肾移植术后尿瘘诊断与治疗

[目的]探讨肾移植术后尿瘘的临床诊断与治疗措施。 [方法]对16例肾移植术后尿瘘病例进行回顾性分析。 [结果]尿瘘发生率为1.26%,13例单纯性尿瘘行保守治疗,保守治疗成功11例,2例因输尿管远端坏死保守治疗失败,行移植肾输尿管膀胱再吻合及带蒂大网膜修补后治愈,尿瘘保守治疗成功率84.6%;3例复杂性尿瘘患者采用带蒂大网膜移植修补,均1次手术成功。 [结论]对于肾移植术后尿瘘患者应高度重视和积极治疗,早期诊断,选择正确治疗措施是救治成功的关键,利用大网膜的生物学特性,采用带蒂大网膜修补肾移植术后复杂性尿瘘和单纯性尿瘘保守治疗失败后病例具有取材方便、组织修复快、尿瘘复发率低的特点,适于临床推广应用。     

肾移植后的尿瘘分类及规范化诊断

：肾移植后尿瘘是一种常见的严重并发症。它可以发生在泌尿系统任何部位，如肾盏、肾盂、输尿管和膀胱。绝大多数的肾移植后尿瘘发生在移植后3周内，少数可发生在1个月后，甚至半年左右。文章根据尿道损伤疾病分类的原理，将肾移植后尿瘘分别按照尿瘘病因、尿瘘部位、病变程度等进行分类；讨论了肾移植后尿瘘经久不愈的原因以及诊断时应注意的几个问题。得出：肾移植后尿瘘一旦发生，应对它的病因及尿瘘部位迅速做出判断，只有这样才能确保选择最佳治疗方案，达到最好的效果。对于肾移植后尿瘘的诊断，必须注明尿瘘的部位，并根据其病理变化程度，注明是单纯性，或是复杂性，使肾移植后尿瘘诊断更加准确及规范化。     

肾移植术后尿瘘分类及治疗体会

目的　总结肾移植术后尿瘘的分类及治疗经验。方法　对我院1998年12月至2008年12月收治的23例肾移植术后出现尿瘘患者的病因、诊断及治疗结果进行回顾性分析。结果　23例患者随访6~12月,保守治疗11例(47.8%),手术12例(52.2%)。手术患者中,9例采用常规手术方法的病人有1例再次出现尿瘘,经二次手术后治愈;3例采用带蒂大网膜修补法,尿瘘无复发,移植肾B超检查无积水,患者肾功能正常。手术一次成功率91.7%(11/12)。其中采用带蒂大网膜修补法成功率为100%。结论　手术是治疗肾移植术后尿瘘的主要方法。采用带蒂大网膜修补肾移植术后复杂性尿瘘具有取材方便、组织修复快、尿瘘复发率低的特点; 同时可以减少局部感染及纤维化的机会, 梗阻并发症少, 远期效果好。     

同种异体肾移植后95例尿瘘患者定性、定量、定位资料的回顾性分析

背景：肾移植后尿瘘发生率较高,不仅影响患者伤口愈合,还可能引起局部及全身感染,严重者导致移植肾丢失甚至威胁患者生命。因此建立尿瘘诊治的规范化标准具有较好的临床应用意义。 目的：回顾性分析肾移植后95例发生尿瘘患者诊治情况。 方法：95例患者中男59例,女36例;年龄19~61岁,尿瘘发生于移植后1~40 d;单纯性尿瘘74例,复杂性尿瘘21例。根据临床经验和诊治常规,参照由第三军医大学大坪医院李黔生等报告的肾移植后尿瘘的定性、定位、定量分类诊断,保守治疗与手术治疗的“五步诊治流程”进行诊断及治疗。 结果与结论：56例采用保守治疗,治愈45例;50例采用手术治疗(含11例经保守治疗无效者),治愈45例,其余5例中2例因伴发严重急性排斥反应,移植肾破裂出血而切除移植肾,3例死于重症肺部感染。90例中获长期门诊或信访随访者71例,随访时间2~11年,失访19例。单纯性尿瘘中56例获得随访,其中41例移植肾功能维持正常,10例诊断为慢性移植肾肾病,4例移植肾失功恢复血液透析,1例因肺癌死亡。复杂性尿瘘中15例获得随访,8例移植肾功能正常,4例诊断为慢性移植肾肾病,3例移植肾失功恢复血液透析。证实采用李黔生提出的“五步诊治流程”可有效规范肾移植后尿瘘患者诊治流程,取得良好临床疗效。     

肾移植术后尿瘘病因68例分析

背景：肾移植后并发尿瘘占泌尿系并发症的40%~70%，其尿瘘的可能诱因包括外科因素和内科因素两个方面。 目的：有效减少和避免同种异体肾移植后尿瘘的发生，延长移植肾的存活。 方法：从病因、诊断和处理方面回顾分析68例肾移植患者术后尿瘘的临床资料，其中男47例，女21例，年龄20~58岁，肾移植后尿瘘发生时间 为3~31 d， 每日漏尿量60~2 000 mL。参照尿道损伤分类标准，按照尿瘘病变程度分为单纯性和复杂性两大类，按照尿瘘的病因及部位分为低位瘘、高位瘘和多发瘘。观察肾移植后尿瘘病例中单纯性和复杂性尿瘘各自发生概率，分析尿瘘的病因。 结果与结论：68例肾移植患者术后尿瘘中，47例为单纯性尿瘘，占69.1%，其中输尿管末端坏死42例，输尿管膀胱吻合口缝合不严4例，伤口感染致吻合口愈合不良1例；复杂性尿瘘21例，占30.9%，其中肾盂瘘2例，输尿管瘘2例，输尿管膀胱吻合口瘘11例，输尿管坏死段大于2 cm 6例。肾移植的任何步骤处理不当都可引起术后尿瘘，术中应根据输尿管血液供应，水肿情况，瘘口大小和输尿管的长度来选择不同的术式，以确保无张力的可靠吻合。发生尿瘘后要根据不同情况及时处理。     

肾移植术后尿瘘诊治“五步流程制度”的建立与意义

背景：肾移植术后尿瘘是一种常见的严重并发症,处理不当可导致移植肾丢失、甚至威胁患者的生命。 目的：建立肾移植术后尿瘘诊治的流程制度,探讨其在临床工作中应用的意义。 设计、时间及地点：制度建立及病例分析,于1993-12/2009-02在重庆市第三军医大学第三附属医院完成。 对象：选取从1993年12月至2009年2月我院共实施肾移植手术1313例,术后发生尿瘘102例,占7.7%。其中男67例,女35例。年龄21～57岁,平均32岁。所有尿毒症患者均对肾移植手术治疗知情同意,并经医院伦理委员会批准。入选标准:(1)肾移植手术后伤口渗尿者;(2)每日漏尿量>50ml者;(3)漏尿持续时间>3天者;(4) 曾行尿瘘修补术者;(5)尿瘘修补术后伤口再次漏尿者;(6)伤口虽无漏尿,但移植肾周有液性囊肿形成,经穿刺抽液检验证实为尿液者;（7）经影像学检查明确尿瘘部位者。排除标准:伤口渗出液经检查为淋巴液、组织间液、或脂肪液化者。 方法：1993年12月～2009年2月肾移植1313例,发生尿瘘102例（占7.7%）。在102例中,34例采用保守治疗,68例采用手术治疗。根据企业管理的模式,研究并制定了肾移植术后尿瘘诊治“五步流程制度”,即定性、定位、定量、定类诊断四步骤,治疗一步骤。 主要观察指标：肾移植术后各种尿瘘治疗效果。 结果：采取保守治疗34例中反复尿路感染2例、输尿管膀胱吻合口狭窄5例;采取手术治疗68例中输尿管与输尿管吻合狭窄2例、输尿管膀胱吻合口狭窄1例和输尿管逆流1例。治疗结果：保守疗法治愈34例(33.4%),手术治愈68例(66.6%),两组死亡3例,占2.9%。死亡原因为尿瘘导致重症肺部感染。 结论：对肾移植术后尿瘘诊断过程制定了“定性、定位、定量、定类”诊断标准,建立诊治过程中的“五步流程”制度,可使尿瘘诊治更加有序及规范化,有利于选择最佳的治疗方案。     

同一机构9年间1 203例肾移植后尿瘘处理27例

目的：尿瘘作为肾移植后早期最常见的外科并发症发生率可高达3%~10%，处理不当容易致移植肾丢失。文章回顾性分析肾移植后并发尿瘘临床资料，结合文献总结其处理经验。 方法：选择解放军广州军区广州总医院2000-12/2009-03肾移植1 203例中发生尿瘘患者27例，接受尸体供肾26例，活体供肾1例，男16例，女11例，平均年龄43岁。所有患者确定为尿瘘后先采取留置18Fr双腔气囊导尿管治疗，如果效果不好可采用手术探查。17例采用保守治疗，其中12例单纯伤口引流+留置膀胱18Fr导尿管双向引流，5例经膀胱镜逆行置入输尿管支架+留置膀胱18Fr导尿管；10例进行开放手术探查，其中5例行移植肾输尿管与膀胱重新吻合术+置入输尿管支架，5例开放手术移植肾输尿管与自体输尿管端端吻合+置入输尿管支架，开放手术中有6例加用带蒂大网膜包绕于吻合口。 结果：移植后因再次尿瘘而行手术损伤肾静脉切除移植肾1例，26例尿瘘治愈,随访3个月~7年，无再发尿瘘、吻合口狭窄、移植肾无积水及尿路感染，肾功能正常。 结论：对于肾移植后尿瘘应早诊断、早治疗,可先采取保守治疗，大多数患者可以治愈，无效后及时采取手术干预，对于复杂性的尿瘘于吻合口处可采用带蒂大网膜包绕提高手术成功率。     

肾移植术后尿路并发症

肾移植是临床治疗终末期肾病的最佳治疗手段，随着免疫抑制剂的发展，肾移植已达到相当成功的水平，但移植后各种并发症仍然威胁着患者移植肾功能甚至生命。一些内科并发症很难预防，但外科并发症临床可采取有效预防措施。文章综合分析肾移植后尿瘘、输尿管梗阻、输尿管返流等常见尿路并发症发生原因、诊断、处理及预防措施。尿路并发症作为肾移植后常见并发症之一，其发生与移植技巧密切相关。如何有效降低肾移植后尿路并发症的发生、一旦发生后如何进行及时诊断、有效处理，成为提高肾移植质量的重要环节。     

肾移植后肺炎的诊断与治疗

背景：肺部感染是肾移植后常见的并发症和主要的死亡原因。 目的：对肾移植后肺部感染的特点、临床表现、诊断和治疗进行综合分析。 方法：应用计算机检索Pubmed数据库1997/2010及万方数据库2001/2010有关肾移植后肺部感染特点、临床诊断及治疗的文章，英文检索词为“kidney transplantation，pulmonary infection”，中文检索词为“肾移植，肺部感染”。排除重复性研究，最终21篇符合要求被选为参考文献。 结果与结论：通过综合文献发现，肾移植后肺部感染的症状和临床经过与普通人的肺部感染不完全相同，临床症状往往不典型，可通过多种手段检测，需要调整免疫抑制剂及规范治疗。肾移植后肺部感染应防治结合，严格做到早诊断、早治疗、联合用药、足量、全程，根据患者机体状况和术后不同时期及时调整免疫抑制用药方案。     

肾移植术后重症肺部感染45例回顾性分析★

目的：肾移植患者术后长期服用免疫抑制剂，机体免疫功能低下，感染发病率高，肺是常见的靶器官。回顾性分析肾移植术后重症肺部感染的病原体检出情况及治疗转归。 方法：①收集2003-10/2007-05解放军总医院第二附属医院全军器官移植中心收治的45例肾移植术后重症肺部感染患者资料，44例为尸体供肾，1例为活体亲属供肾。②采用降阶梯综合疗法治疗肾移植术后重症肺部感染。检验患者体液、分泌物中的致病病原菌，对症治疗；根据情况及时调整免疫治疗方案；纠正贫血、低蛋白血症，持续大量应用免疫球蛋白提高抗感染能力；应用乌司他丁稳定溶酶体膜；使用血必净抗内毒素。 结果：①45例患者中感染发生在术后2个月内者占33 %（14/45），发生在术后2~4个月者占47%（21/45），发生在术后4~6个月者占13%（6/45），发生在术后6个月以上者占9%（4/45）。②检出细菌46例次（48.4%），主要为G-性菌；真菌感染20例次（21.1%）；其他感染29例次（30.5%），包括巨细胞病毒28例次及结核分枝杆菌1例次。③45例患者中22例并发急性呼吸窘迫综合征，6例放弃治疗，其余39例中32例经积极抢救治愈，7例死亡。 结论：肾移植术后肺部感染多发生于术后6个月内，病原体呈多样性。早期发现病原体，综合治疗，及时调整免疫治疗方案，加强全身支持，使用大剂量免疫球蛋白、细胞膜稳定药物及抗内毒素药物是治疗成功的关键。     

外伤后癫痫的外科治疗(附14例报告)

目的 探讨外伤后癫痫的手术治疗方法和效果. 方法 回顾性分析北京军区总医院附属八一脑科医院自2010年11月至2013年7月接受外科手术治疗的14例难治性外伤后癫痫患者临床资料.所有患者均经严格的术前评估,其中5例病灶毗邻重要功能区者分别采用颅内电极植入(4例)和术中神经功能导航(5例);随后分别行皮层电刺激和功能磁共振导航完成脑功能区精确定位及致痫灶与运动区的位置关系确定.手术切除所有患者癫痫病灶,术后定期进行随访并采用Engle分级进行疗效评定. 结果 所有患者均成功实施了癫痫病灶切除术.颅内电极植入的患者经功能磁共振导航和皮层电刺激双重定位,毗邻功能区的癫痫病灶达到精准切除,同时患者运动功能得到良好保护.术后随访12～30个月,Engle Ⅰ级7例、Ⅱ级5例、Ⅲ级2例,未出现永久性神经功能障碍. 结论 对于药物难治性外伤后癫痫,精确定位癫痫病灶和脑功能区后可以经外科切除术获得良好疗效.     

Effectiveness of steroid treatment in myasthenia gravis: a retrospective study

The records of 142 patients with generalized autoimmune myasthenia gravis who had been treated with steroids as the single immunosuppressive agent, collected at regular intervals, were employed for a retrospective evaluation. The effectiveness of treatment was assessed after 24 months; the data from the 6th and 12th months were also considered. After 24 months, 63.4% of the whole sample had improved (33.8% were in clinical or pharmacological remission); 13.4% were unchanged or had worsened and 22.3% had moved to a different immunosuppressive treatment. The rate of positive outcome was higher in patients over the age of 40 at disease onset.     

血管内治疗颅内动脉瘤33例临床分析

目的探讨血管内治疗颅内动脉瘤的方法及效果。方法33例颅内动脉瘤患者共有37枚动脉瘤,其中28枚采用单纯弹簧圈栓塞,9枚采用支架辅助弹簧圈栓塞。结果完全栓塞30枚,次完全栓塞6枚,不完全栓塞1枚。2例Hunt—HessV级患者死亡;1例支架辅助弹簧圈栓塞患者术后出现再出血,经治疗后痊愈;余患者术后随访1个月～2年,未发生再出血和动脉瘤复发。结论血管内治疗颅内动脉瘤是一种安全、微创、有效的方法。宽颈动脉瘤应用支架辅助技术治疗操作简单、并发症少。     

Risperidone long acting injection: Findings of a 2-year retrospective follow-up study

Objective. The aim of this retrospective study was to assess the clinical effectiveness of risperidone long acting injection (RLAI) at 2 years within an acute mental health setting. Method. All patients who received RLAI between July 2002 and December 2004 were identified from pharmacy records, and data collected by retrospective case note review. In order to give an indication that their condition was unresponsive to treatment, patients’ drug histories were reviewed to determine whether or not they had previously been treated with clozapine or received two or more failed trials of other antipsychotic medication. Results. Eighty-four patients were included in the study and 56 discontinued at 2 years. The most common reason for treatment discontinuation was lack of effectiveness, accounting for 32 patients, whilst eight patients discontinued due to adverse effects. Patients remaining on treatment spent 67% of the time in an outpatient setting. Conclusion. The proportion of patients remaining on RLAI at 2 years was 33%. Limitations of the naturalistic methodology used in this study hindered any precise determination of which patients were likely to continue RLAI. However, it was apparent that a history of previous treatment failure with at least two antipsychotics was associated with RLAI treatment discontinuation.     

Angio-architecture of complex cranial dural arteriovenous fistulas: A single centre retrospective review of treatment modalities and outcomes

IntroductionCranial dural arteriovenous fistulas (DAVFs) are rare vascular lesions that often harbour complex angio-architectural features. This subtype of DAVF may require multiple, multimodality, or hybrid treatments. In this paper we aim to identify specific angio-architectural features that are present in complex cranial DAVFs and we report our series with respect to treatment modalities and outcomes.MethodsTwenty-five cranial Borden type II and III cranial DAVFs were treated at our Institution from 2013 to 2017. We classified nine (36%) as complex based on specific angio-architectural features. Treatment strategies were based on fistula location, angiographic features and patient's presenting condition. Phone interviews were used to confirm outcome at 6 and 12 months.ResultsFour patients (45%) presented with acute hydrocephalus, and 3 (33%) with intracranial hemorrhage. Multiple and combined treatment sessions were needed for all complex DAVFs. Five patients required 2 endovascular procedures each. One patient had 2 surgeries. The first line of treatment was endovascular in 6 cases (67%) and surgery in 3 (33%). Two treatment-related (22%) complications occurred. Complete disconnection was achieved in 5 out of 9 patients (55%). Two patients with an incomplete disconnection refused further treatment and were well at last follow up, with a partially treated fistula and persistent CVR. The other 3 patients concluded treatment after the end of our data collection period. At 1 year, 7/9 patients had stable or improved clinical symptoms, and 8/9 patients had GOS of 4 or 5.ConclusionsComplex cranial DAVF often require a multidisciplinary approach and multiple treatment sessions should be expected. Specific angio-architectural features that increase DAVF complexity include multiple arterial feeders, especially transosseous or pial, reflux into multiple cortical veins, sinus occlusion/entrapment, venous aneurysms, segmental stenosis, medial or deep location, and association with the deep venous system.     

Papillary meningioma: an aggressive variant meningioma with clinical features and treatment: a retrospective study of 10 cases

Introduction: Papillary meningioma is a rare subtype of malignant meningiomas. The aim of this retrospective study was to investigate the clinical, radiological, histopathological features and prognosis for papillary meningioma at our institutions. Materials and methods: Ten patients with clinically, radiologically and histopathologically confirmed papillary meningiomas were treated at our hospitals. The clinical data, imaging characteristics, histopathological features, surgical treatment and postoperative follow-up, were analyzed retrospectively. Results: The patients with a mean age of 36.9 years at the time of their initial operations. The papillary meningiomas were predominantly located in the convexity (n = 6). At their initial operation, six patients underwent gross total resection and four patients underwent subtotal resection. The mean post-operative follow-up period was 42.6 months (range: 12–90 months). Six patients underwent multiple surgical resections. The mean time to first recurrence was 21.5 months. On magnetic resonance imaging scan, marked enhancements and dural tail signs were displayed in all lesions. All lesions showed peritumoral edema. Cysts were seen in four lesions. Bone hyperostosis or destruction was seen in six lesions. Cerebrospinal fluid dissemination was seen in three lesions. Incomplete surgical resection was associated with recurrence. MIB-1 labeling index was associated with progression-free survival for patients (p = 0.0442). Conclusions: Papillary meningioma has a tendency to present in middle-aged patients, and it has specific clinical and histopathological characteristics. MIB-1 labeling index and the extent of resection might predict the recurrence. Cystic formation, peritumoral edema, osseous change and CSF dissemination might be neuroimaging characteristics of papillary meningioma, especially in recurrence papillary meningioma.     

The influence of crisis resolution treatment on employment: a retrospective register-based comparative study

Crisis resolution treatment (CRT) is a short-term acute psychiatric home-based treatment offered as an alternative to hospitalization. The purpose of CRT is to support patient recovery by maintaining and improving competencies in relation to everyday life. Individuals with mental disorders are at increased risk of leaving the labor market, which is a central aspect of everyday life. Thus, a primary outcome of interest is whether CRT enables higher employment compared with traditional hospitalization. The aim of this study was to assess the effectiveness of CRT compared with hospitalization in relation to attempted or committed suicides, admissions, readmissions and employment. This study utilized register-based psychiatric data. The CRT intervention, which was carried out in a psychiatric center (N?=?374), was matched to traditional hospitalization treatment in a corresponding area (N?=?9460). The outcomes (suicide attempts, suicides, admissions and readmissions) were replicated by applying propensity score matching (PSM) to evaluate the general treatment effect of CRT. The effectiveness of CRT on employment was estimated by applying PSM combined with a difference-in-difference estimator to account for any time trends. Receiving CRT was associated with significantly more employment after 1 year compared with hospitalization. Furthermore, after 1 year, receiving CRT was associated with fewer suicide attempts, admissions and readmissions. The associations were not significant after two years. The results suggest that CRT patients retain a higher employment rate, which could indicate better recovery. Using CRT could lead to savings in the social security system owing to higher employment rates.     

成人脑干胶质瘤临床特点及预后:单中心10年81例患者回顾性分析

目的 分析单中心成人脑干胶质瘤(ABSG)的临床特点及影响预后的相关因素,探讨成人脑干胶质瘤最佳治疗模式.方法 收集成人脑干胶质瘤患者的一般临床资料及预后相关信息,采用Kaplan-Meier方法计算总生存期(OS)、log-rank检验进行单因素分析、Cox回归模型进行多因素分析,P＜0.05为差异具有统计学意义.结...