体外震波碎石治疗术后Vater壶腹嵌性残石

总结我院 1998～ 2 0 0 0年收治 31例胆道术后胆管残石病例 ,其中 3例Ｖａｔｅｒ壶腹嵌顿性残留结石 ,由于结石紧固包嵌 ,胆道镜下取石网难于通过套取 ,为避免再次手术 ,我们采用体外震波碎石技术治疗 ,取得了满意疗效 ,现报告如下。1　临床资料1.1　一般资料　 3例病人均经Ｔ管造影发现胆总管下端梗阻 ,经Ｔ管窦道胆道镜可见结石嵌顿Ｖａｔｅｒ壶腹部 ,取石网无法张网取石 ,活检钳亦无法钳夹碎石 ,导致取石失败。1.2　治疗方法　术前给予度冷丁 5 0ｍｇ肌注 ,经Ｔ管窦道注入造影剂 ,通过体外震波碎石机Ｘ线定位后碎石 ,完毕后注入 10ｍｌ利…     

胆道镜经T管窦道取石网篮嵌顿12例分析

目的探讨胆道镜经T管窦道取石术中取石网篮嵌顿的原因和对策。 方法回顾性分析湖南省人民医院2017年1月至2019年12月胆道术后经T管窦道取石术中取石网篮嵌顿12例患者资料,统计嵌顿部位结石胆管内径比、结石性质、处理方式、处理结局。 结果12例术中取石网篮嵌顿患者术前T管造影片测量结石直径/胆管狭窄口直径均>1.2 cm,嵌顿结石均为胆色素结石。其中3例通过取石网篮往一侧推进后收网成功、3例使用另外胆道镜进行碎石后取出、6例剪断取石网篮后碎石取出。所有患者均取出取石网篮,其中5例胆道出血,均使用去甲肾上腺素盐水冲洗后止血。 结论需重视胆道镜经T管窦道取石网篮嵌顿,术前T管造影结石胆管内径比可以预测嵌顿可能,碎石有利于避免因强行拔出导致出血,保障手术安全。     

钬激光碎石术在胆道结石中的临床应用(附17例报告)

目的 探讨镇激光碎石术治疗胆道结石的疗效及安全性。方法 纤维胆道镜直视下用钬激光碎石治疗肝内胆管结石和胆道术后残余结石17例。结果 17例经T管造影及术中胆道造影证实共有36枚结石。不用钬激光直接取出7枚结石；经钬激光碎石取出24枚结石，成功率82．8％(24／29)；余5枚结石在3级胆管以上，胆道镜无法直接观察到，未作钬激光治疗。术后1月B超及胆道造影未见肝外胆道内残余结石，未作治疗的肝内胆管结石仍在原位。全部病例无胆道出血、胆漏、肝功能损害等并发症。T管拔除后随访半年，总胆管内未发现残余结石，无胆管扩张及胆管炎征象，肝功能检查无异常。结论 在纤维胆道镜直视下用钬激光碎石治疗肝内胆管结石和胆道术后残余结石，结石清除率可达82．8％，有效、安全。     

经胆道输尿管镜体压弹道碎石处理肝内胆管结石

回顾性分析16例复杂肝内胆管结石患者术中应用经胆道输尿管镜体压弹道碎石术的临床资料。其中15例患者结石取净,1例术后经T管胆道造影及复查B超提示胆总管下段有泥沙样结石残留,经胆道冲洗后结石消失。提示:应用电视监视下经胆道输尿管镜体压弹道碎石是处理复杂肝内胆管结石的一种有效方法,可明显提高肝内胆管结石的疗效,减少结石残留。     

胆管扩张术加支撑管置放使左肝管结石并狭窄免于肝切除

作者经T管行胆管扩张,放置经皮肝穿造影(PTCS)管作支撑,治疗肝内胆管结石并狭窄13例,效果满意.病例选择1991～1992年肝内胆管结石并狭窄13例,男5例,女8例.年龄34～66岁(平均50岁).所有病例均符合下列条件:(1)因肝胆管结石第1次手术治疗;(2)肉眼观左肝正常;(3)无明显肝内胆管癌相关症状.方法在X线监视下,经T管将导丝插过肝内胆管狭窄处,用Teflon扩张器(Medi—Tech,Westwood,Mass) 行胆管扩张,然后置放12F或14F的PTCS管作支撑.扩张术常在术后4周开始,以后隔周进行1次,直到可合适地置放18F～20F的PTCS管作支撑为止.拔除PTCS管,插人改良的纤维胆道镜(CHFP~(10),Olympus),用取石网取出结石.若结石较大(直径>1.5cm)或嵌顿,可经内镜行电气水压碎石,其小碎片可用取石网套取和生理盐水冲洗.必要时可重复胆道镜检和碎石.结石完全排除后至少放置支撑管3个月.胆道镜检及胆道造影证实结石是否取净,若胆管显影欠佳,则行腹部超声波检查.3个月后,若胆道造影显示无结石复发或胆管无狭窄,可拔除支撑管.     

胆道镜在难治性胆管残余结石中的应用

目的探讨胆道镜在难治性胆道残余结石的治疗。方法行胆总管切开取石、T管引流术后的肝内外胆管残余结石患者120例,其中30例为复杂性肝内胆管残余结石,对其临床资料作回顾性分析。结果取石难度较大的主要原因有结石因素和胆管因素;其中结石因素11例,胆道因素19例,其中12例存在肝内胆管狭窄,3例合并胆管的汇流异常或胆管变异;4例结石所在胆管与其汇入的胆管呈锐角。经肝胆B超或CT证实胆管残余结石,再次行胆道镜检查和(或)结合术中胆道镜超选造影,成功发现残余结石,经胆管扩张、液电碎石及取石等措施将残余结石取净,无残留结石发生。结论肝内胆管残余结石难治性的原因复杂,针对不同原因采用不同的方法。结合胆道镜超选造影、胆管扩张、液电碎石可提高取石成功率。     

术中胆道镜取石失败原因分析及对策探讨

目的分析术中使用胆道镜治疗胆道结石常见的失败原因以及对策。方法对自1997年1月至2006年12月间292例曾经使用胆道镜术中取石的病例进行回顾分析。结果292例患者中,术后有胆道残石39例,残石率为13．4％。其中术中明确结石未取净者19例;经术后T管造影及胆道镜明确胆道残石者20例。胆道镜术中取石失败原因是多方面的。39例残石者中包括肝内胆管结石伴胆管变异14例;肝内胆管结石伴胆管开口狭窄11例;肝内胆管大结石嵌顿3例;胆总管下段节段性狭窄伴结石3例。结论术中要细致进行胆道镜检查,要逐叶逐段检查各条胆管,要注意有无胆管变异．要找出狭窄的胆管开口以及胆总管下段有无节段性狭窄等情况,对于大的胆管结石建议行激光或液电碎石。术中B超定位有助于降低术后残石率。     

电子胆道镜下钬激光碎石治疗难取性胆管结石15例报告

目的 探讨电子胆道镜下钬激光碎石治疗难取性胆管结石的临床应用价值.方法 肝内外胆管结石15例,其中Ⅱ级肝管结石8例,Ⅲ级5例,Ⅱ、Ⅲ级均有结石2例;嵌顿结石7例,铸形结石3例,游离结石5例.通过电子胆道镜应用钬激光在直视下碎石,将难取性结石击碎后用取石篮套出,或注水冲出.结果 15例均在电子胆道镜下经钬激光碎石后取石成功,取石时间20～55 min.腔镜手术组8例,其中胆总管一期缝合2例(术前行经内镜逆行胰胆管造影并留置鼻胆管引流),T管引流6例;开腹手术组3例,均留置T管;经窭道取石4例,于窦道留置导尿管,3d后造影明确无残余结石后拔除.术后无胆道出血、胆漏;1例并发胰腺炎,经治疗后痊愈.14例获随访,平均12个月,均经磁共振胰胆管造影或T管造影检查,未发现结石复发、残留以及胆道狭窄.结论 电子胆道镜下钬激光碎石治疗难取性胆管结石,具有创伤小、恢复快、操作简单、安全性较好等优点,有较好的临床应用前景.     

体外震波碎石与纤胆镜联合应用治疗肝内胆管残石的体会

本文报告体外震波碎石与纤维胆道镜联合应用治疗多发肝内胆管残石３０例。震波治疗结石破碎率为９３．３３％，使大结石嵌顿解除，然后行纤胆镜取石，结石取净率为９６．６７％，较以往治疗这类病从仅靠纤胆取石网取平均每例以石次数减少１．３７次延长每个取石网倩次数达２０次。体外震波碎石解决了纤胆镜以吉石、嵌顿结石取出困难的问题，百纤胆镜则又弥补了体外震波碎石后碎无法有胶排出的不足。二者在临床上联合应用有显著的优越     

体内冲击波液电碎石治疗复杂肝内外胆管残余结石

2005年1月～2006年1月，我们对胆道探查术后应用体内冲击波胆道液电碎石治疗复杂肝内外胆管残余结石40例，38例（95％）取石成功，现报道如下。1 临床资料与方法 1．1 一般资料胆道术后T管造影发现肝内结石呈铸型分布，巨大结石，结石嵌顿，术后纤维胆道镜取石中取石篮不易套取，结石被套住后不能取出者，胆管狭窄或相对狭窄均为碎石对象。     

A Randomized Prospective Comparison of Patient‐Assessed Satisfaction and Clinical Outcomes with Radioactive Seed Localization versus Wire Localization

Radioactive seed localization (RSL) has emerged as an alternative to wire localization (WL) in patients with nonpalpable breast cancer. Few studies have prospectively evaluated patient satisfaction and outcomes with RSL. We report the results of a randomized trial comparing RSL to WL in our community hospital. We prospectively enrolled 135 patients with nonpalpable breast cancer between 2011 and 2014. Patients were randomized to RSL or WL. Patients rated the pain and the convenience of the localization on a 5‐point Likert scale. Characteristics and outcomes were compared between groups. Of 135 patients enrolled, 10 were excluded (benign pathology, palpable cancer, mastectomy, and previous ipsilateral cancer) resulting in 125 patients. Seventy patients (56%) were randomized to RSL and 55 (44%) to WL. Fewer patients in the RSL group reported moderate to severe pain during the localization procedure compared to the WL group (12% versus 26%, respectively, p = 0.058). The overall convenience of the procedure was rated as very good to excellent in 85% of RSL patients compared to 44% of WL patients (p < 0.0001). There was no difference between the volume of the main specimen (p = 0.67), volume of the first surgery (p = 0.67), or rate of positive margins (p = 0.53) between groups. RSL resulted in less severe pain and higher convenience compared to WL, with comparable excision volume and positive margin rates. High patient satisfaction with RSL provides another incentive for surgeons to strongly consider RSL as an alternative to WL.     

Bracketed radioactive seed localization vs bracketed wire‐localization in breast surgery

Multiple localizers placed in a bracketed fashion facilitates excision of radiographically extensive breast lesions. In this study, bracketed radioactive seed localization (bRSL) was compared to bracketed wire localization (bWL). We hypothesized that bRSL would achieve adequate margins and decrease re‐operation rates with similar or less specimen volumes (SV) than bWL. Retrospective review identified patients who underwent bracketed breast procedures at an academic medical center. Data collected included patient demographics, tumor features, treatment variables, and surgical outcomes. Wilcoxon rank‐sum test and chi‐square test were used to compare continuous and categorical data, respectively. A multivariable logistic regression model was used to evaluate the association between re‐excision and localization technique after adjusting for clinically relevant variables. Patients who underwent bWL were 3.9 times more likely to undergo re‐excision compared to patients in bRSL group (OR=3.9, 95% CI: 2.0‐7.4). Initial and total SV did not significantly differ between the two groups (P=.4). Patients were significantly more likely to undergo a mastectomy in the bWL group than in the bRSL group (24% vs 7%; P<.01). For patients undergoing excision of radiologically extensive breast lesions, bRSL serves as an alternative to bWL. In this retrospective study, bRSL was associated with a decreased re‐excision rate with similar SV and a lower rate of mastectomy when compared to bWL.     

Radioactive seed localization of nonpalpable breast lesions is better than wire localization

BACKGROUND: The current study sought to validate radioactive seed localization (RSL) as an alternative to wire localization (WL) to facilitate the operative excision of nonpalpable breast lesions. METHODS: One hundred consecutive patients underwent preoperative WL and the next 100 RSL. Margins were considered negative if > or =2 mm from in situ and invasive disease. RESULTS: RSL resulted in 100% retrieval of the seeds and lesions. Sixty-eight percent of patients underwent RSL at least 1 day before surgery. RSL resulted in a 35% relative improvement in the rate of negative margins in the first specimen (P = 0.01) and a 62% relative improvement in the rate of reoperation for positive margins (P = 0.01). The sentinel lymph node (SLN) identification rate was 100% in both groups. CONCLUSIONS: RSL is effective and safe, and this procedure significantly improved the rate of negative margins in the first specimen and the rate of reoperation for positive margins compared to WL. We highly favor RSL over WL.     

A multi-site validation trial of radioactive seed localization as an alternative to wire localization

Abstract:  This study aims to validate radioactive seed localization (RSL) as an alternative to wire localization (WL) in the operative excision of nonpalpable breast lesions. Eligible patients were recruited sequentially. A sample of 99 patients treated with WL was compared to the next 383 patients treated with RSL. Margins were considered "negative" if ≥2 mm from in-situ and invasive disease. Pain and convenience scores were recorded on a 10-point scale. Patient characteristics and histology were similar. The lesion and localization device were retrieved in all patients. Margins of the first specimen were negative in 73% of RSL patients, versus 54% of WL patients (p < 0.001). A second operation was required in 8% of RSL patients to achieve negative margins, versus 25% of WL patients (p < 0.001). Pain scores were not statistically different. However, the RSL group had higher convenience scores (p = 0.015). RSL is safe, effective, and compared to WL, reduces the rates of intraoperative re-excision and reoperation for positive margins by 68%. Patient satisfaction is improved with RSL. We strongly favor RSL over WL.     

Rare localizations of echinococcosis: personal experience

BACKGROUND: The rare localizations of hydatidosis represent an interesting topic, especially with reference to epidemiological and diagnostic problems. Hydatid disease, common in Mediterranean countries, still remains endemic in some regions of Italy. METHODS: In the period April 1983-October 2003 73 patients with hydatid disease were observed. RESULTS: Seven patients (9.5%) presented a primary rare localization (thyroid, kidney, sacrospinal muscle, peritoneum and spleen). The main peculiarity of primary rare hydatidosis localizations concerns diffusion of the infecting embryo; the most reliable hypothesis is that liver and lung can be bypassed through precapillary anastomosis between pre- and post-parenchymal circulation. The new imaging techniques allow a correct topographic evaluation and so a radical surgical treatment. The chemotherapy, complementary to surgery, produced degenerative modifications of parasite in 75.8% of the present cases and reduction of recurrence from 23.3% to 6.7%. At follow up of 1-5 years no patients had recurrence. CONCLUSION: It is important to be aware, especially in countries where echinococcosis is endemic, that it is possible to find an echinococcosis cyst in a rare localization.     

结肠镜在腹腔镜结直肠手术中的应用(附24例报告)

目的 探讨结肠镜在腹腔镜结直肠手术中的应用价值.方法 回顾分析2009年1月至2013年10月为24例患者于腹腔镜术中应用纤维结肠镜辅助定位的临床资料.结果 手术均顺利完成,无一例中转开腹.其中内镜辅助腹腔镜治疗15例,腹腔镜辅助内镜治疗4例,内镜腹腔镜同步切除2例,腹腔镜追加根治术3例.术后无吻合口漏、吻合口出血等并发症发生.术后平均随访18个月,恶性肿瘤患者中无一例复发.结论 双镜的联合应用扩展了单镜治疗的适用范围.增加了手术安全性,明显降低了并发症的发生率,大大减少了手术创伤,是治疗结直肠良恶性肿瘤的合理方法,值得推广.     

In vitro photosensitization II. An electron microscopy study of cellular destruction with mono-L-aspartyl chlorin e6 and photofrin II

Primary sites of subcellular destruction with photofrin II (PfII) and mono-L-aspartyl chlorin e6 (MACE) were determined by transmission electron microscopy (TEM). Potorous tridactylus (PTK2) cells were grown in Rose chambers and incubated for 24 hr with a sensitizer concentration sufficient to provide 100% mortality. Cells were irradiated with laser light and fixed and processed for electron microscopy at various times post-irradiation. The results indicate that PfII initially destroys mitochondria, whereas MACE destroys lysosomes. Both conclusions are consistent with fluorescence subcellular localization studies.     

Intraoperative Ultrasound Localization of Nonpalpable Breast Lesions

Background: The use of preoperative wire localization (PWL) for excision of nonpalpable breast lesions has several disadvantages. The purpose of this study was to evaluate the use of intraoperative ultrasound localization (IUL) and to compare it with PWL.Methods: Twenty-nine patients (22 with cancer) underwent IUL in a solo surgical practice over a 21-month period. They were compared to 22 patients with cancer in the same practice who underwent PWL in a similar time period. Parameters analyzed included accuracy of lesion removal, margin involvement, extent of disease-free margin, and the amount of tissue removed.Results: The targeted lesions were accurately removed 100% of the time, and disease-free margins were obtained at the first operation in 82% of patients in both groups. An equivalent amount of disease-free margin (IUL, 6.6 mm; PWL, 6.7 mm) was obtained with IUL while removing a smaller (IUL, 62.6 cm³; PWL, 81.1 cm³) mean volume of tissue.Conclusions: IUL is an accurate method of localizing most nonpalpable mass lesions identified on mammography. Equivalent margin status can be achieved while removing no more tissue than with PWL. The trauma of wire localization in an awake patient is avoided.     

小切口髓核摘除术切口定位及病变间隙的确认

目的：准确的皮肤切口定位和突出间隙的确认是小切口椎间盘摘除术的成功关键之一。方法：我们对５３８例腰椎间盘突出症病人行过小切口椎间盘摘除术。术前我们采用：读、摸、按相结合的皮肤切口定位法，术中又用摸、摇、触相结合的办法对突出间隙进行再确认。结果：定位准确率可达１００％。避免了使用单一固定的解剖关系定位法所可能造成的定位错误。结论：该方法是利用病人腰椎的正常解剖结构，结合病人病椎的病理变化特点，同时又考虑到病人解剖变异的可能而设计的临床定位法。它对小切口椎间盘突出摘除术有一定的临床指导意义。