可回收金属支架在胆管良性狭窄中应用配合方法探讨

随着内镜附件及内镜技术的不断发展,内镜下放置胆道金属支架姑息性治疗胆胰管恶性狭窄已是目前较为成熟的治疗方法。但对于胆管良性狭窄患者而言处理起来相对较为棘手,传统的治疗方法为外科手术或经皮肝内球囊扩张胆管狭窄。外科手术并发症多、风险大。经皮肝球囊扩张成功率低、复发率高。而内镜下气囊扩张狭窄胆管及置入支架是目前治疗胆管良性狭窄首选方法。我科2010年1月开始将可回收金属支架应用于肝外胆管良性狭窄患者,得到较好的治疗效果,现将可回收胆道金属支架应用时一些操作配合方法报告如下。     

肝移植术后胆管并发症的内镜治疗价值

目的评估肝移植术后胆管并发症内镜治疗的临床价值。方法我院从2001年3月至2006年10月进行的45例肝移植中,术后出现胆管并发症16例,其中胆漏1例,胆管狭窄8例,胆管狭窄并胆管结石2例。11例接受了内镜介入治疗计14次,包括内镜下放置鼻胆管外引流4例,放置支架内引流10例,气囊扩张10例,乳头括约肌小切开7例,乳头括约肌切开加取石2例。结果1例因内镜治疗时导丝无法通过狭窄段,改行PTC放置胆管支架,其余胆管并发症经内镜介入治疗有效。结论ERCP有助于肝移植术后胆管并发症诊断,治疗有效、安全,是肝移植术后胆管并发症首选治疗方法。     

内镜逆行胰胆管造影术在良性胆管狭窄中的应用

随着内镜技术及设备的发展,消化内镜在临床工作中占据了举足轻重的地位。近年来,良性胆管狭窄(benign biliary strictures,BBS)已不再仅由外科治疗。内镜检查手段的更新、全覆膜金属支架的应用、新型可降解支架的研发,为BBS的诊断及治疗开启了新的领域。本文主要着眼于内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)在BBS中的应用。     

ERCP在腹腔镜胆囊切除术后胆管并发症诊治中的应用

目的探讨内镜逆行胰胆管造影（ERCP）在腹腔镜胆囊切除术（LC）后胆管并发症诊治中的应用价值。方法对96例LC术后胆管并发症者行ERCP检查,并根据检查结果给予相应处理。结果本组ERCP显示,胆管残余结石70例,45例采用括约肌切开术（EST）,25例采用乳头气囊扩张术（EPBD）,结石排出67例;胆总管部分狭窄17例,行胆管扩张和内镜逆行胆管内引流术（ERBD）,术后随访1a狭窄解除12例;胆总管完全横断5例,2例行ERBD,黄疸减退后均行外科胆管空肠Roux—en—Y吻合;胆瘘4例,3例经EST治疗后症状减轻,避免手术,1例症状无改善接受手术治疗。结论对Lc术后胆管并发症者行ERCP,有助于明确病因,并指导相应的治疗。     

自膨式金属支架治疗远端胆管恶性狭窄优于塑料支架

【据Clinical Gastroenterology and Hepatology 2020年12月报道】题:自膨式金属支架治疗远端胆管恶性狭窄优于塑料支架(作者Jang S等)经内镜逆行胰胆管造影(ERCP)引导下放置支架治疗胆管恶性狭窄是非常有效的。来自克利夫兰诊所的Jang等进行了一项队列研究,比较了塑料支架(PS)和自膨式金属支架(SEMS)的疗效及不良结局。     

鼻胆管引流预防经内镜逆行胰胆管造影术后胰腺炎及高淀粉酶血症临床分析

目的 探讨经内镜鼻胆管引流术（ENBD）预防经内镜逆行胰胆管造影（ERCP）术后并发急性胰腺炎和高淀粉酶血症的临床疗效.方法 将成功完成ERCP术并有可能发生胰腺炎及高淀粉酶血症的75例患者分成A、B两组,A组35例,术后均行鼻胆管引流,并与B组（40例,非引流患者）比较,观察术后2小时和24小时血清淀粉酶变化及急性胰腺炎的发生情况.结果 A组患者ERCP术后高淀粉酶血症发生率为12.6%,明显低于B组的32.2%（P＜0.05）;A组无急性胰腺炎发生,亦明显低于B组的6.85%（P＜0.05）.结论 经内镜鼻胆管引流能够有效地预防ERCP术后急性胰腺炎及高淀粉酶血症的发生.     

诊断与治疗性胰胆管造影在胆管损伤中的临床应用

目的探讨胰胆管引流（ERCP）在胆管损伤诊断中的作用及其临床应用疗效。方法总结1999年3月至2004年3月收治的31例胆管损伤患者，行诊断性ERCP，选择有内镜治疗价值者作为实施对象，行乳头肌切开术（EST）、鼻胆管引流、塑料支架支撑引流等内镜治疗。结果31例胆管损伤中，胆总管横断或结扎3例，胆管狭窄13例，胆瘘15例，22例（34次）接受内镜治疗，占71％。13例胆管狭窄中，有7例行塑料支架支撑治疗维持8～20个月，4例疗效满意，3例疗效欠佳；15例胆瘘患者行EST、鼻胆管引流，13例胆瘘愈合，2例无效，其中7例因胆管狭窄或有狭窄倾向置入塑料支架支撑维持4～12个月。6例发生术后高淀粉酶血症。结论ERCP对胆管损伤有定性和定位诊断意义，多数胆瘘和部分胆管狭窄患者通过内镜治疗获得痊愈，早期内镜治疗可简化治疗方案，避免再次手术。     

ERCP放置胆管内支架姑息治疗难以切除的恶性胆管梗阻

目的探讨ERCP放置胆管内支架对难以切除的恶性胆管梗阻的临床治疗效果。方法对54例恶性肿瘤引起的梗阻性黄疸患者,经ERCP将导丝插入胆管并超过梗阻部位,扩张狭窄处,用推送导管将已经选择合适的引流支架置于胆管适当部位,其两端均超过梗阻段2cm以上。结果54例患者中51例插管成功,3例插管不成功的患者中1例乳头开口于憩室内,另2例肿瘤完全阻塞导丝无法通过。成功率为94.44%(51/54)。34例胆管内放置8FZ型自膨胀式金属支架,其余20例行8～10F塑料内支架引流。术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻。其中39例2周内血清总胆红素下降50%以上,血清总胆红素退至34μmol/L以下。放置胆管内支架1周后,患者血清总胆红素由术前235.45±56.67μmol/L降至78.36±37.58μmol/L,肝功能较术前显著改善(P<0.05,P<0.01)。31例胆总管下段梗阻患者与12例肝门部胆管梗阻患者相比,放置胆管内支架引流治疗1周、2周后,其胆红素下降明显优于肝门部胆管梗阻患者(P<0.01)。34例放置胆管金属支架患者中,有12例于术后2个月发生支架阻塞,再次放置塑料内支架后引流通畅,1例放置金属支架术后患者第10个月出现支架阻塞予以再次植入金属支架。另外20例放置塑料内支架者,有3例于术后1～4周出现血清总胆红素再次上升,经ERCP检查发现支架移位和阻塞,予以更换内支架,其中1例植入塑料双支架。结论经ERCP内镜下胆管放置内支架,对解除恶性胆管梗阻性黄疸、缓解症状、提高患者生存质量具有满意疗效,对胆总管下段梗阻性黄疸的疗效优于肝门部胆管梗阻。     

ENBD在预防肝吸虫病患者ERCP术后并发胰腺炎的临床价值

目的观察内镜鼻胆管引流术(ENBD)预防肝吸虫性胆道梗阻内镜逆行胰胆管造影术(ERCP)术后并发急性胰腺炎的临床效果。方法收集我院因肝吸虫性胆道梗阻行ERCP治疗的患者106例,其中ENBD组65例,对照组41例,比较两组术后急性胰腺炎的发生率。结果 ENBD组术后发生急性胰腺炎3例(9.2%),对照组则为5例(29.3%),两组比较差异有统计学意义(P0.05)。结论 ENBD能有效预防肝吸虫性胆道梗阻患者ERCP术后急性胰腺炎的发生。     

跨越十二指肠主乳头平行放置双侧金属支架治疗肝门部胆管恶性狭窄的临床研究(含视频)

目的:探讨内镜下跨越十二指肠主乳头平行放置双侧胆管金属支架治疗肝门部胆管恶性狭窄的成功率和疗效。方法:回顾性纳入2012年1月—2018年12月在上海东方肝胆外科医院内镜中心采用改良内镜引流技术(内镜下跨越十二指肠主乳头平行放置双侧金属支架)治疗的肝门部胆管恶性狭窄(Bismuth Ⅱ～Ⅳ型)患者共55例,分析技术成功...     

Relative prevalence of gallstone diseases in Taiwan

For many years, it has been said that Taiwan has the highest relative prevalence of hepatolithiasis among the Asian countries. To confirm this, and to reevaluate the chronological changes regarding gallstone disease in Taiwan, a retrospective nationwide cooperative study was conducted in this country. A total of 17,182 patients from 28 medical centers are included in this survey. A gradual increase during the past 20 years in gallstone prevalence with a concomitant decrease of choledocholithiasis and hepatolithiasis are well demonstrated. Both nutritional and environmental factors are involved in these changes. With respect to hepatolithiasis, Taiwan continues to have the highest prevalence among Asian countries, and 20% may be the average figure for the whole country.The study was conducted with the cooperation of the following 28 institutions: Cathay Memorial Hospital, Chang-Hua Christian Hospital, Cheng Ching General Hospital, Chia-Yi Lin General Hospital, Chung Shan Medical & Dental College, Far Eastern Memorial Hospital, 802 Army General Hospital, 803 Army General Hospital, 804 Army General Hospital, Keelung Chang-Gung Memorial Hospital, Keelung Navy Hospital, Kaohsiung Chang-Gung Memorial Hospital, Kaohsiung Medical College, Kaohsiung Yuan's General Hospital, Kuang Tien General Hospital, Minshen General Hospital, National Cheng Kung University Medical College and Hospital, Provincial Hsinchu Hospital, Provincial Taichung Hospital, Provincial Taoyuan Hospital, Sha-Lu Tung's Memorial Hospital, Taipei Chang-Gung Memorial Hospital, Taipei Mackay Memorial Hospital, Taitung Mackay Memorial Hospital, Triservice General Hospital, Tzu-Chi Buddhist General Hospital, Veterans General Hospital-Taichung, and Veterans General Hospital-Taipei.     

肺动脉扩张对AECOPD频繁入院的预测价值

目的 了解肺动脉扩张对AECOPD患者频繁入院的预测价值.方法 收集我院呼吸内科78例患者临床资料,回顾性分析患者基本资料、肺功能测定、影像学指标,将其分为频繁入院组和非频繁入院组,对有统计学意义的危险因素,进行多因素Logistic回归分析.结果 频繁入院组FEV1占预计值%、FVC占预计值%,FEV1/FVC比值、主动脉直径低于非频繁入院组,频繁入院组肺动脉直径、PA/A＞1所占比例大于非频繁入院组,差别具有统计学意义.多因素分析示PA/A＞1为AECOPD频繁入院的独立危险因素.结论 本研究发现肺动脉扩张（PA/A＞1）对AECOPD患者频繁入院有一定预测价值.     

General thoracic surgery in Finland,a perspective from the Helsinki University Hospital

The field of thoracic surgery is a rapidly developing field due to exciting developments in technology and oncologic treatments as well as continuous innovation in surgical technique. Although the population of Finland is relatively small, general thoracic surgery is represented at a high level in five centralized university centers, Helsinki University Hospital, Tampere University Hospital, Turku University Hospital, Kuopio University Hospital and Oulu University Hospital. Thus, high case volume and good results are achieved in these centers. Here, we describe a short history, current state and future prospects of the field of cardiothoracic surgery in Finland, with a focus on general thoracic surgery and the perspective of Helsinki University Hospital. From the field’s birth in Finland, marked by the first lobectomy, in the late 1930’s, it has grown and adapted more and more modern techniques such as totally minimally invasive esophagectomy and robotic lung cancer surgery. Nowadays, most of general thoracic surgery in Helsinki University Hospital is either minimally invasive or robotic and open surgery is the exception to the norm. Helsinki University Hospital has a strong presence in the European general thoracic surgery community and aims to do so in the future by investing on training & education, research and surgical innovation.     

Minimally invasive esophagectomy learning curves with different types of background experience

BackgroundMinimally invasive esophagectomy (MIE) is a complex procedure with learning associated morbidity. The aim was to evaluate the learning curve for MIE focusing on short-term outcomes in two settings: (I) experienced MIE surgeon in new hospital (Hospital 1); (II) surgeons experienced with open esophagectomy and minimally invasive surrogate surgery (Hospital 2).MethodsIn Hospital 1 and Hospital 2, on intent-to-treat basis number of MIEs were 132 and 57, respectively. The primary outcomes were major complications and anastomosis leaks. Secondary outcomes were operative time, blood loss, lymph node yield, hospital stay and 1-year mortality. Length of learning curves were analyzed with risk-adjusted cumulative sum (RA-CUSUM) method.ResultsIn Hospital 1, major complication and anastomosis leak rates were 9.8% and 4.5%, 22.8% and 12.3% in Hospital 2, respectively. In Hospital 1, complication and leak rates remained stable. In Hospital 2, improvement occurred after 34 cases in major complications and 29 cases in leaks. Of secondary outcomes, improvements were seen in Hospital 1 in operative time after 61, blood loss after 86, lymph node yield after 52, hospital stay after 19 and 1-year mortality after 24 cases. In Hospital 2, improvement occurred in operative time after 30, blood loss after 15, lymph node yield after 45, hospital stay after 50 and 1-year mortality after 15 cases.ConclusionsAccording to this study, learning phase of the individual surgeon determines the outcomes of MIE, not the institutional learning phase.     

社区医师中风病康复培训的研究与思考

目的对社区康复医师进行中风病康复知识培训,观察培训后的效果,总结社区康复人才的培养策略。方法对北京10家社区卫生服务中心的17家社区卫生服务站的康复工作人员共20名进行摸底、培训、现场指导、考核。调研这20名康复医师的学历、职称、工作经验、从事的科室、康复知识的掌握情况,通过培训后,进行4次考核,比较这些康复医师康复知识水平的变化。结果社区康复医师在培训前后对中风病康复知识的掌握情况,第2次与第1次比较、第4次与第2次比较,P<0.05,差异有统计学意义。结合正确回答人数情况,说明社区康复医师在康复培训后对康复知识掌握情况明显提高。结论社区康复医师在康复培训后对康复知识掌握情况明显提高。     

A new tube for exfoliative cytology of the esophagus and stomach

Summary The technique described above has been used over a period of several months in the Marion County General Hospital and the Indianapolis Veterans Hospital. An analysis of the cases thus examined has not yet been carried out. The pathologists who have been accustomed to interpreting gastric washings for malignant cells in these hospitals have been impressed with the superiority of the material provided by the means described.Fellow in Gastroenterology, Marion County General Hospital, 1960–61.From the Clinical Research Laboratory of Eli Lilly & Co., Marion County General Hospital.     

535例心血管疾病高危人群中医体质分布特点分析

目的 分析心血管疾病高危人群的中医体质分布特点。方法 运用心血管疾病危险初筛工具,筛查出535例心血管疾病高危人群,然后再进行中医体质辨识,发现中医体质类型的分布特点,最后对相关因素进行分析。结果 通过调查研究发现,535例心血管疾病高危人群的体质类型中,平和体质253例,占47.3%;偏颇体质282例,占52.7%,其中以气虚质为主,占13.5%。心血管疾病高危人群的性别、年龄、体质指数(BMI)不同分组中的中医体质分布差异有统计学意义(P<0.01)。结论 心血管疾病高危人群的中医体质分布特点,平和体质占主导地位,偏颇体质依次以气虚质、痰湿质、阳虚质、阴虚质为主。     

降钙素原检测在细菌感染中的应用研究

目的探讨血清降钙素原(procalcitonin, PCT)定量检测在细菌感染患者中的诊断价值。方法选取2016年9月—2018年5月在我院住院治疗并发生医院细菌感染者131例,比较血清PCT水平在不同年龄、不同感染严重程度患者之间以及革兰阳性菌和革兰阴性菌感染患者之间的差异。结果 131例患者血清PCT水平均高于正常值;年龄<60岁组与年龄≥60岁组PCT水平比较,差异无统计学意义(P> 0.05);脓毒症组血清PCT水平明显高于局部感染组(P <0.05);革兰阴性菌感染组血清PCT水平明显高于革兰阳性菌感染组(P <0.05)。结论 PCT可以作为细菌感染的重要诊断指标,并能够对患者感染严重程度进行评估。     

BOOK REVIEW FOR GASTROENTEROLOGISTS

Book review in this article:
SURGICAL DISEASES OF THE PANCREAS: John M. Howard, M.D., F.A.C.S., Professor and Chairman, Department of Surgery, Hahnemann Medical College, and Surgeon in Chief, Hahnemann Hospital, Consultant in Surgery, Walter Reed Army Medical Center, Washington, D. C., etc. and George L. Jordan, Jr., M.D., M.S., F.A.C.S., Associate Professor in Surgery, Baylor University College of Medicine, Consultant in Surgery, Veterans Administration Hospital, Attending in Surgery, Methodist Hospital and Jefferson Davis Hospital, Houston, Texas     

阿奇霉素对MPP患儿的疗效及对血清sIL-2R、IL-6、IL-17及IL-23的影响

目的探讨阿奇霉素治疗肺炎支原体肺炎(mycoplasma pneumoniae pneumonia, MPP)患儿的临床效果及对患儿血清可溶性白细胞介素-2 受体(soluble interleukin-2 receptor, sIL-2R)、IL-6、IL-17、IL-23 水平的影响。方法选取我院 2018 年 1—8 月收治的 142 例 MPP 患儿作为研究对象,采用随机数字表法分为阿奇霉素组和红霉素组各 71 例,2 组基础治疗保持一致;对比 2 组患儿的临床效果,sIL-2R、IL-6、IL-17 及 IL-23 水平,各项临床症状缓解时间及不良反应。结果阿奇霉素组的咳嗽消失时间、肺部啰音消失时间、退热时间均短于红霉素组(P 均< 0.05);治疗前,2 组患儿的sIL-2R、IL-6、IL-17 及 IL-23 水平差异无统计学意义(P 均> 0.05);治疗 7 d 后,阿奇霉素组患儿的 sIL-2R、IL-6、IL-17及 IL-23 水平均低于红霉素组(P 均< 0.05);治疗 10 d 后,阿奇霉素组的临床效果优于红霉素组(P < 0.05);阿奇霉素组的不良反应发生率为 5.63%低于红霉素组的 16.90%(P < 0.05)。结论阿奇霉素治疗 MPP 患儿效果优于红霉素,能有效缓解患儿的临床症状并降低 sIL-2R、IL-6、IL-17 及 IL-23 水平。