Objective To explore the effectiveness of folded transverse superficial epigastric artery perforator flap in repairing the large penetrating defect after buccal carcinoma resection. Methods Between January 2019 and June 2021, 12 patients with buccal squamous cell carcinoma were treated. There were 6 males and 6 females with an average of 66.9 years (range, 53-79 years). The pathological stage was T3a-T4b, and the preoperative mouth opening was (3.08±0.46) cm. The disease duration ranged from 6 to 24 months, with an average of 15 months. After buccal carcinoma radical resection and neck lymph node dissection, the penetrating defects in size of 8 cm×6 cm to 16 cm×8 cm and in depth of 0.5-1.5 cm were remained. The transverse superficial epigastric artery perforator flap in size of 8 cm×6 cm to 14 cm×8 cm were harvested and folded to repair the penetrating defects. The donor site was sutured directly. Results All 12 skin flaps survived after operation, and the wounds healed by first intention. No internal or external fistula complications occurred. All incisions at the recipient site healed by first intention. All patients were followed up 12-18 months (mean, 14 months). There was no obvious abnormality in the color and texture of the flap, the oral and facial appearances were symmetrical, and there was no obvious swelling in the cheek. At last follow-up, the patient’s mouth opening was (2.89±0.33) cm, which was not significantly different from that before operation (t=1.879, P=0.087). The subjective satisfaction scores of 12 patients were 6-8 points, with an average of 7.3 points. Significant scars remained at the donor site but concealed in location. Conclusion The folded transverse superficial epigastric artery perforator flap can be used as a surgical method for repairing large penetrating defects after the buccal carcinoma resection, with a good recovery of facial appearance and oral function.
Portal hypertension caused by viral post hepatic liver cirrhosis has brought a heavy burden to medical treatment in China. In addition to liver transplantation, the treatments include drugs, endoscopy, intervention and surgery, but the effect is not satisfactory. At present, the consensus and guideline for portal hypertension often focuse on a single treatment, and there is an urgent need for reasonable, standardized and individualized treatment to minimize the risk of upper gastrointestinal bleeding and improve the long-term survival of patients, which should also be the ultimate goal of multi-disciplinary treatment (MDT) mode of portal hypertension. The MDT diagnosis and treatment method of portal hypertension needs to be obtained in combination with the general situation of patients (including liver function level, upper gastrointestinal bleeding risk, hypersplenism, etc.) and local medical advantages. For patients with acute upper gastrointestinal bleeding, the treatment with less trauma and good hemostatic effect should be selected as far as possible. Patients with previous bleeding history or bleeding cessation should improve the relevant evaluation as soon as possible and submit it to MDT for discussion and selection of the next appropriate treatment. Drugs and endoscopy can be used for high-risk groups of upper gastrointestinal bleeding. Whether surgical preventive treatment can benefit patients or not needs further large sample research support. Minimally invasive surgery is the development direction of surgical treatment. Combination of internal and external treatment may give full play to their respective advantages, reducing the risk of bleeding and improving long-term survival.
ObjectiveTo study the effectiveness of tibial transverse transport combined with the antibiotics embedded bone cement in the treatment of chronic infection of foot and ankle with lower extremity ischemic diseases.MethodsA retrospective analysis was performed on 28 patients with ischemic diseases of lower extremities associated with chronic foot and ankle infection who were treated with tibial transverse transport combined with antibiotic bone cement between August 2015 and October 2019. There were 22 males and 6 females, with an average age of 65.6 years (range, 41-86 years). There were 25 cases of diabetic foot, 2 cases of arteriosclerosis obliterans, and 1 case of thromboangiitis obliterans. The course of infection ranged from 1 to 27 years, with an average of 14.9 years. The healing condition and time of foot and ankle in all patients were recorded and compared, and the Wagner grading and WIFi (W: lower extremity wound classification; I: ischemic classification; Fi: foot infection classification) grading were compared before and at last follow-up.ResultsThe wound surface of 1 diabetic foot patient improved at 111 days after operation, without purulent secretion, and lost follow-up. The remaining 27 cases were followed up 5 to 21 months (mean, 8.4 months). There was no necrosis in the tibial osteotomy incision and the local flap. After operation, 21 cases showed needle reaction of external fixator, but the needle infection gradually improved after the corresponding treatment. Among the 24 patients with diabetic foot, 1 died of multiple organ failure due to pulmonary infection. Acute lower extremity vascular embolism occurred in 1 case, and the foot was amputated due to acute gangrene. In the remaining 22 cases, the wound healing time of foot and ankle was 2.5-11.0 months (mean, 4.6 months). At last follow-up, Wagner grading and WIFi grading of the patients were significantly improved when compared with those before operation (P<0.05). One patient with thromboangiitis obliterans had foot and ankle healing at 6 months after operation. Two patients with lower extremity arteriosclerosis obliterans had foot and ankle healing at 16 and 18 months after operation, respectively.ConclusionTibial transverse transport combined with the antibiotics embedded bone cement is effective in treating chronic infection of foot and ankle with lower extremity ischemic diseases.
ObjectiveTo evaluate the medium-term effectiveness of Waveflex system in the treatment of multiple lumbar degenerative diseases. MethodsBetween May 2010 and July 2012, 26 patients with multiple lumbar degenerative diseases underwent posterior decompression, transforaminal lumbar interbody fusion (TLIF), and internal fixation with Waveflex system. There were 15 males and 11 females, aged 23-65 years (mean, 34.2 years). The disease duration was 9 months to 8 years (median, 3 years and 3 months). The lesion located at L3-S1. The visual analogue scale (VAS), Oswestry disability index (ODI), and the short-form 36 health survey scale (SF-36) were used to evaluate the status of clinical recovery, meanwhile the Stauffer-Coventry evaluation standard was used to access the satisfaction at last followup; the disc space height (DSH), intervertebral angle (IVA), and range of motion (ROM) were measured on X-ray film or three-dimensional CT, and the adjacent segment degeneration was classified by Pfirrmann score based on MRI findings. ResultsAll patients obtained primary incision healing without nerve injury, cerebrospinal fluid leakage, or internal fixation failure. All patients were followed up 31-50 months (mean, 40.6 months). The VAS, ODI, and SF-36 scores were significantly improved at 6 months after operation and last follow-up when compared with preoperative ones (P<0.05), but no significant difference was found between at 6 months and last follow-up (P>0.05). According to the StaufferCoventry evaluation standard, the results were excellent in 21 cases, good in 2 cases, moderate in 2 cases, and poor in 1 case, with an excellent and good rate of 88.5% at last follow-up. X-ray films showed that there was no complication of screws pulling-out or fixed rod rupture and displacement. At 7 days, 6 months, and last follow-up, the DSH of adjacent segment was significantly increased (P<0.05), and the ROM of adjacent segment was significantly decreased (P<0.05) when compared with preoperative ones; there was no significant difference in IVA between at pre-and post-operation (P>0.05). According to Brantigan grade for fusion, 19 cases were rated as grade E, 6 cases as grade D, and 1 case as grade C, and the fusion rate was 96%. There was no significant difference in Pfirrmann score between at pre-operation and last follow–up (Z=0.000, P=1.000). ConclusionThe Waveflex system combined with TLIF is effective and safe to treat multiple lumbar degenerative diseases during medium-term follow-up.
Objective To investigate the venous drainage in retrograde island flaps by fluorescence tracing technique and to observe the pathway of venous drainage. Methods The 0.1mL venous blood was collected from the marginal ear vein of every rabbit (n=20), respectively, and erythrocytes were separated by centrifugation and then were labeled with FITC. Positive rate and fluorescence intensity of FITC-labeled RBC were detected by flow cytometry. RBC morphous was observed under the inverted fluorescence microscope. Saphenous retrograde island fasciocutaneous flap and antegrade islandfasciocutaneous flap (4.0 cm × 3.0 cm in size with vascular pedicle length of 3.0 cm) were successfully establ ished in hind l imbs of 20 New Zealand white rabbits．One hind l imb of each rabbit was randomly assigned as the experimental group and the contralateral side was assigned as the control. The same flap was establ ished in the control group without any fluorescence tracer. According to retrograde or antegrade flaps, the experimental group was divided into 2 groups with 10 rabbits in each group. And then, according to different pathways of tracer-giving, each group was divided into 2 subgroups of artery and vein, with 5 rabbits in each subgroup. The labeled erythrocytes (5 μL) were injected into artery or vein and then flaps were cut down 5 seconds later. The flaps were immediately frozen and chipped (5-7 μm). Consecutive three frozen sections were made and two of them were stained with HE and GENMED, respectively, but the third one was squashed without staining. All frozen sections were observed under the microscope. Results Positive rate of FITC-labeled RBC was beyond 99% and fluorescence intensity was more than or equal to 103. FITC-labeled RBC showed steady green fluorescence under the inverted fluorescence microscope. Fluorescence appeared in all experimental groups, but none was found in the control groups. In antegrade island flap group, fluorescence appeared mainly in lumen of vein, wall of vein and inner membrane and outer membrane of artery. In retrograde island flap group, fluorescence distributed principally in inner membrane and outer membrane of artery and wall of vein. Conclusion The fluorescence tracing is appl icable to the research of venous drainage. Venous drainage in the antegrade island flaps is mainly through lumen of vein, wall of vein and inner membrane and outer membrane of artery. While, venous drainage in retrograde island flaps is principally through inner membrane and outer membrane of artery and wall of vein.
Abstract： Objective To investigate diagnosis and treatment of concealed intrathoracic anastomotic leak of the esophagus. Methods We retrospectively analyzed the clinical data of 32 patients who presented with unexplained sepsis （temperature＞38 ℃ and elevated white blood cell count） after esophagectomy and intrathoracic anastomosis for esophageal carcinoma or gastric cardia carcinoma in Affiliated Hospital, Medical College of Qingdao University from January 2006 to December 2010. All the patients underwent oral water-soluble contrast esophagogram and oral water-soluble contrast computerized tomography of the chest. None of the patients had any sign of contrast leak in these diagnostic examinations, but their chest computerized tomography all showed peri-anastomotic bubble and encapsulated effusion. Fifteen patients were treated as concealed intrathoracic anastomotic leak of the esophagus, including fasting, broad spectrum antibiotic treatment, prolonged gastrointestinal decompression and enteral nutrition via naso-intestinal feeding tube. The other 17 patients were not treated as anastomotic leak of the esophagus and only received broad spectrum antibiotic treatment. Results None of the 15 patients who were treated as concealed intrathoracic anastomotic leak finally developed anastomotic leak proved by oral water-soluble contrast esophagogram and computerized tomography of the chest （0%, 0/15）. Among the 17 patients who were not treated as anastomotic leak, fourteen patients developed anastomotic leak later （82.4%, 14/17）, 2 patients died of aorto-esophageal fistula and 3 patients died of multiple organ dysfunction syndrome. Conclusion Peri-anastomotic bubble and irregular encapsulated effusion in oral water-soluble contrast esophagogram and computerized tomography of the chest should be considered as specific signs of concealed intrathoracic anastomotic leak of esophagus after esophagectomy and intrathoracic anastomosis. Patients with such signs should be treated as anastomotic leak.
Objective To explore the application of personalized guide plate combined with intraoperative real-time navigation in repairing of mandibular defect using fibula muscle flap, providing the basis for the precise repair and reconstruction of mandible. Methods The clinical data of 12 patients (9 males and 3 females) aged from 23 to 71 years (mean, 55.5 years) between July 2019 and December 2021 were recorded. These patients were diagnosed as benign or malignant mandibular tumors, including 2 cases of ameloblastoma, 6 cases of squamous cell carcinoma, 2 cases of osteosarcoma, 1 case of adenoid cystic carcinoma, and 1 case of squamous carcinoma. All patients were treated with mandibular amputation, and then repaired by double-stacked three-segment fibula muscle flap. Preoperative virtual design scheme and guide plate were performed. During the operation, personalized guide plate combined with real-time navigation was used for fibular osteotomy and shaping. Thin-slice CT examination was performed at 2-3 weeks after operation, and was fitted with the preoperative virtual design scheme. The difference between the distance of bilateral mandibular angles relative to the reference plane in three-dimensional directions (left-right, vertical, and anterior-posterior) and the difference of the medial angle of the lower edge of the mandible reconstructed by fibula were measured, and the mean error of chromatographic fitting degree was calculated. Results The guide plate and navigation were applied well, and the fibula shaping and positioning were accurate. The fibula muscle flap survived, the incision healed well, and the occlusal relationship was good. All 12 patients were followed up 1-29 months, with an average of 17 months. There was no significant difference on the distance of bilateral mandibular angles relative to the reference plane in the left-right [(−0.24±1.35) mm; t=−0.618, P=0.549], vertical [−0.85 (−1.35, 1.40) mm; Z=−0.079, P=0.937], and anterior-posterior [(−0.46±0.78) mm; t=−2.036, P=0.067] directions. The difference of the medial angle of the lower edge of the mandible reconstructed by fibula was also not significant [(−1.35±4.34)°; t=−1.081, P=0.303)]. Postoperative CT and preoperative virtual design fitting verified that there was no significant difference in the change of the mandibular angle on both sides, and the average error was (0.47±1.39) mm. ConclusionThe personalized guide combined with intraoperative real-time navigation improves the accuracy of peroneal muscle flap reconstruction of the mandible, reduces the complications, and provides a preliminary basis for the application of visual intraoperative navigation in fibula muscle flap reconstruction of the mandible.
ObjectiveTo compare and analyze clinical effects of video-assisted thoracoscopic surgery (VATS) lobectomy and systematic lymph node harvests for peripheral non-small cell lung cancer (PNSCLC) patients between single-port (SP) and multi-port (MP) with a propensity-matched analysis. MethodsWe retrospectively analyzed the clinical data of 324 patients presented with PNSCLC and admitted in the Affiliated Hospital of Qingdao University from January 2013 through December 2015. Six-eight patients underwent single-port thoracoscopic lobectomy were as a SP group and 256 patients with multi-port thoracoscopic lobectomy. Another 68 patients were produced by a propensity-matched analysis in these 256 patients, to match with SP group as a MP group. There were 26 males and 42 females at age of 54-62 (59.3±10.3) years in the SP group. There were 32 males and 36 females at age of 50-66 (61.5±9.4) years in the MP group. Perioperative outcomes were compared between the two groups. ResultsAll operations were accomplished successfully, without conversion to thoracotomy. Most postoperative outcomes were similar in intraoperative blood loss (136.3±22.7 ml vs. 142.2±20.3 ml), conversion (4.4% vs. 7.4%), lymph node dissection number (19.9±3.5 vs. 20.0±3.0), station (7.9±2.3 vs. 8.3±2.1), postoperative drainage volume (761.4±182.3 ml vs. 736.9±176.4 ml), chest drainage duration (5.2±1.5 d vs. 5.8±1.8 d), length of hospital stay (5.5±2.0 d vs. 5.0±2.5 d), and postoperative complications (2.9% vs. 7.4%) between the two groups (P > 0.05). There were statistical differences in operation time (138.2±20.3 min vs. 126.4±22.4 min), downtrend of pain scores (P=0.03), and patients' satisfaction level (8.8±1.4 vs. 7.3±2.3, P < 0.05). Concision Single-port thoracoscopic lobectomy is not inferior to multi-port and is a safe and feasible surgical procedure for the management of PNSCLC.
Objective To analyze the early effectiveness of unilateral biportal endoscopic discectomy (UBED) combined with annulus fibrosus suture in the treatment of lumbar disc herniation (LDH). Methods The clinical data of 19 patients with LDH treated with UBED and annulus fibrosus suture between October 2020 and October 2021 were retrospectively analyzed. There were 12 males and 7 females with an average age of 39.1 years (range, 26-59 years). The operative segment was L4, 5 in 13 cases, and L5, S1 in 6 cases. The mean disease duration was 6.7 months (range, 3-15 months). Preoperative neurological examination showed that muscle strength, sensation, and tendon reflex weakened or disappeared in varying degrees. Single annulus fibrosus suture (14 cases) or anchor assisted annulus fibrosus suture (5 cases) was selected according to the location of annulus fibrosus tears. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months, and 6 months after operation. Oswestry disability index (ODI) was used to evaluate the function recovery of lumbar spine before operation and at 3 days, 3 months, and 6 months after operation. At 3 days and 3 months after operation, MRI was used to examine the removal of nucleus pulposus and decompression of nerve root. MacNab criteria was used to evaluate the effectiveness at 6 months after operation and the recovery of nerve root function was recorded. Results All operations were successfully completed with a mean operation time of 52.7 minutes (range, 40-75 minutes). There was no complication such as nerve injury, spinal cord hypertension syndrome, or dural sac tear during operation, and no complication such as infection, aggravation of nerve damage, or cerebrospinal fluid leakage after operation. All the patients were followed up 6-10 months (mean, 8.2 months). Postoperative MRI showed that the herniated disc was completely removed and nerve roots were fully decompressed. During the follow-up, there was no recurrence of disc herniation. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and those at 6 months after operation further improved than those at 3 days and 3 months after operation, all showing significant differences (P<0.05). At 6 months after operation, MacNab standard was used to evaluate the effectiveness, and the results were excellent in 14 cases, good in 4 cases, and fair in 1 case, with an excellent and good rate of 94.7%. Neurological examination showed that the sensation and muscle strength of the affected nerve root innervated area recovered significantly when compared with those before operation (P<0.05); the recovery of tendon reflex was not obvious, showing no significant difference when compared with that before operation (P>0.05). ConclusionUBED combined with annulus fibrosus suture is a safe and effective technique for LDH and early effectiveness is satisfactory.