经劈三角肌入路与经三角肌胸大肌入路治疗肱骨近端骨折临床疗效的Meta分析

目的通过Meta分析评测经劈三角肌入路与三角肌胸大肌肌间隙入路治疗肱骨近端移位骨折的临床疗效。 方法检索Pubmed、Embase、等知名数据库,辅以手工检索、文献追溯相关文献,收集2006年1月至2018年04月国内外已发表两种手术入路的对照研究文章。严格评价纳入研究的文献质量及提取相关数据资料,运用RevMan5.3软件统计分析相关数据行Meta分析。 结果纳入10项对照研究,共789例患者。结果分析显示：经劈三角肌入路和三角肌胸大肌入路在手术时间（95% CI：-26.56~9.77,P<0.00001）、术中出血量（95% CI：-73.79~-19.54,P<0.00001）、住院天数（95% CI：-1.35~-0.60,P<0.00001）、术后3个月Constant评分（95% CI：4.38~6.92,P<0.00001）、术后6个月日常生活能力量表（ADL）（95% CI：0.27~2.02,P=0.01）方面,差异均有统计学意义。术后6个月（95% CI：-1.66~6.74,P=0.24）、12月Constant评分（95% CI：-7.01~7.73,P=0.92）、术后12个月ADL（95% CI：-0.18~1.49,P=0.12）、上肢功能评分（DASH）（95% CI：-4.91~2.47,P=0.52）、并发症（95% CI：0.55~1.34,P=0.51）等方面差异无统计学意义。 结论经劈三角肌入路手术时间更短、术中出血量更少、住院时间减短、术后早期功能恢复更好。但在并发症发生率、晚期上肢功能等方面尚无足够证据证明其有明显差异。     

Clinical effect of abdominal aortic aneurysm endografting: 7-year concurrent comparison with open repair

OBJECTIVE: We compared the effectiveness and clinical outcome of open repair versus endovascular aortic aneurysm repair (EVAR) in achieving prevention of abdominal aortic aneurysm (AAA)-related death and graft-related complications. METHODS: Over 7 years from 1997 to 2003, 1119 consecutive patients underwent elective treatment of infrarenal AAAs, 585 with open repair and 534 with EVAR. Patients were regularly followed up at 1, 6, 12 months, and every 6 months thereafter, in EVAR group, and at 3 and 12 months, and yearly thereafter after open repair. Preoperative, intraoperative, and follow-up data were stored in a prospective database. RESULTS: Median follow-up was similar in the 2 groups: 33 months (interquartile range [IQR], 13-50 months) in the EVAR group vs 35 months (IQR, 15-54 months) in the open repair group. EVAR group patients were older than patients in the open repair group: 73 years vs 72 years (P = .04). There were statistical significant differences between the EVAR group and the open repair group with respect to AAA median diameter (52 mm vs 56 mm), coronary disease rate (46% vs 37%; P = .001), pulmonary disease rate (56% vs 38%; P < .0001), and American Society of Anesthesiologists IV score rate (16% vs 6%; P < .0001). Thirty-day mortality in the EVAR group was 0.9% (5 of 534 patients), compared with 4.1% (24 of 585 patients; P = .001) in the open repair group, and major morbidity was 9.1% (49 of 534 patients) vs 18.6% (109 of 585 patients; P < .0001), respectively. The incidence of secondary procedures in the EVAR group was 15.7%, compared with 3% in the open repair group (P < .0001). There were no deaths related to secondary procedures in either group. Six AAAs (1.1%) ruptured after EVAR, 3 of which were fatal; in the open repair group 1 patient (0.2%) underwent successful repeat operatation to treat iliac pseudoaneurysm rupture 5 years after the original procedure. Kaplan-Meier estimates for freedom from aneurysm-related death at 84 months were 97.5% in the EVAR group and 95.9% in the open repair group (log rank test, P = .008). Kaplan-Meier survival estimates at 84 months were 67.1% in the open repair group and 66.9% in the EVAR group (P = NS). At the same interval the risk for secondary procedures was 49.4% for the EVAR group and 7.1% for the open repair group. Of the 11 variables analyzed with logistic analysis, open surgery (hazard ratio [HR], 11; 95% confidence interval [CI], 2.5-54.2; P = .002), American Society of Anesthesiologists IV score (HR, 7.1; 95% CI, 2.7-18.8; P = .0001), and age (HR, 1.06; 95% CI, 1.04-1.13; P = .04) were positive independent predictors of perioperative mortality. CONCLUSION: Our data suggest that at a maximum follow-up of 7 years, patients who undergo EVAR show lower perioperative and late aneurysm-related mortality compared with a younger and substantially healthier group of patients with aneurysms treated with open repair. The higher need for secondary procedures in the endovascular group did not affect superiority of the overall performance of EVAR in the early and late intervals.     

Randomized controlled trial of bipolar diathermy vs ultrasonic scalpel for closed hemorrhoidectomy

AIM:To compare hemorrhoidectomy with a bipolar electrothermal device or hemorrhoidectomy using an ultrasonically activated scalpel.METHODS:Sixty patients with grade Ⅲ or Ⅳ hemorrhoids were prospectively randomized to undergo closed hemorrhoidectomy assisted by bipolar diathermy(group 1) or hemorrhoidectomy with the ultrasonic scalpel(group 2).Operative data were recorded,and patients were followed at 1,3,and 6 wk to evaluate complications.Independent assessors were assigned to obtain postoperative pain scores,oral analgesic requirement and satisfaction scores.RESULTS:Reduced intraoperative blood loss median 0.9 mL(95% CI:0.8-3.7) vs 4.6 mL(95% CI:3.8-7.0),P = 0.001 and a short operating time median 16(95% CI:14.6-18.2) min vs 31(95% CI:28.1-35.3) min,P < 0.0001 was observed in group 1 compared with group 2.There was a trend towards lower postoperative pain scores on day 1 group 1 median 2(95% CI:1.8-3.5) vs group 2 median 3(95% CI:2.6-4.2),P = 0.135.Reduced oral analgesic requirement during postoperative 24 h after operation median 1(95% CI:0.4-0.9) tablet vs 1(95% CI:0.9-1.3) tablet,P = 0.006 was observed in group 1 compared with group 2.There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications.CONCLUSION:Bipolar diathermy hemorrhoidectomy is quick and bloodless and,although as painful as closed hemorrhoidectomy with the ultrasonic scalpel,is associated with a reduced analgesic requirement immediately after operation.     

压力控制容量保证模式用于老年患者术中机械通气的Meta分析

目的 系统评价压力控制容量保证模式(PCV-VG)用于老年患者术中机械通气的有效性和安全性。方法 计算机检索PubMed、Web of Science、The Cochrane Library、中国期刊全文数据库(CNKI)、万方和维普数据库,检索PCV-VG用于老年患者术中机械通气的随机对照试验(RCT),检索时限均从建库至2022年1月31日。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用RevMan 5.4软件进行Meta分析。结果 共纳入12篇文献,共计患者749例,PCV-VG组374例,对照组375例。术中机械通气时两组PaO₂(MD=5.32 mmHg, 95%CI-0.55～11.18,P=0.08)、PaCO₂(MD=0.12 mmHg, 95%CI-0.18～0.41,P=0.43)差异无统计学意义。与对照组比较,PCV-VG组术中机械通气时气道峰压(Ppeak)明显下降(MD=-3.40 cmH₂O, 95%CI-4.69～-2.12,P<0.001),肺动态顺应性(Cdy...     

Aprotinin in major orthopedic surgery: a systematic review of randomized controlled trials

Aprotinin therapy is a promising strategy for reducing blood loss and blood transfusion requirements. The efficacy and safety of aprotinin in orthopedic surgery, however, remain controversial. We searched electronic databases for randomized controlled trials on the efficacy and safety of the use of aprotinin in orthopedic surgery. Thirteen trials that included a total of 506 patients who underwent major orthopedic surgery were analyzed. The pooled intraoperative and perioperative blood loss was significantly less in the aprotinin-treated patients than in the control patients (weighted mean difference [WMD] for intraoperative blood loss = -229 mL, 95% confidence interval [CI] = -367 to -91 mL, P = 0.0011; WMD for perioperative blood loss = -557 mL; 95% CI = -860 to -254 mL; P < 0.0001). The pooled amounts of red blood cell (RBC) units (U) transfused intraoperatively and perioperatively were significantly less in the aprotinin-treated patients than in the control patients (WMD for intraoperative RBC U = -1.1 U; 95% CI = -1.7 to -0.4 U; P = 0.0001; WMD for perioperative RBC U = -1.1 U; 95% CI = -1.7 to -0.5 U; P < 0.0001). Aprotinin was not associated with an increased incidence of deep vein thrombosis (odds ratio = 0.39; 95% CI = 0.14 to 1.05, P = 0.061). The authors conclude that aprotinin reduces the intraoperative and perioperative blood loss and allogeneic blood transfusion requirement and may not be associated with increased risk of deep vein thrombosis in the presence of pharmacological or mechanical prophylaxis in patients undergoing major orthopedic surgery.     

选择性脾动脉栓塞术与传统开腹手术治疗外伤性脾破裂安全性和有效性的Meta分析

目的比较选择性脾动脉栓塞术（PSAE）与传统开腹手术（OS）治疗外伤性脾破裂的临床疗效。 方法检索中国知网、万方数据、维普数据库、PubMed、Web of Science、Embase数据库中关于PSAE和OS两种手术方式治疗外伤性脾破裂的相关文献，检索时间为建库至2022年5月31日。提取文献内数据，采用RevMan 5.3软件进行Meta分析。 结果最终纳入16篇文献共5 238例患者，其中PSAE组1 037例，OS组4 201例。Meta分析显示：相较于OS组，PSAE组术中出血量更少（WMD= -392.95，95% CI：-667.52，-118.38；P=0.005），术中输血量更少（WMD=-433.87，95% CI：-582.85，-284.89；P<0.000 01），手术时间更短（WMD=-60.25，95% CI：-71.99，-48.52；P<0.000 01），抢救成功率更高（WMD=4.00，95% CI：1.32，12.09；P=0.01），且PSAE组术后下床时间（WMD=-14.44，95% CI：-20.32，-8.55；P<0.000 01）和住院时间（WMD=-4.89，95% CI：-5.86，-3.91；P<0.000 01）更短；术后并发症发生率方面，PSAE组术后切口感染（OR=0.21，95% CI：0.11，0.37；P<0.000 01）、肠梗阻（OR=0.24，95% CI：0.10，0.55；P=0.000 8）、肺炎（OR=0.44，95% CI：0.32，0.61；P<0.000 01）的发生率均低于OS组，但两组术后脾脓肿、发热、腹腔积液的比较，差异无统计学意义；术后免疫功能恢复方面，PSAE组术后1个月的CD3⁺水平（WMD=9.27，95% CI：6.32，12.22；P<0.000 01）、CD4⁺水平（WMD=5.60，95% CI：3.86，7.34；P<0.000 01）、CD4⁺/CD8⁺值（WMD=0.35，95% CI：0.18，0.52；P<0.000 01）均高于OS组，但OS组术后1个月的CD8⁺水平高于PSAE组（WMD=-1.20，95% CI：-1.72，-0.68；P<0.000 01）。 结论在外伤性脾破裂患者的诊治中，PSAE较OS有其独到优势，具有操作简单、手术时间短、术中出血量少、术后并发症少、住院时间短、术后免疫功能恢复早等优势，值得临床选用。     

Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial

OBJECTIVE: Many patients with an inguinal hernia are asymptomatic or have little in the way of symptoms from their hernia. Repair is often associated with long-term chronic pain and has a recurrence rate of 5% to 10%. Our aim was to compare operation with a wait-and-see policy in patients with an asymptomatic hernia. METHODS: A total of 160 male patients 55 years or older were randomly assigned to observation or operation. Patients were assessed clinically and sent questionnaires at 6 months and 1 year. The primary endpoint was pain and general health status at 12 months; other outcome measures included costs to the health service and the rate of operation for a new symptom or complication. RESULTS: At 12 months, there were no significant differences between the randomized groups of observation or operation, in visual analogue pain scores at rest, 3.7 mm versus 5.2 mm (mean difference, -1.6; 95% confidence interval (CI), -4.8 to 1.6, P = 0.34), or on moving, 7.6 mm versus 5.7 mm (mean difference, -1.9; 95% CI, -6.1 to 2.4, P = 0.39). Also, the number of patients 29 versus 24 (difference in proportion, 8%; 95% CI, -7% to 23%, P = 0.31), who recorded pain on moving and the number taking regular analgesia, 9 versus 17 (difference in proportion, -10%; 95% CI, -21% to 2%, P = 0.14) was similar. At 6 months, there were significant improvements in most of the dimensions of the SF-36 for the operation group, while at 12 months although the trend remained the same the differences were only significant for change in health (mean difference, 7.3; 95% CI, 0.4 to 14.3, P = 0.039). The rate of crossover from observation to operation 23 patients at a median follow-up of 574 days was higher than predicted. The observation group also suffered 3 serious hernia-related adverse events compared with none in the operation group. CONCLUSIONS: Repair of an asymptomatic inguinal hernia does not affect the rate of long-term chronic pain and may be beneficial to patients in improving overall health and reducing potentially serious morbidity.     

脊柱侧弯矫形手术患者术后肺部并发症的危险因素

目的 分析脊柱侧弯矫形手术患者术后肺部并发症(PPCs)的危险因素。方法 回顾性分析2013年8月至2020年10月择期行后入路脊柱侧弯矫形手术的463例患者病历资料。根据患者术后是否发生PPCs分为两组：PPCs组和非PPCs组。采用倾向性评分匹配和多因素Logistic回归分析脊柱侧弯矫形手术患者发生PPCs的相关危险因素。结果 有154例(33.3%)患者发生PPCs。将性别、年龄、ASA分级、吸烟史、高血压病史、Cobb角作为匹配因子进行倾向性评分匹配,再进行多因素Logistic回归分析,结果显示术中输注异体红细胞(OR=1.983, 95%CI 1.135～3.465,P=0.016)和手术时间延长(OR=1.426, 95%CI 1.112～1.831,P=0.005)是发生PPCs的独立危险因素。结论 手术时间延长、术中输注异体红细胞是脊柱侧弯矫形手术术后肺部并发症发生的危险因素。     

Glisson蒂横断法与Pringle法在肝细胞癌肝切除术中的应用效果Meta分析

背景与目的:Glisson蒂横断法与Pringle法在肝细胞癌(简称肝癌)肝切除术中的应用效果目前尚无一致结论,亦无大样本量的多中心研究予以证实.本研究通过Meta分析方法评价两种方法在肝癌肝切除术中的应用效果,以期在肝切除术术中阻断方式的选择上提供参考.方法:计算机检索中、英文数据库,检索时间为数据库建立至2021年...     

单髁置换术与全膝置换术治疗膝骨关节炎疗效的Meta分析

目的系统评价单髁置换术(UKA)与全膝关节置换术(TKA)治疗膝骨关节炎的临床疗效。 方法计算机检索Cochrane Library、Pubmed、Web of science、中国知识总库(CNKI)、万方数据学术论文总库、中国生物医学文献服务系统、公开发表的单髁置换术与全膝置换术治疗膝骨关节炎的临床研究。由2名研究者按照纳排标准进行文献筛选并提取相关资料，纳入标准为选取随机对照试验(RCT)或非随机对照试验(no-RCT)的文献，患者首次行全膝关节置换术或单髁置换术，观察比较膝关节KSS评分、屈曲膝关节达90°所需时间、关节活动度、疼痛度等结局指标。同时，排除重复发表、无法得到原始相关数据、无法获取全文、以及质量等级较低的文献。用RevMan 5.3.3软件进行数据处理，计量资料采用均数差(MD)为合并统计量，计数资料选择相对危险度(RR)为合并统计量，所有效应量以95%可信区间(CI)表示。通过卡方检验判断研究间异质性，若P≥0.05，I²≤50%，采用固定效应模型；反之分析其异质性来源，若无临床异质性，则采用随机效应模型。若不能进行数据的合并，则进行描述性分析。 结果共纳入7个随机对照试验(RCT)及13个非随机对照试验(no-RCT)。Meta分析结果显示：关节活动度在2、3、6、12、48个月的时间点测量，结果显示两组间在2个月时无异质性[MD＝7.31，95%CI(－0.99，15.61)，P＝0.08]，而在中、远期时存在异质性[MD＝5.90，95% CI(1.07，10.74)，P＝0.02]。屈曲90°所需时间方面单髁组[RCT: MD＝－3.36，95% CI(－6.22，－0.50)，P＝0.02；no-RCT: MD＝－2.94，95% CI(－3.51，－2.37)，P＝0.02]相对于全膝置换组更短。与全膝置换组相比，单髁置换术在术后膝关节KSS评分早中期疗效相当，但在远期疗效方面有着明显的优势。在术中出血量[RCT: MD＝－176.99，95% CI(－205.36，－148.62)，P <0.01；no-RCT: MD ＝－139.08，95% CI(－150.94，－127.22)，P <0.01]及术中引流量[MD＝－77.33，95% CI(－88.18，－66.48)，P<0.01]方面比全膝置换组有着明显的优势。在手术时间方面[no-RCT: MD＝－0.43，95% CI(－7.27，－6.40)，P＝0.90]两组间异质性不明显。 结论单髁置换术在术后膝关节活动度、屈曲90°所需时间、术后膝关节KSS评分、术中出血量、术中引流量方面存在明显优势，在手术时间方面无统计学差异，但是上述研究纳入的高质量文献较少，尚需要更多高质量、大样本的临床试验进一步验证。     

Effect of Nitrous Oxide on Neurologic and Neuropsychological Function after Intracranial Aneurysm Surgery

Background: Laboratory studies suggest that nitrous oxide augments brain injury after ischemia or hypoxia. The authors examined the relation between nitrous oxide use and outcomes using data from the Intraoperative Hypothermia for Aneurysm Surgery Trial.

Methods: The Intraoperative Hypothermia for Aneurysm Surgery Trial was a prospective randomized study of the impact of intraoperative hypothermia (temperature = 33[degrees]C) versus normothermia (temperature = 36.5[degrees]C) in patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping. Anesthesia was dictated by a limited-options protocol with the use of nitrous oxide determined by individual anesthesiologists. All patients were assessed daily for 14 days after surgery or until hospital discharge. Neurologic and neuropsychological testing were conducted at 3 months after surgery. Outcome data were analyzed via both univariate tests and multivariate logistic regression analysis correcting for factors thought to influence outcome. An odds ratio (OR) greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide.

Results: Outcome data were available for 1,000 patients, of which 373 received nitrous oxide. There was no difference between groups in the development of delayed ischemic neurologic deficit. At 3 months after surgery, there were no significant differences between groups in any outcome variable: Glasgow Outcome Score (OR, 0.84; 95% confidence interval [CI], 0.63-1.14; P = 0.268), National Institutes of Health Stroke Scale (OR, 1.29; 95% CI, 0.96-1.73; P = 0.087), Rankin Disability Score (OR, 0.84; 95% CI, 0.61-1.15; P = 0.284), Barthel Activities of Daily Living Index (OR, 1.01; 95% CI, 0.68-1.51; P = 0.961), or neuropsychological testing (OR, 1.26; 95% CI, 0.85-1.87; P = 0.252).     

Continuing uncertainty about the value of percutaneous revascularization in atherosclerotic renovascular disease: a meta-analysis of randomized trials.

BACKGROUND:To study the effect of revascularization on blood pressure (BP) and serum creatinine (SCr) in patients with atherosclerotic renovascular disease (ARVD). METHODS:Three randomized studies comparing balloon angioplasty (plus medication if necessary) with medical therapy alone in patients with ARVD were identified. In one study, patients were stratified and analysed according to whether they had unilateral or bilateral disease. Therefore, four sets of results were available for inclusion in a meta-analysis comparing BP and SCr at 6 months and changes from baseline. RESULTS:The three trials recruited 210 patients. There was no clear benefit for angioplasty when comparing BP at 6 months. Relative to the medical therapy group, the mean (95% CI) systolic/diastolic BP was 2.9 mmHg (-9.1, 3.4)/0.35 mmHg (-3.6, 2.9) lower in the angioplasty group (P=0.4/0.8). There was, however, some suggestion of benefit for angioplasty when changes in BP were compared. There was a greater reduction in the systolic/diastolic BP in the angioplasty group, with a difference of 6.3 mmHg (-11.7, -0.8)/3.3 mmHg (-6.2, -0.4) in the mean change (P=0.02/0.03). There was some suggestion of benefit for angioplasty in terms of changes in SCr, although this was not significant (P=0.06). CONCLUSIONS:The reported trials have been too small to determine reliably the role of angioplasty in ARVD. Although the combined results of three previous trials exclude the possibility of a large improvement in renal function or hypertension after angioplasty, a moderate but clinically worthwhile benefit cannot be ruled out. Further large-scale randomized evidence is needed.     

全膝关节置换术中应用富血小板血浆的临床效果

目的评价全膝关节置换术中局部应用富血小板血浆的临床效果。 方法检索中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、万方数据知识服务平台(WANFANG)、维普资讯中文期刊服务平台(VIP)4个中文数据库和PubMed、Web of Science、荷兰医学文摘数据库(Embase)、循证医学数据库(Cochrane Library)4个外文数据库中公开发表的关于全膝关节置换术中应用富血小板血浆临床疗效的相关文献,按照只纳入随机对照临床试验不纳入综述、非随机试验及动物实验等标准筛选文献,根据文献质量评估标准评价文献,采用标准格式收集数据,运用RevMan 5.3软件对4个结局指标即估计总失血量、膝关节活动度(ROM)、住院时间、术后并发症进行荟萃分析。 结果共纳入7篇随机对照试验,分析结果显示：富血小板血浆(PRP)组估计总失血量比对照组少[均数差(MD)＝-132.32,95%置信区间(CI)(-231.24,-33.40),P＝0.009];PRP组住院时间比对照组短[MD ＝-2.12,95% CI(-3.47,-0.76),P＝0.002];PRP组术后并发症发生率比对照组低[比值比(OR)＝0.45,95% CI(0.22,0.91),P＝0.03]; PRP组膝关节ROM与对照组差异不大[术后2 d：MD ＝0.80,95% CI(-2.87,4.46),P＝0.67;术后3 d：MD ＝1.23,95% CI (-4.12,6.58),P＝0.65;术后5 d：MD ＝2.93,95% CI(-0.60,6.46),P＝0.10;术后7 d：MD ＝2.09,95% CI(-4.63,8.82), P＝0.54;术后2周：MD ＝-0.88, 95% CI(-3.70,1.94),P＝0.54;术后6周：MD ＝3.93,95% CI(-5.17,13.02),P＝0.40;术后3个月：MD ＝1.00, 95% CI(-4.15,6.15),P＝0.70]。 结论全膝关节置换术中应用富血小板血浆时,估计总失血量减少、住院时间缩短、术后并发症发生率降低,但膝关节活动度无明显提高。     

Strategies of smoking cessation intervention before hernia surgery—effect on perioperative smoking behavior

Background Although it is now generally accepted that patients should be advised to quit smoking before surgery, the effect of low-intensive smoking cessation intervention, both on preoperative smoking behavior and on risk reduction, remains unclear. Our objective was to study the effect on perioperative smoking behavior and on postoperative wound infection of different types of low-intensive intervention before herniotomy. Methods Between October 1998 and October 2000, 180 consecutive smokers scheduled for elective herniotomy were advised to quit smoking perioperatively and subsequently allocated randomly to three low-intensive smoking cessation groups: a standard (control) group, a telephone group, which was reminded by telephone, and an out-patient group, which was reminded by means of an out-patient talk and demonstration of nicotine replacement drugs. Spontaneous perioperative smoking behavior was recorded for 64 consecutive non-advised smokers. Postoperative wound infection was evaluated by independent assessors. Results Of the advised patients, 19% (29/149) stopped smoking before surgery compared with 2% (1/64) in the non-advised cohort (P < 0.01). In the standard group 13% (6/48) quit smoking compared with 23% (23/101) in the pooled telephone and outpatient group (NS). In the last group 64% (65/101) reduced or stopped smoking compared with 42% (20/48) in the standard group (P < 0.05). Predictors of failed perioperative cessation of smoking were a CO breath-test at inclusion above 20 ppm (OR: 0.11; 0.02–0-57) and low motivation to quit smoking (OR: 0.25; 0.09–0.70). Wound infection occurred in 6% (13/213) and there was no difference between the groups. Conclusion Low-intensive smoking cessation intervention helps approximately one fifth of patients to stop smoking perioperatively. Patients who are reminded in addition to preoperative advice are more likely to stop or reduce smoking. Failure to stop smoking is greater if the patients are not motivated and if the CO breath test is high at the time of the preoperative advice.     

Isoflurane dosage for equivalent intraoperative electroencephalographic suppression in patients with and without epidural blockade

We conducted a prospective, randomized, controlled trial to establish the effect of epidural blockade on isoflurane requirements for equivalent intraoperative electroencephalographic (EEG) suppression. Fifty patients undergoing abdominal hysterectomy received combined epidural and general anesthesia or general anesthesia alone with isoflurane and alfentanil. Isoflurane was administered by computer-controlled closed-loop feedback to maintain an EEG 95% spectral edge frequency of 17.5 Hz, a target chosen on the basis of a pilot study. In epidural patients, end-tidal isoflurane concentration (FE'(ISO)) was 0.19% smaller (95% confidence interval [CI], -0.32% to -0.06%; P < 0.01), mean arterial blood pressure was 17 mm Hg lower (95% CI, -24 to -9 mm Hg; P < 0.0001), and body temperature was 0.4 degrees C lower (95% CI, -0.7 to 0 degrees C; P < 0.05) than in controls. EEG bispectral index (BIS) was 4 points higher (95% CI, 1 to 7; P < 0.05). EEG median frequency and heart rate were similar in both groups. Epidural patients were 76% more likely (95% CI, 58% to 94%; P < 0.001) to require metaraminol for hypotension and were 28% more likely (95% CI, 3% to 53%; P < 0.05) to require glycopyrrolate for bradycardia. After surgery, the time to eye opening in epidural patients was 2.3 min shorter (95% CI, -4.2 to -0.5 min; P < 0.05). Time to eye opening correlated better with FE'(ISO) in the last 30 s of anesthesia (FE'(ISO) = 0.07 x time to eye opening + 0.31; r(2) = 0.59; P < 0.0001) than with BIS from the same period (BIS = 64 - 1.25 x time to eye opening; r(2) = 0.22; P < 0.001) (P < 0.0001). To maintain similar intraoperative spectral edge frequency, patients receiving combined epidural and general anesthesia require 21% less isoflurane than those receiving general anesthesia alone. This smaller isoflurane dose is associated with faster emergence from anesthesia. IMPLICATIONS: The dose of general anesthetic required to maintain similar intraoperative suppression of brain electrical activity is 21% less in patients with nerve blockade than in those without. This dose reduction results in faster waking times in patients with nerve blockade, which may reflect lighter intraoperative anesthesia. The dose of general anesthetic required to maintain similar intraoperative suppression of brain electrical activity is 21% less in patients with nerve blockade than in those without. This dose reduction results in faster waking times in patients with nerve blockade, which may reflect lighter intraoperative anesthesia.     

Randomized assessment of resource use in fast-track cardiac surgery 1-year after hospital discharge

BACKGROUND: The authors assessed the safety and resource use associated with fast-track cardiac anesthesia (FTCA) after coronary artery bypass graft surgery (CABG) over a 1-yr period. METHODS: One hundred twenty patients were initially randomized to FTCA (n = 60) or conventional anesthetic (n = 60) for primary elective CABG surgery. Patients were followed for 1-yr after index surgery through linkage to universal administrative databases. Acute care hospital readmission rates and length of stay (LOS) and the downstream use of health resources were compared. Resource use was analyzed as use of hospital and rehabilitation center bed-days, expenditures on physician services, and use of cardiac drugs. RESULTS: There were no deaths during the 1-yr follow-up after initial discharge; 15 (25%) patients from both groups were readmitted to acute care hospitals in the follow-up period. The mean LOS for acute care readmission was 0.3 (1.0) in the FTCA and 1.6 (6.3) days in the conventional group at 3 months; P= 0.01, 95% CI (0.1, 5.7) and 0.8 (1.8) and 2.9 (9.6) days at 12 months; P= 0.01, 95% CI (0.2, 7.5). Two (3.3%) patients in the FTCA group and 9 (15%) patients in the conventional group were transferred to rehabilitation facilities. The LOS was 0.3 (1.5) and 2.3 (5.7) days respectively; P= 0.001, 95% CI (0.6, 4.0). Specialist visits were more frequent in the FTCA group 6.2 (13.2) versus 1.9 (2.2) visits respectively; P= 0.002, 95% CI (-9.0, -1.3). Percentage reduction of FTCA cost was 68% at 3 months, P= 0.0002 and 49.5% at 1-yr, P= 0.004 after index hospital discharge. CONCLUSIONS: Fast-track cardiac anesthesia is a safe practice that decreases resource use for a 1-yr period after index hospitalization.     

Randomized Assessment of Resource Use in Fast-track Cardiac Surgery 1-Year after Hospital Discharge

Background: The authors assessed the safety and resource use associated with fast-track cardiac anesthesia (FTCA) after coronary artery bypass graft surgery (CABG) over a 1-yr period.

Methods: One hundred twenty patients were initially randomized to FTCA (n = 60) or conventional anesthetic (n = 60) for primary elective CABG surgery. Patients were followed for 1-yr after index surgery through linkage to universal administrative databases. Acute care hospital readmission rates and length of stay (LOS) and the downstream use of health resources were compared. Resource use was analyzed as use of hospital and rehabilitation center bed-days, expenditures on physician services, and use of cardiac drugs.

Results: There were no deaths during the 1-yr follow-up after initial discharge; 15 (25%) patients from both groups were readmitted to acute care hospitals in the follow-up period. The mean LOS for acute care readmission was 0.3 (1.0) in the FTCA and 1.6 (6.3) days in the conventional group at 3 months;P = 0.01, 95% CI (0.1, 5.7) and 0.8 (1.8) and 2.9 (9.6) days at 12 months;P = 0.01, 95% CI (0.2, 7.5). Two (3.3%) patients in the FTCA group and 9 (15%) patients in the conventional group were transferred to rehabilitation facilities. The LOS was 0.3 (1.5) and 2.3 (5.7) days respectively;P = 0.001, 95% CI (0.6, 4.0). Specialist visits were more frequent in the FTCA group 6.2 (13.2) versus 1.9 (2.2) visits respectively;P = 0.002, 95% CI (-9.0, -1.3). Percentage reduction of FTCA cost was 68% at 3 months, P = 0.0002 and 49.5% at 1-yr, P = 0.004 after index hospital discharge.     

经腹腹膜前疝修补术后腹内疝性肠梗阻的发生情况及其影响因素分析

目的分析腹腔镜经腹腹膜前疝修补术（TAPP）后腹内疝性肠梗阻的发生情况及其影响因素。 方法选取2018年1月至2021年12月北京同仁医院收治的404例腹股沟疝行TAPP术后患者作为研究对象,根据腹内疝性肠梗阻的发生情况将其分为发生组（38例）和未发生组（366例）,分析所选腹股沟疝行TAPP术后患者的临床资料,采用单因素和Logistic回归分析筛选腹股沟疝患者行TAPP术后发生腹内疝性肠梗阻的影响因素。 结果404例患者术后发生腹内疝性肠梗阻38例（9.41%）;2组患者临床资料对比显示年龄、体质量指数（BMI）、疝囊直径、是否嵌顿疝、手术时间以及术中出血量等资料比较,差异均有统计学意义（均P<0.05）;Logistic回归分析结果表明,BMI>24 kg/m²（OR=3.278,95% CI：1.561～6.886,P=0.002）、疝囊直径>5 cm（OR=3.353,95% CI：1.602～7.022,P=0.001）、嵌顿疝（OR=3.208,95% CI：1.546～6.657,P=0.002）、手术时间>100 min（OR=2.437,95% CI：1.174～5.058,P=0.017）、术中出血量>10 ml（OR=2.733,95% CI：1.303～5.735,P=0.008）是TAPP术后发生腹内疝性肠梗阻的独立危险因素。 结论BMI>24 kg/m²、疝囊直径>5 cm、嵌顿疝、手术时间>100 min、术中出血量>10 ml是TAPP术后发生腹内疝性肠梗阻的独立危险因素,医务人员可以通过危险因素尽早识别高风险患者,还可对可以控制的危险因素给予一定的干预措施,以最大能力防止腹内疝性肠梗阻的发生。     

A programme for reducing smoking in pre-operative surgical patients: randomised controlled trial

We assessed the efficacy of a comprehensive programme for stopping smoking in 210 smokers scheduled for surgery, before admission and 3 months after attending a pre-operative clinic. Participants were randomly allocated to receive an intervention incorporating nicotine replacement therapy for patients smoking more than 10 cigarettes per day ("dependent smokers"), or to a control group to receive usual care. Dependent smokers allocated to the intervention group were more likely to report abstinence before surgery than those allocated to receive usual-care (63 (73%) vs. 29 (56%), respectively; OR 2.2 (95% CI 1.0-4.8)), and 3 months after attendance (16 (18%) vs. 3 (5%), respectively; OR = 3.9 (95% CI 1.0-21.7).     

机器人辅助腹腔镜行左半结肠癌根治性切除术安全性与有效性的Meta分析

目的荟萃分析机器人辅助腹腔镜左半结肠癌根治性切除术（RA）与传统腹腔镜左半结肠癌根治性切除术（LA）的安全性与有效性。 方法检索中国知网、万方数据库、PubMed、NCBI等数据库建库至2021年5月报道的RA和LA的对照研究。由两名研究人员独立进行相关研究数据提取和相关文献内容收集,并应用Revman 5.3软件对所收集数据进行分析。 结果共纳入10项回顾性分析研究,涉及4 770例左半结肠癌病例,其中RA 2 309例,LA 2 461例。与LA组相比,RA组住院时间短（MD=-0.74,95% CI：-1.33~-0.16,P=0.01）,住院费用高（MD=1.02,95% CI：0.04~2.00,P=0.04）,术中出血量少（MD=-13.49,95% CI：-20.91~-6.06,P<0.001）,中转开腹率低（OR=0.55,95% CI：0.45~0.69,P<0.001）,清扫淋巴结数量差异无统计学意义（MD=-0.20,95% CI：-2.64~2.24,P=0.87）,手术时间长（MD=42.64,95% CI：13.53~71.74,P=0.004）,术后排气时间早（MD=-0.29,95% CI：-0.49~-0.09,P=0.004）,术后进食时间早（MD=-0.30,95% CI：-0.51~-0.09,P=0.005）,并发症发生率差异无统计学意义（OR=0.78,95% CI：0.60~1.01,P=0.06）。 结论RA安全可行,术后患者胃肠功能恢复更快,但在手术时间、清扫淋巴结数量和并发症发生率方面无明显优势。