33例新生儿先天性膈疝

目的 分析新生儿先天性膈疝的临床表现及诊治经验,以提高先天性膈疝病婴手术成功率及生存质量.方法 回顾性分析2004年1月至2009年9月新生儿重症监护室收治的33例先天性膈疝新生儿临床表现及治疗结果.结果 33例先天性膈疝中21例行手术治疗,术后生存17例,其中4例产前经超声检出者术后均生存.死亡4例,死因与肺发育不良有关.12例未行手术者全部死亡,其中1例生后即刻死亡.结论 新生儿先天性膈疝的病死率较高,应加强产前诊断及产科、新生儿科、小儿心胸外科的合作以提高先天性膈疝病婴的生存率.

Abstract：

Objective To review the clinical experience of diagnosis and treatment of the congenital diaphragmatic hernia in newborn infants. Methods Thirty-three neonates were diagnosed having congenital diaphragmatic hernia in our hospital from Jan. 1,2004 to Sept. 30, 2009. The clinical data was retrospectively reviewed. Results 21 cases were treated surgically and 17 survived, while 4 cases died. The main cause of death was congenital pulmonary dysplasia. Another 12 cases refused to accept surgical treatment and they all died, one died shortly after he was born. Four cases who had been diagnosed by prenatal ultrasonography were survived. Conclusion The mortality of congenital diaphragmatic hernia in neonates was still high. Prenatal diagnosis of the congenital diaphragmatic hernia is very important and the cooperation between the obstetrics, neonatology and cardiothoracic surgery will improve the survival rate of congenital diaphragmatic hernia in newborn infants.     

Pathomorphological changes after liver impact imjury in rabbits

Objective:To investigate the histopathological changes in the liver and other organs after impact injury.Methods:The rabbits were impacted with a BIM-IVbiological impacting machine at the xiphoid process.The sverith of liver injury was graded and scored through gross anatomy,At the same time,the pathological changes in the liver,heart,and lung were observed by light and electron microscopes.Results:Light microscopy showed that the pathological changes in the liver were:1)loss of normal stucture,hemorrrhage and distortion of hepatic logbles;2)cloudy swelling,degeneration,vacuolation and necrosis of liver cells;3) infiltration of neutrophils,The lungs were injured and there were liver cell emboli in the small pulmonary arteries.Electron microscopy showed that the ultrastructure of the liver cells was severely damaged and the cells had significant features of necrosis.Conclusions:the maior pathomorphological changes in the liver after impact injury are hemorrhage and necrosis.They may be compilcated by exfolistion of liver cells to hepatic sinusoids.These cells circulate with the blood to form emboli in the pulmonary blood vessels.     

锂剂促进周围神经损伤修复的初步研究

目的 探讨锂剂对周围神经损伤后神经再生的影响.方法 取48只雌性SD大鼠,制作大鼠右侧坐骨神经损伤动物模型,通过腹腔注射氯化锂,在不同时间点观察动物下肢活动情况,检测小腿三头肌神经电生理及肌湿重,并对损伤远端神经纤维的神经丝蛋白(NF200)、单核巨噬细胞抗原(ED1)、P-75和运动终板进行免疫组织化学染色观察.结果 损伤后4周,实验组动物下肢已接近正常行走步态,对照组右侧肢体仍明显跛行;损伤后2周和4周,实验组的复合肌肉动作电位(CMAP)波幅较对照组明显增大,两组间的差异有统计学意义(P＜0.05);损伤后4周、8周,实验组的小腿三头肌重量较对照组明显增大,两组间差异有统计学意义(P＜0.05);损伤后3 d,在距离损伤远端5 mm处,实验组坐骨神经纤维内NF200呈连续丝状染色,而对照组仍然是颗粒状染色;损伤后4周,在神经肌肉接头处,可观察到实验组肌肉运动终板有新生神经纤维支配,而对照组运动终板上无神经纤维支配,两组ED1及P75染色未见明显差别.结论 锂剂可有效促进周围神经损伤后的再生,但其机制仍需进一步研究.

Abstract：

Objective To evaluate the effect of lithium on nerve regeneration after peripheral nerve injury.Methods Sciatic nerve crash injury model was created on the right side of 48 female SD rats.Lithium was administered after the injury by intraperitoneal injection.Locomotion of the lower limbs, electromyography and wet muscle weight of the triceps muscles were measured at different time points after the injury.Changes of NF200, ED1, P-75 and motor end plate at the distal part of the injured nerve were detected by immunohistostaining.Results Four weeks after sciatic nerve crash injury, animals that received lithium injection restored near normal gait, whereas the control animals were limping.Two and four weeks after the injury, the lithium injection group had significantly higher CMAP amplitude than the control group.Four and eight weeks after the injury, the wet muscle weight in lithium injection group was significantly heavier than the control group.Three days after crush injury, continuous NF200 positive fibers were found 5 mm distal to the injury site in the lithium injection group, whereas in the control group, only granular NF200 positive staining was observed Four weeks after crush injury, new innervations to the motor end plate were detected in the neuromuscular junction in the lithium injection group, but not in the control group.No differences in ED1 and P75 staining were detected.Conclusion Lithium could significantly promote axon regeneration after peripheral nerve crush injury.Its mechanism is subject to further investigation.     

吸入性损伤患者早期气管切开拔管时机及后期并发症分析

Objective To investigate the appropriate extubation time and treatment of late complications after early tracheotomy in patients with moderate or severe inhalation injury. Methods One hundred and fifty patients ( 105 males and 45 females) with inhalation injury were admitted to our hospital from January 2000 to January 2009. Among them, 109 out of 129 cases with moderate inhalation injury received early tracheotomy, and all 21 cases with severe inhalation injury received early tracheotomy. Data were collected for analysis as follows: ( 1 ) incidence of re-intubation due to suffocation and pneumonia incidence after extubation within 2 weeks or after 2 weeks post inhalation injury (PⅡ), and mortality rate within the first week after injury were recorded. (2) Conservative treatments including expectorant, oral antibiotics, and absolute bedrest were recommended for patients who had severe cough, hoarseness or poor pulmonary function after late extubation and closure of tracheostomy wound. Fiberoptic bronchoscopy findings ( tracheostenosis degree, granuloma formation rate, vocal cord paralysis rate) and pulmonary function index ( FEV1 ) data were collected and analyzed in 30 cases with moderate inhalation injury and 10 cases with severe inhalation injury within 3 months after injury for follow-up. Data were processed with t test or chi-square test. Results There was no obvious difference in the rate of re-intubation after extubation in patients with moderate inhalation injury between those done within 2 weeks PⅡ ( 15/70, 21.4% ) and those done after 2 weeks PⅡ (2/25, 8.0% ) ( x 2 = 1.52, P ＞ 0.05 ). Pneumonia incidence in patients of moderate inhalation injury with extubation within 2 weeks PⅡ (21/70, 30.0% ) was lower than those with extubation after 2 weeks PⅡ (15/25, 60.0% ) (x 2= 7.04, P ＜ 0.05). Levels of above-mentioned indexes in patients with severe inhalation injury extubated in diffferent stages were similar to those of patients with moderate inhalation injury.Within the first week after injury, mortality rate of patients with severe inhalation injury was higher than that of patients with moderate inhalation injury ( x 2 = 11.90, P ＜ 0.05 ). During follow-up, tracheostenosis rate in patients with moderate or severe inhalation injury was 100.0%; granuloma formation rate and vocal cord paralysis rate in patients with severe inhalation injury were higher than those of patients with moderate inhalation injury ( with x 2 value respectively 4.59, 13.47, P values all below 0.05 ). The FEV1 value of patients with moderate inhalation injury in the 1st, 2nd, 3rd month after injury was respectively higher than that of patients with severe inhalation injury ( with t value respectively 5.48, 12. 10, 6.25, P values all below 0.05). The values recovered to normal level in the 3rd month after injury. Conclusions Extubation time of tracheotomy for patients with moderate or severe inhalation injury within 2 weeks or after 2 weeks PⅡ has its own advantage and disadvantage, and it should be performed according to specific conditions of each patient. Conservative treatment is optional for late complications of respiratory system.     

吸入性损伤患者早期气管切开拔管时机及后期并发症分析

Objective To investigate the appropriate extubation time and treatment of late complications after early tracheotomy in patients with moderate or severe inhalation injury. Methods One hundred and fifty patients ( 105 males and 45 females) with inhalation injury were admitted to our hospital from January 2000 to January 2009. Among them, 109 out of 129 cases with moderate inhalation injury received early tracheotomy, and all 21 cases with severe inhalation injury received early tracheotomy. Data were collected for analysis as follows: ( 1 ) incidence of re-intubation due to suffocation and pneumonia incidence after extubation within 2 weeks or after 2 weeks post inhalation injury (PⅡ), and mortality rate within the first week after injury were recorded. (2) Conservative treatments including expectorant, oral antibiotics, and absolute bedrest were recommended for patients who had severe cough, hoarseness or poor pulmonary function after late extubation and closure of tracheostomy wound. Fiberoptic bronchoscopy findings ( tracheostenosis degree, granuloma formation rate, vocal cord paralysis rate) and pulmonary function index ( FEV1 ) data were collected and analyzed in 30 cases with moderate inhalation injury and 10 cases with severe inhalation injury within 3 months after injury for follow-up. Data were processed with t test or chi-square test. Results There was no obvious difference in the rate of re-intubation after extubation in patients with moderate inhalation injury between those done within 2 weeks PⅡ ( 15/70, 21.4% ) and those done after 2 weeks PⅡ (2/25, 8.0% ) ( x 2 = 1.52, P ＞ 0.05 ). Pneumonia incidence in patients of moderate inhalation injury with extubation within 2 weeks PⅡ (21/70, 30.0% ) was lower than those with extubation after 2 weeks PⅡ (15/25, 60.0% ) (x 2= 7.04, P ＜ 0.05). Levels of above-mentioned indexes in patients with severe inhalation injury extubated in diffferent stages were similar to those of patients with moderate inhalation injury.Within the first week after injury, mortality rate of patients with severe inhalation injury was higher than that of patients with moderate inhalation injury ( x 2 = 11.90, P ＜ 0.05 ). During follow-up, tracheostenosis rate in patients with moderate or severe inhalation injury was 100.0%; granuloma formation rate and vocal cord paralysis rate in patients with severe inhalation injury were higher than those of patients with moderate inhalation injury ( with x 2 value respectively 4.59, 13.47, P values all below 0.05 ). The FEV1 value of patients with moderate inhalation injury in the 1st, 2nd, 3rd month after injury was respectively higher than that of patients with severe inhalation injury ( with t value respectively 5.48, 12. 10, 6.25, P values all below 0.05). The values recovered to normal level in the 3rd month after injury. Conclusions Extubation time of tracheotomy for patients with moderate or severe inhalation injury within 2 weeks or after 2 weeks PⅡ has its own advantage and disadvantage, and it should be performed according to specific conditions of each patient. Conservative treatment is optional for late complications of respiratory system.     

Survival and number of olfactory ensheathing cells transplanted in contused spinal cord of rats

Objective： To observe the survival and the number of olfactory ensheathing cells （OECs） transplanted in the contused spinal cord, so as to provide a basis for further studying the biological action of OECs.Methods： The rat spinal cords were contused with NYU-impactor Ⅱ at T10 level by dropping a 10 g rod from a height of 25 mm. At the 1st week after injury, OECs isolated freshly from green fluorecense protein （GFP） of the rats were transplanted into the spinal cord at injured site and other two sites 1 mm apart from the caudal and rostral ends with the OECs number of 30000/μl×3 =90000. The survival and the number of OECs were qualitatively and semi-quantitatively observed under the fluorescense microscope from 1 week to 13 weeks after transplantation. The motor function of the cord was evaluated with BBB score.Results： GFP-OECs could survive at least for 13 weeks within the contused spinal cord. Their arrangement was from tight to loose and their number was decreased from 1 week to 13 weeks after injury. The average number of GFP-OECs was 536 at the 1st week, which was less than 1% of the number as compared with original transplantation. After then, the number of GFP-OECs was continually decreased,but the most obvious decrease was found during 1 week to 2 weeks. The extent of decrease at other time points was relatively mild. In contrast to the cell number, motor function of the cord was gradually recovered after transplantation.Conclusions： The survival and the number of GFPOECs are different between the animals and are affected by the pathological reaction of the host cord. Also it is related to the motor function recovery of the contused cord.     

Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries

Purpose: Traumatic diaphragmatic rupture (TDR) needs early diagnosis and operation. However, the early diagnosis is usually difficult, especially in the patients without diaphragmatic hernia. The objective of this study was to explore the early diagnosis and treatment of TDR. Methods: Data of 256 patients with TDR treated in our department between 1994 and 2013 were analyzed retrospectively regarding to the diagnostic methods, percentage of preoperative judgment, incidence of diaphragmatic hernia, surgical procedures and outcome, etc. Two groups were set up according to the mechanism of injury (blunt or penetrating). Results: Of 256 patients with a mean age of 32.4 years (9-84), 218 were male. The average ISS was 26.9 (13-66); and shock rate was 62.9%. There were 104 blunt injuries and 152 penetrating injuries. Preoperatively diagnostic rate was 90.4% in blunt injuries and 80.3% in penetrating, respectively, P<0.05. The incidence of diaphragmatic hernia was 94.2% in blunt and 15.1% in penetrating respectively, P<0.005. Thoracotomy was performed in 62 cases, laparotomy in 153, thoracotomy plus laparotomy in 29, and combined thoraco-laparotomy in 12. Overall mortality rate was 12.5% with the average ISS of 41.8; and it was 21.2% in blunt injuries and 6.6% in penetrating, respectively, P<0.005. The main causes of death were hemorrhage and sepsis. Conclusions: Diagnosis of blunt TDR can be easily obtained by radiograph or helical CT scan signs of diaphragmatic hernia. For penetrating TDR without hernia, “offside sign” is helpful as initial assessment. CT scan with coronal/sagittal reconstruction is an accurate technique for diagnosis. All TDR require operation. Penetrating injury has a relatively better prognosis.     

肝移植后丙型病毒性肝炎复发治疗时获得持续病毒应答的影响因素

Objective To investigate the efficacy of pegylated interferon (Peg-IFN) plus ribavirin to treat hepatitis C virus (HCV) recurrence, and analyze possible factors associated with sustained viral responses (SVR). Methods The enrolled 39 patients, who had recurrence of hepatitis C after liver transplantation and received antiretroviral therapy, were analyzed. Treatment was discontinued in 21 patients due to side effects, and the remaining 18 patients [13 males, 5 female,median age of 54 (27-67) years, treatment duration of 25-105 weeks)] were subjected to whole standard treatment. During the treatment, HCV RNA was measured at 4, 12, 24, and 24 weeks after HCV negative change as well as drug withdrawal. SVR was defined as HCV RNA negativity within 24 weeks after the drug withdrawal. The following variables were analyzed: ages, gender,pretreatment viral load, genotype, early viral response (EVR), levels of alanine aminotransferase before treatment and their association with SVR. Results The mean treatment duration was 57weeks with an SVR achieved in 4/18 (22. 2 %). Statistical analysis revealed that the genotype of non1B (P=0.023), RNA ＜106 copy/ml (P= 0. 044) before treatment and EVR (P=0.019) were the variables associated with SVR. Conclusion Genotype of nor-1B, low level RNA before treatment and EVR were the effective predictors of interferon antiviral therapy for recurrent hepatitis C after liver transplantation.     

Is CT scan a predictor of instability in recurrent dislocation shoulder?

Purpose: Glenoid bone defect and the defect on the posterior-superior surface of the humerus “HillSachs lesion” are the commonly seen bony lesions in patients with recurrent dislocation shoulder. Computed tomography (CT) scan is considered as the best option in assessing the bony defects in the recurrent dislocation shoulder. The aim of this study was to assess the clinical and radiological corelation in the patients with recurrent dislocation shoulder. Methods: Forty-four patients of recurrent dislocation shoulder who were evaluated between January 2015 and December 2017 at a tertiary care center, clinically and radiologically using CT scan and meeting the inclusion criteria, were included. The correlation between the clinical history of the number of dislocations and the bone loss using CT scan was evaluated. Two sided statistical tests were performed at a significance level of a = 0.05. The analysis was conducted using IBM SPSS STATISTICS (version 22.0). Results: All the patients were male with mean age of 25.95 (SD ± 4.2) years were evaluated. Twenty-four patients sustained injury in sporting activities while 20 patients sustained injury in training. There were an average of 4.68 (SD ± 3.1, range 2-15, median 3) episodes of dislocation. Forty-one patients had the glenoid bone loss while 40 had the Hill-Sachs lesions. The mean glenoid width defect was 10.80% (range 0-27%) while the mean Hill-Sachs defect was 14.27 mm (range 0-26.6 mm). The mean area of bone loss of the glenoid surface was 10.81% (range 0-22.4%). The lesions were on track in 34 patients and off track in 10 patients. Conclusions: CT scan of the shoulder joint is an effective method for assessing the amount of bone loss. The number of dislocations are correlated significantly with off-track lesions and the amount of bone loss on the glenoid and Hill-Sachs lesion. The glenoid width bone loss of more than 9.80% or Hill-Sachs defect of more than 14.80 mm are the critical defects after which the frequency of dislocations increases.     

肝移植后丙型病毒性肝炎复发治疗时获得持续病毒应答的影响因素

Objective To investigate the efficacy of pegylated interferon (Peg-IFN) plus ribavirin to treat hepatitis C virus (HCV) recurrence, and analyze possible factors associated with sustained viral responses (SVR). Methods The enrolled 39 patients, who had recurrence of hepatitis C after liver transplantation and received antiretroviral therapy, were analyzed. Treatment was discontinued in 21 patients due to side effects, and the remaining 18 patients [13 males, 5 female,median age of 54 (27-67) years, treatment duration of 25-105 weeks)] were subjected to whole standard treatment. During the treatment, HCV RNA was measured at 4, 12, 24, and 24 weeks after HCV negative change as well as drug withdrawal. SVR was defined as HCV RNA negativity within 24 weeks after the drug withdrawal. The following variables were analyzed: ages, gender,pretreatment viral load, genotype, early viral response (EVR), levels of alanine aminotransferase before treatment and their association with SVR. Results The mean treatment duration was 57weeks with an SVR achieved in 4/18 (22. 2 %). Statistical analysis revealed that the genotype of non1B (P=0.023), RNA ＜106 copy/ml (P= 0. 044) before treatment and EVR (P=0.019) were the variables associated with SVR. Conclusion Genotype of nor-1B, low level RNA before treatment and EVR were the effective predictors of interferon antiviral therapy for recurrent hepatitis C after liver transplantation.     

Surgically treated diaphragmatic perforation after radiofrequency ablation for hepatocellular carcinoma

We review 6 cases of diaphragmatic perforation, with and without herniation, treated in our institution. All patients with diaphragmatic perforation underwent radiofrequency ablation(RFA) treatments for hepatocellular carcinoma(HCC) performed at Kurume University Hospital and Tobata Kyoritsu Hospital. We investigated the clinical profiles of the 6 patients between January 2003 and December 2013. We further describe the clinical presentation, diagnosis, and treatment of diaphragmatic perforation. The change in the volume of liver and the change in the Child-Pugh score from just after the RFA to the onset of perforation was evaluated using a paired t-test. At the time of perforation, 4 patients had herniation of the viscera, while the other 2 patients had no herniation. The majority of ablated tumors were located adjacent to the diaphragm, in segments 4, 6, and 8. The average interval from RFA to the onset of perforation was 12.8 mo(range, 6-21 mo). The median Child-Pugh score at the onset of perforation(8.2) was significantly higher compared to the median Child-Pugh score just after RFA(6.5)(P = 0.031). All patients underwent laparotomy and direct suture of the diaphragm defect, with uneventful post-surgical recovery. Diaphragmatic perforation after RFA is not a matter that can be ignored. Clinicians should carefully address this complication by performing RFA for HCC adjacent to diaphragm.     

Delayed colonic perforation after percutaneous radiofrequency ablation of hepatocellular carcinoma

Radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma. Colonic perforation secondary to RFA of the liver is an uncommon complication that has been reported to have an incidence between 0.1% and 0.3%. Lesions adjacent (within 1 cm) to the colonic wall and those in patients with history of upper abdominal surgery or chronic cholecystitis are particularly at risk. More importantly, thermal injury leading to colonic perforation has proved to have a fatal outcome. We present a case of percutaneous RFA in a patient with hepatocellular carcinoma that was abutting the colonic hepatic flexure. Colonic perforation was diagnosed on the eighth day postablation when the patient was readmitted with peritonitis.     

腹腔镜射频消融治疗多病灶肝癌的疗效及安全性

目的:探讨腹腔镜射频消融(radiofrequency ablation,RFA)治疗多病灶肝癌的可行性、安全性及疗效。方法:2001年10月-2005年8月,我院对15例多病灶肝癌患者在全麻下进行治疗。其中男12例,女3例,平均(51.5±9.0)岁。术前经超声、螺旋CT或MRI发现瘤体36个,其中2个病灶11例,3个病灶2例,4个病灶2例。肿瘤平均直径(3.1±1.1)cm。乙型肝炎13例,丙型肝炎2例。合并肝硬化13例,胆囊结石2例。结果:15例均顺利完成手术,同时行胆囊切除术2例。单个病灶RFA平均时间(30.2±13.3)min,平均总手术时间(98.7±28.5)min,平均总出血量(145.3±82.8)ml。未出现腹腔出血、胃肠道损伤、膈肌损伤及肝功能衰竭等严重并发症。术后1个月螺旋CT增强扫描证实,病灶完全坏死率达100%。随访12-52个月(平均35个月),1例发现肝内新病灶,3例消融部位复发,均采用经皮射频消融进行治疗。3例分别在术后24、28、36个月死于肝内复发及肝功能衰竭。结论:腹腔镜RFA治疗多病灶肝癌安全可行,近期疗效肯定,最大程度保存了受损的肝功能。但应选择肿瘤位于肝脏表面、肝左外叶或邻近胆囊的病例进行治疗。     

兔肝VX2肿瘤RFA后残余瘤与 炎症的鉴别:CT与病理对照

目的通过CT扫描与病理对照,对兔肝VX2肿瘤RFA后残余瘤与炎症进行鉴别。方法兔肝VX2肿瘤射频消融（RFA）后不同时期行CT及病理检查,观察RFA后不同时期的残余瘤与炎症的CT表现。结果CT增强扫描,残瘤与炎症均表现为周边强化带,炎症还表现为强化带外侧的肝组织由内向外逐渐减弱强化影,炎症的这种强化影于术后第2天最强,之后逐渐减弱,2周后基本消失。结论RFA后1周内,CT增强扫描尚不能准确分辨残瘤与炎症反应带;两周后低密度灶周边出现强化影应考虑为残余瘤存在。     

Surgical management of diaphragmatic injuries

Background Traumatic diaphragmatic lesions have variable presentations and need a high index of suspicion to be diagnosed in the acute phase. Delayed diagnosis is frequently associated with considerable comorbidity. Material and Methods The present retrospective study aims to evaluate the radiological findings and discuss the surgical approach for the repair of the injured diaphragm. This study includes fifteen cases with diaphragmatic injuries, which were surgically managed between 1994 and 2005. Injuries resulted from violent blunt trauma in twelve patients and three patients had penetrating injuries. Patients presented with hypotension, respiratory insufficiency, acute abdomen and hemothorax. Preoperative diagnosis was established in 12/15 (80%) patients depending on the clinical and the chest skiagram findings. Intra-operative diagnosis was made in the rest. Injuries were more common on the left side (11/15, 73.33%). All these patients underwent repair of the defect by direct closure in double layer using monofilament polypropylene suture. In addition, laparotomy was performed in four patients who had liver and spleen injury. Concomitant procedures included lobectomy, segmentectomy, repair of lung laceration, spleenectomy, spleenorraphy, repair of gastric perforation, intestinal perforation and mesenteric tear. Results One patient died (1/15, 6.66%) of associated injuries. Two patients with major liver injuries had prolonged drainage and repeated subdiaphragmatic collections. Conclusions Associated lesions particularly influence the outcome after traumatic lesions of the diaphragm. Surgical exploration is mandatory whenever diaphragmatic injuries are suspected. Right-sided injuries are best exposed and managed through the right thoracotomy. Direct suture is effective in preventing future specific complications.     

Traumatic lesions of the diaphragm. Our experience in 33 cases and review of the literature

We reviewed 33 consecutive patients with diaphragmatic injuries. Twenty-nine were admitted in emergency conditions after blunt (22 patients) or penetrating injury, presenting shock, dyspnoea, coma or acute abdomen in 21 cases; major associated lesions were found in 23 patients. Four patients presented acute complications of visceral herniation 2, 4, 84 and 216 months after the trauma. The diagnosis was preoperative in 23 cases, intraoperative in 9; in one case it was missed at laparotomy, becoming evident the day after. The sensibility of preoperative chest x-ray and CT was 86% and 100% in presence of visceral herniation, 14% and 0% in absence of visceral hernia. The diaphragmatic repair was always obtained by direct suture, following 20 haemostatic procedures (liver, spleen, mesenterium) and two bowel resections. The mortality rate was 24.4%; the morbidity rate was 48%. Traumatic lesions of the diaphragm are generally expression of particularly severe trauma whose outcome is mainly influenced by the associated lesions. They are also correlated to specific morbidity and mortality, so the surgical exploration is mandatory whenever this injury is suspected, considering that the preoperative diagnosis relies on visceral dislocation. Associated lesions influence the surgical strategy but a direct suture is usually effective in preventing specific complications.     

Traumatic Lesions of the Diaphragm Our Experience in 33 Cases and Review of the Literature

We reviewed 33 consecutive patients with diaphragmatic injuries. Twenty-nine were admitted in emergency conditions after blunt (22 patients) or penetrating injury, presenting shock, dyspnoea, coma or acute abdomen in 21 cases; major associated lesions were found in 23 patients. Four patients presented acute complications of visceral herniation 2, 4, 84 and 216 months after the trauma. The diagnosis was preoperative in 23 cases, intraoperative in 9; in one case it was missed at laparotomy, becoming evident the day after. The sensibility of preoperative chest x-ray and CT was 86% and 100% in presence of visceral herniation, 14% and 0% in absence of visceral hernia. The diaphragmatic repair was always obtained by direct suture, following 20 haemostatic procedures (liver, spleen, mesenterium) and two bowel resections. The mortality rate was 24.4%; the morbidity rate was 48%. Traumatic lesions of the diaphragm are generally expression of particularly severe trauma whose outcome is mainly influenced by the associated lesions. They are also correlated to specific morbidity and mortality, so the surgical exploration is mandatory whenever this injury is suspected, considering that the preoperative diagnosis relies on visceral dislocation. Associated lesions influence the surgical strategy but a direct suture is usually effective in preventing specific complications.     

Radiofrequency ablation prior to liver transplantation: focus on complications and on a rare but severe case

Abstract: Background: Radiofrequency ablation (RFA) is an established treatment for hepatocellular carcinoma (HCC) in patients awaiting liver transplantation, due to its comparably low rate of complication and high effectiveness. Complications are thought to be rare and mostly self-limiting. By contrast, we report on a life-threatening complication and discuss it in the context of other complications. Patients and methods: Out of a total of 149 RFA procedures, the incidence of major complications was 4% on a per-procedure basis. Mortality was 0.67%. Major complications included intractable pain, intrahepatic hematoma, skinburn at the site of patch electrode, and sectorial bile duct stricture. All complications occurred after percutaneous RFA. Highlighted is a young patient listed for liver transplantation because of HCC recurrence following hepatic resection, who was treated by percutaneous RFA as a bridging therapy until a suitable graft became available. Post-operatively, gastric perforation occurred due to heat injury of the gastric wall. Conclusions: The percutaneous RFA approach can occasionally lead to detrimental complications, particularly in patients with intra-abdominal adhesions, due to previous surgery if new intrahepatic malignant lesions accrue near the resection margin. Even widespread HCC disease can be treated effectively with orthotopic liver transplantation if the tumor growth is limited to the liver.     

Transthoracic hepatic radiofrequency ablation

Background Radiofrequency ablation (RFA) is an alternative for the treatment of unresectable hepatic tumors. Tumors beneath the diaphragmatic dome may be difficult to access by laparoscopy. In these cases, a transthoracic transdiaphragmatic approach for delivering RFA can be used. Methods Three patients with hepatic metastatic disease were treated using a transthoracic transdiaphragmatic approach to deliver RFA therapy for tumors in liver segments 7 and 8. The patients underwent thoracoscopy. The tumors were identified using transdiaphragmatic ultrasound, and transthoracic transdiaphragmatic RFA (TTRFA) was performed. Results In three patients, TTRFA was successfully used to ablate five lesions. There were no perioperative complications, blood loss was minimal, and postoperative hospital stays ranged from 2 to 8 days. There were no recurrences during a follow-up period of 4 to 20 months. Conclusions TTRFA is a viable alternative for hepatic tumors located beneath the dome of the diaphragm that are difficult to access by laparoscopy. Online publication: 13 October 2004     

Hanging maneuver in right hepatectomy for recurrent metastases with diaphragmatic infiltration after radiofrequency ablation: a new indication

The liver hanging maneuver is a safe technique to prevent bleeding during transection when a right hepatectomy by an anterior approach, without previous mobilization of the liver, is required. This article proposes a new indication for this technique. The liver hanging maneuver may be useful during right hepatectomy for local recurrence of liver metastases previously treated by radiofrequency ablation (RFA). In these cases, necrosis or fibrosis induced by RFA and local recurrence may cause strong adhesions between liver parenchyma and the diaphragm, thus increasing the risk of bleeding during liver mobilization. Between January 2003 and March 2006, seven patients with recurrent colorectal liver metastases of the right hemiliver, after previous treatment by RFA, underwent right hepatectomy. Liver resection was feasible with the proposed technique in all patients. In four cases, a limited diaphragmatic resection was associated. There was no mortality. Postoperative morbidity was 42.8 per cent. An anterior approach with the liver hanging maneuver for recurrent liver metastases after RFA should be recommended when the metastases are located posteriorly, are not detachable from the diaphragm, and the preliminary mobilization of the right liver may be difficult.