应用人工材料——Marlex网修补腹壁缺损

目的：总结应用人工材料聚丙烯网修补腹壁缺损。方法：通过手术修补腹壁缺损：其中切口疝１３例,腹股沟疝３２例,腹壁肿瘤１９例。结果：术后切口感染１例,皮下积液３例,其余病例切口Ⅰ期愈合。随诊４１例,未发现疝的复发和形成。结论：认为聚丙烯网是一种理想的修补腹壁缺损的材料。     

Costs and outcomes of inpatient versus outpatient hernia repair

This study sought to compare treatment costs and outcomes for a large number of Medicare patients undergoing inpatient versus outpatient hernia repair around the country. Medicare physician and hospital claims were obtained for all Medicare enrollees residing in eleven states in 1987 and 1988, in order to take advantage of geographic variation in treatment location. All patients undergoing uncomplicated inguinal hernia repair were identified from the surgeon's bill; the location of surgery was then validated by the facility bill (n = 27,036). Over one-third of all hernia repairs in our sample were performed on an ambulatory basis, but with tremendous variation across states, ranging from 89.9% of cases in Washington in outpatient settings to almost none (6.3%) in Georgia. Treatment costs were 56% higher for hernias repaired on an inpatient basis, $2341 versus $1505 for those performed in outpatient settings. There were no detectable differences between inpatients and outpatients along such outcomes as complication rates, deaths and hernia recurrence, but readmission rates were higher for inpatients. The dramatic differences in costs, along with the apparent absence of adverse outcomes, suggests that Medicare should actively encourage surgeons to perform more hernia repairs on an outpatient basis.     

腹股沟疝应用Lichtenstein术式42例体会

目的:探讨成人腹股沟疝Lichtenstein术式的疗效.方法:对42例腹股沟疝病人行Lichtenstein术式无张力修补术的临床资料进行回顾性分析.结果:患者平均住院天数6.7天.42例均得到随访,平均随访7个月,有1例复发.病例术后疼痛较轻,术后发生阴囊肿胀6例,并发尿潴留10例,无切口感染及其它并发症.结论:Lichtenstein无张力修补术适用于各型成人腹股沟疝,术后疼痛轻微,复发率低.     

Wound infections due to Mycobacterium fortuitum after polypropylene mesh inguinal hernia repair

Mycobacterium fortuitum complex is a group of rapidly growing mycobacteria (RGM). These opportunistic pathogens are frequently associated with infections related to surgical procedures involving biomaterials. Two cases of Mycobacterium fortuitum infection occurred in a prospective study of inguinal hernia prosthesis repairs. These infections differed from those caused by other bacteria in terms of pathogenic mechanisms, clinical manifestation and resistance to both prophylactic and therapeutic antibiotics.     

Inguinal Hernia Repair in Older Persons

Groin hernia repair is one of the most common surgeries performed in the United States, with more than 700,000 performed every year. These repairs are commonly performed in an elective setting to alleviate symptoms and prevent obstruction and/or strangulation. Prior studies have demonstrated that watchful waiting is a reasonable option compared with surgery, because of the low risk of life-threatening complications from groin hernias. However, other studies have demonstrated that there is increased risk of mortality after surgery in older persons (age ≥65 years). Therefore, the question is if and when older patients should pursue groin hernia repair. In this article, we provide an evidence-based overview on the management and treatment of inguinal hernia repair in older persons. Focusing on which patients should be repaired, the optimal timing of surgery, what is the best anesthesia, how the repair should be performed, and the importance of understanding frailty should help surgeons and primary care physicians determine the best management of inguinal hernias in older adults.     

Can a surgical treatment centre reduce waiting lists? Results of a natural experiment.

STUDY OBJECTIVE--To determine the effectiveness of the Welsh general surgery (hernia and varicose veins) treatment centre established as part of the NHS reforms, in terms of its impact upon throughput and waiting lists. DESIGN--This was a natural experiment with two control groups--other surgical specialties without treatment centre provision, and general surgery in districts that made only minor use of the facility. SETTING--General Surgery Treatment Centre, Bridgend General Hospital. SUBJECTS--All patients referred between 1 April 1990 and 31 March 1991. MEASUREMENTS AND MAIN RESULTS--Main outcome measures were throughput for hernia and varicose vein operations, non-urgent inpatient waiting list lengths before and after the opening of the centre and patient satisfaction. Altogether 1097 patients were referred during the year. Of these, 160 (15%) did not attend outpatient assessment and 79 (8%) of those who did were unsuitable for surgery. A total of 750 operations were performed--448 (60%) for varicose veins and 261 (35%) hernia repairs. Among the residents of the four main districts using the centre (with valid data available), there was a significant increase in the total number of varicose vein operations performed but no significant increase in hernia repairs. In the six districts that made major use of the centre, general surgery waiting lists for non-urgent cases fell significantly (p < 0.0001) while those for ear, nose, and throat showed no significant change and gynaecology lists lengthened significantly (p < 0.0001). In the three districts that made minor use of the centre general surgery waiting lists showed no change. CONCLUSIONS--Relations between inputs and waiting lists are often unpredictable, but after controlling for confounding trends there is sound evidence that such a centre provides an acceptable and effective approach to the waiting list problem.     

Fascinating history of groin hernias: Comprehensive recognition of anatomy,classic considerations for herniorrhaphy,and current controversies in hernioplasty

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.     

Ambulatory surgery utilization by age level.

We compared ambulatory and inpatient surgery utilization by age level for procedures known to be frequently performed on an ambulatory basis. Our scope of data was the Crouse Irving Memorial Hospital in Syracuse, New York during 1984. The hospital operates one of the largest freestanding ambulatory surgery programs in the United States. The study included 8,348 ambulatory procedures, 42 per cent of all operations performed under the aegis of this institution. At the aggregate, the inpatient surgery included a somewhat lower proportion of young adults and a higher proportion of individuals aged 65 and over did outpatient surgery. For specific procedures, however, age distributions differed. Ambulatory procedures included lower percentages of elderly than did inpatient utilization for inguinal hernia repair, carpal tunnel release, destruction of larynx lesions, hernia repairs, destruction of skin lesions, and other operations, while ambulatory utilization for lens procedures included higher percentages of elderly patients than did inpatient utilization. Physician practice patterns also appeared to influence the setting of certain procedures. The study data suggested that persons involved in health planning should evaluate ambulatory surgery use on an age and procedure-specific basis, and utilization review should evaluate procedures on a case-by-case basis.     

¿Sirven los estudios de variabilidad geográfica de la práctica para informar la desinversión? Varias cautelas y algunas reflexiones

Objective

Disinvestment has been defined as the explicit process of cutting funding, either totally or partially, from health technologies deemed of low-value. Studies of geographic variation in medical practice have been suggested to be useful in guiding decisions on disinvestment, as they may identify unwarranted variations in procedure-rates at the population level. This study aimed to determine the utility of these studies.

Methods

We performed an ecologic study of variations in standardized rates in four «low-value» interventions: proctologic surgery, arthroplasty revision, incisional hernia repair and tonsillectomy. Variation across 199 healthcare areas within the Spanish national health system between 2002 and 2007 was studied by using the extremal quotient (EQ), the empirical Bayes statistic (EB) and the standardized utilization ratio (SUR).

Results

A total of 168,363 proctologic interventions, 41,066 arthroplasty revisions, 222,427 incisional hernia repairs, and 72,724 tonsillectomies were studied. The EQ ranged from a 3-fold variation in proctologic surgery to a 6.5-fold variation in tonsillectomy. The EB figures varied from moderate to high systematic variation: 0.12 in hernia repair and proctology, 0.20 in arthroplasty revision, and 0.30 in tonsillectomy. Twenty-five percent of the healthcare areas showed SUR figures above 1.24 in proctologic interventions, 1.25 in arthroplasty revision, 1.32 in hernia repair and 1.35 in tonsillectomy.

Conclusions

The interventions studied showed moderate to high systematic variation, supporting the usefulness of variation studies in guiding disinvestment policies. Nevertheless, caution should be exercised when evaluating interventions with an uncertain risk-benefit ratio.     

A community-based analysis of ambulatory surgery utilization.

We conducted a study to determine the utilization level for ambulatory surgery and the proportions of specific procedures which could be performed in certain ambulatory settings in one community, Syracuse, New York, which has used this service extensively. It was estimated that, in 1983, 26.9 surgery cases per 1,000 population in Syracuse were performed in ambulatory settings. This level amounted to approximately 37 per cent of hospital-based surgery in the area. Analysis of surgery utilization in two hospital-integrated and freestanding ambulatory surgery facilities indicated that more than 95 per cent of myringotomies, tonsillectomies, and adenoidectomies as well as substantial proportions of carpal tunnel releases, lens extractions, sterilizations, circumcisions, and inguinal hernia repairs in these two facilities were performed in ambulatory settings. The availability of dedicated facilities and full-time staff produced higher utilization for these procedures in freestanding facilities. The utilization levels for individual procedures identified in the study can be employed in the planning of hospital-integrated and freestanding programs.     

垃圾填埋作业机械现场抢修研究及应用

要搞好垃圾填埋作业机械现场的抢修工作，就须注意以预防为主，提高填埋作机械的利用率，介绍了现场抢抢修与平时送修的区别及现场抢修的主要方法。     

Choice of hip prosthesis in patients younger than 50 years

There is no agreement about the most ideal type of hip prosthesis to be used in patients younger than 50 years. The most commonly used hip prostheses in patients younger than 50 years are uncemented or resurfacing prostheses and to a lesser extent cemented prostheses. A good result of a hip prosthesis can be defined as follows: 10 years after surgery more than 90% of the prostheses should be still in situ during endpoint revision for any reason. No trials are available comparing cemented, uncemented or resurfacing hip prostheses. Studies are available of cemented hip prostheses in patients younger than 50 years that prove that more than 90% of the hips are still in situ after 50 years. There are no studies available of uncemented or resurfacing hip prostheses in younger patients that prove that after to years of follow-up 90% or more of the prostheses are still in situ. The Scandinavian hip registers show that the highest rate of prostheses still in situ after 10 years is achieved by cemented hip prostheses.     

Estimating effects of moisture damage repairs on students' health-a long-term intervention study

Health symptom questionnaire responses were collected from upper secondary and high school students (n=245) before comprehensive repairs of moisture damage in the school. The questionnaire study was repeated 1 year (n=227), 3 years (n=256), and 5 years (n=233) after the repairs. The data were analyzed both in cross-sectional design including all respondents, and longitudinally including paired observations of those individuals who had responded both before and after the repairs. In addition, the effect of intervention on health symptoms was analyzed using generalized estimating equations (GEEs), taking into account within-subject correlation between repeated measurements. Compared to the situation before the repairs, the situation after the repairs was significantly improved in most of the 20 symptoms studied among the cross-sectional study populations. However, improvement was not so clear in the paired analysis and GEE analysis among the students who responded to three repeated questionnaires. The results indicate that the repairs succeeded in the sense that new cases of symptomatic students were no longer expected. However, the reversibility of symptoms among the group of exposed individuals may need to be considered separately.     

多层肉膜血管蒂覆盖尿道板切开卷管术式治疗尿道下裂

目的探讨多层肉膜血管蒂覆盖尿道板切开卷管尿道成型术治疗尿道下裂的疗效。方法2006年1月～2009年1月,56例尿道下裂采用尿道板皮下层、阴茎体两侧的筋膜、阴茎体及阴囊的跟斗皮瓣及左右两层背侧包皮血管蒂覆盖成形尿道的方法治疗尿道下裂,观察尿道下裂术前尿道口位置、手术年龄、术后并发症等情况。结果术后随访6月～3年,术后尿瘘5例,无明显尿道狭窄及尿道憩室病例。结论改良Snodgrass术式是治疗尿道下裂较好的术式,该术式成功率高,外形美观,值得推广应用。     

无张力修补术治疗腹外疝的效果及应用优势探究

目的：研究无张力修补术治疗腹外疝的效果及应用优势。方法：研究资料来源于我院2014年2月—2015年9月期间收治腹外疝患者65例,根据随机数字表法,分为2组,无张力疝修补组和传统疝修补组。传统疝修补组行传统疝修补术;无张力疝修补组行无张力修补术。就两组患者手术操作所需时间、术中失血量、下床活动时间、住院天数和并发症出现率进行比较。结果：无张力疝修补组并发症出现率低于传统疝修补组,P＜0.05。无张力疝修补组患者手术操作所需时间、术中失血量、下床活动时间、住院天数均少于传统疝修补组,P＜0.05。结论：无张力修补术治疗腹外疝的效果确切,创伤小,出血少,手术操作简单,可减少并发症,缩短住院时间,值得推广。     

Centralisation of services for children with cleft lip or palate in England: a study of hospital episode statistics

ABSTRACT: BACKGROUND: In 1998, a process of centralisation was initiated for services for children born with a cleft lip or palate in the UK. We studied the timing of this process in England according to its impact on the number of hospitals and surgeons involved in primary surgical repairs. METHODS: All live born patients with a cleft lip and/or palate born between April 1997 and December 2008 were identified in Hospital Episode Statistics, the database of admissions to English National Health Service hospitals. Children were included if they had diagnostic codes for a cleft as well as procedure codes for a primary surgical cleft repair. Children with codes indicating additional congenital anomalies or syndromes were excluded as their additional problems could have determined when and where they were treated. RESULTS: We identified 10,892 children with a cleft. 21.0% were excluded because of additional anomalies or syndromes. Of the remaining 8,606 patients, 30.4% had a surgical lip repair only, 41.7% a palate repair only, and 28.0% both a lip and palate repair. The number of hospitals that carried out these primary repairs reduced from 49 in 1997 to 13, with 11 of these performing repairs on at least 40 children born in 2008. The number of surgeons responsible for repairs reduced from 98 to 26, with 22 performing repairs on at least 20 children born in 2008. In the same period, average length of hospital stay reduced from 3.8 to 3.0 days for primary lip repairs, from 3.8 to 3.3 days for primary palate repairs, and from 4.6 to 2.6 days for combined repairs with no evidence for a change in emergency readmission rates. The speed of centralisation varied with the earliest of the nine regions completing it in 2001 and the last in 2007. CONCLUSIONS: Between 1998 and 2007, cleft services in England were centralised. According to a survey among patients' parents, the quality of cleft care improved in the same period. Surgical care became more consistent with current recommendations. However, key outcomes, including facial appearance and speech, can only be assessed many years after the initial surgical treatment.     

无张力疝修补术40例疗效观察

目的探讨对腹股沟疝患者采用无张力疝修补术的手术疗效,并与传统疝修补术的手术效果作比较。方法入选的80例腹股沟疝患者,根据手术方法随机分为治疗组40例;无张力腹股沟疝修补,对照组40例;传统疝修补手术,比较2组的手术观察指标。结果无张力疝修补术比传统疝修补术手术用时短,术中出血少,术后下地活动时间早,术后无复发且无切口无感染等并发症发生,住院时间短(P<0.05)。结论无张力疝修补手术符合人体正常解剖结构的要求,解剖分离少,手术操作简单、损伤小、并发症少、复发率低,是腹股沟疝修补的首选方法之一,值得临床推广和应用。     

腹股沟疝无张力修补术与传统疝修补术效果比较

目的 对比腹股沟疝无张力修补术与传统修补术的优缺点,总结腹股沟疝无张力修补术经验。方法将笔者所存科室住院手术治疗的84例腹股沟疝患者随机分为两组,A组作无张力修补术,B组按传统修补方式修补。对两组手术患者的手术时间、切口疼痛程度、患者的自主能力、并发症和复发率等进行观察。结果与传统痛修补术相比,腹股沟疝无张力修补术具有方法简便、术后疼痛轻、恢复快、手术指征宽、并发症少、复发牢低的优点。结论本术式是一种更符合人体解剖结构和疝的病理生理的手术方法,易于准广应用。     

无张力疝修补术40例疗效观察

目的探讨对腹股沟疝患者采用无张力疝修补术的手术疗效,并与传统疝修补术的手术效果作比较。方法入选的80例腹股沟疝患者,根据手术方法随机分为治疗组40例;无张力腹股沟疝修补,对照组40例;传统疝修补手术,比较2组的手术观察指标。结果无张力疝修补术比传统疝修补术手术用时短,术中出血少,术后下地活动时间早,术后无复发且无切口无感染等井发症发生,住院时间短（P〈0．05）。结论无张力疝修补手术符合人体正常解剖结构的要求,解剖分离少,手术操作简单,损伤小、并发症少、复发率低,是腹股沟疝修补的首选方法之一,值得临床推广和应用。     

Dependency issues in survival analyses of 55,782 primary hip replacements from 47,355 patients

Artificial hip joints are used in only one hip for about 85 per cent of the patients and in both hips (bilateral) for about 15 per cent of the patients. The occurrence of bilateral prostheses and the influence they have in survival analyses of joint arthroplasties are seldom considered. In this study we therefore focus on issues related to bilateral primary hip prostheses, time to revision surgery, and some commonly used statistical methods. We used information from 47,355 patients with 55,782 primary hip prostheses reported to the Norwegian Arthroplasty Register between 1987 and 2000. Due to the large number of diagnoses, fixation techniques for the prostheses, and combination of prostheses brands, we furthermore considered a 'homogeneous' subset of 8703 prostheses from 7930 patients with primary osteoarthritis, and Charnley prosthesis fixed with antibiotic-containing Palacos cement. Kaplan-Meier curves for all prostheses, ignoring that some patients have bilateral prostheses, were compared with Kaplan-Meier curves using only the first inserted prostheses, and with survival curves modified for patients with bilateral prostheses. Cox regression analyses were used to assess explanatory variables and to adjust for confounding factors. The results from the ordinary Cox regression analyses were compared with results from a marginal model, a shared gamma frailty model, and a model using a time dependent covariate to condition on failures in the opposite hip. We found no practical difference between the three calculated survival curves for the hip replacement data. The ordinary Cox-model and the marginal model gave equivalent results. In the shared gamma frailty model estimates for the risk factors were comparable with the former two approaches. The estimated frailty variance was higher when all data were used, even after adjustment for confounding factors. For the 'homogeneous' data the estimated frailty variance was negligible. Using a time dependent covariate to condition on previous revisions in the opposite hip, we found a higher risk of revision for the remaining primary hip prosthesis if the opposite hip had been revised (RR = 3.49, p < 0.0001). There was no difference in risk for revision between right and left hip prostheses. If the time interval between the two primary operations was more than two years, for the full data, the first hip prosthesis had an increased risk of revision compared to prostheses in patients with only one prosthesis (RR = 1.25, p = 0.01). For the 'homogeneous' data no statistically significant difference was found between unilateral and bilateral prostheses. A revision in one hip, for patients with bilateral prostheses, is a risk factor for revision of the other hip. Thus, in analyses of prostheses survival, dependencies between two hip prostheses from one patient should be considered. However, ignoring possible dependencies does not necessarily have an impact on the results on standard risk factors.