PERCUTANEOUS LAPAROSCOPIC CHOLECYSTECTOMY: INDICATIONS,CONTRAINDICATIONS AND COMPLICATIONS

The indications, contraindications and complications of percutaneous laparoscopic cholecystectomy (PLC) were established from a group of 308 patients referred for cholecystectomy. Of the 308 patients 86% underwent PLC, 5% were commenced laparoscopically, but converted to open cholecystectomy and 9% were performed as open cholecystectomy from the outset. Complications included two bile leaks from the gall-bladder bed, one cystic duct stump leak and three retained stones. Pre-operative rather than intra-operative duct imaging was used so that common duct stones could be removed before operation. PLC is a safe procedure that has now become the standard technique for cholecystectomy.     

A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST (Which Early ST-elevation myocardial infarction Therapy) study.

AIMS: Uncertainty exists as to which reperfusion strategy for ST-elevation myocardial infarction (MI) is optimal. We evaluated whether optimal pharmacologic therapy at the earliest point of care, emphasizing pre-hospital randomization and treatment was non-inferior to expeditious primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: Which Early ST-elevation myocardial infarction Therapy (WEST) was a four-city Canadian, open-label, randomized, feasibility study of 304 STEMI patients (> 4 mm ST-elevation/deviation) within 6 h of symptom onset, emphasizing pre-hospital ambulance treatment and participation of community and tertiary care centres. All received aspirin, subcutaneous enoxaparin (1 mg/kg), and were randomized to one of three groups: (A) tenecteplase (TNK) and usual care, (B) TNK and mandatory invasive study < or = 24 h, including rescue PCI for reperfusion failure, and (C) primary PCI with 300 mg loading dose of clopidogrel. Time from symptom onset to treatment was rapid (to TNK for A = 113 and B = 130 min and for PCI in C = 176 min). The primary outcome, a composite of 30-day death, re-infarction, refractory ischaemia, congestive heart failure, cardiogenic shock, and major ventricular arrhythmia, was 25% (Group A), 24% (Group B), and 23% (Group C), respectively. However, there was a higher frequency of the combination of death and recurrent MI in Group A vs. Group C (13.0 vs. 4.0%, respectively, P-logrank = 0.021), yet no difference between Group B (6.7%, P-logrank = 0.378) and C. CONCLUSION: These data suggest that a contemporary pharmacologic regimen rapidly delivered, coupled with a strategy of regimented rescue and routine coronary intervention within 24 h of initial treatment, may not be different from timely expert PCI.     

鼻内窥镜诊治脑脊液漏的临床研究

目的 探讨鼻内窥镜手术治疗脑脊液鼻漏临床相关因素。方法 对17例（19漏）内窥镜下修补脑脊液鼻漏患者的临床资料作回顾性分析。结果 脑脊液鼻漏17例中，外伤性15例，自发性2例，内窥镜下瘘口修补术一次性治愈15例，成功率88.2%，失败2例，再次修补成功，其中1例颅内高压术后腰穿持续引流减压。结论 内窥镜手术修补脑脊液鼻漏准确、微创；冠位CT薄层扫描对术前瘘口解剖定位有重要意义；影响手术效果的因素与修补材料的固定有关，与修补材料本身无明显关系；术后适当腰穿引流对于临床提示颅内压高、修补区薄弱病例仍需采用。     

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR RECURRENT GASTRIC TUMORS

Endoscopic resection has been accepted as the standard treatment for intramucosal gastric tumors of differentiated type. However, the indication was limited to small tumors to achieve en bloc resection and prevent local recurrence in cases of conventional endoscopic mucosal resection (EMR) such as the strip biopsy and the cap technique. To avoid multi‐fragmental resection, we have developed endoscopic submucosal dissection (ESD) as a new endoscopic resection technique. ESD is a remarkable technique, because we make it possible to remove the lesions en bloc regardless of size, shape, coexisting ulcer, and location. However, it is difficult or impossible to resect recurrent tumors en bloc in conventional EMR owing to hard fibrosis, and some patients need laparotomy. Using ESD, we can dissect the submucosal layer as we directly look at the submucosa, and remove the lesion safely and reliably even in cases of hard fibrosis. The key to treatment of recurrent tumors in ESD are as follows: (i) using enough submucosal injection solution (we use a mixture of Glyceol and 1% 1900 kDa hyaluronic acid preparation); (ii) incising the mucosa without fibrosis; (iii) understanding characteristics of various cutting devices, and changing other devices in difficult situations. In these ways we can remove the majority of the recurrent tumors en bloc. Hence, we consider that ESD is a very effective treatment which achieves excellent en bloc and complete resection rates and enables patients with intramucosal gastric tumors to a recurrent‐free survival even in recurrent tumors.     

Symptoms, diagnosis and endoscopic management of common bile duct stones

Symptomatic BDS commonly cause significant morbidity and attempt at stone removal should be attempted if possible. Complications of CBDS include biliary colic, jaundice, cholangitis and pancreatitis. Investigations aimed to predict the presence of stones within the bile duct include serum bilirubin, AST, ALP, common bile duct diameter and age as independent predictors of choledocholithiasis. TUS is a sensitive test in detecting bile duct dilatation but the sensitivity is reduced in its ability to detect choledocholithiasis. A NIH consensus statement found that ERC, MRC and EUS were comparable in their sensitivities, specificities and accuracy rates for detection of choledocholithiasis. ERC and stone removal using a balloon or basket is often performed following EST. EBD may be performed if patients have uncorrected coagulopathies but the risk of pancreatitis is higher than for EST (although the risk of bleeding complications is lower for EBD). ML is often required in difficult to remove CBDS and using this device, CBDS can be removed in 90–95% of cases. Other forms of lithotripsy including laser lithotripsy and EHL are confined to specialised centres and the evidence for their use is based on small studies. ESWL may clear stones from the bile duct in up to 93% of patients but frequently ERC and stone fragment removal is required post ESWL. The role of medical therapy in difficult to remove CBDS (or in CBDS in patients with severe co-morbid illness preventing ERC + stone removal) is still currently uncertain due to a lack of large randomised control trials.     

Strecker stent in stenotic hemodialysis Brescia-Cimino arteriovenous fistulas

Flexible tantalum stents (Strecker) were used as an adjunct to percutaneous transluminal angioplasty (PTA) in the treatment of stenotic arterial or venous limbs of Brescia-Cimino hemodialysis fistulas. The diagnostic procedure was performed using retrograde fistulography. After PTA with unsatisfactory results, stents were placed in 5 patients with significant residual stenoses and poor fistula function. Within the mean follow-up period of 6.4 months (range 3–10 months) all fistulas were functioning. We conclude that Strecker stent is useful in the treatment of stenotic hemodialysis arteriovenous fistulas as an adjunct to PTA.     

经皮椎体成形术与椎体后凸成形术治疗胸腰椎压缩性骨折的临床疗效比较

目的比较经皮椎体成形术与椎体后凸成形术治疗胸腰椎压缩性骨折的临床疗效。方法对98例胸腰椎压缩性骨折，根据手术方法不同分为椎体成形组和椎体后凸成形组。比较两组术前术后椎体前缘、中线、后缘高度变化，疼痛视觉模糊评分（VAS），手术时间，出血量等方面的差异。结果两组对椎体高度的恢复比较差异有统计学意义（P〈0．01），VAS、手术时间和出血量比较差异无统计学意义（P〉0．05）。结论经皮椎体成形术与椎体后凸成形术具有创伤小、手术时间短、出血量少等微创优点，而椎体后凸成形术具有较好的复位作用。     

Localized wall thickening of the gallbladder mimicking a neoplasm

Clinical diagnosis of chronic cholecystitis is made based on diffuse hyperechoic thickening of the gallbladder wall as shown by ultrasonographic examination. We herein report three cases of chronic cholecystitis showing localized hypoechoic thickening of the gallbladder wall that mimicked gallbladder cancer by ultrasonography. Histologically, hypertrophy of the muscularis propria was a common characteristic finding in these three patients. A smooth surface of the inner hypoechoic layer of the thickened wall was considered to be a reliable finding in the differential diagnosis between this type of chronic cholecystitis and gallbladder cancer.     

影像设备引导下经皮穿刺与支气管填塞治疗耐多药肺结核空洞的疗效分析

目的评价影像设备引导下,经皮穿刺与经支气管填塞,治疗耐多药肺结核空洞的临床疗效。方法CR、CT及生化,病理学确诊的耐多药肺结核空洞患者88例,用经皮穿刺治疗44例(A组)和经支气管填塞治疗44例(B组)。并对照分析其方法,并发症和疗效,评估其应用价值。结果A组闭塞性空洞愈合14例(32%)、净化性空洞愈合16例(36%),无变化及轻微缩小14例(32%),总治愈率为68%;B组闭塞性空洞愈合23例(52.27%),净化空洞愈合17例(38.64%),无变化及轻微变小4例(9%),总治愈率达91%。B组比A组总疗效高出23%(91%~68%),并发症低,疗程缩短1~2个月。结论支气管填塞治疗耐多药肺结核空洞的疗效要优于经皮穿刺的方法。是目前治疗耐多药肺结核空洞的比较有效方法。     

经皮肾穿刺造瘘在上尿路梗阻性疾病的应用

目的:探讨经皮肾穿刺造瘘在上尿路梗阻性疾病(UUTO)的应用价值.方法:对42例UUTO患者,先行经皮肾穿刺造瘘引流,待肾功能改善、机体状况好转或经引流及造影确定诊断之后,12例行经皮肾取石碎石术,11例行开放肾、输尿管切开取石术,4例行开放肾切除术,4例行肾盂输尿管成型(3例加行取石)术,3例经造瘘管注射硬化剂治疗,3例行输尿管肾盏吻合术,3例行输尿管狭窄段切除端端吻合术,1例行输尿管松解术,1例行输尿管皮肤造瘘术.结果:38例患者一次穿刺成功.全部病例均及时解除了上尿路梗阻,肾功能得到改善,或为进一步诊治创造了条件.在保肾治疗的35例,31例治愈出院;4例肾功能改善,维持在轻度氮质血症水平;4例肾切除患者和3例注射硬化剂治疗患者均治愈出院.结论:经皮肾穿刺造瘘安全、有效,在UUTO的诊治中具有重要的应用价值.