洁尔阴洗液保留灌肠在环状混合痔术后的临床应用

为观察洁尔阴洗液保留灌肠在环状混合痔术后应用的临床疗效,将70例行外剥内扎术治疗的环状混合痔患者随机分为两组,各35例,一组术后予洁尔阴洗液保留灌肠（治疗组）,一组术后予1：5000高锰酸钾溶液保留灌肠（对照组）,每晚1次,对比分析两组患者疗效及术后第4天、第8天疼痛和水肿程度。结果显示,两组总有效率均为100％,差异无统计学意义,P〉0．05。但治疗组术后第4天和第8天疼痛及水肿程度明显低于对照组,P〈0．05或P〈0．01。结果表明,洁尔阴洗液保留灌肠用于混合痔外剥内扎术后疗效肯定,可以明显减轻术后疼痛及水肿。     

枸橼酸舒芬太尼喷鼻用于术后镇痛的临床观察

目的探讨枸橼酸舒芬太尼喷鼻用于术后镇痛的有效性和安全性。方法选取50例ASAⅠ或Ⅱ级椎管内麻醉下腹部手术后的女性患者,将枸橼酸舒芬太尼经鼻腔给药,每位患者左右各1喷（每喷量为100μL,2喷含舒芬太尼10μg）,观察各时间点的疼痛评分、血压、心率、SpO2和不良反应。结果舒芬太尼喷鼻后,94%的患者术后疼痛得到明显的缓解,5～10 min后疼痛明显减轻,30 min时接近最大镇痛效应,有效时间至少持续120 min,HR、SBP、DBP、SpO2无显著变化,未发生明显不良反应。结论枸橼酸舒芬太尼喷鼻用于术后镇痛,疗效确切,效果显著。成人10μg/次（2喷）的舒芬太尼是比较合适的剂量,未发生明显不良反应。     

全膝关节置换术后膝关节疼痛的临床处理

目的 探讨全膝关节置换术(TKA)后膝关节疼痛的原因和临床处理方法.方法 2004年1月至2009年6月,收治TKA术后疼痛患者41例,其中男性9例9膝,女性32例35膝;年龄51～84岁,平均63.5岁.关节外疼痛6例中1例为1型复杂区域疼痛综合征(CRPS-1)行保守治疗,其余5例手术治疗.关节内疼痛35例中关节失稳4例、髌骨低位1例、假体悬挂致周围软组织磨损2例、胭肌腱撞击1例采用保守治疗,其余27例手术治疗.定期随访并记录膝关节美国膝关节学会评分(KSS评分)、疼痛视觉模拟评分(VAS评分).结果 41例均获随访,随访时间1～6年.关节外疼痛手术5例,末次随访VAS评分、KSS临床和功能评分分别为2.5±0.2、92.8±2.6和89.0±3.4,膝关节疼痛缓解,功能改善.1例CRPS-1保守治疗,效果尚可.关节内疼痛感染组12例中截肢1例、抗生素骨水泥隔体植入3例、二期翻修8例,随访感染均治愈,术后VAS、KSS临床和功能评分分别为3.8±0.2、88.3±4.6和85.0±4.6,和术前相比差异有统计学意义(P＜0.05).非感染组保守治疗8例,末次随访VAS、KSS临床和功能评分4.5±0.4、85.4±4.2和84.2±2.3;手术治疗15例,末次随访VAS、KSS临床和功能评分3.4±0.1、86.6±5.4和87.1±2.4,与术前相比差异有统计学意义(P＜0.05).结论 TKA术后疼痛需要对手术和患者情况进行系统评估以明确其原因,确诊后制定合理治疗方案一般可获得满意效果,确诊之前严禁手术干预.

Abstract：

Objective To evaluate causes and clinical management of postoperative pain after total knee arthroplasty(TKA). Methods From January 2004 to June 2009, 41 patients(44 knees)with knee pain post TKA were treated. There were 9 male and 32 female patients aging from 51 to 84 years with a mean of 63.5 years. The diagnosis followed to Brown diagnostic system. One case of extraarticular pain was complex regional pain syndrome type 1(CRPS-1)and underwent conservative treatment, the remaining 5cases were treated by surgery. Three cases of joint instability, 1 case of patellar baja, 2 cases of soft tissue impingement caused by overhang of the prosthesis, 1 case of popliteal tendon impact underwent conservative treatment, the other 27 cases underwent surgical intervention. The patients were followed up and the Knee Society Score(KSS)knee score, pain visual analog scale(VAS)score were recorded. Results Forty-one cases were followed up for 1 to 6 years. At the last time of follow-up, the 5 cases received surgical treatment to extra-articular pain showed VAS score as 2. 5 ± 0. 2, KSS clinical and functional score as 92. 8 ± 2. 6 and 89.0 ± 3.4. There was significantly difference compared with preoperative(P ＜ 0. 05). One case of CRPS-1 performed conservative treatment, the therapy was effective. In the infected 12 cases of intra-articular pain, 1 case received amputation, 3 cases received antibiotic bone cement insert, 8 cases received two stage revision. All infections were cured, and VAS score was 3. 8 ± 0. 2, KSS clinical score was 88. 3 ± 4.6,function score was 85.0 ± 4. 6 postoperatively, with significantly difference compared with preoperative(P ＜0. 05). In the 8 cases received conservative treatment in non-infected group, at the last time of follow-up,VAS score was 4. 5 ± 0. 4, KSS clinical and functional score was 85.4 ± 4. 2 and 84. 2 ± 2. 3, with significantly difference compared with preoperative(P ＜ 0. 05). Fifteen cases underwent surgical treatment,at the last time of follow-up, VAS score was 3.4 ± 0. 1, KSS clinical and functional score was 86. 6 ± 5.4and 87. 1 ± 2. 4, with significantly difference compared with preoperative(P ＜ 0. 05). Conclusions Patients with knee pain post TKA need systematic assessment to identify the causes. Appropriate treatment due to the positive diagnosis generally lead to satisfactory results, surgical intervention with indefinite causes is strictly prohibited.     

Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients

Background Context

There is a paucity of literature describing risk factors for adverse outcomes after geriatric lumbar spinal surgery. As the geriatric population increases, so does the number of lumbar spinal surgeries in this cohort.

Which is the best technique for hepatic venous reconstruction in pediatric living-donor liver transplantation? Experience from a single center

Background/purpose

The introduction of the piggyback technique for reconstruction of the liver outflow in reduced-size liver transplants for pediatric patients has increased the incidence of hepatic venous outflow block (HVOB). Here, we proposed a new technique for hepatic venous reconstruction in pediatric living-donor liver transplantation.

Methods

Three techniques were used: direct anastomosis of the orifice of the donor hepatic veins and the orifice of the recipient hepatic veins (group 1); triangular anastomosis after creating a wide triangular orifice in the recipient inferior vena cava at the confluence of all the hepatic veins (group 2); and a new technique, which is a wide longitudinal anastomosis performed at the anterior wall of the inferior vena cava (group 3).

Results

In groups 1 and 2, the incidences of HVOB were 27.7% and 5.7%, respectively. In group 3, no patient presented HVOB (P = .001). No difference was noted between groups 2 and 3.

Conclusions

Hepatic venous reconstruction in pediatric living-donor liver transplantation must be preferentially performed by using a wide longitudinal incision at the anterior wall of the recipient inferior vena cava. As an alternative technique, triangulation of the recipient inferior vena cava, including the orifices of the 3 hepatic veins, may be used.     

CYP2D6＊10等位基因多态性对胃癌术后曲马多镇痛效果的影响

目的：探讨中国人群CYP2D6＊10等位基因对胃癌术后曲马多镇痛效果的影响。方法：70例胃癌根治术患者,手术结束前30min静脉注入负荷剂量曲马多100mg,随后采用持续背景剂量-PCA量的给药模式（曲马多10mg/mL、甲氧氯普胺0.3mg/mL）进行术后镇痛。全麻诱导后抽取血样,采用聚合酶链反应-限制性片断长度多态性方法分析患者CYP2D6＊10基因多态性,根据不同CYP2D6基因型分为3组,比较不同基因组患者之间曲马多的用量。结果：CYP2D6＊10等位基因频率为52.4%,不携带CYP2D6＊10（I组）17例,CYP2D6＊10杂合子（II组）26例,CYP2D6＊10纯合子（III组）20例。48h曲马多用量,III组明显高于I组和II组,I组和II组之间差异无统计学意义。结论：在中国人群中,CYP2D6＊10等位基因对曲马多镇痛效果有显著影响。     

全膝关节置换术后止血带性缺血再灌注损伤的临床研究

目的 探讨全膝关节置换术(TKA)中使用止血带是否会导致缺血再灌注损伤,进而加重各项不良并发症。方法 2009年1月至2010年10月共收治52例拟行初次TKA的患者,采用随机数学表法分为2组：使用止血带组（A组）和未使用止血带组（B组）,每组26例。A组：男11例,女15例;年龄69 ～ 76岁,平均72.5岁。B组：男12例,女14例;年龄67 ～ 77岁,平均72.9岁。两组患者术前一般资料比较差异均无统计学意义(P＞0.05),具有可比性。术后股四头肌活检观测股四头肌肌肉的病理改变,记录并比较两组患者的术后肿胀程度、疼痛视觉模拟评分(VAS)、关节活动度及肌力。结果 A组病理切片示股四头肌溶解,大量中性粒细胞浸润;B组为正常肌肉组织。A组术后1、3、7及14d小腿肿胀程度、膝关节周径及股四头肌肿胀程度的增加率均显著大于B组,差异有统计学意义(P＜0.05)。A组术后6h、1d、3d、5d、7 dVAS疼痛评分明显高于B组,差异均有统计学意义(P＜0.05);而术后14d两组VAS疼痛评分差异无统计学意义(P＞0.05)。B组患者术后3d、7d、14d及1个月膝关节自主活动度均高于A组,术后1、3、7、14d直腿抬高度数也明显优于A组,差异均有统计学意义(P＜0.05)。结论 TKA中使用止血带可引起缺血再灌注损伤,进而加重各项不良并发症的发生。     

结肠代食管在食管切除术后消化道重建中的应用

目的 探讨结肠代食管用于食管切除术后消化道重建的安全性。方法回顾性分析1992年10月至2010年10月在四川省肿瘤医院胸外科接受结肠代食管手术的136例食管癌患者的临床资料。结果136例患者中118例利用左结肠动脉升支供血实施横结肠间置肠段顺蠕动：18例利用结肠中动脉供血,其中12例取右半横结肠和部分升结肠做成顺蠕动,6例取左半横结肠和部分降结肠做成逆蠕动。围手术期并发症发生率26．4％（36／136）,死亡率12．5％（17／136）．其中移植结肠穿孔5例,死亡4例;胸内吻合口瘘5例,均死亡;颈部吻合口瘘10例,无死亡病例：重症肺部感染10例,死亡4例;急性呼吸窘迫综合征7例,死亡3例;不明原因全身感染1例,死亡。术后远期并发症中,吻合口狭窄2例,反流2例,食物运行障碍3例。结论尽管结肠代食管术操作复杂、创伤较大、术后并发症发生率和死亡率均较高,但对于不能使用胃代食管的患者。结肠代食管仍是一种较好的选择。     

高危颈动脉狭窄患者的血管腔内治疗

目的探讨高危颈动脉狭窄患者血管腔内治疗的短期疗效和并发症预防。方法对41例高危颈动脉狭窄患者行颈动脉支架植入术,术前狭窄程度为75.0%～98.0%,狭窄长度1.3～3.6 cm,患者均合并一种或多种内科疾病。结果本组均采用脑保护伞及自膨式支架,操作均获得成功,术中颈动脉造影残余狭窄率≤30%。12例患者于术中出现一过性不同程度心率下降,1例患者支架释放后近端出现动脉夹层,1例患者在支架置入后出现失语及右侧肢体偏瘫,无脑出血,经保守治疗14天后症状缓解。随访33例患者,随访时间3～18个月。随访期间,1例死于恶性肿瘤,1例死于心肌梗死,2例出现支架内再狭窄,但无临床症状,其余患者支架无移位,支架内血流通畅,无脑缺血症状。结论对于高危患者,血管腔内治疗近期疗效较好,规范操作可减少并发症的发生。     

乌司他丁对老年髋关节置换患者术后并发症影响的病例对照研究

目的：探讨围手术期应用乌司他丁对老年髋关节置换患者术后并发症的预防作用。方法：自2009年8月至2010年6月,选择择期行髋关节置换术的老年患者160例,男81例,女79例;年龄65～83岁,平均73.9岁。按美国麻醉医师协会病情估计分级（ASA）属Ⅰ-Ⅱ级。采用随机数字表法将患者随机分为对照组（C组）和乌司他丁组（U组）,每组80例。U组手术切皮前一次性注射乌司他丁1万U/kg,术后l、2、3d缓慢静脉注射乌司他丁5000U/kg;C组只给予等量生理盐水。分别于术前1d、术毕及术后1、2、3d采血测定肝肾功能,包括谷丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、血肌酐（Scr）、尿素氮（BUN）和D二聚体水平,并于术后3d应用彩色多普勒超声检查下肢深静脉血栓（DVT）形成,简易智能状态检查法（MMSE）进行认知功能障碍（POCD）测试。结果：与术前比较,两组患者术后ALT、AST、Scr、BUN和D二聚体水平均升高;与C组比较,U组术后ALT、AST、Scr、BUN和D二聚体水平降低（P〈0.05）。术后3d,C组有32例形成DVT（40%）,22例发生POCD（27.5%）,U组无DVT发生,仅3例发生POCD（3.75%）。结论：围手术期应用乌司他丁能保护重要脏器功能,改善高凝状态,降低DVT和POCD的发生,一定程度预防术后并发症。