人工全膝关节置换术围手术期失血量的影响因素及预防

人工全膝关节置换术(total knee arthroplasty,TKA)对于骨性关节炎、类风湿性关节炎等患者现已成为一种重要的治疗手段,它的应用极大改善了患者的生活质量.虽然术中出血较以往大为减少,但围手术期的失血量(perioperative blood loss,POBL)始终得不到有效控制,增加了患者围手术期风险.同时,由于近年来对于TKA术后静脉血栓栓塞症(venous thromboembolism,VTE)的预防越来越受到重视,而抗凝治疗在一定程度也增加了围手术期失血量.因此,如何减少POBL和术后异体血使用越来越引起关注,国内外相关临床研究也越来越多.

Objective. To investigate the indications, surgical techniques and complications of laparoscopic myomectomy. Materials and methods. A retrospective study was carried out in 74 patients with fibroids >3cm from March, 1995 until May,2000 at PUMC Hospital. Indications for surgery were symptomatic fibroids（ 20 cases） , mainly pain or urine frequency ； progressively increasing fibroid size (7 cases)； coexistent adnexal pathology（ 26 cases） and infertility（ 21 cases） . Results. The number of fibroids of each patient varied from 1 to 4 with single fibroid of 62 cases (83.7％ ).The fibroids were located in anterior wall (30 cases), posterior wall (23 cases) and fundus (21 cases). A total of 93 fibroids were removed from these patients including 16 intramural fibroids and 77 subserous fibroids. The size of dominant fibroids ranged from 3～ 8 cm (mean 4.8 cm). In 19 cases (25.6％ ),the uterine wall was sutured in one layer. Mean duration of operation was 73 minutes and mean blood loss was 82 ml. Longer operating time and more blood loss were observed in patients with fibroids≥ 4cm than those with fibroids <4cm. The difference was statistically significant (P< 0.05). Mean postoperative hospital stay was 3.2 days and overall complication rate was 1.4％ . The average postoperative follow-up period was 22 months (1～ 62 months). All the patients with symptoms showed remission of their complaints at 2-month follow-up. Recurrence of fibroid occurred in 1 case 1 year after initial operation and second laparoscopic myomectomy was given to her successfully. Five patients became pregnant. The pregnancy was uneventful and proceeded to selective caesarean section at term pregnancy in 4 cases. One miscarriage occured at 8 weeks in the 5th case. No adhesions at myomectomy site were found in these 5 patients. Conclusions. Our study suggests the feasibility of laparoscopic myomectomy in selected patients, which leads to effectiveness, low complication rate and satisfactory remission of symptoms. Further study on recurrence and fertility must be continued.

近端髓内钉与锁定加压钢板治疗股骨反转子间的临床分析

目的：探讨近端髓内钉与锁定加压钢板治疗股骨反转子间骨折治疗中应用效果的观察。方法回顾我院在2010年07月至2013年10月收治的120例股骨反转子骨折患者，随机分为观察组组和对照组两组，每组60例。观察组采用近端髓内钉进行治疗，对照组则采用锁定加压钢板进行治疗。且分别对两组患者的术中失血量、手术时间、骨折愈合时间和髋关节功能进行回顾性分析。结果观察组(近端髓内钉)的术中失血量、手术时间、骨折愈合时间和髋关节功能等评价均优于对照组，且两组差异具有显著性，具有统计学意义，P<0.05。结论近端髓内钉治疗股骨反转子间骨折具有术中出血少、功能恢复快、提高患者的术后生活质量等优点，且可以取得显著的临床疗效的,值得临床推广应用。

全膝关节置换术围术期血液管理的研究进展

全膝关节置换术后常并发急性失血性贫血。异体输血是目前纠正术后贫血的主要措施，虽然可以快速纠正贫血，但可能引起各种严重的并发症及其他问题，包括感染、肢体康复时间延长、住院时间延长、死亡率增加等。全膝关节置换术围术期采取血液管理措施可有效降低术后失血，减少或避免异体输血。围术期血液管理措施主要分为三部分：术前纠正贫血、自体血储存；术中止血带、抗纤溶药、局部止血剂、急性等容性血液稀释等的应用；术后自体血回输、遵循输血指征、处理引流和体位控制等。围术期血液管理旨在减少术后失血、降低输血率、改善预后、促进术后康复及降低医疗成本。血液管理理念必须贯穿整个围手术期，临床医生需要根据患者实际情况，结合不同血液管理方法的特点，权衡利弊，制定出高效合理的个体化治疗方案。

剖宫产术中失血测量方法

剖宫产术中因为羊水与失血难以区分,一直以来精确测量剖宫产术中出血量成为一个难题.为了解决这一难题,对2008年6月-7月100例计划剖宫产术者用两种测量方法进行比较,结果发现,100例剖宫产用两种测量方法测得的结果有统计学差异.传统测量方法出血量在200 mL～300 mL,新方法测量在500 mL～800 mL,从各种资料证明新方法更能准确反映正常削宫产术中失血量.

婴儿手术后细胞免疫的变化

近年来,一些研究表明,成人和儿童在麻醉和手术后,产生免疫功能抑制.本文应用经PHA刺激的3H-胸腺嘧啶核苷掺入法,了解淋巴细胞转化状况,以探讨在麻醉下手术对婴儿细胞免疫的影响,并结合本组资料,对预防术后感染略加讨论.

哈林顿器械矫正小儿重症脊柱侧弯的初步报告

我院外科门诊每年可见各种类型的脊柱侧弯病儿300例左右.特发性脊柱侧弯,先天性半椎体和脊髓脊膜膨出所致的为多见.这类畸形不仅造成病儿的体态变形,影响劳动功能,引起病儿和家长的焦虑不安;严重的每能导致内脏受压和心肺功能障碍,影响小儿的生长发育和威胁小儿生命.过去我们也曾用矫形石膏加单纯脊柱融合术治疗,但因矫正力量不足和脊柱融合范围不够等原因,效果很不理想.

腹腔镜治疗>5 cm胃GIST是否安全可行：前瞻性队列研究结果

目的：由于担心术中肿瘤破裂，腹腔镜手术治疗>5 cm胃GIST仍存争议。方法：为探讨腹腔镜手术切除>5 cm胃GIST的可行性及安全性，我们于2011年3月至2015年3月入组一前瞻性研究队列。研究主要终点为术中肿瘤破裂发生率；次要终点包括：中转开腹率、手术时间、手术出血量、恢复流食及固体食物时间、术后住院时间及随访期间肿瘤复发率。结果：共有22例患者进入研究队列，平均肿瘤直径(7.04±1.53)cm，范围：(5.2~10.8cm)，无术中肿瘤破裂。平均手术时间(88.1±31.9)min，估计手术出血量(37.1±18.7)mL，无需输血病例。恢复流食及固体食物时间分别为(1.1±0.6)d及(2.5±0.9)d。平均术后住院时间为(5.4±5.8)d。平均随访时间为(18.9±10.2)月，范围：(2~47月)，随访期内无复发病例。结论：腹腔镜手术切除>5 cm胃GIST安全、可行。

Objective:In this study, using meta-analysis, we compared the LADG with open distal gastrectomy (ODG) in the treatment of patients with advanced gastric cancer.Methods: The RevMan 5.0 software was used for the meta-analysis.Results:The meta-analysis indicated that in comparison with patients who underwent open distal gastrectomy, patients who were treated with LADG had shorter hospital stay, less analgesic requirements and blood loss, less overall complications, including intestinal obstruction, earlier time to liquid ingestion, and less wound infections. Nevertheless, there is no significant difference between LADG and ODG in anastomotic hemorrhage, anastomotic stenosis, duodenal stump leakage, tumor margin, lymph node dissection, mortality, pneumonia or reoperation. And in case of long-term survivals, both OS (overall-survival) and DFS (disease-free survival) showed no significant difference between LADG and ODG.Conclusion:LADG is feasible for the treatment of advanced gastric cancer, and provides several advantages.

Objective:To evaluate the feasibility, safety and the clinical outcomes of the robotic distal gastrectomy for gastric cancer.Methods: We retrospectively analyzed the clinical and follow-up data of 113 cases underwent robotic distal gastrectomy from March 2010 to July 2013.Results:Compared with laparoscopic group, the robotic group had less intraoperative blood loss, more lymph nodes dissection (P<0.05). hTere was no signiifcant difference in the incidence of postoperative complications and neutrophil-lymphocyte ratio between the two groups. hTe follow-up data showed that the 1-, 2- and 3-year survival rates were 91.7%, 77.4% and 72.9% in robotic group while they were 91.2%, 76.2% and 70.4% in laparoscopic group ,and the difference was not significant. Conclusion:Robotic distal gastrectomy for gastric cancer is safe and effective, and it has less harm to the patients, with less intraoperative blood loss, more lymph nodes dissection and quicker postoperative recover than laparoscopic surgery, so it is worthy of popularization and application.

Objective:By employing video laparoscopy, we further demonstrated that mesogastrium, covered by Proper Fascia with anterior surface (A) and posterior surface (P) extends towards and fuses with the “mesogastrium bed”. Therefore, D2 lymphadenectomy plus complete mesogastrium excision (CME) is proposed as a novel approach to en bloc for advanced gastric cancer.Methods: This study was approved by the Tongji Hospital Ethics Committee.Results:A total of 54 patients underwent laparoscopic D2+CME with membrane anatomy. hTe mean number of retrieved regional lymph nodes was 35.04±10.70 (range, 14-55 lymph nodes). The mean volume of blood loss was 12.44±22.89 mL. No operative complication was observed during hospitalization.Conclusion:We believe that the laparoscopic D2 plus CME can minimize the differences in the number of lymph nodes harvested, and substantially reduce the intraoperative blood losses and surgery-related injuries in advanced gastric cancer patients.

Objective:A meta-analysis of high-quality clinical studies was performed to compare LAG and open gastrectomy (OG) for AGC.Methods: Meta-analysis was performed using RevMan 5.0 software (Cochrane Library). Results:Twenty studies were included in final pooled analysis, 2RCTs and 17 NRCTs, compromising 3,409 patients (1,640 LAG, 1,709 OG). LAG was associated with longer operative time(P<0.001) and lower overall complications(P=0.001), estimated blood loss(P<0.001) and hospital stay(P<0.001). hTere were no signiifcant differences between two groups in number of lymph node dissection (P=0.65), overall complication (P=0.86), a 5-year overall survival rate (P=0.53) and 5-year recurrence-free survival (P=0.07).Conclusion:Despite a longer operation time, LAG is a safe technical alternative to OG for AGC with a lower complication rate and enhanced postoperative recovery. Moreover, the oncologic outcomes of LAG for AGC patients were comparable with open approach.

Xinmailong injection solution was invented at 1988 by prof. Li Shunan in Dali medical college. It was made from the material which has high biological activeness to the cardiac and vascular system. During the experimental shock caused by excessive loss of blood in monkey and dog, it was found by ECG that the T-wave of anterion lead on left chest elevated and became high and sharp after acute blood loss. Arterial blood pressure dropped to 8-5.3 kPa for dog and 8-5.3-2.7 kPa for monkey, changes of T-wave all recovered to near normal level after xinmailong solution was injected intravenously (0.05-0.2 mL/kg). These Results implied that xinmailong might improve the ischemia of myocardium induced by hemorrhagic shock.

髋臼骨折病态肥胖对内固定术后并发症的影响

SummaryThree retrospective cohort studies of patients with acetabular fractures examined the impact of morbid obesity on patient complications after operative fracture fixation.The morbidly obese patient appears to have an elevated risk of more perioperative blood loss and of wound infection. While a higher rate of nerve palsy and pulmonary embolism was reported among morbidly obese patients compared with those in other weight categories in all studies, statistical significance was not achieved.One study reported increased risk of deep vein thrombosis (DVT) for obese patients compared with normal-weight patients.3项回顾性队列研究试图阐明髋臼骨折内固定术后，患者合并病态肥胖对术后并发症的影响。研究显示病态肥胖的患者术中失血量和伤口感染率更高。虽然与其他体质量的患者相比，病态肥胖的患者出现神经麻痹和肺栓塞的几率更高，但差异无统计学意义。1项研究报道，与正常体质量患者相比，肥胖患者深静脉血栓形成(DVT)的发生率更高。

Objective:　To evaluate the therapeutic effects of retrograde interlocking intramedullary nailing under arthroscopy on supracondylar femoral fractures.　　Methods:　From June 1999 to December 2000, 17 patients with supracondylar femoral fracture were treated with arthroscopically assisted implantation of retrograde interlocking intramedullary nail and close reduction.　　Results:　More than 6-month follow-up study after operation in 11 patients revealed that the average healing time was 3 months. Average range of the knee motion for all the patients was more than 90 degrees. There was no implant breakage and infection.　　Conclusions:　This new method, combining the advantage of arthroscope and retrograde interlocking intramedullary nail, can provide a stable and reliable fixation, and meanwhile is less invasive to the soft tissue and knee, less operative time and blood loss, minimal disruption of the blood supply in fracture site. It is conducive to the fracture healing and the functional recovery of the knee joint and worthwhile to be recommended.