Left internal carotid artery dissection presenting with headache, Collet-Sicard syndrome and sustained hypertension

The baroreflex maintains blood pressure through the glossopharyngeal (IX) cranial nerve. We report a 54-year-old man who developed a left sided headache, hoarseness, dysarthria, dysphagia, and sustained hypertension from a left internal carotid artery dissection. We hypothesise that interruption of the left IX nerve caused hypertension in this patient.     

Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis

Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation. Methods: We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved preoperatively by stent placement via endoscopy (n= 6, 37.5%), percutaneous access (n= 5, 31%) or bilioenteric anastomosis (n= 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively. Results: Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention; there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%) patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain oral intake during the remaining survival time. Conclusions: We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional result while impairing the quality of life only to a minimal extent. Received: 7 May 1996/Accepted: 12 December 1996     

Endoscopic transthoracic sympathectomy for idiopathic upper limb hyperhidrosis

A 5-Year experience of 51 endoscopic transthoracic dorsal sympathectomies for idiopathic palmar hyperhidrosis in 26 patients is presented. Fifty-two percent complained of excessive sweating over their hands, 28% of axillary sweating and 20% over both areas, with a mean duration of 10 years. The second, third and fourth thoracic ganglia and their interconnecting fibres on the affected side were ablated using diathermy cautery. Over a mean follow up time of 26 months, this procedure was successful in curing or improving intractable sweating in 92%. However, axillary sweating was less well controlled than in the palms with 20% of patients describing residual wetness in the axilla. Compensatory sweating (75%) and gustatory sweating (48%) were the commonest side effects; despite this, most patients were satisfied with the functional and cosmetic outcome. Other complications included a temporary Horner's syndrome in one patient, a pneumothorax in the immediate post-operative period in another and a unilateral non-infective reactionary pleural effusion in a third. Two patients developed recurrence of palmar hyperhidrosis within 6 months of surgery. One has been successfully treated by re-operation on the affected side. All patients complained of mild to moderate interscapular chest pain which was easily controlled by non-steroidal anti-inflammatory agents, and resolved within 7–10 days post-operatively. The technique of endoscope transthoracic sympathectomy is effective, relatively simple to perform and usually requires only an overnight stay. It is recommended as the surgical treatment of choice for upper limb hyperhidrosis unresponsive to conservative measures.     

主动脉夹层50例临床分析

目的 探讨主动脉夹层(AD)的临床表现，以便早期诊断和治疗，降低死亡率。方法 对50例AD患者的临床表现、影像学检查、治疗经过及死亡原因进行回顾性分析。结果 50例行心脏超声检查，确诊者43例(90％)；21例行CT检查。21例诊断为主动脉夹层(100％)；行磁共振显像(MRI)27例，均确诊为主动脉夹层(100％)。经治疗好转出院42例(84％)，1例并发脑梗死且留有一侧肢体活动障碍后遗症。7例死亡(占14％)。结论 早期诊断，有效治疗是降低死亡率的关键，CT、MRI可提供可靠的确诊依据。     

64层螺旋CT三联检查在急性胸痛诊断中的应用

目的探讨64层螺旋CT（MSCT）三联检查显示急性胸痛患者肺动脉、胸主动脉和冠状动脉病变的能力及其临床应用价值。方法70例患者进行64层MSCT回顾性心电门控肺动脉、胸主动脉和冠状动脉联合检查。采用多平面重组（MPR）、最大密度投影（MIP）、曲面重组（CPR）及容积再现（VR）多种重组技术显示肺动脉、胸主动脉和冠状动脉，评价成像质量能否满足临床诊断需要。结果平均扫描时间（8．5±1．0）s，总对比剂用量100ml。肺动脉和主动脉增强后CT值均≥200HU者占95．7％（67／70）；冠状动脉显影图像质量优的节段占85．8％（720／839），图像质量良的节段占8．6％（72／839），图像质量差的节段占5．6％（47／839）。共检出冠状动脉狭窄≥50％者20例，肺动脉栓塞2例，主动脉夹层2例。结论64层MSCT三联检查能够在8s左右1次扫描完成肺动脉、胸主动脉和冠状动脉检查，图像质量可以满足临床诊断需要，在急性胸痛病因诊断中具有很高的临床应用价值。     

Acute type a aortic dissection complicated with acute inferior myocardial infarction following aortic valve replacement

Acute aortic dissection complicated with acute myocardial infarction (AMI) is the most fatal situation. We experienced the successful treatment for acute type A aortic dissection complicated with inferior AMI following aortic valve replacement (AVR). A 60-year-old man had had AVR for aortic regurgitation. Sixteen months after the AVR, he had a sudden onset of severe chest pain with complete atrioventricular block. Immediately, temporary pacing and cardiac catheterization were conducted, showing the occlusion of the right coronary artery due to acute type A aortic dissection. On his way to our hospital, direct current shock was conducted 3 times for ventricular fibrillation. We replaced the ascending aorta combined with coronary artery bypass grafting and the postoperative course was uneventful. The key to treat acute aortic dissection complicated with AMI is early accurate diagnosis, prompt temporary pacing for bradycardia, defibrillation for lethal arrhythmia and insertion of a perfusion catheter if possible. These preoperative hemodynamic stabilization gives us the chance to save these patients.     

颈淋巴结清除改进术138例

探讨颈淋巴结清除术的手术改进方法及其临床效果.方法:回顾性总结138例颈淋巴结清除术患者的手术改进方法和临床效果的临床资料.结果:病理证实有淋巴结转移102例,淋巴结转移数为1～36枚,平均手术时间为2 h,术中出血量为130 ml,手术并发症为2.2%.2年、3年生存率分别为85.6%和8 2.1%.结论:改进后的颈淋巴结清除术具有快速、安全、有效、术中出血少等优点,值得推广应用.     

医疗纠纷尸检86例法医学分析

目的：以法医学观点分析讨论医疗纠纷尸检的意义和重要性。方法：从本系1993年－2001年9月尸检资料中选出涉及医疗纠纷的86例资料，经驻表格逐一登记，分类整理，最后进行分析。结果：医疗纠纷的发生率逐年增多，且多集中于儿科（20例，23.2%)、产科（19例，22.1%)、内科（16例，18.6%)、诊所（10例，11.6%)、外科（9例，10.5%)等。医疗纠纷多与院内猝死、难以避免的并发症死亡、临床诊断不清、误诊、误治及医务人员态度不好等有关。结论：医疗纠纷的发生与许多因素有关，法医受理医疗纠纷尸检在程序上有利于取得社会公信，并有利于纠纷的最终解决。     

Extension of the “Elephant Trunk” Technique in Complex Aortic Pathology: The “Bidirectional” Option

Background. The “elephant trunk” technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the “bidirectional elephant trunk.” This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch.

Methods. The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement.

Results. This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation.

Conclusions. The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.