右美托咪定联合依托咪酯对老年直肠癌根治术患者血液微转移、胃肠功能恢复和认知功能的影响

摘要 目的：探讨老年直肠癌根治术患者麻醉中使用右美托咪定联合依托咪酯,机体血液微转移、胃肠功能恢复和认知功能的变化情况。方法：根据随机数字表法将我院2020年4月~2022年2月期间收治的112例老年直肠癌根治术患者分为对照组（n=56,依托咪酯麻醉）和研究组（n=56,右美托咪定联合依托咪酯麻醉）。对比两组血液微转移情况、血流动力学、麻醉效果、胃肠功能恢复情况和认知功能情况,统计两组不良反应发生情况。结果：两组术后24 h角蛋白20（CK20）阳性表达率均降低,且研究组低于对照组（P<0.05）。两组不良反应发生率组间对比无差异（P>0.05）。研究组插管即刻、术毕即刻、拔管即刻心率（HR）、平均动脉压（MAP）均高于对照组（P<0.05）。两组气管拔管时间、呼吸恢复时间、麻醉苏醒时间组间对比差异不明显（P>0.05）。研究组进食时间、首次排气时间、肠鸣音恢复时间均较对照组更短（P<0.05）。研究组术后1 d、术后3 d简易精神状态检查量表（MMSE）评分高于对照组,术后认知功能障碍（POCD）发生率低于对照组（P<0.05）。结论：依托咪酯联合右美托咪定用于老年直肠癌根治术患者,麻醉效果较好,可维持血流动力学稳定,降低血液微转移,改善胃肠功能和认知功能。     

Alternating immunochemotherapy of advanced gastric carcinoma: A randomized comparison of carbazilquinone and PSK to carbazilquinone in patients with curative gastric resection

A total of 103 patients with advanced gastric carcinoma were randomized after curative surgery to receive an alternate administration of carbazilquinone (CQ and PSK (Krestin) or carbazilquinone alone. Each course of therapies started 1 week after the surgical operation and therapy schedules consisted of 9 courses. In each course of 6 weeks, CQ (2 mg/m²/week) was administered on day 0, 8, and 15. In combined immunochemotherapy group, PSK was given orally in 3-divided doses of 2 g/m²/day from the day of the third CQ administration for consecutive 4 weeks. Estimated survival rate and cumulative survival curve were compared utilizing the data up to 7 years after the operation. There was no overall significant difference in survival rates between the CQ plus PSK group and the CQ alone group, but a group of patients whose disease was classified as S₁ + S₂(N_1–2) survived significantly longer when treated with the combination of CQ and PSK. Neither in more advanced cases (> S₃ or > N₃) nor in cancers of early stages, the addition of PSK provided an additive effect. The favorable result obtained in one subgroup treated with PSK, suggests that the use of this agent in treating gastric cancers should be carefully evaluated in terms of serosal infiltration and nodal metastasis.     

不同水平呼气末正压对老年腹腔镜下结直肠癌根治术患者脑氧供需平衡、炎症因子和脑损伤标志物的影响

摘要 目的：探讨不同水平呼气末正压（PEEP）对老年腹腔镜下结直肠癌根治术患者脑氧供需平衡、炎症因子和脑损伤标志物的影响。方法：选择我院2019年12月-2020年12月收治的90例行腹腔镜下结直肠癌根治术患者，根据随机数字表法分为A组（n=30）、B组（n=30）、C组（n=30），每组均为压力控制容量保证（PCV-VG）模式联合小潮气量加滴定PEEP；其中C组的PEEP值为肺动态顺应性（Cdyn）滴定法下最适PEEP，B组的PEEP=5 cm H₂O，A组的PEEP=0 cm H₂O。对比三组脑氧供需平衡、炎症因子和脑损伤标志物，同时记录三组治疗期间不良反应发生率。结果：气腹后15 min（T1）、停气腹平卧位15 min（T2）时间点，B组、C组颈内静脉血氧饱和度（SjvO₂）、动脉-颈内静脉血氧含量差（AVDO₂）、局部脑组织氧饱和度（rScO₂）高于A组，且C组高于B组同时间点（P<0.05）。术后1 d，B组、C组血清白介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）水平低于A组，且C组低于B组同时间点（P<0.05）。术后1 d，B组、C组血清神经元特异性烯醇化酶（NSE）、S100β低于A组，但C组低于B组同时间点，而脑源性神经营养因子（BDNF）水平高于A组，且C组高于B组同时间点（P<0.05）。三组不良反应发生率组间对比无统计学差异（P>0.05）。结论：Cdyn滴定法下最适PEEP可维持老年腹腔镜下结直肠癌根治术患者脑氧供需平衡，减轻炎症因子分泌，降低脑损伤标志物水平，安全性较好。     

脾动脉结扎联合肝癌切除术治疗肝癌并门静脉高压症临床研究

目的:探讨脾动脉结扎联合肝癌切除术对肝癌并门静脉高压症的治疗效果和临床应用的价值。方法:对2008年10月至2013年10月期间我院收治的84例肝癌并门静脉高压症患者的资料进行回顾性分析,其中脾动脉结扎联合肝癌切除手术的患者50例为研究组,患者34例行肝癌切除及脾切断流术为对照组。比较两组治疗效果及患者术前、术后情况。结果:研究组术前白细胞计数、血小板计数、红细胞计数为(3.1±0.9)×109/L、(58.6±12.7)×109/L、(3.4±0.4)×109/L,术后2周白细胞计数、血小板计数、红细胞计数分别为(5.9±1.5)×109/L、(140.3±50.1)×109/L、(3.6±0.7)×109/L;对照组为术前白细胞计数、血小板计数、红细胞计数为(2.8±1.2)×109/L、(45.8±20.5)×109/L、(3.4±0.4)×109/L,术后2周白细胞计数、血小板计数、红细胞计数为(6.2±0.7)×109/L、(172.5±32.7)×109/L、(3.6±0.3)×109/L。研究组与对照组相比,术后2周白细胞计数、红细胞计数相比差异无统计学意义(P0.05),但术后2周血小板计数研究组低于对照组,差异有统计学意义(P0.05)。研究组术前与术后的白细胞计数、血小板计数、红细胞计数相比,差异均有统计学意义(P0.05)。研究组有17例患者出现术后并发症,占16.0%;对照组有20例患者出现术后并发症,占38.2%;两组对比差异有统计学意义(P0.05)。结论:根据病情合理选择使用脾动脉结扎联合肝癌切除术治疗肝癌并门静脉高压症,可以有效治疗肝癌和脾功能亢进,促进肝功能恢复,对延长原发性肝癌合并肝硬化脾功能亢进患者的生存时间,提高生活质量,具有重要意义。     

靶控输注静脉麻醉和腰硬联合麻醉对直肠癌根治术患者免疫功能的 影响研究

目的：探讨靶控输注静脉麻醉和腰硬联合麻醉对直肠癌根治术患者免疫功能的影响。方法：选择在我院行直肠癌根治术的 72 例患者,将其分为观察组和对照组各36 例,其中观察组给予靶控输注静脉麻醉,对照组采用腰硬联合麻醉,对两组患者手术时 间、术中出血量以及免疫球蛋白水平（IgG、IgA、IgM）、血清白介素-6 水平（IL-6）、肿瘤坏死因子-a 水平（TNF-a）以及T 细胞亚群 （CD3、CD4）水平进行对比。结果：观察组手术平均时间为（130.5± 11.7）min,术中平均出血量为（271.3± 37.8）ml,与对照组比较差 异均无统计学意义（P>0.05）;两组IgG、IgA 及IgM,在T1、T2、T3 及T4 时刻水平比较差异均无统计学意义（P>0.05）;两组IL-6、 TNF-a、CD3 及CD4 在麻醉后较T1 时均有明显变化,比较差异均有统计学意义（P<0.05）,且观察组变化较对照组更为明显,两组 比较差异有统计学意义（P<0.05）。结论：靶控输注静脉麻醉和腰硬联合麻醉对直肠癌根治术患者免疫功能均存在抑制作用,且以 抑制细胞免疫功能为主,而腰硬联合麻醉抑制作用较低,值得推广应用。     

医源性胆管损伤行肝切除术的指征探讨

医源性胆管损伤(IBDI)是腹腔镜胆囊切除术中最常见的并发症。复杂的医源性胆管损伤涉及肝汇流的中断和肝脏血管的损伤,对复杂的医源性胆管损伤患者施行的肝部分切除的目的是去除血管或感染性病变引起的肝实质纤维化和肝萎缩,可以彻底消除胆道狭窄、胆汁淤积及反复发作的胆管炎。肝切除术在医源性胆管损伤的手术治疗中并不是一个标准及必需的程序,但却应被视为对胆囊切除术后胆管损伤外科治疗中的一部分。     

The C-seal: A Biofragmentable Drain Protecting the Stapled Colorectal Anastomosis from Leakage

Colorectal anastomotic leakage (AL) is a serious complication in colorectal surgery leading to high morbidity and mortality rates¹. The incidence of AL varies between 2.5 and 20% ^2-5. Over the years, many strategies aimed at lowering the incidence of anastomotic leakage have been examined^{6, 7}.The cause of AL is probably multifactorial. Etiological factors include insufficient arterial blood supply, tension on the anastomosis, hematoma and/or infection at the anastomotic site, and co-morbid factors of the patient as diabetes and atherosclerosis⁸. Furthermore, some anastomoses may be insufficient from the start due to technical failure.Currently a new device is developed in our institute aimed at protecting the colorectal anastomosis and lowering the incidence of AL. This so called C-seal is a biofragmentable drain, which is stapled to the anastomosis with the circular stapler. It covers the luminal side of the colorectal anastomosis thereby preventing leakage.The C-seal is a thin-walled tube-like drain, with an approximate diameter of 4 cm and an approximate length of 25 cm (figure 1). It is a tubular device composed of biodegradable polyurethane. Two flaps with adhesive tape are found at one end of the tube. These flaps are used to attach the C-seal to the anvil of the circular stapler, so that after the anastomosis is made the C-seal can be pulled through the anus. The C-seal remains in situ for at least 10 days. Thereafter it will lose strength and will degrade to be secreted from the body together with the gastrointestinal natural contents.The C-seal does not prevent the formation of dehiscences. However, it prevents extravasation of faeces into the peritoneal cavity. This means that a gap at the anastomotic site does not lead to leakage.Currently, a phase II study testing the C-seal in 35 patients undergoing (colo-)rectal resection with stapled anastomosis is recruiting. The C-seal can be used in both open procedures as well as laparoscopic procedures. The C-seal is only applied in stapled anastomoses within 15cm from the anal verge. In the video, application of the C-seal is shown in an open extended sigmoid resection in a patient suffering from diverticular disease with a stenotic colon.     

Design and planned analyses of an ongoing randomized trial assessing the preventive effect of Helicobacter pylori eradication on occurrence of new gastric carcinomas after endoscopic resection

BACKGROUND: A causal relationship between Helicobacter pylori infection and gastric cancer has been established. A nonrandomized study has shown eradication of H. pylori after endoscopic resection (ER) of early gastric cancer inhibits development of new carcinomas. SUBJECTS AND METHODS: Eligible subjects are patients with H. pylori infection who are newly diagnosed with early gastric cancer and plan to have ER or who are in the post-resection follow-up phase after ER time of enrollment. Patients are randomly allocated to the eradication or the control arms (no eradication and standard of care). Patients will be evaluated by endoscopy at 0.5, 1, 2, and 3 years after randomization. Diagnosis of a new carcinoma at another site of the stomach is defined as primary endpoint, and recurrence of tumors at the resection site as a secondary endpoint. In addition to intention-to-treat and per-protocol analyses using proportional hazards models, time to recurrence will be compared between treatment and control using multiple logistic regression analyses. In the latter two situations, the models will be adjusted for the factors exerting significant influences on the results. RESULTS: Five hundred and forty-two subjects have been enrolled into the study and are being followed-up. CONCLUSIONS: This study will have the statistical power to demonstrate whether H. pylori eradication therapy exerts any clinically relevant inhibitory effects on occurrence or recurrence of gastric cancer. In addition, it will be able to test the hypothesis that H. pylori infection is a promoter in gastric carcinogenesis.     

血液系统肿瘤患者侵袭性肺部真菌感染的外科手术治疗

目的探讨怀疑肺部有侵袭性真菌感染(invasivefungalinfection,IFI)的血液恶性肿瘤患者行手术切除肺部病灶的安全性及有效性。方法分析2005年4月～2009年7月之间因血液系统肿瘤合并疑似侵袭性肺部真菌感染而接受肺切除术的10名患者,总结术后并发症及死亡率来探讨手术的有效性和安全性。结果手术均在全身麻醉下进行,5例为胸廓切开术,5例为胸腔镜下手术。3例为病灶楔形切除术,7例为肺叶切除术。术后组织病理:确诊真菌感染6例(60%),慢性细菌感染1例,3例未见明确病原菌。术后4例出现并发症:3例为轻度并发症(30%),其中2例气胸后自行吸收,1例局限性肺不张;1例严重并发症为血胸(10%)。术后30d死亡率为10%。术后真菌复发率为16%。随访至2009年8月31日,中位随访时间为3.8个月(0.7～31.1个月),4例(40%)死亡,但手术相关死亡率为0%。结论手术切除不仅有助于明确诊断而且还可以清除病灶、防止IFI复发和允许进一步的免疫抑制治疗,手术本身是安全的。