高位集束结扎精索血管治疗精索静脉曲张213例

精索静脉曲张是常见、多发的泌尿外科疾病，手术治疗方式较多，笔者自2005年2月至2006年12月采用腹膜后高位集束结扎精索血管213例精索静脉曲张病人，效果满意，现报告如下。

温针灸配新加橘核丸治疗精索静脉曲张的临床观察

依据精索静脉曲张病人阴囊睾丸坠胀感,阴囊湿冷、胀痛、隐痛,向同侧会阴、腹股沟和腰部放射等主要表现,应属中医学＂筋瘤＂、＂筋疝＂、＂偏坠＂、＂疝气＂等范畴.精索静脉曲张患者不仅具有上述症状,严重者可造成性功能障碍,甚至造成睾丸萎缩和精子生成障碍,导致男性不育.西医主要以手术为主.但是近年资料显示,对青春期精索静脉曲张者不应急于手术.10年来我们运用温针灸配合口服新加橘核丸治疗该病,取得满意疗效,现报道如下.

警惕青少年精索静脉曲张

青少年患精索静脉曲张者并不罕见,因其症状仅引起阴囊酸胀感,痛苦不深,常得不到患者的足够重视。但青少年时期的精索静脉曲张,如未能得到及时处理,是成年后男子不育的重要因素。英国有一位医生研究了2989名不育者,均为青壮年人,他对这些男性进行了全面检查,并做了超声阴囊检查。

腹膜外经髂窝精索内静脉结扎术62例体会

本院自1985年至1988年采用腹膜外经髂窝结扎精索内静脉治疗精索精脉曲张62例,经临床实践,手术简便,效果良好,现报告如下: 临床资料本组62例均是未婚青年,年龄为18～25岁,左侧59例,右侧2例,双侧1例。中度曲张34例,重度曲张28例。病程1～3年57例,3年以上5例。

强力脉痔灵治疗淤积性皮炎41例

1998.2～12月,我们用德国礼达(JuliusRedel Cesra)大药厂生产的强力脉痔灵(Aescvenforte)治疗淤积性皮炎41例,现报告如下。1 临床资料1.1 病例选择 41例门诊患者,男26例,女15例。年龄46～89岁,平均58岁。病程4个月～15年,平均5.2年。皮疹表现:局部水肿性暗红斑,暗褐色硬结、糜烂、渗液、结痂、脱屑、肥厚、苔藓样变。部位:内踝上部15例,小腿外伸侧19例,小腿内伸侧4例。

蔗糖铁注射液致重症多形红斑型药疹1例

病例：患者,女,71岁。因“尿检异常1年,肾功能不全10月,气促1周”于2月2日入院。既往有高血压病史4年、静脉曲张病史50余年,否认有遗传病及药物过敏史。查体：体温37.4℃,脉搏80次/min,呼吸18次/min,血压：113/69 mm Hg。2月28日起,因肾性贫血开始给予静脉滴注蔗糖铁注射液每天100 mg,次日患者腹部出现散在大小不等的水肿性红斑,疑过敏,给予口服氯雷他定片每天10mg对症治疗,未停用蔗糖铁注射液。

New methods for the management of gastric varices

Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.

Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices

AIM： To evaluate the effect of three interventional treatments involving transvenous obliteration for the treatment of gastric varices, and to compare the efficacy and adverse effects of these methods, METHODS： From 1995 to 2004, 93 patients with gastric fundal varices underwent interventional radiologic embolotherapy at our hospital. Of the 93 patients, 75 were treated with the balloon-occluded retrograde transvenous obliteration （BRTO） procedure; 8 were with the percutaneous transhepatic obliteration （PTO） procedure; and 10 were with the combined BRTO and PTO therapy. A follow-up evaluation examined the rates of survival, recurrence and rebleeding of the gastric varices, worsening of esophageal varices and complications in each group. RESULTS： The BRTO, PTO, and combined therapy were technically successful in 81% （75/93）, 44% （8/18）, and 100% （10/10） patients, respectively. Recurrence of gastric varices was found in 3 patients in the BRTO group and in 3 patients in the PTO group. Rebleeding was observed in 1 patient in the BRTO group and in 1 patient in the PTO group. The 1- and 3-year survival rates were 98% and 87% in the patients without hepatocellular carcinoma （HCC） in the BRTO group, 100% and 100% in the PTO group, and 90% and 75% in the combined therapy group, respectively. CONCLUSION： Combined BRTO and PTO therapy may rescue cases with uncontrollable gastric fundal varices that remained even after treatment with BRTO and/or PTO, though there were limitations of our study, including retrospective nature and discrepancy in sample size between the BRTO, PTO and combined therapy groups.

Is transient elastography a useful tool for screening liver disease?

Transient elastography(TE)is a new non invasive tool for measuring liver stiffness,which is correlated to the histologic stage of liver fibrosis.Several studies in chronic liver disease(CLD)have determined a good accuracy of TE in predicting significant fibrosis and an optimal accuracy in predicting cirrhosis.Normal liver stiffness ranges between 3.3-7.8 KPa and using a cut off of 7.1 KPa,significant fibrosis and cirrhosis can be excluded with a very high negative predictive value(NPV).Positive predictive value(PPV)for the diagnosis of cirrhosis is lower using just a single scan but increases to 90% if high stiffness values are confirmed by a second independent scan.However the presence of fatty liver and metabolic syndrome slightly increases the readings and may reduce the accuracy of the test.It is uncertain if this increase is related to the presence of steatofibrosis or ifit is caused by steatosis itself.TE can be used in screening patients attending the liver clinics to identify those with signifi cant fi brosis or cirrhosis and may be particularly useful in discriminating HBV inactive carriers from chronic hepatitis B patients.TE,however,is not reliable in predicting the presence of esophageal varices in cirrhotics.Another potential indication for TE is the systematic screening of populations at high risk for CLD,such as intravenous drug users and alcoholics,but further studies are needed to determine its diagnostic accuracy in these settings.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: A two-year survey

AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience.Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy.On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters. METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up. RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri- esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded. CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.

Update of endoscopy in liver disease:More than just treating varices

The management of complications in liver disease is often complex and challenging.Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease.In this review,relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension.The main areas covered are safety of endoscopy in patients with liver disease,the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound,esophageal capsule,argon plasma coagulation,spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology.It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices.As the technology in endoscopy expands,so does the role of the endoscopist in liver disease.

Natural history of a randomized trial comparing distal spleno-renal shunt with endoscopic sclerotherapy in the prevention of variceal rebleeding:A lesson from the past

AIM: To compare endoscopic sclerotherapy (ES) with distal splenorenal shunt (DSRS) in the prevention of recurrent variceal bleeding in cirrhotic patients during a long-term follow-up period. METHODS: In 1984 we started a prospective, controlled study of patients with liver cirrhosis. Long-term follow-up presents a natural history of liver cirrhosis complicated by advanced portal hypertension. In this study the effects of 2 types of treatment, DSRS or ES, were evaluated. The study population included 80 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1991. These patients were drawn from a pool of 282 patients who underwent either elective surgery or ES during the same period of time. Patients were assigned to one of the 2 groups according to a random number table: 40 to DSRS and 40 to ES using polidocanol. RESULTS: During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS and another patient suffered duodenal ulcer rebleeding. Eight ES patients suffered at least one episode of gastrointestinal bleeding: 4 from varices and 4 from esophageal ulcerations. Eight ES patients developed transitory dysphagia. Long-term follow- up was completed in all patients except for 5 cases (2 DSRS and 3 ES patients). Five-year survival rates for shunt (73%) and ES (56%) groups were statistically different: in this follow-up period and in subsequent follow-ups this difference decreased and ceased to be of statistical relevance. The primary cause of deathbecame hepatocellular carcinoma (HCC). Four DSRS patients rebled due to duodenal ulcer, while eleven ES patients had recurrent bleeding from esophago-gastric sources (seven from varices, three from hypertensive gastropathy, one from esophageal ulcerations) and two from unknown sources. Nine DSRS and 2 ES patients developed a chronic encephalopathy; 13 DSRS and 5 ES patients suffered at least one episode of acute encephalopathy. Five ES patients had esophageal stenoses, which were successfully dilated. CONCLUSION: In a subgroup of patients with good liver function, DSRS with a correct portal-azygos disconnection more effectively prevents variceal rebleeding than ES. However, this positive effect did not influence the long-term survival because other factors (e.g. HCC) were more important in deciding the fate of the cirrhotic patients with portal hypertension.

Pulmonary embolism after transcatheter arterial chemoembolization for hepatocellular carcinoma:a retrospective analysis on 10 years' experience

To study the clinical characteristics and treatment of pulmonary embolism （PE） after transcatheter arterial chemoembolization （TACE） for hepatocellular carcinoma （HCC）. Methods： The clinical records of 13 512 patients diagnosed with HCC and received TACE from January 2000 to December 2009 were reviewed. Among these patients, 5 031 were allocated into group A who had one or more disorders like diabetes, hypertension, coronary heart disease, obesity or varicose vein of lower limb, while the other 8 481 patients who did not have such disorders were in group B. Results： A total of 39 185 TACE procedures were performed for the 13 512 patients. Five （0.01%） patients in group A developed PE after TACE, of whom two recovered 4 and 5 d later with early anticoagulant therapy while the hypertension, coronary heart disease, obesity or varicose vein of lower limb are possibly more likely to develop PE other 3 died of respiratory failure within 5 h. The mortality of PE was 60% （3/5）. Conelusion： HCC patients with diabetes, after TACE than those without such disorders. Patients who have such disorders should be more carefully observed after TACE and early treatment with heparin should be applied once PE develops.

Long-term results of small-diameter proximal splenorenal venous shunt:A retrospective study

AIM:To investigate recurrent variceal hemorrhage and long-term survival rates of patients treated with partial proximal splenorenal venous shunt.METHODS:Patients with variceal hemorrhage who were treated with small-diameter proximal splenorenal venous shunt in Ruijin Hospital between 1996 and 2009 were included in this study.Shunt diameter was determined before operation using Duplex Doppler ultrasonography.Peri-operative and long-term results in term of rehemorrhage,encephalopathy and mortality were followed up.RESULTS:Ninety-eight patients with Child A and B variceal hemorrhage received small-diameter proximal splenorenal venous shunt with a diameter of 7-10 mm.After operation,the patients’mean free portal pressure (P<0.01)and the flow rate of main portal vein(P< 0.01)decreased significantly compared with that before operation.The rates of rebleeding and mortality were 6.12%(6 cases)and 2.04%(2 cases),respectively.Ninety-one patients were followed up for 7 mo-14 years (median,48.57 mo).Long-term rates of rehemorrhage and encephalopathy were 4.40%(4 cases)and 3.30% (3 cases),respectively.Thirteen patients(14.29%)died mainly due to progressive hepatic dysfunction.Fiveand ten-year survival rates were 82.12%and 71.24%,respectively.CONCLUSION:Small-diameter proximal splenorenal venous shunt affords protection against variceal rehemorrhage with a low occurrence of encephalopathy in patients with normal liver function.

An unusual cause of hematemesis:Goiter

Downhill varices are located in the upper part of the esophagus and are usually related to superior vena cava obstruction. Bleeding from these varices is extremely rare. We describe a 77-year-old patient with hematemesis due to downhill varices as a result of recurrent goiter. A right lobe thyroidectomy was carried out with disappearance of the varices.