雷米芬太尼在老年高血压患者腮腺肿瘤手术中的临床应用

目的:探讨雷米芬太尼在老年高血压患者腮腺肿瘤手术中的临床应用价值。方法:选择拟行腮腺肿瘤手术的高血压患者52例,年龄65～82岁,ASAⅡ或Ⅲ级,随机分成雷米芬太尼组(R)和芬太尼组(F),每组26例。2组均采用全凭静脉麻醉,诱导方法一致。术中R组持续泵入雷米芬太尼0.05～0.2μg/kg.min-1,F组间断给予芬太尼,最大用量不超过8.0g/kg。2组均以丙泊酚和顺式阿曲库铵维持麻醉。记录不同时间点血流动力学参数、术后恢复情况及早期不良反应。结果:R组术中血流动力学更平稳,出血量少,术后苏醒时间和拔管时间较F组显著缩短(P<0.01)。2组患者自主呼吸恢复时间、术后躁动、疼痛和恶心呕吐发生率差异无统计学意义。结论:老年高血压患者行腮腺手术时,采用雷米芬太尼麻醉可维持血流动力学稳定,减少术野出血,提高患者苏醒质量,具有较高的安全性和临床实用性。     

cN0期甲状腺乳头状癌预防性中央区淋巴结清扫的争议与进展

甲状腺癌是近年来全世界发病率较高的恶性肿瘤之一,乳头状癌是其最常见的病理类型,治疗方式以手术为主,中央区淋巴结为其前哨淋巴结,故转移首先发生于此。对于存在中央区淋巴结转移的甲状腺乳头状癌患者,行中央区淋巴结清扫已被国内外学者所认可,但对于cN_0期肿瘤,是否行预防性中央区淋巴结清扫目前尚存争议。笔者就中央区淋巴结的解剖概念、cN_0期甲状腺乳头状癌转移规律、高危因素、对预防性淋巴结清扫的不同观点、并发症的预防及术式的选择等方面进行综述,旨在提高此类疾病的认识,为其治疗方式的完善提供参考。     

Vertebrobasilar dissections: Case series comparing patients with and without dissecting aneurysms

Vertebrobasilar dissections are being increasingly diagnosed due to better awareness and increased availability of modern imaging techniques of the intracranial and extracranial arteries. The clinical presentation and outcome in patients with vertebrobasilar dissections may be complicated by dissecting aneurysms. The aim of this retrospective study was to compare the clinical profile of patients with vertebrobasilar dissections with and without dissecting aneurysms, and to determine predisposing factors to the development of aneurysms. Thirty patients (19 [63%] male; median age 44.5 years) were identified. The patients were divided into two groups, an aneurysmal dissection group with seven patients and a non-aneurysmal dissection group with 23 patients. Eight (27%) patients presented with dissection after trivial trauma, three (10%) following high-speed vehicular trauma, two (7%) were associated with infection, but most (57%) were apparently spontaneous. Migraine with aura (p = 0.008) and female sex (p = 0.03) were observed more frequently in the aneurysmal dissection group. Though vascular risk factors other than hypertension and atrial fibrillation were seen in a greater percentage of patients in the non-aneurysmal dissection group, this was not statistically significant. Patients were treated with antiplatelet agents (n = 8) or warfarin (n = 13) or underwent an endovascular intervention (n = 6). Post-discharge data were available in 19 patients, of whom 14 (74%) were independent at a median follow-up of 4 months. Female sex and migraine with aura may predispose to the formation of acute dissecting aneurysms and this requires further research. Larger, prospective studies are required to ascertain epidemiologic and etiologic factors predisposing patients to the development of both intracranial and extracranial dissecting aneurysms in the vertebrobasilar circulation.     

胰腺离断的技术方法

胰腺手术的操作都涉及胰腺的离断。胰腺离断看似简单,但其实有很多临床医师不甚了解或重视不够之处。笔者总结自己的临床实践体会,从离断的器械、锐性离断和电外科器械离断的选择、胰颈断端血管的处理、断端胰管的处理、胰管断端开口的寻找、胰腺断端的闭合方法、胰腺残面的处理、不同质地胰腺的处理特点、胰腺区域离断的特点等方面来探讨如何更好地离断胰腺,提高手术疗效。     

增强CT诊断孤立性肠系膜上动脉夹层

目的分析增强CT诊断孤立性肠系膜上动脉(SMA)夹层的价值。方法分析22例孤立性SMA夹层的CT特征,提出新的分型方法,并结合文献进行分析。结果 22例夹层均累及SMA弯曲部前壁,其中21例(21/22,95.45%)经增强CT确诊;夹层近端距SMA开口平均(10.31±8.67)mm(0~32.03mm),夹层长度平均(73.37±42.69)mm(15.96~205.91mm)。按症状分组,无症状组(4例)夹层近端距SMA开口平均距离为(16.21±10.97)mm(1.00~32.03mm),有症状组(18例)平均为(9.17±6.15)mm(0~25.98mm);无症状组夹层长度平均为(34.81±44.01)mm(15.96~73.84mm),有症状组平均为(83.46±41.90)mm(26.40~205.91mm)。无症状组真腔狭窄率平均为44.16%±12.33%,有症状组为74.35%±22.37%(P=0.042)。随着夹层向SMA远、近端延展,保守治疗效果变差。结论增强CT是诊断SMA夹层的有效方法。孤立性SMA夹层均累及SMA弯曲部前壁,临床症状及疗效与夹层长度和真腔狭窄度有关。本研究提出的新分型方法有助于全面描述SMA夹层的影像学特征,进而确定治疗方案。     

食管高级别上皮内瘤变的诊断与治疗

目的总结食管高级别上皮内瘤变诊断及治疗方法。方法回顾性分析28例食管高别上皮内瘤变患者的临床资料。结果接受内镜粘膜下剥离术手术治疗的28例患者中,16例（57％）术后病理证实维持高级别上皮内瘤变的诊断,其余12例（43％）术后则诊断为食管癌。结论内镜下病理检查诊断食管高级别上皮内瘤变准确率57％,内镜下活检不能作为高级别上皮内瘤变的确诊依据,应积极随访甚至手术干预。内镜粘膜下剥离术为治疗食管高级别上皮内瘤变的有效方法。     

Pregnancy associated spontaneous coronary artery dissection: A case report and review of literature

BACKGROUNDPregnancy-associated spontaneous coronary artery dissection (PSCAD) is an important cause of chest pain and acute myocardial infarction in pregnant and postpartum women. Pregnancy is considered an isolated risk factor for spontaneous coronary artery dissection. The etiology, pathogenesis, and incidence of PSCAD are not known.CASE SUMMARYWe present a case of a 33-year-old postpartum female who presented with sudden onset chest pain and was diagnosed with spontaneous coronary artery dissection and needed urgent catheterization revealing left anterior descending coronary artery dissection. She underwent emergent coronary artery bypass graft surgery with good post-operative recovery.CONCLUSIONMost patients with PSCAD can be managed conservatively with medical management and have good outcomes. Patients with high-risk presentations benefit from the invasive approach. Coronary artery bypass graft may be required in select few patients based on angiography findings. Due to the risk of recurrent spontaneous coronary artery dissection, subsequent pregnancies are discouraged.     

Endovascular stent-graft placement in aortic dissection: a meta-analysis.

AIMS: This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD). METHODS AND RESULTS: We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively. CONCLUSION: Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.