新型冠状病毒肺炎疫情常态化防控期间安全开展普外科手术策略

随着新型冠状病毒奥密克戎变异株在全球范围广泛流行,疫情常态化防控进入一个新的阶段。普外科由于疾病范围广、急危重症多,是疫情期间社会面就医需求最为迫切的主要专科之一。基于现有的研究证据和临床实践经验,提出安全开展普外科手术的对策。首先,宏观策略上,病房应进行分区布置,并合理制定急诊和择期手术病人收治流程。其次,术中防护的技术细节方面,需重点注意防护装备穿脱、手术烟雾处理、手术标本转运等关键环节。最后,还应重视职业暴露的预防和处置。     

胃肠外科近20年进展和发展趋势

进入21世纪已经20年了,回顾胃肠外科发展历程,疾病谱的改变对胃肠外科医师提出了更高的要求。微创技术、代谢外科、围手术期综合管理和外科质量控制、专业化和多学科团队等全新的理念和治疗模式不断出现并迅速推广,不仅推动了胃肠外科的发展,也是胃肠外科发展的趋势。     

回眸2019--聚焦胃肿瘤的研究进展

目前胃部肿瘤以胃癌、胃肠间质瘤和胃神经内分泌肿瘤最为常见。2019年胃癌的腹腔镜手术方面,一系列的研究成果均显示,微创手术在早期胃癌治疗中的安全性以及进展期胃癌的肿瘤学疗效都与传统开放手术相似,为腹腔镜手术在胃癌治疗中的推广提供了高级别循证医学依据。胃癌综合治疗方面,也有重大研究结果公布,我国的临床研究也逐渐得到国际上的认可和关注。靶向治疗和免疫治疗的应用虽有进展,但在胃癌术后的一线治疗尚未能得到认可。胃肠间质瘤领域,腹腔镜手术也逐渐得到推广,晚期耐药患者手术治疗仍有其价值。胃神经内分泌肿瘤方面,最新研究显示,手术方式应根据肿瘤特性来加以选择,胃癌若合并神经内分泌肿瘤成分则可能预后更差。     

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结直肠癌肝转移的发病率及死亡率逐年升高,多学科综合治疗团队(multidisciplinary team,MDT)对提高病人存活率、改善预后起着重要作用。较传统单一学科诊疗模式,MDT为病人提供了全方位个体化的高质量诊疗。此外,MDT对于医学教育与科研同样有所帮助。MDT在国外已广泛开展,但在国内尚处于起步阶段,缺乏相应的标准。因此,需要重视并规范化开展结直肠癌肝转移的多学科综合治疗。     

内镜黏膜下剥离术治疗直肠病变

目的探讨内镜黏膜下剥离术治疗直肠病变的应用价值。方法对肠镜发现的较大直肠腺瘤和黏膜下肿瘤应用头端弯曲的针形切开刀进行内镜黏膜下剥离术（ESD）治疗：（1）黏膜下注射生理盐水抬高病变，使病变与肌层相分离；（2）预切开病变周围黏膜；（3）剥离病变下方黏膜下层结缔组织，完整切除病变。结果12例低位直肠病变，大小0．6～4．5cm（平均2．8cm），均成功完成ESD治疗。术后11例病理确诊基底和切缘未见病变累及；1例腺癌累及黏膜下层病例接受外科根治手术，手术标本病理未见肿瘤残留。ESD手术时间（自黏膜下注射至完整剥离病变）30～120min（平均52min）。术中出血量平均约75ml，均经电凝、氩离子凝固术和止血夹成功止血，未出现需再次肠镜下治疗的出血。2例剥离深至肌层，出现皮下气肿和少量膈下游离气体，保守治疗好转。9例1个月后肠镜复查，创面基本愈合。结论ESD是治疗消化道病变的新方法，不仅能切除较大的病变，还能提供完整的病理学诊断资料。以往需要外科手术的消化道早期癌和部分黏膜下肿瘤，通过ESD可以达到同样的治疗效果。     

一种高效的小鼠胰岛分离纯化新技术

目的：探讨获得足够数量和较高纯度小鼠胰岛的分离及纯化方法,为进行小鼠的胰岛移植提供实验条件。方法：将6-8周,体质量25-30g的雄性C57BL/6小鼠腹腔麻醉后结扎胆总管,采用胶原酶Ⅴ逆行灌注、原位消化、Ficoll-400梯度离心并用无菌的毛细吸管在相差显微镜下观察并分选胰岛,双硫腙（DTZ）染色鉴定胰岛细胞。体外培养胰岛单细胞,并于第3、8、24天观察胰岛形态。结果：采用该法分离纯化后,每只小鼠可得到390±20个胰岛,胰岛呈圆形或团块状,直径50-150μm,形态完整,折光性好,纯度达85%以上,24d后在培养皿内铺成单个细胞。结论：本研究所用逆行灌注、原位消化及Ficoll-400梯度离心分离、纯化胰岛细胞的方法省时、高效,培养的胰岛细胞活性好,适合进一步研究的需要。     

乳腺良恶性钙化的血清比较蛋白质组学分析

目的 分析乳腺良恶性钙化患者血清蛋白质表达谱,比较不同性质钙化的血清蛋白质差异.方法 钙化型乳腺癌、良性钙化患者血清各10例,经双向凝胶电泳、基质辅助激光解析离子化-飞行时间质谱等对差异蛋白进行分析鉴定和验证.结果 良恶性钙化组比较发现钙化型乳腺癌组血清中特异性的蛋白质2种,上调的蛋白质8种,下调的蛋白质7种.钙化型乳腺癌组触珠蛋白表达高于良性钙化组.结论 乳腺的恶性钙化和良性钙化患者的血清中某些蛋白存在着差异表达,有可能作为鉴别乳腺钙化病变良恶性质的标志物分子.

Abstract：

Objective To find out serum protein difference between breast benign calcification and malignant calcification.Methods The serum samples of the patients with breast cancer and those with benign lesions were collected,10 samples in each category.They all had calcifications on mammygraphy.The mixed protein was assayed by using 2-DE method.The spots with marked different expression were excised from gels and digested into peptides.These peptides were analyzed by MALDI-TOF MS and the peptide mass fingerprintings were got.One of special protein was valided by Western blotting.Results In group of breast cancer with calcification,there were 2 specific proteins.There were 15 differential expression proteins,including 8 up-regulated,and 7 down-regulated.Conclusion Some identified serum proteins have different expression in patients with malignamt or benign calcifications,which may be helpful for the differential diagnosis of benign and malignant calcifications.     

小鼠肝星状细胞分离纯化和体外培养模型的建立

目的 建立小鼠肝星状细胞(m-HSCs)分离纯化的高效稳定方案,并通过原代和传代培养观察其生物学特性.方法 依次应用预灌注液、0.1% Pronase E、0.075% Collagenase NB4G对在体肝脏原位灌注消化.肝脏离体后,在0.02%DNaseI液中磁力搅拌消化10 min,低速离心(25g,5 min)去除残余肝实质细胞,进一步用Optiprep密度梯度液获得纯化的m-HSCs.采用锥虫蓝染色法评估细胞产量及活力;采用自发荧光及油红O染色鉴定细胞纯度;采用光镜、电镜以及Desmin/α-SMA免疫荧光双染色观察细胞形态和生物学特征.结果 分离得到的原代m-HSCs数量为(1.4±0.3)×106/g肝脏,细胞活率＞95%;原代培养24 b后,细胞纯度＞90%,传1代后细胞纯度接近100%.静止期和不同活化阶段的m-HSCs在亚显微结构以及α-SMA表达强度等方面存在差异.结论 建立的m-HSCs分离和纯化方法及体外细胞培养模型具有稳定性和高纯度性及高活率性.

Abstract：

Objective To establish a high-performance and stable model for isolation and purification of mouse hepatic stellate cells, and investigate their biological phenotypes by primary culture and subculture. Methods The liver was digested by in situ perfusion of pre-perfusion solution, 0.1% pronase E and 0.075% collagenase NB4G in turn. The liver was continued to digest using 0.02% DNase Ⅰ liquid with magnetic stirring for 10 min in vitro. After low-speed centrifugation used to remove residual hepatocytes, cells were treated with Optiprep density gradient solution to obtain the purified m-HSCs. Trypan blue staining method was used to calculate cell production and viability. The cell purity was identified by mHSCs autofluorescence and oil red O staining. Light microscopy, electronic transmission microscopy and double immunofluorescence staining of Desmin and α-SMA were done to observe morphological characteristics and biological phenotypes of m-HSCs. Results The yeild rate of m-HSCs was (1.4±0.3)×106/g of liver tissue, the cell viability was more than 95%, the cell purity was more than 90% after 24 h of primary cluture and close to 100% after the first cell passage. The activated m-HSCs had different characteristics of submicroscopic structures and expression level of α-SMA. Conclusion This study established a stable model for isolation, purification and culture of m-HSCs, which obtained the high purity and high-living rate of m-HSCs.     

骨髓间充质细胞和单个核细胞移植对糖尿病小鼠胰岛功能的影响

目的 比较骨髓间充质细胞移植和单个核细胞移植对糖尿病小鼠胰岛功能影响的差异.方法 建立糖尿病小鼠模型并分成3组:对照组(n=14)通过尾静脉注射磷酸盐缓冲液(PBS);单个核细胞组(n=14)通过尾静脉移植骨髓单个核细胞;间充质细胞组(n=14)通过尾静脉移植骨髓间充质细胞.观察移植后1周(n=6)和移植后6周(n=8),各组小鼠血糖的变化、胰岛数量、胰腺组织形态学特征及相关标记物的表达.结果 移植后1周,间充质细胞组小鼠血糖出现显著下降(16.6±1.6)mmol/L,与对照组(26.3±0.5)mmol/L和单个核细胞移植组(24.4±1.3)mmol/L比较差异有统计学意义(P＜0.05),并一直维持到移植后第6周,血糖下降到(16.5±1.5)mmol/L,与对照组(27.7±0.1)mmol/L比较差异有统计学意义(P＜0.05);移植后1周,间充质细胞组小鼠胰岛数目(21.2±1. 1)和胰岛β细胞数目(415.9±25.4)显著增加,与对照组(11.2±1.3)/(65.9±7.1)和单个核细胞组(12.2±1.3)/(64.1±6.5)比较差异均有统计学意义(P均＜0.05).单个核细胞组和间充质细胞组小鼠胰岛中均发现BrdU(+)Insulin(+)细胞和BrdU(+)Insulin(-)细胞.结论 骨髓间充质细胞移植改善糖尿病小鼠胰岛功能的效果优于骨髓单个核细胞移植.移植后胰岛的再生既来源于胰岛β细胞的增殖,也可能来源于胰岛干细胞的分化.

Abstract：

Objective To compare the different effects of bone marrow mononuclear cells vs mesenchymal cells transplantation on islets function of diabetic mice. Methods Mouse diabetic models were created by multiply peritoneal injection of low-dose streptozotocin (STZ) and divided into three groups:control group ( n = 14) , bone marrow mononuclear cells group ( n = 14) , and bone marrow mesenchymal cells group (n = 14). Blood glucose was measured weekly after transplantation by glucometer. Histochem istry and immunofluorescence were performed to characterize pancreatic histology, morphology and markers expressed in receipt pancreas. Results Compared with control group and bone marrow mesenchymal cells group, blood glucose levels in bone marrow mesenchymal cells group were significantly reduced at first week after transplantation[( 16. 6 ± 1.6 ) vs ( 26. 3 ± 0. 5 ) / ( 24. 4 ± 1.3 ) mmol/L, P ＜ 0. 05]and sustained to reduce at 6th week after transplantation[( 16. 5 ± 1.5 ) vs ( 27.7 ± 0. 1 ) mmol/L in control group,P＜0. 05]. One week after transplantation, the islets number in bone marrow mesenchymal cells group was larger than in control group ( 21.2 ± 1. 1vs 11.2 ± 1.3, P ＜ 0. 05 ) and bone marrow mononuclear cells group ( 21.2 ± 1. 1vs 12. 2 ± 1.3 ,P ＜0. 05 ). One weeks after transplantation, the beta cell number in bone marrow mesenchymal cells group was larger than in control group (415.9 ± 25.4 vs 65.9 ±7. 1,P＜0.05) and bone marrow mononuclear cells group (415.9 ±25.4 vs 64. 1 ±6.5,P＜0.05). In bone marrow mononuclear cells and bone marrow mesenchymal cells groups, there were several BrdU ( + )Insulin( - ) cells and BrdU( + )Insulin( - ) cells in the islets. Conclusion The effect of bone marrow mesenchymal cells transplantation to improve diabetic islet function is more satisfactory than bone marrow mononuclear cells transplantation. Bone marrow mesenchymal cells transplantation can initiate pancreatic islets β cells regeneration by both proliferation of β cells and differentiation of pancreatic stem cells.     

胃癌D2根治术后胰漏及其相关因素分析

目的 分析胃癌D2根治术后胰漏的发生率及其原因.方法 连续收集2009年7月1日至12月31日间经复旦大学附属中山医院胃癌专业组收治132例胃癌D2根治术患者的临床资料,测定术后第1、4、7天腹腔引流液及血清淀粉酶浓度,根据术后第1天的腹腔引流液淀粉酶值诊断胰漏.观察胰漏的发生率,并结合临床资料分析影响胰漏发生的因素.结果本组胰漏发生率为17.4%.胰漏的发生与患者年龄、性别、肿瘤部位、肿瘤分期、N分期、切除范围、引流液量及术后血清淀粉酶值无关.结论 胰漏在胃癌D2根治术后发生率较高,术中需常规预防性腹腔引流.