急性外伤性硬膜外血肿的微创穿刺治疗

目的探讨微创穿刺引流术治疗急性外伤性硬膜外血肿的疗效。方法2009年6月-2012年6月采用YL-1型一次性颅内血肿穿刺针行微创穿刺引流术治疗外伤性硬膜外血肿68例。根据CT定位确定穿刺点、穿刺方向及穿刺针长度,以电钻将YL-1型一次性颅内血肿穿刺针送人血肿靶点,抽吸血肿后,血肿腔内分次注入尿激酶（一般用生理盐水2—5ml溶人20000～50000U尿激酶）溶解引流出残存血肿,术后复查CT,血肿基本清除、中线结构移位恢复后拔针。结果68例均穿刺成功。经CT确诊2d完全清除32例,3d22例,5d10例;2例并发新鲜出血中转开颅手术;2例并发脑疝术前采用此方法急救后改骨瓣开颅手术治愈。头痛立即缓解18例,肢体麻木无力立即消失3例,其他病例临床症状3～5d逐渐好转。术后住院7～15d,平均12d。68例随访3—6个月：完全失语1例,智力轻度减退4例（合并脑挫裂伤）,无死亡病例。结论微创穿刺引流术治疗急性外伤性硬膜外血肿操作简便、快捷、创伤小、疗效好。     

Ventricle puncture for external CSF drainage and pressure measurement using a modified puncture needle

Summary A modified needle for external ventricular drainage is presented. Contrary to conventional spinal needles with this instrument the sharp guide can be withdrawn after penetration of the dura, thus, no sharp instrument affects the brain, nor remains within the ventricles in cases of continuous drainage. Furthermore, depth of penetration can be determined preoperatively by means of a set screw also facilitating fixation of the needle. To date, we have used this modified needle in 50 patients for short or long term CSF drainage and for CSF pressure measurements. Trephination was performed with a hand or battery-driven drill. Except for an infection in one case we found no serious complications in our patients. In our opinion, ventricle puncture for external drainage and pressure measurement with this device is a simple and safe method and can be performed on the ward under local anaesthesia.     

YL-1型针微创穿刺引流治疗急性硬膜外血肿的临床分析

目的探讨YL-1型针微创穿刺引流治疗急性硬膜外血肿的临床疗效。方法急性硬膜外血肿19例,采用CT引导定位,以血肿中心为靶点,YL-1型颅内血肿粉碎穿刺针经头皮穿刺冲洗、粉碎、引流血肿,并联合尿激酶(1×104~2×104U/次)溶解血肿。结果本组19例全部治愈,术后持续引流时间平均3.6(3~5)d,无一例需要输血,未出现术中大出血或术后血肿复发。无一例死亡,亦未发生颅内感染、张力性气颅等并发症。拔针前复查CT证实血肿清除90%~100%,占位效应消失或明显减轻。住院时间平均9.6(6~15)d。出院时日常生活量表(activity of daily living,ADL)分级:Ⅰ级17例,Ⅱ级2例。13例随访3~6月,平均(4.5±1.5)月,GOS分级均为Ⅰ级。结论 YL-1型针微创穿刺引流术治疗急性硬膜外血肿,疗效确切、微创、节省医疗费用,手术时准确选择适应证、把握手术时机非常重要。     

Percutaneous needle trephination. Experience in 200 cases

Summary For many years percutaneous needle and classic burr-hole trephination with insertion of plastic catheters for external ventricular drainage are in use. The shortcomings of the conventional puncture needles were compensated for by the development of a modified instrument in recent years.In this prospective study we tried to define advantages and disadvantages of percutaneous ventriculostomy with this modified needle in a large number of patients. We treated and followed a total number of 200 patients with external ventricular drainage for various reasons (42% obstructive hydrocephalus, 27% haematocephalus, 11% malresorptive hydrocephalus, 11% elevated ICP and 9% infections). The ventriculostomy is performed — after percutaneous trepheication with a 1.5 mm drill and 1.2 mm needle under the local aesthesia as a bedside procedure. The modified blunt needle is provided with markings and a set screw which allows insertion to a prefixed depth and a sharp guide which is withdrawn after penetration of the dura. It is then bent rostrally and fixed by a plaster cast. The mean duration of drainage was 9 days (1–30 days). Mean operating time for the whole procedure including fixation and connection to the drainage system was 20 minutes. Overall complication rate was 13% (N=26). Two intracerebral haemorrhages (1%) occurred, of which one was caused by overdrainage. Five (3%) infections in primarily not infectious cases (N=182) were seen. Only one case of infection occurred without loosing of the needle on day 17. In 19 patients (10%) the needles had loosened. Fifteen times this complication was repaired in time and no infection occurred. The overall complication rate (13%) and the needle related risk of bleeding (0.5%) seem average. The true risk of infection with correct handling (0.5%) is very low despite the very long average duration of drainage. The main risk lies in the markedly high danger of loosening (10%), which entails a disproportionally high demand for nursing care. Nevertheless, we regard percutaneous needle trephination as the ventriculostomy method of choice because of its better practicability and low infection rate.     

经皮穿刺肝脓肿引流术的临床应用

目的探讨经皮穿刺肝脓肿引流术的临床应用。方法对13例肝脓肿行经皮穿刺引流术,13例均放置引流管持续引流。结果13例手术均获得成功,成功率100%(13/13)。随访15~45天,症状明显好转,病灶缩小或消失。无一例发生并发症。结论经皮穿刺肝脓肿引流术,可缩短病程,手术成功率高,并发症少,值得推广应用。     

穿刺引流术治疗脑室出血115例报告

目的探讨微创穿刺引流术治疗脑室出血的疗效。方法 2005年11月-2010年11月对115例CT确诊脑室出血,其中重型脑室出血25例,根据患者脑室出血部位和体积选择性穿刺侧脑室额角,采用双侧或单侧脑室引流,术后尿激酶灌注冲洗,直至脑脊液正常,头颅CT确认血肿消失。结果住院期间治愈或好转88例（76.5%）,植物状态11例,死亡16例。98例随访3-12个月,平均6个月：78例复查头颅CT示脑室大小正常,再出血8例,继发性脑积水5例,死亡7例。结论脑室穿刺引流联合尿激酶灌注冲洗,能尽快清除脑室系统及蛛网膜下腔积血,对降低病死率,提高患者术后生存质量有重要意义。     

Causes, prevention and therapy of complications of lymphadenectomy following tumor nephrectomy

In our series of 295 patients who had to undergo a radical nephrectomy. 34% had postoperative wound drainage for longer than 6 days. In 7 patients (2.4%) lymphocele developed, which was cured by percutaneous puncture and drainage in most cases.     

CT引导下经皮穿刺置管引流治疗重症胰腺炎

目的探讨CT引导下经皮穿刺置管引流治疗重症胰腺炎（SAP）的应用价值。方法对192例SAP患者行CT引导下经皮穿刺置管引流,并对疗效进行评价。结果 192例患者中,经治疗后治愈83例（43.23%）,有效73例（38.02%）,无效36例（18.75%）。经前腹壁进针时,经胃、结肠间隙入路为最常用的穿刺路径。结论 CT引导下经皮穿刺置管引流创伤小,疗效较为显著,且便于操作,尤其适用于一般情况较差、不能耐受手术治疗的SAP患者,值得临床推广应用。     

Clinical evaluation of combined spinal-epidural anesthesia by needle-through-needle approach in 485 surgical cases

We analyzed retrospectively the technical and clinical consequences of combined spinal-epidural anesthesia by needle-through-needle approach over the last two years. A Tuohy-type 18-gauge epidural needle (Perican; B. Braun Co.) and long pencil-pointed 27-gauge spinal needle (Whitacre; Becton-Dikinson Co.) were selected. Spinal anesthesia was administered with 0.5% tetracaine. A total of 485 anesthesia cases included 144 cases for lower abdominal, 193 cases for gynecological and 148 cases for orthopedic surgeries. The successful subarachnoid puncture with only one attempt was recorded in 89% of abdominal, 71% of gynecological and 72% of orthopedic cases. On the other hand, in three (0.6%) cases even with several attempts, the puncture was not possible. Inadvertent dural puncture and subarachnoid catheterization occurred in six (1.2%) and four (0.6%) cases, respectively. Inadequate spinal anesthesia was supplemented with epidural anesthesia in 13% of abdominal, 21% of gynecological and 7% of orthopedic cases. No serious complication occurred. We conclude that this needle-through-needle approach facilitates subarachnoid puncture with an ultra-fine spinal needle and subsequent epidural catheterization serves for supplemental and post-operative analgesia unless inappropriate subarachnoid indwelling occurs.     

术中超声在脑外伤后脑室穿刺中的应用

目的探讨术中超声在脑外伤后脑室穿刺中的应用价值。方法选取脑外伤后需接受侧脑室穿刺术的患者68例,随机均分为2组,对研究组实施超声引导下侧脑室穿刺术,对照组实施传统盲穿术,分别记录每例穿刺成功所需时间、单次穿刺成功情况及每组的术后并发症情况,并对两组结果进行比较。结果研究组一次穿刺成功率为100％（34／34）;手术时间5-12min,平均（6．35±1．51）min;术后无并发症发生。对照组24例一次穿刺成功,成功率70．59％（24／34）;手术时间5-17min,平均（11．21±3．10）min;术后8例（8／34,23．53％）出现并发症,分别为穿刺道出血4例、误穿入对侧脑室2例、反复穿刺致使窦道形成1例及脉络丛损伤1例。研究组与对照组间的一次穿刺成功率、穿刺手术时间及术后并发症发生率差异均有统计学意义（P均〈0．05）。结论在脑外伤患者的脑室穿刺术中,超声引导法穿刺成功率明显优于传统盲穿法,手术时间明显短于传统盲穿法,并可减少并发症的发生,可在临床推广应用。     

坐位细针腰麻在急诊剖宫产术中的临床应用

目的探讨坐位细针腰麻在急诊剖宫产术中的临床应用效果。方法选择急诊剖宫产术产妇400例,美国麻醉医师协会（ASA）分级Ⅰ～Ⅱ级,按照随机数字表法分为4组（每组100例）：A组,坐位笔尖样细针腰麻组;B组,侧卧位笔尖样细针腰麻组;C组,坐位普通斜面针腰麻组;D组,侧卧位普通斜面针腰麻组。穿刺成功后注入0．5％布比卡因1．8ml～2．2ml（9mg—11mg）。术毕待麻醉平面消散至T10以下后,送回病房去枕平卧6h,第1、2、3天及时随访。观察记录4组产妇的血压、脉搏血氧饱和度和心率的变化,记录腰麻穿刺次数、穿刺成功率、麻醉操作时间、穿刺开始到切皮时间、切皮到胎儿娩出时间以及术中、术后副作用。结果与B组和D组比较,A组和C组（即两组坐位与两组侧卧位比较）穿刺次数减少[B组（3．2±0．9）和D组（4．1±0．4）,A组（1．1±0．5）和C组（1．2±0．6）]、穿刺成功率提高[B组（90％）和D组（92％）,A组（100％）和C组（98％）]、穿刺时间缩短[B组（5．2±0．6）min和D组（4．1±0．9）min,A组（1．2±0．8）min和C组（2．1±0．7）min]、麻醉操作时间缩短[B组（7．1±0．5）min和D组（6．2＋0．8）min,A组（3．4±0．7）min和C组（4．3±0．6）min]、从穿刺开始到切皮时间缩短[B组（15．2±6．3）min和D组（17．1±4．4）min,A组（10．4±0．5）min和C组（11．3±0．7）min]（P〈0．05）。与C组和D组比较,A组和B组（即两组细针与两组普通针比较）术中低血压发生率降低[C组（18％）和D组（20％）,A组（8％）和B组（10％）]、恶心呕吐发生率减少[C组（10％）和D组（12％）,A组（4％）和B组（5％）]、无术后头痛和腰痛发生[C组（3％）和D组（4％）,A组（0）和B组（0）]（P〈0．05）。结论坐位细针腰麻,操作简便,所需时间短,穿刺次数少,成功率高,术中、?     

改进的多侧孔YL-1型穿刺针及冲洗治疗高血压性脑出血430例报告

目的探讨改进的多侧孔微创穿刺针及冲洗技术治疗高血压性脑出血的疗效。方法将YL-1型颅内血肿粉碎微创穿刺针,末端加以多孔改进后,高温高压消毒后一次性使用。根据CT片行血肿靶点定位,对430例血肿量在25～120 ml进行穿刺引流,等量盐水反复冲洗,术后第2天注入尿激酶,旋转穿刺针并反复冲洗进行穿刺引流。结果穿刺针在脑内留置时间1～4 d,无一例头皮及颅内感染。拔针前及拔针后再出血36例,再出血率8.3%(36/430)。死亡29例,病死率6.7%(29/430),其中4例死于再出血脑疝,11例死于肺炎、心力衰竭,6例死于糖尿病合并肾功能衰竭,8例死于上消化道应激性溃疡出血。按日常生活能力分级(ADL)Ⅰ级85例,Ⅱ级189例,Ⅲ级77组,Ⅳ级17例,总有效率85.5%(368/430)。结论改进的多侧孔微创穿刺针直径相对增大,不易堵塞,冲洗引流通畅,能较快速清除血肿,降低脑内感染机会。     

Surgical treatment of postinfarction left ventricular free wall rupture--experience of 12 cases including 2 successful repairs of acute (blow out) rupture

Left ventricular free wall rupture (LVFWR) complicating myocardial infarction is still a lethal complication. Although there have been reports of successful repair of LVFWR, most of them were of subacute type in which main symptom was cardiac tamponade and the surgical repair was undertaken several hours after the onset of rupture. Between March, 1984 and June, 1987. We treated 12 cases of LVFWR surgically, thoracotomy and open drainage in 2 cases, thoracotomy and direct closure of rupture in 8 cases, median sternotomy and patch closure of rupture in 2 cases. We used cardiopulmonary bypass (CPB) only in 3 cases, because most of the cases except two developed electromechanical dissociation abruptly, requiring an emergency thoracotomy and there was no time for establishing CPB. In the cases of electromechanical dissociation, cardiopulmonary resuscitation and an emergency thoracotomy were performed simultaneously. There were three early survivors (greater than 30 days) by emergency thoracotomy and direct closure of rupture and one survivor (double rupture case) by patch closure on CPB. We believe that acute type of LVFWR in which initial symptom is electromechanical dissociation without any preceding symptoms can be rescued by emergency thoracotomy and direct closure of rupture with no aid of CPB if rupture is a small tear of anterior or lateral left ventricle. For this purpose, prompt diagnosis is mandatory and this is possible by two dimensional echocardiogram even during cardiopulmonary resuscitation.     

超声引导下经不同针数直肠前列腺穿刺活检对前列腺癌的早期诊断效果对比

目的探讨超声引导下经直肠前列腺穿刺活检在诊断前列腺癌的价值。方法选取2013年1月至2016年12月在本院就诊的疑似前列腺癌患者62例，均超声引导下经直肠前列腺穿刺活检，分析不同穿刺法的阳性检出情况。结果本组研究62例患者，穿刺活检病理结果为前列腺癌患者25例（40.32%），其中34例接受10针法穿刺，28例接受12+1针法穿刺，两种穿刺的阳性率分别为35.29%（12/34）和46.43%（13/28），差异无统计学意义（P＞0.05）；前列腺体积≥90 mL患者10针法阳性检出率为33.33%（5/15），明显低于12+1针法的87.50%（7/8），差异比较有统计学意义（P＜0.05）；10针法和12+1针法在不同年龄、前列腺特异性抗原（PSA）及指诊情况下阳性检测率比较差异无统计学意义（P＞0.05）；10针法和12+1针法穿刺后血尿、血便、疼痛、尿潴留及感染发生比例差异比较无统计学意义（P＞0.05）。结论 应根据患者具体情况选取穿刺方法，当患者前列腺体积超过90 mL时，应采取12+1针法穿刺，有助于前列腺癌的检出，而当＜90 mL时，选取10针法穿刺较适宜。     

Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan

BACKGROUND: Percutaneous abscess drainage guided by computed tomography scan is considered the initial step in the management of patients presenting with Hinchey II diverticulitis. The rationale behind this approach is to manage the septic complication conservatively and to follow this later using elective sigmoidectomy with primary anastomosis. METHODS: The clinical outcomes for Hinchey II patients who underwent percutaneous abscess drainage in our institution were reviewed. Drainage was considered a failure when signs of continuing sepsis developed, abscess or fistula recurred within 4 weeks of drainage, and emergency surgical resection with or without a colostomy had to be performed. RESULTS: A total of 34 patients (17 men and 17 women; median age, 71 years; range, 34-90 years) were considered for analysis. The median abscess size was 6 cm (range, 3-18 cm), and the median duration of drainage was 8 days (range, 1-18 days). Drainage was considered successful for 23 patients (67%). The causes of failure for the remaining 11 patients included continuing sepsis (n = 5), abscess recurrence (n = 5), and fistula formation (n = 1). Ten patients who failed percutaneous abscess drainage underwent an emergency Hartmann procedure, with a median delay of 14 days (range, 1-65 days) between drainage and surgery. Three patients in this group (33%) died in the immediate postoperative period. Among the 23 patients successfully drained, 12 underwent elective sigmoid resection with a primary anastomosis. The median delay between drainage and surgery was 101 days (range, 40-420 days). In this group, there were no anastomotic leaks and no mortality. CONCLUSION: Drainage of Hinchey II diverticulitis guided by computed scan was successful in two-thirds of the cases, and 35% of the patients eventually underwent a safe elective sigmoid resection with primary anastomosis. By contrast, failure of percutaneous abscess drainage to control sepsis is associated with a high mortality rate when an emergency resection is performed. The current results demonstrate that percutaneous abscess drainage is an effective initial therapeutic approach for patients with Hinchey II diverticulitis, and that emergency surgery should be avoided whenever possible.     

A case of ruptured intra-renal aneurysm caused by renal allograft biopsy

A 57-year-old male with anuria presented to our emergency room 48 days after living renal transplantation. The diagnosis of acute renal failure due to subcapsular hematoma of transplanted kidney following rupture of intra-renal aneurysm was made based on ultrasonographic findings. He underwent selective arterial coil embolization and open drainage of renal subcapsular hematoma. Diuresis was achieved immediately and the graft function recovered to the baseline level 7 days after drainage. Based on the site of aneurysm, needle biopsies during renal transplant surgery might have caused the aneurysm.     

Current possibilities in the treatment of infected pancreatic necrosis

This is a retrospective study about 80 patients treated for infected necrosis of the pancreas between 1998-2003. Operation was performed in 74 patients, diagnosis was achieved by CT or U.S. guided drainage in 12 patients. In further 6 patients drainage and antibiotic therapy provided cure. In patients who were drained pre-operatively (n=12) the first surgical intervention was performed on average on the 30.2 days after admission, while in the group of patients without drainage surgery became necessary after 15.6 days. The difference is statistically significant (p = 0.001). Our data proved that in certain cases percutaneous drainage can delay surgical intervention. Our results also prove that percutaneous drainage itself can lead to complete cure. In our own practice this stands for about 20% of our patients. In 3 patients we proved that if the patients general condition is stable infected necrosis detected by fine needle aspiration can be successfully treated by antibiotic therapy, without surgical or further radiological intervention.     

腹腔镜胆囊切除术后迟发性迷走胆管漏的预防及处理

目的探讨腹腔镜胆囊切除术后迟发性迷走胆管漏的诊断、治疗及经验教训。方法对1997年2月～2009年8月13例LC后迟发性迷走胆管漏,分别采用开腹胆总管切开、T管引流（1例）,超声定位下腹腔置管引流术（2例）及超声定位下腹腔置管联合ERCP、ENBD（10例）3种方法进行治疗。结果 13例经腹部B超及腹腔穿刺后确诊为迟发性迷走胆管漏,1例因休克急诊行开腹胆总管切开、T管引流术,2例行腹部B超定位下腹腔置管引流术,10例行腹部B超定位下腹腔置管引流、ENBD。2例选择胆囊窝积液区穿刺腹腔置管及ENBD后腹部症状及体征未完全消失,复查腹部B超仍提示腹腔积液,在超声定位下取右下腹麦氏点穿刺置管引流后胆漏停止、腹部症状及体征完全消失。1例迷走胆管漏并发休克,纠正休克后急诊行腹腔探查、胆管切开引流术,术中出现呼吸、心跳骤停,心肺复苏成功,术中经胆总管注水发现胆囊床有直径约0.2mm胆管漏胆,放置T管缝合管壁后,T管缝线针眼渗胆,术后再次出现胆漏,经充分引流等治疗32 d后痊愈。腹部B超定位下腹腔置管引流术,治愈时间12、15 d,平均13.5 d。腹部B超定位下腹腔置管引流、ENBD,治愈时间2～5 d,平均2.8 d。12例随访12～24个月,平均15个月,无胆道狭窄、肠梗阻、胆管结石及其他并发症出现。结论 采用腹部B超定位下腹腔穿刺置管引流联合ENBD胆管减压治疗LC后迷走胆管漏,能达到开腹手术引流胆汁、胆道减压的效果,且具有创伤小,痛苦少,恢复快及住院时间短等优点,值得推广应用。     

Late cardiac tamponade following open-heart surgery. Diagnosis and treatment

Late cardiac tamponade is a rare but serious complication following open-heart surgery. It occurred in 9 (0.8%) of 1 094 consecutive patients 6 to 13 (median 8) days after operation. Six patients had undergone valve replacement and three coronary bypass surgery. All were on anticoagulant medication postoperatively (median TT index 7%). Early symptoms of cardiac tamponade were nausea and general malaise (present in all 9 cases), whereas classical signs of tamponade such as arterial hypotension and distended neck veins appeared late. The cardiac silhouette was radiographically enlarged in all cases, but this finding was seldom diagnostic. Computed tomography gave the surest diagnosis and permitted quantitative assessment of the fluid in the pericardium. Pericardial needle puncture was effective in temporarily relieving the tamponade, but insertion of a tube by the subxiphoid approach gave definitive drainage.     

Puncture method for the treatment of postnecrotic pancreatic cysts

Results of treatment of 39 patients with false pancreatic cysts with fine needle aspiration punctures are analyzed. Diagnostic and treatment value of method is discussed; technical aspects of puncture treatment are described. Aspiration puncture method was effective at 59% cases that permitted to reduce the number of external and internal drainage operations at the patients with false pancreatic cysts.