腹腔镜再手术治疗复发性食管裂孔疝1例报告

1临床资料 患者女,56岁。因腹腔镜胃底折叠术后2年,胃内容物反流伴上腹部烧灼感1年9个月于2006年6月入我院。患者于外院行“腹腔镜食管裂孔疝修补联合胃底折叠术（Nissen）”。但术后3个月起再次出现反流症状,以平卧位为重。1年后自觉反流症状进一步加重,合用胃黏膜保护剂及质子泵抑制剂方可控制症状。     

改良Nissen胃底折叠术治疗胃食管反流病的短期疗效分析

目的:探讨腹腔镜改良Nissen胃底折叠术治疗胃食管反流病的短期疗效。方法:回顾分析2020年6月至2021年11月接受腹腔镜改良Nissen胃底折叠术的81例患者的临床资料，比较术前、术后反流症状及术后并发症的7级李克特量表评分，统计质子泵抑制剂药物的服用情况及对手术的满意程度。结果:患者术后胃食管反流病相关症状的评分均低于治疗前(P<0.05);术后大部分患者出现不同程度的吞咽困难，其中症状不可忽略的吞咽流食困难比例为6.2%,症状不可忽略的吞咽固体困难比例为63%;术后新发腹胀、便秘与腹泻的比例分别为37%、18.5%与11.1%,均为自限性；术后DeMeester评分、酸反流时间百分比及反流总次数均较术前有所改善，术后食管下括约肌压力、食管下括约肌长度及食管下括约肌腹段长度较术前增加；术后6个月体重下降(3.8±3.27)kg(P<0.05),术后6个月身体质量指数下降(1.4±1.31)kg/m²(P<0.05),不同身体质量指数分组间身体质量指数变化值与体重变化值的分布不完全相同；术后6个月质子泵抑制剂停药率为96.3%,疗效满意率为...     

胃折叠术在肥胖治疗中的应用进展

作为目前治疗肥胖最有效的方法, 减重手术术式众多, 但由于大部分的术式引起胃肠道解剖的巨大改变, 使得其存在一定的并发症风险。为了追求更小的创伤, 减重外科医生在经典术式之外开始探索胃折叠手术。胃折叠手术包括胃底折叠术、胃大弯折叠术、内镜下胃成形术、胃底折叠术联合胃大弯折叠术、胃底折叠术联合袖状胃切除术等多种术式, 其疗效和并发症的风险介于药物治疗和袖状胃切除手术之间。胃底折叠术作为一种抗反流的术式, 也可参与到减重手术治疗中, 有效改善肥胖患者和减重手术相关胃食管反流病。胃大弯折叠术和内镜下胃成形术均有很好的减重效果。除了折叠术式本身对体质量的影响, 胃折叠术还能与其他的术式联合。胃底折叠术联合袖状胃切除和胃大弯折叠术, 可降低体质量并减少反流;胃大弯折叠术联合胃旁路等术式, 也可更加有效地降低体质量, 改善代谢。     

胃食管反流性疾病的腹腔镜胃底折叠术治疗

目的探讨中、重度胃食管反流性疾病行腹腔镜胃底折叠术治疗的可行性及安全性.方法回顾性分析2001年6月至2006年6月对137例中、重度胃食管反流性疾病病人行腹腔镜胃底折叠术的的临床资料.结果121例行腹腔镜Nissen胃底折叠术,16例作腹腔镜Toupet胃底折叠术.术后症状完全缓解.术后4个月,食管下段压力由7.28±1.32 mmHg提高到19.01±3.39 mmHg(t=11.69,P＜0.01).24 h pH值监测评分由181.76±95.47降低至8.13±1.96(t=8.38,P＜0.01),较手术前有明显改善,并达到正常范围.长期随访临床效果良好.无严重手术并发症,无中转开腹及死亡病例.结论对于严重的胃食管反流性疾病,腹腔镜胃底折叠术是一种微创、安全、有效的治疗方法.     

胃食管反流病的腹腔镜外科治疗

目的:探讨腹腔镜手术治疗胃食管反流病的临床效果.方法:回顾性分析2008年1月—2011年9月对33例胃食管反流病患者行腹腔镜食管裂孔疝修补和胃底折叠术的临床资料.腹腔镜单纯胃底折叠术5例(Toupet式),腹腔镜食管裂孔疝修补加胃底折叠术25例(Nissen式3例,Toupet式22例),腹腔镜单纯食管裂孔疝修补术3例.结果:全组患者手术均获成功,手术时间90～185 min.术后平均住院6d.无中转开腹及死亡病例,无术后严重并发症.术后随访1～24个月,32例临床症状完全消失,1例明显好转.结论:对于胃食管反流性疾病,腹腔镜食管裂孔疝修补和胃底折叠术是一种微创、安全、有效的治疗方法.     

腹腔镜胃底折叠术治疗儿童严重胃食管反流的现状

自1991年Geage[1]和Dallemagne[2]等相继报道应用腹腔镜胃底折叠术治疗成人严重胃食管反流后,Lobe等[3]1993年报道应用腹腔镜开展儿童Nissen's胃底折叠术,并显示较经典的开腹手术具有明显的优点.在以后的10年中,腹腔镜胃底折叠术治疗儿童保守治疗无效的严重胃食管反流在欧美国家迅速流行和普及.     

腹腔镜胃底折叠术治疗胃食管反流性疾病临床分析

目的　探讨腹腔镜胃底折叠术治疗胃食管反流性疾病的可行性及安全性。　方法　回顾性分析 2 0 0 1年 6月至 2 0 0 1年 10月对 5例行腹腔镜胃底折叠术的胃食管反流性疾病的临床资料。　结果　 3例行腹腔镜Nissen胃底折叠术 ,2例腹腔镜Toupet胃底折叠术。术后症状完全缓解。食道下段压力由 (7 32± 1 34)mmHg提高到 (18 2 0± 3 4 3)mmHg(t=12 2 3,P <0 0 1) ,2 4 -小时PH值监测评分由183 36± 96 76降低到 8 0 4± 2 12 (t=8 4 7,P <0 0 1) ,较手术前有明显改善 ,并达到正常范围。无手术并发症 ,无中转开腹及死亡病例。　结论　对于严重的胃食管反流性疾病 ,腹腔镜胃底折叠术是一种安全、有效的治疗方法。     

腹腔镜抗反流手术猪动物训练模型的建立

目的 分享建立用猪作腹腔镜抗反流手术动物训练模型的经验.方法 对6头小猪全身麻醉下进行腹腔镜下食管裂孔疝修补术,Nissen胃底折叠术,Toupet胃底折叠术,Dor胃底折叠术.记录术中并发症的发生情况、手术步骤、手术重点、技术难点,注意事项等.结果 成功完成腹腔镜食管裂孔疝修补术6次,Nissen胃底折叠术6次,Toupet胃底折叠术6次,Dor胃底折叠术6次.均未出现严重术中并发症.手术时间随着训练次数明显缩短.结论 腹腔镜抗反流手术猪动物训练模型的建立是可行的,手术具有可逆性、可重复操作性等特点,可以为外科医生提供极佳训练机会,明显缩短掌握手术技术时间.     

腹腔镜胃底折叠术治疗胃食管反流病

目的探讨腹腔镜胃底折叠术治疗胃食管反流病的临床效果。方法2008年1月-2011年11月对40例胃食管反流病行腹腔镜胃底折叠术。腹腔镜单纯胃底折叠术7例（Toupt式）,腹腔镜食管裂孔疝修补加胃底折叠术33例（Nissen式5例,Toupet式28例）。结果手术均获成功,无中转开腹及死亡病例,无术后严重并发症。手术时间75～215min,平均112min;术中出血量10-350ml,平均52ml;术后住院5—10d,平均7d。40例术后随访1—24个月,平均16个月,34例临床症状完全消失,6例症状明显好转。结论腹腔镜胃底折叠术治疗胃食管反流病疗效满意。     

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目的观察腹腔镜胃底折叠抗反流手术联合胃袖状切除术对动物模型的可行性和安全性。方法 2013年12月至2014年5月在柯惠上海临床培训中心及奥林巴斯上海实验室对8只小猪行腹腔镜下保留部分胃底的胃袖状切除术联合食管裂孔疝修补术及不同类型胃底折叠术(包括Nissen、Toupet、Dor胃底折叠术)。记录术中情况、手术步骤、技术难点及注意事项等。结果成功完成小猪腹腔镜胃袖状切除术和食管裂孔疝缝合修补术8次,不同类型胃底折叠术24次,即Nissen胃底折叠术、Toupet胃底折叠及Dor胃底前折叠术各8次。无一例中转开腹,所有实验动物均在手术中生命体征保持平稳,平均手术时间为(120.2±13.7)min,出血量为5~80(35.8±11.1)m L。术中1只发生肝损伤出血,其余均未发生脏器损伤及吻合口漏。手术时间随着训练次数明显缩短。结论腹腔镜胃底折叠抗反流手术联合胃袖状切除术对小猪动物模型安全可行,可为临床医师提供极佳训练机会,有助于缩短学习曲线,可能成为治疗肥胖合并胃食管反流病或食管裂孔疝的新型抗反流手术方法。     

中晚期肝癌转化治疗中的几个焦点问题

我国大部分肝癌患者初诊时已处于中晚期,失去了通过手术切除获得长期生存的机会。当前系统治疗的发展、局部治疗技术的进步有望让更多中晚期不可切除肝癌患者从转化治疗中获益。经过初步探索,局部联合系统治疗的多模式、高强度的转化治疗方案展现了可喜的转化成功率。然而,关于如何选择转化治疗目标人群及转化方案、何时序贯手术切除在内的一系列问题尚存在争议。笔者回顾国内外相关研究进展,围绕转化治疗中的几个焦点问题进行探讨。     

Immunostimulation to reduce recurrence after surgery for anal condyloma acuminata: a prospective randomized controlled trial

Aim Human papillomavirus is the most common cause of sexually transmitted disease. It is associated with immunosuppression and shows a marked tendency to recur. We investigated a natural immunostimulant aimed to reduce recurrence. Method A randomized controlled study was carried out including 261 patients allocated to surgical excision alone (control group; n = 122) and surgical excision plus postoperative immunostimulation for 30 days with a natural product (STET; study group; n = 139). Patients with HIV positivity were excluded. All patients gave fully informed consent. Results The patients were followed for 6 months after surgery. Recurrence occurred in 7.2% (10/139) in the study group and in 27.1% (33/122) in the control group (P < 0.0001). There were no significant differences in the sex, sexual orientation, number of lesions, time to diagnosis and treatment or localization of lesions in the two groups. Conclusions Immunostimulation using a natural product significantly reduced the incidence of recurrence of anal condylomata in patients undergoing surgical excision.     

Attitudes and use of complementary medicine in men with prostate cancer

PURPOSE: Patients with cancer are increasingly incorporating complementary therapies into the overall treatment. We determine the prevalence and patterns of use of complementary therapies among patients with prostate cancer. MATERIALS AND METHODS: Patients attending 6 urology institutions for prostate cancer management completed a self-administered questionnaire on complementary therapy. All men diagnosed with prostate cancer were eligible, regardless of age, stage of disease or treatment. RESULTS: A total of 1,099 patients returned the questionnaire. The overall response rate was 78.5%. Complementary therapies had previously been or were currently being used by 23.5% (258) and 18.2% (200) of patients, respectively. Higher levels of education and income were associated with greater use of complementary therapy (p <0.002 by logistic regression). Patients with progressive disease or those primarily treated with hormones were most likely to use complementary therapy. Among the patients using complementary therapy 90% believed that it would help them live longer and improve quality of life, 60% believed it would relieve symptoms and 47% expected it to cure disease. CONCLUSIONS: Complementary therapies are used by a large number of patients with prostate cancer, particularly those with progressive disease or who have undergone multiple treatments. Health care providers need to recognize this growing pattern of use of complementary therapy. Among patients who use complementary therapy the perception of benefit is much greater than that supported by scientific data. Future research should aim to unravel the complex psychosocial dynamics that influence the decision to use complementary therapy by men with prostate cancer and to educate patients about the efficacy of such therapies.     

Ablative therapies for colorectal liver metastases: a systematic review

Aim The standard treatment for colorectal liver metastases (CRLM) is surgical resection. Only 20–30% of patients are deemed suitable for surgery. Recently, much attention has focused on ablative therapies either to treat unresectable CRLM or to extend the margins of resectability. This review aims to assess the long‐term outcome and complication rates of various ablative therapies used in the management of CRLM. Method A literature search was performed of electronic databases including Medline, Cochrane Collaboration Library and the National Library of Medicine’s ClinicalTrials.gov. Inclusion criteria were ablation for CRLM with minimum 1 year follow‐up and > 10 patients, published between January 1994 and January 2010. Results In all, 226 potentially relevant studies were identified, of which 75 met the inclusion criteria. Cryotherapy (26 studies) had local recurrence rates of 12–39%, with mean 1‐, 3‐ and 5‐year survival rates of 84%, 37% and 17%. The major complication rate ranged from 7% to 66%. Microwave ablation (13 studies) had a local recurrence rate of 5–13%, with a mean 1‐, 3‐ and 5‐year survival of 73%, 30% and 16%, and a major complication rate ranging from 3% to 16%. Radiofrequency ablation (36 studies) had a local recurrence rate of 10–31%, with a mean 1‐, 3‐ and 5‐year survival of 85%, 36% and 24%, with major complication rate ranging from 0% to 33%. Conclusion Ablative therapies offer significantly improved survival compared with palliative chemotherapy alone with 5‐year survival rates of 17–24%. Complication rates amongst commonly used techniques are low.     

肿瘤分子靶向药物分类及作用机制

分子靶向治疗与传统化疗的作用机制和副反应不同,是针对肿瘤特殊的分子靶点而起到个体化治疗的作用,对正常组织的毒副反应轻微。10年来,由于靶向治疗独特的作用机制,使肿瘤的治疗模式有了根本性的改变。单克隆抗体和小分子化合物是最重要的两类靶向治疗药物,其作用主要是对酪氨酸受体激酶（RTKs）和非受体激酶、抗血管生成、细胞外基质蛋白酶等方面的抑制。     

Analytical accuracy and reliability of commonly used nutritional supplements in prostate disease

PURPOSE: We determine the analytical accuracy and reliability of commonly used nutritional supplements for prostate disease by comparing the amounts of active ingredients of several brands of vitamin E, vitamin D, selenium, lycopene and saw palmetto. We also compared the amounts of active compound in different lots of the same brand to determine the consistency of the manufacturing process. MATERIALS AND METHODS: Samples purchased at pharmacies and specialty stores were sent for independent chemical analysis. The measured dose was compared to the stated dose on the product label. Analysis of variance was performed to test for significance in interlot reliability. RESULTS: Vitamin E (7 samples) and selenium (5) were within a range of -41% to +57% and -19% to +23% of the stated dosage, respectively. All vitamin D brands (4 samples) were within 15% of the stated dose. Saw palmetto (6 samples) were within a range -97% to +140% of the stated dosages with 3 containing less than 20% of the stated dosages. Lycopene brands were between -38% and +143% of stated dosages. Among the reliability assays 1 of 3 brands of vitamin E, 1 of 2 brands of selenium and 1 of 2 brands of saw palmetto demonstrated statistical differences in interlot dosage (p <0.0055, approximate 20% to 25% differences in dose). The 1 assayed form of vitamin D was reliable between lots. CONCLUSIONS: Commonly used nutritional supplements for prostate disease vary widely in measured dose. Saw palmetto demonstrated tremendous variability with some samples containing virtually no active ingredients. In contrast, the more regulated substances we measured, such as vitamins and minerals, demonstrated less variation.     

La néphropathie lupique : les nouvelles perspectives de traitement

Systemic lupus erythematosus is a chronic autoimmune disease. Both acquired and innate immune systems are involved in the development of this systemic disease. Lupus nephritis usually is the most serious manifestation of systemic lupus erythematosus, with significant morbidity and mortality. The physiopathological development of the renal involvement of lupus has been increasingly elucidated over the years and various target therapies have recently been developed. After some physiopathological reminders, we discuss the conventional treatment of lupus nephritis as well as the various therapeutic advances, in particular the contribution and the place of the new target therapies in the treatment of the lupus nephritis.     

Metastatic Renal Cell Carcinoma: Recent Advances in the Targeted Therapy Era

Context

The treatment of metastatic renal cell carcinoma (mRCC) has recently evolved from being predominantly cytokine based to being grounded in the use of targeted agents.

Objective

To analyse current evidence on the medical management of mRCC.

Evidence acquisition

The PubMed and Medline databases were searched for articles published as of 15 July 2009. Only articles published in English were considered. The search terms were metastatic renal cell cancer, targeted therapy, and immunotherapy. Proceedings from the 2000–2009 conferences of the American Society of Clinical Oncology, the American Urological Association, and the European Association of Urology were also searched for relevant abstracts.

Evidence synthesis

Sunitinib has recently emerged as a front-line standard of care in mRCC. Temsirolimus is considered a first-line therapy for patients with poor risk features. Bevacizumab/interferon is likely to be the next U.S. Food and Drug Administration–approved first-line treatment. The use of sorafenib has moved toward second-line and later therapy. Everolimus was the first agent to show clinical benefit post–tyrosine kinase inhibitor failure in a phase 3 study and is considered the standard of care in this setting. Temsirolimus provided benefit to patients with non–clear-cell histology. In preliminary results, a favourable risk–benefit ratio has been shown with pazopanib and axitinib as first- and second-line treatment. Until combination therapy is clearly shown to be superior to monotherapy, it should be used in the context of a clinical trial. Deciding which is the best sequence to use in mRCC patients remains up to the best judgement of the treating physician. Cytoreductive nephrectomy in the presence of metastatic disease is often indicated as part of an integrated management strategy.

Conclusions

Given considerable advances in understanding the biology of mRCC, several new drugs have recently been developed, offering an increasing number of treatment options. A treatment algorithm based on the best available evidence so far can be therefore postulated, though it continues to evolve as data from ongoing trials become available.     

Bleeding complications precipitated by unrecognized Gingko biloba use after liver transplantation

Because of its neurocognitive enhancing effects, Gingko biloba has emerged as amongst the most commonly used herbal products. We report a liver transplant recipient with potentially life-threatening toxicity resulting from Gingko biloba use. Seven days after a second liver transplantation for recurrent hepatitisB virus infection, subphrenic hematoma was documented in a 59-year-old Korean patient. Failure to control bleeding with CT-guided drainage necessitated exploratory laparotomy for the evacuation of a large subphrenic hematoma. Three weeks later, an episode of vitreous hemorrhage was documented. Unbeknownst to his care providers, the patient had been consuming Gingko biloba throughout the postoperative period. No further bleeding episodes occurred after the cessation of Gingko biloba use. Unrecognized use of herbal products may be associated with serious side effects and adverse clinical sequelae in transplant recipients. Given their increasing popularity, the use of herbal products should be routinely sought as part of the history in transplant recipients.