老爸论文 - 立委NLP频道

Medicine Lecture Notes

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Medicine Lecture Notes

【立委按】老爸的医学生涯电子版另开辟【教育园地】专栏，整理刊载老爸医学生涯中所做的医学讲座、代表性手术记录以及对后生传帮带方面的资料。相信这些资料对于同行和后学自有其参考价值。在老爸一路向上的医学生涯中，职称上最高的一级当然是主任医师的评定。材料中，五例四类手术例案是九四年申报主任医师的必备附件之一。当然，申报成功还要加上省级至全国核心期刊发表论文五篇以上、专业英文笔试合格、医学教学能力（例如下面的医学讲座）及临床领导经验等综合考核评价。

[Editor’s Comment] Dad's electronic version of his medical career has a separate column entitled [Education Garden], which collates and publishes medical lectures given by Dad in his medical career, records of representative surgeries and information on mentoring epigenetic patients. I believe these materials have their own reference value for peers and postgraduates. In dad all the way up in the medical career, title on the highest level, of course, is the chief physician evaluation. Among the materials, five cases with four types of operations were one of the necessary accessories for reporting to the chief physician in 1994. Of course, the success of the application also requires the comprehensive assessment and evaluation of more than five papers published in provincial to national core journals, qualified professional English written examination, medical teaching ability (such as the following medical lectures) and clinical leadership experience.

1. Yellow resistance related clinical problems

1 Jaundice–syndrome. Pre-liver (hemolytic), hepatocellular, and post-liver (obstructive). mixed type

2 Yellow resistance-intrahepatic capillary duct–small bile duct–hepatobiliary duct–common hepatic duct–common bile duct … obstruction.

3 Internal medicine jaundice—surgical jaundice: internal and external hepatic obstruction. (15%-20% difficult to identify)

4 Diagnostic procedures and methods of yellow resistance: clinical, laboratory tests, X-ray, B-US, CT, MRI, PTC, ERCP, radionuclide (isotope iodine 131, De99) imaging, selective angiography ... liver biopsy, laparotomy ...

5 Three elements of diagnosis—yellow stalk or not–location and degree of obstruction–cause of obstruction.

6 the characteristics of surgical jaundice: (1) Biliary colic (Charcot triad, Ranold pentalogy); Painless progressive jaundice is often suggestive of cancer. (2) Physical examination: The right upper abdomen or the whole abdomen shows peritoneal irritation sign and swollen gallbladder. (3) Laboratory tests: bilirubin +85.5umol/L and direct/total bilirubin > 35% or "biliary enzyme separation", AKP↑ and urine bilirubin+and urobilinogen-. (4) Common causes: cholelithiasis, biliary parasites, bile duct stenosis, cancer, inflammation and pancreatic cancer, inflammation, hilar metastatic cancer, Mirizzi snidrome (5) Internal medicine jaundice that needs to be excluded—for example, viral hepatitis, drug-induced liver damage, idiopathic jaundice of pregnancy, sclerosing cholangitis ...

7 Surgical jaundice treatment: strive for early surgery.

8 For preoperative jaundice reduction (especially malignant terrigenous jaundice—liver and kidney, coagulation function, gastric mucosa damage, and immunologic hypofunction, with blood bilirubin of 170umol/L). Methods: (1) External drainage technique —— PTCD, U-tube, cholecystostomy, choledochostomy. (2) Internal drainage technique—biliary and intestinal drainage.

9 Surgeries

9.1 Stone removal+external and internal drainage (T-tube drainage, pelvic biliary-intestinal drainage, Roux-Y, diseased hepatectomy ...)

9.2 Pancreas cancer resection: Whipple and Child surgery

1、阻黄的有关临床问题 (讲稿提要)

1 黄疸 —— 症候群。肝前 (溶血性)、肝细胞性、肝后性 (梗阻性)。混合型

2 阻黄 —— 肝内毛细胆管 – 小胆管 – 肝胆管 – 肝总管 – 胆总管 … 梗阻。

3 内科黄疸 —— 外科黄疽: 肝内、外梗阻。(15%-20%难以鉴别)

4 阻黄的诊断程序和方法: 临床、化验、X线、B-US、CT、MRI、PTC、ERCP、核素 (同位素碘131、得99) 显象、选择性动脉造影 … 肝活检、剖腹探查…

5 诊断三要素 —— 梗黄与否 – 梗阻部位、程度 – 梗阻原因。

6 外科黄疸的特点:

(1) 胆绞痛 (Charcot三联征、Ranold五联征); 无痛性进行性黄疸常提示癌症。
(2) 查体: 右上腹或全腹呈腹膜刺激征、肿大的胆囊。
(3) 化验: 胆红素+85.5umol/L 且直接/总胆红素 >35%或“胆酶分离”、 AKP↑、尿胆红素 +、尿胆原 -。
(4) 常见原因: 胆石症、胆道寄生虫、胆管狭窄、癌、炎症及胰癌、炎、肝门转移癌、Mirizzi Snydrome
(5) 需除外内科黄疸 —— 如: 病毒性肝炎、药物性肝损害、妊娠特发性黄疸、硬化性胆管炎 ……

7 外科黄疸的治疗: 力争早期手术。

8 关于术前减黄问题 (尤其恶性梗黄 —— 肝肾、凝血机能、胃粘膜损害及免疫功能低下等，血胆红素在170umol/L)。方法: (1) 外引流技术 —— PTCD、U管、胆囊造口、胆总管造口术。(2) 内引流技术 —— 胆肠内引流。

9 手术

9.1 取石术+外、内引流术 (T管引流、盆式胆肠内引流、Roux-Y、
病肝切除…)

9.2 胰癌切除: Whipple、Child手术2. Complications of most gastric resection

1 Recent complications

1.1 intraoperative injuries: common bile duct, pancreas, and middle colon artery.

1.2 Postoperative gastric bleeding

1.2.1 Recent—incomplete hemostasis, and open ulceration.

1.2.2 7–10 days after surgery (secondary hemorrhage)–most cases can be self-stopped.

1.3 Leak of duodenal stump (Billroth-II type): (1) poor suture, (2) obstruction of jejunal afferent loop, (3) local poor blood supply.

1.4 3-4% anastomotic emptying disorders

1.4.1 Full anastomosis.

1.4.2 Output loop.

1.5 Input loop syndrome (Formula B-II)

1.5.1 Chronic simple partial obstruction (technical factor) —— Braun anastomosis, Roux-Y anastomosis (30-40Cm).

1.5.2 Causes of acute strangulation complete obstruction (excluding pancreatitis): (1) Input/output junction (high pressure—necrotic perforation), (2) Input loop is too long—internal hernia. Treatment: emergency operation.

1.6 Surgical exploration of output loop obstruction (barium meal examination). Causes: retrocolonic—mesangial foramen narrowing, anterior to the colon—internal hernia.

1.7 Postoperative acute pancreatitis 1% (abdominal amylase—diagnosis). Causes: trauma, sphincter of Oddi spasm, afferent loop obstruction, decreased postoperative protease inhibitor secretion. Treatment: Surgical drainage.

2 Long-term complications

2.1 causes and mechanisms of "dumping" syndrome: ① high pressure in the small intestine—intestinal distension—intestinal hormones such as 5-hydroxytryptamine—accelerated peristalsis and vasodilation—decreased blood volume, k ↑– gravity pulling the residual stomach—stimulating visceral nerves—epigastric and cardiovascular symptoms. Treatment: Surgery to avoid small residual stomach, large anastomosis, diet, posture adjustment, drugs: antihistamine or anti-acetylcholine, anti-spasm and sedatives or anti-5- hydroxytryptamine and other drugs, surgery: aims to reduce the speed of food directly into the jejunum (narrow the anastomosis, change B-11 to B-I type, gastroduodenal jejunal interposition.

2.2 Hypoglycemia syndrome: mechanistic food-rapid-small intestine-blood glucose-insulin-blood glucose treatment: slight food intake.

2.3 Mechanism of basic reflux gastritis: it is caused by the difference in PH of the gastrointestinal tract. The procedure was chan to Roux-Y or plus Braun for that purpose of reducing reflux of intestinal fluid to the stomach.

2.4 Loss of function of pylorus in food mass ileus—coarse fiber, ropy—simple obstruction of small intestine.

2.5 Anemia

2.5.1 Iron deficiency-caused by low acid in the stomach, iron supplement.

2.5.2 Giant cell sex—lack of internal factors, V-B12, folic acid, liver preparations.

2.6 Malnutrition is generally normal.

2.7 Surgical failure of an anastomotic ulcer (Zollinger-Elison syndrome).

1999-5-8 wuhu changhang hospital

2、胃大部分切除的并发症 (讲稿摘要)

1 近期并发症

1.1 术中损伤: 胆总管、胰腺、结肠中动脉。

1.2 术后胃出血

1.2.1 近期 —— 止血不彻底、溃疡旷置。

1.2.2 术后7~10天 (继发性出血) —— 多可自止。

1.3 十二指肠残端漏 (Billroth-Ⅱ式): (1) 缝合不佳,(2) 空肠输入袢梗阻，(3) 局部血供不良。

1.4 吻合口排空障碍 3-4%

1.4.1 全吻合口。

1.4.2 输出袢。

1.5 输入袢综合征 (B-Ⅱ式)

1.5.1 慢性单纯性部分梗阻 (技术因素) —— Braun式吻合、Roux-Y 式吻合(30-40Cm)。

1.5.2 急性绞窄性完全性梗阻 (剔除胰腺炎) 原因: (1) 输入、出交叉 (压力过高—— 坏死穿孔)，(2) 输入袢过长 —— 内疝，治疗: 急症手术。

1.6 输出袢梗阻 (钡餐检查) 手术探查。原因: 结肠后 —— 系膜孔缩窄、结肠前 —— 内疝。

1.7 术后急性胰腺炎1% (腹液淀粉酶 —— 诊断)。原因: 创伤、Oddi 括约肌痉挛、输入袢梗阻、术后抑蛋白酶分泌减少。治疗: 手术引流。

2 远期并发症

2.1 “倾倒”综合征原因和机理: ① 小肠内高压 —— 肠管膨胀 —— 5-羟色胺等肠道激素 —— 蠕动增快和血管扩张 —— 血容量降低，K↑ —— &重力牵拉残胃 —— 刺激内脏神经 —— 上腹和心血管症状。治疗: 手术避免残胃过小、吻合口过大，饮食、体位调节，药物: 抗组织胺或抗乙酰胆碱、抗痉挛和镇静剂或抗5-羟色胺等药物，手术: 旨在减少食物直接进入空肠的速度 (缩小吻合口、改B-11为B-I式、胃十二指肠空肠间置。

2.2 低血糖综合征：机理食物 —— 快速 —— 小肠 —— 血糖↓ —— 胰岛素↓ —— 血糖↓ 治疗: 稍进食物。

2.3 碱性返流性胃炎机理: 胃肠PH差异致使。改手术为Roux-Y或加 Braun，目在减少肠液向胃返流。

2.4 食物团肠梗阻幽门失功能 —— 粗纤维、粘稠 —— 小肠单纯梗阻。

2.5 贫血

2.5.1 缺铁性 —— 胃内低酸致使，补铁。
2.5.2 巨细胞性 —— 内因子缺乏，V-B12、叶酸、肝制剂。

2.6 营养不良一般还正常。

2.7吻合口溃疡手术失败 (胃切除不足，Zollinger-Elison syndrome)。

1999-5-8芜湖长航医院

3. Large intestinal cancer

1 Colon and rectum anatomy: The colon is 150Cm in length and can be divided into cecum, ascending colon, transverse colon, descending colon and sigmoid colon. The rectum was about 12.5Cm long, connected with the anal canal (3–4 cm) under the sigmoid colon, and the retroperitoneal fold was 7.5Cm away from the anal margin.

2 Anatomical and physiological characteristics of colon and rectum: (1) The blood supply is that the terminal artery is poorer than the small intestine; (2) The intestinal wall is thin; (3) There are many enteric bacteria's, with high infection; (4) Absorbing water makes the feces form.

3 Once the colorectal cancer is definitely diagnosed, surgical treatment should be performed as soon as possible. Of course, comprehensive treatment should also be considered. Colorectal cancer has liver metastasis, but if the primary cancer and mesangial lymph node metastasis can still be completely removed, and the metastatic lesions touched in the liver are single, and it is not difficult to locally resect the site, the primary cancer can also be resected and the intrahepatic metastatic lesions can be resected at the same time, which can result in a long-term remission for some patients and a survival period of 5 years or more for a few patients. Cancer at the junction of straight and B accounts for 60% of all colorectal cancers.

4 Operating technical principles of radical resection of colorectal cancer: in order to prevent hematogenous dissemination and local planting of cancer cells during the operation as much as possible, the operation on cancer should be light and squeezing should be avoided; Before free cancer, the pathways of cancer cell intestinal implantation and hematogenous metastasis were blocked first.

5 Intestinal preparation before surgery: Preoperative preparation of the colon (intestine) is an important measure to reduce intraoperative pollution, prevent postoperative infection of the abdominal cavity and incision, and ensure good healing of the anastomosis. The purpose of intestinal preparation is to empty the feces in the colon without flatulence, and the number of intestinal bacteria will be reduced. Bowel preparation method: The colon is cleaned during the operation by regulating diet, taking laxative and cleaning the bowel.

Total fluid was administered three days before surgery, and Folium sennae 30g was orally administered. Fluid was infused for three times a day, 1500-2000ml per day. Or 25 grams of magnesium sulfate one day before surgery, twice a day.
Three days before surgery, metronidazole 0.5 was given orally four times per day and norfloxacin 0.2 was given four times per day.
Clean enema (soapy water) one night before operation, and clean water enema again the next morning.

6 Colonic surgery includes right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoidectomy; Rectal resection includes anterior rectal resection (Dixon's technique), pullout resection (Bacon's technique), abdominoperineal resection (Miles's technique), and retrosacral approach (Klarsks's technique).

7 Surgical procedures:

The bowel was ligated with a cloth tape, including the marginal vessels, at 10cm each from the proximal and distal sides of the margin of the cancer to block the bowel
The arteries and veins that were ready to be cut were exposed at the root of mesangium. They were ligated and cut separately. From then on, the mesangium was gradually cut to the intestinal part that was to be cut. (Digital pressure test can be performed before cutting to visually preserve intestinal blood supply)
Free the intestinal segment including cancer and resect it.
After intestinal anastomosis, the operation area was rinsed with sterile distilled water in order to destroy the exfoliated cancer cells.

8 Postoperative complications:

If the course of the disease is long and there are symptoms of incomplete obstruction, the intestinal preparation may not meet the requirements, and once the abdominal cavity is polluted during the operation, it will cause abdominal infection.
Due to intestinal wall edema and different degrees of intestinal dilatation, anastomotic leakage or anastomotic stenosis caused by large anastomotic tension is easy to occur after colorectal resection.
colorectal resection, abdominal itching, easy to cause abdominal bowel adhesion.
During the operation, it is easy to bleeding or cause accidental injury of other organs, such as ureter, duodenum, pancreas, and inferior vena cava.
Abdominal incision is large, and incision infection is easy to occur.

9 Post-operative treatment:

Pay attention to blood pressure, pulse and respiration within 48 hours after operation.
pay attention to intra-abdominal hemorrhage and wound bleeding.
Remove the catheter after 48 hours of retention after operation.
pay attention to the supplement of liquid, nutrition and electrolyte every day.
a large number of broad-spectrum antibiotics.

April 8, 2005 Li Mingjie Yu Changhang Hospital

3、大肠癌

1 结、直肠解剖:

结肠长度150Cm，可分盲肠、升结肠、横结肠、降结肠、和乙状结肠; 直肠长约12.5Cm, 上接乙状结肠下连肛管 (肛管 3-4Cm)，其腹膜反折部距肛缘7.5Cm。

2 结、直肠解剖、生理特点: (1) 血供为终末动脉较小肠差，(2) 肠壁薄，(3) 肠内细菌多，感染性高，(4) 吸收水份使粪成形。

3 结、直肠癌一旦明确诊断后应尽早地施行手术治疗，当然，还应考虑综合性治疗。

结、直肠癌虽已有肝转移，但如原发癌及系膜淋巴结转移癌尚可完全切除，而肝内触及的转移灶为单个, 且其所在部位做局部切除困难不大时，也可以切除原发癌的同时，将肝内转移灶切除，部分病人可因此而获得较长时间的缓解，少数病人尚可有5年或更长的生存期。

直、乙交界处癌占全部大肠癌的60%。

4 结、直肠癌根治术的操作技术原则: 为了尽可能防止术中癌细胞的血行播散和局部种植，对癌肿的操作要轻，避免挤压; 游离癌肿前，先阻断癌细胞肠腔内种植和血行转移的途径。

5 手术前的肠道准备:

结肠的术前准备 (肠道) 是减轻术中污染，预防术后腹腔和切口感染，以及保证吻合口良好愈合的重要措施。肠道准备的目的是使结肠内粪便排空，无胀气，肠道细菌数量随之减少。

肠道准备方法:
主要是通过调节饮食，服用泻剂及清洁肠道，达到手术时结肠“清洁”的目的。

(1) 术前三天进全流质，同时口服番泻叶30克冲服，三次/日，每天补液1500-2000ml。或术前1天服硫酸镁 25 克，二次/日。

(2) 术前三天口服灭滴灵 0.5，四次/日，加氟哌酸 0.2，四次/日。

(3) 术前一天晚上清洁灌肠 (肥皂水)，次日晨再行清水灌肠。

6 结肠手术分右半结肠切除、横结肠切除、左半结肠切除、乙状结肠切除; 直肠切除分为直肠前切除 (Dixon术式)、拉出切除 (Bacon术式)、腹会阴联合切除 (Miles术式)、经骶后入路 (Klarsks术式) 等…….

7 手术步聚:

(1) 在距癌肿缘远近侧各10cm处，将肠管包括边缘血管在内，以布带扎紧以阻断肠

(2) 在系膜根部显露准备切断的动静脉，分别结扎，切断，自此开始逐步切断系膜至拟切断的肠管部。(切断前可指压试行，以视保留肠管血运)

(3) 游离包括癌肿在内的肠段，予以切除。

(4) 肠吻合完毕后，用无菌蒸馏水冲洗手术区，以期能破坏脱落的癌细胞。

8 术后并发症:

(1) 若病程长，有不全梗阻症状，肠道准备工作可能达不到应有的要求，术中一旦腹腔受到污染后，会引起腹腔感染。

(2) 由于肠壁水肿，又有不同程度肠管扩张，结、直肠切除后，吻合易发生吻合口瘘或因吻合口张力大引起吻合口狭窄。

(3) 结、直肠切除，腹腔搔扰性大，易引起腹腔肠管的粘连。

(4) 术中易出血或引起其他脏器的误伤如输尿管、十二指肠、胰腺、下腔静脉等。

(5) 腹部切口大，易发生切口感染。

9 术后处理:

(1) 术后48小时内注意血压、脉搏、呼吸。

(2) 注意腹腔内出血和伤口出血。

(3) 术后保留导尿48小时后拔除。

(4) 每天注意液体、营养和电解质的补充。

(5) 大量应用广谱抗菌素。

April 8, 2005 李名杰于长航医院

4. Umbilical disease

1 Umbilical embryology - body pedicle: umbilical artery-lateral umbilical ligament (2); Umbilical vein-umbilical intermediate ligament (1); Vitelline canal; Urachal.

2 IgY duct deformity

2.1 Complete patent of vitelline duct — vitelline duct fistula (navel-gut fistula).

2.2 Partial patent yolk sac

2.2.1 Umbilical region — umbilical sinus

2.2.2 Middle part — yolk sac cyst

2.2.3 Bowel — Meckel diverticulum

2.3 Umbilical mucosal residue — umbilical cord (umbilical polyp)

2.4 Residues of vitelline tubule and its vascular fibrotic zona — umbilical enterozona

3 Urachal malformation

3.1 Urachal fistula-patent

3.2 Partial Closure

3.2.1 Umbilical region — urachal sinus

3.2.2 Middle part - urachal cyst

3.2.3 Bladder region-bladder diverticulum

4 Vascular malformations — persistent vitelline canal, urachal and umbilical blood vessels

5 Diseases of navel itself — umbilical hernia, omphalocele, infection, endometriosis, epithelial neoplasm, etc

4、脐部疾病 (讲稿提要)

1 脐部胚胎学 —— 体蒂: 脐动脉-脐外侧韧带(2); 脐静脉-脐中间韧带(1); 卵黄管; 脐尿管。

2卵黄管畸形

2.1 卵黄管完全未闭 —— 卵黄管瘘 (脐肠瘘)。

2.2 卵黄管部分未闭

2.2.1 脐部 —— 脐窦

2.2.2 中间部 —— 卵黄管囊肿

2.2.3 肠部 —— 麦克耳憩室 (Meckel diverticulum)

2.3 脐部粘膜残余 —— 脐茸 (脐息肉)

2.4 卵黄管及其血管纤维化索带残留 —— 脐肠索带

3脐尿管畸形

3.1 脐尿管瘘 —— 未闭

3.2 部分未闭

3.2.1 脐部 —— 脐尿管窦

3.2.2 中间部 —— 脐尿管囊肿

3.2.3 膀胱部 —— 膀胱憩室

4 血管畸形 —— 永存的卵黄管、脐尿管及脐部的血管

5 脐本身疾患 —— 脐疝、脐膨出、感染、子宫内膜异位症、上皮赘生物等

5. Congenital biliary malformations

1 Congenital biliary atresia (divided into six types)

bilioenteral drainage (50 cases +44 cases only, omitted)

2 Congenital choledochal cyst

2.1 Etiology:

2.1.1 Abnormal development of autonomic nerves in the terminal wall of common bile duct (similar to the etiology of Hirschsprung's disease)

2.1.2 Development disorder of common bile duct itself — weak duct wall (similar to the cause of congenital primary hydronephrosis)

2.1.3 Viral infection - obstruction/weak wall - dilatation-cyst

2.2 Pathology:

2.2.1 Extrahepatic (majority): cystic dilatation of common bile duct, diverticulum

2.2.2 Intra-hepatic (Caroli's cyst)

2.2.3 Mixed type (rare)

2.3 Symptom: three major symptoms (usually appear when the patient is three years old, but usually sees doctors later); abdominal pain 60%, lump 90%, jaundice 70%, fever 30%, pale feces, gallbladder pigment urine, intussusception perforation peritonitis and abnormal liver function.

2.4 Diagnosis: (i) three major Intermittent symptoms, (ii) ultrasonic diagnosis, (iii) abdominal X-ray or barium meal examination cholangiography. (iv) cyst puncture.

2.5 Treatment:

2.5.1 Cystectomy — Roux-Y cholangioenterostomy (difficult and with high mortality).

2.5.2 Cyst – duodenal anastomosis (easy and effective): low position, large incision (6Cm), and mucosa aligned suture.

2.5.3 Cyst - jejunal Roux-Y anastomosis.

2.5.4 External drainage of cysts (emergency transition).

2.5.5 Treatment of intrahepatic cyst: hepatectomy

3 Congenital gallbladder malformation

3.1 Abnormal number

3.1.1 Absence of gallbladder – 0.07% – predisposing to bile duct stones.

3.1.2 Double gall bladders – 0.025% of the double gall bladders are more prone to lithiasis and inflammation.

3.2 Location abnormality

3.2.1 intrahepatic gallbladder – 10% more children, with gradual emigration later on.

3.2.2 Left subtalar gallbladder

3.2.3 Right retrohepatic gallbladder

3.3 Morphological abnormalities

3.3.1 Biliary gall bladder – mediastinal membrane in the gall bladder.

3.3.2 bilobar gallbladder – bottom separation.

3.3.3 Leg sac diverticulum

3.3.4 gourd-shaped gallbladder

4 Abnormal adhesion — free gallbladder.

5 Abnormal tissue structure — ectopic tissue: pancreas and gastric mucosa.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Treatment points of radical resection of colon cancer

Training material VIII

Treatment points of radical resection of colon cancer

结肠癌一旦明确诊断后应尽早地施行手术治疗，但手术治疗是治疗原则中的一部分，还应考虑综合性治疗。横结肠癌应采取横结肠切除术，切除范围应包括肝曲和脾曲的整个横结肠，还应包括胃结肠韧带的淋巴结组，然后行升结肠和降结肠端端吻合术，倘若两端张力大而不能吻合，可切除升结肠、盲肠和回肠末段，然后作回肠与降结肠吻合术。

结肠癌虽已有肝转移，但如原发癌及系膜淋巴结转移癌尚可完全切除，而肝内触及的转移灶为单个，且其所在部位做局部切除困难不大时，也可以切除原发癌的同时，将肝内转移灶切除，部分病人可因此而获得较长时间的缓解，少数病人尚可有5年或更长的生存期。

Surgical treatment should be performed as soon as possible after a definite diagnosis of colon cancer, but surgical treatment is part of the principle of treatment and comprehensive treatment should also be considered. Transverse colon cancer shall be subjected to transverse colon resection, which shall cover the whole transverse colon of liver curve and spleen curve as well as the lymph node group of gastric-colon ligament. Then end-to-end anastomosis of ascending colon and descending colon shall be performed. In case the tension at both ends is large enough for anastomosis, the ascending colon, cecum and terminal ileum may be excised, followed by anastomosis of ileum with descending colon.

Although colon cancer has liver metastasis, for example, primary cancer and mesangial lymph node metastasis cancer can still be completely excised, and the metastatic foci touched in the liver are single, and when it is not difficult to locally resect the site, the primary cancer can also be excised and the intrahepatic metastatic foci can be excised at the same time, which can result in long-term remission for some patients, and survival time of 5 years or more for a few patients.

Principles of operation technique in radical resection of colon cancer;

prevent in the process of surgery as much as possible cancer cells hematogenous spread and local planting.
avoid extrusion during the operation of cancer with care.
before freeing the cancer, block pathways to prevent the cancer cells planting in the intestinal cavity and the blood metastasis.

Intestinal preparation before surgery:

Preparation before colectomy is an important measure to reduce intraoperative contamination, prevent postoperative infection of the abdominal cavity and incision, and ensure good healing of the anastomosis. The purpose of intestinal preparation is to empty the feces in the colon without flatulence, and the number of intestinal bacteria will be reduced.

Intestinal preparation method:

The colon is cleaned during the operation by regulating diet, taking laxative and cleaning the intestinal tract.

Three days before surgery, only liquid food is taken, at the same time take 30g oral senna, three times a day, giving 1500-2000 ml of fluid infusion every day.
Three days before surgery, patients are orally administrated with 0.5 metronidazole four times per day and 0.2 norfloxacin four times per day.
One night before operation, perform a clean enema (with soap and water), do it again the next morning with water.

Surgical procedures:

The bowel is blocked with a cloth tape, including the marginal vessels, at a distance of 10cm from each side of the tumor margin.
The arteriole and vein ready to be cut are exposed at the root of mesangium, which was then ligated and cut off respectively. From then on, the mesangium is gradually cut off to the intestinal part which is to be cut off too.
Free the bowel segment with cancer, and remove it.
After the intestinal anastomosis, rinse the operation area with sterile distilled water, in order to be able to destroy the dropped-off cancer cells.

Postoperative complications:

Due to the long course of disease and incomplete obstruction symptoms, intestinal preparation may not meet the requirements; once the abdominal cavity during the operation is polluted, it can cause abdominal infection.
Because of the intestinal wall edema, and different degrees of bowel expansion, with transverse colon resection, the colon end-to-end anastomosis is easy to incur compound mouth fistula or anastomosis stenosis caused by anastomosis tension.
Transverse colectomy leads to abdominal itching, easy to cause abdominal bowel adhesion.
Transverse colectomy is more difficult than that for right or left hemicolectomy, and it is prone to bleeding or accidental injury of other organs, such as ureter, pancreas and inferior vena cava.
abdominal incision is fairly big, prone to incision infection.

Postoperative treatment:

pay attention to blood pressure, pulse, breathing within 48 hours after surgery
pay attention to intra-abdominal hemorrhage and wound bleeding
remove the catheter after 48 hours of postoperative retention
pay attention to supplement liquid and electrolyte every day
doses of broad-spectrum antibiotics

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Treatment of recurrent ulcer after subtotal gastrectomy

Training material VII

Treatment of recurrent ulcer after subtotal gastrectomy

多发性溃疡的发生机制目前尚不完全明了，但有以下几种原因可促使溃疡复发。

一、与手术有关的因素

1、输入袢过长: 约占复发性溃疡病因的3%左右，一般要求应在屈氏韧带下 6-10cm 最为合适。

2、胃切除过少: 一般认为切除过少，不能切去足够的壁细胞，因此，切除胃约在 75% 的组织实属必要。

3、胃窦粘膜存留: 复发性溃疡中有 9% 的病人有胃窦粘膜存留，如第一次手术时剩下 l cm 的胃窦粘膜都有可能发生溃疡复发。

4、由于不适当的选用 Roux-y 吻合，或空肠近袢间侧侧吻合，分流了胃肠吻合区中和酸的胰液和胆汁，增加了溃疡复发机会。

5、用不吸收的丝线缝合吻合口，轻者可致炎症，重者可能溃疡或形成吻合口糜烂。

6、手术中引起胃肠粘膜的损伤，或剪除胃肠粘膜过多。

7、碱性返流性胃炎，由于胆汁返流入胃，致胃酸分泌增加，损害胃粘膜屏障，胆盐与胆酸在胃内亦可破坏溶酶体膜，导致溃疡发生。

The mechanism of multiple ulcerations is currently not fully understood, but there are several reasons why they may recur.

factors related to surgery:

Excessive length of afferent loop: it accounts for about 3% of the causes of recurrent ulcer. The general requirement is that 6-10cm below the ligament of Treitz is the most appropriate.
Too little gastrectomy: It is generally considered that the resection is too little to remove enough parietal cells. Therefore, it is necessary to remove about 75% of the stomach tissue.
Preservation of gastric antrum mucosa: The gastric antrum mucosa is preserved in 9% of patients with recurrent ulcer. For example, the gastric antrum mucosa with the thickness of l cm left during the first operation may have ulcer recurrence.
Roux-y anastomosis or lateral jejunal anastomosis between proximal loops is inappropriately selected, which shunts the neutralized pancreatic fluid and bile in the gastrointestinal anastomosis area and increases the chance of ulcer recurrence.
The anastomosis shall be sutured with non-absorbable silk thread. In mild cases, the anastomosis may be inflamed, while in severe cases, the anastomosis may be ulcerated or eroded.
cause damage to the gastrointestinal mucosa in the operation, or cut off too much gastrointestinal mucosa.
alkaline reflux gastritis, due to bile reflux into the stomach, increase gastric acid secretion, damage the gastric mucosal barrier, bile salts and cholic acid in the stomach can also destroy the lysosomal membrane, leading to the occurrence of ulcers.

Gastric antrum G cell proliferation.
Gastric seminoma or pancreatic ulcer syndrome accounts for about 1.8% of recurrent ulcers.
Ulcer drugs, such as salicylate type, indomethacin, baotaisong, corticosteroids, reserpine, etc. may lead to ulcer recurrence.

Surgical treatment of recurrent ulceration after subtotal gastrectomy:

The recurrence of ulcer is a fundamental failure of the previous operation, so great caution should be exercised during the reoperation to avoid further failure. First of all, the diagnosis should be clear, to better understand the previous operation, carefully observe the recent x-ray barium meal film, pay special attention to whether the residual stomach is too much, followed by gastroscopy, to determine the diagnosis and the location of the lesion, and pathological diagnosis, all these are very important, and also make sure to rule out the possibility of gastric cancer.

About the principle of reoperation:

The principle of retaking the surgery is to correct the defects of the first surgery. During the surgery, we should first explore whether the stomach is left uncut too much, whether the afferent loop is too long, and whether there is gastric antrum left. We should carefully explore the pancreas to exclude pancreatic ulcer and choose different surgery methods according to different situations. For pancreatic ulcer, the surgical methods include simple tumor resection and total gastrectomy. However, in most cases, the tumor is not easy to be found due to its small size, or it is difficult to remove the multiple affected parts, so total gastrectomy is the best policy. After total gastrectomy, the tumor loses its target organ and will most likely degenerate.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Treatment of carcinoma of pancreas head and carcinoma of ampulla (DRAFT)

Training material V

Treatment of carcinoma of pancreas head and carcinoma of ampulla

首先施行胆囊切除术，在切除胆囊的同时应探查胆总管和胰腺头部的病灶大小，侵犯的范围和周围有无与大血管的粘连侵犯等情况。除此以外，还应探查腹主动脉旁淋巴结等。根据手术探查情况，决定手术术式和手术方法。

如探查胰头癌己有广泛转移而无法切除时，可考虑施行胆总管空肠 Roux-y 吻合术，从而解除病人的黄疸问题，减少病人的痛苦和延长病人的生存期，如胆总管已有癌肿侵犯，胆囊又无法保留，则应给予肝总管切开置入T型管引流术。如术中证实无远处转移，病灶尚可活动，应考虑施行胰十二指肠切除术，但应根据以下情况进行选择。

凡诊断为壶腹部周围癌，临床上又无手术禁忌症时，均应力争一期手术切除。如病人长期有严重的黄疸，周身情况不佳，不能耐受一期手术时，可行二期切除手术。但二期手术可能由于腹腔粘连或癌肿转移固定，给手术带来困难。

术前准备:

1、黄疸病人因肝功能受到一定损害，凝血机制往往不佳，术前注射 GS、Vc、Vk1 和辅酶Q10等改善肝功能和凝血机能，促进出、凝血时间恢复正常，以免术中、术后出血，如有重度黄疸或合并胆道感染高烧者，应分期手术，即第一次开腹探查行胆囊造瘘术，或胆总管切开T型管引流术，待2-3周后黄疸消退，再行根治性切除手术。

2、老年体弱、贫血和低量白血症的病人，应适当输新鲜血，有助于凝血机制的改善, 口服胰酶类助消化药物。配血400ml x 3以备术中应用。

3、为了预防和治疗胆道感染，注射广谱抗菌素等。

4、术前一天给予配血 400mmlx3，以备术中应用。

5、术前应邀请麻醉科会诊，请麻醉科医师根据病人的具体情况选择麻醉的种类和方法。

6、术前应与病人家属说明病情及手术的必要性，以及手术中、术后可能出现的各种并发症，甚至发生死亡的可能，取得完全同意后并以签字为凭，方可考虑手术。

7、术前静滴20% Albumin 50 ml。

关于胰十二指肠切除手术步骤问题：

胰十二指肠切除手术步骤比较复杂，手术难度也较大，术中、术后并发症也较多，但可归纳为以下几个程序。

第一，进入腹腔后首先是探查有无远处转移和肿瘤局部的移动性，以及癌肿的原发灶是否来自胰头。

第二，如癌肿原发灶來自胰头，应进行试行分离，最后确定癌肿是否能被切除，同时还需进一步检查癌灶和腔静脉、腹主动脉、门静脉、肠系膜上静脉之间有无实质性浸润，以便最后确定肿瘤能否被切除，如确定癌肿能够根治切除时，便开始切断肝总管、胃、胰腺和空肠。

第三，切除病灶，最后切断钩状突，病变切除之。

第四，重建消化道，按胰、胆、胃或胆、胰、胃的顺序和空肠之间各别吻合。

胰十二指肠切除术式有以下几种，供手术时选择釆用：whipple 法 Child法 Cattel 法。

胰十二脂肠切除术的注意事项：

1、决定能否做胰十二指肠切除术的关键问题有二：（1）胰头后面与腔静脉、腹主动脉之间有无癌肿浸润现象。（2）胰腺后面与门静脉和肠系膜上静脉之间有无癌肿浸润。若其中之一有癌肿浸润时，则不适应做胰十二指肠切除术。

2、处理胰头、体与肠系膜上静脉之间小静脉时，应先结扎后切断，以免出血，如一旦出血，应立即以手指压住出血点，和肠系膜上静脉的上下两端，吸尽血液，看清损伤部位，准确钳夹止血，切勿盲目钳夹造成损伤。

3、胃的切除范围，一般在1/3-1/2不等。

4、胰瘘是胰十二指肠切除术后最危险的并发症，其发生率很高（20%-30%左右），一旦发生，往往有生命危险，必须加强预防措施，减少此一并发症的发生。

术后处理：

1、术后如血压平稳，可取半卧位。

2、腹腔引流管接计量瓶，记录24小时引流量，并观察其性状，如无其他特殊情况发生，一般在术后5-7天拔除引流管。

3、禁食, 持续胃肠减压，静滴 5% GS 和补充电解质、Vc、VB、Vk1 等，一般持续 4-5天，，待肠鸣音恢复后，拔除胃管开始进流质饮食。

4、广谱抗菌素的应用。

5、为了促进创口早期愈合，术后间隔补充血浆或全血，或 20% Albumin 50 ml。

6、注意口腔护理，鼓励病人作有效的咳嗽，并协助病人不断排痰，以防止合并胸膜炎和肺内感染或肺不张等并发症。

7、术后一周内要严密观察有无腹膜炎发生，如有腹膜炎发生，应及时给予引流

First of all, cholecystectomy should be performed. At the same time of cholecystectomy, the size, extent and periphery of lesions in common bile duct and pancreatic head should be explored, as well as whether there is adhesion invasion with large blood vessels. In addition, the para-aortic lymph nodes should also be explored. According to the surgical exploration, decide the surgical operation and surgical method.

If extensive metastasis of carcinoma in the head of pancreas cannot be resected during exploration, Roux-y choledochojejunal anastomosis can be considered, in order to relieve the patient's jaundice, reduce the patient's pain and prolong the patient's survival time. If there is invasion of common bile duct carcinoma and the gallbladder cannot be preserved, T-tube drainage through incision of common hepatic duct should be performed. If it is confirmed during surgery that there is no distant metastasis and the lesion is still mobile, pancreaticoduodenectomy should be considered, but the choice should be made according to the following circumstances.

All patients diagnosed with periampullary cancer and without clinical contraindication to surgery, should strive to a surgical resection. If the patient has severe jaundice for a long time and has poor general condition and cannot tolerate the primary operation, the secondary resection can be performed. However, the second-stage operation may be difficult due to abdominal adhesion or cancer metastasis fixation.

Preoperative preparation:

Patients with jaundice suffer from certain damage to liver function and often suffer from poor clotting mechanism. Pre-operative injection of GS, Vc, Vk1 and coenzyme Q10 can improve liver function and clotting function, promote bleeding and restore clotting time to normal so as to avoid intraoperative and postoperative bleeding. In case of severe jaundice or patients with concurrent biliary tract infection and high fever, staged operation should be performed, i.e., the first laparotomy and fistulization of gallbladder or T-tube drainage of common bile duct incision. After the jaundice disappears two to three weeks, radical resection should be performed.
the elderly, weak, anemia and low volume of patients with hyperlipidemia, should be appropriate to lose new blood, help to improve the clotting mechanism, oral trypsin digestive drugs. Blood matching 400ml x 3 for intraoperative application.
in order to prevent and treat biliary tract infection, injection of broad-spectrum antibiotics, etc.
one day before surgery with blood 400mmlx3, for intraoperative application.
preoperative anesthesia department consultation should be invited, please anesthesiologists according to the specific situation of the patient to choose the types and methods of anesthesia.
preoperative should explain the condition with the patient's family and the necessity of surgery, and surgery, postoperative complications may occur, and even the possibility of death, after obtaining full consent and with signature, can consider surgery.
Intravenous 20% Albumin 50 ml is given before operation.

Problem about surgical procedures of pancreaticoduodenectomy:

Pancreaticoduodenectomy is a complicated procedure with great surgical difficulty and many intraoperative and postoperative complications, but it can be summarized into the following procedures.

First, after entering the abdominal cavity, we first need to explore whether there is distant metastasis and local mobility of the tumor, and whether the primary tumor of cancer comes from the head of pancreas.

Second, if the primary tumor of cancer comes from the head of pancreas, we should try to separate it and finally determine whether the cancer can be removed. At the same time, we need to further check whether there is any substantial infiltration between the cancer and vena cava, abdominal aorta, portal vein and superior mesenteric vein, so as to finally determine whether the tumor can be removed. If it is determined that the cancer can be completely removed, we will start to cut off the common hepatic duct, stomach, pancreas and jejunum.

Third, resection of the lesion, and finally cut off the uncinate process, the lesion resection.

Fourthly, the digestive tract is reconstructed by anastomosis between pancreas, gallbladder, stomach or gallbladder, pancreas, stomach and jejunum in that order. There are several types of pancreaticoduodenectomy, and the whipple method, Child method and Cattel method are optional for operation.

Precautions of pancreaticoduodenectomy:

Two key issues determine whether or not pancreatoduodenectomy can be performed: (i) Whether there is cancer infiltration between the posterior part of pancreatic head and vena cava and abdominal aorta. (ii) There is no cancer infiltration between the back of pancreas and portal vein and superior mesenteric vein. Pancreaticoduodenectomy is not appropriate if one of them has invasion.
processing of pancreatic head, small vein between the body and superior mesenteric vein, should be cut off after ligation, in order to avoid bleeding, such as once bleeding, should immediately with finger pressure bleeding point, and the upper and lower ends of the superior mesenteric vein, absorb blood, see the damage location, accurate clamping hemostasis, do not blind clamp damage.
the scope of gastric resection, generally in 1/3-1/2.
Pancreatic fistula is the most dangerous complication after pancreaticoduodenectomy. Its incidence is very high (about 20%-30%). Once it occurs, it is often life-threatening. Preventive measures must be strengthened to reduce the occurrence of this complication.

Postoperative treatment:

such as stable blood pressure after surgery, desirable half a lie.
The abdominal drainage tube was connected with a metering bottle, and the 24-hour drainage volume was recorded and observed. If no other special circumstances occurred, the drainage tube was generally removed 5-7 days after surgery.
Fasting, continuous gastrointestinal decompression, intravenous drip of 5% GS and supplement of electrolytes, Vc, VB, and Vk1, etc., generally for 4 to 5 days. After the borborygmus recovers, the gastric tube is removed and the fluid diet is started.
the application of broad-spectrum antibiotics.
To promote early wound healing, plasma or whole blood, or 20% Albumin 50 ml was added at intervals after surgery.
pay attention to oral care, encourage patients to make effective cough, and to assist patients with continuous expectoration, in order to prevent combined pleurisy and pulmonary infection or atelectasis and other complications.
within a week after surgery to closely observe the presence of peritonitis, if there is any peritonitis, should be given timely drainage.

术后开发症：

1、胰瘘，多发生在术后5-7天，病人出现腹痛、腹胀、高烧、巩膜黄染和引流量增多现象，应考虑为胰瘘的发生。胰瘘发生后一般采取保守治疗，但必须给于支持疗法。

2、内出血。腹腔出血偶有发生，可给予止血剂的应用、输血等治疗，如有活动性出血，经保守治疗无效时，应给予再次手术止血。

3、腹腔内感染。腹腔内感染也是一种严重的并发症，一旦发生，应首先采取保守治疗。如有脓肿形成，应给予及时的手术引流，除应给予抗菌素治疗外还应给于输血，或血浆，或 20% Albumin。

4、胆瘘，很少发生，一旦发生，应充分地进行引流和体外营养液的补充。

Postoperative development:

Pancreatic fistula occurs more than 5 to 7 days after operation. The patient suffers from abdominal pain, abdominal distension, high fever, scleral yellowing and increased drainage volume. The occurrence of pancreatic fistula should be considered. Conservative treatment is usually adopted after the occurrence of pancreatic fistula, but supportive therapy must be given.
Internal bleeding. Abdominal bleeding occurs occasionally, and can be treated with hemostasis, blood transfusion, etc. If there is active bleeding, and the conservative treatment is ineffective, reoperation shall be performed to stop bleeding.
Intra-abdominal infection. Intra-abdominal infection is also a serious complication that should be treated conservatively first. If an abscess is formed, prompt surgical drainage should be given and, in addition to antibiotic therapy, blood transfusion or plasma, or 20% Albumin.
biliary fistula, rarely occurs, once occurs, should be fully drainage and supplement of nutrient solution in vitro.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Treatment of cardiac cancer

Training material VI

Treatment of cardiac cancer

胃癌在临床上一旦确诊，应考虑尽快地施行手术治疗，但术后还应结合病人的实际情况，采取综合性治疗如化疗、中医中药治疗、免疫治疗等。

胃体癌、胃底癌、贲门癌或全胃癌的癌肿应施行全胃切除术，在临床上根据手术切除的彻底性分为根治性全胃切除术及姑息性全胃切除术。另外根据是否同时切除其他脏器，又可分为单纯性胃切除术和联合脏器切除术两种。全胃切除术的切除范围通常包括全胃，十二指肠球部食管下端的一部分、大网膜、小网膜及胃脾韧带，并在根部结扎，切断胃的所属血管，以清除胃周围转移淋巴结，这就是单纯性全胃切除术。有时脾门及胰腺上缘有转移的淋巴结，需同时将脾及胰尾切除，也有时癌侵及了横结肠或肝左叶，需将部分横结肠或肝左叶一并切除，这就是联合切除术。

是否需作全胃切除术，术前有时难以决定，往往需在剖腹后，根据病变部位，癌肿扩散程度及机体状况等方面来判断。其原因是，凡用胃大部分切除术不能根治，而只有切除全胃才能根治的胃癌才考虑全胃切除术。要慎重选择全胃切除术的适应症，尽量少采用姑息性全胃切除术，尤其是姑息性联合切除术，以免带来不良后果。

手术原则是: 操作时应从周边向中心进行，并在根部结扎，切断胃的所属血管，切断端距癌瘤边缘要有一定的安全距离 (一般在5cm)，操作中用纱布包裹肿瘤井保护腹腔，以做到清除胃周围转移淋巴结，并防止癌细胞扩散。

全胃切除术消化道重建有以下几种方法 (略)。

术后井发症;

1、吻合口瘘：是全胃切除术后最重要并发症，多在术后 5-7 天，即开始进食时出现，如体温上升，脉搏增快，烦躁不安并有腹痛及恶心等症状时，应想到吻合口瘘的可能。一旦确诊应行腹腔引流，同时作空肠造瘘补给营养，加大抗菌素应用。

2、膈下感染: 由于创伤大，腹腔有时受到污染后而出现感染，一般在术后一周后有持续体温升高，血象高，有呃逆现象，往往通过X线摄片或 BUS 检查而定诊断。

3、腹泻：多发生在老年病人，常为消化不良性稀便，病人很快消瘦，主要是由于老年病人消化能力减低，加之全胃切除以后，消化与吸收的机能更加减退，食物刺激小肠使其蠕动增强所致。

4、反流性食管炎: 是一个晚期并发症，主要表现为胸骨后烧灼样疼痛、呃逆、向口腔反流苦水，给予稀盐酸合剂，症状可缓解。

5、营养障碍：主要表现为逐步消瘦及贫血，全胃切除后食物不能充分与胆汁、胰液混合，而且迅速进入空肠，影响消化与吸收。

6、吻合口狭窄: 主要是在吻合时，吻合口内翻过多所致，或因疤痕收缩而引起，或因吻合口过小等均可发生。一旦发生后，可行扩张术或再次手术。

Once gastric cancer is clinically diagnosed, surgical treatment should be considered as soon as possible, but combined with the actual situation of patients after surgery, comprehensive treatments such as chemotherapy, traditional Chinese medicine treatment, immune treatment, etc. should be taken.

Total gastrectomy should be performed for cancers of gastric body cancer, gastric fundus cancer, cardiac cancer or whole gastric cancer. According to the completeness of surgical resection, total gastrectomy is divided into radical gastrectomy and palliative total gastrectomy clinically. In addition, according to whether other organs are resected at the same time, the disease can be divided into simple gastrectomy and combined organ resection. Total gastrectomy usually covers the whole stomach, part of the lower esophagus of the duodenal bulb, the greater omentum, the lesser omentum, and the gastric and splenic ligaments, and ligation is performed at the root to cut off the blood vessels belonging to the stomach in order to remove the metastatic lymph nodes around the stomach. This is pure total gastrectomy.

Sometimes there are metastatic lymph nodes at the splenic hilus and superior margin of pancreas, and the spleen and pancreatic tail need to be removed at the same time. Sometimes the cancer invades the transverse colon or left lobe of liver, and part of the transverse colon or left lobe of liver needs to be removed together. This is called combined resection. Whether total gastrectomy is required is sometimes difficult to determine preoperatively, and often depends on the site of the lesion, the extent of tumor spread, and the body condition after laparotomy. The reason for this is that total gastrectomy is considered for gastric cancer which cannot be cured by most gastrectomy, but only by resection of the whole stomach. The indications of total gastrectomy should be carefully selected, and palliative total gastrectomy, especially palliative combined gastrectomy, should be avoided as much as possible to avoid adverse consequences.

The principle of surgery:

the operation should be performed from the periphery to the center, and ligation should be performed at the root. The blood vessel of the stomach should be cut off, and the cut end should be a certain safe distance (generally 5cm) from the edge of the tumor. The abdominal cavity should be protected by wrapping the tumor well with gauze during the operation, so as to clear the metastatic lymph nodes around the stomach and prevent the spread of cancer cells. There are several methods for digestive tract reconstruction after total gastrectomy (omitted).

Postoperative diseases:

Anastomotic fistula: It is the most important complication after total gastrectomy. It usually occurs 5 to 7 days after surgery, when food is eaten. For example, when the body temperature rises, the pulse increases, the patient is agitated, and there are symptoms such as abdominal pain and nausea, the possibility of anastomotic fistula should be considered. Once diagnosed, abdominal drainage should be performed, together with jejunostomy for nutritional supplement and increased application of antibiotics.
Hypophragmatic infection: Due to large trauma, the abdominal cavity is sometimes infected due to contamination. Generally, the patient has a continuous increase in body temperature, high hemogram, and hiccup after one week after surgery, which is often diagnosed through X-ray film or BUS examination.
Diarrhea: It mostly occurs in the elderly patients, often causing indigestion and loose stool. The patients soon lose weight, mainly due to the reduced digestive ability of the elderly patients. In addition, after the total gastrectomy, the digestive and absorption functions are further reduced, and food stimulates the small intestine to enhance its peristalsis.
Reflux esophagitis: It is a late complication mainly manifested as post-sternal burning-like pain, hiccup, and bitter water regurgitating into the mouth. The symptoms can be relieved after administration of dilute hydrochloric acid mixture.
Nutrition disorder: It is mainly characterized by progressive emaciation and anemia. After total gastrectomy, food cannot be fully mixed with bile and pancreatic juice, and quickly enters the jejunum, thus affecting digestion and absorption.
Anastomotic stenosis: It is mainly caused by excessive turnover in the anastomosis during anastomosis, or caused by scar contraction, or due to excessively small anastomosis. Once it has occurred, dilatation or reoperation may be performed.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Indications of splenectomy and effects on body after splenectomy (DRAFT)

Training material IV

Indications of splenectomy
and effects on body after splenectomy

一、脾切除术指征

(一) 血液病

血液病与脾外科的关系甚为密切，1887年 Spencer 首先为遗传性球形细胞增多症作脾切除术。从此为外科脾切除治疗血液病揭开了新的一页。但对血液病患者进行选择性脾切除或急症脾切除术、以及术前准备、手术时机等，与一般疾病所行脾切除不同，有其特殊性。

1、遗传性球形红细胞增多症 (Hereditary Spherocytosis, HS) 又称家族性溶血性贫血或先天性溶血性黄疸。本病属常染色体显性遗传。凡是确诊HS者临床有贫血与脾大，都应行脾切除治疗。Williams、Schwartz 等均指出，确诊为HS后即使轻型患者，都是脾切除指征，脾切除作为HS的主要治疗方法，并有显著疗效，已被国内外学者公认。由于幼儿手术后易发生感染，故在4岁以下儿童不宜施行脾切除。

2、遗传性椭圆形红细胞增多症 (Hereditary Elliptocytosis, HE) 亦属常染色体显性遗传疾病，临床上无任何症状者可不予治疗，如有贫血、脾大与溶血性黄疸的重型病例，应行脾切除治疗。

3、地中海贫血为遗传性血红蛋白合成障碍性疾病，脾切除对减轻溶血和减少输血量有帮助。脾切除对 α 型地中海贫血有较好疗效，HbE-β 型则差，中科院血研所对29例 α 地中海贫血患者行脾切除术，术后 Hb 明显升高，但术前Hb在 80g/L 以上者，术后 Hb 上升不显，提出因 Hb 在 80g/L 以下者适合手术治疗。同时对11例 β 型地中海贫血患者行脾切除术，其疗效均不如α型。α型地中海贫血脾切除手术指征: (1) 年龄在3岁以上; (2) Hb 在 80g/L 以下; (3) 脾亢伴全血细胞减少; (4) 51Cr 红细胞寿命缩短，脾肝比值 >2，脾定位指数增高者。

4、自体免疫性溶血性贫血 (Autoimmune Hemolytic Anemia, AHA) 是一种后天获得性溶血性贫血，系机体免疫功能紊乱，而产生了能破坏自身正常的红细胞的抗体所致。？？？原理主要是去除了产生破坏自身红细胞或血小板抗体的主要场所，故温抗体型原发性 AHA 适合于脾切除治疗，而冷抗体型 AIHA 的溶血主要发生在血循环或肝脏中，故不适合脾切除治疗。脾切除指征: (1) 药物治疗无效或长期用药，停药后复发者；(2) 合并血小板减少的 Evans 综合症，皮质激素等治疗效果不满意者; (3) 51Cr 同位素体表测定，红细胞主要在脾脏潴留破坏者；(4) 单纯 IgG 型 Coombs 试验阳性脾切除效果佳。国内外报道脾切除疗效一般在 60% 左右。

5. 原发性血小板减少性紫癜 (Idiopathic Thrombocytopenic Purpura, ITP)
本病的发生与自体免疫有关，血小板上均吸附有免疫球蛋白 G，这种带有免疫球蛋白的血小板在胆及肝内被巨噬细胞提前破坏，破坏的部位 2/3 病人在脾。故而多数病例脾切除后血小板计数可迅速上升，关于 ITP 脾切除的疗效报道甚多，有效率在 80% 左右，对于急性 ITP 患者是否行急症脾切除术，意见不甚一致。一般认为，急性 ITP 患者用强的松、大剂量静脉输注丙种球蛋白等无效，出血危及生命时，可进行紧急脾切除术; 慢性 ITP 患者的脾切除指征: (1) 在病程达6个月以上，经用激素或免疫抑制等治疗而未缓解者; (2) 血小板计数低于 25×103/L，有颅内出血或其他脏器大出血者: (3) 激素或免疫抑制剂等药物治疗效果不佳或长期需用较大剂量激素维持者；(4) 对激素或免疫抑制剂应用有禁忌者；(5) 51Cr 标准检查血小板主要在脾脏？？破坏者。

6. 慢性再生障碍性贫血 (Chronic Aplastic Anemia, CCA) Mitchell指出对 CCA 选择性脾切除是有益的，可以减轻溶血，延长血小板寿命和减少输血。CAA 选择脾切除手术指征: (1) 骨髓增生较好，红系偏高，合并溶血而内科治疗无效者；51Cr 测定红细胞或/和血小板寿命缩短，脾脏破坏为主的。中科院血研所对28例 CAA 患者行脾切除治疗，有效率为 65.2%。

7. 慢性粒细胞性白血病 (Chronic Myeloid Leukemid, CML) 70年代，一些学者认为急变细胞在脾脏较多，脾切除可以防止 CML 急性变。但近年来研究，脾切除不能防止 CML 急变，也无何益处。目前对 CML 患者除非巨脾引起机械压追症状、脾亢，龙其是伴有血小板减少者，一般不再主张脾切除术，因为脾切除并不能延长生存或延缓急变的发生。

8. 毛细胞性白血病 (Hairy Cell, HCL) 当伴有脾肿大和脾功能亢进时，是外科脾切除指征。Jansen 认为在以下情况，手术效果较好：(1) 脾在肋缘大于等于4cm; (2) 脾在助缘下 1-3cm，但 Hb<85g/L 或 Hb85-120g/L, pt≤50×109/L; (3 ) 脾摸不到，但Hb<85g/L，pt≤50×109/L.

9. 戈谢病 (Gaucher 病) 多见于幼儿，属常染色体隐性遗传。Mitchell 指出伴脾肿大，脾功亢进是脾切除指征，但脾切除对此病仅是一种对症治疗，可以缓解由于脾功能亢进引起的全血细胞减少等症状，并非能解决先天性家族性类脂代谢的紊乱。

10. 骨髓纤维化症 (Myelofibrasis, MF) 原发性MF的脾切除指征为: (1) 疼痛性脾肿大；(2) 巨脾引起机械性压追症状; (3) 脾功能亢进全血细胞明显减少和难以控制的溶血; (4) 需经常输血或用皮质激素治疗，骨髓涂片尚见部分造血灶，特别是年轻病人。Benbasat 收集了英、法、德文中 321 例 MF 患者脾切除资料，约 64% 患者手术有治标作用，输血量减少，出血倾向和腹痛减轻。但病人于术后可出现代偿性肝肿大，对于合并活动性肝病和 pt 计数偏高者，不适宜脾切除术。

11. 何杰金氏病 (Hodgkin’s Disease, HD) 某些脾脏受累伴脾亢者可以行脾切除术。Mitchell 提出临床分期 IA、IB 和 A 的病例可考虑脾切除或作为剖腹探查的一部分手术，剖腹探查进行肝脏和淋巴结活检并切除脾脏，可以查明腹腔淋巴结受累程度及病变累及范围，便于提出针对性的治疗方案; 同时脾切除还可使患者发热、乏力等全身症状获得缓解，并可解决脾亢和增强对放疗或化疗的耐受性。

T his is the traditional viewpoint of spleen cutting which has lasted for two to three hundred years: “The spleen is not necessary for life. The spleen can be removed at will.” With the development of modern medicine, as well as the in-depth exploration and research on the function of the spleen, it has been gradually found that the spleen has non-negligible immune functions such as anti-infection and anti-cancer. Therefore, selective and effective splenectomy has become a trend of the times. However, to systematically understand the general view of spleen function and the adverse effects on the body after splenectomy, and to correctly grasp the indications of splenectomy are the key to ensure the quality of splenic surgery.

“脾脏并非生命所必需，脾可以随便切除。” 这便是历时二、三百年的传统切脾观点。随着现代医学的发展，以及对脾脏功能深入探索和研究，已陆续发现脾脏具有不可忽视的抗感染、抗癌等免疫功能。因此，选择性有效保脾手术已成为一种时代的倾向。但系统地了解脾脏功能的全貌及去脾后对机体有哪些不利的影响，正确地掌握脾切除的指征，这便是保证脾外科质量的关键之关键。

A, splenectomy indications

(1) Hematopathy

Hematological diseases are closely related to splenic surgery. In 1887, Spencer first performed splenectomy for hereditary spherocytosis. A new page was opened for surgical splenectomy to treat hematological diseases. However, selective splenectomy or emergency splenectomy for patients with hematological diseases, as well as preoperative preparation and operation timing, are different from splenectomy for general diseases and have their own particularities.

Hereditary Spherocytosis, HS) is also known as familial hemolytic anemia or congenital hemolytic jaundice. The disease is autosomal dominant. Splenectomy should be performed for all patients diagnosed with HS who have anemia and splenomegaly in clinic. Williams and Schwartz et al. pointed out that even mild patients after the diagnosis of HS were indications of splenectomy. Splenectomy as the main treatment of HS, with significant efficacy, has been recognized by scholars both in China and abroad. Splenectomy is not recommended for children under 4 years of age due to the susceptibility of infants to infection after surgery.
Hereditary elliptic erythrocytosis (HE) is also an autosomal dominant disease, and it can be treated without any clinical symptoms. In case of severe anemia, splenomegaly and hemolytic jaundice, splenectomy should be performed.
thalassemia for hereditary hemoglobin synthesis disorder, splenectomy to reduce hemolysis and reduce the amount of blood transfusion. Splenectomy had good curative effect on α thalassemia, while HbE-β type was worse. The Institute of Blood Research of Chinese Academy of Sciences performed splenectomy on 29 patients with α thalassemia. The Hb post-surgery increased significantly. However, for the patients with Hb above 80g/L before surgery, the Hb post-surgery did not increase significantly. It was proposed that the patients with Hb below 80g/L were suitable for surgical treatment. At the same time, splenectomy was performed on 11 patients with β -thalassemia, and the curative effects were not as good as those of α-thalassemia. Indications of splenectomy for α -thalassemia: (1) Aged over 3 years old; (2) Hb is below 80g/L; (3) Hyperactivity of spleen with pancytopenia; (4) 51Cr shortened red blood cell life, spleen-liver ratio > 2, and increased spleen positioning index.
Autoimmune Hemolytic Anemia, AHA) is an acquired hemolytic anemia caused by the production of antibodies against red blood cells that can destroy the body's normal function due to the body's immune dysfunction. ? ? ? The principle is to remove the main place where the antibodies that destroy your red blood cells or platelets are produced. Therefore, warm antibody type primary AHA is suitable for splenectomy, while cold antibody type AIHA hemolysis occurs mainly in the blood circulation or liver, so it is not suitable for splenectomy. Indications of splenectomy: (1) patients who failed to respond to medication or took medication for a long time, and relapsed after drug discontinuation; (2) Patients with Evans syndrome complicated with thrombocytopenia, and patients with unsatisfactory therapeutic effects such as corticosteroids; (3) 51Cr isotope body surface measurement shows that red blood cells are mainly in the spleen retention destroyer; (4) Splenectomy with positive IgG-type Coombs test was effective. It has been reported in China and abroad that the curative effect of splenectomy is generally about 60%.
Idiopathic thrombocytopenic purpura (ITP) The occurrence of this disease is related to autoimmune. Immunoglobulin G is adsorbed on the platelets. The platelets with immunoglobulin G are damaged in advance by macrophages in the gallbladder and liver. The damage site is 2/3 in the spleen. Therefore, in most cases, the platelet count can rise rapidly after splenectomy. There are many reports on the efficacy of splenectomy for ITP, with the effective rate of about 80%. There are different opinions on whether to perform emergency splenectomy for patients with acute ITP. It is generally considered that prednisone and high-dose intravenous immunoglobulin are ineffective for patients with acute ITP, and emergency splenectomy can be performed when bleeding is life-threatening. Indications for splenectomy in patients with chronic ITP: (1) those who have been treated with hormones or immunosuppression for more than six months without remission; (2) Patients with platelet count less than 25×103/L and intracranial hemorrhage or massive hemorrhage of other organs: (3) patients who had unsatisfactory therapeutic effects of drugs such as hormones or immunosuppressants, or who needed to maintain a large dose of hormones for a long time; (4) the hormone or immunosuppressive agent application taboo; (5) Platelet detected by 51Cr standard is mainly in spleen? ? Saboteurs.
Chronic aplastic anemia (CCA) Mitchell pointed out that selective splenectomy for CCA was beneficial to reduce hemolysis, prolong platelet life and reduce blood transfusion. Indications for splenectomy for CAA: (1) patients with good bone marrow hyperplasia, high erythroid, and hemolysis, for which medical treatment was ineffective; 51Cr determination of red blood cells and/or platelets life expectancy, spleen damage. The Institute of Hematology of the Chinese Academy of Sciences performed splenectomy on 28 patients with CAA, and the effective rate was 65.2%.
Chronic myeloid leukemia (CML) In the 1970s, some scholars believed that there were more acute transformation cells in the spleen, and splenectomy could prevent acute transformation of CML. However, it has been proved in recent years that splenectomy cannot prevent CML from sudden change and is of no benefit. At present, for patients with CML unless the massive spleen causes symptoms of mechanical chase and hypersplenism, and the massive spleen is accompanied by thrombocytopenia, splenectomy is generally no longer advocated because splenectomy cannot prolong survival or delay the occurrence of sudden changes.
Hairy cell leukemia (HCl) is an indication for surgical splenectomy when accompanied by splenomegaly and hypersplenism. Jansen believed that the surgery had better effects under the following conditions: (1) The spleen was larger than or equal to 4cm at the costal margin; (2) The spleen is 1–3 cm below the synergic edge, but Hb<85g/L or HB85–120 g/L, Pt ≤ 50 × 109/L; (3) The spleen was not palpable, but Hb<85g/L, Pt ≤ 50 × 109/L.
Gaucher disease occurs more frequently in young children and is autosomal recessive. Mitchell pointed out that with splenomegaly, hypersplenism was the indication for splenectomy, but splenectomy was only a symptomatic treatment for the disease, which could alleviate the symptoms such as pancytopenia caused by hypersplenism, rather than solve the congenital disorder of familial lipid metabolism.
Myelofibrasis, MF) The indications of splenectomy for primary MF are as follows: (1) Painful splenomegaly; (2) Giant spleen causes mechanical chase after symptoms; (3) The pancytopenia of hypersplenism and uncontrolled hemolysis; (4) Regular blood transfusion or corticosteroid treatment is needed, and partial hematopoietic foci are still observed on bone marrow smear, especially for young patients. Benbasat collected 321 cases of MF patients with splenectomy data in English, French and German, about 64% of the patients have palliative effect, reduce the amount of blood transfusion, bleeding tendency and abdominal pain. However, the patient may develop compensated hepatomegaly postoperatively, and splenectomy is not appropriate for patients with combined active liver disease and high pt counts.
Hodgkin's Disease, HD): splenectomy can be performed for some patients with splenic involvement and hypersplenism. Mitchell proposed that for cases with clinical stages IA, IB and A, splenectomy or surgery as part of laparotomy could be considered, and laparotomy with liver and lymph node biopsy and splenectomy could be performed to identify the extent of abdominal lymph node involvement and the lesion involvement, so that targeted treatment could be proposed. At the same time, splenectomy can also relieve the patients' systemic symptoms such as fever and fatigue, solve the hypersplenism and enhance the tolerance to radiotherapy or chemotherapy.

(二) 脾功能亢进

主要由于肝硬变导致门静脉高压而引起充血性脾肿大，巨脾在血吸虫性肝硬变时尤为多见。周围血细胞减少是由于脾红髓增生时其正常滤过及储存功能呈病理性亢进时所致。脾切除可使周围血液恢复正常。我国大量晚期血吸虫病人行脾切除后 4-5 年的随访结果，生车率达94%。对肝炎后肝硬化或所谓的班替氏病患者的巨脾应根据脾功能亢进程度，静脉曲张有无及全身情况慎重考虑单纯脾切除或与其它分流及断流手术合用，若患者因任何原因造成显著脾肿大有压迫症状或有脾梗塞、脾破裂之危险者也可考虑脾切除。

B. hypersplenism

Congestive splenomegaly is mainly caused by portal hypertension due to cirrhosis, and splenomegaly is particularly common in schistosomal cirrhosis. The decrease in peripheral blood cells is due to the pathological hyperfunction of the normal filtration and storage functions of the splenic red pulp when it proliferates. Splenectomy can normalize the surrounding blood. According to the 4–5 year follow-up results of a large number of people with advanced schistosomiasis in China after splenectomy, the car-bearing rate has reached 94%. Splenectomy alone or in combination with other shunting and devascularization procedures should be carefully considered in patients with post-hepatitis cirrhosis or so-called Banteay's disease whose massive spleen is in accordance with the degree of hypersplenism, the presence of varicose veins and the general condition. Splenectomy may also be considered in cases where the patient suffers from any cause of marked splenomegaly with symptoms of compression or a risk of splenic infarction or splenic rupture.

(三) 脾破裂

脾切除曾一直是治疗损伤的唯一治疗方法。但自1952年 King 报告了儿童脾切除术后发生爆发性感染 (Overwhelming postspleenectomy infection, OPSI) 引起了人们对脾切除术的重新认识。随着对脾脏生理功能研究的深入，各种脾手术兴起，诸如脾修补术、脾部分切除术等，这些手术保留了脾脏功能，但需要一定的技术水平、经验及术后严密观察。总的原则是抢救生命第一、保留脾脏第二，即在保证生命安全的前提下，尽可能保留脾脏或保存 (或保存一部分) 脾功能，既不要不管损伤程度如何，一律采用切脾治疗，又切忌不顾病人安危而强行保脾治疗。必须根据病情及本医院技术力量，制定适合于自己的单位的切脾适应证，切忌千篇一律，以保证疗效。一般来说，全切除术的适应证：(1) IV 度破裂伤，全脾破裂或广泛性脾实质破裂，脾脏血供完全中断；(2) 有威胁生命的多发伤；(3) 病情重、血压不稳定；(4) 脾缝合术不能有效的止血。

C. Spleen rupture

Splenectomy has always been the only treatment for injury. However, the outbreak of fulminant infection (OPSI) after splenectomy in children reported by King in 1952 has aroused new understanding of splenectomy. With the deepening of research on the physiological function of the spleen, various splenic operations have arisen, such as splenic repair and partial splenectomy, which preserve the spleen function but require a certain technical level, experience and close observation after surgery. The general principle is to save life first and preserve the spleen second, that is, on the premise of ensuring the safety of life, to preserve the spleen or preserve (or preserve part of) the spleen function as much as possible. The spleen cutting treatment should be adopted regardless of the degree of injury, and the spleen conservation treatment should not be forced regardless of the safety of the patient. According to the condition and the technical strength of our hospital, an indication suitable for spleen resection in our unit must be formulated, and no one in common is required to ensure the curative effect. In general, the indications of total resection: (1) Degree IV rupture injury, whole spleen rupture or extensive splenic parenchyma rupture, and complete interruption of splenic blood supply; (2) There are multiple life-threatening injuries; (3) Severe illness and unstable blood pressure; (4) Spleen suture cannot effectively stop bleeding.

二、脾切除术后对机体的影响

(一) 免疫功能低下

脾脏是一个重要的免疫器官，脾脏对机体提供的免疫保护作用是终生的，对婴幼儿和儿童尤其显得重要。脾脏有如一个滤器对侵入血流中的颗粒抗原如细菌首先可发挥机械清除及滤过作用。脾脏还可以产生具有强大调理作用的IgM，经过调理的抗原才易被脾内外吞噬细胞所吞噬。脾脏产生的 Tuftsin，能有效促进多形核细胞吞噬。实验证明半脾切除之后，脾清除能力下降 25%，脾动脉结扎后下降 50%，脾切除后脾清除作用消失。

脾切除后最主要的并发症是由免疫功能低下引起的感染，因为: (1) 脾脏是制造 IgM 的重要场所，感染后首先是 IgM 的增高 (初级免疫反应)。IgM的半衰期只有5天，脾切后 IgM 很快下降，故可发生对感染的免疫应答功能低下；(2) 丧失了脾的“滤器”功能; (3) 不能制造吞噬作用激素，备解素及非特异性调理素，吞噬细胞的吞噬及清除细菌的功能明显减退。据统计外伤而切除脾脏的病人出现凶险的脾切除术后感染 (OPSI) 的危险是正常人群的50倍。因特发性血小板减少症，后天性溶血性贫血，何杰金氏病和其他血液病而施行脾切除者，其出现 OPSI 的危险性更大。

II. Effects on body after splenectomy

(a) low immune function

The spleen is an important immune organ. The immune protection provided by the spleen is lifetime, especially important for infants and children. The spleen acts as a filter for the mechanical clearance and filtration of particulate antigens such as bacteria that invade the bloodstream. The spleen can also produce IgM with a strong conditioning effect, and the conditioned antigen is easily swallowed by the phagocytes inside and outside of the spleen. Tuftsin produced by the spleen can effectively promote the phagocytosis of polymorphonuclear cells. Experiments showed that after hemisplenectomy, the splenic clearance decreased by 25%, and that after splenic artery ligation it decreased by 50%. The splenic clearance disappeared after splenectomy. The most important complication after splenectomy is infection caused by low immune function because: (1) The spleen is an important place for the production of IgM, and the first complication after infection is the increase of IgM (primary immune response). IgM has a half-life of only five days, and it decreases rapidly after splenectomy, so a low immune response to infection may occur. (2) Loss of the "filter" function of the spleen; (3) Can't produce phagocytic hormone, properdin and non-specific opsonin; the phagocytosis of phagocytes and the function of removing bacteria are decreased obviously. The risk of a dangerous post-splenectomy infection (OPSI) is calculated to be 50 times higher in patients with traumatic splenectomy than in the normal population. Splenectomy for idiopathic thrombocytopenia, acquired hemolytic anemia, Hodgkin's disease, and other hematological disorders is associated with a greater risk of developing OPSI.

(二) 血液流变学改变

脾切除后由于细胞碎片，Howell-Jolly小体，Heinz 小体及其他代谢产物无法清除，红细胞内粘度升高，红细胞变形能力降低，因而脾切除术后血液粘度升高。脾切除对血小板的影响包括数量的增加和聚集性的增强。脾切除后约13%的病人血小板可超过100万，持续数月甚至数年，造成血小板增多症。血液和血浆粘度升高，加之血小板数量增加和功能增强，使机体处于一种高凝状态，这是术后血栓和栓塞发生的基础。有报道脾切除后死于闭塞性血管疾病和缺血性心脏病的比例增高，如迁移性血栓性静脉炎，深静脉血栓形成，冠心病等。

任何手术创伤都可导致血液流变学改变，但一般手术后的改变主要在术后近期，而远期大多恢复至术前水平。脾切除术后的上述改变则是持续的，因此对脾切除术后血液流变学指标和血小板聚集性明显增强者，以及血小板数量大于 400×109/l 者要采取预防措施，对原有心、脑血管疾病者更应引起重视。

(b) The changes of blood rheology

After splenectomy, the blood viscosity increased due to the inability to remove cell debris, the Howell-Jolly bodies, the Heinz bodies, and other metabolites, as well as the increased intracellular viscosity of erythrocytes and the decreased deformability of erythrocytes. Effects of splenectomy on platelets include an increase in number and aggregation. In about 13% of patients after splenectomy, platelets can exceed 1 million and last for months or even years, causing thrombocytosis. The increased viscosity of blood and plasma, together with the increased number and function of platelets, places the body in a hypercoagulable state, which is the basis for postoperative thrombosis and embolism. It has been reported that the proportion of patients who die from occlusive vascular disease and ischemic heart disease after splenectomy is increased, such as migratory thrombophlebitis, deep vein thrombosis, and coronary heart disease.

Any surgical trauma can lead to hemorheological changes, but generally the changes after surgery are mainly in the short term after surgery, and most of them return to the preoperative level in the long term. The above changes after splenectomy are persistent, so preventive measures should be taken for patients with significantly enhanced blood rheology indexes and platelet aggregation after splenectomy, and for patients with platelet number greater than 400×109/l, and more attention should be paid to patients with original cardiovascular and cerebrovascular diseases.

三、脾切除术后并发症

脾切除术虽为一中等手术，但并发症却相当多，也有很高的死亡率，根据 Thaeton 统计一家医院 2417 例脾切除总的并发症为 39%，住院死亡率为 10%，危险性相当于或高于全胃切除术。脾切除术后合并发症可根据发生时间的不同分为早期合并症及晚期合井症。

III. Complications after splenectomy Splenectomy is a medium-sized operation, but it has many complications and a high mortality rate. According to Thaeton, the total complication rate of 2417 cases of splenectomy in a hospital is 39%, and the mortality rate in hospital is 10%. The risk is equal to or higher than that of total gastrectomy. The combined complications after splenectomy can be divided into early complications and late complications according to the time of occurrence.

(一) 早期合井症

1、出血术中及术后数内最常见的严重合并症是出血，由于脾上极与胃底距离很近，胃短血管处理不当断端出血是常见的。又如胰尾有时延伸直达脾门，因顾忌伤及胰腺，脾蒂缝扎不牢，或处理脾蒂伤及脾静脉可造成难以控制的出血，门脉高压症尤其是血吸虫性巨脾，周围粘连重且有大量侧支循环，切除脾后膈面及后腹膜常有大量出血和渗血，如止血不完善，不彻底常于术后井发出血。

2、膈下积液、膈下脓肿脾床止血不彻底，导致小量积血，或有淋巴液积聚等原因继发细菌感染而成，胃底损伤可导致胃漏，膈下积液及脓肿，胰尾损伤可导致胰漏、脓肿、胰腺囊肿及胰腺炎。

3、血小板计数过高少数脾切除后可发生严重血小板增高，甚至达 1000×109/L 以上，这种情况多为一过性。

4、左侧胸腔积液及肺炎常见于巨脾尤其是伴有门静脉高压，隔下广泛静脉侧支形成及淋巴管扩张者，因局部创伤，低蛋白血症，术后长期卧床，呼吸运动锻炼不足者。

5、脾热问题脾切除患者术后常出现较长时间发热，短者2周左右，长者可达数月之久。抗生素治疗效果不佳，可笼统称为脾热，其实不同患者的脾热应该有其具体原因，除局部感染外，切脾后免疫功能低下，及脾静脉血栓形成也是常见原因。当然有部分的病例查不出原因，且应用抗生素效果不明显，而经一时期后体温慢恢复正常，人们称之为“不明原因”发热。

(1) Early commingling of wells

The most common serious complication of hemorrhage during and after operation is hemorrhage. Due to the close distance between the superior pole of the spleen and the fundus of the stomach, it is common to have terminal hemorrhage due to improper treatment of short gastric vessels. For another example, the tail of pancreas sometimes extends as far as the splenic hilus. For fear of hurting pancreas, the pedicle of spleen cannot be firmly sutured, or uncontrolled bleeding can be caused by treating the injury of splenic pedicle and splenic vein. Portal hypertension, especially schistosomiasis splenomegaly, has severe peripheral adhesion and a large number of collateral circulation. The resection of the posterior diaphragmatic surface and retroperitoneum of the spleen often results in massive bleeding and bleeding. For example, if the hemostasis is not perfect, the bleeding will not be completely released in the postoperative well.
The hemostasis of the spleen bed for subphrenic effusion and subphrenic abscess is not complete, resulting in a small amount of blood accumulation, or secondary bacterial infection caused by lymph accumulation. Gastric fundus injury can lead to gastric leakage, subphrenic effusion and abscess, and pancreatic tail injury can lead to pancreatic leakage, abscess, pancreatic cyst and pancreatitis.
Platelet count is excessively high. A few patients may suffer from severe thrombocytosis after splenectomy, even reaching more than 1000 × 109/L. This condition is mostly transient.
Left pleural effusion and pneumonia are common in splenomegaly, especially in patients with portal hypertension, extensive collateral formation of inferior septal veins and lymphangiectasia. Due to local trauma, hypoproteinemia, the patients stay in bed for a long time after operation and have insufficient respiratory exercise.

(二) 晚期井发症

1、血栓栓塞性并发症少数病人切除后发生迁移性血栓性静脉炎或严重的深静脉血栓形成及血栓栓塞后井发症，特别是溶血性贫血及骨髓增生异常的病人脾切除后容易发生危险的血小板计数过度上升，必须密切监视病人必要时尽早采用抗凝剂或抗血小板积聚药物治疗。

2、副脾问题据国内外报道，14-30% 的切脾手术患者有副脾，全脾切除后，如遗留副脾在体内，可以完全取代脾脏的功能，甚至原来的溶血或血小板减少症等疾病的复发或疗效不佳，当再次手术切除副脾后症状便可消失。

3、脾切除术后暴发性感染 (OPSD) 早在1919后 Morris 已指出脾切除后可增加感染的局感性，并对滥行脾切除提出警告，但当时未被其他学者所重视，直到 1952 年 King 报告100例儿童球状血球性贫血脾切除后5例发生严重败血症、2例死亡，才引起人们的注意，并命名为“脾切除后暴发性感染（OPSD）”，也有人们称为“脾切除后败血症”。OPSI 的发病年率是 1.45%, 为正常情况感染死亡的 200 倍，OPSI 可发生在切脾后几周至几年之间，而发生越早，死亡率越高，但多发生在切脾后两年内，而且在儿童及患血液病患者中发病幸则更高。

(2) Late onset of well logging

thromboembolic complications occurred in a small number of patients after resection of migratory thrombophlebitis or severe deep vein thrombosis and thromboembolism after well hair disease, especially hemolytic anemia and myelodysplastic patients after splenectomy is prone to dangerous platelet count excessive rise, must closely monitor the patient as soon as possible when necessary using anticoagulant or antiplatelet accumulation drug treatment.
The accessory spleen problem According to the reports in China and abroad, 14-30% of patients undergoing splenectomy have an accessory spleen. After total splenectomy, if the accessory spleen is left in the body, it can completely replace the function of the spleen. Even the original hemolysis, thrombocytopenia and other diseases recur or the curative effect is poor, and the symptoms can disappear after the accessory spleen is resected again.
Post-splenectomy fulminant infection (OPSD) As early as after 1919, Morris pointed out that splenectomy could increase the local sensitivity of infection and warned against indiscriminate splenectomy, but it was not noticed by other scholars at that time. It was not until 1952, when King reported that five of the 100 cases of children with globocytic anemia developed severe septicemia and two died after splenectomy, which was called "OPSD", or "septicemia after splenectomy". The annual incidence rate of OPSI is 1.45%, which is 200 times of the death caused by normal infection. OPSI can occur in weeks to years after splenectomy. The earlier it occurs, the higher the death rate will be. However, it mostly occurs within two years after splenectomy, and the incidence rate is even higher in children and patients with hematological diseases.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical treatment of thyroid cancer

Training material III

Surgical treatment of thyroid cancer

甲状腺癌在病理方面可简单地分为三类:

1、乳头状腺癌: 在临床上最常见，恶性程度较轻，主要是转移至颈部淋巴结。

2、腺泡状腺癌: 恶性程度中等度，主要经血运转移，至骨和肺部。

3、未分化的单纯癌: 恶性程度甚高，极早转移至颈部淋巴结，也可经血运转移至骨和肺部，预后较差。

甲状腺癌在临床方面，手术处理的疗效是符合于病理分类的:

1、在乳头状腺癌，如果切除原发患的同时，将颈部淋巴结仔细、彻底地加以清除，五年治愈率可达90%以上。

2、在腺泡状腺癌，如果颈部淋巴结已有转移，大多已有远处转移，因此即使彻底清除了颈部淋巴结，也不能增高手术疗效。

3、未分化的单纯癌，发展甚快，一般在发病后2-3个月即出现压迫症状 (疼痛、声嘶，呼吸困难) 或远处转移，强行手术切除，不但无益，而且可加速癌细胞经血运的扩散，因此如果怀疑为恶性甚高的单纯癌，可先行穿刺作活组织检查证实之，治疗则以放射为主。

手术切除乳头状腺癌或腺泡状腺癌，一般在气管内麻醉下进行，操作步骤与甲状腺部分切除相同，但要注意以下几个问题:

1、切口要宽大，胸锁乳突肌前缘要剪开，显露就好。

2、不可损破内层被膜，当然也不宜应用丝线穿扎腺体作牵拉用，以防止癌细胞种植在切口中。

3、不保留腺体背面部分，而切除全部腺体，但应尽量保留甲状旁腺，也应尽量不损伤喉返神经，如果癌肿局限在一叶的腺体内，可将患叶的腺体连同甲状腺峡部全部切除之，如果癌肿已侵及左右两叶，就需将两叶腺体连同甲状腺峡全部切除之，但至少应保留一侧的甲状旁腺，不使术后发生严重的手足抽搐，甲状腺内层被膜的完整与否 (被癌组织穿破与否)，对原发癌的能否完全切除，具有决定性的意义。

在切除原发癌肿后，接着就应仔细、彻底地清除患侧的颈部淋巴结。

1、清除颈外侧部的淋巴结组织。

2、颈总动脉和颈内静脉深面的淋巴结，

3、再清除气管前，甲状腺峡部以上的淋巴结。

4、然后再清除甲状腺后气管旁，喉返神经周围的以及上纵隔内的淋巴结，同时切除胸锁乳突肌和其他重要组织 (一侧的颈内静脉和颈总动脉等) 是无需的，并不能增高手术疗效。

如果已有远处转移，对局部可以全部切除的腺癌不但应将患叶的腺体全部切除，患侧的颈部部淋巴结加以清除，同时还应切除健叶的全部腺体，这样一方面可防止由于原发癌的发展、增大而发生压迫性症状，另方面可试用放射碘 131 来治疗远处转移。腺癌的远处转移只能在切除整个甲状腺后，才能撮取放射性碘，如果远处转移，撮取放射性碘量极低微，则在切除整个甲状腺后，由于垂体前叶促状腺激素的分泌增多，反而促使远处转移迅速发展，对这种试用放射性碘无效的病例，应早期给予足够量的甲状腺制剂，以抑制促甲状腺素的产生，远处转移可因此而缩小，至少不再继续发展，手术中可能要施行气管切开以保持呼吸道通畅。

Thyroid cancer in pathology can be simply divided into three categories:

Papillary adenocarcinoma: It is the most common adenocarcinoma in clinic, with mild malignancy, mainly involving metastasis to the cervical lymph nodes.
Alveolar adenocarcinoma: The malignancy is moderate, and it is mainly transferred through blood supply to bone and lung.
undifferentiated simple carcinoma: the malignancy is very high, and it metastasizes to the cervical lymph nodes very early, or it can metastasize to the bone and lung through blood supply, with poor prognosis.

Clinically, the efficacy of surgical treatment of thyroid cancer is in line with the pathological classification:

in the papillary adenocarcinoma, if the resection of the primary disease at the same time, the neck lymph nodes carefully and thoroughly removed, five years the cure rate can reach more than 90%.
n acinar adenocarcinoma, if the cervical lymph nodes have metastasized, most of them have distant metastasis. Therefore, even if the cervical lymph nodes are completely removed, the surgical efficacy cannot be improved.
undifferentiated pure cancer, development is very fast, generally in 2 to 3 months after the onset of the compression symptoms (pain, hoarseness, dyspnea) or distant metastasis, forced surgical resection, not only useless, and can accelerate the spread of cancer cells through the blood supply, so if it is suspected to be very high malignant pure cancer, can first puncture for biopsy confirmed, treatment is given priority to with radiation.

Surgical resection of papillary adenocarcinoma or acinar adenocarcinoma, generally under endotracheal anesthesia, the operation steps are the same as partial thyroidectomy, but should pay attention to the following questions:

incision to wide, sternocleidomastoid muscle leading edge to cut open, show.
do not damage to break the inner capsule, of course, also should not use silk thread wear tie gland for pulling, in order to prevent cancer cells planted in the incision.
The back part of the gland is not preserved, and all the glands are excised. The parathyroid should be preserved as much as possible, and the recurrent laryngeal nerve should not be damaged as much as possible. If the cancer is confined to one lobe of the gland, all the glands in the lobe together with the thyroid isthmus can be excised. If the cancer has invaded the left and right lobes, the two lobe glands together with the thyroid isthmus should be excised completely. However, at least one side of the parathyroid should be preserved, so that no severe convulsion of hands and feet occurs after the operation. Whether the inner capsule of the thyroid is intact or not (worn out by the cancer tissue) is of decisive significance for the complete resection of primary cancer.

After resection of the primary cancer, careful and thorough removal of the cervical lymph nodes on the affected side should follow.

remove the lateral cervical lymph node tissue.
the common carotid artery and internal jugular vein deep lymph nodes,
before the removal of trachea, thyroid isthmus above the lymph nodes.
After that, the paratracheal lymph nodes around the recurrent laryngeal nerve and the lymph nodes in the upper mediastinum should be removed. Meanwhile, the sternocleidomastoid muscle and other important tissues (internal jugular vein and common carotid artery on one side) should be removed. This is unnecessary and cannot increase the curative effect of the operation.

If there is distant metastasis, the local adenocarcinoma can be completely removed not only should be the gland of the diseased leaves all resection, the affected side of the neck lymph nodes to be removed, at the same time should also remove all the glands of the healthy leaves, so on the one hand can prevent due to the development of primary cancer, increase and oppressive symptoms, on the other hand can try radiation iodine 131 to treat distant metastasis. Distant metastasis of adenocarcinoma can only take radioactive iodine after the whole thyroid gland is resected. If the distant metastasis takes radioactive iodine with extremely low amount, then after the whole thyroid gland is resected, the distant metastasis will develop rapidly because of the secretion increase of thyroid-stimulating hormone in anterior pituitary gland. In the case that radioactive iodine is ineffective for trial use, thyroid preparations with sufficient amount should be given early to inhibit the production of thyrotropin. The distant metastasis can shrink because of this, and at least it will not continue to develop. Tracheotomy may be performed during the operation to keep respiratory tract unobstructed.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Extrahepatic biliary injuries

Training material II

Extrahepatic biliary injuries

The vast majority of extrahepatic biliary injuries are iatrogenic, and they have been increasing in recent years, with an incidence rate at about 2–3% (1 out of 300–500 gallbladder surgeries). Of the iatrogenic bile duct injuries, 90% are found in cholecystectomy, 5% in common bile duct exploration, 3% in subtotal gastrectomy, and 2% in duodenal diverticulum resection. In the operation of portacaval shunt and pancreas, if the biliary tract injury is not detected and treated in time during the operation, the consequences are often very serious, which must arouse the surgeon's high attention.

1. Factors causing iatrogenic bile duct injury

1.1 Anatomical factors: There are many anatomical variations of biliary tract, and ignorance of them is likely to cause biliary tract injury.

The cystic duct is too short, or even the neck of the gallbladder is directly connected with the common bile duct, these are likely to lead to the procedure error in mistaking the common bile duct as the cystic duct during ligation.
The cystic duct is too long and it runs parallel to the common bile duct. Tightly clinging to the common bile duct, it flows downward into the common bile duct in the rear of duodenum or head of pancreas. It is easy to cause accidental injury to the common bile duct when separating the cystic duct.
When the cystic duct opens from the right hepatic duct or the right hepatic duct flows into the cystic duct, the right hepatic duct is liable to be injured by mistake if the situation is not identified well.
If the cystic duct is not in the normal position and passes around behind or before the common hepatic duct by 180 and 360 degrees, flowing into the common hepatic duct while both the cystic duct and he common hepatic duct are in the same connective tissue capsule, it is prone to inflammatory adhesion. In such situations, the common hepatic duct may be easily injured by mistake when attempting to separate them by force.
When the pathway of gallbladder artery or right hepatic artery is abnormal, hemorrhage occurs due to injury during operation. Common hepatic duct and common bile duct can be injureddue to clamping or suture hemostasis in a hurry.

1.2 Pathological factors

Acute inflammation, congestion, edema and adhesion lead to unclear local anatomical relationships, fragile tissue, easy damage can be caused by pulling, clamping and separation during the surgery.
When chronic inflammation occurs repeatedly, scar adhesion can cause bile duct shift (scar contraction and traction). If the operator fails to pay attention, forced separation will easily cause biliary tract injury.

1.3 improper operation technology and errors:

The incision is too small, resulting in poor exposure, organ traction and bile duct shift.
When the gallbladder is removed, excessive traction result in damages to the common hepatic duct or common bile duct wall.
If there is bleeding from the gallbladder artery or right hepatic artery during the operation, blindly clamping or sewing causes damages.
Local inflammatory scar adhesion, with unclear anatomical relationships, forcibly separating at hepatic hilus or Calot trigone can cause injury.
Exploration of biliary tract or stone removal with excessive force can cause laceration of hepatic duct or lower segment of common bile duct, or a puncture in bile duct wall.
The posterior wall of common bile duct is accidentally injured when the common bile duct is cut open.
With ulcer of corpus callosum in duodenal bulb, scar contraction, shortening of the interval between pylorus and common bile duct, forced separation during subtotal gastrectomy is likely to cause common bile duct damage.
Many vascular forceps are reserved deep and not removed with timely ligation, the injury is caused easily by "touching" or "bumping" with the vascular forceps.。

1.4 Attention required to the cultivation of surgeons’ skills:

Accidental injury follows the lack of strong sense of responsibility, carelessness, and failure to conduct meticulous dissection to identify the relationship between the cystic duct and common hepatic duct while removing the cyst.
Over-pursuing speed, blind separation, and massive ligation are all possible causes for the injury.
In case of accidents during operation, the operator is not self-possessed and operates blindly in panic.

2 Clinical manifestations

Some cases of bile duct injury are found during the operation and treated in time, but most cases are only definitely diagnosed after the operation when the following symptoms and signs start to appear.

2.1. Abdominal pain: pain in the right upper abdomen spreading to the whole abdomen, with peritoneal irritation. Distending pain in liver area, increased internal pressure of bile duct with ligated bile duct.

2.2. Jaundice: complete ligation of bile ducts and aggravation of jaundice in the early stage. Partial ligation of bile duct, with stricture of bile duct causes mild jaundice or no jaundice temporarily. Bile duct injury or stenosis is often followed by bile duct infection and jaundice.

2.3. External biliary fistula: when the abdominal drainage tube is placed, a large amount of bile may flow out.

2.4. Cold and fever: common manifestations of biliary peritonitis or secondary cholangitis, leading to shock in severe cases.

2.5. Laboratory tests: white blood cells increase and neutrophils increase. Serum bilirubin and alkaline phosphatase may increase.

3. Diagnosis:

3.1. During the operation: The diagnosis rate during the operation accounts for 15–20% of all diagnoses according to the statistics. When seeing bile on the operation wound (seeable when using clean gauze to wipe the wound) or observing liquid leakage in bile duct flushing, the operator needs to carefully check for a clear diagnosis, with timely treatment. Intra-operative cholangiography may assist in the definitive diagnosis in those difficult cases (situations like bile duct rupture, broken end or bile duct sutured).

3.2. In postoperative hospitalization: the diagnosis is not difficult according to the typical clinical manifestations.

3.3. After discharge from hospital: it refers to partial ligation with injury of common bile duct. Usually there are no obvious symptoms in the near future after operation. The wound heals in one stage. There are no signs of biliary peritonitis because the bile duct injury is non-open. Jaundice does not occur either because there is no obstruction of the biliary lumen. However, several months or even years later, due to the injury, stenosis, infection, and cicatricial stenosis, the bile duct gradually becomes thinner, and the biliary flow is no longer smooth, repeated episodes of biliary tract infection appear. This is easily misdiagnosed as "residual stones" in clinical practice, and the definitive diagnosis is indeed difficult. Percutaneous transhepatic cholangiography is an important means to assist examination.

4. Treatment

Once the diagnosis is established, it should be actively treated.

4.1. Timely treatment when injury is found during the operation. When found within 24 hours after the operation, perform emergency surgical treatment when the organization is still healthy, with no serious infection, edema, adhesion. More specifically:

In cases where the injury is small in scope, and there is no or little tension in the anastomosis, transverse suture should be performed with the distal T-tube supporting drainage. The tube should be kept for no less than three months after operation.
In cases with transverse injury (on common bile duct), with local inflammation insignificant, without tension after anastomosis (including Kocher incision and loosening duodenum), end-to-end anastomosis can be performed, with a T-tube placed at the distal end to support draining the wound. The tube shall be placed for 3–6 months after operation.
In cases with numerous common bile duct injuries (especially with injuries larger than 2cm), with high tension after anastomosis, treatment is a challenge, with high risk of failure. Ligation of common bile duct at the distal end and internal biliary-intestinal drainage at the proximal end (Roux-y technique) can be performed to save the case.

4.2. If bile duct injury is found recently after operation, we should try our best to operate within 7–10 days. The operation can be expected to be successful within 7 days after operation. After more than 10 days, local congestion, edema, fragile tissue, adhesion, unclear anatomy, difficult operation, and low success rate, we should first external biliary drainage, and then operate after the inflammation subsides for 3–6 months.

2. 术后近期发现胆管损伤，宜力争在 7-10 天内手术，术后7天内手术可望获得成功。在10天以上，局部充血、水肿，组织脆弱、粘连，解剖不清，操作难度大，成功率低，宜先行胆道外引流，待炎症消退 3-6 个月后再手术。

3. 术后后期诊断胆管损伤性狭窄，也应争取早期手术。因反复发作胆管炎，肝功能损害，继发胆汁性肝硬化，门静脉高压死于上消化道出血或肝昏迷，故应创造条件，争取尽早修复重建。

● 胆肠内引流，肝外胆管较长且扩张，行胆肠 Roux-y 吻合。

● 高位胆管狭窄，肝外胆管较短已无吻合余地，则可行左肝内肝管空肠 Roux-y 吻合术，但应明确左右肝管汇合通畅方可施行。

“Y”吻合旷置肠段在 40-60cm 左右，基本上可无逆行胆道感染发生。

4.3. Early operation should be carried out for the diagnosis of bile duct injury stenosis in the late stage after operation. Because of repeated attack of cholangitis, liver damage, secondary biliary cirrhosis, portal hypertension died of upper gastrointestinal bleeding or hepatic coma, so we should create conditions for early repair and reconstruction. (i) Choledocho-intestinal drainage, long and dilated extrahepatic bile ducts, and choledocho-intestinal Roux-y anastomosis was performed. (ii) If the high bile duct is narrow and the extrahepatic bile duct is short and there is no room for anastomosis, Roux-y left intrahepatic hepatic hepatic jejunal anastomosis may be performed, but it should be clear that the left and right hepatic ducts are confluent and unobstructed before implementation. The size of the "Y" anastomosed open bowel segment is about 40–60 cm, and basically no retrograde biliary tract infection occurs.

1. 适当的切口，良好的麻醉, 肌肉松驰，暴露良好，必要时延长切口或果断改硬膜外阻滞为全麻。

2. 术中应仔细辨认胆囊动脉、胆囊管、肝总管、胆总管的行径和关系，因肝外胆道变异较多，一切组织在未弄清鲜剖关系之前，切勿盲目钳夹、结扎、切断。

3. 争取顺行切除胆囊，但若炎症、水肿、严重粘连、Calot 三角解剖困难，不应强行分离，应改行从胆囊底部开始剥离的逆行法切除胆囊。若仍困难，不得己时则可行胆囊大部切除术，同样可达到切除胆囊之目的。

4. 在两针牵引线间切开胆总管探查时，二针缝线距离不宜过大，以免后壁一同被牵拉，切开时尖刀系“切割开”胆总管前壁而非“刺入”前壁，以免造成后壁损伤。

5. 胃大部切除术，若遇胼胝性十二指肠球部溃疡，由于炎性粘连、疤痕收缩，解剖关系改变，胆总管-幽门间距离缩短，在幽门上方分离时慎防损伤胆总管，在估计困难时应果断改行溃疡旷置 Bancroft 术，可避免误伤胆总管。

6. 术中遇胆囊动脉出血，应采用左手食指置 Winslow 孔内。左拇指在前压迫肝十二指肠韧带，吸净出血后，松开压力观察出血处进行止血，切忌盲目钳夹，缝扎，导致误伤。

7. 探查胆总管下端或左右肝管，(探查，取石) 用力不宜过大，动作不应粗暴，以免造成胆管或括约肌撕裂基至形成戳穿胆管壁造成假道。

8. 熟悉胆道解剖变异，术中时时警惕医源性胆道损伤的可能性，认真、细致操作，摒弃医源性胆道损伤的因素，预防胆管损伤的发生。认织胆管损伤的表现，及时正确处理，使胆管损伤给病人带来的危害降到最低限度，普外科医师在胆囊手术上失误还是比较多的，开好一个胆囊不难，一辈子工作中做好每一个胆囊亦非易事! 同行们，愿我们共同努力。

5. Prevention

Prevention is more important than treatment.

5.1. The appropriate incision, good anesthesia, muscle relaxation, good exposure, when necessary to extend the incision or decisive change epidural block for general anesthesia.

5.2. During the operation, the behaviors and relationships of gallbladder artery, cystic duct, common hepatic duct and common bile duct should be carefully identified. Due to more variation of extrahepatic biliary ducts, all tissues should not be clamped, ligated and cut off blindly before the fresh section relationship is clarified.

5.3. For anterograde cholecystectomy, but if the inflammation, edema, severe adhesion, difficult to dissect the Calot triangle, should not be forced to separate, should be diverted from the bottom of the gallbladder stripping retrograde cholecystectomy. If it is still difficult and inappropriate, subtotal cholecystectomy can be performed, which can also achieve the purpose of gallbladder resection.

5.4. When cutting the common bile duct between the two traction wires for exploration, the distance between the two stitches should not be too large, so as to avoid the posterior wall being pulled together. When cutting, the sharp knife "cuts" the anterior wall of common bile duct rather than "pierces" the anterior wall, so as to avoid the damage to the posterior wall.

5.5. For subtotal gastrectomy, in case of callosal duodenal bulbar ulcer, due to inflammatory adhesion, scar contraction, and changes in anatomical relationship, the distance between common bile duct and pylorus is shortened, so we should be careful to prevent damage to common bile duct when separating above pylorus. When estimation is difficult, we should resolutely switch to ulcer exclusion Bancroft technique to avoid accidental damage to common bile duct.

5.6. In case of gallbladder artery bleeding during the operation, the left index finger should be used to place the Winslow foramen. The left thumb was used to compress the hepatoduodenal ligament in the anterior direction, and after the hemorrhage was sucked out, the pressure was released to observe the bleeding site for hemostasis. It is forbidden to clamp and sew blindly, resulting in accidental injury.

5.7. Explore the lower end of the common bile duct or left and right hepatic duct, (exploration, stone) force should not be too big, the action should not be rough, so as not to cause bile duct or sphincter tear base to form puncture bile duct wall cause false way.

5.8. Be familiar with the anatomical variation of biliary tract, intraoperative always alert to the possibility of iatrogenic bile duct injury, careful and meticulous operation, abandon the factors of iatrogenic bile duct injury, prevent the occurrence of bile duct injury. Recognize weave bile duct damage performance, timely and correct treatment, make bile duct damage to the patient's harm to a minimum, general surgeons mistakes in gallbladder surgery or more, open a gallbladder is not difficult, a lifetime work to do a good job in every gall bladder is not easy! Colleagues, may we make joint efforts.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

New concept of modern surgical blood transfusion

Training material I

New concept of modern surgical blood transfusion

Clinical significance of blood transfusion:

Improve hemodynamics, increase the oxygen content, and maintain the oxidation process;
Supplement plasma protein to maintain osmotic pressure and blood volume;
Increase nutrition to improve the body biochemical function;
Correct the clotting mechanism, to prevent bleeding;
As it contains a variety of antibodies, the body's ability to resist disease can be improved.

Disadvantage of traditional blood transfusion method:

Whole blood is infused regardless of the blood component the patient needs. For example, whole blood is transfused to control hemorrhage (due to coagulation factor deficiency or thrombocytopenia) or control infection (due to granulocyte deficiency), but the whole blood contains limited coagulation factors, platelets or white blood cells, so it is difficult to achieve the expected goal by transfusion of whole blood. Unless a large amount of whole blood is used, the transfusion of large amount of whole blood can increase blood volume and heart burden, and even cause death due to heart failure, pulmonary edema, and severe cases. In addition, infusion of certain undesired components resulted in adverse reactions.

传统输血方法弊端:

不管患者需要什么血液成分都输注全血。如: 为了控制出血 (因凝血因子缺乏或血小板减少) 或控制感染 (因粒细胞缺乏) 等而输注全血，但全血中所含凝血因子、血小板或白细胞数量有限，输注全血很难达到预期目标，除非用大量全血，而输用大量全血可增加血容量，增加心脏负担，甚至心力衰竭、肺水肿、严重者造成死亡。此外，某些不需要的成分输注后导致不良反应。

The concept of modern blood transfusion: The broad definition includes not only the transfusion of whole blood, various blood cell components and their derivatives, plasma and plasma protein products, but also the transfusion of various blood-related components produced by modern biological technology, such as various hematopoietic factors and plasma protein components produced by DNA recombination technology, and various blood substitutes. The concept of modern blood transfusion also extends from input to removal, that is, the removal of extra or pathologically changed blood cells or other blood components from a patient, such as therapeutic apheresis and plasma exchange.

现代输血的概念:

其广义的定义，已不仅是全血、多种血细胞成分及其衍生物、血浆和血浆蛋白制品的输注，也包括以现代生物技术生产的各种与血液相关的成分，如: 以DNA重组技术生产的种种造血因子和血浆蛋白成分，以及各种血液代用品的输注。现代输血的概念，还从输入延伸到去除，即去除患者血液中多余的或发生病理变化的血细胞或其他血液成分，如治疗性血细胞单采术和血浆置换术等。

I. Component blood:

transfusion Whole blood refers to blood collected into containers containing anticoagulants or preservative solutions and obtained without any processing. In the world, 450ml whole blood is generally considered as a unit, while 200ml whole blood is considered as a unit in China.

Whole blood infusion has the following disadvantages:

The preservative solution prescription of whole blood preservation is only designed to preserve red blood cells, so as long as the blood is extracted, the function of some components begins to be lost.
Because only albumin in red blood cells and plasma is preserved in whole blood, other components such as platelets, white blood cells, the main coagulation factors in plasma and complement have rapidly or gradually failed. Therefore, its therapeutic effect can only temporarily supplement red blood cells and blood volume to prevent hemorrhagic shock.
Even if blood is transfused immediately after blood collection, it is impossible to exert the functions inherent to several main components in whole blood because these components do not reach an effective dose in the allowed amount of blood transfusion.
The sterility of whole blood is guaranteed by the aseptic operation of the blood collection process (including the storage and preparation of blood sampler and blood transfusion device). Practice has proved that "sterile", it is impossible to reach 100%; Blood products, which can be heated and treated with organic solvents or surface decontaminants by means of microporous membrane filtration techniques, are characteristically "sterile", and component blood transfusions have been developed to overcome these shortcomings.

一、成分输血

全血即血液采入含有抗凝剂或保存液的容器中，不作任何加工，即为全血。国际上一般以450ml全血为1单位，我国将200ml全血定为1个单位。

全血输注具有如下缺点: (1) 保存全血的保存液处方仅是为保存红细胞而设计的，因此只要血液一经采出，其中某些成分的功能即开始损失。(2) 因为全血中所保存的只是红细胞和血浆中的白蛋白，其他成分如血小板、白细胞、血浆中的主要凝血因子和补体等均已迅速或逐渐失效。故其治疗效果，只能暂时补充红细胞和血容量，防止失血性休克。(3) 即便采血后立即输血，也不可能发挥全血中几个主要成分固有的功能，因为在许可的输血量中这些成分达不到一个有效剂量。(4) 全血的无菌性是靠采血过程 (包括采血器、输血器的储备和准备) 的无菌操作来保证的。实践证明，“无菌”，不可能达到100%；而血液制品 (可借助微孔滤膜过滤技术，加热以及用有机溶剂或表面去污染剂处理) 却可保征“无菌”，因此，为克服以上缺点，出现了成分输血。

Advantages of component transfusion:

improve curative effect: component transfusion is to carry out what components are lac and what components are added to patients, in particular, that blood component can be purified to obtain a blood product with high concentration, high efficiency and convenient storage and transportation, the same blood components of a plurality of blood donors are mixed together to form an effective therapeutic dose, and the curative effect is remarkably improved after infusion.
Reducing reaction: The blood composition is complex, and whole blood transfusion can cause various adverse reactions in the recipient. The diseases transmitted by blood transfusion are even more terrible. Component transfusion can avoid transfusion reaction caused by inputting unnecessary blood components. Currently, blood cells separator can be used to separate blood components from one blood donor for transfusion, and other components can be recycled to the blood donor, which can obviously reduce transfusion reaction and reduce transmission diseases. In the elderly, patients with infantile weight and original cardiac insufficiency can reduce blood transfusion volume and cardiovascular load.
Reasonable use: component transfusion refers to the transfusion of different components of blood to different patients with multiple purposes in one blood. If the various components in whole blood are infused regardless of the needs of patients, the required components are relatively insufficient, and the unnecessary components will be wasted. (4) Economy: using more than one blood can not only save blood, but also reduce the economic burden of society and individuals.

成分输血的优越性:

(1) 提高疗效：成分输血是对患者进行缺什么成分，补充什么成分，特别是可以将血液成分提纯，得到高浓度、高效价，便于保存、运输的血液制品，把多个献血者的同一血液成分混合在一起，成为一个有效的治疗剂量，输注后显著提高疗效。

(2) 减少反应：血液成分复杂，输全血可使受血者发生各种不良反应，再加输血所传播的疾病更可怕。采用成分输血，可避免输入不必要的血液成分所致的输血反应，目前可用血细胞分离机单采一个献血者的血液成分进行输血，而将其他成分回输给献血者，这就可明显减少输血反应及减少传播性疾病。对老年人，儿重及原有心功能不全患者可减少输血容量，降低心血管的负荷。

(3) 合理使用：成分输血是将血液不同成分，输给不同患者，一血多用，如果不考虑患者是否需要，将全血中的各种成分均予输注，所需成分又相对不足，不需要的成分将造成浪费。

(4) 经济：一血多用，既节省血源，又减轻社会、个人的经济负担。

Types of red blood cell products: (I）Oligoplasmic blood，（ii）Concentrated red blood cells，（iii）Substituting plasma blood or crystal salt red blood cells，（iv） Oligoleukocyte red blood cells，（v）Scrubbing red blood cells，（vi）Frozen red blood cells: suitable for the storage of rare blood group and own blood，（vii）Young red blood cells.

Platelet products: （I）Platelet-rich plasma，（ii）Platelet concentrates，（iii）WBC-less platelets.

红细胞制品种类：1. 少浆血 2. 浓缩红细胞 3. 代浆血或晶体盐红细胞 4. 少白细胞的红细胞 5.洗涤红细胞 6. 冰冻红细胞: 适于稀有血型和自身血的贮存 7. 年轻红细胞。

血小板制品：1. 富含血小板血浆 2.浓缩血小板 3. 少白细胞的血小板。

血小板保存: 温度以22℃（上下2度）保存，PH值为6.5-7.2。

Platelet preservation:

The temperature was kept at 22 C (2 C above and below) with a PH of 6.5-7.2.

2. Autotransfusion

In recent years, due to the attention paid by social and medical circles to the transmission of blood transfusion diseases, especially the hepatitis and AIDS after blood transfusion, autotransfusion has risen to an important position, and it is considered to have the following advantages:

the transmission of blood transfusion diseases such as viral hepatitis, AIDS and cytomegalovirus can be avoided;
The alloimmune reaction caused by red blood cells, white blood cells, platelets and protein antigens can be avoided;
hemolytic fever, allergy or graft-versus-host reaction sensitized by immune action can be avoided;
The error accident of allogeneic blood transfusion can be avoided;
The unused blood can be transfused to other patients who need transfusion, which increases the blood supply and source.
patients with autotransfusion because of repeated bleeding, can stimulate red blood cell regeneration, make the patient after surgery hematopoietic speed faster than before;
The collection and long-term preservation of self blood can provide blood storage for patients with rare blood group when they need blood transfusion;
Autoblood collection can provide blood for surgery in remote areas without blood supply conditions;
Some acute internal bleeding, such as rupture of spleen, liver and ectopic pregnancy, can be reinfused under strict conditions without need of anticoagulation (fibrin blood), thus leading to emergency rescue.

二、自身输血

近几年来，由于社会和医务界对输血的疾病传播，特别是输血后肝炎和艾滋病的关注，自身输血已上升到一个重要位置，认为它具有以下优点: (1) 可以避免输血的疾病传播，如病毒性肝炎、艾滋病、巨细胞病毒等；(2) 可以避免红细胞、白细胞、血小板以及蛋白抗原产生的同种免疫反应; (3) 可以避免由于免疫作用而致敏的溶血发热，过敏或移植物抗宿主反应; (4) 可以避免发生输同种异体血的差错事故；(5) 自身血没有用完可以输给其它需要输血的患者，增加了血液供应和来源; (6) 自身输血患者由于反复放血，可以刺激红细胞再生，使患者手术后造血速度比手术前快；(7) 自身血的采集和长期保存，可为稀有血型患者需输血时提供贮血；(8) 自身血采集可为无供血条件的边远地区外科手术提供血源；(9) 某些急性内出血，如脾、肝及宫外孕破裂等，在严格条件下可回输且无需抗凝(脱纤维蛋白血)，可达到应急救命。

Frequency of blood collection:

采血频次: 动员蛋白质进入血浆，便血浆容量恢复到正常所需的最长时间为72小时，因此，除了特殊情况外，采血频次应当是两次间隔不少于3天，最好采血至手术前一周，至少应截止在手术前72小时进行，一般允许采4-5单位血液。

The maximum time required for mobilizing protein to enter plasma and restoring plasma volume to normal is 72 hours. Therefore, except for special circumstances, the frequency of blood collection should be no less than 3 days at the interval between two times. It is best to collect blood one week before surgery. Blood collection should be conducted at least as of 72 hours before surgery. Four to five units of blood are generally allowed.

3. Surgical blood transfusion

三、外科输血

外科输血目的有二: 一是纠正血容量; 二是纠正某种血液成分的缺乏。

外科输血特点:

1、失血量大。失血量估计可从以下几方面进行: 心率、动脉血压、尿量、中心静脉压、红细胞压积。

2、输用库血多。一般库血指采集 24h 后的血制品。(血小板止血功能明显下降、凝血因子的活性下降、血K变化，PH值)

3、输血速度快。

Surgical blood transfusion has two purposes: one is to correct blood volume; the second is to correct the lack of a blood component.

Surgical blood transfusion features:

large amount of blood loss. The amount of blood loss can be estimated from heart rate, arterial blood pressure, urine volume, central venous pressure, and hematocrit.
There is much blood in the transfusion reservoir. General blood storage refers to the blood products after 24h collection. (significant decrease in platelet hemostatic function, activity of coagulation factors, blood K change, PH value)
blood transfusion speed is fast.

(一) 外科输血准则:

1、对腹腔实质脏器手术及血管损伤手术，宜常规用粗针头开放两条静脉通道，确保输血速度。静脉穿刺部位可选择前臂、肘前及头静脉，以利于所补充的血液从上腔静脉回至右心，防止下肢输血而从腹腔内血管破裂处进入腹腔。

2、应量出为入，丢多少补多少，速度宜快不宜慢。

3、大量输血时 (>3000ml)，库血与新鲜血 (贮存<24h) 的比例应为3:1，比例2:1则更佳。

4、严重肝功损害者，如总蛋白量 <45g/l、白蛋白 <25g/l 或白球比例倒置应适当补充血浆或白蛋白，术前应争取血红蛋白高于 100g/l，红细在 3×1012/l 以上，血清总蛋白在 60g/l，白蛋白在30 g/l 以上。

5、因血小板减少引起出血者，也应输入浓缩血小板。

6、腹腔内实质脏器及血管创伤时，腹腔可存留大量血液，严格条件下可回输; 脾切除后也可回收部分脾血。

3.1. Surgical blood transfusion guidelines

3.1.1. to the abdominal cavity parenchyma organ surgery and vascular injury surgery, appropriate convention with thick needle open two venous channels, to ensure the speed of blood transfusion. The forearm, anterior elbow and cephalic vein can be selected for venipuncture, so as to facilitate the return of supplemented blood from the superior vena cava to the right heart and prevent blood transfusion of the lower limb from entering the abdominal cavity through the vascular rupture in the abdominal cavity.

3.1.2. should be within our means, lost how much how much, speed should be fast shoulds not be slow.

3.1.3. For massive blood transfusion (> 3000ml), the ratio of pooled blood to fresh blood (stored < 24h) should be 3:1, and the ratio of 2:1 is better.

3.1.4. severe liver damage, such as total protein content < 45g/l, albumin < 25g/l or white ball ratio inversion cases should be appropriate to supplement plasma or albumin, preoperative hemoglobin should be higher than 100g/l, fine red in more than 3 x 1012/l, serum total protein in 60g/l, albumin in more than 30 g/l.

3.1.5. bleeding caused by thrombocytopenia, also should input platelet concentrate.

3.1.6. In case of trauma to the parenchymal organs and blood vessels in the abdominal cavity, a large amount of blood may remain in the abdominal cavity, which may be transfused under strict conditions; Partial splenic blood can also be recovered after splenectomy.

3.2. preoperative preparation and component transfusion

Many patients are accompanied by anemia before operation. The degree of anemia varies. Of course, in severe cases, hemoglobin must be added to a certain level before the operation can be tolerated. The preoperative hemoglobin level should be reached depends on the comprehensive evaluation of the patient.

Animal experiments have shown that left ventricular function is inhibited when the blood protein concentration falls below 100g/l, but oxygen uptake, mixed venous oxygen tension, and coronary sinus oxygen tension remain unchanged until the hemoglobin falls to 70-80 g/L. This indicates that when the hemoglobin concentration is maintained above 70 to 80 g/L, most operations can still be performed as usual. The hemoglobin level of 70-80g/l requires normal heart, lung, liver and kidney functions, and any organ dysfunction requires a corresponding increase in hemoglobin level. It has been found that patients with septic shock have the highest survival rate when the hemoglobin concentration is maintained at 125 to 150 g/L, while patients with acute respiratory failure have a significant reduction in mortality when the hemoglobin concentration is maintained at 130 to 160 g/L. Therefore, for patients with organ dysfunction, the level of hemoglobin supplementation depends on clinical conditions.

However, due to the improvement of anesthesia methods and the improvement of anesthesia level, the requirements for hemoglobin can be specific and flexible to master according to the patient's situation, anesthesia methods and surgical characteristics. For patients who urgently need surgery for acute hemorrhage, immediate surgery should be performed to stop bleeding and blood transfusion should be performed simultaneously with the surgery.

(二) 术前准备与成分输血

许多患者术前都伴有贫血，其程度不等，当然严重者一定要补充血红蛋白到一定水平后方可耐受手术。对于术前血红蛋白究竟应该达到什么水平，要视接受手术者的情况综合评定。

动物实验表明，当血蛋白浓度降至 100g/l 以下时，左心室功能受到抑制，但直至血红蛋白降至70-80g/l 前，氧摄取率、混和静脉血氧张力及冠状窦氧张力仍保持不变。这表明，当血红蛋白浓度保持在 70-80g/l 以上时，绝大部分手术仍可照常进行。70-80g/l 的血红蛋白水平，要求有正常的心、肺、肝、贤功能，任何脏器功能的不全，均要求相应提高血红蛋白水平。有人发现，脓毒性休克患者，当其血红蛋白浓度保持在 125-150g/l 时存活率最高，急性呼吸衰竭患者当其血红蛋白浓度保持在 130-160g/l 时死亡率可明显下降，因此伴脏器功能不全者，补充血红蛋白到什么水平依临床而定。

但目前由于麻醉方法的进步和麻醉水平的提高，对于血红蛋白要求可以根据病人情况、麻醉方法、手术特点而具体、灵活掌握。对于急待手术的急性出血病人，应立即手术止血，并在手术同时输血。

(三) 外科输血新概念

输血、麻醉、无菌曾被认为促进外科发展的三大要素。有了输血的保证，使手术范围大大扩大，正确掌握术中输血可以迅速纠正失血量，保证手术的成功及病人的安全，输血对外科的发展起到越来越重要的作用。但由于外科输血具有输血量大，输用库血多，输血速度快的特点，输血的并发症发生率相对较高，已越来越受到外科医生的重视，特别是近十多年来对输血的深入研究，外科输血的概念已有了很大的变化，成分输血、自体输血等均有较大的进展。

1、“失血补血”概念的变化

在外科领域，由于手术范围的扩大，术中失血量大，而需要补充血容量机会增多。血量丢失，当然是失血性休克的主要原因，因此“失血补血”的概念曾长期为术者所遵循，以致大量输入血液而忽视细胞外液的补充，致使休克后肾功能衰竭的发生机会增多。近年来大量实验和临床观察表明，严重创伤或复杂的手术，不但丢失全血，而且也使大量功能性细胞外液转移到第三间隙，并使血液浓缩。即使有低血容量休克的病人，输入全血也不如先输入类似细胞外液的晶体溶液见效迅速。所以一般成人手术，失血量在500ml以内，仅补充3倍量晶体液 (如乳酸钠林格液、林格液或生理盐水) 即可满足要求。失血量在500-1000ml，还应追加一半胶体溶液 (如羟乙基淀粉、右旋糖酐等)。失血量超过1000ml，才需要同时输全血或浓缩血细胞。现在已一致认识到失血时不必过早大量输血，应先以代血浆及晶体液扩充血容量使血液稀释，这样还可增加心输出量，降低周围血管阻力，血流速度加快，增加组织灌注，同时还可防止微循环血流障碍。因此临床上改变了“失血补血”概念。

3.3. New concept of surgical blood transfusion

Blood transfusion, anesthesia and sterility were once considered as the three main factors to promote the development of surgery. With the guarantee of blood transfusion, greatly expand the scope of surgery, correctly grasp the intraoperative blood transfusion can quickly correct blood loss, ensure the success of the operation and the safety of the patient, blood transfusion to the development of surgery plays an increasingly important role. However, because surgical blood transfusion has the characteristics of large blood transfusion volume, large amount of transfused blood and rapid blood transfusion, and the incidence of complications of blood transfusion is relatively high, it has attracted more and more attention from surgeons. In particular, through the in-depth research on blood transfusion over the past decade, the concept of surgical blood transfusion has changed greatly, and great progress has been made in component blood transfusion and autologous blood transfusion.

3.3.1. Change of the concept of "blood loss and enrichment"

In the field of surgery, due to the expansion of the scope of the operation, the amount of blood loss during the operation is large, and the chance of needing to supplement blood volume is increased. Loss of blood volume is, of course, the main cause of hemorrhagic shock. Therefore, the concept of "blood loss and blood enrichment" has been followed by surgeons for a long time, so that a large amount of blood was input while extracellular fluid supplement was ignored, resulting in an increased incidence of renal failure after shock. In recent years, a large number of experiments and clinical observations have shown that severe trauma or complicated surgery not only loses whole blood, but also causes a large amount of functional extracellular fluid to be transferred to the third space and causes blood concentration. Even in patients with hypovolemic shock, the introduction of whole blood is not as effective as the introduction of a crystalloid solution resembling extracellular fluid. Therefore, for general adult surgery, the blood loss should be within 500ml, and only three times of crystal solution (such as sodium lactate Ringer's solution, Ringer's solution, or normal saline) can be replenished to meet the requirements. The blood loss ranged from 500 to 1000 mL, and half of the colloidal solution (such as hydroxyethyl starch and dextran) should be added. The amount of blood loss exceeded 1000ml, and the simultaneous transfusion of whole blood or concentrated blood cells was required. It has now been unanimously recognized that it is not necessary to conduct a large amount of blood transfusion prematurely during blood loss; instead, plasma and crystalloids should be replaced to expand the blood volume to dilute the blood, which will also increase cardiac output, reduce peripheral vascular resistance, accelerate blood flow, increase tissue perfusion, and prevent microcirculatory blood flow disturbance. Therefore, that concept of "blood los and blood enrichment" was changed clinically.

2、自体输血

自体输血有近百年历史，但近十余年来的临床和实验研究进展较快，技术设备有较大改进，适应范围不断扩大。今已公认为有临床实用价值的治疗方法，自体输血可解决急需输血而血源短缺的困难，无输血反应，并发症少，无传播的危险。更重要的是不产生对红细胞，白细胞、蛋白抗原等血液成分的免疫反应。人们公认自体输血不需化验血型及交叉试验，能及时有效地将丧失血液重新利用，自身的红细胞活力较库血好、运氧能力高。输后红细胞能立即发挥良好的携氧能力。自体输血主要适应于 (1) 胸腔心血管外伤性手术; (2)肝、脾破裂，异位妊娠破裂，肠系膜血管破裂等腹腔出血; (3)体外循坏心内直视手术，主动脉瘤手术等某些择期手术。近年来已发展到术前数天，或麻醉前采集病人血液，用电解质或血浆增量剂补充血容量的“血液稀释法”。血液稀释疗法主要是通过静脉输液，降低患者红细胞压积和血液粘度，加速血流，改善微循环和组织供氧，以达到治疗目的。在外科手术中应用血液稀释技术，还可以大大节约手术中输血量和减少输血并发症的发生。

3.3.2. autologous blood transfusion

Autologous blood transfusion has a history of nearly one hundred years. However, clinical and experimental research has made rapid progress in the past ten years, with great improvements in technical equipment and an ever-expanding scope of application. It has been recognized as a treatment with clinical practical value. Autologous blood transfusion can solve the difficulty of blood shortage due to urgent need of blood transfusion. There is no transfusion reaction, few complications and no risk of transmission. It is more important not to produce immune response to red blood cells, white blood cells, protein antigens and other blood components. It is generally recognized that autotransfusion does not need blood type tests and cross tests, can timely and effectively reuse the lost blood, and has better red blood cell viability and oxygen transport capacity than reservoir blood. After transfusion, red blood cells can immediately exert good oxygen carrying capacity.

Autotransfusion is mainly suitable for (i) thoracic cardiovascular traumatic surgery; (ii) Liver and spleen rupture, ectopic pregnancy rupture, mesenteric vascular rupture and other abdominal hemorrhage; (iii) Some elective operations such as extracorporeal circulation followed by open heart surgery and aortic aneurysm surgery. In recent years, "hemodilution" has been developed in which a patient's blood is collected several days before surgery or before anesthesia, and blood volume is supplemented with electrolytes or plasma extenders. Hemodilution therapy is mainly through intravenous infusion, reduce the patient's hematocrit and blood viscosity, accelerate blood flow, improve microcirculation and tissue oxygen, in order to achieve the purpose of treatment. Application of hemodilution technique in surgery can also greatly save blood transfusions during surgery and reduce the occurrence of transfusion complications.

3、成分输血

近年来，输血疗法已进入成分输血。成分输血是把全血或血浆用物理的和/或化学方法分离并制成较纯和较浓的各种制品以供临床应用。传统的输血方法是不问病人确实需要什么而千篇一律输血，这样不仅浪费血液，而且还使病人冒不必要的风险。成分输血优点是 (1) 提高输血效果，减轻心脏负担；(2) 减少对不需要的血液成分的反应; (3) 可以达到一血多用，节约用血的目的。成分输血是现代医药和输血发展的必然进程。外科成分输血主要是输用浓缩红细胞。目前对于体循环血容量的恢复和维持，有较好的血浆代用品 (羟乙基淀粉、左旋糖酐等) 或晶体溶液，但都不具有携氧功能，常需要补充红细胞。因此，浓缩红细胞是外科成分输血最常用的，在输血先进的国家，全血的使用已减少到总输血量的20%以下，而浓缩红细胞用量 >80%。

输红细胞为主的输血疗法具有科学性，可行性和一定的先进性，是外科输血的必然趋势。对于接受大手术或严重创伤治疗者，如果血小板低于 50×109/l，为预防术中异常渗血，术前宜预防性浓缩血小板输血，使血小板数升至100×109/l以上。因骨髓功能衰竭引起的血小板减少症，如癌肿化疗或放疗、急性白血病发作期、再生障碍性贫血等，血小板数可低达30×109/l，一般尚不致自发性出血。但如果决定手术，则宜预防性浓缩血小板输血。大量 (15-20单位) 输注冷藏库血，血小板功能几乎完全丧失，更可出现稀释性血小板减少，亦宜输注较大量浓缩立小板预防出血。

自七十年末，血浆已被广泛用于各种中毒疾患的治疗，血浆用于术中清除中毒性休克，并用以补充某种可能缺少的成分，如术中输用新鲜冰冻血浆，含有各种血浆凝血因子。血浆衍化物有血浆蛋白溶液、白蛋白、因子VIII、IX以及丙种球蛋白等。值得注意的是国内冻干血浆的应用过多，最不合理的是用于扩血容量和补充营养。血浆的最大危险是传染肝炎、艾滋病和其他传染病。血浆的不良反应较多、特别是荨麻疹和过敏反应。血浆的组成复杂，一些蛋自可以致敏病人产生抗体，另外也是极大的浪费。因此不论是新鲜冰冻血浆或冻干血浆不可轻易多用。

3.3.3. component blood transfusion

In recent years, transfusion therapy has entered component transfusion. Component transfusion refers to the physical and/or chemical separation of whole blood or plasma and preparation of various purer and thicker products for clinical application. The traditional method of blood transfusion is to transfuse the blood without asking the patients what they really need. This not only wastes blood, but also makes patients take unnecessary risks. Component blood transfusion has that advantage of (1) improving blood transfusion effect and reduce heart burden; (2) reducing reaction to unwanted blood components; And (3) the purposes of multipurpose with one blood and saving blood can be achieved. Component blood transfusion is an inevitable process of modern medicine and blood transfusion development. Surgical component transfusions are primarily transfusions of packed red blood cells. At present, there are good plasma substitutes (hydroxyethyl starch, dextran, etc.) or crystal solutions for the recovery and maintenance of systemic circulating blood volume, but none of them has oxygen-carrying function, and erythrocyte supplementation is often required. Therefore, packed red blood cells are the most commonly used for surgical component transfusion, and in countries with advanced transfusion, the use of whole blood has been reduced to less than 20% of the total transfusion volume, while the use of packed red blood cells is greater than 80%. The transfusion therapy based on red blood cell transfusion is scientific, feasible and advanced to a certain extent, which is the inevitable trend of surgical blood transfusion. For patients undergoing major surgery or severe trauma treatment, if the platelets are less than 50×109/l, in order to prevent abnormal bleeding during the operation, preoperative prophylactic platelet concentrate transfusion is recommended to increase the platelet count to more than 100 × 109/L. Thrombocytopenia caused by bone marrow failure, such as cancer chemotherapy or radiotherapy, acute leukemia onset, aplastic anemia, platelet count can be as low as 30×109/l, generally does not cause spontaneous bleeding. However, if surgery is decided, prophylactic platelet concentrate transfusion is advisable. If a large amount (15–20 units) of blood is infused into the refrigerator, the platelet function will be almost completely lost, and dilutive thrombocytopenia may occur. It is also advisable to infuse a relatively large amount of concentrated riser to prevent bleeding. Since the end of the seventy, plasma has been widely used in the treatment of a variety of poisoning disorders, plasma used to remove toxic shock during the operation, and to supplement some may be missing components, such as the operation with fresh frozen plasma, containing a variety of plasma coagulation factors. Plasma derivatives include plasma protein solutions, albumin, factors VIII, IX, and gamma globulin. It should be noted that the application of lyophilized plasma in China was excessive, and the most unreasonable one was for blood volume expansion and nutritional supplement. The greatest danger of plasma is the spread of hepatitis, aids and other infectious diseases. There were many adverse reactions in plasma, especially urticaria and allergic reaction. The composition of the plasma is complex, some eggs can produce antibody sensitization patients, in addition is also a great waste. Therefore, whether fresh frozen plasma or lyophilized plasma cannot be easily used.

This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30
Changhang Hospital, Li Mingjie

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Level 4 Surgery

Education Campus

Level 4 Surgery

Six Sample Cases

[Editor’s Comments] This part of Education Campus is where the six representative cases of high clinical difficulty are presented, with detailed operation records.  They are: 1. Extended total gastrectomy; 2. Simulated radical surgery for thyroid cancer; 3. Simulated Berne surgery for duodenal rupture; 4. Left lateral hepatectomy, intrahepatic lithotomy and hepatobiliary basin internal drainage; 5. Focal clearance and drainage for acute pancreatitis; 6. Radical surgery for rectal cancer.

Level 4 Surgery: Six Sample Cases

Case 1: Extended Total Gastrectomy

Single Operation Record for Surgery Case 1 from Wuhu Changhang Hospital

Patient Information:
- Name: Yao XX
- Gender: Female
- Age: 74
- Bed Number: 34
- Hospitalization Number: 19052
- Date of Operation: April 21, 1995

Diagnosis:
- Pre-operation: Gastric cardia cancer with esophageal invasion
- Post-operation: Cancer of the gastric fundus, cardia, and esophagus

Procedure:
- Type of Surgery: Total gastrectomy + splenectomy, esophagojejunostomy (Schlatter's method)
- Operation Time: 9:00 AM to 4:00 PM
- Blood Transfusion Volume: 1200 ml

Medical Team:
- Surgeon: Dr. Mingle Li
- First Assistant: Dr. Yang Zonghua
- Second Assistant: Dr. Wu Maowang
- Surgical Nurse: Qian Weilin
- Anesthesia: Continuous epidural block
- Anesthesiologists: Dr. Chen Qibin and Dr. Wang Yisen

Gross Examination of Specimens

The primary cancer was located in the posterior wall near the cardia, extending 1 cm into the lower end of the cardia and esophagus, and penetrating the entire layer. Pathological specimens submitted for examination included the whole stomach, distal esophagus, and spleen.

Detailed Surgical Procedure

The patient was placed in a supine position, and the chest and abdominal areas were disinfected and draped. A midline incision measuring 25 cm in length was made between the xiphoid process and the navel, and the xiphoid process was excised. A layered laparotomy was performed, and the incision was isolated.

Upon examination, the abdominal cavity was free of ascites. No hepatic lesions were found. Minor adhesions were noted between the pancreas, spleen, and the lesion. The tumor was identified on the posterior wall of the gastric fundus at its small curvature, extending into the serosal layer. The tumor dimensions were 10x7x5 cm, and it was spatially separated from the liver. No metastasis was observed in the pelvic floor or other abdominal regions.

A total gastrectomy and splenectomy were planned. A double-tube jejunostomy was created anterior to the colon, followed by a side-to-side anastomosis with the esophagus. Additionally, a Bauwn short-circuit procedure was performed between the jejunal afferent and efferent loops.

The stomach was mobilized, and the left gastric artery was ligated at its origin. The greater and lesser omenta were excised, as well as the anterior layer of the transverse mesocolon. The duodenum was severed 3 cm below the pylorus, and the stump was sealed. Adhesions between the pancreas and stomach were separated from under the pancreatic capsule, and the spleen was excised. Acute dissection was performed in the space between normal tissues surrounding the pericardial mass. The peritoneum at the esophageal hiatus was incised and folded back, and the left and right vagus nerve trunks were severed. The esophagus was bluntly dissected and mobilized downward for 7 cm. At this point, the stomach was entirely mobilized, and the cancerous mass was wrapped and set aside for traction. Lymph nodes from groups (1), (2), (3), (4), (5), (6), (7), (10), (11), and (15) were excised, constituting a radical level 2 surgery.

The jejunum, 20 cm proximally, was lifted anteriorly to the colon and anastomosed laterally with the esophagus, 5 cm above the cardia. The posterior wall was fixed with five intermittent seromuscular layer sutures. A 3 cm incision was made in the mesangial margin of the jejunum opposite to the esophagus and sutured intermittently with the whole layer of the posterior wall of the esophagus. At 4 cm above the cardia, the esophagus was severed, and the entire stomach and spleen were removed from the surgical field.

The anterior wall was then sutured in full layers in a circular pattern. Given the fragile inflammatory condition of the esophagus, tension-reducing sutures were carefully placed. A two-layer suture secured the anastomosis into the jejunum slightly, with no leakage. Further away from the anastomosis, the jejunum was sutured to the septal muscle near the hiatus to reduce tension, and the hiatus was slightly repaired to prevent internal herniation without causing constriction.

Seven cm below the anastomosis, a Braun short-circuit anastomosis was performed between the double loops of the jejunum, measuring 8 cm. A gastric tube was inserted into the proximal jejunum to facilitate postoperative suction and decompression.

The abdominal cavity was thoroughly rinsed, and careful examination revealed no bleeding or leakage. There was no torsion or compression of the intestinal loop replacing the stomach. The abdominal cavity was soaked in distilled water for tumor eradication. After cleaning the abdominal cavity, a double cannula was placed under the septum for wound drainage. The abdomen was closed in the standard sequence. The procedure was uneventful with a blood loss of 400 ml. The patient was safely returned to the ward.

Surgical Conclusion

Despite the extensive surgical intervention, including a total gastrectomy, distal esophagectomy, and splenectomy, as well as the removal of both the greater and lesser omentum and the anterior layer of the transverse mesocolon, the prognosis remains guarded. The surgery achieved radical level 2 but given the advanced stage of the gastric cardia cancer involving extra-gastric organs such as the pancreas, spleen, and distal esophagus, both short-term and long-term prognoses are not optimistic.

Surgeon and Recorder: Dr. Li Mingjie
Date: April 21, 1995

Additional Notes

Postoperative pathology report (952343) identified a poorly differentiated adenocarcinoma at the lateral aspect of the lesser curvature of the cardia, with portions classified as mucinous adenocarcinoma. The lesion measured 10x7 cm and involved the esophagus, cardia, and stomach fundus, penetrating all layers. Out of seven lymph nodes at the lesser curvature, six showed metastatic carcinoma, while none of the five lymph nodes at the greater curvature had metastatic carcinomas. Mild acute inflammation was observed in the spleen.
The patient has survived for six months post-operation and is relatively frail.

Case 2: Simulated Radical Surgery for Thyroid Cancer

Single Operation Record for Surgery Case 2 at Wuhu Changhang Hospital

Name: Gao XX
Gender: Female
Age: 47
Bed No.: 34
Hospitalization No.: 18639

Operation Date: August 30, 1994

Pre-operation Diagnosis: Metastatic Carcinoma of the Right Thyroid Gland
Post-operation Diagnosis: Metastatic Follicular Adenocarcinoma of the Right Thyroid Gland

Surgery Operated: Modified Right Cervical Lymph Node Dissection + Isthmus Resection and Left Thyroidectomy

Operation Time: Started at 9 am, Ended at 2 pm

Blood Transfusion Volume: 400 ml

Surgeon: Mingle Li

Assistant 1: Yang, Zonghua
Assistant 2: Shi, Lianghui
Surgical Nurse: Gao, Qingjie
Anesthesia: Cervical Plexus Block
Anesthesiologist: Chen, Qibin

Post-operative Gross Examination and Pathology:

The resected tumor was dissected and found to be a typical enlarged lymph node. The intraoperative rapid frozen section pathology report (Pathology No. 944346 from the Second Municipal Hospital) indicated metastatic thyroid cancer, specifically follicular adenocarcinoma, with the possibility of papillary adenocarcinoma not being ruled out.

Specimens sent for further pathological examination were labeled as follows: Nine nodes from both superficial and deep cervical lymph nodes on the right side, along with thyroid tissue.

Surgical Procedure:

Step 1: Under cervical plexus anesthesia, the patient was placed in a supine position with the head and neck hyperextended and slightly turned to the left. Standard skin sterilization and draping were performed. An "inverted L-shaped" incision was made in the right anterior neck region, starting from below the right mastoid and ending 2 cm above the sternum. The incision extended leftward to the outer edge of the left sternocleidomastoid muscle and was 18 cm in length. Another incision extended to the right supraclavicular fossa. The original surgical scar was excised, and subcutaneous flaps were carefully elevated to expose the outer edge of the right trapezius muscle, the left sternocleidomastoid muscle, the lower edge of the jaw, and down to the sternal notch.

Step 2: The platysma was incised, and the anterior neck muscles were separated from the midline and transversely cut to expose various nodules and the thyroid gland. No residual traces of the right thyroid lobe were observed. The right common carotid artery, vagus nerve, and internal jugular vein were displaced superficially by the tumor mass. Nine lymph nodes of various sizes were identified in the right subclavian triangle, right sternocleidomastoid muscle region, supraclavicular fossa, and anterior cervical triangle. The largest node had a diameter of 5 cm, while the smaller ones were approximately 1 cm in diameter. The nodes were hard, smooth, and not densely adhered. The trachea was shifted to the left but was not connected to the tumor mass. The left thyroid lobe was slightly enlarged but had no palpable nodules.

Step 3: The right sternocleidomastoid muscle was transversely incised at its middle-to-lower third to improve exposure. A 2 cm lymph node was initially excised from the superficial aspect of a cluster of nodules for rapid pathology, which confirmed metastatic follicular adenocarcinoma of the thyroid. A modified right cervical lymph node dissection was performed, and a total of 9 lymph nodes were excised during the surgery. Care was taken to protect the right common carotid artery (CCA), internal jugular vein (IJV), vagus nerve, and accessory nerve, all of which remained undamaged.

Step 4: The dissection of the thyroid gland continued, and its isthmus along with the major part of the left thyroid lobe was removed. A small piece of glandular tissue, roughly the size of a fingertip, was preserved on the posterior and medial aspect. The residual thyroid tissue was sutured.

Step 5: The surgical cavity was thoroughly irrigated, and hemostasis was meticulously achieved. A Penrose drain was placed, and an additional incision was made for its exit. The anterior neck muscles and the severed right sternocleidomastoid muscle were sutured. The incision was closed in layers with interrupted sutures.

Step 6: Anesthesia was satisfactory throughout the surgery. The anatomical dissection was clear, and there were no injuries to major blood vessels or nerves. Blood loss was minimal, and there were no occurrences of voice hoarseness or coughing. The patient was safely returned to the ward.

Step 7: Despite being a well-differentiated adenocarcinoma, the patient had already experienced cervical lymph node metastasis, requiring re-operation. Unfortunately, the surgery may have been too late for curative intent, making the long-term prognosis less optimistic.

Surgeon and Recorder: Li Mingjie Date: 1994, August 9

Notes:

Post-operative regular histopathology report on 1994/9/2 (City Second Hospital pathology number 944355):
- Papillary and follicular thyroid carcinoma.
- Small foci of metastasis found in the "normal" thyroid tissue.
- Metastasis in most lymph nodes.
Post-operative follow-up has been ongoing for over a year. The patient shows no signs of recurrence and is asymptomatic.

Case 3: Single Operation Record of Wuhu Changhang Hospital

Patient Details:

Name: Li XX
Gender: Male
Age: 29
Department: Surgery
Bed No.: 22
Hospitalization No.: 18158

Operation Details:

Operation Date: October 7, 1993

Pre-operation Diagnosis: Duodenal rupture, peritonitis
Post-operation Diagnosis: Injury to the descending part of the duodenum behind the peritoneum, peritonitis

Surgery Performed: Berne-style procedure (intestinal repair, external drainage of the common bile duct, antral gastrectomy, gastro-jejunostomy, duodenostomy, peritoneal drainage)

Operation Time: Started at 7 PM, ended at 11 PM

Blood Transfusion Volume: 400 ml

Medical Team:

Surgeon: Li Mingjie

Assistant 1: Shen Yaping
Assistant 2: Wu Maowang
Surgical Nurse: Qian Weilin

Anesthesia:

Type: Continuous epidural block
Anesthesiologist: Chen Qibin

Surgical Procedure:

Initial Preparations: The patient was placed in the supine position. The abdomen was routinely disinfected and covered. An 18cm-long midline incision was made on the right side of the abdomen, followed by hemostasis and draping.
Abdominal Examination: Upon opening the abdomen, approximately 100 ml of pale green fluid was found in the peritoneal cavity. The stomach and duodenal bulb appeared normal. The liver was smooth, with a normal color and texture, and no nodules were found. The spleen was slightly hard and weighed around 500 grams. Some bile-like fluid was accumulated around the omental foramen.
Pathological Findings: Extensive edema and thickening were observed in the hepatoduodenal ligament region, as well as around the descending part of the duodenum and the right renal area. A Kocher incision was made to mobilize the descending part of the duodenum. Extensive necrotic tissue and bile-like fluid were found in the retroperitoneal space. A 1.5 cm rupture was found on the right posterior side of the descending duodenum, with mucosa protruding outward.
Repair Work: The common bile duct was opened for decompression. The injury was located 1.5 cm anterior and superior to the papilla. Under direct vision, the ruptured intestinal tube was trimmed and carefully repaired with double-layer suturing, covered by the omentum, without tension. The repair was satisfactory and did not involve the opening of the common bile duct.
Bile Duct and Gastric Work: The common bile duct was flushed to confirm that there were no leaks. A T-tube was placed for external drainage. Antral gastrectomy was performed, along with duodenal ostomy for decompression, and gastrojejunocolic anterior anastomosis, with an anastomotic opening of 4.5 cm.
Final Steps: Following the Berne procedure, except for the vagus nerve of the stomach, which was not severed, the injured part of the duodenum was made into a diverticulum to facilitate successful repair. The abdominal cavity was thoroughly cleaned again, and drainage tubes were placed at the Winslow's foramen and the pelvic floor. The duodenal ostomy tube and the T-tube were both brought out through separate incisions in the abdominal wall and secured.
Closure and Conclusion: The abdomen was closed layer by layer. The operation went smoothly, with no accidental bleeding or collateral damage.

Surgical Conclusion:

The descending part of the duodenum had retroperitoneal injuries and extensive inflammatory edema. Surgery was performed 28 hours post-injury. The condition was critical, but a thorough diverticulum-like treatment was done at the repair site, which is expected to heal well.

Surgeon and Record Keeper:

Surgeon: Li Mingjie
Operation Date: October 7, 1993

Additional Notes:

Postoperative Complications: None reported. The patient recovered smoothly.

Hospital Stay: The patient was discharged after a 34-day hospital stay in good condition.

Follow-up: Two-year follow-up indicated that the patient was living and working normally, with no need for additional medical consultations.

Case 4: Liver and Biliary Duct Stone Disease

Personal Details:

Name: Shui XXX
Gender: Male
Age: 46
Ward: Surgery
Bed No.: 10
Hospitalization No.: 16502

Operation Details:

Operation Date: April 18, 1991

Pre-operation Diagnosis: Liver and biliary duct stone disease
Post-operation Diagnosis: Liver and biliary duct stone disease

Surgery Performed: Major resection of the left lobe of the liver + biliary stone removal + residual gallbladder removal + hepatic duct-to-intestine pelvic internal drainage

Operation Time: Started at 2 pm, ended at 8:40 pm
Blood Transfusion Volume: 1200 ml

Medical Team:

Surgeon: Li Mingjie

Assistant 1: Yang Zonghua
Assistant 2: Shi Lianghui
Nursing Staff: Gao Jieqing

Anesthesia: Intravenous combined intubation general anesthesia
Anesthesiologist: Chen Qibin

Postoperative Gross Examination:

Stones found in the left liver, common hepatic duct, common bile duct, and residual gallbladder.

Pathological Samples Sent:

Left outer lobe of the liver

Surgical Procedure:

Anesthesia and Initial Incision:

The initial epidural anesthesia was ineffective, so intravenous combined endotracheal intubation general anesthesia was administered.
The patient was placed in the supine position. The chest and abdominal areas were disinfected with iodine and alcohol, and sterile sheets were laid in three layers.
A curved incision was made in the right upper abdomen, starting from the left side of the xiphoid process and ending at the tip of the 11th rib on the right, touching the right anterior axillary line. The incision was 30 cm long. The original surgical scar was excised. After achieving hemostasis, sterile towels were placed, and the abdomen was opened layer by layer.
Extensive adhesions were present in the abdomen. After separation, the edge of the peritoneum was sutured to the towel to isolate the incision.

Exploration and Stone Removal:

Adhesions along the liver edge were separated both bluntly and sharply, exposing the common bile duct. The duct was found to be dilated to 2.5 cm and contained multiple stones.
A residual gallbladder from a previous surgery was found, measuring 2.0 cm in diameter and containing stones.
Stones were also palpated in the transverse part of the left hepatic duct.
The liver appeared normal in color and texture, with no occupying lesions or fibrous atrophy. The stomach, intestines, pancreas, and spleen were also normal.
A decision was made to perform a partial resection of the left outer lobe of the liver, remove stones from the liver and bile ducts, remove the residual gallbladder, and conduct hepatic duct reshaping with pelvic hepato-intestinal internal drainage.

Higher-Level Hepatic Duct Incision:

The common hepatic duct was incised at a higher level to remove the stones and to further probe the biliary tract.
The common bile duct and I and II levels of the intrahepatic ducts were filled with stones.
The left hepatic duct had a narrow ring and stones in the deeper parts were difficult to remove, so it was decided to proceed with the resection of the left outer lobe of the liver.

Detachment and Resection:

The falciform ligament, round ligament, left coronary ligament, and left and right triangular ligaments were cut to loosen and lower the liver.
A suture was placed 1.5 cm to the left of the hepatic portal to pre-ligate the left hepatic vein. The hepatoduodenal ligament was then clamped for 25 minutes, and a large portion of the left outer lobe was removed to expose the transition area of the left hepatic duct.
The blood vessels on the cut surface were clamped and ligated to stop bleeding. The tourniquet was released, and the left hepatic duct was opened, revealing 3 grams of bile pigment stones.

Further Exploration and Stone Removal:

Glisson's capsule at the hepatic portal was opened, and the first-level branches of the hepatic duct were separated upward. Stones weighing 4-5 grams were removed from the convergence area of the hepatic ducts.
The "small gallbladder" was then excised, and the distal common bile duct was cleared. The Oddis sphincter was probed with a No. 9 probe, and the gallbladder duct was sutured and repaired without leakage.

Duct Reshaping and Draining:

The common hepatic duct, along with the left and right first-level hepatic ducts, was fully exposed. While suturing, traction was applied to directly expose the second-level hepatic duct openings, clearing them of stones and dilating any narrow parts. Hydrogen peroxide was used for rinsing.
The edge of the hepatic duct basin was reshaped to a diameter of 4.5 cm.

Intestinal Drainage:

The jejunum was cut 15 cm below its starting point, and its mesenteric vascular arch was trimmed. The distant end of the intestinal tube was lifted to the edge of the basin without tension.
A full-thickness, mucosa-to-mucosa, one-layer suture was made at the basin mouth with a stitch spacing of 3 mm. After testing for leaks by squeezing, the anastomosis was further reinforced by covering it with peritoneum.
To reduce tension, the intestine was suspended from the liver bed with several stitches. The lifted intestine took a path anterior to the colon without causing any compression.

Hemostasis and Open Treatment:
- The liver's cut surface was examined, and hot saline-soaked gauze was applied to control bleeding. Once there was no more bleeding or oozing, the area was left open without further covering. This was done with the expectation that any minor postoperative leakage would be beneficial for peritoneal absorption.
Intestinal Anastomosis:
- A side-to-end anastomosis was performed 40 cm from the distant end of the biliary-intestinal loop to the proximal end of the jejunum. Full-thickness interrupted sutures were placed internally, and reinforcing sutures were added externally. An additional synchronous 5 cm suture was made to form a 'Y-shape' to resist reflux.
Final Checks and Drainage:
- The surgical field was thoroughly cleaned. Both anastomotic sites were inspected and found to be satisfactory, with no twisting or compression. Double drainage tubes were placed under the liver and led out through a hole in the right abdomen, where they were sutured in place.
Abdominal Closure and Recovery:
- The abdomen was closed in layers, as is routine. Dressings were applied to cover the wound. The surgery went smoothly, anesthesia was satisfactory, and the patient was returned to the ward.
Surgical Conclusions:

1. Complete Biliary Clearance:
- All gallstones within the liver were removed. The residual gallbladder was excised, and a No. 9 probe confirmed that there was no stricture in the distal common bile duct.
2. Partial Hepatectomy of the Left Lateral Lobe:
- The left lateral lobe of the liver was partially removed, eliminating gallstones and stricture in the left hepatic duct. Hemostasis was adequately achieved on the cut surface of the liver.
3. Reconstruction of Hepatic Duct System:
- The main hepatic duct and the left and right first-level hepatic ducts were collectively reshaped into a "basin" with a diameter of 4.5 cm. All second-level hepatic ducts were dilated and cleaned of stones.
4. Hepaticojejunostomy:
- The hepatic duct was anastomosed to the jejunum in a "basin" fashion. The diameter of the anastomotic site reached 4.0 cm, offering resistance to reflux.
5. Anastomotic Integrity:
- Both anastomotic sites were sutured in an orderly manner. There were no leaks, tension, twisting, or compression.
Surgeon and Record:
- Li Mingjie
- Date: April 19, 1991

Ultrasound Follow-up:

Postoperative ultrasound re-examination and a 4-year follow-up showed no residual stones or recurrence.

Case 5: Surgical Record from Wuhu Changhang Hospital

Patient Information:

Name: Tang (Surname withheld)
Gender: Male
Age: 60
Department: Surgery
Bed Number: 38
Hospital Admission Number: 15539
Surgery Date: November 20, 1989

Preoperative Diagnosis:

Acute severe pancreatitis
Peritonitis
Cholecystolithiasis (Gallbladder stone disease)

Postoperative Diagnosis:

Pancreatic lesion removal
Pancreatic bed drainage
Cholecystectomy (Gallbladder removal)
T-tube drainage of the common bile duct
Abdominal drainage

Surgery Details:

Start Time: 9 PM
End Time: 1:30 AM (next day)
Blood Transfusion: 400 ml
Lead Surgeon: Dr. Li Mingjie

Assistant 1: Huang Hongcheng
Assistant 2: Shi Lianghui
Surgical Nurse: Gao Qingjie

Anesthesia Method: Continuous Epidural Block
Anesthetist: Wang Yisen

Postoperative Gross Findings:

Diffuse edema and bleeding of the pancreas
Focal necrosis
Large amount of hemorrhagic exudate in the abdominal cavity
Extensive saponification spots
Gallbladder stone, edema, and congestion.

Pathology Samples Sent for Examination:

Pancreas
Omentum
Gallbladder

Case 5: Surgical Procedure (First Part)

Initial Steps:

The epidural anesthesia was effective. The patient was placed in a supine position, and the abdomen was disinfected with iodine and alcohol. Sterile drapes were applied in three layers.

Incision:

A vertical incision approximately 20 cm long was made along the right rectus abdominis muscle. The incision started at the xiphoid process and extended 3 cm below the navel. After achieving hemostasis in the subcutaneous tissue, the layers of the abdominal wall were opened sequentially.

Initial Observations:

Upon opening the abdomen, a large amount of cloudy, blood-tinged fluid, estimated at about 2000 ml, gushed out and was suctioned away.
Widespread edema, congestion, and bleeding were observed in the abdominal cavity, along with soapy spots scattered throughout.
The omentum appeared inflamed and clumped together.
The pancreas was severely swollen, exhibiting signs of bleeding and necrosis.
The lesser omental sac contained about 500 ml of fluid.
The gallbladder was congested and swollen, containing multiple stones, with the largest measuring 3.5 cm, along with an abundance of amorphous biliary sludge.
No stones were palpable in the common bile duct or within the liver.
Both liver and spleen appeared normal, as did the appendix.

Further Steps:

Incisions were made at the upper and lower edges of the pancreas' fascial envelope to decompress and drain the pancreas. A small amount of necrotic pancreatic tissue was cleared. A Kocher incision was made to mobilize the head of the pancreas.
Cholecystectomy was performed. The common bile duct was incised and found to have a diameter of 0.8 cm with no stones or parasites visible. The distal end was probed with an 8-number probe, and a T-tube was placed for external drainage.
Part of the omental mass was excised, and the lesser omental sac was opened for better drainage.

Draining and Cleaning:

The abdominal cavity was thoroughly washed and cleaned. Double drainage tubes were placed in the Douglas pouch at the pelvic floor, and single drainage tubes were placed in the retro-pancreatic space and lesser omental sac. These, along with the T-tube, were brought out through separate incisions in the abdominal wall and secured.

Surgical Difficulties:

The surgery was challenging due to significant fluctuations in blood pressure and inconsistent anesthesia depth. However, no accidental injuries or bleeding occurred. During surgery, 3000 ml of fluids, 400 ml of whole blood, and 500 ml of 5% S.B. were administered.

Final Steps:

All surgical instruments and gauzes were accounted for, and the abdomen was closed layer by layer. The patient was safely returned to the ward.

Surgical Conclusions:

The patient had severe acute pancreatitis, which carries a high risk of mortality and an uncertain prognosis.
The surgical procedures, which included decompressing and draining the pancreas and common bile duct, are beneficial for disease control. However, the possibility of further pancreatic necrosis remains.
The gallbladder has been removed, eliminating concurrent gallbladder pathology.

Surgeon and Record Keeper: Dr. Li Mingjie

Date: November 21, 1989

Notes:

Fourteen days post-surgery, the patient experienced a major hemorrhage and shock due to stress-induced ulcers. Emergency intervention stabilized the patient, and a second surgery was not required.
The patient was discharged after full recovery.

Follow-Up:

Six years of follow-up showed no recurrence of the condition.

Case 6: Surgery Record from Wuhu Changhang Hospital

Patient: Xue Somerong
Gender: Female
Age: 44
Department: Surgery
Bed No: 38
Hospital Admission No: 13533

Surgery Date: April 2, 1987

Pre-Operative Diagnosis: Rectal Adenocarcinoma
Post-Operative Diagnosis: Rectal Adenocarcinoma, Dukes Stage B1

Surgical Procedure: Anterior Resection of the Rectum (Dixon Technique)

Surgery Duration: 9am to 1:30pm
Blood Transfusion: 800ml

Surgeon: Dr. Li Mingjie

Assistants: Cai Yalun, Shen Yaping
Surgical Nurse: Gao Jieqing

Anesthesia: Continuous Epidural Block
Anesthetist: Chen Qibin

Post-Operative Gross Examination: Cauliflower-like cancerous mass of 6 cm, involving the entire layer of the intestinal wall.

Pathology Specimen Sent: Rectal cancer tumor along with 25cm above and 5cm below the intestinal tract, and lymph nodes at the root of the mesenteric artery.

Surgical Procedure Details

Surgical Steps

Positioning: The patient was placed in the supine position with the head down at a 15-degree angle and the buttocks elevated. The perineum was disinfected, and a catheter was inserted and kept open at the bedside.
Incision: The abdomen was disinfected in the usual manner. A longitudinal incision of 25cm was made through the left rectus abdominis muscle, extending from two fingerbreadths above the navel to the upper edge of the pubic bone. Hemostasis was achieved in the subcutaneous layer, and the surgical drapes were placed.
Exploration: No ascites were present. The liver appeared normal with no signs of metastasis. There were no enlarged lymph nodes around the root of the inferior mesenteric artery or near the aorta. The entire colon appeared normal, and no adhesions were found in the abdomen. Multiple soybean-sized lymph nodes were present on the small intestine mesentery.
Tumor Identification: A 6cm tumor was identified at the junction of the sigmoid and rectum, involving the entire layer of the intestinal wall but not causing obstruction. The colon was empty.
Procedure Choice: It was decided to perform an anterior resection of the rectum (Dixon Technique). The lumen above and below the tumor was occluded, and 500mg of 5-FU was injected into the bowel at the site of the lesion. A lymph node biopsy was performed at the root of the inferior mesenteric artery.
Vascular Management: The descending branch of the left colic artery was ligated and cut, preserving the marginal artery network. Blood supply to the colon 10cm above the lesion was good.
Dissection: The pelvic reproductive organs appeared normal, with a slightly enlarged uterus in the postmenopausal stage. The appendages were not involved with the cancer. Tubal ligation was planned for the end of the procedure.
Resection and Anastomosis: A segment of the rectum 25cm above and 5cm below the tumor was removed. End-to-end anastomosis was performed in two layers, with no leakage and good blood supply.
Cleaning and Drainage: The abdomen and pelvis were soaked and cleaned with distilled water, 0.1% Cetrimide, 500mg 5-FU, and saline. Hemostasis was carefully achieved.
Closure: The peritoneum was repaired, and the pelvic floor was reconstructed. Double drainage tubes were placed near the anastomosis and brought out through separate stab wounds. A cigarette drain was placed in the Douglas pouch.
Final Count and Closure: All sponges and instruments were accounted for. The abdomen was closed in layers. Blood loss was minimal, and the procedure was completed smoothly. The patient was returned to the ward.

Surgical Conclusion and Follow-up

Surgical Conclusion:

Diagnosis: The tumor at the upper end of the rectum was an adenocarcinoma that was well-differentiated. It had invaded the entire circumference and all layers of the intestinal wall. Despite the prolonged stage of the disease, no extra-intestinal metastasis was found.
Procedure: A standard Dixon radical surgery was performed, and the prognosis is expected to be relatively good.
Anastomosis: The anastomotic site was free of tension, had good blood supply, and the sutures were satisfactory. The risk of postoperative leakage is considered low.
Sterile and Tumor-Free Principles: The surgery was conducted following sterile and tumor-free principles, making the chance of iatrogenic implantation and dissemination extremely low.
Postoperative Treatment: Chemotherapy is recommended post-surgery to enhance the therapeutic effect.

Surgeon and Record Keeper: Li Mingjie
Date: April 2, 1987

Follow-up:

The patient recovered well post-surgery, with no complications.
Length of hospital stay was 26 days, and the patient was discharged in good health.
Eight-year follow-up showed no signs of recurrence or symptoms. The patient's quality of life is comparable to that of a healthy individual.
Rectal examination indicated that the anastomotic site had soft mucosa and the bowel lumen was unobstructed.

from 四级手术例案（6例）

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Treatment of scapulohumeral periarthritis with acupuncture combined with warm moxibustion

Chinese Medicine Paper III

Treatment of scapulohumeral periarthritis with acupuncture combined with warm moxibustion

Abstract

Scapulohumeral periarthritis is a degenerative, aseptic, chronic inflammation that impacts the humeral joint capsule and surrounding soft tissues. Often prevalent in individuals around the age of 50—commonly referred to as the "fifty shoulders"—this study investigates the treatment efficacy of combining acupuncture at Jianyu (LI 15) through Jiquan (EX-B2) with warm moxibustion and a Western medicine approach using prednisolone blocking. The treatment yielded satisfactory results, which are detailed below.

Clinical Data

The study involved 152 patients, comprising 70 males and 82 females. The age range of participants spanned from 42 to 67 years. The duration of their conditions varied from as short as two months to as long as 10 years.

Clinical Manifestations

Patients commonly experienced shoulder pain that extended to the neck and entire upper limb. Additional symptoms included finger numbness, restricted range of motion in abduction, external and internal rotations, various degrees of shoulder joint dysfunction, and muscle disuse atrophy.

Treatment Methods

1. Combined Acupuncture and Warm Moxibustion Group (94 Cases)

Acupoint Selection

Patients were positioned in a sitting posture with their elbows flexed and arms abducted horizontally. Acupoints were identified in the center of the upper part of the deltoid muscle, at the same height as the shoulder and at the lower margin of the acromion.

Acupuncture Depth

Needles were inserted vertically and deeply, approximately four inches, so that the tip could be felt in the axillary region without protruding through the skin.

Manipulation Technique

Initial insertion involved a twirling, lifting, and thrusting technique, followed by additional twirling and tonifying.

Needle Sensation

Patients reported sensations of swelling and numbness radiating from the shoulder to the elbow, and sometimes to the neck and fingers. A local warm sensation was also diffused around the needle site. Needles were retained for 15–20 minutes.

Moxibustion Therapy

Mild moxibustion was performed using either a suspended moxa stick or a fixed moxa holder for about 20 minutes.

Moxibustion Sensation

Patients typically felt a localized heat sensation that extended to the neck and across the shoulder. After moxibustion, some reported a cool sensation that gradually transitioned into warmth, leading to symptom improvement or complete relief. Acupuncture was generally applied in the morning, and moxibustion in the afternoon. A full course lasted seven days.

2. Prednisolone Local Blocking Group (58 Cases)

Prednisolone (25 mg) was combined with 2% procaine (2–4 mL) and injected into key tender points like the greater tuberosity of the humerus and the gluteus monodon. Patients often experienced a rebound effect with worsened symptoms the following day, which then gradually improved. Treatments were administered once a week, with three to five sessions constituting a complete course.

Efficacy Criteria

Complete Recovery: Pain completely relieved, full range of motion restored in the affected limb.
Markedly Effective: Pain largely alleviated and shoulder joint function mostly restored, though some discomfort remains.
Improved: Notable reduction in pain and enhanced shoulder joint functionality compared to pre-treatment.
No Effect: No noticeable change in symptoms post-treatment.

Therapeutic Results

Acupuncture and Warm Moxibustion Group (94 cases):
- Cured: 48 cases (51%)
- Markedly Improved: 24 cases (25.5%)
- Improved: 19 cases (20.2%)
- Ineffective: 3 cases (3.2%)
- Overall Effectiveness Rate: 96.8%
Prednisolone Local Blocking Group (58 cases):
- Cured: 16 cases (27.6%)
- Improved: 24 cases (41.3%)
- Ineffective: 18 cases (31.0%)
- Overall Effectiveness Rate: 69% (P<0.01)

A Typical Case Study

Patient: Wang XX, a 59-year-old woman with a 10-year history of right scapulohumeral periarthritis.
Symptoms: Episodes of severe pain in winter, mild in summer. Limited mobility in the affected limb, with aching pain exacerbated at night.
Previous Treatments: Prednisolone injections, acupuncture, and traditional Chinese medicine provided only mild relief.
Clinical Presentation: The shoulder felt as if bound ("如捆绑状"). Tongue coating was thin and white; pulse was deep and slippery.
Treatment: Deep needling was performed at the "Taiji Spring" located below the Jianyu (LI 15) acupoint. The technique was similar to the standard procedure. Post-needling, the patient felt a warm sensation flowing into her palm, reducing pain by half and improving mobility.
Moxibustion: Applied in the afternoon for 15 minutes, initially causing a cold sensation followed by warmth.
Outcome: Four days post-treatment, the patient experienced no chills and improved muscle flexibility. The right hand could now touch the left shoulder, and backward extension reached the twelfth thoracic vertebrae. After two weeks, all symptoms disappeared, and shoulder function was fully restored.
Follow-up: No recurrence observed in a 4-year follow-up.

Experiences and Insights

Jianyu (LI 15) holds a pivotal role in treating enduring shoulder and arm ailments. Ancient texts often highlighted its efficacy; for instance, it was said that "Zhenquan acupuncture emanates directly from Jianyu (LI 15)," underscoring its therapeutic importance.

Esteemed physicians of the past emphasized the value of focusing on this acupoint when treating shoulder-related conditions. In the "Song of Jade Dragon," penned by Guonao Wang from the Yuan Dynasty, it was noted that the shoulder pain—often aggravated by cold and dampness—could be mitigated by applying both nourishing and reducing techniques at the Jianyu (LI 15) acupoint, further enhanced by moxibustion to maintain overall well-being.

Similarly, Yiding Wu, in the late Qing Dynasty, stressed the effectiveness of this acupoint in his work "On Magic Moxibustion." He observed that people often experienced cold-induced shoulder pain, which could be superficially managed by massaging with warm hands and adding extra blankets at night. However, he advocated for the more targeted approach of using moxibustion at two specific acupoints at Jianyu (BL 15) for effective treatment.

Authors' Personal Experiences

1. Understanding the Nature of the Ailment

Scapulohumeral periarthritis rarely presents as red, swollen, and hot; more commonly, it manifests as cold and damp discomfort. My own practice has demonstrated that acupuncture and moxibustion from Jiquan (CV 4) to Jianyu (LI 15) effectively unblock channels, dispel wind and cold, activate blood flow, and alleviate pain. My mentor, Director Meisheng Zhou, emphasizes that the depth and sensation of the needle insertion are pivotal for an effective outcome. The ideal depth for acupuncture at this point is around 4 cun, and the manipulation should be such that it generates a local warm sensation that radiates to the perineum or extremities. The curative effect often stems from the local warm sensation alone, without necessitating further interventions.

2. The Anatomy Behind Successful Penetration at Jianyu Jiquan

The shoulder joint is unique in its anatomy, offering the largest range of motion among all joints and characterized as a ball-and-socket joint. The glenoid fossa is remarkably shallow, accounting for only 1/3 to 1/4 of the humeral head, and the joint capsule is thin and expansive. Given these anatomical specifics and the unique needling position, penetrating from Jianyu to Jiquan becomes not just feasible but also quite manageable, as long as the practitioner understands the key principles.

3. Comparing with Western Treatment Methods

When contrasted with the control group, which received local blocking treatment using Western medicine, our method stands out for its absence of hormone-induced side effects, symptom rebound, or the discomfort of receiving multiple injections at multiple points. It also outperforms the conventional "strong corrective" therapies in preventing the exacerbation of chronic strain.

This article was originally published in
"Naturopathy" Quarterly, Volume 15, Issue 3 (Autumn), 1992
By Li Yangzhen & Li Mingjie

from 針刺肩髃透極泉穴配合温灸治療肩周炎的體會

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Treatment of acute soft tissue injury with moxibustion

Chinese Medicine Paper II

Treatment of acute soft tissue injury with moxibustion

A Report of 187 cases

Introduction

Since 1987, our clinic has treated 187 cases of acute soft tissue injuries using a combination of moxibustion—with "Zhou's All-Power Moxibustion Pen" invented by Dr. Meisheng Zhou—and conventional Western medicine. We found that moxibustion offers a satisfactory therapeutic effect for acute soft tissue injuries. The details are as follows.

Clinical Data

We examined 187 patients, including 117 males and 70 females. The age range varied from 11 to 78 years, with a majority falling within the 20-50 age bracket. The injuries occurred within a maximum of three days, often within six hours. The most common injury sites were the waist (76 cases) and ankle (69 cases). All patients exhibited closed injuries and primarily suffered from acute muscle sprains, excluding ligament contusions, ruptures, and fractures.

Symptoms

The main symptoms included localized pain, swelling, and restricted movement in the affected area. Pain intensified during maximal static contractions and repetitive movements. Most patients presented with localized tender spots and muscle spasms.

Therapeutic Methods

Moxibustion Group

In the moxibustion group, acupoint selection was strategic, focusing on the areas around the injured site and following traditional meridian pathways. Positive tenderness points identified on the back of the injured area were also included. The approach differed based on the location of the injury:

For Elbow Injuries: The acupoints targeted were Zusanli (ST 36), Quchi (LI 11), Quliao (LI 14), and Chize (CV 12).
For Wrist Injuries: The acupoints used were Yangxi (GB 34), Yangchi (GB 34), Yanggu (GB 34), Waiguan (GB 26), Daling (GB 39), Zhigou (GB 34), and Taiyuan (GB 39).
For Waist Injuries: Shenshu (BL 23), Weizhong (BL 40), Kunlun (BL 60), Yaoyangguan (GB 34), Zhibian (GB 26), Yinmen (BL 21), and Mingmen (BL 21) were targeted.

After the moxibustion pen was ignited, it was held between the thumb and index finger. Medicinal paper was laid flat over the selected acupoints, and the ignited pen was used to lightly tap over the paper 4-5 times. This avoids burning through the paper and prevents scalding. After moxibustion, patients typically reported either no pain or only a slight, mosquito-bite-like sensation. The treated skin area either remained unchanged or turned slightly red.

Care was taken to moderate the intensity of the moxibustion. Too much heat could lead to burns and blisters, whereas too little heat would fail to achieve the desired therapeutic effect. After the moxibustion, peppermint oil was applied to the treated acupoints to prevent blistering. If accidental burns occurred, a specific ointment could be applied for fast healing without scars. The ointment recipe included 6g of toad skin, 6g of borneol, and 250g of sesame oil, mixed and left to sit for 7 days.

Moxibustion was performed twice a day, with each course of treatment lasting three days.

Local Sealing Group

In the Local Sealing Group, treatment involved injections comprising a mixture of 1% lidocaine (2-10 mL) and dexamethasone (5-10 mg). The quantity of the injection varied based on the location of the injury and the age of the patient:

For Wrist Injuries: Typically, 2-4 mL of the mixture was administered.
For Waist Injuries: Generally, a higher volume of 5-10 mL was used.

The critical aspect of this treatment was the precise location of the injection. The medication had to be injected directly into the muscle at the points where the muscle attaches to the bone. In the case of waist injuries, the injection was administered into the belly of the sacrospinalis muscle. This ensures that the medication is not merely injected into the subcutaneous loose tissue, thus enhancing the effectiveness of the treatment.

Treatment Outcomes

The efficacy of the treatments in both groups was compared using statistical analysis. The chi-square value of x is $16.68$ , with a significance level of P $P < 0.01$ . The results indicate that the Moxibustion Group demonstrated significantly better outcomes compared to the Local Sealing Group.

Table: Comparison of Treatment Outcomes Between the Moxibustion Group and Local Sealing Group (%)

Categories	Moxibustion Group	Local Sealing Group
Number of Cases	113	74
Cured	69 (61.1%)	18 (24.3%)
Markedly Effective	22 (19.4%)	18 (24.3%)
Improved	13 (11.5%)	15 (20.3%)
Ineffective	9 (8.0%)	23 (31.1%)
Overall Effectiveness Rate	92.0%	68.9%

Treatment results

The curative effects were compared between the two groups. The statistical treatment showed that the x-square was 16.68, P < 0.01. The curative effect of the moxibustion group was significantly better than that of the local sealing group.

Experiences and Insights

Acute soft tissue injuries are common in clinical practice, particularly affecting the waist and ankle regions. In Western medicine, localized sealing therapy is often the preferred treatment approach. This method aims to facilitate the absorption of stagnant blood, reduce swelling, interrupt the local reflex arc of harmful stimuli, and expedite the resolution of aseptic inflammation, all in an effort to alleviate pain and restore function.

Our experience demonstrates the unique efficacy of moxibustion therapy. After applying warm stimulation to the acupoints, the injured muscle tissue undergoes rhythmic, intense contractions before transitioning into a relaxed state. This process improves the microcirculation at the affected site, elevates metabolic rates, and smoothens the flow of 'qi' (life energy), while harmonizing blood circulation and unblocking meridians. These physiological responses accelerate the absorption of exudates, giving moxibustion therapy its beneficial properties: it alleviates muscle spasms, reduces inflammation, diminishes swelling and pain, and speeds up the recovery of function in the injured area.

Date of Receipt June 09, 1998 by Qi Lizhen

This article was originally originally published in "Shanghai Journal of Acupuncture," February 1999, Volume 18, Issue 1 (Clinical Report)    
By Li Yangzhen & Li Mingjie
Author's affiliation: 241000 Wuhu, Second Affiliated Hospital of Southern Anhui Medical College (Li Yangzhen); Wuhu Changhang Hospital (Li Mingjie)

from 点灸治疗急性软组织损伤 187例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Non-operative treatment of senile cholelithiasis with integrated traditional chinese medicine

Chinese Medicine Paper I

Non-operative treatment of senile cholelithiasis with integrated traditional chinese medicine

Cholelithiasis is a prevalent condition affecting the digestive system, particularly in the elderly. This paper details our experience in treating 26 elderly patients with cholelithiasis through a non-operative approach that integrates Traditional Chinese Medicine (TCM) and Western medicine.

1. Clinical Data

1.1 Patient Demographics

The study included 7 males and 19 females, with age distributions as follows: 17 patients were between 60-70 years old, 6 were between 70-80, and 3 were over 80. Cholelithiasis was confirmed in all cases through B-scan ultrasound. Sub-categories of the condition included 8 cases of gallbladder stones, 9 of common bile duct stones, 5 of gallbladder bile duct stones, and 4 of intrahepatic bile duct stones. Stone diameters ranged from <5mm in 5 cases, 6-10mm in 6 cases, 11-15mm in 11 cases, 16-20mm in 2 cases, and 21-30mm in 2 cases. Multiple calculi were found in 17 patients, while 9 had single calculi.

1.2 TCM Dialectical Classification

Dialectical classifications in TCM primarily focused on liver-qi stagnation, liver and gallbladder damp-heat, and liver stagnation with spleen deficiency.

Common symptoms across these classifications included varying degrees of pain in the right upper quadrant, which could extend to the shoulders and back. Additional symptoms were nausea, vomiting, oil aversion, and reduced appetite and belching.

Liver-Qi Stagnation: Patients typically experienced fluctuating pain points and intensity in the right upper quadrant, often influenced by emotional changes. Additional symptoms included a bitter taste, dry throat, pale tongue with white coating, and a tight pulse. This type is often seen in the early stage of the condition and may be accompanied by biliary colic.
Liver and Gallbladder Damp-Heat: This type often presents with the interplay between cold and heat, episodic biliary colic, and mild to moderate yellowing of the sclera or skin. Urine may appear concentrated, and the tongue often has a yellow and greasy coating. Wiry or slippery pulses are common in patients with concurrent biliary tract infections.
Liver Stagnation and Spleen Deficiency: Symptoms include dull pain in the right upper quadrant, loss of appetite, white tongue coating, and a wiry, thin pulse. This type is more common in patients with chronic cholecystitis.

2. Treatment Methods

2.1 Eligibility Criteria for Integrated Therapy

All patients in this study were treated non-operatively using a combination of Traditional Chinese Medicine and Western medicine. The criteria for selecting this therapeutic approach were as follows:

Gallstones smaller than 5mm and well-functioning gallbladders
Gallstones larger than 5mm in patients with cardiopulmonary dysfunction
Choledocholithiasis smaller than 20mm in diameter or mild cholangitis
Presence of intrahepatic bile duct stones in patients unfit for surgical intervention

2.2 Therapeutic Approaches

2.2.1 Traditional Chinese Medicine (TCM)

The base TCM prescription for oral administration consisted of:

Herba Lysimachiae 20g
Radix Bupleuri 10g
Radix Scutellariae 12g
Radix Curcumae 12g
Radix Aucklandiae 12g
Fructus Aurantii Immaturus 12g
Semen Arecae 12g
Radix Glycyrrhizae 10g

The herbs were decocted in water and administered orally once a day for a treatment duration of 1-2 months. Additional herbs were tailored to individual TCM diagnoses.

2.2.2 Acupuncture Therapy

Acupuncture was performed at the acupoints Ganshu (BL 18), Danshu (BL 23), Yanglingquan (GB 34), and Dannang (BL 20). Sessions were held once or twice a day, with each needle being retained for 30 minutes. Each 10-day period constituted a treatment course, with a two-day interval between courses. The acupuncture therapy aimed to clear meridians, enhance gallbladder function, and aid in stone removal.

2.2.3 Western Medicine

Fluid replacement was used to correct imbalances in water and electrolytes. For antibiotic and antipyretic therapy, 4g of Ampicillin was added to 250-500 ml of saline drip. Metronidazole was prescribed at a dosage of 0.4g three times a day, for a 10-20 day course. Blood cultures and antibiotic sensitivity tests were performed if clinical symptoms did not improve. For patients experiencing vomiting, 5mg of Metoclopramide was injected alternately at the Zusanli (ST 36) acupoint.

Patients with comorbid conditions like coronary heart disease, hypertension, chronic bronchitis, and diabetes were advised to follow an integrated TCM and Western medicine approach for optimum results.

3. Treatment Outcomes

3.1 Efficacy Assessment

The efficacy of the treatment was evaluated based on clinical symptoms, physical signs, and supplementary diagnostic tests.

3.1.1 Complete Cure

Complete disappearance of symptoms and physical signs. Body temperature and hemogram return to normal levels. A follow-up B-scan ultrasonography confirms the absence of any residual stones in the gallbladder or hepatobiliary ducts.

3.1.2 Significantly Effective

Symptoms have fully resolved, body temperature and hemogram are normal, and follow-up B-scan ultrasonography indicates a substantial reduction in the size or number of gallstones or hepatobiliary calculi.

3.1.3 Improved

Symptoms are essentially managed, with normal body temperature and hemogram. However, B-scan ultrasonography shows no significant reduction in gallstones or hepatobiliary calculi.

3.1.4 Ineffective

No changes in symptoms or physical signs post-treatment, and no expulsion of stones as verified by B-scan ultrasonography. Alternative treatment methods are required.

3.2 Summary of Outcomes

Out of the 26 patients treated:

8 patients (31%) were completely cured
12 patients (46%) showed significant improvement
4 patients (15%) showed some improvement
2 patients (7%) did not respond to the treatment

The overall efficacy rate was 93%.

4. Case Study

Patient Details

Name: Mrs. Zhang (anonymized)
Age: 67 years
Occupation: Retired worker
Initial Diagnosis Date: July 10, 1993

Mrs. Zhang had a previous history of cholelithiasis. She experienced recurring pain in her right upper abdomen three times in the past month. On the day of the consultation, she experienced acute colic in her right upper abdomen that radiated to her right shoulder and back. Accompanying symptoms included:

Continuous moaning
Cold intolerance
Fever
Nausea and vomiting
Loss of appetite
Fatigue
Loose stools

Physical examination revealed:

Temperature: 38.7°C
Blood Pressure: 18/12 Kpa
Mild jaundice in the skin and eyes
Tense abdominal muscles
Positive Mofei's sign

Diagnostic Tests

B-scan Ultrasonography: Multiple gallstones, the largest measuring 20×25 mm, and a left intrahepatic bile duct stone.
Blood Work: WBC 8.2×10/L, Neutrophils 0.83, Lymphocytes 0.17.
Liver Function Tests: Jaundice index 29 mmol/L, GPT 74 units, HBSAg negative.
Lipid Analysis: Cholesterol 4.5 mmol/L, Triglycerides 1.18 mmol/L.

Treatment Approach

Traditional Chinese Medicine (TCM) acupuncture was employed, focusing on points Yanglingquan (GB 34), Ganshu (BL 18), and Danshu (BL 23), specifically to alleviate pain related to liver damp-heat and qi stagnation. Western medicine was also used to balance fluids and electrolytes, especially to treat the acute symptoms caused by frequent nausea, vomiting, and diarrhea.

Summary

Most of the 26 patients in the study had a history of gallbladder and biliary tract inflammation. Elevated white blood cell counts and varying degrees of jaundice and liver damage were common. Treatment strategies combining acupuncture, anti-inflammatory measures, fluid replacement, and traditional Chinese herbal medicine effectively controlled inflammation and improved symptoms. This case exemplifies how an integrated approach combining both Chinese and Western medicine can yield superior treatment outcomes.

This article was originally published in Proceedings of First International Conference on Naturopathy in China (37), 1996/05/11;
By Li Mingjie & Li Yangzhen

from 老年胆石症中西医结合非手术治疗

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Prevention and treatment of trichomonas vaginalis and mold infection

Appendix II: by Pan, Yaogui

Prevention and treatment of trichomonas vaginalis and mold infection

Physiology of the Vaginal Canal

The epithelial cells in the vaginal mucosa of healthy adult women contain glycogen. In addition, the vagina hosts gram-negative bacteria, commonly known as Doderlein's bacilli. These bacteria have the ability to convert glycogen into lactic acid, maintaining an acidic environment in the vagina with a pH of 4.5. This acidity serves to inhibit the growth of pathogenic bacteria, thereby preserving the vagina's natural biological characteristics and self-defense functions.

Trichomonas Vaginitis

1. Etiology

The causative agent is Trichomonas vaginalis, a member of the whipworm family. It is pear-shaped and slightly larger than a neutrophil. The organism has four flagella at its apex, a fluctuating membrane around its body, and an axial column at its tail. It moves by rotating along a straight axis and propelling forward.

Optimal growth occurs at a pH range of 5.5 to 6.0, while growth is inhibited at pH levels below 4.5 or above 7.5.

The organism thrives best at temperatures of 35–37°C but can survive for 7-9 hours at temperatures of 10°C and 38-40°C. It can live for 120-150 hours at 25-27°C (typical bath water is around 30°C), survive for 5 days in regular well water, 9 hours in soapy water, and 12-20 hours in dry conditions. Clearly, it can exist widely in nature and is easily transmissible.

2. Methods of Transmission

Direct Transmission: The primary mode is through sexual intercourse.
Indirect Transmission: Transmission can also occur via bathing pools, bath utensils, underwear, and contamination from personal fecal matter and urine, as well as from toilets and medical equipment.

3. Pathogenesis

While theories vary, it's widely accepted that Trichomonas is not inherently pathogenic. Instead, it consumes glycogen in the vagina, obstructs the formation of lactic acid, and thereby reduces vaginal acidity. This disrupts the natural defense mechanisms of the vagina, making it easier for pathogenic bacteria to multiply and trigger an inflammatory response. Trichomonas does not invade tissues to cause pathological changes.

4. Incidence Rate

The incidence rate in China is estimated to be around 20%, similar to the 20-25% rate in the United States and the 10-25% rate in the Soviet Union. Among factory workers, the rate ranges from 16.7% to 32.36%. The incidence is higher in married women compared to unmarried women, and higher in pregnant women than in non-pregnant women.

5. Symptoms and Signs

Symptoms generally appear one week after infection.

Vaginal and Vulvar Itching: There's a sensation of crawling insects, but it does not affect sleep or daily activities. This is triggered by the secretion of vaginal fluids. In some cases, this may escalate to dermatitis.
Increased Vaginal Discharge: The discharge is grey-yellow and foamy (due to the decomposition of carbohydrates and the release of gas). It is thin, with a foul odor, and can sometimes be bloody or purulent. This irritates the skin around the genital area, causing discomfort and pain.
Infertility: Trichomonas can engulf sperm, and the inflammation in the vagina can adversely affect sperm survival, thus hindering pregnancy.
Urinary Symptoms: Symptoms may include frequent urination, urgency, and pain during urination — all indicative of a urinary tract infection.
Speculum Examination: The vaginal wall shows red granules, resembling the appearance of a bayberry.

6. Diagnosis

Diagnosis can be based on the medical history, itching symptoms, and the presence of foamy vaginal discharge. For a definitive diagnosis, microscopic examination of a wet mount to observe live trichomonas is required. Smear and culture methods can also be used for confirmation.

7. Treatment

1. General Treatment:

Maintain personal hygiene, abstain from sexual activity, minimize local irritation, and keep the affected area dry.

2. Local Treatment:

Vaginal Acidification: To restore its biological characteristics and self-cleaning functions. Commonly use 0.5% acetic acid or 1% lactic acid for douching once a day for a 10-day course. Note that pregnant women should only use topical application, and unmarried individuals may use a catheter for douching. Garlic broth fumigation is also effective.
Antiparasitic Treatment: Use of antiparasitic drugs like Metronidazole, Povidone-iodine, and others. Insert one tablet into the vagina every night for a 10-day course. Alternatively, use 100,000 units of Nystatin inserted into the vagina each night for a 14-day course.

3. Systemic Treatment:

Oral Antiparasitic Medication: Typically, both partners take Metronidazole 0.25g/day for a 10-day course. Alternatively, a single dose of 2g (0.25×8) can be taken, with a cure rate reaching up to 95%. Side effects are not notably more than with the 10-day treatment course.
Treating Coexisting Conditions: Treating inflammatory diseases of the reproductive system can restore the natural defenses of the vagina, thereby inhibiting the growth of trichomonas.
Treating Complications: For example, symptomatic treatment for urinary tract infections, and antibiotic treatment for vaginitis (Chloramphenicol 0.25g inserted into the vagina). If symptoms persist after one course of treatment, repeat treatment is advised.

8. Prevention

Strengthen hygiene education and personal hygiene, ban communal bathing, renovate public toilets (change from sitting to squatting styles), isolate bathing utensils (towels, basins), strictly disinfect medical equipment, and manage patients rigorously, especially those carrying the parasite.

Yeast Infection (Candidal Vaginitis)

Yeast infection is caused by Candida albicans and is second only to trichomonas vaginitis in incidence. It is more common in pregnant women, diabetics, and those on long-term antibiotics. It often coexists with other inflammations.

Method of Transmission: Primarily indirect.

Clinical Manifestations and Characteristics

Vulvar Itching: Starts from the inner labia and spreads outward; symptoms are quite prominent.
Vaginal Discharge: Often reduced during the acute phase, resembling curdled milk or bean dregs.
Speculum Examination: The vulva and vaginal mucosa are often covered by a white membrane; removing it reveals mild redness and swelling.
Smear and Suspension Tests: Pathogenic fungi can be observed; culture tests can also be performed.

Treatment

Vaginal Douching: Commonly use 2-4% baking soda or Gentian liquid (4 oz boiled down to 500cc of water), 3 times per day for a 10-day course.
Antifungal Treatment: 500,000 units nightly, inserted into the vagina for a 10-day course.
Topical Treatment: Nystatin ointment (for ulcerated surfaces) or 0.5% Gentian violet applied to the vulva and vaginal walls.
Oral Treatment: 8 tablets of antifungal medication daily.

Prevention

Strengthen hygiene education and clarify modes of transmission for this condition.
Treat primary conditions, such as diabetes, and avoid misuse of antibiotics.
Eliminate sources of infection: Improve bathing utensils, baths, toilets, etc., and strictly disinfect medical equipment to prevent cross-infections.

Comparison Table: Trichomonas Vaginitis vs. Yeast Infection

Categories	Trichomonas Vaginitis	Yeast Infection
Pathogen	Trichomonas; not normally present in a healthy vagina.	Candida albicans; normally present in the vagina.
Mode of Transmission	Primarily direct: sexual intercourse.	Primarily indirect: via bath utensils, pools, etc.
Clinical Features	Inhibits normal formation of lactic acid within vagina, leading to a decrease in vaginal acidity and disruption of its natural defense mechanisms, creating a favorable environment for pathogenic bacteria to grow and proliferate, causing vaginitis. However, it is not pathogenic in itself.	Yeast exists normally but only becomes pathogenic when acidity increases, such as in diabetics or pregnant women.
Pathogenesis	Itching in the vulva and vagina, does not affect work or sleep. Abundant gray-yellow discharge, may contain blood and pus, foamy in appearance. Red granules on the vaginal wall, resembling a bayberry texture. Co-existing symptoms of urethritis. Trichomonas detected in fluid examination.	Intense itching in the vulva, severe cases can affect sleep and work. Vaginal discharge varies, appearing as curd-like clumps or resembling bean curd residue. Vaginal mucous membrane covered by a layer; upon removal, the membrane appears reddened and swollen. No symptoms of urinary tract inflammation. Candida albicans detected in fluid examination.
Treatment	Commonly use acidic solutions for vaginal douching, such as 0.5% acetic acid or 1% lactic acid; garlic-infused liquid also effective. Antiparasitic treatment: Use Metronidazole, Ornidazole, Secnidazole, or Nystatin inserted vaginally or taken orally. Use antibiotics in combination (such as Penicillin, Chlorine, etc.). Treat coexisting conditions, especially urinary tract inflammation (using Nitrofurantoin). Treatment and management of individuals carrying the parasite.	Commonly use alkaline solutions for vaginal douching, such as 2-4% sodium bicarbonate. Use antifungal medications like Nystatin and Griseofulvin for intravaginal application. Generally, antibiotics are not used. Treat underlying conditions, such as diabetes. No need to treat those carrying the fungus (as it normally exists in the vagina).

This paper was originally published in Nanling Medicine,1979；1:45-47
Changhang Hospital, Pan Yaogui

from 潘耀桂：阴道内滴虫和霉菌感染的防治

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Rivanol induction of labour by amnion cavity injection

Obstetrics and gynecology paper II

Rivanol induction of labour via amniotic cavity injection

A Clinical Analysis of 120 Cases

Termination of pregnancy for various reasons at any stage is an essential aspect of obstetrics and gynecology. Despite the growing emphasis on family planning measures, the need for pregnancy termination as a remedial action for contraception and sterilization continues to increase. While early pregnancy termination can often be satisfactorily managed via aspiration and curettage, pregnancies extending beyond 13 weeks require artificial labor induction. Numerous methods exist for this purpose, each with its own advantages and drawbacks. From April to October 1980, our institution conducted a concentrated series of labor inductions using Rivanol amniotic cavity injections. Based on encouraging clinical outcomes, we present a comprehensive analysis and discussion of 120 well-documented cases.

Indications and Contraindications

Applicable Cases: This method is applicable for pregnancies beyond 18 weeks and up to the point of labor. It is suitable for women who either voluntarily seek or are medically advised to terminate their pregnancies, provided there are no contraindications. However, pregnancies extending beyond 34 weeks may result in viable fetuses, except when early delivery is medically advised for the health of the mother or child, and survival of the fetus is anticipated.
Genital Inflammation: For cases where a vaginal approach to labor induction may lead to intrauterine infection, this method is particularly suitable.
Physical Deconditioning and Organ Dysfunction: Individuals with compromised heart, kidney, liver, or lung function, as well as those with acute infectious diseases, must undergo active treatment and show improvement before considering this method.
Urinary Tract Infections: Patients with acute or chronic urinary tract infections need to be stabilized before induction, as ascending infections may exacerbate their condition.
Late Pregnancy Complications: For those in the third trimester with mechanical obstructions in the birth canal, or abnormal fetal positions or malformations, timely interventions like assisted delivery or fetal fragmentation should be considered. Alternatively, labor induction may be abandoned in favor of surgical delivery.

Our analysis offers a nuanced look into the utility and limitations of Rivanol-induced labor, emphasizing its practicality under specific conditions while underscoring the importance of a thorough patient evaluation to determine suitability.

Clinical Data

The study involved 120 participants, ranging in age from 15 to 48 years. Among them, 22 were primiparous (first-time mothers), and 98 had previous pregnancies. The gestational age varied between 18 and 38 weeks. The success rate for one-time induction was remarkably high at 99.11%.

Labor Duration:

Primiparous women averaged 40.3 hours.
Women with prior pregnancies averaged 58.5 hours.
Overall average was 49.4 hours.

Out of 120 cases:

88 experienced complete fetal and placental expulsion in one go.
24 had retained placental tissue.
7 required curettage due to uterine inertia.

One case failed initially but later succeeded with the use of a water-filled balloon for induction. No second doses of medication were needed in this cohort.

Hospital Stay:

The average length of hospital stay was 5 days.
66 patients had a normal temperature during their stay, while 54 experienced low-grade fevers, peaking at 38℃. All normalized post fetal expulsion.

Bleeding:

Average blood loss was approximately 50 ml.
No fatalities occurred, although one case of amniotic fluid embolism was successfully managed during curettage.

Efficacy of Labor Induction

Among the 119 successful inductions, 112 were self-expulsions of the fetus, all of which were stillbirths. The remaining seven cases were between 18 and 24 weeks of gestation and required curettage due to uterine inertia or abnormal fetal positioning, with satisfactory outcomes.

Table 1: Relationship between Drainage Time, Gestational Week, and Cases

gestation weeks	cases	within 24 hours	between 25-48 hours	between 49-72 hours	> 73 hours	average
18-21	38	2	15	18	5	56.1
22-25	35	0	11	21	3	48
26-29	22	1	8	12	1	45.3
30-34	16	7	3	6	0	44
> 35	8	3	3	2	0	42
合计	119	13 10.9%	40 33.0%	59 50%	7 5.9%	47.1

The drainage time predominantly ranged between 25 and 72 hours, accounting for 88% of the cases. Interestingly, the labor duration tended to shorten as the gestational age increased. This suggests a heightened uterine sensitivity, offering more opportunities for natural childbirth.

References

Special Summary of Induced Labor in Second Trimester Pregnancy: Proceedings of National Family Planning Experience Exchange Meeting, 1978.
Department of Obstetrics and Gynecology, Bengbu Third Hospital: Summary of 216 Cases of Induced Labor in Second and Third Trimester Pregnancy by Amnion Cavity Injection from Rever Woer. Compilation of Family Planning Data, 1978.
Liu Yong et al., 'Amniotic Fluid (Literature Review).' Foreign Medical Materials and References, Gynecology and Obstetrics fascicle 2:41, 1975.
Zhou Lijuan et al., 'Effect of Rivanol on Immune Uterus.' Collection of Materials on Rivanol-Induced Labor in the Second Trimester.
Wu Hanjing: Analysis of the Effect of Induced Labor in Middle and Late Pregnancy with 525 Cases Treated with Rivanol Amnion Injection. (Internal Data), 1980.
Shanghai First Medical University, et al: Gynecology and Obstetrics. P: 61-541 People's Health Press, 1978."

This article was originally published in Proceedings of the First Academic Conference on Obstetrics and Gynecology of Anhui Province,Sept. 1980；
Nanling County Hospital, Li Mingjie & Pan Yaogui

from 利凡诺 (Rivanol) 羊膜腔注射引产术

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Extraperitoneal cesarean section

Appendix I: by Pan, Yaogui & Li Mingjie

Extraperitoneal cesarean section

Clinical Summary of 8 Cases

Introduction

The ultimate goal of ending a pregnancy is to deliver the fetus and its appendages, thereby restoring the pregnant woman to her original physiological state. When vaginal delivery is not possible due to birth canal obstruction, or if the fetus is in distress and natural delivery is not a viable option, alternative delivery methods must be considered.

Historical Background

Historical records indicate that as early as 500 years ago, there were classical cesarean sections known as "imperial incisions." In modern medicine, this has evolved into lower segment cesarean sections. Both of these surgical approaches are classified as intraperitoneal cesarean sections. These methods can lead to the contamination of the abdominal cavity with substances like amniotic fluid, meconium, and blood, resulting in symptoms such as enteroparalysis, abdominal distension, and abdominal pain. In severe cases, they may cause complications like intestinal adhesions and peritonitis, leading to poor prognoses. This is particularly concerning for individuals with intrauterine infections.

The Advent of Extraperitoneal Cesarean Section

In 1909, Latzk pioneered the extraperitoneal cesarean section. This technique began to be implemented gradually in China during the 1960s and has only recently started to gain widespread acceptance, along with improvements in the procedure. During the annual meeting of the Obstetrics and Gynecology Department of our province in October 1980, the provincial hospital reported a clinical summary of 30 cases performed since January of that year. Following the meeting, our institution started performing this surgical technique in November and has completed eight cases over the past two months. Herein, we report our preliminary findings and experiences.

Clinical Data

In 1980, our department performed a total of 45 cesarean sections (excluding minor surgeries). These consisted of 12 classical cesarean sections, 25 lower uterine segment cesarean sections, and 8 extraperitoneal cesarean sections. Since November, 8 out of 10 cesarean sections have been performed using the extraperitoneal method. All cases have fully recovered and were discharged from the hospital.

The clinical details of the 8 extraperitoneal cesarean sections were compared to the other surgical methods (averages were used for the comparison). It should be noted that this procedure was newly introduced in November, making a year-long comparison with other methods irrelevant.

Key Observations

The primary advantage of the extraperitoneal cesarean section is the significantly reduced time for intestinal gas evacuation—averaging just 14 minutes and 12 seconds. In contrast, the other two methods require two to three days, thus delaying food intake, increasing fluid requirements, and incurring additional costs.

Surgical Indications

The surgical indications for an extraperitoneal cesarean section are consistent with those for any cesarean section. However, the necessity for this method becomes more pressing in cases of intrauterine infection. In our study, the indications included:

Three cases of birth canal obstruction (cephalopelvic disproportion)
Four cases of intrauterine distress (premature rupture of membranes)
One case of threatened uterine rupture due to cephalopelvic disproportion, resulting in a stillbirth

Anesthesia

All cases were performed under total epidural anesthesia. The resulting muscle relaxation facilitated blunt dissection, and patients remained calm during the procedure.

Surgical Techniques

We employed the Noton method in all cases. A 10-12 cm longitudinal incision was made in the midline between the navel and pubic area. The abdominal wall was dissected layer-by-layer, leaving the peritoneum intact. The uterus was exposed adequately before making the incision. The extraction of the fetus and its appendages, as well as uterine wall suturing, followed standard procedures used in lower segment cesarean sections.

Bladder and peritoneal folds naturally reverted to their original positions without the need for suturing. However, meticulous hemostasis and surgical field cleaning were carried out to minimize postoperative bleeding and heat absorption.

Complications

No cases of bladder injury were reported in the group. Mild hematuria was noted in two cases within 24 hours post-surgery but resolved spontaneously. In three cases, the peritoneum was accidentally torn and was sutured before uterine incision without prolonging the time for intestinal gas evacuation.

Discussion

The most salient advantage of extraperitoneal cesarean sections is that they avoid opening the abdominal cavity, reducing the risk of contamination and subsequent complications. Our data indicate that if the surgical procedure is executed meticulously—with proper dissection, thorough hemostasis, and diligent cleaning of the surgical field—the risk of infection is minimal. Average recovery time is notably short at 4.4 days, with no reported infections.

A significant challenge of the procedure lies in the delicate task of blunt dissection outside the peritoneum. Both the peritoneum and bladder wall are sensitive to injury, which has long discouraged the adoption of this method. However, recent evidence suggests that the procedure is not as daunting as once thought. Indeed, with adequate anatomical understanding and surgical skill, the procedure can be safely and efficiently executed. Even cases involving fetal distress or emergent conditions are not contraindications for skilled surgeons. In our study, except for one case resulting in a stillbirth, all other cases resulted in a safe outcome for both mother and child.

Naming the Procedure

Lastly, regarding the nomenclature for this surgical method, we align with the views of the Department of Obstetrics and Gynecology at Nanjing Workers' Hospital [2]. Given that the procedure involves dissecting the uterus without opening the abdominal cavity, a more accurate name might be "Extraperitoneal Uterine and Fetal Extraction" as opposed to the more ambiguous term "Extraperitoneal Cesarean Section."

Summary

This paper presents a review of eight cases of extraperitoneal cesarean sections conducted in our hospital since November 1980, comparing them with other surgical methods performed within the same timeframe. Our findings, corroborated by a comprehensive review of the literature and hands-on surgical experience, suggest that this method offers advantages in terms of faster postoperative recovery and easier mastery of the surgical technique. With enough skill, this approach could essentially serve as a viable alternative to more traditional methods.

It's important to note that we are in the preliminary stages of employing this surgical technique. Our insights are admittedly limited, and we recognize the need for further data accumulation and refinements in our approach.

References

Clinical application of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology, November 1965 (4) P315
Nanjing Workers' Hospital: Clinical application value of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology, November 1965 (4) P29
Anhui Provincial Hospital: Clinical summary of extraperitoneal cesarean section. Provincial Annual Meeting of Gynaecology and Obstetrics in 1980 (Internal Data)
Su Yingkuan et al. Gynaecology and Obstetrics Surgery (P440). People's Health Publishing House, 1973

This paper was originally published in Proceedings of Provincial Society of Obstetrics and Gynecology Seminar,1981/01/05；
Changhang Hospital, Pan Yaogui & Li Mingjie

from 潘耀桂、李名杰：腹膜外剖腹产术

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Intrauterine abortion combined with tubal pregnancy rupture

obstetrics and gynecology paper I

Intrauterine abortion combined with tubal pregnancy rupture

A Rare Case Report

Simultaneous termination of both intrauterine and extrauterine pregnancies is an exceedingly rare clinical phenomenon. We report a compelling case encountered during a house call.

Patient Background

The patient, a 23-year-old woman, had been married for two years without giving birth. She had regular menstrual cycles but experienced a 52-day amenorrhea accompanied by early pregnancy symptoms such as nausea, food aversions, and drowsiness. On April 22, 1979, she suddenly experienced vaginal bleeding and lower abdominal pain, followed by the expulsion of embryonic tissue. A clinical examination confirmed a complete abortion. Subsequent cessation of vaginal bleeding and alleviation of abdominal pain left her in generally good health.

Clinical Presentation and Diagnosis

Nine days post-abortion, the patient attempted sexual intercourse and immediately experienced right lower abdominal pain, dizziness, and sweating. Initially misdiagnosed at a local hospital as either post-abortion infection or intestinal parasitism, she was given tetracycline and analgesics and sent home. The following morning, she experienced severe abdominal pain and symptoms of shock. Upon emergency admission to the commune hospital, her blood pressure was recorded at 60/30 mmHg, with a pulse rate of 112/min. She displayed pale skin, excessive sweating, and agitation, with generalized abdominal tenderness—particularly in the right lower quadrant.

An emergency diagnostic paracentesis yielded non-clotting, dark-red blood, confirming a diagnosis of ruptured ectopic pregnancy.

Treatment and Outcome

Immediate fluid resuscitation and a 400 ml blood transfusion were administered, followed by surgical intervention under local anesthesia. Approximately 2000 ml of intraperitoneal blood and clots were evacuated. The ampullary region of the right fallopian tube was found to be engorged, resembling the size of a duck egg, and had ruptured. A 3 cm-long male fetus was found free-floating in the abdominal cavity. A right salpingectomy was performed, revealing internal placental tissue. The contralateral fallopian tube and ovary appeared normal, and the uterus was slightly enlarged but soft, with no adhesions. An additional 350 ml of retrieved abdominal blood was reinfused without complications. The patient recovered fully and was discharged 10 days post-operation.

Conclusion

This case underscores the critical nature of thorough evaluations in patients who present with abdominal pain post-abortion, as rare conditions like a simultaneous intrauterine abortion and ruptured ectopic pregnancy could be easily overlooked or misdiagnosed. Prompt diagnosis and surgical intervention were vital in this case, leading to a successful outcome.

This report was originally published in Nanling Medicine,1979;1:21,
05/14/1979, Nanling County Hospital, Pan Yaogui & Li Mingjie

from 宫内妊娠流产合并输卵管妊娠破裂一例报告

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

In commemoration of the 50th anniversary of Dr. Xu Jingbin' s medical career

Appendix

In commemoration of the 50th anniversary of Dr. Xu Jingbin' s medical career

Note from Wei: Mr. Xu Jingbin, a leading authority in Chinese orthopedics, was my father's mentor in the field. During Mr. Xu's lifetime, my dad collaborated with other disciples of Mr. Xu to organize a '50-Year Medical Career Commemoration for Xu Jingbin.' They published a special issue in 'Southern Anhui Medical Journal.' Below is a compilation of relevant information to honor this highly respected and esteemed expert.

a group photo taken in 1973 at the Orthopedic Training Course

In the back two rows are the 'Nine Great Warriors.' In the middle row, on the far right, is Li Mingjie. In the front row are three teachers: On the left is Yuan Sizhong from the regional hospital, who was the class adviser; Mr. Xu is in the center, and to his right is Director Zhang Kan from Yijishan Hospital.

Old Steed Rests in the Stable, a Model in White Coat

— Congratulating Professor Xu Jingbin, a Renowned Orthopedic Expert in China, on His 50 Years in Medicine

To adapt to the favorable conditions of current reforms and openness, and to promote academic exchange and strengthen friendly interactions between orthopedic peers in this region and across the nation, the Wuhu Branch of the Chinese Medical Society hosted this academic seminar. The conference specifically addressed prevalent issues in contemporary orthopedic clinical practice, such as trauma and fractures; internal fixation and non-union; fractures of the femoral neck; microsurgery; spinal canal disorders; and cervical spondylosis. Selected papers that are clinically advanced and practical are published in this supplementary issue of the Southern Anhui Medical College Journal.

In this beautiful season when the spring winds are greening the southern banks of the Yangtze River, and orthopedic peers are gathering in Wannan, it also marks the 50th anniversary of Professor Xu Jingbin's medical career. A renowned orthopedic expert, he has spent decades diligently employing his superb skills to treat numerous patients, alleviating their pain. He has cultivated a large number of skilled clinicians in orthopedics for the party and the people. Using this opportunity to hold an academic celebration that's quite different and meaningful is indeed significant.

Xu Jingbin was born in 1919 in Jiujiang, Jiangxi Province. He graduated from the National Xiangya Medical College in Hunan in 1944. In 1948, he served as the attending physician in orthopedics and surgery at the former Central Hospital; in 1951, he led the surgical team in the Volunteer Army aiding Korea against America. From 1953 until now, he has been the head of the orthopedic department at the PLA Nanjing 81 Hospital. In the early 1950s, he was among the first in the military region and Jiangsu Province to perform lumbar disc herniation removal and debridement for bone and joint tuberculosis. In the 1960s, he introduced the practice of using large amounts of tap water to irrigate severe open wounds, reducing the infection rate to 0.4%. He was the first to report artificial femoral head replacement and occipital-cervical fusion in domestic literature. In the 1980s, he invented a device for treating non-unions, treating hundreds of non-union patients. This non-surgical method has been widely used in hospitals nationwide. In 1986, he was invited to lecture at Columbia University, the New York Orthopedic Center, and the Electrobiology Research Institute in New Jersey, bringing honor to his homeland.

In recent years, through clinical practice, he has innovatively designed many surgical instruments and internal fixation materials. For example, he created a compressive cannulated screw system for treating femoral neck fractures and external fixators for bone drilling, allowing patients to get out of bed and resume activities sooner, thereby avoiding the various complications associated with prolonged bed rest.

Over the past 50 years, he has served everywhere from the military to local communities, from cities to rural areas, and from military camps to factories and mines. In the operating room, under the surgical lights, he's used his scalpel to fight disease and defy death, successfully completing over 3,000 lumbar disc herniation removal surgeries alone. His noble medical ethics, superb skills, and selfless contributions are worthy of our admiration and learning.

He is meticulous in his teaching and tirelessly instructs others. In addition to fulfilling regular clinical training, he has nurtured outstanding professionals in the field of orthopedics who excel in their specializations …………

Excerpts from the Commemorative Supplemental Articles

…………

Efficacy Assessment:

Excellent: Fracture has healed, joint function at the fracture site has returned to normal, and there are no late-stage complications.
Good: Fracture has healed, and the range of joint function at the fracture site is reduced by less than 20 degrees. There are no late-stage complications, or if there are, remedial treatment has brought the condition up to excellent or good standards.
Poor: Fracture has healed, but the range of joint function at the fracture site is reduced by more than 20 degrees, or complications have resulted in permanent disability.

In our group of 110 cases of multiple fractures, the treatment results were:

Excellent in 80 cases (72.7%),
Good in 7 cases (6.4%),
Poor in 11 cases (10%),
Fatalities in 12 cases (10.9%).

Key Takeaways:

Quick, comprehensive examinations and early accurate diagnoses coupled with the correct treatments are crucial for the successful treatment of multiple fractures and traumatic shock. The rate of success in treating shock is directly proportional to whether or not there was proper pre-hospital treatment and how quickly patients were admitted for medical care. Effective rescue should begin at the site of the injury. The first few minutes to hours after the injury are pivotal for a successful rescue. In our group, the majority of survivors were those who received better pre-hospital care or were admitted early. Among the fatal cases, apart from 5 with brainstem injuries and 3 with ruptured spleens, the remaining 4 were delayed due to late admissions. For example, one case of untreated post-injury hypotension went undiagnosed until 48 hours later, by which time blood pressure was undetectable, and progressive respiratory distress led to death the next day. This highlights the importance of immediate first aid, especially considering that the technical skills of grassroots medical personnel, transportation equipment, and urban emergency response capabilities are essential components of emergency care.
Complexity of Multiple Fractures and Traumatic Shock: These cases are often severe and complicated, requiring specialized diagnostic and treatment approaches. It's essential to accurately gather patient history and perform comprehensive examinations, particularly to identify life-threatening, concealed injuries. Monitoring blood pressure alone isn't enough to determine the presence of shock; it must be considered within the context of the patient's overall condition. Timely fluid resuscitation, blood transfusions, and oxygenation are vital to reduce the period of shock. Life-threatening complications should be addressed promptly; waiting is not an option. In this study, 30 cases were treated for shock and fractures concurrently, and 25 cases with general complications or open wounds underwent surgery after achieving stable blood pressure.
Importance of Rapid Volume Replacement: Quick and timely replenishment of blood volume is crucial for treating hemorrhagic shock successfully. Delayed or insufficient volume replacement can lead to complications like Disseminated Intravascular Coagulation (DIC). In this group, 9 cases were saved through aggressive primary injury treatment and voluminous blood transfusions, particularly with fresh blood, which also replenished clotting factors.
Early Treatment of Fractures as an Anti-Shock Measure: The treatment of fractures in patients with multiple injuries and traumatic shock should focus on reducing mortality. Early treatment of fractures should be considered an essential aspect of anti-shock measures. For long tubular bone fractures, strong internal fixation should be performed. For some open fractures, primary internal fixation can be performed as long as conditions allow and wounds are thoroughly cleaned. This simplifies complex fractures, aids in early joint mobility, and speeds up overall recovery.

…………

featured in the 13th volume of the Southern Anhui Medical College Journal, published in 1994

from 骨科导师许竞斌先生从医50周年纪念增刊资料

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Intervertebral disc excision in community health centers

Orthopedic paper VII

Intervertebral disc excision in community health centers

OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER

ABSTRACT

Objective: To assess the long-term efficacy of surgical treatments for lumbar disc herniation (LDH) in a communal healthcare setting.

Methods: This retrospective clinical review analyzes 104 cases of protrusion of the lumbar intervertebral disc that underwent surgical intervention between 1974 and 1980 in a health center within a people’s commune. A comprehensive postoperative follow-up was conducted for periods ranging from 2 to 8 years, with an average follow-up duration of 5 years. The study elaborates on surgical methods employed and presents detailed observations and experiences gathered over the years.

Results: The outcomes of the 104 operated cases were classified as follows: excellent in 68 cases (65.4%), good in 22 cases (21.2%), fair in 10 cases (9.6%), and failure in 4 cases (3.8%). Various exposure techniques such as fenestration and hemilaminectomy were compared, highlighting the importance of complete nerve root decompression. Furthermore, infection control measures and strategies to mitigate postoperative intraspinal hematoma were discussed.

Conclusion: Surgical treatment of LDH in a communal healthcare setting has demonstrated significant efficacy, with a vast majority of patients (86.6%) experiencing good to excellent outcomes. Key insights include the comparable efficacy of fenestration over hemilaminectomy in most cases and the critical role of meticulous decompression and infection control in postoperative success.

Intervertebral disc removal surgery for treating pain in the lumbar and leg regions caused by lumbar disc herniation is a widely accepted etiological treatment. While this procedure has become quite common in hospitals above the county level, it is still less frequently performed in community health centers. Between 1974 and 1980, under the direct guidance of Professor Xu Jingbin, we performed 104 lumbar intervertebral disc removal surgeries at community health centers. A follow-up over a period of 2 to 8 years post-surgery indicated that the vast majority of cases had satisfactory outcomes. Below are some insights on how to improve surgical outcomes in under-resourced community health centers:

General Information

Out of the 104 cases, 85 were male and 19 were female. The oldest patient was 56, and the youngest was 23. There were 49 cases of disc herniation between the 4th and 5th lumbar vertebrae, 31 cases between the 5th lumbar and 1st sacral vertebrae, 22 cases of dual herniations, and 2 cases between the 3rd and 4th lumbar vertebrae. In two cases, the herniated disc nucleus had penetrated into the spinal canal, and 12 cases were accompanied by the formation of bone spurs.

Based on the efficacy assessment standards by Ma Zhiyao et al.[2], the statistical results of surgical outcomes are as follows:

Outcome	great	good	so-so	poor	Total
cases	68	22	10	4	104
%	65.4	21.2	9.6	3.8	100%

Clinical Insights and Observations

Exposure Techniques: Out of 104 cases, eight utilized hemilaminectomy while the remaining employed the "fenestration" technique, including the 12 cases that necessitated bone spur removal. Through direct surgical practice and observation, we found no appreciable difference in exposure between the fenestration and hemilaminectomy methods. Hence, fenestration is generally recommended unless specific conditions, such as disc nucleus intrusion into the spinal canal, dictate otherwise. Utilizing fenestration tends to preserve facet joints and minimize tissue damage, facilitating early postoperative mobility and reducing the risk of nerve root adhesion. In our fenestration group, all patients began ambulatory activities between 3-5 days postoperatively with no observed complications.
Decompression Considerations: Armstrong pointed out in 1951 that dissatisfaction with surgical treatment of lumbar disc herniation was either due to diagnostic errors or failure to entirely eliminate the causative pathology. With advancements in medical technology, the likelihood of misdiagnosis or surgical omission has been minimized. Achieving "complete decompression" has thus gained prominence. After exposing the herniated disc and safeguarding the nerve root, a small scalpel is used to incise around the periphery of the protruding disc. Subsequently, pituitary forceps are used to remove the protruding disc and degenerative tissue from the disc space. This approach aims to achieve "complete clearance," not just removal of the nucleus pulposus, and has been found effective for comprehensive nerve root decompression and recurrence prevention.
Infection Control Measures: Postoperative infection, particularly within the intervertebral space, is a severe complication causing substantial patient distress and elongated recovery timeframes. This is especially significant in less well-equipped grassroots healthcare facilities. To mitigate infection risks, strict aseptic techniques are adhered to. Additionally, the cleared disc space is routinely irrigated under pressure with a 1:1000 Betadine solution. Following irrigation, the surgical site is occluded with Betadine-soaked gauze for approximately three minutes, capitalizing on Betadine's broad-spectrum, high-efficacy, and non-resistance features, which show no adverse effects on neural tissues.
Mitigation of Postoperative Intraspinal Hematoma: Given that the spinal canal should remain free from foreign material, traditional methods involving sutures or muscle tissue for hemostasis are avoided. Pressure-based methods are thus the primary approach for controlling bleeding. Even though minor postoperative intraspinal bleeding is somewhat inevitable, we employ appropriate drainage techniques. Specifically, a small amount of Betadine is intentionally left in the surgical site to dilute any residual bleeding, making it easier to drain. Rubber drainage strips are conventionally placed and removed after 48 hours, with observed drainage volumes ranging from 40 to 250 microliters, demonstrating the efficacy of this approach.

References

[1] Xu Jingbin. "Analysis of the efficacy of LDH," Chinese Journal of Surgery 4421, 1956

[2] Ma Zhiyao et al. "Effects of surgical treatment of LDH," Chinese Medical Journal 5:51, 1965

[3] Lu Yupu et al. "Surgical treatment of LDH," Chinese Journal of Orthopedics 2:77, 1981

[4] OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER, Ding Ming-xiu, Nanling Health School, Anhui

This article was originally published in Proceedings of the Third Orthopedic Academic Conference in Anhui Province"
Ding Mingxiu, Nanling County Health Continuing Education School;
Instructors: Xu Jingbin, Li Mingjie
09/01/1983

from 在基层公社卫生院开展椎间盘摘除手术的体会

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Fifth metatarsal fracture caused by varus sprain

orthopedic paper VI

Fifth metatarsal fracture caused by varus sprain

Report of 30 cases

Abstract

This study presents a clinical analysis of 30 confirmed cases of avulsion fractures at the base of the fifth metatarsal bone caused by inward ankle sprains. The cases were collected from our hospital since 1983 and have been followed up from 1 to 8 years. All cases were between the ages of 23 and 54, predominantly affecting active middle-aged individuals. Typical recovery occurs within 1-2 months with conservative or no treatment.

Clinical Data

Among the 30 patients, 22 were male, and 8 were female. The age range was between 23 and 54 years, with 24 cases under the age of 40. All injuries occurred due to accidental inward twisting of the foot while walking. Of these, 28 cases had insignificant fracture dislocation, and 2 cases exhibited comminuted fractures. Generally, functional recovery was noted within 1 to 2 months, either with conservative treatment or without treatment.

Discussion

Aside from direct force or open wounds, fractures caused by unintentional inward twisting of the foot during regular walking activities often go unnoticed by both clinicians and patients. Diagnosis is often delayed several days until soft tissue swelling recedes but symptoms persist. The mechanism of these fractures involves abrupt excessive inversion of the foot and intense contraction of the peroneus brevis muscle, leading to an avulsion fracture at its point of attachment at the base of the fifth metatarsal. Fracture lines are often oblique, irregular, and separated. Clinically, local tenderness is prominent, often accompanied by subcutaneous bruising and prolonged swelling, which hinders normal walking and activities. An X-ray diagnosis can prevent missed cases.

For fractures where dislocation and separation are apparent, three weeks of external support with an outward plaster cast is required; otherwise, no special treatment is generally necessary. After an appropriate rest period of 2 to 3 weeks, and once symptoms have disappeared, weight-bearing walking and exercises can resume without waiting for radiographic evidence of bone healing.

In our study, 30 cases were observed over 1 to 8 years, and no case exhibited any functional impairment. This was attributed to the fact that the external force from a simple sprain was insufficient to cause severe anatomical disarray or destruction of the transverse and lateral arches of the foot.

This article was originally published in Journal of Wannan Medical College, 1994, Vol 13, Supplemental Issue
Changhang Hospital, Li Mingjie

from 足内翻扭伤致第五跖骨基底部骨折30例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Treatment of femoral neck fracture with closed nailing

orthopedic paper V

Treatment of femoral neck fracture with closed nailing

Report of 45 cases

Abstract

The paper discusses treating 45 cases of traumatic femoral neck fractures using closed reduction and percutaneous triangular pinning. Follow-up conducted over 1-3 years showed delayed healing in one case and avascular necrosis of the femoral head in two cases. The rest of the patients were able to walk without crutches within 3-6 months. The treatment method is characterized by minimal trauma, quick recovery, safety, broad indications, and the preservation of anatomical structures.

Keywords: Closed Reduction, Femoral Neck Fracture, Triangular Pin

Introduction

Femoral neck fractures are clinically common, especially among the elderly. To date, there is still no standardized treatment method, making the search for a safe, effective, and easily disseminated approach a long-standing goal in the field of orthopedics. Since Smith-Petersen first introduced the use of triangular nails for internal fixation in 1931, there have been notable achievements in shortening the duration of treatment, reducing complications related to bed rest, and lowering disability rates, among other aspects. However, the method of open nailing has its disadvantages, such as causing significant trauma, further damaging the periosteum and blood supply, and increasing the risk of infection. On the other hand, closed reduction and percutaneous nailing, including recent developments like compression screws or cannulated screws, have become much simpler and more feasible with the continuous improvement of radiological equipment, technical advancements, innovative tools, and accumulated experience. The text concludes by stating that the authors have recently conducted this type of surgery and have followed up on 45 cases, which will be reported.

Clinical Data

All 45 cases are fresh fractures. There are 30 males and 15 females. Ages range from 40 to 81 years, with an average age of 62. There are 32 cases on the left side and 13 on the right. Six are of the eversion type, while the rest are inversion. There are 34 intracapsular cases (7 subcapital and 27 in the neck) and 11 extracapsular ones (at the base of the neck). Fourteen patients were admitted immediately after the injury. All received early surgery, and the rest underwent surgery within a week. For those with successful nailing, postoperative movement was unrestricted, and they could move around and sit up with assistance. Otherwise, patients received lower limb traction for 2-3 weeks or wore a rotational support shoe. Afterward, they could move with crutches. No surgical infections were reported in any cases.

Follow-Up Results: All cases were followed up for 1-3 years. Three months post-op, 90% (40/45) of patients had bone union, pain-free hips, and could walk without limping, using crutches. In two cases with subcapital fractures, X-rays six months post-op showed localized cystic changes and collapse within the femoral head, but walking was still possible, and slight repair was observed after a year. One case had poor repositioning and resulted in mild limping, while another case had insufficient implant insertion. One year post-op, 25 cases had the nails removed.

Surgical Indications

Apart from non-displaced impacted fractures that do not require special treatment, and comminuted fractures where nailing is expected to be ineffective, this surgical procedure can be applied to all types of fractures.

Surgical Method

For patients admitted within 24 hours of the fracture, who have no specific contraindications for surgery, traction is not pre-arranged and surgery is carried out as soon as possible. At this point, tissue reaction is mild, and muscle elasticity is reversible, making reduction easier. Otherwise, preoperative skeletal traction is applied for 48-72 hours to correct fracture displacement. The proposed reduction plan is determined based on factors such as the direction of the fracture line, the shear force, blood supply to the head, and muscle action.

Epidural blockade anesthesia is usually used to achieve muscle relaxation, facilitate reduction, and make surgery painless. Alternatively, local anesthesia can also be used.

The patient lies supine on the X-ray diagnostic table for reduction using Whitman's method. The principle of "first separation, then joining" is followed. Initially, the leg is slightly externally rotated and adducted to loosen the fracture surface, making it easier to apply traction and correct shortening. The fluoroscope is used to confirm anatomical alignment and to tighten the fracture line. The affected limb is kept in 15° internal rotation to counteract the natural forward tilt, facilitating horizontal needle insertion. A lead marker is used to mark the intersection point between the inguinal ligament and the femoral artery at the surface projection of the center of the femoral head.

A guide needle is inserted 3 cm below the greater trochanter, following aseptic requirements. When it reaches the bone, its closest point, i.e., the tangential point on the outer edge of the femur, is probed to prevent sliding forward or backward. It is inserted horizontally at approximately a 130° angle, using the distance between the insertion point and the target for comparison to reduce X-ray exposure for the surgeon. Skilled surgeons can achieve this almost every time on their first try. A Kirschner wire is inserted transversely from the upper part through the femoral head to the acetabulum to prevent head rotation. Note: This wire should not interfere with the guide wire and should maintain a triangular nail width distance.

A 2 cm incision is made at the skin entry point of the guide wire to reach the bone cortex. A self-made cortical opener (triangular nail with a serrated progressive step) is used to pierce the cortex and pre-make a tunnel. After confirming that the guide wire has not moved, a suitable triangular nail is chosen based on its scale. The nail is carefully driven in to prevent misalignment, jamming, or breaching the head edge. The guide wire and Kirschner wire are then removed. A self-made small round steel tube is used to embed and tighten the fracture surface. The incision is sutured in one layer, followed by compression bandaging. Surgery is then completed.

Discussion

The hip joint is surrounded by abundant muscle tissue and is very strong. Additionally, the shaft and head are not aligned, making it easy for shear stress to cause shortening and dislocation after a femoral neck fracture. The joint also tends to rotate easily within the socket, causing deformities that affect the range of motion in the joint later on. These anatomical and pathological factors often lead to poor outcomes with conservative treatments. Therefore, timely reduction and effective internal fixation, which help maintain proper alignment and allow the patient to get out of bed as soon as possible, are crucial.

Clinical data shows that closed nailing treatment for femoral neck fractures has several advantages: minimal trauma, simplicity, effective fixation, fast recovery, and cost-effectiveness. It not only allows the patient to get up quickly but also retains the patient’s own femoral head, without damaging the anatomy of the hip joint, and largely restores pre-injury function. In our study, functional recovery was achieved in 90% of cases (40/45).

Radiological equipment and technical details are two key elements in this surgical method. Advanced radiological facilities make the procedure even more convenient. The technique focuses on restoring physiological angles and preventing inward and outward rotation of the hip. Accurate needle placement and tight bone fracture contact are essential. With these in place, the patient can move in bed shortly after surgery, aiding overall recovery.

Considering the complex anatomy and mechanics of the hip joint, surgeons must understand the fundamental theories and master the pathology of fractures. Improvements in equipment, traction methods, and positioning can further refine the surgical procedure. Recent years have seen advancements like pressure screws for better insertion, traction frames for effective traction and stable positioning during surgery, and cortical openers for accurate cortical bone chipping, which significantly simplify the surgical process and improve medical outcomes.

Regarding bone non-union and head necrosis, the general rate is between 15%-25%. It's observed that necrosis is generally determined at the time of fracture but only manifests later. Factors such as the degree of dislocation, location of the fracture, timing, and method of reduction, as well as weight-bearing time on the affected limb, are relevant. Preventing iatrogenic re-injury is crucial. Even if this treatment fails due to poor reduction, needle error, or other complications, salvage methods like osteotomy or artificial femoral head replacement are still available.

References

Liu Shijie, Chinese journal of surgery 1980 18: 125
Ouyang Jia, Chinese journal of surgery 1978 16: 123
Wu Zuyao, Chinese journal of surgery 1959 7: 135
Wang Yongchang, Chinese journal of surgery 1982 20:289

This article was originally published in the 1994 supplemental issue of the Journal of Southern Anhui Medical College, pages 37-38
Nanling Hospital, Li Mingjie,Zhang Jianmin, Xu jianzhong
Sept. 1, 1988

from 闭式穿钉治疗股骨颈骨折45例

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Lipoma under soft spinal membrane complicated with high paraplegia

orthopedic paper IV

Lipoma under soft spinal membrane complicated with high paraplegia

Introduction

Intraspinal tumors predominantly consist of extramedullary tumors, accounting for 85% of the cases. However, subdural lipomas are exceedingly rare. Due to their proximity to the spinal cord, the pathological changes and clinical symptoms often get confused with intramedullary tumors. Nevertheless, as benign lesions, their surgical treatment and prognosis differ significantly. We report a case admitted to our hospital who has fully recovered after six months post-surgery.

Case Presentation

The patient is a 39-year-old married male farmer from our county, admitted on March 28, 1979, with case number 1340. He experienced numbness and weakness in both lower limbs accompanied by sharp, band-like pain on the right side of the chest for six months. He had difficulty with bowel and bladder control and was unable to walk or stand for two months. Paralysis had ascended to the level of the nipples, accompanied by breathing difficulties for two weeks.

Clinical Examination

Superficial sensation below the second rib was virtually absent, more so on the right side. Partial sharp pain remained on the left side. Abdominal and cremasteric reflexes were absent. The muscle strength in both lower limbs was graded 8-4, and there were no ankle clonus. Tenderness was observed upon percussion of the spinous processes of the upper thoracic vertebrae, but no deformity was noted. Thoracic spine X-rays were negative. Queckenstedt's test showed complete obstruction of the subarachnoid space. CSF analysis: Pandy's test positive, cell count 10/mm³, and positive for Froin's sign. Paralysis index was 2-4 (sensory 2, motor 1, sphincter 1).

Preoperative Diagnosis

Cervicothoracic intraspinal tumor with paralysis, extramedullary type.

Surgery

On April 4, intraspinal exploration was performed under local anesthesia. Via a posterior midline approach, the laminae of thoracic vertebrae 7-12 were excised. The dura was opened between cervical 6 and thoracic 5. Although fat distribution seemed uniform in the epidural space, a 35x20x12 cm fatty, yellow, soft protrusion was discovered on the dorsolateral aspect of the spinal cord at T1:T2, causing 50% compression. The lesion was partially excised (80%) to avoid spinal cord injury, tagged, and sent for pathology. The surgical field was irrigated. The dura was left open to decompress, and the soft tissues were sutured without drainage.

Postoperative Recovery

Within 48 hours post-surgery, the patient reported a burning sensation in both lower limbs. Gradually, motor and sensory functions improved. On postoperative day 19, the urinary catheter was removed, and the patient could urinate voluntarily and turn himself over. He was discharged after 36 days without any complications.

Pathological Report

The protrusion was identified as "fatty tissue," pathology number 4724.

Six-Month Follow-Up

Six months postoperatively, the patient can walk with crutches, has completely regained sensation, has normal bowel movements, and has normal urinary flow. His appetite is good, nutrition is well-maintained, and he can engage in weaving and other handcrafts.

Discussion

Intraspinal tumors that reside underneath the soft dura mater are, for the most part, growths that overlay the spinal cord. These growths create a space-occupying pressure that leads to spinal canal obstruction, a mechanism distinct from intramedullary tumors that directly damage the spinal cord. While the former mostly consists of benign abnormalities, the latter are primarily malignant. However, both can cause early-onset paraplegia due to their close relationship with the spinal cord, and both can advance rapidly. In this case, the "lipoma" is a benign growth that, within a short span of six months, caused severe obstruction of the spinal canal.

In the case of intramedullary malignant tumors, such as gliomas, paraplegia appears early and is often complete. Benign growths close to the spinal cord usually cause more severe paralysis on the side where the growth is present, commonly known as Brown-Séquard syndrome. This case exhibited varying degrees of paralysis on both sides, with early-onset "intercostal neuralgia" on the right side, which correlates with the intraoperative finding of the growth leaning to the right. Additionally, bladder and rectal functions were not completely impaired.

Clinically, progressive paraplegia accompanied by evidence of obstruction in Queckenstedt's test indicates the need for early surgical intervention to relieve the pressure. Even if the abnormality is benign, prolonged pressure can cause irreversible damage to the spinal cord. Relaxing paralysis, even if it lasts for several weeks, is hard to reverse. In our case, timely surgical decompression yielded good results.

Based on clinical symptoms, the level of paralysis, and tests like Queckenstedt's and spinal angiography, it is possible to understand and locate the spinal canal obstruction. Intraoperatively, the effectiveness of decompression can be judged by the return of pulsations in the spinal cord. When the growth cannot be completely removed, it's crucial to leave the dura mater open as a decompressive measure.

Soft dura mater lipomas are soft, benign tissues. They don't cause localized fatty absorption on the hard dura and show no localized elevation or hardening, making them hard to detect from outside the dura mater. When the dura is cut open, these growths can be clearly identified: a yellow growth overlaying the spinal cord with increased, abnormal vascular distribution, flattening the spinal cord due to pressure.

Conclusion

This paper reports a rare case of a lipoma underneath the soft dura mater, leading to high-level paraplegia. It analyzes the case from a pathological and clinical perspective, comparing it with intramedullary tumors. It suggests that surgical intervention should be performed as early as possible. However, it's not necessary to "completely" remove the tumor; spinal decompression is crucial.

This article was presented at the Second Sessiong of Third Annual Surgical Conference in Anhui Province and originally published in "Nanling Medicine" 1979；1:68.
Nanling Hospital, Li Mingjie

from 软脊膜下脂肪瘤并发高位截瘫

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Surgical analysis of surgical paraplegia

orthopedic paper III

Surgical analysis of surgical paraplegia

Report of 14 cases

Abstract: The article reviews the surgical treatments and long-term follow-ups of 14 patients who experienced paraplegia due to surgical causes over the last 13 years. The outcomes were 10 cases recovered, 3 cases improved, and 1 case deceased. The article details the causes, pathology, and surgical methods, followed by discussions.

Causes Classification:

Spinal Fractures: 7 cases
Spinal Tuberculosis: 5 cases
Intradural Tumors: 2 cases

Spinal Fractures: Particularly in "complete transverse fractures" (refers to fractures affecting the vertebral body, arch, and intervertebral ligaments), dislocations are common. If it happens in the cervical-thoracic section, it often results in spinal cord contusions or compressions, causing paraplegia. Among them, 4 cases had spinal cord destruction observed during surgery, presenting as a mushy substance. No surgical methods could reverse the paraplegia. Apart from one case, which resulted in breathing difficulty and lung infection, leading to death one month post-injury, the rest could generally live for years with disabilities, even capable of manual labor.

Spinal Tuberculosis: Especially in the thoracic section, due to the relatively narrow spinal canal and the inability for abscess to drain, it easily results in spinal cord compression and subsequent paraplegia. All 5 cases were in the lower thoracic section, 4 were vertebral tuberculosis, and 1 was arch tuberculosis. After surgical lesion removal, all recovered. The paper strongly recommends applying thoracic lesion removal and anterior intervertebral bone grafting in suitable cases, which not only increases the effectiveness but also significantly shortens the treatment period.

Intradural Tumors: Generally benign and located extramedullary. Surgery to remove or decompress shows good results. Both cases in this group were extramedullary benign tumors; one was completely removed, and one was mostly removed along with dural decompression, both achieving full recovery. However, surgery should be extremely cautious for malignant tumors to avoid accidental injuries and uncontrolled bleeding.

Overview

Spinal cord dysfunction due to injury or compression can result in varying degrees of paraplegia, which can have serious consequences for the patient. If managed appropriately, the majority of cases can be salvaged. Between 1968 and 1981, the author encountered 14 such cases, all of which underwent surgery, received a definitive diagnosis, and were given corresponding treatments. The outcomes were 10 cases fully recovered, 8 cases improved, and 1 case deceased. This paper introduces and analyzes the causes, pathology, surgical interventions, and prognoses of this patient group.

1. Classification of Causes

Spinal Fractures	Spinal Tuberculosis	Intra-Spinal Canal Tumors
Spinal Cord Injury / Spinal Cord Compression	Vertebral Tuberculosis / Lamina Tuberculosis	Intradural Neurofibrom / Subdural Lipoma
4 / 3	4 / 1	1 / 1

2. Degree of Paralysis

Paralysis Index	1	2	3	4	5	6
Cases	0	0	2	4	3	5

3. Choice of Anesthesia and Surgical Approach

Anesthesia			Surgery
Local Anesthesia	Epidural Anesthesia	General Anesthesia	Posterior Vertebral Approach	Anterolateral Approach	Anterior Trans-Thoracic Approach
2	4	8	11	1	2

4. Surgical Methods

Exploration + Traction	Exploration + Reduction + Fixation	Decompression + Reduction + Fixation	Lesion Removal + Decompression	Lesion Excision
1	3	3	5	2

5. Pathological Changes and Prognosis

Spinal Cord Injury (4 cases)		Spinal Cord Compression (10 Cases)
No Change	died	Recovered
3	1	10

Regarding Spinal Fractures Accompanied by Paralysis

Spinal fractures can appear at various segments of the spine due to different points of external force. However, because the spinal cord terminates at the lower edge of the first lumbar vertebra, below which is the cauda equina comprised of nerve fibers, its injuries are generally not complete. The spinal cord, on the other hand, is very delicate and easily damaged. As a result, the incidence of paralysis accompanying cervical and thoracic spinal fractures is high, and the prognosis is often poor.

The treatment objectives for these patients are:

To explore the spinal cord, ascertain the pathological changes, and attempt to relieve compression or additionally take decompression measures, aiming to restore the vertebral canal's openness and make a prognosis.
Under direct surgical view, to reset the fracture, take care to avoid repeated injuries, and apply strong internal fixation to restore the stability and supportive force of the spinal column.

For these purposes, although the work involves both orthopedics and neurosurgery, neither can be neglected. This is because the recovery of spinal cord function is a matter of life and death, while the recovery of spinal column stability is related to regaining labor capability. Both are often handled concurrently in clinical practice.

1. Case Presentation

2. Typical Case Introductions

Case 1: Male, 36 years old, had a complete transverse fracture and dislocation at the 9th thoracic vertebra. Palpation revealed spinal cord compression without destruction. Under direct vision, fracture reduction and decompression were performed, followed by internal fixation with spinal steel plates. Fourteen days post-surgery, the patient regained urinary function, lower limb muscle strength improved to Grade III, and sensation was restored. Discharged one month after surgery, the patient could walk with crutches in three months and gradually regained full mobility and working capacity. One year later, the steel plate was removed, and the patient was fully recovered.

Case 2: Cervical vertebrae 4 and 5 were shattered, and high-level paralysis was observed. Surgical exploration confirmed spinal cord destruction. Only cranial traction was applied. The patient died one month after surgery due to respiratory failure, lung infection, and bedsores leading to systemic collapse.

Case 3: Male, 42 years old, had a complete fracture at the 8th thoracic vertebra along with paralysis. During surgery, the spinal cord was found to have a mushy appearance. Spinal steel plates were used for internal fixation. Paralysis was not reversed; the muscles in the lower limbs atrophied, while the upper limbs developed. The patient relied entirely on crutches for mobility and had a reflexive bladder but could perform weaving work. He died five years later due to diabetes.

3. Discussion

Spinal fractures accompanied by paralysis pose significant risks. Aside from spinal shock that can recover over time, a few cases arise from vertebral compression causing the rear edge to move backward, compressing the anterior part of the spinal cord. This is often exacerbated by hematomas and reactive edema of the spinal cord. More commonly, the vertebral bodies and their attachments are injured or dislocated in a single plane, causing a "complete transverse fracture of the spine," which disrupts the normal anatomy of the spine. This leads to bone or bone fragments easily damaging and severing the delicate substance of the spinal cord, resulting in function loss that is difficult to recover.

Osterholm believes that once the spinal cord is mechanically compressed, local catecholamine levels increase, causing vascular constriction and blood supply obstruction in the affected area, thus accelerating the development of paralysis or making it irreversible. Based on this theory, it is strongly advised to undertake emergency surgical decompression to avoid missing the treatment window. However, there have been reports of paralysis recovery following delayed surgery. For cases where the spinal cord is already damaged, the goal is merely to explore and avoid further iatrogenic injuries while preserving any remaining spinal function. Allem points out that the spinal cord usually dissolves within 24 to 48 hours after severe injury, which is related to the intrinsic autolytic process within the spinal cord. Therefore, surgery is best performed within 24 hours for patients with partial spinal damage.

According to our long-term follow-up observations, the prognosis primarily depends on the degree of pathological changes in the spinal cord. Recovery is rare for patients with a destroyed spinal cord, as in cases 2, 3, 4, and possibly 7. On the other hand, for those with compressed spinal cords, effective decompression can often lead to full recovery, as in cases 1, 5, and 6.

Studies have shown that displacements greater than 1 cm in the thoracic vertebrae above T12 with complete paralysis often indicate severe spinal cord injury, with little hope for recovery. Displacements less than 1 cm usually indicate mild spinal cord injury with better chances of recovery. However, it should be noted that spinal fractures often have an automatic recoil effect, making the actual displacement greater than what X-rays may show. Overall, the surgical group has a 50% higher recovery rate than the conservative treatment group.

4. Conclusion

Traumatic paralysis can lead to different outcomes. Aside from cases of high-level paralysis which can result in short-term death due to severe complications, paralysis caused by compression can often be reversed through decompression. However, recovery from spinal contusions is less likely. Through surgical repositioning and internal fixation to stabilize the spine, patients can still survive for a prolonged period. It's important to note that there's no clear boundary between "compression" and "contusion," as both can coexist. Moreover, what is observed visually may not be entirely accurate. Those with contusions can still hope to maintain some residual spinal function, while those suffering from compression may also experience worsening paralysis due to edema or localized ischemia. Therefore, individuals suspected of having spinal cord damage should be treated as if they are "compressed" for maximum salvaging.

Regarding Spinal Tuberculosis Complicated by Paralysis

Spinal tuberculosis is usually found in the vertebral bodies, with the appendages rarely affected, accounting for about 1%. Obstruction caused by tubercular matter in the spinal canal can lead to paralysis, often in the thoracic region where the spinal canal is relatively narrow.

The likelihood of thoracic vertebrae tuberculosis leading to paralysis is high, and conservative treatment not only prolongs bed rest but also offers minimal chances of recovery. The complications of paralysis are pressing and demand urgent attention. Thus, early surgery, after appropriate preparation, has become the modern consensus. Under the protection of anti-tuberculosis treatment, complete lesion removal to clear the spinal canal, coupled with bone graft fusion to stabilize the diseased spinal area, can achieve good results and prevent recurrence. All five cases in this group were cured through surgery.

1. Case Presentation

2. Typical Case Studies

Case 1: Male, 35 years old, tuberculosis of the 8th and 9th thoracic vertebrae accompanied by paralysis. After three weeks of anti-tuberculosis preparation, a staged, lateralized surgical plan was carried out. Initially, the lesion on the right side was removed under spinal anesthesia, extracting a large amount of pus, necrotic bone, and tubercular granuloma. Post-surgery, the paralysis showed signs of recovery, but urinary catheterization could not be removed. One month later, a second surgery was planned to remove the lesion on the opposite side and perform spinal fusion. However, the patient experienced a high fever (41°C) and convulsions under general anesthesia, forcing the surgery to be halted. The patient then refused further surgeries and was discharged for home care. Twenty days after returning home, the urinary catheter fell out on its own, and the patient began to urinate independently. Three months later, he was able to walk with crutches and returned to light work after six months. A year after the surgery, the patient carried his ill mother for 40 miles to the hospital, astonishing the surgeons!
Case 3: Male, 36 years old, tuberculosis of the 7th thoracic vertebra arch, accompanied by paralysis. Four months after total laminectomy, he was able to walk, and a year later, he also returned to work. This case had a spinal angiogram showing pseudolocation due to arachnoid adhesions; the lesion was located during surgery and confirmed pathologically post-removal.
Case 5: Female, 29 years old, worker, tuberculosis of the 8th and 9th thoracic vertebrae. The vertebrae had collapsed, causing kyphosis, accompanied by proliferative pulmonary tuberculosis and a healed dislocation of the right hip due to tuberculosis. She was frail and weighed only 42 kilograms. During her pre-surgical hospital stay, her paralysis worsened, and she showed uncontrollable symptoms of sepsis. Surgery was performed under endotracheal ether anesthesia. The lesion was removed through the right thorax in one go, 2.5 diseased vertebrae were excised, and anterior decompression was performed. Tubercular material was scraped out from within a 10 cm section of the spinal canal, revealing a pulsating dura mater. Two rib sections were implanted between the vertebrae. The surgical field was flushed, and the thoracic cavity closed as per routine. The patient had no postoperative complications, the paralysis was quickly relieved, and the body also recovered smoothly. She was able to walk after four months in bed and returned to textile work after a year. X-ray follow-up showed successful bone graft fusion, disappearance of paravertebral abscess shadows, and slightly blunted costal angles.

3. Discussion

Spinal tuberculosis is a specific infection characterized by the presence of tubercular granuloma, caseous material, and pus both inside and outside the spinal canal, especially around the spinal cord. In the narrow thoracic spine, the pus doesn't easily drain, and along with necrotic bone or intervertebral disc tissue, this leads to spinal canal obstruction and consequent paralysis. Tuberculosis sepsis at this stage can affect multiple organs, making the situation far more complex and difficult to manage compared to paralysis caused solely by mechanical compression.

The posterior approach for staged, lateralized lesion removal has been a standard procedure to date. Not only does it eliminate the lesion and break the "tuberculosis barrier," aiding in lesion healing, but it also allows for spinal decompression. This is particularly effective for the recovery of concurrent paralysis, as demonstrated in Case 1. However, the method carries a certain degree of uncertainty. The surgery is performed deep within the body where visibility is limited, requiring reliance on experience to achieve "relative completeness." There's also the risk of accidentally damaging blood vessels, the spinal cord, or internal organs. According to domestic reports, the surgical success rate is 61.6%.

In contrast, the anterior thoracic approach allows for a thorough and effective lesion removal under direct vision. It also removes destructive tubercular material from the spinal canal and relieves spinal cord compression. Combined with reliable anterior decompression of the spinal canal, it significantly aids in the recovery from paralysis. Performing anterior intervertebral bone grafting also promotes compression fusion and helps restore spinal stability. This approach not only avoids the pain and economic burden of multiple surgeries but also significantly increases the cure rate and shortens the treatment duration, as seen in Cases 4 and 5.

In cases of spinal accessory tuberculosis, which has a lower incidence rate and generally better prognosis due to abundant peripheral muscles and good blood circulation, lesions are usually absorbed naturally. However, paralysis can still occur in the thoracic section. Laminectomy for spinal decompression and lesion removal is relatively convenient if it doesn't compromise the small facet joints, as in Case 3.

4. Summary

In cases of traumatic paralysis, except for high-level paralysis, which often leads to early death due to severe complications, paralysis caused by compression often shows a good recovery rate once decompressed. On the other hand, recovery is generally more difficult in spinal cord contusions. However, surgical repositioning and internal fixation to stabilize the spine can still lead to prolonged survival.

It’s important to note that the terms "compression" and "contusion" are not strictly separate and often coexist. What is observed with the naked eye isn't always entirely accurate. Therefore, in cases identified as "contusion," the hope lies in maintaining the remaining functional portions of the spinal cord. For those identified as "compression," secondary spinal cord degeneration can occur due to edema or local ischemia, making the paralysis worse.

Hence, for patients suspected of having substantial spinal cord damage, treatment should be approached as if the spinal cord is "compressed" in order to maximize the chances of recovery.

Regarding Spinal Tuberculosis and Resulting Paralysis

Spinal tuberculosis predominantly affects the vertebral bodies, while appendages of the spine are less commonly involved, accounting for about 1%. When tuberculous material fills the spinal canal and causes an obstruction, it can result in paralysis, most commonly in the thoracic region due to the relative narrowness of the spinal canal there.

The likelihood of paralysis is quite high in cases of thoracic spinal tuberculosis. Conservative treatment doesn't yield significant improvement; not only does it require prolonged bed rest, but the chance of complete recovery is also extremely low. Complications from the resulting paralysis can be aggressive and need immediate attention. Therefore, the modern consensus leans towards early surgical intervention after adequate preparation.

Under the cover of anti-tuberculosis treatment, thorough removal of the lesion to unblock the spinal canal is recommended. Additionally, bone graft fusion to stabilize the affected spinal area can achieve good results and prevent recurrence. All five cases in this group were completely cured after surgical intervention.

1. Case Presentation

2. Case Studies Summary

Case 1: Male, 35 years old, affected at T8-T9
- After three weeks of anti-tuberculosis treatment, he underwent staged, unilateral surgery to remove the lesion on the right side. Postoperative evaluation showed some recovery of paralysis, but a catheter for urination was still necessary.
- A second surgery for the opposite side was planned, but had to be stopped due to high fever and seizures under anesthesia. The patient opted out of additional surgeries and was discharged. After returning home, he started to urinate on his own within 20 days, and six months later, he was able to perform light work. Astonishingly, a year after the surgery, he even carried his sick mother 40 miles to the hospital.
Case 3: Male, 36 years old, affected at T7
- Four months after undergoing decompression of the entire vertebral arch, he could walk. A year later, he resumed work.
- Spinal angiography was performed, revealing false localization due to arachnoid adhesions. The lesion was identified and removed during the surgery and confirmed through pathology.
Case 5: Female, 29 years old, worker, affected at T8-T9
- Also suffering from proliferative pulmonary tuberculosis and a healed form of tuberculosis in the right hip, she weighed only 42 kg.
- During the preoperative preparation period, her paralysis worsened and septicemia symptoms could not be controlled. She underwent surgery, including removal of 2.5 affected vertebrae and spinal decompression.
- After the surgery, she experienced no complications, her paralysis was quickly resolved, and she returned to her textile work within a year. Radiography confirmed bone graft fusion and the disappearance of paravertebral abscesses.

Discussion Summary

Complex Nature of Spinal Tuberculosis
- The disease involves a unique type of infection where tuberculous granuloma, caseous material, and pus accumulate both inside and outside the spinal canal. This is more problematic in the thoracic spine, which is relatively narrow. Along with necrotic tissue and bone, this leads to spinal canal obstruction and paralysis. In addition, systemic symptoms due to tuberculosis further complicate the condition.
Surgical Approaches
- The standard surgical procedure involves staged, unilateral lesion removal via a posterior approach. This not only clears the lesion but also breaks the "tubercular barrier," aiding in healing. It's also effective in relieving paralysis, as in Case 1. However, the procedure is risky due to its "blind" nature.
- The anterior approach via the chest allows for a more effective and safer removal of the lesion under direct vision. It also offers the opportunity for reliable spinal decompression, aiding in the recovery of paralysis. Coupled with anterior interbody bone grafting, it enhances spinal stability.
Rate of Success and Adaptation
- Studies have shown a 61.6% success rate for the posterior approach. The anterior approach not only minimizes the pain and economic burden of multiple surgeries but also significantly improves the cure rate and shortens the treatment period. The authors are leaning towards adopting this approach, as in Case 4 and Case 5.
Attachments of the Spine
- Tuberculosis of the spinal attachments is rare and generally has a good prognosis due to good blood circulation and muscle mass around it. Even in the thoracic spine, where paralysis can occur, laminectomy and lesion removal without destroying the facet joints can achieve good results, as shown in Case 3.

Regarding Spinal Canal Tumors Complicated with Paralysis

Types of Tumors
- Most commonly found are meningiomas in the extradural intrathecal space.
- Gliomas and ependymomas are usually present within the spinal cord.
- Subarachnoid lipomas are relatively rare.
Mechanism of Paralysis
- The tumor creates a space-occupying lesion, putting pressure on the spinal cord.
- As the tumor grows, the paralysis progressively worsens.
- Non-surgical decompression or shunting is usually not effective in reversing this condition, highlighting the need for attention to these cases [7].
Differential Diagnosis
- It's crucial to distinguish these tumors from other conditions causing paralysis, such as transverse myelitis, and subarachnoid hemorrhage to avoid unnecessary surgery and complication.

1. Case Presentation

	Year	Spinal Segment	Queckenstedt's Test	Pathological Diagnosis	Surgical Findings	Surgical Method	Prognosis
1	1969	T10	Partial obstruction	Neurofibroma	T10 right paraspinal, extradural, intrathecal mass of 1.5×1.0x1.0 cm	Complete Tumor Excision	Recovered (2 months)
2	1979	C7 T1	Complete obstruction	Subdural Lipoma	C7 T1 subdural lipoma compressing the spinal cord by 50%, length 3 cm	Partial Tumor Excision (~70%), Dural Decompression	Recovered (6 months)

Case 1: A neurofibroma located at the T10 spinal segment was completely excised. The Queckenstedt's test showed partial obstruction. The patient recovered in 2 months. Straightforward and effective, like a clean piece of code.

Case 2: This one's a bit more complex. A subdural lipoma at C7 T1 caused complete obstruction. About 70% of the tumor was removed and the dura was decompressed. It took 6 months for the patient to recover, but hey, they did recover!

Discussion

Clinical Confirmation

Both cases were diagnosed through clinical neuro-localization, confirmed during surgery. It's like finding a bug in a specific part of the code—difficult but not impossible.

Pre-operative Uncertainty

It was hard to nail down the pathology before surgery, but both cases improved post-operation. The first case was easier to handle with complete tumor excision since the neurofibroma was outside the spinal cord. The second case required a more cautious approach: the benign lipoma was intimately adhered to the spinal cord, so only partial removal was attempted. They also decompressed the dura to relieve pressure.

The Root Cause

The root cause of spinal cord paralysis due to tumors is essentially mechanical compression within the spinal canal. Similar to an overloaded server, the only solution is to alleviate the congestion. Various diagnostic tests like cerebrospinal fluid dynamics and chemical examination can help confirm this.

Diagnostic Methods

Spinal angiography can theoretically localize the lesion, but like any sophisticated AI model, there can be false positives or negatives. Clinicians must consider errors, adhesions, vascular anomalies, and other factors.

Importance of Pre-op Assessment

Efforts must be made to understand whether the tumor is inside or outside the spinal cord, benign or malignant, as this influences both the surgical complexity and prognosis. It's like optimizing an algorithm—you need to know the variables affecting the output.

Urgent Action

If the diagnosis is unclear, it's better to operate sooner rather than later. First, most spinal tumors are benign and easier to treat. Second, even if it's malignant, at least you can relieve the pressure. But caution is crucial; surgeries aren't risk-free. Third, surgical and pathological examinations can confirm the diagnosis, allowing for appropriate management.

Summary

Long-Term Observations

The study recaps 14 cases of paralysis due to surgical causes over a 13-year span. It's like looking back at 13 years of software updates—some work wonders, some need patching. Various treatment methods were evaluated and outcomes of individual cases were discussed.

Outcomes

Of the 14 cases, there were no surgical mortalities. Ten fully recovered; one with a high cervical injury died shortly after surgery; one case is too recent for assessment; two more lived for 5 and 3 years post-operation but eventually died due to complications like diabetes and intestinal obstruction, making it unclear if their paralysis contributed to their deaths.

Tuberculosis and Benign Spinal Tumors

100% effective treatment was shown here. It's like finding that perfect algorithm you've been dreaming about. Treatment for thoracic spine tuberculosis-induced paralysis has significantly advanced, reducing treatment time and increasing the chances of successful outcomes. So, we're overcoming historical fears.

Key Takeaways

For traumatic spinal paralysis, the severity of the spinal injury is the key determinant for outcomes—just like how the root cause of a bug determines how messy the debugging is going to be.

References

Guo Shi Fu et al.: "Preliminary Observations on Pathological Changes After Spinal Injury and Different Treatments (Animal Experiments)," Bone Supplement: 4:176, 1979
Xu Shao Ting: "Early Treatment of Earthquake-Induced Spinal Fractures and Spinal Injuries," Orthopedics Supplement: 4:146, 1980
Guo Ju Ling et al.: "Preliminary Summary of Treatment for Earthquake-Induced Paralysis," Orthopedics Supplement: 1:28, 1978
Fang Xian Zhi et al.: "Lesion Removal Therapy for Tuberculosis of the Joints and Bones," P: 58 (People’s Health Publishing House) 1957
Fan Bing Zhe: "Thoracic Lesion Removal Surgery for Thoracic Tuberculosis," Chinese Journal of Surgery: 7:20, 1959
Wang Zhi Xian: "Thoracic Cavity Lesion Removal Surgery for Spinal Tuberculosis," Chinese Journal of Surgery: 7:271, 1959
Zeng Guang Yi et al.: "Spinal Tumors," Chinese Journal of Surgery: 10:(6)374, 1962
Wu Ying Kai et al. (Trans.): "Soviet War Medical Experience, Selected Translations in Surgery," Volume 11, People’s Health Publishing House: 1956

This article was originally originally published in the proceedings of the Second Orthopedic Academic Conference in Anhui Province; initial draft was written in January 1981 and later revised in September 1981
Nanling Hospital, Li Mingjie

Note: This article has been reviewed by Dr. Yuan Sizhong from the Orthopedic Department of Wuhu District Hospital, to whom we extend our special thanks.

from 外科截瘫14例手术分析

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Transpedicular tuberculosis complicated with paraplegia

orthopedic paper II

Transpedicular tuberculosis complicated with paraplegia

A Case Report

Abstract: Spinal appendage tuberculosis accounts for only 1% of spinal tuberculosis. It is prone to paraplegia in the thoracic section and is easily misdiagnosed. We encountered a case misdiagnosed as spinal cord tumor preoperatively but confirmed as vertebral arch tuberculosis after surgery. After a three-year follow-up, the patient has now fully recovered. Reports on this type of case are rare in China, and we now present our findings.

Case Description

Vertebral appendage tuberculosis accounts for only 1% of spinal tuberculosis and is prone to cause paraplegia in the thoracic segment, easily leading to misdiagnosis [1]. Our hospital encountered one such case, initially misdiagnosed as spinal tumor preoperatively. The postoperative pathology confirmed it to be vertebral arch tuberculosis. After a three-year follow-up, the patient has now recovered completely. Such case reports are rare domestically, and we present it as follows:

The patient, Wu XX, is a 36-year-old married male farmer from Nanling. Medical Record Number: 1928.

He had lumbar back pain for three years, unstable walking for one year, paraplegia for three months, and difficulty with bowel and bladder functions. Admitted to the hospital on April 27, 1976. Examination: Both lower limbs exhibited spastic paraplegia, muscle atrophy, 0-grade muscle strength, and numbness at the T10 level. Knee reflexes were hyperactive, and ankle clonus was present. The paraplegia index was 5 (sensory 2, motor 2, sphincter 1). There was no postural deformity of the thoracic vertebrae, but T4-T10 were tender upon percussion. Queckenstedt's test indicated partial obstruction. The cerebrospinal fluid was yellow, and the protein level was elevated (Pandy's test+). Spinal angiography on May 3rd showed an irregular filling defect on the right side of T11, and a small amount of contrast medium ascended through the narrow passage. Thoracolumbar spine X-ray did not show any specific positive signs. Clinical impression: Extramedullary spinal tumor around T10. Under endotracheal ether anesthesia, exploratory surgery of the spinal cord was performed on May 5, 1976. The posterior midline approach was used, and the lamina of T7-T12 were completely removed without affecting the facet joints. During the operation, Queckenstedt's test still indicated obstruction. Therefore, the dura mater was incised to explore the spinal cord, but no lesion was found. However, granulation tissue was found compressing the spinal cord near the facet joint of the T7 lamina on the right side, which was then scraped off. A thin catheter was used to explore the subarachnoid space, confirming it to be unobstructed. The spinal cord resumed pulsation at this time. During the operation, some adhesions of the arachnoid membrane were seen, but no definitive bone destruction of the vertebral arch was observed. The pathological report confirmed "tuberculosis". Pathology number: 2476 (PLA 127 Hospital). Forty-eight hours postoperatively, the lower limbs had voluntary movement, muscle strength was at level 3, ankle clonus disappeared, sensory function partially recovered, and subsequently gradually improved. The incision healed on time, and the patient could urinate and defecate on his own 20 days postoperatively. He was discharged on May 28 for recuperation and continued anti-tuberculosis treatment, staying in the hospital for 31 days.

Follow-up: Four months postoperatively, the patient started walking with a crutch, abandoned it five months later, and began working a year later. He can now work at 90% efficiency and can walk 20-30 miles. His general condition is normal. Examination: There is partial stiffness of the surgical segment of the spine, so bending and lifting are slightly affected. Re-examination of the X-ray on August 14, 1979, showed no bone destruction or other mutations. Residual contrast medium and absence of lower thoracic spinous processes and lamina were observed.

Discussion:

For cases with spastic paraplegia, clinicians naturally consider space-occupying compression of the spinal cord. However, the diagnosis is often difficult for rare conditions like vertebral arch tuberculosis.
Compared to the vertebral body, the vertebral arch has a richer blood supply and is surrounded by more muscles. If paralysis occurs, surgery is essential. This case report demonstrated good prognosis after the operation.
If surgical exploration and total laminectomy do not damage the articular processes, there is no need to worry about spinal stability.
Iodine contrast imaging is often misleading due to various factors such as membrane adhesions and vascular abnormalities. This case also shows that the iodine contrast agent can remain in the body for years after the operation without causing nerve pain.
This disease is sometimes difficult to differentiate from intraspinal tuberculosis. Both can cause obstruction in the subarachnoid space leading to paraplegia. However, the latter usually has more severe symptoms, often accompanied by other foci of tuberculosis (e.g., pulmonary tuberculosis, pleuritis), and the prognosis is generally more serious.

Conclusion

This paper reports a clinical case of thoracic vertebral arch tuberculosis complicated by paraplegia, along with diagnosis, treatment, and prognosis. In light of the existing literature, we conclude the following:

Vertebral arch tuberculosis has a low incidence rate but a high rate of misdiagnosis.
When located in the thoracic section, the rate of complicating paraplegia is high.
Surgical treatment yields good results.
Issues related to myelography and the stability of the spine after extensive laminectomy are discussed.

References

[1] Tianjin Orthopedic Hospital, Clinical Orthopedics Tuberculosis Edition, P253, People's Health Publishing House, 1974

[2] Wang Guisheng et al, Surgical Treatment of Spinal Tuberculosis Complicated by Paraplegia, Chinese Journal of Surgery, 10:365, 1962

[3] Zeng Guangyi et al, Spinal Tumors, Chinese Journal of Surgery, 10: (6)374, 1962

[4] Yang Weiming et al, Intraspinal Tuberculosis, Chinese Journal of Surgery, 14: (3)165, 1966

南陵县医院外科李名杰原载省骨科年会交流后《芜湖医药》1980；7:47

This article was originally presented at the Provincial Orthopedic Annual Meeting, later published in "Wuhu Medicine," 1980; 7:47
Nanling Hospital, Department of Surgery, Li Mingjie

from 椎弓结核并发截瘫手术一例报告

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

A surgical treatment of spinal tuberculosis

orthopedic paper I

A surgical treatment of spinal tuberculosis

Report of Three Cases

Spinal tuberculosis accounts for 47.28% of all bone and joint tuberculosis and is commonly seen in clinical settings (1). Conservative treatment, even with the advent of anti-tuberculosis drugs, often takes many years and is difficult to cure. Surgical treatment, although significantly improved, usually requires 2-3 major surgeries, costing time and money and causing additional pain. A one-time surgical cure is, therefore, ideal. This paper reports on one case each of cervical, thoracic, and lumbar spinal tuberculosis that were treated with a single planned surgery at our hospital in the years 1975 and 1976.

Case Presentation

Case One

Male, 18 years old, a farmer from Fanchang County. Case number: 12179.

He has experienced neck pain for a year and limited movement for half a year. He has had a fever, neck swelling, and difficulty swallowing for two weeks. He cannot eat or drink, speak, and has had breathing difficulties for four days. X Hospital diagnosed him with tuberculosis of the 3rd and 4th cervical vertebrae and a large abscess behind the pharynx, compressing the trachea and esophagus, following a puncture that drained white, thin pus. He was admitted to our hospital as an emergency case on October 26, 1975. Examination: His neck is immobile, and there is fullness and fluctuation below the jaw. He breathes through his mouth, does not speak, sweats profusely, and is dehydrated but not cyanotic. No other special findings. Quick fluid replacement of 1000cc was done, and emergency surgery was performed two hours after admission under local anesthesia. Through the left anterolateral approach of the neck, 600cc of pus was drained, and the pus cavity wall was scraped off. The cervical vertebrae's periosteum was cut open along the midline, and a pus plug at the lower edge of the 3rd cervical vertebra was removed under direct vision. A 0.5x0.6 cm bone hole was visible. The external opening was enlarged, and tuberculous granulation tissue, cheesy material, and granular fragments were carefully scraped off. The pus cavity was flushed. No bone grafting was done as the intervertebral space had already disappeared and fused naturally. Gentamycin and streptomycin were placed, and rubber pieces were used for drainage. The surgery went smoothly. After the surgery, his breathing stabilized, he could eat and speak. His neck was immobilized postoperatively, and anti-tuberculosis treatment was administered. Sutures were removed on the sixth day, and the incision healed. He was discharged after ten days. A total of 60 grams of streptomycin was injected, and rimifon was taken for half a year. He resumed light labor two months after surgery and full labor a year later. Follow-up after three and a half years showed everything to be normal; his neck movement was unimpeded. An X-ray on August 14, 1979, showed bony fusion of the 3rd and 4th cervical vertebrae, with no necrotic bone, abscess, or bone destruction (X-ray number 2090).

Case Two

Male, 23 years old, from Nanling, a farmer. Case number: 2875.

Admitted to the hospital on May 31, 1976, due to tuberculosis of the 9th and 10th thoracic vertebrae and an adjacent abscess. After pre-operative preparation and ensuring no contraindications to surgery, the procedure was performed under endotracheal ether anesthesia on June 19, 1976. The approach was through the 9th intercostal space on the right side. The mediastinal pleura was incised to enter the thorax and reach the abscess on the vertebrae. The pus was aspirated, and after dealing with the two intercostal veins, the exposure was expanded. Direct vision to the opposite lesion up to the rib-transverse process joint was achieved. Tuberculous granulation tissue, cheesy material, necrotic intervertebral discs, and dead bone were scraped off and flushed. Bone grooves were chiseled above and below the diseased vertebrae, and four rib grafts were implanted tightly. Antibiotics were placed and the area was sutured meticulously. The thoracic cavity was thoroughly rinsed, closed, and a drain was put in place. The post-operative recovery was smooth. The thoracic tube was removed after 26 hours, and a thorax radiograph after 72 hours showed a sharp costophrenic angle. On the fifth post-operative day, the patient's temperature returned to normal, and he was discharged on June 29, 1976, after a 29-day hospital stay. He was advised bed rest for four months and anti-tuberculosis treatment for nine months. Follow-up: The patient started moving around one month after surgery and gradually resumed light work, but developed kyphosis. A year later, he returned to regular labor. Three years post-surgery, an X-ray showed no abscess shadow or dead bone adjacent to the vertebrae. The 9th and 10th thoracic vertebrae had fused, but the bone grafts were absorbed. The 10th vertebra had collapsed, leading to a hump (X-ray number 2104).

Case Three

Male, 50 years old, married, a farmer from Nanling. Case number: 1462.

He suffered from tuberculosis of the 2nd and 3rd lumbar vertebrae, which led to a psoas abscess. He had already been administered 20 grams of streptomycin. He was admitted to the hospital on August 8, 1976. On August 9, 1976, under spinal anesthesia, he underwent lesion removal and anterior bone grafting via a left lumbar incision. The 12th rib was removed and set aside for later use. After extraperitoneal dissection, the lumbar muscle was incised to access the abscess. Subsequently, two lumbar transverse vessels nearby were safely dealt with. This allowed for an expanded exposure and clearing of the abscess from the opposite lumbar muscle. Granulation tissue from the abscess wall was fully scraped off. Immediate pressing with a hot saline-soaked gauze for 5 minutes was done to minimize extensive bleeding. The exposure to the bony hole in the vertebrae was expanded, and necrotic bone, intervertebral disc, and substantial tuberculous tissue were thoroughly removed. After cleaning, the site was deemed satisfactory. A bone groove was chiseled between the affected vertebrae and the removed 12th rib was embedded, completing the lesion removal and anterior bone grafting in one go. Post-operative recovery was smooth, and the incision healed without complications. He was discharged on March 24, 1978, after a 21-day hospital stay. He was advised bed rest for four months and resumed work half a year later. Currently, he works at 90% of his capacity, can walk 50 kilometers without discomfort, and is in good mental and physical health. Three years post-surgery, an examination on August 15, 1979, revealed no palpable masses in both lumbar muscles, no tenderness upon percussion on the spine, and good spinal mobility. A thorax X-ray showed the upper right lung tuberculosis in the absorption and recovery phase. Lumbar X-ray revealed bony fusion from L1 to L4 with no signs of dead bone or abscess (X-ray number 2101).

Discussion

(1) The treatment of spinal tuberculosis has undergone a long evolutionary process. From prolonged bed rest, full-body anti-tuberculosis treatment to palliative abscess incision; from abscess scraping, fistula shortening surgery to radical lesion removal with fusion surgery, and even recently, there has been an attempt to resolve the issue with one operation. However, because of the complex anatomical relationships of the spine and the difficulty of exposure, the high surgical risk hinders a "complete clearance". Thus, curing this type of disease with one surgery has not yet become widespread. By improving external and internal exposure, making complete clearance possible, we went through the three cases mentioned, all of which were cured within half a year, showing superiority compared to other treatment schemes.

(2) In the surgical treatment of spinal tuberculosis, in addition to clearing the abscess and vertebral lesions, the "tuberculosis barrier" is also broken, allowing anti-tuberculosis drugs to reach the lesion, significantly increasing the cure rate compared to conservative treatment alone [3]. During the same period, our hospital treated five other cases, including two cases of thoracic spine tuberculosis with paralysis. These cases underwent one-sided lesion clearance or simple fusion surgery and were all cured, though it took about a year. The cases in this study were cured more quickly due to more thorough clearance.

(3) Treatment of spinal tuberculosis requires both lesion recovery and the restoration of the spine's support and stability, making bone graft fusion an essential part of treatment. Posterior grafting faces tensile stress, which is not conducive to graft growth; anterior grafting, however, is under compressive forces, favoring graft growth. It can be done simultaneously with lesion clearance, using autologous grafts from the external exposure site. Embedding the graft is more effective than covering or filling, providing both temporary and permanent support, making it more reasonable. Still, thorough lesion clearance without mixed infection is a prerequisite, or the graft is easily absorbed or necrosed [3]. Cases two and three in this study had no mixed infections, and the clearances were "satisfactory", hence they underwent anterior grafting.

Bone grafting between vertebrae is susceptible to displacement and absorption due to pressure, so it's imperative to ensure the patient is on bed rest for more than three months. Rural patients often are unwilling to be hospitalized for extended periods. If they move prematurely at home, it can lead to graft failure. In case two, the patient got out of bed just one-month post-op, leading to graft displacement, absorption, vertebral collapse, and a hunched back. In contrast, case three followed medical advice and achieved the expected results, serving as a valuable lesson.

(4) Cervical spine tuberculosis with a retropharyngeal abscess can cause compressive symptoms, leading to difficulties in swallowing, speech, and even breathing, constituting an emergency situation. Given its convenient surgical approach, the operation can be carried out under local anesthesia, with minimal blood loss and damage, making the procedure relatively straightforward. Moreover, the abscess stretches the surrounding tissue, exposing a broad area in front of the diseased vertebra. By adhering to the "midline incision" principle [1], the vertebral lesion can be thoroughly removed under direct vision. Given the rich blood supply in the neck, rapid absorption of the lesion, and strong repair capability, satisfactory outcomes can be easily achieved, as seen in Case 1. Whether to graft, apply traction, or fixate depends on the stability of the affected vertebrae. However, precautions must be taken to prevent cervical cord trauma and avoid serious accidents like high-level paralysis (① Avoid using a bone chisel; ② Do not go beyond the posterior longitudinal ligament during removal).

(5) For thoracic spine tuberculosis, especially between the 3rd to 10th vertebrae, if conditions permit, the thoracic approach can be used to clear lesions on both sides and perform anterior grafting in a single operation. This is preferred by patients and also saves bed space. Although there's the inconvenience of thoracotomy and the risk of infection, it's still considered safe under modern anesthesia, asepsis, and the use of antibiotics. Case 2 was discharged 10 days after the operation for recuperation.

(6) The lumbar spine is deeply situated, surrounded by numerous vital structures, making it hard to expose and the surgery more invasive. Thoroughly removing the lesion isn’t easy, and typically, 2-3 operations are needed. However, given the patient's physical condition, with special handling of the lumbar vessels [1], following the sub-periosteal dissection, the diseased vertebrae can be safely and extensively exposed, facilitating the thorough removal of the lesion.

Regarding the clearance of the contralateral lumbar abscess: by compressing the contralateral lumbar region and directly viewing the source of the pus, and then through the broadened internal exposure, using curettes of various curvatures, one can navigate and scrape away the abscess. If necessary, an incision can be made at a safe location on the contralateral side, guided by the curette, to "meet up" and clear out the abscess. It’s essential to note that all vital organs are located outside the lumbar muscles, so "intramuscular" abscess scraping is generally safe. Still, care should be taken to avoid vascular and nerve damage [9]. On this basis, anterior grafting can also be expected to cure, significantly shortening the treatment duration, as seen in Case 3.

Conclusion

Through the clinical practice of the author's three cases, the clinical process and the 3-4 year follow-up results of cervical, thoracic, and lumbar spine tuberculosis being cured with a single surgery are described. Among them, Case 1 was an emergency, while Cases 2 and 3 both involved anterior grafting. It is pointed out that the key lies in proper exposure and thorough removal. Combined with a review of the literature, some technical measures are proposed, and a preliminary discussion on the treatment of spinal tuberculosis is presented.

References

① Tianjin Hospital Orthopedics, Clinical Orthopedics Tuberculosis Volume, P183 People's Health Publishing House 1974

② Fang Xianzhi: Bone and Joint Tuberculosis Lesion Removal Therapy, People's Health Publishing House 1960

③ Guo Juling: The role and issues of anterior grafting in the treatment of spinal tuberculosis, Chinese Journal of Surgery 11:12, 1963

④ Liu Zhong: Thoracic vertebrae tuberculosis lesion removal through the thoracic cavity, Chinese Journal of Surgery 8:531, 1960

⑤ Fan Bingzhe: Open chest procedure for thoracic vertebral tuberculosis lesion removal, Chinese Journal of Surgery 7:20, 1959

⑥ Wang Zhixian: Thoracic surgery for thoracic lesion removal through the chest, Chinese Journal of Surgery:271, 1959

⑦ Luo Xianzheng: Preliminary report on thoracic extrapleural spinal tuberculosis lesion removal, Chinese Journal of Surgery 12:1144, 1964

⑧ Tian Chengrui: Some insights into the lesion removal therapy for spinal tuberculosis, Tianjin Medical Orthopedics Supplement 2:76:1678

⑨ Yu Peili and others: Injury to the external iliac artery during lumbar vertebrae tuberculosis lesion scraping surgery (Clinical case discussion), Chinese Journal of Surgery 11:936, 1963.

This article was originally published in the Proceedings of First Anhui Province Orthopedic Symposium in 1979.
Nanling Hospital Orthopedics, Li Mingjie

from 脊椎结核的一次手术治疗

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Clinical observation of a new minimally invasive circumcision (to be reviewed)

Surgical paper XX

Clinical observation of a new minimally invasive circumcision

Introduction

The classical treatment for excessive foreskin has long been surgical circumcision, with little breakthroughs in recent years. From October 2003 to February 2005, our hospital treated 52 cases of excessive foreskin using a minimally invasive surgical technique. Here we present the findings.

Materials and Methods

Clinical Data

The study included 52 patients, with ages ranging from 17 to 56 years and an average age of 38 years. Preoperative measurements of the penis in a flaccid state ranged from 2.5 cm to 10 cm. Of these, 40 were married and 12 were unmarried.

Surgical Technique

Materials: The procedure utilizes a minimally invasive surgical ring invented by Mr. Shang Jianzhong, a special researcher at the Chinese Academy of Management Sciences (Patent No. 2003.ZL02 237969.X). The surgical ring is made from injection-molded polypropylene engineering plastic and consists of an inner and outer ring. The two rings are secured together using screws. The product comes in various sizes and is for one-time use in sterile packaging.

Attached Figure 1: Inner Ring of the Minimally Invasive Foreskin Cutter, Outer Ring of the Minimally Invasive Foreskin Cutter, Complete Minimally Invasive Foreskin Cutter (See insert for illustration).

原文插图

Methodology

Preparation: Sterilization is performed, and a hole towel is laid out to expose the penis. A rubber band tourniquet is placed around the base of the penis to block venous return. A distended vein is then punctured, stagnant blood is aspirated, and 2ml of 2% lidocaine is injected. After waiting for 5 minutes, anesthesia is found to be highly satisfactory and complete.
Ring Placement: An appropriately-sized surgical foreskin ring is chosen. The inner ring is first placed around the penis. The foreskin is then everted over the inner ring. If phimosis is present, a small incision is made on the dorsal side to fully expose the glans. The inner plate is retained up to 0.5 cm beyond the coronal sulcus, and the frenulum is left slightly longer, about 1.0 cm.
Outer Ring and Cutting: The outer ring is then placed and screws are tightened. Excess foreskin protruding beyond the compression ring is trimmed. A sterile gauze strip is used to cover the wound, leaving the glans exposed. The tourniquet is then released, completing the surgery.
Post-Operative Care: The ring is removed on the sixth day post-operation, and full recovery is generally achieved in approximately 15-20 days.

Attached Figure 2: Post-healing of Minimally Invasive Foreskin Surgery, Completion of Minimally Invasive Foreskin Surgery, Pre Minimally Invasive Foreskin Surgery (See above insert for illustration).

Results

Out of the 52 cases, primary wound healing was achieved in 50 cases post-operatively. In 2 cases, healing was delayed due to infection caused by engaging in sexual activity before the advised period. There were no long-term complications, and the healed wounds left no scars.

Discussion

Excessive foreskin length can lead to phimosis, where the coronal sulcus is not exposed, causing a buildup of secretions that cannot be eliminated, thereby leading to balanoposthitis. Long-term inflammation could even induce penile cancer. Phimosis can also result in poor penile development and impact sexual life. Excessive foreskin is a common issue plaguing male patients.

Minimally invasive foreskin ring resection is suitable for males with excessive foreskin and phimosis. Traditional treatment methods, such as full circumcision, involve cutting, hemostasis, and suturing, and often leave scars after healing; laser surgery also has drawbacks like thermal injury.

This innovative method breaks away from traditional approaches. It eliminates the need for surgical cutting and suturing. After the ring compresses the distal tissues, ischemia leads to tissue necrosis and eventual detachment, thus completing the circumcision. Generally, the ring is removed around the 6th day, and full recovery is achieved in approximately 15-20 days. The healed wounds leave no scars, and the surgery time is only 2-5 minutes. No additional medical equipment is needed, avoiding complicated hemostasis steps. The incidence of infection is low, no estrogen therapy is needed, and patients can move freely post-operatively. Daily life is not impacted; patients can bathe, urination is unaffected, and there are no complications.

Comparison of New Method and Traditional Methods

	New Method	Traditional (circumcision,laser)
1、surgery	micro, convenient, no pain, no scars	invasive and complicated, with pains and scars
2、resources	one operator only	at least 2 operators needed
3、materials	no need for surgery tool	needs surgery tool in surgery room
4、bleeding	no bleeding	bleeding
5、procedure time	less than 5 min	more than 30 min
6、cost	low cost	more cost

In the 52 cases treated with this method, some patients experienced varying degrees of penile length and girth increase post-operatively, along with enhanced sexual function, due to the alleviation of the restrictions imposed by the foreskin.

Conclusion

This novel minimally invasive surgical approach is superior to traditional methods, with definite therapeutic effects. It is worthy of broader adoption.

原文插图

本文原载…….???

Originally published in "???" 90; 4(3):66 by Li Yangzhen, Li Mingjie, Shang Jianzhong, Wang Tong

from 一种全新微创包皮环切术的临床观察

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Several improvement measures of circumcision

Surgical paper XIX

Several improvement measures of circumcision

Introduction

This paper outlines several innovative methods aimed at improving the effectiveness and safety of circumcision surgeries. The techniques include local venous anesthesia of the foreskin, bloodless surgery through arterial blockage, and the use of human hair as a suturing material.

1. Local Venous Anesthesia of the Foreskin

Procedure:

A rubber band is tied around the base of the penis to block venous return, causing the superficial veins of the penis to engorge. A fine needle is used to puncture the subcutaneous vein on the distal side of the penis, and 2 ml of 2% lidocaine is injected after aspirating stagnant blood.

Advantages:

Provides complete anesthesia.
Eliminates the risk of foreskin edema due to local anesthesia, thereby ensuring a more accurate resection line.

2. Bloodless Surgery via Blood Supply Blockage

Procedure:

The rubber band at the base of the penis is tightened, blocking the dorsal artery and creating a blood-free surgical field. This facilitates precise and complete cutting of the foreskin. Visible ends of severed blood vessels are first ligated, and then the tourniquet is released, ensuring complete hemostasis.

Advantages:

Creates a clear, blood-free surgical field.
Allows for precise cutting and complete hemostasis, aiding the surgical process.

3. Utilizing Human Hair for Suturing

Procedure:

Several strands of long female hair are cut and sterilized by soaking in a disinfectant solution for 5 minutes, followed by a saline rinse. The sterilized hair is then used as suture material.

Advantages:

Enables flexible suturing of both the inner and outer layers of the foreskin, ensuring a tight and accurate anastomosis.
Eliminates the need for the conventional 8-point suturing method, reducing contamination and facilitating healing.
Postoperative suture removal is not necessary as the hair naturally breaks and falls off within 7–10 days.

Results:

In a series of 30 cases using these techniques, there were no incidents of wound dehiscence or infection, and all cases achieved Grade I healing.

These improved circumcision techniques offer multiple benefits, including enhanced anesthesia, a cleaner surgical field, and easier postoperative care.

（论文刊于《交通医学》90;4（3）：66）???

Originally published in "Transportation Medicine Journal" 90; 4(3):66 by Li Mingjie, Changhang Hospital, 1979; 1:70

from 包皮环切术的几点改进

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Subcutaneous heterotopic pancreas of abdominal wall

Surgical paper XIIX

Subcutaneous heterotopic pancreas of the abdominal wall

A Case Report

Introduction

Heterotopic pancreas is typically documented to occur only in internal organs, most commonly beneath the mucosa of the digestive tract. Clinically, it is rare to encounter. To date, there have been no reported cases of heterotopic pancreas located subcutaneously in the abdominal wall. We treated a case in our hospital, which was pathologically confirmed post-surgical resection. We present the report below.

Case Presentation

The patient is a 41-year-old male teacher admitted to our hospital on March 24, 1979, with the medical record number 794.

Approximately one year prior, he had a mass removed from his left lower abdomen at Hospital X. The pathological report identified the mass as a "desmoid tumor." Ten months post-surgery, a recurrent mass the size of a fingertip appeared at the same site, which was asymptomatic. In the past week, the mass suddenly enlarged to the size of an egg and became tender to touch.

On examination, the patient's general condition was normal, with no swollen superficial lymph nodes. A 5 cm oblique surgical scar was observed in the left lower abdomen. Below the scar, a 5x4x3 cm nodular, soft mass was palpable, with limited mobility and mild tenderness. There was no erythema or warmth. The white blood cell count was 5600/mm³, with 58% neutrophils and 42% lymphocytes.

Surgery was performed under local anesthesia immediately upon admission. The mass was located subcutaneously and above the muscle fascia. The boundary was ill-defined, and there was no capsule. The mass was lobulated and yellow in color. A sharp dissection was performed to excise the mass, followed by 24-hour subcutaneous drainage. The incision healed primarily, and the patient was discharged after a 9-day hospital stay. The pathological report confirmed "Heterotopic Pancreas in the Abdominal Wall's Fibrous Tissue" (Pathology No. 4686).

Postoperative Follow-Up

One week after discharge, the patient experienced subcutaneous swelling, pain, and fluctuation, although there was no redness or fever. Antibiotic treatment was administered by the local community hospital, leading to gradual resolution of the symptoms without the need for fluid aspiration. The patient returned to normal within a month.

Originally published in "Nanling Medical Journal" by Li Mingjie & He Jinxian, Department of Surgery, Nanling County Hospital, 1979; 1:70

from 腹壁皮下异位胰腺一例报告

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Abdominal trauma

Surgical paper XIIIX

Abdominal trauma

Literature Review

Introduction

Abdominal trauma, encompassing injuries to both the abdominal wall and internal viscera, is a prevalent medical issue. While the severity of the injury is undoubtedly a significant factor, early diagnosis and appropriate treatment are equally crucial. However, healthcare providers often encounter specific challenges and pitfalls, such as:

Common Pitfalls in Diagnosis and Treatment

Unknown Medical History: The inability to obtain a valuable medical history due to patient coma or overlooked minor trauma.
Subtle Early Symptoms: Lack of apparent signs in the immediate aftermath of the injury, making diagnosis challenging.
Delayed Visceral Rupture: Instances of late-onset rupture that go unnoticed during the initial evaluation.
Distracting Injuries: Concomitant severe injuries, such as cerebral or thoracic trauma, that divert attention away from abdominal injuries.
Misdiagnosis Due to Spinal Involvement: Abdominal signs resulting from lower thoracic spine and chest injuries that may be mistaken for abdominal trauma.
Conservative Approach: An overly cautious attitude, especially when the abdominal wall appears intact, can lead to missed diagnoses and lost opportunities for timely intervention.

Pathogenesis

abdominal trauma refers to injuries to the abdominal wall or internal organs, or both, caused by external force.

Mechanisms of Injury

Direct Impact: Blunt force trauma to the abdomen.
Indirect Impact: Falls from heights, seismic shocks, and other indirect forces.
Non-penetrating Injury: Injuries resulting from vehicular accidents.
Penetrating Injury: Wounds from knives, guns, or explosions.

Categories of Abdominal Viscera

Solid Organs: Liver, spleen, kidney, pancreas.
Cavitary Organs: Stomach, intestines, bladder, gall bladder.
Structural Components: Mesentery, peritoneum, nerves, blood vessels.

Risks and Complications

The main risk of trauma to solid organs and stent structures is hemorrhage; the main risk for hollow organ trauma is the infection caused by the contents overflowing into the abdominal cavity, leading to peritonitis.

In fact, any visceral trauma can result in fatal hemorrhage. Liver and spleen injuries, in particular, can lead to long-term, persistent, and recurrent bleeding. This is because the blood vessel walls of these organs are thin, and the organs themselves are fragile and lack elasticity. Therefore, effective vessel constriction and blood clot formation may not occur. Moreover, once bleeding stops, due to the rich blood supply to these organs, a rise in blood pressure can wash away the hemostatic clot, leading to recurrent bleeding.

The likelihood of hollow organ injury is related to the amount of contents it holds (those with a full stomach are more susceptible to injury); it is related to the degree of fixation (the distal and proximal ends of the small intestine, and the hepatic and splenic flexures of the colon are vulnerable); and it is related to pre-existing conditions (those with prior illnesses are more susceptible to injury).

The nature of substances that irritate the peritoneum determines its pathological changes and abdominal signs:

Gastrointestinal bacteria increase from top to bottom, such as in the case of fecal peritonitis due to colon injury, which has a very strong infectious nature.
The chemical irritability of the gastrointestinal tract decreases from top to bottom, such as in the case of chemical peritonitis caused by perforations in the stomach or duodenum, which can be very severe.
Bile and urine may or may not contain bacteria, but they are chemical mixtures that can lead to peritonitis, albeit a bit later in time.
Blood without bacteria causes minimal irritation to the peritoneum, so the reaction to hemorrhagic peritonitis is usually mild.
Gas irritation of the peritoneum can also produce symptoms.

Regardless of the nature of the material that spills into the abdominal cavity, it often follows its natural drainage route with the peritoneal exudate it produces, leading to the paracolic gutter and the pelvic floor, resulting in intestinal paralysis and abdominal distension.

Symptoms and Signs

Fainting or Shock:
- Abdominal wall contusions are rare, but visceral injuries are common. Substantial visceral organ rupture can cause massive bleeding and can be extremely dangerous. Damage to major blood vessels can be immediately fatal and beyond rescue. Peritonitis due to the perforation of hollow organs leads to toxic shock.
Abdominal Pain:
- Contusions to the abdominal wall are localized and minor; visceral injuries are extensive and persistent.
Abdominal Distension:
- Progressive worsening is a sign of internal bleeding and peritonitis, with inhibited abdominal breathing. However, attention must also be paid to intestinal motility inhibition caused by retroperitoneal injuries and hematomas that stimulate the abdominal plexus.
Abdominal Tenderness:
- Point muscle guarding, tenderness, and rebound tenderness can often indicate the site of injury in the early stages. In the later stages, it becomes generalized and is often corroborative evidence of visceral injury.
Nausea and Vomiting:
- Reflexive in the early stages and due to backflow in the later stages.
Liver Dullness Boundary:
- Abdominal gas distension can cause it to shrink, and a free air layer can make it disappear. After liver rupture, the dullness boundary expands.
Shifting Dullness:
- Often a significant basis for abdominal hemorrhage or effusion.
Intestinal Motility:
- Reflexively weakened in the early stages, leading to an "inactive abdomen" caused by inflammation in the later stages.

Diagnosis

The central issues in diagnosing abdominal trauma are to clarify:

Is it a simple abdominal wall injury, or is there also visceral injury?
Which organ(s) are injured, and is it a single or multiple injuries?
What is the volume and rate of internal bleeding, and has it stopped or is it ongoing?

A detailed medical history should be obtained, including the magnitude and direction of the force, posture at the time of injury, and subsequent reactions such as sudden sharp pain, fainting, and vomiting. Physical examination should include evaluation of muscle guarding, the scope of tenderness, dullness and tympanic areas, and their changes. Body temperature, pulse, respiration, blood pressure, blood and urine tests, X-rays, and ultrasound should be measured. The use of analgesics like morphine should be avoided during observation, except when a diagnosis has been confirmed and surgery is planned. If necessary, exploratory laparotomy should be performed; it's better to act than to miss the opportunity, even if no significant findings are obtained.

Blood Count: An elevated white blood cell count in the early stage is a physiological response to trauma. Some believe that internal bleeding can produce a large amount of hematopoietic stimulants, leading to an elevated white blood cell count when absorbed by the peritoneum. Peritonitis naturally causes elevated white blood cells and a left shift in neutrophils. Internal bleeding presents as anemia.
Hematuria: A strong basis for urological injuries and an effective indicator for monitoring the outcome of the injury.
X-Ray: Free air under the diaphragm is generally considered to have only a 50% positive rate, and attention should be paid to it. Comparison of the diaphragmatic height and movement on both sides can aid in the diagnosis of liver and spleen injuries.
Abdominal Paracentesis: Highly valuable. The characteristics and state of the extracted fluid can often confirm the diagnosis. Because a positive result requires more than 200 ml of fluid in the abdominal cavity, some use lavage to increase the positivity rate. If unsuccessful, change the needle direction and depth or reattempt after an interval. Besides macroscopic observation, amylase quantification and smear tests can be done on the puncture fluid. The presence of multiple types of bacteria without pus cells or the presence of parasitic eggs supports the hypothesis of accidental intestinal entry.
Rectal Examination and Posterior Fornix Puncture in Married Women: These can be included as routine examinations to help with early diagnosis.

Management and Treatment

Shock Management: For patients in shock, use a slight incline position and elevate both legs (to facilitate breathing and venous return). Measures like warming, fluid resuscitation, blood transfusion, oxygen administration, and antibiotics are essential. Given the peritoneum's strong anti-infective ability, fatalities due to infection are far less common than those due to shock or bleeding. Therefore, establishing an open vein and rapidly restoring effective blood volume is of utmost importance.
Surgical Intervention: Surgery for abdominal injuries should ideally be performed within 6 hours. If anti-shock measures are ineffective, forced surgery should be performed to eliminate the source of the problem as one of the life-saving measures.
Surgical Incision: The location of the incision is determined based on the estimated site of injury. The principle is to make the incision as close and convenient as possible to the affected area. A midline vertical incision is generally used, as it allows for quick entry and is easily extendable. Before closing the abdomen, it's crucial to thoroughly wash and aspirate the abdominal cavity. For contamination with bile, pancreas, feces, or urine, drainage should be implemented.

Specific Injuries and Treatments

Spleen Rupture: Standard procedure is removal. Some recent studies advocate for repair in minor injuries to preserve spleen function. Autotransfusion of the patient's own blood can be done without anticoagulants, saving resources and avoiding citrate toxicity.
Small Intestine Rupture: Repairs or resection and anastomosis are the go-to approaches. Externalization of the intestine is less preferred.
Liver Injury:
- Type of Injury: Most liver injuries involve a laceration of the liver tissue, which largely remains intact due to the resiliency of its blood vessels.
- Surgical Interventions: During surgery, the focus is on debridement and individual ligation of severed blood and bile ducts. Further harm to the liver should be avoided. Full-layer mattress sutures are generally used, and the omentum is often laid over the sutured area. Sometimes, omentum or muscle can be used for packing. Gauze packing should be avoided.
- Limited Crush Injuries: For localized crush injuries, partial hepatectomy is recommended.
- Control of Bleeding: If there is profuse bleeding during surgery, temporary occlusion of the hepatic portal can control it (up to 15 minutes at room temperature is allowed). If bleeding can't be controlled, ligation of the hepatic artery often works immediately.
- Post-Operative Considerations: Adequate drainage below the liver is crucial, often with the additional step of controlled decompression of the common bile duct.
Suturing and Complications:
- Suture Material: Both intestinal thread and silk thread are acceptable, although the author believes that No. 4 silk thread is preferable.
- Tightness of Ligations: Ligations should not be too tight; they should be just tight enough to control bleeding. Over-tightening can lead to complications like hepatic necrosis, delayed bleeding, or bile leakage.
- Anecdotal Experience: The author recounts a case of postoperative massive biliary bleeding on Day 21, which required another surgery to ligate the intrinsic hepatic artery.
Blood Transfusion:
- Caution with Bile-Contaminated Blood: Normally, blood contaminated with bile should not be transfused back. However, an anecdotal case saw 1500 mL transfused without adverse effects in a rural setting. It's generally considered safe to transfuse one's own blood back if there are no injuries to the extrahepatic biliary tract.
Colon Injury: Early repair is recommended; late-stage injuries may require externalization and later resection and anastomosis.
Mesenteric Tear: Repair and hemostasis are essential. If blood supply to the intestines is compromised, resection may be needed.
Pancreatic Injury: Small tears can be sutured, and the pancreatic duct can be ligated if damaged. For injuries to the head of the pancreas, reimplantation is necessary to establish a new pancreatic-intestinal pathway.
Stomach and Duodenal Injuries: Repair is standard. Special attention should be given to retroperitoneal injuries of the duodenum.
Extrahepatic Biliary Tract Injury: Repair, fistula creation, and external drainage are options.
Kidney Injury: Generally conservative treatment under close observation is sufficient due to the kidney's high regenerative capacity.

10. Extrarenal Urinary Tract Injury: Injuries to the ureter are rare. Bladder injuries are more common and often associated with pelvic fractures. Repair, fistula creation, and drainage are usual treatments.

11. Diaphragm Injury: More commonly seen on the left side, resulting in diaphragmatic hernia and bleeding. High mortality rates necessitate early thoracic repair.

12. Retroperitoneal Major Vascular Injury: Repair is generally performed unless immediate intervention is not possible. For injuries to the inferior vena cava below the renal veins, ligation is an option.
- General Treatment: Unless the injury is too severe to be managed emergently, the usual approach is to repair the damaged vessel.
- Below the Level of the Renal Vein: Injuries to the inferior vena cava below the level of the renal veins can generally be managed by ligation and cutting off the damaged segment.
- Above the Level of the Renal Vein: For injuries to the inferior vena cava above the level of the renal veins, if repair is not possible, some advocate for ligation. However, this necessitates the removal of the right kidney. The left kidney can rely on collateral circulation (e.g., adrenal vein) and should be unaffected. However, this approach could lead to insufficient venous return to the heart.
Discussion

Early Diagnosis:

Determining whether the injury is confined to the abdominal wall or involves internal organs is crucial for making timely decisions about surgical intervention and life-saving measures. A simple contusion of the abdominal wall can also lead to symptoms like abdominal pain, muscular guarding, and localized tenderness due to muscle bruising and bleeding, which can irritate the peritoneum. These symptoms may even be accompanied by nausea and vomiting. On the other hand, early signs of internal organ damage can be subtle due to minimal initial bleeding and leakage, which may be diluted by intraperitoneal fluid. This makes it easy to confuse the two types of injuries.

Abdominal Wall Contusion:

In cases of abdominal wall contusion, the abdominal pain is usually mild, muscular guarding is localized, and there may be subcutaneous bruising and soft tissue swelling. Generally, systemic disturbance is minimal, and shock is unlikely.

Solid Organ Rupture:

For solid organs, except for the liver and gallbladder, the symptoms of peritoneal irritation are generally less severe compared to hollow organ injuries. While pain may be felt throughout the abdomen, it is most prominent in the area where the damaged organ is located. The following points can assist in the diagnosis:
1. Indicators of Internal Bleeding: After trauma to the lower chest and upper abdominal area, there may be signs of internal bleeding, such as an increased pulse rate, a drop in blood pressure, progressive anemia, and the absence of abdominal breathing.
2. Pain Radiating from the Ribcage: Abdominal pain may be most pronounced in the costal margins and may radiate to the shoulders, back, and waist.
3. Persistent Upper Abdominal Pain: After the injury, pain in the upper abdomen persists and may be accompanied by localized tenderness, muscular guarding, abdominal distension, and reduced bowel sounds.
4. Changes in Liver or Spleen Percussion: On X-ray, there may be an enlargement of the liver or spleen shadow, elevation and reduced movement of the diaphragm on the injured side, and disappearance of the psoas muscle shadow.
5. Presence of Fixed or Shifting Dullness: During abdominal paracentesis, non-clotting dark red blood may be observed. This is due to defibrinated blood, which is also associated with the action of fibrinolysin.

Diagnosis of Hollow Organ Perforation:

Perforation of hollow organs often leads to peritonitis at an early stage, characterized by severe abdominal pain that makes early detection easier. The following points can assist in diagnosis:

Severe Abdominal Pain Lasting Over 4 Hours: This is accompanied by:
- Nausea and bilious vomiting
- Increased pulse rate
- Fixed tenderness upon palpation
- An expanding area of muscular guarding
- Elevated white blood cell count with a leftward shift in differential
- Weakened or absent abdominal breathing
Anemia Not Prominent but Rapid Pulse and Restlessness: Even if anemia is not obvious, a fast pulse rate and symptoms of restlessness or agitation may be present.
Disappearance of Liver Dullness: An X-ray may show the presence of free air under the diaphragm, indicating perforation.
Abdominal Paracentesis Shows Turbid Fluid: Microscopic examination confirms the presence of pathogens, indicating infection.

Early Diagnosis and Treatment:

For patients with multiple injuries, if there is even one reliable indicator, early exploratory laparotomy is advised.

Conditions for Conservative Treatment:

Injury is confined to the abdominal wall.
Although there's internal bleeding, it has stopped and there are no signs of hollow organ perforation; vital signs remain stable.
General condition is still good one or two days post-injury, and any internal infection is localized.
Mild kidney injuries where the hematuria gradually decreases and pain subsides.

Anesthesia:

Complete anesthesia is required to relax the abdominal muscles, facilitating exploration and cleaning of the abdominal cavity. Our majority of cases have safely and satisfactorily used continuous epidural anesthesia, but it should be administered in small, slow doses. Note that the required dosage for these patients is generally less than for typical patients.

Exploration:

Pay attention to the existence of compound injuries to avoid overlooking any. Check retroperitoneal organs like the duodenum, colon, and the bare area of the liver. The omentum often points to the location of the pathology.

Suggested Order of Exploration:

Spleen, liver, pancreas, diaphragm, base of the stomach, bile ducts, duodenum, mesentery, omentum, small intestine (from the jejunum to the ileocecal region), large intestine (note the hepatic and splenic flexures), retroperitoneal organs like kidneys and major blood vessels, and pelvic organs.

Drainage:

The decision to drain is based on the timing of the injury, the degree of infection, and the quantity and quality of the intra-abdominal fluid. For early abdominal contamination, thorough washing is the main approach, supplemented by drainage. Drainage is necessary for liver, gallbladder, pancreas, and intestinal injuries.

Prognosis:

Early death is usually due to severe compound injuries, traumatic shock, and major bleeding. Late death often occurs from generalized peritonitis, toxic shock, and water and electrolyte imbalances. The cure rate for surgical cases can reach around 90%.

References:

Huang Jiaqi, "Surgery," People's Health Publishing House, P: 497, 1964.
Gao Xianming, "Abdominal Trauma," Journal of Surgery, 6: 468, 1951.
Jiang Kegou, "Diagnosis and Treatment of Abdominal Trauma," Journal of Surgery, 6: 376, 1951.
Huang Wen, "Clinical Analysis of 98 Cases of Abdominal Contusion," Chinese Journal of Surgery, 4: 370, 1960.
Gong Songnan, "Closed Abdominal Injury (with analysis of 220 cases)," Chinese Journal of Surgery, 15: (2) 96, 1977.

Originally published in "Nanling Medical Journal" by Li Mingjie, Department of Surgery, Nanling County Hospital, 1979; 59-63.

from 腹部创伤

【李名杰从医67年论文专辑】（电子版）

【李名杰从医67年论文专辑（英语电子版）】

Medicine Lecture Notes

Treatment points of radical resection of colon cancer

Treatment of recurrent ulcer after subtotal gastrectomy

Treatment of carcinoma of pancreas head and carcinoma of ampulla

Treatment of cardiac cancer

Level 4 Surgery: Six Sample Cases

Case 1: Extended Total Gastrectomy

Gross Examination of Specimens

Detailed Surgical Procedure

Surgical Conclusion

Additional Notes

Case 2: Simulated Radical Surgery for Thyroid Cancer

Single Operation Record for Surgery Case 2 at Wuhu Changhang Hospital

Post-operative Gross Examination and Pathology:

Surgical Procedure:

Case 3: Single Operation Record of Wuhu Changhang Hospital

Surgical Procedure:

Surgical Conclusion:

Surgeon and Record Keeper:

Additional Notes:

Case 4: Liver and Biliary Duct Stone Disease

Surgical Procedure:

Anesthesia and Initial Incision:

Exploration and Stone Removal:

Higher-Level Hepatic Duct Incision:

Detachment and Resection:

Further Exploration and Stone Removal:

Duct Reshaping and Draining:

Intestinal Drainage:

Hemostasis and Open Treatment:

Intestinal Anastomosis:

Final Checks and Drainage:

Abdominal Closure and Recovery:

Surgical Conclusions:

1. Complete Biliary Clearance:

2. Partial Hepatectomy of the Left Lateral Lobe:

3. Reconstruction of Hepatic Duct System:

4. Hepaticojejunostomy:

5. Anastomotic Integrity:

Surgeon and Record:

Ultrasound Follow-up:

Case 5: Surgical Record from Wuhu Changhang Hospital

Patient Information:

Preoperative Diagnosis:

Postoperative Diagnosis:

Surgery Details:

Postoperative Gross Findings:

Pathology Samples Sent for Examination:

Case 5: Surgical Procedure (First Part)

Initial Steps:

Incision:

Initial Observations:

Further Steps:

Draining and Cleaning:

Surgical Difficulties:

Final Steps:

Surgical Conclusions:

Surgeon and Record Keeper: Dr. Li Mingjie

Date: November 21, 1989

Notes:

Follow-Up:

Case 6: Surgery Record from Wuhu Changhang Hospital

Surgical Procedure Details

Surgical Conclusion and Follow-up

Surgical Conclusion:

Follow-up:

Abstract

Clinical Data

Clinical Manifestations

Treatment Methods

1. Combined Acupuncture and Warm Moxibustion Group (94 Cases)

Acupoint Selection

Acupuncture Depth

Manipulation Technique

Needle Sensation

Moxibustion Therapy

Moxibustion Sensation

2. Prednisolone Local Blocking Group (58 Cases)

Efficacy Criteria

Therapeutic Results