食管

objective to discuss perioperative complication and management of patient with high risk copd following esophagectomy.methods 45 patients with high risk copd underwent esophagectomy with epidural block combined with general anesthesia.perioperative treatment included smoking cessation,chest physiotherapy,prevention and control of infection of air way and appropriate bronchodilators of air way,breathing exercises,nutrition support and oxygen therapy.painkiller was instilled after surgery,early exercises,ensuring unobstruction of the air way,mechanical ventilation was applied when needed.results 3 had hypoxaemia in operation.after surgery,all patients had spo2 somewhat declined.6 had lung infection.6 were removed of bronchial secretion by bronchoscope.2 were supported by ventilator by using intubation.2 underwent tracheotomy.1 had disturbances of acid base balance and treated by using hydrochloric acid muriatic acid.all patients recovered rather smoothly and discharged from hospital.conclusion high risk copd is not the absolute contraindication of esophagectomy.active management before and after surgery ensures the safety and recovery of patients.

目的 探讨重度慢性阻塞性肺疾病简称慢阻肺病人食管切除术围手术期常见并发症及其处理。方法 45例重度慢阻肺的病人在全麻联合硬膜外阻滞下进行开胸食管切除手术，围手术期处理包括术前戒烟、胸部理疗、预防和控制呼吸道感染、解痉化痰、呼吸功能锻炼、营养支持和氧疗；术后硬膜外镇痛、早期锻炼、保持呼吸道通畅，部分病人予以呼吸支持。结果术中3例出现低氧血症。术后所有病人pao2均有不同程度的下降，6例出现肺部感染，6例行纤维支气管镜吸痰，2例通过气管插管给予呼吸机支持，2例行气管切开术，1例酸碱平衡紊乱使用盐酸精氨酸治疗。所有病人均痊愈出院。结论重度慢阻肺病人并非开胸食管切除手术的绝对禁忌证，积极的术前准备和严格的术后管理可减少和控制术后急性发作，有助于确保此类病人的围手术期安全和康复。

And There was no serious complication;②In the course ofinterventional therapy, Direct portal vein angiography demonstrated vena coronaria ventriculi(100%)andgastricveins(65.26%)andvenagastricaposterior38.43%, Angiography demonstrated venacoronariaventriculi communicate esophagus varicose veins, gastric veins and vena gastrica posterior communicategastric varicose veins. vena coronaria ventriculi had only a small percentage of double vein, about30.57%. The sites of vena coronaria ventriculi arising from the portal vein, splenic vein, portosplenic junction, were found in 52.06%、27.39%、20.55% respectively.③12 extrahepaticprotosystemic shunts were found in these patients. Include gastro-nephrosshuntof 3 cases, 7 caseswere splenetic- nephros shunt and 2 cases shown recanalization of umbilical vein .④The averageportal pressure before and after the procedure were 3.87±1.82kPa and 3.64±1.14kPa in 73patients, but to the time of rebleeding, it was 3.96±0.23kPa in the 11 cases.⑤There werethree kinds of variceal outcome: disappearance (54,low degree (19).⑥Spearman logisticanalyse and ANOVAtest shown liver function class, variceal degree of the splenic necrosis area,the blood direction in portal vein before operation and remain small collateral routes were thesignificant factors concerning outcome of varices.⑦The bleeding volume and portalhypertensive gastropathy are main risk factors of rebleeding.⑧The course of livercirrhosis is the risk factor of survival and extrahepatic portosystemic shunt , fine varices are thebeneficial factors to survival.⑨During all cases'followed-up data, the 1, 2, 3, 4, 5 yearcumulative survival rates and rebleeding rates were 17.81%, 28.77%, 38.36%, 43.84%, 47.95%and93.15%,91.78%,86.30%,83.56%,80.82%respectively. Conclusion The interventional disconnection treatment for liver cirrhosis and portalhypertension was designed suitability. It rapidlycontrol bleeding,butpressure of portal vein was notobvious high, perfusion was not low .it was compared with surgery therapeutic that interventionaldisconnection treatment was safe and had a significant clinical effect to hemorrhage and preventfrom rebleeding.

结果：①术后一过性发热62例(84.9%)，腹痛腹胀48例(65.8%)是介入断流术常见的并发症，未发生严重并发症；②门静脉造影显示胃冠状静脉、胃短静脉和胃后静脉的曲张分流的出现率是100%、65.26%和38.34%；显示食管静脉曲张主要由胃冠状静脉供血，胃静脉曲张主要由胃短静脉和胃后静脉供血；胃冠状静脉大多数为单支，少数为双支，其双支的出现率分别为30.57%；胃冠状静脉开口于门静脉主干的为52.06%，开口于脾静脉主干的为27.39%和开口于门脾静脉交汇处的为20.55%；③发现胃肾分流3例，脾肾分流7例、腹膜后门腔静脉分流2例，以及CTA检查发现脐静脉开放者2例；④73例患者介入断流术前和术后平均自由门静脉压力分别为3.87±1.82kpa和3.64±1.14kpa，前后比较存在显著性差异；11例再次介入手术患者的术前、术后和复发后的自由门静脉压力分别为4.02±0.24kpa、3.82±0.25kpa和3.93±0.23kpa ，前后比较发现首次术前与术后存在显著性差异，首次术前和复发出血术前门静脉压力比较无显著性差异；⑤介入术后复查曲张静脉转归基本消失54例，轻度19例；⑥Spearman相关分析和Logistic多因素回归分析，肝功能分级、静脉曲张程度、门脉血流方向和残存小侧支四个因素对曲张静脉转归有影响；Spearman相关分析和Logistic多因素回归分析门脉高压性胃病和出血量等因素对复发出血时间有影响；⑦COX回归分析，门体分流和曲张静脉转归两个因素对术后生存有影响；⑧术后随访6-70月，1、2、3、4、5年的累计复发出血率和累计生存率分别为17.81%、28.77%、38.36%、43.84%、47.95%和93.15%、91.78%、86.30%、83.56%、80.82%；结论：介入断流术治疗门脉高压食管胃底静脉曲张有独特的优点，可以快速直接控制曲张静脉出血而门静脉压力无显著增高，保证了肝脏灌注；与外科分流术相比适应证广、损伤轻、术后恢复快，不易遗漏曲张静脉；肝功能分级、曲张静脉程度、门脉血流方向和残存侧支血管对食管胃曲张静脉转归有影响；门脉高压性胃病对复发出血时间有影响；门体分流和曲张静脉转归对生存时间有影响。

Each was 12 times.The temperature in rectum,esophagus and tympanum was detected in turn.Results:Of 11 cases,required mediantime of reaching 40℃ in tympanum,esophagus and rectum was 81 min,81 min and 42 min respectively after heating;Above 41℃,it was 72 min,72 min and 72 min.

结果：经测温显示各部位温度于加温后达40℃以上所需中位时间分别为81(24～84)min(鼓膜7次)、81(24～93)min(食管7次)、42(9～72)min(直肠10次)；达41℃中位时间是72(39～96)min(鼓膜4次)、72(42～102)min(食管5次)、72(9～102)min(直肠7次)；40℃以上持续时间分别是鼓膜57(36～96)min，食管39(27～96)min，直肠66(48～111)min；各部位最高温度分别是40.4(39.4～41.3)℃、40.4(39.5～42)℃、41.5(39.2～43)℃。

Three types of reconstruction procedures, including Orr-type Roux-en-Y esophagojejunostomy, P-type jejunal pouch Roux-en-Y esophagojejunostomy and distal jejunal aboral pouch Roux-en-Y esophagojejunostomy, were performed.

全胃切除后消化道重建分别采用全胃切除术后消化道重建Orr式Roux-en-Y食管空肠吻合术、P型空肠袢食管空肠Roux-en-Y吻合术和远端空肠反口贮袋的Roux-en-Y食管空肠吻合术。

Methods Thirty-six patients with caustic esophageal stricture were treated with colon interposition,the colon were brought up to the neck by retrosternal route and the esophagus were performed exclusion,four patients with atresic hypopharynx were treated with two staged operations.

采用结肠代食管治疗36例食管腐蚀性瘢痕狭窄的患者，均经胸骨后径路上提结肠、腐蚀性食管狭窄段旷置，4例合并下咽闭锁的病人分两期手术。

colon interposition is an ideal method for treating caustic stricture of esophagus,the strictured esophagus can be excluded,two staged operations treat atresic hypopharynx is worthy to be popularized.

结肠代食管术治疗食管腐蚀性瘢痕狭窄较为理想，食管狭窄段可旷置，分两期手术治疗合并下咽闭锁的术式，值得临床推广。中国诺宇综合网http：//www.siaaa.com

colon interposition is an ideal method for treating caustic stricture of esophagus,the strictured esophagus can be excluded,two staged operations treat atresic hypopharynx is worthy to be popularized.

结肠代食管术治疗食管腐蚀性瘢痕狭窄较为理想，食管狭窄段可旷置，分两期手术治疗合并下咽闭锁的术式，值得临床推广。转载于中国论文联盟 http：//www.lwlm.com

colon interposition is an ideal method for treating caustic stricture of esophagus,the strictured esophagus can be excluded,two staged operations treat atresic hypopharynx is worthy to be popularized.

结肠代食管术治疗食管腐蚀性瘢痕狭窄较为理想，食管狭窄段可旷置，分两期手术治疗合并下咽闭锁的术式，值得临床推广。中国论文联盟http：//www.lwlm.com

colon interposition is an ideal method for treating caustic stricture of esophagus,the strictured esophagus can be excluded,two staged operations treat atresic hypopharynx is worthy to be popularized.

结肠代食管术治疗食管腐蚀性瘢痕狭窄较为理想，食管狭窄段可旷置，分两期手术治疗合并下咽闭锁的术式，值得临床推广。转载于论文联盟 http：//www.lwlm.cn

Portal braches of 4-5 orders were found in all 19 cases of Child Grade I, with esophageal varices and paragastric varices and no fistula of hepatic artety-portal vein or portal vein embolus; Portal braches of 3-4 orders were displayed in all 16 cases of Child Grade II, besides esophageal varices and paragastric varices, cirsomphalos, retroperitoneal varices, paraesophageal varices, dilated azygos vein were also noted, some patients had fistula and portal vein embolus; in Child Grade III, portal branches of 3~4 orders were displayed with more collateral circulations, dilated left renal vein and paragallbladder varices were appeared, with fistula and portal vein embolus or not.

Child I级19例，肝内门静脉显影4~5级，侧枝循环以食管及胃周静脉曲张为主，没有肝动脉－门静脉瘘或门静脉血栓形成；Child Ⅱ级16例，肝内门静脉显影3~4级，侧枝循环除食管及胃周静脉外，脐周静脉、腹膜后静脉、食管周围静脉、奇静脉也有所开放，部分有肝动脉－门静脉瘘或门静脉血栓形成；Child Ⅲ级6例，肝内门静脉显影3~4级，侧枝循环开放较Ⅱ级增多，可出现左肾静脉扩张或胆囊周围静脉曲张，伴或不伴有肝动脉－门静脉瘘或门静脉血栓形成。16排螺旋CT门静脉造影对上述病例分级为一级17例，二级18例，三级6例，与Child分级结果高度相关。

Fancy gold-plated dangling earrings with facetted White Opal crystals.

花式镀金悬垂耳环与facetted白欧泊水晶。

This essay chooses the study aim from biology teachers in middle school in Shi Jiazhuang which tells us that most of the middle school biology teachers in Shi Jiazhuang have the"burnout", lower successfulness, individualize.

本文选取石家庄市初中生物教师作为研究对象，运用问卷调查的方法对石家庄市初中生物教师职业倦怠的现状进行调查，调查结果发现，石家庄市初中生物教师这一群体普遍存在职业倦怠，情感枯竭程度偏高，成就感偏低，去个性化程度最为严重。