3D完全腹腔镜与腹腔镜辅助右半结肠癌D3根治术近期临床疗效分析

目的 对比3D完全腹腔镜和腹腔镜辅助右半结肠癌根治术病人资料,探讨3D完全腹腔镜右半结肠癌D₃根治术近期临床疗效。方法 回顾性分析2018年1月至2019年3月解放军总医院第一医学中心普通外科行3D腹腔镜右半结肠癌D₃根治术病人87例临床资料,3D完全腹腔镜组47例,腹腔镜辅助组40例。对比两组病人手术情况、术后并发症、术后1年肿瘤复发及生存率情况。结果 3D完全腹腔镜组与3D腹腔镜辅助手术组相比,手术切口短[(4.0±0.8) cm比(6.1±0.8) cm,P<0.001],术后首次排气时间早[(3.0±1.1) d比(3.7±1.8) d,P=0.029],术后住院时间短[(6.9±1.5) d比(7.8±2.3) d,P=0.031],优势显著;在清扫淋巴结数目,吻合口漏、切口感染、腹腔内出血、肠梗阻、淋巴漏、腹泻等并发症,以及术后1年局部复发率、远处转移及生存率方面,与腹腔镜辅助组差异无统计学意义(P>0.05)。结论 3D完全腹腔镜下右半结肠癌D₃根治术病人术后康复快,且不增加手术并发症及术后1年...     

Ad－HGF基因修饰的胎盘间充质干细胞治疗兔肢体缺血的实验研究

目的：研究重组腺病毒介导肝细胞生长因子（ adenoviral vector mediated human hepatocyte growth factor,Ad－HGF）修饰的胎盘源间充质干细胞（ placenta－derived mesenchymal stem cells,PMSC）在兔肢体缺血模型中促新生血管生成的作用。方法无菌取足月产妇胎盘胎儿面中心区域胎盘组织,胶原酶消化法分离干细胞,体外培养传代,感染Ad－HGF 48 h后收集细胞用于治疗兔肢体缺血实验。左侧治疗组后肢缺血肌肉组织内多点注射总细胞数5×106／ml Ad－HGF修饰的PMSC,右侧对照组后肢缺血肌肉组织内注射生理盐水。结果治疗后第14天腹主动脉穿刺行数字减影血管造影（ digital subtraction angiography,DSA）检查,可见左侧肢体缺血治疗后微血管生成数明显多于未治疗右侧肢体,血管形成能力明显增强。苏木精伊红染色法（ HE）后置光镜下观察显示,治疗组毛细血管密度明显大于未治疗组（P＜0．05）。实时荧光定量聚合酶链反应（quantitative polymerase chain reaction,qPCR）检测后肢肌肉组织中血管内皮生长因子（ vascular endothelial growth factor, VEGF）、碱性成纤维细胞生长因子（ basic fibroblast growth factor,bFGF）、HGF的表达明显升高（P＜0．05）。结论经Ad－HGF基因修饰的PMSC能明显促进血管新生,加快局部缺血组织血流循环的重建,是治疗肢体慢性缺血的有效手段。     

血管腔内治疗颈动脉瘤的临床应用研究

目的：探讨颈动脉瘤腔内治疗的可行性。方法：采用血管腔内搭桥及血管栓塞术对不同类型的颈动脉瘤进行腔内治疗。结果：２例患者经腔内治疗后动脉瘤立即消失,术后２４ｈ恢复正常活动及饮食,５ｄ出院。随访３个月无任何并发症。结论：腔内技术治疗颈动脉瘤较传统手术方法具有技术可行、效果可靠、创伤小、恢复快等优点,可能具有广泛应用前景,但远期疗效有待进一步观察。     

瓣膜修复联合腔内光凝或电凝治疗原发性下肢深静脉瓣膜功能不全——附336例临床分析

目的 探讨股部小切口下微创瓣膜修复结合血管内激光或电凝治疗原发性下肢深静脉瓣膜功能不全的新方法.方法 原发性下肢深静脉瓣膜功能不全336例,均取股部小切口,行第一对股浅静脉瓣膜外修复;其中276例以810 nm的半导体激光对迂曲扩张的大隐静脉进行血管内光凝术;另60例选用英国产UM D3000T电刀,由套管送人钢丝,对明显迂曲扩张且较粗的浅静脉,分段电凝.结果 术后当天患者既可下床,无淋巴漏、皮下血肿或下肢水肿等并发症.术后1、2、3、4和5年随访,临床治愈率分别为97.65%,93.71%,92.59%,91.05%和89.71%.结论 联合瓣膜修复结合血管内激光光凝或电凝,是治疗原发性下肢深静脉瓣膜功能不全较好的方法.该方法操作简单、创伤小、恢复快、肢体美观、近期和远期疗效果较好,值得进一步推广应用.     

甲状旁腺腺瘤单侧颈部探查手术治疗56例报道

目的:探讨颈部单侧手术探查治疗甲状旁腺腺瘤的可行性。方法:回顾性分析56例甲状旁腺腺瘤患者的临床资料,对术前影像学定位和术中单侧探查手术方式进行分析。结果:术前行超声、CT、99mTc-MIBI核素扫描定位检查,56例甲状旁腺腺瘤单侧手术探查均获成功,临床治疗效果好。术后均经病理学检查确诊为甲状旁腺腺瘤。结论:B超可作为术中定位首选方法。对定位准确的单发腺瘤,单侧小切口探查术创伤小,是值得推广的手术方法。     

胃肠道手术患者能量需要的研究

目的探讨胃肠道术后患者能量需要量。方法选择胃肠道手术患者203例,术前采用MedGeM床旁代谢仪测定静息能量消耗（REE）,收集术后临床资料,计算术后提供的平均能量,与REE×1.2×1.1（能量供给参考值SEE）比较,分为〈90%SEE,90%-110%SEE,〉110%SEE三组,比较三组人群术前术后人体测量指标、握力、生化指标、免疫营养指标、主观全面营养评定结果（SGA）等。结果术后90%-110%SEE组上臂肌围、左右手握力、血肌酐、血清镁和磷均显著高于其他两组（P〈0.05）,平均住院日和术后停止胃肠减压时间、恢复排便时间和拆线时间与其他两组比较显著缩短（P〈0.05）,且SGA评分正常者显著增加（P〈0.05）,营养不良者显著降低（P〈0.05）。同一组手术前后比较,90%-110%SEE组除血清白蛋白、血红蛋白水平较术前显著下降外（P〈0.05）,其他各项指标术前术后无显著性差异（P〉0.05）。90%-110%SEE范围相当于（1.20±0.15）倍Harris-Benedict公式预测值、（27.22±3.95）倍理想体重和（26.00±3.93）倍实际体重。结论以代谢仪测定结果为基准的90%-110%SEE范围可作为胃肠道术后患者的能量需要参考,如果不能进行实际测量,可根据HB公式1.2倍系数或理想体重27倍系数推断。     

胃、结直肠癌患者手术前后贫血状况的多中心临床调查研究

目的 明确胃、结直肠恶性肿瘤患者手术前后肿瘤性贫血、缺铁性贫血的发生率及其治疗现状.方法 前瞻性收集2009年8月至12月在北京市8家综合医院明确诊断为胃、结直肠恶性肿瘤的患者共262例,检测术前、术后7 d空腹静脉血血红蛋白、血清铁及铁蛋白水平,分析患者手术前后肿瘤性贫血和缺铁性贫血的发生率.结果 在131例胃癌患者中,手术前肿瘤相关性贫血发生率为36.6%,缺铁性贫血发生率为52.1%,其中贫血患者平均年龄高于无贫血患者年龄[(62±11)岁比(57±12)岁,P＜0.05];手术后缺铁性贫血发生率升至72.6%,明显高于术前(P＜0.05).131例结直肠癌患者手术前肿瘤相关性贫血发生率为37.4%,缺铁性贫血发生率为61.2%,其中45%贫血患者结肠肿瘤部位为右半结肠癌;手术后缺铁性贫血发生率明显高于术前(76.7%,P＜0.05).消化道肿瘤性贫血的术前治疗率为10.3%,术后治疗率为22.7%,半数以上的肿瘤性贫血患者接受了输血治疗.结论 胃、结直肠恶性肿瘤患者中缺铁性贫血及肿瘤相关性贫血发生率高,主要病因为缺铁性贫血.老年患者、右半结肠癌患者中贫血发生率高.贫血患者接受治疗比例较低,需要建立系统的肿瘤性贫血治疗规范.

Abstract：

Objectives To determine the prevalence of cancer-related anemia and iron deficiency anemia( IDA ) in patients with gastric and colorectal cancer in North of China. Methods A cross-sectional study of 262 inpatients diagnosed with gastric or colorectal cancer admitted to eight general hospitals in Beijing from August 2009 to December 2009 was performed. The blood samples were took on the day after admission and the seventh day after operation for the tests of hemoglobin, serum iron and ferritin. The morbidity of cancer-related anemia and IDA before and after the surgery was also compared respectively.Results The preoperative morbidity of cancer-related anemia was 36. 6% in 131 patients with gastric cancer, and the morbidity of IDA was 52. 1%. The mean age of the anemic patients was higher than that in cases without anemia[(62 ± 11 ) yrs vs. (57 ± 12) yrs, P ＜ 0. 05]; the postoperative morbidity of IDA increased to 72. 6% ( P ＜ 0. 05 ). In the 131 cases with colorectal cancer, the preoperative incidence of cancer-related anemia and IDA was 37. 4% and 61.2%, respectively. About 45% of the cases with anemia had a tumor in the right colon. Postoperative incidence of IDA was significantly higher than that before the surgery ( 76. 7%, P ＜ 0. 05 ). Only 10. 3% of the anemic patients were treated with chalybeate therapy before surgical procedures, and the proportion was 22. 7% after the operation. More than 50% of anemic patient received blood transfusion. Conclusions Cancer-related anemia is a common clinical manifestation in patients with gastrointestinal cancer, and anemia occurs more frequently in elder and patients with right colon tumor. The treatment to cancer-related anemia is insufficient and a systematic therapy is needed to be established.     

单操作孔胸腔镜联合腹腔镜食管癌根治术六例

目的 探讨单操作孔胸腔镜联合腹腔镜食管癌根治术的可行性及近期疗效。方法2010年3-12月间解放军总医院应用经口置入钉砧头系统（OrVil）．行单操作孔胸腔镜联合腹腔镜食管癌根治术6例。患者先在平卧位下行腹腔镜游离胃并清扫腹腔淋巴结,然后取左侧卧位．在单操作孔胸腔镜下游离食管并清扫胸部淋巴结．最后将胃经膈肌裂孔上提到胸腔后制备管状胃．利用OrVil系统完成胃食管吻合。结果全组手术顺利。无中转开胸病例。手术时间200～320min：腹腔镜手术时间平均75（45～90）min,胸腔镜时间平均160（120～240）min。术中平均出血220（160～300）ml,平均清扫淋巴结12（9-18）枚。术后恢复顺利,未出现吻合口瘘、肺部感染、乳糜胸等严重并发症。结论单操作孔胸腔镜联合腹腔镜食管癌切除后,应用OrVil系统行胃食管胸顶吻合安全、可行。     

腹腔镜胃局部切除术的临床应用

目的 评价腹腔镜胃局部切除术的临床应用价值.方法 回顾性分析2006年2月至2010年1月解放军总医院收治的78例行腹腔镜胃局部切除术患者的临床资料.根据病灶的位置和游离范围,采用全腹腔镜下胃局部楔形切除术、腹腔镜辅助下胃局部切除术和腹腔镜联合内镜切割吻合器肿瘤切除术.探讨患者的手术疗效.结果 78例患者均在腹腔镜下成功完成胃局部切除手术,无一例中转开腹.其中,45例行全腹腔镜胃局部楔形切除术,22例采用腹腔镜辅助下胃局部切除术,11采用腹腔镜联合内镜切割吻合器肿瘤切除术.平均手术时间为75 min(45～120 min),术中平均出血量为60 ml(35～90 ml),切除病灶平均直径为(2.5±1.3)cm(0.7～4.8 cm).术后患者无并发症发生及死亡.术后肠道功能平均恢复时间为35 h(25～42 h),术后平均住院时间为7.5 d(6～9 d).术后病理检查:63例患者为胃间质瘤;11例患者为胃良性疾病,其中异位胰腺组织5例、炎性假瘤2例、增生性息肉2例、神经鞘瘤1例、血管瘤1例;4例患者为类癌,其中位于黏膜层3例、累及深肌层1例.本组患者中位随访时间为26个月,未发现术后出血、吻合口狭窄及戳孔种植.63例胃间质瘤患者中,2例术后行甲磺酸伊马替尼治疗、1例肿瘤复发行再次手术治疗,术后恢复良好.结论 腹腔镜胃局部切除术治疗胃良性疾病、胃间质瘤及早期胃癌安全、可行.

Abstract：

Objective To evaluate laparoscopic local resection for the treatment of gastric tumors. Methods The clinical data of 78 patients who received laparoscopic local resection at the PLA General Hospital from February 2006 to January 2010 were retrospectively analyzed. According to the tumor site and free range, total laparoscopic gastrectomy was applied to 45 patients, laparoscopic local resection was applied to 22 patients, laparoscopic and endoscopic tumor resection was applied to 11 patients. The efficacies of the surgical approaches were investigated. Results Laparoscopic local resection was successfully performed on the 78 patients without conversion to open surgery. The mean operation time and operative blood loss were 75 minutes (range, 45-120 minutes) and 60 ml (range, 35-90 ml), respectively. The mean diameter of the tumor was (2.5±1.3)cm (range, 0.7-4.8 cm). No mortality or morbidity occurred postoperatively. The bowel function recovery time and the duration of hospital stay were 35 hours (range, 25-42 hours) and 7.5 days (range, 6-9 days), respectively. The results of postoperative pathological examination verified that 63 patients were with gastric stromal tumor, 11 patients were with benign gastric diseases, including 5 with gastric heterotopic pancreas, 2 with inflammatory pseudotumor, 2 with hyperplastic polyp, 1 with schwannomas and one with angioma. Four patients were with carcinoid, 3 carcinoids were located in mucous layer and 1 invaded into muscular layer. The median time of follow-up was 26 months, and no anastomotic stenosis or port-site metastasis was observed. Of the 63 patients with gastric stromal tumor, 2 were treated with imatinib mesylate, 1 had tumor recurrence and received reoperation. Conclusion Laparoscopic local resection is safe and feasible for the treatment of benign gastric neoplasms, stromal tumor and early gastric tumors.     

MRI引导乳腺活组织穿刺检查的初步研究

目的:探讨在MRI引导下行乳腺穿刺活检的可行性和临床适应证。材料和方法:采用自制的乳腺固定架,用模型完成乳腺固定架空间定位精确度测试后,为9例志愿者进行临床测试。9例志愿者的病灶均评价为BI-RADS3～5级,其中8例为超声和钼靶不能显示的病灶。使用Mammotome真空辅助穿刺装置,从影像学、外科学和病理学的角度对MRI引导乳腺病变穿刺活检的可行性进行评价。结果:5次模型测试的平均误差为2.2±0.63mm,穿刺精度符合要求。9例病人均成功完成穿刺操作,病理证实1例为不典型导管上皮增生(随访手术完全切除),1例乳腺导管原位癌(ductal carcinoma in situ,DCIS;后续手术切除),2例导管内乳头状瘤(1例全切,1例多发只切除单个病灶),1例窦样血管增生,1例腺瘤部分切除,3例腺病或增生。结论:MRI引导的乳腺活检具有影像学、外科学和病理学方面的可行性,能为钼靶和超声不能检测的病灶提供活检确诊的手段。