三孔打结法腹腔镜胆囊切除术326例

目的：采用三孔打结法行腹腔镜胆囊切除术（LC），进一步减少手术创伤。方法：326例患者在全麻下采用三孔打结法行LC，脐部皮肤皱褶处截第一孔（10mm)置入腹腔镜，剑突下稍偏右截孔（5mm）为主操作孔，右锁骨中线肋缘下2cm处截孔（5mm）为辅助操作孔，借助自制的打结器，应用丝线结扎处理胆囊管及胆囊动脉，胆囊从脐部孔取出。结果：采用此方法行LC成功率达100％，手术时间无明显延长，术后恢复快。结论：三孔打结法LC是一种安全、可行的方法，此方法进一步减少了手术的创伤，有利于术后恢复。     

经脐入路腹腔镜胆囊切除术临床研究

目的：探讨经脐入路行腹腔镜胆囊切除术的可行性。方法：对6例患者采用仅在脐部切开一个切口进行腹腔镜胆囊切除术。结果：6例患者手术均获成功,无中转常规腹腔镜手术或开腹手术。手术时间80～130min,无出血、胆管损伤等并发症发生。术后1d出院,术后1月门诊随访,患者恢复顺利,除脐部外,腹壁无手术瘢痕。结论：经脐入路腹腔镜胆囊切除术技术上是可行的,但难度较大,在开展手术初期应慎重选择病例。     

腹腔镜胆囊大部切除术的应用

目的：探讨腹腔镜胆囊切除术术中某些特殊情况的处理办法。方法：分析总结该院的7例胆囊大部切除术的原因、方法、经验和体会。结果：7例手术顺利，无术后出血、胆瘘及肝外胆管损伤，平均手术时间46min（30－65min),术后恢复顺利，无严重并发症，仅1例并发穿刺孔感染，术后平均住院时间3．5d(2-5)d，随访时间3－12个月，无症状复发，效果满意。结论：在化脓性胆囊炎或胆囊三角严重粘连疤痕化等不能够常规行胆囊切除的病人，行腹腔镜胆囊大部分切除术简便而安全可行，不但能够达到胆囊切除的目的，又能减少肝外胆管和血管损伤，避免了中转开腹；但必须严格掌握适应证，正确处理胆囊残余部分。     

胆囊结石并急性胆囊炎腹腔镜手术356例

目的：探讨腹腔镜手术在治疗胆囊结石并急性胆囊炎中的应用;总结腹腔镜手术治疗胆囊结石并急性胆囊炎的临床经验。方法：回顾分析为2003-2012年356例胆囊结石并急性胆囊炎患者行腹腔镜胆囊切除术的临床资料。结果：329例成功完成手术,27例中转开腹。手术时间32～120min,平均76min,术中出血量20～100ml,术后无严重并发症发生,患者均痊愈出院。结论：胆囊结石并急性胆囊炎行腹腔镜胆囊切除术安全可行。     

三孔缝扎法腹腔镜胆囊切除术的探讨

目的：探讨三孔缝扎法腹腔镜胆囊切除术（LC）的手术方法和适应证。方法：全麻下采用三孔缝扎法行逆行法LC，脐下缘皮肤戳第一孔（10mm）置入腹腔镜，剑突下2－5cm戳孔（10mm)为主操作孔，右锁骨中线肋缘下2cm偏外2－5cm处戳孔（5mm)为辅助操作孔，借助腹腔镜弯钳和腹腔镜持针器1－0可吸收缝线腹腔内打外科结结扎和3－0可吸收缝针线缝扎双重处理胆囊管，打外科结结扎和／或缝扎单重或双重处理胆囊动脉前后分支，胆囊从剑突下孔或脐部孔取出。结果：67例中成功施行三孔缝扎法LC53例（79％），三孔结扎法LC4例，三孔钛夹法LC9例，四孔缝扎法LC1例。无手术并发症。结论：选择合适病人施行三孔缝扎法LC较安全、可行，此方法避免了钛夹和丝线的残留，减少了一个腹壁戳孔，病人容易接受。     

上腹部微瘢痕腹腔镜胆囊切除术

目的 介绍一种在上腹部无手术瘢痕的腹腔镜胆囊切除新术式.方法沿脐左右缘各做一个10mm的弧形切口,各穿刺10mm trocar,分别供操作器械和腹腔镜进出,另在右下腹置入直径5mm加长抓钳用于牵引,用普通腹腔镜器械和电凝钩完成胆囊切除,最后从脐部取出胆囊.结果 共用此法手术32例,平均手术时间50min(30~70min),无中转开腹.其中2例因粘连严重转常规三孔法手术,无出血、胆漏等并发症.术后平均住院时间4d(2~5d).随访4个月~1.5年,右下腹戳孔愈合良好,脐部看不出手术瘢痕.结论 经脐及右下腹入路胆囊切除是可行的,可达到上腹部无手术瘢痕的目的,并且手术难度明显小于经脐三孔法胆囊切除术,值得基层医院推广.     

复杂类型胆囊的非常规腹腔镜胆囊切除术

目的：探讨非常规腹腔镜胆囊切除术治疗复杂类型胆囊的可行性。方法：回顾分析我院1992年10月～2001年12月56例非常规腹腔镜胆囊切除术的临床资料：腹腔镜下逆行法胆囊切除术24例：腹腔镜胆囊大部分切除术24例，其中保留胆囊后壁的胆囊大部分切除术20例，保留胆囊颈部的胆囊大部分切除术4例；胆囊切开取石术8例。结果：本组全部治愈，无胆管损伤。术中出血20～200ml，平均出血80ml．手术时间15～150min，平均手术时间56min。术后出血2例、胆漏2例，腹腔脓肿2例，均保守治疗痊愈。结论：不适于常规腹腔镜胆囊切除术的复杂类型胆囊的腹腔镜手术，可选择非常规腹腔镜胆囊切除术，此术式治疗效果肯定。避免了胆管损伤，降低了中转开腹率，同样达到微创目的。     

经脐单孔腹腔镜胆囊切除术的护理

目的目的总结和探讨经脐单孔腹腔镜胆囊切除术的护理方法。方法使用常规腹腔镜器械对9例慢性胆囊炎患者进行经脐部入路腹腔镜胆囊切除术术后护理方法及效果。结果9例患者手术均获成功,无并发症发生,伤口愈合良好,除脐部外,腹壁无手术瘢痕。结论经脐入路腹腔镜胆囊切除术是新开展的微创手术,虽然手术操作难度较普通腹腔镜胆囊切除术大,但具有无瘢痕的优点,护理方法简单,具有良好的临床应用前景。     

经脐单孔腹腔镜胆囊切除术31例体会

目的:探讨经脐单孔腹腔镜胆囊切除术的安全性和可行性。方法:回顾分析2010年5月~2011年5月上饶肿瘤医院31例经脐单孔腹腔镜胆囊切除术的临床资料。结果:28例成功行经脐单孔腹腔镜胆囊切除术,平均时间43min;3例因暴露困难中转4孔腹腔镜胆囊切除术;1例术后3d出现胆囊窝积液,行B超引导下腹腔穿刺引流术治愈。术后随访2周~1年,无手术相关并发症,脐部切口隐藏脐凹,无可视瘢痕。结论:术前术中严格掌握适应证,由经验丰富的腹腔镜医师开展,经脐单孔腹腔镜胆囊切除术具有微创、美观等优点,安全可行,疗效确切。     

腹腔镜胆囊阑尾联合切除30例分析

目的：探讨腹腔镜胆囊阑尾联合切除术的临床疗效。方法30例腹腔镜胆囊和阑尾联合切除术的患者,全麻后脐上缘置入10 mm trocar 放入30°腹腔镜,剑突下2 cm处置入强生一次性12 mm trocar自肝缘韧带右侧穿出,作为主操作孔,脐水平线近右腋前线相交处置5 mm trocar 作为辅助孔,常规行腹腔镜胆囊切除术。将腹腔镜移至剑突下trocar,脐部trocar 改作主操作孔置入超声刀,右中腹trocar 置牵拉钳,超声刀切除阑尾系膜及根部。结果30例手术均获成功,手术时间40~88分钟,平均49分钟,术中出血10~30 ml,术后住院3~8天,平均3天。30例随访7~11个月,平均9个月,无并发症。结论腹腔镜胆囊阑尾联合切除术效果好,术后恢复快。     

微型腹腔镜治疗小儿斜疝1 500例

目的 介绍开展腹腔镜治疗小儿斜疝的经验和体会。方法 使用微型腹腔镜配合改进的针形器械缝扎内环口周边腹膜治疗小儿斜疝1500例。结果 1500例均经腹腔镜下完成，手术时间5～13min，平均9min，随访3个月～4年半，复发12例，疝囊积液2例。没有腹部并发症。结论 腹腔镜治疗小斜疝创伤小、恢复快、手术时间短、伤口美观、复发率低，值得推广。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.