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再次心瓣膜置换术25例

目的探讨再次心瓣膜置换术的手术时机、方法及并发症的防治。方法回顾性分析再次心瓣膜置换术25例患者的临床资料，男10例，女15例，年龄25～53岁；其中二尖瓣生物瓣置换术后瓣膜衰坏15例，机械瓣置换术后血栓形成致瓣膜功能障碍4例，人工瓣膜感染性心内膜炎4例，瓣周漏2例。术前心功能Ⅲ级10例，Ⅳ级15例。其中3例机械瓣置换术后血栓形成致急性瓣膜功能障碍和2例生物瓣衰坏合并重度心力衰竭行急诊手术。结果早期死亡3例，死亡率12％，均死于术后低心排血量综合征。术后并发脑气栓及大量渗血各1例。存活22例，随访1～16年，晚期死于右心衰竭1例，并发主动脉瓣和二尖瓣瓣周漏1例。其余患者心功能恢复良好。结论合理选择手术时机，术中加强心肌保护，彻底排除心腔残气及防治出血是提高再次心瓣膜置换术疗效的关键。

Prevention of Recurrent Laryngeal Nerve Injury During The Reoperation for Recurrent Thyroid Carcinoma

右侧乳缘下切口在再次瓣膜手术中的应用

目的 探索经右侧乳缘下切口行再次瓣膜手术的临床应用效果。 方法 2012 年 12 月至 2017 年 3 月南京大学医学院附属鼓楼医院共 20 例患者经右侧乳缘下切口行再次瓣膜手术（右侧乳缘下切口组），其中男 11 例、女 9 例，平均年龄（51±8）岁。选取同时期 20 例经胸骨正中切口再次行二、三尖瓣手术患者（正中开胸组），其中男 13 例、女 7例，平均年龄（46±5）岁。右侧乳缘下切口组采用股动静脉插管，上腔静脉常规直角插管，第 4 肋间进胸，不断肋骨，常规升主动脉阻断或心室颤动下完成二、三尖瓣成形或置换、心房颤动消融和左房折叠等术式。 结果 正中开胸组有 3 例开胸时出现心脏破裂，而右侧乳缘下切口组只有 1 例游离下腔静脉时右房破裂。右侧乳缘下切口组开胸体外循环时间和术后住院时间均显著短于正中切口组［（55.0±22.0）min vs.（94.0±38.0）min，P<0.001；（12.3±3.7）dvs.（15.7±6.7）d，P=0.032］。右侧乳缘下切口组开胸时出血量和术后 24 h 引流量均显著少于正中开胸组［（92.0±37.0）ml vs.（342.0±157.0）ml，（202.0±117.0）ml vs.（567.0±254.0）ml，P均<0.001］。 结论 右侧乳缘下切口行再次心脏手术可完成除升主动脉和主动脉瓣操作之外的任何瓣膜和左房操作，具有手术创伤小、出血少、患者术后恢复快、美容效果好等优点。此外，对于外科医生而言，该技术手术难度较低，如果具备正中切口的解剖基础，完全可胜任此手术，但术中需注意肺和心肌保护。

Application of Laparoscope in Biliary Reoperation

目的探讨腹腔镜胆道再次手术的适应证、手术方法及临床效果。方法回顾性分析我院2003年2月至2010年11月期间46例腹腔镜胆道再次手术患者的临床资料，对术中及术后结果进行总结。结果本组45例在腹腔镜下完成手术，1例中转开腹。手术时间为45～270 min(平均120 min)，残株胆囊切除时间为(40±10) min，胆总管切开取石+T管引流时间为(150±50) min，胆总管切开取石+等离子碎石+T管引流时间为(180±40) min，术后出血及漏胆腹腔镜探查术时间为（40±15）min。结石一次性取尽23例，术后残余结石2例，住院4～21 d，平均8.6 d。胆管残余结石患者在术后1个月后经T管瘘道用胆道镜取石。术中十二指肠球部损伤3例，及时发现修补; 术后出现右侧胸腔积液4例、肺部感染2例和漏胆1例，均经非手术治疗痊愈。术后电话随访6～24个月（平均15个月），未见异常。结论腹腔镜胆道再次手术可行，并具有创伤小、恢复快等优点，但术前应严格掌握手术适应证，对手术医生的技术要求也较高。

冠状动脉旁路移植术后围术期心肌缺血

目的 探讨冠状动脉旁路移植术(CABG)术后出现围术期心肌缺血(PMI)的相关危险因素及其处理措施. 方法 回顾性总结2 680例CABG患者的临床资料,并根据术后是否发生PMI将其分为PMI组(30例)和非PMI组(2 650例),分析CABG后出现PMI的危险因素. 结果 PMI组中11例进行急诊再血管化,其余行主动脉内球囊反搏(IABP)或药物治疗;院内死亡7例,死亡率为23.3%.心绞痛症状缓解22例,心电图完全或部分复原9例,残留心肌梗死改变14例.非PMI组院内死亡58例,死亡率为2.2%.两组死亡率之间比较差别具有显著性意义(χ2＝56.04,P＝0.001).多因素分析表明,术前无心肌梗死史、冠状动脉弥漫性病变和术中内膜剥脱为相关危险因素.结论 PMI是CABG术后一种比较危险的并发症,严重者可危及生命,及早诊断和适当的治疗尤为重要,对于因旁路血管堵塞造成的PMI,急诊再次血管移植是挽救患者生命的必要措施.

甲状腺再次手术喉返神经损伤的原因及预防策略

目的探讨甲状腺再次手术中喉返神经损伤的原因及预防策略。 方法回顾性分析2010年1月至2016年1月期间肇庆市第一人民医院收治的59例甲状腺再次手术患者的临床资料。 结果59例患者再次手术术式：一侧叶全切除+对侧叶部分或次全切除34例，甲状腺全切除+双侧中央区淋巴结清扫12例，甲状腺全切除+双侧中央区及颈侧区淋巴结清扫7例，一侧叶残余甲状腺全切除+双侧中央区淋巴结清扫1例，一侧叶残余甲状腺全切除+双侧中央区及颈侧区淋巴结清扫4例，中央区及侧颈区淋巴结清扫1例。再次术后病理诊断：结节性甲状腺肿22例，甲状腺功能亢进5例，结节性甲状腺肿并甲状腺乳头状腺癌（包括微小乳头状腺癌）25例，甲状腺乳头状腺癌6例，甲状腺乳头状腺癌颈部淋巴结转移1例。术后7例发生RLN损伤，其中6例为暂时性损伤，1例为永久性损伤。 结论甲状腺再次手术因解剖层次紊乱、组织瘢痕粘连，致RLN损伤发生的风险增大。术者熟悉RLN解剖、识别变异或病理状况下的RLN、选择合理的途径、精细化操作显露RLN，以及术中应用神经监测仪，均有利于降低RLN损伤的发生率。

Analysis of Reasons of Cardiac Valve Reoperation

ObjectiveTo analyze the reason of 45 patients with cardiac valve reoperation and to evaluate the safety of redo heart valve replacement. MethodsWe retrospectively analyzed the clinical data of 45 patients in our hospital between January 2010 and January 2015. There were 45 patients with 14 males and 31 females at an average age of 51.21± 8.36 years. ResultsThree of 45 patients (6.67%) were died after surgery. Mean follow-up was 36 (4-68) months. A total of 42 patients were alive and without reoperation again. The main reasons of heart valve reoperation included lesions of untreated valve, paravalvular leakage, thrombosis associated with valvular dysfunction, bioprosthesis degeneration, endocarditis, valvular lesions after angioplasty. ConclusionTricuspid regurgitation should be treated aggressively when the mitral valve involved in the first operation. Patients received the secondary heart valve replacement is safe and effective. Strict follow-up system should be established and surgical intervention should be taken timely and appropriately.

Outcomes of complicated congenital heart diseases following multiple re-sternotomy operations: A single-center experience

ObjectiveTo analyze the outcomes of complicated congenital heart diseases (CCHD) patients accepting multiple (>2) re-sternotomy operations.MethodsWe retrospectively analyzed the clinical data of 146 patients undergoing multiple cardiac re-sternotomy operations between 2015 and 2019 in our center. There were 95 males and 51 females with an age of 4.3 (3.1-6.8) years and a weight of 15.3 (13.4-19.0) kg at last operation.ResultsThe top three cardiac malformations were pulmonary atresia (n=51, 34.9%), double outflow of right ventricle (n=36, 24.7%) and functional single ventricle (n=36, 24.7%). A total of 457 sternotomy procedures were performed, with 129 (88.3%) patients undergoing three times of operations and 17 (11.7%) patients undergoing more than three times. Fifty-two (35.6%) patients received bi-ventricular repair, 63 (43.1%) patients received Fontan-type procedures, and 31 (21.2%) patients underwent palliative procedures. Ten (6.8%) patients experienced major accidents during sternotomy, including 7 (4.8%) patients of urgent femoral artery and venous bypass. Eleven (7.5%) patients died with 10 (6.8%) deaths before discharge. The follow-up time was 20.0 (5.8-40.1) months, and 1 patient died during the follow-up. The number of operations was an independent risk factor for the death after operation.ConclusionSeries operations of Fontan in functional single ventricle, repeated stenosis of pulmonary artery or conduit of right ventricular outflow tract post bi-ventricular repair are the major causes for the reoperation. Multiple operations are a huge challenge for CCHD treatment, which should be avoided.

Real-Time Monitoring of Recurrent Laryngeal Nerve During Thyroid Reoperation

Objective To assess the value and usage of real-time monitoring of the recurrent laryngeal nerve (RLN) during thyroid reoperation by RLN monitor. Methods One hundred and one patients were under general anesthesia and thyroidectomy. NIM-Response electromyographic (EMG) monitor system was used for assistant of dissection, exposure and protection of the RLN during the surgical procedures.Results There were 192 RLN were exposed during the surgeries in all 101 patients. The unilateral RLN injured in 10 patients was not specially explored the same side nerve. Among them 190 nerves were confirmed intact, the rest 2 nerves were resected because of tumor involving. Conclusions NIM-Response electromyographic monitor system is sensitive and accurate for preserving the integrity of RLN during the thyroid reoperations. It is valuable for protecting RLN against iatrogenic injury. This system deserves general utilization for thyroid surgery, especially reoperation.

Evaluation of mid-term outcomes of pulmonary valve replacement surgery after repair of tetralogy of Fallot

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.