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開放式與腹腔鏡完全腹膜外腹股溝疝修補術的療效比較

目的比較開放式與腹腔鏡完全腹膜外腹股溝疝修補術（TEP）的療效和安全性。 方法采用前瞻性隨機對照研究方法，將86例成人腹股溝疝患者隨機分為開放式組（43例）和腹腔鏡組（43例），2組患者均行TEP。比較2組患者的手術時間、術后鎮痛劑使用頻次、術后下床活動時間、術后住院時間、總費用、并發癥發生情況及疝復發率。 結果2組患者的手術時間、術后鎮痛劑使用頻次、術后下床活動時間、術后住院時間、陰囊氣腫發生率和血清腫發生率比較差異均無統計學意義（P＞0.05），但開放式組患者的總費用低于腹腔鏡組（P=0.03）。2組均未出現切口感染等其他并發癥，且隨訪期間均未出現疝復發。 結論雖然腹腔鏡TEP具有微創優勢，但開放式TEP的總費用低，只需常規手術器械，且療效與腹腔鏡TEP相當，安全簡便，易于推廣。

Application of Transcutaneous Puncture Drainage Directed by B-Ultrosound for Treatment of Severe Acute Pancreatitis

目的　探討B超引導下穿刺置管引流技術在重癥急性胰腺炎治療中的應用價值。方法　36例重癥急性胰腺炎患者均行腹腔穿刺置管引流，其中經皮肝膽管（膽囊）穿刺置管引流（PTCD）23例，腹膜后積液（膿腫）穿刺置管沖洗引流16例，配合常規內科治療，取得滿意效果。結果　所有患者穿刺置管過程順利，均未出現與穿刺相關的并發癥如氣胸、血胸、腹腔內出血、穿刺部位感染等。所有患者在禁食、胃腸減壓、抗生素、生長抑素、制酸、維持水電解質酸堿平衡及腸內外營養支持治療的基礎上輔以超聲引導下穿刺置管引流，僅1例暴發性胰腺炎患者發生膿腔內大出血導致多器官衰竭而死亡，其余35例均治愈，無中轉開腹手術，患者腹痛、腹脹、腹部壓痛等主要癥狀和體征緩解時間為（4.4±1.3）d（1～7d），尿淀粉酶恢復正常時間為（3.1±1.5）d（2～8d）,住院時間為（23.4±7.3）d（16～55d）。結論　B超引導下穿刺置管引流術操作簡單、創傷輕微，在重癥急性胰腺炎治療中有重要價值。

Medical Glue and Stapling Fixed False Hernia Sac for Preventing Postoperative Seroma in Patients with Direct Hernia

ObjectiveTo compare the effects of medical glue and stapling in the prevention of postoperative seroma for patients undergoing laparoscopic direct hernia repair. MethodsNinty-four patients were randomly by computer generated randomization number divided into two groups: medical glue group (medical glue was used to fix pseudo-direct hernia sac) and stapling group (staple was used to fix pseudo-direct hernia sac).The time of follow-up was two years.The operative time, length of hospital stay, the pain level on first day and 7th day after operation, postoperative complications (seroma, wound infection, wound bleeding), hospital costs, and hernia recurrence rate within 2 years were observed. ResultsThe medical glue group compared with the stapling group, the operative time was shorter〔(35±5.1) min vs.(41±7.5) min〕, hospitalization time was shorter〔(4±0.51) d vs.(5±0.83) d〕, lower postoperative pain score〔the first day: (5±0.52) scores vs.(6±0.33)scores; the 7th day: (3±0.67) scores vs.(4±0.53) scores〕, and lower cost in hospital〔(5 731±560.50) yuan vs.(8 715±534.33) yuan〕, there were significant difference (P < 0.05).The incidence of seroma and other complications after operation and postoperative 1-year and 2-year hernia recurrence rate showed no significant differences (P > 0.05). ConclusionsThe medical glue has good prevention effects on postoperative seroma for patients undergoing laparoscopic direct hernia surgery, with shorter operative time and lower cost.This method is suitable for all levels of hospitals

毒死蜱中毒致胃瘢痕攣縮行全胃切除術1例報道

脾上皮樣血管內皮瘤合并自發性脾破裂、骨髓轉移1例報道及文獻回顧

目的探討脾上皮樣血管內皮瘤（epithelioid hemangioendotheliom，EHE）的臨床特點。方法回顧性分析甘肅省人民醫院收治的1例脾EHE合并自發性脾破裂、骨髓轉移患者的臨床資料，并對已發表的脾EHE相關的個案報道進行文獻回顧。結果本例患者因“左上腹痛5 d，全腹疼痛1 d”入院。影像學診斷自發性脾破裂，急診行脾切除，術后標本免疫組織化學結果示CD34、CD31、ERG及CD163陽性；CK、ATT及D2-40陰性；Ki-67指數約10%。熒光原位雜交檢出CAMTA1基因斷裂重排。診斷為脾EHE。患者術后40 d出現血小板計數降低，行骨髓活檢發現腫瘤骨轉移，口服海曲泊帕乙醇胺片、輸注血小板治療效果欠佳；給予鹽酸安羅替尼膠囊治療2周后，血小板減少情況加重，發生自發性肝臟出血，搶救無效死亡。檢索關于脾EHE的個案報道，并結合本例患者一共納入15例脾EHE，其中男10例，女5例，中位年齡48歲（18～59歲）。單純性脾EHE 7例，脾EHE伴遠處轉移8例。腹部CT及MR檢查無特異性表現。鏡下腫瘤細胞主要由含豐富胞質的上皮樣細胞組成，常排列成條索狀或巢團狀。免疫組織化學結果示CD34、CD31陽性。單純性脾EHE行手術脾切除，預后良好；脾EHE伴遠處轉移者，無有效治療方法，預后不佳。結論脾EHE臨床少見，影像學檢查容易誤診或漏診，病理學及分子檢查有助于準確診斷，合并轉移或多臟器受侵的患者預后較差。

Application of Routine or Selective Intraoperative Cholangiography in Laparoscopic Cholecystectomy

Objective　To explore whether the intraoperative cholangiography （IOC） should be applied in laparoscopic cholecystectomy routinely or selectively. Methods　Data of routine IOC group （1 520 patients）and selective IOC group （457 patients）in laparoscopic cholecystectomy were collected and analyzed， including cholangiography time， success rate， common bile duct stones rate， open cholecystectomy rate， and hospital stay after operation. All IOC cases were performed by home-made cholangiography appliance or infusion needle. Results　There were no significant differences between routine IOC group and selective IOC group on cholangiography time， success rate， open cholecystectomy rate， and hospital stay after operation （P＞0.05）. However， compared with routine IOC group， the common bile duct stones rate， anatomic variation rate， and iatrogenic damage rate were significantly higher in selective IOC group （28.25% vs. 13.43%， 10.71% vs. 7.43%， 2.05% vs. 1.02%， P＜0.05）. Conclusions　For avoiding iatrogenic bile duct damage and residual stones， routine IOC should be applied in early-stage of laparoscopic cholecystectomy， and IOC should be applied selectively when the surgeon have LC technique at their finger ends.