A Call for a National Transplant Surgical Quality Improvement Program

The severity of illness in transplant patients and the complexity of transplant operations results in significant postoperative morbidity and mortality. Remarkable efforts have been made by transplant physicians to study and improve organ allocation, graft and patient survival, immunosuppression and the long-term management of post-transplant complications. Less effort has been spent studying the actual transplant operation and systems of acute transplant care. The National Surgical Quality Improvement Program (NSQIP) has provided a standardized approach to quality improvement and has demonstrated significant potential for a reduction in postoperative morbidity and mortality in other surgical disciplines. Medical centers are under increasing pressure to measure surgical quality and the nexus of transplant surgical quality improvement should not lie in the hands of CMS or JACHO, but rather it should be created and developed within the transplant community. The time has come for a national transplant surgical quality improvement program based on the NSQIP infrastructure. Such a proactive approach toward quality improvement from the transplant community is an excellent investment for patients, providers and health care payers.     

下肢动脉硬化性闭塞症介入治疗围手术期并发症分析

目的 总结下肢动脉硬化性闭塞症介入治疗围手术期相关并发症的防治经验.方法 对207例下肢动脉硬化件闭塞症行介入治疗,统计围手术期各种并发症的发生情况,分析并发症的发生率与泛大西洋介入协会(transAtlantic inter-society consensus,TASC)分型分级之间的关系以及糖尿病和冠心病对重要脏器并发症发生率的影响.结果 本组207例,介入手术成功190例.17例失败,其中13例为介入操作失败、4例死于术后重要脏器并发症.围手术期并发症包括穿刺点出血12例、假性动脉瘤4例、消化道出血2例、动脉破裂6例、脑梗塞8例、急性心衰9例、呼衰13例、肾衰6例、支架内血栓形成5例和蓝趾综合征1例.在本组患者的TASC分型中,股腘动脉病变介入治疗并发症的发生率为39.84%(51/128),高于主髂型的18.99%(15/79)(P<0.05);患有糖尿病以及合并糖尿病和冠心病患者重要脏器并发症的发生率分别为27.66%(13/47)和24.49%(12/49),高于无合并症患者的5%(2/40)(P<0.05).结论 下肢动脉硬化性闭塞症介入治疗围手术期并发症发生率较高可能与术中操作不当、病变类型复杂及合并糖尿病和冠心病有关,术前注意合并症的处理及术中选择合理治疗方式、缩短手术时间等可减少并发症的发生.     

Pleural flap to prevent lobar torsion: a novel technique

Lobar torsion is reported as very rare but sometimes catastrophic complication if overlooked during the early postoperative period following a lobectomy, though it is totally preventable. In this novel technique, a piece of parietal pleural flap is harvested from the posterior wall of the chest using a hook diathermy while keeping its upper border as close to the apex as possible. Finally, distal end of the flap is secured to the upper edge of the lobe using a fine monofilament absorbable suture. This procedure not only protects the lobe from rotation but also maintains continuous expansion of the lung in the early postoperative period and may, therefore, be a good option to prevent such a serious complication in selected patients following a lobectomy.     

颈椎前路手术内置物并发症的分析

在颈椎前路减压、植骨、带锁钢板内固定技术日渐成熟的今天,越来越多的医院开展了该项手术。自1998年2月-2005年8月应用该方法治疗颈椎病215例,发生与内置物钢板及钛网相关的并发症14例,为此积累了一定的经验,现总结如下。1临床资料本组215例,男126例,女89例;年龄42～82岁,平均     

压力梯度长袜和间歇充气装置预防恶性肿瘤患者术后下肢深静脉血栓形成的效果

目的 观察单纯应用压力梯度长袜（CS）或与间歇充气装置（IPC）联合使用预防恶性肿瘤患者术后下肢深静脉血栓（DVT）形成的效果及可能的机制。方法 胸科、泌尿外科、肝胆外科恶性肿瘤根治手术患者240例，随机分为4组：对照组、单纯CS组、CS＋IPC全程组、CS＋IPC术后组，每组60例。术后3～8d内行双下肢深静脉超声检查，记录DVT例数及血栓发生部位（大腿或小腿）。随机选择对照组和CS＋IPC全程组各15例患者，分别于术前、切皮后2h及术后24h各采集外周静脉血2ml，测定D-二聚体（D-D）、纤溶酶原激活物抗原（tPA-Ag）、纤溶酶原激活物抑制物（PAI）、血管性血友病因子（vWF）、凝血酶原时间（PT）和活化部分凝血活酶时间（APTT）。结果 术后3-8d对照组、CS＋IPC全程组、CS＋IPC术后组和单纯CS组DVT发生率分别为49．3％、15．0％、23．3％和30．0％（P〈0．05）。所有发生DVT患者中，除CS组发现1例近端DVT外，其余均为远端DVT。发生DVT患者年龄、卧床时间、危险因素个数等与未发生血栓患者相比差异有统计学意义（P〈0．05）。凝血，纤溶指标：与对照组比较，切皮后2h，CS＋IPC全程组vWF升高，D-D、tPA-Ag降低（P〈0．05），术后24h对照组和cs＋IPC全程组间D—D、vWF、tPA-Ag及PAI差异无统计学意义。结论 CS＋IPC全程或术后使用均能降低高危患者术后DVT的发生，其中CS＋IPC全程使用预防效果最好，可能与IPC增加纤溶活性有关。     

我国大陆恶性高热病例的分析

目的 分析我国大陆恶性高热（MH）病例的临床资料，探讨诊断和治疗中应注意的问题。方法 检索中国生物医学文献数据库，收集1978年1月至2004年3月报道的MH病例34例，分析其流行病学特征、发病特点、临床表现、治疗及转归。结果 我国大陆报道的MH病例以青少年居多，男性多于女性，集中在口腔科手术（尤其是唇腭裂修补术）、骨科手术和小儿外科手术（尤其是先天畸形矫治术），典型的临床表现为突然发生的高碳酸血症、体温急剧升高和骨骼肌僵直等。诊断上主要是根据临床表现，尚未建立骨骼肌体外收缩试验方法，治疗上主要是对症处理，缺乏特效药物（丹曲林）。结论 近几年我国大陆MH病例逐渐增加，应加强对MH发病机制的研究，尽快建立MH的实验诊断标准，增强预防、诊断和治疗MH的能力。     

头皮冠状切口的并发症及其防治

目的：对采用头皮冠状切口所引发的并发症进行分析，探讨防治策略。方法：对我科2003-01～2006—07应用头皮冠状切口行颅颌面骨折修复重建、颌面部肿瘤切除与缺损修复、先天性颅颌面畸形矫正的221例中发生并发症的40例进行分析总结。结果：18例出现头皮麻木及感觉异常，9例有较宽切口瘢痕，6例出现脱发，4例发生颞窝凹陷，2例发生头皮下血肿，2例出现单侧面神经颞支损伤，1例发生鼻眶区肥厚。结论：头皮冠状切口具有切口隐蔽、面部疤痕不明显，显露充分的优点，但对其并发症也不容忽视。应根据具体情况选择合适的切口类型，术中精细的解剖、神经血管的良好保护以及正确的缝合方法可减少并发症的发生。     

Wound Botulism Associated with Black Tar Heroin

The incidence of wound botulism is increasing and the epidemiology of the disease is changing. The majority of new cases are associated with injection drug use, in particular, the use of Mexican black tar heroin. This case report and discussion of wound botulism illustrate the following important points: Dysphagia, dysphonia, diplopia, and descending paralysis, in association with injection drug use, should alert the treating physician to the possibility of wound botulism. In such patients, the onset of respiratory failure may be sudden and without clinically obvious signs of respiratory weakness. For the reported patient, maximum inspiratory force measurements were the only reliable indicator of respiratory muscle weakness. This is a measurement not routinely performed in the ED, but may prove essential for patients with suspected wound botulism. To minimize the effect of the botulinum toxin and to decrease length of hospital stay, antitoxin administration and surgical wound debridement should be performed early.     

335例术后全身炎症反应综合征的临床分析

【目的】了解手术创伤对术后全身炎症反应综合征 (SIRS)的影响。【方法】搜集外科重症监护室 (SICU) 335例患者的术后资料 ,分析不同手术组SIRS发病率 ;手术时间、失血量与SIRS持续时间的关系 ;SIRS持续时间与术后并发症的关系。【结果】术后SIRS发病率为 75 8% ,大手术高达 92 4 % ;无并发症患者失血量与SIRS持续时间呈正相关 (r1=0 783,P<0 0 1) ,手术时间与SIRS持续时间呈正相关 (r2 =0 398,P <0 0 1) ;随着SIRS持续时间延长 ,并发症发病率显著增高 (P<0 0 5 )。【结论】术后SIRS发生、发展与手术创伤密切相关 ;监测SIRS进程有助于及早发现并发症