机器人辅助经尿道前列腺水消融术的临床应用进展

随着前列腺增生微创治疗的不断发展,机器人系统也被广泛引入其治疗当中,相比于机器人腹腔镜手术来说,本文着重介绍近年新出现的辅助水消融的自动化机器人系统。该系统经尿道的入路方式比传统腹腔镜机器人手术损伤更小,而且其处理系统相对简单,便于新手操作,从而降低了学习曲线,减少了手术时间和相关并发症。本文通过综述国外研究经验,为国内引入此技术提供参考借鉴。     

Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection Following Total Hip or Knee Arthroplasty Is Associated With High Attrition Rate and Mortality

BackgroundWe sought to determine the ultimate fate of patients undergoing resection arthroplasty as a first stage in the process of 2-stage exchange and evaluate risk factors for modes of failure.MethodsA retrospective case study was performed including all patients with minimum 2-year follow-up who underwent first-stage resection of a hip or knee periprosthetic joint infection from 2008 to 2015. Patient demographics, laboratory, and health status variables were collected. The primary outcome analyzed was defined as failure to achieve an infection-free 2-stage revision. Univariate pairwise comparison followed by multivariate regression analysis was used to determine risk factors for failure outcomes.ResultsEighty-nine patients underwent resection arthroplasty in a planned 2-stage exchange protocol (27 hips, 62 knees). Mean age was 64 years (range, 43-84), 56.2% were males, and mean follow-up was 56.3 months. Also, 68.5% (61/89) of patients underwent second-stage revision. Of the 61 patients who complete a 2-stage protocol, 14.8% (9/61) of patients failed with diagnosis of repeat or recurrent infection. Mortality rate was 23.6%. Multivariate analysis identified risk factors for failure to achieve an infection-free 2-stage revision as polymicrobial infection (P < .004; adjusted odds ratio [AOR], 7.8; 95% confidence interval [CI], 2.1-29.0), McPherson extremity grade 3 (P < .024; AOR, 4.1; 95% CI, 1.2-14.3), and history of prior resection (P < .013; AOR, 4.7; 95% CI, 1.4-16.4).ConclusionPatients undergoing resection arthroplasty for periprosthetic joint infection are at high risk of death (24%) and failure to complete the 2-stage protocol (32%). Those who complete the 2-stage protocol have a 15% rate of reinfection at 4.5-year follow-up.     

肝内胆管癌术前评估要点

肝内胆管癌（ICC）是发病率仅次于肝细胞癌的原发性肝癌，其恶性程度高，预后差。近年来，ICC的发病率逐步上升。根治性手术切除是目前可能使病人获得长期生存最有效的治疗方式，但根治性切除率低、术后复发率高仍是外科医生和ICC病人共同面临的巨大阻碍。然而由于ICC发病隐匿和恶性程度高的特性使很多病人初诊时便丧失了手术治疗的机会。因此，早期筛查、准确临床诊断、充分术前评估及完备精准的手术方案是手术赖以顺利实施的保障。癌胚抗原（CEA）和CA19-9对ICC的诊断具有一定价值。影像学检查是诊断ICC的最重要手段。腹部超声是临床第一线的早期筛查手段；CT和MRI是临床上用于ICC最常用的影像学检查。三维重建技术为术前残肝体积预估，手术方案制定提供更直接更精准的信息。建立能准确预测ICC预后的分期系统非常重要。术前减黄是否需要尚存争议。残肝体积和肿瘤是否转移是判断手术可切除性的两个要点。腹腔镜探查、腹腔镜超声检查及术中快速冷冻活检是判断是否可实施根治性切除的重要手段。     

Comparison of Gap Balancing vs Measured Resection Technique in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique per Knee

BackgroundTotal knee arthroplasty requires careful surgical technique to attain the goal of a well-aligned and symmetrically balanced knee. Soft tissue balance and correct femoral component rotation are paramount in achieving these goals. The two competing techniques to select femoral component rotation and soft tissue balance are the gap balance technique and the measured resection technique.MethodsWe performed a randomized, prospective study to compare the two techniques in patients undergoing simultaneous bilateral total knee arthroplasty, whereby one technique was performed in each knee. Fifty (50) subjects were enrolled into the study. The inclusion criteria were osteoarthritic varus knee deformities with similar deformities in both knees. Subjects were followed up for a minimum of two years.ResultsThe knees balanced via the gap balance technique had significantly more posterior medial bone removed from the femur than those knees balanced via the measured resection technique (P < .001). Knees in the gap balance group tended to require more medial knee releases in extension and tended to have smaller sized femoral components as a result of cutting more bone from the femur in flexion. The modular tibial polyethylene bearing tended to be thicker in the gap balance group. Despite these differences, average knee flexion and functional revised Oxford Knee Scores at 2-year follow-up were not statistically different.ConclusionAt 2-year follow-up, there were no differences between the function and scores using the two techniques. Long-term follow-up will be necessary to evaluate any differences in long-term durability.     

Patient frailty predicts worse perioperative outcomes and higher cost after radical cystectomy

Background: Relatively few studies investigated the importance of frailty in radical cystectomy (RC) patients. We tested the ability of frailty, using the Johns Hopkins Adjusted Clinical Groups indicator, to predict early perioperative outcomes after RC.Methods: RC patients were identified within the National Inpatient Sample database (2000–2015). The effect of frailty, age and Charlson Comorbidity Index were tested in five separate multivariable models predicting: (1) complications, (2) failure to rescue (FTR), (3) in-hospital mortality, (4) length of stay (LOS) and (5) total hospital charges (THCs). All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.Results: Of 23,967 RC patients, 5833 (24.3%) were frail, 7721 (32.2%) were aged ≥75 years and 2832 (11.8%) had CCI ≥2. Frailty, age ≥75 years and CCI ≥2 were non-overlapping in 86.3% of the cohort. Any two or three of these features were recorded in 12.4 and 1.3%, respectively. Frailty was an independent predictor of all five examined endpoints and the magnitude of its association was stronger or at least equal than that of age ≥75 years and CCI ≥2.Conclusion: Frailty, advanced age and comorbidities represent non-overlapping patients’ characteristics. Of those, frailty represents the most consistent and strongest predictor of early adverse outcomes after RC. Ideally, all three indicators should be considered in retrospective, as well as prospective analyses. Pre-surgical recognition of frail patients should be ideally incorporate in clinical practice in order to address these patients to multimodal pre-habilitation programs that may potentially improve the perioperative prognosis.     

Lingual lymph nodes: Anatomy,clinical considerations,and oncological significance

Lingual lymph nodes are an inconstant group of in-transit nodes, which are located on the route of lymph drainage from the tongue mucosa to the regional nodes in neck levels I and II. There is growing academic data on the metastatic spread of oral cancer, particularly regarding the spreading of oral tongue squamous cell carcinoma to lingual nodes. These nodes are not currently included in diagnostic and treatment protocols for oral tongue cancer. Combined information on surgical anatomy, clinical observations, means of detection, and prognostic value is presented. Anatomically obtained incidence of lingual nodes ranges from 8.6% to 30.2%. Incidence of lingual lymph node metastasis ranges from 1.3% to 17.1%. It is clear that lymph nodes that bear intervening tissues from the floor of the mouth should be removed to improve loco-regional control. Extended resection volume, which is required for the surgical treatment of lingual node metastasis, cannot be implied to every tongue cancer patient. As these lesions significantly influence prognosis, special efforts of their detection must be made. Reasonably, every tongue cancer patient must be investigated for the existence of lingual lymph node metastasis. Lymphographic tracing methods, which are currently implied for sentinel lymph node biopsies, may improve the detection of lingual lymph nodes.