经鼻胃镜放置鼻空肠营养管的临床应用

目的:探讨经鼻胃镜放置鼻空肠营养管的临床价值。方法:对2008年5月至2011年9月复旦大学附属中山医院内镜中心采用经鼻胃镜导丝引导下放置鼻空肠营养管进行空肠营养支持的257例病人临床资料进行回顾性分析。结果:其中256例在鼻胃镜引导下放置空肠营养管成功,成功率为99.6%,平均放置时间为8.4±4.2min。置管并发症为胃黏膜损伤18例(7.0%)和鼻黏膜出血26例(10.1%),无消化道穿孔及大出血等严重并发症,病人耐受良好。结论:经鼻胃镜放置鼻空肠营养管方法便捷,可靠,值得临床推广。     

Qualitative and quantitative radio-anatomical variation of the posterior clinoid process

This study was conducted to investigate the radiological anatomy of the posterior clinoid process (PCP) to highlight preoperative awareness of its variations and its relationships to other skull base landmarks. The PCPs of 36, three-dimensional computed tomographic cadaveric heads were evaluated by studying the gross anatomy of the PCP and by measuring the distances between the PCP and other skull base anatomical landmarks relevant to transnasal or transcranial skull base approaches. PCP variations were found in five specimens (14%): in two the dorsum sellae was absent, in one the PCP and the anterior clinoid process (ACP) were connected unilaterally and in two bilaterally. The mean distance between the right/left PCP and the crista galli was 45.14 ± 4.0 standard deviation (SD_/46.24 ± 4.5 SD, respectively, while the distance to the middle point of the basion at the level of the foramen magnum was 40.41 ± 5.1 SD/41.0 ± 5.2 SD, respectively. The mean distance between the PCP and the ACP was 12.03 ± 3.18 SD on the right side and 12.11 ± 2.77 SD on the left. The data provided highlights the importance of careful preoperative evaluation of the PCP and of its relationships to other commonly encountered skull base landmarks. This information may give an idea of the exposure achievable through different transcranial and transnasal approaches. This is especially relevant when neuronavigation is not available.     

Morphometric measurements of the anterior skull base for endoscopic transoral and transnasal approaches

The objective of this study is to determine the bony limits of the transnasal and transoral approaches to the anterior skull base. The data we present are meant to assist surgeons in preoperative planning for lesions of the sella, clivus, foramen magnum, and odontoid. Using precise measurements undertaken on 41 high-resolution computed tomography scans from patients at the University of Pennsylvania without any history of sinus or sellar pathology, we sought to define the bony limits of transoral and transnasal approaches. Direct measurements and calculated angles were used to assess the dimensions of the anterior skull base. Using our measurements, a transnasal approach can reach an average of 22.5 mm below the plane of the hard palate to the body of C2, and a transoral route can reach 38 mm above the basion along the length of the clivus. Analysis of variance demonstrated no significant differences when subjects were grouped based on race or gender. The measurements outlined within this article help to define the relative dimensions necessary for adapted transoral and transnasal skull base surgeries.     

老年冠心病患者经鼻胃镜检查的安全性分析

目的探讨老年冠心病患者经鼻胃镜检查的安全性。方法选择2012年1月至2012年12月在北京老年医院接受胃镜检查的65岁以上老年患者100例,分为经鼻胃镜及普通胃镜组（各50例）,每组再分为冠心病及非冠心病（各25例）,比较各组胃镜检查中心率、血压、血氧饱和度、心肌耗氧量及心电图变化。结果普通胃镜检查中,冠心病患者心率、血压、心肌耗氧量增加较非冠心病患者明显（P＜0.05）,血氧饱和度下降值较非冠心病患者高（P＜0.05）,冠心病患者心律失常及ST段下移发生率较非冠心病患者高（P＜0.05）;冠心病患者经鼻胃镜检查中,心率、血压、心肌耗氧量增加值较普通胃镜明显低（P＜0.05）,血氧饱和度下降值低（P＜0.05）,心律失常及ST段下降发生率低（P＜0.05）。结论老年冠心病患者经鼻胃镜检查耐受性好,对心血管影响小,安全性高。     

Update on ENT anaesthesia in children

This article is an update of anaesthesia for common paediatric ear, nose and throat (ENT) procedures. ENT pathology is the most common indication for surgery in children. An increasing number are performed as day cases, even in the presence of comorbidities such as obstructive sleep apnoea, but judicious selection of suitable children remains important. Considerations include severity of disease, known difficult airway, complex comorbidities and the surgical centre. The anaesthetic management of frequently performed paediatric ENT procedures will be discussed, including the potential role for dexmedetomidine and recent advances using transnasal humidified rapid insufflation ventilatory exchange.     

Self-training in unsedated transnasal EGD by endoscopists competent in standard peroral EGD: prospective assessment of the learning curve

BACKGROUND: Training programs in unsedated transnasal (UT) EGD are scarce. OBJECTIVE: To prospectively assess the learning curve for unsupervised UT-EGD. SETTING: Endoscopy service, without experience in UT-EGD. SUBJECTS: Consecutive patients referred for diagnostic EGD. INTERVENTION: UT-EGD was attempted in 140 study patients by 2 endoscopists who trained by themselves in UT-EGD (skilled endoscopist [n = 70]; a trainee having recently achieved competency in conventional EGD [n = 70]) and in 10 controls (endoscopist skilled in UT-EGD) by using a 4.9-mm-diameter videoendoscope. MAIN OUTCOME MEASUREMENTS: Technical success, sedation administered, patient tolerance acceptance, procedure duration for each decade of 10 consecutive patients investigated by the same endoscopist; intention-to-treat analysis. RESULTS: Both self-trained endoscopists fulfilled predefined criteria of competency in UT-EGD since the first attempts. They completed examinations of adequate quality with exclusive transnasal scope insertion (n = 139 [99.3%]), no sedation (n = 138 [98.6%]), and patient accepting repeat procedure (n = 135 [96.4%]) in proportions not significantly different from controls for all decades. Compared with a median procedure duration of 5.5 minutes (interquartile range [IQR] 5.0-8.5 minutes) in controls, procedures were significantly longer for all trainee's decades (eg, first decade 20.0 minutes [IQR 15.0-29.0 minutes], P < .001) but none for the skilled endoscopist. Overall discomfort, pain, gagging, and belching were not significantly different for study patients versus controls. Fifty-six of 69 study patients (81%) with a previous history of conventional EGD preferred UT-EGD. LIMITATIONS: Generalizability to other small-caliber endoscopes. CONCLUSIONS: Endoscopists competent in conventional EGD may obtain excellent results with UT-EGD (except for procedure duration) beginning with their first attempts, even without supervision or structured training.