Appropriate extent of surgery for aspirin-exacerbated respiratory disease

The current literature lacks strong guidelines regarding surgical management of patients with aspirin-exacerbated respiratory disease (AERD), who present with the clinical triad of chronic rhinosinusitis with nasal polyposis (CRSwNP), bronchial asthma, and aspirin/nonsteroidal anti-inflammatory drug intolerance. To further define the effectiveness of sinus surgery in treating AERD patients, this review article discusses current evidence regarding outcomes associated with more extensive surgery, the benefits of frontal sinus surgery on polyposis, and the role of Draf III intervention. Numerous studies suggest that Draf III frontal sinusotomy may be an efficacious early intervention due to increased neo-ostial patency and subsequent distribution of topical therapies. Future studies that further investigate the efficacy and safety of extensive surgery in AERD patients are warranted.     

Long-term surgical outcomes of patients with delayed diagnosis of spinal dural arteriovenous fistula

Spinal dural arteriovenous fistula (dAVF) is an extremely rare vascular entity that is usually misdiagnosed. We sought to determine the long-term clinical outcomes of patients undergoing microsurgical treatment for delayed diagnosis of spinal dAVF. This retrospective study identified patients with delayed diagnosed spinal dAVF at our institution from 2009 to 2018. Patients’ data, including demographics, imaging, and follow-up data, were evaluated. This cohort included 65 consecutive patients with 68 dAVFs and a male-to-female ratio of 4:1 and a mean age of 53.5 ± 13.7 years. The presenting symptoms consisted of limb weakness (n = 42, 64.6%), paraparesis (n = 34, 52.3%), sphincter disturbances (n = 8, 12.3%), and pain (n = 13, 20.0%). The proportion of patients with each symptom significantly increased and patients experienced increased disability when the diagnosis was finalized. The mean length of delay of diagnosis was 20.7 ± 30.0 months. Surgery resulted in complete occlusion of the fistula on the first attempt in all patients. Three patients developed recurrent fistulas, and three died in the follow-up period. Improved motor function was achieved in 38 patients (59.5%). Other symptoms, such as sensory disorders, sphincter dysfunction, and pain, improved by 37.3%, 32.3%, and 66.7%, respectively. Patients with spinal dAVF usually exhibit progressive ascending myelopathy and often remain misdiagnosed for months to years. Some patients’ increased disability cannot be reversed through surgery.     

近端血流阻断加压技术在硬脊膜动静脉畸形血管内治疗中的应用

目的探讨近端血流阻断加压技术在硬脊膜动静脉畸形(SDAVF)血管内治疗中应用的安全性和有效性。方法回顾性分析2017年2月至2018年9月海军军医大学附属长海医院神经外科采用血管内治疗的6例SDAVF患者的临床资料。所有患者术中均应用近端血流阻断加压技术,其中1例因未能完全栓塞,改为显微外科手术治疗。术后即刻行数字减影血管造影(DSA),以判断栓塞情况。对所有患者行门诊或电话随访,随访内容为行Aminoff-Logue评分,判断脊髓功能的恢复情况;门诊随访的患者同时复查脊髓MRI,以判断栓塞情况。结果6例患者的手术均成功。术后即刻DSA显示,5例完全栓塞,1例瘘口残留。所有患者术后均未出现永久性神经系统并发症;其中1例术中造影显示肋间动脉夹层的患者,采用弹簧圈闭塞近端肋间动脉后复查胸椎CT,显示肋间肌内血肿形成,术后持续胸背部疼痛3 d后缓解。6例患者中,5例为门诊随访,1例为电话随访;中位随访时间(范围)为5.5个月(4.0~22.0个月)。术后3个月,6例患者的Aminoff-Logue评分均较术前降低[(2.0±0.7)分、(4.0±1.5)分,P<0.05];脊髓功能得到明显改善。术中因拔管困难而留置体内的1例患者,术后6个月随访时无相关并发症。经显微手术治疗的1例患者出院后10个月行DSA随访,未见瘘口显影。结论初步推测近端血流阻断加压技术在SDAVF血管内治疗中是安全、有效的。     

复合手术治疗硬脊膜外动静脉瘘合并硬脊膜动静脉瘘1例 并文献复习

目的 总结硬脊膜外动静脉瘘（SEDAVF）合并硬脊膜动静脉瘘（SDAVF）的复合手术治疗经验。方法 回顾性分析复合手术治疗的1例SEDAVF合并SDAVF的临床资料,并结合文献分析。结果 首先经动脉途径进行ONYX胶栓塞,因胶弥散效果不佳,仅封堵供血动脉,瘘口及引流静脉仍可显影;然后,开放性手术烧灼硬脊膜外扩张迀曲的静脉丛血管,但未剪开硬脊膜探查,术后7 d因并存SDAVF加重血流动力学改变并引起症状加重,再次行介入栓塞时处理SDAVF。术后6个月随访双下肢肌力恢复至4级,大小便功能正常。结论 SEDAVF处理的关键在于闭塞瘘口及近端引流静脉,对于合并的SDAVF,可选择介入治疗。单纯SEDAVF,可选择开放性手术灼闭硬脊膜外扩张迂曲的静脉湖;SEDAVF合并SDAVF,可先行介入栓塞瘘口,解除脊髓静脉高压综合征及硬脊膜外静脉湖压迫症状;如仍末治愈,可行开放手术灼闭硬脊膜外扩张迀曲的静脉湖,解除对脊髓的压迫。     

复合手术在战、创血管伤救治中的应用研究

目的 探讨复合手术在颈部与邻近躯干大血管战、创伤救治中的应用价值和方法。方法 总结我院神经外科与骨科自1978年以来应用复合手术救治42例颈部与邻近躯干大血管战、创伤大出血及晚期合并动静脉瘘与假性动脉瘤的临床资料。大部分病例复杂且已破裂,或即将破裂,又无法解剖出病变上游血管或用止血带控制出血进行血管重建手术。我们采用“放风筝”法治疗4例（其中3例外伤性颈内动脉海绵窦瘘,1例战时多发弹片伤致颅底高位颈内动静脉瘘合并颈外动脉假性动脉瘤）,采用“血管内”止血带辅助外科手术切除假性动脉瘤与动静脉瘘行血管重建血运35例,酌情选择介入与开放手术相结合治疗3例（战伤致左椎动脉动静脉瘘1例,左椎动脉动静脉瘘合并假性动脉瘤破裂大出血1例,医源性颈内动脉损伤大出血1例）。结果 42例全部治愈,无死亡或因治疗加重残废。全部病人随访1年以上,病变消失且血运重建良好。结论 复合手术在救治颈部与邻近躯干大血管战、创伤出血及晚期并发假性动脉瘤与动静脉瘘时,能有效防止出血,增加手术安全性,将复杂、风险大的手术简单化,可在临床中推广应用。     

胰十二指肠切除术后胰瘘的影响因素研究进展

胰十二指肠切除术(Pancreaticoduodenectomy,PD)是治疗壶腹周围恶性肿瘤、癌前病变和部分良性疾病的标准术式。PD手术切除范围广,吻合口多,手术并发症较多。近年来,PD手术死亡率已经由最初的大于50%下降到目前的小于5%,手术并发症发生率也显著下降。PD术后主要并发症有胰瘘、出血、腹腔感染、胆瘘、乳糜瘘、术后胃排空障碍等。其中,胰瘘是导致PD术后早期死亡的主要原因。本文就影响PD术后胰瘘的全身因素、局部因素和手术相关因素进行综述,为降低PD术后胰瘘发生率提供临床可操作性。     

三种不同引流方式对食管癌术后颈部吻合口瘘引流效果的研究

目的:探讨三种不同引流方式对食管癌术后颈部吻合口瘘的引流效果。方法:收集从2013年1月到2016年9月在我科行食管癌手术并术后发生颈部吻合口瘘患者,比较入组患者所采用的不同颈部引流方式的优劣。结果:共有83例患者纳入研究,有34例进入A组,行纱布条引流组;28例进入B组,行造瘘袋引流组;21例进入C组,行胃管负压引流组。所有入组患者一般资料和手术资料对比无明显统计学差异（P>0.05）。观察指标对比结果显示,C组患者瘘口愈合时间较其他两组时间短［（15.90±4.18）天vs（14.60±4.41）天vs（9.65±3.80）天］,住院时间较其他两组短［（18.10±4.17）天vs（16.20±3.78）天vs（12.30±3.29）天］,换药次数较其他两组少［（37.55±8.75）天vs（14.5±3.23）天vs（10.00±2.05）天］,抗生素使用时间也较其他组明显减少［（13.10±2.49）天vs（10.85±1.84）天vs（7.20±1.74）天］。结论:颈部放置负压引流有助于食管癌术后颈部吻合口瘘愈合,值得临床推广与进一步研究。