胆囊颈部结石嵌顿腹腔镜治疗体会

目的总结腹腔镜胆囊切除术治疗胆囊颈部结石嵌顿的经验。方法2001年1月～2008年11月对胆囊颈部结石嵌顿58例采用四孔法和冲吸钝性解剖法行LC。结果47例成功完成LC,9例中转剖腹,原因：一例胆道损伤,一例出血,其它均为胆囊三角解剖不清。术后两例胆漏。术后未发生腹腔内出血,肝下积液等并发症。56例痊愈出院。结论腹腔镜手术治疗胆囊颈部结石嵌顿要掌握好手术时机和适应症,采用充分暴露胆囊三角区,辨清三管关系并把握好中转剖腹手术的时机。     

颈部结石嵌顿的腹腔镜胆囊切除术

胆囊颈部结石嵌顿导致胆囊三角区解剖不清，给腹腔镜胆囊切除（简称I－C）造成一定的困难。我院自开展I．C以来，遇到此类病人31例，除亚例怀疑为Mi－rizZi综合征外，其余病例经仔细操作均完成手术，无严重并发症。现总结如下。临床资料我院自1993年5月至1996年12月共进行I。C432例。其中颈部结石嵌顿31例，占7．2％。31例中男性13例，女性18例，年龄30～72岁，平均47．2岁。病史最长16年，最短2年。术前经B超诊断颈部结石嵌顿、胆囊张力大、胆囊壁增厚28例。胆囊壁增厚达srnmo31例中1例考虑有Mirizzi综合征而中转开胆，余30例均完成I…     

腹腔镜胆囊切除术治疗胆囊颈部结石嵌顿的临床研究

目的 探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆囊颈部结石嵌顿的可行性、安全性和手术时机.方法 回顾性分析腹腔镜胆囊切除术治疗280例胆囊颈部结石嵌顿患者的临床资料.结果 本组中转开腹8例,LC成功率97.1%,无一例发生胆管、肠管损伤,均获治愈.结论 在术者熟练的操作技巧、合理选择中转开腹时机的前提下,胆囊颈部结石嵌顿患者行腹腔镜胆囊切除术是安全可行的.     

腹腔镜在胆囊颈部结石嵌顿中的应用

目的总结胆囊颈部结石嵌顿患者行腹腔镜胆囊切除术（Laparoscopic cholecystectomy,LC）的治疗经验。方法回顾分析腹腔镜手术治疗320例胆囊颈部结石嵌顿患者的临床资料。结果本组中转开腹19例,LC成功率94%,无一例胆管、肠管损伤,均获治愈。结论在术者熟练的操作技巧,合理选择中转开腹时机的前提下,胆囊颈部结石嵌顿患者行腹腔镜胆囊切除术是安全可行的。     

急性胆囊管结石嵌顿的腹腔镜治疗

目的：总结腹腔镜胆囊切除术治疗急性胆囊管结石嵌顿的经验。方法：对42例患者行腹腔镜探查/治疗,7例中转开腹,35例行腹腔镜胆囊切除术。结果：1例术后出血,经保守治疗治愈;1例结石落入胆总管,术后行EST取石痊愈;4例术后出现胆漏,经通畅引流痊愈。29例随访0.5～5年,无胆管炎、胆管狭窄及残余结石情况发生。结论：随着临床经验的积累,腹腔镜胆囊切除术治疗急性胆囊管结石嵌顿是安全可行的。     

腹腔镜处理胆囊管嵌顿性结石31例

1992年2月～2004年12月，我院施行腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）3258例，其中处理胆囊管结石嵌顿31例，取得满意疗效，现就处理方法及结果报道如下。     

腹腔镜胆囊切除术在急性胆囊颈部结石嵌顿治疗中的应用

胆石症发病诱因复杂,以成年女性最为多见,男女发病比约为1∶3,且有随年龄增长差异缩小的趋势。胆石症临床症状具有多样性,部分患者可终身无明显症状,仅在偶然检查中发现。而大部分患者表现为胆囊区绞痛或急慢性胆囊炎。胆石症临床症状与结石大小,所处部位及有无并发感染、梗阻等密切相关。     

胆囊嵌顿结石腹腔镜手术的探讨

目的:探讨胆囊嵌顿结石腹腔镜胆囊切除术的方法.方法:527例行腹腔镜胆囊切除术患者中嵌顿结石58例(11%),在气管插管静脉复合麻醉下行腹腔镜胆囊切除术.结果:嵌顿结石的平均手术时间(110±31) min较非嵌顿者(60±25) min显著延长(P<0.05);平均出血量(120±100) g较非嵌顿者(30±16) g显著增加(P<0.05);中转开腹手术明显增多;术后有2例存在残留结石.结论:对于胆囊嵌顿结石,应用腹腔镜治疗要严格掌握适应症,对于三管合流部炎症较重,而解剖需要60 min以上的病例,以及嵌顿结石的位置无法确认或术野展开困难的病例,应及时中转开腹手术.     

腹腔镜胆囊切除术中胆囊管嵌顿结石的处理经验

本文报道腹腔镜胆囊切除术中15例胆囊管嵌顿结石处理方法:经胆囊管壁外向胆囊底推移结石,再施钛夹;推移不动者剪开嵌顿部位胆囊管前壁,取出结石,切口近侧施钛夹、圈套器套扎或缝扎关闭胆囊管残端.缝扎的1例术后漏少量胆汁,5天后消失.其余14例术后无胆汁漏和其他并发症.住院时间无明显延长.术后随访6～12个月,未发现有胆总管狭窄征象.     

胆囊颈部结石嵌顿性胆囊炎腹腔镜手术68例治疗体会

目的:探讨不同病理状态下胆囊颈部结石嵌顿性胆囊炎LC的手术时机、处理方法及并发症的防治。方法:对68例的临床资料进行回顾性分析。结果:行LC469例中颈部结石嵌顿性胆囊炎68例,63例LC成功,成功率92.6％,并发症1例。结论:既往将胆囊颈部结石嵌顿列为LC的禁忌证,特别是Calot三角致密粘连者或伴胆囊壁坏疸者。随着LC经验的积累,掌握操作技巧及术中配合胆道造影,现已成为LC的适应证,LC治疗胆囊颈部结石嵌顿性胆囊炎安全,可靠。     

肾移植术后单一强的松维持治疗长期存活十八年1例报告

强效免疫抑制剂环孢霉素A（CsA）联合用药方案,使肾脏移植的成活率有了明显的提高,对于肾移植术后初期联合用药的方案看法较为一致,但肾移植诱导治疗后及中长期维持治疗中如何应用CsA或联合用药的观点并非一致．特别是当患者出现长期使用CsA标准剂量治疗经费困难或药物毒副作用问题时,     

Steroid withdrawal for pancreas after kidney transplantation in recipients on maintenance prednisone immunosuppression

Steroid withdrawal from patients taking prednisone for their renal allograft at the time of reinduction of immunosuppression for subsequent pancreas after kidney (PAK) transplantation has not been explored. Our expectation was that lymphocyte depletion, in conjunction with an augmentation of immunosuppression at the time of pancreas transplantation would protect the recipient from rejection of the renal allograft when chronic maintenance steroids are withdrawn. METHODS: Pancreas transplantation was performed using systemic venous drainage and enteric exocrine drainage. Regardless of preoperative immunosuppression, all patients received induction with antithymocyte globulin, a brief taper of intravenous solumedrol over four to five days, maintenance therapy with tacrolimus and sirolimus and either resumption of chronic maintenance steroids or complete withdrawal of steroids. RESULTS: A total of 30 PAK transplants were performed in 29 recipients and divided into two groups: continuation of chronic steroids (n = 10) or steroid-free (n = 19). One pancreas allograft was lost and there was a single mortality in the steroid free group. There was no significant difference in renal function or incidence of infections. CONCLUSION: Steroids can be safely withdrawn following pancreas after kidney transplantation for recipients already on maintenance prednisone in the setting of rabbit antithymocyte globulin induction and tacrolimus and sirolimus maintenance immunosuppression.     

影响尸体肾移植长期疗效和患者预后的因素分析

目的 探讨影响尸体肾移植长期疗效和患者预后的危险因素.方法 对1984年2月至2006年4月间的2256例尸体肾移植患者的资料进行回顾性分析,其中首次肾移植2164例,二次肾移植91例,三次肾移植1例.术前行血液透析者1653例(73.3%),行腹膜透析者319例(14.1%),未进行透析者284例(12.6%).1996年之前组织配型主要采用ABO血型和淋巴细胞毒交叉配合试验;1996年后采用HIA配型和群体反应性抗体(PRA)检测,HLA抗原错配<3个者占60%.免疫抑制方案主要有由环孢素A(CsA)和泼尼松(Pred)组成的二联用药,CsA(或他克莫司)、硫唑嘌呤(或霉酚酸酯)和Pred组成的三联用药,部分病例加用抗淋巴细胞球蛋白(ALG)或抗胸腺细胞球蛋白(ATG),2001年后将ALG(或ATG)改为达利珠单抗.应用Kaplan-Meier分析计算患者及移植肾的1、3、5、10及15年存活率以及移植肾半寿期,对影响受者和移植肾存活率的危险因素进行Log-Rank单因素分析和Cox模型多因素回归分析.结果 术后随访1～20年,患者的1、3、5、10及15年存活率分别为95.3%、89.6%、86.0%、71.3%和61.3%,移植肾的1、3、5、10及15年存活率分别为91.3%、79.3%、74.0%、52.6%和44.8%,移植肾半寿期为(11.58±0.26)年.1984-1995年、1996-2000年与2001-2006年间移植者,其移植肾1、3和5年存活率呈上升趋势(P<0.01).移植肾功能恢复延迟、急性排斥反应、感染、糖尿病及术前PRA阳性是导致移植肾存活率降低的独立危险因素(P<0.05),霉酚酸酯可显著提高移植肾存活率(P<0.01).感染、糖尿病及心脑血管疾病是导致患者存活率下降的独立危险因素(P<0.01).结论 随着移植肾存活率的上升,积极防治感染、糖尿病和心脑血管疾病等并发症,是进一步提高人、肾存活率的关键.     

The treatment of deep vein thrombosis immediately after kidney transplantation: a case report

Ipsilateral acute iliofemoral deep vein thrombosis (DVT) immediately after kidney transplantation is rare but highly morbid, resulting in allograft failure, rupture, or even death. Treatment modalities for iliofemoral DVT occurring just after transplantation are limited due to bleeding risk and impaired renal function. A 55-year-old woman with end-stage renal disease from hypertension underwent a living nonrelated donor procedure using a kidney from her husband. On postoperative day 1, the patient presented edema and pain in the right lower extremity associated with local heat and redness. The symptoms became aggravated with time. Duplex ultrasonography (US) revealed a DVT involving from the right femoral vein to the common iliac vein and an increased resistive index of 0.96 to 0.97. A venogram using carbon dioxide as the contrast medium showed also same findings as the duplex US. After inferior vena cava filter insertion, percutaneous transluminal thromboaspiration (PTA) was performed with complete removal of the thrombus. Early PTA with carbon dioxide as intravenous contrast material seemed to be an effective and safe procedure to treat this complication.     

Osteoporosis after kidney transplantation: preliminary report from a single center

OBJECTIVE: One of the major adverse effects of kidney transplantation is osteoporosis, which is mainly related to steroid use. Only limited data are available on calcitonin therapy for posttransplantation osteoporosis. METHOD: From March 2007 to August 2007, 67 kidney recipients agreed to enter this study. Dual energy X-ray absorptiometry (DEXA) was performed to evaluate bone mineral density (BMD) in the lumbar (L) spine and left femoral neck. We prescribed calcitonin nasal spray to osteoporosis patients (DEXA T < -2.5 SD) who agreed with the treatment. A second and a third DEXA were performed at 3-month subsequent intervals later to evaluate the therapeutic effects. RESULTS: The incidence of osteoporosis in our kidney recipients was 46.26% (31/67 patients). Osteopenia accounted for 38.81% (26/67 patients) and only 14.93% (10/67 patients) were normal. Calcitonin inhalation seemed to improve the BMD with 61% showing improvement on the second DEXA study in our preliminary data. CONCLUSION: Our preliminary data suggested that calcitonin may help to restore bone mass in kidney recipients with osteoporosis. Steroid elimination may prevent the onset of osteoporosis and might even enhance calcitonin efficacy. In the future we need a longer study period to confirm the results and compare it with the outcomes of bisphosphonates therapy.     

Urolithiasis after kidney transplantation in pediatric recipients: a single center report

BACKGROUND: Urolithiasis occurs in approximately 6% of adult kidney transplant (KTx) recipients. Limited data are available on urolithiasis after pediatric KTx. We report the incidence, management of, and risk factors for stone development in children after KTx. METHODS: We reviewed the medical records of 399 children who received KTx at our center between September 1986 and January 2003. Transplant outcomes were compared in stone formers and controls. RESULTS: Twenty (5%) patients, age 9+/-5 (X +/- SD) years, developed stones over the follow-up period (74+/-53 months). Time to stone presentation was 19+/-22 months post-KTx. Presenting features were urinary tract infection (UTI), 8; gross hematuria, 5; microscopic hematuria, 2; dysuria without infection, 6; difficulty voiding, 3; and silent stones, 2. Stones were removed by cystoscopy in 11 (55%) patients. Stone composition was determined in 11 patients: calcium phosphate (55%), calcium oxalate (18%), mixed calcium phosphate and oxalate (9%), and struvite (18%). Factors predisposing to stones in study patients included suture retention (n = 4), elevated urinary calcium excretion (n = 2), recurrent UTI (n = 2), and urinary stasis (n = 2). The incidence of UTI was higher (P = 0.003) and of acute rejection was lower (P = 0.02) in stone patients compared with controls. Patient and graft survival rates and the incidence of chronic rejection did not significantly differ between study patients and controls (P = NS). CONCLUSIONS: Urolithiasis is not uncommon in pediatric KTx patients. Factors associated with post-KTx urolithiasis include retention of suture material, recurrent UTI, hypercalciuria, and urinary stasis. Treatment is associated with excellent outcome and low recurrence rate.     

Hyperacute rejection after single lung transplantation: a case report

Hyperacute rejection is a well-known complication in kidney and heart transplantations. However, its occurrence in lung transplantation is extremely rare, with only 4 cases previously described. A 53-year-old female patient blood type O with end-stage chronic obstructive pulmonary disease underwent left lung transplantation. She had 2 negative pretransplantation evaluations for panel-reactive antibodies. One hour after the vascular clamps were released, progressive hypoxia developed. Fiberoptic bronchoscopy revealed an optimal bronchial anastomosis; an abundant pink frothy fluid was observed on the allograft side. Chest X ray sevealed a completely opacified left lung. Due to the low-compliance of the transplanted lung and the risk for native lung hyperinsufflation, independent mechanical ventilation was employed. Despite all measures, multiple organ failure developed and the patient died 24 hours after the procedure. A necropsy evaluation for confirmed the patency of all anastomoses and no signs of ischemia. Retrospectively, a new evaluation for panel-reactive antibodies was performed, with 24% reactivity. Complement-dependent cytotoxicity crossmatch was negative, however, a flow cytometric analysis was positive for both HLA-I (56%) and HLA-II (45%). Further investigation detected an anti-A2 in the recipient serum and the donor had an A2 antigen. Hyperacute rejection is a rare posttransplantation complication highlighted by its precocity and lethality. With the increased number of lung transplantations performed yearly, it is believed that its incidence will also rise. Therefore, prompt diagnosis and familiarity with management strategies are fundamental.