四肢开放性骨折伴骨缺损治疗方法的研究

目的 探讨一种简单、安全、有效的治疗开放性骨折伴骨缺损方法。方法 对98例开放性骨折伴骨缺损的病人在清创,适当固定后采用：①载药自固化磷酸钙人工骨植入;②抗生素伴自体骨植入;③早期关闭创口,后期取带血管蒂的骨块伴载药自固化磷酸钙人工骨植入。结果 对轻中度污染,骨缺损量较少的开放性骨折伴骨缺损者,采用载药自固化磷酸钙人工骨植入及抗生素伴自体骨植入治疗,二者无明显差异。对污染较重的开放性骨折伴骨缺损者,适用于载药自固化磷酸钙植入治疗。对污较重且伴有节段性缺损大于5cm的开放性骨折伴骨缺损者,适用于早期清创,后期取带血管蒂的骨块伴载药自固化磷酸钙人工骨植入治疗。结论 对开放性骨折伴骨缺损,应根据骨缺损量的多少及污染的程度选用合适的方法,以免多次手术。     

腹腔镜保脾胰体尾切除八例的手术经验

目的总结保留脾脏腹腔镜胰体尾切除术的临床经验与手术技巧。方法自2003年11月至2008年2月,我们对8例胰体尾部良性占位病变患者施行保留脾脏腹腔镜胰体尾切除术。结果本组8例均在腹腔镜下完成,其中1例合并胆囊切除,1例合并右肾上腺肿瘤切除,1例合并子宫肌瘤挖出、左卵巢畸胎瘤挖出,1例合并子宫肌瘤挖出。本组手术时间120—290min,出血量150—600ml。术后住院时间3～9d,无胰漏发生。术后病理诊断：潴留性囊肿2例,浆液性囊腺瘤1例,黏液性囊腺瘤2例,上皮性囊肿2例,先天性囊肿1例。随访9～60个月,症状消失,未见复发。结论对于胰体尾部良性病变,可行保留脾脏的胰体尾部切除,对拥有丰富高级腹腔镜手术经验的术者,开展保留脾脏的腹腔镜胰体尾切除术是安全可行的。     

Gastrointestinal lymphoma and sarcoma. A case for aggressive search and destroy.

The incidence of sarcomas of the gastrointestinal tract has remained the same, but gastrointestinal lymphomas are gradually contributing a larger percentage of malignant gastrointestinal neoplasms. The authors have examined their more recent experience with these relatively rare lesions. Twenty-eight patients (13 with lymphoma, 15 with sarcoma) have been treated at the Vanderbilt University and the Metropolitan Nashville General Hospital since 1976. There were eight men in the group with lymphoma and six in the group with sarcoma. The average age for patients with lymphoma was 66 years; the average age was 57 years in the patients with sarcoma. Seven patients with lymphoma and eight patients with sarcoma had been treated for 6 months to 3 years for presumed peptic ulcer disease. Eight of these 15 patients were found to have perforated tumors at the time of surgical exploration. Three patients (all in the group with sarcoma) had metastatic liver disease or peritoneal implants at the time of diagnosis. Treatment for most patients included resection of the tumor, followed by chemotherapy or radiation in cases of tumor perforation or metastatic disease. The survival rate for patients with lymphoma has averaged 5.5 years, with a 55% 5-year survival rate. Patients with cleaved cell tumors survived longer than those with other types of lymphoma. In the group with sarcoma, the survival rate has been 3.1 years on the average, with a 21% 5-year survival rate.     

HBeAg阳性慢性乙型肝炎合并非酒精性脂肪肝患者的临床与病理学特征

目的探讨HBeAg阳性慢性乙型肝炎患者合并非酒精性脂肪肝病（NAFLD）的临床与病理学特征。 方法选取2013年6月至2017年12月首都医科大学附属北京佑安医院病理确诊的慢性HBV感染（CHI）患者（108例）、NAFLD患者（120例）及HBeAg阳性慢性乙型肝炎合并NAFLD患者（132例）共360例。入组病例均行肝组织活检术,标本分别行HBsAg和HBcAg检测和HE染色。光学显微镜下观察肝组织脂肪变性和纤维化程度。比较各组患者血清学指标以及病理学特征。 结果较CHI患者,NAFLD患者和HBeAg（+）CHB合并NAFLD患者ALT水平显著升高,差异具有统计学意义（P均< 0.05）。较CHI和NAFLD患者,HBeAg（+）CHB合并NAFLD患者的AST与尿酸水平均显著升高,差异具有统计学意义（P均< 0.05）。较NAFLD患者,HBeAg（+）CHB合并NAFLD患者的甘油三酯（TG）水平显著降低,肝纤维化程度显著升高。CHI患者、NAFLD患者和HBeAg（+）CHB合并NAFLD患者三组患者的肌酐水平逐渐升高,差异具有统计学意义（P < 0.05）。各组患者两两比较高尿酸血症所占比例差异均有统计学意义（P均< 0.05）。与CHI患者和NAFLD患者相比,HBeAg（+）CHB合并NAFLD患者中男性高尿酸血症患者比例显著升高,差异具有统计学意义（P均< 0.05）。 结论炎症和纤维化发生率在HBeAg（+）CHB合并NAFLD患者中升高,提示NAFLD的存在可能与CHB病情进展有协同作用。     

The Influence of a New Timing Strategy of Band Adjustment on the Vomiting Frequency and the Food Consumption of Obese Women Operated with Laparoscopic Adjustable Silicone Gastric Banding (LAP-BAND)

Objective: To evaluate the effects of a new timing strategy of band adjustment on the short-term outcome of obese women operated with adjustable silicone gastric banding. Subjects: The outcome of 30 women without binge-eating disorder operated with laparoscopic adjustable silicone gastric banding with a wider intraoperatory band calibration (LAP-BAND) was compared to that of 30 body mass index-matched women without binge-eating disorder previously operated with adjustable silicone gastric banding (ASGB) applied by laparotomy with the usual intraoperatory band calibration. The patients were evaluated 3, 6 and 12 months after surgery. Measurements: (1) weight loss; (2) total daily energy intake; (3) percent as liquid, soft or solid food; (4) vomiting frequency; (5) rate of postoperative percutaneous band adjustments; (6) rate of band-related complications. Results: Both the weight loss and the daily energy intake did not differ between patients with LAP-BAND and patients with ASGB. After surgery, the patients with LAP-BAND ate more solid food and less liquid food than the patients with ASGB. Vomiting frequency was higher in patients with ASGB than in patients with LAP-BAND. The total number of percutaneous band adjustments was higher in women with LAP-BAND than in women with ASGB. Band inflation because of weight stabilization was performed in six (20.0%) women with ASGB and in 19 (63.3%) women with LAP-BAND. Neostoma stenosis occurred in one women with ASGB, but in none of the women with LAP-BAND. One patient with LAP-BAND presented band slippage. Conclusions: The wider intraoperatory band calibration performed in patients with LAP-BAND did not reduce the short-term efficacy of adjustable silicone gastric banding. This new timing strategy of band adjustment required more postoperative percutaneous band inflations, but it improved the eating pattern of the patients (low vomiting frequency and high intake of solid food).     

Quantitative vitreous fluorophotometry in insulin-treated cystic fibrosis patients

A series of 22 patients with cystic fibrosis (CF) of similar clinical severity (9 with normal carbohydrate tolerance and 13 with insulin-treated fasting hyperglycemia) was examined with quantitative vitreous fluorophotometry. All of the CF patients studied had normal fundi on ophthalmoscopy, fundus photographs, and fluorescein angiography. Mean vitreous fluorescein concentration in the CF patients whose hyperglycemia was treated with insulin (11.79 ng/ml) was significantly higher than in CF patients with normal carbohydrate tolerance (6.98 ng/ml, P less than 0.005). Thus, CF patients with fasting hyperglycemia demonstrate a breakdown of the blood-retinal barrier. When CF patients with fasting hyperglycemia were compared with age- and sex-matched type I diabetics, there was no significant difference in mean vitreous fluorescein accumulation. Thus, breakdown of the blood-retinal barrier, one of the earliest detectable functional abnormalities that may be associated with the microangiopathy of diabetes mellitus, also occurs with equal frequency and severity in the diabetes secondary to pancreatic fibrosis associated with CF.     

Role of the martius procedure in the management of urinary-vaginal fistulas

BACKGROUND: Urinary-vaginal fistula is one of the most common and dreaded complications of obstetric trauma in developing countries. Management of these fistulas is complicated by the presence of substantial urethral loss and the tendency of the repair to break down. STUDY DESIGN: We retrospectively studied 46 patients with urinary-vaginal fistulas operated on in our institution over 5 years. Most of the patients had obstetric trauma as the causative factor. Twelve patients had urethrovaginal and 34 had vesicovaginal fistulas. Of the 12 patients with urethrovaginal fistulas, 8 underwent a Martius procedure and 4 were treated with simple anatomic repair. Of the 34 patients with vesicovaginal fistulas, 13 underwent a Martius procedure and 21 were treated with anatomic repair. Nineteen patients had recurrent fistulas and 17 had multiple fistulas. RESULTS: Only one patient with a urethrovaginal fistula treated with a Martius procedure had recurrence, compared with three of four of the patients having anatomic repair. None of the patients with vesicovaginal fistulas treated with a Martius flap had recurrence, compared with 4 of 21 in the anatomic-repair group (19.05%). Thirteen patients with single fistulas (7 urethrovaginal and 6 vesicovaginal) treated with a Martius procedure healed well without failure, compared with 1 failure among 16 fistulas (1 urethrovaginal and 15 vesicovaginal) in the anatomic-repair group. In the group of patients with multiple fistulas, the Martius flap also showed a definite advantage. Eight patients with multiple fistulas were offered the Martius flap. The procedures were successful in all but one, compared with six failures out of nine treated with anatomic repair. None of the patients having primary treatment with the Martius flap had postoperative recurrence, compared with 3 of 18 having anatomic repair (16.67%). Only 1 of 12 patients with recurrent fistulas undergoing Martius flap repair had failure (8.33%), compared with 4 of 7 undergoing anatomic repair (57.14%). None of the patients treated with the Martius procedure experienced dyspareunia postoperatively, compared with 33.33% of the patients treated with anatomic repair. CONCLUSIONS: The overall success rate was far better and the complication rate (especially incontinence and dyspareunia) was considerably less with the Martius procedure. We recommend the Martius procedure for urethrovaginal and vesicovaginal fistulas, especially those that are recurrent or multiple.     

Evaluation of treatment of lung cancer combined with the disease which has needed a semi-emergency operation

Six cases of lung cancer combined with the disease which has needed semi-emergency operation, two cases of unstable angina, two of ileus due to colon cancer, one of impending rupture of abdominal aortic aneurysm and one of purulent cholecystitis with cholelithiasis, were discussed. Mean age was 62.0 years (range, 36 to 73); four were male and two were female. Case 1 and 2 were admitted with anterior chest pain, Case 3 with lumbago and abdominal pain, Case 4 and 5 with an abnormal shadow on chest x-ray film and Case 6 with abdominal pain. Of the two with unstable angina, one was operated on with right upper lobectomy during the first months after aorto-coronary bypass. Of the two with colon cancer, one was operated on with right upper lobectomy during about 5 weeks after right hemi-colectomy. Case 3 with abdominal aortic aneurysm operated on with left upper lobectomy during 4 weeks after replacement of abdominal aorta. Case 4 with cholecystitis was operated on with left pneumonectomy during about 3 weeks after cholecystectomy. The postoperative course of 4 cases and the post-chemotherapy condition of 2 cases were uneventful.     

Großer Flankentumor nach gedeckter Gallenblasenperforation

We report on a 79-year-old woman patient with a tumor with a diameter of 18 cm in the right flank. The medical history of the patient was normal except for a single asymptomatic gallstone, which had been known since 12 years. Sonography and abdominal CT showed an enormous intra-abdominal mass filled with liquid with a permanent union with the gallbladder. We than performed an explorative laparotomy with a tumor resection and a cholecystectomy. The histological examination showed perforation of the gallbladder with a great pseudocyst filled with 1800 ml infected bile and with penetration through the abdominal wall.     

Nonoperative treatment of acute hamate hook fractures.

Six patients with acute and two patients with subacute nondisplaced fractures of the hamate hook were treated with immobilization. The patients with acute fractures were treated within 7 days of the injury, and those with subacute fractures were treated after 7 days. Seven of the eight patients showed documented healing of their fractures. At follow-up (average 8 months) all seven were free of symptoms. One patient with a subacute fracture did not comply with treatment and had a painful nonunion. Our results show that hamate hook fractures that are diagnosed early may heal with nonoperative management. Fractures that fail to heal with immobilization or those with chronic nonunion should be treated with excision of the hook fragment.     

肝损伤的诊断与治疗

目的 总结肝损伤的诊断与治疗经验.方法 回顾性分析2004年1月至2013年12月广东医学院附属南山医院收治的183例肝损伤患者的临床资料.结合B超、CT检查和腹腔穿刺术,明确损伤部位、范围、程度、是否合并其他脏器损伤及其严重程度等,按照美国创伤外科学会-器官损伤分级（AAST-OIS）对患者进行分级.根据体征及各种检查结果综合评估,选择保守治疗或手术治疗.采用门诊及电话方式进行随访,随访时间截至2014年4月.结果 腹上区或肝区疼痛患者176例,不同程度低血压、休克患者98例.142例患者行腹腔穿刺术抽出不凝血,132例患者CT检查结果示肝破裂,88例患者急诊B超检查结果示肝破裂.AAST-OIS Ⅰ级28例,Ⅱ级63例,Ⅲ级45例,Ⅳ级30例,Ⅴ级17例.58例患者保守治疗成功,其中AAST-OIS Ⅰ级21例,Ⅱ级17例,Ⅲ级14例,Ⅳ级5例,Ⅴ级1例.125例患者行手术治疗,其中AAST-OIS Ⅰ级7例,Ⅱ级46例,Ⅲ级31例,Ⅳ级25例,Ⅴ级16例.125例手术治疗患者中,46例仅行腹腔引流术或肝裂伤单纯缝合术;35例行肝裂伤缝合术联合使用大网膜或可吸收止血材料填塞术;13例行不规则性肝切除术;12例行肝动脉结扎或破裂静脉修补术联合清创性肝切除术;9例行规则性肝叶或肝段切除术;8例行肝周纱布填塞术;2例术中因肝静脉、下腔静脉损伤致严重失血性休克死亡.手术治疗患者术中输血量为（400±116） mL.所有患者住院时间为（12±3）d.8例患者术后死亡.保守治疗患者中,1例胆汁漏,1例形成肝内血肿并液化包裹.手术治疗患者中,18例并发胆汁漏,6例术后出血,均经对症处理后治愈.157例患者获得随访,随访率为85.79％（157/183）.随访时间为4～ 30个月,中位随访时间为23个月.随访期间,患者均健康生存,无并发症发生.结论 肝损伤患者临床表现多为腹上区或肝区疼痛,并伴有不同程度休克,结合B超、CT检查及腹腔穿刺术是诊断肝损伤?     

Mistakes in the diagnosis of cancer

Twelve cases are presented in which various non-cancerous lesions were confused with cancer: (1) Vesicovaginal fistula (traumatic) confused with cancer of the bladder; (2) encrustation cystitis confused with cancer of the bladder; (3) bladder calculus confused with cancer of the prostate (recurrent); (4) granuloma of the rectum confused with cancer of the rectum; (5) diverticulitis of the sigmoid confused with cancer of the sigmoid; (6) portal cirrhosis confused with cancer of the colon; (7) polyp of the fundus uteri confused with cancer of the endometrium; (8) foreign body (sponge) in abdomen confused with cancer of the bowel; (9) gallstones confused with cancer of the pancreas; (10) dermatitis of the vulva and perineum confused with cancer of the vulva; (11) intestinal obstruction from radiation damage to bowel confused with the terminal stage of cancer of the cervix; and (12) hemorrhage from simple gastric ulcer confused with gastrointestinal cancer.     

立体定向多靶点手术治疗情感性精神障碍

目的探讨螺旋CT引导下同期双侧多靶点手术治疗情感性精神障碍的疗效和安全性。方法采用螺旋CT定位,对182例情感性精神障碍患者,采用同期双侧多靶点射频热凝手术治疗。按全国精神外科协作组于1990年制定的评定方法进行疗效评定。结果182例患者术后2周随访：显著改善86例,改善81例,无效15例,加重0例,有效率91．76％;166例术后随访6～54个月：恢复38例,显著改善59例,改善52例,无效17例,加重0例,有效率89．76％;术后除早期一过性并发症外,远期并发症发生率小于1％。结论螺旋CT引导同期双侧多靶点手术治疗情感性精神障碍疗效显著,安全性高。     

髋臼周围肿瘤的切除与重建

目的 探讨髋臼周围肿瘤切除与重建的方式及合并症。方法 回顾分析1997年7月至2003年7月髋臼部位原发肿瘤患者行肿瘤切除重建手术的临床资料。3l例患者中,男性19例,女性12例,年龄12～78岁,平均年龄37岁。其中,软骨肉瘤12例、尤文瘤1例、骨肉瘤3例、淋巴瘤1例、癌肉瘤1例、恶性纤维组织细胞瘤1例、骨髓瘤2例、骨巨细胞瘤9例、动脉瘤样骨囊肿1例。2l例患者行髋臼切除、骨盆重建,其中人工半骨盆8例、马鞍式关节7例、灭活再植 人工髋关节置换6例。10例患者行肿瘤刮除 骨水泥填充 人工髋关节置换。结果 21例行Ⅱ区肿瘤切除、髋臼重建的患者中,5例出现局部复发,其中3例为行半骨盆灭活再植的患者。3例骨肉瘤中2例死亡;12例软骨肉瘤患者中,随访9人,6例无瘤生存。术后2个月后,21例患者能够正常坐、扶单拐行走。结论 髋臼区域的肿瘤切除后可行异体或人工半骨盆移植进行修复,或将瘤段骨壳灭活再植进行重建。髋臼周围肿瘤切除重建的过程中应注意：(1)广泛切除肿瘤;(2)熟悉各种髋臼重建方法的优缺点,防止合并症的发生;(3)髋臼重建后的稳定性较差,应注意站立时在健侧拄一手杖,保护再造髋关节;(4)预防皮缘坏死及伤口感染,骨盆肿瘤切除容易发生伤口问题。     

一期切除吻合术治疗左半结肠癌并急性肠梗阻临床疗效观察（附46例报告）

目的 探讨左半结肠癌并急性肠梗阻行一期切除吻合术的安全性及其临床应用.方法 对46例左半结肠癌并梗阻患者行一期肠切除肠吻合术,术中进行有效的结肠减压及清洁灌洗,术后观察疗效.结果 有31例患者左半结肠恶性梗阻患者经保守治疗肠梗阻缓解改限期手术行一期肠切除吻合术,其余15例患者一般情况较好,经全结肠灌洗后一期肠切除吻合术,所有手术均顺利完成,术后并发切口感染8例（17.4％）,吻合口漏4例（8.7％）,经保守治疗痊愈.结论 左半结肠癌并发急性肠梗阻患者行一期肿瘤切除吻合术是安全有效的.     

Detection of glomerular sialic acids in patients with diabetic nephropathy

A study on immunofluorescence of sialic acids in glomeruli from patients with diabetic nephropathy is described. Measurement of sialic acid in sera from 25 patients with diabetes mellitus was also performed. Renal biopsy specimens from 12 patients with diabetic nephropathy were stained with FITC-labeled antihuman IgG antiserum and rhodamine-labeled Triticum vulgaris (WGA) or Limulus polyphemus (LPA). These specimens were also stained with such reagents after treatment with neuraminidase, trypsin or citrate buffer. Both deposition of IgG and binding of WGA in the glomerular capillary walls were observed in all patients with diabetic nephropathy. The binding of WGA in the glomerular capillary walls in diabetic nephropathy was significantly increased compared with that in four normal renal tissues. However, the binding of LPA was hardly observed in the glomerular capillary walls of patients with diabetic nephropathy. The binding of WGA in the glomeruli was markedly decreased after treatment with neuraminidase although it was hardly decreased after treatment with trypsin or citrate buffer. The levels of sialic acid in sera from patients with diabetic nephropathy were markedly increased. It is suggested that accumulated substances in the glomerular capillary walls with an affinity for WGA are mainly composed of N-acetyl glucosamine and/or N-acetyl neuraminic acid in patients with diabetic nephropathy.     

Immunoglobulin E in renal disease.

Samples of renal tissue from 373 patients were examined for the presence of immunoglobulin E (IgE) by immunofluorescent techniques. Only trace to ++ amounts ( on a scale of ++++) were found in 20 patients: 4/9 with post-streptococcal acute glomerulonephritis (GN), 5/30 with GN associated with systemic lupus erythematosus, 3/20 with membranous GN, 1/4 with Goodpasture's syndrome, 2/18 with recurrent microhematuria and focal GN, 1/5 with hemolytic anemia and uremia, 3/73 with renal homografts, and 1/5 with dermatomyositis. No IgE was found in 18 patients with lipoid nephrosis, 8 of whom were being treated with prednisone, nor in 5 patients with focal glomerular sclerosis and the nephrotic syndrome. Serum IgE was measured in 9 of the 20 patients with glomerular deposits of this globulin. With one exception, levels of IgE were within the range generally considered to be normal. However, they were greater than the mean of this range in all but two and near the highest limits of normal in most. Neither the amounts of serum IgE nor the degree of proteinuria could be related to the intensity of stain for IgE in the glomeruli of these patients.     

Ectopic ossification following total hip replacement in juvenile chronic arthritis

Of twenty-one patients with juvenile chronic arthritis (seventeen with juvenile rheumatoid arthritis and four with juvenile ankylosing spondylitis) who had total hip replacement before the age of thirty years, thirteen patients (62 per cent) showed different degrees of ectopic ossification: nine (53 per cent) of the seventeen with juvenile rheumatoid arthritis and all four of those with juvenile ankylosing spondylitis. Human leukocyte antigen B5 was found with an increased frequency in the patients with ectopic ossification. Functional capacity was not impaired regardless of the severity of the ectopic ossification. As in patients with adult-onset disease, ectopic ossification after total hip replacement occurred with a higher frequency in the patients with juvenile-onset ankylosing spondylitis than in those with juvenile-onset rheumatoid arthritis.     

Consciousness and speech evaluation of 96 patients with craniocerebral injury

Objective: To explore the effective methods for evaluating the consciousness and speech status of patients with special types of cerebral injuries.Methods: Atotal of 96 patients with injury in the language center and in coma were treated with operative and correlated conventional therapies. Then their recovery status of consciousness and speech was observed.Results: All the patients were recovered to consciousness. Sixty-nine patients with aphasia were cured completely, but 7 patients were complicated with incomplete ataxic aphasia, 15 with incomplete sensory aphasia,and 5 with incomplete mixed aphasia.Conclusions: For the patients with injury in the language center, evaluation of the conscious state with GCS scoring system has certain limitations and conscious behaviours are advantageous evidences to evaluate the consciousness recovery of the patients. The patients with conscious disturbance and injury in the language center should be considered to have aphasia.     

Saccular damage in patients with idiopathic sudden sensorineural hearing loss without vertigo

OBJECTIVE: Saccule could be damaged in patients with idiopathic sudden sensorineural hearing loss (ISSHL) with vertigo and with high-frequency sensorineural hearing loss. Thus, the saccule might be deteriorated subclinically in ISSHL cases without vertigo. Therefore, we investigated saccular damage in ISSHL patients without vertigo through vestibular evoked myogenic potentials (VEMP). STUDY DESIGN: A prospective study. SUBJECTS AND METHODS: Fifty-two patients with ISSHL without vertigo were enrolled in the study. We identified VEMP in patients with ISSHL and analyzed the association of VEMP with initial hearing threshold, each threshold according to frequency, the type of audiogram, and hearing recovery. RESULTS: For cases with absent VEMP, we found significant differences between patients with 90 dB or more hearing loss and those with a hearing loss less than 55 dB with frequencies over 1000 Hz. Patients with profound hearing loss presented significantly high abnormal and absent VEMP than patients with audiograms of other types. CONCLUSION: These findings suggest that the subclinical deterioration of the saccular neuroepithelium is associated with patients with ISSHL having profound hearing loss at the high frequency.