球囊扩张术治疗贲门失弛缓症

贲门失弛缓症是一种表现为进行性吞咽困难的疾病 ,以往以手术治疗为主。球囊扩张术是治疗本病的一种新的介入治疗技术。我院于 1998年 2月 2 0 0 1年 12月对 18例贲门失弛缓症患者行球囊扩张术治疗效果满意。现报道如下。1　资料与方法1.1　一般资料　　 18例患者 ,男 6例 ,女 12例 ,年龄 2 0～ 72岁 ,平均 4 4岁。病程为 3～ 2 4年 ,平均 8年。主要临床表现为 :吞咽困难 18例 ,返流 16例 ,烧心和胸痛 10例 ,体重减轻 12例。全部病例均经上消化道钡餐造影检查、内窥镜及病理证实 ,排除食管远端浸润癌 (假性失弛缓症 )。根据吴恩惠等[1] 对吞…     

小儿贲门失弛缓症的外科治疗

自1990年11月迄今作者手术治疗小儿贲门失弛缓症5例。其中2例经胸行单纯Heller氏手术,3例经腹行Heller氏手术附加幽门成形术。随访1～3年,疗效满意,无反流性食管炎或复发。作者认为,经胸手术无需附加抗反流手术。     

可取出式全覆膜金属支架治疗难治性贲门失弛缓症

尽管没有洋实的流行病学数据,但来自临床的信息表明贲门失弛缓症有增加的趋势。这一疾病确切的病因还不十分清楚。大多数文献认为,腹腔镜食管下括约肌切开术和气囊扩张术是这一疾病的一线治疗方法,其有效率可达80％～90％,但仍有10％～20％的患者无效。     

球囊扩张和Heller肌切开治疗儿童贲门失弛缓症疗效和安全性的Meta分析

目的采用Meta分析方法评价球囊扩张（BD）和Heller肌切开（HM）治疗儿童贲门失弛缓症的有效性和安全性。方法检索PubMed、EMBASE、Cochrane图书馆、中国生物医学文献数据库、维普全文数据库和万方生物医学期刊数据库。检索的时间均从建库至2012年5月。获得BD和HM治疗儿童贲门失弛缓症的对照研究。由2名作者进行资料提取和文献质量评价。应用RevMan5.0软件进行Meta分析,根据异质性结果选择相应的效应模型分析;无法进行Meta分析时采用描述性分析。结果8篇文献进入Meta分析,均为非随机分组的对照研究。8篇文献均报道了两组的复发率和并发症发生率。BD组与HM组治疗儿童贲门失弛缓症复发率的差异有统计学意义（OR=4.07,95%CI：1.41～11.69,P=0.009）;两组并发症发生率的差异有统计学意义（OR=0.37,95%CI：0.15～0.90,P=0.03）。结论 HM治疗儿童贲门失弛缓症的复发率低于BD,并发症的发生率高于BD。因纳入文献质量较弱且样本量不大,明确结论仍需进一步研究。     

可回收自膨防返流覆膜食道支架治疗食道贲门失弛缓症

目的探讨国产可回收自膨防返流覆膜食道支架在治疗食道贲门失驰缓症的临床应用。方法支架为南京微创医学科技有限公司产MTN-S型形状记忆镍钛合金可回收自膨防返流覆膜杯口球头食道支架,规格80/20mm(长度/直径),交替导丝,超硬导丝,导管,支架回收器。23例患者,钡餐确诊,最大年龄64岁,最小15岁,男性19人,女性4人。病程最长29年,最短12个月。狭窄程度1.0～5.0mm。在电视透视下,将导丝置入胃内(较困难者在胃镜帮助下置入导丝),沿导丝将置入器缓慢送入,支架远端置于胃内,近端在狭窄上方,开始释放,取出导丝和置入器,将回收线拉紧经鼻腔固定于耳廓上。两周时取出并复查钡餐。结果全部病例支架置入一次成功,术后感胸骨后钝痛,持续5～7d,用止痛药能缓解。有1例术后3d支架移入狭窄上方食道内,有2例分别于术后7d和12d滑入胃内,取出支架后重新置入。有1例患者术后1h出现恶心呕吐、疼痛性休克,经抢救无生命危险。所有病例两周时能顺利取出支架,未出现支架嵌顿现象,食道钡餐示狭窄有不同程度开放,达到15mm左右,解除了咽下困难。术后3个月、6个月、12个月钡餐或电话随访,最长者达43个月仍未出现咽下困难。结论支架扩张是随着支架进入体内后温度逐渐升高而扩张,作用于食道四周的力量均匀,疼痛轻微,不易引起食道破裂和出血,取出支架容易。该手术安全、简便、禁忌证少,由于国产支架大幅降低了费用,值得推广应用。     

胃镜下注射A型肉毒杆菌毒素治疗贲门失弛缓症15例临床体会

目的：分析胃镜下注射A型肉毒杆菌毒素治疗贲门失弛缓症的疗效。方法选取2010年11月~2013年11月收治的15例贲门失弛缓症患者作为研究对象,所有患者均采用胃镜下注射A型肉毒杆菌毒素治疗,对比患者入院前使用解痉药物、扩张治疗的临床疗效。结果15例患者在胃镜下注射A型肉毒杆菌毒素治疗后患者之前存在的烧心、胸痛、反食、恶心呕吐以及吞咽困难等临床症状均有好转,只有1例患者存在反食、2例患者存在吞咽困难的症状,患者在治疗前后出现临床症状的具有显著差异,且差异具有统计学意义(<0.05);1年后有2例患者复发,复发率为13.3%。结论胃镜下注射A型肉毒杆菌毒素治疗贲门失弛缓症安全、方便、微创,还具有显著的治疗效果,在注射时把握好注射角度、深度以及注射量可以极大的降低复发率。     

贲门失弛缓症患者HLA—DQB1、DRB1等位基因频率的研究

迄今为止 ,贲门失弛缓症的病因未明。嗜神经病毒感染导致神经元退行性变可能引起本病 ,但电子显微镜检查迷走神经及壁内神经丛未发现病毒颗粒 ,且流行病学研究也不支持本病为感染性疾病。少数家庭中有多人患病 ,揭示可能与遗传有关。有研究显示贲门失驰缓症与ＨＬＡ ＤＱ1相关[1] ,患者体内发现壁内神经元抗体 ,这提示贲门失弛缓症发病与免疫有关 ,为进一步研究其免疫机制 ,我们对 30例贲门失弛缓症患者进行了ＨＬＡ ＤＱＢ1、ＤＲＢ1等位基因频率检测。1　材料与方法1 1　研究对象　为湖北地区汉族人。贲门失弛缓症患者 30例 ,其中男性 18…     

贲门失弛缓症球囊扩张术后食管下端穿孔对胃裸区的启示

患者，女，63岁反复吞咽困难6年，半年前胃镜诊断“贯门失弛缓症”，于我院行内镜下球囊扩张术，手术顺利术后约2h突发剧烈左上腹痛伴左侧背心痛，平躺加重。急诊食道造影示：食管上段扩张，造影剂于食管下端近贲门左侧缘漏出，后沿左侧膈肌向上形成不规则片状影。诊断：贲门失弛缓症球囊扩张术后食管下端穿孔。     

贲门周围血管离断术加胃底血流阻断术治疗门静脉高压症

目的探讨贲门周围血管离断术加胃底血流阻断术治疗门脉高压症的疗效。方法回顾性分析109例采用贲门周围血管离断加胃底血流阻断术治疗的门脉高压症患者的临床资料，对手术前后的肝脏功能、术后并发症及再出血发生率等进行分析。结果全组病例无手术死亡，术后近期无其他并发症发生。随访5个月至6年，再出血率为6．1％（6／99）。结论贲门周围血管离断加胃底血流阻断术治疗门脉高压症不仅操作简便，而且对肝功能无明显影响，术后并发症发生率低，易在基层医院开展，有良好的临床实用价值。     

食管胃底大口径内瘘加胃折叠术治疗贲门失驰缓症

目的探讨食管胃结合部大口径内瘘加胃折叠术与改良Heller术治疗贲门失弛缓症的临床效果差异。方法选取2008年6月至2014年3月在我院确诊为贲门失弛缓症的患者18例,将行食管胃结合部大口径内瘘加胃折叠术者8例作为观察组,采用改良Heller术的患者10例作为对照组;比较2组患者手术疗效及并发症情况。结果 18例患者均成功完成既定手术治疗,术后3个月造影显示造影剂顺利通过食管贲门及吻合口进入胃腔。观察组术后12个月总体有效率为100%,对照组12个月总体有效率为60%,2组比较差异有统计学意义(P=0.014)。观察组并发症发生率低于对照组,差异有统计学意义(P=0.026)。结论食管胃结合部大口径内瘘加胃折叠术,安全性更高,可达到根治效果。     

Percutaneous laser disc decompression for thoracic disc disease: report of 10 cases

Background: Discogenic pain or herniation causing neural impingement of the thoracic vertebrae is less common than that in the cervical or lumbar regions. Treatment of thoracic discogenic pain usually involves conservative measures. If this fails, conventional fusion or discectomy can be considered, but these procedures carry significant risk.Objectives: To assess the efficacy and safety of percutaneous laser disc decompression (PLDD) for the treatment of thoracic disc disease.Methods: Ten patients with thoracic discogenic pain who were unresponsive to conservative intervention underwent the PLDD procedure. Thoracic pain was assessed using the Visual Analog Scale (VAS) scores preoperatively and at 6-month intervals with a minimum of 18-months follow-up. Patients were diagnosed and chosen for enrollment based on abnormal MRI findings and positive provocative discograms. Patients with gross herniations were not included.Results: Length of follow-up ranged from 18 to 31 months (mean: 24.2 mo). Median pretreatment thoracic VAS score was 8.5 (range: 5-10) and median VAS score at final follow-up was 3.8 (range: 0-9). Postoperative improvement was significant with a 99% confidence interval. Of interest, patients generally fell into two groups, those with significant pain reduction and those with little to no improvement. Although complications such as pneumothorax, discitis, or nerve damage were possible, no adverse events occurred during the procedures.Limitations: The study is limited by its small size and lack of a sham group. Larger controlled studies are warranted.Conclusions: With further clinical evidence, PLDD could be considered a viable option with a low risk of complication for the treatment of thoracic discogenic pain that does not resolve with conservative treatment.     

Transmesocolic Approach for Left Side Laparoscopic Pyeloplasty: Comparison with Laterocolic Approach in the Initial Learning Period

Purpose

To evaluate the outcome of transmesocolic (TMC) laparoscopic pyeloplasty compared with conventional laterocolic procedure for surgeons with limited experience.

Materials and Methods

We started laparoscopic pyeloplasty for ureteropelvic junction obstruction in 2009. Since then, 21 patients of left side disease have undergone this surgery in our institution. To access the left ureteropelvic junction, we used the conventional laterocolic approach in 9 patients, while the transmesocolic approach was used in the remaining 12 patients, and perioperative results and follow-up data were then compared.

Results

The mean operative time using the transmesocolic approach was significantly shorter than the conventional laterocolic approach (242 vs. 308 min, p=0.022). Furthermore, there was no complication or open conversion. Postoperative pain was significantly decreased in the TMC group (2.8 vs. 4.0 points, measured using the visual analogue scale on the first postoperative day, p=0.009). Postoperative complications were encountered in two patients. All patients were symptom-free after 1 year of follow-up, and radiologic success rates for each group were 92 and 89%, respectively.

Conclusion

Direct exposure of the ureteropelvic junction via the mesocolon saves time during the colon mobilization procedure. The approach is safe and feasible even for surgeons with limited experience, and has success rates similar to those of the conventional laterocolic approach.     

Endoscopic thoracic laminoforaminoplasty for the treatment of thoracic radiculopathy: report of 12 cases

Background: Spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions. Due to the close proximity to thoracic and abdominal organs, surgical operations can be difficult and carry a greater risk of complications. The most efficacious intervention for thoracic stenosis, whether central or foraminal, refractory to conservative management is uncertain. We aimed to evaluate the efficacy of endoscopic laminoforaminoplasty (ELFP) in the treatment of thoracic radiculopathy.Methods: Twelve patients with radicular pain involving the lower thoracic levels (at or below T6) were treated with ELFP.Results: Seven of twelve patients showed marked improvement in pain scores. Average follow-up scores were 2.9 and 12.08 on the Visual Analog Scale (VAS) and Oswestry Disability Index, respectively. The significance was 0.005 between the pre and post surgical data. One patient with moderate symptoms, two with severe symptoms, and two with crippling symptoms did not report significant improvement on VAS or Oswestry. No complications were encountered.Conclusions: Endoscopic laminoforaminoplasty offers an alternative to fusion or conventional laminotomy with similar success rates. Patients additionally benefit from a decrease risk of complications, short hospital stay, and faster recovery.     

腹腔镜胃十二指肠溃疡穿孔修补的探讨

目的 探讨腹腔镜胃十二指肠溃疡穿孔修补术的手术方法及操作要点。方法 采用腹腔镜下缝合修补溃疡穿孔76例。结果 腹腔镜下缝合修补溃疡穿孔均获成功，无中转开腹，无死亡病例，无癌性穿孔，无并发症发生。结论 腹腔镜消化性溃疡穿孔修补术创伤小，并发症少，操作简单，且集诊断及治疗于一体，显示了微创外科的优越性，是目前适合普及的治疗消化性溃疡穿孔的手术方法。     

Robotic Prostatectomy: What We Have Learned and Where We Are Going

Radical prostatectomy became a mainstay of treatment for prostate cancer in the United States after the pioneering work of Walsh in defining the nerve sparing technique. Efforts to reproduce this operation in a minimally invasive fashion resulted in slow progress that recently have flourished with the application of the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) by Menon and colleagues. This article summarizes the origins of robotic prostatectomy, some of the current data regarding this operation and potential future directions.     

腹腔镜手术悬吊系统的设计与仿真分析

目的 基于现有的气腹装置,在低气压的前提下,设计一款用于微创手术的新型悬吊系统,以暴露更多手术视野,便于手术顺利进行。方法 利用Solidworks软件完成悬吊系统的结构设计,并基于有限元仿真分析技术,研究医用不锈钢、钛合金Ti6Al4V、钛合金Ti6Al7Nb和纯钛4种不同夹子制作材料以及尼龙(polyamide-6,PA6)、涤纶、聚丙烯(polypropylene, PP)3种不同中间平面结构制作材料对悬吊系统使用性能的影响。结果 4种不同材料的夹子在夹持组织过程中,组织的形变量均较低,不会出现所夹持组织从夹子中滑脱的现象。就应力而言,选用医用不锈钢材料时,夹子及其夹持组织的应力均最低;对于中间平面结构的制作材料而言,当选取涤纶材料时,在悬吊系统工作过程中,中间平面结构会在外载荷作用下发生破坏;当选用PP材料时,中间平面结构会发生永久变形,且形变量最高,不利于临床手术的进行。结论 选择医用不锈钢作为夹子的制作材料为最佳。不宜选择涤纶作为中间平面结构的制作材料,选择PA6作为中间平面结构的制作材料为最优。     

内镜下微创甲状腺手术(附12例临床病例报告)

目的内镜下以常规手术器械实施微创甲状腺手术。方法12例甲状腺良性肿瘤,其中4例甲状腺腺瘤、3例甲状腺单发囊腺瘤、5例结节性甲状腺肿。男性3例,女性9例,年龄19～66岁,肿瘤最长径为35mm。于胸骨切迹上自然皮纹处切取小切口(长度15～25mm),置入0°4mm鼻内镜,在直视或监视器下以常规手术器械完成甲状腺手术。结果手术耗时(120±45)min,术中出血(50±30)ml。切口以4-0丝线行表皮下连续缝合。术后第2天拔除引流管,第5天拆线出院,无手术并发症。结论内镜下甲状腺手术可用常规手术器械通过小切口进行手术而达到微创目的,进路简短、手术安全、并发症少、切口美观,值得临床推广应用。     

Hepatoid adenocarcinoma in Barrett's esophagus associated with achalasia: first case report

We report an unusual hepatoid adenocarcinoma in Barrett's esophagus with achalasia, which developed in a 44-year-old Japanese woman. The patient received an esophago-gastrectomy after diagnosis of the tumor and achalasia at the lower esophagus, 4 months before her death due to multiple metastatic tumors of the liver. The main granular tumor removed surgically was a hepatoid adenocarcinoma, mainly composed of clear cancer cells (alpha-1 antitrypsin, albumin and alpha-fetoprotein positive), with elements of choriocarcinoma and tubular adenocarcinoma. Non-neoplastic specialized columnar epithelium was present extensively near the oral side of the tumor edge in the esophagus, indicating Barrett's esophagus. This unusual tumor was therefore considered to have originated in Barrett's esophagus. The gastroesophageal reflux was presumed to have occurred for a long period, as there was a well-preserved fundic gland in the stomach and a history of frequent vomiting from the patient's youth, accounting for the appearance of achalasia.     

Survival rates of patients who undergo minimally invasive surgery for endometrial cancer with cervical involvement

Objective: Compare the oncologic outcomes of patients with intermediate-risk endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery.Methods: Data from 206 patients with intermediate-risk endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients'' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach.Results: Among the 206 patients included in this study, 76 underwent open surgery (36.9%) and 130 underwent MIS (63.1%). In patients with stage IB endometrial cancer, the recurrence rate, disease-free survival, and overall survival were not significantly different between those who underwent minimally invasive surgery and those who underwent open surgery. However, in patients with stage II endometrial cancer, the recurrence rate was significantly higher among those who underwent minimally invasive surgery (37.5% vs. 5.3%, p = 0.013). Patients with stage II endometrial cancer who underwent minimally invasive surgery had a significantly lower disease-free survival (p = 0.012) than those who underwent open surgery, however, the overall survival (p = 0.252) was similar between the two groups.Conclusion: Minimally invasive surgery results in less favorable survival outcomes than open surgery in patients with stage II endometrial cancer.