Laparoscopic anatomic segmentectomy 8 using the outer-Laennec approach

BackgroundLaparoscopic anatomic segmentectomy 8 is a difficult and technically demanding procedure owing to exposure of two major hepatic veins. To safely and accurately perform this procedure, the outer-Laennec approach was developed (Kiguchi et al., 2019) [1], which is based on the structure of Laennec's capsule (Sugioka et al., 2017; Laennec, 1802; Hayashi et al., 2008) [2,3,4]. The capsule comprises two layers: the hepatic and cardiac Laennec's capsules surrounding the major hepatic vein (Kiguchi et al., 2019) [1]. The outer-Laennec approach maintains the strength of the hepatic vein wall, preserving the two layers of Laennec's capsule. We describe a laparoscopic anatomic segmentectomy 8 using the outer-Laennec approach for hepatocellular carcinoma (HCC).MethodsParenchymal transection was initiated to expose the root of the middle hepatic vein and right hepatic vein with the cranio-caudal view. The space between the hepatic Laennec's capsule and liver parenchyma was invaded using the outer-Laennec approach. The cavitron ultrasonic surgical aspirator was used from the root side toward the peripheral side to retain the hepatic Laennec's capsule on the vein wall and avoid splitting the bifurcation of the hepatic vein. The parenchymal dissection process was completed by an S8 Glissonean pedicle dissection.ResultsThe operative time was 296 min, and the estimated blood loss was 10 mL. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. A pathological examination confirmed that the 2.0-cm mass was HCC with negative margins.ConclusionThe outer-Laennec approach is feasible and useful to standardize the safe laparoscopic anatomic segmentectomy 8.     

基于VAS评价右美托咪定在宫颈癌根治术后镇痛及术后快速康复中的临床效果

目的:研究右美托咪定在宫颈癌根治术后镇痛及术后快速康复中的临床应用效果。方法:将2015年7月至2018年7月在本院行宫颈癌根治术的86例患者随机分为对照组和观察组各43例。对照组术后镇痛采用舒芬太尼和格拉司琼，观察组术后镇痛加用右美托咪定。采用视觉模拟评分法（VAS）评价患者术后1 h、6 h、12 h、24 h、48 h疼痛情况，采用Ramesay评分法评价患者不同时间点镇静状况，记录并比较两组患者不同时间点收缩压、舒张压、心率及呼吸频率变化，比较两组患者不良反应发生情况。结果:观察组患者术后6 h、12 h、24 h、48 h VAS评分均明显低于对照组（P＜0.05），Ramesay评分均明显高于对照组（P＜0.05）；观察组和对照组患者术后不同时间点呼吸频率比较，差异无统计学意义，但术后6 h、12 h、24 h观察组患者收缩压、心率均明显低于对照组（P＜0.05），术后1 h、6 h观察组患者舒张压明显低于对照组（P＜0.05）；观察组患者恶心呕吐、高血压发生率较对照组明显减低。结论:右美托咪定用于宫颈癌根治术后镇痛，可以提高镇痛镇静效果，稳定患者血流动力学，有助于术后快速康复。     

手术室护理干预对腹腔镜下结直肠肿瘤切除术患者术后康复的影响

目的探讨手术室护理干预对腹腔镜下结直肠肿瘤切除术患者术后康复的影响。方法选取2015年3月至2018年8月间陕西安康市中心医院收治的80例行腹腔镜下结直肠肿瘤切除患者,采用随机数表法分为观察组和对照组,每组40例。对照组患者采用常规护理,观察组患者在常规护理基础上采用手术室护理干预,比较两组患者术后恢复、负面情绪、生活质量及并发症等情况。结果观察组患者手术出血量、手术时间、肠鸣音恢复时间、肠蠕动恢复时间和下床时间均少于对照组,差异均有统计学意义(均P<0.05)。干预后,观察组患者焦虑和抑郁评分均低于对照组,差异均有统计学意义(均P<0.05)。干预后,观察组患者躯体功能、社会支持、疼痛、精神健康、社会功能、情绪、心理状态和总体健康评分均高于对照组,差异均有统计学意义(均P<0.05)。观察组患者不良反应率为5.0%,低于对照组的20.0%,差异有统计学意义(P<0.05)。观察组患者护理满意度为92.5%,高于对照组的77.5%,差异有统计学意义(P<0.05)。结论手术室护理干预可减少腹腔镜下结直肠肿瘤切除患者手术出血量、手术时间,缩短恢复时间,改善负面情绪,减少不良反应,提高生活质量和护理满意度。     

Impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy

ObjectivesTo determine the impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy.Material and methodsA single-center retrospective study was conducted for a 5-year period in a university hospital center, including 605 patients undergoing total thyroidectomy, 52 of whom had mediastinal-recurrent cellular and lymph-node dissection.EndpointsThe main endpoint was intraoperative number of parathyroid glands as predictor of parathyroid hormone (PTH) level and postoperative hypocalcemia. The secondary endpoint was the correlation between associated mediastinal-recurrent cellular and lymph-node dissection and incidental parathyroidectomy and its impact on PTH level and calcemia in the immediate postoperative period and at 1 month.Results161 patients (26.61%) showed hypocalcemia in the immediate postoperative period and 12 (1.98%) at 1 month. Mediastinal-recurrent cellular and lymph-node dissection increased incidental parathyroidectomy risk 4.6-fold. Mediastinal-recurrent cellular and lymph-node dissection was associated with a statistically “suggestive” decrease in day-1 calcemia (P = 0.03), and no significant decrease at 1 month (P = 0.52). Incidental parathyroidectomy (6.7% of cases with parathyroidectomy versus 1.3% without) did not significantly increase the rate of early hypocalcemia (P = 0.28), but was associated with a “suggestive” worsening at 1 month (P = 0.02).ConclusionHypocalcemia after total thyroidectomy is a complex, probably multifactorial issue. Systematic parathyroid gland identification is not recommended due to the increased risk of gland lesion, mainly by devascularization. Incidental parathyroidectomy may induce hypocalcemia at 1 month postoperatively (statistically “suggestive” association).     

Circumferential Resection Margin as a Hospital Quality Assessment Tool for Rectal Cancer Surgery

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甲状旁腺切除术用于难治性肾性继发性甲状旁腺功能亢进的安全性及近远疗效

背景与目的:甲状旁腺切除术(PTX)是治疗药物不能控制的难治性肾性继发性甲状旁腺功能亢进症(SHPT)的重要手段,但PTX术后仍有可能发生永久性甲状旁腺功能减退,无动力性骨病或难治性骨软化症,且国内尚缺乏对PTX术后远期的疗效观察的研究。本研究进一步评价PTX治疗难治性肾性SHPT的安全性与近远期疗效。方法:纳入2011年1月—2014年12月在安徽医科大学第二附属医院行PTX治疗的139例伴有难治性肾性SHPT的维持性透析患者。收集患者术前及术后3 d、6个月及1、2、3年的临床资料、血全段甲状旁腺激素(iPTH)、血钙、血磷、血红蛋白(Hb)及红细胞压积(Hct)等,观察并记录术后症状缓解情况、术后并发症和随访情况。结果:139例患者的PTX手术成功率为95.7%(133/139),术中共计切除甲状旁腺腺体537枚,平均切除3.86枚/例。12例(8.6%)术后发生一过性喉返神经损伤,其中声音嘶哑9例(6.5%),饮水呛咳3例(2.2%),未予处理术后3个月内均自行好转。术后低钙血症或缺乏维生素D者120例(86.3%),给予西那卡塞、补钙及补充活性维生素D治疗后得到有效控制。全组未发生切口感染、出血、窒息及甲状腺功能减退等外科并发症。患者的贫血状况均有不同程度地改善,Hb和Hct术后6个月明显升高并在随访期间保持稳定;术后iPTH明显降低,术后3 d的血钙、磷、钙磷乘积水平最低,随访3年仍低于手术前,所有变化与术前均有统计学差异(均P0.05)。随访期间无死亡病例。患者术前的骨痛、顽固性皮肤瘙痒、失眠、异位钙化、肌无力伴萎缩症状在术后1 d即明显缓解;身高缩短、骨骼畸形患者随访期间无进行性加重;纳差、全身营养状况及自理能力术后3个月内不同程度地改善。11例(7.9%)持续性SHPT,包括4例(2.9%)术中未完全切除甲状旁腺腺体,1例(0.7%)术中1枚腺体较小而未切除完全,6例(4.3%)术后检查存在纵隔异位甲状旁腺。随访期间,5例(3.5%)腺体未切除完全者的iPTH均800 pg/mL,肌无力及顽固性皮肤瘙痒临床症状明显,再次行PTX;6例(4.3%)存在异位甲状旁腺腺体者,因手术风险较大患者拒绝再次手术,予以药物治疗;8例(5.8%)术后复发,其中6例(4.3%)系前臂移植物复发所致,均在局麻下行前臂皮下移植物切除;2例(1.4%)系颈部原位残留腺体过度增生,予以二次手术,术后症状缓解。所有进行二次手术的患者在随访结束时无明显的临床症状,均未复发。结论:PTX可改善难治性肾性SHPT患者临床症状、贫血及钙磷代谢,且近远期疗效均较好,是治疗难治性SHPT的安全有效方法。     

LCR、PVI与IVCrvi目标导向液体治疗对单肺通气老年全腔镜食管癌根治术患者血流动力学的影响

目的分析乳酸清除率(LCR)、脉搏变异指数(PVI)与下腔静脉内径呼吸变异指数(IVCrvi)液体治疗对单肺通气老年全腔镜食管癌根治术患者血流动力学的影响。方法将拟行单肺通气全腔镜食管癌根治术的106例老年食管癌患者随机均分为对照组和观察组。对照组术中给予常规液体治疗,观察组术中给予以LCR、PVI与IVCrvi为目标导向的液体治疗。比较两组术前(T0)、单肺通气前(T1)、单肺通气15 min(T2)、单肺通气1 h(T3)及单肺通气结束时(T4)的心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、每搏输出量变异度(SVV)和心脏指数(CI)。比较两组液体出入量及药物应用情况。同时记录术前和术后肺功能参数。结果两组各时间点HR比较差异均无统计学意义(P＞0.05),观察组T2~T4时间点MAP、CI和SVV、LCR高于对照组,CVP、PVI、IVCrvi低于对照组(P＜0.05)。观察组单肺通气时间、晶体液用量、总输液量、尿量、出血量及使用去氧肾上腺素占比低于对照组,胶体液用量高于对照组(P＜0.05)。观察组术后第1秒用力呼气量(FEV1)、用力肺活量(FVC)、FEV1/FVC均高于对照组(P＜0.05)。结论以LCR、PVI与IVCrvi为目标导向的液体治疗可稳定单肺通气老年患者全腔镜食管癌根治术患者的血流动力学。     

2 μm激光整块切除与电切治疗非肌层浸润性膀胱癌的临床分析

目的:比较2 μm激光整块切除与电切治疗非肌层浸润性膀胱癌的有效性及安全性。方法:回顾性分析2015年4月-2017年4月分别采用经尿道2微米激光整块切除(50例)和经尿道电切(48例)治疗非肌层浸润性膀胱癌患者临床随访资料。结果:所有患者手术均顺利完成，激光组与电切组患者手术时间相当，两组比较差异无统计学意义(P>0.05)，激光组患者留置尿管、膀胱冲洗及住院时间均少于电切组，比较差异有统计学意义(P<0.05)；激光组患者并发症发生率、一年复发率及术区复发率低于电切组，两组比较差异均有统计学意义(P<0.05)；激光组术后病理含肌层率高于电切组，两组比较差异有统计学意义(P<0.05)。结论:经尿道2微米激光整块切除治疗非肌层浸润性膀胱癌是一种安全、有效的治疗方式且术后肿瘤分期精确、减少肿瘤残留，是治疗非肌层浸润性膀胱癌较好的手术治疗选择，值得临床上推广应用。