Shouldice手术治疗腹股沟疝的整形评价

Shouldice手术在国外已盛行多年,近年来在国内也是益被外科界所推崇[1].作者根据临床百例的实践结合文献对本术式作一介绍和评价.     

INGUINAL HERNIA REPAIR: A COMPARISON BETWEEN LOCAL AND GENERAL ANAESTHESIA

Background : A comparative analysis of outcomes of inguinal hernia repair performed under local (LA) and general anaesthesia (GA) by a single surgeon using a standardized technique of anterior transversalis repair was performed. Ninety-three cases were examined, 56 of which were cases of LA hernia repair. Methods : A retrospective analysis of the patient hospital record was performed with particular attention to intra-operative and postoperative analgesia requirements. Results : An overall series complication rate of 6.5% (6/93) is reported. Only one of 56 LA patients (2%) required more than 24 h of narcotic analgesic injections compared to 11% (4/37) in the GA group (P < 0.05). The mean total postoperative parenteral narcotic requirement in the LA group was 86 ± 14 mg of pethidine as compared to the GA group who had a mean total requirement of 121 ± 17 mg of pethidine (P > 0.08). Conclusions : The LA infiltration technique is an effective method for inguinal hernia repair. This series demonstrates benefits in terms of length of hospital stay and a lower incidence of postoperative parenteral narcotic analgesic requirement although when postoperative parenteral narcotics were required by the LA group of patients, the difference in mean total pethidine requirement was not statistically significant.     

INGUINAL HERNIA REPAIR BY LAPAROSCOPIC SURGEONS: EARLY EXPERIENCE AND ATTITUDES

The introduction of laparoscopic inguinal hernia repair (LIHR) has been controversial. A questionnaire was sent to all general surgeons in New Zealand to document the early experience with LIHR and attitudes towards it. Of the 118 replies (response rate 55%). 74 were from laparoscopic surgeons. 26 of whom had performed 564 (201 public. 363 private) LIHR (23 bilateral) until January 1994. Only nine (35%) of these surgeons had assisted an experienced surgeon before performing an LIHR. and only four (15%) were supervised by an experienced surgeon during their first case. The transabdominal preperitoneal technique of LIHR was used by 14 (54%) surgeons. the extraperitoneal technique by eight (31%), and the tronsabdominal onlny technique by four (15%). There were 29 (5%) recurrences, 17 (3%) neuropathies. seven (1.2%) conversions, four (0.7%) miijor perforations. and one (0.17%) death. Of the 26 surgeons who performed LIHR, 20 (77%) were concerned about the absence of long-term results. 14 (54%) considered that the optimal technique had not been established. 13 (50%) were concerned about the unique complications associated with LIHR. 11 (42%) were less enthusiastic about performing LIHR than previously. 10 (38%) were doubtful about its advantages, and six (23%,) were uncertain about its future and considered that it should only be performed within the context of a controlled trial. This study highlights a number of issues that need to be addressed before the role of LIHR can be determined.     

直肠癌Miles术后并发盆腔腹膜疝的预防和诊治

目的 探讨直肠癌Ｍｉｌｅｓ术后空腹膜疝（ＰＰＨ）的原因、预防和诊治。方法 对我院自１９９６年１月至１９９９年６月间收治的直肠癌Ｍｉｌｅｓ术后并发ＰＰＨ１１例进行回顾性分析。结果 Ｍｉｌｅｓ术后并发ＰＰＨ的发生率为３．６％（１１／３０９）,表现术后不同程度的腹胀,阵发性腹痛３例,呕吐２例,胃管引流液每天超过５００ｍｌ者３例,结肠造瘘口无排气排便１１例,其中２例会阴部引流管引流液为淡绿色小肠液;腹部轻     

大段异体骨关节移植的关节功能重建和术后康复

目的 探讨肢体恶性肿瘤切除后行大段同种异体骨关节移植、骨与软组织的修复重建及术后肢体功能康复的方法。方法 1992年5月－1999年1月,对90例肢体恶性骨肿瘤患者行瘤段切除后,应用不同内固定方式行深低温冷冻异体骨关节移植,术后随访时间18－89个月,平均37．5个月。依据Enneking肢体恶性肿瘤保肢术后功能评价标准进行判定。结果 ①皮肤坏死、早期感染、异体骨骨折及骨不连等是影响术后肢体功能康复的主要术后并发症;②90例患者后肢体功能优良率为73．3％,其中髋关节、膝关节异体骨关节移植术后肢体功能优于肩关节,异体骨段移植优于异体半关节移植,内锁髓内钉固定、异体骨段复合人工关节置换术优于普通的自制内锁髓内钉和加压钢板固定;③术后早期进行功能锻炼,利于肢体康复。结论 选择合适的手术适应证和内固定、完善的软组织修复重建及术后早期行肢体康复训练,大段异体骨关节移植可获得良好的肢体功能康复。     

SCREENING AND MONITORING FOR BLADDER CANCER: REFINING THE USE OF NMP22

PURPOSE: While detecting bladder cancer, bladder tumor markers demonstrate improved sensitivity compared with urinary cytology but the current limitation is the low specificity and positive predictive value, that is high false-positive rate. We examined the clinical categories of the false-positive results, established relative exclusion criteria, and recalculated the specificity and positive predictive value of this assay with these criteria. MATERIALS AND METHODS: A total of 608 patients considered at risk for bladder cancer presented to a urology clinic and submitted a single urine sample. Of the 608 patients 529 (87%) presented with de novo hematuria or chronic voiding symptoms without a diagnosis of bladder cancer. There were 79 (13.0%) patients being monitored with a known history of bladder cancer. Each urine sample was examined via cytology, urinalysis, culture and NMP22 protein assay. All patients underwent office cystoscopy, and transurethral resection and/or biopsy if a bladder tumor was suspected. RESULTS: Of the 608 patients 226 (37.2%) presented with microscopic hematuria, 143 (23.5%) with gross hematuria and 239 (39.3%) had chronic symptoms of urinary frequency or dysuria. There were 52 (8.6%) patients who had histologically confirmed bladder cancer. Of these 52 cancers NMP22 detected 46 (88.5%), whereas cytology identified only 16 (30.8%). When atypical cytology was considered positive, cytology detected 32 (61.5%) cases. In the 135 patients with increased NMP22 values the 46 identified tumors were accompanied by 89 false-positive values yielding a specificity of 83.9% and a positive predictive value of 34.1%. These false-positive results were divided into 6 clinical categories. Exclusion of these categories improved the specificity and positive predictive value of NMP22 to 99.2% and 92.0%, respectively, yielding results similar to urinary cytology (99.8% and 94.1%). CONCLUSIONS: Awareness and exclusion of the categories of false-positive results can increase the specificity and positive predictive value of NMP22, enhancing the clinical use of this urinary tumor marker.     

干细胞:组织器官重建的理想种子细胞

目的阐述干细胞在组织器官重建中的重要性.方法根据研究成果,结合国内外文献,综述干细胞作为细胞治疗及组织工程的种子细胞应用的最新进展.结果干细胞是人体及其各种组织细胞的最初来源,具有高度自我更新能力、高度增殖和多向分化潜能、可植入性和重建能力等特征.无论胚胎干细胞还是成体干细胞均可作为良好的种子细胞,用来进行修复重建外科领域损伤的组织器官的修复和重建治疗,具有广阔的临床应用前景.结论干细胞在组织、器官的修复与功能重建中发挥重要作用,具有广泛的应用前景.深入研究及推广应用,将会大幅度提高临床治疗效果.     

游离髂骨重建跖骨缺损的三维有限元及临床分析

目的 了解1～3跖骨缺损以髂骨重建后对足功能的影响。方法 在足骨骼三维模型上模拟1～3跖骨50％及100％缺损，采用髂骨重建，以有限元法计算得到的最大位移及最大应力为指标，分别评估跖骨缺损和重建后足的位移及应力。分析1996年3月～2003年1月5例跖骨缺损以游离带血管髂骨串联皮瓣重建后的疗效。结果 1～3跖骨缺损对足功能影响较大，与完整足相比较，缺损100％最大位移增加2．15倍，最大应力增加2．12倍；缺损50％最大位移增加1．65倍，最大应力增加2．05倍。模拟髂骨块重建跖骨缺损100％及50％后，最大应力及最大位移与正常数值相近。临床应用的5例，术后骨瓣及皮瓣均成活，随访1～2年。按Maryland足功能评价：优2例，良2例，可1例。结论 1～3跖骨缺损应修复，游离髂骨串联皮瓣移植是较为理想的手术方式。     

HELLP SYNDROME: A CASE REPORT WITH GUIDELINES FOR DIAGNOSIS AND MANAGEMENT

A 25-yr-old patient with a twin pregnancy of 34 weeks gestationdeveloped HELLP syndrome and required urgent delivery by Caesareansection. Before operation, a central venous catheter and urinarycatheter were inserted, and fresh frozen plasma and plateletswere administered to correct hypovolaemia and severe thrombo-cytopenia.This case demonstrates the critical condition of these patientsbefore operation and that extensive preoperative preparationand invasive monitoring are necessary for successful management.The choice of anaesthetic is governed by the presence of liverand renal dysfunction and severe thrombocytopenia.     

异体骨关节移植后骨愈合的X线形式及影响因素

目的探讨肢体恶性肿瘤接受大段同种异体骨关节移植后和异体骨愈合在X线的表现及影响因素，以改进手术方法。方法1992年5月～1999年3月，对收治的90例中可纳入统计的85例骨恶性肿瘤在手术切除长段骨关节后，应用不同内固定方式进行异体骨关节移植，其中16例保留髁部关节面的异体骨段移植，57例异体关节移植，9例复合异体骨段人工髋关节置换，3例膝关节置换。术后平均随访2年9个月，以X线片表现判定骨愈合方式，依据Enneking肢体恶性肿瘤保肢术后的肢体功能标准，评价手术结果。结果85例101处异体骨与自体骨接合部有91处达到临床骨愈合。根据X线片表现特征，异体骨与自体骨间有4种愈合方式，其中以断端周围形成外骨痴、同时植骨间隙逐渐消失最多见；内固定不牢固是引起术后骨不愈合的主要原因；异体骨周围软组织覆盖、血供差及大段异体骨移植后诱发的免疫排异反应等可能影响骨愈合；远离异体骨与自体骨结合部的肿瘤复发或感染、不同长度的异体骨对骨愈合无肯定的负作用；选用牢固的髓内固定、断端周围植骨及采用骨膜袖套技术可减少术后骨不愈合的发生。结论大段异体骨关节移植后骨愈合有不同的X线片表现形式。手术设计应为异体骨提供充足的血液供应、牢固的内固定支撑和完善的软组织覆盖。