腹腔镜胆囊切除术与小切口胆总管探查术的联合应用

目的探讨腹腔镜胆囊切除联合小切口胆总管探查治疗胆囊结石合并胆总管多发结石。方法本组23例胆囊结石合并胆总管多发结石,均来自2007年12月至2012年7月我院收治患者,采用腹腔镜下切除胆囊并解剖显露胆总管前壁,镜下确定腹壁切口位置,做3～5 cm切口入腹,经小切口切开胆总管,取石钳取石后根据情况用纤维胆道镜/硬性输尿管镜行胆道探查取石。结果本组无1例中转扩大切口手术,手术时间90～160 min,平均（120±10）min;住院时间10～20 d,平均13 d;21例拔除＂T＂管痊愈出院;2例术后＂T＂管造影B超检查右肝管残留结石,带管出院,术后6周经胆道镜取石痊愈;2例肺部感染,伤口均甲级愈合。结论该术式治疗胆囊结石合并胆总管多发结石创伤小,较单纯小切口安全,比全腹腔镜术式节省时间,取石彻底,适合基层医院。     

腹腔镜联合胆道镜经胆囊管治疗胆囊结石合并胆总管结石的临床分析

目的探讨应用腹腔镜联合胆道镜经胆囊管行胆道探查治疗胆囊结石合并胆总管结石的临床效果。方法对2014年1月-2015年12月陕西省核工业二一五医院收治的52例胆囊结石合并胆总管结石患者行腹腔镜联合胆道镜经胆囊管胆道探查取石术,观察其临床效果。结果 52例患者中40例顺利完成手术,手术成功率为76.92%。7例改为腹腔镜下胆总管切开取石、T管引流术,5例中转开腹行胆总管切开取石、T管引流术,中转开腹率9.62%。43例患者一次取石成功,占82.69%;剩余9例患者行二次取石,其中行经胆囊管胆道探查取石术者8例,行腹腔镜下胆总管切开取石术者1例。所有患者术后留置网膜孔引流管,术后3~10 d拔除,1例行腹腔镜下胆总管切开取石患者术后出现胆漏,经保守治疗后康复。无胆道出血、胆道感染等发生,平均住院时间(8.24±2.52)d,所有患者均得到随访1年,B超及磁共振胰胆管造影检查肝内外未见结石残留,肝功能胆红素指标正常。结论腹腔镜联合胆道镜经胆囊管进行胆道探查取石术具有创伤小、患者恢复快、并发症少、安全等优点,临床应用需严格掌握其适应证。     

胆囊结石合并胆总管结石的现代外科治疗模式

微创化理念的迅速普及, 微创设备的高速发展, 外科医师可以熟练的运用各种微创化器械使患者在短期内迅速康复. 胆总管结石的治疗方式也发生了巨大变化, 由传统的开腹胆总管切开取石、T管引流, 转变为腹腔镜下胆总管切开取石一期缝合或腹腔镜下胆总管切开取石、T管引流, 腹腔镜下经胆囊管胆道镜取石,或胆囊切除, 术前或术后应用十二指肠镜取出胆总管结石. 腹腔镜、十二指肠镜、胆道镜的三镜联合应用将会是今后治疗胆囊结石合并胆总管结石的现代外科治疗模式.     

腹腔镜联合胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石5年随访效果分析

背景胆囊结石合并胆总管结石的治疗方法有多种,当前较为常用的有腹腔镜下胆囊切除、胆总管探查术,内镜下乳头括约肌切开取石术加腹腔镜胆囊切除术,但前者因术后需放置T管引流、后者因破坏Oddi括约肌而有一定的争议.本研究经胆囊管途径取石,避免了损伤胆总管和Oddi括约肌切开所造成的损伤,在临床中取得了良好的效果.目的探讨腹腔镜下应用胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石的临床效果.方法对2013-01/2013-12的成功实施腹腔镜联合胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石的125例患者进行5年随访,分析其临床治疗效果.结果122例患者成功完成了腹腔镜胆囊切除加联合胆道镜经胆囊管胆总管取石术,手术成功率97.6%,平均年龄58.21岁±13.01岁,手术时间为87.95min±39.12min,术中出血11.27 mL±6.85 mL.所有患者均行球囊扩张,其中33例行胆囊管汇合处微切开, 5例行胆道镜下碎石术.患者术后排气时间为32.48 h±17.85 h.术后住院时间为2.03 d±1.62 d.短期随访并发症5.74%,共7例,其中术后胰腺炎4例,经奥曲肽、乌司他丁等对症治疗后治愈,发生胆漏2例,经ENBD引流后治愈,手术切口感染1例,经换药后治愈. 5年远期并发症4.92%,共6例,胆总管复发结石4例,其中1例合并肝内胆管结石,胰腺炎2例.死亡患者4名, 2例心梗, 1例肺部感染, 1例车祸,均与本手术无关.结论腹腔镜联合胆道镜经胆囊管取石治疗胆囊结石合并胆总管结石近期及远期效果较好,患者创伤小,恢复快,并发症少,在临床掌握适应证的前提下,值得推广.     

十二指肠镜、腹腔镜、胆道镜联合治疗胆结石(附20例报告)

目的 探讨十二指肠镜、腹腔镜、胆道镜联合治疗胆囊结石并胆总管结石的可行性与优越性.方法 选择20例胆囊结石并胆总管结石患者,先经十二指肠镜放置鼻胆管引流(ENBD)以便胆道减压,然后完成腹腔镜胆囊切除术,最后完成腹腔镜胆总管切开、胆道镜探查取石术,并一期缝合胆管.统计分析治疗结果,并发症和患者住院天数.结果 20例均痊愈,无并发症发生,住院时间缩短.结论 十二指肠镜、腹腔镜、胆道镜联合治疗胆囊结石并胆总管结石是一种创伤小、有效、安全且可靠的治疗模式.对掌握了腹腔镜下缝扎技术的普外科医师,可作为一种首选手术方法.     

腹腔镜联合胆道镜治疗老年胆囊结石合并胆总管结石的临床分析

目的探讨腹腔镜联合胆道镜行胆囊切除胆总管切开取石术治疗老年胆囊结石合并胆总管结石病人的安全性和可行性。方法选取我院2012年6月至2014年6月70岁老年胆囊结石合并胆总管结石病人24例作为观察组,行腹腔镜胆囊切除胆总管切开取石术。收集同期开腹胆囊切除、胆总管切开取石病人26例作为对照组。分析比较2组病人的临床疗效。结果 2组病人的手术成功率、手术时间比较,差异无统计学意义(P0.05);观察组较对照组术中出血量少,术后疼痛程度轻,术后通气时间及住院时间明显缩短,2组比较差异均有统计学意义(P0.05)。结论腹腔镜联合胆道镜治疗老年胆囊结石合并胆总管结石可明显减轻术后疼痛程度,缩短住院时间,是一种安全有效的微创治疗方法。     

腹腔镜联合胆道镜、十二指肠镜治疗胆囊结石合并肝内外胆管结石的效果观察

目的总结应用腹腔镜联合十二指肠镜、胆道镜对胆囊结石合并肝内外胆管结石患者的治疗经验及疗效。方法收集2010年3月-2015年3月于梅州市人民医院肝胆外科就诊的胆囊结石合并肝内外胆管结石患者413例,根据患者个体情况分别进行腹腔镜、胆道镜、十二指肠镜"二镜"或"三镜"联合治疗。结果腹腔镜胆囊切除术(LC)+胆道镜经胆囊管胆总管探查取石术(LTCBDE)31例,成功率29.0%(9/31);LC+LCBDE+胆道镜取石术+T管引流术101例,成功率93.1%(94/101);LC+胆总管探查术(LCBDE)+胆道镜取石术+Ⅰ期缝合术96例,成功率97.9%(94/96);LC+LCBDE+肝部分切除术61例,成功率91.8%(56/61);十二指肠乳头括约肌切开术(EST)+LC或LC+EST 155例,成功率93.5%(145/155);腹腔镜+十二指肠镜+胆道镜(同时)10例,成功率90%(9/10)。19例患者中转开腹,治疗总成功率95.4%(394/413),各组病例均治愈,无严重并发症,无死亡病例。结论腹腔镜联合胆道镜、十二指肠镜治疗胆囊结石合并肝内外胆管结石是切实可行和安全可靠的。     

胆管疾病的腹腔镜内镜联合治疗

目的：探讨腹腔镜、内镜联合治疗胆管疾病的方法及疗效。方法：总结分析两家医院应用腹腔镜、十二指肠镜、胆道镜联合治疗1990例胆管疾病的资料。结果：腹腔镜、十二指肠镜联合治疗胆囊结石合并胆总管结石1350例，1次治愈率为93．6％；腹腔镜、胆道镜联合治疗胆管结石332例，治愈率为100％；三镜联合治疗胆管结石258例(29例合并胰腺炎)，Mirizzi综合征24例，治愈率为100％；腹腔镜胆肠吻合术，术前放置鼻胆引流管26例，治愈率为100％。均无严重手术并发症发生。共有1051例患者随访3个月～12年(平均7．8年)，结石复发10例，无胆管狭窄等远期并发症发生。结论：腹腔镜、内镜联合治疗胆管疾病较传统开腹手术创伤轻、痛苦小、手术并发症少。     

十二指肠镜、电子胆道镜和腹腔镜序贯治疗胆总管结石合并胆囊结石834例临床观察

目的探讨十二指肠镜、电子胆道镜和腹腔镜序贯治疗胆总管合并胆囊结石的临床疗效。方法回顾性分析1999年6月至2010年6月间本院采用十二指肠镜、腹腔镜和电子胆道镜序贯治疗的834例胆总管结石并胆囊结石患者。结果 834例接受"二镜"(即腹腔镜、十二指肠镜)治疗,成功793例(95.08%)。41例"二镜"治疗困难转入选择"三镜"(即腹腔镜、十二指肠镜、电子胆道镜)治疗,成功39例(95.12%),"三镜"治疗未取得成功的2例患者因肝门部及小网膜口严重黏连,无法显露胆总管,遂转为开腹手术治疗。834例患者共出现并发症28例。结论序贯性多镜联合技术治疗胆总管结石合并胆囊结石切实可行,并发症率低,安全可靠,值得临床推广。     

急诊腹腔镜手术治疗胆总管结石合并轻、中度急性胆管炎的疗效

目的:探讨腹腔镜胆总管探查取石术(common bile duct exploration,CBDE)联合胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆总管结石(common bile duct stones,C B D S)合并轻、中度急性胆管炎的安全性及有效性.方法:对2009-01/2012-12收治的37例胆囊结石伴CBDS合并轻、中度急性胆管炎患者行腹腔镜CBDE联合LC.除外有重度急性胆管炎、上腹部手术史、严重心肺及其他影响全麻或手术等疾病的患者.常规四孔法完成经胆总管切开的腹腔镜CBDE、T管引流及LC.根据术前MRCP了解结石大小、数量和位置,用推挤、冲吸及胆道镜等方法取石,病情不稳定者,不行术中胆道镜取石.所有患者均不行术中胆道造影.Winslow孔处常规放置腹腔引流管.有胆道残余结石者,术后8 wk行胆道镜取石.结果:37例胆囊结石伴CBDS合并轻、中度急性胆管炎患者,均顺利完成腹腔镜CBDE及LC.手术时间105.54 min±6.30 min;胆总管直径12.86 mm±0.58 mm;单发CBDS 14例(37.8%),多发CBDS 23例(62.2%);术后胆囊病理结果,急性胆囊炎9例(24.32%),慢性胆囊炎28例(75.68%);术后住院天数为11.27 d±0.82 d;总住院天数16.41 d±1.03 d.腹腔镜CBDE术后胆管炎症状及体征明显缓解,实验室检查结果改善.无中转开腹、术后腹腔出血、胆道损伤、手术死亡及伤口感染.术后胆漏4例,经保守治疗治愈.术后胆道残余结石4例,术后经T管窦道胆道镜取净结石.结论:对部分CBDS合并轻、中度急性胆管炎患者,腹腔镜CBDE及LC治疗是安全、有效及可行的.     

Satisfaction with ambulatory care of persons with AIDS

OBJECTIVE: To examine the relation of patient characteristics and site of care to the perception of ambulatory care quality by persons with AIDS (PWAs). DESIGN: Patient surveys and medical record review were used to determine PWAs’ perceptions of their ambulatory care, self-perceived health status, primary care relationships, sociodemographic characteristics, and severity of illness. SETTING: A public-hospital HIV clinic, an academic group practice, and a staff-model health maintenance organization (HMO) that together care for 20% of all Massachusetts PWAs. PATIENTS: All active patients as of February 12, 1990, and all new AIDS patients at each of the three sites during the subsequent 13 months. MEASUREMENTS AND MAIN BESULTS: The primary outcome measure was a six-item scale of patient-rated quality of care (PRQC), a newly developed measure that combined patients’ ratings of their physician care, nursing care, involvement in medical decisions, and overall quality of care. Multiple logistic regression was carried out with low PRQC (lowest quart He) as the dependent variable, to identify correlates of patient perceptions of poor quality. Patients who had a primary nurse were significantly less likely to have low PRQC scores (OR=0.50, 95% CI=0.26 to 0.97). Black patients and patients who used injection drugs were significantly more likely to rate their care in the lowest quartile (OR=2.22, 95% CI=1.04 to 4.78; and OR=2.43, 95% CI=1.13 to 5.23, respectively), as were those who had lower self-perceived health status, after controlling for confounders; no association was found by site or severity. CONCLUSIONS: These results show that primary nursing may be an important determinant of how PWAs rate the quality of their ambulatory care. Furthermore, PWAs who are black or who are injection drug users are less satisfied than are others with the quality of their ambulatory AIDS care. Presented in part at the annual meeting of the Society of General Internal Medicine, April 30, 1993, Arlington, Virginia. Supported by the Agency for Health Care Policy and Research, grant number HS06239.     

分析老年糖尿病患者应用甘精胰岛素联合阿卡波糖治疗的效果

目的探讨甘精胰岛素联合阿卡波糖在老年糖尿病患者中的临床疗效。方法选取该院2018年7月—2019年7月收治的113例老年糖尿病患者作为研究对象,经随机数字表法,划分A组(n=56,阿卡波糖)和B组(n=57,甘精胰岛素+阿卡波糖),比较两组临床疗效、血糖指标。结果B组患者临床治疗总有效率显著高于A组;经治疗,B组患者空腹血糖(FBG)、餐后2 h血糖(2 hPG)、糖化血红蛋白(HbAlc)水平明显低于A组。两组之间比较差异有统计学意义(P<0.05)。结论在老年糖尿病患者中应用甘精胰岛素+阿卡波糖,临床疗效显著,使患者的空腹血糖、餐后2 h血糖、糖化血红蛋白等指标得到了明显改善,安全性强。     

Treatment of patients with Eisenmenger's syndrome with Bosentan

We treated prospectively 14 patients with Eisenmenger's syndrome, with a mean age of 10 years, ranging from 3 to 18 years. Treatment continued for 12 months, and demonstrated a lasting symptomatic improvement, but no improvement in terms of mean saturation of oxygen over 24 hours. Exercise capacity, as judged by peak uptake of oxygen, worsened in the six patients able to perform a treadmill test. The symptomatic benefit from dual blockage of endothelin receptors in these patients may be due to mechanisms other than selective pulmonary vasodilatation alone.     

小剂量垂体后叶素合并硝酸甘油治疗咯血

目的评价小剂量垂体后叶素联合硝酸甘油治疗咯血的疗效及不良反应。方法将50例咯血患者随机分为两组,治疗组在常规治疗基础上（n=26）应用小剂量垂体后叶素联合硝酸甘油;对照组（n=24）在常规治疗基础上仅应用小剂量垂体后叶素。分析其疗效及不良反应。结果48小时后治疗组有效率96.15％（25／26）,对照组有效率58.33％（14／24）,差异有统计学意义（P=0.012）;治疗组对血压影响小,无统计学意义（P〉0.05）,对照组能引起血压升高的副作用（P〈0.05）;治疗组出现头晕头痛、胸闷、心悸、腹痛、腹泻、恶心呕吐、出汗、面色苍白等不良反应比对照组少,差异有统计学意义（P〈0.05）。结论小剂量垂体后叶素联合硝酸甘油治疗中量咯血比垂体后叶素单药治疗中量咯血疗效明显提高,且能减少垂体后叶素不良反应。     

Evaluation of atrial vulnerability with transoesophageal stimulation in patients with atrioventricular junctional: Comparison with patients with ventricular pre-excitation and with normal subjects

The aim of our work was to evaluate the inducibility of atrialfibrillation in a group of patients with atrioventricular junctionalreentrant tachycardia and to compare it with that of patientswith a Kent-type ventricular pre-excitation (Wolff-Parkinson-Whitesyndrome) and a control group. One hundred and twenty-five subjects were separated into groups.Group 1 comprised 49 Wolff-Parkinson-White patients, with amean age of 26.4, range 10.66 years; group 2, 51 patients withatrioventricular junctional reentrant tachycardia inducibleby transoesophageal atrial stimulation andlor clinically documented,with a mean age of 43.4, range 16–78 years; group 3, 25control subjects with a mean age of2.64, range 13–76 years. Each subject underwent atrial transoesophageal stimulation withthe following protocol: programmed atrial stimulation with 1and 2 stimuli during atrial pacing of 100. min^–1 and 150.min^–1; atrial stimulation for 10 s at a rate of 200–300–400–500–600.min^–1 with intervals of 10 s between stimulations, fivesuccessive ‘ramp-up’ atrial stimulations for 9 swith the rate increasing from 100 to 800. min^–1 with intervalsof 10 s between stimulations. The end point was the completionof the protocol or induction of sustained atrial fibrillation(>1 min). The chi-square test was used for statistical analysis. Our resultsshowed that in group 1 atrial fibrillation was induced in 27149patients (55.1%); this was sustained in 13149 (26.5%) and non-sustainedin 14149 (28.5%); in group 2, atrial fibrillation was inducedin 22151 patients (43.0%); it was sustained in 7151 (13.7%)and non-sustained in 15151 (29.4%); in group 3, sustained atrialfibrillation was not induced in any subject and in only onesubject was a non-sustained atrial fibrillation (4 s) induced. The chi-square test showed that group 2 vs group 1 were non-significant,while group 2 vs group 3 and group 1 vs group 3 were significant(P<0.003 and P<0.0007, respectively). Therefore group 2 patients showed a greater atrial vulnerabilityin comparison to the control subjects and a similar vulnerabilityto group 1 patients. It is possible that the greater atrialvulnerability in the patients of group 2 was due to the doublenodal pathway.     

Complications associated with the treatment of haemophiliacs with inhibitors

To examine the safety profile of products used to treat inhibitor patients unresponsive to factor VIII, a review of published clinical experience was performed. The products evaluated were activated prothrombin complex concentrates (aPCCs), such as AUTOPLEX® T, porcine factor VIII and recombinant activated factor VII (rVIIa). Safety characteristics included potential for transmission of infectious agents, anamnesis, thrombogenicity, thrombocytopenia and allergic reactions. While viral transmission has been virtually eliminated, the risk is theoretically higher with plasma-derived products such as aPCC and porcine factor VIII than with rVIIa, although contamination of cultured cells is a concern. Anamnesis occurs with aPCCs and porcine factor VIII, and may induce resistance to further therapy with porcine factor VIII. Thrombosis and disseminated intravascular coagulation are very infrequently reported in patients exposed to aPCCs and rVIIa, and never with porcine factor VIII. The latter is occasionally associated with thrombocytopenia, but this uncommonly limits treatment with this agent. Lastly, allergic reactions occur with about equal frequency with all products, but anaphylaxis is mainly a concern after administration of porcine factor VIII. In conclusion, products currently available are reasonably safe. Considerations such as efficacy, availability, ease of administration and cost must also be considered in making treatment choices.