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胸外科患者术后肺栓塞的诊断与治疗

目的　总结肺栓塞（pulmonary embolism，PE）患者的特点，提高胸外科患者术后并发症的诊断与治疗水平。　方法　回顾性分析上海交通大学附属胸科医院2007年6月至2008年10月收治术后肺栓塞患者22例的临床资料，其中中高危肺栓塞8例，男5例、女3例，平均年龄63.5 （55～76）岁，肺癌5例，食管癌1例，纵隔肿瘤1例，慢性炎性肉芽肿1例，均行溶栓治疗；低危肺栓塞14例，男 11例、女 3例，平均年龄61.7 （55～75）岁，肺癌9例，食管癌5例，均行抗凝治疗。　结果　中高危患者中7例症状在24 h内明显改善，均痊愈出院，随访3个月无复发；1例24 h内好转，48 h后出现严重的肺部感染，并于5 d后死亡。14例低危患者均于治疗3～5 d后氧合改善，随访3个月无复发。　结论　胸外科患者术后肺栓塞的诊断仍较为困难；溶栓治疗是中高危肺栓塞患者的首选治疗方案；深静脉血栓（deep vein thrombosis，DVT）形成是术后肺栓塞的高危因素，应高度重视。

Sarcoidosis-A Disease Needs to Be Differentiated from Lung Cancer

Abstract：　Sarcoidosis is a common systemic disease with noncaseating granulomatous epithelioid nodule and coexisting　granulomatous inflammation. Although sarcoidosis can affect any organ of the body， more than 90% of the patients　demonstrate thoracic involvement， which is often confusing with lung cancer and other diseases. Therefore, thoracic surgeons　must have a clear understanding of sarcoidosis. Moreover， due to the special role of surgery in obtaining pathological specimens， thoracic surgeon plays an important role in the diagnosis and treatment of sarcoidosis. It is not difficult to make diagnosis for patients with typical clinical features of sarcoidosis. However， the majority of patients do not have specific manifestations of sarcoidosis. The cause of sarcoidosis remains unknown， and there is also no specific treatment strategy for it. But recent research has shown that annexin A11 gene may be involved in the pathogenesis of sarcoidosis， and tumor necrosis factor （TNF） inhibitor is effective in the treatwent of sarcoidosis.

Pathogenesis and Therapeutic Prospect of Abdominal Aortic Aneurysm

Objective　To investigate pathogenesis and therapeutic prospect of abdominal aortic aneurysm (AAA). Methods　 Relevant literatures about pathogenesis and ways of treatment for AAA in recent years were reviewed. Results　The formation of AAA are associated with heredity, anatomy, environment and biochemistry and other factors. All factors influence and interact with each other. The metabolic disequilibrium of aortic intermediate extracellular matrix plays an important role in the pathogenesis of AAA. The main reasons for the formation of AAA may be the increase of activity of matrix metalloproteinases and the disequilibrium of genetic expressions of elastin and collagen. The therapy of AAA includes surgical and medical treatment. The methods of medical treatment are still in the process of exploration and research. Conclusion　The formation of AAA is a synergistical result of multiple factors, and medical treatment is an important supplement of surgical treatment.

支气管类癌的诊断与治疗

目的　探讨支气管类癌的临床特点、病理特征、诊疗和预后。　方法　分析首都医科大学附属北京友谊医院1999年1月至2012年1月治疗12例支气管类癌（bronchial carcinoid） 患者的临床资料，其中男7例，女5例；年龄33～69 （49.3±12.4） 岁。主诉为咳嗽、咳痰4例，胸痛3例，痰中带血1例，刺激性干咳1例，另外3例系体检发现；病灶位于右肺7例，左肺5例；中心型病变7例，周围型病变5例。12例中肺叶切除术10例，全肺切除术2例。　结果　全组患者无严重手术并发症，无围手术期死亡。术后免疫组织化学确诊典型类癌8例，不典型类癌4例；12例中8例获得有效随访，随访时间1～76个月，其中典型类癌患者5例，均生存；不典型类癌3例，2例生存，1例死于远处转移。　结论　支气管类癌行支气管镜检查半数可见肿物多隆起于支气管表面，边界清楚、表面光滑，行正电子发射断层扫描（PET）可见病灶处放射性浓聚；术后行免疫组织化学检查可确诊；手术切除可获长期生存，预后主要与病理类型、有无远处转移等有关。

Diagnosis and Management of Concealed Intrathoracic Anastomotic Leak of Esophagus

Abstract：　Objective　To investigate diagnosis and treatment of concealed intrathoracic anastomotic leak of the esophagus.　Methods　We retrospectively analyzed the clinical data of 32 patients who presented with unexplained sepsis （temperature＞38 ℃ and elevated white blood cell count） after esophagectomy and intrathoracic anastomosis for esophageal　carcinoma or gastric cardia carcinoma in Affiliated Hospital, Medical College of Qingdao University from January 2006 to December 2010. All the patients underwent oral water-soluble contrast esophagogram and oral water-soluble contrast computerized tomography of the chest. None of the patients had any sign of contrast leak in these diagnostic examinations, but their chest computerized tomography all showed peri-anastomotic bubble and encapsulated effusion. Fifteen patients were treated as concealed intrathoracic anastomotic leak of the esophagus, including fasting, broad spectrum antibiotic treatment, prolonged gastrointestinal decompression and enteral nutrition via naso-intestinal feeding tube. The other 17 patients were not treated as anastomotic leak of the esophagus and only received broad spectrum antibiotic treatment. Results None of the 15 patients who were treated as concealed intrathoracic anastomotic leak finally developed anastomotic leak proved by oral water-soluble contrast esophagogram and computerized tomography of the chest （0%, 0/15）. Among the 17 patients　who were not treated as anastomotic leak, fourteen patients developed anastomotic leak later （82.4%, 14/17）, 2 patients died of aorto-esophageal fistula and 3 patients died of multiple organ dysfunction syndrome.　Conclusion　Peri-anastomotic bubble and irregular encapsulated effusion in oral water-soluble contrast esophagogram and computerized tomography of the chest should be considered as specific signs of concealed intrathoracic anastomotic leak of esophagus after esophagectomy and intrathoracic anastomosis. Patients with such signs should be treated as anastomotic leak.

Experience in Diagnosis and Treatment of Upper Gastrointestinal Rebleeding after Pericardial Devascularization in Portal Hypertension Patients

目的　 探讨门静脉高压症断流术后上消化道再出血的原因及防治措施。方法　对近8年解放军第302医院肝胆外科收治的因门静脉高压症行脾切除、贲门周围血管离断术后发生上消化道再出血的15例患者的临床资料进行回顾性分析。结果　15例术后消化道再次出血患者中，因急性胃黏膜病变出血9例，残留食管胃底曲张静脉再次破裂大出血5例，围手术期门静脉、脾静脉及肠系膜上静脉血栓形成并呕血1例。围手术期再出血并死亡2例，通过保守或手术治疗治愈13例。结论　断流术是治疗门静脉高压症引起上消化道大出血的良好术式，术后再出血是断流术后常见并发症之一，完善的手术操作、适时祛聚抗凝减少门静脉系统血栓形成可减少断流术后再出血的发生或减轻其症状

Diagnosis and Treatment of 34 Patients with Spontaneous Esophageal Rupture

Objective?To investigate clinical characteristics， diagnosis， and treatment for patients with spontaneous　esophageal rupture， and improve clinical diagnostic and treatment level.?Methods?We retrospectively analyzed the　clinical data of 34 patients with spontaneous esophageal rupture who were treated in Subei People’s Hospital from January 1996 to June 2010. There were 28 male patients and 6 female patients with their age ranging from 32 to 80 years old (mean 57.6 years old). Main clinical manifestations included severe chest and abdominal pain after vomiting， fever， dyspnea and shock. The duration between disease onset and establishing diagnosis ranged from 4 hours to 7 days. Thirteen patients received conservative treatment including chest drainage， retrograde gastrointestinal decompression and enteral nutrition through jejunostomy. Twenty one patients received surgical treatment including layered anastomosis of the ruptured esophagus， retrograde gastrointestinal decompression and enteral nutrition through jejunostomy.?Results?All the patients were cured without in-hospital death. The mean hospital stay of the 13 patients who received conservative treatment was 46 days， while that of the 21 patients who received surgical treatment was 17 days. All the ruptured esophagus were one-stage healed. All the 34 patients were followed up from l to 8 years， including 11 patients in the conservative treatment group and 19 patients in the surgical treatment group， but 4 patients was lost during follow-up. All the patients had a normal diet without symptoms of esophageal stricture， reflux esophagitis or chronic thoracic empyema.?Conclusion　Spontaneous esophageal rupture is a thoracic emergency with a high misdiagnosis rate and mortality．Early diagnosis， early surgical repair of ruptured esophagus and satisfactory chest drainage play a vital role in the treatment for patients with spontaneous rupture of esophagus.

Diagnosis and Treatment of Deep Venous Thrombosis of Lower Limb

目的 总结我科2002年3月至2005年10月收治的下肢深静脉血栓形成(deep vein thrombosis,DVT)患者的诊治经验.方法 本组下肢DVT患者275例,患肢294条.男134例,女141例,年龄14～92岁,平均(50.76±16.43)岁.单侧下肢DVT 256例(左侧159例,右侧97例),19例为双下肢DVT(其中有8例是仅一侧肢体有临床表现); 属混合型194条,中央型74条,周围型26条.行彩色多普勒或静脉造影检查了解血栓部位及范围; 对怀疑有肺动脉栓塞(pulmonary embolism, PE)者行肺部增强CT扫描.治疗包括抗凝、溶栓、祛聚、梯度压力静脉弹力袜以及对症处理.对反复发生PE、存在抗凝治疗禁忌证、需要手术取栓、下肢静脉存在悬浮游离血栓者安置下腔静脉滤器.对发生股青肿患者行手术取栓.疗效评价: 住院期间观察症状变化,监测膝关节上、下15 cm处周径; 对随访患者行CEAP(clinical-etiology-anatomic-pathophysiologic)临床表现分级、功能障碍评分(venous disability score, VDS).结果 本组DVT常见的危险因素包括活动受限史、2周以内有手术史、恶性肿瘤及外伤史.本组患肢主要临床表现包括: 肿胀、疼痛、皮温增高、皮肤暗红、浅静脉迂曲等.并发症: PE 9例,股青肿2例,下腔静脉阻塞综合征3例.275例中2例行手术取栓,25例安置下腔静脉滤器.本组患者症状经治疗后1～5 d开始缓解,出院时膝关节上、下周径较入院时明显缩小(P＜0.05).随访时间6个月～3年,195例(70.9%)的201条(68.4%)患肢获得随访,患肢CEAP分级: C0级78条,C1级53条,C2级16条,C3级20条,C4级15条,C5级11条,C6级8条; VDS评分: 0分77例,1分66例,2分33例,3分19例.结论 下肢DVT的诊断中应注意对危险因素以及无症状的DVT的搜寻; 早期治疗以非手术治疗为主,通过抗凝、溶栓等综合治疗可以达到满意效果; 在早期如发生股青肿应及时手术治疗; 有选择地安置下腔静脉滤器可防止PE的发生; 后期应根据病情特点确定治疗方案和疗程.

原发性纵隔内胚窦瘤一例

Clinical Analysis of Diagnosis and Treatment of Acute Pancreatitis in Pregnancy

目的 探讨妊娠期并发急性胰腺炎(APIP)的病因、发病机理、临床特点及防治措施. 方法 对四川省宜宾市第二人民医院和四川大学华西医院1995年1月至2006年12月期间收治的72例APIP患者的临床资料进行回顾性分析. 结果 本组72例中,属轻型急性胰腺炎(MAP)者49例(68.06%),重症急性胰腺炎(SAP)者23例(31.94%); 有胆囊炎合并胆囊结石病史者43例(59.72%),伴高脂血症者21例(29.17%).采用非手术治疗56例,手术治疗16例,孕妇治愈66例(91.67%),死亡6例(8.33%),死因为多器官功能障碍综合征、急性呼吸窘迫综合征及严重复腔感染; 终止妊娠16例(均为32～38周妊娠),56例继续妊娠; 72例中双胎2例,胎儿死亡共15例(20.27%); 漏诊、误诊6例.结论 APIP的发生与胆结石和高脂血症有关,并于妊娠中晚期发病率高; 其临床表现复杂,易误诊,对孕妇及胎儿威胁极大; 把握该疾病的特点,提高对APIP的认识和警惕性,及时准确的诊断与"个体化"的治疗原则,适时终止妊娠,可以提高其治愈率,降低母婴死亡率.