内镜黏膜下剥离术治疗早期胃癌的临床分析

早期胃癌(early gastric cancer,EGC)是指癌细胞局限于胃壁黏膜或黏膜下层,不论病灶大小及是否存在局部淋巴结转移.近年来,由于包括染色内镜、放大内镜、超声内镜(endoscopic ultrasonograpthy,EUS)、窄带成像技术、自发荧光内镜和共聚焦激光内镜等在内的胃癌早期诊断技术在临床的应用[1],EGC的诊断率已由5%上升至40%~50%[2].     

蓝激光内镜在消化道早癌精准诊断中的进展

目前消化道早癌的诊治已经是热点话题,其定义为病灶局限于黏膜层和黏膜下层的癌,包括早期食道癌、早期胃癌、早期结直肠癌。对于消化道早癌的诊断技术已经从单一的普通白光内镜,逐步过渡到色素内镜、电子染色窄带成像技术(NBI)、智能电子分光技术(FICE)、放大内镜和共聚焦光显微内镜(CLE)等,从而不断提高早期癌的检出率,甚至还能提供病变深度、范围和组织病理学等信息,而蓝激光内镜是来源富士公司推出的蓝激光内镜系统(LASEREO),为精准诊断消化道早癌带来更多可能性。该文就蓝激光成像技术(BLI)在消化道早癌精准诊断中的进展作一综述。     

共聚焦激光显微内镜对胃癌及其癌前病变临床诊断意义

目的探讨共聚焦激光显微内镜对胃癌及其癌前病变临床诊断意义。方法选取我院2012年8月~2013年8月收治的40例胃癌患者的临床资料,利用共聚焦激光显微内镜对患者疾病进行诊断,将其作为观察组,选取同期收治的40例用普通胃镜检查的胃癌患者为对照组,比较普通胃镜与共聚焦激光显微内镜的检测结果,分析共聚焦激光显微内镜的临床诊断价值。结果普通胃镜检查的敏感度为42.9%,特异度为73.1%,准确率为62.5%。共聚焦内镜检查的敏感度为92.9%,特异度为80.8%,准确率为85.0%。共聚焦内镜检测的敏感度、特异度与准确率均优于普通胃镜,对比具有统计学意义(P<0.05)。结论共聚焦激光显微内镜检测的特异性、准确率、敏感度较高,有利于为患者疾病治疗提供依据,在临床中有着较高的临床应用价值,值得临床推广应用。     

共聚焦显微内镜检查术的护理研究

[目的]为使病人顺利完成共聚焦显微内镜的检查,保障安全性、有效性,减少荧光素钠对比剂的不良反应及检查后的不良反应而提供有效的护理措施.[方法]对我院143例共聚焦显微内镜检查病人进行护理,分析各项处理对术后并发症的影响.[结果]143例病人全部完成共聚焦显微内镜检查,病人术前血压与术后血压比较,差异有统计学意义(P<0.01).病人原有过敏史及检查前空腹时间的长短对产生药物不良反应有一定影响,差异有统计学意义(P<0.01),检查后不良反应发生率为21.7%.[结论]术前采取适当的禁食时间,加强解释及做好预见性护理工作,术中给予正确、有效的操作配合及严密的病情观察,是完成共聚焦显微内镜检查的有效保证,也是减少检查并发症的护理关键.     

激光共聚焦显微内镜在胃肠道疾病中的应用

随着科学技术的发展，消化道内镜的更新换代也更加迅速。近年来最主要的表现就是激光共聚焦显微内镜（confocal laser endomicroscopy，CLE）的出现。它将激光共聚焦系统整合于传统内镜上，使临床医生能够在活体内直接观察到组织细胞学的变化，这在以往只能通过病理学家来证实。虽然染色内镜和放大内镜已经能够观察到胃肠道黏膜表面的详细结构，但是激光共聚焦显微内镜却能进一步发现黏膜下的病变，直接指导活检以及更为有效的内镜治疗。本文将概述激光共聚焦显微内镜在胃肠道疾病中的应用。     

纤维共聚焦荧光显微支气管镜临床应用进展

纤维共聚焦荧光显微内镜技术是应用共聚焦显微镜成像原理,对支气管黏膜结构进行扫描,通过非破坏性方式将组织切成薄的光学断层,获得活组织显微图像,然后利用计算机将断层图像综合成三维图像,实时观察活组织的变化,用以诊断早期黏膜病变,并利用特定波长激光激发组织的荧光特性,判断病变性质.无创获得气道黏膜层高度放大的横切面图像,有助于内镜下组织学诊断并指导靶向活检(光学活检),在电子内镜检查同时观察黏膜表面及黏膜内组织学结构,对肿瘤及其癌前病变的诊断准确率高、特异性强.这项新技术的普及应用,将引领世界内窥镜的发展进入激光显微内镜时代.     

共聚焦激光显微内镜在上消化道疾病诊断中的应用

1983年,电子内镜在临床上的成功应用,开启了消化内镜发展史的第三个里程碑,其显像失真性小,清晰度高的特点为消化道疾病的诊断和治疗创造了良好条件,而共聚焦激光显微内镜是电子内镜与共聚焦激光显微镜的组合体,其既保留有电子内镜的优点,同时拥有共聚焦激光显微镜的特点,可获得放大1 000 倍的横切面图像,故可在活体直接对组织进行虚拟病理检查,为某些上消化道疾病的快捷、准确的诊断带来可能.     

共聚焦激光显微内镜在结肠病变中的应用

共聚焦激光显微内镜作为一种新型的诊断工具,受到临床医师的广泛重视。其在消化系统的诊断方面有着独特的优势,已经被应用于结直肠癌、溃疡性结肠炎、Barrett食管、幽门螺杆菌及早期胃癌等疾病的诊断。本文复习近年来共聚焦激光显微内镜在结肠病变中应用的文献进行综述。     

无痛共聚焦激光显微内镜检查的操作配合及护理

目的 探讨无痛共聚焦激光显微内镜检查的操作配合及护理。方法 对85例患者行无痛共聚焦激光显微内镜检查,术前进行充分准备、术中熟练操作配合并做好麻醉监护及抢救准备及术后进行宣教。结果 85例患者顺利完成操作,无并发症及麻醉不良反应发生。结论：护理人员在无痛共聚焦激光显微内镜检查术前给予患者心理疏导、饮食护理、准确判断荧光素钠过敏试验结果、麻醉前的准备;检查中熟练的操作配合、密切观察生命体征;术后并发症的观察是顺利完成该项检查的保证。     

共聚焦内镜对上消化道黏膜病变诊断价值的初步研究

目的初步探讨共聚焦内镜对上消化道黏膜病变的诊断价值。方法应用共聚焦内镜对9例患者进行常规胃镜检查,对正常黏膜和可疑病变部位用共聚焦内镜观察,与相应病变部位活检的病理学结果进行比较分析。结果对患者74个部位进行共聚焦扫查,采集图像1587帧,其中正常黏膜39个,慢性胃炎31个,食管癌3个,食管异位胃黏膜1个。不同部位和病变黏膜的共聚焦图像具有不同的形态学特点,共聚焦内镜对慢性胃炎患者胃黏膜肠上皮化生诊断的敏感性、特异性和准确性分别为85.7%、95.8%和93.5%。结论共聚焦内镜能显示上消化道黏膜的组织和细胞形态,对胃黏膜肠上皮化生的诊断具有较高的准确度。     

腹腔镜下手术治疗肾上腺皮质醇增多症18例护理配合

目的:探讨腹腔镜下手术治疗肾上腺皮质醇增多症患者的护理配合方法.方法:对18例肾上腺皮质醇增多症患者行手术治疗,并给予密切护理配合.结果:本组均于腹腔镜下行手术治疗,经腹腔途径3例,经后腹腔途径15例(其中2例中转开放手术).术后1例出现肾上腺危象,经及时处理,恢复良好;其余患者无严重并发症发生.随访12～30个月,复查B超、CT未见复发.结论:充分的术前准备、默契的术中配合是手术顺利进行及患者早日康复的关键.     

Utility of Endoscopic Ultrasound (EUS)-Guided Fine-Needle Aspiration for Peri-arterial Soft Tissue Cuffs Without Identifiable Pancreas Mass on CT and EUS: A Prospective Comparative Study

Pancreatic cancer may present as a peri-arterial soft tissue cuff (PSTC) around the superior mesenteric artery or celiac axis without an identifiable pancreatic mass. We evaluated the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with a PSTC without definite pancreas involvement and those with a typical pancreatic mass. The patients who underwent EUS-FNA of a PSTC without pancreatic involvement were prospectively enrolled. The patients who underwent EUS-FNA for a pancreatic mass were recruited as a control group. A total of 224 patients underwent 247 EUS-FNAs. Among the 13 patients with a PSTC, 11 were positive for malignancy as determined by EUS-FNA, with 5 diagnosed after the first session and 6 after the second session. The diagnostic yield of PSTCs by EUS-FNA was significantly lower than that for typical pancreatic masses (65% vs. 87%, p = 0.02). An on-site cytopathologist and repeated EUS-FNA are recommended to improve the diagnostic accuracy of this disease entity.     

腹部带蒂皮瓣修复手部深度烧伤的围手术期护理

目的探讨完整的腹部带蒂皮瓣修复手部深度烧伤围手术期护理程序。方法对48例采用腹部带蒂皮瓣手术修复手部深度烧伤的患者进行全方位的护理进行总结,包括术前疾病评估、配合清创换药、心理护理、体位和皮肤准备,感染控制,术后疼痛护理、皮瓣观察、体位护理、并发症防治、功能锻炼、康复指导等。结果48例患者腹部皮瓣移植成活,供瓣区受瓣区均生长良好。出院后3—6个月追踪,除3例术前神经血管指骨严重毁损功能丧失外,其余病例手部日常功能恢复良好。结论采用全方位多学科护理知识科学护理是腹部带蒂皮瓣修复手部深度烧伤患者的有力保障,以确保手术成功、肢体功能恢复、生活质量提高、社会生存能力增强。     

手辅助胸腔镜下双肺转移瘤同期手术的护理配合

目的探讨手辅助胸腔镜下双肺转移瘤同期手术的护理配合要点。方法总结72例手辅助胸腔镜下双肺转移瘤同期手术的术前准备、术中配合、术后器械及设备的清洗保养。结果手术过程顺利,无中转开胸及手术死亡病例。结论实行手辅助胸腔镜手术,对手术室护理质量及腔镜手术器械的清洗保养是一个重大的考验,熟练的手术配合和规范的操作流程可提高手术配合护理质量,是手辅助胸腔镜下双肺转移瘤同期手术顺利进行的主要原因。     

Is Definitive Abdominal Evaluation Required in Blunt Trauma Victims Undergoing Urgent Extra‐abdominal Surgery?

Objectives: To evaluate the utility of routine abdominal computed tomographic (CT) scanning for abdominal evaluation of blunt trauma patients before urgent extra‐abdominal surgery. Methods: In this observational cohort study, we prospectively enrolled all blunt trauma patients at least 8 years of age presenting to the emergency department of a Level 1 trauma center who were initially considered to require urgent extra‐abdominal surgery within 24 hours of presentation. Patients were excluded if they had any of the following: 1) isolated extremity trauma, 2) signs or symptoms of intra‐abdominal injury (including systolic blood pressure <90 mm Hg; abdominal, flank, or costal margin tenderness; abdominal wall contusion or abrasion; pelvic fracture; and gross hematuria), or 3) unreliable findings on abdominal examination (Glasgow Coma Scale score <14, paralysis, or mental retardation). Clinical data were documented on a data sheet before abdominal CT scanning. Results: A total of 254 patients, with a mean (±SD) age of 32.3 (±16.1) years, were enrolled. A total of 201 patients ultimately underwent urgent extra‐abdominal surgery for the following procedures: orthopedic, 182 (91%); facial, 17 (8%); laceration, 7 (3%); vascular, 6 (2%); neurosurgical, 3 (1%); urology, 2 (1%); and ophthalmology, 1 (0.4%). Three patients (1.2%; 95% confidence interval = 0.2% to 3.4%) were found to have intra‐abdominal injuries. Two patients had splenic injuries that required only observation. One patient (0.4%; 95% confidence interval = 0% to 2.2%) underwent laparotomy. This patient sustained multiple injuries in a motorcycle crash, including splenic, kidney, and pancreatic injuries, and underwent a splenectomy. Conclusions: Abdominal CT scanning has a low yield in trauma patients whose sole indication for diagnostic abdominal evaluation is the need for general anesthesia for urgent extra‐abdominal surgery. A small percentage of these patients, however, will have important intra‐abdominal injuries such that further refinement of the recommendations for diagnostic study in this select population is needed.     

Cystic pancreatic masses: cross-sectional imaging observations and serial follow-up

BACKGROUND: We retrospectively reviewed the imaging features of a series of patients with cystic pancreatic masses, the majority of whom underwent imaging surveillance. METHODS: Imaging data from 30 patients with known cystic pancreatic masses were reviewed. Nine patients had surgical and/or cytologic classification. Of the 21 who were not operated on, all underwent serial imaging surveillance. Of these, five had corroborative endoscopic retrograde cholangiopancreatography and 16 were followed by only computed tomography and/or magnetic resonance imaging. RESULTS: In the nonoperated group, mean follow-up time was 30 months (3-144 months). Two patients demonstrated growth, and the remainder remain stable. In the patients who underwent surgery, invasive carcinoma was found in those with lesions larger than 4 cm, involvement of the main pancreatic duct, or visible solid components on the imaging study. Smaller lesions were benign. CONCLUSION: In patients with suspected cystic pancreatic neoplasms, surveillance might be possible if lesions are smaller than 2.5 cm, spare the main pancreatic duct, and demonstrate no solid components.     

搭桥血管重建技术在颅内复杂动脉瘤手术中应用的护理

目的 探讨搭桥血管重建技术在颅内复杂动脉瘤手术治疗中的护理对策.方法 对16例颅内复杂动脉瘤经血管搭桥、血管重建手术,采用动脉瘤孤立加大隐静脉高流量搭桥的方式处理动脉瘤.对动脉瘤手术术前充分准备、术中熟练配合,并提高应对紧急情况的有效处理能力,以提高手术配合质量.结果 16例行大隐静脉高流量血管搭桥术的病人,术中应用有效的护理对策,均达到满意的护理结果.结论 搭桥血管重建手术,手术时间长、配合质量要求高.所以要求护士要有对一般动脉瘤手术配合熟练的基础、术前充分有效的准备、对于术中出现出血等突发情况,能快速、有效地采取相应的护理应急对策,使病人在手术期间获得满意的护理效果.     

胰腺外伤的诊断与手术治疗（附28例分析）

目的：探讨胰腺外伤的诊断与治疗。方法：回顾分析2000年1月-2008年5月间经手术探查确诊的28例胰腺外伤患者的临床资料。结果：胰腺Ⅰ级损伤5例,Ⅱ级损伤7例,Ⅲ级损伤6例,Ⅳ损伤7例,Ⅴ级损伤3例。行清创或加缝合修补、引流11例,部分胰及脾切除7例,胰空肠roux-en—Y吻合5例,胰管外引流术及2期手术2例,十二指肠憩室化手术2例,Wipple手术1例。治愈24例,死亡4例,病死率14．3％,死因为严重多发伤或失血性休克。发生胰瘘5例,均治愈。2期期手术2例。结论：早期诊断,及时剖腹探查,选择合理术式,有效引流及妥善处理合并伤是治疗胰腺损伤、减少并发症和病死率的关键。     

Puncture of solid pancreatic tumors guided by endoscopic ultrasonography: a pilot study series comparing Trucut and 19-gauge and 22-gauge aspiration needles

BACKGROUND AND STUDY AIMS: The aim of this prospective study was to compare endoscopic ultrasonography-guided Trucut needle biopsy (EUS-TNB) with EUS-guided fine-needle aspiration biopsy (EUS-FNAB) using 19- and 22-gauge needles for biopsy from different sites in patients with solid pancreatic cancers. PATIENTS AND METHODS: Sixteen consecutive patients with masses in the uncinate process (n = 3), the head (n = 5), or the body and tail (n = 8) of the pancreas underwent both EUS-TNB and EUS-FNAB. The specimens obtained were evaluated by histopathological analysis alone RESULTS: Tissue specimens were obtained by Trucut needle, and by 19-gauge and 22-gauge aspiration needles in 69 %, 69 %, and 100 % of patients respectively. Sensitivity for malignancy was 69 % for all needles. Tissue sampling by Trucut and by 19-gauge aspiration needle from masses in the uncinate process was impossible. The sensitivity of the Trucut and 19-gauge aspiration needles was 100 % in the 11 patients with successful procedures. If Trucut or 19-gauge aspiration needles had been used for body and tail masses, and the 22-gauge aspiration needle for masses in the uncinate process and head, the sensitivity for malignancy would have been 81 %. CONCLUSIONS: EUS-TNB allows reliable tissue sampling for the diagnosis of pancreatic masses, but its use is limited to lesions in the body and tail of the pancreas. EUS-FNAB using a 22-gauge needle may be useful for accurate diagnosis in some patients with masses in the uncinate process or the head of the pancreas.     

肿块型胰腺炎与胰腺癌的超声诊断与鉴别

目的 探讨肿块型胰腺炎与胰腺癌的超声表现及鉴别诊断要点.方法 回顾性分析我院2001年1月至2010年7月临床确诊的38例肿块型胰腺炎患者和35例胰腺癌患者影像学检查资料,总结其超声声像图特点及鉴别要点.结果 肿块型胰腺炎与胰腺癌超声诊断符合率分别为73.7%(28/38)和77.1%(27/35).17例(44.7%,17/38)肿块型胰腺炎患者出现病灶内强回声斑块,胰腺癌患者中均无此征,两者之间的超声声像图显示率差异有统计学意义(P<0.01);肿块型胰腺炎患者出现后方回声增强的比例(50.0%,19/38)明显高于胰腺癌患者(8.6%,3/35,P<0.01);胰腺癌患者中出现腹腔淋巴结肿大的比例(45.7%,16/35)明显高于肿块型胰腺炎患者(5.2%,2/38,P<0.01).肿块型胰腺炎患者胰管多表现为不光滑扩张并贯穿(26.3%,10/38);胰腺癌患者胰管表现为光滑扩张并中断的比例(54.3%,19/35)明显高于肿块型胰腺炎患者 (7.8%,3/38,P<0.05).肿块型胰腺炎和胰腺癌的超声声像图表现在发病部位、肿块边界轮廓、内部回声、邻近血管的变化及肿块内血流特征等与胰腺癌极为类似,存在较多重叠而难予鉴别,两者之间的超声声像图显示率差异无统计学意义(P >0.05).结论 超声对肿块型胰腺炎与胰腺癌的鉴别诊断具有重要价值.病灶内强回声斑块、病灶后方回声增强、胰管及胆管改变及伴有淋巴结增大是超声检查诊断肿块型胰腺炎和胰腺癌的鉴别要点.