升主动脉-颈内动脉自体静脉转流治疗累及左颈总动脉起始部的巨大真性动脉瘤

目的探讨累及左颈总动脉起始部的巨大真性动脉瘤的手术方法。方法回顾性总结1997年2月至2004年6月间3例该病患者的临床资料，均行手术治疗：胸部正中切口显出前纵隔，切开心包及其返折，显露心脏及其大血管，联合颈部切口显出动脉瘤全貌，升主动脉-颈内动脉自体静脉转流后，于主动脉弓上切除动脉瘤。结果3例均于术后7d治愈出院，分别随访8月、5年、7年无动脉瘤复发。结论利用自体静脉行升主动脉-颈内动脉移植技术，经胸部正中切口根治累及左颈总动脉起始部的巨大动脉瘤，具有显露清晰、操作方便、无须切开胸腔、创伤小、恢复快的优点，是一种较好的手术方案。     

Rotation of the head might not be recommended for internal jugular puncture in infants and children

Background:  Traditionally, we have been puncturing the internal jugular vein (IJV) with the head rotated. However, in adults it has been suggested that rotation of the head increases the magnitude of an overlapping of the IJV to the carotid artery (CA). Therefore, in infants and children, we have examined anatomic relationship between the IJV and the CA under the head in midline and head in rotated position.
Method:  Eleven infants and 51 children were included. Under general anesthesia, the patient was positioned in the Trendelenburg position with a shoulder roll to allow extension of the neck. At first, the head was placed in the midline position. The ultrasound probe was placed perpendicular to the skin, and images of the right IJV and CA were collected at the level of the cricoid cartilage. Then, the head was rotated to the left at 45°. The images were collected in the same way. The position of the right IJV relative to the CA was defined as anterior (A), anterolateral (AL), or lateral (L).
Results:  Rotation of the head increased the magnitude of an overlapping because of more changes from L → AL, L → A, or AL → A ( P  < 0.05, Wilcoxon t -test).
Conclusion:  We conclude that the rotation of the head increases the magnitude of an overlapping of the IJV to the CA in infants and children.     

A congenital arteriovenous aneurysm in the neck

One male case of a congenital arteriovenous aneurysm in the neck was described. It was fed by a distal branch of the external carotid artery and drained into the external jular vein. A swelling of the neck and a bruit of the ear disappeared following resection of this malformation. Nine published cases are summarized and briefly discussed.     

Penetration of the Optic Nerve and Falciform Ligament by an Internal Carotid Artery-Ophthalmic Artery Aneurysm: Case Reoport

We report a case of an internal carotid artery (ICA)-ophthalmic artery aneurysm with penetration of the optic nerve. In addition, this case penetrated the falciform ligament, which severely disturbed optic canal unroofing during surgery. This is the first reported case in which penetration of the optic nerve and falciform ligament has been shown. To remove the anterior clinoid process in this case, the ultrasonic bone curette was a useful tool.     

Displacement of the common carotid artery after laryngeal mask airway placement in infants and children

Background: In adults, placement of the laryngeal mask airway causes increased overlapping of the internal jugular vein (IJV) and common carotid artery (CCA). However, few studies in children have been reported. The aim of this study was to describe the degree of overlap of the IJV and the CCA before and after laryngeal mask airway placement in infants and children. Method: There were 160 children scheduled to undergo Protex^® SoftSeal^® and Ambu^® placement. Patients were initially positioned in the 15° Trendelenburg position with their heads rotated 30° to the left. The ultrasound probe was placed perpendicular to the skin, and the images of the right IJV and CCA were collected at the level of the cricoid cartilage. Following laryngeal mask airway placement, images were collected in the same manner. Results: No statistically significant changes were observed in the overlap index before and after laryngeal mask airway placement. By inflating the laryngeal mask airway cuff, migration of the vessel forward was 24.38% and outward migration was 13.99%. Conclusion: There was no remarkable change in the overlap index before and after laryngeal mask airway placement in children.     

Combined Endovascular-Surgical Management of the Internal Carotid Artery in Complex Tympanojugular Paragangliomas

The infratemporal fossa approach described by Fisch overcame most of the factors that had previously prevented the total removal of tympanojugular paragangliomas (TJP). The remaining problem has been infiltration of the internal carotid artery (ICA) for which there has been no entirely satisfactory solution. At the least, severe encasement risks the possibility of an arterial rupture at surgery. In order to reduce this risk, preoperative endovascular interventions have been employed—mainly balloon occlusion, with or without arterial bypass. Recently, intra-arterial stents to reinforce the encased segment of the ICA have been introduced. This study evaluates our experience with 20 patients affected by TJP in which the ICA has been subjected to preoperative interventions. Ten patients underwent a preoperative balloon occlusion and the other 10 patients had their ICAs reinforced with stents. Problems that arose during embolization necessitated that one patient with a stent required ligation of their ICA. No other problems were encountered during endovascular treatment or surgical resection. In one patient with a stent, it was impossible to establish a cleavage plane between their recurrent tumour and the ICA. These early results are encouraging and suggest that intra-arterial stents have a part to play in the surgical management of large TJPs.     

Merkel Cell Carcinoma of the Maxillary Sinus: An Unusual Presentation of a Common Tumor

Merkel cell carcinoma is most commonly seen in the skin of sun exposed areas, particularly the head and neck and is associated with Merkel cell polyomavirus. Merkel cell carcinoma at an extracutaneous mucosal site of the head and neck is rare. We report a case of a 74-year-old women who presented with an enlarging thyroid mass found to be neuroendocrine carcinoma consistent with Merkel cell carcinoma (positive for synaptophysin, chromogranin, CK20). Subsequent work up revealed a maxillary sinus mass with extension into the nasal cavity. Biopsy was diagnostic for Merkel cell carcinoma (positive for synaptophysin, chromogranin, CK20 and Merkel cell polyomavirus). There are only case reports and small case series of Merkel cell carcinoma arising in the mucosal sites of the head and neck most commonly in the oral cavity, rarely the sinonasal mucosa. Merkel cell carcinoma metastasizing to the thyroid has only been reported in three other case reports, all from skin primaries. In addition to our case, we review the literature of extracutaneous sinonasal Merkel cell carcinoma and metastases to the thyroid.     

Anatomy Relationship around Internal Carotid Artery in the Endoscopic Surgery of Nasopharynx: A Study Based on Computed Tomography Angiography

Objective Anatomic knowledge is needed to avoid injury to internal carotid artery (ICA) during the endoscopic surgery around nasopharynx and its surrounding space. Design We prospectively studied the computed tomography angiography (CTA) data of 28 patients with image processing software. Special attention was given to ICA and various landmarks around nasopharynx. Results The anatomic relationship between ICA and different landmarks around nasopharynx was clearly presented in three-dimension. The fossa of Rosenmuller is the nearest point of the nasopharyngeal cavity to ICA. The opening of the Vidian canal in the middle cranial fossa could be either above, below, or at the level of the horizontal segment of petrous ICA. The pharyngeal trunk of the ascending pharyngeal artery can also be clearly identified in most reconstructed CTA images. Multiple anatomic relationships were also quantified. Conclusions Reconstructed CTA can provide key anatomic information for a safe and accurate endoscopic dissection around nasopharynx.     

Normal values of volume flow in the internal carotid artery measured by a new angle-independant Doppler technique for evaluating cerebral perfusion

Summary Background. Cerebral blood flow is an important parameter when monitoring critically ill patients. Blood flow volume within the internal carotid artery (ICA) was shown to be correlated with the cerebral blood flow. The aim of our study was to provide normal values of the internal carotid artery volume flow using this new technology (QuantixND, Cardiosonix Ltd., Israel).Method. The QuantixND System is an angle-independant Doppler system that employs two digital high resolution ultrasound heads within one probe in an defined angle to each other. Thus several flow velocities within the vessel and the vessel diameter can be measured. 77 healthy patients (41 women, 36 men) were included and divided into age groups of ten-year intervals (mean age 48.9 years). Internal carotid artery flow was evaluated as well as physiological and hematological parameters (hematocrit, arterial blood pressure etc).Findings. We found that the blood flow volume in the ICA decreased significantly with age. No side-to-side effects as well as no gender-related differences could be observed. There was no influence of hemoglobin, hematocrit and blood pressure in this healthy population.Conclusions. There is an age-related decrease in blood flow volume with age that can be easily and exactly determined by the use of the new angle-independant doppler technique.     

胆管减压对急性重症胆管炎大鼠免疫功能的影响

以Ｗｉｓｔａｒ大鼠急性重症胆管炎的动物模型为对象，观察了胆管减压对大鼠免疫功能的影响。结果显示，急性重症胆管炎时，肠源性内毒素等抗原激活单核巨噬细胞系统产生释放多种细胞因子，同时机体细胞免疫功能下降。胆管减压引流对机体免疫功能有保护作用，表现为ＴＮＦ活性显著降低，细胞免疫功能部分恢复。     

左肾旁前间隙入路在保留脾动静脉腹腔镜胰体尾切除术中的应用

目的 探讨保留脾动静脉腹腔镜胰体尾切除术安全快捷的手术入路.方法 回顾总结我院12 例保留脾动静脉腹腔镜胰体尾切除术的手术过程及结果,分析左肾前间隙入路在保留脾动静脉腹腔镜胰体尾切除术中的应用.结果 12 例手术顺利完成,平均手术时间(55±18)min,术中出血量(80±46)mL,术后平均住院时间7.6 d,术后未发生胰漏等并发症.结论 左肾前间隙入路是脾动静脉腹腔镜胰体尾切除术中安全快捷的手术入路.     

An unexpected finding in the resection specimen of a carcinoma of the oral cavity: A case report

IntroductionThe occurrence of two synchronous, primary cancers is rare. Thyroid carcinoma is incidentally found in the resection specimen after surgery for head and neck cancer in 0.3–1.9% of the patients.Presentation of caseIn this report, we describe the case of a 72-year-old patient in whom a primary (synchronous) papillary thyroid carcinoma was found coincidentally upon pathologic examination of lymph nodes recovered from the cervical neck lymph node dissection specimen after a ‘commando’ procedure for carcinoma of the oral cavity.Discussion and conclusionThere is no gold standard concerning treatment of the incidentally discovered thyroid gland carcinoma. The decision to perform surgery depends on the life expectancy of the patient, whether the thyroid gland demonstrates clinical or radiologic lesions, the already completed treatment for the head and neck cancer and should always be adjusted to the specific patient.     

Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus

The purpose of this study was to compare the triceps-sparing approach with olecranon osteotomy regarding their effects on the functional outcomes of intercondylar fractures of the distal humerus managed with open reduction and internal fixation (ORIF), by reviewing 67 cases of intercondylar distal humerus fractures surgically managed with either of the approaches during 2001-2009. The medical records and radiographs of 30 male and 37 female patients, with a mean age of 44.5 years (range, 16-77) and a mean follow-up time of 34.3 months (range, 6-89), were retrospectively reviewed. Flexion, extension, arc of flexion/extension, pronation, supination, arc of pronation/supination and the Mayo Elbow Performance Score (MEPS) were used to assess the functional outcomes of intercondylar distal humerus fractures treated with ORIF through the triceps-sparing approach or olecranon osteotomy. According to the AO Foundation (AO) classification, there were 10 cases of C1, 28 cases of C2 and 29 cases of C3 fractures. At the time of review, all fractures had united. Although there was no overall statistically significant difference in the average flexion, extension, arc of flexion/extension, pronation, supination and arc of pronation/supination between the triceps-sparing group (n = 34) and the olecranon osteotomy group (n = 33), patients above 60 years of age tended to have more extension loss (mean 22.9°, range 0-55°) after ORIF via the triceps-sparing approach, compared with any other surgical approach/age combination group. In the triceps-sparing group, although only 37.5% of patients over the age of 60 years obtained excellent/good MEPS, the rate increased to 100% in patients aged less than 40 years of age (P < 0.05). By contrast, the rate of excellent/good MEPS remained above 80% in all age groups of patients treated with ORIF via olecranon osteotomy. In conclusion, ORIF via the triceps-sparing approach confers inferior functional outcomes for intercondylar distal humerus fractures in patients over the age of 60 years, for whom the olecranon osteotomy approach may be a better choice. However, for patients less than 60 years of age, especially those less than 40 years of age, either approach confers satisfactory outcomes.     

Adductor Canal Block Combined With iPACK (Interspace Between the Popliteal Artery and the Capsule of the Posterior Knee) Block vs Periarticular Injection for Analgesia After Total Knee Arthroplasty: A Randomized Noninferiority Trial

BackgroundThe combination of adductor canal block (ACB) and infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block may provide sufficient motor-sparing anterior and posterior knee analgesia after total knee arthroplasty. This study aimed to determine if ACB with iPACK block was noninferior to ACB with periarticular injection (PAI) when combined with postoperative multimodal analgesia regimen.MethodsSeventy-six patients were randomized to receive either ACB + iPACK block and continuous ACB (CACB) (ACB + iPACK group) or PAI and CACB (ACB + PAI group). Noninferiority was concluded for the primary outcome if the adjusted mean between-group difference in pain on movement at 12 postoperative hours was within 1.3 points on a visual analog pain scale. Pain scores, morphine consumption, functional performance, and adverse events were the secondary outcome measures assessed for superiority.ResultsAdjusted mean differences, (ACB + iPACK) ? (ACB + PAI), in anterior and posterior knee pain scores on movement at 12 postoperative hours were ?0.66 (?1.86, 0.54) and ?0.19 (?1.36, 0.99), respectively. The upper limit of 95% confident interval was lower than the prespecified noninferiority limit. The mean visual analog scale pain scores were low and no clinically significant differences between groups. However, morphine requirement at 48 postoperative hours was significantly higher (P < .05) and showed greater reduced quadriceps strength at 0 and 45 degrees on postoperative day 0 (P = .006 and .04, respectively) in the ACB + iPACK group.ConclusionsACB with iPACK block provides a noninferior analgesia compared with PAI when combined with CACB. However, patients who received ACB + iPACK block may require higher amounts of opioids and have worse immediate functional performance.Level of evidenceTherapeutic level I.