新生儿围产期肝脾出血的临床特点和预后分析

目的 总结新生儿围产期肝脾出血的临床特点、诊治方法 和预后.方法 回顾分析1992年6月1日至2009年6月1日南京医科大学附属南京儿童医院新生儿内、外科收治的围产期肝脾出血新生儿的临床资料,分析病因、临床表现、治疗及预后情况.结果 围产期肝脾出血新生儿共23例,其中巨大儿12例,早产儿6例.主要原因是异常分娩史(剖宫产、胎儿窘迫、产程延长、胎头吸引、急产等)和产伤,分别占65.2%(15/23)和47.8%(11/23).肝出血14例,脾出血6例,肝脾同时出血3例.早期主要临床表现包括反应差、嗜睡、拒乳者21例(91.3%),早期出现黄疸者18例(78.3%),苍白、贫血貌者17例(73.9%),腹胀者15例(65.2%),其他临床表现包括易激惹、呼吸困难、腹壁发紫、阴囊血肿等.保守治疗15例;手术治疗8例,其中死亡3例,病死率13.0%.结论 新生儿围产期肝脾出血与巨大儿、早产儿及异常分娩史有关,以产伤为主要原因,临床表现与出血量有关,早期表现具有非特异性,超声是最好的诊断手段.血流动力学稳定的患儿保守治疗成功率高,出血不止者应尽早手术.

Abstract：

Objective To summarize the clinical characteristics,diagnosis and management methods and prognosis of hepatorrhagia and splenorrhagia of newborns.Methods A retrospective review of clinical data of neonates with hepatorrhagia and splenorrhagia in perinatal period was performed from June 1,1992 to June 1,2009 in Nanjing Children's Hospital.Results There were twenty-three neonates suffered from hepatorrhagia and splenorrhagia in the perinatal period.There were 12 macrosomias and 6 preterm newborns.Abnormal birth history (65.2%,15/23),including caesarean section,fetal distress,application of vacuum extractor,prolonged labour and precipitate labor,were most commom reasons of hepatorrhagia and splenorrhagia,and birth injuries [47.8% (11/23)]was subsequent.In all cases,14 cases were hepatorrhagia,six were splenorrhagia,three were hepatorrhagia and splenorrhagia simultaneously.Primary early symtoms included low response,sleepiness (91.3%,21/23);jaundice 78.3% (18/23);pallor and anemia 73.9% (17/23);abdominal distension (65.2%,15/23) and so on.Ultrasonography and computed tomography may make a definite diagnosis.Fifteen newborns underwent non-operative treatment and 8 received hemostatic laparotomy.The general mortality was 13.0%(3/23).Conclusions Hepatorrhagia and splenorrhagia of neonates in perinatal period is associated with macrosomias,abnormal birth history and preterm birth,and birth injuries were the major etiological factors.Clinical presentations are nonspecific which maybe asociated with the degree of blood loss.Abdominal ultrasonography is an optimal diagnostic method.Nonoperative management may be successful in hemodynamically stable patients,while immediate intervention,such as laparotomy,is required to control persist bleeding.     

Gastrointestinal stromal tumor of the stomach: preliminary results of preoperative evaluation with CT gastrography

Background To determine whether CT gastrography can be used as a comprehensive imaging modality for the evaluation of gastrointestinal stromal tumor (GIST) of the stomach. Methods Thirty patients with gastric GISTs were included. Using CT gastrography, two radiologists determined the morphology, location, size of the tumor, and the nearest distance from the tumor to the gastroesophageal junction or pylorus in consensus. The ability of 3D CT gastrography in dealing with surface-shaded/transparent images and virtual endoscopic images was also evaluated and compared with the results of barium study and gastroscopy, respectively. Results In regard to lesion morphology and location, almost perfect agreements (κ = 0.87 ∼ 1.00) were achieved between CT gastrography and surgery, and the difference in lesion size between CT and surgery was not statistically significant (P = 0.824). In terms of the distance from the tumor to the gastroesophageal junction or pylorus, a statistically significant difference was found between the laparoscopic and open gastric surgery groups (P < 0.001). Findings on CT gastrography were mostly similar or superior to those seen on barium study and gastroscopy. Conclusions CT gastrography can serve as a comprehensive imaging test for the preoperative evaluation of gastric GIST.     

Recurrence after laparoscopic excision of nonparasitic splenic cysts

Background

Minimally invasive treatments for nonparasitic splenic cysts are well described. Recent evidence suggests that laparoscopic splenic cystectomy is associated with high recurrence rates in children. Because these cysts are uncommon, no large series is available. We reviewed our clinical data focusing on cyst recurrences and their management.

Methods

All children who underwent laparoscopic excision of a nonparasitic splenic cyst from January 2002 to December 2006 were identified. Medical and surgical records were reviewed for perioperative details, hospital course, and outcome.

Results

Eight children (median age, 13 years; range, 7-16 years) who underwent laparoscopic splenic cystectomy were identified. The most common presenting complaint was left upper quadrant pain or mass (n = 6; 75%). Median cyst size was 13 cm (range, 4-20 cm). There were no conversions to an open technique, completion splenectomies, or perioperative complications. Cysts were identified pathologically as epidermoid (n = 6) or posttraumatic (n = 2). Median hospital stay was 1.5 days. One child required partial splenectomy because of cyst anatomy and remains recurrence-free at 12 months. Cyst recurrence occurred in 7 patients (88%) at a median of 9.4 months (range, 3-18 months) after initial surgery. Median recurrent cyst size was 5.6 cm (range, 3-11 cm). Of 7 recurrences, 4 (57%) were symptomatic. Percutaneous ultrasound-guided cyst drainage and sclerosis were performed in 2 children with symptomatic recurrences, one of whom required 4 separate interventions. There were no complications during management of cyst recurrences. Five children with recurrence (71%) have been followed conservatively and are free of morbidity at a median of 23 months (range, 8-55 months).

Conclusions

Laparoscopic excision of nonparasitic splenic cysts in children is associated with a high recurrence rate and may be insufficient treatment. Partial splenectomy may decrease recurrence rates. Conservative management of splenic cyst recurrence after laparoscopic excision is associated with good short-term outcomes. If necessary, image-guided management of symptomatic recurrences can be performed safely.     

Natural history of nonoperative management for grade 4 and 5 liver and spleen injuries in children

Purpose

Nonoperative management is standard treatment of blunt liver or spleen injuries. However, there are few reports outlining the natural history and outcomes of severe blunt hepatic and splenic trauma. Therefore, we reviewed our experience with nonoperative management of grade 4 or 5 liver and spleen injuries.

Methods

A retrospective analysis was performed on patients with grade 4 or 5 (high-grade) blunt liver and/or spleen injuries from April 1997 to July 2007 at our children's hospital. Demographics, hospital course data, and follow-up data were analyzed.

Results

There were 74 high-grade injuries in 72 patients. There were 30 high-grade liver and 44 high-grade spleen injuries. Two patients had both a liver and splenic injury. High-grade liver injuries had a significantly longer length of intensive care and hospital stay compared to high-grade spleen injuries. There were also a significantly higher number of transfusions, radiographs, and total charges in the high-grade liver injuries when compared to the high-grade splenic injuries. The only mortality from solid organ injury was a grade 4 liver injury with portal vein disruption. In contrast, there was only one complication from a high-grade splenic injury—a pleural effusion treated with thoracentesis. There were 5 patients with complications from their liver injury requiring 18 therapeutic procedures. Three patients (10%) with liver injury required readmission as follows: one 5 times, one 3 times, and another one time.

Conclusions

Patients with high-grade liver injuries have a longer recovery, more complications, and greater use of resources than in patients with similar injuries to the spleen.     

化疗药物对原代胃癌细胞的体外杀伤效应及其与端粒酶逆转录酶mRNA表达的关系

目的观察化疗药物对原代胃癌细胞的体外杀伤效应,并探讨其与胃癌组织中端粒酶逆转录酶(hTERT)mRNA表达的关系。方法将68例新鲜胃癌组织制备单细胞悬液,台盼蓝染色计数活细胞,分别加入紫杉醇(TZX)、阿霉素(ADM)、顺铂(CDDP)、5-氟尿嘧啶(5-Fu)和丝裂霉素(MMC)培养48 h。四甲基偶氮唑盐(MTT)法观察药物作用后肿瘤细胞活力及代谢活性变化。用原位杂交技术检测hTERT mRNA的表达。结果不同个体的肿瘤细胞对化疗药物敏感性不同,与肿瘤分化有关,TAX、CDDP、5-Fu、ADM和MMC的胃癌细胞抑制率分别为(40.6±6.9)%、(38.4±7.8)%、(38.9±9.2)%、(31.6±8.5)%和(28.9±9.8)%。全组hTERT mRNA表达阳性率为90.0%,hTERT mRNA阳性者对5-Fu和ADM有较强的耐药性。结论hTERT mRNA的高表达可能是胃癌原发性耐药的标志之一,MTT比色法体外药敏实验有助于筛选胃癌的个体化有效化疗药物。     

早期胃癌不同淋巴结清除术的合理评价

目的 合理选择早期胃癌不同淋巴结清除术式。方法 以临床病理资料完整的325例早期胃癌为研究对象,总结其各站淋巴结转移规律及其不同淋巴结清除术的效率,并分析淋巴结转移与病理生物学行为的相关性。结果 全组淋巴结转移率为14．8％,转移度为3．0％。胃下部癌第1站淋巴结转移率为14．5％,各号淋巴结均有转移;第Ⅱ站淋巴结转移率为6．9％,以No．7、8a淋巴结转移率较高,而No．1、9、11P、12a和14v淋巴结几乎无转移。胃中部癌第Ⅰ站淋巴结转移率为13．8％,No．1、3、5、6淋巴结有转移;第Ⅱ站淋巴结转移率为6．9％,仅№．7、8a淋巴结有转移。大癌灶（〉3．0cm）、黏膜下癌、低分化和淋巴管癌栓阳性者的第Ⅰ、Ⅱ站淋巴结转移率较小癌灶（≤3．0cm）、黏膜内癌、高分化和淋巴管癌栓阴性者明显增高（P〈0．05）。结论 单纯D,或D1＋No．7淋巴结清除术适合于癌灶直径≤1．0cm或黏膜内癌;D1＋No．7、8a淋巴结清除术适合于早期胃中、下部癌中直径〉1．0cm、凹陷型、黏膜下癌,其中癌灶直径〉3．0cm、淋巴管癌栓阳性者应加行No．1、9淋巴结清除;标准D：、D,淋巴结清除术应尽量避免施行。     

肝细胞生长因子基因转染对阿霉素诱导胃癌细胞调亡的影响

目的研究肝细胞生长因子（HGF）基因转染对阿霉素诱导的胃癌细胞凋亡的影响。方法先构建HGF基因的真核表达质粒pIRES2-EGFP-HGF,应用pIRES2-EGFP-HGF重组质粒和pIRES2-EGFP空质粒转染人胃癌MKN-45细胞,以未转染组为对照。用转染细胞的培养液培养MDCK细胞后,以细胞形态学改变来分析目的基因mRNA、蛋白的表达,分别用RT-PCR、Western blot测定其功能。MTT法测定阿霉素对细胞生长的抑制作用,DNA凋亡条带法和PI染色法检测细胞凋亡。结果稳定转染HGF基因的MKN-45细胞株可表达HGF mRNA,其分泌的HGF蛋白具有正常功能。MTT检测表明,HGF质粒转染组活细胞数高于空质粒转染和未转染组。0．1μg／ml阿霉素作用细胞后DNA凋亡条带分析发现,空质粒转染及未转染组的MKN-45细胞出现典型阶梯状条带, HGF转染组细胞凋亡条带不显著。流式细胞术结果显示,HGF质粒转染组细胞凋亡率显著低于未转染及空质粒转染组。结论HGF基因稳定转染可显著抑制阿霉素诱导的胃癌细胞凋亡。     

巧用一次性空针针帽行胃管内注药

胃管内注药是昏迷、危重及术后患者常用的护理操作方法之一，多用于患者的营养支持及药物使用。泰尔茂医疗产品生产的SAFEED一次性使用胃管有自带连接器，目的为检查胃管是否通畅，与空针连接抽取胃液时使用，但与一次性负压引流袋（上海曹杨医疗用品厂生产）接头不吻合，无法连接。因此，使用胃肠减压的患者常去除连接器后与负压引流袋连接。当患者需要胃管内注药时。护士多因找不到连接器而采用玻璃接头接橡胶软管再与胃管及空针连接的方法进行胃管内注药，用物繁多，操作不便且浪费时间。     

高龄胃癌患者腹腔镜胃切除术安全性与近期疗效

目的:评价为高龄胃癌患者行腹腔镜胃切除术的安全性及近期疗效.方法:回顾分析2008年7月-2011年12月87例行胃切除术高龄(≥70岁)胃癌患者的临床资料,其中39例行腹腔镜手术(腔镜组),48例行开腹手术(开腹组),比较两组患者的一般情况、手术指标、术后恢复情况、并发症情况及治疗效果.结果:两组患者性别、中位年龄、术前合并症、ASA术前危险度评分、疾病类型均无明显差异(均P＞0.05).与开腹组比较,除平均手术时间无明显差异外(P＞0.05),腔镜组术中平均出血量(73 mL vs.309 mL),肠功能恢复时间(4.1 d vs.5.5 d),进流食时间(4.2 d vs.6d),平均住院时间( 19.1 d vs.25.2 d),术后心肺并发症发生率(28.2％ vs.56.3％)均明显减少(均P＜0.05).平均随访29个月,腹腔镜组和开腹组患者总生存率分别是57.1％和65.9％ (P＞0.05).结论:为高龄患者行腹腔镜胃癌切除术安全可行,可减少患者术中出血量,降低术后心肺并发症的发生率,加快术后胃肠功能恢复.