恶性梗阻性黄疸术前减黄78例临床分析

目的 探讨术前减黄对低位胆道恶性梗阻性黄疽患者行胰十二指肠切除术的影响.方法 对78例行胰十二指肠切除术的低位胆道恶性梗阻性黄疸患者进行回顾性分析.结果 术前减黄组入院时总胆红素为(268±70)μmol/L,至术前下降为(174±55)μmol/L,与减黄前比较差异有统计学意义(P<0.05),与未减黄组术前总胆红素[(248±85)μmol/L]比较差异有统计学意义(P<0.05);术后并发症发生率为40%(31/78),其中减黄组为46%(11/24),未减黄组37%(20/54),两组比较差异无统计学意义(P>0.05),单个并发症发生率两组之间差异亦无统计学意义.结论 术前减黄可以有效降低血清胆红素水平;但术前减黄不能降低低位恶性胆道梗阻患者行胰十二指肠切除术后的病死率和并发症.     

肝门部胆管癌术前减黄临床价值

目的探讨术前减黄对肝门部胆管癌手术切除病人的影响。方法回顾中山大学附属第一医院1999年1月至2005年12月58例血清总胆红素(TB)>85μmol/L的肝门部胆管癌手术切除病人临床资料,分析并发症的发生情况以及减黄和其他因素对术后并发症、病死率的影响。结果术前减黄31例(53.4%,31/58),平均减黄9d,减黄组术前的TB下降为(214±125)μmol/L,与减黄前的(292±103)μmol/L及未减黄组术前的(382±174)μmol/L相比差异有显著性意义。术前减黄可降低天冬氨酸转氨酶(AST)、γ-谷氨酰转肽酶(GGT)、丙氨酸转氨酶(ALP)、直接胆红素(DB)水平。术后并发症总发生率为55.2%(32/58);减黄组为58.1%(18/31),未减黄组为51.9%(14/27),两组之间差异无显著性意义。单个并发症总发生率两组之间差异亦无显著性意义。影响术后病死率的危险因素为肝切除,影响术后肾功能不全的危险因素为TB>340μmol/L。结论术前减黄可以有效降低胆红素水平及改善肝门部胆管癌手术切除病人术前的肝功能;肝门部胆管癌切除手术的风险性较高;术前胆红素过高易引发术后肾功能不全;术前是否减黄与术后并发症发生率不相关。     

深低温停循环主动脉夹层手术后高胆红素血症的危险因素分析

目的研究深低温停循环(deep hypothermic circulatory arrest,DHCA)主动脉夹层手术后高胆红素血症的危险因素。方法回顾性分析青岛大学附属医院177例DHCA下Stanford A型夹层手术患者资料,男126例,女51例,年龄≥18岁,ASA均为Ⅳ级。将患者分为两组:高胆红素血症组(HB组,n=96),血浆总胆红素(total bilirubin,TBIL)51.3μmol/L;正常组(N组,n=81),TBIL≤51.3μmol/L。采用Logistic回归分析高胆红素血症的危险因素。结果术后高胆红素血症发生率为54.2%。阻断时间(OR=1.026,95%CI 1.005～1.048,P=0.017),术中输红细胞(OR=1.192,95%CI 1.032～1.378,P=0.017),术前TBIL(OR=1.098,95%CI 1.038～1.161,P=0.001)是DHCA主动脉夹层手术后高胆红素血症的独立危险因素。采用ROC曲线分析显示,阻断时间、术中输红细胞、术前TBIL的临界值分别为93.5min、3.0U、21.3μmol/L。HB组术后输注血浆量明显多于N组(P0.05)。HB组存活率明显低于N组(81.3%vs 92.6%,P=0.03)。结论DHCA主动脉夹层手术后高胆红素血症的发生率较高,预后较差。阻断时间93.5min、术中输注红细胞3.0U、术前TBIL21.3μmol/L是高胆红素血症发生的危险因素。     

胆道内照射支架应用于肝门部胆管癌致恶性梗阻性黄疸的初步临床研究

目的评估携带~(125)I粒子的胆道内照射支架治疗肝门部胆管癌致恶性梗阻性黄疸的有效性及安全性。方法选取43例因肝门部胆管癌致恶性梗阻性黄疸患者,采用经皮经肝分别穿刺左右侧胆道分支,于肝门部狭窄处植入~(125)I粒子胆道内照射支架,术后留置引流管3~5天,经造影确认支架通畅后予以拔管,封闭穿刺道。记录患者术前与术后的肝功能变化,并观察术后患者生存时间。结果 BismuthⅠ型5例,植入支架5个;Ⅱ型18例,植入支架36个;Ⅲ型4例,植入支架8个;Ⅳ型16例,植入支架25个,患者术前血清总胆红素和直接胆红素分别为(145.54±65.35)μmol/L和(124.73±35.04)μmol/L,术后分别为(65.91±29.43)μmol/L和(35.50±15.12)μmol/L;与术前相比,术后总胆红素、直接胆红素、丙氨酸氨基转移酶、天冬氨酸氨基转移酶、碱性磷酸酶、C-反应蛋白、γ-谷氨酸转肽酶均显著降低(P均0.05),乳酸脱氢酶手术前后差异无统计学意义(P=1.050)。患者中位生存期为13个月(3.0~22.5个月),未出现相关胆道穿孔、胰腺炎、严重胆道感染以及胆道出血等并发症。结论 ~(125)I粒子胆道内照射支架不仅可引流胆汁,减轻黄疸症状,还可近距离内照射胆道肿瘤,起到治疗作用,可延长患者生存时间,有效治疗肝门部胆管癌致恶性梗阻性黄疸。     

射频消融联合金属支架治疗恶性胆管梗阻疗效评价

目的 回顾性分析射频消融术（radiofrequency ablation,RFA）联合金属支架治疗恶性胆管梗阻的安全性和有效性。方法 回顾性分析2013年5月至2015年12月在我院行射频消融术联合金属支架的20例恶性胆道梗阻患者资料。结果 患者RFA术前胆道狭窄处平均直径为（1.7±0.3）mm,术后胆道直径为（5.2±0.2）mm,差异有显著统计学意义（t=1.68,P<0.01）;黄疸缓解率100%,术前总胆红素（264.65± 30.6）μmol/L,术后2周（45.2±14.6）μmol/L（t=1.54,P<0.01）;术前直接胆红素（162.4±45.5）μmol/L,术后2周直接胆红素（18.7±9.6）μmol/L（t=1.73,P<0.05）。术后仅有5例腹痛,2例轻度胆管炎,对症治疗后好转。术后随访6个月,均未观察到胆道再次狭窄。结论 本研究表明射频消融联合金属支架植入治疗恶性胆管梗阻安全有效。     

经PTCD途径胆道金属支架置入术治疗恶性梗阻性黄疸137例临床疗效分析

目的 探讨经皮经肝胆道引流(PTCD)后置入胆道金属支架姑息性治疗恶性梗阻性黄疸的临床应用价值.方法 对137例失去根治性手术机会或不愿行手术治疗的恶性梗阻性黄疸患者,在超声引下行PTCD,术后1周在DSA下经PTCD窦道置入胆道金属支架,经此途径将体外引流转换为内引流.结果 137例患者术前血清总胆红素水平为(274.7±151.5)μmol/L,术后1周血清总胆红素下降到(150.1±100.6)μmol/L (P＜0.01),肝功能明显改善(P＜0.01),术后平均生存时间为(9.29 ±0.77)个月.结论 经PTCD途径胆道金属支架置入术是一种治疗恶性梗阻性黄疸的有效方法,可明显延长患者生存时间、改善生活质量,具有安全、简便、创伤小、可重复等优点.     

术前减黄对肝门部胆管癌手术效果的影响

目的探讨术前经皮经肝穿刺胆道置管引流(percutaneous transheaptic cholangial drainge,PTCD)减黄(preoperative biliary drainage,PBD)对肝门部胆管癌(hilar cholangiocarcinoma,HC)手术效果的影响。方法前瞻性分析2013年6月至2016年6月济南军区总医院行半肝切除术的33例HC患者的临床资料,随机分为减黄组(n=16)和非减黄组(n=17)。对比两组患者手术效果。结果减黄组患者的总胆红素水平[(26.4±7.5)μmol/L vs(308.6±145.2)μmol/L]和谷丙转氨酶水平[(60.1±26.4)U/L vs(525.8±257.5)U/L]显著降低(P0.05);且手术时间[(5.6±0.8)h vs(6.5±1.2)h]、术中出血量[(560.7±159)mL vs(685.3±188.2)mL]和输血量[(398.1±101.5)mL vs(523.5±139.3)mL]以及术后并发症发生率均显著降低(31.3%vs 100%),均P0.05。结论 PBD能显著改善术前肝功能,缩短行半肝切除术的手术时间,减少术中出/输血量,降低术后并发症的发生率。     

术前减黄治疗对梗阻性黄疸患者CA19-9的影响

目的 探讨术前减黄治疗对梗阻性黄疸患者CA19-9和TBil的影响,为梗阻性黄疸患者的鉴别诊断提供依据.方法 回顾性分析2005年7月至2008年7月成都军区总医院收治的32例梗阻性黄疸患者的临床资料.分析17例恶性胆道梗阻性黄疸患者(恶性梗阻组)和15例良性胆道梗阻性黄疸患者(良性梗阻组)通过PTBD进行减黄治疗前后的CAl9-9和TBil的变化情况.采用t检验分析数据.结果 经减黄治疗后,恶性梗阻组患者的TBil由(27l±74)μmol/L下降到(144±33)μmol/L,治疗前后比较差异有统计学意义(t=6.52,P<0.05);CA19-9由(277±114)U/ml下降到(264±98) U/ml,治疗前后比较差异无统计学意义(t=0.34,P>0.05).良性梗阻组患者的TBil和CA19-9均下降明显,分别由(245±67)μmol/L下降到(135±43)μmol/L和(239±103)U/ml下降到(117±84)U/ml,两种指标治疗前后比较差异有统计学意义(t=5.30,3.54,P<0.05).结论 对梗阻性黄疸患者术前进行减黄治疗,动态观察血清CA19-9变化情况,有利于梗阻性黄疸患者的鉴别诊断.     

梗阻性黄疸术前减黄指征及方案的探讨

目的 探讨梗阻性黄疸术前减黄的意义及具体实施方案.方法 2007年9月至2012年9月期间67例行手术治疗的梗阻性黄疸患者,按自定的术前减黄指征:①血清总胆红素(TBIL)＞342.0μmol/L;②年龄＞65岁;③合并胆管炎、肝功能B～C级、心肺功能差、糖尿病血糖控制不理想并伴有其他并发症、营养不良患者.其中28例人选术前减黄组,行透视下经皮经肝胆管引流术(PTBD)及内镜下鼻胆管引流术(ENBD),对减黄组置管后1～2周进行手术.未减黄组39例,常规术前准备后于人院4～6 d进行手术.结果 术前未减黄39例的手术时间、术中出血量、术后并发症的发生率、平均住院时间分别为(356±38) min、(656±72) ml、56.4％(22/39)、(25±6)d.28例术前进行了减黄,其手术时间、术中出血量、术后并发症的发生率、平均住院时间分别为(373±51) min、(634±61) ml、53.6％(15/28)、(34±8)d.术前减黄组与未减黄组手术时间、术中出血量、术后并发症的发生率差异无统计学意义(P＞0.05).两组平均住院时间差异有统计学意义(P＜0.05).结论 选择性进行术前减黄治疗,降低了患者手术风险;建议TBIL＞342.0μmol/L,年龄＞65岁,伴胆管炎,一般条件差的患者行术前减黄治疗.     

术前减黄对重症黄疸患者行胰十二指肠切除术的影响

目的　探讨术前以手术方法减轻梗阻性黄疸 (减黄 )对壶腹周围癌伴重度黄疸患者行胰十二指肠切除术 (PD )的影响。方法　回顾分析对比 2 2例壶腹周围癌伴重度黄疸患者PD术前行减黄手术 (减黄组 ) ,与 3 0例直接行PD手术 (未减黄组 )患者的临床资料。结果　两组临床资料具有可比性 (P >0 .0 5 )。两组均行经典式PD手术 ,减黄组手术时间及术中出血量分别为 3 44(2 40～5 70 )min及 10 5 7(60 0～ 2 10 0 )ml ,较未减黄组的 3 0 6(2 10～ 490 )min及 90 8(2 0 0～ 2 0 0 0 )ml有增多趋势 ,但无统计学差异 (P >0 .0 5 )。减黄组术中输血量为 13 0 0 (80 0～ 2 40 0 )ml ,较未减黄组的93 9(0～ 2 40 0 )ml明显增多 (t =2 .0 5 7,P <0 .0 5 )。术后并发症发生率减黄组为 5 9.1% (13 /2 2 ) ,未减黄组为 5 3 .3 % (16/3 0 ) ,手术死亡率减黄组为 4.5 % (1/2 2 ) ,未减黄组为 6.7% (2 /3 0 ) ,两组比较差异均无显著性 (均P >0 .0 5 )。但在总住院时间上减黄组为 71(4 3～ 10 1)d ,较未减黄组的 47(2 9～ 81)d明显延长 (t =-3 .3 2 2 ,P <0 .0 5 )。结论　对伴有重度梗阻性黄疸的壶腹周围癌患者 ,若能充分进行术前准备 ,一期行PD手术利大于弊。     

胸腰椎骨折椎弓根内固定断裂与植骨融合方式的相关性分析

[目的]探讨胸腰椎骨折椎弓根螺钉内固定系统内固定术后,椎弓根螺钉断裂与植骨融合方式之间的关系,以探讨胸腰椎骨折植骨融合的最佳方式。[方法]回顾性研究1995年5月~2005年12月本院脊柱外科收治的胸腰椎骨折病人197例,其中A组单纯内固定(不植骨)患者14例,B组“H”形椎板植骨21例,C组横突间植骨67例,D组椎间、椎内联合横突间植骨95例。[结果]术后随访6~32个月,内固定断裂12例,其中A组4例,B组3例,C组5例,D组0例,4组中D组内固定断裂率显著低于其他3组(P<0.05)。[结论]椎间、椎体内联合横突间植骨重建脊柱三柱的稳定性,符合人体生物力学原理,能有效降低内固定断裂的发生。     

On the measurement of the functional properties of the CFTR

A number of methods are currently employed to assess the functional properties of CFTR channels and their response to pharmacological potentiators, correction of the defective CFTR trafficking, and vectorial introduction of new proteins. Here we review the most common methods used to assess CFTR channel function. The suitability of each technique to various experimental conditions is discussed.     

The Measurement of the Inclination Angle of the Hamate and Analysis of the Inclination Angle for the Rotation Deformity of the Little Finger in the Fixation of the Carpometacarpal Joint

ObjectiveComplex base fractures of the fifth metacarpal bone and dislocation of the fifth carpometacarpal joint are more prone to internal rotation deformity of the little finger sequence after fixation with a transarticular plate. In the past, we have neglected that there is actually a certain angle of external rotation in the hamate surface of transarticular fixation. This study measured the inclination angle of the hamate surface relative to the fifth metacarpal surface for clinical reference.MethodsIn a prospective single‐center study, we investigated the tilt angle of 60 normal hamates. The study included thin‐layer computed tomography (CT) data from 60 patients from the orthopaedic clinic and inpatient unit from January 2017 to March 2020, including 34 men and 26 women who were 15~59 years old, average 35 years old. The CT data of 60 cases in Dicom format of the hand was input into Mimics and 3‐Matics software for three‐dimensional (3D) reconstruction and measuring the angle α between hamate surface and the fifth metacarpal surface. According to the possible placement of the transarticular plate on the fifth metacarpal surface, we measured the angle β between the hamate surface 1 and the fifth metacarpal surface and the angle γ between the hamate surface 2 and the fifth metacarpal surface.ResultsThe average angle between the hamate surface and the fifth metacarpal surface was 11.66°. The hamate surfaces 1 and 2 have an external rotation angle of 7.30° and 7.51° on average with respect to the fifth metacarpal surface, respectively. There is no statistically significant difference in the angles between the two groups (P > 0.05).ConclusionsThe horizontal angle of the dorsal side of the hamate is different from the back of the fifth metacarpal surface, and the hamate has a certain external rotation angle with respect to the fifth metacarpal surface. No matter how the transarticular plate is placed, the plate always has a certain external rotation angle relative to the fifth metacarpal surface. When the fixation is across the fifth carpometacarpal joint, if the plate does not twist and shape, it will inevitably cause internal rotation of the fifth metacarpal, resulting in internal rotation deformity of the little finger sequence.     

静脉输注甘露醇开放血脑屏障对抗生素透过血脑屏障的影响

目的　通过快速静脉输注甘露醇可逆性开放血脑屏障 (BBB) ,探知此方法能否增加抗生素透过BBB的量 ,在何时达到最高峰 ,其通透量增加后临床上有无不良反应。方法　采用自身配伍设计 ,共 6个样本组。对照组仅使用抗生素 ;其余 5组分别在使用甘露醇前 60、3 0min ,同时使用甘露醇后 3 0、60min使用抗生素 ,各组皆取使用抗生素后 1h的脑脊液测其抗生素浓度。抗生素选用头孢三嗪。结果　测量值经过q检验 ,经 2 0 %甘露醇处理前后的CSF中的头孢三嗪浓度差异有非常显著性。全组患者经临床观察未出现神经系统的不良反应。结论　经静脉快速输注2 0 %甘露醇后可以使透过BBB的水溶性抗生素的量增加 ,两者使用的顺序是在抗生素使用 3 0min内即给予甘露醇快速滴注。该方法不会增加低神经毒性抗生素在中枢神经系统的不良反应。     

Preservation of the pylorus and resection of the head of the pancreas

The historical evolution of the pylorus-preservation resection of the head of the pancreas is traced from the first resections early in this century to relative standardization of the operation, to a lowering of the operative mortality, and to an interest in improving nutritional status after resection. There are many theoretical advantages for the function of the upper gastrointestinal tract after pylorus and gastric preservation, such as maintenance of gastric capacitance and equilibration of osmotic pressure in gastric digestants, foodstuff digestion and absorption, and bowel motility. After the pylorus-preserving resection, gastric emptying is normal, pyloric function to prevent duodenal reflux is often normal, and gastric acids and serum levels of duodenal hormones are at normal levels, whereas after standard pancreatoduodenectomy, all of these are often abnormal. No prospective blinded studies have been published comparing nutritional values after the two operative procedures, but evidence is presented of a satisfactory result with regard to gastric capacitance, body weight gain, and lack of postgastrectomy symptoms. An undoubted advantage of the pylorus-preserving feature is a simplification of the operation. These gains are achieved without increase in operative mortality, without increase in the incidence of jejunal ulcer, and without theoretical or actual decrease in value of the procedure as a cancer operation, except in patients with duodenal carcinoma proximal to the ampulla of Vater.     

下颌全牙弓后移量及最后界的测量

目的：研究下颌牙弓的有效后移量及找寻下颌牙弓移动的后界。方法：选取涉及拔除下颌第三磨牙或下颌第三磨牙缺失的病例18例（男6例,女12例）。采用种植支抗牵引下牙弓向远中,治疗完成时所有病例均明确到达下颌牙弓后界,即下颌第二磨牙远中到达下颌升支前缘软组织交界处。应用治疗前后的曲断片测量下颌第二磨牙远中到升支前缘的距离。结果：下颌第二磨牙后移量为（3.49±1.21）mm;治疗后磨牙后间隙的长度为（4.43±0.97）mm。结论：下颌牙弓可确定性地实现整体后移;最大后移量由磨牙后间隙的长度决定;其最后界止于下颌第二磨牙远中与下颌升支前缘软组织交界处。     

Preservation of the pylorus in resection of the head of the pancreas

Whipple's pancreatoduodenectomy was the standard operation for diseases of the head of the pancreas for more than 40 years, but the results were vitiated in part by poor gastrointestinal function and malnutrition. Reintroduced in 1978, pylorus-preserving proximal pancreatoduodenectomy (PPPP) has had an increasing impact on pancreatic surgery as its benefits have been recognized: improved nutritional status, decreased incidence of postgastrectomy syndromes, and a technically easier operation. Postoperative mortality rates and 5-year survival rates are comparable with those of the classic Whipple procedure. PPPP is indicated for most patients with chronic pancreatitis of the pancreatic head. It is also appropriate for patients with periampullary cancer and for those with pancreatic cancer arising from the lower part of ‘the head and the uncinate process. More than 650 patients have now undergone PPPP: 31% for chronic pancreatitis and 66% for periampullary and pancreatic cancers. We assess the indications for PPPP, outline the operation, and review the results.