摘要:目的:分析微创外科室间隔缺损(ventricular septal defect,VSD)封堵失败原因,以期提高术前超声心动图筛查水平。方法:回顾性分析25例微创外科VSD封堵失败改行修补术病例,对比超声表现及手术所见,归纳总结产生并发症的原因。结果:残余分流与VSD假性膜部瘤右室面具有多个出口和低估VSD大小密切相关;VSD合并主动脉瓣右冠瓣脱垂是主动脉瓣反流的主要原因;封堵器移位与低估VSD大小且使用偏心封堵器有关;原有三尖瓣反流加重和发生Ⅲ度房室传导阻滞VSD均位于隔瓣下方;封堵失败组较封堵成功组缺损偏大,差异具有统计学意义(Plt;0.05)。结论:超声心动图对VSD及其毗邻结构的细致评估,有助于严格适应证,提高手术成功率。 Abstract: Objective:To analyze the failure of perventricular closure of ventricular septal defect (VSD), in order to improve the preoperative echocardiography examination. Methods: Twentyfive cases underwent surgical repair after failure of perventricular closure of VSD were included in this study. With combination of echocardiographic and surgical findings, retrospective analysis of the failure of perventricular closure of VSD were attempted to summarize the cause of complications.Results: Residual ventricular communication was due to underestimation of size of VSD and pseudomembranous aneurysm resulting in multiple outlets of VSD on the right ventricle side; preoperative prolapse of rightcoronary cusp was the main reason for mild or greater than mild aortic valve regurgitation after eccentric device closure of VSD; Underestimation of the size of VSD and using eccentric occluder device were responsible for the displacement of VSD occluder device. Postoperative aggravated tricuspid regurgitation and Ⅲ°atrialventricular block (AVB) were attributed to VSDs located under the septal leaflet of tricuspid valve. The size of VSD in group of failed perventricular device closure of VSD was larger than that in group of successful device closure of VSD,and the difference was significant(Plt;0.05). Conclusion: Echocardiography vividly reveals VSD and adjacent structures, which should be used in accessing the anomaly and defect and formulating surgical plans to reduce surgical morbidity and mortality.
Abstract: Objective To introduce a new technique: transthoracic closure of perimembranous ventricular septal defect (VSD) without cardiopulmonary bypass (CPB) under transesophageal echocardiography (TEE）guidance, and summarize the clinical experiences and midterm followup results. Methods A total of 136 patients with perimembranous VSD, 3 months to 15 years averaging 1.8 years, underwent transthoracic device closure. The weight of these patients ranged from 4.0 to 26.0 kg with an average weight of 12.7 kg. The diameter of their VSD ranged from 3 to 12 mm averaging 5.1 mm. A small transthoracic incision (34 cm incision by inferior sternotomy or 23 cm transverse incision in the third intercostal space) was made and the best location for right ventricular puncture was chosen and the delivery pathway was established under TEE guidance. Proper devices were delivered and then deployed to close the defect. Patients were followed up closely with a standard protocol, arranged for echocardiography, electrocardiogram and chest Xray film. Results In all the cases, 131 cases of VSD (96.3%) were successfully closed. The procedure time was less than 90 minutes and the implanting time was 5.42 minutes (16.3±5.7 min). Symmetrical devices were implanted into 89(67.9%) of the 131 patients and the other 42 patients (32.1%) were closed with asymmetrical ones. The result of TEE soon after operation showed that 3 patients had tiny residual shunt, 4 had new trivial and mild tricuspid regurgitation (TR). However, no TR worsening, aortic regurgitation (AR), complete atrioventricular heart block, or left or right outflow tract obstruction was detected in all patients. One patient 〖CM(159mm〗with transient atrioventricular block restored to sinus rhythm after 3 days of medical treatment. Five cases (3.7%) were converted to conventional open heart repair during the operation. Followup was done to all the patients for a period ranged from 6 months to 30 months (18.3±6.6 months). Tiny residual shunt in the 3 cases mentioned above vanished during the followup period. No new TR, AR, hemolysis, thrombosis, dislocation of the devices, or outflow stenosis was detected postoperatively. The tiny incision caused less psychologic depression. Conclusion Minimally invasive transthoracic device closure of VSD without CPB is a simple, effective and safe intervention under guidance of TEE for most of perimembranous VSD patients. The short and midterm clinical outcomes are promising. Longterm followup is indispensable.
Objective To explore the effectiveness of Nice knot technique for wound closure in Gustilo type ⅢA and ⅢB open tibial fractures. Methods A retrospective study was performed on 22 patients with Gustilo type ⅢA and ⅢB open tibial fractures, who underwent wound closure using the Nice knot technique and were admitted between June 2021 and June 2022. There were 15 males and 7 females. The age ranged from 18 to 67 years, with an average of 41.9 years. The causes of injury included traffic accident in 11 cases, falling from height in 7 cases, and heavy object injuries in 4 cases. Fractures were located on the left side in 9 cases and on the right side in 13 cases. And 9 cases were type ⅢA fractures and 13 were type ⅢB fractures according to Gustilo classification. All patients had extensive soft tissue injuries, and no vascular or neurological damage was observed. The time from injury to debridement was 3-8 hours (mean, 6.5 hours). The sizes of wounds before operation and at 2 weeks after operation were measured and wound healing rate at 2 weeks after operation were calculated. The wound healing time and wound healing grading were recorded. The Vancouver Scar Scale (VSS) score was used to assess the wound scar after wound healed and the excellent and good rate was calculated. Results The wound area was 21.0-180.0 cm2 (mean, 57.82 cm2) before operation, and it was 1.2-27.0 cm2 (mean, 6.57 cm2) at 2 weeks after operation. The wound healing rate at 2 weeks after operation was 76%-98% (mean, 88.6%). After operation, 2 cases needed to adjust Nice knot due to skin cutting and 1 case occurred soft tissue infection on the wound. The other patient’s wounds healed. The average wound healing time was 27.8 days (range, 18-44 days). And the wound healing were grade A in 13 cases and grade B in 9 cases. VSS score was 2-9, with an average of 4.1; 10 cases were rated as excellent, 10 as good, and 2 as poor, with an excellent and good rate of 90.9%. All patients were followed up 9-24 months (mean, 14.6 months). During follow-up, no deep infection or osteomyelitis occurred. Two cases experienced fracture non-union, and were treated with compression fixation and bone grafting. The fractures of the other patients all healed, with a healing time of 85-190 days (mean, 148.2 days). ConclusionNice knot technique can be used in wound closure of Gustilo type ⅢA and ⅢB open tibial fractures effectively, which is easy to operate.
How to effectively repair esophageal fistulas, caused by esophageal perforation, rupture and anastomotic leakage after esophagectomy has always been a key problem for the digestive surgeon. Although there are many clinical treatment methods, the therapeutic effect is still completely unsatisfactory, especially when severe mediastinal purulent cavity infection is associated with the esophageal fistula. In recent years, foreign centers have promoted a new minimally invasive endoscopic treatment technology to repair the esophageal fistula, endoscopic vacuum-assisted closure therapy, with significantly curative effect. In this article, we will review the specific operation, advantages and disadvantages, as well as the clinical efficacy of endoscopic vacuum-assisted closure therapy in treating the esophageal fistulas, to provide a new therapeutic technique for esophageal fistulas and expand the new field of minimally invasive endoscopic therapy.
Objective To analyze the safety and effectiveness of ultrasound-guided thoracoscopic atrial septal defect (ASD) closure. Methods We prospectively collected the clinical data of 12 patients with ASD treated by ultrasound-guided thoracoscopic ASD closure in Fuwai Hospital from January to September 2017. The characteristics of the patients' ASD and operation, operation safety and effectiveness, postoperative complications and follow-up results were analyzed. Results Among the 12 patients, 10 were successfully treated with ultrasound-guided thoracoscopic ASD closure. Two patients switched to ASD repair under thoracoscopy-assisted cardiopulmonary bypass. The size of the ASD was 17-40 (27.22±8.97) mm and the size of the occluder was 36 (30-42) mm. The average postoperative length of hospital stay was 6 days. There were no complications such as arrhythmia, bleeding and pericardial effusion after operation. The average follow-up was 6 (3-10) months after the operation. During the follow-up, no Ⅲ-degree conduction block, occluder dislocation, residual shunt or cardiac pericardial effusion was found. Conclusion Ultrasound-guided thoracoscopic ASD closure is a minimally invasive, safe and effective treatment. This technique provides a new minimally invasive surgical option for patients with large defect diameter and poor edge condition.
ObjectiveTo analyze the clinical effect of vacuum-assisted closure in treating venous ulcer. MethodsThirty seven patients including 21 males and 16 females with lower extremity venous ulcer treated in our hospital from January 2013 to January 2014 were included in our study. Based on random number table, the patients were divided into treatment group [n=19, (66.47±6.22) years old] and control group [n=18, (66.39±5.37) years old]. The treatment group received vacuum-assisted closure, while the control group underwent routine moist therapy. Wound healing and visual analogue pain scores were observed. Chi-square test and t-test were used for statistical analysis. ResultsWound healing rate was 84.2% in the treatment group and 55.6% in the control group, and the difference between the two groups was statistically significant (χ2=26.66, P<0.05). Wound healing time was (13.84±3.13) days in the treatment group and (27.35±1.73) days in the control group, and the difference was statistically significant (t=-7.498, P<0.01). Visual analogue pain scores in the treatment group was 3.53±0.51, and in the control group, it was 4.41±0.51, and the difference was statistically significant (t=-5.197, P<0.01). ConclusionVacuum-assisted closure can significantly improve wound healing and alleviate sufferings in the treatment of venous ulcer.
Objective To discuss the treatment method and effectiveness of Seymour fracture in children and adolescents. Methods Between January 2013 and November 2015, 26 children and adolescents with Seymour fractures were treated. There were 18 males and 8 females, aged from 1 year and 1 month to 17 years (median, 8.2 years). The injury causes included crush in 14 cases, bruise in 10 cases, and puncture in 2 cases. The thumb was involved in 2 cases, index finger in 1 case, middle finger in 12 cases, ring finger in 6 cases, and little finger in 5 cases. The time from injury to operation was 1-15 hours (mean, 3.2 hours). The patients underwent debridement, nail removal, nail matrix repair, closed reduction and osteosynthesis with Kirschner wires, and splinting in emergency. Kirschner wires and splints were removed at 4 weeks after surgery, and functional exercises were done. Results All wounds healed by first intention without infection. The follow-up duration was 2-24 months (mean, 12.3 months). The fracture healing was obtained at 1-2 months (mean, 1.4 months) on X-ray film, and no complications of nonunion, malunion, re-displacement, premature epiphyseal closure, or no growth of the nails occurred. Nail deformity developed in 1 case and no re-operation was given. At last follow-up, 1 patient had 10° extension limitation of the distal interphalangeal joint, but the flexion was normal. The motion range of distal interphalangeal joint was 0-75°, showing no significant difference when compared with that of contralateral side (0-78°). Conclusion The effectiveness for treating Seymour fracture is satisfactory by debridement, nail removal, nail matrix repair, closed reduction and osteosynthesis with Kirschner wires, and splinting in emergency.
ObjectiveTo investigate the application value and research progress of PST technique in preventing anastomotic leakage after rectal cancer surgery. MethodThe related literatures at home and abroad in recent years about the application of left colon artery preservation, suture of anastomotic stoma and closure of pelvic floor peritoneum, and indwelling anal canal （PST technology for short） in rectal cancer surgery were searched and summarized. ResultsPST technology could prevent anastomotic leakage after rectal cancer surgery from many angles, reduce infection and inflammation, promote postoperative rehabilitation and improve the quality of life of patients, and it is simple and easy to do. The great advantages of PST technology are gradually verified and recognized in clinic. ConclusionPST is a safe and feasible method to prevent anastomotic leakage and relieve the symptoms of anastomotic leakage.
Objective To investigate the application of delayed sternal closure (DSC) following arterial switch operation for neonates with transposition of great arteries (D-TGA). Methods We retrospectively analyzed clinical data of 172 neonates underwent arterial switch operation with transposition of great arteries (D-TGA) between June 1st 2009 and December 31st 2015. These neonates were divided into 2 groups including a DSC group (118 patients with 99 males and 19 females) and a non-DSC group (54 patients with 47 males and 7 females). The outcome of the two groups were compared. Results Preoperative mechanical ventilation(P<0.001), emergency surgery (P=0.023) and extracorporeal circulation time (P<0.001) were the risk factors for delayed sternal closure. The incidence of complications of median sternotomy incision in the DSC group was not higher than that in the non-DSC group. The mortality rate in the DSC group was markedly higher than that in the non-DSC group (P<0.001). However, DSC was not a risk factor for the death of the neonates. Conclusion Delayed sternal closure does not increase the incidence of complications of the median sternotomy incision, nor is it a risk factor for the death of the neonates. Reasonable application of delayed sternal closure is helpful for early postoperative recovery of the neonates.
ObjectiveTo explore the method and feasibility of establishing patent ductus arteriosus (PDA) model in Bama miniature pig by using autologous jugular vein, and to provide a large animal model for the development of PDA occluder and the study of pulmonary hypertension associated with congenital heart disease. MethodsFive male Bama miniature pigs weighing about 45 kg were selected to gain the PDA model of the autogenous jugular vein, which was fixed by glutaraldehyde and anastomosed between the ascending aorta and the main pulmonary artery. The patency of PDA was confirmed by echocardiography and angiocardiography immediately and one week after the operation. Two animals were selected to undergo transcatheter closure of PDA via femoral vein 1 week after the operation, and the rest were euthanized to obtain PDA and lung tissue for pathological examination. ResultsThe PDA model was successfully established in all five animals with a success rate of 100.0%. Immediately and 1 week after the operation, echocardiography and angiography showed that PDA blood flow was unobstructed, and hematoxylin-eosin staining showed that PDA endothelialization was good. One week after the operation, two animals were successfully treated with transcatheter femoral vein occlusion. The pathological examination of lung tissue showed thickening of the intima and muscular layer of pulmonary arterioles, thickening of pulmonary interstitium and infiltration of neutrophils. ConclusionIt is safe and feasible to establish a large animal model of PDA by using autogenous jugular vein anastomosis between the ascending aorta and the main pulmonary artery. The model can be used for the development of PDA interventional occlusive devices and the pathophysiological study of congenital heart disease-related pulmonary hypertension.