Volume 89  ·   Issue 11  ·  2009

Cardiovascular and cerebrovascular diseases are the number one killer of modern human beings, and cerebral aneurysm and cerebral arteriovenous malformation (AVM) are common cerebrovascular diseases, which are very harmful. This issue publishes three papers on cerebral aneurysm, which generally reflect the treatment and research level of cerebrovascular disease surgery in China.

Objective To explore the relationship between the characteristic geometry and the risk of rupture in cerebral saccular aneurysm. Methods The clinical features of 473 cerebral saccular aneurysm patients with complete materials of cerebral angiography, 426 with ruptured aneurysm and 47 with unruptured aneurysm, were analyzed retrospectively. The relation of depth, neck width, and aspect ratio (AR) of aneurysms to the risk of rupture were analyzed. Results The mean depth, neck width, and the AR of the patients with ruptured aneurysm were (5.9±3.0) mm, (3.0±1.2) mm, and (2.1±0.9), all significantly lower than those of the unruptured aneurysm patients [(8.0±4.2) mm, (4.8±2.4) mm, and (1.7±0.6) respectively, all P<0.01]. Condnsion AR is not correlated with the location of aneurysms, but reflects the geometrical and hemodynamic features of cerebral saccular aneurysms very well. High AR may be useful in predicting imminent aneurismal rupture. But by now, no definitive AR level is accepted in discriminating between unruptured and ruptured aneurysms.

Objective To evaluate the feasibility of the injectable thermosetting chitosan -glycerophosphate-fibroblast (C-GP-FB) hydrogel as an embolizing material of intracranial aneurysm.Methods 2% chitosan solution and 56% glycerophosphate solution were mixed in different volume ratio to detect the pH, colloidization time at 37℃ ,and mechanic strength. Fibroblasts were isolated from the skin of a rabbit and cultured with C-GP hydrogel of different, ratios so as to determine the best ratio. Six rabbits underwent construction of aneurysm in the right branchioccphalic trunk. Three weeks later C-GP-FB hydrogel was infused into the aneurysm via microtube and balloon. X-ray photography was conducted soon to observe the embolizing effect. Three days, 1 week, and 4 weeks later tea rabbits were killed respectively with their aneurysms taken out to undergo HE staining and microscopy. Result When the ratio of C/GP was 7:1 at pH 7.28, the colloidization time was (260±18) sec, and the mechanic strength reached 14 kPa. The C/GP volume ratio of 7:1 was regarded as the best ratio. When the fibroblasts were cultured with the C-GP hydrogel with the C/GP volume ratio of 7:1 the survival rate of the fibroblasts reached the peak of (89±2.74)%. X-ray photography showed that image of aneurysm failed to be spotted immediately after the infusion of the C-GP hydrogel. HE staining and microscopy showed that C-GP-FB gel had fine visualization under X-ray. Histological section(HE stain) showed that 3 days after the infusion the aneurysms was embolized by the C-GP-FB hydrogel and no obvious inflammatory cell was seen in the arterial wall; the first week there were many cells in the gel, the boundary between the C-GP-FB gel and'vessel wall was clear, and the endotheliocytes were complete; and in the fourth week, the boundary between the gel and vessel wall was obscure, shght degradation could be observed in the edge of hydrogel, and immumofluorescence showed that there were many labeled cell in the gel . Conclusion In the short term view, C-GP-FB hydrogel can be used to embolize aneurysms, at least with an obvious short-term effect.

Objective To summarize the experience in surgical treatment for middle cerebral aneurysm (MCAA), and results and prognosis thereof. Methods The clinical data, including location, size, main presentations, and Hunt & Hess grade, of 55 consecutive MCAA patients were prospectively analyzed. The surgical outcome was evaluated by Glasgow Outcome Scale (GOS). Follow-up was conducted for 23 (11-19) months. Results According to the Hunt & Hess classification, there were 9 cases in grade 0, 12 cases in grade Ⅰ , 23 cases in grade Ⅱ, 8 cases in grade Ⅲ, 2 cases in grade Ⅳ, and 1 case in grade Ⅴ at admission. Headache (42 cases), vomiting (22 cases), and hemiplegia (11 cases) were the top 3 common presentations. Pterional craniotomy was adopted in all cases. Proximal to distal lateral fissure approach was used in 23 cases, distal to proximal approach in 27 cases, and trans-hematoma approach in 5 cases. There were 45 cases treated by direct neck-clipping (clipping and resetting in 6 cases) , 7 cases by parent artery reconstruction, and 3 cases by wrapping by muscle. The location of MCAA was at the bifurcation in 37 cases (37.2%), at proximal middle cerebral artery (MCA) in 13 cases (23.6%), and at distal MCA in 5 cases (9.1%). The largest diameter was 15.5 (3-70) mm. The main postoperative complications included hemiplegia (12 cases), aphasia (3 cases), and seizure (2 cases). Follow-up showed good recovery in 45 cases, moderate disability in 5, and severe disability in 5 according to GOS. There was no vegetative state, death, and recurrence. Conclusion With modern imaging techniques, perfect surgical plan, appropriate surgical approach, and careful microsurgical techniques, treatment of MCAA can be perfected and achieve satisfying outcome.

Objective To investigate the diagnosis of aortic origin of the right pulmonary artery (AORPA) and evaluate the efficacy of surgical treatment therefore. Methods The clinical data of 14 AORPA patients, 9 male and 5 female, aged 4 (60 days -23 years), hospitalized from May 1992 to March 2007, twelve of which were surgically treated through 5 different procedure, and two of which were denied surgical procedure due to Eisenmenger syndrome. Follow-up was conducted for(5.15±3.48)years. Results The diagnosis of 12 out of the 14 patients was confirmed before operation, and 2 of them were misdiagnased by echocardiography. Two patients died during the peri-operational period due to low output syndrome or pulmonary hypertension crisis. One patient died from right cardiac failure 4 yrs after the surgical procedure. Of the 9 surviving patients, 5 were in NYHA functional class Ⅰ, and 4 in class Ⅱ . Conclusion In diagnosis of AORPA right ventriculography and aortic angiography or multi-sliced CT angiography or MRI are necessary to avoid misdiagnosis. The early and mid-long term effects of surgical treatment for AORPA are good, but it was imperative to adopt these procedures as early as possible to heighten the cure efficacy.

Objective To investigate the incidence and influential factors of post-operative nausea and vomiting (PONV) following gynecologic surgery so as to provide guideline effective for clinical management. Methods The clinical data of 492 qualified consecutive female patients who had undergone gynecological surgery were analyzed. Univariate analysis and multivariate logistic regression were applied to examine the relations between the perioperative variables and occurrence of PONV within 6 h or 24 h following gynecologic procedures. Results PONV developed in 218 patients within 24 h following surgery (44.3%) while in 161 patients within 6 h following surgery (32.7%). Multivariate logistic regression analysis identified PONV history and perioperative opioids administration as significant predictors of PONV within 24 h following gynecologic surgery, while PONV history, general anesthesia, and postoperative shivering predictors of PONV within 6 h after surgery, and found the administration of dexamethasone or droperidol as consistent protective factors of PONV within 6 h or 24 h following surgery. Conclusion For gynecologic surgery, previous PONV history will increase the risk for PONV following current surgery. Pefioperative opioids administration will intensify the risk for the development of PONV within 24 h following surgery, while general anesthesia and postoperative shivering for PONV within 6 h after surgery. Perioperative dexamethasone or droperidol will decrease the incidence of PONV within 6 h or 24 h following gynecologic procedures.

Objective To investigate the clinical effect of transcatheter arterial chemoembolization (TACE) combined with high intensity focused ultrasound (HIFU) ablation in treatment of large hepatocellular carcinoma (HCC). Methods Sixty-eight patients with unresectable HCC were randomized into 2 age, tumor size, TNM stages, and liver function grade-matched groups: TACE group (n=30) undergoing TACE and TACE + H1FU group (n=38) undergoing 2-3 weeks after TACE. A total of 88 tumors (9.3±3.2) (5.0-14.5) cm in diameter were detected, and the largest tumor in a specific patients with multiple lesions was selected for observation. Follow-up was conducted for (13±7) (3-24) months to observe the necrosis of tumor, size of tumor, local recurrence, and survival of patient. Results The clinical symptom remission rate was 90. 6% (29/32) in the TACE + HIFU group and 70. 8% (28/38) in the TACE group. The tumor necrosis and minification rates of the TACE + HIFU and TACE groups were 73.7% and 68.4% respectively, both significantly higher than those of TACE group (26.7% and 33.3% respectively, both P<0.01). The tumor local recurrence rate of the TACE + HIFU group was 21.1%, not significantly different from that of the TACE group (33.3%, P>0.05). The median survival duration of the TACE +HIFU group was 18 months, significantly longer than that of the TACE group (10 months, P<0.05). Conclusion Compared with the TACE therapy alone, the combination therapy improves the tumor necrosis rate and prolongs the patients' survival duration.

Objective To evaluate the long-term effects of percutaneous lumbar discectomy(PLD) and microendoscopic discectomy(MED) in treatment of lumbar disc herniation. Methods A questionnaire survey by letter and telephone was conducted among 104 patients undergoing PLD and 82 patients undergoing MED during January 2000 to March 2002, to investigate the Oswestry disability index (ODI), Short Form-36 (SF-36) score, and Japanese Orthopedic Association (JOA) score. Results The excellent/good rate (ODI score=0-20%) of the MED group was 79.27%, significantly higher than that of the PLD group (71.15%, P=0.0397). However, longer The hospitalization duration of the MED group was 11,6 d, significantly longer than that of the PLD group (7.9 d, P<0.01), and the mean cost of the MED group was, significantly higher than that of the PLD group (P<0.01). Long-term complications were observed in 3 patients of the MED group (3.49%) while none in the PLD group. Conclusion Both PLD and MED are minimally-invasive-technique with a long-term efficacy and safety on lumbar disc herniation. Although the long-term outcome of the MED group is better than PLD, the complication rate, hospitalization duration, and cost of the MED group are higher.

Objective To investigate the incidence and prognosis of drug-induced acute renal failure (ARF) in Shanghai. Methods The registration forms of ARF patients admitted in 17 hospitals of and over the middle class in Shanghai from January 1 2004 to December 31 2006 were screened prospectively. The data, such as epidemiology, survival, mortality, and morbidity were analyzed. Results 347 of the 1200 ARF patients (28.9%), 224 males and 123 females, aged (58±20), suffered from drug-induced ARF. 51.0% of the 347 patients were older than 60. 60.2% of the drug-induced ARF in the non-surgical departments were community-acquired, while 55.7% of the drug-induced ARF in the surgical departments were hospital-acquired. Among the non-surgical departments, the incidence of hospital-acquired drug-induced ARF was the lowest in the department of nephrology (9.5%), while higher in the departments of hematology, cardiology, and neurology, and among the surgical departments, it was the lowest in depart6ment of renal surgery, while higher in the departments of liver transplantation, neurosurgery, and cardiovascular surgery. The most common complication was chronic kidney disease (CKD) (n=69, 19.9%), followed by cerebrovascular disease (n=59, 17.0%), diabetes mellitus (n=43, 12.4%), and hypertension (n=41, 11.8%). Renal biopsy showed acute tubular necrosis (18, 37.5%), acute interstitial nephritis (11, 22.9%), and acute infectious tubulo-interstitial nephritis (6, 12.5%). Antibiotics (47.8%) were the head causes of drug-induced ARF, especially aminoglycoside(17.0%) and cephalosporins (12.7%), followed by diuretics (22.2%) and radiocontrasts (13.3%). 22.5% of the drug-induced ARF patients had used two or more drugs. 119 patients (34.3%) needed renal replacement treatment. 100 of the 347 patients (28.8%) died. 188 of the surviving patients (54.2%) had their renal function recovered completely, the renal function of 42 of them (12.1%) was recovered partially, and 17 of then (4.9%) required dialysis when discharged. Conclusion Drug-induced ARF is common with higher incidence in the patients with complications. Antibiotics, diuretic agents, and contrast medium are the main causes.

Objective To observe the short-term outcomes of the application of posterior short-segment fixation combined with intermediate screws in fresh thoracolumbar fracture. Methods Posterior short-segment fixation combined with intermediate screws was used in 27 patients suffering from fresh thoracolumbar fracture, 19 males and 8 females, aged 45 (22-71). X-ray photography was conducted before and after operation. Results The height of fractured vertebra was 57.6%±16.5% of the normal value before operation, and was restored to 93.8%±11.9% after operation; the segmental kyphosis angle on the sagittal plane was 20.8±9.4° before operation, and decrSeased to 5.9±7.4°after operation (beth P<0.001). Conclusion Using pedicle screws on the fractured vertebra via posterior approach conditionally helps reduce the fractured vertebra and correct the kyphosis, and enhance the stiffness of the internal fixation system as well.

Objective To assess the value of computer navigation technique in spinal pedicle screw insertion. Methods 95 patients undergoing spinal pediicle screw internal fixation were randomly divided in 2 groups:navigation group (n=36) undergoing pedicle screw insertion with computer-assisted navigation technique, and conventional group (n=50) undergoing pedicle screw insertion using conventional anatomic landmark combined. The 2 groups were compared in respect to screw canal preparation time, accuracy of screw position, and incidence of postoperative complication. Results 206 screws were inserted in the navigation group,169 being with excellent outcome (82.0%) ,29 with good outcome (14.1%) ,and 8 with bad outcome (3.9%). Nine patients in the navigation group failed to adopt the computer-assisted navigation technique because of different reasons. 285 screws were inserted in the conventional group, 257 being were excellent butcome (90.2%), 28 with good outcome (9.8%), and none with bad outcome. The general fitness rate of the navigation group was 96.1%, not significantly different from that of the conventional group (100%,P>0.05). The screw canal preparation time of the navigation group was (360±22) sec, significantly longer than that of the conventional group [(56±8) sec, P<0.001)]. No postoperative complication was found in both groups. Conclusion The accuracy of pedicle screw insertion using preoperative CT-based navigation technique is not different from that using conventional anatomic landmark, but the operation time is significantly prolonged. Preoperative CT-based navigation technique has limited value in spinal pedicle screw insertion.

：Objective To evaluatethe correlation between prothrombin gene G20210A mutation and deep vein thrombosis aftertotal joint replacement through detecting distribution frequency of single nucleotidepolymorphism of the gene in patients undergoing total joint replacement. Method PCR anddirect sequencing of DNA are used to analyze the frequency of prothrombin gene G20210Amutation in 55 patients undergoing total joint replacement, and the relationship betweenthe mutation and deep vein thrombosis after total joint replacement is evaluated. ResultMorbidity of prothrombin gene G20210A mutation in 55 patients is 0, both in either DVTgroup (27 patients) or non-DVT group (28 patients). There is no significant differentiabetween the two groups (P>0.05). Conclusion Mutation of prothrombin gene G20210A inChinese patients is rare, and there is no correlation between the genetic mutation anddeep vein thrombosis after total joint replacement.

Objective To compare the effects of different calcium sulfate pellets made by different methods in treating segmental defect of bone. Methods Eighty New Zealand white rabbits underwent cutting off a segment in the middle part of radius so as to establish models of radial segmental defect, and than were divided into 4 groups: Group A as control group, Group B with calcium sulfate pellet made by routine method implanted into the defect, Group C with chitosan coated pressed calcium sulfate pellet implanted into the defect, and Group D with chitosan coated pressed calcium sulfate pellet combined with recombinant human bone morthogenetic protein (rhBMP)-2 implanted into the defect:X-ray photography was done every 4 weeks to observe the new bone formation. Four, 8, and 12 weeks 5 rabbits from each group were killed. The defect segments with parts of normal bone at both ends were cut off to undergo fluorescence microscopy and biomechanic three point bending test. Results X-ray photography and histological examination showed that new bone formation of cortex and reconstruction of marrow cavity were seen in Groups D and C, especially in Group D. The new bone mineralization rate of Group D was significantly higher than that of Group C (P<0.05) which was significantly higher than that of Group B (P<0.01). The anti-bonding strength ratio of Group D was (47.5%±2.1%, significantly higher than that of Group C [(39.6±1.7)% ,F=125.3,P<0.01], and the anti-bending strength ratios of Groups D and C were both significantly higher than those of Groups B and A [(23.6±3.3)% and (21.3±2.7)%]. Conclusion Chitosan coated pressed calcium sulfate pellet shows relatively higher anti-bending strength and slightly slower resorption that closely coincide with the growth rate of new bone. It can be used to restore segmental bone defect, and particularly when combined with rhBMP-2.

Objective To study the correlation of intermittent low-dose administration of recombinant human parathyroid hormone (1-34) [rhPTH (1-34)] and the expression of Runx2 during early stage of fracture healing. Method Sixty 2-month old male Sprague-Dawley rats underwent close unilateral femoral fracture and intramedullary nail fixation, and then were randomly divided into 2 equal groups: the operation, and control group undergoing subcutaneous injection of normal saline of the same dose. Six rats from each group were killed with their bilateral femurs taken out on days 2, 4, 7, 14, and 21 after the operation to undergo X-ray photography Tissue RNA and protein were extracted from the bone tissues and the levels of Runx2 mRNA and protein expression were evaluated through real time quantitative PCR and Western-blotting. Blood samples were collected from the abdominal aorta before the rats were killed to undergo detection of serum calcium, phosphorus, and alkaline phosphatase (AKP). Results The Runx2 mRNA levels in the fractured femurs of the rhPTH (1-34) group on days 14 and 21 after the operation were 2.6 and 3.8 times as those of the control group respectively (both P<0.05). The Runx2 protein levels in the fractured femurs of the rhPTH (1-34) group on days 14 and 21 after the operation were significantly higher than those of the control group respectively too. Since day 14 fracture healing was seen, and the status of fracture healing was better in the rhPTH (1-34) group than in the control group on days 14 and 21. The levels of serum calcium ion on days 14 and 21 of the rhPTH (1-34) group were both significantly higher than those of the control group (both P<0.05). There were not significant differences in the serum levels of AKP, osteocalcin and collagen type Ⅰ at any time point between the 2 groups. Conclusion Intermittent low-dose administration of rhPTH (1-34) up-regulates the levels of osteogenesis-specific Runx2 mRNA and protein expression to accelerate the early stage fracture healing during the early stage.

Objective Through an experiment in rabbits, to evaluate the role of reservation flaval ligament using different methods to prevent the epidural adhesion by observing the morphological changes and provide experiment evidences for clinic. Methods 45 adult rabbits were divided into three groups: Group A (treated with no reservation of flaval ligament), Group B (treated with reserving half flaval ligament), and Group C (treated with reserving the complete flaval ligament). Every group has 15 rabbits. At the 2th,4th and 8th weeks, the samples were obtained for gross observation, histological examinations, and the images were analysed by computer. The data were processed using SPSS11.5. Result Gross Observation and Histological Examinations, at the 2th, 4th and 8th postoperative week, there was significant difference between the group A, B and C (gross observation: F2w=4.660, F4w=8.591, F8w=31.858, P<0.05; whistological examinations: F2w=5.190, F4w=9.561, F8w=34.658, P<0.05) . Images analysis: the difference was very significant in the groups at 2th, 4th and 8th weeks (F2w=30.783, F4w=47.350, F8w=25.544,P<0.01). With time passing, the ratio became larger and larger in the same group. Conclusions Reserving the complete flaval ligament can significantly prevent the peridural adhesion from the back as a barrier, and can reduce the adhesion formed.

Endometrial cancer is one of the three major malignant tumors of female reproductive tract, accounting for 7% of female malignant tumors and 20% ~30% of female reproductive tract malignant tumors. In recent years, the incidence of endometrial cancer is increasing worldwide.

Diseases of aortic dilatation include: aortic dissection (AD), real and pseudoaneurysm. At present, there are two types of surgical treatment, namely, traditional open surgery and minimally invasive endovascular isolation surgery (EVE).

Subdural block is one of the rare complications of epidural anesthesia, and only a few cases have been reported in clinical practice [1-7].