高龄患者完全腹腔镜与开腹远端胃癌根治性切除术近期疗效分析

目的对比高龄患者远端胃癌行完全腹腔镜及开腹远端胃癌根治性切除术的近期疗效。方法选取2015年10月—2016年6月在海军总医院就诊的年龄≥70岁的远端胃癌患者77例,分为2组,腹腔镜组41例行完全腹腔镜下远端胃癌根治性切除术,开腹组36例行开腹远端胃癌根治性切除术,比较2组手术时间、术中失血量、淋巴结清扫数目、术后排气时间、术后住院时间、切缘阳性率、术后并发症（吻合口瘘、吻合口梗阻、肺部感染）发生率。结果腹腔镜组手术时间长于开腹组（P<0.05）,术中失血量少于开腹组（P<0.05）,术后排气时间、术后住院时间均低于开腹组（P<0.05）,淋巴结清扫数目多于开腹组（P<0.05）;切缘阳性率、术后吻合口瘘、吻合口梗阻、肺部感染发生率2组差异均无统计学意义（P>0.05）。结论高龄远端胃癌患者行完全腹腔镜下远端胃癌根治性切除术安全、可靠、创伤小,近期疗效优于开腹手术。     

内镜下黏膜剥离术术后出血的观察及护理

随着微创技术的不断发展,大部分消化道恶性肿瘤和没有转移的早期肿瘤都可以在内镜下进行剥离切除,内镜下黏膜剥离术(endoscopic submcosal dissection, ESD)是一项微创的新治疗技术可以免除传统手术的治疗风险,具有创伤小、疗效好、手术技术要求高的特点.ESD常见的并发症有出血、穿孔.     

关于腹腔镜外科医师培训的几点思考

腹腔镜外科的发展使外科技术发生了一场革命,微创外科将成为21世纪外科学发展的主要方向之一。随着器械更新及操作技术的进步,腹腔镜手术的总并发症率逐渐降低,基本与开放手术相当,但严重并发症率却高于传统开放手术,如胆道损伤、大血管损伤及肠穿孔等。分析原因,多数并发症的发生均与术者操作技术不熟练有关。由于腹腔镜外科医师存在“学习曲线”,由“学习曲线”导致的术中并发症是值得重视的问题。要努力减少由于“学习曲线”而产生的手术并发症,加强腹腔镜外科医师规范化的技术操作的培训是十分必要的。     

自膨式金属支架置入后择期手术与急诊手术治疗左半结肠癌伴急性肠梗阻患者的疗效比较

目的 比较自膨式金属支架（self-expanding metal stent,SEMS）置入与急诊手术（emergency surgery, ES）治疗左半结肠癌伴急性肠梗阻的临床疗效。方法 前瞻性收集2020年12月至2022年10月期间在南京医科大学附属苏州医院就诊的左半结肠癌伴急性肠梗阻患者的临床资料。使用随机数表法1∶1分配至SEMS组和ES组，主要结局指标为造口率和腹腔镜手术率。结果 最终纳入分析的SEMS组18例，ES组20例。SEMS组有更低的造口率（16.7%vs. 65.0%,P=0.004），更多的淋巴结清扫数（18.28 vs. 13.25,P=0.01）。SEMS组接受腹腔镜手术的患者比例显着高于ES组（66.7%vs. 10.0%,P=0.001）。SEMS组的术后并发症发生率低于ES组（22.2%vs. 40.0%,P=0.025）。结论 与ES相比，SEMS置入在治疗左半结肠癌伴急性肠梗阻的手术短期结果方面具有明显优势：更低的造口率，更少的术后并发症，更高的微创手术率，更符合现代微创外科及加速康复理念。     

全胸腔镜联合非气腹腹腔镜食管癌根治术72例

目的总结全胸腔镜联合腹部小切口腹腔镜辅助食管癌根治术的临床经验。方法行腔镜辅助下食管癌根治术72例,手术采用全胸腔镜辅助下经右胸游离胸段食管及肿瘤,并清扫纵隔淋巴结,上腹部正中小切口非气腹腹腔镜辅助下完成胃的游离、清扫腹腔内淋巴结及管状胃成型,左颈部切口完成胃食管吻合术。结果全组72例均经胸腔镜辅助下顺利完成食管癌切除术,平均手术时间4.5 h,其中胸腔镜游离平均时间1.6 h,术中平均出血量275 m l,平均每例清扫淋巴结35个,住院时间为6~15 d,平均8.5 d。无中转开胸。术后并发吻合口瘘1例,心律失常2例,肺部感染3例,并发症发生率83.3%,无死亡病例。结论全胸腔镜联合腹腔镜腹壁小切口辅助微创根治食管癌在技术上是安全可行、值得推广的手术方式。     

鼻内镜微创术在150例鼻窦手术中的应用

目的总结微创原则在鼻窦行鼻内镜手术中应用的经验。方法对150例(268侧)鼻内镜手术患者,按照微创外科原则进行手术,术中尽量保留鼻腔内正常的或者通过非手术治疗而可逆的病变黏膜组织,尽可能降低裸露的骨面,重视术前的系统准备、药物处理以及术后的换药等。结果随访6～12个月,其中131例治愈(87.3%),12例好转(8.0%),7例无效(4.7%)。未见严重手术并发症。结论鼻内镜手术中遵循微创外科原则对提高鼻窦手术的疗效意义重大。     

磁吻合技术

磁性压迫吻合技术(MCA)是借助内镜、介入放射学、微创外科技术等将永磁材料制成的吻合装置放入拟行吻合的相邻脏器之间,利用装置间的引力压迫脏器壁层造成局部缺血坏死而形成吻合的非手术治疗方法。该技术通过内镜和介入等微创手段完成,具有组织损伤小、操作简便等优点,在临床上可以实现胃肠吻合、胆肠吻合、肠肠吻合等空腔脏器间的吻合以及活体肝移植和胆肠吻合术后吻合口狭窄的重建等。相信,不久的将来,磁吻合技术作为一种安全有效的非缝合性吻合技术可能会应用于各个领域。     

内镜黏膜下剥离术治疗早期胃癌19例分析

早期胃癌（EGC）是指胃癌病变位于黏膜或黏膜下层,而无论病灶大小和是否有淋巴结转移。近年来开展的EGC内镜黏膜下剥离术（ESD）取得了良好的治疗效果,同时免除了传统手术治疗的风险及术后对生活质量带来的严重影响。我院自2008年1月至10月共采用ESD治疗EGC19例,并取得良好疗效,现将其治疗、并发症及预后分析如下。     

经下腹皮下通路腹腔镜下腹股沟淋巴结整块清扫术联合封闭式负压吸引技术治疗阴茎癌临床效果观察

目的 观察经下腹皮下通路腹腔镜下腹股沟淋巴结整块清扫术（HS-LILD）联合封闭式负压吸引技术（VSD）治疗阴茎癌的临床效果。方法 回顾性分析广西医科大学附属肿瘤医院自2011年5月至2021年5月收治的40例行双侧腹股沟淋巴结清扫术的阴茎癌患者的临床资料。根据治疗手段不同,将患者分入开放组（传统开放双侧腹股沟淋巴结清扫术;n=13,26侧）和腹腔镜组（经下腹皮下通路HS-LILD+VSD;n=27,54侧）。比较两组患者的术中出血量、术后住院时间、引流时间、术中淋巴结清扫数量及并发症发生率。结果 40例患者手术均顺利完成,腹腔镜组无术中转开放手术。腹腔镜组术中出血量少于开放组,术后住院时间和引流时间均短于开放组,差异有统计学意义（P<0.05）。开放组和腹腔镜组术中淋巴结清扫数量差异无统计学意义（P>0.05）。腹腔镜组皮瓣坏死、切口感染、淋巴瘘发生率及并发症总发生率低于开放组,差异有统计学意义（P<0.05）。结论 经下腹皮下通路HS-LILD联合VSD治疗阴茎癌与开放手术具有相当的控瘤效果,且可缩减术后住院时间和引流时间,减少术中出血量,降低并发症发生风险,利于...     

鼻内镜规范化治疗

作为内镜外科技术的重要组成部分，鼻内镜微创外科手术近10余年在国内外得到了广泛地应用。随着该项技术的日益普及，作为该项技术执行者的临床医师的资质、手术设备和手术规范等最终决定着手术疗效，因此，鼻内镜技术在继续纵深发展的同时，必须兼顾医师的规范化培训。     

直肠癌调强放疗中固定铅门技术和分野技术的剂量学比较

目的 研究直肠癌患者应用固定铅门技术(FJT)和分野技术(SFT),分析比较2种不同的调强放疗技术的剂量学差异。方法 选择15例直肠癌患者,进行CT模拟定位,勾画靶区及危及器官,对同一CT图像设计FJT计划和SFT计划。评估靶区及危及器官的剂量分布。结果 FJT计划组PTV₉₅覆盖度降低(t=-2.24,P<0.05);D_mean升高(t=2.54,P<0.05);HI较差(t=3.09,P<0.05),CI无差异。小肠V₅升高(t=4.76,P<0.05),骨髓V₂₀和V₅₀优于SFT计划组(t=-2.66、-3.36,P<0.05),而D_max高于SFT计划组(t=3.30,P<0.05);全身的V₂₀高于SFT计划组(t=2.48,P<0.05)。MU的数量和子野数量明显低于SFT计划组(t=-9.38、-6.46,P<0.05),计划验证通过率优于SFT计划组(t=10.46,P<0.05);治疗时间由原来的平均12 min缩短至6 min,缩短50%。结论 与SFT技术比较,直肠癌患者采用FJT技术,其靶区、危及器官受量均能满足临床治疗要求。患者治疗时间缩短,MU数量降低,单位时间内每天每台机器治疗患者的数量增加,减少患者的等待时间,降低加速器质量保证的难度。     

影像技术导引微创诊疗Ⅲ期非小细胞肺癌现状与应用

肺癌是当今患病率最高的胸部恶性肿瘤，其中以非小细胞肺癌占主要比例，且大多数患者在确诊时已为Ⅲ期，但治疗效果相对较差。目前影像导引微创治疗能够将肿瘤细胞于原位灭活，具有精确定位、精确治疗、创伤小、并发症少等优点，现已成为Ⅲ期肺癌的主要治疗方法之一。本文就各种导引技术、Ⅲ期非小细胞肺癌的治疗选择及微创诊疗现状与应用予以综述。     

Radiotherapy of Prostate Cancer with Multileaf Collimators (MLCs)

Background and Purpose: A technical modification for radiotherapy of prostate cancer is presented to smooth the scalloped dose pattern that occurs at treatment field edge, when a multileaf collimator (MLC) has been used. Material and Methods: Ten patients with prostate cancer receiving postoperative, adjuvant irradiation were studied prospectively. By a three-dimensional planning system (TMS, Helax 6.1B) the irradiation was planned for an 18-MV linear accelerator (Primus 1, Siemens). The volumes of interest (VOI) were the planning target volume (PTV; the region of the prostate including the seminal vesicles), the volume of rectum (V_rectum) and urinary bladder (V_bladder). Two four-field techniques (0°, 90°, 180°, 270°) were planned using beams eye view for setting the leaf position of the MLC. For technique A the MLC was adapted to the PTV using a 0° collimator angle for the lateral fields. For technique B the collimator angle of the lateral fields was optimized to compensate the cascade field shape. Dose-volume histograms of PTV, V_rectum and V_bladder were analyzed. The dose was prescribed for the reference point according to ICRU 50. Film dosimetry was used to show the dose pattern at the field edge produced by the two techniques. Results: Dose to PTV did not differ between technique A and B. Median dose to V_rectum was 82.6% for technique A and 77.3% for technique B (p < 0.001). Technique A irradiates a larger V_rectum than technique B being significant for all isodose levels tested. Median dose to V_bladder did not differ for technique A and B (p > 0.05). Conclusion: The presented technical modification is an effective method to blur the staggered dose distribution that results, when the MLC is conventionally stepped to adapt to the dorsal, irregular PTV border in irradiation of prostate. Especially for irradiation to escalated dose levels, this modification may reduce the dose to the rectum and thus the rectal side effects in comparison to the conventional MLC fields.     

钼靶X线摄片在乳腺癌诊断中的应用价值

目的讨论钼靶X线对诊断乳腺癌的应用价值。方法回顾性分析17例经手术病理证实的乳腺癌X线表现,包括直接征象和间接征象。结果17例乳腺癌患者的X线征象:肿块见于15例,占88.24%,钙化8例,占47.06%,乳腺导管扩张2例,占11.7%,乳晕增厚7例,占41.18%,乳头凹陷8例,占47.06%,乳后间隙肿块3例,占17.65%,液下淋巴结肿大8例,占47.06%。结论钼靶X线摄影是诊断乳腺癌的首选方法。     

早期贲门癌的胃肠双对比造影X线征象分析

目的探讨早期贲门癌的X线表现,提高对本病的认识。方洼回顾性分析经手术及病理证实的36例早期贲门癌的X线表现。结果36倒患者在钡餐造影检查中,主要表现黏膜异常增粗、紊乱、肥大,钡剂通过贲门缓慢,贲门痉挛,黏膜纠集、中断,局部呈结节样或大小不一的颗粒状阴影等。结论双对比造影时体位变换和流动技术的合理应用及胃泡充气良好是诊断早期贲门癌的关键技术,仰卧左前斜一右侧位的动态观察方法是早期贲门癌不可缺少的流动观察体住。     

Effect of brachytherapy technique and patient characteristics on cervical cancer implant dosimetry

Our purpose was to evaluate the relationship between brachytherapy technique and patient characteristics on dose to organs-at-risk (OARs) in patients undergoing high dose rate (HDR) brachytherapy for cervical cancer. From 1998 to 2008, 31 patients with cervical cancer with full dosimetric data were identified who received definitive external-beam radiation and HDR brachytherapy with tandem and ovoid applicators. Doses were recorded at point A, the International Commission on Radiation Units and Measurements (ICRU)-38 rectal point, the ICRU-38 bladder point, the vaginal surface, and the pelvic sidewall. Generalized estimating equations were used to determine the significance of changes in OAR to point A dose ratios with differences in brachytherapy technique or patient characteristics. Patients underwent a median of 5 brachytherapy procedures (range, 3 to 5), with a total of 179 procedures for 31 patients. For all brachytherapy treatments, the average ratios between the doses for the rectal, bladder, vaginal surface, and pelvic sidewall reference points to those at point A were 0.49, 0.59, 1.15, and 0.17, respectively. In general, decreased OAR dose was associated with a lower stage, younger age, increased ovoid size, increased tandem length, and earlier implant number. Increased tandem curvature significantly increased bladder dose and decreased rectal dose. Intravenous anesthesia usage was not correlated with improved dosimetry. This study allowed identification of patient and procedure characteristics influencing OAR dosing. Although the advent of 3-dimensional (3D) image-guided brachytherapy will bring new advances in treatment optimization, the actual technique involved at the time of the brachytherapy implant procedure will remain important.     

A Dosimetric Analysis of IMRT and Multistatic Fields Techniques for Left Breast Radiotherapy

The purpose of this study was to analyze the dosimetric difference between intensity-modulated radiation therapy (IMRT) using 3 or 5 beams and multistatic field technique (MSF) in radiotherapy of the left breast. We made comparative analysis of two kinds of radiotherapy that can achieve improved dose homogeneity. First is a MSF that uses both major and small irradiation fields at the same time. The other is IMRT using 3 or 5 beams with an inverse planning system using multiple static multileaf collimators. We made treatment plans for 16 early left breast cancer patients who were randomly selected and had undergone breast conserving surgery and radiotherapy, and analyzed them in the dosimetric aspect. For the mean values of V₉₅ and dose homogeneity index, no statistically significant difference was observed among the three therapies. Extreme hot spots receiving >110% of prescribed dose were not found in any of the three methods. Using Tukey's test, IMRT showed a significantly larger increase in exposure dose to the ipsilateral lung and the heart than MSF in the low-dose area, but in the high-dose area, MSF showed a slight increase. To improve dose homogeneity, the application of MSF, which can be easily planned and applied more widely, is considered optimal as an alternative to IMRT for radiotherapy of early left breast cancer.     

消融术治疗高危部位肝癌相关技术研究进展

消融治疗以其微创、疗效确切及可重复性好等特点,对包括肝细胞肝癌、肝内胆管细胞癌、转移性肝癌等在内的各类型肝癌的起着十分重要的作用。对于≤3 cm的病灶,消融治疗的疗效已可媲美手术切除。但当病灶位于肝门部、膈顶部、大血管旁及毗邻胃肠道等高危部位时,肝癌的消融疗效还不尽如人意。近年来,各种导航技术及消融辅助手段的出现帮助操作者提高了手术成功率,减少了周围脏器损伤,从而使肝癌消融变得更加安全和有效。该文对导航技术及消融术中各种辅助手段的相关原理、临床应用作一综述。     

高场磁共振灌注成像在胰腺癌诊断中的应用研究

目的 分析高场强磁共振灌注成像技术在胰腺癌中的诊断价值.方法 对33例怀疑胰腺癌的患者依次进行常规MR平扫、MR灌注成像及MR增强扫描,描绘瘤体区、瘤体周边区及正常区的时间-信号曲线(TIC),并分析各区域各项灌注参数的差异性,包括斜率(Slop)、峰值(PE)、达峰时间(TTP)及信号增强率(SR).结果 胰腺癌瘤体区TIC呈缓慢上升趋势,灌注参数Slop、PE、SR小于瘤体周边区及正常区,而TTP明显延长;瘤体周边及正常区TIC早期均呈快速上升趋势,达峰值后走行略有差异,但是瘤体周边的Slop、PE明显低于正常区,TTP略延长,SR无明显差异性;Ⅰ期、Ⅱ期和Ⅲ期、Ⅳ期之间Slop、TTP、SR无明显差异性.结论 MR灌注成像是功能性成像技术,作为常规形态影像学检查的一种补充,可以直观显示胰腺癌和周边胰腺组织的血流动力学改变,间接评估瘤体内肿瘤血管的情况,为胰腺癌的准确诊断及综合治疗提供有价值的信息.     

New ambulatory implant technique of high-dose-rate interstitial brachytherapy for prostate cancer

Purpose The aim of this study was to improve the performance status of prostate cancer patients during high-dose-rate interstitial brachytherapy (HDR-ISBT). To this end, we have developed a new ambulatory implant technique. Materials and methods Ten prostate cancer patients were treated with HDR-ISBT as monotherapy from October 2003 until March 2004. We utilized a new removable template, a flexible applicator with a nonmetallic bead and button stopper, and an inner catheter connecting the applicator and the transfer tube of the brachytherapy unit. We shortened the connector end of the flexible applicator to enable the patient to sit down and walk freely during the treatment time. Results All 10 patients could walk without any support. No problem in the application was observed. Conclusion Our new ambulatory implant technique for HDR-ISBT was able to improve the performance status of prostate cancer patients.