嵌顿性输尿管上段结石三种微创术式的疗效比较

目的比较微创经皮肾穿刺取石术(MPCNL)、经尿道输尿管镜碎石术(URL)以及后腹腔镜输尿管切开取石术(RPLU)治疗嵌顿性输尿管上段结石的疗效。方法140例单侧嵌顿性输尿管上段结石患者,URL组55例,MPCNL组48例,RPLU组37例。术后辅助体外冲击波碎石(ESWL)治疗,其中URL组25例,MPCNL组1例,RPLU组无。术后3d及1个月后统计结石清除率。结果MPCNL组术后3d结石清除率为94%(45/48),术后1个月结石清除率为100%(48/48)。URL组术后3d结石清除率为56%(31/55),术后1个月结石清除率86%(47/55),RPLU组1例因结石上移改开放手术取石成功,术后3d结石清除率为97%(35/36),术后1个月结石清除率100%(37/37),三组并发症发生率无统计学差异。结论对于输尿管上段嵌顿结石,如结石体积较大,肾积水较明显且结石位置接近肾盂者,更适合选择MPCNL治疗;如结石位置偏低,积水较少以及不适宜全麻的患者,或患者主动要求可考虑经尿道输尿管镜手术;对于合适选择性的病例,可行腹腔镜手术,同时可作为经尿道输尿管镜手术失败的补救治疗措施。     

经皮肾镜气压弹道碎石术与开放手术治疗鹿角形肾结石的比较

目的比较经皮肾镜碎石术(PCNL)与开放手术治疗鹿角形肾结石的有效性和安全性。方法回顾性分析我院自2003年6月至2008年12月收治120例鹿角形肾结石患者的临床资料,其中PCNL组79例,开放手术组41例,比较两种治疗手段的手术时间、术中出血量、术后住院天数、结石排净率、并发症发生率等指标。结果 PCNL组与开放手术组的手术时间、术中出血量、术后住院天数差异均有统计学意义(P0.05),结石排净率、术后并发症发生率差异无统计学意义(P0.05)。结论 PCNL是治疗肾鹿角型结石的一种安全有效的治疗方法。     

输尿管上段结石并中、重度肾积水的经皮肾镜碎石术治疗

目的探讨超声引导下经皮肾镜碎石术治疗输尿管上段结石并中、重度肾积水的临床疗效。方法输尿管上段结石并中、重度肾积水患者239例,男136例,女103例。年龄22～75岁,平均45岁。左侧106例,右侧133例,合并患侧结石56例。均采用超声引导下经皮肾镜气压弹道碎石或钬激光碎石治疗。术后留置双J管2～6周。结果 239例均一期碎石成功。平均手术时间40min,术后平均住院时间5d,结石清除率为100%。术中无气胸、腹腔脏器损伤等严重并发症发生;术后大出血1例。结论超声引导下经皮肾镜碎石术治疗输尿管上段结石效率高、并发症少,是治疗复杂性输尿管上段结石并中、重度肾积水的安全、有效方法。     

单球囊单侧穿刺经皮椎体后凸成形术治疗多椎体骨质疏松性压缩性骨折

目的探讨Ⅰ期应用单个球囊单侧穿刺多次扩张经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗多椎体骨质疏松性脊柱压缩性骨折的临床疗效。方法采用单球囊单侧穿刺PKP治疗骨质疏松性脊柱压缩性骨折25例共60个椎体。术后观察疼痛缓解及骨折复位情况,比较手术前后椎体高度和后凸角(Cobb角)的变化。结果所有患者均顺利完成手术。手术时间53～146min,平均30.4min/椎。术中球囊扩张压力为98～320Psi,平均183Psi;扩张体积2～4.5ml,平均3.25ml;扩张次数2～6次,平均3.3次,3例球囊术中破裂。骨水泥注射量2～5ml,平均3.5ml/椎,2例椎管内出现少量渗漏,1例发生椎旁渗漏,均无明显临床症状。患者VAS由术前的(7.5±1.0)分降低到术后的(3.2±0.7)分,椎体前缘高度、中线高度和Cobb角均较术前有明显改善,差异具有统计学意义(P0.05)。术后随访6～24个月,受访患者疼痛症状得到明显缓解,未见神经损伤等并发症发生。结论单侧穿刺单个球囊多次扩张PKP具有手术时间短、治疗费用低、疗效满意等优点,可用于治疗多发性骨质疏松性脊柱压缩性骨折。     

Conversion to hypertrophic vertebral pseudarthrosis following percutaneous vertebroplasty

To determine the role of percutaneous vertebroplasty (PVP) in bone formation and the union of vertebral pseudarthrosis, we analyzed 14 patients with an average follow-up duration of 21 months. Evaluation methods included back pain (visual analog scale: VAS), wedge angle, dynamic mobility, radiographic remodeling including callus and spur formation, and union status. The Student's t test was used for statistical analysis and a probability of less than 0.05 was determined as a significant difference. Back pain improved in all 14 patients with a VAS score of 57.8 ± 23.5 mm (average ± standard deviation) preoperatively and 14.7 ± 16.4 mm at the final follow-up (P < 0.001). The wedge angle decreased from 21.6° ± 8.3° (average ± standard deviation) preoperatively to 13.2° ± 6.9° at the final follow-up (P < 0.001). Callus formation was seen in four patients. Bony spurs were seen in the affected vertebra in preoperative radiographs in all patients, and were further developed to a solidified form during follow up after PVP. Dynamic mobility of the affected vertebrae was 6.9 ± 2.9 mm preoperatively, which decreased to 1.1° ± 0.7° at the final follow-up (P < 0.001). Notably, all patients showed the dynamic vertebral mobility of 2 mm or less. Nevertheless, only two patients exhibited the dynamic vertebral mobility of 0 mm at the final follow-up, which is referred to as bone union. These findings indicate that PVP serves as a mechanical stabilizer for vertebral pseudarthrosis, which leads to immediate pain relief and segmental bony responses.     

开放性椎体成形术治疗胸腰椎转移性肿瘤的临床探讨

目的:探讨开放性椎体成形术在胸腰椎转移性肿瘤治疗中的临床应用和治疗效果。方法:自2003年9月至2009年12月,对21例胸腰椎转移性肿瘤患者施行了后路椎管减压、开放式骨水泥椎体成形联合短节段椎弓根钉固定的手术治疗,其中男14例,女7例;年龄48～73岁,平均59.5岁;病程1～4个月,平均2.5个月。原发病灶:肺癌8例,乳腺癌4例,前列腺癌4例,肝癌2例,甲状腺癌1例,原发病灶不明2例。脊髓神经功能按Frankel分级:B级4例,C级6例,D级5例,E级6例。通过比较手术前后腰背部疼痛VAS评分、病椎前后缘高度、Cobb角及脊髓神经功能恢复程度来分析临床结果。结果:21例患者手术顺利,无严重并发症发生,无脊髓、神经功能加重。术后1周VAS评分由术前的(8.78±0.45)分减少至(2.25±0.36)分。16例合并病理性骨折者,病椎前缘高度由术前(12.7±2.1)mm增加到术后的(19.5±3.9)mm,病椎后缘高度由术前(14.1±1.8)mm增加到术后的(20.3±2.3)mm,Cobb角由术前(26.0±8.9)°减少到术后的(6.0±0.9)°。各项指标与术前相比,差异均有统计学意义(P0.05)。术后脊髓神经功能按Frankel分级:C级2例,D级4例,E级15例。21例均获得随访,时间5～28个月,平均14个月,未发生内固定松动及断裂。15例随访期间死亡。结论:在椎管后路减压内固定的同时,行开放性椎体成形术,手术创伤小、安全性高,能有效重建脊柱稳定性,减轻疼痛,提高患者的生活质量,对于身体状况较差、预期寿命较短的脊柱转移性肿瘤患者提供了一种可选择的手术方式。     

椎体后凸成形术治疗骨质疏松性椎体骨折中期疗效及并发症的临床观察

目的:通过观察球囊扩张后凸成形术(PKP)治疗骨质疏松性椎体骨折的疗效及并发症,探讨骨水泥强化后并发椎体再骨折的原因及对策。方法:自2006年3月至2007年3月,对31例骨质疏松性椎体骨折进行单侧经皮穿刺球囊扩张后凸成形术。男11例,女20例;年龄54～91岁,平均81岁。所有病例随访均超过3年。分别在术前、术后即时及术后1,2,3年测量强化椎椎体前缘高度,进行胸腰背疼痛评分(VAS评分),并统计相关并发症。结果:骨水泥强化椎体前缘高度在术前、术后即时及术后1,2,3年分别为(0.9±0.2)、(2.6±0.3)、(2.6±0.2)、(2.5±0.7)、(2.5±0.4)cm。手术后强化椎体高度恢复明显(P0.05);随着时间延长强化椎体前缘高度逐步降低(P0.05)。手术后胸腰背疼痛明显减轻,与术前比较差异有统计学意义(P0.05);随着时间延长胸腰背疼痛逐年加重,但差异无统计学意义(P0.05)。至随访末期并发强化椎体不愈合再骨折2例,相邻椎体骨折6例,远位节段椎体骨折2例,相邻椎间隙无症状退变5例。结论:球囊扩张后凸成形术(PKP)治疗骨质疏松性椎体骨折早期疗效确实。中期强化椎体高度逐渐降低,疼痛症状不同程度加剧,再骨折比例较高,尤其邻椎退变骨折明显。规范手术适应证、改变灌注材料及减少骨水泥注射量是降低再骨折的有效方法。     

A Simple and Safe Minimally Invasive Technique for Laparoscopic Gastrostomy

Introduction:

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. However, PEG tubes are not always feasible. The aim of the present study was to determine the feasibility, complications, and adequacy of feeding support of a novel laparoscopic gastrostomy technique in adults where PEG tubes were neither feasible nor safe.

Methods:

A retrospective chart review of patients who underwent a laparoscopic gastrostomy from August 2007 to July 2008 was performed. Demographic and outcome data were abstracted.

Results:

Fourteen patients underwent laparoscopic gastrostomy. Nine had obstructing head/neck cancer, 2 had severe head trauma, and one was morbidly obese. Nine patients had previous abdominal surgery. The mean operative time was 29.8 minutes (±7.2). There were no conversions to open gastrostomy. Two ports (5mm and 10mm) were used in the majority of patients (78.5%). No major complications were observed. The mean follow-up was 3.1 months (range, 2 to 8).

Conclusion:

This innovative 2-port laparoscopic technique for gastrostomy tube placement is safe and effective. It allows for the quick, accurate, and safe insertion of the feeding tube under direct visualization and avoids open techniques in patients where PEG tubes are not feasible.     

Laparoscopic Resection of a Small Bowel Lipoma with Incidental Intussusception

Background:

Small bowel tumors are rare entities that often present with nonspecific symptoms. The diagnosis is more likely in patients with occult gastrointestinal bleeding of unknown origin or in adults with small bowel intussusception. Even with exhaustive diagnostic testing, small bowel tumors are often not diagnosed preoperatively. Because 60% to 70% of small bowel tumors are malignant, surgical excision is always recommended.

Methods:

We report the case of a 73-year-old man with occult gastrointestinal bleeding. A small bowel tumor was discovered only after video capsule endoscopy, computed tomography, and multiple endoscopies were performed.

Results:

The patient underwent laparoscopic exploration. An incidental intussusception made the tumor simple to identify. By extending the umbilical port, the tumor was easily removed. The final pathology demonstrated a submucosal lipoma.

Conclusions:

Small bowel lipomas can cause intussusception and gastrointestinal bleeding. When diagnosed preoperatively, laparoscopic resection is feasible.     

经内镜胆管内支架置入术对良恶性胆管梗阻的临床应用

目的探讨经内镜胆管内支架置入术对各种良恶性胆管梗阻的治疗效果。方法95例良恶性胆管梗阻病人先行内镜逆行胰胆管造影（ERCP）检查,确定胆管梗阻病变部位和性质后,再决定使用内镜下塑料胆道支架引流（ERBD）和内镜下金属胆道支架引流（EMBE）。结果95例患者中92例插管成功,成功率96.84%（92/95）。针对良性胆管梗阻行ERBD 28例,主要见于胆总管结石;针对恶性胆管梗阻行ERBD 44例,行EMBE 20例,主要见于胰头癌、胆管癌、壶腹癌、原发性肝癌及肝门、肝内转移压迫胆管,所有病例均在引流后总胆红素及直接胆红素明显下降。结论：经内镜下胆管内支架引流术的应用愈来愈广泛,其操作安全而有效,特别是对各种良恶性病变引起的胆管梗阻起了关键性的治疗作用。