联合应用LC与EST治疗胆囊胆总管结石

目的: 探讨联合应用腹腔镜胆囊切除术(LC)与内镜十二指肠乳头括约肌切开术(EST)治疗胆囊和胆总管结石的疗效. 方法: 对18例病人术前按常规行B超或CT检查,证实为胆囊结石合并胆总管结石.11例先行LC,一个月后行ERCP检查并做EST治疗;7例先行B超、ERCP检查及EST,一周后行LC. 结果: 全组18例均获成功,无中转开腹及严重并发症. 结论: 联合应用LC和EST治疗胆囊结石合并胆总管结石的方法切实可行,具有创伤小、效果好、并发症少、恢复快等优点.     

ERCP、EST联合LC治疗胆囊结石合并胆总管结石的临床分析

目的:探讨内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)、内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆囊结石合并胆总管结石的临床疗效。方法:回顾分析2009年7月至2013年7月为145例胆囊结石合并胆总管结石患者行ERCP+EST+LC/腹腔镜胆总管探查术的临床资料,其中138例LC术前发现合并胆总管结石,先行ERCP+EST,根据EST术后并发症治愈情况再行LC;LC术后发现胆总管残余结石7例,于LC术后1周行ERCP+EST治疗。结果:术前发现合并胆总管结石的138例患者中,129例LC术前取石成功,胆总管结石完全排出,成功率93.5%,ERCP+EST术后出现胰腺炎或高淀粉酶血症11例,胆管炎1例,消化道出血1例,治疗痊愈后行LC。另有9例ERCP插管不成功后行开腹胆囊切除+胆总管探查T管引流术。LC术后发现胆总管残余结石7例,ERCP+EST取石均成功,无并发症发生。结论:ERCP+EST联合LC治疗胆囊结石合并胆总管结石具有创伤小、效果好、并发症少、康复快等优点,扩大了LC的指征,符合外科手术微创化的趋势,可在临床推广应用。     

LC联合内镜EST治疗胆囊结石合并继发胆总管结石的临床研究

目的探讨腹腔镜胆囊切除术（LC）与内镜十二指肠乳头括约肌切开术（EST）联合应用治疗胆囊结石合并胆总管结石的临床效果。方法全组患者先行EST，在B超引导下使用取石网篮取干净总胆管结石，取石后常规放置ENBD管，1周后行鼻胆管造影明确胆总管无结石后行LC治疗。结果全组20例均获得成功，无中转开腹及严重并发症。结论LC与EST联合应用治疗胆囊结石合并胆总管结石，有较好的疗效，具有创伤小、效果好、并发症少、恢复快等优点。     

内镜腹腔镜联合治疗胆囊结石合并胆总管结石

目的评价内镜腹腔镜联合治疗胆囊结石合并胆总管结石的价值. 方法选择性27例胆囊结石合并胆总管结石行ERCP检查,发现胆总管结石后,在11～12点位将乳头切开1.0～2.0 cm,＜1.0 cm的结石用取石网或球囊取出;＞1.0 cm的结石用碎石器粉碎后取出.ERCP术后3～7 d行LC. 结果 ERCP成功25例,其中胆囊管低汇流2例,乳头炎性狭窄6例.发现胆总管下段癌1例,1例EST后取石网篮取石嵌顿不能拖出,余23例经EST一次取石成功,并行LC手术成功.ERCP 2例失败,为十二指肠乳头严重水肿插管失败.ERCP EST术后轻型胰腺炎2例,高淀粉酶血症4例,对症治愈. 结论内镜ERCP与LC的联合应用对进一步明确胆石症诊断、选择手术方式、预防LC并发症具有重要价值.     

胆总管结石的微创治疗

目的探讨微创治疗胆总管结石的效果。方法 2007年1月～2009年1月,对126例胆总管结石采用微创治疗方法。对胆总管结石直径1.0cm,结石数目1～3枚的胆囊结石合并胆总管结石、胆总管结石以及腹腔镜胆囊切除(LC)术后胆总管结石患者先行ERCP,证实胆总管结石后行EST,网篮取石,球囊清理胆管,造影证实无残留结石。对操作次数多、胆汁黏稠、有残渣、乳头术后水肿可能性大的病例放置鼻胆管引流(ENBD)。对胆总管结石直径≥1.0cm且≤2.0cm的单发或多发结石或经EST取石失败者行LC,腹腔镜下胆总管切开取石,联合使用胆道镜行网篮取石,胆总管置T管引流。结石2～3cm者腹腔镜下胆总管切开取石,T管引流。结果 83例先行ERCP、EST者中,76例取石成功,4例网篮取石困难,未能取出结石,1例有结石残留(这5例于EST后4～6d行LC、腹腔镜胆总管切开胆道镜网篮取石、T管引流术成功),1例ERCP时十二指肠穿孔,1例网篮嵌顿于十二指肠乳头,急诊开腹。43例直接行LC、腹腔镜胆总管切开胆道镜网篮取石、T管引流术,均获成功。91例随访6～12个月,失访35例,无胆道感染、胆道狭窄、残余结石等并发症,未发现结石复发。结论 EST后LC是理想的治疗胆囊结石合并胆总管结石的方法 ,但要严格掌握适应证。     

腹腔镜、十二指肠镜联合治疗胆囊结石合并胆总管结石的临床应用

目的总结应用十二指肠镜下乳头括约肌切开术（endoscopic sphincterectomy,EST）联合腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）选择性治疗胆囊结石合并胆总管结石的经验。方法回顾性分析2008～2011年我院应用EST联合LC治疗72例胆囊结石合并胆总管结石的临床资料。胆囊结石直径0.5～3.0 cm,1枚或多枚,胆总管结石1.0～3.0 cm,数目1～3枚。均先行EST用碎石网篮碎石后取尽胆管结石,3～5天后再行LC术治疗胆囊结石。结果本组手术均获成功,无中转开腹,均痊愈出院。手术时间EST 46～100 min,LC 44～95 min,住院7～15 d,平均9.3 d。72例随访6～24个月,平均11.3月,无结石复发及严重并发症发生。结论 EST联合LC是治疗胆囊结石合并胆总管结石的安全、合理、有效的首选微创方法。     

腹腔镜联合十二指肠镜治疗肝外胆管结石

目的探讨腹腔镜胆囊切除（laparoscopic cholecystectomy,LC）联合十二指肠镜乳头括约肌切开术（endoscopic sphincterotomy,EST）治疗肝外胆管结石的临床价值。方法回顾性分析2006年11月～2008年11月我院60例胆囊结石合并胆总管结石行LC联合EST手术治疗的临床资料。均先行内镜逆行胰胆管造影（endoscopic retrogradec holangiopancreatography,ERCP）,其中2例由于ERCP提示胆总管下段严重狭窄而采用开放手术治疗。其余58例经EST取净结石放置鼻胆管引流（ENBD）,肝功能、血淀粉酶正常后行LC治疗。结果ERCP时2例胆总管下段严重狭窄,开腹行胆总管空肠Roux-en-Y吻合。其余58例EST取石成功并放置ENBD,其中2例继发轻型胰腺炎,保守治疗1周后血淀粉酶恢复正常。58例成功实施ERCP＋EST＋ENBD及LC,成功率96.7%（58/60）。无十二指肠漏、十二指肠乳头切开处出血、急性胆管炎和胆漏等并发症。55例随访6～24个月,平均13个月,未见胆管结石残留,无胰腺炎和胆管炎发生。结论ERCP＋EST后行LC手术是治疗胆囊结石合并胆总管结石的有效方法,有很高的临床应用价值,扩大了胆道微创治疗的范围。     

腹腔镜联合十二指肠镜治疗胆囊结石并胆总管结石

目的:探讨应用十二指肠镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)、内镜下十二指肠乳头切开术(endoscopic sphincterotomy,EST)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆囊结石合并胆总管结石的适应证、手术时机和临床效果。方法:回顾分析为63例胆囊结石合并胆总管结石患者采用ERCP、EST联合LC序贯治疗的临床资料。先行EST取出胆总管结石,再于2～5 d内行LC。结果:61例(97%)成功施行EST,2例失败,59例成功完成LC,无出血、胆漏等并发症发生。结论:联合应用EST和LC治疗胆囊结石合并胆总管结石安全可行,具有患者创伤小、康复快、并发症少及无需T管引流等优点,充分体现了当今外科领域微创化的治疗原则,可作为治疗胆囊结石合并胆总管结石的最佳选择。     

腹腔镜联合内镜逆行胰胆管造影术治疗胆囊结石合并胆总管结石的临床体会

目的:探讨内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)联合腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)治疗胆囊结石合并胆总管结石的最佳组合方式。方法:回顾分析2007年1月至2012年11月为203例胆囊结石合并胆总管结石患者行ERCP+内镜乳头括约肌切开术(endoscopic sphincterotomy,EST)联合LC的临床资料。其中138例先行ERCP+EST取出胆总管结石,再行LC(ERCP+LC组);65例先行LC再行ERCP+EST(LC+ERCP组)。对比分析两组手术成功率、总住院时间及并发症情况。结果:两组均无穿孔、出血及重症胰腺炎等严重并发症发生。ERCP+LC组住院时间短[(7.2±2.1)d vs.(8.1±1.9)d],差异有统计学意义(P<0.05)。ERCP+LC组术后胆管残余结石4例,发生急性轻型胰腺炎1例、胆管炎1例,并发症发生率为4.3%;低于LC+ERCP组的12.3%(P<0.05)。结论:对于胆囊结石合并胆总管结石的患者,先行ERCP+EST取石,再行LC,手术并发症较少,住院时间短,是较理想的组合方式。     

MRCP在微创技术治疗胆囊结石合并胆总管结石中的应用

目的评价MRCP在内窥镜联合腹腔镜治疗胆囊结石合并胆总管结石中的应用价值及其微创方式的选择。方法对B型超声检查未发现胆总管结石,但临床高度怀疑的65例胆囊结石病人行MRCP检查,确认胆总管有结石者行EST治疗,术后3~5d再行LC术;如未发现结石则可先行LC术,再根据术后的随访情况决定是否进一步行ERCP+EST。结果经MRCP检查发现胆总管结石13例,均成功行EST+LC术。未发现结石的52例仅行LC术。其中,除2例术后反复出现胆道感染、黄疸,经ERCP证实胆总管残留结石行EST取石外,其余病例术后随访1月~2年均未发现异常。结论根据MRCP检查结果选择不同的微创方式治疗可疑伴有胆总管结石的胆囊结石病人是安全可行的,可使胆总管无结石的可疑病人避免有创ERCP检查所带来的痛苦,值得推广。     

胰腺素腺瘤和囊腺癌的诊治

目的 探讨胰腺囊性肿瘤的诊断和治疗。方法 对1978-1998年收治的均经手术和病理检查证实为胰腺囊性肿瘤的11例临床资料进行回顾性分析。结果 胰腺囊性肿瘤好发于中青年女性,临床表现为病程较长的上腹部肿物和胀痛。钡餐、B超、CT及ER-CP能协助诊断,本组11例中行胰十二指肠切除2例,胰体尾加脾切除6例,肿瘤单纯切除2例,囊肿-空肠袢式吻合1例,手术切除率为90.9%,术后1例死于腹内感染并峰主血症术后存活的10例均获随访（100%）。1例胰腺囊腺瘤手术后3个月死于心肌梗死,1例胰腺囊腺癌术后4年3个月死于癌转移,其余均健在,结论 凡中青年女性,上腹或左上腹出现较大肿块,且病程较长。结合B超和CT检查可对本病的诊断,胰腺囊腺瘤或囊腺癌,癌体虽较大,均有完整的包膜,而易于分离切除,首选手术方式为包括部分胰腺组织的全肿瘤切除术,疗效满意。     

肾脏黏液样小管状和梭形细胞癌(附2例报道及文献复习)

目的 探讨肾脏黏液样小管状和梭形细胞癌(Mucinous tubular and spindle cell carcinoma,MTSCC)的临床及病理学特点.方法 对本院收治的2例肾脏黏液样小管状和梭形细胞癌患者临床及病理特点进行观察和讨论并结合相关文献复习.结果 2例患者术后诊断:肾脏黏液样小管状和梭形细胞癌.临床及病理特征符合相关文献对该型肾癌的报道,术后长期严密随访无复发.结论 MTSCC是罕见的肾癌分型,症状隐匿,具有独特的病理学特征,早期手术是最佳治疗方法,预后良好,罕见预后较差报道.     

Epidemiologic perspectives on immunosuppressed populations and the immunosurveillance and immunocontainment of cancer

The advent in the last several years of effective immunotherapy for cancer has renewed interest in the role of the immune system in controlling cancer. The idea that the immune system can help control cancer has a long history. Solid organ transplant recipients (SOTRs) as well as human immunodeficiency virus (HIV)–infected people are affected by cell‐mediated immune dysfunction. Epidemiologic studies of these populations reveal a pattern characterized by a strongly increased incidence of virus‐related cancers (eg, Kaposi sarcoma, non‐Hodgkin lymphoma, and anogenital cancers). In addition, recent epidemiologic studies have evaluated cancer‐specific mortality among SOTRs and HIV‐infected people following a cancer diagnosis. For a wider range of cancers—not limited to those caused by viruses, and including melanoma and cancers of the colorectum, lung, and breast— these immunosuppressed cancer patients have higher cancer‐specific mortality than other cancer patients. This latter group of cancers somewhat mirrors those for which immunotherapy with checkpoint inhibitors is approved. These epidemiologic observations suggest that there are 2 distinct immune selection processes in humans: immunosurveillance directed against premalignant cells before cancer diagnosis (most relevant for preventing virus‐related cancers), and “immunocontainment” directed against established cancers. These processes thus appear relevant for different groups of malignancies and may have different mechanisms.     

胆汁中氨肽酶N的分离、提纯及其促成核作用的初步研究

目的　观察氨肽酶N(APN )在胆石形成中的成核活性。方法　应用伴刀豆凝集素A亲和层析、羟基磷灰石柱层析及高压液相法从胆石症患者胆汁中分离、提纯胆汁中的APN ,并用模拟胆汁观察APN的成核活性。结果　最终APN纯化倍数达 2 94倍 ,酶的活性为12 .9nM·min-1·μg-1,分子量为 130kDa。随后在模拟胆汁观察到APN有明显的促成核活性。结论　APN在胆固醇结石形成中具有促成核作用。     

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study)

OBJECTIVES: The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane. METHOD: One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results. RESULTS: At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group. CONCLUSION: It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.     

单纯型和复杂型巨乳症的诊断及治疗

目的：探讨单纯型和复杂型巨乳症的临床特点,诊断要点及治疗方法,方法：回顾性分析1990－2000年民治21例巨乳症（37个乳房）,包括单纯型巨乳症16例29个乳房,复杂型巨乳症（巨乳症合并纤维腺瘤病等广范围病变者）5例8个乳房的临床,病理资料,结果：患者平均年龄23岁,21例均行手术治疗,16例单纯巨乳症者施以常规缩乳术,5例复杂型巨乳症中,2例为双乳腺纤维腺瘤病合并巨大型巨乳症,采用皮下腺体切除一期乳房成形术,2例几乎占据全乳的单乳巨纤维腺瘤并巨乳症,1例行皮下肿瘤切除,1例行肿瘤切除乳房成形术;1例双乳腺腺有块样物形成者行选择性腺体大部分切除乳房成形术。经随访至今患者乳房外形满意无肿瘤复发,结论：巨乳症好发于青春发育少女和青年妇女,诊断时应注意区别单纯型巨乳症和复杂型巨也症,术前B超,术中仔细探查及快速病检是必要的,单纯巨乳症常规缩乳术即可,复杂型巨乳症则应区别对待,彻底切除病变,一期乳房成形获得满意疗效,乳腺纤维腺瘤病合并巨乳症者,可采用皮下乳腺切除,真皮及皮下组织蒂一期乳房成形术。     

梗阻性黄疸患者血浆可溶性P-选择素与内毒素、D-二聚体的关系及其意义

目的　研究梗阻性黄疸 (梗黄 )患者血浆可溶性P -选择素 (sP selectin ,sP s)与内毒素 (ET )及D -二聚体 (D d)的关系及其意义。方法　应用ELISA和鲎试剂比色法测定梗黄组、急性胆囊炎组和健康人组血浆sP s ,D d和ET含量。结果　健康人组血浆sP s含量为 (93 .43± 17.65 )ng/ml ,ET (0 .0 0 3 0± 0 .0 0 0 4)EU /ml ,D d(0 .3 9± 0 .2 1)mg/L ;急性胆囊炎组血浆sP s含量为 (2 3 3 .3 2± 82 .12 )ng/ml ,ET (0 .40 12± 0 .15 0 6)EU /ml ,D d(0 .76± 0 .2 7)mg/L ;梗黄组血浆sP s含量为 (3 5 1.90± 93 .83 )ng/ml ,ET(0 .3 814± 0 .14 3 0 )EU /ml ,D d(2 .14± 0 .3 7)mg/L。急性胆囊炎组和梗黄组sP s ,D d及ET均高于健康人组 (P <0 .0 1) ;梗黄组ET与急性胆囊组差异无显著性 ,但梗黄组sP s和D d较急性胆囊炎组高 (P <0 .0 1) ,梗黄组的以上二物质含量呈正相关性 (P <0 .0 1) ;急性胆囊炎组sP s与ET呈正相关性 (P <0 .0 1)。协方差分析表明 ,在相同ET含量时 ,梗黄组sP s高于急性胆囊炎组 (P <0 .0 1) ,且与D d有相关性 ,二者有相同变化趋势。结论　胆道梗阻是ET致血管内皮细胞损伤和血小板活化的敏感性因素 ,梗黄患者血液高凝状态与继发性纤溶反应处于动态平衡 ,提示动态监测血浆sP s和D d变化 ,     

小胃癌及微小胃癌的诊断治疗:附28例报告

目的　探讨小胃癌及微小胃癌的诊断、治疗方法及病理特点。方法　对近 1 0年收治的2 8例小胃癌及微小胃癌的临床病理资料及诊断治疗方法进行回顾性分析。结果　本组微小胃癌 1 0例 ,小胃癌 1 8例 ,占同期早期胃癌手术病例的 34 .6 %。其中上消化道造影检出率为 8.3 % ,胃镜检查加活检的检出率为 78.8%。病灶均位于胃体和胃窦部。行胃癌D1根治术 6例 ,D2术 2 2例。小胃癌组的浸润深度显著深于微小胃癌组 (P <0 .0 5)。微小胃癌组无胃周淋巴结转移 ,小胃癌组淋巴结转移 2例 (1 1 .1 % )。术后 5年总生存率为 92 .9% ,其中微小胃癌组为 1 0 0 % ,小胃癌组为85.7%。结论　小胃癌及微小胃癌在早期胃癌中所占比例 >1 /3。胃镜检查加活检是诊断小胃癌及微小胃癌的主要手段 ,根治术后 5年生存率高 ,预后较好。     

胆囊十二指肠瘘的诊断与治疗

目的 探讨胆囊十二指肠瘘的发生机制、病理改变、诊断方法及治疗过程中的注意事项。方法 回顾性分析17年间收治的11例胆囊十二指肠瘘患者的临床资料。结果 全部经手术证实和治疗。10例继发于胆囊炎、胆囊结石；1例为溃疡病所致，仅1例于术前确诊。9例痊愈，2例死亡，均死于术后腹腔严重感染。结论 胆囊十二指肠瘘大多继发于胆囊炎和胆囊结石，多伴有胆囊萎缩、周围粘连明显等病理情况。X线检查、钡餐、ERCP等对诊断较有价值。治疗原则是切除胆囊、清除结石、切断瘘管、修补十二指肠瘘口，并根据情况探查胆总管或行胆肠内引流。     

Incidence and Predictors of Cancer Following Kidney Transplantation in Childhood

Cancer risk is increased substantially in adult kidney transplant recipients, but the long‐term risk of cancer in childhood recipients is unclear. Using the Australian and New Zealand Dialysis and Transplant Registry, the authors compared overall and site‐specific incidences of cancer after transplantation in childhood recipients with population‐based data by using standardized incidence ratios (SIRs). Among 1734 childhood recipients (median age 14 years, 57% male, 85% white), 289 (16.7%) developed cancer (196 nonmelanoma skin cancers, 143 nonskin cancers) over a median follow‐up of 13.4 years. The 25‐year cumulative incidences of any cancer were 27% (95% confidence intervals 24–30%), 20% (17–23%) for nonmelanoma skin cancer, and 14% (12–17%) for nonskin cancer (including melanoma). The SIR for nonskin cancer was 8.23 (95% CI 6.92–9.73), with the highest risk for posttransplant lymphoproliferative disease (SIR 45.80, 95% CI 32.71–62.44) and cervical cancer (29.4, 95% CI 17.5–46.5). Increasing age at transplantation (adjusted hazard ratio [aHR] per year 1.10, 95% CI 1.06–1.14), white race (aHR 3.36, 95% CI 1.61–6.79), and having a functioning transplant (aHR 2.27, 95% CI 1.47–3.71) were risk factors for cancer. Cancer risk, particularly for virus‐related cancers, is increased substantially after kidney transplantation during childhood.