AIM The incision in rectal cancer operation is adopted commonly in the left mid-lower abdomen. But thereare some defects for the incision, which is close to the artificial colotomy, readily be contaminated by feces,difficult to treat the lesions in hepatic and cholecystic area at the same time and in the weakened area ofabdominal wall. So, we employed the abdominal right lower paramedian incision to solve these problems.METHODS The abdominal right lower paramedian incision is from publc tubercle upward to 3 cm- 4 cmabove navel. The incision should be extended upward if individual need of performing hepatic and cholecysticoperation, or placing catheter or pump in hepatic artery or portal vein for chemotherapy at the same time.RESULTS One hundred and eighty three cases with rectal cancer were adopted this incision in differentoperation procedure, and out of them 41 patients were taken different operation on hepatic and cholecysticlesions and place a catheter or pump to hepatic artery or portal vein. Operators feel that the incision dose nothinder exploring and operating in all of the patients.CONCLUSION The right lower paramedian incision of abdomen is far away from the artificial colotomy,and it can reduce the feces contamination, lower down the rate of incision hernia and paramedian hernia orfistula. Furthermore, it is easy to treat the complicated hepatic and cholecystic lesion. So, authors suggestthat this incision is useful for the operation of rectal cancer, and it is worth to populize in clinical practice.

Acute severe pancreatitis (ASP) was habitually called acute hemorrhagic necrotizing pancreatitis. Butaccording to the pathological finditgs of our 139 surgical cases, 59.7% belonged to necrotizing type, whilehemorrhagic necrotizing type only accounted for 23.0%. Involvement of pancreas is not necessarily diffuse,3.7% only affected pancreatic tail. The incidence of the disease is highest in 41 - 60 year age group. Earlyrecognition of severe type of the disease is always an emphasis in clinical studies. CT scanning is the maindiagnostic tool used. Clinical diagnostic criteria offer some help in clinical practice. Banks' criteria is morecommonly used in western countries instead of Ranson criteria in the past. For clinical evaluation of theprogress of the disease, APACHEII scoring method is commonly used. Classification of CT findings ishelpful in judging the severity of the disease. Once the diagnosis was definitely established, should it betreated surgically or managed by medical way? The pendulum had swung for many years. Our currentconsensus is “combined treatment system”. That is: patients with uninfected pancreatic necrosis shouldreceive non-surgical treatment. The success rate is over 85%. Cases of infected necrosis went downhill,vigorous treatment should be given immediately. Otherwise, late stage operation should by all means be considered and wait for localization of theinfection with the hope of complete cure after single drainage operation. “Obstructive biliary pancreatitis”and “Ruptured pancreatic abscess causing peritoritis” are indicated for immediate operation. Cure rate bynon-surgical treatment is significantly increased, with a success rate of operative treatment of 80%. Medicaltreatment is administered by the combined traditional Chirtese and Western medicine. Besides all thenecessary supportive and symptomatic treatment, three major aspects of treatment should be speciallyemphasized: ① pancreatic infection. According to the bacterial spectrum, concentration of antibiotics in thepancreas and drug sensitivity test, we advocate the use of quinolone class antidacterial agents such asimipenem, Ofloxacin,ciprofloxacin, etc as drug of first choice. ② Inhibition of pancreatic secretion usingGabexate mesilate or synthetic analogue of somatostatin. The two analogues that are widely used in China areOctreotide (Sandostatin) introduced to China earlier; and the 14-pepitide somatostatin (Stilamin) introducedlater but also has been used for some years. There were reports about the benefits and drawbacks of the twoand sometimes quite controversial. According to our experience in using these two analogues, we have notmet with serious side effects of Octreotide as reported in the western literatures. The action of Stilamin onsphincter of Oddi is causation of relaxation, but the action of Octreotide on it was quite controversial. Somereported about its spasmodic action on the sphincter. We have studied in dog experimentation and provedthat Sandostatin can significantly lower the basal pressure of sphincter of Oddi. Our consensus of their use inASP is that either can be used as available, except in most severe cases, we prefer Stilamin. However,Saadostatiu has some merits in the following conditions: It can be given hypodermically orintramuscatarly. It is more suitable for outpatients with milder disease. (?) Chronic pancreatitis with acuteflare up. ③ Treatment with traditional Chinese medicine: according to the Chinese theory of thepathogenesis -“wetness and heat stagnated at middle focus”, the principle of treatment is “relieving liver,adjutsting gas, clearing heat, drying wetness, getting through and driving down”. We have made aprescription consisting of several important ingredients, in the form of decoction. Since the 1980s, we havestudied a few Chinese herbal medicines separately. They were all proved to have promising effect. Inconclusion, in ASP, we advocate combination of Western and traditional Chinese medical treatment.

胸椎管狭窄症的治疗现状及研究进展

胸椎管狭窄症(thoracicspinalstenosis，TSS)是指由于先天、退变或内分泌及全身系统性疾病等因素导致胸椎管容积变小，胸脊髓、神经根受压，从而引起相应临床症状和体征的疾病，可分为原发性胸椎管狭窄症(primarythoracicstenosis)和继发性胸椎管狭窄症(secondarythoracicstenosis)。原发性胸椎管狭窄症指先天性的椎管矢状径＜10mm，加之后天退变等因素造成胸脊髓、神经根受压，出现临床症状的疾病。继发性胸椎管狭窄症与内分泌或全身系统性疾病有关，典型表现为全脊柱的环形狭窄[1]。TSS多发生于中老年人，以下胸椎为主，上胸椎次之。与熟知的颈椎病、腰椎管狭窄症等疾病相比，TSS发生率相对较低[2-6]，许多TSS的患者同时合并颈椎病或腰椎疾病，往往容易误诊和漏诊[7-10]。随着CT与MRI技术逐步应用于临床及手术技术的发展，TSS进一步为人们所认识[11]，但由于其特殊的生理及解剖结构，其手术高致瘫率仍是一大难题，笔者就其近年来的治疗现状及进展作一简要综述。

脊柱转移癌的术前评估和手术方式评价

脊柱是恶性肿瘤骨转移常见的部位[1]，约占骨转移的2/3。有尸检报告显示70%的癌症患者伴有脊柱转移。其中，伴有脊髓压迫的脊柱转移癌患者占5%～14%[2]。近年来，随着检测技术的进步，尤其是 PET/CT的使用，脊柱转移癌的确诊率不断提高。在治疗方面，脊柱转移癌患者的管理理念也发生了转变，从单纯放、化疗逐渐演变为在放、化疗的基础上，积极进行外科手术治疗。试验证明，这种联合治疗比既往的单纯放、化疗对改善患者生存质量更有优势[3]。

骨质疏松性椎体压缩骨折治疗进展

随着经济的发展和科技的进步，老年性疾病越来越多地被人们重视。骨质疏松症作为一种常见疾病，无声无息地影响着老年人的生活，其严重的后果是骨折以及骨折造成的残疾和死亡。脊柱骨折是骨质疏松症常见的骨折部位之一，因其严重影响生活质量和造成巨大经济开支逐渐受到社会和医生的高度关注。骨质疏松性椎体压缩骨折(osteoporoticvertebralcompressionfractures，OVCFs)的发生率与年龄、性别、种族等因素密切相关，国外关于发病率的报道较多。一项研究估计，2000年全球发生140万例椎体压缩骨折，其中51%发生在欧洲和美国[1]。另一项多中心、多国家前瞻性研究分析了2451名女性脊柱影像资料，年龄在65～80岁，没有明确骨质疏松病史，但结果显示32%女性至少1个椎体骨折，而其中34%的骨折初未被发现[2]。目前国内尚无权威数据，北京协和医院徐苓等[3]报道北京地区50岁以上女性椎体骨折发生率15%，低于美国女性。OVCFs患者较一般人有更高的死亡率，主要是长期卧床而引起的并发症所致。

微创与精准：现代关节外科追求的目标

本期刊出的“关节外科”专题的论著都与关节外科的微创与精准理念有关。“微创”指在不降低治疗效果的前提下尽量做到：缩小手术切口，减少组织损伤，降低对机体和心理的干扰损害。“精准”指诊断准确、手术精细，精确辨别病变组织与正常组织的界限，无多余操作，避免人为损伤。微创与精准二者密切关联、相辅相成。微创是实现精准的手段，精准是微创的前提条件。其目的都是以小的手术损伤，获得佳的治疗效果。这正是现代关节外科追求的目标。

骨肿瘤规范化治疗与研究展望

近30年来，骨与软组织肿瘤的治疗在整个骨科领域中所占的比重虽然不大，但其进步是非常显著的。随着化疗的引入，手术技术的提高，综合治疗和规范化治疗的倡导，骨与软组织肿瘤的诊治水平和策略有了长足的发展。对于常见的骨与软组织原发肿瘤，治疗的总体方案归结为以手术为主导，放化疗为辅助的综合治疗，患者的生存率较前大大提高，复发率明显降低，功能评定显著改善。在当前的总体治疗策略上，我们仍然一贯地推崇骨肿瘤的规范化治疗，并不遗余力地在全国进行推广。倡导规范化、推动规范化、推崇创新研究，是目前骨肿瘤学科的鲜明特点。

严格掌握原发性脊柱肿瘤全脊椎整块切除的适应证

原发性脊柱肿瘤相对少见，约占所有脊柱肿瘤的20%，全身骨肿瘤的6. 6%～8. 8%[1]。尽管原发性脊柱肿瘤的诊治原则与四肢骨肿瘤基本相同，但由于脊柱解剖复杂，毗邻脊髓神经、大血管及重要脏器结构，其外科切除难度较大、风险较高，既往多采用次全切除方式，局部复发率居高不下，治疗效果远不如四肢骨肿瘤。近20年来，随着脊柱外科技术的不断进步、脊柱内固定与重建器械的飞速发展及肿瘤学认识的逐步融入，脊柱肿瘤的治疗由过去的简单椎板切除、减压到现在的全脊椎切除，由过去的分块切除到现在的整块切除，使得脊柱肿瘤的临床疗效明显提高。

徐万鹏教授与我国的骨肿瘤现代治疗--记本刊总编辑徐万鹏教授

徐万鹏，《中国骨与关节杂志》总编辑，我国著名骨科专家。1963年毕业于北京医学院医疗系，先后在北京积水潭医院、北京大学人民医院的骨科和骨肿瘤科工作。2004年后，兼职于首都医科大学北京世纪坛医院骨科，骨肿瘤科。徐万鹏教授从医50余年，不断实践，治疗了来自全国各地的骨肿瘤患者万余例，励精于骨科肿瘤专业，为我国骨肿瘤医学的发展做出了重大贡献。

软组织肉瘤的非计划切除

虽然软组织肿瘤的发病率较高，但其中以良性肿瘤居多[1]，而软组织肉瘤的发病率较低，仅占所有恶性肿瘤的0.8%～1.0%[2-3]。在我国，目前尚没有有效的转诊制度。骨与软组织肿瘤的患者，特别是软组织肿瘤的患者的治疗既有在骨科进行的，也有在普通外科进行的，甚至于在其他的一些外科专业科室接受治疗[4]。即便是在骨科进行治疗，也多不是经由专业的骨与软组织肿瘤专业医师。另一方面，我国的骨与软组织肿瘤专科培训工作尚不普及，地区差别较大。甚至于发达地区的大型综合医院，其骨与软组织肿瘤的治疗理念也与专科医师存在巨大的差异。临床上，特别是那些发生在深筋膜浅层的肿物，经常会见到在没有术前影像学检查的情况下，或仅凭一个B超报告就进行了草率的切除而术后病理证实为软组织肉瘤的病例。有时甚至是直到复发再次就诊时都没有第一次手术后病理诊断的病例。因此，治疗方法参差不齐，效果难以保障。一旦患者术后诊断为肉瘤，就会给患者造成不必要的损失。

强直性脊柱炎的治疗指南介绍

强直性脊柱炎( ankylosing spondylitis，AS )是一种累及中轴及外周关节的慢性炎性进展性风湿病，AS 是脊柱关节炎( spondyloarthritis，SPA )的原型。2010年欧洲抗风湿病联盟( EULAR )及国际脊柱关节炎协会( assessments in ankylosing spondylitis international society，ASAS )共同更新了AS的治疗指南，该指南同样适用于SPA的治疗[1]。同年中华医学会风湿病分会也更新了我国 AS 诊断及治疗指南，两个指南的更新对于AS及SPA的治疗具有指导意义。近年来，随着传统药物及生物制剂治疗 AS 研究的深入，国内外又发表了许多关于 AS 治疗的研究。现综合介绍如下。

内窥镜辅助的颅底手术

目的探讨鼻内窥镜在颅底手术中应用的可行性和临床意义。方法对鼻内窥镜下颅底区域手术44例进行回顾性分析，其中鼻内进路颅底手术25例，传统进路的颅底手术19例。结果44例颅底手术中，1例紧嵌于斜坡内金属异物未能取出；1例垂体瘤患者鞍底开窗后穿刺均为血性，仅做鞍底扩大开窗和穿刺活组织检查，术后视力有所改善；1例复发性颅咽管瘤并发梗阻性脑积水，术后颅高压未完全改善；1例蝶窦腺癌侵犯鞍底及鞍旁，仅行部分切除术加激光治疗，随访2年半无复发，其余病例均一次手术治愈。并发症：脑脊液鼻漏2例，尿崩症1例，均经保守治疗短期内治愈，鼻中隔穿孔1例，未做特殊处理。结论①经鼻内窥镜颅底区域的手术是可行的，只要病例选择适当，可充分体现该手术进路直接、创伤小、无颜面切口等优点；②和手术显微镜结合使用，可弥补手术显微镜只能观察物镜直线正前方结构，不能窥视弯曲的通道或较深隐窝的局限性，以达到彻底清除病变又能大限度的保留功能的目的。

胸骨后甲状腺肿物的外科治疗

目的探讨胸骨后甲状腺肿物切除手术入路及方法.方法回顾分析27例胸骨后甲状腺肿物临床资料.结果 27例胸骨后甲状腺肿物患者接受外科治疗,均获成功.其中结节性甲状腺肿10例,甲状腺腺瘤9例,结节性甲状腺肿癌变4例,甲状腺乳头状癌伴气管旁淋巴结转移3例,甲状腺滤泡状癌伴气管旁和纵隔淋巴结转移1例.23例(良性病变19例,恶性肿瘤4例)颈部低位领式切口入路切除(占85.2%),3例颈部低位领式切口并胸骨正中劈开入路的占11.1%,1例开胸入路并颈部低位领式切口入路切除(占3.7%).术后并发症发生率为25.9%,其中术后伤口出血较为常见,占42.9%.结论颈部低位领式切口入路切除胸骨后甲状腺肿物是可行的,它容易操作,安全可靠,又具有损伤小、并发症少等优点.

单侧喉返神经损伤神经修复术式探讨

目的探讨5种神经修复术治疗单侧喉返神经损伤声带麻痹的疗效.方法 1993年1月～2001年4月治疗外伤性单侧喉返神经损伤声带麻痹38例,病程从损伤即刻至2年不等.资料完整者35例,其中行神经减压术8例、颈襻主支喉返神经吻合术16例、喉返神经端端吻合术6例、颈襻神经肌蒂埋植术3例、颈襻神经植入术2例.手术前后喉镜、嗓音声学参数、肌电图检查等评价手术效果.结果病程4个月内神经减压5例恢复了正常的声带内收及外展功能,4个月以内1例、以上2例及颈襻主支吻合组、喉返神经端端吻合组则未恢复声带运动.但上述3种术式均能使喉内收肌获有效的再神经支配,满意地恢复声带的肌张力、肌体积、声带振动对称性及正常黏膜波,声门闭合良好,嗓音恢复正常.颈襻神经肌蒂埋植术及颈襻神经植入术均能改善声嘶,但无恢复正常病例.结论①单侧喉返神经损伤神经修复治疗以神经减压效果佳;②颈襻主支吻合术、喉返神经端端吻合术也能有效地恢复喉的发音功能;③喉神经修复术式选择应根据病程、神经损伤程度、类型而定.

膈神经替代喉返神经修复治疗双侧声带麻痹

目的探讨膈神经喉返神经吻合和内收肌支环杓后肌植入术(膈神经手术)治疗双侧喉返神经损伤声带麻痹的有效性、可行性.方法第二军医大学长海医院耳鼻咽喉科1999年8月～2001年7月治疗外伤性双侧喉返神经损伤声带麻痹6例.病程1周～18个月,一侧作膈神经手术,而另一侧作颈袢肌蒂环杓后肌植入术.手术前后电子喉镜、频闪喉镜观察声门大小、声带运动、振动情况,嗓音声学参数分析,喉肌电图检查评价手术效果.结果术后2～3周检查发现4例声门较术前增大2～3 mm,但声带固定不动,2例无明显改善.术后6个月5例膈神经修复侧均恢复了较大幅度的吸气性声带外展功能,外展幅度可达3～5 mm,而肌蒂植入侧仅轻微外展或固定不动,幅度均在1 mm以内.此5例均顺利拔管,并能承受较大强度的体力活动,1例仍在随访中.术后4个月6例肌电图检查显示膈神经修复侧自发、诱发电位均明显大于肌蒂植入侧,自发电活动与肋间肌基本同步,而较肌蒂植入侧延迟100～200 ms.声音估价显示3例声嘶术后较术前好转,2例无变化.术后半年肺功能均恢复正常.结论膈神经喉返神经吻合内收肌支环杓后肌植入术安全可行,较颈袢肌蒂植入术更能有效地恢复声带吸气性外展运动,值得临床推广应用.

原发性面神经肿瘤的诊断与治疗(附14例报告)

目的总结面神经肿瘤的临床特点,探讨诊断方法和治疗措施.方法回顾性总结解放军总医院1986年1月～2000年12月间手术治疗、病理证实的14例原发性面神经肿瘤病例的临床表现、诊断和治疗的经验.结果 14例患者中面神经鞘瘤9例,面神经纤维瘤3例,面神经血管瘤2例.面神经肿瘤的首发症状常见为面瘫(10/14),其次是听力下降(5/14).常见体征是面瘫(10/14),其次是鼓室内肿物(5/14),再次是外耳道肿物(4/14).本组14例面神经肿瘤均经手术切除治疗,手术中保留面神经完整1例,术后随访3年,面神经功能正常.保持部分面神经连续2例,分别随访1年和3.5年,1例面神经功能为Ⅱ级,1例为Ⅲ级.耳大神经移植桥接面神经6例,平均随访4.5年,面神经功能Ⅱ级2例,Ⅲ级3例,Ⅳ级1例.股外侧皮神经移植桥接面神经1例,随访6年,面神经功能Ⅲ级.1例桥小脑角面神经鞘瘤患者,在肿瘤切除术后9个月时行二期面神经-舌下神经吻合,术后随访3年,面神经功能恢复为Ⅱ级.面神经中断者因断端寻找困难而未处理3例,平均随访2.5年(6月～ 4年),均为完全性面瘫(Ⅵ级).结论面神经肿瘤常见首发临床表现为面神经麻痹.一旦考虑为面神经肿瘤,应尽早手术.在切除肿瘤的同时,尽可能保留面神经的连续性或行一期面神经功能重建,若不能行一期面神经功能重建也要尽可能在短期内行二期功能重建手术.

脑脊液鼻漏的治疗

目的总结脑脊液鼻漏治疗的临床经验,评价不同的治疗方法,提出脑脊液鼻漏外科治疗的术式.方法回顾分析1991年3月～2001年11月83例脑脊液鼻漏.共有5种治疗形式,保守治疗17例,开颅手术修补8例, 鼻外入路修补术2例,显微镜下鼻内入路修补术3例,鼻内镜下修补术54例.分析保守治疗的时间及外科治疗各组病例的病因、伴发病、漏口部位及修补材料等.讨论手术时机、手术适应证和术中的关键问题.结果随访6个月～9年.17例保守治疗全部治愈,平均治愈时间16 d.开颅手术8例、鼻外入路的2例和显微镜下鼻内入路的3例均治愈.54例鼻内镜下修补术者1次手术治愈49例(90.1%);2次手术治愈2例(2/4),3次手术治愈1例,4次手术治愈1例,终成功率98%,1例额窦漏口者第一次手术失败后改为鼻外入路修补成功.结论鼻内镜下脑脊液鼻漏修补术是外科治疗脑脊液鼻漏的首选术式,其他术式可依病情需要适当选择.外伤性或手术并发的脑脊液鼻漏保守治疗的时间一般为2～4周,个别病例可达6～8周.

累及颅底肿瘤的手术切除与入路选择

目的探讨颅底肿瘤切除的佳手术入路.方法回顾分析1993～2000年中国医学科学院中国协和医科大学肿瘤医院外科处理侵及颅底肿瘤84例的经验,讨论侵及颅底不同部位病变手术入路特点,以求选择好的手术入路彻底切除肿瘤,同时尽量保护颅底、颅内重要结构,减少并发症.结果患者年龄6～78岁,平均43.8岁.良性肿瘤14例,恶性肿瘤70例.采用各种手术入路切除累及咽旁颅底肿瘤38例;同时有前、中颅底破坏7例;肿瘤同时累及中、后颅底13例;侧颅底颞下窝肿瘤26例.用各种组织瓣修复颅底缺损或填充60例.6例并发脑脊液漏,2例迟发脑脓肿,修复组织瓣部分坏死3例,无手术死亡及严重颅脑并发症.恶性肿瘤3年生存率67.5%(27/40).结论佳手术入路的选择应相对于颅底不同部位的肿瘤,针对特殊的解剖结构而选择,可以根据以下几个因素综合考虑:①肿瘤部位及累及的范围;②安全、充分地切除肿瘤;③正常功能结构及外观影响小;④便于可靠有效地修复.

Combined modality therapy for stage ⅠB cervical cancer

Objective:To evaluate the current approaches for multimodality therapy for stage ⅠB cervical cancer. Methods:The relevant literature has served as a source for identified high or intermediate risks and management of stage ⅠB cervical cancer. Result:The high risks include pelvic lymph node metastasis (PLNM), positive resection margin (PRM), and the in-volvement of parametrium (IPM). The intermediate risks include deep stromal invasion (DSI), bulky tumor size ( BTS), lymphovascular space invasion (LVSI). Adeno-carcinomatous histo-type is the new risk feature relevant to poor prognoses. Both radical hysterectomy plus bilateral pelvic lymph node dissection(PLND) and radical radiotherapy have proven to be equally effec-tive. Surgery is more performed for stage ⅠB1 disease;radiotherapy or chemoradiotherapy is preferable for stage ⅠB2 disease. For patients with one high risk or two of intermediate risks, radical hysterectomy plus PLND followed by concurrent chemoradiotherapy can improve overall survival(OS) and disease-free survival (DFS). Conclusion:The management should be indi-vidualized for stage ⅠB cervical cancer. The optimized multidisciplinary therapy can benefit pa-tients with the best cure and minimum morbidity and complications.