146例严重肺动脉高压者二尖瓣替换术疗效分析

评价风湿性二尖瓣病变伴重度肺高压病人的手术效果。采用方差分析、卡方检验对肺动脉收缩压（ＳＰＡＰ）≥９．３３ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）并接受二尖瓣替换术（ＭＶＲ）的１４６病人的临床资料进行分析，将其分为４组。Ａ组：极重度肺高压（ＳＰＡＰ≥１３．３ｋＰａ）；Ｂ组：心功能严重低下组（心脏指数ＣＩ≤３３．３４）；Ｃ组：心功能减低或正常组（３３．３４≤ＣＩ≤６６．６８）；Ｄ组：高心排血量组（ＣＩ≥６６．６８）。其中每组按一次和二次手术再分为２个亚组。结果示一次手术组总死亡率为５．３％；Ａ１、Ｂ１、Ｃ１、Ｄ１４组术前临床情况、所用术式和心脏阻断时间等无差异，但Ｂ１组低心排（２４．２％）早期死亡率（１５．２％）明显高于其它３组（Ｐ＜０．０５），而Ｄ组无死亡。二次手术组总死亡率为２８．２％；各亚组低心排及死亡率均明显高于一次手术各组。由此认为，二尖瓣病变伴重度肺动脉高压病人，ＭＶＲ后低心排和早期死亡率与术前心脏指数有关。当心脏指数＞３３．３４时，即使肺动脉压和全肺阻力同时极度增高者，术后低心排和死亡率亦不因此增加。当ＣＩ＜３３．３４时，术后低心排及早期死亡率较高。重度肺动脉高压者施行二次ＭＶＲ手术时风险性较大     

急症腹部手术后并发急性肺损伤的防治

目的：探讨腹部急症手术后肺损伤的预防和治疗。方法：回顾性分析４０例外科危重病人（ＡＰＡＣＨＥⅡ＞８分）首次手术后２４小时内的ＰａＯ２／ＦｉＯ２、ＡａＤＯ２和呼吸频率（ＢＲ）与急性肺损伤（ＡＬＩ）的关系,分为ＡＲＤＳ组（ Ⅰ组,１２例）和急性肺功能不全组（Ⅱ组,２８例）,同时分析液体治疗和机械通气模式在防治ＡＲＤＳ中的作用,并计算死亡率。结果： Ⅰ组的ＰａＯ２／ＦｉＯ２、ＡａＤＯ２、ＢＲ和死亡率分别为１８．２±４．5ｋＰａ、２６８．７±４１．３ｍｍＨｇ、３３．７±６．９次／分和４１．７％（５／１２）;Ⅱ组则分别为２３．０±５．9ｋｐａ、２４３．８±５３．１ｍｍＨｇ、２６．９±７．６次/分和３．６％（１／２８）。结论：外科危重病人术后２４小时内往往伴有不同程度的急性肺损伤,极易发生ＡＲＤＳ;ＰａＯ２／ＦＩＯ２和呼吸频率是早期发现ＡＲＤＳ的临床指标;控制补液量、早期给予激素和尽早加用ＰＥＥＰ（呼气末正压）是防治ＡＲＤＳ的三大重要措施。     

经尿道汽化电切术治疗前列腺增生症（附42例报告）

我们自１９９７年１２月～１９９８年１１月采用经尿道前列腺汽化电切术（ＴＵＥＶＡＰ）共治疗良性前列腺增生症（ＢＰＨ）４２例,效果良好。报告如下。临床资料　本组４２例年龄５６～８４岁,平均７２－５岁。病程１～１１年,平均４－２年。均有严重的排尿困难,有尿潴留者２３例,术前行膀胱造瘘者１１例。ＩＰＳＳ（３１－２±１－２）分,ＱＯＬ（５－１±０－４）分;Ｂ超测定前列腺体积为（４４－７±９－５）ｍｌ;最大体积为９８－３ｍｌ,最大尿流率（ＭＦＲ）为（６－２±１６）ｍｌ／ｓ,剩余尿（Ｒ）为（１３１±４１－６…     

谷胱甘肽S-转移酶-π和多药耐药相关蛋白在膀胱癌的表达及相关性研究

目的 探讨不同耐药模式的耐药因子对膀胱癌化疗耐药形成的影响。方法 应用免疫组织化学技术检测４４例膀胱移行上皮癌和６例正常膀胱粘膜标本中谷胱甘肽Ｓ－转移酶－π（ＧＳＴ－π）和多药耐药相关蛋白（ＭＲＰ）表达,并用计算机图像分析技术进行半定量分析。结果 ４４例膀胱移行上皮癌ＧＳＴ－π、ＭＲＰ表达的阳性率分别为７２．７％和６８．２％,明显高于在正常粘膜的表达（１６．７％、３３．３％,Ｐ〉０．０５）;ＧＳＴ－π的表达有随肿瘤分级、分期升高的趋势,化疗后复发病例亦高于初发病例,但差异无显著性（Ｐ〈０．０５）;ＭＲＰ的表达与肿瘤的分级、分期及其化疗与否并无明显相关;两者的表达显示有明显的相关性（ｒ＝０．６８５,Ｐ〈０．００１）。结论 ＧＳＴ－π和ＭＲＰ两者表达的相关性提示其表达可能存在共同的调节机制,从而使之在膀胱癌化疗耐药     

腹腔镜胆囊切除术中肺功能变化的临床研究

本文观察了１２例ＡＳＡ１级胆囊结石病人腹腔镜胆囊切除术中的肺功能变化。年龄为４０．７±９．４岁，体重６１．４±９．４ｋｇ。Ｍｉｄａｚｏｌａｍ－Ｆｅｎｔａｎｙｌ－Ｉｓｏｆｌｕｒａｎｅ－Ｔｒａｃｒｉｕｍ维持麻醉，控制呼吸，间歇正压通气。连续监测吸气气道峰压（ＰＩＰ），动态肺应性（ＬＣ），ＰＥＣＯ２，ＥＫＧ，ＮＩＢＰ和ＳｐＯ２。结果：体位改变对ＰＩＰ和ＰＥＣＯ２无明显影响（Ｐ＞０．０５），却使ＬＣ下降９．７％（Ｐ＞０．０５）。腹腔充气后３０分钟ＰＩＰ上升１７％（Ｐ＜０．０５），ＬＣ与麻醉后和充气前相比分别下降２５．８％和２０．８％（Ｐ＜０．０１），ＰＥＣＯ２增加１９．１％（Ｐ＜０．０１）；腹腔充气后６０分钟，ＰＩＰ和ＰＥＣＯ２未继续增加，但ＬＣ继续下降，比麻醉后和充气前下降３４．２％和２７．１％（Ｐ＜０．０１）。本文显示腹腔镜胆囊切除术中肺顺应性显著下降，气道压明显升高，ＰＥＣＯ２明显增加。     

巨大左心室瓣膜病的外科治疗

提高巨大左心室病人瓣膜替换术的手术疗效。方法回顾性分析３７例施行瓣膜替换术的巨大左心室病人。术前平均ＥＤＤ７６．１ｍｍ，ＥＳＤ５６．１ｍｍ，ＥＦ０．５１，ＦＳ０．２６；心功能Ⅲ级９例，Ⅳ级２８例。ＡＶＲ１３例，ＭＶＲ１７例，ＡＶＲ＋ＭＶＲ７例。结果术后早期发生心、肺、肝，肾等重要器官并发症１７例，死亡２例。     

主动脉瓣替换术后近期及晚期左心室功能随访

目的：评价主动脉瓣替换（ＡＶＲ）术后左心功能的近期及其远期效果。方法：对１９７８年１２月至１９９６年１２月期间连续１２９例单纯行ＡＶＲ的病人进行分析。结果：术前Ｂ超示左心室舒张末期内径（ＬＶＥＤＤ）、收缩末期内径（ＬＶＥＳＤ）分别为（６４．５±９．３）ｍｍ、（４４．７±９．９）ｍｍ,术后１４天至３个月分别为（５１．９±７．２）ｍｍ、（３１．５±４．５）ｍｍ（Ｐ＜０．０１）;术后１～２年分别为（４７．６±６．１）ｍｍ、（２９．５±５．４）ｍｍ（Ｐ＜０．０１）。手术死亡率３．９％。术后随访６个月至１６年,平均４．４年,累计随访５０１病人·年。晚期死亡６例（１．２％病人·年）,５年及１０年生存率分别为８９．３％、７７．３％。血栓栓塞及与抗凝有关的出血率分别为０．８％病人·年、１．０％病人·年。结论：ＡＶＲ术后９５％病人的心功能恢复至Ｉ或Ｉ级,长期效果满意。故主动脉瓣病变、ＬＶＥＤＤ扩大并出现症状的病人,应行主动脉瓣替换术。     

激光心肌血运重建术治疗冠心病的临床体会

目的：总结１９９７ 年７ 月至１９９８ 年１２ 月激光心肌打孔治疗５０ 例冠心病病人的临床经验。资料和方法：５０ 例病人平均年龄（６４ ±８） 岁,７０ 岁以上１５ 例。术前心绞痛（３ ．７ ±０ ．７） 级,４０ ％ 为不稳定心绞痛。有陈旧性心肌梗塞史者３３ 例、高血压病３３ 例、糖尿病１９ 例。冠状动脉（ 冠脉） 搭桥和经皮冠脉内成形术后各４ 例。超声心动图示左室射血分数平均为０ ．５１ ±０ ．１１ 。均经冠状动脉及左室造影、单光子发射计算机断层扫描（２０１ 铊－ ＳＰＥＣＴ） 心肌活性测定、运动试验等多项检查,认为有激光心肌血运重建术（ＴＭＬＲ） 指征。在全麻下经左胸前外侧第５ 肋间隙进胸,显露左心室壁。采用高功率二氧化碳激光打孔器（ 美国ＰＬＣ 公司） ,在食管超声监测下对左室壁缺血区域打孔（２１ ±５） 个。结果：术后早期死亡１ 例,余者均于术后１３ ～２５ 天出院。术后并发急性心梗、心功能不全各１ 例,一过性房颤、频发室性早搏各３例。术后３ 、６ 、１２ 个月心绞痛分别改善为（２ ．１ ±０ ．３） 级、（１ ．７ ±０ ．３） 级和（１ ．７ ±０ ．３） 级（ Ｐ＜ ０ ．０５） ,ＳＰＥＣＴ示１９ 例（７０ ％ ） 随访病人心肌灌注得到不同程度改善。     

无支架异种生物瓣膜主动脉瓣替换术后左室功能变化

评价无支架异种生物瓣膜主动脉瓣替换术后２年左室功能的变化。将８０例同期施行主动脉瓣替换病人分为２组，５０例（年龄６９．３±９．３岁）应用ＴｏｒｏｎｔｏＳＰＶＴＭ瓣；３０例（年龄７１．６±７．７岁）作为对照组接受支架人工瓣膜替换。术前、术后１、６、１２及２４个月间记录Ｍ型及Ｄｏｐｐｌｅｒ超声心动图，采用计算机图像数字分析，定量测定左室功能的变化。随访期间，Ｔｏｒｏｎｔｏ组主动脉瓣跨瓣压差为０．８±０．６ｋＰａ（６．０±４．５ｍｍＨｇ），明显低于对照组２．３±０．９ｋＰａ（１７．３±６．８ｍｍＨｇ）；术后１个月，左室心肌质量下降２５％，左室＋Ｖｃｆ及－Ｖｃｆ明显增加（２．０±０．８／１．４±０．３ｓ－１，Ｐ＜０．０１；２．８±１．２／１．８±０．７ｓ－１，Ｐ＜０．０１）。术后６个月，左室功能进一步改善，心室肥厚的消退更趋完全，该变化在其后的随访期间保持稳定。结论：与支架瓣膜相比，无支架异种生物瓣膜具有较大瓣口开放面积及低跨瓣压差，这促进了术后左室功能的恢复及病理性肥厚的逆转     

经内镜乳头括约肌切开治疗乳头狭窄的临床研究

为观察内镜乳头括约肌切开（ＥＳＴ）治疗十二指肠乳头良性狭窄的临床疗效，对６０例乳头良性狭窄病人进行ＥＳＴ治疗，３０例施行改良ＥＳＴ，另３０例行常规ＥＳＴ。观察两组病人术后并发症，临床症状改善情况。改良组术后并发症发生率６．７％，常规组３．３％（Ｐ〉０．０５）。改良组乳头再狭窄临床症状复发者占６．７％，而常规组复发者占３０％（Ｐ〈０．０５）。结果表明：改良ＥＳＴ治疗乳头良性狭窄的疗效优于常规ＥＳＴ。     

带腹直肌蒂胸骨-肋软骨瓣翻转移植整复漏斗胸畸形

目的 探讨整复先天性漏斗胸的手术方法。方法 ①根据前胸壁漏斗状凹陷畸形的病变范围,设计胸骨前面皮肤正中垂直切口线。②采用带腹直肌蒂胸骨-肋软骨瓣,前后翻转移植整复严重漏斗胸畸形。结果 1999年至2005年,于临床应用7例,全部获得成功,畸形矫正满意,术后无复发。结论 带腹直肌蒂胸骨-肋软骨瓣前后翻转移植是一种治疗漏斗胸前胸壁严重漏斗状凹陷畸形较好的方法。     

Re-operation of pectus excavatum

We performed surgical reconstruction on 1655 cases of deformed thoracic cage, we later operated again on 11 of these to repair postoperatively re-deformed anterior chest walls. Based on these experiences, we have concluded as follows. 1: Postoperative recurrence of funnel chest deforming is mainly due to insufficient resection of costal cartilages. In particular transection of the sternum at low levels during sternal turn-over procedure results in postoperative recurrence of depression in the upper anterior chest wall. 2: In young children who have undergone sternal turn-over procedure, the first and second costal bones and cartilages overgrow and protrude anteriorly, and in compensation their junctions to the sternum recess posteriorly. This results in a depression in the upper anterior chest wall. 3: We recommend sternal turn-over with overlapping of the sternum for repair of postoperative funnel chest deformity. Through this procedure, the extent of resection of costal cartilages can easily be determined and the depression of the anterior chest wall satisfactorily reconstructed. 4: In re-do surgery, we obtained pathological evidence confirming our clinical experience that our sternal turn-over technique does not interfere with blood circulation or development of the turned-over sternum even though the sternum is not connected to the rectus abdominus muscle pedicle, preserved internal mammary vessels, or anastomosis of the internal mammary vessels.     

A simple sternal turnover procedure using a vascular pedicle for a funnel chest

We have improved the sternal turnover surgical procedure by using a vascular pedicle for a funnel chest. Rather than performing a simple sternal turnover, we thought it better to use the sternum with the vascular pedicle attached, anticipating that this would lead to fewer postoperative complications and a more desirable result. The following method for performing the operation was devised: (1) cutting the deformed sternum at the second intercostal position; (2) cutting the second costal cartilages to allow a repositioning of the vascular pedicle onto the presternal surface; (3) turning the sternum over, placing one end on the other, and attaching one end to the other; and (4) making a groove in the turned-over sternum to prevent the decussated vascular pedicle from becoming constricted. By using this method, it is easily possible to keep the bilateral internal thoracic vessels intact. We used this surgical technique on a 17-year-old boy and obtained very favorable results.     

Modification of Ravitch’s operation for funnel chest with a living rib and “lapel flap”

A modified Ravitch’s operation was performed on a 15-year-old boy for funnel chest. To prevent recurrence of chest depression, fixation with the 8th rib, vascularized with the pedicled serratus anterior muscle flap, and a combined pectoralis major and rectus abdominis muscle flap, were used. The end result was satisfactory. Received: 15 January 1997 / Accepted: 4 July 1997     

胸腹壁随意皮瓣联合腹直肌肌瓣修复胸壁缺损

目的探讨胸腹壁随意皮瓣联合腹直肌肌瓣移位修复胸壁缺损的临床应用价值。方法2002年1月～2005年6月,对5例胸壁缺损患者行胸腹壁随意皮瓣联合腹直肌肌瓣移位修复术。其中胸骨骨髓炎术后、胸骨肿瘤刮除术后、胸骨结核病灶清除术后各1例,心脏手术术后2例;均因感染致胸骨及内置物外露,病程6个月～2年。先行病灶清除,视创面大小设计切取15cm×10cm的胸腹壁随意皮瓣,然后切取腹直肌肌瓣移位修复胸壁缺损。结果术后4例皮瓣期愈合,1例皮瓣延期愈合,无并发症。皮瓣外观良好,无臃肿及色素沉着,X线片显示胸骨死骨阴影消失。随访1～3年,平均1年6个月,无复发。腹部供区皮肤愈合良好,无腹壁疝发生。结论胸腹壁随意皮瓣联合腹直肌肌瓣移位修复术是治疗胸骨体周围胸壁缺损的一种简单、有效方法,值得推广应用。     

改良胸骨上举术治疗漏斗胸的远期疗效

目的 总结改良胸骨上举术治疗漏我的远期疗效。方法 对１９８５年１０至１９９４年１０月期间,收治的１３７例漏斗胸病儿进行了远期随访,随访资料完整者１２１例。包括：胸廓外形、Ｘ线胸片,心肺功能检测。结果 除１例复发外,所有病儿的胸廓外形和漏斗指数都恢复正常,心功能亦恢复下沉但肺功能的恢复比较缓慢。结论 改良胸骨上举术治疗漏我可取得较满意的疗效。     

Aesthetic and functional correction of female,asymmetric funnel chest – A combined approach

There is still sparse information published about the surgical correction of female funnel chest deformity. Women with severe asymmetric funnel chest deformity often present with asymmetric, hypoplastic breasts. These patients frequently complain of physiological limitations in connection with gross aesthetic impairment. To correct these two features a combined approach is presented in this study. 10 women were operated with correction of the thoracic wall deformity by open retrosternal mobilisation and metal plate fixation. Either during the same procedure or in a secondary operation, submuscular breast augmentation was performed to correct breast hypoplasia and asymmetry. All patients tolerated the operation very well without any complications. Aesthetic outcome was rated good to excellent in secondary breast augmentation, whereas simultaneous implant positioning was prone to cause symmastia. In conclusion we recommend correction of female asymmetric funnel chest by primary sternal reduction with secondary breast augmentation during metal plate removal 1 year after.     

A vascularised rib strut technique for funnel chest correction.

We have refined the Ravitch technique of sternal elevation for surgical correction of funnel chest. Our major modification is introducing a living rib strut for supporting the elevated sternum. The left 5th rib with a vascular pedicle from the internal thoracic artery is turned 180 degrees beneath the sternum. We have used this method in 10 cases. The results have all been satisfactory.     

Single-stage repair of the anterior chest wall following sternal destruction complicated by mediastinitis

Purpose

Although various techniques have been described, the ideal reconstructive procedure for treating massive sternal fragmentation and necrosis is still a matter of debate. Sometimes, reconstruction is so challenging that repetitive operations are required, particularly when complicated by mediastinitis and sternal osteomyelitis.

Methods

Five patients (three males, two females, median age 66) with severe osteomyelitis and sternal destruction after receiving myocardial revascularization underwent partial or radical sternal resection, omental flap transposition, titanium mesh implantation and rectus abdominis muscle flap transposition. The final procedure involved single-stage closure.

Results

One patient died 9 days after the final procedure due to pneumonia and septicemia. The other patients received antibiotics for at least 6 weeks postoperatively. The mean hospital stay was 36 days. Optimal wound healing was observed, with acceptable cosmetic disorders.

Conclusions

Although lateral sternal support is the first-line surgical treatment for sternal dehiscence, performing primary closure of complicated defects is often impossible. Aggressive treatment modalities are required in such cases for anterior chest wall defects. This technique provides the ability to perform rigid and stable sternal closure in complicated cases.     

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis

OBJECTIVE: Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. METHODS: Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). RESULTS: Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. CONCLUSION: We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.