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41.
IntroducciónGastric volvulus is characterized by a rotation, in its long or short axis, generating various degrees of obstruction, which can occur acutely or chronically.CaseA 45-year-old female. Refers to the performance of laparoscopic Nissen fundoplication 4 years ago. In December 2018, she presented a recurrence of the symptoms associated with reflux, for which a new laparoscopic fundoplication was performed (outside our medical unit) without eventualities or apparent complications. Six months later, he was admitted to our medical unit due to intolerance to the oral route. Thoraco-abdomino-pelvic tomography reports images suggestive of gastric volvulus and mixed hiatal hernia with protrusion of colon, stomach, duodenum, jejunum and mesenteric vessels, with data suggestive of complication or ischemia of these structures. An emergency operating room was requested to perform an exploratory laparotomy. Gastric volvulus, ischemia and gastric necrosis were observed in the cavity, for which a total gastrectomy and restitution of the intestinal transit were carried out by means of an esophagus-jejunum end-to-side Roux-en-Y anastomosis.DiscussionThere is no scientific evidence or algorithms described for the management of this condition, according to the management described in the literature, decision-making by our team surgical procedure matches current recommendations.ConclusionIn accordance with what is described in the literature, we consider it important to carry out a retrospective study that describes the bases for standardizing the management of this complication, and assessing models for conducting prospective multicenter studies that allow the creation of an algorithm and clinical guideline. 相似文献
42.
Anirban Gupta David Chang Kimberley E. Steele Michael A. Schweitzer Jerome Lyn-Sue Anne O. Lidor 《Journal of gastrointestinal surgery》2008,12(12):2119-2124
Introduction Paraesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more
co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors
are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially
modifiable variables leading to improved outcomes.
Methods We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database
over a 5-year period (2001–2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were
included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated
with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality.
Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson
Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting
further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary,
and thromboembolic events, (VTE)).
Results Of the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment
variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further
adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients,
while adjustment for cardiac complications or pneumothorax did not eliminate the difference.
Conclusions While PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained
by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance
of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention
should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events. 相似文献
43.
Robotic laparoscopic surgery has revolutionized minimally invasive surgery and has increased in popularity due to its important
benefits. However, evaluation of surgical performance during human robotic laparoscopic procedures in the operating room is
very limited. We previously developed quantitative measures to assess robotic surgical proficiency. In the current study,
we want to determine if training task performance is equivalent to performance during human surgical procedures performed
with robotic surgery. An expert with more than 5 years of robotic laparoscopic surgical experience performed two training
tasks (needle passing and suture tying) and one human laparoscopic procedure (Nissan fundoplication) using the da Vinci™ Surgical
System (dVSS). Segments of the human procedure that required needle passing and suture tying were extracted. Time to task
completion, distance traveled, speed, curvature, and grip force were measured at the surgical instrument tips. Single-subject
analysis was used to compare training task performance and human surgical performance. Nearly all objective measures (8 out
of 13) were significantly different between training task performance and human surgical performance for both the needle passing
and the suture tying tasks. The surgeon moved slower, made more curved movements, and used more grip force during human surgery.
Even though it appears that the surgeon performed better in the training tasks, it is likely that during human surgical procedures,
the surgeon is more cautious and meticulous in the movements performed in order to prevent tissue damage or other complications.
The needle passing and the suture tying training tasks may be suitable to establish a foundation of surgical skill; however,
further training may be necessary to improve transfer of learning to the operating room. We recommend that more realistic
training tasks be developed to better predict performance during robotic surgical procedures and testing the transferability
of basic skill acquisition to surgical performance. 相似文献
44.
Brant K. Oelschlager Kyle Yamamoto Todd Woltman Carlos Pellegrini 《Journal of gastrointestinal surgery》2008,12(7):1155-1162
Introduction This study describes the use of vagotomy in patients during complex laparoscopic esophageal surgery (e.g., reoperative antireflux
surgery (rLARS) or paraesophageal hernia (PEH) repair) when, after extensive esophageal mobilization, the gastroesophageal
junction cannot be made to reach the abdomen without tension. In doing so, we hope to understand the risk incurred by vagus
nerve division in this setting in order to evaluate its role in managing the short esophagus.
Methods One hundred and sixty-six patients underwent rLARS or PEH repair between 1/1998 and 6/2003 at our institution. Clinical data
was obtained from a prospectively maintained database and systematic patient questionnaires administered for this study. Follow-up
was available for 102 (61%) of these patients, at a median of 19 months (range 6–69 months).
Results Fifty-two patients underwent rLARS while 50 patients underwent PEH repair. Thirty patients had a vagotomy during the course
of their operation (Vag Group; 20 anterior, six posterior, four bilateral), 13 in the rLARS group (25%), and 17 in the PEH
group (34%). The primary presenting symptoms for rLARS and PEH repair patients were improved in 89% in the Vag Group and 91%
in the No Vag Group. Similarly, there was no difference in the severity of abdominal pain, bloating, diarrhea, or early satiety
between the Vag and No Vag groups at follow-up. No patient required a subsequent operation for gastric outlet obstruction.
Conclusions Vagotomy during rLARS and PEH repair does not lead to a higher rate delayed gastric emptying, dumping syndrome, or other side
effects. Thus, we propose vagotomy to be a legitimate alternative to Collis gastroplasty when extensive mobilization of the
esophagus fails to provide adequate esophageal length.
Presented at the annual meeting of The Society for Surgery of the Ailmentary Tract New Orleans, 2004
This work was supported in part by the Mary and Dennis Wise Fund. 相似文献
45.
Due to its large prevalence, gastro-oesophageal reflux disease is an ideal target for companies developing medical devices designed to cure reflux. Indeed, because medications leave part of the patients unsatisfied, there is a potential place for alternative therapies, capable of restoring an efficacious anti-reflux barrier, but without the drawbacks of surgery. For more than a decade, several novel endoluminal therapies were developed, clinically evaluated, put on the market and, for many of them, withdrawn due to economic considerations, lack of efficacy or complications. These therapies were designed to act on the gastro-oesophageal junction and reinforce mechanically the anti-reflux barrier by three different ways: suturing, radiofrequency energy application, or implantation of foreign materials. Most of the published data come from open uncontrolled studies with short-term enthusiastic results. There are a few randomized control trials assessing the true efficacy of these modalities, showing often less impressive results than the open studies did, due to a high placebo effect in mild gastro-oesophageal reflux disease. Although endoscopic treatment of gastro-oesophageal disease is still an interesting topic of investigation, one can draw some lessons from the recent experiences and foresee which place these techniques could find in the management of patients suffering from reflux. 相似文献
46.
Jacob A. Chisholm Glyn G. Jamieson Carolyn J. Lally Peter G. Devitt Philip A. Game David I. Watson 《Journal of gastrointestinal surgery》2009,13(6):1064-1070
Background Obesity has long been considered to be a predisposing factor for gastroesophageal reflux. It is also thought to predispose
patients to a poorer clinical outcome following antireflux surgery. This study examined the effect of body mass index (BMI)
on clinical outcomes following laparoscopic antireflux surgery.
Methods Patients were included if they had undergone a laparoscopic fundoplication, their presurgical BMI was known, and they had
been followed for at least 12 months after surgery. The clinical outcome was determined using a structured questionnaire,
and this was applied yearly after surgery. Patients were divided into four groups according to BMI: normal weight (BMI < 25),
overweight (BMI 25–29.9), obese (BMI 30–34.9), and morbidly obese (BMI ≥ 35). The most recent clinical outcome data was analyzed
for each BMI group.
Results Patients, 481, were studied. One hundred three (21%) had a normal BMI, 208 (43%) were overweight, 115 (24%) were obese, and
55 (12%) were morbidly obese. Mean follow-up was 7.5 years. Conversion to an open operation and requirement for revision surgery
were not influenced by preoperative weight. Operating time was longer in obese patients (mean 86 vs 75 min). Clinical outcomes
improved following surgery regardless of BMI.
Conclusions Preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery. Obesity is not a contraindication
for laparoscopic fundoplication.
Financial disclosure: None of the authors have a financial interest in the outcome of this study. The study was not sponsored
by a commercial entity. 相似文献
47.
Reginald V. N. Lord Steven R. DeMeester Jeffrey H. Peters Jeffrey A. Hagen Dino Elyssnia Corinne T. Sheth Tom R. DeMeester 《Journal of gastrointestinal surgery》2009,13(4):602-610
Background and Aims Gastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux
disease (ERD), and Barrett’s esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies.
In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett’s
esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower
esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication.
Methods From the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified
50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was
healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4)
BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux
surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal
low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a
detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal
esophageal pH monitoring; and were interviewed at least 1 year after operation.
Results One hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant
preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients
with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and
more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in
only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients
in all GERD categories.
Conclusions Compared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux
barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia
reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients. 相似文献
48.
St Peter SD Valusek PA Calkins CM Shew SB Ostlie DJ Holcomb GW 《Journal of pediatric surgery》2007,42(1):25-30
Objectives
Herniation of the fundoplication wrap through the esophageal hiatus is a common reason for surgical failure in children who have undergone laparoscopic Nissen fundoplication. Extensive mobilization of the gastroesophageal junction in combination with decreased adhesions after laparoscopy may contribute to the development of this complication. In an attempt to decrease the incidence of wrap migration, we changed our technique to minimal mobilization of the intraabdominal esophagus and to placement of esophageal-crural sutures. In this study, we investigate the impact of these modifications on outcome.Methods
A retrospective analysis was performed on all patients undergoing laparoscopic fundoplication by the senior author (GWH) from January 2000 through December 2004. Those undergoing operation with extensive esophageal mobilization and without esophagocrural sutures (January 2000 to March 2002) (group I) were compared with those in whom there was minimal esophageal dissection with placement of these esophagocrural sutures (April 2002 to December 2004) (group II).Results
Two hundred forty-nine patients underwent laparoscopic Nissen fundoplication during the study period. One hundred thirty patients were in group I, and 119 patients were in group II. The rate of transmigration decreased from 12% in group I to 5% in group II (P = .072). The relative risk of transmigration with extensive esophageal mobilization and without the esophagocrural sutures was 2.29.Conclusions
This retrospective study has shown that placement of esophagocrural sutures and minimization of the dissection around the esophagus results in a more than 2-fold reduction in the risk of wrap transmigration after laparoscopic Nissen fundoplication. 相似文献49.
Introduction
Nissen fundoplication has been performed laparoscopically for over 15 years, being associated with shorter hospital stay and
fewer complications than conventional open surgery with good long-term outcomes. Day-case laparoscopic Nissen fundoplication
(LNF) is rarely performed in the UK and most series in the literature report length of stay >2 days.
Methods
The objective of this study was to examine the safety and efficacy of day-case LNF. The clinical records of all patients undergoing
LNF under the care of three surgeons in a district general hospital (DGH) during a 5-year period (January 2003 to December
2007) were reviewed to examine length of stay, complications, length of procedure, grade of operating surgeon and symptoms
on follow-up.
Results
One hundred thirteen day-case LNFs were recorded in this series. Day-case LNF patients had median age of 45 years (range 20–68 years,
65% (64.6%) male) and 98% were American Society of Anesthesiologists (ASA) grade I or II. Twenty-one cases (19%) were performed
by higher surgical trainees. Median operative time was 54 minnutes (range 25–120 min). Only one perioperative complication
(port-site bleed) occurred, treated without prolonging length of stay. The proportion of all LNF performed as day cases increased
from 8% to 52% during the study period. Median operative time has significantly reduced from the first 20 consecutive LNF
cases to the latest 20 cases [65 min (range 40–120 min) versus 48 min (range 25–72 min); p = 0.037]. At follow-up (median 7 weeks, range 2–31 weeks) 82% of patients had improvement in all presenting symptoms. Eight
patients had postoperative complications [wound infection (n = 2), persistent regurgitation requiring laparoscopic division of a gastric band adhesion (n = 1), dysphagia (n = 5 with two patients requiring redo partial fundoplication and one patient requiring dilatation) and there were no conversions
to open surgery.
Conclusion
Day-case LNF is safe and effective for treating selected patients with gastroesophageal reflux disease (GERD) in a DGH. The
proportion of day-case LNFs is increasing in our unit. Half of the LNFs in a DGH can be done as day cases. Experience is associated
with a significant reduction in operative time. 相似文献
50.
Gasper WJ Sweet MP Hoopes C Leard LE Kleinhenz ME Hays SR Golden JA Patti MG 《Surgical endoscopy》2008,22(2):495-500
Background Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease (ESLD). This disease can lead
to microaspiration and may be a risk factor for lung damage before and after transplantation. A fundoplication is the best
way to stop reflux, but little is known about the safety of elective antireflux surgery for patients with ESLD. This study
aimed to report the safety of laparoscopic fundoplication for patients with ESLD and GERD before or after lung transplantation.
Methods Between January 1997 and January 2007, 305 patients were listed for lung transplantation, and 189 patients underwent the procedure.
In 2003, routine esophageal studies were added to the pretransplantation evaluation. After the authors’ initial experience,
gastric emptying studies were added as well.
Results A total of 35 patients with GERD or delayed gastric emptying were referred for surgical intervention. A laparoscopic fundoplication
was performed for 32 patients (27 total and 5 partial). For three patients, a pyloroplasty also was performed. Two patients
had a pyloroplasty without fundoplication. Of the 35 operations, 15 were performed before and 20 after transplantation. Gastric
emptying of solids or liquids was delayed in 12 (92%) of 13 posttransplantation studies and 3 (60%) of 5 pretransplantation
studies. All operations were completed laparoscopically, and 33 patients recovered uneventfully (94%). The median hospital
length of stay was 2 days (range, 1–34 days) for the patients admitted to undergo elective operations. Hospitalization was
not prolonged for the three patients who had fundoplications immediately after transplantation.
Conclusions The results of this study show that laparoscopic antireflux surgery can be performed safely by an experienced multidisciplinary
team for selected patients with ESLD before or after lung transplantation, and that gastric emptying is frequently abnormal
and should be objectively measured in ESLD patients.
Presented as a Poster of Distinction at the Spring 2007 Meeting of the Society of Gastrointestinal and Endoscopic Surgeons
(SAGES) at Las Vegas, Nevada, 18–22 April 2007 相似文献