Validation de la reproductibilité de la mesure de la surface de l’orifice régurgitant par planimétrie dans l’insuffisance aortique : une étude préliminaire d’échocardiographie trans-œsophagienne tridimensionnelle

Background

Aortic regurgitation is mainly evaluated by trans-thoracic echocardiography using multi-parametric qualitative and semi quantitative tools. All those parameters can fail to meet expectations, resulting in an imperfect diagnostic reliability and assessment of aortic regurgitation severity can be challenging.

Objectives

We sought to evaluate feasibility and intra- and inter-observer reproducibility of aortic regurgitant orifice area measured by planimetry with tridimensional trans-esophageal echocardiography on patients with at least grade 2/4 aortic regurgitation.

Patients and methods

Consecutive patients with at least grade 2/4 aortic regurgitation measured by trans-thoracic echocardiography and referred for trans-esophageal echocardiography for any reason were included. Planimetric reconstructions of regurgitant orifice area were studied and reproducibility indexes between senior and junior observers were calculated.

Results

Twenty-three patients were included in this study. Intra- and inter-observer reproducibility were excellent with an ICC of 0.95 [0.88–0.98], P < 0.0001 and 0.91 [0.79–0.96], P < 0.0001, respectively. Mean length of the measurement was 6.6 ± 0.9 min [CI95% 6.23–7.01].

Conclusion

Planimetric measurement of the aortic regurgitant orifice using tridimensional trans-esophageal echocardiography seems to be feasible and has great intra- and inter-observer reproducibility. Reconstruction durations were compatible with a daily use. There is a need now to investigate the reliability of this measurement as compared with the reference technique.     

Urethral adenocarcinoma associated with intestinal-type metaplasia,case report and literature review

The presence of glandular epithelium in urinary tract biopsies poses a diagnostic challenge. Intestinal metaplasia of the urethra may be seen in many congenital, iatrogenic, and reactive conditions, as well as in association with malignant conditions such as urethral adenocarcinoma. We present a case of a 61 year-old woman presenting with microscopic hematuria. Successive biopsies showed glandular epithelium with focal atypia in close association with inflammation, but no overt malignancy. Only on surgical resection was the associated high grade adenocarcinoma revealed. When intestinal-type mucosa is present within a urinary tract biopsy, associated malignancy may be present only focally. Thorough sampling and consideration of the differential diagnosis is imperative.     

网膜填塞法闭合经自然腔道内镜手术胃壁瘘口的研究

目的应用动物模型评价网膜填塞法闭合经自然腔道内镜手术(NOTES)胃壁瘘口方法的可行性及有效性。方法 29只杂种犬经胃前壁内镜下全层切开(10 mm),经此入路完成NOTES腹腔探查术,其中12只应用网膜填塞法闭合胃壁瘘口(网膜填塞组),17只内镜钛夹闭合(钛夹组),闭合成功动物术后存活2周。比较两种胃壁瘘口闭合术的操作耗时、闭合成功率以及瘘口愈合和腹腔感染发生率。结果网膜填塞法闭合胃壁瘘口的成功率为91.7%(11/12),高于内镜下钛夹闭合方法成功率82.4%(14/17),但未见显著统计学差异(P>0.05);网膜填塞闭合法操作平均耗时(11.7±2.1)min/例次,明显低于钛夹闭合法(25.0±5.6)min/例次(P<0.05)。25只动物胃壁闭合成功后者术后均存活14 d,复查胃镜见胃壁瘘口愈合良好。处死后实验动物未发现腹腔严重感染及明显脏器损伤;网膜填塞组8只犬(72.7%,8/11)可见胃壁瘘口处胃壁浆膜面黏连,显著高于钛夹闭合组(14.3%,2/14,P<0.05)。结论网膜填塞法能有效闭合NOTES经胃壁瘘口,与传统内镜钛夹闭合法相比具有操作简单、成功率高的优点,但容易发生瘘口黏连是其明显不足。     

超声乳化白内障摘出联合CTR植入治疗高度近视并发白内障

目的：探究超声乳化白内障摘出联合囊袋张力环(CTR)植入治疗高度近视并发白内障患者的疗效,并分析其安全性。

方法：回顾性分析我院186例186眼行超声乳化白内障摘出+人工晶状体(IOL)植入治疗的高度近视并发白内障患者临床资料,其中98例98眼联合CTR植入治疗(联合组),88例88眼未联合CTR植入治疗(对照组)。记录两组术前,术后1、3、6mo时最佳矫正视力(BCVA, LogMAR)、视觉质量\〖高阶像差的均方根值(RMS)\〗、角膜内皮细胞密度,评估术后1、3、6mo时前囊口面积、IOL倾斜角变化情况,并比较两组术后前囊膜混浊、后囊膜混浊、囊袋收缩综合征等并发症发生情况差异。

结果：两组BCVA具有交互效应(P<0.05),两组术后BCVA值均较术前降低(P<0.05),且联合组术后BCVA值均低于对照组(P<0.05)。两组总高阶像差RMS具有交互效应(P<0.05),两组术后总高阶像差RMS均较术前升高(P<0.05),且联合组术后总高阶像差RMS均低于对照组(P<0.05)。两组术后前囊口面积具有交互效应(P<0.05),组内均随术后时间的延长而降低(P<0.05),且联合组术后3、6mo时均高于对照组(P<0.05)。两组术后IOL倾斜角具有交互效应(P<0.05),组内均随术后时间的延长而升高(P<0.05),且联合组术后3、6mo时均低于对照组(P<0.05)。两组术后角膜内皮细胞密度均较术前降低(P<0.05),但并无交互效应(P>0.05)。

结论：超声乳化白内障摘出+IOL植入+CTR植入术可改善高度近视并发白内障患者视觉功能,术后并发症少,疗效及安全性良好。     

经腹腹腔镜膀胱外乳头式输尿管膀胱再植术治疗输尿管开口异位1O例报告

目的：探讨输尿管开15异位患者经腹腹腔镜膀胱外乳头式输尿管膀胱再植术的可行性和临床效果。方法：对10例输尿管开口异位患者均采用经腹腹腔镜膀胱外乳头式输尿管膀胱再植术。全麻,仰卧位患侧抬高,建立腹腔镜工作通道（经肚脐5mmTrocar,经腹直肌外侧缘左侧5mm／10mmTrocar,右侧12mmTrocar）,充分游离患侧扩张输尿管,注意保护同侧正常输尿管,于靠近膀胱处离断异位开口输尿管,自同侧Trocar切口拉出腹壁,体外裁剪输尿管至大致正常直径,5／0可吸收线缝合输尿管管壁,末端制成乳头状,置入双J管后回纳腹腔;于膀胱底部后壁做全层切口,将输尿管末端乳头及双J管插入膀胱内,使用5／0可吸收线于膀胱全层与输尿管浆肌层间断吻合6～8针,吻合结束后膀胱注水测试有无漏尿,放置引流管及尿管。结果：10例手术均获成功,手术耗时90～160min,术中出血30～50ml,术后4～6天拔引流管,7～10天拔除尿管,术后1个月拔除双J管。术后随访1～11个月阴道无漏尿,尿常规正常,B超示肾积水减轻或消失。结论：重复肾输尿管开口异位患者经腹腹腔镜膀胱外乳头式输尿管膀胱再植是可行性的,临床效果等同于开放手术,且具有创伤小、恢复快、手术瘢痕基本不可见的优点。     

A Prospective Patient-centred Evaluation of Urethroplasty for Anterior Urethral Stricture Using a Validated Patient-reported Outcome Measure

Background

Studies of interventions for urethral stricture have inferred patient benefit from clinician-driven outcomes or questionnaires lacking scientifically robust evidence of their measurement properties for men with this disease.

Objective

To evaluate urethral reconstruction from the patients’ perspective using a validated patient-reported outcome measure (PROM).

Design, setting, and participants

Forty-six men with anterior urethral stricture at four UK urology centres completed the PROM before (baseline) and 2 yr after urethroplasty.

Intervention

A psychometrically robust PROM for men with urethral stricture disease.

Outcome measurements and statistical analysis

Lower urinary tract symptoms (LUTS), health status, and treatment satisfaction were measured, and paired t and Wilcoxon matched-pairs tests were used for comparative analysis.

Results and limitations

Thirty-eight men underwent urethroplasty for bulbar stricture and eight for penile stricture. The median (range) follow-up was 25 (20–30) mo. Total LUTS scores (0 = least symptomatic, 24 = most symptomatic) improved from a median of 12 at baseline to 4 at 2 yr (mean [95% confidence interval (CI)] of differences 6.6 [4.2–9.1], p < 0.0001). A total of 33 men (72%) felt their urinary symptoms interfered less with their overall quality of life, 8 (17%) reported no change, and 5 (11%) were worse 2 yr after urethroplasty. Overall, 40 men (87%) remained “satisfied” or “very satisfied” with the outcome of their operation. Health status visual analogue scale scores (100 = best imaginable health, 0 = worst) 2 yr after urethroplasty improved from a mean of 69 at baseline to 79 (mean [95% CI] of differences 10 [2–18], p = 0.018). Health state index scores (1 = full health, 0 = dead) improved from 0.79 at baseline to 0.89 at 2 yr (mean [95% CI] of differences 0.10 [0.02–0.18), p = 0.012]).

Conclusions

This is the first study to prospectively evaluate urethral reconstruction using a validated PROM. Men reported continued relief from symptoms with related improvements in overall health status 2 yr after urethroplasty. These data can be used as a provisional reference point against which urethral surgeons can benchmark their performance.     

神经内镜经鼻蝶入路切除颅底脊索瘤的临床疗效及其影响因素分析

目的探讨神经内镜经鼻蝶入路切除颅底脊索瘤的手术策略、临床疗效及其影响因素。方法回顾性分析2004年1月至2021年3月首都医科大学附属北京天坛医院神经外科采用神经内镜经鼻蝶入路切除的颅底脊索瘤患者的临床资料,共纳入373例患者(共行500例次手术)。其中2004—2019年为早期手术组,采用以肿瘤为中心的手术策略;2020—2021年为近期手术组,依据肿瘤的起源部位及其沿着颅底骨缝、神经和大血管孔道延伸生长的特点进行顺序探查和切除(探查顺序形似"龟背")。比较两种手术策略切除肿瘤程度的差异。随访患者的无进展生存期(PFS)和总生存期(OS),采用Kaplan-Meier法生存分析,采用log-rank检验分析不同临床特征患者间PFS和OS的差异。结果500例次手术中,413例次为早期手术组,肿瘤的全切除率、次全切除率、部分切除率分别为35.1%(145例次)、36.6%(151例次)、28.3%(117例次);87例次为近期手术组,肿瘤的全切除率、次全切除率、部分切除率分别为52.9%(46例次)、37.9%(33例次)、9.2%(8例次),两组肿瘤的切除率差异有统计学意义(P<0.001)。500例次手术,脑脊液漏的发生率为4.6%(23例次)。373例患者中,术后1例(0.3%)死亡,1例(0.3%)发生大面积脑梗死;共325例(87.1%)患者获得完整的随访资料,中位随访时间为31个月(3~193个月)。182例(56.0%)复发,估计总体患者的中位PFS为24个月(95%CI:17.5~30.5);85例(26.2%)死亡,估计总体患者的中位OS为106个月。生存分析显示,与原发性肿瘤、肿瘤体积小、肿瘤全切除、病理学类型为经典型或软骨型肿瘤及术后放疗的患者比较,复发性肿瘤、肿瘤体积大、肿瘤非全切除、病理学类型为去分化或差分化或肉瘤样型肿瘤及术后未行放疗患者的PFS和OS均短,差异均有统计学意义(均P<0.05)。结论依据颅底脊索瘤生长侵袭特点,采用"龟背"形顺序探查、切除肿瘤的手术策略有利于提高肿瘤的切除程度。肿瘤是否原发、体积大小、切除程度、病理学类型、术后是否放疗可能与颅底脊索瘤患者术后的PFS和OS有关。