隐神经-大隐静脉营养血管远端蒂复合瓣移植修复小腿、踝足部创伤

目的:在显微解剖学基础上,观察隐神经-大隐静脉营养血管远端蒂复合瓣移植修复小腿、踝足部创伤的临床效果。方法:选择2004-05/2007-04由解放军南京军区福州总医院骨科、解放军第97医院骨科、解放军第107医院骨科采用隐神经-大隐静脉营养血管远端蒂复合瓣移植修复小腿、踝足部组织缺损48例,患者对治疗均知情同意。其中皮瓣修复小腿、踝周及足部的创面感染、缺损23例;肌皮瓣修复小腿上段、下段的溃疡、骨髓炎和骨钢板外露12例,跟骨内侧骨髓炎5例;骨皮瓣修复伴有胫骨缺损和跟骨骨不连的创面8例。术后定期随访,观察隐神经-大隐静脉营养血管远端蒂皮瓣移植修复术后的存活情况及骨皮瓣的骨愈合、功能情况。结果:48例患者术后均有程度不同的皮瓣肿胀,其中3例皮瓣远侧边缘少量坏死,经换药愈合;皮瓣部分坏死植皮1例。伤口Ⅰ期愈合44例,Ⅱ期愈合4例。所有病例经5￣15个月随访,创面及骨不连修复,外形满意。结论:隐神经-大隐静脉营养血管远端蒂皮瓣、复合瓣用于外伤造成的小腿远端骨缺损、骨不连、大的死腔以及踝足部的缺损创面修复,具有快捷方便,抗感染力强,成活率高和愈合快的优点。     

Surveillance for Barrett's oesophagus: results from a programme in Northern Ireland

BACKGROUND: The reported incidence of adenocarcinoma in patients with Barrett's oesophagus in surveillance programmes varies widely. Great Britain has one of the highest incidence rates of this cancer in the world, but there are no data from Ireland reporting its incidence in patients with Barrett's oesophagus undergoing surveillance. We carried out a study of all such patients at a large District General Hospital in Northern Ireland. METHODS: A retrospective review of all patients with Barrett's oesophagus from January 1986 to March 2004 at Altnagelvin Area Hospital, Derry, Northern Ireland was performed. Barrett's oesophagus was defined as specialized intestinal metaplasia present in the tubular oesophagus. RESULTS: A total of 277 patients had Barrett's oesophagus. Twenty-one patients had adenocarcinoma and two patients had high-grade dysplasia at initial endoscopy and were excluded. Of the remaining 254 patients, 178 were entered into the surveillance programme (127 men, 51 women). The average follow-up period was 3.4 years, resulting in 613 patient-years of follow-up. Three patients developed adenocarcinoma, an incidence of 1/204 patient-years of follow-up. Two of the three patients had early-stage (T1 or T2) cancers detected and are alive and well. A total of 429 surveillance endoscopies were performed, and a marked year-on-year increase in the workload generated as a result of the surveillance programme was observed. CONCLUSIONS: The incidence of adenocarcinoma in patients in Northern Ireland was similar to the incidence reported by other large institutions. Clinical benefit is suggested but is not certain from these data, because of biases that affect surveillance programmes. Large multicentre studies are required to determine whether surveillance is beneficial.     

Low-dose midazolam sedation: an option for patients undergoing serial hepatic venous pressure measurements

The hepatic venous pressure gradient (HVPG) is becoming increasingly used clinically. It is useful in the differential diagnosis of portal hypertension and provides a prognostic index in cirrhotic patients. Performance of serial measurements has been shown to be useful in guiding pharmacological therapy of portal hypertension and variceal hemorrhage. The technique is safe to perform; however, many patients are anxious and reluctant to undergo serial measurements. The effects of sedatives on portal pressure measurements have not yet been defined. The objective of this study was to evaluate the effects of midazolam on the HVPG. Twenty patients with compensated cirrhosis were included in this prospective, double-blind study. The HVPG was determined by subtracting the free hepatic venous pressure (FHVP) from the wedged hepatic venous pressure (WHVP). Patients were randomized to receive either placebo, 0.02 mg/kg midazolam, or 0.03 mg/kg midazolam, administered intravenously over 3 minutes. Immediately after drug administration and every 3 minutes thereafter, for a total of 30 or 40 minutes, measurements were repeated. Three hours later, patients were asked to state whether the sedative affected their state of comfort/relaxation. The effects of both doses of midazolam on HVPG did not differ significantly from those of placebo. Furthermore, neither dose of midazolam induced significant changes in HVPG as compared with baseline values. However, higher-dose midazolam (0.03 mg/kg) was associated with significant reductions in FHVP from baseline and a tendency for a reduction in WHVP. Both doses significantly increased patient comfort and relaxation during the test. Midazolam, used at a dose of 0.02 mg/kg, is effective in increasing patient comfort and relaxation during hepatic venous pressure measurements, without significantly affecting pressures (HVPG, WHVP, or FHVP). It is therefore an acceptable option for patients undergoing serial hepatic venous pressure measurements.