联合胸降主动脉节段置换的T4期食管癌根治术36例临床分析

目的总结T4期侵犯胸降主动脉的局部晚期食管癌手术的治疗经验,探讨同期行降主动脉节段切除及人造血管置换的应用方法和操作技巧。方法回顾分析我院2001年1月至2010年12月36例在食管癌手术同时行胸降主动脉部分切除置换患者的手术方法和治疗结果。所有患者均采用左后外侧切口经第6肋间进胸,由胸降主动脉左侧切开血管外膜,切断相应肋间动脉,常温下在受累主动脉上、下分别阻断,切除食管肿瘤及受累主动脉,并行人造血管置换。胃充分游离后,经食管床上提至左颈部与食管残端吻合。结果本组均顺利完成根治性肿瘤切除,无围术期死亡,无截瘫、肾脏及肠道功能衰竭等严重并发症,出现乳糜胸2例,晚期吻合口瘘1例。术后住院时间10．0～42．0d,平均（15．5±7．2）d。术后病理检查均为鳞状细胞癌,均侵犯主动脉外膜,9例（25％,9／36）有中层浸润,全组未发现内膜受侵,有区域淋巴结转移者19例（52．8％,19／36）。患者1、3、5年生存率分别为80．6％、46．2％、20．0％。结论对于侵犯胸降主动脉的局部晚期食管癌,可联合采用主动脉节段切除并人造血管重建的方法达到根治目的,提高肿瘤切除率,改善患者生活质量和远期治疗效果。     

同期非体外循环下降主动脉置换治疗侵犯主动脉的局部晚期食管癌

目的:总结T4期侵犯降主动脉的食管癌同期应用非体外循环下降主动脉置换行食管癌根治的方法和经验。方法:对26例T4期侵犯主动脉的局部晚期食管癌患者常规行左侧开胸,于非体外循环下阻断降主动脉,行受侵主动脉段切除、人工血管置换,再行食管癌切除、食管-胃左颈部吻合。结果:26例患者术后未出现主动脉瘘、吻合口瘘、截瘫等严重并发症,均于2周内顺利恢复,3年及5年生存率分别为40.0%和21.4%,中位生存时间为35个月。结论:对于食管癌侵犯主动脉的患者,在有条件的情况下,同期降主动脉置换合并食管癌根治可延长患者生存时间、改善生存质量。     

"杂交"手术治疗DeBakey Ⅰ型主动脉夹层

目的 总结应用无深低温停循环的升主动脉置换、升主动脉-主动脉弓分支血管旁路、腔内隔绝的"杂交"手术治疗DeBakey Ⅰ型主动脉夹层的方法和经验.方法 2009年1月至2010年6月,39例、平均年龄(55±16)岁的DeBakey Ⅰ型主动脉夹层病人进行无深低温停循环的"杂交"手术.病人经股动脉、右腋动脉插管灌注,先于常规体外循环下行升主动脉和主动脉瓣置换,再采用四分支人工血管、"Y"形人工血管或单根人工血管行升主动脉-主动脉弓分支血管旁路手术,再经股动脉逆行径路数字减影血管造影(DSA)下或术中顺行径路食管超声定位下行主动脉弓-降主动脉腔内隔绝术.结果 全组均手术成功,升主动脉处理时8例行单纯升主动脉人工血管置换,20例行Bentall手术(其中冠状动脉移位采用Carbrol法11例),11例行Wheat手术;升主动脉-主动脉弓分支血管旁路手术采用四分支人工血管16例、"Y"形人工血管15例、单根人工血管序贯法8例;主动脉弓-降主动脉腔内隔绝术采用DSA下股动脉逆行径路36例,术中人工血管分支顺行径路3例,均使用1枚支架.体外循环(61±22)min,主动脉阻断(48±18)min.术后(30±9)h拔除气管插管,24 h胸液小于300 ml,无偏瘫、截瘫、严重感染、凝血障碍等并发症.所有病人均治愈出院,平均术后(21±6)天出院.术后随访1～15个月,平均(8.4±7.2)个月,病人均健康生存,无脏器功能不全.术后3个月行CT主动脉血管成像检查,显示膈肌水平假腔闭合率为91.2%.结论 常温体外循环下升主动脉置换、升主动脉-弓部血管旁路、腔内隔绝的"杂交"手术治疗DeBakey Ⅰ型主动脉夹层,简化了DeBakey Ⅰ型主动脉夹层外科治疗方法,该手术方法避免了深低温停循环,减少了术后并发症,提高了外科治疗效果.

Abstract：

Objective Some major procedures for DeBakey type Ⅰ aortic dissection used to be performed with deep hypothermic circulatory arrest, which had been associated with more complications than seen with standard extracorporeal circulation. We reviewed the cases who received the treatment for DeBakey type Ⅰ aortic dissection by hybrid procedure without deep hypothermic circulatory arrest. The procedure consisted of ascending aorta replacement, ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion. Methods From January 2009 to June 2010, 39 patients [mean age (55 ±16) years] who had DeBakey Ⅰ aortic dissection underwent hybrid procedure without deep hypothermic circulatory arrest. The femoral artery and right axillary artery were cannulated for perfusion. The ascending aorta and/or aortic valves were replaced under conventional extracorporeal circulation with Bentall procedure or Wheat procedure. The aortic arch branch vessels were dissected and the proximal part was sealed. Then the ascending aorta-aortic arch branch vascular bypasses were constructed with 4-bifurcation vascular grafts, Y-shape bifurcated vascular grafts or artificial vessels. Finally the endovascular grafts were deployed via the femoral incisions monitored dynamically with DSA, or via the ascending aortic bifurcated vessels monitored with transesophageal echocardiography. Results The operation succeeded in all 39 patients. Eight patients underwent ascending aorta replacement without aortic valve replacement or prosthesis, 20 patients underwent Bentall procedure ( Carbrol procedure were used in 11 cases), and 11 underwent Wheat procedure. For ascending aorta-aortic branch vascular bypass reconstruction, sequential anastomoses were performed in 8, Y-shaped bifurcated grafts were used in 15, and 4-bifurcated grafts were employed in 16 patients. The endovascular stent grafts were deployed via the former femoral incisions in 36 patients and via ascending aortic bifurcated vessels in 3. The cardiopulmonary bypass time was (61 ±22) minutes, the aortic crossclamp time was (48 ±18) minutes, and the post-operative intubation time was (30 ±9) hours. The thoracic drainage from each patient was less than 300 ml in 24 hours. No complication, such as hemiplegia, paraplegia, severe infections, renal failure or coagulation disorder, was observed. The duration of hospitalization was (21 ±6) days. No hospital death occurred. Follow-up was performed 1 to 15 months [mean (8.4 ±7.2) months] postoperatively. All patients survived without any organ dysfunction at follow up. The CTA examination 3 months after operation revealed that the false lumens had been closed in 91.2% of the patients. Conclusion Our findings indicated that the hybrid procedure, which combining ascending aorta replacement,ascending aorta-aortic arch branch vascular bypass reconstruction and endovascular graft exclusion under conventional extracorporeal circulation, may be an option for avoiding the possible complications associated with profound hypothermic circulatory arrest. The novel hybrid operation may improve the surgical outcomes and provide a simplified surgical approach for the treatment of DeBakey Ⅰ aortic dissection.     

C-myc siRNA抑制大鼠自体移植静脉再狭窄的研究

目的静脉移植术后c-myc基因持续高表达是导致血管内膜增生进而再狭窄的原因之一。文中探讨通过局部给药方法给予针对c-myc基因的小分子干扰RNA(siRNA)对自体移植静脉内膜增生的影响。方法建立SD大鼠自体颈外静脉-颈总动脉移植模型。32只大鼠按移植静脉外膜局部给药不同处理方式方法分为未处理组(No treatment组)、凝胶组(Gel组)、无义序列组(scramble sequence group,SCR组)、c-myc RNA干扰组(C-myc siRNA组),于术后3周处死大鼠取移植静脉,光学显微镜下测量内膜厚度,免疫组化染色检测移植静脉增殖细胞核抗原(proliferating cell nuclear antigen,PCNA)、c-myc蛋白的表达,Q-RT-PCR检测移植静脉c-myc mRNA的含量。结果 C-myc siRNA组内膜厚度[(15.0±2.2)μm]显著低于No treatment组[(58.3±8.3)μm]、SCR组[(60.5±6.1)μm]和Gel组[(63.5±5.4)μm]。C-myc siRNA组静脉内膜区和中膜区PCNA阳性细胞率显著低于SCR组[分别为(8.4±2.2)%vs(68.5±5.0)%,P<0.05和(15.0±3.1)%vs(55.2±7.5)%,P<0.05],c-myc蛋白阳性细胞率C-myc siRNA组显著低于SCR组[(30.6±2.6)%vs(48.5±3.5)%,P<0.05]。C-myc siRNA组移植静脉中c-myc mRNA的表达相对量显著低于SCR组(0.48±0.05 vs 1.00±0.12,P<0.05)。结论C-myc siRNA能抑制移植静脉中平滑肌细胞的增殖,抑制内膜的增生,减轻移植静脉再狭窄程度。     

体外循环导致大鼠小肠微循环损伤的机制研究

目的定量分析研究体外循环（CPB）对小肠微循环功能的影响,并初步探讨其可能的微观病理生理机制。方法建立大鼠常温CPB模型,20只大鼠均分为对照组和CPB组,以异硫氰酸荧光素标记牛白蛋白及吖啶橙作为示踪剂,分别标记血浆及白细胞,并采用活体荧光显微镜技术,在CPB前、CPB30min、CPB60min、CPB后60min、CPB后120min,定量分析小肠壁小动脉直径、收集静脉红细胞流速、功能毛细血管密度、毛细血管通透性、白细胞附壁情况。结果CPB可以使肠壁小动脉直径减小,收集静脉血流速度减慢,黏膜及肌层功能毛细血管密度减低,血管壁通透性增加及大量白细胞附壁,转流停止后120min,各项改变达到峰值。结论常温CPB可以导致大鼠明显而持续的小肠微循环损伤,血流重新分配和炎性细胞浸润可能是最主要的致伤因素。     

心脏移植术后的免疫治疗与监测

同种异体原位心脏移植是治疗各种原因所致终末期心脏病的有效方法。我院于１９９４年７月进行了１例同种异体原位心脏移植术,术后进行了系列化的免疫监测和正规的三联免疫治疗。现报告如下。临床资料病人男,３０岁。严重胸闷、心悸、肝脏肿大伴严重室性心律失常。经检查...     

坏死性筋膜炎的中西医治疗进展

坏死性筋膜炎是以皮肤、皮下组织和筋膜进行性坏死,很少或不累及肌肉组织为特点的感染性疾病,是外科的一种急危重症,病势凶险,病死率高.目前主要治疗手段为早期积极手术清创,联合使用广谱足量抗生素,基础营养支持,可配合负压引流及高压氧等其他治疗手段.中医在治疗坏死性筋膜炎方面有独特优势,根据疾病所处时期,辨证采用"清热解毒""...