失代偿期肝硬化患者的社区管理建议

本文结合2018年欧洲肝脏研究学会发布的《失代偿期肝硬化患者的管理临床实践指南》中关于失代偿期肝硬化相关并发症的诊疗，引发对失代偿期肝硬化患者诊疗环节中社区管理的讨论，以期全科医生在诊疗和预防工作中做出合理决策，提高该类患者的预后、生活质量等。     

复方半枝莲汤治疗失代偿期乙型肝炎肝硬化的临床效果及患者血清T细胞亚群分析

目的:探讨复方半枝莲汤治疗失代偿期乙型肝炎肝硬化的临床效果。方法:选取2016年1月-2018年1月于通辽市传染病医院进行治疗的失代偿期乙型肝炎肝硬化患者60例,按照随机方式分为两组,对照组为恩替卡韦^+保肝对症的常规治疗;研究组在对照组治疗方式的基础上联合使用复方半枝莲汤,研究对比两组患者临床疗效以及血清T细胞亚群等指标的差异。结果:治疗后研究组和对照组治疗有效率分别为96.7%(29/30)和76.7%(23/30)研究组,临床疗效显著优于对照组(P<0.05);治疗前两组患者乙肝病毒的脱氧核糖核酸(Hepatitis B virus Deoxyribonucleic Acid,HBV-DNA)及肝功能指标无显著变化(P>0.05),研究组治疗后各指标下降程度显著优于对照组(P<0.05);治疗前两组患者CD8^+、CD4^+、CD4^+/CD8^+指标无明显差异(P>0.05),治疗后CD4^+提升,CD8^+下降,CD4^+/CD8^+指标上升,CD8^+、CD4^+、CD4^+/CD8^+指标较对照组更加显著(P<0.05);治疗后研究组和对照组不良反应的发生率分别为6.7%(2/30)和33.3%(10/30),研究组不良反应发生率显著低于对照组(P<0.05)。结论:常规治疗同时联合复方半枝莲汤治疗失代偿期乙型肝炎肝硬化效果显著,可有效改善患者肝功能,抑制HBVDNA的复制,提高免疫功能,且具有良好的治疗安全性。     

Bariatric surgery before,during, and after liver transplantation: a systematic review and meta-analysis

Morbid obesity is considered a relative contraindication for liver transplantation (LTX) because of increased risk of complications. The aim of this study was to investigate the role of bariatric surgery before, during, and after LTX. A systematic review of MEDLINE, EMBASE, CENTRAL, and PubMed databases was performed for studies investigating bariatric surgery in patients before, during, or after LTX. Random-effects meta-analysis of proportions was used to calculate pooled effect estimates. One hundred eighty-seven patients underwent bariatric surgery before LTX (8 studies). After surgery, 82% (95% confidence interval, 62%–97%) of patients were successfully listed for LTX and 70% (95% confidence interval, 40%–93%) successfully received LTX. The 30-day mortality rate was 0%. The graft survival rate after 1 year was 70% (95% confidence interval, 30%–99%). Thirty-day minor and major complications rate was 4% and 1%, respectively. Thirty-two patients underwent bariatric surgery during LTX (2 studies). The 30-day mortality rate after surgery was 0% and 1-year graft survival was 100%. Sixty-four patients underwent bariatric surgery after LTX (9 studies). The 30-day mortality was 0%, but 5 deaths occurred beyond 30 days (7.8%). Bariatric surgery may be safe and feasible as a bridge to LTX for patients who would otherwise be ineligible and post-LTX patients for weight loss.     

腹腔镜肝切除治疗58例肝内胆管细胞癌的临床探讨

目的探讨腹腔镜肝切除治疗肝内胆管细胞癌(ICC)的安全性及可行性。方法采用回顾性研究方法。收集2016年1月—2018年12月湖南师范大学附属第一医院行腹腔镜肝切除治疗的58例ICC患者的临床资料。其中男性34例,女性24例;年龄34~71岁,中位年龄54岁。观察指标:(1)手术治疗情况:手术方式、手术时间、术中出血量、术中输血率、术中肝门阻断时间、中转率、术后并发症、术后住院时间、术后胃肠道恢复时间、围手术期有无死亡病例及非计划手术病例。(2)术后病理情况。(3)随访。采用门诊和电话方式进行随访,了解患者术后生存情况。随访时间截至2019年6月。正态分布的计量资料以均数±标准差(Mean±SD)表示,计数资料用频数和百分比(%)表示。结果本研究共纳入58例患者,其中48例患者在腹腔镜下完成ICC根治性外科切除手术,10例患者行腹腔镜中转开腹。(1)手术治疗情况:手术方式有腹腔镜下左半肝(Ⅱ、Ⅲ、Ⅳ段)切除,腹腔镜下右半肝(Ⅴ、Ⅵ、Ⅶ、Ⅷ段)切除,腹腔镜下右肝后叶(Ⅵ、Ⅶ段)切除,腹腔镜下扩大右后叶切除,腹腔镜下肝中叶(Ⅳ、Ⅴ、Ⅷ段)切除,腹腔镜下Ⅴ、Ⅵ段切除,腹腔镜下左半肝(Ⅱ、Ⅲ、Ⅳ段)联合肝尾叶(Ⅰ、Ⅸ段)切除,腹腔镜扩大左半肝切除,腹腔镜下Ⅵ段切除,腹腔镜下Ⅶ、Ⅷ段切除,腹腔镜左肝外叶(Ⅱ、Ⅲ段)切除,腹腔镜右肝肿块切除;手术时间(320.38±107.68)min;术中出血量(262.34±76.06)mL;术中输血率为0(0/58);术中肝门阻断时间(48±15)min;其中10例腹腔镜中转开腹手术,中转率17.2%(10/58);术后胆瘘发生率为6.9%(4/58),保守治疗、通畅引流(T管负压吸引)后痊愈出院;无其他严重并发症发生。术后住院时间(9.34±3.39)d;术后胃肠道恢复时间(1.84±0.57)d;围手术期内无死亡病例及非计划手术病例。(2)病理情况:术中32例行淋巴结清扫,术后26例病理结果提示胆管细胞癌未行淋巴结清扫;病理学检查结果显示,所有肿瘤切缘的病理报告均为阴性,4例淋巴结清扫并提示淋巴结转移阳性。(3)随访结果:58例ICC患者中,49例获得术后随访,随访时间为6~36个月,术后肿瘤生存时间为4~36个月,28例获得无瘤生存,17例患者出现肝内转移并多发淋巴结转移,4例患者发现肝内转移后行微波消融治疗,9例患者失访。结论腹腔镜肝切除经验丰富的中心,应用腹腔镜治疗肝内胆管细胞癌是安全及可行的。     

Novel strategy in the treatment of liver metastases – Hepatic resection combined with stereotactic body radiotherapy

BackgroundTo evaluate the safety, feasibility and outcomes of patients treated for colorectal liver metastases (CLM) with an innovative combined approach – hepatic resection and Stereotactic body radiotherapy (SBRT) using CyberKnife® system.MethodsThis was a retrospective cohort study conducted in a single institution. Patients with CLM and no evidence of extrahepatic disease were included during a 6-year study period.ResultsIn total, 19 patients with 63 liver lesions underwent liver resection combined with SBRT of unresectable lesions. Major hepatectomy was performed in 42.1% patients; postoperative complications were noted in 31.6% patients. 27 unresectable lesions were treated by SBRT with a total dose of 50–60 Gy in five fractions.The median follow-up of study patients was 29.7 ± 20.58 months. Local control of CLM at 1 and 2 years was achieved in 89.5% of patients. Out-of-field hepatic recurrence was diagnosed in 63.1% patients. The 1-year disease-free survival (DFS) was 52.6%; 2-year DFS was 31.6%. The overall actuarial survival rates at 1 and 2 years were 88.2% and 50.4%.ConclusionLiver resection combined with SBRT presents a promising therapeutic option for patients with CLM which traditionally are unresectable. The additional use of SBRT allows for the effective clearance of the disease for thoroughly selected patients.     

Carcinogenicity and chronic toxicity of hydrazine monohydrate in rats and mice by two-year drinking water treatment

The carcinogenicity and chronic toxicity of hydrazine monohydrate was examined by administrating hydrazine monohydrate in drinking water to groups of 50 F344/DuCrj rats and 50 Crj:BDF₁ mice of both sexes for two years. The drinking water concentration of hydrazine monohydrate was 0, 20, 40 or 80 ppm (wt/wt) for male and female rats and male mice; and 0, 40, 80 or 160 ppm for female mice. Survival rates of each group of males and females rats and mice were similar to the respective controls, except female rats administered 80 ppm. Two-year administration of hydrazine monohydrate produced an increase in the incidences of hepatocellular adenomas and carcinomas in rats of both sexes along with hepatic foci. In mice, the incidences of hepatocellular adenomas and carcinomas were increased in females, and significantly increased incidences of hepatocellular adenomas in females administered 160 ppm were observed. Thus, hydrazine monohydrate is carcinogenic in two species, rats and mice. Additionally, non-neoplastic renal lesions in rats and mice and non-neoplastic nasal lesions in mice were observed.