通力协作、共同提高脊柱转移瘤的治疗水平

转移瘤是脊柱最为常见的恶性肿瘤。常因椎体和附件的广泛破坏导致脊柱不稳，引起临床上难以处理的疼痛；若侵犯椎管压迫脊髓，将会严重损害患者的神经功能，患者只能长期卧床，严重影响生活质量。对脊柱转移瘤既往多采用保守治疗，然而长期卧床会导致各种并发症。临床上部分晚期肿瘤患者的死亡多是由各种并发症所致。近年来，随着肿瘤综合治疗的广泛开展，恶性肿瘤患者的生存期明显延长；我国人口逐渐老龄化，使晚期恶性肿瘤患者相应增多。     

褥疮的中医护理进展

褥疮是临床高位截瘫、晚期痛症及其他病情危重等长期卧床患者的常见并发症，也是护理工作中较棘手的问题。祖国医学在治疗和预防褥疮方面有其独到之处，现综述如下。     

晚期恶性肿瘤患者的护理关怀

我国现有癌症患者700多万，每年新增200万以上，其中50％为晚期肿瘤，伴随出血、厌食、呕吐、疼痛等并发症的发生，长期手术和放化疗治疗使患者本人遭受极大的身心损害和经济负担的压迫，且随时可能发生死亡。本文统计了我院20年来各科收治的恶性肿瘤患者1774例，其中晚期恶性肿瘤826例，现对其治疗情况及晚期护理情况做一总结。     

全膝关节置换术后并发症的现状与进展

人工全膝关节置换术（Total KneeArthropl asty,TKA）能非常有效地根除晚期膝关节病痛,恢复膝关节功能以及提高患者生活质量,现已被认为是成功的外科手术之一[1]。长期的研究已经证明了TKA良好的生存率,但其并发症种类繁多,发生率不尽相同,本文就其主要并发症的作一综述。     

老年结直肠癌患者的围手术期处理

老年结直肠癌患者多伴有重要脏器病变,各系统功能低下,由于晚期和进展期病例多,合并内科疾病和肠梗阻者较多,使患者对麻醉和手术的耐受性降低,术后并发症和病死率增加。因此我们就老年结直肠癌患者围手术期常见的并发症处理进行探讨。贫血与营养不良:老年结直肠癌患者因长期慢性失血、消耗和毒素因子破坏造血功能而导致贫血和营养不良,贫血可以导致细胞代谢障碍、器官功能障碍,直接影响病人的手术耐受力、术后切口愈合、组织的修复与器官功能的恢复,增加并发症的发生与死亡率的提高。文献报道高龄结直肠癌病人营养不良发生率达85%,因此术前…     

法洛四联症根治术后远期心脏结构功能异常与肺动脉瓣置换术

法洛四联症(TOF)是1岁以上病儿中最常见的紫绀型先天性心脏病[1].TOF术前诊断、手术技术和围手术期处理技术不断进步,不仅近期疗效满意,长期随访也表明,术后20年的生存率在90%以上[2-4],术后40年的生存率仍能达到76%[5].但以持续的肺动脉瓣反流为核心的一系列远期并发症正逐渐显现.现围绕法洛四联症根治术远期疗效做综述如下.     

不同年龄组儿童法洛四联症根治术治疗效果比较

目的 比较不同年龄组儿童法洛四联症手术根治效果,为探讨法洛四联症最佳手术时间提供依据.方法 1990年1月至2006年12月545例儿童法洛四联症接受根治手术,按手术年龄分为1岁以下婴儿组(114例)、1～5岁幼儿组(326例)和5岁以上儿童组(105例).3组进行围术期情况、术后近期病死率、并发症发生率比较.对包括107例1岁以下婴儿在内的479例法洛四联症术后病儿进行了1个月～16年随访,对3组残余心脏畸形发生率、活动能力及心律失常发生率进行比较.结果 3组围术期情况无统计学差异.术后早期病死率和并发症发生率分别为4/114例、14/326例、4/105例(P＞0.05)和17/110例、58/312例、20/101例(P＞0.05).术后室性心律失常发生率分别为20.9%、30.7%和39.0%(P＜0.05).长期随访各组生存率差异无统计学意义,最大活动能力婴儿期接受手术法洛四联症病儿约为正常同龄儿童(82.2±5.5)%.结论 不同年龄组儿童法洛四联症根治术生存率和并发症发生率相似,术后随访心功能均良好.婴儿期手术能更早建立正常肺血流、改善缺氧情况和降低远期室性心律失常的发生.因此法洛四联症病儿最佳根治年龄应在1岁以内.     

SKY骨扩张器椎体后凸成形术在老年胸腰椎骨折患者中的应用

随着社会的老龄化,骨质疏松导致的老年人椎体压缩性骨折发生率逐年增多。传统的治疗方法是卧床休息及对症处理。由于其病程长易造成患者心肺、消化、泌尿系统并发症和生活质量下降。长期卧床易导致骨质进一步脱钙而疏松,形成恶性循环。而开放性的手术治疗,也因患者骨质疏松和全     

法洛四联症合并一侧肺动脉缺如的手术治疗

目的报告法洛四联症合并一侧肺动脉缺如的外科治疗。方法８例法洛四联症合并一侧肺动脉缺如患者，左侧肺动脉缺如７例，右侧肺动脉缺如１例；其中２例肺动脉闭锁。６例行一期根治术，２例先行体－肺动脉分流术，再分别于术后８个月和１１个月行二期根治术。６例应用带单瓣补片跨瓣加宽右心室流出道，２例采用右心室到肺动脉带瓣管道。结果全组术后出现呼吸衰竭２例，低心排血量综合征３例；其中１例死于心力衰竭，死亡率１２．５％。７例长期存活者术后随访０．５～５．０年，平均２．５６年，无晚期死亡，心功能Ⅰ级６例，心功能Ⅱ级１例。结论法洛四联症合并一侧肺动脉缺如根治术时，必须严格掌握手术适应证，右心室流出道跨瓣补片应带单瓣     

160例肺癌患者射频消融术后并发症分析

目的探讨射频消融术治疗晚期非小细胞肺癌并发症的发生情况,并分析其防治方法。方法收集2004年6月~2013年12月间住院的晚期非小细胞肺癌患者160例,均行射频消融术治疗,观察患者并发症发生情况并分析降低其发生率的方法。结果 160例晚期非小细胞肺癌患者均顺利完成射频消融治疗,无术中死亡患者。术后并发症包括发热、胸痛、气胸、胸腔积液、出血、咯血、肺炎、膈神经损伤和空洞等,经对症处理后均好转,患者可耐受。结论射频消融术治疗晚期非小细胞肺癌安全、有效,但也会引起并发症。预防并发的发生症对提高晚期非小细胞肺癌患者生活质量有临床意义。     

First pulmonary valve replacement with Freedom Solo stentless valve in an adolescent. A case report

Tetralogy of Fallot (TOF) is a common form of cyanotic heart disease. Complete surgical correction in younger age group offers good long-term results with reasonable morbidity and improved prognosis in patients with TOF. However, following corrective surgery pulmonary valve replacement (PVR) might be required for residual pulmonary regurgitation in order to avoid irreversible right ventricular remodeling. Otherwise, residual uncorrected pulmonary regurgitation may lead to right ventricular dilatation, impaired biventricular function, ventricular arrhythmias and limited exercise capacity. We report the first case of Freedom Solo stentless valve (Sorin Group, Saluggia, Italy) implantation in the pulmonary position in an adolescent with severe pulmonary insufficiency 12 years after the repair of TOF. Pericardial stentless valves may be an alternative choice for pulmonary valve replacement to improve right ventricular contractile recovery and remodeling after PVR and may have impact on long-term survival.     

Extracorporeal membrane oxygenation for circulatory support after repair of congenital heart defects

Extracorporeal membrane oxygenation was used for cardiovascular support in 13 infants and children with complex congenital heart disease and 1 premature neonate treated in preparation for pericardial patch tracheoplasty for long-segment tracheal stenosis. Nine patients were weaned from extracorporeal membrane oxygenation. There were five (36%) early deaths and four (29%) late deaths. Cannulation sites included right carotid/jugular vessels, femoral artery and vein, and right atrium and aorta. In 4 patients, the neck vessels were repaired at decannulation. Five survivors had normal growth and neurodevelopmental evaluations at follow-up. Extracorporeal membrane oxygenation can be successfully used as biventricular support in patients with intractable low cardiac output syndrome after repair of congenital heart disease. Best results are obtained in patients who have several hours of stability after operation before initiation of support. Hemorrhagic complications are reduced and long-term neurodevelopmental outcomes appear promising with right neck vessel cannulation and repair. No bleeding complications were observed in patients cannulated through the neck vessels.     

Tetralogy of Fallot: perioperative anesthetic management of children and adults

Tetralogy of Fallot (TOF) is a common congenital heart defect in children. Perioperative considerations include preoperative preparation for surgery, intraoperative anesthetic management, and common postoperative issues in the intensive care unit. Surgical debates have shifted away from 2-stage versus single-stage repairs to debates of how surgery to limit pulmonary insufficiency (PI) may have significant long-term impact as the child grows. There are many adult survivors of TOF repair in infancy who now present with a unique set of problems related to PI and right ventricular dysfunction. These adults provide new insights into congenital heart disease (CHD) and how management strategies early in life may have significant implications much later in life. Patients with complex CHD should have lifelong follow-up, so our knowledge will continue to improve, and the best possible care can be provided for these patients.     

Complete repair of tetralogy of Fallot in the neonate: results in the modern era

OBJECTIVE: To review more than a decade of experience with complete repair of tetralogy of Fallot (TOF) in neonates at the University of Michigan; to assess early and late survival, perioperative complications, and the incidence of reoperation; and to analyze patient, procedural, and morphologic risk factors to determine their effects on outcome. SUMMARY BACKGROUND DATA: Palliation of TOF with systemic-to-pulmonary artery shunts has been the accepted standard for symptomatic neonates and infants. Complete repair has traditionally been reserved for infants older than 6 months of age because of the perception that younger and smaller infants face an unacceptably high surgical risk. RESULTS: A retrospective review from August 1988 to November 1999 consisted of 61 consecutive symptomatic neonates with TOF who underwent complete repair. Thirty-one patients had TOF with pulmonary stenosis, 24 had TOF with pulmonary atresia, and 6 had TOF with nonconfluent pulmonary arteries. The mean age at repair was 16 +/- 13 days, and the mean weight was 3.2 +/- 0.7 kg. Before surgery, 36 patients were receiving an infusion of prostaglandin, 26 were mechanically ventilated, and 11 required inotropic support. Right ventricular outflow tract obstruction was managed with a transannular patch in 49 patients and a right ventricle-to-pulmonary artery conduit in 12. Cardiopulmonary bypass time averaged 71 +/- 26 minutes. Hypothermic circulatory arrest was used in 52 patients (mean 38 +/- 12 minutes). After cardiopulmonary bypass, the average intraoperative right/left ventricular pressure ratio was 55% +/- 13%. There were no new clinically apparent neurologic sequelae after repair. The postoperative intensive care unit stay was 9.1 +/- 8 days, with 6.8 +/- 7 days of mechanical ventilation. There was one hospital death from postoperative necrotizing enterocolitis on postoperative day 71 and four late deaths, only one of which was cardiac-related. Actuarial survival was 93% at 5 years. Follow-up was available for all 60 hospital survivors and averaged 62 months (range 1-141 months). Twenty-two patients required a total of 24 reoperations at an average interval of 26 months after repair. Indications for reoperation included right ventricular outflow tract obstruction (19), branch pulmonary artery stenosis (11), severe pulmonary insufficiency (4), and residual ventricular septal defect (1). The 1-month, 1-year, and 5-year freedom from reoperation rates were 100%, 89%, and 58%, respectively. CONCLUSIONS: Complete repair of TOF in the neonate is associated with excellent intermediate-term survival. Although the reoperation rate is significant, this is to be expected with the complex right ventricular outflow tract and pulmonary artery anatomy seen in symptomatic neonates and the need for conduit replacement in patients with TOF with pulmonary atresia.     

Early replacement of pulmonary valve after repair of tetralogy: is it really beneficial?

OBJECTIVES: Debate on the proper timing of pulmonary valve replacement (PVR) after repair of tetralogy of Fallot (TOF) is still continuing. Significant pulmonary regurgitation (PR) could result in right ventricular (RV) dysfunction, exercise intolerance, arrhythmia, and sudden death. We analyzed clinical results of PVR after repair of TOF to investigate potential risk factor for late outcomes. METHODS: From January 1993 to July 2002, 58 patients (38 males and 20 females) received PVR after repair of TOF. More than moderate degree of PR was observed in these patients by echocardiography. Mean age at PVR was 13.5+/-9.6 years (1.2-44) and TOF repair was performed at 5.2+/-7.1 years of age (0.5-34). Therefore, PVR was performed at 8.3+/-5.2 years (4 months-28 years) after repair. Preoperative electrocardiogram showed complete right bundle branch block in 49 patients (84.5%). Mean duration of QRS complex was 142+/-30 ms. Major arrhythmia occurred in eight patients. Twenty-nine patients complained decreased physical activity and 10 patients showed clinical signs of right heart failure. RESULTS: Early death occurred in one patient (2.5%). Major complication occurred in three patients (complete heart block in two, aortic rupture in one). Follow-up was performed for 2.5+/-2.4 years (46 days-10.3 years). There was no late death. Postoperative cardiothoracic ratio was significantly decreased (0.61+/-0.07 to 0.55+/-0.06, P < 0.001). Marked symptomatic improvement was noted in all patients. Postoperative symptomatic group (n = 14) showed older age at repair of TOF (12.5+/-10.7 vs 2.6+/-2.3 years, P = 0.003), older age at PVR (23.2+/-12.8 vs 10.1+/-5.0 years, P = 0.001), longer interval between repair of TOF and PVR (10.6+/-7.0 vs 7.5+/-4.2 years, P < 0.05), higher degree of functional class (2.4+/-0.5 vs 1.4+/-0.8, P < 0.001), and longer duration of hospitalization (30.0+/-14.2 vs 18.9+/-11.4 days, P = 0.004) than postoperative asymptomatic group (n = 43). CONCLUSIONS: In patients with significant PR after repair of TOF, PVR had clinical benefits including symptomatic improvement with low mortality and morbidity. Proper timing must be carefully selected according to objective evaluation of RV function. In our study, earlier PVR prior to symptomatic manifestation showed beneficial effects.     

Complete repair of tetralogy of Fallot in infancy

We reviewed our long-term results of complete repair of tetralogy of Fallot (TOF) in infant. One hundred and sixty infants diagnosed as TOF underwent complete repair between January 1990 and April 2002. Mean age at the operation was 8.1+/-2.6 months. Correction was accomplished through a short right ventriculotomy of less than 30% of the ventricular height in all patients. A transannular patch was used in 78 patients (49%). There were four early deaths and no late death. Follow-up was complete in all survivors. All patients are currently in New York Heart Association functional class I or II. Actuarial freedom from reoperation at 1 and 10 years were 94.0 and 87.5%, respectively. Echocardiographic studies at follow-up showed excellent right ventricular function in most patients. Our results suggest that early complete repair of TOF yielded acceptable results with low mortality and morbidity. Transventricular repair of intracardiac pathology can be safely applied to yield good postoperative right ventricular function.     

法洛四联症矫治术后远期肺动脉瓣关闭不全的治疗进展

随着外科、麻醉、灌注及围术期处理技术的不断发展,法洛四联症(TOF)行常规矫治手术的手术死亡率低于2%～3%,而远期预后越来越受到关注,其中远期肺动脉瓣反流是困扰心脏外科医师和影响患者预后的重要因素;由此带来的右心室扩张、右心室功能不全、致死性心律失常等直接影响患者的生存质量和术后远期生存率。目前,对肺动脉瓣反流的治疗方法包括肺动脉瓣置换术(PVR)、介入治疗、镶嵌治疗等,PVR是治疗肺动脉瓣反流的主要方法,该方法能明显改善患者的心功能和临床症状,延长患者的生存时间;介入治疗因不需要行再次开胸手术,减少了手术创伤和手术风险,而且能改善右心室压力、肺动脉瓣反流程度,使许多患者受益。我们对TOF矫治术后远期肺动脉瓣反流的病理生理改变、PVR的手术指征、肺动脉瓣反流临床治疗进展和早期防治进行综述。     

Dilatation of ascending aorta in patients with repaired coarctation

The long-term outcome following repair of typical aortic coarctation in adulthood may be complicated by disorders of the ascending aorta. Follow-up averaging 15 years revealed a 3.8% incidence of dilatation of the ascending aorta after such late repair. Hypertension and concomitant aortic valvular disease were common in these patients. Aortic dilatation can appear years after coarctation repair, irrespective of the operative technique and its success, and can lead to death from aortic dissection or rupture of an aortic aneurysm. Careful follow-up after coarctation repair in adulthood is advisable to detect late aortic complications.     

Complete repair of Tetralogy of Fallot with absent pulmonary valve including the role of airway stenting

Tetralogy of Fallot (TOF) with absent pulmonary valve (APV) represents an extreme form of tetralogy where pulmonary insufficiency and mild annular stenosis often results in massive pulmonary arterial (PA) dilatation. The aneurysmal left and right PAs often compress the adjacent trachea and bronchi, leading to airway obstruction and respiratory failure in infancy. Between 1991 and 1997, 11 patients underwent a single stage repair of TOF and APV using a valved (10 patients) or nonvalved (1 patient) homograft conduit and PA reduction arterioplasty. There was one (1/11 [9.1%) perioperative and one (9.1%) late death. Both deaths were related to airway complications. Morbidity associated with postoperative respiratory complications and ventilator-dependency due to underlying tracheobronchomalacia is an important problem. Intermediate follow-up shows a high incidence of reintervention for conduit stenosis and/or insufficiency and tracheobronchial compression. These infants also required multiple hospitalizations for recurrent respiratory infections secondary to their tracheobronchomalacia. Stenting of the right and left main bronchi with balloon expandable metallic stents is a new experimental therapy that has been useful in two recent patients with respiratory failure despite satisfactory intracardiac repair. It may provide an attractive alternative therapy to prolonged mechanical ventilation with positive end expiratory pressure in patients with severe tracheobronchomalacia. Complete repair with a valved homograft conduit and reduction pulmonary arterioplasty in infancy at the time of diagnosis is the procedure of choice for infants with TOF with APV. With this approach the patient outcome is essentially determined by their airway status and airway management.     

Surgical correction of tetralogy of Fallot in a 61-year-old patient

Tetralogy of Fallot (TOF) is a congenital heart disease that is usually diagnosed and treated during infancy. Only 3% of such patients reach the age of 40 without surgery. We describe a 61-year-old woman with uncorrected TOF that was successfully treated by radical surgery. The patient presented with exertional dyspnea, insomnia, and malaise. Echocardiography and cardiac catheterization indicated a dilated, severely hypertrophic right ventricle, ventricular septal defect, an overriding aorta, and infundibular stenosis in the right ventricular outflow tract. All symptoms disappeared after full surgical correction, which remains the preferred treatment for adult TOF because it confers long-term survival and an improved quality of life.