神经导航在垂体巨大腺瘤再次经鼻蝶入路手术中的应用

目的 探讨神经导航在垂体巨大腺瘤再次经鼻蝶入路手术中的应用价值。方法 回顾性分析2017年6月至2019年6月在神经导航辅助下进行再次手术治疗的27例垂体巨大腺瘤的临床资料。结果 术后视力及视野缺损明显改善10例,部分改善14例,无明显改善3例;血清皮质醇水平降低6例,正常21例。7例术前血清泌乳素增高中,6例术后降至正常;1例仍偏高。5例术前生长激素升高病人,术后生长激素降至正常。15例术前头晕头痛中,术后改善12例,无明显变化3例。2例术后出现脑脊液漏,经卧床及腰椎穿刺术置管引流后治愈。术后3个月复查MRI,显示肿瘤全切除22例,次全切除3例,部分切除2例。未全切除病人3个月后行伽玛刀治疗。结论 垂体巨大腺瘤再次经鼻蝶入路手术时,在解剖结构破坏的情况下,利用神经导航可以引导术者准确到达病灶,降低手术风险,提高肿瘤全切除率     

医源性胆道损伤的处理及再手术时机

目的:探讨医源性胆道损伤的处理及再手术时机。方法:对2004年1月～2008年1月收治的37例医源性胆道损伤患者的临床资料进行回顾性分析。结果:开腹胆囊切除、腹腔镜胆囊切除及胆总管探查是医源性胆道损伤的主要原因,占94.6%(35/37),其中36例行手术治疗,占97.3%,术中发现胆管损伤并行损伤修复者3例,占8.1%,24 h以内行急诊剖腹探查者9例,占24.3%,胆道重建修复手术38例次。34例随访6个月～1年,疗效优良率达82.3%。结论:医源性胆道损伤最常见于胆囊切除术,根据损伤的时间及类型采取相应的处理方法,早期发现和及时且正确地处理对预后十分重要。胆管空肠Roux-en-Y内引流术是目前最常用且疗效肯定的胆道重建方法。     

原位肝移植术后再手术的原因分析及护理

目的 探讨原位肝移植术后再手术的原因及护理特点.方法 回顾性分析3年间施行的241例原位肝移植患者的临床资料,对需再手术病例的原因和护理特点进行分析总结.结果 241例患者中,再次手术30例,再手术率为12.4%.再手术原因包括:腹腔内出血14例占46.7%,胆道并发症8例占26.6%,移植术后不同部位感染4例占13.3%,伤口愈合不良2例占6.7%,肝癌复发2例占6.7%.术后死亡7例,再手术死亡率为23.3%.结论 原位肝移植术后再手术的原因是多方面的,其中腹腔内出血和胆道并发症是最主要的原因.了解再手术的原因,并依此制订护理措施,对提高肝移植存活率和生活质量具有重要意义.     

Pre-Operative Planning Using Real-Time Virtual Sonography,an MRI/Ultrasound Image Fusion Technique,for Breast-Conserving Surgery in Patients with Non-Mass Enhancement on Breast MRI: A Preliminary Study

The purpose of this retrospective study was to evaluate the effect of pre-operative planning using real-time virtual sonography (RVS), a magnetic resonance imaging (MRI)/ultrasound (US) image fusion technique on breast-conserving surgery (BCS) in patients with non-mass enhancement (NME) on breast MRI. Between 2011 and 2015, we enrolled 12 consecutive patients who had lesions with NME that exceeded the US hypo-echoic area, in which it was particularly difficult to evaluate the tumor margin. During pre-operative planning before breast-conserving surgery, RVS was used to delineate the enhancing area on the breast surface after additional supine breast MRI was performed. We analyzed both the surgical margin positivity rate and the re-operation rate. All NME lesions corresponded to the index cancer. In all patients, the diameter of the NME lesion was greater than that of the hypo-echoic lesion. The median diameters of the NME and hypo-echoic lesions were 24?mm (range: 12–39?mm) and 8.0?mm (range: 4.9–18?mm), respectively (p?=?0.0002). After RVS-derived skin marking was performed on the surface of the affected breast, lumpectomy and quadrantectomy were conducted in 7 and 5 patients, respectively. The surgical margins were negative in 10 (83%) patients. Two patients with positive margins were found to have ductal carcinoma in situ in 1 duct each, 2.4 and 3.2?mm from the resection margin, respectively. None of the patients required additional resection. Although further prospective studies are required, the findings of our preliminary study suggest that it is very well possible that the use of RVS-derived skin marking during pre-operative planning for BCS in patients with NME would have resulted in surgical outcomes similar to or better than those obtained without the use of such marking.     

Unscheduled return to the operating theatre after head and neck surgery with free flap repair

The purpose of this study was to benchmark the unscheduled postoperative return to theatre rate (URTT) of patients undergoing head and neck surgery with free tissue transfer in a UK setting, and identify opportunities for quality improvement. Between August 2009 and June 2019, data on 1000 patients undergoing surgery in a single institution were prospectively assembled, and the electronic healthcare records of all patients scrutinised to obtain data on putative predictive factors. Categorical factors were analysed with the chi squared test, and continuous variables with the t test or Mann-Whitney U test, as appropriate. Multivariate logistic regression was used to identify independent predictive variables and to determine the predictive value of the final model. Of the 1000 patients 26.5% had one or more URTT, and 4.6% experienced flap failure with a 1% perioperative mortality. Failure of primary healing at the flap to mucosal interface with leakage of whole saliva into the neck wound was the single most prevalent problem (15.4%) followed by flap salvage procedures (7.4%). Independent predictive variables of URTT were perioperative transfusion, duration of procedure, requirement for tracheostomy, and previous radiotherapy to the head and neck. The C-index was weak (0.61) for this model. URTT substantially increased the duration of hospital stay. It is a poor experience for patients, and is associated with increased healthcare costs. It potentially disrupts the flow of care to other patients, and may be associated with a delay to required adjuvant therapy. Quality improvement initiatives should focus on optimising the probability of primary healing at the flap to mucosal interface, and reducing the number of flap salvage procedures.     

Surgery for aortic coarctation: a 30 years experience

Objective: A retrospective study to review the experience of a single center with surgery for aortic coarctation over a period of 30 years (1970–1999). Methods: Criteria for inclusion: (a) aortic coarctation, isolated or associated with congenital heart defect; (b) surgery between 1970 and 1999. Data recorded: (1) date of surgery; (2) age at surgery; (3) associated lesions; (4) surgical technique; (5) simultaneous surgical procedures; (6) early and late surgical results in term of: (a) deaths; (b) need for reoperation because of re-coarctation or other cardiac lesion; (c) residual/recurrent pressure gradient, evaluated at cuff/Doppler at rest; (d) systemic hypertension, requiring medical treatment. Results: One hundred and forty-one patients underwent surgery for aortic coarctation: 30 neonates, 29 infants, 45 children and 37 adults. Associated lesions were found in 8/37 (=21.6%) adults and in 73/104 (=70.1%) pediatric patients. There were no hospital deaths. During the follow-up there were one late death in the adults group (1/37=2.7%) and three late deaths in the pediatric group (3/104=2.9%), all unrelated with aortic coarctation. Re-operation because of re-coarctation occurred only in ten late survivors of the pediatric group (10/101=9.9%), 9/10 operated on before 1980 (P<0.00001). End-to-end anastomosis, enlarged to the aortic arch in neonates, was associated with the lowest incidence of re-coarctation (P<0.005). A significant (>20 mmHg at rest) pressure gradient was found in none of the adults, and in seven of the 91 pediatric patients (7/91=7.7%) late survivors. Three adults (3/36=8.3%) late survivors are on medical treatment to control systemic hypertension. Conclusions: The long-term results of our retrospective study confirm that surgery has to be considered the gold standard for the treatment of aortic coarctation. The interventional angioplasty techniques have to provide long-term outcome at least similar to the results obtained with surgery.     

Reference function of old electrical stimulation electrode in cochlear-reimplantation in children

ObjectivesTo explore the causes of cochlear implantation and reference function of old electrical stimulation electrode in cochlear reimplantation in children.MethodsThe causes, surgical methods and problems found during the operations of 24 cases of cochlear reimplantation in Henan Children's Hospital from June 2016 to April 2018 were analyzed.ResultsTwenty-three cases successfully completed the surgery of cochlear-reimplantation, and the remaining one case had approximately 1/3 of the anterior end of the residual cochlear electrode due to high resistance at the time of withdrawal of the electrodes. The causes of re-implantation were implant equipment failure (eleven cases), elevated impedance values of all electrodes after head trauma (two cases), and implant prolapse together with the electrode caused by a traffic accident (one case).ConclusionThe old stimulus electrode can provide an important reference to reduce the risk of operation and ensure the success of the reoperation.     

经腹膜后途径二次肾区腹腔镜手术的探讨

目的探讨二次肾区经腹膜后腹腔镜手术治疗泌尿系疾病的可行性。方法 2006年1月～2012年1月我院对7例有同侧开放或腹腔镜经腹膜后途径手术史者经腹膜后途径行二次肾区腹腔镜手术,其中2例为肾上腺嗜铬细胞瘤术后复发,2例为肾囊肿术后同侧复发,1例为开放肾盂输尿管连接部成形术后继发肾积水导致无功能肾,1例为后腹腔镜肾上腺肿物切除术后同侧肾萎缩无功能,1例为肾癌肾部分切除术后复发。2次手术间隔2.5～8.3年,平均3.5年。第2次手术均取经腹膜后入路,直视下经第12肋下2 cm与骶棘肌外侧交界处进入后腹腔建立气腹,在腋中线髂嵴上2 cm处做第2穿刺点,腋前线肋缘下为第3穿刺点,先从解剖清晰、粘连轻处按解剖层次,逐步暴露手术部位完成手术。结果手术均获成功,手术时间75～213 min,平均131 min;术中出血量50～400 ml,平均156 ml。2例腹膜损伤,无腹腔内脏器损伤,术后第3天胃肠道恢复,逐渐进食。术后住院4～12 d,平均9 d。6例随访4～38个月,平均18个月,患者恢复良好,肾囊肿及肿瘤未见复发。结论在熟练掌握后腹腔镜技术的前提下,再次后腹腔镜下肾区手术是可行的。     

某院2012年非计划再手术病例分析

目的 加强手术质量管理,提高医疗质量.方法 结合病案统计系统采集的手术信息,对某医院2012年所有非计划再手术病例进行回顾性分析.结果 2012年住院手术共计8673例,非计划再手术病例7例,非计划再手术率0.08%,非计划再手术的发生与患者自身的基本身体状况、手术难度有一定关系,术区感染是造成非计划再手术的主要原因.结论 严格执行患者病情评估与术前讨论、手术分级授权管理制度及手术操作规程,可以降低非计划再手术的发生.     

局部复发性胃癌再手术的难点与要点

目的:探讨胃癌局部复发的再手术治疗的难点与要点。方法:总结23例胃癌手术后局部复发的治疗经验与体会。从复习原发灶的生长方式和胃癌的进展方式分析局部复发病变难以切除的原因。结果:残胃复发8例、手术野复发6例及部位不明者9例中,共切除8例,切除率为34.8%。在可切除者中除1例为残胃黏膜下癌,均对手术野粘连和被浸润的脏器进行了合并切除;余者均因癌肿包绕重要血管、脏器而未能切除。结论:初次手术所致的腹腔粘连使局部复发的进展方式发生变化:①复发灶沿粘连带直接浸润的范围广,涉及重要血管、脏器者多。这是造成再切除困难的主要原因;②淋巴结转移途径增多、范围广;③粘连组织包绕残胃,使不易发生腹膜播种。因此,术前宜尽量明确复发的部位和范围,观察原发灶的生长方式有利于判断腹腔内复发的范围和切除的可能性。对被浸润的脏器及其系膜应作足够的切除。术后随诊以早期发现复发也是提高治疗效果的要点。