内科微创肺减容术的研究进展

传统的外科肺减容术治疗慢性阻塞性肺疾病（COPD）有严格的适应证，并且副作用大、并发症多。于是人们研究出多种基于同样原理但是采用内科微创技术的减容方法。目前常用的内科微创肺减容术有使用单向活瓣、生物蛋白胶等封堵支气管使靶肺萎陷、不张，或采用支气管内药物灌注肺泡加封堵使靶肺组织纤维化等。此外，还有人提出人工旁路增加呼出气量的方法。尽管目前还缺少大规模的随机对照临床试验结果，但是内科微创肺减容术已展现了其巨大的临床应用前景，也将为治疗COPD提供更多的选择。     

不同微创手术方式治疗自发性脑出血疗效对比：单中心回顾性分析

目的评估不同微创手术方式治疗自发性脑出血（ICH）的安全性、有效性及长期预后。 方法回顾性分析浙江大学医学院附属第二医院神经外科自2019年1月至2020年12月收治的微创手术治疗的356例ICH患者相关资料，根据手术方式的不同，将患者分为内镜组、立体定向组、小骨窗开颅组。分析3组患者的基线资料、围术期以及长期预后情况，评估不同微创手术方式治疗ICH的安全性、有效性。 结果本研究共纳入356例患者，其中内镜手术组116例，立体定向组135例，小骨窗开颅组105例。3组患者的年龄、性别、既往病史、出血位置以及术前GCS评分等基线资料比较，差异无统计学意义（P>0.05）；内镜组与立体定向组手术时长和术中失血量明显少于小骨窗开颅组，而立体定向组术后再发出血率明显高于其他2组，差异有统计学意义（P<0.05）。内镜组和小骨窗开颅组术后24 h血肿清除率高于立体定向组，内镜组术后3 d血肿清除率优于小骨窗开颅组和立体定向组，差异均具有统计学意义（P<0.05），而小骨窗开颅组与立体定向组比较差异无统计学意义（P>0.05）。术后7 d立体定向组和内镜组NIHSS评分明显低于小骨窗开颅组，预后良好率亦高于小骨窗开颅组；术后6个月内镜组和立体定向组NIHSS评分明显低于小骨窗开颅组，预后良好率高于小骨窗开颅组，差异均具有统计学意义（P<0.05）。 结论微创手术方式治疗ICH效果明确，可明显改善患者的长期预后，其中内镜辅助下血肿清除术血肿清除效率高且并发症少。     

胫骨平台骨折关节镜下微创治疗的疗效分析

目的观察关节镜下微创治疗胫骨平台骨折的临床疗效。方法将2010-02—2012-06收治的112例胫骨平台骨折患者随机分为两组,对照组给予常规手术治疗,观察组在关节镜下微创手术治疗。结果观察组的疗效优于对照组（P〈0．05）,优良率也高于对照组（P〈0．05）;切口长度、术中出血量和愈合时间均少于对照组（P均〈0．01）;而两组患者的手术时间比较差异无统计学意义（P〉0．05）。结论对于胫骨平台骨折患者采取关节镜下微创治疗具有损伤小、术后恢复快的优点,临床效果较好,值得在临床中推广应用。     

Surgical specimen extraction via a prophylactic ileostomy procedure: A minimally invasive technique for laparoscopic rectal cancer surgery

AIM To retrospectively evaluate the safety and feasibility of surgical specimen extraction via a prophylactic ileostomy procedure in patient with rectal cancer. METHODS We systematically reviewed 331 consecutive patients who underwent laparoscopic anterior resection for rectal cancer and prophylactic ileostomy in our institution from June 2010 to October 2016, including 155 patients who underwent specimen extraction via a prophylactic ileostomy procedure(experimental group), and 176 patients who underwent specimen extraction via a small lower abdominal incision(control group). Clinical data were collected from both groups andstatistically analyzed. RESULTS The two groups were matched in clinical characteristics and pathological outcomes. However, mean operative time was significantly shorter in the experimental group compared to the control group(161.3 ± 21.5 min vs 168.8 ± 20.5 min; P = 0.001). Mean estimated blood loss was significantly less in the experimental group(77.4 ± 30.7 mL vs 85.9 ± 35.5 mL; P = 0.020). The pain reported by patients during the first two days after surgery was significantly less in the experimental group than in the control group. No wound infections occurred in the experimental group, but 4.0% of the controls developed wound infections(P = 0.016). The estimated 5-year disease-free survival and overall survival rate were similar between the two groups.CONCLUSION Surgical specimen extraction via a prophylactic ileostomy procedure represents a secure and feasible approach to laparoscopic rectal cancer surgery, and embodies the principle of minimally invasive surgery.     

Computer-navigated minimally invasive total knee arthroplasty for patients with retained implants in the femur

Total knee arthroplasty (TKA) in patients with knee arthritis and retained implants in the ipsilateral femur is a challenge for knee surgeons. Use of a conventional intramedullary femoral cutting guide is not practical because of the obstruction of the medullary canal by implants. Previous studies have shown that computer-assisted surgery (CAS) can help restore alignment in conventional TKA for patients with knee arthritis with retained femoral implants or extra-articular deformity, without the need for implant removal or osteotomy. However, little has been published regarding outcomes with the use of navigation in minimally invasive surgery (MIS)-TKA for patients with this complex knee arthritis. MIS has been proven to provide less postoperative pain and faster recovery than conventional TKA, but MIS-TKA in patients with retained femoral implants poses a greater risk in limb malalignment. The purpose of this study is to report the outcome of CAS-MIS-TKA in patients with knee arthritis and retained femoral implants. Between April 2006 and March 2008, eight patients with knee arthritis and retained femoral implants who underwent the CAS-MIS-TKA were retrospectively reviewed. Three of the eight patients had extra-articular deformity, including two femur bones and one tibia bone, in the preoperative examination. The anteroposterior, lateral, and long-leg weight-bearing radiographs carried out at 3-month follow-up was used to determine the mechanical axis of lower limb and the position of components. The mean preoperative femorotibial angle in patients without extra-articular deformity was 3.8° of varus and was corrected to 4.6° of valgus. With the use of navigation in MIS-TKA, the two patients in this study with extra-articular femoral deformity also obtained an ideal postoperative mechanical axis within 2° of normal alignment. Overall, there was a good restoration of postoperative mechanical alignment in all cases, with a mean angle of 0.4° of varus. No limb malalignment or component malposition was found. In clinical assessments, there were also significant improvements in knee specific scores, functional scores, and motion arc. The results of this study suggest that navigation can help achieve accurate alignment and proper prosthesis positioning in MIS-TKA for patients with retained femoral implants and for whom intramedullary rod guidance is impractical.     

C型臂图像拼接技术在下肢复杂骨折微创术中的临床应用效果分析

目的探讨移动式c型臂实时图像拼接技术在临床骨科微创手术中的应用效果。方法对43例下肢复杂性骨折均采用微创手术治疗,术中对下肢进行c型臂透视并采集2～4幅图像,经过图像拼接技术处理后得到骨折复位后内固定手术部位的1张全景图像,对术中拼接图像进行评价;术后行DR或CR摄片检查并进行相关角度测量。结果术后43例均获随访,随访时间6—16个月,平均8个月,术后及术后3月复查X线片示骨折对位、对线佳,骨折均愈合,无钢板断裂和螺钉松动,其术中拼接图像的评定结果为全组43例中,优27例,良15例,可1例,差0例,优良率为97．67％。43例患者测量的角度均在正常范围以内,拼接完整图像和术后DR或CR图像的比较差异无统计学意义（P〉0．05）。结论移动式c型臂拼接技术的全景成像能够及时、有效地满足了骨科医生在术中重构股骨和胫骨骨折部位全景图像的需要,避免了临床对术中骨折的复位整体效果判断有误和内固定物不适当等现象,为进一步提高临床骨科微创手术质量提供强有力的支持和保障。     

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1) Laparoscopic surgery;(2) Robotic surgery;and(3) Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.     

The therapeutic outcome of minimally invasive synovectomy assisted with arthroscopy in the rheumatoid knee

Abstract

The purpose of the present study was to retrospectively evaluate the therapeutic outcome of minimally invasive synovectomy assisted with arthroscopy (MISAA). From 1995 to 2003, MISAA was performed on 30 knees of 18 rheumatoid arthritis patients. The mean follow-up period was 74.4 months. Radiographic assessment according to Larsen's radiological classification, the conversion ratio to total knee arthroplasty (TKA), and postoperative change of the range of flexion were evaluated retrospectively. There were 10 knees in grade I, 14 knees in grade II, and 6 knees in grade III, preoperatively. All the knees in grade I and 8 of 14 knees in grade II maintained the same grade until the latest follow-up. The other 6 knees in grade II and all the knees in grade III deteriorated to grade IV and were converted to TKA after MISAA. The mean range of flexion significantly increased postoperatively except the knees that were converted to TKA. MISAA is effective for rheumatoid knees in grade I or II, and improves range of flexion.     

The therapeutic outcome of minimally invasive synovectomy assisted with arthroscopy in the rheumatoid knee

The purpose of the present study was to retrospectively evaluate the therapeutic outcome of minimally invasive synovectomy assisted with arthroscopy (MISAA). From 1995 to 2003, MISAA was performed on 30 knees of 18 rheumatoid arthritis patients. The mean follow-up period was 74.4 months. Radiographic assessment according to Larsen's radiological classification, the conversion ratio to total knee arthroplasty (TKA), and postoperative change of the range of flexion were evaluated retrospectively. There were 10 knees in grade I, 14 knees in grade II, and 6 knees in grade III, preoperatively. All the knees in grade I and 8 of 14 knees in grade II maintained the same grade until the latest follow-up. The other 6 knees in grade II and all the knees in grade III deteriorated to grade IV and were converted to TKA after MISAA. The mean range of flexion significantly increased postoperatively except the knees that were converted to TKA. MISAA is effective for rheumatoid knees in grade I or II, and improves range of flexion.     

基底节区脑出血行微创术后患者联合早期有创机械通气治疗的相关因素分析

目的：对基底节区脑出血行微创术患者联合早期有创机械通气治疗的相关因素进行分析。方法：回顾性分析我科基底节区脑出血行微创术患者,将微创术后联合早期有创机械通气患者临床资料核实整理后对可疑因素进行多因素非条件Logistic回归模型分析。结果：纳入病例60例,通过分析选择有显著统计学意义的因素：入科24h最高体温、接受微创手术时间、血肿增大比例、GCS评分、入科时CRP( P<0. 05～0. 01)进行单因素Logistic回归分析,后选择有显著统计学意义的因素进行多因素非条件Logistic回归分析。显示入科时CRP、血肿增大比例与早期机械通气关系最为密切。结论：入科时CRP、血肿增大比例是早期机械通气高危因素。在临床工作中应得到高度重视。     

Minimally invasive surgery for submucosal(subepithelial) tumors of the stomach

Minimally invasive surgery has become common in the surgical resection of gastrointestinal submucosal tumors(SMTs). The purpose of this article is to review recent trends in minimally invasive surgery for gastric SMTs. Although laparoscopic resection has been main stream of minimally invasive surgery for gastrointestinal SMTs, recent advances in endoscopic procedures now provide various treatment modalities for gastric SMTs. Moreover, investigators have developed several hybrid techniques that include the advantages of both laparoscopic and endoscopic procedure. In addition, several types of reduced port surgeries, modification of conventional laparoscopic procedures, have been recently applied to the surgical resection of SMTs. Meanwhile, robotic surgery for SMTs requires further evidence and improvement.     

Research considerations in the evaluation of minimally invasive pancreatic resection (MIPR)

The IHPBA/AHPBA-sponsored 2016 minimally invasive pancreatic resection (MIPR) conference held on April 20th, 2016 included a session designed to evaluate what would be the most appropriate scientific contribution to help define the increasing role of MIPR internationally.Participants in the conference reviewed the assessment of numerous pertinent scientific designs including randomized controlled trial (RCT), pragmatic international RCT, registry-RCT, non-RCT with propensity matching, and various types of clinical registries including those aiming to create a quality improvement data system or a learning health care system. The strengths and weaknesses of each of these designs, the status of trials which are currently recruiting patients, and pragmatic considerations were evaluated.A recommendation was made to establish a clinical registry to collect data prospectively from around the world to assess current practices and provide a framework for future studies in MIPR.     

不同取标本途径在直肠癌微创手术中的疗效对比

目的对常规直肠癌经辅助切口取标本与经自然腔道取标本手术（NOSES）进行比较,探讨NOSES的近远期疗效。 方法回顾性分析2018年1月至2020年12月大连医科大学附属第二医院胃肠外科行直肠癌微创手术的217例患者的临床资料,根据标本取出方式不同分为NOSES组（研究组）和传统经腹部辅助切口组（对照组）。采用PSM平衡两组患者术前基本资料,研究组和对照组各纳入患者63例,比较两组患者的围手术期资料、术后病理资料及远期随访资料。 结果研究组患者腹壁切口更短（t=-19.791,P＜0.001）,术后离床时间更早（t=-5.978,P＜0.001）,胃肠道功能恢复更快（t=-7.656,P＜0.001）,疼痛评分更低（术后12 h：t=-4.372,P＜0.001;术后24 h：t=-5.835,P＜0.001）,两组对比差异均存在统计学意义。研究组患者切口并发症发生率明显低于对照组,差异存在统计学意义［（0）vs.（9.5%）,χ²=4.375;P=0.028］。采用Clavien-Dindo分级标准对术后并发症进行分类,研究组共8例术后并发症（12.7%）,其中CD Ⅰ级并发症3例（4.8%）,CD Ⅱ级并发症2例（3.2%）,CD Ⅲ级并发症3例（4.8%）;研究组术后并发症发生率较对照组低,但差异无统计学意义［（12.7%）vs.（22.2%）,χ²=1.983;P=0.159］。对比两组患者的术后病理资料及远期随访资料,在淋巴结检出总数（t=0.603,P=0.548）、近切缘（t=-0.110,P=0.912）及远切缘长度（t=-0.126,P=0.900）、总生存率（χ²=0.002,P=0.962）及无病生存率（χ²=0.625,P=0.429）上,差异均无统计学意义。 结论NOSES安全可行,具有术后疼痛轻、损伤小、胃肠道功能恢复较快等优点,具有与传统经辅助切口取标本手术相似的长期肿瘤学结果。     

Non-robotic minimally invasive gastrectomy as an independent risk factor for postoperative intra-abdominal infectious complications: A single-center,retrospective and propensity score-matched analysis

BACKGROUND Minimally invasive surgery for gastric cancer(GC) has gained widespread use as a safe curative procedure especially for early GC.AIM To determine risk factors for postoperative complications after minimally invasive gastrectomy for GC.METHODS Between January 2009 and June 2019, 1716 consecutive patients were referred to our division for primary GC. Among them, 1401 patients who were diagnosed with both clinical and pathological Stage Ⅲ or lower GC and underwent robotic gastrectomy(RG) or laparoscopic gastrectomy(LG) were enrolled. Retrospective chart review and multivariate analysis were performed for identifying risk factors for postoperative morbidity.RESULTS Morbidity following minimally invasive gastrectomy was observed in 7.5% of the patients. Multivariate analyses demonstrated that non-robotic minimally invasive surgery, male gender, and an operative time of ≥ 360 min were significant independent risk factors for morbidity. Therefore, morbidity was compared between RG and LG. Accordingly, propensity-matched cohort analysis revealed that the RG group had significantly fewer intra-abdominal infectious complications than the LG group(2.5% vs 5.9%, respectively; P = 0.038), while no significant differences were noted for other local or systemic complications.Multivariate analyses of the propensity-matched cohort revealed that non-robotic minimally invasive surgery [odds ratio = 2.463(1.070–5.682); P = 0.034] was a significant independent risk factor for intra-abdominal infectious complications.CONCLUSION The findings showed that robotic surgery might improve short-term outcomes following minimally invasive radical gastrectomy by reducing intra-abdominal infectious complications.     

Seasonal changes in plasma testosterone, thyroxine, and cortisol levels in wild rabbits (Oryctolagus cuniculus algirus) of Zembra island

Annual variations in testosterone, thyroxine, and cortisol concentrations were recorded in plasma samples obtained monthly from male wild rabbits living in their natural biotope. For comparison, a group of animals was held in semicaptivity close to Tunis. Zembra is an uninhabited, hardly accessible island, north of the bay of Tunis and is a part of a large, protected zone of natural reserve. Warrens of Zembra appear to subsist from a very remote past, without any contact with other strains. In both natural and captive environments, testosterone levels peak sharply in October, decline in November-December, and are low from January to September. Thyroxine titers also peak in October but a second peak occurs in spring, the magnitude of which is markedly higher in natural than in captive conditions. As to cortisol, netting in Zembra results in stress-induced high values but semicaptive specimens exhibit a clear-cut annual rhythm peaking in January.     

颅内血肿微创穿刺粉碎清除术治疗高血压脑出血的临床观察

目的观察为高血压脑出血患者行颅内血肿微创穿刺粉碎清除术的实际效果,总结其临床价值。方法回顾2011年06月~2013年10月高血压脑出血患者75例,将其分成微创组35例,对照组40例,为对照组患者应用传统开颅手术,为微创组患者在应用颅内血肿微创穿刺粉碎清除术,临床治疗后,对比两组患者的神经功能评分及临床治疗有效率。结果与治疗前相比,两组神经功能缺损评分均有所降低,但对比两组数据,差异显著(P0.05);从临床治疗有效率看,微创组为88.57%。对照组为65.00%,经统计、对比,差异显著,存在统计学意义(P0.05),说明微创组治疗效果优于对照组。结论为高血压脑出血患者行颅内血肿微创穿刺粉碎清除术,疗效确切,值得应用、推广。     

The impact of marginal lung function on outcomes in the era of minimally invasive thoracic surgery

BackgroundThe effect of marginal lung function on outcomes after lung resection has traditionally been studied in the context of open thoracic surgery. Its impact on postoperative outcomes in the era of minimally invasive lung resection is unclear.MethodsIn this retrospective cohort study, we included adult patients who underwent minimally invasive lung resection at our institution between January 2017 and May 2020 for known malignancy or lung nodule. Marginal lung function was defined as pre-operative forced expiratory volume in 1 second (FEV1) and/or diffusion lung capacity of carbon monoxide <60% of predicted. Our outcomes included a composite outcome of pulmonary morbidity and/or 30- and 90-day mortality, and hospital length of stay. We used multivariable logistic and Poisson regression models to identify associations with outcomes, and Kaplan-Meier and Cox models to estimate survival.ResultsOf 300 patients, 88 (29%) had marginal lung function. Patients in the marginal group were more likely to be female (69% vs. 56%; P=0.028), and more likely to have: hypertension (HTN) (83% vs. 71%; P=0.028), chronic obstructive pulmonary disease (COPD) (38% vs. 12%; P<0.001), interstitial lung disease (ILD) (9% vs. 3%; P<0.019), and ischemic heart disease (28% vs. 18%; P=0.033). Patients were similar in terms of age (68±8 vs. 68±10 years; P=0.932), and other comorbidities. Anatomic lung resection comprised 56.8% of the marginal group vs. 74% in the non-marginal group (P=0.003). The most common complication was prolonged air leak (18.2% vs. 11.8%; P=0.479). Marginal lung function had a trend toward increased composite respiratory complications (22.7% vs. 15.1%; P=0.112) and 90-day mortality (5.7% vs. 4.2%; P=0.591), although they did not reach statistical significance. There was a statistically significant 1-day average increase in length of stay in the marginal lung function cohort (4.6 vs. 3.4 days; P<0.015) with a stronger association with diffusion lung capacity of carbon monoxide than FEV1. Survival was similar (marginal function HR =1.0; P=0.994).ConclusionsIn the era of minimally invasive thoracic surgery, lung resection in patients with marginal lung function may be considered in select patients. These findings aid in the selection consideration and counseling of this patient population.     

PHILOS钢板微创治疗老年肱骨近端骨折的疗效观察

目的探讨老年肱骨近端骨折的微创手术治疗。方法采用肩部外侧小切口手术入路,使用PHILOS锁定钢板治疗老年肱骨近端骨折42例,评价疗效。结果3例患者失访,余患者均得到随访,随访时间为4～13m,无伤口感染,无上举乏力,无复位丢失,无内固定松动,无骨折不愈合,无肱骨头坏死,愈合时间为12～20W。肩关节功能采用Neer评分法,优23例,良12例,可4例。优良率为89．7％。结论肩部外侧小切口手术入路结合PHILOS锁定钢板治疗老年肱骨近端骨折具有手术时间短,损伤小,术中出血少及术后功能恢复好。     

经胸微创室间隔缺损封堵62例疗效分析

目的总结微创经胸室间隔缺损(VSD)封堵的经验,探讨手术的疗效和安全性。方法入选2010年1月~2013年10月简阳市人民医院心血管外科住院的室间隔缺损患者62例,男性28例,女性34例,年龄2~57岁。所有患者在经食道超声心动图的监测下由右心室表面荷包送入封堵器,闭合室间隔缺损。结果封堵成功61例,1例因置入后主动脉瓣返流明显加重,改为体外循环。随访12个月,无封堵器移位、心律失常、残余分流、溶血等并发症。结论经胸微创封堵治疗室间隔缺损安全、可行,创伤小,恢复快。     

Imaging and monitoring in minimally invasive valve surgery using an intra-aortic occlusion device: a single center experience

BackgroundMinimally invasive approach through a right mini-thoracotomy is a world-wide used procedure for mitral valve surgery. We performed a retrospective analysis based on our center experience in order to propose an effective, safe and reproducible method using an intra-aortic occlusion device.MethodsThis is a retrospective analysis on 48 consecutive patients undergoing mitral valve surgery through a right anterolateral mini-thoracotomy in our center. An intra-aortic occlusion device was used for aortic clamping and cardioplegia delivery. Simultaneous multi-plane three-dimensional echocardiography imaging was acquired to detect the venous cannulas position, the intra-aortic device location in the ascending aorta, the balloon inflation, the complete occlusion of the aorta, the cardioplegia delivery, the origin and the blood flow in the right coronary artery. Aortic root pressure was measured by the tip of the intra-aortic occlusion device. A bilateral upper extremity invasive arterial pressure monitoring was detected. Neuromonitoring was performed through bilateral cerebral oximetry.ResultsThe analysis has shown no aortic dissection, neurological damage type 1 and myocardial ischemia in the study population. In 3 cases a distal displacement of the intra-aortic occlusion device was promptly detected by the combined use of echocardiographic imaging and by a drop of the right cerebral oximetry saturation and of the right radial artery pressure.ConclusionsThe combined use of transesophageal simultaneous multi-plane three- dimensional echocardiography imaging, bilateral upper extremity invasive arterial pressure monitoring, aortic root pressure and cerebral oximetry is an effective, safe and reproducible method in patients undergoing minimally invasive valve surgery using an intra-aortic occlusion device.