外科及术后因素对加速康复外科模式下髋、膝关节置换术住院时间的影响

近年来,加速康复外科(enhanced recovery after surgery,ERAS)模式的广泛应用使得髋、膝关节置换术(total hip/knee arthroplasty,THA/TKA)患者可以早康复、早下床、早出院,但是仍有部分患者因各种原因尤其是外科及术后因素而延迟出院。本文通过对ERAS模式下THA/TKA患者住院时间影响因素的相关研究进行整理和分析,对导致住院时间延长的外科及术后因素做一综述。

外科护士职业危害因素与防护

分析外科护士常见职业危害因素，认为强化职业安全教育，提高防护措施，预防感染及针对化学因素、物理因素的防护，同时加强心理调节，提高适应能力，可减少职业危害因素的损伤，最大限度地保护外科护士和患者的安全，真正达到职业安全防护。

Pre-operative factors that can predict neoplastic polypoid lesions of the gallbladder

AIM:To investigate the preoperative factors that can predict neoplastic polypoid lesions of the gallbladder(PLGs) as well as malignant PLGs.METHODS:A retrospective analysis was conducted on the 210 consecutively enrolled patients who underwent cholecystectomy due to a PLG larger than 10 mm,as was determined by preoperative trans-abdominal ultrasonography or endoscopic ultrasonography.We ana-lyzed the medical,laboratory,radiologic data and the pathologic results.RESULTS:In 210 cases,146 had non-neoplastic polyps(69.5%) and 64 cases were neoplastic polyps(30.5%).An older age(≥ 65 years),the presence of diabetes mellitus(DM) and the size of polyp(≥ 15 mm) were revealed to be independent predictive variables for neoplastic polyps with odd ratios(OR) of 2.27(P = 0.044),2.64(P = 0.021) and 4.94(P < 0.01),respectively.Among the neoplastic PLGs,an older age(≥ 65 years),the presence of DM and polyp size(≥ 15 mm) were associated with malignancy with ORs of 4.97(P = 0.005),6.13(P = 0.001) and 20.55(P < 0.001),respectively.CONCLUSION:Among patients with PLGs larger than 10 mm in size,higher risk groups such as elderly patients more than 65 years old,those with DM or a large polyp size(≥ 15 mm) should be managed by cholecystectomy.

Obesity paradox among elderly patients with coronary artery disease undergoing non-cardiac surgery

Background High body mass index （BMI） is a risk factor for chronic cardiac disease. However, mounting evidence supports that high BMI is associated with less risk of cardiac morbidity and mortality compared with normal BMI, also known as the obesity paradox. There- fore, we sought to determine the existence of the obesity paradox in regard to perioperative 30-day cardiac events among elderly Chinese patients with known coronary artery disease undergoing non-cardiac surgery. Methods A post-hoc analysis of a prospective, multi-institutional cohort study was performed. Patients aged 〉 60 years with a history of coronary artery disease and undergoing non-cardiac surgery were grouped according to BMI： underweight （〈 18.5 kg/m2）, normal weight （18.5-24.9 kg/m2）, overweight （25-29.9 kg/m2） and obese （≥ 30 kg/m2）. Demographic information, perioperative clinical variables and incidence of 30-day postoperative cardiac adverse event were retrieved from a research database. Results We identified 1202 eligible patients （BMI： 24.3 ± 3.8 kg/m2）. Across BMI groups, a U-shaped distribution pattern of incidence of 30-day postoperative major cardiac events was observed, with the lowest risk in the overweight group. When using the normal-weight group as a reference, no difference was found in either the obesity or overweight groups in terms of a major cardiac adverse event （MACE）. However, risk of a 30-day postoperative MACE was significantly higher in the underweight group （odds ratio [OR] 2.916, 95% confidence interval [CI]： 1.072-7.931, P = 0.036）. Conclusion Although not statistically significant, the U-shaped relation between BMI and cardiac complications indicates the obesity paradox possibly exists.

Impact of lymphatic and/or blood vessel invasion in stage Ⅱ gastric cancer

AIM： To determine the prognostic value of lymphatic and/or blood vessel invasion （LBVI） in patients with stage 11 gastric cancer. METHODS： From January 2001 to December 2006, 487 patients with histologically confirmed primary gas- tric adenocarcinoma were diagnosed with stage 11 gas- tric cancer according to the new 7th edition American Joint Committee on Cancer stage classification at the Department of Gastric Cancer and Soft Tissue Surgery, Fudan University Shanghai Cancer Center. All patients underwent curative gastrectomy with standard lymph node （LN） dissection. Fifty-one patients who died in the postoperative period, due to various complications or other conditions, were excluded. Clinicopathologicalfindings and clinical outcomes were analyzed. Patients were subdivided into four groups according to the status of LBVI and LN metastases. These four patient groups were characterized with regard to age, sex, tumor site, pT category, tumor grading and surgical procedure （subtotal resection vs total resection）, and compared for 5-year overall survival by univariate and multivariate analysis. RESULTS： The study was composed of 320 men and 116 women aged 58.9 ± 11.5 years （range： 23-88 years）. The 5-year overall survival rates were 50.7% and the median survival time was 62 too. Stage Ⅱ a cancer was observed in 334 patients, including 268 T3N0, 63 T2N1, and three TIN2, and stage Ⅱb was observed in 102 patients, including 49 patients T3N1, 51 T2N2, one TIN3, and one T4aN0. The incidence of LBVI was 28.0% in stage II gastric cancer with 19.0% （51/269） and 42.5% （71/167） in LN-negative and LN- positive patients, respectively. In 218 patients （50.0%）, there was neither a histopathologically detectable LBVI nor LN metastases （LBVI-/LN-, group I）; in 51 patients （11.7%）, LBVI with no evidence of LN me- tastases was detected （LBVILN-, group 11）. In 167 patients （38.3%）, LN metastases were found. Among those patients, LBVI was not determined in 96 patients （22.0%） （LBVI-γLN, group Ⅲ）, and was determined in 71 patients （16.3%） （LBVI＋LN＋, group Ⅳ）. Correla- tion analysis showed that N category and the number of positive LNs were significantly associated with the presence of LBVI （P 〈 0.001）. The overall 5-year sur- vival was significantly longer in LN-negative patients compared with LN-positive patients （56.1% vs 42.3%, P = 0.015）. There was a significant difference in the overall 5-year survival between LBVI-positive and LBVI- negative tumors （39.6% vs 54.8%, P = 0.006）. Overall 5-year survival rates in each group were 58.8% （ Ⅰ）, 45.8% （Ⅱ）, 45.7% （Ⅲ） and 36.9% （Ⅳ）, and there was a significant difference in overall survival between the four groups （P=-0.009）. Multivariate analysis in stage 11 gastric cancer patients revealed that LBVI in- dependently affected patient prognosis in LN-negativepatients （P = 0.018） but not in LN-positive patients （P = 0.508）. CONCLUSION： In LN-negative stage 11 gastric cancer patients, LBVI is an additional independent prognostic markeF, and may provide useful information to identify patients with poorer prognosis.

Effect of perioperative blood transfusion on clinical outcomes in hepatic surgery for cancer

Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of different types of complications: infectious complications, tumor recurrence, decreased survival. Even if there is clear evidence of transfusion-induced immunosuppression, it is difficult to demonstrate that transfusion is the only determinant factor that decisively affects the outcome. In any case there are several motivations to reduce the practice of blood transfusion. The advantages and drawbacks of different transfusion alternatives are reviewed here, emphasizing that surgeons and anesthetists who practice in centers with a high volume of liver resections, should be familiar with all the possible alternatives.

探讨外科护理的风险因素和安全管理

手术是外科疾病的重要治疗手段.然而,手术创作、麻醉、加之疾病本身的刺激,可通过一系列神经内分泌反应,引起机体生理功能的紊乱,产生不同程度的心理压力,从而削弱机体的防御能力和手术的耐受力、直接影响手术预后.围手术期护理旨在术前、术中、术后整个诊治期间加强对病人的护理,全面评估病人,做好充分的术前准备,认真分析手术前、术中、术后护理的风险因素,加强手术护理的风险管理,是提高手术护理质量和保障手术顺利及病人生命安全的重要环节,因此手术护理人员应有高度工作责任心、严谨的工作态度、应具有相关的法律法规知识.有较强的风险防范意识,杜绝一切差错事故的发生,笔者集多年的工作实践探讨如下.

Noninfectious Fever Following Aortic Surgery:Incidence,Risk Factors,and Outcomes

Objective To determine the incidence, course, potential risk factors, and outcomes of noninfectious fever developed in patients after aortic surgery. Methods Patients who received operation for aortic aneurysm or dissection in our center from January 2006 to January 2008 were reviewed. Patients who met one of the following criteria were excluded： having a known source of infection during hospitalization; having a preoperative oral temperature greater than or equal to 38.0℃; undertaking emergency surgery; having incomplete data. Univariate analysis was performed in patients with noninfectious postoperative fever and those without, with respect to demographics, intraoperative data, etc. Risk factors for postoperative fever were considered for the muhivariate logistic regression model if they had a P value less than 0.10 in the univariate analysis. Results Totally 463 patients undergoing aortic surgery were enrolled for full review. Among them, 345 （74.5%） patients had noninfectious postoperative fever, the other 118 （25.5%） patients didn＇t develop postoperative fever. Univariate analysis demonstrated that several risk factors were associated with the development of noninfectious postoperative fever, including weight, surgical procedure, minimum intraoperative bladder temperature, temperature upon intensive care unit （ICU） admission, discharge, and during ICU stay, as well as blood transfusion. In a further multivariate analysis, surgical site of thoracic and thoracoabdominal aorta （odds ratio： 4.861; 95% confidence interval： 3.029-5.801; P=0.004）, lower minimum intraoperative bladder temperature （odds ratio： 1.117; 95% confidence interval： 1.01-1.24; P=0.04）, and higher temperature on admission to the ICU （odds ratio： 2.57; 95% confidence interval： 1.28-5.18; P=0.008） were found to be significant predictors for noninfectious postoperative fever. No difference was found between the febrile and afebrile patients with regard to postoperative hospitalization duration （P=0.558） or total medical costs （P=0.896）. Conclusion Noninfectious postoperative fever following aortic surgery is very common and closely related with perioperative interventions.

Correction of hypovitaminosis D improved global longitudinal strain earlier than left ventricular ejection fraction in cardiovascular older adults after orthopaedic surgery

Background Cardiovascular diseases and insufficient levels of vitamin D are risk factors for adverse surgical outcomes, and they are both commonly present among older adults undergoing orthopaedic surgery. Giving the cardiovascular effects of vitamin D, pre-operative diagnosis of hypovitaminosis D would be a valuable step for the implementation of supplementation protocols. We investigated if the nor- malization of serum 25 [OH] D could ameliorate cardiac performance of older adults suffering from cardiovascular diseases. Methods We enrolled 47 older adults scheduled for major orthopaedic surgery and suffering from hypovitaminosis D. Patients underwent 6-months cal- cifediol supplementation with a starting dose at first post-operative day of 50 ~tg/die in liquid preparation. Down-titration to 20 Ixg/die at 3-months assessment was planned. Cardiac performance was evaluated by measuring left ventricular ejection fraction （LVEF） and global longitudinal strain （GLS） during pre-operative assessments and at 1-month, 3-months, 6-months follow-ups. Results Six months of cal- cifediol supplementation were associated with a significant improvement of both LVEF （＋ 3.94%; 95% CI： -4.0789 to -0.8232; P 〈 0.01） and GLS （＋ 18.56%; Z = -5.895; P 〈 0.0001）. Conclusions Calcifediol supplementation normalized serum 25 [OH] D concentration after 1-month treatment. GLS offered better insights into myocardial contractile amelioration than LVEF, thus being useful for detecting earlier subclinical changes that may anticipate hemodynamic modifications.

Prognostic factors in 408 elderly lung cancer patients over 70 years old

Objective: The incidence and mortality of lung cancer in people over 70 years were increased in the past 10 years. We defined age 70 years as boundary line of the elderly patients in lung cancer and analyzed and identified the factors affecting prognosis. Methods: A retrospective study had enrolled 408 cases of lung cancer aged over 70 years old and SPSS13.0 software was used in univariate analysis and COX regression analysis to analyze factors affecting prognosis, such as gender, age, complications, symptoms, pathological type, clinical stage, effusion, surgery, radiotherapy, chemotherapy and so on. Results: In univariate analysis, symptoms, stage, effusion, surgery, chemotherapy and chemotherapy cycles showed affecting prognosis significantly. In COX regression analysis, it showed that clinical stage (P = 0.000), surgery (P = 0.013), chemotherapy cycles (P = 0.001) were independent prognostic factors. Conclusion: Elderly lung cancer patients could be benefit from surgery and adjuvant chemotherapy while early stage. At late stage, their survival time may be prolonged when receive chemotherapy at least 4 cycles. Single-agent chemotherapy would be a good choice for elderly lung cancer. Effusion, particularly, pericardial effusion significantly influenced the prognosis, so that it should be effectively controlled.

Effect of retension sutures on abdominal pressure after abdominal surgery

To evaluate the effect of retention sutures on abdominal pressure and postoperative prognosis in abdominal surgery patients. Methods： This prospective cohort study included patients who were admitted to Daping Hospital from May 15, 2014 to October 11, 2014. A total of 57 patients were enrolled, including 18 patients in the ＂U＂ type retention suture group, 17 patients in the intermittent retention suture group, and 22 patients in non-retention suture group. The demographic data, clinical data and risk factors for abdominal wound dehiscence were recorded. The bladder pressure （IVP） was monitored preoperatively, intraoperatively, and four days postoperatively. Additionally, the incidence of abdominal wound dehiscence and infection 14 days after the operation was recorded. Results： During the operation, the IVP decreased and then increased; it was at its lowest I h after the start of the operation （5.3 mmHg _＋ 3.2 mmHg） and peaked after tension-reducing （8.8 mmHg _＋ 4.0 mmHg）. The IVP values in the ＂U＂ type retention suture group and intermittent retention suture group were higher than in the non-retention suture group 4 days after operation （p 〈 0.005）. The Visual Analogue Scale （VAS） pain scores were 3.9 ~ 2.2, 3.8 ~ 2.0, and 3.0 _＋ 1,0 in the retention suture group, intermittent retention suture group and non-retention suture group, respectively. The VAS pain scores in the ＂U＂ type tension-reducing group and intermittent tension-reducing group were higher than in the non-tension-reducing group （p 〈 0,005）. Conclusion： Although retention sutures may reduce the incidence of postoperative wound dehiscence in abdominal surgery patients, they can increase the IVP and postoperative pain.