提升我国日间手术管理水平的思考与建议

分析了我国日间手术的现状、存在的问题,从建立高效顺畅的日间手术服务流程、确保日间手术质与量的平衡发展、完善日间手术医疗服务链、建立日间手术评价体系、完善日间手术医保支付方式以及开展日间手术能力审核六个方面,为提升我国日间手术管理水平提供建议。     

飞秒激光在白内障手术中的应用新进展

飞秒激光辅助的白内障手术是目前最热门的白内障手术之一。即在计算机系统引导下利用飞秒激光进行透明角膜切口的制作,晶状体核裂解和晶状体前囊膜的切开,明显降低了传统超声乳化手术中的并发症,具有十分广阔的临床应用前景。然而飞秒激光辅助的白内障手术目前仍然处于临床应用初级阶段,其昂贵的价格是影响其研究和应用的主要原因,手术安全性及远期屈光效果仍然需要长期的随访观察。本文根据文献资料,就飞秒激光在白内障手术中的优势及临床应用的局限性进行综述。     

Distal arteriovenous fistula to maintain patency of the venous drainage of a latissimus dorsi flap following subclavian vein repair

Successful reconstructive surgery with muscle flaps depends on adequate arterial supply and undisturbed venous drainage. Combining such surgery with reconstructive vascular surgery of a large-caliber vein that is responsible for the venous drainage of the flap poses an additional challenge--the repaired vein's susceptibility to thrombosis. Every attempt must be made to prevent venous outflow obstruction following muscle flap surgery. Data from the vascular surgery literature demonstrate a low success rate for subclavian vein repair. The success rate with venous reconstructive surgery has been greater when a distal arteriovenous fistula accompanied the repair. The present case described the use of a temporary distal cephalic-brachial arteriovenous fistula to maintain the patency of the venous drainage of a pedicled latissimus dorsi muscle flap, following subclavian vein repair, for one-stage coverage of a large chest wall defect.     

经鼻内镜手术进展

颅底手术正随着经鼻内镜手术的发展而发生着转变。经鼻内镜手术最初开发于鼻窦手术,但其适应症已逐渐扩大到其它领域,可以用于治疗大量的疾病。经鼻内镜手术的主要优点是：它利用天然的孔道来处理大量的颅内、鼻窦病变,避免了皮肤切口、面部骨瓣切口、脑回缩等直接开颅所不可避免的后遗症。与传统的神经外科手术相比,发病率和死亡率下降,并间接减少了住院时间和管理成本。本文就经鼻内镜手术的进展进行综述。在综述中阐述了经鼻内镜手术的适应症和基本原则,以及显露、特别是重建技术的进展,这些进展要求在可接受的并发症前提下达到更广泛的切除;讨论了经鼻内镜手术的局限性,尤其是,虽然这种手术往往是“微创”,但它并不是完全没有并发症;展望了经鼻内镜手术的适应症会不断拓宽,并发症会越来越少的美好未来。     

经鼻内镜手术进展

颅底手术正随着经鼻内镜手术的发展而发生着转变。经鼻内镜手术最初开发于鼻窦手术,但其适应症已逐渐扩大到其它领域,可以用于治疗大量的疾病。经鼻内镜手术的主要优点是:它利用天然的孔道来处理大量的颅内、鼻窦病变,避免了皮肤切口、面部骨瓣切口、脑回缩等直接开颅所不可避免的后遗症。与传统的神经外科手术相比,发病率和死亡率下降,并间接减少了住院时间和管理成本。本文就经鼻内镜手术的进展进行综述。在综述中阐述了经鼻内镜手术的适应症和基本原则,以及显露、特别是重建技术的进展,这些进展要求在可接受的并发症前提下达到更广泛的切除;讨论了经鼻内镜手术的局限性,尤其是,虽然这种手术往往是"微创",但它并不是完全没有并发症;展望了经鼻内镜手术的适应症会不断拓宽,并发症会越来越少的美好未来。     

快速康复外科护理在胃肠道肿瘤围手术期的实践与进展

快速康复外科(fast track surgery,FTS)是胃肠道肿瘤围手术期护理发展的新趋势,它全面改变了胃肠外科的面貌,并且对传统护理学形成强烈冲击,传统的护理模式已无法适应现代FTS的发展。本文对近年来FTS在胃肠道肿瘤围手术期的护理进行综述,并结合临床工作实践,探讨目前护理理念的转变,并对未来的胃肠道肿瘤围手术期的护理模式进行展望。     

Duration of clinical effects and absence of referred hyperalgesia after femoral vein cannulation in rats

The goal of this study was to assess the duration of pain-related clinical effects and referred hyperalgesia after surgery in rats. Isoflurane anesthesia with or without femoral vein cannulation was performed (n = 6 per group). Body weight and food and water consumption were monitored daily for 48 h, and tail-flick latency was measured twice daily for 24 h after surgery. Water consumption at 24 h after surgery was significantly decreased in the surgical group compared with baseline values and those of the anesthesia group. Body weight change and food consumption showed nonsignificant decreases compared with baseline in both groups 24 h after the procedure. There was a trend toward decreased food consumption after surgery compared with that for the anesthesia-alone group. Tail-flick latency was nonsignificantly decreased the afternoon after surgery compared with baseline values or that after anesthesia alone. Tail-flick latency was similar to baseline and between groups 24 h after surgery. All parameters were similar between groups and compared with baseline by 48 h after surgery. Our results show some changes in postsurgical pain-related parameters only during the initial 24-h period after femoral cannulation surgery, but only the change in water consumption was significant. Although this study involved only a small number of animals, our findings suggest that femoral vein cannulation produces a less painful stimulus than that seen in studies assessing these parameters after abdominal surgery. Hyperalgesia from a distant painful stimulus could not be measured in this model by using the tail-flick assay.     

Studies on the hormonal regulation of fuel metabolism in the human newborn infant undergoing anaesthesia and surgery

Little is known of the endocrine and metabolic milieu in preterm and term neonates exposed to surgical stress. In order to define the effects of anaesthesia and surgery on the hormonal regulation of intermediary metabolism, the levels of plasma insulin, glucagon, adrenaline and noradrenaline were measured in addition to blood glucose, lactate, pyruvate, alanine, acetoacetate, hydroxybutyrate, glycerol and plasma-free fatty acids in 38 neonates (23 term, 15 preterm) undergoing surgery. Blood samples were drawn pre-operatively, at the end of surgery, and at 6, 12 and 24 h post-operatively. Plasma levels of adrenaline and noradrenaline increased significantly in response to surgery. In term neonates, plasma insulin concentrations were unaltered at the end of surgery, but were significantly increased throughout the post-operative period; plasma glucagon levels were unchanged at the end of surgery but had significantly decreased by 24 h after surgery. Insulin levels in preterm neonates remained unchanged during surgery as well as in the post-operative period. All neonates developed a significant peri-operative hyperglycaemia which persisted up to 12 h after surgery. Blood lactate and pyruvate increased during surgery, accompanied by significant increases in plasma free fatty acids, total ketone bodies and glycerol concentrations by the end of surgery. Blood glucose concentrations were significantly correlated with plasma adrenaline levels at the end of surgery and with plasma glucagon at 6 h post-operatively. The insulin/glucose ratio was significantly decreased at the end of surgery in term and preterm neonates. Further analysis showed that total parenteral nutrition given just before surgery and thiopentone anaesthesia given during surgery significantly augmented the peri-operative hyperglycaemic response of term neonates. Thus, stress-related hormonal changes in preterm and term neonates may precipitate a catabolic state characterized by glycogenolysis, gluconeogenesis, lipolysis and mobilization of gluconeogenic substrates in the post-operative period. Prevention of these metabolic derangements by anaesthetic or hormonal manipulation may possibly help to improve the clinical outcome of neonates undergoing surgery.     

Female college students and cosmetic surgery: an investigation of experiences, attitudes, and body image

This large, multisite study investigated female college students' experiences with and attitudes about cosmetic surgery. The study also assessed the relationship between several aspects of body image, including appearance satisfaction and investment and symptoms of body dysmorphic disorder, and interest in cosmetic surgery. Thirty (5 percent) of the 559 women surveyed reported that they had undergone cosmetic surgery. Two thirds of respondents reported knowing someone who had received cosmetic surgery, and approximately one third indicated that a family member had undergone surgery. Overall, participants held relatively favorable attitudes about surgery. Regression analysis suggested that a greater psychological investment in physical appearance and greater internalization of mass media images of beauty predicted more favorable attitudes toward cosmetic surgery. Fourteen women (2.5 percent) screened positive for body dysmorphic disorder based on the nature and severity of their self-reported body-image concerns. Results of this study provide new information on young women's experiences and attitudes about cosmetic surgery and how these attitudes relate to body image.     

Advantages of arthroscopy of the knee joint]

Arthroscopic surgery causes considerably less soft tissue damage than conventional surgery. As the result of the development of an optical system employed with a chip camera and a video chain arthroscopic knee surgery can be ideally documented with excellent picture quality. Besides the advantage of soft-tissue sparing procedures, diagnosis is substantially improved and operative procedures can be kept to a minimum. This means, in particular in the case of meniscus procedures, that only the damaged areas are removed, this minimising changes to the biomechanics of the knee. The technical equipment, the arthroscopic surgery technic and the advantages of the knee arthroscopy are discussed.     

Plastic surgery and psychotherapy in the treatment of 100 psychologically disturbed patients

This paper reviews the senior author's long-term experience with the surgical-psychiatric treatment of 100 aesthetic surgery patients with significant psychological disturbances. Patients with psychological disturbances of a magnitude generally considered an "absolute contraindication" for surgery were operated on and later assessed to determine the psychological impact of surgery. Patient follow-up averaged 6.2 years (maximum follow-up 25.7 years). Of the 87 patients who underwent operation (7 patients were refused surgery and 6 voluntarily deferred surgery), 82.8 percent had a positive psychological outcome, 13.8 percent experienced "minimal" improvement from surgery, and 3.4 percent were negatively affected by surgery. There were no lawsuits, suicides, or psychotic decompensations. Patients with severe psychological disturbances frequently benefited from combined surgical-psychiatric treatment designed to address the patient's profound sense of deformity. This study suggests that plastic surgeons are "passing up" a significant number of patients who may be helped by combined surgical-psychological intervention.     

Sham surgery trial controls: perspectives of patients and their relatives

this study reports on qualitative research conducted in the UK with people with Parkinson's Disease and their relatives on the subject of "sham surgery." It explores attitudes toward sham surgery and reasoning about hypothetical participation in a sham-controlled trial. Results showed that attitudes toward sham surgery may not necessarily predict trial participation behavior. A small majority of interviewees deemed sham surgery ethically acceptable with certain provisos, but hypothetical participation was driven primarily by disease severity and a lack of standard treatment options, with a preference for receiving the real surgery over sham. Ethical implications for patient equipoise and the autonomy of patients' research participation decisions are discussed.     

眼科手术等候期患者家属对健康教育需求的调查

目的:了解眼科手术等候期患者家属对健康教育的需求。方法:采用自行设计的调查问卷对100名在患者手术过程中等候的家属进行调查。调查内容包括手术等候中希望获得的相关信息及其需求程度,需要的健康教育方式及每种健康教育的需求程度。结果:1).眼科手术等候中,家属强烈需要的信息有手术效果(76%)、术后饮食指导(60.4%)、手术费用(57.3%)、患者目前病情(54.2%)、术后头位指导(51%)。2).最需要的健康教育方式是与医生护士交谈(66%)。结论:对手术等候期的患者家属应根据需求实施科学有效的健康教育,用恰当的方式及时提供家属想要了解的信息,使他们具有良好的应对能力和心理承受能力,在照顾患者的过程中为患者提供有效的支持系统。     

两种腹腔镜肾上腺切除术式治疗原发性醛固酮增多症效果评价

目的：比较腹腔镜肾上腺全切术与部分切除术治疗原发性醛固酮增多症的效果。方法：对152例原发性醛固酮增多症分别采用肾上腺全切术（A组82例）和肾上腺部分切除术（B组70例）进行治疗,测量并比较两组患者手术时间、手术失血量、住院时间以及术后一月内血压恢复者比例。结果：两组患者性别、年龄、高血压和低血钾在组间情况无统计差异,具备可比性（P〉0．05）。A组患者手术时间、术后一月内血压恢复比例高于B组（P〈0．05）,而失血量和住院时间无组间差异（P〉0．05）。结论：在腹腔镜肾上腺切除手术中,肾上腺全切取得了较好的效果,具有较高的临床应用价值。     

The preoperative use of the relaxation response with ambulatory surgery patients

The efficacy of the regular elicitation of the relaxation response in reducing surgical anxiety and pain in an ambulatory surgery setting was studied in a population of patients scheduled for the surgical removal of a skin cancer. Forty-nine patients with skin cancer were enrolled in the study immediately after being informed of the ned for surgery; 21 of these patients elicited the relaxation response 20 minutes per day until the day of surgery, 21 read for 20 minutes per day, and 7 were noncompliant and were excluded from the study. Contrary to expectations, neither group of patients showed any increase in anxiety immediately before or after surgery on either psychological or physiological measures. Thus, there were no differences between the two groups on any of the psychological or physiological measures of anxiety, nor were there any differences in pain perception. There were statistically significant subjective differences; the experimental patients stated that the relaxation-response technique had reduced their anxiety several days before surgery and reportedly experienced their highest levels of anxiety prior to entering the study, while the controls experienced their highest levels of anxiety during and after surgery. This suggests that (1) minor outpatient surgery does not lead to detectable increased anxiety levels on the day of surgery and (2) regular elicitation of the relaxation response can alter subjective reports of distress associated with surgery.     

Comparison of Robotic Surgery with Laparoscopy and Laparotomy for Treatment of Endometrial Cancer: A Meta-Analysis

Purpose

To compare the relative merits among robotic surgery, laparoscopy, and laparotomy for patients with endometrial cancer by conducting a meta-analysis.

Methods

The MEDLINE, Embase, PubMed, Web of Science, and Cochrane Library databases were searched. Studies clearly documenting a comparison between robotic surgery and laparoscopy or between robotic surgery and laparotomy for endometrial cancer were selected. The outcome measures included operating time (OT), number of complications, length of hospital stay (LOHS), estimated blood loss (EBL), number of transfusions, total lymph nodes harvested (TLNH), and number of conversions. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated using either a fixed-effects or random-effects model.

Results

Twenty-two studies were included in the meta-analysis. These studies involved a total of 4420 patients, 3403 of whom underwent both robotic surgery and laparoscopy and 1017 of whom underwent both robotic surgery and laparotomy. The EBL (p = 0.01) and number of conversions (p = 0.0008) were significantly lower and the number of complications (p<0.0001) was significantly higher in robotic surgery than in laparoscopy. The OT, LOHS, number of transfusions, and TLNH showed no significant differences between robotic surgery and laparoscopy. The number of complications (p<0.00001), LOHS (p<0.00001), EBL (p<0.00001), and number of transfusions (p = 0.03) were significantly lower and the OT (p<0.00001) was significantly longer in robotic surgery than in laparotomy. The TLNH showed no significant difference between robotic surgery and laparotomy.

Conclusions

Robotic surgery is generally safer and more reliable than laparoscopy and laparotomy for patients with endometrial cancer. Robotic surgery is associated with significantly lower EBL than both laparoscopy and laparotomy; fewer conversions but more complications than laparoscopy; and shorter LOHS, fewer complications, and fewer transfusions but a longer OT than laparoscopy. Further studies are required.     

Fate of Registrars in the South-Western Region

The fate of registrars in general surgery in the South-Western Region has been surveyed. Once a man has taken a registrarship in general surgery he is largely committed to surgery as a career. Consequently, if he fails to obtain promotion in the Health Service he emigrates, and as a result about 37% of British graduates who become surgical registrars eventually settle abroad.     

不同子宫手术方案对生育期妇女卵巢功能的影响

目的:研究不同子宫手术方案对生育期妇女卵巢功能的影响。方法:随机选取自2014年1月至2015年4月于我院进行手术治疗的200例生育期妇女作为研究对象。针对所有患者在术前1d及术后6个月分别进行静脉采血5 m L,比较患者手术前后促卵泡激素(FSH)及雌二醇(E2)水平,不同年龄与手术方案患者手术前后血清抗苗勒氏管激素(AMH)的水平。结果:术后患者的FSH及E2水平与术前比较,差异无统计学意义(P0.05)。40岁者手术后的血清AMH水平显著低于术前,差异有统计学意义(P0.05)。在手术方式中,子宫切除术(子宫全切及广泛性子宫切除)后患者血清AMH显著低于术前的水平,差异有统计学意义(P0.05)。在手术途径中,腹腔镜辅助子宫切除术后患者血清AMH显著低于术前的水平,差异有统计学意义(P0.05)。结论:≥40岁患者在接受子宫手术时可能会影响其卵巢储备功能,而子宫全切、广泛性子宫切除以及腹腔镜辅助子宫切除术对患者术后卵巢功能影响更大。     

早期胃癌的治疗现状与进展

胃癌是常见的消化道肿瘤之一,是我国死亡率最高的恶性肿瘤之一。与日本韩国等发达国家相比,我国胃癌患者多数在就诊时已处于进展期,早期胃癌所占比例不足10%。传统的开腹胃癌手术仍是治疗早期胃癌的主要手段。相较于传统开腹手术,腹腔镜手术对于早期胃癌的治疗优势是显而易见的。早期胃癌患者行腹腔镜手术,具有术后恢复快,生活质量好,近期疗效佳等优势。内镜黏膜下剥离术(ESD,endoscopic submucosal dissection)是近年来出现的一项新的治疗早期胃癌的手段。本文就传统开腹手术、腹腔镜手术及ESD分别在早期胃癌治疗中的应用进行了综述。微创手术治疗早期胃癌将逐渐代替开腹手术,成为早期胃癌治疗的主要手段。     

Influence of surgery on in-vitro cytokine production by human monocytes

Surgery leads to significant modulation of the immune system, in which cytokines play a major role. Circulating interleukin 6 (IL-6) and IL-1 have been reported following surgery whereas tumor necrosis factor alpha (TNF-alpha) is only found in gut ischemia-associated surgery. We have investigated the consequences of surgery on in-vitro cytokine production by human monocytes stimulated by lipopolysaccharide (LPS) and staphylococcal toxic shock syndrome toxin-1 (TSST-1). Comparisons were made between the responsiveness of cells obtained the day before (D-1), during (D0) and after (D1, D2, D3) surgery. Patients undergoing abdominal aortic surgery (N = 9), carotid surgery (N = 4) and spinal surgery (N = 4) have been studied. A significant decrease of TNF-alpha, IL-1 beta and IL-1 alpha production by monocytes prepared from blood samples taken during the surgery was noticed, whereas IL-6 production was not significantly modified. On D2 a significant increase of monocyte responsiveness was observed and levels of cytokine productions rose back to initial values by the end of the follow up. The diminished in-vitro cytokine production observed during surgery might be the consequence of the effects of anaesthetic drugs, whereas the enhancement observed on D2 might reflect the surgical stress, leading to in-vivo priming of circulating monocytes.