腰椎间盘突出症的量化手术适应证

回顾１０３例手术证实的腰椎间盘突出症，将诊断依据标准化计分，试图找到比较适用而标准的手术适应证，从分档的疗效评定结果可以看出：计分大于１５分者有明显的手术指征；计分９至１５分者有手术指征，但应谨慎；而计分小于９分者，应慎之又慎，为手术的相对禁忌证。     

颅骨钻孔一次性清除小儿急性硬膜外血肿

目的:介绍颅骨钻孔一次性清除小儿急性硬膜外血肿的手术方法并探讨其手术指征。方法:回顾性分析经颅骨钻孔一次性清除其急性硬膜外血肿患儿的手术操作及手术效果。结果:15例手术病例其中14例经颅骨钻孔一次性清除,仅1例残余少量血肿,全部病例术后24hGCS计分均达15分。结论:颅骨钻孔一次性清除小儿急性硬膜外血肿的手术方法,简单实用、安全有效,但手术指征应适度严格。     

外侧裂池附近小片脑挫裂伤灶致恶性颅高压32例临床分析

目的探讨外侧裂池附近小片脑挫裂伤灶致恶性颅高压原因、手术指征及手术方法,提高治疗效果。方法回顾分析32例外侧裂池附近小片脑挫裂伤灶致恶性颅高压原因、手术指征及手术方法。结果 10例保守治疗成功;5例因发生脑疝后手术,2例术后出现大面积脑梗塞后死亡,余3例存活;17例因格拉斯格计分(GCS)评分进行性下降,环池受压,侧裂池消失,或伴中线移位大于等于5mm而早期手术,均存活。结论外侧裂池附近脑挫裂伤治疗初期应密切注意观察病情,手术指征应适当放宽。     

胆源性重症急性胰腺炎的早期手术治疗 (附28例分析)

目的 探讨胆源性重症急性胰腺炎（BSAP）早期手术的可行性、指征和术式。方法 回顾性分析本院经早期手术或延期手术治疗的28例BSAP的临床资料。结果 早期手术（15例）：死亡2例（13.3%）;术后重要并发症6例（40.0%）;再手术3例（20.0%）;平均手术时间90min。延期手术（13例）：死亡2例（15.4%);术后重要并发症7例（53.8%）;再手术2例（15.4%）;平均手术时间125min。结论 早期手术治疗BSAP是可行的,胆道梗阻性者一般应早期手术,无胆道梗阻性者手术指征仍应严格掌握,手术方式宜简单有效。     

上消化道异物的外科治疗

目的 总结上消化道异物的外科治疗经验。方法 在186例上消化道异物中9例行外科治疗。并对其临床特点、手术指征、手术入路及处理技巧进行回顾性分析。结果 9例患者术后无并发症，全部治愈出院。结论 对位于食管第二狭窄或长度超过9cm的胃十二指肠异物以及经内镜取出失败者均有剖腹手术指征。手术入路应根据异物部位而选择。处理技巧适采用小切口取异物，切口缝合后，以纵隔胸膜或大网膜复盖。     

肝癌合并门静脉高压症的治疗选择

肝癌合并门静脉高压症病情复杂,临床治疗十分困难。治疗选择应根据引起门静脉高压的因素而采取个体化治疗。病人病情允许,适宜采用同期联合手术,但争议较多;无法耐受同期联合手术者,应选择分期手术;对于全身情况较差无手术指征的病人,原则上以非手术治疗为宜。正确掌握手术适应证,严格控制术中出血及积极防治术后并发症是有效治疗的关键。     

腰椎间盘突出症再次手术32例临床分析

回顾性分析32例腰椎间盘突出症初次手术失败后再手术患的诊治情况。全部病人随访2-10年，根据术后感觉，运动等恢复情况评定，优15例，良9例，优良率75%，腰椎间盘突出症再次手术原因是多元性的，有医源性，也有非医源性的因素，根据本组病人分析，医源性因素为主要原因，提示应严格掌握腰椎间盘突出的手术指征，尽量避免再次手术。     

腹腔镜在腹部外伤中的应用

近几年来,腹部损伤的发生率有增加的趋势.传统处理的方法是:有手术指征者即行开腹探查术;无手术指征者保守观察,带有一定的盲目性.腹腔镜手术为治疗腹部外伤提供了新途径,其临床应用价值也越来越被人们所认识.2001年5月-2003年5月我们用腹腔镜探查腹部外伤16例,效果满意,现报道如下.     

头部严重损伤的预后因素

头部严重损伤的预后因素,包括昏迷程度、脑干反射、颅内损伤类型、颅内压和多感觉道激发反应等。允许手术损伤与不可手术损伤者的预后不同,但神经手术治疗本身并不是确定预后的因素。 1974年,Glasgow昏迷指数的应用,提供了一套标准指标,在损伤后的早期即可预测死亡率。三项指标以数字计分(3～15分),高者正常,低者有损害。昏迷、     

肾癌保留肾单位手术的临床价值(附17例报告)

目的　评价肾癌保留肾单位手术的临床价值。　方法　回顾性研究 17例行保留肾单位手术的肾癌患者临床资料 ,其中单侧 15例 ,双肾异时性肾癌且一侧为多发肿瘤 2例。绝对指征 2例 ,相对指征 6例 ,选择性指征 9例。肿瘤直径 2～ 6cm ,均为T1期 (1997年TNM标准 ) ;行改良肾肿瘤剜除术 (切缘于肾肿瘤外 1cm正常肾实质处 ) 15例 ,肾上极切除术 1例 ,楔形切除术 1例。 2 0例同期肾癌临床及分期相当但行根治性手术的患者资料作随访对照 ,并作生存率时序检验。　结果　 17例患者随访 3～ 6 3个月 ,平均 35 .2个月 ,未见并发症及残肾肿瘤复发。无瘤生存率与根治性手术者相近。　结论　肾癌保留肾单位手术安全、有效 ,适合于对侧肾功能正常、一侧局限的偶发肾肿瘤患者。     

Surgical therapy of the patient with valvular lesion combined with coronary disease

We studied on operative indication, operative problem, and operative result in patients with valvular lesion with coronary disease. In 650 cases, 51 cases combined with coronary stenosis and ACBG (9 cases) or OTCA (6 cases) were performed in 15 cases of them. For operative indication, ACBG was applied in case with proximal stenosis of more than 70% and OTCA was applied in case with mild localized stenosis. Cardioplegia during operation was important and heart temperature should be kept less than 15 degrees C. In those cases with combined operation, there were no early deaths but one late death (3 years after operation). After operation, chest pain disappeared and clinical symptom and ability for exercise were improved. According to NYHA classification, the improvement before and after operation were class I, none and 11 cases; class II, one case and three cases; class III, 12 cases and none and class IV, two cases and none.     

后路显微内窥镜（METRx^TM）下钙化型腰椎间盘突出症的治疗

目的探讨经后路显微内窥镜椎间盘切除手术系统（MED）治疗钙化型腰椎间盘突出症的适应证选择及手术技巧。方法2000年12月至2008年6月,使用后路显微内窥镜系统治疗钙化型腰椎间盘突出症25例,详细介绍了手术过程、手术适应证及操作技巧。治疗组钙化型腰椎间盘突出症与一组单纯腰椎间盘突出症MED手术组进行手术时间、术中出血量、术后住院时间、术后下地活动时间、恢复日常生活时间及住院费进行术后短期项目比较。结果术后短期疗效评价依照Nakai分级,优良率91．7％。治疗组有2例脑脊液漏,其中1例转为开放手术,余无严重并发症。钙化型腰椎间盘突出症与单纯腰椎间盘突出症组比较除手术时间和术中出血量差异有统计学意义（P〈0．05,P〈0．01）外,其余项目均无统计学意义（P〉0．05）。治疗组行腰、腿疼平均目测视觉类比评分法（VAS评分）显示术前与术后3、6、12个月明显下降。Oswestry功能指数（ODI）术前与术后3个月比较,从术前平均45．6降至术后22．4（P〈0．01）。结论对钙化型腰椎间盘突出类型进行分类,术前评估,严格掌握适应证,熟练操作技巧是钙化型腰椎间盘突出症行MED治疗成功的关键。     

医源性胆管损伤的严重后果

目的探讨胆囊切除术中严重医源性胆管损伤的原因、处理方法、经验教训与预防对策。方法回顾性分析本院1992年10月至2005年4月共处理的202例医源性胆管损伤中9例（4．45％）致严重后果者的临床资料，以致死致残（胆道残废），处理棘手，引发医疗纠纷及耗资巨大，判定为严重后果。结果严重医源性胆管损伤中5例死亡；4例为胆道残废，赔款或继续医疗费用巨大。结论胆囊切除术或胆道探查术中注意规范性、轻柔操作、认真细致、谨慎的作风、熟悉解剖等能有效避免胆管损伤；胆管损伤后及时发现并处理效果良好；防重于治。     

Multivisceral central pancreatectomy for pancreatic neuroendocrine tumor: A case report on a novel surgical technique

IntroductionCentral pancreatectomy (CP) is considered a viable alternative to subtotal distal pancreatectomy, for lesions involving the neck or proximal pancreatic body. Multivisceral central pancreatectomy (MVCP) for locally advanced tumors of the pancreatic body remains unreported.Presentation of caseWe hereby report a case of locally advanced pancreatic neuroendocrine tumor (NET) with gastric involvement. The patient underwent successful central pancreatectomy with subtotal gastrectomy for locally advanced NET of the pancreas. In the follow up period, relevant complications like pancreatic insufficiency or pancreatic fistula were not encountered. The patient is doing well more than ten months after resection.DiscussionA MVCP can be considered in patients with limited pancreatic involvement, as long as sufficient pancreatic parenchyma can be preserved. Additional organ involvement mandating resection should not be considered a contra indication to this procedure. With careful surgical planning and meticulous technique, risk of post operative complications after MVCP can be minimized with added benefit of long term endocrine and exocrine integrity.ConclusionsCP is a viable alternative and can be performed with adjacent organ resection, with acceptable post operative outcomes.     

Use of ultrasonographic risk score in the timing of operative intervention for acute cholecystitis

Timing of operative intervention for acute cholecystitis has long been a subject of debate. However, actual or impending perforation constitutes an absolute indication for prompt operative intervention. To discriminate these cases from those undergoing observation with conservative treatment, clinical and ultrasonographic findings were reviewed and analyzed in 17 patients with acute cholecystitis. Specificity, sensitivity, and accuracy of ultrasonography in discriminating cases of acute cholecystitis, in terms of timing of operative intervention, were calculated retrospectively based on the operative findings. The risk score for each ultrasonographic finding was determined, and the total risk score was calculated for each patient. The calculated total risk score was found to be well correlated with the macroscopic appearance of the gallbladder at operation in cases of acute cholecystitis. Therefore, this score should be useful in determining the timing of operative intervention for acute cholecystitis. However, the usefulness of the variables should further be established prospectively in other patient populations.     

Civilian gunshot wounds to the head: a prospective study

Previous retrospective studies of cranial gunshot wounds have failed to determine whether aggressive field resuscitation, triage to a neurosurgical center, and early surgical intervention can improve the assumed poor outcome of these severely injured patients. Therefore, we studied 100 consecutive patients prospectively to establish a systematic approach to treatment. If the patient retained two or more neurological signs after aggressive field resuscitation/intubation, a computed tomographic scan was performed. Rapid surgical debridement was done unless the patient deteriorated to clinical brain death. The Glasgow Coma Scale (GCS) score after resuscitation was 3 to 5 in 58 patients, 6 to 8 in 8 patients, 9 to 12 in 12 patients, and 13 to 15 in 22 patients. Seventy-six computed tomographic scans and 43 craniotomies were performed. The Glasgow Outcome Scale scores showed that 60 patients died, 2 were vegetative, 6 were severely disabled, 20 were moderately disabled, and 13 had good outcomes. There were 10 postoperative deaths. No patient with a GCS score of 3 to 5 had a satisfactory outcome; however, outcome progressively improved as the GCS score increased. We conclude that all cranial gunshot patients should initially receive aggressive resuscitation. Patients with stable vital signs should be examined by computed tomographic scan. If the patient's GCS score after resuscitation is 3 to 5 and no operable hematomas are present, then no further therapy should be offered. All patients with a GCS score greater than 5 should receive aggressive surgical therapy.     

Conservative approach to the elderly patient with burns

A retrospective analysis of 55 elderly patients (more than 60 years of age) was undertaken to compare results of conservative management to standard operative treatment. Thirty-one percent of the patients died early from their injury. Twenty-three patients were treated without operation, with emphasis on careful outpatient wound care and physical therapy. The remaining 15 patients required excision and grafting of burn wounds or amputation. Conservatively managed patients had fewer complications, a shorter hospital stay, and functional results equal to the operative group. These results suggest that many elderly burn patients can be managed without operation with good outcome and lessened morbidity.     

Preoperative Grading System for Predicting Operative Conditions in Laparoscopic Cholecystectomy

Purpose In a previous retrospective study, we predicted the operative conditions for abdominal wall-lifting laparoscopic cholecystectomy (ALLC), using a new preoperative grading system. We conducted the present study to evaluate the validity of our grading system prospectively, and to improve the operative outcome.Methods Ninety-seven patients underwent cholecystectomy between January 2000 and March 2002, and were prospectively examined according to our preoperative grading system. Allotting 0–5 points for nine preoperative factors, the total combined score was defined as the predictive score. The postoperative score was defined by allotting 0–8 points to five operative factors. The ratio of the preoperative score / postoperative score was defined as the skill score.Results The mean postoperative score was significantly correlated with the predictive score (P 0.01). The mean operation time and the mean postoperative score differed significantly among surgeons with skill scores higher or less than 1.25 (P 0.05). They were significantly improved (P 0.05) by choosing an operator according to the predictive score and skill score.Conclusion Our preoperative grading system using the predictive score is a valid method of predicting the actual operative conditions of ALLC. An adequately skilled operator should be chosen according to the difficulty of each case, to ensure the best possible operative outcome.     

股前外侧游离皮瓣移植

作者采用游离股前外侧皮瓣移植治疗严重瘢痕挛缩畸形、深部溃疡等。结果显示４６例中４５例存活,有效率９７．８％。作者认为该皮瓣供区隐蔽,解剖方便,血管恒定,且切取后不会对供区造成外形上的影响,是一种理想的供瓣区。但在静脉曲张性溃疡及伴有心血管疾患病例应慎用。     

Treatment and rehabilitation of dysmelic children

It is reasonable to make the plan of treatment and rehabilitation of dysmelic children in infancy and to realize it after an agreement with the parents, if possible in a care system. A careful operative indication considering the possibilities of orthetic-prothetic supply from every respect is necessary. The supply of the orthopaedic apparatus is generally individually planned and it succeeds only rarely to use standard prosthesis and orthesis. It is worthwhile to strive that the rehabilitation procedure should enable the child to go to the general school in the usual time. Based on the presentation of a few cases the author describes the ground principles of treatment-rehabilitation summarized in the paper.