门静脉高压症术后再出血外科治疗的探讨（附65例临床分析）

目的：探讨门脉高压症术后再出血外科治疗手术方式的选择。方法：回顾性分析总结65例门脉高压症术后再出血的治疗情况。结果：47例采用了不同术式的外科治疗,其中行肠腔侧侧分流术29例,肠系膜下静脉腔静脉分．流术6例,肠系膜上静脉属支腔静脉分流术4例,肠系膜上静脉属支左肾静脉分流术2例,断流术6例,手术死亡5例,结论：外科治疗目前仍是治疗门脉高压症术后再出血的主要手段,且以择期手术为宜,其中肠腔侧侧分流术是断流术后再出血治疗的首选术式,选择性分流术（DSRS,DSCS）术后再出血的外科治疗主要采用脾切除加断流术,当肠腔分流术后再出血时,行肠系膜下静脉左肾静脉分流术或肠系膜上静脉属支腔静脉分流术是可行的,手术创伤小,疗效较好。     

脐静脉—大隐静脉转流术在重度门脉高压大出血中的应用

目的 探讨以脐静脉-大隐静脉转流术治疗重度门脉高压、食管胃底静脉曲张大出血的临床应用.方法 对30例肝功能差或伴有心肺肾等重要器官功能不全的门脉高压、食管胃底静脉曲张破裂大出血病人,急诊经上腹白线切口暴露并游离脐静脉,游离适当长度的右侧大隐静脉.脐静脉血流已开放者,可直接将其与大隐静脉吻合;若未开放,用F3-5胆道探子将其重新打通,再与大隐静脉吻合,并对照吻合前后门静脉压力、血流速率及血流量.结果 30例手术均成功,术后近期效果良好.术前后门静脉最大血流速率和血流量分别为18.93±7.71cm/s、17.11±6.56cm/s和1686.37±816.32ml/min、1442.35±672.34ml/min;食管钡餐造影,23例食管曲张静脉消失,7例明显好转.结论 脐静脉-大隐静脉转流术具有微创、简便、疗效确实等优点,对于肝功能差、伴有心肺肾等重要器宫功能不全的患者尤为适用.     

DSA对下消化道出血的诊断价值(附32例分析)

目的：探讨DSA对下消化道出血的诊断价值。资料与方法：对32例不明原因性消化道出血患者进行DSA检查，19例经手术病理证实。结果：DSA发现25例病变，阳性率为78．1％。其中血管性病变13例，肿瘤6例，憩室2例，非特异性炎症1例，溃疡2例，息肉1列。结论：DSA对下消化道出血，尤其对小肠和胆道出血病变的定位、定性诊断具有重要价值。     

硫氧还蛋白相互作用蛋白表达下调减轻大鼠蛛网膜下腔出血后早期脑损伤

目的观察大鼠蛛网膜下腔出血(subarachnoid hemorrhage,SAH)后早期硫氧还蛋白相互作用蛋白(thioredoxin-interacting protein,TXNIP)表达变化,检测干预前后TXNIP及下游凋亡因子表达,探讨TXNIP参与SAH后早期脑损伤(early brain injury,EBI)的可能机制。方法血管内穿刺法建立SAH模型。97只成年雄性SD大鼠,随机分为假手术对照组(Sham组,17只)、SAH组(32只)、Control si RNA组(12只)、TXNIP si RNA组(12只)、白藜芦醇(resveratrol,RES)对照组(12只)、RES干预组(12只)。Western blot检测SAH后各时间点及干预前后TXNIP、p-ASK-1、Caspase-3表达变化,荧光共聚焦检测TXNIP在神经元定位,TUNEL法检测细胞凋亡与TXNIP共定位,同时进行脑水肿评估(6只/组)和行为学评分(12只/组)。结果采用TXNIP si RNA和TXNIP抑制剂RES干预后死亡率、行为学评分及脑水肿(F=7.964,P0.05)得到改善。荧光共聚焦显示TXNIP在大鼠脑神经元广泛表达,且主要位于胞浆。荧光TUNEL提示TXNIP与皮层区及海马区凋亡细胞共定位。Western blot发现与Sham组(0.476±0.043,n=3)比较,TXNIP在SAH后12h(0.729±0.548)表达逐渐增高,72h(1.509±0.071)仍处于较高水平,同时伴随下游凋亡因子的增高,差异有统计学意义(F=7.806,P0.05)。采用TXNIP si RNA和TXNIP抑制剂RES干预后,TXNIP表达下调(F=900.849,P0.05,n=3),下游凋亡因子出现下降(p-ASK1,F=32.897,P0.05;Caspase-3,F=89.120,P0.05)。结论大鼠SAH后早期TXNIP表达增加,通过其促凋亡机制参与EBI发生,下调TXNIP能减轻大鼠SAH后EBI,这可能为临床SAH早期治疗提供新的治疗思路。     

Prognostic factors of early outcome and discharge status in patients undergoing surgical intervention following traumatic intracranial hemorrhage

Over the past several decades, the rate of traumatic brain injury (TBI)-related emergency room visits in the United States has steadily increased, yet mortality in these patients has decreased. This improvement in outcome is largely due to advances in prehospital care, intensive care unit management, and the effectiveness of neurosurgical procedures, such as decompressive craniectomies. It is imperative to identify clinical factors predictive of patients who benefit from early mobilization of resources and operative treatment. Equally important is the identification of patients with good prognostic signs among patients receiving surgical intervention for TBI. We conducted a retrospective chart review of 181 patients requiring craniectomies and craniotomies for decompression or evacuation of an intracranial hemorrhage following TBI at a single level I trauma center between 2008-2010. Demographic features and perioperative clinical characteristics of these patients were examined in relation to favorable outcomes, defined as discharge to home or a rehabilitation facility, and unfavorable outcomes, defined as in-hospital mortality or discharge to step-down medical facilities. Younger age, greater Glasgow Coma Scale (GCS) score on admission, absence of preoperative coagulopathies, absence of hypernatremia, and absence of fever were all independent predictors of favorable outcome. Additionally, increased operative duration and increased length of hospital stay were identified as independent predictors of negative outcomes after surgery. This work supports some of the current prognostic models in the literature and identifies additional clinical variables with predictive value of early outcome and discharge status in patients undergoing surgical evacuation of traumatic intracranial hemorrhages.     

Temporal changes in extra-axial brain hematoma's signal intensity in magnetic resonance images of trauma patients: A preliminary,technical study

IntroductionDating the exact or estimated time of trauma is an important issue facing forensic medicine. Several clinical and radiological methods were used to achieve this purpose. In the recent study, we aimed to track the changes in the signal intensity of the extra-axial brain hematoma using magnetic resonance imaging (MRI) conventional sequences as well as diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC).Materials and methodsConsidering inclusion and exclusion criteria, all patients with blunt head trauma were involved. After proper management., stabilization, and resuscitation, the participants were assessed using conventional sequences of MRI and DWI twenty-four hours, forty-eight hours, and three weeks after the injury. Temporal changes of signal intensity were compared by Wilcoxon ranged test.ResultsSixteen patients sustaining blunt head trauma were included in this study. The study showed that during the time, diffusion restriction could be seen in an extraaxial hematoma. At the first 24 hours, the signal of hematoma was void in 87.5% of DWI and 100% of ADC. On the second day, they were hypo-signal in 75% of DWI and 100% 0f ADCs, and after three weeks, 100% of cases were hyper-signal in DWI and hypo-signal ADCs.ConclusionThis preliminary study has shown that the DWI can be used to detect and track the extra-axial hematoma. The signal intensity was void during the first twentyfour hours, although it became hypo-signal after 48 hours. Of note, the diffusion restriction is noted after three weeks.     

经导管动脉化疗栓塞术治疗原发性肝癌破裂大出血

目的探讨TACE治疗原发性肝癌破裂大出血的效果。方法回顾性分析21例接受TACE的原发性肝癌破裂大出血患者,对其TACE后出血改善情况、中远期生存率及其影响因素进行分析。结果 21例患者止血成功率为100%,术后平均动脉压由术前的（72.74±18.20）mmHg上升至（92.40±17.89）mmHg,与术前比较差异有统计学意义（P=0.0011）。术后3、6、12、24个月生存率分别为85.71%（18/21）、71.43%（15/21）、61.90%（13/21）、19.05%（4/21）。结论 TACE是治疗原发性肝癌破裂大出血的首选有效方法,患者预后受肝硬化程度、肝功能分级、肿瘤范围等因素影响。     

腹腔镜胆囊切除术中肝中静脉及其属支误伤出血的防范及处理

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中肝中静脉及其属支误伤出血的预防和处理方法。方法对我院2008年1月至2010年1月期间27例行LC时肝中静脉及其属支损伤破裂出血患者的临床资料进行回顾性分析。结果 27例患者均在腹腔镜下止血成功,其中17例通过腹腔镜下填塞压迫止血,6例通过腹腔镜下钛夹钳夹止血,4例通过腹腔镜下缝扎止血。3种止血方法中以腹腔镜下填塞压迫止血法的手术时间最短、术中出血量最少,分别为(90.26±12.46)min和(240.32±80.15)ml,但3种止血方法的手术时间及术中出血量之间比较差异均无统计学意义(P>0.05)。结论 LC中要尽量在正确的层次分离胆囊床,以减少肝中静脉及其属支的损伤。采取正确的止血措施或止血困难时及时中转开腹,对安全完成手术至关重要。     

胰十二指肠切除术后出血的危险因素分析

目的:探讨胰十二指肠切除术(PD)后腹腔和消化道出血的危险因素。方法:回顾性分析2005年5月—2011年5月在新疆医科大学第一附属医院行PD手术的132例壶腹周围癌患者的临床资料。结果:132例患者中,术后(腹腔和消化道)出血27例(20.5%),其中术后消化道出血12例(9.1%),腹腔内出血6例(4.5%),腹腔兼消化道出血9例(6.8%)。单因素分析结果显示,术中出血量、术中输血量、术后腹腔感染、胰瘘、胆瘘及胰肠吻合口瘘与PD术后出血有关(均P<0.05);多因素分析结果表明,术中出血量≥500 mL(P<0.000,95%CI=6.900~103.775)、胰瘘(P=0.003,95%CI=2.319~55.717)及腹腔感染(P=0.043,95%CI=1.046~19.364)是PD术后出血的独立危险因素。结论:术中出血量≥500 mL,胰瘘,腹腔感染是胰十二指肠切除术后出血的独立危险因素。     

自发性胃十二指肠动脉瘤破裂出血一例

目的 报道1例罕见的胃十二指肠动脉瘤自发性破裂出血,提高临床医师对该病的认识。方法 全腹CTA（256层iCT）及剖腹探查。结果 经全腹CTA、术中探查确诊为胃十二指肠动脉瘤破裂出血。结论 胃十二指肠动脉瘤自发性破裂出血死亡率极高,一经确诊应迅速得到确切治疗,手术止血效果好,并可清除腹腔积血以助术后恢复。