2015年 · 第53卷第09期

With the development of medical imaging, the detection rate of pancreatic cystic disease has been greatly improved. Because the etiologies and biological behaviors covered by pancreatic cystic diseases vary greatly, ranging from well-defined benign tumors to precancerous lesions, and low-grade malignant or borderline tumors, makers of treatment decisions for such diseases have put forward higher requirements.

Trigeminal neuralgia is a common clinical cranial nerve disease. Its prevalence rate is 182 people/100,000, and the annual incidence rate is 3~5 people/100,000. It mostly occurs in adults and the elderly, and the onset age is 28~89 years old, 70% ~80% of cases occur over 40 years old, and the peak age is 48~59 years old. However, the latest WHO survey data show that trigeminal neuralgia is trending younger, and the prevalence of the population is rising, which seriously affects the quality of life, work and social interaction of patients, and also increases medical expenditure^[1,2,3]。 At present, the treatment of trigeminal neuralgia mainly includes drug therapy, radiofrequency thermocoagulation, semilunar balloon compression, stereotactic radiosurgery and microvascular decompression surgery. In addition, many non-mainstream treatment methods are also used. Coupled with the differences between medical technology levels in different regions, many patients have not been able to get scientific and effective treatment so far. Therefore, it is an inevitable choice for the majority of patients to write the consensus of experts on the diagnosis and treatment of trigeminal neuralgia, standardize the treatment choices of trigeminal neuralgia, and improve the overall treatment effect. We look forward to sharing the clinical experience and wisdom of more experts, referring to a large number of literature materials, learning from and absorbing the new ideas, new methods and new technologies that have been reported in recent years, and striving to make the expert consensus not only meet the requirements of the rapid development of modern medical technology, but also maximize pain relief and improve patients' quality of life.

I remember when I was young and first entered the industry, people often looked at my hands with envy and said with a deliberate smile, "You have surgeon's hands." This is a compliment, because usually it is said that your hands are soft, with long, flexible fingers and soft and fair skin. Doctor's hands are different from those of working people, doctor's hands are for fine work, for making art – or so I think.

Male, 28 years old. After eating greasy food, he suddenly suffered from severe pain in the upper abdomen, nausea and vomiting. Blood amylase was tested at the local hospital at 799 U/L, and he was diagnosed as acute pancreatitis. After 48 hours of treatment, the condition did not improve, and gradually appeared dyspnea, disturbance of consciousness, apathy, and urination gradually decreased. The emergency department was transferred to our hospital. The patient was admitted to the hospital in a coma state, still responding to painful stimulation, and mild cyanosis of the lips; Body temperature 37.6 ℃, pulse 133 beats/min, blood pressure 99/52 mmHg (1 mmHg =0.133 kPa) (dopamine pump controls blood pressure), shortness of breath. The patient had total abdominal distension, abdominal muscle tension, no intestinal sound, and positive mobile voiced sound. Emergency white blood cell count 3.95 g/L, hemoglobin 135×10⁹/L, total bilirubin 61.9 μ mol/L, direct bilirubin 36.5 μ mol/L, ALT 37 U/L, AST 135 U/L, R-glutamyl transpeptidase 59 U/L, urea nitrogen 24.53 mmol/L, creatinine 360 μ mol/L, serum amylase 332 U/L, serum lipase 342 U/L; Blood gas analysis : pH 7.17, PaO₂62 mmHg, PaCO₂30 mmHg, PaO₂/FiO₂120. Emergency abdominal CT examination revealed severe pancreatic swelling, extensive peripancreatic exudation and peritoneal effusion (Figure 1)。 Admission diagnosis: severe acute pancreatitis, respiratory failure, renal failure, coma cause to be investigated.

A 32-year-old male was admitted to the ICU ward of the general surgery department of our hospital due to "distension and pain in the upper abdomen with progressive aggravation of nausea and vomiting for 11 days". The patient was diagnosed with acute pancreatitis in another hospital 10 days ago due to upper abdominal distension and pain accompanied by nausea and vomiting for 1 day. After 10 days of non-surgical treatment, his condition progressively aggravated, with high fever, aggravated abdominal distension, dyspnea and anuria and was transferred to our hospital. Six years of previous history of gallbladder stones. Physical examination: temperature 39.4 ℃, pulse 130 beats/min, breathing 35 beats/min, blood pressure 140/90 mmHg (1 mmHg =0.133 kPa). The patient was irritable and there was no yellowing stain on the skin and sclera. Abdominal distension, tenderness in the upper abdomen and periumbilical area, mild rebound pain, no muscle tension, inaccessible liver and spleen, negative mobile voiced sound, inaccessible intestinal sound. Laboratory test: white blood cell count 30×10⁹/L, neutrophils 0.89, hemoglobin 74 g/L, hematocrit 22%; Liver and kidney function: total bilirubin 9.4 μ mol/L, glutamyl transpeptidase 111 U/L, creatinine 322 μ mol/L; Blood gas analysis: PaO₂65.5 mmHg, PaCO₂35.7 mmHg, HCO₃^-24 mmol/L; Coagulation function: international normalized ratio 1.8, prothrombin time 19 s; Blood culture (outer hospital): Candida albicans; CT plain scan showed pancreatic swelling and massive peripancreatic exudation (Figure 1)。 Admission diagnosis: severe acute pancreatitis, infection secondary to accumulation of acute necrosis, acute renal failure, acute respiratory failure, coagulation dysfunction, fungemia.

Male, 28 years old. He was referred to our hospital on July 22, 2013 because of "the deterioration of his condition 7 days after debridement and drainage of peripancreatic necrotic tissue and diaphragm repair". The patient was admitted to the local hospital for treatment 8 days ago due to closed thoracic and abdominal trauma caused by car crushing the thorax and abdomen. Obvious chest pain with dyspnea and hemoptysis at admission, no abdominal pain, abdominal distension, bilateral hip pain; Vital signs were stable with no abnormal abdominal signs; Chest CT showed patch shadows in the upper lobe of left lung, a small amount of bilateral pleural effusion, multiple rib fractures, and abdominal CT showed no obvious abnormalities (Figure 1)。 Diagnosis of systemic polytrauma, closed thoracic trauma, multiple rib fractures, pleural effusion, pelvic fracture. On 15 Jul 2013 (the second day after onset), the patient's dyspnea gradually worsened, his heart rate increased to 130 beats/min, and his white blood cell count was 26.2×10⁹/L, G% 95.24%, body temperature 39.5 ℃, showing shock. Re-examination of chest CT showed a large amount of pleural effusion on the left side, and the left diaphragm was elevated. After closed thoracic drainage, dark red bloody fluid was drawn out. After obtaining the consent of the family, thoracotomy and laparotomy were performed. During the operation, the left diaphragm was ruptured, the soft tissues of the tail of the pancreas and the left upper abdomen were severely crushed, and there were more necrotic tissues around the pancreas. Debridement and drainage of peripancreatic necrotic tissue and diaphragm repair were performed. The patient's condition was slightly relieved after surgery and then worsened again.

Spinal degenerative lesions rank third among active-duty pilots grounded, study shows^[1]。 The appearance of lesions may be related to many factors. At present, it is generally believed that weightless environment and high load (+ Gz) play a major role in various influencing factors^[2,3]。 Relevant foreign studies show that the incidence of disc herniation after flight is high^[4]。 However, the mechanism of intervertebral disc degeneration is not completely clear at present. We studied the effects of simulated weightlessness environment on lumbar degeneration and the molecular biological mechanisms using tail suspension simulated weightlessness experimental animal model.

Takayasu arteritis (TA) is an autoimmune disease that is more common in young Asian women^[1]。 The main pathological manifestations are diffuse irregular thickening and fibrosis of the whole thickness of the artery, and most of the involved blood vessels are stenotic or occluded. A few patients may also show dilatation or aneurysm-like changes. brachiocephalic takayasu arteritis (BCTA) was the most pathological type^[2]Clinical manifestations often vary depending on the site of the lesion. The combined surgical technique of endovascular and vascular bypass grafting for BCTA has not been reported in the literature. From March 2009 to June 2014, our department applied the combined surgical technique to reconstruct the carotid arterial blood flow in 13 patients with BCTA, and achieved satisfactory results.

anterior cervical discectomy and fusion (ACDF) is a widely used method for the treatment of degenerative cervical disc disease, but the complications of this method have attracted more and more attention. The ideal bone graft fusion is to achieve instant stability after implantation and promote fusion, while being able to reconstruct and maintain intervertebral height and cervical physiological curvature well. From September 2011 to September 2013, 55 patients with degenerative cervical intervertebral disc disease were treated with anterior cervical decompression zero-notch intervertebral bridge fixation cage (ROI-C intervertebral cage) in our department, of which 48 patients (87.3%) were followed up for more than 12 months (mean follow-up time 18.1 months). Forty-eight patients who were followed up for more than 12 months were now clinically analyzed.

A 62-year-old female came to our hospital on April 13, 2014 due to "gradual chest tightness and shortness of breath after activity within 2 weeks after coronary angiography, mild depressed edema of both lower limbs, accompanied by bilateral pleural effusion". On December 18, 2013, the patient went to another hospital for "chest pain for more than 1 month". The electrocardiogram showed sinus rhythm and T wave changes. He was diagnosed with chest pain to be examined and coronary heart disease was possible. He planned to undergo coronary angiography. Preoperative echocardiography showed mild aortic insufficiency. After perfect preoperative examination, he underwent coronary angiography through the left radial artery. Intraoperatively, a drug-coated stent was placed in the anterior descending artery. Echocardiography of this hospitalization showed partial tear of the right coronary valve of the aortic valve with moderate to severe regurgitation, enlargement of the left atrium with mild mitral regurgitation, and mild to moderate pulmonary hypertension. On 22 May 2014, the patient underwent surgery under general anesthesia. Intraoperative transesophageal echocardiography showed partial avulsion of the right coronary valve with unlimited opening, flail of the avulsed aortic valve at closure, moderate to severe aortic valve regurgitation, and mild mitral valve regurgitation (Figure 1)。 Transverse aortic incision was performed after conventional cardiopulmonary bypass through median sternal incision. Exploration showed that the right coronary valve leaflet was avulsed about 0.3 cm from the root at the junction between left and right coronary valves of the aortic valve, and the remaining leaflet was soft in texture (Figure 2), then 5-0 absorbable suture with spacer was applied to suture the avulsed leaflet, and the water injection test showed that the aortic leaflet alignment was good. Postoperative transesophageal echocardiography showed mild aortic valve insufficiency, the patient recovered well after operation, and the patient was discharged on the 7th day. On August 19, 2014, the patient was followed up in the outpatient clinic and complained that chest tightness and shortness of breath were significantly relieved after activity, and edema of both lower limbs and pleural effusion resolved. Reexamination echocardiography showed mild aortic valve insufficiency and left atrial enlargement.

Male, 49 years old. The main reason was "chest tightness for 2 years and aggravated for 2 days after activity", and he was admitted to the emergency department on August 30, 2014. The patient went to the doctor 2 years ago due to chest tightness. Chest CT found bullae in both lungs, with a larger left side. He did not receive further treatment and only received regular review. During the outpatient review on August 11, 2014, CT showed multiple bullae on both sides, still large on the left side, and no signs of pneumothorax were seen (Figure 1)。 Two days ago, the patient had aggravated chest tightness after activity without obvious inducement, and came to the emergency department of our hospital. Physical examination showed weak breathing sounds in both lungs. Chest X-ray fluoroscopy showed multiple thin-walled cavities in the upper fields of both lungs, increased light transmittance in both lung fields, pneumothorax bands were visible on both sides, and lung compression was about 20%. Bilateral pneumothorax and bullae were diagnosed, and both lungs were compressed by about 20%. Arterial blood gas analysis: oxygen partial pressure 73 mmHg (1 mmHg =0.133 kPa), carbon dioxide partial pressure 39.5 mmHg, oxygen saturation 95%. Yu checked normally. The patient underwent emergency surgery on 30 August 2014: general anesthesia and double-lumen tracheal intubation. First, the left side of the recumbent position was elevated by 45°, and an operating hole about 4 cm long was made under the xiphoid process, and a 30° thoracoscope was placed to remove mediastinal fat and pericardial fat. One-lung ventilation on the right side, opening the left mediastinal pleura into the chest cavity. The sponge forceps gently compressed the heart, and a small number of fascicular adhesions at the top of the left chest were seen, left emphysema, and several bullae in the upper lobe of the left lung, fused with each other, approx. 8 cm ×8 cm ×6 cm. Using a self-developed extended elbow electrocoagulation knife (produced by the surgical instrument factory of Shanghai Medical Equipment Group Co., Ltd.,Figure 2The bullae of the upper lobe of the left lung were removed with a laparoscopic cutting stapler (Endo-GIA, 60 mm green staple box). Then adjust the body position to elevate the right side by 45°, change the left side to single lung ventilation, open the right mediastinal pleura from the original incision, and explore the apical segment of the upper lobe of the right lung. There are also several bullae fused with each other. Excision of pulmonary bullae with a laparoscopic cutting-stapler. There is no air leakage on both sides of the water test, and one 28 F drainage tube is placed from the operation hole to the left and right chest cavities respectively (Figure 3)。 The intraoperative bleeding volume was 50 ml on the left side and 20 ml on the right side, and the operation time was 150 min. Postoperatively, pain was assessed using a visual analog scale, every 8 hours, and the score was reduced to 0 on the second postoperative day. Early movement out of bed 18 h postoperatively. On the first day after surgery, the chest X-ray showed good recovery of both lungs (Figure 4)。 The drainage tube was removed and discharged on the 3rd postoperative day. After 1 month follow-up, the patient complained of improvement in chest tightness and no pain in the wound.