单孔加一孔联合ERAS在高位直肠及乙状结肠癌中的应用

目的 探讨单孔加一孔腹腔镜手术联合 ERAS 治疗高位直肠及乙状结肠癌的近期疗效。方法 回顾性分析 2017 年 11 月至2018 年 10 月在福建省肿瘤医院胃肠肿瘤外科进行加速康复外科干预的 92 例高位直肠及乙状结肠癌患者资料，根 据手术方式的不同，分为单孔加一孔手术联合快速康复外科组39 例及常规腹腔镜手术联合ERAS 组 53 例，对比两组围术 期情况。结果 两组患者基线资料无明显统计学差异（P ＞ 0.05），且在手术时间、出血量、上下切缘、清扫淋巴结数量及 并发症方面无明显统计学差异（P ＞ 0.05）。但单孔加一孔手术联合ERAS 组较常规手术联合ERAS 组，总切口长度更短 [（6.7±1.1）cm 比（8.5±1.3）cm，P=0.000]，术后首次下床时间更早 [（22.2±5.2）h 比（27.1±7.9）h，P=0.001]，首次排便 时间更早[（70.2±19.8）h比（83.1±20.4）h，P=0.005]，术后第一天C反应蛋白值更低[（43.5±28.6）mg/L比（57.2±33.2） mg/L，P=0.038]，术后住院时间更短 [（7.0±1.7）d 比（8.1±2.1）d，P=0.010]，且术后 2~4 天疼痛评分更低（P ＜ 0.05）。 结论 经验丰富的腔镜医师采用单孔加一孔手术治疗高位直肠及乙状结肠癌并联合 ERAS 干预是安全可行的，且单孔加一孔 手术可减低操作难度，具有疼痛轻、术后恢复快等优势，值得临床推广。     

Surgical outcomes of gastrectomy with D1 lymph node dissection performed for patients with unfavorable clinical conditions

BackgroundGastric cancer (GC) patients with advanced age and/or multiple morbidities have limited expected survival and may not benefit from extended lymph node resection. The aim of this study was to evaluate the surgical outcomes of these GC patients who underwent gastrectomy with D1 dissection.MethodsWe retrospectively reviewed all GC patients who underwent gastrectomy with curative intent from 2009 to 2017. The decision to perform D1 was based on preoperative multidisciplinary meeting, and/or intraoperative clinical judgment.ResultsAmong 460 enrolled patients, 73 (15.9%) underwent D1 lymphadenectomy and 387 (84.1%) D2 lymphadenectomy. Male gender, older age, American Society of Anesthesiologists score (ASA) III/IV, higher neutrophil-to-lymphocyte ratio (NLR) and higher Charlson Comorbidity Index (CCI) were more common in the D1 group. Postoperative major complications were significantly higher in D1 group (24.7% vs 12.4%, p < 0.001) and mostly related to clinical complications. Locoregional recurrence was higher in the D1 group (53.8% vs 39.5%, p = 0.330) however, without statistical significance. No difference was found in disease-free survival (DFS) between D1 and D2 patients with positive lymph nodes (p = 0.192), whereas overall survival was longer in the D2 group (p < 0.001). Multivariate analysis showed a statistically significant impact on survival of age ≥70 years, CCI ≥5, total gastrectomy, D1 lymphadenectomy and advanced stages (III/IV).ConclusionsFrail patients had high surgical mortality even when submitted to D1 dissection. DFS was comparable to D2. Extent of lymphadenectomy in high-risk patients should take in account the expectation of a decrease in surgical risk with the possibility of impairment of long-term survival.     

托特罗定治疗直肠癌术后排尿功能障碍患者的效果观察

目的 探讨托特罗定在直肠癌术后排尿功能障碍患者中的应用效果。方法 选择2016年2月～2019年6月期间于我院接受治疗的85例直肠癌术后排尿功能障碍患者,采用随机数字表法分为对照组(n=42)与观察组(n=43)。两组均连续治疗8周,观察两组治疗前后排尿功能障碍分级,并比较两组治疗前后尿动力学指标,同时记录两组治疗期间不良反应发生情况。结果 治疗8周后,两组入选者排尿功能障碍分级均低于治疗前,且与对照组相比,观察组更低,差异有统计学意义(P0.05);治疗8周后,两组入选者最大尿流率(Mean maximal flow rate,Qmax)、排尿量(Mean voided volume,Vcomp)、最大尿道压(Maximum urethral pressure,MUP)水平均高于治疗前,残余尿量(RVU)水平均低于治疗前,且与对照组相比,观察组Qmax、Vcomp、MUP水平更高,RVU水平更低,差异有统计学意义(P0.05);观察组不良反应发生率(9.30%)与对照组(0.00%)比较,差异无统计学意义(P0.05)。结论托特罗定治疗直肠癌术后排尿功能障碍患者效果显著,利于减轻患者排尿功能障碍,改善尿动力学指标及膀胱过度活动症状,且不良反应较少。     

腰椎术后迟发性硬脊膜撕裂所致脑脊液漏的发病及治疗

目的探讨腰椎术后迟发性硬脊膜撕裂(late presentation of dural tears,LPDT)所致脑脊液漏的发病及治疗方法,为临床管理患者提供新的思路及治疗方案。方法选取自2015年1月至2017年12月于我院腰椎组进行腰椎后路手术的患者,分析患者的一般信息和脑脊液漏情况,根据随访情况及复查情况分析并查找具有LPDT的患者及其治疗方式、并发症以及临床结局。结果共2359例腰椎术后患者纳入研究,脑脊液漏患者共43例(1.82%),术中或术后5天内出现的硬脊膜撕裂(dural tears,DT)伴脑脊液漏患者36例(1.53%),术中发现DT 23例(0.98%),LPDT所致脑脊液漏患者7例(0.30%),其中,2例分别于术后3周、4个月行局部清创+硬脊膜修补手术,5例经卧床休息保守治疗,5例恢复在良好及以上,2例恢复较差,而非延迟性脑脊液漏患者术后恢复未发生较差结局。结论术中未被识别的LPDT所致的脑脊液漏在脊柱术中是一个比较特殊的并发症,需要提高临床认识和予以恰当的治疗,对于有可疑症状的患者应当提高警惕,以帮助患者更好地恢复,减少长期后遗症。     

Bloqueo ecoguiado bajo el músculo multífido para el dolor postoperatorio tras cirugía de columna lumbar: serie prospectiva de casos

We describe a series of 15 patients scheduled for single level lumbar spine decompression with instrumentation receiving ultrasound (US) guided submultifidus block (SMFB). In this series, injections of local anesthetic deep to the multifidus muscle provided reliable block of dorsal rami of spinal nerves at multiple levels. With US, the multifidus muscle can be identified both in axial and parasagittal planes. Needle tip is easily visualized beneath the multifidus and medial to the transverse process. Good quality analgesia was documented by pain scores. There were no adverse events. Further studies are needed to compare this nerve block with routine multimodal analgesia or with the recently described thoracolumbar interfascial plane block to compare safety and analgesic efficacy.     

Bariatric surgery in the elderly: a randomized prospective study comparing safety of sleeve gastrectomy and Roux-en-Y gastric bypass (BASE Trial)

BackgroundThe aging population along with the obesity epidemic has increased the number of older patients undergoing bariatric surgery. Nevertheless, there is still conflicting data regarding surgical safety in this population.ObjectivesThe aim of this study was to compare the surgical morbidity of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for older patients.SettingUniversity hospital, São Paulo, Brazil.MethodsWe performed a prospective randomized clinical trial from September 2017 to May 2019. Obese patients aged ≥65 years were randomized to LSG or LRYGB. Data collection included demographic information, body mass index (BMI), and co-morbidities. We assessed readmission, postoperative complications, and mortality. Complications were scored according to Clavien-Dindo classification.ResultsA total of 36 patients, with a BMI between 35.5 and 52.8 kg/m² were randomized to either LSG (18 patients) or LRYGB (18 patients). The overall complication rate was similar between LSG and LRYGB (3 versus 7, P = .13). Severe complication was more prevalent in LRYGB patients but had no statistically significant difference (0 versus 3, P = .07). Each group had 1 readmission and there was no mortality in 90-day follow-up.ConclusionsMorbidity and mortality rates of bariatric surgery are low in elderly obese patients. Despite not statistically significant, LSG had a lower rate of severe complications compared with LRYGB in this population setting.     

Impact of an enhanced recovery program for cesarean delivery on postoperative opioid use

BackgroundCesarean delivery is one of the most common surgeries performed worldwide and the adoption of enhanced recovery programs for cesarean delivery is gaining popularity. We tested the hypothesis that implementation of an enhanced recovery program for cesarean delivery would be associated with a decrease in postoperative opioid consumption.MethodsWe compared a retrospective cohort of women delivered by elective cesarean delivery (January 1, 2017 to June 30, 2018) to a prospective cohort exposed to the enhanced recovery protocol (July 1, 2018 to December 31, 2018). The primary outcome was inpatient maternal opioid use, measured as total oral morphine equivalents. Secondary outcomes included postoperative 0–10 pain scores, length of stay, 30-day postoperative complication rates, and hospital re-admissions.ResultsData from 541 patients were analyzed. The enhanced recovery cohort used significantly less oral morphine equivalents compared with the pre-enhanced recovery cohort (60.3 mg vs 104.3 mg, P <0.001). The number of patients who required opioid medication within 24 h of discharge was significantly reduced in the enhanced recovery cohort (41.1% vs 74.6%, P <0.001). There were no significant differences in average pain scores (1.6 vs 1.9, P=0.037).ConclusionsThe implementation of an enhanced recovery program for cesarean delivery was associated with a significant reduction in postoperative opioid consumption throughout hospitalization, with average pain scores remaining <2. Implementation of this program was also associated with an increase in the number of patients who were opioid-free 24 h prior to discharge.     

坐骨重叠征与发育性髋关节脱位手术后再脱位的相关性分析

目的提出坐骨重叠征(ischium overlap sign,IOS)的概念,并分析其与发育性髋关节脱位(developmental dysplasia of the hip,DDH)手术后再脱位的关系。方法回顾性分析2013年9月至2017年5月山东大学附属省立医院治疗的88例(105髋)DDH患儿病例资料,其中男童16例、女童72例;平均年龄12(5~24)个月,平均随访时间34(15~59)个月;双侧17例,左侧63髋,右侧42髋;1髋为髋臼发育不良,11髋半脱位,93髋全脱位。术中行髋关节造影检查,按照Bowen标准选择闭合或切开复位石膏固定术。IOS是指在人类位髋关节造影平片上股骨头软骨内缘与坐骨外缘的重叠关系,二者重叠为Ⅰ度,相接为Ⅱ度,分离为Ⅲ度。将93髋全脱位按照IOS分度进行分组,比较组间再脱位发生率。结果 1髋髋臼发育不良和11髋半脱位者IOS均为Ⅰ度。93髋全脱位中IOSⅠ度14髋,Ⅱ度39髋,此两组均行闭合复位石膏固定,无再脱位病例;Ⅲ度40髋中,闭合复位石膏固定17髋,6髋再脱位;切开复位石膏固定23髋,1髋再脱位。本研究发现Ⅲ度组的再脱位发生率(7/40,17.5%)高于其他两组(P=0.006)。IOS为Ⅲ度的40髋中,闭合复位的再脱位发生率(6/17,35.3%)高于切开复位(1/23,4.4%),差异有统计学意义(X^2=4.518,P=0.034)。结论 IOS与DDH术后再脱位有一定的关系,IOS为Ⅲ度的髋关节如行闭合复位,再脱位的风险较高。