ALPPS与采用不同栓塞材料PVE对肝再生及手术切除率影响研究

目的 比较不同栓塞材料的门静脉栓塞术（PVE）与联合肝脏分隔和门静脉结扎的二步肝切除术（ALPPS）对剩余肝体积（FLR）增长速率的影响,比较各组FLR的增长速率,二期手术切除率、术中数据和术后并发症。方法 采用单中心、前瞻性、非随机对照的对比研究。2014年11月至2019年12月,海军军医大学第三附属医院共126例因FLR不足导致无法切除的肝细胞癌（HCC）或肝内胆管癌（ICC）病人,将其分为4组：ALPPS组及分别采用氰基丙烯酸正丁酯（NBCA）、微球、明胶海绵作为栓塞材料的PVE组。主要终点为FLR增长速率和二期手术切除率。结果 各组的手术切除例数及二期手术切除率分别为：ALPPS组38例（99.4%）,NBCA组32例（76.2%）,明胶海绵组20例（60.6%）,微球组10例（83.3%）。ALPPS组、NBCA组、微球组的FLR增长速率分别为15.1 mL/d,10.0 mL/d和 8.5 mL/d,均高于明胶海绵组（3.7 mL/d）。结论 采用NBCA及微球作为栓塞材料的PVE导致FLR增长速率低于ALPPS,两种栓塞材料的PVE二期手术切除率相当。使用NBCA作为栓塞材料的PVE其FLR增长速率高于微球,且这两种栓塞材料的栓塞效果均优于明胶海绵。     

介入治疗内脏动脉瘤的远期疗效

目的观察介入治疗内脏动脉瘤(VAA)的远期疗效。方法回顾性分析30例接受介入治疗VAA患者(41个瘤灶),术后随访时间均12个月,观察治疗效果及并发症。结果对12个肾动脉瘤、8个脾动脉瘤行动脉瘤填塞术,其中5个脾动脉瘤、5个肾动脉瘤采用裸支架辅助填塞;对13个脾动脉瘤、1个肝动脉瘤行动脉瘤栓塞术;对4个肾动脉瘤行载瘤动脉支架植入术,其中3个采用多层裸支架植入术、1个采用覆膜支架植入术;对2个肾动脉瘤、1个腹腔干动脉瘤行保守治疗;均获得成功。1个脾动脉瘤栓塞术后出现部分脾梗死,1个左肾多发动脉瘤植入支架后瘤腔小部分显影。术后随访12～55个月,平均(23.44±12.48)个月,期间脾梗死者梗死面积未增大、未见脓肿形成,瘤腔部分显影病变显影面积未增大。30例患者中,1例因心力衰竭死亡,余均存活,无VAA复发及其他并发症。结论介入治疗VAA远期疗效较好,且安全性较高。     

经导管动脉栓塞治疗局部晚期乳腺癌伴皮肤破溃

目的 观察经导管动脉栓塞（TAE）用于改善经常规化学治疗（化疗）无效的局部晚期乳腺癌伴皮肤破溃的效果。方法 10例晚期乳腺癌经常规化疗及系统靶向治疗均无效,肿瘤增大伴皮肤破溃,伴恶臭、渗液、出血及感染等;于DSA引导下对其行TAE栓塞肿瘤供血动脉,术后观察症状改善情况。结果 10例均成功栓塞肿瘤供血动脉,技术成功率100%;术后均未出现栓塞相关皮肤坏死及神经损伤。术后7天皮肤症状均明显改善;术后30天9例皮肤破损面积减小、1例皮肤破溃加重;术后2个月内6例、术后3个月内10例皮肤破损面积增大并症状复发。结论 TAE用于治疗伴皮肤破溃的局部晚期乳腺癌能在短期内显著改善症状,但中长期效果有限。     

Functional transition: Inconsistently parallel to the increase in future liver remnant volume after preoperative portal vein embolization

BACKGROUNDPreoperative portal vein embolization (PVE) is a widely used strategy to enable major hepatectomy in patients with insufficient liver remnant. PVE induces hypertrophy of the future liver remnant (FLR) and a shift of the functional reserve to the FLR. However, whether the increase of the FLR volume (FLRV) corresponds to the functional transition after PVE remains unclear.AIMTo investigate the sequential relationship between the increase in FLRV and functional transition after preoperative PVE using 3-dimensional (3D) computed tomography (CT) and ^99mTc-galactosyl-human serum albumin (^99mTc-GSA) single-photon emission computed tomography (SPECT) fusion images. METHODSThirty-three patients who underwent major hepatectomy following PVE at the Department of Gastroenterological Surgery I, Hokkaido University Hospital between October 2013 and March 2018 were enrolled. Three-phase dynamic multidetector CT and ^99mTc-GSA SPECT scintigraphy were performed at pre-PVE, and at 1 and 2 wk after PVE; 3D ^99mTc-GSA SPECT CT-fused images were constructed from the Digital Imaging and Communications in Medicine data using 3D image analysis system. Functional FLRV (FFLRV) was defined as the total liver volume × (FLR volume counts/total liver volume counts) on the 3D ^99mTc-GSA SPECT CT-fused images. The calculated FFLRV was compared with FLRV.RESULTSFFLRV increased by a significantly larger extent than FLRV at 1 and 2 wk after PVE (P < 0.01). The increase in FFLRV and FLRV was 55.1% ± 41.6% and 26.7% ± 17.8% (P < 0.001), respectively, at 1 wk after PVE, and 64.2% ± 33.3% and 36.8% ± 18.9% (P < 0.001), respectively, at 2 wk after PVE. In 3 of the 33 patients, FFLRV levels decreased below FLRV at 2 wk. One of the three patients showed rapidly progressive fatty changes in FLR. The biopsy at 4 wk after PVE showed macro- and micro-vesicular steatosis of more than 40%, which improved to 10%. Radical resection was performed at 13 wk after PVE. The patient recovered uneventfully without any symptoms of pos-toperative liver failure.CONCLUSIONThe functional transition lagged behind the increase in FLRV after PVE in some cases. Evaluating both volume and function is needed to determine the optimal timing of hepatectomy after PVE.     

Assessment of high-energy phosphorus compounds in the rat kidney by in situ31P nuclear magnetic resonance spectroscopy: effect of ischemia and furosemide

Summary ³¹P nuclear magnetic resonance (NMR) spectroscopy of the in situ rat kidney was performed by a surface coil method, and the effects of ischemia and furosemide infusion were assessed.³¹P NMR spectra of the kidney subjected to 30 min of ischemia returned completely to the pre-ischemic level after 60 min of reperfusion. But the³¹P NMR spectra after 60 min of ischemia did not recover, even after 120 min of reperfusion. Levels of -ATP and inorganic phosphate (Pi) decreased and the chemical shift of Pi increased after intravenous infusion of furosemide. This increase in chemical shift might signal an alkalotic change in intracellular pH. Furosemide infusion prior to ischemia is thought to protect the kidney from injury induced by 60 min of warm ischemia. The chemical shift of Pi returned to the pre-ischemic level earlier than -ATP and Pi. In conclusion, according to the findings of³¹P NMR spectroscopy, furosemide infusion prior to ischemia may be effective in protecting the kidney against ischemic injury. But the change in Pi peak and the causes of the dissociation of Pi and -ATP should be examined further.     

腔内血管技术在肝静脉回流障碍综合征治疗中的应用

目的：探索一种简单、安全、有效的治疗肝静脉回流障碍（Budd-Chiari)综合征的新方法。方法：在11例肝静脉回流障碍综合征患中,应用经皮穿刺下腔静脉气囊扩张成形术治疗获得成功后,有9例患同时置入血管内支架。3例肝静脉完全闭塞在下腔静脉腔内治疗术成功后1周内行肠系膜上静脉－下腔静脉间人造血管“H”型分流术。结果：11例患,除1例在腔内治疗后出现轻度心功能不全表现外,无手术并发症,术后随访6－35个月,血管内支架通畅、无移位,分流血管无血栓栓塞,门脉高压症状明显缓解,患生活质量提高。结论：腔内血管技术是肝静脉回流障碍综合征的首选治疗方法。     

Hepatic artery angiography and embolization for hemobilia after hepatobiliary surgery

目的　观察血管造影和肝动脉栓塞术对胆道术后胆道出血的诊断和治疗价值。方法　 9例在胆道手术后 7天到 3个月出现上消化道出血。所有患者行急诊肝动脉造影并采用明胶海绵和微钢圈进行肝动脉栓塞治疗。结果　肝动脉造影检查可见肝动脉假性动脉瘤 3例 ;肝动脉弥漫性出血 3例 ;右肝动脉胆道瘘 2例和肝动脉小肠瘘 1例。通过肝动脉栓塞控制胆道出血 7例 ,其中 1例再出血。 7例患者随访其中 3例死于多功能脏器衰竭。 2例因技术原因无法止血 ,数天后死亡。结论　胆道手术后出现上消化道出血如怀疑是胆道出血 ,应首先采用肝动脉血管造影检查 ,同时尽可能早地采用选择性肝动脉栓塞术治疗胆道出血 ,可获得较好的临床效果。     

电解可脱卸弹簧圈栓塞治疗颅内破裂动脉瘤的疗效及影响因素

目的：探讨电解可脱卸弹簧圈（Guglielmi detachable coil,GDC）栓塞治疗颅内破裂动脉瘤的近期疗效及相关影响因素。方法：应用GDC栓塞治疗123例157枚动脉瘤,分析动脉瘤几何形态学、病情严重程度对栓塞效果及临床治疗的影响。结果：Hunt-Hess分级Ⅰ-Ⅱ级患中,预后良好（GOS＞3分）为100％,Ⅲ、Ⅳ-Ⅴ级患中分别为95．0％、76．0％;窄颈动脉瘤完全栓塞率、大部栓塞率及部分栓塞率分别为92．4％、5．7％、1．9％,宽颈动脉瘤中分别为80．8％、13．5％、5．8％,大动脉瘤的疗效明显低于小动脉瘤。结论：动脉瘤的栓塞程度不仅与瘤颈大小有关,还受瘤体大小的影响。而临床预后与Hunt-Hess分级呈负相关。     

急诊冠状动脉内支架植入治疗急性心肌梗死——围术期死亡和近期预后的研究

为评价急性心肌梗死(AMI)患者急诊经皮冠状动脉腔内成形(PTCA)和冠状动脉内支架植入围术期死亡和近期预后的影响因素,通过对74例行急诊冠状动脉内支架植入的AMI,术后6个月内的临床随访和冠状动脉造影随访,进行多因素相关回归分析。结果表明,多支病变患者的糖尿病、高血压和高血脂的合并比例明显高于单支病变患者;总围术期内死亡率为5.4％,剔除合并心源性休克患者后,死亡率为1.4％;12例75岁以上的患者中,2例死于心源性休克,1例死于心脏破裂,5例心源性休克患者死亡3例;术中非致命性合并症的发生率在单支和多支病变组之间差异无显著性(P>0.05);多元回归分析表明血流动力学状态和患者的年龄是决定AMI患者围术期死亡的独立相关因素;多支病变患者术后6个月内心脏事件发生率明显高于单支病变组;术前和术后6个月内的患者左心室射血分数(LVEF)明显改善;而且单支和多支病变组之间术后6个月时的LVEF之间无显著性差异。     

肝癌化疗栓塞术对肝脏血流动力学和储备功能的影响

1目的　探讨化疗栓塞术对肝癌病人肝脏血流动力学和肝储备功能 (HFR)的影响。2方法　对 17例肝癌病人行肝动脉插管化疗栓塞治疗 ,采用彩色多谱勒血流显像仪 (CDFI)显像、CT扫描测量的方法对栓塞前后的血流动力学和肝实质丢失率 (PHER)的改变进行临床观察。3结果　门静脉和脾静脉血流量、血流速度均于栓塞7d后明显上升 ,并达到高峰 (F=14.86～ 332 .5 5 ,q=6 .48～ 36 .43,P<0 .0 1) ,以后逐渐回落至栓塞前水平 ,而血管内径于栓塞前后无明显改变 ;门静脉充血指数 (CI)于栓塞前后无明显改变 (t=1.45 ,P>0 .0 5 ) ;栓塞后 PHER为10 .6 3%～ 43.83% ,平均 2 6 .13% ,多数病人 PHER<40 %时 ,栓塞后 HFR能满足术后代偿需要。4结论　对门静脉血流动力学的定量分析为肝动脉化疗栓塞术的预后估计提供了重要资料。综合 PHER可以正确评估栓塞对肝脏HFR的影响。