临床手术能力教学是贯穿整个住院医师规范化培训阶段的重点和难点内容,有效解决办法较少,临床手术能力教学的高效实施和保证培训效果关系到住院医师规范化培训质量.该院将多模态的数据、影像、3D重建、手术规划、手术导航等混合现实技术应用于住院医师规范化培训,在临床手术能力教学中提高了学员学习积极性、效率和质量,这种基于医疗大数据与人工智能技术平台的培训方法值得推广.

目的：探讨重症风湿性瓣膜病的术后管理方法。方法回顾分析126例重症瓣膜性心脏病行瓣膜置换术患者的临床资料。结果126例患者中，围术期死亡10例（死亡率7．94％），包括术中左心室破裂死亡1例，术后低心排综合征死亡5例，术后恶性心律失常死亡2例，术后5 d 突发左心房破裂死亡1例，术后9 d 突发左心衰死亡1例；术后远期死亡1例。其余患者发生严重并发症32例，其中，27例并发低心排综合征，2例发生恶性心律失常，1例出现急性肾功能衰竭，2例出现术后心包填塞，经相应处理后恢复。结论术后细致恰当的管理对重症瓣膜病患者手术恢复有非常重要的意义。

呼吸机治疗是胸心外科危重症患者的重要救治方法，也是临床带教的重点内容。开胸术后使用呼吸机的患者，多为呼吸衰竭、行抢救性治疗的危重患者，病情变化大，还可能发生呼吸机的机械故障等各种异常情况，如果医生基础功不扎实，不能根据报警做出及时正确的处理，甚至可能危及患者生命[1]。一个优秀的胸外科医生，不仅外科手术熟练，而且能够处理危重症患者。那么，呼吸机的熟练掌握也就是必不可少的技术。对于来我科进修学习的胸心外科医生，为了更好地进行呼吸机治疗的学习，我们总结了历年带教的经验，现将其介绍如下。

Objective To analyze and summarize the skills and complications of extracorporeal membrane oxygenation( ECMO) cannu-lation and vein intubation. Methods The clinical data of 21 patients of V-A or V-V ECMO in our hospital from January 2009 to July 2014 were analyzed retrospectively. And the techniques of different catheter sites were summarized. Results Three cases were successfully insert-ed catheter by jugular vein puncture with one time. Four patients with ascending aorta intubation died from uncontrolled severe hemorrhage. Eight peripheral catheter site had a small amount of bleeding,with no more bleeding after pressurized bandage. There were no complications like bleeding, hematoma, hemothorax and pneumothorax in the period of ECMO. Conclusion In the process of the ECMO catheter, the standardized operation could reduce the incidence of serious complicaions including bleeding.

Objective Explore the ‘dual‐tutorial teaching’ model in the application of cardiac surgical teaching .Methods 93 eighth grade clinical medicine students of 2011‐2013 school year in our depart‐ment trainee ,were divided into two groups according to the exam scores for sorting before entering the unit :the dual‐tutorial teaching group(odd number sorting ,46 students) and the control groups(e‐ven number sorting ,46 students) .The dual‐tutorial teaching group was including cardiac surgeons and intensive care physicians ,the control group was only include cardiac surgeons .The exam scores and the satisfaction of students of two groups were appraised by the same total teaching teachers .Re‐sults The theory and practical skills record of clinical skill of dual‐tutorial teaching group were signifi‐cantly higher than that of control group (P<0 .05) ,and the students of dual‐tutorial teaching group were more satisfied (P< 0 .05) .Conclusion ‘Dual‐tutorial teaching’ model enhanced the teaching effect in the eighth grade students of medicine ,more in line with the specialized characteristic of cardi‐ac surgery clinical teaching .

At present eight years of clinical medicine teaching in all Medical Universities are in the stage of exploration .Some problems appeared in the clinical teaching of our eight years medical program of&nbsp;cardiothoracic surgery .We also summarized some preliminary experience .This paper has carried on the preliminary discussion in practicing teaching in eight‐year medical students of cardiothoracic sur‐gery .

Objective To evaluate the heart function in patients with rheumatic heart disease before and after modified MAZE procedure using irrigated radiofrequency operation by quantitative tissue velocity imaging(QTVI).Methods Fifty-six patients with rheumatic heart disease and atrial fibrillation(group 1:25 patients with valve replacement and MAZE operation;group 2:31 patients with only valve replacement).The parameters of heart movement were measured by QTVI.The patients were measured at preoperative period,1 month and 3 months postoperative respectively.Results ① The preoperative movements of heart are turbulence.The order of heart movement recovers partially after MAZE operation.②LVEF were lower than that before operation in group one but not in group two.③LVEF had no change in group two,but increased in group one.The SD of mitral and tricuspid annuli began to increase at the 3rd month after operation in group one but not in group two.Conclusion MAZE operation is beneficial to the recovery of heart function.But drug therapy is still needed shortly after operation,when the injured myocardium has not recovered completely.

Objective To review the experience of urgent heart valve replacement operation in 41 patients.Methods 41 patients endured urgent heart valve replacement operation from July 1998 to July 2007.24 patients had infectious endocarditis,7 patients had severe mitral stenosis,2 patients had severe aortic stenosis,5 patients had rupture of chordae tendineae of mitral valve,2 patients had severe aortic valve regurgitation combind with ruptured aortic sinus aneurysm,and 1 patients had aortic valve regurgitation after intervention.Results There were no operative deaths.2 case died of mechanical valve infected,4 case died of acute renal failure,2 case died of low cardiac output syndrome,and 3 case dead because of the cerebral infarction aggravated.The mortality rate was 26.8%.Conclusion The patients who have severe valvular heart disease should accept the urgent valve replacement if they fit the operation indication,and the protection of lung and kidney should be noticed postoperation.

Objective To summarize the clinical experience in treatment of 8 patients with gastroesophageal anastomotic bleeding after operation due to the esophagogastrectomy and gastroesophageal mechanical anastomosis.Methods From January 1990 to May 2007,8 patients who occured the severe gastroesophageal anastomotic bleeding among the 1106 patients underwent the surgery of gastroesophageal mechanical anastomosis in our department were re-operated.Results The 7 patients in this group were cured and had not any complications,such as anastomotic leakage,gastric perforation,death and so on;1 patient was dead because of the fistula of gastroesophageal anastomotic and pulmonary infection.Conclusion The gastroesophageal anastomotic bleeding is one of the most serious complications in the surgery of gastroesophageal mechanical anastomosis;It is critical to diagnose and re-operate as early as possible.

Objective To investigate and review the surgical experience of treating LANSCLC.Methods From June 1999 to June 2006,21 patients with LANSCLC underwent surgical treatment.There were 3 cases for right upper lobectomy and replacement or partial resection of superior vena cava,2 cases for right pneumonectomy and replacement or partial resection of superior vena cava,2 cases for right upper lobectomy and bronchoplastic sleeve lobectomy and replacement or partial resection of superior vena cava,1 cases for right pneumonectomy and tracheobronch-oplastic procedure and replacement or partial resection of superior vena cava,3 cases for right pneumonectomy and tracheobronchoplastic procedure,2 cases for tracheal and carinal resection and reconstruction plus right sleeve pneumonectomy,3 cases for left pneumonectomy and thoracic aorta partial resection and reconstruction,4 cases for left pneumonectomy and partial resection of the left atrium,1 cases for left pneumonectomy and thoracic esophageal resection in 1cases.Results One died early with a mortality rate of 4.76%.Three had operative complication with the incidence rate of 14.28%,including two laryngeal nerve injury and one pulmonary closure.The duration of follow-up was 5-65 months(mean,38.5 months) and the 1,3,5-year survival rates were 80.6 %,45.7% and 23.2% respectively.Conclusion Extended resection is a good choice for patients with LANSCLC to improve survival time and life quality,but the proper surgical indication should be classified strictly.

Objective To investigate risk factor of arrhythmia in postoperative patients with esophageal carcinoma,and to find the way to prevent it.Methods 63 cases were found arrhythmia by consecutive electrocardiogram monitoring in 270 patients after esophageal cancer operation.multiple factors were classification statistic.Results Arrhythmia crest-time was in postoperative 36 hours,which sinus tachycardia morely appeared.Age60 years old,preoperativly ECG dysfunction(P0.01).FEV1/FVC70%,esophagogastri anastomasis position was on the aortic arch,preoperativly blood potassium density 4mmol/L,and complications(P0.05)are correlated with arrhythmia.Conclusion Age,preoperativly ECG,FEV1/FVC,esophagogastri anastomasis position,preoperativly blood potassium density,and complication are correlated with arrhythmia.It is very important therapia method of arrhythmia that finding and removing remote cause,reasonable using antiarrhythmic drug.

Objective To summarize the clinical experience of video-assisted thoracoscopic sympathectomy for palmar hyperhidrosis.Methods From March 2004 to December 2006,32 patiens suffering from palmar hyperhidrosis underwent video-assisted thoracoscopic sympathectomy.Their clinical materials were analysed retrospectively and the literatures were reviewed.Results The selective video-assisted thoracoscopic sympathectomy was successfully performed in all patients.The operation time(both side) was 28-76 min with an average of 42 min.The median hospital stay was 4.8 d(range: 3 to 5 d).The mean follow-up was 22.5 months(range: 10 to 41 months).Nine patients developed compensatory(increased) sweating in the trunk,5 patients in the thighs and the feet,and 3 patients in all these regions,but the symptoms were mostly tolerable and required no further treatment.Conclusion Video-assisted thoracoscopic sympathectomy is a safe,effective and minimally invasive therapeutic solution for patients with palmar hyperhidrosis.

Objective To evaluate and summarize the experience of surgical treatment for esophageal and gastric cardial carcinoma.Methods A retrospecive analysis was compiled of 1 924 surgically treated patients with esophageal carcinoma or gastric cardial carcinoma between January 1990 to December 2006.The patients were divided into A and B groups: 624 patients(group A) were treated surgically in the first 9 years,1300 patients(group B) in the next 8 years.Results The overall resection rate was 92.67%,the rate of esophageal and cardial carcinoma was 93.75% and 89.02% respectively(P=0.015).The overall hospital mortality was 1.46%;it was 2.56% for group A,0.85% for group B(P=0.006).The incidence of intrathoracic anastomotic leakage and thoracic gastric leakage occurred in 33 patients with an overall incidence of 2.23%;the incidence of group A and group B was 3.80% and 1.55%,respectively(P=0.011).The overall 5-year survival was 23.64%.The 5-year survival for esophageal and cardial carcinoma was 26.35% and 18.47% respectively.Conclusion The results of treatment approach for esophageal and gastric cardial carcinoma is still unsatisfactory.The indications for surgical treatment have been extended greatly.And the using of circular staplers in esophagogastroanastomosis reduced the incidence of leakage markedly.Early diagnosis and proper treatment is the key for getting a good outcome.

目的 总结1 924例食管癌和贲门癌的外科治疗经验.方法 分析1990～2006年1 924例食管癌和贲门癌外科手术患者的临床资料.将患者按时间段分为两组进行比较,1990年1月～1998年12月的624例患者为甲组,1999年1月～2006年12月的1 300例患者为乙组.结果 全组患者总的肿瘤切除率为92.67%,食管癌和贲门癌的切除率分别为93.75%和89.02%,其中甲、乙两组患者的切除率分别为90.54%和93.69%;总的围术期死亡率为1.46%,甲、乙两组分别为2.56%和0.85%;总的胸内吻合口瘘和胸胃瘘的发生率为2.23%,甲、乙两组分别为3.80%和1.55%;总的5年生存率为23.64%,其中食管癌为26.35%,贲门癌为18.47%.结论 食管、贲门癌总的治疗效果没有明显的改善,但手术适应证已明显拓宽,机械吻合的广泛应用显著降低了吻合口瘘的发生.早诊断、早治疗是该病治疗的关键.

因误食氢氟酸导致消化道出血、低血容量性休克、中毒性心肌炎等,救治早期予禁食水、全静脉营养、抗炎、抑酸、激素冲击、心肌营养、维持水、电解质平衡及输注红细胞等处理。伤后1个月复查心肌酶谱、电解质、心电图等回复正常,早期治疗结束,效果满意。

目的总结重症肌无力采取胸腺瘤及胸腺增生切除术治疗经验,探讨重症肌无力合并胸腺瘤及胸腺增生的外科治疗。方法对33例重症肌无力合并胸腺瘤及胸腺增生的患者行外科手术治疗。结果全组死亡1例,死亡原因为肌无力危象,4例症状无明显好转,其余28例随访1～5年,手术效果好。结论重症肌无力是自身免疫性疾病,胸腺被认为是导致发病的重要原因,胸腺切除是治疗重症肌无力的有效方法,选择好手术时机,结合适量的抗胆碱酯酶抑制剂及血浆置换等措施,治疗效果会更加理想。

七年制临床医学专业实习是临床教学中非常重要的一环,对于衔接前一阶段医学基础、临床通科的学习与下一阶段专科定向培养有着非常重要的作用,教学的好坏直接影响学生临床思维、科研思维、医德医风等的树立.本文将七年制学生进行胸心外科实习的带教体会做一总结,现报告如下.

Objective To evaluate the heart function in healthy people by quantitative tissue velocity imaging.(QTVI). Methods Twenty healthy individuals' parameters of hearts movement were measured by QTVI . Results The hearts moved orderly, and the atriums and the ventricles moved harmoniously. The velocity of contraction changed gradient from the apex to the bottom, and the bottom was the fastest. Conclusion 1. DTI/QTVI is fit for observing and measuring the movement of heart. 2. Evaluation of heart function should concern both right and left parts of hearts.

激光心肌血运重建术(transmyocardial laser revascularization, TMR)是指采用高强度激光在缺血的心肌区域内打数个至数十个贯穿整个心室壁的微孔,从而对缺血性心脏病进行治疗.对于弥漫性病变,小血管病变、多支血管病变,以及支架植入后再狭窄等造成的心绞痛,TMR是临床医生考虑采取的治疗手段之一.