奥曲肽联合泮托拉唑预防内镜逆行胰胆管造影术后胰腺炎

目的：探讨内镜逆行胰胆管造影（ERCP）术后胰腺炎的预防措施。 方法：将2010年7月—2012年11月间行ERCP术后的患者100例,随机分为观察组和对照组,每组各50例患者。观察组术后给予联合应用生长抑素（奥曲肽0.1 mg/8 h皮下注射连用24 h）和质子泵抑制剂作预防治疗（泮托拉唑40 mg/d静脉滴注连用2 d）,对照组给予生理盐水静脉滴注。比较两组患者ERCP术后3,12,24 h的血清淀粉酶情况,及胰腺炎的发生情况。 结果：两组一般资料比较具有可比性;在术后3,12,24 h各时间点比较,观察组血清淀粉酶水平均明显低于对照组（均P<0.05）;观察组术后12,24 h高淀粉酶血症发生率及术后急性胰腺炎明显均低于对照组（18% vs. 42%;8% vs. 22%;2% vs. 16%）（均P<0.05）。 结论：联合应用生长抑素和质子泵抑制剂可减少ERCP术后高淀粉酶血症与胰腺炎的发生率,是一种安全且有效的ERCP术后胰腺炎预防措施。     

镜下甲状腺手术无重大并发症发生的经验

目的总结预防镜下甲状腺手术并发症的经验. 方法双侧病变12例经前胸入路,单侧病变41例经腋下入路,用自制的器械做从切口到甲状腺的皮下隧道,宽约5 cm,充CO2压力4 mm Hg,用腹腔镜器械与超声刀完成病灶的分离、切除.结果腺瘤41例(单侧34例,双侧7例),结节性甲状腺肿12例(单侧7例,双侧5例).术后1例出现皮下隧道血肿,保守治愈,无神经损伤及甲状旁腺并发症发生.结论超声刀及持续系统低腔隙压是预防并发症有效方法.     

Endoscopic treatment or surgery for undifferentiated early gastric cancer?

BACKGROUND: Although almost all (96%) the surgical cases of undifferentiated intramucosal early gastric cancer (EGC) have been found not to have lymph node metastasis (LNM), local treatment by endoscopic mucosal resection (EMR) is not accepted as an alternative treatment to surgery for this type of EGC. If a subgroup of patients with undifferentiated EGC with negligible risk of LNM can be defined, unnecessary surgery can be avoided. This study was conducted to determine this subgroup among undifferentiated EGC patients in whom the risk of LNM can be highly ruled out in an attempt to identify candidates who can be treated by EMR. METHODS: Data from 175 patients surgically resected for undifferentiated EGC were retrospectively collected, and clinicopathological factors were multivariately analyzed to identify predictive factors for LNM. RESULTS: Multivariate logistic regression analysis identified two independent risk factors for LNM, namely, a large tumor (>/=20 mm, P = 0.011) and presence of lymphatic involvement (P = 0.0005). Using these two risk factors as the predictive factors, LNM was observed in 5.8% of patients who had neither of the two predictive factors, whereas 23.1% or 13.1% of patients with one or two predictive factors had LNM, respectively. In contrast, the LNM rate was calculated to be 60% in patients who had both factors. Lymph node metastasis was not found in any of 6 patients with small intramucosal lesions (<10 mm) without lymphatic involvement. CONCLUSIONS: An intramucosal undifferentiated EGC that is smaller than 10 mm without lymphatic involvement can safely be treated by EMR alone, given the negligible possibility of LNM. When histological examination of endoscopically resected specimens shows lymphatic involvement or unexpectedly larger tumor size than that determined at pre-EMR endoscopic diagnosis, an additional surgical procedure should be considered.     

经皮肾镜取石术联合二期输尿管软镜手术治疗孤立肾复杂性结石的疗效研究

目的 探讨一期经皮肾镜取石术(PCNL)联合二期输尿管软镜手术(retrograde intrarenal surgery,RIRS)治疗孤立肾复杂性结石的临床疗效.方法 回顾性分析2008年4月至2012年5月收治的21例孤立肾鹿角形结石或多发性结石患者的临床资料,男15例,女6例.年龄19～76岁,平均45岁.其中先天性孤立肾3例,对侧肾切除孤立肾9例,功能性孤立肾9例.鹿角形结石13例,多发性结石8例.结石最大径3.8 ～6.8 cm,平均4.6 cm.全麻下,行C臂X线定位下PCNL,采用第四代EMS超声碎石系统碎石.术后常规留置6F双J管及肾造瘘管.术后1d复查KUB及CT评估残留结石部位及大小.PCNL术后3～30 d行RIRS.全麻下,先取截石位,拔除双J管,在C臂X线引导下置入斑马导丝及12 ～14 F输尿管软镜鞘.采用Olympus P5纤维软镜或者电子软镜及200μm钬激光光纤(8～20 W)碎石.对于＜2 cm残留结石,粉碎后自行排出或套石篮取出.对于＞2 cm的残留结石,以钬激光击碎结石后,用套石篮将较大的碎石片转移至肾盂,改俯卧位,行二期PCNL取石,术后均留置双J管.术后1d复查KUB,术后1～2d拔除肾造瘘管,2～3周拔除双J管.术后3个月复查KUB或CT,评估结石清除率.结果 本组21例PCNL中采用单通道18例,双通道2例,3通道1例.手术时间45 ～175 min,平均95 min.残留结石大小1.0～3.5 cm,平均1.9 cm.结石残留在下盏7例、上盏及下盏4例、中盏及下盏6例、上中下盏均残留4例.PCNL术后发热2例,1例迟发性出血患者采用超选择性肾动脉栓塞治愈.RIRS手术时间35 ～ 95 min,平均72 min.RIRS术后1 d结石清除率为85.7％(18/21).3例残留结石患者中,1例经二期PCNL、2例经ESWL治疗后,结石清除率95.2％ (20/21).2例RIRS术后发热和输尿管石街形成,采用输尿管硬镜取石术治愈.术后3个月随访,患者肌酐为88 ～ 230 μmol/L,平均(138.7±38.3) μmol/L,平均下降了(16.8±25.4)μmol/L,肾功能改善15例,稳定5例,恶化1例,与术前比较差异有统计学意义(P＜0.05).结论 一期PCNL联合二期RIRS治疗孤立肾复杂性结石安全有效,出血量少,可有效保护肾功能.     

Biomechanical comparison of locked plating and spiral blade retrograde nailing of supracondylar femur fractures

Objective

Biomechanical comparison between locked plating and retrograde nailing of supracondylar femur fractures with simulated postoperative weight-bearing.

Methods

The Locking Condylar Plate (LCP) and Retrograde/Antegrade EX Femoral Nail (RAFN) were tested using 10 paired elderly cadaveric femurs, divided into Normal and Low Bone Mineral Density (BMD) groups, with a simulated AO/OTA type 33-A3 supracondylar femur fracture. Each specimen was subjected to 200,000 loading cycles in an attempt to simulate six weeks of postoperative recovery with full weight-bearing for an average individual. The construct's subsidence due to cyclic loading, and axial stiffness before and after the cyclic loading were measured and their correlation with BMD was studied. The two implants were compared in a paired study within each BMD group.

Results

LCP constructs showed higher axial stiffness compared to RAFN for both Normal and Low BMD groups (80% and 57%, respectively). After cyclic loading, axial stiffness of both constructs decreased by 20% and RAFN constructs resulted in twice as much subsidence (1.9 ± 0.6 mm). Two RAFN constructs with Low BMD failed after a few cycles whereas the matched pairs fixed with LCP failed after 70,000 cycles.

Conclusions

The RAFN constructs experienced greater subsidence and reduced axial stiffness compared to the LCP constructs. In Low BMD specimens, the RAFN constructs had a higher risk of failure.     

应用金属夹缝合胃壁全层缺损的动物实验

目的探讨应用金属夹缝合胃全层缺损的可行性、安全性和有效性。方法48只新西兰大白兔按随机数字表法分为4组,每组12只。在胃体部全层切开直径2cm的缺损后,第1组不缝合胃壁缺损．第2组用金属夹夹闭胃壁黏膜层．第3组用金属夹夹闭胃壁全层,第4组用3-0丝线缝合胃壁全层。分别于术后第3天和第7天处死各组动物,大体观察创面愈合情况;测定创面爆破压;并取创面组织,行苏木精-伊红染色和Masson染色,评价创面炎性反应及组织纤维增生情况。结果第1组动物术后34h内全部死亡,其他各组动物均良好存活．所有存活动物无腹腔内出血和感染表现。第2、3组与第4组相比,手术耗时短[（45．8±1．6）min和（42．5±1．5）min比（48．0±1．4）min,P〈0．05];第3天创面爆破压低]（36．9±4．6）mmHg和（39．8±4．1）mmHg比（50．5±4．2）mmHg,P〈0．05];第7天创面爆破压3组间差异无统计尝意义[（95．0±7．9）mmHg、（97．8±6．8）mmHg和（98．5±7．0）mmHg,P〉0．05]。相同时间点创面苏木精．伊红染色显示金属夹缝合组炎性反应较轻,Masson染色反映创面愈合无明显差别。结论应用金属夹缝合胃部全层缺损,无论夹闭胃黏膜层或全层组织,均能达到与手术缝线缝合相同的临床愈合效果和质量。     

内镜下逆行胰胆管造影并发十二指肠穿孔15例诊治分析

目的总结内镜下逆行胰胆管造影术（ERCP）并发十二指肠穿孔的临床诊治策略。方法2005年1月至2011年12月间杭州市第一人民医院共对11250例患者进行ERCP．其中15例（0．13％）出现十二指肠穿孔．对该15例患者的临床资料进行回顾性分析。结果15例患者中男性6例．女性9例．年龄45-87岁。7例为十二指肠乳头括约肌切开（EST）穿孔,5例为内镜致十二指肠壁穿孔．3例为导丝和网篮致穿透性穿孔。所有患者均有程度不一的腹痛和腹胀症状：上腹部CT提示胰周和后腹膜不同程度的积气或积液。7例穿孔在ERCP中经X线透视即获诊断：8例于术后3h至5d出现腹痛、腹胀、皮下积气和发热等症状,经腹部平片或上腹部CT明确诊断。9例患者采取内科保守治疗．其中4例在穿孔后3h内发现．采用内镜下金属钛夹封闭穿孔口加鼻胆管引流术．无腹腔脓肿发生,住院时间10-15d;5例于穿孔后10h至5d诊断,并发肠瘘2例,腹腔脓肿4例。死亡1例,住院时间15-105d。6例患者采取手术治疗,其中4例在穿孔后4-8h手术者术后无脓肿形成．住院时间18．21d：另2例分别于穿孔后24h和30h手术,术后反复腹腔出血1例．腹腔脓肿致多器官功能衰竭死亡1例。结论对于ERCP并发十二指肠穿孔。首要的是依靠术中及时发现及术后CT等检查尽早明确诊断：治疗上除传统的外科手术外．应积极采用内镜下金属钛夹、鼻胆管引流术等内镜微创治疗。     

第四代EMS经皮肾镜治疗婴幼儿上尿路感染性结石体会

目的 探讨应用第四代EMS经皮肾镜取石术(PCNL)治疗婴幼儿上尿路感染性结石的临床疗效和安全性.方法 回顾性分析48例PCNL使用第四代EMS治疗上尿路感染性结石的患儿资料.男22例,女26例;年龄1 ～13岁,平均9岁.右侧25例,左侧23例;结石最大2.4cm ×3.1cm,最小0.7cm×1.0cm.结果 PCNL术后结石完全清除43例(89.6％),Ⅱ期PCNL取石3例(6.3％),术后体外震波碎石术( ESWL)2例(4.2％).术中无患者输血,平均住院时间9.6天,6例(12.5％)出现术后发热,全组病例均未出现严重感染性休克、大出血、肾动静脉瘘及邻近脏器损伤等并发症.结论 第四代EMS联合PCNL是治疗婴幼儿上尿路感染性结石安全有效的方法.     

中间人路腔镜甲状腺手术与开放手术的临床对比研究

目的对照分析由甲状腺中间人路行腔镜甲状腺手术与开放手术的临床疗效,探讨新人路腔镜甲状腺手术的可行性和优点。方法回顾性分析2008年8月至2010年12月中山大学附属第五医院微创中心采用甲状腺中间人路完成的腔镜甲状腺切除术192例（腔镜组）和开放甲状腺切除术240例（开放组）患者的临床资料,对照分析两组患者的年龄、手术时间、术中出血量、术后第1天引流量、术后住院时间、术后并发症等临床资料。结果腔镜组的手术时间为（112．5±42．7）min,明显长于开放组（52．6±30．8）min,两组比较差异有高度统计学意义（P〈0．01）。腔镜组术后第1天的引流量为（192．5±45．2）ml,明显多于开放组（44．0±28．7）ml,差异有高度统计学意义（P〈0．01）。两组患者的术中出血量、术后住院时间、术后并发症发生率等观察指标差异均无统计学意义。结论采用甲状腺中间入路新手术径路行腔镜甲状腺手术是一种安全、可行的方法,具有美容效果好、术后恢复快、术后并发症少的优点。     

跟骨骨折外侧入路术后皮肤坏死缺损的治疗

目的探讨运用逆行腓肠神经营养血管皮瓣,治疗跟骨骨折外侧入路术后皮肤坏死缺损的临床疗效。方法2009年9月至2011年12月,应用逆行腓肠神经营养血管皮瓣,修复跟骨骨折外侧入路术后皮肤坏死缺损24例。缺损大小:3.0 cm×1.5 cm～5.0 cm×2.5 cm,皮瓣切取大小:4.0 cm×3.0 cm～6.0 cm×4.0 cm,术中腓肠神经与受区皮神经吻合以重建感觉功能。结果24例皮瓣全部成活,受区创口Ⅰ期愈合,皮瓣供区切口Ⅰ期愈合。皮瓣术后未出现明显肿胀及血管危象等。术后随访6～15个月,皮瓣外形恢复满意,无明显色素沉着及瘢痕挛缩,无窦道及皮肤溃疡形成,皮瓣两点辨别觉达7～12 mm。结论逆行腓肠神经营养血管皮瓣是跟骨骨折外侧入路术后,皮肤坏死缺损较为理想的治疗方法。