35例腔镜甲状腺手术喉返神经显露的技巧与体会

目的 探讨腔镜下甲状腺切除术中喉返神经显露的技巧及预防其损伤的方法.方法 2012年4～12月我院行胸乳晕入路腔镜下甲状腺切除术35例,术中充分利用气管食管沟、甲状腺下动脉及甲状软骨下角等解剖标志常规显露喉返神经.结果 35例腔镜甲状腺手术均顺利完成,无中转开放手术,术中共显露喉返神经40条.行单侧腺叶大部切除10例,单侧腺叶切除20例,双侧腺叶大部切除5例.手术时间（45.4±10.1）min,出血量（25.1±5.1）ml;术后无声音嘶哑、呼吸困难等并发症发生.30例术后随访1～9个月,（4.5±0.9）月,1例出现甲状腺功能减退,无肿瘤复发.结论 术中要充分利用气管食管沟、甲状腺下动脉及甲状软骨下角等解剖标志寻找喉返神经.扎实的开放甲状腺手术解剖喉返神经的基础和娴熟的腔镜甲状腺手术技能是显露喉返神经的关键.     

腔镜甲状腺手术喉返神经的显露技巧

目的:探讨腔镜甲状腺手术中喉返神经的显露技巧。方法:回顾分析56例腔镜甲状腺近全/全切除术的临床资料,总结腔镜手术中喉返神经的显露入路及方法。结果:53例手术获得成功,3例因术中冰冻病理报告为甲状腺乳头状癌而中转开放行患侧颈部淋巴结改良清扫术。手术时间平均125.3 min,其中23例经腺体下极入路,20例经峡部向气管食管沟入路;13例经甲状软骨下角入路。术后住院期间及出院后3个月随访,患者均无声音嘶哑。结论:腔镜甲状腺手术中剖显喉返神经是安全、可行的,可避免喉返神经损伤。     

胸壁入路腔镜甲状腺手术中喉返神经的显露与保护

目的探讨胸壁入路腔镜甲状腺手术中喉返神经显露的技巧,预防喉返神经医源性损伤。方法回顾性收集2013年8月至2014年12月期间于兰州军区兰州总医院行胸壁入路腔镜甲状腺手术的45例患者的临床资料。手术时利用甲状腺下动脉、气管食管沟及甲状软骨下角显露喉返神经。结果 45例患者中,行单侧腺叶大部切除18例,行单侧腺叶切除22例,行双侧腺叶大部切除5例;手术时间108~125 min、(120±7)min,术中出血量18~25 m L、(23±4)m L。术后均无不适,无并发症发生。术后所有患者均获访,随访时间6~12个月,平均9个月。随访期间出现甲状腺功能减退2例,其余均正常,且2例甲状腺乳头状癌患者均未复发。结论术中显露喉返神经有利于避免喉返神经损伤。     

腔镜下甲状腺切除术中喉返神经的显露与保护

目的 探讨腔镜下甲状腺切除术中显露和保护喉返神经的方法。方法 施行经胸入路腔镜下甲状腺腺叶切除术时，常规显露并保护喉返神经。结果 8例经胸入路腔镜下甲状腺腺叶切除术。均清楚显露并有效保护了喉返神经。结论 熟练掌握甲状腺游离和切除的顺序及精湛的手术技巧是清楚显露并有效保护喉返神经的关键。     

甲状腺手术中直视显露喉返神经的意义及方法比较

目的 探讨甲状腺手术中直视显露喉返神经的意义及方法.方法 216例甲状腺手术中常规显露喉返神经328条(其中3例为喉不返神经,均位于右侧),经甲状腺下方径路150条,占45.73%,经甲状腺侧方径路178条,占54.27%.结果两种方法均未出现永久性喉返神经损伤;经甲状腺下方径路暂时性喉返神经损伤3例,占2%,显露甲状腺段喉返神经平均用时5 min;经甲状腺侧方径路暂时性喉返神经损伤2例,占1.12%,显露甲状腺段喉返神经平均用时3 min.结论 术中常规显露喉返神经是安全有益的,侧方分离显露喉返神经是一种用时短、损伤小、出血少的手术方法.     

甲状腺术中喉返神经损伤的预防

解剖尸体50具(100侧喉返神经),结果发现:右侧喉返神经位于甲状腺下动脉前方占50.0％,左侧喉返神经居下动脉后方为76.0％(P<0.05);64侧喉返神经入喉前分为2～5支;89.0％喉返神经经甲状腺悬韧带内侧入喉,其入口位于甲状软骨下角前下方者占91.0％。在此基础上,采取紧贴甲状腺腺体纵行解剖甲状腺悬韧带的手术方法施行甲状腺手术70例(83侧),术中显露喉返神经39侧,未显露44侧,均无喉返神经损伤。作者认为预防喉返神经损伤的关键在于掌握其解剖特点,熟练手术技巧,而不在于是否常规显露喉返神经。     

经胸乳晕入路腔镜下甲状腺手术58例

目的:探讨经乳晕入路腔镜甲状腺切除术的临床应用价值和显露保护喉返神经的方法。方法:回顾性分析58例经胸乳晕入路腔镜下甲状腺切除术的临床资料。结果:58例均顺利完成手术,其中喉返神经解剖显露38例,解剖双侧喉返神经1例,左侧16例,右侧21例。手术时间60～265min,喉返神经解剖显露的时间5～10min。术中出血量5～30mL,术后引流量为40～150mL。术后颈部活动良好,无皮下淤斑、皮下积液,无出血、窒息,未见有声音嘶哑、咳嗽、手足抽搐、皮下气肿等并发症。结论:经乳晕入路腔镜甲状腺手术安全可行,是一种具有良好的微创、美观效果的手术方法;熟练掌握甲状腺游离切除的顺序和血管神经脉络化游离技巧是清楚显露并有效预防术中喉返神经损伤的关键。     

腔镜甲状腺手术中喉返神经损伤预防

目的探讨腔镜甲状腺切除术中预防喉返神经损伤的方法。方法对2002年3月至2006年10月暨南大学附属第一医院采用胸乳入路施行腔镜甲状腺腺叶切除术的492例临床资料,及术中采用躲避喉返神经或解剖喉返神经技术进行分析。结果2例出现暂时性喉返神经损伤,无永久性喉返神经损伤。结论熟悉与甲状腺手术相关的解剖知识,掌握腔镜下组织结构清楚暴露和避免神经热损伤的手术技巧是预防喉返神经损伤的关键。     

腔镜甲状腺切除术中喉返神经的显露

目的探讨腔镜甲状腺切除术中喉返神经的显露技巧,避免因显露而造成的喉返神经医源性损伤。方法2011年4月～2012年4月,行胸乳晕人路腔镜下甲状腺切除术17例。于乳腺前皮下置入troear,注入CO2（压力6mmHg）建立操作空间,用超声刀显露喉返神经。结果17例均顺利完成喉返神经显露,其中7例行腔镜双侧甲状腺腺叶手术（6例双侧叶结节和1例甲状腺癌）,5例行一侧甲状腺叶切除术（一侧腺叶多发结节）,5例行一侧腺叶次全切除术。喉返神经主干位于甲状腺下动脉之前、之后和动脉分叉之间的比例分别为17．6％（3／17）、47．1％（8／17）和35．3％（6／17）,术后未见声音嘶哑等发生。结论尽管甲状腺下动脉与喉返神经的关系不固定,应用甲状腺囊外解剖和上翻技术,在切除腺体的同时可以显露喉返神经,减少喉返神经损伤。     

复发性结节性甲状腺肿再手术中喉返神经的保护探讨

【摘要】〓目的〓探索结节性甲状腺肿术后复发再手术中喉返神经的保护策略。方法〓选取我科32例复发性结节性甲状腺手术患者,回顾性分析其手术、临床资料。结果〓通过术中精细解剖,清晰暴露甲状腺解剖标志——Berry韧带和Zuckerkandl结节,明确喉返神经“起点”与“终点”,完整切除腺体,保护喉返神经完好;术后3例患者出现暂时性声音嘶哑,予以神经营养和理疗,2例患者术后两周内恢复正常,1例患者术后四周内恢复正常。结论〓结节性甲状腺肿术后复发再手术者,喉返神经毗邻结构因粘连而层次不清,术者掌握必要的手术技巧和精细操作,暴露关键的甲状腺解剖标志以显露喉返神经,是避免其医源性损伤的重要方法。     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Differences in Osteocyte Density and Bone Histomorphometry Between Men and Women and Between Healthy and Osteoporotic Subjects

Bone defects related to osteoporosis develop with increasing age and differ between males and females. It is currently thought that the bone remodeling process is supervised by osteocytes in a strain-dependent manner. We have shown an altered response of osteocytes from osteoporotic patients to mechanical loading, and osteocyte density is reduced in osteoporotic patients, which might relate to imperfect bone remodeling, leading to lack of bone mass and strength. Hence, information on osteocyte density will contribute to a better understanding of bone biology in males and females and to the assessment of osteoporosis. Osteocyte density as well as conventional histomorphometric parameters of trabecular bone were determined in cancellous iliac crest bone of healthy postmenopausal women and men and of osteoporotic women and men. Osteocyte density was higher in healthy females than in healthy males and lower in osteoporotic females than in healthy females. Bone mass was reduced in osteoporotic patients, both male and female. In females, trabecular number was reduced, whereas in males, trabecular thickness was reduced and eroded surface was increased. There were no correlations between the parameter groups bone architecture, bone formation, bone resorption, and osteocyte density. These results are consistent with impaired osteoblast function in osteoporotic patients and with a different mechanism of bone loss between men and women, in which osteocyte density might play a role. The reduced osteocyte numbers in female osteoporotic patients might relate to imperfect bone remodeling leading to lack of bone mass and strength. M. G. Mullender and S. D. Tan contributed equally to this work.     

肝内胆管囊腺瘤和囊腺癌的CT、MRI及病理表现

目的探讨肝内胆管囊腺瘤和囊腺癌的CT、MRI和病理特点。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤和2例肝内胆管囊腺癌的影像及临床病理资料，将病变的影像表现与其病理大体形态及组织学表现作对照分析。结果6例肝内胆管囊腺瘤，女4例、男2例；2例肝内胆管囊腺癌均为女性病人；8例病人平均年龄55岁。所有病灶均表现为多房囊性肿块，肿瘤囊腔各分房内常为多种液体成分，在CT上可表现为不同密度、在MRI上可表现为不同信号强度。囊内出现多发大小不等的壁结节在胆管囊腺癌内更常见，囊内有分隔但无壁结节只见于胆管囊腺瘤。在7例CT扫描中，4例胆管囊腺瘤和1例胆管囊腺癌可见囊壁或分隔上钙化，囊壁、囊内分隔及囊内结节均为轻、中度延迟增强。肿瘤中出现卵巢样间质见于3例胆管囊腺瘤和1例胆管囊腺癌，且均为女性病人。结论肝内胆管囊腺瘤和囊腺癌是肝脏不常见的囊性肿瘤，影像上多房、囊内有分隔且各分房囊内密度或信号不一致，高度提示肝内胆管囊腺瘤或囊腺癌的诊断，如囊内伴有多发大小不等的结节，则进一步提示囊腺癌的可能。但影像学表现不能区分肿瘤中有无卵巢样间质。