可动式椎间盘镜下单侧开窗双侧减压治疗腰椎管狭窄症

目的 探讨可动式椎间盘镜下单侧开窗双侧减压治疗腰椎管狭窄症的疗效.方法 2007年6月至2009年6月采用可动式椎间盘镜下单侧开窗双侧减压治疗退行性腰椎管狭窄症32例,男14例,女18例;年龄56～74岁,平均65岁.均为双侧椎管狭窄合并椎问盘突出,有间歇性跛行和坐骨神经痛等症状,双下肢症状以一侧为重.在症状严重侧行棘突旁2 cm纵切口,在可动式椎间盘镜下行单侧椎板间隙开窗,神经根通道减压、突出髓核摘除;在棘突和椎板腹侧分别向上、下方用棉片压低保护硬膜囊,潜行咬除棘突基底部,在棘突基底、椎板腹侧与硬膜囊背侧之间形成工作空间,经此空间潜行咬除对侧椎板下缘和增厚的黄韧带,直至显露松解对侧神经根起始部.结果 术中无神经损伤发生,无中途转开放手术病例.发生硬膜囊撕裂2例,用棉片将其压低后完成手术.手术时间5～100min,平均70min;术中出血量50～350ml,平均150ml.术后CT示减压充分,中央椎管和对侧椎管扩大,对侧椎板、关节突和椎旁肌等结构保留完好.全部病例随访6～24个月,平均12个月.根据Macnab标准,优21例,良11例.结论 可动式椎间盘镜下单侧开窗双侧减压治疗腰椎管狭窄症操作简便,能保留对侧结构,达到双侧减压目的 ,早期随访结果优良.对双侧严重骨性狭窄者应慎用.     

胆道内镜对肝移植术后胆管损伤变化的观察

目的 对原位肝移植术后胆道并发症进行内镜观察和治疗,为肝移植胆管损伤机制的研究提供参考和帮助.方法 利用胆道内镜技术,对肝移植术后正常组、胆管损伤组、肝动脉损伤组的病例进行观察,内镜下取活检进行病理分析.对于无T管者,应用子母胆道镜进行.结果 正常的9例肝内外胆管解剖正常,无狭窄、瘢痕,胆管黏膜颜色正常,供-受体胆管吻合口愈合佳.病理学检查均可见修复性的黏膜组织,被覆上皮完整,上皮下纤维组织和小血管增生,散在浆细胞、淋巴细胞浸润.胆管损伤组的12例中,胆管内有各种类型的单发、多发及铸型结石,胆管均有不同程度的损伤,经内镜取净结石、解除梗阻后,胆管黏膜均有不同程度的修复,造影检查胆树恢复正常.肝动脉损伤组3例:胆管壁缺血坏死,丧失胆管的组织结构,仅见纤维样组织构成的管道,明显充血,胆泥和结石完全灌满供体胆树,Ⅲ级胆管间断具有胆管的组织结构;病理学检查:胆管壁弥漫坏死,结构不清,大量胆汁渗入,可见增生的肉芽组织和化脓灶.结论 原位肝移植并胆管损伤、缺血的病例术后胆管均有不同程度的损伤,胆道内镜是诊治肝移植术后胆道并发症的首选方法.     

Bilateral decompression via unilateral fenestration using mobile microendoscopic discectomy technique for lumbar spinal stenosis

Objective: To evaluate the feasibility and clinical efficacy of bilateral decompression via unilateral fenestration (BDUF) with mobile microendoscopic discectomy (MMED) for lumbar spinal stenosis. Methods: From June 2007 to June 2009, 32 patients were treated by the technique of BDUF with MMED for lumbar spinal stenosis in our hospital. All patients complained of bilateral sciatic neuralgia and intermittent claudication that was dominant in one limb. CT scan and MRI revealed disc herniation and bilateral stenosis of the spinal canal. Patients with bilateral severe osseous stenosis and multilevel stenosis were excluded. Results: The procedure was technically successful in all patients, bilateral decompression and spinal canal enlargement being achieved by unilateral fenestration. The mean operative time was 70 min (range, 50–100 min), with a mean blood loss of 150 ml (range, 50–350 ml). No significant complication was noted; dural tears were encountered in only two patients without obvious side effects. The patients were followed up for 3 to 24 months (mean, 12 months) and the clinical results were excellent in 21 cases and good in 11 cases according to the MacNab scale. Conclusion: The procedure of BDUF can be performed in conjunction with the MMED technique for lumbar spinal stenosis with good clinical results; however, severe bilateral osseous stenosis may be not suitable for this technique.     

吲哚菁绿分子荧光影像技术在乳腺癌单孔法腔镜前哨淋巴结活检术中的应用

目的:探讨吲哚菁绿(ICG)分子荧光影像技术在单孔法腔镜前哨淋巴结活检术中的应用价值.方法:选取2019年3月至2019年12月收治的行腔镜前哨淋巴结活检术的20例早期乳腺癌患者,均以ICG联合纳米碳混悬注射液作为示踪剂.手术切除的前哨淋巴结送术中冰冻病理检查及常规石蜡病理检查.比较前哨淋巴结检出率、前哨淋巴结转移数量...     

经椎间孔入路经皮内窥镜下腰椎椎间盘切除术治疗腰椎椎间盘突出症的疗效及预后影响因素分析

目的探讨经椎间孔入路经皮内窥镜下腰椎椎间盘切除术(PETD)治疗腰椎椎间盘突出症(LDH)的临床疗效,并探讨影响患者预后的相关因素。方法采用前瞻性队列研究设计,纳入2015年8月—2016年9月诊断为LDH并行PETD治疗的102例患者。分别于术前1 d及术后1 d、3个月、6个月、12个月、36个月时评估疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)、日本骨科学会(JOA)评分,采用改良MacNab标准评估临床疗效。分析患者临床特征和影像学资料等因素对预后的影响。结果86例患者完成36个月及以上随访,其中男56例、女30例,年龄19~88(46.96±14.03)岁,随访36~46(40.91±3.21)个月。86例患者手术顺利完成,无术中转开放手术。并发症发生率为1.2%(1/86),复发率为5.8%(5/86)。术后1 d、3个月、6个月、12个月、36个月,腰痛和腿痛VAS评分及ODI均较术前下降,JOA评分较术前升高,差异均有统计学意义(P<0.05)。根据改良MacNab标准,术后36个月优良率为94.2%(81/86)。突出髓核(HNP)越大,术后腿痛VAS评分、ODI和JOA评分改善越明显,差异有统计学意义(P<0.05);与体质量指数(BMI)<25 kg/m^2的患者相比,BMI≥25 kg/m^2的患者JOA评分改善较小,差异无统计学意义(P>0.05)。结论PETD治疗LDH可取得满意疗效。HNP大小是影响患者预后的主要因素,BMI可能对预后也有一定影响,但尚需扩大样本量进一步研究。     

Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection

BACKGROUND: Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. This study aimed to introduce a laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection that is applicable for submucosal tumor resection independent of tumor location and size. METHODS: Seven patients underwent LECS for the resection of gastric submucosal tumors. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device. RESULTS: In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In four of seven cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The remaining three tumors were in the posterior gastric wall. In two cases, the tumors were more than 5 cm in diameter, and one was a GIST of the remnant stomach. The mean operation time was 169 +/- 17 min, and the estimated blood loss was 7 +/- 2 ml. The postoperative course was uneventful in all cases. CONCLUSIONS: The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.     

鼻内镜治疗颅底疾病112例报告

目的探讨鼻内镜径路治疗颅底疾病的价值。方法2002年5月~2006年12月,对112例颅底疾病行鼻内镜径路手术,其中脑脊液鼻漏39例,垂体瘤4例,脑膜膨出或脑膜脑膨出3例,蝶筛囊肿9例,蝶窦炎伴息肉2例,真菌性蝶窦炎12例,内翻性乳头状瘤11例,鼻咽纤维血管瘤6例,骨化纤维瘤2例,骨纤维异常增殖2例,脊索瘤7例,颅咽管瘤2例,鳞癌10例,未分化癌1例,乳头状瘤癌变2例。结果全组均在鼻内镜下处理,其中20例病变为次全切除,包括鳞癌8例、未分化癌1例、脊索瘤7例、颅咽管瘤2例、骨纤维异常增殖2例。脑脊液鼻漏1次手术成功31例(79.5%),2次成功4例,3次成功4例,最终成功率100%。1例脑膜脑膨出术后2个月复发并伴脑脊液漏,内镜下再次手术成功。1例内翻性乳头状瘤术后11个月复发,改行鼻侧切开术。1例真菌性蝶窦炎术后4个月复发行再次内镜手术。1例脑脊液鼻漏术后颅内感染。结论鼻内镜径路可以处理多种颅底疾病,是一种安全、有效、微创的手术方式,但仍需严格掌握手术适应证,特别是恶性肿瘤。     

腔内泌尿技术Ⅰ期或Ⅱ期手术治疗结石性脓肾

目的:探讨运用腔内泌尿外科技术治疗结石性脓肾的疗效和价值.方法:对52例结石性脓肾患者,14例行Ⅰ期手术(包括4例行经皮肾镜取石术;6例经尿道输尿管镜取石术;4例行经皮穿刺肾造瘘引流联合经尿道输尿管镜取石术);38例行Ⅱ期手术,即Ⅰ期经皮肾穿刺造瘘引流,Ⅱ期腔内技术取石术或肾切除术.结果:48例患者肾盂、肾盏漏斗和输尿管梗阻部结石均被取净,6例行肾切除术;无术后大出血和感染性休克等严重并发症;36例随访1～12个月,34例肾功能得到不同程度的恢复.结论:腔内技术安全、有效、微创,保肾率高,应作为结石性脓肾的首选治疗方法,应根据具体情况选择Ⅰ期还是Ⅱ期手术.     

内镜置入胆道金属支架治疗肝门部胆管癌

目的 探讨通过内镜置入自膨式胆道金属支架治疗肝门部胆管癌的疗效.方法 回顾性分析2004年7月至2009年7月成都军区总医院收治的73例肝门部胆管癌患者行内镜胆道金属支架置入术的操作成功率、减黄有效率、支架通畅时间和生存时间以及术后并发症.结果 支架置入成功70例,3例失败.其中单金属支架置入62例,双侧金属支架置入3例,金属支架+塑料支架置人5例.减黄有效率为87%(61/70),中位支架通畅时间为190 d,中位生存时间为246 d.术后发生胆管炎7例,胰腺炎3例,出血2例.结论 内镜置入自膨式胆道金属支架治疗肝门部胆管癌创伤小、减黄效果好,可作为无法手术切除的肝门部胆管癌患者解除胆道恶性梗阻的首选治疗方法.     

内镜下经筛蝶入路视神经减压术的应用解剖

目的 研究内镜下经筛蝶入路视神经减压术的相关解剖以及在手术中的意义.方法 手术显微镜下解剖福尔马林固定的成人尸头视神经管标本15例(30侧),观察视神经管的解剖特点和毗邻关系,并根据鼻内镜入路测定相关参数.结果 ①视神经颈内动脉三角(optic carotid triangle,OCT)与视神经、眼动脉、海绵窦和颈内动脉关系恒定,OCT出现率为66.7%.②鼻小柱基底前缘到视神经管眶口、管中部和颅口内侧缘的距离分别为(72.79±5.40)mm、(75.85±5.10)mm和(79.34±4.95)mm,仰角分别为(39.45±3.68)°、(37.30±4.24)°和(35.45±4.16)°.③视神经内侧壁眶口、管中部和颅口的鞘膜厚度分别为(0.70±0.18)mm、(0.51±0.15)mm和(0.49±0.22)mm,眶口与管中部、颅口差异有统计学意义(P＜0.01);④视神经管眶口、管中部和颅口内侧缘离颅正中矢状面的旁开距分别为1/2(12.69±2.73)mm、1/2(19.61±3.47)mm和1/2(25.79±3.23)mm.结论 OCT是内镜下经筛蝶入路视神经减压术首选的解剖定位标志,减压关键在视神经眶口,从视神经内侧壁与上壁交界处切开鞘膜安全且容易操作.