肝脏炎性假瘤5例报告并文献复习

目的:探讨肝脏炎性假瘤的诊治及治疗方法。方法:回顾性分析查阅自2015年1月—2018年1月间收治的5例肝脏炎性假瘤患者的临床资料。结果:术前3例诊断为肝恶性肿瘤,2例诊断为肝脓肿。4例行手术切除,1例行穿刺活检,病检均诊断为炎性假瘤。结论:肝脏炎性假瘤为临床少见疾病,因其真正发病机理尚不清楚,缺乏典型的临床表现、无特殊生化检查以及影像学结果而难以从病因学、症状学以及影像学的角度准确诊断,明确诊断必须依靠病理检查。手术切除为目前主要治疗方式,效果良好。     

肝细胞腺瘤47例的诊断与外科治疗

目的 总结肝细胞腺瘤(hepatocellular adenoma,HCA)的诊断与外科治疗经验.方法 回顾性分析1989-2009年收治的47例HCA患者的临床资料.结果 本组47例肝细胞腺瘤均为单发病变,术前确诊7例(14.9％),误诊为其他性质的肝占位病变40例(85.1％),最后诊断经术中快速冰冻病理切片或术后病理证实,术前误诊率高达85.1％,其中误诊肝癌11例,肝血管瘤10例,局灶性结节增生14例,肝占位性质待查5例.术前经B超、CT、MRI、DSA等影像检查,只能提示肝占位病变,最后确诊仍需手术探查和病理检查.本组47例HCA均无明确诱因,均采取手术治疗,分别行局部切除、肝段、肝叶或半肝切除术.为预防复发或恶变,切缘距瘤体边缘1.0cm以上.本组术后随访45例,随访率达95.7％,随访6年患者均存活,未见肿瘤复发.结论 HCA临床少见,术前误诊率高,手术切除是HCA惟一有效的治疗方法,预后良好.     

肝细胞腺瘤的诊治

目的 探讨肝细胞腺瘤(hepatocellular adenoma,HCA)的诊断和治疗经验.方法 回顾性分析我院1990年1月至2007年4月收治的18例HCA患者的临床、病理和影像学资料.结果 男女比例为11:7,1例女性患者有口服避孕药史.33%(6/18)的患者表现为右上腹不适或右上腹痛.CT和MRI增强扫描显示不规则出血或脂肪变性,多数病灶动脉期均匀强化,门脉期及延迟期造影剂退出.全部患者均经手术完整切除肿瘤.10例病灶内有出血表现,2例病理检查发现癌前病变.术后随访至2007年12月均存活无复发.结论 国内HCA多为自发性,且与口服避孕药无关,增强扫描有一定特异表现.手术完整切除肿瘤是首选的治疗方法,且预后良好.     

肝脏血管平滑肌脂肪瘤的诊断与治疗八例报告

目的 为提高对肝脏血管平滑肌脂肪瘤（angiomyolipoma,AML)的认识,作出正确诊断和治疗。方法 回顾分析8例肝AML的临床表现、影像学表现、病理学检查及外科治疗。结果 8例中术前做出正确诊断者仅1例,其中4例误诊为恶性肿瘤,8例均获得手术切除,术后恢复良好。结论 肝AML有其临床特点,CT或MRI亦具特异性。目前AML在术前常难做出正确诊断,与发病少、缺乏认识及影像学表现多样性有关。该病手术治疗效果好。     

肝细胞腺瘤诊断与外科治疗的体会

目的总结肝细胞腺瘤(HCA)诊断与外科治疗的经验与体会。方法回顾性分析2002年1月至2012年12月期间,我院手术治疗13例HCA患者的临床资料。结果术前确诊HCA 4例,误诊肝细胞肝癌3例、肝脏局灶性结节增生2例。全组均行手术治疗,采取半肝、肝叶、联合肝段和局部切除,术后病理均获确诊,其中单发病灶11例,多发病灶2例。术后11例获随访,时间1~5年,l例复发,l例恶变。结论 HCA临床少见,术前容易误诊。手术切除是HCA有效的治疗方式,预后良好。     

小儿肝脏巨大良性肿瘤及肿瘤样病变

目的 小儿肝脏良性肿瘤及肿瘤样病变的诊断、鉴别诊断和治疗具有较多困难。本文总结小儿肝脏良性肿瘤的临床特点和手术治疗经验。方法五年间手术切除12例肝脏良性肿瘤和瘤样病变,其中男性6例,女性6例,平均年龄6．4岁,肿瘤类型：婴儿性血管内皮瘤3例;肝结节性增生、肝囊肿和肝错构瘤各2例;炎性假瘤、炎性肌纤维母细胞瘤和淋巴管瘤各1例。术前均行各项常规检验以及B超、CT和／或MRI影像学检查。结果所有病例术前HBsAg为阴性,3例AFP轻度增高（〈200ng／L）,血红蛋白和白蛋白化验值显著高于同期的恶性肿瘤组（123．82±12．4对102±16．74和39．36±9．68对32．63±4．84,P〈0．05）。术前影像学检查中10例肝良性肿瘤（83％）未能明确肿块性质,6例（50％）初步诊断为肝母细胞瘤或肝细胞癌等。本组肿瘤平均直径11．09±2．98cm（8—16cm）,全部12例用肝肿瘤切除术治疗,其中左叶切除1例、左外叶切除3例、右叶或右叶肝段5例,瘤体切除术3例,无并发症和手术死亡。随访6个月～7年,全部健康存活,无复发。结论肝脏良性肿瘤和瘤样病变具有病理分类繁多、每种病变在临床上少见和罕见的特点;常以肝占位变出现,但缺乏特征性症状和体征,影像学资料非常难与恶性肿瘤相鉴别,即使肿瘤巨大,全身一般情况也良好。在充分的术前准备和良好的手术技巧的条件下,小儿肝脏良性肿瘤手术切除成功率非常高,预后良好。     

肝血管周上皮样细胞瘤的诊断与外科治疗

目的 总结肝血管周上皮样细胞瘤（PEComa）的临床特征,探讨该病的诊断与治疗方法.方法 回顾性分析2008年1月至2012年1月南京医科大学第一附属医院收治的16例肝PEComa患者的临床资料,总结该病的发病情况、临床特点、影像学特征、手术及病理检查情况.患者行部分肝切除术后定期复查腹部B超、肝功能和肿瘤标志物,必要时复查腹上区CT,了解肿瘤有无复发、转移.随访时间截至2012年12月.结果 16例患者中发病以中年女性患者居多,8例无自觉症状,其他患者表现为右季肋区不适、肝区隐痛或胀痛.肿瘤均为单发,位于肝右叶11例、肝左叶4例、肝尾状叶1例.术前B超检查无明显特异性征象,CT检查示肿瘤呈不均匀低密度表现.16例患者均行部分肝切除术,术后病理检查示均为R0切除,无手术并发症发生及患者死亡.免疫组织化学检测示16例患者上皮样肿瘤细胞中恶性黑色素瘤HMB-45、Melan-A和血管平滑肌肌动蛋白均呈阳性.16例患者均获随访,平均随访时间为27.9个月（9.0 ～46.0个月）,随访期内无肿瘤复发和死亡.结论 肝PEComa好发于中年女性患者,无特异性临床表现,术前CT检查有利于肝PEComa的鉴别诊断,行部分肝切除术治疗近期疗效良好.     

原发性肝脏神经内分泌肿瘤一例报告并文献复习

目的探讨原发性肝脏神经内分泌肿瘤的临床特征、诊断和鉴别诊断以及治疗方法。方法报告1例55岁女性原发性肝脏神经内分泌肿瘤的病例。术前增强CT、增强MRI、全身PET/CT均提示肝右叶恶性肿瘤,且除外肝外肿瘤。予病人行肝7、8段切除术,术后组织病理及免疫组化确诊为肝脏神经内分泌肿瘤,G2级;术后病人未进行化疗或其他辅助治疗。结果该病人随访4年至今,状态良好,生活工作正常,无肝脏肿瘤复发,也无其他部位肿瘤发生。结论原发性肝脏神经内分泌肿瘤极其罕见,其诊断和鉴别诊断是一个连续的过程;单发病灶和少有典型的类癌综合征是其重要的临床特征;积极的根治性手术是目前治疗该病最有效的方法。     

肝细胞腺瘤36例临床分析

目的 探讨肝细胞腺瘤(HCA)的准确诊断及合理治疗方法.方法 回顾性分析近3年来收治的36例HCA患者的临床、病理、影像学资料及治疗效果.结果 大多数HCA患者无明显症状,血清学检查正常.病理显示局部癌变1例,瘤内出血坏死19例,其中1例肿瘤破裂出血至腹腔.大多数病灶CT、MRI增强扫描后动脉期病灶均匀强化,门静脉、延迟期造影剂退出.手术切除疗效确切.结论 HCA无特异性临床表现,CT、MRI增强扫描对HCA有较高的诊断价值;因其可发生破裂出血及癌变,故对怀疑HCA者手术切除是首选的治疗方法.     

计算机辅助手术系统在儿童肝脏原发性间叶肿瘤手术中的应用

目的 探讨Hisense CAS计算机辅助手术系统在儿童肝脏原发性间叶肿瘤手术中的应用优势。方法 收集2009年4月至2020年11月在青岛大学附属医院接受肝脏间叶肿瘤手术的8例肝脏间叶源性肿瘤患儿的临床资料,其中男3例,女5例,年龄0.9～9岁;间叶错构瘤4例,胚胎性肉瘤4例。其中4例运用Hisense CAS计算机辅助手术系统对其增强CT数据进行三维重建。结果 术前根据CT检查拟实施精准肝切除术,4例成功进行肝脏及肿瘤的三维重建,并进行模拟肝切除。根据术前制定的手术计划成功实施肝中叶切除术2例,肝右叶切除术1例,肝左叶切除术2例,肝脏肿瘤切除术3例。术后恢复好,病理检查证实皆为肝脏间叶肿瘤。随访3个月至5年未见并发症及复发。结论 肝脏间叶肿瘤影像学特征不明显,很难与其他肝脏肿瘤区分,肿瘤体积较大,术前规划难度较高,Hisense CAS计算机辅助手术系统的3D可视化技术能补充CT检查结果,辅助医师设计最优手术方案,有助于安全根治性切除肿瘤。     

Histochemical and contractile properties of striated muscles of urethra and levator ani of dogs and sheep

AIMS: To understand their possible importance in long- and short-term control of continence, some properties of the striated muscles of the urethra and pelvic floor (levator ani) of dogs and sheep were investigated, especially fiber types and contractile characteristics. MATERIALS AND METHODS: Striated muscles of urethra and levator ani of 29 male and 6 female dogs and 11 male and 6 female sheep were removed and cut into strips. Some strips were frozen and stained for ATPase at pH 9.4 and 4.3 for fiber typing; others were set up in an organ bath to study contractile responses to nerve stimulation. RESULTS: All muscles contained both type I (slow) and type II fibers, ranging from 97% type II in female greyhound urethra to 60% in female sheep levator ani. For each muscle, there were fewer type II muscles in sheep than in dog. The diameters of the urethral fibers were about 60% of the levator ani in dogs and 34% in sheep. Contraction of the urethral muscle was faster than for levator ani and declined to about 80% of the peak, 500 msec after the beginning of stimulation at 20 Hz. The levator ani contraction rose to a steady level as long as stimulation continued. CONCLUSIONS: Both the levator ani and urethral striated muscles contain slow and fast fiber types. The levator ani muscles are capable of sustained contraction with rapid onset which will produce long-term closure of the urethra. The circular urethral muscle contraction was faster but less well maintained.     

Incorporation and release of85Sr and14C-proline-hydroxyproline in mineral and collagen of bone and incisor teeth of growing rats

The extent to which exchange and reutilization processes of mineral tracers affect skeletal mineral accretion and resorption measurements was evaluated by comparing the rates of appearance and disappearance of⁸⁵Sr and¹⁴C-proline-hydroxyproline in bones and teeth in growing rats for 12 days following simultaneous parenteral injection of these tracers. Expressions for the relative rates of collagen synthesis and breakdown, which unlike mineral metabolism are considered not to be complicated by exchange phenomena, were based on¹⁴C-proline conversion to¹⁴C-hydroxyproline; the specific activity of the latter was determined. Both the mineral and the collagen specific activities reflected the rates and patterns of growth of the samples assayed; rapid growth and a short interval of time between formation and resorption of tissue in themetaphyseal bone which contains the cartilagineous growth plate, slow growth and an interval of time between formation and resorption of tissue indiaphyseal bone and incisor teeth which is longer than the 12 days of the experiment. However, in metaphyseal bone the specific activity collagen/mineral ratio dropped by one half during the 4–12 day interval in contrast to diaphyseal bone and incisor teeth in which no change in this ratio was observed during this period of time. The data indicate that collagen in the metaphyseal growth zone is removed by resorption before it has become fully mineralized, and that exchange is a relatively unimportant factor in the long term kinetics of bone mineral.

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Zusammenfassung Das Ausmaß, bis zu welchem Austausch- und Wiederverwendungsprozesse der mineralen Tracer die Messungen des mineralen Skelett-Auf- und Abbaues beeinflussen können, wurde ausgewertet; zu diesem Zweck wurde die Geschwindigkeit des Auftretens und Verschwindens von⁸⁵Sr und von¹⁴C-Prolin-Hydroxyprolin in Knochen und Zähnen von wachsenden Ratten während der 12 auf die simultane parenterale Injektion dieser Tracer folgenden Tage verglichen.Der Ausdruck für die relative Geschwindigkeit des Kollagen-Auf- und Abbaues, bei welchem im Gegensatz zum Mineralmetabolismus kein Mitwirken des Austauschphänomens vermutet wird, basiert auf der Umwandlung von¹⁴C-Prolin zu¹⁴C-Hydroxyprolin; die spezifische Aktivität des letzteren wurde bestimmt.Aus der spezifischen Aktivität des Minerals sowie jener des Kollagens konnten die Geschwindigkeit und die Art des Wachstums der untersuchten Proben ersehen werden, d.h.schnelles Wachstum und ein kurzes Zeitintervall zwischen Bildung und Resorption des Gewebes imKnochen der Metaphyse, die auch die knorpelige Wachstumsplatte enthält, und andererseitslangsames Wachstum und längeres Zeitintervall (länger als die 12 Tage des Experimentes) zwischen Bildung und Resorption des Gewebes imKnochen der Diaphyse und in den Schneidezähnen. Immerhin fiel die spezifische Aktivität des Kollagen/Mineral-Anteils im Knochen der Metaphyse während dem 4–12tägigen Zeitintervall auf die Hälfte, im Gegensatz zum Knochen der Diaphyse und der Schneidezähne, bei welchen während dieser Zeitspanne kein Unterschied in diesem Verhältnis beobachtet wurde.Diese Ergebnisse zeigen, daß Kollagen in der Wachstumszone der Metaphyse durch Resorption verschwindet, bevor es ganz mineralisiert ist, und daß der Austausch ein relativ unwichtiger Faktor in der Kinetik auf lange Sicht des Knochenminerals ist.

     

Instrumented ligamentotaxis and stabilization of compression and burst fractures of dorsolumbar and mid-lumbar spines

Background:

Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique employing the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra.

Materials and Methods:

The study includes 15 Denis burst and two Denis type D compression fractures between T₁₂ and L₃. The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patients after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in vertebral body height, sagittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated.

Results:

The preoperative and postreduction percentile vertebral heights at, zero (immediate postoperative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at preoperative, and postoperative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively.The preoperative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final followup. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications.

Conclusion:

Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short contoured rod derotation technique and the instrumented stabilization of the fractured spine are found to be effective procedures which contribute to the fractured vertebral body consolidation without recollapse and maintain the motion segment function.     

Principles and Practice of Hemofiltration and Hemodiafiltration

There is growing interest in the convective dialysis therapies, hemofiltration (HF) and hemodiafiltration (HDF). Both require dialysis membranes which are highly permeable to solutes as well as fluid, and in both cases large volumes of ultrafiltration are the condition for convective transport. In HDF the convection is combined with diffusion, and as a consequence, maximum clearance over the entire molecular weight spectrum is achieved. Optimal forms of HDF provide urea clearance 10–15% higher than the corresponding diffusive mode. The larger the solute, the greater is the impact of convection, and β₂-microglobulin (β₂m) levels may be up to 70% reduced. Traditional postdilution HF provides high clearance of medium sized and large molecules. Satisfactory clearance of small solutes requires blood flows in excess of 500 ml/min. With access to practically unlimited volumes of substitution solution through on-line ultrafiltration, predilution HF can now be used. This increases the clearance of small solutes to an acceptable range. For HDF as well as HF, large patient populations consistently treated for longer periods of time are needed to make valid outcome comparisons with other therapies.     

骨折不愈合与延迟愈合的成因与治疗

目的探讨骨折不愈合与延迟愈合的成因、报肯治疗的方法与设果。方法对1990年7月～2004年12月间收治的107例骨折不愈台、54例骨折延迟愈合2例先天性胫骨骨不连进行回顾性研究，分析原因，随访治疗结果。18例延迟愈合行保守治疗，本组其他145例行手术治疗，结果除2例先天性胫骨骨不连外，其余161例的成因中均有医源性因素。10例失去随访，153例平均随访17（6-28）个月，骨折均获骨性连接，愈合时间平均10（6-14）个月，肢体功能恢复良好，结论医源性技术缺陷是骨折不愈合与延迟愈合的主要原因，针对各种不同因素进行合理治疗可获得满意效果。     

Recognition and management of phaeochromocytoma and paraganglioma

Phaeochromocytomas and paragangliomas (PPGL) are catecholamine-secreting neuroendocrine tumours arising from the chromaffin cells in the adrenal medulla. These tumours may be identified incidentally, as part of a work-up for multiple endocrine neoplasia or following haemodynamic surges during unrelated procedures. Advances in perioperative management and improved management of intraoperative haemodynamic instability have significantly reduced surgical mortality from around 40% to less than 3%. Surgery is the definitive treatment in most cases and laparoscopic resection where possible is associated with improved outcomes. Anaesthetic management of PPGL cases represents a unique haemodynamic challenge both before and after tumour resection. In this article we describe the physiology of these tumours, their diagnosis, preoperative optimization methods, intraoperative anaesthetic management and management of postoperative complications.     

Physiology and pharmacology of nausea and vomiting

Nausea and vomiting are both very unpleasant experiences. The physiology is poorly understood; however, understanding what we do know is key to tailoring a preventative or therapeutic antiemetic regime. There are two key sites in the central nervous system implicated in the organization of the vomiting reflex: the vomiting centre and the chemoreceptor trigger zone. There are five key neurotransmitters involved in afferent feedback to these areas. These are histamine (H₁ receptors), dopamine (D₂), serotonin (5-HT₃), acetyl choline (muscarinic) and neurokinin (substance P). Postoperative nausea and vomiting will occur in around one-third of elective patients who have no prophylaxis. This can result in many detrimental effects including patient dissatisfaction, unplanned admission and prolonged recovery. It is therefore essential that clinicians understand how they can prevent and treat nausea and vomiting using either a single agent or a combination of antiemetics to target relevant receptors. Commonly used drugs include antihistamines, dopamine antagonists, serotonin antagonists and steroids. More novel agents are being developed such as aprepitant, a neurokinin receptor antagonist, palonosetron, a 5HT₃ receptor antagonist and nabilone, a synthetic cannabinoid.     

Physiology and pharmacology of nausea and vomiting

Nausea and vomiting are both very unpleasant experiences. The physiology is poorly understood; however, understanding what we do know is key to tailoring a preventative or therapeutic antiemetic regime. There are two key sites in the central nervous system implicated in the organization of the vomiting reflex: the vomiting centre and the chemoreceptor trigger zone. There are five key neurotransmitters involved in afferent feedback to these areas. These are histamine (H₁ receptors), dopamine (D₂), serotonin (5-HT₃), acetyl choline (muscarinic) and neurokinin (substance P). Postoperative nausea and vomiting will occur in around one-third of elective patients who have no prophylaxis. This can result in many detrimental effects including patient dissatisfaction, unplanned admission and prolonged recovery. It is therefore essential that clinicians understand how they can prevent and treat nausea and vomiting using either a single agent or a combination of antiemetics to target relevant receptors. Commonly used drugs include antihistamines, dopamine antagonists, serotonin antagonists and steroids. More novel agents are being developed such as aprepitant, a neurokinin receptor antagonist, palonosetron, a 5HT₃ receptor antagonist, and nabilone, a synthetic cannabinoid.