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胸外科进展 ——第21届欧洲胸外科医师年会介绍

从第93届美国胸外科年会看国际心血管外科发展现状与趋势

胸外科围手术期气道管理专家共识（2012年版）

Application of Double Flap Extension Technique in Complicated Arterial Switch Operation

Abstract：　Objective?To summarize the clinical experience，surgical technique and indication of coronary artery implantation with double flap extension technique in arterial switch operations （ASO） in D-transposition of the great arteries （D-TGA） and Taussig-Bing anomalies.?Methods?From January 2006 to June 2011， 21 patients （13 males and 8 females；age 110.0±84.5 d；weight 5.4±4.2 kg） with D-TGA or Taussig-Bing anomalies associated with complex coronary artery malformations underwent ASO with double flap extension technique for coronary artery implantation in Shanghai Children’s Medical Center affiliated to Medical College of Shanghai Jiaotong University. All the patients had a main trunk of right coronary artery or dilated right ventricular conus branch originated from the left or right aortic sinus，with abnormal course of anterior looping to the aorta. The double flap extension technique was described as followed： a long coronary button was excised as a flap from the aorta; another pedicle flap on the pulmonary artery （neoaorta） was cut to extend to the button of coronary artery with an equal distance; the side edges of the flap and the button were sutured together to form a lengthened coronary artery tube.?Results?No operative death occurred in hospital. The postoperative duration of mechanical ventilation was 101.6±53.6 h. The duration of ICU stay was 9.5±4.9 d. Postoperatively，low cardiac output syndrome occurred in 9 cases，pulmonary hypertension crisis in 2 cases，pneumonia in 6 cases，and acute kidney failure in 2 cases. Eleven patients underwent delayed sternum closure. All the patients were discharged after proper treatment. Follow-up was complete in 17 cases. The duration of follow-up was 2 months to 5 years. Growth and development were significantly improved in all the patients during follow-up. No patient had ischemic ECG changes. One patient underwent reoperation for supravalvular pulmonary stenosis 2 years after ASO.?Conclusion?Double flap extension technique for coronary implantation in complicated ASO can significantly decrease postoperative death due to coronary artery malformations，especially for patients who have two-stage ASO and patients whose main trunk of right coronary artery or dilated right ventricular conus branch originates from the left or right aortic sinus with abnormal course of anterior looping to the aorta.

胸外科癌症患者围术期低蛋白血症分析

目的　探索胸外科癌症患者围术期发生低蛋白血症的处理方法。　方法　回顾性分析河北医科大学第四医院2010年3～5月经组织病理学确诊的20例癌症患者的临床资料，其中男9例，女11例；年龄60 （34～78）岁；食管癌14例，肺癌6例。检测患者行常规开放式手术前、后血清白蛋白水平、术后胸腔引流量和引流液中蛋白质含量，行经左胸食管癌切除术11例，经右胸食管癌切除术3例，肺叶切除术6例。　结果　20例患者术后24 h、48 h、72 h平均胸腔引流量分别为512.5 ml、294.0 ml和168.5 ml。行不同术式患者术后24 h胸腔引流量差异有统计学意义（P＜0.05）。20例患者术后24 h、48 h、72 h胸腔引流液中平均总蛋白质含量分别为29.9 g/L、27.2 g/L和25.9 g/L。术前和术后第1、3、5 d血清白蛋白含量分别为38.0 g/L、29.0 g/L、23.0 g/L 和25.8 g/L。患者术后第3 d低蛋白血症发生率最高［75.0% （15/20）］ 。　结论　胸外科常规开放式手术患者术后低蛋白血症的发生率较高，但白蛋白的补充时机尚需进一步探讨。

Validation of Four Different Risk Stratification Models in Predicting Early Death of Chinese Patients after Isolated Coronary Artery Bypass Grafting Surgery

Abstract: Objectives To evaluate the accuracy of four existing risk stratification models including the Society of Thoracic Surgeons(STS) 2008 Cardiac Surgery Risk Models for Coronary Artery Bypass Grafting (CABG), the European System for Cardiac Operative Risk Evaluation (EuroSCORE), the American College of Cardiology/American Heart Association (ACC/AHA) model, and the initial Parsonnet’s score in predicting early deaths of Chinese patients after CABG procedure. Methods We collected clinical records of 1 559 consecutive patients who had undergone isolated CABG in the Fu WaiHospital from November 2006 to December 2007. There were 264 females (16.93%) and 1 295 males (83.06%) with an average age of 60.87±9.06 years. Early death was defined as death inhospital or within 30 days after CABG. Calibration was assessed by the Hosmer-Lemeshow (H-L) test, and discrimination was assessed by the receiveroperatingcharacteristic (ROC) curve. The endpoint was early death. Results Sixteen patients(1.03%) died early after the operation. STS and ACC/AHA models had a good calibration in predicting the number of early deaths for the whole group(STS: 12.06 deaths, 95% confidence interval(CI) 5.28 to 18.85; ACC/[CM(159mm]AHA:20.67deaths, 95%CI 11.82 to 29.52 ), While EuroSCORE and Parsonnet models overestimated the number of early deaths for the whole group(EuroSCORE：36.44 deaths，95%CI 24.75 to 48.14；Parsonnet：43.87 deaths，95%CI 31.07 to 56.67). For the divided groups, STS model had a good calibration of prediction(χ2=11.46, Pgt;0.1)，while the other 3 models showed poor calibration（EuroSCORE：χ2=22.07，Plt;0.005；ACC/AHA：χ2=28.85，Plt;0.005；Parsonnet：χ2=26.74，Plt;0.005）.All the four models showed poor discrimination with area under the ROC curve lower than 0.8. Conclusion The STS model may be a potential appropriate choice for Chinese patients undergoing isolated CABG procedure.

The Influence of Different Doses of Low Molecular Weight Heparin on Coagulation Function in Patients after Thoracic Surgery

Abstract： Objective To compare the influence of different doses of low molecular weight heparin on blood coagulation system of patients who have received thoracic surgery. Methods Eightytwo patients (with lung cancer, esophageal cancer, thymoma, pleural endotheliomas or other diseases) who were treated in Tongji Hospital of Huazhong University of Science and Technology from January 2009 to March 2010 were divided into three groups, based on the time of hospitalization. In the control group, there were 24 patients including 10 females and 14 males with an average age of 43.5±21.3 years. No low molecular weight heparin was given after operation. There were 32 patients in group I, including 14 females and 18 males, with an average age of 45.2±18.6 years. An amount of 0.2 ml (2 125 U) low molecular weight heparin was subcutaneously injected daily during the first 7 days after operation. In group Ⅱ, there were 26 patients including 11 females and 15 males with an average age of 43.8±20.1 years. An amount of 0.4 ml (4 250 U)low molecular weight heparin was subcutaneously injected daily during the first 7 days after operation. The differences of preoperative and postoperative coagulation factors including prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib), D dimer (D-D), platelet count (PLT) and anti-Ⅹa activity were observed. Results The preoperative average values of PT, APTT, Fib, D-D, PLT of all the three groups were in the normal range and showed no significant difference (Pgt;0.05). For all three groups, after operation, PT prolonged, APTT shortened, the amount of Fib, D-D increased, PLT reduced on the 3rd day and then increased on the 7th day and anti-Ⅹa activity increased, all of which showed a significant difference from preoperative values (Plt;0.05). The amount of Fib in group Ⅱ was significantly lower than that in group Ⅰ after operation (the 5th day after operation: 4.7±2.5 g/L vs. 7.0±3.3 g/L, Plt;0.05); the amount of D-D in group Ⅱ was significantly lower than that in the control group (the 5th day after operation: 891.3±891.3 μg/L vs. 1 583.2±984.7 μg/L, Plt;0.05) and group Ⅰ (the 5th day after operation: 891.3±891.3 μg/L vs. 1 452.6±1 052.9 μg/L,Plt;0.05); and the anti-Ⅹa activity of group Ⅱ was significantly higher than that in group Ⅰ (the 5th day after operation: 0.54±0.05 U/ml vs. 0.29±0.04 U/ml, Plt;0.05). Conclusion In a certain weight range, fixeddose (4 250 U) of low molecular weight heparin is able to improve postoperative hypercoagulable state and avoid the occurrence of venous thromboembolism without increasing risk of complications like bleeding.

左心瓣膜手术后重度三尖瓣反流的外科治疗

目的 总结左心瓣膜手术后重度三尖瓣反流（TR）的外科治疗经验。 方法 回顾性分析自1999年2月至2009年12月上海交通大学医学院附属仁济医院31例左心瓣膜手术后重度TR患者的临床资料，男3例，女28例；年龄35～60岁（38.4 ± 8.3岁）。 31例左心瓣膜手术后重度TR患者均合并心房颤动，有不同程度的右心功能不全表现，其中心功能分级（NYHA）Ⅱ级3例，Ⅲ级24例，Ⅳ级4例。所有患者接受了三尖瓣手术，其中18例采用CarpentierEdwards半硬环行三尖瓣成形术（TVP），13例采用生物瓣行三尖瓣置换术（TVR）。对上述患者术前、术后的临床资料进行比较。 结果 围术期死亡2例，均死于心力衰竭，以右心功能衰竭为主。29例生存患者术后无严重并发症发生，均好转出院。随访29例，随访时间3个月~9年（5.3±2.5年），随访期间均给予强心、利尿等治疗。术后3个月患者心功能均有明显改善（NYHA分级Ⅰ级3例，Ⅱ级19例，Ⅲ级5例，Ⅳ级2例）；超声心动图提示：TR明显改善，右心房内径（50.2±8.8 mm vs. 63.1±12.4 mm，P=0.005）、右心室内径（28.3±7.1 mm vs. 35.7±8.2 mm，P=0.008）较术前明显缩小。 结论 对左心瓣膜手术后重度TR患者，早期应积极地行外科手术治疗；手术方式应根据患者三尖瓣的具体情况和手术者的经验，以选择置入半硬成形环的TVP为主，必要时采用生物瓣行TVR。但对有严重右心功能衰竭（NYHA分级Ⅳ级）患者需慎重选择手术治疗，应以内科保守治疗为主。

Progress in Antimicrobial Prophylaxis for Thoracic and Cardiovascular Surgery

Abstract： Appropriate prophylactic administration of antibiotics for thoracic and cardiovascular surgical procedure can reduce postoperative morbidity and decrease the overall cost due to infections. Prophylactic antibiotics should be given within 30 minutes preceding incision intravascularly. Serum levels of free drug above the minimal inhibitory concentration (MIC) for common contaminating bacteria should be maintained for the entire surgical period. Prophylactic antibiotics after operation are useless for patients without risk factors predisposing to postoperative infection. Heart and(or) lung transplant patients should be given antiviral and antifungal prophylaxis. Selection of antibiotics must be based on the pharmacokinetic, pharcodynamic and pharmacoeconomic properties of antibiotics and features of surgery. The policy of antibiotic prophylaxis must be modified in response to alterations in antibiotic resistance pattern which is constantly changing in hospital.

Cryoanalgesia on Intercostal Nerves for Post-Thoracotomy Pain： A Clinical Report

Objective To investigate the effects of cryoanalgesia for post-thoracotomy pain on the intercostal nerves. Methods Two hundred and eight patients suffering from thoracotomy were divided into three groups, according to different analgesia received respectively. Cryoanalgesia group （n = 80）： cryoanalgesia on the intercostal nerves, intercostals nerves was freezed at -55 ℃ for 90 seconds ; patient controlled analgesia by vein （PCA group, n= 80）： patient controlled analgesia was practiced intravenously, and control group （n = 48）： Dolantin given irregularly intra-muscularly and/or tramadol orally. Severity of pain was graded by visual analogue scale. Forced expiratory volume in one second（FEV1.0） was measured and pulmonary complication after operation was compared. Results There was a statistically significant improvement in postoperative pain scores and an improvement in respiratory function tests for patients in cryoanalgesia group（X2 = 74.93,15.04,P〈0. 05）. FEV1.0 in cryoanalgesia group was significantly higher than that in control group（1. 97±0.27L vs. 1. 39±0. 14 L,P〈0. 05）. Pulmonary complication in cryoanalgesia group after operation was lower than that in control group （6. 25% vs. 31. 25%, P〈0. 05 ）, Conclusion Cryoanalgesia on post-thoracotomy pain is very effective and may improve the respiratory function after operation.