术前内镜引流在疑似可切除的肝门部胆管恶性肿瘤患者外科治疗中的价值

目的探讨术前内镜引流在疑似可切除的肝门部胆管恶性肿瘤患者外科治疗中的价值。方法我院在2010．1—2014．12期间，对收治入院的肝门部胆管恶性肿瘤患者进行全面的术前影像学评估，将评估后的病人分成3组：肿瘤可切除组；肿瘤肯定不能切除组；肿瘤疑似可切除组。可切除组采用手术治疗，肯定不能切除组采用内镜治疗（内镜治疗不成功者采用PTCD），对疑似可切除组采用术前内镜引流，1—2天后再行剖腹探查手术，术中探查能够切除肿瘤者则予以切除，不能切除者则直接关腹。本文主要对疑似可切除这一组病人（共17例）的临床资料进行回顾性分析和总结。结果本组17例中，男11例，女6例，年龄46～63岁，平均年龄52岁。术前Bismuth分型：Ⅱ型2例，Ⅲ型11例，Ⅳ型4例。术前影像学评估均不能确定肿瘤能否切除，外科手术前1～2天行内镜鼻胆管引流术（ENBD，11例）或内镜下塑料支架置入术（ERBD，6例）。术中探查提示：胆囊癌侵及肝门部胆管3例，均行姑息性胆囊切除术；肝癌侵及肝门部胆管4例，行左半肝切除联合右肝管空肠R—Y内引流术1例，3例行肿瘤活检术；原发性胆管癌10例，行根治性切除2例，姑息性切除2例，余6例仅行肿瘤活检。7例病人术后1～2周将鼻胆管引流改为塑料支架引流。全组1患者出院时均无胆道外引流管，黄疸有效缓解率为100％。结论对疑似可切除的肝门部胆管恶性肿瘤患者术前I一2天先行内镜引流，既可增加该类病人外科手术切除的机会，也可有效避免对术中明确不能切除的患者实施“U”型管外引流，从而最大限度地提高该类病人的生活质量。

术前内镜在腹腔镜结直肠微小肿瘤定位的临床价值研究

目的探讨术前内镜在腹腔镜结直肠微小肿瘤定位的临床应用价值。方法回顾性分析2018-06—2020-06间河南大学第一附属医院普通外科行手术治疗的63例结直肠微小肿瘤患者的临床资料。依据内镜肿瘤定位时机分为术前内镜组(38例)和术中内镜组(25例)。比较2组患者的基线资料、术中情况,以及术后临床指标。结果2组患者的基线资料差异无统计学意义(P>0.05)。术前内镜组的手术时间、术后通气时间均短于术中内镜组,术后腹胀发生率低于术中内镜组,差异有统计学意义(P<0.05)。2组微小肿瘤定位准确率和术后吻合口漏发生率、住院时间差异无统计学意义(P>0.05)。结论对腹腔镜结直肠微小肿瘤实施手术前2~4 h行内镜定位,有利于缩短手术时间,降低术后腹胀发生率,而且不影响吻合口的愈合,能使患者最大获益。

术前内镜超声对胃癌浸润深度及手术可切除性评估的研究

胃癌是最常见的消化道恶性肿瘤之一。内镜超声检查术(endoscopic ultrasonography,EUS)对消化道管壁的高分层成像能力使其成为判断癌肿局部浸润深度的有力工具,同时,对超声范围内的周围结构的观察使得对淋巴结或邻近脏器受累情况的了解成为可能。国内外研究指出,EUS在对胃癌分期中存在分期过度(overstaging)或分期不足(understag-

鼻内镜下经前囟钩突切除术治疗慢性鼻-鼻窦炎疗效观察

目的探究慢性鼻-鼻窦炎(CRS)患者鼻内镜下前囟钩突切除术后复发的危险因素。方法回顾性分析我院124例鼻内镜下经前囟钩突切除术治疗的CRS患者临床资料,根据患者术后是否复发分为复发组(26例)和未复发组(98例),比较复发与未复发患者的临床资料,运用二分类Logistic回归分析法探究患者术后复发的危险因素。结果复发组患者病程长于未复发组,伴变应性鼻炎、伴支气管哮喘、伴鼻中隔偏曲例数多于对照组,遵医用药、按时随访复查、知晓防治知识例数少于对照组,VAS评分及CT扫描(前组筛窦积分、后组筛窦积分、蝶窦积分、额窦积分、窦口鼻窦复合体积分、鼻窦总积分)均高于对照组,差异有统计学意义(P<0.05);Logistics回归分析结果显示:伴变应性鼻炎/伴支气管哮喘(OR=6.117,P<0.05)和VAS评分(OR=5.371,P<0.05)、CT前组筛窦积分(OR=6.123,P<0.05)、CT蝶窦积分(OR=14.614,P<0.05)是CRS患者鼻内镜下前行钩突切除术后复发的危险因素。结论伴变应性鼻炎/伴支气管哮喘和VAS评分、CT前组筛窦积分、CT蝶窦积分偏高是慢性鼻-鼻窦炎患者鼻内镜下前囟钩突切除术后复发的危险因素,应针对存在上述危险因素的患者加强对患者的健康指导,减少术后复发。

术前超声内镜检查在指导胸腔镜食管癌手术选择中的应用价值

目的给予接受胸腔镜食管癌手术的患者术前超声内镜检查,并对其临床效果与具体价值进行分析、探讨。方法选取2019年3月—2021年3月枣庄市立医院接收的120例食管癌患者,将其按照诊断顺序分为常规组与观察组,各60例。常规组术前给予CT检查;观察组术前给予患者超声内镜检查。对比两组患者的基本资料与患病信息(食管癌术前分期情况、食管癌切除情况)。结果观察组患者术前分期(N0~N1期)诊断率为92.30%、66.66%,明显高于常规组(55.55%、33.33%),差异有统计学意义(P<0.05);观察组患者不同分期(N0~N1期)食管癌的切除率为89.74%、90.47%,明显高于常规组(69.44%、58.33%),差异有统计学意义(P<0.05)。结论将术前超声内镜应用于胸腔镜食管癌手术中,可提升术前对食管癌的分期诊断,预后效果显著。

鼻内镜下筛前神经、蝶腭神经阻断术联合穴位贴敷治疗变应性鼻炎的远期疗效分析

目的:分析鼻内镜下筛前神经、蝶腭神经阻断术联合穴位贴敷治疗变应性鼻炎的远期疗效。方法:选取2014年8月~2015年7月我院收治的变应性鼻炎患者78例,按随机数字表法分为对照组35例和观察组43例。对照组予以糠酸莫米松鼻喷雾剂和盐酸西替利嗪片治疗,观察组应用鼻内镜下筛前神经、蝶腭神经阻断术联合穴位贴敷治疗。分析两组治疗3个月、24个月临床疗效。结果:两组患者治疗3个月、24个月后症状积分与治疗前比较,差异具有统计学意义(P<0.05);两组治疗24个月后症状积分、临床疗效与治疗3个月后比较,均具有统计学意义(P<0.05);治疗3个月后对照组与观察组症状积分、临床疗效比较,差异无统计学意义(P>0.05);治疗24个月后对照组与观察组症状积分、临床疗效比较,差异具有统计学意义(P<0.05)。结论:鼻内镜下筛前神经、蝶腭神经阻断术联合穴位贴敷治疗变应性鼻炎远期疗效显著,值得临床推广应用。

冠状缝前入路神经内镜手术对高血压基底节区脑出血患者神经功能及并发症影响

目的目前,临床上在治疗高血压基底节区脑出血患者时常行开颅血肿清除术治疗,但该术式创面大、易感染,不利于预后,而随着神经内镜技术水平的提升,冠状缝前入路神经内镜手术也逐渐应用至该病症治疗中,本研究探讨冠状缝前入路神经内镜手术对高血压基底节区脑出血患者神经功能及并发症影响。方法以本院2018-07-01-2019-07-01收治的高血压基底节区脑出血患者为研究对象,根据观察组的性别、年龄、高血压病程和血肿容积,选择与之匹配的行开颅血肿清除手术治疗的30例患者为对照组,观察并比较两组患者术后神经功能、手术指标及并发症发生情况。结果治疗后,观察组美国国立卫生研究院卒中量表评分(National Institute of Health stroke scale,NIHSS)为(14.63±3.14)分,低于对照组的(14.63±3.14)分,t=8.079,P<0.001。观察组手术时间为(47.61±6.73)min,短于对照组的(63.17±7.64)min,t=8.371,P<0.001;观察组术中出血量为(38.21±3.17)mL,少于对照组的(42.41±4.68)mL,t=4.070,P<0.001;观察组ICU住院时间为(5.17±1.31)min,短于对照组的(8.37±1.52)min,t=8.735,P<0.001。观察组并发症发生率为3.33%,低于对照组的26.67%,差异有统计学意义,χ~2=4.706,P=0.030。结论临床上治疗高血压基底节区脑出血患者时,采取冠状缝前入路神经内镜手术的效果较好,可以有效改善患者神经功能,缩短手术及ICU住院时间,减少术中出血量,并降低并发症发生风险。

Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration

AIM： to evaluate the role of endoscopic ultrasonographyguided fine needle aspiration （EUS-FNA） in the preoperative diagnosis of gastrointestinal stromal tumor （GIST）.METHODS： From September 2002 to June 2006, Fiftythree consecutive EUS-FNAs of GI tract subepithelial hypoechoic tumors with continuity to proper muscle layer suspected as GIST by standard EUS were evaluated prospectively. The reference standards for the final diagnosis were surgery （n = 31）, or clinical follow-up （n = 22）. Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens were compared.RESULTS： In 2 cases puncture was not performed because of anatomical problems. The collection rate of adequate specimens from the GI tract subepithelial hypoechoic tumor with continuity to proper muscle layer was 82% （42/51）. The diagnostic rate for the tumor less than 2 cm, 2 to 4 cm, and 4 cm or more were 71% （15/21）, 86% （18/21）, and 100% （9/9）,respectively. In 29 surgically resected cases, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EUS-FNA using immunohistochemical analysis of GIST were 100%（24/24）, 80% （4/5）, 96% （24/25）, 100% （4/4）, and 97% （28/29）, respectively. No major complications were encountered.CONCLUSION： EUS-FNA with immunohistochemical analysis is a safe and accurate method in the pretherapeutic diagnosis of GIST. It should be taken into consideration in decision making, especially in early diagnosis following minimal invasive surgery for GIST.

Relationship between preoperative staging by endoscopic ultrasonography and MMP-9 expression in gastric carcinoma

AIM: To investigate the relationship between the staging by endoscopic ultrasonography (EUS) and the expression of carcinoma metastasis associated gene in the patients with gastric carcinoma. METHODS: Sixty-three patients with gastric cancer were diagnosed by electric gastroscopy and EUS. The preoperative staging of gastric cancer was measured by EUS and compared with pathologic staging and MMP-9 expression. Peripheral serum level of MMP-9 was measured with enzyme-linked immunosorbent assay (ELISA), while the expression of MMP-9 protein was tested with immunohistochemistry and hybridization in situ in the gastric carcinoma tissues. RESULTS: The total accuracy of EUS in estimating invasive depth of gastric cancer was 80.95%, while that in estimating lymphatic metastasis was 73.02%. Serum MMP-9 levels were consistent with the expression of MMP-9 protein and MMP-9 mRNA in tissue, a result closely correlated with invasive degree, staging with EUS and lymphatic metastasis in gastric cancer (P < 0.05). The total accuracy of estimating invasive depth in gastric cancer was 95.22% using both EUS and MMP-9. CONCLUSION: The MMP-9 level of preoperative serum presents the reference value for preoperative staging by EUS in the patients with gastric cancer. When serum MMP-9 level in gastric cancer is significantly high, physicians should pay closer attention to the metastasis which reaches the serosa or beyond. Combining EUS and MMP-9 improves the accuracy in deciding the invasion and metastasis in the patients with gastric carcinoma.

outcomes of preoperative endoscopic nasobiliary drainage and endoscopic retrograde biliary drainage for malignant distal biliary obstruction prior to pancreaticoduodenectomy

AIM to compare the outcomes of preoperative endoscopic nasobiliary drainage (ENBD) and endoscopic retrograde biliary drainage (ERBD) in patients with malignant distal biliary obstruction prior to pancreaticoduodenectomy (PD). METHODS Data from 153 consecutive patients who underwent preoperative endoscopic biliary drainage prior to PD between January 2009 and July 2016 were analyzed. We compared the clinical data, procedure-related complications of endoscopic biliary drainage (EBD) and postoperative complications of PD between the ENBD and ERBD groups. Univariate and multivariate analyses with odds ratios (ORs) and 95% confidence intervals (95% CIs) were used to identify the risk factors for deep abdominal infection after PD. RESULTS One hundred and two (66.7%) patients underwent ENBD, and 51 (33.3%) patients underwent ERBD. Endoscopic sphincterotomy was less frequently performed in the ENBD group than in the ERBD group (P = 0.039); the EBD duration in the ENBD group was shorter than that in the ERBD group (P = 0.036). After EBD, the levels of total bilirubin (TB) and alanine aminotransferase (ALT) were obviously decreased in both groups, and the decreases of TB and ALT in the ERBD group were greater than those in the ENBD group (P = 0.004 and P = 0.000, respectively). However, the rate of EBD procedure-related cholangitis was significantly higher in the ERBD group than in the ENBD group (P = 0.007). The postoperative complications of PD as graded by the Clavien-Dindo classification system were not significantly different between the two groups (P = 0.864). However, the incidence of deep abdominal infection after PD was significantly lower in the ENBD group than in the ERBD group (P = 0.019). Male gender (OR = 3.92; 95% CI: 1.63-9.47; P = 0.002), soft pancreas texture (OR = 3.60; 95% CI: 1.37-9.49; P = 0.009), length of biliary stricture (= 1.5 cm) (OR = 5.20; 95% CI: 2.23-12.16; P = 0.000) and ERBD method (OR = 4.08; 95% CI: 1.69-9.87; P = 0.002) were independent risk factors for deep abdominal infection after PD. CONCLUSION ENBD is an optimal method for patients with malignant distal biliary obstruction prior to PD. ERBD is superior to ENBD in terms of patient tolerance and the effect of biliary drainage but is associated with an increased risk of EBD procedure-related cholangitis and deep abdominal infection after PD. (C) The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.

Endoscopic thyroidectomy through anterior chest wall: a report of 28 cases

Objective: To retrospectively evaluate the feasibility and clinical value of endoscopic thyroidectomy through anterior chest wall. Methods: From December 2002 to May 2003, 28 patients with an average of age of 28 years old (rangeing from 20 to 45) were performed endoscopic thyroidectomy through anterior chest wall. The subcutaneous space in the anterior chest wall and the subplatysmal space in the neck were bluntly dissected through a 10-mm incision between the nipples, and CO 2 was insufflated at 6-8 mmHg to create the operative space. Three trocars were inserted in the mammary regions; and dissection of the thyroid, division of the thyroid vessels and parenchyma were performed endoscopically using an ultrasonically activated scalpel. The recurrent laryngeal nerve, the superior laryngeal nerve, and the parathyroid glands were preserved properly. Results: There were 3 mass resections, 17 subtotal lobectomies, 2 total lobectomies, 6 subtotal lobectomies plus contralateral mass resections. The mean operative time was (87.1±26.0) min; the mean blood loss during operation was (47.9±19.6) ml; and the mean postoperative hospital stay was (3.4±0.7) d. The drainage tubes were pulled out at 36-60 h postoperatively. There were no conversions to open surgery or complications. No scars can be found in the neck, and the patients were satisfied with the postoperative appearance. Conclusion: Endoscopic thyroidectomy through anterior chest wall combined with low-pressure subcutaneous CO 2 insufflation is a feasible and safe procedure. It can bring satisfactory cosmetic results. It is believed that endoscopic thyroidectomy by such approach will find a role in the future.