干燥法长期保存角膜片板层治疗性角膜移植1267例临床研究

目的:评价干燥脱水法长期保存角膜片在板层治疗性角膜移植术中的效果。方法:保存角膜片选自我院眼库干燥保存符合临床标准、复水透明的完整角膜片,临床病例选自我院角膜病组1976年8月～1999年12月期间行板层治疗性角膜移植患者1267例,从手术前后视力比较、原发病灶控制、植片存活情况进行临床效果综合分析。结果:保存角膜片复水透明合格率为94.9%,临床治愈率:感染性角膜溃疡/穿孔88.8%,血管翳性全角膜白斑98.3%,化学及热烧伤(穿孔,睑球角粘连等)92.1%,圆锥角膜及急性圆锥角膜99.5%,角膜变性(边缘性及前基质层)99.0%,其他88.9%,平均总治愈率:93.5%。结论:1.对各种严重的角膜感染、药物治疗无法控制的病人,治疗性角膜移植术是唯一有效的方法。2.采用无水氯化钙——硅胶干燥脱水长期保存的供体角膜能为临床随时提供角膜材料,是一项简单易行、便于推广应用的成功率很高的保存方法。眼科学报2003;19:110-113。

Pre-operative hypoalbuminemia is a major risk factor for postoperative complications following rectal cancer surgery

AIM:To determine the relationship between pre-operative hypoalbuminemia and the development of complications following rectal cancer surgery, as well as postoperative bowel function and hospital stay. METHODS:The medical records of 244 patients undergoing elective oncological resection for rectal adenocarcinoma at Siriraj Hospital during 2003 and 2006 were reviewed. The patients had pre-operative serum albumin assessment. Albumin less than 35 g/L was recognized as hypoalbuminemia. Postoperative outcomes, including mortality, complications, time to first bowel movement, time to first defecation, time to resumption of normal diet and length of hospital stay, were analyzed. RESULTS:The patients were 139 males (57%) and 105 females (43%) with mean age of 62 years. Fifty-six patients (23%) had hypoalbuminemia. Hypoalbuminemic patients had a significantly larger tumor size and lower body mass index compared with non-hypoalbuminemic patients (5.5 vs 4.3 cm;P < 0.001 and 21.9 vs 23.2 kg/m2;P = 0.02, respectively). Thirty day postoperative mortality was 1.2%. Overall complication rate was 25%. Hypoalbuminemic patients had a significantly higher rate of postoperative complications (37.5% vs 21.3%;P = 0.014). In univariate analysis, hypoalbuminemia and ASA status were two risk factors for postoperative complications. In multivariate analysis, hypoalbuminemia was the only significant risk factor (odds ratio 2.22,95% CI 1.17-4.23;P < 0.015). Hospitalization in hypoalbuminemic patients was significantly longer than that in non-hypoalbuminemic patients (13 vs 10 d, P = 0.034), but the parameters of postoperative bowel function were not significantly different between the two groups. CONCLUSION:Pre-operative hypoalbuminemia is an independent risk factor for postoperative complications following rectal cancer surgery.

A case of biliary gastric fistula following percutaneous radiofrequency thermal ablation of hepatocellular carcinoma

Percutaneous radiofrequency thermal ablation （RFA） is an effective and safe therapeutic modality in the management of liver malignancies, performed with ultrasound guidance. Potential complications of RFA include liver abscess, ascites, pleural effusion, skin burn, hypoxemia, pneumothorax, subcapsular hematoma, hemoperitoneum, liver failure, tumour seeding, biliary lesions. Here we describe for the first time a case of biliary gastric fistula occurred in a 66-year old man with a Child＇s class A alcoholic liver cirrhosis as a complication of RFA of a large hepatocellular carcinoma lesion in the nl segment. In the light of this case, RFA with injection of saline between the liver and adjacent gastrointestinal tract, as well as laparoscopic RFA, ethanol injection （PEI）, or other techniques such as chemoembolization, appear to be more indicated than percutaneous RFA for large lesions close to the gastrointestinal tract.

Clinical Features and Treatment of Bronchogenic Cyst in Adults

Objective To investigate the clinical features and management of bronchogenic cyst in the adults. Methods We retrospectively reviewed 50 patients admitted to our hospital with histopathologically proved bronchogenic cyst from January 1983 to December 2007. Of all the patients, 28 were male and 22 were female, with an average age of 36.9 (range, 18 to 64) years. The symptoms, location of the cysts, imaging evaluation, surgical treatment manner, and outcome of these patients were analyzed. Results Symptoms were present in 33 of the 50 patients, and cough was the most common symptom. Thirteen patients presented with complications: hemoptysis, infected cyst, dysphagia, paralysis, and hoarseness. The locations of the cysts included the mediastinum (28 cases), pulmonary parenchyma (12 cases), hilar area (3 cases), visceral pleura (1 case), and some rare locations including the intestinal mesentery (1 case), retroperitoneum (1 case), adrenal gland (1 case), neck (2 cases), and dura matter of the cervical verte-brae (1 case). Chest X-ray was performed in 36 patients and computed tomography (CT) was performed in 41 patients. The bronchogenic cyst in CT was characterized as a round, well circumscribed, unilocular mass, with density ranging from that of water to high density (0-50 Hu). As for treatment, complete resection of the bronchogenic cyst was performed in 47 (94%) patients, subtotal resection was performed in 3 (6%) patients. Open surgery was performed in 45 (90%) patients, and thoracoscopy (video-assisted thoracic surgery) was performed in 5 (10%) paitients. Of the 12 patients with intrapulmonary cyst, 11 patients underwent lobectomy and 1 patient underwent wedge resection. Postoperative sequelae occurred in 2 patients, 1 with persistent air leakage and 1 with hoarseness. All patients were proved with bronchogenic cyst pathologically. The average follow-up period was 6.5 years (range, 4 months to 10 years), and no late sequelae or recurrence of the cyst occurred. Conclusions The clinical and imaging presentations of bronchogenic cyst in adults are variable. Surgical resection is the best way for diagnosis and treatment. Both open surgery and thoracoscopy are appropriate for the selected candidates.

Postmyotomy dysphagia after laparoscopic surgery for achalasia

AIM: To determine predictive factors for postoperative dysphagia after laparoscopic myotomy for achalasia.METHODS: Logistic regression was used to investigate the possible association between the response (postoperative dysphagia, with two levels: none/mild and moderate/severe)and several plausible predictive factors.RESULTS: Eight patients experienced severe or moderate postoperative dysphagia. The logistic regression revealed that only the severity of preoperative dysphagia (with four levels; mild, moderate, severe, and liquid) was a marginally significant (P=0.0575) predictive factor for postoperative dysphagia.CONCLUSION: The severity of postoperative dysphagia is strongly associated with preoperative dysphagia. Preoperative symptomatology can significantly impact patient outcome.

Clinical utility of the platelet-lymphocyte ratio as a predictor of postoperative complications after radical gastrectomy for clinical T2-4 gastric cancer

AIMTo identify simple and sensitive markers for postoperative complications after gastrectomy, the predictive values were compared among candidate preoperative factors.METHODSThree-hundred and twelve patients with previously untreated clinical T2-4 gastric cancer who underwent a D2 standard gastrectomy (distal gastrectomy or total gastrectomy) were included in the analysis. Correlations between 21 parameters that can be determined by preoperative routine blood tests and clinically relevant postoperative complications (grade II or higher according to the Clavien-Dindo classification) were evaluated. The optimal cutoff values and clinical significance of the selected markers were further evaluated by subgroup analyses according to age, body mass index, operative procedure and clinical disease stage.RESULTSSixty-six patients (21.1%) experienced grade II or higher postoperative complications. The platelet-lymphocyte ratio (PLR, total lymphocyte count/platelet count × 100) exhibited the highest area under the curve value (0.639) for predicting postoperative complications among the 21 parameters, and the optimal cutoff value was determined to be 0.71 (sensitivity = 70%, specificity = 56%). In the univariate analysis, the odds ratio of a low PLR for the occurrence of postoperative complications was 2.94 (95%CI: 1.66-5.35, P < 0.001), and a multivariate binomial logistic analysis involving other potential risk factors identified a low PLR as an independent risk factor for postoperative complications (OR = 3.32, 95%CI: 1.82-6.25, P < 0.001). In subgroups classified according to age, body mass index, operative procedure and clinical disease stage, the low PLR group exhibited an increased incidence of postoperative complications.CONCLUSIONThe preoperative PLR is a simple and useful predictor of complications after curative gastrectomy in patients with clinical T2-4 gastric cancer.

Esophagotracheal fistula caused by gastroesophageal reflux 9 years after esophagectomy

Fistula between digestive tract and airway is one of the complications after esophagectomy with lymph node dissection. A case of esophagotracheal fistula secondary to esophagitis 9 years after esophagectomy and gastric pull-up for treatment of esophageal carcinoma is described. It was successfully treated with transposition of a pedicled pectoralis major muscle flap.

Stent placement is effective on both postoperative hepatic arterial pseudoaneurysm and subsequent portal vein stricture:A case report

To treat postoperative bleeding after hepato-pancreato-biliary surgery, interventional radiology has become essential. We report a case of coincidental pseudoan-eurysm and jejunal varices that were both successfully treated by stent-grafts. After a pancreaticoduodenec-tomy, the patient developed a pseudoaneurysm in the hepatic artery and a stenosis in its periphery. After establishing hepatic arterial flow by placing stent-grafts over both the pseudoaneurysm and the stenosis, the pseudoaneurysm was embolized with microcoils. Nine months later, the patient developed jejunal varices caused by a severe stricture in the main trunk of the portal vein. Percutaneous transhepatic portography was performed and stent-grafts were placed over the stenotic segment. A venoplasty using stent-grafts nor-malized the portal blood flow and the jejunal varices vanished. Although stenosis occurred due to scarred tissues from leakage after pancreaticoduodenectomy, stent-grafts were useful for managing jejunal bleeding post-operatively.

Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

AIM： To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh （CTP） and model for end-stage liver disease （MELD） score to predict that outcome. METHODS： We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint. RESULTS： Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD （12.8 ＋ 3.9 vs 12.6 ＋ 4.7, P = 0.9） or in the mean CTP （7.6 ± 1.2 vs 7.7 ± 1.7, P = 0.8） between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures （MELD： 22.4 ± 8.7 vs 15.2 ± 6.4, P = 0.0007; CTP： 9.9 ± 1.8 vs 8.5 ± 1.8, P = 0.008）. The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them （AUC = 0.755 ± 0.066 for MELD vs AUC = 0.696 ± 0.070 for CTP, P = 0.3）. CONCLUSION： The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.

Local anesthesia with ropivacaine for patients undergoing laparoscopic cholecystectomy

AIM:To investigate the effect of pain relief after infu-sion of ropivacaine at port sites at the end of surgery.METHODS:From October 2006 to September 2007,72 patients undergoing laparoscopic cholecystectomy(LC) were randomized into two groups of 36 patients.One group received ropivacaine infusion at the port sites at the end of LC and the other received normal saline.A visual analog scale was used to assess postoperative pain when the patient awakened in the operating room,6 and 24 h after surgery,and before discharge.The amount of analgesics use was also recorded.The demographics,laboratory data,hospital stay,and perioperative complications were compared between the two groups.RESULTS:There was no difference between the two groups preoperatively in terms of demographic and lab-oratory data.After surgery,similar operation time,blood loss,and no postoperative morbidity and mortality were observed in the two groups.However,a significantly lower pain score was observed in the patients undergo-ing LC with local anesthesia infusion at 1 h after LC and at discharge.Regarding analgesic use,the amount of meperidine used 1 h after LC and the total used during admission were lower in patients undergoing LC with local anesthesia infusion.This group also had a shorter hospital stay.CONCLUSION:Local anesthesia with ropivacaine at the port site in LC patients signif icantly decreased post-operative pain immediately.This explains the lower meperidine use and earlier discharge for these patients.

Research progress of traditional Chinese medicine nursing techniques for the management of postoperative complications in mixed hemorrhoids

Mixed hemorrhoids,especially ring-shaped mixed hemorrhoid,is still a headache for anorectal surgeons due to its post-operative complications.In recent years,clinicians have been studying and exploring to avoid and alleviate these complications.In the Chinese medicine industry,the application of traditional Chinese medicine nursing technology has good and unique effect in prevent local pain,perianal edema,promote wound healing,relieve urinary retention,improve constipation,relieve anxiety,and so on.This article summarized the evidences of investigated the role of traditional Chinese medicine nursing technique in preventing and treating mixed hemorrhoid so that practitioners can make decision based on the best available evidences.

EXPERIENCE ON SURGICAL MANAGEMENT OF RUPTURE OF ABDOMINAL AORTIC ANEURYSM

Objective. To describe our surgical experience on rupture of abdominal aortic aneurysm .Methods. Two cases of ruptured aortic aneurysms with severe complication were analyzed. Aorta reconstruction procedures were performed using bifurcated e-PTFE grafts during emergency operation. Diagnosis, preoperadve resuscitation, emergency surgical intervention, and postoperative complications of these patients were summarized and discussed.Results. Rupture of aortic aneurysm in both patients presented as a huge retroperitoneum haematoma by computed tomography scan. They were successfully saved by prompt body fluid compensation, emergency procedure, intraoperative resuscitation, and postoperative intensive care.Conclusions. Correct diagnosis, prompt surgical management, immediate intraoperative proximal aorta clamping during procedure, and effective management of postoperative complications were the key points to successful treatment of ruptured aortic aneurysm.

Application of enhanced recovery after surgery program for posterior lumbar decompression and fusion

Objective: To establish and optimize an enhanced recovery after surgery (ERAS) program, for the classic posterior lumbar decompression and fusion (PLDF).Methods: 1.An ERAS for PLDF procedure during the perioperative period had been designed. 2.A total of 155 patients (73 in the ERAS group and 82 in the traditional health care group) were analyzed, and their clinical outcomes were compared. The evaluation indexes included physiological function, postoperative visual analogue scale (VAS), pain score, postoperative complications. Results: ERAS significantly promoted early food-taking (7.93±2.15h vs 24.54 ± 5.72h, P < 0.00), early catheter removal (36.31 ± 8.42h vs 71.48 ± 13.75h, P < 0.00), early defecation (3.80 ± 1.3 days vs 5.3±1.41 days, P < 0.00);reduced the incidence of urinary tract infection (2.7% vs 9.7% P = 0.01) and shorter hospital stay (3.80 ± 1.04 days vs 7.29±1.62 days, P < 0.00), while no difference between the two groups in vomiting, lung infection, wound bleeding and infection. Conclusion: ERAS for PLDF can facilitate the recovery of physiological function, reduce postoperative pain, reduce operative complications and morbidity after surgery and contribute to a shorter hospital stay. Further research is needed to optimize the process.

Deep venous thrombosis after gastrectomy for gastric carcinoma:A case report

The treatment of gastric carcinoma consists of neoadjuvant chemoradiation,partial gastrectomy,subtotal gastrectomy,total gastrectomy,extended resection,and postoperative chemotherapy.Currently,gastrectomy and extended lymphadenectomy is the optimal choice for late gastric carcinoma.Postoperative complications are common after total gastrectomy including hemorrhage,anastomotic leakage,f istula,and obstruction.However,deep venous thrombosis(DVT) is an uncommon complication after gastrectomy for gastric carcinoma.We describe a case of a 68-year-old female patient with DVT after gastrectomy for gastric carcinoma.The patient was treated with anticoagulants and thrombolytics and subjected to necessary laboratory monitoring.The patient recovered well after treatment and was symptom-free during a 3-mo follow-up.We conclude that correct diagnosis and treatment of DVT are crucial.

TREATMENT OF SODIUM DISORDERS AFTER SURGERY OF CRANIOPHARYNGIOMA

Objective.To study the treatment of the patients with blood sodium disorder after craniopharyngioma surgery. Method.The blood sodium in 44 patients with craniopharyngiomas was daily examined from operative to post-operative days. Hypernatremia is defined as [Na]>145 mmol/l, and hyponatremia as [Na]<135 mmol/L. Results.Of the 44 patients, 36 developed sodium disorder. Among them, simple hyponatremia was 16 patients, simple hypernatremia was 9 patients, and alternative sodium disorder was 11 patients. Conclusion.The blood sodium disorder in patients with craniopharyngiomas after surgery appears to present complicated changes. Three types of blood sodium disorder could be determined as simple hyponatremia, simple hypernatremia, and alternative sodium disorder. Treatment of the sodium disorder in patients with craniopharyngiomas after surgery could be carried in accordance with the above three types.

CLINICAL OBSERVATION ON ACUPOINT DIGITAL PRESSING FOR TREATING IRRITABLE SYMPTOMS AND SIGNS OF POSTOPERATION OF MYOPORTHOSIS

Objective: To explore a new effective approach for treatment of the local irritable symptoms and signs resulted from myoporthosis operation. Methods: 263 cases of radial keratotomy outpatients were divided into control group (n=49, 90 eyes) and treatment group (n=214, 412 eyes). Patients of control group were treated with 0.5% Chloramphenicol eye drops, 3 times daily, 1-2 drops/time, and with 0.5% Erythromycine eye ointment every night. In treatment group, patients were treated with acupoint and hand reflection area digital pressing method except with the same eye drops and eye ointment. Body acupoints used were Cuanzhu (BL 2), Yuyao (EX HN 4), Sizhukong (TE 23), Sibai (ST 2) and Taiyang (EX HN 5). The hand reflex areas used were Eye Area, Liver Area, Kidney Area, Spleen Area, Heart Area and Lung Area. Five days constituted a therapeutic course. Results: Following 3 courses (15 days) of treatment, the markedly effective rate and total effective rate of treatment group and control group were 74.51% and 38.89%, 94.17% and 66.67% respectively. There was a significant difference between two groups in the total effective rate (P<0.05), showing the therapeutic effect of treatment group being better than that of control group. Conclusion: Acupoint digital pressing is rather effective in treatment of myoporthosis post operation irritable symptoms and signs.

The Experimental Study on Implantation of Intraocular Lens in Different Animals

Objective: To prevent the complications in cataract surgeries, the eyes of rabbits and monkeys were implanted with intraocular lens for 360 days. Methods: The eyes of the rabbits were performed with phacoemulsification and soft intraocular lens implantation. The eyes of the monkeys were performed with extracapsular cataract extraction and hard intraocular lens implantation. Results: The postoperative reactions included corneal edema, anterior chamber exudation, posterior capsule opacification and so on. The complications in the eyes of the rabbits were more than that in the eyes of the monkeys. Conclusion: The different postoperative reactions happened in different animals. In clinical the choice of the operative method and intraocular lens depended on the case in order to acquire the best sight.

MECHANICAL ANALYSIS AND TREATMENT OF HARRINGTON-RODS BROKEN AFTER INITIAL OPERATION FOR SCOLIOSIS

Twenty-two cases of scoliosis with Harrington-rods broken after operation were treated by rod-sleevemethod. The results of follow-up from 1 year and 3 months to 9 years and 3 months showed that all of thepatients, but one patient occurred Harrington-rod rebroken and one’s fixation being removed because ofback pain in 6 months and 5 years and 11 months after rod-sleeve prpcedure, respectively, had no com-plaints. The author also found that the rod underwent a decrease in cross-sectional area of approximately43. 7 % at the ratchet-shaft junction in experimental study on Harrington-rods, and stress unfairly distribu-tion, stress concentration and cyclic loading producing fatigue in metals were proved to be the main cause ofbroken by mechanical analysis of Harrington-rod loaded in the body. In concluson, the rod-sleeve proce-dure was the effective method to keep from, Ha rrington - reds broken.

Vascular and biliary complications after liver transplantation: interventional treatment

OBJECTIVE: To evaluate the value of angiography and cholangiography on the diagnosis and interventional treatment of vascular and biliary complications after liver transplantation. METHODS: Sixteen of 46 patients (15 men and 1 woman, 17 - 60 years old) after orthotopic liver transplantation received angiography due to abnormal ultrasonography or edema of lower limbs, or cholangiography due to progressing jaundice. Percutaneous transluminal angioplasty or drainage was performed in some patients. RESULTS: Fifteen patients experienced vascular complications and 4 patients had biliary complications. Three of them appeared to have both vascular and biliary complications. Hepatic artery complications were the most common complications (9/16), including hepatic artery thrombosis or stenosis (6/9), bleeding (2/9) and hepatic artery-dissecting aneurysm (1/9). One patient with hepatic artery thrombosis received transcatheter thrombolysis and two patients with bleeding received coil embolization. Inferior vena cava and portal vein stenosis were observed in 6 and 2 patients, respectively. After balloon angioplasty or stent placement, clinical symptoms were alleviated. Biliary complications, including biliary stricture and anastomotic bile leak, occurred in 4 patients. Jaundice decreased after percutaneous transhepatic cholangiography and drainage. CONCLUSIONS: Besides diagnosis, interventional methods include mini-invasive treatment for patients with vascular and biliary complications after liver transplantation. Balloon angiography and stent placement for venous stenosis are useful procedure for the treatment of these problems.

Effect of ear acupuncture plus injection at Zusanli(ST 36) on shoulder pain and cytokines after gynecologic laparoscopic surgery

Objective： To explore the clinical efficacy of ear acupuncture plus injection at Zusanli（ST 36） in treating shoulder pain after laparoscopic gynecological surgery, and to observe its effect on cytokines.Methods： Two hundred patients with shoulder pain after laparoscopic gynecological surgery were randomized into two groups based on their visiting sequence, 100 cases each. The observation group was intervened by ear acupuncture plus injection at Zusanli（ST 36）, and the control group was intervened by oral administration of Ibuprofen, 10 d as a treatment course. The clinical efficacies of the two groups were compared after 2 treatment courses; the visual analogue scale（VAS）,present pain intensity（PPI） and 36-item short-form health survey（SF-36） were measured before and after the treatment;the changes of interleukin（IL）-6 and IL-10 after the treatment were also observed.Results： The VAS and PPI scores were significantly changed after the treatment in both groups（both P〈0.01）. After the treatment, the VAS score in the observation group was significantly different from that in the control group（P〈0.05）. The component scores of SF-36 were significantly changed after the treatment in both groups（P〈0.01）; after the treatment, the scores of physical functioning（PF）, bodily pain（BP）, social functioning（SF）, and mental health（MH） in the observation group were significantly different from those in the control group（all P〈0.05）. The contents of IL-6 and IL-10 dropped significantly after the intervention in both groups（both P〈0.01）, and the between-group differences were also statistically significant（both P〈0.01）. The total effective rate of the observation group was higher than that of the control group（P〈0.05）.Conclusion： Ear acupuncture plus injection at Zusanli（ST 36） can significantly improve the shoulder pain after laparoscopic gynecological surgery, down-regulate the expressions of IL-6 and IL-10, and boost the recovery.