腹腔镜联合肠梗阻导管治疗复杂性粘连性肠梗阻的可行性分析

目的:探讨腹腔镜联合经鼻肠梗阻导管治疗复杂性粘连性肠梗阻的可行性及潜在优势。方法:回顾性收集符合复杂性粘连性肠梗阻纳入标准、经鼻肠梗阻导管治疗后梗阻未缓解并行手术治疗者65例,随机分为腹腔镜治疗组31例,开腹手术治疗组34例。比较两组围手术期安全性及治疗效果间差异。结果:两组患者年龄、性别、ASA评分及手术史等一般资料比较差异均无统计学意义。31例腹腔镜探查患者共中转5例,34例行开腹手术治疗。在术后并发症率、排气时间、进食时间及术后住院时间方面,腹腔镜组优于开腹组,存在统计学差异(P<0.05)。腹腔镜组患者术后随访复发率(7.7%)低于开腹组(14.7%),具备统计学差异。结论:腹腔镜联合肠梗阻导管治疗复杂性粘连性肠梗阻安全、微创、效果可靠,可显著减低术后复发率,可作为复杂性肠梗阻的有效治疗方式。

康熙民心思想述议

民心思想是康熙治国方略的核心之一，他一生的施政实践基本上贯彻了这种思想。主要内容有：致治之道，民为最要；民为邦本，修德安民；思培邦本，念切民依；道重观民，政先求瘼；息事宁人恤民之善经；持己廉洁，爱养黎元；实心为民，勤求乐利；崇尚清节，治之要务；崇奖廉善，摈斥贪残；保爱良善。

The vital threat of an upper gastrointestinal bleeding: Risk factor analysis of 121 consecutive patients

AIM： To analyze the importance in predicting patients risk of mortality due to upper gastrointestinal （UGI） bleeding under today＇s therapeutic regimen. METHODS： From 1998 to 2001, 121 patients with the diagnosis of UGI bleeding were treated in our hospital. Based on the patients＇ data, a retrospective multivariate data analysis with initially more than 270 single factors was performed. Subsequently, the following potential risk factors underwent a logistic regression analysis： age, gender, initial hemoglobin, coumarines, liver cirrhosis, prothrombin time （PT）, gastric ulcer （small curvature）, duodenal ulcer （bulbus back wall）, Forrest classification, vascular stump, variceal bleeding, MalloryWeiss syndrome, RBC substitution, recurrent bleeding, conservative and surgical therapy. RESULTS： Seventy male （58%） and 51 female （42%） patients with a median age of 70 （range： 21-96） years were treated. Their in-hospital mortality was 14%. While 12% （11/91） of the patients died after conservative therapy, 20% （6/30） died after undergoing surgical therapy. UGI bleeding occurred due to duodenal ulcer （n = 36; 30%）, gastric ulcer （n = 35; 29%）, esophageal varicosis （n = 12; 10%）, Mallory-Weiss syndrome （n = 8, 7%）, erosive lesions of the mucosa （n = 20; 17%）, cancer （n = 5; 4%）, coagulopathy （n = 4; 3%）, lymphoma （n = 2; 2%）, benign tumor （n = 2; 2%） and unknown reason （n = 1, 1%）. A logistic regression analysis of all aforementioned factors revealed that liver cirrhosis and duodenal ulcer （bulbus back wall） were associated risk factors for a fatal course after UGI bleeding. Prior to endoscopy, only liver cirrhosis was an assessable risk factor. Thereafter, liver cirrhosis, the location of a bleeding ulcer （bulbus back wall） andpatients＇ gender （male） were of prognostic importance for the clinical outcome （mortality） of patients with a bleeding ulcer.CONCLUSION： Most prognostic parameters used in clinical routine today are not reliable enough in predicting a patient＇s vital threat posed by an UGI bleeding.Liver cirrhosis, on the other hand, is significantly more frequently associated with an increased risk to die after bleeding of an ulcer located at the posterior duodenal wall.

Anabolic steroid abuse causing recurrent hepatic adenomas and hemorrhage

Anabolic steroid abuse is common among athletes and is associated with a number of medical complications. We describe a case of a 27-year-old male bodybuilder with multiple hepatic adenomas induced by anabolic steroids. He initially presented with tumor hemorrhage and was treated with left lateral hepatic segmentectomy. Regression of the remaining tumors was observed with cessation of steroid use. However, 3 years and a half after his initial hepatic segmentectomy, he presented with recurrent tumor enlargement and intraperitoneal hemorrhage in the setting of steroid abuse relapse. Given his limited hepatic reserve, he was conservatively managed with embolization of the right accessory hepatic artery. This is the first reported case of hepatic adenoma re- growth with recidivistic steroid abuse, complicated by life-threatening hemorrhage. While athletes and bodybuilders are often aware of the legal and social ramifications of steroid abuse, they should continue to be counseled about its serious medical risks.

Colonic duplication in adults: Report of two cases presenting with rectal bleeding

Gastrointestinal duplication is an uncommon congenital abnormality in two-thirds of cases manifesting before the age of 2 years. Ileal duplication is common while colonic duplication, either cystic or tubular, is a rather unusual clinical entity that remains asymptomatic and undiagnosed in most cases. Mostly occurring in pediatric patients,colonic duplication is encountered in adults only in a few cases. This study reports two cases of colonic duplication in adults. Both cases presented with rectal bleeding on admission. The study was focused on clinical, imaging,histological, and therapeutical aspects of the presenting cases. Gastrografin enema established the diagnosis in both cases. The cystic structure and the adjacent part of the colon were excised en-block. The study implies that colonic duplication, though uncommon, should be included in the differential diagnosis of rectal bleeding.

Duodenal variceal bleeding after balloon-occluded retrograde transverse obliteration: Treatment with transjugular intrahepatic portosystemic shunt

We report a case of duodenal varix bleeding as a long term complication of balloon occluded retrograde transvenous obliteration (BRTO), which was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 57-year-old man was admitted to the emergency room suffering from melena. He had under-gone BRTO to treat gastric varix bleeding 5 mo before admission. Endoscopy and a computed tomography (CT) scan showed complete obliteration of the gastric varix, but the nodular varices in the second portion of the duodenum expanded after BRTO, and spurting blood was seen. TIPS was performed for treatment of duodenal variceal bleeding, because attempts at endoscopic varix ligation were unsuccessful. The post-operative course was uneventful and the patient was discharged without complications. A follow up CT scan obtained 21 mo after TIPS revealed a patent TIPS tract and complete obliteration of duodenal varices, but multinodular hepatocellular carcinoma had developed. He died of hepatic failure 28 mo after TIPS.

Removal of Pb^(2+) and Cd^(2+) by adsorption on clay-solidified grouting curtain for waste landfills

Pb2+ and Cd2+ in leachate were adsorbed on clay-solidified grouting curtain for waste landfills with equilibrium experiment. The cation exchange capacity was determined with ammonium acetate. And the concentration of heavy metal cations in leachate was determined with atomic absorption spectrophotometer. Their equilibrium isotherms were measured, and the experimental isotherm data were analyzed by using Freundlich and Langmuir models. The results show that the adsorption capacities of the heavy metal cations are closely related to the compositions of clay-solidified grouting curtain, and the maximum adsorption appears at the ratio of cement to clay of 2∶4 in the experimental conditions. At their maximum adsorption and pH 5.0, the adsorption capacities of Pb 2+ and Cd 2+ are 16.19mg/g and 1.21mg/g. The competitive adsorption coefficients indicate that the adsorption of clay-solidified grouting curtain for Pb2+ is stronger than that for Cd 2+ . The adsorption process conforms to Freundlich’s model with related coefficient higher than 0.996.

Validation of the Rockall scoring system for outcomes from non-variceal upper gastrointestinal bleeding in a Canadian setting

AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death. METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding and Endoscopy including information of 1869 patients with non-variceal upper gastrointestinal bleeding treated in Canadian hospitals. Risk scores were calculated and used to classify patients based on outcomes. For each outcome, we used χ2 goodness-of-fit tests to assess the degree of calibration, and built receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the discriminative ability of the scoring system. RESULTS: For rebleeding, the χ2 goodness-of-fit test indicated an acceptable fit for the model [χ2 (8) = 12.83, P = 0.12]. For surgical procedures [χ2 (8) = 5.3, P = 0.73] and death [χ2 (8) = 3.78, P = 0.88], the tests showed solid correspondence between observed proportions and predicted probabilities. The AUC was 0.59 (95% CI: 0.55-0.62) for the outcome of rebleeding and 0.60 (95% CI: 0.54-0.67) for surgical procedures, representing apoor discriminative ability of the scoring system. For the outcome of death, the AUC was 0.73 (95% CI: 0.69-0.78), indicating an acceptable discriminative ability. CONCLUSION: The Rockall scoring system provides an acceptable tool to predict death, but performs poorly for endpoints of rebleeding and surgical procedures.

Gastric mucosal injury due to hemorrhagic reperfusion and efficacy of Salvia miltiorrhizae extract F and cimetidine

AIM: To observe the gastric mucosal injury caused by hemorrhagic shock and reperfusion and to compare the effect between Salvia miltiorrhizae extract F (SEF) and cimetidine (CI) on it. METHODS: A model of hemorrhage/reperfusion injury was produced by Itoh method. Wistar rats were randomly divided into three groups: 0.9% sodium chloride treatment group (NS group), SEF treatment group (SEF group), and CI treatment group (CI group). Saline, SEF and CI were injected respectively. The index of gastric mucosal lesions (IGML) was expressed as the percentage of lesion area in the gastric mucosa. The degree of gastric mucosal lesions was categorized into grades 0, 1, 2, 3. Atom absorption method was used to measure the intracellular calcium content. Radioimmunoassay was used to measure the concentrations of prostaglandins. RESULTS: IGML (%) and grade 3 (%) were 23.18±6.82, 58.44±9.07 in NS group, 4.42±1.39, 20.32±6.95 in SEF group and 3.74±1.56, 23.12±5.09 in CI group, and the above parameters in SEF group and CI group decreased significantly (IGML: SEF vs NS, t=6.712, P=0.000<0.01; CI vs NS, t=6.943, P=0.000<0.01; grade 3: SEF vs HS, t=8.386, P=0.000; CI vs HS, t=8.411, P= 0.000), but the grade 0 and grade 1 damage in SEF group (22.05±5.96, 34.12±8.12) and CI group (18.54±4.82, 30.15±7.12) were markedly higher than those in NS group (3.01±1.01, 8.35±1.95; grade 0: SEF vs HS, t=8.434, P=0.000<0.01; CI vs NS, t=7.950, P=0.000<0.01; grade 1: SEF vs NS, t =8.422, P=0.000<0.01; CI vs NS, t=8.448, P=0.000<0.01). The intracellular calcium content (μg/mg) in SEF group (0.104±0.015) and CI group (0.102±0.010) was markedly lower than that in NS group (0.131±0.019, SEF vs NS, t=2.463, P=0.038<0.05; CI vs HS, t=3.056, P=0.017<0.05). The levels (pg/mg) of PGE_2, 6-keto-PGF_(1α) and 6-keto-PGF_(1α)/TXB_2 were 540±183, 714±124,17.38±5.93 in NS group and 581±168, 737±102, 19.04±8.03 in CI group, 760±192,1 248±158, 33.42±9.24 in SEF group, and the above parameters in SEF group markedly raised (PGE_2: SEF vs NS, t=2.282, P=0.046<0.05; SEF vs CI, t=2.265, P=0.047<0.05; 6-keto-PGF_(1α): SEF vs NS, t=6.583, P=0.000<0.000; SEF vs CI, t=6.708, P=0.000<0.01; 6-keto-PGF_(1α)/TXB_2: SEF vs NS, t=3.963, P=0.003<0.001; SEF vs Cl, t=3.243, P=0.009<0.01), whereas TXB_2 level in SEF group (45.37±7.54) was obviously lower than that in NS group (58.28±6.74, t=3.086, P=0.014<0.05) and CI group (54.32±6.89, t=2.265, P=0.047<0.05). No significant difference was shown between NS group and CI group (PGE_2: t=0.414, P=0.688>0.05; 6-keto-PGF_(1α): t=0.310, P=0.763>0.05; TXB_2: t=1.099, P=0.298>0.05; 6-keto-PGF_(1α)/TXB_2: t=0.372, P=0.718>0.05). CONCLUSION: Both SEF and CI could inhibit reperfusioninduced injury in gastric mucosa, but with different mechanisms. SEF could not only enhance the protective effect of gastric mucosa, but also abate the injury factors, while CI can only abate the injury factors.

Gastrointestinal stromal tumor of appendix incidentally diagnosed by appendiceal hemorrhage

Gastrointestinal stromal tumor is rare, which arises from the mesenchymal tissues in the gastrointestinal tract, and it is extremely rare in the appendix. Only a few cases have been found in this location to date. Although the annual incidence of lower gastrointestinal bleeding has been increasing, bleeding related to the appendix is quite rare. We herein present a very rare case of gastrointestinal stromal tumor incidentally found by appendiceal hemorrhage.

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound(TRUS)-guided multiple biopsy of the prostate,but is usually mild and stops spontaneously.We report what is believed to be the first case of life-threatening rectal bleeding following this procedure,which was successfully treated by endoscopic intervention through placement of three clips on the sites of bleeding.This case emphasizes endoscopic intervention associated with endoclipping as a safe and effective method to achieve hemostasis in massive rectal bleeding after prostate biopsy.Additionally,current data on the complications of the TRUS-guided multiple biopsy of the prostate and the options for treating fulminant rectal bleeding, a consequence of this procedure,are described.

Lower gastrointestinal bleeding: Association with Sevelamer use

Stercoral ulceration results from impaction of hard fecal mass on the colonic wall and is a relatively unknown cause of lower gastrointestinal bleeding. In this report, we describe a case of lower gastrointestinal bleeding due to stercoral ulceration resulting from Sevelamer, a drug which is commonly associated with constipation.

CLINICAL OBSERVATION ON LUMBAR INTERVERTEBRAL DISC HERNIATION TREATED BY TRACTION COMBINED WITH ACUPUNCTURE

Objective: To observe the therapeutic effect of traction combined with acupuncture on lumbar intervertebral disc herniation (LIDH). Methods:Eighty-three patients diagnosed as LIDH were randomly divided into treatment group (n=42)and control group (n=41). In the treatment group, besides lumbar traction, electroacupuncture at Jiaji (EX-B 2, L 3～5), Shenshu (BL 23), Qihai (CV 6), Mingmen (GV 4), Huantiao (GB 30), Chengshan (BL 57) and Yanglingquan (GB 34) was added. In the control group, only lumbar traction was applied. Results: In treatment group, the cure plus markedly effective rate was 80.95% with a total effective rate of 92.86%, while in control group, it was 39.02% with a total effective rate of 80.48%. The therapeutic effect in the treatment group was obviously better than that in the control group (P<0.001). Conclusion: Lumbar traction plus EA can effectively alleviate or even eliminate clinical symptoms and signs of lumbar intervertebral disc herniation.

Retrograde jejunoduodenogastric intussusception due to a replacement percutaneous gastrostomy tube presenting as upper gastrointestinal bleeding

Percutaneous endoscopic gastrostomy (PEG) tube complications can be serious or life threatening. Retrograde intussusception is a very rare complication of PEG tubes with only 9 cases reported in the literature. We describe a case of retrograde intussusception, associated with the use of a Foley catheter as a replacement gastrostomy tube, presenting with upper gastrointestinal bleeding. To our knowledge, this is the first reported case of PEG-related retrograde intussusception successfully managed in a non-surgical manner. Retrograde intussusception likely occurred due to migration of the replacement tube with resultant securing and invagination of the proximal jejunum when the gastrostomy tube was anchored to the abdominal wall.

Acute upper gastrointestinal bleeding in operated stomach: Outcome of 105 cases

AIM: To compare the causes and clinical outcome of patients with acute upper gastrointestinal bleeding (AUGB) and a history of gastric surgery to those with AUGB but without a history of gastric surgery in the past.METHODS: The causes and clinical outcome were compared between 105 patients with AUGB and a history of gastric surgery, and 608 patients with AUGB but without a history of gastric surgery.RESULTS: Patients who underwent gastric surgery in the past were older (mean age: 68.1±11.7 years vs 62.8±17.8 years, P= 0.001), and the most common cause of bleeding was marginal ulcer in 63 patients (60%). No identifiable source of bleeding could be found in 22 patients (20.9%) compared to 42/608 (6.9%) in patients without a history of gastric surgery (P = 0.003). Endoscopic hemostasis was permanently successful in 26 out of 35 patients (74.3%) with peptic ulcers and active bleeding or non-bleeding visible vessel. Nine patients (8.6%) were operated due to continuing or recurrent bleeding,compared to 23/608 (3.8%) in the group of patients without gastric surgery in the past (P= 0.028). Especially in peptic ulcer bleeding patients, emergency surgery was more common in the group of patients with gastric surgery in the past [9/73 (12.3%) vs 19/360 (5.3%), P = 0.025].Moreover surgically treated patients in the past required more blood transfusion (3.3±4.0 vs 1.5±1.7, P = 0.0001) and longer hospitalization time (8.6±4.0 vs 6.9±4.9 d,P = 0.001) than patients without a history of gastric surgery. Mortality was not different between the two groups [4/105 (3.8%) vs 19/608 (3.1%)].CONCLUSION: Upper gastrointestinal bleeding seems to be more severe in surgically treated patients than in non-operated patients.

Application of laparoscopy in diagnosis and treatment of massive small intestinal bleeding: Report of 22 cases

AIM: To investigate the diagnostic and therapeutic value of laparoscopy in patients with massive small intestinal bleeding. METHODS: Twenty-two patients with massive small in- testinal bleeding and hemodynamic alteration underwent laparoscopic laparotomy in our unit from December 2002 to April 2005. Post pathologic sites were found, laparos- copy- or laparoscopy-assisted part small intestinal resec- tion including pathologic intestinal site and enteroanas- tomosis was performed in all these patients. RESULTS: The bleeding sites were successfully detected by laparoscopy in all these 22 patients. Massive small intestinal bleeding was caused by jejunum benign stromal tumor in 8 cases, by jejunum potential malignant stromal tumor in 5 cases, by jejunum malignant stromal tumor in 1 case, by Mechel’s diverticulum in 5 cases, by small intestinal vascular deformity in 2 cases, and by ectopic pancreas in 1 case. A total of 16 patients underwent laparoscopy-assisted enterectomy and enteroanastomosis of small intestine covering the diseased segment and 6 patients received enterectomy of the diseased segment under laparoscope. No surgical complications occurred and the outcome was satisfactory. CONCLUSION: Laparoscopy in diagnosis and treatment of massive small intestinal bleeding is noninvasive with less pain, short recovery time and definite therapeutic efficacy.

Qing Dai, a traditional Chinese medicine for the treatment of chronic hemorrhagic radiation proctitis

Objective： To evaluate the efficacy and safety of Qing Dai （indigo naturalis）, a traditional Chinese medicine, in the treatment for chronic hemorrhagic radiation proctitis. Methods： Ten patients with chronic hemorrhagic radiation proctitis between January 2005 to January 2008 were treated with Qing Dai. Qing Dai was administered orally at a dose of 1.5 g, bid for 5 consecutive days, every 2 weeks for two courses. Patients were followed up every 3 months. The clinical response and side-effects were evaluated. Results： Six patients showed improvement of rectal bleeding to grade 0-1 after 1 course of Qing Dai therapy. Four patients had reduced rectal bleeding to grade 0-1 after 2 courses of the therapy. The median follow-up time was 10 months （range： 6-24）. During the follow-up period, 1 patient experienced recurrent rectal bleeding and was managed with topical formalin dabbing, which controlled the symptom. No treatment toxicity was observed. Conclusion： Qing Dai may be a safe and effective treatment for chronic hemorrhagic radiation proctitis.

Protective effect of Astragalus membranaceus on intestinal mucosa reperfusion injury after hemorrhagic shock in rats

AIM： To study the protective effect of Astragalus rnernbranaceus on intestinal mucosa reperfusion injury and its mechanism after hemorrhagic shock in rats. METHODS： A total of 32 SD rats were randomly divided into four groups （n = 8, each group）： normal group, model group, low dosage group （treated with 10 g/kg Astragalus membranaceus） and high dosage group （treated with 20 g/kg Astragalus membranaceus）. The model of hemorrhagic shock for 60 min and reperfusion for 90 min was established. Therapeutic solution （3 mL） was administrated before reperfusion. At the end of the study, the observed intestinal pathology was analyzed. The blood concentrations of lactic acid （LD）, nitric oxide （NO）, endothelin-1 （ET-1）, malondialdehyde （MDA） and the activity of superoxide dismutase （SOD）, glutathione peroxidase （GSH-PX） in intestinal mucosa were determined. RESULTS： The intestinal mucosa pathology showed severe damage in model group and low dosage group, slight damage in high dosage group and no obvious damage in normal group. The Chiu＇s score in low dose group and high dose group was significantly lower than that in model group. The content of MDA in model group was higher than that in low and high dose groups, while that in high dose group was almost the same as in normal group. The activity of SOD and GSH-PX was the lowest in model group and significantly higher in high dose group than in normal and low dose groups. The concentrations of LD and ET-1 in model group were the highest. The concentrations of NO in model group and low dose group were significantly lower than those in high dose group and normal group. CONCLUSION： High dose Astraga/us membranaeus has much better protective effect on hemorrhagic shockreperfusion injury of intestinal mucosa than low dose Astragalus membranaceus. The mechanism may be that Astragalus membranaceus can improve antioxidative effect and regulate NO/ET level during hemorrhagic reperfusion.

Diagnosis and treatment of small intestinal bleeding:Retrospective analysis of 76 cases

AIM: To investigate the causes of small intestinal bleed- ing as well as its diagnosis and therapeutic approaches. METHODS: A retrospective analysis was conducted ac- cording to the clinical records of 76 patients with small intestinal bleeding admitted to our hospital in the past 5 years. RESULTS: In these patients, tumor was the most fre- quent cause of small intestinal bleeding (37/76), fol- lowed by Meckel’s diverticulum (21/76), angiopathy (15/76) and ectopic pancreas (3/76). Of the 76 patients, 21 were diagnosed by digital subtraction angiography, 13 by barium and air double contrast X-ray examination of the small intestine, 11 by 99mTc-sestamibi scintigraphy of the abdominal cavity, 6 by enteroscopy of the small intestine, 21 by laparoscopic laparotomy, and 4 by ex- ploratory laparotomy. Although all the patients received surgical treatment, most of them (68/76) received part enterectomy covering the diseased segment and entero- anastomosis. The follow-up time ranged from 1 year to 5 years. No case had recurrent alimentary tract bleeding or other complications. CONCLUSION: Tumor is the major cause of small in- testinal bleeding followed by Meckel’s diverticulum and angiopathy. The main approaches to definite diagnosis of small intestinal bleeding include digital subtraction an- giography, 99mTc-sestamibi scintigraphy of the abdominal cavity, barium and air double contrast X-ray examina- tion of the small intestine, laparoscopic laparotomy or exploratory laparotomy. Part enterectomy covering the diseased segment and enteroanastomosis are the most effective treatment modalities for small intestinal bleed- ing.