30例胸腰椎骨折外科治疗的临床分析

目的：探讨我院30例胸腰椎骨折的外科治疗手段,分析其临床疗效。方法根据患者椎骨骨折的具体病情经患者的伤椎椎弓根置钉并且观察恢复情况。结果30例患者均未发生定位错误,愈合人数29例。结论经伤椎椎弓根置钉治疗胸腰椎处的骨折,能够有效的恢复椎管容积和椎体高度,解除脊髓神经受压,改善脊神经的功能,有效地恢复脊柱的稳定性,并且手术操作简便,是比较有效的临床外科手术方法。     

多节段胸腰椎结核的外科治疗

目的探讨多节段胸腰椎结核采取前后路联合入路病灶清除植骨内固定联合化疗的临床疗效。方法选取2007年1月至2017年12月本院收治的多节段胸腰椎结核患者28例,术前常规化疗2～4周,平均3周,手术先采用胸腰椎后入路行椎弓根螺钉固定,再行侧前方入路彻底清除病灶内脓肿、死骨、肉芽组织及坏死椎间盘在病椎上下正常椎体内行内固定,采用"钛网+自体髂骨植骨支撑,15例、自体髂骨植骨支撑10例、自体肋骨植骨支撑3例。结果28例患者均获得1～6年的随访,平均2.2年。其中合并脊髓损伤伴不全瘫者17例,按Frank分级:B级2例,C级11例,D级4例。B级2例恢复到C级;C级11例中,其中5例恢复到D级,6例恢复到E级;D级4例均恢复到E级。病灶静止、骨性融合26例,术后半年内有2例复发。1例再次手术,重新行病灶清除,去除植骨块改用钛网加髂骨植骨8个月后骨性融合;1例抗痨治疗无效,患者放弃治疗。无钢板、螺钉松动、断裂。结论术前常规化疗,术中彻底清除病灶植骨融合内固定,术后继续化疗,是外科治疗多节段胸腰椎结核获得良好效果的保证。     

胸心血管外科临床实习带教体会

临床实习是每一个医学生的必经之路。而胸心血管外科的实习因为其专科性强,理论知识短时间内难以掌握,同学们实习中积极性不高,使实习效果差。为了加强胸心血管外科实习带教,首先要认识其重要性,其次选择专业技能及自身素质较好的带教老师,完善带教管理制度,积极与同学沟通,调动同学实习的积极性,鼓励、激发同学们的热情,更好的完成胸心外科临床实习。     

重症急性胰腺炎的外科治疗

重症急性胰腺炎(SAP)发病急,病程进展迅速,病死率高。在诊治方面,大多数学者都倾向于采用“个体化治疗方案”。故在选择治疗方案上十分棘手[1]。我院自1995年1月至2005年12月共收治SAP 130例,现就其治疗情况及体会报告如下。1资料与方法1.1临床资料我院自1995年1月至2005年12月     

一例 FBN1基因变异所致家族遗传性胸主动脉瘤/夹层患者临床表现及遗传学分析

目的:对1例超声心动图表现为B型主动脉夹层及胸主动脉瘤的患者及其家系进行基因检测,明确其可能的致病变异基因。方法:对先证者进行全外显子测序,重点分析遗传性主动脉疾病相关致病基因,依据ACMG指南,判定变异的致病性。并应用Sanger测序对患者及家系成员的候选位点进行检测。结果:二代测序结果经生物信息学分析,在患者的基因...     

203例老年胆石症外科治疗的临床分析

目的分析老年胆石症外科治疗的临床特点为临床诊疗提供参考。方法入选203例老年胆结石患者,随机分为胆囊切除术组（n=101）和综合手术组（n=102）。胆囊切除组行胆囊切除术,综合治疗组行胆囊切除术合并胆总管探查取石术。治疗后分别对两组的临床特点与效果进行分析。结果两组患者在手术时间方面差异具有统计学意义,综合手术组手术时间长于胆囊切除术组（P〈0.05）;但在手术出血量和住院时间方面,两组相比差异无统计学意义（P〉0.05）。综合手术组结石清除率高于胆囊切除术组,术后复发率低于胆囊切除术,两组相比差异具有统计学意义（P〈0.05）。两组在术后并发症方面差异无统计学意义（P〉0.05）。结论胆囊切除术合并胆总管探查取石术结石清除率高、术后复发率低,是治疗老年胆石症较好的外科方法之一。     

多节段胸腰椎间盘突出的外科治疗

目的　探讨椎间盘多节段突出的发病机理、临床特点、诊断方法及外科治疗效果。方法　对 10 8例多发性椎间盘突出患者 (胸腰椎间盘突出 13例、胸椎间盘突出 11例、腰椎间盘突出 84例 ) ,从发病的临床特征、影像学改变以及手术治疗的临床效果进行分析。结果　全部病例经术后 8个月～ 12年的随访 ,总优良率达到 93%以上。结论　椎间盘多发性突出临床差异较大 ,其神经根受压临床表现比较复杂。故本病必须认真仔细系统检查结合CT或MRI获得确诊。手术的目的在于突出物摘除、椎管减压、神经根松解 ,维持脊柱稳定性 ,可获得满意的临床效果。     

70岁以上患者颈段及胸上段食管癌的外科治疗

目的探讨70岁以上患者颈段及胸上段食管癌的外科治疗。方法回顾性分析68例70岁以上颈段及胸上段食管癌患者的临床资料,全组患者均经左胸左颈二切口食管癌切除局部淋巴结清扫,食管-胃颈部吻合术。结果 68例患者均顺利完成手术切除食管肿瘤,死亡3例,其余病例恢复良好出院,术后主要并发症为心、肺并发症及吻合口瘘。结论高龄高位食管癌手术难度大、术后并发症多,经左胸左颈二切口颈部吻合手术方式能缩短手术时间,减少术后并发症,提高手术疗效。     

胸肋重叠抬举术治疗漏斗胸12例

漏斗胸是最常见的前胸壁畸形,主要由前胸壁凹陷形成。由于前胸壁的凹陷,使胸腔容积缩小。国内外报告都证明漏斗胸病人确实存在呼吸循环功能障碍,且因畸形存在,病人因形体异常而产生一定的心理损害。因此,及时行手术矫治是完全必要的。我科应用胸肋重叠抬举术治疗漏斗胸12例,疗效满意,现报道如下。     

The surgical pathology of thoracic aortic aneurysms

In 63 resected thoracic aortic aneurysms, the commonest histological finding (45 cases, 71.4%) was cystic medionecrosis. These cases formed two groups, 29 with widespread fragmentation and loss of elastic tissue (elastopathy) and 16 cases without elastopathy who were older and included most of the 18 cases of dissecting aneurysms. Thirteen patients had the Marfan syndrome, 10 showing cystic medionecrosis with elastopathy, indistinguishable from the cases with no Marfan stigmata although partial 'dissections' were mainly found in the Marfan patients, Histological appearances ranged from normal to complete loss of media. Cystic changes in muscle fibres apparently preceded elastic fragmentation. Fourteen cases (22%) had aortitis: 4 were syphilitic and 3 of other known aetiology. In 7 patients the aetiology of the inflammatory process was unknown and appearances included granulomatous infarct-like lesions and necrotizing aortitis or changes indistinguishable histologically from syphilis.     

Pathogenic FBN1 variants in familial thoracic aortic aneurysms and dissections

Marfan syndrome (MFS) due to mutations in FBN1 is a known cause of thoracic aortic aneurysms and acute aortic dissections (TAAD) associated with pleiotropic manifestations. Genetic predisposition to TAAD can also be inherited in families in the absence of syndromic features, termed familial TAAD (FTAAD), and several causative genes have been identified to date. FBN1 mutations can also be identified in FTAAD families, but the frequency of these mutations has not been established. We performed exome sequencing of 183 FTAAD families and identified pathogenic FBN1 variants in five (2.7%) of these families. We also identified eight additional FBN1 rare variants that could not be unequivocally classified as disease‐causing in six families. FBN1 sequencing should be considered in individuals with FTAAD even without significant systemic features of MFS.     

Autosomal dominant inheritance of a predisposition to thoracic aortic aneurysms and dissections and intracranial saccular aneurysms

A genetic predisposition for thoracic aortic aneurysms and dissections (TAAD) can be inherited in an autosomal dominant manner with decreased penetrance and variable expression. Four genes identified to date for familial TAAD account for approximately 20% of the heritable predisposition. In a cohort of 514 families with two or more members with presumed autosomal dominant TAAD, 48 (9.3%) families have one or more members who were at 50% risk to inherit the presumptive gene causing TAAD had an intracranial vascular event. In these families, gender is significantly associated with disease presentation (P < 0.001), with intracranial events being more common in women (65.4%) while TAAD events occurred more in men (64.2%,). Twenty‐nine of these families had intracranial aneurysms (ICA) that could not be designated as saccular or fusiform due to incomplete data. TGFBR1, TGFBR2, and ACTA2 mutations were found in 4 families with TAAD and predominantly fusiform ICAs. In 15 families, of which 14 tested negative for 3 known TAAD genes, 17 family members who were at risk for inheriting TAAD had saccular ICAs. In 2 families, women who harbored the genetic mutation causing TAAD had ICAs. In 2 additional families, intracranial, thoracic and abdominal aortic aneurysms were observed. This study documents the autosomal dominant inheritance of TAADs with saccular ICAs, a previously recognized association that has not been adequately characterized as heritable. In these families, routine cerebral and aortic imaging for at risk members could prevent cerebral hemorrhages and aortic dissections. © 2011 Wiley‐Liss, Inc.     

HTAD patient pathway: Strategy for diagnostic work-up of patients and families with (suspected) heritable thoracic aortic diseases (HTAD). A statement from the HTAD working group of VASCERN

Heritable thoracic aortic diseases (HTAD) are rare pathologies associated with thoracic aortic aneurysms and dissection, which can be syndromic or non-syndromic. They may result from genetic defects. Associated genes identified to date are classified into those encoding components of the (a) extracellular matrix (b) TGFβ pathway and (c) smooth muscle contractile mechanism. Timely diagnosis allows for prompt aortic surveillance and prophylactic surgery, hence improving life expectancy and reducing maternal complications as well as providing reassurance to family members when a diagnosis is ruled out. This document is an expert opinion reflecting strategies put forward by medical experts and patient representatives involved in the HTAD Rare Disease Working Group of VASCERN. It aims to provide a patient pathway that improves patient care by diminishing time to diagnosis, facilitating the establishment of a correct diagnosis using molecular genetics when possible, excluding the diagnosis in unaffected persons through appropriate family screening and avoiding overuse of resources. It is being recommended that patients are referred to an expert centre for further evaluation if they meet at least one of the following criteria: (1) thoracic aortic dissection (<70 years if hypertensive; all ages if non-hypertensive), (2) thoracic aortic aneurysm (all adults with Z score >3.5 or 2.5–3.5 if non-hypertensive or hypertensive and <60 years; all children with Z score >3), (3) family history of HTAD with/without a pathogenic variant in a gene linked to HTAD, (4) ectopia lentis without other obvious explanation and (5) a systemic score of >5 in adults and >3 in children. Aortic imaging primarily relies on transthoracic echocardiography with magnetic resonance imaging or computed tomography as needed. Genetic testing should be considered in those with a high suspicion of underlying genetic aortopathy. Though panels vary among centers, for patients with thoracic aortic aneurysm or dissection or systemic features these should include genes with a definitive or strong association to HTAD. Genetic cascade screening and serial aortic imaging should be considered for family screening and follow-up. In conclusion, the implementation of these strategies should help standardise the diagnostic work-up and follow-up of patients with suspected HTAD and the screening of their relatives.     

The genetics of aortopathies: Hereditary thoracic aortic aneurysms and dissections

Aortopathies encompass a variety of inherited and acquired pathologies that increase risk of life‐threatening dissection or rupture. Identifying individuals with hereditary thoracic aortic aneurysm and dissection (HTAAD) for longitudinal monitoring, medical therapy, or elective and preventative repair is paramount to reduce risk of cardiovascular‐related mortality and complications from dissection and rupture. Over the past couple of decades, pathogenic variants in numerous genes have been identified in relation to HTAAD. The genetic diagnosis can help stratify patient risk and provide guidance on medical treatment, timing of prophylactic surgical repair, as well as longitudinal surveillance and imaging. Implicated genes and their associated proteins have been found to act on a diverse variety of pathways, cells and structural components linked to transforming growth factor beta (TGF‐β) signaling pathways, disruption of the vascular smooth muscle cell contractile apparatus, and primary disruption of extracellular matrix homeostasis. This review describes relevant genetic variants that may help identify and guide the management of hereditary thoracic aortic aneurysms and dissections.     

主动脉窦瘤破裂外科治疗21例

目的：探讨先天性心脏病主动脉窦瘤破裂后手术方法和疗效。方法：回顾性分析21例主动脉窦瘤破裂病人的临床资料。全组均在全麻低温体外循环下经右室切口和/或主肺动脉横切口行修补术，并同时纠治心内合并畸形。结果：本组无手术死亡病例，术后出现肺水肿1例、心衰2例、二度房室传导阻滞1例，均治愈。随访3个月～5a,疗效优者20例，良者1例术后残留主动脉瓣关闭不全。结论：主动脉窦瘤破裂病势凶险，一旦确诊，尽早手术治疗，不要为改善心功能而延误手术时机；手术治疗远期效果满意。     

David手术在主动脉根部瘤合并主动脉瓣二叶畸形治疗中的应用

目的 探讨David手术在治疗主动脉根部瘤合并主动脉瓣二叶畸形中应用的临床效果。方法 回顾性研究。纳入南京大学医学院附属鼓楼医院心胸外科2016年1月—2019年1月行David手术治疗主动脉根部瘤合并主动脉瓣二叶畸形的11例患者临床资料。其中男8例、女3例,年龄18～60(35±13)岁;主动脉瓣轻度反流7例、轻中度反流4例,心功能Ⅱ级5例、Ⅲ级5例、Ⅳ级1例。观察患者围术期指标;术后定期复查心脏超声,观察人工血管通畅情况及主动脉瓣反流情况,包括左室射血分数、主动脉瓣反流程度、平均跨瓣压差、峰值跨瓣压差及最大血流速度。结果 11例患者均成功实施手术。围术期观察指标:体外循环时间(246.1±27.2)min,主动脉阻断时间(207.5±21.5)min,术后机械通气时间4.5(3.25,9.25)h,重症监护时间(2.8±1.5)d,术后24 h引流量(418.2±299.0)mL。所有患者术后随访18~30个月,平均22.5个月,未见死亡及二次手术病例。随访期间心脏超声显示患者人工血管血流均通畅,主动脉瓣轻微反流8例、轻度反流3例,平均跨瓣压差均＜10 mmHg(1 mmHg=0.133 kPa),末次随访时,患者心功能Ⅰ级8例、Ⅱ级3例,较术前明显改善。结论 采用David手术结合主动脉瓣修复技术治疗主动脉根部瘤合并中度以下反流的主动脉瓣二叶畸形,其临床疗效满意。     

Comparison of costs of endovascular repair versus open surgical repair for abdominal aortic aneurysm in Korea

This study was designed to compare the hospital-related costs of elective abdominal aortic aneurysm (AAA) treatment and cost structure between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in Korean health care system. One hundred five primary elective AAA repairs (79 OSRs and 26 EVARs) performed in the Seoul National University Hospital from 2005 to 2009 were included. Patient characteristics were similar between two groups except for older age (P = 0.004) and more frequent history of malignancy (P = 0.031) in EVAR group. Thirty-day mortality rate was similar between two groups and there was no AAA-related mortality in both groups for 5 yr after repair. The total in-hospital costs for the index admission were significantly higher in EVAR patients (mean, KRW19,857,119) than OSR patients (mean KRW12,395,507) (P < 0.001). The reimbursement was also significantly higher in EVAR patients than OSR patients (mean, KRW14,071,081 vs KRW6,238,895, P < 0.001) while patients payments was comparable between two groups. EVAR patients showed higher follow-up cost up to 2 yr due to more frequent imaging studies and reinterventions for type II endoleaks (15.4%). In the perspective of cost-effectiveness, this study suggests that the determination of which method to be used in AAA treatment be more finely trimmed and be individualized.