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Diagnosis and Treatment of Deep Venous Thrombosis of Lower Limb

目的 总结我科2002年3月至2005年10月收治的下肢深静脉血栓形成(deep vein thrombosis,DVT)患者的诊治经验.方法 本组下肢DVT患者275例,患肢294条.男134例,女141例,年龄14～92岁,平均(50.76±16.43)岁.单侧下肢DVT 256例(左侧159例,右侧97例),19例为双下肢DVT(其中有8例是仅一侧肢体有临床表现); 属混合型194条,中央型74条,周围型26条.行彩色多普勒或静脉造影检查了解血栓部位及范围; 对怀疑有肺动脉栓塞(pulmonary embolism, PE)者行肺部增强CT扫描.治疗包括抗凝、溶栓、祛聚、梯度压力静脉弹力袜以及对症处理.对反复发生PE、存在抗凝治疗禁忌证、需要手术取栓、下肢静脉存在悬浮游离血栓者安置下腔静脉滤器.对发生股青肿患者行手术取栓.疗效评价: 住院期间观察症状变化,监测膝关节上、下15 cm处周径; 对随访患者行CEAP(clinical-etiology-anatomic-pathophysiologic)临床表现分级、功能障碍评分(venous disability score, VDS).结果 本组DVT常见的危险因素包括活动受限史、2周以内有手术史、恶性肿瘤及外伤史.本组患肢主要临床表现包括: 肿胀、疼痛、皮温增高、皮肤暗红、浅静脉迂曲等.并发症: PE 9例,股青肿2例,下腔静脉阻塞综合征3例.275例中2例行手术取栓,25例安置下腔静脉滤器.本组患者症状经治疗后1～5 d开始缓解,出院时膝关节上、下周径较入院时明显缩小(P＜0.05).随访时间6个月～3年,195例(70.9%)的201条(68.4%)患肢获得随访,患肢CEAP分级: C0级78条,C1级53条,C2级16条,C3级20条,C4级15条,C5级11条,C6级8条; VDS评分: 0分77例,1分66例,2分33例,3分19例.结论 下肢DVT的诊断中应注意对危险因素以及无症状的DVT的搜寻; 早期治疗以非手术治疗为主,通过抗凝、溶栓等综合治疗可以达到满意效果; 在早期如发生股青肿应及时手术治疗; 有选择地安置下腔静脉滤器可防止PE的发生; 后期应根据病情特点确定治疗方案和疗程.

Clinical Analysis of Diagnosis and Treatment of Acute Pancreatitis in Pregnancy

目的 探讨妊娠期并发急性胰腺炎(APIP)的病因、发病机理、临床特点及防治措施. 方法 对四川省宜宾市第二人民医院和四川大学华西医院1995年1月至2006年12月期间收治的72例APIP患者的临床资料进行回顾性分析. 结果 本组72例中,属轻型急性胰腺炎(MAP)者49例(68.06%),重症急性胰腺炎(SAP)者23例(31.94%); 有胆囊炎合并胆囊结石病史者43例(59.72%),伴高脂血症者21例(29.17%).采用非手术治疗56例,手术治疗16例,孕妇治愈66例(91.67%),死亡6例(8.33%),死因为多器官功能障碍综合征、急性呼吸窘迫综合征及严重复腔感染; 终止妊娠16例(均为32～38周妊娠),56例继续妊娠; 72例中双胎2例,胎儿死亡共15例(20.27%); 漏诊、误诊6例.结论 APIP的发生与胆结石和高脂血症有关,并于妊娠中晚期发病率高; 其临床表现复杂,易误诊,对孕妇及胎儿威胁极大; 把握该疾病的特点,提高对APIP的认识和警惕性,及时准确的诊断与"个体化"的治疗原则,适时终止妊娠,可以提高其治愈率,降低母婴死亡率.

胸外科患者术后肺栓塞的诊断与治疗

目的　总结肺栓塞（pulmonary embolism，PE）患者的特点，提高胸外科患者术后并发症的诊断与治疗水平。　方法　回顾性分析上海交通大学附属胸科医院2007年6月至2008年10月收治术后肺栓塞患者22例的临床资料，其中中高危肺栓塞8例，男5例、女3例，平均年龄63.5 （55～76）岁，肺癌5例，食管癌1例，纵隔肿瘤1例，慢性炎性肉芽肿1例，均行溶栓治疗；低危肺栓塞14例，男 11例、女 3例，平均年龄61.7 （55～75）岁，肺癌9例，食管癌5例，均行抗凝治疗。　结果　中高危患者中7例症状在24 h内明显改善，均痊愈出院，随访3个月无复发；1例24 h内好转，48 h后出现严重的肺部感染，并于5 d后死亡。14例低危患者均于治疗3～5 d后氧合改善，随访3个月无复发。　结论　胸外科患者术后肺栓塞的诊断仍较为困难；溶栓治疗是中高危肺栓塞患者的首选治疗方案；深静脉血栓（deep vein thrombosis，DVT）形成是术后肺栓塞的高危因素，应高度重视。

Clinical Analysis of 17 Patients with Chest Injuries in Lushan Earthquake

Objective To summarize our treatment experience for patients with chest injuries in “4•20” Lushan earthquake. Methods Medical records of 17 patients with chest injuries after 2013 Lushan earthquake who were admittedto the Department of Thoracic Surgery，West China Hospital were analyzed retrospectively. The diagnosis of chest injuries was mainly confirmed by medical history，physical examination，X-ray and CT scan of the chest. Clinical characteristics and treatment outcomes were analyzed. Among the 17 patients，there were 14 men and 3 women with their age of 57.3±16.1 years. Results There were 12 patients （70.6%）with crash injury of heavy objects，4 patients （23.5%） with fall injury and 1 patient with road traffic injury. Chest injuries were skin and soft tissue contusion in 17 patients （100%），rib fracturein 15 patients （88.2%） including 1 patient with abnormal respiratory movements，pulmonary contusion in 15 patients （88.2%），hemopneumothorax in 11 patients （64.7%），sternal fracture in 1 patient （5.9%） and bilateral pneumothorax with widespread subcutaneous emphysema in 1 patient （5.9%）. Thirteen patients （76.5%） had concomitant brain，abdominal，orthopedic or nerve injuries. One patient underwent left thoracotomy，clot removal and internal fixation of rib fractures for left coagulated hemothorax and left lower lobe atelectasis. All the 17 patients received timely and effective treatment and there was noin-hospital mortality. Conclusions Mechanisms of earthquake injuries are often complex，and patients often have multipleinjuries. The main types of chest injury are rib fractures and pulmonary contusion. Tube thoracostomy is a simple andeffective treatment strategy for them. Satisfactory pain management and bronchoscopy procedure can effectively help patientswith removal of respiratory secretions and maintenance of airway patency.

食管癌术后下消化道出血的诊治分析

原发性纵隔内胚窦瘤一例

Diagnosis and Management of Concealed Intrathoracic Anastomotic Leak of Esophagus

Abstract：　Objective　To investigate diagnosis and treatment of concealed intrathoracic anastomotic leak of the esophagus.　Methods　We retrospectively analyzed the clinical data of 32 patients who presented with unexplained sepsis （temperature＞38 ℃ and elevated white blood cell count） after esophagectomy and intrathoracic anastomosis for esophageal　carcinoma or gastric cardia carcinoma in Affiliated Hospital, Medical College of Qingdao University from January 2006 to December 2010. All the patients underwent oral water-soluble contrast esophagogram and oral water-soluble contrast computerized tomography of the chest. None of the patients had any sign of contrast leak in these diagnostic examinations, but their chest computerized tomography all showed peri-anastomotic bubble and encapsulated effusion. Fifteen patients were treated as concealed intrathoracic anastomotic leak of the esophagus, including fasting, broad spectrum antibiotic treatment, prolonged gastrointestinal decompression and enteral nutrition via naso-intestinal feeding tube. The other 17 patients were not treated as anastomotic leak of the esophagus and only received broad spectrum antibiotic treatment. Results None of the 15 patients who were treated as concealed intrathoracic anastomotic leak finally developed anastomotic leak proved by oral water-soluble contrast esophagogram and computerized tomography of the chest （0%, 0/15）. Among the 17 patients　who were not treated as anastomotic leak, fourteen patients developed anastomotic leak later （82.4%, 14/17）, 2 patients died of aorto-esophageal fistula and 3 patients died of multiple organ dysfunction syndrome.　Conclusion　Peri-anastomotic bubble and irregular encapsulated effusion in oral water-soluble contrast esophagogram and computerized tomography of the chest should be considered as specific signs of concealed intrathoracic anastomotic leak of esophagus after esophagectomy and intrathoracic anastomosis. Patients with such signs should be treated as anastomotic leak.

下行性坏死性纵隔炎的诊断与治疗

目的　探讨下行性坏死性纵隔炎（DNM）的诊断和治疗方法。　方法　回顾性分析1988年1月至2009年12月青岛大学医学院附属医院收治11例DNM患者的临床资料，其中男8例，女3例；年龄25～71 （55±3）岁。早期收治的患者外科治疗采用颈部清创、引流，或经颈部纵隔引流；后期收治的患者采用颈、胸部同期清创、引流及术后冲洗。　结果　行单纯颈部清创、引流及经颈部纵隔引流的7例患者中死亡4例，均死于严重纵隔感染导致多器官功能衰竭，3例生存患者均为感染尚未侵犯下纵隔和胸腔；行颈、胸部清创、引流和冲洗的4例患者全部治愈。随访7例，随访时间3个月，患者恢复良好。　结论　DNM病情凶险，一旦发病迅速进展为脓毒血症，甚至死亡。重视口咽部和颈部感染患者的胸部症状、体征变化，及时行胸部CT检查是尽早诊断DNM的关键。尽早进行颈、胸部彻底清创、充分引流及有效冲洗是治疗DNM成功的关键。

电视胸腔镜在肺部小结节诊断与治疗中的应用

目的　探讨电视胸腔镜技术对早期周围型肺癌诊治的临床意义。　方法　自2007年1月至2011年1月南京军区福州总医院共施行电视胸腔镜肺部小结节切除手术245例，其中男147 例，女98例；年龄（55.8±6.7）岁。行全胸腔镜肺叶切除术160例，术中中转开胸在胸腔镜辅助下经小切口行肺叶切除术23例，肺楔形切除术62例。　结果　本组无死亡，所有患者均明确病理诊断，确诊率100%。术后住ICU时间1～5 （2.6±1.5） d，胸腔引流时间1～8 （3.8±1.2） d，术后住院时间5～12 （7.9±3.5） d。术后病理诊断：良性病变55例，其中肺炎性假瘤27例，肺结核球13例，肺错构瘤15例；恶性肿瘤190例，其中细支气管肺泡癌116例，腺癌38例，细支气管肺泡癌合并腺癌28例，鳞癌5例；转移癌3例。随访242例，随访时间1～48个月，平均随访21个月，失访3例。55例良性疾病患者远期无并发症发生；187例原发性恶性肿瘤患者，术后未发生肿瘤远处转移，随访至今无死亡患者。　结论　电视胸腔镜技术有利于早期非小细胞肺癌的诊断，提高手术切除率，改善预后。

Sarcoidosis-A Disease Needs to Be Differentiated from Lung Cancer

Abstract：　Sarcoidosis is a common systemic disease with noncaseating granulomatous epithelioid nodule and coexisting　granulomatous inflammation. Although sarcoidosis can affect any organ of the body， more than 90% of the patients　demonstrate thoracic involvement， which is often confusing with lung cancer and other diseases. Therefore, thoracic surgeons　must have a clear understanding of sarcoidosis. Moreover， due to the special role of surgery in obtaining pathological specimens， thoracic surgeon plays an important role in the diagnosis and treatment of sarcoidosis. It is not difficult to make diagnosis for patients with typical clinical features of sarcoidosis. However， the majority of patients do not have specific manifestations of sarcoidosis. The cause of sarcoidosis remains unknown， and there is also no specific treatment strategy for it. But recent research has shown that annexin A11 gene may be involved in the pathogenesis of sarcoidosis， and tumor necrosis factor （TNF） inhibitor is effective in the treatwent of sarcoidosis.