经腹腔途径腹腔镜肾癌根治术112例经验总结

目的总结经腹腹腔镜肾癌根治性切除术的经验。方法 2007年11月至2010年11月经腹腹腔镜肾癌根治术112例,男70例,女42例。年龄34～82岁,平均55.3岁。右侧62例,左侧50例。肿瘤直径2.5～12.0cm,平均直径7.1cm。术前临床分期T1M0N060例、T2M0N040例、T3aM0N010例、T3bM0N02例。结果112例手术均成功,1例膈肌损伤,术中修补,手术时间30～90min,平均61min。术中出血约50～400ml,平均85ml。术后24～48h开始进食,5～10d出院。术后病理报告透明细胞癌92例、囊性肾细胞癌3例、嫌色细胞癌12例、集合管癌4例、错构瘤（术前临床诊断为肾癌）1例。术后随访1个月～3年,失访35例,4例集合管癌术后3～6个月死于肺转移,其余未发现肾窝及切口转移,均无瘤生存。结论经腹腔途径腹腔镜肾癌根治术具有术中创伤小、术后恢复快、疼痛小的优点,是一种安全、有效的治疗方法。     

后腹腔镜肾癌根治术28例临床体会

目的探讨后腹腔镜肾癌根治术的临床疗效。方法对28例行后腹腔镜肾癌根治性切除术治疗的肾细胞癌患者的临床资料进行回顾性分析。结果 28例患者手术均获成功,平均手术时间116 min（96～175 min）,平均术中出血量96 mL（70～500 mL）,术后平均住院时间8.5 d（7～10 d）。术后切口感染1例,腹膜破裂3例,伤口愈合延迟1例。随访3～24个月,未见肿瘤复发及穿刺通道的种植转移。结论后腹腔镜肾癌根治术疗效确切、创伤小、安全性高。     

腹腔镜肾癌根治术56例

目的:探讨经腹腹腔镜肾癌根治性切除术的经验及评价临床价值.方法:2000年10月至2006年3月共收治肾癌56例,男35例,女21例,年龄33～81岁(平均59岁),肿瘤平均直径5.4 cm,左侧30例,右侧26例,46例肿瘤直径小于8 cm,采用经腹腹腔镜肾癌根治术.10例肿瘤直径大于8 cm,采用手辅式腹腔镜肾癌根治术.结果:55例腹腔镜肾癌根治手术成功,1例右肾动脉损伤改开放手术,1例胰腺损伤,1个月后治愈;手术时间85～360min,平均155 min.术中出血量约50～420 mL,平均100 mL.3例穿刺口周围出现不同程度皮下气肿,3 d后自行消失.术后24 h下床活动,48 h开始进食,术后7 d出院.41例随访0.5～5年,无肿瘤复发,无穿刺孔种植转移.结论:腹腔镜肾癌根治术具有术中创伤小、术后恢复快、疼痛小的优点,对于T1～T2N0M0期肾肿瘤,效果优于开放手术,是一种安全、有效的治疗方法.因此,腹腔镜肾癌根治术是今后的发展方向.     

后腹腔镜肾癌根治术64例报告

目的 探讨后腹腔镜肾癌根治术的技术要点和临床效果.方法 2004年1月～2007年12月采用后腹腔镜技术行肾癌根治术64例,术前均行B超、IVU、胸片、CT或MRI检查,证实肾脏实质恶性肿瘤,未发现肾蒂淋巴结转移、远处转移、肾静脉或腔静脉癌栓.临床分期为T1～T3aN0M0,健侧肾功能正常.观察手术时间、术中出血量、术中术后并发症及手术效果.结果 手术均1次成功,手术时间60～180 min,平均90min,术中出血80～240mL,术中术后均未输血,引流管拔除时间24-72 h,肠功能恢复时间18-48h,下床活动时间48-72h.64例患者中52例获得随访3～36个月,无肿瘤复发及切口种植转移.结论 后腹腔镜肾癌根治术具有创伤小、恢复快、疗效可靠的特点,可部分替代传统的开放手术,具有良好的临床应用前景.     

肾嗜酸细胞腺瘤的临床诊治分析

目的提高肾嗜酸细胞腺瘤（renal oncocytoma,RO）的诊疗水平。方法回顾分析13例RO患者临床资料。13例患者中,男4例,女9例;肿瘤单发12例,单侧多发1例;肿瘤最大直径为1.0～6.9cm,平均3.3cm;肿瘤位于左肾上极2例,左肾中极2例,左肾下极3例,右肾上极4例,右肾中极1例,右肾下极1例。所有患者术前均行B超、IVU检查,12例行CT检查,3例行MRI检查。结果 12例术前诊断为肾癌,1例考虑为RO。13例中8例行根治性肾切除术,5例行肾部分切除术。术后病理均证实为RO。随访1～183个月无肿瘤复发或转移。结论 RO是一种临床少见的良性肿瘤,术前确诊较困难,与肾癌较难鉴别,诊断有赖于病理组织学和免疫组化检查,保留肾单位手术为首选治疗方法。     

后腹腔镜肾癌根治术和开放手术的临床疗效比较

目的与传统开放手术比较,评价后腹腔镜肾癌根治术的手术方法及临床疗效。方法回顾性分析和比较同期94例早期肾癌根治术的临床资料,其中后腹腔镜肾癌根治术(A组)55例,开放性肾癌根治术(B组)39例,对手术时间、术中出血量、术后并发症及术后恢复情况等进行比较。A组患者肿瘤大小1.8～6.5(平均4.9)cm,B组患者肿瘤大小3.0～6.8(平均5.5)cm。患者术前均行B超、IVP、CT或MRI等检查明确诊断,临床分期均为:T1N0M0～T2 bN0M0。结果后腹腔镜组和开放手术组手术时间分别为(146±10.5)和(121±12.4)min(P>0.05),术中出血量分别为(80±12)和(210±17)ml(P<0.01),术后住院天数分别为(5.1±1.2)和(8.4±1.6)天(P<0.05)。两组病人术中术后均未发生严重并发症,随访6～18个月未见肿瘤复发及转移。结论后腹腔镜肾癌根治术与开放手术相比较,具有创伤小、并发症少、恢复快等优点,对于局限性肾癌的肿瘤控制与开放手术相当,值得临床推广应用。     

后腹腔镜肾部分切除术治疗小肾癌(附11例报告)

目的 探讨后腹腔镜下肾部分切除术治疗小肾癌的临床价值.方法 对11例小肾癌患者行后腹腔镜下肾部分切除术治疗,肿瘤直径2.0～4.0 cm,平均3.0 cm.观察手术时间、术后住院时间、阻断方式及时间、术中出血和术后并发症及术后效果.结果 11例手术均获成功,手术时间120～160m in,平均140m in.术中出血50～250mL,平均120mL.肾动脉血流阻断时间25～45min,平均30m in.术后住院5～7 d,平均6d.11例小肾癌切下肿瘤后的切缘均为阴性.术后随访3～12个月,复查B超、CT均未见肿瘤残留及复发,静脉尿路造影提示患侧残肾功能良好.结论 后腹腔镜肾部分切除术具有创伤小、出血少、住院时间短以及术后恢复快等优点,是替代开放手术治疗小肾癌安全有效的方法.     

后腹腔镜下肾癌根治术（附43例报告）

目的探讨后腹腔镜下肾癌根治术的手术方法及技巧。方法其中男26例,女17例,年龄34～78岁,平均年龄58岁。左侧23例,右侧20例。肿瘤直径2．0～6．5cm,平均3．5cm。所有患者均行后腹腔镜下肾根治性切除。结果所有手术均顺利完成,无1例改开放,术中及术后未发生严重并发症。手术时间50～120min,平均75rain。术中出血50～200ml,平均80ml,1例患者因术前即有贫血,术后输血400ml。术后住院时间5～9d,平均6．5d。术后病理均证实为肾细胞癌,随访2个月～5年余,1例术后1年腹膜后淋巴结转移死亡,1例术后2年出现肝转移死亡,其余均存活。结论后腹腔镜下肾癌根治术是有效、安全的治疗方法,掌握适当的手术适应证,通过改良的手术方法及熟练的手术技巧可以确保手术的效果。     

手助腹腔镜根治性肾切除术21例报告

目的探讨手助腹腔镜根治性肾切除术的临床应用价值。方法采用手助腹腔镜根治性肾切除治疗肾肿瘤21例。结果21例手助腹腔镜手术均成功。手术时间80～150min，平均110min；术中出血20-300mL。平均85mL；病理报告均为肾细胞癌（透明细胞癌20例，乳头状细胞癌1例）；术后住院时间5-14d,平均8d。结论采用手助腹腔镜根治性肾切除治疗肾肿瘤是安全有效的，与开放手术相比，具有损伤小、痛苦少、出血少、术后恢复快等优点。     

肾嗜酸细胞腺瘤的诊疗分析

目的:探讨肾嗜酸细胞腺瘤的临床及病理特点,提高临床诊治水平。方法:回顾性分析11例肾嗜酸细胞腺瘤患者的临床资料。肿瘤直径为2.5~7 cm,平均4.2 cm,分别位于左肾5例、右肾6例,肾上极4例、肾下极5例、肾中极2例。术前均诊断为肾癌而行肾癌根治术。结果:术后病理证实均为肾嗜酸细胞腺瘤。大体观察肿瘤包膜完整,切面呈淡黄或棕黄色,质地均匀,2例肿瘤中央可见白色星芒状瘢痕样病灶,未见明显出血坏死灶。结论:肾嗜酸细胞腺瘤是一种较少见的良性肾脏肿瘤,常易被误诊为肾癌。其CT影像特征有助于术前诊断,确诊有赖于病理组织学和免疫组化。保留肾单位手术为首选治疗方法,其预后良好,但应密切随访。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.