Treatment of spontaneous intracerebral haemorrhage. A retrospective analysis of 74 consecutive cases with special reference to computertomographic data

The surgical treatment of spontaneous intracerebral haemorrhage (SIH) is still a matter of controversy, although most Neurosurgeons agree that surgery is indicated in selected cases. The introduction of computer tomography (CT) permits a more accurate determination of the localization, size and expansion of an intracerebral haemorrhage. The aim of this study is to evaluate the results of surgical and conservative therapy in selected cases and to search for parameters that could help to predict the outcome and facilitate the decision between surgery and conservative therapy. Seventy-four patients treated following SIH during the years 1976-1980 were analyzed. The decision for surgical treatment was made on the basis of the patient's conditions and the findings in the CT scan. Thirty-nine patients with mainly medium-sized haemorrhages underwent surgery and 35 were conservatively treated. The mortality after three months was 5/39 (13%) in the surgical and 7/35 (20%) in the conservative group. The volume of haemorrhage was significantly larger in the patients who died and 9/10 patients with a haematoma volume above 80 ml died. Five of these 10 were operated and the other 5 not and surgery seemed to be of little benefit to this group. Dilatation of the contralateral ventricle is another indicator of a bad prognosis. Long-term follow-up investigation was carried out 4-38 months after the initial treatment. Total mortality was 19 out of 68 patients that could be reached for late follow-up. Eleven patients (29%) were fully recovered and 16 had minor neurological deficits. There was no difference in late results between the surgical and the conservative groups, but the patients in the surgical group were generally in a worse condition and had larger haemorrhages that the others. The fact that the total mortality in this material is lower than in other conservatively treated series favours surgery in selected cases of SIH. The use of CT gives valuable information as to the prognosis and especially the volume of haemorrhage seems to be a good prognostic factor.     

The value of suction wound drain after carotid and femoral artery surgery: a randomised trial using duplex assessment of the volume of post-operative haematoma.

BACKGROUND: The use of vacuum suction drains after carotid endarterectomy (CEA) and groin dissection for arterial reconstruction surgery remains controversial. A large multicentre prospective randomised trial would be needed to show any difference if clinical end points (infection and haematoma) are used. Therefore, we conducted a study to evaluate the value of wound drainage using accurate duplex measurement of haematoma expecting a 25% difference in volume between drained and non-drained wounds. PATIENTS AND METHODS: Seventy consecutive patients undergoing CEA and 73 patients who underwent 106 groins dissection were separately and blindly randomised into two groups: group (a) with wound drain and group (b) without wound drain. A duplex scan was carried out post-operatively to document the presence and volume of any wound haematoma. RESULTS: The majority of wounds did not show any evidence of collections. 1. In the CEA patients duplex scan revealed wound haematoma in 8 patients with a median volume of 25 ml (5-65) in group (a) in comparison to 7 wound haematomas 31 ml (3-72) in group (b). Median suction drain drainage was 42 ml (10-120) when used. There was no significant difference between the two groups. Three patients 4.3% (two from the drain group) underwent evacuation of haematoma post-operatively.2. In the groin dissection patients most of the documented collections were trivial. Ultrasound scans showed 21 collections (20%), of these 7 (34%) were in group (a) and 14 (66%) were in group (b). There was no significant difference in wound collections between the two groups (p = 0.28). Only 5 collections (75%) exceeded 10 ml, three of them were in the drain group. One patient (1%), who did not have a drain, developed a wound collection, which needed re-exploration. When a drain was used the median drainage was 64.5 ml (range 10-220). CONCLUSION: These results based on accurate measurement of wound collection suggest that there is no benefit in terms of reduction of the volume of haematoma on wound drainage after CEA or arterial reconstruction surgery involving the groin. A selective policy of use of drainage is therefore recommended.     

Wound drainage versus non-drainage for proximal femoral fractures. A prospective randomised study

OBJECTIVES: The purpose of this prospective randomised study was to examine whether routine drainage in surgery for traumatic hip fractures is useful. BASIC PROCEDURES: At the end of surgery for hip fractures, 200 consecutive patients (51 men, 149 women) were randomised to receive suction drainage or not. The status of wound healing was evaluated, with specific reference to haematoma formation or wound infection. Indices of blood loss were the average blood loss during operation, a decrease in the haemoglobin level, fluid collected by the drain, and blood transfusion. MAIN FINDINGS: The severity of wound haematoma and the number of wound infections was not significantly different between the two groups. The average blood loss during operation was 172 ml in the drainage group and 179 ml in the non-drainage group. The volume of drainage fluid was 146 ml. The haemoglobin concentration decreased by 1.4 mg/dl in the drainage group and by 1.3 mg/dl in the non-drainage group (P = 0.83). During admission, 55 patients in the drainage group received 2.5 units of blood and 50 patients in the non-drainage group received 2.7 units. CONCLUSIONS: The severity of wound haematoma does not lead to statistically significant differences in wound infection rate. The routine use of suction drains may not prevent wound infections.     

The CT criteria for conservative treatment — but under close clinical observation — of posterior fossa epidural haematomas

Summary In order to assess whether the indications for conservative treatment of supratentorial epidural haematomas are applicable also to posterior fossa epidural haematomas (PFEDH), the author reviewed the records of 25 patients. With a PFEDH volume of no more than 10 ml, a thickness of no more than 15 mm, a midline shift of no more than 5 mm, and in the absence of a significant intracranial haematoma elsewhere on computed tomography (CT) scans, the patients undergoing conservative treatment achieved the same excellent outcome as those undergoing early surgery. These CT criteria for conservative treatment of PFEDHs are similar to those of supratentorial epidural haematomas except the volume factor, namely, 10 ml in the former against 30 ml in the latter. That means a PFEDH of 10 ml or larger in the small posterior fossa may produce the same degree of midline shift and compression, and be as dangerous as an epidural haematoma of 30 ml or larger in the more capacious supratentorial compartment. But also for epidural haematomas of the posterior fossa, which initially are smaller than 10 ml, the general rule remains valid that they should be under close clinical supervision     

Should breast biopsy cavities be drained?

A total of 112 women was entered into a randomised study to investigate the effects of suction drainage on haematoma formation in breast biopsy wounds. Of 107 evaluable patients, 52 received drainage and 55 had no drain. The wounds were examined 1 week after operation when the volume of wound haematoma was measured using ultrasonography. Haematomas were present in 48 (87%) patients with undrained wounds compared with 34 (65%) patients with drained wounds (P = 0.014, chi 2 test). Median haematoma volume was 20 ml (range 0-172.5 ml) in the undrained group compared with 2 ml (range 0-100 ml) in the drained group (P = 0.001, Mann-Whitney U test). There was one wound infection in each group. There was no difference in median pain score or duration of pain between the groups. While suction drainage significantly reduces the incidence and volume of wound haematomas, this does not appear to influence outcome.     

Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study

A controlled randomized study of endoscopic evacuation versus medical treatment was performed in 100 patients with spontaneous supratentorial intracerebral (subcortical, putaminal, and thalamic) hematomas. Patients with aneurysms, arteriovenous malformations, brain tumors, or head injuries were excluded. Criteria for inclusion were as follows: patients' age between 30 and 80 years; a hematoma volume of more than 10 cu cm; the presence of neurological or consciousness impairment; the appropriateness of surgery from a medical and anesthesiological point of view; and the initiation of treatment within 48 hours after hemorrhage. The criteria of randomization were the location, size, and side of the hematoma as well as the patient's age, state of consciousness, and history of hypertension. Evaluation of outcome was performed 6 months after hemorrhage. Surgical patients with subcortical hematomas showed a significantly lower mortality rate (30%) than their medically treated counterparts (70%, p less than 0.05). Moreover, 40% of these patients had a good outcome with no or only a minimal deficit versus 25% in the medically treated group; the difference was statistically significant for operated patients with no postoperative deficit (p less than 0.01). Surgical patients with hematomas smaller than 50 cu cm made a significantly better functional recovery than did patients of the medically treated group, but had a comparable mortality rate. By contrast, patients with larger hematomas showed significantly lower mortality rates after operation but had no better functional recovery than the medically treated group. This effect from surgery was limited to patients in a preoperatively alert or somnolent state; stuporous or comatose patients had no better outcome after surgery. The outcome of surgical patients with putaminal or thalamic hemorrhage was no better than for those with medical treatment; however, there was a trend toward better quality of survival and chance of survival in the operated group.     

Neuroendoscopic surgery for intracerebral haemorrhage--comparison with traditional therapies.

Endoscopy is a new therapeutic option for hypertensive intracerebral haemorrhage. Although it has the advantages of being less invasive than craniotomy and more effective than conservative treatment, not all patients are candidates for it. Since it is important to clarify which characteristics of patients are indications for this operation, we retrospectively evaluated the role of endoscopic surgery in comparison with traditional treatments for hypertensive intracerebral haemorrhage. Seven patients were treated with endoscopic surgery in our institution between January 2000 and November 2001. Two had thalamic haemorrhage, 4 putaminal haemorrhage, and 1 intracerebral haemorrhage. The average age of patients was 55 years. Endoscopic operation was mainly selected for haematomas more than 20 ml and less than 40 ml in volume. Generally, endoscopy yielded good outcomes with GR in 50 % of patients. Adequate indications for endoscopic operation may be the following; 1) Putaminal haematoma of small-intermediate size, 2) Haematoma situated deep in the brain, e. g., thalamic haemorrhage, 3) Intraventricular haematoma, 4) High-risk patients who cannot tolerate general anaesthesia.     

Haematoma evacuation does not improve outcome in spontaneous supratentorial intracerebral haemorrhage: A case-control study

Summary Surgical intervention in supratentorial intracerebral haemorrhage (ICH) is still controversial. We assessed the value of haematoma evacuation with a case-control study. 145 consecutive patients with supratentorial spontaneous ICH without tumour or vascular abnormalities were analysed. Haematoma evacuation was performed in 24 patients. Age, sex, Glasgow Coma Scale (GCS), level of consciousness, pupillary reaction on admission, localisation, aetiology and volume of the haematoma, presence of ventricular blood, and Glasgow Outcome Scale (GOS) on discharge were analysed. From statistical analysis 40 patients >80 years and with haematoma volume <10ml, who were always treated conservatively, were excluded. Prognostic factors retained from a multiple regression model with the dichotomised GOS scale (GOS 1–3, 4+5) as response variable were GCS, haematoma volume and location. The only difference between all medically treated and operated patients was haematoma volume, which was larger in the operated patients. All 24 evacuated cases could be matched to a medically treated control regarding age, haematoma volume and location, GCS, and pupillary reaction. Significant differences between the two groups could not be detected. Outcome was not different between the two groups. After separating the sample into patients with and without ventricular haemorrhage, there was no different outcome between the two groups either. We conclude that haematoma evacuation did not improve outcome in supratentorial spontaneous ICH. Since haematomas were evacuated mainly in clinically deteriorating patients, our data suggest that the only effect of haematoma evacuation is to stop progressive deterioration rather than to improve overall clinical outcome.     

Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients

Background

Chronic subdural haematoma (CSDH) is a common entity in neurosurgery with a considerable postoperative recurrence rate. Computerised tomography (CT) scanning remains the most important diagnostic test for this disorder. The aim of this study was to characterise the relationship between the recurrence of CSDH after treatment with burr-hole irrigation and closed-system drainage technique and CT scan features of these lesions to assess whether CT findings can be used to predict recurrence.

Methods

We investigated preoperative and postoperative CT scan features and recurrence rate of 107 consecutive adult surgical cases of CSDH and assessed any relationship with univariate and multivariate regression analyses.

Results

Seventeen patients (15.9 %) experienced recurrence of CSDH. The preoperative haematoma volume, the isodense, hyperdense, laminar and separated CT densities and the residual total haematoma cavity volume on the 1st postoperative day after removal of the drainage were identified as radiological predictors of recurrence. If the preoperative haematoma volume was under 115 ml and the residual total haematoma cavity volume postoperatively was under 80 ml, the probability of no recurrence was very high (94.4 % and 97.4 % respectively).

Conclusions

These findings from CT imaging may help to identify patients at risk for postoperative recurrence.     

Hospital volume and surgical outcomes of lung cancer in Japan

Objective This study aimed at analyzing results of surgery for lung cancer in relation to hospital volume to see if a straightforward relation exists between hospital volume and surgical outcome. Methods Two data sets collected nationwide in Japan were retrospectively studied by statistical analysis: 18 055 patients operated on during an average year for the most recent 4 years for an analysis of hospital mortality and 3233 patients operated on duraing 1989 for analysis of the 5-year survival rate. First, we examined the correlations of hospital volume with each outcome, which was estimated using the empirical Bayes (EB) method to stabilize any large variation due to the small sample. Then we estimated the volume effects using generalized regression models. Perioperative mortality and the 5-year survival rate in relation to hospital volume were measured. Results No statistically significant correlations between hospital volume and each outcome have been shown (EB mortality 1.51%, P = 0.0566; 5-year survival 48.9%, P = 0.333). Regarding the volume effect, only the lowest-volume subgroup showed a statistically significant higher perioperative mortality rate and a lower 5-year survival rate compared to the highest-volume counterpart, but many hospitals of the lowest-volume subgroup had operated on more patients with advanced-stage disease. Conclusions No straightforward correlation was seen between hospital volume and surgical outcome. Hospital volume may not be a suitable single tool to predict the outcome of lung cancer surgery. We should reserve the conclusion that low-volume hospitals offer less effective surgery. We need a risk-adjusted database to study this topic.     

结直肠癌同时性肝转移的同期手术切除

目的探讨同时性结直肠癌肝转移行同期切除原发瘤和肝转移瘤的安全性和有效性。方法回顾性总结分析从1981年5月至2005年11月在我院住院治疗的43例结直肠癌同时性肝转移同期手术的临床病理资料及结果并结合文献复习。结果43例患者中男性21例,女性22例,中位年龄52岁,手术持续中位时间180min。共30例术中输血,中位输血量800ml。术后总住院时间10—50d,中位时间15d。并发症发生率18．6％（8／43）,手术死亡率2．3％（1／43）。全组总的中位生存期为25个月,5年生存率19．1％。R0切除组的中位生存期48个月,5年生存率33．8％;非R0切除组的中位生存期为20个月,5年生存率7．6％。两组的生存时间经LogRank检验差异明显,P=0．002。结论同时性结直肠癌肝转移同期手术的安全性和有效性可以保证。对可切除的同时性结直肠癌肝转移应争取同期手术,并争取R0切除。     

Comparison of the effect of two dose schedules of oral omeprazole with oral ranitidine on gastric aspirate pH and volume in patients undergoing elective surgery

We have compared gastric aspirate pH and volume at induction of anaesthesia in 222 patients who had received either omeprazole or ranitidine before elective operations. Omeprazole was given orally either as 40 mg on the evening before and 40 mg on the morning of surgery or as 80 mg on the morning of surgery. Ranitidine 150 mg was given orally on the evening before surgery and 2 h before anaesthesia. Treatment success was defined as aspirate pH > or = 2.5 and volume < 25 ml at induction of anaesthesia. Treatment was successful in 84% (95% confidence interval (CI) 73-91%) of patients in the omeprazole 40 + 40 mg group, 84% (95% CI 73-91%) in the ranitidine group and 73% (95% CI 61-83%) in the omeprazole 80 mg group. There were no statistically significant differences between the groups. Twelve patients in the omeprazole 80 mg group had gastric pH < 2.5 and four had volume > 25 ml. Only three patients had a gastric pH < 2.5 in the omeprazole 40 + 40 mg group and none had volume > 25 ml, which compared well with the ranitidine group. Omeprazole, given as 40 mg in the evening and 40 mg on the morning of operation, has a potential role for use in patients at risk for aspiration during general anaesthesia.      

A magnetic resonance imaging-based study of retropubic haematoma after sling procedures: preliminary findings

OBJECTIVE: To determine, using magnetic resonance imaging (MRI), the incidence of retropubic haematoma and any associated clinically significant effects after a xenograft (porcine dermis) sling (XS) or the tension-free vaginal tape (TVT) procedure. PATIENTS AND METHODS: Between October 2003 and March 2004, 24 consecutive patients presenting with stress urinary incontinence (SUI) were enrolled in this prospective study; 12 each underwent an XS or TVT procedure. A vaginal balloon pack was used for only 3 h after XS and not after TVT. All patients had pelvic MRI 6-8 h after surgery. The primary outcome measure was the incidence and distribution of retropubic haematoma after each sling technique. Secondary outcome measures included the interval to the first three spontaneous voids, the bladder emptying efficiency of the first three voids, a visual analogue scale pain score at 24 h after surgery, and the short-term (6-month) cure rate for SUI. RESULTS: Overall, six (25%) patients (four XS and two TVT) developed a retropubic haematoma. Most commonly, they spread along the right paravesico-urethral space between the right half of the levator ani and the bladder neck. Patients with large haematomas took significantly longer to void (median 14.5 vs 6.0 h, P = 0.048). There was no difference in pain score in patients with or with no haematoma. None of the patients had clinically detectable haematomas in the suprapubic wound. All six patients with haematomas were cured or improved at the 6-month follow-up. CONCLUSIONS: MRI is a useful noninvasive method for detecting retropubic haematomas soon after surgery. There was a surprisingly high incidence of retropubic haematomas, especially after the XS procedure. Retropubic haematomas may influence postoperative voiding efficiency.     

The long-term prognosis of coronary artery bypass surgery--the influence of preoperative left ventricular volume on the prognosis of cardiac death]

We have assessed the long-term prognosis about cardiac death of isolated coronary artery bypass surgery from 1972 to 1988 in 361 consecutive patients. The duration of follow-up were from 0.4 years to 14.6 (mean 5.7) years. Of the 361 study patients, the operative morality was 4.7% (17 patients) and 29 patients (8.0%) died during follow-up, 11 (3.0%) of which were from cardiac causes. Actuarial survival rate was 85.2% at 10 years after surgery. The 10 year-survival rate was similar for patients with single, double, triple vessel disease, and left main trunk disease (94.5%, 83.7%, 75.1% and 89.1%, respectively). For patients with and without old myocardial infarction, the 10 year-survival rate was significantly different (75.4% and 93.3%, respectively) (p less than 0.005). In order to detect which factors of preoperative cardiac function among cardiac index, LV end-diastolic pressure, LV end-diastolic volume index, LV end-systolic volume index, and LV ejection fraction influenced the long-term prognosis, multivariant regression analysis was performed. Only LV end-systolic volume index was a significant factor, and the discriminative point was 50 ml/m2. For patients with LV end-systolic volume index less than 50 ml/m2 and greater than or equal to 50 ml/m2, the 10 year-survival rate was significantly different (88.3% and 32.9%, respectively) (p less than 0.005). In conclusion, the most significant factor influencing longterm prognosis after coronary artery bypass surgery was left ventricular end-systolic volume, indicating the importance of preventing preoperative dilatation of left ventricle.     

The timing of drain removal—empiricism or science?

Surgical drains are commonly used in plastic surgery. Drains are subsequently removed at arbitrary volumes depending on local protocols. The rational for when to remove a drain has not been scientifically determined. We compared removal of drains at ≤30?ml/24?h vs. ≤50?ml/24?h for 158 wounds, in 90 patients. Postoperative complications, length of hospital stay and resulting cost–benefit were considered. Prospective data were collected for two consecutive similar cohorts of patients undergoing abdominoplasty, bilateral breast reduction and breast augmentation. In the first cohort, drains were removed when drainage was ≤30?ml/24?h and the second cohort when ≤50?ml/24?h. Demographics, days of drainage, surgeon grade and duration of postoperative hospital stay were recorded. Patient records were then analysed and complications recorded, including haematoma, infection, seroma, wound breakdown and fat necrosis. The median postoperative stay for all three operations for both drainage cohorts was similar with no statistically significant difference; however, the drainage time in breast augmentation was significantly less in the <50?ml/24?h group. There were no significant differences in outcome measures between the patients undergoing abdominoplasty, breast reduction or breast augmentation. Drain removal at ≤50 vs. ≤30?ml/24?h did not result in an increase in postoperative morbidity or adverse outcome in any of the three different operation types.     

Arthroscopic ankle debridement: 5-year survival analysis

Little information exists regarding the long term prognosis following ankle arthroscopy, particularly in avoiding further major surgery. The purpose of this study is to evaluate the prognosis of arthroscopic ankle treatment. We also investigated the relationship between the arthroscopic treatment and time for a further major ankle surgery. In this consecutive case series study using a prospectively collected database, 80 consecutive patients (80 ankles) having ankle arthroscopy with the finding of osteoarthritis or impingement were identified and their outcome at five years was ascertained. Fifty five (69%) patients had soft tissue impingement, and 25 (31%) patients had osteoarthritic degenerative changes. Seven (9%) patients had further major surgery and 6 (8%) had repeat arthroscopy. The surgery was required for 7 arthritic ankles among which, however, survival analysis showed no significant difference between those under 50 and those over 50 years. Twenty-eight percent of osteoarthritic patients progressed to major ankle surgery, within 5 years of arthroscopic treatment. None of the patients with impingement symptoms required further major surgery. In conclusion, arthroscopically treated impingement ankles were found to have an excellent prognosis, while osteoarthritic ankles had a less favoured prognosis, with a high proportion requiring further major surgery. Age did not appear to affect the prognosis in the osteoarthritic group.     

Emergency neurosurgery by general surgeons at a remote major hospital

BACKGROUND: Due to the geographical remoteness of Darwin, which has no resident neurosurgeon, emergency transfer of patients for neurosurgery is usually impractical. In Darwin emergency neurosurgery must be undertaken by general surgeons. METHODS: Data from the operating theatre, Emergency Department and Intensive Care Unit were prospectively recorded on all patients who underwent an emergency neurosurgical procedure between January 1992 and June 2004. Outcomes were assessed by retrospective case note review. RESULTS: Three hundred and five neurosurgical procedures were performed upon 258 patients (average 26.5 procedures per year), including 130 craniotomies, 88 burr holes, 3 posterior fossa craniotomies, 2 decompressive frontal lobectomies, 4 decompressive craniectomies, 25 elevations of fracture and 33 ventricular drains only. Assault/domestic incident (31%) was a more common aetiology than motor vehicle accidents (29%). Outcome was best for extradural haematoma (82% good/moderate) and chronic subdural haematoma (84% good/moderate). In contrast, 44% with acute subdural haematoma and 77% with intracerebral haematoma died. Irrespective of type of bleed, Glasgow Coma Scale (GCS) score at presentation was a reliable predictor of outcome following surgery (61% correlation): 60% with GCS less than 9 died whereas 79% with GCS over 11 had a good recovery. Acute Physiology And Chronic Health Evaluation, version 2 and Simplified Acute Physiology Score, version 2 scores were also independent predictors of outcome. Time from presentation to operation for extradural haematoma and acute subdural haematoma was prolonged (more than 4 h) in 48% and was associated with worse outcome (P = 0.0001). Neither extremes of age nor the particular surgeon performing the operation affected outcome. CONCLUSIONS: General surgeons undertake a substantial number of procedures across a broad spectrum of emergency neurosurgery in Darwin. Outcomes following surgery appear acceptable.     

The Prognostic Importance of the Volume of Traumatic Epidural and Subdural Haematomas Revisited

Summary  The size of a traumatic intracranial haematoma at the moment of diagnosis can be impressive. Haematoma thickness is an inaccurate estimator of haematoma volume, and association with patient outcome is controversial. In this study computerized volumetry of off-line digitized CT scans was used to relate haematoma volume with both patient characteristics on admission and at the six months outcome.  This retrospective study covered the time period 1981/1990. Ninety eight patients operated upon for an epidural haematoma and 91 patients operated upon for an acute subdural haematoma were analyzed. The relative importance of clinical data, CT scan parameters, and calculated haematoma volumes was determined by multivariate analysis.  Volume of the haematoma did not correlate with preoperative neurological condition or the six months outcome in either group, and consequently is not of additional prognostic value.     

Traumatic intracerebral lesions without extracerebral haematoma in 218 patients

Summary 218 of the 852 patients in the HIT-2 study of head injury had intracerebral lesions only. They were analysed to get more information on the optimal treatment of these severely injured patients. The initial CT scans were reviewed to exclude patients with extracerebral lesions, and to make a radiological diagnosis of contusion, contusion under a depressed fracture, diffuse axonal injury, or intracerebral haematoma. Deterioration after admission to hospital was seen in 71% of patients. Patients with contusions, and contusions from depressed fractures in particular showed a worse outcome than expected, while patients with diffuse injury had a tendency to improve rather than to deteriorate. Patients with intracerebral haematoma seemed to improve if the mass was evacuated. Nimodipine had an impact only in patients with contusions. Our findings mandate surgical evacuation of contusions and intracerebral haematomas in patients with lesions larger than 20 ml who also have radiological signs of a mass effect. Regardless of an apparently good clinical state in the early phase, intracerebral lesions larger than 50 ml seemed to benefit from surgery as compared to nonsurgical treatment.The findings indicated that a further refinement of diagnostic criteria may enable individually tailored head injury treatment to interfere with most important pathogenic mechanisms. More accurate diagnoses will improve head injury treatment and outcome, and are a prerequisite for making successful pharmaceutical trials of head injury in the future.     

射频消融处理胆囊床在T1b期胆囊癌根治性手术中的应用

目的探讨射频消融处理胆囊床在T1b期胆囊癌根治性手术中的应用及在不同期手术中的疗效。方法回顾性分析首都医科大学附属北京朝阳医院西院肝胆胰脾外科2011年4月1日至2019年3月31日收治的21例T1b期胆囊癌手术患者的临床资料,将术中冰冻病理确诊的患者纳入同期手术组,术后确诊补做手术及外院切除胆囊后在首都医科大学附属北京朝阳医院西院补充手术患者纳入二期手术组。观察两组患者手术时间、出血量、生存率及生存时间等差异并统计两组患者5年累积生存率及总体生存时间。结果所有患者均完成胆囊癌根治术,其中男性14例,女性7例,年龄26-70(49.0±13.5)岁,无围手术期死亡病例。同期手术组纳入15例,二期手术组纳入6例。同期手术组出血量少于二期手术[(101.3±35.5)ml比(177.0±44.6)ml],差异具有统计学意义(P<0.05)。两组患者手术时间、生存率、生存时间差异均无统计学意义(均P>0.05)。两组患者5年累计生存率56.5%,总体生存时间(79.0±9.3)个月。结论射频消融处理胆囊床在T1b期胆囊癌根治性手术中安全和有效。对于术中难以明确诊断的T1b期胆囊癌,二期手术可获得与同期手术相同的疗效。