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Surgical Managemen t for Coarctation of Aorta Associated with Heart Anomalies in Infan ts

Corresponding author: Y I Ding -hua, E -mail: yidh@fmmu. edu. cnAbstract: 　Objective　To investigate the optimal surgical approaches for coarctation of aorta (CoA ) associated with heart anomalies (CoA -HA ) in infants through analyzing the immediate and long-term outcome post-operation. Methods　From May 1998 to November 2006, 29 patients with CoA -HA were admitted to this institute. Subclavian flap angioplasty was performed in three patients, excision of coarctation and end-to-side anastomoses in six pat ients,and end-to-end anastomoses in the remaining 20 pat ients. Their clinical data were retrospect ively reviewed and the long-term follow -up results obtained through telephone o r letters. 　Results　Three patients died of operations, of whom one died of low cardiac output syndrome, one died of sepsis and one died of multiple organs failure. In two months’to eight years’follow -up , no later death and severe neurological complications were found. Two patients suffered from recurrent coarctation, but had no sense of symptoms and free from re-operation. In all pat ients neither systemic hypertension, nor arterial aneurysm and aortic valve regurgitation were found. 　Conclusions　Mortality of surgical corrections is accepted fo r CoA -HA in infants. Preoperative heart dysfunction and prolonged mechanical ventilation are the high risks of operative death. Recurrent coarctation is the major later comp lication.

二尖瓣置换术后左心室后壁破裂修补二例

Clinical Characteristics and Surgical Treatment of Thoracic Hemangioma

Abstract： Objective To investigate the clinicopathological characteristics, improve the accuracy of clinical diagnosis， and reduce postoperative complications of thoracic hemangioma. Methods Clinical records of 9 patients with thoracic hemangioma who underwent surgical resection in West China Hospital of Sichuan University from January 2006 to August 2012 were retrospectively analyzed. There were 2 males and 7 females with their average age of 47.9±19.3 （18-71）years. Six patients underwent thoracotomy， 1 patient underwent complete video-assisted thoracoscopic surgery （VATS）， 1 patient underwent video-assisted mini-thoracotomy， and 1 patient underwent staged operations which were performed by neurological surgeons and thoracic surgeons separately. Imaging characteristics, intraoperative gross tumor features, and pathological characteristics of resected hemangioma specimens were analyzed. Clinical outcomes of different surgical strategies for the treatment of hemangioma were compared. Results Nine patients with thoracic hemangioma were included in this study. Imaging studies showed the tumor as a round-shaped mass in 66.7% （6/9） of these patients and a lobulated mass in the remaining 33.3% （3/9） patients. Magnetic resonance imaging （MRI） assessment was helpful for preoperative diagnosis of hemangioma， with T2 weighted imaging tumor enhancement as the main MRI feature. Thoracic operation time was 106.3±60.1 （60-192） min， and intraoperative blood loss was 91.1±43.7 （30-150） ml. All the patients were followed up for 3-6 years except 1 patient who was followed up for 1 month. None of the patients had hemangioma-related death， recurrence or metastasis during follow-up. Conclusions Thoracic hemangiomas are usually benign entities and often locate in the mediastinum. Surgical strategies should be determined by the size and location of the tumor as well as the surgeon’s technique level. VATS has the advantages of being minimal invasive, causing less intraoperative blood loss and shorter length of hospital stay for the treatment of hemangioma. Resection of a dumbbell-type hemangioma may need cooperation between neurological and thoracic surgeons.

急性创伤性膈肌破裂的早期诊断与治疗

目的　总结急性创伤性膈肌破裂的早期诊治经验。 方法　回顾性分析1996年8月至2012年8月内江市第一人民医院收治的37例急性创伤性膈肌破裂行外科手术治疗患者的临床资料，男30例，女7例；年龄15～43岁。左侧膈肌破裂26例，右侧膈肌破裂11例。直接暴力损伤16例，间接暴力损伤21例。交通伤17例，刀刺伤13例，高处坠落伤4例，枪弹伤2例，钢筋穿透伤1例。对其发病原因、合并伤、诊断及手术方式进行分析。 结果　术前确诊26例，术中探查确诊11例。 治愈33例，死亡4例，病死率10.81%。4例均合并有多器官损伤，死亡原因：失血性休克、多器官功能衰竭。随访25例，随访时间4个月至10年，患者生活质量良好。 结论　早期诊断和积极手术治疗是救治创伤性膈肌破裂的关键。动态观察伤员病情变化，及时行胸部X线片或CT检查是早期诊断膈肌破裂的主要措施，一旦确诊膈肌破裂均应行外科手术治疗。

老年危重心瓣膜病的外科治疗与围术期处理

目的　总结老年危重心瓣膜病患者的手术治疗和围术期处理经验。　方法　回顾性分析 2008年6月至2010年6月中国医科大学附属第一医院37例60岁以上老年危重心瓣膜病患者手术治疗的临床资料，其中男21例，女16例；年龄60～79 （67.3±6.9）岁。二尖瓣病变15例，主动脉瓣病变8例，主动脉瓣＋二尖瓣病变14例；合并左心房血栓9例，三尖瓣反流11例。　结果　围术期死亡3例，其中死于术后肺部感染1例，多器官功能衰竭1例，脑梗死1例。术后发生并发症18例，包括呼吸道并发症、室性心律失常、低心排血量综合征和急性肾功能衰竭等，经相应的治疗治愈。随访26例，随访时间6～23个月，心功能分级（NYHA）Ⅰ级13例，Ⅱ级12例，Ⅲ级1例。　结论　完善的术中操作、加强围术期处理，可有效降低老年危重心瓣膜病患者术后并发症的发生和病死率。

Ebstein畸形的外科治疗

目的　总结Ebstein畸形（Ebstein anomaly）的手术治疗经验，以提高临床疗效。　方法　2005年5月至2010年9月济宁医学院附属医院手术治疗Ebstein畸形21例，其中男7例，女14例；年龄3～46 （17±11）岁。心功能分级（NYHA）Ⅰ级7例，Ⅱ级10例，Ⅲ～Ⅳ级4例；超声心动图提示：三尖瓣重度反流12例，中度反流4例，轻度反流5例；全组患者中1例行三尖瓣置换术，20例行三尖瓣成形术，采用Danielson法2例，Carpentier法18例，其中5例行一个半心室矫治术；同期矫治合并畸形。　结果　术后无死亡，术后发生低心排血量及室性心律失常各1例，经积极治疗痊愈；复查超声心动图提示：三尖瓣反流减轻。术后随访1个月～5年，7例三尖瓣反流消失；13例存在轻度三尖瓣反流；1例三尖瓣反流加重，心功能不全，于术后3年行三尖瓣置换术，术后心功能恢复至Ⅰ～Ⅱ级。　结论　Ebstein畸形是一种少见的先天性心脏病，采用Carpentier法施行三尖瓣成形效果良好；对三尖瓣和右心室发育不良患者施行一个半心室矫治，有利于改善右心功能。

小儿主动脉缩窄或主动脉离断合并心内畸形的诊断与外科治疗

目的　探讨主动脉缩窄（CoA）或主动脉离断（IAA）合并心内畸形的诊断及手术方式选择。　方法　2003年1月至2010年3月济宁医学院附属医院手术治疗14例小儿CoA（9例）或IAA（5例）合并心内畸形 ［包括室间隔缺损（VSD）、房间隔缺损（ASD）、房室隔缺损（APSD）等畸形，但不包括单纯合并动脉导管未闭（PDA）］ 患者， 其中男10例，女4例；年龄0.7～12.0 （3.2±4.5）岁；体重5.5～25.5 （10.2±5.5） kg。分期手术3例，经胸骨正中切口径路一期手术矫治11例。　结果　手术死亡2例，其中1例为分期手术，二次手术行VSD修补术后死于急性左心衰竭；1例术前诊断为VSD＋PDA合并重度肺动脉高压，术前未发现IAA，术后死于急性肾功能衰竭。随访12例，随访时间6～84 （32±22）个月，患者恢复良好。复查心脏超声心动图提示：胸主动脉轻度狭窄2例，继续随访观察。　结论　多层螺旋CT和核磁共振成像是目前诊断CoA和IAA的首选检查方法。经胸骨正中切口径路一期手术治疗CoA或IAA合并心内畸形婴幼儿，可获较好的显露及疗效。

Surgical Treatment of Hilar Cholangiocarcinoma

目的 探讨肝门部胆管癌2种手术方法的疗效。方法 回顾性分析我院1998～2006年期间收治的37例肝门部胆管癌患者的临床资料。结果 37例患者中13例行根治性手术切除, 其1年与3年的生存率分别为100%（13/13）和76.92%（10/13），中位生存期为22.43个月； 另24例行姑息性手术（均为肝内胆管内引流术），其1年与3年生存率分别为54.55%（12/22）和9.09%（2/22），中位生存期为15.42个月。结论 根治性手术是治疗肝门部胆管癌的主要手段； 姑息性手术，如合理的肝内胆管内引流能改善患者的生存质量。

Surgical Treatment of Tetralogy of Fallot with Anomalous Coronary Artery

Abstract： Objective To summarize our surgical experience of tetralogy of Fallot（TOF） with anomalous coronary artery（ACA）， explore diagnostic method of ACA， and evaluate surgical strategy choices and clinical outcomes of right ventricular outflow tract（RVOT） reconstruction. Methods From January 2004 to January 2010， 29 patients with TOF and ACA underwent total correction in Wuhan Asia Heart Hospital. There were 18 male patients and 11 female patients with their median age of 7 years （5 months to 33 years）and median body weight of 18 （5 to 51） kg at operation. Their preoperative arterial oxygen saturation was 65%-91%. One patient underwent RVOT enlargement and repair of ventricular septal defect via right atrial approach. Three patients underwent RVOT enlargement， repair of ventricular septal defect and main pulmonary artery enlargement using autologous pericardium patch via right atrial approach. Three patients received pulmonary artery translocation （REV） technique. Five patients received double outlet technique. Eleven patients underwent RVOT enlargement via incisions above， below or beside coronary arteries （single patch or two patch technique）. Six patients underwent RVOT reconstruction using trans-annular patch after coronary artery bypass grafting. Results　 The median cardiopulmonary bypass time was 78 （65-102） min， median aortic crossclamp time was 50（40-82） min， and median operation time was 150 （126-178） min. There was no early death or severe coronary artery injury. Two　 patients underwent reexploration because of postoperative bleeding. Two patients had low cardiac output and were both cured with inotropic support. The median follow-up period was 51 （21-83）months and there was no late death during　 follow-up. All the patients were in New York Heart Association （NYHA） classⅠduring follow-up， their left ventricular ejection fraction was normal， there was no sign of myocardial ischemia in electrocardiogram， and their arterial oxygen saturation was 96%-99%.Mean early RVOT gradient （△P） was 19 （8-38） mm Hg， and the RVOT gradient （△P） did not increase during follow-up. Conclusion Preoperative diagnosis of ACA in TOF patients can be made by 64-slice multislice compute tomography （64-MSCT）. Proper surgical strategy for RVOT reconstruction should be chosen according to the distribution of coronary arteries to achieve satisfactory surgical outcomes.

The Hot Point and Difficult Key Point in Surgical Treatment of Thyroid Disease

甲状腺外科疾病常见，有许多进展和进步，这是热点； 但许多治疗意见不一，分歧极大，长久难以统一，故又有许多难点