腹腔镜肝叶切除治疗肝内外胆管结石16例临床报道

目的:探讨腹腔镜左肝叶切除在治疗左肝内外胆管结石中的价值。方法:2003年11月至2007年10月间,我院对16例左肝内外胆管结石病人运用自行设计的腹腔镜下专用彭氏多功能手术解剖器(PMOD)行腹腔镜下左肝外叶切除术,其中男7例,女9例,年龄36～69岁,平均年龄47.2岁,其中单纯左肝外侧叶胆管结石3例,左肝外侧叶胆管结石伴胆囊结石3例,左肝外侧叶胆管结石伴胆总管结石2例,左肝外侧叶胆管结石伴胆总管结石及胆囊结石8例。结果:本组16例病人均在完全气腹下进行操作,无中转开腹,未进行肝门血管阻断。其中2例行腹腔镜下单纯左肝外叶切除,3例行腹腔镜下左肝外叶切除联合胆囊切除,3例行腹腔镜下左肝外叶切除联合胆总管切开、胆道镜取石术,8例行腹腔镜左肝外叶切除术联合胆囊切除、胆总管切开及胆道镜取石术,手术时间平均为238min,术中平均出血量为430m1,切除肝脏的最大标本体积为20cm×7cm×4cm术后一例并发肝创面胆漏,经再次手术治疗后痊愈。其余均无并发症发生。术后24h均能下床活动,术后1-3天即进食,1周左右出院,留置T管者出院时均行胆道造影未发现有残余结石,2～3周后拔除T管。结论:腹腔镜左肝外叶切除联合胆总管切开、胆道镜取石是治疗左肝内外胆管结石的有效、可靠的方法,值得推广。     

腹腔镜肝切除联合术中胆道镜治疗左肝内胆管结石56例临床分析

目的探讨腹腔镜肝叶切除联合术中胆道镜治疗左肝内胆管结石的安全性及有效性。方法回顾性分析我院2014年1月至2019年1月收治的56例腹腔镜肝切除联合术中胆道镜治疗左肝内胆管结石患者的临床资料。结果本组患者中腹腔镜左肝外叶切除+胆道探查取石+T管引流20例(35. 7%),腹腔镜左半肝切除+胆道探查取石+T管引流34例(60. 7%),中转开腹左半肝切除2例(3. 6%)。手术时间(210±78) min,术中出血(700±400) ml,住院时间(15. 4±6. 8) d。术后胆漏2例(3. 6%),转氨酶升高超正常值3倍及以上者6例(10. 7%),左侧胸腔积液2例(3. 6%),胆道残余结石4例(7. 1%),无术后出血、膈下脓肿、肝功能衰竭、切口感染等并发症发生。术后随访3～24月无胆管结石复发。结论腹腔镜肝切除联合术中胆道镜治疗左肝内胆结石具有创伤小、并发症少等优点,是安全和有效的。     

两镜联合微创治疗肝内外胆管结石的应用

目的 探讨肝内外胆管结石应用腹腔镜联合胆道镜微创手术治疗的方法及适应证.方法 分析2007年1月～2009年4月应用腹腔镜联合胆道镜微创手术治疗肝内外胆管结石120例.结果 120例患者中116例完成胆总管切开取石引流术,成功率96.7％,手术时间50～120min,平均(80±32)min,术后无胆瘘和严重并发症,随访1个月～2年,无结石复发.结论 腹腔镜联合胆道镜治疗肝内外胆管结石微创手术方法安全有效,熟练规范的内镜操作技术是手术成功的关键.     

肝内外胆管结石手术治疗230例临床分析

目的 探讨各种手术方式治疗肝内外胆管结石的临床效果.方法 分析230例肝内外胆管结石患者的不同的临床表现采取不同的手术治疗方式(其中单纯胆总管切开取石或术中胆道镜取石122例,肝左叶切除20例,肝右叶部分切除33例,腹腔镜联合胆道镜取石12例,单纯腹腔镜胆总管切开取石13例,胆肠吻合30例).结果 全组患者切口感染36例(15.7％),胆道出血3例(1％),胆肠吻合口瘘1例(3.3％).肝内外胆管结石术后复发或残石23例(10％).结论 对肝内外胆管结石应采用不同手术方式,但须注意解除胆道狭窄,去除病灶,通畅引流是预防胆管炎复发,减少再次手术的关键;腹腔镜联合胆道镜治疗肝内外胆管结石是一种微创、安全、可靠、的技术,但应掌握好适应证.     

外科手术和纤维胆道镜联合治疗肝内胆管结石

该院自１９９２年起对６０例肝内胆管结石患者进行手术和纤维胆道镜联合治疗,其中经肝外胆管切开取石辅以术中或术后纤维胆道镜应用４２例,肝左外叶切除辅以术中或术后纤维胆道镜应用１０例,行左、右肝管或肝门部胆管切开整形、胆肠吻合辅以术中或术后纤维胆道镜应用８例,联合治疗肝内胆管结石的残石率为１．７％。     

肝叶切除手术联合胆道镜治疗胆管结石的护理

目的探讨肝叶切除手术联合胆道镜探查取石治疗胆管结石的观察护理。方法对36例行肝叶切除手术联合胆道镜探查取石治疗胆管结石的患者术前进行有效的心理护理，术后加强护理，预防并发症。结果36例手术全部成功，患者术前心理状态稳定，术后未发生严重并发症。结论肝叶切除手术联合胆道镜探查取石治疗胆管结石是治疗胆管结石的有效方法，术前准备充分，术后加强护理是手术成功的重要保证。     

三镜联合微创治疗肝内外难治性胆管结石(附86例报告)

目的 探讨腹腔镜、纤维胆道镜和纤维十二指肠镜联合应用于微创治疗肝内外难治性胆管结石.方法 回顾分析自2004年6月～2007年5月该科86例肝内外胆管难治胜结石患者行三镜联合微创治疗(术前经纤维十二指肠镜行逆性胰胆管造影检查或取石,术中腹腔镜,胆道镜经胆囊管或胆总管行肝内外胆管探查取石术,术后纤维胆道镜检查或取残石)的临床资料.结果 86例患者除2例中转开腹外,其余均在三镜联合下完成手术.未发生与手术相关严重并发症.结论 三镜联合治疗肝内外胆管难治性结石具有微创的优势,临床疗效安全可靠,值得临床推广应用.     

腹腔镜肝切除术治疗原发局限性肝内胆管扩张

目的 探讨腹腔镜肝切除治疗原发局限性肝内胆管扩张的临床疗效及手术方法的可行性和优缺点.方法 一共有10例原发局限性肝内胆管扩张患者接受腹腔镜下肝切除手术,其中,男性7例,女性3例;平均年龄47岁.有2名患者行肝右叶切除,4名患者行肝左叶切除,另外4名患者行肝左外叶切除.3名伴有普通胆管结石患者在术中行胆道镜取石术.结果 手术平均耗时303.9 min,手术平均失血量为217 mL.操作者在进行腹腔镜手术中都没有采用手辅助措施,也没有患者腹腔镜手术中或者术后又执行开放性手术.接受手术的10例患者中有9例恢复良好,一名行左半肝切除患者在术后出现了粘液积聚,重新入院后采用经皮穿刺引流治疗.患者平均住院时间为5.3 d,术后半年内胆囊炎没有复发.结论 由具备肝胆外科和腹腔镜两个方面专业知识以及受过相关专业训练的外科医生执行的腹腔镜肝切除术是治疗原发局限性肝内胆管扩张安全有效的方法.     

腹腔镜、纤维胆道镜联合治疗肝内外胆管结石

目的 探讨腹腔镜联合纤维胆道镜治疗肝内外胆管结石的方法及效果.方法 选择近5年来该院收治的45例肝内外胆管结石患者,于腹腔镜下行胆总管探查+纤维胆道镜取石+T管引流术,有残余结石者术后2月经T管瘘道行纤维胆道镜取石.结果 45例手术均获成功,无中转开腹,平均手术时间为(95.0±22.5)min,术中平均失血量为(85.6±16.5)mL,平均住院时间为(7.5±2.6)d,术后并发胆漏2例,腹腔感染1例,均经保守治疗治愈,术后11例胆道残余结石患者经1～3次胆道镜取净.结论 腹腔镜联合纤维胆道镜治疗肝内外胆管结石疗效好,创伤小,恢复快,安全可靠,值得应用.     

肝切除联合纤维胆道镜治疗复杂肝胆管结石40例

目的:探讨复杂肝内胆管结石的综合治疗.方法:回顾性分析肝切除并配合术中及术后纤维胆道镜处理的40例复杂肝内胆管结石患者的临床资料.结果:40例患者均行相应的肝部分切除和术中或术后1次至数次纤维胆道镜取石.术后残余结石率10.5%(4/38),治愈率为92.1%(35/38).再次肝切除率2.5%(1/40).结论:肝部分切除术是治疗复杂肝内胆管结石的核心手段,联合术中及术后胆道镜取石可以明显降低术后残石率及再次肝切除手术率,提高手术疗效.     

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.