腹腔镜下完整全结肠系膜切除治疗右半结肠癌的临床疗效分析

目的探讨腹腔镜下完整全结肠系膜切除(CME)对右半结肠癌患者的临床疗效。方法选取2016年11月至2018年11月我院收治的右半结肠癌患者85例,分为观察组43例和对照组42例,观察组行腹腔镜下CME治疗,对照组行开腹CME手术治疗,比较两组患者的临床效果及术后情况。结果两组患者术后皮质醇(COR)、促肾上腺皮质激素(ACTH)、肾上腺素(E)均明显高于本组术前,且两组间比较差异有统计学意义(P0.05);观察组术中出血量、排气时间、下床时间、住院时间、并发症率明显低于对照组(P0.05),两组手术时间、淋巴结清扫数、复发率比较,差异无统计学意义(P 0.05)。结论腹腔镜下CME可有效减少患者的手术创伤、应激反应,有利于减少患者术后并发症、缩短其术后恢复时间,对于右半结肠癌患者可优先选择腹腔镜CME。     

腹腔镜下全结肠系膜切除对右半结肠癌根治术患者手术效果及恢复情况的影响

目的探讨腹腔镜下全结肠系膜切除(CME)对右半结肠癌患者的手术效果及恢复情况的影响。方法选取2015年1月-2017年12月右半结肠癌患者70例,依据随机数字表分为腹腔镜组和开腹组,每组35例。腹腔镜组行腹腔镜下CME治疗,开腹组行开腹CME手术治疗,比较两组患者的治疗结果及恢复情况。结果两组患者术后皮质醇(COR)、促肾上腺皮质激素(ACTH)、肾上腺素(E)均明显高于术前,腹腔镜组术后COR、ACTH、E明显低于开腹组,差异均有统计学意义(P<0.05);两组患者的手术时间、淋巴结清扫数和复发率比较,差异均无统计学意义(P>0.05),腹腔镜组术中出血量、排气时间、下床时间、住院时间和并发症率明显少于开腹组,差异均有统计学意义(P<0.05)。结论腹腔镜下CME与开腹术式的治疗效果一致,且可有效减少患者的手术创伤、减轻应激反应,有利于减少患者术后并发症、缩短术后恢复时间,对于右半结肠癌患者应优先选择腹腔镜CME术式进行治疗。     

中间入路法在腹腔镜与开腹右半结肠癌根治术中的应用

目的探讨中间人路法在腹腔镜辅助与传统的开腹右半结肠癌根治术中的临床应用价值。方法将65例结肠癌患者按不同的手术方法分为2组：腹腔镜组（腹腔镜辅助下右半结肠癌根治术组,35例）和开腹组（传统的开腹右半结肠癌根治术组,30例）。腹腔镜组患者行腹腔镜辅助下中间人路法右半结肠癌根治术,开腹组患者行传统的开腹中间入路法右半结肠癌根治术。观察2组患者术中出血量、手术时间和术后肛门排气时间、淋巴结清扫数目、术后住院时间及术后并发症（肺部感染、肠梗阻和切口感染）发生的情况。结果腹腔镜组无中转开腹。腹腔镜组患者的术中出血量、手术时间、术后排气时间及术后住院时间与开腹组比较差异均有统计学意义（均P〈0.05）,腹腔镜组患者的淋巴结清扫数目和肠梗阻、肺部感染及切口感染发生率与开腹组比较差异均无统计学意义（均P〉0.05）。结论采用中间入路法,无论行腹腔镜辅助下右半结肠癌根治术,还是行传统的开腹右半结肠癌根治术,均具有手术视野和解剖层次清晰、容易游离、损伤小、并发症少及安全、有效等优点,且腹腔镜辅助下中间入路法右半结肠癌根治术的术中出血量、术后排气时间及住院时间均优于传统的开腹中间入路法右半结肠癌根治术。     

腹腔镜辅助右半结肠癌全结肠系膜切除的淋巴结清扫效果及并发症观察

目的观察腹腔镜辅助右半结肠癌全结肠系膜切除的临床疗效。方法选择2013年1月至2016年1月右半结肠癌患者96例,将其随机分为两组,每组48例。两组患者均行全结肠系膜切除术,对照组给予开腹右半结肠癌根治术,观察组借助腹腔镜开展手术。对比两组患者手术情况及并发症发生情况。结果观察组淋巴结清扫数目为(22.4±2.9)个,明显多于对照组[(16.9±2.4)个],差异有统计学意义(P0.05);观察组术中出血量、术后排气时间等其他手术指标明显优于对照组,差异有统计学意义(P0.05);观察组术后并发症发生率明显低于对照组,差异有统计学意义(P0.05)。结论腹腔镜辅助右半结肠癌全结肠系膜切除可显著增强淋巴结清扫效果,预防并发症,可取得较佳的预后效果。     

右半结肠癌完整结肠系膜切除技巧及疗效分析

目的探讨右半结肠系膜癌行完整结肠系膜切除(CME)的手术技巧及疗效差异。方法 57例Ⅰ~Ⅲ期右半结肠癌患者,行CME患者28例纳入CME组,行传统结肠癌根治术患者29例纳入传统组,比较2组患者手术时间、术中出血、淋巴结清扫数目、术后恢复时间、术后半年、1年、2年复发与转移情况。结果 CME组淋巴结清扫总数[(20.1±7.1)枚]和阳性淋巴数[4(0,10)枚]明显多于传统组[(16.6±5.3)枚、2(0,6)枚],手术时间[(205.4±35.5)min]、术中出血量[(151.8±67.3)mL]、术后排气时间[3(2,4)d]、进食时间[5(4,6)d]和术后3年复发转移率(28.6%)明显少于传统组[(224.0±35.5)min、(231.0±100.4)mL、4(2,6)d、5(4,6)d、51.7%],差异均有统计学意义(P0.05)。结论 CME在右半结肠癌患者可提高淋巴结清扫数量、缩短手术时间、减少术中出血量,促进患者术后恢复,降低术后复发与转移,提高患者生存率。     

腹腔镜全结肠系膜切除术21例回顾分析

目的:探讨腹腔镜全结肠系膜切除术(complete mesocolic excision,CME)的可行性、安全性及有效性。方法:回顾分析2012年6月—2014年6月在江苏省常熟市第一人民医院普外科行腹腔镜CME的21例患者(腔镜组)与行结肠癌开腹手术的27例患者(开腹组)的临床资料。比较2组患者术中出血量、淋巴结清扫数目,术后开始下床时间、肛门排气时间、进半流食时间,住院天数、住院费用和并发症情况。结果:腔镜组与开腹组性别、年龄、分化程度、TNM分期、淋巴结清扫数目、并发症发生率差异均无统计学意义(P0.05);腔镜组术中出血量、术后开始下床时间、肛门排气时间、进半流食时间、住院天数、住院费用均少于或早于开腹组(P0.05、0.01)。结论:腹腔镜CME安全、可行、有效,较开腹手术存在多方面的优势。     

手辅式腹腔镜右半结肠癌根治术在老年肥胖患者中的应用及评价

目的评价手辅式腹腔镜右半结肠癌根治术在老年肥胖患者中的疗效及应用价值。方法回顾性分析行手辅式腹腔镜右半结肠癌根治术的老年肥胖患者20例,并与同期行开腹右半结肠癌根治术的老年肥胖患者25例进行对照,对比两组的手术安全性、术后恢复、肿瘤根治性以及应激反应的指标。结果两组均无手术死亡病例,均行一期吻合,手辅式腹腔镜组（A组）无一例中转开腹;A组手术时间与开腹手术组（B组）差异无显著性（P〉0.05）;A组术中出血量少、术后体温恢复快、排气快、下床活动早,术后住院时间短,与开腹组相比较,差异具有显著性（P〈0.01）;A组手术切除标本长度、清扫淋巴结总数及术后并发症分别与B组相比较,差异无显著性（P〉0.05）;C反应蛋白、白介素6、促肾上腺皮质激素及皮质醇浓度两组手术后均明显升高,但B组升高比A组明显（P〈0.05）。结论运用手辅式腹腔镜技术能集中开放和腹腔镜手术的优势完成复杂的手术,手辅式腹腔镜右半结肠癌根治术对肥胖患者是一种安全、有效的手术方式,对术后恢复和机体应激反应有明显的改善,能体现出微创的优势,有较高的临床应用价值。     

右半结肠癌行完整结肠手膜切除术和传统根治术近期疗效的分析

目的:探讨完整结肠系膜切除术(complete mesocolic excision,CME)在右半结肠癌手术中的临床应用价值。方法:回顾性分析我科2012年6月至2014年6月收治的27例行CME治疗的右半结肠癌患者和同期行传统根治术治疗的32例右半结肠癌患者的临床病理资料,评价手术质量,对比短期疗效。结果:CME组达到优层面切除26例(96.3%),显著高于对照组14例(43.8%),淋巴结清扫平均总量CME组明显多于传统结肠癌根治术,阳性淋巴结检出率CME组Dukes A期患者与对照组相比无显著差异,Dukes B期和C期患者阳性淋巴结检出率明显高于对照组,两组比较差异有统计学意义。CME组在手术时间、术中出血量、术后排气时间、住院时间及并发症发生率与传统根治术相比无统计学意义。结论:CME手术通过高质量的标准化手术完整切除结肠系膜并最大化地清扫淋巴结,从而提高结肠癌的手术疗效,且不增加手术风险及术后并发症,临床上值得推广。     

手辅式腹腔镜在老年肥胖患者右半结肠癌根治术中的应用

目的 观察手辅式腹腔镜(HALS)应用于老年肥胖患者右半结肠癌根治术中的安全性及有效性.方法行HALS右半结肠癌根治术的老年肥胖患者20例(HALS组),同期行开腹右半结肠癌根治术的老年肥胖患者25例为对照组,比较两组手术安全性、术后恢复情况、肿瘤根治结果以及应激反应等指标.结果两组均无手术死亡病例,均行一期吻合,HALS组无一例中转开腹,手术时间与开腹手术组差异无统计学意义(P>0.05);HALS组术中出血量少、术后体温恢复快、排气时间早、下床活动早、术后住院时间短,与开腹组相比差异有统计学意义(均P<0.01);HALS组手术切除标本长度、清扫淋巴结总数及术后并发症与开腹手术组差异无统计学意义(均P>0.05);C-反应蛋白、白细胞介素-6、促肾上腺皮质激素及皮质醇浓度两组手术后均明显升高,但开腹手术组升高更明显(均P<0.05).结论运用HALS技术能集开放和腹腔镜手术的优势完成复杂的手术,HALS右半结肠癌根治术对肥胖患者是一种安全、有效的手术方式,对术后恢复和机体应激反应有明显的改善.     

手助腹腔镜与全腹腔镜在右半结肠癌根治术中应用的前瞻性病例对照研究

目的探讨手助腹腔镜与全腹腔镜在右半结肠癌根治术中的应用价值,对比分析两种术式的优劣,为术式选择提供客观依据。方法 316例右半结肠癌患者分别采用手助腹腔镜右半结肠癌根治术(手助腹腔镜组,n=167)和全腹腔镜右半结肠癌根治术(全腹腔镜组,n=149)行右半结肠癌根治术。分析指标包括手术时长、术中出血量、术后疼痛级别、术后引流量、切口美容评分、住院时间、住院费用及并发症比率等。结果手术时长、术中出血量及术后引流量手助腹腔镜组明显低于全腹腔镜组,差异有显著性(P0.05);术后胃肠功能恢复时间手助腹腔镜组高于全腹腔镜组,差异有显著性(P0.05);并发症比率、住院时间及住院费用两组间比较差异无显著性(P0.05);术后疼痛级别手助腹腔镜组高于全腹腔镜组,差异有显著性(P0.05);切口美容评分全腹腔镜组高于手助腹腔镜组,差异有显著性(P0.05)。结论手助腹腔镜右半结肠癌根治术在手术时长、术中出血量及术后引流量等方面具有优势,切口美容评分、术后疼痛程度及术后胃肠功能恢复时间全腹腔镜右半结肠癌根治术优于手助腹腔镜术式,对于操作熟练的术者,可优先选用全腹腔镜操作。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.