Search

体外循环心脏直视手术后并发精神障碍的临床分析

目的 探讨体外循环心脏直视手术后并发精神障碍的病因和防治措施，以减少术后精神障碍并发症的发生。 方法 对1998年1月至2007年5月收治的45例体外循环心脏直视术后发生精神障碍患者的临床资料进行回顾性分析，分析其危险因素、临床表现、防治措施和预后。 结果 45例患者经积极治疗，精神症状大多在4d内痊愈，且无复发。术后死亡2例，其中1例双瓣膜置换术患者术后3d死于低心排血量，1例于冠状动脉旁路移植术后8d死于以肾功能衰竭为主的多器官功能衰竭。随访29例，随访率67.4%(29/43)，随访时间2～43个月(21.5±7.8个月)，无精神障碍复发者；失访14例。 结论 体外循环心脏直视手术后精神障碍的发生是由于病理生理、环境、个体因素等多种因素作用的结果，应采取综合防治措施。

单侧原发性自发性气胸行双侧肺大泡切除术的治疗效果

摘要： 目的 探讨单侧原发性气胸行双侧肺大泡切除术的可行性及治疗效果，以寻求单侧原发性气胸最有效的治疗方法。 方法 回顾分析我科自2003年3月至2008年12月 413例单侧原发性自发性气胸患者的临床资料和随访结果，其中男371例，女42例；年龄18～41岁，平均年龄27.7岁。气胸位于左侧285例，右侧128例；首次发生气胸252例，再次发生气胸161例；单发性肺大泡65例,多发性肺大泡348例；肺大泡直径≤1cm 361例，直径＞1 cm 52例；肺大泡位于肺上叶370例，位于肺中叶或下叶背段43例。采用双侧腋下第3～5肋间小切口行双侧肺大泡切除术282例，在电视胸腔镜下行双侧肺大泡切除术131例。 结果 手术时间110.3±48.4 min，拔除气管内插管时间6.5±1.2 d，住院时间8.1±2.3 d。术后出现复张性肺水肿3例，伤口感染3例，均经相应的治疗治愈；术后二次开胸止血1例。随访287例，随访时间17.0±6.3个月，随访期间所有患者无并发症发生，复查胸部X线片无气胸复发。结论 年轻的单侧自发性气胸患者往往双侧肺都有相对称的病变存在，患者能耐受同期双侧肺大泡切除术，同期双侧肺大泡切除术可根治双侧肺大泡病变，并能有效地预防气胸的复发。

体外循环心内直视手术中肝素耐药的原因分析及处理措施

摘要： 目的 探讨体外循环(CPB)心脏直视手术中肝素耐药的原因及处理措施。 方法 自1998年1月至2007年5月我科对1 258例心脏病患者行CPB心脏直视手术，术中19例患者（心脏粘液瘤7例、风湿性心脏病3例、感染性心内膜炎3例、房间隔缺损2例、法洛四联症2例、室间隔缺损1例、右心室双出口1例）出现肝素耐药，男8例，女11例；年龄4～58岁(37±12岁)。其中14例补充肝素后全血激活凝血时间(ACT)gt;480 s；5例补充肝素后ACT仍lt;480 s，给予静脉输注新鲜冰冻血浆或全血后ACT达480 s以上；平均追加肝素13 750 U。另有3例CPB术中ACT很快缩短，平均再补充肝素7 500 U后ACTgt;480 s。 结果 19例患者CPB时间58±27 min，主动脉阻断时间45±22 min；心脏自动复跳17例，15～30 J除颤心脏复跳2例；住ICU时间1～3 d，平均住院时间14.5 d，均痊愈出院。术后随访13例(68.4%)，随访时间2～26个月，心功能恢复至Ⅰ级11例，Ⅱ级2例，无栓塞及出血等严重并发症发生；失访6例。 结论 CPB心脏直视手术中肝素耐药常见于心脏粘液瘤、感染性心内膜炎及紫绀型心脏病等，与血液中出现类似肝素的粘多糖物质、抗凝血酶Ⅲ(ATⅢ)含量及活性低、血小板计数增高、术前抗凝治疗及使用避孕药等因素有关，术中需加强ACT的监测。

刀刺伤致升主动脉裂伤手术救治成功一例

选择性肺动脉灌注治疗晚期肺癌

目的　探讨对晚期肺癌患者的治疗手段，使失去手术机会的患者得到有效的治疗。　方法　采用化疗泵行选择性肺动脉灌注。　结果　80例晚期肺癌患者中肺部包块缩小67例，症状好转或明显缓解70例。　结论　选择性肺动脉灌注方法简便、安全、有效，不失为治疗晚期肺癌的一种有效手段。

Clinical Study on Surgical Stabilization for Traumatic Flail Chest

目的　通过对连枷胸两种不同治疗方法的比较，探讨该病的优化治疗方案。 方法　将2005年1月－2012年11月收治的80例枷胸患者按入选标准分为：保守组40例，通过胸部外固定和（或）呼吸机内固定等方法治疗；手术组40例，采用镍钛记忆合金环抱式接骨器手术内固定骨折的肋骨，比较两种治疗方法和疗效及并发症情况。 结果　保守组和手术组各死亡3例，原因为呼吸道感染致呼吸衰竭，两组无差异，但ICU停留和住院天数、机械通气时间、呼吸道感染等并发症手术组明显低于保守组（P＜0.01）。手术组无胸壁畸形，而保守组有18例，两组比较差异有统计学意义（P＜0.01）。出院3个月后，手术组患者部分肺功能指标显著优于保守组（P＜0.01）。 结论　手术治疗连枷胸可迅速稳定胸壁，消除反常呼吸和激烈疼痛对呼吸的影响，还可减轻连枷胸对患者远期肺功能的影响，具有较高的临床应用价值。

Relationship between UGT1A1 Polymorphisms and Adverse Effects of Irinotecan in Patients with Esophageal Carcinoma

ObjectiveTo investigate the distribution of uridine diphosphate-glucuronosyltransferase 1A1 (UGT1A1) gene polymorphisms in esophageal carcinoma (EC) patients, and their relationship with adverse effects (delayed diarrhea and neutropenia) of Irinotecan. MethodsForty-eight patients with esophageal squamous carcinoma who were admitted to Sichuan Provincial People's Hospital between January and October 2012 were recruited in the study. There were 37 male and 11 female patients with their age of 56 (25-38) years. Formalin-fixed, paraffin-embedded samples were collected from those EC patients and genomic DNA was extracted. UGT1A1 polymorphisms were detected by PCR and DNA sequencing. Three genetic loci were investigated including UGT1A1* 28 (TA6 > TA7), UGT1A1* 6 (211G > A) and UGT1A1* 93 (-3156G > A). Adverse effects (delayed diarrhea and neutropenia) of patients with different UGT1A1 polymorphisms after Irinotecan treatment were recorded. The relationship between UGT1A1 polymorphisms and Irinotecan-induced adverse effects was analyzed. ResultsUGT1A1 polymorphisms were detected in 10 out of 48 (20.8%) EC patients. UGT1A1* 93 (-3156G > A)polymorphisms were most common with the polymorphism rate of 16.7% (8/48), followed by GT1A1* 6 (211G > A) polymorphisms with the polymorphism rate of 4.2% (2/48). The incidences of grade 3~4 diarrhea and grade 3~4 neutropenia after Irinotecan treatment in the patients with UGT1A1 polymorphisms were 60.0% and 40.0% respectively, which were significantly higher than those of the patients with wild type UGT1A1 (21.1% and 15.8% respectively, P < 0.05). UGT1A1 polymorphism rates were 45.5% (5/11) in female patients and 13.5% (5/37) in male patients, which were significantly different (P < 0.05). ConclusionsIn EC patients, 2 polymorphism loci including UGT1A1* 93 (-3156G > A) and GT1A1* 6 (211G > A) can effectively predict adverse effects caused by Irinotecan treatment. UGT1A1 polymorphism rate of male patients is significantly lower than that of female patients.

The Efficacy of Surgical Treatment for Non-small Cell Lung Cancer with Single Brain Metastasis

目的　探讨非小细胞肺癌合并孤立性脑转移灶的手术治疗效果，分析影响患者生存期的因素。 方法　回顾性分析2005年1月－2011年5月46例接受手术治疗的非小细胞肺癌合并孤立性脑转移灶患者的临床资料，其中男35例，女11例；年龄35～67岁，平均53.2岁；所有患者均行肺部原发肿瘤及脑部转移肿瘤切除术，其中肺叶切除术42例，全肺切除术4例，术后全部患者行全脑放射治疗，部分患者行系统化学疗法3～6周期。对随访患者的生存时间采用对数秩检验，分析影响生存率的因素。 结果　术后病理检查提示腺癌27例，鳞癌15例，大细胞癌2例，其他类型2例。患者1年生存率80%，2年生存率41%，3年生存率14%，中位生存期23个月，平均生存期（27.8 ± 4.5）个月（乘积极限法）。对数秩检验结果提示N0与N1患者比N2患者生存率高（P=0.024），腺癌患者生存期比非腺癌患者生存期长（P=0.002）。 结论　外科手术治疗非小细胞肺癌合并孤立性脑转移灶的患者可以取得良好的治疗效果，腺癌患者及无纵隔淋巴结转移的患者生存期长。

Operative Opportunity for Active Infective Endocarditis

【摘要】　目的　探讨活动期感染性心内膜炎（infectiue endocarditis，IE）患者心脏手术的最佳时期。　方法　回顾分析1999年9月-2009年9月行外科治疗的92例IE患者的临床资料。IE诊断标准为修订的Duke标准。采用SPSS 12.0软件包，分析了年龄、性别、是否是院内感染IE、合并症（糖尿病、慢性阻塞性肿疾病、癌症）、病原菌、手术时间等因素与手术并发症及6个月病死率的关系。　结果　56例患者在确诊为IE后7 d内手术，36例患者在确诊7 d后，并抗生素治疗完成后手术。葡萄球菌为主要感染菌株，与栓塞、脓肿及感染性休克显著相关。最常见的手术指征是重度的瓣膜关闭不全合并心功能不全。6个月的病死率为12%。早期手术与晚期手术比较，病死率增高。单因素分析显示，与6个月病死率相关的因素包括葡萄球菌感染和感染性休克。多因素分析显示感染性休克为6个月内死亡的预测因子。感染性休克的患者尽管行了早期手术，病死率仍为67%。严重瓣膜关闭不全的患者，若未出现心衰，无手术（早期或晚期）死亡。　结论　手术患者的预后由是否发生过感染性休克决定。晚期手术组患者结果好于早期手术组，但结果的差异可能并不是手术的时期不同，而是感染性心内膜炎的严重程度不同造成的。对于有重度瓣膜返流但无心衰的患者，早期手术可能在缩短住院时间，预防心衰发生上有帮助。【Abstract】　Objective　To discuss the optimal time of cardiac operations in patients with infective endocarditis (IE).　Methods　We analyzed the clinical data of 92 patients with IE diagnosed by the modified Duke criteria between September 1999 and September 2009. SPSS 12.0 was used to analyze predictors of 6-month mortality, including age, sex, nosocomial origin of infection, comorbid conditions (diabetes, chromic obstructive pulmonary disease, cancer), the causative microorganisms, the timing of cardiac operation, and the complications.　Results　Fifty-six patients underwent operation within the first 7 days after diagnosis of infective endocarditis, and 36 received operation at the completion of antibiotic treatment 7 days after the diagnosis. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 12%. Early operation showed an increased mortality compared with late operation. Univariate analysis showed that factors associated with 6-month mortality included staphylococci infection and septic shock. Multivariate analysis revealed that septic shock was a predictor of 6-month mortality. Despite early operation for patients with septic shock, 67% of them died. No death occurred to patients with severe regurgitation but without heart failure after undergoing (early or late) operations.　Conclusions　The prognosis for surgically treated patients is determined by the occurrence of septic shock. The outcome in patients undergoing late operations is favorable compared with patients undergoing early operations. This difference is probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefits in shortening the length of hospitalization and preventing development of heart failure.

成都市胸外科医疗质量控制中心体系建设实践与讨论