热消融治疗甲状腺乳头状癌的有效性评估

目的通过对甲状腺乳头状癌（PTC）热消融后复发再手术病例进行分析,探讨热消融是否能用于可手术的PTC患者。 方法回顾性分析2015年5月至2019年8月间青岛大学附属烟台毓璜顶医院甲状腺外科热消融治疗后再手术的23例患者资料。所有患者在外院行热消融治疗前均行甲状腺细针穿刺（FNA）,20例穿刺病理为PTC,3例不除外PTC可能。15例行甲状腺癌根治术,1例行侧颈部淋巴结改良根治术,7例患者因存在复发结节压迫症状,行甲状腺腺叶切除术。 结果再手术后石蜡病理示,56.52%（13/23）见癌细胞,43.47%（10/23）未查见癌细胞,30.43%（7/23）见中央区淋巴结转移。2例消融对侧发现新发甲状腺结节,术后石蜡病理证实为PTC。 结论热消融治疗PTC无法彻底处理原发灶,达不到根治效果。对于可行手术治疗的PTC患者,不建议热消融治疗。     

不同手术入路在髋臼骨折治疗中的应用

目的探讨不同手术入路在髋臼骨折治疗中的应用。方法选取2005年4月至2008年4月收治的各类髋臼骨折23例,男14例,女9例,年龄22～58岁。骨折依据Letournel分型,根据不同骨折类型采用不同手术入路进行骨折切开复位内固定术,10例采用Kocher—Langenbeck入路,8例采用髂腹股沟入路,5例采用Kocher—Langenbeck及髂腹股沟联合入路。结果术后随访时间为12～26个月,平均随访18个月,髋臼骨折复位效果采用Matta标准进行X线评估,18例获得解剖复位,3例复位良好,2例复位较差。临床效果评估采用改良的Merled’Aubigne和Postel评分系统,优17例,良3例,一般0例,差3例,优良率为86．96％。23例患者中3例出现术后并发症,1例为腹股沟疝,1例发生睾丸鞘膜积液,1例为坐骨神经牵拉伤。结论术前三维CT扫描对骨折的分型及手术入路的选择有重要意义。多数情况运用单一的Kocher—Langenheck或髂腹股沟入路均可使骨折的显露和复位问题得到解决。对于复杂的髋臼骨折或合并骨盆骨折、髋关节脱位者,依据骨折情况,可考虑采用Kocher—Langenbeck及髂腹股沟联合入路。     

Stapling techniques to facilitate resection of the head of the pancreas

Thirteen patients underwent duodenocephalopancreatectomy (DCP) with the mechanical staplers to divide the pancreatic neck and to secure haemostasis of the retroportal pancreatic lamina. The stapling techniques used on the pancreas are described. In nine patients with DCP the stapled distal pancreas was anastomosed to the jejunum with Roux-en-Y drainage; one pancreatic complication and no deaths were observed. In four other patients undergoing DCP who were at high risk for severely compromised general conditions, reconstruction of the digestive tract was simplified by leaving the stapled distal pancreas definitively closed: pancreatic complications were recorded in two cases, with no deaths. Mechanical staplers considerably facilitated resection of the neck of the pancreas and of the retroportal pancreatic lamina. All 13 patients who underwent DCP with the use of stapler techniques on the pancreas, including four high-risk patients, were discharged to convalesce on an oral diet after a median postoperative hospital stay of 23 days (range 16-90 days).     

老年患者腹腔镜胆囊切除术的麻醉处理

目的:探讨全身麻醉和全麻复合硬膜外麻醉对老年患者腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的麻醉效果。方法:30例老年患者行LC,随机分成全麻组(A组,15例)和全麻复合硬膜外麻醉组(B组,15例),分别记录患者入室后、麻醉诱导后、气管插管即刻、切皮、CO2气腹建立后及气管拔管后即刻的收缩压(systolic blood pressure,SBP)、舒张压(diastolic blood pressure,DBP)、心率(heart rate,HR);记录术毕患者苏醒时间、拔管时间和离开手术室时间;拔管后即刻、10min、20min、30min伤口疼痛程度。结果:(1)B组气管插管即刻、CO2气腹后及拔管后即刻的血流动力学较A组稳定,两组比较差异有统计学意义(P<0.05);(2)两组苏醒时间、拔管时间和离室时间差异无统计学意义(P>0.05),但苏醒期间患者发生烦躁反应A组(5例)远高于B组(2例),与A组比较,B组发生烦躁反应发生率较低(13.3%),差异有统计学意义(P<0.05);(3)B组拔管后各时间点VAS评分明显低于A组(P<0.05)。结论:老年患者LC实施硬膜外复合全麻,能减轻术中的应激反应,血流动力学稳定,减轻患者苏醒期疼痛,降低术后烦躁反应发生率,可改善老年患者LC的麻醉效果。     

Audit of open cholecystectomy in a district general hospital.

This retrospective study audited all non-malignant biliary surgery carried out in a district general hospital between January 1985 and December 1990. Surgery was performed on 722 patients: 555 (77 per cent) were women and 167 (23 per cent) were men. The mean(s.d.) age of the patients was 49(16) years. Elective admissions accounted for 70 per cent of cases and 30 per cent were emergency admissions. Ultrasonography confirmed the diagnosis in 93 per cent of cases. An elective operation was performed in 542 patients and 180 patients underwent an urgent or emergency operation. Simple cholecystectomy was performed on 616 patients (85 per cent); 92 (13 per cent) also underwent common bile duct exploration and 14 (2 per cent) had an additional unrelated procedure. The mean(s.d.) hospital stay was 12.3(6.3) (range 4-34) days. There was one perioperative death. The general overall morbidity rate was 25 per cent and the procedure-related morbidity rate was 7 per cent. For simple cholecystectomy (n = 630) there were no deaths; the general morbidity rate was 15 per cent and the procedure-related rate was 3 per cent.     

Aortic aneurysms--who should do them?

All patients undergoing abdominal aortic aneurysm repairs in a district general hospital between 1 January 1983 and 31 December 1987 were reviewed. Of the 76 cases, 53 were planned and 23 were ruptured aneurysms. The male:female ratio was 4.4:1, and the age range was 47-84 years (mean 67.6 +/- 6.97 years). Half underwent an ultrasound scan, showing a maximum diameter range of 3-12 cm. Fifty-seven (75%) had tube grafts, and 19 (25%) bifurcation grafts. The 30-day mortality was 3.7% for planned cases, and 26% for ruptured cases. The principal operator in 55 (72.5%) cases was a consultant; consultant anaesthetists were involved in 61.3% cases. We conclude that aneurysm surgery can safely be performed in a district general hospital by a general surgeon with an interest in vascular surgery.     

Surgical tactics in complicated sigmoid diverticulitis

Between January 1972 and February 1988 139 admissions (136 patients) for diverticulitis were registered. Treatment remained conservative in 47 cases. 23 cases underwent elective surgery. In 69 patients emergency-laparotomy had to be done. In 41 cases (3 deaths) the abdomen was washed out and drained, followed by a proximal colostomy. In 23 of these patients a free perforation had to be oversewn. 6 patients were treated by Hartmann resection (1 death). Primary resection, anastomosis and proximal colostomy were performed in 15 cases. 3 patients underwent exterritorization and resection. 4 patients with colonic ileus were initially treated by colostomy alone. There were 2 late deaths both from pulmonary embolism. Of the 63 patients who had a colostomy constructed 4 (6.3%) never had the stoma closed. There were 2 persistent stomas in the 41 patients who had a preliminary colostomy alone (4.9%) and the incidence of persistent stoma in 5 patients who had a Hartmann resection was 40% (2 cases). -The three-stage resection makes good results, provided that a free perforation is solidly oversewn to prevent further fecal contamination. Primary resection with anastomosis and proximal colostomy, which is more and more used in suitable cases, considerably shortens duration of treatment. Hartmann resection remains second choice because of the known high incidence of persistent stoma. It is submitted to surgeon's experience to choose at any situation the best procedure regarding age and general state, local findings and extent of peritonitis. With this tactic hospital lethality of emergency operation was 4 of 69 patients (5.8%), overall lethality 6 (8.7%). Intestinal continuity was restored in 94% of surviving patients.     

Prognostic markers of the epithelial tumors of the large intestine

The surgical treatment of large bowel malignant tumors is now the most important therapeutic approach. The aim of our study was to evaluate a possible prognostic implication of ploidy and NM23 expression. The study includes 120 non selected patients who underwent surgery for colorectal cancer. The analysis of ploidy was obtained with cytometric test. The cases with only one gaff G0/G1 were considered as diploid. Patteras with more than one aneuploidic population were classified as multiploidic or poliploidic. While NM23 expression was evaluated with a double blind retrospective study by two separate equipe of authors in different centres. NM23 positivity degree was classified in 3 classes: absent or weak if < 10%; moderate if 10-50%; strong if > 50%. Forty-two patients (35%) were classified as diploidic; 30 patients (25%) as aneuploidic; 40 patients (33.2%) as multiploidic; in 8 cases (6.7%) the material was inadequate. Among the two groups who evaluated NM23 expression the group I a positivity: absent or weak in 32 cases (26.7%); moderate in 62 cases (51.7%); strong in 26 cases (21.6%); while the group II shows positivity: absent or weak in 30 cases (25%); moderate in 52 cases (43.3%); strong in 38 cases (31.7%). We cannot consider ploidy and the NM23 research as independent prognostic factor.     

A simplified approach to diagnostic rectal biopsy in infants and children

During a two year period, ninety-four patients underwent 103 rectal biopsies using the suction capsule technic (71 patients for diagnosis of Hirschsprung's disease and 23 to aid in the diagnosis of various neurologic storage disorders). In nine prospective and eighteen retrospective cases the suction biopsy accurately determined the diagnoses of Hirschsprung's disease. No false-positive or false-negative results were encountered. The technic is simple and safe, requiring neither an operating room nor general anesthesia. No complications were seen after this procedure.     

胰腺实性假乳头状瘤的临床病理特点及诊治体会

目的 探讨胰腺实性假乳头状瘤（SPTP）临床病理特点及诊治经验。方法 回顾性分析2004年2月至2012年11月经病理证实的23例SPTP病例的临床特征、手术及病理资料和随访结果。结果 男7例,女16例;年龄10～63岁,中位年龄39岁。肿瘤位于胰头/颈部8例,胰体尾部15例。1例行单纯胰腺肿瘤局部切除,4例行胰十二指肠切除,2例行胰腺中段节段性切除（1例为腹腔镜手术）,5例行胰腺体尾切除（其中1例因合并肝癌加行肝右后叶切除）,11例行胰腺体尾切除加脾切除。术后住院6～35 d,中位术后住院日13 d。术后总并发症发生率43.5%（10/23）,无再手术及围手术期死亡病例。肿瘤直径1.5～15 cm,平均（5.9±0.7）cm。病理特征为肿瘤细胞围绕纤细血管轴心形成特征性的假乳头状结构,细胞形态一致,核异型性不明显。8例表现为胰腺组织、神经浸润或脾脏侵犯,诊断为恶性胰腺实性假乳头状瘤。免疫组化显示AAT/AACT、Vimentin、β-catenin、CD56阳性率均100%,Syn、CgA、CD10、PR部分阳性。23例均获随访,平均38个月,无术后复发转移及死亡,1例合并肝癌患者术后2年因肝癌复发再次行肝癌切除术,无SPTP复发转移。结论 SPTP临床表现无明显特异性;增强CT检查有助于肿瘤定位和手术风险评估;确诊依赖于病理学诊断和免疫组化;手术完整切除肿瘤能获得良好预后。     

MSCTA在诊断肾静脉变异中的价值

分析多层螺旋CT血管造影（MSCTA）对肾静脉（RV）变异的诊断价值。方法回顾性分析352例行腹部MSCTA检查患者,采用容积再现（VR）“血管生长”技术进行RV重建。结果352例共检出RV变异36例,检出率10.2%。双侧RV变异2例;右肾RV变异11例;左侧肾RV变异23例,包括主动脉周围型RV变异12例（3.4%）,完全性主动脉后位型RV变异6例（1.7%）;其他5例（1.4%）。结论MSCTA能清楚显示肾静脉变异,为临床提供解剖学资料。     

结直肠癌并急性结肠梗阻的外科处理--附225例临床分析

目的　探讨结、直肠癌并急性结肠梗阻病例的外科处理原则和方法。方法　回顾性分析我院自１９８２ 年至１９９８ 年收治的２２５ 例结、直肠癌并急性结肠梗阻病例,结合近年国内、外文献,综合评价其外科处理方法。结果　２２５ 例患者均经手术治疗,出现并发症２３ 例;死亡１３ 例,病死率为５－８ ％ ,其余均痊愈出院。结论　结、直肠癌并急性结肠梗阻的处理要根据病人的全身情况和肿瘤的局部情况来进行综合判定。适应证掌握恰当,一期肿瘤切除和吻合术是安全的。     

Penile prosthesis surgery under local penile block anaesthesia via the infrapubic space

The aim of this study was to evaluate the effectiveness and patient tolerance to local penile block anaesthesia via the infrapubic space with penile prosthesis implantation. Local anaesthesia was administered using a 23-guage 1.5-inch needle. A 50-50 mixture of 0.5% bupivicaine (Marcaine) and 0.5% lidocaine (Xylocaine) without adrenaline was injected into the infrapubic space with additional subcutaneous penile ring infiltration at the level of the penile root. A total number of 159 patients underwent this technique, mean age 57 years (range 34-86). In 148 (93%) patients, no booster sedation was needed; eight (5%) patients needed a boost of the pre-operative sedative during crural dilatation; three (1.8%) patients required general anaesthesia owing to insufficiently effective local anaesthesia and unexpectedly difficult dilatation. It is concluded that local anaesthesia was effective and safe to produce a pain-free procedure in 93% of cases. However, as the need for booster sedation or general anaesthesia exists, the procedure should be performed under monitored anaesthetic care and pre-operative evaluation should be performed as for general anaesthesia.     

Immediate complications of transurethral resection of the prostate: study of 1000 consecutive cases

The authors reviewed the charts of 1000 patients who underwent transurethral resection of the prostate. When the 30-day postoperative period was studied, it was found that 139 patients suffered complications and 6 died. Infectious complications (urinary tract in 63 cases and septicemia in 23 cases) were the commonest followed by hemorrhage and urinary retention. The deaths were related to cardiac problems.     

创伤性主动脉损伤的外科治疗策略

目的总结创伤所致主动脉损伤的外科治疗策略。方法纳入2009年1月至2018年1月北京安贞医院心血管外科治疗的34例创伤性主动脉损伤患者(交通肇事伤31例、坠落伤2例、物体砸伤1例)。男23例,女11例。患有高血压病10例,胸主动脉假性动脉瘤9例,胸主动脉离断6例,主动脉夹层共19例。开放手术5例,年龄(44.80±20.57)岁;2例A型主动脉夹层行Bentall+孙氏手术,1例B型夹层及2例胸主动脉假性动脉瘤行术中支架人工血管置入术。胸主动脉腔内修复术29例,年龄(45.93±11.01)岁。结果开放手术时间(403.20±30.30)min,患者住院(19.00±6.04)天;胸主动脉腔内修复术手术时间(105.72±27.76)min,患者住院(5.76±3.08)天。所有患者术后随访(45.09±23.10)个月,两组均无死亡,2例胸主动脉腔内修复术患者因封闭左锁骨下动脉未开通而出现左上肢乏力麻木。结论创伤性主动脉损伤应根据患者全身情况、损伤等级、损伤累及部位及解剖特点来选择不同的治疗方案。但远期预后仍有待确定。     

Quality of documented consent for the de-escalation of care on a general and trauma surgery service

Postoperative and posttrauma mortality in the acute care setting often occurs after a decision for de-escalation of care. It is important that the quality of consent for de-escalation of care is maintained to ensure patient autonomy. This retrospective review aims to determine the quality of the consent process for care de-escalation in patients on a trauma and general surgery service who sustained in-hospital mortality. One hundred thirty-three patients (99 trauma) were identified who died in 1 year. Of these patient deaths, 80 (60%) involved de-escalation of care. In three (3%) cases, there were no documented discussions for de-escalation consent. Of the remaining cases, documentation was considered optimal 21 per cent of the time. Only nine (11%) patients were able to participate in a discussion of their end-of-life care. The other 23 patients who were initially competent lost their ability to participate in discussions after a debilitating event. In this study, the majority of patients who died on a surgical service underwent a de-escalation of care. The documentation quality was suboptimal in most cases. Earlier and more thorough discussion of the patient's end-of-life wishes may improve the de-escalation of care consent process.     

胰腺实性假乳头状瘤47例临床分析

目的:探讨胰腺实性假乳头状瘤(SPTP)的临床特征、治疗及其预后。方法:回顾性分析南昌大学第一附属医院普通外科2007年1月—2018年12月经收治并经术后病理证实的47例SPTP患者的临床资料。结果:全组男11例,女36例,平均年龄(32±15)岁;肿瘤位于胰头部16例,胰颈部8例,胰体尾部23例;术前通过影像学初步诊断为SPTP者21例(44.7%),6例术前行超声内镜引导下细针穿刺活检术,仅1例(16.7%)确诊为SPTP;行胰十二指肠切除术10例,胰体尾联合脾脏切除术12例,保留脾脏的胰体尾切除术8例,胰腺中段切除术5例,肿瘤局部切除术10例,保留十二指肠胰头切除术1例,胰体尾联合脾脏、左肾及左肾上腺切除+下腔静脉切开取栓术1例。术后并发症发生率为19.1%(9/47),无再手术和手术相关死亡。肿瘤免疫组化结果显示,PR、CD56、NSE呈阳性表达居多。术后43例获随访,平均随访时间(41.7±31.4)个月,1例术后复发,所有随访患者均存活。结论:SPTP是一种好发于年轻女性的潜在低度恶性肿瘤,其临床表现无特异性,确诊有赖于病理组织学检查,手术切除是首选治疗方法,预后良好。     

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目的总结胰腺实性假乳头状瘤(SPT)的临床特征与诊断经验。方法对2000年2月至2007年3月在中国人民解放军总医院经术后病理证实的24例SPT的临床表现和实验室、影像学、术前及术中病理检查等资料进行回顾性分析。结果女性23例,男性1例,平均年龄24.4岁。首诊临床表现为腹部肿物5例、腹痛7例、腹泻1例、恶心腹胀2例等,9例无任何临床症状。血清肿瘤标记物水平均正常。影像学检查均提示胰腺或腹腔内边界清楚的实性或囊实性占位病变,肿瘤位于胰头部13例,胰体部4例,胰尾7例,核磁共振(MRI)的诊断符合率(40.0%)要高于CT(16.7%)。术前2例行超声引导下肿瘤活组织检查,6例行术中快速冰冻病理检查,分别有1例和3例诊断为SPT。结论SPT的正确诊断依赖于临床表现、影像学特征,尤其是病理学检查的综合分析。     

乳晕入路腔镜甲状腺切除术与开放手术的临床对比分析

目的：探讨腔镜技术用于甲状腺手术获得美容效果的临床应用价值及其安全性和可行性。方法：选择2008年1月-2011年08月行甲状腺良性肿物手术的患者80例,其中腔镜甲状腺手术40例（腔镜组）,单侧23例,双侧17例;传统开放甲状腺手术40例（开放组）,其中单侧22例,双侧侣例,2组行单侧大部分切除术或者双侧甲状腺大部分切除术,麻醉方法均采用气管插管全身麻醉。分别比较2种术式单侧和双侧的手术时间、术中失血量、术后住院时间、术后引流量、引流天数、住院费用、术后美容效果、术后并发症。结果：全部病例手术成功,2组均无术后大出血、喉返和喉上神经损伤、甲状旁腺损伤等严重并发症。腔镜组手术时间较长,2组单侧及双侧分别比较差异均无统计学意义（P〉0．05）;腔镜组术中出血量、住院时间、术后引流量、术后引流时间、术后并发症较开放组少,2组单侧及双侧分别比较差异均有统计学意义（P〉O．05）。虽然住院费用腔镜组高于开放组（P〈O,05）,但腔镜组取得较好美容效果。结论：乳晕入路腔镜甲状腺切除术与开放手术均是安全、有效的手术方法,腔镜手术有更加令人满意的美容效果,有着传统开放甲状腺手术不可比拟的优点,对适应证明确者,应该是值得推崇的手术方式。     

经11肋上缘径路微创经皮肾镜处理肾上盏结石23例报告

目的:探讨经11肋上缘径路微创经皮肾镜术(MPCNL)处理肾上盏结石的安全性及临床疗效.方法:肾上盏多发性结石或鹿角型结石患者23例,男16例,女7例.均作全麻,气管插管选择双腔管,男性为F37,女性为F35.行患侧输尿管逆行插管,改体位为俯卧位,在B超定位下,于腋中线与腋后线之间紧贴11肋上缘进针,针尖方向指向上盏结石穿刺,穿刺时将患侧肺处于负压状态.沿导丝扩张形成F16的工作通道.置入输尿管镜或李逊镜,采用气压弹道碎石器在灌注泵配合下边冲洗边碎石.结果:23例均一期完成手术,无穿刺失败或中转开放手术.手术时间(65.6±14.8)min,出血量(150.2±42.2)ml,1例术中输红细胞2 U.结石清除率为86.9%(20/23).无术中大出血,无肠道、肝脾脏损伤等.1例出现液胸,术后并发症为肾周血肿1例,继发性出血1例.结论:经11肋上缘径路经皮肾镜处理肾上盏结石有足够的手术安全性,手术效果良好.