Mini-open thoracoscopically assisted thoracotomy versus video-assisted thoracoscopic surgery for anterior release in thoracic scoliosis and kyphosis: a comparison of operative and radiographic results

BACKGROUND CONTEXT: Combining anterior release and interbody fusion with posterior instrumented fusion is an accepted treatment for severe rigid spinal deformity. Video-assisted thoracoscopic surgery (VATS) and mini-open thoracoscopically assisted thoracotomy (MOTA) are two minimally invasive approaches to the thoracic spine. Both reduce surgical trauma, improve cosmesis and provide effective exposure for release and fusion. Published data and the authors' surgical experience have demonstrated that both techniques are equivalent in degree of release to traditional open thoracotomy, but no comparison between these two minimally invasive alternatives has been published to our knowledge. PURPOSE: This study compared MOTA and VATS under the hypothesis that both result in similar corrections and comparable operative parameters when used in conjunction with posterior instrumented fusion. STUDY DESIGN/SETTING: Retrospective chart review of consecutive case series by two surgeons. PATIENT SAMPLE: Twenty-one (13 female, 8 male) patients underwent MOTA and 24 patients (17 female, 7 male) underwent VATS for anterior release, discectomy and fusion prior to posterior instrumented fusion. OUTCOME MEASURES: Outcomes were measured at a minimum of 1-year follow-up and included radiographic Cobb measurements and operative parameters. METHODS: The indications for surgery included rigid and severe scoliosis or thoracic kyphosis. Data collection included preoperative demographics, number of levels released, primary curve correction, operative time and blood loss. Data were normalized per number of levels released anteriorly. Statistical analysis of results was done using a two-sample t test assuming equal variances with two-tail p values less than .05. RESULTS: More anterior levels were operated on average in the VATS group (6.33 vs. 4.38 levels). Curve correction per anterior level released was similar in both groups (8.7 and 8.8 degrees/level for MOTA and VATS, respectively). There was a significant difference in operative time with MOTA averaging 131.7 minutes and VATS averaging 162.8 minutes. However, a comparison of the operative time per anterior level operated, approached statistical significance in favor of VATS (33.0 vs. 28.4 minutes, p=.08). There was no significant difference in estimated blood loss during the anterior portion of the surgeries. There was a trend toward decreased blood loss per operated level favoring VATS (68.4 vs. 38.9 cc, p=.09). CONCLUSIONS: Both approaches resulted in corrections that compare favorably with open thoracotomy. We suggest that a factor in choosing between these two minimally invasive techniques is the number of thoracic levels requiring release. For four levels or less, MOTA provides an excellent alternative to standard thoracotomy. For five or more levels, VATS provides for excellent exposure of additional levels with the advantages of less operative time and blood loss per operated level.     

Ethics and Society: Filiation in assisted reproduction: potential conflicts and legal implications

Filiation, or a person's parentage, is one of the major componentsof someone's identity, often with important implications forthat person's welfare in social and personal terms. Fertilityspecialists are enjoined to consider the welfare of the child,and this is a legal requirement in assisted reproduction techniquesin the UK. This paper is in three parts, discussing some ofthe potential problems regarding filiation of the prospectivechild born of assisted reproduction techniques, in relationto the use of gametes and embryos. The first two parts concentrateon the status of children born as a result of treatment givenposthumously, and on filiation problems associated with donationof gametes or embryos, and surrogacy. The third part comparesBritish and French legislation with special regard to the welfareof the child, as well as underlining the common trends and principlesenunciated in both legislations. This is particularly appropriateat a time when the European Society for Human Reproduction andEmbryology is about to issue ethical guidelines in assistedreproduction, and when both the Council of Europe and the EuropeanCommission have commissioned studies on the implications ofthe assisted techniques, including those concerning status ofthe potential children.     

Development of computer-assisted simulation procedure to analyze receptor modulatory processes

Summary Experimentally induced changes in neurotransmitter receptors have been analyzed by means of a computer assisted simulation procedure over a wide range of free ligand concentrations. This approach allows to evaluate, for a given range of ligand concentrations, the relative influence of simultaneous variations in binding parameters (i.e. dissociation constant or K_d and in maximal number of binding sites or B_m) and to predict the net and final effect of the experimental condition on the receptor-mediated transmission line. The function representing the changes in bound values versus the respective free ligand concentrations, has been studied analytically on the basis of all the possible values that the percent changes in both K_d and B_m parameters induced by a given experimental condition can assume. A well characterized change in the pattern of bound radioligand could in this way be defined. This approach, developed to show in an immediate and clear way treatment-induce changes in receptor populations or to fit directly rough experimental data expressed as differences in bound values versus free ligand concentrations, seems to be an useful complement to the widely used saturation analysis of binding data.     

卵巢低反应患者大剂量超排卵的助孕结局

在辅助生殖助孕中通常采用控制性卵巢刺激(controlled ovarian hyperstimulation, COS),以获得适当数量的卵子用于体外受精,既希望获得理想的辅助生殖助孕成功率,又能降低卵巢过度刺激并发症.COS中约有9%~24%[1,2]的卵巢低反应发生率.卵巢低反应者获得有效卵子数少、可移植胚胎数少或无胚胎移植、取消治疗周期率高,累计成功率更低等,导致较差的治疗结局,是辅助生殖助孕中面临的棘手问题.针对卵巢低反应者,大多数辅助生殖中心仍会采用增加促性腺激素(Gn)的起始和(或)总用量以期获得提高助孕结局的目的.而大剂量Gn是否为改善低反应患者助孕结局的有效策略却仍存在争议.     

电视硬质气管镜治疗大气道良性肿瘤

目的探讨电视硬质气管镜在大气道良性肿瘤治疗中的价值.方法2002年9月～2005年4月,我院应用电视硬质气管镜治疗大气道良性肿瘤7例,其中气管1例,隆突1例,左主支气管3例,右主支气管2例.手术采用静脉全身麻醉,喷射通气供氧,探查评估气道后,首先冷冻或电凝肿瘤,破坏肿瘤血供,再以活检钳分块取出,蒂部采用冷冻或氩气凝固处理;对于宽蒂肿瘤,内镜下将肿瘤主体清除后中转开胸行气管局部切除吻合术.结果7例手术均顺利,无一例死亡和严重并发症发生.6例气管窄蒂良性肿瘤镜下完整摘除,1例气管膜部宽蒂平滑肌瘤先内镜清除肿瘤主体后中转开胸行气管局部切除.术后病理为错构瘤2例,平滑肌瘤3例,嗜酸性肉芽肿性腺瘤1例,炎症组织1例.7例随访3～36个月,平均17.3月,无肿瘤复发.结论电视硬质气管镜治疗大气道良性肿瘤安全可靠.     

局部麻醉下经电视胸腔镜和小切口开胸诊治胸膜、肺部疾病

目的探讨局部麻醉下经电视胸腔镜和胸部小切口诊治胸膜、肺部疾病的可行性。方法自2002年2月至2005年3月,对30例胸膜、肺疾病患者施行局部麻醉下开胸手术。按手术方法的不同将患者分为两组,小切口开胸组:16例,在局部麻醉下采用胸部小切口在开放性气胸状态下对增厚的胸膜和弥漫性肺疾病进行活组织检查;电视胸腔镜组:14例,在局部麻醉下经胸腔镜在闭合性气胸状态下诊治恶性胸水、复发性气胸等。结果小切口开胸组中行胸膜活检13例,其中10例为恶性肿瘤胸膜转移、胸膜淀粉样变1例、胸膜纤维增生样改变2例;弥漫性肺疾病活检3例,3例中肺间质性纤维化2例、型肺结核1例。电视胸腔镜组14例中,除1例因发现胸腔内有致密粘连而转行全身麻醉下开胸手术外,其余13例均在局部麻醉下完成胸膜活检,复发性气胸肺大泡切除,顽固性胸水的胸膜固定术;电视胸腔镜组中用胸腔镜辅助诊断为恶性胸水4例,肝性胸水1例;胸腔镜辅助治疗10例,其中顽固性(含肝性胸水)胸水行胸膜固定术8例,复发性气胸行肺大泡切除和胸膜固定术2例。两组患者均无手术并发症和死亡。结论局部麻醉下经胸腔镜及胸部小切口能够完成胸膜、肺疾病活检术及简单的手术。该方法经济、微创、对麻醉要求低,有利于临床普遍开展。     

计算机辅助导航骨科手术及医用机器人技术在创伤骨科的应用

本文介绍了计算机辅助导航骨科手术(CAOS)及医用机器人技术在创伤骨科应用中的主要进展、当前在临床应用中存在的主要问题和相关对策,并对其未来的发展趋势进行了预测,同时简要介绍了北京积水潭医院创伤骨科在计算机辅助导航骨科手术及医用机器人技术方面的研究进展。当前骨科手术导航定位所应用的医学图象导引系统已经由使用单一的C型臂、CT等传统影像设备向应用三维C型臂、多模态图像处理系统等新型影像设备转变,基于多模态图像的导航系统将有可能成为导航手术的主流。医用机器人已经在自动化程度和人机交互模式方面,有了长足进展,摆脱了原有工业机器人的结构模式。医学图像后处理技术及其它相关信息技术极大地丰富了导航和机器人外科,只有在不断完善光学定位技术的同时,加大对其它定位方法的研究,才能够提高定位精度;要对相关设备进行开放式结构设计,使不同导航系统的注册软件能够互相兼容,手术器械能够通用,降低设备成本。骨科医生要正确认识计算机辅助导航骨科手术及医用机器人技术,在充分了解CAOS的技术特点、基本原理、操作程序的基础上,对要实施的手术具有深刻的理解,才能开展CAOS手术。目前,迫切需要建立CAOS技术标准、临床适应证和手术操作规范,进行CAOS产品之间的技术比较和评估,便于医生选择合适的CAOS产品。伴随快速发展的信息技术,数字化手术室、智能化微创导航手术系统、医用机器人辅助的远程医疗将有可能成为未来CAOS技术的主要组成部分。     

Computerized diagnosis: implications for clinical education

The advent of the small computer as a basic clinical tool will have a significant impact on clinical practice and medical training. The application of probability theory to clinical diagnosis has led to the development of several practical diagnostic programs which run on small computers. Expert systems--interactive programs which function as 'electronic consultants'--have now been successfully developed for a number of clinical situations. Experience with two of these, INTERNIST/CADUCEUS and MYCIN, has provided insight into problems and prospects for expert systems in medicine. Less complex programs, particularly those employing clinical prediction rules, and expert system shells, seem well suited for clinical environments. Although computerized medical diagnosis holds great promise as an aid to clinicians, its success will largely be determined by the quality of the information that clinicians provide for analysis. A brief review of the status of bedside diagnosis reveals that data-gathering strategies and techniques must be better understood. In order to take full advantage of computer programs for diagnosis, basic diagnostic skills must be more heavily emphasized in clinical training.     

喉部CT仿真内窥镜成像技术的探讨

目的：探讨喉部CT仿真内窥镜(CT virtual endoscopy，CTVE)的成像质量及其影响因素。方法：对84例喉部螺旋CT扫描者行CTVE成像，根据喉腔内部结构、病灶、黏膜皱襞的显示情况和有无伪影将CTVE图像分为3级，分别比较CTVE技术在不同的扫描层厚、重建层厚及阈值的情况下图像质量的优劣。结果：CT原始扫描层厚为2mm、3mm分别与5mm、8mm的CTVE图像质量相比较，有显著性差异(P＜0．05)；重建层厚为2mm、3mm与5mm相比较，均有显著性差异(P＜0．05)；阈值为 -800— -600HU与阈值为-300HU相比较，有显著性差异(P＜0．05)。结论：不同的CT原始扫描层厚、重建层厚及阈值对CTVE图像的质量影响有明显差异。选用合适的原始扫描参数及重建参数，可以提高CTVE图像的质量，对喉部疾病的诊断很有帮助。     

助孕技术的发展对人类生殖伦理观念的冲击

新近发展的助孕技术给众多不孕夫妇带来为人父母的喜悦之时，也对人们传统的生殖伦理观念形成冲击并挑战现存法律制度。人们不仅要肯定助孕技术的合理性，也要警惕其所产生的潜在的破坏性影响。合理利用该技术和制定相应的法规是避免出现伦理和社会混乱的有效途径。