姑息性手术治疗不能切除的胰头癌

本文报告我院１０年间姑息性手术治疗不能切除的胰头癌１００例。最常见的症状为黄疸（８１％），腹痛或背痛（５２％），体重减轻（４３％）。手术方法：肝总管空肠Ｒｏｕｘ－Ｙ形吻合术４７例，肝总管空肠Ｒｏｕｘ－Ｙ形吻合和胃空肠吻合术３７例，胆囊空肠Ｒｏｕｘ－Ｙ形吻合术８例，肝内或肝外胆管置管外引流术８例。手术死亡率为６％，胆肠吻合和预防性胃空肠吻合术的手术死亡率为５．４％。近期并发症为３９％，其中伤口感染多见。远期并发症为２３％，其中以胆囊空肠吻合术后的胆管炎和黄疸多见。我们认为姑息性手术治疗不能切除的胰头癌应尽量选择肝总管空肠Ｒｏｕｘ－Ｙ形吻合术，同时作预防性胃空肠吻合。     

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目的 分析胆肠吻合术治疗肝内胆管结石并胆道狭窄的选择和疗效。方法 对１９９１年９月至１９９８年１２月６９例行胆肠吻合术的肝内胆管结石并胆道狭窄病例进行总结,包括临床表现、结石部位、狭窄情况、手术方式和治疗效果等。结果 胆管狭窄主要位于１￣２级胆管内。５１例（７３．９％）行肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,１８例（２６．１％）采用胆总管十二指肠吻合术,随访结果表明,肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合     

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目的 研究复杂的肝内胆管结石的手术治疗方法。方法 对１５例肝内胆管广泛多发结石病人,实施左肝外叶切除广口肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术,并进行跟踪随访。结果 本组无严重术后并发症。随访３．５￣７．５年,平均４．８年,１４例症状完全消失,１例偶有胆管炎发作。Ｂ超检查;１３例无残石,２例右肝后叶残留少量结石。结论 左肝外叶切除广口肝胆管空肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术治疗肝内胆管广泛多发结石远期疗效较     

成人胆总管囊肿的诊治

目的 进一步探讨成人胆总管囊肿的诊断和治疗。方法 回顾性分析１９９５年１月至１９９９年１月手术室治疗成人胆总管囊肿４２例资料,术后随访平均为３５个月,随访率为８０％。结果 行囊肿十二指肠吻合术２例,囊肿空肠Ｒｏ７ｕｘ－Ｙ吻合术１０例,行囊肿切除加肝总管空肠Ｒｏｕｘ－Ｙ吻合术３０例;术后胆瘘２例,腹腔出血、胰瘘各１例,无手术死亡。结论 囊肿切除加肝总管空肠Ｒｏｕｘ－Ｙ吻合术应为肝外胆管囊肿治疗的首选     

医源性胆管损伤并狭窄（附18例分析）

本文报告１８例医源性胆管损伤，１４例发生于胆囊切除，４例发生于胃大部切除。４例经总胆管十二指肠吻合，７例经胆管修补Ｔ管支撑，２例胆管端端吻合Ｔ管支撑，５例经肝总管空肠Ｒｏｕｘ一ｅｎ一Ｙ吻合，１７例治愈，１例死于心脏病。作者认为Ｒｏｕｘ一ｅｎ一Ｙ吻合术疗效最可靠。     

损伤性高位胆管狭窄41例报告

目的 总结损伤性高位胆管狭窄外科治疗的经民教训。方法 性调查４１例损伤性高位胆管狭窄患者的治疗方法，并发症及远期疗效。结果 采用胆肠吻主３８例，无手术死亡。其中肝管空肠Ｒｏｕｘ－Ｙ吻合术２６例，随访２～１０年，优良率８３．３％；肝管十二指肠吻合１２例，随访３年以上，优良率７０％。结论 肝管空肠Ｒｏｕｘ－Ｙ吻合术是治疗损伤性高位胆管狭窄的最佳方式，肝管十二指肠吻合术对高危胆管狭窄患者仍然是有效方法之     

右肝后叶胆管结石的外科治疗

目的 探讨右肝后叶胆管结石的治疗方法。方法 回顾性分析了作者收治57例右肝后叶胆管结石的临床资料及随访结果。结果 57例实施肝叶（段）切除14例，肝叶（段）切除 胆管T管引流14例；肝叶（段）切除 右肝后叶胆管切开整形，胆管空肠吻合术23例，右肝后叶胆管切开整形，胆管空肠吻合术3例。右肝后叶胆管切开取石，U管引流3例。术后随访2-13年，采用肝（段）切除或肝叶（段）切除 胆管T管引流者远期疗效优良率为100%（28/28），肝叶（段）切除 右肝后叶胆管切开整形，胆管空肠吻合术或右肝后叶胆管切开整形，胆管空肠吻合术优良率为92.31%(24/26)，肝外胆管切开取石，U管引流术后远期疗效差。结论 对于右肝后叶胆管结石的病人。有手术适应症者应尽量选用以肝叶（段）切除为主的治疗方法，必要时可辅助右肝后叶胆管切开整形，胆管空肠吻合或选用右肝后叶胆管切开整形，胆管空肠吻合术；而右肝后叶胆管切开取石，U管引流仅适应年老，体弱的病例，或急诊过渡性手术。     

成人先天性胆管囊肿的诊断与治疗(附97例报告)

作者总结了近３０年来成人先天性胆管囊肿９７例的治疗经验。患者平均就诊年龄为３７岁。多数患者症状不典型，常致诊断延误。７４例（７６％）合并肝胆胰系统疾病，１６例合并癌变，癌变率１７％。发现胰胆管合流异常２８例。９４例患者共行胆道手术１６９例次，囊肿切除、肝管空肠Ｒｏｕｘ－Ｙ吻合术及囊肿内引流术为主要术式。术后长期随访表明内引流术后常因胆管炎复发和囊肿癌变而需再次手术，相反囊肿切除术明显降低了胆管炎的复发率及癌变的发生。作者认为囊肿切除、肝管空肠Ｒｏｕｘ－Ｙ吻合术应作为成人胆管囊肿的首选术式。     

胆管空肠Roux-Y吻合术后十二指肠球部溃疡二例报告

胆管空肠Ｒｏｕｘ－Ｙ（ＣＪＲ－Ｙ）吻合术是一种较常选用的胆肠内引流术式。本文报告２例ＣＪＲ－Ｙ吻合术后十二指肠球部溃疡,并讨论有关问题。１　病例报告例１　女,５１岁。右上腹反复疼痛二十余年,巩膜黄染一周。Ｂ超诊断：慢性胆囊炎、胆总管多发性结石、肝内胆管结石。１９８４年１０月行胆囊切除、胆总管探查。因肝内胆管结石难以取尽而行胆总管空肠Ｒｏｕｘ－Ｙ吻合术（横断胆总管）。术中未发现胃十二指肠明显异常。１９９１年开始反复出现中上腹腹胀、嗳气,呕吐酸水,饥饿性隐痛,进食能缓解。１９９５年开始反复出现黑色大…     

右肝后叶结石的手术治疗

近来，我们应用经右肝后叶胆管联合切开右肝后叶上、下段胆管．原位整形．胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合术治疗右肝后叶结石１２例．获满意疗效．无胆道出血及手术死亡。文中讨论了右肝内胆管的正确辨认、手术适应症及手术操作要点。     

Vertebral rotation and pedicle length asymmetry in the normal adult spine

Summary Rotation in the horizontal plane of vertebra T8, T9 or T10 was determined on CT scans of 25 male and 25 female patients with normal spines. The pedicle length was measured using a new method, and the right/left pedicle length index was calculated. In 38 (76%) of the patients there was vertebral rotation to the right with a mean Cobb angle of 3.0°, and in 4 (8%) rotation to the left, mean Cobb angle 2.2° (P0.01). In 8(16%) there was no measurable rotation. The pedicle length index was greater than 1.05 in 9 subjects, between 0.95 and 1.05 in 16 and less than 0.95 in 25, indicating a predominance of longer pedicles on the left side. In 21 out of the 38 patients with vertebral rotation to the right, the left pedicle was longer than the right one (P0.01). The results indicate that the normal spine is afflicted with a vertebral rotation to the right in association with a longer pedicle on the left. The significance of these observations for the pathogenesis of idiopathic scoliosis remain uncertain.     

结核毁损肺单侧全肺切除的麻醉处理

目的探讨结核毁损肺单侧全肺切除的麻醉处理. 方法 80例结核毁损肺行单侧全肺切除病人,术前肺功能减损轻度者30例(G组),中度者35例(M组),重度者15例(S组).56例行左侧全肺切除:44例使用双腔支气管导管(Carlon管10例、White管20例、左侧Robertshaw管8例、右侧Robertshaw管6例)、右单腔支气管导管7例、气管导管5例.24例行右侧全肺切除:21例使用双腔支气管导管(Carlon管19例、左侧Robertshaw管2例)、左单腔支气管导管2例、气管导管1例.痰量>50 ml/d的16例病人中,采用双腔支气管导管7例、右单腔支气管导管7例、左单腔支气管导管2例. 结果 G组、M组未发生围手术期并发症,S组术后发生急性呼吸衰竭5例(33.33%).痰量>50 ml/d的病人中,2例使用左单腔支气管导管的病人术后均发生健侧支气管病灶播散;而使用双腔支气管导管和右单腔支气管导管未发生结核播散. 结论结核毁损肺重度肺功能减损者,术前FEV1占预计值的百分比<35%,MVV占预计值的百分比<40%,行单侧全肺切除手术要慎重.术前痰量＞50 ml/d的病人,应选择双腔支气管导管或右单腔支气管导管,确保两肺分隔满意,以防止术后健侧支气管病灶播散.     

腹腔镜手术治疗肝癌128例的疗效评析

目的 探讨腹腔镜手术治疗肝癌的临床价值.方法 回顾性分析2007年3月至2009年10月第三军医大学西南医院采用腹腔镜手术治疗128例肝癌患者的临床资料.其中原发性肝癌116例,转移性肝癌12例.行腹腔镜肝切除术107例,单纯腹腔镜下RFA治疗15例,腹腔镜下门静脉右支结扎降期治疗6例.结果 107例行腹腔镜肝切除术患者中7例中转开腹手术,5例中转手助式腹腔镜肝切除术.规则性肝切除88例,包括左外叶切除21例、左半肝切除15例、超左半肝切除2例、中肝切除1例、右半肝切除11例、右后叶切除9例、单肝段切除29例;两个以上部位联合切除4例;非规则性肝切除15例.肝切除术的平均手术时间(228±92)min,术中平均出血量(393±213)ml,无手术死亡,16例术后出现并发症,术后平均住院时间(8±4)d.126例患者随访1～42个月,12例行腹腔镜肝切除术者于术后3～16个月死亡,术后平均生存时间(118±7)周,平均无瘤生存时间(105±7)周.行腹腔镜下BFA治疗的2例患者分别于术后9个月及11个月死亡;行腹腔镜下门静脉结扎的2例患者于术后行二期根治性切除.结论 腹腔镜手术治疗肝癌安全可行,具有创伤小、恢复快的优点.     

Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: early results of a randomized prospective study

BackgroundStandard laparoscopic colectomy (SLC) for cancer is a safe, feasible, and oncologically effective procedure with better short-term and similar long-term results of open colectomy. Conversely, owing to technical difficulties in colonic resection and full mesenteric dissection, single-incision laparoscopic colectomy (SILC) has been considered unsuitable for oncologic purposes. We compared the technical feasibility and early clinical outcomes of SLC and SILC for cancer.MethodsIn this prospective randomized clinical trial, 16 (50%) patients underwent SLC (10 left and 6 right) and 16 (50%) patients underwent SILC (8 left and 8 right).ResultsDemographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 16 ± 5 in the SLC and 18 ± 6 in the SILC group (P = NS). Surgical time was 124 ± 8 minutes and 147 ± 5 minutes, respectively (P = NS). Surgical mortality was nil and the major morbidity rate was 6.3% in both groups.ConclusionsSILC for cancer is a technically feasible and safe oncologic procedure with short-term results similar to those obtained with a traditional laparoscopic approach.     

Modified Glenn connection for acutely ischemic right ventricular failure reverses secondary left ventricular dysfunction.

BACKGROUND: Right heart failure after cardiopulmonary bypass can result in severe hemodynamic compromise with high mortality, but the underlying mechanisms remain poorly understood. After ischemia-induced right ventricular failure, alterations in the interventricular septal position decrease left ventricular compliance and limit filling but may also distort left ventricular geometry and compromise contractility and relaxation. This study investigated the effect of acute isolated right ventricular ischemia on biventricular performance and interaction and the response of subsequent right ventricular unloading by use of a modified Glenn shunt. METHODS: In 8 pigs isolated right ventricular ischemic failure was induced by means of selective coronary ligation. A modified Glenn circuit was then established by a superior vena cava-pulmonary artery connection. Ventricular performance was determined by conductance catheter-derived right ventricular pressure-volume loops and left ventricular pressure-segment length loops. Hemodynamic data at baseline, after right ventricular ischemia, and after institution of the Glenn circuit were obtained during inflow occlusion, and the load-independent contractile indices were derived. RESULTS: Right ventricular free-wall ischemia resulted in acute right ventricular dilation (118 +/- 81 mL vs 169 +/- 70 mL, P =.0008) and impairment of left ventricular contractility indicated by the reduced end-systolic pressure-volume relation slope (50.0 +/- 19 mm Hg/mm vs 18.9 +/- 8 mm Hg/mm, P =.002) and preload recruitable stroke work index slope (69.6 +/- 26 erg x cm(-3) x 10(3) vs 39.7 +/- 13 erg x cm(-3) x 10(3), P =.003). In addition, left ventricular relaxation (tau) was significantly prolonged (33.3 +/- 10 ms vs 53.0 +/- 16 ms, P =.012). Right ventricular unloading with the Glenn shunt reduced right ventricular dilation and significantly improved left ventricular contraction, end-systolic pressure-volume relation slope (18.9 +/- 8 mm Hg/mm vs 35.8 +/- 18 mm Hg/mm, P =.002), preload recruitable stroke work index slope (39.7 +/- 26 erg x cm(-3) x 10(3) vs 63.0 +/- 22 erg x cm(-3) x 10(3), P =.003), and diastolic performance (tau 53.0 +/- 16 ms vs 43.5 +/- 13 ms, P =.001). CONCLUSIONS: Right ventricular ischemia-induced dilation resulted in acute impairment of left ventricular contractility and relaxation. A modified Glenn shunt attenuated the left ventricular dysfunction by limiting right ventricular dilation and restoring left ventricular cavity geometry.     

Surgical resection and chemotherapy improve survival rate for patients with hepatoblastoma

BACKGROUND: The authors reviewed retrospectively their experience in 30 children with hepatoblastoma (HB). Despite an increased trend in the incidence of HB during the last 2 decades, an encouraging cure rate has been achieved with complete resection of the tumor and chemotherapy before or after surgery with cisplatin plus doxorubicin (Adriamycin) or cisplatin plus vincristine plus 5-Fluorouracil. RESULTS: There were 10 female and 20 male patients. For the period from 1963 to 1980 there were 8 patients, and for the period from 1981 to 1998 there were 22 patients. Their mean age at surgery was 16 months (range, 3.5 months to 5.5 years). Tumors were localized to the right lobe in 10 (42%), to the left lobe in 7 (29%), and in both lobes in 7 (29%) of the resected patients. Tumors were greater than 10 cm in size in 16 (67%) of these patients. Twenty-four patients (80%), underwent liver resection before or after chemotherapy. One patient (3%) with an unresectable tumor received chemotherapy and a liver transplant. In 5 patients (17%) the hepatic involvement was too extensive for resection. The types of resection performed were right lobectomy in 7, left lobectomy in 6, right trisegmentectomy in 8, left trisegmentectomy in 2, and middle hepatectomy in 1. The overall survival rate for 35 years of the study was 60% (18 of 30). With the association of surgery and chemotherapy (1981 through 1998) survival rate is 82% (14 of 17). Overall median follow-up in our study is 8 years (range, 2.5 to 24 years). CONCLUSIONS: There has been a dramatic improvement in the results of treatment of hepatoblastoma. Formerly, only 25% to 30% of patients were cured, whereas today, with combination of chemotherapy and surgery, 75% to 80% may be cured.     

Ⅲ型肝门部胆管癌的外科治疗（附35例分析）

目的总结Ⅲ型肝门部胆管癌的手术经验。方法回顾性分析我院1999年1月至2006年12月，行手术切除的35例Ⅲ型肝门部胆管癌的临床资料。Ⅲa型16例，行肝门部胆管切除8例，行联合右半肝＋右侧尾状叶切除7例，行联合右半肝＋尾状叶切除、门静脉分叉部切除主干左支吻合1例。Ⅲb型19例，行肝门部胆管切除8例，行联合左半肝＋左侧尾状叶切除9例，行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合1例．行联合左半肝＋尾状叶切除、门静脉分叉部切除主干右支吻合、肝固有动脉分叉部切除主干右支吻合1例。结果本组32例获得随访，随访时间18～113个月。肝门部胆管切除病例术后病理根治性切除率为37．5％，联合肝叶切除病例术后病理根治性切除率73．7％，3例联合肝叶切除＋血管切除病例均获术后病理根治性切除。肝门部胆管切除术后并发症发生率为31．3％，联合肝叶切除组术后并发症发生率为31．6％。3例联合肝叶切除＋血管切除病例术后均无胆肠吻合口漏、肝断面坏死、胆漏等严重并发症。结论联合肝叶切除，必要时行受累分叉部血管切除重建，有益于提高Ⅲ型肝门部胆管癌的根治性切除率，且不增加术后并发症的发生率。     

Bilateral Thoracoscopic Minimally Invasive Direct Coronary Artery Bypass Grafting Using Internal Thoracic Arteries

Background. Single-vessel coronary artery bypass grafting of the left internal mammary artery (ITA) to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting procedure without cardiopulmonary bypass for patients with multivessel disease.

Methods. Both ITAs were thoracoscopically harvested using video imaging. Limited bilateral anterior thoracotomies were performed in the fourth intercostal spaces, thus exposing the right coronary artery and the left anterior descending coronary artery. The right ITA–right coronary artery and ITA–left anterior descending coronary artery anastomoses were performed without cardiopulmonary bypass using 8-0 polypropylene sutures.

Results. This procedure was successfully performed in 3 patients. The patients were extubated in the operating room. Postoperative angiographic studies showed patent left ITA and right ITA grafts.

Conclusions. Bilateral thoracoscopic minimally invasive direct coronary artery bypass grafting can be used to treat patients with a proximally diseased left anterior descending coronary artery and right coronary artery. Bilateral thoracoscopic ITA harvesting is a less invasive surgical technique that may become an option for the management of multivessel coronary artery disease.     

Surgical therapy of paroxysmal atrial fibrillation with the "corridor" operation.

Patients with paroxysmal atrial fibrillation may be extremely disabled despite medical therapy. Based on recent concepts of atrial fibrillation, a surgical open heart procedure was designed to isolate a "corridor" from the right and the left atrium. The corridor consists of the sinus node area, the atrioventricular nodal junction, and the connecting right atrial mass, small enough to prevent atrial fibrillation. Between 1987 and 1990, 20 patients with severely disabling symptoms due to frequent paroxysmal atrial fibrillation underwent the corridor operation, with permanent success in 16 patients. In 8 patients, left atrium to corridor conduction reappeared shortly after the procedure. Reoperation was performed in these patients without extracorporeal circulation. The site of persistent conduction between the left atrium and the corridor could consistently be localized adjacent to the coronary sinus. Nevertheless, reoperation failed to isolate permanently the corridor in 4 patients. During a mean follow-up of 20 months, atrial fibrillation dominating the ventricles was never observed nor inducible in the corridor in the 16 patients with a successful operation. In all cured patients, sinus node function remained undisturbed. Paroxysmal atrial flutter inside the corridor arose in 1 patient and a paroxysmal focal tachycardia in another. All 16 cured patients experienced a clear improvement in quality of life. Refinement of the surgical technique to obtain persistent isolation between the left atrium and the corridor is needed. These results demonstrate that the concept of the corridor operation is sound and justify its use in the treatment of drug-refractory paroxysmal atrial fibrillation.     

Diagnosis of hyper- and hypomotility of the upper cervical spine using functional computerized tomography

At present, there are few methods that are of any assistance in evaluating the ligaments of the upper cervical spine. It is obvious that a lesion of these ligaments could result in instability of the cranial cervical junction. Nine healthy adults and 45 patients with suspected rotatory instability of the upper cervical spine after trauma were examined using functional CT-scans. After CT scans of the upper cervical spine had been obtained with the patient in a neutral position, the head was passively rotated to the left and right and held in these positions by adhesive tape. CT scans were performed for the left and right rotation. The range of axial rotation was measured in relation to the neutral position at the level of the occiput, atlas and axis using identical bony landmarks. A mean rotation of 4.2 degrees to the right and 3.8 degrees to the left was measured at the occiput/atlas level. The mean difference between left and right rotation in individual patients was 2 degrees. The mean rotation of C1-2 was 41.8 degrees to the right and 44.3 degrees to the left. The mean difference between left and right rotation was 2.8 degrees. A 98% confidence interval for allocating a pathological case to the distribution of healthy adults was defined. According to this rule, occiput/atlas rotation of 8 degrees or more, C1-2 rotation of 56 degrees or more, a left/right OCC/C1 difference of 5 degrees or more and a left/right C1-2 difference of 8 degrees or more were considered to be pathological.(ABSTRACT TRUNCATED AT 250 WORDS)