Mohs显微描记手术在鼻部皮肤基底细胞癌治疗中的应用

目的 评价Mohs显微描记手术治疗鼻部皮肤基底细胞癌的效果。方法 2014年,对40例鼻部皮肤基底细胞癌患者进行Mohs显微描记手术,观察手术效果,并与传统扩大切除手术进行比较。结果 40例基底细胞癌均通过Mohs显微描记法切除,肿瘤扩大切除范围平均1.8 mm。39例均Ⅰ期愈合,术后外形、效果满意。术后随访6~24个月,无1例复发。结论 对于鼻部基底细胞癌,Mohs显微描记手术比传统扩大切除更彻底,可提供更多的创面修复方案。     

Mohs Micrographic Surgery in the Treatment of Rare Aggressive Cutaneous Tumors: The Geisinger Experience

BACKGROUND: Mohs micrographic surgery (MMS) offers high cure rates and maximum tissue preservation in the treatment of more common cutaneous malignancies, but its effectiveness in rare aggressive tumors is poorly defined. OBJECTIVE: Evaluate the effectiveness of MMS in the treatment of six rare aggressive cutaneous malignancies as seen by Mohs surgeons working at a referral center. METHODS: Retrospective chart review of 26,000 cases treated with MMS at the Geisinger Medical Center Department of Dermatology during a 16-year period with the following diagnoses: poorly differentiated squamous cell carcinoma (PDSCC), dermatofibrosarcoma protuberans (DFSP), microcystic adnexal carcinoma (MAC), extramammary Paget's disease (EMPD), Merkel cell carcinoma (MCC), and sebaceous carcinoma (SEB CA). Patient demographic data, tumor measurements, treatment characteristics, and marginal recurrence rates were compiled and evaluated. RESULTS: The mean numbers of cases identified per year for each tumor type were as follows: PDSCC, 6.19; DFSP, 2.44; MAC, 1.63; and EMPD, 0.63. For PDSCC, 85 cases were available for follow-up with a local recurrence rate of 6% at a mean follow-up time of 45 months. For DFSP, there were 35 cases with no local recurrence at a mean follow-up of 39 months. For MAC, there were 25 cases with a local recurrence rate of 12% at a mean follow-up of 39 months. For EMPD, there were 10 cases with no local recurrences at a mean follow-up of 34 months. CONCLUSIONS: Collectively, our data on PDSCC, DFSP, MAC, and EMPD, combined with other studies in the literature, show that MMS is the most effective therapy for these rare aggressive cutaneous malignancies.     

Lymphoscintigraphy, Sentinel Lymph Node Biopsy, and Mohs Micrographic Surgery in the Treatment of Merkel Cell Carcinoma

BACKGROUND: Merkel cell carcinoma (MCC) is an aggressive cutaneous malignancy with a high incidence of occult nodal metastases. MCC is believed to be similar in natural history to thick or ulcerated melanomas in its propensity for locoregional recurrence and early lymph node metastasis. Studies have shown that nodal status is statistically correlated to survival in MCC. Radiolocalization and superselective lymph node biopsy is a recent technique that has been proven to be of great value in evaluating the status of occult lymph node disease in malignant melanoma and breast cancer patients. OBJECTIVE: In previously untreated patients, an orderly progression of metastases is observed for both cutaneous carcinomas and malignant melanomas and is anticipated for MCC. METHODS/RESULTS. We present two patients with MCC of the head and neck who underwent simultaneous Mohs micrographic surgery and sentinel lymph node biopsy with intraoperative radiolocalization. CONCLUSION: Sentinel lymph node biopsy and intraoperative lymphoscintigraphy may prove to be a useful technique in evaluating occult nodal involvement and in limiting the potentially unnecessary morbidity of more comprehensive lymph node dissections in MCC patients who do not yet have metastatic involvement.     

Giant Keratoacanthoma of the Upper Extremity Treated with Mohs Micrographic Surgery: A Case Report and Review of Current Treatment Modalities

Keratoacanthomas are fast-growing, solitary, cutaneous neoplasms that usually show spontaneous regression. The development of giant variants and aggressive behavior have been described. Clinically, a keratoacanthoma larger than 20 to 30mm is classified as a giant keratoacanthoma. A major challenge in dealing with these neoplasms is the difficulty of clinically and histologically differentiating them from squamous cell carcinoma. The authors report a practical approach using Mohs micrographic surgery for evaluation of large tumors. With this method, the lateral margins are evaluated and cleared prior to excision of the bulk of the tumor. The authors also describe alternative therapies for giant keratoacanthomas and present a case of a 61-year-old woman with a rapidly growing tumor on her left arm. Skin biopsy was consistent with a well-differentiated squamous cell carcinoma with focal features of a keratoacanthoma. The patient underwent Mohs micrographic surgery using the described approach, and no recurrence has been noted in four years. Surgical excision remains the treatment of choice for giant keratoacanthomas. Mohs micrographic surgery is a logical treatment option for giant keratoacanthomas. This case illustrates a useful approach that may prove valuable when treating large specimens during Mohs micrographic surgery.The authors present a case of a previously healthy 61-year-old Caucasian woman who presented to the dermatology clinic for evaluation of a rapidly growing exophytic tumor on her left arm. She first noticed the lesion two months prior to presentation and reported that it had nearly doubled in size over a period of three weeks. There was no history of trauma to the left arm. She had no significant past medical history and took no medications.Physical examination revealed a well-demarcated, 5x6cm plaque with raised margins and central ulceration involving the left lateral arm (Figure 1). The overlying skin was diffusely erythematous. There was no evidence of regional lymphadenopathy or hepatosplenomegaly. The rest of the examination was unremarkable. All preoperative laboratory tests, including wound cultures, were unremarkable.Open in a separate windowFigure 1Clinical presentation on initial evaluation. On the left arm, there is a well-demarcated, 5x6cm plaque with raised margins and central ulceration.Preoperative biopsy revealed a well-differentiated squamous cell carcinoma (SCC) (Figure 2). Histologically, this tumor also shared features characteristic of a keratoacanthoma (KA) with squamous cell metaplasia, lymphohistiocytic infiltrate, and keratinocyte atypia.Open in a separate windowFigure 2Photomicrograph of the preoperative biopsy showing a well-differentiated squamous cell carcinoma with focal areas suggestive of keratoacanthomasThis case illustrates a distinct approach to the management of a giant KA using Mohs micrographic surgery (MMS) and summarizes the current treatment modalities for giant KAs.     

复合皮移植与皮肤软组织扩张术在烧伤整形治疗中的应用效果

目的 分析复合皮移植与皮肤软组织扩张术在烧伤整形治疗中的效果。方法 选取2021年8月-2023年 8月我院收治的90例烧伤患者为研究对象,采用随机数字表法分为对照组和研究组,各45例。对照组接受 复合皮移植术治疗,研究组接受皮肤软组织扩张术治疗,比较两组临床疗效、围术期指标、并发症发生率 及患者满意度。结果 研究组治疗总有效率为91.11%,高于对照组的75.56%（P ＜0.05）;研究组创面愈合 时间、血运恢复时间及住院时间均短于对照组（P ＜0.05）;研究组并发症发生率为6.67%,低于对照组的 22.22%（P＜0.05）;研究组患者满意度为95.56%,高于对照组的82.22%（P ＜0.05）。结论 在对烧伤患者 进行整形治疗时,实施皮肤软组织扩张术的效果较好,有助于患者创面愈合及局部血运恢复,降低并发症 发生率,提高患者满意度。     

加速康复外科理念在脊柱骨折围手术期中的应用研究

目的:探讨加速康复外科理念(ERAS)在脊柱骨折围手术期中的应用。方法:选取天津市天津医院脊柱外科收治的100例接受脊柱手术治疗脊柱骨折的患者,其中50例接受ERAS计划的患者为ERAS组,50例在实施ERAS计划之前接受手术的回顾性队列患者为对照组,比较两组患者术后疼痛评分(VAS评分)、阿片类药物消耗量、住院时间、术后30 d并发症和30 d再住院率。结果: ERAS组术后VAS评分为术后第1天(6.80±1.90)分,第2天(6.50±2.10)分,第3天(5.80±1.60)分,出院时(3.80±1.10)分和术后1个月(3.20±1.30)分均低于对照组,差异有统计学意义(P<0.05);术前,ERAS组与对照组阿片类药物消耗量差异无统计学意义(P>0.05),ERAS组阿片类药物消耗量术后第1天(12.50±3.90)片,第2天(10.50±3.70)片,第3天(8.70±3.10)片均低于对照组,差异有统计学意义(P<0.05);ERAS组平均住院时间为(3.90±1.62) d小于对照组(7.14±3.45) d,差异有统计学意义(P<0.05);术后30 d并发症发生率,对照组(30%)高于ERAS组(12%),差异有统计学意义(P=0.03);两组30 d再住院率差异无统计学意义(P=0.37)。结论: ERAS可显著加快脊柱骨折患者术后恢复,让更多的脊柱外科患者受益,值得推广应用。     

A Dermal Equivalent Engineered with TGF‐β3 Expressing Bone Marrow Stromal Cells and Amniotic Membrane: Cosmetic Healing of Full‐Thickness Skin Wounds in Rats

Transforming growth factor beta‐3 (TGF‐β3) has been shown to decrease scar formation after scheduled topical applications to the cutaneous wounds. This study aimed to continuously deliver TGF‐β3, during the early phase of wound healing, by engineering a dermal equivalent (DE) using TGF‐β3 expressing bone marrow stromal cells (BM‐SCs) and human dehydrated amniotic membrane (hDAM). To engineer a DE, rat BM‐SCs were seeded on the hDAM and TGF‐β3 was transiently transfected into the BM‐SCs using a plasmid vector. Pieces of the dermal equivalent were transplanted onto the full‐thickness excisional skin wounds in rats. The process of wound healing was assessed by image analysis, Manchester Scar Scale (MSS), and histopathological studies 7, 14, 21, and 85 days after the excision. The results confirmed accurate construction of recombinant pcDNA3.1‐TGF‐β3 expression system and showed that the transfected BM‐SCs seeded on hDAM expressed TGF‐β3 mRNA and protein from day 3 through day 7 after transfection. After implantation of the DE, contraction of the wounds was measured from day 7 through 21 and analyzed by linear regression, which revealed that the rate of wound contraction in all experimental groups was similar. Histologic evaluation demonstrated that transfected BM‐SCs decreased retention and recruitment of the cells during the early stage of wound healing, decreased the formation of vascular structures and led to formation of uniformly parallel collagen bundles. MSS scores showed that TGF‐β3 secreting cells significantly improved the cosmetic appearance of the healed skin and decreased the scar formation. From these results, it could be concluded that transient secretion of TGF‐β3, during the early phase of healing, by BM‐SCs seeded on hDAM can improve the cosmetic appearance of the scar in cutaneous wounds without negatively affecting the process of wound repair.     

胆胰术后胃瘫综合征的防治体会(附20例报告)

目的探讨胆胰术后胃瘫综合征(postoperative gastroparesis syndrome,PGS)发生的病因、诊断方法、治疗手段和疗效。方法20例胆胰术后PGS患者,均行保守治疗,其中全胃肠外营养(totalparenteral nutrition,TPN)8例,全肠内营养(total enteral nutrition,TEN)12例,其中加行足三里针炙5例。结果TPN组1例胰头癌患者因发生胰漏,诱发全身多器官功能衰竭而于术后第11d死亡,死亡前PGS未能治愈。其余19例患者均经保守治疗痊愈。在PGS治疗期间,TPN组发生霉菌感染2例,导管败血症1例;TEN组未发生与治疗相关的并发症。平均治愈时间:TPN组(34.2±3.5)d;TEN组为(26.3±8.6)d;TEN加针灸者为(20.5±9.3)d。结论胆胰术后PGS应尽量明确诊断,避免盲目手术治疗,保守支持治疗是有效治疗手段,TEN加针刺足三里的效果明显。     

Skin Allograft in the Treatment of Toxic Epidermal Necrolysis (TEN)

BACKGROUND: TEN is a severe form of exfoliative dermatitis. Its course is acute and its outcome fatal in 40% of cases. Wound cover to prevent fluid/protein loss and infections and to control pain, is the first step, as for burns. Skin allograft can be successfully used for this purpose. OBJECTIVE: We report two cases of TEN with de-epithelialization of 50 and 70% of the total body surface area. The patients were given support therapy and treated with human glycerol-preserved skin allografts for wound cover. METHODS: Patients were grafted with glycerol-preserved donor skin, obtained from a skin bank. RESULTS: Re-epithelization of treated areas was complete in 8 days; pain relief was obtained soon after the graft. CONCLUSIONS: Glycerol-preserved skin allograft is an effective treatment in extensive skin loss, for its barrier and analgesic effect. Quality standards of this product ensure safety and simplicity of use at limited cost.     

主动脉内球囊反搏救治心脏手术后室性心律失常的疗效观察

目的　评价主动脉内球囊反搏(IABC)治疗心脏手术后室性心律失常的效果。　方法　对33例因心脏手术后出现室性心律失常使用IABC的病例进行分析，观察心律恢复情况、ST段转复情况、监测桡动脉和主动脉压力波形，记录血管活性药物用量。　结果　所有患者在应用IABC后1～2小时室性心律失常由原来的Ⅱ～Ⅴ级恢复到0～Ⅰ级(Lown分级)。ST段的抬高或降低在30分钟～1小时后恢复正常。所有患者在应用IABC后，桡动脉压的基础收缩压均在早期有所下降，从90±19mmHg下降到78±21mmHg(P＜0.05)；基础舒张压从71±16mmHg上升到131±25mmHg(P＜0.01)；平均动脉压增加。多巴胺用量由8±2μg/ml     

髂腹股沟皮瓣(骨皮瓣)修复手、前臂皮肤软组织(骨)缺损

目的　观察髂腹股沟皮瓣 (带髂骨皮瓣 )修复手部及前臂皮肤软组织 (骨骼 )缺损。　方法　 19例手部、前臂皮肤软组织缺损 ,其中 4例伴骨缺损 ,应用该皮瓣进行修复 ,最大面积 10cm× 16cm ,最小 5cm× 8cm。　结果　皮瓣全部成活 ,随访 2～ 2 5个月 ,皮瓣质地良好 ,外观及功能满意。　结论　该皮瓣切取方便、血供丰富 ,供区均能直接缝合 ,是修复手部、前臂软组织缺损的好方法。