腹部器官簇移植治疗终末期肝病合并胰岛素依赖的2型糖尿病五例

目的 总结了改良的腹部器官簇移植(MCT)治疗终末期肝病合并胰岛素依赖的2型糖尿病(T2DM)患者的经验.方法 回顾性分析了单中心连续实施的5例MCT的资料.5例全部为男性,原发病为乙型肝炎后肝硬化合并T2DM 3例,乙型肝炎后肝硬化合并T2DM 1例,原发性肝癌(HCC)合并T2DM 1例.受者切除患肝后,原位植入包括肝脏、胰腺、部分十二指肠的器官簇,器官簇来源于同一个供者.胆道和胰腺外引流采用供者十二指肠与受者上段空肠Roux-en-Y吻合或者侧侧吻合方式.术后采用巴利昔单抗诱导,他克莫司(Tac)+吗替麦考酚酯(MMF)+皮质激素联合应用预防排斥反应,之后过渡至单用Tac维持治疗.结果 5例手术均顺利,患者于术后早期(8～27 d)完全脱离胰岛素治疗,并且血糖水平维持正常.其中3例术前C肽水平严重降低,术后早期明显升高,并维持于正常水平.1例术后发生移植物抗宿主病,并死亡,其他4例顺利恢复,术后分别随访22、15、5和4个月,均存活,并已恢复正常生活,移植物功能正常,血糖水平正常.结论 腹部器官簇移植是治疗终末期肝病合并胰岛素依赖的2型糖尿病的有效手段.

Abstract：

Objective Modified upper abdominal cluster transplantation (MCT), which was inspired by the classical cluster transplant technique, has been proven more effective and feasible in the treatment of patients with end stage liver diseases associated with insulin-dependent diabetes mellitus (DM) than orthotopic liver transplantation (OLT) alone. In this study, we summarized our experience with MCT in 5 consecutive patients suffering from end stage liver diseases associated with insulin-dependent type 2 DM in our single center.Methods Five patients with hepatitis B-related chronic liver cirrhosis and insulin dependent type 2 DM received MCT in our single center. The biliary and exocrine pancreatic drainage reconstructions were achieved by a Roux-en-Y duodenojejunostomy or a side-to-side duodenojejunostomy. A quadruple immunosuppressive regimen based on tacrolimus including Basiliximab induction, mycophenolate mofetil (MMF) and steroids was used in the early stage post-transplant, and then converted to tacrolimus monotherapy.Results All of the patients experienced an uneventful post-operative recovery. They were rendered independent from insulin therapy shortly after transplantation. The fasting glucose and glycosylated hemoglobin levels were within normal range. In addition, the fasting C-peptide value was increased from much lower than the normal range pre-transplant to within normal range post-transplant and maintained stable since then. However, the third patient suffered from graft verse host disease (GVHD) 20 days post-operatively and died from severe infection on the post-operative 47 days. The other 4 patients had returned to work and a normal lifestyle over 22, 15, 5 and 4 months of follow-up.Conclusion MCT is an effective method in treating patients suffering from end stage liver diseases combined with insulin-dependent type 2 DM. Whether a cluster graft would increase the risk of GVHD needs further investigation.     

肾盂鳞状细胞癌临床特点分析

目的 探讨肾盂鳞状细胞癌的诊治特点.方法 回顾性分析1991年10月至2009年5月收治8例肾盂鳞状细胞癌患者资料.临床表现血尿8例,腰痛7例,腹部包块1例.B超检查8例,IVU检查8例,CT检查4例.术前诊断为肿瘤3例,诊断为肾结石5例,结石术中发现肿瘤并经冰冻病理确诊2例.8例患者均经手术治疗,行根治性肾输尿管切除4例、单纯性肾切除3例、姑息性切除术1例.结果 8例病理诊断均为鳞状细胞癌.中分化6例,高分化和低分化各1例;pT1 1例,pT2 1例,pT3 3例,pT4 3例;淋巴结转移2例.获随访7例,失访1例.术后生存时间2～42个月,中位时间6个月,患者均死于肿瘤复发及转移.结论 肾盂鳞状细胞癌恶性程度高,常合并结石,术前诊断困难,确诊时多为中晚期,术后短期内易复发转移,预后极差.

Abstract：

Objective To review the diagnosis and treatment of squamous cell carcinoma of renal pelvis. Methods The clinical data from October 1991 to May 2009 of eight cases of squamous cell carcinoma of renal pelvis were reviewed and analyzed retrospectively. The symptoms of the patients were hematuria (eight cases), pain (seven cases) and abdominal mass (one case). All patients underwent B-ultrasound and IVU examination and four cases underwent CT scan. Three cases were diagnosed as having a tumor before surgery. Five cases were diagnosed as renal calculus, two of the five cases were diagnosed by intraoperative frozen section. Radical nephroureterectomy were performed in four cases, nephrectomy in three cases and palliative resection in one case. Results Histological classification revealed that six cases were moderately differentiated, one case was well differentiated and one case was poorly differentiated. Two cases had stage pT1/pT2 and six cases had stage pT3/pT4. 2 cases had regional lymph nodes metastasis. Seven cases were followed-up. All patients died of tumor recurrence or metastasis. The median tumor specific survive time was six months (range from two months to 42 months). Conclusions Squamous cell carcinoma of renal pelvis is often occurs concurrently with urolithiasis which could lead to difficulty in diagnose before operation. As the most of the patients were diagnosed with advanced stage disease, squamous cell carcinoma of renal pelvis tended to early recurrence and metastasis and the prognosis was very poor.     

脊髓型颈椎病一期后前路减压术后疗效不佳原因分析

目的 观察采用一期后前路联合手术治疗脊髓型颈椎病的临床效果,分析部分病例疗效不佳的原因.方法 回顾性研究采用一期后前路联合手术治疗的脊髓型颈椎病67例,得到随访的55例,男38例,女17例;年龄32-74岁,平均52.0岁.比较手术前、术后随访时JOA评分,评价临床治疗效果,从年龄、病程、肌肉萎缩、术前JOA评分及MR...     

IL11类似物c(CGRRAGGSC)与人前列腺癌PC-3细胞体外结合特性的研究

目的:探讨白细胞介素11(IL11)类似物环九肽c(CGRRAGGSC)与人前列腺癌PC-3细胞的体外结合特性。方法:采用荧光染料LSS670标记c(CGRRAGGSC)合成LSS670-c(CGRRAGGSC),流式细胞仪测定其与PC-3细胞体外结合的荧光强度,计算其竞争抑制试验中的半数抑制量(IC50)和平衡抑制常数(K i),荧光显微镜观察LSS670-c(CGRRAGGSC)在PC-3细胞的定位;用99mTc标记c(CGRRAGGSC)合成99mTc-DTPA-c(CGRRAGGSC)与PC-3细胞进行放射受体结合分析,Scatchard作图法计算标记物与PC-3细胞结合的平衡解离常数(Kd)和每个细胞上的最大结合位点数(Bm ax)。结果:LSS670-c(CGRRAGGSC)与人前列腺癌PC-3细胞的结合具有可饱和性,浓度与时间呈依赖性。未标记c(CGRRAGGSC)与LSS670-c(CGRRAGGSC)对PC-3受体具有竞争性抑制作用[IC50=(6.31±0.12)nmol/L,Ki=(2.11±0.14)nmol/L]。LSS670-c(CGRRAGGSC)荧光主要集中在PC-3细胞膜上,Kd值为(0.11±0.02)nmol/L,Bm ax为(230±34)fmol/mg pro。结论:c(CGRRAGGSC)符合特异性配体的标准。     

精准肝切除治疗原发性肝癌的安全性及有效性

目的 观察精准肝切除治疗原发性肝癌患者的安全性和有效性.方法 86例原发性肝癌患者按频数匹配原则随机分为两组.常规对照组(n=44)采用常规手术处理方法;精准组(n=42)采用精准肝切除,观察比较两组手术失血量、术后肝功能、住院时间、并发症发生及预后等情况.结果 精准组与常规对照组相比,术中出血量少[(320±315)ml比(613±526)ml;P<0.001],术后肝功能恢复快(术后7 d ALT为82.7 U/L比321.7 U/L;P<0.001),并发症发生率低(7.1%比20.5%;P<0.001),住院时间缩短(12.3 d比18.6 d;P<0.001).术后1年肿瘤复发率分别为26.2%(11/42)和38.6%(17/44);术后1年生存率分别为78.6%(33/42)和65.9%(29/44),两组预后比较差异有统计学意义(P=0.010;P=0.018).结论 肝切除患者在准确的术前评估后采用精准肝切除,手术打击较小,可以减少术后并发症与住院时间,加速患者的康复.

Abstract：

Objective To evaluate the the safety and efficiency of precise liver resection for patients with primary liver cancer. Methods 86 patients with primary liver cancer were randomized to receive conventional routine hepatectomy (n=44) or the precise liver resection (n=42). Outcomes were compared between the precise hepatectomy group and the routine group, including, the blood loss, operation time, morbidity and mortality. Results There were significant differences in morbidity rates (7.1% vs. 20.5%; P<0.001), the blood loss [(320±315) ml vs. (613±526) ml;P<0.001) , postoperative alanine aminotransferase (ALT) value (in postoperation 7 d, 82.7 U/L vs.321.7 U/L; P<0.001) and length of hospital stay (12.3 d vs. 18.6 d; P<0.001) between precise hepatectomy and routine groups. The 1 year tumor recurrence rate and 1 year survival rate were 26.2%(11/42) and 78.6% (33/42) in precise liver resection group, 38.6% (17/44) and 65.9%(29/44) in routine liver resection group,with significant difference (P=0.010;P=0.018). Conclusion Precise liver resection is safe and effective in the treatment of liver tumor without much injury to patients.     

非手术疗法治疗疑难腰腿痛的体会

临床上遇到难治的、复杂的腰腿痛,如巨大型腰椎间盘突出症、复杂的腰椎间盘突出症及马尾损伤等,首先要明确诊断,治疗时要根据患者的不同类型、病情轻重及复杂因素来采取针对性的非手术治疗方法,而且还要有足够的耐心,才能得到满意的疗效.根据笔者临床治疗经验,总结出疑难腰腿痛应早期诊断,早期正确治疗尤为重要.     

股骨干顺行髓内钉固定后同侧股骨颈骨折的治疗

目的：探讨股骨干骨折行顺行髓内钉固定后发现同侧股骨颈骨折的治疗方法。方法：回顾性分析2000年1月至2010年1月股骨干骨折行顺行髓内钉固定后术中或术后发现同侧股骨颈骨折的患者12例,全部以2枚螺钉分别自髓内钉前后方固定股骨颈骨折,定期随访,评估骨折愈合及功能恢复情况。结果：术后随访10—36个月,平均16．5个月。股骨颈骨折平均愈合时间3．6个月,股骨干骨折平均愈合时间5．4个月,无股骨头坏死发生。按Harris评分标准髋关节功能：优7例,良3例,可2例。结论：股骨干骨折顺行髓内钉固定后发现同侧股骨颈骨折,以2枚螺钉分别自髓内钉前后方固定股骨颈骨折方法可行,固定可靠,手术创伤小,骨折愈合率高。     

单侧椎弓根螺钉联合对侧经皮椎板关节突螺钉固定治疗下腰椎病变的临床观察

 目的 探讨单侧椎弓根螺钉联合对侧经皮椎板关节突螺钉固定治疗下腰椎病变的可行性和疗效。方法 男 8例.女 22例;年龄 39~68岁.平均 53.7岁。腰椎间盘退变 11例.腰椎间盘突出症术后原位复发 4例.巨大型腰椎间盘突出 5例.腰椎间盘突出伴椎管狭窄 4例.腰椎退行性滑脱(I度) 6例。 L_3.4 2例、L_4.5 20例、L₅S₁ 8例。采用单侧显露、减压、同侧椎弓根螺钉固定.同时在自行设计的瞄准器引导下经皮对侧进行椎板关节突螺钉固定并椎间融合器植骨方法治疗。观察手术时间、术中出血量和术后引流量。通过影像学评价椎板关节突螺钉位置。采用日本骨科学会(Japanese Orthopaedic Association. JOA)下腰痛评分系统(29分法)评价疗效。结果 手术时间 75~110 min.平均 89 min;术中出血量为 180~500 ml.平均 285 ml.均未输血。椎板关节突螺钉位置I型 24例. II 型 6例。术后 2例病例出现终板切割.融合器部分陷入终板及椎体内。随访时间 12~36个月.平均 22.5个月。除 1例不能明确外.其余均获得骨性融合.融合率为 96.7%。随访过程中椎弓根螺钉与椎板关节突螺钉未出现松动、移位、断裂.椎间融合器亦无移位现象。 JOA评分由术前的 10~16分(平均 13.0分)提高到 22~27分(平均 25.2分).改善率为 61.7%~90.5%.平均 72.5%。结论 单侧椎弓根螺钉联合对侧经皮椎板关节突螺钉固定具有操作简单、创伤小、稳定性好、融合率高和并发症少等优点.是部分下腰椎病变固定融合的较好选择。     

恶性副神经节瘤的诊治探讨

目的：提高恶性副神经节瘤（MPGL）的诊治水平。方法：回顾性分析2003年4月～2011年1月诊治的12例MPGL患者的临床资料。高血压10例（83．3％）,腰腹部疼痛3例（25．0％）。血浆游离变肾上腺素类物质（MNs）和24h尿儿茶酚胺（CA）升高者分别为100．0％（12／12）和83．3％（10／12）。B超、CT、MRI和131I-间碘苄胍扫描（131I-MIBG）定位准确率分别为83．3％（10／12）、91．7％（11／12）、80．0％（4／5）和88．9％（8／9）。1例行放射治疗,11例行开放手术治疗。结果：原发性肿瘤9例,复发性肿瘤3例;单发性肿瘤8例,多发性肿瘤4例。根据肿瘤的中心定位：腹主动脉旁6例,下腔静脉后2例,膀胱2例,肾门2例。根据术中所见确诊恶性5例（41．7％）。病理检查11例,确诊恶性8例（72．7％）。肺转移1例,肝转移1例,骨转移1例,局部淋巴结转移3例．广泛淋巴结转移2例,2个或多个脏器同时发生转移2例。9例随访4～84个月,平均39个月;复发4例,再次手术;因多发浸润及远处转移死亡2例。结论：病理难以区分副神经节瘤的良恶性,需结合影像学检查、生化检查及术中所见。根治性肿瘤切除是治疗MPGL最有效的方法,肿瘤复发时再次手术仍然有效;无法手术者可用放化疗控制高血压及延缓疾病进展。长期随访观察肿瘤的转移情况是确诊疑似病例的重要方法。     

体外循环下小儿肌部室间隔缺损的镶嵌治疗

目的 探讨镶嵌模式(hybrid procedure)治疗小儿肌部室间隔缺损(Mvsd)的手术方法及临床应用.方法 2006年1月至2010年6月,在体外循环心内直视手术下采用手术及封堵相结合的镶嵌技术矫治小儿Mvsd 45例,其中男20例,女25例;年龄52天～12岁;体重3～32 kg.7例为单个Mvsd,38例为多发性VSD.同时合并大血管错位(D-TGA)1例、法洛四联症(TOF)2例、肺动脉狭窄(PS)3例、动脉导管未闭(PDA)6例、房间隔缺损(ASD)6例、主动脉缩窄1例.均在心脏停跳后直视下将导引钢丝经三尖瓣孔自心脏右室面穿过VSD至左室面,直视下置入导引器,然后送入封堵器,完成Mvsd封堵.多发性VSD 38例,予自体心包片修补膜周部等较大的VSD,心内其他畸形同期完成矫治.结果 42例置入单枚封堵器(直径4～10 mm)、3例置入双枚封堵器(直径4～7 mm).手术经过顺利,术前左室射血分数(EF)均在正常范围,术后1天小于8月龄组EF均值低于正常,大于8月龄组EF正常,两者差异有统计学意义.术后常规每天给予5 mg/kg肠溶阿司匹林3～6个月.术后随访超声检查示封堵器位置无偏移,无残余分流,无二尖瓣、主动脉瓣反流、Ⅲ度传导阻滞及新发心律失常等.术后因重症感染放弃治疗1例,无远期死亡病例.结论 体外循环下镶嵌技术治疗小儿 Mvsd明显降低了围手术期并发症及病死率,简化了手术过程,降低了手术风险,是一种安全、有效的方法.

Abstract：

Objective To summarize the technique and clinical experience of hybrid procedure under cardiopulmonary bypass (CPB) in children with muscular ventricular septal defect (mVSD). Methods From January 2006 to June 2010, 45 cases of mVSD underwent hybrid procedure with CPB. mVSDs were closed with devices under direct vision in 45 cases. Of them, there were 20 males and 25 females. They ranged from 52 days to 12 years [mean (2.05 ±2.48) year] in age and from 3 to 30 kg [(11.93 ±7.70)kg] in body weight. Preoperatively, most of children were highly susceptible to respiratory tract infections. The hybrid approach was used in all patients with CPB under the guidance of transesophageal echocardiography (TEE). The diameter of mVSDs ranged from 2 to 7 mm under TEE. Of 45 cases, 40 patients had increased rates of pulmonary blood flow. 29 patients had left axis deviation and 12 cases had sinus arrhythmia on electrocardiography (ECG). 19 had other congenital heart lesions, including transposition of great arteries in 1 case, tetralogy of Fallot in 2, pulmonary artery stenosis in 3, patent ductus arteriosus in 6, atrial septal defects in 6) and aorta coactation in 1. The quantity of VSDs were from 1 to 7 (single, in 7; two, in 24 case; three, in 8 case; four, in 5 case and seven, in lease. 37 patients were combined with pulmonary hypertension in our cohort. 38 patients with another large VSD and 19 with other congenital heart lesions were required surgical repair at sometime. Results The hybrid procedures were undertaken in all 45 cases of this cohort. All cases were successful and no deaths occurred during operation. A total of 48 devices were implanted in 45 patients, including single devices in 42 cases (device size ranged from 4 to 10 mm) and two devices in 3 cases (device size ranged from 4 -7 mm). The average time on CPB was (58.28 ±20.70) min , while aortic crossclamp time was(34. 94 ± 14.75) min. In addition, the time on mechanical ventilation postoperatively ranged from 2 hours to 6 days. Compared to the older children, 20 infante aged less than 8 monhad a significant difference in cardiac function in the early postoperative period. One infant was given up treatment because of serious infection. Anather cases recovered with the use of supportive treatment, such as using vasoactive agents, digoxin, inhaling nitric oxide, diuresis, and so on. The enteric-coated aspirin was given at dose of 5 mg ? kg -1. day -1 for a period of 3 to 6 months as usual postoperatively. All patients attended follow-up at 1 week, 1 month, 3 months, 6 months, 1 year and 2 years post-procedure. No major complications were encountered during this period. All cases were no instance of migration of any of the devices, residual shunt, aortic regurgitation, atrioventricular valve dysfunction, Ⅲo atrial-ventricular conduction block, new arrhythmia, and so on. There are no death in long-term follow-up. Conclusion Hybrid procedure is safe and effective for the closure of congenital heart defects in children.