硬膜外腔阻滞对胸部手术应激反应的影响

目的 观察硬膜外腔阻滞对胸部手术应激激素和细胞因子的影响。方法20例食管癌手术病人,随机分为两组,每组10例,即全麻复令硬膜外腔阻滞(GEA)组和全麻(GA)组,分别测定麻醉诱导前、手术2h、手术4h、术毕、术后1d及术后3d的血浆去甲肾上腺素、肾上腺素、血清促肾上腺皮质激素(ACTH)、皮质醇、C-反应蛋白、IL-6及IL-10的水平。结果 血浆去甲肾上腺素和血清皮质醇GEA组术中术后无显著改变,但GA组术毕和术后1d显著升高(P<0.05),术后3d恢复至术前水平,组间比较前者有显著差异(P<0.05)。两组血浆肾上腺素、IL-10术中术后均无显著变化。两组血清ACTH、IL-6及CRP术中术后均显著升高(P<0.05),组间比较无显著差异。结论 硬膜外腔阻滞可以减轻胸部手术的应激反应。IL-6是较CRP更灵敏的反映组织损伤的炎性指标。     

Ectopic cervico-mediastinal thymoma confirmed by flow cytometric analysis of tumor-derived lymphocytes

Ectopic cervical or cervico-mediastinal thymomas are very rare and most of them are asymptomatic, except for the presence of a cervical mass. We present the case of a 71-year-old man with an ectopic cervico-mediastinal thymoma threatening superior vena cava syndrome. He had a slight headache and presented with venous dilatation on the chest wall. A computed tomographic scan and magnetic resonance, imaging of the chest demonstrated a mass extending from the right neck to the hilum, that indented the trachea and compressed and displaced the brachiocephalic veins anteriorly. Under a right hemicollar incision and median sternotomy, the mass was resected en bloc together with the thymus. The resected specimen was an encapsulated mass measuring 11×7×4 cm. The pathological diagnosis was type AB, non-invasive thymoma, confirmed by 3-color flow, cytometry of tumor-derived lymphocytes. Flow cytometry using biopsy material may contribute to the preoperative diagnosis of ectopic thymoma.     

MEASUREMENT OF SURGICAL COSTS: A CLINICAL ANALYSIS

Because of reduced health care funding it is becoming necessary for surgeons to take a greater interest in the costs of individual operations. This study reports costs directly measurable to the patient, and also the indirect costs of hospital overheads, an operating suite and teaching, which were 37, 10 and 15%, respectively (62%), of hospital budget. A scheme has been developed which could give surgeons a standard to report direct costs. Pre-admission, ward, operating room, recovery, intensive care and post-admission are defined as cost periods and the modalities of staff, equipment (capital, maintenance and replacement), imaging, laboratory and consumables apply to each. This strategy was applied to assess open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) as an example. The direct costs for OC were $3706 and LC $2868, a difference of $838; the indirect and direct costs were OC $6004 and LC $4646, a difference of $1358. Thus indirect cost magnified the difference between the operations. Bed stay, density of nursing and use of disposable instruments were the major influences on direct costs. The individual cost advantage of a shorter bed stay may be countervailed by an increased hospital activity. The main patient benefit of new operations may be improved quality of life and more rapid return to work with prevention of salary losses. A method has been developed to define costs of a particular surgical operation with the purpose of stimulating surgeons' interest in this topic and developing a common style of reporting. This method should help clinicians dealing with hospital finances and waiting lists. Indirect costs are a hidden substantial cost of surgery. Considerably more attention needs to be paid to indirect costs in controlling surgical budgets.     

Multicentre prospective audit of surgical outcomes and acute complications following short course pre-operative radiotherapy for resectable rectal cancer

BACKGROUND: The addition of short course pre-operative radiotherapy to total mesorectal excision reduces local recurrence in resectable adenocarcinoma of the rectum. In a previous retrospective study potential factors associated with early complications following this combination were identified. The aim of this study was to examine these relationships in a prospective multicentre audit. METHODS: One hundred and seven patients who received short course pre-operative radiotherapy in four cancer centres between 1 October 2001 and 30 September 2002 were included. Data including patient age, radiotherapy field length, overall treatment time, operation type, surgical outcomes and complications occurring within 3 months of the 1st day of radiotherapy were collected. These were compared and combined with the previously studied cohort of 176 patients treated at one centre between 1st January 1998 and 31st December 1999. RESULTS: In the prospective cohort only patient age (P=0.001) was significantly associated with acute complications. However, both the overall treatment time (median 9.0 vs 11.0 days P <0.0001) and field length (median 16.6 vs 17.0 cm P=0.03) were significantly shorter in this cohort when compared to the previous retrospective study. In patients from both studies (n=283), increasing age (P=0.002) and field length (independent of operation type) (P=0.02) were independently associated with an increased risk of acute complications. CONCLUSIONS: This study suggests that meticulous selection of patients for short course pre-operative radiotherapy and smaller planning target volumes may be associated with a lower risk of acute complications. The use of MRI scanning to stage pelvic disease may reduce the number of patients with R1 resections receiving short course pre-operative radiotherapy.     

国产重组人脑钠素与硝普钠用于心脏手术围术期处理的对比研究

目的 对重组人脑钠素（rhBNP）用于心脏手术围术期处理的可行性、安全性和有效性进行初步观察，并与硝普钠的作用进行比较。方法 选择择期心脏手术病人22例，随机分为rhBNP组（B组）和硝普钠（SNP）组（s组），每组11例。比较rhBNP与SNP对病人血流动力学和肝肾功能的影响。结果 与给药前和S组比较，B组用药后15、30、60、120和180min各点心输出量增加显著（P〈0．05，P〈0．01）；B组与给药前比较，给药后即刻、15、30和60min时点外周血管阻力下降显著（P〈0．05）；给药后即刻、15和30点与S组比较，下降显著（P〈0．05）。B组肺毛细血管楔压（PCWP）与用药前比较，用药后即刻、15、30、60、120和180min下降显著（P〈0．05，P〈0．01）；与S组比较，给药后30、60、120和180min差异有统计学意义（P〈0．05，P〈0．01）。S组PCWP与用药前比较，用药后60min、120min和180min下降显著（P〈0．05）。B组与输注rhBNP前以及S组比较，平均动脉压、心率和中心静脉压差异均无统计学意义。输注rhBNP后病人24h尿量明显增加。用药过程中以及30d后进行电话随访，未见药物不良反应。结论 rhBNP用于心脏手术围术期处理是可行的，具有改善心功能和稳定循环的作用。     

National survey on the management of primary hyperparathyroidism by Swiss endocrinologists

Background From the endocrine surgeon’s perspective, it is important to know how endocrinologists manage patients with primary hyperparathyroidism (pHPT). The aim of this survey was to evaluate the preoperative diagnostic workup and referral pattern for parathyroidectomy by Swiss endocrinologists. Materials and methods The survey was conducted by mailing a questionnaire to all members of the Swiss Society for Endocrinology and Diabetes in spring 2005. Results The questionnaire was sent back by 68 of 124 endocrinologists (55%). The median annual case volume of patients with pHPT was 6 (range 1–50). The mean fraction of these patients referred for surgery was 59 ± 24%. This fraction was significantly higher in the German-speaking part of Switzerland than in the French-speaking part (67 ± 21% vs 51 ± 27%). When considering surgery for asymptomatic pHPT, 62% of the endocrinologists rely routinely on the recommendations of the NIH consensus conference and 86% on the subsequent guidelines of the workshop in 2002. Sixty-seven percent of the endocrinologists routinely perform localization studies before possible referral for surgical exploration. Typically, they consisted of an ultrasonography of the neck (93%) and a ^99mTc-MIBI scintigraphy (80%). The impact of the availability of a minimally invasive surgical procedure on the number of patients referred for surgery seems to be considerable. Sixty-one percent of the participants would expand the indication for surgery if the operation could be done by a limited surgical approach. Conclusions In a relevant fraction of patients with pHPT, endocrinologists still do not regard curative therapy as mandatory. Surprisingly, there are significant cultural differences concerning referral patterns to surgery between the German-speaking and the French-speaking parts of Switzerland. Minimally invasive procedures seem to lower the threshold for referral for surgical therapy. This work was presented at the 2nd Biennial Congress of the ESES, May 2006, Krakow, Poland.     

Ross术后中远期主动脉瓣反流的危险因素分析

Objective To analyze the risk factors of the postoperative mid- and long-term aortic valvular regurgitation after ROSS procedure(pulmanary valve homograft transplantation). Methods Between March 1998 and July 2007,47 patients[25male, 22 female, mean age (13.31±5.79) years, ronge 1-34 years] with aortic valvular disease underwent the Ross procedure at our insti tution. There were 6 patients suffering fron rheumatic heart disease and 41 patients suffering from congenital heart disease. The aver age aortic blood flow velocity was (4.67±3.47) m/s, the average pressure gradient across aortic valve (88.26±58.06)mm Hg, LVEDD (45.53 ±10.78) mm, EF 0.69±0.08. All the patients were followed up in out-patient departement by ultrasonic cardio gram. Multiple logistic regression analysis was performed to find out the risk factors of the postive aortic valvular regurgitation. Results There was no poetoperative death in hospital. The mean follow-up periods was (36.15±22.1) months, rasnge from 12 to 110 months and none long-dated death. Compared with the data recorded in hospital, the diamenters of the aortic sinus and aortic annu lus enlarged significantly, respectively from (26.16±5.10) mm to (32.37±6.84) tam and from (19.41 ～3.98) mm to (23.45± 5.86) mm. The average flow velocity d the homograft (new aortic valve) was(1.39±0.48) m/s, graclient pressure (8.17+6.16) mm Hg. Mild aortic regurgitstion was present in 5 patients (10.6%), moderate aortic tegmgitafion in 2 pmieats (4.3%) and aevere aortic regurgitation in 1 petient (2.1%). The rate of free from regurgitation was 82.9%. Multiple logistic analyses identified the per esence of bicuspid aortic valve, enlargement of aortic annulus and age above 14 years as the risk factors for posterative aortic regurg itation. Conclusion The Ross procedure is a safe and effective procedure with good clinical results in mid-and long-term follow-up. However, the presence of bicuspid aortic valve, enlargement of aortic annulus and age above 14 years preoperatively were identified as the risk factors for postoperative aortic regurgitation.     

电视胸腔镜心血管外科手术150例

目的 总结、分析150例电视胸腔镜心血管外科手术的临床结果。方法 应用电视胸腔镜手术技术对动脉导管未闭、房间隔缺损、室间隔缺损、三尖辨关闭不全、冠状动脉-肺动脉瘘、心包积液、原发性长Q-T综合征、雷诺病，心包囊肿等进行治疗。结果 动脉导管未闭均成功在胸腔镜下钳闭；房缺、室缺在胸腔镜体外循环下进行补片修补，冠状动脉瘘胸腔镜下修补；心包积液进行心包活检与开窗引流；长Q-T综合征进行胸腔镜下左T2、T3胸交感神经节切除，均无严重并发症，术后患者恢复良好。结论 电视胸腔镜心血管外科手术可取得满意的临床治疗结果。     

手法复位石膏外固定治疗Barton骨折

Barton骨折是桡骨远端背侧、掌侧缘骨折,合并腕的半脱位,是一种较少见的关节内骨折。自1998年以来对21例Barton骨折患者采用闭合手法整复、石膏夹板外固定治疗,经随访观察,疗效满意。