B超引导经皮肾造瘘术中并发肾静脉损伤3例临床分析

目的总结经皮肾造瘘术中肾静脉损伤的原因及处理策略。方法回顾分析2009~2014年间经皮肾造瘘及经皮肾镜取石术发生的3例肾静脉损伤患者的临床资料。男性1例,女性2例;均在建立经皮肾通道过程中发生导丝穿入肾静脉,肾造瘘管沿导丝误入肾静脉及腔静脉,术后经CT检查明确。3例患者术后均在彩超监测下分次逐步拔除肾造瘘管。结果 3例患者拔除肾造瘘管后,未发生肾静脉瘘口出血,未行外科手术干预,未出现肾功能损害。结论经皮肾造瘘术中发生肾造瘘管误入肾静脉后,采用留置并夹闭肾造瘘管、分次逐步拔除肾造瘘管是安全可靠的,可以避免外科手术干预。     

经皮肾镜术后肾造瘘管夹闭时间对出血量、发热及漏尿率的影响

目的 探讨经皮肾镜术后夹闭造瘘管时间长短对其出血、发热及术后漏尿的影响.方法 131例患者随机分为4组:不夹闭肾造瘘管组33例、夹闭30 min组34例、夹闭2h组31例、持续夹闭组33例.分析术前术后血红蛋白降低量、发热及漏尿情况.结果 夹闭造瘘管的时间与术后出血量无明显关系(P＞0.05)；对于非尿路感染患者,无论术后夹闭造瘘管的时间长短,与未夹闭造瘘管组相比,并不增加术后发热的可能(P＞0.05)；夹闭肾造瘘管的患者与未夹闭造瘘管组相比,漏尿率明显增加(P＜0.05),而且如果夹闭时间超过2h,漏尿发生的机率增大(P＜0.05).结论 术后夹闭30 min造瘘管可明显减少术后出血,且不增加发热及漏尿的风险.     

经皮肾手术肾造瘘管误入静脉系统的诊治分析

目的探讨经皮肾手术肾造瘘管误入静脉系统的诊治特点。方法回顾性分析2006年1月至2020年12月湖南省郴州市第一人民医院和湖南省郴州市第四人民医院共收治的6例肾造瘘管误入静脉系统患者的临床资料。男4例, 女2例;中位年龄41.0(38.5, 53.0)岁;有对侧上尿路手术史3例, 同侧上尿路手术史1例, 无上尿路手术史2例;孤立肾2例;铸形肾结石2例(合并轻度肾积水1例, 中度肾积水1例), 输尿管结石4例(合并轻度肾积水2例, 中度肾积水1例, 重度肾积水1例)。6例均行经皮肾镜取石术(PCNL), 术中在筋膜扩张器扩张后, 拔出扩张器内芯时血液由工作鞘涌出, 立即留置肾造瘘管并夹闭, 结束手术。5例术后返回病房后行CT检查明确诊断, 1例术中经肾造瘘管注入造影剂肾静脉显影, 早期明确诊断。6例中行左侧手术5例, 右侧1例;肾造瘘管末端位于同侧肾静脉内3例(均为行左侧手术), 经同侧肾静脉至下腔静脉2例(均为左侧手术), 经同侧肾静脉、下腔静脉至对侧肾静脉1例(行右侧手术)。6例均无合并肾静脉或下腔静脉血栓。监测患者生命体征, 严格卧床, 予抗感染治疗;保持造瘘管夹闭状态, 采用一步...     

B超定位下经皮肾造瘘术并发肾静脉损伤三例报告

目的 总结经皮肾造瘘术(PCN)中肾静脉损伤的处理方法.方法 PCN术中发生肾静脉损伤3例.男2例,女1例.年龄分别为43、55及72岁.例1因左肾鹿角形铸型结石行左肾经皮肾镜取石术(PCNL),术中穿刺扩张后出现大出血,留置肾造瘘管并夹闭.CT检查提示肾造瘘管进入下腔静脉,并通过右心房进入右颈内静脉.例2因右肾下盏结石行右肾PCNL,B超定位穿刺成功后有少量出血,扩张至16 F鞘后出现大出血,KUB示肾造瘘管进入肾静脉.例3因胃癌晚期肿瘤侵犯双侧输尿管,导致双肾积水、肾衰竭,行右肾PCN术弓l流尿液.穿刺后出现静脉性出血,放置肾造瘘管并夹闭,KUB示肾造瘘管部分进入下腔静脉.3例患者术后48h内在X线监视下逐次将肾造瘘管退至肾静脉破口处,24～48h后再退至集合系统.每次退管3～4cm.结果 3例出血均控制,血液动力学状态稳定.拔管后均未出现再出血,未行外科手术干预,未出现肾功能进一步损害.结论 PCN术中肾静脉损伤及其导致的严重静脉性出血可以通过留置并夹闭肾造瘘管,分次逐渐退出肾造瘘管而愈合.该方法可以避免外科手术干预,不会对患肾功能造成进一步损害.     

经皮肾取石术后不留置肾造瘘管的适应证和安全性

目的探讨经皮肾取石术（percutaneous nephrolithotomy,PCNL）后不留置肾造瘘管的适应证和安全性。方法根据PCNL术前、术中情况选择合适病例。入选标准：术前B超报告肾盂积水〈4 cm,血清肌酐值正常;单一穿刺通道;术前、术中无尿路感染征象;术中无出血,集合系统无大面积穿孔;无结石残留,或虽有小结石残留但不需要行二次经皮肾手术者;术中顺利置入双J管;手术时间〈2 h。共入选240例输尿管上段及肾结石,按手术次序的奇偶数分为2组（各120例）：A组术后不放置肾盂造瘘管,B组术后放置F14肾盂造瘘管。结果240例均一期手术成功。2组结石清除率分别为98.3%（118/120）和96.7%（116/120）,二者相比无统计学差异（χ^2=0.171,P=0.679）。2组术中、术后均无输血病例;术后18例发热（A组8例,B组10例,χ^2=0.240,P=0.624）,均无感染性休克。术后48 h B超检查2组患者均未见肾周积液。结论对于经过严格选择的患者,经皮肾取石术后不放置肾盂造瘘管安全而有效。     

肥胖患者侧卧位微创经皮肾镜取石术导丝误入右心房及肾造瘘管误入腔静脉一例报告并文献复习

目的 探讨肥胖患者行B超引导下侧卧位微创经皮肾镜取石术(mininimally invasive percutaneous nephrolithotomy,MPCNL)中肾静脉损伤导致造瘘管置入腔静脉、导丝进入右心房的处理方法. 方法 回顾性分析2014年5月收治的1例左输尿管结石左肾积水男性患者的临床资料.年龄30岁.因反复左侧腰部疼痛5年,检查发现左肾结石伴左肾积水入院.患者有大量饮酒史3年,高血压病、糖尿病史6个月.体质指数35.9 kg/m2.查体:血压150/110 mmHg(1 mmHg=0.133 kPa).左肾区叩痛明显.B超检查:左侧肾盂输尿管连接处见约1.5 cm×1.0 cm强光团,后伴声影,左肾中度积水.CT检查:左侧输尿管上段结石伴左肾中度积水,增强扫描左肾皮质CT值100 HU.全麻下行B超引导下侧卧位MPCNL.术中建立经皮肾通道时因出血导致视野不清,留置斑马导丝及肾造瘘管准备二期行MPCNL. 结果 术后第7天复查CT发现导丝位于右心房,肾造瘘管位于腔静脉内达肝门水平.在CT引导下拔出导丝,每次约10 cm,观察5 min,患者无不良反应则再拔出10 cm,共5次将斑马导丝退入肾造瘘管内,将肾造瘘管退至肾分支静脉内距肾盂1 cm处停止,待分支肾静脉穿刺口血栓形成和愈合.术后第9天再次在CT监视下将肾造瘘管退入肾盂内,引流出清亮黄色尿液.术后第14天在全麻下经原通道行MPCNL,于肾盂输尿管连接处寻及约1.5 cm×1.0 cm结石,在输尿管镜下行气压弹道碎石术,检查各肾盏及输尿管上段无残石后,留置双J管及肾造瘘管,术中及术后无血尿,患者无不适.二次手术后3d拔除肾造瘘管.二次手术后1个月拔除双J管,患者无特殊不适. 结论 肥胖患者行B超引导下侧卧位MPCNL时经皮肾通道建立难度大,术中穿刺深度与术前CT检查测量的距离存在误差,易导致损伤.术中肾静脉损伤及肾造瘘管误入腔静脉时,可以通过夹闭造瘘管进行止血.在充分做好抢救准备的前提下,可在CT引导下分次逐步拔除导丝及造瘘管.     

微创经皮肾造瘘与输尿管镜下置管两种引流方法治疗肾积脓的比较

目的 比较微创经皮肾造瘘与经尿道输尿管置管引流治疗肾积脓的疗效及优缺点,旨在指导临床治疗.方法 收集2002年6月至2012年6月我院186例肾积脓患者的资料,其中68例行微创经皮肾穿刺造瘘术（实验组）,118例行经尿道输尿管置管引流术（对照组）,对两种治疗方法、临床疗效及优劣等资料进行评价.结果 两组患者年龄,性别,体重指数,发病时间,病史情况、和术前感染指标均无统计学差异（P＞0.05）.比较结果提示微创经皮肾穿刺造瘘引流术优于输尿管镜下置管引流术,差异有统计学意义（P=0.027）,两组患者手术用时比较差异有统计学意义（P=0.006）,术后并发症比较差异无统计学意义（P＞0.05）.结论 采用微创经皮肾造瘘与输尿管镜下置管两种引流方法治疗肾积脓均安全有效,选择哪种引流方法最终取决于临床情况（患者全身情况、感染严重程度、结石大小、梗阻部位及程度）来制订个体化方案,选择不同的治疗方法.     

不留置肾造瘘管经皮肾取石术治疗肾脏畸形患者

为评价完全不留置肾造瘘管经皮肾取石术对肾脏畸形患者的治疗效果和安全性，Aghamir等对60名肾脏生长发育畸形的肾结石患者进行了一项前瞻性研究。其中，肾脏畸形包括马蹄肾、肾集合系统先天性旋转不良以及异位肾。作者随机地将患者分成两组，每组30人，一组接受不留置肾造瘘管经皮肾取石术，另一组采用留置肾盂引流管、输尿管导管的标准术式，     

新型末端纤柔型经皮肾造瘘引流管的设计与临床应用

目的介绍一种专用于经皮肾镜取石术(PCNL)的末端纤柔的肾造瘘引流管,初步探讨其应用于PCNL的可行性。方法回顾分析2018年3月至2018年10月南方医科大学珠江医院收治的100例行PCNL的患者资料,术中使用本新型管道者50例,设为新型管道组,其余50例患者术中留置常规肾造瘘管,设为常规管道组。分析比较2组患者携带造瘘管及尿管的时长、住院时长、拔管过程中及拔管后出血情况等指标;验证新型管道组拔管后再次插入的成功率。结果新型管道组与常规管道组比较留置造瘘管的时长[(21.13±2.12)h vs.(55.67±18.52)h]、留置尿管时长[(40.40±4.75)h vs.(73.34±20.12)h]、住院时间[(48.48±3.39)h vs.(87.36±21.55)h]、术后第1天视觉模拟评分法(VAS)评分[(3.08±1.00)分vs.(4.76±1.41)分]、拔管后出血病例血红蛋白(△Hb)[(4.60±1.14)g/L vs.(20.00±2.83)g/L]均明显低于常规管道组(P<0.05)。2组术后腹膜后血肿发生率及一期碎石率差异无统计学意义(P>0.05);新型管道组拔管后再次插入的成功率为100%。结论在经皮肾镜取石术中使用末端纤柔型肾造瘘管,可以减少住院时间,减轻患者携带造瘘管相关不适,提高医疗安全性,值得进一步临床探讨和研究。     

经皮肾镜术中误入下腔静脉伴血栓形成一例并文献复习

目的探讨经皮肾镜碎石取石术（percutaneous nephrolithotomy, PCNL）中穿刺误入下腔静脉,留置肾造瘘管后出现下腔静脉血栓的处理办法。 方法结合文献复习,回顾性分析2017年5月我院收治的1例左肾铸型结石患者的临床资料。患者男,59岁,于全麻下行左PCNL。术中穿刺建立通道后出血汹涌,视野不清,中止手术,留置并夹闭肾造瘘管。术后第3日复查CT提示肾造瘘管经左肾静脉、下腔静脉至肝脏,下腔静脉内血栓形成。行经皮下腔静脉及左肾动脉造影,置入下腔静脉滤器及溶栓导管,透视监视下拔出左肾造瘘管。 结果拔出肾造瘘管后,患者无不良反应,血流动力学状态稳定,反复经导管造影,未见造影剂外溢。经溶栓治疗后,术后第11日再次行下腔静脉造影未见充盈缺损,顺利回收滤器。 结论PCNL术中穿刺误入下腔静脉,留置肾造瘘管伴下腔静脉血栓形成时,在血管造影辅助下分步缓慢拔出肾造瘘管并行溶栓治疗的方法安全、可靠,可避免外科手术的二次伤害及血栓相关并发症的发生。     

Percutaneous gastric tube placement: Comparison of trans-abdominal and trans-oral approach in patients with chronic ascites

Purpose

The purpose of this study was to compare the trans-abdominal (TA) and trans-oral (TO) approaches for fluoroscopic-guided gastrostomy tube placement in patients with chronic ascites.

An unusual case of airway obstruction at the tip of an endotracheal tube caused by insertion of a nasogastric tube

We report an unusual case of ventilatory impediment caused by the obstruction of an endotracheal tube (ETT) by a nasogastric (NG) tube. A 72-year-old woman with bronchial asthma was scheduled for colostomy closure. An ETT of 7.5-mm internal diameter (ID) could not be advanced, and finally a 5.0-mm ID ETT was placed, because she had post-intubation tracheal stenosis. When an NG tube was inserted after endotracheal intubation, ventilation suddenly became nearly impossible. She was treated for an asthmatic attack, but her respiratory condition did not recover. We then exchanged the ETT for a laryngeal mask airway (LMA) and removed the NG tube. It was suspected that the cause of the airway obstruction was that the NG tube in the esophagus compressed the membranous portion of the stenotic trachea and the tip of the ETT was obstructed.     

Univent管和双腔管用于单肺通气的比较

单肺通气可通过双腔支气管导管(double-lumentube,DLT)技术和支气管阻塞技术来实现。DLT在临床上使用最普遍,但DLT的有效管腔小、病人术后不易耐受而常需换管、声门暴露不佳者插管困难及没有小儿的型号等缺点,使其使用范围受到限制。带扭力控制阻塞装置(torque control blocker     

腹腔镜手术中采用“腹腔镜下双J管置入器”放置双J管：附视频

目的总结和介绍应用专利产品“腹腔镜下双J管置入器”,在腹腔镜手术中放置双J管的经验及技巧,评价其临床价值。方法45例患者接受腹腔镜下输尿管切开取石术,术中均使用双J管专用置入器,将双J管置入输尿管中。分析该操作的完成时间、成功率、并发症以及相应的处理。结果本组腹腔镜手术45例,44例术中置管顺利,放置双J管所需时间30s～7min,平均56S。双J管放置准确到位的42例,双J管近端未进入肾盂2例。1例置管阻力较大,远端未能进入膀胱,后改截石位,输尿管镜检查发现双J管远端穿出输尿管腔外,输尿管镜下取出双J管,重新放置。术后无漏尿等并发症发生。结论腹腔镜下利用专利产品置入器放置双J管,方法简单,效果确切,值得在临床推广应用。     

鼻肠管减压及奥曲肽治疗术后早期炎症性肠梗阻的临床研究

目的 评价、比较鼻肠减压导管以及奥曲肽,在腹部手术后早期炎症性肠梗阻保守治疗中的作用.方法 2005年3月至2009年1月期间45例腹部手术后早期炎症性肠梗阻的患者,使用鼻胃管减压等常规保守治疗无效后,非随机分为肠减压导管治疗组(23例)以及奥曲肽治疗组(22例),比较两种治疗方法与常规保守治疗方法以及两种治疗方法之间的疗效差别.结果 经鼻胃管减压的常规保守治疗无效的45例患者,经过上述两种治疗方法的保守治疗,3-12 d所有患者的肠梗阻均得以缓解;与奥曲肽治疗组相比,肠减压导管治疗组的自主排气时间更短[(4.7±1.9)d比(6.7 ±1.6)d]、腹围恢复得更快[(90.4±2.0)%比(95.1±1.3)%],但累计胃肠减压量[(4037±1155)ml比(3316±1038)m1]及日均胃肠减压量[(890±181)ml比(492±83)ml均更多,两组差异均有统计学意义(P均＜0.05).结论 肠减压导管以及奥曲肽治疗术后早期炎症性肠梗阻安全有效,肠减压导管的治疗时间更短,奥曲肽能够降低胃肠减压量.     

A procedure to elongate the stomach tube in the esophageal replacement

When the stomach tube has to be lengthened in case of antethoracic esophageal replacement, a circumferential seromuscular incision is made and the lesser curvature side of the tube is cut through, in the same line of incision. The rent produced is longitudinally suture-closed, by which a definite elongation (about 2 cm by each incision), is obtained. In our department the antethoracic use of the stomach tube has been carried out since 1968, the elongation procedure was started in 1973 as a trial, then its application became more frequent since 1978 and was performed whenever the tube seemed to be deficient in length. The stomach tube was used in 40 cases, of which 17 underwent the elongation procedure. With regard to the suture leak at the site of the antethoracic esophagogastric anastomosis, the incidence was 50 per cent from 1968 to 1972, 54 per cent from 1973 to 1977 and 22 per cent in the last 5 years. Thus, a distinct improvement has occurred with time. These data were reported at the 7th World Congress of the Collegium International Chirurgiae Digestive, Tokyo, September, 1982     

颈椎管扩大术疗效探讨

本文报告56例颈椎管扩大术，单开门颈椎管扩大术50例，双开门颈椎管扩大术6例。治疗多发性椎间隙颈椎病19例，后纵韧带骨化症（简称OPLL）18例，OPLL合并颈椎外伤3例，颈椎管狭窄合并OPLL2例，发育性颈椎管狭窄症14例，术后一个月和一年分别评估疗效，均明显优于以往的椎板减压术。     

Feasibility of early removal of chest tube in the operating room for spontaneous pneumothorax: A prospective randomized controlled study

Background/ObjectiveChest drainage tube after surgery causes pain and prolonged length of hospital stay. Especially, young patients tend to experience greater postoperative pain than elderly patients. Therefore, we needed to discuss the indication of chest tube placement. The purpose of this study was to demonstrate the safety and advantages of post-operative management without drainage tube placement, by comparing cases with and without drainage tube placement.MethodsPatients who underwent bullectomy for spontaneous pneumothorax were enrolled in this prospective randomized controlled study and randomized into two groups: group with a post-operative chest tube and group without a chest tube. Surgery and post-operative management were performed according to our protocol.ResultsAmong the 42 patients, pneumothorax occurred in 1 patient with a chest tube a day after tube removal. Patients without chest tube had significantly lower post-operative pain (P = 0.107～P < 0.001), despite their reduced use of rescue drugs. The mean length of post-operative hospital stay was 2.5 days in patients with chest tube, which was significantly longer than that of patients without chest tube (1.2 days; P < 0.001).ConclusionsOur patient selection and surgical protocols may be feasible and contribute to post-operative pain control.     

Occult pneumothorax in the blunt trauma patient: Tube thoracostomy or observation?

Background

The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes.

Methods

A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status—dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures.

Results

In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p = 0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p = 0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces.

Conclusion

The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial.