Surgical management of acquired post-intubation tracheo-oesophageal fistulas: 27 patients

From 1962 to 1987, 27 patients with tracheo-oesophageal fistulae (TOF) were treated at our institution. Mean age was 43 years. The indications for respiratory support were blunt chest trauma (11), neurological dysfunction (8), and acute pulmonary distress syndrome (8). TOF symptoms occurred 12–200 days (mean 43) after initiation of ventilatory support and was caused by tracheostomy tube cuff (17), intubation tube cuff (8), or injury at the site of tracheostomy (2). The size of the fistula ranged from 0.3 to 5 cm (mean 2 cm). Seventeen of the 27 patients were operated upon. A simple repair of the TOF was performed via a cervical approach in 10 patients; tracheal resection and reconstruction was done in 4 patients presenting with tracheal stenosis, while 2 patients with slight tracheal stenosis had a simple repair of the TOF without the need for further tracheal surgery. Three patients underwent primary oesophagostomy, followed later by colon interposition. Five patients died. Ten cases were not operated upon: the TOF closed spontaneously in 1 patient, 1 patient was lost to follow-up and 8 died. In our series, significant tracheal stenosis occurred in only 6 patients (22%), only 4 of whom had tracheal resection. Simple repair of TOF provides excellent results with a low mortality (10%) considering the poor condition of the patients, and should be considered the procedure of choice. Surgical oesophageal diversion (i.e. cervical oesophagostomy and suture of distal oesophagus) is usually unnecessary.     

应用阴囊中隔翻转-折叠-推进瓣I期修补阴茎阴囊交界处的巨大尿瘘

目的探讨应用阴囊中隔翻转一折叠一推进瓣I期再造尿道、防水层及被覆修补阴茎阴囊交界处巨大尿瘘的有效性。方法自2011年1月至2012年7月,共收治30例阴茎阴囊处巨大尿瘘患者,尿瘘大小为1．0～2．0em。术中切取阴囊中隔,并将此瓣分为3个区域,其中A瓣翻转形成尿道;B瓣去表皮形成筋膜瓣折叠覆盖于A瓣切口上,形成防水层;C瓣推进覆盖创面。结果30例患者术后随访6～12个月,均无尿道狭窄及尿瘘发生,再造尿道排尿通畅,阴茎伸直良好。术后皮瓣29例成活,均为I期愈合;1例C瓣因静脉回流较差,术后出现肿胀,皮瓣发黑,最终干性坏死,创面痂下愈合,严密观察至术后15d,排尿通畅,未见尿瘘形成;3个月后返院复查,C瓣区域瘢痕形成,自觉排尿可,无尿道狭窄。有2例患者自觉阴茎阴囊外形欠佳。结论应用阴囊中隔翻转一折叠一推进瓣I期修补阴茎阴囊交界处的巨大尿瘘,即应用一个筋膜皮瓣I期同时再造尿道、防水层及被覆,其方法简单可靠,供区破坏小,效果满意。     

Free microvascular transfer of the vermiform appendix for creation of a tracheo-oesophageal fistula: A new method of voice reconstruction.

BACKGROUND: Voice rehabilitation following laryngectomy can take many forms. As its basic premise, vibrating air must be transferred to the mouth where articulation takes place and speech can be produced. It requires a source of air, a conduit for transfer, and a mechanism for prevention of regurgitation and aspiration. Creating a tracheo-oesophageal fistula and maintaining it with a vascularised appendix has been the intention of this report. METHODS: Three patients with an average age of 53 years underwent the procedure of free transfer of the appendix for voice restoration during the months of September 2004 through December 2004. All patients had laryngectomies and one had total cervical oesophageal reconstruction with a pedicled pectoralis major flap. Voice evaluation, swallowing function, and presence of aspiration were evaluated. RESULTS: All flaps survived without complications. The results of swallowing function were unaltered from preoperative levels. All flaps remained patent at an average follow-up period of 8 months. All three patients could produce loud voice, which was intelligible at a reasonable distance. Maximal phonation time was 4s in two patients and 5s in one patient. Voice rehabilitation using the free appendix flap can achieve a phonation time which is low and words and short phrases that are intelligible but limited so far to this level. The donor site morbidity is low and aspiration was not present. The results of this study indicate that this method may have a potential role in voice reconstruction but requires more experience and refinement of this technique.     

原发性腹膜后巨大肿瘤切除术中大血管的处理

目的　通过回顾性地研究近 15年手术切除原发性腹膜后巨大肿瘤的经验 ,总结术中大血管的处理方法和技巧对预后及术后并发症的影响。方法　对近 15年完整切除的 5 6例原发性腹膜后巨大肿瘤术中处理过程进行归纳分析 ,总结肿瘤生长部位对腹腔大血管处理的影响和处理受累大血管的技巧。结果　累及左、中、右和左右腹部的原发性腹膜后巨大肿瘤的切除率分别为 87.5 %、35 .7%、5 2 .2 %和 2 6 .7%。结扎切断脾血管 2 3例次 ,修补大血管 14例次。 4例次为意外紧急处理 ,其余均为预防性程序性处理 ;术后死亡 1例。血管修补组与同期血管壁残瘤组 2 8例比较 ,2年复发率分别为 14.3%和 5 3.6 % ,差异显著 ,P <0 .0 1。结论　对于累及腹腔大血管的原发性腹膜后巨大肿瘤 ,左侧大血管较易处理 ,手术切除率明显高于右侧 ;仔细结扎切断脾血管和预防性地切除受累大血管壁再行修补血管是保证手术安全性、提高腹膜后巨大肿瘤切除率、减少复发率的重要操作步骤。     

右上腹非肝源性巨大肿瘤的手术治疗

目的 探讨右上腹非肝源性巨大肿瘤的诊治.方法 回顾分析我院2004年5月至2009年12月收治的9例右上腹非肝源性巨大肿瘤患者的临床资料.结果 9例中7例术前影像学诊断未能区分肿瘤为非肝源性,2例术中不能除外肿瘤是否来源于肝脏.9例肿瘤均手术切除,其中联合半胃切除1例,肝下下腔静脉侧壁部分切除2例,右肾脂肪囊完全切除2例,胰十二指肠、横结肠切除1例,胰体尾胰管切断后胰肠吻合1例.手术历时318～660 min,中位时间390 min.术中失血量400～6000ml,中位失血量2560m1;术中输血量0～5250ml,中位输血量2450 ml.切除肿瘤直径11～30 cm,平均为14.5 cm;切除肿瘤重量960～5100 g,平均为2465 g.恶性肿瘤8例,恶性潜能未定肿瘤1例(胰腺实性假乳头状瘤).术后胰漏1例,无严重并发症和手术死亡.术后5个月复发1例.术后1年存活率100％,2年存活率56％,3年存活率33％.1例患者存活已超过5年.结论 右上腹非肝源性巨大肿瘤与肝脏关系密切,易被误诊为巨大肝脏肿瘤.应仔细分析其影像学特征,正确区分肿瘤是否为非肝源性并予积极手术治疗.此类肿瘤手术切除率高,治疗效果令人满意.     

Successful treatment of myocotic thoracic aortic aneurysm by in situ graft replacement with omental wrapping

Mycotic thoracic aortic aneurysm is a fatal disease. We report a case of a 67-year-old man presenting with contained rupture of a mycotic thoracic aortic aneurysm. Urgent in situ graft replacement was successfully performed with omental wrapping to prevent postoperative graft infection.     

Changing trends in the etiology and management of vesicovaginal fistula

Vesicovaginal fistula has remained a scourge and of public health importance, causing significant morbidity, and psychological and social problems to the patient. Continuous wetness, odor and discomfort cause serious social issues. The diagnosis has been traditionally based on clinical evaluation, dye testing, cystoscopic examination and contrast studies. A successful repair of such fistulas requires an accurate diagnosis and timely surgical intervention using techniques that are based on basic surgical principles with or without the use of interpositional flaps. The method of repair depends on the type and location of the fistula, and the surgeon's training and expertise. The main complications are recurrence and stress/urge incontinence. Prevention must include universal education, improvement in the social and nutritional status of women, discouraging early marriages, and the provision of improved accessible healthcare services.     

Surgical management for the prevention of pancreatic fistula following distal pancreatectomy

Although the mortality rate related to pancreatic surgery has been reduced recently, the postoperative morbidity is still high, because of various complications. Pancreatic fistula is one of the most common complications following distal pancreatectomy, and is generally hard to cure. Several surgical techniques and devices, such as the use of fibrin-glue sealing, stapler closure, an ultrasonic dissector, or an ultrasonically activated scalpel have been advocated to prevent pancreatic fistula. In the present review we provide an overview of several devices used for the prevention of pancreatic fistula following distal pancreatectomy.     

慢性胰腺炎合并胰管结石的外科治疗

目的 探讨慢性胰腺炎合并胰管结石的外科治疗方法.方法 回顾性分析66例慢性胰腺炎合并胰管结石患者的临床资料,将其分为4型:Ⅰ型28例分布在胰头部;Ⅱ型30例在胰体部;Ⅲ型1例在胰尾部;Ⅳ型7例在胰头、胰体、胰尾部主胰管.10例(Ⅰ型4例,Ⅱ型5例,Ⅳ型1例)经镇痛、抑酸、应用生长抑素、抗感染等治疗.10例(Ⅰ型)行内镜取石术.Ⅰ型14例行胰头十二指肠切除术和保留十二指肠胰头部分切除术;Ⅱ型25例行胰管切开取石+胰管空肠吻合术;Ⅲ型1例行胰尾部+脾切除术;Ⅳ型6例行Puestow-Gillesby和胰颈部离断+胰管探查取石+胰管两断端空肠Roux-en-Y吻合术.结果 62例随访2个月至15年,Ⅰ型术后结石复发4例,Ⅱ型2例,Ⅲ型0例,Ⅳ型3例.结论 慢性胰腺炎合并胰管结石确诊后应争取早日手术治疗,根据结石分布范围选择相应的治疗方式.正确的术前及术中诊断、分型及个体化处理在预防慢性胰腺炎合并胰管结石外科治疗后结石复发中有重要意义.     

大鼠肾脏在体持续灌注模型的建立

目的 建立大鼠肾脏在体持续灌注模型,为移植肾持续灌注保存的基础研究提供简便可靠的动物模型。 方法 雌性大鼠30只,根据灌注入口不同随机分为3组：右肾动脉入口组(无需显微缝合)、腹主动脉入口组(需要在显微镜下行腹主动脉穿刺口的缝合)、左肾动脉入口双肾对照组(需要显微缝合左肾动脉开口,在不影响全身循环的情况下实现自身左右肾脏不同保存方法的对照)各10只,均以卵巢静脉作为灌注液的流出道。分别计算3组的灌注成功率与肾脏持续灌注2 h再灌注成功率。 结果 右肾动脉入口组灌注成功率为80%,再灌注成功率100%;腹主动脉入口组灌注成功率为100%,再灌注成功率为80%;左肾动脉入口双肾对照组灌注成功率为80%,再灌注成功率为50%。 结论 3种简便大鼠肾脏在体持续灌注模型均建立成功,对于显微外科初学者,无需显微缝合的右肾动脉入口方法最为简便可靠,次要选择腹主动脉入口组;具有扎实显微外科基础的术者,左肾动脉入口双肾对照组可实现右侧肾脏静态低温保存与左侧肾脏持续灌注保存的自身对照,不失为较好的选择。     

Transanal endoscopic-assisted proctoplasty--a novel surgical approach for individual management of patients with imperforate anus without fistula

Background/Aim

Imperforate anus without fistula consists of a spectrum of defects with variable distance between the rectal pouch and the perineum. We have developed a novel surgical approach for individual management of these patients based on precise knowledge of the level of the anomaly.

Methods

All consecutive patients with imperforate anus without fistula between 2002 and 2004 had sigmoidostomy performed after having failed to pass meconium in the first 24 hours. The upper pouch was intraluminally visualized using retrograde endoscopy through the sigmoid mucous fistula. The distal termination of the rectum was clearly identified as by convergence of the anal columns. Bright translumination of the endoscope light from the rectum to the anal dimple within the external sphincter indicated a low malformation amenable to transanal proctoplasty. The rectum was incised from below under endoscopic visual control. Poor translumination indicated a higher defect, in which case, the operation was converted to standard posterior sagittal anorectoplasty.

Results

Seven patients (6 boys) were identified. Four patients (3 boys) completed transanal endoscopic-assisted proctoplasty. In all cases, the convergence of anal columns indicating rectal termination was right above the anal pit at the site of the maximal external sphincter squeeze. In 3 patients, the operation was converted to posterior sagittal anorectoplasty after verification of a higher anomaly by endoscopy. There were no operative complications. The median follow-up was 3 months (range, 1-26 months). All patients have an appropriate size anus and regular bowel actions.

Conclusions

Transanal endoscopic-assisted proctoplasty allows safe and anatomical reconstruction of the anorectum, as well as contemporaneous closure of the sigmoidostomy in a significant proportion of patients with imperforate anus without fistula, avoiding the potential complications associated with the open posterior sagittal approach.     

Management of patients with combined tracheoesophageal fistula,esophageal atresia,and duodenal atresia

INTRODUCTION

Patients with combined esophageal atresia (EA), tracheoesophageal fistula (TEF), and duodenal atresia (DA) pose a rare management challenge.

PRESENTATION OF CASE

Three patients with combined esophageal atresia (EA), tracheoesophageal fistula (TEF), and duodenal atresia safely underwent a staged approach inserting a gastrostomy tube and repairing the EA/TEF first followed by a duodenoduodenostomy within one week. None of the patients suffered significant pre- or post-operative complications and our follow-up data (between 12 and 24 months) suggest that all patients eventually outgrow their reflux and respiratory symptoms.

DISCUSSION

While some authors support repair of all defects in one surgery, we recommend a staged approach. A gastrostomy tube is placed first for gastric decompression before TEF ligation and EA repair can be safely undertaken. The repair of the DA can then be performed within 3–7 days under controlled circumstances.

CONCLUSION

A staged approach of inserting a gastrostomy tube and repairing the EA/TEF first followed by a duodenoduodenostomy within one week resulted in excellent outcomes.     

Endorectal pull-through with posterior sagittal approach to the repair of postoperative rectourethral and rectovaginal fistula

Background/purpose: Rectourethral (RUF) or rectovaginal fistula (RVF) is a troublesome complication after anorectal surgery because of dense adhesions around the fistula. The authors applied a new technique for the redo surgery.Methods: Case 1 is Hirschsprung’s disease in a 1-year-old boy who underwent modified Duhamel’s procedure and had RUF. Case 2 is rectovestibular fistula in an 11-year-old girl who had anterior sagittal anorectoplasty complicated by RVF. Case 3 is multiple urogenital anomalies including rectovesical fistula in a 4-year-old boy in whom transvesical repair was unsuccessful. The colon was mobilized as far as possible at laparotomy. The rectum was opened via a posterior sagittal approach leaving 1 cm of the anal canal. Extended endorectal mucosectomy was performed to the dentate line, and the fistula was closed from inside of the rectum. The remaining mucosal cuff was everted out of the anus and the intact colon was pulled through the rectum and anastomosed to the cuff extraanally.Results: The postoperative contrast enema showed no recurrent fistula, and defecation was not impaired.Conclusions: Endorectal pull-through of the intact colon can spare troublesome mobilization of the fistula and can prevent the recurrence of fistula. Rectal incision via a posterior sagittal approach provides a direct view of the fistula.     

肝内胆管细胞癌的外科治疗及预后因素分析

目的探讨肝内胆管细胞癌（ICC）患者的外科治疗方法和影响手术预后的因素。方法回顾性分析80例经手术治疗的ICC患者的临床病理资料,对其中71例肿瘤切除的患者行术后生存预后的单因素和多因素分析。结果本组80例手术患者术后中位生存时间为21．5月。1、3、5年生存率为68．6％、40-3％、25．4％。根治性手术切除组和姑息性手术切除组的中位生存时间分别为40个月及15个月,两组间比较差异有统计学意义（X^2=13．62,P〈0．001）。本组总的肿瘤切除率为88．8％（71／80）,对可能影响患者肿瘤切除术后生存的15个因素分别进行单因素分析,结果表明肿瘤大小、肿瘤数目、淋巴结转移、术前血清CAl9-9水平、手术切缘及邻近组织器官侵犯对预后有影响（P〈0．05）。COX模型多因素分析结果表明手术切缘和肿瘤数目是两个独立预后因素。结论手术切除是ICC的首选治疗方法,R0切除和单个肿瘤是评估ICC患者肿瘤切除术后取得良好预后的独立指标。     

Surgical management of cervical cord injury with ossification of the cervical posterior longitudinal ligament

Objective: To identify an appropriate surgical approach for the management of cervical cord injury with ossification of the posterior longitudinal ligament. Methods: A retrospective study of 25 cases of cervical cord injury with ossification of the posterior longitudinal ligament was performed. Two cases were classified as Frankel grade A, three as grade B, fourteen as grade C, and six as grade D. Treatment procedures consisted of anterior decompression with instrumentation (twelve patients), posterior decompression (eight patients), and combined anterior and posterior decompression (five patients). Results: There were no iatrogenic injuries of great vessels, trachea, esophagus or spinal cord. All patients were followed up for 15–86 months (average, 38.3 months). All segment with anterior fixation attained solid fusion, without implants loosening or breakage. No reclosed open‐door was found after posterior laminoplasty. Twenty‐one patients improved by one to two Frankel grades. The patients with complete spinal cord injury achieved no neurologic recovery, but did experience relief of upper limb pain or numbness. Conclusion: The surgical outcomes of cervical cord injury with ossification of the posterior longitudinal ligament were satisfactory. It is important to select a suitable surgical approach according to the findings on radiological imaging and the clinical characteristics and general condition of the patients.     

新生儿先天性食管闭锁及气管食管瘘围术期的呼吸管理

目的探讨新生儿先天性食管闭锁及气管食管瘘围术期的呼吸管理,术中单肺通气(OLV)的临床应用及其安全性。方法 18例年龄6h～10d、体重1380～3100g、行食管闭锁及气管食管瘘食管端端吻合术患儿,麻醉诱导静脉注射阿托品0.01mg/kg、芬太尼2μg/kg、维库溴铵0.1mg/kg,面罩吸2%～4%七氟醚1min,气管插管尽可能插过气管食管瘘口。使用压力控制通气呼吸模式。麻醉维持吸入1%～3%七氟醚。术中压迫右侧肺,使其尽量萎陷,造成左肺OLV,调节呼吸参数,维持SpO2>90%。术中监测ECG、SpO2、PETCO2、BP、T。记录麻醉诱导前后、OLV10min、30min及术毕时的SpO2、PETCO2、HR、T。结果 OLV后所有患儿SpO2均有不同程度下降,适当调节呼吸参数,3例使用呼气末正压通气(PEEP),其中1例肺部感染重的患儿间隔恢复双肺通气,使SpO2维持90%以上。OLV30min,17例患儿SpO2较OLV10min时升高(P<0.05)。OLV10、30min时HR均较诱导后减慢。术中T维持在35.5～37.0℃。全部患儿术后安全返回病房。结论新生儿先天性食管闭锁及气管食管瘘围术期,采用单腔气管插管,术中人工肺萎陷法OLV麻醉时,恰当的呼吸管理,应用压力控制通气,七氟醚吸入维持麻醉是安全有效的。     

营养支持对消化道瘘患者高代谢状态的作用

目的 观察营养支持对消化道瘘并发严重腹腔感染患者高代谢状态的作用.方法 29例消化道瘘并发严重腹腔感染患者应用肠外营养4～8 d,然后进行肠内营养或肠内+肠外营养.在营养支持前、支持后第10、28天进行营养评价.结果 营养支持治疗后第10天血清前白蛋白、纤维连接蛋白显著升高(t=3.72,3.52,P<0.01);第28天体质量、血清白蛋白、转铁蛋白、前白蛋白、纤维连接蛋白明显升高,与治疗前比较差异有统计学意义(t=3.97,6.57,7.09,3.51,3.58,P<0.01).结论 营养支持能明显改善消化道瘘并发严重腹腔感染患者的高代谢状态.     

妊娠合并急性A型主动脉夹层的外科治疗

目的 总结妊娠合并急性A型主动脉夹层的治疗经验.方法 2007年1月至2012年2月,6例妊娠合并急性A型主动脉夹层的患者接受治疗,年龄24～37岁,平均31岁.妊娠12～38周,平均24.5周.4例马方综合征,2例妊娠期高血压.主动脉夹层病理分型A3S1例,A2C2例,A3C3例.5例手术治疗,1例药物保守治疗.手术在低温体外循环或深低温停循环选择性脑灌注下完成.其中Bentall手术1例,Bentall加孙氏手术2例,升主动脉替换加孙氏手术2例,术后母亲和活体胎儿均接受随访.结果 接受药物治疗患者治疗9天后因为主动脉夹层破裂母体及胎儿死亡.5例接受外科手术患者母体均生存,胎儿成活3例,死亡2例.体外循环75～210min,平均167min;主动脉阻断83～145min,平均98min;停循环19～27min,平均23.5min.随访1.0～3.5年,平均2.2年,5例均生存.CT示手术部位形态、结构、血流无异常,支架远端的自体血管无扩张;3例婴儿生长发育好,智力正常.结论 妊娠合并急性A型主动脉夹层患者应及时手术治疗,药物治疗风险高、夹层破裂可导致母体及胎儿死亡的不良后果.术前应在多学科会诊下综合考虑主动脉病理改变、妊娠周龄来决定灌注部位、体外循环方法,选择恰当的胎儿处理方式及手术方式,从而最有效的保证母婴的安全.     

套入隔离法修补复杂后尿道直肠瘘(附11例报告)

目的 探讨后尿道直肠瘘合并尿道狭窄或闭锁、肛管狭窄的手术修复方法。方法 对１１例复杂后尿道直肠瘘病人采用套入隔离法进行治疗。其中７例合并长段尿道狭窄或闭锁者采用经耻骨、会阴带蒂阴茎阴囊联合皮管套入瘘孔隔离法,４例合并肛管狭窄者采用经腹会阴直肠腔内结肠拖出瘘孔隔离法。结果 １１例均治愈,随访１～２０年,仅４例需短期尿道扩张,全部排尿、粪通畅。结论 对某些广泛硬化的复杂性后尿道直肠瘘采用瘘孔隔离方法修