腹腔镜下复位治疗腹膜透析导管移位24例

腹膜透析（PD）或血液透析（HD）是终末期肾病（ESRD）患者必须选择的治疗方法。成功的进行腹膜透析,首先是要保证腹透管的置放成功,而常规手术下的腹膜透析置管有4．4％-30％的导管功能障碍发生率。我们利用腹腔镜顺利的解决移位、包裹的导管,并确保其不再发生功能障碍。现将结果报道如下。     

腹腔镜下置Tenckhoff管的临床优势#$NL 作者：洪本林 张文意 李少鹏 杨清渭 李真慧 谢丹莉 林雅萍 陈鸿德

目的：为比较腹腔镜下与常规手术置Tenckhoff管方法的优劣。方法：对我院近5年(2012.2～201710) 63例慢性肾脏病需透析者, 其中男性31例,女性32例,年龄24岁~73岁,平均年龄(52.1+-3.3)岁,采取患者自愿选择的方式,分为腹腔镜下手术置管组(Ⅰ组)30例,常规手术置管组(Ⅱ组)33例,Ⅰ组采用腹腔镜下腹膜透析置管+腹股沟内环口内固定导管,Ⅱ组采用传统开腹手术或套管针置管,其中Ⅰ组腹部有手术史11例,占36.67%,Ⅱ组腹部有手术史2例,占6.06%,记录术前患者的基本情况、平均随访时间,比较两组住院时间及术后近期及远期并发症如切口感染、手术出血、腹腔出血、管周渗漏、导管出口及隧道感染、腹膜炎、疝、导管异位、引流不畅、堵管等方面的差异。结果：随访时间截止至2017年10月, Ⅰ组住院天数7～22天(平均13天), Ⅱ组院天数11～32天(平均32天), (P<0.05)。Ⅰ组切口感染、手术出血、腹腔出血等手术相关并发症明显低于Ⅱ组(均P<0.05);腹膜炎Ⅰ组发生2例,发生率6.7%;Ⅱ组发生5例次,发生率15.2%, (P<0.05)。Ⅰ组发生导管出口及隧道感染者2例,Ⅱ组发生导管出口及隧道感染者3例,差异均无统计学意义(P>0.05)。机械并发症(包括导管移位、导管功能不良、堵管、疝等) Ⅰ组无,Ⅱ组有7例(占21.2%),发生机械并发症其中脐疝2例(占6.1%),导管移位4例(占12.12%),(P<0.05)。结论:腹腔镜引导下Tenckhoff管置管+内固定较常规手术置管的早期及晚期并发症均低,技术存活率高,同时其定位准确、安全,切口愈合快,住院时间短,是目前临床上较为理想的腹膜透析置管方法, 但其住院平均费用较高及麻醉风险高。     

直型与卷曲型鹅颈腹膜透析导管的临床应用

目的：对比观察不同类型鹅颈腹膜透析(PD)导管的性能及可能引起的并发症,探讨不同导管的最佳适应证。方法：回顾性分析2007年3月至2010年2月在南京军区南京总医院全军肾脏病研究所行PD置管手术患者358例,按置入导管种类的不同分为鹅颈直管组及鹅颈卷曲管组。两组患者随访时间均大于3个月。观察两组患者的透析液流量、导管移位、隧道感染、出口感染、PD液渗漏等发生情况。结果：直管组231例,卷曲管组127例,两组患者的年龄、原发病情况无差别,两组患者PD隧道感染率和出口感染率无差别(P＞0.05)。直管组患者出现导管移位7例(3.0％),而卷曲管组多达26例(20.4％),两组相比有显著性差异(P＜0.01);且鹅颈直管自行复位率高,需要重新置管的患者较少。另外发现以耻骨联合上11cm定位的直管移位率低。结论：不同类型鹅颈导管各有优缺点,相比直管,卷曲管导管移位率较高。     

腹腔镜下置Tenckhoff管的临床优势

目的:比较腹腔镜下与常规手术置Tenckhoff管方法的优劣。方法:63例慢性肾脏病需透析患者,采取自愿选择的方式,分为腹腔镜下手术置管组(Ⅰ组)30例,常规手术置管组(Ⅱ组)33例,Ⅰ组采用腹腔镜下腹膜透析置管+腹股沟内环口内固定导管,Ⅱ组采用传统开腹手术或套管针置管,比较2组住院时间、术中及术后早期(1个月内)和晚期(1个月后)并发症如切口感染、手术出血、腹腔出血、管周渗漏、导管出口及隧道感染、腹膜炎、疝、导管移位、引流不畅、堵管等方面的差异。结果:Ⅰ组住院7～22d,平均13 d,Ⅱ组住院11～32 d,平均19 d(P0.05)。Ⅰ组腹腔出血明显少于Ⅱ组(均P0.05);腹膜炎Ⅰ组发生2例(6.7%),Ⅱ组发生4例次(12.1%)(P0.05)。导管出口及隧道感染者Ⅰ组发生2例(6.7%),Ⅱ组发生3例(9.1%),差异无统计学意义(P0.05)。机械并发症(包括导管移位、导管功能不良、堵管、疝等)Ⅰ组无,Ⅱ组有6例(18.2%)。结论:腹腔镜引导下Tenckhoff管置管+内固定较常规手术置管的早期及晚期并发症发生率低,技术存活率高,同时其定位准确、安全,切口愈合快,住院时间短,是目前临床上较为理想的腹膜透析置管方法。     

腹腔镜建立腹直肌隧道在腹膜透析管置入术中的临床应用

目的 比较腹腔镜引导下建立腹直肌隧道行腹膜透析管置入术与常规腹膜透析管置入术(开放式手术置管)患者的疗效及并发症发生率.方法 选择我院2009年1月～ 2011年12月首次置管并接受腹膜透析治疗的终末期肾病患者60例,将60例患者分为腹腔镜建立腹直肌隧道腹膜透析管置入组(A组)和开放式手术腹膜透析管置入组(B组),每组各30例,记录两组患者术前的基本情况、术后并发症、生存时间、退出或死亡等结局.结果 平均随访患者12.5个月,A组发生导管机械性功能障碍(堵管)1例(3.33％),B组5例(16.67％),其中漂管4例,堵管1例,两组比较差异有统计学意义(P＜0.05).A组发生导管周围渗漏1例(3.33％),B组2例(6.67％).A组术后2周发生感染2例,均为皮下隧道炎;B组术后2周发生感染2例,皮下隧道炎和腹膜炎各1例.结论 腹腔镜建立腹直肌隧道进行腹膜透析置管,管周腹膜透析液渗漏率低,较常规手术导管机械性功能障碍发生率明显下降,尤其对有腹腔手术史的患者.     

经皮穿刺置管法在婴幼儿先心病术后腹膜透析的应用

目的 总结应用经皮穿刺留置腹膜透析(腹透)管在先心病术后患儿行腹膜透析治疗时的临床经验。方法 回顾总结我科2006年9月至2014年9月,18例先心病婴幼儿术后并发急性肾功能衰竭减行腹透治疗的临床资料,其中男10例,女8例。年龄3月~16个月,体重4.5~15kg。体外循环下行根治手术11例,姑息手术7例。腹透导管在超声引导下经皮穿刺放置至盆腔最低点。腹透期间动态检测血气分析、电解质、血清肌酐、血尿素氮等变化。结果 全组死亡3例(病死率 16.7%),其中1例尿量已经恢复(尿量>1 ml／kg),但肾功能尚未完全恢复。治愈13例,患儿住院期间尿量和肾功能恢复正常。将死亡组与治愈组相关数据进行比较,治愈组和死亡组在腹膜透析治疗后,肾功能均有改善,但死亡组行腹膜透析时间较晚,并且腹透效果不理想。结论 先心病术后患儿并发急性肾功能衰减时,需早期行腹透治疗。经皮穿刺留置腹透导管行腹膜透析治疗的疗效肯定,操作方便,并发症少,可降低病死率。     

胃镜下和谐夹联合缝线快速放置鼻空肠营养管的应用分析

目的 探讨改良后的胃镜下放置鼻空肠管的方法及应用效果。方法 选取2017年7月至2019年7月深圳市第二人民医院105例因疾病不适合经口进食且消化道无梗阻、需放置鼻空肠管进行肠内营养的患者。进行随机分组,分传统方法组(A组,52例)和改良后方法组(B组,53例),观察并比较两组置管成功率、置管时间、并发症发生率。结果 两组鼻空肠管放置达十二指肠降段以下至水平段一次成功率A组88. 46%,B组100%,置管深度达75～110 cm。A组置管时间为(5. 21±1. 23) min,患者呕吐脱管6例再次置管成功,无并发症发生; B组置管时间为(3. 12±1. 10) min,无脱管,无并发症发生。B组置管时的舒适程度明显优于A组(P 0. 01)。结论胃镜下和谐夹联合缝线放置鼻空肠管是一种安全、高效、迅速、不易滑脱移位、减少医疗费用、对患者损伤小、患者舒适度高的肠内营养途径,值得临床推广应用。     

不同原因腹膜透析管移位的处理

腹透管移位是腹膜透析（腹透）的并发症之一［１，２］，常导致腹透失败。我科近５年来共施行近３００例腹透手术，其中１５例发生腹透管移位。我们根据不同原因的腹透管移位进行导尿、钢丝矫正、手术复位等处理，收到了理想的效果。现报道如下。对象和方法一、一般资料：１５例腹透管移位的病人中，男性８例，女性７例，年龄１１～６５岁、原发病为慢性肾炎６例，高血压病５例，糖尿病２例，狼疮性肾炎１例，急性肾炎１例。二、导管移位情况：移至中腹部１０例，下腹部４例，其中１例伴导管扭曲，膈下１例。三、矫正方式：（１）导尿；（２…     

腹腔镜下腹膜透析置管术的疗效及安全性

目的:比较腹腔镜下与常规腹膜透析(PD)置管术的疗效和安全性。方法:前瞻性随机入选瑞金医院肾脏内科自2008年12月至2010年4月首次置管并接受PD治疗的ESRD患者共50例,随机分为腹腔镜组(A组)和常规手术组(B组)各25例,记录术前两组的基本情况、并发症、生存时间、退出或死亡等结局;同时对A组患者比较术前、术后肝肾功能。结果:截止2010年6月,5例(10%)死亡,其中A组2例、B组3例,两组10个月生存时间分别为(A组vsB组:86.6%vs82.9%,P0.05)。两组共发生腹膜炎9例(12例次),总腹膜炎发生率为0.29次/患者年,A组腹膜炎发生率(0.24次/患者年)低于B组(0.34次/患者年)(P0.05)。两组首次腹膜炎发生时间分别为A组(31.79士23.8)周,B组(14.93士10.40)周(P0.05)。2次皮下隧道及出口感染均发生于A组(P0.05)。各项机械并发症差异均无统计学意义(P0.05),但A组无漂管发生,而B组却发生4例(P0.05)。A组术前、术后肝肾功能无差异。结论:腹腔镜下PD置管可降低术后近期内PD感染率,从根本上解决PD漂管,而且腹腔镜组患者术后未出现肝肾功能损害。     

不同PICC插管时机与老年消化系统肿瘤患者置管并发症的关系

目的探讨不同PICC插管时机与老年消化系统肿瘤患者置管并发症的关系。方法选取我院2015年2月～2018年2月收治的老年消化系统肿瘤患者110例,均行手术治疗。根据PICC插管时机分成A组(n=56)与B组(n=54)。A组于术前1d置管,B组于术后化疗前置管。记录患者置管期间并发症发生率,并根据是否发生并发症分成并发症组、非并发症组,比较两组临床特征,采用Logistic回归性分析明确置管并发症的危险因素。结果 A组并发症发生率为5. 36%,低于B组的18. 52%,差异有统计学意义(P 0. 05)。并发症组年龄≥75岁、术后化疗前置管占比分别为69.23%、76. 92%,高于非并发症组的39. 18%、45. 36%,差异有统计学意义(P 0. 05)。Logistic回归性分析提示年龄(≥75岁)、置管时机(术后化疗前)是置管并发症的危险因素(P0. 05)。结论在术前1d置管,能进一步降低置管并发症风险,且PICC插管时机是患者置管并发症发生的危险因素。     

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.     

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.     

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.     

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.