小儿扁桃体摘除术120例呼吸道管理体会

2004年1月～2006年12月,我们对3例下咽癌患者行全喉、全下咽、部分颈段食管切除,颈淋巴结清扫,游离空肠修复下咽、部分颈段食管手术,经精心护理,效果满意.现将围术期护理体会报告如下.     

移植空肠修复下咽癌颈段食管切除3例围术期护理

2004年1月～2006年12月,我们对3例下咽癌患者行全喉、全下咽、部分颈段食管切除,颈淋巴结清扫,游离空肠修复下咽、部分颈段食管手术,经精心护理,效果满意.现将围术期护理体会报告如下.     

游离空肠移植重建下咽及颈段食管的临床分析

目的探讨游离空肠修复下咽及颈段食管肿瘤切除术后组织缺损的方法和疗效。方法回顾性分析采用游离空肠重建下咽颈段食管7例,为下咽癌侵及颈段食管,均行全喉、下咽及颈段食管切除。术前均行x线食管造影及胃镜检查,了解病变范围,术后复查x线食管造影。术后均补充放疗。随访7个月～24个月。结果本组7例患者移植游离空肠全部成活。1例于术后13d发现咽瘘,经换药、抗炎等处理后18d痊愈。1例患者于术后95d无明确诱因出现上消化道大出血死亡。1例患者术后5个月出现进食困难,发现胸段食管癌,放弃治疗于术后11个月死亡。5例患者随访至今游离空肠均成活良好,无吻合口狭窄及进食困难。结论以游离空肠修复下咽及颈段食管部位肿瘤切除术所致缺损,并发症较少,成功率高,恢复消化道的连续性安全可靠。     

游离空肠修复下咽及颈段食管肿瘤切除术后组织缺损的护理

目的 探讨游离空肠修复下咽及颈段食管肿瘤切除术后组织缺损及组织瓣的监测和护理.方法 对25例患者行游离空肠修复肿瘤切除术后下咽及颈段食管组织缺损的临床资料进行回顾性分析 结果 1例游离空肠修复术后出现游离空肠坏死,24例成功修复组织缺损,经过组织辩护理、鼻饲管护理、营养支持、并发症的观察与护理,患者恢复良好.3例发生咽瘘,经换药和时症处理后愈合.结论 以游离空肠修复下咽及颈段食管部位肿瘤切除术所至缺损,改善了患者的进食状况.经过相关护理措施,显著提高了忘者的生存质量.     

自体游离空肠移植重建下咽颈段食管病人的护理

[目的]对自体游离空肠移植重建下咽颈段食管的护理进行总结.[方法]总结、分析了13例自体游离空肠移植重建下咽、颈段食管病人的护理过程.[结果]13例病人中12例恢复顺利,无护理并发症发生;1例移植肠管部分坏死.出院随访13例病人均健在.[结论]术前进行个体化的心理护理,重视肠道准备及营养支持,术后重点做好体位护理,做好生命体征及血氧饱和度监测及护理,排气、鼻饲饮食的观察与护理;气管切开、全喉切除术护理;并发症的观察及预防.     

全喉全下咽全食管切除胃上提修复术的护理配合

下咽恶性肿瘤大多数为鳞状细胞癌,因早期缺乏特异性表现,确诊时患者多属晚期,病变范围广泛,甚至侵至颈段食管,因此手术切除范围大及术后组织缺损大,为修复带来困难。全喉全下咽全食管切除胃上提修复术为治疗下咽癌的重要手术方法之一,但下咽癌切除术后下咽及颈段食管缺损的一期重建是重点,这也意味手术室在手术护理配合上要相应与之配合。我院头颈外科2006—2008年7月行下咽癌全喉全下咽全食管切除胃上提修复术8例,笔者将手术护理配合要点进行总结,现报道如下。     

自体空肠移植重建下咽颈段食管的临床疗效分析(附九例报道)

目的:探讨自体空肠移植重建下咽颈段食管的应用及临床疗效。方法:回顾性分析自体空肠移植重建下咽颈段食管的9例病例,均为下咽癌,其中1例癌肿侵及颈段食管。术中切除全下咽、颈段食管、全喉,同时行颈淋巴清扫,用自体空肠移植进行消化道重建。结果:术后移植肠管全部成活,随访1~22个月,未出现癌肿复发和死亡。结论:对于下咽颈段食管等部位肿瘤,根治后形成环周缺损,用自体空肠移植进行消化道重建,是一个较好的选择。     

自体游离空肠移植重建下咽颈段食管病人的护理

[目的]对自体游离空肠移植重建下咽颈段食管的护理进行总结。[方法]总结、分析了13例自体游离空肠移植重建下咽、颈段食管病人的护理过程。[结果]13例病人中12例恢复顺利，无护理并发症发生；1例移植肠管部分坏死。出院随访13例病人均健在。[结论]术前进行个体化的心理护理，重视肠道准备及营养支持，术后重点做好体位护理，做好生命体征及血氧饱和度监测及护理，排气、鼻饲饮食的观察与护理；气管切开、全喉切除术护理；并发症的观察及预防。     

下咽癌保留喉功能切除术加颈淋巴结清扫术56例围术期护理

目的:探讨下咽癌保留喉功能切除术+颈淋巴结清扫术患者围术期护理方法.方法:对56例下咽癌保留喉功能切除术+颈淋巴结清扫术患者术前做好心理护理、术前准备;术后密切观察病情变化,做好气管切开、饮食及口腔护理,积极预防并发症发生.结果:本组平均住院22 d,均恢复经口进食和语言功能.其中切口浅表性感染4例、误咽5例,经对症处理和护理后,切口一期愈合,可经口进食.结论:做好下咽癌保留喉功能切除术+颈淋巴结清扫术围术期护理,可减少术后并发症的发生,促进患者早日康复.     

下咽癌合并糖尿病侵犯颈段食管患者行多学科联合复杂手术的预见性护理

下咽癌是头颈部恶性肿瘤中较为常见的一种,好发于环状软骨后区、梨状隐窝、咽后壁等部位,易发生局部浸润和扩增,常累及食管及口咽[1-2]。目前,下咽癌侵及食管且无远处器官转移的患者仍以手术治疗为主。该手术涉及颈、胸、腹等多个部位,其风险高、创伤大,有研究显示,此类手术外科并发症发生率高达20.0%~74.3%[3]。2020年5月4日,我院收治1例下咽癌合并糖尿病侵及颈段食管的患者,成功实施了全喉全下咽颈段食管切除+游离空肠切除移植+气管造瘘+双侧颈淋巴结清扫术,围术期实施预见性护理,效果满意。现报告如下。     

高分子泡沫材料负压封闭引流修复足踝部皮肤软组织缺损

背景：有研究表明,对于开放性骨折伴软组织缺损在不可能关闭软组织缺损和未找到可用的肌肉和肌皮瓣前,将负压封闭引流高分子泡沫材料作为人工替代皮肤覆盖创面是一种较好的方法。目的：观察高分子泡沫材料负压封闭引流修复足踝部皮肤软组织缺损的疗效。方法：选择25例足踝部皮肤软组织缺损患者,其中14例采用高分子泡沫材料负压封闭引流技术联合拉网植皮治疗,另11例采用传统换药联合植皮打包覆盖创面治疗。比较两组治疗的临床效果差异。结果与结论：负压封闭引流组中10例植皮完全成活,成活率为71%;另4例通过换药最终覆盖创面。传统换药组中6例植皮完全成活,成活率为55%;剩余5例中3例通过换药愈合,2例行二次植皮。两组植皮成活率差异无显著性意义（P 〉0.05）。负压封闭引流组等待二期手术时间、二期手术前换药次数及缺损完全修复时间均少于传统换药组（P 〈0.05）。提示高分子泡沫材料负压封闭引流技术可加快游离植皮修复足踝部皮肤软组织缺损创面愈合速度,缩短病程。     

Radiographic evaluation of the free jejunal graft

Jejunal autotransplantation is an increasingly popular method of reconstructive surgery for the upper aerodigestive tract following laryngopharyngectomy. From 1977 to 1985, 55 free jejunal grafts were performed on 49 patients. Thirty patients (61%) experienced reconstructive complications including graft failure in 6, fistula in 18, and strictures in 10. Postoperative dysphagia occurred in 26 patients (53%). The cause of the dysphagia is often complex and related to a number of factors that are discussed. While jejunal autotransplantation is successful in selected patients, complications are not infrequent. The radiologist plays an important role in the evaluation and follow-up of these patients.     

Hemodynamic effects of pneumonia: I. Normal and hypodynamic responses

Since an excessive mortality from pneumonia persists in spite of antimicrobial therapy, the hemodynamics during and after the acute phase of pneumonia were studied in 17 patients. None of the patients had clinical heart disease and all had normal venous pressures. The arteriovenous oxygen difference was used to assess the adequacy of the circulation to meet peripheral tissue perfusion, and a spectrum of arteriovenous oxygen differences was noted. In 11 patients, tissue perfusion was considered adequate because the arteriovenous oxygen difference did not exceed 5.5 vol%. In six patients, the arteriovenous oxygen difference was greater than 5.5 vol% and these six patients differed hemodynamically from the others. In these six patients during the acute phase of pneumonia, cardiac output was decreased, and total peripheral resistance and hematocrit were increased. When five patients with varying arteriovenous oxygen difference were studied during exercise in the acute phase, cardiac output increased while venous pressure remained unchanged. Arteriovenous oxygen difference in these five exercising patients increased in all, but most markedly in those with an initially widened arteriovenous oxygen difference. The inadequate response to pneumonia is most consistent with depressed myocardial function, but the possibility of decreased intravascular volume as a contributory factor could not be excluded.     

脱细胞真皮基质黏膜组织补片在喉咽癌切除咽喉修复中的应用:25例随访

背景:异体脱细胞真皮基质黏膜组织补片(acellular dermalmatrix,ADM)作为一种新型组织修复材料,目前已经广泛应用于头颈部肿瘤术后组织缺损修复.但下咽癌手术多涉及咽、喉部组织缺损的修复与功能重建,其在下咽癌术后下咽缺损修复中的应用效果有待更多的研究验证.目的:实验拟验证脱细胞真皮基质黏膜组织补片在喉咽癌切除术后喉咽修复中的作用效果.设计、时间及地点:回顾性病例分析,于2005-05/2006-06在解放军第三军医大学大坪医院野战外科研究所耳鼻咽喉-头颈外科完成.对象:男性喉咽癌确诊患者25例,年龄45-68岁,其中肿瘤原发于梨状窝侧壁22例,原发于喉咽后壁3例,病理诊断为均鳞状细胞癌.方法:根据临床分期不同采用部分或全喉咽切除术,术后均采用正海生物有限公司提供的海奥~(TM)脱细胞异体真皮基质组织补片进行咽腔黏膜修复.修复黏膜片状缺损时可单独使用ADM,其局限性在于单纯应用ADM不能完成空间结构重建,因此对于喉咽全切除患者,喉咽腔重建时结合肌皮瓣等其他材料.主要观察指标:咽腔术部黏膜修复情况及患者吞咽、呼吸、发音等功能重建情况.结果:25例患者均进入结果分析,无脱落.25例患者均无咽瘘发生,1例部分喉咽切除术后20 d出现颈部局灶性皮下感染,换药后创面愈合.喉咽部分切除的15例患者均发生不同程度呛咳.术后30～60 d吞咽功能基本恢复,3例患者进食流质时仍有轻微呛咳,可以忍受,不影响进食.喉呼吸功能均恢复,术后6～12个月拔除气管套管.喉咽全切除10例患者喉咽腔重建均获得成功,术后20 d左右即恢复正常饮食.术后随访12～30个月,ADM修复区外观与正常黏膜相似,无明显咽腔狭窄.随访24个月以上10例,其中1例肿瘤复发,再次手术后健在.结论:ADM具有良好的组织相容性、塑形性和易操作性,与受区组织可以完全无差别融合,可用于喉咽癌术后组织缺损修复,利于发音、呼吸、吞咽等功能恢复,与肌皮瓣及其他颈部修复材料联合应用亦能取得满意疗效.     

Surgical implications of jejunal diverticula

To gain insight into the surgical significance of acquired jejunal diverticula, we reviewed the experience at the teaching hospitals in our city during the past ten years. An antemortem diagnosis of jejunal diverticulosis was made in 27 men and 59 women with a mean age of 69.6 years. In 71 patients the diagnosis was made during upper gastrointestinal roentgenologic evaluation for abdominal symptoms, in three it was made during mesenteric arteriography or bleeding scan for massive rectal bleeding, in six it was made during exploratory laparotomy for acute abdominal signs and symptoms, and in the remaining six it was an incidental intraoperative finding. Surgical indications occurred in 13 patients (15%) and consisted of massive lower gastrointestinal bleeding in four patients, blind loop syndrome in three, small bowel obstruction in three, diverticular perforation in two, and chronic abdominal pain requiring jejunal resection in one. In three additional patients with melena and nine with chronic abdominal pain, jejunal diverticulosis was the only abnormality detected; none of these patients had operation. Although the majority of patients with jejunal diverticula do not require surgical treatment, it may be necessitated by complications such as bleeding, perforation, obstruction, blind loop syndrome, or intractable abdominal pain.     

动静脉脉冲系统预防下肢长管状骨骨折内固定术后深静脉血栓形成的临床研究

目的:比较动静脉(AV)脉冲系统及阿司匹林在降低下肢长管状骨内固定术后预防深静脉血栓中的作用。方法:采用完全随机对照的方法,将216例行下肢长管状骨内固定手术治疗患者分为3组,第1组有75例术后使用AV泵治疗,第2组的73例患者术后给予100mg阿司匹林治疗,第3组68例手术后未行任何预防深静脉血栓措施。在术后分别使用双重超声波测定下肢远、近端的静脉血栓。同时测量大腿、小腿的周长。结果:有4例使用AV泵的患者、8例使用阿司匹林治疗的患者出现血栓,第3组有15例发生深静脉血栓。第1、2组差异没有显著性意义(P>0.05),第1、2组与第3组相比在深静脉血栓发生率上差异有显著性意义(P<0.05);在AV泵治疗组,术后大腿及小腿水肿明显减轻。第1组与第2、3组相比在减轻下肢水肿上差异有显著性意义(P<0.01)。结论:在下肢长管状骨内固定手术后,AV泵治疗及阿司匹林治疗均能有效的降低血栓发生率。AV泵可有效促进下肢长管状骨术后水肿消除。     

Late venous laceration after inappropriate placement of a left internal jugular hemodialysis catheter: a case report

Central venous catheterization is a necessary and common method of building the circulation pathways of patients with end-stage kidney disease. Venous rupture is a severe and fatal complication of central venous catheterization. We herein present a case of slowly occurring venous rupture after reinsertion of a left internal jugular vein (IJV) catheter. A man in his early 70s was hospitalized with end-stage kidney disease. We inserted a hemodialysis catheter through the left IJV. A short section of the patient’s catheter slipped out 1 month later. The original catheter was reinserted at its primary position without a guidewire. The patient reported chest pain and developed hypotension during dialysis the next day. He underwent femoral venous catheter insertion and heparin-free dialysis. The patient finally recovered and underwent regular hemodialysis using an arteriovenous fistula in the left forearm. This is the first reported case of venous laceration after repeated left IJV catheterization. Left IJV catheterization is associated with high rates of complications and should be closely monitored with the help of radiography during and after the operation. Central venous catheters should be carefully placed with clear knowledge of their direction and location to prevent serious complications.     

Venous thromboembolism associated with hip and knee arthroplasty: current prophylactic practices and outcomes.

Joint registry and hospital data bases for 5,024 total hip and total knee arthroplasties done between 1986 and 1988 at the Mayo Clinic were used to study prophylactic measures and frequency of symptomatic deep venous thrombosis and pulmonary embolism. In virtually all patients, graduated compression stockings were used, with or without another type of prophylaxis. Only 44 of 3,115 patients who underwent hip arthroplasty (1.4%) and 32 of 1,909 patients who underwent knee arthroplasty (1.7%) had definite or probable deep venous thrombosis or pulmonary embolism. Death definitely or possibly attributable to pulmonary embolism occurred in 11 patients who underwent hip arthroplasty (0.35%) and 1 patient who underwent knee arthroplasty (0.05%). Although patients with a history of deep venous thrombosis or pulmonary embolism were more likely to receive warfarin than were patients without such a history, the relative risk of symptomatic deep venous thrombosis or pulmonary embolism in patients who underwent hip arthroplasty and received warfarin postoperatively was approximately half that in patients who received other types of prophylaxis. The risk of death from pulmonary embolism was similarly diminished in the group that received warfarin. The lower rates of these complications in the patients who received warfarin support the prophylactic use of this agent after total hip arthroplasty.     

维持性血液透析患者动静脉内瘘血管瘤样扩张的原因探讨及预防

目的探讨长期维持性血液透析患者动静脉内瘘血管瘤样扩张的原因及预防措施。方法选择上海交通大学附属第一人民医院。肾内科长期透析1～32年患者350例,339例前臂内瘘、9例上臂内瘘、2例移植内瘘。常规血液透析或血液滤过透析治疗,内瘘穿刺方法为阶梯式或局域穿刺,透析后内瘘止血方法为透明胶带结合指压法或弹力绷带压迫法。有瘤样扩张的患者作为A组,无瘤样扩张的患者作为B组。结果动静脉内瘘血管瘤样扩张患者（A组）42例（12％）,29例（69％）血管瘤样扩张的患者伴高血压,但和B组61％高血压患病率相比无显著性差异（P〉0．05）。24例（57．1％）患者为透析10年以上的长期透析患者,仅9．6％为透析5年以下患者。42例患者前臂内瘘35例,上臂内瘘6例,移植内瘘1例。主要发生于穿刺点部位的瘤样扩张29例,近吻合口的瘤样扩张8例,静脉全段扩张3例,假性动脉瘤2例。A组采用局域穿刺的比例为69％,远高于B组21％（P〈0．01）。2／3的上臂内瘘患者伴血管的瘤样扩张。内瘘吻合方式、透析后止血方式、血钙、血磷及甲状旁腺激素（PTH）水平对瘤样扩张的形成无明显影响。结论长期血液透析患者动静脉内瘘血管瘤样扩张的原因与局部反复穿刺、内瘘部位、高血压及血管本身的病变有关。预防内瘘的瘤样扩张对内瘘的长期保护具有重要意义。     

颈动脉体瘤20例诊疗及手术并发症回顾分析

目的探讨颈动脉体瘤(carotid body tumor,CBT)的诊断、治疗经验和手术并发症的防治策略。方法回顾性分析2005年7月—2013年10月行手术治疗的20例颈动脉体瘤临床资料。结果本组主要表现为无痛性颈部肿物,5例伴咽部不适,2例声音低沉。均曾在外院就诊,其中5例误诊,误诊为淋巴结增大原因待查3例,颈淋巴结结核2例;6例明确诊断CBT,曾行肿物活检或尝试行肿瘤切除均失败;余9例高度怀疑CBT。20例均在我院经颈部计算机断层X线血管造影(CTA)或磁共振血管造影(MRA)检查诊断为CBT,其中双侧4例,单侧16例,共24个瘤体。20例均行手术治疗,除1个瘤体延伸至颅内未完整切除外,余23个瘤体均一期手术完整切除。围手术期无死亡发生,术后出现脑神经损伤表现13例。术后共14例获得随访,11例脑神经损伤中,7例经保守治疗完全或部分恢复,4例无明显恢复。结论 CBT临床易误诊,提示临床接诊无痛性颈部肿物应考虑CBT可能,及时行颈部CTA或MRA检查有助于诊断。早期确诊并选择适当的手术方案可减少并发症的发生。