“手术优先”正颌正畸联合矫治成人骨性牙颌面畸形的初步临床研究

目的 :初步探讨'手术优先'正颌正畸联合矫治成人中重度骨性牙颌面畸形的临床疗效。方法 :回顾性分析接受'手术优先'正颌正畸联合治疗的中重度骨性牙颌面畸形的23例成年患者的治疗过程,并对短期临床疗效进行初步评价。结果:截至目前所有患者均顺利完成整个'手术优先'正颌正畸联合治疗程序,治疗后随访至少6个月以上(随访时间6~23个月,平均10.3个月),均获得较为满意的面部外形和咬合关系。整个治疗周期为9~16个月,平均13.2个月。结论 :'手术优先'正颌正畸作为新策略可以选用于矫治成年中重度骨性牙颌面畸形,缩短治疗周期,短期临床效果满意,长期临床疗效有待进一步评价。

模拟“手术入路”自主探究式教学法在局部解剖学实习中的应用

目的:探讨局部解剖学实习中采用模拟"手术入路"自主探究式教学法的教学效果。方法:在2012级本科临床医学专业分别抽取两个班作为实验组和对照组,两组进行对比性研究。结论:模拟"手术入路"自主探究式实习法既能培养学生的实习兴趣和知识探究习惯,也能激发学生自主学习的动力和提高实习动手的积极性,是局部解剖学实习的一种行之有效的方法。

电视胸腔镜手术16例报告

共完成电视胸腔镜手术１６例，包括电刀切除肺内肿块２例，纵隔囊肿摘除２例，胸腔内取异物２例，肺大泡切除和胸膜粘连术２例，纵隔淋巴结活检２例，胸膜活检和胸膜粘连术１例，凝固性血胸血块清除１例，肺楔形切除１例，左下和右下肺叶切除各１例，恶性胸膜间皮瘤切除１例。本组无严重并发症，仅１例恶性胸膜间皮瘤术中剥离肿瘤时出血，立即改为开胸手术。１６例ＶＡＴＳ均痊愈出院。对ＶＡＴＳ的适应证、禁忌证、手术切口、术野暴露和外科手术技术进行了讨论。

教材“手术”让课堂焕发生命的活力

新课程标准下的新教材并非"圣经",教师应根据地区、学校、学生的不同,对教材进行适当的"手术","活化"教材,做到"形异神同",从而让课堂焕发生命的活力。

一份“手术记录”失真失准危要害分析

I临床工作中，因手术记录词不达意或文字不通顺，引起岐意误解的事时有发生；有甚至记录失真失准而造成的医疗差错事故屡见不鲜。医者在医疗过程中不严谨务实，不负责任，马马虎虎，致病者不仅多次受痛苦折磨，而且额外耗费经济，有甚者造成病残或死亡，应追究法律责任的。当今社会法律意识观念日渐加强并有所健全规范化，对其重的是要绳之以法。在医疗文书书写过程中应严格把握三句话六个字：“真实、准确。

Research progress on the correlation between aqueous humor components and pathogenesis and postoperative complications in patients with different types of cataracts

Aqueous humor provides the necessary nutrition for the lens and transports the metabolites in the eye.It was a liquid that can directly reflect the microenvironment in the eye'and it can be easily obtained during the operation.This review intended to analyze the components of aqueous humor in patients with different types of cataracts'so as to reflect the pathogenesis and development of the disease'evaluate the incidence of postoperative complications and provide reference value for the surgical design of sequential cataract surgery.The aqueous humor components of different types of cataracts showed different degrees of inflammation'oxidative stress and extracellular matrix remodeling.The biomarker of early neuropathy in diabetic cataract was neural cell adhesion molecule-1(NCAM1).Transforming growth factor-β(TGF-β)was the evaluation factor of disease development in patients with pseudoexfoliation syndrome.The relationships between postoperative complications of different types of cataracts and aqueous humor components were as follows:Macular edema after diabetic cataract surgery was associated with tumor necrosis factor-alpha;capsular contraction after high myopic cataract surgery was related to monocyte chemoattractant protein-1(MCP-1)and TGF-β2;Klotho and glutathione S-transferase P 1(GSTP1)were associated with high intraocular pressure after primary open-angle glaucoma complicated by cataract surgery;capsular contraction after retinitis pigmentosa complicated by cataract surgery was associated with matrix metalloproteinases;pro-inflammatory cytokines and fibroblast growth factor 4 in the aqueous humor of congenital cataracts were associated with posterior capsular opacification after surgery.Granulocyte colony stimulating factor 3 and MCP-1 were the main cytokines mediating the pain of the second eye in the binocular sequential cataract surgery short interval(1 wk)'while MCP-1 mediated pain in the long interval(6 wk).The second eye after binocular sequential cataract surgery had a higher level of proinflammatory factors.The components of aqueous humor in patients with different types of cataracts were related to the pathogenesis and postoperative complications of the disease.Monitoring the components of the aqueous humor could help better understand the intraocular microenvironment of different types of cataracts and provide a reference for predicting the development of the disease and implementing relevant targeted therapy.

Cranial ultrasound in perioperative period of acute severe traumatic brain injury

Objective To observe the value of cranial ultrasound for perioperative patients with acute severe traumatic brain injury(sTBI).Methods Data of 55 sTBI patients who underwent craniotomy were retrospectively analyzed.The patients were divided into observation group(n=15)and control group(n=40)according to received perioperative cranial ultrasound or not.The general data and surgical data were compared between groups,and ultrasonic data of observation group were analyzed.Results The proportions of good prognosis 1 and 6 months after operation in observation group were both higher than those in control group,while the incidence of cerebral infarction in observation group was lower than that in control group(all P<0.05).No significant difference of general data nor other surgical data was found between groups(all P>0.05).Acute encephalocele occurred in 1 case in observation group during operation,and cranial ultrasound accurately showed the contralateral secondary epidural hematoma.Increased intracranial pressure in different degrees were found in all 15 cases(15/15,100%)in observation group after operation with transcranial color coded Doppler(TCCD)or transcranial Doppler(TCD),while cerebral vascular spasm was observed in 5 cases(5/15,33.33%),among them 4 cases(4/5,80.00%)were diagnosed cerebral infarction based on CT examination.Conclusion Cranial ultrasound could be used to evaluate changes of sTBI in perioperative period and guide adjusting treatment strategy in time,being valuable for reducing risk of postoperative cerebral infarction and improving prognosis.

Comparative study on the efficacy of transoral robotic surgery and non-robotic surgery for tongue base tumors

Objective:To compare the efficacy of transoral robotic surgery(TORS)and non-robotic surgery(NRS)in the treatment of tongue base tumors.Methods:A total of 45 patients with tongue base tumors treated in our hospital were selected,and they were divided into the TORS group and NRS group according to different surgical methods.The surgical indicators and postoperative complications of patients in the two groups were compared and analyzed.Results:Compared with the NRS group,the operative time,bleeding volume and length of hospital stay were less in the TORS group,and the postoperative recurrence rate was less in the TORS group than that in the NRS group.The incidence rate of dysphagia and restricted mouth opening in the TORS group was lower than that in the NRS group within 30 d after surgery,and the difference was statistically significant(P<0.05).Conclusion:TORS has better minimally invasive advantages in the treatment of tongue base tumors,including less intraoperative bleeding,smaller trauma,shorter length of hospital stay and faster recovery.

Risk Factors of Early Complications after Pancreaticoduodenectomy in 200 Consecutive Patients

To study the risk factors for early complications after pancreaticoduodenectomy （PD）. Methods： Two hundred patients undergoing PD at our hospital between December 1996 and September 2002 were reviewed retrospectively. Standard PD was performed on 176 cases, standard PD with extended lymphadenectomy on 24 patients, whereas pylorus-preserving PD was not used. An end-toside combined with mucosa-to-mucosa pancreaticojejunostomy was performed on the patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy on the patients with a soft pancreas and a non-dilated duct. The risk factors with the potential to affect the incidence of complications were analyzed with SAS 8.12 software. Logistic regression was then used to determine the effect of multiple factors on early complications. Results： The overall rate of the major com- plications was 21% （42/200）, with the failure of pancreaticojejunal anastomosis being the most frequently encountered. Age （odds ratio [OR] 2.162）, diabetes mellitus （OR 4.086）, total serum bilirubin level （OR 7.556）, end-to-end pancreaticojejunostomy （OR 2.616）, T tube through the choledochojejunostomy （OR 0.100）, and blood transfusion over 1000 mL （OR 2.410） were the significant risk factors for the morbidity. Conclusion： The results from published series concerning morbidity after pancreaticoduodenectomy are not comparable because of lack of homogeneity between them. The knowledge of the complications rate in each particular department turns out essentially to provide the patient with tailored information about risks before surgery. Additionally, management of postoperative complications is essential for improving the results of this operation.

Clinical Application of Exclusive Right-Thoracic Approach in Surgery with or without Laparotomy for Mid-Upper Esophageal Cancer

OBJECTIVE To evaluate the clinical application of a right-thoracic approach with or without laparotomy for mid-upper esophageal cancer. METHODS We retrospectively reviewed the data of 34 esophageal cancer patients who received Belsey surgery or a modified Ivor-Lewis surgery from November 1992 to April 2007. Twenty of the patients underwent a Belsey prodecdure （Group A） from November 1992 to January 2001 and 14 underwent a modified Ivor-Lewis prodecdure （Group B） from May 2001 to April 2007. RESULTS Twenty patients with esophageal cancer received an esophagectomy through an exclusive right-thoracic approach （Belsey surgery）, and 14 patients received an esophagectomy through a right-thoracic approach combined with a laparotomy （modified IvorLewis surgery）. The complication rate was 15% （3/20） and 7.1% （1/14） respectively. The survival rate was 42.9% （5-year survival） and 38.7% （5-year survival） respectively for these two groups. CONCLUSION An exclusive right-thoracic approach （Belsey surgery） is associated with more complications. It is not a routine surgery for cancer of the mid-upper thorax of the esophagus, but can be selectively used as palliative esophagectomy for esophageal cancer patients with poor pulmonary function. Modified Ivor-Lewis surgery can simultaneously be utilized to resect the primary tumor and dissect lymph nodes of the thorax and abdomen. With a shorter time period of surgery and postoperative recovery period, modified Ivor-Lewis surgery can achieve better effects with patients who have midupper esophagus cancer.

Diagnosis and Treatment of Liver Cystadenocarcinoma:Report of 18 Cases

Objective： To discuss the diagnosis and treatment of liver cystadenocarcinoma. Methods： The clinical, imaging, and pathological data of 18 patients with liver cystadenocarcinoma between January 2000 and December 2004 in our hospital were retrospectively analyzed. Results： The liver cystadeno- carcinoma was seen in males and females （m/f： 9/9）; mean age was 51 years. Ultrasonography revealed cystic parenchymatous mass echoes of fluid predominance with uneven margins. Nonenhanced CT revealed intrahepatic low-density space occupying shadows with nodular protrusions on the margins in all cases. Enhancement CT revealed that part of the nodular protrusions and tissues around the lesions were enhanced and the delayed phase disappeared. 66.67% （12/18） of the lesions were more than 10 cm in diameter. The diagnosis of liver cystadenocarcinoma was confirmed by postoperative pathology in all cases. Of these patients, 12 lesions were in the left lobe, 3 in the right lobe, 1 in the mid lobe, 1 in the right and left lobe, and 1 in the caudate lobe. Of tile 18 patients, 6 had completely resect the cystadenocarcinoma, 2 were surgically explored, one received TAE＋fine needle aspiration cytology＋injection of chemotherapy drugs, and 9 underwent radical hepatectomy＋choledochostomy or T-tube drainage, in which, one patient underwent choledochostomy＋left hepatectomy＋radical gastrectomy for cancer＋lymphadenectomy; one patient underwent resection of the cystadenocarcinoma, who had relapse 20 months after the initial procedure. The patient received repeat reseet for the recurrent cystadenoeareinoma＋eholangio-jejunostomy. Six months later she had another relapse and received repeat reseet （only PMCT） for the recurrent cystadenoearcinoma. The patient died from eholangiopleural fistula after third time operation （PMCT） was attempted perioperatively. Seven patients died of metastatic disease after operation. The remaining 10 patients were alive without cancer recurrence or metastasis （mean follow-up 20 months）. Conclusion： Liver eystadenocarcinoma is rarely seen and grows slowly. It shows some typical clinical and imaging features. The crux for diagnosing and treating liver cystadenoeareinoma is how familiar the surgeon is with the pathology and clinical features of the condition. Prolonged survival can be achieved by radical resection of the tumor.

Novel operating theatre scheduling method based on estimation of distribution algorithm

In order to improve the efficiency of operating rooms,reduce the costs for hospitals and improve the level of service qualities, a scheduling method was developed based on an estimation of distribution algorithm（ EDA）. First, a scheduling problem domain is described. Based on assignment constraints and resource capacity constraints, the mathematical programming models are set up with an objective function to minimize the system makespan. On the basis of the descriptions mentioned above, a solution policy of generating feasible scheduling solutions is established. Combined with the specific constraints of operating theatres, the EDA-based algorithm is put forward to solve scheduling problems. Finally, simulation experiments are designed to evaluate the scheduling method. The orthogonal table is chosen to determine the parameters in the proposed method. Then the genetic algorithm and the particle swarm optimization algorithm are chosen for comparison with the EDA-based algorithm, and the results indicate that the proposed method can decrease the makespan of the surgical system regardless of the size of operations. Moreover, the computation time of the EDA-based algorithm is only approximately 5 s when solving the large scale problems, which means that the proposed algorithm is suitable for carrying out an on-line scheduling optimization of the patients.

The Diagnosis and Treatment of Virilizing and Fem- inizing Adrenal Syndrome

Objective: To inquire into diagnosis, and treatment of virilizing andfeminizing a-drenal syndrome, differential diagnosis between benign and malignant sex hormoneproducing adrenal neo-plasma and, treatment principles of congenital adrenal hyperplasia (CAH).Methods: Eight cases of CAH and 5 cases of sex hormone producing adrenal neoplasma were admitted tohospital during 1986-1996. The former included 3 rare cases of 17 a hydroxylase deficiency. Thelatter included 3 cases of feminizing adrenal tumor and 2 cases of virilizing adrenal tumor.Results: Weight, size and CT of the tumor, DHEA, 17 -ks, sex hormone levels, infiltration, andmetastasis were closely related to the degree of differentiation of the tumors. Conclusion:Virilizing and feminizing adrenal neoplasm were removed surgically by different incisions. Modifiedsubcostal incision was recommended as the best choice for huge adrenal mass. Corticoadrenal hormonetreatment fa CAH should be individualized according to the different types of the disease. Sexhormones were not suitable for children suffering from 17 hydroxylase deficiency before puberty.

An Analysis of Prospective Outcome of Re-resection for Recurrent Live Cancer and Extrahepatic Metastases,a Follow-up of 267\Cass

Objective To evaluate the prospective outcome and summarize experience in re-resection for recurrent liver cancer and extrahepatic metastases. Methods The clinical data of 267 patients with recurrent primary liver cancer (PLC) after re-resection from January 1960 to July 2000 were retrospectively analyzed. Re-hepatectomy was performed on 205 cases, resection of extrahepatic metastases on 51 cases and combined resection of recurrent liver cancer and extrahepatic metastases on 11 cases. The clinico-pathologic features, operation type and survival were compared. Results The types of liver re-resection included left lateral lobectomy in 11.2% of patients, hemihepatetomy and extended hemi-hepatectomy in 4.4%, local radical resection in 68.3%, other subsegmentectomy in 17.1%. The peak recurrence rate (64.4%) occurred at 1–2 years. The overall 1-, 3, 5- and 10-year survival rates after second resection were 81.0%, 40.3%, 19.4% and 9.0% respectively, while they were 77.5%, 29.8%, 13.2% and 6.61% respectively after the third resection. The median survival time was 44 months. The re-resection with extrahepatic metastases also provided the possibility of longer survival. Conclusion The results suggest that subsegmentectomy and local excision is appropriate for the hepatic repeat resection. The peak recurrence may be correlated with portal thrombus and operative factor. The re-resection can be indicated not only in intrahepatic recurrent metastases but also in extrahepatic metastases in selected patients. Re-resection has become the treatment of choice for recurrence of PLC, as neither chemotherapy nor other nonsurgical therapies can achieve such favorable results. Key words prospective outcome - re-resection - primary liver cancer - recurrence - extrahepatic metastases

多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值

目的探讨多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值。方法 9例颅底肿瘤术前均行DynaCTA检查及MRI薄层(2 mm)增强扫描检查,将多组影像数据输入工作站,采用"双容积重建"技术进行脑血管及MRI的影像融合,通过静态及动态融合影像观察肿瘤与脑结构、血管及颅骨的毗邻关系,并对肿瘤的诊断、手术治疗及预防血管并发症进行分析。结果 9例均获得满意的影像融合、具有很好的空间一致性,在一张影像上可以清晰显示病变及其周围脑结构、血管及颅骨解剖关系,提高精准性诊断,并应用于指导治疗策略、设计手术划及预防并发症。9例均恢复满意出院。结论多模态影像融合对提高颅底肿瘤的诊断精准性、提高肿瘤全切除率、降低病死率和残疾率效果肯定,对血管损伤并发症治疗疗效肯定。

Surgical Resection of Right or Total Caudate Lobe of the Liver Including the Paracaval Portion

Objective To explore the method for and experience of the right or total caudate lobectomies including the paracaval portion. Methods The right posterior approach was employed for right caudate lobectomy and the left lateral approach for total caudate lobectomy. Prior to liver parenchymal transection, dissection was made to separate the caudate lobe and the tumor from the retrohepatic inferior vena cava (IVC). The transection was carried out by forceps and finger fracture with or without some kind of hepatic vascular occlusion. Results A total of 7 right and 6 total caudate lobectomies were performed, all including resection of the paracaval portion. There were no operative deaths or severe complications. The mean intraoperative blood loss was 896 ml (range: 250–2 000 ml). Among the 13 hepatectomies, 10 were done under portal triad clamping with a mean clamp time of 25 min (range: 10–83 min). There was a mean postoperative hospital stay of 12 days (range: 9–22 days). Conclusion Athough deeply located and in close proximity to the trunk of the main hepatic veins and the portal pedicle, the caudate lobe including paracaval portion can be safely resected either alone or combined with liver resection. Key words hepatectomy - liver neoplasms - inferior vena cava-surgery

Clinical Experience of Primary Retroperitoneal Tumor: Report of 600 Cases

Objective： To summarize the experience of management for primary retroperitoneal tumor （PRPT） and to analyze the factors influencing the outcome after operation. Methods： The data of 600 cases of PRPT in General Hospital of PLA were reviewed retrospectively. Results： Of 600 cases of PRPT, 546 were surgically treated. Among theme 369 were malignant and 177 benign. 366 cases were followed up for 1 month to 15 years. The 1-years 3-year, and 5-year survival rate in the patients subject to complete resection was 90.5%, 73.2% and 53.6%, respectively, and that in incomplete resection patients was 70.6%, 32.0%, 5.7% respectively （P〈0.01）. The Cox multi-various regression analysis revealed showed completeness of tumor resection, sex and histologic type were associated closely with local recurrence. Conclusion： Sufficient preoperative preparation and complete tumor resection play important roles for reducing recurrence and improving survival.

The Role of Transesophageal Echocardiography for Transcatheter Closure of Atrial Septal Defects with the Amplatzer Septal Occluder

Objective: To evaluate of the role of transesophageal echocardiography (TEE)in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. Methods:Sixty- two patients (10 to 55 years of age) were selected for percutaneous closure of ASD bytrans-esophageal echocardiography, which was also used to monitor the procedure, to select theappropriate size of the Amplatzer device, to verify its position, and to access the immediateresults of the procedure. During the follow-up, transthoracic echocardiography (TTE) or TEE was usedto evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiacchamber diameters. Results: The mean ASD diameter by TTE ([19. 1 +- 5. 8] mm) was significantlysmaller (P< 0. 001) than the stretched diameter of the ASD (25. 1 +- 6. 4) mm. There are nosignificant differences between the TEE -measured value (23. 5+_6. 2) mm and the stretched diameterof the ASD (P > 0. 05). Due to proper patient selection all procedures were successful. There wasimmediate and complete closure in 61/62 patients, only one patients had trivial residual shunt.Follow- up was performed using TTE or TEE right after operation, 1 d, 1 month, 3 months, 6 monthsand yearly thereafter. Ail, patients remain asymptomatic without any clinical or technical problems.Conclusion: With the aid of TEE, percutaneous closure of ASD can be performed successfully, safely,and effectively.

The Observation of Pituitary Function in Patients with Acute Pituitary Apoplexy before and after Transsphenoidal Surgery

Objective： To explore the pituitary function of acute pituitary apoplexy and its effect by transsphenoidal surgery. Methods： The clinical data and endocrine hormones level of 25 patients with acute pituitary apoplexy who underwent transsphenoidal surgery from Jan. 2002 to June 2004 were retrospectively analyzed. Results： 13 cases underwent surgery within 3 days after admission and 22 cases within 1 week. Of the 25 cases, 9 patients suffered the impairment of pituitary-thyroidal function, 14 cases of pituitary-adrenal function and 11 cases of pituitary-gonadal function before surgery. After surgery, 5/9, 8/14 and 7/11 were recovered from the corresponding hypopituitarism. Conclusion： Hypopituitarism is a major manifestation of acute pituitary apoplexy. Urgent surgery decompression contributed to the improvement of pituitary function. Patients with hypopituitarism after surgery required the corresponding hormones replacement therapy.