Thoracoabdominal Aortic Aneurysm Repair: Results of Conventional Open Surgery

ObjectivesThe aim of this study is to report our experience in the surgical repair of thoracoabdominal aortic aneurysms (TAAAs) over the last 27 years against the background of evolving surgical techniques.MethodsWe reviewed the prospectively collected data of 571 patients who underwent open TAAA repair between 1981 and 2008. Data were analysed using univariate and multivariate analysis (logistic regression). Pre-, intra- and postoperative risk factors were used to develop risk models for in-hospital mortality, spinal cord deficit and renal failure. Recent published series were used to highlight the different treatment modalities and explore results.ResultsSeventy patients (12.3%) died in the hospital, the 30-day mortality was 8.9%, 37 patients (6.5%) required postoperative dialysis and 47 patients (8.3%) developed paraplegia or paraparesis. The incidence of paraplegia in the left heart bypass group was 4.4%. The predictors for hospital mortality were increasing age (odds ratio 1.096 per year, 95% confidence interval (CI): 1.05–1.14) and the need for haemodialysis (odds ratio 10, 95% CI: 4.7–21.1). For postoperative spinal cord deficit, we found three protecting factors: age above 75 years (odds ratio 0.14, 95% CI: 0.19–1.09), the presence of a post-dissection aneurysm (odds ratio 0.4, 95% CI: 0.17–0.94) and the combined use of cerebrospinal fluid drainage and motor-evoked potentials (odds ratio 0.28, 95% CI: 0.14–0.56). The urgency of procedure (odds ratio 4, 95% CI: 1.8–9) and preoperative serum creatinine level (odds ratio 1.007 per micromole per litre, 95% CI: 1.0–1.01) were significant risk factors for renal failure.ConclusionsOpen TAAA repair intrinsically has substantial complications, of which spinal cord ischaemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. An overview of the results of recently published series is given along with an analysis of our data.     

腹腔镜胆囊切除术胆管并发症的防治

目的 :探讨腹腔镜胆囊切除术中避免胆道损伤的有效方法。方法 :回顾性分析 1 996～ 2 0 0 2年行腹腔镜胆囊切除的临床资料。其中胆道损伤 9例 ,包括胆总管横断 2例 ,胆总管电灼伤 1例 ,胆总管夹闭 2例 ,胆囊管残端漏 1例 ,胆囊床损伤或胆囊迷走胆管损伤 3例。胆总管损伤患者均行一期手术 ;胆囊床损伤或胆囊迷走胆管损伤的患者行穿刺抽液或置管引流治愈。结果 :本组患者 1例因发生胆肠吻合口狭窄而再次手术 ,其它患者恢复顺利。结论 :严格规范的操作 ,胆囊三角良好的显露 ,辨清肝总管、胆总管和胆囊管之间的关系 ,正确处理胆囊床和胆囊管是避免肝外胆管损伤和预防胆漏的关键。     

创伤性主动脉损伤的临床病理特征及其腔内治疗的疗效分析

背景与目的 各类高能量冲击性外伤如车祸、高空坠落等对主动脉造成的损伤往往较为隐匿而难以发现,且使病情更为复杂。在手术治疗严重的外伤前,对损伤的主动脉进行修复是十分必要的。目前胸主动脉腔内修复术（TEVAR）因其创伤小、恢复快的优势得以广泛开展,为避免耽误多发伤的专科治疗提供较大帮助。本研究通过分析创伤性主动脉损伤（TAI）的病变特点,并比较TAI与Stanford B型主动脉夹层行TEVAR的疗效,探讨其治疗策略。方法 回顾性分析中南大学湘雅医院2015年11月—2020年12月内行TEVAR治疗的20例TAI患者（TAI组）,以及同期行TEVAR治疗的50例非创伤性Stanford B型主动脉夹层患者（非TAI组）资料,比较两组患者的临床资料和随访情况。结果 两组在性别、年龄等方面差异无统计学意义（均P>0.05）,TAI组高血压患者比例低于非TAI组（40.0% vs. 74.0%,P<0.05）。TAI组的局限型撕裂、第一破口多位于主动脉峡部的比例高于非TAI组（80.0% vs. 34.0%;70.0% vs. 24.0%,均P<0.05）,而破口数量≥2、弓上受累及破口与左锁骨下动脉（LSA）的距离<15 mm的比例低于非TAI组（30.0% vs. 78.0%;10.0% vs. 52.0%;40.0% vs. 72.0%,均P<0.05）,TAI组支架放大率大于非TAI组（P<0.05）。TAI组住院时间明显长于非TAI组（16.80 d vs. 11.20 d,P<0.05）,且其术后并发症发生率高于非TAI组（20.0% vs. 4.0%,P<0.05）。随访结果显示,两组在并发症发生率、存活时间等方面差异无统计学意义（均P>0.05）,但TAI组假腔体积变化率及血栓吸收率均高于非TAI组（95.0% vs. 72.0%;90.0% vs. 58.0%,均P<0.05）。结论 TAI因不同机制的多发伤使得病情急、重且复杂,故而修复血管时应根据损伤情况进行个体化治疗方案,包括手术时机的选择、支架的长度、支架放大率、锚定区的判断及考虑LSA是否保留或封闭等。TEVAR术后,TAI患者的假腔体积变化率及假腔血栓吸收情况明显优于非TAI患者,反映了TAI中期主动脉重塑良好,进而说明TAI行TEVAR能获得较好的治疗效果,但远期疗效仍需进一步探寻。     

妇科腹腔镜手术中泌尿系损伤的临床特点及处理

目的:探讨妇科腹腔镜手术发生泌尿系损伤的主要原因、诊断、治疗方法及预防措施。方法:回顾分析2004年5月至2010年12月妇科腹腔镜手术发生泌尿系损伤患者的临床资料,总结分析患者疾病类型、盆腔情况、手术方式、损伤特点、诊疗情况及预后等。泌尿系损伤均经泌尿科手术治疗。结果:2 138例妇科腹腔镜手术中,共发生输尿管损伤7例,膀胱损伤2例,总泌尿系损伤率0.42%。经泌尿科手术,预后良好。结论:泌尿系损伤是妇科腹腔镜手术较严重的并发症,术者需高度警惕,术后注意观察,一旦出现术后腹痛、腹胀、恶心呕吐、发热、阴道流液、腹膜炎等症状时,应及时进行相关检查,及时处理,治疗以手术为主。     

泌尿外科经腹腹腔镜腹壁穿刺血管损伤的临床分析

目的探讨泌尿外科经腹腹腔镜腹壁穿刺过程发生血管损伤的原因、处理及预防措施。 方法回顾分析我院泌尿外科2012年9月至2017年9月间1 025例经腹腹腔镜手术腹壁穿刺过程出现的6例血管损伤患者的临床资料,分析其原因,总结处理及预防措施。 结果共发生血管损伤6例,其中腹主动脉损伤1例,右髂总动脉损伤1例,腹壁下血管损伤4例,肠系膜动脉损伤1例,其发生率为0.585%（6/1 025）。4例腹腔镜下止血成功,2例中转开放手术止血。 结论腹腔镜腹壁穿刺导致血管损伤由多种原因引起,腹腔粘连、过度消瘦或肥胖是血管损伤发生的危险因素,需术前个体化评估;对腹部血管解剖的深入理解和术中规范操作是减少其发生的关键;掌握血管损伤的临床表现和处理方法,才能降低对患者的创伤及后遗症。     

Blunt traumatic aortic injury in the elderly population

ObjectiveBlunt thoracic aortic injury (BTAI) is a major cause of morbidity and mortality in trauma patients. Although outcomes for BTAI have been described in younger patient populations, elderly patients may present with different patterns of injury and have unique factors contributing to morbidity and mortality. This study aims to describe patterns of presentation and management in elderly patients presenting with BTAI using a nationwide database.MethodsPatients aged 65 years and older with BTAI from 2007 through 2016 were identified from the American College of Surgeons Trauma Quality Improvement Program database. Baseline demographics, initial physiologic variables, and clinical outcomes were extracted from the database. Our primary outcome was in-hospital mortality. An adjusted Poisson generalized regression model was used to compare rates of mortality for thoracic endovascular aortic repair (TEVAR), open repair, and nonoperative management.ResultsDuring the study period, 1322 patients aged 65 years and over sustained BTAI and survived past triage. Mean age was 74.7 years, and 60% were male. There were low incidence rates of concomitant major head (9.4%), spine (3.1%), and abdominal (5.7%) injuries. Three hundred fifty (26.5%) underwent TEVAR, 58 (4.4%) open repair, and 914 (69.1%) were managed nonoperatively. Utilization of TEVAR increased from 13.1% to 32.7% from 2007 to 2015, with subsequent decline to 19.9% in 2016 in favor of nonoperative management. Age, gender, and mean Injury Severity Scores (ISS) did not significantly differ by management. In-hospital mortality for the entire cohort was 37.9%. In an adjusted Poisson generalized regression model using inverse probability of treatment weighting controlling for age, race, gender, ISS, and hypotension, TEVAR was associated with the lowest mortality rate (1.31 deaths/100 person-years; 95% confidence interval [CI], 1.17-1.46) compared with open repair (2.53; 95% CI, 2.32-2.75; P < .001) and nonoperative management (3.91; 95% CI, 3.60-4.25; P < .001). There was a higher incidence of acute kidney injury, acute respiratory distress syndrome, and surgical site infection in the TEVAR group.ConclusionsThis study describes the management of and outcomes for BTAI in the elderly population. The majority of patients did not undergo operative repair, which was associated with a higher risk of in-hospital mortality. In an adjusted analysis, TEVAR was associated with the lowest mortality rate, compared with open repair and nonoperative management.     

Aortic pseudoaneurysm after endarterectomy for small aorta syndrome

IntroductionSmall Aorta Syndrome (SAS) or hypoplastic aorto-iliac syndrome is a rare pathology of the aorta that affects almost exclusively young or middle-aged women and is characterized by smaller dimension of the aorta and iliac axes. Etiopathogenesis is unclear and many factors have been invoked. The smaller caliber of the aorta and iliac arteries may predispose to aorto-iliac occlusive disease development.In the past aorto-iliac endarterectomy (AE) with patch closure was utilized as an alternative to surgical bypass in order to correct steno-obstructive syndromes affecting carriers of SAS. Little is known about long term outcomes of this type of surgery.Presentation of the caseDuring investigations for acute colecystitis, an aortic pseudoaneurysm (PA) was diagnosed by ultrasound in a 73 old year woman. She was submitted twenty-two years ago for SAS with disabling claudication to aortic endarterectomy (AE) with patch graft insertion. Considering all the vascular options available she was submitted to open surgery with replacement of the aortic bifurcation.DiscussionAortic PA is a relatively common complication after bypass surgery but is rarely observed after AE. It requires prompt intervention to prevent subsequent complications such as rupture, thrombosis, distal embolism or aorto-enteric fistula.ConclusionEndovascular treatment for aortic PA should be always considered the treatment of choice but the open surgical option was preferred in this particular case because of the small diameters of the iliac accesses, making them unsuitable for an endovascular approach.     

DeBakeyⅢ型主动脉夹层动脉瘤腔内隔绝术的围手术期处理

目的：探讨ＤｅｂａｋｅｙⅢ型主动脉夹层动脉瘤腔内隔绝术的围手术期处理。方法：６５例ＤｅｂａｋｅｙⅢ型主动脉夹层动脉瘤病人接受了腔内隔绝术。术后监测各项生命体征,观察尿量及颜色、两上肢脉搏及血压、上下肢血供及末梢循环、肢体肌力变化、胸背部疼痛及神经反射。结果：移植物置入成功率为９８．４６％,术中输血量平均为９３．５ｍｌ。心电监护平均４８ｈ,其中５２例入ＩＣＵ病房,平均监测１９ｈ。胃管留置平均３ｈ,尿管平均留置１６ｈ。术后发生脑血管意外２例、胸骨后疼痛５例、左上肢乏力３例、血小板降低６４例、术后发热５８例、切口渗血或血肿５例。术后３０天内死亡２例。结论：主动脉夹层动脉瘤腔内隔绝术的围手术期处理有一定特殊性。该术式虽属微创手术,但术后易出现脑血管意外、心源性猝死、分支动脉闭塞及移植物引起的胸痛、大量Ｘ射线引起的腔内隔绝术后综合征等,应掌握处理的特殊性。     

Initial management of suspected biliary injury after laparoscopic cholecystectomy

Although rare, iatrogenic bile duct injury (BDI) after laparoscopic cholecystectomy may be devastating to the patient. The cornerstones for the initial management of BDI are early recognition, followed by modern imaging and evaluation of injury severity. Tertiary hepato-biliary centre care with a multi-disciplinary approach is crucial. The diagnostics of BDI commences with a multi-phase abdominal computed tomography scan, and when the biloma is drained or a surgical drain is put in place, the diagnosis is set with the help of bile drain output. To visualize the leak site and biliary anatomy, the diagnostics is supplemented with contrast enhanced magnetic resonance imaging. The location and severity of the bile duct lesion and concomitant injuries to the hepatic vascular system are evaluated. Most often, a combination of percutaneous and endoscopic methods is used for control of contamination and bile leak. Generally, the next step is endoscopic retrograde cholangiography (ERC) for downstream control of the bile leak. ERC with insertion of a stent is the treatment of choice in most mild bile leaks. The surgical option of re-operation and its timing should be discussed in cases where an endoscopic and percutaneous approach is not sufficient. The patient's failure to recover properly in the first days after laparoscopic cholecystectomy should immediately raise suspicion of BDI and this merits immediate investigation. Early consultation and referral to a dedicated hepato-biliary unit are essential for the best outcome.     

Is male gender a risk factor for bile duct injury during laparoscopic cholecystectomy?

Background Since its introduction in the late 1980s laparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Unfortunately, the rate of iatrogenic biliary duct injuries (BDIs) has at least doubled after the adoption of the laparoscopic method. Population-based studies reporting the distribution of laparoscopic BDI patients according to gender and the severity of the BDI are mostly lacking. The purpose of the present study was to analyze the BDIs sustained during laparoscopic cholecystectomy in and around Turku University Central Hospital, with a special reference to the distribution of patients according to gender and the severity of the BDI.Patients and methods A total of 3,736 laparoscopic cholecystectomies (2,627 female patients, 1,109 male) was performed in and around Turku University Central Hospital from 1995 to 2002 (by the end of April). The number and severity of BDIs and the gender of BDI patients were recorded, and the risk of BDI during laparoscopic cholecystectomy was calculated for the total patient population and for both genders separately.Results The risk of BDI was 0.86% for the total patient population, 0.95% for female and 0.63% for male. The most conspicuous finding was that the female gender was predominant in the severe types of BDI. However, the risk of mild BDI seemed to be fairly equal in both genders.Conclusion We conclude that female gender seems to be a risk factor for severe iatrogenic BDI during laparoscopic cholecystectomy.     

腹腔镜胆囊切除术严重并发症10例分析

目的对腹腔镜胆囊切除术发生严重并发症的常见原因进行分析. 方法回顾分析986例腹腔镜胆囊切除术中出现的10例严重并发症的诊治经过. 结果因钛夹松脱致胆漏2例,膈下脓肿1例,胆总管损伤3例,胆总管残余结石2例,十二指肠损伤1例,气腹针穿刺致空肠穿孔1例.经治疗未出现严重后果. 结论导致腹腔镜胆囊切除并发症的原因为局部粘连、炎性水肿严重,脐孔周围严重的腹腔粘连,胆囊解剖的变异,术者经验欠丰富、操作欠熟练.     

Aortic rupture during reoperative bariatric surgery

Morbid obesity has become a very common problem worldwide, causing severe health-related consequences including cardiovascular or metabolic diseases, arthritis, sleep apnea, or an increased risk of cancer. Bariatric surgery was shown to be the only way to achieve sustainable weight loss and to decrease the frequency and severity of metabolic and cardiovascular comorbidities. The purpose of this article is to present a case of bariatric surgery complicated with lesion of the aorta with a lethal outcome.     

腹腔镜再手术处理腹腔镜胆囊切除术后并发症21例

目的探讨腹腔镜再处理腹腔镜胆囊切除术后并发症的价值。方法1996年10月～2007年10月，共行754例腹腔镜胆囊切除术，对21例术后并发症行再次腹腔镜探查。结果21例均在腹腔镜下明确诊断，其中胆漏11例，术后腹腔内出血6例，腹腔积液2例，十二指肠球部穿孔和术后黄疸各1例。除术后黄疸为肝总管横断中转开腹以外，余20例均在腹腔镜下完成手术。21例随访1—11年（平均6年），无胆道并发症发生。结论腹腔镜再手术处理腹腔镜胆囊切除术后并发症可行，创伤小，安全，有效。     

腹腔镜胆囊切除术1 660例临床总结

目的:探讨LC并发症预防及处理。方法:总结1997年12月~2004年3月,1660例LC患者手术方法、发生并发症原因、并发症预防及治疗资料。结果:1660例全部治愈,无死亡病例,并发症26例,其中胆漏12例,出血12例,过敏性休克2例,中转开腹38例,置腹腔引流管83例。结论:规范手术操作是减少并发症的基础,重视并发症的预防及正确处理是提高手术成功率的关键,正确把握中转手术指征及放置腹腔引流管是成功开展腔镜手术的重要措施。     

主动脉手术后非感染性发热的临床研究

目的研究主动脉手术后非感染性发热的发生率、临床过程、危险因素及其对患者转归的影响。方法回顾性研究2006年1月至2008年1月期间因主动脉瘤或主动脉夹层在北京阜外心血管病医院行手术治疗549例患者的临床资料,在排除术前或术后明确合并感染者、术前发热者(口腔温度≥38℃)、急诊手术者、非发热相关原因死亡者及病历资料不全者后,将最终入选的463例患者按照术后是否发热分为发热组(345例,非感染性发热,最高口温38.0～39.3℃)和无发热组(118例,术后无发热);对两组患者的一般资料、手术资料和术后情况等进行组间比较;对P≤0.001的指标行多元logistic回归分析,以寻找影响术后非感染性发热的预测指标。结果主动脉手术后有74.5%(345/463)的患者出现非感染性发热。手术结束当天和术后第1 d发热组患者最低日体温高于无发热组(P=0.000,0.000);手术结束当天、术后第1 d、2 d、3 d和4 d,发热组患者的最高日体温均高于无发热组(P=0.000,0.000,0.000,0.047,0.018)。单变量分析结果:体重(P=0.000)、手术类型(P=0.000)、术中膀胱温度最低值(P=0.000)、ICU口温(P=0.000)和输血(P=0.000)均为影响术后发热的危险因子;多元logistic回归分析结果:胸主动脉和胸腹主动脉手术(比值比:4.861;95%的可信区间:3.029,5.801;P=0.004),较低的术中膀胱温度最低值(比值比:1.117;95%的可信区间:1.013,1.244;P=0.040)和较高的ICU初始口温(比值比:2.570;95%的可信区间:1.280,5.182;P=0.008)均是术后非感染性发热的预测因子。结论主动脉手术后非感染性发热十分常见,手术部位(胸主动脉或胸腹主动脉)、术中低核心体温及术后短期内体温升高可能是主动脉手术后非感染性发热的危险因素。     

腹腔镜胆囊切除术并发症的原因及处理

目的探讨腹腔镜胆囊切除术并发症发生的原因及预防处理. 方法回顾分析我院1991年3月～2003年7月行LC的13 278例的临床资料. 结果发生并发症110例(0.83%).其中胆管损伤19例(0.14%),胆漏37例(0.28%),胆总管残余结石31例(0.23%),腹腔出血4例(0.03%),胃肠道损伤5例(0.04%),腹腔内脓肿3例(0.02%),切口感染及切口疝6例(0.05%),严重皮下气肿5例(0.04%).死亡5例(0.04%). 结论胆管损伤、胆漏和胆总管残余结石是LC的主要并发症,绝大部分并发症是能够预防和治愈的.     

腹腔镜手术265例报告

目的 :探讨腹腔镜外科手术的方法与疗效。方法 :行腹腔镜胆囊、阑尾、腹股沟疝、肠粘连、子宫附件等手术 2 6 5例。结果 :成功行腹腔镜胆囊切除术 2 32例 ,阑尾切除术 2 2例 ,肝囊肿开窗 2例 ,卵巢切除 5例 ,疝修补或者疝囊高位结扎 7例 ,肠粘连松解术 1例 ,子宫切除 1例 ,不孕症通水及盆腔松解粘连术 3例 ,输卵管病灶切除 2例。中转开腹 2例 ,其中 1例胆囊坏疽 ,分离困难 ,另 1例为术中胆囊动脉上钛夹时撕裂出血。二次手术 1例 ,为胆囊管关闭不全引起胆漏。术后均痊愈出院 ,无严重并发症发生。结论 :腹腔镜外科手术安全、有效 ,具有创伤小、术后恢复快等优点     

LC 3000例的严重并发症分析

施行LC3000例,发生严重并发症14例,其中膈下脓肿1例,胆漏4例,腹腔内积血3例,胆总管损伤5例,胆总管残余结石1例。13例经剖腹手术治愈,1例死亡。为预防LC并发症应遵守LC资格医生的规定,严格术前适应性训练,准确可靠地解剖胆囊三角,处理胆囊管和胆囊动脉,术中始终保证器械在视野内移动,在最佳视野下操作,规范LC操作程序和正确认识及施行中转剖腹胆囊切除术等。