术中腹腔内温热灌注化疗在胃癌治疗中的应用

目的探讨术中腹腔内温热灌注化疗对胃癌术后腹腔种植转移和生存期的影响。方法将212例进展期胃癌根治性切除术后患者随机分成观察组92例,术中予以腹腔温热灌洗化疗(丝裂霉素30mg、顺铂100mg溶于蒸馏水2000ml中,加温至43℃～45℃,灌入腹腔保留30min后吸尽)和术后氟尿嘧啶(5-FU)10～15mg/kg、丝裂霉素(MMC)0.1～0.15mg/kg、阿霉素(ADM)0.5～1mg/kg静脉化疗,每周1次,2～3次为1疗程;对照组120例,术中用蒸馏水2000ml常规冲洗,术后按上述方法单纯静脉化疗。对两组患者术后腹腔种植转移率及1、3、5年生存率进行比较。结果观察组与对照组术后2年内腹腔种植转移率分别为14.1%和37.5%(P<0.01)。观察组术后1、3和5年生存率分别为98.9%、68.5%和52.2%;对照组为95.0%、56.7%和37.5%,两组3年和5年生存率差异有统计学意义(P<0.05)。结论术中温热灌注化疗具有杀灭腹腔游离癌细胞的作用,对进展期胃癌根治术后腹腔种植转移复发有较好的防治作用,能明显提高患者术后生存率。     

扩大壁细胞迷走神经切断术治疗十二指肠溃疡急性穿孔176例

目的探讨扩大壁细胞迷走神经切断术（EPCV）治疗十二指肠溃疡并发急性穿孔的远期临床疗效。方法对1979年以来采用EPCV治疗的176例十二指肠溃疡并发急性穿孔患者的临床资料进行总结,分析评价疗效,评价内容包括术后并发症发生率、溃疡复发率、胃排空功能、胃镜和上消化道钡餐检查结果和营养状态及Visick分级。结果全组患者有153例（86.9%）获得5年随访。无手术死亡者。进食后上腹发生间断性胀痛13例（8.5%）,有时返酸12例（7.8%）,经服用吗叮啉可缓解。出现粘连性肠梗阻行粘连松解术4例（2.6%）,溃疡复发4例（2.6%）,均发生在术后2-3年内。浅表性胃炎21例（13.7%）,十二指肠球部变形31例（20.3%）,胃窦蠕动功能较好,胃排空功能正常。全组无贫血发生,体重增加者116例（75.8%）。Visick改良分级,146例为Ⅰ级和Ⅱ级,优良率占95.4%,Ⅲ级3例（2.0%）,Ⅳ级4例（2.6%）。结论EPCV术具有手术操作简便、术后并发症较少、溃疡复发率低、患者术后远期营养状况良好、生活质量较高的优良疗效,是治疗十二指肠溃疡并发急性穿孔首选的安全有效术式之一。     

氧化应激及丝裂原活化蛋白激酶在醛固酮加盐诱导肾脏损害中的作用

目的 探讨氧化应激与丝裂原活化蛋白激酶（MAPKs)在醛固酮加盐诱导肾脏损伤中的作用。 方法 SD大鼠随机分为以下5组: ⑴ 0.5%乙醇作为对照组； ⑵ 1%氯化钠+0.5%乙醇（氯化钠组）； ⑶ 1%氯化钠+醛固酮+0.5%乙醇（醛固酮组）；⑷ 1%氯化钠+醛固酮+0.5%乙醇+依普利酮（依普利酮组），⑸ 1%氯化钠+醛固酮+0.5%乙醇+超氧化物歧化酶模拟物tempol（tempol组）。实时定量PCR检测肾皮质NADPH氧化酶亚基p22phox、Nox-4 和 gp91phox mRNA水平。Western印迹检测肾皮质磷酸化ERK1/2、JNK及ERK5蛋白表达。 结果 与氯化钠组大鼠相比，醛固酮组大鼠的血压[（165±5）比（118±3） mm Hg]及尿蛋白量（24 h） [(101.0±24.0) 比 (9.1±3.0) mg]显著增高(P均 < 0.05)；肾皮质脂类过氧化反应产物（TBARS）水平明显升高[(0.23±0.02) 比 (0.09±0.01) nmol/mg 蛋白，P < 0.05]；肾皮质NADPH氧化酶亚基p22phox、Nox-4和 gp91phox mRNA表达显著升高[分别为氯化钠组的(2.3±0.2)、(4.3±0.8)和(3.0±0.3)倍，P < 0.05]；肾皮质ERK1/2、JNK与ERK5活性显著增高[分别为氯化钠组的(3.3±0.3)、(2.3±0.3)和(3.0±0.2)倍，P < 0.05]。依普利酮或tempol明显降低醛固组大鼠的血压、尿蛋白量（24 h） [依普利酮组和tempol组分别为(10.0±2.0)、(9.3±2.0) mg]以及肾皮质TBARS水平[依普利酮组和tempol组分别为(0.08±0.01)和(0.11±0.03) nmol/mg 蛋白] (P < 0.05)；并使肾皮质组织ERK1/2、JNK及ERK5活性降至接近对照组水平。 结论 氧化应激与MAPKs通路激活在醛固酮加盐诱导的肾脏损伤中发挥重要作用。     

乳腺癌前哨淋巴结活检临床应用现状的思考

乳腺癌淋巴结清除术及其范围是影响术后患侧上肢功能的主要因素.准确了解腋淋巴结转移状况是合理制定乳腺癌综合治疗计划的重要依据之一,也是预测患者预后的最重要临床病理指标.另一方面,由于清除没有转移的区域淋巴结没有任何预后优势,对临床腋淋巴结转移阴性(cNo)的患者均施行腋淋巴结清除术,约70%患者不能从腋淋巴结清除术中获益.毋庸置疑的,从低位(Level I)至中低位(Level I+LevelⅡ)乃至全腋(Level I+LevelⅡ+LevelⅢ)淋巴结清除术,随着手术范围的扩大,在对腋淋巴结转移状况评价准确性得到保障的同时,术后发生相关并发症的概率随之增加,对生活质量的负面效应也随之增大.为了最大程度地降低手术相关并发症,又能最大程度地降低因为手术范围缩小对腋淋巴结转移状况评价的误差,乳腺癌前哨淋巴结活检(sentinel lymph node biopsy,SLNB)指导下的腋淋巴结处理模式由此诞生.     

七氟醚麻醉对幼鼠海马c-Jun氨基末端激酶表达和神经细胞凋亡的影响

目的 评价七氟醚麻醉对幼鼠海马c-Jun氨基末端激酶(JNK)表达和神经细胞凋亡的影响.方法 健康雄性SD大鼠40只,日龄30～35 d,体重100～110 g,采用随机数字表法,将其随机分为2组(n=20):对照组(C组):吸入含有30%氧气的空氧混合气体5 h;七氟醚组(s组):吸入3%七氟醚5 h,并维持麻醉箱氧浓度为30%.苏醒后1 h时,每组随机处死10只大鼠,取两侧海马组织,分别采用免疫组化法和Western blot法测定磷酸化JNK(p-JNK)的表达水平,采用TUNEL法检测神经细胞凋亡情况.苏醒后24 h时,每组随机取10只大鼠,采用Morris水迷宫测试认知功能.结果 与C组比较,S组海马组织p-JNK表达上调,凋亡细胞计数升高,潜伏期延长和平台象限停留时间缩短(P＜0.05或0.01).结论 吸入3.0%七氟醚可能通过激活JNK信号通路,诱发海马神经细胞凋亡,从而导致幼鼠认知功能降低.

Abstract：

Objective To investigate the effects of sevoflurane anesthesia on the expression of c-Jun N-terminal kinase (JNK) and neuronal apoptosis in hippocampus in juvenile rats.Methods Forty healthy male SD rats, aged 30-35 days, weighing 100-110 g, were randomly divided into 2 groups (n = 20 each): control group (group C) and sevoflurane group (group S) . Group C inhaled a gas mixture of oxygen and air for 5 h and group S 3% sevoflurane for 5 h. The concentration of oxygen in both groups was maintained at 30% . Ten rats in each group were scarified at 1 h after regaining consciousness and the hippocampi removed for determination of phospho-JNK expression (by immuno-histochemistry and Western blot) and neuronal apoptosis (by TUNEL) . Another 10 rats were selected at 24 h after regaining consciousness to assess the cognitive function using Morris water maze. Results Compared with group C, phospho-JNK expression was significantly up-regulated, the number of apoptotic neurons increased, the latency prolonged and the duration of staying at the original platform quadrant shortened in group C ( P ＜ 0.05 or 0.01) . Conclusion Inhalation of 3.0% sevoflurane can induce neuronal apoptosis in hippocampus by activating JNK signaling pathway, thus leading to cognitive decline in juvenile rats.     

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.     

超声联合CT引导下经皮冷冻治疗胰腺癌85例

目的评估超声和CT引导经皮冷冻治疗胰腺癌的安全性及可行性。方法回顾性分析2008年11月至2010年5月在我院接受超声联合CT引导下经皮冷冻治疗的胰腺癌患者85例的临床资料,其中不可切除胰腺癌67例,拒绝手术治疗的可切除性胰腺癌患者18例,共计86个瘤灶接受121次经皮冷冻治疗。依据肿瘤的大小、形状及位置,分别选用1～8根探针。胰头癌采用经腹穿刺,胰体尾癌经腹或经背穿刺的方法。采用两个冷冻一复温循环,冷冻温度为（-160±10）℃,复温温度（25±5）℃,均持续5～10min。于冷冻前后检查CT,评估状态（kamofsky performance status,KPS）评分,观察冷冻治疗后并发症及术后住院时间。结果全组121例次经皮冷冻治疗均顺利完成,无一例死亡。出院时KPS较治疗前提高（P〈0．叭）。冷冻后1～3个月肿瘤平均直径明显缩小[（4．7±0．3）VS．（4．1±0．4）,P〈0．01],所有瘤灶冷冻区活性消失。平均住院时间为（8．0±0．6）d。结论超声联合CT引导经皮冷冻治疗胰腺癌安全可行,具有微创、准确、适形等特点,为临床胰腺癌治疗提供了新的技术手段。     

肱骨近端Ⅱ-Ⅲ级骨巨细胞瘤保肢手术与康复训练7例

目的：探讨瘤段扩大切除加人工假体置换术及围手术期的康复治疗对肱骨近端骨巨细胞瘤的保肢、关节功能恢复的效果。方法：自2007年3月到2010年3月,共收治肱骨近端Ⅱ-Ⅲ级骨巨细胞瘤7例,男3例,女4例,平均年龄34.6岁（18～49岁）,平均病程19个月（6～35个月）。7例术前均经病理检查及X线证实为肱骨近端骨巨细胞瘤。临床表现为进行加重的肩部疼痛,体检臂近端肿胀、压痛明显,肩关节活动障碍。所有病例采用瘤段扩大切除后以定制的人工假体置换,围手术期辅以康复训练。采用CMS评分及OSIS评分评价患肩功能与患肩稳定性。结果：7例均获随访,时间14～35个月,平均17个月。术后随访无重大并发症发生,无复发病例。术后1年7例患肩CMS评分平均为70.7分（63～82分）,OSIS评分平均25.1分（18～29分）。肩关节功能优2例,良5例;肩关节稳定性优1例,良6例。结论：瘤段扩大切除加人工假体置换术辅以围手术期功能训练治疗肱骨近端Ⅱ-Ⅲ级骨巨细胞瘤疗效确切,达到切除肿瘤与保肢目的。     

血清睾酮雌二醇比值变化对精子缺陷及生育力的影响

目的 了解血清睾酮(T)/雌二醇(E2)比值变化对精子缺陷程度及男性生育能力的影响.方法对90例已婚育龄男性进行血清T、E2、卵泡刺激素(FSH)、黄体生成素(LH)、催乳素和精液参数、精子形态测定,计算血清T/E2和精子多重缺陷指数.根据血清T/E2分为≤10(1组)、＞10(2组)及＞20(3组)分别比较.结果 1、2、3组精子密度和精子活动力分别为(66.8±39.6)×106、(57.6±33.9)×106、(77.4±26.0)×106/ml和(46.6±16.4)%、(44.9±16.0)%、(53.9±14.4)%,3组间差异无统计学意义(P均＞0.05).1组头部缺陷精子为(81.4±9.4)%,明显高于3组的(74.0±10.7)%(t=2.482,P=0.016);1、2组颈部缺陷精子为(16.9±8.6)%和(12.7±9.8)%,均明显高于3组的(7.1±3.9)%(t=4.113、2.050,P=0.000、0.046);1、2、3组尾部缺陷精子分别为(22.6±14.6)%、(14.6±9.0)%和(6.5±5.7)%,组间差异有统计学意义(t=2.722、3.996、3.110,P=0.008、0.000、0.003).2组精子畸形指数(SDI)(1.4±0.3)明显高于1组(1.3±0.2,t=2.293,P=0.025);2、3组畸形精子指数(TZI)分别为1.6±0.3和1.6±0.2,明显高于1组的1.4±0.2(t=2.285、2.727,P=0.025、0.009).1、2、3组中配偶有生育或妊娠经历者分别为13、16、6例,组间差异无统计学意义(x2=3.285、0.854、0.199,P=0.070、0.355、0.655),但2、3组相对危险度分别为1组的2.4倍和1.8倍.1、2、3组中特发性不育病例分别为25、15、7例,组间差异均无统计学意义(x2=0.735、0.200、0.038,P=0.391、0.655、0.845),1组相对危险度分别为2、3组的1.5倍和1.3倍.相关性分析结果发现,血清T/E2与头、颈和尾部缺陷精子比率呈显著负相关(r=-0.209、-0.316、-0.335,P=0.048、0.002、0.001).结论血清T/E2与精子头、颈及尾部缺陷呈显著负相关,其下降与男性生育概率降低有关,但并不影响精子密度及活动力,表明男性体内维持较高比例的T/E2水平对于精子发生过程中的精子形成阶段及受精能力有重要意义.

Abstract：

Objective To study the effect of the serum testosterone/estradiol ratio (T/E2) alteration on sperm defect and fertility. Methods The testosterone, estradiol, FSH, LH, PRL,sperm parameters and sperm morphology of 90 men were analyzed and the T/E2 and multiple anomalies index (MAI) were calculated. The patients were divided into 3 groups; T/E2≤10 (Ⅰ), T/E2＞10 (Ⅱ), and T/E2＞20 (Ⅲ). Results The sperm concentration and motility among the 3 groups were not significantly different (P＞0. 05). The percentages of the sperm whose head, neck and tail were abnormal declined gradually with the increase of the T/E2 in serum. The percentage of sperm head defeet of group Ⅰ was significantly higher than that of group Ⅲ (t=2. 482, P=0. 016) and that of sperm neck defect of groups Ⅰ and Ⅱ were significantly higher than that of group Ⅲ (t=4.113, 2. 050, P=0.000, 0. 046, respectively). The percentage of sperm tail defect among 3 groups was significantly different (t=2. 722, 3. 996, 3. 110, P=0. 008, 0. 000, 0. 003, respectively). The SDI of group Ⅱ was significantly higher than that of group Ⅰ (t= -2. 293, P= 0. 025). But the TZI increased gradually with the increase of the serum T/E2 and the TZI of groups Ⅱ and Ⅲ were significantly higher than that of group Ⅰ (t=2. 285, 2. 727, P=0. 025, 0. 009, respectively). The percentage of the men in group Ⅰ whose partners became pregnant was 29. 5% and those of groups Ⅱ and Ⅲ were 50% and 42.9%, respectively. Although the percentage among three groups was not different statistically (x2 = 3. 285, 0. 854, 0. 199, P= 0. 070, 0. 355, 0. 655, respectively), the relative risks of groups Ⅱ and Ⅲ were 2.4 and 1.8 times of that of group Ⅰ. There were 25, 15, 7 cases of idiopathic infertility among the 3 groups, respectively. The relative risk of I group was 1.5 and 1.3 times of that of Ⅱ and Ⅲ groups. The correlation analysis showed that the T/E2 in serum had significantly negative correlation with the percent of the sperm head or neck or tail defects (r= -0. 209, -0. 316 and -0. 335,respectively and P= 0. 048, 0. 002 and 0. 001, respectively). Conclusions The decrease of T/E2 in serum was correlative with the decrease of fertility probability, but it did not alter the sperm density and the sperm motility. It showed that the level of the T/E2 in serum was important for spermatogenesis and sperm fertilizing capability.     

VEGF-ASODN转染对胃癌细胞VEGF表达及生长的抑制作用

目的研究血管内皮细胞生长因子（VEGF）-反义寡核苷酸（ASODN）转染胃癌细胞SGC-7901对其VEGF表达和生长的抑制作用。方法人工合成硫代磷酸化VEGF-ASODN,转染胃癌细胞SGC-7901,24h后实时荧光定量RT-PCR检测细胞VEGF mRNA起始拷贝数,ELISA法检测细胞及培养液上清中VEGF蛋白含量,Western blot法检测细胞生存素（survivin）蛋白含量,流式细胞仪检测细胞凋亡情况,用MTT实验检测转染对细胞活性的影响,用细胞生长曲线表示转染对细胞生长的影响。结果VEGF-ASODN能显著降低VEGF mRNA水平、降低胃癌细胞及其培养液中VEGF蛋白含量、降低survivin蛋白含量、增加细胞凋亡、抑制细胞活性及生长（P〈0.05）。结论VEGF-ASODN转染胃癌细胞SGC-7901能显著抑制VEGF和survivin蛋白表达、增加细胞凋亡、抑制细胞生长。