腹腔镜高选择性迷走神经切断术联合Nissen胃底折叠术:效果如何?——腹腔镜Nissen迷走神经切断术治疗胃食管返流

背景：Nissen胃底折叠术（Nissen fundoplication，NF）已不是治疗胃食管返流性疾病（gastroesophageal reflux disease，GERD）的唯一、有效的方法。对于能降低胃酸的手术方式来讲，如高选择性迷走神经切断术（highly selective vagotomy，HSV），也不仅仅是一种辅助治疗方法。对高选择性迷走神经切断术联合Nissen胃底折叠术（Nissen fundoplication with highly selective vagotomy，NFHSV）治疗GERD的作用目前尚无完整的评价。方法：2003年6月～2005年6月8例女性病人接受NFHSV，8例均有6个月GERD病史，经药物治疗症状无缓解，有餐前痛、消化性溃疡或严重的胃炎。平均随访时间12个月，术前、术后进行烧心严重程度评分测定（heart burn severity score，HSS）。结果：平均手术时间110min，无手术并发症。1例术后须用质子泵抑制剂，术后经戒烟5个月后停药。8例术后症状和烧心严重程度评分测定有明显改善。结论：NFHSV是有效的联合手术方式，尚需要进一步的研究证实这一联合术式的完全有效性和安全性。     

Predicting Stricture in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Logistic Regression Analysis

Gastrojejunostomy stricture after Roux-en-Y gastric bypass occurs in 3 to 27% of morbidly obese patients in the USA. We questioned whether preoperative patient characteristics, including demographic attributes and comorbid disease, might be significant factors in the etiology of stricture. In this study from November 2001 to February 2006 (51 months), at a high-volume bariatric center, of the 1,351 patients who underwent laparoscopic gastric bypass, 92 developed stricture (6.8%). All but two were treated successfully by endoscopic dilation. All patients stopped nonsteroidal anti-inflammatory medications 2 weeks prior to surgery and did not restart them. The operative procedure included the use of a 21-mm transoral circular stapler to create the gastrojejunostomy; the Roux limb was brought retrogastric, retrocolic. In an effort to reduce our center’s stricture rate, late in the study, U-clips used at the gastrojejunostomy were replaced by absorbable sutures, and postoperative H₂ antagonists were added to the treatment protocol. The change to absorbable polyglactin suture proved to be significant, resulting in a lower stricture rate. The addition of H₂ antagonists showed no significant effect. Following the retrospective review of the prospective database, univariate and multivariate logistic regression analyses identified factors associated with the development of stricture. Gastroesophageal reflux disease and age were each shown to be statistically significant independent predictors of stricture following laparoscopic gastric bypass. Presented at the 2006 Annual Meeting of the Society for Surgery of the Alimentary Tract, May 20–24, Los Angeles, CA (poster presentation).     

电针胃经经穴促进大鼠胃黏膜修复过程中相关蛋白磷酸化的研究

目的:探讨电针促胃黏膜修复过程中对相关蛋白磷酸化的影响。方法:20只SD大鼠分为空白组、模型组、针刺非穴组和针刺穴位组,每组5只。使用无水乙醇灌胃法制作大鼠胃黏膜损伤模型。针刺非穴组取"足三里""梁门""四白"穴旁的对照点,针刺穴位组取"足三里""梁门""四白"穴,每次电针30 min,每日1次,共治疗7 d。对大鼠的胃黏膜细胞分别进行磷酸化抗体蛋白芯片检测,同时筛选720种磷酸化蛋白的表达差异,并进行比较。结果:模型组胃黏膜损伤指数与空白组比较显著升高(P<0.01);针刺穴位组胃黏膜损伤指数低于模型组和针刺非穴组(P<0.01),而与空白组比较差异无统计学意义(P>0.05)。蛋白芯片分析示:针刺穴位组与针刺非穴组均可上调模型大鼠的蛋白磷酸化的水平(≥1.5倍),但针刺穴位组上调的蛋白大多数参与了细胞的增殖,而针刺非穴组只有几种蛋白参与细胞增殖;同时针刺穴位组与针刺非穴组还可下调蛋白磷酸化水平(≥1.5倍),且针刺组下调的蛋白参与抑制细胞凋亡,而针刺非穴组下调的蛋白基本不参与细胞活动。结论:电针足阳明胃经穴可引起大鼠胃黏膜损伤后修复信号蛋白的磷酸化水平发生变化,提示电针促进胃黏膜修复的机制与胃黏膜损伤后修复信号蛋白的磷酸化有关。     

下肢静脉性溃疡的外科微创治疗

目的探讨下肢静脉性溃疡外科微创治疗的效果。方法对31例(33侧患肢)下肢静脉性溃疡通过静脉造影检查明确引起溃疡的原发病变,根据患肢血流动力学异常的种类和程度对10例(11侧患肢)行高位大隐静脉结扎联合静脉腔内激光治疗术;17例(18侧患肢)行高位大隐静脉结扎联合静脉腔内激光治疗、内镜深筋膜下交通静脉离断术;4例(4侧患肢)行高位大隐静脉结扎联合静脉腔内激光治疗、内镜深筋膜下交通静脉离断和股浅静脉瓣膜包窄术。溃疡一律行周缘环行缝扎。结果术后33侧患肢浅静脉曲张均消失,色素沉着、湿疹样病变均明显减轻;24侧小腿酸胀沉重感、疼痛、水肿12~16d消失;溃疡18~40d内愈合。随访1~36个月,平均14.8月,3侧(9.1%)肢体溃疡复发。结论纠正浅静脉、交通支静脉、深静脉功能不全和重视溃疡创面的处理是治疗下肢静脉性溃疡的有效疗法,静脉腔内激光治疗、内镜深筋膜下交通静脉离断术操作简便、微创、安全,联合股浅静脉瓣膜包窄术可以有效地减少下肢静脉性溃疡的复发。     

二羧乙基锗倍半氧化物的抗大鼠实验性胃溃疡作用及其作用机理研究

二羧乙基锗倍半氧物(Dicarboxyethyl GermaniumSesquioxide,DEG)是人工合成的有机锗化合物。它能对抗Shay幽门结扎性溃疡的形成,使胃液中PGE_2含量增加,胃蛋白酶活性和游离酸度明显降低。DEG还能对抗消炎痛型,五肽胃泌素型和酒精型溃疡的形成,促进醋酸型溃疡的愈合,但对应激型和利血平型溃疡无对抗作用。DEG的主细胞分泌功能比对照组明显减弱。实验结果表明,DEG的抗溃疡作用可能与增加胃内PGE_2含量、抑制胃液分泌和促进蛋白质合成有关。     

Travel distance, age, and sex as factors in follow-up visit compliance in the post-gastric bypass population

BACKGROUND: There is no consensus regarding the optimal rate of follow-up in the post-bariatric surgery patient population. METHODS: The records of all patients who underwent laparoscopic Roux-en-Y gastric bypass from 2001 to 2003 were reviewed. Using patient zip codes, travel distances were calculated between the patients' places of residence and our clinic. Patients were then assigned to 1 of 3 cohorts according to the following distances: (1) < 50 miles, (2) 50 to 100 miles, and (3) > 100 miles. Patient compliance with follow-up appointments at 3 weeks, 3 months, 6 months, 9 months, and 12 months was analyzed. Linear trends were identified using the Mantel-Haenszel test. Age and sex were analyzed as possible predictors of compliance using the chi(2) test. P values < .05 were considered statistically significant. RESULTS: The study group comprised 150 patients (127 females and 23 males). The 3 cohorts contained 115, 21, and 14 patients, respectively. All patients in each cohort were compliant with the 3-week follow-up appointment. Although there were differences in compliance between cohorts at each of the remaining appointments, only the 9-month (70.3% vs 61.9% vs 35.7%) visit showed statistical significance (P = .035). The 6-month visit trended toward significance (85.2% vs 76.2% vs 64.3%; P = .088). Males were more likely to be compliant with the 12-month follow-up (P = .040). When controlling for sex, travel distance was also a predictor of compliance at this follow-up visit (P = .024). Age was not predictive of compliance (P = .827). CONCLUSION: Based on our findings, we conclude that travel distance from the clinic does not significantly affect compliance at the initial follow-up, 3-month, and 12-month appointments. However, distance does tend to affect compliance at the 6-month appointment and significantly affects compliance at the 9-month appointment. Males are more likely to be compliant at the 12 month follow-up visit. We must continue to strive for 100% follow-up in our post-bariatric surgery patients.     

Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass

The authors present the case of a 43-year-old women who underwent a laparoscopic gastric bypass in 2003 for morbid obesity. They report that 2 years later, she had maintained significant weight loss, but had developed acute abdominal pain, followed by nausea and emesis. In the emergency room, she had diffuse tenderness, tachycardia, and leukocytosis. After initial resuscitation, a computed tomography was performed, which showed free air above the liver and thickened small bowel loops. She was brought emergently to the operating room for laparoscopy. At surgery, turbid fluid and inflamed small bowel loops were seen. A perforated marginal ulcer was discovered in the Roux limb, approximately 2 cm distal to the gastrojejunal anastomosis. The perforation was oversewn primarily and patched with omentum. The repair was tested by intraoperative endoscopy. A gastrostomy tube also was placed within the gastric remnant for enteral access. The patient did extremely well postoperatively, and had an uneventful postoperative course. She was discharged on postoperative day 4. The gastrostomy tube was removed at 1 month, and at this writing, she remains well since surgery. An upper endoscopy at 2 months was completely normal, and the Helicobacter pylori test results were negative. The gastric pouch had not significantly enlarged since initial surgery, as indicated by both endoscopy and barium study. Marginal ulcer is reported to be 0.6% to 16% after laparoscopic gastric bypass [1]. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H. pylori infection, nonsteroidal antiinflammatory use, and smoking [2]. Unfortunately, none of these applied to the reported patient. Because her exact etiology remains unknown, she at this writing continues to receive proton pump inhibitor therapy. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

贲门癌近端胃切除术后残胃排空障碍的诊断和治疗

目的探讨贲门癌术后胃瘫的临床诊治方法。方法对我院2001年1月～2006年12月收治的贲门癌术后胃瘫18例的临床资料进行回顾性分析。结果本组经胃肠减压,营养支持,维持水、电解质代谢平衡及促进胃肠动力药物等治疗后均得以缓解。结论贲门癌术后胃瘫的诊断主要依据临床表现;胃镜检查有其重要价值;排除机械性梗阻后应积极采取非手术治疗,不应盲目再次手术。     

肝硬化门脉高压性胃粘膜损害52例临床分析

本文对５２例肝硬化门脉高压性胃粘膜损害患者临床分析表明，肝功能损害与胃粘膜病变有显著相关性，而与胃底食道静脉曲张没有显著相关性。同一组病人中ＰＨＧ与ＧＥＶ的发生率虽有差异，但认为这种差异的临床意义不大。结合文献对ＰＨＧ的发生机理和诊断治疗进行了讨论     

Quality of ulcer healing influences the relapse of gastric ulcers in humans

The usefulness of dye-contrast endoscopy for the evaluation of the quality of gastric ulcer healing and the prediction of relapse was investigated. Sixty consenting patients whose ulcers healed during 3 months of treatment underwent endoscopy for the identification of the pattern of mucosal regeneration. Patients were monitored for relapses for up to 18 months after antiulcer therapy had ended. The pattern of regeneration was flat in 24 patients, nodular in 25 and intermediate in 11. Internal hypoechoic areas seen by endoscopic ultrasonography were less common and histological maturity was better in the patient group with the flat pattern compared with the patient group with the nodular pattern of mucosal regeneration. Prostaglandin E, synthesis was highest in the group with the flat pattern of mucosal regeneration and the relapse rate was lowest in this group. We conclude that the evaluation of the quality of ulcer healing is possible and that findings in individuals may aid the prediction of relapse for particular patients.