Quality of life after surgery of the alimentary tract

In recent decades, patient-reported outcomes have become important in clinical medicine. Nowadays, health-related quality of life (HRQOL) is considered a primary outcome in many clinical trials, and it is often the major criterion for judging treatment success. At the beginning of the 21st century, morbidity and mortality rates after surgery of the alimentary tract have dropped dramatically and they can no longer be considered the only outcome measures to determine the success of a surgical procedure. QOL c...     

The surgical decision in tetralogy of Fallot: weighing risks and benefits with decision analysis

The preferred management of the symptomatic infant less than 2 years of age with tetralogy of Fallot remains unsettled. In this study decision analysis was used to assess the risks and benefits of three courses of action: (1) primary intracardiac repair; (2) palliative operation in infancy and delayed intracardiac repair; and (3) treatment with propranolol in infancy and delayed intracardiac repair. For each action the likelihood was determined of three possible outcomes for the patient: (1) death, (2) poor surgical result, or (3) good surgical result. Each outcome was associated with an estimated life expectancy. The best action was defined as that resulting in the longest life expectancy. With use of previously reported data and those from experience at one institution, a range of probabilities was estimated for death before operation, surgical mortality, success of propranolol treatment and hemodynamic result of operation. The choice of action was affected most by the mortality of primary intracardiac repair and the likelihood of a good hemodynamic result from intracardiac repair. Less important factors were the outcome of a palliative operation and the likelihood of success with propranolol therapy. It was found that in the institution studied if the mortality rate of primary intracardiac repair is 10 percent or less, intracardiac repair should be performed; otherwise propranolol treatment, which allows delay in intracardiac repair, should be selected. Both alternatives are preferable to palliative operation. With decision analysis, the clinician can use probabilities and life expectancy appropriate to a given clinical setting in determining the best management for the infant with tetralogy of Fallot.     

Enterolithiasis

Enterolithiasis or formation of gastrointestinal concretions is an uncommon medical condition that develops in the setting of intestinal stasis in the presence of the intestinal diverticula, surgical enteroanastomoses, blind pouches, afferent loops, incarcerated hernias, small intestinal tumors, intestinal kinking from intra-abdominal adhesions, and stenosing or stricturing Crohn’s disease and intestinal tuberculosis. Enterolithiasis is classified into primary and secondary types. Its prevalence ranges from 0.3% to 10% in selected populations. Proximal primary enteroliths are composed of choleic acid salts and distal enteroliths are calcified. Clinical presentation includes abdominal pains, distention, nausea, and vomiting of occasionally sudden but often fluctuating subacute nature which occurs as a result of the enterolith tumbling through the bowel lumen. Thorough history and physical exam coupled with radiologic imaging helps establish a diagnosis in a patient at risk. Complications include bowel obstruction, direct pressure injury to the intestinal mucosa, intestinal gangrene, intussusceptions, afferent loop syndrome, diverticulitis, iron deficiency anemia, gastrointestinal hemorrhage, and perforation. Mortality of primary enterolithiasis may reach 3% and secondary enterolithiasis 8%. Risk factors include poorly conditioned patients with significant obstruction and delay in diagnosis. Treatment relies on timely recognition of the disease and endoscopic or surgical intervention. With advents in new technology, improved outcome is expected for patients with enterolithiasis.     

肝细胞癌自发性破裂出血的治疗对策选择（附30例报告）

目的探讨肝细胞癌（HCC）自发破裂出血患者在治疗对策上的选择。方法对本院2008年1月-2011年12月收治的30例HCC破裂出血患者的临床资料进行回顾性分析,其中行Ⅰ期手术9例,急诊经导管肝动脉化疗栓塞术（TACE）治疗21例,TACE治疗后再手术切除10例,其余11例均为单纯TACE治疗,从临床治疗效果进行评价分析。计数资料比较采用卡方检验或Fisher′s检验。结果21例经急诊TACE治疗者止血成功率为100%,其中10例患者TACE治疗后2~5周内进行Ⅱ期手术,术后病理证实均为HCC,术后3个月复查均未见腹腔肿瘤种植转移灶,术后1 年存活率70%（7/10）; 9例行Ⅰ期手术切除的患者中,围手术期内死亡2例,3个月内发生腹腔或切口种植转移者5例（5/7）,术后1 年存活率44.4%（4/9）;11例单纯TACE治疗患者术后1 年存活率为27.3%（3/11）。急诊TACE联合手术切除HCC破裂出血在提高抢救成功率、减少术后并发症及提高患者生存时间上均优于急诊手术切除及单纯的TACE治疗。结论HCC自发性破裂出血患者应首选急诊TACE治疗,再联合手术切除,可以明显提高抢救成功率和手术切除率,并可显著降低肿瘤腹腔种植转移率,延长患者生存时间。     

Necrotic Bowel Induces Takotsubo-Like Myocardial Injury

Although chest pain in association with ST-segment electrocardiographic deviation is often indicative of cardiac ischemia, it has also been associated with noncardiac conditions. The case of a 63-year-old woman that we report here is extraordinary because her presentation of “acute abdomen” did not appear severe enough to warrant urgent surgical intervention, whereas the chest pain and electrocardiographic changes (supported by rising troponin levels) created strong clinical suspicion of acute coronary syndrome. Was the evidence of cardiac ischemia a primary event, or was it a sequela of an acute surgical condition? Noncardiac surgical cases associated with evidence of myocardial injury can be extremely challenging from a diagnostic and management perspective. We believe that the accuracy of the clinical diagnosis is crucial to a well-considered approach.     

Surgical recurrence in Crohn's disease: Are we getting better?

Crohn’s disease (CD) still remains a challenging chronic inflammatory disorder, both for colorectal surgeons and gastroenterologists. The need for recurrent surgery following primary intestinal resection is still considerable, though recent evidence suggested a declining rate of recurrence. Several conflicting surgical parameters have been identified that might impact on the postoperative outcome positively, such as access to the abdomen, anastomotic configuration or type of disease. Additionally, promising results have been achieved with the increased use of immunosuppressive medications in CD. Consequently, the question arises if we are getting better as a result of novel medical and surgical strategies.     

Adenocarcinoma of an ileostomy in a patient with ulcerative colitis

A case is reported of adenocarcinoma of the ileum following surgical management of ulcerative colitis. In this patient it seems likely that the carcinoma arose in a pre-existing tubulovillous adenoma of rectal origin. This case report draws attention to the need to exclude any possibility of retention of large-intestinal mucosa in the ileostomy when transecting the ileum, either at primary colectomy or when dismantling an ileorectal anastomosis.     

Optimizing perioperative Crohn’s disease management: Role of coordinated medical and surgical care

AIM: To investigate rates of re-establishing gastroenterology care, colonoscopy, and/or initiating me-dical therapy after Crohn’s disease(CD) surgery at a tertiary care referral center.METHODS: CD patients having small bowel or ileocolonic resections with a primary anastomosis between 2009-2012 were identified from a tertiary academic referral center. CD-specific features, medications, and surgical outcomes were abstracted from the medical record. The primary outcome measure was compliance rates with medical follow-up within 4 wk of hospital discharge and surveillance colonoscopy within 12 mo of surgery. RESULTS: Eighty-eight patients met study inclusion criteria with 92%(n = 81) of patients returning for surgical follow-up compared to only 41%(n = 36) of patients with documented gastroenterology follow-up within four-weeks of hospital discharge, P < 0.05. Factors associated with more timely postoperative medical follow-up included younger age, longer length of hospitalization, postoperative biologic use and academic center patients. In the study cohort, 75.0% of patients resumed medical therapy within 12 mo, whereas only 53.4% of patients underwent a colonoscopy within 12 mo of surgery.CONCLUSION: Our study highlights the need for coordinated CD multidisciplinary clinics and structured handoffs among providers to improve of quality of care in the postoperative setting.     

Results of pulmonary arterial banding in infancy. Survey of 5 years' experience in the New England Regional Infant Cardiac Program.

The results of pulmonary arterial banding in 238 infants, 12 percent of the infants admitted to the New England Regional Infant Cardiac Program, is reviewed. Overall survival to age 1 year was 63 percent. Survival was least likely (37 percent) in those who required banding within the 1st month of life. Additional surgery decreased the survival rate in those operated on after 1 month of age. Infants with anomalies for which no corrective surgical procedure is available (23 of 238) have only a 30 percent chance of survival. Those with lesions correctable within the 1st year (133 of 238) have a 74 percent survival rate; 52 percent (82 of 238) of those for whom a curative operation is available after the 1st year survive. These pulmonary arterial banding data coupled with results of primary correction should provide the data base required for an intelligent decision in respect to appropriate surgical treatment of infants with critical heart disease.     

Culprit for recurrent acute gastrointestinal massive bleeding: &ldquo;Small bowel Dieulafoy&rsquo;s lesions&rdquo; - a case report and literature review

A Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It can be located anywhere in the gastrointestinal tract. We describe a case of massive gastrointestinal bleeding from Dieulafoy’s lesions in the duodenum. Etiology and precipitating events of a Dieulafoy’s lesion are not well known. Bleeding can range from being self-limited to massive life- threatening. Endoscopic hemostasis can be achieved with a combination of therapeutic modalities. The endoscopic management includes sclerosant injection, heater probe, laser therapy, electrocautery, cyanoacrylate glue, banding, and clipping. Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection. Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis, angiographic embolization or surgical wedge resection of the lesions. We present a 63-year-old Caucasian male with active bleeding from the two small bowel Dieulafoy’s lesions, which was successfully controlled with epinephrine injection and clip applications.     

经典病灶清除手术治疗复杂复合性脊柱结核104例临床分析

目的 探讨用经典病灶清除术治疗复杂复合性脊柱结核的外科围手术期处理及手术方法和手术时机的选择,以减少此类患者的手术并发症。 方法 回顾性分析104例复杂复合性脊柱结核患者,对其临床特点进行分析,采用经典病灶清除手术,对手术效果进行临床分析。 结果 104例患者无死亡及心、肺、肝、肾等器官的严重并发症。104例患者中90例是第一次手术,术后切口1期愈合82例,1期愈合率91.1%（82/90）,余8例经换药引流愈合,未在同一侧进行第二次手术。外院（指第三家医院）转来的14例患者中,分别在对侧行病灶清除,原刀口行窦道切除术后治愈。所有患者术后3个月复查血红细胞沉降率均恢复正常,X线检查显示：椎体呈骨性融合者65例,纤维融合者39例。随访2年,所有患者均无复发,X线复查显示椎体均呈骨性融合,达到临床治愈。 结论 谨慎对待复杂复合性脊柱结核患者的外科治疗手术时机和手术技巧,在抗结核药物治疗基础上,采用经典病灶清除手术治疗复杂复合性脊柱结核可以取得满意疗效。     

The Impact of Clostridum Difficile on Surgical Rate Among Ulcerative Colitis Patients: A Systemic Review and Meta-analysis

There is growing recognition of the impact of Clostridum difficile infection (CDI) on patients with inflammatory bowel disease. Clostridium difficile infection causes greater morbidity and mortality. This study aimed to evaluate the impact of C. difficile on surgical risk among ulcerative colitis (UC) patients. We searched the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, ACP Journal Club, DARE, CMR, and HTA. Studies were included if fulfilled the following criteria: (1) Cohort or case–control studies, which involved a comparison group that lacked CDI, (2) Patients were given a primary diagnosis of UC, (3) Comorbidity of CDI was evaluated by enzyme immunoassay of stool for C. difficile toxin A and B or C. difficile stool culture, (4) Studies evaluated surgical rate, and (5) Studies reported an estimate of odds ratio, accompanied by a corresponding measure of uncertainty. Five studies with 2380 patients fulfilled the inclusion criteria. Overall, meta-analysis showed that UC with CDI patients had a significant higher surgical rate than patients with UC alone. (OR=1.76, 95% CI=1.36–2.28). C. difficile infection increased the surgical rate in UC patients. However, results should be interpreted with caution, given the limitations of this stud.     

高位胆管空肠Roux-en-Y吻合术后吻合口狭窄再手术15例诊疗体会

目的探讨高位胆管空肠Roux—en-Y吻合术后吻合口狭窄行吻合口重建的手术方法。方法回顾性分析2007年2月至2011年11月间的15例因高位胆管空肠Roux-en-Y吻合术后吻合口狭窄再手术的患者临床资料。结果 15例全部行吻合口重建,术中切除原胆肠吻合口行规范的肝门胆管空肠吻合7例,行肝总管空肠吻合6例,1例切除肝方叶后行左右肝管空肠吻合,左肝外叶切除3例;15例随访时间平均33.2月,术后胆漏1例,3例有胆管炎表现。结论打开肝门板显露胆管汇合处是高位胆管-空肠吻合得以重建的关键;再手术时需采用个体化的手术方案。     

205例肺结核合并支气管结核的外科治疗回顾分析

目的探讨肺结核合并支气管结核的外科治疗效果和手术适应症。方法总结1973年1月至2007年底手术切除的205例肺结核合并支气管结核的临床疗效。全组肺结核包括：原发综合征3例、浸润性肺结核19例、空洞性肺结核53例、慢性纤维空洞性肺结核45例、结核瘤或干酪性肺炎48例、结核性支气管狭窄27例、毁损肺10例。按照支气管结核分型,I型30例、Ⅱ型91例、川型50例、IV型34例。结果全肺切除术15例、全肺切除+胸廓成形术（胸改术）32例、肺叶切除术106例、肺叶切除术+胸改29例、支气管袖状成形术14例,其他手术9例。全组临床治愈率93.0%,手术并发症率为11.2%,手术死亡率为0.05%。结论虽然肺结核合并支气管结核是以抗结核药物为主要治疗方法,但目前仍有部分患者需要外科治疗。手术可提高肺结核合并支气管结核的临床治愈率。     

Clinical literature review of 1858 Crohn's disease cases requiring surgery in China

AIM: To summarize the clinical characteristics of Crohn’s disease (CD) patients who underwent surgery in China.METHODS: We searched four main Chinese electronic databases: CBM, VIP, CNKI, and Wanfang (from January 1990 to October 2013). Then, we selected and carefully read 97 studies and extracted the surgical data for CD. We found that 1858 patients with CD underwent surgery between 1961 and 2012. The patients were stratified into two groups according to the year of surgery: 1961-2000 and 2000-2012. The clinical characteristics of these CD cases were compared between the two groups.RESULTS: The mean age at the time of surgery was 38.13 years. The most common locations of disease were the small intestine (40.84%), the colon (33.60%) and the ileocolon (23.09%). The primary indications for surgery were intestinal obstruction or stricture (23.84%), failure of drug therapy (14.80%), acute abdominal disease (13.46%), abdominal mass (10.93%), intestinal fistulae (9.90%), intestinal perforation (8.45%), perianal disease (6.73%), gastrointestinal bleeding (4.79%), and abdominal abscess (4.04%). The rate of diagnosis of CD before surgery was low (34.78%), and the misdiagnosis rate was 20.49%. The predominant surgical procedure for CD was bowel resection (69.54%). The rate of surgical complications was 20.34%, and the primary complications of surgery were infection (39.44%) and intestinal fistulae (26.09%). The relapse rate after surgery was 27.71%. For the periods of 1961-2000 and 2000-2013, the rates of both misdiagnosis before surgery and surgery related-death decreased (34.90% vs 12.10%, P < 0.001, and 23.53% vs 5.26%, P < 0.001, respectively).CONCLUSION: The rates of surgical complications and misdiagnosis were higher, whereas the rate of CD-associated tumor and the relapse rate were lower in China than in West countries.     

Intrapericardial teratoma in the newborn

Two cases of intrapericardial teratomas occurring in the newborn are reported. The first was a cystic, well differentiated tumour which was totally excised. The child was alive and well with no evidence of the disease 10 months later. The second was a predominantly solid teratoma which consisted of both mature and immature tissues. It was removed but recurred 2 months later with pleural and pericardial invasion. The patient underwent reoperation but death occurred 9 days after surgical treatment. The recurrence was histologically similar to the primary tumour. The second case is probably the first malignant intrapericardial teratoma described in a neonate. Its morphology and clinical behaviour suggest that, as in ovarian and sacrococcygeal teratomas, the presence of immature neuroepithelium carries a poor prognosis. In such cases radio- or chemotherapy should be performed.     

原发性肺隐球菌病12例临床分析

目的探讨免疫功能无异常的原发性肺隐球菌病患者cT征象及CT引导下经皮肺穿刺活检在诊断中的价值。方法回顾性分析浙江大学医学院附属邵逸夫医院经病理证实的12例原发性肺隐球菌病患者的临床资料。结果（1）12例患者的CT征象均为单肺叶发病,其中单发结节4例,局限性多发混杂的结节和（或）肿块和（或）肺实变8例,此外还可见支气管充气征／小泡征（9例）、空洞（2例）和“晕”征（4例）。（2）9例行CT引导下经皮肺穿刺活检,其中7例病理学确诊。（3）12例患者中7例行手术切除,术后2例行氟康唑治疗,余5例未用药,其中1例术后5个月发生隐球菌性脑膜炎;另5例用氟康唑治疗。结论免疫功能无异常者时有发生肺隐球菌病的可能;肺隐球菌病的临床症状与影像学表现明显不相称;大多数肺隐球菌病的CT主要征象为局限性多发混杂的结节和（或）肿块和（或）肺实变,如同时有支气管充气征／小泡征、晕征,则具有特征性;尽早采用CT引导下经皮穿刺活检将有助于该病的早期诊断;氟康唑治疗该病效果好,有助于预防严重并发症的发生。     

原发性肝细胞癌体部立体定向放疗的疗效及安全性

近年来,随着肿瘤放疗技术进展,原发性肝细胞癌(hepatocellular carcinoma,HCC)的放疗引起越来越多的关注,越来越多的证据也表明其较好的疗效。其中,体部立体定向放疗(stereotactic body radiation therapy,SBRT)对于不适合一线手术或经皮射频消融技术的HCC患者,在提高局部控制率方面发挥了重要作用。SBRT的研究已经开展了很多,也获得了明确的疗效。但关于恰当治疗适应证,合理剂量分割等方面的研究仍有限。本文综述SBRT对于不可手术的HCC患者的有效性、安全性、适应证和剂量分割模式。     

胰腺内分泌肿瘤的外科治疗

目的提高对胰腺内分泌肿瘤的认知和诊疗水平。方法回顾性分析1968～2005年收治的78例胰腺内分泌肿瘤患者的临床资料。结果胰岛素瘤49例，均为良性，其中40例行单纯肿瘤摘除术（2例在腹腔镜下完成），2例在摘除的同时行胰腺空肠Roux—en—Y吻合术，7例行胰体尾切除术；胰高血糖素瘤4例，均有肝转移，行原发病灶及部分转移灶切除术；胰多肽瘤21例，恶性8例，手术切除16例，其余5例因肿瘤无法切除而放弃手术；舒血管肠肽瘤1例和胰腺类癌3例，均为恶性，行外科手术。术后均获得满意的疗效。结论手术切除是胰腺内分泌肿瘤最为理想的治疗方法。术前定性诊断尤为重要，关键是提高对这类肿瘤的认知水平。对胰岛素瘤不强求术前定位诊断，应慎用有创性诊断方法，术中胰腺探查是定位的关键。其他内分泌肿瘤术前多可依影像学检查定位诊断。手术方式根据肿瘤生长部位而定。姑息性切除手术亦可明显缓解症状。即便是恶性肿瘤，其预后亦明显好于胰腺外分泌肿瘤。     

Transcatheter Mitral Valve Intervention for Chronic Mitral Regurgitation: A Plethora of Different Technologies

Chronic mitral regurgitation (MR) remains a common cardiovascular condition resulting in significant morbidity and mortality. With an aging population, increasing trends for both primary (degenerative) and secondary (functional) MR have become apparent. Although the gold standard remains surgical intervention with mitral valve repair/replacement, comorbid conditions have steered the development of less invasive technologies to mitigate perioperative surgical risk. Transcatheter mitral valve repair using a percutaneous edge-to-edge technique is the most widely available choice at present. However, other transcatheter mitral valve repair techniques such as annuloplasty and chordal implantation are notable alternatives. Moreover, emerging technologies in transcatheter mitral valve replacement are rapidly establishing their roles in the field of chronic severe MR therapy. Hence, it is imperative to understand the indications and limitations of these various transcatheter mitral valve interventions to provide the best and most up-to-date clinical care for patients. This review will outline current evidence and patient selection criteria for such device-based therapies.