微创内固定系统治疗膝关节周围骨折的并发症

[目的]分析使用微创内固定系统(less invasive stabilization system,LISS)治疗膝关节周围骨折时的并发症。[方法]自2005年7月~2007年10月,应用LISS治疗89例患者共91侧骨折,其中股骨远端骨折45侧;胫骨近端骨折46侧。[结果]术后随访时间为13~29个月,平均14.4个月。骨折平均愈合时间为16周(11~25周)。膝关节功能为优45侧,良35侧,可11侧,优良率为87.9%。10侧肢体(11%)出现钢板刺激症状,其中有2侧出现迟发的皮肤软组织全层裂开。7例(8%)骨折对位不良。2例(2%)骨折术后复位丢失。1例(1%)骨折延迟愈合。1例(1%)内固定失败。2例(2%)出现医源性神经损伤,腓浅神经与腓深神经损伤各1例。9例(10%)共14枚螺钉出现"冷焊接现象"(cold-welding)致内固定取出困难。[结论]LISS是一种治疗膝关节周围骨折有效而可靠的方法,但在临床应用中要严格掌握手术指征及操作规程。     

袖套式prolene线单层连续缝合在胰肠吻合中的应用

目的:探讨袖套式prolene线单层连续缝合在胰肠吻合中的应用价值。方法:采用前瞻、随机对照设计,将2009年8月—2014年3月124例行胰十二指肠切除术(PD)患者根据不同胰肠吻合方式分为3组,分别采用传统端端或端侧套入式吻合(套入式吻合组),胰管空肠黏膜端侧吻合(黏膜端侧吻合组),袖套式prolene线单层连续缝合(袖套式缝合组),比较各组胰瘘发生率及其他手术相关指标。结果:袖套式缝合组的胰肠吻合时间明显短于另两组(均P<0.05);全组总胰瘘发生率18.5%(23/124),袖套式缝合组胰瘘发生率(4.8%)明显低于套入式吻合组(29.3%)与黏膜端侧吻合组(22.0%)(均P<0.05);3组间其他并发症差异均无统计学意义(均P>0.05)。按胰管直径与胰腺质地分层后的组间比较显示,胰管直径<3 mm时,袖套式缝合组胰瘘发生率(7.1%)明显低于黏膜端侧吻合组(50.0%)(P<0.05);软质地胰腺时,袖套式缝合组胰瘘发生率(11.8%)明显低于套入式吻合组(53.3%)与黏膜端侧吻合组(53.8%)(均P<0.05)。按胰管直径与胰腺质地分层后的组内比较显示,套入式吻合组中,硬质地胰腺亚组胰瘘发生率(15.4%)明显低于软质地亚组(53.3%)(P<0.05);黏膜端侧吻合组中,大直径胰腺亚组(7.4%)胰瘘发生率明显低于小直径胰管亚组(50.0%),硬质地亚组胰瘘发生率(7.1%)明显低于软质地亚组(53.8%)(均P<0.05);袖套式缝合组中,各亚组间差异无统计学意义(均P>0.05)。结论:袖套式prolene线单层连续缝合方法安全简便,能降低PD术后的胰瘘发生率,尤其在胰管直径<3 mm或软胰腺质地时采用此法优势明显。     

多层螺旋CT对胫骨平台骨折分型及治疗的临床价值

[目的]探讨多层螺旋CT(MSCT)容积重组技术(VRT)和多平面重建(MPR)在胫骨平台骨折(TPF)分型及治疗中的临床应用价值.[方法]2005年8月-2009年2月对45例49侧TPF患者的病例资料进行回顾性分析.其中男32例,女13例;年龄20～65岁(平均46岁).4例为双侧TPF.所有患者均行X线检查和64层螺旋CT扫描仪扫描.在轴位CT扫描后行VRT和MPR成像.按照Schatzker分型标准,应用X线片与64层螺旋CT扫描(包括VRT、MPR成像)分别进行分型和制定相应的治疗方案.[结果]参考VRT、MPR成像后,更改X线分型13侧(13/49)、更改治疗方案8侧(8/49)、发现胫骨髁问嵴骨折15侧(漏诊率46.9%)和腓骨近端骨折6例(漏诊率28.6%).[结论]MSCT(VRT+MPR)可以清晰显示TPF塌陷的范围和程度、细节及隐匿骨折,有助于骨折的正确分型、降低漏诊率和选择合理的治疗方案,是X线片和轴位CT扫描有效的补充手段,具有较高临床应用价值.     

几丁糖预防硅凝胶乳房假体包膜挛缩的实验研究

目的　探讨几丁糖预防硅凝胶乳房假体置入术后包膜挛缩的效果。方法　以 18只雌性SD大白鼠为实验对象 ,随机分为 3组。于大白鼠两侧背阔肌下各置入小型模拟硅凝胶假体。左侧为实验组 ,剥离腔内注入几丁糖 ,右侧为对照组。术后 4、8、12周分组切取包膜行组织学检查 ,测量其厚度和Ⅰ、Ⅲ型胶原的面密度。结果　实验侧与对照侧包膜结构相似 ,可分为致密层和疏松层两层结构。术后 4周 ,实验侧包膜全层厚度、致密层厚度均小于对照侧 (P <0 .0 1) ,Ⅰ型、Ⅲ型胶原的面密度均低于对照侧 (P <0.0 1)。术后 8、12周 ,实验侧包膜全层厚度、致密层厚度均小于对照侧(P <0.0 5 ) ,Ⅰ型胶原的面密度低于对照侧 (P <0 0 5 ) ,Ⅲ型胶原的面密度与对照侧无差异 (P >0.0 5 )。结论　几丁糖可明显预防硅凝胶乳房假体置入术后的早期包膜挛缩     

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目的评价腹腔镜腹股沟疝修补术(LIHR)的临床疗效。方法回顾性分析2001年1月至2011年12月上海交通大学医学院附属瑞金医院普外科2056例(2473侧)行LIHR的临床资料,其中经腹腹膜前修补术(TAPP)874例(1005侧),全腹膜外修补术(TEP)1175例(1458侧),腹腔内修补术(IPOM)7例(10侧)。2473侧疝中,斜疝1481侧(59.9%),直疝525侧(21.2%),复发疝225侧(9.1%),复合疝206侧(8.3%),股疝36侧(1.5%)。疝分型:Ⅰ型疝95侧(3.8%),Ⅱ型疝995侧(40.2%),Ⅲ型疝1157侧(46.8%),Ⅳ型疝226侧(9.1%)。手术由同组医师完成,术式选择由术者决定,随访时间3～60个月(中位时间35个月)。结果 1例TAPP因腹腔广泛粘连中转为Lichtenstein术。病人术后无需应用镇痛剂。2周和4周内恢复非限制性活动率为99.0%和99.9%。共6例复发,复发率为0.24%。TAPP和TEP各3例复发。发生3例严重并发症,分别为戳孔疝、肠管损伤和机械性肠梗阻,其他并发症依次为血清肿129例(5.2%)、尿潴留34例(1.4%)、暂时性神经感觉异常26例(1.1%)、麻痹性肠梗阻3例(0.12%)。结论 LIHR是安全有效的手术,合理选择手术适应证和规范化操作可以获得良好的临床效果。     

青少年特发性胸椎侧凸后路凸侧胸廓成形术的并发症分析

目的:探讨青少年特发性胸椎侧凸患者后路凸侧胸廓成形术的并发症发生原因及预防措施。方法:自1999年1月～2006年9月,共有410例青少年特发性胸椎侧凸患者在我科施行脊柱侧凸后路矫形内固定术,同时行同一切口下的凸侧胸廓成形术,男86例,女324例。年龄11～18岁,平均14.7岁。术前剃刀背畸形15°～48°,平均32°。统计并发症发生情况。结果:凸侧胸廓成形的肋骨切除数平均4.2根,术后剃刀背畸形0°～14°,平均6°。无手术死亡病例。24例(5.8%)术中发生壁层胸膜穿孔,6例(1.5%)术后胸腔积液,3例(0.7%)术后气胸,1例(0.2%)术后呼吸困难需间歇性吸氧,34例(8.3%)术后有局部反常呼吸,17例(4.1%)术后诉不同程度的胸壁疼痛,9例(2.2%)诉局部皮肤麻木或感觉减退,3例(0.7%)早期手术的患者术后肋骨残端突出明显,1例(0.2%)皮下血肿,1例(0.2%)皮肤压疮。经相应处理后,患者大多恢复满意。319例平均随访28个月,仅4例仍残留有胸壁皮肤感觉减退。结论:凸侧胸廓成形术是一种安全、有效的改善"剃刀背"畸形的手段。提高手术技巧,术后积极处理,可以减少甚至避免相关并发症的发生。     

不同长度的下颈椎经关节螺钉侧位X线片评价

目的评价侧位X线片在了解下颈椎经关节螺钉固定中不同长度螺钉钉尖安全位置的作用。方法选用7具尸体颈椎标本,从C3、4~C5、6直视下依次置入经关节螺钉,分别置入螺钉钉尖仅为四层皮质固定(0mm)和超出皮质2、4、6mm各42枚,分别摄标本侧位X线片。根据X线片,将每个椎体分为前Ⅰ、Ⅰ、Ⅱ、Ⅲ和Ⅳ区。逐一记录螺钉钉尖在X线片上相应椎体各区的位置。结果共有87枚螺钉位于前Ⅰ区,其中42枚是当螺钉钉尖为四层皮质固定时(100%);37枚是当钉尖超出下位椎体上关节突侧前方皮质2mm时(88%);8枚是当钉尖超出4mm时(19%)。共有71枚螺钉位于Ⅰ区,其中5枚是当钉尖超出2mm时(2%);34枚是当钉尖超出4mm时(80%);32枚是当钉尖超出6mm时(76%)。10枚位于Ⅱ区的螺钉均是当钉尖超出6mm时的投影。没有发现螺钉钉尖位于Ⅲ区和Ⅳ区。不同长度的经关节螺钉钉尖在侧位X线片上的投影位置在颈椎各节段间差异无统计学意义(P>0.05)。结论在评价下颈椎经关节螺钉固定中不同长度的螺钉钉尖安全位置方面,侧位X线片有一定意义。下颈椎经关节螺钉理想长度的钉尖位置应该位于前Ⅰ区。     

上尿路结石二次经皮肾镜取石术操作的原因探讨

目的:总结上尿路结石行二次(或二次以上)经皮肾镜取石术(PCNL)操作的原因,提高PCNL技能。方法:回顾性分析我院行PCNL治疗的1 041例上尿路结石患者的资料,对其中进行二次(或二次以上)PCNL操作的病例,根据其行二次PCNL操作的原因进行总结和分析。结果:1 041例上尿路结石患者(共1 203侧上尿路)中进行二次(或二次以上)PCNL操作的病例共252侧(20.9%),行二次PCNL操作的理由包括:结石负荷大、分布广182侧(72.2%);通道或肾集合系统黏膜出血29侧(11.5%);脓肾(感染)22侧(8.7%);孤立肾或肾功能不全7例(2.8%);集合系统穿孔3侧(1.2%);未发现或未能进入残留结石所在肾盏的盏颈口4侧(1.6%);通道建立失败以及不合理3侧(1.2%);麻醉意外等2例(0.79%)。二次PCNL操作时行局部麻醉204侧(81.0%),全麻48侧(19.0%);俯卧位221侧(87.7%),侧卧位31侧(12.3%)。1 203侧上尿路行一次PCNL操作的清石率为74.1%;行二次PCNL操作后的清石率为91.0%;252侧行二次PCNL操作的患者清石率为80.9%。1 203侧上尿路仅行一次PCNL操作的951侧上尿路患者的平均住院时间是10.8d,行二次PCNL操作的252侧上尿路患者的平均住院时间是13.4d。结论:结石负荷大、分布广,脓肾(感染)以及出血是上尿路结石行二次PCNL操作的主要原因。二次PCNL操作对于减轻第一次PCNL出血和感染的风险,提高清石率有很好的作用。但其增加患者的痛苦和住院时间。     

减少阴茎癌腹股沟淋巴结清扫术并发症的临床技巧研究(附30例报告)

目的探讨减少阴茎癌腹股沟淋巴结清扫术后并发症的手术操作技巧及其效果。方法回顾性分析2000年1月至2011年10月间收治的30例行改进根治性双侧腹股沟淋巴结清扫术的阴茎癌患者的临床资料。30例共60侧行腹股沟淋巴结清扫,其中29例为阴茎癌手术时同期淋巴清扫。清扫范围足够,淋巴结清除彻底,改进技术包括设计腹股沟"S"形皮肤切口、通过确认Campas筋膜的膜性解剖标志层来分离皮瓣、皮瓣边缘缝线牵引、完整保留阔筋膜、尽可能保留阴部外浅静脉、术后良好的引流及加压包扎。结果 30例患者随访5～128个月,共发生并发症15侧次(25.0%),其中轻度皮瓣坏死4侧次(6.7%)、切口感染3侧次(5.0%)、淋巴水肿8侧次(13.3%),无下肢深静脉血栓。结论通过改进腹股沟淋巴结清扫术可有效减少阴茎癌患者腹股沟淋巴结清扫术后并发症。     

腰椎侧凸软骨终板退变的X线表现及临床意义

目的探讨腰椎侧凸软骨终板退变的X线表现及其临床意义。方法收治的退变性腰椎侧凸43例,均行X线平片检查,观察其影像学特点。分别测定凹侧和凸侧每个椎体头、尾侧关节软骨的钙化层厚度,均数行t检验。结果 X线片显示椎间隙楔形样变、椎间隙狭窄、终板钙化和骨赘形成。退变的软骨终板潮标明显前移,钙化和骨化层增厚,形成突向外侧的椎体边缘的骨赘。凹侧和凸侧椎间盘关节软骨钙化层厚度分别为(35±8)μm和(72±12)μm,差异有统计学意义(P0.01)。结论软骨终板退变较其他椎间盘退变的X线征象出现早,详细研究其X线特点,对于诊断退变性腰椎侧凸和设计合理的手术方式具有重要的指导作用。     

滋养动脉结扎对胫骨血供的影响

目的 探讨滋养动脉结扎对胫骨血供的影响。方法 采用放射性核素显像法观察滋养动脉结扎后兔胫骨血供的变化。结果 滋养动脉结扎后当天,胫骨各段的血供均吴不同程度下降（Ｐ〈０．０５）,其中胫骨远段骨干下降幅度最大,近段骨干及近干骺端次之,远干骺端下降最少。术后第４ｄ远段骨干血供较前恢复,近段骨干及近干骺端超过健侧,远干骺端恢复正常。第９ｄ后,除远段骨干外,其余三骨段均恢复正常。这段骨干的缺血状况直至第２４     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Colonialism and disability: The situation of blind people in colonised Algeria

Our article analyses the mode of assistance to the blind in Algeria from the beginning of the 20th century until the Declaration of Independence of the country (1962). If Muslim blinds face discriminatory practices, all the blind – French citizens and subjects – are victims of unequal treatment because they are not entitled to the social measures granted to the blind in metropolitan France. Nevertheless, during the first decades of the 20th century many actors travel between metropolitan France and the Algerian colony and introduce on the Algerian territory innovating practices developed in France (Braille schools for the blind, eye clinics, promotion of manual work). They thus disrupt traditional practices of assistance to the blind, which are intrinsically related to Islam. Moreover, we want to underline the agency of the blind in the context of colonial Algeria, since blind association leaders take part in the colonial policy making of assistance to the blind. From the 1930's, they start to claim the equality of rights of the blind of Algeria with those of metropolitan France. This research allows to reflect on the construction of the citizenship of the blind in a colonial context.     

Pancreas divisum and the dominant dorsal duct syndrome

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.     

Inclusive social networks and inclusive schools for disabled children of migrant families

This research project (carried out between March 2008 and November 2010) aims to investigate the relationship between migrant disabled students and the Italian school system. It was commissioned by the City of Bologna – Department of Education and Anti-discrimination Policies – which aimed to adopt guidelines and tools to facilitate the inclusion of migrant disabled students aged 0–14. The scale of the migratory phenomenon and impact on the education and health systems of the host countries have given rise to new organizational, social and cultural problems; schools and education services play a key role in facilitating the process of inclusion, not only by offering appropriate responses to the cultural transformations, but also by fostering cultural exchange and dialogue among youths and educating them on global coexistence. Schools are the best environments for meeting the needs of families by making them feel welcome; this is confirmed by teachers themselves, who however seek greater support from local services, also in terms of the involvement and participation of migrant families (with the presence of cultural mediators). Here, we focus on: a presentation of the concluding stages of the research, educational commitments and a summary of the research team's draft guidelines aimed at increasing the quality of the processes of inclusion of disabled children of migrant families.     

Resection of the retroportal pancreatic lamina during a cephalic pancreaticoduodenectomy: first dissection of the superior mesenteric artery

We report a modification of the standard resection of the retroportal pancreatic lamina during pancreaticoduodenectomy. The resection begins with the dissection of the origin of the superior mesenteric artery (SMA) above the left renal vein and a step-by-step section of the retroportal pancreatic lamina on the right side of the SMA, then the pancreatic head is retracted to the left and freed from the portal vein, and lastly the neck of the pancreas is transected. This technique allows a total lymph node clearance, secures the dissection of the SMA, and allows safe identification of anatomic variations like a replaced right hepatic artery originating from the SMA.     

A cost-benefit evaluation of using propofol and alfentanil for a short gynecological procedure

It is well established that the immediate recovery after propofol or alfentanil anesthesia is short. Although the drugs themselves are more expensive than older drugs, a potential for saving costs arises. Concerning the benefits in terms of late recovery, less information is available. With vaginal termination of pregnancy (VTP), anesthesia is supposed to be the major cause of sick-leave. Does propofol and alfentanil anesthesia for VTP reduce sick-leave compared with thiopental and nitrous oxide anesthesia, and do the increased costs of the drugs outweigh the reduced costs of sick-leave? Data were obtained from 39 of 40 patients in ASA class I accepted for VTP and allocated to either propofol and alfentanil anesthesia (PA) or thiopental and nitrous oxide anesthesia (TN). A questionnaire was filled in by the patients at home after regaining full fitness. The number of patients with a sick-leave of 2 days or less in the groups was compared statistically with the number of patients with 3 days or more off work. The economic impact from the reported sick-leave was calculated for each study group, using data from national statistics. The figures were compared with the calculated costs of the drugs. The median number of days of sick-leave was 1 in the PA-group and 2 in the TN-group (range 0–3 and 0–5, respectively). Nineteen of the 20 patients in the PA-group and 13 of the 19 patients in the TN-group needed a short sick-leave period of 2 days or less (one-sided test of proportions, P<0.05). At the time of the study each patient was paid 210 SEK/day from the social insurance system and the mean cost of the drugs was 72 and 15 SEK/patient in the PA- and TN-groups, respectively. Using the mean difference in sick-leave between the groups of 0.8 days/patient (rather than the difference in median values of 1), a net gain of 111 SEK/patient was the result of changing from thiopental-nitrous oxide anesthesia to propofol-alfentanil anesthesia. Although the cost of drugs was higher, costs for the social insurance system and for the individuals themselves were reduced by almost 50%, when using the propofol and alfentanil combination, resulting in an overall benefit corresponding to almost twice the increase in the cost of anesthesia.     

Colonialisme et handicap : la situation des aveugles dans l’Algérie colonisée

Our article analyses the mode of assistance to the blind in Algeria from the beginning of the 20th century until the Declaration of Independence of the country (1962). If Moslem blinds face discriminatory practices, all the blind – French citizens and subjects – are victims of unequal treatment because they are not entitled to the social measures granted to the blind in mainland France. Nevertheless, during the first decades of the 20th century, many actors travel between mainland France and the Algerian colony and introduce on the Algerian territory innovating practices developed in mainland France (Braille schools for the blind, eye clinics, promotion of manual work). They thus disrupt traditional practices of assistance to the blind, which are intrinsically related to Islam. Moreover, we want to underline the agency of the blind in the context of colonial Algeria, since blind association leaders take part in the colonial policy making of assistance to the blind. From the 1930s, they start to claim the equality of rights of the blind of Algeria with those of mainland France. This research allows to reflect on the construction of the citizenship of the blind in a colonial context.     

Andrology. Origin and development of a special discipline in medicine. Reflection and view in the future

A general survey comments on the problems of andrology as a special medica discipline. A retrospective and an outlook concerning the different future possibilities of andrology is given. Special emphasis is placed on: examination of the ejaculate, morphology of the testicles, andrological training and further education; in the discussion of the future prospects special consideration is given to the responsibility of andrologists--also with respect to in-vitro-fertilization--and the significance of andrology for the inhabitants of the Third World.