早期应用低分子肝素预防腹腔镜脾切除食管胃底静脉断流术后门静脉血栓形成临床研究*

目的 研究早期使用低分子肝素预防腹腔镜脾切除食管胃底静脉断流术（LSED）治疗患者术后门静脉血栓（PVST）发生的作用。方法 我院2014年3月至2015年6月期间收治的112例肝硬化门静脉高压症（PHT）患者,所有患者均行LSED治疗,按患者入院顺序分为两组,每组56例,对照组56例患者采用常规抗凝治疗,另56例患者在上述基础上采用低分子肝素治疗（观察组）。随访两组患者两周,观察两组患者肝功能、门静脉血流状况、凝血功能、PVST以及并发症发生情况。结果 两组患者治疗前后血清TBIL、ALB、INR水平均无显著性差异（P＞0.05）;治疗前两组患者门静脉最大血流速度、平均血流速度和门静脉直径无明显差异（P＞0.05）;治疗后观察组患者门静脉最大血流速度、平均血流速度和门静脉直径分别为（20.83±1.15）cm/s、（15.12±1.19cm/s）和（15.86±3.12）mm,均大于对照组的上述指标【分别为（14.36±0.74）cm/s、（10.28±0.71）cm/s和（14.27±2.96）mm,P＜0.05】;治疗前两组患者凝血功能指标比较无显著差异（P＞0.05）;治疗后,观察组患者血APTT、PT、FIB和TT分别为（25.72±3.64） s、（14.96±2.26）s、（3.51±0.86）g/L和（20.11±3.65）s,均长于对照组的上述指标【分别为（23.37±3.52）s、（13.87±2.14）s、（2.62±0.73）g/L和（18.14±3.23）s,均P＜0.05】;术后观察组和对照组PVST发生率分别为7.14%和42.86%,观察组明显较低（P＜0.05）,观察组和对照组其他并发症发生率无显著相差（P>0.05）。结论 早期应用低分子肝素对预防LSED术后门静脉血栓具有良好的作用,能有效改善凝血功能,同时降低各种并发症,安全性高。     

改良四步法腹腔镜巨脾切除联合贲门周围血管离断术临床效果研究

目的 总结改良四步法用于腹腔镜巨脾切除联合贲门周围血管离断术（LSPD）的疗效和经验。方法 回顾性分析2012年6月至2015年6月浙江省人民医院肝胆胰外科及微创外科采用改良四步法行LSPD的105例病人的临床资料。结果 105例病人均完成手术,其中2例（1.9%）中转开放手术,余103例在腹腔镜下顺利完成。手术时间为（175.6±49.8）min,术中出血（310.9±240.9）mL。术后发生腹腔出血1例,胰瘘1例,腹腔感染2例,脾静脉血栓2例,肝功能不全3例。1例肝功能不全进展出现肝性脑病放弃治疗自动出院,其余病人通过保守治疗均治愈出院。术后住院时间为（8.7±3.6）d 。术后随访12～48个月,2例分别在术后3月余、术后1年再发上消化道出血,经急诊内镜发现1例为食管中上段静脉曲张伴出血,1例为胃窦及胃体广泛糜烂伴出血。结论 采用改良四步法行LSPD成功率高,术后并发症发生率低,病人术后恢复快,且中长期随访出血复发率低,值得临床推广应用。     

Esophagogastric junction distensibility in hiatus hernia

Hiatus hernia is known to be an important risk factor for developing gastroesophageal reflux disease. We aimed to use the endoscopic functional lumen imaging probe (EndoFLIP) to evaluate the functional properties of the esophagogastric junction. EndoFLIP assessments were made in 30 patients with hiatus hernia and Barrett's esophagus, and in 14 healthy controls. The EndoFLIP was placed straddling the esophagogastric junction and the bag distended stepwise to 50 mL. Cross‐sectional areas of the bag and intra‐bag pressures were recorded continuously. Measurements were made in the separate sphincter components and hiatus hernia cavity. EndoFLIP measured functional aspects such as sphincter distensibility and pressure of all esophagogastric junction components and visualized all hiatus hernia present at endoscopy. The lower esophageal sphincter in hiatus hernia patients had a lower pressure (e.g. 47.7 ± 13.0 vs. 61.4 ± 19.2 mm Hg at 50‐mL distension volume) and was more distensible (all P < 0.001) than the common esophagogastric junction in controls. In hiatus hernia patients, the crural diaphragm had a lower pressure (e.g. 29.6 ± 10.1 vs. 47.7 ± 13.0 mm Hg at 50‐mL distension volume) and was more distensible (all P < 0.001) than the lower esophageal sphincter. There was a significant association between symptom scores in patients and EndoFLIP assessment. Conclusively, EndoFLIP was a useful tool. To evaluate the presence of a hiatus hernia and to measure the functional properties of the esophagogastric junction. Furthermore, EndoFLIP distinguished the separate esophagogastric junction components in hiatus hernia patients, and may help us understand the biomechanics of the esophagogastric junction and the mechanisms behind hiatal herniation.     

Hem-o-lok结扎夹在Ⅱ、Ⅲ型食管胃结合部腺癌手术中的应用

目的比较使用Hem-o-lok结扎夹与传统结扎技术在Ⅱ、Ⅲ型食管胃结合部腺癌手术中的效果,分析结扎夹的优越性。方法随机将20例Ⅱ、Ⅲ型食管胃结合部腺癌需行近端胃切除术的患者分成两组,第一组术中使用Hem-o-lok结扎夹闭胃周血管,第二组使用传统结扎技术,比较两组间离断胃周血管时间及术中出血量。结果两组手术均成功,第一组离断胃周血管时间及术中出血量分别为（15.20±1.22）min和（0.50±0.85）ml,均小于第二组的（24.60±1.50）min和（2.20±1.48）ml（P〈0.05）。结论Ⅱ、Ⅲ型食管胃结合部腺癌行近端胃切除术时,使用Hem-o-lok结扎夹在离断胃周血管时间及术中出血量方面优于传统结扎技术。     

How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia

Background

The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities.

Purpose

The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.     

An experimental study on viability of the devascularized trachea

This experiment was designed to evaluate the effect of varying extents of devascularization to the viability of the trachea, and the influence of preservation of the right bronchial artery on the ischemia of the widely devascularized trachea. In experiment 1, the canine trachea was devascularized in a stepwise manner, and the regional blood flow was measured in each situation. This experiment revealed that the regional blood flow decreased to one-third of the non-treated trachea when the bilateral bronchial arteries were transected, and to nil when the cervical and mediastinal trachea was devascularized. In experiment 2, in which dogs were divided into 2 groups depending on preservation of the right bronchial artery, the trachea was stepwisely devascularized and the regional blood flow measured. This experiment indicated that the regional blood flow in the trachea when the right bronchial artery was preserved did not so remarkably diminish, though the cervical and mediastinal trachea was devascularized. In experiment 3, dogs were divided into 3 groups according to the extent of devascularization of the trachea and to the presence or absence of the preserved right bronchial artery, and were followed for 2 months postoperatively. This experiment demonstrated that the preservation of the right bronchial artery prevented tracheal necrosis caused by devascularization of the cervical and mediastinal trachea. We concluded that the regional tracheal blood flow markedly decreased and that tracheal necrosis occurred following devascularization of the cervical and mediastinal trachea when the bilateral bronchial arteries were transected. The preservation of the right bronchial artery however, prevented a decrease in the regional blood flow and necrosis of the widely devascularized trachea.     

改良Sugiura手术治疗食道静脉曲张出血34例分析

为34例食道静脉曲张出血(EVB)病人行改良Susiura手术。经1～5年随访观察无肝性脑病及再出血,亦无手术死亡。并对手术要点进行了讨论。     

经上腹左胸手术和Ivor-lewis手术治疗Siewert Ⅱ型食管胃交界部腺癌的疗效比较

目的:对比经上腹左胸手术和Ivor-lewis手术治疗Siewert Ⅱ型食管胃交界部腺癌（adenocarcinoma of the esophagogastric junction,AEG）在术中和术后各参数中的差别,以及患者预后的差异。方法:回顾性收集320例于河北医科大学第四医院胸外科行根治性手术的Siewert Ⅱ型 AEG患者的数据,其中行上腹左胸手术的患者175例,行Ivor-lewis手术的患者145例。比较两组患者的临床病理特征、术中和术后情况、总生存时间（overall survival,OS）和无病生存时间（disease-free survival,DFS）,并对影响AEG患者预后的情况进行单因素和多因素分析。结果:两组患者在肿瘤最大直径、pTNM分期、pN分期和下残阳性方面比较有统计学差异(P<0.05);与Ivor-lewis手术相比,行上腹左胸手术患者的术中时间缩短了30 min(P=0.034),术后吻合口瘘发生率更低(1.71% vs 4.83%,P=0.041);相比Ivor-lewis患者,行上腹左胸手术的患者可以获得更好的OS和DFS（P<0.05）;单因素和多因素分析显示术前新辅助治疗是Siewert Ⅱ型AEG患者预后的影响因素（P<0.05）。结论:经上腹左胸手术可以彻底切除肿瘤,保留膈肌的完整,缩短开胸时间,有利于术后快速康复。同时,术后吻合口瘘等并发症的发生率低,有利于及时进行术后辅助治疗,更利于改善AEG患者的预后。     

无痛内镜下食管胃静脉曲张治疗术对轻微肝性脑病的影响

目的 探讨无痛内镜下食管胃静脉曲张治疗术(组织胶注射+套扎或组织胶+硬化剂注射)对轻微肝性脑病(MHE)的影响.方法 采用前瞻性队列研究,将92例食管胃静脉曲张患者分为MHE组(n=44)和无肝性脑病组(对照组,n=48).采用数字连接试验(NCT)、数字符号试验(DST)评估两组患者术前、术后2 h和术后24 h M...