目的 探讨脾切除联合贲门周围血管离断术治疗经颈静脉肝内门体分流术(TIPS)术后食管胃底静脉曲张复发破裂出血的安全性及有效性.方法 回顾性分析2016年5月至2021年4月宁夏回族自治区人民医院TIPS术后食管胃底静脉曲张复发破裂出血行脾切除联合贲门周围血管离断术17例患者的临床资料.统计其手术时间、术中出血量、术后并发症及复发率,分析手术安全性及疗效.结果 全部患者完成了脾切除联合贲门周围血管离断术.行原位脾切除8例、传统法脾切除7例、包膜内脾切除2例;紧贴胃、食管下段选择性贲门周围血管离断术11例、保留自发性胃肾分流的选择性贲门周围血管离断术6例.平均手术时间186 min(145～518 min),手术出血量348 mL(225～2500 mL),无手术死亡病例.术后门静脉血栓3例,肺部感染1例,肝性脑病1例.术后2年食管胃底静脉曲张消失6例,轻中度残留10例,重度静脉曲张1例.结论 脾切除联合贲门周围血管离断术是治疗TIPS术后食管胃底静脉曲张复发破裂出血的有效方法.

背景:缺血后处理可缓解心肌缺血再灌注损伤,但是其具体机制尚不清楚.目的:探讨lncRNA MALAT1在缺血后处理所引起衰老心肌自噬水平降低中的作用.方法:①27只22-24月龄SD大鼠随机分为3组:假手术组、缺血再灌注组和缺血后处理组,每组9只,采用苏木精-伊红染色和Masson染色观察心肌组织形态学变化;②体外使用8 mg/mL D-半乳糖诱导大鼠心肌(H9C2)细胞9 d后,分为正常氧组、缺氧复氧组和缺氧后处理组.Western blot检测衰老心肌组织及衰老心肌细胞中LC3Ⅱ/Ⅰ和p62蛋白的表达;采用qRT-PCR检测衰老心肌组织和衰老心肌细胞中MALAT1相对表达;转染自噬双标腺病毒(RFP-GFP-LC3)观察衰老心肌细胞自噬流的变化;衰老心肌细胞转染MALAT1干扰片段和过表达质粒,Western blot检测各组细胞中LC3Ⅱ/Ⅰ和p62蛋白的表达.结果 与结论:①与缺血再灌注组比较,缺血后处理组心肌组织结构基本清晰,细胞核完整,心肌组织间蓝色胶原纤维沉积减少;②与缺血再灌注组比较,缺血后处理组LC3Ⅱ/Ⅰ表达降低且p62表达增高(P<0.05);③与缺氧复氧组比较,缺氧后处理组LC3Ⅱ/Ⅰ表达降低(P<0.01)且p62表达增加(P<0.05),细胞内自噬体和自噬溶酶体数量均减少(P<0.01);④与缺血再灌注组比较,缺血后处理组衰老心肌组织的MALAT1表达降低(P<0.01);与缺氧复氧组比较,缺氧后处理组衰老心肌细胞的MALAT1表达降低(P<0.01);⑤衰老心肌细胞转染MALAT1干扰片段和过表达质粒后,与缺氧复氧+si-NC组比较,缺氧复氧+si-MALAT1组LC3Ⅱ/Ⅰ表达降低且p62表达增加(P<0.01);与缺氧后处理+ad-NC组比较,缺氧后处理+ad-MALAT1组LC3Ⅱ/Ⅰ表达增加且p62表达降低(P<0.01);⑥结果表明:lncRNA MALAT1介导的自噬水平降低是衰老大鼠心肌缺血后处理发挥保护作用的重要机制.

本研究对28例脾切除联合断流术后患者测定门静脉压力梯度及其对普萘洛尔的反应性。结果表明，术后第3天患者门静脉压力梯度基线压力平均为（15.1±11.2）mmHg。对普萘洛尔有反应者15例，剂量增至100 mg/d仍无反应者13例。患者对普萘洛尔的降压反应存在个体差异并存在量效反应。

Objective To study the application of technetium 99 m Tc-labeled stannic acid（99 mTc-DTPA） and dialytic fluid in the diagnosis of suspected thoracoabdominal leakage in PD patients by using the characteristics of radionuclide auto-imaging.Methods Pleural effusion occurred in 10 patients undergoing PD treatment for renal failure after dialysis. 99 m Tc-DTPA was mixed with 2 L 1.5% dextran peritoneal dialysis fluid, and static and delayed radionuclide 99 m Tc-DTPA imaging was performed to observe whether thoracoabdominal leakage was present.Results Six of the 10 patients with suspected thoracoabdominal leakage were diagnosed by local static imaging and delayed imaging with abnormal radiation enhancement in the thoracic cavity within 15 min to 8 h. Four patients underwent local static imaging and delayed imaging until 6～8 h, and no abnormal radioactivity distribution was found in the thoracic cavity. The imaging was negative and thoracoabdominal leakage was ruled out.Conclusion Radionuclide 99 m Tc-DTPA imaging has a high positive rate in the diagnosis of suspicious thoracoabdominal leakages. It has important application value for further treatment and is worthy of clinical promotion.

背景与目的:急性胆源性胰腺炎(ABP)是临床上一种常见疾病,其最常见的病因为胆总管结石.目前主流观点认为,对于发病早期的ABP患者应尽早行内镜下逆行性胰胆管造影(ERCP)、内镜下十二指肠乳头括约肌切开术(EST)联合鼻胆管引流术(ENBD).然而在以上治疗过程中是否应该同期行胰管支架引流术的争议较多.针对这一问题,本研究通过对比EST联合ENBD术中放置与不放置胰管支架的两组ABP患者的临床疗效,探讨胰管支架在治疗ABP治疗中的临床价值.方法:回顾性分析2015年1月—2020年1月期间宁夏回族自治区人民医院收治的70例ABP患者的临床资料.其中,30例在接受常规保守治疗的同时急诊72 h内完成EST+ENBD+胰管支架内引流手术(观察组),40例在接受常规保守治疗同时急诊72h内完成EST+ENBD(对照组).比较两组患者的临床改善情况及总体结局.结果:两组患者性别、年龄、发病到接受EST手术的时间、术前实验室指标差异均无统计学意义(均P>0.05).观察组疼痛缓解时间、住院时间、血清淀粉酶恢复正常时间较对照组明显缩短,差异有统计学意义(均P<0.05);两组转氨酶与胆红素恢复正常水平时间差异无统计学意义(均P>0.05).观察组死亡1例(3.3％),对照组死亡2例(5.0％);观察组并发症(胰周积液、胰腺假性囊肿、胰源性腹水)发生率为6.7％,对照组为17.5％;观察组需要B超和(或)CT引导穿刺引流1例(3.3％),对照组3例(7.5％);观察组无接受外科清创引流手术患者,对照组1例;观察组转入ICU治疗1例(3.3％),对照组4例(10.0％),观察组以上总体临床结局指标均优于对照组,但差异均无统计学意义(均P>0.05).结论:在ABP患者的治疗中采用胰管支架引流能迅速缓解临床症状,并可能降低并发症的发生率,改善预后,提高整体疗效.ABP患者在早期接受EST+ENBD手术的同时推荐放置胰管支架.

患者女,28岁,5天前体检超声发现甲状腺右叶结节,无明显疼痛及其他不适;既往体健.查体:颈部及全身未见异常.实验室检查:甲状旁腺激素升高(171.20 pg/ml).颈部超声:甲状腺右叶腺体内见1个囊实性回声结节,边界清,形态规则,结节内及周边可见血流信号(图1A).

Objective:To study the clinical results of personalized surgical treatment for portal hypertension based on portal venous hemodynamics.Methods:A retrospective study was performed on patients with portal hypertension who underwent surgical treatment from January 2016 to December 2020 at the People’s Hospital of Ningxia Hui Autonomous Region and Wuhai People’s Hospital. Of 229 patients included into this study, there were 156 males and 73 females, with age of (4±11) years old. Portal vein CT and ultrasound doppler examination were performed preoperatively and portal vein manometry and ultrasound doppler examination were performed intraoperatively to evaluate portal venous hemodynamics. Based on the evaluation results, different surgical treatments were adopted. Postoperative complications and results of the operations were recorded. Long-term outcomes were evaluated by the rate of recurrence of gastroesophageal varices which was classified as disappearance, mild, moderate and severe according to endoscopic findings.Results:All the 229 patients completed the operations successfully. All together 13 operative treatments were used: (1) simple splenectomy ( n=11); (2) devascularization ( n=176), including 86 patients with splenectomy combined with extensive devascularization, 44 patients with splenectomy combined with selective devascularization and with preservation of paraesophageal veins, 39 patients with splenectomy combined with selective devascularization and reconstruction of spontaneous portosystemic shunt (34 patients with selective devascularization and reconstruction of spontaneous gastrorenal shunt and 5 patients with selective devascularization and reconstruction of spontaneous splenorenal shunt), 4 patients with secondary devascularization for variceal recurrence and 3 patients with devascularization and preservation of spleen; (3) shunt procedures were performed in 42 patients including 21 patients with splenectomy combined with coronary renal shunt, 11 patients with splenectomy combined with coronary-caval shunt, 6 patients with distal splenorenal shunt, 2 patients with proximal splenorenal shunt combined with devascularization, 1 patient with right gastroepiploic vein-inferior vena cava shunt and 1 patient with trans-inferior mesenteric vein coronary renal shunt. There were no operative deaths. The Clavien-Dindo grade 3 and above postoperative complication rate was 6.6% (15/229). Two hundred and eight patients were followed up for 6-60 months, with a median follow-up of 38 months. Severe recurrent varices were found in 21 patients (10.1%, 21/208), with 5 patients (2.4%, 5/208) presented with variceal bleeding. The rate of severe varices after selective shunting and selective devascularization by reconstructing the spontaneous portosystemic shunt (4.2%, 3/72) was significantly lower than that of the other devascularization procedures (13.7%, 17/124)(χ 2=4.53, P=0.033). Conclusion:Better clinical results were achieved by selecting the appropriate surgical procedures based on portal venous hemodynamic characteristics of patients. Selective shunting and selective devascularization by reconstructing the spontaneous portosystemic shunts significantly reduced the recurrence rate of severe varies.

Objective:To investigate the computed tomography (CT) examination anato-mical features and clinical significance of paraesophageal vein (PEV) in portal hypertension.Methods:The retrospective and descriptive study was conducted. The clinical data of 173 patients with portal hypertension who were admitted to the People's Hospital of Ningxia Hui Autonomous Region from January 2018 to June 2021 were collected. There were 124 males and 49 females, aged from 22 to 71 years, with a median age of 47 years. Observation indicators: (1) preoperative CT examinations; (2) surgical situations; (3) follow-up. Follow-up was conducted using outpatient examination to detect surgical effects once every 3 months within postoperative 6 months and once every 6 months after postoperative 6 months. The follow-up was up to June 2021. Measurement data with skewed distribution were represented as M(range) and count data were described as absolute numbers. Results:(1) Preoperative CT examinations. The CT detection rate of PEV in the 173 portal hyper-tension patients was 52.60%(91/173). Of 173 patients, 82 cases were negative with PEV and 91 cases were positive with PEV. Of the 91 patients who were positive with PEV, there were 46 cases with paraesophageal varices, 24 cases with thick PEV, 21 cases with thin PEV, 8 cases without esophageal varices and 83 cases accompanied with esophageal varices. Of the 83 patients who were accom-panied with esophageal varices, there were 44 cases with PEV converged alone with azygos vein or semiazygos vein, 39 cases with paraesophageal varices formed above the diaphragm confluent with esophageal varices into azygos vein. (2) Surgical situations. All the 173 patients underwent surgery successfully, including 8 cases undergoing splenectomy, 86 cases undergoing splenectomy combined with modified complete devascularization, 35 cases undergoing splenectomy combined with spontaneous gastrorenal shunt reconstructing devascularization, 41 cases undergoing splenectomy combined with PEV preserving devascularization and 3 cases undergoing splenectomy combined with PEV ring constriction. None of 173 patients had surgical relative death, 67 cases had complica-tions, including 3 cases undergoing splenectomy, 29 cases undergoing splenectomy combined with modified complete devascularization, 11 cases undergoing splenectomy combined with spontaneous gastrorenal shunt reconstructing devascularization, 23 cases undergoing splenectomy combined with PEV preserving devascularization and 1 case undergoing splenectomy combined with PEV ring constriction underwent complications. (3) Follow-up. Of the 173 patients, 159 cases were followed up for 6 to 42 months, with a median follow-up time of 28 months. In the 7 cases undergoing splenectomy who were followed up, there were 6 cases without esophageal varices and 1 case with recurrence of esophageal varices. In the 79 cases undergoing splenectomy combined with modified complete devascularization who were followed up, there were 5 cases without esophageal varices, 67 cases with mild to moderate residual of esophageal varices, 5 cases with severe residual of esophageal varices, 1 case with recurrence of esophageal varices and 1 case with recurrence of esophageal varices hemorrhage. In the 34 cases undergoing splenectomy combined with sponta-neous gastrorenal shunt reconstructing devascularization who were followed up, there were 7 cases without esophageal varices and 27 cases with mild to moderate residual of esophageal varices. In the 36 cases undergoing splenectomy combined with PEV preserving devascularization who were followed up, there were 4 cases without esophageal varices, 21 cases with mild to moderate residual of esophageal varices, 5 cases with severe residual of esophageal varices, 4 cases with recurrence of esophageal varices and 2 cases with recurrence of esophageal varices hemorrhage. In the 3 cases undergoing splenectomy combined with PEV ring constriction who were followed up, there were 2 cases with mild to moderate residual of esophageal varices, 1 case with severe residual of esophageal varices.Conclusions:The CT detection rate of PEV in portal hypertension patients is >50% and the internal diameter and distribution of blood vessels are different in patients. CT examination anatomical features of PEV can be used to guide the formula-tion of surgical methods.

目的 探讨脂肪酸结合蛋白4(FABP4)在同型半胱氨酸(Hcy)诱导的大鼠心肌细胞焦亡中的作用.方法 培养大鼠心肌细胞,分为对照组(0 mmol/L Hcy)与Hcy组(3 mmol/L Hcy),采用Western blotting检测各组FABP4、焦亡相关蛋白NOD样受体蛋白3(NLRP3)、半胱天冬酶-1(caspase-1)、白细胞介素-1β(IL-1β)的表达情况;采用qRT-PCR检测FABP4 mRNA表达变化;采用免疫荧光染色法检测焦亡相关蛋白的表达变化;用FABP4抑制剂(BMS-309403)处理心肌细胞,然后将细胞分为对照组(0 mmol/L Hcy)、Hcy组(3 mmol/L Hcy)及Hcy+BMS-309403组(3 mmol/L Hcy和50μmol/L BMS-309403),再次检测焦亡相关蛋白的表达水平.结果 Western blotting检测结果显示,与对照组比较,Hcy组FABP4、NLRP3、caspase-1、IL-1β表达水平明显升高(P<0.05);qRT-PCR结果显示,与对照组比较,Hcy组FABP4表达水平明显升高(P<0.05);免疫荧光染色结果显示,与对照组比较,Hcy组NLRP3、caspase-1、IL-1β荧光强度明显增强.加入FABP4抑制剂(BMS-309403)同时给予Hcy干预后,与Hcy组比较,Hcy+BMS-309403组FABP4、NLRP3、caspase-1、IL-1β表达水平明显下降(P<0.05或P<0.01).结论 FABP4可能对Hcy诱导的大鼠心肌细胞焦亡有促进作用.

目的 探讨导丝进入胰管的困难性胆管插管策略应用于内镜逆行胰胆管造影术(ERCP)中的临床效果.方法 回顾性分析该院63例导丝进入胰管的困难性胆管插管患者的临床资料.依次采用双导丝法、胰管预切开法和胰管支架法选择性胆管插管,根据不同胆管插管方法分为双导丝组、胰管预切开组和胰管支架组.分析各组的插管成功率、插管时间及ERCP术后并发症之间的差异.结果 3组总体插管成功率为96.8％.双导丝组、胰管预切开组及胰管支架组的插管时间分别为(70.7±28.6)、(116.6±43.2)和(129.1±88.2)s,组间比较,差异有统计学意义(P<0.05).ERCP术后高淀粉酶血症总体发生率为39.3％,胰管预切开组明显高于其他两组(P<0.05).ERCP术后胰腺炎(PEP)总发生率为21.3％,胰管预切开组明显高于其他两组(P<0.05).ERCP出血发生率为6.6％.未发生重症胰腺炎和十二指肠穿孔病例.结论 导丝进入胰管后依次采用双导丝法、胰管预切开法和胰管支架法选择性胆管插管,上述方法插管成功率高,手术安全可行.

目的 比较腹腔镜胆囊切除联合腹腔镜胆总管探查胆道支架引流术(LC+LCBDE+支架)和内镜下括约肌切开取石术(EST)联合LC(即EST+LC)两种微创手术方式治疗胆囊结石合并胆总管结石的临床效果.方法 回顾性分析宁夏回族自治区人民医院肝胆外科97例胆囊结石合并胆总管结石病人的临床资料,其中52例行LC+LCBDE+支架,45例行EST+LC,比较两组病人的手术时间、术中出血量、住院时间、住院费用及术后并发症发生率.结果 LC+LCBDE+支架组病人的住院时间、住院费用、术后并发症发生率均低于EST+LC组,手术时间长于EST+LC组,差异均有统计学意义(均P＜0.05),两组病人术中出血量比较,差异无统计学意义(P＞0.05).结论 两种手术方式各具优势,LC+LCBDE+支架术比EST+LC治疗胆囊结石合并胆总管结石具有住院时间短、住院费用低、并发症发生率低等优点,但手术时间较长.

目的 利用冠脉CT血管成像无创性分析糖尿病和高血压患者冠脉斑块特点.方法 回顾性分析2017年7月至2018年10月入宁夏回族自治区人民医院就诊的高血压(95例)、糖尿病(23例)、高血压合并糖尿病(68例)以及对照组(60例)患者的临床资料,四组患者均行256排螺旋CT冠脉血管成像检查(CCTA),利用卡方检验比较各组患者冠脉斑块分布、支数、性质及冠脉狭窄程度组间差异.结果 四组患者冠脉斑块发生率差异有统计学意义(P=0.001),冠脉斑块多分布于左前降支差异无统计学意义(P=0.515),多支冠脉受累差异有统计学意义(P<0.001),以糖尿病合并高血压组中比例最高.四组患者冠脉斑块类型中非钙化斑块的发生率差异有统计学意义(P<0.001),病例组更易发生冠脉狭窄(P<0.001),轻度、中度及重度冠脉狭窄差异均有统计学意义(P均<0.05).结论 糖尿病、高血压的存在均可增加冠脉斑块发生率,更易导致冠脉狭窄,冠脉CCTA在冠脉斑块无创性识别及性质分析中存在潜力.

目的 研究经内镜逆行性胰胆管造影术后胆总管结石的复发情况,评价胆管塑料支架对胆总管结石复发率的影响.方法 回顾性分析收治的118例胆总管结石患者的临床资料,按照术式分为胆管支架组和鼻胆管组,比较2组患者的性别、年龄、结石数量等指标有无统计学差异,通过电话随访、制订问卷等方式了解患者结石首次复发情况.结果 2组患者在性别、年龄、结石数量等指标比较差异均无统计学意义(P＞0.05);胆管支架组患者复发率为24.59％,鼻胆管组复发率为10.53％,放置胆管支架术后结石复发率高于鼻胆管组(P＜0.05).结论 胆管塑料支架置入术后结石复发率要高于鼻胆管引流组.

目的:探讨经内镜逆行胰胆管造影(ERCP)术后应用自制C/S-J型胆道自行脱落支架行胆道引流的安全性与有效性.方法:将2015年10月-2018年10月期间收治的184例的胆管结石患者分为3组,分别行ERCP+十二指肠乳头切口(EST) +C/S-J型胆道自行脱落支架内引流术(C/S-J组,104例),ERCP+EST+经内镜鼻胆管引流术(ENBD)(ENBD组,40例),ERCP+EST+经内镜胆道支架引流术(ERBD)(ERBD组,40例).比较各组ERCP术后胰腺炎、胆管炎发生情况,并记录C/S-J组支架排出情况.结果:各组患者在性别、年龄、结石大小、结石数量、术前胆囊切除情况、术前胆管炎情况均无明显差异(均P＞0.05);C/S-J组、ENBD组、ERBD组ERCP术后急性胰腺炎发生率分别是6.73％(7/104)、7.50％(3/40)、10.00％(4/40),急性胆管炎的发生率分别是0.96％(1/104)、0.00％(0/40)、2.50％(1/40),组间无统计学差异(均P＞0.05).C/S-J组2例术后第1天支架从胆道排出,1例术后3个月支架未排出,后经十二指肠镜成功取出,其余患者支架在9～14d内脱落并经消化道自行排出体外,平均为10.2 d.无消化道梗阻、出血及穿孔等并发症发生.结论:采用自制C/S-J型胆道自行脱落支架行胆道引流安全、有效,能弥补ENBD与ERBD的不足之处.

1病例资料患者女性,18岁,回族,主因"间断呕血、黑便7年,加重3d"于2018年10月18日收住本院。7年前患者因呕血、黑便于当地医院就诊,诊断为"上消化道出血",予以输血、止血等内科保守治疗后好转。5年前因上腹胀痛伴黑便于宁夏某医院就诊,完善相关检查诊断为"多囊肝",行胃镜检查无食管胃底静脉曲张,予以对症处理。期间患者间断有呕血、黑便症状,伴恶心,平均每年发作1次,多次予以输血等内科保守治疗。2年前患者因"食管胃底静脉曲张破裂出血、门静脉高压症"行经颈静脉肝内门体分流术,术后仍有反复呕血、黑便,平均每半年发作

2019年12月下旬一场起源于湖北武汉不明原因肺炎疫情在全国迅速蔓延.目前,此类肺炎被证实为由一种新型冠状病毒感染引起,此病毒被WHO暂命名为2019-nCoV.宁夏回族自治区地处西北,离重度疫区地理位置较远,截至2020年2月8日已确诊49例,疑似34例(数据来自宁夏回族自治区卫生健康委员会官方网站),主要发病原因为输入性病例及聚集性发病.

对5例有自发性脾肾静脉分流的门静脉高压症患者采取静脉曲张输入血管离断、脾静脉近端结扎联合或不联合脾切除的手术方法。结果表明，术后胃食管静脉曲张及脾功能亢进症状消失或缓解，肝功能改善。术后发生肺栓塞1例，无其他手术相关并发症。本手术使胃食管静脉血经胃-脾-肾静脉分流通道引流至肾静脉，达到了选择性分流目的。

目的 探讨组蛋白去乙酰化酶2(histone deacetylase 2,HDAC2)在D-半乳糖(D-galactose)诱导的衰老心肌细胞自噬水平降低中的作用.方法 使用D-galactose刺激大鼠心肌细胞H9c2衰老后,β-半乳糖苷酶染色验证模型是否成功;透射电镜观察未给予D-galactose对照(control)组与给予D-galactose组的自噬情况;Western Blot检测LC3B及p62的蛋白表达;分别采用qRT-PCR与Western Blot检测control组与D-galactose组HDAC2的mRNA与蛋白表达;同时,D-galactose组干扰HDAC2的表达后,Western Blot检测HDAC2的自身表达及LC3B与p62的蛋白表达,免疫荧光染色观察LC3B的定位及表达;最后,Western Blot检测control组与D-galactose组H3K14ac的蛋白表达;D-galactose组干扰HDAC2的表达后,Western Blot检测H3K14ac的蛋白表达.结果 成功复制了衰老心肌细胞模型;经过D-galactose干预后,细胞内的自噬结构较未干预组明显减少;Western Blot结果显示,LC3BⅡ/Ⅰ水平降低,p62表达升高;qRT-PCR与Western Blot结果均证实D-galactose组与control组相比HDAC2的mRNA和蛋白水平明显降低;干扰HDAC2的表达后,Western Blot结果显示干扰HDAC2后的D-galactose组(Ad-shHDAC2)与未干扰HDAC2的D-galactose组(Ad-shNC)相比,LC3BⅡ/Ⅰ水平降低,p62表达升高,免疫荧光染色结果显示Ad-shHDAC2与Ad-shNC相比LC3B荧光强度要低;Western Blot结果显示,D-galactose组H3K14ac水平与control组相比明显升高;干扰HDAC2的表达后,Western Blot结果显示Ad-shHDAC2组与Ad-shNC组相比,H3K14ac表达进一步增加.结论 D-galactose能够诱导衰老心肌细胞自噬水平降低,且HDAC2的表达降低介导H3K14高乙酰化水平可能是衰老心肌细胞自噬水平降低的重要机制之一.

目的 探讨剑突下3 mm鞘管(微切口)二孔法腹腔镜胆囊切除术的应用体会.方法 回顾性分析2018年6月至2019年5月在宁夏医科大学附属吴忠市人民医院和宁夏回族自治区人民医院实施剑突下微切口(4 mm),配合右侧腋前线肋缘下针式组合式显露器进行二孔法腹腔镜胆囊切除术的36例患者临床资料.结果 36例中除1例改为三孔法外,其余35例均顺利完成手术,成功率97.2％.手术时间(38.2±10.5)min,术后平均住院时间2.3 d,所有患者术后均无出血、胆漏、胆道损伤等并发症的发生.总体住院费用低于三孔法腹腔镜胆囊切除术.结论 剑突下微切口二孔法腹腔镜胆囊切除术,术中显露满意,操作方便易学,术后外观几乎等同于单孔腹腔镜效果,此术式符合微创美观、操作简便、经济实用、安全可靠的原则,值得进一步推广.

目的 探讨门静脉高压症并胃静脉曲张及自发性胃肾分流道时选择性断流的手术方法及其临床疗效.方法 对手术前门静脉CT检查发现有胃静脉曲张伴自发性胃肾分流道的患者,在脾切除术后离断结扎胃静脉曲张的输入血管,保留自发性胃肾分流道.纵行离断肝胃韧带.不对食管下段及胃底贲门进行游离.观察门静脉压力变化、手术时间、手术出血量、术后胃肠功能恢复情况、门静脉血栓发生率、胃静脉曲张消失率以及复发出血率.结果 本组共31例,手术时间(221±128)min,手术出血量(326±228)mL,术中门静脉自由压力为切脾前(35.5±17.52)cmH2O、切脾后(26.5±21.35)cmH2O、断流后(28.3±22.61)cmH2O.术后平均胃管拔除时间(2.8±1.5)d,无胃瘫及肝性脑病发生,术后随访时间22个月(6～48个月),无复发出血,胃静脉曲张消失26例(83.87%)、明显缩小5例(16.13%),CT显示原胃肾分流道通畅,发生门静脉血栓3例(9.68%).结论 保护自发性胃肾分流道的选择性断流术可有效降低胃食道静脉曲张的压力,达到防治出血的目的;同时不影响来自肠系膜上、下静脉血流进入肝脏代谢,达到选择性分流术的效果.不游离食管下段及胃底贲门可简化手术操作,降低手术并发症.