恶性腹膜间皮瘤的诊治体会

目的 探讨恶性腹膜间皮瘤的诊治方法。方法 回顾分析16例恶性腹膜间皮瘤临床表现、实验检查及治疗方法。结果 16例中术前确诊3例,剖腹探查10例,急诊手术1例,腹腔镜探查2例。随访12例,半年内死亡2例,2年内死亡7例,1例生存超过2年。另2例为近1年内患者,继续治疗中。结论 恶性腹膜间皮瘤无特异性症状,诊断困难,误诊率高。诊断主要依据脱落细胞检查、腹腔穿刺活检、腹腔镜及剖腹探查。预后差,综合治疗有望延长患者生存期。     

子宫静脉内平滑肌瘤病2例及文献复习

目的:探讨子宫静脉内平滑肌瘤病(IVL)的临床表现和诊治要点。方法:对2例确诊IVL患者的临床资料进行回顾分析,并对相关文献进行复习。结果:2例IVL患者临床表现与子宫肌瘤的临床表现相同,术前无特异性诊断方法,病理检查是诊断该病的依据。结论:IVL无特异性临床表现,术前不易诊断,应注重术中探查及病理检查。     

腹腔镜与开腹腹膜透析置管术式比较

目的：探讨腹腔镜与开腹腹膜透析置管的疗效及早期与晚期并发症。方法选择新疆医科大学第一附属医院2009年1月1日-2013年6月1日确诊为慢性肾功能衰竭（符合 CKD5诊断标准）患者135例,根据患者意愿选择手术方式,43例行腹腔镜腹膜透析置管术（A组）,92例行开腹腹膜透析置管术（B组）,均采用标准Tenckhoff导管,比较两组患者手术前后生化指标水平、围手术期情况、腹膜透析导管（腹透管）使用寿命、术后早期与晚期并发症的差异。结果两组术后肌酐（Scr）、尿素氮（BUN）及血磷水平明显低于术前,而血红蛋白（Hb）、血钙水平明显高于术前,差异有统计学意义（P ＜0．01）;两组术后 Scr、BUN、Hb、血钙及血磷水平比较差异无统计学意义（P ＞0．05）;A组在手术时间、切口长度、术中出血量及围手术期疼痛方面优于 B组,但 A组手术相关费用明显高于B组,差异有统计学意义（P ＜0．05）;两组1个月及6个月腹透管使用寿命相同,差异无统计学意义（P＞0．05）,但 A组1、2、3及4 a腹透管生存率明显高于B组,差异有统计学意义（P ＜0．05）;B组术后早期并发症明显高于A组,差异有统计学意义（P ＜0．01）,主要表现为早期移位及切口疼痛（P ＜0．05～0．01）;B组晚期移位率、腹透管堵塞率明显高于 A组,差异有统计学意义（P ＜0．05）,两组腹膜炎、腹壁疝、腹透液渗漏、出口及隧道感染方面差异无统计学意义（P ＞0．05）。结论两种腹膜透析置管术各有利弊。腹腔镜腹膜透析置管术具有创伤小、腹透管使用寿命长、术后近期与远期并发症发生率低等优点,值得在临床推广应用。但对经济条件差、心肺功能差而不能耐受全麻及合并症多的患者建议选择开腹置管术。     

Comparison between peritoneal tuberculosis and primary peritoneal carcinoma: a 16-year, single-center experience

Background  Peritoneal tuberculosis and primary peritoneal carcinoma can both present as an abdominal mass and ascites with elevated serum CA125. The purpose of our study was to evaluate the clinical features of peritoneal tuberculosis, compare them with features of primary peritoneal carcinoma, and establish definitive diagnostic procedures.

Methods  We conducted a retrospective study in patients with peritoneal tuberculosis from January 1995 to October 2010 at Peking Union Medical College Hospital. During this time, the data of 38 patients with primary peritoneal carcinoma were reviewed.

Results  The median age was 34 years (range, 19–80 years). The most common symptoms were abdominal distension (16/30, 53.3%) and an abdominal mass (12/30, 40.0%). The serum CA125 level was elevated in 25 patients (83.3%). The median level of cancer antigen CA125 was 392.5 U/ml (range, 0.6–850.0 U/ml). Abdominal ultrasound revealed a pelvic mass in 25 patients and ascites in 20 patients. Diagnostic laparoscopy was performed in 15 patients (50.0%) and exploratory laparotomy was performed in 12 patients (40.0%), and 3 patients (10.0%) who underwent laparoscopy converted to laparotomy because of severe adhesions. The intraoperative findings were adhesions, multiple white tubercles, and ascites. Frozen tissue sections were obtained in 17 patients, and 14 of whom showed chronic granulomatous reactions. Final pathological examinations confirmed the diagnosis.

Conclusions  Peritoneal tuberculosis should be considered as a differential diagnosis, especially for young women with an abdominal mass, ascites, and elevated serum CA125 levels. Laparoscopy is a useful diagnostic method for peritoneal tuberculosis, and intraoperative frozen sections are recommended when the diagnosis is in doubt.

     

Disseminated Penicilliosis marneffei in a patient with acquired immunodeficiency syndrome: a first case report from China

Ｉｎ 1988 ,ｔｈｅｆｉｒｓｔｔｈｒｅｅｃａｓｅｓｏｆｄｉｓｓｅｍｉｎａｔｅｄｐｅｎｉｃｉｌｌｉｏｓｉｓｄｕｅｔｏＰｅｎｉｃｉｌｌｉｕｍｍａｒｎｅｆｆｅｉ (Ｐ .ｍａｒｎｅｆｆｅｉ)ａｍｏｎｇＡＩＤＳｐａｔｅｉｎｔｓｗｅｒｅｒｅｐｏｒｔｅｄ .Ｅｖｅｒｓｉｎｃｅ ,ｃａｓｅｓｆｒｏｍｏｔｈｅｒａｒｅａｏｆｔｈｅｗｏｒｌｄｗｅｒｅｒｅｐｏｒｔｅｄａｎｄａｌｌｗｅｒｅｒｅｐｏｒｔｅｄｔｏｂｅｉｎｆｅｃｔｅｄｉｎＳｏｕｔｈｅｒｎＡｓｉａｏｒＣｈｉｎａ 1　Ｂｙ 1995,ｔｈｅｎｕｍｂｅｒｏｆｔｈｅＰ ｍａｒｎｅｆｆｅ…     

急性播散性脑脊髓炎七例诊治体会

目的 探讨急性播散性脑脊髓炎(ADEM)的临床特点及诊治方法.方法 对7例临床确诊为ADEM患者进行随访,并对其临床和影像学表现、治疗及预后进行分析.结果 2例发病前有上呼吸道感染史,1例有腹泻史,1例有注射破伤风疫苗史,3例无明确诱因.患者的临床表现多样,颅脑MRI显示以脑白质为主的多发性病灶,可累及大脑皮质、丘脑、脑干、脊髓.7例均使用激素治疗,同时应用人血丙种球蛋白,其中6例经6个月～1年随访无复发,5例有不同程度后遗症.结论 ADEM临床表现多样,MRI表现有一定特性,及早应用糖皮质激素治疗效果显著.     

Diagnosis and surgical treatment of intraveneous leiomyomatosis extending into the heart: two cases report and review of the literature

Objective

To investigate the clinical characteristics, diagnosis and surgical treatment of intravenous leiomyomatosis (IVL), and outline the differences between Chinese and overseas cases.

Methods

Clinical data of two IVL cases, treated in our hospital, were analyzed retrospectively and the related literature was also reviewed. The data of preoperative diagnostic rate, surgical procedures, and postoperative recurrence between patients in China and other countries were compared.

Results

The first stage operation was performed successfully in 2 patients. However, they refused subsequent therapies, including a second stage operation to excise the remnants of the tumor, uterus, bilateral oviducts and ovaries, and anti-estrogen therapy. Both suffered from IVL recurrence, one at 6-month and the other at 9-month, and died at 16-month and 12-month respectively after the first stage surgery. Worldwide reports of 110 IVL cases were reviewed, which included 28 cases in China and 82 cases in other countries. In the majority of the Chinese patients, tumors only extended into the right atrium rather than the right ventricle (RA 22 cases vs RV 4 cases). However, among the overseas patients, the rate of extension into the right atrium was similar to that of extension into the right ventricle (RA 41 cases vs RV 38 cases). The rate of hysterectomies was not significantly different between Chinese and overseas patients (67.86% vs 55.9%, P=0.278). The rate of correct preoperative diagnosis in the Chinese patients was significantly lower than that in the overseas patients (32.14% vs 80%, P=0.000002), as well as the rate of complete excision of the tumor (22.7% vs 75.5%, P=0.000001). The proportion of patients who undergoing a single-stage or a two-stage operation was similar in Chinese and overseas patients. The recurrence rate was significantly higher in the Chinese patients than in the overseas patients (36.8% vs 9.1%, P=0.0055), and the patients with tumor recurrence were partial tumor excision patients.

Conclusion

The possibility of IVL should be considered if echocardiography in female patients demonstrates a tumor in the right heart and a mass in the inferior vena cava (IVC). Further imaging should be performed to confirm the diagnosis. The correct diagnosis and accurate preoperative delineation of tumor extension are essential for an optimal surgical outcome. The key point in IVL treatment is the complete excision of tumors (single-stage or two-stage surgical procedure).     

自制腹膜反折悬吊装置在腹侧肾肿瘤后腹腔镜下肾部分切除术中的应用

目的 应用自制腹膜反折悬吊装置行腹侧肾肿瘤后腹腔镜下肾部分切除术,验证其安全性和可行性。方法 选择2018年1月至6月在海军军医大学（第二军医大学）东方肝胆外科医院泌尿外科行后腹腔镜下肾部分切除术治疗的腹侧肾肿瘤患者15例,术中应用自制简易腹膜反折悬吊装置（由Hem-o-lok夹和与之连接的穿刺器、固定装置及施夹钳组成）。15例患者中男9例、女6例,平均年龄为（62.5±9.2）岁,平均肿瘤最大径为（2.9±1.0）cm,均为位于肾脏腹侧的单发肿瘤。统计分析术中出血量、手术时间、肾热缺血时间、术后平均住院时间等临床资料。结果 15例患者后腹腔镜下肾部分切除术均顺利完成,平均手术时间为（88.9±24.5）min,平均肾热缺血时间为（21.4±4.6）min,平均术中出血量为（72.0±16.6）mL,平均术后住院时间为（6.9±1.2）d,术中、术后均未输血,也均未发生重大手术并发症。结论 应用自制腹膜反折悬吊装置行腹侧肾肿瘤后腹腔镜下肾部分切除术是安全可行的,便于手术操作,同时具有经济简便的优势,值得在临床推广。     

单孔腹腔镜与传统多孔腹腔镜胆囊切除术疗效对比荟萃分析

目的 对单孔腹腔镜胆囊切除术(single-incision laparoscopic cholecystectomy,SILC)与传统腔镜胆囊切除术(conventionallaparoscopic cholecystectomy,CLC)疗效进行系统评价.方法 检索2010年1月至2015年1月Medline(Ovid SP),PubMed,Embase,Science Citation Index,Cochrane Central Register of Controlled Trials等外文数据库以及中国生物医学文献数据库.按照纳入排除标准筛选符合标准的文献,Cochrane风险评估偏倚工具进行文献质量评价.使用Review Manager 5.2对术中出血量、术后疼痛评分、外观满意度评分、手术时间、术后住院时间、正常活动恢复时间及不良事件发生率等指标进行荟萃分析.结果 本研究共纳入12项随机对照试验,1022例(SILC 534例;CLC 488例)胆囊疾病患者.SILC在术后6～8h疼痛、患者外观满意度方面显著优于CLC (P=0.001;P＜0.00001),差异有显著性意义.与CLC相比,SILC手术时间相对较长(P=0.002),差异有显著性意义.SILC与CLC在术中出血、不良事件发生率、术后住院时间、正常活动恢复时间方面无差异.结论 SILC提供与CLC相当的安全性和有效性,且具有更好的微创、美观和术后疼痛减轻等特点,值得临床应用.     

后腹腔镜下肾固定术 (附28例报告)

目的: 探讨后腹腔镜下肾固定术的手术方法和疗效.方法:采用后腹腔镜下手术治疗肾下垂28例.28例患者均为女性.年龄26～45岁,平均(34±2.5)岁.右侧15例,左侧12例,双侧1例.术前症状:腰区酸胀27例,腰区明显疼痛1例,频发尿路感染16例,血尿12例,其中肉眼血尿8例,镜下血尿4例.肾图显示患侧呈梗阻性表现12例.静脉肾盂造影提示肾下垂Ⅱ度10例,Ⅲ度14例,Ⅳ度4例.患侧轻度肾积水7例.1例双侧肾下垂采用经腹途径,其余27例均采用后腹腔途径.经后腹腔镜完整游离患侧肾脏,其中8例钳夹牵拉的肾下极血管.26例将下垂游离肾脏用腔镜内缝合技术固定于腰大肌,2例用外打结方法固定于患侧腰区皮下.结果:28例手术均获得成功.平均手术时间(125±9) min,平均住院时间(8±1.2) d,平均卧床时间(7±1.3) d.术后复查静脉肾盂造影提示患侧肾脏位于正常位置.27例腰区酸胀患者中24例症状消失,3例改善;1例腰区疼痛患者症状消失;16例频发尿路感染患者症状均消失;12例血尿患者中有10例症状消失.平均随访(24±4.2)个月,有一定的复发症状,包括血尿复发2例,1例复发尿路感染,4例复发患侧腰区酸胀.结论:后腹腔镜手术具有创伤小、疼痛轻、康复快等优点,有望成为理想的肾下垂手术方法之一.     

腹膜透析相关的混合菌感染的发生和治疗失败的危险因素——814例多中心回顾性研究

目的 明确混合菌腹膜透析相关性腹膜炎（PDAP）发生和治疗失败的危险因素。方法 回顾性收集2013~2019年期间,在吉林省4家三甲医院腹膜透析（PD）中心随访的PDAP患者临床资料,将其分为混合菌PDAP组和对照组。比较两组患者的临床资料与治疗结果,应用多因素回归分析探讨影响混合菌PDAP发生和当次治疗失败的独立危险因素。结果 共纳入814例次PDAP,分为混合菌PDAP组（79例次PDAP）和对照组（735例次PDAP）。与对照组相比,混合菌PDAP组老年人（>65岁）和难治性PDAP占比更高,第1天透出液白细胞计数更多,抗生素治疗天数更长（P<0.05）。混合菌PDAP组拔管和发生治疗失败（拔 管+PDAP相关性死亡）的风险分别是对照组的2.972倍（OR=2.972,95% CI 1.634~5.407,P<0.001）和2.692倍（OR=2.692, 95%CI1.578~4.591,P<0.001）。老年人（>65岁）发生混合菌PDAP的风险是中青年人的1.937倍（OR=1.937,1.207~3.109,P=0.006）;合并糖尿病（OR=5.554,95% CI 1.021~30.201,P=0.047）、致病菌类型为混合真菌（OR=343.687,95%CI 21.554~5480.144,P< 0.001）或铜绿假单胞菌感染（OR=11.518,95% CI 1.632~81.310,P=0.014）分别可使混合菌PDAP患者治疗失败（拔管+PDAP相关性死亡）的风险增加4.554倍、342.687倍、10.518倍。结论 本地区近3年混合菌PDAP在整体PDAP中的占比较以往升高,混合菌感染是当次PDAP治疗失败的独立危险因素。老年人是发生混合菌PDAP的独立危险因素,合并糖尿病与致病菌混合真菌感染或混合铜绿假单胞菌感染是混合菌PDAP当次治疗失败的独立危险因素。     

经脐单孔多通道腹腔镜下放置腹透管的初步尝试

目的尝试应用经脐单孔多通道腹腔镜下放置腹透管,总结初步应用体会。方法 2009年5至8月对2例慢性肾功能衰竭且需行腹膜透析的患者行经脐单孔多通道腹腔镜下放置腹透管。结果手术顺利完成,时间分别为15、25min,出血约20ml,未额外增加工作通道,术后1d出院。结论经脐单孔多通道腹腔镜下放置腹透管安全、有效,术后无明显手术瘢痕,美容效果良好。     

二孔法腹腔镜胆囊切除术31例临床分析

对2008年4月至2009年7月在我院治疗的31例胆囊结石和胆囊息肉患者行二孔法腹腔镜胆囊切除术（LC）治疗。二孔法LC手术成功29例,改4四孔法手术2例,均无手术并发症发生。结果提示,二孔法LC安全、有效,是更为微创、实用的手术技术。     

Single incision laparoscopic liver resection: a case report

Laparoscopic procedure as a minimally invasive surgery has been introduced into many abdominal surgeries. Smaller incisions of the abdominal wall reduce postoperative pain and the risk of wound complications, and provide an excellent cosmetic result compared with open surgery. Natural orifice transluminal endoscopic surgery （NOTES）, a no-scar surgery, is a hot spot of modern surgery. However,     

巨大腹腔游离体1例报告并文献综述(英文)

Introduction Peritoneal loose bodies are usually small,white or pale gray,pea-shaped objects with a smooth glistening surface,occasionally found during laparotomy or autopsy[1].They usually lie free in the peritoneal cavity,0.5-2.5 cm in diameter.We reported herein a case of a giant loose body measuring 9.5 cm,and discussed how such a large mass can develop and the related problems.     

腹膜透析相关腹膜炎患者治疗失败预测模型的构建和验证：一项多中心临床研究

目的 构建和验证腹膜透析相关性腹膜炎（PDAP）患者治疗失败的风险预测模型。方法 对2013年1月1日~2019年12月31日在吉林省3个腹膜透析中心发生PDAP的腹膜透析（PD）患者进行了回顾性分析。收集入选者基线临床资料,主要研究终点为治疗失败。根据腹膜透析中心地域的不同,将数据分为训练集（吉林大学第二医院、吉林大学第一医院二部）和验证集（吉林市中心医院）。采用Logistic风险回归模型筛选影响PDAP治疗失败的危险因素,用Stata建立预测模型;用ROC曲线和校准曲线评估模型的区分度和准确性,并以DCA曲线评估列线图的临床有效性。结果 共纳入977例次PDAP,训练集中625例次,其中78例治疗失败,验证集中352例次,其中35例治疗失败。建模队列多因素Logistic回归分析结果显示,血清白蛋白、第5天腹透液白细胞计数、透析龄和致病微生物类型是治疗失败的独立危险因素,在训练集中的C统计量为0.827（95% CI：0.784–0.871）。在验证集中,C统计量为0.825（95%CI：0.743-0.908）。预测模型在训练和验证集的校准方面都表现良好。结论 基于血清白蛋白、第5天腹透液白细胞计数、透析龄和致病微生物类型构建了预测模型,性能良好。     

52例肾癌患者腹腔镜根治术临床分析

目的探讨肾癌腹腔镜根治术的手术方法及临床效果。方法52例肾癌患者施行腹腔镜下根治术。结果手术时间100—160min,平均125min;术中出血量40～230ml,平均90ml。术后7～10d痊愈出院。肠道恢复时间为术后1—3d,平均1．5d。术后恢复良好,无明显并发症。手术后随防1～29个月,一般状况良好,无肿瘤复发及转移。结论腹腔镜肾癌根治术创伤小、术中出血少、术后恢复快等优点,是一种安全、有效的治疗方法。     

播散性隐球菌病1例分析

分析在1例肝硬化脾切除术后患者被新型隐球菌侵入血流引起播散性隐球菌病的临床表现、治疗措施与实验室检测结果。患者,男性,30岁,于2016年3月因“脾大、脾功能亢进”行“脾切除+贲门周围血管离断术”,术后多次无明显诱因发热,体温最高39℃,相继伴背痛、左下肢脓肿和右髋关节痛。CT和MRI显示患者肺部病变及多处骨质破坏,期间抗生素治疗效果不佳。2017年4月19日对脓液直接革兰染色、墨汁染色,使用API 32C、Vitek 2 Compact、rDNA ITS和IGS序列分析等方法对分离自患者脓液、血液中的菌株进行鉴定,检测患者血清中隐球菌抗原,使用ATB FUNGUS 3进行抗真菌药敏试验。结果在新鲜脓液标本墨汁染色后菌株呈现厚厚的荚膜,从脓液及血液中分离出的菌株经API 32C、Vitek 2 Compact、rDNA ITS和IGS序列分析均鉴定该菌为新型隐球菌,血清新型隐球菌荚膜抗原阳性。该菌对5-氟胞嘧啶、两性霉素B、氟康唑、伊曲康唑及伏立康唑的最小抑菌浓度分别为：<4 mg/L、<0.5 mg/L、4 mg/L、≤0.25 mg/L和0.125 mg/L。给予“氟康...     

Efficacy and safety of Changfu peritoneal dialysis solution: a multi-center prospective randomized controlled trial

Background A multi-center large scale study is needed to confirm the efficacy and safety of domestic peritoneal dialysis (PD) solutions. Some researchers believe that 6 L/d is enough for adequate dialysis, but there is no multi-center prospective study on Chinese population to confirm this. In this study, we evaluated the efficacy and safety of domestic PD solution (Changfu) and its difference between 6 L and 8 L dosage.

Methods Adult PD patients who had taken PD therapy for at least one month were selected and divided into four groups according to two dialysis solution brands and two dialysis dosages, i.e., 6 L dose with Changfu dialysis solution, 6 L dose with Baxter dialysis solution, 8 L dose with Changfu dialysis solution, and 8 L dose with Baxter dialysis solution. After 48 weeks, the changes of primary and secondary efficacy indices were compared between different types and different dosages. We also analyzed the changes of safety indices.

Results Changes of Kt/V from baseline to 48 weeks between Changfu and Baxter showed no statistical differences; so did those of creatinine clearance rate (Ccr). Normalized protein catabolic rate (nPCR) from baseline to 48 weeks between Changfu and Baxter showed no statistical differences; so did those of net ultrafiltration volume (nUF) and estimated glomerular filtration rate (eGFR). Changes of nPCR from baseline to 48 weeks between 6 L and 8 L showed no statistical differences; so did those of nUF and eGFR. The decline of Kt/V from baseline to 48 weeks in 6 L group was more than that in 8 L group. Change of Ccr was similar. During the 48-week period, the mean Kt/V was above 1.7/w, and mean Ccr was above 50 L·1.73 m-2·w-1. More adverse events were found in Changfu group before Changfu Corporation commenced technology optimization, and the statistical differences disappeared after that.

Conclusions The domestic PD solution (Changfu) was proven to be as effective as Baxter dialysis solution. During 48-week period, a dosage of 6 L/d was enough for these patients to reach adequate PD. Clinical study promotes technological optimization, further helps to improve the safety indices of the medical products.