骨盆骨折大出血救治技术与流程

由于骨盆的特殊结构,其内侧的血管网损伤导致不可压迫性出血。即使创伤中心和救治体系的建设,以及损害控制技术等发展,病死率仍然高达30%~60%。损害控制性复苏、骨盆带、外固定支架、复苏性腹主动脉内球囊阻断(REBOA)、动脉栓塞和腹膜外填塞等技术不断发展,部分已经得到普及,但迄今仍没有公认的确定性止血流程。我国正在普遍建设创伤中心,亟待制订适合我国的骨盆骨折大出血患者的救治流程,以提高救治成功率。本文阐述控制骨盆骨折大出血的外科技术和流程进展供同道参考。     

盆筋膜解剖及其与直肠固有筋膜关系研究

目的 探讨盆筋膜的结构、范围及其与直肠固有筋膜的层次关系。方法 2020年12月至2021年3月对由广东药科大学生命与生物制药学院人体解剖与胚胎学系及中山大学中山医学院人体解剖学教研室提供的12具（男性5具、女性7具）骨盆标本进行大体观察，并对Denonvilliers筋膜进行组织学观察。结合2019年12月至2021年3月中山大学附属第三医院胃肠外科收治的20例直肠癌病人（男性10例、女性10例）的盆腔磁共振图像和手术视频进行解剖学印证。结果 12具骨盆大体标本显示，盆筋膜与Gerota筋膜相延续，部分纤维于S4水平构成直肠骶骨筋膜，向下与直肠固有筋膜融合终止于联合纵肌；部分纤维与后方骶前筋膜融合构成肛提肌上筋膜及肌间纤维。Denonvilliers筋膜在盆腔前外侧约2点、10点处与盆筋膜相延续构成完整筒状结构，包绕内层由直肠固有筋膜封套的直肠系膜；除“侧韧带”处有盆腔自主神经直肠支、淋巴管、直肠中动脉相连外，两层筋膜形成完整的双筒状结构，横断面呈同心圆状。除直肠支进入直肠固有筋膜外，盆腔自主神经主要分支均位于盆筋膜内层及Denonvilliers筋膜以外，沿直肠固有筋膜轮廓游离能够避免损伤盆腔自主神经。在7具女性骨盆标本中均能见到菲薄的Denonvilliers筋膜结构。直肠癌病人的横断面磁共振图像能够看到直肠固有筋膜与外侧盆筋膜、Denonvilliers筋膜的轮廓和间隙，手术视频资料也可见到完整盆壁筋膜和Denonvilliers筋膜的轮廓。结论 直肠癌手术中，在盆筋膜、Denonvilliers筋膜与直肠固有筋膜两层结构的间隙进行分离，并保持两层筋膜的完整性，对于保证肿瘤根治性和保护排尿及性功能至关重要。     

2型糖尿病患者不同脂质参数与糖尿病肾病的关系

目的:探讨2型糖尿病(T2DM)患者不同脂质参数与糖尿病肾病(DKD)发生的相关性。方法:检测226例T2DM患者血清TC、TG、LDL-C、HDL-C水平及相关生化指标,计算血浆致动脉硬化指数(AIP)以及脂质三角相关指标(TC/HDL-C、TG/HDL-C、LDL-C/HDL-C)。根据DKD临床诊断标准和Mogensen分期标准分为:Ⅰ~Ⅱ期组136例,Ⅲ期组55例,Ⅳ~Ⅴ期组35例。应用多因素logistic回归分析不同脂质参数与DKD发生的关系。结果:与Ⅰ~Ⅱ期组相比,随着DKD分期加重,TC、TG、LDL-C、LDL-C/HDL-C、AIP水平明显增高(P<0.01)。LDL-C/HDL-C和AIP与24 h尿蛋白水平呈正相关(r=0.724;r=0.769,均P<0.05)。LDL-C/HDL-C和AIP是T2DM合并DKD患者的独立预测因子(P=0.002;P=0.004)。结论:LDL-C/HDL-C和AIP对T2DM合并DKD病情进展有较高的预测价值,可为临床诊治提供参考。     

Research Priorities in Pelvic Venous Disorders in Women: Recommendations from a Multidisciplinary Research Consensus Panel

Pelvic venous disorders (PeVDs) in women can present with chronic pelvic pain, lower-extremity and vulvar varicosities, lower-extremity swelling and pain, and left-flank pain and hematuria. Multiple evidence gaps exist related to PeVDs with the consequence that nonvascular specialists rarely consider the diagnosis. Recognizing this, the Society of Interventional Radiology Foundation funded a Research Consensus Panel to prioritize a research agenda to address these gaps. This paper presents the proceedings and recommendations from that Panel.     

Análisis del tratamiento del prolapso de órganos pélvicos mediante colposacropexia mínimamente invasiva con 24 horas de ingreso

ObjectivesThe objective of this study is to analyze the impact (in terms of safety and saving of hospital costs) of the implementation of a new protocol for the correction of pelvic organ prolapse (POP) by minimally invasive sacrocolpopexy (MISC) with 24-hour hospital stay.Material and methodsProspective observational study of the first 78 MISC procedures performed consecutively. 46 procedures (59%) were performed with 24-hour hospital stay, and 32 (41%) required more than 24 hours. The postoperative complications were determined for each group: visits to the Emergency Department, reoperations, and the average cost per procedure regarding hospital stay and ER visits. The cost model was established according to the data of the Analytical Accounting System of the Jiménez Díaz Foundation Hospital and of the Official State Gazette of Madrid.ResultsThere were no differences regarding intraoperative or postoperative complications between both groups. The number of visits to the Emergency Department, reinterventions or hospital re-admissions was lower in the 24-hour hospital stay group, without reaching statistical significance. The implementation of the MISC protocol with 24-hour hospital stay represented a saving of 607.91€ per procedure in hospital costs.ConclusionsCorrection of the POP with MISC with a 24-hour hospital discharge policy was feasible and safe in at least 59% of the patients, with similar complications, visits to the Emergency Department or hospital readmission rates.     

阴道锥体训练联合生物反馈盆底肌治疗尿失禁老年人盆底肌康复研究现状

目的研究阴道锥体训练联合生物反馈盆底肌治疗尿失禁老年人的临床疗效及对盆底肌的影响。方法选取84例从2016年9月至2018年3月本院收治的尿失禁老年患者进行研究,以随机抽签法将其均分为联合组及对照组,每组42例。对照组予以常规盆底肌训练治疗,联合组则予以阴道锥体训练联合生物反馈盆底肌治疗。对比两组在临床疗效、治疗前后盆底肌力情况、治疗前后尿动力学参数指标水平以及生活质量变化情况等方面的差异。结果联合组与对照组在总有效率方面比较,前者高于后者(P<0.05)。治疗后联合组盆底肌力分级为Ⅳ级、Ⅴ级的人数占比相比对照组较高(P<0.05)。治疗后联合组与对照组在VLPP、PMUC水平方面比较,前者高于后者(P<0.05)。治疗后联合组与对照组I-QOL评分相比治疗前较高,且联合组相比对照组较高(P<0.05)。结论阴道锥体训练联合生物反馈盆底肌治疗老年尿失禁患者的疗效显著,有利于促进盆底肌力的恢复,且有效改善患者尿动力学参数,提高生活质量,具有较高的临床推广应用价值。     

Endogenous motion of liver correlates to the severity of portal hypertension

BACKGROUND Degree of portal hypertension(PH) is the most important prognostic factor for the decompensation of liver cirrhosis and death, therefore adequate care for patients with liver cirrhosis requires timely detection and evaluation of the presence of clinically significant PH(CSPH) and severe PH(SPH). As the most accurate method for the assessment of PH is an invasive direct measurement of hepatic venous pressure gradient(HVPG), the search for non-invasive methods to diagnose these conditions is actively ongoing.AIM To evaluate the feasibility of parameters of endogenously induced displacements and strain of liver to assess degree of PH.METHODS Of 36 patients with liver cirrhosis and measured HVPG were included in the casecontrol study. Endogenous motion of the liver was characterized by derived parameters of region average tissue displacement signal(dantero, dretro, d RMS) and results of endogenous tissue strain imaging using specific radiofrequency signal processing algorithm. Average endogenous strain μ and standard deviation σ of strain were assessed in the regions of interest(ROI)(1 cm × 1 cm and 2 cm × 2 cm in size) and different frequency subbands of endogenous motion(0-10 Hz and 10-20 Hz).RESULTS Four parameters showed statistically significant(P 0.05) correlation with HVPG measurement. The strongest correlation was obtained for the standard deviation of strain(estimated at 0-10 Hz and 2 cm × 2 cm ROI size). Three parameters showed statistically significant differences between patient groups with CSPH, but only dretro showed significant results in SPH analysis. According to ROC analysis area under the curve(AUC) of the σROI[0…10 Hz, 2 cm × 2 cm] parameter reached 0.71(P = 0.036) for the diagnosis of CSPH; with a cut-off value of 1.28 μm/cm providing 73% sensitivity and 70% specificity. AUC for the diagnosis of CSPH for μROI[0…10 Hz, 1 cm × 1 cm] was 0.78(P = 0.0024); with a cut-off value of 3.92 μm/cm providing 73% sensitivity and 80% specificity. Dretro parameter had an AUC of 0.86(P = 0.0001) for the diagnosis of CSPH and 0.84(P = 0.0001) for the diagnosis of SPH. A cut-off value of-132.34 μm yielded 100% sensitivity for both conditions, whereas specificity was 80% and 72% for CSPH and SPH respectively.CONCLUSION The parameters of endogenously induced displacements and strain of the liver correlated with HVPG and might be used for non-invasive diagnosis of PH.     

Anatomical structures at risk using different approaches for sacrospinous ligament fixation

For 50 years now, sacrospinous ligament fixation (SSLF) has been used to treat pelvic organ prolapse consequent on altered integrity of the pelvic myofascial structures. It is usually performed vaginally, but it has recently been performed laparoscopically through either an anterior or a posterior approach, with the broad ligament as a landmark to differentiate the two. In the present study, these two laparoscopic approaches were assessed using Thiel-embalmed cadavers. The anterior and posterior approaches were compared in terms of the closest distance to anatomical structures at risk, including pelvic viscera, the obturator nerve, and vascular structures. The posterior approach was more often closer to the investigated vessels and the rectum. The obturator nerve and the ureter were close to both the anterior and posterior approaches. The urinary bladder was closer using the anterior approach. From an anatomical standpoint, therefore, the anterior laparoscopic approach for SSLF is more likely to cause injury to the urinary bladder, whereas the posterior approach is more prone to causing rectal and vessel injuries. This study illustrates, from a basic science perspective, the importance of combining fascia research, novel endoscopic or minimally invasive surgical exposures informed by anatomy, and contemporary trends in gynecology in order to improve patient outcomes. Clin. Anat. 33:522–529, 2020. © 2019 Wiley Periodicals, Inc.     

附件炎性包块的诊断

附件炎性包块是指盆腔炎性疾病引起的附件区包块，多由性传播疾病的病原体（如淋病奈瑟菌和沙眼衣原体）感染引起，性生活活跃的年轻女性是高危人群。附件炎性包块会严重影响女性的生殖健康，故预防重于治疗。盆腔炎性疾病的临床表现差异较大，尚无敏感且特异的实验室检查指标，阴道超声诊断附件炎性包块的准确性较高，是临床常用的检查手段。