超聲引導(dǎo)經(jīng)皮穿刺置管引流治療細(xì)菌性肝膿腫療效分析（發(fā)表于中國(guó)實(shí)用外科雜志）趙宇1 ，王墨飛（通訊作者）1 ，張遠(yuǎn)石1 ，徐玲劼2 ，王卓2 ，梁健1中圖分類(lèi)號(hào)：R6 文獻(xiàn)標(biāo)志碼： A[關(guān)鍵詞] 肝膿腫; 穿刺; 引流術(shù)Keywords hepatapostema; puncture;..; drainage 2004年7月至2009年6月，本院采用超聲引導(dǎo)下經(jīng)皮肝穿刺置管引流治療細(xì)菌性肝膿腫36例，效果良好，分析報(bào)道如下。1 資料與方法1.1一般資料 本組36例中男20例，女16例。年齡 32~81歲，平均57歲。膿腔長(zhǎng)徑3.6~12.7cm，平均5.8cm。主要癥狀為寒戰(zhàn)、高熱、肝區(qū)持續(xù)疼痛和肝臟腫大。白細(xì)胞計(jì)數(shù)升高31例。肝右葉27例，肝左葉4例，雙葉均受累5例。其中單發(fā)肝膿腫28例，多發(fā)肝膿腫8例。術(shù)前由超聲及CT檢查證實(shí)診斷。1.2穿刺置管與治療方法 病人取平臥位或左側(cè)臥位，常規(guī)消毒鋪巾，1%利多卡因局部浸潤(rùn)麻醉，以18 G PTC針在超聲直視下穿刺插入膿腔，抽吸出膿液證實(shí)穿刺準(zhǔn)確后，退出針筒，膿液送菌培養(yǎng)，自穿刺針置入導(dǎo)絲后退出針芯。以刀尖于穿刺部做2mm左右小切口，導(dǎo)絲引導(dǎo)下7F、12F介入擴(kuò)管順次擴(kuò)張穿刺針道，用改良同軸導(dǎo)管技術(shù)將一次性塑料吸痰管送入膿腔：適當(dāng)型號(hào)的擴(kuò)管插入透明塑料管內(nèi)以起支撐作用，兩者相當(dāng)于同軸導(dǎo)管的內(nèi)外導(dǎo)管，順導(dǎo)絲一起插入膿腔后，退出擴(kuò)管而將塑料管留置于膿腔內(nèi)完成操作(原同軸導(dǎo)管技術(shù)是借助外導(dǎo)管的支撐作用向體內(nèi)更深部送入更細(xì)小的內(nèi)導(dǎo)管)。置管后盡量抽盡膿液，以生理鹽水、慶大霉素液、0.5%甲硝唑沖洗膿腔后導(dǎo)管外接引流袋。術(shù)后臥床休息，根據(jù)細(xì)菌學(xué)培養(yǎng)結(jié)果及時(shí)調(diào)整抗生素，反復(fù)沖洗保持引流通暢，注意觀察引流物的量及性質(zhì)，如膿液較稠難以抽出，可注入適量的α-糜蛋白酶，促進(jìn)液化。如體溫正常，癥狀、體征明顯好轉(zhuǎn)，超聲檢查膿腫消失或直徑＜2cm，引流液變清亮，<10 mL/d時(shí)拔除引流管。1.3結(jié)果 本組36例，共40個(gè)膿腔，膿液培養(yǎng)32例陽(yáng)性，其中肺炎克雷伯菌17例，大腸埃希菌13例，金黃色葡萄球菌2例。平均置引流管7.5d，所有病例置管后均引流通暢，臨床癥狀明顯改善，體溫多在2~3d內(nèi)降至正常。無(wú)出血、膽瘺及彌漫性腹腔感染等并發(fā)癥。2 討論 經(jīng)皮肝膿腫穿刺以其操作方法簡(jiǎn)便易行、病人痛苦少、成功率高、治療費(fèi)用低廉而廣泛應(yīng)用于肝膿腫的治療，而置管引流同單純穿刺抽吸治療相比治愈率明顯提高，是肝膿腫治療的首選方法。目前，國(guó)內(nèi)外多采用向膿腔內(nèi)置入多側(cè)孔8~10F豬尾管，由于導(dǎo)管過(guò)細(xì)常致使引流不暢，因此，達(dá)不到理想的引流效果。我們參照彭貴祖等[1]報(bào)道的方法，采用改良同軸導(dǎo)管技術(shù)將足夠粗大的塑料管引入膿腔從而達(dá)到引流通暢的效果，克服了單純Seldinner技術(shù)只能引入較小導(dǎo)管難以滿足引流通暢的缺點(diǎn)。 過(guò)去認(rèn)為多房性肝膿腫不宜行經(jīng)皮肝穿刺置管引流，而Liu等[2]報(bào)告膿腔內(nèi)的分隔不是穿刺引流術(shù)的禁忌證。本組8例多房性肝膿腫經(jīng)穿刺引流取得良好效果。我們認(rèn)為多數(shù)多房性肝膿腫之間可相通，不宜各個(gè)分別穿刺，反復(fù)沖洗即可獲得良好引流效果。但對(duì)于多房分隔、膿腔較大、互不交通的膿腫，治療效果較差，應(yīng)考慮手術(shù)引流。針對(duì)不同肝葉的多發(fā)性肝膿腫，我們選擇較大的兩個(gè)膿腔分別進(jìn)行穿刺置管，較小的膿腔單純穿刺抽膿沖洗，結(jié)合應(yīng)用有效抗生素，多能取得較好療效。Ferraioli等[3]對(duì)比穿刺置管與手術(shù)引流治療效果，證實(shí)兩種方法在治療細(xì)菌性肝膿腫方面均可取得相似效果，而在住院時(shí)間、治療費(fèi)用及并發(fā)癥發(fā)生率等方面，穿刺組明顯優(yōu)于手術(shù)組。Tan等[4]報(bào)告直徑>5cm的膿腫，手術(shù)引流總有效率優(yōu)于穿刺引流。本組17例膿腫直徑＞5cm，且伴有高血壓、糖尿病等疾病行穿刺置管引流也獲得良好效果。 經(jīng)皮肝穿膿腔置管引流的并發(fā)癥多由操作失誤引起，多可避免。我們體會(huì)操作過(guò)程中需注意以下問(wèn)題：（1）膿腫穿刺時(shí)機(jī)：一旦確診為肝膿腫，在應(yīng)用有效抗菌藥物治療的同時(shí)，應(yīng)盡早穿刺置管引流。對(duì)于高熱、中毒癥狀較重者，有人主張先用3~7d抗生素，控制毒血癥后再作引流。本組21例入院時(shí)毒血癥嚴(yán)重，在輸入大量抗生素的同時(shí)立即行此治療，2~3d后體溫很快下降，肝區(qū)疼痛緩解，中毒癥狀消失。說(shuō)明對(duì)毒血癥較重的病人早期施行經(jīng)皮肝穿膿腔置管引流是適宜的，可盡早去除病灶，減少膿毒素的吸收。（2）穿刺技術(shù)：超聲引導(dǎo)下直視穿刺的穿刺點(diǎn)一般在腋中線，以保證平臥位時(shí)引流管在最低位，保持引流通暢。要求穿刺處與膿腫間要有相當(dāng)厚度的肝組織，不宜選擇膿腫突出于肝臟表面處。穿刺針進(jìn)入腹腔后進(jìn)針要緩慢，如有落空感并見(jiàn)到膿液溢出證實(shí)穿刺成功，此時(shí)應(yīng)盡量抽盡膿液并注生理鹽水、慶大霉素液、0.5%甲硝唑沖洗膿腔，且將引流管在超聲引導(dǎo)下置于膿腫最深處，選擇引流管要足夠粗，避免引流不暢。本組36例均一次穿刺成功，置管順利。（3）術(shù)后處理及拔管時(shí)機(jī)：術(shù)后應(yīng)每日用生理水或加入慶大霉素液、甲硝唑沖洗膿腔，以保持引流通暢，繼續(xù)靜脈應(yīng)用抗生素治療，如膿液較稠難以抽出，可注入適量的a-糜蛋白酶，促進(jìn)膿液液化，必要時(shí)更換引流管。部分病例引流后仍有少許滲液，可經(jīng)引流管向膿腔內(nèi)注射少量10%氯化鈉溶液，促進(jìn)膿腔壁壞死。一般體溫正常，癥狀、體征明顯好轉(zhuǎn)，超聲檢查膿腫消失或直徑＜2cm，引流液變清亮，引流量＜10 mL/d時(shí)，可拔除引流管。本組病人經(jīng)超聲復(fù)查證實(shí)引流7~10d后膿腔均閉合。參考文獻(xiàn)[1]彭貴祖，萬(wàn)仁華，張永模．改良同軸導(dǎo)管技術(shù)經(jīng)皮經(jīng)肝穿刺置管引流治療細(xì)菌性肝膿腫38例[J]．中華普通外科雜志，2001，16(8)：504．[2]Liu CH，Gervais DA，Hahn PF，et al．Percutaneous hepatic abscess drainage：do multiple abscesses or multiloculated abscesses preclude drainage or affect outcome? [J]．J Vasc Interv Radiol，2009，20(8)：1059-1065．[3]Ferraioli G，Garlaschelli A， Zanaboni D，et al．Percutaneous and surgical treatment of pyogenic liver abscesses：observation over a 21-year period in 148 patients[J]．Dig Liver Dis，2008，40(8)：697-698．[4]Tan YM，Chung AY，Clow PK，et al． An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm[J]．Ann surg，2005，241(3)：485-490．

男性乳癌38例臨床分析（發(fā)表于中國(guó)普通外科雜志）王墨飛1，涂巍1，尹遜國(guó)2，胡祥2（1.中國(guó)醫(yī)科大學(xué)附屬第四醫(yī)院 乳腺疾病診療中心；遼寧 沈陽(yáng) 10032；2.大連醫(yī)科大學(xué)附屬第一醫(yī)院 普通外科，遼寧 大連 116011）摘要：目的 探討男性乳癌的臨床特點(diǎn)、診治及預(yù)后。方法 回顧性分析兩間醫(yī)院38例男性乳癌患者的臨床資料。術(shù)前依據(jù)B超，鉬鈀攝影，細(xì)針穿刺等方法確診。乳癌根治切除術(shù)3例，改良根治術(shù)27例，乳腺單純切除術(shù)5例，放棄手術(shù)3例，術(shù)后單純放療4例，單純內(nèi)分泌治療7例，放療加化療9例，化療加內(nèi)分泌治療8例。結(jié)果 年齡53～82（平均58.5）歲，TNM分期包括Ⅰ期13例，Ⅱ期19例，Ⅲ期4例，Ⅳ期2例。隨訪時(shí)間2個(gè)月至10年，平均73.8個(gè)月，隨訪率為73.6﹪。死亡13例；其中8例死于復(fù)發(fā)及轉(zhuǎn)移，5例死于心腦血管疾病。5，10年總體生存率分別為71.4﹪和53.6﹪；Ⅰ，Ⅱ期5，10年特異性生存率為91.7﹪和83.3﹪；Ⅲ，Ⅳ期6例中隨訪4例，均于3年內(nèi)死亡，無(wú)3年生存病例。結(jié)論 男性乳癌病程長(zhǎng)，預(yù)后差，生存率低，以改良根治術(shù)為主的綜合治療是目前對(duì)男性乳癌的主要治療模式，預(yù)后與臨床分期有一定的關(guān)系。關(guān)鍵詞 男性乳癌；診斷；治療；預(yù)后中圖分類(lèi)號(hào)： R737.9 文獻(xiàn)標(biāo)識(shí)碼：AAnalysis of 38 cases of Male Breast CancerWang Mofei1，Tu-Wei1，Yi Xunguo2，Hu-Xing 2 （1.Diagnosis and Treatnent Center for Manmary Diseases，The Fourth Affiliated Hospital，China Medical University．Shenyang，Liaoning 110032，China；2.Department of Gernral surgery，The First Affiliated Hospital，Dalian Medical University．Dalian，Laoning 116011，China．）Abstract：Objective To explore the clinical characteristics，diagnosis and treatment，prognosis of male breast cancer．Methods The clinical data of 38 cases of male breast cancer who were treated in two hospital during the past 10 years were analyzed retrospectively．The diagnosis mainly taken on preoperative B-ultrasound，radiography with molybdenum target tube and fine needle aspiration etc．Among 38 cases radical master was conducted in 3 cases，modified radicalmastectrmy in 27 cases，Simple breast-ectomy in 5 cases，Quit operation in 3 cases．Radiotherapy were adopted in 4 cases posteoperation，Simple endocrinotherapy in 7 cases，radiotherapy plus chemotherapy in 9 cases，chemotherapy plus endocrinotherapy in 8 cases．Results Median age at treatment was 58.5 (53-82)years．TNM staging include stageⅠin 13 cases，stageⅡ in 19 cases，stageⅢ in 4 cases，stageⅣ in 2 cases． Median follow-up was 73.8 months (2 months-10 years)，follow-up rate was 73.6﹪．during the follow-up，13 cases died and include 8 cases died of local recurrence and metastasis and 5 cases died of heart and brain disease．5- and 10-year Overall survival were 71.4﹪ and 53.6﹪；5- and 10-year disease-specific survival of stageⅠ，Ⅱ were 91.7﹪ and 83.3﹪；4 cases of stageⅢ，Ⅳ were followed，all died in 3 years．Conclusion Male breast cancer has the following clinical characteristics longer course，poor prognosis and lower survival rate．The combined therapy with modified radical mastectomy as the first choice is the treatment mode male breast cancer．There is a certain cor-relation between the prognosis of male breast cancer and clinical stage of the disease．Keywords Male breast cancer；Diagnosis；Treatment；PrognosisCLC number: R737.9 Document code: A

腹腔鏡和開(kāi)腹結(jié)腸癌根治術(shù)遠(yuǎn)期療效分析（發(fā)表于中國(guó)現(xiàn)代普通外科進(jìn)展雜志）王墨飛1 李春雨1 胡祥2 李震1 張健2 金俊哲1 【摘要】 目的 評(píng)價(jià)腹腔鏡和開(kāi)腹結(jié)腸癌根治術(shù)在遠(yuǎn)期療效方面的差異。方法 2003年10月至2009年6月，由同一手術(shù)組醫(yī)生行結(jié)腸癌根治術(shù)183例，其中腹腔鏡下完成81例，開(kāi)腹完成102例，依據(jù)分期對(duì)比兩組患者術(shù)后遠(yuǎn)期并發(fā)癥，局部復(fù)發(fā)、遠(yuǎn)處轉(zhuǎn)移及5年生存率。結(jié)果 兩組在性別，年齡，病理類(lèi)型及腫瘤位置等方面差異無(wú)統(tǒng)計(jì)學(xué)意義 (P>0.05)；除術(shù)后粘連性腸梗阻發(fā)生率腹腔鏡組少于開(kāi)腹組外(Ⅰ/Ⅱ期 P=0.036, Ⅲ期 P= 0.042)，切口疝、種植率，局部復(fù)發(fā)及遠(yuǎn)處轉(zhuǎn)移兩組比較差異均無(wú)統(tǒng)計(jì)學(xué)意義（P>0.05)； 5年累計(jì)生存率，Ⅰ/Ⅱ期腹腔鏡組77.4%，開(kāi)腹組75.7%，差異無(wú)統(tǒng)計(jì)學(xué)意義（P= 0.626）， Ⅲ期腹腔鏡組71.8%，開(kāi)腹組65.6%，差異無(wú)統(tǒng)計(jì)學(xué)意義（P = 0.517）。結(jié)論 腹腔鏡結(jié)腸癌根治術(shù)遠(yuǎn)期療效與開(kāi)腹手術(shù)相似，但術(shù)后遠(yuǎn)期并發(fā)癥少，值得推廣?！娟P(guān)鍵詞】 結(jié)腸腫瘤 腹腔鏡 結(jié)腸外科 并發(fā)癥Analysis on long-term results of laparoscopic surgery versus open surgery for colon cancer Wang Mo-fei1，Hu Xiang2，Zhang Jian2，Li Yong-shuang1，Jin Jun-zhe1．1.Department of Anorectal Surgery，The 4th Affiliated Hospital of China Medical University．Shenyang 110032，China；2.Department of Gernral surgery，The First Affiliated Hospital of Dalian Medical University．Dalian 116011，China．【Abstract】 Objective To evaluate the long-term results of laparoscopic (LP) and open (OP) radical resection for colon cancer. Methods 183 patients with colon cancer from October 2003 to June 2009 were divided into laparoscopic groups（81cases） and open operation groups (102 cases). Long-term postoperative complications，local recurrence，distant metastasis and 5-year survival rate were compared between the two groups by stage. Results There were no statistical differences in sex，age，pathology type and tumor location between the two groups( P>0. 05 ) . The incidence of postoperative adhesive intestinal obstruction was significantly lower in LP group than that in OP group(P=0.036 in stageⅠ/Ⅱ, P= 0.042 in stage Ⅲ), There were no significant differences in the incidences of incision hernia，incision seeding，local recurrence and distant metastasis for each stage between the two groups( P>0.05). The 5-year survival rates were， respectively 77.4% in LP group and 75.7% in OP group for stage Ⅰ/Ⅱ（P= 0.626），and 71.8% and 65.6% for stage III (P = 0.517). Conclusion Long-term results of laparoscopic resection are similar to those of open resection for colon cancer，but laparoscopic surgery has less long-term complications.【Key words】 Colon neoplasms Laparoscopy Colon surgery Complication