目的 探讨对发病时间>72 h的急性阑尾炎行腹腔镜阑尾切除术治疗的安全性及疗效.方法 回顾性分析鞍钢集团总医院2013年1月至2019年10月腹腔镜手术治疗急性阑尾炎675例临床资料,根据发病的时间差异,分为>72 h组158例和≤72 h组517例,比较两组患者的病理特征、应用抗生素比例、手术情况和术后并发症发生情况.结果 两组病理类型差异有统计学意义(χ2=23.690,P=0.002),术后均无严重并发症发生.与≤72 h组相比,>72 h组入院前抗生素使用比例更高(94.30％vs 82.21％,χ2=10.361,P=0.037),手术时间更长(t=3.998,P=0.029),术中出血量更多(t=2.368,P=0.035).结论 对于发病时间>72 h的急性阑尾炎患者行腹腔镜阑尾切除术安全可行,可以避免二次住院手术治疗,缩短病程,减少住院费用和患者痛苦.

患者,男性,75岁,以"上腹部不适伴返酸6个月,间断呕血10 d,再发1 d"为主诉于2017 年6 月25 日入鞍钢集团总医院治疗.患者于6个月前无明显诱因出现上腹部不适伴返酸,进食后无缓解,于当地医院行胃镜检查提示在胃小弯胃窦后壁靠近幽门口有隆起型肿物,约1.5 cm×1.5 cm,边界清楚,病理提示胃黏膜腺体增生,间质炎细胞浸润.初步诊断:胃窦部黏膜下占位,考虑间质瘤可能性大,建议行超声胃镜检查,患者拒绝并出院自行口服"胃药治疗",期间仍间断上腹部不适.10 d 前患者无明显诱因出现呕血,共4 次,暗红色,总量约400 ml,伴有返酸、胸闷、胸骨后疼痛等不适,血红蛋白尚处于正常范围,急诊来鞍钢集团总医院消化内科就诊,给予抑酸、止血治疗,患者病情稳定后不同意胃镜、CT检查及进一步治疗,自动出院.1 d 前患者再次呕血,量约100 ml,再次以"消化道出血"入院.入院查体:体温36.5 ℃,脉搏72次/min,呼吸19次/min,血压111/66 mmHg(1 mmHg=0.133 kPa),神清语明,皮肤巩膜无黄染,球结膜无水肿,口唇无发绀,非贫血貌,颈无强直,颈静脉无怒张,未触及浅表肿大淋巴结,呼吸平稳,肋间隙均等,双肺呼吸音清,未闻及干湿性啰音,心律齐,无杂音,腹平坦,上腹部深压痛,无反跳痛及肌紧张,肝脾肋下未触及,移动性浊音(-),肠鸣音正常,双下肢无水肿.患者入院后给予禁食水、抑酸、止血、补液治疗,腹部CT检查(图1)提示:胃窦部扩张积液.增强CT(图2)提示:胃窦部囊性病变,考虑胃窦壁囊肿.胃镜(图3)提示:胃窦部小弯侧后壁见一隆起,约5.0 cm×5.0 cm,表面有一凹陷性溃疡,大小0.6～0.8 cm, 表面覆厚苔,呈类圆形,表面黏膜充血肿胀,考虑胃隆起样病变伴表面溃疡,病理提示胃黏膜慢性炎症.内镜超声(图4)提示:胃窦部小弯侧起源于固有肌层的囊性肿物,考虑胃囊肿.心电图、胸片、血常规、肝功能、肾功能、血糖、离子均未见明显异常,入院诊断:胃囊肿壁溃疡出血.患者择期在全麻下行腹腔镜腹腔探查术,术中见胃窦部小弯侧囊性包块,位于浆膜下,表面光滑,边界清楚,胃周淋巴结略肿大,无融合,考虑性质为良性.

患者女,26岁,因"原剖腹产切口处肿块2年"入院,查体:腹平软,下腹术痕偏右可触及一约10 cm×9 cm肿物,腹部CT考虑腹壁硬纤维瘤.入院诊断:腹壁肿物 硬纤维瘤?行全麻下腹壁肿物切除+腹壁缺损补片修补术.术中见肿物大小约9 cm×7 cm,于深筋膜前游离皮瓣至肿物边缘3 cm,切开腹壁肌筋膜,将肿物和周围组织切除,冰冻病理示:(腹壁肿物)考虑硬纤维瘤,断缘 (外上、内侧缘、外侧缘)均阳性,内上切缘阴性.将断缘阳性部位再向外扩切1 cm至断缘阴性,由切口置入20 cm×15 cm复合补片并将下缘与陷窝韧带、耻骨梳韧带、腹股沟韧带、耻骨联合骨膜缝合固定,上方和两侧用钩针将补片周边缝合固定于腹壁,缺损边缘筋膜与补片连续缝合固定,闭合切口后再于腹腔镜下用螺旋钉将补片边缘与耻骨后、耻骨梳韧带和腹壁固定.术后少量排气后逐渐出现腹胀,消化道造影示小肠近端扩张,全腹CT示小肠腹壁疝伴肠梗阻.考虑患者为腹壁缺损修补处裂开、小肠嵌顿、肠梗阻.急诊行腹壁嵌顿小肠松解还纳+腹壁缺损裂开补片修补术.

患者女,65岁,以"腹痛伴渐进性腹胀、停止排气排便7 d"为主诉入院.7 d前进食后出现腹部阵发性绞痛,脐周为主,无放散,偶有恶心、反酸、呕吐正常胃内容物多次,吐后腹痛略缓解,无发热,腹略胀,肛门停止排气、排便,于当地医院给予对症治疗后未见明显好转,腹胀逐渐加重,难以忍受来诊,急诊检查后以"急性肠梗阻,消化道穿孔?"收入院.既往4年前有心肌梗死、原发性高血压病史20余年,糖尿病病史8年,脑梗死伴小脑萎缩病史3年.查体:T 37.5℃,P 127次/分, R 35次/分,Bp 141/107 mmHg(1 mmHg=0.133 kPa).表情淡漠,意识模糊,问答不确切,平躺腹部极度膨隆(图1),腹壁张力较高,未见胃肠型及蠕动波,全腹压痛不明显,无反跳痛及肌紧张,肝肺浊音界消失,肠音未闻及,未闻及气过水音,移动性浊音阴性.双下肢无凹陷性水肿,神经系统查体未见明显异常.腹腔内压力(intra-abdominal pressure, IAP)测定为12 mmHg.腹部CT提示:腹腔内可见大量游离气体,肠管广泛扩张(图2).考虑低位肠梗阻,消化道穿孔.心电图:窦性心动过速.血常规:白细胞12.8×109/L,中性粒细胞87.4％,血红蛋白105 g/L,血钾3.0 mmol/L,尿素氮12μmol/L,肌酐145μmol/L,谷氨酸9.71 mmol/L.入院诊断(:1)急性低位肠梗阻,乙状结肠癌;(2)消化道穿孔;(3)腹腔内高压症(intra-abdominal hypertension,IAH)(;4)急性肾损伤(;5)低钾血症(;6)高血压(;7)糖尿病.急诊在全麻下开腹探查手术,术中开腹时有大量气体溢出,进腹后见少量淡黄色液体渗出,肠管广泛扩张,以结肠最为明显,其内可见大量粪便及气体,远端距腹膜反折15 cm处,可见大小约5 cm×4 cm×4 cm质硬肿物,局部纠集造成乙状结肠截断梗阻(图3),远端结直肠空虚,反复探查整个结肠未见穿孔,肝脏、胃肠表面、大网膜及腹膜未见明确转移灶,术中考虑患者为乙状结肠癌造成的闭襻性肠梗阻合并非外科性高张力气腹,决定行乙状结肠癌切除术+近端单腔造瘘术+远端封闭术.

Objective To investigate the inhibitory effect of antisense oligonucleotide against insulin-like growth factor 1 receptor (IGR-1R) on tumor growth in human hepatocellular carcinoma orthotopic implantation models and its influence on the blood indicators in nude mice.Methods We did the experiment 3 times,and 40 models for each time were divided into 5 groups randomly:NS control group,three IGF-1R antisense oligdeoxynucleotides (ASODN) [75,50,25 mg/(kg· day)] groups and 5-fluorouracil (5-Fu) control group.Eighty nude mice served as normal control group.The agents were given for 25 times through intravenous injection in human hepatocellular carcinoma orthotopic implantation models.When the experiment was over,the volume and weight of tumor were measure,the inhibitory rate of tumor growth was calculate,and the pathomorphological change was examined.Alpha fetal protein (AFP),routine blood test and biochemical indexes were determined in three experiments respectively.Results The average volume and weight of tumor in IGF-1R ASODN group was significantly reduced as compared with those in NS control group.The inhibitory rate of tumor growth in 75 mg/(kg·day) IGF-1R APSODN group in three experiments were 76.36％,71.81％ and 78.81％,55.65％,61.74％ and 63.58％ in 50 mg/(kg·day) group,and 47.72％,50.34％ and 54.30％ in 25 mg/(kg· day) group respectively.Large piece of necrosis and fibrosis could be seen under a light microscope in IGF-1R ASODN groups.AFP in IGF-1R ASODN groups was lower (P＜ 0.05) than in NS control group,PLT in IGF-1R ASODN group [75 mg/(kg·day)] was lower than in NS control group (P＜0.05),and GLU in IGF-1R ASODN group [75 mg/(kg· day) and 50 rmg/(kg· day)] was higher than in normal control group (P ＜0.05).There was no significant difference between IGF-1R ASODN group and normal control group in other blood indicators.Conclusion IGF-1 R ASODN is an anti-hepatoma biological agent with high efficiency and low side-effect.

患者, 男, 80岁, 入院2 h前为寻求性快感将鳝鱼置入肛门, 自觉下腹部撕裂样疼痛, 难以忍受, 伴有心慌、胸闷、呼吸急促、四肢冰冷等症, 多次试取, 均未成功, 急来我院就诊。腹部CT重建:(1)考虑乙状结肠穿孔;(2)盆腔内异物, 结合病史考虑为鳝鱼。心电图及各项抽血化验未见明显异常。入院诊断:(1)急性腹膜炎、乙状结肠穿孔?(2)盆腔内异物。急诊在全麻下行腹腔镜下腹腔探查+鳝鱼取出+乙状结肠穿孔修补术, 术后5 d逐步恢复饮食, 间断排便, 术后7 d拔出引流管, 术后9 d切口拆线, 病愈出院。

目的 探讨Sandwich教学法在ICU创伤教学中的应用效果.方法 选取2018年6月至2019年1月于我院ICU见习的30例规培医师及青年医师作为研究对象,随机分为Sandwich教学组与传统教学组各15例.结果 Sandwich教学组在病史采集、体格检查、临床判断、治疗方案、整体表现方面得分高于传统教学组(P<0.05).Sandwich教学组在提高学习的主动性,理解和掌握基础知识、提高思维能力及创伤救治胜任力、课程满意均高于传统教学组(P<0.05).结论 Sandwich教学法应用在青年医师在ICU创伤教学中,取得良好效果,值得推广.

案例式立体教学法(Case three-dimensional teaching method,CTTM),是将案例教学法与立体教学法有机结合,其基本内涵是以典型案例为基础,应用现代化光电及计算机技术将案例相关的音视频、医学影像、动画与案例有机结合,实现单一化的教学方法向立体化、多维化教学方法的转变,减少传统教学中教师集中讲授,学生被动学习的教学模式.在CTTM教育模式下指导教师在教学过程中尽可能的发挥学生的主观能动性,提高学生学习效率,培养思考及创新能力.我们将此教学方法应用于在重症医学科住院医师规范化培训的学员和参加科室轮转的青年医师的培训中,并采用迷你临床演练评估量表(Mini-clinical evaluation exercise,Mini-CEX)对教学效果进行评价,取得满意效果,现将此教学实践介绍如下.

Objective To study the impact of weight loss surgery after 3 months of stable condition through intervention on patients with obese hyperlipidemic acute pancreatitis (HLAP).Methods Ten patients with obese HLAP who underwent laparoscopic sleeve gastrectomy (LSG) at the General Surgery Department of our hospital were followed-up at 1,3,6,12,24 months after surgery.Their weight,BMI,EWL,and blood parameters (TG,LDL-C,HDL-C,TC,FPG,HbA1c,UA,hs-CRP,ESR,and hemorheology indexes) were compared.The impact on postoperative obese HLAP was assessed.Results The weight,BMI,EWL and blood index (TG,LDL-C,HDL-C,TC,FPG,HbA1c,UA,hs-CRP,ESR,and hemorheology indexes) of the patients gradually decreased.The decrease was significantly different from that before surgery (P＜0.05),which became stable at 12 months and with no recurrence at 24 months after surgery.Conclusions LSG reduced body weight and improved metabolic status of the patients.It stopped the occurrence of obese HLAP.LSG can be used as an effective intervention for patients with obese HLAP.

Objective Emergency sigmoid colonostomy surgery is usually needed for traumatic or iatrogenic rectum/sigmoid colon perforation, while wound infection and subsequent incisional hernia are common. This article aims to discuss how to simultaneously treat incisional hernia and sigmoid colon stoma with minimal trauma. Methods From January 2012 to July 2016, 3 cases of abdominal incisional hernia complicated with sigmoid colon stoma were treated in General Hospital of Ansteel Group. The clinical data were retrospectively analyzed. Results All 3 patients underwent laparoscopic operation successfully. The operation time was 150-210 min with an average of 170 min. The blood loss was 20-70 ml. The patients were discharged from the hospital in 8 to 10 days after the surgery. Stoma incisions and trocar incisions were healed, without anastomotic leakage, abdominal infection, seroma and other complications. After a follow-up period of 6 to 48 months, no intestinal leakage, mesh removal and hernia recurrence occurred. Conclusion It is feasible to repair hernia with simultaneous sigmoid colon stoma closure. However, it is necessary to make proper mesh selection, careful intraoperative operation and rigorous perioperative management.

患者女,55 岁,半月前体检发现胆囊息肉,无不适,于本院进一步行腹部彩超检查提示胆囊壁增厚,约 0.4 cm;胆囊息肉,直径约 1.0 cm,遂以"胆囊息肉"收入院.既往因子宫肌瘤行子宫全切手术,输血 200 ml.查体:体温 36.9℃,脉搏 85 次 / 分,呼吸 15 次 / 分,血压 17.955/11.305 kPa,心、肺未见明显异常,腹部平坦,下腹可见纵行手术瘢痕,腹软,无压痛,肝、胆、脾肋下未触及,未触及腹部包块,移动性浊音阴性,肠音正常.双下肢无凹陷性水肿,神经系统未见明显异常.上腹部增强 CT提示:(1) 肝脏多发囊肿;(2) 胆囊内小息肉;(3) 脾脏多发低密度灶,考虑淋巴管瘤可能性大;(4) 左肾结节影,考虑小肾癌;(5)双肾小囊肿.心电图、胸平片未见异常.请泌尿科会诊考虑肾脏病变为恶性,建议同期手术治疗.入院诊断为:(1) 胆囊息肉;(2) 脾脏多发淋巴管瘤;(3) 肾脏肿物,考虑为小肾癌;(4) 肝脏多发囊肿.

Objective To explore the clinical advantages of 3D laparoscopic transabdominal preperitoneal inguinal hernia repair(TAPP). Methods From February 2016 to May 2017, 60 patients who underwent TAPP surgery in Ansteel Group Hospital were randomly divided into 3D laparoscopic group and 2D laparoscopic group, 30 patients in each group. The intraoperative blood loss, operation time, postoperative hospital stay, hospitalization cost and postoperative complications were observed and compared between the 3D group and 2D group. Results This group of 60 patients with laparoscopic TAPP surgery successfully completed the operation. The operation time of the 3D group was shorter than that of the 2D group, and the difference was statistically significant (P 0.05). There were 5 cases of scrotal seroma in the two groups. There was no difference between the two groups (P>0.05). There were no complications such as urinary retention, temporary sensory neuropathy and chronic pain in the two groups. Conclusion The 3D laparoscopic technique greatly improves the surgeon's hand-eye fit, provides the most accurate spatial positioning, reduces the difficulty of surgical operation, and shortens the operation time and learning curve. Key words: Hernia, inguinal; Herniorrhaphy; 3D laparoscopic; 2D laparoscopic

Objective To verify whether procalcitonin (PCT) and C-reactive protein (CRP) can be used as an early predictor of anastomotic leakage (AL) and determine the optimal cut-off value, so as to provide evidence for early identification of AL after colorectal cancer surgery. Methods From January 2013 to April 2017, four hundred and eight cases undergoing colorectal cancer operation in Anshan Iron and Steel Group General Hospital were selected. The concentration of PCT, CRP and the white cell count (WBC) were detected 3, 5 d after operation (POD). The methods of operation, AL and other complications after operation were recorded. The differences of PCT, CRP and WBC levels among the AL group, the non-AL group and the non-complication group were compared on 3rd, 5th POD. According to the ROC curve, the prediction accuracy of PCT, CRP and WBC for AL were compared, and their sensitivity (SE), specificity (SP), joint sensitivity, joint specificity, negative predictive value (NPV), positive predictive value (PPV), the best critical value were also calculated. Results AL occurred in 19 cases, and the PCT and CRP values of the AL group were higher than the other two groups (P<0.05). The AUC of PCT and CRP was 0.773 and 0.839 on 3rd POD, and 0.893 and 0.863 on 5th POD, respectively. The prediction accuracy of the 5th POD was better than that of the 3rd POD for AL. The optimal cut-off value of PCT on 5th POD was 2.15 g/L, and NPV, PPV, SE, and SP of AL were 96.4%, 32.1%, 84.2% and 90.7%, respectively. The optimal cut-off value of CRP on 5th POD was 129.5 mg/L, NPV, PPV, SE, and SP of AL were 95.7%, 19.6%, 94.7% and 77.6%, respectively. A joint-detection of PCT and CRP could provide higher SE and SP up to 100.0% and 70.4%, respectively. Conclusions PCT and CRP are valuable indicators for early diagnosis of AL after colorectal surgery. Combined detection of PCT and CRP on 5th POD may be more conducive to the prediction of AL. Key words: Colorectal surgery; Anastomotic leak; Procalcitonin; C-reactive protein

Objective To study the relationship of early postoperative CRP and PCT with pancreatic fistula after pancreaticoduodenectomy (PD);to study whether the combination of CRP and PCT can be used as an early predictor of pancreatic fistula;and to determine the optimal cut-off values of CRP and PCT for early diagnosis of pancreatic fistula after PD.Methods Postoperative pancreatic fistula and other complications were recorded in 82 patients after PD carried out at the Anshan Iron and Steel Group General Hospital from January 2013 to May 2017.PCT and CRP were measured on the 1st to the 5th postoperative day (POD).CRP and PCT were compared between the pancreatic fistula group and the non-complication group on pancreatic fistula prediction.The sensitivity,specificity,and combined sensitivity,combined specificity,negative predictive value,positive predictive value and optimal cut-off value were calculated.Results 56 patients developed postoperative complications,including 17 patients with pancreatic fistula,and 39 patients with non-pancreatic fistula.The postoperative CRP and PCT were correlated with postoperative pancreatic fistula and with other complications.The higher the CRP and PCT,the higher the risk of postoperative pancreatic fistula.The ROC curves suggested that CRP and PCT had a high predictive value for pancreatic fistula,especially on POD 2.The optimal cut-off value of CRP was 189.05 mg/L,the sensitivity was 94.1％,the specificity was 81.5％,the positive predictive value was 94.7％,and the negative predictive value was 24.4％.The optimal cut-off value of PCT was 0.89 mg/dl,the sensitivity was 88.2％,the specificity was 84.6％,the positive predictive value was 91.3％,and the negative predictive value was 20.5％.The sensitivity and specificity of combined CRP with PCT on POD 2 in predicting pancreatic fistula after operations were 100％ and 69.1％,respectively.Conclusion Combined CRP and PCT had a high early predictive rate in the identification of pancreatic fistula after PD.

电焊工尘肺(Welder's pneutnoconissis)是指长期吸入电焊烟尘所致的慢性肺部损害,由于电焊烟尘是一种混合性粉尘,所以电焊工尘肺属于混合性尘肺的一种[1],目前我国仍然用X线胸片作为诊断尘肺的主要手段.

神经白塞综合征(NBS)是白塞病(BD)众多特殊表现之一.NBS 的头颅 MRI 文献少有报道.1992～2001年,我院收治了3例 NBS 患者,均做了头颅 MRI,间或有 MRI 增强或颅 CT.现将2例典型病例报告如下.

1 病例报告 病例1,女,16岁.双颊、额部对称散发针头大小的红色丘疹13年.间断抽搐3年.智力正常.无家族史.体检:双眼前房、眼底均未见异常.左眼鼻下方视野缺损.胸部 CT 未见异常.MR 表现:双侧侧脑室室管膜下多发小结节影,边缘光滑锐利,T1W 呈稍高信号, T2W 呈低信号,注入 Gd-DTPA 后病灶略有强化.右侧顶枕叶白质内见一0.8 cm×1.2 cm×0.9 cm椭圆形长T1长T2信号影,信号与脑脊液一致,边缘光滑,周边无水肿.MR 诊断:脑结节性硬化.