2015年 · 第53卷第08期

Achilles tendon is the thickest and strongest tendon in the human body, about 15 cm long, located behind the lower leg, connecting the triceps of the calf and the calcaneus. Its main function is to be responsible for the plantar flexion of the ankle joint, and it plays an important role in the completion of walking, running, jumping and other movements. Achilles tendon rupture refers to the interruption of Achilles tendon tissue continuity caused by various reasons. It is a common type of tendon injury, which occurs in male athletes, especially adults who regularly engage in physical exercise. According to the time of injury, Achilles tendon rupture is divided into acute, subacute and chronic Achilles tendon rupture. Acute Achilles tendon rupture refers to the rupture of Achilles tendon within 2 weeks of injury; According to the degree of fracture, it is divided into incomplete fracture and complete fracture; According to whether the broken end communicates with the outside world, it is divided into open fracture and closed fracture. Acute Achilles tendon rupture referred to in this guideline is limited to closed, complete ruptures that occur near the middle segment of the Achilles tendon.

In 2002, the American Association of Neurological Surgeons (AANS) /Congress of Neurological Surgeons (CNS) jointly developed the Guidelines for the Management of Acute Atlas Fractures in Adults.^[1]。 In 2012, the American Congress of Neurosurgeons revised the guidelines based on English literature prior to 2011 and published a revised version of the guidelines in 2013^[2]。 However, the development of clinical diagnosis and treatment technology is changing with each passing day, and clinical research results in related fields are constantly innovating. The inherent evidence-based nature of evidence-based clinical guidelines determines that they should be revised periodically. In order to provide orthopedic surgeons in China with the most effective information on the management of atlas fractures, the Spinal Trauma Working Group of the Orthopedic Surgeons Branch of the Chinese Medical Doctors Association organized relevant experts to prepare this guide for 6 months. On the basis of fully studying the 2012 revised Guidelines for the Management of Acute Atlas Fractures in Adults issued by the American Congress of Neurosurgeons, drawing on its formulation methods, and based on a systematic retrospective analysis of the currently published Chinese and English literatures on the treatment of atlas fractures in adults, the compilation expert group developed this guide. The medical evidence summarized in the guidelines has been carefully analyzed and graded in strict accordance with evidence-based medicine standards.

Trauma is a major health problem worldwide at present. The WHO reported that around 5 million people died from trauma worldwide in 2000, accounting for 9 percent of all deaths worldwide^[1]。 China Injury Prevention Report released by the former Ministry of Health in August 2007 shows that about 200 million injuries occur in China every year, with 700,000 to 750,000 deaths, accounting for about 9% of the total deaths, and is the fifth cause of death^[2]。 Road traffic accidents and falling from heights are the most important causes of trauma in China, which often lead to serious trauma, and it is easiest to involve the main body of social labor force-young and middle-aged people, which brings a heavy burden to families and has an important impact on social economy.

Working in a hospital operating room can be stressful, which may lead to adverse events¹。 The stress of the surgeon comes from several factors, among which the effects of surgical instrument failure are particularly pronounced²。 For surgical instruments in question, surgeons often choose to throw them out at random. Although this action is convenient and beneficial to relieve pressure, it also brings us to the safety consideration of delivering surgical instruments.

surgical site infection (SSI) is the highest incidence of nosocomial infection among surgical inpatients, accounting for 38% of surgical infection patients; It ranked 3rd among all hospitalized patients with nosocomial infection, reaching 16%^[1]。 The Surgical Infection Prevention Program is a program established by the Centers for Disease Control and Prevention (CDC) to advocate the reduction of SSI through the rational use of prophylactic antibiotics^[2,3,4]。 The specific measures of the surgical infection prevention program include the following aspects: cefoxitin is recommended, and ertapenem or ciprofloxacin can be used if you are allergic to cephalosporins; It is recommended that antibiotics be given within 1 h prior to surgical incision; It is recommended that antibiotics should be given prophylactically again during the operation if the operation time exceeds 3 hours; It is recommended that antibiotics be discontinued within 24 hours after surgery. However, the above measures and recommendations have not been well implemented and observed in actual clinical work. We studied patients who underwent definitive surgery for intestinal fistula, and preoperatively administered ertapenem prophylactically to explore the effect of different postoperative discontinuation times on the incidence of SSI.

Male, 48 years old. He was admitted to hospital on December 27, 2014 because of "extrahepatic bile duct tumor found on physical examination for 2 months". Two months ago, the patient was found to occupy the common bile duct, no chills, fever, nausea and vomiting, abdominal pain, abdominal distension, jaundice and other symptoms during ultrasound examination in the local hospital. Re-examination of abdominal enhanced CT showed choledochal cyst, which was not treated at that time. On December 11, 2014, magnetic resonance cholangiopancreatography was performed in the outpatient department of our hospital: the common bile duct above the ampulla was cystically dilated, and about 28 mm ×65 mm T2WI mixed abnormal signal shadow was seen in the common bile duct area. No abnormal stenosis or dilatation of intrahepatic bile duct and pancreatic duct was seen. Consider the possibility of choledochal cyst with local malignant transformation (Figure 1)。 After admission, the relevant tests were completed, and the results of blood routine, blood biochemistry, coagulation function and tumor indexes were all negative. Ultrasound examination showed that the extrahepatic bile duct was widened, and heterogeneous nodular medium echo filling was seen in the lumen. The wider part was about 3.1 cm. There was no blood flow signal in the color Doppler flow diagram, and the structure of the bile duct wall was complete and continuous. Enhanced CT examination showed no dilatation of intrahepatic bile duct, cystic dilatation of common hepatic duct and common bile duct, and flocculous slightly high-density shadows were seen inside. The plain scan was 22 HU, and the enhanced scan was 46 HU. The edge was smooth, and the pancreatic duct was not dilated (Figure 2)。 Preoperative diagnosis: cystic dilatation of the bile duct with local malignant transformation? Mucinous cystadenoma of the bile duct?

Male, 64 years old. He was admitted to our hospital on April 16, 2013 because "the medial left retroperitoneal diaphragm occupied space for 2 days". During the course of the disease, the patient had no history of fever, low back pain and abdominal pain. Physical examination showed no obvious positive signs. Laboratory tests showed no abnormalities in blood routine, erythrocyte sedimentation rate, tumor markers and other tests. CT plain scan + enhanced examination showed that there was a non-uniform density mass shadow above the left kidney and on the inner side of the diaphragm, with scattered calcification shadows, with a clear boundary, about 2.8 cm ×3.2 cm in size. The enhanced scan showed 65 Hu in arterial phase and 111 Hu in venous phase, with a clear boundary with the upper pole of the kidney, no obvious abnormalities in both kidneys and adrenal glands, no abnormalities in liver, gallbladder, pancreas and spleen, no enlarged lymph nodes in retroperitoneum, and no peritoneal effusion (Figure 1)。 Consider the possibility of "source of benign tumor of diaphragm". After general anesthesia, the patient adopted the right lateral recumbent position, and underwent retroperitoneal laparoscopic resection of the left subdiaphragmatic tumor through the left lumbar. The perirenal fascia was incised and looked up along the renal surface. The tumor was found on the dorsal side of the kidney, about 2.0 cm ×3.0 cm in size, adhering to the diaphragm. Along the junction between the diaphragm and the tumor, the tumor was completely excised by electrocoagulation with ultrasonic knife, and the tumor histopathology was sent for examination. Pathological findings: The macroscopic examination showed a piece of gray-white tissue, about 3.5 cm ×3.0 cm ×2.0 cm in size, with envelope on the surface and local calcification inside, and gray-white matter tough on the remaining section. Histopathological diagnosis showed a large amount of inflammatory cell infiltration, mainly plasma cells, accompanied by myofibroblast proliferation and focal calcification, which was considered as inflammatory myofibroblastoma (FIG. 2A)。 Immunohistochemical results showed positive expression of diffuse smooth muscle actin and vimentin (Figure 2B、Figure 2C)。 The patient was followed up by telephone 1 year after surgery, and no recurrence was found in CT reexamination in another hospital.