微创入路腹膜后胰腺坏死组织清除术：操作技术与围术期管理

微创入路腹膜后胰腺坏死组织清除术（MARPN）是基于肾镜或软质内镜等可视化设备,以窦道作为手术路径,对腹膜后、胰周坏死组织进行清除的一种治疗感染性胰腺坏死（IPN）的微创手术方法,但其普及性仍有待提高,其适应证、具体技术细节、术后管理等方面还需进一步研究和探讨。在国内外一些大规模的胰腺外科中心,包括笔者所在中心,MARPN已经成为治疗IPN的主要手段,并且从已发表的数据来看均取得了较好疗效。笔者所在中心经过多年的探索和实践,对于MARPN已积累大量病例和经验,并对手术的步骤、流程和技术细节进行了标准化和规范化。在此,笔者就MARPN的操作技术及围术期管理进行介绍,以期该技术更为广泛、安全、有效地开展。     

Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications

Background

Enteral nutrition (EN) is a widely used, standard-of-care technique for nutrition support in critically ill and trauma patients.

Objective

To review the current techniques of gastrointestinal tract access for EN.

Methods

For this traditional narrative review, we accessed English-language articles and abstracts published from January 1988 through October 2012, using three research engines (MEDLINE, Scopus, and EMBASE) and the following key terms: “enteral nutrition,” “critically ill,” and “gut access.” We excluded outdated abstracts.

Results

For our nearly 25-year search period, 44 articles matched all three terms. The most common gut access techniques included nasoenteric tube placement (nasogastric, nasoduodenal, or nasojejunal), as well as a percutaneous endoscopic gastrostomy (PEG). Other open or laparoscopic techniques, such as a jejunostomy or a gastrojejunostomy, were also used. Early EN continues to be preferred whenever feasible. In addition, evidence is mounting that EN during the early phase of critical illness or trauma trophic feeding has an outcome comparable to that of full-strength formulas. Most patients tolerate EN through the stomach, so postpyloric tube feeding is not needed initially.

Conclusion

In critically ill and trauma patients, early EN through the stomach should be instituted whenever feasible. Other approaches can be used according to patient needs, available expertise, and institutional guidelines. More research is needed in order to ensure the safe use of surgical tubes in the open abdomen.     

Bone biopsy: indications,techniques, and complications

Bone biopsy is the gold standard for diagnosing the type and severity of renal osteodystrophy (ROD) in end-stage renal disease (ESRD) patients. In this article we review the indications, techniques, and complications of this minimally invasive procedure. The importance of careful preparation is emphasized.     

Domino liver transplantation: indications, techniques, and outcomes

The long-term shortage of livers available for transplantation has spurred the development of many strategies to bolster the donor organ supply. One particularly innovative strategy is domino liver transplantation in which a select group of liver transplant recipients can donate their explanted native livers for use as liver grafts in other patients. Several hereditary metabolic diseases (such as familial amyloid polyneuropathy, maple syrup urine disease, and familial hypercholesterolemia) are caused by aberrant or deficient protein production in the liver, and these conditions can be cured with an orthotopic liver transplant. Although their native livers eventually caused severe systemic disease in these patients, these livers are otherwise structurally and functionally normal, and they have been used successfully in domino liver transplants for the past 15 years. This article will review the indications for donating or receiving a domino liver transplant, the surgical techniques necessary to perform these transplants, as well as the recently revealed long-term outcomes and risks of domino transplantation.     

Percutaneous nephrostomy: techniques, indications, and results.

During the past six years at our institution, percutaneous nephrostomy has been utilized for temporary diversion of the upper urinary tract in 33 patients and 42 individual kidneys. Two techniques are described, one of which has been developed recently by one of us (A.R.G.). Indications and results, including complications, are discussed. In our experience this procedure has been found to be safe and highly useful in the management of selected patients who have unilateral or bilateral urinary tract obstruction from a variety of reasons.     

Patellar instability: arthroscopic surgery, indications and techniques

A significant incidence of knee pain and disability arises from patellofemoral disorders. An accurate diagnosis relies both on a comprehensive history and a careful physical examination; radiologic modalities also play an important part in the diagnosis and follow-up. Most patellofemoral disorders can be examined in three groups: pain due to soft tissue abnormalities, patellar instability, and patellofemoral osteoarthritis. Conservative therapy can be successful in many patellofemoral disorders. Surgical treatment consists of lateral release, medial plication and reconstruction of the medial patellofemoral ligament, proximal and distal realignments, patellar osteotomies, and patellectomy. In traumatic dislocations primary reconstruction or arthroscopy assisted medial stabilization can be performed.     

Total mastectomy: indications and techniques

Total mastectomy is an effective operation for patients who are candidates for a prophylactic mastectomy. This operation removes a larger percentage of breast tissue than subcutaneous mastectomy. The cosmetic results of total mastectomy with immediate reconstruction compare favorably with those of subcutaneous mastectomy.     

Percutaneous biopsies: indications and techniques

Breast inflammation is a difficult clinical problem as it can result from a variety of causes: specific or non-specific infectious mastitis, which may or may not be complicated, primary or secondary inflammatory mastitis or inflammatory cancer. The main objective of radiology is to eliminate an inflammatory cancer. Other objectives are to characterise an inflammatory condition (where the clinical context is valuable in guiding diagnosis but which often requires a micro- or macrobiopsy) or to obtain a microorganism in cases of complicated infectious mastitis (a diagnostic procedure but also comprising the first stage of treatment). Whether for bacteriological or histological purposes, percutaneous samples therefore play a large part in the diagnostic procedure, other than in the clinical context of pregnancy where mastitis is more easily diagnosed because of its frequency. The guidance method is usually ultrasound, and the needle chosen will depend on the radiological or ultrasound signal: puncture with an 18G needle will be used for a bacteriological sample, microbiopsy of a mass or lymph nodes, or macrobiopsy in the case of microcalcifications.     

Meniscal repair: indications and techniques

Meniscal tears are exceedingly common. Because the meniscus serves many vital functions to the knee joint, the preservation of meniscal tissue through meniscal repair is ideal. However, not all meniscal tears are amenable to repair, and each case must be critically assessed for repair suitability. It has been well documented that meniscal healing is enhanced in the setting of concurrent anterior cruciate ligament (ACL) reconstruction. This may influence the indications for repair, as well as the repair technique. Meniscal repair techniques have evolved over time from initial open repairs to inside-out and outside-in suture repairs to newer all-inside repair devices. The current gold standard remains inside-out vertical mattress suture repairs. All-inside repairs are best reserved for special circumstances, such as in the setting of concurrent ACL reconstruction.     

Penis tumours: techniques and indications

Although penis epidermoid carcinoma is a relatively rare tumour, early identification and treatment are necessary to avoid mutilating and sometimes morbid surgery. Awareness of disease epidemiology is mandatory for preventing the evolution of an underlying tumour (absent or insufficient hygiene, congenital or acquired phimosis, preepitheliomathous lesions such as Bowen's disease). Conservative surgical or radio-therapeutic techniques may be considered, provided the lesion is superficial and with a diameter < 30 mm. In all other cases, penis amputation is necessary. Penis epidermoid carcinoma spreads by vascular and lymphatic diffusion. Dynamic scintigraphy for the identification of a sentinel node and screening of subclinical metastasis is currently under evaluation. In case of palpable inguinal adenopathy, inguinal lymphadenectomy should be proposed if technically performable. Although superficial lymphadenectomy is associated with a low morbidity rate (about 3% of mild complications) deep inguinal Lymphadenectomy is far more morbid and disabling. Compliance with pre- and post-operative measures, and total patient compliance are necessary to minimize as far as possible such morbidity.     

Staged urethroplasty: indications and techniques

There is still a place for staged urethroplasty. There are some indications for staged urethral reconstruction such as strictures associated with chronic inflammation, fistula, false passage, urethral stones, urethral diverticula, abscess, failed prior repair, complicated hypospadias, severe trauma, neurologic diseases, extensive BXO strictures and long strictures. Staging a urethroplasty should not be considered a step backwards rather instead we should learn from experience and realize there are some patients who are too complex to reconstruct in a single stage.     

Ankle arthrodesis: indications and techniques

Patients with ankle arthritis and deformity can experience severe pain and functional disability. Those patients who do not respond to nonoperative treatment modalities are candidates for ankle arthrodesis, provided pathologic changes in the subtalar region can be ruled out. Several techniques are available for performing the procedure; the most successful combine an open approach with compression and internal fixation. The foot must be positioned with regard to overall limb alignment and in the optimal position for function. A nonunion rate as high as 40% has been reported. Osteonecrosis of the talus and smoking are known risk factors for nonunion. When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain.