Significance of intraoperative monitoring of arterial blood flow velocity and hepatic venous oxygen saturation for performing minimally invasive surgery in a patient with multiple calcified pancreaticoduodenal aneurysms with celiac artery occlusion

Even for patients with multiple pancreaticoduodenal aneurysms, successful treatment with noninvasive operative procedures can be employed, if intraoperative devices are considered. A 73‐year‐old man, without any symptoms, was admitted to our hospital and had computed tomography (CT) scanning to examine his liver for hepatitis C virus (HCV). Selective superior mesenteric artery (SMA) angiography confirmed multiple aneurysms in the anterior inferior pancreaticoduodenal artery (AIPDA), one aneurysm in the posterior inferior mesenteric artery (PIPDA), and another in the occluded celiac trunk, all with severe calcification. All of the aneurysms were thought to communicate with each other. With the celiac artery occlusion, the right hepatic artery (RHA) was revealed to be supplied by collateral arteries from the aneurysms in the AIPDA, and the left hepatic artery was shown to be supplied by collaterals from the left gastric artery. Intraoperative Doppler echography, at the time of the clamping of both IPDAs, demonstrated a marked decrease of blood velocity in all aneurysms (before clamping, >50 cm/s; after, <10 cm/s), although loss of pulsation and a marked decrease of flow in the RHA were inevitable. Therefore, each of these two IPDAs were ligated on the proximal side to the aneurysm, thus preserving the blood flow of the pancreas head fed by the PIPDA; bypass grafting from the AIPDA to the RHA, using the great saphenous vein, was done at the same time. After the creation of an anastomosis, the hepatic venous oxygen saturation (ShvO2) increased from 38% (at the time of ligation of the IPDAs) to 57% under ventilation. The patient's postoperative clinical course was uneventful. We describe and discuss our successful noninvasive operative management of multiple pancreaticoduodenal aneurysms, done while monitoring the blood flow and ShvO2, with some consideration of the literature.     

环状软骨前裂开对兔环状软骨生长发育的影响

目的:观察环状软骨前裂开对环状软骨生长发育的影响。方法:将幼兔环状软骨前正中裂开,8月后测量环状软骨内径,计算其管腔面积。结果:(1)与对照组比较,实验组兔环状软骨管腔面积无显著性差异(P>0.05)。(2)裂开处均由软组织连接,未形成过多瘢痕。结论:环状软骨前裂开对环状软骨及动物的生长发育无明显影响。     

腹腔镜下经腹部和后矢状路联合修补术后复发性直肠尿道瘘和直肠阴道瘘

目的介绍腹腔镜下经腹部和后矢状路联合手术治疗直肠肛门手术后复发性直肠尿道瘘和直肠阴道瘘。方法5例术后多次复发性直肠尿道瘘或直肠阴道瘘患儿，男3例，女2例，年龄3～13岁。腹部在腹腔镜下游离结肠，远端尽可能从骶前向盆腔分离肠管，近端肠管游离保证正常结肠能无张力拖至肛门处吻合。低位盆腔肠管分离通过后矢状位切口（肛缘后上1cm），正中切开直肠后壁，直肠内剥离黏膜至齿状线，直视下修补瘘口，近端切断结肠，将正常结肠拖出与肛门吻合。结果所有患儿排便功能良好，仅1例有轻度污粪，未见瘘管复发。结论腹腔镜下经腹部和后矢状路游离结肠、直肠，创伤小，视野清晰，避开了粘连紧密的瘘管分离，完整结肠拖出避免了瘘管的复发，后矢状路直肠切开能直视下显示并修补瘘管。     

椎管扩大成形术治疗腰椎管狭窄

目的：探讨椎管扩大成形术治疗腰椎管狭窄的效果。方法：椎板减压后复位，用棘突或髂骨植于一侧开槽处扩大椎管，并进行椎板及关节突关节植骨，对54例随访病人的手术前后临床表现及X线和CT进行比较。结果：随访6—39个月，临床优良率为81．1％。随访X线片显示椎板明显后移，CT测量与术前对比显示椎管内径扩大明显。结论：椎管扩大成形术操作简单，效果满意，术后并发症少，是治疗腰椎管狭窄的又一选择。     

胰腺假性囊肿的诊治体会

目的 总结胰腺假性囊肿的诊治体会。方法 回顾性分析46例胰腺假性囊肿患者的临床资料，7例保守治疗，行内引流术12例，外引流术9例，序贯式内外引流术5例，胰腺部分切除术13例。结果 保守治疗者均痊愈，无复发；行内引流术者中有1例发生肠瘘，其余11例恢复良好无复发；行外引流术1例出现胰瘘，2例复发；行胰腺部分切除术者有1例出现胰瘘，其余恢复良好。结论 根据病情和病程选择合适的术式是治疗胰腺假性囊肿的关键。     

甲基强的松龙在胸椎管狭窄症围手术期的应用

目的探讨甲基强的松龙(MP)在胸椎管狭窄症围手术期应用的价值.方法对82例胸椎管狭窄症采用单纯后路胸椎板切除术患者进行回顾性研究.所有患者手术减压前30min给予MP 1000mg冲击.76例减压术后第1日起每日200mg递减,术后第5d停药.术后出现脊髓缺血再灌注(IR)损伤6例,其中3例MP用法同上;另3例术后出现脊髓IR损伤时即刻按NASCIS-Ⅱ方案治疗.结果本组76例术后呈现不同程度的恢复.另6例术后出现脊髓IR损伤,其中术后MP每日200mg递减治疗的3例患者神经功能恢复较慢,1例于术后6个月恢复至正常,2例术后1年随访时肌力恢复满意但肢体仍有麻痛感;采用NASCIS-Ⅱ方案治疗的3例患者中,2例于治疗后48h神经功能基本恢复正常,1例于术后1个月双下肢功能完全恢复正常.发生应激性溃疡1例.结论胸椎管狭窄症手术减压患者围手术期应用MP,具有预防和治疗脊髓继发性损伤的作用.     

腰椎管狭窄症术后下肢残留麻木的发生率及影响因素

[目的]探讨腰椎管狭窄症术后下肢残留麻木的发生率和影响因素。[方法]2001年1月～2003年2月手术治疗56例腰椎管狭窄症患者，术后随访10d，1、3个月、1年和2年，记录患者神经功能和残留症状。[结果]术前82．1％的患者有下肢麻木，术后10d，1、3个月、1年和2年分别有43．6％、39．I％、36．6％、35．3％和35．7％的患者下肢残留麻木，与病程、术前JOA评分和椎管狭窄类型有关，与年龄和神经根直径无关。[结论]腰椎管狭窄症患者术后1个月内下肢麻木恢复最快，术后1年和2年下肢麻木发生率为35．3％和35．7％，推测神经组织的潜在恢复能力影响下肢麻木的发生率。     

Does monthly native arteriovenous fistula blood-flow surveillance detect significant stenosis--a randomized controlled trial.

BACKGROUND: Clinical practice guidelines recommend that the preferred method of surveillance for arteriovenous fistula (AVF) is the measurement of AVF blood flow (Qa). As these recommendations are based on observational studies, we conducted a randomized, prospective, double-blind, controlled trial to assess whether Qa surveillance results in an increased detection of AVF stenosis. METHODS: A total of 137 patients were randomly assigned to receive either continuing AVF surveillance using current clinical criteria (control, usual treatment) or usual treatment plus AVF blood-flow surveillance by ultrasound dilution (Qa surveillance group). The primary outcome measure was the detection of a significant (>50%) AVF stenosis. RESULTS: There were 67 and 68 patients assigned to the control and Qa surveillance groups, respectively. Patients in the Qa surveillance group were twice as likely to have a stenosis detected compared with the control hazard ratio (HR) confidence interval (CI) group (2.27, 95% 0.85-5.98, P = 0.09), with a trend for a significant stenosis to be detected earlier in the Qa surveillance group (P = 0.09, log rank test). However, using the Qa results alone prior to angiography, the area under the receiver operating characteristic curve demonstrated, at best, a moderate prediction of (>50%) AVF stenosis (0.78, 95% CI 0.63-0.94, P = 0.006). CONCLUSION: This study demonstrates that the addition of AVF Qa monitoring to clinical screening for AVF stenosis resulted in a non-significant doubling in the detection of angiographically significant AVF stenosis. Further, large multi-centre randomized trials are feasible and will be necessary to confirm whether Qa surveillance and the correction of detected AVF stenosis will lead to a reduction in AVF thrombosis and increased AVF survival.     

椎弓根钉辅助下后外侧融合在退变性腰椎管狭窄症手术中的应用

目的探讨退行性腰椎管狭窄症(degenerativelumbarspinestenosisDLSS)的特点、椎弓根钉辅助下的后外侧融合手术要点及其在退变性腰椎管狭窄症减压术中的作用和意义。方法回顾性分析2000年1月～2003年12月间59例腰椎管狭窄症患者的临床症状、椎管减压和椎弓根钉辅助下的后外侧植骨融合的手术和术后随访情况,手术结果通过问卷式调查由患者进行自我评价,评价内容分为:腰痛、腿痛、日常活动水平、是否服用止痛药物四个方面进行。结果59例患者随访6～48个月,平均22.5个月,8例患者1年后失访。其中治疗效果优21例(35.6%),良32例(54.2%),可4例(6.8%),差2例(3.4%)。术中术后的并发症主要有:神经根损伤、硬膜囊撕裂、FBSS(FailedBackSurgerySyndrome)、ASD(AdjacentSegmentDisease)、椎弓根钉断裂等。结论DLSS包括多部位狭窄性病理改变,术中减压应当按照一定的步骤全面减压。椎弓根钉辅助后外侧融合可以提供腰椎即刻稳定,提高了远期融合率,使得滑脱椎体复位并保持椎间高度,减少椎管狭窄的进展和再发,从而提高手术的治疗效果。     

Vaginal stenosis in patients treated with radiotherapy for carcinoma of the cervix

The aim of our study was to determine the incidence, timing, and severity of vaginal stenosis in patients with carcinoma of the cervix who had received pelvic and/or vaginal radiotherapy as part of their treatment. We also sought to determine if there were any predisposing factors for the development of stenosis. A retrospective chart review was undertaken for all the patients diagnosed with carcinoma of the cervix between January 1, 1990, and December 31, 2000 and treated with pelvic and/or vaginal radiation at Westmead Hospital. Since January 1, 1990, data regarding vaginal stenosis has been prospectively recorded on all the patients. Data collected included patient demographics, stage of disease, treatments administered, and incidence, timing, and severity of vaginal stenosis. One hundred and eighty-eight patients were treated. Mean age was 58.6 years. Thirteen percent of patients had stage IB disease, 45% had stage II disease, 39.5% had stage III disease, and 1.5% had stage IV disease. One hundred and seventy-nine patients returned for follow-up, and data regarding vaginal toxicity were available in 98%. Twenty-seven percent had grade 1 toxicity (partial stenosis or shortening but not complete occlusion), and 11% had grade 2 (complete occlusion). Stenosis of any grade was noted at a mean of 9.6 months and median of 7.5 months (range, 26 days-5.6 years) from completion of treatment. The only prognostic factor associated with increased risk of stenosis was age greater than 50 years (odds ratio 2.26). Vaginal stenosis is a common complication of pelvic and vaginal radiotherapy, occurring in 38% of patients. Stenosis occurs most often in the first year after treatment. Patients over the age of 50 are most at risk.