目的:探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）致胆管损伤的原因、预防措施和经验教训。方法:分析2007年8月～2008年8月期间我院胆道外科收治的3例胆管严重损伤病例资料。结果:3例LC术致胆管严重损伤的患者均发生肝门部胆管狭窄，并均在肝门胆管成形后行胆管空肠Roux-en-Y吻合术，吻合口直径2.0～3.0 cm。术后患者恢复良好，均顺利出院，住院时间为10～15天。随访1～6个月，1例于术后2月出现肝区隐痛，口服消炎药可控制，其余未见异常不适。结论:术中仔细辩清肝总管、胆总管与胆囊管的三者关系是预防LC术胆管损伤的关键。胆管空肠Roux-en-Y吻合术是处理胆管损伤的重要手术方式。LC术时，胆道外科医生思想上要高度重视，不可盲目追求速度。
Abstract： Objective To summarize our operative experiences of cardiac reoperation after mechanical valve prosthesis replacement and investigate the causes of reoperation and the perioperative techniques and operation methods. Methods From January 2001 to December 2008, we performed reoperation on 105 patients (59 males and 46 females, aged 50.2±10.6 years old) who had undergone mechanical valve prosthesis replacement. Among the patients, there were 31 cases of mitral valvular replacement (+ tricuspid valvular plasticity), 38 cases of aortic valvular replacement (+ tricuspid valvular plasticity), 11 cases of Bentall procedure, 7 cases of mitral and aortic bivalvular replacement (+tricuspid valvular plasticity), 8 cases of tricuspid valvular replacement, 6 cases of repairing of prosthetic leakage, and 4 others cases. The time interval between two operations was 3 months to 18 years (46.3 ±31.9 months). Before reoperation, the cardiac function (NYHA) of the patients was class Ⅱ in 27 patients, class Ⅲ in 53 patients, and class Ⅳ in 25 patients. Results There were 6 hospital deaths with a mortality of 5.71%(6/105). All others recovered to NYHA class ⅠⅡ. The causes of mortality included 1 case of multiple organ failure, 1 case of low cardiac output after operation, 1 case of aortic pseudoaneurysm rupture, 1 case of severe infection due to brain complication and 2 cases of prosthetic valve endocarditis (PVE). The causes for cardiac reoperation after mechanical valve prosthesis replacement were 67 cases of prosthetic leakage (63.80%), 16 cases of PVE (15.23%), 14 cases of prosthetic thrombosis (13.33%) and 8 cases of other valvular anomalies. Followup was done for 11 to 107 months, which showed two cases late deaths of cardiac arrest and cerebral hemorrhage. Conclusion Patients who have received mechanical valve prosthesis replacement may undergo cardiac reoperation due to paravalvular prosthetic leakage, paravalvular endocarditis, and prosthetic thrombosis. The keys to a successful cardiac reoperation include appropriate preoperative preparations, operational timing, and suitable choosing of cardiopulmonary bypass and operational skills.
ObjectiveTo explore the clinical value of soluble suppression of tumorigenesis-2 (sST2) in replacement of N-terminal fragment of the brain natriuretic peptide precursor (NT-proBNP) in cardiac function evaluation in renal failure patients after cardiac surgery.MethodsSixty patients with renal insufficiency after cardiac surgery from January 2019 to June 2019 were divided into a test group, including 34 males and 26 females, with an average age of 49-78 (63.3±4.5) years. Another 60 patients with normal renal function were divided into a control group, including 37 males and 23 females, with an average age of 53-77 (61.7±3.8) years. The perioperative left ventricular ejection fraction, cardiac troponin T, creatine kinase-MB, sST2 and NT-proBNP were compared.ResultsIn patients of the test group, the NT-proBNP level increased significantly during perioperative period, and the change range was different from other cardiac function indexes. The change of sST2 in perioperative period was similar to other cardiac function indexes, which could reflect the change degree of cardiac function after operation.ConclusionsST2 is more important to reflect the change degree of cardiac function in patients with renal dysfunction after cardiac surgery than NT-proBNP.
ObjectiveTo evaluate mid-term outcomes of pulmonary valve replacement surgery after repair of tetralogy of Fallot.MethodsA total of 73 patients with repaired tetralogy of Fallot who underwent pulmonary valve replacement surgery in our hospital from January 2010 to January 2020 were enrolled, including 42 males and 31 females. The median age was 3.9 (0.2-42.8) years at initial repair and 20.0 (2.0-50.0) years at pulmonary valve replacement. The clinical data of the patients were recorded and analyzed.ResultsThere was no death in postoperative 30 d. The average follow-up time was 35.6±28.5 months, and no death occurred during the follow-up. One patient underwent a second reintervention after initial pulmonary valve replacement. The 1- and 5-year survival rates were both 100.0%, the 1- and 5-year reintervention-free rates were both 100.0%, and the 1- and 5-year valve failure-free rates were 100.0% and 67.1%. There was no significant difference in valve failure-free rates between different age groups (P=0.49) and different type of valve groups (P=0.74). The right (P=0.006) and left (P=0.002) ventricular ejection fractions were significantly improved, and the QRS duration was shortened after pulmonary valve replacement (P=0.006).ConclusionMid-term outcomes of surgical pulmonary valve replacement were satisfactory in patients with repaired tetralogy of Fallot, while the long-term effects should be further emphasized in clinical practice.
Objective To investigate whether different degrees of primary varus knee affect joint function and stability in patients undergoing anterior cruciate ligament (ACL) reconstruction. Methods A clinical data of 160 patients with primary varus knee, who were admitted between January 2020 and December 2021 and met the selection criteria, was retrospectively analyzed. All patients underwent primary ACL reconstruction using autologous single-bundle hamstring tendon. Patients were divided into three groups based on the hip-knee-ankle angle (HKA): group A (64 patients with HKA 0°-3°), group B (55 patients with HKA 3°-6°), and group C (41 patients with HKA 6°-9°). Except for the significant difference in HKA among the three groups (P<0.05), baseline data such as age, gender, affected side, body mass index, interval between injury and operation, Kellgren-Lawrence grading, posterior tibial slope, proportion of combined meniscal injuries, Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) objective score, anterior drawer test, Lachman test, pivot shift test, and the results of KT1000 (side-to-side difference, SSD) showed no significant difference (P>0.05). At last follow-up, joint stability was assessed through the anterior drawer test, Lachman test, pivot shift test, and SSD; joint function was evaluated using the Tegner score, Lysholm score, and IKDC objective score. Results All incisions in the three groups healed by first intention after operation. All patients were followed up 24-31 months, with an average of 26 months; there was no significant difference in the follow-up time among the three groups (Z=0.675, P=0.714). At last follow-up, the knee stability and functional assessment indicators in each group significantly improved when compared to preoperative ones (P<0.05); there was no significant difference among the three groups (P>0.05) in terms of the anterior drawer test, Lachman test, pivot shift test, IKDC objective scores, and the changes of the Lysholm scores and Tegner scores. The Kellgren-Lawrence grading and HKA at last follow-up were consistent with preoperative results in the three groups. ConclusionVarying degrees of primary varus knee do not affect early knee joint stability and functional recovery after ACL reconstruction, and there is no significant difference in effectiveness between different degrees of varus knee.
Objective To evaluate clinical outcomes of mild-to-moderate or moderate functional mitral regurgitation（FMR）after aortic valve replacement （AVR） in patients with severe aortic stenosis （AS），and analyze prognostic factors of these patients with mild-to-moderate or moderate FMR （2＋to 3＋）. Methods From September 2008 to December 2011，a total of 156 patients with severe AS （peak aortic gradient （PAG）≥50 mm Hg） as well as FMR （2＋to 3＋） underwent surgical treatment in Zhongshan Hospital. There were 95 male and 61 female patients with their average age of 59.2±10.5 years. Detailed perioperative clinical data were collected，and postoperative patients were followed up. The ratio of FMRpreoperative/FMR postoperative was calculated. Patient age，gender，body weight，history of hypertension，ventricular arrhythmia，atrial fibrillation （AF），left ventricular ejection fraction （LVEF），left ventricular end-diastolic diameter （LVEDD），left atrial diameter （LAD），pulmonary artery hypertension （PAH），PAG were assessed by logistic multivariate regression analysis. Results Six patients died postoperatively，including 4 patients with low cardiac output syndrome and 2 patients with refractory ventricular arrhythmia. Perioperative mortality was 3.8%. The average follow-up time was 20.3±8.5 months and follow-up rate was 85.3% （133/156）. Eight patients died during follow-up，including 3 patients with heart failure，2 patients with ventricular arrhythmia，and 3 patients with anticoagulation-related cerebrovascular accident. Multivariate regression analysis showed that FMR preoperative/FMR postoperative ratio was not correlated with age≥55 years，male gender，body weight≥80 kg，LVEDD≥55 mm，LVEF≤50%，history of hypertension or ventricular arrhythmia. However，LAD≥50 mm，PAH≥50 mm Hg，PAG≤75 mm Hg and preoperative AF were negatively correlated with postoperative FMR improvement. Conclusions Risk factors including LAD≥50 mm，PAH≥50 mm Hg，PAG≤75 mm Hg and preoperative AF are negatively correlated with postoperative improvement of FMR （2＋to 3＋）. Patients with severe AS and above risk factors should receive concomitant surgical treatment for their FMR during AVR，since preoperative FMR（2＋to 3＋）usually does not improve or even aggravate after AVR.
Objective To analyze the cl inical effects of modified transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degenerative disease. Methods From October 2003 to December 2006, 33 patients with lumbar degenerative disease (L3-S1) were treated by modified TLIF. There were 14 males and 19 females with an average age of 52.2 years(33 to 70 years). The median disease course was 1.8 years (4 months to 15 years). A total of 42 levels were fused, including 24 cases of single level and 9 cases of double levels. The results of preoperative diagnosis were lumbar degenerative spondylol isthesis with stenosis (8 cases), isthmic spondylol isthesis (5 cases), degenerative lumbar stenosis (16 cases), huge herniated disc with segmental instabil ity (3 cases) and failed back surgery syndrome (1 case). During the modified TLIF procedure, total inferior facet process and inner half summit of superior facet process of TLIF side were resected to make the posterior wall of foramen opened partly. After the bone graft (3 to 5 mL) was placed into the interbody space, a single rectangle Cage was inserted obl iquely from 30° to 40° toward the midl ine. Combined with pedicle screw instrumentation, TLIF was accompl ished. Middle canal and opposite side nerve root decompression were performed simultaneously when necessary. Results Intraoperative dura mater rupture, postoperative cerebral spinal fluid leakage, deep wound infection and transient nerve root stimulation occurredin 1 case respectively, and were all recovered after treatment. No patients had permanent neurologic deficit or aggravation. All patients were followed up for 20 to 58 months (mean 27.2 months). At the follow-up after 1 year postoperatively, all the operated segments achieved fusion standard and no broken screw or Cage dislocation occurred. All 13 cases of spondylol isthesis were reduced thoroughly and maintained satisfactorily. Nineteen patients remained sl ight chronic back pain. There was significant difference (P lt; 0.05) in JOA score between preoperation (14.9 ± 5.1) and postoperation (25.9 ± 3.0). The rate of cl inical improvement was 80.5% (excellent in 24 cases, good in 7 cases, and fair in 2 cases). Conclusion The modified TLIF carries out the less invasive principles in opening operations, simpl ifies the manipulation and expands the indication of TLIF to some extent, and the cl inical results for the treatment of lumbar degenerative disease is satisfactory.
ObjectiveTo compare the long-term durability of valved homograft conduit (VHC) in patients with Ross and non-Ross right ventricular outflow tract (RVOT) reconstruction. MethodsPatients who underwent RVOT reconstruction using VHC in Fuwai Hospital from January 2008 to October 2020 were retrospectively included. Patients who received Ross RVOT reconstruction were allocated to a Ross group and patients who received non-Ross RVOT reconstruction were allocated to a non-Ross group. The survival and reintervention-free rates of the two groups were evaluated with the Kaplan-Meier survival curve and log-rank test. The propensity score matching analysis was performed on the patients who completed ultrasound follow-up in the two groups, and the VHC dysfunction-free rate was compared between the two groups. ResultsA total of 243 patients were enrolled, including 142 males and 101 females, with a median age of 6 years (4 months to 56 years). There were 77 patients in the ROSS group and 166 patients (168 operations) in the non-ROSS group. The cardiopulmonary bypass time in the Ross group was shorter than that in the non-Ross group (175.4±45.6 min vs. 200.1±83.5 min, P=0.003). Five patients in the non-Ross group died early after the operation. The follow-up was available in 231 patients (93.1%), with the average follow-up time of 61.7±44.4 months. During the follow-up, 5 patients in the non-Ross group died. The 12-year survival rate was 100.0% in the Ross group and 93.2% in the non-Ross group (log-rank, P=0.026). In addition, 1 patient in the Ross group and 7 patients in the non-Ross group received VHC reintervention. There was no significant difference in the reintervention-free rate between the two groups (log-rank, P=0.096). Among the 73 patients in the Ross group and 147 patients in non-Ross group who were followed up by ultrasound after discharge, 45 patients (20.5%) developed VHC dysfunction. Before matching, the long-term durability of VHC in the Ross group was better than that in non-Ross group (10-year VHC dysfunction-free rate: 66.6% vs. 37.1%, log-rank, P=0.025). After the propensity score matching, 64 patients included in each group, and there was no statistical difference in the long-term durability of VHC between the two groups (10-year VHC dysfunction-free rate: 76.3% vs. 43.0%, log-rank, P=0.065). In the subgroup analysis, the 10-year VHC dysfunction-free rate in the Ross group was higher than that in the non-Ross group (71.0% vs. 20.0%, log-rank, P=0.032) among patients aged<6 years at surgery. However, there was no significant difference in the 10-year VHC dysfunction-free rate between the two groups (53.7% vs. 56.7%, log-rank, P=0.218) among patients aged ≥6 years at surgery. ConclusionAfter the propensity score matching analysis, the long-term durability of VHC has no significant difference between the Ross group and non-Ross group. The long-term durability of VHC after Ross surgery is superior to that of non-Ross surgery in patients aged<6 years at surgery.
ObjectiveTo evaluate the clinical outcome of valved homograft conduits (VHC) used for right ventricular outflow tract (RVOT) reconstruction in Fuwai Hospital in recent 13 years, and explore the factors influencing the long-term durability of VHC. MethodsClinical data of patients using VHC for RVOT reconstruction in Fuwai Hospital from November 2007 to October 2020 were retrospectively analyzed. The Kaplan-Meier survival curve was used to evaluate survival, VHC reintervention and VHC dysfunction. Cox proportional risk regression model was used to analyze the risk factors for VHC dysfunction. ResultsFinally 251 patients were enrolled, including 145 males and 106 females. The median age at surgery was 6.0 (0.3-67.0) years. Early death occurred in 5 (2.0%) patients. The follow-up was available for 239 (95.2%) patients, with the follow-up time of 0.3-160.0 (61.3±45.4) months. Five patients died during the follow-up, and the 1-year, 6-year, and 13-year survival rates were 96.6%, 95.5% and 95.5%, respectively. Eight patients received VHC reintervention during the follow-up, and freedom rates from VHC reintervention were 100.0%, 97.1% and 82.4% at 1 year, 6 years and 13 years, respectively. A total of 226 patients were followed up by echocardiography after discharge, with the follow-up time of 0.2-138.0 (48.5±40.5) months. During the follow-up, 46 (20.4%) patients developed VHC dysfunction, and freedom rates from VHC dysfunction at 1 year, 5 years, and 10 years were 92.6%, 79.6% and 59.3%, respectively. Univariate Cox regression analysis showed that age<6 years and VHC diameter<19 mm were risk factors for VHC dysfunction (P=0.029, 0.026), but multivariate regression analysis only indicated that age<6 years was an independent risk factor for VHC dysfunction (P=0.034). ConclusionThe early and late outcomes of VHC used for RVOT reconstruction are satisfactory, and the long-term durability of VHC is also optimal. In addition, age<6 years is an independent risk factor for VHC dysfunction.
Objective To summarize the clinical features, surgical methods, and prognosis of bucket-handle meniscal tears (BHMTs), and provide guidance for clinical treatment. Methods The clinical data of 91 BHMTs patients (91 knees), who met the selection criteria and were admitted between January 2015 and January 2021, was retrospectively analyzed. There were 68 males and 23 females. Age ranged from 16 to 58 years with an average of 34.4 years. The injury was caused by sports in 68 cases, traffic accident in 15 cases, and falls or sprains in 8 cases. There were 49 cases of left knee injury and 42 cases of right knee injury. The time from the onset of symptoms to the admission ranged from 1 day to 13 months (median, 18 days), including >1 month in 35 cases and ≤1 month in 56 cases. Medial BHMTs occurred in 52 cases and lateral BHMTs in 39 cases. There were 36 cases with ACL rupture and 12 cases with discoid meniscus. The knee extension was limited more than 10° in 55 cases. According to the condition of meniscus injury, the meniscus suture with Inside-out combined with All-inside techniques (54 cases) or meniscoplasty (37 cases) under arthroscopy were selected. ACL reconstruction was performed in all patients with ACL rupture with autogenous hamstring tendon. Postoperative complications were observed. International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were used to evaluate knee function, and clinical failure was recorded. Results Two patients developed intermuscular venous thrombosis, which improved after oral anticoagulant therapy. No vascular injury, postoperative infection, joint stiffness, or other complications occurred in all patients. All patients were followed up 24-95 months, with a median of 64 months. A total of 12 cases (13.19%) failed the operation and were re-operated or given oral anti-inflammatory analgesics and rehabilitation therapy. At last follow-up, IKDC score and Lysholm score of 91 patients significantly increased when compared with those before operation (P<0.05), while Tegner score significantly decreased (P<0.05). The above indexes of patients treated with meniscus suture and meniscoplasty were also significantly different from those before operation (P<0.05). ConclusionBHMTs occurs mostly in young men and is one of the important reasons for the limitation of knee extension after trauma. Arthroscopic meniscus suture and meniscoplasty can obtain good effectiveness according to individual conditions of patients. But the latter can better preserve the shape and function of meniscus, and theoretically can obtain better long-term outcomes, which needs to be confirmed by further research with larger sample size.