老年胃癌患者外科治疗安全性及腹腔镜手术可行性探讨

 目的　探讨老年胃癌患者手术治疗的安全性及老年胃癌患者腹腔镜手术的可行性。方法　回顾性分析手术治疗的65岁以上老年胃癌患者共104例（其中21例行腹腔镜手术）的临床及病理资料,分析不同年龄组及不同手术方式组围手术期并发症发生率及短期疗效等。结果　≤75岁患者组（55例）的术前合并疾病发生多于＜75岁组（49例）（77例次、40例次）（χ2＝8.03,P＜0.01）,以高血压和糖尿病为主,但术后并发症的发生数两组平均（0.45±0.65）次／例、（0.67±0.92）次／例,差异无统计学意义（U＝1208.5,P＝0.301）。腹腔镜手术组的术前合并疾病、术后并发症、手术时间、术中出血量与开腹手术组相比差异无统计学意义,但腹腔镜手术组较开腹手术组术后住院时间较短及较早进食流质饮食。各组的术后病理情况差异无统计学意义。结论　老年胃癌患者在条件允许的情况下仍应积极行手术治疗,并尽可能按规范范围清扫。腹腔镜手术术后患者肠道功能恢复较快,可缩短住院时间。     

Stanford A型主动脉夹层的外科治疗

目的总结A型主动脉夹层的外科治疗经验。方法回顾分析手术治疗68例StanfordA型主动脉夹层患者的临床资料。其中急性主动脉夹层45例,慢性主动脉夹层23例。采用中低温体外循环53例,深低温停循环(DHCA)和上腔静脉逆行灌注脑保护11例,DHCA加选择性脑灌注4例。急诊手术39例(其中紧急手术19例),择期手术29例。术式为升主动脉置换术7例,升主动脉加右半弓置换术6例,升主动脉加全弓置换术3例,升主动脉加全弓置换加术中支架置入术4例,Bentall手术34例,改良的Wheat术12例,同时行主动脉瓣成形术2例、二尖瓣成形1例。结果全组死亡5例(7%),其中急诊手术3例,急诊手术病死率8%(3/39);择期手术2例,择期手术病死率7%(2/29)。共随访58例,随访率92%(58/63),随访时间(37±22)个月(5~77个月),死亡4例,累积1,3和5年的生存率分别是100%,95%和86%。结论StanfordA型夹层的手术方式应根据内膜破口位置决定,正确的手术指征、技巧和脑保护是手术成功的关键。     

GeneXpert MTB/RIF检测技术在结核性胸膜炎诊断中的应用价值

目的评价GeneXpert MTB/RIF(简称"GeneXpert")检测技术对结核性胸膜炎诊断的应用价值。方法选取2017年1-12月辽宁省鞍山市结核病医院内科病房初诊疑似结核性胸膜炎患者180例。所有患者均在超声引导下行胸腔穿刺留取胸腔积液并立即送检,胸腔积液分别行抗酸染色涂片法检查(简称"涂片法")、BACTEC MGIT 960液体培养法(简称"MGIT 960培养")和GeneXpert检测。以临床确定诊断为参考标准,评价涂片法、MGIT 960培养和GeneXpert检测胸腔积液标本中结核分枝杆菌(MTB)的敏感度、特异度、阳性预测值、阴性预测值和一致率。结果在180例疑似结核性胸膜炎患者中,162例(90.00%)患者临床确诊为结核性胸膜炎,18例(10.00%)患者最终排除结核性胸膜炎。162例临床确诊患者中,61例(37.65%)MGIT 960培养阳性;101例(62.35%)根据临床表现、胸腔积液的生化指标、胸部影像和抗结核治疗有效等临床诊断为结核性胸膜炎。18例非结核性胸膜炎患者包括肺癌胸膜转移9例,结节病1例,系统性红斑狼疮性胸膜炎1例,胸膜间皮瘤2例,肾病综合征2例,心功能不全2例和低蛋白血症1例。以临床确诊结果为参考标准,涂片法、MGIT 960培养和GeneXpert检测的敏感度分别为0.00%(0/162)、37.65%(61/162)、54.94%(89/162);特异度均为100.00%(0/18);阳性预测值分别为0.00%(0/0)、100.00%(61/61)、100.00%(89/89);阴性预测值分别为10.00%(18/180)、15.13%(18/119)、19.78%(18/91);一致率分别为10.00%(18/180)、43.89%(79/180)、59.44%(107/180)。GeneXpert检测的敏感度明显高于涂片法和MGIT 960培养,差异有统计学意义(X~2=119.82,P=0.000)。结论 GeneXpert检测技术在结核性胸膜炎的诊断中具有较高的临床应用价值。     

Laparoscopic approaches for splenic artery aneurysms

Abstract

Background: Therapeutic options for splenic artery aneurysm include endovascular management, laparoscopic surgery, and open surgery, although their indications and applications as standard therapy remain controversial. Methods: Between August 2009 and March 2011, three patients with splenic artery aneurysm were treated at our institution. All patients underwent laparoscopic surgery. Results: There was no conversion to open surgery. The mean operative time was 204.7 min (range: 147–265 min) and the mean intraoperative blood loss was 30 mL (range: 0–90 mL). There was no mortality or morbidity. Conclusions: The laparoscopic approaches for splenic artery aneurysm were safe procedures.     

微创下腰椎经椎间孔椎体间融合术混合内固定治疗复发性腰椎间盘突出症的可行性研究

目的 探讨微创腰椎经椎间孔椎体间融合术(MIS-TLIF)采用椎弓根螺钉结合对侧经椎板关节突螺钉混合内固定治疗复发性腰椎间盘突出症的可行性.方法 选取2010年1月至2011年12月符合纳入排除标准的16例复发性腰椎间盘突出症患者资料进行回顾性研究.其中男性10例,女性6例,年龄35 ～ 68岁,平均45岁.采用单侧切口工作通道下完成MIS-TLIF手术,在完成椎管减压、椎体间融合和单侧椎弓根螺钉内固定后,同一切口经棘突根部向对侧置入经椎板关节突螺钉,进行围手术期指标观察、影像学和疗效评价.视觉模拟量表(VAS)评分和Oswestry功能障碍指数(ODI)评分的比较采用重复测量方差分析.结果 所有患者均在工作通道下顺利完成椎管内减压、椎体间融合和混合内固定,无患者出现神经症状.平均手术时间(148±75) min,术中出血量(186±226) ml,术后平均下床活动时间(32±15)h,平均住院日(6±4)d,手术切口长度平均(29±4) mm,经椎板关节突螺钉平均长度(52 ±6) mm.患者术后随访12 ～ 24个月,平均16.5个月.术后X线和CT显示混合内固定位置良好,经棘突椎板关节突螺钉均穿过椎板和关节突关节,术后随访期间腰痛和腿痛VAS与ODI评分与术前相比较均明显改善,差异有统计学意义(腰痛VAS:F=52.845,P=0.000;腿痛VAS:F=113.480,P=0.000; ODI评分:F=36.665,P=0.000).结论 单侧切口MIS-TLIF采用混合内固定可治疗复发性腰椎间盘突出症,具有创伤小、恢复快等优点.     

射频闭合与传统剥脱术治疗下肢静脉曲张的对照研究

目的评价射频闭合(radiofrequency endovenous obliteration,RFO)的疗效。方法 56例(56条肢体)大隐静脉曲张患者随机分为两组,每组28例。RFO组利用射频能量使大隐静脉全程闭合,静脉剥脱组用传统方法高位结扎剥脱大隐静脉。两组病例小腿散在的曲张浅静脉均采用点式剥脱处理。比较两组病例的切口数、术后疼痛、平均住院日和短期疗效等情况。结果 RFO组平均切口少、术肢疼痛轻、无皮下血肿,术后平均住院日(2．50±1．00)d。静脉剥脱组的术后平均住院日(4．14±0．85)d。结论 RFO闭合大隐静脉具有创伤小、恢复快、腿部少留瘢痕等优点,是一种可部分替代传统大隐静脉高位结扎剥脱术的有效方法。     

The requirement for informed consent prior to nursing care procedures

AIM OF THE PAPER: The aim of this paper is to examine the extent to which there is a requirement to obtain informed consent prior to nursing care procedures. RATIONALE: The requirement for nurses to obtain consent prior to nursing care procedures is addressed in various nursing policy documents. It is important that nurses understand the legal and ethical rationale behind the principles of informed consent so that the principles are applied appropriately to the particular context of nursing care. ARGUMENT: The ethical and legal rationale behind the concept of informed consent and its relevance to nursing practice are examined. In this paper, it is argued that the function of informed consent is to protect patient autonomy and to promote meaningful decision-making. Given the potential for nursing care procedures to infringe patient autonomy, consent is clearly a relevant concept in nursing. Furthermore, in law, any touching without consent is a potential battery. Informed consent is often associated as a rigid procedure, only relevant to surgical or research procedures. Consent should be obtained prior to nursing care procedures whenever patient autonomy is at stake. However, information-giving should be determined by the needs of the patient and approached in such a way as to facilitate meaningful decision-making. Given the individual nature of infringements to patient autonomy, it is difficult to predetermine all those care procedures that require consent; any list of procedures would fail to be comprehensive. CONCLUSIONS: The principles of informed consent should underpin our approach to nursing care procedures, which should not be mechanistic but determined by the needs of individual patients.     

骨样骨瘤的诊断与治疗

目的:研究骨样骨瘤的临床特点以及外科治疗效果,提高诊治水平。方法:回顾性分析1997年1月至2009年10月确诊的35例骨样骨瘤的临床资料,其中男25例,女10例,平均发病年龄21岁(6～49岁)。最常见的部位为胫骨(13例)和股骨(7例)。发病至确诊时间平均为12个月(1～24个月),典型的症状为疼痛,夜间加重,服用非甾体抗炎药可缓解,影像学表现为一圆形或卵圆形的瘤巢。所有患者均经手术治疗:单纯肿瘤切除9例,肿瘤刮除或切除人工骨或自体骨植骨19例,肿瘤刮除或切除植骨固定7例。结果:术后平均随访49个月(2个月～12年),所有患者疼痛症状均消失,未见病灶复发。1例术后4个月出现胫骨病理性骨折,经钢板螺钉内固定后治愈。1例术后5年窦道形成,行窦道切除、髓内钉取出、清创术后治愈。结论:根据典型临床表现、影像学特点,骨样骨瘤的诊断并不困难,为缓解症状、提高生活质量、预防远期并发症,确诊后应尽早手术治疗。     

升主动脉置换术或成形术治疗主动脉瓣病变合并的升主动脉瘤样扩张

目的 对比分析主动脉瓣病变合并升主动脉瘤扩张在行主动脉瓣置换术(AVR)的同时施行升主动脉置换术(A组)或成形术(B组)的结果,探讨两种方法的临床效果及适应证.方法 A、B两组术前年龄、性别、心功能分级、主动脉瓣病变、左室射血分数等差异均无统计学意义.A组主动脉直径(49.45±3.96)mm,B组(49.31±3.68)mm,差异亦无统计学意义.行AVR后A组常规置换升主动脉,B组纵行切除部分升主动脉壁,缝合后包裹28～30 mm人工血管.结果 A、B两组术后均无死亡.A组主动脉阻断(71.70±17.13)min、体外循环(110.52±27.51)min,均明显大于B组的(57.13±16.32)min(P=0.025)和(97.31±19.46)min(P=0.004).两组术中及术后输血量、并发症发生率差异无统计学意义.结论 主动脉瓣病变合并升主动脉瘤样扩张,年轻病人主动脉直径≥40 mm时应积极手术处理扩张的升主动脉.升主动脉成形术,同时外包裹人工血管的方法较升主动脉置换术更为简单、安全,但升主动脉壁必须无粥样硬化或溃疡.     

内固定应用于脊柱结核治疗的安全性探讨

Objective To investigate the efficiency and safety of instrumentation to treat spinal tu-berculosis. Methods Fifty-one patients of spinal tuberculosis were treated with one-stage or two-stage de-hridement, strut autografting, and anterior or posterior instrumentation with screw rod system, combined with one-year triple agents postoperative antituberculous chemotherapy from April 1985 to May 2005. There were 6 in cervical spine, 19 in thoracic spine, 16 in thoracolumbar spine and 10 in lumbosacral spine. The level of the lesion were 6 cases for single vertebrae, 30 for two vertebrae, 11 for three vertebrae and 4 for more than four vertebrae. All patients were given triple agents antituberculous chemotherapy at least two weeks before operation. The operative procedures included cervical anterior approaches in 6 cases for debridement, fusion and plate-screw fixation, upper lateral transthoracic procedures for debridement, fusion and screw rod fixation in 11, posterior debridement, fusion and transpedicular screw system fixation in 6, two-stage anterior and posterior operation in 18 cases. The instrumentation included 6 Luque, 3 Z-plate, 8 TSRH, 5 Ventrofix, 4 Kenada, 5 Moss-Miami, 6 Isola, 3 CDH, 2 Caspaz, 2 C-D, 1 Zielke, 1 Dick, 1 Oriell, 1 Ozion, 1 Zephir, 1 Tenor, and 1 USS. Results All patients were followed up prospectively for 3.2 to 23.5 years postoperatively. The back pain was obviously relieved postoperatively. Patients with neurological function deficiency im-proved. The solid fusion was achieved in all patients, except one patient due to tuberculosis recurrence. The major complication included one sinus formation and one case with temporary deterioration of neurological function, recovered with appropriate treatment. Average preoperative kyphosis angle was 34.17°, and that was 10.45° immediately after surgery. There was a 3.2° loss of kyphosis correction during follow-up period. Con-clusion Spinal tuberculosis treated with instrumentation is effective and safe.