腹腔镜胆囊切除术中联合ERCP治疗胆囊结石合并肝外胆管结石

目的:探讨腹腔镜胆囊切除(LC)术中联合ERCP治疗胆囊结石合并肝外胆管结石的临床应用价值。方法:通过分层匹配,回顾性分析LC术中及术前行ERCP治疗胆囊结石合并肝外胆管结石病例各41例,比较两组病例在手术操作时间、取石成功率、并发症发生率、住院时间、病人舒适度及住院相关费用等指标上的差异。结果:LC术中ERCP与术前ERCP具有相似的临床疗效和安全性,总体住院费用无统计学差异。虽然术中ERCP组的手术时间相对较长,但其住院时间较短,病人舒适度较好。结论:LC术中联合ERCP治疗胆囊结石合并肝外胆管结石具有较好的可行性,其应用前景值得期待。     

腹腔镜保留肾单位术三级培训模式初探

目的 介绍腹腔镜保留肾单位术的三级培训模式.方法 三级培训模式的内容包括体外模拟阶段、动物模型训练和临床实践操作.以小型猪作为实验模型建立腹腔镜保留肾单位术的标准操作方式.临床实践操作又细分为三步进行,包括辅助手术、开展相对简单的腹腔镜手术和进行LNSS. 结果 4名学员均成功完成全部三级培训内容.其中体外模拟培训累计时间平均为70 h.经过体外模拟培训后全部学员均能够熟练地掌握腔镜器械下缝针打结等基本操作技能.4名学员均完成动物模型LNSS 20例,其中半肾切除术6例.肾上极或下极平均手术时间由最初的(120.0±10.9)min降低到在完成12台LNSS时的(69.0±5.2)min,差异有统计学意义(P<0.01).学员在开展后腹腔镜肾囊肿去顶术和上段输尿管切开取石术等相对简单的手术7～9例后,各自成功地完成LNSS手术3例,均未出现术中并发症.LNSS平均手术时间为87 rain,肾脏热缺血时间平均为25 min.结论 "三级培训模式"能够帮助年轻医生掌握LNSS这类高难度复杂性泌尿外科腹腔镜手术,显著地降低手术并发症的发生,提高手术疗效,有利于腹腔镜手术的推广应用.     

PTCD在老年恶性梗阻性黄疸ERCP操作失败患者中的疗效观察

[摘 要] 目的 探讨老年恶性梗阻性黄疸（MOJ）患者ERCP操作失败后行PTCD补救治疗的临床疗效。方法 选取53例ERCP操作失败后行PTCD治疗的老年MOJ患者作为研究组,并选取同期46例首选PTCD治疗的老年MOJ患者作为对照组,回顾性分析两组治疗前后临床症状和肝功能变化情况,手术成功率,术后并发症发生率及病死率等。结果 研究组ERCP操作失败的主要原因为肿瘤致胆管严重狭窄,导丝无法通过,占67.9%;失败后行PTCD补救治疗,手术成功率为94.3%,与对照组比较无统计学差异（ χ 2 =0.135,P=0.714）;并发症发生率为30.0%,虽略高于对照组（24.4%）,但差异并无统计学意义（ χ 2 =0.368,P=0.544）。由于肿瘤侵犯较重,研究组胆道支架置入成功率明显低于对照组（35.8% vs 69.6%, χ 2 =11.208,P=0.001）,但术后2周,研究组临床症状及肝功能各项指标均较术前明显改善（P＜0.01）。两组减黄效果相当,均无死亡病例。结论 老年MOJ患者 ERCP操作失败后行PTCD补救治疗,其手术成功率、并发症发生率及病死率均与首选PTCD治疗无差异,临床疗效显著,值得临床参考。     

胆囊结石合并胆总管结石的微创外科治疗进展

胆石症包括胆囊结石、胆总管结石和肝内胆管结石.胆囊结石合并胆总管结石占胆石症的9.2％ ～ 14.3％,当前临床常用的治疗方法包括传统的开腹胆囊切除及胆总管切开取石+T管引流术(Opencholecystectomy choledocholithotomy and T-tube drainage,OC-OCHTD);经内镜逆行胰胆管造影(ERCP)+内镜下括约肌切开取石(EST),二期腹腔镜胆囊切除术(LC)(即ERCP/EST+LC);同期腹腔镜胆囊切除+胆总管切开取石(LCBDE),这三种术式各有特点.与传统的开腹手术比较,后两者为微创手术治疗方法,体现了微创技术的优势,但手术适应证和操作技术需要不断总结和提高.目前,关于后两种微创方法治疗的文献报道较多,在诸如手术适应证、住院费用、手术时间、治疗风险、并发症、住院时间等方面存在一定争议.比较LCBDE和ERCP/EST+ LC,两者各有优缺点.但是在符合适应证的情况下,LCBDE是一期治疗胆囊结石合并胆总管结石患者的首选方法.对患者而言,无论哪种手术方案,创伤小、操作安全、并发症少的方法才是最适合的治疗手段.     

ERCP术后肝包膜下血肿破裂并腹腔出血一例

内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)是目前诊断和治疗肝胆胰疾病最常用的微创操作技术[1-3]。虽然ERCP是一种快速有效的诊疗手段,但是在消化道内镜检查中它的并发症发生率也较高,常见的并发症包括急性胰腺炎、胆管感染、出血、十二指肠穿孔和心肺功能变化,但肝包膜下血肿(hepatic subcapsular hematoma,HSH)是十分罕见的,常常与手术操作损伤有关[2,4-6]。现报道2019年8月中国科学院大学深圳医院和中山大学附属第七医院合作诊治的一例ERCP术后9 h发生HSH破裂出血急诊行剖腹探查的病例资料并进行相关文献复习。     

内镜逆行性胰胆管造影术与腹腔镜胆总管探查术治疗胆囊切除术后胆总管结石的疗效比较

目的比较内镜逆行性胰胆管造影术(ERCP)与腹腔镜胆总管探查术(LCBDE)治疗胆囊切除术后胆总管结石的临床疗效。方法胆囊切除术后胆总管结石病人88例,其中行ERCP46例(ERCP组),行LCBDE42例(LCBDE组),比较两组病人的手术时间、术中并发症发生率、结石完全清除率、术后住院时间、住院费用和术后并发症发生率。结果两组病人操作顺利,无术中并发症发生。ERCP组和LCBDE组手术时间分别为(59.53±13.95)分钟和(119.94±24.32)分钟、术后住院时间分别为(5.61±2.56)天和(7.83±2.28)天,住院费用分别为(13.24±1.92)千元和(15.82±1.75)千元,两组比较差异均具有统计学意义(P0.05)。ERCP组病人结石完全清除率、术后并发症发生率分别为95.7%和4.3%,LCBDE组分别为97.6%和7.1%,两组比较差异无统计学意义(P0.05)。结论 ERCP和LCBDE均是治疗胆囊切除术后胆总管结石安全、有效的方法。ERCP在手术时间、术后住院时间及住院费用方面较LCBDE有明显优势,但对于年轻病人及结石较大的病人,LCBDE是更好的选择,临床上应根据病人情况制定个体化的治疗方案。     

胆总管结石早期内镜治疗与手术治疗的对比分析

目的探讨胆总管结石的早期内镜下逆行胰胆管造影检查和治疗与手术治疗的临床疗效及安全性。方法 56例胆总管结石的住院患者中,26例实施ERCP术,同期30例患者实施传统胆总管切开取石患者为对照组。结果 26例患者顺利实施ERCP操作,病情均得到明显改善,同对照组相比没有明显增加并发症发生率。结论 ERCP胆总管结石患者具有微创、安全、有效,是治疗胆总管结石的一种有效方法。     

特发性脊柱侧凸动物模型研究进展

特发性脊柱侧凸(IS)是一类至今病因尚不明确的脊柱三维畸形,受伦理学限制,动物模型是研究此类疾病病理过程与生理变化的基础。IS模型根据建立方法可大致分为病因学模型与机械方法模型两大类。病因学模型由病因学假说入手,模拟IS的病理过程与生理环境,其中硬骨鱼类模型作为非诱导侧凸模型多用于IS基因的研究;松果体切除类模型应用最多,但存在较大争议;生长激素类模型关注于体内激素水平变化导致的脊柱生长异常,具有广泛应用前景;神经损伤类模型是IS病因学研究的新思路,但建模难度较大。机械方法模型则通过手术等方法直接或间接破坏脊柱正常结构导致其侧凸,包括外固定模型和内固定模型,其中内固定模型主要通过椎体钉固定术和椎体栓固术建立。各类模型都有其特点及适用性,选取合适模型至关重要。总体而言,病因学研究及探索性研究以小动物模型为主,而生物力学研究及治疗方面研究大动物模型更具优势。该文对IS动物模型研究进展作一综述。     

两种微创术式治疗胆囊结石合并胆总管结石的效果观察

目的观察腹腔镜胆囊切除术(LC)+胆总管探查取石术(LCBDE)与内镜逆行胰胆管造影(ERCP)/内镜十二指肠乳头括约肌切开术(EST)+腹腔镜胆囊切除术(LC)治疗胆囊结石合并胆总管结石的临床疗效。方法采用LC+LCBDE治疗40例,实施ERCP/EST+LC治疗50例。对90例胆囊结石合并胆总管结石患者的临床治疗资料进行回顾性分析。比较两种术式的手术成功率、手术时间、住院时间、结石清除率及并发症发生率。结果 2种术式的手术成功率、手术时间、结石清除率及并发症发生率比较,差异均无统计学意义(P0.05)。但LC+LCBDE的住院时间短于ERCP/EST+LC,差异有统计学意义(P0.05)。结论 LC+LCBDE与ERCP/EST+LC治疗胆囊结石合并胆总管结石均有微创、结石清除率高、术后并发症少等优点,但LC+LCBDE术后恢复时间更短。应根据患者病情及术者的操作熟练程度综合分析,合理选择治疗方法。     

ERCP并发肠穿孔的外科治疗

<正>ERCP(经内镜逆行胰胆管造影)内镜技术现已广泛应用,并且由单纯诊断工具成为某些胆胰疾病的首选治疗方法。ERCP操作一般认为安全性较高,但其相关并发症如胰腺炎、出血、胆管炎等也高达5%~10%,死亡率0.1%~1.0%~([1])。肠穿孔是ERCP最为严重的并发症,相对少见,发生率0.14%~1.60%,但死亡率则高达4.2%~29.6%~([2])。ERCP肠穿孔能否早期诊断、是否需要外科治疗、何时     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Differences in Osteocyte Density and Bone Histomorphometry Between Men and Women and Between Healthy and Osteoporotic Subjects

Bone defects related to osteoporosis develop with increasing age and differ between males and females. It is currently thought that the bone remodeling process is supervised by osteocytes in a strain-dependent manner. We have shown an altered response of osteocytes from osteoporotic patients to mechanical loading, and osteocyte density is reduced in osteoporotic patients, which might relate to imperfect bone remodeling, leading to lack of bone mass and strength. Hence, information on osteocyte density will contribute to a better understanding of bone biology in males and females and to the assessment of osteoporosis. Osteocyte density as well as conventional histomorphometric parameters of trabecular bone were determined in cancellous iliac crest bone of healthy postmenopausal women and men and of osteoporotic women and men. Osteocyte density was higher in healthy females than in healthy males and lower in osteoporotic females than in healthy females. Bone mass was reduced in osteoporotic patients, both male and female. In females, trabecular number was reduced, whereas in males, trabecular thickness was reduced and eroded surface was increased. There were no correlations between the parameter groups bone architecture, bone formation, bone resorption, and osteocyte density. These results are consistent with impaired osteoblast function in osteoporotic patients and with a different mechanism of bone loss between men and women, in which osteocyte density might play a role. The reduced osteocyte numbers in female osteoporotic patients might relate to imperfect bone remodeling leading to lack of bone mass and strength. M. G. Mullender and S. D. Tan contributed equally to this work.     

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7–12, 2020