Combined anterior and posterior surgeries in the treatment of spinal tuberculous spondylitis

Methods for the treatment of tuberculous spondylitis still are controversial. The authors treated 32 consecutive patients with a two-stage surgical technique combined with antituberculous chemotherapy for 1 year. After anterior debridement, fusion with autogenous anterior iliac tricortical strut bone graft was done, and in a second stage, posterior instrumentation and fusion with autogenous posterior iliac corticocancellous bone graft was done 11 days (range, 4-22 days) later. Postoperatively, patients were encouraged to ambulate with brace protection as early as possible. Twenty-nine patients were followed up for a minimum of 2 years (median, 4.7 years; range, 2-10 years) of whom 28 patients achieved solid fusion (97%). All patients had improvement of back pain including the only patient with pseudarthrosis. Neurologic deficits completely recovered in 84% (16 of 19) of patients after 3 months. Kyphotic deformity improved in all 29 patients (34.6 degrees versus 17.3 degrees ) with the average correction angle of 17.3 degrees. Clinically, 27 patients had achieved a satisfactory outcome (93%). There were no evident surgical complications. The authors, therefore, recommend a two-stage surgical technique combined with antituberculous chemotherapy to treat patients with severe vertebral body destruction attributable to tuberculosis because of its high success rate and a low complication rate.     

Effect of core pancreas temperature during cadaveric procurement on human islet isolation and functional viability

BACKGROUND: Success of human pancreatic islet isolation depends largely on the techniques used during pancreas procurement and the quality of the gland. Warm ischemia of the pancreas of any duration during organ procurement may be detrimental to subsequent islet yield and functional viability of the islets. The aim of this study was to correlate pancreas procurement technique with the core temperature within the pancreas during in situ procurement to the recovery and in vitro function of isolated human islets. METHODS: Alternative pancreata were recovered from human cadaveric organ donors with needle-point myocardial temperature probes placed within the body of the pancreas. After vascular flushing with University of Wisconsin organ preservation solution, the first group of human pancreata were removed after standard liver and kidney procurement followed by in situ dissection of the pancreas. The second group of pancreata were removed using a similar protocol, except that the lesser sac was opened (and the spleen was mobilized to the midline) rapidly at the time of aortic cross-clamp. An additional 3-4 L of ice slush solution was placed behind and in front of the pancreas and replenished throughout the procurement process for the liver and kidneys. Immediately after recovery, in both groups, the pancreas was placed in cold University of Wisconsin solution and transported to the islet isolation laboratory for processing. Islets were isolated using a standard protocol of Liberase perfusion via the duct, gentle mechanical dissociation, and Ficoll purification. RESULTS: The absence of in situ ice-chilling of the entire pancreas during liver and kidney procurement caused the core pancreas temperature to rise to a peak of 18.2 degrees C; but when the pancreas was surrounded and replenished with iced saline slush, the core pancreas temperature was maintained at approximately 4 degrees C. The lower pancreas temperature correlated with a significantly higher recovery of islets in the group of pancreata surrounded with iced saline (223+/-35x10(3) IE vs. 103+/-26x10(3) IE; mean +/- SEM). Functional ability of the islets was also significantly improved in glucose static incubation, with a stimulation index of 4.4+/-0.3 in the iced-saline pancreas group versus 3.0+/-0.4 in the standard procurement group (P<0.05, paired t test). CONCLUSIONS: Procurement technique and the maintenance of a low temperature of the pancreas are critical to subsequent islet recovery and function. Maintaining a low pancreas temperature during procurement through the addition and replenishment of iced saline slush surrounding the anterior and posterior aspects of the pancreas greatly improves islet yield and functional viability of the isolated islets and is essential for success in clinical islet transplantation.     

Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse-sigmoid sinus

OBJECT: The aim of this study was to assess the efficacy and safety of radiosurgery for the treatment of dural arteriovenous fistulas (DAVFs) located in the region of the transverse-sigmoid sinus. METHODS: A series of 20 patients with DAVFs located in the transverse-sigmoid sinus, who were treated with gamma knife surgery between June 1995 and June 2000, was evaluated. According to the Cognard classification, the DAVF was Type I in four patients. Type IIa in seven, Type IIb in two, and combined Type IIa+b in seven. Nine patients had previously been treated with surgery and/or embolization, whereas 11 patients underwent radiosurgery alone. Radiosurgery was performed using multiple-isocenter irradiation of the delineated DAVF nidus. The target volume ranged from 1.7 to 40.7 cm3. The margin dose delivered to the nidus ranged from 16.5 to 19 Gy at a 50 to 70% isodose level. Nineteen patients were available for follow-up review, the duration of which ranged from 6 to 58 months (median 19 months). Of the 19 patients, 14 (74%) were cured of their symptoms. At follow up, magnetic resonance imaging and/or angiography demonstrated complete obliteration of the DAVF in 11 patients (58%), subtotal obliteration (95% reduction of the nidus) in three (16%), and partial obliteration in another five (26%). There was no neurological complication related to the treatment. One patient experienced a recurrence of the DAVF 18 months after angiographic confirmation of total obliteration, and underwent a second course of radiosurgery. CONCLUSIONS: Stereotactic radiosurgery provides a safe and effective option for the treatment of DAVFs involving the transverse and sigmoid sinuses. For some aggressive DAVFs with extensive retrograde cortical venous drainage, however, a combination of endovascular embolization and surgery may be necessary.     

湿热交换过滤器预防术中病人低体温的临床研究

目的：探讨湿热交换过滤器（heat and moisture exchanger and filter,HMEF）预防术中全麻病人低体温的临床应用价值。方法：择期颅脑手术的成年病人60例，随机分为A、B两组，每组30例。置入直肠温度探测头接Datex Ⅱ型多功能监测仪持续监测体温。观察组（A组）在气管导管与呼吸回路间安置HMEF，对照组（B组）则不放置。将两组间体温的变化进行比较。结果：A组在诱导后、术中于术毕体温也有下降，但组间各期比较无显著差异（P＞0．05）。B组在诱导后60分钟时体温下降最为明显,为2．6℃，与A组（1．4℃）同期比较有非常显著意义（P＜0．01）。术毕寒战发生率两组间相比也有显著差异（P＜0．05）。结论：使用湿热交换过程过滤器的预防术中低体温的作用。     

同种输血可能是心脏术后感染的因素之一

目的：探讨同种输血和输血量与心脏手术后感染的相关性，方法：选择12岁以上心脏病人266例，在静吸复合麻醉、低温心肺转流下行心脏外科手术。根据是否输用同种血和输血量分成三组：A组（n=71）为对照组，无同种输血；B组(n=51）同种输血量≤400ml;C组(n=144）同种输血量≥800ml。对三组病例术后感染情况进行分析比较。结果：A组术后感染2例（2．81％），B组感染12例（23．6％），C组感染37例（25．6％），B、C组感染率显著高于A组（P＜0．01）。结论：同种输血是心脏手术后感染的危险因素之一，但是否是感染独立的相关因素尚需进一步研究。     

咪唑安定靶控输注时镇静深度的预测

目的　探讨咪唑安定 (MDZ)靶控输注镇静时目标血药浓度、效应室浓度与脑电指标双频指数 (BIS)、95 %边缘频率 (95 %SEF)预测镇静深度的临床价值及MDZ在区域麻醉靶控输注镇静中的适宜目标浓度。方法　选择ASAⅠ～Ⅱ级的择期手术患者 14例 ,以血药浓度作为靶控输注目标浓度。第一阶段靶浓度为 5 0ng/ml,继以 5 0ng/ml浓度梯度递增 ,每一阶段维持 15分钟 ,至镇静评分 (OAA/S评分法 )达 1分后停药 ,观察并双盲记录目标血药浓度、效应室浓度、BIS、95 %SEF、血液动力学和镇静评分各指标至患者清醒 ,用Spearman’s等级相关进行相关分析。 结果　镇静起效期(0AA/S5～ 1)OAA/S与BIS、95 %SEF、目标血药浓度、效应室浓度的相关系数分别为r =0 735、0 4 15、- 0 4 87和 - 0 6 89(P值均 <0 0 0 1)。镇静恢复期 (0AA/S1～ 5)分别为r =0 6 14、0 2 94、-0 5 5 1和 - 0 4 97(P值均 <0 0 1)。不同镇静评分时各指标变化有显著差异。血液动力学指标未见与镇静评分相关。结论　MDZ靶控输注镇静时 ,目标血药浓度、效应室浓度、BIS和 95 %SEF均可用于镇静深度的预测 ,镇静评分与BIS相关最好 ,镇静深度宜维持在OAA/S评分 2～ 3分 ,目标血药浓度 10 0ng/ml左右 ,BIS在 77～ 81之间。     

山莨菪碱等对Oddi括约肌作用的临床测压研究

目的 用经胆道镜Oddi括约肌压力测定方法观察临床常规剂量吗啡、硝酸甘油、西沙必利、硫酸镁、山莨菪碱对Oddi括约肌作用及相互间拮抗作用。方法 选择术后患者70例,分7组;对照组1、硝酸甘油组、西沙必利组、吗啡组、对照组2、硫酸镁组和山莨菪碱组。用经胆道镜压力测定方法,测十二指肠压力、Oddi括约肌基础压力及收缩幅度和胆总管压力。结果硝酸甘油组Oddi括约肌基础压力及收缩幅度下降了(23.07±24.18)和(20.72±26.10)mmHg(P<0.05),西沙必利组下降了(14.99±19.94)和(19.44±24.33)mmHg(P<0.05),吗啡组增加了(15.40±15.44)和(47.90±32.08)mmHg(P<0.05);硫酸镁组下降了(7.40±24.17)和(71.74±66.84)mmHg(P<0.05),山莨菪碱组下降了17.00±17.49和85.34±70.49mmHg(P<0.05)。结论 临床常规剂量硝酸甘油、西沙必利可以降低Oddi括约肌基础压力及收缩幅度,临床常规剂量吗啡有升高Oddi氏括约肌基础压力及收缩幅度的作用,而硫酸镁、山莨菪碱可以拮抗吗啡对Oddi氏括约肌的作用。     

铁丝夹板牵引治疗掌指骨骨折

目的：对掌指骨骨折应用铁丝夹板牵引治疗方法进行探讨。方法：对372例468个掌指骨骨折选择性地应用铁丝夹板的牵引整复固定治疗。结果：所有患指无一例感染坏死、骨折延迟愈合或不愈合，功能恢复良好，疗效满意，总优良率92.5%。结论：铁丝夹板牵引、固定治疗掌指骨骨折是一种较好的方法，操作简便，创伤小，对严重粉碎性骨折、斜形骨折及开放性骨折手术后的患进行牵引、外固定，有良好的维持复位作用。     

腹腔镜在诊治闭合性腹外伤中的应用

目的 :探讨腹腔镜在诊治腹部闭合性损伤中的价值。方法 :经腹腔镜对 4 8例原因不明闭合性腹外伤进行诊断和治疗。结果 :4 7例通过腹腔镜明确诊断 ,33例在腹腔镜下得到治疗 ,12例中转开腹手术 ,无并发症和手术死亡病例。平均手术时间 34min ,平均住院 5 8d。结论 :腹腔镜不仅是安全且准确的诊断方法 ,而且是良好的治疗手段     

磁共振胆胰管成像对壶腹部肿瘤诊断的价值

目的 评价磁共振胆胰管成像对壶腹部癌的诊断价值。方法 通过总结23例壶腹部癌的MRCP及MRI影像资料。对磁共振影像诊断与病理学诊断与病理学诊断的符合率进行回顾性分析。结果 磁共振胰管成像的定位诊断率为100%，与病理诊断的符合率也达91.3%。结论 磁共振胆胰管成像是一种非介入性胆胰管成像技术，具有不需要对比剂，无创伤及图像清晰的优点，对壶腹部癌有较高的诊断价值。