目的 评价射频消融在腹腔镜解剖性半肝切除术治疗肝细胞癌(HCC)中的价值.方法 选择单县东大医院2017年1月～2019年12月21例原发性肝细胞癌(HCC)患者作为研究对象,均采用射频消融联合腹腔镜解剖性半肝切除术治疗,观察患者手术时间、术中出血量、术后住院时间,术后并发症发生率及死亡率.所有患者术后均随访12个月,观察术后复发率.结果 21例患者均成功完成手术,手术成功率100％;其行左半肝切除术12例,占57.14％,平均手术时间(296.47±25.71)min,术中平均出血量(336.82±43.75)mL,术中实施射频消融平均止血次数(5.37±0.88)次,止血成功率100％;行右半肝切除术9例,占42.86％,平均手术时间(307.52±31.07)min,术中平均出血量(319.60±37.95)mL,术中实施射频消融平均止血次数(5.07±0.63)次,止血成功率100％;所有患者均未行肝门阻断.术后并发症发生率为38.10％,术后平均住院时间(10.42±2.16)d.所有患者术后均随访12个月,6个月肝外肺部转移1例,12个月肝外转移2例,分别为肺和膈肌转移,死亡1例,1年生存率为95.24％.结论 射频消融能防治肝肿瘤破裂和正常肝实质破裂出血,巩固安全边界,有利于腹腔 镜手术的成功.

目的 研究精准脾切除术在肝豆状核变性合并脾功能亢进患者中的术后效果.方法 选取2016年1月～2019年10月收治的肝豆状核变性合并脾功能亢进患者60例进行研究,按随机数表法分成研究组及传统组各30例.传统组实施.传统脾切除术治疗,研究组则实施精准脾切除术治疗.比较两组各项手术指标水平,术后并发症发生情况,手术前后应激反应状况等方面的差异.结果 研究组术后引流量、术后出血量均少于传统组,且住院时间短于传统组(均P＜0.05).研究组及传统组在术后腹腔出血、发热、门静脉血栓发生率方面对比,前者低于后者(均P＜0.05).术后研究组及传统组在皮质醇、C反应蛋白(CRP)、白细胞介素-6(IL-6)水平方面对比,前者低于后者(均P＜0.05).结论 精准脾切除术应用于肝豆状核变性合并脾功能亢进患者中的效果显著,有利于促进患者早日康复,降低术后并发症发生风险,减轻应激反应,值得临床推广应用.

目的 分析妊娠合并阑尾炎治疗中应用腹腔镜手术的临床疗效.方法 选取46例妊娠合并阑尾炎患者,按照随机数字表法分为对照组和研究组,每组23例.对照组予以常规开放手术治疗,研究组予以腹腔镜手术治疗.对比两组治疗效果.结果 研究组手术时间、术后排气时间、住院时间均明显短于对照组,术中出血量少于对照组,差异有统计学意义(P＜0.05).研究组术后并发症发生率为4.35％,明显低于对照组的26.09％,差异有统计学意义(P＜0.05).结论 对孕早、中期妊娠合并阑尾炎患者实施腹腔镜手术治疗效果更好,安全性更高,具有临床推广应用价值.

目的:分析影响接受根治性手术后肝内胆管细胞癌患者预后的因素.方法:选择2014年1月至2017年12月期间在青海省人民医院、山东省临沂市人民医院和山东省菏泽市单县东大医院接受根治性手术的肝内胆管细胞癌患者160例为研究对象.回顾分析这些患者的临床资料,找出影响其预后的因素.根据腹腔淋巴结清扫范围将其分为无清扫组(75例)、常规清扫组(30例)及扩大清扫组(55例),并对比三组患者的预后.结果:1)进行单因素分析的结果显示,这160例患者血红蛋白、血清白蛋白、谷氨酰转肽酶、癌胚抗原、癌抗原19-9水平、凝血酶原时间、肿瘤直径、发生淋巴结转移的情况及腹腔淋巴结清扫范围与其预后之间存在关联,P<0.05.2)进行多因素logistic回归分析的结果显示,血清癌抗原19-9的水平、肿瘤直径及腹腔淋巴结清扫范围是影响这些患者预后的重要因素,P<0.05.3)无清扫组患者、常规清扫组患者与扩大清扫组患者的三年累积生存率依次是9.33％、53.33％、40％.常规清扫组患者和扩大清扫组患者的三年累积生存率均高于无清扫组患者,P<0.05.常规清扫组患者的三年累积生存率高于扩大清扫组患者,P<0.05.结论:血清癌抗原19-9的水平、肿瘤直径及腹腔淋巴结清扫范围是影响接受根治性手术后肝内胆管细胞癌患者预后的重要因素.在对肝内胆管细胞癌患者实施根治性手术后,对其进行常规腹腔淋巴结清扫的效果较好.

人肝细粒棘球蚴病是棘球蚴绦虫引起的一种人兽共患寄生虫病,也称肝包虫病,细粒棘球蚴的致病机制主要是对器官挤压,其次是细粒棘球蚴分泌的毒素对人体的毒性反应.目前,肝包虫病主要通过手术进行根治治疗.随着微创手术及精准手术标准的引用,腹腔镜手术治疗肝包虫病得到了长足的发展,本文将从腹腔镜肝包虫病适应症的选择、腹腔镜手术治疗肝包虫病的优势与劣势、腹腔镜手术与其他手术方式治疗效果对比、腹腔镜治疗肝包虫病的新技术、新方法、目前腹腔镜手术治疗肝包虫病存在的问题等方面作一综述.

囊型肝包虫病是青藏高原畜牧区常见的一种地方病,严重危害当地民众的健康,病死率2％～4％[1].对于较大的包虫囊肿,仍以手术治疗为主[2].近年来,随着3D腹腔镜技术的发展与普及,以及青藏高原地区民众对于肝包虫手术微创化的渴望,我们团队2016年开始尝试3D腹腔镜技术治疗肝囊型包虫,但肝包虫囊肿意外破裂仍是一个比较棘手的问题[3,4].我科2016年1月～ 2018年1月对87例囊型肝包虫病在全麻下行3D腹腔镜下肝包虫囊肿切除手术,其中13例在手术过程中发生囊肿破裂,占14.9％,现总结报道如下.

目的:探讨腹腔镜D2根治术联合淋巴结清扫治疗进展期胃癌患者的临床疗效.方法:选择2016年6月～2018年6月本院收治的135例患者为观察对象,随机分为观察组(n=68)和对照组(n=67).观察组给予腹腔镜D2根治术联合淋巴结清扫,对照组给予常规开腹D2根治术联合淋巴结清扫.观察比较两组临床疗效、手术时间、术中出血量、术后排气时间、住院时间、淋巴结清扫总数及并发症.结果:两组疗效整体比较差异明显(Z=-3.335,P=0.001);观察组有效率为91.18％和对照组85.07％比较,差异无统计学意义(χ2=1.203,P=0.273).观察组手术时间较对照组时间长(t=2.347,P=0.021),术中出血量、术后排气时间和住院时间则低于对照组(t=-8.273,P=0.000;t=-5.489,P=0.000;t=-4.686,P=0.000).观察组和对照组淋巴结清扫总数、术后并发症发生率比较均无明显差别(t=0.312,P=0.758;χ2=2.969,P=0.085).结论:腹腔镜D2根治术联合淋巴结清扫治疗进展期胃癌的临床疗效及淋巴结清扫数量与开腹手术相当,可有效减少术中出血量,缩短术后排气时间及住院时间,安全性高.

目的:探究在囊型肝包虫病治疗时,选择3D腹腔镜行肝包虫囊肿手术治疗的效果.方法:对40例囊型肝包虫病患者采用3D腹腔镜肝包虫囊肿切除术,同时密切观察患者各项临床情况,评价其治疗效果.结果:40例患者均顺利实施手术,手术中平均出血(229.5±145.5)mL;平均手术用时(116.4±62.5)分钟;手术后平均出院时间为(7.15±2.05)天.结论:3D腹腔镜肝包虫囊肿切除术治疗囊型肝包虫病效果良好,临床可广泛应用.

目的 探讨腹腔镜联合胆道镜手术治疗肝包虫病患者的临床效果.方法 2015年2月～2016年8月在我院接受手术治疗的104例肝包虫病患者,52例接受经腹腔镜下内囊摘除术,另外52例采用经腹腔镜联合胆道镜内囊摘除术治疗,比较两组患者的治疗效果.结果 腹腔镜联合胆道镜手术患者胆漏检出率为80.8％,明显高于腔镜组的63.5％(P<0.05);术中出血量为(33.2±20.8)ml,明显少于腔镜组的[(82.1±45.3)ml,P<0.05];胆漏发生率、感染发生率、拔管时间、肠腔排气时间、住院日分别为9.6％、13.5％、(11.5±4.6)d、(1.8±0.7)d、(10.5±5.3)d,明显优于腔镜组的[34.6％、36.5％、(24.3±7.8)d、(3.3±0.6)d、(17.1±7.8)d,P<0.05].结论 腹腔镜联合胆道镜手术治疗肝包虫病患者,效果确切,不良反应少,与传统单纯应用腹腔镜手术比,具有疗效好、创伤小、恢复快等优点.

Objective To investigate the clinical efficacy of three-dimensional (3D) laparoscopic surgery in treatment of hepatic cystic echinococcosis.Methods The retrospective cross-sectional study was conducted.The clinical data of 40 patients with hepatic cystic echinococcosis who underwent 3D laparoscopic surgery in the Qinghai Province People's Hospital from March 2016 to July 2017 were collected.All the 40 patients were treated using 100 mg hydrocortisone on preventing intraoperative anaphylaxis.The experienced surgeons with proficiency in the laparoscopic technology in the same team finished surgery.Patients underwent respectively 3D laparoscopic excision of internal capsule in hepatic echinococcosis + residual cavity treatment,external capsule resection in hepatic echinococcosis and partial hepatectomy based on their conditions.Observation indicators:(1) intraoperative situations:operation completion,surgical procedures,operation time,volume of intraoperative blood loss and blood transfusion;(2) postoperative recovery situations:time to initial anal exsufflation,time for initial fluid diet intake,time for out-of-bed activity,time of indwelling drainage-tube,wound healing,postoperative complications and duration of postoperative hospital stay;(3) follow-up:number of patients with follow-up,follow-up time,oral anti-echinococcosis medical therapy during follow-up,hepatic echinococcosis recurrence and abdominal cavity implantation metastasis.Follow-up using outpatient examination and telephone interview was performed to detect the abdominal symptoms,oral anti-echinococcosis medicine,hepatic echinococcosis recurrence and metastasis up to September 2017.Measurement data with normal distribution were represented as (x)± s.Measurement data with skewed distribution were described as M (range).Results (1) Intraoperative situations:all the 40 patients underwent successful laparoscopic surgery,including 17 undergoing excision of internal capsule in hepatic echinococcosis + residual cavity treatment,15 undergoing external capsule resection in hepatic echinococcosis and 8 undergoing partial hepatectomy.Two patients were combined with abdominal and pelvic hydatids and underwent 3D laparoscopic excision.Operation time and volume of intraoperative blood loss of 40 patients were respectively (100 ± 28) minutes and (86± 24) mL,without intraoperative blood transfusion.(2) Postoperative recovery situations:time to initial anal exsufflation and time for initial fluid diet intake in 40 patients were (2.4± 1.8)hours and (1.7±0.9)days.Forty patients had out-of-bed activity on the day of surgery.Of 40 patients,abdominal drainage-tubes of 39 were placed for 2-3 days;abdominal drainage-tube of 1 with postoperative residual cavity-induced bile leakage was indwelled for 2 months and then was removed.Wound healing and duration of postoperative hospital stay in 40 patients were Class-A healing and (10.5 ± 2.1) days.During hospitalization,39 patients didn't have bleeding,bile leakage,anaphylactic shock,intestinal adhesion and obstruction;1 patient with postoperative residual cavity-induced bile leakage had indwelling drainage-tube removal at 2 months postoperatively.(3) Follow-up:all patients were followed up for 2-15 months,with a median time of 9 months.During the follow-up,40 patients were not complicated with discomforts and received oral antiechinococcosis medical therapy,without hepatic echinococcosis recurrence and abdominal cavity implantation metastasis.Conclusion The 3D laparoscopic surgery is safe and feasible in the treatment of hepatic cystic echinococcosis,and has an obvious advantage in the treatment of irregular hepatic cystic echinococcosis,with good short-term outcomes.

Objective To investigate the effect of laparoscopic lymphadenectomy in patients with adenocarcinoma of esophagastric junction (AEG).Methods 105 patients with AEG underwent open or laparoscopic surgery from June 2014 to September 2015 were enrolled in the study and divided into minimally invasive group (n = 70) and laparotomy group (n = 35). The baseline data, lymphadenectomy result and perioperative data were compared between the two groups.Results Total number of splenic hilar lymph nodes dissection in minimally invasive group was significantly more than that in laparotomy group (P < 0.05). But there were no significant differences in the total number of lymph node dissection, number of positive lymph node dissection, positive rate of all node, number of positive splenic hilar lymph node dissection and positive ratef of splenic hilar lymph node between two groups (P > 0.05). Operation time, intraoperative blood loss, length of incision, positive proximal margins rate, thoracoabdominal resection rate and spleen resection rate in minimally invasive group were significantly lower than that in laparotomy group, esophagus resection length was significantly bigger than that in laparotomy group (P < 0.05). No death occurred postoperatively in all patients. The time of anus exsufflation, first intake liquid diet and postoperative ambulatory episode in minimally invasive group were significantly lower than that in laparotomy group (P < 0.05). There were no significant differences in the incidence of complications between two groups (P > 0.05).Conclusions Compared with open surgery, laparoscopic surgery is superior in splenic hilar lymph nodes dissection of AEG, with longer esophageal cutting distances, lower thoracoabdominal resection and spleen resection rate. It is safe and feasible, worthy of clinical promotion.

目的:探讨高强度聚焦超声治疗高原地区囊性肝包虫的有效性及安全性,为临床治疗高原地区肝包虫提供依据.方法:选取本院2014年1月-2016年6月收治的高原地区囊性肝包虫患者16例进行分析,所有患者均明确诊断为囊性肝包虫病,且均采用高强度聚焦超声进行治疗,观察患者术后肝区疼痛、发热、术区皮肤损害等并发症并比较手术后患者肝功能指标变化情况,并选取同期行手术治疗的30例患者作为对照组进行比较.结果:观察组及对照组治疗期间均未发生影响治疗的严重不良反应,肝功能指标改善情况及术后随访复发率组间差异均无统计学意义(P＞0.05).结论:高强度聚焦超声治疗高原地区囊性肝包虫效果显著,且安全性高,值得临床推广.

目的：探讨进展期中低位直肠癌新辅助放化疗后肿瘤部位及手术方式对患者预后的影响。<br>　　方法：回顾性分析行手术治疗的123例进展期中低位直肠癌患者的临床资料，所有患者均接受术前新辅助放化疗，术后继续按术前方案化疗。采用Kaplan-Meier法计算生存率，Log-rank法进行3年无瘤生存（DFS）率影响因素的单因素分析，COX模型进行多因素分析。<br>　　结果：123例患者3年DFS率为84.55%（104/123）；单因素分析结果显示：新辅助放化疗后T分期降期、术后淋巴结阴性、环周切缘阴性患者的3年DNF率明显升高（P<0.05），性别、年龄、肿瘤距肛缘距离、不同手术方式之间3年DFS率差异无统计学意义（P>0.05）；肿瘤距肛缘距离2~3cm组与4~5cm组、6~7cm组之间的3年DFS率存在升高的趋势，但差异无统计学意义（P>0.05）。将肿瘤距肛缘距离各亚组按不同手术方式进行对比结果显示：6~7cm组保留肛门括约肌手术患者的3年DFS率（91.89%）与2~3cm组切除肛门括约肌手术患者的3年DFS率（80.95%）比较差异无统计学意义（χ2=2.043， P>0.05）；但明显高于4~5cm组保留括约肌手术患者的3年DFS率（72.97%），差异具有统计学意义（χ2=4.437，P<0.05）；COX模型多因素分析结果显示：术后淋巴结及病理环周切缘状况是预后的独立影响因素（χ2=12.459、15.283，P<0.05）。<br>　　结论：术后淋巴结及环周切缘状况是影响接受新辅助放化疗局部进展期中低位直肠癌患者预后的主要影响因素；但仍存在肿瘤位置越低，预后情况越差的趋势；对于肿瘤距离肛缘4~5cm的患者而言，虽然能够实施保留肛门括约肌手术，但并不能从生存期中获益，值得进一步探讨。

Objective:To explore the effects of different altitudes by observing the patientsu0027 hepatic function following laparoscopic cholecystectomy( LC).Methods:Based on the selection criteria,80 patients with chronic gallbladder diseases underwent LC.According to the different altitude during the operation,these patients were divided into two groups:patients of group A in Xining area( an average elevation of 2 200 m);patients of B group in Xinghai area( an average elevation of 3 300 m).The CO2 pneumoperitoneum pressure was kept on 14 mm Hg during the operation.Then,the fasting peripheral venous blood was collected on the preoperative day 1and the postoperative day 1,day 3 and day 5,in order to determine the change of liver function,including alannine aminotransferase( ALT),aspartate aminotransferase( AST),alkaline phosphatase( ALP),total bilirubin( TBIL),direct bilirubin( DBIL) and indirect bilirubin( IBIL).Results:Compared with data on the preoperative day 1,ALT,AST,TBIL and DBIL on the postoperative day 1,day 3 of two groups were significantly increased,especially on the 3rd postoperative day( P 0.05).Until to the 5th postoperative day,the ALT,AST,TBIL and DBIL in group A returned to preoperative levels,but the group B remained at a higher level.In comparison with group A,the level of ALT,AST,TBIL and DBIL in group B were higher after surgery( P 0.05).Conclusions:If pneumoperitoneum pressure is constant,the altitude of the surgical site is one of the reasons for the change of liver function after LC.With the increase of altitude,the effect on liver function is more obvious,the duration is longer,especially on the 3rd postoperative day.

目的:对不同CO2气腹压对高海拔地区行腹腔镜胆囊切除术前后患者肝功能的影响进行对比研究,探讨高海拔地区低气腹压行腹腔镜手术的可行性.方法:在高海拔地区选择90例慢性胆囊疾病患者,行腹腔镜胆囊切除术,根据术中气腹内压的不同,分为三组:低气腹压10mmHg组、中气腹压12mmHg组、高气腹压14mmHg组,分别在术前1天、术中0.5h、术后第1、3、5天,取空腹外周静脉血测定肝功能各项指标,包括谷丙转氨酶、谷草转氨酶、碱性磷酸酶、总胆红素、直接胆红素、间接胆红素.术中分别取三组患者少许肝组织(气腹作用时间点相同取肝组织),分别测定过氧化产物丙二醛(MDA)、超氧化物歧化酶(SOD)、还原性谷胱甘肽(GSH)、过氧化氢酶(CAT)活性.结果:90例患者均顺利完成腹腔镜下胆囊切除术,三组患者年龄构成及术前肝功能无明显差别,在海拔3 300m左右的青藏高原地区,CO2气腹压是行腹腔镜胆囊切除术后患者引起肝功能变化的主要因素,10mmHg的气腹压对肝功能无明显影响,气腹压力越高,对肝功能的影响越明显,持续时间越长,尤其以谷丙转氨酶、谷草转氨酶、总胆红素、直接胆红素较为显著,且以术后第三天最为显著,而对碱性磷酸酶、间接胆红素无显著影响;术中0.5小时,三组各项指标相比均无明显差异;与低气腹压组和中气腹压组相比,高气腹压组患者肝细胞内MDA活性显著增高,而SOD、GSH、CAT活性显著降低.结论:在高海拔地区地区行腹腔镜胆囊切除术,气腹压应选择与平原地区有区别,应选用低气腹压力值.

包虫病又称棘球蚴病,是一种人畜共患的寄生虫病,主要流行于西北地区.包虫病可发生于人体各脏器,多发于肝脏,其他部位包虫病较为罕见,我院1989-2012年共收治腹膜后及肌肉多发包虫3例.现总结报道如下.

重症急性胰腺炎是严重的外科疾病,易并发胰外器官损伤,其中心肺等外周循环器官损伤是其最严重的并发症,微循环改变和血管活性物质在其中起着重要作用.微循环障碍作为重症急性胰腺炎(SAP)发病中的重要环节正受到越来越多的关注.微循环方面的研究显示,SAP早期即发生血循环障碍,出现胰腺小叶内动脉括约肌、微血管内皮细胞损伤、凝血和纤溶系统的改变[1],这与SAP早期单核巨噬细胞系统、粒细胞系统、血管内皮细胞系统激活释放多种细胞因子和炎症介质有关[2].

病例资料 病例1,男,24岁,因左腰背部坠胀感2个月余入院检查.查体:左肾区有叩痛.CT扫描示左肾下极可见椭圆形软组织影,边界清楚,密度低于肌肉,病灶呈囊状低密度影,大小约11.3 cm×6.4 cm,增强后囊壁强化.完善相关检查后,在全麻下行腹膜后肿块切除术,取第1 1肋缘下切口进入,术中见左肾下极囊性肿块,表面呈暗红色,包膜完整,与周围无粘连,仔细游离完整切除包块,术后病理报告肿瘤细胞梭形、细胞浆淡染,栅状排列,伴出血囊性变,诊断神经鞘瘤出血囊性变.病例2,男,32岁,因当地医院检查发现右肾积水转入我院,经B超及腹部X线平片+静脉尿路造影检查,诊断为右输尿管上段受压并肾积水,下腹部CT检查示,偶然发现腹膜后右腰大肌前缘紧邻输尿管一软组织密度团块影,大小约7.4 cm×4.1 cm,增强扫描病灶呈轻中度持续强化.在全麻下取右侧第12肋间切口进入,行腹膜后肿瘤切除术,术中见右腰大肌前缘紧邻椭圆形肿块,压迫右输尿管上端,肉红色,包膜完整,与周围轻度粘连,术后病理

<正>病例资料患者,女,年龄56岁,藏族,因"发现左背部无痛性包块3年余"入院。患者3年前因平躺睡觉感左背部不适,扪及左侧背部一约4 cm×3 cm大小包块,当时未予特殊处理,3年来包块逐渐增大,现增至为一约8 cm×6 cm大包块,无痛、质硬、边界清、活动度差,局部无红肿发热。患者长期生活于牧区,有狗、羊密切接触史。血清学检查:包

目的:探讨重症急性胰腺炎(SPA)并发胰性脑病(PE)的临床特点、发病机制、诊断及治疗措施.方法:回顾性分析132例SPA中9例PE患者的临床资料.结果:9例PE患者,保守治疗6例,手术治疗3例,死亡4例(44.4%),存活5例(55.6%),其中治愈3例,好转2例.结论:目前胰性脑病仍无明确的诊断标准,只能根据病史、临床表现、辅助检查及排他性诊断,一旦发生,病死率高.尽早控制原发病,早期诊断、早期综合治疗是取得较好疗效的关键.