肺移植治疗终末期肺气肿19例报告

目的 探讨肺移植治疗终末期肺气肿的手术适应证、术式的选择及术后疗效.方法 报告肺移植治疗终末期肺气肿19例,患者术前CT检查均以弥漫性肺气肿为主,均经2～3年不同程度的吸氧治疗,其中依赖呼吸机的有5例.手术方式分别为:单肺移植6例;单肺移植加对侧肺减容术7例;双肺移植6例.结合这19例患者的肺移植效果进行分析和总结.结果 单肺移植的受者中,术后第1天内有2例受者胸腔引流量超过2000 ml,再次剖胸探查止血.19例受者术后机械通气时间为3～22 d,平均呼吸机脱机时间为7 d.术后1个月内死亡5例,死亡原因分别为:原发性移植物功能丧失1例、支气管吻合口漏1例、重症急性排斥反应(4A级)1例及重症细菌和霉菌感染2例.6例双肺移植的受者术后早期均康复出院.19例患者术后1、2、3年存活率分别为73.7%、63.2%和52.6%.结论 肺移植是治疗终末期肺气肿最有效的方法;单肺移植口丁作为终末期肺气肿的常用术式,单肺移植结合对侧肺减容术可以更好的利用供肺,同时又解除了术后对侧自体肺的并发症;对年龄较轻及有双肺感染的终末期肺气肿患者,应首选双肺移植,双肺移植较单肺移植术后并发症更少.     

肺移植术后早期原发性移植物失功的危险因素与防治CSCD

目的 探讨肺移植患者术后早期（〈7天）发生原发性移植物失功（primary graft dysfunc-tion,PGD）的危险因素与预后分析.方法 回顾性分析2002年9月至2013年12月接受肺移植治疗的286例终末期肺病患者临床资料,术后均在重症监护病房连续有创监测生命体征、机械通气及免疫抑制治疗.根据早期PGD发生情况,将286例患者分为PGD组和非PGD组.对两组患者的年龄、术式（单肺或双肺移植）、肺动脉压力、供肺缺血再灌注时间、是否应用体外循环（CPB）等进行多因素logistic回归分析比较.结果 术后早期发生3级PGD 22例,死亡10例,病死率45.4％.单肺移植7例,其中体外膜式氧合（ECMO）辅助下3例;双肺移植15例,其中CPB辅助下2例,ECMO辅助下6例.PGD患者术后30天、1年、5年生存率分别为55％、40％、25％,显著低于非PGD组84.9％、78.6％和49.2％.统计学分析显示,术前合并肺动脉高压、供体缺血再灌注时间、术中失血量是肺移植患者术后早期发生PGD的危险因素,术中ECMO支持则是PGD发生保护因素.而年龄、性别、手术方式、手术时间、术前呼吸机依赖并非影响移植术后早期PGD发生的危险因素.结论 3级PGD是肺移植术后常见的严重并发症,病死率极高,对于合并危险因素较多患者,应在围手术期加强管理,进行积极预防;早期诊断,及时治疗能有效提高肺移植手术的成功率.     

肺移植术后需要临床干预的气道狭窄患者生存结局的影响因素

目的 分析肺移植术后需要临床干预的气道狭窄患者生存结局的影响因素。方法 回顾性分析肺移植术后需要临床干预的66例气道狭窄患者的临床资料。采用单因素和多因素Cox回归模型分析所有气道狭窄患者和早期气道狭窄患者生存结局的影响因素,采用Kaplan-Meier法计算总生存率并绘制生存曲线。结果 66例气道狭窄患者,中位无气道狭窄时间为72(52,102)d,27%(18/66)发生中心气道狭窄,73%(48/66)发生远端气道狭窄。术后机械通气时间[风险比（HR）1.037,95%可信区间（CI）1.005～1.070,P=0.024]和手术类型（HR 0.400,95%CI 0.177～0.903,P=0.027）均与肺移植术后气道狭窄患者的生存结局存在相关性,术后机械通气时间越长,受者死亡风险越高;接受双肺移植的气道狭窄患者的总生存率优于单肺移植。在亚组分析中,3级原发性移植物失功（PGD）(HR 4.577,95%CI 1.439～14.555,P=0.010)和免疫抑制药（HR 0.079,95%CI0.022～0.287,P<0.001）与肺移植术后早期气道狭窄患者生存结局均...     

再次肺移植治疗肺移植术后闭塞性细支气管炎综合征

目的探讨再次肺移植治疗肺移植术后闭塞性细支气管炎综合征(BOS)的疗效。方法回顾性分析无锡市人民医院胸外科7例因肺移植术后BOS行再次肺移植的受者临床资料。其中男性5例,女性2例,中位年龄45岁(29~70岁),原发病包括间质性肺炎2例、慢性阻塞性肺疾病2例、支气管扩张1例、原发性肺动脉高压1例、骨髓移植术后慢性闭塞性细支气管炎1例。首次肺移植术后7例患者均出现肺功能进行性下降,最终诊断为BOS。再次肺移植术式为5例单肺移植和2例序贯式双肺移植,其中1例双肺移植和1例单肺移植在体外膜肺氧合辅助下完成。结果 1例受者术中出血2 000 m L,术后第2天出现急性肺水肿,于术后第8天因重症肺部感染死亡。1例受者术中出现心跳骤停,于术后第4天因多器官功能衰竭死亡。其余5例受者手术过程顺利,术后恢复良好,均在术后1个月内出院。截至2017年7月,随访半年以上的4例受者肺功能检测示一秒用力呼气容积分别为2.0、1.8、1.8、2.5 L,分别占术后基线值92.3%、91.1%、89.1%、92.1%,生活质量明显改善,日常活动不受限。结论再次肺移植是治疗肺移植术后BOS的有效方法,但受者选择标准、手术方式、影响术后生存的危险因素等关键问题仍需进一步研究。     

矽肺患者33例肺移植术后护理

目的总结矽肺患者行肺移植术后的护理要点及相关经验。方法回顾性分析2007年7月至2016年4月南京医科大学附属无锡人民医院33例行肺移植术的矽肺患者临床护理资料。从移植肺维护(包括气道管理和胸部物理治疗)、液体管理、体外膜肺氧合(ECMO)护理、原发性移植物失功(PGD)观察与护理、早期肺康复和心理护理等方面总结经验。结果 33例受者平均ICU住院时间(9±3)d(3~32 d);平均机械通气时间为(3.8±1.2)d(2~24 d)。21例受者术后第2天拔管脱机,10例术后第3~5天拔管脱机,2例受者分别在术后第3、5天出现肺部感染、呼吸衰竭,暂未拔除气管插管,术后第7、8天行气管切开术。33例受者中2例死亡,其中1例术后发生PGD、急性心力衰竭、重度肺水肿;另1例术中出血4 500 m L,术后发生PGD,术后第7天发生多器官功能衰竭。其余31例均康复出院,术后1个月生存比例为93.8%(31/33)。结论矽肺患者肺移植术后并发症的预防和观察是护理的重点与难点,术后合理有效地护理是其术后顺利康复出院的重要保障。     

体外膜肺氧合辅助下序贯式双肺移植的麻醉管理

目的 总结体外膜肺氧合(ECMO)辅助下序贯式双肺移植的麻醉处理及术中运用ECMO支持的经验.方法 8例终末期肺病患者术前进行了充分的调整和准备,手术均为双侧前胸切口序贯式双肺移植.麻醉诱导常规采用咪唑安定、芬太尼、依托咪酯及维库溴铵诱导,肌肉松弛后行气管内插管;术中麻醉维持以静脉持续泵注丙泊酚和维库溴铵,间断静注芬太尼.术中严密监测各项生命体征,根据血气指标及生命体征调节机械通气参数,必要时行手控通气.所有患者于麻醉诱导后进行股动、静脉穿刺置管,并给予ECMO辅助,转流期间维持激活凝血时间(ACT)160～200s,血流量1.8～2.5 L·m-2·min-1.结果 所有患者在麻醉诱导机械通气下生命体征平稳,手术过程顺利.结论 ECMO是双肺移植术中心肺辅助的有效手段,可提高肺移植手术的麻醉成功率.     

双肺移植治疗特发性肺动脉高压二例

目的 探讨双肺移植治疗特发性肺动脉高压(IPAH)的可行性及围手术期的处理方法.方法 回顾分析2例IPAH患者接受双肺移植的临床资料,2例均经右心导管术确诊为IPAH.例1为男性,17岁,体重45kg,身高165 cm,术前心功能不全Ⅳ级,肺动脉收缩压和平均压分别为110和70 mm Hg(1 mm Hg=0.133 kPa),右心房压力为18mm Hg.例2为女性,16岁,体重58 kg,身高162 cm,术前心功能不全Ⅳ级,肺动脉收缩压和平均压分别为148和72 mm Hg,右心房压力为23mm Hg.术前胸部X线片及CT显示,2例患者心脏扩大并向左偏,肺动脉增粗突起,左下肺部的血管增粗扭曲.例1和例2均在体外膜肺氧合(ECMO)支持下行序贯式双侧单肺移植术,先行右全肺切除,植入右供肺,后行左全肺切除,植入左供肺,完成双侧前外侧切口不横断胸骨序贯式双肺移植术.供、受者体型较为匹配,ABO血型相同或相容,供肺冷缺血时间为185～300 min.例1和例2术中ECMO支持时间分别为550和450 min,出血量分别为3000和1200 ml.结果 术后12 h患者胸部X线片和CT显示双侧移植肺清晰,心脏大小恢复正常.例1和例2分别在术后16和13 h撤离ECMO;术后第3和第4天均出现不同程度的血液动力学不稳定,发生急性左心功能衰竭,于术后第3和6天行气管切开呼吸机辅助正压通气,经强心、利尿、扩血管等治疗,分别于术后第33和12天脱离呼吸机,术后第93和32天康复出院.出院时,心脏超声检查显示,患者心脏形态及心功能明显改善,心功能达Ⅰ级.2例患者分别随访25和10个月,已恢复正常的工作和学习,生活质量良好.结论 对于终末期IPAH经内科保守治疗效果欠佳的患者行序贯式双肺移植是可行的.良好的供肺切取和保护技术、术中ECMO的支持以及术后左心功能衰竭的防治是手术成功的关键.     

异体单肺移植术后感染的预防护理

对4例异体单肺移植术后患者实施强化预防感染的护理,除1例术后1 d因呼吸衰竭、右心功能衰竭死亡外,余3例顺利出院,无1例感染.提出强化护理人员及各级医务人员,包括保洁人员预防感染的意识;制定监护病房的管理制度,使用单间病房,采取保护性隔离措施;加强人工气道的管理;严格按操作规程执行护理工作,可避免或减少术后感染的发生,提高肺移植术的成功率及肺移植患者的生存质量.     

23例次肺移植术后受者的临床分析

目的 评估23例次肺移植术后受者的临床预后情况.方法 总结2003年1月至2007年8月施行的23例次(21例患者)肺移植的临床资料.分析存活率及并发症.结果 肺移植围手术期死亡率为13%;术后3个月、1年、2年和3年的累积存活率分别为82.6%、82.6%、69.7%和58.1%.受者术后2个月时的通气和换气功能较术前明显改善(P<0.05).有10例受者术后6个月内出现轻度急性排斥反应,经激素冲击治疗后均缓解.4例受者分别于术后8个月、9个月、14个月和24个月时出现慢性排斥反应;术后6、12和24个月时未发牛慢性排斥反应的受者分别为95%、78.2%和71.1%.术后肺部感染发生率为33.3%;气管吻合口软化和狭窄发生率为14.3%.结论 肺移植术后受者的中期存活率较高;肺部感染和支气管吻合口软化及狭窄是肺移植术后主要并发症.     

肺减容术治疗慢性阻塞性肺气肿

目的　为了提高肺气肿患者生存质量 ,探讨肺减容手术治疗慢性阻塞性肺气肿的可行性。　方法　本组肺减容手术 16例 ,其中同期双侧肺减容手术 9例 ,胸腔镜辅助小切口肺减容术 4例 ,标准后外侧切口单侧肺减容术 3例。术前根据计算机体层摄影术 (CT)和同位素肺通气肺灌注扫描选择肺气肿手术“靶区”,术中使用带牛心包垫的直线型切割缝合器切除病变 ,防止肺泡漏。　结果　手术时间 90～ 2 5 0分钟 ,平均 146分钟 ;主要并发症有肺泡漏≥ 7天 6例 ,心房颤动 2例 ,呼吸衰竭 1例 ,术后胸腔内出血 1例。 13例手术结束即拔出气管内插管 ,3例带管回病房需要机械通气。随访2～ 40个月 ,14例健在 ,术后患者呼吸困难指数上升为 级 1例 , 级 10例 , 级 3例。　结论　慢性阻塞性肺气肿选择性手术能改善患者肺功能 ,长期效果尚需要观察     

Is the reexcision rate higher if breast conservation surgery is performed by surgical trainees?

BACKGROUND: It is essential that surgical trainees obtain adequate operative experience without compromising patient outcome. The aim of this study was to compare the reexcision and local recurrence rates between consultants (attending surgeons) and surgical trainees (residents) after breast conservation surgery. METHODS: Prospective data were obtained from the local breast cancer registry for all patients who had breast-conservation surgery between 1994 and 2000. Reexcision was carried out if the margins were deemed inadequate after taking the clinical and pathologic features into consideration. RESULTS: The primary operation (n = 505) was wide local excision = 377; wire-guided excisions = 107; and quadrantectomy = 21 patients. Sixty-five percent (n = 330) were operated on by consultants and 35% (n = 175) by residents. Second procedures (n = 137) were performed for involved margins in 95 and close margins in 31 patients. The patients in both groups were equally matched. The reexcision rate was similar for both groups of surgeons (P = 0.58). On multivariate analysis, the factors determining reexcision were nodal status, type of first procedure, and tumor type. The local recurrence rate was comparable in both groups (P = 0.33). CONCLUSIONS: In patients with breast cancer treated by conservation surgery during a 7-year period, the reexcision and local recurrence rates were similar for both groups of surgeons.     

Effect of immunosuppressive drugs on the release of metalloproteinases from human polymorphonuclear leukocytes

The concentration of the metalloproteinases type I collagenase and gelatinase was measured in isolated polymorphonuclear leukocytes (PMNLs) of renal transplant recipients treated either with cyclosporin A (CyA) and prednisolone (Pr) (n=8) or azathioprine (Aza) and Pr (n=8), and of healthy subjects (n=12). PMNLs of CyA- and Aza-treated transplant patients displayed markedly higher gelatinase content (2427±489 and 3284±357 ng/10⁷ cells) than PMNLs of controls (528±83 ng/10⁷ cells). There was also a higher content of type I collagenase in PMNLs (3374±292 ng/10⁷ cells) of Aza-treated patients and significantly elevated levels in PMNLs of patients receiving CyA (3625±229 ng/10⁷ cells) compared with healthy subjects (2878±151 ng/10⁷ cells). In contrast, neutrophil lactoferrin content was lower in transplant patients. Thus, immunosuppressive drugs may reduce the release of leukocyte proteinases, which are known for their deleterious role in proteolytic tissue and matrix breakdown. In vitro, the effects of different immunosuppressive drugs on the release of lactoferrin, collagenase and gelatinase were investigated on FMLPNTL-stimulated PMNLs isolated from healthy subjects. CyA but not Aza or Pr caused inhibition of gelatinase, collagenase and lactoferrin release.     

Clinicopathologic Impact of Early Medullary Ray Injury in Patients Following Kidney Transplantation

Background

Previously, we explored the histopathologic characteristics of medullary ray injury (MRI) inducing interstitial fibrosis and tubular atrophy (IF/TA) to determine its etiologies, which include calcineurin inhibitor (CNI) toxicity and urologic complications. However, we did not examine the effects of these etiologies on long-term kidney allograft prognosis, because biopsy timing differed among cases.

Aspects of personality in patients with pituitary adenomas

Summary In 24 patients suffering from pituitary tumours, aspects of personality as covered by the FPI (Freiburger Personality Inventory), the Gie\en test and the STAI (State-Trait-Anxiety Inventory) were investigated in order to find out changes or problems which demand special treatment.The most interesting result concerns state and trait-anxiety scores being increased pre-surgically and normalizing to some extent after treatment. Most of the other explored aspects did not show but tendencies which demand further investigation.Relationships between hormone levels and tumour size could not be shown. As a result of this investigation, special psychological treatment should be considered in acromegaly and Cushing's disease.Dedicated to Prof. Dr. Friedrich Loew on the occasion of his 65th birthday and the 25th anniversary of the Homburg Neurosurgical University Clinic, which has been founded and built up by him.     

Electroencephalographic investigations in sellar tumours,with special regard to different methods of operative treatment

Summary Sixty-six patients with tumours in the sellar region were examined. All were operated on either by the transfrontal or the transsphenoidal route. Pre- and postoperative longitudinal electroencephalographic investigations were performed.Preoperative electroencephalograms showed a normal frequency content in cases of intrasellar tumours or those reaching the chiasma. Nearly all cases had irregularities in the temporal regions. Tumours compressing the third ventricle had slower average frequencies and a general slowing in all cases. Besides these alterations unilateral delta waves or bitemporal dysrhythmic groups were sometimes found.A connection between extension of the tumour and its histological nature could not be found, but the operative approach influenced the electroencephalographic disturbances enormously. After a transfrontal approach and removal of the tumour the electroencephalogram was unchanged. Sometimes a mild transient bitemporal slowing was present. But after a transfrontal operative approach a general slowing was common, usually with focal marked slow activity in the right fronto-temporal area.     

Functional, life-threatening disorders and splenectomy following liver transplantation

Splenectomy (SPL) in cirrhotic patients undergoing liver transplantation (LTx) may resolve specific problems related to the procedure itself, in case of functional and life-threatening clinical situations often occurring as a result of liver cirrhosis and portal hypertension. METHOD: A single-center experience of ten splenectomies in a series of 180 consecutive adult liver transplant patients over a period of 6 yr is reported. The mean patient age was 46.8 +/- 9.5 yr (range 25 57 yr). Indications for SPL were post-operative massive ascitic fluid loss (n = 3), severe thrombocytopenia (n = 3), acute intra-abdominal hemorrhage (n = 2), infarction of the spleen (n = 1), and multiple splenic artery aneurysms (n = 1). RESULTS: Extreme ascites production due to functional graft congestion disappeared post-SPL, with an improvement of the hepatic and renal functions. SPL was also effective in cases of thrombocytopenia persistence post-LTx, leading to an increase in the platelet count after about 1 wk. Bleeding episodes related to left-sided portal hypertension or trauma were also resolved. The rejection rate during hospitalization was 0%, and no other episodes were recorded in the course of the long-term follow-up. However, sepsis with a fatal outcome occurred in 4 patients, i.e. between 2 and 3 wk post-SPL in three cases and 1 yr after the procedure as a result of pneumococcal infection in the last case. Fatal traumatic cranial injury occurred 3 yr post-LTx in another case. Five patients (50%) are still alive and asymptomatic after a median follow-up period of 36 months. CONCLUSION: The lowering of the portal flow appears to resolve unexplained post-operative ascitic fluid loss as a result of functional graft congestion following LTx. However, because of the enhanced risk of SPL-related sepsis, a partial splenic embolization (PSE) or a spleno-renal shunt could be used as an alternative procedure because it allows us to preserve the immunological function of the spleen. SPL is indicated in case of post-transplant bleeding due to left-sided portal hypertension and trauma, spleen infarction, and to enable prevention of hemorrhage in liver transplant patients with multiple splenic artery aneurysms. Severe and persistent thrombocytopenia could be treated with PSE. Because the occurrence of fatal sepsis post-SPL is a major complication in LTx, functional disorders, such as ascites and thrombocytopenia, should be treated with a more conservative approach.     

Macronutrients,minerals, vitamins and energy

Carbohydrates have the general formula C_n(H₂O)_n. Monosaccharides have between three and six carbon atoms and exist as chains or ring structures. As rings, they link with other monosaccharide rings. The major carbohydrate in humans is glucose, which is stored as glycogen: branching chains of glucose molecules. Fat (triglyceride), which makes up adipose tissue, consists of three fatty acids bonded to glycerol, but other lipids include phospholipids and steroids. Proteins are composed of chains of amino acids linked by amide bonds folded on each other to form protein structures. Vitamins and minerals are obtained from the diet and are required in varying quantities for a variety of metabolic processes. Energy is derived from the oxidation of carbohydrate, fat and protein. Energy expenditure and substrate oxidation can be calculated from oxygen consumption, carbon dioxide production and urinary nitrogen excretion.