目的 探讨术中神经监测(IONM)信号异常在判断甲状腺癌手术喉返神经(RLN)损伤的类型与转归中的作用.方法 回顾性分析2018年1月至2020年12月在首都医科大学附属北京友谊医院普外科确诊行甲状腺癌根治术并应用IONM的705例甲状腺癌病人临床资料.根据IONM结果、手术记录、术后症状,以及喉镜检查结果,分析IONM信号异常原因、RLN损伤及类型,研究IONM信号异常在判断RLN损伤的类型与转归中的作用.结果 705例病人中,63例(8.9％)IONM信号异常,包括RLN真性损伤42例(5.9％),短暂性损伤11例(1.6％),假损伤10例(1.4％).与RLN短暂性损伤和假损伤相比,肿瘤侵犯或粘连(21.4％,9/42)是RLN真性损伤的重要原因(P＜0.05),后者均出现术后喉镜结果异常,64.3％出现术后声音嘶哑或饮水呛咳症状.此外,RLN显性损伤9例(1.3％),RLN非显性损伤44例(6.2％).RLN显性损伤均为真性损伤;非显性损伤者中,33例为真性损伤(4.6％)、11例为短暂性损伤(1.6％).此外,IONM 一过性信号异常占RLN真性损伤者21.4％,短暂性损伤者90.9％,假损伤者40.0％,差异有统计学意义(P＜0.05);IONM信号异常部位,信号衰减幅度与RLN损伤类型差异无统计学意义(P＞0.05).结论 甲状腺癌术中IONM信号异常可能源于RLN真性损伤、短暂性损伤或假损伤.即使RLN外观正常,术者应重视一过性IONM信号异常,如不及时终止操作,对RLN加以保护,短暂性损伤可能成为真性损伤.在未使用IONM情况下,RLN短暂性损伤可能被忽视,真性损伤可能增加.

Objective:To explore the preventive value of "integrated prevention strategy" for nipple and areola ischemia after single-port endoscopic subcutaneous mastectomy.Methods:The clinical data of 72 patients with breast cancer who received single-port endoscopic subcutaneous mastectomy in Beijing Friendship Hospital, Capital Medical University from July 2019 to July 2021 were retrospectively analyzed, they were all female. The follow-up period was up to July 2022. According to the perioperative treatment methods, the patients were divided into observation group ( n=40) and control group ( n=32). The patients in the observation group who adopted the "integrated prevention strategy" scheme, and patients in the control group who adopted the conventional treatment scheme. The incidence of postoperative nipple and areola ischemic was compared between the two groups, and the postoperative cosmetic effect, quality of life and satisfaction of patients were evaluated. Measurement data were expressed as mean ± standard deviation ( ± s), and t-test was used for comparison between groups; the Chi-square test was used to compare the data groups. Results:The postoperative drainage volume in the observation group was significantly lower than that in the control group [(632.40±226.37) mL vs (774.91±239.85) mL], and the difference was statistically significant ( P=0.013). Two weeks after operation, there was 1 case of nipple and areola ischemia in the observation group, and 7 cases in the control group, the difference was statistically significant between the two groups ( P=0.019). Twelve months after operation, the score of breast satisfaction (83.93±11.64 vs 67.28±11.52), chest satisfaction (89.63±8.06 vs 83.03±9.49) and psychosocial well-being (89.43±12.42 vs 78.88±10.40) in the observation group were better than those in the control group, the differences were statistically significant ( P<0.05). Conclusion:"Integrated prevention strategy" can effectively prevent the occurrence of nipple and areola ischemic after single-port endoscopic subcutaneous mastectomy and improve patient satisfaction, which has certain promotion value.

Objective:To explore the significance of exposing the circummammary ligament under endoscopy and the effect of membrane anatomy in breast reconstruction.Methods:The case data of 49 breast cancer patients who underwent endoscopic nipple-sparing mastectomy combined with one-stage breast reconstruction with prosthesis implantation in Beijing Friendship Hospital, Capital Medical University from February 2014 to December 2021 were retrospectively analyzed, there were 44 cases of posterior pectoralis prosthesis implantation, 5 cases of anterior pectoralis prosthesis implantation. The anatomical structure of the circummammary ligament was observed under endoscopy during operation, and the annular mammary ligament was used as an anatomical marker to complete subcutaneous glandectomy and prosthesis implantation for breast reconstruction, the BREAST-Q scales were used to evaluate the postoperative effect.Results:The medial sternal ligament, sub clavicular ligament, lateral confluence ligament and triangular ligament condensation could be clearly exposed in all 49 cases. Breast reconstruction module of BREAST-Q were used to evaluate the surgery effect after breast cancer surgery, the scores of postoperative breast satisfaction, chest wall status, psychosocial status and sexual health status were 81.43±12.57, 88.39±10.61, 88.04±13.70, 74.82±15.93.Conclusion:The endoscopic technique is beneficial to expose the circummammary ligament during operation, and surgical resection and reconstruction can better restore the appearance of the breast and improve postoperative satisfaction according to the principle of membrane anatomy.

Objective:To investigate the surgical method and clinical application value of single-port inflatable endoscopic prepectoralis prosthesis implantation for breast reconstruction (external prosthesis wrapping Off-Label).Methods:From September 2021 to February 2022, 7 breast cancer patients who underwent single-port inflatable endoscopic prepectoralis prosthesis implantation breast reconstruction (Off-Label) in Beijing Friendship Hospital, Capital Medical University were retrospectively analyzed. Statistical analysis of surgical complications, postoperative movement deformities, postoperative chest wall pain, postoperative quality of life and satisfaction scores of patients were conducted.Results:All 7 patients successfully completed the operation. There were no complications such as postoperative bleeding, infection, ischemic necrosis of nipple-areola complex or skin flap, postoperative movement deformity, postoperative chest wall pain, capsular contracture, prosthesis exposure or removal. The BREAST-Q scale was used to evaluate the quality of life and satisfaction after breast reconstruction. Postoperative breast satisfaction (55-100 points), chest wall status (52-89 points), and social psychological status (62-100 points) can be compared High rating.Conclusion:The single-port inflatable endoscopic prepectoral prosthesis implantation breast reconstruction (Off-Label) can achieve better radical effect and cosmetic effect through a shorter operation time, and the postoperative quality of life and satisfaction of patients are higher.

目的 探讨两步法单孔腔镜乳房重建手术在早期乳腺癌治疗中的临床应用价值.方法 21例早期乳腺癌患者于乳房皮下腺体切除术即刻行两步法单孔腔镜乳房重建手术;记录手术情况、术后并发症及美容效果;术后6个月,应用BREAST Q乳腺癌患者结局量表评价患者对外观满意度和生活质量.结果 21例均顺利完成两步法单孔腔镜乳房重建手术,无中转开放手术病例;术后无假体取出、包膜挛缩发生,2例发生乳头、乳晕缺血坏死,发生率为9.5％.术后6个月,BREAST Q量表评分乳房满意度为(75.3±2.2)分,胸壁状态评分为(90.4±1.5)分,社会心理状态评分为(86.1±2.0)分,性健康程度评分为(71.4±2.6)分.结论 两步法单孔腔镜乳房重建手术在早期乳腺癌治疗中应用效果良好,患者可获较好的外观满意度和生活质量.

目的 观察吲哚菁绿显像在预防腹腔镜结直肠癌根治术后吻合口漏中的应用效果.方法 选取2018年1月～2019年12月我院收治的260例结直肠癌患者作为研究对象,按照随机数字表法将其分为观察组与对照组,每组各130例.对照组患者采用腹腔镜结直肠癌根治术治疗,观察组患者在腹腔镜结直肠癌根治术中应用吲哚菁绿显像观察吻合口肠段血运.比较两组患者手术相关指标、术后吻合口漏发生率及围手术期死亡率.结果 两组患者手术时间、术中出血量、术后排气时间、围手术期死亡率比较差异无统计学意义(P＞0.05),观察组患者术后B级和C级吻合口瘘发生率低于对照组(P＜0.05),观察组患者术后住院时间短于对照组(P＜0.05).结论 吲哚菁绿显像应用于腹腔镜结直肠癌根治术,可降低术后吻合口漏发生率.

目的 探讨应用皮下负压引流器预防下消化道开腹手术切口愈合不良的价值.方法 回顾性分析2018年10月至2020年1月首都医科大学附属北京友谊医院普外科收治的113例下消化道开放手术病人的临床资料.根据腹壁缝合时是否放置皮下引流器,分为皮下引流组(78例)和对照组(35例).比较两组病人切口愈合情况,分析切口愈合不良与临床特征的关系以及开放手术切口愈合不良的影响因素.结果 113例病人中,切口愈合不良发生率为14.2％(16/113),其中皮下引流组切口愈合不良发生率为5.1％(4/78),对照组为34.3％(12/35),两组差异具有统计学意义(P＜0.05).多因素分析提示,影响切口愈合不良发生的独立危险因素为未放置皮下引流器(OR=14.510,95％CI 3.411～61.735,P=0.001)、糖尿病(OR=7.064,95％CI 1.286～38.789,P=0.024)及吻合口漏/残端漏(OR=15.004,95％CI 1.876～119.996,P=0.011).结论 下消化道开放手术切口愈合不良发生率较高,应用皮下负压引流器能有效减少其发生,且操作方便、价格低廉.

吻合口漏是直肠癌手术常见的严重并发症,其发生率为2.4％～15.9％,吻合口漏发生后的病死率可高达16％[1-3].近年来,随着全直肠系膜切除(total mesorectal excision,TME)手术的推广、腹会阴联合切除手术数量的减少以及低位(超低位)吻合的增加,加之微创技术的普及、新辅助治疗策略的实施以及器械吻合技术的发展,使得直肠癌术后吻合口漏持续成为结直肠外科的热点问题[4].此外,对局部进展期直肠癌病人,新辅助放化疗已被推荐为标准治疗方法,其可降低直肠癌临床分期,提高低位直肠癌保肛率,增加环周切缘的阴性率[5].但研究表明,新辅助放化疗是腹腔镜及开放TME手术后吻合口漏的独立危险因素,其吻合口漏发生率可达8.5％～23.6％[6-9].