Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologica...Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis- Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.展开更多
BACKGROUND:The present study aimed to explore the relationship between surgical methods,hemorrhage position,hemorrhage volume,surgical timing and treatment outcome of hypertensive intracerebral hemorrhage(HICH).METHOD...BACKGROUND:The present study aimed to explore the relationship between surgical methods,hemorrhage position,hemorrhage volume,surgical timing and treatment outcome of hypertensive intracerebral hemorrhage(HICH).METHODS:A total of 1 310 patients,who had been admitted to six hospitals from January 2004 to January 2008,were divided into six groups according to different surgical methods:craniotomy through bone fl ap(group A),craniotomy through a small bone window(group B),stereotactic drilling drainage(group C1 and group C2),neuron-endoscopy operation(group D) and external ventricular drainage(group E) in consideration of hemorrhage position,hemorrhage volume and clinical practice. A retrospective analysis was made of surgical timing and curative effect of the surgical methods.RESULTS:The effectiveness rate of the methods was 74.12% for 1 310 patients after onemonth follow-up. In this series,the disability rate was 44.82% 3–6 months after the operation. Among the 1 310 patients,241(18.40%) patients died after the operation. If hematoma volume was >80 mL and the operation was performed within 3 hours,the mortality rate of group A was signifi cantly lower than that of groups B,C,D,and E(P<0.05). If hematoma volume was 50–80 mL and the operation was performed within 6–12 hours,the mortality rate of groups B and D was lower than that of groups A,C and E(P<0.05). If hematoma volume was 20–50 mL and the operation was performed within 6–24 hours,the mortality rate of group C was lower than that of groups A,B and D(P<0.05).CONCLUSIONS:Craniotomy through a bone f lap is suitable for patients with a large hematoma and hernia of the brain. Stereotactic drilling drainage is suggested for patients with hematoma volume less than 80 mL. The curative effect of HICH individualized treatment would be improved via the suitable selection of operation time and surgical method according to the position and volume of hemorrhage.展开更多
目的:通过对Gamma3、股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)及动力髋螺钉(dynamic hip nail,DHS)治疗的老年股骨粗隆间骨折患者围手术期失血量的分析,了解老年股骨粗隆间骨折患者围手术期失血的特点。方法:回...目的:通过对Gamma3、股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)及动力髋螺钉(dynamic hip nail,DHS)治疗的老年股骨粗隆间骨折患者围手术期失血量的分析,了解老年股骨粗隆间骨折患者围手术期失血的特点。方法:回顾性分析了我科2007年1月1日至2012年12月31日诊治的408例采用Gamma3、PFNA及DHS治疗的老年股骨粗隆间骨折患者的临床资料。使用Gross方程,根据身高、体重、术前和术后的血常规变化,计算围手术期的失血量,并比较Gamma3组、PFNA组及DHS组的失血量区别。结果:Gamma3治疗组患者共96例,平均手术时间为(74.7±25.0)min,平均显性失血量为(103.5±83.0)mL,平均总失血量为(831.9±474.8)mL,平均隐性失血量为(728.3±455.5)mL。PFNA治疗组患者共84例,平均手术时间为(69.0±27.1)min,平均显性失血量为(91.5±111.4)mL,平均总失血量为(825.7±478.0)mL,平均隐性失血量为(734.2±455.7)mL。DHS治疗组患者共40例,平均手术时间为(97.5±25.0)min,平均显性失血量为(283.6±142.1)mL,平均总失血量为(695.7±502.4)mL,平均隐性失血量为(412.1±457.6)mL。结论:通过3种内固定方式的比较发现,DHS治疗粗隆间骨折切口大、手术时间长、术中出血多,Gamma3和PFNA治疗老年股骨粗隆间骨折虽然具有切口小、手术时间短、术中出血少等优点,但围手术期的隐性失血较多,临床应予以足够的重视,以减少术后并发症的发生。展开更多
目的对采取股骨近端防旋髓内钉（ proximal femoral nail anti - rotation, PFNA）内固定方法治疗的老年股骨转子间骨折的术前和术中显性、隐性出血量进行临床分析，为临床围术期处理提供必要的数据支撑。方法回顾性分析2005年12月-2010...目的对采取股骨近端防旋髓内钉（ proximal femoral nail anti - rotation, PFNA）内固定方法治疗的老年股骨转子间骨折的术前和术中显性、隐性出血量进行临床分析，为临床围术期处理提供必要的数据支撑。方法回顾性分析2005年12月-2010年9月采用PFNA内固定治疗的216例股骨转子间骨折患者的临床资料，对患者术前、术后血常规以及术中、术后出血、输血情况等进行分析，对患者围术期的显性和隐性出血情况进行评估。结果216例患者术中平均失血48．9ml，无一例进行术中输血。42例术后第2～4天血色素下降明显（〈9g／L）患者进行输血，平均输血300ml；216例患者术后的平均显性失血量为62．3ml，平均隐性失血量为385ml，男女之间差异无统计学意义。结论股骨转子间骨折老年患者比较多见，与术中微创操作所见的出血量极少（〈70m1）不同，PFNA内固定治疗转子间骨折术后的隐性失血量较多，提示应严格注意术后患者的生命体征监测以减少并发症的产生。展开更多
目的:对采取股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)和动力髋螺钉(dynamic hipscrew,DHS)内固定方法治疗的老年股骨粗隆间骨折的术中及术后显性、隐性失血量进行分析,为临床围手术期处理提供必要的数据支撑。方...目的:对采取股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)和动力髋螺钉(dynamic hipscrew,DHS)内固定方法治疗的老年股骨粗隆间骨折的术中及术后显性、隐性失血量进行分析,为临床围手术期处理提供必要的数据支撑。方法:回顾性分析2001年12月30日至2010年9月30日间采用PFNA内固定手术治疗的216例及采用DHS内固定手术治疗的168例股骨粗隆间骨折患者的临床资料,对患者术前、术后血常规以及术中及术后失血、输血情况等指标进行分析,同时对围手术期的显性、隐性失血情况做出评估。结果:采用PFNA治疗的患者平均术中失血(48.9±2.8)mL;术后平均显性失血量为(62.3±3.8)mL,平均隐性失血量为(385.0±6.2)mL。采用DHS治疗的患者平均术中失血(124.9±7.8)mL;术后平均显性失血量为(73.9±4.7)mL,平均隐性失血量为(243.4±6.3)mL。两组相比,DHS术中出血量及术后的显性出血量均多于PFNA(P<0.01),但PFNA术后隐性出血量及PFNA总体出血量均多于DHS(P<0.01)。结论:PFNA和DHS内固定治疗股骨粗隆间骨折均存在较多的术后隐性失血量,提醒临床医生注意术后患者的生命体征监测以减少并发症的发生。展开更多
Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls.Currently there may be sufficient evidence to support the routine use of hip ...Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls.Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures.However for the physiologically young patients,preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands.The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures.Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population.Furthermore,other management variables such as surgical timing,the role of capsulotomy and the choice of implant for fixation remaincontroversial.This review will focus both on the demographics and injury profile of the young patient with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.展开更多
文摘Severe acute pancreatitis (SAP) develops in about 25% of patients with acute pancreatitis (AP). Severity of AP is linked to the presence of systemic organ dysfunctions and/or necrotizing pancreatitis pathomorphologically. Risk factors determining independently the outcome of SAP are early multi-organ failure, infection of necrosis and extended necrosis (> 50%). Up to one third of patients with necrotizing pancreatitis develop in the late course infection of necroses. Morbidity of SAP is biphasic, in the first week strongly related to early and persistence of organ or multi-organ dysfunction. Clinical sepsis caused by infected necrosis leading to multi-organ failure syndrome (MOFS) occurs in the later course after the first week. To predict sepsis, MOFS or deaths in the first 48-72 h, the highest predictive accuracy has been objectified for procalcitonin and IL-8; the Sepsis- Related Organ Failure Assessment (SOFA)-score predicts the outcome in the first 48 h, and provides a daily assessment of treatment response with a high positive predictive value. Contrast-enhanced CT provides the highest diagnostic accuracy for necrotizing pancreatitis when performed after the first week of disease. Patients who suffer early organ dysfunctions or at risk of developing a severe disease require early intensive care treatment. Early vigorous intravenous fluid replacement is of foremost importance. The goal is to decrease the hematocrit or restore normal cardiocirculatory functions. Antibiotic prophylaxis has not been shown as an effective preventive treatment. Early enteral feeding is based on a high level of evidence, resulting in a reduction of local and systemic infection. Patients suffering infected necrosis causing clinical sepsis, pancreatic abscess or surgical acute abdomen are candidates for early intervention. Hospital mortality of SAP after interventional or surgical debridement has decreased in high volume centers to below 20%.
基金supported by a grant from Shanghai Pudong New Area(PWZxkq2011-01)
文摘BACKGROUND:The present study aimed to explore the relationship between surgical methods,hemorrhage position,hemorrhage volume,surgical timing and treatment outcome of hypertensive intracerebral hemorrhage(HICH).METHODS:A total of 1 310 patients,who had been admitted to six hospitals from January 2004 to January 2008,were divided into six groups according to different surgical methods:craniotomy through bone fl ap(group A),craniotomy through a small bone window(group B),stereotactic drilling drainage(group C1 and group C2),neuron-endoscopy operation(group D) and external ventricular drainage(group E) in consideration of hemorrhage position,hemorrhage volume and clinical practice. A retrospective analysis was made of surgical timing and curative effect of the surgical methods.RESULTS:The effectiveness rate of the methods was 74.12% for 1 310 patients after onemonth follow-up. In this series,the disability rate was 44.82% 3–6 months after the operation. Among the 1 310 patients,241(18.40%) patients died after the operation. If hematoma volume was >80 mL and the operation was performed within 3 hours,the mortality rate of group A was signifi cantly lower than that of groups B,C,D,and E(P<0.05). If hematoma volume was 50–80 mL and the operation was performed within 6–12 hours,the mortality rate of groups B and D was lower than that of groups A,C and E(P<0.05). If hematoma volume was 20–50 mL and the operation was performed within 6–24 hours,the mortality rate of group C was lower than that of groups A,B and D(P<0.05).CONCLUSIONS:Craniotomy through a bone f lap is suitable for patients with a large hematoma and hernia of the brain. Stereotactic drilling drainage is suggested for patients with hematoma volume less than 80 mL. The curative effect of HICH individualized treatment would be improved via the suitable selection of operation time and surgical method according to the position and volume of hemorrhage.
文摘目的:通过对Gamma3、股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)及动力髋螺钉(dynamic hip nail,DHS)治疗的老年股骨粗隆间骨折患者围手术期失血量的分析,了解老年股骨粗隆间骨折患者围手术期失血的特点。方法:回顾性分析了我科2007年1月1日至2012年12月31日诊治的408例采用Gamma3、PFNA及DHS治疗的老年股骨粗隆间骨折患者的临床资料。使用Gross方程,根据身高、体重、术前和术后的血常规变化,计算围手术期的失血量,并比较Gamma3组、PFNA组及DHS组的失血量区别。结果:Gamma3治疗组患者共96例,平均手术时间为(74.7±25.0)min,平均显性失血量为(103.5±83.0)mL,平均总失血量为(831.9±474.8)mL,平均隐性失血量为(728.3±455.5)mL。PFNA治疗组患者共84例,平均手术时间为(69.0±27.1)min,平均显性失血量为(91.5±111.4)mL,平均总失血量为(825.7±478.0)mL,平均隐性失血量为(734.2±455.7)mL。DHS治疗组患者共40例,平均手术时间为(97.5±25.0)min,平均显性失血量为(283.6±142.1)mL,平均总失血量为(695.7±502.4)mL,平均隐性失血量为(412.1±457.6)mL。结论:通过3种内固定方式的比较发现,DHS治疗粗隆间骨折切口大、手术时间长、术中出血多,Gamma3和PFNA治疗老年股骨粗隆间骨折虽然具有切口小、手术时间短、术中出血少等优点,但围手术期的隐性失血较多,临床应予以足够的重视,以减少术后并发症的发生。
文摘目的对采取股骨近端防旋髓内钉（ proximal femoral nail anti - rotation, PFNA）内固定方法治疗的老年股骨转子间骨折的术前和术中显性、隐性出血量进行临床分析，为临床围术期处理提供必要的数据支撑。方法回顾性分析2005年12月-2010年9月采用PFNA内固定治疗的216例股骨转子间骨折患者的临床资料，对患者术前、术后血常规以及术中、术后出血、输血情况等进行分析，对患者围术期的显性和隐性出血情况进行评估。结果216例患者术中平均失血48．9ml，无一例进行术中输血。42例术后第2～4天血色素下降明显（〈9g／L）患者进行输血，平均输血300ml；216例患者术后的平均显性失血量为62．3ml，平均隐性失血量为385ml，男女之间差异无统计学意义。结论股骨转子间骨折老年患者比较多见，与术中微创操作所见的出血量极少（〈70m1）不同，PFNA内固定治疗转子间骨折术后的隐性失血量较多，提示应严格注意术后患者的生命体征监测以减少并发症的产生。
文摘目的:对采取股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)和动力髋螺钉(dynamic hipscrew,DHS)内固定方法治疗的老年股骨粗隆间骨折的术中及术后显性、隐性失血量进行分析,为临床围手术期处理提供必要的数据支撑。方法:回顾性分析2001年12月30日至2010年9月30日间采用PFNA内固定手术治疗的216例及采用DHS内固定手术治疗的168例股骨粗隆间骨折患者的临床资料,对患者术前、术后血常规以及术中及术后失血、输血情况等指标进行分析,同时对围手术期的显性、隐性失血情况做出评估。结果:采用PFNA治疗的患者平均术中失血(48.9±2.8)mL;术后平均显性失血量为(62.3±3.8)mL,平均隐性失血量为(385.0±6.2)mL。采用DHS治疗的患者平均术中失血(124.9±7.8)mL;术后平均显性失血量为(73.9±4.7)mL,平均隐性失血量为(243.4±6.3)mL。两组相比,DHS术中出血量及术后的显性出血量均多于PFNA(P<0.01),但PFNA术后隐性出血量及PFNA总体出血量均多于DHS(P<0.01)。结论:PFNA和DHS内固定治疗股骨粗隆间骨折均存在较多的术后隐性失血量,提醒临床医生注意术后患者的生命体征监测以减少并发症的发生。
文摘Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls.Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures.However for the physiologically young patients,preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands.The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures.Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population.Furthermore,other management variables such as surgical timing,the role of capsulotomy and the choice of implant for fixation remaincontroversial.This review will focus both on the demographics and injury profile of the young patient with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.
