2012年7月12日 星期四

分享小手術- Port-A cut down method~~

每個GS resident都會遇到的手術
分享一下自己的經驗~~

幾個定位的方法..

1. Clavicle以下兩指幅(除非你的手指很大...XD)
2. Greater tubercle, 就是Cephalic vein向下鑽到Axillary Vein的地方

這兩個點就取決你Wound的最高點,
最高點超過這個地方一定要挖到很深很後面去才找得到,
那就直接改Puncture就好了...

3. Incision的位置,我都選在Groof的中央,下去就可以看得到。在術前用手指稍微按壓一下病人,確定一下Groof的位置即可...

以上三點就會決定你Wound的位置跟走向,要開多大?自己方便就好,我記得我的第一台Port-A拉了5cm...XD

不過我Wound 會稍微偏Pactoris Major一點,這樣下去打開PM的Facia後,往Deltoid的方向慢慢把Muscle撥開,就可以近的到Groof裡面...

4. 進Fascia前,記得打點Local, 把Fascia跟下面的Muscle分開,這樣會更好進Groof, 不會迷失在一堆Muscle當中.

5. 通常打開Facia進Groof以後,會有一堆Soft tissue,
我會用Smooth夾起來稍微燒開,輕輕的Blunt dissection一下(電燒頭 or Right angle, 以前也用過Kelly or Mosquito),自然就有Vessel跳出來...

6. 胖的比較好找,太瘦的常會吃鱉...XD
一切都是油花適當最好!!

7. 迷路了? 把自動開或Auto-retractor拿掉,重新Approach就好

8. 進了血管,記得要請病人把頭轉到你這邊來,轉到底,這樣Port-A會更容易進Brachiocephalic vein, 記得放Port-A的時候要問一下病人脖子會不會不舒服, 手會不會酸, 有不舒服可能就上腦或繞進手臂了,記得拔出來重推...

9. 位置確定:
我都用Arrythmia法...但不是每個病人都會跳Arrythmia
不過Port-A可以整隻塞進去超過40cm, 大概都沒問題...
有阻力可以多試幾次,但怎樣都放不進去,
改Puncture真的是比較快得選擇...^^

我大概都這樣就打的到,成功率蠻高的
打不到的我都改Puncture...
我跟小寶學長這樣用,在內科的退貨率其實很低...XD

2012年5月28日 星期一

Annals of Surgery 2012/05/28 CRS related topics

Annals of Surgery: May 2012 - Volume 255 - Issue 5 - p 922–928

Post-LAR syndrome: incontinence, urgency, and frequent bowel movements

Risk factors(Higher LARS score):
with radiotherapy (P < 0.0001), tumor height less than 5 cm (P < 0.0001), and total mesorectal excision (P = 0.0163).

Evaluated by LAR symdrome score





Over 30: Major LAR symptoms(+)==> 影響生活!




Annals of Surgery : Volume 255(5), May 2012, p 929–934Open Versus Laparoscopic Resection of Primary Tumor for Incurable Stage IV Colorectal Cancer: A Large Multicenter Consecutive Patients Cohort Study

Methods: exclusion of any curative surgery!!


1. The complication rate after laparoscopic surgery (17%) was significantly lower than that after open surgery (24%) (P = 0.02),
the difference was greater (4% vs 12%; P < 0.001)  to severe (>=grade 3) complications

2. Laparoscopic surgery significantly lower hospital stay than that for open surgery (14 vs 17 days; P = 0.002)

3. Univariate: laparoscopic group was significantly better than that for open surgery (median survival time: 25.9 vs 22.3 months, P = 0.04)



Major risk factors of Survival: Tumor related factors(R2 organ, CEA, age)



Conclusion:Laparoscopic surgery in palliative surgery has advantages in the short term and no disadvantages in the long term.

Annals of Surgery: POST AUTHOR CORRECTIONS, 11 May 2012
doi: 10.1097/SLA.0b013e318257d2c1


Anastomotic Leak Is Not Associated With Oncologic Outcome in Patients Undergoing Low Anterior Resection for Rectal Cancer

Methods:
low anterior resection (1991-2010) for rectal adenocarcinoma (<=15 cm from anal verge) were retrospectively analyzed

Conclusion:
anastomotic leakage was not associated with risk of local recurrence.
Defunctioning stoma was associated with lower incidence of clinical leakage (2.2% vs. 6.3%, p=0.05) but not with difference in oncologic outcome.