Total pancreatectomy in the treatment of acute necrotising and hemorrhagic pancreatitis indications-technique

The place of total pancreatectomy in the treatment of pancreatitis is still not clear: the author is in favour of this operation and gives the indications, surgical technique, complications and results. The operation is indicated in cases of necrosis involving more than ${\raise0.5ex\hbox{${\raise0.5ex\hbox{ rds of the gland, or the whole of the head and part of the body of the pancreas. The duodenum and pancreas should be removed in one piece and intestinal continuity should be restored performing choledocho-jejunal and gastro-jejunal anastomoses.It is important to carry out this operation early, between the 3rd and 6th days, treating all areas of necrosis before the lesions become the site of uncontrollable infection.     

Three cases of occult thyroid cancer with mediastinal lymph node metastasis manifesting as a mediastinal cyst

We experienced three cases (one 38-year-old male, 58-year-old and 67-year-old females) whose resected mediastinal cysts proved to be metastatic lymph nodes from occult thyroid cancer. Primary lesions in thyroid gland were detected by echography in all three cases though they were detected in one case out of two by CT, in one out of three by 201T1 scintigraphy, in two out of three by 123I scintigraphy. After these examinations on thyroid gland, operations (one lobectomy, one hemithyroidectomy, one total thyroidectomy) were performed. Primary lesions in thyroid gland were all papillary carcinomas, and ranged 4 x 3 mm to 12 x 10 mm in size. Multiple foci were found in two cases, many intrathyroidal metastases in one case, cervical lymph node metastases in two cases. In cases of mediastinal cyst, thyroid gland should be examined by echography paying attention to the mediastinal lymph node metastasis from occult thyroid cancer. When occult thyroid cancer with mediastinal lymph node metastasis is diagnosed, total thyroidectomy followed by 131I radiation therapy is recommended as the treatment for a primary lesion, because of multiple foci in thyroid gland and intrathyroidal metastases.     

Management of the facial nerve in parotid gland surgery

Sacrifice of the facial nerve leaves a severe cosmetic deformity, but is necessary in the management of some malignant tumors of the parotid gland. Of 1,600 patients with tumors of the parotid gland seen at the Mayo Clinic over a twenty-two year period, 296 had malignant tumors of this gland; part or all of the facial nerve was sacrificed in 102 patients. Removal of the nerve was more often necessary in patients who had had previous operation for tumor of the parotid gland or who had tumors of high degree of malignancy; it also was necessary in some cases of cylindroma. In general, it is concluded that for tumors of a moderate degree of malignancy (mucoepidermoid carcinoma, acinic cell carcinoma, and cylindroma [adenocystic carcinoma]) the nerve may be preserved; the need for partial or total sacrifice of the nerve is determined on a selective basis depending on the anatomic findings in the course of the operation. For more undifferentiated tumors, the nerve almost always should be sacrificed and the gland with the tumor can be removed en bloc. If the nerve has to be removed, a free nerve graft should be considered to bridge the defect; good results can be expected in more than 70 per cent of these cases.     

肾上腺囊性疾病的诊治（附23例报告）

目的：探讨肾上腺囊性疾病的诊治方法及手术适应征,方法：总结我院1980年1月－2000年2月期间收治的肾上腺囊性疾病患者23例临床资料,其中单纯性囊肿16例,假性囊肿6例,包虫性囊肿1例,作保守治疗,3例,手术治疗20例,其中作囊肿去顶减压13例,肾上腺切除4例,根治性肾上腺切除1例,囊肿姑息切除1例,包虫内囊切除1例。结果：除2例恶性肿瘤患者在5个月内死亡外,21例患者均健在,临床症状消失。结论：对直径＜3cm的单纯性囊肿宜作保守治疗,严密随访,对假性囊肿,包括出及肿瘤源性,寄生虫性,直径＞3cm的单纯性囊肿,宜采用手术治疗。     

Endothoracic goitre: anatomoclinical and therapeutic considerations

Substernal goitre is a clinical condition in which the masin bulk of the enlarged gland is firmly located in the chest. The incidence of this pathology ranges in literature from 1.7% and 30%. This study examines 230 cases of substernal goitre out of a total 5.362 operations performed from 1965 to 2000, for thyroid gland pathologies (4.36%). According to their experience the Authors propose a classification based on the anatomical location of the goitre: right, left, anterior and posterior goitre are therefore identified. The surgical procedures performed include 136 subtotal thyroidectomies (59.1%), 59 emithyroidectomies (25.7%) and 23 total thyroidectomies (10%). In 12 cases the operation was confined to removal of the mediastinal mass (5.2%). The cervical approach was the only surgical access route used in all the patients, regardless of the different anatomical variants. Appreciable venous stasis, due to the mediastinal mechanical obstruction exerted by the goitre, was always evident at the operation. In order to limit the risk of bleeding during operation, careful hemostasis of the major vascular pedicles must be performed. Any attempt to legate the smallest vessel, should be avoided since it is a difficult, useless and time-consuming procedure. Minor bleeds promptly stop as soon as the pathological mass is removed. Ligation of the vascular pedicles can be easily achieved; in this way, the goitre is freed from its anatomical connections and the surgeon can safely manage the substernal portion of the mass. The mortality reported in this study was 0.43% (one patient died 30 days postoperatively due to respiratory complications), whereas the morbidity rate was 2.6%.     

Determination of necrosis in necrotizing pancreatitis

The diagnosis of necrosis and its extent in acute necrotizing pancreatitis is one main problem in establishing criteria for possible pancreatectomy. With this in mind a clinicopathological analysis was carried out on 54 patients who had undergone pancreatic resection for acute necrotizing pancreatitis. The macroscopic appearance of the gland correlated poorly with its histology. Parenchymal necrosis varied from 0 to 100 per cent of the resected specimen though all the glands were considered totally or subtotally necrotic. In the clinicobiochemical status no criteria were found determining the extent of necrosis. Obesity, hypotension, hypocalcaemia and elevated serum creatinine in severely ill patients (as determined by Ranson criteria) strongly supported extensive peripancreatic and septal necrosis; however, 38 per cent of patients developed necrosis without those stigmata. While waiting for new methods to determine necrosis we prefer conservative treatment. In contrast to our previous tactics we think that resection should be limited to extreme cases in order to avoid resection of glands with limited necrosis and thus mainly reversible parenchymal damage.     

可选择供血血管的足外侧皮瓣移植术

目的 总结临床应用足外侧皮瓣移植术的经验。方法 1992年起，开展选择供血血管的足外侧皮瓣移植术58例（67侧），其中单独移植30例，与足背其它皮瓣联合移植28例（37侧）。结果 术后55例（64侧）皮瓣完全成活，2例皮瓣全部坏死，1例皮瓣部份坏死。结论 足外侧皮瓣为多元性供血，手术时根据供，受区情况可灵活选择皮瓣的供血血管。     

脐外侧襞在腹股沟嵌顿疝修补术中应用的临床研究

目的探讨脐外侧襞疝修补手术在腹股沟嵌顿疝中的应用价值。方法选择腹股沟嵌顿疝并肠梗阻65例患者实施经腹疝内容物还纳，缝合疝囊颈口腹横肌，利用脐外侧襞对疝内口腹壁薄弱区域进行修补。结果62例患者成功进行手术，3例因肥胖脐外侧襞不明显，游离疝囊，缝合封闭内环口及周围腹；手术时间35～90min，平均56min；术后8～12h患者能下床活动，腹腔引流管均在术后2～4d内拔除，平均住院时间6．8d；所有患者无切口感染、肠漏、腹腔脓肿、腹膜炎、肠梗阻等并发症发生，康复出院。所有病例术后随访3～36个月，复查无复发。结论根据患者情况有选择经腹利用脐外侧襞修补腹股沟嵌顿疝是一种安全、有效、可行的方法，值得推广。     

Transsphenoidal pituitary surgery in the treatment of patients with Cushing's disease

Transsphenoidal adenomectomy is the treatment of choice for patients with Cushing's disease. The combination of high serum and urinary cortisol and high plasma ACTH point to a nonadrenal source for Cushing's syndrome. It is important to rule out an ectopic source of ACTH production. Imaging of the sella with MRI and CT and sampling petrosal sinus blood for ACTH measurement should allow differentiation between the two conditions. For younger patients, every effort should be made to preserve the normal gland. If in the younger patient the adenoma cannot be clearly demonstrated, it is appropriate to remove the central portion of the gland, as advocated by Hardy. Should hypercortisolism persist, radiation therapy to the sella should be considered before attempting total hypophysectomy. In the woman past childbearing age, a total hypophysectomy can readily be considered if a sharply demarcated adenoma is not found. In fact, we counsel our older patients before operation that a total hypophysectomy is a possibility. For the patient with an aggressive tumor that is not cured by pituitary operation, radiation therapy must be considered. If it is not possible to wait for the therapeutic effect of radiation, adrenal suppression with aminoglutethimide, metyrapone, or ketoconazole is indicated. Adrenalectomy may be considered.     

Tuberculosis of the breast]

The author observed 6 cases of mammary gland tuberculosis. 3 patients showed disseminated nodular form of mammary gland tuberculosis, 2--sclerotic form and 1--ulcerative form. Contrast-free mammography is an essential aid in diagnosis. Surgical intervention with postoperative specific antibacterial therapy is a radical method of treatment. Sectoral resection of the mammary gland should be carried out in young patients and amputation--in elderly ones.     

肠系膜上静脉血栓形成32例诊疗体会

目的探讨肠系膜上静脉血栓形成(MVT)的诊断与治疗。方法回顾性分析我院2000年~2004年收治的32例MVT的临床资料。结果本组行手术治疗14例。其中,有2例行二次手术治疗。治愈29例,死亡3例。结论提高对本病的认识,及时应用螺旋CT三维重建等检查方法早期诊断及围术期采取恰当的溶栓、抗凝治疗是防止复发、降低病死率的重要措施。手术治疗仅适用于出现腹膜炎等肠坏死征象的病例。强调彻底扩大切除坏死肠管及相应系膜。     

自发性肾上腺出血

目的　提高自发性肾上腺出血的诊治水平。　方法　回顾性总结 1 1例自发性肾上腺出血患者的诊治资料。　结果　 1 0例仅表现为患侧腰痛 ,1例为输尿管癌术中发现肾上腺肿物。肾上腺功能均正常。B超检查 1 1例 ,3例表现为囊性肿物 ,其内可见点状、分隔样强回声 ,7例表现为低回声肿物 ,1例输尿管癌术前肾上腺B超正常。 1 0例CT扫描表现为卵圆形、边界清楚低密度病灶 ,CT值 34 .7～ 85 .0HU ,>50 .0HU者 6例 ,其中 1例可见液平面 ;增强CT扫描 3例 ,肿物无强化。MRI检查 3例 ,显示肾上腺区不均匀肿物 ,T1加权像为等信号 ,T2加权像为低信号。行肾上腺及肿物切除术 6例 ;行部分肾上腺及肿物切除术 5例。术后病理为肾上腺髓质内出血 ,血肿外包绕肾上腺组织。术后肾上腺皮质功能正常 ,随访 7个月～ 8年 ,无肾上腺皮质功能低下表现。　结论　B超、CT、MRI可以帮助诊断自发性肾上腺出血。双侧肾上腺出血、腰腹痛症状明显、单侧肾上腺出血但血肿 >5cm者应采取手术治疗 ,行部分肾上腺及血肿切除术 ,尽量保存血肿周围健康肾上腺组织。     

重症急性胰腺炎的手术治疗探讨

目的 探讨重症急性胰腺炎的手术治疗和非手术疗法转手术治疗的指征和时机。方法 回顾性分析1996年1月至1999年12月收治的重症急性胰腺炎213例。结果 重症胆源性胰腺炎手术治疗52例,治愈率为92%。死亡病例平均生存31d,主要死亡原因是多器官功能衰竭（MODS）和胰腺坏死感染;非手术治疗43例,治愈率为88%。死亡病例平均生存3d,主要死亡原因为中毒性休克、严重感染和MODS。重症非胆源性胰腺炎手术治疗65例,治愈率为75%。死亡病例平均生存56d,死亡原因有MODS、感染、消化道瘘和腹腔内出血;非手术治疗56例,治愈率89%。死亡病例平均生存8d。早期死亡的原因有休克、肾功能衰竭和呼吸衰竭等,后期死亡的原因主要是感染。结论（1）胆源性胰腺炎有胆道梗阻者应行急诊手术,出现坏死感染也需手术治疗;（2）非胆源性胰腺炎宜先采用非手术治疗。出现坏死感染者需要手术治疗,对病情迅速恶化者也应及时手术引流;（3）胰腺的包裹坏死液化感染需要手术治疗。     

乳腺积乳囊肿的病因及诊治

本文报告乳腺积乳囊肿56例。年龄23～52岁,平均27.5岁。术前50例诊断正确,误诊6例。特别提出局部肿块波动感试验阳性,A超显示液平段,B起显示无回声,试穿抽出乳汁,对诊断有一定价值。治疗以手术切除为主;仅有7例穿刺抽吸乳汁得以治愈。     

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目的 总结分析甲状腺Hürthle细胞肿瘤诊治经验.方法 回顾性分析东南大学附属中大医院2002-2006年收治的15例甲状腺Hürthle细胞肿瘤的临床病理资料.结果 病人均以发现颈部包块就诊.女性14例.术前甲状腺功能检查均正常,B超、ECT无法确诊,细针穿刺发现Hürthle细胞.术中快速冰冻均能确诊.15例中,13例为良性,其中8例行腺叶切除加峡部切除,3例单纯腺叶切除,2例合并甲状腺乳头状癌而行根治术;2例为恶性,均行根治手术.术后随访无复发.结论 应充分认识甲状腺Hürthle细胞肿瘤,重视细针穿刺细胞学检查.术中冰冻切片检查对诊断很重要.选择合适的手术方式可使病人获得良好的预后.     

颌面颈部巨大良性肿瘤的整形外科治疗

目的:研究面颈部巨大良性肿瘤的整形外科治疗。方法:回顾性分析1993年到2004年的6例面颈部巨大肿瘤的整形外科治疗方法。结果:6例面颈部巨大肿瘤中神经纤维瘤1例,淋巴管瘤3例,脂肪瘤1例,腮腺混合瘤1例,除1例经过4次手术外,其余5例均行1次手术治疗,效果良好。结论:面颈部巨大的肿瘤患者大多伴有面颈部软组织及骨组织畸形,在手术中应遵循整形美容外科及微创治疗的原则,进行颌面颈部的外形及功能整形。     

距骨损伤与距骨坏死及其治疗

目的　探讨距骨损伤对距骨缺血坏死的影响及其治疗方法。方法　本文通过 2 5例距骨重度骨折脱位、 3例距骨全脱位和 17例距骨周围脱位的治疗 ,并分别经平均 7年和 2年 5个月的随访观察 ,来分析三种不同类型的损伤对距骨缺血坏死的影响。结果　距骨重度骨折脱位和全脱位缺血坏死率和创伤性关节炎发生率达 10 0 % ,距骨周围脱位则无缺血坏死发生。作者比较重度距骨骨折脱位和全脱位采用切开复位内固定、距骨切除和关节融合术三种治疗方法的结果 ,仅融合术最为满意。结论　作者建议在距骨有发生缺血坏死高危损伤的病例 ,融合术应是首选的方法     

SuperPATH微创人工全髋关节置换的早期疗效及临床应用价值

目的探讨SuperPATH微创人工全髋关节置换术的早期疗效及临床应用价值。方法采集2016年5月至2017年6月间我院收治的60例(35例股骨头坏死,25例股骨颈骨折)需行人工全髋关节置换术患者相关资料,30例行SuperPATH经皮辅助入路纳入实验组,其中男20例,女10例,股骨头坏死16例,股骨颈骨折14例,平均年龄为(71.2±3.1)岁;30例行常规后外侧入路纳入对照组,其中男15例,女15例,股骨头坏死19例,股骨颈骨折11例,平均年龄为(71.2±3.2)岁。观察两组手术切口长度、手术时间、术中出血量、术后引流量、手术前后血红蛋白变化及术后1周、1个月、3个月、6个月疼痛视觉模拟评分(visual analogue scale,VAS)和Harris评分。结果实验组的手术切口长度、术中失血量、术后引流量、手术前后血红蛋白变化均较对照组少,差异具有统计学意义(P<0.05),实验组手术时间较对照组长,差异具有统计学意义(P<0.05);术后1周、1个月随访时两组VAS评分、Harris评分比较,差异具有统计学意义(P<0.05);术后3个月随访时两组VAS评分比较,差异无统计学意义(P>0.05),两组Harris评分比较,差异具有统计学意义(P<0.05);术后6个月随访时两组VAS评分、Harris评分比较,差异无统计学意义(P>0.05)。结论SuperPATH入路微创人工全髋关节置换术治疗股骨头坏死和股骨颈骨折较传统后外侧入路全髋关节置换术具有软组织损伤小、出血少,术后恢复快、近期疗效较好等优点,患者满意度高,可实现术后快速康复。     

Histologic assessment on resected hepatocellular carcinoma specimens with preoperative transcatheter hepatic arterial chemo-embolizations]

Twenty-six cases of hepatocellular carcinoma were divided randomly into 3 groups, treated by transcatheter hepatic arterial chemo-embolizations with agents of MMC 20 mg, MMC 20 mg plus lipiodol 10 ml, and MMC 20 mg plus MTXmc 150 mg, respectively, 2 to 3 weeks before surgery. Pathologically, all main tumors in the resected specimens were necrosed to a certain extent, with extensive necrosis in the MMC-MTXmc group, whereas there was no necrosis of cancer cells in tumor capsules, daughter nodules, and intraportal vein emboli. We consider that the transcatheter arterial chemoembolization is effective in reducing tumor burden, but not enough in eradicating all cancer cells, so surgical resection should be carried out whenever resection is possible. For preventing tumor recurrence, direct puncture of the main trunk of the portal vein to infuse 500 mg of 5-FU during operation and injection of MMC 20 mg through a catheter inserted into the hepatic artery 4 weeks after operation is suggested.     

乳房下垂矫正术中的乳房悬吊结构重建

目的总结用乳房悬吊结构重建方法矫正轻、中度乳房下垂的临床经验。方法通过乳晕边缘切口，去除上半腺体后松弛的浅筋膜深层，上提腺体至正常位置并固定于深筋膜，腺体浅面按真皮乳罩原理进行悬吊并适当切除乳晕周边多余皮肤，或采用聚丙烯单丝网片对腺体进行悬吊，术后腺体周围形成强大的纤维粘连，从而重建乳腺的悬吊支持结构。同时进行腺体的适当折叠塑形或置入乳房假体增加丰满程度。结果共行轻、中度下垂32例手术（其中单纯悬吊10例，悬吊同时假体隆乳20例，采用聚丙烯网片悬吊2例），手术时间90～150min，平均110min。术中出血量30～100ml，平均58ml。均未发生乳头乳晕坏死感觉障碍等并发症。术后随访6～12个月，平均11．3月，术后外形改善满意率90．6％（29／32）。结论对于不伴腺体肥大的乳房轻、中度下垂，采用乳房悬吊结构重建，是一种创伤相对小，安全，有效的矫正方法。