涉及全椎骨之脊柱肿瘤的外科治疗

本文报告了4例涉及椎体及其后部结构的全椎骨肿瘤的外科治疗,介绍了全椎骨切除术的手术方法及手术注意事项。手术采用后路附件切除,上下椎体Steffee钢板内固定,前路椎体切除自体髂骨植骨融合,初步效果满意。本手术难度大、出血多、危险性高,术中采用控制性低血压,以减少出血。     

Some practical perspectives for educating gifted children

This article identifies common characteristics of educationally related programs that form a common basis for understanding and working with gifted programs. Special approaches and programs for educational enrichment as well as specific activities that have been successful are discussed.     

The effects of training, immobilization and remobilization on musculoskeletal tissue

Compared with the knowledge on immobilization, the effects of remobilization on musculoskeletal tissues have not been well established. What is sure is that remobilization and rehabilitation of any component of the musculoskeletal tissues require much more time than the time needed to cause the immobilization atrophy. With intensive rehabilitation, the functional properties of skeletal muscles can be improved significantly even years after the injury and following immobilization, but no study has shown whether full recovery is possible and whether these rehabilitated muscles are able to respond normally to further training. Experimental studies have given evidence that slow-twitch muscle fibres have better capacity for recovery than fast-twitch fibres, most likely due to better circulation and higher protein turnover. Also evidence has been given that fibre regeneration is possible through satellite cell activation and myotube formation. Very little is known, however, about the effects of age, gender or the level of preimmobilization muscle performance on the restoration capacity. Also the fate of the marked structural changes (for example, connective tissue accumulation) induced by immobilization is unknown. Tendon and ligament tissues are likely to respond appropriately to remobilization, resulting in acceleration of collagen synthesis and fibril neoformation. However, there is a strong suspicion that remobilized tendons and ligaments will not achieve all the biochemical and biomechanical properties of their healthy counterparts. Specifically, the amount of weak type III collagen has been shown to be overrepresented in these tissues instead of mature, strong type I collagen. It is not known whether this is an important risk factor for ruptures during later activity. The effects of remobilization on muscle-tendon junction and proprioceptive organs are not known. It would not be surprising if the serious structural changes induced by immobilization were unrestorable. In the literature dealing with immobilization and remobilization, cartilage degeneration is always a major concern, because not only too strenuous training or immobilization, but also unskilful remobilization may activate this process leading finally to osteoarthrosis. Bone may be one of the best components of musculoskeletal tissues to respond to remobilization, probably because the immobilization atrophy of bone is largely quantitative (osteoporosis) only. The prerequisites for bony recovery are that the follow-up time is long enough (months) and that immobilization has not exceeded about 6 months, the time limit between active and inactive (irreversible) osteoporosis. Prevention of the atrophying effects of immobilization can be very successful if performed properly. According to present knowledge, there are many methods for the purpose, including preimmobilization training early, controlled mobilization; optimal positioning of the immobilized joint; muscular training during immobilization; early weightbearing; exercise with the nonimmobilized extremity; and electrical stimulation. Lots of education and information will be needed, however, before these methods are deeply rooted in the daily routines of the attending physicians, physical therapists, athletic trainers and other persons involved in the treatment of musculoskeletal problems.     

The callous elbow and aging of the upper arm

The author describes his surgical approach to the problems of the aging upper arm and elbow region. Surgery at an appropriate age can prevent the progressive wrinkling of the elbow which is further aggravated by aging of the upper arm. The author's operation is aimed at correcting both portions of the arm anatomy at the same time.     

局部晚期非小细胞肺癌外科治疗中的气道重建

背景与目的部分局部晚期非小细胞肺癌患者需要采取不同的气道重建方式，以彻底切除病变并最大限度保存肺功能。本研究旨在探讨气道重建中的外科相关问题。方法回顾分析研究2003年1月～2005年6月2206例肺癌手术中100例气道重建患者的临床资料，其中鳞癌42例，腺鳞癌23例，腺癌11例，粘液表皮样癌5例，腺样囊性癌4例，类癌3例及其它混合散在分布类型12例。ⅠB期34例，ⅡB期23例，ⅢA期23例，ⅢB期20例。主要手术方式包括：右上叶袖状切除42例，右下叶袖状切除1例，左上叶袖状切除24例，左下叶袖状切除4例。两叶袖状切除8例，隆凸成形重建17例，肺叶袖状切除合并肺动脉成形4例。结果97例患者为完全性切除（R0），3例为不完全性切除（R1）。术后5例出现并发症，分别为肺部感染2例，胸腔感染1例，支气管胸膜瘘1例，肺泡胸膜瘘1例，并发症发生率为5％。术后住院日为4～27日（中位11日）。99例治愈出院，肺部感染导致死亡1例，手术死亡率为1％。结论对局部晚期非小细胞肺癌采取适当的气道重建方式，符合外科手术原则，可取得较满意的治疗效果。对血管、气管、支气管的处理技巧是手术获得成功的关键。     

A review of incisional hernia repairs: preoperative weight loss and selective use of the mesh repair

At the Shouldice Clinic pre-operative weight loss is used prior to incisional hernia repairs. Mesh repair is selectively used, based on specific hernia characteristics. A series of 236 patients were reviewed and followed up for 36 months. Data were available on 188 patients (80%). There were 15 recurrences (8%). The number of obese patients was reduced from 67 (35.6%) to 25 (13.3%) through the weight loss program. The hernia diameter, gastrointestinal complications, and surgical site infection were significantly related to recurrence but not the type of repair, obesity, location, or previous recurrences. The risk factors of incisional hernias include size, intestinal complications and infections. A selective use has a comparable result to the exclusive use of mesh repair. Weight reduction has yet to be shown to affect the rate of recurrence, and further prospective studies are required.     

后腹腔镜手术治疗嗜铬细胞瘤

目的探讨后腹腔镜手术治疗嗜铬细胞瘤的适应证及手术安全性. 方法采用后腹腔镜手术治疗肾上腺嗜铬细胞瘤患者15例(双侧2例),腹主动脉旁嗜铬细胞瘤1例.对照组为开放手术治疗的肾上腺嗜铬细胞瘤16例,腹主动脉旁嗜铬细胞瘤1例.结果后腹腔镜手术组16例患者行后腹腔镜手术18例次,17例次取得成功,1例因术中出血改行开放手术.肿瘤最大径2.0～6.5(3.8±1.6)cm.手术时间45～150(85±31)min,出血量10～100(32±22)ml.术后吗啡用量0～40(12.5±7.8)mg;术后恢复进食时间1～3(1.8±0.7)d;下床活动时间2～3(2.3±0.5)d;术后住院时间4～9(6.5±1.3)d.开放手术组肿瘤最大径1.5～6.0(4.3±1.3)cm.手术时间90～240(155±39)min,出血量50～600(273±105)ml,9例输血.术后吗啡用量10～120(61±24)mg;术后恢复进食时间2～4(2.9±0.5)d;术后下床活动时间3～6(4.8±0.7)d;术后住院时间8～11(8.8±0.9)d.结论对于有一定腹腔镜手术经验者,后腹腔镜手术并不增加嗜铬细胞瘤手术的危险性,且具有手术时间短、出血少、创伤小、疼痛轻、康复快等优点.该法有望成为治疗肾上腺嗜铬细胞瘤的首选手术方法.     

Implications of remarriage and stepfamily formation for marriage education*

Couples in remarriages with stepchildren are a significant portion of the marriage population and have unique educational needs regarding aspects of couple functioning within the context of stepfamily development. From a review of the literature, we examine current curricula focused on these couples. Information is offered on implementation issues regarding recruitment, delivery context, facilitator and participant characteristics, and evaluation.     

Breast augmentation with silicone implants: the role of surgical drainage—report on 502 consecutive patients

Breast augmentation is one of the most frequently performed cosmetic surgery procedures worldwide. We report on a series of 502 consecutive cosmetic breast augmentations by a single surgeon, using both the submuscular and submammary approaches. A vacuum drain was placed in the surgical pocket at the end of the procedure. The drain fluid collection was recorded immediately after the surgery and the following day before removal. A tenfold increase in the amount of fluid collection was noted in the drain’s reservoir. Thirteen patients presented with minor wound healing problems at the second postoperative follow-up, which were treated conservatively; two of them had the implant removed and replaced after 2 months. There were only two capsular contractions at 1-year follow-up. We focus our discussion on the drainage in the early postoperative period and conclude that the routine use of a surgical drainage reduces the risk for complications. Based on our findings, we advocate that short-term routine use of a surgical drain is advisable.     

MRI测量颈胸角在选择颈胸段脊柱手术入路中的临床应用

目的 :探讨在颈胸段脊柱术前应结合患者的颈胸段MRI的个体特征和疾病情况 ,选择手术创伤最小的手术入路。方法 :共 76例患者 ,其中 2 6例为颈胸段脊柱损伤 ,35例为颈胸段脊柱肿瘤 ,脊髓型颈椎病 12例 ,以及 3例颈胸段椎板减压术后后凸畸形。男 4 7例 ,女 2 9例。平均年龄 4 5 5岁 ,年龄范围 19～ 6 5岁。同时抽取 95套颈胸段MRI片。作胸骨上切迹向后水平延长线和胸骨上切迹向后上方至C7T1椎间盘前缘中点的连线 ,测量两线之夹角 ,称为颈胸角 (cervicothoracicangle ,CTA)。结果 :CTA平均为 4 7 6 4°(范围 2 5°～ 73°)。大于此平均角度且病灶在胸骨切迹水平线以上时可考虑低位下颈椎入路 ,5 0例 ;CTA较小 ,且病灶范围广 ,或尚累及T3 、T4,可以考虑经胸骨柄入路 ,13例 ;病灶范围广泛 ,经全胸骨入路 3例 ;Ⅰ期或Ⅱ期前后联合入路 5例 ;经右侧肩胛下后外侧胸腔入路 5例。结论 :颈胸段脊柱手术应尽量选择低位下颈椎入路等创伤较小的入路 ,其次考虑经胸骨柄入路。长节段脊柱受累的患者才考虑经右侧肩胛下后外侧胸腔或经全胸骨等创伤较大的入路。术前可以结合患者的病灶累及范围和颈胸手术角等MRI影像学表现 ,从而利于选择最合适的手术入路 ,减少手术风险、手术创伤和并发症 ,利于患者早日康复