急诊左半结肠一期切除吻合术25例治疗体会

目的探讨急诊左半结肠切除一期肠吻合的可行性。方法腹腔探查完后，用布带结扎横结肠，游离肠系膜后，于预切除肠段的上端切开作肠外减压，挤压排空粪便，切除病变肠管，端端吻合，术后作肛管扩张，停留肛管引流，胃肠减压。结果全部病人预期痊愈出院，无发生吻合口漏和腹腔污染。结论该法有利于吻合口的愈合，增加左半结肠一期切除吻合的安全性，减少第2次手术痛苦，可推荐为左半结肠急诊切除一期吻合的良好方法。     

Surgical treatment of metastatic lung tumors — Recent changes in techniques and indications

Between 1969 and 1995, 180 patients underwent complete resection of lung metastases during initial thoracotomy at our institute, involving the resection of 917 pulmonary nodules at 202 thoracotomy procedures. The overall postmetastasectomy 5- and 10-year survival rates were 46% and 30%, respectively. Of 111 patients who underwent segmentectomy and/or local excision, 57 had multiple metastases, 39 of whom were treated by Nd:YAG laser after 1986, and 18 by conventional procedures before 1985. The average number of tumors resected per patient treated with the Nd:YAG laser was significantly greater than that of those treated with conventional procedures. However, the survival curve of the laser-treated group was better than that of the laser-nontreated group. Moreover, slightly better survival was achieved in patients operated on after 1992 compared with those operated on before 1991. We conclude that the laser technique may be warranted to afford complete resection of metastases and adequate pulmonary reservation in combination with a selected approach for thoracotomy under the exact detection of tumor localization using the most recent high-quality computed tomography (CT) scan. Furthermore, a one-stage operation to control synchronous intra- and extrapulmonary malignamcies may become a possible option in combination with selective adjunctive therapy.     

左半结肠癌急性梗阻一期切除吻合的安全保证——彻底快速而无污染的肠减压术(英文)

目的研究一种彻底快速而毫不污染手术野的术中肠减压方法,以便提高手术的安全性。方法游离系膜后,钳夹下将拟切除肠段的下端先切断,将其近侧断端置入并固定于粘附在手术床边的塑料袋中;松开肠钳,肠内容物自由流入袋内;双手交替推挤膨胀的肠段,由近而远,由小肠向大肠,直至大、小肠的内容物彻底排空。钳夹下切断上端,移除切下的肠段和充满粪便的塑料袋。结果使用本法行肠减压术,一期切除急性梗阻的左结肠癌31例,均未发生吻合口漏,创口一期愈合。另有6例肝段切除同时切除未作肠道准备的结肠癌亦取得同样结果。同法亦用于各种急性小肠梗阻,均未造成腹腔污染。结论本法可推荐为术中肠减压的首选方法。     

Assay discrepancy in mild haemophilia A due to a factor VIII missense mutation (Asn694Ile) in a large Danish family

Factor VIII gene analysis in a large consanguinous Danish family comprising 24 affected males and four homozygously affected females revealed an Asn694Ile mutation within the A2 domain. The factor VIII gene mutation led to a mild haemophilia A phenotype with factor VIII function displaying discordance between one-stage clotting and chromogenic two-stage assays. In one-stage assays, values ranged from 0.05 to 0.30 IU/ml (males) and from 0.19 to 0.29 IU/ml (homozygous affected females), whereas the chromogenic two-stage assay produced values of around only 50% of the one-stage result [0. 02-0.12 IU/ml (males); 0.06-0.10 IU/ml (females)]. The differences are suggested to be caused by the effect of the mutation on the active cleaved form of the factor (F)VIII protein. As the original amino acid (Asn) is conserved in all known FVIII A2 sequences, but not in ceruloplasmin, we suggest that Asn694 is involved in an A2-specific functional role. Examination of a homology model of the A domains predicts that the Asn694Ile mutation (i) results in the loss of two potential hydrogen-bonding interactions and (ii) hampers the integration of the bulky side-chain of Ile into the A2 domain core, probably causing an altered stability and/or folding of the protein. Interestingly, the disease in this Danish family was originally proposed to be von Willebrand-Jürgens disease. However, the current study rules out the co-existence of either von Willebrand's disease or the presence of the Normandy variant of von Willebrand factor (type 2N).     

Ⅰ期手术治疗结肠穿孔的疗效研究

目的研究Ⅰ期手术治疗结肠穿孔的有效性及安全性。方法将綦江区人民医院胃肠外科2011年9月至2014年4月收治的37例结肠穿孔患者分为观察组与对照组。观察组行Ⅰ期穿孔修补术或肠切除吻合术;对照组行分期手术,Ⅰ期行穿孔修补术或肠管切除术,Ⅱ期行近端肠管造瘘术。比较两组患者的疗效及安全性。结果两组患者术中出血量、切口感染发生率、心肺并发症发生率及住院时间比较,差异无统计学意义(P0.05);观察组患者术后肛门排气、排便时间大于对照组,住院费用高于对照组,组间比较差异均有统计学意义(P0.05)。所有患者均安全度过围术期,无严重并发症发生,观察组19例患者中发生术后吻合口瘘1例、切口感染3例、无腹腔感染发生。结论对部分结肠穿孔患者行Ⅰ期手术治疗安全有效,值得临床推广。     

Aiming at One-Stage Corrective Surgery for Extended Thoracic Aortic Dilatation

Definitive treatment of extended thoracic aortic dilatation is a major surgical challenge. Histopathology of resected thoracic aortic wall may reveal undiagnosed aortitis affecting outcome. We sought to investigate the benefit of thorough histopathology after one-stage corrective surgery for the treatment of extended thoracic aortic dilatation. Five patients underwent one-stage corrective surgery using the hybrid open arch repair by the frozen elephant trunk together with endovascular aortic grafting. A representative sample of the resected aortic arch was procured for histology. T- and B-lymphocytes, plasma cells, macrophages, and immunoglobulin G4 (IgG4) positivity were evaluated by immunohistochemistry. The mean preoperative maximum aortic diameter was 54 mm (range, 41–79 mm). The mean follow-up was 18 months (range, 1–24 months). As confirmed by computed tomography (CT) upon follow-up, complete thrombosis of the false lumen at the level of the frozen elephant trunk was achieved in all patients with dissection. One patient was operated due to atherosclerotic dilatation of the thoracic aorta, and postoperative CT showed successful exclusion of the atherosclerotic dilatation; this 75-year-old man was diagnosed with IgG4-positive aortitis and experienced unexpected blindness after surgery without evidence of emboli or long-term neurological impairment upon repeated brain CT. The hybrid open arch repair by the frozen elephant trunk and simultaneous endovascular repair is a feasible choice for one-stage surgery through sternotomy aiming at definitive treatment of extended thoracic aortic pathology. However, systematic evaluation of inflammation may reveal concealed aortitis affecting postoperative outcome and need for long-term surveillance.     

One-Stage Revision Arthroplasty Using Cementless Stem for Infected Hip Arthroplasties

The objective of this retrospective study was to evaluate our results with one-stage revision using cementless femoral stem for infected hip arthroplasties. Twenty-four patients were included in the study. The acetabular component was cemented in 9 cases. In 2 patients a structured bone allograft was necessary to fill an acetabular defect. After a mean follow-up of 44.6 months, 23 patients showed no signs of infection (95.8%), the mean functional response according to the Merle d’Aubigné scale was 13.8 and the mean Harris Hip Score was 65.4. One-stage revision hip arthroplasty using cementless femoral stem was associated with a high success rate.     

Tantalum Acetabular Augments in One-stage Exchange of Infected Total Hip Arthroplasty: A Case–control Study

During the one-stage exchange procedure for periprosthetic joint infection (PJI) after total hip arthroplasty (THA), acetabular defects challenge reconstructive options. Porous tantalum augments are an established tool for addressing acetabular destruction in aseptic cases, but their utility in septic exchange is unknown. This retrospective case–control study presents the initial results of tantalum augmentation during one-stage exchange for PJI. Primary endpoints were rates of re-infection and short-term complications associated with this technique. Study patients had no higher risk of re-infection with equivalent durability at early follow-up with a re-infection rate in both groups of 4%. In conclusion, tantalum augments are a viable option for addressing acetabular defects in one-stage exchange for septic THA. Further study is necessary to assess long-term durability when compared to traditional techniques for acetabular reconstruction.     

双膝骨关节炎一期与二期全膝关节置换的比较

目的比较双侧膝关节骨关节炎行一期或二期双侧全膝关节置换术(total knee arthroplasty,TKA)的临床疗效和安全性。方法回顾分析我院2005年4月至2012年4月93例双侧膝关节骨关节炎患者分别接受一期(A组)或二期(B组)TKA治疗的临床资料。其中A组54例,男5例,女49例,年龄56~79岁,平均(65.8±6.5)岁;B组39例,男6例,女33例,年龄53~82岁,平均(66.1±7.7)岁。术前两组患者一般资料差异无统计学意义,具有可比性。比较两组患者术后住院总天数、总出血量、隐性出血量、输血量、引流量、术后血红蛋白、治疗费用及术后疗效(KSS评分、关节活动度及并发症),根据Gross方程计算总失血量及隐性失血量。结果两组患者术后引流量、输血量、总出血量、隐性出血量、住院天数及住院总费用差异均有统计学意义(P0.05);两组患者手术前后KSS评分、术前膝关节活动度(range of motion,ROM)差异均无统计学意义(P0.05),但术后KSS评分均较术前明显改善(P0.05);两组患者术后血肿发生率、深静脉血栓(deep venous thrombosis,DVT)发生率、切口愈合不良发生率及感染率差异均无统计学意义(P0.05),但是总并发症发生率差异有统计学意义(P0.05)。结论一期双侧TKA手术创伤较大,术后并发症发生率较高,有可能增加假体周围感染的风险,因此对这一术式的选择要慎重。我们建议对于年龄较轻、术前合并疾病较少及身体素质较好的双侧膝关节骨关节炎患者,充分告知相关手术风险,并经患者同意的情况下,可考虑一期双侧TKA。     

Characteristics of prosthetic joint infections due to Enterococcus sp. and predictors of failure: a multi-national study

The objective of this study was to review the characteristics and outcome of prosthetic joint infections (PJI) due to Enterococcus sp. collected in 18 hospitals from six European countries. Patients with a PJI due to Enterococcus sp. diagnosed between January 1999 and July 2012 were retrospectively reviewed. Relevant information about demographics, comorbidity, clinical characteristics, microbiological data, surgical treatment and outcome was registered. Univariable and multivariable analyses were performed. A total of 203 patients met the inclusion criteria. The mean (SD) was 70.4 (13.6) years. In 59 patients the infection was diagnosed within the first 30 days (29.1%) from arthroplasty, in 44 (21.7%) between 31 and 90 days, in 54 (26.6%) between 91 days and 2 years and in 43 (21%) after 2 years. Enterococcus faecalis was isolated in 176 cases (89%). In 107 (54%) patients the infection was polymicrobial. Any comorbidity (OR 2.53, 95% CI 1.18–5.40, p 0.01), and fever (OR 2.65, 95% CI 1.23–5.69, p 0.01) were independently associated with failure. The only factor associated with remission was infections diagnosed later than 2 years (OR 0.25, 95% CI 0.09–0.71, p 0.009). In conclusion, prosthetic joint infections due to Enterococcus sp. were diagnosed within the first 2 years from arthroplasty in >70% of the patients, almost 50% had at least one comorbidity and infections were frequently polymicrobial (54%). The global failure rate was 44% and patients with comorbidities, fever, and diagnosed within the first 2 years from arthroplasty had a poor prognosis.