胸主动脉腔内修复体外开窗与选择性隔绝左锁骨下动脉的前瞻性队列研究

【摘要】目的 探讨胸主动脉腔内修复（TEVAR）体外开窗与选择性隔绝左锁骨下动脉的安全性和有效性。 方法 前瞻性队列研究分析 2012 年 9 月至 2017 年 10 月十堰市太和医院心脏大血管外科收治的 117 例胸主动脉病变患者的临床资料,根据左锁骨下动脉处理方式不同分为直接选择性隔绝LSA腔内修复组（endovascular exclusion,EE）和体外开窗LSA腔内修复组（invitro fenestration,IF）,比较两组患者的治疗效果和3年随访结果。结果 围术期结果上,EE组手术时间( 62.0 ± 5.4 )min短于IF组,脑梗塞、左上肢缺血发生率分别为7.14%（4/56）、10.71 % ( 6 / 56 )高于IF组,差异有统计学意义（ P 均＜ 0.05 ）;EE组的内漏、脊髓缺血、术后 30 天病死、支架覆盖T10发生率分别为 5.36 % （ 3 / 56 ）、 5.36 %（ 3 / 56 ）、 1.79 % （ 1 / 56 ）、 12.50 % ( 7 / 56 )与IF组相比,差异无统计学意义（ P 均＞ 0.05 ）。随访结果方面,生存出院患者 116 例,失访 12 例,持续随访 104 例,随访率 89.7 ％（ 104 / 116 ）。随访时间 36~60 个月,平均（ 38.1 ± 3.2 ）月。3 年随访结果显示EE组未增加主动脉源性死亡,但脑梗塞和上肢缺血发生率高于IF组。EE组、IF组随访3年累计生存率分别为 82.23 % 和 85.19 % 。两组间 3 年生存曲线总体比较差异无统计学意义（X2=0.055, P=0.814 ）。 结论 选择性隔绝左锁骨下动脉腔内修复可缩短手术时间,有效延长锚定区,降低内漏发生,但增加脑梗塞、脊髓缺血、左上肢缺血发生风险,体外开窗重建左锁骨下动脉腔内修复手术并发症低,两组中期随访结果满意,远期尚需进一步评估。     

下颌骨囊肿开窗减压术的回顾分析

目的:探讨保守治疗下颌骨囊肿的方法并评价其疗效。方法:对2000—2006年收治的22例接受保守治疗并随访的下颌骨囊肿病例资料进行综合分析。结果:22例下颌骨囊肿直径为3.5～8.5cm。一期开窗减压术后3～6个月颜面畸形基本消除;术后3、6、12个月X线片复查,囊腔大小分别平均缩小30%、50%、75%;且二期囊肿切除术后6～12个月下颌骨缺损区完全修复。结论:保守治疗较大下颌骨囊肿可以保存下颌骨的连续性及囊肿邻近的重要组织结构;能有效保存牙齿,改善咬合关系;促进新骨生成,减少对下颌骨发育的干扰和手术次数,较快地消除颜面畸形。     

Computed tomography virtual intravascular endoscopy in the evaluation of fenestrated stent graft repair of abdominal aortic aneurysms

Background: This study aimed to investigate the diagnostic value of computed tomography virtual intravascular endoscopy (VIE) in the follow‐up of patients with abdominal aortic aneurysm (AAA) treated with fenestrated stent grafts. Methods: A total of 19 patients (17 males and 2 females; mean age: 75 years) with AAA undergoing fenestrated stent grafts were retrospectively studied. Pre‐ and post‐fenestration computed tomography data were reconstructed for the generation of VIE images of aortic ostia and fenestrated stents and compared with two‐dimensional axial and multiplanar reformation (MPR) images. Serum creatinine was measured pre and post fenestration to evaluate the renal function. Results: The mean intra‐aortic length measured by VIE, two‐dimensional axial and MPR were 4.7, 4.4 and 4.6 mm, respectively, for the right renal stent; 5.0, 4.9 and 5.0 mm, respectively, for the left renal stent; and 5.9, 6.0 and 6.0 mm, respectively, for the superior mesenteric artery stent. Comparisons of these measurements did not show significant difference (P > 0.05). The mean diameters of renal artery ostia measured on VIE visualization pre and post fenestration were 9.2 × 8.3 and 10 × 8.9 mm for the right renal ostium; 8.3 × 7.1 and 9.9 × 8.9 mm for the left renal ostium, with significant changes observed (P < 0.01). No renal dysfunction was observed in this group. Conclusion: VIE is a valuable visualization tool in the follow‐up of fenestrated stent graft repair of AAA by providing intraluminal appearance of fenestrated stents and measuring the length of stent protrusion.     

微创小骨窗开颅在高血压脑出血中的应用

目的:探讨微创小骨窗在治疗高血压脑出血中的临床经验和体会。方法:回顾性分析2002年6月-2005年6月经用小骨窗微创手术治疗高血压脑出血38例的临床资料,均采用小骨窗开颅早期或超早期显微镜下血肿清除,术后予尿激酶溶解引流残余血肿。结果:38例中疗效优者8例;良好者17例;疗效差者10例;死亡3例。病死率7.9%。结论:微创小骨窗开颅是高血压脑出血的一种效果满意的手术方法。其手术操作损伤小、时间短、创伤轻微;术后防治并发症和积极的康复治疗对预后至关重要。     

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration

OBJECTIVE: To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting. STUDY DESIGN: Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals. METHODS: Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described. RESULTS: All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements. CONCLUSIONS: The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.     

Evaluation of Painful HIP Arthroplasty

The evaluation of chronic pain after hip arthroplasty has always been a difficult problem and recently scintigraphy has been recommended as a suitable method of examination for this purpose. On the basis of radiographic and laboratory studies, scintigraphy, allergy tests, cultures and histological examinations, in 16 patients with chronic pain in the hip after arthroplasty, it is concluded that radiography and scintigraphy together give valuable information about the cause of pain, especially if the prosthesis is infected. Fenestration of the femoral cortex may verify the diagnosis before replacement of the prosthesis.     

A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas

OBJECTIVE: To determine the difference between two laparoscopic methods for the management of endometriomas with regard to recurrence of signs and symptoms and pregnancy rate. DESIGN: Prospective, randomized clinical trial. SETTING: Infertility and gynecologic endoscopy units of two medical university hospitals. PATIENT(S): One hundred patients with endometriomas who had either infertility or pelvic pain. INTERVENTION(S): Patients were randomly divided into two groups; one group underwent cystectomy (group 1), and fenestration and coagulation were performed for the other (group 2). MAIN OUTCOME MEASURE(S): A comparison of recurrence of signs and symptoms of endometriomas and pregnancy rates in two groups. RESULT(S): Fifty-two patients were studied in group 1 and 48 in group 2. The recurrence of symptoms, such as pelvic pain and dysmenorrhea, was 15.8% in group 1 and 56.7% in group 2 after 2 years. The rate of reoperation was 5.8% in group 1 and 22.9% in group 2 and these differences were statistically significant. The cumulative pregnancy rate was significantly higher in group 1 (59.4%) than in group 2 (23.3%) at 1-year follow-up. CONCLUSION(S): Laparoscopic cystectomy of endometriomas is a better choice than fenestration and coagulation because the former technique leads to a lower recurrence of signs and symptoms and a lower rate of reoperation and a higher cumulative pregnancy rate than the latter.     

中、下鼻道联合开窗术与中鼻道开窗术治疗非侵袭型真菌性上颌窦炎效果评价

目的 评价中、下鼻道联合开窗术与中鼻道开窗术治疗非侵袭型真菌性上颌窦炎的疗效.方法 选择本科2007年1月～2011年12月被诊断为非侵袭型真菌性上颌窦炎51例患者临床资料,根据治疗方法不同分为两组,A组26例采用鼻内镜中、下鼻道联合开窗术式;B组25例采用鼻内镜中鼻道开窗术式.结果 术后随防1年评定疗效,A组治愈25例,复发1例,治愈率为96.2%;B组治愈23例,复发2例,治愈率为92.0%.结论 鼻内镜中、下鼻道联合开窗术与中鼻道开窗术是治疗非侵袭性真菌性上颌窦炎的主要手段,疗效肯定、创伤小、术后复发率低;而且中、下鼻道联合开窗术式比单纯中鼻道开窗术式疗效更佳.