电视腹腔镜外科手术在胃肠道肿瘤的临床应用

目的探讨腹腔镜外科技术在胃肠道肿瘤手术中的应用。方法经电视腹腔镜行胃肠道肿瘤手术１８例,其中右半结肠切除术４例,横结肠癌根治术３例,乙状结肠癌根治术５例,乙状结肠癌姑息切除术并肝转移癌电凝固化１例,胃癌术后复发转移行探查活检１例,胃巨大恶性淋巴瘤行探查活检１例,晚期回肠癌行小肠侧侧吻合术１例,乙状结肠腺瘤切除术２例。结果均获成功,无中转开腹,手术时间平均１６５．０分钟。术后平均３１．２小时胃肠功能恢复,无并发症发生,术后平均住院８．２天。１３例切除肿瘤的结肠癌术后随访２月～３０月,仅１例横结肠癌术后２３月出现肺转移。结论腹腔镜胃肠肿瘤手术损伤小、恢复快、胃肠干扰小、术后疼痛轻,值得进一步探索开展。     

前路减压植骨双凤尾档板固定术治疗胸腰椎骨折伴不完全性截瘫

目的：寻找一种简便而实用的固定方法,观察其对治疗胸腰椎爆裂骨折伴不完全性截瘫的作用。方法：回顾分析２３例前路减压植骨并用自行设计的双凤尾档板固定术治疗的胸腰椎骨折伴不完全截瘫患者的临床资料。结果：２３例胸腰椎骨折伴不完全截瘫患者术前后凸成角２７．５°,术后为６°。骨愈合时间平均为４．５个月,无一例不愈合。２２例有Ｆｒａｎｋｅｌ分级一级以上的改善。结论：经前路手术减压、植骨、固定可同时进行,采用大块植骨双凤尾档板固定手术操作简便,固定可靠,植骨融合率高,重建了脊柱的稳定性,可获得脊髓神经功能最大改善。     

Syringobulbia Caused by Delayed Postoperative Tethering of the Cervical Spinal Cord – Delayed Complication of Foramen Magnum Decompression for Chiari Malformation

Summary  Postoperative tethering of the high cervical spinal cord is a rare cause of neurological deterioration after foramen magnum decompression (FMD) with duraplasty for Chiari type I malformation. A review of the literature revealed that only 5 cases have been reported. This entity is not widely known to occur as a complication of the common surgical procedure for Chiari type I malformation. A 17-year-old boy experienced rapidly progressive neurological deterioration over a 3-month period. FMD and duraplasty with lyophilized cadaver dura had been performed 8 years previously. Follow-up MR images showed that the cerebrospinal fluid (CSF) space dorsal to the cord was gradually disappearing and that syringobulbia had developed. Opening the dura mater of the posterior fossa revealed dense fibrous scarring, arachnoid thickening over the cervicomedullary area, and tethering the cord to the dura from the medulla to C2. The adhesions were dissected free, and the tethering was released. A syringosubarachnoid (SS) shunt was inserted and duraplasty was performed with an expended polytetrafluoroethylene sheet (Gore-Tex). Postoperative MR images demonstrated that the syringobulbia had completely collapsed and that a dorsal CSF space was present. Follow-up MR images provided significant information on the cervical spinal cord tethering after FMD with duraplasty for Chiari malformation. We encourage sharp surgical detethering and duraplasty with Gore-Tex to avoid retethering. Early recognition and treatment of this unusual but important complication are emphasized.     

能谱CT等渗甘露醇胃肠低张造影诊断消化道疾病的价值

目的评价口服等渗甘露醇胃肠低张造影结合能谱成像在消化道疾病诊断中的临床价值。方法回顾性分析56例经手术与病理证实消化道病变患者的资料,所有患者均行口服复方聚乙二醇电解质散清洁肠道,检查当日口服2．5％甘露醇等渗溶液行肠道充盈并低张。采用双能CT宝石能谱成像技术行平扫及双期增强扫描,将原始数据应用能谱分析软件,获得组织最佳对比噪声比（CNR）的单能图像,结合水一碘分离图及能谱曲线分析,并在ADW4．5工作站上进行MPR、MIP和VRT。结果56例患者均能顺利完成检查,胃肠道适度扩张、充盈密度均匀,气粪影干扰少,胃壁及肠壁与低密度的胃腔和肠腔形成鲜明的对比。清楚显示胃肿瘤15例,小肠肿瘤9例,小肠Crohn病2例,小肠过敏性紫癜1例,小肠血管畸形2例,结肠肿瘤13例,结肠息肉8例,直肠肿瘤6例,直肠息肉2例,降结肠及乙状结肠缺血3例。结论口服等渗甘露醇胃肠低张造影可以提供良好的胃肠道显示背景,是一种安全、方便、高效的胃肠检查方法,同时结合能谱成像,可突显小病灶,优化血管成像,判断病灶同源性等方面具有一定的价值,且可真正达到胃肠道一站式检查。     

激光与臭氧治疗腰椎间盘突出症的临床疗效分析及安全性探讨

目的回顾性研究对比经皮激光汽化减压术（percutaneous laser disc decompression,PLDD）与臭氧消融术（ozone ablation,O3）治疗腰椎间盘突出症（lumbar disc herniation,LDH）的临床疗效及安全性。方法选取近5年分别采用PLDD或O3治疗LDH的患者64例,PLDD组31例,O3组33例,对两种方法治疗后3和12个月的临床疗效、治疗前后的疼痛改变、复发率及并发症发生率进行比较分析。结果疗效评价,PLDD组3个月优良率80.6%、12个月优良率83.9%;O3组3个月优良率72.7%、12个月优良率60.6%。3个月疗效PLDD组与O3组比较差异无显著意义（P〉0.05）;12个月疗效PLDD组好于O3治疗组,两组比较差异有显著意义（P〈0.05）。疼痛学评价,采用疼痛视觉模拟评分法（visual analogue scale,VAS）进行评价。两组患者治疗后3和12个月的VAS值较治疗前明显降低,疼痛明显好转,与治疗前比较差异有显著意义（P〈0.05）。两组患者的并发症发生率和复发率均较小,差异无显著意义（P〉0.05）。结论 PLDD及O3两种方法安全性高,均是治疗LDH的有效方法。     

胃肠道MRI造影剂钆喷酸葡胺口服溶液144例临床研究

目的：进行胃肠道ＭＲＩ造影剂钆喷酸葡胺口服溶液的临床验证，研究其用于胃肠道ＭＲＩ造影的临床效果和安全性，材料与方法；钆喷酸葡胺口服溶液，含Ｇｄ－ＤＴＰＡ１０ｍｍｏｌ／Ｌ，使用时温开水稀释１０倍。入选病例１４４例，其中１３４例上中腹病变患者口服给药，１０例下腹病变患者灌肠给药，剂量为５－１０ｍｌ／ｋｇ体重。观察给药前后胃肠道内信号及发与临近器官对比显示情况，记录心率，呼吸频率的变化和不良反应。结果：     

Palliative treatment of neoplastic strictures by self-expanding nitinol Strecker stent

The purpose of this study was to evaluate technical and clinical results of self-expanding esophageal stent implanted in patients with malignant esophageal strictures and clinically significant dysphagia. From June 1992 to September 1994, 27 patients with inoperable tumors of the esophagus or gastric cardiac were treated by placement of 37 self-expanding nitinol stents. Water-soluble contrast and endoscopy studies were performed after the procedure and during the follow-up period. Successful stenting of the stricture was achieved in 27 patients. The mean dysphagia grade dropped from 2.3 to 1 (SD ± 0.54) immediately after the procedure. After the insertion of the stent, 16 patients died in a period of time ranging from 0 to 13 months (mean 5.6 months), whereas at the end of the study 11 patients were alive 4–15 months after the procedure (mean 8.3 months). No major complications were observed. The results of this study are encouraging because esophageal stent placement was technically easy and clinically effective. Correspondence to: F. Maspes     

Thoracolumbar fracture stabilization: comparative biomechanical evaluation of a new video-assisted implantable system

Minimally invasive techniques for spinal surgery are becoming more widespread as improved technologies are developed. Stabilization plays an important role in fracture treatment, but appropriate instrumentation systems for endoscopic circumstances are lacking. Therefore a new thoracoscopically implantable stabilization system for thoracolumbar fracture treatment was developed and its biomechanical in vitro properties were compared. In a biomechanical in vitro study, burst fracture stabilization was simulated and anterior short fixation devices were tested under load with pure moments to evaluate the biomechanical stabilizing characteristics of the new system in comparison with a currently available system. With interbody graft and fixation the new system demonstrated higher stabilizing effects in flexion/extension and lateral bending and restored axial stability beyond the intact spine, as well as having comparable or improved effects compared with the current system. Because of this biomechanical characterization a clinical trial is warranted; the usefulness of the new system has already been demonstrated in 45 patients in our department and more than 300 cases in a multicenter study which is currently under way.     

舒尼替尼治疗伊马替尼耐药胃肠间质瘤的疗效及安全性分析

目的探讨舒尼替尼治疗伊马替尼耐药胃肠间质瘤（GIST）的疗效及安全性。方法回顾性分析2008年5月至2012年4月间在福建医科大学附属协和医院接受舒尼替尼治疗的48例伊马替尼耐药GIST患者的临床资料。舒尼替尼用药方案：18例患者采用50mg／d服药4周,停药2周（50mg／d4／2组）;30例患者采用37．5mg／d连续口服（37．5mg／dCDD组）。结果48例患者舒尼替尼中位治疗时间为56周．按Choi标准于治疗后24周进行近期疗效评估．获完全缓解1例,部分缓解12例,疾病稳定21例,疾病进展14例,客观有效率为27．1％（13／48）,疾病控制率为70．8％（34／48）。48例患者中位随访时间为89周,中位无进展生存期（PLUS）为48周,中位总体生存期（OS）为92周。分组分析显示：既往伊马替尼剂量为400mg／d者,其PFS和Os均优于既往伊马替尼剂量大于400mg／d者（中位PFS：53比35周,P=0．018;中位OS：157比71周,P=0．003）;外显子11突变者0s劣于外显子9突变者（中位0s：71比157周,P=O．008）。治疗期间的主要不良反应有手足综合征（25例,52．1％）、恶心（24例,50．0％）、疲乏（23例,47．9％）和中性粒细胞减少（21例,43．7％）。按舒尼替尼给药方案分组分析,50mg／d4／2组腹泻及手足综合征的发生情况较37．5mg／dCDD组更为严重（P=0．027,P=0．048）。结论舒尼替尼治疗伊马替尼耐药的GIST疗效较好。在伊马替尼400mg／d耐药后应直接换用舒尼替尼而不要加大伊马替尼用药剂量。外显子9突变者舒尼替尼的治疗效果优于外显子11突变者。舒尼替尼37．5mg／d连续口服的用药方案安全性较好。     

合并其他消化道恶性肿瘤的胃肠间质瘤临床病理特征及其诊治

目的探讨合并其他消化道恶性肿瘤的胃肠间质瘤（GIST）患者的临床病理特征及诊治方法。方法回顾性分析2004年9月至2012年11月间在上海仁济医院接受手术治疗的525例原发性GIST的临床资料,其中合并其他消化道恶性肿瘤者46例．未合并其他消化道恶性肿瘤者479例。结果合并其他消化道恶性肿瘤的46例GIST患者术前诊断率仅为2．2％（1／46）,按NIH术后危险度分级,极低危患者36例（78-3％）,低危患者9例（19．6％）,高危患者1例（2．2％）。与未合并其他消化道肿瘤的GIST患者相比,合并者多见于老年患者（P=0．001）,多发生于胃（P=0．000）,肿瘤直径更小（P=0．000）,核分裂像更少（P=0．000）,危险度更低（P=0．000）。46例患者5年生存率为36．1％,显著低于未合并者的82．2％（P=0．000）。结论合并其他消化道恶性肿瘤的GIST大多为低危或极低危险度,对预后影响较小,其预后主要取决于合并的消化道恶性肿瘤,故对其治疗主要针对合并的恶性肿瘤,同时在不明显增加手术风险和术后并发症的情况下可考虑一并切除GIST。