腹腔镜下胆总管探查一期缝合术后引流方式的研究进展

随着腹腔镜、胆道镜及缝合技术的快速发展,腹腔镜下胆总管探查（LCBDE）+一期胆总管缝合（PDC）已成为了治疗胆总管结石的主要方法。相比传统T管,该方法能降低患者术中出血,缩短手术及住院时间等,然而单纯的PDC往往缺乏有效的支撑引流,术后胆总管压力较大,增加了患者胆漏及胆总管狭窄的风险,因此有人提出了一期缝合胆总管兼顾内外引流的手术方式,不仅能降低术前胆总管压力,减轻胆道炎症水肿,提高缝合质量,术后还能保持一定引流,减少患者术后胆漏及胆道狭窄的发生。     

腹腔镜下胆总管一期缝合在老年胆总管结石病人中的应用效果

目的 比较腹腔镜下胆总管一期缝合与T管引流两种术式对老年胆总管结石病人的治疗效果。方法 收集2017年1月至2021年1月南京医科大学附属南京医院普外科收治的老年胆总管结石病人135例,根据胆总管的缝合方式分为一期缝合组和T管引流组,分别对2组病例术前、术中以及术后恢复情况进行对比分析。结果 一期缝合组64例,T管引流组71例。2组病人术前相关资料比较,差异无统计学意义(P>0.05);2组平均胆总管直径、管壁厚度、术中出血量比较,差异无统计学意义(P>0.05)。一期缝合组平均术程时长较T管引流组更短(P<0.05)。2组病人术后排气时间和住院时间差异无统计学意义(P>0.05)。一期缝合组和T管引流组术后胆瘘发生率分别为7.81%和4.23%,差异无统计学意义(P>0.05)。一期缝合组出现严重胆瘘后再次手术1例;T管引流组无严重胆瘘致二次手术病例,但有1例病人出院后T管不慎滑脱,另有3例病人来院拔除T管时出现胆瘘。结论 腹腔镜下胆总管一期缝合不会导致并发症增多,同时可降低病人术后护理负担,病人治疗后舒适度和满意度高,是治疗老年胆总管结石的一项安全、有...     

不同缝合方法对腹腔镜下卵巢囊肿剥除术患者残留卵巢储备功能的影响比较

目的 比较不同缝合方法对腹腔镜下卵巢囊肿剥除术患者残留卵巢储备功能的影响。方法 选择2017年4月至2019年10月广西壮族自治区人民医院收治的卵巢子宫内膜异位囊肿患者120例,采用随机数字表法将其分为囊内多点连续缝合法组(A组)、基底部连续U型缝合法组(B组)、囊外连续缝合法组(C组)、囊外间断缝合法组(D组),每组30例。比较四组的手术时间和术中出血量,以及术前(T₁)、术后1个月(T₂)、术后3个月(T₃)、术后6个月(T₄)和术后1年(T₅)的卵巢储备功能相关指标[包括血清雌二醇(E₂)、孕激素(P)、卵泡刺激素(FSH)、黄体生成素(LH)、窦卵泡数(F0)、卵巢间质动脉血流的收缩期峰值流速(PSV)、舒张期低值流速(EDV)、阻力指数(RI)、搏动指数(PI)]。结果 B组手术时间最短,术中出血量最少,与其他三组比较差异有统计学意义(P<0.05)。在T₂～T₅时间点,四组E₂     

对临床医学生开展实习上岗前心电图技能强化培训的研究

目的 探讨对临床医学生开展实习上岗前心电图技能强化培训的价值.方法 对299名2010级临床医学五年制和七年制学生进行实习上岗前心电图技能强化培训,在培训前进行问卷调查,了解临床医学生是否认为有必要进行实习上岗前心电图技能培训及考核临床医学生在校学习期间对正常心电图、急性心肌梗死(AMI)心电图相关知识及心电图阅图的掌握情况,并对其进行心电图理论授课及心电图阅图技能培训.结果 培训前、后对正常心电图、AMI心电图的相关知识及心电图阅图分析(合格率)情况进行比较,差异有统计学意义(P<0.05),培训后问卷调查大部分临床医学生认为培训有重要价值.结论 临床医学生在实习上岗前强化心电图技能培训是很有必要的.     

腹腔镜下两种一期缝合术式治疗胆总管结石的效果比较

正胆总管结石为肝胆外科常见疾病,因其可能造成急性胆总管梗阻致胆汁淤积、感染等严重并发症,需采取积极的手术治疗措施。随着微创外科理念的普及以及腔镜和内镜技术日益成熟,开腹手术已较少应用于胆总管结石的治疗,现多采用腹腔镜或(和)十二指肠镜的微创术式治疗[1]。国内外胆总管结     

腹腔镜下卵巢手术采用不同缝合方法对卵巢分泌性激素的影响

目的探讨腹腔镜下卵巢巧克力囊肿剥除术中残留卵巢皮质采用2种不同的缝合止血方法对术后卵巢分泌性激素的影响。方法选取收治的单侧卵巢巧克力囊肿患者60例施行腹腔镜下囊肿剥除手术,应用随机分组法分为两组,A组30例术中创面采用基底部连续U型缝合法,B组30例采用囊外连续缝合法。对所有患者术前、术后1个月、术后3个月分别抽外周静脉血,采用化学发光法检测卵泡刺激素(FSH)、黄体生成素(LH)、雌二醇(E_2),对两组以上指标进行比较,以评判不同缝合方法对卵巢分泌性激素的影响。结果两组患者术后1个月E_2水平较术前明显降低,FSH、LH较术前明显升高,与术前相比差异有统计学意义(P0.05);术后3个月,E_2水平较术前稍升高,FSH、LH较术前稍降低,但与术前比较差异无统计学意义(P0.05)。术后1个月,B组对卵巢激素的影响均大于A组,差异有统计学意义(P0.05)。结论腹腔镜下卵巢子宫内膜异位囊肿剔除术中无论采用基底部连续U型缝合或囊外连续缝合法止血法,在术后3个月内均对卵巢分泌性激素造成影响,尤以囊外连续缝合法对卵巢功能的影响更为显著。所有患者卵巢分泌性激素的功能在术后3个月内可恢复正常。     

腹腔镜胆总管探查术后Ι期缝合和T管引流的疗效比较

目的比较分析腹腔镜下胆总管探查后胆管Ⅰ期缝合和T管引流的疗效,探讨胆管Ⅰ期缝合的临床应用标准。方法回顾性分析吉林大学第一医院2014年7月-2015年7月间所有胆总管结石患者的临床资料,选择符合纳入标准的患者51例,其中胆总管Ⅰ期缝合26例,T管引流25例,对比分析两组患者在术前术后TBil的变化、胃肠道功能恢复时间、术后第1天腹腔引流管引流量、腹腔引流管拔出时间、并发症、术后住院时间、住院总费用等情况。计量资料组间比较采用t检验,计数资料组间比较采用χ2检验。结果两组患者在术后住院时间、住院总费用等方面差异均有统计学意义(t值分别为-7.067、-3.126,P值分别为0.001、0.003)。两组患者术后各出现1例并发症,治疗后均痊愈。结论在严格把握手术适应证的基础上,胆总管探查术后胆管Ⅰ期缝合具有住院时间短、费用低、患者生活质量高等优点,安全可行,值得临床推广。     

腹腔镜子宫下段肌层折叠缝合联合宫腔镜治疗剖宫产术后子宫瘢痕憩室的临床效果观察

［摘要］　目的　观察腹腔镜子宫下段肌层折叠缝合联合宫腔镜治疗剖宫产术后子宫瘢痕憩室（CSD）的临床效果。方法　选择2015年1月至2019年12月邯郸市中心医院收治的CSD患者26例,根据治疗方式不同分为观察组(采用宫腔镜子宫瘢痕憩室切除联合腹腔镜子宫下段肌层折叠缝合修复子宫下段肌层,14例)和对照组（采用宫腔镜引导下经腹腔镜切除子宫瘢痕后重新缝合修复子宫下段肌层,12例）。比较两组患者的手术时间、术中出血量、术后住院时间,以及术后子宫下段肌层的恢复情况。结果　两组手术时间、术后住院时间比较差异无统计学意义（P>0.05）。观察组术中出血量少于对照组,差异有统计学意义（P<0.01）。与术前比较,两组术后子宫下段肌层厚度均显著增厚（P<0.01）,但两组间比较差异无统计学意义（P>0.05）。结论　腹腔镜子宫下段肌层折叠缝合联合宫腔镜治疗CSD疗效确切,且手术操作更简易,术中出血量更少,值得临床推广。     

老年胆总管结石患者腹腔镜胆道探查一期缝合术后发生胆道并发症的影响因素

目的 分析老年胆总管结石(CBDS)患者腹腔镜胆道探查一期缝合术(LCBDE)后发生胆道并发症的影响因素。方法 选取接受LCBDE治疗的113例老年CBDS患者,依据术后3个月时有无发生胆道并发症分为发生组和未发生组。由研究人员设计基线资料调查问卷,询问患者及其家属基本情况,记录并比较两组一般资料、实验室指标,通过单因素与多因素分析,找出老年CBDS患者LCBDE术后发生胆道并发症的影响因素。结果 发生组浑浊胆汁、胆总管下端结石嵌顿、十二指肠乳头开闭蠕动异常占比高于未发生组,血清白蛋白水平低于未发生组,差异有统计学意义(P<0.05);经多项Logistic回归分析结果显示,浑浊胆汁、胆总管下端结石嵌顿、十二指肠乳头开闭蠕动异常均是老年CBDS患者LCBDE术后发生胆道并发症的危险因素(OR>1,P<0.05);血清白蛋白水平高是保护因素(OR<1,P<0.05)。结论 老年CBDS患者LCBDE术后发生胆道并发症可能受浑浊胆汁、胆总管下端结石嵌顿、十二指肠乳头开闭蠕动及血清白蛋白水平低等多种因素影响。     

Evaluation of clinical endobronchial ultrasound skills following clinical versus simulation training

Background and objective: Endobronchial ultrasound with transbronchial needle aspiration (EBUS‐TBNA) is a pulmonary procedure that can be challenging to learn. This study aims to compare trainee EBUS‐TBNA performance during clinical procedures, following training with a computer EBUS‐TBNA simulator versus conventional clinical EBUS‐TBNA training. Methods: A prospective study of pulmonary trainees performing EBUS‐TBNA procedures on patients with suspected lung cancer and mediastinal adenopathy. Two cohorts of trainees were each evaluated while performing EBUS‐TBNA on two patients. Group 1 received training by performing 15 cases on an EBUS‐TBNA simulator (n = 4) and had never performed a clinical EBUS‐TBNA procedure. Group 2 received training by doing 15–25 EBUS‐TBNA procedures on patients (n = 4). Results: There was no significant difference in the primary outcome measure of total EBUS‐TBNA procedure time/number of successful aspirates between Groups 1 and 2 (3.95 (±0.93) vs 3.64 (±0.89), P = 0.51). Total learner EBUS‐TBNA procedure time in minutes (23.67 (±5.58) vs 21.81 (±5.36), P = 0.17) and percentage of successful aspirates (93.3% (±5.8%) vs 86.3% (±6.7%), P = 0.12) were not significantly different between Group 1 and Group 2. The only significant difference found between Group 1 and Group 2 was time to intubation in minutes (0.99 (±0.46) vs 0.50 (±0.42), P = 0.04). Conclusions: EBUS‐TBNA simulator use leads to rapid acquisition of clinical EBUS‐TBNA skills comparable with that obtained with conventional training methods using practice on patients, suggesting that skills learned using an EBUS‐TBNA simulator are transferable to clinical EBUS‐TBNA performance. EBUS‐TBNA simulators show promise for training, potentially minimizing the burden of procedural learning on patients.     

手术直播演示结合分级腹腔镜模拟器训练法在普外科腹腔镜培训中的研究

目的手术直播演示结合分级腹腔镜模拟器训练法在普外科腹腔镜培训中的应用效果。 方法首都医科大学附属北京中医医院参加住院医师规范化培训基地第1阶段普外科、泌尿外科及妇科专业住院医师和本院纳入第1阶段住院医师规范化培训的普外科、泌尿外科及妇科专业研究生组成，共120名。腹腔镜基本技能培训为期1个月，内容包括3部分：手术直播演示每周2台；理论授课每周2次，每次1 h；模拟训练4周，操作每天4 h，包括（初级模块——基本技能训练；中级模块——简单及高级缝合训练；进阶模块——腹腔镜必要技巧训练；高级模块——模拟手术培训）。随机分为3组，其中试验组采用手术演示＋理论授课＋腹腔镜模拟训练；对照组采用理论授课＋手术演示；空白组采用仅进行理论授课，不参与其他培训，安排下一期参加培训。 结果培训后腹腔镜理论考核成绩试验组为（82.00±6.72）分，对照组为（83.40±6.51）分，空白组（83.20±5.72）分，均较培训前提高，但差异均无统计学意义（P＞0.05），且3组间培训前后理论成绩差异不显著，差异无统计学意义（P＞0.05）。腹腔镜操作技能考核成绩试验组培训后初级模块——基本技能训练、中级模块——简单及高级缝合训练、进阶模块——腹腔镜必要技巧训练、高级模块——模拟手术培训各项操作技能成绩分别为（86.00±5.98）、（86.00±5.98）、（85.00±5.13）和（82.50±6.38）分，较试验组培训前的（37.00±10.81）、（18.00±7.68）、（16.00±8.21）和（10.50±10.50）分显著提高，差异有统计学意义（P＜0.05）；明显高于对照组（46.00±9.95）、（44.00±9.40）、（39.00±7.18）和（35.00±7.18）分，差异均有统计学意义（P＜0.05）；明显高于空白组（36.00±8.21）、（18.50±6.71）、（16.50±9.44）和（11.00±9.68）分，差异均有统计学意义（P＜0.05）。 结论腹腔镜技能模拟训练能有效提高临床医学生的腹腔镜操作技能。     

Effect of driving training on car crashes and driving skills in older people: A systematic review and meta-analysis

The primary aim of this systematic review was to examine the efficacy of driving interventions with regard to a reduction in motor vehicle crashes and improvements in driving skills among older people. The secondary aim was to identify the optimal type (on-road or off-road) and dosage (period, sessions, and duration) of driving interventions for improving driving skills in older people. We searched MEDLINE, EMBASE, PsycINFO, and Scopus of Systematic Reviews for papers published from their inception to December 1, 2020, as well as the reference lists of the included papers. The selected studies were randomized controlled trials examining the effects of driving interventions among community-dwelling older drivers aged 65 years and over. A meta-analysis of two studies (n = 960) showed that driving interventions significantly reduced the number of motor vehicle crashes per person-years. Ten studies (n = 575) were included in the meta-analysis showing that the interventions significantly improved the driving skill scores. Driving skill scores significantly improved after on-road training, and in interventions of at least 3 h, 3 sessions, and 3 weeks. Driving interventions significantly improve driving skills and reduce motor vehicle crashes among older drivers aged 65 years and over. On-road training is more efficacious than off-road training and driving interventions of at least 3 h taking place in 3 sessions over a period of 3 weeks may be required to improve driving skills in older drivers. Geriatr Gerontol Int 2023; 23: 771–778 .     

阶梯式培训模式在普通外科进修医师腹腔镜技术培训临床教学中的应用

目的探讨针对普通外科进修医师的腹腔镜手术技能阶段式培训新模式。 方法选取2015年3月至2017年5月,在新疆维吾尔自治区人民医院学习的68名进修医师,评估其腹腔镜阶段式培训模式对腹腔镜掌握程度。针对不同程度的学生采用不同的理论学习、观看操作录像、模拟器训练及动物模拟手术完成情况等项目进行阶梯式训练,出科理论及操作考试形式客观对进修学员培训情况进行考核。 结果所有进修医师均能熟悉掌握腹腔镜基本操作技能,熟练掌握了腹腔镜规范基本操作技能,理论及实践操作考核合格率为100%,学习效果及满意度显著,并取得良好的教学效果。 结论针对普通外科进修学员的具体情况,临床教学理论与腹腔镜培训相结合,开展腹腔镜技术阶梯式教学,学习效果显著,取得良好的教学效果。     

Technical skills and training of upper gastrointestinal endoscopy for new beginners

The incidence of gastric cancer remains high in SouthKorea.Upper gastrointestinal(GI) endoscopy,i.e.,esophagogastroduodenoscopy(EGD),has a higher diagnostic specificity and sensitivity than the upper GI series.Additionally,EGD has the ability to biopsy,through taking a tissue of the pathologic lesion.Successful training of EGD procedural skills require a few important things to be learned and remembered,including the posture of an examinee(e.g.,left lateral decubitus and supine) and examiner(e.g.,one-man standing method vs one-man sitting method),basic skills(e.g.,tip deflection,push forward and pull back,and air suction and infusion),advanced skills(e.g.,paradoxical movement,J-turn,and U-turn),and intubation techniques along the upper GI tract(e.g.,oral cavity,pharynx,larynx including vocal cord,upper and middle and lower esophagus,gastroesophageal junction,gastric fundus,body,and antrum,duodenal bulb,and descending part of duodenum).In the current review,despite several limitations,we explained the intubation method of EGD for beginners.We hope this will be helpful to beginners who wish to learn the procedure.     

腹腔镜模拟培训在微创外科研究生临床教学中的应用

目的探讨腹腔镜模拟培训在微创外科专业学位研究生临床教学中的应用效果。 方法采用腹腔镜模拟训练结合临床教学模式对我科24名微创外科专业学位研究生进行临床教学,教学结束时考核教学效果,调查教学满意度,比较考核前后的成绩。 结果培训后学生出科平均成绩、合格率、优秀率、主观对自己基本操作熟练程度评分、满意度评分等均高于培训前,且差异有统计学意义（P<0.001）。 结论微创外科研究生临床教学理论与腹腔镜模拟培训相结合,可有效提高微创外科研究生对腹腔镜基本操作及视觉能力,提高腹腔镜操作者的基本技能,取得良好的教学效果,但考核标准仍需要完善。     

70岁以上老年人腹腔镜结直肠癌手术的安全性

目的探讨腹腔镜手术治疗70岁以上老年人结直肠肿瘤的安全性。方法回顾性总结113例腹腔镜辅助和开腹结直肠手术治疗70岁以上老年人结直肠肿瘤的经验,比较腹腔镜手术组(腹腔镜组)35例、传统开腹手术组(开腹组)78例和65岁以下腹腔镜手术组(对照组)35例的手术安全性、并发症及随访结果等情况。结果腹腔镜组、对照组无手术相关死亡患者,开腹组有2例因术后肺部感染而死亡。腹腔镜组有7例(20.0%)发生术后并发症,显著少于开腹组的33例(42.3%)(P<0.05).而与对照组的3例(8.6%)比较,差异无统计学意义。腹腔镜组术中出血、排气时间与进食半流质时间分别为(92±50)ml、(2±1)d 和(5±2)d,与开腹组(156±119)ml、(3±3)d和(6±1)d 比较,差异有统计学意义(P<0.05)。腹腔镜组与对照组手术时间、术中出血及主要并发症差异无统计学意义(P>0.05)。腹腔镜组与开腹组短期内(30个月)肿瘤局部复发、远处转移率类似,累计生存率(仅肿瘤相关死亡)分别为80.4%与82.1%,差异无统计学意义。结论腹腔镜手术治疗70岁以上老年人结直肠癌安全、有效,是治疗老年人结直肠肿瘤较好的选择方法。     

Importance of conversion for results obtained with laparoscopic colorectal surgery

PURPOSE: The need for a conversion is a problem inherent in laparoscopic surgery. The present study points up the significance of conversion for the results obtained with laparoscopic colorectal surgery and identifies the risk factors that establish the need for conversion. METHOD: The study took the form of a multicentric, prospective, observational study within the Laparoscopic Colorectal Surgery Study Group. A total of 33 institutions in Germany, Austria, and Switzerland participated. The study period was 3.5 years. Cases were documented with the aid of a standardized questionnaire. RESULTS: Within the framework of the Laparoscopic Colorectal Surgery Study Group, a total of 1,658 patients were recruited to a multicenter study over a period of three and one-half years (from August 1, 1995 to February 1, 1999). The observed conversion rate was 5.2 percent (n=86). The patients requiring a conversion were significantly heavier (body mass index, 26.5vs. 24.9) than those undergoing pure laparoscopy. Resections of the rectum were associated with a higher risk for conversion (20.9vs. 13 percent). Intraoperative complications occurred significantly more frequently in the conversion group (27.9vs. 3.8 percent). The duration of the operation was significantly increased after conversion in a considerable proportion of the procedures performed. Postoperative morbidity (47.7vs. 26.1 percent), mortality (3.5vs. 1.5 percent), recovery time, and postoperative hospital stay were all negatively influenced by conversion, in part significantly. Institutions with experience of more than 100 laparoscopic colorectal procedures proved to have a significantly lower conversion rate than those with experience of fewer than 100 such interventions (4.3vs. 6.9 percent). CONCLUSION: Although, of itself, conversion is not considered to be a complication of laparoscopic surgery, it is true that the postoperative course after conversion is associated with appreciably poorer results in terms of morbidity, mortality, convalescence, blood transfusion requirement, and postoperative hospital stay. The importance of experience in laparoscopic surgery can be demonstrated on the basis of the conversion rates. Careful patient selection oriented to the experience of the surgeon is required if we are to keep the conversion, morbidity, and mortality rates of laparoscopic colorectal procedures as low as possible.Supported by Ethicon Endosurgery, Norderstedt, Germany, and Takeda Pharma, Aachen, Germany.     

Use of a clinical pathway in laparoscopic gastrectomy for gastric cancer

AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.METHODS: A standardized clinical pathway for gastric cancer (GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1% (n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 83.88% (n = 1740) and 84.36% (n = 2071), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications (n = 463, 9.7%) and the need for patient observation (n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54 (1.1%). In a multivariate analysis, the intraoperative events (OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male (OR = 1.459), advanced age (OR = 1.727), total gastrectomy (OR = 2.444), combined operation (OR = 1.731), and ASA score (OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.     

Motivational enhancement and coping skills training for cocaine abusers: effects on substance use outcomes

AIMS: This clinical trial investigated effects of motivational enhancement treatment (MET) and group coping-skills training (CST) tailored for cocaine dependence. Effects of MET were hypothesized to be greater with CST and for less motivated patients. DESIGN AND INTERVENTIONS: A 2 x 2 design investigated two individual sessions of MET compared to meditation-relaxation (MRT), followed by four group sessions of CST versus drug education (ED), as daily adjuncts to intensive treatment. SETTING: The substance abuse program provided full-day treatment with a learning-theory and 12-Step orientation. PARTICIPANTS: Cocaine-dependent patients were recruited. MEASUREMENTS: Assessment included treatment retention; change in cocaine-related urge, self-efficacy, pros and cons, and motivation; substance use and problems during 12-month follow-up. Findings Of 165 patients, follow-up status is known for 90% (n = 149). Patients in MET with low initial motivation to change reported less cocaine and alcohol relapse and use days and fewer alcohol problems than MET patients with higher initial motivation. MET produced more employment improvement than MRT, with no other significant benefit for MET. Patients with higher motivation had more cocaine use and alcohol problems after MET than MRT. Group CST reduced cocaine and alcohol use during follow-up for women only and reduced alcohol relapse for men and women. CONCLUSIONS: MET is more beneficial for patients with lower initial motivation than for patients with high initial motivation. CST reduced cocaine and alcohol use for women only and reduced alcohol relapses, in contrast to results with lengthier individual CST.