Quand et avec quelles conséquences opérer une tumeur neuroendocrine du pancréas ou du grêle ?*<br/>When to Operate and What Are the Consequences of a Surgical Resection of a Neuroendrocine Tumour in the Pancreas or Small Bowel

Neuroendocrine tumors (NET) are rare and can occur in all parts of the digestive tract. They can be functional or non-functional. All patients presenting NET should be discussed for the surgical management within the RENATEN tumor board. For sporadic pancreatic NET, surgery is recommended for non-functional lesion >2 cm in size and/or associated with ductal dilatation. For non-aggressive tumor, parenchyma-sparing surgery should be preferred to avoid exocrine and endocrine pancreatic insufficiency. For small bowel NET, surgery must always be considered to avoid complications such as small bowel obstruction. Lymphadenectomy must include at least 8 noded. Surgery must avoid short bowel syndrome.

Résumé
Les tumeurs neuroendocrines (TNE) sont des tumeurs rares et peuvent survenir dans tout le tube digestif. On distingue les tumeurs fonctionnelles associées à des symptômes secondaires à l’activité sécrétoire de la tumeur et les tumeurs non fonctionnelles. Tout patient présentant une TNE doit être discuté en RCP RENATEN. Concernant les TNE duodénopancréatiques sporadiques, la chirurgie est nécessaire devant une TNE fonctionnelle ainsi que devant une TNE non fonctionnelle de plus de 2 cm, associées ou non à un retentissement canalaire. Pour les tumeurs supposées peu ou pas agressives, il sera toujours privilégié une stratégie d’épargne parenchymateuse afin d’éviter l’insuffisance pancréatique endocrine et exocrine. Concernant les TNE du grêle, la chirurgie doit être systématiquement envisagée, y compris en cas de métastases ou de carcinose associée afin d’éviter une complication mécanique telle qu’une occlusion. Un curage ganglionnaire comportant au minimum huit ganglions doit être effectué. Ce curage doit être large tout en préservant une vascularisation suffisante afin d’éviter la survenue d’un syndrome de grêle court.     

常温机械灌注修复长时间冷保存供肝的大动物实验研究

目的探索常温机械灌注(NMP)在挽救大动物边缘供肝中的价值。 方法6只雄性、10～12月龄巴马小型猪分为静态冷保存(SCS)6 h组和SCS 24 h组,每组3只,分别于供肝获取后SCS 6 h、24 h后进行2 h NMP复苏。基于荷兰Organ Assist公司Liver Assist系统和供体猪自身血液,整合四通道生理仪器及自制灌注管路搭建NMP平台。在NMP过程中分别于灌注0、15、60、90、120 min 5个时间点收集灌注液用于肝功能(ALT、AST)检测及血气分析(pH、氧分压)。灌注结束取肝左叶相同位置少许组织,以10%甲醛固定,用于后续HE染色。 结果NMP开始时,SCS 24 h组ALT、AST水平略高于SCS 6 h组,之后AST、ALT水平均缓慢上升。NMP开始时SCS 24 h组pH值中位数为7.28,氧分压中位数为46 mmHg(1 mmHg＝0.133 kPa,下同),均低于SCS 6 h组(7.36,52 mmHg),经过2 h NMP后SCS 24 h组pH值和氧分压逐渐接近甚至优于SCS 6 h组。HE染色发现,灌注前SCS 24 h组肝脏充血严重,炎性细胞浸润明显;NMP 2 h后,肝脏充血明显改善、炎性细胞减少,与SCS 6 h组无明显差异。 结论基于Liver Assist系统和供体猪自身血液成功搭建的NMP平台,可有效改善长时间冷保存的边缘供肝质量,提示NMP在修复边缘供肝、扩展供肝来源方面具有重要临床及基础研究价值。     

叶轮泵式全人工心脏的搏动式输出研究

旋转叶轮泵的发展使研制新型全人工心脏成为可能。本文通过模型样机研制和流体力学特性测试,探索以叶轮式血泵为结构基础的新型全人工心脏。新研制的全人工心脏样机采用两个轴流泵作为基本单位共同设置在筒形外壳中,不需压力补偿腔。外壳由钛合金制成,直径65mm,长度70mm。在体外模拟循环台上采用持续输出和搏动输出两中方式对左心泵和右心泵的的转速,输出压力,流量,能耗和效率特性进行测试。模拟循环装置由模拟左,右心房,血泵,阻力调节器,流量计串联组成,采用30％甘油水溶液作为循环介质。通过调节阻力测定特定泵转速下压力和流量。采用ST3PR式时间继电器周期性导通电源对泵电机绕组间隙性馈电。体外模拟测试表明全人工心脏在搏动输出条件下可满足机体的血液动力学基本要求,左心泵在14700r／min的最高转速条件下可以达到5L／min流量和100mmHg的压力输出,右心泵在约8000rpm转速和25mmHg后负荷下达到相似流量,可满足肺循环的要求．总功耗能12瓦,效率约10％。本研究结果表明叶轮泵式全人工心脏可实现搏动输出,流体力学特性可达到全人工心脏的基本要求。     

电视腹腔镜辅助下阴式全子宫切除35例

目的为提高阴式子宫全切术的效果.方法从1997年7月起,对妇科良性疾病需行全子宫切除的35例患者,全部采用腹腔镜辅助下的阴式全子宫切除.结果33例成功开展了腹腔镜辅助下阴式全子宫切除,成功率达94%.如按传统的TVH选择病人,35例患者中只有12例适宜做阴式子宫全切,只占34%.结论辅以腹腔镜后可有效提高TVH的成功,且尚具有其他显著的优点.     

Practical Strategies for Engaging Individuals With Obesity in Primary Care

Although widely recognized as a chronic disease that requires long-term, structured, and multidisciplinary management, obesity remains largely underdiagnosed and undertreated. The prevalence of obesity continues to increase dramatically, with the highest rates seen in the United States. Despite the availability of several clinical practice guidelines, published studies suggest that health care professionals (HCPs) infrequently and inconsistently follow guideline recommendations. Barriers to HCP participation in obesity management are likely to inhibit obesity counseling in primary care. Improving HCP obesity-related practices and counseling is important. This article discusses current practices, barriers to effective obesity management, and recommendations to improve HCP obesity management and counseling, based on findings from a PubMed search and clinical experience. The aim of the article is to share best-practice strategies for engaging patients.     

Systemic venous drainage: can we help Newton?

In recent years substantial progress occurred in the techniques of cardiopulmonary bypass, but the factor potentially limiting the flexibility of cardiopulmonary bypass remains the drainage of the systemic venous return. In the daily clinical practice of cardiac surgery, the amount of systemic venous return on cardiopulmonary bypass is directly correlated with the amount of the pump flow. As a consequence, the pump flow is limited by the amount of venous return that the pump is receiving. On cardiopulmonary bypass the amount of venous drainage depends upon the central venous pressure, the height differential between patient and inlet of the venous line into the venous reservoir, and the resistance in the venous cannula(s) and circuit. The factors determining the venous return to be taken into consideration in cardiac surgery are the following: (a) characteristics of the individual patient; (b) type of planned surgical procedure; (c) type of venous cannula(s); (d) type of circuit for cardiopulmonary bypass; (e) strategy of cardiopulmonary bypass; (f) use of accessory mechanical systems to increased the systemic venous return. The careful pre-operative evaluation of all the elements affecting the systemic venous drainage, including the characteristics of the individual patient and the type of required surgical procedure, the choice of the best strategy of cardiopulmonary bypass, and the use of the most advanced materials and tools, can provide a systemic venous drainage substantially better than what it would be allowed by the simple ‘Law of universal gravitation’ by Isaac Newton.