钳式Ligasure和FOCUS超声刀在甲状腺癌手术中的应用比较

目的比较钳式Ligasure和FOCUS超声刀在甲状腺癌手术中的临床应用效果。方法回顾性分析2015年11月至2016年4月期间行甲状腺癌手术患者的临床资料,76例患者行全甲状腺切除+中央区淋巴结清扫术,由同一甲状腺专科医师完成,使用Ligasure完成手术者35例(Ligasure组),使用Focus超声刀完成手术者41例(超声刀组)。采用SPSS 19.0统计软件包分析,两组患者的肿瘤大小、术前血清钙值、PTH值、手术时间、术后24 h引流量等计量资料用(x珋±s)表示,采用t检验;ASA分级、术后并发症比较采用χ2检验,P0.05为差异有统计学意义。结果两组在手术时间、术后引流量及术后并发症的比较上差异均无统计学意义(P0.05)。两组患者均未出现永久性喉返神经损伤和永久性甲状旁腺功能减退,均未发生术后出血和切口内血肿。结论钳式Ligasure和FOCUS超声刀均能安全,有效地运用于甲状腺癌手术,达到相同的手术效果,术者可根据自身习惯选择合适的手术器械。     

甲状腺术后的甲状腺功能维护

甲状腺功能减退是甲状腺手术最常见的并发症.左甲状腺素钠（L-T4）是治疗甲状腺功能减退的首选药物,甲状腺功能维护可于术后早期进行,L-T4的需要量受多个因素及目标TSH的影响,实施过程中应考虑患者的特殊性（依从性差、妊娠、老年）,并定期（4～6周）复查甲状腺功能,根据目标TSH调整最佳用药剂量,避免治疗不足和治疗过度.T3分次给药或L-T4/T3联合治疗可作为L-T4治疗失败患者的选择.     

新型护理流程在腹股沟疝日间手术患者中的应用

目的探讨新型护理流程在腹股沟疝日间手术患者中的应用。 方法选取2018年6月至2019年6月,首都医科大学附属北京朝阳医院疝和腹壁外科日间腹股沟疝手术患者224例,采用随机数字表法将患者分为试验组和对照组,每组112例。2组患者均行腹股沟疝修补术,对照组患者采用普通病房日常管理模式,给予常规护理;试验组患者应用新型护理流程。2组术后均随访2～6个月,比较2组患者对护理的满意度、患者对腹股沟疝疾病知识知晓率及护士错误率、工作时间。 结果试验组总满意度高于对照组,差异有统计学意义（P<0.05）。试验组患者对疾病知晓率高于对照组,试验组护士错误率低于对照组,试验组护士工作时间明显少于对照组,差异均有统计学意义（P<0.05）。 结论对日间腹股沟疝手术患者运用新型护理流程进行病房管理,优化了医护人员工作流程,提高护理工作质量,提高了患者对疾病知晓程度,增加了参与感,整体就医感受满意度明显提高。同时护理资源得到有效利用,具有推广的价值。     

Influence of Helicobacter pylori infection on gastrointestinal symptoms and complications in bariatric surgery patients: a review and meta-analysis

Background

Numerous papers have discussed the importance of preoperative detection and eradication of Helicobacter pylori (HP) in bariatric patients.

Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay

Background In western countries, laparoscopic gastric banding is increasingly used in the surgical treatment of morbid obesity. This study aimed to investigate the feasibility, safety, morbidity, and costs of an outpatient procedure (OP) compared with an overnight stay (OS). Methods In a 2-year period, 50 consecutive patients were randomized to an OP group or an OS group. Results In the OP group, 76% of the patients were successfully discharged the same day, without readmissions. Four procedures were converted, and one complication occurred. The patients in the OP group seemed to experience more pain (p = 0.009). Satisfaction scores were 8.1 (OP) and 8.8 (OS) (p = 0.06). Half of the OP patients and most of the OS patients preferred a clinical admission. The OP treatment cost 600 euros less than OS. Conclusion With proper patient selection, laparoscopic gastric banding can be performed safely and at lower cost as an outpatient procedure.     

Laparoscopic donor nephrectomy with a 23-hour stay: a new standard for transplantation surgery

OBJECTIVE: To determine the outcomes associated with laparoscopic donor nephrectomy (LDN) performed as a 23-hour day surgery protocol. SUMMARY BACKGROUND DATA: Living donor renal transplantation is associated with immediate graft function and prolonged graft survival. The recent application of laparoscopic technology to living renal donation has refocused attention on the advantages of this donor source. LDN is associated with decreased donor pain, length of stay, time out of work, and opportunity costs. The authors hypothesized that LDN would be a viable 23-hour stay procedure. METHODS: All living donation procedures since May 1998 have been performed with LDN. The 23-hour protocol was initiated in January 1999. LDNs performed from May 1998 to December 1998 and traditional open donor nephrectomy procedures from May 1996 to May 1998 served as historical controls. The following variables were examined: donor sex, related versus nonrelated donation, operative time, blood loss, length of stay, time out of work, recipient and donor serum creatinine levels, hospital charges, and complications. RESULTS: The 23-hour LDN protocol was associated with high degrees of donor satisfaction. Thirty-six of the 41 donors were discharged within 23 hours; 1 was readmitted. Time out of work was equivalent to that of the control group; graft function was identical among all three comparison groups. Hospital charges were equivalent between the control group and the open nephrectomy group and were significantly decreased in the 23-hour group. CONCLUSIONS: Laparoscopic donor nephrectomy can be performed as a 23-hour stay procedure without incurring additional complications or donor dissatisfaction. By further decreasing opportunity costs and disincentives for donation, LDN may increase the number of potential donors appearing for evaluation.     

Neoadjuvant therapy and breast cancer surgery: a closer look at postoperative complications

Background

Neoadjuvant therapy is important in the treatment of advanced breast cancer.

Methods

Postoperative complications in neoadjuvant patients were analyzed.

Results

One hundred forty patients underwent 148 breast cancer surgeries after neoadjuvant therapy: 28% breast-conserving therapy procedures, 36% mastectomies, 28% mastectomies with immediate reconstruction, and 8% mastectomies with delayed reconstruction. Forty-seven patients (34%) suffered 59 complications: 18% of those undergoing breast-conserving therapy, 30% of those undergoing mastectomy, 44% of those undergoing mastectomy with immediate reconstruction, and 67% of those undergoing mastectomy with delayed reconstruction. Major complications occurred in 18% of patients. Skin loss occurred in 6% of patients. One patient had partial nipple necrosis. Three patients suffered implant loss. One patient had deep inferior epigastric artery perforator flap loss. Eleven hematomas and 5 infectious complications required reoperation.

Conclusions

Surgery after neoadjuvant therapy is safe, but careful counseling is warranted given that 18% of patients experienced major complications. Complications rates are higher with reconstruction, but feared complications of skin, nipple, implant, or flap loss were infrequent.     

How to perform a thyroidectomy in an outpatient setting

Purpose  In France, the current practice for postoperative care of thyroidectomy is still inpatient care. No series of outpatient thyroidectomy has been reported. The aim of this work was to assess the acceptability, feasibility, and safety of outpatient unilateral thyroid lobectomy in a university hospital. Materials and methods  The procedure was proposed to patients presenting with nodule(s) in one lobe of the thyroid and fulfilling predetermined inclusion criteria. The surgical protocol included no drainage and, progressively, no dressing. Standard anesthetic, analgesic, and antiemetic protocols were used. Unplanned admission, complication, and re-operation rates were evaluated. Results  Among 153 unilateral thyroid lobectomies performed, 95 (62%) were planned for outpatient surgery. The proportion of outpatient unilateral thyroid lobectomies increased during an 8-year period from 36% to 90%. One patient was re-operated because local hemorrhage was diagnosed in the recovery room. He was discharge the next day. Eighteen patients (13.7%) were admitted because of nausea (n = 6), dizziness, and physical discomfort mostly due to anxiety (n = 5). Seventy-seven patients were discharged as planned 6 to 8 h after the operation. No patient was readmitted. Conclusions  Outpatient unilateral thyroid lobectomy is feasible and safe in the setting of appropriate facilities and management protocol. Strict control of postoperative nausea is essential, and a preoperative education for ambulatory surgery is useful to minimize patient anxiety and increase acceptability.     

Varicocoele surgery as day surgery—a regional hospital experience

From July 1994 to February 2001, 60 patients underwent varicocoele surgery in the Day Surgery Centre, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, PRC. The mean age of these patients was 25.9 years (ranged 9–66). Their symptoms included pain/discomfort (41.7%), mass/swelling (36.7%), infertility (8.3%) and cosmetic reasons (1.7%). In seven patients the indication was not clearly defined. 31 (51.7%) varicocoele operations were laparoscopically performed, 26 (43.3%) by an open method and in four patients (6.7%) the method was not mentioned. The median operative time was 34 min. We successfully reduced or abolished the symptoms of varicocoele in 68.7% of patients whose indication was pain or discomfort and restored fertility in 80% of patients whose indication was infertility. There was only one unplanned hospital admission. There were no anaesthetic or post-operative complications. Varicocoele surgery performed on a day surgery basis is feasible, with a high operative success rate and potential cost reduction.     

A comparison of laparoscopic and open hernia repair as a day surgical procedure

To evaluate the merits of laparoscopic inguinal hernia repair (LHR) compared to conventional open hernia repair (OHR) a randomized study has been conducted.All patients were day surgical cases, of which 44 were randomized to a standardized OHR under local anesthetic (LA) and 42 to an LHR under general anesthesia (GA). Fifteen LHR patients had bilateral repairs.Operative time for OHR was 30.5 min, for unilateral LHR 35 min, and for bilateral LHR 60 min. OHR patients were discharged after a median of 134.5 min, which was significantly shorter than LHR patients, whose median discharge was 225 min (P<0.01). Pain scores, activity levels, analgesia requirements, and time taken to return to work were not significantly different following surgery in either group (P<0.05). There have been two recurrent hernias and one small bowel obstruction in the LHR group.We conclude that both repairs can be successfully performed as day surgical procedures. The added cost of LHR at this stage does not warrant its widespread use in unilateral hernia repairs. Which procedure is adopted should be individualized; however, patients with bilateral hernias on presentation can be successfully managed as day cases, obviating the need for hospitalization or two operations.     

Early bioavailability in day surgery: a comparison between orally, rectally, and intravenously administered paracetamol

Purpose:

Compare early bioavailability of rectal, effervescent oral, and i.v. paracetamol.

Scope:

Five groups of N = 7 patients received 1 or 2 g paracetamol orally or rectally or 1 g i.v. immediately after day surgery. Paracetamol concentrations taken after 20, 40 and 80 min. Median plasma paracetamol concentrations for 1 versus 2 g effervescents were 78 (25-114) versus 108 (95-146) μmol L⁻¹ at 80 min and 16 (9-30) versus 17 (10-30) μmol L⁻¹ for 1 versus 2 g suppositories. Paracetamol i.v. gave median 97 (77-135) μmol L⁻¹ after 40 min.

Conclusion:

Only intravenously and 2 g effervescent paracetamol gave therapeutic concentrations during the period studied.     

Surgeon's experience as a factor for emetic sequelae after middle ear surgery

Purpose: To test the hypothesis that an experienced surgeon is associated with less postoperative nausea and vomiting (PONV).
Methods: A post hoc analysis was done on the data of 167 patients from 3 randomized studies on the prevention of PONV, with transdermal scopolamine, ondansetron and propofol, in middle ear surgery under general anaesthesia.
Results: The patients in the residents' group suffered more from PONV (69% vs. 42%, P <0.01) and from retching or vomiting (52% vs. 23%, P <0.001) than those in the specialists' group. The proportion of patients needing droperidol was also higher in the residents' group (66% vs. 27%, P <0.001). The durations of anaesthesia and surgery seemed to correlate positively with PONV. In matched-pair analysis, residentship was confirmed as a risk factor for emetic symptoms. In the residents' group, prophylaxis of PONV resulted in a decrease in retching and vomiting from 71% to 29% ( P <0.01), and in patients needing droperidol from 87% to 46% ( P <0.01).
Conclusion: The patients operated by residents need more aggressive prophylaxis for PONV than those operated by specialists in middle ear surgery.     

重睑术后并发上睑下垂的临床研究

目的探讨重睑术后并发上睑下垂的临床表现及其发生原因，并尝试其矫正方法。方法根据重睑术后上睑下垂程度的不同，将其临床表现大致分为3度，对25例重睑术后并发上睑下垂患者行矫正术，术中根据粘连的情况分析其产生原因，并根据不同原因采取不同的解决方法。结果该组25例，其可能发生的原因主要是由于手术操作不当导致上睑提肌腱膜损伤、腱膜与眶隔或皮肤发生粘连，导致上睑提肌的负荷增加或功能受限。结论上睑局部解剖结构在重睑术中有重要意义，只要熟悉眼睑的解剖层次，并谨慎操作，可避免重睑术后上睑下垂并发症的发生。     

Breast asymmetry following thoracic surgery in childhood

Asymmetrical breast development may result from direct damage to breast tissue by burns, radiation, or breast surgery. However, asymmetrical development may also occur after childhood thoracic surgery. Two such cases are described, in which reduction mammoplasty has been or will be performed after developmental maturity.