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目的客观评价腔镜辅助下甲状腺切除术治疗甲状腺疾病的有效性及安全性。方法计算机检索MEDLINE、EMBASE、PubMed、CBM及Cochrane图书馆2006年第2期;手工检索有关中文杂志。纳入腔镜辅助下甲状腺切除术与传统手术治疗甲状腺疾病的随机对照试验,并对其方法学质量进行评价。用Revman4.2.8软件进行统计分析。结果共纳入4个随机对照试验,包括164例病人。Meta分析结果显示,腔镜辅助甲状腺切除术与传统甲状腺切除术相比,有较好的美容效果[WMD1.05,95%CI(0.47,1.62)];术后疼痛较轻[WMD-8.20,95%CI(-11.60,-4.80)];并发症发生率二者差异无统计学意义[RR1.90,95%CI(0.65,5.54)];腔镜辅助手术耗时较长[WMD18.96,95%CI(17.23,20.69)]。结论腔镜辅助手术具有美容、微创的优势,但适应证范围较窄,手术时间较长。治疗甲状腺癌尚有待进一步开展随机对照研究以评价疗效。     

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全甲状腺切除术在临床的应用日益增多。如何保护甲状旁腺、减少和避免发生严重甲状旁腺损伤已成为学界关注的重要问题。手术分级管理制度、专科医生培养、手术者高度负责的态度、手术中操作精细和仔细检查辨认、即刻自体甲状旁腺移的补救措施等环节构成了完整的预防规程,可使全甲状腺切除术的永久性甲状旁腺功能减退症发生率有效降低。     

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目的 评价直肠外翻切除应用吻合器技术在低位结直肠吻合术中的安全性和有效性。方法 自1991年以来为21例下段直肠癌病人施行了低位直肠癌外翻切除吻合术。Dukes：A期11例，C期4例。肿瘤距齿线2－3cm11例，3－5cm10例。结果 直肠闭合和肠吻合过程顺利，未发现吻合口裂开。全组病人均获得随访，发生吻合口狭窄1例（4．8％），局部复发2例（9．5％）。术后3－6个排便功能均控制良好。结论 直肠外翻切除吻合术方法简单、并发症少。能完成手术法缝合或双吻合器技术难以完成的低位直肠吻合术。     

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目的探讨胃肠阃质瘤联合脏器切除的指征及方法.方法回顾性分析1994-2005年复旦大学附属肿瘤医院收治的22例胃肠间质瘤行联合脏器切除的病例资料.结果联合脾切除8例,姑肠切除6例,肾脏切除5例,肝部分切除1例,十二指肠切除1例,卵巢切除1例,胰体尾切除3例,肾上腺切除1例,两个脏器切除3例,三个脏器切除2例,5倒胃间质瘤及2例小肠问质瘤淋巴结清扫术后,未证实淋巴结转移,病理检查提示肿瘤累及肾、脾、胰、各2例,肠系膜与大网膜各1例,全组无死亡病例.随访14例,9例存活,5例因肿瘤复发转移死亡.结论胃肠问质瘤如侵犯周围脏器,联合脏器切除对病人可能有益,掌握手术指征也很重要.与靶向药物结合外科治疗胃肠间质瘤更为适合.     

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??Application of pelvic peritoneum reconstuction accompanied with irrigation and negative pressure drainage in robotic abdominoperineal resection for rectal cancer CAO Chuan-lin??LIU Dong-ning??TANG Cheng??et al. Department of General Surgery??the First Affiliated Hospital of Nanchang University??Nanchang 330006??China
Corresponding author??LI Tai-yuan??E-mail??jylitaiyuan@sina.com
Abstract Objective To explore feasibility and efficacy of pelvic peritoneum reconstuction (PPR) accompanied with irrigation and negative pressure drainage after robotic abdominoperineal resection (APR) for rectal cancer. Methods The clinical data of 59 cases of low-rectal cancer patients treated from December 2014 to April 2016 in the First Affiliated Hospital of Nanchang University were analyzed retrospectively. Among all the cases, 31 cases received PPR accompanied with irrigation and negative pressure drainage in robotic APR (closed group) and 28 cases received gravity drainage without PPR (unclosed group). Operative and postoperative details were compared between two groups. Results No conversion occurred in the two groups. The pelvic peritoneum was closed successfully in closed group. There was no significant difference between the two groups in terms of operation time ??(186.6±23.0) min vs. (176.9±19.4)min??P=0.088???incidence of perineal hernia ??0(0/31) vs. 7.1%(2/28)??P=0.221?? and incidence of intestinal obstruction ??3.2%(1/31) vs. 10.7%(3/28)??P=0.337??. Compared with unclosed group??closed group displayed lower incision infection rate ??6.5%(2/31) vs. 32.1%(9/28)??P=0.011??. The intra-oprerative blood loss??the number of retrieved lymph node??positive circumferential resection margin and time to remove the drainage tube were similar between two groups. One case of tumor recurrence occurred in unclosed group. Conclusion PPR is necessary after robotic APR for rectal cancer??which accompanied with irrigation and negative pressure drainage might significantly reduce incidence of complications.     

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我国的门静脉高压症中85％～90％是由肝硬化所致．当前，外科治疗的主要目的是治疗和预防食管胃底曲张静脉破裂出血及消除脾功能亢进。诸多学者依据门静脉系血流动力学变化的特点，已设计和开展了多种不同组合的术式。     

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脾脏切除术是一种开展比较广泛的手术，它用于治疗脾脏疾病至今已有400余年的历史；部分脾切除术用于治疗脾脏外伤亦有200余年历史。如何实施规范的全脾切除及部分脾切除是保障手术成功、减少术后并发症的关键。本文介绍一下两种术式规范操作技术要点。     

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??Laparoscopic and hybrid laparoscopic robotic pancreaticoduodenectomy: a report of 80 cases HONG De-fei*??LIU Ya-hui??ZHANG Yu-hua??et al. *Department of Hepatobiliary and Pancreatic Surgery??minimally invasive surgery??Zhejiang Provincial People’s Hospital?? Hangzhou 310014??China
Corresponding author??HONG De-fei??E-mail??hongdefi@163.com
Abstract Objective To investigate the role of Laparoscopic and robotic assisted pancreaticoduodenectomy??LPD??in periampullary lesions. Methods The clinical data including perioperative and short-term outcomes of 80 cases of LPD performed in Zhejiang provincial people’s hospital (67) and Frist clinical hospital of Jilin university (13) between 2013.12 and 2016.01 were reviewed retrospectively. Results 80 patients attempted LPD while three ??3.8%?? required conversation to open procedure. Five patients ??6.3%?? underwent LPD combined with partial resection of portal vein or superior mesentery vein. The mean operation time was ??351.2±84.1??minutes??estimated blood loss was ??204.7±165.9?? ml and mean postoperative hospital stay was ??16.6±10.1?? days. Seven cases underwent binding pancreatico-gastric anastomosis while other cases were all underwent pancreatico-jejunostomy duct to mucosa anastomosis including 45 cases performed under laparoscopic system and 25 cases performed under Robotic system. 11 cases had pancreatic fistula according to ISGPF definition??including six cases of grade A??three cases of grade B and two cases of grade C (reoperation was required for postoperative intra-abdominal hemorrhage). Three patients suffered from postoperative intra-abdominal bleeding. Three patients had gastrointestinal bleeding. Five patients had delayed gastric empty and six cases had bile leakage after operation. Pathologic results showed pancreatic ductal adenocarcinomas in 32 patients??duodenal papillary adenocarcinoma in 16 patients??adenocarcinomas at ampulla of Vater or common bile duct in 23 cases??intraductal papillary mucinous neoplasms in four patients??neuroendocrine tumors in two patients and other disease in three patients. All patients underwent R0 resection. Conclusion Our results show that the LPD is technique safe and feasible at high volume minimal invasive and pancreatic centers. Da-Vinci robotic system has advantage in pancreatojejunal and portal vein reconstruction.     

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??Total mesopancreas excision in laparoscopic pancreaticoduodenectomy for the treatment of pancreatic head carcinoma: An analysis of 34 patients ZHANG Jian-sheng??WANG Tian-yang??LIU Run-tian??et al. The Second Hospital of Hebei Medical University??Shijiazhuang 050000??China
Corresponding author??ZHANG Jian-sheng??E-mail: 15130119600@163.com
Abstract Objective To evaluate the feasibility and clinical efficacy of total mesopancreas excision (TMpE) in laparoscopic pancreaticoduodenectomy (LPD) of pancreatic head carcinoma. Methods From November 2014 to January 2017??34 patients of pancreatic head carcinoma applied artery priority TMpE during the LPD in Department of Hepatobiliary Surgery, the Second Hospital of Hebei Medical University. The clinical and pathological data were analyzed retrospectively, and the complications and postoperative survival were observed and followed up. Results All 34 patients underwent complete laparoscopic surgery. The mean operation time was 468.7±78.2 min and the mean blood loss was 748.5±256.5 mL. Postoperative complications were reported in 13 patients??including 5 cases of pancreatic fistula??and no perioperative death was noted. The pathological examination showed that 7~25(14.6±3.8) lymph nodes were dissected, including 1~8(2.7±1.1) with metastasis in 23 cases. Of all the 34 cases, R0 resection was achieved in 28 cases (82.4%). After 8(1??25) months' follow-up, by January 30, 2017??7 cases were dead, with the postoperative survival of 11(5??14) months??including 1 case dead of pulmonary infection 2 months after operation and the other 6 cases dead of tumor recurrence. The other 27 cases are still in follow-up. Conclusion TMpE is feasible and safe for pancreatic head carcinoma in the LPD and is helpful to increase the R0 resection rate.     

妊娠期甲状腺结节的特点与诊疗进展

妊娠期甲状腺结节的发病率明显升高,这可能与妊娠期内环境的改变有关.目前,对妊娠期甲状腺结节的诊断和治疗尚无统一规定.为更好的了解妊娠期内环境的改变与甲状腺结节的关系以及妊娠期甲状腺结节的具体诊断、治疗策略,本文就妊娠期甲状腺结节的可能发病因素和妊娠期甲状腺结节的诊治进展作一综述.     

甲状腺结节钙化的临床价值

目的探讨甲状腺结节钙化在临床诊治中的意义。方法回顾性分析2002年6月至2003年8月中山大学附属第一医院收治的543例甲状腺结节病人的临床、B超扫描和病理资料。543例甲状腺结节中良性病变473例(87·1%),恶性病变70例(12·9%)。结果121例甲状腺结节有钙化,占22·3%,其中恶性肿物的钙化发生率(52·9%)明显高于良性甲状腺肿物(17·8%,P<0·05)。单发结节、伴有颈部淋巴结肿大甲状腺肿物为恶性的可能性大(P<0·05)。结论B超检查发现甲状腺结节钙化,并有结节边界模糊、形态不规则、低回声和血流信号丰富时,宜采用积极的治疗方法。     

单发良性甲状腺结节切除术103例

目的探讨对甲状腺结节患者选择适当的病例,采用甲状腺腺瘤摘除术代替传统甲状腺叶加峡部切除术的治疗效果。方法回顾性分析我科收治的单发良性甲状腺结节患者215例,其中实验组103例行甲状腺腺瘤摘除术．对照组112例采用传统甲状腺叶加峡部切除术。比较两组术后并发症,住院天数以及住院费用。结果两组病例全部治愈。甲状腺腺瘤摘除术手术组和传统甲状腺叶加峡部切除术手术组术后并发症分别为0．9％和9．8％,P〈0．05。住院天数4．5±1．5和7．5±2．0天,P〈0．05。住院费用分别为5950±215和7315±410元,P〈0．05。术后颈部僵硬,麻木,不适感持续时间短。结论甲状腺结节患者选择适当的病例行甲状腺瘤摘除术,手术创伤小,并发症少,术后恢复快,切口美观,值得临床推广。     

甲状腺结节合并钙化与甲状腺癌关系的临床研究

目的 探讨甲状腺结节合并钙化与甲状腺癌的关系及其对甲状腺癌高危人群筛选的临床意义.方法 回顾性分析2006年3月至2009年3月行甲状腺手术的1771例患者中甲状腺结节合并不同类型钙化的甲状腺癌发生率.结果 本组病例中恶性肿瘤500例,甲状腺癌的钙化发生率为68.4%,良性疾病中的钙化发生率为27.0%,差异有统计学意义(χ2=259.5,P＜0.05).微钙化诊断甲状腺癌的特异性为89.4%,阳性预测值为66.3%,与其在良性疾病中的差异有统计学意义(χ2=368.6,P＜0.01).年龄＜45岁的甲状腺癌发生率为39.2%,≥45岁的甲状腺癌发生率为22.9%,差异有统计学意义(χ2=51.12,P＜0.05).单发结节的甲状腺癌发生率为31.7%,多发结节为26.4%,两者差异有统计学意义(χ2=4.766,P＜0.05).B超显示淋巴结肿大最终证实为甲状腺癌转移的比例为26.8%.结论 钙化尤其是微钙化对于诊断甲状腺癌的特异性较高,具有重要的临床意义.甲状腺癌的高危人群包括:甲状腺结节合并微钙化、年龄＜45岁及单发结节.

Abstract：

Objective To investigate the relationship between thyroid nodules with calcification and thyroid carcinoma and its significance in the screening of thyroid carcinoma in high risk group.Methods The clinical data of 1771 patient undergoing surgery for thyroid nodules from March, 2006 to March, 2009 in Huashan Hospital, Fudan University were retrospectively analyzed. Results Among 1771 patients, 500 were finally identified as having malignant tumors. Incidence of calcification in thyroid carcinoma was 68. 4%, and that in benign thyroid nodules was 27.0% ( χ2 = 259. 5, P ＜ 0. 05 ). The specificity of microcalcification for the diagnosis of carcinoma was 89. 4%, and its positive predictive value was 66. 3% ( χ2 = 368.6, P ＜ 0. 01 ). The incidence of thyroid carcinoma in patients ＜ 45 years was 39.2%, while that in patients ≥ 45 years was 22.9% ( χ2 = 51.12, P ＜ 0. 05 ). The incidence of carcinoma in patients of single thyroid nodule was 31.7% and that in those with multiple nodules was 26. 4% (χ2 =4. 766,P ＜ 0. 05). Metastasis was pathologically diagnosed in 26. 8% of lymph nodes found by preoperative ultrasonography. Conclusions The specificity of thyroid nodule calcification, especially microcalcification is high for the diagnosis of thyroid carcinoma. High-risk index for carcinoma includes thyroid nodules with microcalcification, ＜ 45 years old and single thyroid nodule.     

自主功能性甲状腺结节104例临床分析

目的提高对自主功能性甲状腺结节（ＡＦＴＮ）的诊断与治疗水平。方法１０４例ＡＦＴＮ中同位素结合促甲状腺激素刺激扫描诊断１６例,结合甲状腺激素抑制扫描诊断２０例,结合手术前后扫描诊断６８例。全部病例均行手术治疗,手术方式有单纯结节摘除,一叶部分或全切除,双叶次全切除及癌根治术。结果１０４例ＡＦＴＮ中,同位素扫描为“热结节”者９４例,“温结节”者１０例,继发甲状腺机能亢进２５例（２４％）,７６例来自地方性甲状腺肿流行区。病理类型：结节性甲状腺肿７６例（７３１％）,甲状腺腺瘤２６例（２５０％）,甲状腺癌２例（１９％）。对２６例ＡＦＴＮ患者进行术后３～２２年随访,未发现结节复发及甲低等并发症。结论碘缺乏可能在ＡＦＴＮ形成中起重要作用;同位素扫描是诊断ＡＦＴＮ的主要手段;ＡＦＴＮ患者一旦确诊应及时治疗,手术是较好的治疗方法。     

甲状腺结节内钙化与甲状腺癌的关系研究

目的 探讨超声探测到的甲状腺结节内钙化与甲状腺癌的关系.方法 收集本院5年间行甲状腺手术患者4186例,对比甲状腺结节术前彩色超声检查与术后病理诊断.结果 甲状腺癌患者甲状腺结节内钙化,微小钙化和非微小钙化的发生率明显高于良性疾病中的发生率(P＜0.05).微小钙化对于预测甲状腺癌更有意义(P＜0.01),它在≥45岁和＜45岁组问比例分别为2.4%和16.8%,差异有统计学意义(P＜0.05);钙化在不同性别问差异无统计学意义(P＞0.05);伴钙化的恶性结节在单发与多发组间比例为70.7%和49.1%,差异有统计学意义(P＜0.05).结论 超声探测到微小钙化病灶对诊断甲状腺癌的特异性高,特别是对乳头状甲状腺癌.微小钙化对诊断微小乳头状癌有重要临床意义.     

肝脏孤立性坏死结节十例

目的 探讨肝脏孤立性坏死结节的临床表现、治疗方法和预后.方法 回顾性分析经手术治疗的10例肝脏孤立性坏死结节患者的临床资料.结果 该病好发于男性(7/10),中位年龄47岁.患者多无临床症状(8/10);多不合并肝炎病毒感染,肿瘤标记物CA199,AFP,CEA等正常.本组9例患者为单发病灶,l例为2个病灶,其中7个病灶位于肝左叶,4个病灶位于肝右叶.结节大小为(2.9±1.1) cm.MRI检查T1WI扫描肿瘤呈低信号或中信号,T2WI扫描肿瘤呈低或稍高信号,增强扫描无强化或有周边强化,MRI有较高的诊断准确率,达66.7％ (4/6).术前穿刺活检较难定性.术后病理检查提示病灶结节中心由坏死的肝细胞组成,周边为增生的纤维细胞、炎性细胞及多核巨细胞,5例患者存在肝组织脂肪变性.10例患者病灶均经手术切除,经随访6～67个月,无复发.结论 该病病因尚未达成共识,由于临床少见,临床医师认识不足,容易误诊,如能诊断准确,可随访观察,本病预后良好.     

B超诊断在甲状腺肿块临床鉴别诊断中的作用

目的探讨甲状腺肿块的B超误诊原因及B超在甲状腺肿块临床诊断鉴别诊断中的作用.方法回顾性分析307例甲状腺肿块的B超诊断和病理诊断结果.结果 B超诊断与病理诊断符合率相差较大.B超提示甲状腺多发性结节的绝大多数为结节性甲状腺肿,B超提示甲状腺单发结节的病理为结节性甲状腺肿和腺瘤的的比例约为3∶2.B超提示为甲状腺实质性占位的则恶性肿瘤的可能性较大.结论临床医师不能把B超诊断当成临床诊断.B超提示为甲状腺多发结节的大多数为结节性甲状腺肿,提示为单发结节的应结合其它检查进一步鉴别,确诊有待病理学检查.B超提示为甲状腺实质性占位则要考虑恶性肿瘤的可能.     

TSH水平与甲状腺乳头状微小癌之间的关系探讨

目的探讨促甲状腺激素(TSH)与甲状腺乳头状微小癌之间的关系。方法回顾性分析2006年1月至2016年2月手术治疗的341例甲状腺结节患者,根据病理结果分为两组:甲状腺乳头状微小癌组104例,良性甲状腺结节组237例,收集并比较各组临床实验资料。数据分析采用SPSS 19.0统计软件,计量资料采用(x珋±s)表示,患者在年龄、结节直径、TSH浓度、淋巴结转移与TSH关系比较使用t检验;甲状腺乳头状微小癌发生率与TSH的关系采用χ2趋势检验,以P0.05表示差异具有统计学意义。结果甲状腺乳头状微小癌组患者结节直径平均为(1.92±1.13)cm,低于良性甲状腺结节组患者的(2.82±1.44)cm(t=-5.654,P0.05);甲状腺乳头状微小癌组患者TSH平均为(3.01±1.51)μIU/ml,高于良性甲状腺结节组患者的(1.90±1.32)μIU/ml(t=6.836,P0.05),差异均有统计学意义;按照TSH水平分为0.34μIU/ml、0.34~1.00μIU/ml、1.01~2.00μIU/ml、2.01~5.60μIU/ml和5.60μIU/ml,甲状腺乳头状微小癌组发生比例分别为11.76%、14.29%、23.94%、39.06%和53.33%,检验结果显示TSH水平越高其甲状腺乳头状微小癌的发生率越高(χ2=28.783,P0.05);甲状腺乳头状微小癌伴淋巴结转移患者TSH为(5.07±1.31)μIU/ml、明显高于无淋巴结转移患者的(2.83±1.55)μIU/ml,差异比较有统计学意义(t=5.844,P0.05)。结论 TSH可作为预测甲状腺乳头状微小癌风险的指标之一,可为临床诊断提供参考依据。     

三种术式治疗甲状腺癌的疗效比较

目的探讨乳晕入路腹腔镜、小切口腹腔镜与开放手术治疗甲状腺癌的疗效及免疫水平改善情况。 方法选取138例甲状腺癌患者,随机分为A、B、C三组,各46例,分别给予乳晕入路腹腔镜手术、小切口腹腔镜手术及开放手术。三组数据的分析应用统计学软件SPSS22.0完成。手术相关指标、免疫功能指标用( ±s)表示,三样本的比较采用单因素方差分析,两样本的比较采用独立t检验;临床治疗总有效率和术后并发症分析采用四格表χ²检验;P<0.05为差异有统计学意义。 结果A组手术时间,长于B组及C组(均P<0.05),A组术中出血量、术后引流量均高于B组、低于C组(均P<0.05);A组、B组住院时间均短于C组(P<0.05)。A、B、C三组患者的总有效率分别为95.7%,90.9%,76.1%,A组及B组总有效率均高于C组(P<0.05)。A、B、C三组患者并发症发生率分别为6.5%、8.7%、32.6%(P<0.05),其中A、B两组并发症发生率均低于C组,差异均有统计学意义(均P<0.05)。术后A组及B患者的NK细胞水平均低于C组(P<0.05),A组及B组患者的CD3^＋、CD4^＋水平均高于C组(P<0.05),即A组患者经手术创伤应激导致的免疫抑制作用最小。 结论乳晕入路腹腔镜、小切口腹腔镜均具有良好的手术效果,二者术后并发症发生率均较低,小切口腹腔镜的手术时间、术中出血量及术中引流量等方面均优于乳晕入路腹腔镜,但是乳晕入路腹腔镜对患者的免疫抑制作用较小,二者手术效果均优于开放手术,值得推广应用。