乳腺癌淋巴结清扫新术式的临床可行性研究

目的设计并临床验证乳腺癌腋窝及锁骨下逆行淋巴结清扫法的临床可行性；同时探索保乳手术的实施策略。方法对78例女性乳腺癌住院患者（42例施行保乳手术，36例施行改良根治术）采用逆行腋窝及锁骨下淋巴结清扫法进行引流区域的淋巴结清扫。结果78例均未出现神经、血管损伤等并发症，术后恢复顺利；随访3～29个月，未见1例复发和转移，也未发现上肢疼痛、肿胀等并发症。结论逆行腋淋巴结清扫法，对各组淋巴结显露清晰，能全面掌握区域淋巴结状况，操作简便易行，适用于各种保留胸肌或保乳的乳腺癌手术。     

声门上型喉癌颈廓清术34例临床观察

目的探讨声门上型喉癌不同颈廓清术方法及其预后。方法对34例声门上型喉癌进行颈廓清术治疗,其中20例选用传统根治性颈廓清术,14例采用区域选择性颈廓清术治疗。结果根治性颈廓清术两年复发率为25%,5年生存率为60%;区域选择性颈廓清术分别为28.5%和57.1%,两组情况相似(P>0.05)。前组并发症为40%,后组为14.3%,前组明显较高(P<0.05)。结论声门上型喉癌行区域选择性颈廓清术能够保证治疗的疗效,并减轻传统治疗模式所带来的不良反应。     

全乳晕入路腔镜下甲状腺微小乳头状癌手术的临床经验及疗效

目的：探讨全乳晕入路腔镜甲状腺微小乳头状癌的手术经验和疗效。方法：选取2016年6月至2017年12月 中南大学湘雅二医院收治的甲状腺微小乳头状癌患者共117例,根据患者意愿分为腔镜手术组(n=72)和开放手术组 (n=45),比较两组中央区淋巴结清扫数、术中出血量、术后引流量及术后并发症发生和复发情况。结果：与开放手 术组相比,腔镜手术组术中出血量少(P<0.05)、手术时间较长(P<0.05);两组淋巴结清除数、术后引流量及并发症发 生率的差异均无统计学意义(均P>0.05);平均随访时间超过20个月,两组均无复发。结论：全乳晕入路腔镜下甲状腺 微小乳头状癌手术并行中央区淋巴结清扫是安全可行的,具有颈部无痕、出血少、住院时间短等优点,更易被年轻 患者所接受。     

结直肠肿瘤内镜黏膜下剥离术(ESD)手术时间的影响因素分析

目的 分析ESD治疗结直肠肿瘤的手术时间的影响因素.方法 回顾性分析210例结直肠癌肿瘤患者ESD治疗的临床资料.将手术时间分为≥60 min和＜60 main两部分,采用逻辑回归分析对包括肿瘤部位、类型、病理诊断、非抬举征、术中严重出血等5个变量进行分析.结果 210例结直肠ESD平均手术时间(50.3-42.8) min,病灶平均大小(31.9 ±44.9)cm2,整块切除率为91.4％,R0切除率为90.5％,治愈性切除率为88.6％.穿孔发生率为5.2％(11/210),迟发性出血率为0.5％(1/210).多因素回归分析提示,肿瘤直径≥40 mm或跨结肠袋(OR 3.466;95％CI:1.594～7.538)、病变位于弯曲部(OR 2.270;95％ CI:0.175～9.227)是影响结直肠ESD手术时间的独立危险因素(时间≥60min).结论 结直肠肿瘤直径≥40mm或跨结肠袋,病变位于弯曲部可明显延长ESD手术时间,使手术难度增加.     

Ⅰ期非小细胞肺癌淋巴结清扫中胸腔镜手术的效果

目的探讨胸腔镜下Ⅰ期非小细胞肺癌（NSCLC）根治术中淋巴结清扫的效果。方法收集经胸腔镜手术治疗74例（胸腔镜组）及开胸手术治疗80例（开胸组）的Ⅰ期NSCLC患者的临床资料,比较分析2组淋巴结清扫数目的差异,同时比较2组术中出血量、术后胸腔引流量、声音嘶哑、心肺总并发症的差异。结果胸腔镜组在双侧N2淋巴结清扫的数量高于开胸组（P〈0．05）;2组双侧N1淋巴结清扫数量差异无统计学意义（P〉0．05）;2组术中出血量、术后胸腔引流量、声音嘶哑发生率及心肺总并发症发生率差异均无统计学意义（P〉0．05）。结论在Ⅰ期NSCLC根治术中,胸腔镜下系统性淋巴结清扫在技术上符合肿瘤外科原则,优于开胸手术。     

择区性颈淋巴结清扫术在临床颈淋巴结阴性甲状腺癌患者中的应用

目的 探讨择区性颈淋巴结清扫术在颈部高危临床颈淋巴结阴性(cN0)甲状腺癌患者中的应用价值.方法 前瞻性分析2006年8月至2011年6月,中国医学科学院肿瘤医院头颈外科收治的63例颈部高危cN0甲状腺癌患者的临床资料.结果 63例患者均经病理证实为甲状腺乳头状癌,侧颈淋巴结隐性转移率为39.7％.单因素分析结果显示,63例患者术后病理检查甲状腺被膜侵犯患者的侧颈淋巴结隐性转移率为46.9％,而甲状腺被膜未侵犯患者的侧颈淋巴结隐性转移率为14.3％,差异有统计学意义(P=0.028).Ⅵ区淋巴结转移患者的侧颈淋巴结隐性转移率为54.3％,而Ⅵ区淋巴结阴性患者的侧颈淋巴结隐性转移率为21.4％,差异有统计学意义(P=0.008).原发灶肿瘤≥2 cm患者的侧颈淋巴结隐性转移率为41.4％,而原发灶肿瘤＜2 cm患者的侧颈淋巴结隐性转移率为38.2％ (P =0.803).术前超声检查发现侧颈淋巴结肿大,但不考虑转移的34例患者中,17例出现隐性淋巴结转移,转移率为50.0％,而侧颈淋巴结术前超声检查阴性患者的隐性淋巴结转移率为27.6％ (P =0.072).多因素Logistic回归分析结果显示,仅Ⅵ区淋巴结转移与侧颈淋巴结隐性转移有关(P=0.017).而原发灶肿瘤被膜侵犯、原发肿瘤大小和术前超声检查侧颈淋巴结状态与侧颈淋巴结隐性转移无关(均P ＞0.05).结论 择区性颈淋巴结清扫术对颈部高危的cN0甲状腺癌患者是可行的,能及时发现和清除侧颈隐性淋巴结的转移.建议对甲状腺被膜侵犯和Ⅵ区淋巴结转移的cN0甲状腺癌患者,常规行颈部Ⅲ、Ⅳ区淋巴结清扫.     

腹腔镜根治性膀胱切除术后淋巴漏发生因素分析及预防措施

目的:探讨腹腔镜根治性膀胱切除术后淋巴漏原因及相关危险因素、预防措施。方法:收集2015年01月至2020年12月在我院泌尿外科行腹腔镜根治性膀胱切除及盆腔淋巴结清扫术患者的年龄、BMI、术前术后血红蛋白、术前术后白蛋白、清扫淋巴结数、阳性淋巴结数、术中是否Hem-o-lock夹闭淋巴管资料,采用t检验和Logistic回归分析淋巴漏发生因素。结果:45例患者中,淋巴漏组18例,非淋巴漏组27例,t检验显示阳性淋巴结数与术后淋巴漏发生密切相关,Logistic回归分析显示是否使用Hem-o-lock夹闭淋巴管及阳性淋巴结数与术后淋巴漏发生密切相关。经营养支持、补充白蛋白、抗感染、保持引流管通畅,术后10~20天淋巴漏均治愈。结论:阳性淋巴结数及清扫术后是否夹闭淋巴管是淋巴漏发生的高危因素,术后贫血严重患者更易发生淋巴漏。加强营养,纠正贫血,补充白蛋白,术中精准操作,使用Hem-o-lock确切结扎可减少淋巴漏的发生。     

国际学员三站式强化内镜黏膜下剥离术动物模拟培训的实践

目的　探索家猪离体胃模型在对国际学员进行内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）培训中的应用价值。方法　对15名国际学员进行为期20 d的ESD培训,第一阶段为理论知识学习,完成消化内镜基础及动物模拟培训调查问卷。第二阶段将其随机分为离体动物模型组（A组,８人）和临床观察学习组（B组,7人）。A组在临床观察学习期间,同时按照规范操作步骤进行离体动物模型培训课程。培训结束时考核两组学员ESD操作情况,并再次完成问卷。应用SPSS 20.0进行t检验和卡方检验。结果　A组与B组ESD总操作时间差异有统计学意义（P＜0.05）,注射时间、标记时间差异没有统计学意义（P＞0.05）,切开时间及黏膜剥离时间差异有统计学意义。A 组与B组的ESD操作速度差异无统计学意义。两组切除标本大小差异无统计学意义。两组均有1例为分块切除病灶,其余为整块切除。在操作过程中各发生1例穿孔。同时,对比离体动物模型组学员培训前后操作情况,发现培训后ESD总操作时间、切开时间明显提高。结论　以理论知识为基础结合家猪离体胃动物模型培训的内镜培训具有较高的教学参考价值,能够使各国学员熟悉并初步掌握ESD的基础理论知识及操作方法,帮助各国学员日后在临床开展ESD操作。     

Value of subcarinal lymph node dissection in esophageal cancer surgery: A case-control study

We investigated the value of subcarinal lymph node dissection in esophageal cancer surgery. Altogether, 240 patients with esophageal cancer admitted to our department between June 2012 and January 2016 were prospectively assigned to an experimental group (subcarinal lymph node dissection group, n = 120 cases) and a control group (uncleaned group, n = 120 cases). The number of subcarinal lymph nodes and the rate of subcarinal lymph node metastasis were determined, and the factors influencing subcarinal lymph node metastasis were analyzed using logistic regression in the experimental group. The operation time, postoperative complications, intraoperative blood loss, postoperative hospital stay, total postoperative hospital cost, and 5-year survival rate were compared between the 2 groups. In the experimental group, an average of 6.03 subcarinal lymph nodes were dissected, and the lymph node metastasis rate was 18.33%. The subcarinal lymph node metastasis rate in the experimental group was related to the size of the subcarinal lymph nodes, depth of tumor invasion, and tumor location. The 5-year survival rate was higher in the experimental group than in the control group (44.2% vs 30.0%, χ² = 6.407, P = .04). The subcarinal lymph node metastasis rate in patients with esophageal cancer is high. Patients with mid-thoracic esophageal cancers that infiltrate beyond the esophageal muscle layer with subcarinal lymph node size > 1.0 cm should undergo lymph node resection, despite increased operation time, incidence of postoperative pulmonary infection, hospitalization time, and total postoperative cost; lymph node resection may improve the 5-year survival rate.     

Intestinal barrier dysfunction is involved in the development of systemic inflammatory responses and lung injury in type A aortic dissection: a case-control study

BackgroundThe definite pathogenesis of lung injury complicated by type A aortic dissection (TAAD) remains unclear. In this paper, we investigated the relationship between intestinal injury, lung injury, and systemic inflammatory responses, with the aim of exploring the mechanism underlying intestinal injury and its impact on systemic inflammatory responses and lung injury in patients with TAAD.MethodsPatients with TAAD (n=36) and those with aortic root aneurysm (ARA) (n=30) were compared. TAAD patients were younger and had higher creatinine (Cr) than ARA patients. White blood cell (WBC) count, neutrophil count, neutrophil percentage, interleukin (IL)-6, IL-8, tumor necrosis factor α (TNF-α), C-reactive protein (CRP), histamine (HIS) levels, PaO₂-FiO₂ ratio, diamine oxidase (DAO), intestinal fatty acid binding protein (iFABP), and peptidoglycan (PGN) were measured using the same laboratory methods between the two groups.ResultsIncreased WBC [(9.70±4.05)×10⁹/L vs. (5.88±1.2)×10⁹/L, P<0.001], neutrophil [(7.65±4.27)×10⁹/L vs. (3.40±0.97)×10⁹/L, P<0.001], neutrophil percentage [(74.73±13.42)% vs. (57.67±9.45)%, P<0.001], IL-6 (37.48±4.87 vs. 20.90±0.92 pg/mL, P<0.001), IL-8 (97.15±9.11 vs. 69.46±3.17 pg/mL, P<0.001), TNF-α (71.32±10.35 vs. 33.90±2.27 pg/mL, P<0.001), CRP (10.67±1.62 vs. 4.43±0.26 µg/mL, P<0.001), HIS (13.29±1.88 vs. 7.63±0.58 ng/mL, P<0.001), DAO (24.94±4.72 vs. 10.92±2.44 U/L, P<0.001), iFABP (879.01±190.12 vs. 206.35±42.20 pg/mL, P<0.001), and PGN (31.10±5.51 vs. 12.52±2.20 ng/mL, P<0.001) and decreased PaO₂-FiO₂ ratio (365.35±146.47 vs. 447.86±70.80 mmHg, P=0.01) were detected in TAAD group relative to ARA group. In TAAD group, positive correlations were detected between DAO and inflammatory cytokines [IL-6 (r=0.56, P<0.001), IL-8 (r=0.61, P<0.001), TNF-α (r=0.71, P<0.001), and CRP (r=0.68, P<0.001)], between iFABP and inflammatory cytokines [IL-6 (r=0.72, P<0.001), IL-8 (r=0.71, P<0.001), TNF-α (r=0.90, P<0.001), and CRP (r=0.89, P<0.001)], between DAO and PGN (r=0.52, P<0.001), between iFABP and PGN (r=0.74, P<0.001), between PGN and inflammatory cytokines [IL-6 (r=0.85, P<0.001), IL-8 (r=0.44, P<0.001), TNF-α (r=0.61, P<0.001), and CRP (r=0.73, P<0.001)]. In acute TAAD subgroup, PGN and PaO₂-FiO₂ ratio were negatively correlated (r=−0.50, P=0.036).ConclusionsSystemic inflammatory responses in TAAD patients may lead to lung and intestine injury, and the latter may be involved in the development of systemic inflammatory responses and lung injury in these patients.