冠心病合并其他器质性心脏病的外科治疗

目的分析冠心病合并其他器质性心脏病的临床特点,探讨一期外科治疗的方法和临床疗效。方法分析2004年4月至2006年4月冠心病合并其他器质性心脏病患者13例,其中风湿性心脏病联合瓣膜病1例,二尖瓣病变4例,二尖瓣退行性病变3例,主动脉瓣关闭不全3例,升主动脉瘤1例,继发孔房缺1例。因冠心病首诊入院5例,以其他器质性心脏病首诊入院8例。术前有心绞痛症状者8例,无心绞痛5例。体外循环下一期外科治疗。结果无死亡病例,13例均顺利出院。冠脉搭桥+瓣膜置换8例,冠脉搭桥+瓣膜成形3例,冠脉搭桥+Bentall+室壁瘤切除1例,冠脉搭桥+房缺修补1例。手术中搭桥1～3支,平均(1.92±0.73)支。术后1周,左心室舒张末内径(LVDD)为(51.77±2.64)mm,较术前[(58.92±3.81)mm]明显缩小(P<0.05)。随访3个月,心绞痛症状完全消失,心功能(NYHA)明显提高(P<0.05)。结论冠心病合并其他器质性心脏病临床症状无特异性,容易漏诊。虽然手术风险性和难度增加,但未得到血液重建,对患者更将是致命性的灾难,应争取一期手术。     

外科治疗56例心脏非黏液性肿瘤的临床分析

目的探讨心脏非黏液性肿瘤临床特点,总结外科治疗经验。方法对我院1996年10月至2005年3月进行外科治疗的56例心脏非黏液性肿瘤的临床资料进行回顾性分析,总结其临床表现、发生部位、肿瘤性质和外科治疗特点等。结果心脏非粘液性肿瘤占本院同期手术患者的0.14%,良性肿瘤28例,恶性肿瘤28例,其中继发性心脏肿瘤8例。良性肿瘤最常见的是生长在心室,共18例;恶性肿瘤最常见的生长部位是心房,共15例。外科治疗行急诊手术者12例。心包开窗引流术2例,探查术1例,术中肿瘤全部切除者26例,部分切除27例,术后住院期间死亡1例。结论心脏非黏液性肿瘤临床表现各异、病理类型多样、病变广泛,手术原则为尽可能切除肿瘤和保持心脏结构的完整性和功能。     

自体血预充技术对血液保护作用的研究

目的研究采用自体血预充技术对体外循环下心脏手术的血液保护作用。方法40例非急诊手术的首次接受体外循环下心脏冠脉搭桥的患者,依性别(男女比例)、年龄、体重、身高、体表面积(BSA)和射血分数(EF)进行配对后分为两组:自体血预充组(n=20)和经典预充组(n=20)。自体血预充组:用1250ml晶体液和8000IU肝素预充,体外循环开始前先采用自体血预充技术置换出大部分最初预充液,维持平均动脉压(MAP)在50mmHg以上。经典预充组:1250ml晶体液和8000IU肝素预充。心肌保护均采用Calafiore温血停跳液灌注。体外循环中保持温度35.0℃～35.5℃,流量2.5～2.8L·min-·1m-2。所有患者按标准手术步骤进行手术。手术结束前将体外循环系统中余血全部回输给患者。结果自体血预充组平均置换出(894±171)ml的最初预充液,患者体外循环中,手术结束时,术后6h、1d、2d的HCT水平均明显高于经典预充组(P<0.05)。自体血预充组围术期人均输血量明显低于经典预充组[(0.16±1.09)U/人和(0.97±2.18)U/人,P<0.05]。自体血预充组患者术后胸腔引流量较经典预充组明显减少(303±89ml和495±112ml,P<0.05)。结论自体血预充技术的应用能减少血液稀释,减少围术期输血量,保护血液。     

腹腔镜和开腹结直肠手术的炎性反应比较

目的对比分析腹腔镜和开腹结直肠手术患者全身和腹腔炎性反应的差异,为腹腔镜手术对结直肠肿瘤中的应用提供理论依据。方法对51例2004年4-8月间收治的乙状结肠和直肠恶性肿瘤患者,采用腹腔镜辅助手术25例(LAP组),开腹手术26例(OPEN组)。术毕骶前留置引流管。观察并比较两组患者的一般情况和炎性反应及与手术相关的各项指标。结果两组患者在年龄、性别、ASA分级、术前血红蛋白及白蛋白水平、肿瘤Dukes分期和手术方式差异均无统计学意义(P＞0．05)。在切口长度、手术时间、肠道功能恢复时间、住院时间的比较中,LAP组占有明显优势(P＜0．05)。腹腔引流量在术后第1天,两组间差异无统计学意义(P＞0．05)；而术后2-4 d,LAP组明显低于OPEN组(P＜0．05)。LAP组术后第1天,周围血中性粒细胞[(7．30±2．62)×10~9/L]、白介素(IL)-10[(19．46±3．31)pg/ml]和C反应蛋白(CRP)[(2．76±2．17)mg/dl]水平均显著低于OPEN组(P＜0．05)。术后第4天两组间差异无统计学意义(P＞0．05)。术后第1天,两组腹腔引流液的IL-10、肿瘤坏死因子(TNF)及CRP水平差异无统计学意义(P＞0．05),术后第4天LAP组IL-10 [(22．53±15．47)pg/ml]明显低于OPEN组(P＜0．05)。结论术后早期,腹腔镜结直肠手术的腹腔炎性反应与开腹手术相当,而全身炎性反应较开腹手术轻。腹腔镜结直肠手术临床上体现出恢复快、并发症少、住院天数少的优势。     

Surgical Complications and Long-Term Outcome of Different Biliary Reconstructions in Liver Transplantation for Primary Sclerosing Cholangitis—Choledochoduodenostomy versus Choledochojejunostomy

Choledochojejunostomy (CJS) is commonly used for biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC). We alternatively performed choledochoduodenostomy (CDS) and side-to-side choledochodocholedochstomy in a large cohort of patients. Fifty-one patients with PSC, transplanted between 1988 and 2000, were analyzed retrospectively. Biliary reconstruction was CDS in 25 (49%), CJS in 20 (39%) and CC in 6 transplantations (12%). Biliary leaks occurred in the early follow-up (< or =41 days) only in CDS patients (20%). However, in the late follow-up (>4 months), stricturing of anastomosis was found once in CDS (4%) and CJS (5%). Later (>9 months), intrahepatic bile duct strictures were diagnosed in four CDS (16%), one CJS (5%) and one CC (17%) patient(s). In 48% of CDS (12/25), 60% of CJS (12/20) and 17% of CC (1/6) at least one incidence of cholangitis was observed. Overall, biliary complication rates were significantly higher in CDS (40%) than CJS (10%) and CC (17%); of those none in CC and 12% in CDS were anastomosis-related. Graft/patient survival showed no significant differences among groups. Based on our results we consider CJS the standard method for biliary reconstruction in PSC; however, in selected cases where CJS is difficult to accomplish because of previous surgery or for retransplantation, CDS may present an alternative technique.     

经皮椎弓根技术治疗胸腰椎骨折的临床探讨

目的:探讨微创经皮椎弓根螺钉内固定手术治疗胸腰椎骨折的可行性及其疗效。方法:20例胸腰椎骨折病例,男13例,女7例;年龄28~65岁,平均48·2岁。其中16例损伤平面以下无神经功能损害、无双下肢和大小便障碍;4例有不同程度的脊髓损伤,按Frankel分级:C级1例,D级3例。在C形臂X线的定位下确定需要固定的椎弓根根部,做4个1·5cm长的切口,固定与复位均在4个小切口内完成。结果:所有病例均获随访,时间9~18个月,平均15个月。术后患者椎体高度均有不同程度恢复,椎体后凸畸形获得不同程度矫正。手术时间约1·5h,出血量约80ml。结论:微创经皮椎弓根螺钉内固定手术操作简便、安全可靠,具有创伤小、出血少、疼痛轻、恢复快、住院时间短等优点。     

外科治疗ⅢA期N2非小细胞肺癌的预后分析及临床意义

目的 探讨影响ⅢA期N2非小细胞肺癌（NSCLC）预后的因素，并分析经手术治疗不同亚组病人的生存率差异。方法 分析1997年1月至2000年1月146例手术治疗的ⅢA期N2 NSCLC病人的可能影响预后因素：病理类型、肿瘤位置、肿瘤大小、手术方式、临床N2情况，N2转移组数及个数、术后辅助治疗等，并用Kaplan-Meier曲线及Logr ank检验生存率差异，Cox单因素、多因素分析各因素对生存率的影响。结果 ⅢA期N2 NSCLC病人的3年和5年生存率分别为19．86％和14．56％。单因素分析示肿瘤位置、临床N2情况、N2转移组数及个数是影响生存率的因素；多因素分析示肿瘤大小、临床N2情况，N2转移组数和肿瘤位置影响预后。右肺下叶肿瘤单组或单个N2转移，预后最好。结论 纵隔N2转移淋巴结的大小、个数和组数是影响术后生存率主要因素。手术前未发现N2转移（mN2），有1组N2转移（N2h），N2转移数少于4个者手术治疗效果好。右肺下叶肿瘤发生单组N2淋巴结转移预后好。     

Dermatofibrosarcoma protuberans: a population-based cancer registry descriptive study of 66 consecutive cases diagnosed between 1982 and 2002

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare malignant tumour of the skin, with an estimated incidence of 0.8 to five cases per 1 million people per year. OBJECTIVE: To study epidemiological, immunohistochemical and clinical features, delay in diagnosis, type of treatment and outcome of DFSP from 1982 to 2002. METHODS: Using data from the population-based cancer registry, 66 patients with pathologically proved DFSP were included (fibrosarcomatous DFSP were excluded). Each patient lived in one of the four departments of Franche-Comté (overall population of 1 million people) at the time of diagnosis. The main data sources came from public and private pathology laboratories and medical records. The rules of the International Agency for Research on Cancer were applied. RESULTS: The estimated incidence of DFSP in Franche-Comté was about three new cases per 1 million people per year. Male patients were affected 1.2 times as often as female patients were. The trunk (45%) followed by the proximal extremities (38%) were the most frequent locations. DFSP occurred mainly in young adults between 20 and 39 years of age. Mean age at diagnosis was 43 years, and the mean delay in diagnosis was 10.08 years. Our 66 patients initially underwent a radical local excision. Among them, 27% experienced one or more local recurrences during 9.6 years of follow-up. There was one regional lymph node recurrence without visceral metastases. These recurrences were significantly related to the initial peripheral resection margins. We observed a local recurrence rate of 47% for margins less than 3 cm, vs. only 7% for margins ranging from 3 to 5 cm [P=0.004; OR=0.229 (95%, CI=0.103-0.510)]. The mean time to a first local recurrence was 2.65 years. Nevertheless, there was no death due to the DFSP course at the end of the follow-up, and the final outcome was favourable. CONCLUSION: Our study emphasizes the importance of wide local excision with margins of at least 3 cm in order to prevent local recurrence. However, the recent development of inhibitors of signal transduction by the PDGFB pathway should soon modify the surgical strategy, which is often too mutilating.     

重症急性胰腺炎102例临床分析

目的探讨重症急性胰腺炎的合理治疗方案。方法以1985年1月～2005年8月间收治的102例重症急性胰腺炎作研究对象，比较手术组与非手术组的主要并发症和死亡率。A组：1985年1月～1993年12月以手术治疗为主41例；B组：1994年1月～2005年8月以早期非手术治疗为主61例。结果手术组死亡率和并发症发生率明显高于非手术组，两组病死率及并发症发生率比较差异有显著性（P〈0．05）。结论重症急性胰腺炎采用早期非手术治疗能有效降低病死率和并发症发生率。大多数重症急性胰腺炎可经非手术治愈。