结节性甲状腺肿合并甲亢的治疗现状

结节性甲状腺肿（结甲）伴发甲状腺功能亢进（甲亢）又称毒性结节性甲状腺肿或结甲继发甲亢。其发病机制尚未明确，治疗原则也有别于原发甲亢。近年来随着基础研究的深入，治疗方式也有新的认识。     

桥本病合并结节性甲状腺肿的诊治分析

为总结桥本病 (HD)合并结节性甲状腺肿的诊治经验 ,回顾分析 1 7年间外科手术治疗的桥本病 1 38例中 2 6例 (1 8.84%)桥本病合并结节性甲状腺肿的临床资料。 2 6例中手术前诊断甲状腺癌 6例 ,结节性甲状腺肿 1 3例 ,甲瘤 2例 ,误诊率 80 .8%。 2例合并甲癌。术中根据快速病理检查结果 ,采取不同范围的手术。术后随访发生甲状腺机能减退 1例。提示桥本病临床上诊断困难 ,易误诊 ;应重视桥本病合并其他甲状腺疾病的诊断。术中快速病理检查是获得正确诊断的有效方法 ,有利于选择适当的手术方式。     

Emergency interventions in complicated colonic diverticulosis

An account is given in this paper of 480 patients who had been hospitalised for colonic diverticulosis or diverticulitis in the surgical department of the Municipal Waid Hospital of Zurich, between 1970 and 1986. Laparotomy had to be performed on 219 of them (45.6 per cent), among them 84 emergency interventions. The average age of these patients was 70.7 years. Indications for emergency surgery included diffuse or locally delimited peritonitis with abscess development in 72 patients, ileus in ten cases, and massive colon haemorrhage in two. The latter two cases were handled with good success by subtotal colectomy with ileorectostomy and, one of them with the source of bleeding known, by colotomy and suturing of that source of bleeding. Sigmaincontinence resection according to Hartmann has been considered the optional approach since 1977 to diffuse peritonitis and to many cases of ileus (n = 39). In more recent time, anastomosis has been used as primary approach to some patients who survived fibrinous abdominal peritonitis (n = 4). The mortality rate associated with drainage operations according to expectation, has been clearly higher than that following resection, the comparable figures being 32.3 and 17.2 per cent. That has been attributable to non-removal of the septic focus. After all, nowadays combined antibiotic therapy is commonly used for seven to ten days for simultaneous control of both aerobic and anaerobic pathogens. This has become routine practice and involves aminoglycoside, metronidazole, and ampicillin. Overall mortality associated with emergency interventions is clearly higher than that after planned operations, the figures being 22.6 and 4.4 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Emergency surgery for complicated acute diverticulitis

Aim  Antecedent attacks of diverticulitis are thought to increase the risk of complicated diverticulitis, and unless elective surgery is performed, a high proportion of patients with recurrent symptoms will require emergency operations for complicated diverticulitis with its associated morbidity. In this multicentre study, we aim to assess impact of previous attacks of diverticulitis on patients requiring an emergency surgical intervention.
Method  All patients operated on as an emergency for complicated diverticulitis were retrospectively analysed. Patients were separated into two groups: group A included patients without previous history of diverticular disease, and group B those with previous attacks of diverticulitis.
Results  A total of 96 patients were included in the study. Group A included 68 (70.8%) patients, and group B 28 (29.2%) patients. Generalized peritonitis was the reason for operation in 50 (73.5%) patients in-group A and only four (14%) patients in group B. Perforated diverticulitis occurred more often in group A, whereas pericolonic abscess and phlegmon formation occurred more commonly in group B. Resection was performed in all patients in group B; 50% had a Hartmann's procedure, and the other 50% patients had primary anastomosis. Hartmann's procedure was performed in 52 patients (76.5%) in group A, and 8 patients (11.7%) had resection and primary anastomosis. No difference in postoperative complications was identified between the groups.
Conclusion  Multiple attacks of diverticulitis are not associated with an increased risk of complicated diverticulitis. Recurrent episodes of diverticulitis are not associated with a less favourable outcome or an increased risk of fatality if complications ensue.     

Emergency surgical treatment of complicated acute diverticulitis

Twenty-five percent of patients undergoing surgery for acute complicated diverticulitis represent emergencies. This condition is currently treated by colonic resection with primary anastomosis with or without colostomy, or by a Hartmann operation. We report on our experience with 52 consecutive patients with generalized peritonitis (8 cases), peri- and paracolonic abscesses (19 cases), severe pelvic abscesses (12 cases) and multiple abscesses with visceral fistulas (13 cases). All patients had emergency surgery. In 50/52 patients (96.2%) we performed a colonic resection with primary anastomosis using a mechanical stapler and in 2/52 a Hartmann operation. The overall mortality rate was 5.8%. The morbidity rate was 22% with 9 anastomotic leakages. A diverting colostomy was constructed in 16 patients and opened in only 8 patients. In 4 cases a parastomal hernia occurred after late closure and reduction of the colostomy. This data suggest that colonic resection with primary anastomosis, even without colostomy, is a safe procedure for the emergency treatment of acute complicated diverticulitis.     

Emergency laparoscopic surgery for complicated diverticular disease

Objective The aim of this study was to analyse the outcome of emergency laparoscopic surgical management of complicated diverticular disease. Method A prospectively collected electronic database of all colorectal laparoscopic procedures between April 2001 and September 2007 has been used to identify outcomes in patients presenting with complicated diverticular disease. Results Sixty‐six patients (28 men), median age 69 years (23–95), ASA grade II (12), III (38), IV (16) have undergone emergency surgery for complicated diverticulitis – Hinchey grades I (27), II (29), III (7) and diverticular bleeding (3) over a 6½‐year period: 43 high anterior resections, 17 Hartmann’s resections and seven low anterior resections. Diverticular fistulas were seen in 16 patients: colovaginal (7), colovesical (2), colo‐fallopian (4), entero‐colic (3). The median operation time was 110 min (45–195 min). There was one conversion to open surgery. Postoperative analgesia was provided by intravenous Paracetamol in 33 patients (50%), patient‐controlled analgesia in 24 (36%), oral Paracetamol and Oramorph (12%) and epidural opioid infusion (1.5%). The median time to normal diet was 24 h (4 h–6 days) and median hospital stay 5 days (2–30). There were two deaths (3.3%); anastomotic leak, ventricular fibrillation (VF) cardiac arrest. Other complications included: wound infection eight (12%), anastomotic leak four (8%), port‐site hernia one and one case of Clostridium difficile colitis requiring colectomy. There were five (7.5%) returns to theatre and two readmissions (3%). Conclusion Laparoscopic resectional surgery in complicated diverticular disease is a feasible, safe and a largely predictable operation that allows for early hospital discharge and, in our opinion, improved patient care. We are encouraged to continue to offer our patients the option of an emergency laparoscopic resection.     

Electro-impulse therapy in combined treatment of patients with thyrotoxic goiter complicated by cardiac fibrillation

Cardiac fibrillation was revealed at admission in 260 (5.2%) of 4996 patients who were to undergo subtotal resection of thyroid gland for toxic goiter. In 114 (43.8%) patients sinus rhythm was restored with drugs in preoperative period. Electroimpulse therapy was carried out in other 146 patients which was effective in 89% cases. Efficacy of electroimpulse therapy depended mainly on the arrhythmia duration. Restoration of sinus rhythm before operation in patients with toxic goiter improves conditions of preoperative preparation and decreases the risk of surgical treatment. There were no lethal outcomes.