硬膜外穿刺针外套管在腹腔镜小儿斜疝高位结扎术中的应用

目的探讨硬膜外穿刺针外套管在腹腔镜小儿斜疝疝囊高位结扎中的应用价值。方法2003年4月-2006年5月,我院对230例小儿斜疝手术应用硬膜外穿刺针外套管代替雪橇钩针实施腹腔镜疝内环口荷包高位结扎术。结果230例手术均获得成功,手术时间：单侧161例8-10 min,嵌顿疝39例15-20 min,双侧30例16-20 min;术后未见有阴囊水肿及睾血疼痛及缺血坏死。术后随访2-6个月111例,6-12个月52例,12-24个月37例,24-36个月30例,无复发。结论硬膜外刺针外套管可替代小儿疝囊结扎专用的雪橇钩针,简便,经济,适合在所有基层医院推广。     

Malignant transformation of spinal meningeal melanocytoma. Case report and review of the literature

Meningeal melanocytomas are rare tumors and malignant transformation of these lesions is even rarer. The authors report on a case of a 57-year-old man who presented with a melanocytoma located at the L5-S1 level. After gross-total resection of the tumor, it recurred 1 year later as a malignant melanoma. In addition, multiple subcutaneous metastases were found at that time. The patient was treated with radiation therapy (5000 cGy). Five months later metastases in the liver and the left ninth rib were discovered. The pertinent literature is reviewed and disease criteria are presented to distinguish meningeal melanocytoma from malignant melanoma and from meningiomas or schwannomas containing melanotic pigment. Patients and investigators should be cautioned that a meningeal melanocytoma may recur and transform into a malignant melanoma.     

The laterally extended medial hemisoleus flap for reconstruction of a tibial wound in the distal third of the leg

A soleus flap as a local reconstructive option for soft-tissue coverage of a tibial wound in the distal third of the leg has never been well recognized. In a 2-year period, seven patients underwent reconstruction of a less extensive tibial wound (4 × 3 to 10 × 4 cm) in the distal third of the leg after orthopedic trauma with the laterally extended medial hemisoleus flap. The flap was elevated with emphasis on the preservation of the most distal perforators from the posterior tibial vessels to the flap as possible while allowing adequate rotation of the flap to cover the exposed tibia and/or hardware and on the possible preservation of foot planter flexion by reconstruction of the proximal Achilles’ tendon. In this series, there was no total or partial flap loss. All patients healed their tibial wounds primarily with reliable soft-tissue coverage, evidenced fracture healing, and good cosmetic outcome during follow-up. Thus, the laterally extended medial hemisoleus flap described by the author can be a reliable option for soft-tissue coverage of a less extensive tibial wound in the distal third of the leg. It offers a more cost-effective approach for managing this unique problem and can be performed by most reconstructive surgeons without microsurgical expertise.     

Impaired hepatic regeneration by ischemic preconditioning in a rat model of small-for-size liver transplantation

OBJECTIVE: Graft size is one of the major risk factors in adult-to-adult living donor liver transplantation and rapid regeneration is an essential post-operative requirement. Ischemic preconditioning (IPC) has been shown to be an effective strategy in the reduction of hepatic ischemia-reperfusion injury and stimulation of liver regeneration. This study was designed to evaluate the effects of IPC on liver regeneration in small-for-size liver grafts. METHODS: We employed a rat orthotopic liver transplantation model using small-for-size (30%) grafts, in the presence or absence (control) of IPC (10 min of ischemia followed by 15 min of reperfusion). Survival rate, graft injury, hepatocellular proliferation, cell cycle progression, Stat3 activation, as well as TNF-alpha and IL-6 expression were assessed. RESULTS: IPC significantly enhanced the extent of graft injury and hindered hepatic regeneration in small-for-size liver grafts. The 7-day survival rate was also reduced by IPC, but failed to reach statistical significance. IPC did not affect TNF-alpha levels, but significantly decreased the elevation of IL-6 after reperfusion. These findings were correlated with down-regulation of cyclin E and cyclin D1, and decreased numbers of PCNA-positive nuclei in IPC grafts. These results were inconsistent with Stat3 activation, as P-Stat3 exhibited a stronger and prolonged pattern of expression in the IPC group, compared to controls. CONCLUSIONS: Ischemic preconditioning may impair liver regeneration in small-for-size liver grafts by decreasing IL-6 and blunting cell cycle progression, through a mechanism at least partially independent of Stat3.     

Acute kidney injury after radical gastrectomy: a single center study

Objectives

To investigate the incidence of acute kidney injury (AKI) and identify risk factors for AKI in patients who undergo radical gastrectomy.

Methods

This study included 536 patients underwent radical gastrectomy. Primary outcome was AKI, defined as a ≥50 % increase in serum creatinine relative to baseline during the first three postoperative days. Secondary outcomes were duration of hospitalization and all-cause hospital mortality within 30 days after radical gastrectomy.

Results

A total of 37 (6.9 %) patients developed postoperative AKI. Age, body mass index (BMI), presence of hypertension, hyperlipidemia, poor blood glucose control, and preoperative higher cystatin C were associated with increased frequency of AKI. By multivariable analyses, the independent risk factors for AKI were age, BMI, hypertension, hyperlipidemia, and preoperative cystatin C.

Conclusions

Postoperative AKI is not infrequent after radical gastrectomy. Age, BMI, hypertension, hyperlipidemia, and preoperative cystatin C are independently associated with increased risk of postoperative AKI.     

Immunoglobulin A nephropathy in horseshoe kidney: Case reports and literature review

Horseshoe kidney is the most common congenital renal fusion anomaly. Immunoglobulin A nephropathy is a common glomerulonephritis worldwide. However, the co‐occurrence of these diseases had not been reported in the literature. We report the first two cases with the occurrence of immunoglobulin A nephropathy in horseshoe kidney. The first case was a 26‐year‐old male with hypertension and proteinuria (1.4 g/24 h), his pathological finding was primary immunoglobulin A nephropathy. The second case was a 15‐year‐old female who presented with recurrent peliosis on bilateral lower extremities, haematuria and proteinuria (1.7 g/24 h). Her renal biopsy finding was Henoch–Schonlein purpura nephritis (secondary immunoglobulin A nephropathy). In both cases, renal biopsy was performed by experienced doctors under ultrasonic guidance at the renal upper pole and no postoperative complications were observed. After they were treated based on the renal pathological findings for 6 months, urine protein excretion decreased significantly and blood pressure and serum creatinine stabilized. It is possible that immunoglobulin A nephropathy occurs in a horseshoe kidney patient. Renal biopsy may be valuable and viable for horseshoe kidney patients with heavy proteinuria to identify pathologic type of glomerulopathy and to guide treatment, if renal biopsy is performed by experienced doctors at the renal upper pole under renal ultrasonic guidance.     

Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Introduction

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

Methods

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

Results

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test).

Conclusions

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.     

Risk factors for intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma: A meta-analysis

PurposeAfter radical nephroureterectomy (RNU), approximately 22% to 47% of patients with upper tract urothelial carcinoma (UTUC) develop a subsequent intravesical recurrence (IVR). Considering this high incidence of occurrence, several risk factors were reported as predictive of IVR after RNU. Until recently, most of the risk factors were still under debate. The aim of study was to conduct a meta-analysis based on the recent literature to explore the risk factors for IVR after RNU for UTUC.Patients and methodsAn electronic search of the Medline, Embase, Cochrane Library, CancerLit, and ClinicalTrials.gov databases was performed to identify relevant studies published before May 2013. The studies were included if they reported risk factors related to bladder or IVR after RNU for UTUC.ResultsOverall, 40 studies, with 12,010 patients, were included in our meta-analysis. Our study indicated that a statistically significant difference in IVR after RNU was found in the male vs. female patients (odds ratio [OR] = 0.72, 95% CI: 0.59–0.85), ureteral vs. renal pelvis (OR = 1.18, 95% CI: 1.00–1.36), T2–4 vs. Tis, Ta, and T1 (OR = 0.53, 95% CI: 0.40–0.66), larger vs. smaller tumor size (OR = 1.02, 95% CI: 1.01–1.03), and previous/synchronous bladder cancer vs. the absence of bladder cancer (OR = 1.59, 95% CI: 1.26–1.9). No significant differences in IVR after RNU were found in the younger vs. older age groups, multifocal tumors vs. single tumor, G3 vs. G1 and G2, high vs. low grade, N0 vs. N+, concomitant carcinoma in situ vs. the absence of carcinoma in situ, positive vs. negative lymphovascular invasion, open vs. laparoscopic nephroureterectomy, and endoscopic vs. transvesical technique.ConclusionsOur study showed that female patient; ureteral tumor; larger tumor; Tis, Ta, and T1; and the history of bladder cancer were significant risk factors related to IVR after RNU.     

美国血管外科学会2018年腹主动脉瘤诊治指南解读

根据循证医学的基本原则,美国血管外科学会（SVS）在系统性回顾的基础上,于2018年1月发布了腹主动脉瘤（AAA）治疗指南,针对AAA的诊断评估、治疗方式、麻醉及围术期处理、术后管理及随访、经济效益学分析5个方面做了重点阐述,并给出111条具体的推荐建议,并按GRADE法给出了推荐强度及证据级别。笔者对该指南中涉及的新观点或推荐意见、以及与临床诊疗过程中的密切相关点作一解读,以期读者更好的理解该指南。