张立平教授治疗消化道术后胃肠功能紊乱经验

消化道术后胃肠功能紊乱影响着患者们的生活质量。张立平教授认为术后胃肠功能紊乱，证属本虚标实，临床治疗当从调理中焦-脾胃肝为切入点，强调"脾胃为本""中焦一体"的治疗思路，总结出脾胃虚弱、肝郁脾虚两个证型，临证时以培土达木为基本治疗原则，辨证论治，临床疗效显著。     

Time-Driven Activity-Based Cost Comparison of Three Imaging Pathways for Suspected Midgut Volvulus in Children

ObjectiveTo use time-driven activity-based costing to compare the costs of pathways for evaluating suspected pediatric midgut volvulus using either fluoroscopic upper gastrointestinal examination (UGI) or focused abdominal ultrasound (US).MethodsProcess maps were created through patient shadowing, medical record review, and frontline staff interviews. Using time-driven activity-based costing methodology, practical capacity cost rates were calculated for personnel, equipment, and facility costs. Supply costs were included at institutional purchase prices. The cost of each process substep was determined by multiplying step-specific capacity costs by the median time required for each step, and substep costs were summed to generate total pathway cost. Multivariate sensitivity analyses were performed applying minimum and maximum labor costs. Assuming UGI would be used to troubleshoot nondiagnostic US, a break-even analysis was performed to determine the cost impact of varying frequencies of UGI on the total cost of the US-based pathway.ResultsProcess maps were created from 105 (48 girls, 57 boys) patient encounters. Base case pathway times were 90 min (UGI) and 55 min (US). Base case cost for UGI was $282.74 (range: $170.86-$800.82) when performed by a radiology practitioner assistant and $545.66 (range: $260.97-$1,974.06) when performed by a radiologist. Base case cost for US was $155.67 (range: $122.94-$432.29) when performed by a sonographer and $242.64 (range: $147.46-$1,330.05) when performed by a radiologist. For a US-based pathway, the total cost break-even pathway mix (percent UGI required for troubleshooting) was 57%.ConclusionUS can be a faster and less costly alternative to UGI in pediatric patients with suspected midgut volvulus.     

野生型胃肠道间质瘤的研究进展

胃肠道间质瘤(GIST)是最常见的消化道间叶组织来源肿瘤,约10%的GIST患者分子检测无KIT/PDGFRA基因突变,称为野生型GIST。根据是否有琥珀酸脱氢酶B(SDHB)表达缺失,野生型GIST可分为SDH缺陷型和非SDH缺陷型,SDH缺陷型包括无综合征相关性、Carney三联征相关性及Carney-stratakis综合征相关性GIST;非SDH缺陷型包括BRAF突变、Ⅰ型神经纤维瘤病相关性、K/N-RAS突变及四重野生型GIST等。野生型GIST的发生发展、临床病理特征和治疗原则均与KIT或PDGFRA突变的GIST有较大差异。本文就野生型GIST的分子机制和临床诊疗进展做一综述。     

胃肠道间质瘤诊断方法的研究进展

胃肠道间质瘤（gastrointestinal stromal tumor，GIST）是起源于胃肠道间叶组织的肿瘤，由于GIST存在恶性潜能，且多数GIST患者无明显临床症状，所以GIST的早期发现、诊断和治疗显得尤为重要。GIST通常在内窥镜、超声内镜（endoscopic ultrasound，EUS）检查中发现。GIST的诊断取决于形态学和免疫组织化学染色，因此组织样本的充足性是其关键。近年来，新的成像技术的应用和分子生物学的发展提高了GIST的诊断准确率，并为GIST的预后及辅助治疗提供了依据。     

Cefoperazone-sulbactam and risk of coagulation disorders or bleeding: a retrospective cohort study

ABSTRACT

Objectives: Limited evidence has suggested that cefoperazone-sulbactam causes coagulation disorders and bleeding.

Methods: The authors conducted a retrospective study to compare patients receiving cefoperazone-sulbactam versus those treated with cefoperazone-tazobactam or ceftazidime. Propensity-score matching was used to explore whether treatment with cefoperazone-sulbactam increased the risk of prothrombin time (PT) prolongation, coagulation disorders, and bleeding, or decreased platelets (PLT).

Results: The cohort included 23,242 patients. Among patients receiving cefoperazone-sulbactam, the risk of PT prolongation, coagulation disorders, decreased PLT, and bleeding was 5.3%, 9.2%, 15.7%, and 4.2%, respectively. Propensity-score matching analyses suggested that cefoperazone-sulbactam increased the risk of PT prolongation (aOR 2.26, 95% CI 1.61–3.18), coagulation disorders (aOR 1.81, 95% CI 1.43–2.30), and decreased PLT (aOR 1.46, 95% CI 1.25–1.72), but not increase bleeding (aOR 1.05, 95% CI 0.79–1.40) compared with ceftazidime. Patients receiving cefoperazone-sulbactam had higher risk of PT prolongation (aOR 1.53, 95% CI 1.11–2.10), coagulation disorders (aOR 1.53, 95% CI 1.21–1.95), but not decreased PLT (aOR 0.93, 95% CI 0.81–1.07) or bleeding (aOR 1.11, 95% CI 0.87–1.42), compared with those receiving cefoperazone-tazobactam.

Conclusion: Cefoperazone-sulbactam may be associated with a higher risk of PT prolongation and coagulation disorders compared with cefoperazone-tazobactam and ceftazidime.     

扬州地区肝硬化食管静脉曲张初次出血80例患者诊治分析

目的探讨扬州地区肝硬化食管静脉曲张初次出血患者诊治特点。方法回顾性分析2010年1月-2013年12月苏北人民医院消化内科收治的80例肝硬化食管静脉曲张初次出血患者病例资料。计数资料用率或构成比表示,率的比较采用χ2检验。结果由乙型肝炎导致肝硬化所引起的食管静脉曲张破裂出血所占比例最大;三腔二囊管临床运用可最大限度地挽救患者生命,为后期治疗提供时间;基础治疗包括止血、输血、抑酸、补液等,后期以硬化剂、套扎、硬化剂+套扎、手术、经颈静脉肝内门体分流术(TIPS)为主,但套扎运用最为广泛;患者出血初期各项指标变化有利于指导临床治疗,对患者预后具有良好的评估作用。结论扬州地区肝硬化引起的食管静脉曲张破裂出血病因呈现复杂交叉性,治疗方法仍需进一步完善,以达到个体化治疗水平;及时正确的救治,对提高临床疗效、降低病死率有重要意义;早期的健康体检,对疾病诊治起关键性的作用。     

When should patients begin ambulating following lower limb split skin graft surgery? A systematic review

Pretibial lacerations and lower limb wounds are referred to plastic surgery teams for split skin graft surgery. Traditionally, these patients have been immobilised on bedrest following surgery. More recently, patients have commenced ambulation earlier to avoid medical complications and facilitate discharge. The objective of this literature review was to determine when such patients should begin walking. A literature search was undertaken using the electronic databases AMED, Cinahl, Embase, Medline (via Ovid), PEDro and Pubmed. Clinical trials using human subjects, written in English, were included. Seventeen (of 1137) papers met the inclusion criteria and were reviewed. The literature suggested that patients should begin walking immediately or at the earliest possible opportunity after lower limb skin graft surgery. Although the literature advocated early ambulation, the evidence base presented with a number of recurrent methodological limitations, including small sample sizes, lack of a control sample, and limited follow-up. Accordingly, further research employing large, well-designed, randomised controlled trials is recommended. It will then be possible to understand with greater certainty when patients should begin walking after lower extremity split skin graft surgery.     

LONG‐TERM FOLLOW UP OF PATIENTS WITH SMALL GASTROINTESTINAL STROMAL TUMORS IN THE STOMACH USING ENDOSCOPIC ULTRASONOGRAPHY‐GUIDED FINE‐NEEDLE ASPIRATION BIOPSY

Background: Gastrointestinal stromal tumors (GIST) are one of the most common mesenchymal tumors of the gastrointestinal tract. GIST are defined by positive immunohistochemical staining for KIT or CD34 and thus are generally diagnosed after surgery. Because small GIST are rarely diagnosed before surgery, the clinical course of these small tumors is not clear. The aim of the present study was to follow changes in size and configuration of small GIST that were pathologically confirmed using endoscopic ultrasonography‐guided fine‐needle aspiration biopsy (EUS‐FNAB). Methods: Between July 1997 and December 2003, 16 tumors in 16 patients (10 men and 6 women) with an immunohistochemical diagnosis of GIST were regularly followed in our hospital. The median patient age when EUS‐FNAB was performed was 62 years (range 26–82 years) and the median follow‐up period was 4.9 years (range 0.5–9.6 years). Results: Fourteen tumors showed no remarkable changes in size and shape during follow up compared with the initial diagnosis. Two tumors enlarged: one tumor approximately doubled its diameter in 8 years and the other tumor increased from 1.8 cm at diagnosis to up to 10 cm after only 2 years. Doubling time of the latter tumor was calculated as 3.1 months. Conclusions: We conclude that EUS‐FNAB might be a good modality for final diagnosis of GIST without surgery, and that GIST without rapid growth on follow up can be endoscopically followed.     

Prospect of Endoscopic Mucosal Resection for Early Gastric Cancer: Our Devices in Insulated‐Tip Electrosurgical Knife Method

In Kobe University Hospital, a new method for endoscopic mucosal resection (EMR) using insulated‐tip electrosurgical knife (IT‐EMR) for early gastric cancer (EGC) was introduced from November 2001. To achieve an effective and safe IT‐EMR procedure, we use a high‐frequency surgical unit for cutting and coagulation (ERBOTOM ICC 200) with automatically controlled cutting mode (ENDOCUT). In this study, we show not only our results of IT‐EMR for EGC in comparison with those of the conventional strip biopsy method, but also the optimal conditions for the apparatus of a high‐frequency surgical unit to prevent complications such as bleeding and perforation.