覆膜支架治疗Ⅲ型主动脉夹层

目的探讨覆膜支架治疗Ⅲ型主动脉夹层的方法和疗效。方法对14例Ⅲ型主动脉患者行爱膜支架治疗。术前强化CT检查明确诊断。术中先行主动脉造影，明确内膜破口位置，分辨真假腔，然后根据病变血管近端正常血管直径加上其直径的15％～20％选择支架型号。沿腹股沟下方约2cm处横行切开，游离股动脉并切开，插入支架输送器，硝普钠降收缩压至70～90mmHg，于破口位置缓慢释放支架，封闭主动脉内膜破口，重新造影，观察支架位置，是否有内漏．．结果14例均成功植入支架，患者疼痛症状消失。升主动脉造影示真腔扩大，假腔消失12例，小内漏2例（经球囊扩张后仍有）。术后1周，1、6个月行强化CT检查示真腔扩大，假腔内血栓形成并缩小，远断血运改善，无截瘫、左上肢缺血及支架移位等并发症．结论覆膜支架治疗Ⅲ型主动夹脉层创伤小，操做简单，手术死亡率低，并发症少．恢复快，近期效果好．     

SUCCESSFUL ENDOSCOPIC CLOSURES OF COLONIC PERFORATIONS REQUIRING ABDOMINAL DECOMPRESSION AFTER ENDOSCOPIC MUCOSAL RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY COLON CANCER

Endoscopic submucosal dissection (ESD) for colorectal cancer is not widely accepted because of its technical difficulty and the risk of perforation. In addition, the risk of peritonitis cannot be completely eliminated even if a perforation is closed successfully. Reported here are two cases of early colon cancer in which the patients sustained iatrogenic perforations of the ascending colon during conventional endoscopic mucosal resection and of the sigmoid colon during ESD, respectively, requiring abdominal decompression with an 18 G Medicut needle. Both of these perforations were successfully treated by endoscopic clipping. In conclusion, conservative medical management may be possible in patients who have undergone successful closure of colonic perforations using endoscopic clipping. In order to perform immediate endoscopic closure, abdominal decompression has been useful to decrease patient discomfort and colonic lumen collapse. Now, CO₂ insufflation is being used effectively for the prevention of pneumoperitoneum.     

TECHNIQUES AND PITFALLS OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL TUMORS

Endoscopic submucosal dissection (ESD) for colorectal tumors is steadily being developed. Safety and standardization of ESD for colorectal tumors have not been yet established because of the technical difficulties and the unsuitable anatomical characteristics of the colon and rectum. The authors mainly use a Flex knife for mucosal incision and a Hook knife for submucosal dissection to perform ESD safely. Skillful colonoscopic control, selection of scope, distal attachment tip hood, adequate high‐frequency generator and correct approach strategy should all be considered for safe performance of ESD. However, the incidence of indicative lesions is rare because the majority of colorectal tumors are adenomatous large laterally spreading tumors, which can be cured by intentional endoscopic piecemeal resection. At present, ESD for colorectal tumors should be performed only at central facilities that have expert colonoscopists. With the development of new devices and associated techniques, technical standardization of ESD for colorectal tumors is expected in the near future.     

胸腔镜辅助小切口手术诊治肺周围型结节

目的探讨胸腔镜辅助小切口手术在诊断和治疗肺周围型结节病变中的临床应用价值。方法胸腔镜辅助小切口手术诊治肺周围型结节55例，其中单发结节54例，多发结节1例。肺楔形切除术23例；肺叶切除联合淋巴结清扫治疗原发性肺癌32例，采用常规开胸手术器械及胸腔镜用器械切除肺叶，自制淋巴结摘除钳完成淋巴结清扫。结果55例均在胸腔镜下完成手术。手术时间35～180min，平均109min，术中出血量50～400ml，平均122min。均未输血，1例术后漏气术后32d出院，1例切口延迟愈合，术后19d出院，余53例术后住院4～11d，平均8．3d。无严重并发症。术后病理：良性病变15例，原发性肺癌38例，非典型性腺瘤样增生1例，转移性肺癌1例。良性病变行肺楔形切除术，32例原发性肺癌行解剖学肺叶切除联合淋巴结清扫，4例肺癌胸膜广泛播散未手术处理，2例肺癌因肺功能差行姑息性肺楔形切除。结论胸腔镜辅助小切口手术有助于明确诊断肺周围型结节病变，治疗临床早期原发性肺癌的长期疗效有待随访观察。     

Extended total arch replacement for type B aortic dissection with ascending aneurysm following healed aortic dissection

We describe a case of type B aortic dissection with large ascending aortic aneurysm occurring 12.8 years after aortic root replacement (Cabrol procedure) in a non-Marfan patient with cystic medial necrosis of the aorta. We have successfully performed an extended total aortic arch replacement using a four-branched graft through the “L-indsion” approach (a combination of a left anterior thoracotomy and upper half median sternotomy). Of note, a histological specimen from the aneurysmal ascending aortic wall revealed “healed aortic dissection” with fibrous tissue replacing the media and intima in addition to multiple foci of cystic medial necrosis.     

偏心圆剥离法在隆乳术中的应用

以往以乳头为圆心的同心圆剥离法常形成假体的移位，使假体的体表轮廓与前方的自然乳房分离，产生“双重乳房”现象。在研究了女性不同体位下不同的乳房形态及总结了以前的经验后，提出了偏心圆剥离的概念。偏心圆手术设计方法：以乳头为圆心，按其内侧、下侧为直径３／５的比例，以外侧、上侧为直径２／５的比例，形成一偏心圆的剥离范围。偏心圆的直径因考虑到假体的不同形态、大小及底面直径，以经中心假体纵截面的周长的１／２再放大２ｃｍ，作为剥离范围的直径。自１９９１年１０月以来已应用了１７６例，无一术后移位现象，也没有固较多地剥离胸大肌内、下侧止点纤维而影响上肢活动。自然乳房并不是静态的圆锥形或半球形，它具有伸缩的组织学特点，又有随体位变动而变化的特点。用偏心圆法剥离，可使置入的假体与前方的自然乳房融为一体，消除“双重乳房”现象，而成为“真实”的乳房。同时也应积极寻找一种与身体组织相容性好的，弹性、比重与女性乳腺较为一致的，假体容量相对恒定的生物性材料。这样隆乳术才可以更广泛地开展。     

喉癌的颈清扫术(附5例报告)

本文报告5例喉癌颈清扫术,对其适应症、手术方式等进行了初步分析。认为CN_(1,2),无论病理LN是否阳性均应行ND。CN_3者ND要慎重考虑。CN_0一般不施行ND,除声门上癌或声门癌侵及声门上区时例外。术式以FND为宜。     

Angiography and magnetic resonance imaging of aortic dissection

This review article describes and illustrates the role of angiography and magnetic resonance imaging in the evaluation of aortic dissection. Clinical findings, complications, classification, and treatment of dissection are reviewed as well.     

Left internal carotid artery dissection presenting with headache, Collet-Sicard syndrome and sustained hypertension

The baroreflex maintains blood pressure through the glossopharyngeal (IX) cranial nerve. We report a 54-year-old man who developed a left sided headache, hoarseness, dysarthria, dysphagia, and sustained hypertension from a left internal carotid artery dissection. We hypothesise that interruption of the left IX nerve caused hypertension in this patient.