混合痔手术治疗技术新进展

：痔(Haemorrhoids)是直肠末端黏膜、肛管皮肤下痔静脉丛屈曲或扩张而形成的柔软静脉团,是外科常见的疾病。尽管保守治 疗适用于大部分患者人群,但是手术治疗却适用于大部分严重病人,比如外剥内扎术就被视为治疗IV 度痔的金标准。痔的手术 治疗有传统手术和微创手术,为了减轻患者的痛苦、加速恢复、减少并发症的发生,PPH 和TST 等新型手术方式也逐渐被应用于 III痔的治疗中,这些手术方法的目的是纠正痔疮的病因及病理生理基础,具有微创、痛苦小的特点,但往往复发率较高。随着手术 方式的改进以及操作技术的成熟,痔的外科治疗效果也取得了长足的进步。本文对混合痔的外科手术技术作一综述,为临床治疗 提供理论依据。     

Gender-related differences in octogenarians with congenital coronary artery fistula: a report of two cases and a review

Aim

To highlight gender-related differences in octogenarians with a congenital coronary artery fistula (CAF).

Materials and methods

We present two elderly female patients with a congenital fistula, a septuagenarian and a nonagenarian, and review the world literature between 1954–2010.

Results

The septuagenarian patient presented with easy fatigability and the nonagenarian patient with acute myocardial infarction contralaterally to the fistula. Coronary angiography (CAG) demonstrated a coronary-pulmonary artery fistula (CPF). The nonagenarian patient underwent percutaneous coronary intervention of the right coronary artery. CAG revealed a CPF associated with a huge multiple aneurysmal formation. Data from 57 mainly symptomatic patients with a mean age of 75.3 years (range 70–87 years) were collected. The cohort was subdivided into female (mean age 84.3 years) and male (mean age 75.2 years) subgroups and compared with each other. Multi-origin (bilateral and multilateral) was prevalent in females, 40% versus 12% in males. Aneurysmal formation was found in females and males in 40% and 18%, respectively. Ethnicity was 65% Caucasian and 35% Asian. Multi-origin fistulas were prevalent in the Asian (45%) compared with the Caucasian (11%) subset.

Conclusions

A septuagenarian and a nonagenarian female patient with congenital CAF are presented. On reviewing the literature, important differences were found between elderly females and males with congenital CAF.     

后磨牙模拟根管模型制备与研究

目的：制备后磨牙模拟根管模型。方法：依照预实验中测试的牙本质和树脂根管模型材料的布氏硬度值（牙本质HB72,树脂块HB54）选取纯铜质铜管为材料（纯铜HB58）同时利用预实验中确认的后磨牙模拟根管模型弯曲角度的范围（70°-60°）并参照树脂根管模型相关数据,设计不同弯曲角度（70°,64°,60°）的纯铜质根管模型,将20套镍钛根管锉随机分为4组,其中3组根管锉分别预备相应角度的10个纯铜质后磨牙根管模型,另一组在临床预备10个后磨牙根管作为对照组。所有镍钛根管锉均在疲劳寿命测试装置中测试疲劳寿命。结果：选用根管长度为16mm±1mm,弯曲半径为5mm,内径为0.70mm的纯铜质铜管制作后磨牙根管模型。其中在弯曲角度为70°的后磨牙根管模型中有33%（2/6）近似临床;在弯曲角度为64°的后磨牙根管模型中有67%（4/6）近似临床;在弯曲角度为60°的后磨牙根管模型中有33%（2/6）近似临床。结论：弯曲角度为64°的纯铜制后磨牙模拟根管模型更接近于临床实际,可为体外研究镍钛根管锉各项指标提供一个较为理想的模型。     

外科治疗囊性听神经瘤14 例临床观察

目的:探讨囊性听神经瘤的临床特点及手术经验。方法:回顾分析2006年1月-2010年12月我院收治的14例囊性听经瘤的临床资料。结果:肿瘤全切除12例,不全切除2例,无死亡病例,术后4例病人面瘫加重,1例病人听力丧失。结论:与实质性听神经瘤相比,囊性听神经瘤体积较大,病程短,始发症状不典型,颅神经常被累及,可不发生内听道扩大,脑积水发生率低,手术效果差。     

Surgical issues surrounding use of aromatase inhibitors

There are important surgical issues related to the use of the third generation aromatase inhibitors in both the neoadjuvant and adjuvant settings. Neoadjuvant hormone therapy is effective at downstaging tumours, particularly large tumours initially thought to be inoperable or requiring mastectomy. Randomised trials have shown that the newer aromatase inhibitors letrozole and anastrozole increase the numbers of women who are suitable for breast-conservation compared with tamoxifen, and that letrozole is superior to tamoxifen in terms of clinical response.

Aromatase inhibitors are most effective in ER-rich tumours and are clinically and biologically effective in both HER2 positive and negative tumours, whereas HER2 positive tumours show a level of resistance to tamoxifen.

In neoadjuvant studies comparing aromatase inhibitors with tamoxifen, the duration of use has been 3–4 months, by which time any response is usually evident but longer treatment periods produce continued shrinkage and response. The re-excision rate following breast conservation surgery after neoadjuvant hormone therapy is favourable compared with the rates following immediate wide local excision. Local recurrence rates are acceptable in patients undergoing neoadjuvant therapy and breast-conserving surgery providing post-operative radiotherapy is given.

Adjuvant aromatase inhibitors, as well as having an effect on metastatic disease and survival, reduce local and regional recurrence.     

胸部双源性疾病外科治疗的临床决策

胸部双源性疾病随人口的老龄化而逐年增加,而老年人的心肺及各种脏器功能随年龄的增长逐渐衰退,并发症多,手术风险大,对此类病人的外科治疗如何做出正确的临床医疗决策呢？我们以循证医学理论为基础,努力做到临床医疗决策的科学性,治疗方案的合理性,大胆尝试,逐步从分期手术向一期手术过渡,既达到了解决病人疾苦,救治病人的目的,又解决了医疗需求的增加和卫生资源短缺的矛盾,取得了满意的效果,降低了医疗成本,节约了医疗资源,产生了明显的社会和经济效益。     

Post-operative course in a surgical model of acute myocardial infarction in the rabbit

This study was undertaken to evaluate the post-operative (post-OP) course of rabbits in a surgical model of myocardial infarction (MI). Ten New Zealand White rabbits were subjected to coronary artery ligation after lateral thoracotomy. Anesthesia was delivered using a xylazine-ketamine-isoflurane protocol after endotracheal intubation. Among other cardiorespiratory parameters, arterial pressure was monitored via central ear artery catheterization. Post-OP care included oxygen, antibiotic and analgesic treatment as well as nutritional and fluid support. A series of cardiorespiratory, hematological, blood biochemical and clinical parameters were assessed during the first 21 days. The mortality rate was 10%. Hypotension and hypothermia, noted during the operation, reverted within the first few post-MI hours. Electrocardiographic alterations, which included ST segment elevation and Q wave, appeared after MI and remained throughout the study period. Tachycardia was observed during the first 5 days. Hematological examination revealed mild and transient anemia during the post-OP period and leucocytosis up to the 5th day. Urea was increased up to the 12th post-MI hour while increased AST, ALT, LDH and CK levels normalized by the first 4-5 days. Although the post-OP anorexia period lasted around 5 days, the animals did not manage to regain their body weight by the end of the study period. In conclusion, the present model offers a low mortality rate and could be useful in mid- or long-term MI studies. The animals go through a critical post-OP period of around 5 days during which special care should be given. After that time, their clinical and blood laboratory parameters tend to normalize.     

巨大痛风石手术切除一例及文献复习

目的:探讨晚期巨大痛风石结节的临床表现及手术治疗效果.方法:回顾性分析一例典型病例患者的临床资料、手术方法的选择以及病理学表现.结果:该患者为晚期通风症患者,发展为痛风石.表现为痛风石结节增生,破坏肌腱以及骨组织.各项辅助检查以及手术后病理结果均支持痛风病的诊断.通过手术切除第一跖趾关节旁巨大痛风石,疗效满意.结论:痛风是一种因嘌呤代谢紊乱所致的疾病,本例患者经过各种保守对症治疗均无效.接收此患者后,通过文献复习分析以及临床检查确诊,本病例痛风病变已发展至晚期巨大痛风石结节.只有通过手术治疗才能彻底治愈.手术后证明对晚期巨大痛风石结节同时伴有骨关节破损的痛风石患者行手术治疗是完全可行,且疗效显著.     

Direct Pressure Monitoring Accurately Predicts Pulmonary Vein Occlusion During Cryoballoon Ablation

Cryoballoon ablation (CBA) is an established therapy for atrial fibrillation (AF). Pulmonary vein (PV) occlusion is essential for achieving antral contact and PV isolation and is typically assessed by contrast injection. We present a novel method of direct pressure monitoring for assessment of PV occlusion.Transcatheter pressure is monitored during balloon advancement to the PV antrum. Pressure is recorded via a single pressure transducer connected to the inner lumen of the cryoballoon. Pressure curve characteristics are used to assess occlusion in conjunction with fluoroscopic or intracardiac echocardiography (ICE) guidance. PV occlusion is confirmed when loss of typical left atrial (LA) pressure waveform is observed with recordings of PA pressure characteristics (no A wave and rapid V wave upstroke). Complete pulmonary vein occlusion as assessed with this technique has been confirmed with concurrent contrast utilization during the initial testing of the technique and has been shown to be highly accurate and readily reproducible.We evaluated the efficacy of this novel technique in 35 patients. A total of 128 veins were assessed for occlusion with the cryoballoon utilizing the pressure monitoring technique; occlusive pressure was demonstrated in 113 veins with resultant successful pulmonary vein isolation in 111 veins (98.2%). Occlusion was confirmed with subsequent contrast injection during the initial ten procedures, after which contrast utilization was rapidly reduced or eliminated given the highly accurate identification of occlusive pressure waveform with limited initial training.Verification of PV occlusive pressure during CBA is a novel approach to assessing effective PV occlusion and it accurately predicts electrical isolation. Utilization of this method results in significant decrease in fluoroscopy time and volume of contrast.     

Esophageal squamous cell carcinoma and adenocarcinoma in Malaysia – Pooled data from upper gastrointestinal centers in a multiethnic Asian population

BackgroundEsophageal cancer is the sixth leading cause of cancer death worldwide with considerable geographical histological variation There is a paucity of data in esophageal cancer in demographics, histology, and survival among the multi-ethnic Malaysian population. This paper is a review of esophageal cancer epidemiology and survival among esophageal cancer patients from data collected by the Malaysian Upper Gastrointestinal Surgical Society.MethodsThis is a multicenter retrospective observational study of esophageal cancer patients from six upper gastrointestinal surgical centers in Malaysia between 2005 and 2019. Patient characteristics, histological type and stage were compared and survival analyzed.ResultsThere were 820 patients with esophageal cancer included, where 442 (53.9 %) cases had squamous cell carcinoma (SCC) and 378 (46.1 %) had adenocarcinomas (AC). Malays were the predominant ethnicity with AC (66.7 %) while Indians were the ethnic majority (74.6 %) with SCC. Majority of patients (56.8 %) presented as stage IV disease. Overall, the 1-, 3-, and 5-years’ survival were 35.8 %, 13.8 % and 11.0 %, respectively. Surgical resection with curative intent yielded the best 5-year survival (29.4 %). Intervention in stage IV AC yielded superior survival when compared to SCC (median survival, 7.9 months vs 4.8 months; p, 0.018) Our series demonstrated an increase in AC to SCC over the last 15 years.ConclusionsThere was an ethnic preponderance seen between different histology in this region, not previously discussed. An increase in AC was observed over the last 15 years. Late diagnosis seen in most patients imparts poor prognosis as curative surgery affords the best outcome.