经胸微创非体外循环下封堵室间隔缺损:多中心经验和近中期随访结果

目的 总结多中心应用食管超声引导、经胸微创小切口、非体外循环(CPB)下封堵室间隔缺损(VSD)的临床经验和近、中期随访结果.方法 432例病儿,男235例,女197例;年龄3个月～15岁,平均(3.2±1.9)岁;体重4.0～26.0 kg,平均(13.3±5.6)kg.膜周部VSD 351例,嵴上或嵴内型VSD 57例,肌部VSD 24例(17例多发VSD).VSD直径3～12 mm,平均(5.3±1.6)mm.膜周部VSD,经剑突下或胸骨下端3～4 cm小切口进胸;嵴内或嵴上VSD,经胸骨左缘第3肋间2～3 cm小横切口进胸.暴露右心室表面,在食管超声引导和实时监测下,穿刺右心室游离壁,导引钢丝经右心室腔穿过VSD到达左心室腔,沿导引钢丝导入输送鞘管建立轨道.通过输送鞘管直接将封堵器安放在VSD部位.经食管超声多切面反复评估封堵器的位置和与周边组织的关系,若无异常情况即可释放封堵器.结果 432例中417例封堵成功(96.5%),15例(3.5%)术中改为常规CPB手术.封堵成功者中,选用对称伞238例(57.1%),偏心伞179例(42.9%).13例(3.1%)发生新的微量至轻度三尖瓣反流,11例(2.6%)术后发生不完全右束支传导阻滞,3例(0.7%)术后发生一过性完全性房室传导阻滞.术后383例(91.8%)病儿在2 h内拔除气管插管,3～5天出院.术后416例(96.2%,416/432例)随访12～38个月,平均(19.3±11.6)个月,无近、中期死亡.1例术后6个月发生完全性房室传导阻滞.其余无明显异常.结论 应用食管超声引导、经胸微创非CPB下封堵VSD技术,是一种相对简单有效的治疗方法,近、中期临床结果满意,但远期结果需要进一步观察.

Abstract：

Objective Transesophageal echocardiography (TEE) guided, minimally invasive perventricular device occlusion of ventricular septal defects ( VSDs) without cardiopulmonary bypass ( CPB) has been applied in multiple centers. We reported experiences and the mid-term results. Methods Four hundred and thirty-two cases from 4 cardiac centers were involved in the study. There were 235 males and 197 females, aged from 3 months to 15 years, with a body weight varying from 4.0 to 26.0 kg. Three hundred and fifty-one patients had perimembranous VSDs, 57 had intracristal or supracristal VSDs and 24 had muscular VSDs (17 had multiple muscular VSDs). The diameter of the VSD ranged from 3 to 12 (5.3 ±1.6 ) mm.For those with perimembranous or muscular VSDs, a 3 to 5 cm inferior sternotomy was made, but for those with intracristal or supracristal VSDs, a 2 to 3 cm incision was made parastemally through the left third intercostal space. Being monitored and guided with TEE, the device was deployed to occlude the VSD through the puncture at the free wall of the right ventricle. TEE was used for assessing the residual shunting, the left and right ventricular outlet tracts, valvular function and for detecting any arrhythmia, The devices would be released if the heart rhythm was normal, as well as the residual shunting and valvular regurgilalion were not detected. Results The procedure was completed successfully in 417 cases(96.5% ) and converted to traditional surgical closure with CPB in the other 15 cases(3.5% ). Concentric devices were used in 238 cases(57.1% )and eccentric devices were used in 179 patients(42.9% ). Successful procedures finished in less than 90 minutes, and the deployment and evaluation of the devices were completed in 5 to 60 (18. 2 ± 8.6) minutes. No residual shunt and detectable aortic or tricuspid insufficiency and arrhythmia was observed. Patients were extubated within 2 hours and discharged 3 to 5 days after the operation. During fellow-up period from 3 months to 2 years, no clinically significant complications occurred. Conclusion The minimally invasive device closure of VSD under TEE guidance without CPB is proved to be a simple, safe and effective treatment for a considerable number of children with VSD. Its use in the clinical practice should be encouraged.     

腹腔镜手术治疗原发性醛固酮增多症227例

Objective To evaluate clinical significance of laparoscopic adrenalectomy for treatment of primary aldosteronism.Methods From Jan.1999 to Dec.2009,227 patients(92 males and 135 females)with a confirmed diagnosis of primary aldosteronism underwent laparoscopic adrenalectomy.The median age was 42years old,ranging from 22 to 69 years old.The median disease duration was 4.6 yeas,ranging from 2 months to 15 years.5 cases underwent peritoneal laparoscopic adrenalectomy and 222 cases underwent retropefitoneal laparoscopic adrenalectomy.All cases had hypokalemia,hpertension,high plasma aldosterone and low plasma rennin preoperatively.Of all the cases,there were 205 cases with aldosterone-producing adenomas among whom 80 cases underwent total adrenalectomy and 125 cases underwent partial adrenalectomy.There were 22 cases with unilateral adrenal hyperplasia and all of them underwent total unilateral adrenalectomy.Results Procedures were successfully performed in all the 227 cases.The operation duration ranged from 15 to 156 min(39 min as the median)and the blood loss ranged from 5 to 220 ml(20 ml as the median).The hospitalization time ranged from 5 to 9 days (6.9±1.2 days as the median).All the cases were followed up from 6 months to 2 years(1.2 years as the median).Postoperative potassium level resumed normal in all cases.Blood pressure resumed normal in 180 cases(80%).No adrenocortieal insufficiency and any other complication occurred.Conclusion Retropreitoneal laparoscopic partial or total adrenalectomy for treatment of primary aldosteronism is a safe and feasible procedure.     

不同类型尺骨鹰嘴骨折的内固定选择

Objective To discuss options of internal fixation devices for different types of olecranon fractures. Methods A retrospective analysis was done for 62 patients with olecranon fractures who had been treated in our department from February 2007 to November 2009. Of them, 36 cases were treated with tension band wiring (TBW) and 26 cases with plating. The differences between the 2 groups were compared according to Broberg and Morrey scales. Results The patients were followed up for 6 to 24 months (average, 11 months) . There were no significant differences between the 2 groups in terms of scores of Broberg and Morrey scales (χ2 = 1. 484, P =0. 361 ) . There were 5 losses of reduction in the TBW group while there were 2 cases of myositis ossificans in the plating group. Conclusions Internal fixation by TBW is preferred in the majority of patients with simple olecranon fractures. Dorsal plating is particularly indicated in the comminuted fracture and fracture dislocations.     

自体肺动脉补片主动脉弓成形治疗婴儿主动脉缩窄合并弓发育不良

Objective To discuss the operative techniques and results of coarctation resection plus aortoplasty with pulmonary autograft patch for coarctation of the aorta combined with hypoplastic aortic arch in infant.Methods Between May 2007 and Dec 2009,14 cases including 9 males and 5 females with caorctation of the aorta and hypoplastic aortic arch underwent coarctation resection plus aortoplasty with pulmonary autograft patch in our hospital.The age ranged from 23 days to 17 months,with a median of 4.33 months.The mean body weight was (6.14 ±2.36) kg.All patients were diagnosed as aortic coarctation combined with VSD and hypoplastic aortic arch.The surgery was performed under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion in 8 cases and circulation arrest in 6 cases.Fresh pulmonary autograft patch harvested from the main pulmonary artery was used for aortoplasty.The associated VSD was repaired in the same stage.Results All patients survived except one died from circulatory failure during the perioperative period.Low cardiac output syndrome occurred in another case who was cured afterwards by correspondent treatments.No residual obstruction was detected by echocar-diography after the operation.Follow-up was carried out in 13 cases from 4 months to 3 years.Echocardiographic examination showed that the pressure gradient across the aortic arch was less than 16 mm Hg in all cases.The blood velocity at the descending aortic arch was not significantly changed during the follow-up period as compared with that of the immediate after operation.Computed tomography showed that the morphology of aortic arch was normal.The left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before operation,and no aortic aneurysm were detected in these patients.Conclusion Conclusion Coarctation resection plus aortoplasty with pulmonary autograft patch is the optimal surgical method for treating coarctation of the aorta combined with hypoplastic aortic arch in infant.     

自体肺动脉补片主动脉弓成形治疗婴儿主动脉缩窄合并弓发育不良

Objective To discuss the operative techniques and results of coarctation resection plus aortoplasty with pulmonary autograft patch for coarctation of the aorta combined with hypoplastic aortic arch in infant.Methods Between May 2007 and Dec 2009,14 cases including 9 males and 5 females with caorctation of the aorta and hypoplastic aortic arch underwent coarctation resection plus aortoplasty with pulmonary autograft patch in our hospital.The age ranged from 23 days to 17 months,with a median of 4.33 months.The mean body weight was (6.14 ±2.36) kg.All patients were diagnosed as aortic coarctation combined with VSD and hypoplastic aortic arch.The surgery was performed under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion in 8 cases and circulation arrest in 6 cases.Fresh pulmonary autograft patch harvested from the main pulmonary artery was used for aortoplasty.The associated VSD was repaired in the same stage.Results All patients survived except one died from circulatory failure during the perioperative period.Low cardiac output syndrome occurred in another case who was cured afterwards by correspondent treatments.No residual obstruction was detected by echocar-diography after the operation.Follow-up was carried out in 13 cases from 4 months to 3 years.Echocardiographic examination showed that the pressure gradient across the aortic arch was less than 16 mm Hg in all cases.The blood velocity at the descending aortic arch was not significantly changed during the follow-up period as compared with that of the immediate after operation.Computed tomography showed that the morphology of aortic arch was normal.The left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before operation,and no aortic aneurysm were detected in these patients.Conclusion Conclusion Coarctation resection plus aortoplasty with pulmonary autograft patch is the optimal surgical method for treating coarctation of the aorta combined with hypoplastic aortic arch in infant.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

Hybrid procedure with cardiopulmonary bypass for muscular ventricular septal defects in children

Objective: To summarize the technique and clinical experience of the hybrid procedure with cardiopulmonary bypass in children with muscular ventricular septal defect (mVSD). Methods: From January 2006 to June 2010, 45 cases of mVSD underwent hybrid procedures with cardiopulmonary bypass (CPB) under the guidance of transesophageal echocardiography. mVSDs were closed with devices under direct vision in the 45 cases. Fourteen patients had another lesion that required surgical repair. Large membranous VSDs were closed with a pericardial patch after the initiation of CPB in 38 cases. Results: Out of the 45 cases, 42 had only one occluder and three had two occluders. The size of the device for mVSD closure ranged from 3 to 8 mm. All cases recovered smoothly after treatment without residual shunting, aortic or mitral valve regurgitation, or restriction of surrounding structures. All the children survived the operation with no late deaths during the follow-up. Conclusion: The hybrid procedure is safe and effective for the closure of congenital heart defects in children.     

食道超声引导下小切口室间隔缺损封堵术的疗效分析

目的评估食道超声引导下小切口室间隔缺损(室缺)封堵术的疗效。方法 2008年10月～2009年6月,45例先天性室间隔缺损患儿,男27例,女18例,平均年龄3.5岁(14个月～11岁),平均体重16.8 kg(9～30 kg)。经胸心脏超声显示室间隔缺损,8例为嵴内型,36例为膜部型(其中6例伴有膜部瘤形成),1例为肌部型。缺损直径3～10 mm,平均4.5mm。气管插管全身麻醉后,经胸骨下段正中切口,长3～5 cm。在食道超声的引导下,经右室游离壁置入腰部直径5～16 mm的国产室缺封堵器。结果 45例均成功封堵,无中转体外循环病例。42例术后无残余分流,3例封堵后即刻超声示少量残余分流,术后5天复查超声示分流消失。2例术后心电图示右束支传导阻滞,无Ⅲ度房室传导阻滞发生,余43例术后心电图无异常改变。术后住院时间3～7 d,平均4.4 d。随诊3～6个月,1例术后1个月大量心包积液,经心包穿刺后痊愈,余44例均恢复良好,无Ⅲ度房室传导阻滞,无残余分流,无封堵器晚期移位,无瓣膜关闭不全加重。结论食道超声引导下小切口室缺封堵术创伤小,安全性高,近期疗效满意。     

Outcomes of intraoperative device closure of muscular ventricular septal defects

BACKGROUND: The surgical management of muscular ventricular septal defects (mVSD) in the small infant is a challenge particularly when multiple and associated with complex cardiac lesions. Devices for percutaneous implantation have the advantage of ease of placement and for the double umbrella designs a wide area of coverage. We reviewed our experience and clinical outcomes of intraoperative mVSD device closure for such defects in small infants. METHODS: Since October 1989, intraoperative VSD device closure was a component of the surgical strategy in 14 consecutive patient implants (median age, 5.5 months; range, 3 to 11 kg), whose defects were thought difficult to approach using conventional techniques. Nine patients had associated complex cardiac lesions, 10 multiple mVSDs, and 4 patients had a previous pulmonary artery banding. RESULTS: There were 2 early deaths, 1 in a severely ill child who preoperatively had pulmonary hypertension and left ventricular failure and another in a patient with a hypoplastic left heart. Mean pulmonary to systemic flow ratio before device insertion was 3.5:1. Complete closure was achieved in 5 patients and clinically insignificant residual shunts persisted in 7. In 2 infants with significant residual lesions concomitant pulmonary artery banding was required. Postoperative mean pulmonary to systemic flow ratio was 1.7:1. In follow-up of the 12 surviving infants (mean, 41 months), 8 had complete closure and 3 persistent residual shunts. One patient with no residual shunting required heart transplantation for progressive ventricular failure 9 years after operation. All devices were well positioned on postoperative echocardiograms. There was 1 late death due to aspiration in a patient with a tiny residual shunt. CONCLUSIONS: Infants requiring operative intervention with mVSDs are difficult to manage and have an increased mortality and morbidity. Intraoperative VSD device placement for closure of mVSDs is feasible, can avoid ventriculotomy, division of intracardiac muscle bands, and is ideally suited for the neonate or infant.     

经食管超声心动描记术在先天性心脏病镶嵌治疗中的应用

目的观察TEE在非体外循环下先天性心脏病镶嵌治疗中的临床应用价值。方法回顾性分析167例TTE初筛拟行先天性心脏病镶嵌治疗的患者,术前TEE检查进一步筛选患者,指导选择适当封堵器,术中TEE监测引导置入封堵器并评价其疗效。结果本组167例中,24例房间隔缺损(ASD)和121例室间隔缺损(VSD)成功完成镶嵌治疗,1例ASD和5例VSD术后即刻TEE可见一丝残余分流,术后3个月复查1例ASD和4例VSD残余分流消失,1例VSD右心室流出道血流速度稍加快,1例VSD术前无主动脉瓣反流,术后出现轻-中度反流。3例ASD和9例VSD镶嵌治疗不顺利,转体外循环。对1例ASD和2例VSD由于缺口过小而放弃治疗。7例VSD合并主动脉瓣脱垂直接放弃镶嵌治疗,转修补术。结论在非体外循环下先天性心脏病的镶嵌治疗中,TEE能为选择适应证和封堵器提供技术支持,实时监测指导及评价手术,降低手术风险,提高手术成功率。     

Successful repair of a traumatic ventricular septal defect using an amplatzer occluder guided by three-dimensional transesophageal echocardiography

Transesophageal echocardiogram (TEE) guided perventricular cardiac intervention has gained popularity in recent years. We present a special case of perventricular closure conducted for a traumatic apical muscular ventricular septal defect (mVSD) under the guidance of three-dimensional (3D) TEE with an Amplatzer mVSD occluder and further discuss the important role of 3D TEE in perventricular cardiac intervention.     

经食管超声心动图在机器人心脏手术中的应用

目的探讨经食管超声心动图(transesophageal echocardiography,TEE)在机器人体外循环心脏手术中的应用价值。 方法对110例心脏病患者在机器人体外循环术中行TEE检查,体外循环转机前评估心脏病变,验证经胸超声心动图(transthoracic echocardiography,TTE)结果,根据结果协助手术医师进一步确定手术方案。建议外周体外循环过程中,TEE引导下腔静脉插管(经股静脉)、上腔静脉插管(经右侧颈内静脉)。心脏复搏后,TEE评估手术疗效、手术并发症、排气情况。将其结果进行回顾性分析。 结果本组患者全在机器人下完成手术,其中2例中转右前外侧切口。体外循环转机前TEE诊断与TTE结果有7例不相符,经术中证实TEE准确性100%。TEE引导所有下、上腔静脉插管成功,成功率100%,体外循环过程中无静脉引流不畅。心脏复搏后2例室间隔缺损有残余分流、1例二尖瓣成形后仍有中度反流、1例主动脉瓣置换术后瓣周漏,经再次阻断处理后均取得满意效果。其余患者手术疗效确切,术后再次TTE证实无手术相关并发症。 结论TEE在机器人体外循环术中能提高手术成功率及安全性,是有效的术中诊断手段。     

腔镜在小儿肿瘤治疗中的应用

目的探讨腔镜手术治疗小儿肿瘤的可行性、安全性、有效性。方法 2001年1月～2009年3月,应用腔镜手术治疗小儿肿瘤45例,男27例,女18例。年龄28天～12岁(1岁12例,≥5岁6例),肿瘤直径2～15cm。对良性肿瘤及囊性肿瘤大小不作限制;对恶性实体肿瘤,选择直径5cm者应用腔镜进行切除。良性肿瘤35例:甲状腺肿瘤4例,腹部畸胎瘤2例,卵巢囊肿13例,肠系膜淋巴管瘤1例,肠系膜囊肿1例,腹膜后巨大囊肿1例,肾上腺腺瘤6例,胰腺囊肿1例,胰腺胰岛素瘤1例,肾囊肿2例,纵隔肿瘤3例,肿瘤直径3～15cm,(7.3±2.8)cm;恶性肿瘤10例:肾上腺神经母细胞瘤2例,肾母细胞瘤2例,腹部恶性畸胎瘤2例,纵隔恶性畸胎瘤1例,肺转移肿瘤3例,肿瘤直径2～5cm,(4.2±0.9)cm。均通过腔镜行肿瘤切除术,术中冰冻病理确诊,对良性肿瘤实施肿瘤完整切除,对恶性肿瘤采用根治性切除。结果 45例全部手术成功,无中转开放手术,无不能完整切除者。手术时间30～185min,(112.6±41.7)min。出血量5～50ml,无输血病例。手术后第1～3天进食水,住院时间平均3～10d(6.5±2.5)d。术后无并发症发生。无围手术期死亡。术后病理回报肿瘤切除完全,边缘无肿瘤组织残留。术后随访6个月～8.5年,35例良性肿瘤均健康生存,无肿瘤复发;10例恶性肿瘤中8例仍健康生存,2例肝母细胞瘤肺转移患儿术后5、10个月因多发转移死亡。结论应用腔镜手术治疗小儿良性、囊性肿瘤及直径5cm的恶性实体肿瘤可行、安全、有效。     

婴幼儿血管环外科诊治

目的 总结婴幼儿先天性血管环外科诊治的临床经验.方法 2009年9月至2010年12月诊断并手术治疗14例血管环患儿,其中男9例,女5例;年龄2月～6岁;体重4.5～15.0 kg.所有病例术前均行X线胸片、超声心动图及增强多排螺旋CT检查确诊,行食管造影及纤维支气管镜检查各5例.病理类型包括双主动脉弓1例、肺动脉吊带7例、右位主动脉弓伴左位动脉导管/韧带6例,7例患儿合并心内畸形.全组患儿存在不同范围(12％～62％)和程度(45％～74％)的气管狭窄,5例术前存在局限性食管狭窄.12例患儿在体外循环下手术同期矫治心内畸形,2例在非体外循环下手术.结果 术后辅助呼吸7～ 308 h,中位数21 h;ICU停留16 ～314 h,中位数79.5 h.1例肺动脉吊带患儿住院死亡(7.1％).13例出院.失访1例,12例随访1～ 15个月,患儿消化道症状消失,活动耐力改善.呼吸道症状不同程度缓解,5例(41.7％,5/12例)仍然存在呼吸道症状.结论 临床上对有长期呼吸道和(或)消化道症状的患儿需考虑血管环的可能,增强CT是确定血管环诊断的最佳方法.血管环应尽早手术治疗,合并的长段气管狭窄需手术治疗,近-中期效果良好.     

"缘对缘"瓣膜成形术在先天性心脏病合并重度三尖瓣关闭不全中的应用

目的 总结运用"缘对缘"成形技术治疗先天性心脏病病人的重度三尖瓣关闭不全的效果.方法 2001年4月至2010年3月,对14例先大性心脏病合并重度三尖瓣关闭不全病人采用常规三尖瓣瓣环成形和"缘对缘"技术行三尖瓣成形.年龄7～62岁,平均(31.2±16.1)岁.先大性心脏畸形包括继发孔房间隔缺损6例,房室管畸形5例,继发孔房间隔缺损合并二尖瓣关闭不全2例,三房心1例.结果 14例出院时均无不适,无住院死亡及术后并发症.术后超声心动图检查示三尖瓣关闭不全无或微量11例,轻度3例.随访3～97个月,平均(51.6±26.8)个月.随访时超声心动图检查示均无三尖瓣狭窄,三尖瓣关闭不全无或微量5例,轻度8例,中度1例.结论 "缘对缘"成形技术纠治先天性心脏病合并重度三尖瓣关闭不全简单、有效.