大动脉转位术后吻合口生长的随访研究

目的随访分析大动脉转位术（ASO）后的主动脉（AO）、肺动脉（PA）吻合口生长情况,以了解ASO术后的长期疗效。方法回顾性分析自1999年12月至2007年12月上海交通大学医学院附属上海儿童医学中心施行ASO 331例患者的相关资料,其中完全性大动脉错位合并室间隔完整型（TGA／IVS）111例,完全性大动脉错位合并室间隔缺损（TGA／VSD）123例,右心室双出口伴肺动脉瓣下室间隔缺损、肺动脉高压（Taussig-Bing）73例,快速二期大动脉转位术（Stage-Switch）24例。随访228例,随访时间20．4±18．6个月;随访超声心动图报告752张,平均每例随访3．3次。根据超声心动图所测AO、PA吻合口直径大小,分析吻合口的生长情况。结果TGA／IVS患者AO、PA吻合口直径（近期为0．74±0．17cm和0．65±0．13cm,远期1．09±0．31cm和0．84±0．21cm）,TGA／VSD患者AO、PA吻合口直径（近期为0．76±0．20cm和0．63±0．14cm,远期为1．09±0．24cm和0．82±0．22cm）,Taussig-Bing患者AO、PA吻合口直径（近期为0．84±0．25cm和0．74±0．20cm,远期为1．05±0．30cm和0．85±0．24cm）远期较近期均有明显生长（P〈0．05）;Stage—Switch患者AO吻合口直径（近期为0．93±0．19cm,远期为1．19±0．29cm）远期相对于近期有明显生长（P〈0．05）,PA吻合口直径（近期为0．90±0．27cm,远期为1．00±0．32cm）远期较近期有生长,但差异无统计学意义（P〉0．05）。随访至2008年11月,共有6例患者因左、右心室流出道梗阻而需再次手术,术后有3例无残余梗阻,3例仍有残余梗阻。结论ASO的主动脉和肺动脉离断再缝合连接之后,血管能够随着年龄增加而生长,但也会发生狭窄。在长期随访中,有个别患者需要再次手术干预。     

影响大动脉转位术死亡率的危险因素分析

目的分析大动脉转位术（arterial switch operation，ASO）治疗完全性大动脉错位（complete transposition of the great arteries，TGA）的手术结果，探讨影响死亡率的危险因素。方法收集2003年1月至2004年12月期间，我院对67例TGA患者施行ASO的临床资料，包括住院病历、超声心动图和手术记录。应用x^2检验和logistic多变量回归分析对患者的手术年龄、体重、诊断、冠状动脉分型、体外循环时间、主动脉阻断时间、停循环时间、术后呼吸机辅助时间、延迟关胸等因素进行统计分析，分析影响死亡率的危险因素。结果施行ASO的67例TGA患者中，围手术期死亡5例（7．5％）。单变量分析结果表明，影响ASO死亡率相关的危险因素有：年龄（P=0．004）、体重（P=0．042）、冠状动脉分型（P=0．006）和体外循环时间（P=0．048）。伴有室间隔缺损（ventricular septal defect，VSD）的患者（TGA／VSD）术后住心脏监护室（CICU）时间（P=0．004）和术后住院时间（P=0．007）明显长于室间隔完整（intact ventricular septum，IVS）的患者（TGA／IVS）。logistic多变量回归分析结果表明，患者手术时年龄（P=0．012）、冠状动脉畸形（P=0．001）和较长的体外循环时间（P=0．002）是影响ASO死亡率的危险因素。结论对TGA患者及时施行ASO可获得良好的临床效果，患者手术时年龄、冠状动脉畸形和较长的体外循环时间是影响死亡率的危险因素。     

快速二期动脉转位术后患者左心室功能和主动脉瓣反流的远期随访

目的通过对快速二期动脉转位术(ASO)的长期随访,探讨其远期并发症和预防措施。方法随访研究2002年9月至2007年9月期间上海儿童医学中心21例行快速二期动脉转位术患者的临床资料,其中男13例,女8例;手术年龄75 d(29~250 d),体重5 kg(3.5~7.0 kg)。对患者的左心功能锻炼期资料和二期动脉转位术术中和术后数据进行统计分析,并采用logistic逐步回归分析方法筛选对术后远期主动脉瓣反流加重的危险因素。结果术后远期肺动脉和主动脉吻合口直径较术后早期有所增加(0.96±0.30 cm vs.0.81±0.28 cm,t=-1.183,P=0.262;1.06±0.25 cm vs.0.09±0.21 cm,t=-1.833,P=0.094),但差异无统计学意义。术后远期肺动脉和主动脉吻合口血流速度无明显增快,说明吻合口无梗阻。术后远期心功能较术后早期有所改善,但左心室射血分数(LVEF)值的变化差异无统计学意义(62.88%±7.28%vs.67.92%±7.83%,t=1.362,P=0.202);术后早期与术后远期比较左心室舒张期末直径(LVDd)差异有统计学意义(2.16±0.30 cm vs.2.92±0.60 cm,t=-5.281,P=0.003),术后远期左心室舒张期末后壁厚度(LVPWT)较术后早期略有增长(0.39±0.12 cm vs.0.36±0.10 cm,t=0.700,P=0.500),但差异无统计学意义。术后远期随访中发现,主动脉瓣反流程度有4例(30.77%,4/13例)较术前加重,7例无变化,2例较术前减轻,反流程度均未达到中度以上。logistic回归分析结果显示:术前较小的Ao/PA瓣窦直径比值、较长的随访时间与术后主动脉瓣反流加重有关。结论快速二期动脉转位术后主动脉瓣反流发生率较高,远期无死亡,无再手术,生存情况良好,但仍需定期随访,密切观察吻合口和主动脉瓣的关闭情况。     

两种不同手术方式矫治完全性大动脉错位伴有室缺和肺动脉狭窄的效果分析

目的 回顾性分析两种不同手术方式矫治完全性大动脉错位(TGA)伴有室间隔缺损(VSD)和肺动脉狭窄(PS)的效果.方法 对46例TGA/VSD/PS的患者进行手术矫治,其中采用主动脉根部移位/重建双室流出道术,即Nikaidoh术27例(N组),Rastelli手术19例(R组).N组采用自身心包补片重建右室流出道(RVOT),其中1例用同种异体带瓣管道Homograft;R组使用Homograft重建RVOT.两组均无手术前姑息手术史.结果 N组因术后严重心功能衰竭死亡1例(3.7%),R组无死亡.术后早期并发症的发生率两组相近.手术平均年龄N组(16.3±16)个月,R组(51±20)个月,N组明显小于R组(P=0.028).N组术后无明显残余左、右心室流出道梗阻(LVOTO、RVOTO),而R组有37%患者分别存在LVOTO或RVOTO(P＜0.05),但N组术后89%患者存在轻-中度肺动脉血反流现象,R组仅1例患者存在轻度反流(P＜0.05),两组手术早期心功能状况差异无统计学意义;随访期两组均无死亡,但R组有4例(23.6%)因LVOTO、RVOTO再手术治疗.结论 Nikaidoh术矫治TGA/VSD/PS患者,在解剖上更胜一筹,适宜于小的年龄患者.     

华西医院开设胸外科术后随访护士门诊

近日,华西医院胸外科术后随访门诊在门诊部正式开诊。华西医院胸外科以收治肺癌、食管癌和胸外伤患者为主,2010年手术量已突破2 000台,属于全国领先地位。2009年我们就将快速康复理念引入术后患者的治疗、护理中,胸外科患者手术后平均     

减重代谢外科术后随访的挑战与对策

正减重代谢外科近年来获得了广泛认可和接受,在中国大陆减重代谢手术例数逐年增长,2020年总手术例数超过14000例~([1]),手术方式仍然以袖状胃切除术为主,减重代谢外科不同于肿瘤外科,根据ASMBS的声明,评价减重代谢外科的效果主要依据手术目的、评估术后不同年限的多余体重减少率(EWL)、2型糖尿病缓解率以及合并疾病的缓解情况~([2])。减重代谢外科的随访工作尤其重要。     

伴左心室流出道梗阻的完全性大动脉转位行动脉调转术后左心室流出道及主动脉瓣功能随访

目的探讨伴左心室流出道梗阻的完全性大动脉转位患者行动脉调转术后,左心室流出道梗阻的改善情况及主动脉瓣功能情况。方法 2002~2013年共549例患儿于阜外心血管病医院行动脉调转术,其中42例患者合并左心室流出道梗阻,其中男31例、女11例,中位月龄12个月(7 d至96个月);中位体重6.5(3.5~26.0)kg,外周经皮血氧饱和度52%~85%;左心室流出道病变类型包括肺动脉瓣异常,瓣下隔膜,隧道样狭窄,肌性狭窄,附属瓣膜组织及复合病变。术中根据病变类型采取不同方法:瓣交界粘连行交界切开,瓣下隔膜予以切除,单纯肌性狭窄则切除肥厚肌束或部分室间隔,环形或隧道样狭窄则切除纤维组织和肥厚肌肉,副瓣样组织或无功能腱索,予以切除,通过室间隔缺损跨越至左心室的腱索,切下重植。结果平均体外循环时间147~344(193.5±73.1)min,主动脉阻断时间139(109~305)min,呼吸机使用时间36(3~960)h,住ICU时间5(1~48)d。体外膜式氧合(ECMO)辅助3例,均成功撤除。早期死亡2例,1例为多器官功能衰竭,1例为严重感染。随访期间死亡1例,原因不明,失访3例,接受随访患者36例,随访时间24(3~116)个月;再发左心室流出道梗阻1例,为瓣下局限增厚纤维组织所致,新主动脉瓣轻度狭窄1例,新主动脉瓣少量反流11例,中量反流2例;随访时中位左心室-主动脉压差4(2~49)mm Hg,较术前[37.2(12.1~70.6)mm Hg]有明显改善(Z=-5.153)。1年时心脏事件免除率为91%±5%,5年时为78%±8%。结论对于合并左心室流出道梗阻的完全性大动脉转位,需结合解剖情况与压差评估梗阻严重程度,指征把握恰当,行动脉调转术可获得满意的中远期效果。     

Nikaidoh术治疗完全型大动脉错位伴室间隔缺损和肺动脉狭窄的早期结果

目的回顾性研究Nikaidoh术治疗完全型大动脉错位伴室间隔缺损和肺动脉狭窄(TGA/VSD/PS)的早期结果。方法在2004年1月至2005年12月期间,有8例TGA/VSD/PS患者在我院接受Nikaidoh术矫治,手术年龄4～29个月(11.4±7.6个月),体重5.2～11.0kg(8.0±1.9kg);所有患者房室连接一致,其中伴房室瓣骑跨1例,左肺动脉狭窄1例,本组患者术前均未行其他手术,手术均采用改良Nikaidoh术,即主动脉根部移位和重建左、右心室流出道,除1例冠状动脉同时移植和使用Homograft重建右心室流出道外,用自体心包补片扩大重建右心室流出道。结果手术死亡1例,无1例出现明显左室流出道梗阻(LVOTO)和右室流出道梗阻(RVOTO),轻度肺动脉反流3例,中度4例,除1例死亡患者外,其余左心功能均正常;随访时间平均8.8个月(3～18个月),7例存活;心功能状况佳,射血分数(EF)0.64±0.02;短轴缩短率(FS)0.33±0.02。未出现进展性主动脉瓣反流、LVOTO、RVOTO和肺动脉反流加重。结论Nikaidoh术适宜于治疗TGA/VSD/PS,尤其当解剖上存在不宜行Rastelli术的患者,早期结果良好。     

《中国胸心血管外科临床杂志》检索系统收录情况

至2011年1月,我刊被11种检索系统收录：1俄罗斯《文摘杂志》（AJ）     

LeCompte操作对大动脉侧侧位Taussig-Bing畸形患儿大动脉调转术后中远期再干预的影响

目的 探究LeCompte操作对于侧侧位Taussig-Bing畸形行一期大动脉调转术（arterial switch operation,ASO）围术期死亡率及中远期再干预率的影响。方法 回顾性分析2006—2017年间于上海儿童医学中心确诊为侧侧位Taussig-Bing畸形行一期ASO患者的临床资料。根据是否行LeCompte操作将患者分为两组：行LeCompte操作组和未行LeCompte操作组;比较两组患者的临床资料。结果 共纳入92例患者。行LeCompte操作组32例,男24例、女8例,中位手术年龄65.0 d,平均体重4.3 kg,其中15例（46.9%）合并主动脉弓畸形并同期行修补术,12例（37.5%）合并冠状动脉畸形。未行LeCompte操作组60例,男45例、女15例,中位手术年龄81.0 d,平均体重4.8 kg,其中22例（36.7%）合并主动脉弓畸形,35例（58.3%）合并冠状动脉畸形。行LeCompte操作组的平均体外循环时间与未行LeCompte操作组差异无统计学意义[（179.0±60.0）min vs.(203.0±74.0)min,P=0.09...     

Follow-up after polypectomy

Progress in understanding the biology, natural history, and relationship to colorectal cancer has provided the basis for a rational approach to patients with adenomas. Pathological assessment of polyps is essential for initial management; only adenomas require search for synchronous neoplasia. A finding of a 30%–50% synchronous rate has been observed. After clearing of the colon of all adenomas, follow-up examination will reveal a 30%–50% rate of metachronous adenomas, but usually with unimportant pathology. Patients with no special concerns at initial polypectomy can have surveillance at intervals of approximately 3 years, while those with an incompletely cleared colon, numerous polyps, or large sessile or malignant adenomas need individualized surveillance. Working guidelines can be provided at this time pending observations in ongoing trials. It is expected but not yet proven that control of colonic adenomas will reduce the incidence and mortality from colorectal cancer. Further research into the biology of adenomas and cancer will undoubtedly provide a clear understanding of susceptibility for colorectal adenomas and more selective control strategies.

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Resumen El progreso en la comprensión de la biología, la historia natural, y la relación con el cáncer colorrectal provee el fundamento para un enfoque racional del paciente con adenoma. La valoración histopatológica de los pólipos es esencial en la primera fase de su manejo; sólo los pacientes con adenomas requieren ser investigados para neoplasia sincrónica. Se ha encontrado una tasa de incidencia sincrónica de 30%–50%. Después de limpiar el colon de la totalidad de los adenomas, el examen de seguimiento revela una tasa de adenomas metácronos de 30%–50%, pero usualmente con patología no importante. Pacientes libres de riesgos especiales en el momento de la polipectomía pueden ser controlados a intervalos de 3 anos, mientras que aquellos con un colon no totalmente limpio de adenomas, o con pólipos numerosos, o con adenoma malignos requieren seguimiento individualizado. Es posible plantear pautas de trabajo, pendientes de las observaciones que se deriven de estudios actualmente en progreso. Se espera, aunque aun no está probado, que la resección de los adenomas del colon habrá de disminuir la incidencia y la mortalidad del cáncer colorrectal. Futuros estudios sobre la biología de los adenomas seguramente aportará una más clara comprensión de la susceptibilidad de los adenomas colorrectales y permitirá delinear estrategias de control más selectivas.

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Résumé Les progrès dans la compréhension de la biologie, de l'histoire naturelle, et de la relation avec le cancer colorectal constituent la base d'une approche rationnelle des patients ayant des adénomes. Un examen histologique des polypes est indispensable avant tout traitement; seuls les adénomes demandent la recherche d'une néoplasie synchrone. On a observé un taux de néoplasie synchrone de 30% à 50%. Après avoir débarassé le côlon de tous les adénomes, le suivi révélera un taux de 30% à 50% d'adénomes métachrones, mais généralement bénins. Les patients n'ayant pas eu de problème particulier à la première polypectomie doivent Être surveillés à des intervalles de 3 ans environ tandis que ceux qui ont un côlon incomplètement nettoyé, des polypes nombreux, des grands polypes sessiles, ou des adénocarcinomes ont besoin d'une surveillance particulière. On peut tracer quelques recommandations à l'heure actuelle en attendant les résultats des études en cours. Il est probable mais cependant pas encore démontré que l'ablation des adénomes coliques réduira l'incidence et la mortalité du cancer colorectal. De plus amples recherches dans la biologie des adénomes et du cancer apporteront sûrement des éclaircissements sur la survenue des cancers colorectaux et sur les méthodes de contrôles plus sélectives.

     

Follow-up after urinary diversion

With modern forms of urinary diversion being widely employed during recent years, the awareness of possible complications and appropriate follow-up strategies gains rising importance and current follow-up strategies are reviewed herewith. Follow-up investigations after urinary diversion have to address possible surgical complications, metabolic changes as well as the risk of secondary malignancies in the incorporated bowel segments. The most important and possible deleterious surgical complication is upper tract dilation and obstruction following ureteroenteric anastomotic stenosis and occurs in 2-30% depending on the surgical technique and evaluated series. The most appropriate follow-up study to detect upper tract dilation is ultrasonography while the associated obstructional component can best be estimated by functional renographic studies (MAG(3) renal scan). The significance of reflux associated with urinary diversion remains controversial although experimental studies and clinical observations suggest a risk of renal functional deterioration associated with reflux which is certainly true in ureterosigmoidostomy following pyelonephritic changes. Possible metabolic changes include hyperchloremic metabolic acidosis and problems related to malabsorption due to bowel resection and incorporation of bowel segments into the urinary tract. The incidence of hyperchloremic acidosis is related to the form of urinary diversion, being higher in continent forms than in incontinent diversions, while hyperchloremic metabolic acidosis is most frequently encountered in ureterosigmoidostomy. While acute complications of metabolic acidosis may encompass hyperventilation as well as severe changes of serum electrolytes and acid base balance leading to cardiac arrhythmias necessitating immediate hospital treatment with intravenous alkalinizing, chronic acidosis may lead to osteopenia through hypocalcemia and stimulation of osteoclastic activity. Metabolic acidosis can be best detected by regular blood gas analysis. To prevent these complications prophylactic administration of alkalinizing agents (e.g. potassium citrate) should be readily performed. Malabsorption of bile acid strongly correlates with the length of ileum resected and can induce both chologenic diarrhea and malabsorption of liposoluble vitamins (A, D, E, K). Vitamin B(12) is exclusively absorbed in the distal ileum, serum levels therefore may be reduced following resection of distal ileum. This will not occur during the first 3-5 years following diversion because B(12) deposits usually will last for this period. Later, however, serum levels of vitamin B(12) should be checked annually while others favor routine substitution of this vitamin. The incidence of cancer occurring at the ureterointestinal anastomosis seems to be highest in patients with ureterosigmoidostomy varying between 2 and 29% with polypoid benign lesions being more frequent. The most common type of tumor is adenocarcinoma which has also been reported in colonic and ileal conduits as well as augmentation cystoplasty using either colon or ileum. Since the time interval between surgery and cancer occurrence is longer than 10 years, the newer forms of continent diversion theoretically also inherit the risk of tumor formation, which, however, has yet to be established because these diversions are only in wide use since 10 years. Currently, annual endoscopic controls are recommended in those patients with diversions where feces and urine are in contact with urothelium starting 5 years after surgery. Although formal guidelines for follow-up after urinary diversion have not yet been established by the working group on oncology of the German urological association, this paper suggests a follow-up strategy addressing surgical complications, metabolic changes and the risk of secondary malignancies. Copyright Copyright 1999 S. Karger AG, Basel     

Follow-up after intensive care

Until recently, an intensive care unit (ICU) stay was deemedsuccessful if a patient survived to go to the ward. Practitionersin neonatal medicine have always been concerned with the functionaloutcome of their infants. However, practitioners in adult intensivecare have historically paid little attention to the long termoutcomes of their patients. Also, little consideration was takenof the patient dying on the ward or soon after leaving hospitalor indeed if the patient went home with an appalling qualityof life.     

Follow-up after anaesthetic anaphylaxis

Background: The anaesthetic allergy clinic has been established at our institution for 30 years. Our practice has been to give patients a letter detailing the results of their investigations to pass on to subsequent anaesthetists. Our aims were to assess the adequacy of this letter in ensuring this vital communication, and to quantify the effectiveness of our recommendations on the safety of future anaesthesia. Methods: A project was undertaken to contact 606 previous clinic patients living in New South Wales by using last known addresses on our database, public telephone listing and local doctors. The review also involved collecting information, where available, about subsequent anaesthesia and the adequacy of information transfer about medications given safely or otherwise at this time. Results: Of 606 patients, 246 were contactable. Of these, 183 had been anaesthetised subsequently, all safely. It was found that in only 11 cases had the patient's clinic letter been updated with the information from subsequent anaesthesia. We updated the letters of 82 patients with new information to improve the safety of drug selection for future anaesthesia. Conclusions: Although clinic testing allowed a high degree of safety in subsequent anaesthesia, it is evident that there is a need for systems to be implemented to improve the flow of patient anaesthetic allergy information after subsequent anaesthesia.     

随访中永久性结肠造口患者存在问题及护理对策

目的:探讨随访中永久性结肠造口患者存在问题,护理干预对永久性结肠造口患者功能恢复的影响。方法:回顾性分析2009年4月～2012年4月250例随访的永久性结肠造口患者的临床资料。结果:对每例患者存在问题实施相应的护理对策,经积极的治疗和精心护理,患者均治愈。结论:为院外患者随访服务可提供专业化和延续性的护理,可以减轻肠造口患者的痛苦,提高其生活质量。     

Follow-up results after lumbar renucleotomy

This is a report on the results of reoperations of lumbar disc prolapses. Ninety-seven operations in ninety-one patients were performed for recurrence of a disc prolapse. The recurrence rate of the cases reviewed was 6.5 per cent. More than 80 per cent of the ninety-one patients who had answered a questionnaire were satisfied with the result of reoperation. About 66 per cent of the patients were able to pursue their former occupation, 20 per cent required vocational rehabilitation, in about 20 per cent of the cases disablement was acknowledged.     

Follow-up after polypectomy of colorectal adenomas

Summary Five hundred eighty-two patients with colorectal adenomas or early cancers were polypectomized from 1974 to 1985. In 100 patients, total colonoscopy was performed more than twice after the initial polypectomies. These patients were divided into three groups: group A patients underwent total colonoscopy at 1-year intervals; group B patients underwent total colonoscopy at 2-year intervals, group C patients underwent total colonoscopy at 3-year or more than 3-year intervals. The frequency and location of newly developed adenomas were investigated. The detection rate for new adenomas was 13% in group A and 50% in group B; thus, there was a significant difference between group A and group B (P<0.01). The transverse colon is the only segment where the topological proportion of newly developed adenomas increased in comparison with that of index adenomas (P<0.05). The detection rate for new adenomas was significantly higher in patients who had carcinoma in situ at the time of initial polypectomy (P<0.05). Questionnaires about colonoscopy and colonic adenomas were therefore mailed to the patients who were lost to follow-up after the polypectomy.