经迷路—小脑幕入路切除大型听神经瘤

作者采用经迷路－内听道－小脑幕联合入路切除３０例大型听神经瘤，肿瘤全切除率达９６．７％，无手术死亡。面神经解剖保留率为５３．３％，功能保留率为３６．７％，该入路的主要优点是：（１）进路直接，显露良好；（２）充分打开内听道；（３）手术后反应轻；（４）入路可灵活变通或改良。对于手术技术，手术后并发症的防治和面神经保留等进行简要讨论。     

听神经瘤显微手术治疗和面听神经功能保护的探讨

目的探讨听神经瘤显做于术治疗和面听神经功能保护的疗效。方法分析1999年10月至2002年10月收治经枕下乙状窦后内听道入路手术切除30例听神经瘤的资料，全部病例采用保留面听神经功能的显做外科技术。结果听神经瘤手术全切除29例（96．7％），次全切除1例；面神经解剖保留25例（83．3％），手术后12周面神经功能保留21例（70％）；耳蜗神经解剖保留25例83．3％），手术后2周有效听力保留2例（占术前存在有效听力患者的28．6％），有效听力丧失但可测听力保留15例。结论枕下乙状窦后经内听道入路的听神经显微手术，能够取得较好的肿瘤全切除率和面听神经功能保留率.     

显微手术切除大型听神经瘤

目的 探讨应用显微外科技术切除大型听神经瘤（直径≥３１ｍｍ）的治疗效果。方法 大型听神经瘤经ＣＴ或ＭＲＩ扫描检查确诊，应用显微率枕下－乙状窦后入路行肿瘤切除术２２８例，结果 全切除１８４例（８０．７％），次全切除３３例（１４．５％），部分切除１１例（４．８％），术中面神经解剖保留率为８２．９％（１８９例），术后死亡３例（１．３％）。长期随访观察２０１例（平均３．８年），其中恢复良好者１８９例（９４     

大型听神经瘤的显微手术治疗及面神经保护探讨

目的：总结经枕下乙状窦后入路显微外科手术切除听神经瘤及面神经保护的经验和技巧,以提高肿瘤的全切率和面神经的保留率。方法31例听神经瘤患者采用经枕下乙状窦后入路显微手术治疗,术中均行面神经电生理监测及面神经保护。结果肿瘤全切29例（93．6％）,大部分切除2例（6．4％）。术中面神经解剖保留28例（90．3％）,面神经功能状态 H-B 分级：Ⅰ～Ⅱ级22例（70．9％）,Ⅲ～Ⅳ级7例（22．6％）,Ⅴ～Ⅵ级2例（6．5％）。无长期昏迷及死亡病例。结论娴熟的显微操作技巧和术中面神经电生理监测有助于提高肿瘤切除率及保护面神经。     

小骨窗显微手术切除大型桥小脑角肿瘤及神经功能保护

目的探讨大型（直径≥3cm）桥小脑角肿瘤的小骨窗显微手术切除方法及神经功能保护。方法回顾性分析经乙状窦后入路小骨窗显微手术切除的32例大型桥小脑角肿瘤患者的临床资料,肿瘤全切除28例（87．5％）,次全切除4例（12．5％）。结果本组无手术死亡病例。面神经解剖保留率为93．8％（30／32）,面神经功能（House—BrackmannI、Ⅱ级）保留率为78．1％（25／32）,听神经解剖保留率为87．5％（28／32）,听力保留率68．8％（22／32）。结论采用乙状窦后入路小骨窗显微手术切除大型桥小脑角肿瘤是一种安全、有效的手术方法,在保留神经功能完整性的前提下应尽量切除肿瘤。     

食管癌,贲门癌手术入路的探讨

为了评估食管癌，贲门癌各种手术入路的优缺点，我们总结食管贲门癌手术２１２０例，其中病变位于食管颈，胸上，中，下段及贲门者分别为２６，２８０，９３６，４０８，４７０例，经左后外侧剖胸，包括左胸，左颈两切口者１９９５例，并发症６．６％（１３３／１９５５）；经右胸－腹正中－颈三切口者５８例，并发症２４．１％，（１４／５８）颈腹二切口者２０例；胸腹联合切口者３９例，并发症７．６％（３／３９）；经上腹正中切     

腹部手术后肠瘘的治疗

为提高手术后肠瘘的治愈率，作者总结了１９８９年１２月至１９９６年１０月间收治的腹部手术后肠瘘２４例，包括十二指肠瘘６例，高位小肠瘘３例，低位小肠瘘７例，结肠瘘８例。１６例行保守治疗，治愈率７５％（１２／１６）；８例行手术治疗，治愈率８７．５％（７／８）。全组死亡率２０．８％（５／２４）。作者认为治疗应遵循以下原则：（１）明确诊断；（２）结合生长抑素的应用加强营养支持治疗；（３）控制感染；（４）针对患者的具体情况，正确选择手术时机；（５）积极治疗肠道原发疾病，加强重要脏器功能的监护。     

腹部手术后肠瘘的治疗

为提高手术后肠瘘的治愈率，作者总结了１９８９年１２月至１９９６年１０月间收治的腹部手术后肠瘘２４例，包括十二指肠瘘６例，高位小肠瘘３例，低位小肠瘘７例，结肠瘘８例，１６例行保守治疗，治愈率７５％（１２／１６），８例行手术治疗，治愈率８７．５％（７／８），全组死亡率２０．８％（５／２４），作者认为治疗应遵循以下原则：（１）明确诊断；（２）结合生长抑素的应用加强营养支持治疗；（３）控制感染；（４）针对     

肝切除治疗肝内胆管结石

探讨肝切除术治疗肝胆管结石的效果。方法分析１９８９年７月－１９９９年７月采用肝切除术治疗１８４例肝内胆管结石患者的结石部位和分布情况、手术方式、手术后并发症、病理结果等情况。结果肝内胆管结石以左肝为主（１６５例）,肝切除也以左肝叶段切除为多（１５３例）;３２例出现手术后并发症（１７．３９％）无手术死亡。随访３月－１０月年,效果优良者占９６．２０％,包括４例早期胆管癌。结论肝切除术手是治疗内胆管结珠     

大型听神经瘤的显微手术治疗

目的：报道听神经瘤经枕下－乙状窦后显微手术切除的临床经验。提高大型听神经瘤的全切除率和面、听神经的保留率。方法：回顾性分析临床39 经显微神经外科手术治疗的大型听神经瘤，对影响肿瘤全切除的因素及手术中的关键技术点进行分析。结果：肿瘤全切除34例（占87．2％），次全切5例。术中解剖保留面神经31例（79．5％），听神经解剖保留15例（38．5％），其功能保留率分别为56．4％、17．95％。结论：应用显微外科技术是提高听神经瘤手术切除率和面、听神经解剖和功能保留率的关键。术中诱发电位的应用可提高面、听神经解剖和功能保留率。     

Abdominal Complications After Lung Transplantation in a Brazilian Single Center

Surgical and nonsurgical abdominal complications have been described after lung transplantation. However, there is limited data on this event in this population. The objective of this study was to analyze the incidence of abdominal complications in patients undergoing lung transplantation at the Heart Institute of the Faculty of Medicine, University of São Paulo (InCor-HCFMUSP) between the years 2003 and 2016. The main causes of abdominal complications were inflammatory acute abdomen (7 patients; 14%), obstructive acute abdomen (9 patients; 18%), gastroparesis (4 patients; 8%), distal intestinal obstruction syndrome (4 patients; 8%), perforated acute abdomen (7 patients; 14%), cytomegalovirus (CMV; 6 patients; 12%), and other reasons (12 patients; 26%). Separating these patients according to Clavien-Dindo classification, we had 21 patients (43%) with complications grade II, 4 patients (8%) with complications grade IIIa, 7 patients (14%) with grade IIIb complications, 7 patients (14%) with grade IV complications, and 10 patients (21%) with grade complications V. In conclusion, abdominal disorders are seriously increased after lung transplantation and correlate with a high mortality. Early abdominal surgical complication has worse prognosis.     

Coronary Artery Bypass Surgery in Patients with Malignancy: A Single-Center Study with Comparison to Patients Without Malignancy

Abstract Background: There is debate on the timing and outcome of coronary artery bypass surgery in patients with coincident malignancy. In this study, we compared the outcome of coronary artery bypass graft (CABG) in such patients with those without malignancy. Methods: The patients were selected from those who had undergone coronary artery bypass surgery in the last decade. The study group (group I) included the patients with malignancy in remission. The control group comprised those patients who were selected randomly from those without any malignancy. The patients were retospectively examined with regard to preoperative, operative, and postoperative data from personal files, computerized recording system, and operation reports. Results: Group I included 48 patients (age 48 to 69; 29 male) while group II included 50 patients (age = 38 to 73; 35 male). In group I, comorbidity rates were: renal dysfunction in 12 (25%), obstructive lung disease 10 (21%), congestive failure in four (8%) patients. The malignancy rates were: lung in 15 (31%), breast in 10 (21%), stomach in five (10%), colon in four (8%), renal in one (2%), Hodgkin's lyphoma in three (6%), leukemia in two (4%), ovarian in three (6%), and prostate in five (10%) patients. In group II, the comorbidity rates were: diabetes mellitus 18 (36%), renal dysfunction in five (10%) and obstructive lung disease in 13 (26%) patients. In group I, chemotherapy and radiotherapy were performed in 38 and 34 patients, respectively. In groups I and II, the CABG was elective in 47 (98%) and in 45 patients (90%); the off‐pump surgery was performed in 27 (56%) and 12 (24%) patients, respectively. The total duration of bypass was 37 ± 6 minutes and 44 ± 5 minutes; the duration of aortic clamp was 26 ± 4 and 29 ± 7 minutes, respectively, in groups I and II. Posoperative complication rates were: infection in 12 (25%), bleeding in eight (17%), acute renal insufficiency in eight (17%), prolonged air escape in five (10%), and prolonged entubation in 17 (35%) patients in group I and atrial fibrillation in 11 (22%) patients in group II. Mortality rates in both groups were two (4%). Conclusion: CABG in patients with comorbid malignancy is as safe as the other patients. In patients with full remission of malignancy, the surgeons should be encouraged about the safety of CABG.     

Post-dysenteric hemolytic uremic syndrome in children during an epidemic of Shigella dysentery in Kwazulu/Natal

We report 81 of 107 cases of hemolytic uremic syndrome (HUS), admitted between July 1994 and February 1996, following an outbreak of Shigella dysenteriae type 1 dysentery in Kwazulu/Natal. All patients, excluding 1, were black with a mean age of 38 months (range 1 – 121); 50 (61.7%) were males. The mean duration of dysentery was 11.3 days (range 1 – 41) and HUS 15 days (range 1 – 91). Most patients had acute oliguric renal failure (90.1%); 42 (51.6%) required peritoneal dialysis. Complications included encephalopathy 30 (37.0%), convulsions 12 (14.8%) and hemiplegia 2 (2.3%), gastrointestinal perforation 8 (9.9%), protein losing enteropathy 26 (32.1%), toxic megacolon 4 (4.9%), rectal prolapse 5 (6.2%), hepatitis 11 (13.6%), myocarditis 5 (6.2%), congestive cardiac failure 3 (3.7%), cardiomyopathy 3 (3.7%), infective endocarditis 1 (1.2%), septicemia 15 (18.5%), disseminated intravascular coagulation 17 (21%). Leukemoid reactions were found in 74 (91.3%) patients, hyponatremia in 56 (69.1%), and hypoalbuminemia in 67 (82.7%). Stool culture for Shigella dysenteriae type I was positive in only 7 (8.6%) patients; Shiga toxin assays were not performed. Outcome was as follows: recovery 32 (39.5%), impaired renal function 8 (9.9%), chronic renal failure 26 (32.1%), end-stage renal disease 1 (1.2%), and death 14 (17.3%) patients. Received November 26, 1996; received in revised form and accepted April 15, 1997     

Evaluation of risk factors in the development of postoperative complications in patients undergoing liver resection for cancer

A consecutive series of 134 hepatic resections for primary and metastatic cancer were analyzed to identify the risk factors for post-operative complications in patients with and without impaired liver reserve. Between January 1992 and January 2000 were performed 55 hepatectomies (41%--group 1) in 54 cirrhotic patients for hepatocarcinoma and 79 hepatic resections (59%--group 2) in 66 patients for primary hepatic malignancies or metastatic liver tumours in non cirrhotic liver. Among major postoperative complications bile leakage was recorded in 8 patients (6%) (6% with impaired liver reserve and 6% with normal reserve), hepatic failure in 8 patients (6%) (9% vs 4%; P = NS), ascites in 7 patients (5%) (11% vs 1%; P = 0.01), pneumonia in 4 patients (3%) (5% vs 1%; P = NS), intra-abdominal abscess in 2 patients (1%) (2% vs 1%; P = NS), postoperative haemorrhage in 2 patients (1%) (4% vs 0; P = NS), and gastrointestinal bleeding in 2 patients (1%) (4% vs 0; P = NS). There were 6 perioperative deaths (4%) (7% vs 2%; P = NS). The mean hospital stay was 21 +/- 10 days (range: 5-57) (24 +/- 10 vs 20 +/- 10; P = 0.02). Liver resection is a safe procedure even in cirrhotic patients providing they are well selected and there is minimal intraoperative blood loss.     

Comparison of treatment results between holmium laser endourethrotomy and optical internal urethrotomy for urethral stricture

Purpose

We comparatively evaluated urethral stricture (US) treatment outcomes, efficacy and complications, using either holmium laser endourethrotomy (HLU) or optical internal urethrotomy (OIU) since studies such as this are scarce in literature.

Methods

During 2003?C2008, 50 men aged 17?C78?years were operated on for primary or refractory US, 32 (64%) and 18 (36%) patients, respectively. The average stricture length was 1.86?cm. Strictures were single or multiple, forty-one (82%) and nine (18%) patients, respectively, and were located in the anterior or posterior urethra in 27 (54%) and 32 (64%) patients, respectively. US were iatrogenic in 32 (64%) and idiopathic in 18 (36%). Patients were divided into two groups, grpA and grpB, each containing 25 patients who were treated using either HLU or OIU, respectively. An evaluation scale of 1?C3 was adopted and took maximum flow rate (Q_max), postvoid residual (PVR), and quality of life (QL) into consideration. A score of ??1 was very good, ??2 was good, and ??3 was poor.

Results

Treatment results were evaluated after 3, 6, and 12?months, respectively. Evaluation of grpA was as follows: five (20%), nine (36%), and seven (28%) patients scored a ??1; thirteen (52%), nine (20%), and four (16%) patients scored a ??2; and seven (28%), eleven (44%), and fourteen (56%) patients scored a ??3. Evaluation of grpB: seven (28%), ten (40%), and five (20%) patients scored a ??1; eleven (44%), seven (28%), and ten (40%) patients scored a ??2; and seven (28%), eight (32%), and ten (40%) patients scored a ??3.

Conclusions

Neither complication rate nor degree of efficacy between HLU and OIU for US revealed a significant difference. We found both laser and conventional urethrotomies to be safe and effective modes of treatment.     

Comparative Study of Diabetes Mellitus Resolution According to Reconstruction Type After Gastrectomy in Gastric Cancer Patients with Diabetes Mellitus

Background

This study was conducted to investigate diabetes mellitus (DM) resolution after gastrectomy according to reconstruction type in gastric cancer patients.

Methods

Two hundred twenty-nine gastric cancer patients with DM who underwent gastrectomy with curative intent from May 2003 to December 2009 were enrolled. Changes in fasting blood sugar concentration and the dosage of oral hyperglycemic agents or insulin were compared between reconstruction types.

Results

The numbers of patients who underwent distal gastrectomy with a Billroth I (BI), Billroth II (BII), Roux-en-Y gastrojejunostomy (RYGJ), or total gastrectomy with Roux-en-Y esophagojejunostomy (RYEJ) were 119 (51.7%), 54 (23.5%), 40 (17.4%), and 16 (6.9%), respectively. DM remitted in 45 (19.7%) patients: 18 BI patients (15.1%), 11 BII patients (20.3%), 8 RYGJ patients (20.0%), and 8 RYEJ patients (50.0%). DM improved in 85 (37.1%) patients: 41 BI patients (34.4%), 25 BII patients (46.2%), 15 RYGJ patients (37.5%), and 4 RYEJ patients (25.0%). The DM remission or improvement rate was higher in the duodenal bypass group (BII, RYGJ, RYEJ) than in the BI group (67.2% vs. 49.5%, P?=?0.022), and the DM remission rate was higher in the RYEJ group than in the distal gastrectomy group (50.0% vs. 17.3%, P?=?0.002).

Conclusions

Many gastric cancer patients with DM who received a gastrectomy showed remission or improvement of DM. The duodenal bypass group had higher DM remission or improvement rate than the BI group, and the RYEJ group had the highest DM remission rate.     

Repeat Retrourethral Transobturator Sling in the Management of Recurrent Postprostatectomy Stress Urinary Incontinence After Failed First Male Sling

Background

A failure rate between 20% and 45.5% after retrourethral transobturator sling (RTS) is reported. Recommendations for the management of persistent or recurrent postprostatectomy stress urinary incontinence (SUI) after failed male sling do not exist.

Objective

The aim of this study was the prospective evaluation of the efficacy of repeat RTS (RRTS) in patients after failed first RTS.

Design, setting, and participants

Between March 2007 and August 2009, 35 patients with mild to severe SUI after failed first RTS were treated with a second AdVance sling (American Medical Systems, Minnetonka, MN, USA).

Measurements

Preoperative and postoperative evaluation included daily pad use, 1-hr pad test, postvoiding residual (PVR) urine, uroflowmetry, and quality-of-life (QoL) scores.

Results and limitations

After 6 mo, 45.5% (15 of 33 patients) showed no pad use; 30.3% (10 of 33 patients), one dry “security” pad; 3% (1 of 33 patients), one wet pad; 6.1% (2 of 33 patients), two pads; 3% (1 of 33 patients), pad reduction ≥50%; and 12.1% (4 of 33 patients), treatment failure. After 16.6 mo, 34.5% (10 of 29 patients) showed no pad use; 37.9% (11 of 29 patients), one dry “security” pad; 3.4% (1 of 29 patients), one wet pad; 3.4% (1 of 29 patients), two pads; 10.3% (3 of 29 patients), pad reduction ≥50%; and 10.4% (3 of 29 patients), treatment failure. Daily pad use and pad weight decreased significantly. PVR and uroflowmetry results showed no significant change. QoL improved significantly. Postoperative acute urinary retention was observed in 23.6% of patients.

Conclusions

RRTS is an effective and safe treatment option for the management of SUI after failed first RTS.     

Incidental radiologic findings in breast cancer patients who undergo staging prior to neo-adjuvant chemotherapy

NCCN guidelines discourage the use of staging imaging for newly diagnosed patients with early breast cancer (BC). When performed, incidental radiologic findings of uncertain significance are often encountered. The purpose of this study was to compare incidental findings seen on staging imaging with distant recurrence in patients undergoing neo-adjuvant chemotherapy (NAC). 396 patients with BC who had NAC from 2008 to 2016 were identified from a prospectively maintained data base. Staging imaging was reviewed. Of 396 patients with BC treated with NAC, patients with a positive PET/CT for metastatic disease (n = 36, 9.1%), those that did not undergo staging imaging (n = 49, 12.4%), or those that did not have a reported incidental finding (n = 49, 12.4%) were excluded from analysis. Of the 262 patients who met criteria, mean age was 50 years (range: 26–88). 201 (76.7%) patients had stage I-II cancer, and 61 (23.3%) patients had stage III cancer. Overall, 146 (55.7%) patients had an incidental finding on imaging. 90 (34.4%) patients had one finding, 42 (16.0%) patients had two, and 14 (5.3%) patients had three or more findings. The majority of incidental findings were seen in the ovary/uterus (29.7%), followed by lung (18.4%), liver (10.3%), and bone (9.0%). 5 (3.4%) patients had additional imaging performed. At mean follow-up of 3.7 years (range: 0.7–10.8), 43 (15.6%) patients had a distant recurrence. Of these patients, only 5 (1.9%) patients had distant metastasis in the same organ that was initially thought to be an incidental finding. Our results suggest that breast cancer patients with incidental findings on preoperative staging imaging are unlikely to be indicative of sites for future metastasis.     

Treatment of fractures of the thoracolumbar spine by combined anteroposterior fixation using the Harms method

Forty-three patients with fractures of the thoracolumbar spine submitted to surgical treatment using the Harms method (dorsoventral operations) were studied prospectively with a follow-up of at least 12 months and evaluated on the basis of clinical and radiologic parameters and in relation to their professional activities. Thirty-five patients (81.3%) were males and eight (18.7%) females, ranging in age from 17 to 67 years (mean 34.08 ± 11.51 years). Seven patients (16.2%) presented fractures of more than one vertebra, and associated lesions were present in 15 patients (34.8%). Monosegmental fixation was performed in 7 patients (16.3%), bisegmental fixation in 29 (67.4%), and trisegmental fixation in 7 (16.3%). No patient was submitted to any type of external immobilization during the postoperative period and all patients were allowed to sit up in bed and to walk as soon as their clinical conditions permitted. Thirty-nine patients were followed up for a period ranging from 12 to 36 months (mean 16.58 ± 6.83 months). Four patients died during the postoperative period (three of pulmonary embolism and one of septicemia). Forty-two patients sat up in bed between the 2nd and 6th postoperative day, and those who did not present a disabling lesion (Frankel D or E) or other associated lesions walked between the 4th and 10th postoperative day (mean 6.14 ± 6.06 days). The neurological signs and symptoms improved in 16 patients (37.3%), were unchanged in 26 (60.4%), and worsened in 1 (2.3%). Twenty-three patients (87.5%) who had no neurological damage (Frankel E) returned to their professional activities after respective periods of disability of 1 month (three patients), 2 months (four patients), 3 months (one patient), 4 months (seven patients), 5–7 months (five patients), 8–12 months (one patient), and more than 12 months (three patients). The ability to work of the 24 patients without neurological damage was 100% in 21, 50% in 2, and zero in 1. The ability to walk of this group of patients was 1–5 km for 4 and more than 5 km for the remaining 20 patients. The complications observed were death (four patients; three cases of pulmonary embolism and one case of septicemia), infection (two patients), Stevens-Johnson syndrome (one patient), and meningitis (one patient). The mean kyphosis of the fractured segment was 22.17°± 10.97° preoperatively, 8.55°± 6.9° postoperatively, and 10.30°± 8.84° on the occasion of late evaluation. No loss of correction occurred in 28 patients (71.8%), a 5° loss was observed in 3 patients (7.6%), a 6° loss in 3 (7.6%), a 7° loss in 3 (7.6%), and a loss of more than 10° in 2 (5.2%). Received: 20 June 1997 Revised: 6 November 1997 Accepted: 21 November 1997     

Evans syndrome and systemic lupus erythematosus: clinical presentation and outcome

ObjectiveTo review the clinical, laboratory and outcome features of Evans syndrome (ES) in systemic lupus erythematosus (SLE) patients.MethodsWe reviewed the charts of 953 SLE patients followed up regularly at our service. ES was defined as the presence of hemolytic anemia and thrombocytopenia concomitantly or sequentially. Clinical and laboratory manifestations occurring during the disease course, as well as concomitant diseases and survival was carefully reviewed.ResultsWe identified ES in 26 of 953 (2.7%) SLE patients. Twenty-three were women with mean age at SLE diagnosis of 25.7 years. Four (15%) patients had disease onset before the age of 16. In the majority of patients (92%), immune thrombocytopenia and AIHA appeared simultaneously at the beginning of SLE. Active features of SLE were a frequent finding concomitant to ES, especially arthritis (77%), malar rash (61.5%), photosensitivity (57.6%), oral ulcers (34.6%), nephritis (73%), serositis (54%), neuropsychiatric (19%) and pulmonary (15%) manifestations. In addition to this multisystemic disease, 34.6% of our patients had an association with another autoimmune disease such as antiphospholipid syndrome. Recurrence of ES was observed in only four (15%) patients. After follow-up time of 8.72 years, 19 patients (73%) were in remission and seven (27%) patients died.DiscussionES is a rare manifestation in SLE, occurring in patients with severe multisystemic SLE manifestations. Treatment strategies frequently used in SLE contribute to longer disease remission and less frequent exacerbation than observed in the general population with ES.