A case of reoperation of coarctation of the aorta 13 years after corrective surgery of coarctation of the aorta, ventricular septal defect and pulmonary hypertension in infancy]

A 13-year-old boy underwent corrective surgery of CoA + VSD + PH at 50-day. Vascular murmur and hypertension was present so that he was admitted to our hospital. Systemic pressure was 164/106 mmHg (right arm) and systolic blood pressure at right leg was 70 mmHg. The systolic pressure gradient was 94 mmHg. The intracardiac pressure was within normal limit and there was no shunt. And the stenosis of descending aorta was present at the distal of subclavian branch and that pressure gradient was 76 mmHg. The diagnosis was established recurrent coarctation and operation was performed. The recurrent coarctation was 8 mm in diameter and longitudinal incision was made and woven Dacron patch aortoplasty was done. Aortic cross clamping time was 43 minutes. Postoperative clinical course was smooth. At 4 weeks after aortography was performed and no appreciable stenosis of the descending aorta was revealed. The pressure gradient decreased from 76 mmHg to 11 mmHg.     

Surgical Technique of Anterolateral Approach for Tibial Plateau Fracture

A 66‐year‐old woman had sustained crush injury 3 hours prior to her presentation to our hospital. The diagnosis was defined as lateral tibial plateau fracture of the right knee (Schatzker III). Supine position was set up and a pad was put under the affected hip. After sterilization of the surgical field the sterilized sheets were placed beneath the leg in order to be higher than the other side. A rolled sheet was put under the knee joint so that the knee joint was flexed around 30° to 40°. After the surgical field was draped the skin was incised. Iliotibial band was incised by blade (not by electrotomy) and sharp dissection was performed in the Gerdy's tubercle. Capsulotomy was made by cutting the tibial meniscal ligament. Then the meniscus was tagged superiorly and the articular surface was clearly visualized. A window was made in the lateral cortex beneath the plateau, so the impacted fragment was elevated through the window. The metaphyseal void was filled by bone allograft. The placement of the raft‐screw plate must be ensured that the raft screws passing the plate could purchase the subchondral bone. After perfect placement of the plate was defined, the femoral distractor was removed and the knee joint was relaxed. It was ensured that the alignment of the lower leg was normal, and then the other screws were inserted. Following placing drainage in the wound the iliotibial band was closed and the subcutaneous soft tissue and skin were closed in layer.     

Postpneumonectomy esophagopleural fistula--successful one-stage repair with omental flap and thoracoplasty

A 69 year-old man, who had undergone left pneumonectomy for squamous cell carcinoma of the lung 21 months ago, was admitted with a high temperature and chest pain. A diagnosis of empyema was made, and a chest tube was inserted for drainage. Bronchopleural fistula was not noted. Noticing that food was leaking through the drainage tube, a diagnosis of esophagopleural fistula was made radiologically. Surgery was done in October, 1987, after irrigating an empyema space for two months. The fistula was approximately 4 cm below the carina, and it was closed directly. The omentum was sutured around the closed site to reinforce and obliterate the empyema space. Furthermore, additional thoracoplasty was done because the cavity was too large to close only with the omentum. The postoperative course was uneventful. He was able to eat specially prepared foods within 4 weeks, and was discharged on the 60th day after the operation. This patient could possibly be the first case who had undergone an omental flap for the closure of a postpneumonectomy esophagopleural fistula.     

Ureteral avulsion: a rare complication of ureteroscopy

A case of ureteral avulsion as a complication of ureteroscopy is presented. A 55-year-old woman was admitted to the hospital with the complaint of hematuria. The intravenous pyelography revealed a calculus measuring 16 x 12 mm located in the left upper ureter. Transurethral ureterolithotripsy was performed with 8 F rigid ureteroscopy. A safety guide wire was inserted and left ureteral olifice was dilated to 9 F. The ureteroscopy was smoothly introduced just under the stone. The stone was fragmentated with a pneumatic lithotripter. A part of the stone was pushed back to the renal pelvis, so the ureteroscope was passed to that stone and fragmentation was done as much as possible. The ureteroscopy was gently pulled out to the bladder, but the distal ureter was torn at the ureteral orifice and could be seen at the urethral orifice. Pelvis, upper ureter and middle ureter were intact, so open intervention for repair was not performed. A 6Fr double pigtail stent was placed over the safety guidewire. Cystscopy indicated a part of the distal ureter was protruded from the ureteral orifice. Eight weeks later, the protruded part of ureter was necrotic and calcified for ischemia. Transurethral resection of necrotic ureter was performed. Histologically, resected ureter changed necrotic tissue for ischema. Postoperatively intravenous pyelography did not reveal left hydronephrosis and cystoscopy indicated that the left ureteral orifice was almost normally repaired.     

不同骨质疏松风险评估工具的筛检效果评价

目的通过对7种骨质疏松风险评估工具的对比,评价其社区与临床应用价值,为预防和筛查骨质疏松提供科学依据。方法共纳入299名40周岁以上的中老年人,其中女性均已绝经,应用双能X线骨密度仪测量其骨密度值并诊断是否患有骨质疏松症,计算各个工具得分,比较变量、灵敏度、特异度和曲线下面积(area under the curve,AUC)。结果绝经后妇女的各个工具得分均有统计学意义(P0.05),亚洲人骨质疏松自评工具(osteoporosis self-assessment tool for asian, OSTA)的灵敏度为96.3%,特异度为6.3%,AUC为0.710;骨质疏松风险评估工具(osteoporosis risk assessment instrument, ORAI)的灵敏度为90.1%,特异度为12.7%, AUC为0.661;骨质疏松风险简单评估(simple calculated osteoporosis risk estimation, SCORE)的灵敏度为25.9%,特异度为81.9%, AUC为0.686;骨质疏松危险指数(osteoporosis index of risk, OSIRIS)的灵敏度为90%,特异度为30.8%, AUC为0.734;骨质疏松预筛选风险评估(osteoporosis prescreening risk assessment, OPERA)的灵敏度为38.2%,特异度为84%, AUC为0.658;美国骨质疏松基金会快速诊断法(National Osteoporosis Foundation, NOF)的灵敏度为90.4%,特异度为26.6%, AUC为0.652。仅NOF筛检的中老年男性骨质疏松具有统计学意义(P0.05),NOF的灵敏度为93.5%,特异度为25.8%, AUC为0.697;而男性骨质疏松症风险评估(male osteoporosis risk estimation score, MORES)筛检的灵敏度为74.1%,特异度为29.0%,AUC为0.575,不具有统计学意义(P=0.190)。结论 OSTA的灵敏度最高,且仅有2个变量,使用最为简便,适合筛检大样本人群;OSIRIS灵敏度和特异度均较好,用于临床筛检更为准确;ORAI和NOF灵敏度较高,适合筛检阳性人群;SCORE和OPERA特异度较好,适合筛检阴性人群;NOF可用于筛检中老年男性骨质疏松。     

Extremely elderly patient in whom the pacing lead was implanted via the femoral vein

We report on an extremely elderly patient in whom we were unable to insert a pacing lead via the subclavian or internal jugular vein because of a superior vena cava obstruction; we instead inserted the pacing lead via the femoral vein. The patient was a 98-year-old male. Thirty-nine years previously, pacemaker implantation was performed for complete atrioventricular block. Afterwards, pacemaker replacement and reimplantation had been performed a total of 15 times. The patient was recently admitted because of pacing failure. Pacemaker replacement was performed, but pacing was not possible because of disconnection of the pacing lead. Insertion of a new pacing lead was attempted via both subclavian veins and the right jugular vein but failed; this approach was abandoned and temporary pacing was done. Superior vena cava obstruction was noted on chest computed tomography (CT), and pacing lead insertion through the superior vena cava was deemed unfeasible. Myocardial electrode implantation was also considered, but general anesthesia was deemed problematic because of the patient's extreme age. A pacing lead was inserted via the right femoral vein, and the generator was implanted in the right lower abdomen. Postoperative pacing was satisfactory.     

Congenital atresia of the left main coronary artery ostium--a case suffering from ventricular tachycardia

A case of congenital atresia of the left main coronary ostium suffering from ventricular tachycardia underwent coronary artery bypass operation. The patient was 17 years old boy. When he was 9 years old he visited our department for the purpose of examining cardiac disease. The diagnostic impression was mitral regurgitation. At 16 years old he suddenly complained tachycardia during exercise. He admitted to our hospital and the tachycardia was proved to be ventricular tachycardia. Left ventriculogram demonstrated a small range of akinesis at the left ventricular apex. And coronary cineangiogram revealed atresia of the left main coronary artery. The left coronary artery was perfused with collateral circulations from right coronary artery. Electrophysiological study was performed. The ventricular tachycardia could be reproducibly initiated and terminated by programmed stimulation. The catheter endocardial mapping was also performed. The source of ventricular tachycardia was supposed to be at the left ventricular apex. At 18 years old coronary artery bypass operation was performed. Internal mammary artery graft was placed to the left anterior descending artery and a saphenous vein graft was placed from the ascending aorta to the left circumflex artery. A small size of myocardial infarction was recognized at the left ventricular apex. And epicardial mapping revealed that the source of arrhythmia was the same region as the myocardial infarction was recognized. Endocardial resection or cryoablation was not performed. Post-operative study was performed 8 months after surgery. The graft flow of the internal mammary artery to the left anterior descending artery was not sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)     

81例Klinefelter综合征的临床与细胞遗传学分析

目的：对734例男科病人作细胞遗传学检查,得出Klinefelter综合征的发病率,发现一些少见的体征及Klinefelter综合征不同类型染色体核型。方法：外周血淋巴细胞培养和镜下核型分析．常规的临床查体。结果：发现Klinefelter综合征81例,他们都有睾丸小、无精子、第二性征发育不良的Klinefelter综合征的“经典”体征,也发现个别病例伴有唇腭裂体征．激素水平与睾丸活检与文献资料相符。结论：男性不育症的细胞遗传学检查必不可少,细胞学确诊的Klinefelter综合征是临床结论性诊断依据,可免除病人为生育四处求医治疗和睾丸活检之苦。     

Intra-graft balloon pumping--a clinical case report]

A 29-year-old female underwent tube graft replacement of distal aortic arch and descending aorta for dissecting aneurysm. After 42 minutes of aortic cross-clamping the patient was initially weaned satisfactorily from cardiopulmonary bypass (CPB). However, cardiac arrhythmia and cardiac arrest necessitated reestablishment of CPB. Electro-cardiography showed inferior myocardial infarction. To wean CPB intraaortic balloon pumping (IABP) was mandatory. But because of dissecting aortic aneurysm IABP in conventional method was contra-indicated. Intra graft balloon pumping (IGBP) was initiated while the patient was on full CPB. A low-porosity woven Dacron tube graft (22 mm) was anastomosed end-to-side to ascending aorta. A balloon was inserted into the tube graft to establish IGBP. This IGBP provided effective circulatory assist. The patient was weaned from CPB 1 hours after reestablishment of IGBP. Postoperative course was stable. The patient was returned to the operating room for removal of the balloon 3 days postoperatively. We reported the case for whom IGBP was effective. IGBP was effective circulatory support for the patient when conventional use of IABP was contra-indicated.     

Esophageal leiomyoma enucleated under the thoracoscopy; report of a case

We report a case of a 40-year-old male with a posterior mediastinal mass that was 8 cm in size and located behind the trachea. The thoracoscopic surgery was performed. The tumor was located from the level of left brachiocephalic vein to the carina. The mediastinal pleura over the tumor was longitudinally opened by cautery-scissors. The azygos vein lying over the tumor was divided by means of an endoscopic stapler. The muscular layer of the esophagus was also longitudinally opened. The tumor was enucleated. Then, the dissected proper muscle layer of the esophagus was suture-closed. The postoperative course was uneventful. On the first postoperative day Gastrografin was swallowed, showing the absence of leaks. The patient was discharged on the fourth postoperative day. The advantages of the thoracoscopic surgery are as follows: rapid, full recovery of the patient; decreased postoperative pain; short postoperative hospital stay. Esophageal leiomyoma in selected patient was suitable for thoracoscopic enucleation.     

Clinical results following enlargement of the cervical spinal canal by means of laminoplasty

Since 1978, cervical spinal canal laminoplasty has been performed on 75 patients in our hospital with cervical radiculomyelopathy and followed with studies of from 6 months to 8 years (average 4 years and 6 months). Overall results: the pre-operative score, using the Japanese Orthopaedic Association Scoring System, was 7.4 and the post-operative score was 15.2; the improvement was 81.0%. In congenital spinal stenosis, the average pre-operative score was 6.3 while the post-operative score was 14.2; the improvement was 66.9%. The pre-operative score of multiple disc lesions was 7.9 and the post-operative score was 15.2; the improvement was 82.8%. And the pre-operative score of OPLL was 7.3 and the post-operative score was 15.3; the improvement was 81.9%. Improvement may be due not only to the degree of enlargement of the spinal canal, but also to improvement in the circulation within the spinal cord and nerve roots. No case worsened after the surgery.     

Clitoral enlargement caused by prepucial hemangioma: a case report]

A 4-year-old girl visited with the chief complaint of clitoral enlargement which was first pointed out when she was one year old. She has received excision of the femoral tumor, which was histologically an arteriovenous hemangioma, at 4 years old. The prepuce was darkly purplish and the clitoral neck was enlarged without enlargement of the clitoral glans. The external genitalia otherwise were normal and there were no virilizing signs. The mass was excised at the preoperative diagnosis of prepucial hemangioma. The mass was enclosed in the prepuce and adherent to its skin and there was no enlargement of the clitoris itself. The histopathological diagnosis was arteriovenous hemangioma.     

Meckel's diverticulum. Investigation of 600 patients in Japanese literature.

A total of 600 cases, comprising 4 of our cases and 596 others in Japan, was analyzed, and the diagnosis of Meckel's diverticulum was made in only 34 of them. The rate of diagnosis was 5.7 per cent, which is very low. The most common complication of this disease was intestinal obstruction, the second most common was intussusception, the third was inflammation, and the fourth was rectal bleeding. Ectopic tissue, present in ninety-three patients, consisted of ectopic gastric mucosa in fifty-eight. 99mTc-P scanning was performed on fifteen patients. In twelve of them ectopic gastric mucosa was observed. However, it was not found in three, all of whom had false-positive scans.     

A case of suspected cholesterol embolism

A 53 year old male was admitted with the diagnosis of brain stem infarction. Severe stenosis of the bilateral internal carotid arteries was revealed by cerebral angiography. During the angiography, he complained of acute abdominal pain and was referred to abdominal surgical department. He was diagnosed as thrombo-embolism of the superior mesenteric artery and treated conservatively. The symptoms improved, but renal function became worse and the toe was found to be blue. Cholesterol embolism was suspected by nephrologists and thrombolytic therapy was discontinued. Steroid was administrated and LDL-apheresis was performed. The renal function was aggravating and hemodialysis was required. Emergency neurosurgical operations are sometimes performed immediately after cerebral angiography and the neuroanesthesiologists should be aware of the pathology of cholesterol embolism in perioperative management.     

不同评分模型预测肾移植术后移植物功能延迟恢复的效能研究

目的  分析国内外评分模型对我国肾移植术后移植物功能延迟恢复（DGF）的预测效能。方法  前瞻性分析112例肾移植供者、220例受者的临床资料。将KDRI模型、Jeldres模型以及本中心模型预测的DGF与肾移植受者实际DGF发生率进行对比,分析各模型的预测效能,利用受试者工作特征（ROC）曲线的曲线下面积（AUC）比较预测的准确性。结果  220例肾移植受者中,DGF发生率为14.1%（31/220）。KDRI模型预测DGF高危供者41例,AUC为0.57,灵敏度为0.37,特异度为0.66,阳性预测值为22%。Jedres模型预测DGF高危受者22例,AUC为0.56,灵敏度为0.13,特异度为0.92,阳性预测值为20%。本中心模型预测DGF高危供者25例,AUC为0.80,灵敏度为0.53,特异度为0.84,阳性预测值为40%。结论  与KDRI和Jedres模型比较,本中心预测模型具有较高的AUC及灵敏度,对DGF有较好的预测效能,是目前适合我国公民逝世后器官捐献供者的评估体系。     

全腔镜胸乳入路右侧甲状腺叶切除加中央区淋巴清扫术

建立操作空间,切开颈白线,显露甲状腺。分离峡部下缘显露气管,并以气管为辨识,靠左侧横断峡部,分离椎状叶同时清扫Ⅵa区LN,分离部分硬固定,增加腺体游离度。显露并脱帽法离断上极血管,沿真假被膜间游离腺体外侧,分离右甲状腺下极血管,显露右喉返神经,显露下甲状旁腺。分离Berry韧带,显露保护喉返神经外上方的上甲状旁腺,完整切除右甲状腺叶。取出标本,展示并保留标本,右下甲状旁腺自体移植。分离气管左侧清扫Ⅵc区左侧界,切开胸腺上部清扫Ⅵc下界,沿右颈总动脉表面清扫Ⅵb区外侧界,沿右喉返神经表面分离清扫Ⅵb区LN。进一步游离喉返神经下段,分离并清扫Ⅵb区喉返神经后方LN,中央区清扫结束展示清扫后右甲状腺区域。缝合颈白线,放置引流。     

复杂性输尿管上段结石的微创治疗方法比较

目的:比较体外冲击波碎石(ESWL)、逆行输尿管镜碎石(URL)、微创经皮肾镜取石(MPCNL)、后腹腔镜输尿管切开取石(RLU)治疗复杂输尿管上段结石的疗效,探讨复杂性输尿管上段结石的最佳治疗方法.方法:回顾性分析、比较四种微创方法治疗复杂性输尿管上段结石患者232例的临床资料.结果:一次治疗成功率ESWL 43%,URL 71.8%,MPCNL 85.7%,RLU 96.7%.术后3个月结石清除率ESWL 81%,URL 85.9%,MPCNL96.4%,RLU 100%.效率商为ESWL 0.50,RLU 0.65,MPCNL 0.84,RLU 0.97.结论:对于复杂性输尿管上段结石的微创治疗,应根据患者临床情况及实际要求制定治疗方案.     

应用局部皮瓣治疗仰趾畸形

目的:探讨烧、创伤后,足背瘢痕挛缩所致仰趾畸形的治疗。方法:术中将足背瘢痕切除,彻底松解挛缩,将弓弦状伸肌腱切除部分或切断,切除部分挛缩的跖趾关节背侧关节囊,使关节复位,克氏针外固定,在拇指内侧或小趾侧,以跖趾关节处为蒂设计逆行皮瓣,转移覆盖外露的跖趾关节,供区及瘢痕切除后创面行全厚或断层皮片修复。结果:本组7例,均采用逆行皮瓣修复,畸形完全纠正,无继发畸形。结论:应用拇指及小趾侧方逆行皮瓣转移,治疗仰趾畸形可达到满意效果。     

Carcinoma of the stomach.

Seventy-five cases of stomach carcinoma were analyzed. The incidence was highest between 41 and 50 years of age. Male to female ratio was 4:1. The average duration of symptoms was one year. There was no correlation between incidence and the dietary and smoking habits of the patients. Epigastric pain was the commonest complaint followed byanorexis, vomiting and loss of weight. Anemia was the commonest finding. Epigastric mass was present in nearly 50% of cases. Pyloric obstruction was common. Upper gastrointestinal x-ray studies were rewarding. Occult blood was often found in the stools. The majority of patients were about equally distributed between blood groups A and O. Many patients had no or low acid levels but 7.5% had normal or high acid levels. At operation, the growth was commonly found near the pylorus. Diffuse involvement was infrequent. Curative surgery could be done in only 20% of cases. One-third of the patients had palliative gastrojejunostomy. The operative mortality and morbidity were high. The overall five-year survival was only 5%.     

蛋白A免疫吸附治疗肺移植术后新生DSA介导的急性排斥反应

目的  探讨肺移植术后新生供者特异性抗体(dnDSA)介导的急性排斥反应的治疗方法。方法  回顾性分析1例肺移植术后早期出现抗体介导的急性排斥反应(AMR)受者的资料,分析其诊疗经过。结果  受者因系统性硬化症相关性终末期间质性肺病接受右肺移植,术前群体反应性抗体(PRA)Ⅰ类阳性(11%),术前未行特殊预处理,手术当日及术后予以抗胸腺细胞球蛋白诱导治疗。术后早期受者康复顺利,术后13 d出现胸闷、气促,并呈进行性加重,迅速进展为Ⅰ型呼吸衰竭,PRA Ⅰ类上升为58%,并出现dnDSA,其位点为A24：02,平均荧光强度(MFI)值为2 110,据国际心肺移植学会指南,拟诊为(可能)AMR。予血浆置换、蛋白A免疫吸附、糖皮质激素冲击、利妥昔单抗及免疫球蛋白静脉滴注等综合治疗后,PRA及DSA水平逐渐下降,术后20 d DSA MFI值为0,受者临床情况逐渐好转,呼吸困难消失,气促逐渐缓解,呼吸衰竭纠正,肺部渗出影逐渐吸收;术后45 d,受者完全康复出院。随访1年,受者状态良好,生活质量与同龄健康人相同,PRA Ⅰ类为5%,Ⅱ类为阴性,未出现DSA。结论  在传统药物治疗基础上加用蛋白A免疫吸附治疗,能有效去除受者循环血液中的DSA,减轻靶器官损害,近期及远期治疗效果理想。针对肺移植术后AMR,采用传统药物治疗联合免疫吸附,可以达到理想治疗效果。