腘动脉陷迫综合征26例外科诊疗经验

目的总结腘动脉陷迫综合征(PAES)的外科治疗经验。方法回顾性分析北京协和医院2006年3月至2016年1月收治的26例PAES患者(共34条肢体)。病变的肢体中,有4条仅仅为肌肉组织压迫造成,无器质性狭窄,1条肢体在狭窄后出现动脉瘤,余均表现为腘动脉管壁增厚或腔内血栓形成。2条肢体行大隐静脉原位转流术,19条肢体行静脉补片或人工补片成形联合异常肌束切除术,4条肢体行单纯的腘动脉手术松解,另外4条肢体先行插管溶栓术,再行腘动脉松解,5条肢体行病变血管切除、自体大隐静脉间位移植术。结果补片成形术组动脉1年通畅率94.7%;单纯腘动脉松解组1年通畅率75%;大隐静脉原位转流术肢体(2条)术后通畅率100%;插管溶栓术肢体(4条)术后通畅率50%;腘动脉松解联合大隐静脉间位移植术(5条)1年通畅率80%。结论 PAES是血管外科诊疗的一大难点。多种术式中,切开取栓、内膜剥脱联合补片成形术的中长期疗效显著;如病程短、探查腘动脉通畅,单纯肌束切除解压能达到治疗目的;如病变节段过长,仅仅解除腘动脉压迫及内膜剥脱创伤大、效果不显著,行大隐静脉原位转流术和间位移植术效果较好。     

带毛囊全层皮片移植修复术后腋毛缺损

(1)带毛囊全层皮片:选取带阴毛会阴部全层皮片,须保留完整毛囊,以利皮片成活后毛发正常生长.(2)改善上肢功能:本术式主要用于腋下术后局部腋毛缺损的修复,采取全层皮片多点移植可以减小腋下皮肤的张力,改善上肢功能障碍.(3)心理健康:传统腋毛区皮肤切除或皮下搔刮术只注重去除异味,而忽视局部毛发缺失对患者心理健康的影响,带毛囊全层皮片移植术恰好能弥补这方面的缺陷.     

下腹部全厚层游离皮片修补乳癌切除创面16例

过去对乳癌切除后遗留的较大创面,常用患者大腿中厚层皮片做游离移植。不仅术后在大腿上留下较大创面,增加病人痛苦,一旦继发感染,还会遗留较大疤痕。而且,取皮时需要一定设备,技术要求也较高。我们自1984年1月至1986年7月间,用患者下腹部正中的椭圆形或梭形游离全厚层皮片,来修补乳癌切除后缺损的创面16例,获得满意效果,现报告如     

大隐静脉动脉化治疗下肢慢性缺血88例

目的探讨静脉动脉化治疗下肢广泛动脉闭塞的疗效.方法对广泛动脉闭塞无流出道的慢性缺血患者88例（104条肢体）施行大隐静脉原位一期静脉动脉化加腰交感神经节切除.结果104条肢体中,随访82条,随访6个月至6年,平均3年.所有患者间歇性跛行明显减轻,夜间疼痛好转,创面愈合良好,下肢无肿胀.结论本术式可使动脉血流通过大隐静脉通道,改善或重建缺血下肢的血液循环.     

腹腔镜女性膀胱癌根治性切除-原位回肠新膀胱术初步报告

目的探讨腹腔镜女性膀胱癌根治性切除-原位回肠新膀胱术的可行性。方法2003年2月～2006年7月,为8例女性膀胱癌患者施行腹腔镜膀胱、子宫、附件全切除-原位回肠新膀胱术。全麻,仰卧位,头低15°,大腿外展,膝关节屈曲。下腹部置入5个trocar。在髂血管分叉处剪开腹膜,游离输尿管,切断子宫圆韧带、卵巢韧带。沿盆壁向下游离子宫阔韧带,清扫盆腔淋巴组织。离断主韧带、骶韧带、双侧输尿管及膀胱侧血管蒂。于阔韧带基底部切开腹膜,沿子宫颈两侧游离打开阴道穹隆。切开前腹膜反折,游离膀胱前间隙,切断阴蒂背深静脉复合体,膀胱颈下方0.5cm处切断尿道。靠近阴道穹隆处横断阴道并封闭残端。在下腹正中线上做4～5cm切口,取出标本。切口外构建"M"形去管回肠储尿囊,输尿管"插入式"种植于储尿囊。储尿囊回纳腹腔,在腹腔镜下做储尿囊与尿道吻合。结果8例手术时间(344.5±42.1)min,术中出血(373.9±81.3)ml。术后随访6～46个月,平均26个月,其中>12个月6例,半年内均能自主排尿,1例日间偶有尿失禁,1例夜间尿失禁,1例排尿困难。膀胱容量(333.6±40.4)ml。残余尿量0～183ml,(51.2±18.1)m...     

股腘动脉闭塞症的手术治疗

目的 探讨股腘动脉旁路移植术治疗下肢动脉硬化闭塞症(C、D级病变)的近中期疗效.方法 2005年1月至2009年2月,170例患者(191条肢体)行股动脉以远血管重建术.其中男性108例,女性62例;年龄45～85岁,平均67岁.症状包括间歇性跛行78例,静息痛62例,下肢缺血性溃疡19例,远端组织坏死11例.所有患者术前均行动脉造影检查,根据TASC Ⅱ分级:C级病变127条肢体,D级病变64条肢体.手术方法包括大隐静脉原位旁路移植术15条肢体,大隐静脉转位20条肢体,人工血管旁路移植术128条肢体,大隐静脉与人工血管组合旁路移植术28条肢体.结果 围手术期无死亡病例.术后随访6～36个月,平均(24±6)个月;76例失访,随访率57%(109/191).一期通畅率84.4%(92/109),其中人工血管旁路移植通畅率88.2%(75/85),大隐静脉(原位、转位、组合)旁路移植通畅率70.8%(17/24).二期通畅率89.9%(98/109).结论 人工血管旁路移植术是治疗严重股腘动脉闭塞症(TASC C和D级病变)的主要方法,手术疗效满意.     

全椎板整块切除原位回植法治疗游离型腰椎间盘突出症

目的 探讨全椎板整块切除原位回植法治疗游离型腰椎间盘突出症的临床特点及疗效。方法 28例游离型腰椎间盘突出症患者均采用全椎板整块切除原位回植法治疗。结果 28例随访6～54个月,平均21个月。根据Macnab标准评定,优20例,良6例,差2例。结论 游离型腰椎问盘突出症是手术的绝对适应证,全椎板整块切除原位回植法治疗游离型腰椎问盘突出症可获得满意疗效。     

直接处理下肢静脉瓣膜功能不全手术的新经验

作者报道11条下肢深静脉功能不全施行手术治疗的经验。所有患肢都有明显静脉系统郁血的临床表现,如肿胀、顽固性溃疡等。其中3条肢体有下肢深静脉血栓形成史;4条曾施行大隐静脉剥脱术;6条曾作筋膜下交通静脉结扎术。     

全层皮片原位缝合治疗大面积皮肤撕脱伤

我科自1986年1月～1987年2月,共收治下肢大面积皮肤撕脱伤7例,均采用全层皮片开窗原位缝合Ⅰ期闭合创面,疗效满意,报道如下。 本组男3例,女4例,年龄4～41岁。车祸伤6例,砸伤1例。片状撕脱5例,套式撕脱2例。损伤面积3.5％～17％,平均10.8％。合并肌肉挫     

全尿路上皮癌1例

<正>患者,男,66岁。既往2010年11月在我院因左侧肾盂癌、膀胱癌(术前泌尿系CT检查提示左侧肾盂癌,膀胱占位病变;膀胱镜检取病变组织做病理检查为高级别乳头状尿路上皮癌),行左侧肾输尿管切除、膀胱袖套式切除术(术后病理检查为肾盂、输尿管、膀胱高级别乳头状尿路上皮癌)。2012年2月因膀胱癌复发行根治性膀胱全切、去带乙状结肠原位新膀胱术(术前及术后病理检查为     

游离腹直肌瓣加植皮修复小腿及足踝部软组织缺损

目的探讨应用游离腹直肌瓣加中厚游离植皮修复小腿和足踝部软组织缺损的方法和疗效.方法 1998年5月～2002年12月,采用以腹壁下动、静脉为蒂的一侧腹直肌瓣游离移植加中厚植皮修复2例小腿、9例足踝部因外伤所致软组织缺损伴有骨、肌腱外露及骨髓炎患者.病程为1个月～10年.缺损范围3 cm×4 cm～8 cm×14 cm;切取腹直肌瓣4 cm×6 cm～8 cm×15 cm.结果术后11例移植肌瓣均成活,8例创口Ⅰ期愈合,3例移植中厚皮片坏死经再植皮后愈合.11例术后获随访6个月～4年,外形及功能良好.结论游离腹直肌瓣加中厚游离植皮修复小腿与足踝部软组织缺损具有血运好、抗感染力强和顺应性好等优点,可用于填充缺损及修复不规则创面,术后外形良好,克服了肌皮瓣肥厚臃肿的缺点.     

The folded double paddled free flap for oral cavity reconstruction

Summary Six radial forearm flaps, two transverse rectus abdominis flaps and one latissimus dorsi myocutaneous flap were used in a bipaddled fashion for full thickness defects of the cheek and the floor of the mouth resulting from cancer resection. The flaps provided both intraoral lining and skin cover in all cases. Immediate reconstruction was carried out following tumor resection in six cases. In three patients who presented with large full thickness defects due to failure of primary reconstruction, late reconstruction with double paddled free flaps was performed. All transfers were successful, in the latissimus dorsi transfer a minimal area of necrosis occurred at the tip of the flap. A salivary fistula developed in two cases, both healed spontaneously up to three weeks postoperatively. The average operating time was 5.5 h; the average hospital stay was 13.4 days.     

Reconstruction of large thoracoabdominal defects using two-stage free tissue transfers and prosthetic materials.

Very large full thickness defects of the thorax or abdomen after tumoral resections commonly need to be reconstructed with free tissue transfers. We retrospectively analysed the protocol of performing the free tissue transfer before the wide excision in 15 patients (mean age of 48) with large tumours of the thorax and abdomen. During the first stage, the flap was folded on itself in a strategic position close to the future resection site and microsurgical anastomoses performed. The second stage surgery consisted of the full thickness excision and definitive reconstruction of the defect by unfolding the flap over prosthetic material. The inclusion criteria were: large thoracoabdominal resections exposing lung or bowel and requiring the use of prosthetic material as part of the reconstruction after resection for locally aggressive tumours such as dermatofibrosarcoma protuberans. In 8/10 patients, vein grafts were used in the arterial anastomosis. The mean time interval between the first and the second stage was 17 days (7-50 days). Flap survival was one hundred percent on first attempt. In one patient who had presented with a large abdominal haemangioma, pulmonary embolism occurred during the second stage. In another patient, an infection under the flap occurred 3 years after reconstruction. Results of this series of patients support our belief that a two-stage microsurgical strategy can be useful in selected patients where large free flaps (with grafted pedicle) in combination with prosthetic materials have to be performed for reconstruction of full thickness defects of the trunk or the abdomen.     

Das Schicksal der Restsaphena nach stadiengerechter Varizenoperation

Partial resection of the greater saphenous vein is currently the standard procedure for early stage varicosis. The intact vein segment left in situ is thought to be suitable for a later bypass graft. A study was performed to reconsider this concept. Forty-eight patients (60 legs) were examined between 2 and 7 years after partial stripping of the greater saphenous vein. Following clinical examination, X-ray opaque markers were placed over the scar where the left segment of the saphenous vein was ligated during the former operation. Phlebography was performed to visualize deep and superficial veins. Initial length of the vein segment was calculated from the marker to the ankle. Informed consent was obtained from all patients. Of the 60 vein segments in situ, 9 were intact while 14 were obviously occluded in full length. Thirty-seven vein segments showed some form of pathologic changes that involved on average one-fourth of the total vein length. Of these, 17 showed partial thrombotic occlusion, 14 showed irregular wall contours consistent with previous thrombosis, and in 6 the proximal part of the vein was not adequately visible. It is concluded that partial stripping of the saphenous vein can preserve a vein segment for later bypass grafts. However, graft length will be limited especially when stripping below the knee is necessary.     

Minimal-invasive Resektionen von Magentumoren

BACKGROUND: Submucosal and mucosal gastric tumors occur infrequently and have a highly variable clinical course. MATERIALS AND METHODS: Between 1996 and 2001, 44 patients with tumors of the stomach wall underwent a laparoscopic local resection in three different procedures and were analyzed prospectively. RESULTS: Laparoscopic resections were performed on 44 patients (21 female, 23 male). The mean age of the patients was 65.3 years (range: 23-78). We performed the laparoscopic intragastric resection (LIR) on 18, the full thickness resection (LVR) on 17, and the extramucosal enucleation (LER) on 9 patients.The laparoscopic resection was combined with endoscopy in 24 patients. The immunohistological examination of the specimens showed gastrointestinal stroma cell tumors (GIST) in 24 cases, leiomyomas in 10 cases, adenomas in 2 cases, neurinomas or benign neurofibromas in 4 cases, neuroendocrine tumors (NET) in 2 cases, and an ectopic pancreas islet in 1 patient. In all of these patients, the surgical margins in the pathological specimens were tumor-free without lymphatic or venous invasion. None of the patients with GIST or NET had distant metastases. Intraoperative complications occurred in three cases (6.8%). Two repeat laparoscopic procedures (4.6%) were necessary. No fatal outcome or relapse in the follow-up over 23.4 months (range: 1-74) was registered. CONCLUSIONS: Laparoscopic or laparoendoscopic resection of gastric tumors is practicable with relatively few of complications. The level of patient comfort is high.     

Suboptimal results in full thickness skin graft urethroplasty using an extrapenile skin donor site

We performed 22 full thickness skin graft urethroplasties for treatment of urethral stricture disease or hypospadias. Excellent results were achieved in 18 cases in which a penile skin donor site was used. Three failures occurred in 4 cases in which the full thickness graft was raised from the inner aspect of the upper arm. These results suggest caution when extrapenile skin is used for such repairs.     

Reconstruction of the radial forearm free flap donor site using integra artificial dermis

Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. We describe a staged reconstruction using Integra followed by ultrathin skin grafting that results in highly aesthetic and functional outcomes for these defects. A retrospective review of 29 patients undergoing extirpative head and neck oncologic resection were examined. Integra graft placement was performed at the time of RFFF harvest followed by autologous split thickness skin grafting at 1 to 5 weeks postoperatively. Healing fully occurred within 4-6 weeks with negligible donor site complications, excellent cosmesis, and minimal scar contracture. Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures.     

原位缝合结合负压封闭引流治疗手及前臂皮肤逆行撕脱伤

目的探讨原位缝合结合负压封闭引流（vacuum sealing drainage。VSD）治疗手或前臂皮肤逆行撕脱伤的临床疗效。方法对2012年3月-2013年3月收治的10例手或前臂皮肤逆行撕脱伤患者,共计11处逆行撕脱皮肤（其中1例为手掌和手背2处逆行撕脱伤）,根据每例逆行撕脱皮肤局部血运情况,分别采取不同的手术方法。其中,3处采取对整块逆行撕脱皮肤原位缝合后辅以VSD治疗（原位缝合组）;2处采取对整块逆行撕脱皮肤反取植皮并辅以VSD治疗（反取植皮组）;其余6处分别同时进行了原位缝合辅以VSD治疗和反取植皮辅以VSD治疗方法,即对每处逆行撕脱的皮肤一部分进行原位缝合（原位缝合组,6处）,另一部分进行反取植皮（反取植皮组,6处）。因此,研究对象包括原位缝合组（3＋6）处和反取植皮组（2＋6）处,共计17处逆行撕脱皮肤。比较两组术后的皮肤功能。结果术后所有逆行撕脱皮肤均成活,全部患者均获2-6个月随访。平均3．7个月。原位缝合组皮肤感觉：S3＋5处,S33处,S21处;反取植皮组皮肤感觉：S22处,S16处。原位缝合组皮肤在外观、耐磨度上均优于反取植皮组。结论原位缝合结合VSD治疗手及前臂皮肤逆行撕脱伤临床效果好．术中应尽可能保留有血运、适合原位缝合的皮肤及皮下组织。     

A Comparison of Full and Split Thickness Skin Grafts in Radial Forearm Donor Sites

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.     

A study of basal cell carcinoma of the inner canthus, 1967-72.

Basal cell carcinoma was the commonest malignant lesion at the inner canthus. Reconstruction following excision was most commonly achieved with a post-auricular full thickness graft. Provided excision is adequate, a local flap is a good alternative. There is no evidence that the use of a graft increased recurrence, but it may have allowed earlier detection. The primary recurrence rate after primary surgical excision was 3.6 per cent. Recurrence occurred in several cases when histology indicated incomplete excision. Follow-up under these circumstances should be continued for up to 10 years. When adequate primary surgical excision was performed, there was no evidence that rodent ulcer of the inner canthus behaves differently or has a worse prognosis than at other sites. There has probably been undue concern in the past about epiphora following resection of the lacrimal drainage system.