胆道术中胆汁细菌培养及药敏试验

目的　探讨胆道外科感染的常见病原微生物及其对 1 4种抗生素的敏感情况 ,为临床用药提供参考。方法　对近 3年来胆道手术中获取的胆汁标本进行培养和药敏实验。结果　 32 5例胆汁标本培养以革兰氏阴性菌为主 (占 84 .3% ) ,其中大肠艾希氏菌 4 7例 (占 2 0 .4 % ) ,肠杆菌属 38例(占 1 6 .5 % )最多见。对革兰氏阴性菌较为敏感的有丁胺卡那霉素、万古霉素、环丙沙星。菌必治和复达欣对革兰氏阳性、阴性菌均敏感。结论　胆道外科感染主要选用针对革兰氏阴性杆菌和厌氧菌的抗生素 ,严重感染时须用广谱抗生素 ,结合外科引流原则     

胆道闭锁诊治体会

目的　分析胆道闭锁诊断、治疗及预后情况 ,探讨胆道闭锁的早期诊断和治疗策略。方法　回顾性分析我院近 5年收治的 2 8例胆道闭锁患儿诊断手段、手术年龄、手术方式及术后生存率。结果　胆道闭锁早期诊断率为 1 4 % (4 / 2 8) ,手术时年龄 1 3～ 2 70d ,6 0d以内 4例 (1 4 % ) ;6 1～ 90d 1 3例 (4 6 % ) ;91～ 1 2 0d 8例 (2 9% ) ;1 2 0d以上 3例 (1 1 % )。没有患儿接受肝移植 ,1～ 5年生存率为35 % (9/ 2 5 )。结论　密切观察临床表现、掌握胆道闭锁的影像学特点和及时采用腹腔镜探查可提高胆道闭锁的早期诊断率。完善手术方式、让更多的患儿接受肝移植、开辟新的治疗方法如抑制肝胆管细胞凋亡、抗体及基因治疗可提高胆道闭锁的长期治愈率     

Impact of Portal Venous Pancreas Graft Drainage on Kidney Graft Outcome in Simultaneous Pancreas-Kidney Recipients Reported to UNOS

Clinical data on the potential immunologic impact of portal (PD) vs. systemic (SD) venous pancreas graft drainage on outcome remains controversial. We reviewed the UNOS database to study the effect of PD vs. SD on the incidence of kidney graft rejection and survival in first cadaveric simultaneous pancreas-kidney (SPK) recipients transplanted 1994-2001. We studied three groups: all SPK (n=6629, 13% PD) (group I), SPK on tacrolimus (n=3563, 17% PD) (group II), and SPK on tacrolimus performed at centers with significant PD experience (n=948, 46% PD) (group III). The cumulative kidney graft rejection incidence for PD vs. SD was only significantly different in group I (for PD vs. SD, respectively: at 6 months, 31% vs. 36% [p=0.015]; at 1 year, 37% vs. 43% [p=0.006]). Kidney graft survival was similar in all groups for PD vs. SD. Multivariate analysis of group III showed only transplantation during the earlier era (1994-96), but not SD, to be an independent risk factor for kidney graft rejection. Portal venous pancreas graft drainage does not affect kidney graft rejection and survival in SPK recipients on tacrolimus. Our data suggests that the efficacy of current immunosuppressive protocols and increasing center experience are clinically much more relevant than any potential immunologic advantage of portal venous drainage in SPK recipients.     

Biliary atresia--a fifteen-year review of clinical and pathologic factors associated with liver transplantation

Purpose

The aim of this study was to identify clinical and pathologic factors associated with liver transplantation in infants with biliary atresia initially treated with Kasai hepatic portoenterostomy (KHPE).

Methods

Institutional Review Board approval was obtained. Records of patients with biliary atresia diagnosed between January 1986 and December 2000 were reviewed. Patients were divided into those who never required transplantation, those who underwent transplant in the first year after KHPE, and those who required transplantation later in childhood. Analysis of variance (ANOVA) compared multiple factors among the 3 groups. Proportional analysis compared those who required transplantation against those who did not. Statistical significance was considered achieved if P was less than .05.

Results

Forty-five patients were identified. Survival after KHPE was 96% (43 of 45). Sixteen (37%) never required transplantation, 13 (30%) underwent transplant within 1 year after KHPE, and 14 (33%) underwent transplant more than 1 year after KHPE. ANOVA comparison showed that the duration of jaundice before KHPE as a predictor for liver transplantation approached significance (P = .082). Proportional analysis found that a longer initial duration of jaundice before KHPE (P = .016) and failure to establish biliary flow (P = .033) were also significant predictive factors. An initial requirement for phototherapy (P = .057) and ductules less than 200 μm in diameter (P = .060) showed a trend toward predictor of liver transplantation.

Conclusions

A longer duration of jaundice before KHPE, failure to establish bile flow, requirement for phototherapy in the neonatal period, and ductules smaller than 200 μm are associated with liver transplant after KHPE.     

负压引流和内口修补术治疗肛周脓肿的疗效分析

为观察负压引流对促进肛周脓肿术后创面愈合的疗效。将100例肛周脓肿患者随机分为治疗组和对照组,每组50例,治疗组采用一期肛周脓肿戳洞负压引流和内口修补术治疗,对照组采用肛周脓肿常规一期根治术治疗。观察两组术后创面愈合时间、肛门疼痛评分及术后复发评分。结果显示,治疗组在创面愈合时间、术后疼痛评分及术后6个月复发评分方面均优于对照组（P〈0．05）。结果表明,戳洞负压引流和内口修补术能显著缩短肛周脓肿术后创面愈合时间,并减轻术后疼痛,降低复发率。     

VSD技术结合全厚皮片植皮修复足背部大面积皮肤软组织缺损

目的探讨应用负压封闭引流（vacuum sealing drainage,VSD）技术结合全厚皮片植皮修复足背部大面积皮肤软组织缺损或毁损的临床效果。方法对10例车祸伤导致的足背部大面积皮肤软组织缺损或毁损者采用先以VSD技术覆盖创面,待肉芽组织生长良好后再以全厚皮片植皮进行修复。结果10例患者足部创面愈合良好,足部植皮一期成活,植皮无破溃,无瘢痕挛缩,足部外形不臃肿,是部功能无明显影响。结论该手术方法操作简单,风险低,术后护理方便,植皮区不需二期整形,不影响足部功能,是修复足背部皮肤软组织缺损的理想方法。     

持续封闭负压引流结合三棱针多点打孔对蝮蛇咬伤的治疗效果观察

目的：观察腹蛇咬伤后咬伤部位早期持续封闭负压引流（VSD）结合三棱针打孔法治疗的效果.方法：根据患者中毒时间、病情严重程度采用配伍设计,选取2012年7-8月份我院接诊手部腹蛇咬伤肿胀患者40例,随机分为A组（切开引流组,10例,在咬伤部位行＂＋＂字形切开至皮下层）、B组（切开引流＋VSD组,10例,伤口＂＋＂字形切开,然后行持续VSD）、C组（单纯三棱针打孔组,10例,在咬伤伤口周围用三棱针多点打孔20～30个）和D组（三棱针打孔＋VSD组,10例,在咬伤伤口周围用三棱针多点打孔20～30个,然后行持续VSD）.入院后同时给予抗腹蛇毒血清、抗感染及中医中药等治疗.观察患者患肢肿胀消退时间、伤口部位感染、脓肿、坏死发生率及住院时间.结果：①各组间患肢肿胀消退时间差异显著,D组明显低于A、B、C组[（2.1±1.5）d比（5.0±2.7）d,（3.4±1.7）d,（3.1±3.0）d;P〈0.05];②B、D组无一例出现伤口部位感染、脓肿形成及坏死,与A、C组（20%和40%）比较差异显著（P〈0.05）.③各组间伤口愈合时间及住院时间差异显著,D组均明显低于A、B、C组[（3.5±1.5）d比（7.5±2.5）d,（5.3±1.3）d,（4.7±1.3）d; P〈0.05].结论：腹蛇咬伤后咬伤部位早期三棱针打孔法结合持续VSD可显著缩短患者患肢肿胀消退时间及住院时间.     

The Comarr Memorial Award for Distinguished Clinical Service: The Legacy of A. Estin Comarr,MD

Abstract

Background

Subfascial wound suction drains are commonly used after spinal surgery to decrease the incidence of post-operative hematoma. However, there is a paucity of literature regarding their effectiveness.

Objective

To report four cases of post-operative spinal epidural hematoma causing massive neurological deficit in patients who had subfascial suction wound drains.

Methods

During an 8-year period, a retrospective review of 1750 consecutive adult spinal surgery cases was performed to determine the incidence, commonalities, and outcomes of catastrophic neurological deficit caused by post-operative spinal epidural hematoma.

Findings

Epidural hematoma causing major neurological deficit (American Spinal Injury Association B) was identified in 4 out of 1750 patients (0.23%). All four patients in this series had subfascial wound suction drains placed prophylactically at the conclusion of their initial procedure.

Results

Three patients developed massive neurological deficits with the drain in place; one patient had the drain removed at 24 hours and subsequently developed neurological symptoms during the following post-operative day. Significant risk factors for the development of hematoma were identified in two of the four patients. Average time to return to the operating room for hematoma evacuation was 6 hours (range 3–12 hours). Neurological status significantly improved in all four patients after hematoma evacuation.

Conclusions

Post-operative epidural hematoma causing catastrophic neurological deficit is a rare complication after spinal surgery. The presence of suction wound drains does not appear to prevent the occurrence of this devastating complication.     

Outcomes of Irreversible Electroporation for Perihilar Cholangiocarcinoma: A Prospective Pilot Study

PurposeTo investigate the safety and efficacy of percutaneous or open irreversible electroporation (IRE) in a prospective cohort of patients with locally advanced, unresectable perihilar cholangiocarcinoma (PHC).Materials and MethodsIn a multicenter Phase I/II study, patients with unresectable PHC due to extensive vascular involvement or N2 lymph node metastases or local recurrence after resection for PHC were included and treated by open or percutaneous IRE combined with palliative chemotherapy (current standard of care). The primary outcome was the number of major adverse events occurring within 90 d after IRE (grade ≥3), and the upper limit was predefined at 60%. Secondary outcomes included technical success rate, hospital stay, and overall survival (OS).ResultsTwelve patients (mean age, 63 y ± 12) were treated with IRE. The major adverse event rate was 50% (6 of 12 patients), and no 90-d mortality was observed. All procedures were technically successful, with no intraprocedural adverse events requiring additional interventions. The median OS from diagnosis was 21 mos (95% confidence interval, 15–27 mos), with a 1-y survival rate of 75% after IRE.ConclusionsPercutaneous IRE in selected patients with locally advanced PHC seems feasible, with a major adverse event rate of 50%, which was below the predefined upper safety limit in this prospective study. Future comparative research exploring the efficacy of IRE is warranted.