手背深度烧伤的综合治疗

目的:探讨手背深度烧伤后保护手的外观及功能的有效治疗方法。方法:对10例(16只手)手背深二度烧伤患者进行早期削痂植皮术及后期功能康复治疗。结果:10例全部治愈,经随访,手外观满意,功能恢复良好。结论:手背部的深二度烧伤通过早期手术治疗及后期的功能锻炼,可有效保持手的外观,最大程度恢复手的功能。

足底内侧皮瓣游离移植治疗二例手掌疤痕

本文报告采用足底内侧皮瓣游离移植方法治疗2例手掌疤痕,获得成功。并对此皮瓣的解剖特点、设计、手术方法、优点进行了讨论。

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.

Video-assisted Endoscopic Thyroidectomy by the Breast Approach

Objective: To retrospectively evaluate the feasibility and clinical value of video assisted endoscopic thyroidectomy by the breast approach. Methods: From December 2002 to May 2003, 28 patients with a mean age of 28 years (range from 20 to 45 years) were selected and given video assisted endoscopic thyroidectomy by the breast approach. The subcutaneous space in the breast area and the subplatysmal space in the neck were bluntly dissociated through a 10 mm incision between the nipples, and CO 2 was insufflated at 6 8 kban to create the operative space. Three trocars were inserted in the mammary regions, and dissection of the thyroid and division of the thyroid vessels and parenchyma were performed endoscopically using an ultrasonically activated scalpel. The recurrent laryngeal nerve, the superior laryngeal nerve, and the parathyroid glands were preserved properly. Results: Among the patients, 3 were mass resections, 17 subtotal lobectomies, 2 total lobectomies, and 6 subtotal lobectomies plus contralateral mass resections. The mean operative time was (87.1±26.0) min; the mean estimated blood loss was (47.9±19.6) ml; and the mean postoperative hospital stay was (3.4±0.7) d. The drainage tubes were pulled out at 36 60 h postoperatively. There were no conversions to open surgery or complications. No scars left in the neck, and the patients were satisfied with the postoperative appearance. Conclusion: Video assisted endoscopic thyroidectomy using a breast approach and low pressure subcutaneous CO 2 insufflation is a feasible and safe procedure, which results in satisfactory appearance. We believe that video assisted endoscopic thyroidectomy by such approach will play a role in the future.

Preoperative evaluation with T-staging system for hilar cholangiocarcinoma

AIM： To investigate the clinical value of T-staging system in the preoperative assessment of hilar cholangiocarcinoma. METHODS： From March 1993 to January 2006, 85 patients who had cholangiocarcinoma diagnosed by operative tissue-biopsy were placed into one of three stages based on the new T-staging system, and it was evaluated the resectability and survival correlated with T-staging. RESULTS： The likelihood of resection and achieving tumor-free margin decreased progressively with increasing T stage （P 〈 0.05）. The cumulative 1-year survival rates of T1, T2 and T3 patients were 71.8%, 50.8% and 12.9% respectively, and the cumulative 3-year survival rate was 34.4%, 18.2% and 0% respectively; the survival of different stage patients differed markedly （P 〈 0.001）. Median survival in the hepatic resection group was greater than in the group that did not undergo hepatic resection （28 mo vs 18 mo; P 〈 0.05）. The overall accuracy for combined MRCP and color Doppler Ultrasonagraphy detecting disease was higher than that of combined using CT and color Doppler Ultrasonagraphy （91.4% vs 68%; P 〈 0.05 ）. And it was also higher in detecting port vein involvement （90% vs 54.5%; P 〈 0.05）.CONCLUSION： The proposed staging system for hilar cholangiocarcinoma can accurately predict resectability, the likelihood of metastatic disease, and survival. A concomitant partial hepatectomy would help to attain curative resection and the possibility of longterm survival. MRCP/MRA coupled with color Doppler UItrasonagraphy was necessary for preoperative evaluation of hilar cholangiocarcinoma.（OR = 2.46, 95% CI = 0.98-6.14）, and a significantly elevated risk of developing esophageal cancer among alcohol drinkers among alcohol drinkers （OR = 9.86, 95% CI = 3.10-31.38）. CONCLUSION： ADH2 and ALDH2 genotypes areassociated with esophageal cancer risk. ADH2＊1 allele and ALDH2＊2 allele carriers have a much higher risk of developing esophageal cancer, especially among alcohol drinkers.

Long-term results of endosurgical and open surgical approach for Zenker diverticulum

AIM: To assess the effectiveness of minimally invasive versus traditional open surgical approach in the treatment of Zenker diverticulum. METHODS: Between 1976 and 2006, 297 patients underwent transoral stapling (n = 181) or stapled diverticulectomy and cricopharyngeal myotomy (n = 116). Subjective and objective evaluations of the outcome of the two procedures were made at 1 and 6 mo after operation, and then every year. Long-term follow-up data were available for a subgroup of patients at a minimum of 5 and 10 years. RESULTS: The operative time and hospital stay were markedly reduced in patients undergoing the endosurgical approach. Overall, 92% of patients undergoing the endosurgical approach and 94% of those undergoing the open approach were symptom-free or were significantly improved after a median follow-up of 27 and 48 mo, respectively. At a minimum follow-up of 5 and 10 years, most patients were asymptomatic after both procedures, except for those individuals undergoing an endosurgical procedure for a small diverticulum (< 3 cm). CONCLUSION: Both operations relieve the outflow obstruction at the pharyngoesophageal junction, indicating that cricopharyngeal myotomy has an important therapeutic role in this disease independent of the resection of the pouch and of the surgical approach. Diverticula smaller than 3 cm represent a formal contraindication to the endosurgical approach because the common wall is too short to accommodate one cartridge of staples and to allow complete division of the sphincter.

Efficacy of endoscopic therapy for gastrointestinal bleeding from Dieulafoy’s lesion

AIM： To investigate the endoscopic hemostasis for gastrointestinal bleeding due to Dieulafoy＇s lesion. METHODS： One hundred and seven patients with gastrointestinal bleeding due to Dieulafoy＇s lesion were treated with three endoscopic hemostasis methods： aethoxysklerol injection （46 cases）, endoscopic hemoclip hemostasis （31 cases）, and a combination of hemoclip hemostasis with aethoxysklerol injection （30 cases）. RESULTS： The rates of successful hemostasis using the three methods were 71.7% （33/46）, 77.4% （24/31） and 96.7% （29/30）, respectively, with significant differences between the methods （P 〈 0.05）. Among those who had unsuccessful treatment with aethoxysklerol injection, 13 were treated with hemoclip hemostasis and 4 underwent surgical operation; 9 cases were successful in the injection therapy. Among the cases with unsuccessful treatment with hemoclip hemostasis,7 were treated with injection of aethoxysklerol and 3 cases underwent surgical operation; 4 cases were successful in the treatment with hemoclip hemostasis. Only 1 case had unsuccessful treatment with a combined therapy of hemoclip hemostasis and aeth- oxysklerol injection, and surgery was then performed. No serious complications of perforation occurred in the patients whose bleeding was treated with the endoscopic hemostasis, and no releeding was found during a 1-year follow-up. CONCLUSION： The combined therapy of hemoclip hemostasis with aethoxysklerol injection is the most effective method for gastrointestinal bleeding due to Dieulafoy＇s lesion.

Minilaparotomy to rectal cancer has higher overall survival rate and earlier short-term recovery

AIM： To report our experience using mini-laparotomy for the resection of rectal cancer using the total meso- rectal excision （TME） technique, METHODS： Consecutive patients with rectal cancer who underwent anal-colorectal surgery at the authors＇ hospital between March 2001 and June 2009 were included, In total, 1415 patients were included in the study, The cases were divided into two surgical proce- dure groups （traditional open laparotomy or mini-lap- arotomy）, The mini-laparotomy group was defined as having an incision length ≤ 12 cm. Every patient un- derwent the TME technique with a standard operation performed by the same clinical team. The multimodal preoperative evaluation system and postoperative fast track were used. To assess the short-term outcomes, data on the postoperative complications and recovery functions of these cases were collected and analysed. The study included a plan for patient follow-up, to ob- tain the long-term outcomes related to 5-year survival and local recurrence. RESULTS： The mini-laparotomy group had 410 pati- ents, and 1015 cases underwent traditional laparoto- my. There were no differences in baseline characteris- tics between the two surgical procedure groups. The overall 5-year survival rate was not different between the rnini-laparotorny and traditional laparotorny groups （80.6% vs 79.4%, P = 0.333）, nor was the 5-year local recurrence （1.4% vs 1.5%, P = 0.544）. However, 1-year mortality was decreased in the rnini-laparotorny group compared with the traditional laparotorny group （0% vs 4.2%, P 〈 0.0001）. Overall 1-year survival rates were 100% for Stage Ⅰ, 98.4% for Stage Ⅱ, 97.1% for Stage Ⅲ, and 86.6% for Stage Ⅳ. Local recurrence did not differ between the surgical groups at 1 or 5 years. Local recurrence at 1 year was 0.5% （2 cases） for mini-laparotorny and 0.5% （5 cases） for traditional laparotorny （P = 0.670）. Local recurrence at 5 years was 1.5% （6 cases） for mini-laparotorny and 1.4% （14 cases） for traditional laparotorny （P = 0.544）. Days to first ambulation （3.2 ± 0.8 d vs 3.9 ± 2.3 d, P = 0.000） and passing of gas （3.5 ± 1.1 d vs 4.3 ± 1.8 d, P = 0.000）, length of hospital stay （6.4 ± 1.5 d vs 9.7 ± 2.2 d, P = 0.000）, anastomotic leakage （0.5% vs 4.8%, P = 0.000）, and intestinal obstruction （2.2% vs 7.3%, P = 0.000） were decreased in the rrnini-laparotorny group compared with the traditional laparotorny group. The results for other postoperative recovery function indi- cators, such as days to oral feeding and defecation, were similar, as were the results for immediate post- operative complications, including the physiologic and operative severity score for the enumeration of mortal- ity and morbidity score. CONCLUSION： Mini-laparotomy, as conducted in a sin- gle-centre series with experienced TME surgeons, is a safe and effective new approach for minimally invasive rectal cancer surgery. Further evaluation is required to evaluate the use of this approach in a larger patient sample and by other surgical teams.

Thinking in three's: Changing surgical patient safety practices in the complex modern operating room

The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgical safety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone havebeen unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stake-holders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to bring these team members together and influence the emergence of a safer OR.

Efficacy of Surgical Therapy for Carotid Body Tumors

Objective To evaluate the efficacy of surgical therapy for carotid body tumors. Methods A retrospective analysis was conducted, covering the diagnosis, surgical procedure, postoperative complications, and prognosis of 120 cases of carotid body tumors in Peking Union Medical College Hospital from 1949 to May, 2011. Results Surgical excision was successfully performed in 111 cases with 117 tumors. In all those cases, 50 underwent simple tumor resection, 42 underwent resection of tumors and ligation of the external carotid arteries, 7 underwent co-resection of tumors and common carotid arteries, internal carotid arteries, as well as external arteries without vascular reconstruction, and the other 12 cases experienced tumor resection and vascular reconstruction as internal carotid arteries were involved. After operation, 3 cases developed cerebral infarction, 30 cases showed cranial nerve palsy, including 15 cases of hypoglossal nerve damage, 10 cases of vagus paralysis, and 5 cases of Horner's syndrome. Conclusion It is essential to make a proper surgical strategy, which can reduce postoperative com- plications.

Gastrointestinal autonomic nerve tumors:A surgical point of view

AIM: Gastrointestinal autonomic nerve tumors are uncommon stromal tumors of the intestinal tract. Their histological appearance is similar to that of other gastrointestinal stromal tumors. We report two cases and performed an analysis of the literature by comparing our findings with the available case reports in the medical literature.METHODS: Two patients were admitted with abdominal tumor masses. One occurred in the stomach with large multiple liver metastases and the second originated in Meckel's diverticulum. The latter site has never been reported previously. Both patients underwent surgery. In one patient gastrectomy, right liver resection and colon transversum resection were performed to achieve aggressive tumor debulking. In the other patient the tumor bearing diverticulum was removed.RESULTS: Postoperative recovery of both patients was uneventful. Histological examination, immunohistochemical analysis and electron microscopy revealed the diagnosis of a gastrointestinal autonomic nerve tumor. The patient with the tumor in Meckel's diverticulum died 6 mo after surgery because of pneumonia. The patient with liver metastases have been alive 13 years after initial tumor diagnosis and 7 years after surgery with no evidence of tumor progression. In light of our results, we performed athorough comparison with available literature reports.CONCLUSION: Radical surgical resection of gastrointestinal autonomic nerve tumors seems to be the only available curative approach to date, and long term survival is possibleeven in large metastasized tumors.

Prognostic analysis of patients suffering from intrahepatic cholangiocarcinoma

Objective： The outcome of surgical treatment of patients with intrahepatic cholangiocarcinoma （ICC） is poor. This study was designed to analyze prognostic factors after surgical procedure for ICCs. Methods： A retrospective clinical analysis was made in 183 cases of ICC, admitted to Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China, from December 1996 to July 2003. Fifteen clinicopathologic factors that could possibly influence survival were selected. A multivariate analysis of these individuals was performed using the Cox Proportional Hazards Model. Results： The accumulative 1-, 3-and 5-year survival rates of the patients were 51.3%, 21.6% and 11.8% respectively. The statistical analysis showed that surgical procedure, lymph node metastasis, serum level of CA19-9 and pathological differentiation grade affected postoperative survival significantly, but transfusion, postoperative radiotherapy and chemotherapy, diameter of tumor, serum level of AFP, cirrhosis, preoperative total serum bilirubin level （TBIL）, ratio of albumin to globulin （A/G）, sex and age were not significant factors influencing postoperative survival. Conclusion： Major hepatectomy with systematic lymph node dissection may be recommended for the surgical treatment of ICC. Aggressive treatment and prevention on postoperative intrahepatic recurrence and lymph node metastasis are important strategy to improve the survival for ICC.

Transthoracic En-bloc Esophagectomy

In patients with esophageal carcinoma surgical resection remains the standard of curative treatment. For locally advanced tumors (pT1sm–pT3) transthoracic esophagectomy with extended lym- phadenectomy is the standard surgical procedure since it o?ers a complete removal of the primary tumor and possible lymph node metastases. This surgical resection is appropriate for squamous cell but also adenocarcinoma of the esophagus because both histological entities demonstrate a lymphatic spread to the abdominal compartment and the upper mediastinum. In-hospital mortality rates are between 6% and 9%; anastomotic leakage and pulmonary complications mainly contribute to postoperative morbidity. In terms of 5-year survival the transthoracic procedure o?ers a better prognosis compared to the transhiatal resection. 五笔字型计算机汉字输入技术

Palliative cardia resection with gastroesophageal reconstruction for perforated carcinoma of the gastroesophageal junction

Iatrogenic perforation of esophageal cancer or cancer of the gastroesophageal(GE)junction is a serious complication that,in addition to short term morbidity and mortality,significantly compromises the success of any subsequent oncological therapy.Here,we present an 82-year-old man with iatrogenic perforation of adenocarcinoma of the GE junction.Immediate surgical intervention included palliative resection and GE reconstruction.In the case of iatrogenic tumor perforation, the primary goal should be adequate palliative(and not oncological)therapy.The different approaches for iatrogenic perforation,i.e.surgical versus endoscopic therapy are discussed.

Pancreatic cancer–Palliative therapy: surgery (bypass/resection)

Objective: We compare the outcome of palliative pancreaticoduodenectomy and palliative surgical bypass in patients with advanced pancreatic carcinoma in our hospital. Recent published related articles are also reviewed. Methods: A respective analysis was performed comparing the perioperative parameters and outcome of 20 patients who underwent pancreaticoduodenectomy with a gross suspected cancer residue and 30 patients who underwent a surgical bypass, all of the patients were diagnosed as in advanced stages intra-operatively. Results: The two groups were comparable with patient characteristics, including age, gender, initial symptoms and concomitant major organ diseases. Tumors are similar in size and intra-operatively diagnosed as in advanced stages in both groups. All of the patients in the resection group were microscopically proved having cancer residue. One postoperative mortality occurred in the resection group (5%), zero in the bypass group (P > 0.05). Overall complications were significantly higher in the resection group (30% vs. 0, P < 0.01), including 2 patients developed Acute Respiratory Distress Syndrome (ARDS), zero in the bypass group (P < 0.01); hemorrhage and transfusions in the resection group were much more than that in the bypass group (P < 0.05). Hospital stay after resection was significantly longer than bypass (20 vs. 12 days, P < 0.01). Hospital fee after resection was 4 times more than after bypass (median 61.500 vs. 15. 300 yuan, P < 0.01). Survival was significantly longer after resection (median 12.2 vs. 7.1 months, P < 0.01). Conclusion: Our results show that palliative resection in advanced pancreatic carcinoma lengthens the survival time of the patients, but this is paid for significantly higher complications than bypass.

Aggressive surgical management after transarterial chemoembolization(TACE)for liver metastases from ocular melanoma

Metastatic melanoma is also a challenge for surgeons. Recently, it has been reported that aggressive surgery combined with supportive therapy may be potential benefit for the condition. Therefore, we report a case of ocular melanoma metastatic to multiple visceral sites treated by cytoreductive surgery after initial intra-,arterial hepatic chemoembolization

Median sternotomy closure:review and update research

Cardiac surgery is a very common operation nowadays all over the world.Median sternotomy is a routine procedure required for cardiac access during open heart surgery.The complications of this procedure after the cardiac surgery range from 0.7% to 1.5% of all cases,and bear a high mortality rate if they occur.Every individual surgeon must pay great attention on every detail during the sternal closure.This article shows the details as to conventional information and updated progress on median sternotomy closure.The update contents involve in biomechanics,number of wires twists,biomaterial and so on.According to our experience,we recommend four peristernal single/double steel wires for sternal closure as our optimal choice.

An effective algorithm for needle tip displacement compensation in robot-assisted percutaneous surgery

This paper presents an automatic compensation algorithm for needle tip displacement in order to keep the needle tip always fixed at the skin entry point in the process of needle orientation in robot-assisted percutaneous surgery. The algorithm, based on a two-degree-of-freedom （2-DOF） robot wrist （not the mechanically constrained remote center of motion （RCM） mechanism） and a 3-DOF robot ann, firstly calculates the needle tip displacement caused by rotational motion of robot wrist in the arm coordinate frame using the robotic forward kinematics, and then inversely compensates for the needle tip displace- ment by real-time Cartesian motion of robot arm. The algorithm achieves the function of the RCM and eliminates many mechanical and virtual constraints caused by the RCM mechanism. Experimental result demonstrates that the needle tip displacement is within 1 inm in the process of needle orientation.

髂腹部削薄皮瓣在手外伤组织缺损中的应用

目的探讨在手外伤组织缺损中应用髂腹部削薄皮瓣修复的效果及应用价值。方法回顾性分析2013年2月至2014年2月本院骨科门诊收治的58例手外伤组织缺损患者临床资料,其中12例行急诊修复术,46例行髂腹部削薄轴型皮瓣修复手术。随访恢复效果。结果 46例行髂腹部削薄轴型皮瓣修复患者,皮瓣均已成活。随访3个月及以上患者27例,25例对外形恢复满意,满意率92.0%,手功能基本不受影响。结论针对手外伤组织缺损患者,髂腹部削薄皮瓣是修复手部皮肤缺损的理想材料,能极好地保留患者手部功能,安全可靠,同时不至于影响美观,值得借鉴推广。

Application of minimally invasive surgery in traumatic brain injury

This article aims to expound the essence of minimally invasive surgery as well as when and how to use it in craniocerebral trauma surgery according to the characteristics of the disease. In neurosurgery, the importance of tissue protection should be from the inside to the outside, i.e. brain→dura→skull→scalp. In this article, I want to share my opinion and our team＇s experience in terms of selecting surgical approaches and incision, surgical treatment of the skull, dura handling, intracranial operation and placement of drainage based on the above theory. I hope this will be helpful for trauma surgeons.