止血夹预防早期胃癌内镜黏膜下剥离术后迟发性出血的疗效分析

目的评价止血夹预防早期胃癌内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)后出血的疗效。方法回顾性收集2013年6月—2020年8月就诊于北京友谊医院确诊为早期胃癌行ESD患者资料459例, 将其分为病变切除后使用止血夹预防性夹闭创面的A组162例、病变切除后未使用止血夹夹闭创面的B组297例, 观察术后2周患者是否发生出血。对患者进行单因素及亚组分析, 分析每组患者的术后出血发生率及临床病理特征。结果 A组术后出血发生率3.1%(5/162), B组术后出血发生率8.1%(24/297), 差异有统计学意义(χ2=4.418, P=0.036)。A组与B组进行亚组比较, 肿瘤长径>20 mm时, 两组术后出血率差异有统计学意义[3.5%(2/57)比15.3%(13/85), χ2=5.016, P=0.025];肿瘤位于胃下部时, 两组术后出血率差异有统计学意义[1.0%(1/97)比10.4%(20/192), χ2=8.425, P=0.004];肿瘤浸润深度为M/SM1时, 两组术后出血率差异有统计学意义[3.2%(5/15...     

青海地区结直肠小息肉内镜下冷切割疗效临床研究

目的　探讨结直肠小息肉应用冷切割,以及预防性使用止血夹治疗的安全性及有效性。方法　选择2021年1月至2022年3月青海省人民医院符合纳排标准的260例结肠小息肉患者,分层随机分为冷圈套切除术（cold snare polypectomy,CSP）治疗的CSP组、CSP+预防性使用止血夹治疗的CSP+止血夹组、热圈套切除术（hot snare polypectomy,HSP）治疗的HSP组及HSP+预防性使用止血夹治疗的HSP+止血夹组,每组各65例。比较治疗情况、出血发生率及其他并发症发生率。结果　患者基本特征和息肉病变特征4组间差异无统计学意义（P>0.05）。4组出现的并发症,术中即时出血发生率［5例（7.69%）、4例（6.15%）、3例（4.62%）、3例（4.62%）］,以及术后迟发性出血发生率［0例（0.00%）、0例（0.00%）、1例（1.54%）、0例（0.00%）］,4组间差异均无统计学意义（χ2=0.778,P=0.855;χ2=3.012,P=0.390）;术后腹痛发生率,HSP组［7例（10.77%）］最高,与CSP组［1例（1.54%）］及CSP+止血夹组［1例（1.54%）］相比差异有统计学意义（P<0.05）。单个息肉治疗时间,CSP组最短［（2.18±1.07）min］,HSP组次之［（2.83±0.82）min］,CSP组+止血夹组再次之［（3.15±1.16）min］,HSP组+止血夹组用时最长［（4.88±1.85）min］,4组间差异有统计学意义（F=50.397,P<0.001）。结论　推荐使用冷切割治疗结直肠小息肉,如术中判断无出血及穿孔风险,无须预防性使用止血夹。     

内镜黏膜下剥离术治疗≥20 mm结直肠肿瘤的临床结局分析

目的 探讨大的结直肠肿瘤经内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗的结局,并分析影响ESD疗效的因素。方法 从2016年11月—2019年12月在北京医院消化内科行ESD治疗的结肠肿瘤患者中,筛选出病变长径≥20 mm、活检病理为结直肠腺瘤或腺癌的患者共82例,收集分析患者的临床特点、ESD及病理结果等资料。结果 82例患者病变均为单发,病变长径（29.72±10.74）mm,分为侧向发育型肿瘤（laterally spreading tumors,LST）组46例,主要位于升结肠及回盲部（47.8%,22/46）;腔内突出型肿瘤组36例,病变均位于左半结肠,其中约一半位于乙状结肠（52.8%,19/36）。总体的整块切除率81.7%(67/82),治愈性切除率72.0%(59/82),出血和穿孔的发生率分别为2.4%(2/82)和1.2%(1/82)。LST-G、LST-NG、腔内突出型肿瘤3组的治愈性切除率[91.4%(32/35)、63.6%(7/11)、55.6%(20/36),P=0.003]和外科手术率[8.6%(3/35)、18.2%(2/11)和36.1%(13/36),P=0.010]差异均有统计学意义。多因素回归分析结果显示,病变形态为腔内突出型肿瘤(OR=3.396,95%CI：1.014～11.374,P=0.047)和黏膜下层重度纤维化（F2型）(OR=5.508,95%CI：2.216～13.692,P=0.001)是长径≥20 mm结直肠肿瘤ESD非治愈性切除的独立危险因素。结论 ESD治疗长径≥20 mm的结直肠肿瘤总体有效、安全,但不同类型病变的黏膜下侵犯比例和治疗结局存在一定差异,腔内突出型肿瘤和严重的黏膜下层纤维化是造成非治愈性切除的危险因素。     

消化道早期癌内镜黏膜下剥离术后出血的危险因素分析

目的 探讨内镜黏膜下剥离术（ESD）治疗消化道早癌并发出血的独立危险因素。方法 2008年6月至2015年2月福建省立医院消化内镜中心,及2015年5月至2018年4月福建省立医院南院消化内镜中心,行ESD治疗的430例消化道早癌（449处病灶）,按术后出血情况分为出血组和未出血组,分析患者一般情况、内镜治疗情况及术后病理结果等因素与ESD术后出血的关系。结果 430例消化道早癌（449处病灶）行ESD治疗,16例（3.7%）发生术后出血。按是否发生术后出血分成出血组（n=16）和未出血组（n=433）后,单因素分析结果提示,患者年龄（t=0.465,P=0.642）、性别构成（χ2=0.035,P=0.642）、是否有糖尿病（χ2=0.647,P=0.421）、是否有冠心病（P=1.000）、病灶大小（t=1.598,P=0.111）、是否≥2个病灶（P=1.000）、病变部位（χ2=6.183,P=0.289）、操作时间（t=1.335,P=0.201）、病理分级（χ2=0.687,P=0.709）、病变浸润深度（χ2=0.134,P=0.714）2组间差异均无统计学意义,是否有高血压病2组间差异有统计学意义（χ2=4.793,P=0.029）。Logistic回归分析结果显示,有高血压病是ESD术后出血的独立危险因素（OR=3.358,95%CI：1.227～9.186,P=0.018）。结论 高血压与消化道早癌ESD术后出血密切相关,伴有高血压者ESD术后出血风险大。     

早期胃癌内镜黏膜下剥离术非治愈性切除的后续治疗策略分析

目的　评价早期胃癌内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）非治愈性切除后追加外科手术的临床意义。方法　2014年1月—2020年12月,在华中科技大学同济医学院附属协和医院行ESD治疗,术后病理结果为非治愈性切除的69例早期胃癌病例纳入回顾性观察,依据真实世界里后续是否追加外科手术分为追加手术组（n=12）和随访组（n=57）。主要观察临床和病理资料的组间差异,追加手术组的外科手术情况,2组三年无复发和肿瘤特异性生存率,影响随访组三年无复发生存率的独立危险因素。结果　与随访组比较,追加手术组的黏膜下层浸润率［66.7%（8/12）比21.1%（12/57）,χ2=7.927,P=0.005］、脉管侵犯率［33.3%（4/12）比1.8%（1/57）,P=0.003］和神经侵犯率［16.7%（2/12）比0.0%（0/57）,P=0.028］更高。追加手术组追加外科手术距ESD手术的间隔时间为18.5 d（7～55 d）,外科手术用时（286.4±85.9）min,清扫淋巴结（25.6±7.4）枚,4例（33.3%）有肿瘤残留,4例（33.3%）发生术后并发症（均经保守治疗好转后出院）,无围手术期死亡病例;有1例于外科手术后17个月发生肝转移,手术后22个月因胃癌肝转移死亡,1例外科手术后22个月因非肿瘤原因死亡,三年无复发生存率和三年肿瘤特异性生存率分别为91.7%（11/12）和91.7%（11/12）。随访组三年无复发生存率和三年肿瘤特异性生存率分别为87.7%（50/57）和100.0%（57/57）。多因素Cox回归分析显示肿瘤长径≥2 cm是影响随访组患者三年无复发生存率的独立危险因素（P=0.037,HR=15.595,95%CI：1.181～205.952）。结论　对于ESD非治愈性切除的早期胃癌患者,追加外科手术或密切随访均是安全可行的后续治疗策略,临床医师应根据患者的内镜手术病理结果,结合患者的身体状况和手术意愿进行合理选择;而对于原发肿瘤长径≥2 cm者,建议积极追加外科手术治疗。     

胃部病变内镜黏膜下剥离术后出血危险因素分析

[目的]探讨内镜黏膜下剥离术(ESD)治疗胃部病变术后出血的危险因素。[方法]收集行胃ESD治疗的899例患者的临床资料,对病例的年龄、性别、病变直径、病变位置、手术持续时间、创面处理方式等进行单因素及多因素分析,总结术后出血的危险因素及发病时间规律,为术前及术中评估出血风险提供参考。[结果]899例患者中,20例(2.22%)出现术后出血,其中90%发生在术后5 d内。单因素χ²分析结果显示,男性的出血发生率高于女性,病变直径≥3 cm的出血发生率高于病变直径<3 cm的患者,不同病变位置及创面处理方式的出血发生率存在差异(P<0.05)。多因素Logistic回归分析结果显示,未使用止血夹(P=0.008,OR=4.487,95%CI:1.478～13.620)、病变直径≥3 cm(P=0.008,OR=3.376,95%CI:1.371～8.313)是胃ESD后出血的独立危险因素。[结论]未使用止血夹、病变直径≥3 cm的患者,胃部病变ESD后出血的发生率较高,术后5 d是发生出血的危险期。     

内镜黏膜下剥离术治疗老年早期胃癌的初步评价

目的探讨内镜黏膜下剥离术（ESD）治疗老年早期胃癌的疗效和安全性。方法按照入选标准对于年龄≥60岁的早期胃癌患者进行ESD治疗,观察疗效及术中并发症情况,术后予禁食、抑酸补液治疗,并定期随访评价病灶有无残留和复发。结果共有55例患者入组,男性44例,女性11例。完整大块切除率100％,组织学完全切除率为92．7％（51／55）。术中少量出血率16．4％,贲门胃底部发生率（5／13,35．5％）高于其他部位（P=0．02）。穿孔发生率（1／55,1．8％）,位于胃角,予金属夹夹闭。术后迟发出血3例（3／55,5．5％）,其中2例病变位于胃窦,24h内发生,均经急诊胃镜下治疗成功止血,1例胃角,术后1周发生,1月反复,内科保守治疗有效。总随访时间2月-38月,中位随访时间7月,共随访51例,失访率7．2％,无病灶残留,1例患者于ESD治疗后8月随访时发现复发,转外科行手术治疗。结论ESD是治疗老年早期胃癌的一种有效且安拿的治疗方法。     

内镜黏膜下剥离术与内镜黏膜切除术治疗早期胃癌患者的疗效比较

[目的]探究内镜黏膜下剥离术(ESD)与内镜黏膜切除术(EMR)治疗早期胃癌患者的疗效。[方法]选取2014-02—2016-12我院收治的186例早期胃癌患者,根据治疗方法的不同分为ESD组和EMR组,ESD组采用ESD进行治疗,EMR组采用EMR进行治疗,观察比较2组患者手术时间、住院时间及术中出血、穿孔的发生情况,并对2组患者进行病理组织学疗效评价。[结果]2组患者手术时间及住院时间比较差异无统计学意义。ESD组中有5例发生术中出血,2例发生穿孔;EMR组中有17例发生术中出血,9例发生穿孔。2组患者术中出血、穿孔发生情况比较差异均有统计学意义(χ2=6.853、4.422,P<0.05)。ESD组可能治愈性切除率、非治愈性切除率、肿瘤复发率低于EMR组(χ2=10.225、11.976、10.123,P<0.05),但ESD组一次性完全切除率、治愈性切除率高于EMR组(χ2=22.763、27.991,P<0.05),说明采用ESD治疗早期胃癌更彻底,2组病理组织学疗效评价比较差异均有统计学意义。[结论]采用ESD能有效降低早期胃癌患者术中出血及穿孔的发生情况,病灶切除彻底,肿瘤复发率低,值得在临床上进一步推广。     

两种黏膜切开刀在食管病变内镜黏膜下剥离术中的有效性及安全性比较

目的比较单极内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)电刀（简称T刀）与Dual刀在ESD治疗食管病变中的有效性及安全性。方法纳入2018年6月—2019年1月期间就诊于苏州大学附属第一医院、诊断为食管病变且行ESD治疗的59例患者,采用随机数字表法分为Dual刀组（30例）及T刀组（29例）。比较两组操作时间、切除速度、完全切除率以及并发症发生率等情况。结果T刀组与Dual刀组患者在性别、年龄、合并症等方面差异均无统计学意义（P>0.05）。T刀组、Dual刀组的手术时间分别为（57.86±24.62）min和（66.28±29.48）min,差异有统计学意义（t=1.189,P=0.024）;切除速度分别为（22.80±7.31）mm2/min和（16.20±7.24）mm2/min,差异有统计学意义（t=3.484,P=0.001）;病灶完全切除率分别为86.2%（25/29）和86.7%（26/30）,差异无统计学意义（χ2=0.108,P=0.742）。T刀组出现并发症2例（6.9%）,Dual刀组并发症共5例（16.7%）,两组并发症发生率比较差异无统计学意义（χ2=0.574,P=0.449）。两组均未见术后穿孔、出血情况。结论在食管病变ESD中,T刀相较于Dual刀能缩短手术时间,提高切除速度,安全性、有效性具有一定优势。     

钛夹联合尼龙绳牵引辅助技术在内镜黏膜下剥离术治疗早期胃角癌中的临床研究

目的 评估钛夹联合尼龙绳牵引辅助下内镜黏膜下剥离术（ESD）治疗早期胃角癌及癌前病变的应用价值及安全性。方法 以2018年1—12月在杭州市第一人民医院行ESD治疗的59例早期胃角癌及癌前病变患者为研究对象,采用随机数字表法随机分入常规ESD组（对照组,n=28）和钛夹联合尼龙绳牵引组（试验组,n=31）。比较两组患者的黏膜下补充注射次数、ESD手术时间、病灶面积、黏膜剥离时间、单位时间切除率、病灶完整切除率以及手术并发症等情况。结果 试验组黏膜下补充注射次数少于对照组[（2.3±1.1）次比（3.7±1.4）次,t=4.557,P＜0.001];试验组的病灶面积和对照组相比差异无统计学意义 [（12.7±2.6）cm2比（11.7±2.7）cm2,t=1.485,P=0.143];试验组ESD手术时间[（72.4±24.7）min比（93.6±28.9）min,t=3.043,P=0.004]和黏膜剥离时间[（67.7±23.3）min比（88.2±28.3）min,t=3.054,P=0.003]短于对照组,单位时间切除率高于对照组[（20.2±3.2）mm2/min比（14.3±3.4）mm2/min,t=6.879,P＜0.001]。两组患者的一次性完整切除率均为100.0%。两组患者均未出现穿孔及术后出血等,试验组术中出血率低于对照组[19.4%（6/31）比35.7%（10/28）, χ2=1.992,P=0.158]。结论 使用钛夹联合尼龙绳牵引辅助技术可降低胃角ESD的技术难度、缩短操作时间、降低术中出血可能,具有较好的应用价值。     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Changes in connexin43, the gap junction protein of astrocytes, during development of the rat pineal gland

Abstract: The abundance of gap junctions between rat pineal astrocytes formed by connexin43 (Cx43) was studied during development. Levels and distribution of Cx43 were measured by immunoblotting and indirect immunofluorescence, respectively. The amount of Cx43 in cells located within the gland was low until about the 7th postnatal day and increased to adult values between the 14th and 21st days postpartum. Although astrocytes, recognized by their vimentin immunoreactivity, were scarce before birth, they were abundant by the 7th postnatal day suggesting that the low levels of Cx43 found at this age corresponded to a low expression of this protein. Localization of the immunoreactivity to Cx43 and vimentin showed a close correlation, indicating that mature or immature pineal astrocytes form gap junctions made of Cx43. Since Cx43 levels attained their adult values at about the time the innervation and the functional state of the gland reached maturity (2–3 weeks after birth), it is proposed that astrocyte gap junctions are involved in the function of the adult rat pineal gland.     

Conservative management of perforated duodenal diverticulum： A case report and review of the literature

Duodenal diverticula are a relatively common condition. They are asymptomatic, unless they become complicated, with perforation being the rarest but most severe complication. Surgical treatment is the most frequently performed approach. We report the case of a patient with a perforated duodenal diverticulum, which was diagnosed early and treated conservatively with antibiotics and percutaneous drainage of secondary retroperitoneal abscesses. We suggest this method could be an acceptable option for the management of similar cases, provided that the patient is in good general condition and without septic signs.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.     

Presence of immunoreactive growth hormone and prolactin in the ovine pineal gland

Abstract: The use of antisera raised against bovine growth hormone (GH) and ovine prolactin (PRL) enabled the detection of related immunoreactive (ir) sequences of proteins in ovine pineal tissue. The isolation of PRL-like ir-material was accomplished using a 0.25 M ammonium sulphate (pH 5.5) extraction followed by ethanol precipitation, whereas the resulting 2.0 M ammonium sulphate (pH 7.0) precipitate contained a GH-like immunoreactivity. Gel chromatography of the GH-like immunoreactivity (Sephadex G-100) indicated the presence of several GH-like fragments ranging in the M_r range of 7,000 to 55,000. Analyses of the PRL-like ir-material found in pineal tissue on HPLC using a TSK 545-DEAE column led to the resolution into a single peak of immunoreactivity. A single peak of activity was also observed following chromatofocusing and hydrophobic interaction chromatography of the ir-peak from the TSK 545-DEAE column. The PRL-like ir-material inhibited the binding of [¹²⁵I]ovine PRL-S14 to anti-ovine PRL antibodies without showing an affinity for binding to anti-rat PRL or anti-bovine GH antibodies. Scatchard analysis of the binding of pineal PRL-like ir-material and pituitary ovine PRL-S14 to liver membranes from day-20 pregnant rats revealed similar affinity constants (K_a of 4.7 ± 0.2 × 10⁹ M^-1). In addition, the replication of Nb 2 Node rat lymphoma cells was stimulated by pineal PRL-like ir-material, an effect known to be specific for lactogenic hormones. The pineal PRL-like immunoreactivity appeared on sodium dodecyl sulfate polyacrylamide gels as a single major band of M_r 24,000. The functional status of PRL-and GH-like ir-material in the ovine pineal remains to be determined, but evidence is presented that the overall protein synthesis rate of the rat pineal responded to circulating concentrations of PRL.     

Microbiology of human immunodeficiency virus anorectal disease

PURPOSE: Individuals who are seropositive for the human immunodeficiency virus are at high risk for opportunistic infection and anorectal disorders. Little prospective information is available regarding anorectal pathogens in these patients. METHODS: One hundred sixty-three HIV-seropositive patients presented to the colorectal clinic between 1989 and 1992. Forty-seven (29 percent) patients were thought to have an infectious process and were prospectively studied using a standardized multiculture protocol. RESULTS: Mean age was 33 (range, 19–59) years. All were male; high-risk behavior accounted for 87 percent of HIV transmissions. Presenting complaints included anorectal pain (79 percent), pus per anum (28 percent), and blood per anum (26 percent). Examination revealed perianal tenderness (60 percent), condyloma (38 percent), perianal ulcers (38 percent), and anal fissures (34 percent). Sixty-six sets of cultures were performed; 28 patients had one set, 15 had two sets, and 4 had three sets. Thirty-two of these 47 patients (68 percent) had positive cultures including herpes (50 percent), cytomegalovirus (25 percent),Neisseria gonorrhoeae (16 percent), chlamydia (16 percent), acidfast bacilli (2 percent), and others (9 percent). Six of 32 patients with positive cultures had more than one organism cultured. Sixteen (50 percent) patients with positive cultures were treated medically, 8 (25 percent) were treated surgically and 8 (25 percent) were treated with both modalities. Sixty-one procedures were performed on 17 patients for condylomata. Eighteen patients had 20 procedures for abscesses, 50 percent of whom had positive cultures for other than common bowel flora; all improved. Fourteen patients underwent 33 procedures for perianal fistulas.Mycobacterium fortuitum was cultured from one patient who required 13 procedures for abscesses and fistulas. Forty-five (96 percent) patients were followed for an average of 12.5 months ±2.9 SEM (range, 1–94 months). Symptoms were improved or resolved in 22 of 32 (69 percent) patients with positive cultures and in 11 of 13 (84 percent) with negative cultures. CONCLUSIONS: Specific pathogens may often be identified in human immunodeficiency virus-seropositive patients with anorectal disorders if aggressively sought. Although patients without specific pathogens identified may be expected to improve with planned empiric treatment, positive identification allows more directed therapy.