肝细胞癌TACE术后严重并发症分析

目的 评价经导管肝动脉化疗栓塞术(TACE)治疗肝细胞癌(HCC)的严重并发症。方法回顾分析556例原发性肝癌患者1000次TACE术后出现的近期严重并发症。结果本组TACE包括上消化道大出血3次(0．3％)，肝功能衰竭26例(2.6％)，碘油肺栓塞5例(0．5％)，碘油脑栓塞2例(0．2％)及肝脓肿2例(0．2％)。结论肝癌TACE术后严重并发症直接影响到病人的预后，应重视并预防其发生，给予适当处理。     

脊柱手术后并发肺栓塞11例临床分析

目的分析脊柱手术后并发肺栓塞的临床特点,探讨早期诊断、治疗方法。方法1995年1月至2006年5月,在我院接受脊柱手术患者10993例,其中术后出现肺栓塞患者11例。回顾性分析该11例患者的临床特点及诊断、治疗方式。结果脊柱术后肺栓塞占同期我院脊柱手术总数的0．1％;出现肺栓塞的时间为术后5～14d（平均9．8d）,患者可见呼吸困难、心悸、胸痛、咯血等特征性肺栓塞症状;本组死亡5例,死亡率45．5％。早期使用肺动脉造影明确诊断、早期经肺动脉导管介入治疗可以显著降低死亡率。结论肺栓塞是脊柱手术后的严重并发症,术后1～2周是致死性肺栓塞的高危时段,死亡率高;肺动脉造影与介入治疗在早期诊断、治疗中占有重要地位。     

肝动脉化疗栓塞对原发性肝癌患者术后生存及肿瘤复发的影响

目的探讨原发性肝癌患者手术后肝动脉化疗栓塞（TACE）对肿瘤复发率及患者术后生存率的影响，为原发性肝癌的临床综合治疗提供指导。方法原发性肝癌患者手术后行TACE治疗22例（手术＋TACE组）、仅行手术切除而不行TACE治疗患者20例（单纯手术组），对两组患者术后肿瘤复发率及患者生存率进行比较。结果手术＋TACE组与单纯手术组比较，前者肿瘤1年复发率显著低于后者（P〈0．05），但两组2年复发率差异无显著性（P〉0．05）。手术＋TACE组1年及2年生存率（76．1％，48．2％）均明显高于单纯手术组（52．8％，23．6％）（P〈0．05）。结论原发性肝癌手术后结合TACE治疗，可明显降低肿瘤近期复发率且显著提高患者生存率。     

TACE治疗原发性肝癌后并发肝脓肿的影响因素

目的 观察TACE治疗原发性肝癌后并发肝脓肿的影响因素。方法 采用倾向性评分匹配法回顾性收集99例接受TACE治疗的原发性肝癌患者,其中26例TACE后并发、73例未并发肝脓肿;根据治疗方式将其分为传统TACE(cTACE)组(n=48)和药物栓塞微球TACE(DTACE)组(n=51)。比较并发肝脓肿与未并发肝脓肿患者临床资料的差异,以logistic回归分析筛选TACE治疗原发性肝癌后并发肝脓肿的影响因素。结果 TACE治疗原发性肝癌后并发与未并发肝脓肿患者之间,肿瘤供血血管数目、碘油量及栓塞剂种类差异均有统计学意义(P均<0.05)。cTACE组内并发与未并发肝脓肿患者血糖及栓塞剂种类差异有统计学意义(P均<0.05);DTACE组内并发与未并发肝脓肿患者碘油量差异有统计学意义(P<0.05)。TACE治疗原发性肝癌后并发肝脓肿的保护因素为患者年龄<55岁、无靶向药物联合免疫检查点抑制剂治疗史(靶免史)、仅栓塞1支肿瘤供血动脉、碘油量少及仅使用1种栓塞剂,TACE次数≥3则为危险因素(P均<0.05)。结论 患者年龄、靶免史、TACE次数、肿瘤供血血...     

原发性肝癌切除术后预防性TACE并发肝内胆管损伤的诊治

目的 探讨原发性肝癌切除术后预防性TACE并发肝内胆管损伤的危险因素及临床诊治方法。 方法 78例原发性肝癌切除术后预防性TACE治疗,对术后发生肝内胆管损伤的临床表现、影像学征象及导致胆管损伤的相关因素进行回顾性分析。结果 5例并发肝内胆管损伤,其中2例仅有影像学改变,无明显临床症状,3例出现黄疸、高热、上腹部胀痛等症状,采用胆汁瘤引流或经皮经肝胆道穿刺引流术（PTCD）后症状缓解。其中肝细胞性肝癌1例,肝胆管细胞性肝癌4例,2例伴有胆道手术。1例有肝硬化背景,4例无肝硬变背景。结论 原发性肝癌术后预防性TACE治疗仅限于有早期复发可能的高危患者,无肝硬变者、有胆道手术者是预防性TACE术后造成肝内胆管损伤的相关因素,胆汁瘤引流和PTCD是有效治疗方式。     

经肝动脉化疗栓塞联合无水酒精注射治疗原发性肝癌的疗效评价

目的探讨肝动脉化疗栓塞术联合无水酒精注射治疗原发性肝癌的疗效。方法61例不能手术切除的中晚期肝癌和拒绝手术的早期肝癌患者随机分为A,B两组。A组：经导管肝动脉化疗栓塞组（TACE组）,共34例;B组：肝动脉化疗栓塞联合无水酒精注射治疗组（联合治疗组）,共27例。结果TACE组的完全坏死率、肿瘤缩小率及1年死亡率分别为26．5％,61．8％和35．3％;而联合治疗组分别为92．6％,92．6％和3．7％。两组间完全坏死率、肿瘤缩小率及1年死亡率的差异皆有显著性意义（其相应P值分别为0．000,0．1305,0．004）。结论肝动脉化疗栓塞联合无水酒精注射治疗效果明显优于单纯化疗栓塞。     

部分性脾栓塞术在肝癌伴脾功能亢进治疗中的应用

目的评价部分性脾栓塞术（PSE）在原发性肝癌伴脾功能亢进介入治疗中的疗效及临床意义。方法原发性肝癌伴脾功能亢进患者12例，男10例，女2例．平均年龄51．1岁；肝功能Child－PughA级3例，B级9例；在行肝动脉插管化疗栓塞术（TACE）的同时行PSE；术后定期复查血常规和肝功能。结果本组脾栓塞面积为50％～60％，无脾脓肿等严重并发症。术后WBC和PLT显著提高（P〈0．05），并长期维持在较高水平，RBC数量和HG量无明显改变（P〉0．05）。TBIL、ALT和AST无明显变化（P〉0．05），TBA下降（P〈0．05）。结论PSE能纠正脾功能亢进，提高血WBC和PLT的数量，使原发性肝癌伴脾功能亢进患者的TACE能顺利进行，是一种安全、有效的治疗方法。     

肝动脉栓塞化疗对大肝癌根治术后复发率及生存率的影响

目的探讨肝动脉栓塞化疗对于预防原发性大肝癌根治术后复发的疗效。方法对1997年1月～2002年12月我院68例行大肝癌根治术的患者按术后是否行介入治疗分为TACE组（24例）和对照组（44例），对比分析两组患者术后1、2、3年的累积复发率和生存率。结果对68例原发性大肝癌行根治性切除后的患者，术后随访最长49个月。TACE组术后l、2、3年累积复发率分别为16．7％、34．3％、49．5％：1、2、3年的累积生存率分别为83．3％、70．2％、53．7％。对照组1、2、3年的累积复发率分别为36．4％、58．0％、68．5％：1、2、3年的累积生存率分别为63．6％、48．3％、25.3％，两组差异有显著性（P〈0．05）。结论原发性大肝癌根治术后辅以介入治疗是预防肝癌术后复发的有效手段，能显著提高远期生存率。     

原发性肝癌TACE术后早期离床活动流程构建的循证实践

目的探讨循证护理在原发性肝癌经导管肝动脉栓塞术(TACE)术后早期离床活动流程构建及应用效果。方法将拟择期行TACE术的原发性肝癌患者80例随机分为对照组与观察组,各40例。对照组实施常规护理,观察组利用循证护理构建早期离床活动流程并实施;比较两组患者下床活动时间、术后并发症及焦虑自评量表(SAS)评分。结果观察组术后离床活动时间显著提前,术后皮肤压伤、发热、腰背疼痛发生率及术后3 d SAS评分显著降低,与对照组比较差异有统计学意义(P<0.05,P<0.01)。结论循证护理有效构建了原发性肝癌患者TACE术后早期离床活动流程,缩短了下床活动时间,降低了术后压伤、发热、腰背疼痛并发症,改善了焦虑状况。     

CT、MRI和DSA评估原发性肝癌经导管肝动脉化疗栓塞术后肿瘤活性及临床预后

探讨CT、MRI和DSA用于原发性肝癌经导管肝动脉化疗栓塞术(TACE)后肿瘤活性及临床预后评估的价值。2016年5月—2018年10月,40例原发性肝癌患者均行经TACE治疗,术后3～6月行CT、MRI和数字减影血管造影(DSA)检查,并以DSA检查作为标准,评价原发性肝癌TACE术后CT和MRI对病灶残余或复发的检出率、肿瘤包膜检出率以及对不同碘油沉积类型的肝癌患者病灶残余或复发的检出率。结果显示,40例原发性肝癌患者TACE后经DSA发现病灶62个,其中44个为术后残余或复发,另外18个为术后无残余或复发。MRI检查的准确性93.6%,敏感性90.9%,特异性100%。CT检查准确性80.7%,敏感性72.7%,特异性100%。MRI检查对不同碘油沉积类型的原发性肝癌患者TACE术后病灶残余或复发检出率均高于CT检查(P0.05)。结果表明,对原发性肝癌TACE患者,MRI检查诊断价值优于CT检查,MRI为无创检查,可反复用于评估原发性肝癌TACE术后肿瘤活性及临床预后。     

经导管动脉化疗栓塞术治疗肝细胞癌 致碘化油肺、脑栓塞

目的探讨和分析经导管动脉化疗栓塞术（TACE）治疗肝细胞癌（HCC）中发生碘化油肺、脑栓塞的原因和机制,寻找相应的预防和治疗措施。方法通过回顾采用TACE治疗3例HCC发生碘化油肺、脑栓塞及复习相关文献,分析TACE治疗HCC中发生碘化油肺、脑栓塞的原因、机制、预防和治疗措施。结果3例均为巨块型HCC患者,1例为71岁女性,在接受第3次TACE时发生碘化油脑栓塞,经积极治疗后意识仍不清楚成为植物状态,1年后死亡。余2例患者均为老年男性患者,分别在接受第2、3次TACE时发生碘化油肺和脑栓塞,出现急性呼吸困难和意识丧失,经抢救治疗后好转。文献报道碘化油脑栓塞12例患者中,6例经膈下动脉进行TACE治疗。结论TACE治疗HCC术中碘化油脑和肺栓塞是罕见而又极其严重的并发症,发生的原因和机制为栓塞肋间动脉和（或）膈下动脉、碘化油用量较大和潜在的微小瘘口开放,应以预防为主,一旦发生应积极抢救治疗。     

肝移植后肺部感染的因素分析及防治

目的探讨引起肝脏移植后肺部感染的常见因素及其防治策略,为肝移植后肺部感染治疗的进一步研究提供临床参考意见。方法采用回顾性分析方法,分析我院2000年1月至2009年12月67例肝移植受者肺部感染的发生率、病死率、易感因素及防治措施等。结果 67例肝移植受者9例发生肺部感染,感染率13.4%,1例死亡,病死率11.1%,移植前后有多种因素与术后肺部感染有关。结论肝移植术后肺部感染率、病死率较高,合理预防、早期诊断和及时处理,对于提高肝移植效果至关重要。肝移植临床医生应根据本地区、本单位致病微生物流行病学特点及实际医疗条件结合每个患者的具体情况,及时修正诊断与治疗,制定合理的预防与治疗方案。     

Pulmonary embolism. Modern concepts

Pulmonary embolism is a common disorder and an important cause of morbidity and mortality. Since genetic predisposition appears to explain only about one fifth of cases, identification of other risk factors is critical. Pulmonary embolism ranges from incidental, clinically unimportant thromboembolism to massive embolism with sudden death. The initial diagnostic approach in patients with suspected pulmonary embolism commonly involves transesophageal echocardiography and ventilation-perfusion scanning. In patients with indeterminate findings on these exams, thoracic spiral computed tomography, magnetic resonance imaging and magnetic resonance angiography have shown promise. Pulmonary angiography is becoming less used because it is invasive and expensive. Unfractioned heparin is considered the treatment of choice for most patients with pulmonary embolism, except those with hemodynamic instability, who may need thrombolytic therapy. There is limited information on the efficacy and safety of low-molecular-weight heparin for the initial treatment of symptomatic pulmonary embolism. An up to date review of the international literature focused in the epidemiology, pathophysiology, diagnosis, potential treatment and prognosis is presented.     

肾移植术后肺部感染28例诊治分析

目的探讨同种异体肾移植术后肺部感染的诊断和治疗经验。方法回顾性分析28例同种异体肾移植术后肺部感染患者的临床资料。结果 28例患者肺部感染发病时间为术后3个月以内6例,术后4～6个月18例,术后6个月以后4例。患者均以发热起病,早期呼吸道症状轻微,未经治疗者易发展为重症肺炎。肺部体征早期多不明显,X线胸片表现常滞后,胸部CT或磁共振成像有助于早期诊断。肾移植术后肺部感染以细菌、巨细胞病毒、真菌感染为主,混合感染常见。经给予联合使用抗感染药物、减少或者撤除免疫抑制剂、静脉应用肾上腺皮质激素(激素)、营养支持治疗,必要时辅以无创通气或者呼吸机辅助呼吸治疗等综合治疗,治愈22例,死亡6例(均为重症肺炎并发急性呼吸窘迫综合征患者)。结论肾移植术后肺部感染病情进展快,发展为重症肺炎病死率高,应及时予胸部CT或磁共振成像检查,同时加强病原体监测,确诊后及早予使用抗感染药物、调整免疫抑制剂剂量、应用激素、营养支持等治疗,以提高治愈率。     

Surgical treatment of pulmonary artery sarcoma

OBJECTIVE: Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delayed in most cases. Newer imaging techniques could allow early diagnosis in patients with symptoms of pulmonary vascular obstruction. Surgical resection improves clinical symptoms and offers the only chance of cure. We report the case histories of 7 patients with primary pulmonary artery sarcomas treated by surgical resection with or without adjuvant therapy. METHODS: Seven patients (3 women and 4 men; mean age, 52.3 years; preoperative New York Heart Association functional class III/IV, n = 5/2) underwent operations. Malignancy was preoperatively suspected in 5 patients, and 2 patients had a presumptive diagnosis of chronic pulmonary embolism. Tumor resection with partial or total prosthetic replacement (n = 2), reconstruction (n = 5), or both, of central parts of the pulmonary arteries was performed in 6 patients. Thromboendarterectomy was necessary in 4 patients, and pneumonectomy was necessary in 2 patients. Six patients received adjuvant therapy. RESULTS: There was no perioperative mortality. All patients had a substantial improvement in exercise tolerance and hemodynamics 3 months after their operations. Four patients died 7, 9, 18, and 19 months after their operations because of recurrent tumor or pulmonary metastases. Two patients are alive 21 and 35 months after primary surgical repair, with pulmonary metastases detected by computed tomographic scans. One patient is alive 62 months after resection without clinical or radiologic signs of tumor recurrence or metastasis. CONCLUSIONS: Early diagnosis of primary pulmonary artery sarcomas can be improved by computed tomography and magnetic resonance scanning. Radical surgical resection probably presents the only chance for cure. The role of neoadjuvant or adjuvant treatment modalities has to be defined. Pulmonary artery sarcoma need not necessarily be a fatal diagnosis.     

肺动脉栓塞54例临床分析

为提高肺动脉栓塞的诊断和治疗水平，回顾性分析了５４例肺动脉栓塞病例。重点分析常见病因、症状、体征及实验室检查结果。本组５４例病死率为３７％，深静脉血栓形成是肺动脉栓塞发生的主要原因，其发生率为５５％，细菌性心内膜炎、手术、外伤、肿瘤、活动量减少是常见诱因。结论：放射性核素肺灌注和通气扫描相结合具有很高的诊断价值，应做为必查项目；及时诊断和治疗可显著降低病死率和病残率。     

Pulmonary emboli: the differential diagnosis dilemma

Pulmonary embolism is a rare but serious medical condition, with an estimated mortality of 5% to 20%. Many patients receiving physical therapy may be at risk for developing pulmonary embolism, especially after periods of immobilization or surgery. Patients presenting with dyspnea, chest pain, or tachypnea, particularly after trauma or surgery, have an increased likelihood of pulmonary embolism. Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism.     

Pulmonary embolism in neurosurgical patients: diagnosis and treatment

Pulmonary embolism was suspected in 45 neurosurgical patients who were treated between January, 1980, and December, 1981. Hypoxemia with respiratory alkalosis and sudden tachycardia gave rise to this suspicion more often than any other sign or symptom. Perfusion lung scanning confirmed the presence of pulmonary embolism in 23 of these cases. A retrospective analysis of the clinical course of these 23 patients suggested that one or more previous episodes of pulmonary embolism had occurred in 16 cases (69.6%), and had been either overlooked or misdiagnosed. Treatment was started immediately after diagnosis. Twenty-one patients were given heparin; however, two could not be treated because of contraindication to using anticoagulant drugs. Two patients died during treatment. The 21 surviving patients were assessed and 11 of them submitted again to perfusion lung scanning 1 week after diagnosis: 14 had improved, but seven did not show significant changes either clinically or on perfusion lung scanning. Nine treated patients developed hemorrhage, but it was readily controlled. In two of the nine patients, hemorrhage involved the surgical area. It is stressed that pulmonary embolism may be suspected and diagnosed in neurosurgical patients at an early stage. Heparin may be given and the survival rate appears to be better than previously reported figures.     

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??Diagnosis and treatment of pulmonary embolism after surgical operation: an analysis of 13 cases YANG Ren*??WANG Qiang??FENG-Yong??et al. *Department of General Surgery, Shengjing Hospital Affiliated to China Medical University??Shenyang 110004??China
Corresponding author ??FENG Yong??E-mail:Feny@sj-hospital.org
Abstract Objective To study the diagnosis, treatment and prevention of postoperative pulmonary embolism and reduce the incidence. Methods The diagnosis and treatment procedures of 13 patients with postoperative pulmonary embolism admitted between October 2006 and September 2010 in the Department of General Surgery of Shengjing Hospital Affiliated to China Medical University were analyzed. Some experiences of preventing pulmonary embolism by using low molecular heparin were explored. Results Ten of 13 pulmonary embolism patients were diagnosed and 3 patients were misdiagnosed. Ten patients survived and 3 patients died. There was no pulmonary embolism happened in patients who were evaluated middle or more risk because of using low molecular heparin after August 2009. Conclusion Pulmonary embolism after operation should be valued. Early diagnosis and treatment are the keys for suspicious patients. Evaluating risk before operation and using low molecular heparin after operation are necessary to prevent pulmonary embolism.