肝静脉直接入心房的(功能)单心室患者的改良Fontan术式及早中期疗效

目的:总结肝静脉直接入心房(SHV)的(功能)单心室患者的改良Fontan术式及早中期临床结果。方法:回顾性分析2009-01至2015-12阜外医院对39例SHV的(功能)单心室患者施行改良Fontan术的临床资料。男26例(66.7%),平均年龄(6.98±3.62)岁,平均体重(20.79±9.66)kg,术前平均肺动脉压(m PAP)9.77±2.51(4~15)mm Hg(1mm Hg=0.133k Pa)。依据SHV患者是否合并下腔静脉与心尖同侧(ACJ),分为SHV组(n=29)和SHV+ACJ组(n=10)。对术后早期(术后3个月)及中期(5年)进行临床结果分析。结果 :两组患儿的临床资料比较差异无统计学意义(P0.05)。39例患者中,一期手术20例,二期手术19例(18例为Glenn术后,1例为B-T术后)。选择的改良Fontan术式主要采取外管道—共同开口术式(30例,76.9%)。19例患者建立体外循环并阻断主动脉,体外转流时间72~446 min,平均(189.74±84.96)min,主动脉阻断26~171min,平均(89.05±43.96)min;另19例患儿并行循环,体外转流时间60~209 min,平均(109.99±98.86)min。术后早期因并发症再次手术10例。术后院内死亡3例,死亡率7.7%。36例患儿平均随访时间3.90(0.83~7.17)年,35例心功能为Ⅰ级,1例为Ⅱ级,5年生存率100%。结论 :SHV的(功能)单心室患者行改良Fontan术后早中期随访结果良好。而改良Fontan术式的选择应依据下腔静脉与肝静脉间的距离以及是否合并ACJ。     

改良腋下小切口深筋膜浅层入路在连枷胸内固定手术中的临床应用

目的探讨改良腋下小切口深筋膜浅层入路在连枷胸内固定手术中的临床应用效果。方法分析我院传统手术治疗组(25例)及改良手术内固定组(26例)治疗连枷胸的临床资料,比较两组的治疗效果。结果两组患者均治愈,改良手术组术中平均住院时间、手术时间、术中出血量、手术切口长度、疼痛指数、切口感染率、肺炎发生率等指标与传统手术组相比,差异有统计学意义(P<0.01),肺功能检查结果显示改良手术组与传统手术组相比,差异有统计学意义(P<0.01)。结论改良腋下小切口深筋膜浅层入路在连枷胸内固定手术中具有操作简便,手术时间短,对神经、血管、肌肉损伤小,对患者肺功能影响较小,手术患者创伤小,切口美观,可缩短住院时间,减少并发症的发生等优点,是一种连枷胸内固定手术的理想方法。     

腹腔镜与开腹完整结肠系膜切除术164例的临床对比研究

目的探讨腹腔镜与开腹结肠癌完整结肠系膜切除术(complete mesorectal excision,CME)在术后恢复、手术质量及中期疗效方面的差异。 方法收集滨州医学院附属淄博市中心医院腹腔镜外科2010年12月至2014年9月间实施的164例结肠癌CME手术患者的临床资料。其中腹腔镜手术组92例,开腹手术组72例,比较两组患者的术后恢复、肿瘤根治性、术后感染发生率及中期复发率方面的差异。 结果腹腔镜组在术中出血量、术后排气时间、术后下床时间、切口感染率方面均优于开腹手术组,两组患者的近端切缘、远端切缘长度及淋巴结清扫数目的差异均无统计学意义(P>0.05),两组患者在手术时间方面无统计学差异(P>0.05)。164例患者中,有134例(81.7%)接受了术后随访,中位随访时间21个月。腹腔镜组与开腹组的局部复发率分别为4.3%(4/92)和4.2%(3/72),差异均无统计学意义(P>0.05)。 结论腹腔镜结肠癌CME手术较开腹手术能显著缩短患者术后恢复时间,且能达到与开腹手术相同的肿瘤根治范围,中期复发率于开腹手术相当,有良好发展前景。     

传统开腹手术和腔内修复术治疗腹主动脉瘤破裂的临床对照研究

目的:分析比较传统开腹手术与腔内修复手术治疗腹主动脉瘤破裂的临床疗效。方法:选取2013年1月至2014年12月,我院收治的54例腹主动脉瘤患者为研究对象,根据患者所采用的手术方式将患者分为两组,分别为开腹手术组和腔内手术组。比较分析两种手术方法术中出血量、输血量,术后ICU观察时间、禁食时间、住院时间、以及手术费用;记录患者围手术期的并发症发生率和病死率,同时在患者出院后对两组患者每隔3个月进行随访,比较两组患者两年生存率及并发症发生率。结果:腔内手术组的出血量、手术时间、ICU观察时间、术后禁食时间以及术后住院时间均小于开腹手术组,差异有统计学意义(P<0.05),但是手术费用则明显高于开腹手术组,差异有统计学意义(P<0.05);围手术期,腔内手术组的肺部并发症和电解质紊乱发生率均低于开腹手术组,差异具有统计学意义(P<0.05),病死率以及其他并发症发生率差异无统计学意义;术后随访腔内手术组的生存率均高于开腹手术组,差异有统计学意义(P<0.05)。结论:腔内修复术治疗腹主动脉瘤破裂具有手术时间短、创伤性小、术后恢复时间短,长期疗效好等优点,值得临床推广应用。     

电视胸腔镜下双侧肺大疱同期手术的疗效分析

目的研究分析单侧自发性气胸合并双肺肺大疱采用电视胸腔镜下双侧肺大疱同期手术的可行性、安全性及有效性。方法收集我院从2003年1月到2011年1月期间行胸腔镜双侧肺大疱同期切除手术的患者40例,并与同时间段行单侧胸腔镜下肺大疱切除的患者60例进行疗效对比分析。结果两组患者均治愈康复出院,双侧手术组手术时间长于单侧手术组,术中出血量多于单侧手术组,术后留置胸管时间及术后住院天数长于单侧手术组,住院费用明显高于单侧手术组,以上比较差异均有统计学意义(P0.05)。两组术后并发症发生率比较,差异无统计学意义(P0.05)。术后两组均随访24个月,在随访12个月内的气胸复发率上无明显统计学差异(P0.05);在随访24个月的气胸复发率上差异存在统计学意义(P0.05)。结论对于单侧自发性气胸合并双侧肺大疱的患者,行电视胸腔镜下双侧大疱同期手术,能有效地预防气胸复发和对侧气胸发作。该方法安全、可行、有效,值得在临床上积极开展。     

成人功能性单心室的一期Fontan手术治疗

目的:总结和分析成人功能性单心室Fontan手术治疗的早、中期结果。方法: 自2001年11月~2010年11月,共15例成人功能性单心室患者行一期Fontan手术治疗,术前心功能NYHA Ⅱ级4例,NYHA Ⅲ级11例;手术适应证为肺动脉发育良好,肺动脉平均压≤15 mmHg;手术方法为心外管道法Fontan手术,6例行人工血管和右心房开窗吻合,随访3月～6年。结果: 围术期死亡2例,术后平均拔除气管插管时间11 h（6～576 h）,平均住院时间13 d（7～44 d）,平均中心静脉压13 mmHg（7～16 mmHg）,平均动脉血氧饱和度96％（87%～99％）;12例患者心功能得到明显改善,4例心功能NYHA Ⅰ级,8例心功能NYHA Ⅱ级,1例心功能仍为NYHA Ⅲ级。结论: 一期心外管道法Fontan手术治疗成人功能性单心室手术早期和中期疗效良好。     

胃癌合并胆囊结石同期手术治疗的可行性及安全性分析

目的研究胃癌合并胆囊结石同期手术治疗的可行性及安全性。方法选取我院2015年3月~2016年6月胃癌合并胆囊结石患者56例,分两组,手术组A行单纯胃癌根治术治疗;手术组B行同期手术治疗。就两组患者手术结束时间、手术引流量和出血量、术后住院观察时间和术后并发症率进行比较。结果手术组B术后并发症率跟手术组A差异无统计学意义(P0.05)。手术组B患者手术结束时间、手术引流量和出血量、术后住院观察时间跟手术组A差异无统计学意义(P0.05)。结论胃癌合并胆囊结石同期手术治疗的可行性及安全性高,值得推广。     

大肠肿瘤手术中采用不同术式的应用效果对比研究

目的探讨不同术式用于治疗大肠肿瘤的临床疗效。方法收治大肠肿瘤患者124例,根据手术方式分为悬吊式腹腔镜组42例(悬吊组)、CO2气腹腹腔镜组42例(气腹组)和开腹手术组40例(开腹组)。比较各组的手术效果。结果三组患者均获得手术成功,无死亡病例。三组手术时间、切除肠管长度以及切除淋巴结个数差异均无统计学意义(P0.05),但悬吊组和气腹组的术中出血量以及排气时间均较开腹组显著减少和缩短(P0.05)。结论悬吊式腹腔镜术、CO2气腹腹腔镜术和开腹手术治疗大肠肿瘤疗效相当,但前两种术式创伤更小,术后恢复更快,值得推广应用。     

开放手术与腹腔镜手术治疗直径>6 cm肾上腺良性肿瘤临床疗效对比分析

目的对比分析开放手术和腹腔镜手术治疗直径 6 cm肾上腺良性肿瘤疗效及安全性差异。方法选取直径 6 cm肾上腺良性肿瘤患者共150例,按随机数字表法分为开放手术组(75例)和腹腔镜手术组(75例),分别采用开放手术和腹腔镜手术,比较两组术中术后临床观察指标差异、重症监护病房(ICU)转运率及围手术期并发症发生率。结果腹腔镜手术组术中术后临床观察指标均显著优于开放手术组(P 0. 05);两组患者ICU转入率比较差异无统计学意义(P 0. 05);腹腔镜手术组术后并发症发生率显著低于开放手术组(P 0. 05);两组术中并发症发生率比较差异无统计学意义(P 0. 05)。结论相较于开放手术,腹腔镜手术治疗直径 6 cm肾上腺良性肿瘤操作用时更短,可实现早期快速恢复,且有助于降低术后并发症发生的风险。     

微创改良手术方法治疗静脉曲张的疗效观察

目的观察微创改良手术方法治疗静脉曲张的疗效。方法选择我院外科收治的单侧大隐静脉曲张患者50例作为研究对象,将其随机分为微创改良手术组(W组,25例)和传统手术组(C组,25例)。W组患者采用微创改良手术方法,C组患者采用传统手术方法。观察两组患者的疗效。结果 W组患者的手术时间、术中出血量、住院时间等指标均明显优于C组,差异有统计学意义(P0.05)。结论微创改良手术方法治疗静脉曲张,具有手术时间短、术中出血量少、缩短住院时间的优点,值得借鉴。     

Influence of ventricular morphology on aerobic exercise capacity in patients after the Fontan operation

OBJECTIVES: This study investigated the influences of ventricular morphology, hemodynamics and clinical findings on exercise capacity in patients after the Fontan operation. BACKGROUND: Determinants of exercise capacity after the Fontan operation remain unclear. METHODS: Peak oxygen uptake (PVo2) was determined in 105 patients by exercise test and compared to hemodynamics and clinical findings. Patients were divided into three groups based on ventricular morphology: those with a right ventricle (group RV), a biventricle (group BV) and a left ventricle (group LV). RESULTS: Ten patients with atrioventricular valve regurgitation (AVVR) or hypoxia exhibited a low PVo2. After excluding these patients, although PVo2 did not correlate with hemodynamics, except ventricular ejection fraction (p < 0.02), it correlated with age at the Fontan operation and exercise test (p < 0.002). The PVo2 was higher in group LV (63+/-9%) than in groups RV (55+/-9%) and BV (55+/-12%) (p < 0.01), while an inverse correlation between PVo2 and age at operation was demonstrated only in group RV (p < 0.05). Groups RV or BV and age at exercise test were associated with a lower PVo2, whereas group LV was an independent predictor of a higher PVo2 (p < 0.01). During 4.2 years of follow-up, a decrease in peak heart rate was related to a decrease in PVo2 (p < 0.05). The PVo2 decreased in group RV (p < 0.01). CONCLUSIONS: In addition to AVVR, hypoxia, and heart rate response, ventricular morphology is related to exercise capacity. Early Fontan operation may be beneficial in terms of exercise capacity, especially in the group RV patients.     

Percutaneous transhepatic dual chamber pacing in children with Fontan circulation.

Permanent pacing is often required following the Fontan operation and is usually performed epicardially as there is no direct access to the ventricle from the systemic veins. Dual chamber endocardial pacing was achieved by the transhepatic approach in two children with Fontan circulation. The patients were a 7 year old boy with left atrial isomerism, single ventricle with pulmonary stenosis, interrupted inferior vena caval vein with azygous continuation, and direct drainage of the hepatic veins to the right sided atrium, and a 6 year old girl with tricuspid atresia. This approach to endocardial pacemaker implantation is potentially of considerable value in patients who do not have direct access to the ventricle from the systemic veins.     

Incidence and factors influencing the spontaneous closure of Fontan fenestration

Introduction: The Fontan operation is the final stage of single ventricle palliation in patients with complex congenital heart disease. Fenestration in the Fontan conduit, providing an atrial level right to left shunt, has been shown to reduce early postoperative morbidity. However, there is limited data on the long‐term fate of this fenestration. The aim of this study is to define the rate of spontaneous closure of the fenestration in the Fontan conduit and factors predictive of the fate of the fenestration.
Methods: This was a retrospective study reviewing the medical records of the patients who underwent fenestrated Fontan operation at our center. Preoperative, intraoperative and postoperative variables including the status of the Fontan fenestration were extracted and analyzed.
Results: Of 67 patients included in the study, 15 (22%) had spontaneous closure of the fenestration. Of the remaining 52 patients, 11 (20%) had procedural closure of this fenestration (10 via cardiac catheterization and 1 via surgery) at a median duration of 3 months after the Fontan operation. Patients with higher preoperative pulmonary vascular resistance and a history of postoperative systemic venous thromboembolism had higher likelihood of having persistence of the fenestration with P value of .045 and .037, respectively.
Conclusions: The rate of spontaneous closure of the Fontan fenestration was 22% in our study. Elevated preoperative pulmonary vascular resistance and history of systemic venous thromboembolism are predictive of persistent Fontan fenestration.     

一次性根治术与切开挂线术对腺源性肛瘘患者的疗效对比

目的分析比较一次性根治术与切开挂线术对腺源性肛瘘患者的疗效。方法将重庆医科大学附属第一医院收治的88例腺源性肛瘘患者随机分为一次性根治术组(DRO组)和切开挂线术组(ITD组),各44例,DRO组给予一次性根治术治疗,ITD组给予切开挂线术治疗。对比两组患者住院时间,应用视觉模拟评分法(VAS)评估术后6 h、12 h、24 h、48 h患者的疼痛程度,并比较伤口愈合时间、术后2周时的排便功能恢复情况,另统计并对比两组患者手术治愈率及术后并发症及复发情况。结果DRO组住院时间及伤口愈合时间均明显长于ITD组(P<0.05)。经重复测量方差分析,VAS评分差异有统计学意义(P<0.05);两组组内术后48 h VAS评分<术后24 h<术后12 h<术后6 h,差异均有统计学意义(P<0.05);DRO组术后6 h、12 h、24 h、48 h VAS评分均显著低于ITD组(P<0.05)。术后2周时两组排便功能恢复情况等级分布差异显著(P<0.05)。两组治愈情况等级分布差异不显著(P>0.05)。术后两组总并发症发生率无显著差异(P>0.05)。随访1年,DRO组复发率为2.27%,显著低于ITD组的18.18%(P<0.05)。结论在腺源性肛瘘患者的治疗中,一次性根治术与切开挂线术的治愈率相当,术后并发症少,一次性根治术能够减轻患者术后疼痛,促进排便功能恢复,降低复发率,切开挂线术能够缩短住院时间,加快伤口愈合。     

单心室合并完全性肺静脉异位引流的外科治疗

目的:探讨单心室合并完全性肺静脉异位引流(TAPVC)的外科治疗效果。方法:2009-05至2011-09,我科共收治单心室合并TAPVC患儿11例,年龄(30.1±21.4)个月,体重(11.0±3.2)kg。例2行改良B-T分流术,例1、3～6、8、9、11行一侧或双侧双向腔肺分流术,例7、10行一期改良Fontan术。例1、6～9、11同期行TAPVC矫治术。结果:例6、10围术期死亡(18.2%,2/11),死亡原因分别为中枢神经系统感染和多器官功能衰竭。存活的患儿随访1～29个月,例4死亡,余患儿氧饱和度改善,未发现残余肺静脉梗阻,例5行二期改良Fontan术并顺利出院。结论:单心室合并TAPVC患儿仍具有较高早期死亡率,术前明确诊断TAPVC并制定合理的个体化治疗方案是提高手术疗效的关键。     

Systolic and diastolic performance late after the Fontan procedure for a single ventricle and comparison of those undergoing operation at <12 months of age and at >12 months of age.

To evaluate whether surgical history can influence systolic and diastolic properties of a functional single left ventricle after Fontan operation, we echocardiographically investigated 31 patients (mean age 93.7 months; range 21 to 276); 21 patients were >12 months of age (group A) and 10 were <12 months of age (group B) at the time of the Fontan and/or cavopulmonary procedure. In group A we found persistent abnormalities of left ventricular mass index (95.9 vs 64.1 g/m(2), p <0.05) at long-term follow-up, whereas group B had normal left ventricular mass (61.9 vs 64.1 g/m2, p = NS). In contrast, a diastolic pattern characterized by augmented late diastolic filling was present in both patient groups regardless of age at operation and length of follow-up (E/A in group A 1.3 +/- 0.4, E/A in group B 1.6 +/- 1.5, E/A in controls 1.7 +/- 0.6; A vs B, p = NS; A vs controls, p <0.05). We concluded that patients with a single left ventricle who undergo an unloading procedure performed within the first year of life have complete normalization of left ventricular mass, although a diastolic filling pattern suggestive of augmented compliance persists, regardless of the age at operation.     

Outcome of single ventricle and total anomalous pulmonary venous connection

Management of patients with single-ventricle physiology is significantly affected by anomalies of pulmonary venous return at all stages, whether primary palliation, bidirectional Glenn shunt, or completion of Fontan circulation. We treated 25 patients with pulmonary venous anomalies and single ventricle by staged palliation, from June 1996 to May 2005. Visceral heterotaxy with atrial isomerism was present in 19 of them. Primary palliation with a systemic-to-pulmonary artery shunt was undertaken in 15 patients. There were 5 early deaths, of which 4 were due to obstruction of pulmonary venous return. A bidirectional Glenn shunt was constructed in 17 patients including 10 who had it as a primary palliative procedure. There were 7 early deaths after the bidirectional Glenn procedure; only one was due to pulmonary venous obstruction. Five patients attained completion of the Fontan procedure. There was one early death after the Fontan operation. Anomalous pulmonary venous return can significantly complicate the management of patients with single ventricle, with an impact on survival in early infancy. Palliation with the aim of instituting extracardiac conduit Fontan circulation allows greater latitude and more streamlined management.     

Exercise tolerance and cardiorespiratory response to exercise after the Fontan operation for tricuspid atresia or functional single ventricle

To determine the impact of the Fontan operation on exercise tolerance and on the cardiorespiratory response to exercise, we compared the results of graded exercise to maximal effort of 81 patients with tricuspid atresia or single functional ventricle studied preoperatively with those of 29 patients studied postoperatively. Postoperatively, the values for total work performed, duration of exercise and maximal oxygen uptake increased significantly. Regardless of operative status, the maximal heart rate during exercise was reduced. The cardiac output and stroke volume response to exercise were subnormal after operation. Systemic arterial blood oxygen saturation was reduced markedly preoperatively both at rest and during exercise; postoperatively, it was significantly greater than the preoperative value but it remained slightly abnormal. The ventilatory response to exercise (respiratory rate, minute ventilation and ventilatory equivalent for oxygen) decreased toward normal after operation. Exercise tolerance and the cardiorespiratory responses to exercise improve after the Fontan operation. Formal exercise testing is essential to quantitate the degree of improvement.     

Effects of postural change on oxygen saturation and respiration in patients after the Fontan operation: platypnea and orthodeoxia

The aim of this study was to assess whether platypnea and orthodeoxia occur in Fontan patients. We divided 14 Fontan patients into 2 groups: 8 patients who had pulmonary arteriovenous fistulas and/or intra-atrial shunts (group A) and 6 patients who had neither pulmonary arteriovenous fistulas nor intra-atrial shunts (group B). They were compared with 9 controls (group C). Arterial oxygen saturation, minute ventilation per body weight and ventilatory equivalent for carbon dioxide were measured in the supine and then sitting positions. In group A, 1 patient had platypnea and 3 patients had orthodeoxia (changes in the saturation from the supine position to the sitting position were -4% to -7%) accompanied with slight hyperpnea, and all 4 patients had both pulmonary arteriovenous fistulas and intra-atrial shunts. Contrary, patients in group B had neither platypnea nor orthodeoxia. The saturation was significantly lower and the minute ventilation was significantly higher in the sitting position than in the supine position in group A (p < 0.05). The other groups showed no significant difference in the saturation or the minute ventilation between the 2 positions. All groups showed the ventilatory equivalent was significantly higher in the sitting position than in the supine position (p < 0.05 to 0.01). We demonstrated platypnea and orthodeoxia in Fontan patients with pulmonary arteriovenous fistulas and intra-atrial shunts. We believe platypnea and orthodeoxia should be regard as a complication in Fontan patients with pulmonary arteriovenous fistulas and/or intra-atrial shunts.