先天性胆总管囊肿,亦称先天性胆总管扩张症,是一种先天性胆管壁发育不全所致的胆管囊状扩张性疾病[1],其确切病因尚不完全清楚[2].胆总管囊肿的发生率为0.7％,约75％的患者在儿童时期被确诊[3].儿童和成人患者之间存在相似之处,但只有成人有恶性肿瘤的报告[4].国际上目前最广泛应用的是1977年由Todani改进的Ⅰ～Ⅴ五分型法[1]:胆总管扩张、胆总管憩室样扩张、胆总管末端膨出、胆管多发性扩张和肝内胆管单发或多发性囊状扩张(亦称Caroli病),其中Ⅰ型占70％～90％.成人胆总管囊肿可表现为非特定症状,如腹痛、黄疸、胆石症和胰腺炎,由于非特定症状,较难作出诊断[4].

目的 探讨经脐单孔腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的价值. 方法 回顾性比较我科2014年1月～ 2015年6月单孔LC 50例(单孔腔镜组)与传统三孔 LC 50例(传统腔镜组)的临床资料,比较2组手术时间、术中出血量、术后并发症、住院费用及患者满意度. 结果 单孔腔镜组与传统腔镜组手术时间分别为(60.4 ±20.5)、(56.8±16.1) min,2组比较无明显差异(t=0.968,P=0.336);术中出血量分别为(23.7±9.5)、(22.1±8.2) ml,2组比较无明显差异(t=0.904,P=0.368);术后并发症分别为1、2例,2组比较差异无统计学意义(x2=0.000,P=1.000);住院费用分别为(7950.0±1136.3)、(9580.4±1361.5)元,有统计学差异(t=-6.501,P=0.000);单孔腔镜组患者满意度(8.7±1.0)分,明显高于传统腔镜组(7.2±1.0)分(t=7.328,P=0.000). 结论 经脐单孔LC治疗胆囊良性疾病安全、有效,美容效果更佳,患者更满意,值得推广.

目的 探讨进展期远端胃癌手术中清扫No.14v组淋巴结对患者预后的影响,为胃癌患者淋巴结清扫范围提供临床数据.方法 回顾性分析兰州大学第二医院2013年1月至2014年1月收治的进展期远端胃癌D2根治术的患者167例作为研究对象,其中行胃癌D2根治术且术中快速病理显示第6组淋巴结阳性No.14v组淋巴结清扫的患者28例作为试验组;其中行胃癌D2根治术且术后病理显示第6组淋巴结阳性患者24例作为对照组.记录患者手术相关数据,病理相关数据及术后患者随访数据,分析术中清扫No.14v组淋巴结对患者预后的影响.结果 两组患者手术时间、术中出血量、并发症发生率比较,差异均无统计学意义(P>0.05);两组患者手术时间、术中出血量、并发症发生率比较,差异均无统计学意义(P>0.05);试验组患者中位淋巴结清扫总数目31.43枚,多于对照组的29.29枚,但差异无统计学意义(P>0.05);试验组患者3年生存率为57.14％,对照组为29.17％,两组比较,差异有统计学意义(P<0.05).结论 对于进展期远端胃癌第6组淋巴结阳性的患者进行No.14v组淋巴结的清扫能够提高患者的3年生存率,值得临床推广.

目的 探讨全腹腔镜远端胃癌根治术在治疗肥胖胃癌患者中的近期临床疗效.方法 回顾性分析2013年1月至2016年12月在该院微创外科行全腹腔镜远端胃癌根治术的肥胖患者24例(研究组)和同期在该院行开腹远端胃癌根治术的肥胖患者24例(对照组)的临床资料.结果 研究组患者的术中出血量、术后首次排气时间、切口长度、住院时间等指标均显著优于对照组,差异均有统计学意义(P<0.05).研究组淋巴结清扫总数目、手术时间、术后并发症发生率与对照组比较,差异均无统计学意义(P>0.05).结论 全腹腔镜远端胃癌根治术治疗肥胖胃癌患者能够显著改善近期临床相关指标,有利于患者的术后恢复.

Objective To discuss the value of fast track surgery(FTS)in perioperative period of laparoscopic colon resection. Methods We selected 200 cases of laparoscopic colon resection in our hospital from September 2013 to September 2015. The cases were randomly divided into either traditional group(control group)or fast track surgery group(FTS group),with 100 cases in each group.The time to flatus, time to defecation, time to intake semi-liquid diet, length of hospital stay, and postoperative complications were compared. Results As compared with the control group,the FTS group had shorter flatus time[(28.0 ±4.4) h vs.(40.9 ±5.4)h,t=-18.520,P=0.000],shorter defecation time[(38.8 ±5.3)h vs.(50.7 ±4.3)h,t=-17.436,P=0.000],shorter time to semi-liquid diet[(2.3 ±0.8)d vs.(4.2 ±0.7)d, t=-17.874, P=0.000], shorter postoperative hospital stay[(6.2 ±1.3)d vs.(9.2 ±1.6)d, t =-14.552, P=0.000], and lower incidence of postoperative pulmonary infection(6% vs.20%, χ2=8.665, P =0.003). Conclusion Fast track surgery combined with laparoscopy accelerates gastrointestinal functional recovery,being helpful for patient's postoperative recovery.

Objective:To systematically evaluate the short outcomes of robotic versus laparoscopic gastrectomy for gastric cancer. Methods:Such data bases as PubMed,Cochrane Library,Embase,CBM,CNKI,WanFang Data were searched,and other sources like the relevant references were also retrieved to collect the clinical controlled trials about robotic versus laparoscopic gastrectomy for gastric cancer published by Dec. 2013. After literature screening,data extraction and quality evaluation were performed by two reviewers independently according to the inclusion criteria,the meta-analysis was conducted using RevMan5. 2 software. Results:A total of eight clinical controlled trials involving 2 276 patients were included in the study. The results of meta-analysis showed:the time of operation of robotic surgery was significantly longer than the laparoscopic surgery [MD = 37. 82,95% CI =(21. 82,53. 82)( P 0. 01)];but the blood loss of robotic surgery was significantly less than that of the laparoscopic surgery [MD =-53. 79,95% CI =(-70. 01,-37. 57)( P 0. 01)]. The time of first flatus and the postoperative hospital stay in robotic group were significantly less than those in the laparoscopic group,their MD and 95% CI were [-0. 26(-0. 47,-0. 06)],[-0. 66,(-1. 20,-0. 12)](P 0. 05). The differences between two groups had no statistical significance in the number of lymph node dissection and postoperative complications( P 0. 05). Conclusions:It may be concluded that robotic gastrectomy is a safe and effective alternative to laparoscopic gastrectomy and is justifiable under the setting of clinical trials. The same radical effect with laparoscopic surgery can be obtained with advantages such as the less bleeding and faster recovery after surgery.

Objective To compare the application value of Endo-GIA procedure and secondary splenic pedicle disconnection for laparoscopic splenectomy.Methods The clinical data of 60 patients underwent laparoscopic splenectomy were retrospectively analysed.They were divided into two groups according to the method of splenic pedicle disconnection:group A (30 cases) was given Endo-GIA procedure and group B (30 cases) was given secondary splenic pedicle disconnection.The operation time,perioperative blood loss,postoperative exhaust time,indwelling time of drainage tube,hospitalization expenses and hospitalization time between two groups were observed.Results Sixty patients successfully underwent surgery,operation time in group A was shorter than that in group B (P=0.000),but perioperative blood loss,postoperative exhaust time,indwelling time of drainage tube,hospitalization time and hospitalization expense in group B were better than those in group A[(230.90 ± 9.92) ml vs.(300.10 ± 50.36) ml,(28.5±3.2)hvs.(31.6±5.3)h,(5±2)dvs.(7±3)d,(9.68±0.98)dvs.(12.16±1.34) d,(3.31 ± 0.50) million yuan vs.(4.65 ± 0.80) million yuan] (P =0.000).The incidence of complications such as postoperative fever,peritoneal effusion and hyperamylasemia between two groups had no significant difference (P ＞ 0.05).Conclusion Two methods for laparoscopic splenectomy is safe and feasible,but the secondary splenic pedicle disconnection for laparoscopic splenectomy is lower in perioperative blood loss,hospitalization expenses than Endo-GIA procedure,suitable for poor areas of northwest China.

Objective To investigate the efficacy of two digestive tract reconstruction methods after laparoscopic total gastrectomy of gastric cancer.Methods Forty patients of gastric cancer were divided into two groups,20 cases were treated by Roux-en-Y jejunal anastomosis (Roux-en-Y group),and another 20 cases were treated by Moynihan anastomosis (Moynihan group).The surgery,postoperative complications and long-term survival were compared between two groups.Results The operative time,intraoperative bleeding,operative mortality,dumping syndrome,diarrhea and survival rate between two groups had no significant difference (P ＞0.05).But the rate of reflux esophagitis in Roux-en-Y group (2/20) was significantly lower than that in Moynihan group (15/20)(P ＜ 0.05).Conclusion The two methods of digestive tract reconstruction are all safe and practicable,but Roux-en-Y jejunal anastomosis for reconstruction after gastric resection is easy to operate with few complications,and it is an appropriate method of digestive tract reconstruction.

目的探讨微创治疗胆总管结石的效果。方法 2007年1月～2009年1月,对126例胆总管结石采用微创治疗方法。对胆总管结石直径<1.0cm,结石数目1～3枚的胆囊结石合并胆总管结石、胆总管结石以及腹腔镜胆囊切除(LC)术后胆总管结石患者先行ERCP,证实胆总管结石后行EST,网篮取石,球囊清理胆管,造影证实无残留结石。对操作次数多、胆汁黏稠、有残渣、乳头术后水肿可能性大的病例放置鼻胆管引流(ENBD)。对胆总管结石直径≥1.0cm且≤2.0cm的单发或多发结石或经EST取石失败者行LC,腹腔镜下胆总管切开取石,联合使用胆道镜行网篮取石,胆总管置T管引流。结石2～3cm者腹腔镜下胆总管切开取石,T管引流。结果 83例先行ERCP、EST者中,76例取石成功,4例网篮取石困难,未能取出结石,1例有结石残留(这5例于EST后4～6d行LC、腹腔镜胆总管切开胆道镜网篮取石、T管引流术成功),1例ERCP时十二指肠穿孔,1例网篮嵌顿于十二指肠乳头,急诊开腹。43例直接行LC、腹腔镜胆总管切开胆道镜网篮取石、T管引流术,均获成功。91例随访6～12个月,失访35例,无胆道感染、胆道狭窄、残余结石等并发症,未发现结石复发。结论 EST后LC是理想的治疗胆囊结石合并胆总管结石的方法 ,但要严格掌握适应证。

十二指肠穿孔是ERCP常见的并发症之一,严重者会危及患者生命,早期诊断、早期手术对避免威胁患者生存质量的并发症具有重要的意义[1].作者对5例十二指肠穿孔进行回顾性临床分析,报告如下。