΢�������ڵ�����Ƽ�֢����������еĵ�λ

微创技术 (minimallyinvasivetechnique ,MIT)是指在病人的诊断和治疗过程中采用的介入超声学、介入放射学、内镜、胆道镜和腹腔镜技术 ,以期在达到诊断和治疗目的的前提下 ,能最大程度地减少损伤 ,维持机体内环境稳定。近年来微创技术在胆道外科急症领域的应用方面显示了良好的发展前景。1　微创技术在急性胆囊炎诊治中应用1 1　腹腔镜胆囊切除治疗急性胆囊炎自 1987年法国医师Mouret完成第 1例腹腔镜胆囊切除术 (LC)后 ,短短 10余年LC就风靡了全世界 ,成为治疗胆囊良性疾病的“金标准”。但是急性胆囊炎由于局部充血水肿、周围粘连严…     

��������֢���������������еĵ�λ

在当前重症急性胰腺炎 (SAP)的综合治疗体系中 ,以加强监护为主的保守治疗占据着主导地位 ,而手术在SAP治疗中的地位 ,本文试从以下几个方面进行探讨。1　外科手术治疗急性胰腺炎 (AP)的历史演变在 2 0世纪的前 30年 ,AP的诊断是建立在手术和活检的基础上 ,鉴于一部分通过手术而诊断的病人存活了下来 ,许多外科医生如Woolsey、Moynihan等均建议对AP直接采取手术治疗 ,以降低其过高的病死率。当 192 9年发现了血淀粉酶升高这一AP的标志性特征后 ,已不再需要诊断性的剖腹手术。医学工作者也逐渐认识到 ,绝大多数的AP病人是可以自愈的 …     

�����ڷ�˨�������еĵ�λ������

??The importance and method of anticoagulation in the treatment of pulmonary thromboembolism LI Yan-xia, ZHANG Zhong-he. The First Affiliated Hospital of Dalian Medical University, Dalian116011, China
Corresponding author: ZHANG Zhong-he, E-mail: medlbyby@vip.sina.com
Abstract Pulmonary embolism (PE) is one of the common diseases in respiratory and cardiovascular emergencies. All PE patients should undergo rapid risk stratification (Grade 1C). For patients with evidence of hemodynamic compromise, we recommend use of thrombolytic therapy unless there are major contraindications owing to bleeding risk (Grade 1).Thrombolytic therapy is the important treatment for PE. For the majority of patients with PE, we recommend against using thrombolytic therapy. Anticoagulation is the basic treatment for PE. It is highly effective in reducing mortality and preventing recurrent VTE during treatment??and the bleeding risk is not high. Anticoagulant treatment plays a pivotal role in the management of patients with PE applying to various kinds of PE patients. Although of rapid onset, the haemodynamic benefits of thrombolysis over heparin appear to be confined to the first few days. One week after treatment, the changes in the severity of vascular obstruction and the reversal of RVD were no longer different between thrombolysis-treated and heparin-treated patients. However, anticoagulation methods differ when relate to special cases of PE during pregnancy ranges, PE combining tumor, heparin-induced thrombocytopenia, right heart thrombi, and etc.     

�ھ������ڸ���ֲ���󵨵�����֢�еĵ�λ������

目的 探讨内镜治疗在肝移植术后胆道并发症中的地位和作用。方法 对1993年4月至2002年12月实施的210例肝移植病人临床资料进行回顾性分析。结果 共确诊29例肝移植术后胆道并发症。胆道并发症发生率为13．8％，与胆道并发症相关的病死率为1．4％。内镜治疗占53．3％(24／45)。结论 内镜下逆行胰胆管造影(ERCP)对胆道并发症既能准确诊断，又能提供有效的介入治疗手段。ERCP治疗吻合口漏、吻合口狭窄和胆总管结石的疗效理想，对缺血性胆管病变的诊断作用大于治疗作用。     

��˨ҩ����֫��ȱѪ�����еĵ�λ������

??The status and value of thrombolysis drugs in the treatment of limb ischemia HUANG Xiao-zhong, ZHANG Ji-wei. Department of Vascular Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai200127, China
Corresponding author: ZHANG Ji-wei, E-mail??zhangjiwei001@sina.com
Abstract Artery thromboembolism of limbs accouts for a large proportion in peripheral vascular diseases with high morbidity and mortality. It could harm the preservation of limbs and human health. Fibrinolytic therapy is one of the most important ways of the treatment. In recent years thrombolysis drug use and research have made a lot of progress. Concentrated in two ways: (1) Deep and further understanding of the traditional thrombolysis drugs, achieveing the precise use. (2) New thrombolysis drugs success to fibrinolytic therapy bring new opportunities.     

������ֲ�ڸΰ������еĵ�λ������

1　原发性肝细胞性肝癌肝移植在原发性肝细胞性肝癌(ＨＣＣ)治疗中的地位经历了一个肯定—否定—再认识的过程。在肝移植发展的早期阶段,基于肝移植手术带来的巨大风险性、术后免疫抑制剂的副作用及术后疗效不确定性考虑,以ＨＣＣ为代表的肝胆恶性肿瘤曾经是此阶段肝移植的主要适应证。在全球最初10例临床肝移植中,8例为肝脏恶性肿瘤病人,Ｓｔａｒｚｌ开展的第一例肝移植受者也是ＨＣＣ病人。我国于1977～1983年开展57例肝脏移植,其中52例为肝癌病人。20世纪80年代中期以后,随着ＣｓＡ和ＵＷ液的问世,以及体外静脉转流技术的应用、外科手术…     

�ھ��ڼ��Ե�Դ�������������еĵ�λ����Ԥʱ��

对于急性胆源性胰腺炎,内镜治疗具有重要的地位。行内镜逆行胰胆管造影术(ERCP)及内镜超声检查可明确诊断,指导进一步治疗。早期行经内镜鼻胆管引流(ENBD)、经内镜乳头括约肌切开术(EST)、胰管支架置入可及时解除梗阻,降低胆管、胰管压力,引流胆汁及胰液,缓解胰腺炎,降低并发症的发生率。内镜治疗可能导致出血、穿孔、胰腺炎加重、腹膜后感染等严重并发症,因此应严格掌握适应证,对于伴有急性胆管炎的急性胆源性胰腺炎,早期内镜治疗是绝对适应证;对于不伴有急性胆管炎的重症急性胰腺炎,应严密观察,除留置空肠营养管之外的早期内镜治疗并没有明显益处。     

ǻ�����������ټ��������еĵ�λ��������

??The effect and evaluation of Endoscopic technique in the treatment for breast diseases JIANG Jun. Breast Disease Center,Southwest Hospital, Third Military Medical University ,Chongqing 400038,China
Abstract Application of endoscopic technique has promoted the development of surgical treatments for breast diseases greatly in recent years. Through integrating advantages of open, endoscopic and plastic surgery, adopting a series of innovative surgical strategies and optimizing the operative techniques and procedures, a unique and quasi-complete endoscopic-technical system has been established. Endoscopic technique is not only an effective method of surgery for breast diseases but also has advantages of minimally invasive and aesthetic results over open surgery. It offers the opportunity to overcome and resolve several technical troubles in the surgical treatment for breast diseases, and it will improve the treatment effect of patients with breast cancer.     

�����г��ڸΰ���ѧ���ۺ������еĵ�λ

??Status of surgery in the multidisciplinary treatment of hepatocellular carcinoma LAU WY??LAI ECH??LAU SHY. Faculty of Medicine??the Chinese University of Hong Kong??Shatin??New Territories??Hong Kong SAR??China
Corresponding author??LAU WY??E-mail??josephlau@cuhk.edu.hk
Abstract Partial hepatectomy remains the main “curative” treatment strategy for hepatocellular carcinoma (HCC). The combined use of surgery with other treatment modalities is used increasingly. The aims of treatment include: ??1??decrease tumor recurrence by neoadjuvant or adjuvant therapy????2??treatment strategy to increase resectability by increasing volume of future liver remnant????3??tumor downstaging followed by salvage surgery. However??it is still unclear whether the combination therapies are effective. More studies are needed to define their roles in the curative treatment of HCC.     

��ǰθ����θ����λ���ٴ���ֵ

我科自 1995年 1月至 2 0 0 0年 12月手术治疗胃癌 2 5 4例 ,术前均常规进行胃镜检查 ,其中 2 18例曾在其他医院或我院内科做过胃镜检查。我们随机将本科 (外科组 )和外单位 (对照组 )胃镜检查与术中诊断做对比分析 ,旨在提高胃镜对胃癌的正确率。1　临床资料全组 2 18例 ,男 171例 ,女 47例。年龄 19～ 72岁 ,平均 5 6 6岁。全部病例均经手术证实癌肿部位及浸润范围。手术切除 176例 (根治性切除 12 1例 ,姑息性切除 5 5例 ) ,胃空肠吻合 2 7例 ,空肠造瘘术 6例 ,手术探查加活检 9例。按照国际胃癌分期 ,根据手术所见及病理 ,T1 N0 M0 14…     

��ȫ�Ը�ǻ��Զ��θ���������븹ǻ������Զ��θ����������Ч�Ա�Meta����

??Totally laparoscopic distal gastrectomy and laparoscopic-assisted distal gastrectomy??A Meta-analysis of efficacy comparation WANG Jun-fu, XIE Yong, HU Lin, et al. Department of Gastrointestinal Surgery, the Second Affiliated Hospital of Nanchang University, Nanchang330006, China
Corresponding author: LI Hong-lang, E-mail: lihonglang6802@163.com
Abstract Objective To compare the effect difference of totally laparoscopic distal gastrectomy??TLDG?? and laparoscopic-assisted distal gastrectomy ??LADG??. Methods Randomized controlled trial reports on TLDG and LADG from 2008 to 2013 were collected from PubMed??EMBASE??Medline??China National Knowledge Infrastructure (CNKI) and Wanfang databases. RevMan 5.1 software was used for data analysis. Results According to the included criteria, 6 clinical trials were selected finally. Meta-analysis showed that: blood loss in TLDG group was 31.26mL less than that in LADG group (P=0.005); The frequency of analgesic usage in the TLDG group was 0.38 times lower than LADG group (P=0.04); serum C-reactive protein levels decreased 0.93g/L after one day in TLDG group (P=0.03). There was no statistical difference in operation time, hospital stay, postoperative first exhaust time and complications between the two groups??P??0.05??. Conclusion It could not demonstrate the clinical superiority of TLDG over LADG based on the current data. The surgical method may be selected according to patients’ conditions and the surgeon’s preference.     

����θ����������CTӰ���ص��о�

??Study of CT imaging in diagnosis of malignant gastrointestinal stromal tumors SUN Xue-feng*,ZHANG Xiao-peng,TANG Lei, et al. *Department of Radiology, Peking University School of Oncology, Beijing Cancer Hospital & Institute, Beijing 100036, China Corresponding author: Zhang Xiao-peng, E-mail: zxp@bjcancer.org Abstract Objective To investigate the CT imaging features of malignant gastrointestinal stromal tumors (GISTs). Methods The morphologic characteristics of tumor were evaluated according to tumor size, shape, homogeneity, density compared with liver, contrast enhancement, presence of calcifications, ulcerations and the anatomical relationship to the intestinal wall, and the infiltration of adjacent visceral organs. Results Of the 46 patients with GISTs, 14 cases were classified as benign tumors, 32 cases as malignant tumors.There were differences in size,margin, enhancement pattern between benign and malignant tumors. Presence of ulcers or small vessels in /around the tumor arranged in clumps or in line was more frequently observed in primary malignant GISTs (P <0.05). No statistical differences of enhancement degree, growth pattern and presence of calcifications were observed between benign and malignant GISTs. Conclusion Malignant GISTs are typically large, with irregular margin and heterogeneous enhancement pattern. Presence of ulcers, and small vessels in/around the tumor which arranged in clumps or in line are more frequently observed in primary malignant GISTs. There are no differences in enhancement degree, growth pattern, and presence of the calcifications between benign and malignant GISTs.     

����������θ������Ѫ�е�Ӧ�ü�����֢

选择性血管造影诊断及栓塞治疗胃肠道出血 ,方法简便安全 ,效果迅速可靠 ,为临床首选治疗方法之一。近年 ,随着导管技术的进步及新型导管材料的开发和应用 ,人们再次认识到介入治疗在胃肠道出血中的应用价值。介入治疗有自身的特点 ,包括治疗技术的选择 ,靶血管的选择 ,栓塞剂及其用量的选择 ,以及并发症的防治等对治疗效果均有一定影响。本文结合近年文献 ,就胃肠道出血介入治疗的临床应用及其并发症的防治等 ,综述如下。1　胃肠道出血介入治疗的适应证及方法胃肠道出血可分为上消化道出血和下消化道出血 ,出血原因可分为炎症性、肿瘤性、…     

����������Ѫ����Ʒ�չ�е����ü���λ

??Role and status of open surgery in the development of vascular surgery XIN Shi-jie, LIN Ruo-ran. Department of Vascular Surgery,the First Hospital of China Medical University??Shenyang 110001??China
Corresponding author: XIN Shi-jie??E-mail??xinshijie1963@aliyun.com
Abstract The morbidity of vascular disease is increasing daily?? while endovascular repair??EVR?? technique is becoming riper than before. It leads to most of the patients choose EVR instead of open surgical repair??OSR???? which can also obtain satisfactory therapeutic effects. In addition?? the phenomenon of the vascular surgeon neglect and forgot OSR should draw everyone’s attention. Overall?? OSR technique is essential grounding of each vascular surgeon.     

�������CT�ڸ�����λ����е�Ӧ��̽��

目的探讨多层螺旋CT(MSCT)平扫、增强并结合瘘管造影对肛瘘进行定位诊断的临床应用价值。方法2004年7月至2006年5月间温州医学院附属第一医院对32例临床疑诊为肛瘘的病人使用16层螺旋CT扫描和瘘管造影。原始图像采用多平面重建(MPR)和容积重建(VR)技术进行三维重建,后处理图像由放射科专业医生完成。将术前获取的影像学资料与显微肛瘘手术和随访结果进行比较。结果MSCT上4例未发现肛瘘,5例为单纯性肛瘘,23例为复杂性肛瘘,均经过手术证实,肛肠专科检查将8例复杂性肛瘘误诊为单纯性肛瘘。MSCT上低位肛瘘6例,高位肛瘘22例,均经过手术证实,其中肛肠专科检查将8例高位肛瘘误诊为低位肛瘘,MSCT上3例括约肌外瘘误诊为括约肌上瘘。MSCT对术前内口、支管、脓腔评价的准确率分别为62.1%、89.3%、100.0%。MSCT后处理重建技术中,MPR包括曲面重建(CPR)可清晰显示瘘管的具体位置及其与肛管内外括约肌、肛提肌的关系,VR能三维再现瘘管的形态和走行特点。结论MSCT平扫、增强并结合瘘管造影是一种有效而可靠的对肛瘘进行定位诊断的检查方法,可以为手术提供有效依据。     

��ܾ����ö�λ����δ�Ѽ��׿���������������е�Ӧ��

??Application of localization needles under fiberoptic ductoscopy to the operation of intraductal space occupying lesions without palpable massYUAN Zhu,QU Xiang,ZHANG Zhong??tao,et al.Department of General Surgery,Beijing Friendship Hospital Affiliated to Capital University of Medical Sciences,Beijing 100050,China Corresponding author??ZHANG Zhong??tao,E??mail:zhangzht@medmail.com.cn AbstractObjectiveTo evaluate the value of localization needles under fiberoptic ductoscopy (FDS) for localizing intraductal space occupying lesions without palpable mass.MethodsNinty??two patients with nipple discharge accepted 117 cases of fiberoptic ductoscopy examination from August 2006 to March 2008 at Beijing Friendship Hospital. By the localization needles system under FDS,the intraductal space occupying lesions with unpalpable mass in 24 patients were localized and excised. FDS diagnosis,operation and pathologic diagnosis were analyzed retrospectively.ResultsTwenty-one of 24 patients with intraductal space occupying lesions were pathologically diagnosed (87??5%).Intraductal papilloma and galactocele were found in 16 patients and 2 patients respectively.Intraductal cancer and invasive duct cancer were found in 2 patients and 1 patient respectively.ConclusionApplication of localization needles under FDS can detect intraductal space occupying lesions early and locate accurate site,which is favorable to improve the diagnosis of early breast cancer and successful rate of operation.     

����������е�Ǻ��ؽ���ʽ����ʷ�ݱ�

在肠道部分切除之后，重建肠道的连续性是一常规的手术步骤。利用机械进行消化道吻合重建的这一思想几乎与手术历史本身一样古老。1826年Lembert提出的重建消化道应浆膜化，即浆膜对浆膜进行吻合的基本原则，一直延用至今。许多吻合器的发展也都遵循这一原则。     

Ҫ��������θ����������

1　晚期胃肠癌的概念“晚期”胃肠癌 ,一般指ＴＮＭ分期的Ⅲｂ期和Ⅳ期。细言之 ,胃癌的Ｔ3 Ｎ2 (Ⅲｂ)、Ｔ4 Ｎ1、2、3 与Ｍ1(Ⅳ ) ;大肠癌不论Ｔ情况 ,Ｎ2 、Ｎ3 (Ⅲｂ)与Ｎ4 Ｍ1(Ⅳ )均属于ＤｕｋｅｓＤ者。以及胃肠癌术后发生的血行转移、腹膜转移、远处淋巴结转移和重要而复杂解剖部位的局部复发。均列入晚期胃肠癌。2　晚期胃肠癌仍为多数徐光炜统计我国住院胃癌病人 ,2 0世纪 80年代与 70年代比较 ,Ⅰ Ⅱ期提高 33 4% ,Ⅳ期从 5 2 1%下降到10 5 % ,这是近年疗效提高的重要因素。但据中国医科大学与上海第二医科大学瑞金医院的报告…     

����������TNM����

恶性肿瘤的合理治疗计划应根据肿瘤分期制定，统一规范的肿瘤分期有助于临床医师制定治疗方案，帮助评价疗效。而且统一规范的肿瘤分期将促进不同医疗单位的医疗信息规范化，这有利于医疗信息的交流和肿瘤研究的发展。今后，本刊将根据每期的重点选题有选择地刊登UICC(第6版)制定的肿瘤TNM分期，以供读者参考借鉴。