Incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall protruding through the stoma

The case is reported of incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall protruding through the stoma. An 82-year-old woman presented with suspected parastomal intestinal hernia. The patient had undergone total cystectomy with ileal conduit construction 3 years previously, followed by stomal reconstruction surgery for stomal stenosis 2 years later. She had been taking various kinds of purgatives for severe constipation. Initially, this case was diagnosed as parastomal hernia, but emergency surgery demonstrated that incarcerated intestinal hernia in a hernia sac of reversed ileal conduit wall was protruding through the stoma. This case was apparently caused by high abdominal pressure and thinning of the ileal conduit wall.     

Simple correction of ureteral stomal stenosis for cutaneous ureterostomy

Cutaneous ureterostomy is a simple procedure to perform, but has some morbidity owing to stomal stenosis. We describe a new and simple technique applied to the stomal stenosis for cutaneous ureterostomy.     

Anesthetic management of apicoaortic bypass in patients with severe aortic stenosis

Apicoaortic bypass (AAB), or apicoaortic conduit insertion, is a conventional surgical method that has been regaining attention due to the aging population and the increasing number of repeat surgeries. The indication for the procedure has been extended as an alternative for aortic stenosis when the usual sternotomy or aortic clamping is considered to be difficult, e.g., in patients with severe calcification of the ascending aorta (porcelain aorta), or in patients with a patent coronary artery bypass graft located adjacent to the posterior surface of the sternum. Herein, we report our recent anesthetic management of three patients undergoing AAB. Once the apicoaortic conduit is inserted, blood from the left ventricle is ejected via two routes, the narrowed native aortic valve and the apicoaortic conduit. Thus, it is necessary to elucidate any change in blood flow after the withdrawal of the extracorporeal circulation, by using intraoperative transesophageal echocardiography. Furthermore, if a rigid apical connector is not used, anastomosis of the cardiac apex and conduit is conducted under ventricular fibrillation without the infusion of cardioplegic solution; thus, patients are deemed likely to suffer increased myocardial damage. As a rigid apical connector was not used in the three present patients, the administraction of adequate catecholamines was needed for the withdrawal of the extracorporeal circulation. In addition, because those undergoing AAB often have extremely poor cardiac reserve preoperatively owing to the administration of adequate catecholamines was needed for the withdrawal of the extracorporeal circulation. In the three present patients, anesthetic management was successful, and there were no intraoperative or immediate postoperative complications.     

Quality of life in patients having an ileal conduit, continent reservoir or orthotopic neobladder after cystectomy for bladder carcinoma

BACKGROUND: To compare the QOL in patients with ileal or colon conduits (IC), continent urinary reservoir (CR) and ileal neobladder (NB), a retrospective study was conducted using a questionnaire sent by mail. METHODS: Seventy-nine patients with a mean age of 60 years were included in this study. A total of 36, 22 and 21 underwent IC, CR and NB, respectively and were alive at the time of this study. A structured questionnaire consisting of 97 questions that covered general condition and physical condition, reconstruction-related symptoms, psychological status, sexual life, social status and satisfaction with the treatment was employed. RESULTS: The IC group frequently complained of changes in bathing habits and loss of using public baths in comparison with the CR and the NB groups. High scores for loss of sexual desire were obtained in the IC, the CR and the NB groups, in this order. Because of the nearly physiological voiding, the NB group desired a voiding condition like pre-operative status as compared with the IC and the CR groups. However, for most of the questionnaire items no difference was seen among the IC, CR and NB groups concerning general condition, reconstruction-related symptoms, psychological status, sexual life, social status, satisfaction with the treatment and global satisfaction with life and health. CONCLUSIONS: There was little difference in the QOL score of the questionnaire and satisfaction among the IC, CR and NB groups. It was suggested that almost every patient accepted and adapted to the present status of general quality of life in each group.     

Fate of tetraplegic patients managed by ileal conduit for urinary control: Long-term follow-up

BACKGROUND: A study was conducted to evaluate our experience of ileal-conduit formation in tetraplegic patients with special reference to late complications due to upper urinary tract stones and pyocystis. METHODS: Ileal-conduit formation was performed in 16 patients with tetraplegia to improve urinary management. The mean age at operation was 46 years (range 19-70) and the mean follow-up period was 8.7 years (range 2-17). We evaluated the results retrospectively from patients' medical records. RESULTS: Two patients died 2 years after the procedure and one patient died 8 years after the ileal-conduit formation. Five patients suffered from repeated renal or ureteral stone. In three of these cases, serious urinary tract infections developed whenever the stone caused an obstruction. Three patients received a cystectomy at the time of the ileal-conduit formation. Eight patients suffered from empyema of the bladder and in two of these cases a subsequent cystectomy was required. CONCLUSIONS: Ileal-conduit formation should be cautiously considered as an option in the urinary management of tetraplegic patients, particularly when more conservative management strategies have proved unsuccessful. However, an antirefluxing mechanism for the ileal conduit may be necessary, and a simultaneous cystectomy may improve the results.     

Major urologic surgery and rhabdomyolysis in two obese patients

Urologic surgery performed in the lithotomy position sometimes results in the serious complications of rhabdomyolysis and acute renal failure. Patients in which this occurs are almost always found to have compartmental syndromes. The two patients we present herein did not show any sign of a compartmental syndrome, but both were obese and underwent surgery for more than 6 h. The possible mechanism of rhabdomyolysis without compartmental syndrome (without local signs and symptoms of muscle damage) is discussed, and rhabdomyolysis and urologic surgery are reviewed.     

Outcome of deceased donor renal transplantation in patients with an ileal conduit

Renal transplantation in recipients with an ileal conduit is uncommon and occasionally controversial as it has been associated with high morbidity and mortality rates. We report on 17 patients with an ileal conduit who received a deceased donor renal transplant at our institution between January 1986 and December 2012. We retrospectively reviewed their allograft and surgical outcome. There were four mortalities at five, five, 39, and 66 months post‐transplant. Sixteen of 17 grafts functioned immediately; one patient had primary non‐function secondary to vascular thrombosis. Thirteen of 17 (76.5%) grafts were functioning at a mean follow‐up period of 105 months. The mean serum creatinine at follow‐up was 111 μM (±38.62). Five patients had seven episodes of urosepsis requiring hospital admission, and five patients received treatment for renal stone disease. We conclude that given improvements in immunosuppression, surgical technique, infection treatment, and selection criteria, we believe that renal transplantation in the patient with an ileal conduit yields excellent graft survival, although there is a high morbidity rate in this cohort of patients in the long term.     

二期翻修治疗膝关节肿瘤型人工关节感染

目的探讨二期翻修术治疗膝关节肿瘤型人工关节感染的疗效。方法 2003年8月-2010年8月,收治22例保肢术后膝关节肿瘤型人工关节感染患者。男11例,女11例;年龄15～55岁,平均29.6岁。其中20例为初次关节置换术后感染,2例为翻修术后;术后15 d～89个月发生感染。感染按照Coventry和Fitzgerald等人工关节感染分型标准:Ⅰ型3例,Ⅱ型15例,Ⅲ型4例。发生感染至该次入院时间为5～47个月,平均10.2个月。细菌培养提示阳性9例,阴性13例。2例出现发热,白细胞计数升高。一期清创术取出假体,临时骨水泥填充旷置;待感染控制后行二期翻修。结果一期清创术前C反应蛋白及红细胞沉降率均明显高于二期翻修术前,差异有统计学意义(P<0.05)。术后患者均获随访,随访时间5～63个月,平均23.6个月。一期清创术后18例(81.8%)感染控制,其中1例拒绝二期翻修,17例行二期翻修术;17例中1例因术后5个月感染复发,行截肢术。4例(18.2%)感染未控制,行截肢术。保肢率为77.3%(17/22)。1例肾癌骨转移患者因原发病于术后1年6个月死亡。末次随访时16例关节功能采用美国骨与软组织肿瘤学会功能评分(MSTS 93)为(69.4±12.7)分。结论肿瘤型人工关节重建后感染,应根据情况及时行二期翻修手术,可获得较好疗效。     

颈动脉狭窄患者CEA应用颈动脉转流效果观察

目的:探讨颈动脉狭窄患者行颈动脉内膜剥脱术(CEA)术中使用颈动脉转流有效性及安全性。方法:回顾性分析79例颈动脉狭窄患者,术中通过经颅多普勒监测双侧大脑中动脉血流速度(VMCA)。阻断颈动脉前后记录系统收缩压、术侧VMCA、对侧VMCA。将79例患者分为两组:A组V2-a<40%V1-a 41例,使用颈动脉转流;B组V2-a≥40%V1-a 38例,未使用颈动脉转流。提高血压使术侧VMCA达到50%V1-a,即刻和恢复血供后记录系统收缩压、术侧VMCA、对侧VMCA。结果:A组、B组不良事件发生率分别为22.0%、5.3%(P=0.032);A组、B组主要不良事件发生率分别为9.8%、5.3%(P=0.743)。结论:颈动脉狭窄患者行CEA术,术中使用颈动脉转流增加不良事件发生率,但对主要不良事件发生率无明显影响,不常规推荐使用颈动脉转流管。     

病态肥胖患者困难气道预测方式的研究进展

在肥胖人群中,病态肥胖（BMI≥35 kg/m²）是数量增长最快的一类。病态肥胖会使脂肪在颈部和腹部异常积聚,会导致上呼吸道狭窄、舌体肥大、膈肌上抬等解剖及呼吸生理的改变,使得病态肥胖患者成为困难气道的高发人群。要保证此类患者手术时通气的顺利和稳定,麻醉科医师在术前对病态肥胖患者进行针对困难气道有效的预测是至关重要的。本文旨在通过分析病态肥胖的不利影响和总结病态肥胖患者困难气道预测的新趋势,指导麻醉科医师对困难气道做出准确的术前预测。     

微创经皮肾取石术治疗肥胖肾结石的疗效及安全性评价

目的:评价微创经皮肾取石术治疗肥胖肾结石的疗效和安全性。方法:收集2007~2011年在我院行PCNL治疗的肾结石患者159例,并将患者分为三组:正常组(18.5≤BMI24)、超重组(24≤BMI28)和肥胖组(BMI≥28)。比较三组患者的外科治疗结果。结果:正常组、超重组及肥胖组结石清除率分别为92.3%、90.9%和89.7%,其他指标如住院时间、血红蛋白下降率、止痛药使用率、术后发热率等各组间差异无统计学意义。结论:采用PCNL治疗肥胖患者肾结石可取得同治疗正常体重患者类似的安全性和有效性。     

The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese

BackgroundBecause of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure.MethodsWe performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m². The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up.ResultsMean patient age was 53 years (range 32–75 yr) with mean BMI of 46 kg/m² (range 41–60 kg/m²). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively.ConclusionThe PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.     

高龄腰椎管狭窄症患者手术治疗的安全性及有效性

目的:分析高龄腰椎管狭窄症患者接受手术治疗的临床疗效及并发症,评价其安全性和有效性。方法:自2015年12月~2017年6月,共有49例75岁以上的腰椎管狭窄症患者在我院接受腰椎后路减压融合内固定术,其中获得半年以上随访且资料完整的患者44例,单节段融合11例,双节段融合21例,3节段融合7例,3节段以上融合5例。34例(77.3%)患者合并高血压,13例(29.5%)合并糖尿病,9例(20.5%)合并冠心病(3例曾行心脏支架植入术,1例曾行心脏搭桥术),6例(13.6%)有脑梗死病史但无明显后遗症,2例(4.5%)合并慢性阻塞性肺疾病,2例(4.5%)慢性肾功能不全。将患者分为短节段融合组(3节段,n=32)和长节段融合组(≥3节段,n=12)。统计两组患者的一般资料、术中出血量、手术时间、疼痛视觉模拟量表(visual analoge score,VAS)评分、Oswestry功能障碍指数(ODI)以及手术并发症。将患者对手术疗效的主观满意度分为满意、基本满意、不满意、非常不满意。结果:44例患者均顺利完成手术,手术时间为234.2±74.56min(100~411min),术中出血量为475.5±343.4ml(100~1400ml)。术后发生脑脊液漏2例,切口愈合不良5例。随访13.8±2.1个月(6~25个月),末次随访时,VAS评分由术前的7.53±1.19分改善至2.38±1.58分(P0.001),ODI由术前的(70.32±6.90)%改善至(46.38±9.89)%(P0.001);8例出现螺钉松动,2例cage后移,2例cage下沉,再手术2例。30例对疗效满意,6例基本满意,5例不满意,3例非常不满意,满意率为81.8%。两组患者年龄和BMI无显著性差异,长节段融合组女性患者占比较高,手术时间较长,出血量较多;两组患者的VAS评分改善率和ODI改善率无显著性差异;与长节段融合组相比,短节段融合组再手术比例、螺钉松动比例以及cage后移比例较低。结论:高龄腰椎管狭窄症患者并存病较多,围手术期内固定相关并发症较多,且与融合节段有关。围手术期积极控制内科疾病,术中仔细操作,手术的安全性可以得到保障,术后临床症状和功能评分均可以获得显著性改善。