34例肝门部胆管癌的诊断和治疗

目的:探讨肝门部胆管癌合理选择治疗方式,方法:对34例患者按不同的治疗方式分为根治性切除, 姑息性切除,胆肠内引流,金属支架内引流和外引流5组,分析各种治疗方式与病变分型,生存时间和并发症的关系.结果:生存时间,根治性切除组3.3年,姑息性切除组平均20个月,胆肠内引流组平均13个月,金属支架内引流组平均12个月;外引流组6.3个月;总并发症23.5%,手术死亡率0.结论:肝门部胆管癌的治疗应首选根治性切除,选择性和肝段切除是更适合的,姑息性切除的疗效优于各种内外引流术,胆肠吻合内引流术和金属支架内引流疗效相似.     

肾癌相关新基因GYLZ-RCC18反义寡核苷酸转染对肾癌细胞系GRC-1的作用

目的：探讨肾癌相关新基因GYLZ－RCC18在肾癌发生发展中的作用机制。方法：采用逆转录PCR方法检测GYLZ－RCC18在肾癌和正常肾细胞系中的表达,将第一编码区起始处的20个碱基的反义和正义寡核苷酸导入肾癌细胞系GRC－1,连续观察对肾癌细胞生长、增殖凋亡、死亡率、形态学的影响。结果：GYLZ－RCC18在肾癌细胞系中表达明显高于正常肾细胞系;导入GYLZ－RCC18反义寡核苷酸后,GRC－1细胞的核分裂可明显减少,导致GRC－1细胞死亡,抑制癌细胞的生长和增殖活性,并可特异诱导GRC－1连续凋亡。结论：GYLZ－RCC18是肾癌发生发展密切相关的癌基因,其表达可促进肾癌细胞的生长和增殖,并通过抗癌细胞死亡和凋亡机制对癌细胞起保护作用。     

尿中胰蛋白酶原激活肽对重症急性胰腺炎的早期预测价值

目的　评估尿中胰蛋白酶原激活肽（TAP）对重症急性胰腺炎（SAP）患者的早期预测价值。方法　出现首发症状后48h内入院的急性胰腺炎（AP）患者41例（轻型29例、重症12例）及对照组11例,在入院时、24h、48h及72h取尿样测定TAP浓度,同时对每个患者在入院后48h进行APACHEⅡ评分。结果　入院时重症组尿TAP值（95nmol/L)高于轻型组（20nmol/L,P＜0.005)及对照组(15nmol/L,P＜0.005)。入院时尿中TAP值≥35nmol/L预测SAP的特异性和敏感性分别为89.7%和91.7%,而APACHEⅡ≥9诊断SAP的特异性和敏感性仅为72.7%和75.0%。90%的患者可通过TAP预测AP的严重程度,而APACHEⅡ评分仅能对73%的患者进行正确评价。结论　首发症状出现后48h内入院的AP患者尿中TAP浓度可早期预测SAP。     

阻钉技术对交锁髓内钉断钉的影响

目的探讨阻钉技术对交锁髓内钉断钉的预防作用。方法2003年1月~2005年8月,采用交锁髓内钉固定长骨干骨折56例,男32例,女24例。年龄21~65岁,平均34岁。其中股骨骨折26例,胫骨骨折30例,均为新鲜、闭合性骨折。骨折类型:中部横断骨折10例,中部短斜形骨折11例,中部长斜形或螺旋形骨折20例,远、近1/3骨干骨折15例。前期32例患者采用常规的交锁髓内钉固定骨折(组),后期24例中部长斜形或螺旋形骨折及远、近1/3骨折患者采用交锁髓内钉配合阻钉固定骨折(组)。结果获随访12~21个月,平均16个月。组3例患者骨折未愈合,其中1例股骨中部长斜形骨折主钉在骨折线附近断裂,另2例胫骨远1/3骨折主钉在靠近骨折端的第1个锁钉孔处断裂;其余患者术后6~12个月获骨性愈合,但骨折处出现较多骨痂。组患者于术后3~8个月获骨性愈合,骨折对位、对线良好,无断钉发生。结论阻钉技术配合交锁髓内钉应用可明显增强骨折断端稳定性,减少断钉发生。     

应激性溃疡时幽门区局部一氧化氮含量变化对胆汁返流的影响及机理探讨

目的探讨胆汁返流与幽门区局部神经递质一氧化氮的变化对应激性溃疡发病的影响及可能的机理。方法采用冷束缚应激方法复制应激性溃疡的动物模型，将60只成年SD大鼠分为两部分，第1部分：对照组10只，溃疡组30只，用于观测影响应激性溃疡发生的相关因素；第2部分：左旋硝基精氨酸甲酯（L—NAME）预处理组10只（L—NAME组），生理盐水预处理组10只（生理盐水组），用于观测幽门区局部一氧化氮含量变化对其他因素的影响。分别检测各组胃内胆汁酸浓度、胃黏膜溃疡指数（Guth评分）以及胃内pH值，用生化试剂盒检测幽门区一氧化氮的含量。结果溃疡组应激结束后1h幽门区一氧化氮含量达到峰值（P〈0．01），应激结束后2h胃内胆汁酸浓度和pH值均达到峰值（P〈0．01），应激结束后4h胃内溃疡指数达到峰值（P〈0．01）。L-NAME组的胃内胆汁酸浓度、溃疡指数及一氧化氮含量较生理盐水组显著降低（P〈0．01，P〈0．05），而胃内pH值的差异无统计学意义（P〉0．05）。幽门区一氧化氮含量与胆汁酸浓度呈正相关（r=0．715，F=12．55，P=0．017）。结论幽门区一氧化氮含量变化与胆汁的返流量之间存在正相关关系，而L—NAME的幽门区局部干预使幽门区一氧化氮含量减少，幽门松弛程度降低，胆汁返流量也随之减少，进而降低溃疡指数，起到保护胃黏膜的作用。     

小剂量纳洛酮静脉注射未能减轻吗啡静脉镇痛的不良反应

目的 研究术后吗啡病人自控静脉镇痛（PCIA）中加用小剂量的纳洛酮对镇痛效果、吗啡用药量及其不良反应的影响.方法 选择ASA Ⅰ或Ⅱ级下肢骨科手术92例,在所有入选病人中,有3例结果显示可疑而退出.所有病人都在L2～3腰-硬联合麻醉下进行手术,术后立即开始PCIA.依用药方案不同随机分为三组：Ⅰ组（29例）,吗啡复合纳洛酮1组,两药浓度比为1 600：1;Ⅱ组（32例）,吗啡复合纳洛酮2组,浓度比为2 000：1;Ⅲ组（28例）,单纯吗啡作为对照.各组静脉泵中的吗啡浓度相同为100 ml生理盐水中加入80 mg吗啡.镇痛泵的设定参数为：PCA量为2 ml,锁定时间为8 min,无背景剂量.记录术前病人的年龄、身高、体重等一般情况,记录启动PCA泵前后病人的SpO2,术后2、6、24 h病人的疼痛视觉模拟评分（VAS）、吗啡的消耗量及恶心、呕吐、瘙痒等不良反应和各处理药物的用量.结果 根据实际进入的89例研究结果显示各组无论在吗啡的消耗量还是在术后不良反应的发生率上差异都无统计学意义,Ⅰ组、Ⅱ组和Ⅲ组术后恶心发生率分别为58.6%、65.6%和64.2%,呕吐的发生率分别为31.1%、34.3%和35.7%,瘙痒的发生率分别为41.3%、40.6%和42.8%,另外各组需要应用补救药物的例数差异也无统计学意义.结论 在术后吗啡PCIA治疗药液中加入小剂量纳洛酮对减少吗啡消耗量,降低恶心、呕吐的发生率无明显效果.     

Osteonecrosis of the jaw induced by orally administered bisphosphonates: incidence, clinical features, predisposing factors and treatment outcome

Summary Osteonecrosis of the jaw (ONJ) is a well-known devastating side effect of bisphosphonate therapy for cancer. Several ONJ cases of patients using oral bisphosphonates have been reported in the literature. The present study analyzed the clinical features, predisposing factors, and treatment outcome of 11 patients with oral bisphosphonates-related ONJ. Introduction and hypothesis Osteonecrosis of the jaw (ONJ) is a well-known side effect of parenteral bisphosphonates therapy. Although ONJ has been reported in patients using oral bisphosphonates, documentation of this entity is sparse. It was hypothesized that the clinical features, predisposing factors, and treatment outcome of this population are different from those of oncologic patients. Methods This retrospective bi-central study involved 98 ONJ patients, 13 of whom were treated with oral bisphosphonates. Two patients were excluded because of previous use of intravenous bisphosphonates. The profiles of 11 patients were analyzed. Results The mean duration of alendronate use before developing ONJ was 4.1 years. ONJ was triggered by dental surgery in 9 patients and by ill-fitted dentures in 2. Heavy smokers were the most recalcitrant subjects. Among the nine patients with at least 6 months of follow-up, ONJ healed completely in three, partially in four, and not at all in two. Conclusions ONJ is a rare devastating side effect of oral bisphosphonates associated with patient morbidity and high financial burden. Clinicians must be aware of this entity and inform patients of the risks of dental surgery. The synergistic effect of smoking in the pathogenesis of ONJ should be further investigated.     

Facial Fractures in Kajang Hospital,Malaysia: A 5-Year Review

Abstract Objective: The objective of this study was to determine the demographic data as well as other relevant data pertaining to the management of patients with maxillofacial injury in a Malaysian government regional hospital. Study Design: Medical records of 313 patients who sustained maxillofacial injury treated in Kajang Hospital, Selangor, Malaysia over a 5-year period (1998–2002) were collected. Data regarding age, gender and race, etiology of injury, site of injury, other associated injuries and treatment undertaken were analyzed. Results: Two hundred and forty-nine male (79.6%) and 64 female patients (20.4%) were treated for maxillofacial trauma. The patients' age range from 1 to 67 years old, with a median age of 23 years old. A high number of Malays (60.1%) sustained maxillofacial injury, followed by Indians (16%), Chinese (13.4%) and other races (10.5%). Road traffic accident was the main etiology for maxillofacial injury with 230 cases (73.5%), followed by fall (16.6%), assault (5.4%), industrial accident (2.6%), sports injuries (0.6%) and others (1.3%). Mandibular fractures were the most common, occurring in 83.1% of the cases while the midfacial fractures accounted for 16.9%. Majority of patients were treated with closed reduction and intermaxillary fixation (88.1%) and 11.9% underwent open reduction and internal fixation. Conclusion: Road traffic accident involving motorcyclists was the main cause of maxillofacial trauma in Malaysia. The most common facial fracture was the mandibular fracture. Non-surgical manipulation of fracture was the most common treatment carried out in this hospital.     

Surgical management of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis

Aneurysms of the visceral arteries, especially of the pancreaticoduodenal artery, are rare. They show a wide clinical spectrum, ranging from asymptomatic incidental findings to rupture-inducing catastrophic bleedings. Since growth progression and the risk of rupture cannot be foreseen and there is no relation between the size of the aneurysm and propensity to rupture, rupture unfortunately carries a high mortality, >50%. Thus, all aneurysms of the pancreaticoduodenal artery should be treated. The therapy of choice, either operative intervention or catheter embolization, is determined by many factors. Among these are localization, size, relation to other vessels and neighboring organs, the urgency of intervention, and the experience of the therapist. Surgical therapy should be favored in patients with pancreaticoduodenal artery aneurysm due to celiac trunk occlusion. We report here our experience in the surgical treatment of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis over the last 5 years.     

Hepatobiliary rhabdomyosarcoma mimicking choledochal cyst: Lessons learned

INTRODUCTION

The differential diagnosis of hepatic cystic lesions is a challenging process especially in case of hepatic rhabdomyosarcoma (HRMS) presenting as hepatic cyst.

PRESENTATION OF CASE

We introduce our experience with a case of HRMS in a 3-year-old female patient who was misdiagnosed to have type IV-A choledochal cyst and definitive correct diagnosis was reached after the pathological and immunohistochemical examination of the surgically resected lesion. This case presentation is followed by important practical messages to hepatobiliary surgeons regarding HRMS.

DISCUSSION

HRMS is a rare pediatric tumor. Jaundice is the most common presentation of HRMS followed by abdominal pain and vomiting. Great effort is needed to differentiate the tumor from choledochal cyst and infectious hepatitis. Through evaluation using available imaging studies together with clinical anticipation is mandatory for establishing the correct diagnosis.

CONCLUSION

Differentiation of HRMs from choledochal cyst mandates through evaluation and clinical anticipation. HRMS should be suspected in any child with obstructive jaundice. Once diagnosis is established, multidisciplinary treatment is the best management strategy and it has proved better surgical outcome and long term survival.