鼻内镜下局部生理盐水注射治疗鼻出血

鼻利特尔区出血时选择有效、迅速、操作简便的治疗方法,对减轻患者痛苦和减少并发症十分重要。笔者对150例（176侧）鼻利特尔区出血的门诊病例采用生理盐水黏膜下注射方法治疗的效果进行观察,效果显著。现报道如下。     

Cyanoacrylate spray as treatment in difficult-to-manage gastrointestinal bleeding

Gastrointestinal bleeding can be a life-treating event that is managed with standard endoscopic therapy in the majority of cases. However, up to 5%-10% of patients may have persistent bleeding that does not respond to conventional measures. Several endoscopic treatment techniques have been proposed as strategies to control such cases, such as epinephrine injection, hemoclips or argon plasma coagulation, but there are certain clinical scenarios where it is difficult to achieve hemostasis even though adequate use of the available resources is made. Reasons for these failures can be associated with the lesion features, such as extent or location. The use of long-standing techniques in nontraditional scenarios, such as with cyanoacrylate for gastric varices sclerosis, has been reported with favorable results. Although new products such as TC-325 or Ankaferd Blood Stopper hemosprays may be useful, their formulations are not available worldwide. Here we present two clinical cases with very different scenarios of gastrointestinal bleeding, where the use of cyanoac-rylate in spray had favorable results in uncommon indications. Cyanoacrylate used as a spray is a technique that can be used as an alternative method in emergent settings.     

微生物纤维-甲硝唑促进拔牙创愈合的临床研究

目的探讨微生物纤维(Microberfiber,MB)、与甲硝唑(FLA)的止血、封闭创口、消炎及促进肉芽组织生长的作用。方法选临床正畸拔牙患者80人,将患牙拔除后右侧牙窝内放入MB-FLA做为实验组,牙窝左侧常规咬纱布止血20～30分钟做为对照组。结果实验组拔牙窝愈合程度明显优于对照组。结论MB-FLA具有明显的止血、消炎及促进成纤维细胞及成骨细胞生长的作用,有利于伤口的早期愈合,减少术后并发症的发生。MB-FLA是一种理想的创内充填物。     

Hemostasis in liver transplantation:Pathophysiology,monitoring, and treatment

Recent findings in the pathophysiology and monitoring of hemostasis in patients with end stage liver disease have major impact on coagulation management during liver transplantation. There is increasing evidence, that the changes in both coagulation factors and platelet count regularly observed in patients with liver cirrhosis cannot be interpreted as a reliable indicator of diffuse bleeding risk. Instead, a differentiated view on hemostasis has led to the concept of a rebalanced coagulation system: While it is important to recognize that procoagulant factors are reduced in liver cirrhosis, it is also evident that synthesis of anticoagulant factors and fibrinolytic proteins produced in the liver is also diminished. Similarly, the decreased platelet count may be counterbalanced by increased platelet aggregability caused by highly active von Willebrand multimeres. The coagulation system is therefor stated to be rebalanced. While under normal "unstressed" conditions diffuse bleeding is rarely observed, however both diffuse bleeding or thrombus formation may occur when compensation mechanisms are exhausted. While most patients presenting for liver transplantation have severe cirrhosis, liver function and thus production of pro- and anticoagulant factors can be preserved especially in cholestatic liver disease. During liver transplantation, profound changes in the hemostasis system can occur. Surgical bleeding can lead to diffuse bleeding as coagulation factors and platelets are already reduced. Ischemia and tissue trauma can lead to alterations of hemostasis comparable to trauma induced coagulopathy. A further common disturbance often starting with the reperfusion of the transplanted organ is hyperfibrinolysis which can eventually precipitate complete consumption of fibrinogen and an endogenous heparinization by glycocalyx shedding. Moreover, thrombotic events inliver transplantations are not uncommon and contribute to increased mortality. Besides conventional laboratory methods, bed-side monitoring of hemostasis(e.g., thrombelastography, thrombelastometry) is often used during liver transplantation to rapidly diagnose decreases in fibrinogen and platelet count as well as hyperfibrinolysis and to guide treatment with blood products, factor concentrates, and antifibrinolytics. There is also evidence which suggests when algorithms based on bed-side hemostasis monitoring are used a reduction of blood loss, blood product use, and eventual mortality are possible. Notably, the bed-side monitoring of anticoagulant pathways and the thrombotic risk is not possible at time and thus a cautious and restrictive use of blood products is recommended.     

Perclose缝合器在脑血管造影和介入治疗术后的应用

目的 评价Perclose缝合器在脑血管造影和介入治疗术后应用的安全性、有效性和临床应用价值.方法 将289例脑血管造影和介入治疗术后患者,采用随机数字表法分为两组:应用Perelose缝合止血143例(缝合组),应用手工压迫止血146例(手工压迫组).比较两组即刻止血时间、下肢制动时间、血管并发症、止血成功率和因卧床引起的不适发生率.结果 缝合组和手工压迫组止血成功率分别为96.5%(138/143)和97.9%(143/146),两组止血成功率比较差异无统计学意义(P>0.05);缝合组即刻止血时间、下肢制动时间分别为(3.13±2.17)min和(1.99±1.11)h,较手工压迫组的(15.91±3.27)min和(17.93±7.82)h明显缩短(P<0.01),小血肿、大血肿及术后不适的发生率较手工压迫组明显降低(P<0.01).结论 脑血管造影和介入治疗术后应用Perclose缝合器安全、有效,能大幅度缩短卧床时间,降低血管并发症.     

复合大孔聚多糖止血材料对肝脏钝挫伤止血的有效性研究

目的研究具有交联微孔结构的复合大孔聚多糖止血材料(MPCHM)应用于模拟临床肝脏钝挫伤的止血效果,评价其对肝功能修复作用的有效性和安全性。 方法建立动物肝脏钝挫伤模型,将24只新西兰兔按照随机数字表法分为实验组(使用MPCHM)和空白组(不使用任何止血材料),分别记录止血时间和出血量。在术后第1、4、8周采集兔的外周血进行血常规、生化分析及凝血两项检测,所得数据指标进行独立样本t检验。 结果实验组止血时间为(105.00±29.15) s,空白组止血时间为(381.00±54.86) s,差异有统计学意义(t＝－4.442,P<0.05)。实验组出血量为(0.45±0.26) g,空白组出血量为(1.26±0.51) g,差异有统计学意义(t＝－14.048,P<0.05)。实验组淋巴细胞含量于术后第1、8周显著低于空白组,差异均有统计学意义(t＝－12.595、－7.909,P值均小于0.05),丙氨酸氨基转移酶和天门冬氨酸氨基转移酶于术后第8周显著低于空白组,差异均有统计学意义(t＝－5.613、－3.656,P值均小于0.05),白细胞计数术后显著高于空白组,差异均有统计学意义(t＝5.521、6.433、2.399,P值均小于0.05),白蛋白于术后第1、8周显著高于空白组,差异均有统计学意义(t＝3.120、5.168,P值均小于0.05)。实验组术后活化部分凝血活酶时间和凝血酶原时间处于正常值范围内。 结论MPCHM具有良好的生物安全性,能促进肝功能恢复,降低机体对于肝损伤的应激反应,不会引起机体炎症反应、排斥反应及生物毒性。本课题研究为临床肝损伤止血无法完全保存肝组织这一难题的解决提供新思路。     

内镜经鼻颅底肿瘤切除术中的止血策略

目的探讨如何在内镜经鼻颅底良性肿瘤切除手术中,针对不同的出血方式采取科学的综合止血措施。方法回顾性分析了首都医科大学宣武医院耳鼻咽喉头颈外科2012年2月～2016年4月收治的161例颅底良性肿瘤患者,全部患者行内镜经鼻手术入路。将全部患者分为两组：2014年2月之前住院的病例74例,未采取新材料、新技术止血措施的为对照组。术中血管出血主要应用双极或单极电刀电凝止血,创面渗血主要采用纱条、纱布或明胶海绵压迫止血。2014年2月以后住院的患者87例,采取新型止血材料以及射频等离子刀等新技术止血措施的为实验组。实验组采取综合止血方法,如术前根据影像学资料分析肿瘤的供血血管,术中尽可能先解剖分离相关责任血管,以射频等离子刀予以切断、凝结;切除肿瘤时,以射频等离子刀切割、凝结交替进行,逐步分离肿瘤;手术创面毛细血管渗血,采取速即纱（Surgicel）压迫止血、或射频等离子刀凝结止血;海绵窦等大的静脉窦出血,采用速即纱或Surgiflu/Surgifoam填塞止血。对于术中的出血量、止血方法、手术时间,进行记录、对比分析。结果所有患者术前均行常规实验室化验检查、颅底CT及MRI检查、部分患者行头颅DSA检查。对照组患者中,术中出血量50～2 100 ml,平均410+50 ml;手术时间50～310 min,平均120+20 min。实验组患者中,术中出血量50～1 600 ml,平均280+50 ml;手术时间45～220 min,平均90+20 min。实验组与对照组两者相比较,出血量及手术时间都明显减少,差异具有统计学意义（P<0.05）。出血量与肿瘤的性质、部位、血供相关,肿瘤血供丰富、位置深在、周围解剖结构关系复杂者,出血量较大;与肿瘤的大小无关;与手术时间无关。结论熟练掌握内镜颅底外科相关区域的三维解剖,尤其是重要血管神经的走行,是手术成功的前提;科学运用止血新材料、新技术,针对不同出血方式采取相应的止血方法,以保持术野清晰,是手术成功的关键。     

“预防性缝扎法”在扁桃体切除术中的止血效果

＂预防性缝扎＂是外科手术中比较有效、可靠的止血方式。一般的扁桃体手术都是先切除扁桃体,再止血。但是扁桃体下极的出血,再合并小颌、肥胖等特殊口腔结构的患者,会给止血带来很大的困难。我们应用＂预防性缝扎法＂,并配合电刀应用,在扁桃体切除术中止血效果良好,且预防了术后出血,报道如下。1资料与方法1.1临床资料2012年2月至2015年2月,烟台市北海医院耳鼻喉科共收治慢性扁桃体炎患者60例,其中男32例,女28例;5～68岁,平均28岁;病程1～6年;分成研究组（30例）和对照组（30例）。