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    • 開展全胸腔鏡肺葉切除術,加強中遠期隨訪

      全胸腔鏡肺葉切除術代表了胸腔鏡技術的制高點,是胸部微創外科王冠上的一顆明珠。  胸腔鏡肺葉切除術最早報告于1992年,短短十幾年之后分別于2006年和2007年成為美國國家綜合癌癥網絡(NCCN)和美國胸部醫師協會(ACCP)肺癌治療指南中與開胸手術并列的肺癌標準手術方式,關于全胸腔鏡肺葉切除的安全性、可行性的爭論已經結束[1]。目前,研究的重心已經轉到考量胸腔鏡對比開胸手術的圍手術期優勢和遠期療效。現通過回顧近幾年在國際主要會議上交流并發表的文獻,對全胸腔鏡肺葉切除術的現狀、進展進行分析。1 國際研究現狀   2008年第34屆美國西部胸外科協會年會上,美國杜克大學的學者報告了697例胸腔鏡肺葉切除患者和382例開胸手術患者手術資料的對比研究,結果顯示:胸腔鏡肺葉切除術顯著減少了術中輸血、術后心房顫動、肺不張、肺炎、敗血癥和腎功能不全的發生,也顯著降低了圍手術期的病死率。在傾向性評分匹配的284例患者中,有69%的胸腔鏡手術者無術后并發癥,而開胸組并發癥發生率為51%,差異有統計學意義。此外,胸腔鏡手術后胸腔引流時間和住院時間也顯著短于開胸手術患者[2]。2008年第88屆美國胸外科協會年會(AATS)上,emorial SloanKettering癌癥中心的大樣本對照研究探討了胸腔鏡手術并發癥。該研究包括398例胸腔鏡和343例開胸手術的早期非小細胞肺癌患者,同樣發現胸腔鏡組手術并發癥發生率低于傳統開胸組,比值比(OR)為0.73(P=0.06)。此研究中以5年生存率為遠期生存評價指標,胸腔鏡組生存率(79%)高于開胸組(75%),但差異無統計學意義(P=0.08)。采用傾向性評分匹配后的統計結果也類似[3]。 2009年第89屆美國胸外科學會(AATS)年會上,美國紐約長老會醫院聯合杜克大學的胸外科醫師總結了美國胸外科醫師協會(STS)數據庫中,2002~2007年所有接受肺葉切除的患者資料,包括1 281例胸腔鏡肺葉切除術和5 042例開胸手術患者。研究者通過傾向性評分方法選擇了與胸腔鏡手術患者匹配的1 281例開胸手術患者,對比了圍手術期并發癥發生情況發現,胸腔鏡手術患者中無并發癥發生率顯著高于開胸手術患者(738% vs. 65.3%,Plt;0001);分類比較顯示,肺部并發癥、心律失常、二次插管、術后輸血等并發癥發生率胸腔鏡組均顯著低于 開胸組;此外,胸腔鏡組胸腔引流時間和住院天數也較開胸組短[4]。2008年第44屆美國胸外科醫師協會年會報告的系統性回顧[5]和2009年發表的包含21項胸腔鏡與開胸手術治療早期肺癌對比研究的Meta分析[6]顯示,胸腔鏡手術遠期生存不僅不劣于,甚至可能優于傳統開胸手術。其中的系統評價總結了PubMed上自1992年胸腔鏡肺葉手術報告以來至2007年4月間所有手術治療早期肺癌的文章,對比了這些手術報告中胸腔鏡手術和開胸手術資料,共6 300例。對比結果發現,接受胸腔鏡手術的患者術后并發癥、胸腔引流時間、住院時間顯著低于開胸手術者,而遠期生存率高,特別是4年生存率,胸腔鏡手術比開胸手術患者絕對值高17%[6]。 2 國內現狀 與胸腔鏡肺葉切除術在國際上的發展相比,我國第1例手術于1996年完成,相差僅4年,但由于受到經濟發展和技術經驗的限制未能真正發展起來,直到2006年才真正形成規模開展。由于時間短,限制了各中心的病例數和隨訪時間,目前國內雖已有論著報道,但病例數少且缺乏隨訪。《中國胸心血管外科臨床雜志》18卷第2期發表了北京大學人民醫院楊帆等“連續300例全胸腔鏡肺葉切除術及中期隨訪分析”的論著,在一定程度上填補了這個空白。該論文總結了北京大學人民醫院單中心連續300例全胸腔鏡肺葉切除術的臨床資料,手術時間為2006年9月至2009年12月,是投稿時國內最大宗的病例報告。除了手術資料,該文進一步報告了3年隨訪結果。此外,作者對比了良、惡性疾病的手術特點,分析了中轉開胸的風險因素,這正是臨床工作中所關注的問題。該研究總結的300例全胸腔鏡手術患者中,有273例完成胸腔鏡手術,中轉開胸27例,中轉開胸率為900%。完成胸腔鏡手術的時間3.17±0.88 h,患者術中出血225.7±195.2 ml,術后并發癥發生率136%。這些指標國外報告的結果為手術時間1.3~4.8 h,術中出血量72~253 ml,中轉開胸率0.0%~15.7%[5],術后并發癥發生率16.4%[6]。以上的對比數據表明國內全胸腔鏡肺葉切除術的客觀指標達到了國外報道的平均水平。經過平均14.4個月(0~39個月)的隨訪,該研究中的213例非小細胞肺癌患者累計1年總生存率為95.0%,3年總生存率869%,也與國外報道相似[6]。  對于良、惡性疾病手術的對比和中轉開胸手術風險因素分析是該研究的亮點。該研究發現良性疾病手術并不比肺癌手術簡單,原因主要在于慢性炎癥的粘連。中轉開胸原因分析也發現,粘連是中轉開胸的最主要原因。分層分析顯示,中轉開胸與疾病性質、病變位于左、右側及患者性別無關,只有肺上葉切除與中轉開胸顯著相關。作者分析其原因是血管解剖特點和肺上葉更多見的結核性粘連。以上的總結與分析對于胸腔鏡肺葉切除手術的初學者可謂是寶貴的、可借鑒的經驗。  但該論文也存在著一些欠缺。(1)所有的病例均來自單中心,北京大學人民醫院,這使手術資料受到了該單位的技術水平、病例來源和手術適應證選取等因素的影響,研究結果離開這個前提會有怎樣的變化仍是未知。(2)該研究僅僅總結了胸腔鏡手術資料,沒有與類似的開胸手術病例進行比較,無法回答胸腔鏡與開胸手術優劣差異的問題,而該問題更是學術界所關心的問題。(3)該研究時間為2006~2009年,開展全胸腔鏡肺葉切除術的時間跨度較大,包含了所謂“學習階段”的病例,也包括了“成熟時期”的病例,甚至也有一些“成熟時期”年輕醫師“學習階段”的病例,對于僅300例資料而言,這些病例可能占一定數量,使結果摻雜更多的影響因素。(4)由于肺癌患者預后的最重要因素是腫瘤分期,因此預后報告原則上是應依據分期分組,但由于病例數的限制,該研究無法做到這點。(5)隨訪時間較短,而接受手術的肺癌患者以早期為主,還需要遠期隨訪(至少5年)才能真正反映治療的效果。瑕不掩瑜,“連續300例全胸腔鏡肺葉切除術及中期隨訪分析”一文雖存在的一些不足,但對我國胸腔鏡肺葉切除術的發展起到了積極的推動作用,而這些不足正為后續的經驗總結提供了研究點。隨著我國經濟的發展,為掃清胸腔鏡肺葉切除術的經濟障礙提供了條件;高水平的胸腔鏡肺葉切除學習班、研討會又為克服技術困難打下了基礎。相信全胸腔鏡肺葉切除手術的燎原之火能越燃越旺,造福更多患者。同時希望我國醫療工作者和研究者開展設計科學、樣本量足夠大的胸腔鏡肺葉切除術有效性和安全性的臨床研究,并及時制作高質量系統評價總結臨床研究結果,為全面推動我國胸腔鏡肺葉切除術的開展提供高質量、可靠的臨床證據。

      Release date:2016-08-30 05:56 Export PDF Favorites Scan
    • Complexity Analysis of Gait Signal Based on Jensen-Shannon Divergence

      When people are walking, they will produce gait signals and different people will produce different gait signals. The research of the gait signal complexity is really of great significance for medicine. By calculating people's gait signal complexity, we can assess a person's health status and thus timely detect and diagnose diseases. In this study, the Jensen-Shannon divergence (JSD), the method of complexity analysis, was used to calculate the complexity of gait signal in the healthy elderly, healthy young people and patients with Parkinson's disease. Then we detected the experimental data by variance detection. The results showed that the difference among the complexity of the three gait signals was great. Through this research, we have got gait signal complexity range of patients with Parkinson's disease, the healthy elderly and healthy young people, respectively, which would provide an important basis for clinical diagnosis.

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    • Problems about Recurrent or Metastatic Gastric Cancer and Its Integrative Treatment

      Release date:2016-08-28 04:20 Export PDF Favorites Scan
    • Analysis of Sleep Electroencephalograph Signal Based on Detrended Cross-Correlation

      The quality of sleep has a great relationship with health and working efficiency. The result of sleep stage classification is an important indicator to measure the quality of sleep, and it is also an important way to diagnose and treat sleep disorders. In this paper, the method of detrended cross-correlation analysis (DCCA) was used to analyze sleep stage classification, sleep electroencephalograph signals, which were extracted from the MIT-BIH Polysomnographic Database randomly. The results showed that the average DCCA exponent of the awake period is smaller than that of the first stage of non-rapid eye movement (NREM) sleeps. It is well concluded that the method of studying the sleep electroencephalograph with this method is of great significance to improve the quality of sleep, to diagnose and to treat sleep disorders.

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    • Comparison of the effectiveness of unicompartmental arthroplasty and total knee arthroplasty based on patient scale data

      ObjectiveTo compare the patient-reported outcomes regarding function, joint amnesia, and the quality of life after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). Methods The clinical data of patients who received UKA or TKA between September 2017 and June 2018 were retrospectively analyzed. After propensity score matching, 40 patients (40 knees) each in TKA group and UKA group were finally included in the study. There was no significant difference between the two groups in gender, age, body mass index, surgical side, preoperative knee range of motion, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score, clinical and function scores of knee society score (KSS) (P>0.05). At 2 years after operation, WOMAC score, KSS clinical and function scores were performed on the two groups of patients, and compared with preoperative ones; knee injury and osteoarthritis outcome score-physical function short form (KOOS-PS), short-form 36 health survey scale (SF-36 scale), and forgotten joint score (FJS) were also performed. Results At 2 years after operation, the total score of WOMAC, the clinical and function scores of KSS in the two groups significantly improved when compared with preoperative ones (P<0.05), but there was no significant difference in the total score of WOMAC, the individual score of WOMAC, the clinical and function scores of KSS between the two groups (P>0.05). The total KOOS-PS score in the UKA group was significantly lower than that in the TKA group (t=4.243, P=0.000), and the scores of writhing/knee rotation, kneeling, and squatting in the UKA group were significantly lower than those in the TKA group (P<0.05). The total FJS score in the UKA group was significantly higher than that in the TKA group (t=?6.334, P=0.000). In the UKA group, the scores of 7 items were significantly lower than those of the TKA group (P<0.05) including when walking over 15 minutes, when climbing stairs, when walking on uneven ground, when standing for long periods, when doing housework or gardening, when taking a walk or hiking, and when doing your favorite sport. The SF-36 scales of physiological function, energy, social function, emotional function, and mental health in the UKA group were significantly higher than those in the TKA group (P<0.05). Conclusion Compared with TKA, patients treated with UKA may have better knee function recovery, joint amnesia, and higher quality of life.

      Release date:2022-01-12 11:00 Export PDF Favorites Scan
    • 重癥風濕性心瓣膜病的外科治療

      Release date:2016-08-30 06:23 Export PDF Favorites Scan
    • 電視胸腔鏡手術治療食管憩室

      目的 探討電視胸腔鏡在食管中段憩室切除術中的可行性及安全性。 方法  1999年 1月~ 2 0 0 3年 2月共施行電視胸腔鏡食管中段憩室切除術 6例 ,術前均經食管 X線鋇餐造影及胃鏡檢查確診為食管中段憩室。結果  6例患者均完全在胸腔鏡下完成手術 ,無中轉開胸患者 ,無死亡患者及嚴重并發癥發生 ;術后隨訪無復發。結論 胸腔鏡下行食管中段憩室切除術是一種安全可行的微創術式。

      Release date:2016-08-30 06:24 Export PDF Favorites Scan
    • Application of Rigid Bronchoscopy in the Treatment of Tracheobronchial Disease

      Objective To summarize our experience of using rigid bronchoscopy in the managent of patients with tracheobronchial disease. Methods From Sep.2002 to Nov.2007, 44 patients of tracheobronchial disease(31 men,13 women, median age 51.9 years) underwent rigid bronchoscopic operations. All procedures were carried out under general anesthesia with high frequency jet ventilation. After the rigid bronchoscope was placed in the main trachea through the mouth , the airway was checked out firstly, and then the lesion was removed by repeated freezing, argon plasma coagulation, cauterization or mechanical ablation, and a stent maybe implanted while needed. Results All 54 procedures were accomplished endoscopically without mortality or major morbidity (16 clearence,19 core out,8 scar clearance,3 foreign body removal, 8 stent insert or removal).The lesion located at trachea in 19 cases, at carina in 4 cases,at left main bronchus in 11 cases and at right main bronchus in 10 cases. There were 17 benign diseases and 27 malignant diseases. There were 3 slight complications. 16 patients compliating with benign disease were followed-up and 1 patient was missed,there was no tumor recurrence except 3 patients complicating with tracheal scar who received reoperations during 4-44 (mean 23.0) months follow-up period. Of the 27 malignant cases,23 patients were followed-up and 4 patients were missed, the follow-up period were 5-58(mean 27.1)months.3 patients died in one months after operation of other disease; the other patients all survived more than one month,especially 7 patients who received radical resection of the tumor survived more than one year. Conclusions These data show that rigid bronchoscope can be applied safely and effectively in the management of tracheobronchial disease.

      Release date:2016-08-30 06:09 Export PDF Favorites Scan
    • 電視縱隔鏡術診治胸部疾病76例

      目的探討電視縱隔鏡檢查在肺癌的術前分期、縱隔腫物、惡性胸腔積液診治中的應用。方法76例患者中行頸部縱隔鏡術38例,胸骨旁縱隔鏡術16例,經肋間縱隔鏡術22例。結果經縱隔鏡檢查確診為腺癌21例,轉移性低分化鱗癌18例,結核6例,胸腺鱗狀細胞癌5例,非何杰金淋巴瘤5例,肺小細胞癌4例,胸腺瘤3例,縱隔神經母細胞熘3例,何杰金淋巴瘤2例,胸膜問皮瘤2例,神經鞘瘤1例,胸腺增生1例,原始神經外胚葉腫瘤1例,淋巴結炎癥1例,反應性增生1例。2例術前纖維支氣管鏡病理診斷為左肺下葉鱗癌,經電視縱隔鏡檢查確診為右氣管旁淋巴結轉移。結論電視縱隔鏡術不但是肺癌術前病理分期的重要檢查方法,還可作為縱隔疾病和惡性胸腔積液診治的方法之一。

      Release date:2016-08-30 06:26 Export PDF Favorites Scan
    • 電視胸腔鏡肺切除的手術方法

      目的 為了評價電視胸腔鏡肺切除術在肺部腫瘤治療中的可行性,而對其手術方法和治療原則進行探討. 方法 回顧性分析1992年10月至2000年3月,127例胸腔鏡肺切除術患者的臨床資料,其中肺楔形切除術71例,肺葉切除術50例,全肺切除術6例. 結果 全組無手術死亡及嚴重并發癥, 手術時間、引流時間、住院時間均明顯縮短.全組平均胸腔引流時間2.4天,平均住院天數10.6天. 結論 胸腔鏡肺切除術是安全可行的,只要嚴格掌握手術適應證,運用合理的手術方法和技巧,一般可以達到與常規開胸手術同樣的效果.

      Release date:2016-08-30 06:31 Export PDF Favorites Scan
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