非返性喉返神经的术前诊断与术中保护

目的总结甲状腺手术术前判定和术中识别及保护非返性喉返神经的经验。方法回顾性分析2009年1月至2012年12月收治的1358例甲状腺手术患者的临床资料,探讨非返性喉返神经的术前判定和术中识别及保护技巧。结果所有患者术前均行颈部增强CT,术中常规暴露喉返神经,其中有4例术前颈部增强CT提示食管后方异常的右锁骨下动脉,术中在正常位置未见喉返神经,均证实为非返性喉返神经,平均手术时间为95min,平均失血量为56ml,术后发音良好,双侧声带活动正常。结论术前颈部增强CT发现食管后方异常右锁骨下动脉,高度提示右侧非返性喉返神经存在,术中仔细操作,有助于避免损伤。     

Risk of brain tumors in children and susceptibility to organophosphorus insecticides: the potential role of paraoxonase (PON1)

Prior research suggests that childhood brain tumors (CBTs) may be associated with exposure to pesticides. Organophosphorus insecticides (OPs) target the developing nervous system, and until recently, the most common residential insecticides were chlorpyrifos and diazinon, two OPs metabolized in the body through the cytochrome P450/paraoxonase 1 (PON1) pathway. To investigate whether two common PON1 polymorphisms, C-108T and Q192R, are associated with CBT occurrence, we conducted a population-based study of 66 cases and 236 controls using DNA from neonatal screening archive specimens in Washington State, linked to interview data. The risk of CBT was nonsignificantly increased in relation to the inefficient PON1 promoter allele [per PON1(-108T) allele, relative to PON1(-108CC): odds ratio (OR) = 1.4; 95% confidence interval (CI), 1.0-2.2; p-value for trend = 0.07]. Notably, this association was strongest and statistically significant among children whose mothers reported chemical treatment of the home for pests during pregnancy or childhood (per PON1(-108T) allele: among exposed, OR = 2.6; 95% CI, 1.2-5.5; among unexposed, OR = 0.9; 95% CI, 0.5-1.6) and for primitive neuroectodermal tumors (per PON1(-108T) allele: OR = 2.4; 95% CI, 1.1-5.4). The Q192R polymorphism, which alters the structure of PON1 and influences enzyme activity in a substrate-dependent manner, was not associated with CBT risk, nor was the PON1(C-108T/Q192R) haplotype. These results are consistent with an inverse association between PON1 levels and CBT occurrence, perhaps because of PON1's ability to detoxify OPs common in children's environments. Larger studies that measure plasma PON1 levels and incorporate more accurate estimates of pesticide exposure will be required to confirm these observations.     

Minimally-invasive parathyroidectomy: a good operative procedure for primary hyperparathyroidism even without the use of intraoperative parathyroid-hormone assessment or a gamma probe

OBJECTIVE: To evaluate the results of minimally-invasive parathyroidectomy without the use of intraoperative parathyroid-hormone assessment or a gamma probe. DESIGN: Retrospective. METHODS: In 2 community hospitals in the Netherlands, 49 patients with primary hyperparathyroidism in whom preoperative investigations had shown a solitary adenoma underwent minimally-invasive surgery by the lateral neck approach. In total 9 men and 40 women with an average age of 58 years (limits: 25-84) underwent this procedure. More extensive preoperative investigations were carried out at the Mesos Medisch Centrum (n = 29) including neck CT in 76% of patients as well as ultrasonography, and scintigraphy. At the Diakonessenhuis (n = 20) scintigraphy was the preferred method of adenoma localisation. Intraoperative parathyroidhormone assessment and a gamma probe were not used in the operative procedure. At the Diakonessenhuis intraoperative frozen-section investigations were done. RESULTS: In 44 of the 49 patients (90%) minimally-invasive parathyroidectomy resulted in normocalcaemia. In the remaining 5 patients a second procedure was necessary--a conventional neck exploration and also resulted in normocalcaemia. In 2 of these patients the adenomas had been missed during first procedure by the surgeon, while in 3 other patients preoperative examinations were falsely positive in the sense that the adenoma proved to be present but in an area other than that indicated by preoperative imaging. Permanent recurrent laryngeal-nerve paralysis complicated the postoperative course in 2 patients. The success rate of the minimally-invasive operation was the same for both groups. CONCLUSION: Without the use of intraoperative parathyroid-hormone assessment or a gamma probe minimally-invasive parathyroidectomy was successful in 90% of patients.     

459例神经鞘瘤多发部位临床分析

目的研究神经鞘瘤的流行病学和不同部位分布情况,为防治这一临床常见软组织肿瘤提供参考资料。方法统计本院2002年1月-2012年6月住院手术并经过病理学证实的459例神经鞘瘤患者的流行病学和治疗学资料,按照流行病学、各部位发病率等进行分别统计。结果神经鞘瘤男女比例为1：1．20,颅神经鞘瘤发病率占全身发病率的53．59％,颅神经发病中桥小脑角占86．99％。椎管内神经鞘瘤排第2位。占神经鞘瘤全身发病率的40．52％,颈椎、胸椎和腰椎为56：49：58,即发病顺序为颈椎〉腰椎〉胸椎〉其他。病理上可见多种改变。如坏死、囊变、液化和细胞丰富等。结论神经鞘瘤是一种常见的住院治疗疾病．通过流行病学的统计可对神经鞘瘤的发病率和分布情况进行了解,同时认为颅神经鞘瘤最为常见,其次为颈椎神经并以颈椎为主。     

Postoperative radiotherapy in patients with salivary duct carcinoma: clinical outcomes and prognostic factors

This study sought to investigate the clinical outcome and the role of postoperative radiotherapy for patients with salivary duct carcinoma (SDC) who had undergone surgery and postoperative radiotherapy. We performed a retrospective analysis of 25 SDC patients treated between 1998 and 2011 with surgery and postoperative radiotherapy. The median prescribed dose was 60 Gy (range, 49.5–61.4 Gy). The clinical target volume (CTV) was defined as the tumor bed in four patients, the tumor bed and ipsilateral neck in 14 patients, and the tumor bed and bilateral neck in six patients. Local control (LC), disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and prognostic variables were analyzed with the log-rank test. The 5-year LC, DFS and OS were 67%, 45% and 47%, respectively. Disease recurrence was found in 12 patients: seven as local, four as regional and eight as distant failure. Perineural and lymphovascular invasion was a significant prognostic factor for LC (P = 0.03). Local failure was common, and the presence of local recurrence significantly affected the OS (P < 0.05). We conclude that surgery and postoperative radiotherapy is expected to decrease the risk of local failure and contribute to good prognoses for patients with SDC. It might be advisable to have the CTV include the cranial nerves involved and the corresponding parts of the skull base in cases of pathologically positive perineural invasion.     

Management of metastases to the lymph glands of the neck.

The survival rate of matched pairs of patients, one patient in each pair being submitted to prophylactic neck dissection, the other to a policy of "wait and see" has been measured: there was no significant difference in the survival rates of the two groups. Surgery for most patients with a gland in the neck gives better results than radiotherapy, and can produce satisfactory results with such procedures as supraglottic laryngectomy to epiglottic tumours and replacement with the deltopectoral flap for tonsillar tumours. On the other hand, surgery is probably contraindicated for patients with antral carcinoma and a gland in the neck, whom it rarely cures. Surgery does not increase the survival of patients with bilateral glands in the neck (except those with supraglottic tumours) and its contraindicated. Surgery can prolong the survival of patients with nodes fixed to the skin, the mandible or the external carotid artery, and may occassionally cure such patients.     

正中神经双卡综合征的围手术期康复治疗

目的介绍三级序贯式康复治疗在正中神经双卡综合征围手术期的应用。方法自2005年2月到2009年2月,应用以理疗、手法治疗,注射及小针刀微创治疗,开放手术为阶梯的三级序贯式康复治疗方案,对42例正中神经双卡综合征患者进行围手术期康复治疗。结果42例正中神经双卡综合征的患者中,10例经颈部理疗、手法椎孔外颈神经松解完全治愈。有18例经颈部理疗、手法治疗未完全好转,再行腕管糖皮质激素注射,10例治愈,其余8例行腕管小针刀微创切开治愈。8例先行腕管糖皮质激素注射未完全治愈,再经颈部非手术松解3周治愈。6例腕管综合征,手术切开减压,术后12周手麻未完全缓解,改颈部康复治疗后4周痊愈。结论正中神经双卡综合征首选非手术治疗,当非手术治疗失败或症状比较严重时应及时手术治疗。过于积极的手术减压不一定能达到预期的疗效,应用围手术期三级序贯式康复治疗方案,可以使早期患者免于手术,晚期患者免于两次手术,减少医疗风险。     

Pain and dysphagia in patients with squamous carcinomas of the head and neck: the role of perineural spread

Clinical and pathological features of perineural spread have been investigated in patients with squamous carcinomas at several sites in the head and neck. In 100 surgical cases, the clinical and pathological findings were congruent in 76%. Combined clinical and histological evidence of perineural invasion was recorded in 33% and the overall incidence of nerve involvement detected morphologically was 44%. Perineural infiltration was demonstrated histologically in 51% of major excisions from the buccal cavity and in 34% of resections from the oropharynx, hypopharynx and cervical oesophagus. The neurological findings were dominated by hypoaesthesia, dysaesthesia and referred pain – mainly in the territories of cranial nerves V and IX. Multiple and/or sequential nerve involvement was occasionally seen. No correlation was established between nerve invasion and metastasis to regional lymph nodes. Long-distance infiltration of nerve trunks, and multiple involvement, are grave prognostic features.

In 17 terminal patients submitted to autopsy, 65% had combined clinical and pathological evidence of perineural spread and the overall incidence of nerve involvement detected morphologically was 88%. Sensory changes again predominated. Multiple nerve involvement was observed in 35%. An apparently new `dysphagia syndrome' is described in 4 patients with oropharyngeal carcinomas in whom gross mechanical obstruction was simulated by a combination of perineural spread of tumour into the ipsilateral vagal trunk, sometimes accompanied by segmental infarction, variable invasion of the sympathetic chain, and `splinting' of the pharynx by local fibrosis and tumour in the soft tissues of the neck. Short-term palliation was achieved in these patients with high-dose steroids.

     

Pediatric Hydatidosis in Iranian Referral Pediatrics Center

Background

Hydatidosis is one of the major zoonotic diseases that cause considerable public health problems in Iran. The present study was designed to investigate pediatric hydatidosis in patients referred to the Children Medical Center Hospital in Tehran, Iran during 2005-2010.

Methods

Data were collected from the records of 17 patients referred to the center with hydatidosis. Data included demographic data; laboratory results, type, and site of cysts, clinical manifestations, and treatment.

Results

Nine patients were boys (52.9%) and eight (47.1%) were girls. Most patients referred from central areas of Iran (58.8%). Seven patients had cysts in their lungs (41.2%) and three cases (17.6%) in liver. Six cases (35.3%) had simultaneous lung and liver cysts, 3 patients (17.6%) had brain cysts (alone or in combination with other organs involvement) and 2 patients (11.7%) showed multi-organ involvement. All patients were treated by albendazole and underwent surgery, recurrence was seen in 4 (23.5%) of the cases and one patient died due to rupture of the cyst and anaphylactic shock.

Conclusion

Multi-organ involvement seems to be on the rise in children, this has led to the necessity for physicians to be more aware of clinical features, search, and rule out other organs for involvement diagnosis once a cyst is detected in one organ.     

Cerebral stereotactic biopsy and surgery: Report of 100 cases

OBJECTIVE: To report the results of the use of the stereotactic techniques in the management of intra cranial lesions. MATERIALS AND METHODS: Between july 1994 and march 1998, we carried out 117 stereotactic procedures of whom only 100 cases were analyzed. All the procedures were achieved after a CT scan. Patients were separated in two groups: (A) stereotactic biopsy (91 patients), (B) surgery with laser guidance (9 patients). The mean age in group A was 38 years (2-75 years) versus 27 years (11-66 years) in group B. The sex-ratio was 1.3. RESULTS: In the group A, the correct pathological diagnosis was obtained in 91.2% of cases. Glial tumors was the frequent histopathological variety of tumor (67.47%). Only one patient was operated after biopsy for a bilateral meningioma of the anterior 1/3 of the falx. There was only one death (1.09%) and 3.29% of transitory complications. In the group B, all patients were operated with laser guidance. Thirty seven per cent of patients underwent radiotherapy after the stereotactic biopsy or surgery. CONCLUSION: Stereotactic biopsy is a reliable method for the histopathological diagnosis of deep-seated brain lesions. Surgery with laser guidance is a useful alternative for the management of small deep-seated lesions or lesions located in functional areas.     

双侧甲状腺乳头状癌手术治疗方法的探讨

目的 探讨双侧甲状腺乳头状癌的手术治疗方法.方法 回顾性分析55例双侧甲状腺乳头状癌患者的临床资料.行双侧甲状腺全切除术52例,行一侧腺叶全切除+对侧近全切除术3例.结果 双侧功能性颈淋巴结清扫术中,5例均见双侧颈淋巴结转移,阳性率为100.0%(5/5);单侧功能性颈淋巴结清扫术中,9例见颈淋巴结转移,阳性率为81.8%(9/11).双侧中央区淋巴结清扫术中,1例见中央区淋巴结转移,阳性率为25.0%(1/4);单侧中央区淋巴结清扫术中,14例见中央区淋巴结转移,阳性率为66.7%(14/21).术后随访0.5～12.9年,53例无瘤生存,2例伴远处转移者也取得良好效果.结论 双侧甲状腺乳头状癌为多发癌,宜行双侧甲状腺全切除术.应结合患者的肿瘤分期,考虑是否行颈淋巴结清扫术.     

Eyelid drooping: diagnosis on the basis of an algorithm

Five patients presented with eyelid drooping (blepharoptosis). A 26-year-old man with oculomotor disorders without anisocoria and a slow progressive course without fluctuations had a myogenic condition. His diplopia was alleviated by prism glasses. Surgical correction of the ptosis was planned. An 81-year-old man in whom the symptoms showed a course that varied over time had a disordered neuromuscular transmission that responded well to pyridostigmine. A 57-year-old man with oculomotor disorders and a dilated pupil on the affected side had an injury to the oculomotor nerve (and other cranial nerves), which remained stable after endovascular treatment of the causative aneurysm. A 22-year-old man had a constricted pupil (Horner's syndrome) and pain in the head and neck due to dissection of the internal carotid; his symptoms disappeared spontaneously. A 34-year-old woman had an isolated ptosis due to detachment of the aponeurosis of the M. levator palpebrae superioris following the chronic use of hard contact lenses; she was advised as to how to remove the lenses cautiously, to prevent further detachment. Eyelid drooping can have many causes. A systematic arrangement of the information gathered by a careful medical history and neurological examination often provides a reasonably accurate indication of the possible causes of the complaints.     

Retrospective study of 167 ovarian tumors

OBJECTIVE: Our purpose was to assess clinical particularities, diagnosis and therapeutic problems of ovarian tumors. STUDY DESIGN: A retrospective study of 156 patients having undergone an operation for ovarian tumor not suspected to be malignant between january 1991 and june 1998. The clinical, ultrasonographic and tumor marker data were analysed. RESULTS: Mean age of our patients was 34 years. 19 patients were menopausal. All ovarian masses were considered as benign at ultrasonographic scan. Serum CA125 level was measured in 42 cases. It was abnormal in 2 cases. 102 patients underwent laparotomy. 54 patients underwent laparoscopy, of these, 19 were converted to laparotomy due to a suspect macroscopic diagnosis (2 cases) or to technical difficulties (13 cases). Histological findings were 150 benign ovarian tumors, 12 fonctional cysts and 5 malignant ovarian tumors. Therefore, preoperative assessment had failed diagnosis of cancer in 5 cases. CONCLUSION: The clinical, ultrasonographic and tumor markers triad remains the best preoperative approach currently available for ovarian tumors. However, the final diagnosis remains histological.     

Early hypothyroidism after subtotal thyroidectomy in patients with Graves' disease--the role of the preoperative conservative treatment and hormonal status

AIM: The aim of the present study was to evaluate the role of the preoperative antithyroid drug treatment and hormonal status in the development of early postoperative hypothyroidism after subtotal thyroidectomy in patients with Graves' disease. MATERIAL AND METHODS: Eighty-five patients with Graves' disease (males : females ratio 1:5.54, age range 19 to 64, 37.52 +/- 1.09 yrs) who had previously undergone surgical treatment were enrolled in the study. All patients underwent bilateral subtotal thyroidectomy with the amount of remnant tissue of 2-3 g for each lobe (total 4-6 g). Development of early (within one year after the operation) postoperative hypothyroidism was analyzed regarding the type of the antithyroid drug, preoperative dose, duration of the preoperative medical treatment, FT3, FT4, FT3/FT4 and hTSH. RESULTS: Forty six percent of all examined patients (54.12%) were euthyroid and 39 (45.88%/)--hypothyroid. Postoperative hypothyroidism was developed by 33.33% of the patients that had received preoperatively propylthiouracil compared with 50.82% of those treated with methymazol (p > 0.05). The duration of the preoperative treatment was 38.36 +/- 3.53 months for the hypothyroid patients and 30.11 +/- 2.34 months for the euthyroid patients (p < 0.05). Postoperative hypothyroidism developed in 58.70% of the patients with preoperatively suppressed thyroid-stimulating hormone (hTSH) and in 33.33% of those with normalized values of hTSH (p < 0.05). No statistically significant between-group difference was found in the preoperative dose of antithyroid agent, mean values of free triiodothyronine (FT3), free thyroxine (FT4), FT3/FT4, thyrotropic hormone (TSH). CONCLUSIONS: Longer preoperative antithyroid drug treatment and suppression of hTSH in the preoperative period correlated with higher risk of hypothyroidism after subtotal thyroidectomy. The type and the preoperative dose of the antithyroid agent, as well as the mean values of thyroid hormones before the operation have no prognostic significance for postoperative thyroid hypofunction.     

Section of Ophthalmology: Meeting Held at Manchester Royal Eye Hospital: Isolated Oculomotor Palsy Caused by Intracranial Aneurysm

The present paper is concerned with the 55 aneurysms out of a total of 158 that caused isolated paralysis of the oculomotor nerve. The majority arose from the internal carotid artery after it had pierced the dura (supraclinoid). Rarely the aneurysm sprang from the basilar artery. In two-thirds of the cases there had been a subarachnoid hæmorrhage from leakage. Not more than 10% of patients had arteriosclerosis. Calcification of the sac is not a sign that the aneurysm has thrombosed. The only certain way of demonstrating the position and size of an intracranial aneurysm is by arteriography, which is a safe procedure.The correct treatment is by carotid ligature. In about 8% of normals the circle of Willis is incomplete, therefore percutaneous compression must first be tried. The only fatalities from ligature were in persons in the acute stage of subarachnoid hæmorrhage, not from meningeal bleeding alone. In this type of case a clip applied to the neck of the sac is probably a better method. In the more usual cases where the hæmorrhage has been spontaneously arrested common carotid ligature in the neck is probably a little safer than intracranial clipping.     

Carotid endarterectomy for women and men

Carotid endarterectomy is the standard of care for people with severe symptomatic carotid stenosis. We analyzed population administrative data and clinical trial data to determine whether sex differences exist in the use and outcomes of this surgical procedure. We studied patients in Ontario who underwent carotid endarterectomy between 1982 and 1994 (n = 12,949) and patients with severe carotid stenosis who were enrolled in two randomized trials of endarterectomy (n = 1646). We compared the proportion of men and women who underwent carotid endarterectomy in each group, over time, and after adjustment for demographic factors. Men were twice as likely as women to receive carotid endarterectomy in the administrative analysis (65% versus 35%, p < 0.001) and in the clinical trial analysis (70% versus 30%, p < 0.001). The relatively lower use in women was consistent in every age group and in every year studied. Men in the administrative database were somewhat less likely than women to die or be institutionalized after surgery (5% versus 6%, p = 0.007). Men in the clinical trial database were also less likely than women to experience perioperative stroke or death, although the results were not statistically significant (6% versus 7%, p = 0.32). Patients who were assigned to surgical therapy, compared with those assigned to medical therapy, had a significant decrease in the risk of adverse events at 1 year, and the net benefit appeared similar in women and men. Carotid endarterectomy is performed relatively infrequently on women despite their similar lifetime burden of disease and similar short-term perioperative risks compared with men.     

胰岛细胞瘤25例外科诊治分析

目的探讨胰岛细胞瘤的临床诊断和外科治疗方法。方法对某院2001.1~2010.12收治的胰岛细胞瘤25例患者的临床资料进行回顾,结合相关文献进行诊治分析。结果 25例患者中,非功能性胰岛细胞瘤12例,功能性胰岛细胞瘤13例。肿瘤位于胰头7例,胰颈4例,胰体尾14例。肿瘤直径0.5~20cm。13例功能性胰岛细胞瘤均有Whipple三联征。全部病例术前均行B超和/或CT检查,7例术前行DSA检查。25例患者均行手术治疗,单纯肿瘤切除16例,胰体尾部切除5例,胰体尾切除加脾切除2例,胰颈部切除1例,瘤灶切除后十二指肠修补+旷置+胰头-十二指肠空肠壁吻合1例。术后发生胰漏1例。全部患者治愈出院。结论 NIT无特异临床表现,但影像学检查能较有效检出。FIT临床主要表现为典型的Whipple三联征。CT和DSA是有效的术前定位方法。手术切除是胰岛细胞瘤治疗的最佳选择。     

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND: Malnourished head and neck cancer patients are at increased risk of postoperative complications. OBJECTIVE: We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery. DESIGN: Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding. RESULTS: Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died. CONCLUSIONS: Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.     

Training in cognitive-behavioural therapy for mental health professionals: a pilot study of videoconferencing

A foundation course in cognitive-behavioural therapy (CBT) was developed specifically for delivery via videoconferencing at 256 kbit/s. A two-part, 20-week programme was evaluated at seven sites, with a total of 12 participants, in rural and remote Western Australia. Eleven of the participants completed a pre- and post-training knowledge test. There was a significant improvement in their knowledge of CBT after training. Ten participants also completed a satisfaction questionnaire. The majority were satisfied with the training they received and stated that the training had given them greater confidence in their ability to use CBT with their patients. This study lends support to the use of videoconferencing in the training of rural and remote mental health practitioners.