氧合指数及弥散指数对新型冠状病毒肺炎合并急性呼吸窘迫综合征的机械通气患者预后的评估研究

背景　《新型冠状病毒肺炎诊疗方案（试行第七版）》指出若重症、危重症患者的治疗中使用高流量鼻导管氧疗或无创通气后短时间（ 1~2 h） 内病情无改善甚至恶化,应当及时进行气管插管和有创机械通气,但其并未给出客观参考指标,而通常使用的氧合指数在该类患者临床应用中存在不足,故而探寻更有参考价值的预后评估指标显得尤为重要。目的　分析新型冠状病毒肺炎（COVID-19）患者出现急性呼吸窘迫综合征（ARDS）进行机械通气治疗时氧合指数和弥散指数对患者预后评估的差异。方法　选取2020-01-25至03-14在武汉科技大学天佑医院ICU收治的行机械通气的COVID-19并发ARDS患者39例,其中2例因24 h内死亡脱失,以患者28 d的预后结果分为生存组（n=11）和死亡组（n=26）,记录呼吸机参数设置与对应的血气数值,分析氧合指数、弥散指数与患者28 d预后的相关性。结果　生存组最差氧合指数、入ICU时弥散指数、最差弥散指数高于死亡组（P<0.05）。入ICU时氧合指数预测死亡的灵敏度为100.0%,特异度为46.2%,ROC曲线下面积（AUC）为0.654,AUC与参考值比较,差异无统计学意义（P=0.144）;最差氧合指数预测死亡的灵敏度为3.8%,特异度为100.0%,AUC为0.862,AUC与参考值比较,差异有统计学意义（P<0.05）;入ICU时弥散指数预测死亡的灵敏度为7.7%,特异度为100.0%,AUC为0.734,AUC与参考值比较,差异有统计学意义（P<0.05）;最差弥散指数预测死亡的灵敏度为100.0%,特异度为80.8%,AUC为0.902,AUC与参考值比较,差异有统计学意义（P<0.05）。结论　对于COVID-19患者发生ARDS时,弥散指数是比氧合指数灵敏度高且可信度高的预后评估指标。     

Resección anterior ultrabaja con anastomosis mecánica en el tratamiento del cáncer de recto del tercio inferior

Tumors of the lower third of the rectum are a challenge for the surgeon. Among the various techniques of surgical treatment of these lesions, radical surgery and ultra low anterior anastomosis is one of the therapeutic options. This technique is a defy both in the evaluation of the potential patient as in the surgical technique. Such evaluation and treatment processes must be audited in order to keep proper quality indices both in the oncological as in their functional results. This is only possible when both the multidisciplinary and surgical teams have an adequate and ongoing specialized training and a satisfactory volume of patients treated. Details of this technique, its indications and results are reported in this paper.     

rt-PA 动脉溶栓联合机械取栓治疗急性脑栓塞的临床疗效研究

目的：观察 rt-PA 动脉溶栓联合机械取栓治疗急性脑栓塞的临床疗效。方法回顾性分析 rt-PA 动脉溶栓联合机械取栓治疗的10例急性脑栓塞病例,采用 NIHSS 评分评估患者治疗前及治疗24 h 后的神经功能缺损程度,3月后采用改良 Rankin 量表（mRS）评估患者预后。结果治疗24 h 后患者 NIHSS 评分显著低于治疗前（P 〈0.01）,3月后 mRS 0~2分为90%。结论rt-PA 动脉溶栓联合机械取栓是治疗急性脑栓塞的一种有效方法。     

Standardized lung recruitment during high frequency and conventional ventilation: similar pathophysiologic and inflammatory responses in an animal model of respiratory distress syndrome

Objective To evaluate standardized lung recruitment strategy during both high frequency oscillation (HFO) and volume-targeted conventional ventilation (CV+V) in spontaneously breathing piglets with surfactant washout on pathophysiologic and inflammatory responses.Design Prospective animal study.Setting Research laboratory.Subjects Twenty-four newborn piglets.Interventions We compared pressure support and synchronized intermittent mandatory ventilation, both with targeted tidal volumes, (PSV+V, SIMV+V) to HFO. Animals underwent saline lavage to produce lung injury, received artificial surfactant and were randomized to one of the three treatment groups (each n=8). After injury and surfactant replacement, lung volumes were recruited in all groups using a standard protocol. Ventilation continued for 6 h.Measurements and main results Arterial and central venous pressures, heart rates, blood pressure and arterial blood gases were continuously monitored. At baseline, post lung injury and 6 h we collected serum and bronchoalveolar lavage samples for proinflammatory cytokines: IL 6, IL 8 and TNF-, and performed static pressure-volume (P/V) curves. Lungs were fixed for morphometrics and histopathologic analysis. No physiologic differences were found. Analysis of P/V curves showed higher opening pressures after lung injury in the HFO group compared to the SIMV+V group (p<0.05); no differences persisted after treatment. We saw no differences in change in proinflammatory cytokine levels. Histopathology and morphometrics were similar. Mean airway pressure (P_aw) was highest in the HFO group compared to SIMV+V (p<0.002).Conclusions Using a standardized lung recruitment strategy in spontaneously breathing animals, CV+V produced equivalent pathophysiologic outcomes without an increase in proinflammatory cytokines when compared to HFO.This study was supported in part by a grant from the Research and Education Fund of Childrens Hospitals and Clinics–St. Paul, Minnesota. Dräger Babylog supplied by Dräger Critical Care Systems, Survanta provided by Ross laboratories.     

全腹腔镜及腹腔镜辅助远端胃癌毕Ⅰ式胃肠道重建的对比研究

目的:探讨全腹腔镜毕Ⅰ式胃肠道重建(三角吻合)的可行性、安全性及临床疗效。方法:回顾分析2013年6月至2014年1月施行的41例腹腔镜远端胃癌根治术的临床资料,其中23例行全腹腔镜毕Ⅰ式胃肠道重建术(三角吻合,A组),18例行腹腔镜辅助毕Ⅰ式胃肠道重建术(B组),对比分析两组患者的手术疗效。结果:两组患者胃肠道重建时间[(24±12)min vs.(26±15)min]、术后首次进流食时间[(3.7±1.8)d vs.(3.9±2.1)d]、术后住院时间[(8.5±2.7)d vs.(8.7±2.9)d]差异无统计学意义。A组止痛药使用次数明显少于B组[(1.7±1.5)vs.(3.5±1.9),P<0.05]。术后随访3~10个月,均未发生吻合口狭窄、吻合口漏、吻合口出血等手术并发症。结论:全腹腔镜毕Ⅰ式胃肠道重建(三角吻合)是安全、可行的,近期疗效满意,远期疗效尚需进一步观察研究。     

腹腔镜前列腺癌根治术中膀胱尿道吻合技术

前列腺癌根治术是治疗早期局限型前列腺癌的首选方法。随着腔镜器械的不断发展及手术技术的持续改进,腹腔镜前列腺癌根治术已成为治疗局限型前列腺癌的标准术式,它除了具有与开放手术一样的治疗效果外,还具有创伤小、恢复快的微创优势,迅速在国内大中型医院广泛开展。膀胱尿道吻合是腹腔镜前列腺癌根治术中最关键的步骤之一,如何减少膀胱尿道吻合的难度,提高手术效率并保证吻合的质量,是国内外泌尿外科专家所一直关注并期待解决的课题。本文总结了近几年国内外腹腔镜前列腺癌根治术中膀胱尿道吻合的技术改进和我们自身手术经验,与广大泌尿外科同行共飨。     

Effects of a single-lung recruitment maneuver on the systemic release of inflammatory mediators

Objective To study the hypothesis, that systemic levels of pro-inflammatory and anti-inflammatory cytokines may be affected by a single recruitment maneuver in mechanically ventilated patients.Design Prospective, interventional clinical trial.Setting Intensive care unit of a university hospital.Patients Sixteen mechanically ventilated patients with clinical and radiological signs of atelectasis.Interventions A single recruitment maneuver (RM) was performed by elevating the airway pressure to 40 cmH₂O for 7 s.Measurements and main results Plasmatic concentrations of interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12p70 and tumor necrosis factor (TNF-α), arterial blood gases and hemodynamic parameters were measured immediately before and 5–360 min after the RM. The RM caused a minor, nevertheless significant improvement of oxygenation (p = 0.02) and carbon dioxide elimination (p = 0.006) as well as a moderate drop of the mean arterial pressure (p = 0.025). In contrast, plasma concentrations remained unaffected by the RM in all six mediators measured.Conclusion A single inflation with an airway pressure of 40 cmH₂O for 7 s improved gas exchange only slightly and did not modify systemic levels of inflammatory mediators in mechanically ventilated patients with radiological evidence of atelectasis.This study was supported by departmental funds     

胸、腹腔镜联合全喉切除治疗颈段食管癌

目的探讨胸、腹腔镜联合全喉切除治疗颈段食管的可行性和疗效。方法2009年1月一2014年7月胸、腹腔镜联合全喉切除治疗33例颈段食管癌。胸腔镜下分离食管、腹腔镜下管胃成形、全喉切除、气管永久造口、胃咽吻合术。结果胸部手术时间40～66min,平均53min;腹部手术时间35～51min,平均44rain;颈部手术时间128～150min,平均139min。术中出血量130～270ml,平均150ml。术后住院时间8～14d,平均12d。病理均为鳞状细胞癌,其中高分化2例,中分化19例,中一低分化7例,低分化5例。切缘病理学检查无癌组织残留。31例淋巴结转移。并发症：吻合口漏2例,喉返神经损伤3例,肺部感染6例,胃排空障碍2例,吻合口狭窄1例,无死亡病例。33例随访1个月～5年,术后1、3、5年生存率分别为87．9％、54．5％、45．5％。结论颈段食管癌应采取积极的手术治疗,胃咽吻合术是颈段食管癌切除后较为理想的修复手段。     

三角吻合技术在腹腔镜远端胃癌根治术中的应用

目的比较三角吻合的全腹腔镜远端胃切除术（totally laparoscopic distal gastrectomy,TLDG）与传统腹腔镜辅助下远端胃切除术（laparoseopie—assisted distal gastrectomy,LADG）的临床疗效。方法比较2013年1—6月我科32例三角吻合TLDG与32例传统腹腔外吻合的LADG临床资料。结果64例手术均获成功。LADG组1例出现吻合口漏,1例出现吻合口狭窄,吻合口相关并发症发生率6．2％（2／32）。TLDG组均未出现吻合口漏、吻合口狭窄或吻合口出血等吻合口相关并发症。三角吻合的TLDG组三角吻合耗时（30．0±12．8）min。与LADG组相比,TLDG组手术时间[（177．9±37．9）minvs．（186．7±39．1）min,t=-0．914,P=0．364]、清扫淋巴结总数[（33．4±11．8）枚VS．（31．8±12．1）枚,t=0．536,P=0．594]、进流质食时间[（3．5±1．8）d vs．（3．7±1．7）d,t=-0．457,P=0．649]均无明显差异,但住院时间[（8．2±2．4）dVS．（12．7±2．6）d,t=-7．194,P=0．000]、肛门排气时间[（2．0±1．2）dVS．（3．5±1．3）d,t=-4．796,P=0．000]明显缩短,术中出血量[中位数40ml（15～96m1）vs．中位数98ml（50～158m1）,Z=-2．388,P：0．017]明显减少,且术后患者VAS评分[术后第1天：（3．04-1．2）分vs．（6．0±1．6）分,t=-8．485,P=0．000;术后第3天：（1．7±0．7）分vs．（4．2±0．8）分,t=-13．304,P=0．000]和需要的止痛剂剂量[（1．6±0．8）支vs．（3．7±2．8）支,t=-4．079,P=0．000]明显减少。结论三角吻合技术应用于全腹腔镜下远端胃癌根治术是安全可行的,近期效果显著。