论医疗“并发症”在医疗侵权案件中的司法归责判断

目的探讨医疗"并发症"在医疗侵权诉讼案件中的具体免责事由与判断标准。方法通过对比分析司法界和医学界对于医疗"并发症"的不同理解,借鉴医疗"并发症"在司法实践过程中的实际情况,对医疗"并发症"的概念进行分类,分析医疗"并发症"免责原因。结果医务人员只有在详细的履行了"并发症"告知义务,并且采取有效的措施预防和治疗"并发症"的情况下才能最终免责。结论医疗"并发症"并非绝对是医院的免责事由。

Research progress on the correlation between aqueous humor components and pathogenesis and postoperative complications in patients with different types of cataracts

Aqueous humor provides the necessary nutrition for the lens and transports the metabolites in the eye.It was a liquid that can directly reflect the microenvironment in the eye'and it can be easily obtained during the operation.This review intended to analyze the components of aqueous humor in patients with different types of cataracts'so as to reflect the pathogenesis and development of the disease'evaluate the incidence of postoperative complications and provide reference value for the surgical design of sequential cataract surgery.The aqueous humor components of different types of cataracts showed different degrees of inflammation'oxidative stress and extracellular matrix remodeling.The biomarker of early neuropathy in diabetic cataract was neural cell adhesion molecule-1(NCAM1).Transforming growth factor-β(TGF-β)was the evaluation factor of disease development in patients with pseudoexfoliation syndrome.The relationships between postoperative complications of different types of cataracts and aqueous humor components were as follows:Macular edema after diabetic cataract surgery was associated with tumor necrosis factor-alpha;capsular contraction after high myopic cataract surgery was related to monocyte chemoattractant protein-1(MCP-1)and TGF-β2;Klotho and glutathione S-transferase P 1(GSTP1)were associated with high intraocular pressure after primary open-angle glaucoma complicated by cataract surgery;capsular contraction after retinitis pigmentosa complicated by cataract surgery was associated with matrix metalloproteinases;pro-inflammatory cytokines and fibroblast growth factor 4 in the aqueous humor of congenital cataracts were associated with posterior capsular opacification after surgery.Granulocyte colony stimulating factor 3 and MCP-1 were the main cytokines mediating the pain of the second eye in the binocular sequential cataract surgery short interval(1 wk)'while MCP-1 mediated pain in the long interval(6 wk).The second eye after binocular sequential cataract surgery had a higher level of proinflammatory factors.The components of aqueous humor in patients with different types of cataracts were related to the pathogenesis and postoperative complications of the disease.Monitoring the components of the aqueous humor could help better understand the intraocular microenvironment of different types of cataracts and provide a reference for predicting the development of the disease and implementing relevant targeted therapy.

Comparative study on the efficacy of transoral robotic surgery and non-robotic surgery for tongue base tumors

Objective:To compare the efficacy of transoral robotic surgery(TORS)and non-robotic surgery(NRS)in the treatment of tongue base tumors.Methods:A total of 45 patients with tongue base tumors treated in our hospital were selected,and they were divided into the TORS group and NRS group according to different surgical methods.The surgical indicators and postoperative complications of patients in the two groups were compared and analyzed.Results:Compared with the NRS group,the operative time,bleeding volume and length of hospital stay were less in the TORS group,and the postoperative recurrence rate was less in the TORS group than that in the NRS group.The incidence rate of dysphagia and restricted mouth opening in the TORS group was lower than that in the NRS group within 30 d after surgery,and the difference was statistically significant(P<0.05).Conclusion:TORS has better minimally invasive advantages in the treatment of tongue base tumors,including less intraoperative bleeding,smaller trauma,shorter length of hospital stay and faster recovery.

“证”、“症”、“征”与相关医学术语规范用字的意见

“证”、“症”、“征”在医学领域是使用频度颇高的三个 (字 )词 ,由于其音、形、义相近 ,因而在取舍时不易辨别。虽然在全国科技名词委公布的《医学名词》中已有规范 ,但在实际应用上仍然见仁见智、不尽相同。为此 ,本刊组织中、西医学界一些专家 ,就此三词据理辨析 ,以求正本清源 ,达成一致意见。本栏刊出后 ,欢迎广大读者来文来函 ,进一步发表意见。

Risk Factors of Early Complications after Pancreaticoduodenectomy in 200 Consecutive Patients

To study the risk factors for early complications after pancreaticoduodenectomy （PD）. Methods： Two hundred patients undergoing PD at our hospital between December 1996 and September 2002 were reviewed retrospectively. Standard PD was performed on 176 cases, standard PD with extended lymphadenectomy on 24 patients, whereas pylorus-preserving PD was not used. An end-toside combined with mucosa-to-mucosa pancreaticojejunostomy was performed on the patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy on the patients with a soft pancreas and a non-dilated duct. The risk factors with the potential to affect the incidence of complications were analyzed with SAS 8.12 software. Logistic regression was then used to determine the effect of multiple factors on early complications. Results： The overall rate of the major com- plications was 21% （42/200）, with the failure of pancreaticojejunal anastomosis being the most frequently encountered. Age （odds ratio [OR] 2.162）, diabetes mellitus （OR 4.086）, total serum bilirubin level （OR 7.556）, end-to-end pancreaticojejunostomy （OR 2.616）, T tube through the choledochojejunostomy （OR 0.100）, and blood transfusion over 1000 mL （OR 2.410） were the significant risk factors for the morbidity. Conclusion： The results from published series concerning morbidity after pancreaticoduodenectomy are not comparable because of lack of homogeneity between them. The knowledge of the complications rate in each particular department turns out essentially to provide the patient with tailored information about risks before surgery. Additionally, management of postoperative complications is essential for improving the results of this operation.

Protocol of Interventional Treatment for Hepatocellular Carcinoma

To establish a reasonable protocol for interventional treatment ofhcpatocellular carcinoma (HCC). Methods: The data of 1000 HCC patients treated by different kinds ofinterventional treatments were reviewed with their results of biochemistry, imaging, pathology andsurvival rate evaluated. The values as well as the pros and cons of these various kinds ofinterventional treatments were compared in order to find an optimal protocol. Results:Segmental-transcatheter oil chemoembolization (S-TOCE) could more effectively eradicate the tumoryet inflicting less damage on the noncancerous hepatic tissue and giving much higher survival ratethan the conventional transcatheter oil chemoembolization (C-TOCE). Precutaneous ethanol injection(PEI) in combination with chemoembolization could eliminate the residual tumor and significantlyincrease the survival rate without damaging the noncancerous hepatic tissue. The living quality orsurvival rate could be improved by choosing different ways of interventional treatments to cut downthe complications. Conclusion: The selection of different interventional treatments should bo doneaccording to the size and type of HCC. Active management is indicated for different complicationspresenting along with HCC.

Surgical treatment of the biliary ductal stricture complicating localized left hepatolithiasis

AIM To summarize the experience in the clinical treatment of the biliary ductal strictures complicating localized left hepatolithiasis in recent two decades.

Transcatheter to Close the Patent Duetus Arteriosus and Atrial Septal Defects in Children

Objective: To evaluate the therapeutic effect, safety and complications oftranscathetering Amplatzer device in the closure of patent ductus arteriosus (PDA) and atrial septaldefects (ASD) in children. Methods: Patients with PDA (n = 25) and ASD ( n = 16), confirmed byechocardiography, were treated by transcatheterization. Amplatzer occluder device was placed by thetranscatheterization with the image support of X-ray and transthoracic echocardiography ( TTE) . TheTTE, ECG and X-ray examination were engaged to evaluate the therapeutic results on the time pointsof 24 h , 1, 3 , 6, 12 months after the operation, and all these cases were engaged to the follow-upexamination. Results: The cardioangiographic diameter was 13.0-28.0 mm ([19.3+-4.9] mm) in ASD and2.0-7.7 mm ([3.9+-1.5] mm) in PDA . The diameter of the Amplatzer occluder selected were 13.0-30.0mm ( [20.6+-5.1] mm) in ASD and 4.0-12.0 mm ([6.6+-1.9] mm) in PDA , respectively. All the Amplatzeroccluders were placed successfully. There were no complications during and after the operation.Very small residual shunt was still found soon after the operation in 10 cases , and there were noresidual or recanalization after three months of the operation. The pulmonary artery pressure andheart size were significantly decreased in follow-up examination . Conclusion: Transcatheteringclosure with Amplatzer device is an effective, simple and safe technique in the treatment of ASD andPDA in children.

多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值

目的探讨多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值。方法 9例颅底肿瘤术前均行DynaCTA检查及MRI薄层(2 mm)增强扫描检查,将多组影像数据输入工作站,采用"双容积重建"技术进行脑血管及MRI的影像融合,通过静态及动态融合影像观察肿瘤与脑结构、血管及颅骨的毗邻关系,并对肿瘤的诊断、手术治疗及预防血管并发症进行分析。结果 9例均获得满意的影像融合、具有很好的空间一致性,在一张影像上可以清晰显示病变及其周围脑结构、血管及颅骨解剖关系,提高精准性诊断,并应用于指导治疗策略、设计手术划及预防并发症。9例均恢复满意出院。结论多模态影像融合对提高颅底肿瘤的诊断精准性、提高肿瘤全切除率、降低病死率和残疾率效果肯定,对血管损伤并发症治疗疗效肯定。

Pathophysiology of pulmonary complications of acute pancreatitis

Acute pancreatitis in its severe form is complicated by multiple organ system dysfunction, most importantly by pulmonary complications which include hypoxia, acute respiratory distress syndrome, atelectasis, and pleural effusion. The pathogenesis of some of the above complications is attributed to the production of noxious cytokines. Clinically significant is the early onset of pleural effusion, which heralds a poor outcome of acute pancreatitis. The role of circulating trypsin, phospholipase A2, platelet activating factor, release of free fatty acids, chemoattractants such as tumor necrsosis factor （TNF）- alpha, interleukin （IL）-1, IL-6, IL-8, fMet-leu-phe （a bacterial wall product）, nitric oxide, substance P, and macrophage inhlbitor factor is currently studied. The hope is that future management of acute pancreatitis with a better understanding of the pathogenesis of lung injury will be directed against the production of noxious cytokines.

IT IS GASTROESOPHAGEAL REFLUX DISEASE, NOT ASTHMA: A CASE REPORT

THE incidence of gastroesophageal reflux disease （GERD） is high in Western nations. Its extraesophageal manifestations such as asthma, paroxysmal laryngospasm, and excessive throat phlegm,

Rapid progression of hepatocellular carcinoma after Radiofrequency Ablation

AIM:To report the results of radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) in cirrhotic patients and to describe the treatment related complications (mainly the rapid intrahepatic neoplastic progression). METHODS:Eighty-seven consecutive cirrhotic patients with 104 HCC (mean diameter 3.9 cm,1.3 SD) were submitted to RFA between January 1998 and June 2003.In all cases RFA was performed with percutaneous approach under ultrasound guidance using expandable electrode needles. Treatment efficacy (necrosis and recurrence) was estimated with dual phase computed tomography (CT) and alpha- fetoprotein (AFP)level. RESULTS:Complete necrosis rate after single or multiple treatment was 100%,87.7% and 57.1% in HCC smaller than 3 cm,between 3 and 5 cm and larger than 5 cm respectively (P=0.02).Seventeen lesions of 88(19.3%) developed local recurrence after complete necrosis during a mean follow up of 19.2 mo.There were no treatment-related deaths in 130 procedures and major complications occurred in 8 patients (6.1%).In 4 patients,although complete local necrosis was achieved,we observed rapid intrahepatic neoplastic progression after treatment.Risk factors for rapid neoplastic progression were high preoperative AFP values and location of the tumor near segmental portal branches. CONCLUSION:RFA is an effective treatment for hepatocellular carcinoma smaller than 5 cm with complete necrosis in more than 80% of lesions.Patients with elevated AFP levels and tumors located near the main portal branch are at risk for rapid neoplastic progression after RFA.Further studies are necessary to evaluate the incidence and pathogenesis of this underestimated complication.

Extraintestinal manifestations and complications in inflammatory bowel diseases

Crohn＇s disease （CD） and ulcerative colitis （UC） are chronic inflammatory bowel diseases （IBD） that often involve organs other than those of the gastrointestinal tract. These nonintestinal affections are termed extraintestinal symptoms. Differentiating the true extraintestinal manifestations of inflammatory bowel diseases from secondary extraintestinal complications, caused by malnutrition, chronic inflammation or side effects of therapy, may be difficult. This review concentrates on frequency, clinical presentation and therapeutic implications of extraintestinal symptoms in inflammatory bowel diseases. If possible, extraintestinal manifestations are differentiated from extraintestinal complications. Special attention is given to the more recently described sites of involvement; i.e. thromboembolic events, osteoporosis, pulmonary involvement and affection of the central nervous system.

Intrahepatic cholestasis of pregnancy-current achievements and unsolved problems

Intrahepatic cholestasis of pregnancy （ICP） is the most common pregnancy-related liver disorder. Maternal effects of ICP are mild; however, there is a clear association between ICP and higher frequency of fetal distress, preterm delivery, and sudden intrauterine fetal death. The cause of ICP remains elusive, but there is evidence that mutations in genes encoding hepatobiliary transport proteins can predispose for the development of ICP. Recent data suggest that ursodeoxycholic acid is currently the most effective pharmacologic treatment, whereas obstetric management is still debated. Clinical trials are required to identify the most suitable monitoring modalities that can specifically predict poor perinatal outcome. This article aims to review current achievements and unsolved problems of ICR

Multiple pathogenic factor-induced complications of cirrhosis in rats: A new model of hepatopulmonary syndrome with intestinal endotoxemia

AIM： To develop and characterize a practical model of Hepatopulmonary syndrome. （HPS） in rats.METHODS： The experimental animals were randomized into five feeding groups： （1） control （fed standard diet）, （2） control plus intraperitoneal injection with lipopolysaccharide （LPS）, （3） cirrhosis （fed a diet of maize flour, lard, cholesterol, and alcohol plus subcutaneously injection with carbon tetrachloride （CCI4） oil solution）, （4） cirrhosis plus LPS, and （5） cirrhosis plus glycine and LPS. The blood, liver and lung tissues of rats were sampled for analysis and characterization. Technetium 99m-labeled macroaggregated albumin （Tc99m-MAA） was used to test the dilatation of pulmonary microvasculature.RESULTS： Typical cirrhosis and subsequent hepato- pulmonary syndrome was observed in the cirrhosis groups after an 8 wk feeding period. In rats with cirrhosis, there were a decreased PaO2 and PaCO2 in arterial blood, markedly decreased arterial 02 content, a significantly increased alveolar to arterial oxygen gradient, an increased number of bacterial translocated within mesenteric lymph node, a significant higher level of LPS and tumor necrosis factor-α （TNF-α） in plasma, and a significant greater ratio of Tc99m-MAA brain-overlung radioactivity. After LPS administration in rats with cirrhosis, various pathological parameters got worse and pulmonary edema formed. The predisposition of glycine antagonized the effects of LPS and significantly alleviated various pathological alterations.

Treatment efficacy of radiof requency ablation of 338 patients with hepatic malignant tumor and the relevant complications

AIM： To investigate the treatment efficacy of radiofrequency ablation （RFA） of hepatic malignant tumor and the relevant complications. METHODS： A total of 338 patients with 763 hepatic tumors underwent ultrasound-guided RFA （565 procedures）. There were 204 cases of hepatic cellular carcinoma （HCC） with 430 tumors, the mean largest diameter was 4.0 cm. Of them, 48 patients （23.5%） were in stages Ⅰ-Ⅱ （UICC Systems） and 156 （76.5%） in stages Ⅲ-Ⅳ There were 134 cases of metastatic liver carcinoma （MLC）, with 333 metastases in the liver, the mean diameter was 4.1 cm, the liver metastases of 96 patients （71.6%） came from gastrointestinal tract. Ninety-three percent of the 338 patients were treated using the relatively standard protocol. Crucial attention must be paid to monitor the abnormal changes in ultrasound images as well as the vital signs of the patients to find the possible hemorrhage and peripheral structures injury in time. The tumors were considered as ablated completely, if no viability was found on enhanced CT within 24 h or at 1 mo after RFA. These patients were followed up for 3-57 too. RESULTS： The ablation success rate was 93.3% （401/430 tumors） for HCC and was 96.7% （322/333 tumors） for MLC. The local recurrence rate for HCC and MLC was 7.9% （34/430 tumors） and 10.5% （351333 tumors）, respectively. A total of 137 patients （40.5%） underwent 2-11 times of repeated ablations because of tumor recurrence or metastasis. The 1st, 2nd, and 3rd year survival rate was 84.6%, 66.6%, and 63.1%, respectively; the survival rate from 48 patients of I-II stage HCC was 93.7%, 80.4%, and 80.4%, respectively. The major complication rate in this study was 2.5% （14 of 565 procedures）, which consisted of 5 hemorrhages, i colon perforation, 5 injuries of adjacent structures, 2 bile leakages, and 1 skin burn. CONCLUSION： RFA, as a minimally invasive local treatment, has become an effective and relatively safe alternativefor the patients of hepatic malignant tumor, even of advanced liver tumor, tumor recurrence, and liver metastases. Knowledge about possible complications and their control may increase the treatment efficacy and help to promote the use of RFA technique.

Cardiopulmonary,complications in chronic liver disease

Patients with cirrhosis and portal hypertension exhibit characteristic cardiovascular and pulmonary hemodynamic changes. A vasodilatatory state and a hyperdynamic circulation affecting the cardiac and pulmonary functions dominate the circulation. The recently defined cirrhotic cardiomyopathy may affect systolic and diastolic functions, and imply electromechanical abnormalities. In addition, the baroreceptor function and regulation of the circulatory homoeostasis is impaired. Pulmonary dysfunction involves diffusing abnormalities with the development of the hepatopulmonary syndrome and portopulmonary hypertension in some patients. Recent research has focused on the assertion that the hemodynamic and neurohumoral dysregulation are of major importance for the development of the cardiovascular and pulmonary complications in cirrhosis. This aspect is important to take into account in the management of these patients.

Pancreatic fistula after pancreatectomy:Evolving definitions,preventive strategies and modern management

Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently < 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula (PF). The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.

E-cadherin expression pattern in primary colorectal carcinomas and their metastases reflects disease outcome

AIM： To investigate the changes that occur in E-cadherin expression during the process of metastasis in colorectal cancer.METHODS： E-cadherin expression was detected by immunohistochemistry and two indices of expression were calculated which reflected the level of expression and the locations （membrane and cytoplasm）. Univariate and multivariate survival analyses were used to assess the value of these two E-cadherin indices as predictors of both disease-free （DFS） and disease-specific （DSS） survival. RESULTS： E-cadherin membrane index （MI）, but not cytoplasmic index （CI）, was significantly higher in primary tumors than their metastases （P = 0.0001）. Furthermore, both primary tumor MI and CI were higher among the patients who developed subsequent metastasis （P = 0.022 and P = 0.007, respectively）. Interestingly, both indices were higher in liver metastase compared to other anatomic sites （MI, P = 0.034 and CI, P = 0.022）. The CI of the primary tumors was a significant predictor of DFS （P = 0.042, univariate analysis）, with a strong inverse correlation between CI and DFS （P = 0.006, multivariate analysis）. Finally, the MI of primary tumor proved to be a significant independent predictor of DSS, with higher indices being associated with a more favorable outcome （P = 0.016）. CONCLUSION： Examination of E-cadherin expression and distribution in colorectal tumors can be extremely valuable in predicting disease recurrence. The observation that aberrant cytoplasmic expression of E-cadherin can predict disease recurrence is obviously of great importance for both patients and clinicians, and significantly affects decisions concerning the therapy and management of the patients.