难治性癫痫外科治疗现状

癫痫是许多发展中国家较常见的神经系统疾病,其中约20％～25％患者经抗癫痫药物治疗无效而需手术治疗。事实表明,精确的致痫灶定位可以提高手术的成功率,早期有效的外科治疗不仅使患者癫痫发作消失或频率减少,且能显著改善患者生活质量。本文就难治性癫痫的术前评估及外科治疗方法做一综述。     

Diagnosis and surgical management of intractable constipation

Seventy-four patients with intractable constipation, of whom thirty-three had slow and forty-one normal intestinal transit, were investigated to determine the aetiology of their disorder and plan treatment. Patients with slow transit had a greater incidence of abdominal pain and distension (P less than 0.001) and only 9 per cent had a normal call to stool compared with 71 per cent of those with normal transit (P less than 0.001). Internal and sphincter function as assessed by sphincter pressures, length and the recto-anal inhibitory reflex did not reveal any difference between the groups and normal controls; similarly anal sensation and rectal compliance were normal. However, those with normal transit had a higher threshold of rectal sensation than controls (P less than 0.05). Slow transit patients failed to show a postprandial increase in rectosigmoid motility compared with controls (P less than 0.05). Whilst the majority failed to inhibit the external sphincter on bearing down, half of those with normal transit produced either partial or complete inhibition. Both groups were able to increase the anorectal angle on straining. Twenty-two normal transit patients had abnormal perineal descent compared with controls (P less than 0.0005). Patients with perineal descent exhibited abnormal rectal morphology. Rectal intussusception was observed in 13 of 35 evacuation proctograms. On the basis of the data presented, we could not justify internal sphincterotomy of puborectalis division. Our policy in severe slow transit constipation was to offer colectomy and ileorectal anastomosis. In five out of seven to date, a successful result has been achieved. Eight patients with rectal intussusception have undergone an abdominal rectopexy with significant improvement in three. In our hands, the evacuation proctogram and transit studies were the most useful preoperative investigations.     

Current status of the peritoneovenous shunt for the management of intractable ascites.

Renewed interest in the management of intractable ascites has led to the use of a peritoneovenous shunt for its control. Analysis of Canadian experience with this technique in the last 2 years has demonstrated that there are problems associated with it that have not been reported in the surgical literature. A group of 60 patients who underwent peritoneovenous shunting at several Canadian centres was analysed. The operative mortality was 20% but was related to the underlying disease rather than to the operative procedure. Although the initial response to shunting was excellent in 53%, long-term patency (more than 3 months) was achieved in only 43%, but the procedure greatly improved the quality of life in those patients. The indications for shunting, the complications, results and cumulative patency rates are discussed.     

Infectious endocarditis. Role of surgical therapy

The problem of infectious endocarditis (IE) is approached through a review of personal experience. The series examined consists of patients, 17 with active and 21 dormant infection. Furthermore 12 in the first group, 18 in the second had natural heart valves, while 5 in group I, 3 in group II had been given artificial ones. After an analysis of the aetiopathogenic, clinical and diagnostic aspects of the condition with emphasis on the fact that Staphylococcus aureus is currently more responsible for infections in natural valves and the epidermidis for acute prosthesis infections which have a higher early and late mortality rate (40% in hospital, 33.3% long-term), the paper discusses the criteria for surgical intervention. In line with opinions expressed in the literature, it is pointed out that, while the patient's haemodynamic status is certainly the main criterion for any decision, other factors such as embolism, impaired conduction, kidney failure and expansion of the infection to contiguous tissues, should not be under-estimated.     

Role of endocrine therapy in the neoadjuvant surgical setting

Most neoadjuvant (preoperative) therapy of breast cancer has involved the use of chemotherapy, but primary endocrine therapy has also been shown to be effective in postmenopausal women with estrogen receptor-positive tumors. Neoadjuvant therapy can reduce tumor volume, permitting surgery for otherwise inoperable tumors or allowing breast-conserving surgery rather than mastectomy for operable tumors. The preoperative treatment setting also allows for assessment and comparison of responses to different agents, which may then be used in the adjuvant therapy setting following surgery. Since tumor biopsies can be obtained before, during, and after preoperative therapy, the relationship between biomarkers and response or resistance to surgery can be investigated. In the Edinburgh Breast Unit, neoadjuvant endocrine therapy with aromatase inhibitors has been more successful than with tamoxifen. Recurrence rates following preoperative endocrine therapy and breast-conserving surgery have been acceptably low, provided that radiation therapy was also administered postoperatively. Both the probability of response to neoadjuvant letrozole or tamoxifen and the degree of tumor shrinkage increased as estrogen receptor expression increased, consistent with the results of other studies. Attempts to identify biomarkers of response to neoadjuvant endocrine therapy are under way, with early indications that reduced cell proliferation 14 days after initiation of treatment correlates with responses to tamoxifen.     

Effect of propranolol on intractable ascites following liver resection

Hepatic and respiratory failure, common complications following liver resection for hepatocellular carcinoma (HCC), especially when it is combined with liver cirrhosis, can be overcome by careful management of the circulatory and respiratory systems. Another common complication is intractable ascites which resists conventional therapy, such as, diuretics and protein replacement. Here we report a case in which intractable ascites was successfully treated with propranolol. The patient, a 48-year-old man who underwent liver resection for HCC combined with cirrhosis, started to suffer from ascites about 1 week after surgery. Upon administration of propranolol (1 mg/kg/day) with furosemide, his body weight decreased 500 g/day, returning to the preoperative value in 2 weeks in parallel with the normalization of the PRA. No side effects were observed during the medication period. Propranolol, a beta-adrenergic antagonist, is thought to suppress renin secretion from the juxtaglomerular apparatus in the kidney by blocking its beta-adrenergic receptor, thus suppressing the entire renin-angiotensin-aldosterone system. We concluded that propranolol is a promising drug for intractable ascites encountered with liver cirrhosis.     

Role of intraoperative insulin monitoring in surgical management of insulinoma

BACKGROUND AND PURPOSE: Precise localization and surgical excision is the therapeutic strategy for insulinomas. However, it is often difficult to localize the insulinomas, because of their small size. Surgeons may not localize and remove all of them together, particularly in patients with multiple insulinomas. We reviewed our experience to confirm the efficacy of blood glucose and intraoperative immunoreactive insulin (IRI) monitoring for surgical management of insulinomas. PATIENTS AND METHODS: Thirty-nine patients with insulinoma were surgically treated in our department. Perioperative blood glucose monitoring was performed in 14 patients, intraoperative quick IRI assay of the peripheral blood in 10 patients, and assay of a portal sample in 4 patients by an IMX analyzer. RESULTS: Rebound response of blood glucose to insulinoma removal was not always noted (8/14; 57%). Seven of ten patients showed a decrease of peripheral serum IRI levels within 15 minutes after removal of the insulinoma. The other two patients showed a rebound response of peripheral blood glucose or portal IRI. All the patients who had intraoperative monitoring of peripheral blood and peripheral and portal IRI had no recurrent insulinoma syndrome after surgical removal of their insulinomas. CONCLUSION: Combined monitoring of peripheral blood glucose and peripheral and portal IRI are helpful in the surgical management of insulinomas, as they can indicate that no insulinoma remains.     

Role of intraoperative ultrasonography in the surgical management of insulinomas

The findings in 35 surgically treated patients with insulinoma and 43 tumors of these patients were analyzed to confirm the efficacy of diagnostic modalities and surgical interventions. The rate of accurate preoperative tumor localization was 72% by angiography, 53% by computed tomographic scan, 55% by ultrasonography, and 83% by percutaneous transhepatic portal vein sampling. Extensive operative exposure and palpation detected 81% of the tumors and intraoperative ultrasonography demonstrated 96% of the tumors. Intraoperative ultrasonography was significantly better than any other diagnostic procedure and was able to demonstrate the anatomical relationship of the insulinoma to the essential structures of the pancreas. Intraoperative ultrasonography also helped determine the safest route for enucleating the insulinomas. Five patients (14%) in our series had metastatic diseases; 2 of these patients with metastases beyond the lymph nodes died due to the growth of tumors. The other 33 patients were free of insulinoma syndrome after the removal of the insulinomas. Streptozotocin was used in 1 patient with recurrent malignant insulinoma, with encouraging results.     

重症肌无力外科治疗的围手术期处理

目的探讨重症肌无力（MG）外科治疗的围手术期处理方法及疗效。方法158例患者，男65例，女93例，年龄3—61岁，OssemanⅠ型93例，Ⅱa型38例，Ⅱb型17例，Ⅲ型10例。术前正确处理合并症，使用药物控制肌无力症状，术中完整切除胸腺并清扫前纵隔脂肪；术后联合使用抗胆碱酯酶药、激素及免疫抑制剂，应用呼吸机进行人工辅助呼吸，防治重症肌无力危象。结果全组患者均无手术或住院死亡，Ⅰ型MG患者术后早期症状缓解26例，明显改善19例，改善27例；Ⅱ、Ⅲ型MG患者术后早期症状缓解33例，明显改善21例；总有效率为76．6％。结论重症肌无力患者经充分的围手术期处理，可安全接受手术治疗，手术疗效好。     

Role of medical therapy in the management of acromegaly

Medical therapy plays an important role in the management of patients with acromegaly and is commonly used adjunctively after surgical resection of the pituitary tumor. Generally, surgery alone provides a 50 to 70% rate of cure; however, the outcome depends on the experience and ability of the surgeon and the characteristics of the tumor. The role of postsurgical medical therapy is to achieve long-term biochemical control of the growth hormone (GH)/insulin-like growth factor I (IGF-I) axis. In some patients, medical therapies may be implemented sooner as primary or preoperative therapy. Somatostatin analogs have been the mainstay of medical therapy for acromegaly. The somatostatin analog octreotide produces normalization of IGF-I in approximately 50% of patients but is associated with gastrointestinal adverse effects, including the development of gallstones. Octreotide requires thrice-daily subcutaneous administration. Long-acting formulations of somatostatin analogs (octreotide LAR, lanreotide) are at least as effective and as well tolerated as short-acting octreotide. Unfortunately, some patients are suboptimally responsive to or become intolerant of these agents. Pegvisomant belongs to a new class of agents known as GH-receptor antagonists. This novel agent competitively binds to the GH receptor, blocking IGF-I production. Pegvisomant is highly effective in achieving normal IGF-I concentrations and in reducing signs and symptoms of acromegaly, even in patients resistant to previous treatments. Pegvisomant has been proved safe and well tolerated and has no effect on gallbladder motility. GH levels remain elevated. Transient elevations in liver enzyme levels require monitoring but rarely necessitate termination of therapy. Normalizing IGF-I concentrations with pegvisomant also may have a beneficial effect on carbohydrate metabolism and cardiovascular risk.     

应用补片治疗脐疝合并肝硬化严重腹水的临床研究

目的目前,对于肝硬化合并复杂脐疝最适当的治疗方式仍无定论,本研究的目的是评估使用聚丙烯（polypropylene）补片治疗脐疝合并肝硬化严重腹水的临床应用。方法回顾性分析2008年3月至2012年6月,国泰综合医院共收治9例脐疝合并肝硬化严重腹水的患者,均接受补片修补脐疝治疗。9例患者均置放负压密闭式引流管（Jackson-Pratt draintube）到腹腔内做腹水的减压,每天引流腹水量约1000ml,持续1个月。于出院后1个月与6个月追踪复诊。结果手术后3个月复发脐疝1例,原因是补片无法与肚脐的皮肤和腹壁充分粘合。本组患者都没有出现腹膜炎与伤口感染的现象。Jackson-Pratt引流管拔除后的伤口必须用缝线缝合。因为长期大量腹水流失,必须密切检测血清中自蛋白值并补充蛋白质。脐疝修补手术前、后均必须持续使用利尿剂排出腹水。结论应用永久性补片治疗脐疝合并肝硬化严重腹水的患者,并发症少,复发率低。在手术前后使用抗生素治疗并注意无菌技术操作,应用补片治疗肝硬化合并严重腹水的脐疝患者是一种安全、简单而有效的治疗方式。