基于一体化手术平台的LC联合术中ERCP治疗胆囊结石合并胆总管结石的效果研究

目的 探讨一体化手术平台中行腹腔镜胆囊切除术（LC）联合术中内镜逆行性胆胰管造影（ERCP）治疗胆囊结石合并胆总管结石的效果,并与序贯二步法ERCP+LC进行比较。方法 回顾性分析2019年12月至2020年12月由台州医院和恩泽医院肝胆胰外科完成治疗的82例胆囊结石合并胆总管结石患者临床资料,其中在一体化手术平台完成LC联合术中ERCP治疗的37例患者分为A组,完成序贯二步法ERCP+LC治疗的45例患者分为B组,比较两组手术时间、术中出血量、结石清除率、疼痛评分、排气时间、下床活动时间、术后并发症发生率、住院时间、住院费用等指标的差异。结果 两组术前基本资料比较无统计学差异,具有可比性（P>0.05）。两组在手术时间、术中出血量、结石清除率、术后疼痛评分、住院费用等方面无明显统计学差异（P>0.05）。A组术后排气时间[（16.0±4.5）h vs （19.9±6.0）h]、下床活动时间[（8.4±2.0）h vs （13.4±3.8）h]以及住院时间[（4.7±0.7）d vs （7.4±1.0）d]均明显短于B组（P<0.05）。两组患者在术后疼痛评分、住院费用方面无明显差异（P>0.05）。A组患者手术并发症总发生率[2.7%（1/37） vs 20.0%（9/45）]明显少于B组,差异有统计学意义（P<0.05）。结论 在一体化手术平台行LC联合术中ERCP治疗胆囊结石合并胆总管结石较序贯二步法ERCP+LC效果更好,能缩短住院时间,减少手术并发症,且不增加住院费用,是一种较好的治疗手段。     

Endoscopic internal drainage for the management of leak,fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients

BackgroundEndoscopy plays a pivotal role in the management of adverse events (AE) following bariatric surgery. Leaks, fistulae, and post-operative collection after sleeve gastrectomy (SG) may occur in up to 10% of cases.ObjectivesTo evaluate the efficacy and safety of endoscopic internal drainage (EID) for the management of leak, fistula, and collection following SG.SettingRetrospective, observational, single center study on patients referred from several bariatric surgery departments to an endoscopic referral center.MethodsEID was used as first-line treatment for the management of leaks, fistulae, and collections. Leaks and fistulae were treated with double pigtail stent (DPS) deployment in order to guarantee internal drainage and second intention cavity obliteration. Collections were treated with endoscropic ultrasound (EUS)–guided deployment of DPS or lumen apposing metal stents.ResultsA total of 617 patients (83.3% female; mean age, 43.1 yr) were enrolled in the study for leak (n = 300, 48.6%), fistula (n = 285, 46.2%), and collection (n = 32, 5.2%). Median follow-up was 19.5 months. Overall clinical success was 84.7% whereas 15.3% of cases required revisional surgery after EID failure. Clinical success according to type of AE was 89.5%, 78.5%, and 90% for leak, fistula, and collection, respectively. A total of 10 of 547 (1.8%) presented a recurrence during follow-up. A total of 28 (4.5%) AE related to the endoscopic treatment occurred. At univariate logistic regression predictors of failure were: fistula (OR 2.012), combined endoscopic approach (OR 2.319), need for emergency surgery (OR 1.755), and previous endoscopic treatment (OR 4.818).ConclusionEarly EID for the management of leak, fistula, and post-operative collection after SG seems a safe and effective first-line approach with good long-term results.     

内镜下全腹膜外Sublay修补在腹壁疝中的应用

目的评价腹壁疝内镜下全腹膜外Sublay(TES)手术的效果并总结经验。方法回顾性总结国内10所医院自2016年3月至2019年7月115例腹壁疝内镜下TES手术的患者资料。分析患者情况、疝的特点、手术经过和结果。结果115例计划实施TES的患者中,因严重腹膜破损中转为IPOM修补患者1例,其余均成功手术。可以缝合缺损患者108例(94.74%),需要永久补片固定患者15例(13.16%)。放置引流患者76例(66.67%),中位手术时间为144 min,术中无严重并发症发生。随访时间3~45个月,总并发症发生率为20例(17.54%),其中出现血清肿患者5例(4.38%)。绝大多数患者术后仅出现轻微疼痛,未出现慢性疼痛。结论在腹壁疝的治疗中,对熟悉腹壁解剖的外科医师而言,TES是一种有效、安全的修复手段。在熟悉手术的基础上适应症可逐步拓展。     

Full‐Endoscopic Foraminotomy with a Novel Large Endoscopic Trephine for Severe Degenerative Lumbar Foraminal Stenosis at L5S1 Level: An Advanced Surgical Technique

To (i) introduce the technical notes of a novel full‐endoscopic foraminotomy with a large endoscopic trephine for the treatment of severe degenerative lumbar foraminal stenosis at L₅S₁ level; (ii) assess the primary clinical outcomes of this technique; (iii) compare the effectiveness of this full‐endoscopic foraminotomy technique and other previous techniques for lumbar foraminal stenosis. From January 2019 to August 2019, a retrospective study of L₅S₁ severe degenerative lumbar foraminal stenosis was performed in our center. All patients who were diagnosed with severe foraminal stenosis at L₅S₁ level and failed conservative treatment for at least 6 weeks were identified. Patients with segmental instability or other coexisting contraindications were excluded. A total of 21 patients were enrolled in the study. All patients were treated by full‐endoscopic foraminotomy using large endoscopic trephine. The visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated preoperatively and at 1, 3, 6 months, and 1 year after the surgery, and the modified MacNab criteria were used to evaluate clinical outcomes at the last follow‐up. There were 10 males and 11 females with a mean age of 66.38 ± 9.51 years. Five patients had a history of lumbar surgery. The mean operative time was 63.57 ± 25.74 min. The mean follow‐up time was 13.29 ± 1.38 months. The mean postoperative hospital stay time was 1.29 ± 0.56 days. The mean preoperative VAS score significantly decreased from 7.38 ± 1.02 to 2.76 ± 1.09 (t = 19.759, P < 0.01), 2.25 ± 1.02 (t = 21.508, P < 0.01), 1.60 ± 1.05 (t = 31.812, P < 0.01), and 1.45 ± 1.10 (t = 25.156, P < 0.01) at 1 month, 3 months, 6 months, and 1 year after the operation. The mean preoperative ODI score significantly decreased from 64.66% ± 4.91% to 30.69% ± 4.59% (t = 33.724, P < 0.01), 29.44% ± 4.50% (t = 32.117, P < 0.01), 24.22% ± 4.14% (t = 33.951, P < 0.01), and 22.44% ± 4.94% (t = 30.241, P < 0.01) at 1 month, 3 months, 6 months, and 1 year after the operation. At the last follow‐up, 19 patients (90.48%) got excellent or good outcomes. One patient suffered postoperative dysesthesia, and the symptoms were controlled by conversion treatment. One patient took revision surgery due to the incomplete decompression. There were no other major complications. Percutaneous endoscopic decompression is minimally invasive spine surgery. However, the application of endoscopic decompression for L₅S₁ foraminal stenosis is relatively difficult due to the high iliac crest and narrow foramen. Full‐endoscopic foraminotomy with the large endoscopic trephine is an effective and safe technique for the treatment of degenerative lumbar foraminal stenosis.     

Endoscopic therapy of weight regain after bariatric surgery

Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological, anatomical and metabolic factors. Surgical revision of these patients has significant risks and limited benefits. Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective, safe, less invasive and even reproducible treatment. We herein discuss the indication, selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery. Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.     

大鼠吻侧前扣带皮层的传入投射纤维联系——荧光金逆行追踪法研究

本文采用荧光金(FG)逆行束路追踪技术研究了大鼠前扣带皮层吻侧(rostralanteriorcingulatecortex,rACC)的传入投射纤维联系。将0.2μl的3%荧光金注入到大鼠单侧rACC,7d后灌注取材,将切片贴于载玻片上,在荧光显微镜下观察FG标记神经元的分布。FG标记神经元主要位于注射区同侧的许多皮层和皮层下结构,如丘脑中线核群和板内核群、杏仁核、次级视皮层、次级听皮层、外嗅皮层和嗅周皮层等。上述结果表明rACC不但接受来自丘脑的伤害性信息传入,也接受来自视、听、嗅皮层等的环境信息的传入。本研究的结果为rACC参与痛的情绪反应提供了形态学证据。     

奇静脉逆行灌注在主动脉手术中对脊髓保护的解剖学研究

目的 :为主动脉手术中脊髓保护提供形态基础和术式设计。方法 :解剖观察了 3 1例成人标本的奇静脉系、椎静脉丛 ,以及脊髓静脉回流途径。结果 :观测奇静脉系及相关静脉 ,其直径为 ( x±s) :奇静脉为 (9.2± 1.9)mm ,半奇静脉为 (5 .5± 1.2 )mm ,副半奇静脉为 (3 .8± 0 .9)mm ,左最上肋间静脉为 (2 .0±0 .4)mm ,右最上肋间静脉为 (1.9± 0 .4)mm ,左腰升静脉为 (2 .3± 0 .5 )mm ,右腰升静脉为 (2 .2± 0 .6)mm。根据奇静脉属支的配布和肋间静脉汇入形式 ,将奇静脉系分为 4种类型。奇静脉及其属支中存在静脉瓣 ,有个体差异。脊髓静脉密集 ,与椎内静脉丛有丰富的网络连接 ,并通过神经根静脉与椎外静脉丛、奇静脉系相交通。结论 :在主动脉手术中应用奇静脉逆行灌注脊髓保护 ,是一种行之有效的新术式。     

以骨间背侧动脉为蒂逆行岛状皮瓣的应用解剖学

在60侧灌注血管染料的新鲜成人上肢标本上,观察了骨间背侧血管在前臂背侧的起点、走行和分支,发现该动脉终末支在腕上2.5cm 水平,与骨间掌侧动脉背侧支之间有恒定的吻合支相连,并以此吻合支为蒂,设计了前臂骨间背侧血管逆行岛状皮瓣。     

食管癌早癌内镜黏膜下剥离术后发生食管狭窄的危险因素分析及预测模型建立

目的 分析食管癌早癌内镜黏膜下剥离术(ESD)后发生食管狭窄的危险因素并建立相应的预测模型。方法 回顾性分析六安市人民医院消化内科于2018年6月至2021年12月收治的52例符合标准的早期食管癌患者病理和临床资料,根据患者术后是否发生食管狭窄分为狭窄组(n=15例)与非狭窄组(n=37例)。比较两组患者基线资料,分析筛选获得与术后发生食管狭窄有关的指标,再将有关指标纳入多因素logistic回归分析中得出影响术后发生食管狭窄的独立因素,并基于上述因素对应系数构建线性回归模型,采取受试者工作特征(ROC)曲线评估模型的预测价值,选择拟合优度检验评判预测值与实际值的一致性情况。结果 两组患者固有肌层损伤、病变环周范围、肿瘤浸润深度、剥离的纵径长度比较,差异有统计学意义(均P<0.05)。多因素logistic回归分析结果提示有固有肌层损伤(OR=4.310,95%CI:2.307～8.055)、病变环周范围>3/4环周(OR=12.820,95%CI:3.781～43.470)、肿瘤浸润深度进展至M3～SM1期(OR=6.482,95%CI:2.747～15.294)、长剥离...