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腹股沟疝514例诊治体会

腹膜后副神经节瘤3例报道

　病例1　女，31岁，因发现腹部包块7个月入院，无疼痛、发热、恶心、呕吐等。B超发现右中上腹脊柱右侧前方有一14 cm×10.5 cm大囊实性包块，内有弱回声点，包膜完整。CT检查示右侧腹腔内有一囊实性低密度肿块，10 cm×10 cm大，囊性区CT值为20 Hu，实性区为44 Hu。术中见右上腹腹膜后、十二指肠下方有一10 cm×10 cm×8 cm大肿块，包膜完整，切开包块见有4个2～4 cm大囊肿，其内为咖啡色液体。遂行包块切除，病愈出院。病理报告为腹膜后副神经节瘤并出血。术后随访3年无复发，后失访。　　病例2　女，22岁，因发现左上腹包块1个月入院，无其他不适。查体： 左上腹扪及15 cm×10 cm大包块，边界清楚，表面凹凸不平，质硬，不活动，无压痛。B超检查示左上腹有一10 cm×8 cm大实性包块。术中见左上腹膜后有一15 cm×10 cm×10 cm大包块，包膜完整，表面凹凸不平，包块与胰尾及横结肠系膜粘连，基底部有2条0.7 cm直径血管通入。遂行包块切除，病愈出院。病理报告为腹膜后副神经节瘤。随访5年后失访。 　　病例3　男，38岁，发现左上腹包块5个月入院，偶有头晕、头痛，未引起重视。查体： BP 110/70 mm Hg（1 mm Hg=0.133 kPa），左上腹扪及15 cm×15 cm大包块，边界清楚，无压痛。B超发现左上腹12.3 cm×10.3 cm异常回声区，边界清楚，为囊实性。CT检查示胰体尾部10.4 cm ×12.0 cm大包块，内有多个大小不等囊腔，实性区CT值38 Hu，囊性区CT值11 Hu，增强后为85 Hu。术中见左上腹腹膜后有一15 cm×12 cm×12 cm大包块，包膜完整，内有7个2～10 cm大小囊肿，内为咖啡色液体。包块血供丰富，有数条直径为0.1～0.4 cm血管通入。术中扪压包块时血压达280/160 mm Hg，经降压后切除包块，切除包块后血压为80/60 mm Hg，经升压后完成手术，病愈出院。病理报告为腹膜后副神经节瘤。免疫组化CgA（+）， Syn（+）， CK灶性（+），EMA（-），CD117（-），Ki-67指数5%。随访1年无复发及高血压。　　讨论　腹膜后副神经节瘤是起源于腹膜后交感性副神经节组织的肿瘤，是一种源于嗜铬组织的内分泌肿瘤，可能是一种多基因遗传疾病。该病可发生于任何年龄，无明显性别差异。该瘤分功能性和非功能性两种。功能性副神经节瘤又称嗜铬性副神经节瘤，具有儿茶酚胺分泌功能； 非功能性副神经节瘤又称非嗜铬性副神经节瘤、化学感受器瘤。功能性副神经节瘤由于分泌过多的儿茶酚胺类物质，临床上可出现阵发性或持续性高血压、头晕、头痛、心悸、多汗及偶发的胃肠道功能紊乱； 当肿瘤受到挤压、应激状态时，可释放大量儿茶酚胺类物质，从而引起急性肺水肿、心脑血管意外、急性心肌损害、心功能衰竭等危象的发生。非功能性副神经节瘤主要表现为肿块缓慢生长对周围组织的压迫症状。本组病例1、2为非功能性； 病例3系功能性，因术前未能考虑本病，致术中挤压包块时出现血压急剧升高，经及时降压后切除肿块。恶性腹膜后副神经节瘤除上述临床表现外，还可出现局部浸润及远处转移。手术切除是该病惟一有效而可靠的方法，一经诊断应尽早手术切除。术中应尽可能完整切除包块，彻底清扫淋巴结。对功能性肿瘤术中应尽量减少对瘤体的挤压，避免因过度释放儿茶酚胺类物质而引起高血压危象的发生。对术中探查导致血压骤然升高，应立即停止手术，在气管插管麻醉下，选用α-受体阻滞剂（酚苄明和钙离子通道阻滞剂），肿瘤切除术后给予升压，并心电监护，必要时监测中心静脉压，防止过量、过快输液诱发右心衰竭、肺水肿。副神经节瘤对放、化疗都不敏感。但有作者认为放、化疗可作为术后的辅助治疗，对预防术后复发、转移，提高生存率有一定帮助，主张用环磷酰胺、长春新碱、氨烯咪胺联合化疗。对本病行长期随访十分重要，文献报道5年生存率为59%。

胆囊残株炎23例诊治体会

APPLICATION OF ISOIONIC MICROTRAUMA ARTHROSCOPE ON TREATMENT OF KNEE ARTHROPATHY

Objective To investigate the clinical applicationand curative effect of isoionic microtrauma arthroscope on treatment of knee arthropathy. Methods From May 2003 to November 2004, 52 cases of knee joint injury were cured by using isoionic microtrauma arthroscope, including 30 cases ofknee osteoarthritis, 10 cases of meniscus injury, 5 cases of kneecap dislocation, 5 cases of laxity of anterior cruciate ligation and 2 cases of rheumatoid arthritis. In accordance with Lysholm criterion for knee joint function, the scores were 35.5±4.9 before operation. Results All of these patients were followed up for 2-17 months. The scores of knee joint function was 86.4±5.3 after operation, and there was significant difference (Plt;0.001). Conclusion Isoionic microtrauma arthroscope is characterized by low-temperature hemoagglutination, crimpling,boiling, cutting and hemostasia, which makes kneejoint arthroscope operation easier-to-do, miner histological scathe and lighter side effect; so it is favourable for functional recovery and its curative effect is satisfactory.

Risk factors for non-steroidal anti-inflammatory drug-induced intestinal mucosa injury: a systematic review

ObjectivesTo systematically review the risk factors for intestinal injury induced by non-steroidal anti-inflammatory drugs(NSAIDs).MethodsWe comprehensively searched WanFang Data, CNKI, Web of Science, EBSCO, PubMed and The Cochrane Library databases to collect studies on risk factors of NSAIDs-induced intestinal injury. Two reviewers independently screened literature, extracted data and assessed risk of bias, and then, meta-analysis was performed by using RevMan 5.2 and STATA 12.0 software.ResultsA total of 6 case-control studies were included, in which 265 patients were in the case group and 301 patients in the control group. The results of meta-analysis showed that PPI was an independent risk factor for NSAIDs-induced intestinal injury (OR=1.59, 95%CI 1.07 to 2.35, P=0.02). In addition, patients with osteoarthritis (OR=2.44, 95% CI 1.11 to 5.36, P=0.03) or rheumatoid arthritis (OR=3.04, 95% CI 1.31 to 7.03, P=0.01) was associated with intestinal mucosal injury induced by NSAIDs. Gender, age, smoking history, drinking history, H2RA and rebamipide medication history, cardiovascular disease and cerebrovascular disease were not associated with intestinal injury.ConclusionsPPI is an independent risk factor for NSAIDs-induced intestinal injury. However, studies with high-quality, larger sample size are required to further verify that PPI increases the prevalence of intestinal injury.

The Application of Air Leak Test Combined with Methylene Blue Solution Leak Test in Detection of Anastomotic Leakage after Total Mesorectal Excision in Rectal Cancer

Objective　To investigate the application of air leak test combined with methylene blue solution leak test in the detection of anastomotic leakage after total mesorectal excision （TME） in rectal cancer. Methods　In total of132 patients with rectal cancer underwent Dixon according to TME in our hospital from Mar. 2010 to Mar. 2013 were enrolled. All patients were randomly divided into air leak test group （n=65） and air leak＋methylene blue solution leak test group （n=67）. The intestinal anastomosis of patients in air leak test group were clamped at 2 cm from the upper endof bowel， then injecting 500 mL distilled water to pelvic， and placing 24# Foley catheter through the anus. The catheter balloon was injected with water to close anus， and then injected with 50 mL gas to find the anastomotic leakage where bubbles happened， and then repaired it. Patients of air leak＋methylene blue solution leak test group were treated with methylene blue solution test in addition. After sucking out of the distilled water in pelvic and gas in the rectum， 1 bottle of methylene blue solution （20 mg） and 50 mL saline were injected， observing the location where the methylene blue solutionleaking out and repaired it. Results　Three cases （4.62%） of anastomotic leakage were found during operation in air leak test group， and 9 cases （13.85%） were found after operation. Of the 9 cases， 5 cases were cured with placement of adeq-uate drainage and symptomatic treatment， 3 cases were cured with anal patch， and 1 case was cured with transverse colon fistula and drainage. In total of 15 cases （22.39%） were found anastomotic leakage， 2 cases of them were found by air leak test and another 13 cases were found by methylene blue solution leak test during operation in air leak＋methylene bluesolution leak test group， but no one suffered anastomotic leakage after operation. Compared with air test group， detectionrate of anastomotic leakage during operation was higher （P＜0.05）， and incidence rate of anastomotic leakage after opera-tion was lower in air leak＋methylene blue solution leak test group （P＜0.05）. Conclusions　Large anastomotic leakage can be found by using air leak test， and small and hidden leakage can be found by using methylene blue solution leak test， combination method of the two experiments is better. Repair can be performed effectively under direct vision.

地市级医院建立日间手术中心的探索与实践

日间手术起步于欧美，近 20 年在我国得到迅速的开展，特别是发达地区的教学医院，相继成立了专门的日间手术中心。通过对国内已开展的日间手术中心的实地考察与研究，德阳市人民医院经过长达 2 年的准备，于 2016 年 6 月 1 日成立了日间手术中心。该文从我国日间手术的发展现状出发，对德阳市人民医院成立日间手术中心的实践过程进行回顾性总结，包括前期择期手术预入院，与市医疗保险管理局联合完成结算报销系统改造和择期手术患者就诊流程改造的回顾，日间手术中心成立过程中遇到相关问题的探索，并对支撑日间手术中心发展密切相关的医疗保险、绩效问题进行研究。