脑膜中动脉栓塞术治疗慢性硬膜下血肿:Meta分析

目的 系统评价脑膜中动脉(MMA)栓塞术治疗慢性硬膜下血肿(CSDH)的有效性及安全性。方法 检索PubMed、Embase、Cochrane Library、Web of Science、中国知网、万方医学网及维普数据库自建库至2021年11月栓塞MMA或以传统手术治疗CSDH相关临床队列研究,依据纳入及排除标准筛选文献,采用Stata 16.0软件进行分析。结果 最终纳入8篇文献、共1 482例CSDH患者,根据治疗方法分为栓塞组(n=318)及传统手术组(n=1 164)。栓塞组中,70例接受单纯MMA栓塞;其中248例接受栓塞联合手术治疗,包括67例术前栓塞、32例术后辅助栓塞、118例术后复发补救栓塞和31例未提及栓塞时机。Meta分析结果显示,栓塞组治疗失败率[RR＝－1.28,95%CI(－2.09,－0.47),P<0.05]、再次手术干预率[RR＝－1.59,95%CI(－2.27,－0.91),P<0.05]均低于传统手术组,而治疗相关并发症发生率组间差异无统计学意义[RR＝－0.40,95%CI(－0.93,0.13),P=0.13]。结论 MMA栓塞术治疗CSDH安全、有效。     

抗血栓治疗对大结肠息肉患者内镜下黏膜切除术后迟发性出血的影响

背景与目的 抗血栓治疗被认为是结肠息肉切除术后出血的危险因素。然而,抗血栓治疗对大结肠息肉患者术后迟发性出血的影响尚未完全明确。因此,本研究探讨抗血栓治疗及其相关因素对大结肠息肉患者行内镜下黏膜切除术（EMR）后迟发性出血的影响,以期提高医生对该类患者围手术期管理的认识。方法 回顾性收集2019年1月—2022年12月因大结肠息肉（>10~20 mm）行EMR的157例患者资料,根据EMR期间是否接受抗血栓治疗、使用抗血栓药物类型、术前是否停用抗血栓药物,分别将患者分为抗血栓组（n=51）与非抗血栓组（n=106）、抗凝组（n=33）与抗血小板组（n=36）、停药组（n=35）与未停药组（n=41）。比较各组间术后迟发性（24 h至30 d内）出血发生率及出血时间点的差异,并通过Kaplan-Meier曲线分析各组间术后30 d累积出血发生率。结果 抗血栓组与非抗血栓组迟发性出血发生率差异有统计学意义（19.61% vs. 5.66%,χ²=7.32,P=0.01）;抗血栓组的出血时间点明显早于非抗血栓组（t=2.17,P=0.047）;抗血栓组术后30 d累积出血发生率明显高于非抗血栓组（χ²=6.18,P=0.01）。抗凝组与抗血小板组迟发性出血发生率差异无统计学意义（24.24% vs. 27.78%,χ²=0.11,P=0.74）,两组在出血时间点、术后30 d累积出血发生率方面差异均无统计学意义（t=0.25,P=0.80;χ²=0.13,P=0.72）。停药组与未停药组迟发性出血发生率差异有统计学意义（14.29% vs. 29.27%,χ²=3.97,P=0.046）,未停药组在出血时间点方面明显早于停药组（t=3.03,P=0.01）;停药组术后30 d累积出血发生率明显低于未停药组（χ²=4.36,P=0.04）。结论 抗血栓治疗可能导致大结肠息肉EMR后迟发性出血发生率升高,但术后迟发性出血发生率与抗血栓药物类型无明显关系。术前适当停药可能是降低患者术后出血的有效策略。     

经颈内静脉植入输液港:导管尖端处于不同位置时1年内并发症发生率与导管通畅率

目的 对比观察经颈内静脉（IJV）入路植入完全植入式静脉输液港（TIVAP）后,导管尖端处于不同位置时1年内并发症发生率及导管通畅率。方法 回顾性分析2 104例接受经IJV入路植入TIVAP的肿瘤患者,将接受经右IJV入路者（R组,n=1 903）分为导管尖端位于右心房上部［即上腔静脉（SVC）与右心房交界（CAJ）下方0.5～1.0 cm亚组（R1亚组,n=376）］与位于SVC下1/3至CAJ间亚组（R2亚组,n=1 527）,将接受经左IJV入路者（L组,n=201）相应分为L1亚组（n=64）及L2亚组（n=137）;记录2组内各亚组患者基本资料、植入TIVAP 1年内并发症发生率及导管通畅率,并进行亚组间比较。结果 2组内亚组间患者性别、年龄、临床诊断及肿瘤分期,以及气胸/血气胸、局部皮肤损伤、TIVAP感染、导管相关性血栓、药物外渗、导管移位及心律失常等并发症发生率差异均无统计学意义（P均＞0.05）。R1（94.15%）与R2亚组（93.78%）（χ²=0.069,P=0.793）、L1（98.44%）与L2亚组（89.78%）1年内导管通畅率差异均无统计学意义（Yates连续性校正χ²=3.563,P=0.059）。结论 经左或右IJV入路植入TIVAP后,导管尖端位于右心房上部与SVC下1/3与CAJ之间时,1年内并发症发生率及导管通畅率均无明显差异。     

微导丝贯穿法联合臭氧介入治疗输卵管阻塞性不孕症

目的 观察微导丝贯穿法联合臭氧介入治疗输卵管阻塞性不孕症效果。方法 回顾性分析149例输卵管阻塞性不孕症患者资料,其中A组（n=44）接受常规输卵管再通术（FTR）,B组（n=51）接受微导丝贯穿法FTR,C组（n=54）接受微导丝贯穿法联合臭氧FTR治疗;比较治疗后1个月各组输卵管复通率及1年内自然妊娠率。结果 治疗后1个月,A、B、C组输卵管复通率分别为63.38%（45/71）、80.22%（73/91）及92.78%（90/97）,各组依次升高（P均＜0.05）;1年内A、B、C组自然妊娠率分别为20.45%（9/44）、27.45%（14/51）及48.15%（26/54）,C组高于A、B组（P均＜0.05）,且A、B组差异无统计学意义（P=0.427）。结论 微导丝贯穿法联合臭氧介入治疗输卵管阻塞性不孕症效果优于常规FTR及单独微导丝贯穿法FTR。     

FOLFOX-肝动脉灌注化疗联合程序性死亡受体-1抑制剂和靶向药物治疗中国肝癌分期Ⅲa期肝细胞癌

目的 观察FOLFOX-肝动脉灌注化疗（HAIC）联合程序性死亡受体-1（PD-1）抑制剂和靶向药物治疗中国肝癌分期（CNLC）Ⅲa期肝细胞癌（HCC）的价值。方法 回顾性分析61例接受PD-1抑制剂+靶向药物治疗的CNLC Ⅲa期HCC患者,根据是否接受联合FOLFOX-HAIC治疗将其归入观察组（n=30）及对照组（n=31）;比较组间一般资料、治疗方案、不良反应及疗效,分析观察组方案的治疗价值。结果 组间患者一般资料及PD-1抑制剂+靶向药物方案差异均无统计学意义（P均＞0.05）;1～2级不良反应中,观察组恶心、呕吐及腹痛发生率均高于对照组（P均＜0.05）,而其余1～2级及3级不良反应组间发生率差异均无统计学意义（P均＞0.05）。观察组客观缓解率（ORR）、无进展生存期（PFS）及总生存期（OS）均高于对照组（P均＜0.05）。结论 FOLFOX-HAIC联合PD-1抑制剂+靶向药物治疗CNLC Ⅲa期HCC疗效较佳而安全性尚可。     

颈动脉斑块常规超声及超声造影预测颈动脉狭窄患者缺血性脑卒中

目的 观察常规超声及超声造影(CEUS)评估颈动脉斑块、预测颈动脉狭窄患者缺血性脑卒中的价值。方法 回顾性分析115例经超声证实的颈动脉斑块致狭窄(狭窄率≥50%)患者,根据近6个月内有无缺血性脑卒中将其分为症状组(n=53)及无症状组(n=62)。以单因素分析及多因素logistic回归分析筛选颈动脉狭窄患者发生缺血性脑卒中的颈动脉斑块超声特征,建立回归模型,绘制受试者工作特征(ROC)曲线,评估其预测患缺血性脑卒中的效能。结果 单因素分析显示,组间颈动脉狭窄率、斑块表面形态及斑块内新生血管分级差异均有统计学意义(P均<0.05)。多因素logistic回归分析显示,斑块表面形态及斑块内新生血管分级为颈动脉狭窄患者发生缺血性脑卒中的独立预测因素,建立回归模型Y=－4.914+2.272X₁+2.354X₂(X₁为斑块表面形态,X₂为斑块内新生血管分级),其预测缺血性脑卒中的曲线下面积为0.886。结论 常规超声联合CEUS评估颈动脉狭窄患者颈动脉斑块有助于预测缺血性脑卒中。     

Orsrio生物可降解聚合物支架与第2代耐用聚合物支架预防心肌梗死:Meta分析

目的 采用meta分析对比观察Orsiro生物可降解聚合物西罗莫司洗脱支架(Orsiro-SES)与第2代耐用聚合物支架(DPS)预防心肌梗死(MI)的效果。方法 检索PubMed、Embase、Cochrane Library、中国知网、万方医学网和维普数据库自建库至2022年9月关于Orsiro-SES和第2代DPS的随机对照研究;依据纳入及排除标准筛选文献,利用RevMan 5.3软件分析Orsiro-SES与第2代DPS预防MI效果。结果 纳入20篇文献,共13 247例接受Orsiro-SES(Orsiro-SES组,n=6 809)或第2代DPS(DPS组,n=6 438)植入术患者。支架植入后1、2、3、5年, 组间MI发生率差异均无统计学意义(OR=0.86、0.85、0.82、0.91,P=0.17、0.18、0.10、0.37)。支架植入后1、2、5年组间靶血管MI发生率差异均无统计学意义(OR=0.83、0.84、0.94,P=0.12、0.21、0.64);支架植入后3年,Orsiro-SES组靶血管MI发生率低于DPS组(OR=0.76,P=0.04)。结论 Orsiro-SES与第2代DPS预防MI效果相当,前者或对预防靶血管MI具有一定优势。     

常规超声及超声造影特征与肝内胆管癌表达Ki-67水平的相关性

目的 观察肝内胆管癌（ICC）常规超声及超声造影（CEUS）特征与其表达Ki-67水平的相关性。方法 回顾性分析77例经病理确诊的ICC患者,根据目标病灶Ki-67表达水平将其分为高表达组（Ki-67≥20%,n=53）及低表达组（Ki-67＜20%,n=24）,比较组间常规超声及CEUS特征;将组间差异有统计学意义的变量纳入多因素logistic回归分析,筛选与ICC表达Ki-67水平相关的超声特征。结果 Ki-67高表达组ICC平均最大径大于低表达组[（6.2±2.0）cm vs.（5.2±1.9）cm,P=0.041],最大径＞5 cm ICC占比高于低表达组（66.04% vs. 33.33%,P=0.007）。组间常规超声所见ICC形态、边界及内部回声表现差异均无统计学意义（P均＞0.05）。CEUS中,高表达组ICC呈周边环状增强及增强后病灶范围较前增大者占比均高于低表达组（P均＜0.05）;组间ICC增强模式、病灶内部是否存在无增强区及峰值强度差异均无统计学意义（P均＞0.05）。病灶最大径＞5 cm（OR=5.612,P=0.004）及周边环状增强（OR=3.880,P=0.025）为预测ICC高表达Ki-67的独立因子。结论 ICC病灶最大径＞5 cm、CEUS呈周边环状增强提示其可能高表达Ki-67,有助于临床制定治疗决策。     

微波消融与手术切除治疗孤立性T1N0M0期甲状腺乳头状癌

目的 观察微波消融(MWA)与手术切除(SR)治疗孤立性T1N0M0期甲状腺乳头状癌(PTC)的价值。方法 纳入接受MWA(MWA组,n=364)或SR(SR组,n=364)治疗的728例孤立性T1N0M0期PTC患者,比较组间治疗相关及术后随访资料,对比MWA与SR疗效。结果 MWA组与SR组手术时间分别为23(14,38)min及72(33,180)min,术中失血量为2(1,5)ml及10(8,30)ml,术后住院时间为1(1,3)天及2(1,6)天,差异均有统计学意义(P均＜0.01)。MWA组16例疾病进展,包括局部复发1例、新发PTC 12例及颈部淋巴结转移3例;SR组15例疾病进展,包括新发PTC 11例及颈部淋巴结转移4例;组间疾病进展差异均无统计学意义(P均＞0.05)。并发症发生率组间差异无统计学意义(χ²=-3.36,P＞0.99)。至随访期末,MWA组T1期PTC肿瘤缩小率为89.45%~100%,肿瘤消失率为70.60%(257/364);T1a期肿瘤消失率显著高于T1b期PTC(P＜0.05)。结论 MWA治疗孤立性T1N0M0期PTC的安全性及有效性与SR相当。     

对比直接抽吸一次性取栓与支架取栓治疗急性大脑中动脉闭塞的辐射剂量

目的 对比观察直接抽吸一次性取栓（ADAPT）与常规支架取栓治疗急性大脑中动脉闭塞的辐射剂量。方法 回顾性分析54例大脑中动脉闭塞患者,按照不同介入治疗方法分为ADAPT组（n=29）和支架组（常规支架取栓,n=25）;比较2组术中透视时间、空气比释动能（AK）、剂量面积乘积（DAP）、摄影序列数和摄影帧数以及上述指标之间的相关性。结果 ADAPT组透视时间、AK、DAP、摄影序列数和摄影帧数均低于支架组（P均<0.05）。ADAPT组25例（25/29,86.21%）、支架组13例（13/25,52.00%）AK值<1.0 Gy,ADAPT组中AK值<1.0 Gy者占比高于支架组（P<0.01）;ADAPT组22例（22/29,75.86%）、支架组11例（11/25,44.00%）DAP值<100 Gy·cm²,ADAPT组中DAP<100 Gy·cm²者占比高于支架组（P=0.01）。透视时间与DAP（r=0.60,P<0.01）、AK（r=0.69,P<0.01）均呈正相关,DAP与AK呈正相关（r=0.81,P<0.01）。结论 ADAPT治疗急性大脑中动脉闭塞的辐射剂量低于常规支架取栓。     

Toothbrush swallowing

We encountered four cases of toothbrush swallowing and reviewed the literature on this subject. A total of 31 toothbrushes within the gastrointestinal tract have been reported. None have passed spontaneously. Several have caused significant complications related to pressure necrosis, including gastritis, mucosal tears, and perforation. The recommended treatment is endoscopic retrieval and postoperative monitoring for 24 hours in case of esophageal or gastric injury.     

Physiology of swallowing

The mechanism behind normal swallowing is complex and multifactorial. Due to the close proximity of the pathways of swallowing and respiration, precise coordination between these functions is vital in order to avoid entry of material into the airway and to ensure optimal health and nutrition in general. Swallowing can be divided into three stages: oral, pharyngeal and oesophageal, and although initiation of the swallow is often under voluntary control, swallowing is also triggered frequently throughout the day as a reflex action due to the presence of saliva in the oropharynx. Dysphagia is a symptom frequently encountered by clinicians and its causes are vast and varied. A thorough understanding of the physiology of swallowing remains necessary to conduct a full assessment and instigate appropriate treatment for these patients in whom dysphagia is often debilitating and may significantly affect their quality of life. We present an account of the physiology of swallowing, using clinical examples to illustrate certain aspects.     

Disorders of swallowing

Disorders of swallowing are very common and, when looked for, occur regularly in most branches of surgery. Dysphagia is often not the patient's presenting complaint and can be easily missed. The consequences of missed or delayed diagnosis of dysphagia can be insidious but profound and, in some cases, fatal. The investigation and treatment of these patients is normally highly multidisciplinary, potentially involving gastroenterology, general surgery, otolaryngology, acute medicine, stroke medicine, paediatrics, speech and language therapy (SLT) and dietitians. While this article is aimed at surgeons and will thus concentrate mostly on those conditions seen by surgeons, it must be remembered that the most common cause of dysphagia is a neurological disturbance and is managed by physicians and SLT. That said, the incidence of these conditions rises with age, as does the incidence of many surgically treatable conditions. It is therefore common to assess a patient with a known neurological condition for the presence of a second pathology affecting their swallow. A basic knowledge of non-surgical conditions is therefore useful.     

Disorders of swallowing

Disorders of swallowing are very common and, when looked for, occur regularly in most branches of surgery. Dysphagia is often not the patient’s presenting complaint and can be easily missed. The consequences of missed or delayed diagnosis of dysphagia can be insidious but profound and, in some cases, fatal. The investigation and treatment of these patients is normally highly multidisciplinary, potentially involving gastroenterology, general surgery, otolaryngology, acute medicine, stroke medicine, paediatrics, speech and language therapy (SLT) and dietitians. While this article is aimed at surgeons and will thus concentrate mostly on those conditions seen by surgeons, it must be remembered that the most common cause of dysphagia is a neurological disturbance and is managed by physicians and SLT. That said, the incidence of these conditions rises with age, as does the incidence of many surgically treatable conditions. It is therefore common to assess a patient with a known neurological condition for the presence of a second pathology affecting their swallow. A basic knowledge of non-surgical conditions is therefore useful.     

Physiology of swallowing

The mechanism behind normal swallowing is complex and multifactorial. Due to the close proximity of the pathways of swallowing and respiration, precise coordination between these functions is vital in order to avoid entry of material into the airway and to ensure optimal health and nutrition in general. Swallowing can be divided into three stages: oral, pharyngeal and oesophageal and although initiation of the swallow is often under voluntary control, swallowing is also triggered frequently throughout the day as a reflex action due to the presence of saliva in the oropharynx. Dysphagia is a symptom frequently encountered by clinicians and its causes are vast and varied. A thorough understanding of the physiology of swallowing remains necessary to conduct a full assessment and instigate appropriate treatment for these patients in whom dysphagia is often debilitating and may significantly affect their quality of life. We present an account of the physiology of swallowing, using clinical examples to illustrate certain aspects.     

Cervical spine motion during swallowing

Purpose

There have been several studies regarding the relationship between deglutition and the cervical spine; however, the movement of the cervical spine during deglutition has not been specifically studied. The purpose of the present study was to clarify how the cervical spine moves during normal deglutition.

Methods

We conducted videofluorography in 39 healthy individuals (23 men; 16 women; mean age, 34.3 years) with no evidence of cervical spine disease and analyzed images of the oral and pharyngeal phases of swallowing using an image analysis technique. Analyzed sections included the occiput (C0) and the first to seventh cervical vertebrae (C1–C7). The degrees of change in angle and position were quantified in the oral and pharyngeal phases.

Results

In the pharyngeal phase, C1, C2, and C3 were flexed (the angle change in C2 was the most significant with a mean flexion angle of 1.42°), while C5 and C6 were extended (the angle change in C5 was the most significant with a mean extension angle of 0.74°) in reference to the oral phase. Angle changes in C0, C4, and C7 were not statistically significant. C3, C4, C5, and C6 moved posteriorly (the movement in C4 was the most significant, mean = 1.04 mm). C1, C2, and C3 moved superiorly (the movement in C2 was the largest, mean = 0.55 mm), and C5 and C6 moved inferiorly. Movements in C0 and C7 were not statistically significant.

Conclusions

These findings suggest that the cervical spine moves to reduce physiological lordosis during deglutition.