肝内肝动脉-门静脉分流的研究进展

近年来，随着多层螺旋CT或MR动态增强成像、高分辩力DSA和彩色Doppler超声扫描（CDUS）等新技术的发展和临床广泛应用，不仅明显提高了伴发于肝脏疾病和累及门脉血流的肝外病变中的肝内器质性或功能性肝动脉-门静脉分流（aaerial portal venous shunt，APVS）的检出率，而且可以显示血液动力学改变引起的局部肝实质密度或信号强度增高（即局部肝实质一过性灌注异常），甚至还可辨别肝内APVS对门静脉血流方向的影响。于此文中，笔者主要通过近期文献的复习，对肝内APVS的研究进展作了较全面的综述，以供同道参考讨论。     

肝癌肝动脉与门脉肝静脉主支分流的介入治疗

我院在肝癌介入治疗中发现肝动脉与门静脉主支和肝动脉与肝静脉主支分流6例。其中4例肝动脉与门静脉主支分流,1例肝动脉与右肝静脉分流,1例肝动脉与门静脉主支及左肝静脉双向分流。肝癌动静脉分流的血管造影表现,依王颂     

肝海绵状血管瘤的动脉造影分型

目的 探讨肝海绵状血管瘤(CHL)动脉造影表现分型及其临床意义.资料与方法 102例CHL患者,男35例,女67例,年龄23～70岁,平均41.3岁.所有患者行肝动脉造影:导管位于肝固有动脉水平,对比剂注射流率5 ml/s,DSA连续完整采集动脉期、实质期图像.按照下述标准将动脉造影表现分为4型:富血型(Ⅰ型),乏血型(Ⅱ型),动静脉分流(AVS)型(Ⅲ型),门静脉供血型(Ⅳ型).各型判定标准:富血型为供血动脉轻-中度增粗,动脉期可见较多异常血窦显影,实质期异常血窦充盈瘤体大部分区域.乏血型为供血动脉无增粗,动脉期可见数量不多的异常血窦在瘤体周边显影,实质期异常血窦充盈瘤体小部分区域.出现AVS则不论富、乏血与否直接判定为AVS型.门静脉供血型则为动脉期及实质期完全无瘤体染色,直接或回流性门静脉造影显示异常血窦充盈染色.分型确定后对Ⅰ～Ⅲ型患者行平阳霉素碘油乳剂(PLE)肝动脉栓塞.统计总体瘤体缩小率和各型瘤体缩小率并分析其差别.结果 102例动脉造影全部成功.其中,富血型58例(56.8%),乏血型30例(29.4%),AVS型13例(12.7%),门静脉供血型1例(0.98%).在AVS型患者中,肝动脉-门静脉分流11例,肝动脉-肝静脉分流2例.分流时相出现于动脉期10例,出现于实质期3例.总体瘤体缩小率为46.7%,富血型瘤体缩小率为56.3%,而乏血型为27.9%,AVS型46.6%.各型之间瘤体缩小率差异有统计学意义(P＜0.05),而富血型和AVS型均较乏血型为高,差异有统计学意义(P＜0.05),但富血型和AVS型之间差异无统计学意义(P＞0.05).结论根据肝动脉造影表现可将CHL分为富血、乏血、AVS、门静脉供血四种类型.其中富血、乏血及AVS型之间行PLE肝动脉栓塞时瘤体缩小率有显著差别.此分型可作为选择疗法和估计瘤体缩小程度的依据.     

肝海绵状血管瘤的动脉造影分型及介入治疗

目的:对症状性肝海绵状血管瘤(SCHL)进行分型,采用平阳霉素碘油乳剂动脉硬化性栓塞(PLE-IASE)方法治疗并评价其疗效.材料和方法:89例SCHL分为三型:Ⅰ型为富血型,Ⅱ型为乏血型,Ⅲ型为动静脉分流型(AVS).所有患者行PLE-IASE.结果:富血型51例,乏血型26例,AVS型12例.总体瘤体缩小率为46.6%,其中富血型56.2%,乏血型27.9%,动静脉分流型46.5%.动脉造影分型之间瘤体缩小率差异有显著性意义.结论:SCHL根据动脉造影表现可分为富血、乏血、AVS三种类型.富血型和AVS型瘤体缩小率较乏血型高,差异有显著性意义.富血型和AVS型之间瘤体缩小率差异则无显著性意义.     

多层螺旋CT诊断肝癌合并动-静脉瘘及癌栓

目的:分析肝癌合并动-静脉瘘及癌栓的多层螺旋CT(MSCT)动态增强表现,探讨其诊断肝癌合并动-静脉瘘及癌栓的作用及临床价值。材料和方法:13例肝癌肝动脉-门静脉瘘病例均采用MSCT动态增强扫描,并完成动脉期、门脉期三维重建,分析肝动-静脉瘘的增强特征及其合并门静脉癌栓的CT表现。结果:13例肝癌肝动脉-门静脉分流中巨块型8例、结节型4例和弥漫型1例。肝癌合并主干型肝动静脉瘘9例、末稍型3例和混合型2例。13例中8例合并门静脉癌栓。动脉期门静脉主干显影密度大于脾静脉或肠系膜上静脉7例,门静脉左右分支的显影密度大于门静脉主干3例。结论:肝癌合并动静-脉瘘及癌栓有特征性的MCCT表现,MS能正确诊断并对临床制定治疗方案及判断预后提供依据。     

肝动静脉分流的多层螺旋CT检查

随着螺旋CT尤其是多层螺旋CT肝动脉增强扫描技术及后处理技术的发展，肝动静脉分流的检出率明显升高，正确认识及诊断本病对临床实际工作帮助很大。     

PVA-TACE治疗肝细胞癌并肝肺分流的临床疗效及预后分析

目的：评价聚乙烯醇微粒肝动脉化疗栓塞（PVA-TACE）治疗肝细胞癌（HCC）并肝肺分流（HPS）的临床疗效,分析影响生存预后的因素。 方法：回顾性分析42例HCC并HPS患者资料,依据分流途径分为门静脉-腔静脉分流组（A组,9例）与肝动脉-肝静脉分流组（B组,33例）。依据分流速度采用不同规格聚乙烯醇（PVA）微粒进行肝动脉化疗栓塞（TACE）治疗,随访并分析生存期及术后并发症。采用Kaplan-Meier法计算累积生存率,采用Cox模型分析生存预后的影响因素。 结果：42例患者中位生存期（OS）为9.5个月,6、12个月生存率分别为74.9%、39.4%。A组与B组中位OS分别为10.5个月、9.5个月,两组生存期无明显差异（χ²=0.410,P=0.522）。Cox回归分析结果显示：行为状态（PS）评分较高（HR=2.454,P=0.026）、肿瘤负荷>50%（HR=3.477,P=0.019）及门静脉主干癌栓形成（P=0.006）为预后的独立危险因素,而多次栓塞（HR=0.329,P=0.008）为预后的独立保护因素。 结论：经谨慎选择病例,PVA-TACE治疗HCC合并HPS安全、有效。经多次栓塞治疗患者预后较好,而PS评分较高、肿瘤负荷较大及门静脉主干癌栓形成的患者预后不良。     

肝细胞癌肝动脉门静脉分流形成的相关因素分析

目的总结肝细胞癌(HCC)合并肝动脉门静脉分流(APS)、肝动脉肝静脉分流(AVS)的发生率,并探讨影响HCC APS形成的相关因素。方法回顾分析2009年1月-2010年12月经动脉栓塞(TAE)治疗的.497例HCC患者的影像学和病历资料,总结APS、AVS的发生率,采用单因素分析APS的发生与HCC患者性别、年龄、乙型肝炎病史、肝硬化基础、肝癌切除史、甲胎蛋白(AFP)、肿瘤类型、肿瘤数目和门静脉癌栓(PVTT)的相关性,并行多因素Logistic回归分析。结果HCC合并APS的发生率为10.5%(52/497),合并AVS的发生率为1.6%(8/497),同时合并APS与AVS的有3例(0.6%)。单因素分析显示:乙型肝炎病史、肝硬化基础、肿瘤类型、肿瘤数目和门静脉癌栓与HCC患者APS的发生相关;多因素Logistic回归分析显示:肝硬化基础、巨块型肿瘤、肿瘤多发、门静脉癌栓是HCC合并APS发生的危险因素。结论HCC患者有肝硬化基础、巨块型肿块、多发肿瘤、门静脉癌栓会诱发APS的发生     

肝动静脉分流的多层螺旋CT检查

随着螺旋CT尤其是多层螺旋CT肝动脉增强扫描技术及后处理技术的发展,肝动静脉分流的检出率明显升高,正确认识及诊断本病对临床实际工作帮助很大.     

肝内动脉-门静脉分流：功能性分流的诠释

于本文中,作者将由于肝动脉和门静脉血流的功能性重新分配而形成的肝内动脉-门静脉分流(intrahepatic arterial-portal venous shunts, IHAPVSs),皆定义为功能性肝内动脉-门静脉分流(functional IHAPVSs或F-IHAPVSs);以此从概念上区别于由于肝内动脉-门静脉瘘或直接交通而形成的器质性肝内动脉-门静脉分流(organic IHAPVSs或O-IHAPVSs),如伴发于进展期肝细胞癌和其他恶性肝脏肿瘤的O-IHAPVSs以及伴发于先天性肝脏血管畸形、遗传性出血性毛细血管扩张症和肝脏外伤(包括医源性损伤)等的O-IHAPVSs。在F-IHAPVSs中,最常见的是由于各种原因使向肝性门静脉血流减少而致肝动脉血流代偿性(或继发性)增多所形成的F-IHAPVSs,其形成机制分为3类：经肝窦性,如伴发于肝硬化的F-IHAPVSs;窦后性,如伴发于布加综合征患者急性期的F-IHAPVSs;窦前性,如伴发于胃肠道出血性休克患者的F-IHAPVSs。另一种F-IHAPVSs常见于一些原发性肝动脉血流增多的肝脏疾患,如伴发于富血型肝海绵状血管瘤、血供丰富的小肝细胞癌和肝胆炎性病变等的IHAPVSs,皆归之于F-IHAPVSs范畴;然而,此类F-IHAPVSs的形成机制是随其基础疾病而不同。临床上,依据下列3个要点可作出F-IHAPVSs的影像诊断：①首先是伴有肝内动脉-门静脉瘘或直接交通的各种肝脏疾病(已如上述)的临床和影像学表现皆已经被排除;②肝动脉DSA动脉期像上显示门静脉早显的特征性表现;或(和)③肝脏CT/MR动态增强成像动脉期像上显示一过性肝实质强化(THPE),特别是如同时见到门静脉早显,则可确认为F-IHAPVSs无疑。但是,在鉴别诊断上,F-IHAPVSs必须仔细地与O-IHAPVSs、肝脏迷走静脉或体循环的异常向肝性引流静脉等所引起的局部肝实质灌注作鉴别;此外,伴发于肝硬化的小THPE如呈现为孤立小结节状时,则需谨慎地与小的肝细胞癌灶作鉴别。     

Polyvinyl alcohol terminal chemoembolization for hepatocellular carcinoma with hepatic arteriovenous shunts: Safety,efficacy, and prognostic factors

PurposeTo evaluate the safety and efficacy of polyvinyl alcohol (PVA) terminal chemoembolization and to identify the prognostic factors associated with survival in hepatocellular carcinoma (HCC) patients with hepatic arteriovenous shunts (HAVS).Materials and methodsOf 133 patients’ managements were retrospectively analyzed. HAVS was classified into three types: slow-flow, intermediate-flow and high-flow. The size of the PVA used was determined following the scheme: slow-flow HAVS: 300–500 μm PVA; intermediate-flow HAVS: 500–710 μm PVA; high-flow HAVS: 710–1000 μm PVA. The HCCs with slow-flow and intermediate-flow HAVS were embolized by PVA plus chemotherapeutic agents lipiodol emulsion, while the high-flow HAVS were treated by PVA with chemotherapeutic agents. Survival curves were calculated by Kaplan-Meier method and compared by log-rank test. The influence of possible prognostic factors on survival were analyzed by multivariate Cox proportional-hazards method.ResultsThe median overall survival (OS) of 133 patients was 9.1 months. The median OS of the slow-flow type, intermediate-flow type and high-flow type patients were 10.8, 9.1 and 7.3 months, respectively. There was no statistically significant difference among different HAVS types (P = 0.239). The 30-day mortality was 3.8%. Cox multivariate survival analysis revealed that initial preoperative AFP value ≥ 400 ng/ml (HR = 2.105, P = 0.006) was an independent risk factor. While multiple embolization (HR = 0.482, P = 0.011), tumor remission (HR = 0.431, P = 0.041) and multimodality therapy (HR = 0.416, P = 0.004) were independent protection factors.ConclusionIt is safe and effective for HCCs with HAVS treated by terminal chemoembolization therapy with PVA plus chemotherapeutic agents lipiodol emulsion (or PVA plus chemotherapeutic agents). The HCCs with HAVS achieves good prognosis with multiple embolization, tumor remission and multimodality therapy, while achieves poor prognosis with inital preoperative high AFP value (≥400 ng/ml).     

PVA-TACE治疗肝癌并肝动-静脉分流的疗效及生存预后

目的：探讨聚乙烯醇微粒肝动脉化疗栓塞（PVA-TACE）治疗肝细胞癌（HCC）并肝动-静脉分流（HAVS）的疗效预测及生存预后影响因素分析。 方法：回顾性分析113例HCC并HAVS,依据分流速度不同采用不同规格PVA化疗栓塞。依据疗效分为肿瘤控制组（A组,63例）与肿瘤进展组（B组,50例）,随访并分析生存期,采用Kaplan-Meier法计算累积生存率,疗效预测因素采用多因素logistic回归分析,生存预后因素采用Cox模型分析。 结果：113例患者的中位生存期（OS）为11.0个月。A、B组中位OS分别为14.5个月、9.2个月,两组患者的生存期差异有统计学意义（χ²=15.215,P<0.001）。多因素logistic回归分析显示：肿瘤分布于单叶（OR=0.222,P=0.003）及无癌栓形成（OR=0.126,P=0.024）患者的疗效较好。多因素Cox回归分析显示：年龄≤50岁（HR=0.616,P=0.049）、多次栓塞治疗（HR=0.550,P=0.039）及肿瘤控制（HR=0.443,P=0.002）为预后的独立保护因素,而肿瘤负荷>50%（HR=3.156,P<0.001）及分流栓塞程度较低（HR=2.011,P=0.002）为预后的独立危险因素。 结论：PVA-TACE治疗HCC并HAVS是安全、有效的。肿瘤单叶分布及无血管癌栓侵犯肿瘤控制较好。肿瘤负荷较大及分流栓塞程度较低患者预后较差,年轻、多次栓塞治疗及肿瘤控制的患者预后较好。     

肝癌合并动静脉瘘的介入诊断及治疗

目的 分析肝细胞癌(HCC)合并肝动脉一静脉瘘(HAVS)的诊断及介入处理方法，探讨临床疗效。方法 收治的453例肝细胞癌，33例合并HAVS。根据造影诊断分别进行明胶海绵或弹簧圈堵塞瘘口，合并或单独使用丝裂霉素、卡铂粉、碘油混合乳剂进行瘤体栓塞。此外，对于冈HAVS所致的严重门脉高压反复上消化道出血3例患者，实施了经皮肝穿刺胃冠状静脉栓塞术。结果 肝动脉-门静脉瘘(HAPS)24例，HAVS7例，混合型2例：HAVS经处理瘘口达到完全栓塞后行肝动脉化疗栓塞(TACE)时，26例丝裂霉素、卡铂、碘油乳剂均能较好地沉积在瘤体内其余7例瘤体内栓塞剂沉积不好其中3例反复上消化道出血的患者经皮肝穿刺胃冠状静脉栓塞术后1d出血停止。结论 对于肝细胞癌合并HAVS患者，数字减影血管造影(DSA)是必要的检查手段，栓塞治疗是有效的治疗方法。     

Health effects of therapeutic use of 131I in hyperthyroidism.

Since 1942, therapy with radioiodine (Na131I) has gained a major role in the treatment of benign thyroid disorders, notably hyperthyroidism caused by Graves' disease or toxic multinodular goiter. The very large series of patients treated so far offer the opportunity for an assessment of both benign and malignant side effects. Hyperthyroidism is sometimes observed after radioiodine therapy due to radiation induced thyroid hormone or by an immunological mechanism. Despite the numerous attempts to design dosage schedules aiming at euthyroidism, hypothyroidism occurs in the majority of patients throughout life. Transient hypothyroidism may be observed within the first year after therapy and is caused by an immunological mechanism. Radioiodine therapy in Graves' disease may induce or worsen ophthalmopathy, which can be prevented by steroids effectively. Hypoparathyroidism and hyperparathyroidism have been reported after radioiodine therapy but probably do not exceed the normal incidence. Sialitis is commonly observed but mostly in patients treated with radioiodine for thyroid cancer. There are no indications for induction of genetic abnormalities after radioiodine therapy although no definite conclusion can be reached. Much attention has been paid to malignant disease. In very large series, no effects of radioiodine therapy on survival have been observed. Some studies report an increased relative risk for certain types of cancer (notably thyroid cancer, stomach cancer, bladder and kidney cancer or hematological malignancies). However, these observations were not confirmed by other large studies, so that no definite conclusion with respect to risk for certain types of malignant disease can be drawn. However, radioiodine therapy for benign thyroid disorders has generally been considered safe and without major side effects, hypothyroidism being the most frequent one.     

Physical activity in human hypertension. A mechanisms approach

The concept of treating hypertension without medication is seen as an attractive alternative to the problems that can arise with the use of drug therapy. Weight loss, salt restriction, relaxation therapy, and exercise have been the non-pharmacological treatments for hypertension. The role of long term exercise in lowering resting arterial pressure in hypertension, and its use as a non-drug therapy have been studied. Epidemiological studies of athletic ability, occupation, and leisure-time activities have provided equivocal findings and the effect of training on chronic high blood pressure of hypertensives is still unclear. Further well-controlled studies (with respect to training intensities, weight loss, concurrent hypotensive medication, salt restriction, and hypertensive classification), with an emphasis on elucidating the physiological mechanisms involved, are required so that the contribution of exercise to hypertensive therapy can be determined.     

Diagnosis and therapy of differentiated thyroid cancer

Summing up, we can state the following: Diagnosis of thyroid cancer seems easy, since the organ lies immediately beneath the skin, so that tumour growth could be readily detected, and also since thyroglobulin (tg) is an ideal and well-tried tumour marker. Nevertheless, malignant thyroid nodes are still frequently misinterpreted as benign, as benign strumae occur quite often. In view of the fact that malignant follicular carcinomas have a tendency to produce metastases via the bloodstream, in all tumours larger than 1 cm to 1.5 cm no change should be made in the classical therapeutic approach (total thyroidectomy, radioiodine therapy and levothyroxine suppression therapy), whereas in so-called occult papillary thyroid cancer (i.e. carcinomas smaller than 1-1.5 cm) hemithyroidectomy and lifelong suppression therapy can be satisfactory. It follows from this that in view of the low complication rate even with maximal therapy of differentiated thyroid cancer and the advantages resulting therefrom for follow-up care, the total ablation therapy should be retained as standard treatment. The low incidence of thyroid cancer justifies, inter alia, central follow-up care, the more so since this is usually performed on an interdisciplinary basis and there is as yet no standardised procedure for thyroglobulin determination.     

脊柱创伤仿生治疗新理念

仿生学伴随着科学技术的发展而诞生,其内容主要是模仿生物的特点从工程学角度设计机械或设备,解决人们生产和生活中的一系列需求.仿生学在军事、医学等许多领域得到广泛应用.笔者在对仿生学、医学仿生学、骨科仿生治疗理念进行深入探讨的基础上,提出脊柱创伤仿生治疗学(STBT)这一新理念,并对其概念和内涵进行阐述,为攻克脊柱创伤治疗...     

Imaging-guided acute ischemic stroke therapy: From "time is brain" to "physiology is brain"

The number of potential patients who are actually treated for acute ischemic stroke is disappointingly low, and effective treatments are making a minor impact on this major public health problem. Imaging is not regularly used to identify the ischemic penumbra, a key concept in stroke physiology, though it is capable of doing so in a clinically relevant manner. Evidence is accumulating that identification of the ischemic penumbra and making treatment decisions on the basis of its presence provide substantial benefit to patient outcomes. Moreover, the same studies suggest that an unexpectedly large proportion of patients are suitable for therapy well past the traditional time windows because of the existence of a substantial ischemic penumbra. Modern MR imaging and CT systems, now widely available, are capable of answering the most relevant physiologic questions in acute ischemic stroke. This capability presents new opportunities and responsibilities to neuroradiologists to make appropriate imaging readily available and to have the imaging data rapidly processed and interpreted. In this article, acute ischemic stroke therapy, including the role of imaging in current medical practice, is reviewed, and an evidence-based alternative to contemporary acute ischemic stroke therapy is suggested.     

慢性皮肤溃疡外治法实验研究近况

慢性皮肤溃疡由于其发生于体表,病程长、对外观影响大及并发症多等特点,对患者的生活和工作质量造成了极大的危害,是现代社会影响人们生活和工作质量的一个重要并发症.而外治法在本病治疗中起着重要的作用.该文旨在探讨慢性皮肤溃疡外治法实验研究近况,发展外治法,以期为慢性皮肤溃疡的防治提供可靠的理论依据、新的技术方法和研究思路.     

放射治疗联合免疫检查点抑制剂的不良反应

放射治疗与免疫检查点抑制剂（immune-checkpoint inhibitors,ICI）在抗肿瘤方面具有协同作用,这种作用涉及与免疫系统间的复杂效应机制,并可能改善肿瘤患者的临床结果。然而,放疗联合ICI协同调节免疫应答的同时也可能引发治疗相关不良反应。鉴于联合治疗的临床研究与实践日益增加,需要关注放疗和ICI联合研究中不良反应事件的发生风险,进而评估联合治疗的安全性。