食管裂孔疝嵌顿并胃坏疽十分罕见。本文回顾1例9岁6个月女性患儿先天性食管裂孔疝嵌顿并胃坏疽的发病、诊断及治疗过程，总结该病的临床表现和诊治要点。患儿患先天性食管裂孔疝嵌顿，病情危重，胸部CT及上消化道造影可明确诊断，行胃大部切除及食管裂孔疝修补后出现食管远端出血及食管－胃连接处狭窄，早期手术解除嵌顿是降低术后并发症及病死率的关键。
Severe acute respiratory infection caused by a novel coronavirus(SARS-CoV-2), WHO named COVID-19, is the major clinical concern globally. Both the world health organization and the National Health Commission have issued interim guidelines and management strategy for the diagnosis and treatment of COVID-19. These comprehensive guidelines establish the basic norms for the clinical practice. However, cardiovascular diseases have their special pathophysiological characteristics. The surgical treatment strategies for emergency and critical cardiovascular diseases requires specific recommendations or guidelines. From 16 January to 12 February 2020, the department of cardiovascular surgery in Wuhan Union Hospital had performed 15 emergency cardiovascular operations. The perioperative success rate is 100%. Based on our clinical practice, we summarized the relevant experience as a complement to the WHO and National Health Commission guidelines, hope to provide references for the cardiovascular surgeons.
2013年1月至2018年8月在我瓣膜中心确诊二尖瓣黏液样变(Barlow综合征)并由单一术者进行二尖瓣修复手术的患者,经筛选入组25例。回顾术前超声心动图资料,术中二尖瓣修复技术,观察患者近、中期的治疗效果。25例患者中,24例修复效果满意,1例因修复失败术中改为二尖瓣置换术,成形成功率98.9%。所有患者均术后恢复良好,无并发症及死亡发生,均正常出院。术中体外循环(93.47±22.69)min,阻断(68.57±14.67)min。二尖瓣均采用人工瓣膜成形环,尺寸36(34,40)mm。术后住院(7.2±3.3)天。出院前复查超声心动图,二尖瓣微量反流15例,二尖瓣轻度反流9例。随访3～71个月,平均36.5个月。随访期间无患者死亡,无心血管不良事件,无再次心脏手术发生。二尖瓣修复术治疗Barlow综合征导致二尖瓣关闭不全的近、中期临床效果满意。
Objective:To investigate the application of low-dose chest CT(LDCT) in the screening of pulmonary subsolid nodules in population and the application value of artificial intelligence.Methods:People who received chest LDCT screening between January 2015 and December 2017 were included. A retrospective study was developed to analyze the enrolled population features , detection of pulmonary subsolid nodules and independent predictors of subsolid nodules , and to evaluate the accuracy of the artificial intelligence reading method.Results:Result of three cross-sectional studies reveals that the detection rates of pulmonary subsolid nodules were 0.42%, 0.69% and 0.92% in three rounds. 726 cases who completed the three rounds of screening were included in the cohort study. The cohort population was predominantly male(83.2%), with a median age of 43 years, and nearly half of the subjects(47.0%) had a history of smoking. GEE revealed that the patient's family history of lung cancer( OR=8.753, 95% CI: 1.877-40.816, P=0.006) was an independent predictor of the detection of subsolid nodules. In the 110 kVp tube voltage group, AUC of AI model was 0.740, and AUC of the manual reading method was 0.721, no significant differences were observed( P=0.502); when the preseted cutoff value of AI model was 0.75, the NRI was -0.15, indicating the accuracy of AI model was inferior to manual method( P=0.006). In the 130 kVp tube voltage group, AUC of the model was 0.888, and AUC of the manual reading method was 0.756, no significant differences were observed( P=0.128); and the NRI was 0.19, indicating the accuracy of AI model was not inferior to manual method( P=0.123). Conclusion:This population' s detection rates of pulmonary subsolid nodules were 0.42%-0.92%. Family history of lung cancer was an independent predictor of subsolid pulmonary nodules. The result of AI pulmonary nodule detection model could be a reference when the training set data parameters match the actual application parameters.
比较单纯血管翳清除术与传统二次瓣膜置换手术在治疗主动脉机械瓣血管翳形成患者的短期临床疗效差异。2015年3月至2019年10月，共26例患者(女性18例)因主动脉机械瓣置换术后血管翳形成导致瓣膜失功，根据术式不同将患者分为血管翳清除组(接受单纯血管翳清除术)与瓣膜置换组(接受传统二次瓣膜置换手术)。本研究着重比较两组患者术前一般情况，观察两组患者围手术期实验室指标、超声心动图特征，并对其进行随访，以评估两种手术方式在治疗人工瓣膜血管翳上的疗效差异。两组患者术前一般资料差异无统计学意义，全部患者接受择期手术治疗，同期行二尖瓣置换手术8例，三尖瓣修补术15例(置换3例，成形12例)，主动脉根部手术2例，术后无早期不良事件发生。血管翳清除组患者术中体外循环时间(128.7 min对179.7 min， P<0.05)及升主动脉断时间(74.2 min对132.7 min， P<0.05)均显著少于瓣膜置换组患者，术后炎症反应更低，两组患者在其他实验室检查及超声心动图指标方面差异无统计学意义。与传统二次瓣膜置换手术患者相比，单纯血管翳清除术式能够明显减少体外循环时间、大幅降低转机过程带来的全身炎症反应、降低患者住院时间。术后短期内无明显不良影响，是一种值得推广的创新型手术方式，其远期疗效尚待进一步随访调查。
Objective:To describe eraly and midterm outcome of the Rastelli repair in Fuwai hospital Patients.Methods:From May 2010 to March 2017, 71 patients with transposition of the great arteries(TGA)with ventricular septal defect(VSD)and right ventricular outflow tract obstruction(RVOTO) or double outlet right ventricle(DORV)with VSD and RVOTO underwent Rastelli repair. 48 cases male , 23 cases female . Age at operation is(4.7±2.7) years. There are 10 TGA cases, 27 DORV cases, 34 CTGA cases in this group. 30 patients(42.3% , 30/71)received palliative operation prior to the Rastelli procedure, including 13 BT shunt and 17 bi-Glenn operation. 31 patients(43.7%, 31/71 )underwent the Rastelli procedure with VSD enlargement. Right ventricle-to-pulmonary artery connection were created with the use of 9 homografts, 56 valved bovine jugular vein, 6 man-made valved Gore-Tex conduit. The overall mean right ventricle-to-pulmonary artery conduit size was(17.9±3.3)mm.Results:CPB time was(209.0±83.4)minutes, aortic crossclamping time was(132.0±71.1)minutes, mechanical ventilation time was(102.6±81.7)h. Early mortality was 1.4%(1/71). morbidity in hospital was 16.9%, 4 patients with Ⅲ AVB implanted permanent pacemaker, Subxiphoid pericardial window drainage in 3 cases, delayed sternal closure in 3 and re-thoratomy for hemaostsis in 2.Follow up is from 4 months to 6.8 years. Overall survival was 97.2% and 97.2% at 1 and 5 years, respectively. Freedom from RVOTO was 98.6% and 84.1% at 1 and 5 years, respectively. Freedom from reintervention was 98.6% and 90.0% at 1 and 5years, respectively. 1 patients performed a conduit replacement. Seven patients performed 10 times balloon dilatation . Time-related freedom from recurrent LVOTO on echocardiogram in all patients, and the pressure gradient of the LV to the aorta was(10.5±8.8 )mmHg at the most recent follow-up.Conclusion:The Rastelli operation remains the preferred procedure for part of the DORV , CTGA , TGA with VSD and severe fixed valvular or subvalvular PS. The Rastelli procedure can be performed with low early mortality. There is frequent need for late reoperation, especially for conduit replacement.
Objective:To explore the outcomes and mechanisms of coronary endarterectomy combined with electrocautery in patients with diffused coronary artery disease undergoing coronary artery bypass grafting (CABG).Methods:From January 2017 to September 2018, 300 patients undergoing CABG with left anterior descending artery endarterectomy were randomly divided into two groups, after fully informed the risks and other related issues regarding the operations. All the patients in the two groups were treated with CABG. In the study group, patients underwent electrocautery immediately after endarterectomy, whereas in the control group, patients underwent endarterectomy only. The electrocardiogram and serological examination (TNI, IL-6 and TNF-a) were performed at 2 h, 24 h, 72 h and 120 h after operation. The follow-up duration was 1 year.Results:Nine patients in the study group, and 25 patients in the control group had ST segment elevation. The levels of TNI, IL-6 and TNF-a were continuously increased in both groups, and reached the peak at 24 h, then decreased slowly. The levels of TNF-a were significantly lower at 2 h postoperatively in the study group ( P=0.01). There was no significant difference in the levels of TNI and IL-6 between the two groups. The levels of TNI, TNF-a and IL-6 were significantly lower in the electrocautery group at 24 h, 72 h, and 120 h after operation( P<0.05). One year after operation, incidences of ST segment elevation in the study group were significantly lower than that in the control group, and there was no significant difference in restenosis rate and myocardial infarction rate. Conclusion:Endarterectomy combined with electrocautery may prevent the restenosis of the lumen and blood turbulence, smooth the inner wall of the vessel, slow down the release of inflammatory factors in the peripheral blood, inhibit the expression of inflammatory factors in the vessels, and reduce the myocardial damage. The short-term effect was satisfactory; the long-term anti-inflammatory and antithrombotic effect still need further investigations.
Objective:To evaluate lung protection of remote limb ischemic preconditioning after pulmonary resection.Methods:Methods sixty adult patients scheduled for elective pulmonary resection, were randomly divided into control group(group C, 30 cases) and remote limb ischemic preconditioning(group RLIP, 30 cases) using a random number table. Before one-lung-ventilation(T0), at 30 minites, 1 hour and 2 hours of OLV(T1, 2, 3), 15minites after re-expansion of the collapsed lung(T4), blood samples were drawn from the radial artery and vein for blood gas analysis, alveolar-arterial oxygen gradient(A-aDO 2)、pulmonary shunt ratio(Qs/Qt)were calculated. Extraction time of closed thoracic drainage tube, length of hospital stay, the incidence of in-hospital complications after operation were recorded. Results:Compared to T0 , each group at T1-T4, A-aDO 2 were obviously increased. We found that at T3, A-aDO 2 of group C increased much more higher and statistically significant( P<0.05). Compared to group RLIP, Qs /Qt of group C were significantly increased at T2( P<0.05). Compared with C group, the expression of microtubule-associated protein 1 light chain 3B in lung tissues was significantly"up-regulated in RLIP group( P<0.05). Followed the extraction time of closed thoracic drainage tube, length of hospital stay, the incidence of in-hospital complications after operation there were no statistically different( P>0.05). Conclusion:Remote limb ischemic preconditioning had some protective effect after pulmonary resection, which mechanism may be related to enhancing autophagy in the operated 1ung tissues of the patients.
回顾性分析2015年4月至2018年12月收治的10例右心系统子宫静脉平滑肌瘤病女性患者的临床资料，年龄35～53岁，平均(45±6)岁。全组均联合妇科医师，在全麻下行一期肿瘤完整切除，其中6例取体外循环下胸腹联合切口，4例取非体外循环下单纯腹部切口。术后1例出现急性肾衰、肺部感染等并发症，家属拒绝继续治疗，术后第9天自动出院。余9例患者均康复出院。电话或门诊随访3～47个月，平均(29±13)个月，1例术后2月余因肠梗阻再次住院，予保守对症治疗后好转出院。子宫静脉平滑肌瘤病的诊断较困难，一期手术可取得较好的中长期生存率和生存质量，术后复发率较低。
2017年1月至2018年6月3例纵隔肿瘤伴上腔静脉阻塞综合征患者行全上腔静脉置换术，根据3D-CTBA重建影像技术进行术前手术规划，确定上腔静脉、左无名静脉、右无名静脉的形态、直径、受累范围和纵隔病灶的大小、部位。充分术前准备，麻醉干预。按照3D-CTBA重建结果，术中精准分离肿瘤周围组织，切除被侵组织肿瘤病灶和受累的上腔静脉、左无名静脉、右无名静脉部分。完整切除纵隔肿瘤，应用合适材料(人工血管、自体心包)行上腔静脉、左无名静脉、右无名静脉血管吻合重建。平均病灶直径7.5 cm，平均手术时间306 min，平均术中出血183 ml。术后病理诊断侵袭性胸腺瘤2例，胸腺癌1例。3例患者上腔静脉梗阻症状均得到改善，无围手术期死亡，随访至今均生存。
Objective:To observate the changing trend of flow of in-situ bilateral internal mammary artery as grafts during perioperative period in patients undergoing coronary artery bypass grafting(CABG), and to compare the parameters of flow between LIMA and RIMA.Methods:A total of 57 patients , 50 males and 7 femails, mean aged(57.8±10.1) years, underwent bilateral IMA CABG in our hospital from August 2016 to January 2019. Transthoracic ultrasound of IMA examination was performed before CABG. The blood flow, the PI(pulsation index) and other parameters were measured and recorded by intraoperative TTFM.Results:There was no significant difference of the average diameter and PI between LIMA and RIMA, but the preoperative flow of RIMA is higher( P=0.026) in our study. There was no significant difference of the average flow and PI between LIMA and RIMA recorded by TTFM( P>0.05), but the higher diastolic flow(DF) in LIMA grafts( P=0.022) compared with RIMA grafts may be associated with the different target sites( P<0.05). Compared with the preoperative flow and PI of IMA, the intraoperative flow and PI of both LIMA and RIMA grafts were better( P<0.001). Conclusion:Compared with the preoperative flow of IMA, both flow of LIMA and RIMA are better. In spite of the targets exist difference , there are no significant difference of the average flow and PI between LIMA graft and RIMA graft recorded by TTFM.
Objective:To investigate the best neutralization ratio of protamine and heparin during off-pump coronary artery bypass grafting(OPCABG) by analyzing the advantages and disadvantages of heparin residue after OPCABG.Methods:From July 2018 to January 2019, 112 patients undergoing elective OPCABG were included in this study. The patients’ whole blood was drawn at 2 time points, including before entering operating room and entering intensive care unit, to receive thrombelastography(TEG) and heparinase-modified thromboelastography(hmTEG) . Conventional coagulation indexes such as activated coagulation time(ACT) were also detected. All the patients were divided into 3 groups, the non-heparin residue group(30 cases), heparin residue group 1(42 cases) and heparin residue group 2(40 cases) according to the laboratory results of TEG, hmTEG and ACT. We observed the dosage of each group of protamine and heparin, as well as the ratio of heparin and protamine. The changes of R time in TEG and ACT between 3 groups were analyzed and compared. Postoperative chest tube drainage at postoperative 12 h and 48 h, cTnI peak value, incidence of perioperative myocardial infarction(MI), incidence of reoperation and poor wound healing, amount of blood loss and transfusion, and acute renal injury were compared between the 3 groups.Results:No significant trio-group differences existed in basic clinical characteristics(all P>0.05). Postoperative R(CKH)time was similar in the 3 groups( P>0.05). Comparing with heparin residue group 1 and heparin residue group 2, the ACT after protamine neutralizing heparin and postoperative R time were decreased, the dosage of protamine, ratio of heparin and protamine, cTnI peak value were increased in the non-heparin residue group( P<0.05). Comparing with heparin residue group 2, the dosage of heparin, postoperative chest tube drainage at postoperative 12h and 48h, amount of blood transfusion and transfusion probability were significantly decreased in non-heparin residue group( P<0.05), but compared with group 1 of heparin residue, there was no significant difference in the above indexes( P>0.05). The perioperative myocardial infarction, incidence of reoperation and poor wound healing, postoperative acute renal injury and time of in ICU stay showed no significant differences between the 3 groups( P>0.05). Conclusion:Moderate heparin residue after OPCAB suggests that it has myocardial protective effect, and does not significantly increase the risk of bleeding. A large number of heparin residues can affect the coagulation function and lead to bleeding tendency, increase the amount of blood loss and transfusion. It is reasonable to make ACT after protamine neutralize heparin higher than the level of ACT before operation, and not higher than 20% of the level before operation.
Objective:Mitral valve replacement is more frequently performed in elder patients with rheumatic valve diseases. Mitral valve repair may be feasible in young patients with suitable anatomy in rheumatic mitral valve disease, but still controversial in elder patients. Our study was to compare mitral repair to bioprosthetic replacement in patients aged 60 years or older.Methods:Eighty two patients(age ≥60 years) underwent mitral valve surgery(mitral repair or bioprosthetic replacement)in our single institution from January 2014 to January 2016 were reviewed, including 25 cases of repair(MVP) and 57 cases of bioprosthetic replacement(MVR). 5 years follow-up oganalysis.Results:Mean age in MVP and MVR was 64.43 years and 67.28 years, respectively. There were no statistically differences in extracorporeal circulation time( P=0.99) and aorta blocking time( P=0.88); the operative mortality rate in MVR was 5.3% while none in MVP( P=0.24). During follow-up 6 deaths happened in MVR, 4 of them died from MACE while the other 2 died from other causes. There was no death in MVP( P=0.17). No redo or other complications were found during follow-up. Conclusion:In patients aged 60 years or older with rheumatic mitral valve disease, mitral repair is associated with a same perioperative and mid-term result compared with bioprosthetic replacement. Rheumatic mitral valves could be repaired in elderly patients.
Congenital tracheal stenosis is a rarebut life-threatening disorder. In recent years, the improvement of surgical skills has significantly reduced the incidence of postoperative complications and mortality in children. Through researching the relevant published articles and books, this review introduces the pathology, types, commonsurgical methods of congenital tracheal stenosis, summarizes the surgical indications for tracheoplasty, and prospects for providing some suggestions for thetreatment of congenital tracheal stenosis.
Objective:The aim of our study was to compare the short-term and long-term outcomes between minimally invaisive Ivor-Lewis esophagectomy(MIILE)and minimally invasive McKeown esophagectomy(MIME) for squamous cell carcinoma of middle and lower esophagus.Methods:The data of 268 patients diagnosed with middle and lower esophageal spuamous cell carcinoma who had received MIILE or MIME between August 2010 and March 2014 at department of thoracic surgery, The First Affiliated Hospital of University of Science and Technology of China(Anhui Provincial Hospital), was analyzed retrospectively. We divided the subjects into two groups according to the mode of the operation, each group was identified 81 patients after propensity score matching. We were using t test, χ2 test, Kaplan- Meier curve and Log- rank test to compare preoperative data and overall survival of the two groups. Results:Compared with MIME, MIILE had lower complication in pulmonary infection and anastomotic fistula, also had less operating time, whereas MIME had an advantage in the number of lymph nodes dissection adjacent to recurrent laryngeal nerve( P<0.05). The 1-year、3-year、5-year survival rate of MIILE were 87.7%、59.2%、45.9%, and the 1-year、3-year、5-year survival rate of MIME were 86.4%、58.7%、42.8%.There were no significant difference between two groups in 5-year survival rate. Conclusion:For squamous cell carcinoma of middle and lower esophagus, minimally invasive Ivor-Lewis esophagectomy and minimally invasive McKeown have no significant difference in long-term survival, but minimally invasive Ivor-Lewis esophagectomy has advantages in reduce the operating time, decrease pulmonary infection and anastomotic fistula during perioperative period.Nevertheless minimally invasive McKeown has an advantage in dissection of the lymph nodes adjacent to recurrent laryngeal nerve.
对2018年8月至2019年3月上海交通大学医学院附属同仁医院诊治的4例气管憩室导致慢性咳嗽患者的临床和病理资料进行分析，胸部高分辨HRCT检查显示，胸廓入口处气管旁右侧后壁的类圆形或不规则囊状或柱状气体影，连续横断薄层扫描或多平面重建等后处理技术发现气囊与气管之间无或有一较细的管道相连，气管镜检查均未见明显异常通道，术后病理报告示气管憩室。经颈部沿皮纹横弧形切口顺利切除气管憩室，术后慢性咳嗽症状消退，随访2～8个月，疗效满意。
The frozen section (FS) technology has been widely used in the process of surgical pathology since its time-saving nature exhibited superiority over traditional paraffin method. Therefore FS, of great value in providing preliminary pathological diagnosis, offers guidance in the extension of surgical resection. However, it remains controversial whether the early-stage lung adenocarcinoma could be accurately identified in FS. This review aims to generalize the studies concerning the accuracy of FS in identifying early-stage lung adenocarcinoma, analyzing the interference factors, comparing the similarities and differences between frozen sections and traditional paraffin sections. It also gives insight into whether FS can provide significant guidance for surgeons to perform resection on early-stage lung adenocarcinoma.
Background: Prediction of in-hospital death is important for patient management as well as risk-adjusted evaluation of Congenital heart disease (CHD) surgery performance. Using a large database containing CHD surgery records of 12 years, we aim to establish patient-level in-hospital mortality prediction models.Methods: Patients with congenital heart disease who underwent surgery at Shanghai Children’s Medical Center from January 1, 2006, to December 31, 2017 were included in the study. Each procedure was assigned a complexity score based on Aristotle Score with modification. In-hospital mortalities for various surgery procedures were estimated. In-hospital death prediction models including a procedure complexity score and patient-level risk factors were constructed using logistic regression analysis and machine learning methods. The predictive values of the models were tested. Results: Among 24,684 patients underwent CHD operations, there were 595 (2.4%) in-hospital deaths. The results showed that AUC of the prediction model based on logistic regression is 0.864 (95% CI: 0.833-0.895, P <0.001), the sensitivity is 0.831 and the specificity is 0.786. The AUC of the Gradient boosting model is 0.884 (95 %% CI: 0.858-0.909, P <0.001), the sensitivity and specificity were 0.838 and 0.785 respectively. The feature importance analysis found that the variable (average score) that had the greatest impact on the model's prediction performance was operation score (95.6), and other variables (average scores) were Age (days) (95.5), Ultrasound MV （54.6）, Ultrasound atrial level （54.5）, Palliative operation (45.8), Operation history (38.8), Ultrasound TV2 (32.1), Urgent operation (30.8), Ultrasound ventricular level (30.5), and Spo2 ≤ 90% (30.3).Conclusions: Model constructed using machine learning method and logistic regression containing procedure complexity score and pre-operative patient-level factors had high accuracy in in-hospital mortality prediction. Operation score and age have the greatest impact on model prediction performance.
Objective:To analyze clinical outcomes of myocardial incision and tearing for the treatment of myocardial bridge.Methods:A retrospective cohort study was conduct to review the clinical date of 29 patients who underwent surgical myotomy from January 2014 to January 2018 in the Second Hospital of Lanzhou University. A total of 11 patients(incision group) were experienced traditional myotomy on myocardial bridge that the myocardium was longitudinally incised along the direction of the coronary artery, while 18 patients(tearing group) were treated by myocardial incision combined with tearing that longitudinally incised myocardium and deeply tissue tearing. The operation time of surgical myotomy, the amount of bleeding, the number of branches of vascular injury and the number of ventricular ruptures during operation were compared between the two groups. After followed up half a year to one year, the clinical symptoms of angina pectoris, myocardial ischemia by electrocardiogram suggested, and coronary stenosis by coronary CT suggested were collected.Results:The operation time of surgical myotomy, the amount of bleeding patients and the number of branches of vascular injury during operation in the incision group were higher than those in the tearing group( P<0.05). There was no significant difference for the number of ventricular ruptures during operation( P>0.05). After followed up half a year to one year, there was no significant difference in the clinical symptoms of angina pectoris, myocardial ischemia by electrocardiogram suggested, and coronary stenosis by coronary CT suggested( P>0.05). Conclusion:Myocardial incision combined with tearing is a surgical procedure with short operation time and low bleeding risk, which is more beneficial than the traditional longitudinally incised for the myocardial bridge.
Objective:The purpose of this study was to explore new method for evaluating the severity of extravascular lung water in patients after bilateral lung transplantation.Methods:The study was performed in 50 patients after bilateral lung transplantation in our hospital from 2017 to 2018. Picco were implanted during the operation .Two hours after the operation, a doctor monitored the index of EVLWI and PVPI.At the same time, another doctor carried out examination of lung ultrasonography and Calculated the numbers of B line. After ultrasonography, the doctor used ELISA to determine the level of SDC-1.Results:EVLWI were significantly correlated with the number of B-line and the level of SDC-1 ( RS=0.833, RS=0.747, P<0.05), PVPI were significantly correlated with the number of B-line and the level of SDC-1 ( RS=0.738, RS=0.626, P<0.05). Conclusion:The number of B-line and the level of SDC-1 have a good correlation with extravascular lung water. The combination of the two indicators might be used as a reliable index for evaluating the degree of extravascular lung water after bilateral lung transplantation.
