ObjectiveTo summarize the experience and lessons of right ventricular decompression in children with pulmonary atresia and intact ventricular septum (PA/IVS) and to reflect on the strategies of right ventricular decompression.MethodsThe clinical data of 12 children with PA/IVS who underwent right ventricular decompression in our hospital from March 2015 to December 2019 were reviewed retrospectively. There were 10 males and 2 females with a median age at the time of surgery was 5 d (range, 1-627 d). Correlation analysis between the pulmonary valve transvalvular pressure gradient and changes in Z score of tricuspid valves after decompression was performed.ResultsOne patient died of refractory hypoxemia due to circulatory shunt postoperatively and family members gave up treatment. There were 2 (16.67%) patients received postoperative intervention. The pulmonary transvalvular gradient after decompression was 31.95±21.75 mm Hg. Mild pulmonary regurgitation was found in 7 patients, moderate in 2 patients, and massive in 1 patient. The median time of mechanical ventilation was 30.50 h (range, 6.00-270.50 h), and the average duration of ICU stay was 164.06±87.74 h. The average postoperative follow-up time was 354.82±331.37 d. At the last follow-up, the average Z score of tricuspid valves was 1.32±0.71, the median pressure gradient between right ventricle and main pulmonary artery was 41.75 mm Hg (range, 21-146 mm Hg) and the average percutaneous oxygen saturation was 92.78%±3.73%. Two children underwent percutaneous balloon pulmonary valvoplasty at 6 and 10 months after surgery, respectively, with the rate of reintervention-free of 81.8%. There was no significant correlation between pulmonary transvalvular gradients after decompression and changes in Z score of tricuspid valves (r=–0.506, P=0.201).ConclusionFor children with PA/IVS, the simple pursuit of adequate decompression during right ventricular decompression may lead to severe pulmonary dysfunction, increase the risk of ineffective circular shunt, and induce refractory hypoxemia. The staged decompression can ensure the safety and effectiveness for initial surgery and reduce the risk of postoperative death.
Objective To evaluate the short-term effectiveness of local laminectomy and interlaminar lumbar instrumented fusion (ILIF) through a small incision for lumbar spinal stenosis. Methods Between November 2009 and January 2011, 16 patients with lumbar spinal stenosis were treated by local laminectomy and ILIF through a small incision. Therewere 7 males and 9 females with an average age of 52.8 years (range, 49-67 years). Sixteen patients had lumbar degenerative stenosis with an average disease duration of 4 years and 7 months (range, 2 years-9 years and 4 months). Four cases complicated by lateral recessus stenosis, 3 by lumbar disc herniation. Involved segments included L3, 4 in 2 cases, L4, 5 in 4 cases, L5, S1 in 4 cases, L3, 4 and L4, 5 (double segments) in 2 cases, L4, 5 and L5, S1 (double segments) in 4 cases. The effectiveness was evaluated with the pre- and post-operative Visual Analogue Scale (VAS) scores, Oswestry Disabil ity Index (ODI). The cross-sectional areas of spinal canal were measured by CT scanning and were compared between pre- and post-operation. Results The average operative time was 47 minutes (range, 35-80 minutes); the average blood loss was 145 mL (range, 120-350 mL); and the average hospital ization days were 7.8 days (range, 4-15 days). Cerebrospinal fluid leakage occurred in 1 case, and healing of incisions by first intention was achieved in the others. The patients were followed up 12-22 months (mean, 14.8 months). CT scanning showed interspinous fusion in 14 cases and possible fusion in 2 cases after operation, with an average fusion time of 4.6 months(range, 3-10 months). The postoperative VAS score, ODI, and cross-sectional area were significantly improved when compared with preoperative values (P lt; 0.05). Conclusion The ILIF can promote fusion between spinous processes, provide spine stabil ization, and protect the spinal cord. The procedure has small incision, simple method of fixation and fusion.
Objective To determine the surgical indications for posterior expansive open-door laminoplasty (EOLP) extended to the C1 level. Methods Seventeen patients undergoing C3-7 or C2-7 open-door laminoplasty were included as the case group between September 2005 and January 2010, whose spinal cord injury symptoms were not alleviated or aggravated again because of the cervical stenosis at C1-4 level, and the causes of the surgery itself were eliminated, all of these patients underwent reoperation with decompress upward to C1 level. Fifteen patients with cervical stenosis who underwent C2-7 laminoplasty and C1 laminectomy were selected as the control group. There was no significant difference in gender, age, and disease duration between 2 groups (P gt; 0.05). The pre- and post-operative cervical curvature and spinal cord compression were evaluated according to the patients’ imaging data; the pre- and post-operative neurological recovery situation was evaluated by Japanese Orthopaedic Association (JOA) 17 score and spinal cord function Frankel grade; the neurological recovery rate (according to Hirabayashi et al. method) was used to assess the postoperative neurological recovery situation. Results In the case group, 8 patients underwent primary C3-7 laminoplasty. In 3 of these patients, there was a cervical stenosis at C1, 2 level, and discontinuous cerebrospinal fluid around the spinal cord was observed; 5 of them with a compression mass which diameter was exceed 7.0 mm in the C2-4 segments. The remaining 9 patients in the case group underwent primary C2-7 laminoplasty, and the diameter of the compression mass was exceed 7.0 mm in the C2-4 segments. In all 17 patients of the case group, reoperation was performed with the decompression range extended to the C1 level, and the follow-up time was 35-61 months with an average of 45.6 months. Cervical curvature: there were 11 cases of cervical lordosis, 4 cases of straight spine, and 2 cases of cervical kyphosis before operation; but after operation, 2 cases of cervical lordosis became straight spine and 1 straight case became kyphosis. The postoperative neurological improvement was excellent in 8 cases, good in 7, and fair in 2. In the control group, all the patients had a compression mass which anteroposterior diameter was exceed 7.0 mm in the C2-4 segments before operation. The follow-up time was 30-58 months with an average of 38.7 months. Cervical curvature: there were 13 cases of cervical lordosis and 2 cases of straight spine before operation; but after operation, 1 case of cervical lordosis became straight spine. The postoperative neurological improvement was excellent in 8 cases, good in 6, and fair in 1. No significant difference was found in the JOA score at pre- and post-operation between 2 groups (P gt; 0.05); however, there were significant differences (P lt; 0.05) in the JOA score between at last follow-up and at preoperation. Conclusion The initially surgical indications which can be used as a reference for EOLP extended to C1 are as follows:① Upper cervical (C1, 2) spinal stenosis: C1 posterior arch above the lower edge part of cerebrospinal fluid around the spinal cord signal is not continuous, and the anteroposterior diameter of the spinal canal actual is less than 8.0 mm as judgment standard. ②There is a huge compression at the lower edge of C2-4 vertebrae, and the most prominent part of the diameter is exceed 7.0 mm, which can not be removed through the anterior cervical surgery, or the operation is high-risk.
【Abstract】Objective To discuss the clinical significance of postoperative application of gastrointestinal decompression after anastomosis of lower digestive tract. Methods Three hundred and sixty-eight patients undergoing excision and anastomosis of lower digestive tract were divided into two groups: the group with postoperative gastrointestinal decompression and the group without it. The clinical therapeutic outcomes and incidences of complications were compared between the two groups. Results The volume of gastric juice in the decompression group was about 200 ml every day after operation. Both groups had a smaller abdomenal circumference before operation than after operation （P＜0.001）. No difference in the time of first passage of gas from anus and defecation after operation was found between the two groups. The incidence of complications in the decompression group was obviously higher than that of non-decompression group (28.0% vs. 8.2%, P＜0.001); the incidence of pharyngolaryngitis of the former was up to 23.1%. There was also no difference found between these two groups regarding the hospital stay after operation.Conclusion The present study shows that application of gastrointestinal decompression after excision and anastomosis of lower digestive tract cannot effectively reduce the gastrointestinal tract pressure and has no obvious effect on prevention from postoperative complications. On the contrary, it may increase the incidence of pharyngolaryngitis and other complications. Therefore, it is more beneficial for the recovery of patients without gastrointestinal decompression.
ObjectiveTo investigate the feasibility of thoracolapascopic esophagectomy (TLE) without routine nasogastric (NG) intubation for patients with esophageal cancer (EC). MethodsClinical data of 78 EC patients under-going TLE without perioperative NG intubation in Affiliated Cancer Hospital of Zhengzhou University from January to September 2013 were analyzed (non-NG intubation group, including 48 male and 30 female patients with their age of 61.1± 8.5 years). Seventy-eight EC patients undergoing TLE with routine NG intubation for 7 days in 2012 were chosen as the control group (NG intubation group, including 50 male and 28 female patients with their age of 60.3±7.0 years). Operation time, postoperative morbidity, gastrointestinal functional recovery and patient discomfort were compared between the 2 groups. ResultsThere was no in-hospital death in either groups. There was no statistic difference in the incidences of pulmonary infection (16.7% vs. 19.2%, P=0.676), anastomotic leakage (1.3% vs. 2.6%, P=0.560) or NG tube replacement (3.8% vs. 2.6%, P=0.649) between non-NG intubation group and NG intubation group. Time for recovery of intestinal motility (2.5± 1.1 days vs. 4.3±1.2 days, P < 0.05) and time for air evacuation (3.6±1.7 days vs. 5.8±2.1 days, P < 0.05) of non-NG intubation group were significantly shorter than those of NG intubation group. Ninety-seven percent of the patients (76/78)in NG intubation group had uncomfortable feeling including dry mouth and sore throat, and only 6% of the patients (5/78) in non-NG intubation group had nausea. All the patients were followed up for 3 months after discharge. There was no intestinal obstruction, pneumonia or late anastomotic leakage during follow-up. ConclusionTLE without routine NG intubation is safe and feasible for EC patients, which can not only reduce patients' discomfort but also improve early recovery of gastrointestinal function.
ObjectiveTo explore the clinical characteristics and surgical treatment strategies of delayed spinal cord injury (SCI) caused by atypical compression of old thoracolumbar fracture.MethodsBetween January 2011 and June 2018, 32 patients with delayed SCI caused by atypical compression of old thoracolumbar fracture who met the inclusion criteria were admitted and divided into group A (20 cases, underwent anterior subtotal vertebral body resection+titanium mesh reconstruction+screw rod internal fixation) and group B (12 cases, underwent posterior 270° ring decompression of vertebral canal+titanium mesh reconstruction+screw rod internal fixation) according to the different operation approaches. There was no significant difference between the two groups in age, gender, cause of injury, fracture segment, disease duration, preoperative American Spinal Injury Association (ASIA) classification, and preoperative back pain visual analogue scale (VAS) score, lumbar Japanese Orthopaedic Association (JOA) score, kyphosis angle, and vertebral canal occupational ratio (P>0.05). The incision length, operation time, intraoperative blood loss, complications, and bone fusion time of reconstructed vertebrae were recorded and compared between the two groups; the kyphosis angle, back pain VAS score, and lumbar JOA score were used to evaluate the effectiveness.ResultsExcept that the incision length in group A was significantly shorter than that in group B (t=?4.865, P=0.000), there was no significant difference in intraoperative blood loss and operation time between the two groups (P>0.05). There was no deaths or postoperative paraplegia cases in the two groups, and no deep infection or skin infection occurred. There was 1 case of cerebrospinal fluid leakage, 1 case of inferior vena cava injury, and 1 case of chyle leakage in group A. No serious complications occurred in group B. There was no significant difference in the incidence of complications between the two groups (P=0.274). All 32 patients were followed up 12-61 months, with an average of 20.8 months. The follow-up time for groups A and B were (19.35±5.30) months and (23.25±12.20) months respectively, and the difference was not significant (t=?1.255, P=0.219). The reconstructed vertebrae in all cases obtained bony fusion postoperatively. The fusion time of groups A and B were (8.85±2.27) months and (8.50±2.50) months respectively, and the difference was not significant (t=0.406, P=0.688). The kyphosis angle, back pain VAS score, and lumbar JOA score of the two groups at each time point after operation and last follow-up were significantly improved when compared with preoperatively (P<0.05); the lumbar JOA score was further improved with time postoperatively (P<0.05), while the kyphosis angle and the VAS score of back pain remained similarly (P>0.05). Comparison of kyphosis angle, back pain VAS score, and lumbar JOA score between the two groups at various time points postoperatively showed no significant difference (P>0.05). At last follow-up, the JOA score improvement rate in groups A and B were 83.87%±0.20% and 84.50%±0.14%, respectively, and the difference was not significant (t=–0.109, P=0.914); the surgical treatment effects of the two groups were judged to be significant.ConclusionIn the later stage of treatment of old thoracolumbar fractures, even mild kyphosis and spinal canal occupying may induce delayed SCI. Surgical correction and decompression can significantly promote the recovery of damaged spinal cord function. Compared with anterior approach surgery, posterior approach surgery has the advantages of less trauma, convenient operation, and fewer complications, so it can be preferred.
Objective To explore the injury mechanism of the severethoracolumbar burst fracture and the necessity of anterior decompression and reconstruction with internal fixation. Methods From January 1999 to January 2004, 21 patients were treated with anterior decompression and reconstruction. The fractures were located at T12 in 6 patients, L1 in12, L2 in 4, L3 in 3,and L4 in 1. Four patients were treated with the “anterior approach” and “posterior approach” surgeries for severe column fractures.Results All the patients were restored to the normal physiological radian, and the spinal canal was decompressed completely. They werefollowed up for 1-6 years, and the bony fusion was observed radiologically.The spinal cord function was improved to the 1-3 Frankel grade in all the patients except 2. There were no such complications as leakage of the cerebrospinal fluid, platescrew loosening or breaking, or segment instability. The clinical effects were satisfactory. Conclusion The operation of the anterior decompression and reconstruction with internal fixation for severe thoracolumbar burst fracture has advantages of complete decompression, full bonegrafting, and firm internal fixation. It canrestore the spinal height and improve the spinal cord function.
Objective To observe and measure the approach next to the erector spinae in the thoracic and lumbar segments of the spine and adjacent anatomical structures by the topographic method, to clarify the positioning method and safe range so as to provide the anatomical basis of the approach for spinal canal decompression. Methods Twelve formaldehyde-treated adult cadaver specimens were selected, including 6 males and 6 females with an average age of 43 years (range, 27-52 years) and with an average height of 166 cm (range, 154-177 cm). The related data of the approach at T1-S1 levels were respectively measured: the distance between the lateral edge of the erector spinae and the spinous process, the length of the approach, the angle between the approach and the horizontal plane, the size of intervertebral foramen, and the vertical distance between the segmental artery and the upper edge of the vertebrae. Results The distance between the lateral edge of the erector spinae and the spinous process ranged from (41.75 ± 3.29) mm to (74.54 ± 7.08) mm. The length of the approach ranged from (66.75 ± 10.81) mm to (97.13 ± 13.35) mm. The angle between the approach and the horizontal plane ranged from (38.38 ± 6.16)° to (53.67 ± 4.40)°. The vertical distance between the segmental artery and the upper edge of the vertebrae ranged from (9.50 ± 0.60) mm to (18.30 ± 1.56) mm. The size of foraminal was also measured. The spinal canal could reach when iliocostalis lateral edge was used as the starting point in the lumbar segments, and longissimus lateral edge as the starting point in the thoracic segments. It was confirmed that there was enough safe space for the spinal decompression without the resection of the articular process. Conclusion The approach next to the erector spinae can reach spinal canal to achieve the purpose of decompression through the intervertebral foramen. The minimally invasive approach is feasible and safe. It has the value of the operative application.
Objective To evaluate the cl inical outcomes and values of anterior segmental decompression and double-plate fixation (ASDDF) for treatment of ski p cervical spondylotic myelopathy (SCSM). Methods Between June 2005 and June 2008, 17 patients with SCSM were treated with ASDDF. There were 10 males and 7 females with an average age of 58.8 years (range, 41-74 years) and an average disease duration of 9.7 months (range, 6-39 months). According to JapaneseOrthopaedic Association (JOA) score system, 2 patients were rated as extreme severe condition, 7 as severe, 7 as moderate, and 1 as mild. MRI images showed 42 affected cervical disc levels, including 26 disc levels with high-intensity intramedullary lesions on T2, 4 with low-intensity intramedullary lesions on T1, and 12 with significant cord compression but no signal change; according to Nagata classification scale, there were 5 abnormal segments at class I, 21 at class II, and 16 at class III. The rate of fusion, the Cobb angle, and the range of motion (ROM) of the cervical spine were measured preoperatively and postoperatively by the X-ray examinations. The improvement of the neurological function was evaluated by the JOA score. Results The average time of follow-up was 28.6 months (range, 24-58 months). After operation, dysphagia occurred in 2 cases (symptom rel ief after 1 month), hoarseness in 1 case (symptom rel ief after 3 months of methylcobalamin treatment), and degeneration of adjacent segments without symptom in 3 cases. The X-ray films showed the fusion rate of 100% at 12 months after operation without displacement, resorption or collapse of bone graft, and without breakage or loosening of plate and screw. The Cobb angles were (13.3 ± 10.4)° preoperatively, (15.8 ± 10.8)° immediately postoperatively, and (15.4 ± 11.4)° at last follow-up; the ROM of the cervical spine were (41.3 ± 17.4)° preoperatively and (23.8 ± 18.8)° at last follow-up; and the JOA scores were 8.2 ± 2.9 preoperatively, 13.7 ± 3.0 at 12 months postoperatively, and 13.9 ± 2.8 at last follow-up. All indexes showed significant differences between before operation and after operation (P lt; 0.05). The results of JOA scores were excellent in 8 cases, good in 6, fair in 2, and poor in 1 with an average improvement rate of 66.8% (range, 14%-88%) for the neurological function. Conclusion Adequate decompression, high rate of fusion, sol id mechanical stabil ity, improvement of total cervical lordosis,and the neurological function can be achieved through ASDDF for treatment of SCSM.
Although extracorporeal membrane oxygenation (ECMO) has been in existence since the 1970s as a means of supporting respiratory or cardiac function, early application of this technology was plagued by high complication rates. Peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) causes higher left ventricular end-diastolic pressure, pulmonary edema, left ventricular distention, ventricular arrhythmia, low coronary perfusion, myocardial ischemia, substantial thrombus formation within left ventricule cavity and even multiple organ dysfunction. Mechanical left ventricular decompression is required to treat these related complications. In this article, we reviewed the problems associated with left ventricular decompression supported by peripheral V-A ECMO in patients with cardiogenic shock.