尿道下裂修复中非手术技术因素对疗效的影响

目的:探讨尿道下裂手术修复中的非手术技术因素对手术效果的影响。方法:将1999年1月~2006年1月收治的285例尿道下裂患者,以2003年1月为界限分为两组,比较两组的手术效果,分析非手术技术与疗效的关系。结果:2003前组治疗尿道下裂165例,平均住院时间18d;出现尿瘘17例,并发尿道外口狭窄6例、吻合口狭窄3例、尿道长段狭窄1例,尿囊形成5例。总手术成功率为81%。2003后组共治疗尿道下裂120例,平均住院时间12d;术后近期出现尿瘘5例,其中3例在术后3个月内自行愈合;并发尿道外口狭窄并尿囊形成1例,尿道外口狭窄2例、吻合口狭窄1例。总手术成功率为95%。结论:术中优化非手术技术因素(如:废除膀胱造瘘,容易更换敷料,不用拆线等)能减轻患者痛苦,提高手术成功率。     

An audit of failed non-operative management of abdominal stab wounds

Selective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures.

Methods

The metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12 h) there is little additional morbidity. Recognition of the need for surgical intervention after 12 h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time.

Results

A total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12 h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3).

Conclusion

Clinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12 h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.     

非手术治疗急性外伤性脾破裂37例分析

目的探讨用非手术方法治疗急性外伤性脾破裂的可行性及适应症选择。方法回顾性分析我院1989年7月至2008年8月间用非手术方法治疗37例急性外伤性脾破裂的临床资料及治疗结果。结果37例病人均经腹部超声检查或CT检查明确诊断，其损伤分级为Ⅰ级损伤27例，Ⅱ级损伤9例，Ⅲ级损伤1例，有合并伤3例，经非手术治疗痊愈出院。结论用非手术方法选择性治疗急性外伤性脾破裂是一种较安全有效的治疗手段。     

RUPTURED SPLEEN IN THE ADULT: AN ACCOUNT OF 205 CASES WITH PARTICULAR REFERENCE TO NON-OPERATIVE MANAGEMENT

A series of 205 ruptured adult spleens, half of them due to personal assault, has been collected from several hospitals. In some of these cases a trial of non-operative management has become standard practice unless other abdominal injuries are suspected. One hundred and thirty-seven cases were managed this way initially, successfully so in 80%. Splenectomy was performed in 70 patients with eight deaths; three of them in the 27 instances where non-operative management was said to have failed. None of these eight deaths was due to operative delay.     

术后早期炎性肠梗阻疗效的长期随访分析（附121例报告）

目的 探讨术后早期炎性肠梗阻的治疗方法与长期随访结果。方法 回顾性分析1999年1月至2008年12月南京军区南京总医院解放军普通外科研究所治疗的术后早期炎性肠梗阻病人中随访121例的临床病例。该研究的主要和次要终点目标为因肠梗阻而手术和肠梗阻复发。结果 121例病人均采用非手术治疗而痊愈,随访2~116（43.23±12.75）个月,无一例因肠梗阻而再次手术治疗;14例（11.57%）病人发生肠梗阻复发,其中6例（4.96%）因症状明显需入院治疗。结论　长期随访结果表明,以非手术治疗为主的术后早期炎性肠梗阻,肠梗阻复发率低,手术不是肠梗阻复发病人的主要治疗手段。     

脉络宁硬膜外自控式注射配合手法治疗腰椎间盘突出症

目的探索脉络宁硬膜外腔自控式注射配合推拿牵引等手法综合治疗腰椎间盘突出症(LIDH)的疗效。方法选择符合纳入标准的LIDH患者156例,随机将患者分为4组:推拿牵引手法治疗组(TMM组,n=38)、脉络宁硬膜外注射+手法治疗组(MET组,n=40)、脉络宁硬膜外自控式注射+手法治疗组(MPT组,n=36)及西药硬膜外自控式注射+手法治疗组(WPT组,n=42)。分别记录4组治疗前与每个疗程后1 d、总疗程后1个月的疼痛视觉模拟评分(VAS)值;记录治疗前和治疗后1、3个月Oswestry功能障碍指数(ODI)分值,进行ODI疗效评价,并计算优良率及有效率。结果 MET、MPT、WPT 3组患者每个疗程结束后1 d及总疗程后1个月进行VAS值测定均比TMM组降低(P<0.01或<0.05),治疗后1、3个月临床疗效评定有效率及优良率均优于TMM组(P<0.01或<0.05),但MPT、WPT组更佳(P<0.01),且疗效稳定。结论脉络宁硬膜外自控式注射配合推拿牵引等手法治疗LIDH,可使治疗周期缩短、避免多次应用类固醇激素药,且疗效稳定,该方法是其他保守疗法效果不佳又惧怕手术的LIDH患者的一种良好选择。     

Non-operative management of isolated liver trauma

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.     

One-Year Results of Prospective Research Study Using 10 kHz Spinal Cord Stimulation in Persistent Nonoperated Low Back Pain of Neuropathic Origin: Maiden Back Study

PurposeSpinal cord stimulation (SCS) is a recommended treatment for chronic neuropathic pain. Persistent nonoperative low back pain of neuropathic origin has profound negative impacts on patient’s lives. This prospective, open label, research study aimed to explore the use of SCS in patients with associated features of central sensitisation such as allodynia and hyperalgesia.Materials and MethodsTwenty-one patients with back pain and hyperalgesia or allodynia who had not had prior spinal surgery underwent a SCS trial followed by full implantation. SCS comprised administering electrical impulses epidurally at a frequency of 10 kHz and pulse width of 30 μsec. Patients attended follow-up visits after 6 and 12 months of SCS. Repeated measure ANOVAs/Friedman tests explored change after 6 and 12 months of 10 kHz SCS. Independent sample t-tests/Mann–Whitney U tests examined differences in response after 12 months of 10 kHz SCS.ResultsBack and leg pain, quality of life (QoL), pain-related disability, and morphine equivalence significantly improved compared with baseline following 6 and 12 months of 10 kHz SCS. There were no increases in the consumption of opioids, amitriptyline, gabapentin or pregabalin in any patient. After 12 months of treatment, 52% encountered ≥50% improvement in back pain, 44% achieved remission (0–3 cm back pain VAS), 40% reported ODI scores between 0 and 40 and 60% experienced a reduction of at least 10 ODI points. Patients reporting ≥10-point improvement in ODI had significantly longer pain history durations and experienced significantly greater improvements in back pain, leg pain and QoL than those reporting <10-point improvement in ODI.ConclusionThe 10 kHz SCS improved back and leg pain, QoL, pain-related disability and medication consumption in patients with nonoperative back pain of neuropathic origin. With further research incorporating a sham control arm, the efficacy of 10 kHz SCS in this patient cohort will become more established.     

刚果（金）中国维和二级医院输尿管结石18例的诊治特点

目的：探讨输尿管结石在刚果（金）中国维和二级医院的诊治特点.方法：对2008-11/2009-03入院的18例输尿管结石患者,先通过B超及尿常规反复动态检查明确诊断,然后实施非手术的综合治疗.结果：18例患者均诊断明确,治疗后13例将结石排出,治愈率72%,其余5例疼痛症状缓解.结论：在刚果（金）医疗条件较差的环境下,通过反复动态的泌尿系B超及尿常规检查,可明显提高输尿管结石的确诊率.提示非手术疗法是治疗输尿管结石的有效手段之一,可以在这一地区推广使用.