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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.

Problems about Recurrent or Metastatic Gastric Cancer and Its Integrative Treatment

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.

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。

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.

电视胸腔镜肺切除的手术方法

目的 为了评价电视胸腔镜肺切除术在肺部肿瘤治疗中的可行性,而对其手术方法和治疗原则进行探讨. 方法 回顾性分析1992年10月至2000年3月,127例胸腔镜肺切除术患者的临床资料,其中肺楔形切除术71例,肺叶切除术50例,全肺切除术6例. 结果 全组无手术死亡及严重并发症, 手术时间、引流时间、住院时间均明显缩短.全组平均胸腔引流时间2.4天,平均住院天数10.6天. 结论 胸腔镜肺切除术是安全可行的,只要严格掌握手术适应证,运用合理的手术方法和技巧,一般可以达到与常规开胸手术同样的效果.

电视胸腔镜手术治疗食管憩室

目的　探讨电视胸腔镜在食管中段憩室切除术中的可行性及安全性。　方法　 1999年 1月～ 2 0 0 3年 2月共施行电视胸腔镜食管中段憩室切除术 6例 ,术前均经食管 X线钡餐造影及胃镜检查确诊为食管中段憩室。结果　 6例患者均完全在胸腔镜下完成手术 ,无中转开胸患者 ,无死亡患者及严重并发症发生 ;术后随访无复发。结论　胸腔镜下行食管中段憩室切除术是一种安全可行的微创术式。

Potential mechanism of cisplatin resistance in non-small cell lung cancer A549 cells analyzed by the whole-transcriptome

ObjectiveTo reveal the potential mechanism of cisplatin resistance in non-small cell lung cancer A549 cells by comparing the expression profiles of wild-type A549 cells and cisplatin-resistant A549 cells (A549/DPP) through whole transcriptome sequencing analysis.MethodsThe cisplatin resistant A549 (A549/DDP) cell line was first established. Then, the whole-transcriptome analysis was conducted both on A549 and A549/DDP cells. Next, the differentially expressed RNAs of lncRNA-seq, circRNA-seq, and miRNA-seq data were identified, respectively, followed by functional enrichment analysis. Finally, a comprehensive analysis based on the whole transcriptome data was performed and the construction of the ceRNA network was carried out.ResultsA total of 4 517 lncRNA, 123 circRNA, and 145 miRNA were differentially expressed in A549/DDP cells compared with the A549 cell line. These different RNAs were significantly enriched in cancer-related pathways. The ceRNA network contained 12 miRNAs, 4 circRNAs, 23 lncRNAs, and 9 mRNA nodes, of which hsa-miR-125a-5p and hsa-miR-125b-5p were important miRNAs based on the topological analysis.ConclusionTumor necrosis factor signaling pathway and p53 signaling pathway are involved in A549/DPP resistance. Hsa-miR-125a-5p and hsa-miR-125b-5p may be potential targets for reversing cisplatin resistance.

Application of Endoscopic Linear Stapling Device in Com plete Video-assisted Thoracoscopic Lobectomy

Objective To investigate the application and techni ques of endoscop ic linear stapling device in complete video-assisted thoracoscopic lobectomy, a n d to improve the safety and quality of the operation. Methods From September 2006 to January 2008,sixty consecutive complete video-assisted thoracoscopic lo b ectomies were performed. The patients include 30 men and 30 women with average a ge of 59.8 years old. Eight patients suffered from benign lung lesions, and 52 p atients suffered from primary lung cancers or other pulmonary malignancy. The op erations were performed under general anesthesia with doublelumen intubation a nd complete thoracoscopy.The procedures include 12 right upper lobectomies, 10 right middle lobectomies, 14 right lower lobectomies, 8 left upper lobectomies a nd 16 left lower lobectomies. All arteries, veins, bronchus involved were manag ed with endoscopic linear stapling devices. Results All the pr ocedures were successful with one conversion case（1.67%） due to tense lymph no des adhesion, no severe complications, as active bleeding, continuous air leak, foreign body reac tion or operation related death occured. Endoscopic linear stapling devices were used for stapling in 381 different procedures with average of 6.35 per case, am ong which 124 (2.06 per case)were for pulmonary arteries, 66(1.10 per case) for pulmonary veins, 60 for lobar bronchus and 131 for interlobar fissures.A period of 11.3 months (2-18 months) follow-up of all patients shows no dela yed bleeding, bronchialpleural fistula, pyothorax or pneumonia. Concl usion The application of endoscopic linear stapling device is one of th e major difficulty in complete video-assisted thoracoscopic lobectomy. Careful manipulation under some specific principles is the key for the security of the operation.