经锁骨下动脉途径植入药盒导管化疗的护理

随着介入技术的迅猛发展,介入治疗在恶性肿瘤的治疗中发挥着越来越大的作用,为大量中晚期肿瘤患者带来了新的希望。2008年开始,我科尝试对一些肝癌、胆囊癌、胰腺癌、     

改良式经皮肝动脉化疗药盒植入技术中国专家共识(2022版)

近年来,肝动脉灌注化疗(HAIC)作为介入治疗技术之一,应用于治疗进展期肝胆恶性肿瘤的效果逐渐受到认可。但不同临床中心的HAIC操作技术差别较大,缺乏行业规范,且多数以一次性穿刺留管形式完成。为了满足HAIC需长时间持续灌注、多次反复给药的特点,经皮肝动脉化疗药盒系统比一次性穿刺留管更具优势。改良式经皮肝动脉化疗药盒系统植入术采用管头固定技术、肝内外血流再分布术,具有创伤小、导管移位率低、实现全肝灌注、患者舒适性高、并发症少等优点,已在国内外多个临床中心得以证实。为了更好地规范HAIC治疗技术,通过回顾文献并经临床实践和充分讨论,参与本共识编写专家达成改良式经皮肝动脉化疗药盒植入术标准化操作流程、技术要点、HAIC方案、术后并发症防治、药盒系统维护及相关护理常规等共识。     

经皮经肝门脉导管药盒植入治疗肝癌7例报告

对于失去手术机会的中晚期肝癌患者,肝动脉灌注化疗栓塞术成为目前主要的治疗手段。同时联合微波治疗、热射频消融治疗、冷冻治疗、B超引导下的瘤体内无水酒精注射等治疗措施均有一定的疗效,故对中晚期肝癌由单一的治疗模式转变综合治疗模式。我科2002年10月至2004年6月对7例不能手术的中晚期肝癌患者经肝动脉灌注化疗栓塞术无效者,行经皮经肝门脉导管药盒植入,门静脉持续灌注化疗取得了较好疗效,现报道如下：     

冠状-锁骨下动脉窃取综合征的治疗

目的确定锁骨下动脉血管重建术是否可以避免和治疗冠状动脉和锁骨下动脉窃取综合征.方法 1985年-2004年40名被诊断患有冠心病伴锁骨下动脉阻塞病,其中在冠状动脉移植手术前被诊断的病人为组1(n=10),冠状-锁骨下动脉窃取综合征发生在冠状动脉旁路移植手术后被诊断的病人为组2(n=30).组1病人直接接受同侧锁骨下动脉旁路移植术和同侧乳内动脉被使用为至少冠状动脉旁路当中的一个管道.组2病人接受胸外锁骨下动脉-颈动脉旁路术,20例经皮下穿刺血管成形和支架术,作为冠状-锁骨下动脉窃取综合征的治疗.结果所有病人经过治疗后症状消失.一名病人接受了经皮血管成形和支架术后,死于进行性的肾衰竭.随访共计为117病人年(平均3.1年/病人).组1血管旁路移植术后的开放率是100%(平均随访3.7年).组2经过经皮穿刺血管内成形和支架术或旁路移植术后(平均随访2.9年).结论锁骨下动脉血管重建术可以避免冠状-锁骨下动脉窃取综合征,并对其提供有效的治疗,同时降低了手术风险.中期随访显示旁路管道具有良好的开放率.     

锁骨下动脉近端闭塞的诊疗进展

锁骨下动脉近端闭塞是一种常见的外周动脉疾病,发病率约为1.9％.其常见症状为上肢缺血、头晕和短暂性脑缺血发作.由于大部分锁骨下动脉疾病患者无临床症状,该疾病常被忽视.现分别介绍锁骨下动脉近端闭塞的五种常见诊断方法(无创四肢动脉血压、双功能超声、计算机体层血管成像、磁共振血管成像和数字减影血管造影)以及三种治疗方法(药物...     

经皮植入药盒系统肝动脉持续小剂量灌注氟脲嘧啶脱氧核苷治疗晚期原发性肝癌的临床疗效与毒副反应

目的探讨经肝动脉持续性灌注氟脲嘧啶脱氧核苷(FUDR)治疗晚期原发性肝癌的临床疗效与毒副反应。方法 28例无外科手术指征的晚期原发性肝癌患者,采取经左锁骨下动脉植入药盒肝动脉内灌注FUDR0.4 mg·m~(-2)·d~(-1),持续14 d,每3周重复1次。有肝外转移者用表阿霉素60 mg/m~2,iv,d1。结果有效率为17.9%,稳定者为42.9%,疾病控制率60.7%。甲胎蛋白(AFP)下降超过20%者为21.4%,客观有效率为83.3%,生存期23.5个月。全组Karnofsky评分(KPS)改善者35.7%,稳定者39.3%。中位生存期为10.2个月,1年及2年生存率分别为57.1%和10.7%,其毒副作用可以耐受。结论经药盒肝动脉持续性灌注FUDR是治疗晚期原发性肝癌的有效方法,可改善患者的生存质量,延长生存期。     

左颈总动脉至左锁骨下动脉转流加支架象鼻术治疗复杂Stanford B型主动脉夹层

目的:总结左颈总动脉至左锁骨下动脉转流,加支架象鼻术治疗复杂Stanford B型主动脉夹层的临床经验及效果。方法:回顾性分析2009年1月至2011年12月,北京安贞医院5例男性复杂型Stanford B型主动脉夹层患者,行左颈总动脉至左锁骨下动脉转流加直视下支架象鼻手术。平均年龄(48.4±10.5)岁,合并高血压5例,急性夹层2例,慢性夹层3例,胸降主动脉覆膜支架置入术后Ⅰ型内漏2例。合并风湿性心脏病1例,合并糖尿病1例。结果:5例Stanford B型主动脉夹层患者均于全麻下行左颈总动脉至左锁骨下动脉转流加直视下支架象鼻术。同期手术包括1例主动脉瓣及二尖瓣机械瓣置换术。平均体外循环时间(151.8±29.2)min,心肌阻断时间平均(76.0±34.39)min,选择性脑灌注时间平均(21.2±8.0)min。住院时间平均(19.8±6.2)d,术后住院时间平均(9.0±2.7)d,ICU时间平均(1.4±0.5)d。5例患者均无截瘫、脑梗死,无围手术期死亡。术后复查夹层破口均封闭良好,未见残余漏。结论:左颈总动脉至左锁骨下动脉转流加直视下支架象鼻手术对复杂型Stanford B型夹层,是有效的外科治疗手段。近期效果满意,远期效果有待进一步观察。     

肝动脉栓塞化疗联合经皮射频消融治疗老年人肝癌

我院2000年2月～2003年2月开展肝动脉栓塞化疗（TACE）联合经皮射频消融（PRFA）治疗不能手术治疗的老年人肝癌的临床研究,以探讨2种方法联合治疗的价值.     

锁骨下动脉窃血综合征及其外科治疗

１９８０年１２月以来，收治９名锁骨下动脉窃血综合征患者，均以脑缺血及上肢缺血为主要症状。７例做了动脉造影检查，５例行人工血管移植术，１例锁骨下动脉窃血综合征是由颈肋压迫所致，做了颈肋切除术；手术治疗６例，效果良好。在讨论中，作者指出：动脉粥样硬化、大动脉炎为锁骨下动脉窃血综合征的主要病因，颈肋压迫也可为病因之一。人工血管转流术（尤其是腋─腋动脉人工血管转流术）是常用有效的手术方法。     

不同入路重建左锁骨下动脉的有效性和安全性比较

目的：探讨不同入路重建左锁骨下动脉（left subclavian artery, LSA）的有效性和安全性。方法：选取2017年5月至2020年6月,在遂宁市中心医院行体外预开窗治疗的102例患者,根据LSA重建入路的不同分为A、B两组。A组（47例）采用股动脉入路,B组（55例）采用肱动脉入路。比较两组手术成功率、手术时间,术后脑卒中、截瘫、内漏、伤口并发症及住院时间,并随访24个月观察两组并发症及生存结局。结果：A组的手术成功率为100%,明显高于B组91.9%(P <0.05)。同时,A组的手术时间明显短于B组,伤口并发症明显少于B组（均P <0.05）。两组间卒中、截瘫、内漏、术后住院时间及术后24个月并发症和生存情况,差异均无统计学意义（均P>0.05）。结论：经股动脉入路重建左锁骨下动脉具有成功率高、手术时间短及术后并发症少等优势,是一种值得推广的手术方式。     

Strategies for drug targeting in pancreatic cancer

BackgroundPancreatic cancer is expected to replace lung cancer as the second greatest cause of cancer mortality by 2025. It has been a particularly the most lethal kind of cancer.ObjectiveDespite the new innovations, research, and improvements in drug design; there are many hurdles limiting their therapeutic applications such as intrinsic resistance to chemotherapeutics, inability to deliver a sufficient concentration of drug to the target site, lack of effectiveness of drug delivery systems. These are the major contributing factors to limit the treatment. So, the main objective is to overcome these types of problems by nanotechnology and ligand conjugation approach to achieve targeted drug delivery.MethodNanotechnology has emerged as a major approach to develop cancer treatment. Regardless of the severity, there are several issues that restrict the therapeutic impact, including inadequate transport across biological barriers, limited cellular absorption, degradation, and faster clearance.ResultTargeted drug delivery may overcome these obstacles by binding a natural ligand to the surface of nanocarriers, which enhances the drug's capacity to release at the desired site and minimizes adverse effects.ConclusionThis study will investigate the possible outcomes of targeted therapeutic agent delivery in the treatment of pancreatic cancer, as well as the limitations and future prospects.     

Novel percutaneous adventitial drug delivery system for regional vascular treatment.

A novel intracoronary microsyringe system (MicroSyringe) was developed for regulated drug injection into the adventitial space. In this report, the feasibility, safety, and distribution pattern of vascular treatment with this modality were tested in 17 swine by delivering Oregon green-labeled paclitaxel (OGP) and tacrolimus. Coronaries were harvested 0.5-96 hr postinjection and analyzed for drug by fluorescence histochemistry (OGP) and liquid chromatography-mass spectrometry (tacrolimus). Histopathological analysis was subsequently performed. The microsyringe deliveries were performed safely in all cases. In the OGP-injected group, within 2 hr postprocedure there was intense staining of the adventitia, media, and endothelium around the injection site, and by 23 hr staining extended distally by 27.5 mm. With tacrolimus, similar longitudinal drug distribution was seen; furthermore, by 48 hr there was detectable drug over 40 mm proximal and distal to the injection site. Significant levels of tacrolimus were detectable in coronaries at 96 hr. Percutaneous adventitial delivery is safe, feasible, and provides consistent dosing for complete treatment of a vascular territory.     

CD95在胰腺癌细胞化疗敏感性中的作用研究

目的 探讨CD95系统在胰腺癌细胞对化疗敏感性中的作用。方法 通过脂质体介导将CD95基因转入胰腺癌细胞株SW1990，G418筛选转导CD95基因的细胞克隆，Northern-blot和Western-blot检测转导细胞中CD95的表达；MTT法观察转导细胞对氟尿嘧啶（5-FU）、阿霉素（ADM）、双氟脱氧胞苷（GCB）及与抗CD95单克隆抗体联合治疗的反应；流式细胞仪（FCM）检测化疗药诱导转导细胞凋亡的作用。结果 CD95基因转导的SW1990细胞可稳定地过表达CD95，其mRNA与蛋白的表达均较未转导及空白对照组显著增高，抗CD95单抗可阻滞转导细胞的生长。临床相关药物浓度的化疗药对转导细胞的生长抑制作用明显高于未转导细胞，加入抗CD95单抗可显著增强化疗药的作用。ADM诱导胰腺癌细胞凋亡作用较明显，且转导细胞显著高于未转导细胞，结论 转导CD95基因可提高SW1990细胞对化疗药的敏感性，部分逆转其耐药性，化疗药与抗CD95单抗联合应用对胰腺癌细胞具有协同作用。     

经皮埋置125碘籽治疗不能切除性胰腺癌

目的 研究经皮埋置^125碘籽对不能手术切除性胰腺癌的治疗价值。方法 在B超监视下，经皮穿刺注入^125碘籽入胰肿瘤内。按肿瘤大小，注入30～80粒，放射活性15～40mCi。结果 13例均为不能手术切除的进展期胰腺癌，经^125碘籽局部埋置后，69．2％的病例腹痛改善，38．5％的病例腹痛几乎完全消失；53．8％的病例肿瘤缩小；中位生存期13个月，6、12、18和24个月生存率分别为92.3％、53．8％、38．5％和15．3％。结论 经皮植入^125碘籽对病人的侵袭性小，而取得的结果与常规手术、放化疗的结果大体相似，可作为不能切除性胰腺癌的治疗手段。     

Development of chemotherapy and significance of conversion surgery after chemotherapy in unresectable pancreatic cancer

While surgery currently remains the only potentially curative treatment available for pancreatic cancer, only 20% to 30% of patients have resectable disease at diagnosis. Recently, with the introduction of intensive chemotherapy regimens such as oxaliplatin, irinotecan, fluorouracil plus leucovorin (FOLFIRINOX) and gemcitabine plus nab‐paclitaxel, for the treatment of unresectable pancreatic cancer, the antitumor activity and overall survival in patients with pancreatic cancer have dramatically improved. These advances in intensive chemotherapy have led to the possibility of conversion of unresectable disease to resectable disease, and it has been reported that more than 20% of pancreatic cancer patients with unresectable locally advanced disease at diagnosis undergo successful conversion surgery after FOLFIRINOX therapy. In metastatic pancreatic cancer, resection for the primary lesion of pancreatic cancer may show some benefits for some patients with complete resolution of metastases by chemotherapy. Furthermore, surgical resection in some patients with only a few metastases, so‐called oligometastases, have also been reported. Conversion surgery is becoming increasingly possible with the introduction of intensive chemotherapies, however, the actual clinical benefits of resection in such cases has not yet been sufficiently investigated. The long‐term safety, feasibility and outcomes still need to be investigated in well‐designed, multi‐institutional studies on a large number of patients.     

Evaluation of CA19-9 serum levels for monitoring disease activity during chemotherapy of pancreatic adenocarcinoma

Summary Between 1987 and 1990 21 patients with proven adenocarcinoma of the pancreas were treated with chemotherapy in four different phase II studies. For 14 patients, serial measurements of CA19-9 serum levels and clinical evaluations of response by computed tomography scan and/or ultrasound were available. Clinical stable disease and progressive disease were accompanied by stable or exponentially rising serum levels of CA19-9. One patient with clinical partial remission showed a 90% decline of CA19-9. However, a 75% decline of CA19-9 was also observed in a patient with rapidly progressive disease. These data seem to indicate that the CA19-9 serum level may be used as an easy and sensitive tool to evaluate progressive disease during chemotherapy.     

Efficacy of chemotherapy for patients with metastatic or recurrent pancreatic adenosquamous carcinoma: A multicenter retrospective analysis

Background/objectivesPancreatic adenosquamous carcinoma (PASC) is a rare variant of pancreatic ductal adenocarcinoma (PDAC). The usual treatment for metastatic or recurrent PASC is systemic chemotherapy in accordance with the PDAC treatment strategy. This study aimed to investigate the efficacy of chemotherapy, especially the benefit of recent combination therapies, in patients with metastatic or recurrent PASC.MethodsWe conducted a multicenter retrospective analysis of 116 patients with metastatic or recurrent PASC treated with first-line chemotherapy between April 2001 and December 2017 at 24 Japanese institutions.ResultsCombination chemotherapies included gemcitabine + nab-paclitaxel (GnP, n = 28), fluorouracil/leucovorin + irinotecan + oxaliplatin (FFX, n = 10), gemcitabine + S-1 (GS, n = 10), and others (n = 9). Monotherapies included gemcitabine (n = 51) and S-1 (n = 8). The median overall survival (OS) was 6.5, 7.3, and 4.3 months for the whole cohort, the combination therapy group, and the monotherapy group, respectively. Multivariate analysis indicated that combination therapy showed a better trend in OS than monotherapy (hazard ratio = 0.68; 95% confidence interval, 0.38–1.20). GnP or FFX were selected in 58.7% of patients after FFX was approved in Japan, and revealed a median OS, median progression-free survival, and objective response rate of 7.3 months, 2.8 months, and 26.9% in GnP and 7.2 months, 2.3 months, and 20.0% in FFX respectively.ConclusionsThis study suggests that combination therapy may be more effective than monotherapy. GnP and FFX showed similar and clinically meaningful efficacy for patients with metastatic or recurrent PASC.     

Micro-emulsion based emulgel: a novel topical drug delivery system

Topical delivery systems for drugs make localized administration of the drug anywhere in the body through ophthalmic, vaginal, skin and rectal routes. Topical formulations encompass a wide variety of formulations intended for cosmetic or dermatological application, to healthy as well as diseased skin. Drugs may be administered for localized or systemic effect. Topical preparations can be formulated with varying physico-chemical properties, as solid, semisolid or liquid. Micro-emulsion of drug is prepared and incorporated into emulgel, having novel topical drug delivery system as dual release control system. Micro-emulsions are micronized; thermodynamically stable systems having low interfacial tension prepared by adding co-surfactant have several features like enhanced permeability, good thermodynemic stability and prolong release. Emulgel prolongs the drug release, increases patient compliance and stability of emulsion. The prepared emulgel is evaluated for various parameteres like pH, viscosity, globule size; spreadability etc. whereas micro-emulsion is evaluated for various parameters like viscosity, pH, zeta-potential etc.     

Contrast-enhanced harmonic endoscopic ultrasonography for evaluating the response to chemotherapy in pancreatic cancer

Background and aimsContrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is used for the diagnosis of pancreatic cancer (PC). Here, we examined the usefulness of CH-EUS for evaluating therapeutic responses in PC.MethodsThe study included 23 patients with PC who received chemotherapy. Patients underwent contrast-enhanced computed tomography (CE-CT) and CH-EUS before chemotherapy and at the time of evaluation of the therapeutic response. Patients with a ≧50% reduction in serum carbohydrate antigen 19–9 levels after chemotherapy were defined as “super responders”. The incidence of an avascular area in the tumor on CH-EUS after chemotherapy was compared between “super responders” and non-super responders.ResultsNine patients were included in the “super responders” group.Tumor reduction rates did not differ significantly between CE-CT and CH-EUS in the “super responders”. The appearance of an avascular area was detected in 7 of 9 super responders (77.8%) and in 4 of 14 non-super responders (28.6%), and the difference was significant (P = 0.036). The mean survival time of patients with an avascular area after chemotherapy was longer than that of without an avascular area.ConclusionsDetection of avascular areas by CH-EUS after chemotherapy may predict long-term survival of patients with PC.     

Implantation of a drug delivery system during surgery for patients with primary hepatocarcinoma

BACKGROUND: Postoperative regional chemotherapy is one of the most effective methods to decrease the recurrent rate and improve the prognosis of primary hepatocarcinoma (PHC). This study was undertaken to assess the optimal pathway to implant the drug delivery system (DDS) in the different ways of resecting PHC so as to offer a valuable reference to clinical implantation of the DDS. METHODS: One hundred and ninety cases were divided into two groups according to whether the tumors were resected completely (A) or not (B). Groups A and B were subdivided into three groups a, b and c according to the pathway selected for DDS implantation. The patients in subgroup a received DDS implantation through both the hepatic artery and portal vein (A+P-implanted group), the patients in subgroup b received DDS implantation through the portal vein (P-implanted group), and the patients in subgroup c received DDS implantation through the hepatic artery (A-implanted group). RESULTS: The 1- and 3-year recurrent rates of subgroup c in group A were higher than those of subgroup b, and there was no significant difference between subgroups a and b. Compared with subgroups a and c, the 1- and 3-year survival rates of subgroup b were similar to those of group a but higher than those of group c. The 1- and 3-year survival rates between subgroups a and b in group B were significantly different. The prognosis of subgroup c was lower than that of subgroup a and no significant difference was observed between subgroups b and c. CONCLUSIONS: The DDS should be implanted into the portal vein when PHC is resected completely. It may be better to implant it into both portal vein and hepatic artery if the tumor cannot be completely resected.