肝移植术后脾动脉盗血综合征治疗选择及安全性评价（附5例报告）

目的 分析肝移植术后脾动脉盗血综合征（SASS）不同时机治疗方式选择的临床效果,评价脾动脉栓塞的疗效及其安全性。方法 回顾性分析2004年1月至2013年12月武警总医院191例肝硬化、脾脏增大,术前脾动脉直径/肝动脉直径≥1.5、但术中肝动脉血流≥30 cm/s的肝移植病人SASS发生率及临床表现。根据确诊时机和程度分别采取脾动脉栓塞、肝动脉与脾动脉或腹主动脉重新吻合、脾动脉结扎或脾脏切除,比较4种处理方式的临床效果及安全性。结果 17例（8.9%）病人确诊为SASS,绝大多数（16/17,94.1%）发生在术后15 d内。5例急诊行脾动脉栓塞后肝总动脉血流［栓塞前（16.6±3.0）cm/s vs. 栓塞后（39.3±7.7）cm/s,P＜0.001］立即改善,阻力指数全部恢复到正常水平（0.5～0.8）,未观察到相关并发症。12例继发肝动脉血栓形成病人取出血栓或溶栓后行肝动脉与腹主动脉吻合（4例）、脾动脉结扎（3例）或脾切除（5例）;其中3例接受再次肝移植;2例因肝功能衰竭死亡。结论 SASS是肝移植术后严重并发症,及时诊断并行脾动脉栓塞是有效的补救措施,具有可靠的疗效和安全性。     

“保胆”理念正误

胆囊切除术是公认的胆囊良性疾病的治愈手段，国内外学术界对于手术适应证和手术时机已有明确共识。近年来，“保胆手术”治疗胆囊良性疾病颇受热议，一些医生将“保护胆囊”的学术观点等同于“保留胆囊”的手术技术，这种误解可能导致病人出现差异性的预后。因此，临床医师应明晰“保护胆囊”理念与“保胆手术”的差别，对胆囊良性疾病的诊疗原则有正确的理解和应用。     

Repair of superficial osteochondral defects with an autologous scaffold-free cartilage construct in a caprine model: implantation method and short-term results

OBJECTIVE: To compare four different implantation modalities for the repair of superficial osteochondral defects in a caprine model using autologous, scaffold-free, engineered cartilage constructs, and to describe the short-term outcome of successfully implanted constructs. METHODS: Scaffold-free, autologous cartilage constructs were implanted within superficial osteochondral defects created in the stifle joints of nine adult goats. The implants were distributed between four 6-mm-diameter superficial osteochondral defects created in the trochlea femoris and secured in the defect using a covering periosteal flap (PF) alone or in combination with adhesives (platelet-rich plasma (PRP) or fibrin), or using PRP alone. Eight weeks after implantation surgery, the animals were killed. The defect sites were excised and subjected to macroscopic and histopathologic analyses. RESULTS: At 8 weeks, implants that had been held in place exclusively with a PF were well integrated both laterally and basally. The repair tissue manifested an architecture similar to that of hyaline articular cartilage. However, most of the implants that had been glued in place in the absence of a PF were lost during the initial 4-week phase of restricted joint movement. The use of human fibrin glue (FG) led to massive cell infiltration of the subchondral bone. CONCLUSIONS: The implantation of autologous, scaffold-free, engineered cartilage constructs might best be performed beneath a PF without the use of tissue adhesives. Successfully implanted constructs showed hyaline-like characteristics in adult goats within 2 months. Long-term animal studies and pilot clinical trials are now needed to evaluate the efficacy of this treatment strategy.     

ALPPS与采用不同栓塞材料PVE对肝再生及手术切除率影响研究

目的 比较不同栓塞材料的门静脉栓塞术（PVE）与联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）对剩余肝体积（FLR）增长速率的影响,比较各组FLR的增长速率,二期手术切除率、术中数据和术后并发症。方法 采用单中心、前瞻性、非随机对照的对比研究。2014年11月至2019年12月,海军军医大学第三附属医院共126例因FLR不足导致无法切除的肝细胞癌（HCC）或肝内胆管癌（ICC）病人,将其分为4组：ALPPS组及分别采用氰基丙烯酸正丁酯（NBCA）、微球、明胶海绵作为栓塞材料的PVE组。主要终点为FLR增长速率和二期手术切除率。结果 各组的手术切除例数及二期手术切除率分别为：ALPPS组38例（99.4%）,NBCA组32例（76.2%）,明胶海绵组20例（60.6%）,微球组10例（83.3%）。ALPPS组、NBCA组、微球组的FLR增长速率分别为15.1 mL/d,10.0 mL/d和 8.5 mL/d,均高于明胶海绵组（3.7 mL/d）。结论 采用NBCA及微球作为栓塞材料的PVE导致FLR增长速率低于ALPPS,两种栓塞材料的PVE二期手术切除率相当。使用NBCA作为栓塞材料的PVE其FLR增长速率高于微球,且这两种栓塞材料的栓塞效果均优于明胶海绵。     

基于SEER数据库男性乳腺癌手术切除病人预后分析及列线图建立

目的 分析男性乳腺浸润性导管癌手术切除病人的独立预后因素及构建预后列线图,同时验证该模型的准确性。方法 从美国国立癌症研究监测、流行病学和最终结果（SEER）数据库中下载2010—2018年间诊断为男性乳腺浸润性导管癌且经过手术切除的1662例病人的临床病理特征及治疗信息。随机数字分组法将病人按照3∶1分为训练队列（1246例）和验证队列（416例）。 通过单因素及多因素 COX分析筛选出独立预后因素并构建预测1、3、5年的总生存率（OS）的列线图。一致性指数（c-指数）和校准曲线确定列线图预测的准确性和判别能力。结果 年龄、肿瘤直径、临床TNM、病理学分级、婚姻状态5个指标均是OS的独立预后因素（P均<0.05）。基于独立预后因素构建了1、3、5年OS的列线图。训练队列中列线图的c-指数为0.730（95%CI 0.694-0.766）,高于美国癌症联合委员会（AJCC）临床TNM分期系统 0.628（95%CI 0.588-0.668）;验证队列列线图的c-指数为0.737（95%CI 0.680-0.794）,高于AJCC 临床TNM分期系统 0.584（95%CI 0.516-0.652）。校准曲线表明列线图预测生存率与实际生存率具有良好的一致性。结论 基于年龄、肿瘤直径、临床TNM、病理学分级、婚姻状态的独立预后因素构建的列线图能较准确地显示男性乳腺癌手术切除病人预后,有利于进行临床个体化预后评估。     

Stabilisation of periprosthetic fractures with angular stable internal fixation: a report of 13 cases

Introduction: Periprosthetic fractures of the femur present a challenging surgical problem. The aim of this study was to retrospectively evaluate the outcome of periprosthetic fractures stabilised with an angular stable, less invasive stabilisation system (LISS). Patients and methods: Thirteen patients (ten total hip-, two total knee-, one total hip- and knee-arthroplasty) with periprosthetic fractures were treated with the LISS internal fixator (in ten cases minimal invasive). Six patients had previous operations due to periprosthetic fractures. The average follow-up period was 20 months, follow-up rate 85%. Results: All fractures showed radiographic fracture healing without implant loosening. Except one patient, all patients had returned to their pre-operative activity level. No early post-operative complications were seen. There was one implant failure after 4 months and two cases of malunion. Conclusion: The cases showed the internal fixator to be effective for the stabilisation of periprosthetic fractures, even in cases of poor bone quality with good functional outcomes. The internal fixator, with the option of minimal invasive application, is the preferred method of osteosynthesis in periprosthetic fractures.     

我国日间手术开展现状与前景展望

日间手术在国外已有上百年的发展历史,现已成为欧美国家重要手术模式。我国于20世纪初开始开展日间手术,但目前尚未普及,发展不平衡问题比较突出,存在认识不清、开展不规范、与医保支付对接不畅等问题。日间手术是一种使国家、医院和病人三方均受益的新型手术模式。近年来,国家相关管理部门积极引导,开展日间手术的医院明显增多,可以预见,我国日间手术即将进入快速发展的新阶段。因此,有条件的医院可以从简单、易操作的病种开始,落实临床路径,积累经验,再逐步稳妥展开。在保证质量的前提下,不断拓展日间手术范围,提高三、四级手术比例。同时,积极与医保支付政策对接,采取灵活的方式,获得医保的支持,更好地促进我国日间手术的快速发展。     

基于Wnt/β-catenin信号通路探讨枸杞多糖对压疮大鼠创面愈合的影响

目的 探讨枸杞多糖(Lycium barbarum polysaccharides,LBP)对压疮(pressure ulcer,PU)大鼠创面愈合及Wnt/β-catenin信号通路的影响。方法 采用随机数字表法将18只SD大鼠分为3组,即空白组、模型组和LBP组。采用缺血再灌注损伤方法制备PU大鼠模型并给予LBP干预2周。观察各组大鼠治疗后第1天、3天、7天和14天创面的治愈率。创面组织取材进行HE染色病理检测。采用ELISA进行血清 肿瘤坏死因子(tumor necrosis factor,TNF)-α、白细胞介素(interleukin,IL)-6、IL-1β、超氧化物歧化酶(superoxide dismutase,SOD)、丙二醛(malondialdehyde,MDA)、血管内皮生长因子(vascular endothelial growth factor,VEGF)表达水平检测。Wnt1、β-catenin和GSK-3β的 mRNA和蛋白表达水平采用RT-qPCR方法和蛋白印迹方法进行检测。结果 在第3天、7天和14天时,LBP组大鼠创面愈合率明显高于模型组,差异有统计学意义(P<0.05)。HE染色结果表明LBP可以减轻组织炎性浸润增加毛细血管数量。LBP治疗后与模型组比较可以有效降低血清中TNF-α、IL-6和IL-1β的表达水平,差异有统计学意义(P<0.05)。LBP治疗后与模型组比较,可以明显提高血清SOD和VEGF表达水平,降低MDA表达水平,差异有统计学意义(P<0.05)。与模型组比较,LBP治疗后PU大鼠创面组织中Wnt1和β-catenin的mRNA及蛋白表达明显升高,而GSK-3β的mRNA及蛋白表达明显降低,差异有统计学意义(P<0.05)。结论 LBP在PU大鼠创面愈合过程中发挥了抗氧化和抗炎的特性,同时通过对Wnt/β-catenin信号通路的调控达到促进皮肤创面愈合的作用。     

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??Ultrasound characteristics of thyroid microcarcinoma PAN Fu-shun*??XIE Xiao-yan??LI Xiao-xi??et al. *Department of Ultrasound, the First Affiliated Hospital of Sun Yat-sun University, Guangzhou 510080,China
Corresponding author??XIE Xiao-yan??E-mail??xxy1992@live.cn
Abstract Objective To investigate the ultrasound characteristics of thyroid microcarcinoma. Methods The ultrasound imaging of thirty-four cases of thyroid microcarcinoma confirmed by surgery and pathology between January 2003 and January 2009 at the First Affiliated Hospital of Sun Yat-sun University was analyzed retrospectively. Results Thirty-two (94.1%) cases were detected as hypo-echo nodules. Twenty-eight (85.3%) cases were with irregular shape. Twenty-six (76.5%) cases were with irregular edges calcification. Blood flow was detected in 7 cases with CDFI and lymph node metastasis was found in 4 cases. Conclusion Hypo-echo nodules, regular shape, irregular edges and calcification are the ultrasound characteristic. Comprehending the characteristics may improve the pre-operation diagnosis efficacy.     

上期有奖图片读解答案

患者因诊断为右下肺肿瘤性病变,拟手术治疗。手术所见:右肺灰褐色,多处黑色素沉着,右下肺后基底段3ｃｍ×32ｃｍ实性包块,右下肺多处炎性改变。病理报告:右下支气管扩张伴局灶性出血肺梗死。讨论　肺组织供氧来自三方面:肺动脉系统、支气管动脉系统及局部肺野的气道。所以肺栓塞后,当支气管动脉和/或气道受累,肺动脉压增高,支气管动脉与肺动脉间侧支循环不能有效建立时才发生肺梗死,其发生率不到10%。肺梗死区域内肺泡或间质内出血性改变,邻近肺组织发生水肿和肺不张。梗死区有明确红色实质界限,范围1～5ｃｍ,呈楔形,基底为周围肺实质,尖端…