内镜黏膜下剥离术和挖除术治疗上消化道肿瘤的疗效及安全性分析

目的:分析内镜黏膜下剥离术(ESD)和黏膜下挖除术(ESE)治疗上消化道肿瘤的疗效及安全性。方法:回顾性分析2017年1月至2019年4月我院消化内科接受ESD或ESE治疗的68例上消化道肿瘤住院患者的临床资料,收集患者基础疾病、手术时间、病变部位大小、整块切除率、并发症等资料,同时采用Logistic回归分析对术中穿孔进行危险因素分析。结果:64例患者完整切除瘤体(94.12%),肿瘤平均直径(16.98±8.29)mm。食管病灶病理类型以高级别上皮内瘤变为主,有15例(22.06%);胃部病灶分布以胃体、胃底和胃窦居多,分别有18例(26.47%)、16例(23.53%)和12例(17.65%),病理类型以间质瘤最多,占36.76%;11例患者发生并发症(16.18%),4例患者出现术后出血(5.88%),经过内镜下止血后好转,8例患术中穿孔(11.76%),均行内镜下尼龙绳联合钛夹行荷包缝合,其中1例患者术中穿孔合并术后迟发性出血;病灶最大直径(≥25 mm,P=0.036)和病灶部位(胃底,P=0.015)是导致ESD或ESE术中穿孔的独立危险因素。结论:ESD和ESE治疗上消化道肿瘤安全有效,但需注意病灶大小和胃底病变,因其是导致术中穿孔的独立危险因素。     

超声内镜辅助下内镜黏膜下切除术对食管癌前病变患者肿瘤标志物及应激反应指标的影响

目的:探讨超声内镜(EUS)辅助下内镜黏膜下切除术(EMR)对食管癌前病变患者肿瘤标志物及应激反应指标的影响。方法:选择山东大学齐鲁医院青岛院区消化内科于2016年3月至2018年4月期间收治的食管癌前病变患者137例,采用随机数字表法将患者分为常规组(n=68,常规胃镜下行EMR)和EUS组(n=69,EUS辅助下行EMR),比较两组患者临床指标,比较两组术前、术后血清肿瘤标志物及应激反应指标水平,比较两组术前、术后1周相关遗传学分子水平。结果:EUS组手术时间、术后流质饮食时间均短于常规组(P0.05),并发食管黏膜小穿孔例数、使用钛夹止血例数均少于常规组(P0.05)。两组患者术后肿瘤特异性生长因子(TSGF)、细胞角蛋白19血清片段21-1(CYFRA21-1)、鳞状上皮细胞癌抗原(SCC-Ag)均较术前升高,但EUS组低于常规组(P0.05)。两组患者术后肾上腺素(E)、去甲肾上腺素(NE)、肾素(R)、血管紧张素Ⅱ(AngⅡ)、醛固酮均较术前升高,但EUS组低于常规组(P0.05)。两组患者术后1周细胞周期素E(Cyclin E)、转化生长因子-α(TGF-α)均较术前降低,且EUS组低于常规组(P0.05)。结论:相比于常规胃镜,经EUS辅助下EMR治疗食管癌前病变可有效改善患者的临床指标,减轻患者应激反应,有利于降低血清肿瘤标志物及遗传学分子水平。     

两种内镜手术对消化道神经内分泌肿瘤的切除效果及安全性评价

目的:探讨内镜下两种手术方法对消化道神经内分泌肿瘤的切除效果和安全性。方法:选取64例消化道神经内分泌肿瘤患者,随机分为A组和B组,每组各32例。A组接受内镜下黏膜切除术,B组接受内镜下黏膜剥离术。分析和比较两组所切除组织的病理学检查结果、手术时间、切除肿瘤的直径和厚度、治疗费用、住院时间、肿瘤完全切除率、垂直切缘阴性率以及并发症的发生率。结果:A组的手术时间为(8.95±1.63) min,治疗费用为(2127.70±468.31)元,均显著少于B组(P0.05);两组患者切除肿瘤直径和厚度、住院时间、垂直切缘阴性率对比差异均没有统计学意义(P0.05);B组的肿瘤完全切除率为93.75%,显著高于A组(P0.05);A组并发症发生率为3.13%,显著低于B组(P0.05)。结论:两种内镜下手术方式均可有效清除消化道神经内分泌肿瘤病灶。内镜下黏膜切除术的手术时间、费用及并发症的发生率更少低,而内镜下黏膜剥离术能够更彻底地清除肿瘤组织。     

Numerical simulation of two-phase non-Newtonian blood flow with fluid-structure interaction in aortic dissection

The behavior of blood cells and vessel compliance significantly influence hemodynamic parameters, which are closely related to the development of aortic dissection. Here the two-phase non-Newtonian model and the fluid-structure interaction (FSI) method are coupled to simulate blood flow in a patient-specific dissected aorta. Moreover, three-element Windkessel model is applied to reproduce physiological pressure waves. Important hemodynamic indicators, such as the spatial distribution of red blood cells (RBCs) and vessel wall displacement, which greatly influence the hemodynamic characteristics are analyzed. Results show that the proximal false lumen near the entry tear appears to be a vortex zone with a relatively lower volume fraction of RBCs, a low time-averaged wall shear stress (TAWSS) and a high oscillatory shear index (OSI), providing a suitable physical environment for the formation of atherosclerosis. The highest TAWSS is located in the narrow area of the distal true lumen which might cause further dilation. TAWSS distributions in the FSI model and the rigid wall model show similar trend, while there is a significant difference for the OSI distributions. We suggest that an integrated model is essential to simulate blood flow in a more realistic physiological environment with the ultimate aim of guiding clinical treatment.     

全胸腔镜下肺叶切除联合系统淋巴清扫对肺癌患者血清疼痛相关因子和免疫功能的影响及预后的影响因素分析

摘要 目的：探讨全胸腔镜下肺叶切除（VATS）联合系统淋巴清扫对肺癌患者血清疼痛相关因子和免疫功能的影响,并分析预后的影响因素。方法：选择我院于2014年3月~2016年3月期间收治的肺癌患者116例,采用随机数字表法分为对照组和研究组,各58例。对照组患者给予传统开胸肺叶切除联合系统淋巴清扫治疗,研究组给予VATS联合系统淋巴清扫治疗,对比两组手术相关指标、血清疼痛相关因子和免疫功能,随访记录研究组患者5年生存率,分析预后的影响因素。结果：与对照组相比,研究组手术时间更长,术中出血量更少,术后住院时间、切口长度、引流时间更短（P<0.05）。两组术后1 d去甲肾上腺素（NE）、前列腺素E2（PGE2）、P物质（SP）、皮质醇（Cor）水平均较术前升高,但研究组低于对照组（P<0.05）。两组术后1 d CD3⁺、CD4⁺、CD4⁺/CD8⁺均较术前降低,但研究组高于对照组,CD8+较术前升高,但研究组低于对照组（P<0.05）。单因素分析结果可知：研究组患者的预后与组织分化、吸烟史、病灶直径、临床分期、清扫淋巴结个数有关（P<0.05）。多因素Logistic回归分析结果可知：临床分期、清扫淋巴结个数是研究组患者预后的影响因素（P<0.05）。结论：ATS联合系统淋巴清扫可减轻肺癌患者术后疼痛及免疫抑制,虽然手术时间更长,但可以改善其他围术期指标。此外,临床分期、清扫淋巴结个数是患者预后的影响因素,应引起临床重视。     

老年胆总管结石患者ERCP治疗前后炎性因子、免疫功能的变化及术后并发胰腺炎的危险因素研究

摘要 目的：观察老年胆总管结石患者经内镜逆行胰胆管造影术（ERCP）治疗后,炎性因子、免疫功能的变化,并分析术后并发胰腺炎的危险因素。方法：纳入2015年3月~2021年5月期间来我院接受治疗的老年胆总管结石患者250例,均接受ERCP治疗,观察治疗前后炎性因子、免疫功能的变化,记录两组一次性取石成功率、术中出血量、手术时间、住院时间及术后并发症发生率。采用多因素Logistic回归分析术后并发胰腺炎的危险因素。结果：本次研究纳入的患者一次性取石成功率为96.80%（242/250）,术中出血量（16.57±1.34）ml,手术时间（46.38±5.19）min,住院时间（8.82±1.35）d。术后并发症发生率12.80%（32/250）。治疗后,患者的CD3⁺、CD4⁺、CD4⁺/CD8⁺较治疗前升高,CD8⁺较治疗前下降（P<0.05）。治疗后,患者的血清白介素-6（IL-6）、C反应蛋白（CRP）和肿瘤坏死因子-α（TNF-α）水平较治疗前下降（P<0.05）。按照ERCP术后是否并发胰腺炎进行分组,其中26例发生胰腺炎的患者纳为并发组,未并发胰腺炎的224例纳为未并发组。单因素分析结果显示,ERCP术后并发胰腺炎与胰管显影、性别、胆总管结石病史、体质量指数（BMI）、Oddi括约肌功能障碍（SOD）病史、ERCP手术时间、多次插管、胰腺炎病史、导丝进入胰管、阻塞性黄疸有关（P<0.05）。多因素Logistic回归分析结果显示：SOD病史、性别为女、BMI≥30 kg/m²、胰腺炎病史、ERCP手术时间≥60 min、多次插管、胰管显影是ERCP术后并发胰腺炎的危险因素（P<0.05）。结论：ERCP治疗老年胆总管结石患者,疗效显著,术中出血量少,患者术后恢复较快,但患者术后有一定的并发症发生,主要以胰腺炎为主。且术后并发胰腺炎的危险因素较多,可采取适当措施改进操作环节,减少术后胰腺炎的发生。     

胃炎性纤维性息肉的临床特征及内镜下诊治

摘要 目的：研究胃炎性纤维性息肉（IFP）的临床特征及内镜下诊断和治疗情况。方法：收集2010.1.1~2021.1.1陕西省人民医院确诊的11例IFP,重点分析其超声内镜表现及临床特征,探索其内镜下治疗价值。结果：IFP多发生在胃窦,均发生于40岁以上人群,男女比例无明显差别,平均直径1.2 cm,大部分临床无症状,有时可引起出血或腹痛。超声内镜示其为粘膜下隆起,孤立、界清,表面多光滑,均起源于粘膜下层,呈低回声,界清,类圆形;内镜下粘膜挖除术治疗IFP,手术时间短,恢复快,并获得完整的标本,术后病理有助确诊。结论：胃炎性纤维性息肉多发生40岁以上人群,多为胃窦孤立的粘膜下病变,多无症状,超声内镜有助于IFP的术前精确评估,内镜下粘膜挖除术是治疗IFP一项安全有效的方法,术后病理最终确诊。     

Intermediate fenestrations reduce flow reversal in a silicone model of Stanford Type B aortic dissection

Pulsatile, three-dimensional hemodynamic forces influence thrombosis, and may dictate progression of aortic dissection. Intimal flap fenestration and blood pressure are clinically relevant variables in this pathology, yet their effects on dissection hemodynamics are poorly understood. The goal of this study was to characterize these effects on flow in dissection models to better guide interventions to prevent aneurysm formation and false lumen flow. Silicone models of aortic dissection with mobile intimal flap were fabricated based on patient images and installed in a flow loop with pulsatile flow. Flow fields were acquired via 4-dimensional flow MRI, allowing for quantification and visualization of relevant fluid mechanics. Pulsatile vortices and jet-like structures were observed at fenestrations immediately past the proximal entry tear. False lumen flow reversal was significantly reduced with the addition of fenestrations, from 19.2 ± 3.3% in two-tear dissections to 4.67 ± 1.5% and 4.87 ± 1.7% with each subsequent fenestration. In contrast, increasing pressure did not cause appreciable differences in flow rates, flow reversal, and vortex formation. Increasing the number of intermediate tears decreased flow reversal as compared to two-tear dissection, which may prevent false lumen thrombosis, promoting persistent false lumen flow. Vortices were noted to result from transluminal fluid motion at distal tear sites, which may lead to degeneration of the opposing wall. Increasing pressure did not affect measured flow patterns, but may contribute to stress concentrations in the aortic wall. The functional and anatomic assessment of disease with 4D MRI may aid in stratifying patient risk in this population.     

Bicarbonate and chloride secretion in Calu-3 human airway epithelial cells

Serous cells are the predominant site of cystic fibrosis transmembrane conductance regulator expression in the airways, and they make a significant contribution to the volume, composition, and consistency of the submucosal gland secretions. We have employed the human airway serous cell line Calu-3 as a model system to investigate the mechanisms of serous cell anion secretion. Forskolin-stimulated Calu-3 cells secrete HCO-3 by a Cl-offdependent, serosal Na+-dependent, serosal bumetanide-insensitive, and serosal 4,4'-dinitrostilben-2,2'-disulfonic acid (DNDS)-sensitive, electrogenic mechanism as judged by transepithelial currents, isotopic fluxes, and the results of ion substitution, pharmacology, and pH studies. Similar studies revealed that stimulation of Calu-3 cells with 1-ethyl-2-benzimidazolinone (1-EBIO), an activator of basolateral membrane Ca2+-activated K+ channels, reduced HCO-3 secretion and caused the secretion of Cl- by a bumetanide-sensitive, electrogenic mechanism. Nystatin permeabilization of Calu-3 monolayers demonstrated 1-EBIO activated a charybdotoxin- and clotrimazole- inhibited basolateral membrane K+ current. Patch-clamp studies confirmed the presence of an intermediate conductance inwardly rectified K+ channel with this pharmacological profile. We propose that hyperpolarization of the basolateral membrane voltage elicits a switch from HCO-3 secretion to Cl- secretion because the uptake of HCO-3 across the basolateral membrane is mediated by a 4,4 '-dinitrostilben-2,2'-disulfonic acid (DNDS)-sensitive Na+:HCO-3 cotransporter. Since the stoichiometry reported for Na+:HCO-3 cotransport is 1:2 or 1:3, hyperpolarization of the basolateral membrane potential by 1-EBIO would inhibit HCO-3 entry and favor the secretion of Cl-. Therefore, differential regulation of the basolateral membrane K+ conductance by secretory agonists could provide a means of stimulating HCO-3 and Cl- secretion. In this context, cystic fibrosis transmembrane conductance regulator could serve as both a HCO-3 and a Cl- channel, mediating the apical membrane exit of either anion depending on basolateral membrane anion entry mechanisms and the driving forces that prevail. If these results with Calu-3 cells accurately reflect the transport properties of native submucosal gland serous cells, then HCO-3 secretion in the human airways warrants greater attention.     

细胞内铜/锌超氧化物歧化酶在人胸主动脉夹层的表达研究

目的:探讨细胞内铜/锌超氧化物岐化酶(copper zinc superoxide dismutase,Cu/Zn-SOD,SOD-1)在人胸主动脉夹层(humanthoracic aortic dissection,hTAD)中的表达情况及其在hTAD中的可能作用。方法:蛋白质印迹法(Western blot,WB)检测SOD-1在TAD和正常人胸主动脉(NA)中膜组织中的表达情况,免疫组织化学染色(immunohistochemistry,IHC)验证SOD-1在动脉壁中的表达和定位。结果:蛋白质印迹和免疫组化染色均显示SOD-1在TAD组表达量较NA组减低(P<0.05);免疫组化染色进一步显示,SOD-1主要位于主动脉壁中膜平滑肌细胞的胞质内,其在夹层主动脉壁中膜撕开处表达缺失。结论:SOD-1在TAD中表达量减少,可能由于参与氧化应激引起的脂质过氧化和炎症反应,以及细胞外基质(extracellular matrix,ECM)的降解等机制所致。