扩大操作口电视辅助内窥镜下脊柱前路手术的探讨（附14例报告）

目的：探讨借助影像内窥镜扩大操作切口直视下脊柱前路手术的安全性和适用性。方法：双腔导管气管内插管麻醉下侧卧位，操作切口５ｃｍ长，采用电视辅助内窥镜系统光源，直视下操作，完成８例脊柱胸椎结核病灶清除及植骨融合，３例脊柱肿瘤瘤体切除椎间植骨术，２例脊柱骨折脊髓减压及内固定术，１例后凸畸形矫正内固定及植骨融合术。结果：手术均获成功。术中平均出血量４６０ｍｌ，平均手术时间２４２ｍｉｎ，术后平均引流量３９４ｍｌ。术后影像学评价病灶清除减压彻底。术后并发肺不张２例，胸腔积液１例，右肢体麻木１例，经治疗痊愈。结论：扩大操作口借助影像内窥镜系统直视下脊柱前路手术安全，创伤较小，出血少     

Long-term survivors after resection of carcinoma of the head of the pancreas: significance of histologically curative resection

Background/Purpose The prognosis of patients with pancreatic cancer is said to have not been improved markedly by any procedures in the past 20 years. Since 1973, we have gradually extended the area of dissection when performing curative resection for pancreatic cancer to improve the resection rate and prognosis. Nineteen patients have survived for 3 years or more, and the 5-year survival rates of patients with cancer of the head of the pancreas were 23.9% for macroscopically curative resection and 34.3% for histologically curative resection.Methods We histologically observed surgical specimens, cut into 3- to 5-mm sections and compared the histologic characteristics of the 19 patients who survived for 3 years or more with those of 41 patients who died of cancer within 3 years (excluding 6 operative and hospital deaths), in order to find the conditions required for long-term survival.Results The following conditions were associated with long-term survival: (1) tumor diameter 3cm or less; (2) either absence of lymph node metastasis or metastasis limited to the n₁ group; (3) degree of invasion of the anterior pancreatic capsule of zero (s0); and (4) either no retropancreatic invasion (rp0) or exposed retropancreatic invasion (rpe) with no cancer invasion of dissected peripancreatic tissue ew(–).Conclusions At present, because the rpe rate is more than 70%, resection of the pancreas, including the superior mesenteric vein and the retropancreatic fusion fascia, is essential for a curative resection, because the retropancreatic tissue between the back of the pancreas and this fascia is anatomically considered to be in the position of the subserosal tissue in the gallbladder or stomach. Combined resection of the superior mesenteric artery may further improve the results of resection for pancreatic cancer, from the anatomical viewpoint.     

Clinical outcome of laparoscopically assisted endorectal pull-through in Hirschsprung's disease: comparison of abdominal and perineal approaches

Background/Purpose

Laparoscopically assisted endorectal pull-through (EPT) via a perineal approach using a prolapsing technique (PA) for Hirschsprung’s disease (HD) has been reported. However, the clinical outcome after this approach has not been reported. The purpose of this study was to compare the clinical outcome of PA and the conventional transabdominal approach (TA).

Methods

In the period between 1990 and 2001, 20 cases of HD underwent EPT with TA (group O), and 21 underwent EPT with PA (group L). There was no difference in age and weight distribution between the 2 groups. Clinical outcome was assessed 3 years after surgery.

Results

The operation time was comparable in the 2 groups (4.9 ± 0.8 v 5.2 ± 0.8 hr), whereas blood loss (98 ± 52 v 36 ± 30 mL) and postoperative complications requiring surgical intervention (26% v 0%) were significantly lower in group L. The incidence of postoperative enteritis (27% v 28%) and voluntary defecation (more than once every/2 days) were compatible in the 2 groups (70% v 87%). Soiling (small amount of involuntary stooling; >1 per month) was significantly less frequent in group L (45% v 14%).

Conclusions

Laparoscopically assisted ETP with PA is less invasive and can provide a better clinical outcome compared with TA in terms of postoperative soiling.     

多节段颈椎间盘突出症的前后路手术疗效比较

目的　比较多节段颈椎间盘突出症颈椎前后路手术疗效。　方法　回顾性总结 1999年以来治疗的 5 6例多节段颈椎间盘突出症病例 ,其中前路手术组 37例 ,采用摘除病变椎间盘、选择性椎体次全切除、植骨融合及前路钢板固定 ;后路手术组 19例 ,采用全椎板减压、侧块钢板固定。　结果　前路手术者术后随访 6个月～ 4年 5个月 ,平均 2年 10个月 ;后路手术者随访 1年 5个月～ 5年 1个月 ,平均 3年 8个月。两组 JOA评分及硬脊膜囊矢状径比较术前差异无统计学意义 (P>0 .0 5 ) ,术后差异有统计学意义 (P<0 .0 1) ,前路手术组高于后路手术组 ;术后改善率前路手术组高于后路手术组 ,差异有统计学意义 (P<0 .0 1) ;并发症例数前路手术组略多于后路手术组。　结论　前路手术组疗效明显优于后路手术组。前路减压、植骨、钢板固定术是治疗多节段颈椎间盘突出症的有效方法     

Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism

BACKGROUND: Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach. METHODS: A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded. RESULTS: Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study. CONCLUSION: Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.     

改进的侧前方手术径路在胸腰椎爆裂性骨折中的应用

目的 探讨改进的侧前方手术径路减压内固定治疗胸腰椎爆裂性骨折的疗效. 方法 2003年4月至2006年9月利用胸腰段的解剖关系,改进成"L"形肌间隙经椎间孔入路行骨折减压内固定治疗胸腰椎爆裂性骨折,临床应用16例(改进径路组),并将11例经传统胸腹膜外入路(传统径路组)作为对照组,比较两组住皮肤切口到完全显露椎体出血量、手术时间及总出血量、疗效等方面的差异,并观察术中、术后并发症情况. 结果 27例患者于术均获成功.所有患者获得6～26个月(平均13个月)随访.改进径路组从皮肤切口到完全显露椎体的出血量平均为(80.0±56.5)mL,总出血量平均为(450.0±273.1)mL,手术时间平均为(119.0±35.5)min;传统径路组从皮肤切口到完全显露椎体的出血量平均为(350.0±145.5)mL,总出血量平均为(900.1±421.3)mL,手术时间平均为(193.2±48.3)min,两组上述指标比较差异均有统计学意义(P<0.05).两组在Cobb角改善、伤椎前缘高度比值及神经功能恢复差异均无统计学意义(P>0.05).两组术中均无严重并发症发生,无截瘫加重、植骨块塌陷及高度丢火现象,无假关节肜成和内固定失败. 结论改进的"L"形肌间隙经椎间孔径路行胸腰椎爆裂性骨折侧前方减压入路简捷,出血少.既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸腹膜损伤等并发症.     

Two cases of meningococcal purpura fulminans: the ‘less is more’ approach

This study presents a case series of patients with meningococcal purpura fulminans who were treated at a tertiary referral centre within a few days of each other. Presenting with signs and symptoms of florid meningococcal sepsis, they were managed initially by physicians and intensivists, whereas the development of large purpuric areas and tissue necrosis was managed expectantly by plastic surgeons. When the patients were deemed to have recovered clinically and the necrosis delineated, surgical management was implemented with subsequent involvement of various rehabilitation services. This article highlights the cases of two patients, and their clinical presentation, management and rehabilitation together with a current literature review on this area.     

腹腔镜完全腹膜外与经腹腹膜前疝修补术临床对照分析

目的比较腹腔镜完全腹膜外疝修补术(TEP)和腹腔镜经腹腹膜前疝修补术(TAPP)治疗腹股沟疝的安全性和有效性。方法回顾性分析2003年1月至2004年6月TEP 30例(36例次)以及同期TAPP 61例(64例次)临床资料。比较两组平均手术时间、术后平均住院时间、术后并发症、术后复发以及治疗费用。结果平均手术时间和术后住院时间TEP组分别为(58.33±13.60)m in和(5.23±1.85)d,TAPP组为(63.28±20.04)m in和(5.87±1.52)d,两者差异无显著性(P>0.05)。术后并发症TEP组5例,TAPP组13例,两组差异无显著性(P>0.05)。术后平均随访时间TEP组13(3~21)个月,TAPP组为14(4~23)个月;TEP组无复发病例,TAPP组有2例复发。平均手术费用TEP组为(6 359.32±596.86)元,TAPP组为(8 298.18±713.83)元,两者差异有显著性(P<0.01)。结论TEP与TAPP治疗腹股沟疝均安全有效;TEP相对TAPP手术费用更低,临床推广更具优势。     

下腔静脉型布加综合征合并下腔静脉血栓形成的治疗及随访分析

目的探讨下腔静脉（inferior vena cava,IVC）型布加综合征（Budd-Chiari syndrome,BCS）合并IVC血栓形成的治疗方法、疗效及预后。方法回顾性分析2004年4月至2012年6月期间因膜性或短段闭塞性IVC型BCS合并IVC血栓形成于郑州大学第一附属医院行介入治疗的128例患者的临床资料,比较行小球囊预开通治疗及可回收支架治疗患者的疗效。结果 128例患者中,9例行搅拌溶栓治疗（搅拌溶栓组）,56例行小球囊预开通治疗（预开通组）,63例行可回收支架治疗（可回收支架组）。除可回收支架组有1例患者于术中发生支架断裂、行外科手术外,其余127例患者的介入手术均成功。术后可回收支架组发生支架移位2例,余2组无并发症发生。预开通组与可回收支架组的尿激酶用量、溶栓时间、住院时间以及总并发症发生率比较差异均无统计学意义（P〉0.05）,但可回收支架组的住院费用高于预开通组（P〈0.01）。术后128例患者均获访,随访时间18-66个月,平均44.2个月。随访期间,搅拌溶栓组有1例、预开通组有6例、可回收支架组有6例患者发生原闭塞处的再次狭窄闭塞,预开通组与可回收支架组的再次狭窄闭塞率比较差异无统计学意义（P〉0.05）。复发患者经再次扩张治疗后未再发生管腔狭窄和血栓形成。结论搅拌溶栓技术治疗IVC型BCS合并IVC新鲜血栓形成安全而有效;小球囊预开通技术及可回收支架技术治疗IVC型BCS合并IVC陈旧性血栓形成的效果满意,且前者更经济。     

肝细胞癌合并下腔静脉癌栓的手术治疗

目的 探讨肝细胞癌(简称肝癌)合并下腔静脉癌栓的手术治疗方法。方法 采用肝切除 腔静脉取栓治疗4例肝癌合并下腔静脉癌栓患者,取栓方法包括经荷栓肝静脉取栓(1例)和下腔静脉切开取栓(3例),后者又分在全肝血流阻断下取栓(2例)和在萨氏钳局部血管阻断下取栓(1例)。结果 4例肝癌及下腔静脉癌栓均得到成功切除,术中无明显并发症发生;术后除l例发生中等量胸水外,无其他并发症发生;随访中3例已死亡,分别生存30、10和14个月;1例尚存活,已生存7个月。结论 肝癌合并下腔静脉癌栓的手术治疗安全可行,其基本术式为肝切除 下腔静脉切开取栓。