87例意外胆囊癌多中心诊疗分析

目的 分析多中心意外胆囊癌（IGBC）病例治疗现状,探讨IGBC的诊断与治疗要点。方法回顾性分析2013年1月至2020年6月上海市浦东新区6家医院收治的87例IGBC患者临床资料,男27例（31.03%）,女60例（68.97%）;年龄34～89岁,平均68岁。术前诊断为胆囊结石伴胆囊炎67例,其中合并胆总管结石9例;胆囊息肉4例;胆囊腺肌症5例;胆囊结石合并胆囊息肉8例;慢性胆囊炎2例。术前87例患者均行B超检查;26例行CT检查,其中6例发现胆囊壁局部或不规则增厚;术前行肿瘤标志物检测52例,CA199升高7例（67～238 kU/L）。结果 同期6家医院行腹腔镜胆囊切除术（LC）16 411例,IGBC占比0.53%;同期胆囊癌根治术219例,IGBC占比39.73%。87例IGBC中,急诊LC 25例（28.74%）,择期LC62例（71.26%）;术中冰冻病理发现IGBC 70例,术后常规病理发现IGBC 17例;行胆囊癌根治术65例,未行根治术22例。术后病理检查,Tis期15例,T1期20例,T2期28例,T3期22例,T4期2例。45例获得随访,随访时间3～96个月,中位时间26个月。T分期越早,生存期越长（P=0.01039）,根治性手术明显改善患者的生存期（P=0.00423）。结论 意外胆囊癌应从胆囊良性疾病的规范化诊治角度入手防治,才能减少其发生;根治手术能提高意外胆囊癌患者术后的生存期。     

腹腔镜胆囊切除术意外胆囊癌58例诊治分析

[摘 要] 目的 探讨腹腔镜胆囊切除术（LC）意外胆囊癌的诊断与治疗。方法 回顾性分析2007 年5 月至2017 年5 月武警安徽省总队医院收治的意外胆囊癌患者58 例临床资料。结果 LC术中发现24 例,术后发现34例;TNM分期T1b 12例,T2 34例,T3 6例,T4 6例。24例术中快速冰冻病理检查证实为胆囊癌,其中22例中转开腹行胆囊癌根治术;34例术后病理证实,其中24例行二次开腹手术。非根治组：12例,仅行单纯胆囊切除术,术后1、2、3年累积生存率分别为65.0%、42.5%、18.0%。根治组：46例,行胆囊癌根治术,术后1、2、3年累积生存率分别为82.5%、62.5%、45.7%,两组生存曲线比较差异有统计学意义（P＜0.05）。结论 胆囊癌患者预后与手术方式、临床分期密切相关,对存在胆囊癌高危因素的患者,建议尽早行胆囊切除术。意外胆囊癌多为早期胆囊癌,应重视术中检查及病理检查,T1b～T3 期宜行根治手术,晚期患者应根据病情行姑息手术。     

原发性胆囊癌63例诊治分析

目的 总结原发性胆囊癌的诊治经验,探讨其诊断与治疗的有效途径.方法 回顾性分析我院1994年1月至2005年6月外科治疗的63例原发性胆囊癌患者的临床病理资料.结果 本组中有69.8%(44/63)患者合并胆囊结石.最常见的症状为腹痛、黄疸及消瘦.全部63例病人术前均行B超检查,诊断符合率为68.3%(43/63),有18例病人术前同时行cT或MRCP检查,诊断符合率为83.3%(15/18).早期癌(Nevin Ⅰ,Ⅱ期)10例(15.9%),中晚期癌(NevinⅢ～Ⅴ期)53例(84.1%).10例行单纯胆囊切除术,26例行胆囊癌根治术,4例行扩大胆囊癌根治术,23例行姑息性手术,晚期(Ⅳ～Ⅴ期)病例中有13例行根治术和4例行扩大根治术,根治切除率为42.5%(17/40).术后39例患者获得随访,其中早期胆囊癌的1年生存率(83.3%)明显高于中晚期胆囊癌(27.3%)(83.3% vs 27.3%,P＜0.05),晚期胆囊癌中行根治性切除患者的1年生存率(55.6%)明显高于只行姑息性手术者(55.6% vs 11.8%,P＜0.05)(11.8%).结论 提高胆囊癌疗效的关键在于早期诊断,B超和CT等结合可提高胆囊癌的诊断率.对有恶变倾向的胆囊结石患者,应行预防性胆囊切除,积极的根治性或扩大根治性手术有助于改善中晚期病例的预后.     

胆囊癌危险因素的单中心回顾性分析

目的:探讨胆囊癌相关的危险因素,为该疾病的防治提供理论依据。方法:采用病例对照研究方法,选取2009年1月—2017年12月就诊于中南大学湘雅医院诊断为胆囊癌的316例患者以及同期就诊的316例年龄组成、性别比例与前者相近的其他疾病患者,分析胆囊癌发病相关危险因素分析。结果:316例胆囊癌患者平均年龄(60.2±10.6)岁,50岁及以上患者占82.28%,男女比例为1:1.95,156例(49.4%)合并胆囊结石,其中胆囊充填型结石30例。单因素及多因素分析显示,胆囊结石是胆囊癌唯一的危险因素(OR=6.72,95%CI=4.52~10.02,P0.01)。在研究时间范围内胆囊癌合并胆囊结石患者例数呈先上升后下降趋势,每年占胆囊癌患者总例数比例基本一致;女性胆囊癌患者中合并胆囊结石比例较男性高(P0.01)。胆囊癌合并胆囊结石患者中未行根治性手术以及TNM分期为ⅢB、Ⅳ期的比例均较胆囊癌非胆囊结石患者高(均P0.05)。结石直径越大或充填型结石的发生胆囊癌的相对危险度增加(均P0.05)。结论:胆囊结石可能是胆囊癌的主要危险因素之一。随着胆囊结石直径的增大、数目的增多,患胆囊癌的风险也在增加。胆囊癌合并胆囊结石的患者分期相对较晚,对于发展为胆囊癌相对危险度较高的结石类型,建议及时行手术治疗。     

黄色肉芽肿性胆囊炎78例临床分析北大核心CSCD

目的探讨黄色肉芽肿性胆囊炎（xanthogranulomatouscholecystitis,XGC）的病因、诊断及治疗。方法回顾性分析1985年1月至2012年12月78例经病理确诊的XGC患者的临床资料。结果78例患者均行B超检查,其中50例同时行CT检查,术前诊断：慢性结石性胆囊炎60例,胆囊癌伴胆囊结石8例,胆囊占位性病变10例。术前诊断胆囊结石的68例中胆囊颈结石并嵌顿者达67例,占98．5％,由于胆汁淤积、渗入破损的胆囊壁,可引起XGC的发生。78例均行手术治疗：胆囊切除术48例,胆囊部分切除或大部切除术13例,胆囊切除加肝脏部分楔形切除术12例,胆囊与周围粘连成块状误诊为胆囊癌行肝脏部分切除术5例;其中合并胆总管结石17例同时行胆总管切开取石术;损伤肝总管2例同时行胆管空肠Roux—en—Y形吻合术。78例手术或易或难,可顺利完成,无严重并发症。结论XGC是一种特殊类型慢性胆囊炎,并伴黄色肉芽肿形成。术前诊断困难,术中快速冷冻或术后石蜡切片病理检查是诊断的关键手段。     

原发性胆囊癌43例临床分析

胆囊癌是预后最差的消化道恶性肿瘤之一,早期发现并进行手术治疗,是降低其死亡率的关键[1].我们回顾分析了2000-2003年我科收治的43例手术治疗的原发性胆囊癌患者的临床病例资料,现报告如下. 1临床资料 1.1一般资料 本组43例,男性10例,女性33例,年龄40～82岁,中位年龄6l岁.合并胆囊结石并/或胆管结石者占51.2%(22/43)、梗阻性黄疸44.2%(19/43). 1.2影像学检查 本组有22例胆囊癌得到病理证实,术前B超检查诊断符合率为63.6%(14/22),CT检查诊断符合率为70.6%(12/17).其余21例依据病史、临床表现、B超和cT检查获得胆囊癌临床诊断.     

小切口胆囊切开取石术在高龄患者中的应用

高龄胆囊结石患者常伴有重要脏器的功能不全 ,在胆囊结石急性发作时 ,即使是胆囊切除也难以耐受。为探索微创安全的治疗方法 ,本文回顾总结了自 1988年 10月～ 2 0 0 0年 9月因难以耐受胆囊切除而采用小切口胆囊切开取石术患者 39例 ,随访时间 5～ 12年 ,无结石复发 ,现报告如下。临床资料1.一般资料 :本组男 13例 ,女 2 6例。年龄 6 7～ 89岁 ,平均78岁。术前均行 B超或 B超加 CT检查诊断为胆囊泥沙样结石6例 ,单发结石 7例 ,多发结石 2 6例 ,伴急性胆囊炎者 31例 ,胆绞痛者 8例 ;合并糖尿病者 9例 ,合并糖尿病酮症酸中毒者 1例 ,合并心…     

术后确诊胆囊癌的临床特点及治疗决策

胆囊癌极易按良性病的胆囊结石、胆囊炎实施规范单纯胆囊切除。现将本院自 1 986年以来胆囊切除术后经病理证实胆囊癌 1 0例 ,报告如下。1　临床资料1 .1　一般资料本组 1 0例 ,男 2例 ,女 8例 ;男∶女 1∶ 4,年龄2 5～ 80岁 ,平均 6 2 .5岁 ,其中 >5 0岁者占 70 % (7/1 0 )。 9例合并结石 ,并存率为 90 % ,7例为多发性结石 ;2例为单发结石 ,直径均 >2 cm。胆囊炎病史 >5年者 6例 ,以发作性腹痛、腹胀为临床表现者占70 % (7/1 0 ) ,3例以急腹症为表现 ,其中 1例伴轻度黄疸。病程中分别行 1～ 1 0次 B超检查 ,结果均无对胆囊癌有诊断意义的…     

原发性胆囊癌62例诊治体会

原发性胆囊癌是胆道恶性肿瘤最多见的一种类型,早期胆囊癌行根治性手术术后5年生存率可达100%,而晚期胆囊癌5年生存率只有5%左右。因此早期诊断是提高疗效,改善预后的关键[1]。我们总结了我院1993年1月至2003年12月收治的原发性胆囊癌62例临床资料,对其诊断与治疗加以探讨。临床资料1.一般资料:本组62例,男25例,女37例。年龄31～85岁,平均58.4岁。合并胆囊结石43例(69.35%),胆囊息肉恶变7例(11.29%)。首发症状以上腹痛或右上腹痛最为常见,共31例,其次为黄疸27例。生化检查:总胆红素升高27例,转氨酶升高25例。B超检查62例,诊断胆囊癌45例,诊…     

胆囊癌仅行腹腔镜胆囊切除术的长期疗效观察

目的观察胆囊癌患者仅行腹腔镜胆囊切除术(LC)后的长期疗效。方法回顾性分析北京协和医院基本外科1998年1月至2018年12月期间收治且符合纳入标准的52例仅行了LC的胆囊癌患者的临床病理资料。结果本研究共纳入52例患者,其中男23例,女29例,年龄(67±12)岁。52例患者均因胆囊占位、胆囊结石等原因行LC治疗。有23例患者为术后意外胆囊癌,有29例患者术前或术中即诊断为胆囊癌。11例T1a期术后意外胆囊癌患者接受密切随诊,其余41例患者因高龄、基础疾病重、自身意愿等原因拒绝行根治性手术。52例患者的LC均顺利完成。术后5例患者发生了Clavien-DindoⅠ级并发症。52例患者随访(40.2±33.8)个月,随访期内有31例患者死亡,有21例仍存活;相较于存活患者,死亡患者的年龄更大、住院时间更长、肿瘤分期更晚(P0.050),T1a期患者的生存期要显著优于T1b及以上分期患者(113.5个月比39.6个月,P0.001)。结论 LC在T1a期胆囊癌患者中可达到根治效果,同时因LC手术操作安全、术后并发症少,还可使部分特殊患者达到追求术后生活质量的要求。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.