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澳門醫學雜誌®

Revista de Ciências da Saúde de Macau 季刊 2001 年 4 月創刊第 9 卷第 3 期 2009 年 9 月 26 日出版

目次

主辦澳門特別行政區政府衛生局編輯澳門醫學雜誌編輯委員會澳門特別行政區

CP 3002 若憲斜巷衛生局行政樓 2 樓電話: (+853)-8390 7307

(+853)-8390 6524 傳真: (+853)-8390 7304 電郵: [email protected] 網址: http://www.ssm.gov.mo

主編李展潤執行副主編, 編輯部主任

黃祥龍出版和發行澳門特別行政區政府衛生局印刷澳門文寶印務有限公司澳門慕拉士大馬路激成工業中心第二期十一樓 J座電話: (+853)-2848 1581 傳真: (+853)-2852 7546 電郵: [email protected]

國際標準刊號 ISSN 1608–7801 ©2009 年版權歸澳門特別行政區政府

衛生局所有

論著和研究輸澳雞蛋蛋黃彈性改變的析因研究⋯⋯⋯⋯⋯湯家耀蕭巧玲蕭巧玉等

生物製劑在中重度尋常型銀屑病中的應用⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯谷臻

雜交技術治療弓部和胸段主動脈病變⋯⋯⋯⋯⋯鄭月宏蔡念鄧鴻儒等超聲對急性闌尾炎的診斷價值⋯⋯⋯⋯⋯⋯⋯⋯⋯李峻梁樹民林甯等

肺结核外科疗效分析⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯楊德康熊信國成向陽等急性闌尾炎的多層螺旋CT表現與診斷探討⋯⋯楊貞勇譚文斌譚蕾等體外衝擊波治療肌肉骨骼系統痛症病人之研究⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯鄭翠萍蘇詠妍譚蓮麗

“無煙食肆＂政策執行情況調查⋯⋯⋯⋯⋯⋯蕭巧玲柯慶建羅玉蓮等綜述和講座人參皂苷 Rb1體內外代謝研究進展⋯⋯⋯⋯⋯⋯梁永炎燕茹阮建清等局部晚期非小細胞肺癌綜合治療進展⋯⋯⋯⋯⋯⋯⋯⋯⋯王衛華肖光莉

心理防禦機制研究新進展⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯柳蘊瑜王峘申荷永膠囊內鏡檢查對小腸不明原因疾病的應用價值⋯⋯⋯⋯⋯徐義祥楊冬華從護理到優質護理、從及格護士到專家型護士

學習 Benner’s “ From novice to expert” 模式⋯⋯⋯⋯⋯⋯⋯⋯尹一橋“三葉人字草＂的探究⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯劉興烈劉敏雯劉宏偉

中醫藥對艾滋病治療的進展⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯特木爾

短篇和病例報告

ANCA相關性血管炎合併獲得性血友病 A 一例並文獻複習⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯李惠君戴冽鄭東輝等

表現為腎病綜合征的急性鏈球菌感染後

腎小球腎炎 1 例⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯陳彥黃凱風梁蝶逢新生兒肺透明膜病的影像分析 1 例⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯鄭偉基謝學斌副腫瘤天疱瘡合併閉鎖性細支氣管炎⋯⋯⋯⋯⋯⋯⋯⋯⋯陳洪涛張德洪

巨細胞病毒性前葡萄膜炎⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯魏志成梁珍

出現躁狂前驅症狀的血管性癡呆症 1 例報告⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Carlos Duarte 黄輝鄭曉欣

巨細胞病毒引起的反復性前段葡萄膜炎 1 例報告⋯⋯⋯⋯⋯⋯⋯⋯金宏

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醫學文摘 116 例早期子宮內膜癌臨床分析⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯MSCT 評價直腸癌漿膜面浸潤及其相關因素分析⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯β3腎上腺素能受體基因多態性與高血壓病患者首次心腦血管事件的相關性⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯宮頸上皮內瘤變和宮頸癌中不同類型 HPV的感染狀況⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯超聲造影在肝移植術後血管源性並發症中的應用⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

信息和動態

2009 年 H1N1 流感大流行澳門特別行政區應對工作中期報告⋯⋯⋯⋯⋯澳門衛生局疾病預防控制中心2009年大流行甲型H1N1流感疫苗問與答⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯2009年大流行甲型H1N1流感疫苗接種篩查表⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯第一屆人類乳頭瘤病毒疫苗(亞太及中東區)國際會議摘要⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯王錦詠馬耀明

工具和資料甲型 H1N1 流感診療方案（2009 年第三版）⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯醫學科技發展 60 年紀事⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯2009NCCN乳腺癌治療指南解讀⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯白內障細說標準化治療⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

【澳門醫學雜誌】2009 年稿約 (中文, 葡文, 英文) ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

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本期責任校對：蕭瓊葡文、英文翻譯和校對：Jorge Humberto MORAIS，林明理，蕭瓊

Revista de Ciências da Saúde de Macau®澳門醫學雜誌 Trimestral Lançamento da revista em Abril de 2001 Volume IX Número 3 26 de Septembro de 2009

ÍNDICE

Organização Serviços de Saúde(SS) da Região Administrativa Especial de Macau (RAEM) Gabinete Editorial Conselho Editorial da RCSM

CP 3002 RAEM 2o piso, Edifício da Administração dos Serviços de Saúde de Macau Tel : (+853)-8390-7307

(+853)-8390-6524 Fax: (+853)-8390-7304 E-mail: [email protected]

http://www.ssm.gov.mo Editor-Chefe LEI Chin Ion (李展潤) Editor Geral HUANG Xiang-long (黃祥龍) Edição Serviços de Saúde(SS) da RAEM Impressão

Tipografia Man Bo Lda. Tel : (+853)-2848 1581 Fax: (+853)-2852 7546 E-mail: [email protected]

ISSN 1608-7801

Propriedade ©2009 : Serviçosde Saúde(SS) da RAEM

Dissertação e Investigação Estudo dos factores de alteração da elasticidade da gema de ovos

importados no mercado de Macau⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯TONG Ka-Io, SIO Hao-Leng, SIO Hao-Iok e outros

Aplicação dos produtos biológicos na psoríase, do estado moderado até ao estado severo⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯KOK Chon

Tratamento de alteração patológica da parte do arco da aorta e da parte torácica com tecnologia de hibridização⋯⋯⋯⋯⋯⋯⋯⋯⋯ZHENG Yuehong,CHOI Nim, DENG Hongru e outros

Valor da ecografia no diagnóstico da apendicite aguda⋯⋯⋯⋯⋯⋯⋯LI Jun, IIANG Shu Ming, LIN Ning e outros

Análise dos efeitos após operação cirúrgica da tuberculose pulmonar⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯YANG De Kang, XIONG Xin Guo, CHENG Xiang Yang e outros

Discussão sobre o valor da TAC espiral multicorte no diagnóstico da apendicite aguda⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯YANG Zhengyong, TAN Wenbing, TAN Lei e outros

Estudo relacionado com ondas de choque extracorpóreas no tratamento dos doentes com dores no sistema musculoesquelético⋯⋯⋯⋯⋯⋯⋯⋯

CHIANG Choi Peng, SOU Veng In, TAN Lian Li Avaliação sobre a implementação da política de “Estabelecimentos de

Restauração sem Tabaco”⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯SIO Hao Leng, O Heng Kin, LO Iok Lin e outros

Revisão e Palestras Progresso no estudo de biotransformação de “ginsenoside Rb1” ⋯⋯⋯

LEONG Weng-Im, YAN Ru, YUAN Jianqing e outros Desenvolvimento da terapia combinada no tratamento do cancro

pulmonar de não pequena célula localmente avançada⋯⋯⋯⋯⋯⋯WANG Wei Hua, XIAO Guang Li

Avanço sobre o estudo do mecanismo de defesa psicológica⋯⋯⋯⋯⋯LAO Wan U, WANG Huan, SHEN He Yong

Valor da utilização da endoscopia por cápsula para conhecer a etiologiadesconhecida do intestino delgado⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHOI I Cheong, YANG Dong Hua

Aprendizagem do método “Benner’s From Novice to Expert” na vida de enfermagem⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

VAN Lat Kio Discussão sobre o medicamento tradicional chinês “Kummerowia

Striata” ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LIU Xinglie, LIU MinWen, LIU HongWei

Progresso no tratamento do SIDA na medicina tradicional chinesa⋯⋯TE MU Er

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Relatório Sucinto e Estudo de Caso Um caso de hemofilia A adquirida com vasculite associada ao ANCA e reconsideração da respectiva

literatura médica⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LEI Wai Kuan, DAI Lie, ZHENG DongHui e outros

Um caso de glomerulonefrite com manifestação de sindrome nefrótica de pós-infecção estreptocócica aguda⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHEN Yan, HUANG Kaifeng, LEONG Tip Fong e outros

Análise imagiológica da doença de membrana hialóide pulmonar de um recém-nascido⋯⋯⋯⋯⋯⋯⋯ZHENG Weiji, XIE Xuebin

Pênfigo paraneoplásico e bronquiolite atrésico⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHAN Hong Tou, CHEONG Tak Hon

Uveíte anterior com citomegalovírus⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯NGAI Chi Seng, LEONG Chan

Relatório de um caso de demência vascular com o pródromo de mania⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Carlos Duarte, WONG Fai, CHEANG Hio Lan

Caso clínico uveite anterior recorrente causado per citomegalovírus⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Jin Hong

Resumos de Artigos Médicos Internacionais

Análise clínica de 116 casos de carcinoma de endométrio precoce⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Análise dos factores relacionados com infiltração da túnica serosa do carcinoma rectal, utilizando a

tomografia computadorizada multi-slice⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Relacionamento entre o polimorfismo do gene do receptor β3-adrenérgico e o primeiro evento

cardiocerebrovascular ocorrido em doente com hipertensão⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Situação de infecção pelos vários tipos de vírus do papiloma humano (HPV) entre a neoplasia cervical

intraepitelial e o carcinoma cervical⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Aplicação de ecografia nos casos de complicação vascular após a transplantação de fígado⋯⋯⋯⋯⋯⋯

Artigos da RCSM e autores (em Chinês, Português e Inglês) ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

Revisão em Chinês : SIO Keng Revisão em Português e Inglês : Jorge Humberto MORAIS, LAM Meng Lei, SIO Keng

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Health Science Journal of Macao®澳門醫學雜誌 Quarterly Established in April 2001 Volume IX Number 3 September 26, 2009

CONTENTS

Sponsor

Health Bureau of Macao Special Administrative Region of Macao ( MSAR )

Editorial Office

Editorial Committee of HSJM 2nd floor, Administrative Building, Health Bureau of Macao, CP 3002, MSAR Tel : (+853)-8390 7307

(+853)-8390 6524 Fax: (+853)-8390 7304 E-mail: [email protected] Website: http://www.ssm.gov.mo

Editor-in-Chief

LEI Chin Ion (李展潤) Executive Editor-in-Chief

Xiang-Long HUANG (黃祥龍) Publishing

Health Bureau of MSAR Printing

Tipografia Man Bo Lda. Tel : (+853)-2848 1581 Fax: (+853)-2852 7546 E-mail: [email protected]

ISSN 1608-7801

Copyright © 2009: Health Bureau of MSAR

Original Articles and Research A Factorial Study on the Alteration of Egg Yolk Elasticity in Macao⋯⋯⋯⋯⋯

TONG Ka-IO, SIO Hao-Leng, SIO Hao-Iok, et al. The Use of Biologic Treatment in Modrate to Severe plaque psoriasis⋯⋯⋯⋯

KOK Chon

Hybrid Aortic Endovascular Repair with Simultaneous Supra-Aortic Branch orIliac Artery Revascularization⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯ZHENG Yuehong, CHOI Nim, DENG Hongru

Diagnostic Value of Ultrasound in Acute Appendicitis⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LI Jun, lIANG Shu Ming, LIN Ning, et al

Surgery for Pulmonary Tuberculosis⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯YANG De Kang, XIONG Xin Guo, CHENG Xiang Yang, et a.

Diagnostic Value of multi-Slice Spiral CT for Acute Appendicitis⋯⋯⋯⋯⋯YANG Zhenyong, TAN Wenbing, TAN Lei, et al

Treatment of Extracorporeal Shockwave Therapy for Usculo-SkeletalpainPatients⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHIANG Choi Peng, SOU Veng In, TAN Lian Li.

Survey on the Implementation of the “Smoke-free Restaurant” Policies⋯⋯⋯SIO Hao Leng, O Heng Kin, LO Iok Lin, et al

Collective Reviews and Lectures

Progress in Biotransformation of Ginsenoside RB1⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LEONG Weng-Im, YAN Ru, YUAN jianqing, et al

Development of Combined Therapy for Locally Advanceed Non-Small Cell Lung Cancer⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯WANG Wei Hua, Xiao Guang Li

The Advance of the Psychological Defensive Mechanisms Research⋯⋯⋯⋯LAO WAN U, WANG Huan, SHEN He Yong

The Values of Using Capsule Endoscopy in Unknown Small Bowel Diseases ⋯⋯CHOI I Cheong ,YANG Dong Hua

Benner’s From Novice to Expert Model in Nursing Practice⋯⋯⋯⋯⋯⋯⋯VAN Lat Kio

The Inquisition of Kummerowia Striata⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LIU Xinglie, LIU MinWen, LIU HongWei

The Progress of the Chinese Medicine’s Treatment of AIDS⋯⋯⋯⋯⋯⋯⋯TE MU Er

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Short Report and Case Report Acquired Hemophilia A in Patient with ANCA –Associated Vasculitides:

A Case Report and Review of Literature⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LEI Wai Kuan, DAI Lie, ZHENG DongHui, et al

Case Study of Acute Postdtreptococcal Glomerulonephritis with Manifestations of Nephrotic Syndrome⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHEN Yan, HUANG Kaifeng, LEONG Tip fong,e t al

Imaging Analysis of Pulmonary Hyaline Membrane Disease in Newborn: Case Report ⋯⋯⋯⋯⋯⋯⋯⋯ZHENG Weiji, XIE Xuebin

Paraneoplastic Pemphigus and Braonchiolitis Obliterans⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHAN HONG Tou, CHEONG Tak Hon

Anterior Uveitis with Cytomegalovirus Infection⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Ngai Chi Seng Leong Chan

Mania as a Prodrome to Vascular Dementia: A Case Report⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Carios Duarte, WONG Fai, CHEANG Hio Lan

Recurrent Anterior Uveitis Caused by Cytomegalovirus: A Case report⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯JIN Hong

Foreign Medical Abstracts

Clinical Analysis of 116 Cases of Early Stage Endometrial Cancer⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Analysis of Factors Related to the Infiltration of Serosa by Rectal Carcinomas Using

16-channel Multi-slice CT⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Relationship between β3-AR gene T190C Polymorphism and the first Cardiovascular and

Cerebrovascular Events in Hypertensive Patients⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯The Infection Condition of Different Types of Human Papilloma Virusin Cervical Intraepitheliai

Neoplasia and CervicaI Carcinoma⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Application of Contrast-enhanced Ultrasound in Detecting Vascular Complications after Liver

Transplantation⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

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Articles of HSJM to authors ( in Chinese, Portuguese, and English) ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯ 275

Proofreader in Chinese : SIO Keng Revision Portuguese / English : Jorge Humberto MORAIS, LAM Meng Lei, SIO Keng

Revista de Ciências da Saúde de Macau 澳門醫學雜誌, September 2009, Vol.9, No.3

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‧論著和研究‧

輸澳雞蛋蛋黃彈性改變的析因研究

湯家耀蕭巧玲蕭巧玉唐海誼* 【摘要】目的本研究旨在探討影響輸澳雞蛋蛋黃彈性的物理因素。方法本研究採用析因設

計，對兩種來源（美國及湖北）合共 72 隻雞蛋分別作十二種處理──包括了儲存（室溫、4oC、-12oC），搖晃（有、無），水煮（20 分鐘、60 分鐘）因素的各個水平的所有組合。所有雞蛋經處理後，取出蛋黃，並進行重量、彈跳高度和可承受壓力測試。蛋黃彈跳高度為 10cm或以上且可承受壓力為 1000g或以上者則被界定為“彈力蛋”。結果相關分析顯示蛋黃彈跳高度與可承受壓力高度相關（r=0.845, p=0.000）。蛋黃平均彈跳高度為 6.8±4.1cm。多變量方差分析顯示蛋黃彈跳高度與來源（p=0.004）、儲存溫度（p=0.000）、儲存溫度和水煮時間的交互作用（p=0.000）有關。蛋黃平均可承受壓力為724±784g。分析顯示蛋黃可承受壓力與儲存溫度（p=0.000）、水煮時間（p=0.000）、儲存溫度和水煮時間的交互作用（p=0.000）有關。本研究共產生 10 隻“彈力蛋”。曾經冷凍儲存的雞蛋與不曾經冷凍儲存的雞蛋比較，出現“彈力蛋”的比值比（OR）為 252364。煮沸 60 分鐘的雞蛋與煮沸 20 分鐘的雞蛋比較，出現“彈力蛋”的比值比（OR）為 33。結論冷凍和長時間水煮是產生“彈力蛋”的主要物理因素。【關鍵詞】雞蛋; 彈性; 彈力蛋; 物理因素

A Factorial Study on the Alteration of Egg Yolk Elasticity in Macao TONG Ka-Io, SIO Hao-Leng SIO Hao-Iok, TONG Hoi-Yee*. Center for Disease Control and Prevention. Department Health, Macao SAR, China. Tel: (+853)-85041501; E-mail: [email protected]; *School of Health Sciences, Macao Potyte-chnic Institute, Macao SAR, China; Tel: (+853)-83998632; E-mail: [email protected]. 【Abstract】 Objective This factorial study aimed to investigate the physical factors which might

alter the yolk elasticity of imported hen eggs in Macao. Methods Eggs of two distinct origins, i.e., USA and Hubei were randomly assigned into 12 different treatment groups. Each treatment was a combination of various attributes of the three main physical factors, namely storage temperatures (room temperature, 4oC or -12oC), shaking (presence or absence) and hard-boiling time (20min or 60min). A total of 72 eggs were included in the study. All egg yolks were tested for weight, bounce height and resistant pressure. Yolks with bounce heights ≧10cm and resistant pressures ≧1000g were regarded as “elastic eggs”. Results Correlation test showed that bounce height was correlated with resistant pressure (r=0.845, p=0.000). The average bounce height of egg yolks was 6.8±4.1cm. Multivariate analysis revealed that the bounce height of yolk was correlated with egg origin (p=0.004), storage temperature (p=0.000), and the interaction of storage temperature and hard-boiling time (p=0.000). The average resistant pressure of egg yolks was 724±784g. It was demonstrated that resistant pressure was correlated with storage temperature (p=0.000), hard-boiling time (p=0.000), the interaction of storage temperature and hard-boiling time (p=0.000). A total of 10 elastic eggs were produced in the present study. When comparing eggs which had been stored frozen with those which had not, the odds ratio of forming “elastic eggs” was 252364. Comparing eggs which had been hard-boiled for 60 min with those for 20 min, the odds ratio of forming “elastic eggs” was 33. Conclusion Freezing and prolonged hard-boiling were the two main factors leading to the formation of “elastic eggs”. 【Keywords】 Egg; Elasticity; Elastic eggs; Physical factors

引言

2009 年 2月澳門特區先後有多名居民烹煮雞蛋後發

現蛋黃有強的彈性而向公共行政部門投訴。事件被懷

作者單位：中國, 澳門特別行政區, 衛生局, 疾病預防控制中心; Tel: (+853)-85041501; E-mail: [email protected]; *中國, 澳門特別行政區, 澳門理工學院高等衛生學校; Tel: (+853)-83998632; E-mail: [email protected].

疑與盛傳的“人造假蛋”有關，導致公眾的高度關注。其

後，民政總署報稱聯同珠海市出入境檢驗檢疫局進行了

試驗，將真雞蛋經冷凍、搖晃和長時間水煮後，製造出

有强彈性的蛋黃，因此，相信“彈力蛋”是雞蛋暴露於嚴

寒並經長途運輸而產生的物理變異所致。

其後，香港至少三個不同機構分別以內地雞蛋進


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行類似的小測試，亦確認可得到“彈力蛋”。

為進一步瞭解“彈力蛋”的時空分布，在互聯網上

用 google 搜尋器搜尋提及發現煮熟雞蛋黃有強彈性的

具體個案的報導，發現：1)就全中國龐大的雞蛋供銷

而言，僅發現極少數的具體個案。2)近三年每年都

有，但今年明顯較多──2007 年 1 月在北京和武漢共

2 個個案；2008 年 3 月在江蘇和山東共 3 個個案；

2008 年 11 月至 2009 年 2 月在山東、上海、北京、福

建共 12 個個案，同時，港澳特區亦各有逾十個投訴。

3)所有個案均發生在 11 月底至 3 月期間，2 月最多，

其次 1 月。4)報告個案的並非嚴寒地區，多屬華東及

沿海地區較富裕的城市。

檢索所有關於蛋黃彈力的科學文獻，發現曾有一

些研究揭示若在蛋雞飼料中添加共軛亞麻油酸

（Conjugated Linoleic Acid, CLA）可使雞蛋經水煮熟

透後，蛋黃質地呈橡膠樣、有彈性和較難打破[1,2]。

基於上述情況，本實驗擬通過規範和系統的設

計、定量的和統計學的檢測，解答初步物理變異試驗

未完全說明的問題，包括：

1. 蛋黃彈性的定量描述；

2. 來源因素（其中包含飼料因素）對蛋黃彈性的影響

的檢定；

3. 儲存溫度、搖晃、水煮時間三項物理處理因素對蛋

黃彈性的影響的檢定。

材料和方法

研究策略：本實驗採用析因設計，對兩個來源的

雞蛋分別作十二種處理——包括了儲存（室溫、4℃、

-12℃），搖晃（有、無），水煮（20 分鐘、60 分鐘）

因素的各個水平的所有組合。

樣本採集：2009 年 2 月下旬在批發市場購買來源

地為湖北的雞蛋及在超級市場購買來源地為美國的雞

蛋。兩種來源的雞蛋，排除所有有破損者後，各取 36

隻，分別按電腦隨機數列編入十二個處理組。

樣本處理：

1. 儲存：所有雞蛋按預先編定的組別分成三批，分別

在室溫（約 20oC）、家用冰箱冷藏室（經測定為

4oC）和冷凍室（經測定為-12oC）儲存 24小時。

2. 搖晃：經儲存的雞蛋按預先編定的組別重新分成兩

批，一批以實驗室搖晃器搖晃 3小時，速度設定為

100rpm，水溫設定為 20oC；另一批以自來水浸泡

（水溫約 20oC）靜置 3小時。

3. 水煮：經搖晃或靜置的雞蛋按預先編定的組別重新

分成兩批進行水煮──將雞蛋和足量冷水放入鍋，

置電磁爐上大火加熱至沸騰，一批在煮沸後調小火

保持沸騰 20 分鐘，另二批在煮沸後調小火保持沸

騰 60分鐘。

4. 測試：經水煮的雞蛋以冷水浸泡、剝殼，然後取出

蛋黃進行下列三項測試：

1) 重量：以準確至 0.0001g的電子天秤量度；

2) 彈跳高度：讓蛋黃在 100cm 高度自由下落，

由兩名研究人員目測反彈高度，以不同顏色

標示每 2cm為一級；

3) 可承受壓力：將蛋黃置於彈簧磅上，在蛋黃

正上方以穩定和漸進方式施加壓力，由三名

研究人員目測蛋黃破裂時磅的讀數，以每

100g為一級。

數據分析：使用 SPSS 軟件(v10.0)進行單變量、

雙變量和多變量分析。

結果

蛋黃重量範圍為 9.74~17.25g，平均為 14.04±1.36g。

多變量方差分析顯示蛋黃重量與來源有關，未顯示與

各種處理因素及其交互作用有關。兩種來源雞蛋的蛋

黃重量有顯著差異，湖北雞蛋範圍為 12.59~17.25g，

平均為 14.87±1.04g，美國雞蛋範圍為 9.74~15.44g，平

均為 13.21±1.13g。相關分析顯示蛋黃重量與彈跳高度

（ r=-0.115, p=0.337 ）或可承受壓力（ r=0.075,

p=0.532）不相關。

蛋黃彈跳高度範圍為 1~21cm，平均為 6.8±4.1cm。多


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變量方差分析顯示蛋黃彈跳高度與來源、儲存溫度、

儲存溫度和水煮時間的交互作用有關（表一，圖一）。

兩種來源雞蛋的蛋黃彈跳高度有顯著差異，湖北雞蛋

範圍為 1~15cm，平均為 5.7±3.5cm，美國雞蛋範圍為

3~21cm，平均為 7.8±4.4cm。按儲存溫度進行分層分

析顯示，室溫儲存雞蛋，水煮 20 分鐘組的彈跳高度顯

著高於水煮 60 分鐘組；4℃儲存雞蛋，兩組無顯著差

異；-12oC儲存雞蛋，水煮 60 分鐘組的彈跳高度顯著

高於水煮 20 分鐘組。按水煮時間進行分層分析顯示，

水煮 20 分鐘雞蛋，三個儲存溫度組彈跳高度無顯著差

異；水煮 60 分鐘雞蛋，室溫和 4℃ 組之間無顯著差

異，-12℃組顯著高於該兩組。相關分析顯示蛋黃彈跳

高度與可承受壓力高度相關（r=0.845, p=0.000）。表一蛋黃彈跳高度的多變量方差分析

F p 模型 3.523 0.000 來源 9.274 0.004 儲存溫度 19.884 0.000 搖晃 0.152 0.698 水煮時間 1.030 0.315 來源 x儲存溫度 0.384 0.683 來源 x搖晃 0.152 0.698 來源 x水煮時間 1.762 0.191 儲存溫度 x搖晃 0.482 0.621 儲存溫度 x水煮時間 11.567 0.000 搖晃 x水煮時間 0.006 0.938 來源 x儲存溫度 x搖晃 0.299 0.743 來源 x儲存溫度 x水煮時間 1.213 0.306 來源 x搖晃 x水煮時間 0.055 0.816 儲存溫度 x搖晃 x水煮時間 0.116 0.891 來源 x 儲存溫度 x 搖晃 x 水 0.348 0.708

圖一：蛋黃彈跳高度按儲存溫度和水煮時間的分佈

0

2

4

6

8

10

12

14

16

18

20

0 1 3 5 7 9 11 13 15 17 19 21 23

彈跳高度(cm)

蛋

數

無冷凍煮20分無冷凍煮60分冷凍煮20分冷凍煮60分

蛋黃可承受壓力範圍為 150~3450g，平均為

24±784g。多變量方差分析顯示蛋黃可承受壓力與儲存

溫度、水煮時間、儲存溫度和水煮時間的交互作用有

關（表二）。按儲存溫度進行分層分析顯示，室溫和

4oC兩種條件下，水煮 20分鐘組和水煮 60分鐘組無顯

著差異；-12℃儲存雞蛋，水煮 60 分鐘組蛋黃可承受

壓力顯著高於水煮 20 分鐘組。按水煮時間進行分層分

析顯示，在水煮 20 分鐘和水煮 60 分鐘兩種條件下，

同樣發現室溫和 4℃ 組之間無顯著差異，-12℃組顯著

高於該兩組。

表二蛋黃可承受壓力的多變量方差分析

F p 模型 4.028 0.000 來源 0.753 0.390 儲存溫度 20.701 0.000 搖晃 0.430 0.515 水煮時間 15.997 0.000 來源 x儲存溫度 1.121 0.334 來源 x搖晃 0.004 0.950 來源 x水煮時間 1.892 0.175 儲存溫度 x搖晃 0.618 0.543 儲存溫度 x水煮時間 12.192 0.000 搖晃 x水煮時間 0.004 0.950 來源 x儲存溫度 x搖晃 0.001 0.999 來源 x儲存溫度 x水煮時間 2.072 0.137 來源 x搖晃 x水煮時間 0.101 0.752 儲存溫度 x搖晃 x水煮時間 0.009 0.991 來源 x儲存溫度 x搖晃 x水煮時間 0.017 0.983

將蛋黃彈跳高度為 10cm 或以上且可承受壓力為

1000g 或以上者界定為“彈力蛋”，則共有 10 隻“彈力

蛋”，其在各處理組產生情況如表三所示。表三按來源、儲存和處理條件產生“彈力蛋”情況簡表

（n/N = “彈力蛋”數/測試雞蛋數）湖北蛋美國蛋

室溫 4℃ -12℃ 室溫 4℃ -12℃

無搖晃煮沸20m 0/3 0/3 1/3 0/3 0/3 0/3

煮沸60m 0/3 0/3 2/3 0/3 0/3 3/3

搖晃 3h 煮沸20m 0/3 0/3 0/3 0/3 0/3 0/3

煮沸60m 0/3 0/3 2/3 0/3 0/3 2/3

鑒於室溫組和 4℃組完全沒有產生“彈力蛋”，將

兩者合併，然後進行 Logistic 回歸分析。結果（表

四）顯示來源和處理因素中，僅儲存溫度和水煮時間

對“彈力蛋”的產生有影響。曾經冷凍儲存的雞蛋與不

曾經冷凍儲存的雞蛋比較，出現“彈力蛋”的比值比


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（OR）為 252364。煮沸 60 分鐘的雞蛋與煮沸 20 分

鐘的雞蛋比較，出現“彈力蛋”的比值比（OR）為 33。

表四產生“彈力蛋”的 Logistic回歸分析

β p Exp(β) 水煮時間 3.497 0.005 33.000 儲存溫度 12.439 0.831 252364.4常數 -14.837 0.799 0.000

模型 p=0.000

討論

冷凍和長時間水煮是產生“彈力蛋＂的主要因素

本研究採用了系統和規範的析因設計、隨機分

組、盲法和定量測量，對“彈力蛋”現象進行統計學描

述和檢驗。經實驗發現：1) 即使未經施加特別的處

理，水煮熟透（hard-boiled）雞蛋的蛋黃有一定的彈

性。2) 雞蛋經冰凍和長時間水煮，蛋黃彈性顯著增

加，可產生“彈力蛋”。3) 搖晃對蛋黃彈性無影響。4)

美國雞蛋蛋黃的彈跳高度比湖北雞蛋要高一些，但在

產生“彈力蛋”方面，兩種來源並無差異，所以，初步

不提示來源（包括飼料因素）是“彈力蛋”產生的重要

因素。

進一步解釋“彈力蛋”的時空分佈

冰凍和長時間水煮兩個因素是“彈力蛋”產生的關

鍵。根據相關文獻［3］，冷凍過程可使蛋黃中的蛋白質

發生變性，從而增加了蛋黃的濃稠度。倘若雞蛋進一

步經過解凍的程序，則可使蛋黃出現不可逆的膠化現

象（irreversible gelation），影響蛋黃質地。

故此，在正常情況下，雞蛋在儲存和運輸過程

中，須防止冰凍。換言之，雞蛋被冰凍是不正常的情

況，只可能因生產經營者的過失或故意而造成。同

時，只有很少的消費者會基於特別的需要將雞蛋長時

間水煮。這解釋了為何全國消費極大量的雞蛋，卻只

有極少數的“彈力蛋”個案。

雞蛋被冰凍自然較容易在冬季發生，但若其主要

原因是過失或故意，則其時空分布會與過失或故意的

分布相同，而未必符合嚴寒天氣的時空分布。

今年港澳突然發現較多的“彈力蛋”個案，提示這

期間可能有一批曾經被過失或故意冷凍的雞蛋供應港

澳。就所掌握的資料，未能推測這與 2008 年底雞蛋檢

出三聚氰胺而使雞蛋正常供銷一度受到影響有無關

係。

研究限制

本研究主要的限制因素包括：未涵蓋更多來源的

雞蛋；未取得飼料和雞蛋化學成份方面的直接證據；

測試蛋數不多，未能有效推論蛋黃彈性的正常範圍；

兩個彈性指標的效度未經檢定，測量採用肉眼判定

法，未使用更精確的測量設備。

參考文獻

1 Ahn DU, Sell JL, Jo C, et al. “Effect of dietary conjugated linoleic acid on the quality characteristics of chicken eggs during refrigerated storage.” Poultry Science, 1999, 78: 922-928.

2 Watkins BA, Feng S, Strom AK, et al. “Conjugated linoleic acids alter the fatty acid composition and physical properties of egg yolk and albumen.” J. Agric. Food Chem., 2003, 51: 6870-6876.

3 Yamamoto T, Juneja LR, et al. Hen eggs: their basic and applied science. USA: CRC Press LLC, 1997.


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The use of biologic treatment in moderate to severe plaque psoriasis Kok Chon

【Abstract】Objective To analyze biologic treatment in moderate to severe plaque psoriasis patient clearance rate. To date, there is little long term management in clinical trials. Methods In this study, 8 patients were received biologic treatment during Sep 2007 to June 2009 in out patient department. All patients were screened for tuberculosis with tuberculin test, blood analysis for hemogram, biochemistry and a chest X-ray. 6 patients started on infliximab 5mg/kg infusion at week 0, 2, 6 then interval 8 weeks, 2 patients started on etanercept subcutaneously injection 50mg twice weekly for three months, then 50mg per week for maintenance. Response to treatment was categorized as follow: >80% clearance, 50%-80% clearance, 30%-50% clearance, 80% clearance rate, one of patient failed to response, for etanercept group, 50%-80% and >80% clearance rate were achieved. Compared to clearance rate: at week 12, infliximab group is much high; at week 24, two groups have no significant difference. Conclusion Biologic treatment resulted in rapid relieved the symptom and sign of moderate to severe plaque psoriasis patients and significant improvement their quality of life. There were generally well tolerated.

【Key words】Biologic treatment; Plaque psoriasis; Psoriatic arthritis; Tumor necrosis factor-α(TNF-α); Infliximab; Etanercept; Quality of life

生物製劑在中重度尋常型銀屑病中的應用谷臻. 中國, 澳門特別行政區,仁伯爵綜合醫院, 皮膚科, Tel (+853)-8390 8945; E-mail: [email protected] 【摘要】目的分析生物製劑在中重度尋常型銀屑病患者中的清除率。方法由 2007 年 9 月

至 2009 年 6 月，共有八名中重度尋常型銀屑病患者接受生物製劑治療。所有患者在接受治療前須進行結核菌素試驗、血常規、血生化及胸片檢查。其中 6名患者接受 infliximab 5mg/kg 靜脈點滴，在 0. 2. 6 星期各一次，然後每隔 8 個星期做一次治療。另外 2 名患者接受 etanercept 皮下注射每星期100mg 為期三個月，然後減量至每星期 50mg。療效評估採用以下方法: >80% 清除率，50%-80%清除率， 30%-50%清除率， 80%清除率, 1名患者症狀加重。而 etanercept組清除率上升至 50%-80%和>80%。兩組比較在 12周時 infliximab 組比 etanercept 組清除率高：24 周時兩組無明顯差異。結論生物製劑可迅速緩解中重度尋常型銀屑病患者的症狀和明顯改善患者的生活質量。在治療過程中並無出現明顯毒副作用。

【關鍵詞】生物製劑; 尋常型銀屑病; 銀屑病關節炎; 腫瘤壞死因子-α; 類克; 恩利; 生活質量

Introduction

Psoriasis is a common, chronic inflammatory multi-system disease with predominately skin and joint manifestation, affecting approximately 1-3% of the population[1]. An early report showed that the prevalence

Authors address: Department of dermatology, Centro Hospitalar Conde de S Januario, Macao SAR China, Tel (+853)-8390 8945; E-mail: [email protected]

rate of psoriasis in Mongoloid races of the Far East including Hong Kong was 0.3%. Patients with psoriasis often have serious comorbiditis that increase cardiovascular risk, hypertension, hyperlipidemia, metabolic syndrome and type II diabetes.

Until recently, conventional treatment of psoriasis has been limited to methotrexate, cyclosporine, acitretin, high-intensity psoralen ultraviolet A, and ultraviolet B irradiation. Thought these treatment have been used in some selected patients with good therapeutic results,


170

there still a need for convenient, targeted systemic agents that achieve rapid control with less potential for drug-related, serious toxicities over the short and long term. Tumor necrosis factor(TNF-α), an inflammatory cytokines, is suggested to play a vital role in the pathogenesis of psoriasis. It has been demonstrated in a mouse model that TNF –α is the primary cytokine mediating activation and proliferation of resident T cells, which are essential in the development of psoriasis lesion. Elevated TNF-α has been found in serum and skin lesions in patients with psoriasis and correlates with disease activity. In addition, agents TNF –α that block have been shown to be effective in those patients. Therefore, treatments targeting TNF –α may represent a new option for the management of psoriasis.

Two biologic agents ( infliximab and etanercept ) was used in out patient department, infliximab is a recombinant a monoclonal antibody composed of human constant and murine variable regions, which binds with high affinity and specificity to TNF-α and neutralizes its biological activity, it is administered intravenously. Etanercept is a fully human receptor fusion protein that binds TNF-α with greater affinity than natural receptors[6].

Infliximab and etanercept was approved for plaque

psoriasis indication by US Food and Drug Administration in 2006 and 2002.

Patients and methods

The study was retrospective. 8 patients treated with infliximab or etanercept during Sep 2007 to June 2009 The following date was collected: age, sex, duration of psoriasis, family history, joint involvement, number of hospital admission（Table 1）.

Table 1 Demographic and characteristics of patients TOTAL NUMBER OF PATIENTS 8 Male No ( % ) 7 ( 87.5% )Age (years) mean ( range ) 33-62 ( 49)Duration of psoriasis (years) mean(range) 5-20 (9) Psoriatic arthritis No (%) 1 (12.5%) No of hospital admission 1 (12.5%) Family history of psoriasis 0 (0%)

Pretreatment screening included full blood court,

urea and electrolyte and liver function tests, personal

and family history of tuberculosis was taken and patients were screened for tuberculosis with the tuberlin test (Mantoux) and chest X-ray

Table 2 Previous treatments PREVIOUS TREATMENTS NO (%)

Narrowband ultraviolet B 8 (100%) Oral acitretin 7 ( 87.5% )Oral acitretin + Narrowband ultraviolet B 7 ( 87.5% )Methotrexate 5 (62.5%) Cyclosporine 3 (37.5%)

Total 8 patients were received biologic treatment, 7

(87.5%) men and 1(12.5%) women with a mean age of 49 years (range 33-62). 100% had chronic plaque psoriasis. The mean duration of psoriasis was 9 years (range 5-20), 8(100%) patients had narrowband ultraviolet B therapy, patients had been on two or more systemic agents including retinoid with narrowband ultraviolet B therapy ( N=7 87.5%), Methotrexate ( N=5 62.5% ), acitretin (N=7 87.5%), Cyclosporine (N=3 37.5%)（Table 2）. Dosage regimen

6 (75%) patients started on infliximab infusion of 5mg/kg at week 0, 2 and 6 initially, maintenance therapy is usually every 8 weeks. 2 (25%) patients started on etanercept 50mg twice weekly , after 12 weeks, dosage is generally reduced to 50mg weekly. Efficacy

The response to biologic treatment was globally assessed with documentation from clinical compiled by treating physician during the patient’s hospitalization and from the clinical summary. The result was categorized as follow: >80% clearance, 50%-80% clearance, 30%-50% clearance,


171

Results

Table 3 characteristics of 8 patients who received biologic treatment RESPONSE BY % OF CLEARANCE

PATIENT NO

AGE/SEX (YEARS)

BIOLOGIC AGENTS

BIOLOGIC DOSAGE

week 12 week 24

ADDITIONAL INFORMATION

1 34/M Infliximab 5mg/kg 50%-80% worse Add Methotrexate 12.5mg/week at week 12

2 46/M Infliximab 5mg/kg 50%-80% 50%-80% Nail improvement 3 62/F Infliximab 5mg/kg 50%-80% >80% Nail improvement 4 52/M Infliximab 5mg/kg 50%-80% 50%-80% Nail improvement 5 54/M Infliximab 5mg/kg 50%-80% 50%-80% Nail improvement 6 48/M Infliximab 5mg/kg 50%-80% 50%-80% Nail improvement 7 51/M Etanercept 50mg 2/wk for 12 weeks

then 50mg 1/week 30%-50% 50%-80% Nail improvement

8 44/M Etanercept 50mg 2/wk for 12 weeksthen 50mg 1/week

30%-50% >80% Psoriatic arthritis symptom relieved at week 12

In above patients with moderate to severe plaque

psoriasis, it show the high efficacy, rapid onset and long term maintenance of therapeutic response for skin as well as nail lesions

In infliximab group, at week 12, 6 patients achieved

50%-80% clearance rate, at week 24, 4 patients maintenance 50%-80% clearance rate, 1 patient had >80% clearance rate and one patient failed to infliximab treatment, now add methotrexate 12.5mg/week for combination therapy[4].

In etanercept group, patients has initially response

slowly for the first 12 week, it achieved 30%-50% clearance rate, but it continue to increase with achieving rate to 50%-80% and >80%.

All the patient had nail improvement during

treatment（Table 3）.

Discussion

As psoriasis is a chronic disease that usually needs long-term treatment, successful management of psoriasis encompasses the assessment patient’s quality of life. Symptom of depression in patients with psoriasis has been shown to be related to impairment in health related quality of life, arising from dissatisfaction with treatment and illness related stress. Biologic treatment is good news for recalcitrant psoriasis patients.

Tumor necrosis factor-α play an important role in

preventing mycobacterium infection; the possible reactivation of tuberculosis should be considered when using TNF-α inhibitor. Therefore, pretreatment screening of latent tuberculosis is recommended[3].

Two biologic agents (infliximab and etanercept)

have been shown in previous trials to be effect against recalcitrant psoriasis with no serious toxic effect. Although infliximab monotherapy is highly effective in the treatment of skin and nail disease in patient with moderate to severe psoriasis with a rapid onset of action and a sustained effect in most patients, the reason for one patient lost response from week 24, it possible explanation for this loss include change in serum infliximab concentration or the presence of neutralizing antibodies. Therefore, maintaining and good response seemed to depend on achieving measurable concentrations of infliximab in serum.

Treatment with etanercept 50mg twice-weekly

showed sustained effectiveness in reducing rapidly the signs and symptoms (e.g. pain, swelling and stiffness) of psoriatic arthritis and in increasing functional capacity in week 12[3].

Serious adverse events must be monitored closely

for fungal or bacterial infections, infusion reactions, tuberculosis, demyelinating events, heart failure, or malignancies. In fact, no serious side effects occurred during the treatment[8, 9].

The results of the present study show that in this


172

population of patients with moderate to severe plaque psoriasis, infliximab effects more rapidly than etanercept, but for long term clearance rate, both of them have almost the same result[7]. In addition, these data demonstrate that continuous treatment with biologic agents resulted in sustained improvement in clinically important signs and symptoms.

In conclusion, biologic treatment resulted in rapid and significant improvement in the sign and symptom of moderate to severe plaque psoriasis. There were generally well tolerated[5].

References

1 Alan Menter,, Alice Gottlieb, Steven R. Feldman, MD. Guidelines of care for the management of psoriasis and psoriatic arthritis. JAAD 2008, 2: 826-864.

2 L E Kristensen, A Gulfe, T Saxne, P Geborek. Efficacy and tolerability of anti-tumor necrosis factor therapy in psoriatic arthritis patients: results from the South Swedish Arthritis treatment group. Ann Rheum Disease 2008;

67:364-369. 3 Jung Im Na, Jun Hyung Chan PARK, Sang Woong YOUN.

Low dose etanercept therapy in moderate to severe psoriasis in Korean. Journal of Dermatology 2008, 35:484-490.

4 Kristian Reich, Christopher Griffiths, Jonathan Barker, et al. Recommendation for the long term treatment of psoriasis with infliximab: a dermatology expert group consensus. Journal of Dermatology. 2008, 217:268-275.

5 K Ahmad, S Rogers. Two years of experience with etanercept in recalcitrant psoriasis. British Journal of Dermatology. 2007, 156:1010-1014.

6 Monica Lawry. Biological therapy and nail psoriasis. Dermatologic therapy. 2007, 20:60-67.

7 G.G.Krueger, R.G.Langley, A.Y.Finlay. Patient-reported outcomes of psoriasis improvement with etanercept therapy: results of a randomized phase III trial British Journal of Dermatology. 2005, 153:1192-1199

8 Rocco Serrao, Mark DP Davis. Goeckeman treatment for remission of psoriasis refractory to biologic therapy. JAAD 2009, 2:348-349.

9 Daniel J.Lovell, Andreas Reiff, Norman T et al. Safety and Efficacy of up to Eight Years of Continuous Etanercept Therapy in Patients With Juvenile Rheumatoid Arthritis. American College of Rheumatology. 2008, 58: 1496-1504.


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雜交技術治療弓部和胸段主動脈病變

鄭月宏蔡念* 鄧鴻儒* 郭昌宇** Rui FURTADO*

【摘要】目的本文回顧行分析並報告本組手術結合微創這一新型雜交技術治療弓部、胸、腹段主動脈病變的診治體會。方法自 2007 年 6 月-2008 年 5 月在澳門仁伯爵綜合醫院工作期間應用雜交技術治療主動脈病變 5 例。胸降主動脈瘤累及半弓合併夾層 1 例，弓降主動脈瘤 1 例，DebarkeyIII 型急性主動脈夾層 1 例，累及雙側髂總、髂內動脈的腎下腹主動脈瘤 2 例。弓降主動脈瘤正中開胸行升主動脈至雙側頸總人工血管搭橋＋左頸總動脈至左鎖骨下動脈搭橋術，同期

DSA 下經股動脈釋放 Zenith 覆膜支架。Debakey III 型夾層行左頸總至左鎖骨下動脈搭橋後釋放覆膜支架封閉破口。對於累及雙側髂內動脈的腹主動脈瘤，預先髂內、外動脈搭橋後釋放腹主動脈分

叉支架。結果 5 例手術成功完成，術後即刻造影和隨訪 CTA無內漏發生，隨訪期 2 月-10月。出血量約 200-600ml 之間，均未輸血。1 例弓部雜交術後 ARDS 隨後肺部感染，術後三周行氣管切開，經對症治療後痊癒出院，術後三月出現急性左心衰，經控制血壓（下肢）後恢復。1 例術後三周進食時突因心臟意外死亡。兩例弓部雜交治療病例各頸動脈阻斷時間均小於 10 分鐘，均無神經併發症或者輕微神經症狀。結論選擇適宜的不同組合的主動脈雜交方式是本組治療的前提。除卻治療費用高的因素之外，應用手術結合微創這一新型雜交技術治療胸腹主動脈病變，有利於減少

外科創傷和體外循環等所帶來的血流動力學改變。【關鍵詞】主動脈瘤; 夾層; 雜交; 外科

Hybrid Aortic Endovascular Repair with Simultaneous Supra-Aortic Branch or Iliac Artery Revascularization ZHENG Yuehong, CHOI Nim*, DENG Hongru*, KOUK CU**, RUI Furtado* . Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medial Sciences, Beijing, 100730, PR China; Tel : (+86-10)-65296014; E-mail : [email protected]; *CP 3002, Department of General Surgery, Central Hospital Centre S. Januario(CHCSJ), Macao SAR, PR China. 【Abstract】 Objective Repair of aortic arch aneurysm is technically demanding and usually

requires complex circulatory management. Operative morbidity and mortality may be prohibitive with traditional surgical intervention. We described our experience with 5 hybrid endovascular procedure for aorta repair with different kinds of bypass followed by concomitant placement of stent graft in the aorta. Methods A retrospective report was performed to evaluate this new hybrid technique.Data of 5 consecutive patients in Macau who presented with aortic aneurysm or dissection from 2007 to 2008 treated with the hybrid aorta repair were analyzed. 2 Complete surgical rerouting of the supra-aortic vessels was followed by the endovascular repair of aortic arch aneurysm with a Zenith TX2 stent graft. Hybrid left carotid-subclavian bypass with Zenith stent graft deployment covering the ostium of the LSA was performed in a Debakey type III aortic dissection case. 5 Procedure were successfully completed with exclusion of the aortic aneurysm. All stent grafts were deployed retrograde from the femoral artery in five patients. Results Technical success with complete aneurysmal exclusion was achieved in all patients (100%). At a follow-up period of 2--10 months, there was no incidence of endoleak. Documented perioperative neurologic events did not occurred in all patients. 1 patient suffered ARDS and following treachuostmy,recovered 3 months later. There was one death resulting from a postoperative myocardial infarction 3 weeks later. Conclusions Hybrid arch repair provides an alternative to patients otherwise considered prohibitively high risk for traditional open arch and thoracoabdominal aorta repair. 【Key words】 Aortic aneurysm; Dissection; Surgery; Hybrid 主動脈弓、降部動脈瘤由於嚴重神經併發症等

具有極高手術風險，傳統弓手術高併發症率和死亡率

對於外科醫生是極大挑戰。Hybrid technique常被譯

作者單位：100730, 中國, 中國醫學科學院, 北京協和醫學院 , 北京協和醫院 , 血管外科 ; Tel : (+86-10)-65296014; Email : [email protected] ; *CP 3002, 中國, 澳門特別行政區, 仁伯爵綜合醫院, 外科; **仁伯爵綜合醫院影像科

作“複合”技術或“雜交”技術，最近國內外已將此技術應用于大血管病人。本文報告雜交技術治療主動脈病

變的初步體會。

材料和方法

作者自 2007 年 6 月-2008 年 5 月在澳門仁伯爵


174

綜合醫院工作期間，應用雜交技術治療主動脈病變 5例。均為男性。胸降主動脈瘤累及左半弓合併夾層 1例，弓降主動脈瘤 1 例，DebarkeyIII 型急性主動脈夾層 1 例，腎下腹主動脈瘤累及雙側髂動脈 2 例。詳細資料介紹如下。例 1，男性，51 歲，合併高血壓史，因突發休克就診而被迫急診處理。術前 CTA 弓降主動脈瘤合併夾層形成，胸降主動脈瘤累及左側半弓合併夾層形

成，弓上三支分支血管變異，雙側鎖骨下動脈共幹自

左側弓部發出。急診正中開胸，切除部分胸腺，避免

損傷喉返神經、胸導管等，依次分離無名靜脈、升主

動脈以及弓部、右頸總動脈、鎖骨下動脈共幹、左頸

總動脈，側壁阻斷升主動脈 2/3 後用 Gore-Tex 16-8mm 分叉人工血管行升主動脈至雙側頸總人工血管搭橋術，雙側頸動脈阻斷時間均小於 10 分鐘。由於雙側鎖骨下動脈共幹的原因，頸部左鎖骨上另行切口

用 Gore-Tex 7mm 人工血管左頸總動脈至左鎖骨下動脈搭橋術，結紮鎖骨下動脈共幹近端、雙側頸總起始

部以防內漏，然後鈦夾標記升主動脈吻合口以遠

5mm，作為支架釋放用錨定區標記，標準關胸麻醉狀態下轉送 DSA室。同期 DSA下經股動脈切口，釋放 Zenith TX2 第一件覆膜支架隔絕主動脈弓、降主動脈上段。介入治療後影像無即時內漏發生。例 2 為 76 歲胸主動脈瘤患者，術前 CTA 示弓降部動脈瘤最大徑 65mm，測量發現支架釋放錨定區需覆蓋主動脈弓上分支。擇期正中開胸與上述方法相

同游離無名靜脈、升主動脈、弓部以及三分支，

Gore-Tex16-8mm分叉以及 8mm直型人工血管行升主動脈至三支血管（右頸總、左頸總、左鎖骨下動脈）

搭橋術。同期 DSA 下經股動脈切口，然後經股動脈釋放 Zenith TX2（42-38mm，38-38mm）二件覆膜支架對接隔絕主動脈弓降段。介入治療後無即時內漏發

生。手術過程順利，各血管吻合口通暢無出血，雙側

頸動脈阻斷時間均小於 10分鐘。例 3 為 DebarkeyIII 型急性主動脈夾層，由於破口貼近左鎖骨下動脈缺乏近段錨定區，而術前 CTA示左椎動脈為主導供血支，預先行左頸總動脈――左鎖骨下動脈搭橋轉送 DSA 室，經股動脈逆行釋放Zenith TX2支架封閉主動脈破口。例 4腹主動脈瘤右側髂內動脈栓塞後釋放 Zenith AAA 分叉支架後發現

左髂內動脈開口覆蓋，雙側髂內無血供，遂同期經腹

膜外行左髂外、髂內動脈人工血管搭橋。例 5為累及雙側髂內動脈的腹主動脈瘤，預先左側髂外、髂內動

脈搭橋後釋放 Zenith AAA 分叉支架，將髂支延伸至髂外動脈。

結果

5 例手術成功完成，手術出血量約 200-600ml 之間，均未輸血。術後即刻造影和隨訪 CTA 無內漏發生，隨訪期 2 月-10 月。例 1 弓部雜交術後發生ARDS 然後肺部感染，術後三周氣管切開，對症治療於術後 2 月出院，1 月後發生二次急性左心衰，經檢查上、下肢血壓差別大，而左頸總動脈至左鎖骨下動

脈搭橋由於鎖骨下共幹原因雙側上肢血壓低，告知通

過測量下肢壓力控制血壓穩定後恢復，隨訪半年無異

常。例 2高齡患者術後恢復過程順利，惜術後三周進食時突因心臟意外死亡。兩例弓部雜交治療病例各頸

動脈阻斷時間均小於 10 分鐘，均無輕微神經症狀或者神經併發症。其他病例手術順利恢復無併發症，術

後 CTA隨診血管橋通暢，未見內漏等異常。

討論

應用四分支血管置換弓降部動脈手術較為棘手，常需體外循環（DHCA）輔助和嚴格圍手術期迴圈、呼吸等重症監護管理。本組利用分叉血管重建弓

上分支同期腔內技術重建主動脈弓，這樣一種外科結

合介入治療的雜交技術，對於患者循環、呼吸、神經

系統干擾相對小。若主動脈夾層破口靠近主動脈弓部

遠端，此時如果左椎動脈為主導供血支，用帶膜支架

封堵破口時必然覆蓋左鎖骨下動脈開口，可能會引起

嚴重神經併發症。手術結合微創這一新近發展的雜交

技術，通過預先搭橋提供足夠錨定區再行介入治療，

能夠避免此類難題。雜交技術與傳統手術相比，能減

少創傷和併發症，對於傳統手術治療禁忌的患者提供

了另一種選擇。相對國情來講，雜交技術缺點是治療

費用較高[1-2]。傳統概念的雜交由Angelini 1996 年提出，指分期冠脈支架植入和搭橋手術用於治療冠心病，以後延


175

伸至大血管治療領域。Coppola[3] 等 2007 年報告一例74 歲主動脈弓部動脈瘤下方破裂，首先解剖外途徑行股動脈到雙側頸動脈臨時搭橋保持腦灌注，然後支

架覆蓋升主動脈遠端和弓部以及降主動脈近端，這樣

隔絕主動脈弓破裂口，然後行標準主動脈頸動脈搭橋

手術。Chiesa[4] 治療一例主動脈弓動脈瘤，主動脈上方血管起源變異，通過外科技術行顱外血管重建，然

後Zenith TX2帶膜支架一期修復主動脈弓。較多病例是Szeto[5] 等回顧性報導自 2005 年 6 月以來雜交治療主動脈病變 8 例，除第一例病人圍手術死亡外，有 2例神經併發症經治療好轉。分支覆膜支架治療胸腹主動脈瘤已經得到應用，也有應用雜交技術的報導，Torsello[6] 等利用雜交技術治療一例 46 歲胸腹主動脈瘤患者，將升主動脈作為重建弓上血管和腹腔臟器血供的源頭，利用 3個分叉血管分別重建雙頸動脈、腹腔幹、腸系膜上動

脈、雙腎動脈，一周後二期覆膜支架隔絕胸腹主動脈

瘤。也可以利用人工血管從右側的鎖骨下或頸動脈向

左側的鎖骨下動脈和頸動脈搭橋，再覆膜支架封堵破

口和左鎖骨下或左頸總動脈。Valerio[7] 等報導利用人工血管左頸總動脈至鎖骨下動脈旁路後，再用覆膜支

架治療累及弓的梭狀動脈瘤，術中造影顯示血管橋和

左乳內動脈通暢。血管外科目前的發展趨勢是以往無法想像的，介入醫學的發展改變了血管疾病的治療模式。證據醫

學表明應用手術結合微創這一雜交技術治療胸、腹主

動脈病變是可行的，有利於減少外科創傷和傳統手術

所帶來的巨大生理改變，簡化複雜病例治療過程。雜

交技術也對外科醫師提出了更高的要求，除了具備嫺

熟的手術技巧外還需要血管介入操作能力，並具有足

夠的醫學影像學知識，而團隊的術後監護管理經驗至

關重要。

參考文獻

1 鄭月宏, 管珩, 劉昌偉, 等. 複雜主動脈瘤破裂的搶救. 中華普通外科雜誌, 2003, 18:178-179.

2 鄭月宏, 管珩. 基因表達譜晶片對主動脈瘤細胞週期和細胞凋亡相關基因的研究 . 中華外科雜誌 , 2002, 40 :817-819.

3 Coppola R, Bonifazi R, Gucciardo M, et al. Ruptured aortic arch aneurysm: transposition of aortic arch branches after insertion of thoracic endovascular stent with extra-anatomic brain perfusion. Interact Cardiovasc Thorac Surg, 2007, 6:376-378.

4 Chiesa R, Melissano G, Bertoglio L, et al. Hybrid repair of an aortic arch aneurysm with complex anatomy: right aortic arch and anomalous origin of supra-aortic vessels. J Vasc Surg, 2007, 46:128-130.

5 Szeto WY, Bavaria JE, Bowen FW, et al. The hybrid total arch repair: brachiocephalic bypass and concomitant endovascular aortic arch stent graft placement. J Card Surg, 2007, 22:97-102.

6 Torsello G, Can A, Umscheid T, et al. Hybrid thoracoabdominal aneurysm repair with simultaneous antegrade visceral revascularization and supra-aortic debranching from the ascending aorta.J Endovasc Ther, 2007, 14:342-346.

7 Valerio N, Bucci F, Redler A, et al. Vascular Thoracic endograft positioning and carotid-subclavian bypass grafting in a patient with a saccular aneurysm at the aortic arch. 2007, 15:221-225.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Coppola%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Chiesa%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Szeto%20WY%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Torsello%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Valerio%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Coppola%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bonifazi%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gucciardo%20M%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Chiesa%20R%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Melissano%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bertoglio%20L%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Szeto%20WY%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bavaria%20JE%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bowen%20FW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Torsello%20G%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Can%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Umscheid%20T%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Valerio%20N%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bucci%20F%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstracthttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Redler%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract


176


超聲對急性闌尾炎的診斷價值

李峻梁樹民林甯譚蕾鄧小雯郭詠楠余國威譚文斌鄭偉基

【摘要】目的探討超聲對急性闌尾炎的診斷價值。方法應用低高頻探頭結合對 107 例臨床懷疑闌尾炎的患者進行超聲掃查，並將觀察結果與手術病理對照。結果急性闌尾炎 67 例，其超聲診斷符合率為 82.1%，其中單純性闌尾炎 17 例，佔 25.4%，化膿性闌尾炎 40 例，佔 59.7%，壞疽性闌尾炎 3 例，佔 4.5%,闌尾周圍膿腫 7 例，佔 10.4%。各型急性闌尾炎聲像圖具有特異性。結論超聲檢查對急性闌尾炎的診斷具有重要價值。

【關鍵詞】急性闌尾炎; 超聲檢查 Dignosis Value of Ultrasound in Acute Appendicitis LI Jun, LIANG Shu Ming, LIN Ning, TANG Lei, DENG Xiao Wen, GUO Yong Nan, YU Guo Wei , TAN Wen Bin, ZHENG Wei Ji. Diagnostic Imaging Center, Kiang Wu Hospital, Macao SAR, PR China; Tel : (+853)-82950382; E-mail : [email protected]

【Abstract】 Obiective To explore the diagnostic value of ultrasound in acute appendicitis. Methods The low-frequency and high-frequency ultrasound probe were performed on 107 patients with doubtful acute appendicitis via clinical diagnosis .The examination results were compared with surgery and pathology. Results The ultrasound diagnosis rate of acute appendicitis was 82.1%.Among 67 acute appendicitis patients, there were 17cases with acute simple appendicitis(25.4%),40 cases with acute suppurative appendicitis (59.7%),3 cases with gangrenous appendicitis(4.5%),7 cases with periappendicular abscess(10.4%). Conclusion Ultrasound plays a important role in the diagnosis of acute appendicitis.

【Key words】 Acute appendicitis; Ultrasound

急性闌尾炎是腹部外科急症中最常見的疾患，居

急腹症之首，約占一般綜合性醫院外科住院病人的

10-15%。發病率一般估計為 1:1000，國外有報導每年每 700人中就有一人患急性闌尾炎。患者大多數為青少年，3 歲以下和 60 歲以上的患者少見，但臨床上也有新生兒發生急性闌尾炎並穿孔的[1]。既往急性

闌尾炎常以症狀、體征及實驗室檢查作出診斷，不典

型的病例及發生在兒童、孕婦、肥胖者和老年患者時

診斷比較困難，有導致闌尾穿孔、腹膜炎等併發症的

可能，因此尋找一種簡便無創的影像學診斷方法非常

重要，自 1986 年Puylaert首次報導有關盲腸區進行超聲探頭分級壓縮檢查的論著以來，已證明超聲有助於

急性闌尾炎的診斷[2]，隨著超聲檢查的廣泛應用，尤

其是高頻超聲的問世，為臨床診斷闌尾炎提供了更多

較直觀的依據。本文回顧性分析經手術及病理證實的

67 例急性闌尾炎的超聲檢查結果，旨在探討超聲對急性闌尾炎的診斷價值。

作者單位：中國, 澳門特別行政區, 澳門鏡湖醫院, 影像科; Tel : (+853)-82950382; E-mail : [email protected].

資料與方法

1 資料 2006 年 11 月至 2008 年 8 月術前經超聲檢查、術後經病理證實的急性闌尾炎 67 例，其中男 38 例，女 29 例，年齡 6-68 歲，平均 37.8 歲。臨床症狀：轉移性右下腹痛，持續性或陣發性右下腹或臍周痛，

噁心、嘔吐。體征：右下腹壓痛、反跳痛，有時不明

顯。

2 方法採用 GE LOGIO 9 及 LOGIO 5 彩色超聲診斷儀，凸陣低頻探頭及線陣高頻探頭相結合。檢查時患

者取仰臥位，個別病例加用左或右側臥位，先用低頻

凸陣探頭全面掃查右下腹，找到壓痛最明顯處，發現

可疑病變處繼而換用高頻線陣探頭緩慢逐級加壓多切

面掃查，詳細觀察病變的聲像圖表現，並拍片存檔。

結果

超聲診斷與病理結果對照見表。


177

表急性闌尾炎超聲診斷與病理結果對照分類總數

（n）診斷正

確（n）漏診

（n）準確率（%）

單純性闌尾炎 17 10 7 58.8% 化膿性闌尾炎 40 35 5 87.5% 壞疽性闌尾炎 3 3 0 100% 闌尾周圍膿腫 7 7 0 100%

不同病理類型的闌尾炎有著不同的聲像圖特徵。單純性闌尾炎 17 例：10 例可見或隱約可見闌尾呈盲管狀結構，無蠕動，輕度腫脹，管壁層次尚清，粘膜

層連續中斷或毛糙，4 例腔內有少量積液，1 例見腔內有糞石強回聲光團伴聲影。7 例未能顯示闌尾及異

常聲像。急性化膿性闌尾炎 40 例：35 例可見闌尾腫脹明顯，直徑 7-15mm，闌尾壁增厚，僵硬，漿膜毛糙回聲增強，腔內積液，6 例腔內見糞石強回聲光團伴聲影，4 例周邊見少量液性暗區。5 例未見明顯增粗的闌尾，僅見局部腸管少量積液。急性壞疽性闌尾

炎 3 例：闌尾因梗阻積膿，闌尾明顯腫脹變形不規則，直徑約 10-19mm，壁部分或全部壞死，結構消失，周圍被低及無回聲區包裹。闌尾周圍膿腫 7 例：表現為右下腹混合回聲包塊或較大範圍的游離的無回

聲區，周邊的腸管擴張，部分積液。

討論

正常闌尾發生於盲腸的尖端，長約 5-7cm，直徑約 0.5cm，腔狹小，遠側為盲端呈游離狀態，全部為腹膜所包被，並有一三角形的系膜，由於此系膜比闌

尾要短，從而導致闌尾不能完全伸直而呈捲曲狀，形

如蚯蚓。因它為一細長的游離盲管，故位置極不恒

定，以回腸前位、盆位、盲腸後位多見，其他有回腸

後位、盲腸下位及外位等，鑒於其位置多變，加上周

圍腸氣

示正常

近年也

98%[4-5

盲瓣順

腸尋找

顯示可

尤其是

大[5]。

圖 2 急性化膿性闌尾炎
圖 1 急性單純性闌尾炎圖 3 急性壞疽性闌尾炎炎
的

闌

有]。

鐘

闌

疑

第

我

圖 4 闌尾周圍膿腫

干擾，大部分學者認為超聲檢查一般難以顯

尾[3]。但隨著超聲儀器及診斷技術的發展，

部分學者提出正常闌尾的顯示率可達 61-作者提出了三種尋找闌尾的方法：即(1) 回轉向移動法；(2) 自上而下縱切升結腸、盲尾；(3) 右下腹麥氏點區及周圍任意掃查，闌尾斷面後兩端延伸尋找闌尾開口及盲端。

一種方法作者認為對提高闌尾顯示率幫助極

們在以往的工作中發現絕大多數的正常闌尾


178

難以顯示，尤其是肥胖及腸氣多的患者，作者提出的

方法值得我們在今後的工作中借鑒。急性單純性闌尾炎：系病變早期，管腔出現梗阻

因素，內壓升高，炎症從黏膜和黏膜下層開始，漸向

肌層和漿膜擴散。外觀主要改變是充血、輕度腫脹

(見圖 1)，表面附少量纖維素性滲出物，腔內可有少量積液。超聲僅表現為闌尾輕度腫脹，部分單純性闌

尾炎闌尾腫脹不明顯，腔內也無明顯積液，超聲檢查

可無陽性發現，本組有 7 例即為此種情況，此時超聲檢查的意義在於除外其他急腹症引起的右下腹痛，為

闌尾炎提供間接的參考依據，超聲檢查陰性不能除外

闌尾炎。急性化膿性闌尾炎闌尾顯著腫脹，漿膜高度

充血並有膿性滲出物附著，炎性反應直達肌層及漿膜

層，闌尾周圍的腹腔內可有膿性滲出液存留，形成局

限性腹膜炎。超聲表現為闌尾腫脹明顯，闌尾壁增

厚，僵硬，漿膜毛糙回聲增強，腔內積液(見圖 2)，如見到糞石對確定闌尾意義很大。其中 5 例未見明顯增粗的闌尾，僅見局部腸管少量積液，4 例為患者肥胖或腸道氣體多，1 例闌尾位置較深，為盲腸後位。急性壞疽性闌尾炎系一種重型闌尾炎，闌尾因內腔阻

塞、積膿、腔內壓力增高及闌尾系膜靜脈受炎性反應

波及而發生血栓性靜脈炎，均可引起闌尾管壁缺血壞

死，常有穿孔，並有較多滲出液。如果炎症繼續擴

散，可引起彌漫性腹膜炎,如發展速度較慢，闌尾穿孔後大網膜或腸管將闌尾包裹並形成粘連，出現炎性

包塊或闌尾周圍膿腫。超聲表現為闌尾明顯腫脹變形

不規則，壁部分或全部壞死，結構消失，周圍被低及

無回聲區包裹(見圖 3)。闌尾周圍膿腫表現為右下腹混合回聲包塊或較大範圍的游離的無回聲區，周邊的

腸管擴張，部分積液。急性壞疽性闌尾炎及闌尾周圍

膿腫超聲檢查容易發現混合性包塊(見圖 4)，但要注意與其他疾病鑒別，本組臨床懷疑闌尾炎的病例中有

一例發現右下腹混合性包塊及管狀低回聲區，手術結

果為橫結腸癌並穿孔。所以腫脹的闌尾要注意與腸管

鑒別，後者管徑較大，探頭加壓容易壓縮，可見腸蠕

動。本組病例中還有一例右下腹痛的急診患者超聲發

現腹腔有大片游離的液性暗區，但未發現腫大的闌

尾，經進一步探查發現為原發性肝癌破裂引起的腹腔

積血，後經 CT 及手術證實。另有一例闌尾輕度腫大的病例，周圍積液較多，手術後發現除慢性闌尾炎

外，還合併有小腸異物（魚骨）並穿孔。所以在發現

闌尾病變較輕或不明顯，而腹腔積液較多時，應想到

有其他病變的可能，以免誤診及漏診。另外，右下腹

痛也要注意排除其他原因，如右輸尿管結石、右側輸

卵管炎、卵巢囊腫蒂扭轉、宮外孕、黃體破裂等。超聲診斷急性闌尾炎的重要依據是超聲直接徵象

如闌尾腫脹，同時局部有明顯的壓痛，闌尾壁增厚，

結構紊亂，闌尾腔積液等。但由於闌尾的形態、大小

及位置都有較大的差異，加上腸腔氣體的干擾，超聲

容易出現假陰性或假陽性的結果。因此在檢查時應注

意結合間接徵象：如鄰近腸管的擴張積液，蠕動減弱

或消失，闌尾附近盆腹腔積液等，另外結合臨床也非

常重要。綜上所述，超聲方法簡便、無創、便於重複，急性

闌尾炎超聲的直接及間接徵象，能為其分型及病程進展

提供參考，在急性闌尾炎的診斷中具有重要作用。

參考文獻

1 夏穗生. 腹部外科急症診斷與治療. 第 1 版. 西安:世

界圖書出版社, 2002. 309. 2 Puylaert JBCM. Acute appendicitis: US evaluation using

graded compression. Radiology, 1986, 158:355-60. 3 王純正, 徐智章. 超聲診斷學. 第 2 版. 北京:人民軍

醫出版社, 2003. 368-370. 4 Lee JH. Operator-dependent techniques for graded

compression sonography to detect the appendix and to diagnose acute appendicitis. Am J Roentgenol, 2005, 184:91-97.

5 文革, 趙景亭, 劉小珍, 等. 成人正常闌尾的超聲檢查及臨床意義研究. 中國超聲醫學雜誌, 2008, 24:536-539.


179


肺结核外科疗效分析楊德康熊信國* 成向陽何建行

【摘要】目的分析研究近年來 40 例肺結核外科治療方法及療效。方法收治肺楔形切除術 15 例，肺段切除術 8 例，袖狀肺葉切除術 5 例，肺葉切除術 10 例，全肺切除 1 例，左主支氣管節段切除 1 例。觀察手術前後肺功能及血氣分析相關指標變化情況。結果無手術死亡，術後出現併發症 3 例，1 例為支氣管胸膜瘺，經Ⅱ期手術帶蒂大網膜覆蓋支氣管殘端治癒，另 2 例分別於手術後 12 個月及 18 個月時出現輕度吻合口狹窄。手術前後第 1 秒用力呼出量（FEV1）有顯著性差異,1 秒率（FEV1%），動脈血氧分壓（PaO2），及動脈二氧化碳分壓（PaCO2）則無顯著性差異。結論對於肺楔形切除者，切緣距離病灶應大於 1cm，對病灶範圍較廣泛者，宜作標準的肺段切除或肺葉切除。對於結核性支氣管狹窄應將狹窄阻塞性病變的支氣管連同受累肺葉一併切除。【關鍵詞】結核; 支氣管; 胸外科

Surgery for Pulmonary Tuberculosis YANG De Kang, XIONG Xin Guo*, CHENG Xiang Yang, HE Jian Xing. Department of Cardiothoracic Surgery , Guangzhou Institute of Respiratory Diseases, State Key Laboratory of Respiratory, Guangzhou, Guangdong Province, 510120, China; *Correspondent author: Department of Cardiothoracic Surgery , Guangzhou Institute of Respiratory Diseases, State Key Laboratory of Respiratory, Guangzhou, Guangdong Province, 510120, China; Tel: +(86-20)-8333 7750-7042; E-mail:[email protected].

【Abstract】 Objective To review the approaches and effect of surgery for 30 cases of pulmonary tuberculosis recently. Methods There were 15 cases of lung wedge resection ,8 cases of lung segment resection,5 cases of sleeve lobectomy, 10 cases of lobectomy, 1 case of pneumotomy, 1 case of left main bronchial reconstruction.Some related items of lung function test and blood gas analysis were observed before and after surgery. Results There was no mortality during operation, 3 cases of post surgery morbidities, 1 case of bronchopleural fistula, which has been cured through second surgery for bronchial stump covered with pedicled greater omentum, and the other 2 cases of anastomotic stenosis respectively 12 months and 18 months after surgery. There was significant statistical difference in first second force expiratory volume (FEV1) and no significant difference in FEV1%, partial pressure of oxygen (PaO2),and partial pressure of carbon dioxide ( PaCO2). Conclusions The wedge resection requires the resection margin more than 1 cm distance away from the lesion, and if the lesion is extensive, it is suggested of standard segment resection or lobectomy. It is recommended for tuberculosis bronchostenosis to accept the resection of bronchia with constrictive and obstructive disease, together with the involved lobe.

【Key words】 Tuberculosis; Bronchus; Thoracic surgery

肺結核發病呈逐年增多趨勢，單純內科治療面臨

的局限性亦日趨明顯，因此外科介入治療的指徵也隨

之不斷擴大[1]。外科治療不同類型，不同部位，不同

大小肺結核，有相應的多種具體手術方式需慎重選

擇，所以具體術式的適應證，手術技巧以及療效在不

斷深入研究中，在最大程度切除病灶以及最大程度保

存肺功能的目標前提下，綜合運用不斷改良成熟的肺

作者單位：510120, 中國, 廣州, 國家呼吸疾病重點實驗室, 廣州呼吸疾病研究所, 胸心外科; *通訊作者:510120, 中國, 廣州, 國家呼吸疾病重點實驗室, 廣州呼吸疾病研究所, 胸心外科; Tel: +(86-020)-8333 7750-7042; E-mail: [email protected]

段或肺葉切除技術，以達最佳遠期治療效果。近年我

們實施了肺結核病外科手術治療 40 例，分析總結如下：

資料和方法

1 一般資料 2004 年 1月至 2008 年 1月間收治老年肺結核患者 40 例，男性 28 例，女性 12 例。年齡 22－69歲，中位年齡 51 歲。有明確的肺結核或頸淋巴結結核病史者 23 例，佔 59%。


180

以咳嗽、氣促為主者 20 例，喘鳴為主 7 例，有咯血症狀 10 例。病程最長 8 年，最短 13月。曾誤診為外周肺癌 10 例，支氣管哮喘 8 例，支氣管擴張症4 例。

全組經 X 線胸片或胸部 CT 檢查，顯示類圓形

陰影 20 例，肺葉不張 12 例，不規則團塊狀陰影 8例。查痰抗酸桿菌陰性 31 例，陽性 9 例。術前經纖維支氣管鏡（纖支鏡）檢查，報告支氣管內膜結核

12 例，結核性肉芽腫 7 例，纖支鏡下見左主支氣管嚴重狹窄 1 例，以致纖支鏡不能通過，右主支氣管狹窄 3 例，有 21 例均見相應肺葉的支氣管開口不同程度的狹窄或閉塞。術前做過纖支鏡下狹窄部位鉗夾或

電燒灼術 6 例。1 例左主支氣管廣泛內膜結核，術前行纖支鏡放置支架，但支氣管狹窄仍進行性加重。全

組患者均經正規抗結核治療 3~6 個月。經 PET-CT 檢查 15 例，明確報告外周型肺癌 5 例，肺癌與結核瘤相鑒別 4 例，肺結核瘤 6 例。

術前及術後半年間觀察患者肺功能及血氣指

標，記錄第 1 秒用力呼出量（FEV1）， 1 秒率（FEV1%），動脈血氧分壓（PaO2），及動脈二氧化碳分壓（PaCO2）。肺功能檢測使用義大利科時邁（COSMED）Micro Quark 一體化肺測試儀，血氣分析使用Radiometerabl 520血氣分析儀。患者術後均接受隨訪 6月至 4 年，中位時間 2 年。 2 術中所見和手術方式

全組均以胸腔鏡輔助小切口完成手術，球形病

灶 23 例（57.5%），作距病灶緣 1cm 的楔形切除術15 例，另 8 例作規則的肺段切除術。不規則團塊病灶 10 例（25%），均施行肺葉切除術，病灶內有乾酪樣壞死 5 例（ 50%），合併化膿性改變 3 例（33.3%）。1 例左主支氣管中下段狹窄、左上下葉支氣管均通暢、肺無異常者，施行了左主支氣管中下段

節段切除，將左上下葉支氣管開口相對緣間縫合構成

大口，再與左主支氣管上端斷口端端吻合。左主支氣

管下段狹窄以及左上葉支氣管開口閉塞但左下葉支氣

管通暢 2 例，施行了袖狀左上肺葉切除，把左下葉支氣管與左主支氣管上段端端吻合。對右主支氣管下段

狹窄及右上葉支氣管開口狹窄或閉塞，但中間支氣管

通暢者 3 例，施行了袖狀右上肺葉切除，把中間支氣管開口與右主支氣管上段作端端吻合。單純中葉支氣

管開口閉塞並中葉不張 3 例，僅作右中肺葉切除。左主支氣管廣泛內膜結核且浸潤至肺葉支氣管 1 例，行左全肺切除術。全組病例均作術中冰凍病理檢查，均

報告符合結核病樣改變。

3 資料統計方法

手術前後肺功能及血氣指標採用配伍組設計，

計數資料採用 SPSS 13.0 統計分析軟體進行兩因素方差分析，P


181

討論

1 支氣管結核的診斷肺結核發病率有逐年增加趨勢，以結節性、團

塊性病灶為主要表現者極其容易與小肺癌或外周型肺

癌相混淆，而表現肺不張者，因其支氣管阻塞症狀酷

似中央型肺癌及支氣管哮喘，極易誤診[2-3]。我們認

為對於肺部結節性或團塊性病灶，應儘早選擇外科介

入，及時明確病理診斷。對有反復咳嗽、氣促、胸痛

和血痰症狀，胸片或CT檢查顯示肺不張或肺葉含氣不全者應及早作纖支鏡檢查。纖支鏡檢查對鑒別支氣

管結核和支氣管肺癌有獨特價值。儘管反復痰塗片及

培養抗酸桿菌陰性，但經纖支鏡抽吸、刷檢和灌洗等

手段檢查，陽性率高達 94%[4]。另有人提出，儘管纖支鏡下取活組織檢查報告為慢性炎症改變，經抗炎治

療 2~3 周，支氣管內膜病變無好轉，而改用抗結核治療後有好轉者，應及早考慮支氣管結核的可能。沒

有及時的正規抗結核治療，支氣管結核勢必遷延發

展，最後產生支氣管內膜瘢痕狹窄，這是不可逆性病

理改變，非手術治療難以改善氣道通氣。

2 手術指徵對於肺內直徑大於 2cm的結節性病灶積極進行

手術治療，目前已成共識[1]。而對於病灶肺的楔形切

除，我們主張切緣要距病灶有 1cm為妥，嚴防緊鄰病灶緣切削，甚至剔挖，嚴防切割縫合器切面貫穿病

灶，嚴防再在病灶上搔刮，以清除病灶。楔形切除不

完整是術後仍有較長時間咯血或血痰的主要原因。術中探查，一經證實病灶緊鄰段支氣管或葉支

氣管，應當機立斷作規則的標準肺段切除或肺葉切

除，規則的肺段切除要求清楚分離結紮肺段動靜脈，

穩妥結紮段支氣管，並經水試無漏氣為度，這是預防

術後咯血，遲發性咯血或血痰和支氣管胸膜瘺的有效

措施。支氣管內膜結核早期為炎症滲出期，此時常在

正規抗結核治療下好轉或治癒。如病情未能控制，即

進入潰瘍肉牙腫期。近年有報告在此期使用纖支鏡作

肉牙腫組織鉗夾取出，或鏡下電凝燒灼肉芽腫組織，

可使氣道通氣有所改善。有不少患者經上述治療，病

情時好時壞，最終走向瘢痕狹窄期。其支氣管彈性組

織嚴重破壞，纖維組織增生，管腔狹窄和阻塞，最後

產生了肺不張，或出現局限性肺氣腫，肺含氣不全。

反復出現阻塞性肺炎，繼而肺內出現小膿瘍，張力性

空洞和支氣管擴張症逐漸形成。因而，對於瘢痕狹窄

期支氣管結核，只要排除了機體內有活動性結核病

變，應及早手術治療[5]。本組病例術中所見，大部分

病變在主支氣管中下段。受累段支氣管管壁增厚，韌

實有竹節感。縱行切開管腔可見腔內呈環形狹窄，近

端口徑稍大，遠端口徑細小，呈錐管狀。病變多累及

葉支氣管開口，嚴重者可見葉支氣管開口呈針尖形狹

窄或完全閉塞。手術方法是將狹窄的主支氣管以及受

累肺葉袖狀切除，把正常肺葉的支氣管與主支氣管上

段端端吻合。本組均採用 4 號絲線或 3/0 prolene 線或用 3/0 單蕎線作全層間斷縫合，務求進針均勻，針距 1.5~2mm為宜。縫閉前應吸淨管腔內分泌物，必要時加用生理鹽水灌洗後吸淨。吻合畢，應仔細檢查

吻合口並用縱隔胸膜披蓋。本組 3 例術中懷疑吻合口不夠牢靠，使用奈維網包裹後並噴灑倍繡生物蛋白膠

加強。全組袖狀肺葉切除病例，無出現支氣管吻合口

瘺的併發症。對於病變嚴重的病例，如主支氣管�

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