食管支架材料选择及在老年食管癌的应用

目的:分析组织工程人工食管不同代替材料的应用及相容性,探讨其在老年食管癌置入后的疗效,寻求永久性的人工植入材料。方法:以gene chip,protein chip,artificial neural network,gastrointestinal cancer,diagnosis"为英文检索词,"组织工程食管、人工食管,生物相容性,食管瘤,诊断"为中文检索词。由第一作者检索2000-01/2010-09PubMed数据及万方数据库,纳入与组织工程食管研究、人工食管置入后的生物相容性评价以及不同材料组织工程食管的实验分析相关的文献,排除重复性研究。保留中英文30篇文献进一步归纳总结。结果:目前人工食管主要的并发症有吻合口瘘、狭窄、坏死、反流等。未来人工食管的研究方向主要集中在人工食管的构建理念以及构建材料的选择上,主要有以下几种观点:①选择理想的材料并构建成合适的形状。②体外培养-移植体内-诱导食管再生。③研制一种可精确调控的可生物降解的生物型人工食管,直接将其植人机体内,并以此为支撑物,在体内最终诱导、再生出新生的食管。结论:组织工程食管的研究有朝着应用组织工程学方法构建与正常食管结构相类似的食管替代物,材料的选择从单一的生物惰性材料向可降解吸收的生物活性材料转变的多元化研究发展的趋势。     

食管支架材料选择及在老年食管癌的应用

目的：分析组织工程人工食管不同代替材料的应用及相容性,探讨其在老年食管癌置入后的疗效,寻求永久性的人工植入材料。方法：以gene chip,protein chip,artificial neural network,gastrointestinal cancer,diagnosis＂为英文检索词,＂组织工程食管、人工食管,生物相容性,食管瘤,诊断＂为中文检索词。由第一作者检索2000-01/2010-09PubMed数据及万方数据库,纳入与组织工程食管研究、人工食管置入后的生物相容性评价以及不同材料组织工程食管的实验分析相关的文献,排除重复性研究。保留中英文30篇文献进一步归纳总结。结果：目前人工食管主要的并发症有吻合口瘘、狭窄、坏死、反流等。未来人工食管的研究方向主要集中在人工食管的构建理念以及构建材料的选择上,主要有以下几种观点：①选择理想的材料并构建成合适的形状。②体外培养-移植体内-诱导食管再生。③研制一种可精确调控的可生物降解的生物型人工食管,直接将其植人机体内,并以此为支撑物,在体内最终诱导、再生出新生的食管。结论：组织工程食管的研究有朝着应用组织工程学方法构建与正常食管结构相类似的食管替代物,材料的选择从单一的生物惰性材料向可降解吸收的生物活性材料转变的多元化研究发展的趋势。     

壳聚糖管状支架联合肌瓣修补颈段食管部分缺损

背景：多年来使用肌肉、皮肤、骨骼肌瓣及胃、肠等管腔组织等作为人工食管修补食管缺损,但效果都不甚理想。目的：探讨壳聚糖管状支架联合肌瓣修补颈段食管部分缺损的可行性。方法：取30只大耳白兔,制作颈段食管部分缺损动物模型,实验组20只破损处植入壳聚糖管状支架,外覆自体颈部肌瓣修补;对照组10只直接覆盖自体颈部肌瓣修补。于植入后第2,4,8周观察支架吸收及破损处组织学变化;植入后第10周行食管钡透,观察有无狭窄发生及食管蠕动。结果与结论：植入后2周,实验组及对照组均见肌肉组织结构,细胞肿大,炎性细胞浸润,表现为急性炎症反应。植入后4周,实验组替代物肌瓣组织结构清晰,炎性反应减弱,无明显纤维组织增生;对照组缺损处肌组织结构可见,肌肉组织表面可见纤维组织细胞生长,伴有少许炎性细胞。植入后8周,实验组肌肉组织瓣表面大部分鳞状上皮化,可见食管黏膜组织,黏膜下伴有慢性炎性反应,较4周时明显减轻;对照组为慢性炎症反应,伴有明显纤维组织增生,表面无鳞状上皮化生及黏膜再生。钡餐透视显示实验组食管通畅无狭窄,蠕动减弱;对照组食管部分狭窄,无蠕动。表明壳聚糖管状支架联合肌瓣可较好修补颈段食管部分缺损。     

应用钛镍合金-硅橡胶组合式人工食管重建食管缺损

背景:当食管有病变时通常用胃来替代食管,这样将改变生理性消化通道,从而导致一些诸如返流、进食不畅、消化不良等并发症.如果有一种人工食管来替代病变食管,这些可能的并发症将显著减少,并简化手术操作.目的:观察食管部分切除后,应用钛镍合金硅橡胶组合式人工食管重建缺损部分的情况.设计、时间及地点:观察性动物体内实验,于1999-05/2001-05在广州医学院第二附属医院动物实验室完成.材料:选用普通家猪16只,体质量30～35 kg,雌雄不拘.钛镍合金硅橡胶人工食管,长10 cm,内径20mm,内层为硅橡胶,外层为钛镍合金网,由北京有色金属研究总院稀贵所提供.方法:以普通家猪作动物实验,切除一段长约7 cm的胸段食管,以人工食管替代,分别于术后第1,2,3,4,5,6,7,8周及第3,4,6,8,10,12个月处死动物,尸体解剖,标本作连续切片、苏木精-伊红染色病理观察.主要观察指标:动物尸体解剖情况,组织病理学观察缺损食管部分新生情况.结果:纳入家猪16只,1只因术中大出血休克死亡,1只因麻醉意外死亡,其余14只动物生存期从7 d～1年不等.①动物处死后,从原胸壁切口开始进胸,4只动物见胸壁存在小脓腔,腔内见黄白色脓液,已包裹,与胸腔不相通,1只动物人工食管脱落后滞留于胃内;1只动物因术中吻合时缝合的人工食管过多且边距不均匀,导致人工食管扭曲,形成食管内嵌.1周时间人工食管周围形成假道,即"新生食管",包绕人工食管.②"新生食管"起初以肉芽组织为主(约2周),2周后代以纤维结缔组织,4周后,食管上皮细胞爬行并可完全覆盖"新生食管"内腔,可观察到新生的平滑肌细胞,但未见到腺体再生.人工食管脱落后"新生食管"中间段均见不同程度的狭窄,随着时间的增加(约6个月后),狭窄段趋于稳定.结论:一定长度下的食管缺损可通过应用钛镍合金硅橡胶组合式人工食管重建修复.     

脱细胞猪主动脉基质重建犬颈段食管的实验

目的:探索用脱细胞猪主动脉基质重建食管缺损的可行性。方法:实验于2005-02/2006-02在解放军第二军医大学长海医院胸心外科研究所完成。选用健康杂种犬7只,清洁级,雌雄不拘,体质量16.5～19.4kg,采用酶消化法制备脱细胞猪主动脉基质,以脱细胞猪主动脉基质置换7只犬颈段2cm的食管缺损。分别于术后1,2,3个月各处死实验犬1只,取出新生食管。大体观察新生食管愈合、肉芽生长及黏膜爬行再生情况,常规法行光镜检查和扫描电镜检查,观察食管再生和改建情况。结果:7只实验犬除实验犬1因化脓性腹膜炎术后3d死亡外,其余6只均存活。①大体观察结果:所有实验犬术后未出现吻合口瘘,存活犬术后45～60d出现不同程度的狭窄症状,3只术后狭窄经扩张治疗后进食改善,体质量恢复到术前水平,1只在行狭窄扩张治疗时新生食管撕裂死亡。②食管再生和改建情况:脱细胞猪主动脉基质能诱导新生血管的形成,达到生物学固定;实验犬术后1个月新生食管完全上皮化,并可见血管平滑肌再生;术后2个月时黏膜上皮分化为8～10层,上皮下可见有序排列的胶原纤维;术后3个月时上皮进一步分化为8～12层,上皮下有序排列的胶原纤维较前增厚,并可见横纹肌岛状再生。脱细胞猪主动脉基质逐步降解吸收。结论:①脱细胞猪主动脉基质原位替代食管后未因排异反应和假体感染而脱落。②诱导了宿主食管组织上皮细胞、平滑肌和横纹肌细胞的再生,有望成为人工食管的理想替代材料。     

探析管状胃代食管术与全胃代食管术治疗食管癌的临床疗效

目的 探究食管癌治疗中,管状胃代食管术与全胃代食管术两种手术方式的临床效果。方法 选取2013年7月至2015年7月间在我院接受手术治疗的60例食管癌患者为研究对象,按照不同手术方法分为对照组和研究组,每组30例,对照组患者实施全胃代食管术治疗,研究组实施管状胃代食管术治疗,对比两组患者手术时间、术后引流时间、住院时间,观察患者反流性食管炎、胃食管吻合瘘以及胸胃综合症等不良反应发生情况。结果 两组在手术时间、术后引流时间及住院时间等方面数据差异较小,不存在统计学意义(P>0.05),但研究组患者不良反应发生明显低于对照组,差异存在统计学意义(P<0.05)。结论 与全胃代食管术相比,管状胃代食管术在食管癌患者的治疗中应用效果较佳,可显著降低术后不良反应发生情况,可推广应用。     

管状胃代食管术与全胃代食管术治疗食管癌的临床疗效探析

目的:探究食管癌治疗中,管状胃代食管术与全胃代食管术两种手术方式的临床疗效差异。方法:选取2013年7月~2015年7月在我院接受手术治疗的60例食管癌患者为研究对象,随机分为对照组和研究组,每组30例,对照组实施全胃代食管术治疗,研究组实施管状胃代食管术治疗,对比两组患者手术时间、术后引流时间、住院时间,观察患者反流性食管炎、胃食管吻合瘘以及胸胃综合征等不良反应发生情况。结果:两组在手术时间、术后引流时间及住院时间等方面数据差异较小,无统计学意义(P>0.05),但研究组患者不良反应发生明显低于对照组,差异存在统计学意义(P<0.05)。结论 :与全胃代食管术相比,管状胃代食管术在食管癌的治疗中应用效果较佳,可显著降低术后不良反应发生,值得推广应用。     

食管鳞癌两种食管重建方式术后并发症的比较

[目的]探讨管状胃食管重建在食管鳞癌手术的安全性、可行性及术后并发症的处理措施.[方法]回顾分析2007年9月至2012年9月收治的72例食管鳞癌患者的临床资料.其中42例行管状胃食管重建,30例行全胃食管重建,对比分析两种手术患者术后并发症,包括食管吻合口瘘、肺部感染、腹部切口感染、返流性食管炎、吻合口狭窄.[结果]管状胃食管重建术后各种并发症发生率均低于全胃食管重建术,差异有统计学意义（P＜0.05）.[结论]在食管鳞癌手术中,与全胃食管重建相比,管状胃食管重建在减少术后并发症方面具有明显优势,手术安全可靠,适于基层医院开展.     

脱细胞猪主动脉基质重建犬颈段食管的实验

目的：探索用脱细胞猪主动脉基质重建食管缺损的可行性。 方法：实验于2005-02／2006-02在解放军第二军医大学长海医院胸心外科研究所完成。选用健康杂种犬7只，清洁级，雌雄不拘。体质量163-19Akg，采用酶消化法制备脱细胞猪主动脉基质，以脱细胞猪主动脉基质置换7只犬颈段2cm的食管缺损。分别于术后1。2，3个月各处死实验犬1只，取出新生食管。大体观察新生食管愈合、肉芽生长及黏膜爬行再生情况，常规法行光镜检查和扫描电镜检查。观察食管再生和改建情况。 结果：7只实验犬除实验犬1因化脓性腹膜炎术后3d死亡外，其余6只均存活。①大体观察结果：所有实验犬术后未出现吻合口瘘，存活犬术后45—60d出现不同程度的狭窄症状。3只术后狭窄经扩张治疗后进食改善，体质量恢复到术前水平，1只在行狭窄扩张治疗时新生食管撕裂死亡。②食管再生和改建情况：脱细胞猪主动脉基质能诱导新生血管的形成，达到生物学固定；实验犬术后1个月新生食管完全上皮化，并可见血管平滑肌再生；术后2个月时黏膜上皮分化为8-10层。上皮下可见有序排列的胶原纤维；术后3个月时上皮进一步分化为8-12层，上皮下有序排列的胶原纤维较前增厚，并可见横纹肌岛状再生。脱细胞猪主动脉基质逐步降解吸收。 结论：①脱细胞猪主动脉基质原位替代食管后未因排异反应和假体感染而脱落。②诱导了宿主食管组织上皮细胞、平滑肌和横纹肌细胞的再生，有望成为人工食管的理想替代材料。     

镍钛合金人工食管替代食管后的组织反应与损伤

背景：前期实验证实镍钛合金人工食管是一种可用于替代被切除食管段,重建食管通道的食管人工代用品。目的：观察镍钛合金人工食管替代食管术后的组织反应及对邻近组织器官的损伤。方法：切除8只小型香猪一段70 mm胸段食管,将镍钛合金人工食管两端分别套入远近端正常食管腔内约10 mm,在食管与镍钛合金人工食管涤沦连接环作全层连续缝合吻合连接。术后第7天开始应用饮食调控方法调控脱管时间。分别在术后1,2,3,4个月各处死2只带管实验猪进行解剖,观察植入镍钛合金人工食管在新生食管形成过程中的组织反应和对紧密接触邻近组织器官的损伤。结果与结论：各时间段植入镍钛合金人工食管原位停留支撑,未见胸内出血、气胸、脓胸、食管穿孔、吻合口瘘等术后邻近组织器官损伤并发症。实验动物带管进食半固体食物无进食困难（Bown＇SⅡ级）。解剖所见：壁层胸膜与肺轻度膜状粘连,胸腔内无胸液,新生食管完全包裹人工食管,新生食管与邻近肺、主动脉器官组织轻度膜状粘连,未对邻近肺、主动脉及食管黏膜造成严重损伤,植入周期食管黏膜由食管残端向新生食管中间部再生延伸直到完全覆盖整条新生食管。新生食管组织学所见：镍钛合金人工食管替代食管植入周期的组织反应表现为无菌性炎症反应和异物反应,以术后1个月组织反应最为严重,随后逐渐减轻。     

不同缝皮材料对肺癌患者术后切口疼痛的影响

目的比较缝线与缝皮钉缝合切口对肺癌患者术后切口早期疼痛的影响,并总结护理经验。方法选取我院2011年1～12月肺癌开胸手术患者130例,对照组（缝线缝合切口）58例,观察组（缝皮钉缝合切口）72例。记录两组患者基本情况、手术麻醉情况、术后一般情况、咳嗽意愿评分、手术切口状况及主要护理干预措施,并根据简明疼痛问卷对患者术后早期疼痛情况进行评价。结果两组患者手术顺利,均痊愈出院。与对照组比较,观察组患者术后切口红肿和皮下积液发生率明显降低（P〈0．05）,咳嗽意愿评分明显提高（P〈0．01）,术后早期的1级、2级发生率有显著变化（P〈0．05）,1级疼痛患者数增加,2级疼痛患者数减少。结论不同切口缝合材料是肺癌开胸手术患者早期疼痛发生率不同的直接影响因素,与缝线相比,缝皮钉具有痛苦小、切口美观及愈合快的特点。护理上要求多翻身、叩背,指导并鼓励患者咳嗽、咳痰,及早下床活动。     

闭式心内膜下心肌活检术：介绍自制活检钩针及用法

随着“再灌注损伤”理论的阐明,对心肌保护的电镜研究面临着新的问题:即获取再灌注期心内膜下心肌,观察其缺血-再灌注损伤。由于此时心脏已经缝合复跳,一般方法不易取到内膜下心肌。我们自1984年秋季自行设计制成“活检钩针”,经离体羊心试用并修改针形摸索手法,同年12月用于临床取材制作电镜草品,1989年以后用于取材做光镜组化观察。迄今取材逾百,镜下观察效果满意,未发生并发症。本法取材制作均简易,手法易掌握,取活检效果可靠。方法较独特且用途可不限于心肌,值得介绍。     

The current evidence on stapled versus hand‐sewn anastomoses in the digestive tract

The innovation process and developments in technology have given surgeons new products which can improve their performance and benefit our patients. Before the era of laparoscopic surgery one of the most important applications in surgical practice was the introduction of staplers. In this article, the evidence supporting the decision whether to use a mechanical device (stapler) or to make a hand‐sewn anastomosis is presented. A sytematic review of the literature was performed. The search included published meta‐anaylses, randomized clinical trials and comparative studies. Key words for the initial search were: surgical anastomosis, stapler, hand‐sewn. There was no language restriction. The reference lists from the selected articles were also checked by the author. Literature data on main outcomes concerning the application of one or the other surgical technique have been analysed. The literature search yielded published data on various procedures in digestive surgery. Most of the available high‐quality evidence was for gastric and colorectal resections. Resection of the esophagus, use of staplers in emergency procedures and some initial reports on pancreatic surgery were also retrieved. The evidence from the literature shows that stapler anastomoses take less operative time and are more costly than hand‐sewn anastomoses. Regarding the morbidity and leaks rate the staplers give equal or better results when compared with the hand‐sewn technique. Nevertheless, proper handling of staplers and experience remain crucial issues if one wants to gain benefits when using these devices.     

Extracellular matrix remodeling following myocardial injury

While current therapeutic strategies restore blood flow to the ischemic myocardium and limit infarct size, adverse left ventricular (LV) remodeling that progresses to dysfunction remains a significant complication following myocardial infarction (MI). The extracellular matrix (ECM) is a key component in the remodeling process, and increases in collagen occur in the infarct area to replace necrotic myocytes and form a scar. The ECM is coupled to the cell through cell surface receptors, primary of which are the integrins. In addition, the matrix metalloproteinases coordinate ECM turnover through degradation of ECM components. Several laboratories have demonstrated matrix metalloproteinase (MMP) participation in remodeling events that lead to LV dilation, and inhibition or targeted deletion of specific MMPs has beneficial effects post-MI. MMP inhibition is a particular focus of recent studies designed to understand the underlying mechanisms of LV remodeling and to evaluate pharmacologic strategies that target the ECM to affect adverse LV remodeling following MI.     

Chemoattractant activity of degradation products of fetal and adult skin extracellular matrix for keratinocyte progenitor cells

Biological scaffolds composed of naturally occurring extracellular matrix (ECM) have been utilized as templates for the constructive remodelling of numerous tissues in preclinical studies and human clinical applications. The mechanisms by which ECM induces constructive remodelling are not well understood, but it appears that the degradation products of ECM scaffolds may play key roles in cell recruitment. The objective of the present study was to investigate the effects of age and species of the tissue from which ECM is harvested on the chemoattractant activity of degradation products of ECM for human keratinocyte stem and progenitor cells. Adult human skin ECM, fetal human skin ECM and adult porcine skin ECM were prepared, enzymatically digested, characterized by SDS-PAGE and evaluated for in vitro chemoattractant activity for human keratinocyte progenitor and stem cells (HEKn). Degradation products of human fetal skin ECM showed greater chemoattractant activity than human adult skin ECM degradation products for the HEKn. Degradation products of porcine adult skin ECM showed greater chemoattractant activity than human adult skin ECM. The human fetal skin ECM degradation products showed the strongest chemoattractant activity for the HEKn. The findings of this study support the concept that the mechanism of ECM scaffold remodelling involves the recruitment of lineage-directed progenitor cells by scaffold degradation products, and that both the age and species of the tissue from which the ECM is harvested have an effect upon this chemoattractant potential.     

Elastic fibres and vascular structure in hypertension

Blood vessels are dynamic structures composed of cells and extracellular matrix (ECM), which are in continuous cross-talk with each other. Thus, cellular changes in phenotype or in proliferation/death rate affect ECM synthesis. In turn, ECM elements not only provide the structural framework for vascular cells, but they also modulate cellular function through specific receptors. These ECM-cell interactions, together with neurotransmitters, hormones and the mechanical forces imposed by the heart, modulate the structural organization of the vascular wall. It is not surprising that pathological states related to alterations in the nervous, humoral or haemodynamic environment-such as hypertension-are associated with vascular wall remodeling, which, in the end, is deleterious for cardiovascular function. However, the question remains whether these structural alterations are simply a consequence of the disease or if there are early cellular or ECM alterations-determined either genetically or by environmental factors-that can predispose to vascular remodeling independent of hypertension. Elastic fibres might be key elements in the pathophysiology of hypertensive vascular remodeling. In addition to the well known effects of hypertension on elastic fibre fatigue and accelerated degradation, leading to loss of arterial wall resilience, recent investigations have highlighted new roles for individual components of elastic fibres and their degradation products. These elements can act as signal transducers and regulate cellular proliferation, migration, phenotype, and ECM degradation. In this paper, we review current knowledge regarding components of elastic fibres and discuss their possible pathomechanistic associations with vascular structural abnormalities and with hypertension development or progression.     

A look between the cardiomyocytes: the extracellular matrix in heart failure

The extracellular matrix (ECM) of the heart dynamically interacts with various cellular components of the myocardium, including the myocytes and connective tissue cells. With the development and progression of heart failure, left ventricular (LV) myocardial remodeling occurs. The progression of LV remodeling is accompanied by alterations in the structure and function of the ECM that occur after injury resulting from neurohormonal activation, changes in LV loading conditions, and alterations in myocardial perfusion and metabolism and is secondary to a host of nonmyocyte signaling pathways that affect repair and remodeling of the myocardium as a whole. This article attempts to review some of these processes and their interactions and to provide a focus to the often overlooked contribution of the ECM to the development and progression of heart failure and thereby its potential role as a target for therapy for heart failure.     

胸腔镜辅助小切口食管下段贲门癌手术

目的：总结21例胸腔镜辅助下小切口完成食管下段及贲门癌手术的治疗经验和体会。方法：全组病例均采用全麻双腔气管插管，电视胸腔镜辅助下左胸6cm小切口完成食管下段及肿块的游离，上腹旁正中约10cm的切口完成胃大小弯及贲门肿块的游离和切除，残胃与食管在胸内完成吻合。结果：1例死于术后并发症。余顺利出院。结论：电视胸腔镜下小切口完成食管下段及贲门癌的切除的术式，具有创伤小、恢复快、操作易等优点。     

Regulation of extracellular matrix remodeling and cell fate determination by matrix metalloproteinase stromelysin-3 during thyroid hormone-dependent post-embryonic development

Interactions between cells and extracellular matrix (ECM), in particular the basement membrane (BM), are fundamentally important for the regulation of a wide variety of physiological and pathological processes. Matrix metalloproteinases (MMP) play critical roles in ECM remodeling and/or regulation of cell-ECM interactions because of their ability to cleave protein components of the ECM. Of particular interest among MMP is stromelysin-3 (ST3), which was first isolated from a human breast cancer and also shown to be correlated with apoptosis during development and invasion of tumor cells in mammals. We have been using intestinal remodeling during thyroid hormone (TH)-dependent amphibian metamorphosis as a model to study the role of ST3 during post-embryonic tissue remodeling and organ development in vertebrates. This process involves complete degeneration of the tadpole or larval epithelium through apoptosis and de novo development of the adult epithelium. Here, we will first summarize expression studies by us and others showing a tight spatial and temporal correlation of the expression of ST3 mRNA and protein with larval cell death and adult tissue development. We will then review in vitro and in vivo data supporting a critical role of ST3 in TH-induced larval epithelial cell death and ECM remodeling. We will further discuss the potential mechanisms of ST3 function during metamorphosis and its broader implications.     

颈阔肌皮瓣重建下咽癌切除后颈段食管缺损的护理

颈阔肌皮瓣重建颈段食管缺损是自行设计的新手术方法。术前做好心理护理、口腔护理 ,防止呼吸道感染发生 ,加强营养 ,全面做好手术准备。术后密切观察颈部伤口 ,固定好重建食管腔内支架管 ,加强口腔、鼻咽部护理 ,严格气管造口管理 ,做好饮食护理 ,以减少术后并发症的发生。