腹腔镜食管裂孔疝修补胃底折叠术临床分析

目的探讨腹腔镜食管裂孔疝修补胃底折叠术的安全性和疗效。方法对我院27例食管裂孔疝患者施行腹腔镜食管裂孔疝修补术。同时行胃底折叠术，其中18例行Nissen胃底折叠术，9例行Toupet胃底折叠术。结果27例腹腔镜食管裂孔疝修补术全部获得成功，临床症状消失或减轻，术后无并发症。结论应用腹腔镜治疗食管裂孔疗效确切，具有较大的临床实用价值，     

腹腔镜食管裂孔疝修补术联合不同抗反流术式治疗食管裂孔疝合并胃食管反流病的临床比较

目的探讨并比较腹腔镜食管裂孔疝修补术联合不同抗反流术式治疗食管裂孔疝(HH)合并胃食管反流病(GERD)的效果。方法回顾性分析该院2014年1月-2017年1月行腹腔镜食管裂孔疝修补术联合抗反流术治疗的HH合并GERD患者67例的病例资料。根据抗反流术式的方法分为3组,其中29例采用腹腔镜Nissen胃底折叠术(Nissen组),18例行腹腔镜Toupet胃底折叠术(Toupet组),20例行腹腔镜Dor胃底折叠术(Dor组)。比较3组手术情况及术后恢复情况,术后随访1年,观察手术前后胃镜、高分辨率食管测压及24 h食管pH监测结果,发放GERD-Q症状评分评估患者GERD症状,使用GERD相关生命质量量表(GERD-HROL),记录两组术后并发症发生率、手术失效率及复发率。结果 3组患者手术情况、术后恢复情况及术后第1年胃镜检查情况比较,差异均无统计学意义(P0.05);Toupet组术后1年食管下括约肌(LES)静息呼吸平均值低于Nissen组和Dor组,反流时间、反流次数、无效吞咽高于Nissen组和Dor组,差异均有统计学意义(P 0.05),但Nissen组和Dor组比较,差异无统计学意义(P0.05),3组术后1年LES静息压最小值、24 h pH阻抗监测、DeMeester评分、GERD-Q症状评分和GERD-HROL量表评分比较,差异均无统计学意义(P0.05);3组患者术后并发症发生率、手术无效率及复发率比较,差异均无统计学意义(P0.05)。结论腹腔镜食管裂孔疝修补术联合3种胃底折叠术治疗HH合并GERD均可起到抗反流的效果,但Nissen和Dor手术在改善LES静息呼吸压力值、反流和无效吞咽方面的效果优于Toupet手术。     

腹腔镜胃底折叠术联合胃大弯折叠术治疗肥胖合并胃食管反流的护理

[目的]探讨腹腔镜胃底折叠术联合胃大弯折叠术治疗肥胖合并胃食管反流的护理。[方法]回顾分析2014年12月—2016年12月接受腹腔镜胃底折叠术联合胃大弯折叠术治疗10例肥胖合并胃食管反流病人的临床护理资料。[结果]10例病人均顺利完成腹腔镜胃底折叠术+胃大弯折叠+食管裂孔疝修补术+肠粘连松解术,术后住院5～7d。术后10例病人均未出现严重并发症,均达到减重效果。[结论]胃底折叠术联合胃大弯折叠术是治疗肥胖合并胃食管反流病或食管裂孔疝的新手术方法,做好充分的术前准备、心理护理是保证手术顺利进行的前提;术后加强并发症的观察与护理、正确的体位、合理的饮食、药物治疗和各种管道的精心护理是保证手术疗效的重要措施。实施随访护理、体重管理是提高手术成功率、达到减重效果的关键。     

腹腔镜食管裂孔修补和胃底折叠术的临床应用(附45例报告)

目的 总结腹腔镜食管裂孔疝修补和胃底折叠术治疗胃食管反流性疾病的经验.方法 回顾性分析2000年1月以来45例腹腔镜食管裂孔疝修补和胃底折叠术的临床资料,其中男32例,女13例,平均年龄51.9岁(25～78岁);胃底折叠方法 包括Niseen术式33例、Rossetti术式10例、Toupet术式2例(含1例复发的食管裂孔疝再手术).结果 手术用时45～120min,术中失血10～100mL,无中转开腹和手术死亡病例.1例术中撕裂胸膜致气胸,1例术后出现轻度胃排空障碍,4例术后有轻度吞咽梗阻感.术后平均住院4.7 d,随访3～75个月仅1例患者胃镜提示食管炎复发.结论 腹腔镜食管裂孔疝修补和胃底折叠术治疗胃食管反流疾病是安全有效的,应根据患者的食管动力状态和解剖选择完全折叠或部分折叠术式.     

腹腔镜胃底折叠与食管扩张术治疗儿童胃食管反流病致消化性食管狭窄

目的：探讨儿童胃食管反流病(gastroesophageal reflux disease, GERD)致消化性食管狭窄(peptic esophage-al stricture, PES)的临床特点及诊治经验。方法回顾分析1例儿童食管裂孔疝、GERD 致 PES 的诊治经过。结果患儿7岁,表现为吞咽困难、胸骨后疼痛4年,伴发作性憋气3个月。胃镜和上消化道造影诊断：GERD,反流性食管炎(LA-D 级),PES,食管裂孔疝。行食管裂孔疝修补术并腹腔镜下胃底折叠术及内镜下食管扩张术治疗,随访1.5年所有症状明显缓解。结论 PES 是 GERD 引起的严重并发症,通常合并有严重的病理性酸反流、食管炎、胆汁反流、食管裂孔疝和明显的食管动力障碍。抗反流手术加食管扩张治疗可有效控制 GERD,改善 PES 引起的吞咽困难。     

腹腔镜手术治疗胃食管反流病与贲门失弛缓症

目的探索3种腹腔镜胃底折叠术治疗胃食管反流病及贲门失弛缓症行Heller肌切开后抗反流术的安全性与可行性.方法1995年12月～2005年3月对55例胃食管反流病人和6例贲门失弛缓症病人共施行腹腔镜抗反流手术61例.其中男23例、女38例,平均55岁.单纯反流性食管炎11例;滑动型食管裂孔疝伴反流性食管炎38例,旁疝型食管裂孔疝伴反流性食管炎1例,混合型食管裂孔疝伴反流性食管炎5例,贲门失弛缓症6例.术前常规行胃镜与上消化道钡餐检查者61例,加行食管测酸、测压检查者50例.腹腔镜单纯胃底折叠术11例(Nissen式1例、Toupet式10例).腹腔镜食管裂孔疝修补+胃底折叠术44例((Nissen式12例、Toupet式32例).Heller肌切开+Dor胃底折叠术6例.其中在腹腔镜下还联合实施了胆囊切除术4例,腹腔粘连松解4例,腹股沟隐性疝高位缝扎1例,食管下段血管瘤、胆囊及阑尾切除1例,胆囊及左肾切除1例,Heller-Dor术+肝血管瘤和胆囊切除1例.结果全组病人平均手术120 min(60～360min),术中平均出血15 mL(10～100mL),术后日平均引流20 mL(10～100mL),平均住院7 d(5～12 d).其中前10例使用电刀者平均用时210 min(180～360min),中转开腹1例;后51例使用超声刀者平均用时100min(60～180 min).术中脾被膜划破出血2例,13例Nissen式胃底折叠术后有1例出现吞咽困难,1个月后缓解.53例随访病人中51例不再需要服药.其中6例Heller肌切开Dor胃底折叠术病人术后第2天即可顺畅进食,且无反流.结论与传统的经胸或开腹手术相比,腹腔镜抗反流手术治疗胃食管反流病和贲门失弛缓症行Heller肌切开后病人具有心肺干扰小、麻醉难度低、创伤小、痛苦轻、并发症少、住院时间短、康复快和疗效好等突出优点.经过不断改进手术设计和加强训练可使手术时间迅速缩短一半以上(由180～360 min降至60～180 min).手术疗效方面Toupet式胃底折叠术优于Nissen式胃底折叠术,Heller肌切开后加行Dor胃底折叠术可有效地起到抗反流作用.     

内镜下贲门缝合术治疗食管裂孔疝合并胃食管反流病失败二例分析

目的分析胃食管反流病(gastroesophageal reflux disease,GERD)内镜下贲门缝合术失败的原因,并总结食管裂孔疝合并GERD患者的最佳治疗方法。方法回顾分析2例内镜下贲门缝合术失败的GERD患者治疗经过。结果 2例长期伴有严重的GERD症状,于外院行内镜下贲门缝合术,术后症状复发。入我院后再次GERD评估,明确仍有病理性反流,且胃镜检查示存在食管裂孔疝,遂行腹腔镜食管裂孔疝修补术加胃底折叠术,术后症状均缓解。术后随访,患者反流症状均明显缓解,无吞咽困难等并发症,完全停用抗反流药物。结论对于伴有严重GERD症状、长期内科治疗效果不佳且合并有食管裂孔疝者,推荐选择腹腔镜食管裂孔疝修补术加胃底折叠术。     

腹腔镜手术治疗食管裂孔疝八例体会

目的探讨使用腹腔镜行食管裂孔疝修补术的疗效和安全性。方法对8例食管裂孔疝患者行腹腔镜食管裂孔疝修补术,其中3例行360°胃底折叠术,5例行270。胃底部分折叠术。4例采用丝线缝合修补食管裂孔,4例应用补片修补食管裂孔。结果8例腹腔镜食管裂孔疝修补术全部成功。手术时间平均（120±30）min,术中出血量平均（50±12）ml,无术后并发症,术后平均住院（4．5±2．5）d。术后症状完全消失7例,好转1例。随访1～2年,无复发。结论腹腔镜食管裂孔疝修补术具有疗效确定、安全和创伤小的优点,值得进一步推广应用。     

腹腔镜Nissen胃底折叠术的临床疗效评价

目的评价腹腔镜Nissen手术的优越性。方法应用腹腔镜食管裂孔疝修补和胃底折叠术治疗食管裂孔疝患者31例。结果本组患者全部获得手术成功，仅1例发生纵隔气肿。术后随访6个月-7年，临床症状完全消失，无一例疝复发。结论腹腔镜食管裂孔疝修补和胃底折叠术具有创伤小、痛苦少、住院时间短等优点，是当今治疗食管裂孔疝手术的金标准。     

腹腔镜胃底折叠和食道裂孔疝修补的手术配合

腹腔镜胃底折叠和食道裂孔疝修补术治疗胃食管返流性疾病在国外已有近10年的历史,其疗效确切,且有创伤小、痛苦轻、恢复快等优点,但在国内此类疾病的外科治疗开展得还很少。我院2002年11月-2003年4月应用电视腹腔镜行胃底折叠术和食道裂孔疝修补术治疗胃食管返流性疾病4例。现将手术护理配合介绍如下。     

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.     

Dissociable correlates of two classes of retrieval processing in prefrontal cortex

Although substantial evidence suggests that the prefrontal cortex (PFC) implements processes that are critical for accurate episodic memory judgments, the specific roles of different PFC subregions remain unclear. Here, we used event-related functional magnetic resonance imaging to distinguish between prefrontal activity related to operations that (1) influence processing of retrieval cues based on current task demands, or (2) are involved in monitoring the outputs of retrieval. Fourteen participants studied auditory words spoken by a male or female speaker and completed memory tests in which the stimuli were unstudied foil words and studied words spoken by either the same speaker at study, or the alternate speaker. On "general" test trials, participants were to determine whether each word was studied, regardless of the voice of the speaker, whereas on "specific" test trials, participants were to additionally distinguish between studied words that were spoken in the same voice or a different voice at study. Thus, on specific test trials, participants were explicitly required to attend to voice information in order to evaluate each test item. Anterior (right BA 10), dorsolateral prefrontal (right BA 46), and inferior frontal (bilateral BA 47/12) regions were more active during specific than during general trials. Activation in anterior and dorsolateral PFC was enhanced during specific test trials even in response to unstudied items, suggesting that activation in these regions was related to the differential processing of retrieval cues in the two tasks. In contrast, differences between specific and general test trials in inferior frontal regions (bilateral BA 47/12) were seen only for studied items, suggesting a role for these regions in post-retrieval monitoring processes. Results from this study are consistent with the idea that different PFC subregions implement distinct, but complementary processes that collectively support accurate episodic memory judgments.     

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.     

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.