腹腔镜下胃癌D2根治术联合射频消融应用于胃癌肝转移的临床疗效

目的 探讨腹腔镜下胃癌D2根治术联合射频消融肝转移瘤应用于胃癌肝转移的临床疗效。方法 选取该院2017年1月－2020年1月收治的可切除胃癌肝转移需行胃癌D2根治术联合射频消融的患者62例,随机分为对照组和观察组,每组各31例。对照组采用开腹胃癌D2根治术联合射频消融治疗,观察组采用腹腔镜下胃癌D2根治术联合射频消融治疗。比较两组患者手术指标、血清肿瘤标志物指标、免疫相关指标和并发症情况。结果 对照组术中出血量多于观察组,肠功能恢复时间、住院时间明显长于观察组（P < 0.05）,手术时间短于观察组（P < 0.05）;术后两组患者血清甲胎蛋白（AFP）、癌胚抗原（CEA）水平降低（P < 0.05）,观察组血清AFP、CEA水平均低于对照组（P < 0.05）;术后两组患者CD4⁺、CD8⁺、CD4⁺/CD8⁺水平均较术前降低（P < 0.05）,观察组CD4⁺、CD4⁺/CD8⁺水平明显高于对照组（P < 0.05）;观察组并发症发生率12.90%低于对照组41.94%（P < 0.05）。结论 腹腔镜下胃癌D2根治术联合射频消融治疗胃癌肝转移有利于患者术后康复,可明显改善血清肿瘤标志物水平及机体免疫功能,降低围术期并发症发生率。     

负压创面治疗在经胸乳入路腔镜甲状腺切除术中的应用研究

目的 研究负压创面治疗（NPWT）防治经胸乳入路腔镜甲状腺切除术（ETE）后腔道并发症的效果。方法 选取2020年6月－2021年9月在该院住院行经胸乳入路ETE的患者48例,采用随机数表法分为治疗组（NPWT组）和对照组（常规加压包扎组）,每组24例。比较两组患者手术时间、术中出血量、术后引流量、术后住院天数、手术并发症和腔道并发症发生率。结果 两组患者手术时间、术中出血量和手术并发症比较,差异均无统计学意义（P > 0.05）。治疗组术后引流量少于对照组,术后住院时间短于对照组,腔道皮下积液发生率低于对照组,两组患者比较,差异均有统计学意义（P < 0.05）。结论 NPWT可以明显降低经胸乳入路ETE术后腔道皮下积液的发生率,有利于患者术后快速康复。     

肺超声评分预测肺癌根治术后心肺并发症的研究

目的 探讨肺癌根治术后心肺并发症的危险因素及肺超声评分对心肺并发症的预测价值。方法 选择2022年6月至2022年12月上海市胸科医院胸外科择期行肺癌根治术的患者132例，根据术后心肺并发症发生情况分为并发症组（n＝16）和无并发症组（n＝116）。收集患者一般资料、手术相关信息及术后心肺并发症发生率。患者术前进行肺超声检查，采用12分区法，得出肺超声评分。采用多因素logistic回归分析心肺并发症发生的危险因素，采用ROC曲线构建肺超声评分对肺癌根治术后心肺并发症的预测模型。结果 肺癌根治术后心肺并发症发生率为12.1%（16/132）。与无并发症组相比，并发症组男性患者比例更高（P＝0.037）、年龄更大（P＝0.002）、开放手术的比例更高（P＝0.006）。两组患者的手术范围差异有统计学意义（P＜0.001）。并发症组患者的肺超声评分显著高于无并发症组患者[（11.0±6.9）分vs（3.6±4.5）分, P＝0.001）]。Logistic回归分析显示，手术范围及肺超声评分是影响术后心肺并发症的危险因素。ROC曲线显示，肺超声评分预测心肺并发症的截断值为12.5分，曲线下面积（area under the curve, AUC）为 0.812（95%CI 0.687～0.938）。结论 手术范围及肺超声评分是肺癌根治术后心肺并发症的危险因素。肺超声评分可以预测肺癌根治术后心肺并发症，评分＞12.5分时发生心肺并发症的风险较大。     

MR与CT图像融合技术在帕金森病深部脑电刺激术后的应用

目的 采用CT和MRI图像融合技术评价帕金森病（PD）患者深部脑电刺激（DBS）术后电极位置准确性的应用价值。方法 收集接受双侧DBS疗法的32例PD患者,采用术后颅脑薄层CT和术前MRI图像融合（融合组）技术并与常规术后复查MRI图像（常规组）比较,分析电极位置精确度及检查耗费时间。结果 融合组与常规组测量的电极位置相关性较好（P均<0.008）;融合组与常规组电极尖端位置比较,除左侧电极y轴、z轴方向差异有统计学意义外（t=-2.34、-3.08,P均<0.05）,余差异均无统计学意义（P均>0.05）。术后复查MR检查时间为（7.65±0.33）min,术后复查CT时间为（2.85±0.29）min,差异有统计学意义（P<0.05）。结论 DBS术后应用头部薄层CT与MRI图像融合能精确定位电极位置,并可避免PD术后复查MRI的潜在风险,缩短术后复查的时间。     

胆道支架和鼻胆管引流在腹腔镜胆总管探查术后一期缝合中的应用

目的 对比胆道支架和鼻胆管引流在腹腔镜胆总管探查术（LCBDE）后一期缝合中的临床疗效。方法 回顾性分析2016年8月－2021年1月在该院行内镜逆行胰胆管造影术（ERCP）取石失败的74例患者的临床资料，分为支架引流组（n = 38）和鼻胆管引流组（n = 36）。支架引流组ERCP取石失败后放置胆道支架引流，鼻胆管引流组ERCP取石失败后放置鼻胆管引流，两组患者均行腹腔镜胆总管切开取石一期缝合术。比较两组患者手术时间、术后住院时间、术后并发症发生率、术后肠道功能恢复时间、术后胆总管结石复发率和住院时间。结果 两组患者胆管缝合方式、手术时间、术中出血量、术后并发症总发生率和住院费用比较，差异均无统计学意义（P > 0.05）。鼻胆管引流组术后胆瘘发生率明显低于支架引流组，住院时间明显短于支架引流组，术后肠道功能恢复时间明显长于支架引流组，术后总补液量多于支架引流组，差异均有统计学意义（P < 0.05）。结论 ERCP取石失败后放置鼻胆管引流，可降低LCBDE术后一期缝合的胆瘘发生率，缩短住院时间，但放置胆道支架引流患者肠道功能恢复更快，补液量更少。因此，在临床操作中，应根据患者具体情况，选择相应的个体化引流方式。     

加速康复外科胃癌患者术后不常规留置导尿管的可行性

  目的  探讨加速康复外科胃癌患者术后不常规留置导尿管的可行性。  方法  回顾性分析2016年6月至2017年3月, 南京总医院普通外科采用加速康复外科理念择期行胃癌根治术患者的临床资料。入选患者麻醉诱导期插入导尿管, 手术结束时即刻拔除导尿管并以此时间为观察起始点, 记录患者术后首次排尿时间、首次排尿量、重插尿管的比例, 分析首次排尿延迟及重插尿管的危险因素。  结果  137例患者纳入本研究, 其中男性90例(65.7%), 女性47例(34.3%), 平均年龄(58.9±10.1)岁, 术后首次排尿时间为(5.3±2.1)h, 首次自解尿量(298.9±101.3)ml, 重置尿管比例为11.7%(16/137);相比开腹组, 机器人组自主排尿率高, 诱导排尿率、重置导尿管及尿路刺激征发生率均较低(P均 < 0.05);以术后6 h首次排尿时间作为分界, 与≤ 6 h组相比, >6 h组术中输液量、尿量及术后首次自解尿量均较多, 首次下床活动时间延迟(P均 < 0.01)。  结论  加速康复外科胃癌患者术后即刻拔除尿管是可行的, 术中控制性输液、多模式镇痛是不常规留置导尿管的基础条件, 机器人手术有利于患者术后早期恢复自主排尿。     

新型连续灌注可调负压清石鞘装置在经皮肾镜取石术中的应用

目的 评估新型连续灌注可调负压清石鞘（VMP）装置在经皮肾镜取石术（PCNL）中的安全性和可行性,探讨其碎石、清石效率和优势。方法 回顾性分析2016年1月－2021年2月解放军总医院海南医院64例行PCNL治疗的肾结石患者的临床资料。根据治疗方案不同分为VMP组（n = 36）和常规PCNL组（SP组,n = 28）。所有患者均于麻醉后在超声引导穿刺下逐步扩张,建立（F16～F20）经皮肾通道,使用VMP装置（VMP组）或常规经皮肾装置（SP组）行钬激光碎石。比较两组患者围手术期指标和清石率（SFR）等。结果 所有患者均顺利完成手术。VMP组术中平均灌注时间明显短于SP组［（42.72±29.11）和（74.82±37.33）min,P = 0.000］,SFR明显高于SP组（94.4%和75.0%,P = 0.035）。VMP组术后24 h血红蛋白（Hb）变化为11.00（5.00,11.25）g/L,SP组为3.00（-3.75,13.75）g/L,差异有统计学意义（P = 0.005）,术后住院时间明显短于SP组［（7.56±2.65）和（9.21±3.26）d］,差异有统计学意义（P = 0.028）。两组患者术后24 h白细胞（WBC）和血清肌酐（SCr）变化比较,差异无统计学意义（P > 0.05）。结论 PCNL术中使用VMP安全、可行且有效,较常规PCNL能明显缩短术中灌注时间和术后住院时间,减轻术后疼痛,降低感染风险。     

3D-CT描述胃周血管腹腔干变异在腹腔镜下胃癌根治术中的作用

目的 分析3D-CT描述胃周血管腹腔干变异对腹腔镜下胃癌根治术的作用。方法 回顾性分析2019年1月－2021年1月该院收治的185例胃癌患者的临床资料，均采用3D-CT描述胃周血管腹腔干变异情况，依据腹腔干情况分为观察组（腹腔干常见型，n = 159）和对照组（腹腔干罕见型，n = 26），两组均采用腹腔镜下胃癌根治术治疗。比较两组患者的围术期指标、手术前后炎性反应情况和不良反应。结果 观察组平均出血量、手术时间和首次排气时间均少于对照组；手术后两组患者的血清白细胞介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）、高敏C反应蛋白（hs-CRP）、去甲肾上腺素（NA）、促肾上腺皮质激素（ACTH）水平明显高于术前，但观察组少于对照组，差异均有统计学意义（P < 0.05）。结论 胃癌患者腹腔镜手术前经3D-CT描述胃周血管腹腔干变异情况，能够在一定程度上减少术中出血量、缩短手术时间、促进术后排气、缓解围术期炎性反应，安全性较佳。     

腹腔镜胆总管探查取石术治疗复杂性肝内胆管结石的效果及对血清炎症因子的影响

目的 分析腹腔镜胆总管探查取石术治疗复杂性肝内胆管结石的临床价值。方法 选取2018年2月－2020年2月该院复杂性肝内胆管结石患者106例，随机分为常规组（n = 53）和治疗组（n = 53），治疗组接受腹腔镜胆总管探查取石术，常规组接受传统开腹胆总管探查取石术。比较两组患者治疗后的手术效果、炎症因子水平、并发症发生率、结石复发率和生活质量评分。结果 治疗组肛门恢复排气时间、住院时间和手术时间均明显短于常规组，术中出血量明显少于常规组（P < 0.05）。术后3 d，C反应蛋白（CRP）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）和白细胞介素-1（IL-1）水平明显低于常规组（P < 0.05）。治疗组并发症发生率和结石复发率明显低于常规组（P < 0.05），生活质量评分明显高于常规组（P < 0.05）。结论 采用腹腔镜胆总管探查取石术治疗肝内胆管结石，不仅可以提高治疗效果，降低结石复发率，还抑制炎性因子释放，促进机体恢复。     

FLOT方案新辅助化疗联合腹腔镜D2根治术在局部进展期胃癌中的应用及预后价值分析

目的：探讨FLOT方案新辅助化疗联合腹腔镜D2根治术对局部进展期胃癌的治疗效果及预后价值。方法：回顾性分析2015年1月至2017年12月苏州市相城人民医院普外科收治的86例局部进展期胃癌患者的病例资料，分为FLOT方案新辅助化疗+腹腔镜D2手术组（联合治疗组，n=43）和单纯腹腔镜D2手术组（单纯手术组，n=43）。评估2组临床资料、疗效和不良反应，比较2组患者的生存差异。结果：2组患者临床资料、不良反应发生率差异无统计学意义。联合治疗组R₀切除率高于单纯手术组（χ²=5.108，P=0.024）；联合治疗组术后T₁+T₂分期、N₀+N₁分期高于单纯手术组（χ²=5.677，P=0.017；χ²=10.488，P=0.001）。中位随访时间为54个月，联合治疗组的中位OS为51个月，单纯手术组的中位OS为33个月，联合治疗组更有生存优势（χ²=4.306，P=0.038）。结论：在局部进展期胃癌中，FLOT方案新辅助化疗联合腹腔镜D2根治术可提高R₀切除率，降低肿瘤分期，延长总生存期，有临床应用推广价值。     

胃肠道手术中每搏量变异监测对液体管理的指导作用

目的比较每搏量变异（SVV）和中心静脉压（CVP）监测对胃肠道手术患者术中输液管理及预后的影响。方法选择2012年3月至2012年12月行择期全麻下胃肠道手术患者80例,随机分为CVP组和SVV组,每组加例。CVP组术中监测CVP及桡动脉压,sVV组术中SVV及心输出量。记录并比较两组病人术前、术中、术后的输血、输液量、手术时间、住院时间、排气排便时间、术后进食时间等。结果SVV组患者术中输液量明显少于CVP组（P〈0．05）;SVV组患者术中出血量明显少于CVP组（P〈0．05）;术后3天输液总量、术中尿量及患者术后排便时间差异无统计学意义（P均〉0．05）;SVV组术后肛门排气时间、术后进食时间、住院时间明显短于CVP组（P均〈0．05）。术后并发症CVP组9例,SVV组5例,两组并发症发生率差异无统计学意义（P〉0．05）。结论sVV指导输液可以减少术中输液量,缩短住院时间,有利于手术患者的康复。     

肝素对感染性休克犬早期肠黏膜损伤保护作用的研究

目的 通过对血浆标示物D-乳酸和I-FABP的测定及分析,验证感染性休克犬早期肠脂肪酸结合蛋白和D-乳酸表达水平发生变化以及肝素对感染性休克犬早期空肠绒毛微循环改善及肠脂肪酸结合蛋白和D-乳酸表达水平的影响.方法 通过静脉注射LPS方法建立比格犬早期感染性休克模型.将40只实验犬随机(随机数字法)分为空白对照组,LPS组,基础治疗组,肝素治疗组.术后稳定1h,即T0点,给LPS造模后1h,即T1点,之后序贯观察5h分别为T2,T3,T4,T5,T6点.在相应观察时间点(T1、T3、T6时间点)采集犬静脉血,经1 500 r/min,15 min离心后取血浆,以EP管分装后置入-80℃保存,通过ELISA法测定肠脂肪酸结合蛋白(I-FABP)和D-乳酸(D-lac).同时应用OPS观察空肠绒毛微循环的变化.结果 肝素组IFABP (21.6±2.3) pg/mL比较LPS组IFABP(100.48±8.42) pg/mL会明显下降,差异具有统计学意义(P＜0.05);同时微循环有相应的改善.基础治疗组与LPS组比较未见明显变化,P＞0.05.结论 感染性休克早期存在肠黏膜微循环障碍及肠黏膜损伤.肝素对早期感染性休克犬肠黏膜微循环障碍具有改善作用,进而保护肠黏膜屏障功能.     

Assessment of the effect of rapid crystalloid infusion on stroke volume variation and pleth variability index after a preoperative fast

Objective  

Stroke volume variation (SVV) during controlled mechanical ventilation is a useful predictor in response to volume expansion, and pleth variability index (PVI), a novel algorithm allowing for automated and continuous calculation of the respiratory variations in the pulse oximeter waveform amplitude, can also predict fluid responsiveness non-invasively in mechanically ventilated patients. The aim of this study was (1) to determine whether acute fluid infusion affects SVV and PVI, and (2) to compare the two values in the case of acute fluid infusion after a preoperative fast following general anesthesia induction.     

Goal-Directed Fluid Therapy Based on Stroke Volume Variations Improves Fluid Management and Gastrointestinal Perfusion in Patients Undergoing Major Orthopedic Surgery

Objective

To evaluate the influence of stroke volume variation (SVV)-based goal-directed therapy (GDT) on splanchnic organ functions and postoperative complications in orthopedic patients.

Subjects and Methods

Eighty patients scheduled for major orthopedic surgery under general anesthesia were randomly allocated to one of two equal groups to receive either intraoperative volume therapy guided by SVV (GDT) or standard fluid management (control). In the SVV group, patients received colloid boluses of 4 ml/kg to maintain an SVV <10s% when in the supine position or an SVV <14s% if prone. In the control group, fluids were given to maintain a mean arterial pressure >65 mm Hg, a heart rate <100 bpm, a central venous pressure of 8–14 mm Hg, and a urine output >0.5 ml/kg/h. Intraoperative organ perfusion, hemodynamic data, hospitalization, postoperative complications, and mortality were recorded.

Results

The heart rate at the end of surgery was significantly lower (p < 0.05), there were fewer hypotensive episodes (p < 0.05), the arterial and gastric intramucosal pH were higher (p < 0.05 for both), the gastric intramucosal PCO₂ was lower (p < 0.05), the intraoperative infused colloids and the total infused volume were lower (p < 0.05 for both), and the postoperative time to flatus was shorter (p < 0.05) in the GDT group than in the control group. No differences in the length of hospital stay, complications, or mortality were found between the groups.

Conclusion

SVV-based GDT during major orthopedic surgery reduced the volume of the required intraoperative infused fluids, maintained intraoperative hemodynamic stability, and improved the perioperative gastrointestinal function.Key Words: Goal-directed fluid therapy, Stroke volume variation, FloTrac/Vigileo system, Orthopedic surgery     

Prospective comparison of the effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy on complications in thoracoscopic lobectomy

ObjectiveRestrictive fluid therapy is recommended in thoracoscopic lobectomy to reduce postoperative pulmonary complications, but it may contribute to hypovolemia. Goal-directed fluid therapy (GDFT) regulates fluid infusion to an amount required to avoid dehydration. We compared the effects of GDFT versus restrictive fluid therapy on postoperative complications after thoracoscopic lobectomy.MethodsIn total, 124 patients who underwent thoracoscopic lobectomy were randomized into the GDFT group (group G, n = 62) or restrictive fluid therapy group (group R, n = 62). The fluid volume and postoperative complications within 30 days of surgery were recorded.ResultsThe total fluid volume in groups G and R was 1332 ± 364 and 1178 ± 278 mL, respectively. Group R received a smaller colloid fluid volume (523 ± 120 vs. 686 ± 180 mL), had a smaller urine output (448 ± 98 vs. 491 ± 101 mL), and received more norepinephrine (120 ± 66 vs. 4 ± 18 µg) than group G. However, there were no significant differences in postoperative pulmonary complications, acute kidney injury, length of hospital stay, or in-hospital mortality between the two groups.ConclusionRestrictive fluid therapy performs similarly to GDFT in thoracoscopic lobectomy but is a simpler fluid strategy than GDFT.Trial registration: This study has been registered at the Chinese Clinical Trial Registry (ChiCTR2100051339) (http://www.chictr.org.cn/index.aspx).     

Meta-analysis of the short-term outcomes of robotic-assisted compared to laparoscopic gastrectomy

Objective:To compare the short-term outcomes of gastric cancer patients treated with robotic gastrectomy (RG) or laparoscopic gastrectomy (LG). Introduction:Robotic gastrectomy (RG) has been used for gastric cancer since 2002. This meta-analysis evaluates the safety and efficacy of robotic gastrectomy (RG) and conventional laparoscopic gastrectomy (LG) for gastric cancer. Material and methods: Pubmed, Embase and The Cochrane Library were searched, and manual searches were performed up to March 31, 2013. Five non-randomized control trials that reported RG and LG for gastric cancer were included. Outcomes evaluated were operation time, number of retrieved LN, blood loss, the length of the resection margin, complications, length of postoperative hospital stay. Results:Of 1796 patients in five studies, 551 were allocated to RG and 1245 to LG. Operation time was significantly shorter in the latter group (weighted mean difference 42.9; 95 % confidence interval 20.87 to 64.92 min; p < 0.05). Blood loss weighted mean difference was –16.07 (95 % confidence interval –32.78 to 0.64 mL; p < 0.05) and postoperative stay weighted mean difference was –1.98 (95 % confidence interval –3.66 to –0.3 days; p < 0·05); both were less in the RG group. LN, length of the resection margin, and postoperative complications were similar in both groups. Conclusion: It may be concluded that RG is a safe and comfortable alternative to LG and is justifiable in the light of clinical trials.     

The osmotic link between hypoglycaemia and hypovolaemia

Objective. Hypoglycaemia is regularly accompanied by hypovolaemia. To suggest a mechanism for this phenomenon, we reviewed data from eight studies conducted by our group and examined the circumstances under which rebound hypoglycaemia develops after intravenous infusion of glucose solutions. Material and methods. Forty healthy volunteers and 40 patients received a total of 122 infusions of glucose solutions at different rates, volumes and concentrations. Plasma glucose and the haemodilution were measured repeatedly during and for at least 2?h after the infusions ended. Glucose kinetics was calculated using a one‐compartment turnover model and the plasma volume expansion was estimated from changes in Hb. Results. A strong linear correlation was found between the glucose level and the plasma volume expansion in all series of experiments (p<0.001). After infusion, there was a risk of hypoglycaemia and hypovolaemia developing in healthy volunteers with a high glucose clearance and when infusing glucose solutions of higher concentrations than 2.5?%. Few and mild hypoglycaemic events occurred in patients with insulin resistance, such as in diabetics and in those undergoing surgery. The immediate linear relationship between hypoglycaemia and hypovolaemia suggests an osmotic link between the two parameters. More specifically, infused fluid accompanies glucose during uptake into the cells, while volume expansion by the same fluid has already elicited an effective diuretic response. Conclusion. Hypovolaemia is a consequence of hypoglycaemia after intravenous infusion of glucose solution and is caused by the osmotic translocation of fluid from the extracellular to the intracellular fluid space that occurs despite effective renal elimination.     

脓毒症患者血清肠型脂肪酸结合蛋白、二胺氧化酶水平检测对早期肠组织损伤及预后的评估价值

目的　探讨血清肠型脂肪酸结合蛋白（ I-FABP）,二胺氧化酶（ DAO）对脓毒症患者早期肠组织损伤及预后的评估价值。方法　选择 2019年 4~12月于同济大学附属同济医院急诊科收治的 80例脓毒症患者及 40例同期健康体检者（对照组）。脓毒症患者又根据急性胃肠损伤分级 (AGI)分为非 AGI组（n=35）,AGI组（n=45）。根据入院 28天内死亡情况,将患者分为存活组（ n=51）与死亡组（ n=29）。比较各组患者血清 I-FABP,DAO及其他临床特征,采用 logistic回归分析脓毒症患者 28天内预后的危险因素。结果　与对照组比较,非 AGI组和 AGI组患者 I-FABP（20.28±3.37, 26.15±4.67μg/L vs 17.16±2.44 μg/L）,DAO（2.49±0.63, 3.28±0.87mmol/L vs 1.31±0.34 mmol/L）水平升高（ F=65.92, 94.24, P<0.05）;与非 AGI组比较, AGI组 I-FABP,DAO水平亦显著升高（ P<0.05）。I-FABP,DAO与 CRP,D-乳酸呈显著正相关（ r=0.415,0.477,0.426和 0.465,均 P<0.05）,而与 TNF-α,IL-6无明显相关性（ P>0.05）。与存活组比较,死亡组年龄较大, MV时间明显延长, CRP,PCT,APACHE II评分, SOFA评分, AGI评分, I-FABP,DAO显著升高（ t=2.27~11.21,均 P<0.05）。多因素 logistic回归分析显示,APACHE II评分（ OR=3.13,95%CI:1.67~4.48）, AGI分级（ OR=2.36,95%CI:1.38~3.49）,I-FABP（OR=1.73,95%CI:1.24~2.51）,DAO（OR=1.42,95%CI:1.13~1.84）均是 28天内死亡的独立危险因素（ χ2=9.37~20.67,均 P<0.05）。结论　脓毒症患者血清 I-FABP和 DAO明显升高,与 CRP和 D-乳酸间有良好相关性,可反映早期肠组织损伤,有效预测脓毒症患者预后。