右腋下直小切口在小儿心脏病手术中的显露体会

目的：总结右腋下微创直切口先天性心脏病矫治经验;方法：回顾性分析2010年3月至2013年6月间,采用右腋下微创直切口实施的先天性心脏病矫治121例,房间隔缺损(ASD)31例,室间隔缺损(VSD)82例,ASD合并VSD 3例,所有VSD均为膜部或膜周部,部分型心内膜垫缺损(PECD)1例,ASD合并部分型肺静脉畸形引流(PAPVC)2例,ASD合并肺动脉瓣狭窄2例。结果：全组手术顺利,无死亡,无严重并发症发生。体外循环时间(78±18)min,主动脉阻断时间(44.0±12.0)min。引流量(275±135)ml,术后呼吸机辅助呼吸3-9.5h,术后住院时间(6.8士1.4)d,无房室传导阻滞,无二次开胸止血术,出院时测量手术切口长4.3-6.5cm。结论：右腋下微创直切口剖胸具有损伤小、恢复快、切口隐蔽美观、不破坏胸廓连续性等优点,值得临床推广。     

婴儿右腋下直小切口心内直视术694例临床分析

目的:探讨右腋下直小切口在婴儿常见先天性心脏病(先心病)心内直视手术中的应用效果。方法:回顾性分析我院2009年4月至2014年12月,采用右腋下直小切口对694例婴儿先心病行心脏直视手术的临床资料,其中男性349例,女性345例,年龄2~12个月,平均(8.0±3.2)个月,体质量4.0~11.2kg,平均7.5kg。行室间隔缺损(VSD)修补术535例,房间隔缺损(ASD)修补术36例,VSD+ASD修补术56例,VSD修补术+二尖瓣成形术(MVP)9例,VSD修补术+ASD修补术+二尖瓣成形术(MVP)3例,肺动脉瓣狭窄(PVS)交界切开术15例,ASD修补术+PVS交界切开术11例,VSD修补术+PVS交界切开术3例,部分肺静脉异位引流(PAPVC)矫治术9例,部分房室管畸形(PECD)矫治术12例,法洛四联症(TOF)根治术5例。结果:手术死亡10例(1.44%),术后发生右肺不张4例,右侧气胸2例,肺部感染21例,切口液化19例,Ⅲ°房室传导阻滞1例,脑气栓1例,二次开胸止血5例。术后6个月至1年门诊随访595例(85.7%),发现VSD残余漏7例,右下肺不张1例,二尖瓣轻度关闭不全4例,二尖瓣中度关闭不全1例。结论:在婴儿常见先心病直视手术中选用右腋下直小切口,只要把握好手术适应症,熟练掌握技术操作要点,均可取得满意临床效果。     

右腋下直切口心内直视手术166例

目的:总结166例右腋下直切口心内直视手术的外科治疗经验。方法:选择性地对先天性心脏病(先心病)、房间隔缺损、室间隔缺损及肺动脉瓣狭窄等患者采用右腋下直切口心内直视手术。结果:全组患者无手术死亡病例。术后引流量明显减少,1例2次开胸止血,余均顺利出院。术后出院天数和住院费用均减少。结论:对先心病采用右腋下直切口,手术失血少、损伤轻、术后恢复快、切口隐蔽并美观。     

三种入径治疗先天性心脏病的比较

目的分析比较正中切口、右腋下直切口、胸腔镜三种不同人径治疗先天性心脏病的效果。方法随机选择正中切口组20例,其中房间隔缺损（ASD）3例,室间隔缺损（VSD）7例,VSD合并PFO8例（合并ASD2例）;右腋下直切口组14例,其中ASD6例（合并三尖瓣关闭不全1例）,VSD3例,VSD合并PFO4例;胸腔镜组17例,其中ASD6例,VSD9例,VSD合并PFO2例。比较三组患者的手术时间、体外循环时间、主动脉阻断时间、引流量、呼吸机辅助时间、ICU时间、术后住院天数、总费用等指标,分析其疗效。结果三组手术时间、体外循环时间、主动脉阻断时间差异均无统计学意义（P〉0．05）;引流量正中切口组为（185．0±44.3）ml,明显高于腋下直切口组的（94．6±75．3）ml（P〈O．05）;呼吸机辅助时间正中切口组为（10．9±8．3）h,明显高于腔镜组的f4．2±2-3）h（P〈0．05）;正中切口组的ICU时间为（39．8±10．7）h,术后住院天数为（7．6±1.3）d,总费用（27943±2352）元,均明显高于腋下直切口组的（26．9±9．1）h,（6．5±1．2）d,（25786±1130）元（P〈O．05）和腔镜组的（20．0±2．2）h,（6．1±1．1）d,（25225±2900）元（P〈O．05）。结论右腋下直切口和胸腔镜治疗先天性心脏病具有创伤小、瘢痕隐蔽、术中及术后出血少、术后恢复快、住院天数短和费用低等优点,值得推广。     

经右腋下直切口体外循环低温室颤下行心内直视手术38例

目的总结经右腋下直切口体外循环低温室颤下行心内直视手术的治疗结果,探讨本术式的适应证及禁忌证。方法以2006年6月至2010年12月,经右腋下直切口体外循环低温室颤下行心内直视手术的38例患者为试验组,其中单纯房间隔缺损21例、室间隔缺损13例、二尖瓣置换4例;以同期经胸骨正中切口行体外循环下低温停跳心内直视手术的165例患者为对照组。观察两组体外循环时间、术后12h血清肌钙蛋白T、辅助通气时间、输血量、住院时间、住院费用等指标,并进行比较。结果两组患者术后生存率差异无统计学意义。低温室颤组患者体外循环时间稍长于对照组,但术后12h血清肌钙蛋白T低于对照组,辅助通气时间两组差异无统计学意义,输血量、住院时间、住院费用低温室颤组均低于对照组。结论经右腋下直切口体外循环低温室颤下行心内直视手术安全,与传统手术方法相比,具有出血少、住院时间短等优点,在严格掌握适应证的情况下,值得临床推广。     

微创右腋下直切口与胸骨正中切口在心内直视手术中的对比

目的:比较右腋下直切口与胸部正中切口两种手术路径,在心内直视手术治疗常见先天性心脏病(先心病)的临床结果。方法:回顾性分析2012年5月至2014年2月,常见简单先心病房间隔缺损、室间隔膜部缺损、部分性心内膜垫缺损行微创右腋下直切口心内直视手术33例,选取既往相同疾病行传统胸部正中切口41例。对比两组患者手术时间、体外循环时间、输血量、术后引流量、术后呼吸机使用时间、术后住院时间及预后并进行总结。结果:两组患者均无死亡、出血致二次手术等重大并发症,在体外循环时间、术后呼吸机使用时间上两组比较,差异无统计学意义(P>0.05),而在手术时间、输血量、术后引流量和术后住院时间方面微创右腋下直切口组均优于传统胸骨正中切口组,差异有统计学意义(P<0.05)。术后随访6个月,两组患者超声心动图(UCG)均未发现残余分流、心包积液等并发症,传统胸部正中切口组4例患者出现鸡胸畸形,而微创切口组均恢复良好。结论:在常见先心病心内直视手术治疗中,微创右腋下直切口安全美观,并不增加术后并发症的发生,在术后恢复上显著优于传统胸骨正中切口。     

右腋下微创直切口手术矫治先天性心脏病的优势

目的探讨右腋下微创直切口手术矫治先天性心脏病的优势。方法选取2011年7月—2013年6月我院收治的先天性心脏病患儿56例,均采用右腋下微创直切口手术。结果患儿均顺利完成手术,无死亡病例,无严重并发症发生。患儿手术体外循环时间为(63.4±18.2)min;主动脉阻断时间为(37.6±14.3)min;术后24 h胸腔及心包引流量平均为(70±32)ml;呼吸机辅助时间平均为(10.8±3.2)h;术后住院时间平均为(6.4±2.7)d。结论右腋下微创直切口手术具有损伤小、恢复快、切口隐蔽美观、不破坏胸廓连续性等优点,值得临床推广。     

右腋下小切口剖胸矫治5公斤以下婴儿室间隔缺损

目的:探讨右腋下小切口剖胸心内直视手术矫治5 kg以下婴儿室间隔缺损的安全性和手术效果。方法:与正中切口手术的病例(正中组,n=113)比较,分析右腋下小切口剖胸(右侧组,n=85)矫治婴儿室间隔缺损的效果,评价指标包括:术前资料、围术期指标、术后病死率及并发症。结果:两组病例大多术前指标差异无统计学意义(P0.05),仅正中组体质量[(4.61±0.41)vs.(4.95±1.18)kg,P0.05]、体表面积[(0.27±0.02)vs.(0.28±0.01)m2,P0.05]、术前有肺炎史的病例所占比例(44.2%vs.64.7%,P0.05)低于右侧组。右侧组手术切口小于正中组[(6.01±0.85)vs.(9.13±1.04)cm,P0.05],手术时间[(143.64±22.41)vs.(152.12±22.80)min,P0.05]、术后住院时间较正中组短[(7.13±2.60)vs.(8.86±3.67)d,P0.05],引流量[14.6(12,16)vs.16.4(13,20)mL/kg,P0.05]和输血量[10(0,20)vs.11.1(0,20)mL/kg,P0.05]也较正中组少,两组其他围术期指标类似(P0.05)。结论:右腋下小切口剖胸心内直视手术矫治婴儿室间隔缺损病例的效果确切、可靠。     

右胸外侧小切口与胸骨正中切口心内直视手术的对比研究

目的探讨右胸外侧小切口行心内直视手术的疗效及治疗体会。方法回顾分析1999年6月～2009年3月期间,常见先心病患者行经右胸外侧小切口手术97例,与同期行正中切口进行同类先心病手术129例的治疗效果进行比较研究,对比研究两组主动脉阻断时间、体外循环时间、术后胸液量、辅助呼吸时间、术后平均住院时间、鸡胸发生率及住院死亡率。结果两组均无住院死亡;主动脉阻断时间、体外循环时间右胸组与正中组比较差异无统计学意义(P0.05);右胸组与正中组比较:平均总胸腔引流量分别为(223.9±127.1)ml,(379.4±203.9)ml;辅助呼吸时间分别为(248.5±74.4)min,(293.1±122.3)min;术后平均住院时间分别为(7.7±1.2)d,(9.4±0.86)d;鸡胸发生率分别为0%,2.3%(3/129);右胸组均低于正中组(P0.05)。结论右胸外侧小切口可安全有效地用于部分心内直视手术,与正中切口手术相比,明显缩短术后气管插管及住院时间,切口隐蔽,美观效果好。     

闭式体外循环辅助下经右胸前外侧小切口微创心脏外科手术的临床总结

目的:总结微创直视心脏外科手术(MIDCS)的近期临床效果。方法:2013-09至2015-05我院完成MIDCS 42例,其中男18例,女24例。房间隔缺损修补术16例,室间隔缺损修补术4例,二尖瓣置换术16例,二尖瓣成形术1例,主动脉瓣置换术5例。直视心脏外科手术方法为股动、静脉及右颈静脉插管行体外循环,双腔气管插管。做右胸前外侧切口3~5 cm,经肋间入胸腔,剪开心包,进入心腔完成手术。结果:42例患者全部手术成功,无围手术期及出院后近期死亡,无胸骨切口感染。体外循环时间98~142 min,平均(122.4±23.7)min;主动脉阻断时间0~118 min,平均(48.3±26.2)min。术后气管插管时间8~76 h,平均(17.4±13.1)h,监护时间45~124 h,平均(54.6±32.6)h;术后住院时间6~12 d,平均(8.2±1.3)d。患者切口长度3~7 cm,平均(4.8±1.5)cm;术后第1天引流量(356.9±283.8)ml,未输血患者27例(64.3%)。结论:MIDCS近期效果好,手术安全性高,适用范围广;创伤小,并发症少,切口美观。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

N-acetyl-L-cysteine combined with mesalamine in the treatment of ulcerative colitis： Randomized,placebo-controlled pilot study

AIM： To evaluate the effectiveness and safety of oral N-acetyl-L-cysteine （NAC） co-administration with mesalamine in ulcerative colitis （UC） patients.
METHODS： Thirty seven patients with mild to moderate UC were randomized to receive a four-wk course of oral mesalamine （2.4 g/d） plus N-acetyl-L-cysteine （0.8 g/d） （group A） or mesalamine plus placebo （group B）. Patients were monitored using the Modified Truelove-Witts Severity Index （MTWSI）. The primary endpoint was clinical remission （MTWSI ≤ 2） at 4 wk. Secondary endpoints were clinical response （defined as a reduction from baseline in the MTWSI of ≥ 2 points） and drug safety. The serum TNF-α, interleukin-6, interleukin-8 and MCP-1 were evaluated at baseline and at 4 wk of treatment. RESULTS： Analysis per-protocol criteria showed clinical remission rates of 63% and 50% after 4 wk treatment with mesalamine plus N-acetyl-L-cysteine （group A） and mesalamine plus placebo （group B） respectively （OR = 1.71; 95% CI： 0.46 to 6.36; P = 0.19; NNT = 7.7）. Analysis of variance （ANOVA） of data indicated a significant reduction of MTWSI in group A （P = 0.046） with respect to basal condition without significant changes in the group B （P = 0.735） during treatment. Clinical responses were 66% （group A） vs 44% （group B） after 4 wk of treatment （OR = 2.5; 95% CI： 0.64 to 9.65; P = 0.11; NNT = 4.5）. Clinical improvement in group A correlated with a decrease of IL-8 and MCP-1. Rates of adverse events did not differ significantly between both groups.
CONCLUSION： In group A （oral NAC combined with mesalamine） contrarily to group B （mesalamine alone）, the clinical improvement correlates with a decrease of chemokines such as MCP-1 and IL-8. NAC addition not produced any side effects.     

Delorme's transrectal excision for internal rectal prolapse

Surgical therapy of functional outlet obstruction in patients with internal rectal intussusception may include abdominal, perineal, or transrectal procedures. Because abdominal procedures often result in significant physiologic impact but unrelieved constipation, the authors have elected Delorme's transrectal excision for management of these patients. Since a short-term placebo effect attends many therapies, this report describes results of transrectal excision only after a threeyear postoperative period. Delorme's transrectal excision of internal intussusception accomplished sustained symptomatic relief in over 70 percent of otherwise refractory constipated patients. The association of internal intussusception with other abnormalities underscores the importance of defining both anatomic and functional components when selecting patients whose constipation may require surgical therapy. Critical technical elements, surgical pitfalls, and potential complications of the procedure are discussed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

The oral glucose tolerance test: A comparison of the time points on the basis of limit values,normal dispersion,and reproducibility

Summary Time points in the glucose tolerance test (GTT) are compared on the basis of limit values, dispersion within a reference population, and reproducibility. We suggest using the distance between a limit value and the median reference value as a measure of the magnitude of abnormality. The distance between 140 mg/100 ml and the median fasting plasma glucose value is chosen as a standard distance and limits for other points in the GTT are calculated to equal this standard distance of abnormality. We suggest that the probability of correctly interpreting an inividual result is directly related to the reproducibility of the test and inversely related to the percentage of the total range of values which is dispersed among the normal population. The ratio of reproducibility to percentage normal dispersion is proposed as an index of the probability of correctly interpreting an individual result. According to this index, the probability of correct interpretation varies in order: fasting plasma glucose concentration>3-h>2-h>0.5-h>1-h plasma glucose concentration.