完全腹膜外疝修补（TEP）手术腹膜前CO2充气对人体的影响

目的完全腹膜外疝修补（TEP）手术需在腹膜前建立间隙，并且应用CO，充气维持足够的操作空间。本临床研究通过腹膜前CO2充气对患者呼吸和循环的影响，从病理生理学的角度来论证TEP手术的安全性。方法2005年1月至6月，本中心行TEP手术的腹股沟疝患者20例（18例斜疝，2例直疝），均为男性，年龄平均60．2岁。腹膜前建立间隙并用CO2充气，维持压力于12mnHg，分别记录充气前、充气后5min、充气后30min、拔管后四个时间段的心率（HR）、血压（BP）、呼气末CO2分压（EtCO2）以及血气分析测定值（PH、PCO2、HCO3）。结果进行统计分析。结果手术均顺利完成，手术时间平均32．6min，术后疼痛分数（VAS）平均（2．7±1．4）分，术后住院平均（3．2±0．5）d，3例患者出现皮下气肿。病理生理指标中HR和PH值在充气后有一定幅度的下降，BP、EtCO2、PCO2和HCO3值在充气后有一定幅度的上升，与充气前指标差异有统计学意义，并且随着充气时间延长变化幅度有所增加，各指标在拔管后迅速恢复并接近充气前水平。结论TEP手术腹膜前CO2充气，CO2在皮下组织弥散可能会形成皮下气肿，CO2吸收会出现CO2蓄积及酸中毒，并造成血压上升及心率减慢。通过麻醉师的合理处理，可以将指标控制在合理的安全范围内，术后能迅速恢复。     

双镜联合治疗结肠直肠肿瘤的临床应用现状

结肠直肠癌是目前最常见的恶性肿瘤之一，其发病率也呈逐年上升趋势。早期发现、早期治疗是提高结肠直肠癌病人预后唯一有效的方法。散发性结肠直肠癌遵循着“息肉-腺瘤-高级别瘤变-癌”的演变、发展过程，因此对结肠直肠癌前病变的早期治疗是降低结肠直肠癌发生率及提高其预后的有效途径。由于越来越多的结肠直肠癌病人得到早期诊断与治疗，其生存率也不断提高：因此，     

老年患者腹腔镜结直肠手术的安全性研究

Objective To compare the outcomes of laparoscopic colorectal surgery in elderly (≥ 70 years) and younger (< 70 years) patients, and to evaluate the safety of laparoscopic colorectal surgery in elderly. Methods From Aug. 2007 to Dec. 2007, 25 patients with colorectal cancer undergone laparoscopic colorectal surgery were studied prospectively. Ten patients aged 70 years or older (Elder Group), and 15 patients less than 70 years (Younger Group). The parameters of perioperative hemodynamics, blood chemistry, and intraabdominal organs perfusion were recorded periodically during operation and compared between the two groups. Results Elder group had a higher ASA degree (P<0.01). Mean age, height, weight, the classification of the disease, operative time, blood loss and complication were not significantly different between the two groups. The HCO3 value and PaCO2 value increased significantly intraoperatively, while the pH value decreased significantly. These parameters returned to basal line at the end of operation, with the decreased electrolytes, especially the kaliopenia and hypocalcemia. The CVP increased significantly at the beginning of operation and after fluid expansion, and decreased postoperatively. Gastric mucosal pH(pHi) decreased when the operation began. The partial pressure of gastric mucesa (PgCO2) increased significantly at the end of operation.Other parameters of hemodynamics including HR, CI, and SI were not significantly different during operation. The CVP of elder group was higher than that of younger group at 5 min after the beginning of the operation, while the MAP of elder group was lower than that of younger at 15 min after the end of the operation. Other parameters of hemodynamics including oxygenation, pedusion, and blood chemistry were not significantly different. Conclusions For laparoscopic colorectal surgery, no significant adverse response attributes to elderly patients. The compensation capacity of the elderly is lower. With the reasonable anesthesia administration, the adverse response can be controlled effectively.     

老年患者腹腔镜结直肠手术的安全性研究

Objective To compare the outcomes of laparoscopic colorectal surgery in elderly (≥ 70 years) and younger (< 70 years) patients, and to evaluate the safety of laparoscopic colorectal surgery in elderly. Methods From Aug. 2007 to Dec. 2007, 25 patients with colorectal cancer undergone laparoscopic colorectal surgery were studied prospectively. Ten patients aged 70 years or older (Elder Group), and 15 patients less than 70 years (Younger Group). The parameters of perioperative hemodynamics, blood chemistry, and intraabdominal organs perfusion were recorded periodically during operation and compared between the two groups. Results Elder group had a higher ASA degree (P<0.01). Mean age, height, weight, the classification of the disease, operative time, blood loss and complication were not significantly different between the two groups. The HCO3 value and PaCO2 value increased significantly intraoperatively, while the pH value decreased significantly. These parameters returned to basal line at the end of operation, with the decreased electrolytes, especially the kaliopenia and hypocalcemia. The CVP increased significantly at the beginning of operation and after fluid expansion, and decreased postoperatively. Gastric mucosal pH(pHi) decreased when the operation began. The partial pressure of gastric mucesa (PgCO2) increased significantly at the end of operation.Other parameters of hemodynamics including HR, CI, and SI were not significantly different during operation. The CVP of elder group was higher than that of younger group at 5 min after the beginning of the operation, while the MAP of elder group was lower than that of younger at 15 min after the end of the operation. Other parameters of hemodynamics including oxygenation, pedusion, and blood chemistry were not significantly different. Conclusions For laparoscopic colorectal surgery, no significant adverse response attributes to elderly patients. The compensation capacity of the elderly is lower. With the reasonable anesthesia administration, the adverse response can be controlled effectively.     

大肠肿瘤癌旁淋巴结p53基因检测的临床意义

目的：探讨癌旁淋巴结ｐ５３基因检测与Ｄｕｋｅｓ Ｂ期大肠肿瘤患者临床预后的关系。材料与方法：３０例Ｄｕｋｅｓ Ｂ期大肠肿瘤患者，取癌灶组织、癌旁淋巴结组织及远切端正常大肠粘膜组织，选用ＰＣＲＳＳＣＰ（聚合酶链反应－单链构像多态性）法行ｐ５３基因第５～８外显子检测，同时进行临床随访。结果：３０例患者中，ｐ５３基因突变率为４３．３％（１３／３０），有癌旁淋巴结ｐ５３基因突变的大肠肿瘤患者局部复发率明显高于未突变者（８０％比１２％，Ｐ＜０．０５）。结论：癌旁淋巴结ｐ５３基因检测将有助于发现病理检查中所不能发现的微转移灶和准确判断预后。     

Hartmann手术在急诊肠癌梗阻病例中的选用

目的 分析Hartmann手术在梗阻性直乙结肠癌急诊手术中疗效，认为该术式可供选用。方法 回顾性分析本院自1989年8月至1999年8月收治直肠乙状结肠癌1386例，梗阻208例，需急诊手术75例，其中直肠(包括交界处)癌27例、乙状结肠癌48例，行Hartmann手术分别12例和9例。Dixon术6例，乙状结肠切除术23例，单纯结肠造瘘24例。病理：Dixon术Duke’sB期2例，C期4例，乙状结肠癌Duke’sB期8例。C期14例，D期l例。Hartmann术Duke’sB期7例，C期12例，D期2例。单纯造瘘术Duke’sC期4例。D期19例，手术方式根据急诊手术病人全身情况，肿瘤局部浸润、大小、粘连、肠壁管情况、估计术后复发、术中安全等选择，统计各种不同术式术后，病人并发症、死亡率、局部复发。远处转移以及5年生存率。结果 (1)本组梗阻急诊手术资料，不管手术选用何种方式，总的局部复发率。远处转移率明显偏高，5年生存率偏低；(2)一期切除吻合与Hartmann术，术后并发症无显著差异，术后局部复发，远处转移及5年生存率均无显著性差异；(3)单纯造瘘5年生存率较一期切除和Hartmann术明显下降。讨论(1)预防和减少直肠乙状结肠癌梗阻的发生是提高疗效的关健，早期发现，早期诊断是减少梗阻癌的根本，在此基础上的早期手术是重点，如何变急诊手术为限期手术是治疗梗阻的一个重要环节，内支撑架成功应用是个好办法；(2)积极治疗梗阻性直肠乙状结肠癌的原发病灶，努力达到“根治”目的，不提倡相对较多的单纯造瘘；(3)寻求梗阻性直肠乙状结肠癌合理的综合治疗方法。     

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目的评价腹腔镜腹股沟疝修补术(LIHR)的临床疗效。方法回顾性分析2001年1月至2011年12月上海交通大学医学院附属瑞金医院普外科2056例(2473侧)行LIHR的临床资料,其中经腹腹膜前修补术(TAPP)874例(1005侧),全腹膜外修补术(TEP)1175例(1458侧),腹腔内修补术(IPOM)7例(10侧)。2473侧疝中,斜疝1481侧(59.9%),直疝525侧(21.2%),复发疝225侧(9.1%),复合疝206侧(8.3%),股疝36侧(1.5%)。疝分型:Ⅰ型疝95侧(3.8%),Ⅱ型疝995侧(40.2%),Ⅲ型疝1157侧(46.8%),Ⅳ型疝226侧(9.1%)。手术由同组医师完成,术式选择由术者决定,随访时间3～60个月(中位时间35个月)。结果 1例TAPP因腹腔广泛粘连中转为Lichtenstein术。病人术后无需应用镇痛剂。2周和4周内恢复非限制性活动率为99.0%和99.9%。共6例复发,复发率为0.24%。TAPP和TEP各3例复发。发生3例严重并发症,分别为戳孔疝、肠管损伤和机械性肠梗阻,其他并发症依次为血清肿129例(5.2%)、尿潴留34例(1.4%)、暂时性神经感觉异常26例(1.1%)、麻痹性肠梗阻3例(0.12%)。结论 LIHR是安全有效的手术,合理选择手术适应证和规范化操作可以获得良好的临床效果。     

老年患者腹腔镜结直肠手术的安全性研究

Objective To compare the outcomes of laparoscopic colorectal surgery in elderly (≥ 70 years) and younger (< 70 years) patients, and to evaluate the safety of laparoscopic colorectal surgery in elderly. Methods From Aug. 2007 to Dec. 2007, 25 patients with colorectal cancer undergone laparoscopic colorectal surgery were studied prospectively. Ten patients aged 70 years or older (Elder Group), and 15 patients less than 70 years (Younger Group). The parameters of perioperative hemodynamics, blood chemistry, and intraabdominal organs perfusion were recorded periodically during operation and compared between the two groups. Results Elder group had a higher ASA degree (P<0.01). Mean age, height, weight, the classification of the disease, operative time, blood loss and complication were not significantly different between the two groups. The HCO3 value and PaCO2 value increased significantly intraoperatively, while the pH value decreased significantly. These parameters returned to basal line at the end of operation, with the decreased electrolytes, especially the kaliopenia and hypocalcemia. The CVP increased significantly at the beginning of operation and after fluid expansion, and decreased postoperatively. Gastric mucosal pH(pHi) decreased when the operation began. The partial pressure of gastric mucesa (PgCO2) increased significantly at the end of operation.Other parameters of hemodynamics including HR, CI, and SI were not significantly different during operation. The CVP of elder group was higher than that of younger group at 5 min after the beginning of the operation, while the MAP of elder group was lower than that of younger at 15 min after the end of the operation. Other parameters of hemodynamics including oxygenation, pedusion, and blood chemistry were not significantly different. Conclusions For laparoscopic colorectal surgery, no significant adverse response attributes to elderly patients. The compensation capacity of the elderly is lower. With the reasonable anesthesia administration, the adverse response can be controlled effectively.     

血管内皮生长因子C表达与大肠癌预后的关系

目的：研究血管内皮生长因子 C(VEGF-C)在大肠癌组织中的表达水平及其与大肠癌临床病理特征、微 血管密度(MVD)及预后的关系。方法：抽取1996年1月～1998年1月行结直肠癌根治术且接受正规随访的大肠癌 病例69例；采用 EnVision 免疫组织化学技术检测 VEGF-C 在69例大肠癌及20例正常大肠组织的表达；采用抗 CD34免疫组织化学技术评价大肠癌 MVD；采用 Axioplan 2 Imaging 显微图像分析系统对免疫组织化学染色结果进 行定量。结果：94． 2%(65/69) 大肠癌组织和30%(6/20) 正常大肠组织检测到 VEGF-C 表达，染色定位于肿瘤细胞浆； 大肠癌 VEGF-C 表达显著高于相应正常大肠组织(P＜0． 01) ，且与大肠癌淋巴结转移、MVD 及临床分期显著相关(P＜ 0． 05) ，而与病人年龄(≤68；＞68岁)、性别、肿瘤浸润深度、远处转移、分化程度及肿瘤部位相关性均无统汁学意义； VEGF-C 高表达的病人组总生存率和无病生存率均显著低于 VEGF-C 低表达病人组(P＜0． 05) 。结论：VEGF-C 在大肠 癌中异常高表达，且与大肠癌淋巴结转移、临床分期、无病生存率与总生存率显著相关，可作为大肠癌预后判断标记物。     

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目的分析并比较腹腔镜辅助与开腹手术行右半结肠切除术的短期及远期疗效。方法将2003年6月至2010年9月在上海交通大学医学院附属瑞金医院行手术治疗的324例右半结肠癌病人纳入研究。其中腹腔镜组(LR组)177例,开腹组(OR组)147例。回顾性分析比较两组临床资料、手术相关资料、术后疗效及长期存活率等的差异。结果两组病人临床资料间的差异无统计学意义;LR组在术后恢复方面均显著优于OR组;术后并发症发生率OR组为22.45%,LR组为12.99%,差异有统计学意义。OR组淋巴结清扫数(11.4±4.1)枚,LR组为(15.2±10.1)枚,差异有统计学意义。两组在肿瘤复发与转移方面的差异无统计学意义。LR组1、3、5年总存活率为97.18%、83.73%及70.37%,OR组为94.56%、77.84%及66.97%,差异无统计学意义。结论腹腔镜辅助右半结肠切除术治疗右半结肠癌安全、有效,短期疗效优于开腹手术,远期疗效与开腹手术相当。