Pancreatic invasion is a prognostic indicator after radical resection for carcinoma of the ampulla of Vater

Sixty-three patients who had undergone pancreatoduodenectomy for carcinoma of the ampulla of Vater were analyzed with respect to tumor extent and prognosis. The postoperative mortality rate was 3% and overall survival rates 3 and 5 years after surgery were 55% and 46%, respectively. pTNM stage did not reflect prognosis after resection in patients at stages 2 and 3, while pancreatic invasion and regional lymph node metastasis clearly reflected prognosis after resection. Of the 26 patients who had no pancreatic invasion, regional lymph node metastasis was seen in only 19%, whereas of the 37 patients with pancreatic invasion, 62% exhibited lymph node metastasis. These factors were significantly correlated (P<0.001). Pancreatic invasion appeared to be an indirect indicator of regional lymph node metastasis. We conclude that, to improve prognosis for patients with pancreatic invasion, extended resection including extended lymphadenectomy, is a preferable additional procedure.     

胰十二指肠切除术治疗胰头和壶腹部癌230例分析

了解胰十二指肠切除术治疗胰头和壶腹部癌的效果和影响病人生存的因素。方法:分析230例胰头和壶腹部癌的主要表现,辅助检查、手术并发症、手术死亡率,调查术后生存情况及影响病人长期生存的因素。结果:本组病人出现黄疽90.9％,腹痛56.1％,发热32.6％,白陶土样大便13.5％。B超、CT和ERCP检查准确率分别为68.3％、79.3％和66.6％。手术并发症72例(31.3％),死亡20例(8.7％)。术后1、3、5年存活率分别为46.7％,17.4％和52％。肿瘤直径、淋巴结转移和切缘状态是影响病人术后生存的因素,而肿瘤分化程度和病人年龄对生存率无明显影响。结论:胰头和壶腹部癌临床表现有多样性,B超和CT等辅助检查有局限性,手术有高并发症,5年生存率低下,手术治疗远近期效果都不理想。     

Rare type of congenital aneurysm of the right sinus of Valsalva protruding superiorly into the pericardial space

We report a rare type of aneurysm of the sinus of Valsalva. The orifice of the aneurysm was in the right sinus of Valsalva and protruded superiorly, which is a direction not typical of right sinus of Valsalva aneurysms. Intraoperatively, it became clear that the aneurysm was located in the right sinus of Valsalva with extracardiac protrusion. Inspection through the aortotomy revealed that the orifice of the aneurysm opened between the orifice of the right coronary artery and the commissure between the right and left coronary cusps. The aneurysm was obliterated with a pledgeted suture from outside the orifice of the aneurysm. Early prophylactic surgical treatment of the aneurysm makes the operation simple and prevents subsequent development of complications, such as compression of the coronary artery, thrombosis, and/or spontaneous rupture.     

胰头十二指肠切除术71例分析

目的探讨如何提高胰头壶腹部恶性肿瘤的手术切除率和手术成功率。方法对1981～1997年收治的71例胰头十二指肠切除术患者的术后并发症、病死率及术前术中诊断情况进行分析。结果71例中恶性肿瘤61例,良性疾病10例（14．2％）,有并发症24例（33．8％）,死亡8例（11．2％）。结论要提高胰头壶腹恶性肿瘤的手术切除率和治愈率,关键是早期诊断、妥善的围手术期处理和精湛的手术技巧。     

根治性切除治疗胰头癌的手术体会

目的 总结提高胰头癌手术根治率和降低术后并发症发生率的经验。方法 回顾性分析我院1996年1月至2005年3月期间的55例胰头癌根治术患者的临床资料。结果 本组55例胰头癌根治性切除术患者中男31例，女24例，均为胰腺导管癌。2002年前、后根治率分别为25．9％（29／112）和34．7％（26／75），并发症发生率分别为48．3％（14／29）和19．2％（5／26）。提高根治性手术技巧包括胰周淋巴结及神经丛清扫、联合血管切除、综合无血术野技术等。结论 提高胰头癌手术根治率和降低术后并发症发生率有赖于对胰头癌病理生理特点的深入了解和手术技巧的成熟。     

The stepwise introduction of innovation into orthopedic surgery: the next level of dilemmas

The optimum method for the appropriate introduction of innovative technologies into orthopedics is a vital but vexing issue. Compromises in the introduction process are driven by (a) the magnitude of the problem addressed (incidence and severity), (b) the advantages and risks of the proposed solution, and (c) the “universal dilemma,” meaning the inherent “gap” between all the nonhuman supporting data and the unknowns of both efficacy and long-term safety in large human usage over many years. Drawing on the data generated and the actual decision tree used in the introduction of a new highly cross-linked polyethylene as a case study, this article illustrates these “subsequent dilemmas.”     

法洛四联症根治术后近期疗效的影响因素分析

目的 分析影响法洛四联症（TOF）根治术后近期疗效的主要风险因素，探讨改善疗效的方法。方法 219例TOF患者根据手术后近期疗效的不同分为两组，A组（n=110）：术后心功能恢复良好，术后2周内能顺利出院，无严重并发症发生，出院时心功能分级（NYHA）Ⅰ或Ⅱ级，随访6个月内左心室射血分数（LVEF）〉0．50；B组（n=109）：术后2周内未能出院，有严重并发症发生，出院时心功能分级（NYHA）Ⅱ或Ⅲ级，随访6个月内LVEF〈0．50。分析比较两组患者的临床资料，并用logistic回归和模型选择分析影响TOF根治术后近期疗效的危险因素。结果 A组心功能恢复好、无死亡患者，出院时心功能（NYHA）为Ⅰ或Ⅱ级，LVEF〉0．50；B组死亡8例（7．34％），生存患者出院时心功能（NYHA）为Ⅱ或Ⅲ级，LVEF〈0．50（P〈0．01）。A组患者术后24h胸腔引流量、辅助呼吸时间、正性肌力药物维持循环时间和住院时间均少于或短于B组（P〈0.01）；而B组患者的体外循环时间和升主动脉阻断时间长于A组，跨瓣环补片的比率大于A组，Nakata指数小于A组（P〈0.01）。logistic回归分析结果显示：手术年龄（OR=0．69）、术前血氧饱和度（0R=0．98）、红细胞压积（OR=0．94）、跨瓣环补片数（OR=46．86）、Nakata指数（OR=16．90）、术后胸腔引流量（OR=0．84）、心律失常（0R=0．87）和术后切口感染发生率（OR=63．57）等对TOF根治术后近期疗效有明显的影响（P〈0.01）。结论 提早行TOF根治手术的年龄、术前降低红细胞压积、改善外周血氧饱和度、早期加行姑息手术以促进肺动脉发育，加强围手术期监护等是提高TOF根治术后近期疗效的有效措施。     

胰十二指肠切除术治疗胰头及壶腹部癌（附97例临床分析）

为提高胰头及壶腹部癌的疗效，总结９７例胰十二指肠切除术（ＰＤ）治疗胰头及壶腹部癌的诊治经验。癌肿切除率为３４．４％，手术并发症发生率为３８．４％，手术死亡率为１１．３％，术后１、３和５年生存率分别为６８．８％、４３．１％和３０．０％。认为要提高本病早期诊断率，必须对可疑高危病人提高警惕，首选Ｂ超检查，Ｂ超和ＥＲＣＰ两项联合检查可提高本病早期诊断。     

中药周期性阶段疗法治疗肝肾阴虚型黄褐斑疗效观察

目的：观察中药周期性阶段疗法治疗黄褐斑的临床疗效。方法：将123例患者随机分为两组,治疗组62例,采用月经后服用补精血颗粒与月经前及经期服用理气养血活血颗粒的周期性阶段治疗;对照组61例,采用补精活血颗粒的持续性给药治疗,2个疗程后判定临床疗效。结果：总有效率治疗组为95.08%,对照组为93.22%,两组比较差异无统计学意义（P〉0.05）。结论：两组临床疗效相当,均能有效治疗黄褐斑。     

超关节夹板固定加悬垂石膏治疗肱骨中下段骨折

应用超关节夹板固定加悬垂石膏治疗肱骨中下段骨折２７例。经治疗后随访，Ｘ片复查骨折均在６～８周内愈合。无一例延迟愈合或不愈合。作者认为：夹板固定及石膏塑造同时并用，达到固定和牵引，维持骨折的稳定，消除局部剪力，促进骨愈合的目的。     

Organs of Zuckerkandl: their surgical significance and a review of a century of literature

BACKGROUND: Organs of Zuckerkandl (O of Z) harbor the potential for deadly paragangliomas. Paragangliomas are one of the surgical causes of hypertension. Major treatises of medicine offer very little information on this topic. METHODS: PubMed Medline and Google searches were performed to obtain reported cases of paragangliomas of the O of Z. A total of 135 cases of paragangliomas of the O of Z were found. Each case was reviewed and charted. Charts then were analyzed. RESULTS: Seventy-four percent of patients with this neoplasm have hypertension. Eighty percent of patients undergo an operation with more than 30% having an incorrect preoperative diagnosis. These tumors have a 43% mortality when presenting acutely. CONCLUSIONS: Individuals aged < or =50 years with hypertension should be considered for screening for pheochromocytoma/paraganglioma with uring and/or serum catecholamines. Twenty-four-hour collections for urinary metanephrines and vanillylmandelic acid are diagnostic of functional tumors. A high degree of suspicion should follow with radiologic and chemical diagnostic studies. Triple-phase helical computed tomographic scans, metaiodobenzyl-guanidine scans, and magnetic resonance imaging with gadolinium-diethylenetriaminepentaacetic acid infusion are the standard for radiologic diagnosis. Treatment is always surgical excision. Phase II trials are in order for neoadjuvant and adjuvant treatment options.     

Eingeschränkte chirurgische Radikalität beim okkulten Karzinom der Papilla Vateri

Zusammenfassung Neun histologisch gesicherte benigne Adenome der Papilla Vateri wurden konsekutiv durch transduodenale Vollwandexzision mit gleichzeitigem regionärem Lymphknotenstaging ohne nennenswerte postoperative Komplikationen behandelt. 4 Patienten hatten in der postoperativen Histologic ein pT₁ G₁ pN₀-Karzinom im Adenom, das vorher weder makroskopisch noch im intraoperativen Schnellschnitt identifiziert wurde. Ein radikaler Zweiteingriff wurde unterlassen, und alle 4 Patienten sind nach 1–8 Jahren rezidiv- und metastasenfrei.

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Limited radicality in surgery of occult carcinomas of the papilla of Vater

Summary Nine histologically proven benign adenomas of the papilla of Vater were consecutively treated by transduodenal full thickness excision and simultaneous staging of regional lymph nodes without severe postoperative complications. 4 patients had a small well differentiated (pT₁ G₁ pN₀) carcinoma, although there was neither macroscopically nor by frozen sections any suspicion of a malignant tumour. A more radical pancreatoduodenectomy was not carried out and the 4 patients are without tumour recurrence or metastases 1–8 years postoperatively.

     

A horse named 'Twilight Sleep': the language of obstetric anaesthesia in 20th century Britain

Historians of medicine frequently marginalize or completely ignore the importance of linguistics in the development and dissemination of medical theories and clinical techniques, both in professional culture and in society at large. This is particularly true in the history of pain relief in labour, despite the significant role played by popular attitudes to birth and pain relief in the development of clinical services. This paper uses a simple form of citation analysis to examine shifts in the usage of terms related to regional nerve block techniques in The Lancet and The Times from 1900 to 1999. Graphical representations of these data are used to relate changes in the incidence of citations to key events in the 20th century history of obstetric anaesthesia in Britain. A study of the rise and fall of 'twilight sleep' in the early part of the century is used to demonstrate the advantages and disadvantages associated with this approach to medical history. Conclusions from this analysis are used to suggest (tentative) models for the acceptance and diffusion of medical words in professional and popular vocabularies.     

额肌动力上睑SMAS提紧治疗上睑下垂方法研究

目的:研究重度上睑下垂的动力选择、上睑提升传动结构再造、传动方向设置和再造动力的起止点。方法:根据多年临床实践及尸体解剖研究，以治疗2例家族性先天肌原性上睑下垂的过程，确定额肌作为上睑动力的解剖结构的命名；动力源滑车设计，动力传动组织结构；动力传布的方向；动力源额肌瓣的起点和止点设计，以及动力源额肌瓣的长宽设计等。结果:以额肌作为动力，额骨眶上缘作为滑车，上睑SMAS瓣为动力传动组织结构，取宽12～15mm，长15～20mm的长方形额肌上睑SMAS瓣，置于眼轮匝肌后方。眶缘上1cm额肌和SMAS结合处，作为上睑动力源的起点，上睑睑板上1／3，为再造上睑动力的止点。修复后静态时，使矫正的上睑缘高于健侧1～2mm，即位于角膜上缘，或角膜上缘1mm。2例患者手术治疗后功能和外形得到改善。结论:额肌上睑SMAS提紧是治疗先天性重度上睑下垂和复发性上睑下垂的良好方法，手术操作简便。再造动力功能良好。     

Combined pentalogy of Cantrell with tetralogy of Fallot, gallbladder agenesis, and polysplenia: a case report

A male newborn with pentalogy of Cantrell, tetralogy of Fallot, agenesis of the gallbladder, and polysplenia died at 3 days of age. Polysplenia was not previously reported in this association.     

Evaluation of patients' quality of life aspects after cardiac pacemaker implantation

Objective

To evaluate patients'' quality of life aspects after pacemaker implantation, relating it to gender, age, and implantation timespan.

Methods

A total of 107 clinically stable patients of both genders (49.5% women and 50.5% men) over 18 years old (average 69.3±12.6 years) and presenting an implantation timespan of three to 12 months (average 6.36±2.99 months) were evaluated. The evaluation included personal, clinical, and implant data as well as quality of life questionnaires (AQUAREL and SF-36). Statistical analysis was conducted using the t test and Pearson correlation, with a 5% significance level.

Results

The lowest SF-36 score referred to physical aspects, and the highest score referred to social aspects. In AQUAREL, the lowest score referred to dyspnea, and the highest referred to discomfort. There was a significant association between gender and quality of life in SF-36 (physical functioning and emotional aspects) and in AQUAREL (dyspnea). A negative correlation was observed between age and quality of life (functional capacity in SF-36, and discomfort in AQUAREL) in relation to implantation timespan, a correlation with vitality from SF-36.

Conclusion

Lower quality of life scores were found in physical aspects and dyspnea; and higher scores in social aspects and discomfort. Men presented higher quality of life scores related to physical functioning, emotional aspects and dyspnea. As age increases, quality of life worsens regarding functional capacity and discomfort; and the longer the pacemaker implantation timespan, the worse quality of life when it comes to vitality. Gender, age, and implantation timespan influence quality of life; thus, these variables must be considered in strategies for improving quality of life of patients with pacemakers.     

Significance of Resegmentation in the Pathogenesis of Vertebral Body Malformation

Human embryos and fetuses were investigated histologically to elucidate the possible pathogenesis of congenital malformations of the vertebral body. Special attention was paid to the early development of the vertebral column, particularly the often-questioned stage of resegmentation, important as the stage during which the malformations might develop. Evidence of resegmentation was found in 7 embryos ranging from 7 mm C-R length (5 weeks after fertilization) to 13 mm (6 weeks). Moreover, the formation of the definitive vertebral body was considered to be intimately related to the intersegmental artery. As for Junghanns' concept that the cartilaginous body consists of two lateral halves, it was not observed in our specimens, nor was it found in the latest literature on normal vertebral development. Congenital malformations of the vertebral body were classified into two categories: failure of formation and failure of segmentation. They were demonstrated in an embryo of 13 mm and a fetus of 70 mm which were in the developmental stages of chondrification and early ossification, respectively. According to these observations, we conclude that most malformations of the vertebral body occur in the early stage of definitive vertebral body anlage formation.     

The origins of surgery. 2: From barbers to surgeons*

The art, craft and science of surgery is a highly interpersonal skill, central to a variety of traditions and cultures throughout human history. The development of surgery parallels the evolution of the human race from prehistory to the present time. This review attempts to examine the changing concepts and practices in surgery from the earliest era, enshrouded in mysticism and magic, through a manual craft performed by barbers and artisans, to a dignified profession based on science and technology. The evolution of surgery in the previous millennia is reviewed against the culture and morals, the politics and religion, and the philosophy and science of its period; in so doing assessing its perspective on the threshold of a new millennium.      

The origins of surgery: 1. From prehistory to Renaissance*

The art, craft and science of surgery is a highly interpersonal skill, central to a variety of traditions and cultures throughout human history. The development of surgery parallels the evolution of the human race from prehistory to the present time. This review attempts to examine the changing concepts and practices in surgery from the earliest era, enshrouded in mysticism and magic, through a manual craft performed by barbers and artisans, to a dignified profession based on science and technology. The evolution of surgery in the previous millennia is reviewed against the culture and morals, the politics and religion, and the philosophy and science of its period; in so doing assessing its perspective on the threshold of a new millennium.      

Men with hip fractures have poorer nutritional status and survival than women

Background Many hip fracture patients have a poor nutritional status which may be one explanation for their increased mortality.

Patients and methods We studied nutritional status and other mortality-related factors prospectively in 165 patients with hip fractures (85 women). We concentrated on differences between death rates and survival rates at 3 months and at 1 year, and between those patients who died within 3 months and those who died later.

Results In general, men had a poorer nutritional status and a larger number of comorbidities. Also, there were more smokers and alcohol abusers amongst the men. Of the patients who died during the first 3 months, most were men, and their initial nutritional status was poorer than that of women. Multivariate logistic regression analysis revealed a correlation between mortality and total serum protein, retinol binding protein and the number of comorbidities. Among patients who died after 3 months, mortality was associated with the number of comorbidities and smoking.

Interpretation The higher mortality rate in men than in women after hip fracture may in part be explained by the poor nutritional status in men.