FLR不足导致无法切除的肝细胞癌（HCC）或肝内胆管癌（ICC）病人,将其分为4组：ALPPS组及分别采用氰基丙烯酸正丁酯（NBCA）、微球、明胶海绵作为栓塞材料的PVE组。主要终点为FLR增长速率和二期手术切除率。结果 各组的手术切除例数及二期手术切除率分别为：ALPPS组38例（99.4%）,NBCA组32例（76.2%）,明胶海绵组20例（60.6%）,微球组10例（83.3%）。ALPPS组、NBCA组、微球组的FLR增长速率分别为15.1 mL/d,10.0 mL/d和 8.5 mL/d,均高于明胶海绵组（3.7 mL/d）。结论 采用NBCA及微球作为栓塞材料的PVE导致FLR增长速率低于ALPPS,两种栓塞材料的PVE二期手术切除率相当。使用NBCA作为栓塞材料的PVE其FLR增长速率高于微球,且这两种栓塞材料的栓塞效果均优于明胶海绵。     

原发性肝癌切除术后门静脉血栓相关性肝坏死的临床分析

目的 探讨原发性肝癌切除术后门静脉血栓相关性肝坏死的临床表现及诊疗方法。方法 回顾性分析上海东方肝胆外科医院2018年11月至2019年10月8例原发性肝癌切除术后门静脉血栓相关性肝坏死患者的临床资料,包括患者的人口统计学特征、临床表现、手术方式、实验室检查及影像学检查结果、临床诊疗及预后等。结果 原发性肝癌切除术后门静脉血栓相关性肝坏死均发生在术后2周内,无特异性临床症状和体征,实验室检查主要表现为肝功能谷丙转氨酶、乳酸脱氢酶急剧升高,凝血功能指标异常。8例患者中增强CT显示肝脏呈广泛性坏死6例,局限性坏死2例,显示门脉血栓形成5例,肝脏坏死的发生部位与血栓形成的门静脉支血供区域并非完全相关。超声检查5例,均未能显示肝脏组织坏死改变,显示门脉血栓形成4例。8例患者中,7例予以抗凝、改善微循环、护肝等治疗,5例存活,2例死亡;1例患者病情较轻,给予低分子右旋糖酐、改善微循环等治疗后病情缓解。结论 肝功能急剧恶化为原发性肝癌切除术后早期发生门静脉血栓相关性肝坏死主要初发表现,肝脏广泛性坏死或局限性坏死、伴有或不伴有门脉血栓的增强CT表现为其影像学特征。抗凝、改善微循环治疗有一定效果。该病症确切的发病机制、有效的防治方法需要重视和进一步研究。     

术前纤维蛋白原水平对肝细胞癌微血管侵犯及预后的影响

目的 探讨术前血清纤维蛋白原（fibrinogen,FIB）水平与肝细胞癌（hepatocellular carcinoma,HCC）微血管侵犯（microvascular invasion,MVI）的关系及FIB对根治切除术后HCC预后的影响。方法回顾性分析福建医科大学孟超肝胆医院2015年1月至2019年4月行根治性肝切除手术的566例HCC患者的临床数据。通过绘制受试者工作特征曲线（receiver operating characteristic curve,ROC）分析FIB预测MVI的能力,并确定FIB预测MVI的最佳临界值;依据该临界值分为低FIB组和高FIB组,采用χ2 检验分析FIB与临床病理因素之间的关系;采用Kaplan-Meier法进行生存分析,采用Log-rank法进行差异性检验,单因素、多因素Cox回归分析法评价HCC预后的影响因素。结果 术前FIB预测MVI的最佳临界值为2.7 g/L。根据临界值分组,高FIB组（FIB＞2.7 g/L）MVI阳性率高于低FIB组（FIB≤2.7 g/L）[64.0%（183/283）vs 47.0%（133/283）,P＜0.01],高FIB组无复发生存率（recurrence-free survival,RFS）低于低FIB组（两组1、2、3年RFS分别为68.6%、47.0%、35.4%,以及71.5%、60.0%、48.3%,P＜0.05）,但两组总体生存率（overall survival,OS）差异无统计学意义（P=0.14）。单因素和多因素Cox回归分析显示FIB是HCC的RFS危险因素（HR=1.37,95%CI 1.07～1.75,P=0.011）,MVI是影响HCC者预后的独立危险因素（HR=6.65,95%CI 2.78～15.87,P＜0.001）。结论 本研究显示,术前纤维蛋白原水平与微血管侵犯呈正相关,与肝细胞癌根治性切除术后无复发生存率呈负相关。     

Visceral fat is associated with high-grade complications in patients undergoing minimally invasive partial nephrectomy for small renal masses

Introduction:Minimally invasive partial nephrectomy is standard of care treatment for small renal masses.Objective:We evaluated the relationship between subcutaneous and visceral obesity with high-grade postoperative 30-day complications in patients undergoing minimally invasive partial nephrectomy.Methods:We retrospectively identified 98 patients at our institution from 2014 to 2017 who underwent laparoscopic or robotic-assisted partial nephrectomy due to suspected renal cell carcinoma. Patients were stratified based on presence or absence of high-grade (Clavien ≥ IIIa) 30-day postoperative complications. Means were compared with the independent t test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of high-grade 30-day complications.Results:Mean nephrometry score was 6.7 with 21 (21.4%) patients having hilar tumors. Mean estimation of blood loss was 207 mL, mean operating time was 223 min, and mean warm ischemia time was 23 min. The majority of patients had clear renal cell carcinoma (n = 83, 84.7%) and pT1a disease (n = 76, 77.6%) with negative margins (n = 89, 90.8%) on pathology. There were 5 (5.1%) patients who experienced a high-grade postoperative 30-day complication. Mean visceral fat index was an independent predictor of high-grade 30-day complications (odds ratio: 1.02; 95% confidence interval: 1.002–1.03; p = 0.027).Conclusions:Visceral obesity should be considered as a prognostic indicator of outcomes in patients undergoing surgical treatment for a small renal mass.     

Functional anatomical hepatectomy guided by indocyanine green fluorescence imaging in patients with localized cholestasis: Report of four cases

BACKGROUNDLiver cancer is a malignant tumor with a high incidence. At present, the most effective treatment is laparoscopic hepatectomy (LH). Indocyanine green fluorescence imaging (ICG-FI) has become an important tool in LH, and the most common fluorescent types of tumors are total fluorescence, partial fluorescence, and rim fluorescence.CASE SUMMARYWe presented four cases of LH guided by ICG-FI in which we also observed the fourth special fluorescent type. When the tumor or intrahepatic stone compresses the adjacent bile duct to cause local cholestasis, the liver segment or subsegment with obstructed bile drainage will show strong fluorescence. Complete removal of the lesion together with the fluorescent liver parenchyma may help reduce the risk of tumor or stone recurrence.CONCLUSIONThis type of partial fluorescence can indicate local biliary compression, and the resection method is related to bile drainage, which may be called functional anatomical hepatectomy and ensures radical resection of the lesion.     

Hemodynamic and oxygen delivery-consumption changes during partial liver resection

The effects of partial liver resection on hemodynamics and the oxygen delivery-consumption relationship were evaluated in ten patients with hepatocellular carcinoma. The cardiac index and oxygen delivery were increased significantly (P 0.05) at 30 minutes after incision, 30min after liver resection and in the recovery room. Oxygen delivery decreased significantly (P 0.05) during liver resection. Oxygen consumption remained low throughout the procedure. We did not discover any flow-dependent change in oxygen consumption. Although our patients persisted a hyperdynamic state throughout surgery, their arterial ketone body ratio remained low. Therefore, it may be necessary to maintain a hyperdynamic state during partial liver resection in order to increase hepatic blood flow.(Iwasaka H, Kitano T, Mizutani A, et al.: Hemodynamic and oxygen delivery-consumption changes during partial liver resection. J Anesth 7: 145–150, 1993)     

Initial treatment of the early stages (I, II) of supraglottic squamous cell carcinoma: partial laryngectomy versus radiotherapy

The purpose of this study was to define the treatment of choice (partial laryngectomy vs radiotherapy) in the early stage of supraglottic squamous cell cancer (ESSC). One hundred and fifteen patients with ESSC were treated with either partial laryngectomy (25 patients) or with radiotherapy(90 patients) between January 1984 and December 1996. All patients had a follow-up of over ¶29 months. Radiotherapy (RT) had a local control rate of 79%, which increased to 90% with salvage surgery, and a high larynx preservation rate (83%). Partial laryngectomy (PL) offered a better initial local control rate of 84%, which increased to 88% with salvage surgery, and functional results were also good (80%). No statistically significant differences were found between RT and PL. RT was less costly, showed better suitability for treatment, produced moderate morbidity and sequelae, and local recurrence was easier to rescue. However, it is a once-only application technique. PL showed higher immediate postoperative morbidity, higher cost and lower suitability for treatment but had fewer sequelae, offered the best initial local control and is multi-applicable. No clear oncological arguments were found in our series to define whether PL or RT is the treatment of choice for ESSC. Both are effective therapies. Secondary factors such as suitability for treatment, morbidity, cost and applicability should be individually evaluated when choosing the type of treatment. As the laser endoscopic approach decreases morbidity and costs and makes the condition more suitable for treatment, it could be the treatment of choice for ESSC, in cases where local tumoral extent and larynx exposure allow radical excision.