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。     

内镜黏膜下剥离术治疗食管早期癌及癌前病变

目的 探讨内镜黏膜下剥离术(ESD)治疗食管早期癌及癌前病变的应用价值.方法 对胃镜发现的食管早癌和上皮内瘤变、深度未超越黏膜卜层者15例进行ESD治疗:(1)黏膜下注射生理盐水抬高病变;(2)预切开病变周围黏膜;(3)沿病变下方黏膜下层完整剥离病变.结果 15例食管早癌和上皮内瘤变病变,最大卣径2.5～4.5 cm(平均3.2 cm).14例病变成功完成ESD治疗,ESD成功率93.3%(14/15).所有剥离病变全部得到病理确诊,基底和切缘未见病变累及.ESD手术时间(白黏膜下注射至完整剥离病变)45～150 min,(平均75 min).术中出血量平均30 ml,均经电凝、氙离子凝固术和止血夹成功止血,未出现需再次内镜下治疗的出血;ESD穿孔发生率0(0/15).术后随访14例,随访期6～18个月(平均11.5个月),创而完全愈合,无一例病变残留和复发.结论 ESD是治疗食管早癌和癌前病变的新方法,不仅能完整切除较大的病变,还能提供完整的病理学诊断资料.     

微探头超声内镜指导内镜下剥离联合圈套结扎治疗上消化道固有肌层肿瘤的初探

目的探讨微探头超声内镜指导内镜下剥离联合圈套结扎治疗来源于上消化道固有肌层黏膜下肿瘤（SMT）的疗效和安全性。方法对内镜发现的上消化道SMT行EUS,对其中来源于固有肌层的SMT行圈套结扎后应用针形切开刀行对应内镜下剥离治疗：内镜下圈套结扎病变;预切开病变表面中央的黏膜;剥离黏膜下层组织显露病变,完整切除病变。结果来源于上消化道固有肌层的SMT共13例,术后病理诊断为食管平滑肌瘤2例,胃平滑肌瘤3例,胃间质瘤7例,胃血管球瘤1例。病变直径0．8～1．5cm,平均1．2cm。13例病变均一次性完整切除,其中1例术后出现消化道穿孔,应用金属夹成功封闭,未转外科手术。结论微探头超声内镜指导内镜下剥离联合圈套结扎治疗来源于上消化道固有肌层直径≤1．5cm的SMT是安全、有效的,可完整切除病变,提供完整的病理学诊断资料,可达到与外科手术同样的治疗效果。     

内镜黏膜下剥离术在消化道肿瘤治疗中的应用

目的探讨内镜黏膜下剥离术（ESD）在治疗消化道肿瘤中的应用价值。方法收集近2年电子胃肠镜发现的15例胃与大肠黏膜及黏膜下肿瘤,内镜超声检查和/或病理活检进一步明确病灶大小,位置及性质,ESD操作步骤;黏膜下注射液体以抬高病灶,接着预切开病灶周围黏膜,之后使用Hook刀或IT刀沿病灶黏膜下层完整剥离病灶。结果 15例患者均顺利完成ESD治疗,病变直径1.0～3.5cm,平均2.3cm,ESD手术时间30～175min,平均73min,ESD治疗过程中创面均有少量出血,均经电凝或金属钛夹止血,无术后延迟出血发生,穿孔发生率为6.7%（1/15）,术后随访1～8个月,未见肿瘤残留或复发。结论 ESD作为一种内镜微创治疗,能实现较大病灶的完全剥离,为临床提供完整的病理学资料,也为消化道早期黏膜及黏膜下肿瘤的治疗开辟了新的治疗途径。     

内镜黏膜下剥离术治疗消化道固有肌层肿瘤

目的 探讨内镜黏膜下剥离术(ESD)治疗来源于消化道固有肌层黏膜下肿瘤(SMT)的疗效和安全性.方法 对内镜发现的消化道SMT进行超声检查,对来源于固有肌层的SMT应用头端弯曲的针形切开刀进行ESD治疗:(1)黏膜下注射生理盐水;(2)预切开病变周围黏膜;(3)剥离黏膜下层组织显露病变,一次性完整切除病变.结果 来源于固有肌层的消化道SMT 10例,术后病理诊断为食管平滑肌瘤1例,胃平滑肌瘤1例,胃间质瘤6例,直肠平滑肌瘤和间质瘤各1例.病变最大直径0.5～3.0 cm(平均1.4 cm).9例病变一次性完整剥离,1例创面肿瘤残留接受外科手术.ESD手术时间30～150 min(平均73.5 min).1例术中出现消化道穿孔,应用金属夹成功闭合,未转开腹手术修补.术中平均出血量约40 ml,术后均未出现出血,亦未出现其他并发症.结论 ESD治疗来源于固有肌层的消化道SMT安全、有效,大多可以一次性完整切除病变,提供完整的病理学诊断资料,达到外科手术同样的治疗效果.     

内镜黏膜下剥离术在治疗胃肠道黏膜切除术后残留和复发病灶中的应用

目的 探讨内镜黏膜下剥离术(ESD)治疗胃肠道黏膜切除术(EMR)后残留、复发病变的疗效和安全性.方法 自2006年6月至2007年11月对EMR术后内镜随访发现的15例残留和复发病变进行ESD治疗,先于黏膜下注射生理盐水以抬高病变,接着预切开病变周围黏膜,再沿病变下方黏膜下层进行剥离,对瘢痕形成部位直接应用Hook刀沿瘢痕基底切线方向进行切开.结果 15例EMR术后残留和复发病变,位于胃6例、结肠3例、直肠6例,病变直径0.8～3.5 cm,平均2.3 cm.所有病变抬举征(一).14例病变成功完成ESD治疗,成功率93.3%(14/15),13例术后病理切缘和基底无肿瘤累及,完整切除率86.7%(13/15).ESD手术时间60～155 min,平均87 min.治疗中创面均有少量出血,全组未出现术后出血.2例治疗中局部剥离较深、腹腔出现游离气体,成功保守治疗,未转外科手术,ESD穿孔发生率13.3%(2/15).术后平均随访13个月,无复发.结论 ESD治疗EMR术后残留和复发病变相对安全、有效,不仅能完整切除残留和复发病变,还能提供完整的病理诊断资料.     

内镜黏膜下挖除术治疗胃固有肌层问质瘤

目的探讨内镜黏膜下挖除术（endoscopicsub—mucosalexcavation,ESE）治疗胃固有肌层间质瘤的疗效和安全性。方法对内镜超声（EUS）发现的源于胃固有肌层的黏膜下肿瘤（submucosaltumor,SMT）行ESE治疗：黏膜下注射生理盐水抬高病变,切开病变周围黏膜,剥离病变周围组织,完整切除病变。结果17例源于胃固有肌层的黏膜下肿瘤均成功挖除,2例ESE治疗中发生穿孔．应用金属止血夹成功夹闭。术后病理诊断为间质瘤,其中胃底8例,胃体8例,胃窦1例。病变最大直径0．7～4,3（平均1．5）cm。全组未出现ESE术后出血,随访2～30个月,恢复良好,未出现复发或转移。结论ESE治疗小的胃固有肌层间质瘤安全、有效,能一次性完整切除病变,提供完整的病理诊断资料。且术后恢复快。     

内镜黏膜下剥离术治疗上消化道病灶的初步评价

目的 探讨内镜下黏膜剥离术(ESD)处理上消化道病灶的疗效和安全性.方法 以胃镜检查发现的上消化道黏膜病灶及黏膜下病灶作为入选对象,通过超声内镜和(或)活检病理检查明确病灶大小、位置、范围、性质,应用钩刀、IT刀、氩气刀及高频电凝电切术进行ESD操作,步骤包括:(1)胃镜及黏膜染色确定病灶,针刀或者氩气刀标记病灶;(2)黏膜下注射含靛胭脂及肾上腺素生理盐水抬高病变;(3)预切开病变周围黏膜一圈;(4)自病变黏膜下层完整剥离病灶.术后应用抑酸、黏膜保护剂治疗,术后第1、2、6个月内镜随访,评价溃疡是否愈合以及病灶有无残留与复发.结果 2006年8月至2008年1月,共153例患者进入观察研究.黏膜病变85例(溃疡型病灶2例,隆起型病灶48例,糜烂型病灶35例),病灶直径0.4～5.0 cm,平均2.0 cm;手术时间15～210 min.平均55min.所有病例均切除病灶,其中1例迟发性出血行内镜下紧急止血,7例穿孔均保守治疗愈合.随访期溃疡创面均愈合,其中4例复发,3例再次ESD完整切除病灶,1例手术切除.黏膜下肿瘤68例,52例术前行超声内镜检查,其余病例经术后病理证实.病灶直径0.4～4.0 cm,平均1.2 cm;手术时间10～182 min,平均41 min;68例完整剥离黏膜下肿瘤,1例改行尼龙绳结扎治疗.1 1例穿孔均保守治疗,1例术后出血未控制行手术治疗.结论 ESD作为一种微创治疗方法,能实现较大病变的一次性大块剥离,剥离的病变能提供完整的病理诊断资料,病变局部的复发率低,并发症少,为上消化道黏膜层病灶尤其是早期肿瘤以及黏膜下肿瘤的治疗开辟了新的途径.     

大型低位直肠肿瘤的内镜下黏膜切除术与内镜黏膜下层剥离术的临床对比研究

目的 对比观察内镜下黏膜切除术（endoscopic mucosal resection，EMR）与内镜黏膜下层剥离术（endoscopic submucosal dissection，ESD）对大型低位直肠肿瘤的治疗效果。方法选择肿瘤直径大于3．0cm，肿瘤下缘距肛缘齿状线小于5cm，有内镜治疗适应证的56例低位直肠肿瘤，应用EMR或ESD进行治疗，其中EMR治疗36例，ESD治疗20例，术后3～18个月行内镜随访确认有无残留，以评价切除效果，记录术中及术后发生的并发症及处理情况，并分析切除标本的病理组织学结果。结果 接受EMR治疗的36例中，35例经首次或再次EMR治疗病变完整清除，肛门功能完好，保肛治愈率为97．2％，术后病理报浸润癌（SM癌）再追加外科Mile’s根治手术者1例（2．8％）；接受ESD治疗的20例中，11例经首次或再次ESD治疗完整清除病变，肛门功能完好，治愈率55．0％，ESD治疗未成功改行EMR成功清除病变6例（30．0％），肛门功能均完好，全组保肛治愈率为85．0％，ESD组因严重并发症（迟发性大出血）转外科行Mile’s手术者2例（10．0％），因病变残留转行外科Mile’s手术者1例（5．0％）。并发症：EMR组术中平均出血20ml，最大出血160ml，均无需输血治疗，无穿孔发生，无术后并发症。ESD组平均术中出血150ml，最大术中出血量800ml，均内镜下止血成功，但3例患者需接受输血400ml，另有2例于术后26h及44h发生迟发大出血，内镜下止血失败转行外科手术。结论EMR是一种安全微创的内镜治疗手段，对大多数平坦型大肠肿瘤能达到完全切除效果，与EMR相比，ESD对低位直肠病变切除的效果不及EMR术，且手术风险更大。     

内镜黏膜下剥离术治疗消化道早期癌及癌前病变

目的 探讨内镜黏膜下剥离术(ESD)治疗消化道早期癌及癌前病变的操作方法、疗效、并发症等.方法 采用前瞻性研究方法,按照入选标准选取食管、胃、结直肠早癌及癌前病变患者28例,共治疗病变29处.内镜下明确病变边界,采用氩离子凝固(APC)或针式刀在距病变边缘0.3～0.5 cm处环周点状凝固标记,再行黏膜下注射,使病变完全抬起,在距离标记点约0.5 cm处用针刀及IT刀环行切开黏膜至黏膜下层,用IT刀逐渐将黏膜剥离,部分病变回缩后用圈套器将病变黏膜圈套电凝切除.术中出血用热凝同止血钳、APC或金属夹止血.切除病变回收送病理.所有病例均按计划内镜随访.结果 本组29处病变中,22处病变完整切除,6处病变分块切除,1处病变未能全部切除.胃窦病变完整切除率为100.0%(12/12),胃角至贲门间病变为5/7,食管病变为3/5,结直肠病变为2/5.1例出现术后迟发出血.胃窦病变平均手术耗时最短,为48 min.20例随访1～12个月均无病变残留或复发.结论 ESD技术可以根据病变的大小及形状确定切除范围,对较大病变可以整块切除.缺点之一是操作过程较复杂、技术难度较大.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.