颈前路手术治疗多节段脊髓型颈椎病的研究进展

累及≥3个节段的脊髓型颈椎病称为多节段脊髓型颈椎病(multilevel cervical spondylotic myelopathy,MCSM),其致残率较高,应尽早手术干预.颈椎前路减压融合术是治疗脊髓型颈椎病的手术方式,但随着手术节段的增加,减压及重建难度增大.学者们对MCSM的手术方式进行了很多尝试和改良,但...     

臀肌筋膜挛缩症的外科手术治疗

臀肌筋膜挛缩症(Gluteal Muscle Contracture,GMC)是指由于各种原因引起的臀肌及其筋膜挛缩,导致髋关节功能受限,表现出特殊的症状、体征的临床综合征。GMC多发生于青少年和儿童患者,目前普遍认为一旦确诊GMC,应尽早手术治疗。随着临床技术的发展,GMC的手术方式也在不断创新、不断发展,其大致分为开放式手术和微创手术两大类,两者虽各具优缺点,但针对不同的患者都取得了不错的治疗效果。本文现对GMC的外科手术治疗的进展作一简要综述。     

Monitoring surgical performance using risk-adjusted cumulative sum charts

The cumulative sum (CUSUM) procedure is a graphical method that is widely used for quality monitoring in industrial settings. More recently it has been used to monitor surgical outcomes whereby it 'signals' if sufficient evidence has accumulated that there has been a change in the surgical failure rate. A limitation of the standard CUSUM procedure in this context is that since it is simply based on the observed surgical outcomes, it may signal as a result of changes in the referral pattern, such as an increased proportion of high-risk patients, rather than due to a change in the actual surgical performance. We describe a new CUSUM procedure that adjusts for each patient's pre-operative risk of surgical failure through the use of a likelihood-based scoring method. The procedure is therefore ideally suited for settings where there is a variable mix of patients over time.     

Patients in acute surgical wards: a survey in Glasgow.

A survey was made of all patients in general surgical, urological, and orthopaedic and accident wards in Glasgow on one day in June 1975. Its purpose was to define features of acute surgical practice of relevance to the future planning of resources, particularly bed numbers. Over 40% of the patients in both surgical and orthopaedic wards were over 65 years. Most patients had serious conditions and could not have been treated other than by admission to an acute surgical ward. But a substantial minority no longer needed such facilities and could have been transferred to second-line beds, although many still required skilled nursing care. Delay in the discharge of elderly patients from acute surgical wards as a consequence of non-surgical (often medical or social) problems results in a proportion of acute surgical beds fulfilling a second-line function. Unless arrangements for the earlier discharge of these patients are made any reduction in acute surgical beds is likely to restrict elective surgery, especially in orthopaedics.     

TREATMENT OF GENITO-URINARY TUBERCULOSIS WITH STREPTOMYCIN AND SYNERGISTIC DRUGS

The use of newer drugs in the treatment of genito-urinary tuberculosis is usually auxiliary to accepted surgical and medical procedures. The treatment of choice is removal of the tuberculous focus by surgical methods whenever this can be achieved. Risk of tuberculous complications of surgical operation may be greatly reduced by the use of these drugs. There is also a significant place for such treatment when disease is too far advanced to permit surgical removal. Under these conditions, the principal result is one of palliation only in many circumstances. The drugs of choice at this time are a combination of streptomycin and para-aminosalicylic acid (PAS) and the treatment is frequently more prolonged than in the case of tuberculosis of other organs.     

Innovative surgical approach for the Pierre Robin anomalad: subperiosteal release of the floor of the mouth musculature

The Pierre Robin anomalad presenting with severe respiratory distress is a difficult situation still associated with a significant mortality rate. A surgical approach based on a new idea is described. The concept is that the musculature of the floor of the mouth is under increased tension and pushes the tongue upward and backward with secondary respiratory obstruction. The surgical approach consists of a subperiosteal release of the musculature of the floor of the mouth through a 2-cm submental incision. So far this procedure has been used in four patients with severe obstruction, and marked improvement has occurred postoperatively in all cases. This surgical technique is simple and is associated with little morbidity. It should lessen the need for tracheostomy, which carries a greater morbidity, especially in newborns. We think that this new surgical approach can significantly improve the outcome of the severe form of Pierre Robin anomalad.     

Standard abdominal wound edge protection with surgical dressings vs coverage with a sterile circular polyethylene drape for prevention of surgical site infections (BaFO): study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: Postoperative surgical site infections cause substantial morbidity, prolonged hospitalization, costs and even mortality and remain one of the most frequent surgical complications. Approximately 14% to 30% of all patients undergoing elective open abdominal surgery are affected and methods to reduce surgical site infection rates warrant further investigation and evaluation in randomized controlled trials. METHODS: To investigate whether the application of a circular plastic wound protector reduces the rate of surgical site infections in general and visceral surgical patients that undergo midline or transverse laparotomy by 50%. BaFO is a randomized, controlled, patient-blinded and observer-blinded multicenter clinical trial with two parallel surgical groups. The primary outcome measure will be the rate of surgical site infections within 45 days postoperative assessed according to the definition of the Center for Disease Control. Statistical analysis of the primary endpoint will be based on the intention-to-treat population. The global level of significance is set at 5% (2 sided) and sample size (n = 258 per group) is determined to assure a power of 80% with a planned interim analysis for the primary endpoint after the inclusion of 340 patients. DISCUSSION: The BaFO trial will explore if the rate of surgical site infections can be reduced by a single, simple, inexpensive intervention in patients undergoing open elective abdominal surgery. Its pragmatic design guarantees high external validity and clinical relevance. Trial registration http://www.clinicaltrials.gov NCT01181206. Date of registration: 11 August 2010; date of first patient randomized: 8 September 2010.     

旋割法制备气管螺旋条评价

目的通过改进螺旋剪法建立制备气管螺旋条的旋割法。方法 40只豚鼠,用旋割法和螺旋剪法制备离体豚鼠气管螺旋条,在Kreb＇s液中平衡孵育2 h后,以组胺histamine（浴槽浓度2.0×10-3g/L）和乙酰胆碱acetylcholine（浴槽浓度2.0×10-4g/L）引发气管螺旋条收缩,用BL420生物信号采集系统与张力传感器测定标本张力变化值。数据采用SPSS11.5软件在α=0.05的信度下进行t检验。结果 2 g负荷下,旋割法标本histamine引发收缩幅度是螺旋剪法制备标本的1.31倍,乙酰胆碱引发收缩幅度旋割法是螺旋剪法制备标本的1.208倍,经t检验,P〈0.05,差异均具有显著性;旋割法标本,histamine引发2 g负荷标本收缩幅度是1 g负荷的1.48倍,乙酰胆碱引发2 g负荷标本的收缩幅度是1 g负荷的1.38倍,经t检验,P〈0.05,差异均具有显著性;旋割法标本经hista-mine或acetylcholine激发收缩,洗净药物重复激发6次收缩幅度的RSD值分别为19.8%和19.1%,螺旋剪法标本经histamine或acetylcholine 6次重复引发诱发收缩幅度的RSD值分别35.3%和33.7%。结论与螺旋剪法制备气管螺旋条标本比较,旋割法制备螺旋条标本对收缩诱导剂histamine与acetylcholine的敏感性高,标本负荷以2 g较好,旋割法标本重复利用收缩幅度变化值较螺旋剪法标本小。     

Integrated scheduling of elective surgeries and surgical nurses for operating room suites

Facing an acute shortage of surgical nurses, operating room suites in China are more and more aware of the need to use surgical nurses efficiently. This goal is hard to achieve due to the strong interactions between the nurse and the surgery scheduling process. This paper addresses the benefit of integrating elective surgery and surgical nurse scheduling in terms of nurse utilization. First, an integer programming (IP) model is proposed to schedule elective surgeries and surgical nurses simultaneously. Then an efficient genetic algorithm (GA) is proposed based on the IP formulation due to the computational complexity of the integrated scheduling problem. A case study using real-life data is presented to validate the performance of the integrated approaches (the IP model and the GA) by comparing them with a two-stage approach that schedules elective surgeries and surgical nurses sequentially.     

An integrated approach to patient-specific predictive modeling for single ventricle heart palliation

In patients with congenital heart disease and a single ventricle (SV), ventricular support of the circulation is inadequate, and staged palliative surgery (usually 3 stages) is needed for treatment. In the various palliative surgical stages individual differences in the circulation are important and patient-specific surgical planning is ideal. In this study, an integrated approach between clinicians and engineers has been developed, based on patient-specific multi-scale models, and is here applied to predict stage 2 surgical outcomes. This approach involves four distinct steps: (1) collection of pre-operative clinical data from a patient presenting for SV palliation, (2) construction of the pre-operative model, (3) creation of feasible virtual surgical options which couple a three-dimensional model of the surgical anatomy with a lumped parameter model (LPM) of the remainder of the circulation and (4) performance of post-operative simulations to aid clinical decision making. The pre-operative model is described, agreeing well with clinical flow tracings and mean pressures. Two surgical options (bi-directional Glenn and hemi-Fontan operations) are virtually performed and coupled to the pre-operative LPM, with the hemodynamics of both options reported. Results are validated against postoperative clinical data. Ultimately, this work represents the first patient-specific predictive modeling of stage 2 palliation using virtual surgery and closed-loop multi-scale modeling.     

Evaluating the impact of flexible practices on the master surgical scheduling process: an empirical analysis

This study focuses on the master surgical scheduling problem and adds two main contributions. First, it presents a novel mixed integer programming model to support the master surgical schedule production. Second, it uses the model to investigate the impact, in terms of scheduled surgeries, of the flexible management of three critical resources, namely surgical teams, operating rooms and surgical units. Our analysis revealed that to maximise the number of surgeries scheduled, it is sufficient to introduce flexibility with respect to surgical teams and ORs. In fact, if both these resources are managed flexibly, then introducing flexibility with respect to surgical units carries no additional advantages. However, if surgical teams or ORs (or both) are not managed flexibly, then managing surgical units flexibly produces significant benefits. In addition, our study shows that if surgical teams cannot be managed flexibly, then introducing flexibility with respect to ORs yields significant benefits. Similarly, it reveals that if ORs cannot be managed flexibly, then introducing flexibility with respect to surgical teams yields significant benefits as well. The work is based on real data from the Meyer University Children’s Hospital in Florence.     

恒河猴肠套叠的B超诊断与手术治疗

目的对发生肠套叠的恒河猴,采用手术治疗法挽救其生命。方法使用B超确诊具有肠套叠临床症状的恒河猴,确诊后动物实施手术治疗。结果经B超确诊肠套叠共5例,实施手术4例,手术成功率达100%,愈后恢复良好。1例采取常规保守治疗,没有进行手术治疗而死亡。结论 B超诊断技术是确诊肠套叠的一种好方法,手术治疗法是治疗肠套叠最有效的方法,用B超诊断技术在非人灵长类动物兽医临床上的应用及相关的外科手术均有一定的参考价值。     

Aspiration biopsy cytology, mammography and clinical exploration: a modern set up in diagnosis of tumors of the breast.

Six hundred and two mammary tumors were examined clinically, by mammography and cytology, with a histologic checkup following surgical biopsy. There were 247 cases of malignoma and 355 benign cases. The limited reliability of the individual methods is demonstrated, and it is shown that their combined use can improve the diagnosis. More malignomas are detected, and preoperative diagnosis is made more safely. If all three methods yield identical results, as was the case in 50.2% of the malignant and 32.7% of the benign lesions, the probability of diagnostic error is less than one per cent. With a malignoma thus established, surgical treatment may follow immediately, or irradiation can be started. In benign cases a surgical biopsy may be foregone and further developments may be awaited with due provision for regular control. If the three methods yield conflicting or doubtful results, elucidation by surgical biopsy and histology is indicated.     

Radiation therapy after radical prostatectomy: strike early, strike hard! The case for adjuvant radiation therapy

With a large local tumor, when surgical extirpation results in a positive surgical margin, adjuvant radiotherapy is the routine approach for a variety of solid tumors, such as head and neck cancers, rectal cancer, lung cancer, and breast cancer. With prostate cancer, however, surgery and radiotherapy are considered as alternative single-modality treatments, and their combination is far less enthusiastically embraced. Despite a trend toward earlier clinical diagnosis of prostate cancer since the introduction of prostate-specific antigen (PSA) screening, modern surgical series continue to show a 15%-25% incidence of positive surgical margins. Postoperative radiotherapy, whether delivered as "adjuvant therapy" shortly after surgery or as "salvage therapy" when serum PSA becomes detectable, effectively improves local control and prolongs disease-free survival.     

Hybrid cardiac procedure: the ultimate cooperation

In medical terms, a hybrid therapy or procedure is a mixture of therapies from different subspecialities. By these definitions, a hybrid cardiac procedure is a combination of surgical and catheter-based intervention to the heart. Hybrid coronary artery revascularisation is a combination of surgical and catheter-based intervention to the diseased coronary arteries.     

A new method of auditing surgical mortality rates: application to a group of elderly general surgical patients.

In a prospective study of 505 patients aged 65 years or over admitted to a general surgical unit the overall hospital mortality rate was 14.5% and the postoperative mortality rate 12.0%. These rates fell to 3.6% and 5.8% respectively when deaths in non-viable patients were excluded from the analysis. An audit of surgical outcome that fails to identify non-viable patients is therefore potentially misleading. A standardised system of reporting surgical mortality is proposed to aid the comparison of results from different units. The key elements of this system are (a) the separation of the results from non-viable and potentially viable patients; (b) the consideration of both operative and non-operative mortality; (c) the differentiation between medical and surgical causes of postoperative mortality; and (d) the identification of patients who are discharged from the unit but who have residual malignancy. Data presented in such a way should be of direct relevance to surgeons and physicians who are seeking ways of improving the service provided for surgical patients of all ages.     

Left ventricular endocardial pacing in cardiac resynchronisation therapy: Moving from bench to bedside

In cardiac resynchronisation therapy, failure to implant a left ventricular lead in a coronary sinus branch has been reported in up to 10% of cases. Although surgical insertion of epicardial leads is considered the standard alternative, this is not without morbidity and technical limitations. Endocardial left ventricular pacing can be an alternative as it has been associated with a favourable acute haemodynamic response compared with epicardial pacing in both animal and human studies. In this paper, we discuss left ventricular endocardial pacing and compare it with epicardial surgical implantation. Ease of application and procedural complications and morbidity compare favourably with epicardial surgical techniques. However, with limited experience, the most important concern is the still unknown long-term risk of thromboembolic complications. Therefore, for now endovascular implants should remain reserved for severely symptomatic heart failure patients and patients at high surgical risk of failed coronary sinus implantation.     

Long-Term Catheterization of the Intestinal Lymph Trunk and Collection of Lymph in Neonatal Pigs

Catheterization of the intestinal lymph trunk in neonatal pigs is a technique allowing for the long-term collection of large quantities of intestinal (central) efferent lymph. Importantly, the collection of central lymph from the intestine enables researchers to study both the mechanisms and lipid constitutes associated with lipid metabolism, intestinal inflammation and cancer metastasis, as well as cells involved in immune function and immunosurveillance. A ventral mid-line surgical approach permits excellent surgical exposure to the cranial abdomen and relatively easy access to the intestinal lymph trunk vessel that lies near the pancreas and the right ventral segment of the portal vein underneath the visceral aspect of the right liver lobe. The vessel is meticulously dissected and released from the surrounding fascia and then dilated with sutures allowing for insertion and subsequent securing of the catheter into the vessel. The catheter is exteriorized and approximately 1 L/24 hr of lymph is collected over a 7 day period. While this technique enables the collection of large quantities of central lymph over an extended period of time, the success depends on careful surgical dissection, tissue handling and close attention to proper surgical technique. This is particularly important with surgeries in young animals as the lymph vessels can easily tear, potentially leading to surgical and experimental failure. The video demonstrates an excellent surgical technique for the collection of intestinal lymph.     

仿真手术刀在虚拟外科手术系统中的应用与研究

目的 设计了一种基于手术刀的虚拟外科手术系统,培训外科实习医生熟悉并体验外科手术的过程.方法 符合外科医生实际操作习惯设计仿真外科手术系统专用的手术刀,完成各种结构设计、三维定位跟踪、力反馈选型,设计配套软件系统,使其提供逼真的三维虚拟场景.结果 在所建立的虚拟手术台上所做的虚拟切割实验表明,该虚拟外科手术系统使操作者体验到真实做手术的感觉,完全可用于外科医生的培训当中,使得受训者获得逼真的手术教学效果.结论 利用这种仿真手术刀进行虚拟外科手术系统的解决方案,并构建了一个虚拟手术台,为训练外科实习医生熟练使用手术刀提供了一个方便快捷的途径.     

Overview of surgical treatments for breast cancer-related lymphedema

Breast cancer-related upper extremity lymphedema is an unsolved iatrogenic complication with a reported incidence ranging from 9 to 41 percent. The increase in volume and recurrent cellulitis of the affected limb cause both physical and mental distress to many breast cancer survivors. However, postmastectomy lymphedema has received little attention, and no curative treatment is available. Conservative treatment with decongestive therapy has been the primary choice for lymphedema treatment, but it is cumbersome and has limited benefits. To date, there is no consensus on surgical procedure and protocol. However, refinements in microsurgical techniques and improved examination devices may lead to the establishment of a standard surgical treatment for lymphedema. This review of surgical procedures for the treatment of postmastectomy lymphedema focuses on microsurgical lymphovenous shunt operations and discusses current issues in surgical treatment and the need for uniform treatment standards.