经口咽入路单节段固定治疗不稳定性寰椎骨折的研究进展

寰椎骨折是常见的颈椎骨折类型,由于上颈椎特殊的解剖结构,寰椎骨折通常为不稳定性骨折。以往的寰椎骨折治疗方法中,外固定往往带来低骨愈合率和远期颈痛,而颈枕融合与寰枢椎融合则牺牲了颈椎活动度。近年来,有学者经口咽入路到达寰椎前方,通过前路寰椎侧块螺钉及配套钢板同时完成骨折块的复位及固定,随访证明此术式保证骨性融合的同时最大程度地保留了颈椎活动度,还具有出血少、不剥离后路组织等优点,但存在术中脊髓与椎动脉的损伤及术后较高感染率等并发症,且对于其固定强度及手术的适应范围方面仍有待进一步研究证明。总之,经口咽入路单节段固定是治疗寰椎骨折的有效方法,给脊柱外科医师提供了新的思路。     

A new transoral modality for the treatment of lingual thyroglossal duct cyst with suspension laryngoscopy by plasma coblation

IntroductionLingual thyroglossal duct cysts (LTGDC) are a rare kind of thyroglossal duct cyst. However, Sistrunk surgery is not very suitable for this type of cyst. This study aimed to explore the efficacy of transoral excision of LTGDC by plasma coblation.MethodsThe present study reviewed 11 patients, comprising seven males and four females, who had been diagnosed with LTGDC preoperatively by computed tomography (CT) and fibre-optic electronic laryngoscopy. Of those patients, two had recurrence after surgery of epiglottic cysts. All these patients underwent transoral excision by plasma coblation. Then, we collected preoperative data of the patients, observed the effect of surgery, and analysed factors relevant to LTGDC, including the estimated bleeding amount, postoperative hospitalisation, complications and recurrence rates.ResultsThe connection between LTGDC and hyoid was tapered on sagittal images of CT, which was vital evidence for the diagnosis of LTGDC. Surgery was performed successfully for all 11 patients, and all recovered without complication. There was no evidence of recurrence after surgery, during follow up for 3–43 months.ConclusionsTransoral surgery for LTGDC can be performed successfully by plasma coblation, which is an effective and safe surgical treatment. Fibre-optic electronic laryngoscopy and CT are essential to the diagnosis of LTGDC in order to avoid missing detection and misdiagnosis.     

经口腔前庭入路腔镜甲状腺手术并发症预防及处理：单中心1 941例及文献报道152例多中心数据分析

背景与目的 经口腔前庭入路腔镜甲状腺手术（TOETVA）不仅可彻底切除病灶,而且术后完全无痕。但是此技术具有一定难度,手术并发症的出现不可避免。本研究以笔者所在中心临床数据为主,结合其他中心报道的数据,探讨此手术并发症预防及处理的经验。方法 回顾性分析笔者中心2016年3月—2022年10月期间2 710例甲状腺肿瘤患者行手术治疗的临床资料。其中1 941例行TOETVA,49例行经颏下联合经口腔镜甲状腺手术（TOaST）,110例行机器人辅助下经口甲状腺手术（TORT）,610例行传统颈部皮肤切开甲状腺手术（TCA）,分析各种甲状腺手术并发症的发生情况及处理,以及一项联合5家独立医疗机构关于TOETVA手术并发症的临床研究的数据。结果 笔者中心数据显示,TOETVA组出现皮肤损伤16例（0.82%）、气管损伤2例（0.1%）、暂时性喉返神经损伤38例（1.96%）,术后感染5例（0.26%）,永久性甲状旁腺功能减退1例（0.05%）;TOETVA组各项主要手术并发症发生率与其他术式组差异均无统计学意义（均P>0.05）;所有并发症均经适当的处理后缓解或自行痊愈。联合5家独立医疗机构的152例TOETVA手术并发症统计显示,皮肤损伤9例（5.9%）,气管破损3例（1.3%）,暂时性喉返神经损伤5例（4.7%）,术后感染1例（0.7%）。结论 TOETVA除了自身的优势外,并无增加的并发症发生率。笔者中心TOETVA手术并发症发生率低于文献报道,这提示手术例数的增多与经验的积累是减少TOETVA手术并发症手术质量的关键。     

The outcome of prolonged postoperative antibiotics on wound healing in orthognathic surgery: A meta-analysis

We conducted a meta-analysis to assess the outcome of prolonged postoperative antibiotics (PA) on wound healing in orthognathic surgery (OS). A systematic literature search up to January 2023 was performed and 1021 related studies were evaluated. The chosen studies comprised 1057 OS subjects who participated in the selected studies' baseline, 446 of them used short-term PA, and 611 used long-term PA. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of prolonged PA on wound infection after OS by the dichotomous methods with a random or fixed effect model. The short-term PA resulted in significantly higher wound infection (OR, 4.27; 95% CI, 2.97–6.14, P < 0.001) with low heterogeneity (I² = 27%) compared to the long-term PA in OS. The short-term PA resulted in significantly higher wound infection compared to the long-term PA in OS. Though care should be taken when dealing with the results since a large number of the selected studies had <100 subjects as a sample size.     

经口咽寰枢椎侧块关节复位块状骨支撑植骨治疗颅底凹陷症并寰枢椎脱位

目的:探讨经口咽寰枢椎侧块关节牵开复位、三面皮质块状骨支撑植骨、内固定治疗颅底凹陷症合并寰枢椎脱位的价值.方法:2009年12月～2011年12月我院收治33例合并寰枢椎脱位的颅底凹陷症患者,均有脊髓压迫症状.术前寰齿间隙(ADI)3.8～12.1mm (7.9±3.9mm),齿状突顶部与Chamberlain线的垂直距离(DCL) 3.0～15.6mm (9.3±6.2mm),寰枢椎垂直脱位指数(VAAI)0.35～0.51 (0.46±0.07),颈髓延髓角(CMA)112°～145°(127°±13°),JOA评分7～10分.均采用经口咽寰枢椎侧块关节牵开复位、三面皮质块状髂骨支撑植骨、TARP内固定术治疗.记录手术时间、手术出血量等,观察并发症发生情况.术后随访8～23个月,平均11.5个月,复查影像学评价寰枢椎脱位复位和脊髓压迫改善情况,采用JOA评分改善率对脊髓功能改善情况进行评价,在CT扫描图像上观察螺钉位置及植骨融合情况.结果:手术时间110～185min (145±35min),出血量35～85ml(58±18ml).共置入寰椎侧块螺钉66枚,枢椎逆向椎弓根螺钉41枚,枢椎椎体螺钉25枚.术后钉道扫描显示,寰椎螺钉均位于侧块内,2枚逆向枢椎椎弓根螺钉偏外进入椎动脉孔,导致椎动脉孔闭塞,小脑缺血梗死,其余枢椎螺钉均无偏差.术后发生咽后壁感染1例,将钢板取出后改行后路手术获得愈合.术后CT重建图像显示陷入枕骨大孔的齿状突获得较理想复位,脊髓受压解除,ADI改善为0.2～4.5mm( 2.3±2.1 mm),VAAI改善为0.6～0.84(0.74±0.08),CMA改善为140°～178°(157°±15°),与术前比较均有显著性差异(P＜0.01).植骨块镶嵌在寰枢侧块关节间隙,术后6～11个月均获骨性愈合.术后患者肢体麻木、肌肉无力等症状均较术前有明显改善,术后3个月复查JOA评分恢复至13～16分(15.2±0.9分),末次随访时为13～17分(15.3±0.8分),与术前比较均有显著性差异(P＜0.01).结论:经口咽寰枢椎侧块关节牵开复位三面皮质块状髂骨支撑植骨内固定术是治疗颅颈交界区病变的有效方法,但有一定风险和难度,应在严格掌握手术适应证和严格围手术期处理的条件下合理应用.     

Thyroglossal duct cysts in children: a 30-year survey with emphasis on clinical presentation,surgical treatment,and outcome

Background: Thyroglossal duct cysts (TGDC) are one of the most common congenital anomalies found in the anterior neck region of children. Sistrunk’s procedure, described in 1920 already, is still considered as the gold standard. However, clinical reality shows that in a minority of patients, marsupialization and simple cyst excision are still performed as well. Cyst recurrence is the most feared complication. The main goal of this retrospective study is to determine risk factors of recurrence. Furthermore, data on presentation characteristics, management and outcome were collected as well.

Methods: The data of 104 patients aged between 0 and 16 years who underwent surgery for TGDC at the University Hospital of Brussels between 1986 and 2016 were retrospectively analyzed. We focused on aspects of clinical presentation, intra- and postoperative treatment and long-term follow-up.

Results: Overall recurrence of TGDC was seen in twelve of the 104 cases (11.5%). Eight out of these 12 showed a preoperative infection, 4 out of 12 had intra-operative cyst rupture. Five out of the 12 patients had not been treated by the Sistrunk procedure, but by cyst excision or marsupialization only. Non-adherence to the Sistrunk procedure appeared to be the only significant risk factor of TGDC recurrence.

Conclusion: Our study shows that Sistrunk’s operation for thyroglossal duct cyst in pediatric patients is significantly superior in reducing the risk of cyst recurrence compared to other surgical treatments. Preoperative infection and cyst rupture did not influence the recurrence rates.     

Long-term outcome of idiopathic retroperitoneal fibrosis treated with surgical and/or medical approaches.

BACKGROUND: Retroperitoneal fibrosis is a severe disease that affects the ureters, causing renal insufficiency in three-quarters of patients. The optimal treatment is far from being established. METHODS: Seventeen patients with idiopathic retroperitoneal fibrosis and ureteral entrapment followed in our unit for at least 1 year were selected for this study. At presentation 13 patients had renal insufficiency. All patients received steroids, associated with ureterolysis in five (group 1), with azathioprine in six (group 2) and with tamoxifen in six (group 3). Four patients of group 2 and five of group 3 received ureteral stenting or nephrostomy. There were no significant differences among the three groups or the clinical and biochemical characteristics at presentation. RESULTS: All patients of groups 1 and 2 entered remission after therapy. One patient from group 3 did not respond to therapy. During a mean follow-up of 56 +/- 41 months, three patients (two from group 1, one from group 2, 18%) had a recurrence of the disease, which fully responded to retreatment in all three cases. At the last observation, all patients were alive; three patients (18%) had renal insufficiency, of them one from group 1 had to start dialysis 6 years after ureterolysis, one patient from group 2 and one from group 3 had serum creatinine of 1.5 mg/dl. Renal survival was 100% at 5 years and 80% at 10 years. CONCLUSIONS: In most patients, each of the three different therapeutic approaches restored renal function and significantly reduced the fibrotic mass in the short-term and maintained stable serum creatinine in the long-term.     

机器人与腹腔镜手术治疗造口旁疝18例临床分析

目的探讨达芬奇机器人和腹腔镜微创手术在造口旁疝治疗中的应用。 方法回顾性分析2018年4月至2022年4月在福建医科大学附属协和医院使用达芬奇机器人系统和腹腔镜行微创造口旁疝无张力修补术的18例患者资料。记录并比较两组手术时间、术中出血量、恢复进食时间、术后切口感染、麻痹性肠梗阻、引流管拔除时间、住院天数等,远期随访指标包括复发、补片感染、慢性疼痛。 结果18例均顺利完成造口旁疝无张力修补术,合并行造口重建术4例（22.2%）。Sugarbaker法修补13例（72.2%）,其中使用达芬奇机器人系统2例,使用腹腔镜11例;Keyhole法修补5例（27.7%）,其中使用达芬奇机器人系统1例,使用腹腔镜4例。手术时间191~406 min,平均（276.8±71.3）min。术中出血量20~100 ml,平均（29.3±22.2）ml。术后第2天恢复流质饮食,第3天进食半流质;放置引流管病例,术后5~7 d拔除引流管;常规腹带束缚3~6个月。术后住院时间3~19 d,平均（8.2±4.7）d。术后复发1例（5.6%）,切口感染1例（5.6%）,麻痹性肠梗阻3例（16.7%）,肺部感染6例（33.3%）,切口感染及麻痹性肠梗阻病例均经过非手术治疗后痊愈出院。随访期间均未出现复发、补片感染、慢性疼痛。 结论使用达芬奇机器人系统和腹腔镜进行微创造口旁疝无张力修补术均安全可行,围手术期并发症少,术后恢复快,疗效确切。     

“U”形截骨孟氏架外固定矫治膝内外翻畸形33例

本文通过对３３例膝内、外翻畸行“Ｕ”形截骨孟氏架外固定治疗及疗效观察，认灯一法矫形确切、固定牢靠、调整灵活、组织损小、截骨愈合早、功能恢复快、是膝内，外翻畸形手术治疗的好方法。     

生长抑素预防胰腺手术后胰瘘的Meta分析

目的:评价生长抑素是否可以降低胰腺手术后胰瘘的发生风险。方法:检索Pubmed(1966年1月—2012年11月)、EMBASE(1974年1月—2012年12月)、CENTRAL(2012年第4期)、中国期刊全文数据库(CNKI 1994年3月—2012年12月)以及美国临床肿瘤学会(ASCO)、欧洲肿瘤协会(EM-SO)官方网公开发表的关于生长抑素应用预防胰腺手术后胰瘘的临床随机对照研究(RCTs)。应用Stata11.0统计软件分析生长抑素组与对照组患者术后胰瘘发生率有无差别。结果:共15项研究纳入分析,其中生长抑素组纳入1 089例患者,术后发生胰瘘者141例;对照组1 035例,共241例患者发生胰瘘。Meta分析结果显示预防性应用生长抑素组患者术后胰瘘发生风险明显小于对照组(RR=0.63,95%CI:0.47～0.86,P=0.003)。结论:胰腺手术后预防性生长抑素可显著降低胰腺手术后胰瘘的发生风险。     

The effect of preoperative planning and impaction grafting surgical technique on intraoperative and postoperative complication rate for femoral revision patients with moderate to severe bone loss mean 4.7-year results

This study reports the results of 41 revision hips, implanted by a single surgeon using impaction grafting (mean follow-up, 4.7 years). All hips had Paprosky scores of III or IV. Harris hip scores improved from 43 to 82. There was 1 intraoperative and 2 postoperative fractures. A single stem was revised during the study. Radiographic review showed the 40 unrevised stems to be stable, and graft incorporation was seen in at least 1 zone in 100% of the femurs. There was no stem subsidence greater than 2.5 mm. The results of this study demonstrate that preoperative planning and a surgical technique, which emphasizes femoral support and vigorous impaction grafting, resulted in an acceptable incidence of complications.     

A review of 103 cases with elective repair for abdominal aortic aneurysm: an analysis of the risk factors based on postoperative complications and long-term follow-up

From 1982 through 1992, 103 patients (mean age: 69 years) underwent an elective repair of an abdominal aortic aneurysm (AAA) at our institution. One or more postoperative complications occurred in 30 patients (29%), with a mortality rate of 1.9%. Factors which were found to be significantly associated with postoperative complications based on an univariate analysis included male sex (P = 0.0082), operation time (P = 0.0006), the size of the aneurysm (P = 0.0045), the amount of blood loss during operation (P = 0.0037), poor lung function (P = 0.0155), and the platelet count (P = 0.0468),. A simple linear regression analysis showed that there were significant correlations among the AAA size, the duration of operation and the amount of blood loss. The age at operation, however, did not influence morbidity or mortality. Complete survival information was obtained in 96 (95%) patients, while the influence of preoperative risk factors on late survival was also examined by the Kaplan-Meier method. The factors influencing long-term survival were determined to be renal dysfunction and age at the time of operation.     

Familial dermal eccrine cylindroma (Turban Tumor) —A report of two cases with emphasis on the surgical approach

Summary Two patients with familial dermal eccrine cylindroma of the scalp and the face are reported. This rare, disfiguring disease may represent a serious challenge to plastic surgeons. The scant literature on this subject is reviewed, and all modalities of surgical treatment are discussed. A rather conservative approach is recommended for less florid cases.     

Cholesterol atheroembolic renal disease. Report of 3 cases with emphasis on diagnosis by skin biopsy and extended survival

Because antemortem diagnosis is difficult, renal failure due to cholesterol atheroembolism has, until recently, been regarded as a uniformly irreversible and generally fatal disease. Of late, recovery of renal function in several patients in whom the diagnosis was made by organ or other invasive biopsy has been reported. Three cases of cholesterol atheroembolic renal failure in which the diagnosis was made by simple, noninvasive biopsy of the skin in areas showing livedo reticularis are described. Two of the patients, including 1 who required dialysis for 2 months, had an extended survival with recovery of renal function.     

Long-term Result of Treatment of Prader-Willi Syndrome by Scopinaro's Bilio-pancreatic Diversion. Study of Three Cases and the Effect of Dextrofenfluramine on the Postoperative Evolution

The Prader-Willi syndrome shortens the life of patients due to the morbid obesity which it entails. The compulsive hyperphagia associated with it makes a dietetic treatment or a gastroplasty difficult. This study presents the case-histories of three patients suffering from the Prader-Willi syndrome who were operated on by means of a Scopinaro's bilio-pancreatic diversion. Following a marked reduction the first year, the weight loss stabilized and then tended to diminish. The observation of three cases which continued for two and a half to six years did not reveal any considerable metabolic problems. The deficiency of iron, vitamins D and B12 as well as folic acid had to be made up by supplementation. These results are comparable with the most favorable ones in the literature. Even if the effect on the weight loss is not spectacular, the operation manages to hold off the development of the obesity, inexorable for those with the Prader-Willi syndrome, and prevents lethal complications, without having notable side effects. Lifting coercive dietary measures improves the quality of life.     

A prospective survey of postoperative nausea and vomiting with special regard to incidence and relations to patient characteristics, anesthetic routines and surgical procedures

We performed a prospective study on 421 patients subjected to routine general-, orthopaedic-, urologic-, gynecological and paediatric surgery to estimate the current incidences of nausea and vomiting during the first 24 hours after surgery.
The overall incidences of postoperative nausea or vomiting were 17% and 28%, respectively. Postoperative emetic symptoms were not related to age in adults. Women had more often emetic symptoms than men ( P <0.01). In general, opiate premedication was more frequently associated with postoperative nausea and vomiting than benzodiazepines ( P <0.01), but in otherwise comparable subgroups of patients undergoing major surgery, this difference was not confirmed. Balanced general anaesthesia caused more nausea (23%) and vomiting (53%) than face-mask anaesthesia (13% and 15%, respectively) or regional blocks (12% and 7%, respectively) ( P <0.001). There was a positive correlation between the duration of anaesthesia and the incidence of postoperative emetic symptoms ( P <0.001). The incidences of postoperative nausea and vomiting after abdominal surgery were 23% and 58% respectively. Corresponding figures for orthopaedic surgery were 25% and 34%, other kinds of extra-abdominal surgery 18% and 32% and for laparoscopy 21% and 25%. After minor gynecological-, urological-and paediatric surgery the incidences were less than 20%.
In conclusion female gender, balanced anaesthesia, lengthy duration of anaesthesia, and abdominal and orthopaedic operations appeared to be most frequently associated with postoperative emetic symptoms.     

Spinal tuberculosis in a developed country. A review of 26 cases with special emphasis on abscesses and neurologic complications

A retrospective study of 26 cases was analyzed to review the sometimes unfamiliar clinical appearance and outcome of Pott's disease. Swiss nationals (46%) were older than patients from Mediterranean or developing countries (mean age, 69 versus 29 years). The number of vertebrae initially involved was 2.2. Localization was lumbar in ten cases, thoracic and lumbar in two, and thoracic or cervical in 14. Abscesses were present in 15 (57%) subjects and appeared during treatment in 20% of these cases. They were twice as frequent in non-Swiss patients. Three patients had surgery because of progression of the abscess under treatment. Ten cases needed single or multiple aspirations. Three of six lumbar abscesses were initially visualized only by computed tomography. Neurologic complications occurred in 12 (46%) patients, 11 of whom had cervical or thoracic vertebrae involved. In four cases (33%), the neurologic deficit developed during the first two months of treatment. Three patients had laminectomies, two without any benefit. Outcome was favorable for 11 of 12 patients without any difference between conservative treatment and surgery. Neurologic symptoms are in most cases related to radicular and medullary inflammation, with arachnoiditis and without compression. The possible benefit of steroids seems promising enough to warrant further investigation.     

Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection. An international audit by ESCP and S‐ECCO

Aim

Patient‐ and disease‐related factors, as well as operation technique, all have the potential to impact on postoperative outcome in Crohn's disease. The available evidence is based on small series and often displays conflicting results. The aim was to investigate the effect of preoperative and intra‐operative risk factors on 30‐day postoperative outcome in patients undergoing surgery for Crohn's disease.

Method

This was an international prospective snapshot audit including consecutive patients undergoing right hemicolectomy or ileocaecal resection. The study analysed a subset of patients who underwent surgery for Crohn's disease. The primary outcome measure was the overall Clavien–Dindo postoperative complication rate. The key secondary outcomes were anastomotic leak, reoperation, surgical site infection and length of stay in hospital. Multivariable binary logistic regression analyses were used to produce odds ratios and 95% confidence intervals.

Results

In all, 375 resections in 375 patients were included. The median age was 37 and 57.1% were women. In multivariate analyses, postoperative complications were associated with preoperative parenteral nutrition (OR 2.36, 95% CI 1.10–4.97), urgent/expedited surgical intervention (OR 2.00, 95% CI 1.13–3.55) and unplanned intra‐operative adverse events (OR 2.30, 95% CI 1.20–4.45). The postoperative length of stay in hospital was prolonged in patients who received preoperative parenteral nutrition (OR 31, 95% CI 1.08–1.61) and those who had urgent/expedited operations (OR 1.21, 95% CI 1.07–1.37).

Conclusion

Preoperative parenteral nutritional support, urgent/expedited operation and unplanned intra‐operative adverse events were associated with unfavourable postoperative outcome. Enhanced preoperative optimization and improved planning of operation pathways and timings may improve outcomes for patients.     

Observations on bronchiolo-alveolar carcinomas with special emphasis on localized lesions. A clinicopathological, ultrastructural, and immunohistochemical study of 11 cases

Pathological and clinical features in early localized mucinous and nonmucinous bronchiolo-alveolar carcinomas (BAC) have not been adequately compared. In an attempt to characterize such lesions, we studied the clinicopathological, ultrastructural, and immunohistochemical features of three mucinous and eight nonmucinous BAC (four Clara cell, four Type II pneumocyte) along with one sheep pulmonary carcinoma (SPC). Tumor border, associated fibroplasia, tumor cell incohesion, lymphocytic infiltrate, T-lymphocytes, Langerhans cells (LC), and Leu-M1 and OC 125 immunoreactivity were evaluated. Localized tumors of both types had a similarly favorable prognosis, even when the tumor size was greater than 3 cm or showed more complex histology. Type II pneumocyte carcinomas with tumor cell disassociation and desquamation or a pseudomesotheliomatous phenotype did poorly. Clara cell and type II carcinomas elicited an LC and T-lymphocyte immune response. LC and T-lymphocytes were absent in mucinous BAC and SPC. All of the three mucinous and three of the seven nonmucinous BAC were Leu-M1 negative, indicating that Leu-M1 may not distinguish between BAC and mesothelioma, especially in a small biopsy specimen. Tumors with absent or slight Leu-M1 immunoreactivity had a favorable outcome irrespective of cell type and presence or absence of LC. Inasmuch as OC 125 was negative in all cases of BAC, OC 125 may be a useful adjunct in the immunodiagnosis of mesothelioma. Our investigation supports the view that two different groups of tumors are assembled under the single nosologic entity of BAC: one, mucinous, which grows along an unaltered pulmonary alveolar framework and elicits a B-lymphocytic response, and the other, nonmucinous, which induces desmoplasia and elicits an LC and T-lymphocytic response. Only mucinous BAC represent a biologic entity distinct from conventional pulmonary adenocarcinomas.