Endoluminal loco-regional resection by TEM after R1 endoscopic removal or recurrence of rectal tumors

Purpose The aim of this study is to evaluate the safety and efficacy of endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) after R1 endoscopic resection or local recurrence of early rectal cancer after operative endoscopy. Material and methods Twenty patients with early rectal cancer were enrolled, including patients with incomplete endoscopic resection, or complete endoscopic resection of a tumor with unfavorable prognostic factors (group A, ten patients), and local recurrence after endoscopic removal (group B, ten patients). At admission, histology after endoscopic polypectomy was: TisR1(4), T1R0G3(1), T1R1(5) in group A, and TisR0(8), T1R0(2) in group B. All patients underwent ELRR by TEM with nucleotide-guided mesorectal excision (NGME). Results Mean operative time was 150?minutes. Complications occurred in two patients (10%). Definitive histology was: moderate dysplasia(4), pT0N0(3), pTisN0(5), pT1N0(6), pT2N0(2). Mean number of lymph-nodes was 3.1. Mean follow-up was 79.5 months. All patients are alive and disease-free. Conclusions ELRR by TEM after R1 endoscopic resection of early rectal cancer or for local recurrence after operative endoscopy is safe and effective. It may be considered as a diagnostic procedure, as well as a curative treatment option, instead of a more invasive TME.     

彩色多普勒超声对胆囊疾病的诊断价值

目的 :评价彩色多普勒超声对胆囊疾病的诊断价值。方法 :12 2例胆囊病变 ,其中原发性胆囊癌 5 9例 ,胆囊息肉 4 0例 ,腺瘤 7例 ,腺肌增生 2例 ,胆泥沉积 4例 ,慢性胆囊炎伴胆囊结石 10例。观察病灶内血供 ,测定 Vmax、RI,并与 4 8例健康者对照。结果 :胆囊癌内血流分布以分枝状或杂乱型为主 ,Vmax (43.3± 18.3) cm/ s明显高于其他各组 (P<0 .0 1) ;胆囊息肉和腺瘤内血流分布以点状或线状为主 ,RI为 0 .5± 0 .0 8,明显低于其他各组 (P<0 .0 1) ;胆囊腺肌增生和胆泥沉积区内无血供 ;慢性胆囊炎内 Vmax、 RI与健康对照组间无显著性差异。如以病灶内血流速度大于 30 cm/ s作为诊断胆囊癌的指标 ,其敏感性和特异性分别为 85 .2 %、 92 .9%。结论 :彩色多普勒超声对不同胆囊疾病具有鉴别诊断价值。     

Cholecystokinin cholecystography in the diagnosis of chronic acalculous cholecystitis and biliary dyskinesia

Now that the active fragment of the cholecystokinin molecule has been made available for use in clinical practice, reports on the value of cholecystokinin cholecystography must be re-evaluated to determine if the procedure is worthwhile in patients with persistent symptoms and a normal conventional oral cholecystogram. Such an analysis discloses that there is no uniform agreement on what constitutes an abnormal examination and raises serious questions concerning the scientific validity of much of the data. It is apparent that there is no immutable evidence to date to indicate that cholecystokinin cholecystography is an accurate technique to determine which patients in this category will benefit from cholecystectomy.     

影响意外胆囊癌治疗决策及疗效的因素

目的探讨影响意外胆囊癌治疗决策及疗效的因素,以提高意外胆囊癌患者的疗效与预后。方法采用F isher精确概率计算法,分析15例意外胆囊癌患者死亡与发现时TNM分期或Nevin分期及胆囊破裂的相关性,探讨意外胆囊癌患者发现时间、发现时TNM分期或Nevin分期、胆囊破裂、第一次手术及是否再手术、胆囊结石病程长短和年龄与患者生存时间的关系。结果11例意外胆囊癌术后诊断,1例尸检诊断,3例术中诊断。术后诊断的时间1周到2年不等,4例有胆囊破裂,术后7个月死于胆囊癌,11例无胆囊破裂术后存活。本组意外胆囊癌患者死亡与TNM分期或Nevin分期的相关性统计学分析,P=0.0007,与胆囊破裂的相关性的统计学分析,P=0.0003。术后较早诊断的意外胆囊癌以早期胆囊癌多,术后较晚诊断的多是晚期胆囊癌。晚期意外胆囊癌多见于胆囊结石病程较长的老年患者。结论意外胆囊癌的发现时间、TNM或Nevin分期、第一次手术方式和再手术、有无胆囊破裂、胆囊结石的病程、患者年龄是影响意外胆囊癌治疗决策和疗效的因素。     

粪便钙卫蛋白检测在结直肠癌诊断中的作用探究

目的探讨粪便钙卫蛋白检测在结直肠癌诊断中的作用。方法选取本院2012年10月至2014年10月诊治的炎症性肠病患者246例为Ⅲ组,结直肠癌患者246例为Ⅱ组,非癌息肉患者246例为Ⅰ组,健康体检人员246例为对照组,均行粪便钙卫蛋白检测。结果Ⅰ组粪便钙卫蛋白[(145.52±4.14)μg/g]高于对照组[(18.05±3.76)μg/g],差异有统计学意义(P0.05)。Ⅱ组粪便钙卫蛋白[(557.63±24.81)μg/g]高于对照组和Ⅰ组,差异有统计学意义(P0.05)。Ⅲ组粪便钙卫蛋白[(896.50±113.57)μg/g]高于对照组、Ⅰ组和Ⅱ组,差异有统计学意义(P0.05)。结肠癌患者粪便钙卫蛋白[(205.36±31.24)μg/g]高于直肠癌患者[(126.84±19.07)μg/g],差异有统计学意义(P0.05)。B期粪便钙卫蛋白[(197.58±23.16)μg/g]高于A期[(107.36±11.25)μg/g],差异有统计学意义(P0.05)。C期粪便钙卫蛋白[(143.09±18.27)μg/g]高于A期,却低于B期,差异有统计学意义(P0.05)。D期粪便钙卫蛋白[(168.25±16.38)μg/g]高于A期和C期,却低于B期。差异有统计学意义(P0.05)。结论粪便钙卫蛋白检测可为结直肠癌临床诊断提供准确的科学依据,并且操作方便、价格低廉、患者依从性高,适用于门诊筛查,值得临床推广使用。     

20例新式微创保胆取石术的应用体会

目的探讨新式微创保胆取石术的临床应用价值。方法回顾分析我院2009年12月至2011年6月采用新式微创保胆取石术治疗20例胆囊结石患者的临床资料。结果 20例均成功取尽结石,结石最大直径约3.5 cm,平均手术时间75 min,出血10～20 ml,平均住院5 d,无出血、胆漏等并发症发生。结论新式微创保胆取石术具有安全性高,操作简单,患者创伤小、痛苦轻、康复快、并发症少等优点,同时保持了胆道的完整性及胆囊功能,但术后结石复发有待更进一步的研究和长期随访。     

胆囊息肉样病变的处理

目的 讨论胆囊息肉样病变(GPL)的诊断和处理.方法 回顾性分析2002年至2011年10年间经超声检查处理的GPL病例.结果 使用腹部超声检查方法确认GPL共591例,其中349例为女性,占59.1％;年龄范围20～73岁.有395例出现腹痛等症状,39.9％是单发息肉,9.8％同存胆囊结石.使用超声检查GPL的特异性为92.5％.136例使用腹腔镜胆囊切除术,对涉及胆囊癌的病例拟施行开腹胆囊扫除术.结论 多数小的GPL为良性,可静止多年.但具有年龄＞50岁,息肉直径＞10 mm的这两条主要危险因素的患者,应预测可能为恶变的GPL.其余恶变的危险因素尚有同存胆囊结石、单发性息肉、有临床症状的息肉等.     

胆囊癌发生相关危险因素的探讨

目的 探索胆囊癌发生的相关危险因素,为防治胆囊癌提供理论依据.方法 回顾性分析2000年1月至2010年12月北京协和医院收治的153例胆囊癌患者(胆囊癌组)的临床病理资料,并抽取同期收治的300例胆囊结石患者(胆囊结石组)和300例非胆道疾病的成年患者(对照组)作为对照进行1:2病例对照研究.计数资料采用x2检验,对相关危险因素先进行单因素分析,采用x2检验,筛选出有统计学意义的可疑危险因素,再用多因素Logistic回归方程进行分析.结果 胆囊癌组与对照组患者比较,年龄、胆囊结石病史、绝经年龄、累积行经时间、生育与否及生育次数是胆囊癌的危险因素,差异有统计学意义(x2=58.22,180.14,9.59,24.30,18.66,15.17,P＜0.05);年龄、胆囊结石病史、累积行经时间及生育次数是胆囊癌的独立危险因素(x2=55.76,180.95,24.30,8.54,P＜0.05);进一步分析发现,有胆囊结石的患者罹患胆囊癌的危险性是无相关病史患者的34倍( OR =34.22).绝经年龄越晚(51～55岁)、累积行经时间越长(≥30年)、生育次数较多(3次)的女性患胆囊癌的可能性越大(OR=3.96,9.68,3.51).胆囊癌组胆囊结石患者与胆囊结石组患者比较,年龄、胆囊结石病程、累积行经时间及生育次数是胆囊癌的危险因素(x2=70.66,16.66,11.59,4.69,P＜0.05);年龄、胆囊结石病程及累积行经时间是患胆囊癌的独立危险因素(x2=64.29,8.82,5.58,P＜0.05);进一步分析发现,罹患胆囊癌危险性随着年龄升高而增大,胆囊癌发生的危险性随着结石病程延长而升高.对于女性患者,累积行经时间≥30年也会增加罹患胆囊癌的危险因素.结论 年龄、胆囊结石病史、胆囊结石病程、累积行经时间及生育次数可能是胆囊癌发病的危险因素.对于年龄≥60岁、胆囊结石病程≥3年的患者应切除胆囊,以降低胆囊癌的发病率;女性患者有以上表现者应高度重视,及时诊断和治疗.     

pT2期胆囊癌的手术治疗及预后

目的：探讨pT2期胆囊癌的治疗与预后。方法：15例pT2期胆囊癌病例入选,对比分析存活率和手术相关的4个预后因素,包括手术方式、手术中是否有胆汁溢出,手术切缘是否残留肿瘤、淋巴结是否转移。结果：全组单纯胆囊切除术8例,胆囊癌根治术7例;胆汁溢出发生3例,手术切缘肿瘤残留3例,淋巴结转移5例。多因素分析表明手术切缘是否残留肿瘤、手术方式、胆汁溢出及淋巴结是否转移是影响预后的独立因素;Log-rank检验表明生存率与手术切缘是否阴性、手术方式、胆汁溢出及淋巴结是否转移有相关性。结论：对于pT2期胆囊癌患者,如果患者无淋巴结转移,术中无胆汁溢出,手术切缘肿瘤无残留,行根治性胆囊癌手术可达到较好效果。     

Serrated polyp detection rate during screening colonoscopy

Aim The adenoma detection rate is an important quality indicator for colonoscopy, but recently, serrated polyps of the large bowel have been recognized as important premalignant lesions. As they are often more difficult to see than adenomas, the detection rate of serrated polyps is set to become a more stringent indicator of quality in colonoscopy than adenoma detection rate. Here we aim to provide preliminary data on serrated polyp detection. Method This is a retrospective review of prospectively collected data. Colonoscopies were stratified by one of six colorectal surgeons, each of whom had performed more than 1000 colonoscopies. Exams were separated by indication and the number of patients with at least one adenoma or one serrated polyp recorded. Time of withdrawal in normal examinations was noted. Results Eighteen thousand and three colonoscopies were included. Average completion rate was 96.3 ± 1.2%. Mean serrated detection rate for all examinations was 20.6 ± 4.8% and for screening examinations only was 13.9 ± 5.0%. Corresponding means for adenoma detection were 31.5 ± 6.7% and 20.7 ± 4.1%, respectively. Simple regression of overall adenoma detection rate versus overall serrated detection rate was not significant (R = 0.571, P = 0.237), but was significant for screening exams (R = 0.854, P = 0.031). There was a strong relationship between time of withdrawal and serrated detection rate (screening, R = 0.908, P = 0.012; overall, R = 0.956, P = 0.003). Conclusion Taking time to withdraw the colonoscope is essential for maximum detection of serrated polyps. The ability to find adenomas does not necessarily correlate with an ability to find serrated polyps.