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开展全胸腔镜肺叶切除术，加强中远期随访

全胸腔镜肺叶切除术代表了胸腔镜技术的制高点，是胸部微创外科王冠上的一颗明珠。　　胸腔镜肺叶切除术最早报告于1992年，短短十几年之后分别于2006年和2007年成为美国国家综合癌症网络（NCCN）和美国胸部医师协会（ACCP）肺癌治疗指南中与开胸手术并列的肺癌标准手术方式，关于全胸腔镜肺叶切除的安全性、可行性的争论已经结束［1］。目前，研究的重心已经转到考量胸腔镜对比开胸手术的围手术期优势和远期疗效。现通过回顾近几年在国际主要会议上交流并发表的文献，对全胸腔镜肺叶切除术的现状、进展进行分析。1 国际研究现状 　　2008年第34届美国西部胸外科协会年会上，美国杜克大学的学者报告了697例胸腔镜肺叶切除患者和382例开胸手术患者手术资料的对比研究，结果显示：胸腔镜肺叶切除术显著减少了术中输血、术后心房颤动、肺不张、肺炎、败血症和肾功能不全的发生，也显著降低了围手术期的病死率。在倾向性评分匹配的284例患者中，有69%的胸腔镜手术者无术后并发症，而开胸组并发症发生率为51%，差异有统计学意义。此外，胸腔镜手术后胸腔引流时间和住院时间也显著短于开胸手术患者［2］。2008年第88届美国胸外科协会年会（AATS）上，emorial SloanKettering癌症中心的大样本对照研究探讨了胸腔镜手术并发症。该研究包括398例胸腔镜和343例开胸手术的早期非小细胞肺癌患者，同样发现胸腔镜组手术并发症发生率低于传统开胸组，比值比（OR）为0.73（P=0.06）。此研究中以5年生存率为远期生存评价指标，胸腔镜组生存率（79%）高于开胸组（75%），但差异无统计学意义（P=0.08）。采用倾向性评分匹配后的统计结果也类似［3］。 2009年第89届美国胸外科学会（AATS）年会上，美国纽约长老会医院联合杜克大学的胸外科医师总结了美国胸外科医师协会(STS)数据库中，2002~2007年所有接受肺叶切除的患者资料，包括1 281例胸腔镜肺叶切除术和5 042例开胸手术患者。研究者通过倾向性评分方法选择了与胸腔镜手术患者匹配的1 281例开胸手术患者，对比了围手术期并发症发生情况发现，胸腔镜手术患者中无并发症发生率显著高于开胸手术患者(738% vs. 65.3%，Plt;0001)；分类比较显示，肺部并发症、心律失常、二次插管、术后输血等并发症发生率胸腔镜组均显著低于 开胸组；此外，胸腔镜组胸腔引流时间和住院天数也较开胸组短［4］。2008年第44届美国胸外科医师协会年会报告的系统性回顾［5］和2009年发表的包含21项胸腔镜与开胸手术治疗早期肺癌对比研究的Meta分析［6］显示，胸腔镜手术远期生存不仅不劣于，甚至可能优于传统开胸手术。其中的系统评价总结了PubMed上自1992年胸腔镜肺叶手术报告以来至2007年4月间所有手术治疗早期肺癌的文章，对比了这些手术报告中胸腔镜手术和开胸手术资料，共6 300例。对比结果发现，接受胸腔镜手术的患者术后并发症、胸腔引流时间、住院时间显著低于开胸手术者，而远期生存率高，特别是4年生存率，胸腔镜手术比开胸手术患者绝对值高17%［6］。 2 国内现状 与胸腔镜肺叶切除术在国际上的发展相比，我国第1例手术于1996年完成，相差仅4年，但由于受到经济发展和技术经验的限制未能真正发展起来，直到2006年才真正形成规模开展。由于时间短，限制了各中心的病例数和随访时间，目前国内虽已有论著报道，但病例数少且缺乏随访。《中国胸心血管外科临床杂志》18卷第2期发表了北京大学人民医院杨帆等“连续300例全胸腔镜肺叶切除术及中期随访分析”的论著，在一定程度上填补了这个空白。该论文总结了北京大学人民医院单中心连续300例全胸腔镜肺叶切除术的临床资料，手术时间为2006年9月至2009年12月，是投稿时国内最大宗的病例报告。除了手术资料，该文进一步报告了3年随访结果。此外，作者对比了良、恶性疾病的手术特点，分析了中转开胸的风险因素，这正是临床工作中所关注的问题。该研究总结的300例全胸腔镜手术患者中，有273例完成胸腔镜手术，中转开胸27例，中转开胸率为900%。完成胸腔镜手术的时间3.17±0.88 h，患者术中出血225.7±195.2 ml，术后并发症发生率136%。这些指标国外报告的结果为手术时间1.3~4.8 h，术中出血量72~253 ml，中转开胸率0.0%~15.7%［5］，术后并发症发生率16.4%［6］。以上的对比数据表明国内全胸腔镜肺叶切除术的客观指标达到了国外报道的平均水平。经过平均14.4个月（0~39个月）的随访，该研究中的213例非小细胞肺癌患者累计1年总生存率为95.0%，3年总生存率869%，也与国外报道相似［6］。　　对于良、恶性疾病手术的对比和中转开胸手术风险因素分析是该研究的亮点。该研究发现良性疾病手术并不比肺癌手术简单，原因主要在于慢性炎症的粘连。中转开胸原因分析也发现，粘连是中转开胸的最主要原因。分层分析显示，中转开胸与疾病性质、病变位于左、右侧及患者性别无关，只有肺上叶切除与中转开胸显著相关。作者分析其原因是血管解剖特点和肺上叶更多见的结核性粘连。以上的总结与分析对于胸腔镜肺叶切除手术的初学者可谓是宝贵的、可借鉴的经验。　　但该论文也存在着一些欠缺。（1）所有的病例均来自单中心，北京大学人民医院，这使手术资料受到了该单位的技术水平、病例来源和手术适应证选取等因素的影响，研究结果离开这个前提会有怎样的变化仍是未知。（2）该研究仅仅总结了胸腔镜手术资料，没有与类似的开胸手术病例进行比较，无法回答胸腔镜与开胸手术优劣差异的问题，而该问题更是学术界所关心的问题。（3）该研究时间为2006~2009年，开展全胸腔镜肺叶切除术的时间跨度较大，包含了所谓“学习阶段”的病例，也包括了“成熟时期”的病例，甚至也有一些“成熟时期”年轻医师“学习阶段”的病例，对于仅300例资料而言，这些病例可能占一定数量，使结果掺杂更多的影响因素。（4）由于肺癌患者预后的最重要因素是肿瘤分期，因此预后报告原则上是应依据分期分组，但由于病例数的限制，该研究无法做到这点。（5）随访时间较短，而接受手术的肺癌患者以早期为主，还需要远期随访（至少5年）才能真正反映治疗的效果。瑕不掩瑜，“连续300例全胸腔镜肺叶切除术及中期随访分析”一文虽存在的一些不足，但对我国胸腔镜肺叶切除术的发展起到了积极的推动作用，而这些不足正为后续的经验总结提供了研究点。随着我国经济的发展，为扫清胸腔镜肺叶切除术的经济障碍提供了条件；高水平的胸腔镜肺叶切除学习班、研讨会又为克服技术困难打下了基础。相信全胸腔镜肺叶切除手术的燎原之火能越燃越旺，造福更多患者。同时希望我国医疗工作者和研究者开展设计科学、样本量足够大的胸腔镜肺叶切除术有效性和安全性的临床研究，并及时制作高质量系统评价总结临床研究结果，为全面推动我国胸腔镜肺叶切除术的开展提供高质量、可靠的临床证据。

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.

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.

Problems about Recurrent or Metastatic Gastric Cancer and Its Integrative Treatment

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.

Effect of High Mobility Group Box-1 on The Death Pathways of Pancreatic Acinar Cell in Rat with Severe Acute Pancreatitis

ObjectiveTo explore the effect of the serum high mobility group box-1 (HMGB1) on oncosis of pancreatic acinar cells in the rat with severe acute pancreatitis (SAP). MethodsThirty-two healthy SD rats were randomly divided into 2 groups:sham operation group (SO group, n=8) and SAP group (n=24). Rats of SO group were only flipped the intestinal canal after laparotomy, but rats of SAP group were induced by retrograde injection of 3% sodium taurocholate into bilio-pancreatic duct in addition. Rats of SO group were sacrificed at 6 hours after operation, and rats of SAP group were sacrificed at 6 (SAP-6 hour group, n=8), 12 (SAP-12 hour group, n=8), and 24 hours (SAP-24 hour group, n=8) after operation respectively. Pancreatic tissues were stained by HE to observe pathological changes. Serum HMGB1 was measured by ELISA, and the oncosis percentage of pancreatic acinar cells was examined by flowcytometry. ResultsPathological results showed that structural integrity was observed in pancreatic acinar, and occasionally a single inflammatory cell infiltration was observed in rats of SO group. Swelling, interstitial edema, and inflammatory cell infiltration were observed in rats of SAP-6 hour group. Some necrosis of pancreatic acinar cell, stromal vascular congestion, and focal necrosis were observed in rats of SAP-12 hour group and SAP-24 hour group, which the pathological damage were worse over time. Levels of serum HMGB1 and oncosis percentages of pancreatic acinar cells in rats of 3 SAP subgroups were all higher than those of SO group (P < 0.01), and the 2 kinds of indexes both increased over time (P < 0.05). There was positive correlation between concentration of serum HMGB1 and oncosis percentages of pancreatic acinar cells in SAP rat during 24 hours after operation (r=0.846, P < 0.01). ConclusionsHMGB1 seems to play an important role in SAP by inducing oncosis of pancreatic acinar cells when inducing inflammatory reaction in rat with SAP.

重症风湿性心瓣膜病的外科治疗

The Value of Endobronchial Ultrasoundguided Transbronchial Needle Aspiration in the Evaluation of Thoracic Diseases

Abstract： Objective To introduce the new procedure of endobronchial ultrasoundguided transbronchial needle aspiration (EBUSTBNA) for staging lung cancer and diagnosing thoracic diseases, in order to determine its value in the evaluation of thoracic diseases. Methods We retrospectively reviewed the data of all patients examined with EBUSTBNA our institution between September 2009 and May 2010. Among the patients, there were 75 males and 31 females with an average age of 62.3 years old. Based on their primary indication, we divided all the 106 patients into three categories. (1) There were 76 patients with known or bly suspected lung cancer. Enlarged mediastinal lymph nodes on radiographic examination of the chest (≥1.0 cm) were detected in all the patients. (2) There were 22 patients with enlarged mediastinal lymph nodes or mediastinal masses of unknown origin. (3) There were 8 patients with pulmonary mass located close to the central airways. Results (1) 76 patients underwent EBUSTBNA for known or bly suspected lung cancer. Among them, 58 patients were confirmed to have mediastinal lymph nodes metastasis on EBUSTBNA. Sixteen in the 18 patients with negative EBUSTBNA underwent thoracoscopy or thoracotomy for pulmonary resection and mediastinal lymph node dissection. Postoperative pathology confirmed that 12 patients did not have metastatic nodes, 2 patients had metastatic nodes and 2 other patients had benign lesions within the lung. The diagnostic sensitivity, specificity and accuracy of EBUSTBNA for the mediastinal staging of lung cancer were 96.66%(58/60), 100.00%(12/12) and 97.22%(70/72), respectively. (2) 22 patients underwent EBUSTBNA for the evaluation of mediastinal adenopathy or mass in the absence of any identifiable pulmonary lesion. Among them, 7 had malignancy, 13 had benign diseases on EBUSTBNA and the sensitivity of EBUSTBNA in distinguishing malignant mediastinal diseases was 87.50% (7/8). (3) 8 patients with pulmonary mass located close to the central airways were accessed by EBUSTBNA. Definite diagnosis was achieved in 7 patients, and lung cancer was detected in 6 patients. The sensitivity and the diagnostic accuracy of EBUSTBNA for the diagnosis of unknown pulmonary mass was 85.71%(6/7) and 87.50%(7/8), respectively. All the procedures were uneventful, and there were no complications. Conclusion EBUSTBNA is a highly effective and safe procedure. We believe that EBUSTBNA should be used routinely in the diagnosis and staging of thoracic diseases.

改良三尖瓣成形术的效果评价

目的 比较一种改良三尖瓣成形术与Kay 成形术的成形效果，总结治疗经验。 方法 回顾性分析江苏省人民医院2006 年1 月至2008 年1 月60 例功能性三尖瓣反流患者的临床资料。按手术方式不同将60 例患者分为两组：改良三尖瓣成形术组（改良组），30 例，其中男14 例，女16 例；年龄（42.80±5.70）岁；Kay 成形术组，30 例，其中男15 例，女15 例；年龄（45.30±8.30）岁。术前两组患者的年龄、性别、心功能分级（NYHA）和三尖瓣反流分级差异均无统计学意义（P ＞ 0.05)。比较两组患者术前、术后住院及术后随访期间的右心房横径、右心室舒张期末内径和三尖瓣反流面积。 结果 两组患者手术时间、体外循环时间、住重症监护室时间、呼吸机辅助时间、住院时间差异均无统计学意义。术后全部患者痊愈出院。改良组随访时间为（19.62±8.65）个月，远期1 例死于肺部感染；随访三尖瓣无反流13 例，Ⅰ级反流14 例，Ⅱ级反流2 例，Ⅲ级反流1 例，无Ⅳ级反流。Kay 成形术组随访时间为（18.96±9.23）个月，远期死亡2 例，分别死于顽固性右心衰竭和脑出血；随访无三尖瓣反流9 例，Ⅰ级反流12 例，Ⅱ级反流5 例，Ⅲ级反流2 例，Ⅳ级反流2 例。术后早期改良组和Kay 成形术组右心房横径[（4.51±0.85）cm vs. (5.69±1.21) cm]、右心室舒张期末内径[（2.85±0.45） cm vs.（ 3.47±0.83） cm] 和三尖瓣反流面积[（4.17±2.54） cm2 vs.（ 25.12±2.39 cm2）] 较术前均明显下降（P ＜ 0.05）；术后随访改良组和Kay成形术组右心房横径[（3.95±0.66） cm vs.（ 4.52±0.38） cm，P=0.705] 差异无统计学意义，右心室舒张期末内径[（2.59±0.63）cm vs.（ 2.98±0.47） cm， P=0.002] 和三尖瓣反流面积[（8.76±3.45） cm2 vs.（ 12.16±5.28） cm2， P=0.004] 改良组优于Kay 成形术组。 结论 改良三尖瓣成形术的远期成形效果优于Kay 成形术。

硬质气管镜下放置支架治疗大气道阻塞性疾病

摘要: 目的 为治疗大气道内阻塞性疾病，探讨现代硬质气管镜下气管支架技术的价值。 方法 2002年9月至2008年5月，对7例大气道阻塞性疾病患者在硬质气管镜下放置气管支架，其中良性病变1例，为右主支气管外伤后瘢痕狭窄；恶性病变6例，包括食管癌术后气道狭窄4例，原发性气管肿瘤1例，气管肿瘤术后气道狭窄1例。静脉全身麻醉，不插管，仰卧位，经口置入硬质气管镜，喷射通气。首先对气道进行全面的检查和评估，将气道内病变清除或直接扩张气道，直视下利用施放器放置支架；术后不需要辅以机械通气。 结果 共放置支架7枚，每例患者1枚，包括气管支架3枚，左主支气管3枚，右主支气管1枚。手术顺利，无严重并发症及围手术期死亡。失访1例，随访6例，随访41.4±20.5个月；5例恶性疾病患者中有1例于术后1个月因心脏病猝死，4例术后平均生存14.7个月；1例良性疾病患者术后1个月因刺激性咳嗽将支架取出，随访27个月未再出现气道狭窄。 结论 硬质气管镜下放置支架治疗大气道内阻塞性疾病安全、可靠，操作简单，值得临床推广。