腹腔镜手术治疗胆石症的现状与展望

腹腔镜手术治疗胆石症的现状与展望王炳煌电视腹腔镜手术是现代电子科学、内窥镜技术与传统外科技术相结合的产物。１９８７年３月法国ＰｈｉｌｉｐｅＭｏｕｒｅｔ成功地完成了世界上第一例电视腹腔镜胆囊切除手术（ＬＣ）。随后Ｄｕｂ－ｏｉｓ、Ｐｅｒｉｓｓａｔ等相继报...     

肝动脉栓塞加手术切除治疗大肝癌37例

作者报告３７例大肝癌采用肝动脉栓塞（ＴＡＥ）加手术切除的疗效及临床病理研究结果。３７例肝癌直径５～２４ｃｍ（平均１１．２Ｃｍ）。ＴＡＥ与动脉灌注化疗同时进行。化疗药物括氟尿嘧啶（５－ＦＵ）、阿霉素（ＡＤＭ）或表阿霉素（Ｅ－ＡＤＭ）、丝裂霉素（ＭＭＣ）和顺铂（ＣＤＤＰ）。多采用三种药物联合方案。肝动脉末梢栓塞剂采用国产或进口碘化油,用明胶海绵颗粒作近端栓塞。手术切除前进行１～４次ＴＡＥ,每次相隔４～６周。１７例ＡＦＰ值增高者ＴＡＥ后１０例降至正常水平。肿瘤直径由平均１１．２ｃｍ降至８．５ｃｍ（缩小２６％）。栓塞后手术切除病理标本显示９２％有肿瘤组织坏死,范围达４０％～１００％。１、２、３年生存率分别为８０％、６６．７％和５３．３％。作者认为ＴＡＥ加手术切除是大肝癌的有效治疗方法。     

移植物CD45RO分子mRNA表达指数增高在大鼠小肠移植排斥反应 …

目的 探讨有核血细胞共同抗原ＣＤ４５分子重要异型ＣＤ４５Ｒ０分子ｍＲＮＡ表达水平在小肠移植排斥反应中的预报作用。方法 采用显微外科技术制作Ｗｉｓｔａｒ大鼠自体小肠移植模型、Ｗｉｓｔａｒ→ＳＤ大鼠异体小肠移植模型，异体移植模型依不给免疫抑制剂、予小剂量环孢Ａ ＣｓＡ、予全量ＣｓＡ而分为３组。使用逆转录－聚合酶链式反应和毛细管电泳技术测定移植术后４ｄ移植小肠中ＣＤ４５Ｒ、ＣＤ４５Ｒ０分子ｍＲＮＡ的表达     

瘤袋与右房搭桥吻合治疗升主动脉夹层动脉瘤术后出血

瘤袋与右房搭桥吻合治疗升主动脉夹层动脉瘤术后出血杨辰垣，蓝鸿钧，孙宗全，张凯伦，刘成硅升主动脉夹层动脉瘤切除手术后出血，用常规方法往往难以控制。１９９３年３月～１９９４年１２月我们采用Ｃａｂｒｏｌ手术方案连续为３例升主动脉夹层动脉瘤病人作了手术。其中...     

CD44在颅内转移瘤及脑胶质母细胞瘤中的表达研究

目的　研究 Ｃ Ｄ４４ 粘附分子在颅内转移瘤及脑胶质母细胞瘤中的表达情况及其与这些肿瘤发生侵袭、转移的关系。方法　用抗 Ｃ Ｄ４４ 正常型（ Ｃ Ｄ４４ｓ） 蛋白单克隆抗体及抗 Ｃ Ｄ４４ 变体型（ Ｃ Ｄ４４ｖ３１０） 蛋白多克隆抗体免疫组化染色检测１０ 例正常脑组织、２０ 例脑胶质母细胞瘤和２０ 例颅内转移瘤中 Ｃ Ｄ４４ 粘附分子的表达情况。结果　１０ 例正常脑组织中 Ｃ Ｄ４４ｓ 和 Ｃ Ｄ４４ｖ３１０ 表达均阴性;２０ 例脑胶质母细胞瘤 Ｃ Ｄ４４ｓ 阳性表达率为１００ ％ , Ｃ Ｄ４４ｖ３１０ 表达阴性;２０ 例颅内转移瘤 Ｃ Ｄ４４ｓ 表达阳性率为９０ ％ , Ｃ Ｄ４４ｖ３１０ 表达阳性率为７０ ％ 。 Ｃ Ｄ４４ｖ３１０ 在颅内转移瘤及脑胶质母细胞瘤的表达差异有显著性（ Ｐ＜ ０ ．０１） 。结论　脑胶质母细胞瘤中 Ｃ Ｄ４４ｓ 的表达可能与其脑内侵袭过程有关,无 Ｃ Ｄ４４ｖ 表达可能与其很少发生颅外转移有关; Ｃ Ｄ４４ｖ 可能在颅内转移瘤向颅内转移的过程中起重要作用,且有可能成为颅内转移瘤诊治的有用指标之一。     

腰椎椎弓崩裂合并滑脱的外科治疗初探

分析１９８３年３月至１９９４年５月３３例腰椎椎弓崩裂合并滑脱病人的外科治疗情况，提出病因，诊断要点及手术适应症，强调减压是解除症状的关键，复位前先行松解。就内固定选择进行了比较，认为短棒ｃｏｔｒｅｌ－Ｄｕｂｏｕｓｓｅｒ（ＣＤ）为佳，有效椎弓根内固定是帮助复位，提高融合率的重要措施，高质量的融合可防止再滑脱使远期疗效优良。     

CD_3－TIL抗肿瘤作用的实验研究

作者研究了人原发性肝癌浸润淋巴细胞（ＴＩＬ）在体外经ＣＤ３单抗和重组人ＩＬ－２（Ｉｎｔｅｒ－ｌｅｕｋｉｎ－２）刺激诱导成为ＣＤ３－ＴＩＬ，并且ＣＤ３－ＴＩＬ与单纯ＩＬ－２诱导的ＴＩＬ进行了体外增殖能力及体内外抗肿瘤作用的比较。结果发现，ＣＤ３单抗浓度为１００ｎｇ／ｍｌ时，为ＴＩＬ体外刺激增殖的最适剂量；ＣＤ３－ＴＩＬ在体外的扩增能力显著高于ＴＩＬ，并且在体外杀伤肿瘤细胞的活性显著地高于ＴＩＬ。体内试验发现ＣＤ３－ＴＩＬ可使裸鼠成瘤期显著地延长、瘤体缩小、荷瘤裸鼠生存期延长，表明ＣＤ３－ＴＩＬ细胞具有较强的体外增殖能力及有效地杀伤肿瘤细胞的活性，可望该实验为临床上治疗原发性肝癌提供实验依据。     

颅外颈动脉瘤术后脑阻塞性病变诊治分析

１９８６～１９９６年间，治疗颈动脉瘤６０例（６３个），３例出现术后脑阻塞性病变（ＣＶＯＤ）。ＣＶＯＤ原因２例与颈动脉栓塞有关，１例主后喉痉挛气管切开后并发症，经治疗后无一例死亡。提出：颈动脉瘤术后出现的栓塞性改变得造成同侧脑阻塞性病变的重要原因，术前的Ｍａｔａｓ试验，术中尽量减少脑缺血时间，提高手术操作技术，术后预防局部压迫等是防治术后ＣＶＯＤ的关键。     

过继TAK细胞免疫治疗在晚期肾癌的应用价值

１９９３年５月～１９９４年１０月，用过继ＴＡＫ细胞免疫治疗晚期肾癌１７例。按Ｒｏｂｓｏｎ分期，Ⅲ期２例，Ⅳ期１５例。每疗程输注ＴＡＫ细胞总数２×１０９～３×１０９，根据病人情况做１～３疗程。ＣＲ１例，ＰＲ３例，近期有效率可达２３．５％；配合手术治疗，近期有效率可达３７．５％。至１９９５年２月，本组病人治疗后平均生存期已１０个月。治疗前后肝、肾功能无明显变化，约５０％病人输注后无任何不适，部分病人输注后有发热，寒颤。此方法ＩＬ－２用量少、杀伤性Ｔ细胞增殖快、杀瘤亲和性高、副作用轻、费用低、见效快、疗效好，是治疗晚期肾癌的一种有效的辅助手段。     

CD44V6和E—CD的表达与胃癌生物学特性的关系

目的 探讨ＣＤ４４Ｖ６（ＣＤ４４ ｓｐｌｉｃｅ ｖａｒｉａｎｔ Ｖ６）和Ｅ－ＣＤ（ｃａｄｈｅｒｉｎ）表达与胃癌发生发展的关系,评价ＣＤ４４Ｂ６和Ｅ－ＣＤ在胃癌诊断、浸润转移潜能及预后判断中的作用。方法 采用ＳＰ免疫组化染色方法,检测２０例正常胃粘膜上皮,４３例异型增生和１０１例胃癌组织的ＣＤ４４Ｖ６和Ｅ－ＣＤ的表达情况。结果 正常胃粘膜ＣＤ４４Ｖ６呈阴性表达,异型增生粘膜ＣＤ４４Ｖ６阳性表达率为３     

颈内动脉眼动脉段动脉瘤的手术治疗

目的 对28例颈内动脉眼动脉段动脉瘤进行回顾分析,总结该部位动脉瘤手术方式和结果以进一步改善疗效.方法 2004年5月至2009年8月手术治疗28例(30个)颈内动脉眼动脉段动脉瘤,其中微小动脉瘤4个,小型动脉瘤2个,中型动脉瘤4个,大型、巨大动脉瘤20个.结果 共手术处理28例患者的28个眼动脉段动脉瘤.19例行动脉瘤夹闭或动脉瘤切除+颈内动脉重建,9例行高流量颅内外动脉搭桥+动脉瘤切除+颈内动脉重建或颈部颈内动脉结扎动脉瘤孤立.17例术后行数字减影血管造影、CT血管成像或磁共振血管成像复查,5例搭桥血管通畅,2例搭桥血管闭塞.1例动脉瘤少量残留,余动脉瘤不显影.GOS 4～5分占78%(22/28),死亡1例.结论 颈内动脉眼动脉段动脉瘤尤其是大型巨大型动脉瘤处理困难.辅助高流量颅内外搭桥手术、选择合适的动脉瘤夹,才能取得良好的手术效果.     

Giant aneurysm of the pericallosal artery causing acute subdural hematoma--case report

A 66-year-old female presented with a very rare giant aneurysm of the distal pericallosal artery. She lost consciousness and was admitted. Computed tomography demonstrated a subdural hematoma over the left cerebral convexity and a mass in the frontal lobe. Cerebral angiography disclosed a giant aneurysm located on the distal segment of the right pericallosal artery. The subdural hematoma was removed and the aneurysmal neck was clipped, but she died 15 days after the operation. Autopsy found the giant aneurysm (33 x 30 x 27 mm) on the distal segment of the right pericallosal artery. Highly atheromatous changes were recognized in part of the aneurysmal wall, the arteries near the circle of Willis, and the distal anterior cerebral artery (ACA) adjacent to the aneurysm. There were no anomalous vessels such as azygos ACA. Giant aneurysms situated beyond the genu of the corpus callosum are extremely rare. Atherosclerosis was probably a major etiological factor in this case.     

Does anatomical completeness of the circle of Willis correlate with sufficient cross-perfusion during unilateral cerebral perfusion?

OBJECTIVES: The aim of the study was to evaluate the role of anatomical completeness of the circle of Willis for sufficient brain perfusion during unilateral cerebral perfusion and the methodology of the preoperative and intraoperative functional assessments of adequate cross-perfusion. METHODS: This prospective observational study included all elective patients (99) who underwent elective open arch surgery (hemiarch in 74 and arch replacement in 25 patients, respectively) at our institution between September 2004 and September 2006. Preoperative neuro-vascular evaluation included color-coded duplexsonography of the extracranial arteries, cranial CT angiography, and transcranial sonography. A functional test of cerebral cross-perfusion was performed during cross-clamping of the common carotid artery during cannulation by transcranial Doppler, electroencephalography and measurement of somatosensory evoked potentials. These examinations, which were completed through measurement of arterial pressure in both radial arteries, also served as an intraoperative assessment of cerebral perfusion during surgery. During mild hypothermic (30 degrees C) circulatory arrest with a mean duration of 18 min (range, 7-70) brain protection using unilateral cerebral perfusion was performed in all patients. RESULTS: As assessed in preoperative CT angiography, the circle of Willis was complete in only 59 patients. Eighteen patients showed a singular abnormal location within the circle of Willis, 13 patients presented with abnormalities within the posterior communicating arteries on both sides, and 9 patients within the anterior and posterior communicating arteries. Nevertheless, functional tests during carotid artery cross-clamping as well as intraoperative cerebral monitoring including transcranial Doppler showed no pathology in any patient, and only one patient with severe aortic valve calcification suffered from embolic minor stroke after surgery. CONCLUSIONS: The anatomical status of the circle of Willis assessed with cranial CT angiography does not correlate with functional and intraoperative tests examining the cerebral cross-perfusion. The authors do not recommend cranial CT angiography as a preoperative standard examination before open arch surgery in which unilateral cerebral perfusion is scheduled.     

A temporal transsylvian approach to anterior circulation aneurysms.

Operative management of cerebral aneurysms remains a technically challenging problem in modern neurosurgery despite major advances in microsurgical techniques. This is largely caused by the difficulty of exposing and handling these aneurysms, which are located around the circle of Willis at the base of the brain. Large cranial windows, generous brain retraction, and local brain resection have, at times, been employed to overcome these difficulties. In the present report, an exclusively temporal approach to the anterior aspect of the circle of Willis for surgical treatment of aneurysms arising from the anterior circulation is described. This approach limits the surgical preparation and the craniotomy to the temporal area, protects the temporal branch of the facial nerve from injury, and provides a superior cosmetic appearance soon after surgery. It provides a lateral transsylvian exposure to the base of the brain and thus permits the safe dissection and exposure of the aneurysms using microsurgical techniques with minimal, if any, retraction of the frontal lobe. The need for routine resection of the gyrus rectus for exposure of anterior communicating artery aneurysms is alleviated. This approach can be considered in patients harboring large or small incidental or acutely ruptured anterior circulation aneurysms. The outcome of 96 consecutive patients who underwent this procedure is described to illustrate its safety and effectiveness.     

Giant aneurysm arising from the anterior cerebral artery and causing an isolated homonymous hemianopsia

A case of a giant aneurysm arising from the anterior cerebral artery and producing a left homonymous hemianopsia is presented. The aneurysm caused lateral compression of the posterior part of the optic chiasm. After preoperative dynamic assessment of the circle of Willis by angiography and by electroencephalographic recording during carotid artery compression, the aneurysm was trapped with microclips on the anterior cerebral artery proximal and distal to it. Visual field examination 6 months postoperatively showed complete visual field recovery. This is the first case of homonymous hemianopsia caused by an angiographically proven giant aneurysm of the ACA.     

Giant aneurysm of the distal anterior cerebral artery: associated with an anterior communicating artery aneurysm and a dural arteriovenous fistula.

We describe an unusual case of a giant pericallosal artery aneurysm, producing psychomotor depression from mass effect, associated with a smaller aneurysm of the anterior communicating artery, a dural arteriovenous fistula, and a meningioma. Magnetic resonance imaging (MRI) and cerebral angiography demonstrated the giant aneurysm and the meningioma. Cerebral angiography provided a detailed appreciation of the cerebral circulation, including both aneurysms, the dural arteriovenous fistula, and the potential collateral supply to the involved anterior cerebral distribution. The anterior communicating artery aneurysm was successfully clipped as was the distal anterior cerebral branch supplying the giant aneurysm before its resection. The patient made a full recovery but with persisting, slight dysphasia. We conclude that computed tomography, cerebral angiography, and MRI are of specific value in the assessment of giant aneurysms, but only angiography can provide detailed characterization of the aneurysm and demonstrate other possible cerebrovascular pathology such as multiple aneurysms and arteriovenous fistulas.     

Digital subtraction angiography and dynamic computed tomography for evaluating the hemodynamics in cases of giant intracranial aneurysm

Dynamic computed tomography (CT) and digital subtraction angiography were used for postoperative evaluation of the hemodynamic changes in five patients with giant or large intracranial aneurysms. The lesions in four of these cases were giant or large aneurysms of the internal carotid artery, and were treated by occlusion of the cervical internal carotid artery and superficial temporal-middle cerebral artery anastomosis. The lesion in the fifth case was a giant aneurysm of the right vertebral artery, which was treated by proximal clipping of the vertebral artery. Preoperative digital subtraction angiography revealed aneurysmal staining, and dynamic CT scanning indicated the rapid transit of contrast medium in the dome of the aneurysm. Dynamic CT scanning immediately after operation indicated a low flow state in all of the aneurysms, suggesting that they were thrombosed. Although within a few months the peripheral edges of the aneurysms became enhanced, dynamic CT scanning revealed a slower transit of contrast medium through the centers of the aneurysms than in the basilar artery, and digital subtraction angiography failed to demonstrate aneurysmal staining, suggesting that the aneurysms remained thrombosed. The present data indicate that dynamic CT scanning and digital subtraction angiography may be useful for relatively noninvasive evaluation of the hemodynamic changes in patients with giant intracranial aneurysms.     

Anterior communicating artery aneurysm in the sella turcica: case report

BACKGROUND: Only 3 such reported intrasellar aneurysms have arisen from the anterior communicating artery. CASE DESCRIPTION: A neurologically normal 38-year-old man complaining of headache underwent cranial magnetic resonance imaging, which showed a heterogeneously enhancing, partially calcified intrasellar mass. The normal pituitary gland was identified at the bottom of the sella, and the optic chiasm was located superior to the aneurysm. Digital subtraction angiography and three-dimensional computed tomography angiography demonstrated the mass to be a partially thrombosed anterior communicating artery aneurysm. Frontotemporal craniotomy was performed, but initial attempts to occlude the neck of the aneurysm were unsuccessful. We could not expose the dome of the aneurysm or confirm the anatomic relationship of the pituitary to the aneurysm. The patient declined further intervention, and close follow-up has been maintained. CONCLUSION: Our case suggested that unlike intrasellar aneurysms arising from the internal carotid artery, intrasellar aneurysms originating from the anterior communicating artery are likely to present difficulty in dissecting the neck of the aneurysm from the bilateral optic nerves and pituitary stalk, impeding direct aneurysm clipping. When we operated upon a patient with a large unruptured intrasellar aneurysm originating from the anterior communicating artery via the prechiasmatic space, we encountered considerable technical difficulty.     

Anterior communicating aneurysm missed at angiography: report of two cases treated surgically

We report two young adults with definite clinical and computed tomographic (CT) signs of subarachnoid hemorrhage in whom initial angiography showed spasm of the anterior portion of the circle of Willis, but no aneurysm. Repeat angiography some days later, when the vascular spasm had cleared, was likewise negative. In both patients, operation revealed an anterior communicating artery aneurysm, which was successfully excluded from the circulation. Our aims in reporting this unusual experience are to stress the practical importance of CT scanning in the diagnosis and treatment of subarachnoid hemorrhage and to discuss the decision to operate.     

Magnetic resonance angiographic evidence of sex-linked variations in the circle of willis and the occurrence of cerebral aneurysms

OBJECT: In this study the authors investigated the relationship between variations in the circle of Willis observed on magnetic resonance (MR) angiograms and locations of cerebral aneurysms, and evaluated the risk of aneurysm formation. METHODS: One hundred thirty-one patients with cerebral aneurysms were retrospectively selected from a series of 4518 patients who underwent MR angiography at one neurosurgical institute. Variations in the anatomy of the circle of Willis were simply classified into Type A, in which there was no visualization of a unilateral A1 segment, and Type P, in which there was a fetal type of posterior cerebral artery that was continuously delineated from the internal carotid artery (ICA) through the posterior communicating artery. All other variations in the circle of Willis were defined as Type O (ordinary type of variations). An additional 440 patients who did not harbor cerebral aneurysms were randomly selected for a comparison. Anterior communicating artery aneurysms were significantly related to the Type A anatomy and ICA aneurysms to Type P anatomy. Male patients who did not harbor aneurysms tended to have Type A anatomy, whereas women had a significantly greater incidence of Type P. CONCLUSIONS: This sex-linked difference in anatomical variations may be correlated to the well-known sex-linked difference in aneurysm distribution.