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代謝性疾病外科手術方式的發展及演變

Prevention of Postoperative Acute Renal Failure in Patients with Malignant Obstructive Jaundice

Objective　To investigate the protection of renal function and the prevention of acute renal failure （ARF） in patients with malignant obstructive jaundice in perioperative period of radical resection. Methods　A series of clinical interventions had been taken since 2004 in our treatment team, including control of endotoxemia, depression of biliary tract before operation, maintenance of adequate effective blood volume, nutritive support, administration of mannitol and low dose of furosemide, and avoidance of disseminated intravascular coagulation. The incidence of perioperative ARF in 206 patients with malignant obstructive jaundice who had been radically resected from 2000 to 2007 was retrospectively studied, and the RIFLE criteria was used for ARF classification. This study was progressed in two periods. The first one was from Jan. 2000 to Dec. 2003, and the second one was from Jan. 2004 to Dec. 2007. Results　After 2003, the proportion of radical resection rose from 44.8% to 57.1% （P＜0.05), and the rate of perioperative ARF dropped from 15.1% to 6.7%（P＜0.05), among which the proportion in the RIFLE-R (Risk) stage had no significant change, while in the RIFLE-F (Failure) stage it dropped from 10.5% to 2.5% (P＜0.05). Finally, perioperative mortality rate dropped from 16.3% to 5.8% (P＜0.05). Therefore, the reduction of ARF was mainly attributed to the reduction in RIFLE-F stage. Conclusion　By using the latest RIFLE criteria to classify ARF, it illustrates that our perioperative interventions have effectively decreased ARF, limited ARF in its early and reversible stage, and prevented advancing.

肝臟肺吸蟲病1例報道

　　患者，女，35歲，因反復右上腹痛伴發熱15 d急診入院。15 d 前患者無明顯誘因感右上腹持續性脹痛，放射至背心，同時出現發熱，最高體溫（T）39 ℃，伴惡心、嘔吐、腹脹等，抗生素治療后癥狀有好轉，其后上述癥狀反復發作，抗生素治療有效，為進一步診治來我院。入院時查體： T 38.3 ℃，R 87次/min， P 20次/min，BP 109/68 mm Hg(1 mm Hg=0.133 kPa)； 急性病容，神志清楚，皮膚、鞏膜無黃染； 心、肺(-)； 腹軟，右上腹壓痛、叩痛，肌張力不高; 肝臟于肋下4 cm，質軟，輕觸痛，移濁(-)。急診血常規： Hb 99.8 g/L, WBC 6.5×109/L； B超： 左、右肝低密度占位。入院診斷： 肝膿腫，肝腫瘤待排。入院后按肝膿腫治療,用三聯抗生素，T 36.7～39.5 ℃，右肝區叩痛。經上述抗感染治療5 d后，T仍達39.2 ℃，復查血常規： Hb 100.2 g/L,WBC 6.3×109/L,N 0.496,淋巴細胞比例0.096，淋巴細胞數0.58×109/L； 嗜酸性細胞比例0.341，嗜酸性細胞數2.05×109 /L。TB 12 μmol/L，DB 4.2 μmol/L，AST 17 U/L，ALT 19 U/L，Alb 37.7 g/L,GLB 32.0 g/L； 血清CEA、CA15-3、AFP、CA19-9 均正常； 血培養24 h陰性。 心電圖、胸片未見異常。CT檢查： 左肝內葉、右肝前葉低密度占位但無明顯液性暗區形成(圖1)； 復查B超： 肝右前葉及左外葉稍弱回聲區7.2 cm×3.0 cm、4.3 cm×4.2 cm及 2.5 cm×2.0 cm大，邊界不清，內見蜂窩狀無回聲。經全科討論認為，肝低密度占位明確，以細菌性肝膿腫可能性大，經抗感染治療后T仍高達39.2 ℃，有手術引流指征。于入院后第6天急診行肝膿腫引流+活檢。術中見左、右肝增大，色澤紅； 左肝SⅡ、SⅢ各捫及包塊約1.5 cm×2.0 cm×2.0 cm大，切開后有粉紅色膿液； 右肝SⅤ～SⅥ各有包塊6 cm×6 cm×6 cm大，質較硬，切開后有黃白色膿液20 ml及淡黃色顆粒樣物，膿腫壁厚約0.5 cm，似干酪樣。取含膿腫壁的肝組織送病檢。術后診斷： 細菌性肝膿腫或肝結核繼發細菌性肝膿腫。術后1 d癥狀緩解，T 37.4 ℃，肝區叩痛減輕，膿腔引流約10 ml/d。術后3 d，腸功能恢復，開始進流食，下床活動，T逐步降至正常，膿腔引流＜5 ml/d。術后第5天拔出引流管后出院。血培養報告： 1周無細菌、真菌生長； 膿液涂片： 革蘭染色無細菌，未見抗酸桿菌。術后病理報告： 肝組織內竇道樣嗜酸性膿腫形成，可見夏科-雷登結晶，未見蟲體及蟲卵， 多為肺吸蟲病。　　討論　肝臟肺吸蟲病罕見，文獻中僅有數例報道。本例為中青年女性，起病急，以發熱、右上腹痛為主癥，T高達39.5 ℃，無畏寒、寒戰。抗生素治療有效，但反復發作。WBC總數和中性粒細胞比例正常，淋巴細胞比例（0.096）明顯降低，嗜酸性細胞絕對數及比例（0.341）明顯增高。影像學檢查示左、右肝多發性低密度區，但無明顯液性暗區形成。術中探查： 肝明顯增大，顯暗紅色，符合炎性表現，膿液有粉紅色及黃白色，含淡黃色顆粒物，膿壁明顯增厚（約0.5 cm），有干酪樣物，引流后無明顯膿液流出，臨床癥狀緩解，T降至正常。本例臨床表現與常見細菌性肝膿腫很相似，但本例感染癥狀明顯,而WBC不高，中性粒細胞正常，淋巴細胞明顯減少，嗜酸性細胞明顯增高，這符合寄生蟲感染表現。此病術前明確診斷困難，易診斷為細菌性肝膿腫，但若注意其特殊的血常規結果，結合影像學檢查中的無典型表現，均可提示非細菌性肝膿腫的可能性。

硅膠內襯套治療地震擠壓傷截肢術后1例報告

目的：觀察硅膠內襯套應用于地震擠壓傷截肢術后患者殘端滲液不止的治療效果。方法：采用個案分析。14歲女性少年，因地震擠壓傷致左小腿中上段截肢，給予綜合康復治療，傷口愈合后安裝假肢，殘端出現水泡，原傷口少量漿液性液體滲出不止，給予加戴硅膠內襯套。結果：患者殘端傷口滲液逐漸減少，水泡消失，正常熟練使用假肢，日常生活活動能力提高，正常上學。結論：硅膠內襯套是處理截肢術后殘端滲液較好的方法。

Development and prospect of medical education based on 5G technology

The development of the fifth generation mobile networks (5G) technology has brought great breakthroughs and challenges to clinical medicine and medical education. In the context of “5G + medicine”, the development of telemedicine, emergency rescue, intelligent analysis and diagnosis has opened up new horizons for clinical medicine. Facing the constant impact of high technology, the focus of medical education should be on the cultivation of students’ integrated medical view, critical thinking, communication abilities and skills, and creativity. The “5G + education” model will be presented by means of virtual reality, artificial intelligence, cloud computing and other technologies, providing a new direction for the development of medical education. This article summarizes the key points and prospects of medical education under 5G technology in order to provide a reference for the field of medical education to adapt to the changes in the 5G era.

The application of silicone prosthesis in the immediate breast reconstruction

Objective To evaluate the feasibility of immediate breast reconstruction with silicone prosthesis for breast tumor. Methods The clinical data of the 42 patients with breast tumor who had undergone breast reconstruction with silicone prosthesis from January 2012 to June 2017 were collected retrospectively. The postoperative complications and cosmetic results were analyzed. Results All patients underwent operation successfully. The surgical time was 230–435 min (mean of 325 min), the intraoperative blood loss was 100–160 mL (mean of 130 mL), and the hospitalization time was 18–33 d (mean of 24 d). The cosmetic results was excellent in 26 patients, good in 8 patients, bad in 8 patients, and fine rate was 81.0% (34/42). Rate of patients’ overall satisfaction with breast reconstruction was 73.8% (31/42) and rate of aesthetic satisfaction was 78.6% (33/42). After operation, seroma occurred in 2 patients, and the ischemic necrosis in nipple and areola occurred in 3 patients. All the patients were followed-up for 4–70 months, and the median follow-up time was 37 months. During the follow-up period, no patient had metastasis or recurrence. Six patients received radiotherapy, among them 2 patients appeared Ⅱ-grade capsular contracture. Conclusion The breast reconstruction with silicone prosthesis is a simple, easy, and effective surgical procedure.

Rehabilitation Nursing for Patients with Lower Limb Amputation before Prosthetic Fitting

ObjectiveTo explore the clinical effect of systematic rehabilitation nursing for patients with lower limb amputation before prosthesis fitting. MethodsFifty patients with lower limb amputation before prosthetic fitting from January 2009 to December 2012 were assessed by rehabilitation team members, and then received the nursing progress according to the assessment results. The conditions of the patients before and after nursing intervention were evaluated and compared. ResultsAfter the patients received systematic rehabilitation nursing intervention, the standard rate of rehabilitation nursing knowledge and satisfaction rate of the nursing quality at the departure of the patients was 87.24% and 93.25% respectively. The muscle strength reached level 4 or higher in 4 patients, who could have the prosthesis fitting. ConclusionSystematic rehabilitation nursing for patients with lower limb amputation before prosthesis fitting can help patients to reserve the function as possible, improve the ability of living and quality of life, and reduce the burden of the patients and family to return to society earlier.

Multifactorial Analysis of 233 Pancreaticoduodenectomy Cases Related to Risk Factors of Postoperative Complications and Death

【Abstract】 Objective To multifactorially analyze the risk factors related to the post-pancreaticoduodenectomy (PD) complications and death. Methods Two hundred and thirty-three PD cases were analyzed, average age 56, of those cases, 210 malignant with 72 pancreatic head and 138 periampullary involvement, 23 benign. Fifty-nine cases suffered coexisting vital organ disorders. Results Sixty-three cases (27.0%) experienced postoperative complications, among those 58 cases (24.9%) early complications, 28(12.0%) infection, 15(6.4%) organ systemic disorder, 14(6.0%) bleeding, 12(5.2%) pancreatic fistula, 15(6.4%) reoperations, 16 postoperative death during hospitalization. The independent risk factors related to the postoperative complications included coexisting vital organ disorders, operation methods, main pancreatic duct (MPD) diameter and surgeon’s experiences, those related to the death during hospitalization included preoperative serum creatinine, coexisting vital organ disorders, surgeon’s experiences; those related to the reoperation included preoperative CA19-9, surgeon’s experiences, tumor diameters, lymph nodes metastasis; and those related to the pancreatic fistula included operation methods, MPD diameters and surgeon’s experiences. Conclusion Coexisting vital organ disorders and surgeon’s experiences are the independent risk factors related to postoperative complications and death during hospitalization, operation methods, MPD diameter and surgeon’s experiences are the independent risk factors related to the pancreatic fistula. Thus, it is very important to choose the appropriate PD candidates, select the right operation method and to familiarize the operation.

全胸腔鏡左肺上葉袖式切除術視頻要點

The application of latissimus dorsi myocutaneous flap in the breast reconstruction

Objective To explore the value of the application of latissimus dorsi myocutaneous flap in the breast reconstruction. Methods The clinical data of the 36 patients with breast tumor who had undergone breast reconstruction with latissimus dorsi myocutaneous flap from January 2012 to December 2016 were collected retrospectively. The postoperative complications and cosmetic results were analyzed. Results Thirty-six patients with breast tumor who underwent breast reconstruction with latissmus dorsi myocutaneous flap, including 32 patients with immediate breast reconstruction and 4 patients with delayed breast reconstruction respectively. The operative time of the patients who undertwent immediate breast reconstruction was 235–490 min (mean of 325 min), the intraoperative blood loss was 200–260 mL (mean of 220 mL), and the hospitalization time was 18–33 d (mean of 23.6 d). The total operative time of patients who underwent delayed breast reconstruction was 325–550 min (mean of 355 min), the total intraoperative blood loss was 200–250 mL (mean of 220 mL), and the total hospitalization time was 27–45 d (mean of 32.5 d). The cosmetic results was excellent in 22 patients, good in 8 patients, fair in 6 patients, respectively, and fine rate was 83.3% (30/36). There was no flap loss, but donor site seroma occurred in 21 patients, partial necrosis of the surgical margin of back skin occurred in 1 patient, partial necrosis of the nipple and areola skin occurred in 2 patients. All the patients were followed-up for 3–60 months, and the mean follow-up time was 37 months. During the follow-up period, no patient occurred metastasis or recurrence. After undergoing radiotherapy, reconstructive breast volume of 2 patients significantly contracted. None of the patients had significant limb function. Conclusion The breast reconstruction with the latissimus dorsi myocutaneous flap is a simple, easy, and effective surgical procedure.