上消化道异物56例胃镜取出体会

上消化道异物是指误吞或故意吞入消化道的各种物体,根据异物的成因分为两类,即外源性异物和内源性异物。根据异物的不同形状分为长条形异物、锐利异物、圆钝异物及不规则异物。根据异物停留的部位分为食管异物、胃内异物和十二指肠异物。以往,上消化道异物多经外科手术取出。近年来,随着内镜治疗技术的不断发展,越来越多的上消化道异物可以通过内镜取出,并取得较好的疗效。我院自2004年5月~2014年5月应用胃镜成功取出上消化道异物56例,其中食管异物28例、胃内异物25例、十二指肠异物3例;均为单一异物,动物骨骼27例、硬币15例、牙刷4例、铁钉3例、螺丝2例、枣核2例、螺丝帽1例、大头针1例、蛔虫1例;年龄分布:儿童15例、成人41例;应用普通胃镜取出10例、应用无痛苦胃镜取出46例。

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.

SURGICAL TREATMENT OF METASTATIC SPINAL TUMOR

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Role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy

AIM:To evaluate the role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy. METHODS:The medical records of thirteen patients with pyogenic liver abscess who underwent surgical treatment between January 1995 and December 2002 were retrospectively reviewed to determine the clinical presentation, indication and nature of surgery, and out-come of surgery. RESULTS:The patients were predominantly women (10/13) with a mean age of 65 ± 17 years. Their main presenting symptoms were abdominal pain (100%) and fever (77%). The aetiologies included biliary (n = 6), cryptogenic (n = 3), portal (n = 2), and trauma (n = 2). Seven patients underwent percutaneous drainage as the initial treatment. Of these, three patients developed peritonitis secondary to peritoneal spillage. Another four patients failed to respond because of multilocula-tion. Salvage surgery was required in these patients. Six patients proceeded to straight laparotomy:two had marked sepsis and multiloculated abscess that precluded percutaneous drainage, and four presented with perito-nitis of uncertain pathology. Surgical procedures included deroofment and drainage (n = 9), liver resection (n = 3), peritoneal lavage (n = 2), cholecystectomy (n = 4), and exploration of common bile duct (n = 2). One patient required reoperation because of bleeding. Three patients required further percutaneous drainage after surgery. The overall mortality was 46%. Four patients died of multiorgan failure and two patients died of pulmonary embolism. CONCLUSION:Surgical treatment of pyogenic liver ab-scess is occasionally needed when percutaneous drainage has failed due to various reasons. Mortality rate in this group of patients has remained high.

Effects of various anesthetic techniques and PaCO_2 levels on cerebral oxygen balance in neurosurgical patients

Objective: To assess the effects of various anesthetic techniques and PaCO2 levels on cerebral oxygen supply/consumption balance during craniotomy for removal of tumors, and to explore an anesthetic technique for neurosur-gery and an appropriate degree of PaCO2 during neuroanesthesia. Methods: One hundred and fourteen patients with supratentorial tumors for elective craniotomy, ASA grade I - II , were randomly allocated to six groups. Patients were anesthetized with continuous intravenous infusion of 2% procaine 1. 0 mg · kg-1 · min-1 in Group I , inhalation of 1. 0% - 1. 5% isoflurane in Group II , and infusion of 2% procaine 0. 5 mg·kg · min-1 combined with inhalation of 0.5% -0.7% isoflurane in Group III during the period of study. The end-tidal pressure of CO2(PET CO2 ) was maintained at 4.0 kPa in these 3 groups. In Group IV, V and VI, the anesthetic technique was the same as that in Group I but the PETCO2 was adjusted to 3. 5, 4. 0 and 4. 5 kPa respectively for 60 min during which the study was performed. The radial arterial and retrograde jugular venous blood samples were obtained at the onset and the end of this study for determining jugular venous bulb oxygen saturation ( SjvO2 ) , arteriovenous oxygen content difference (AVDO2) and cerebral extraction of oxygen (CEO2). Results: In Group I and I SjvO2, AVDO2 and CEO2 remained stable. Although SjvO2 kept constant, AVDO2 and CEO2 decreased significantly (P <0. 05) in Group II. Moreover, AVDO2 and CEO2 in Group II were significantly lower than those of Group III (P<0. 05). In Group IV, 60 min after hyperventilation, SjvO2 and jugular venous oxygen content ( CjvO2 ) decreased markedly (P < 0. 01 ) while CEO2 increased significantly ( P <0.01) . In addition, SjvO2, CjvO2 and CEO2 in Group IV were significantly different from the corresponding parameters in Group V and Group VI (P <0. 05) . In view of sustained excessive hyperventilation, SjvO2 was less than 50% in 37.5% patients of Group IV. Conclusion: Anesthesia with intravenous infusion of procaine combined with isoflurane inhalation proved to be more suitable for neurosurgery than procaine intravenous anesthesia or isoflurane inhalation anesthesia alone. PaCO2 at 4.0 -4. 5 kPa in patients undergoing craniocerebral surgery during neuroanesthesia would be beneficial in both decreasing ICP and maintaining cerebral oxygen supply/consumption balance.

Sex-related changes in tumor consistency in prolactinoma patients after bromocriptine pretreatment

Objective It has long been reported that prolactinomas treated with bromocriptine increase fibrosis and may affect surgical outcomes.We retrospectively studied 238 consecutive patients with histopathologically confirmed prolactinomas undergoing microsurgery in a single neurosurgery department of Tongji Hospital(Wuhan,China) from 2012 to 2015 in order to evaluate tumor consistency changes after bromocriptine pretreatment and surgical outcomes.Methods We divided the patients into four groups;males in the dopamine agonist(DA) group,females in the DA group,males in the no DA group,and females in the no DA group,and we compared the surgery process,specimen Masson staining,and clinical outcomes of the four groups.According to a previously published classification,the operative notes from an experienced neurosurgeon were reviewed to classify the consistency of tumors as "fibrous" or "nonfibrous".Results No differences in tumor consistency were found in male patients with or without DA treatment.However,in female patients with DA treatment,tumors were likely to be harder in texture than the tumors of female patients without DA treatment.Despite tumor consistency differences between sexes,the tumor biological remission rate was similar between groups,as was the rate of tumor resection.Discussion Our study indicates that preoperative DA therapy impacts tumor consistency in female patients but not male patients.Although the surgical and histopathological outcomes are not influenced,these findings may provide useful information for the choice of operative approach and surgery process for pituitary adenoma.

无功能垂体神经内分泌肿瘤术后垂体功能减退的影响因素分析

目的探讨无功能垂体神经内分泌肿瘤术后垂体功能减退的影响因素.方法回顾性分析中国国家脑肿瘤注册登记平台中郑州大学第一附属医院神经外科于2019年1月至2022年12月登记的无功能垂体神经内分泌肿瘤单病种数据,共纳入患者1210例.收集患者的年龄、性别、临床症状、术前及术后激素水平、手术方式、手术时长和随访时间;收集患者肿瘤的体积、术前是否发生瘤卒中、Knosp分级、质地和切除程度.采用单因素和多因素logistic回归分析(向后剔除法)判断术后垂体功能减退的影响因素.结果1210例患者中,617例(51.0%)术后存在垂体功能减退.1210例患者的随访时间[M(Q_(1),Q_(3))]为6.5(3.0,11.2)个月.单因素logistic回归分析结果显示,术前发生瘤卒中、术前垂体功能减退、肿瘤体积以及手术时长均是患者术后垂体功能减退的影响因素(均P<0.05).多因素logistic回归分析结果显示,术前发生瘤卒中(OR=1.96,95%CI:1.20~3.26,P=0.008)、术前垂体功能减退(OR=2.89,95%CI:2.09~4.05,P<0.001)以及肿瘤体积较大(OR=1.02,95%CI:1.00~1.03,P=0.015)均是术后垂体功能减退的危险因素.结论术前垂体功能减退、肿瘤体积较大、发生瘤卒中的无功能垂体神经内分泌肿瘤患者,术后垂体功能减退的风险较高.

EXPERIENCE OF MINIMALLY INVASIVE TREATMENT IN 520 PATIENTS WITH INTRACR ANIALANEURYSMS

Objective.To summarize the experience of minim ally invasive treatment in 520patie nts with intracranial aneurysms on a retrospective study.Methods.The measures used in the treatment of520patients were reviewed in terms o f timing of surgery,induced-hypotensive anesthesia,b rain protection combined with temporal occlusion of the feeding artery,exter-nal drainage of CSF,dynamic monitoring of intracranial pressure,blood flow velocity,serum osmolality and CT scanning,anti-vasospasm therapy a s well as selected interventional en dovascular embolization of aneurysms.Results.Of the 520patients,485were treated with either direct clipping or endov ascular embolization and35patients were treated non-surgic ally.In 449patients undergoing dir ect clipping and 36undergoing endov ascu-lar embolization,intraoperative r upture of aneurysm occurred in 27(6.0%)and 0%,respectively.Death oc-curred in 13(2.6%),hemiplegia in 8(1.6%),and vegetative state in 2(0.4%).The operative mortality of direct clipping was 3.8%in 210patie nts before 1990and 1.8%in 275patien ts after 1990(36patients undergo-ing endovascular embolization,the operative mortality was 0%).Conclusion.The outcome of patients with intracranial aneurysms can be markedly impr oved and the opera-tive mortality can be lowered by mini mally invasive treatment.

盐酸氢吗啡酮在重症监护室神经外科术后镇痛的临床研究

研究盐酸氢吗啡酮在重症监护室神经外科术后镇痛的临床效果。方法 本研究选择自2020年3月至2022年3月于我院接受神经外科手术的重症监护患者共计70例作为研究对象,采用“随机数字抽签法”进行分组并给予不同的术后镇痛方案,对照组(n35,给予枸橼酸地佐辛注射液术后自控镇痛),实验组(n35,给予盐酸氢吗啡酮术后自控镇痛),对两组患者术后的疼痛及镇静评分,围术期的应激反应及炎症水平进行比较。结果 观察组术后4h及12h的NRS及Ramsay评分均低于对照组(P<0.05);观察组与对照组的术毕时应急反应、炎症因子无组间差异;术后4h、12h后两组的炎症因子PCT、CRP、TNF—α、IL-6及IL-8均呈现下降趋势,尤其是观察组的炎性因子水平显著低于对照组(P<0.05);结论 在重症监护神经外科术后镇痛中应用盐酸氢吗啡酮具有显著的临床效果,可有效降低患者的术后疼痛情况,稳定患者的术后镇静情况,减少炎症因子水平,利于患者术后康复。

Long-term follow-up study of 72 patients with transient ischemic attacks

Objective To observe the long-term follow-up of 72 patients with transient ischemic attack (TIA) and evaluate the clinical significance of neurovascular surgical indication. Methods Seventy-two patients with TIA collected from years 1959 to 1977 were followed up by means of face-to-face communication with the patients themselves or their families till year 1998. According to the principle of life table, the recurrence of TIA after the first attack, occurrence of complete stroke and myocardial infarction, fatality rate, causes of death and survival rate every year, and the 95% confidence interval were calculated and analyzed.Results Till 1998, the recurrent rate of TIA in 72 patients was 27.9%, the occurrence rate of complete stroke 65.7%, and that of myocardial infarction 8.4%. The fatality rate was 72.7%. Among the deaths, 2 (3.8%) patients died of myocardial infarction. It was shown from the study that the main cause of death was complete stroke, accounting for 59.6% of all deaths, with the main cause in non-elderly patients being cerebral hemorrhage, and that in the elderly patients being cerebral infarction. The 20-year survival rate was 39.9% and its 95% confidence interval was (28.4%, 51.4%). Nineteen cases were indicated for neurovascular surgical operation, accounting for 26.6% of the 72 patients. Conclusions In the long-term follow-up study, about one third of the patients had the recurrent TIA. The occurrence rate of complete stroke was markedly higher than that of myocardial infarction. Presumably, the effect of neurovascular surgical operation on the prevention of complete stroke in patients with TIA is limited.

A young and booming approach:the extreme lateral supracerebellar infratentorial approach

Surgical accesses to lesions of the posterolateral pontomesencephalic junction（PMJ）region and the posterolateral tentorial gap remain a challenge in the field of neurosurgery.Since the first report of application of the extreme lateral supracerebellar infratentorial（ELSI）approach in resecting the PMJ lesions in 2000,a few articles concerning the ELSI approach have been published.The present review mainly provided an intimate introduction of the ELSI approach,and evalu- ated it in facets of patient position,skin incision,craniectomy,draining veins,retraction against the cerebellum,exposure limits,patient healing,as well as advantages and limitations compared with other approaches.The ELSI approach is proposed to be a very young and promising approach to access the lesions of posterolateral PMJ region and the posterolateral tentorial gap.Besides,it has several advantages such as having a shorter surgical pathway,causing less surgical complications,laborsaving,etc.Still,more studies are needed to improve this approach.

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.

Comparison of laparoscopic selective colectomy based on barium-strip examination and subtotal colectomy for adult slow-transit constipation

Background:Surgical management of adult slow-transit constipation(ASTC)can be effective for patients with intractable symptoms.This study aimed to evaluate whether barium-strip examination and selective colectomy improved post-operative outcomes in ASTC patients in comparison with subtotal colectomy.Methods:A retrospective cohort study of 53 cases with refractory ASTC was conducted between June 2008 and June 2014.Patients were evaluated by the barium-strip technique,colonoscopy,defecography and anorectal manometry.Patients in the standard group underwent laparoscopic subtotal colectomy and patients in the laparoscopic selective colectomy(LSC)group underwent LSC at the precise location identified by barium strip.Spontaneous bowel movements,the Wexner Constipation Scale and the Gastrointestinal Quality of Life Index(GIQLI)were assessed post-operatively at 3,6,12 and 24 months.Results:A total of 49 patients were included in the analysis.The median follow-up was 37 months(range,26–60 months).The mean post-operative hospital stay was 12 days and similar between groups(P=0.071).The length of colon resection,operative time and intra-operative blood loss were reduced in the LSC group(all P<0.05).No major complications occurred.A similar number of patients(24 in the standard group and 25 in the LSC group)exhibited hypoganglionosis or aganglionosis in the colon-wall muscle layer(P=0.986).Although there were no significant differences in post-operative spontaneous bowel movements and the Wexner Constipation Scale between the two groups,the mean GIQLI of the LSC group was significantly higher at 3,6 and 24 months post-operatively(all P<0.05).Conclusions:LSC based on barium-strip examination is an appropriate modality for treating ASTC.

Operative treatment of medial rotation contracture of the shoulder caused by obstetric brachial plexus palsy

To introduce an operation of subscapularis slide from its origin and anterior release from its insertion for treatment of medial rotation contracture, subluxation and dislocation of the shoulder caused by obstetric brachial plexus palsy (OBPP). Methods: Thirty six cases with medial rotation contracture of the shoulder were diagnosed by measurement of the inferior glenohumeral angle, passive lateral rotation of the shoulder and plain radiographs. Subscapularis slide was performed in 24 cases with simple medial rotation contracture, and anterior release in 12 cases with complex contracture medial rotation contracture combined with subluxation, dislocation, or other deformities of the shoulder joint. Systems of Mallet scoring and Gilbert grading for the shoulder were used to evaluate the postoperative shoulder function. Results: With follow up for a minimum of six months, 32 cases got apparent gains from operations, accounting for 88.8 % of the total operated on. The younger the child was, the better the result. Of 4 cases with no operative effects, 3 had no flexion of the elbow preoperatively, suggesting a poor recovery of the upper trunk of the brachial plexus; the rest one had no repair of the severed subscapularis tendon. Conclusions: Subscapularis slide and anterior release of the shoulder are effective for treatment of medial rotation contracture as well as its consequence of subluxation and dislocation of the shoulder in OBPP. The operative effect is related to childrens age and the recovery extent of the upper trunk of the brachial plexus.

Surgical management for sciatic nerve injury

To summarize surgical treatments an d their corresponding curative effects on sciatic nerve injuries. Methods: Surgical treatments on sciatic nerve injury were perfo rmed in 28 patients from January 1990 to July 2000. The treatments included neur olysis, neurolysis plus partial nerve anastomosis, nerve anastomosis and nerve t ransplantation. The curative effect was evaluated according to Sunderland criter ia. Results: Of 28 cases, 22 patients were followed up with a follo w up period of 13 months to 5 years (average 30 months). Of 22 nerves, 7 were e xcellent, 5 good, 7 fair and 3 poor, with an excellence rate of 54.5 %. Conclusions: The fair results of sciatic nerve injury are relat ed to its structural character. Surgical exploration should be performed if nerv e function does not recover 3 months after primary operation and if Tinels sig n and electromyogram show no signs of nerve regeneration. Electrophysiological m onitoring in the operation is useful in electing surgical methods and predicting the results of nerve anastomosis.