HIFU消融MR T2WI不同信号子宫肌瘤的临床疗效及安全性分析

目的探讨HIFU对MR T2WI不同信号子宫肌瘤的消融效果及安全性。方法对156例患者共210个子宫肌瘤行HIFU消融治疗。根据术前MR T2WI表现分为低信号组、等信号组、高信号组及混杂信号组,比较各组间术前肌瘤体积、术中消融治疗参数(声源功率、辐照时间、治疗剂量及治疗强度)、能效因子、术后消融率、肌瘤缩小率及术中、术后不良反应发生率的差异。结果 4组间术前肌瘤体积(χ~2=14.720,P=0.002)、术中辐照时间(F=10.422,P0.001)、治疗剂量(χ~2=30.973,P0.001)、能效因子(F=3.953,P=0.009)、消融率(F=4.313,P=0.006)差异均有统计学意义。低信号组术前肌瘤体积明显小于高信号组(P=0.032)及混杂信号组(P=0.029);高信号组术中辐照时间明显长于低信号组(P0.001)及混杂信号组(P=0.006),治疗剂量明显大于低信号组(P0.001)、等信号组(P=0.023)及混杂信号组(P=0.013)。高信号组能效因子明显高于且消融率明显低于低信号组(P=0.016、0.003)、等信号组(P=0.012、0.006)及混杂信号组(P=0.002、0.003)。术中及术后均无严重并发症发生,且4组间放射痛、皮肤烫伤、治疗区疼痛等术中不良反应及阴道排液、下腹部疼痛、骶尾部疼痛等术后不良反应差异均无统计学意义(P均0.05)。结论 HIFU治疗对MR T2WI不同信号的子宫肌瘤均安全、有效。但其中高信号肌瘤消融难度较大,术后疗效相对较差。     

高强度聚焦超声治疗子宫肌瘤后腹壁T2WI表现影响因素

目的 观察高强度聚焦超声(HIFU)治疗子宫肌瘤后腹壁T2WI表现的影响因素。方法 回顾性分析541例因子宫肌瘤接受HIFU治疗患者治疗前后盆腔MRI及HIFU治疗相关资料,根据腹壁T2WI信号有无改变将其分为信号改变组及信号正常组,采用单因素及多因素回归分析腹壁T2WI表现的相关影响因素。结果 135例(135/541,24.95%)信号改变,包括70例(70/135,51.85%)腹壁脂肪层、21例(21/135,15.56%)腹壁肌肉层、44例(44/135,32.59%)腹壁脂肪层及肌肉层信号改变,可见腹壁T2WI呈斑片状或条索状高信号、脂肪抑制(FS)-T2WI呈稍高或混杂高信号;406例(406/541,75.05%)T2WI腹壁信号正常。组间年龄、体质量指数、腹壁厚度、腹壁脂肪厚度、生产史、腹壁瘢痕、子宫肌瘤T2WI信号、HIFU平均功率、治疗时间、辐照时间、治疗强度、治疗剂量、治疗体积及术中皮肤灼烧感差异均有统计学意义(P均<0.05)。腹壁瘢痕、腹壁脂肪厚度、子宫肌瘤T2WI信号、HIFU平均功率、辐照时间、治疗强度、治疗体积及术中皮肤灼烧感均为子宫肌瘤HIFU治疗后腹壁T2WI表现的独立影响因素(P均<0.05)。结论 腹壁瘢痕、腹壁脂肪厚度、肌瘤T2WI信号、HIFU平均功率、辐照时间、治疗强度、治疗体积及术中皮肤灼烧感为子宫肌瘤HIFU治疗后腹壁T2WI表现的影响因素。     

HIFU消融治疗不同MRI特征子宫肌瘤的效果

目的探讨HIFU消融治疗不同MRI特征子宫肌瘤的效果。方法回顾性分析经HIFU治疗的96例子宫肌瘤患者资料,比较HIFU治疗不同位置、类型、MRI信号特征和强化程度的子宫肌瘤的消融率和能效因子,并评估其安全性。结果平均肌瘤体积、消融率、能效因子分别为(107.14±70.85)cm3、(72.48±11.04)%和(7.45±3.05)J/mm3。不同位置、类型、信号特征和强化程度的子宫肌瘤之间,HIFU消融率和能效因子差异均有统计学意义(P均0.05),对前壁、肌壁间、T2WI低信号、T1WI轻度强化肌瘤的消融率更高、能效因子更低(P均0.05)。术中、术后未发现严重不良反应。结论 HIFU治疗子宫肌瘤相对安全,消融效果确切,其对前壁、肌壁间、T2WI低信号、T1WI轻度强化的子宫肌瘤的消融效果更好。     

HIFU消融子宫肌瘤后浆肌层损伤对消融治疗有效性及安全性的影响

目的探讨HIFU消融子宫肌瘤后浆肌层损伤对消融治疗有效性及安全性的影响。方法对400例接受HIFU消融治疗的子宫肌瘤患者,依据术后增强MR T1WI显示子宫肌层灌注全时段矢状位或轴位图像上子宫浆肌层是否出现灌注缺损分为损伤组和完整组。比较2组间患者年龄、体质量指数(BMI)、子宫肌瘤位置、类型(浆膜下、黏膜下及肌壁间肌瘤)、体积、肌瘤前缘至前腹壁的距离、消融参数(功率、总剂量)、消融后肌瘤无灌注区体积(NPV)、消融率、能效因子、术后并发症及患者术后妊娠率的差异。结果损伤组90例,完整组310例。2组间患者年龄、子宫肌瘤体积、肌瘤前缘至前腹壁的距离、HIFU消融功率、NPV差异均无统计学意义(P均0.05),宫肌瘤位置及类型差异均有统计学意义(P均0.05);损伤组较完整组患者BMI及消融率更高(P均0.05)、HIFU消融总剂量及EEF更低(P均0.05)。2组均未出现国际介入放射治疗学会(SIR)分级C～F级并发症,发热、骶尾部疼痛、下腹部疼痛等SIR A、B级并发症差异均无统计学意义(P均0.05);术后妊娠率分别为5.56%(5/90)及2.26%(7/310),差异无统计学意义(χ~2=1.596,P=0.206),无妊娠及分娩相关不良事件发生。结论 HIFU消融子宫肌瘤后可能出现子宫浆肌层损伤,高BMI、位于宫底的浆膜下肌瘤、易消融肌瘤(消融剂量及EEF低、消融率高)HIFU消融术后浆肌层损伤风险高。浆肌层损伤对于术后妊娠及分娩并无显著影响。     

丙酸睾丸酮在高强度聚焦超声治疗子宫肌瘤中的临床应用

目的探讨高强度聚焦超声(HIFU)治疗子宫肌瘤前辅助应用丙酸睾丸酮的临床价值。方法将60例子宫肌瘤患者随机分为两组,HIFU治疗前联合丙酸睾丸酮治疗(研究组)或仅接受单纯HIFU治疗(对照组)。观察并记录HIFU治疗参数指标、发生凝固性坏死时的声像图灰阶改变、术中不良反应及术后并发症,测量并计算肌瘤内无灌注区体积、消融率、治疗后6个月子宫体积缩小率及肌瘤体积缩小率,并进行统计学分析。结果两组间HIFU治疗的治疗功率、治疗时间、辐照时间、治疗强度、治疗剂量差异均无统计学意义(P均0.05)。研究组出现团状强回声的比例[53.33%(16/30)]高于对照组[26.67%(8/30),2χ=4.444,P=0.035]。两组间出现团状强回声的辐照时间、治疗过程中患者不良反应、治疗后肌瘤内无灌注区体积、消融率、治疗后6个月子宫体积缩小率及肌瘤体积缩小率差异均无统计学意义(P均0.05)。两组中HIFU治疗后并发症患者均经对症治疗后好转,无严重并发症发生。结论 HIFU治疗子宫肌瘤前辅助应用丙酸睾丸酮并不能有效提高消融率及治疗后肌瘤体积缩小率,但在一定程度上有利于治疗中团状强回声的出现。     

MR T2WI信号特征预测HIFU消融治疗子宫腺肌病疗效

目的探讨MR T2WI信号特征对HIFU消融治疗子宫腺肌病疗效的预测作用。方法 502例接受HIFU消融治疗的子宫腺肌病患者,根据术前MR T2WI信号特征分为Ⅰ组(以低信号为主,可有少量等信号)和Ⅱ组(以等信号为主,可有少量低信号);每组进一步分为A(无稍高和极高信号)、B(有稍高信号)、C(有极高或极高合并稍高信号)亚组。分析子宫腺肌病T2WI信号特征与超声消融效果和参数的关系。结果Ⅰ组与Ⅱ组病灶体积消融率(NPVR)差异无统计学意义(t=-0.504,P=0.612)。两组中A亚组NPVR均高于B亚组及C亚组(Ⅰ组:LSD-t=2.608、3.677,P=0.009、0.001;Ⅱ组:LSD-t=3.255、3.778,P=0.001、0.001),B亚组与C亚组NPVR差异无统计学意义(Ⅰ组:LSD-t=-0.852,P=0.395;Ⅱ组:LSD-t=0.278,P=0.781)。Ⅰ组与Ⅱ组辐照时间、总消融剂量和能效因子(EEF)差异均无统计学意义(辐照时间:t=-1.716,P=0.087;总消融剂量:t=-1.676,P=0.094;EEF:Z=0.044,P=0.965);两组A亚组辐照时间、总消融剂量和EEF均低于B亚组及C亚组(P均0.05),B亚组与C亚组辐照时间、总消融剂量和EEF差异均无统计学意义(P均0.05)。结论 MR T2WI信号特征对HIFU消融治疗子宫腺肌病难易程度和消融效果具有重要预测作用。     

高强度聚焦超声治疗子宫肌瘤致腹壁皮肤热损伤的影响因素

目的 分析高强度聚焦超声(HIFU)治疗子宫肌瘤致腹壁皮肤热损伤的影响因素。方法 回顾性分析260例接受HIFU治疗的子宫肌瘤患者,对比52例治疗后出现治疗区域腹壁皮肤热损伤(皮损组)与208例无皮肤热损伤患者(对照组)的一般资料、肌瘤特征及治疗相关参数,采用多因素logistic回归分析发生皮肤热损伤的影响因素。结果 组间腹壁瘢痕及皮下脂肪厚度、肌瘤T2WI呈高/混杂信号、治疗时间、辐照时间、治疗能量及声通道疼痛反应差异均有统计学意义(P均<0.05);多因素分析显示,腹壁瘢痕[OR=2.956, 95%CI(1.460,5.986),P=0.003]和皮下脂肪厚度[OR=1.050,95%CI(1.015,1.086),P=0.005]、肌瘤T2WI呈高/混杂信号[OR=2.250,95%CI(1.164,4.349),P=0.016]及声通道疼痛反应[OR=4.670,95%CI(2.360,9.241),P<0.001]均为皮肤热损伤的独立影响因素。结论 HIFU治疗子宫肌瘤时,患者腹壁瘢痕及皮下脂肪厚度、肌瘤T2WI信号及声通道疼痛反应均为致腹壁皮肤热损伤的影响因...     

高强度聚焦超声消融单发性子宫肌瘤能效因子的影响因素

目的分析单发性子宫肌瘤高强度聚焦超声(HIFU)消融过程中能效因子(EEF)的影响因素。方法回顾性分析218例接受HIFU治疗的单发性子宫肌瘤患者。选择可能影响EEF的因素作为自变量,以EEF为因变量,采用Stepwise regression方法建立多重线性回归模型。结果 HIFU治疗平均EEF为(7.62±5.39)J/mm3。6个预测因子被引入多重线性回归模型,包括靶皮距、前倾位(子宫位置)、贯穿型(肌瘤类型)、肌瘤最大径、低信号(T2WI信号强度)及增强T1WI强化程度。其中EEF与靶皮距、增强T1WI强化程度、贯穿型(肌瘤类型)呈正相关,与肌瘤最大径、低信号(T2WI信号强度)、前倾位(子宫位置)呈负相关,且肌瘤最大径对EEF影响最大(标准系数为-0.292)。结论对子宫呈前倾位且肌瘤血供少、含水量低、最大径长、靶皮距小的非贯穿型单发性子宫肌瘤,HIFU消融EEF小,难度低。     

HIFU消融不同T2WI信号子宫肌瘤疗效差异的组织声学性质

目的探讨HIFU消融T2WI低、等、高信号子宫肌瘤组织声衰减和声速的差异。方法收集经手术切除的子宫肌瘤标本45个。对患者术前行MR检查,根据T2WI信号强度将肌瘤分为低信号、等信号、高信号3种类型。采用插入取代式脉冲传输法测量肌瘤标本的声速和声衰减。结果 45个子宫肌瘤标本中,T2WI低信号肌瘤7个,等信号肌瘤9个,高信号肌瘤29个,其组织声速分别为(1 597.86±15.17)m/s、(1 586.70±10.83)m/s、(1 576.57±10.06)m/s,低、等信号肌瘤组织与高信号肌瘤组织比较差异均有统计学意义(P均0.05);声衰减分别为(4.03±1.34)dB/cm、(2.54±1.17)dB/cm、(1.04±0.66)dB/cm,低和等信号肌瘤组织与高信号肌瘤组织、低信号肌瘤组织与等信号肌瘤组织比较差异均有统计学意义(P均0.05)。结论 T2WI低、等、高信号子宫肌瘤组织声速、声衰减的差异可能是导致HIFU消融子宫肌瘤疗效差异的重要原因。     

高强度聚焦超声治疗子宫肌瘤对骶骨影响因素探讨

目的探讨HIFU治疗子宫肌瘤影响骶骨MR的因素。方法子宫肌瘤患者52例,根据子宫位置分为前位、后位、中位三组;依肌瘤位置分为前壁、后壁、侧壁三组;按肌瘤类型分为肌壁间肌瘤、浆膜下肌瘤、黏膜下肌瘤三组;根据肌瘤体积分为〈47 mm3和≥47 mm3两组;按肌瘤距骶骨的距离分为〈30 mm,≥30 mm两组;按HIFU辐照时间分为〈2500 s和≥2500 s两组;根据治疗能量分为〈700 000 J和≥700 000 J两组;按治疗最大功率分为〈340 W和≥340 W两组。采用χ2检验分析骶骨影响的相关因素。结果〈30 mm组较≥30 mm组易导致骶骨出现异常MR信号（P〈0.01）;HIFU辐照时间≥2500 s较易引起骶骨MR异常信号;治疗能量≥700 000 J较易导致骶骨MR异常信号;骶骨MR异常信号与子宫位置、肌瘤位置、肌瘤类型、肌瘤体积及HIFU治疗最大功率无显著相关性（P〉0.05）。结论肌瘤骶骨间的距离、HIFU治疗能量、辐照时间在高强度聚焦超声治疗子宫肌瘤中可能对患者骶骨出现异常MR信号起一定的作用。     

Congenital high scapula

Congenital high scapula is also known as Sprengel's deformity. The elevation of the scapula is accompanied by its rotation to a varus position. A series of 19 cases is presented, with 4 bilateral cases. A modified Woodward procedure was performed in all the surgical cases using the basic Woodward technique modified by correcting the tilting of the glena. The operative results were judged on cosmetic and functional criteria. The age of the patients and the presence of an omovertebral bone did not influence the results. Associated cervical spine anomalies were of negative prognosis. Results in this series showed only three fair or poor results; the other cases (79%) were all improved cosmetically and functionally with normal shoulder abduction following reorientation of the scapulo-humeral joint.     

浮线对口引流顶端挂线治疗高位后马蹄形肛周脓肿（附50例报告）

目的探讨高位后马蹄形肛周脓肿的手术方法。方法齿线处内口以下部位完全切开、内口以上部位脓腔顶端挂线,后位切口虚挂橡皮筋对口引流。结果50例全部治愈,疗程15～35 d,无后遗肛瘘,无肛门失禁、狭窄、畸形、缺损,肛门功能正常。结论手术一次性成功,避免了二期手术,缩短疗程,减轻患者需多次手术痛苦,术后随访至今,无复发,肛门功能良好。     

High risk plaque, high risk patient or high risk procedure?

SAPPHIRE, a randomised trial of endarterectomy versus angioplasty in 'high-risk' patients, concluded that angioplasty was 'not inferior' to surgery. This has subsequently been translated to mean that angioplasty was 'preferable' or 'advisable' in patients considered high-risk for surgery, with no further discrimination between symptomatic and asymptomatic individuals. Moreover, there have been suggestions that the accepted procedural risks may have to be increased in these patients. In fact, 71% of patients in SAPPHIRE were asymptomatic in whom there was an average 6% 30-day death/stroke rate. At this level of risk, neither surgery nor angioplasty could ever prevent long-term stroke. The concept of identifying high-risk patients is laudable, but they should be high risk for stroke (i.e. symptomatic). There is currently little systematic evidence to include asymptomatic patients within this definition.     

Early high urinary diversion

In many cases of long-standing upper urinary tract obstruction, indications for high urinary diversion become evident at an early age. However, because of existing continuity of urinary tract and stable (although usually abnormal) renal function, there is a tendency to avoid surgical intervention. Frequently, it is only when renal function markedly deteriorates that high urinary diversion is considered, and many times it is too late to prevent complete renal failure. Since most patients are in the pediatric age group, we are becoming aware that early high urinary diversion in the face of poorly draining upper tracts may not only increase renal function, but also ultimately save the patient's life.     

The high hip center

Revision of a failed acetabular component presents many challenges to the arthroplasty surgeon. The goal in most cases should be to reconstruct the acetabulum by positioning the hip center as close as possible to the anatomic hip center. However, severe acetabular bone stock deficiency and distorted acetabular anatomy often preclude placement of the acetabular component at the true anatomic hip center. In these cases, many options exist for reconstruction of the acetabulum, including placement of the cup superiorly at a high hip center. Although biomechanical studies have shown that superolateral placement of the hip center may lead to increased moments and forces across the hip (leading to potentially higher rates of loosening), superior only displacement of the hip center does not seem to adversely affect the forces about the hip. Proximal placement of the hip center facilitates contact between intact, viable host bone and the acetabular implant, thereby reducing the need for structural bone grafts, and increasing the chances for stable bony ingrowth. With proper patient selection and meticulous surgical technique, the high hip center can be a useful technique for reconstruction of the deficient acetabulum in the patient with a loose acetabular component after total hip arthroplasty.