巨脾大部切除术后残脾T、B淋巴细胞分布与定量研究

目的 探讨巨脾大部切除后残脾组织内T、B淋巴细胞浸润情况.方法 收集门静脉高压症患者巨脾标本13例,术后8年穿刺获取残脾标本13例,另设外伤性脾组织13例作对照.采用免疫组化染色,光镜下观察T、B淋巴细胞分布并计数.结果 T、B淋巴细胞在残脾组分别为(59.769±9.429)个/10-5像素面积、(10.822±1.938)个/10-5像素面积;巨脾组为(34.715±3.497)个/10-5像素面积、(2.369±0.664)个/10-5像素面积;对照组为(48.229±14.869)个/10-5像素面积、(6.844±0.807)个/10-5像素面积.残脾组与巨脾组与对照组比较差异有统计学意义(P＜0.05),巨脾组与对照组比较差异亦有统计学意义(P＜0.05).结论 巨脾大部切除后,残脾单位面积T、B淋巴细胞数目明显增加,提示残脾的免疫功能可能有所改善.     

Minimally invasive splenectomy in grade IV splenic trauma: A case report associated with high-grade renal trauma

Introduction and importanceIn closed abdominal trauma, the spleen is the most frequently injured organ (30–45%). Splenic lesions grades IV-V have higher failure rates with nonoperative management (NOM). The minimally invasive approach is an alternative when NOM fails. This is the first reported case of a patient with splenic and left renal trauma, both grade IV, with combined management, which consisted of a minimally invasive surgical resolution of the splenic trauma and a conservative management of the renal trauma, with a satisfactory recovery of the patient. This contributes to understanding the benefits of minimally invasive surgery in moderate splenic trauma associated with other high-grade injuries.Case presentationWe present a 45-year-old woman with a multiple trauma after a motorbike vs car traffic accident. On physical examination, she was hemodynamically stable, with abdominal guarding and generalized rebound tenderness associated with multiple upper and lower limb fractures. An abdominal CT scan revealed grade IV splenic and left renal trauma, with moderate hemoperitoneum. A minimally invasive laparoscopic approach for hemoperitoneum drainage and splenectomy was performed.Clinical discussionThere is currently no consensus to define the indications for minimally invasive treatment on splenic trauma. While laparotomy is the standard treatment, it is not without potential severe complications, while laparoscopy providing a treatment option in selected cases with hemodynamic stability.ConclusionThe role of the minimally invasive approach is safe and feasible in selected patients with high-grade splenic lesions and hemodynamic stability, including the association with other organic lesions such as kidney trauma.     

脾切除术在成人不明原因发热伴明显脾肿大诊治中的意义

目的分析总结脾切除术在成人不明原因发热伴明显脾脏肿大病人诊治中的意义及其围手术期的处理。方法统计分析1993—2004年我院22例成人不明原因发热伴明显脾肿大并接受脾切除术病人的临床资料,包括发热的时间、脾脏大小、肝脾功能、术后肝脾病理结果、血小板变化、术后发热改善情况、术后并发症和手术死亡率等。结果术后有7例病人不再发热(31.8%),体温逐渐降至正常。3例病人住院期间死亡,其中,2例死亡原因与手术有关,故手术相关的死亡率为9.0%(2/22)。另外1例脾非何杰金氏淋巴瘤病人在术后2个月死于化疗引起的感染。22例术后病理分别是:5例脾单纯性的淤血肿大、5例脾非何杰金氏淋巴瘤、3例脾中性粒细胞白血病、5例不明原因的脾髓外造血、2例脾嗜血细胞综合征、1例脾结节病和1例脾嗜酸细胞浸润。22例术后血小板计数都显著上升(124.7±81.4)×10~9/L vs(332.5±152.6)×10~9/L(P=0.0024,ANOVA)。结论对于长期发热和脾脏肿大病人,脾切除有积极意义:一定程度上可以明确诊断、纠正脾亢,同时,切除脾脏本身也是去除了一个巨大的病灶,还可以解除巨脾对腹腔的压力。但要重视这类病人的围手术期处理,以降低术后并发症和死亡率。     

脾切除对不明原因发热伴脾肿大病人的临床意义

目的探讨不明原因发热伴脾肿大时行脾切除术的临床意义及围手术期处理方法。方法回顾性分析我院1990年1月~2005年12月收治的不明原因发热伴脾肿大病人43例的临床资料。本组病例均行脾切除术,并取肝组织及腹腔淋巴结活检,以明确病理诊断。结果本组43例中,最终明确诊断者40例,占93.0%。其中,以血液系统恶性疾病最多见,占60.6%。大部分病人术后均接受了正规化疗,病情缓解。术后并发症发生率为25.6%,以感染最为常见。脾切除术后1月内死亡2例。结论对于不能明确诊断的发热伴脾肿大的病人,脾切除术具有十分重要的临床意义,应尽早施行。     

门静脉高压巨脾大部切除后残脾神经分布与定量研究

目的：观察门静脉高压巨脾大部切除后残脾神经纤维分布与密度变化,评估残脾保留的价值。 方法：选取门静脉高压脾肿大行脾大部切除并残脾腹后固定术患者13例,收集患者术后切取的巨脾组织,以及术后8年穿刺获取的残脾组织,另取外伤性脾组织13例为正常对照。采用免疫组化法检测脾神经肽Y（NPY）和神经丝蛋白200（NF 200）阳性神经纤维分布及密度。 结果：3组脾组织NPY和NF200阳性神经纤维的分布部位大致相同,但两者在巨脾组织中的密度明显较高。红髓部分的定量分析显示,巨脾组织NPY与NF200阳性神经纤维密度均明显高于残脾组织和正常脾组织（均P<0.05）,而两种阳性神经纤维密度在残脾组织与正常脾组织间差异无统计学意义（均P>0.05）。 结论：巨脾大部切除术后残脾神经纤维分布及含量与正常脾大致相同,提示解除高压环境后,残脾神经功能能逐渐恢复正常。     

Abdominal wall hernia and aortic injury secondary to blunt trauma: Case report and review of the literature

INTRODUCTION

Traumatic abdominal wall hernia (TAWH) and traumatic abdominal aortic injury (TAAI) are two uncommon complications secondary to blunt trauma. In both TAWH and TAAI, reported cases are often associated with poly-trauma. TAWH may be initially missed if more pressing issues are identified during the patient''s primary survey. TAAI may be an incidental finding on imaging or, if severe, a cause of an acute abdomen and hemodynamic abnormality.

PRESENTATION OF CASE

A 54-year-old white male suffered a TAWH and TAAI (pseudoaneurysm) due to severe blunt trauma. TAWH was apparent on physical exam and the TAAI was suspected on computed tomography (CT). The patient''s TAWH was managed with a series of abdominal explorations and the TAAI was repaired with endovascular stenting.

DISCUSSION

TAWH and TAAI are commonly due to severe blunt trauma from motor vehicle collisions. Diagnosis is made through physical exam, imaging studies, or surgical exploration. A variety of surgical techniques achieve technical success.

CONCLUSION

The patient with blunt trauma to the abdomen is at risk for TAWH and TAAI, which are often associated with other injuries. Investigations should include thorough clinical exam through secondary survey and radiologic imaging in the hemodynamically normal patient.     

Sudden death from contusion of the right atrium after blunt chest trauma: case report and review of the literature

Occult cardiac injury following blunt trauma is more common than generally suspected. Myocardial lesions range from myocardial contusion to cardiac rupture. Myocardial contusion is not uncommon, it is usually a benign disorder which often remains undiagnosed. We report the case of a previously healthy 29-year-old man who was involved in a fight and suffered from blunt heart injury leading to contusion of the right atrium. The patient died soon after the injury and before admission to the Hospital. The diagnosis was made at autopsy. The present case is of special interest because of the unusual eliciting event and the rarity of the contusion site (right atrium). It is reported in order to raise the index of suspicion in physicians treating patients involved in a fight and aid in prompt diagnosis of myocardial contusion.     

Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience

BACKGROUND: State-legislated trauma systems have been enacted in an attempt to improve trauma care. Blunt splenic injury incidence without a legislated trauma system was examined for changes in care with a hypothesis that a voluntary system may perform equally with a legislated system. METHODS: Data from a statewide discharge database for the years 1993 to 2002 were examined. RESULTS: There were 276,425 trauma admissions overall, with blunt splenic injury occurring in 1.76%. Average Injury Severity Score (ISS) increased in trauma centers and decreased in the community. Trauma centers (TC) had more multisystem injuries. Splenic injury diagnosis increased 44% in TC between the early and late periods but only 7% in community facilities. Splenectomies increased 16% in TC but declined 16% in community hospital. Splenic salvage rate improved at both types of facilities. CONCLUSIONS: Splenic salvage rates improved over time in hospitals with no formal trauma system. Community hospitals cared for more than 50% of splenic injuries but transferred complex multisystem injuries, including splenic injuries, suggesting evolving care. Non-invasive imaging has increased the recognition of splenic injuries in both community hospitals and TC. Splenectomies are performed less, but have increased in TC with increasing ISS scores.     

巨脾大部切除后残脾纤维组织的分布与定量研究

目的 探讨门脉高压症巨脾大部切除后残脾组织内胶原、弹力及网状纤维的变化,为巨脾保脾术寻找理论依据.方法 选取门静脉高压症脾肿大患者13例,采用手术和穿刺活检获取脾组织标本,分为巨脾组和残脾组.另设外伤性脾破裂标本13例为对照组.应用Masson染色、EVG染色及改良氨银染色,光镜下进行比较分析.结果 胶原纤维、弹力纤维、网状纤维含量,残脾组分别为(7.81±0.83)％、(7.72±3.42)％、(4.67±1.09)％;巨脾组分别为(7.76±0.81)％、(7.21±3.18)％、(4.79±1.20)％;对照组分别为(3.21±0.51)％、(1.67±3.22)％、(10.92±0.86)％.残脾组胶原、弹力、网状纤维含量与巨脾组比较差异无统计学意义(P＞0.05).残脾组与巨脾组胶原和弹力纤维含量比对照组增多,差异有统计学意义(P＜0.05);残脾组和巨脾组网状纤维含量比对照组减少,差异有统计学意义(P＜0.05).结论 巨脾大部切除残脾固定腹膜后,不会加重脾组织的纤维化程度.     

A safe surgical technique for the partial resection of the ruptured spleen. A clinical report

A consecutive series of 11 patients with an acute blunt splenic injury were treated with a ‘safe resection’ technique. 57% of the injured spleens (range 35–100%) were saved. None of the patients had any signs of secondary bleeding in control CT scan and the mortality was zero. No second-look laparotomies were performed. Follow-up time was at least two months (range 2 month–6 yr). Operation time was in average 120 min. Total mean peroperative bleeding was 1400 ml.

Partial resection may offer patient a change for normal function of the injured spleen. However, it is not yet known what is the critical mass of spleen tissue needed for humans. The follow-up time of the present study is still too short to estimate this fact, but further studies may show the benefit of the present method in avoiding serious long term immunological complications of splenectomy.

This present study introduces a novel technique for partial resection of injured spleen. Operation can be performed safely and quickly with a complication risk comparable to splenectomy. Resection is applicable even for multi-trauma patients.     

Perforation of gastroesophageal junction,stomach, and diaphragm following blunt abdominal trauma: A near miss: A case report

IntroductionBlunt abdominal trauma causing Gastro-esophageal junction (GEJ), diaphragm, and gastric perforation in children is a very rare occurrence. However, the injury is serious and life-threatening with significant morbidity and mortality.Presentation of caseWe report an unusual case of a 14-year-old boy with an accidental fall from the tree with blunt abdomen trauma with a perforating injury to GEJ, stomach, and diaphragm.DiscussionMultiple vital organs in the abdominal cavity are vulnerable to damage in blunt abdominal trauma. The rarity of perforation, diagnostic delay, and early septic occurrence sums up to higher patient morbidity and mortality. A high degree of suspicion and urgent laparotomy and surgical repair forms the cornerstone in management.ConclusionEarly suspicion along with effective resuscitation and early laparotomy and surgical repair is crucial for survival and optimal outcome of the patient.     

Outcome of total splenectomy with portosystemic shunt for massive splenomegaly and variceal bleeding in cystic fibrosis

Multilobular biliary cirrhosis and portal hypertension are frequent complications of cystic fibrosis liver disease, leading to esophageal varices and splenomegaly. Therapy is focused on variceal bleeding control; however, reduction of spleen volume is also important to restore gastric volume and resolve invalidating abdominal discomfort. We report long-term follow up (median duration, 5.5 years; range, 14 months-21.5 years) of 6 patients with cystic fibrosis (4 men, 2 women; median age, 14 years; range, 8-18 years) who underwent splenectomy with a splenorenal shunt operation. Three patients received elective surgery for massive splenomegaly with important abdominal discomfort, recurrent variceal bleeding, and hypersplenism. Three were urgently treated to control variceal bleeding after several sessions of sclerotherapy. All but 2 received antipneumococcal vaccination before surgery. Four patients had a weight gain of 10% within 3 months of surgery, and 3 developed spontaneous puberty. Lung function remained stable, and there was an overall reduction of respiratory tract infections. The youngest patient, however, died of overwhelming septicemia during treatment with steroids. Although total splenectomy has important risks, in well-selected cases, it can have benefits. Immuno- and chemoprophylaxis, combined with patient awareness of supplementary risk of infections is indispensable to minimize septic complications.     

Coeliac axis dissection secondary to blunt abdominal trauma: A case report and review of the literature

Coeliac axis dissection as a result of blunt abdominal trauma is rare. This case report describes a 31-year-old male who after losing control of his motorbike sustained a coeliac axis dissection diagnosed on initial trauma pan-CT. This was managed non-operatively. In the context of blunt trauma, coeliac axis dissection is a marker of significant injury and is rarely found in isolation. The diagnosis of these injuries requires a high index of suspicion. Successful management needs to be tailored to each patient individually, though many can be managed non-operatively.     

手助腹腔镜技术在巨脾切除中的应用

目的:探讨手助腹腔镜技术在巨脾切除术中的应用。方法:用手助腹腔镜技术实施1例巨脾切除术。结果:顺利完成手助腹腔镜巨脾切除,手术时间3h,术中失血30ml,切除脾脏约40cm×15cm×10cm大小,未中转开腹,无术中术后并发症发生,住院7d,治愈出院。结论:手助腹腔镜脾切除术对于巨脾是可行的、安全的,而且保留了微侵袭外科恢复快的优点,为组织学检查提供足够大的标本。     

Small bowel perforation due to blunt trauma directly to the inguinal region: A case report

We report on a patient with intestinal perforation caused by direct blunt trauma to the inguinal region. The patient had been previously diagnosed with an inguinal hernia. The perforation was managed surgically, and he subsequently underwent hernia repair. In our opinion, intestinal perforation caused by inguinal region trauma in patients with inguinal hernias is a rare and unfortunate situation but one that reveals the importance of inguinal hernia repair.     

腹腔镜下门静脉高压症巨脾切除的手术技巧和风险评估（附九例报告）

目的探讨腹腔镜下门静脉高压症巨脾切除的手术技巧及手术风险评估。方法回顾性分析2011年6月至2011年10月实施腹腔镜下门静脉高压症巨脾切除手术9例的临床资料。结果本组成功施行全腹腔镜下手术6例,因出血中转开腹手术3例,手术中转率33．3％。无手术并发症发生,无死亡病例。结论腹腔镜下门静脉高压症巨脾切除病人术前要根据影像学检查进行评估,严格把握腹腔镜手术适应证,脾蒂的处理是全腹腔镜下手术成功的关键,术中大出血是腔镜手术失败中转开腹的主要原因。术中谨慎、耐心的操作,果断的判断中转手术时机对于确保病人安全最为重要。尽管风险很大,只要掌握好关键技术,腹腔镜下门静脉高压症脾切除还是安全、可行的。     

Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma

IntroductionThe management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management.MethodsA retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy.Results181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04–0.49 CI 95%, P < .01).ConclusionBoth level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs.     

43例外伤性脾破裂的治疗体会

目的总结外伤性破裂的治疗方法与经验。方法对我院1995～2004年12月外伤性脾破裂43例患者资料进行回顾性分析,其中40例患者进行剖腹探查,术中行脾修补术13例,脾部分切除术9例,全脾切除13例,脾切除加自体脾脏移植术5例,3例在严密观察下行保守治疗。结果2例脾破裂患者术后因合并颅脑损伤和严重复合伤死亡,41例患者痊愈出院。结论遵循“抢救生命第一,保留脾脏第二”的原则,根据脾损伤伤情及病人的全身情况去选择手术方式,分别施行脾修补术,部分脾切除术,全脾切除术,全脾切除术加自体脾片移植术。如果伤情允许术中尽量保留器官,对不能保脾的伤者可行脾片移植术以保术后病人有良好的免疫功能。     

Left axillary lymphadenopathy as initial presentation of metastatic prostate cancer: A rare case report

Introduction and importanceAdvanced prostate cancer often presents with lower urinary tract symptoms together with features of cancer on digital rectal examination. The commonest sites of metastasis include bone, liver and lungs. Metastasis to axillary lymph nodes is extremely unusual particularly as initial presentation of the disease.Case presentationWe report an atypical case of a 40-year male patient presented with left axillary mass and normal initial urological evaluation. Histopathology and immunohistochemistry of the biopsies from the axillary mass and prostate confirmed the diagnosis of prostate adenocarcinoma. The patient declined anti-androgen monotherapy treatment and succumbed two months after establishment of the diagnosis.Clinical discussionProstate cancer contributes significantly to the overall global cancer burden. Lymphatic metastasis to axillary lymph nodes is a very rare manifestation of prostate cancer and only a few cases have been reported in the literature. Therefore, clinical diagnosis of patients presenting with axillary lymphadenopathy may cause diagnostic delay. Careful physical and imaging examinations combined with pathological analysis are essential in the diagnosis of advanced prostate cancer with unusual presentation.ConclusionIn theory, prostate cancer can cause metastatic spread to any part of the body. However, metastasis to axillary nodes has not been frequently noticed. Our report highlights the importance of considering prostate cancer among differential diagnoses in Afro-Caribbean males presenting with symptoms suggestive of chest and abdomino-pelvic cancer.