重症心脏瓣膜病的外科治疗

目的 总结重症心脏瓣膜患者围术期处理及外科手术经验,提高患者的治愈率.方法 回顾性研究1999年9月至2004年10月外科治疗78例重症心脏瓣膜患者的围术期处理、术中心肌保护及术中手术方法.结果 78例中75例治愈;发生并发症13例：低心排综合征5例、活动性出血二次开胸止血3例、脑栓塞2例、迟发性心脏破裂1例、肾功能不全1例、肺部感染1例,其中死亡3例.结论 加强围术期处理,采用冷-温血心肌保护液,选择双叶瓣、保留左房室瓣瓣下结构或左房室瓣后瓣及瓣下结构,延长辅助呼吸时间,重症心脏瓣膜病亦可取得良好的手术效果.     

氯诺昔康静脉自控镇痛与吗啡硬膜外自控镇痛的临床比较

目的 比较骨科手术后患者氯诺昔康静脉自控镇痛（PICA）与吗啡硬膜外自控镇痛（PCEA）的临床效果和不良反应。方法 100例ASAⅠ～Ⅱ骨科择期手术患者随机分为两组：PICA（n=50）和PCEA组（n=50）。PICA组于手术结束前约30min静注氯诺昔康8mg和恩丹西琼（恩丹西酮）4mg后连接镇痛泵（48mg氯诺昔康＋生理盐水至100m1）；PCEA组于手术结束前约30min硬膜外腔注入吗啡1mg和恩丹西酮4mg加生理盐水至10ml后连接镇痛泵（9mg吗啡＋布比卡因150mg＋生理盐水至100m1）。连续量为2ml／h，自控量为0．5ml／15min。术后连续监测BP、RR、ECG、Sp02，定时观察记录视觉模拟评分法（VAS）及恶心呕吐、嗜睡、多汗、皮肤瘙痒等不良反应的发生情况。结果 两组术后4h、8h、16h、20h、24h、32h和48h各时间点的VAS评分吗啡PCEA组略低于氯诺昔康PICA组，但差异无显著意义（P〉0．05）。恶心、呕吐、嗜睡、多汗、皮肤瘙痒发生率PCEA组明显多于PICA组（P〈0．05）。结论 骨科手术后氯诺昔康PICA与吗啡PCEA均有良好的镇痛效果，但氯诺昔康PICA组不良反应较少，值得临床推广应用。     

腹部闭合性创伤163例诊治报告

目的探讨提高腹部创伤的诊治成功率的措施。方法对163例腹部闭合性创伤的临床资料进行回顾性分析总结。结果治愈154例（94．5％）．死亡9例（5．5％），死于失血性休克3例，多器官功能衰竭4例，严重颅脑外伤2例。结论早期迅速而准确的诊断及细致有效的手术探查是提高抢救成功率的关键。     

Iatrogenic dissection of the portal vein during TIPS procedure

Dissection of the portal vein is a rare entity which has been rarely described during transjugular intrahepatic portosystemic shunt (TIPS) procedure. We report three cases of dissection during this procedure and their complications. One dissection was immediately treated with coaxial stents. The two others were complicated either by a thrombus or by a false aneurysm. In the first case a second parallel stent was used to treat this complication. The patient with the portal vein false aneurysm was transplanted 4 days after this diagnosis. Portal vein dissection in TIPS procedure appeared to be less rare than has been reported and must be considered as a potential cause of TIPS dysfunction. Received: 5 May 1999; Revised: 14 July 1999; Accepted: 14 July 1999     

Day-case laparoscopy: a comparison of prophylactic opioid, NSAID or local anesthesia for postoperative analgesia

BACKGROUND: The study was aimed to evaluate the analgesic efficacy, postoperative comfort, recovery characteristics and side effects of three different analgesic agents administered prophylactically. METHODS: Eighty patients undergoing day-case minor operative laparoscopy were randomly allocated into four groups to receive tenoxicam 20 mg i.v. (Group T), fentanyl 100 microg i.v. (Group F), 5 ml of bupivacaine 2.5 mg/ml for infiltration of trocar sites (Group B), 30, 10 and 5 min before incision respectively. Bupivacaine, 35 ml, 2.5 mg/ml was also administered into the pelvic cavity in Group B. Group P received only placebo. Postoperative pain, analgesic requirements, first response to verbal stimulus, first analgesic requirement, ability to walk without help, to drink and to void, blood pressures, SpO2 and respiration rates were recorded in the PACU. Postoperative pain was evaluated by verbal rating scale. Pain scores, analgesic requirements and side effects were evaluated by telephone calls until the 48th postoperative hour. RESULTS: Postoperative pain scores were lower and time to requirement of rescue analgesics was longer in groups F and B compared to Group P. In the PACU, analgesic requirements were lower in Group B, compared to Group P. Nausea and vomiting were increased in Group F. CONCLUSION: Tenoxicam 20 mg i.v. was found to be ineffective whereas bupivacaine was superior to other groups in reducing pain and analgesic requirements. Bupivacaine also increased time to first analgesics and obtained better recovery characteristics, underlining its value in prophylactic pain management compared to the other two agents.     

下咽环周缺损重建方法的选择

目的 比较下咽环周缺损的两种主要重建方法,即游离空肠移植术(简称游离空肠)和胃上提咽胃吻合术(简称咽胃吻合)的优缺点。方法 回顾性分析1979年7月-2002年7月行喉全切除下咽全切除的晚期下咽癌或喉癌复发患者共125例的资料,其中采用咽胃吻合术式92例,游离空肠术式33例。结果 咽胃吻合组出现并发症40例(43％),手术死亡10例(11％),游离空肠组并发症7例(21％),没有手术死亡病例,两组差异有显著性(P值分别为0.023和0.048)。多因素分析发现与重建有关的并发症发生的危险因素分别是:咽胃吻合术式(风险比2.97;95％可信区间1.14;7.76)和术前血浆白蛋白水平<40.0g/L(风险比2.87;95％可信区间1.33;6.16)。咽胃吻合组发生进食反流或梗阻的比例(76％)明显高于游离空肠组(12％),差异有显著性(P=0.00)。前者术后体重平均下降3.3 kg(95％可信区间-5.7;-1.0),后者术后体重平均增加了2.8kg(95％可信区间0.9;4.7)。结论 选择游离空肠术的患者手术死亡率、外科并发症均明显低于咽胃吻合术的患者,游离空肠组生活质量明显好于咽胃吻合组的患者。建议下咽环周缺损重建首选游离空肠移植术。     

上颌骨外旋入路切除颅底及咽旁间隙肿瘤

目的：探讨颅底及咽旁间隙肿瘤切除的最佳手术入路。方法：2例咽旁间隙肿瘤、1例颅底肿瘤患者均采用上颌骨外旋入路，取Weber-Ferguson-Longmire切口，形成以咬肌为蒂的上颌骨肌皮瓣并外旋，充分暴露鼻咽部及咽旁间隙，直视下完整切除肿瘤。以颊部脂肪堵塞残留空腔，行上颌骨骨瓣复位。结果：3例术后切口愈合良好，颌面部无明显畸形及颌面功能障碍，其中1例术后行放疗。3例术后随访10个月～2年，肿瘤均无复发。结论：上颌骨外旋是切除颅底及咽旁间隙肿瘤的较佳手术入路，能充分暴露颅底及咽旁间隙、鼻咽部，在直视下完整分离切除肿瘤，手术安全，损伤小，术后功能恢复良好。     

Nephrolithiasis associated with autosomal dominant polycystic kidney disease: contemporary urological management

PURPOSE: We evaluate the role of contemporary urological intervention in patients with nephrolithiasis associated with autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: Intervention for upper tract stones associated with autosomal dominant polycystic kidney disease was performed in 5 women and 2 men 29 to 65 years old (mean age 47). Indications for intervention consisted of flank pain in 6 patients and/or hematuria in 2. A total of 12 procedures (mean 1.7 per patient) were performed, including shock wave lithotripsy in 6 patients, percutaneous nephrolithotomy in 2, retrograde endoscopy or manipulation in 3 and extended pyelonephrolithotomy in 1. RESULTS: All patients were rendered stone-free or had only residual "dust." Hospital stay for 5 patients was 1 night or less and there were no complications. Renal function for each patient was stable or improved as measured by serum creatinine. CONCLUSIONS: Most patients with autosomal dominant polycystic kidney disease who require intervention for nephrolithiasis can be safely and effectively treated with essentially any or all contemporary, minimally invasive techniques. The choice of intervention can be based primarily on size and location of the upper tract stones rather than the associated presence of polycystic kidneys.     

Clinical Features and Surgical Treatment of A-pattern Exotropia

IntroductionAnA鄄patternexotropiashowssignificantlymoreexodeviationindowngazeversusupgaze,inwhichthechangeofbinocularalignmentresemblesthealphaberA.Accordingtopublishedreports[1～4],A鄄patternexotropiaisviewedastheleasttypeofAandVpatterns.However,thepr鄄evalenceofA鄄patternexotropiaratherincreasedinourclinicalstudies[5],inwhichparticularattentionwaspaidtoobservethedeviationindownwardgazeandassesssuperiorobliquefunction.Accordingly,clinicalcharacteristics,surgicaltreatmentandtreatmentoutcome…     

The modern endoscopic approach to ureterocele

PURPOSE: During the last 20 years the surgical approach to ureterocele has evolved from major open surgery to minimally invasive endoscopic puncture. We believe that the endoscopic approach decreases the need for open surgical procedures. We identified specific factors that predict the need for repeat surgery. MATERIALS AND METHODS: We reviewed the charts of 60 new patients with ureterocele treated with primary endoscopic incision between 1991 and 1995. Followup ranged from 4 to 62 months (mean 20). Mode of presentation, ureterocele location, associated vesicoureteral reflux and association of the ureterocele with a duplex system were evaluated. Ureterocele wall thickness was assessed subjectively via radiographic and cystoscopic methods, and categorized as thin, intermediate and thick. RESULTS: All 9 patients with a single system ureterocele had an intravesical ureterocele. No patient had associated reflux nor did any require a secondary open procedure. In 3 cases new onset ipsilateral reflux into the ureterocele spontaneously resolved. Of the 51 patients with a duplex system and associated ureterocele 19 (37%) required a secondary open procedure. The ureterocele was intravesical and ectopic in 22 (43%) and 29 (57%) cases, respectively. Reflux was associated with the ureterocele in 27 patients (53%), and 12 (44%) required a secondary open procedure. A total of 11 patients underwent ureteral reimplantation of 15 refluxing renal units and only 2 renal units required ureteral tapering. Reflux is no longer present in 14 of the 15 renal units (93%). Patients with a thick walled ureterocele required repeat puncture more frequently than those with a nonthick ureterocele. CONCLUSIONS: With the use of modern endoscopic techniques children with intravesical and single system ureteroceles require secondary open surgery less frequently than those with ectopic and duplex system ureteroceles. The mode of presentation does not predict the need for a repeat open procedure. Thick walled ureteroceles require repeat endoscopic puncture more frequently than thin and intermediate walled ureteroceles.