胃癌腹腔镜手术与开腹手术效果观察

对腹腔镜手术与开腹手术治疗胃癌随机对照试验开展循证医学研究,现报道如下。1资料与方法1.1研究对象选择1989年1月1日—2011年1月30日公开发表的腹腔镜手术治疗胃癌与开腹手术治疗胃癌的随机对照研究,     

机器人手术系统在结直肠癌手术临床应用现状

机器人手术系统的优点是三维图像清晰和操作稳定灵活,缺点是力反馈缺失、费用昂贵和手术时间延长。其可安全应用于结直肠癌手术,具有创伤小和术后恢复快的特点。机器人结肠癌手术的安全性和有效性已得到肯定,但关于长期生存的研究证据仍不够。目前,与腹腔镜手术比较,机器人直肠癌手术并未在肿瘤短期和长期结局方面显现出优势。机器人手术系统在结直肠癌手术中的合理应用还需进一步的前瞻性随机对照研究。随着第4代达芬奇Xi手术系统面世和外科技术的不断进步,机器人手术系统将在结直肠癌手术中发挥更重要的作用。     

锁骨骨折手术与非手术治疗的Meta分析

目的通过Meta-分析来比较锁骨骨折手术与非手术的疗效。方法通过检索最近10年的关于锁骨骨折手术与非手术治疗对照研究的4篇文章,采用循证医学Meta分析法对肩关节功能、残余疼痛、术后并发症、愈合率及患者满意度进行综合分析。结果Meta分析发现,手术治疗与非手术治疗相比较,在肩关节功能、残余疼痛及患者满意度方面并无明显统计学差异;手术治疗可大大提高骨折愈合的机会,而非手术治疗可明显降低并发症发生机会。结论手术治疗除了能提高骨折愈合率之外与非手术治疗没有明显差异,因此在临床工作中对于治疗方法的选择应该谨慎。     

手术焦虑症研究

焦虑情绪是一种防御反应 ,是人尚未接触到应激源但已预感到即将发生的危险或威胁时的情绪反应。手术作为一种直接影响身体安全的应激源 ,不可避免地将会引起病人出现焦虑。关于手术焦虑的研究在国外自上世纪 4 0年代起就已经开始系统研究。国内大规模的研究则是在 90年代中期。在中国生物医学文献库以手术、焦虑作为主题词检索(1981～ 2 0 0 1) ,查出文献 16 9条。我国关于手术焦虑的研究起步虽晚 ,但成就令人瞩目。在比较有意义的 2 0篇文献里 ,国内有关手术焦虑的研究目前主要集中在以下几个领域 ,术前焦虑状态的研究、术前术后焦虑程度的…     

老年人桡骨远端骨折手术治疗与非手术治疗的比较

概要 根据2项回顾性队列研究的结论,尚不能明确对于老年人桡骨远端骨折的治疗,手术治疗与非手术治疗何者更有效.尽管研究结果提示,与非手术治疗相比,手术治疗能获得更好的影像学复位效果,但是2种治疗方法腕部的最终功能恢复和活动度并无差异.对于疼痛的残留情况和握力恢复各研究结论不一.研究认为,手术治疗的患者关节炎发生率较低,但是1项研究报道,当骨折为关节外骨折时,接受手术治疗的患者骨关节炎发生的比例更高.两治疗组并发症的发生率相似.     

腹腔镜辅助与开腹直肠癌手术围手术期及长期生存率比较的研究

由于直肠手术操作局限于狭小的骨盆,且腹腔镜器械本身存在一定的局限性,腹腔镜辅助直肠癌手术难度较大。当前缺乏充分的证据证明腹腔镜辅助直肠癌手术能达到开腹手术同样的疗效。本研究是一项拟行的Ⅱ期随机对照临床试验的前期研究,比较腹腔镜辅助直肠癌手术与开腹手术,以评估腹腔镜手术的安全性以及肿瘤治疗效果。     

机器人手术的临床应用分析

目的运用文献计量学的方法分析国内外机器人手术相关研究文献,了解机器人手术的临床应用现状。 方法计算机检索Web of Science和CNKI数据库,查找国内外机器人手术相关研究文献。运用Citespace 5.1.R6和Excel 2016分析机器人手术相关研究文献的国家合作关系、发文量、作者、机构、词频、期刊分布、被引频次等。 结果目前国际上开展机器人手术研究的国家共有67个,发文量居前列的主要有美国、德国、意大利、中国等,其中以美国的发文量最多,且与其他国家的合作度最高。1999年开始机器人手术研究文献量逐年增加,且国外文献量增长趋势尤为显著。国外机器人手术研究文献的期刊分布种类和被引频次明显多于国内。当前机器人手术研究热点集中于外科手术、泌尿外科、肿瘤等方面。 结论机器人手术是当前微创外科学研究的一大热点,主要应用于良性、恶性肿瘤切除,发展速度较快。与国际水平相比,国内机器人手术研究及临床应用相对滞后,主要表现在研究论文数量少、被引频次少及与其他国家的合作度低等方面。     

足踝手术支架在骨科手术机器人辅助手术中的有效性与安全性研究

背景:骨科手术机器人Ti-Robot(由北京积水潭医院与北京天智航医疗科技股份有限公司等单位合作研发)已在国内骨科手术治疗中得到越来越普遍的应用,作为划时代的创新技术,医护人员在使用Ti-Robot的过程中需要逐步掌握。经过一段时间的使用和观察,并结合足踝外科的术中护理需要,自主研制开发了一种足踝手术支架在术中辅助手术。目的:分析足踝手术支架在术中辅助Ti-Robot进行手术的应用效果,与常规手术方式进行有效性和安全性的对比研究。方法:回顾性分析2018年4月至2019年4月完成的Ti-Robot足踝手术30例,其中常规手术方式的15例为对照组,使用足踝手术支架辅助手术的15例为研究组。术中分别记录患者体位固定、患者示踪器固定、机器人执行和定位所用时间,以及术中采集影像资料时C型臂X线机透视调整的次数。结果:术中两组患者的体位固定、患者示踪器固定及机器人执行引导和定位所用时间比较,差异均有统计学意义(P<0.01);两组C型臂X线机透视调整的次数比较,差异无统计学意义(P>0.05)。足踝手术支架使肢体固定更稳定牢靠,手术入路方式的选择更为自由,安全性更高。结论:足踝手术支架作为Ti-Robot在足踝外科手术的必要辅助配件,其应用显著提高手术效率,并减少患者创伤,提升术中护理的医患满意度,但仍存在不足之处,需要进一步改进。     

机器人手术在胃癌微创手术中的应用:机遇与挑战

近年来,机器人手术逐渐成为腹腔镜微创技术发展的主要潮流,并广泛运用于临床腹部外科治疗。相比腹腔镜手术,机器人手术的清晰度更高,稳定性更佳,操作更加便捷,缝合更加精确。目前,大量研究已经证实了机器人胃癌根治术的安全性及可行性。一些研究显示,在术后住院时间、手术出血以及淋巴清扫方面,机器人手术都要优于传统开腹手术和腹腔镜手术,而术后并发症及短期死亡率等与开腹和腹腔镜手术相比无明显差异。但是,另外一些研究显示,机器人手术的手术出血和淋巴清扫与腹腔镜手术相比无明显差异,提示机器人手术在这两方面是否存在优势还有争议。然而,较长的手术时间、高昂的使用费用以及缺乏力反馈是该系统的主要缺陷。作为一项新技术,机器人手术必然还存在着不足和缺陷,但其已经突破了目前腹腔镜技术的瓶颈,是现代外科史上的一次巨大的飞跃。     

腰椎间盘突出症手术失败的再手术治疗

目的:本文报告20例腰椎间盘突出症手术失败再手术的病人,目的在于分析手术失败的原因和再手治疗的有关问题。方法:回顾1989年至1996年间的1218例腰椎间盘突出症手术病人,选择其中20例因初次手术失败而接受再次手术的病人,对其再手术的原因和手术治疗进行回顾性研究。结果:初次手术失败的原因主要是突出间盘切除不全和术后发生疤痕性椎管狭窄,另外,马尾损伤、腰椎骨质增生、软骨板破裂及腰骶神经节椎管内异位畸形等亦是手术失败的原因。结论:作者强调首次手术应采用开窗术进行椎管减压和髓核摘除。再次手术难度较大,但病变显露应从正常解剖部位开始,仔细地去除疤痕和其它致病因素,以免神经根或神经组织的损伤。     

Clavicular midshaft fractures Operative versus nonoperative treatment

There is some evidence to suggest that midshafl clavicular fractures can be successfully treated With either operative or nonoperative methods but that there are fewer complications associated with nonoperative techniques. Most available data come from case series, and comparative studies are needed to determine the veracity of this preliminary data.     

闭合性脾破裂39例非手术治疗体会

目的　总结闭合性脾破裂的非手术治疗经验。方法　对 1990～ 2 0 0 0年 12月采用非手术治疗的 39例脾破裂的临床资料进行回顾性分析。结果　 39例均痊愈出院。其中非手术治疗成功33例 (84 .8% ) ,住院时间 8～ 2 2d ,平均 15d。余 6例因在非手术治疗期间出现血液动力学不稳或延迟性出血而中转手术治愈。结论　在严格掌握适应证和密切动态观察伤情变化的条件下 ,非手术治疗脾破裂是安全可行的 ,对非手术治疗期间血液动力学不稳定或发生延迟性出血者应及时手术     

A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury.

Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries. METHODS: Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis. RESULTS: During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients. CONCLUSIONS: This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.     

Rates of reoperation and nonoperative intervention within 30 days of bariatric surgery

BackgroundComplications arising from laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are not insignificant and can necessitate additional invasive interventions or reoperations.ObjectivesIn this study, we identify early complications that result in nonoperative and operative interventions after LSG and LRYGB, the timeframe within which to expect them, and factors that influence the likelihood of their occurrence.SettingMulti-institutional database from across North America.MethodsData for this study were obtained from Metabolic and Bariatric Accreditation and Quality Improvement Program participant use files for 2015 and 2016. Statistical analysis was performed using STATA 15. Univariate analysis using Χ² for categoric data and independent t test for continuous data was performed to determine between group differences. Multivariable logistic regression analysis was used to identify predictors of operative and nonoperative reinterventions.ResultsIn 2015 and 2016, 243,747 underwent LRYGB or LSG, of which 3013 (1.24%) required a second operative procedure and 1536 (0.63%) required an invasive but nonoperative intervention. Complications occurred in 5.48% of LRYGB patients and 2.28% of LSG patients, the most common of which was bleeding. LSG was associated with far fewer nonoperative and operative interventions (.85% versus 2.2%, respectively) than LRYGB (.67% versus 2.5%). Renal insufficiency, including dialysis dependency, was an important predictor of reoperations among bariatric surgery patients. This was also true of nonoperative interventions; however, history of pulmonary embolism, and use of therapeutic anticoagulation were marginally stronger predictors.ConclusionsIn a representative, multinational sample, operative and nonoperative interventions were half as likely among LSG patients compared with LRYGB; however, overall rates still remained low. These findings, in conjunction with new efficacy data demonstrating comparable long-term weight loss between LRYGB and LSG, provide further support for the safety, effectiveness, and cost efficiency of LSG.     

Evaluation of a 15-year experience with splenic injuries in a state trauma system

BACKGROUND: The management of splenic injuries has evolved with a greater emphasis on nonoperative management. Although several institutions have demonstrated that nonoperative management of splenic injuries can be performed with an increasing degree of success, the impact of this treatment shift on outcome for all patients with splenic injuries remains unknown. We hypothesized that outcomes for patients with splenic injuries have improved as the paradigm for splenic injury treatment has shifted. METHODS: Consecutive patients from 1987 to 2001 with splenic injuries who were entered into a state trauma registry were reviewed. Demographic variables, injury characteristics, and outcome data were collected. RESULTS: The number of patients who were diagnosed with splenic injuries increased from 1987 through 2001, despite a stable number of institutions submitting data to the registry. The number of minor injuries and severe splenic injuries remained stable, and the number of moderately severe injuries significantly increased over time. Overall mortality rate improved but primarily reflected the decreased mortality rates of moderately severe injuries; the mortality rate for severe splenic injuries was unchanged. CONCLUSION: Trauma centers are seeing increasing numbers of splenic injuries that are less severe in magnitude, although the number of the most severe splenic injuries is stable. The increased proportion of patients with less severe splenic injuries who are being admitted to trauma centers is a significant factor in the increased use and success rate of nonoperative management.     

Nonoperative management of blunt splenic and hepatic trauma in the pediatric population: significant differences between adult and pediatric surgeons?

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.     

Cost effectiveness of anterior cruciate ligament reconstruction in young adults.

The cost effectiveness of ligament reconstruction for acute anterior cruciate ligament tears in young adults was compared with the cost effectiveness of nonoperative management. A decision tree was constructed to predict the expected functional outcomes for operative and nonoperative treatment. Outcome probabilities were derived from the surgical and natural history literature. Cost data were based on averaged figures from the senior author's institution. Utility values were determined from a questionnaire administered to 285 local university students. Cost effectiveness was calculated in terms of dollars spent per additional quality adjusted life year provided by the surgical reconstruction for the initial 7 years after an injury. The operative strategy provided 5.10 quality adjusted life years versus 3.49 years for nonoperative treatment, yielding a marginal effectiveness of 1.61 quality adjusted life years. The estimated total costs of the operative and nonoperative strategies were $11,768 and $2333, respectively, for a marginal cost of $9435. The resulting marginal cost effectiveness ratio was $5857 per quality adjusted life year. These data suggest that, when based on functional outcomes, anterior cruciate ligament reconstruction is a cost effective method of treatment for acute tears in young adults. The cost effectiveness ratio predicted compares favorably with those of other health care interventions that aim to improve quality of life.     

The lax shoulder in females. Issues, answers, but many more questions

A review of the existing data on shoulder laxity in females reveals there are insufficient data to confirm the commonly held belief that shoulders in females are more lax than shoulders in males. Laxity is not synonymous with instability. Although females may have increased generalized joint laxity relative to males, generalized joint laxity does not correlate with shoulder laxity. There is conflicting data regarding shoulder laxity and gender. A review of patients with multidirectional instability who were treated operatively showed that 55% of the patients were female (N = 94) and 45% were male (N = 77), but the number or gender of patients who were treated nonoperatively was not reported. Multidirectional instability is reviewed in the context of the lax shoulder in the female. Initial treatment should be nonoperative, emphasizing physical therapy and dynamic stabilization of the shoulder. If nonoperative treatment fails, open or arthroscopic inferior capsular shift stabilization is recommended. Additional basic science and clinical trials are needed to determine whether thermal capsulorrhaphy should be considered in the treatment of patients with multidirectional instability of the shoulder.     

Nonoperative management of acute epidural hematomas: a "no-brainer"

BACKGROUND: Acute epidural hematomas are generally considered to require urgent operation for clot evacuation and bleeding control. It has become increasingly apparent, however, that many epidural hematomas will resolve with nonoperative management. The purpose of the current study was to review our experience with nonoperative management of acute epidural hematomas. METHODS: Patients admitted to our busy urban level I trauma center with an epidural hematoma were identified using our trauma registry. Patients were excluded if they suffered other significant intracranial injury mandating operative intervention. Patient records were reviewed and relevant data collected. Patients who required subsequent craniotomy were compared to those who did not in order to identify risk factors for failure of nonoperative treatment. RESULTS: Between January 1995 and June 2004, 84 patients were identified. The mean age was 27 +/- 1.6 years and 68 (81%) were male. Mean Glasgow Coma Scale in the emergency department was 13.7 +/- 0.3. The most common mechanism of injury was a fall. Fifty-four (64%) patients were initially managed nonoperatively and 30 (36%) were taken directly to the operating room for craniotomy. Nonoperative management was successful in 47/54 (87%) patients. Failure of initial nonoperative management was not associated with adverse outcome. There were no deaths in patients managed operatively or nonoperatively. Seventy-two (86%) patients were discharged to home with excellent neurologic outcome. CONCLUSIONS: Epidural hematomas can be successfully managed nonoperatively in an appropriately selected group of patients. Moreover, failure of initial nonoperative management has no adverse effect on outcome.     

Surgeon equipoise as an inclusion criterion for the evaluation of nonoperative versus operative treatment of thoracolumbar spinal injuries

Background contextProspective studies have failed to demonstrate the superiority of either operative or nonoperative treatment of thoracolumbar fractures. Similar to other surgical fields, research has been limited by the variability in surgical interventions, difficult recruitment, infrequent pathology, and the urgency of interventions.PurposeTo outline factors precluding randomized controlled trials in spinal fractures research, and describe a novel methodology that seeks to improve on the design of observational studies.Study design/settingA preliminary report describing an observational study design with clinical equipoise as an inclusion criterion. The proposed methodology is a cohort study with head-to-head comparison of operative and nonoperative treatment regimens in an expertise-based trial fashion. Patients are selected retrospectively by an expert panel and clinical outcomes are assessed to compare competing treatment regimens. Surgeon equipoise served as an inclusion criterion.Patient samplePatients with closed or open thoracolumbar spinal fracture with or without neurological impairment, presenting to one of two different trauma centers between 1991 and 2005 (N=760).Outcome measuresHomogeneity of baseline clinical and demographic data and distribution of prognostic risk factors between the operative and the nonoperative cohort.MethodsPatients treated for spine fractures at two University hospitals practicing opposing methods of fracture intervention were identified by medical diagnosis code searches (n=760). A panel of spine treatment experts, blinded to the treatment received clinically has assessed each case retrospectively. Patients were included in the study when there was disagreement on the preferred treatment, that is, operative or nonoperative treatment of the injury. Baseline and initial data of a study evaluating nonoperative versus operative spinal fracture treatment are presented.ResultsOne hundred and ninety patients were included in the study accounting for a panel discordance rate of 29%. The distribution of baseline characteristics and demographics of the study populations were equal across the parallel cohorts enrolled in the study, that is, no differences in prognostic factors were observed.ConclusionsThe use of clinical equipoise as an inclusion criterion in comparative studies may be used to avoid selection bias. Using multivariate analysis of retrospectively assembled parallel cohorts, a valid comparison of operative and nonoperative spine fracture treatment strategies and their outcomes is possible.