广东省住院医师规范化培训教学病例讨论实施指引

教学病例讨论是住院医师规范化培训（住培）的重要教学模式,旨在培养住院医师的临床思维能力,但目前缺乏成熟的实施指引。为更好地发挥教学病例讨论的作用,广东省医师协会毕业后医学教育工作委员会组织广东省部分住培教学专家,参考省内各大医学院校的经验,结合专家组的临床教学体会,形成广东省住院医师规范化培训教学病例讨论实施指引,供广东省住培教学参考。     

小鼠异体Sertoli细胞诱导胰岛移植免疫耐受的作用

Objective To study whether the sertoli cell allograft can achieve the immunotolerance and protect the co-transplant islet allograft on the heterotopic situation. Methods The diabetic C57 mice were used as recipients, and healthy BALB/C mice as islet donors,respectively. Healthy BALB/C and C57 mice were used as testis sertoli cell donors. The recipients were randomly divided into 4 groups,6 mice in each group : group A: only transplant with islet allograft;group B: co-transplant with islet allograft and serto-li isograft;group C:co-transplant with islet allograft and sertoli allograft;group D:sham-operated group. The blood and urine glucose levels in the models, and the survival time of the graft were observed. Results The mean survive time of graft in groups A, B, and C was (6.50±2.35 ), (55.67±4.84), and (51.33± 5.05 ) days respectively. In group D, blood glucose level was abnormal. The hyperglycemia of the diabetic C57 mice could be reversed by the transplant methods of groups B and C. The mean survival time in groups B and C was longer than in group A P < 0.05, but there was no significant differences between groups B and C,P > 0.05. Conclusion The sertoli cells can induce local immunotolerance and protect the co-transplant islet allograft. Sertoli cell isograft can obtain the same local immunotolerance as the sertoli cell allograft.     

高脂血症对直肠癌开腹及腹腔镜手术合并症的影响

目的 探讨高脂血症状态对直肠癌手术合并症的影响.方法 回顾分析2005年3月至2009年9月接受开腹或腹腔镜直肠癌根治术的382例患者的临床资料,根据患者术前的血脂水平,分为高脂血症组及正常血脂组,采用卡方检验和t检验处理相关临床数据.结果 术前合并高脂血症的自肠癌患者201例,血脂正常者181例.高脂血症组患者与正常血脂组患者相比,手术出血量增多(t=11.318,P＜0.01)、术后恢复进食时间(t=5.956,P＜0.01)及拔除引流管时间延长(t=4.781,P＜0.01)、伤口脂肪液化发生率升高(x2=3.988,P＜0.05),术后住院天数亦增加(t=2.449,P＜0.05),而手术时间(t=0.374,P＞0.05)及吻合口瘘发生率(x2=0.239,P＞0.05)两者差异无统计学意义.直肠癌接受腹腔镜手术患者,与开腹手术患者相比,手术出血量少(t=10.078,P＜0.01)、术后恢复进食(t=6.366,P＜0.01)及拔除引流管时间短(t=7.654,P＜0.01)、住院天数少(t=4.241,P＜0.01)、伤口脂肪液化发生率低(x2=5.203,P＜0.05),但手术时间延长(t=8.456,P＜0.01).接受腹腔镜手术的患者中,高脂血症组患者与正常血脂组患者相比,虽然术中出血仍较多(t=8.784,P＜0.01),但在术后恢复进食时间(t=0.356,P＞0.05)、术后住院天数(t=0.248,P＞0.05)、拔除引流管时间(t=0.261,P＞0.05)等方面,差异无统计学意义.结论 直肠癌患者术前合并高脂血症会导致手术出血量增加、术后恢复时间延迟、伤口脂肪液化发生率升高,应用腹腔镜技术进行直肠癌根治术可消除因高脂血症所导致的术后恢复延迟.

Abstract：

Objective To study the effect of hyperlipidemia on postoperative complications in patients of colorectal cancer (CRC) undergoing open or laparoscopic surgery. Methods Clinical data of 382 CRC patients who received either traditional or laparoscopic operation from Mar. 2005 to Sep. 2009 were reviewed. By preoperative blood lipid levels, patients were divided into hyperlipidemia group and normal blood lipid group. Data were analyzed by Chi-square test and T test. Results In hyperlipidemia group of 201 CRC cases, volume of blood loss ( t = 11.318, P ＜ 0.01 ), time to resume oral intake( t =5.956, P ＜ 0.01 ), drainage tube removing (t = 4.781, P ＜ 0.01 ), hospital stay( t = 2.449, P ＜ 0.05 ), and incidence of wound liquefaction( x2 =3.988 ,P ＜0.05) were inferior to the other 181 cases in normal blood lipid group, while no difference was observed in operation time ( t = 0.374, P ＞ 0.05 ) and incidence of anastomotic leakage( x2 = 0.239, P ＞ 0.05 ). Patients who received laparoscopic operation had less blood loss (t=10.078 ,P ＜0.01 ), less time to resume oral intake(t =6.366,P ＜0.01 ) and earlier drainage tube removing ( t = 7.654, P ＜ 0.01 ), shorter hospital stay ( t = 4.241, P ＜ 0.01 ) and lower incidence of wound liquefaction ( x2 = 5. 203, P ＜ 0.05 ), though longer operation time ( t = 8.456, P ＜ 0.01 ) comparing with those receiving traditional operation. Among patients who received laparoscopic operation, there was no difference observed postoperatively in time to resume oral intake ( t = 0.356, P ＞ 0.05 ) and drainage tube removing (t = 0.261, P ＞ 0.05 ), and hospital stay (t = 0.248, P ＞ 0.05 ) between the hyperlipidemia group and normal blood lipid group, though the former suffered from more blood loss (t =8.784,P ＜0.01).Conclusions Hyperlipidemia impacts adversely on hemorrhage, delayed recovery and increasing rate of wound liquefaction on rectal cancer surgery. Laparoscopic surgery effectively eliminates prolonged postoperative recovery caused by hyperlipidemia.     

“弹琵琶”手法在小儿男性腹股沟斜疝术中的应用

目的探讨在小儿男性腹股沟斜疝术中寻找疝囊的简便技巧。方法男性腹股沟斜疝择期手术患儿129例(144侧),应用"弹琵琶"手法寻找疝囊,行疝囊高位结扎术。结果全部病例均顺利找到疝囊,行高位结扎疝囊144侧;切口平均长度为1.0 cm,术中寻找疝囊时间平均2.5 min,平均手术时间12.7 mim;术后近期阴囊轻度水肿12例,未发生其他并发症;平均随访21月,2例单侧巨大型腹股沟斜疝患儿术后复发;5例术后出现对侧腹股沟斜疝。结论在小儿男性腹股沟斜疝择期手术中,应用"弹琵琶"手法寻找疝囊,行疝囊高位结扎术,可达到操作简便、微创、快速、安全的效果。     

3D腹腔镜治疗胃肠肿瘤44例临床分析

目的探讨3D腹腔镜在胃肠肿瘤手术中的应用。 方法回顾性分析2013年10月至2015年6月应用Olympus 3D腹腔镜系统完成手术44例的临床资料,其中右半结肠切除术12例,左半结肠切除3例,乙状结肠切除11例,低位直肠前切除术10例,远端胃癌根治术8例,统计分析手术时间、出血量、术后住院时间等数据。 结果44例胃肠肿瘤腹腔镜手术均获成功,无中转开腹。手术时间为(173.52±48.65) min,术中出血量为(71.59±35.17) ml,术后住院时间为(8.66±2.21) d。 结论3D腹腔镜成像系统还原了三维立体手术视野,手术解剖更精细,从而减少手术并发症发生,降低手术难度,缩短手术时间,具有腹腔镜和开腹的优势,适合更复杂的腹腔镜手术。     

小鼠异体Sertoli细胞诱导胰岛移植免疫耐受的作用

Objective To study whether the sertoli cell allograft can achieve the immunotolerance and protect the co-transplant islet allograft on the heterotopic situation. Methods The diabetic C57 mice were used as recipients, and healthy BALB/C mice as islet donors,respectively. Healthy BALB/C and C57 mice were used as testis sertoli cell donors. The recipients were randomly divided into 4 groups,6 mice in each group : group A: only transplant with islet allograft;group B: co-transplant with islet allograft and serto-li isograft;group C:co-transplant with islet allograft and sertoli allograft;group D:sham-operated group. The blood and urine glucose levels in the models, and the survival time of the graft were observed. Results The mean survive time of graft in groups A, B, and C was (6.50±2.35 ), (55.67±4.84), and (51.33± 5.05 ) days respectively. In group D, blood glucose level was abnormal. The hyperglycemia of the diabetic C57 mice could be reversed by the transplant methods of groups B and C. The mean survival time in groups B and C was longer than in group A P < 0.05, but there was no significant differences between groups B and C,P > 0.05. Conclusion The sertoli cells can induce local immunotolerance and protect the co-transplant islet allograft. Sertoli cell isograft can obtain the same local immunotolerance as the sertoli cell allograft.     

异位甲状旁腺腺瘤并肾功能不全1例

病例资料 患者男,55岁．因“腰部酸痛1年”于2004年7月26日入住我院泌尿外科。查体：双侧肾区叩击痛阳性。既往有高血压病史,个人史、家族史均无特殊。实验室检查：血钙3．36mmol／L,血磷1．33mmol／L,血碱性磷酸酶（AKP）85．0mmol／L,BUN16．61mmol／L．Cr 312．8μmol／L。B超示：双肾结石,右侧输尿管上段结石并右肾重度积水。先后行右肾穿刺造瘘,右侧输尿管切开取石．左肾经皮肾镜碎石取石,术后结石无残留。     

腹腔镜胃癌根治术后营养支持的临床疗效

目的 探讨肠内营养与肠外营养对腹腔镜胃癌根治术后营养不良患者的临床疗效.方法 通过前瞻性对照研究分析2007年12月至2010年4月在中山大学附属第三医院行腹腔镜胃癌根治术60例患者营养支持的临床资料,按随机数字表法分为肠内营养组和肠外营养组(每组各30例),比较营养支持后两组患者的人体测量学,营养学指标,营养相关并发症及费用.计量资料采用t检验,计数资料采用x2检验.结果 肠内营养组患者体质指数、三头肌皮褶厚度、上臂肌围、Hb、转铁蛋白、Alb分别为(16.9±2.4)kg/m2、(10.6±2.5)mm、(24.2±2.5)cm、(106±15)g/L、(2.2+0.4)g/L、(39±3)g/L,肠外营养组患者分别为(16.6±2.1)kg/m2、(9.2±1.3)mm、(24.0±3.4)cm、(102±18)g/L、(2.0+0.4)g/L、(38±3)g/L,两组比较差异均无统计学意义(t=0.52,1.72,0.05,0.93,1.94,1.29,P＞0.05).但肠内营养组前白蛋白、氮平衡水平、肛门排气时间、每日相关费用、菌群失调、糖代谢紊乱、肝功能损害分别为(0.30±0.10)g/L、0.8±0.3、(29±10)h、(210±30)元、1例、2例、2例,肠外营养组分别为(0.25±0.09)g/L、0.4±0.2、(38±6)h、(700±50)元、9例、12例、15例,两组比较差异有统计学意义(t=2.03,6.08,2.25,10.38,x2=7.68,9.32,13.87,P<0.05).结论 腹腔镜胃癌根治术后对患者实施营养支持可促进患者的恢复,而肠内营养疗效优于肠外营养,可作为营养支持的首选途径.     

内镜无法切除的结直肠息肉腹腔镜手术前定位方法对比研究

目的 评价内镜无法切除的结直肠息肉患者行腹腔镜手术前结肠镜检查钛夹定位、美蓝注射定位的应用效果.方法 回顾性分析2006年8月至2012年9月中山大学附属第三医院收治的31例内镜下无法切除的结直肠息肉患者的临床资料,其中腹腔镜手术前以钛夹定位者18例为钛夹组,以美蓝定位者13例为美蓝组.钛夹组：常规结肠镜检查,首先取组织行病理检查,随后在息肉上下缘组织各置入钛夹1～2枚标记,结肠镜检查结束后立即行卧位腹部X线片检查确定金属钛夹位置而判定息肉的部位.美蓝组：腹腔镜手术前24 h内清洁肠道,施行结肠镜检查,用内镜注射针刺入息肉基底旁黏膜下,推注美蓝1 mL,见黏膜鼓起一蓝色疱疹.息肉所在水平肠管的四周肠壁均以同样方法注射美蓝,共4点.如果上述两种定位方法失败,最后行术中结肠镜定位.所有患者按结直肠肿瘤治疗原则行腹腔镜肠段及相应系膜切除术,分析两组患者的定位效果和治疗情况.计量资料采用t检验,计数资料采用x2检验.结果 钛夹组患者定位成功率为15/18,美蓝组患者定位成功率为8/13,两组比较,差异无统计学意义（x2=0.284,P＞0.05）.8例定位失败者均改用术中结肠镜定位,但手术时间延长至（44±13） min.31例患者均未发现定位错误.本组患者4例行腹腔镜右半结肠切除术,11例行腹腔镜左半结肠切除术,9例行腹腔镜乙状结肠切除术,7例行腹腔镜直肠前切除术.钛夹组和美蓝组患者术后均无手术并发症发生和患者死亡,标本长度、近切缘距肿瘤上缘距离、远切缘距肿瘤下缘距离（结肠息肉）、远切缘距肿瘤下缘距离（高位直肠息肉）、淋巴结清扫数目分别为（20 ±7）cm、（11 ±4）cm、（8.6 ±3.1）cm、（4.2±1.1）枚、（8±5）枚和（20±5）cm、（9 ±3）cm、（9.1±2.8）cm、（4.6±0.5）枚、（7±6）枚,两组比较,差异无统计学意（t=0.053,0.918,0.21     

腹部术后急性阑尾炎的临床分析

目的 探讨腹部手术后并发急性阑尾炎临床特点.方法 回顾性分析1995年1月～2004年6月间11例术后急性阑尾炎患者的病例资料.结果 术前确诊的急性阑尾炎有9例,剖腹探查确诊的为2例,均于原发病术后7～15天行阑尾切除术,术后均恢复良好,痊愈出院.结论 对术后出现腹痛、发热等相关阑尾炎表现的患者要有足够的重视,积极排除伴发急性阑尾炎的可能,B超对诊断有一定的辅助作用.积极手术治疗是其安全有效的治疗方法.