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體外循環心內直視手術中肝素耐藥的原因分析及處理措施

摘要： 目的 探討體外循環(CPB)心臟直視手術中肝素耐藥的原因及處理措施。 方法 自1998年1月至2007年5月我科對1 258例心臟病患者行CPB心臟直視手術，術中19例患者（心臟粘液瘤7例、風濕性心臟病3例、感染性心內膜炎3例、房間隔缺損2例、法洛四聯癥2例、室間隔缺損1例、右心室雙出口1例）出現肝素耐藥，男8例，女11例；年齡4～58歲(37±12歲)。其中14例補充肝素后全血激活凝血時間(ACT)gt;480 s；5例補充肝素后ACT仍lt;480 s，給予靜脈輸注新鮮冰凍血漿或全血后ACT達480 s以上；平均追加肝素13 750 U。另有3例CPB術中ACT很快縮短，平均再補充肝素7 500 U后ACTgt;480 s。 結果 19例患者CPB時間58±27 min，主動脈阻斷時間45±22 min；心臟自動復跳17例，15～30 J除顫心臟復跳2例；住ICU時間1～3 d，平均住院時間14.5 d，均痊愈出院。術后隨訪13例(68.4%)，隨訪時間2～26個月，心功能恢復至Ⅰ級11例，Ⅱ級2例，無栓塞及出血等嚴重并發癥發生；失訪6例。 結論 CPB心臟直視手術中肝素耐藥常見于心臟粘液瘤、感染性心內膜炎及紫紺型心臟病等，與血液中出現類似肝素的粘多糖物質、抗凝血酶Ⅲ(ATⅢ)含量及活性低、血小板計數增高、術前抗凝治療及使用避孕藥等因素有關，術中需加強ACT的監測。

單側原發性自發性氣胸行雙側肺大泡切除術的治療效果

摘要： 目的 探討單側原發性氣胸行雙側肺大泡切除術的可行性及治療效果，以尋求單側原發性氣胸最有效的治療方法。 方法 回顧分析我科自2003年3月至2008年12月 413例單側原發性自發性氣胸患者的臨床資料和隨訪結果，其中男371例，女42例；年齡18～41歲，平均年齡27.7歲。氣胸位于左側285例，右側128例；首次發生氣胸252例，再次發生氣胸161例；單發性肺大泡65例,多發性肺大泡348例；肺大泡直徑≤1cm 361例，直徑＞1 cm 52例；肺大泡位于肺上葉370例，位于肺中葉或下葉背段43例。采用雙側腋下第3～5肋間小切口行雙側肺大泡切除術282例，在電視胸腔鏡下行雙側肺大泡切除術131例。 結果 手術時間110.3±48.4 min，拔除氣管內插管時間6.5±1.2 d，住院時間8.1±2.3 d。術后出現復張性肺水腫3例，傷口感染3例，均經相應的治療治愈；術后二次開胸止血1例。隨訪287例，隨訪時間17.0±6.3個月，隨訪期間所有患者無并發癥發生，復查胸部X線片無氣胸復發。結論 年輕的單側自發性氣胸患者往往雙側肺都有相對稱的病變存在，患者能耐受同期雙側肺大泡切除術，同期雙側肺大泡切除術可根治雙側肺大泡病變，并能有效地預防氣胸的復發。

選擇性肺動脈灌注治療晚期肺癌

目的　探討對晚期肺癌患者的治療手段，使失去手術機會的患者得到有效的治療。　方法　采用化療泵行選擇性肺動脈灌注。　結果　80例晚期肺癌患者中肺部包塊縮小67例，癥狀好轉或明顯緩解70例。　結論　選擇性肺動脈灌注方法簡便、安全、有效，不失為治療晚期肺癌的一種有效手段。

Relationship between UGT1A1 Polymorphisms and Adverse Effects of Irinotecan in Patients with Esophageal Carcinoma

ObjectiveTo investigate the distribution of uridine diphosphate-glucuronosyltransferase 1A1 (UGT1A1) gene polymorphisms in esophageal carcinoma (EC) patients, and their relationship with adverse effects (delayed diarrhea and neutropenia) of Irinotecan. MethodsForty-eight patients with esophageal squamous carcinoma who were admitted to Sichuan Provincial People's Hospital between January and October 2012 were recruited in the study. There were 37 male and 11 female patients with their age of 56 (25-38) years. Formalin-fixed, paraffin-embedded samples were collected from those EC patients and genomic DNA was extracted. UGT1A1 polymorphisms were detected by PCR and DNA sequencing. Three genetic loci were investigated including UGT1A1* 28 (TA6 > TA7), UGT1A1* 6 (211G > A) and UGT1A1* 93 (-3156G > A). Adverse effects (delayed diarrhea and neutropenia) of patients with different UGT1A1 polymorphisms after Irinotecan treatment were recorded. The relationship between UGT1A1 polymorphisms and Irinotecan-induced adverse effects was analyzed. ResultsUGT1A1 polymorphisms were detected in 10 out of 48 (20.8%) EC patients. UGT1A1* 93 (-3156G > A)polymorphisms were most common with the polymorphism rate of 16.7% (8/48), followed by GT1A1* 6 (211G > A) polymorphisms with the polymorphism rate of 4.2% (2/48). The incidences of grade 3~4 diarrhea and grade 3~4 neutropenia after Irinotecan treatment in the patients with UGT1A1 polymorphisms were 60.0% and 40.0% respectively, which were significantly higher than those of the patients with wild type UGT1A1 (21.1% and 15.8% respectively, P < 0.05). UGT1A1 polymorphism rates were 45.5% (5/11) in female patients and 13.5% (5/37) in male patients, which were significantly different (P < 0.05). ConclusionsIn EC patients, 2 polymorphism loci including UGT1A1* 93 (-3156G > A) and GT1A1* 6 (211G > A) can effectively predict adverse effects caused by Irinotecan treatment. UGT1A1 polymorphism rate of male patients is significantly lower than that of female patients.

Surgical Treatment for Ruptured Sinus of Valsalva Aneurysm

【摘要】 目的 探討主動脈竇瘤破裂（RSVA）的臨床特點、診斷及外科治療方法。 方法 2004年1月-2009年12月對28例RSVA患者在體外循環下行RSVA修補術，同期行室間隔缺損修補術18例，房間隔缺損修補術4例，主動脈瓣成形術2例，主動脈瓣置換術4例。術后隨訪3個月～6年，平均32.4個月。 結果 28例患者均無手術死亡和殘余分流。失訪4例。心功能Ⅰ級20例，Ⅱ級4例；復查心臟彩色超聲心動圖無主動脈竇瘤復發或殘余分流，主動脈瓣輕-中度反流2例。 結論 外科手術是RSVA的最有效治療方法，竇瘤破口直徑gt;0.5 cm者宜用補片修補。伴有中或重度主動脈瓣關閉不全時需根據主動脈瓣病變程度以及手術者經驗決定，必要時需放寬換瓣指征。【Abstract】 Objective To evaluate the clinical characteristics, diagnosis, and surgical treatment of ruptured sinus of Valsalva aneurysm (RSVA). Methods Twenty-eight patients with RSVA were treated surgically in extracorporeal circulation. Repair of RSVA with patch were taken in all patients while closure of ventricular septal defect (VSD) in 18 patients, closure of atrial septal defect (ASD) in four patients, aortic angioplasty (AA) in two patiens and replacement of aortic valve in four patients. Results There was no death and no residue leak after operation. The patients were followed-up for 24 patients, ranged from three months to six years, with the average 32.4 months. The cardiac function of 20 patients was found to be of NYHA classⅠand four patients of classⅡ. Review the heart colour echocardiography, there was no residual tumor or sinus and aortic regurgitation light-moderate in two patients. Conclusions Surgery is the most effective treatment for RSVA, the breaches of sinus tumor in diametergt;0.5 cm is used to repair. When the patients with moderate or severe aortic regurgitation, whether it is necessary to relax in disc indications depends on the degree of aortic disease and performer’s experience.

Clinical Analysis of Cardio Mitral Valvuloplasty for Improving Mitral Valve Regurgitation

目的　總結68例二尖瓣成形術的臨床經驗，評估其術后臨床效果。 方法　回顧分析2001年12月－2011年12月進行二尖瓣成形術治療的68例二尖瓣關閉不全患者的臨床資料。成形術的方法為：人工瓣環植入、雙孔成形、后瓣矩形切除、贅生物切除及心包補片修復、腱索轉移等。術中采用注水實驗和經食管超聲心動圖檢查評估成形效果。 結果　68例患者中手術死亡2例，二次開胸止血1例，肺部感染3例。全部患者術中注水實驗和食管超聲心動圖檢查顯示成形效果滿意。存活66例患者隨訪6個月，術后10 d、6個月彩色多普勒超聲心動圖檢查：左心房內徑、左心室舒張末內徑縮小。術后6個月彩色多普勒超聲心動圖檢查：無或微量反流33例，輕度反流27例，輕～中度反流5例，中度反流1例。 結論　根據二尖瓣關閉不全的特征，選擇相應的二尖瓣成形技術，可以取的較好的臨床效果。

Application of Thoracoscopy Combined with Laparoscopy in Esophagectomy for Esophageal Carcinoma

目的探討胸腹腔鏡在食管癌手術中應用的可行性及近期療效。 方法2012年6月至2013年10月四川省人民醫院胸外科90例食管癌患者行胸腹腔鏡聯合食管癌切除術，其中男54例、女36例，年齡47～83歲，平均（63.15±11.10）歲。手術先行胸腔鏡游離胸段食管并清掃淋巴結，再腹腔鏡游離胃行食管胃左頸部吻合術。記錄手術時間、術后胸腔引流管放置時間、平均住院時間、淋巴結清掃枚數、術后并發癥等。 結果全部無圍術期死亡。手術時間260～450 min。術后4～11 d（平均5 d）拔除胸腔閉式引流管，胸腔總引流量為530～4 260 ml。全組共清掃縱隔淋巴結（氣管旁、右下肺韌帶、食管旁、隆凸下及左右喉返神經鏈旁）、腹腔淋巴結（賁門旁、胃左動脈旁）及頸部淋巴結1 395枚，平均每例15.5枚，15例（16.7%）發現淋巴結轉移。術后發生吻合口瘺7例（7.8%），聲音嘶啞5例（5.6%），肺部感染5例（5.6%），乳糜胸2例（2.2%），均經保守治療后痊愈。術后10～14 d出院。門診及電話隨訪82例，隨訪率91.1%，隨訪時間1～16個月，患者全部生存，無復發。 結論胸腹腔鏡聯合行食管癌根治術在技術上是安全可行的，近期療效可靠。

胸腹腔鏡聯合食管癌根治術視頻要點

劍突下入路單孔胸腔鏡手術治療自發性氣胸 30 例Subxiphoid approach single-incision video-assisted thoracoscopic surgery for 30 patients with spontaneous pneumothorax

目的 探討劍突下入路單孔胸腔鏡手術治療自發性氣胸的安全性和可行性。 方法 回顧性分析 2014 年 8 月至 2016 年 1 月間劍突下入路單孔胸腔鏡手術治療自發性氣胸 30 例患者的臨床資料，其中男 19 例、女 11 例，年齡 16～28（20.5±5.2）歲。 結果 手術均順利完成，無中轉開胸，無術后出血、漏氣等并發癥。手術時間（30.5±12.4）min，術中出血量（20.0±10.0）ml，術后胸腔引流管留置時間（1.5±0.8）d，術后住院時間（3.5±0.5）d。術后隨訪 1 個月，無復發、感染等其他并發癥。 結論 劍突下入路單孔胸腔鏡手術治療自發性氣胸安全、可行。