食管胃结合部腺癌的微创外科治疗

食管胃结合部腺癌具有相对独立的临床病理特征和治疗策略。随着微创外科的快速发展,部分早期食管胃结合部腺癌可通过腹腔镜或内镜手术获得治愈性切除。食管胃结合部腺癌的微创外科治疗应遵循恶性肿瘤根治手术的基本原则,重视术前分期评估的准确性,严格把握适应证,合理选择微创外科治疗方式。未来,应加强微创外科治疗的技术培训,进一步规范食管胃结合部腺癌微创外科治疗技术,并开展多中心、前瞻性、随机对照临床研究,明确食管冒结合部腺痛微创外科治疗的安伞件和疗效。     

胎羊单侧输尿管梗阻后肾脏病理相关研究

【摘要】〓目的〓探讨胎儿期发生单侧输尿管梗阻后,梗阻侧肾脏的病理变化过程。方法〓对孕75~85天的胎羊实行手术造成其单侧输尿管不完全性梗阻,在术后不同时期,取双侧肾脏(对侧肾脏作为对照),进行大体标本、组织学和分子学(PAX2和VEGF的表达)的检测。结果〓梗阻侧肾脏,表现为皮质变薄,皮质囊性改变、间质纤维化、肾小球数目减少;PAX2表达显著升高,而VEGF表达明显减少。结论〓在胎羊模型中,输尿管发生梗阻后,梗阻侧肾脏随之而来发生明显的病理变化。     

Biomechanical and anatomical considerations in lumbar spinous process fixation—an in vitro human cadaveric model

Background contextAlthough multiple mechanisms of device attachment to the spinous processes exist, there is a paucity of data regarding lumbar spinous process morphology and peak failure loads.PurposeUsing an in vitro human cadaveric spine model, the primary objective of the present study was to compare the peak load and mechanisms of lumbar spinous process failure with variation in spinous process hole location and pullout direction. A secondary objective was to provide an in-depth characterization of spinous process morphology.Study designBiomechanical and anatomical considerations in lumbar spinous process fixation using an in vitro human cadaveric model.MethodsA total of 12 intact lumbar spines were used in the current investigation. The vertebral segments (L1–L5) were randomly assigned to one of five treatment groups with variation in spinous process hole placement and pullout direction: (1) central hole placement with superior pullout (n=10), (2) central hole placement with inferior pullout (n=10), (3) inferior hole placement with inferior pullout (n=10), (4) superior hole placement with superior pullout (n=10), and (5) intact spinous process with superior pullout (n=14). A 4-mm diameter pin was placed through the hole followed by pullout testing using a material testing system. As well, the bone mineral density (BMD) (g/cm³) was measured for each segment. Data were quantified in terms of anatomical dimensions (mm), peak failure loads (newtons [N]), and fracture mechanisms, with linear regression analysis to identify relationships between anatomical and biomechanical data.ResultsBased on anatomical comparisons, there were significant differences between the anteroposterior and cephalocaudal dimensions of the L5 spinous process versus L1–L4 (p<.05). Statistical analysis of peak load at failure of the four reconstruction treatments and intact condition demonstrated no significant differences between treatments (range, 350–500 N) (p>.05). However, a significant linear correlation was observed between peak failure load and anteroposterior and cephalocaudal dimensions (p<.05). Correlation between BMD and peak spinous processes failure load was approaching statistical significance (p=.08). 30 of 54 specimens failed via direct pullout (plow through), whereas 8 of 54 specimens demonstrated spinous process fracture. The remaining cases failed via plow through followed by fracture of the spinous process (16 of 54; 29%).ConclusionsThe present study demonstrated that variation in spinous process hole placement did not significantly influence failure load. However, there was a strong linear correlation between peak failure load and the anteroposterior and cephalocaudal anatomical dimensions. From a clinical standpoint, the findings of the present study indicate that attachment through the spinous process provides a viable alternative to attachment around the spinous processes. In addition, the anatomical dimensions of the lumbar spinous processes have a greater influence on biomechanical fixation than either hole location or BMD.     

颈部三角吻合术在微创食管切除术中的应用

目的：评价三角吻合术在微创食管切除、食管胃颈部吻合术中应用的安全性和有效性。方法回顾性分析2013年1月至2014年3月在复旦大学附属中山医院胸外科接受胸腹腔镜食管癌根治切除加食管胃颈部吻合术的137例患者的临床资料,其中三角吻合77例（三角吻合组）,管状吻合60例（管状吻合组）。结果三角吻合组和管状吻合组术中吻合时间分别为（18．0±3．9） min 和（17．0±2．9） min,差异无统计学意义（P＝0．099）;术后吻合口瘘发生率分别为3．9％（3/77）和10．0％（6/60）,差异无统计学差异（P＝0．152）;吻合口狭窄发生率分别为1．3％（1/77）和15．0％（9/60）,差异有统计学意义（P＝0．002）。两组患者在围手术期死亡率、心血管并发症、肺部并发症等方面的差异均无统计学意义（P＞0．05）。结论颈部三角吻合术是一种安全、有效的吻合方法,可以降低术后吻合口狭窄的发生。     

家庭肠内营养对改善晚期胃癌患者生活质量的应用价值

目的研究家庭肠内营养（HEN）对晚期胃癌患者改善生活质量的意义。方法回顾性分析浙江省人民医院胃肠外科2010年6月1日至2012年6月1日连续收治的60例无法手术切除及复发转移的晚期胃癌患者的病历资料,根据是否进行HEN分为肠内营养（EN）组（25例）和对照组（35例）。EN组营养支持方式包括经空肠造瘘管EN、经鼻胃肠管完全或部分EN;对照组中存在胃癌伴梗阻的患者进行全肠外营养（TPN）,其余患者完全经口饮食。在持续1年的随访过程中,分别于第1、3、6和12月进行Kamofsky评分和Spitzer指数测定。第6月时行EORTCQLQ—c30评分。全组患者均接受FLOFOX4方案（奥沙利铂、四氢叶酸钙、氟尿嘧啶）静脉化疗。结果两组患者在基线资料方面差异无统计学意义。1年随访期间,两组共有53例患者死亡,其中EN组21例,对照组32例。KamoHky评分结果显示,EN组在第3、6、12月的评分结果分别为平均57．4、39．6和28．2,明显优于对照组的平均45．3、29．2和20．1（分别为P=0．041、P=0．012和P=0．015）。Spitzer评分结果显示,EN组在第3、6、12月的评分结果分别为5．12、4．04和2．54,也明显优于对照组的4．32、3．21和1．97（分别为P=0．048、P=0．035和P=0．024）。EROTCQLQ-30评分结果显示,EN组在功能量表方面同样均明显优于对照组（均P〈0．05）,“呼吸费力”、“疼痛”和“疲劳”阳性症状较对照组轻（分别为P=0．025、P=0．044和P=0．016）;但“腹泻”症状较对照组明显（P=0．047）。结论HEN作为一项营养干预措施,能在有限的生存期内改善晚期胃癌患者的生活质量。     

脊髓损伤的疫苗治疗

目的:总结目前脊髓损伤疫苗治疗基础研究的进展,分析脊髓损伤疫苗治疗的可行性,提出研究中的问题和进一步研究的方向。资料来源:应用计算机检索Medline1988-01/2004-12关于脊髓损伤疫苗治疗研究的文章。检索词“spinalcordinjury”and“vaccination”并限定文章的语种类为English。资料选择:对资料进行初审,纳入标准:①关于脊髓损伤疫苗应用可行性分析。②细胞免疫、体液免疫、主动性免疫和被动免疫及各种类型疫苗治疗分析研究。③关于脊髓损伤疫苗与实验性自身免疫性脑脊髓炎关系的研究。排除标准:重复性研究。资料提炼:共收集到符合上述要求的文献45篇,排除22篇重复性研究。23篇符合纳入标准:其中2篇关于脊髓损伤疫苗可行性分析研究,1篇关于脊髓损伤的综述,18篇关于细胞免疫、体液免疫、主动性免疫和被动免疫及各种类型疫苗治疗分析研究,2篇关于实验性自身免疫性脑脊髓炎与脊髓损伤疫苗关系的研究。资料综合:脊髓损伤后,血脑屏障的破坏使得脊髓损伤的疫苗治疗成为可能。脊髓损伤局部炎症在严格调控下可以起到修复和神经功能改善的作用。疫苗刺激的细胞免疫及体液免疫均可促进损伤后神经组织的修复。各种途径的脊髓损伤疫苗实验研究结果表明促进了轴突再生和神经功能的恢复,但不能完全杜绝实验性自身免疫性脑脊髓炎的发生。结论:脊髓损伤的疫苗治疗是一种免疫治疗方法,帮助机体自身治疗脊髓损伤。其实验研究结果较好,但也存在一定的问题。目前仍缺乏疫苗安全性和有效性的研究,将在进一步研究中得到完善。     

Renal Outcomes in Patients with Type 1 Diabetes and Macroalbuminuria

Macroalbuminuria, defined as urine albumin excretion rate (AER)≥300 mg/d, has long been considered a stage of irreversible kidney damage that leads reliably to GFR loss. We examined the long-term renal outcomes of persons with type 1 diabetes who developed incident macroalbuminuria during the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study. One hundred fifty-nine participants developed incident macroalbuminuria and were subsequently followed for a median duration of 9 years (maximum of 25 years). At the time of macroalbuminuria diagnosis, mean (SD) age was 37 (9) years, mean (SD) duration of diabetes was 17 (5) years, median AER was 524 mg/d, and mean (SD) eGFR was 108 (20) ml/min per 1.73 m². Ten years after macroalbuminuria diagnosis, the cumulative incidence of a sustained reduction in AER to <300 mg/d was 52%, mostly but not entirely under treatment with renin-angiotensin system inhibitors. The cumulative incidence of impaired GFR (sustained eGFR<60 ml/min per 1.73 m²) 10 years after macroalbuminuria diagnosis was 32%, including 16% who developed ESRD. Lower hemoglobin A1c and BP and regression to AER<300 mg/d were associated with reduced risk of developing impaired GFR. In conclusion, people with type 1 diabetes who develop macroalbuminuria are at high risk of progressive kidney disease. However, through at least 10 years of follow-up, AER could often be controlled, and GFR frequently remained in the normal range.Macroalbuminuria, defined as urine albumin excretion rate (AER)≥300 mg/d, has long been considered a stage of irreversible kidney damage that leads reliably to GFR loss.¹ In early published type 1 diabetes cohorts, macroalbuminuria was associated with a 15-year cumulative incidence of ESRD as high as 75%.^2,3 However, contemporary long-term renal outcomes of macroalbuminuria have not been fully characterized.The Diabetes Control and Complications Trial (DCCT) and its observational follow-up, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, present a valuable opportunity to examine macroalbuminuria and its long-term clinical outcomes. In DCCT/EDIC, the onset of macroalbuminuria can be defined with confidence using frequent longitudinal measurements of AER, participants have been followed for up to 25 years after the diagnosis of macroalbuminuria, and outcomes were meticulously recorded using standardized methods. Previous work in this cohort has shown that most cases of impaired GFR are preceded by macroalbuminuria,⁴ which is associated with a 50-fold higher risk of developing impaired GFR (eGFR<60 ml/min per 1.73 m²).⁵ Here, we extend these studies by comprehensively evaluating the long-term renal outcomes of incident macroalbuminuria in the DCCT/EDIC cohort and examining the risk factors for its progression to impaired GFR.