心肌梗死并发室间隔穿孔的外科治疗

目的:探讨提高心肌梗死并发室间隔穿孔(VSR)外科治疗疗效的方法.方法:回顾性分析1994年10月至2007年10月37例接受手术治疗的VSR患者的临床资料.男性24例,女性13例,平均年龄(63.4±7.6)岁.其中VSR修补合并同期冠状动脉再血管化26例(再血管化组),单纯VSR修补11例(单纯修补组).结果:围手术期再血管化组病死率15.4%(4/26),低于单纯修补组的63.6%(7/11),P=0.006.出院患者26例均获得随访,平均随访(34.0±29.8)个月,总随访时间57人年.再血管化组晚期死亡2例,单纯修补组3例.再血管化组6～8年生存率为(64.3 ±21.0)%,单纯修补组4年生存率为(25.0±21.7)%,组间差异有统计学意义.21例患者获得中长期生存,心功能Ⅰ～Ⅱ级17例,Ⅲ～Ⅳ级4例.再发VSR 4例.多因素分析发现未冉血管化、心源性休克、急诊手术为早期死亡危险因子,未再血管化、术后低心排是晚期死亡的危险因子.结论:VSR修补术同期施行再血管化手术可提高围手术期生存率和中长期生存率,合理选择手术时机、手术方法,对提高VSR围手术期生存率、减少VSR再发非常重要.     

十二指肠球后溃疡穿孔的处理

目的探讨十二指肠球后溃疡穿孔临床上正确的围手术期处理办法。方法回顾性分析我院1998年5月至2004年11月6例十二指肠球后溃疡穿孔的临床症状、穿孔部位、手术方式、治疗结果和随访情况。结果6例患者均为溃疡穿孔，分别行急诊手术，术后1例死亡，1例转院，4例完全治愈。结论术中根据患者条件选择合理的手术方式，重视术后引流，早期肠内营养是改善患者预后的关键。     

经内镜逆行胰胆管造影相关穿孔诊治分析

目的 探讨经内镜逆行胰胆管造影术（ERCP）所致消化道穿孔的诊疗策略和经验教训。方法 回顾性分析我院2005年3月至2015年12月收治的10例ERCP相关消化道穿孔病例的Stapfer分型、穿孔原因、并发症、治疗措施和术后住院时间,总结不同Stapfer分型消化道穿孔的诊治经验。结果 Stapfer I型穿孔2例,均行手术治疗预后较好。Stapfer II型穿孔7例,4例行保守治疗成功,平均术后住院时间19 d;3例ERCP后24 h之内行手术治疗,平均术后住院28 d。Stapfer III型穿孔1例,为胰管穿孔,放置胰管支架术后仍并发重症胰腺炎,术后18 d行胰腺炎清创术,病理确诊为胆囊癌,家属放弃治疗,于术后57 d死亡。结论 CT检查有助于ERCP相关穿孔的早期诊断,依据患者的一般情况及穿孔的Stapfer分型制订个体化治疗可获得较为理想的预后。     

十二指肠球后溃疡穿孔5例诊治分析

目的探讨十二指肠球后溃疡穿孔的诊治方法。方法回顾性分析笔者所在医院2004年12月至2016年10月期间收治的5例十二指肠球后溃疡穿孔患者的临床资料。结果 5例患者均经病史、查体、实验室检查和影像学检查初步诊断为上消化道穿孔,均行急诊剖腹探查术,术中所见证实均为十二指肠球后溃疡穿孔,手术治疗后均治愈出院。结论消化道穿孔诊断不难,但不易确诊十二指肠球后溃疡穿孔,根据患者条件及穿孔位置合理选择手术方式,术后引流通畅及早期肠内营养是关键。     

腹腔镜下穿孔修补术联合高选择迷走神经切断术治疗十二指肠溃疡穿孔

目的探讨腹腔镜下穿孔修补术联合高选择迷走神经切断术治疗十二指肠溃疡穿孔的近期疗效。方法腹腔镜下修补溃疡穿孔,电刀游离迷走神经并进行高选择性切断。结果15例手术成功,无中转开腹手术,手术时间80-120 min,平均100 min;术中出血量150-300 ml,平均225 ml。15例术后随访12-36个月,平均29个月,13例术后1年复查胃镜溃疡消失,1例术后2年出现幽门梗阻保守治疗后好转出院,1例术后3年溃疡复发,经口服药物治疗易控制。结论腹腔镜下穿孔修补术联合高选择迷走神经切断术治疗十二指肠溃疡穿孔具有创伤小,恢复快,效果肯定等优点。     

腹腔镜胃十二指肠溃疡穿孔修补术36例的体会

目的总结腹腔镜胃十二指肠溃疡穿孔修补术的手术经验。方法对2006年4月。2008年12月我科36例急性消化性溃疡穿孔患者采用腹腔镜修补进行回顾性分析。结果36例中十二指肠球部溃疡穿孔30例,胃窦部溃疡穿孔6例,穿孔直径0．5—1．1cm,手术时间30～185min,平均75min,手术均在腹腔镜下完成。1例术后发现穿孔闭合不良,经保守治疗治愈。其余35例术后恢复顺利,住院时间6－9d,术后无切口感染、腹腔脓肿、肠粘连等并发症。结论腹腔镜手术治疗消化性溃疡穿孔．只要具备成熟技术,与开腹手术同样安全有效。     

腹腔镜胃十二指肠溃疡修补术治疗急性胃十二指肠溃疡穿孔

目的:总结腹腔镜胃十二指肠溃疡修补术治疗急性胃、十二指肠溃疡穿孔的临床经验。方法:1997年6月至2007年12月35例急性胃十二指肠溃疡穿孔患者施行腹腔镜消化性溃疡穿孔修补术。结果:35例中十二指肠球部溃疡穿孔28例,胃窦部溃疡穿孔7例,穿孔直径0.5～0.8cm,手术时间80～180min,手术均获成功,术后患者疼痛轻微,均未使用止痛剂。术后康复顺利,术后住院5～10d,平均6.5d,切口均甲级愈合,痊愈出院。出院后予以内科根除幽门螺杆菌、口服H2受体拮抗剂治疗。结论:腹腔镜手术治疗急性胃、十二指肠溃疡穿孔,与开腹手术同样安全有效。胃溃疡穿孔患者术中需快速病理检查,若为恶性病变应中转开腹。     

腹腔镜穿孔修补术治疗急性胃十二指肠溃疡穿孔

目的总结腹腔镜胃十二指肠溃疡穿孔修补术治疗急性胃、十二指肠溃疡穿孔的临床经验。方法 2005年1月至2010年6月112例急性胃十二指肠溃疡穿孔患者在本院施行腹腔镜消化性溃疡穿孔修补术。结果 112例中十二指肠球部溃疡穿孔84例,胃窦部溃疡穿孔28例,穿孔直径0.2～1.2cm,手术时间30～80分钟,手术均获成功,无任何手术并发症。术后患者疼痛轻微,均未使用止痛剂。术后恢复顺利,术后住院5～9天,平均6.5天,切口均甲级愈合,痊愈出院。随访3～36个月,无复发。结论腹腔镜手术治疗急性胃、十二指肠溃疡穿孔,与开腹手术同样安全有效。腹腔镜溃疡穿孔修补术具有创伤小、术中出血少、恢复快、住院时间短、并发症少等优势,应作为首选。腹腔镜下手术困难时应选择开腹手术。     

胃癌穿孔的诊治体会

目的:探讨胃癌穿孔的诊断、手术时机及术式选择。方法:对我院急诊收治的42例胃癌穿孔患者的资料进行回顾分析。结果:40例急诊手术治疗,其中一期根治性切除术14例,姑息性切除术6例,穿孔修补术后2~3周内行根治性切除术5例,穿孔修补+短路手术6例,单纯穿孔修补术9例。2例因诊治为溃疡穿孔保守治疗,2周后胃镜检查示胃癌。限期行根治性切除术。本组手术后一月内死亡5例,死亡率为11.9％。42例中获随访38例,失访4例,其中根治性手术、姑息性切除术、单纯修补术、穿孔+短路手术者,平均生存期分别为30个月、16个月、6个月、8个月。结论:术中探查与活检是诊断胃癌穿孔的重要依据。合理的手术时机及术式选择是延长患者生存期和提高患者生存质量的关键。     

乙状结肠自发穿孔（附11例报告）

目的 探讨乙状结肠自发性穿孔的病因、诊断及治疗。方法 回顾性分析1984年1月－2000年9月收治的11例乙状结肠自发性穿孔病人的临床资料。结果 11例均经手术探查证实乙状结肠穿孔。既往有慢性便秘史4例，合并轻度直肠脱垂1例，余6例无特殊记载。9例术前误诊为急性阑尾炎穿孔、上消化道穿孔、结肠癌穿孔、炎性穿孔或粪块性穿孔。2例行单纯修补术后,9列行结肠造口及相关手术，其中7例术后2－3个月行二期闭瘘，术后恢复，2例术后死亡。结论 乙状结肠自发性穿孔与病人本身乙状结肠所处的形态和位置有很大关系，其腹内压和肠管内压增高是该病的诱因；该病缺乏特异的临床表现及体征，提高术前确诊率的关键在于对本病有充分的认识；治疗以手术米，术式根据病人年龄、全身情况、腹腔污染程度、发病时间来定，以修补关闭穿孔或肠管切除吻合加乙状结肠造口术为最佳术式。     

Post infarction ventricular septal rupture: Repair by endoventricular patch plasty with infarct exclusion—Vijaya Heart Foundation Technique

Background Surgical repair of a postinfarct ventricular septal rupture (VSR) remains a difficult surgical challenge associated with a significant operative mortality. Materials and Methods We introduce a new operative procedure of infarct exclusion with polytetrafluroethylene (PTFE) patch and closure of ventriculotomy without pledged or felt. There were 8 men and 2 women with age range of 47 to 71 years. All of them were in the acute phase of the myocardial infarction and 6 were in cardiogenic shock at the time of operation. In 8 patients the VSR was anterior and one of the two patients with posterior VSR had concomitant transventricular mitral valve replacement. Results There was one postoperative death. Multi organ failure was the only independent predictor of operative mortality and 2 patients developed renal failure. Patients have been followed up for a mean of 18 months. There have been no late deaths. In follow-up assessment of ventricular function by echocardiography all patients had normal right ventricular function and mild or moderate impairment of left ventricular function and none had a residual ventricular septal defect. Conclusion Deferral of operation for patient in cardiogenic shock after VSR represents a failed therapeutic strategy. Conversely, repair of acute postinfarction ventricular septal defect by endocardial patch plasty avoids additional damage to the right ventricle, remodels the acutely infarcted left ventricle, and enhances survival.     

Transatrial Repair of Post-infarction Posterior Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction. The event occurs 2~8 days after an infarction and often precipitates cardiogenic shock. Post myocardial infarction VSR is known for difficult to repair. Especially, Transmural myocardial infarction involved in the posterior VSD area, exposure of the affected site is difficult and postoperative mortality rate is high. We have experienced a case of a 75-year-old female patient who suffered posterior VSD due to acute myocardial infarction, and attained good result by approaching the lesion through right atrial incision and repaired the defect by using patch closure technique.     

心肌梗塞后室间隔穿孔的手术治疗

探讨急性心肌梗塞后室间隔穿孔的手术时机选择及影响手术疗效的因素。１６例急性心肌梗塞后室间隔穿孔病人接受了手术治疗。平均年龄５４．５岁。术前合并心源性休克５例，充血性心力衰竭伴肺水肿１例。１４例行冠状动脉造影，单支病变８例，多支病变６例，合并室壁瘤１３例。急症手术４例，择期手术１２例。行穿孔直接缝合２例，补片修补１３例，双侧补片修补１例；同期冠脉搭桥９例，室壁瘤切除或折叠１３例。术后应用主动脉内球囊反搏（ＩＡＢＰ）者８例。２例急症手术者早期死亡。结论：室间隔穿孔应先行内科治疗控制心源性休克，包括应用ＩＡＢＰ或左心室辅助等，使病人能坚持到穿孔４８小时后再积极手术。分流量小者应延至３～６周后手术。心源性休克是影响术后早期死亡率的主要因素     

Early and late results of entire septal patch technique for post infarction ventricular septal rupture

Objectives

Surgical results for post-infarction ventricular septal rupture (VSR) remain poor, even today. The aim of this study was the establishment and clinical evaluation of a simple, standardized septal patch technique for this disease.

Methods

From 1999 to 2011, 16 consecutive patients with a mean age of 73.1?±?10.1 (range 55?C89) underwent emergency repair of VSR following anterior myocardial infarction. Entire septal patch technique, in which a large pericardial patch is fixed reciprocally between transmural sutures placed in the posterior free wall adjacent to the ventricular septum and anterior left ventriculotomy closing sutures, thus almost entirely covering the septal wall, was used in all cases.

Results

Mean interval between the onset of septal rupture and surgery was 1.3?±?0.6?(range 1?C3)?days. Eight patients presented cardiogenic shock and 14 patients underwent preoperative intra-aortic balloon pumping. Average operation, cardiopulmonary bypass, and aortic clamp time were 233?±?71?(145?C360), 128?±?51?(82?C240), and 46?±?15?(29?C76)?min, respectively. Coronary artery bypass grafting was performed concomitantly in five cases. Average intra-operative blood loss was 340?±?184?(123?C740)?g. Thirty-day mortality was 0?%, and in-hospital mortality was 13.3?% (2/16). Significant residual shunt occurred in one patient. All hospital survivors were followed up with a mean period of 44.5?±?40?(5?C131)?months. Five-year survival of all operated patients was 69?±?14?%.

Conclusions

Entire septal patch technique proved to be an easily reproducible method for anterior VSR that demonstrated stable early and late results.     

Thrombolysis and postinfarction ventricular septal rupture.

We studied all patients with postinfarction ventricular septal rupture referred to the Oxford Heart Centre for operation over a 4 1/2-year period. Twenty one women and 8 men were admitted to the Centre, 13 of whom had received streptokinase and 16 of whom had not. The median interval between symptomatic onset of myocardial infarction and the development of septal rupture was 24 hours for those treated by early thrombolysis (all streptokinase) and six days for those who were not. Of the 26 patients who underwent surgical repair, three were operated on less than 36 hours after streptokinase infusion, in one case within 12 hours of thrombolytic treatment. Macroscopic observation of the disintegrating myocardium showed muscle bundles dissected by blood rendered incoagulable by thrombolytic treatment, together with the histologic features of reperfusion injury. The overall surgical mortality rate for the streptokinase group was 33% and for the others 21%. The patient operated on within 12 hours of thrombolytic treatment recovered uneventfully. Six of seven surgical deaths were caused by left ventricular or biventricular failure and one by gastrointestinal hemorrhage. All survivors were in New York Heart Association classes II or III between 2 weeks and 4 1/2 years after operation. We conclude that thrombolysis leads to early breakdown of the interventricular septum after acute myocardial infarction but does not preclude early repair.     

Acute postinfarction septal rupture: long-term results

From 1973 to 1989, 66 patients received early surgical repair for acute postinfarction ventricular septal rupture. Mean age was 64 +/- 7 years (range, 45 to 80 years). Ventricular septal rupture occurred soon after acute myocardial infarction (3.4 +/- 4 days), and the first medical treatment occurred 6.7 +/- 7 days after onset of acute myocardial infarction. Three patients had a previous myocardial infarction. The site of the rupture was anterior in 38 patients (57%) and posterior in 28 (43%). Forty-four patients (67%) were in shock at the time of admission. Intraaortic balloon pumping was used preoperatively in 28. Operation was performed at the time of maximal efficacy of medical treatment. The same technique was used in all cases. Associated procedures included coronary bypass grafting in 5 patients and valvar operation in 5. The patients have been carefully followed up for up to 16 years. Hospital mortality was 45% (30 patients) and was cardiac related or due to acute renal failure in 25 patients (83%). No correlation could be revealed between early death and age, sex, preoperative intraaortic balloon pumping, or year of operation. Location of the ventricular septal rupture (early mortality of 57% for posterior versus 37% for anterior ventricular septal rupture) and shock at the time of admission (52% versus 32%) showed a trend toward significance (0.08 less than or equal to p less than 0.10). Response to initial active therapy has a strong predictive value (mortality of 70% in unresponsive patients versus 14% in responders; p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical management of ventricular septal defect complicating myocardial infarction.

In an 18 month period six patients were treated by operation for ventricular septal defect occurring as a complication of acute myocardial infarction. Each septal defect occurred within one week of the myocardial infarct but the interval from infarction to operation ranged from 8 days to 7 months. All patients had intractable cardiac failure and two were in cardiogenic shock at the time of operation. Preoperatively right and left heart catheterisation with left ventriculography and biplane coronary arteriography was performed in every case. At operation the principle of "total correction" of all the cardiac defects was followed so that in addition to closure of the septal defect each patient required one or more additional operative procedures such as resection of left ventricular infarct or aneurysm, mitral valve replacement or coronary artery vein bypass grafts. All six patients survived operation but one died four weeks postoperatively from perforation of an acute peptic ulcer. In one patient the ventricular septal defect recurred and was successfully closed four months later. The surviving patients remain well at follow-up.     

Surgical treatment of ventricular septal defect secondary to myocardial infarction

13 patients were operated on during 1974-88 for ventricular septal defect secondary to myocardial infarction. 7 infarctions were inferior and 6 anterior. At the time of operation 5 patients were in shock. Besides the correction of ventricular septal defect coronary artery by-pass grafting was performed in 6 patients and left ventricular aneurysmectomy in 3 patients. The operative mortality was 31%. The cause of death was low output syndrome in 3 cases and a new rupture through the left ventricular free wall in one case. Postoperative shunting was detected in 5 patients. During an average follow-up time of 6.3 years (range 0.5-15 years) 3 patients died from a new myocardial infarction. The mean performance levels of the patients still living was NYHA II. Prompt diagnosis of a ventricular septal defect due to myocardial infarction and its immediate surgical treatment is recommended. The results are poor in the presence of primary shock and for inferior infarction.     

急性心肌梗死后室间隔穿孔的外科治疗

目的总结急性心肌梗死后室间隔穿孔的外科治疗经验,探讨外科手术治疗的时机和方法。方法自1999年1月至2008年12月,外科治疗22例急性心肌梗死后室间隔穿孔患者,其中男17例,女5例;年龄39～78岁,平均年龄61.77岁。前室间隔穿孔18例,后室间隔穿孔4例,均合并室壁瘤。22例患者均行室间隔穿孔修补术及室壁瘤切除术,16例患者同期接受冠状动脉旁路移植术,移植血管2.11±1.57支。结果围术期死亡2例（9.09%）,其中1例术后死于严重低心排血量综合征,1例死于大面积脑栓塞。其余20例患者均治愈出院,出院时心功能分级（NYHA）Ⅲ级4例,Ⅱ级12例,Ⅰ级4例。超声心动图检查提示：未发现有室间隔残余分流,有轻度二尖瓣反流2例。术后左心室舒张期末内径（LVEDD）与术前比较明显减小（50.27±5.33mmvs.57.94±6.79mm,t=4.437,P=0.000）。随访16例,随访时间3～24个月（13.9±6.5个月）,失访4例。随访期间无晚期死亡,无心血管事件发生。心功能分级（NYHA）Ⅱ级11例,Ⅰ级5例。超声心动图提示：LVEDD与术前比较明显缩小（49.50±4.66mm vs.57.94±6.79mm,t=5.041,P=0.000）,左心室射血分数（LVEF）较术前明显提高（55.08%±6.72%vs.45.57%±11.31%,t=2.719,P=0.013）。结论急性心肌梗死后室间隔穿孔是急性心肌梗死的严重并发症之一,掌握适当的手术时机、完善的术前准备、积极的围手术期治疗、正确的手术方法和避免术后并发症的发生,能有效地降低患者的病死率,改善其预后。     

Surgical treatment of ventricular septal defect complicating acute myocardial infarction. Experience of a north Italian referral hospital

The purpose of our study was to evaluate the clinical outcome of postinfarction ventricular septal defect (VSD) of patients referred to our institution for surgical treatment, by assessing the role of several operative, pre- and post-operative variables on mortality. The medical records of 58 consecutive patients (mean age 73+/-7 years), operated on after 14+/-12 days from the acute myocardial infarction were retrospectively reviewed and the data were analyzed. Associated procedures were left ventricular reconstruction in 13 patients and aortocoronary bypass grafting in 47 (81%). The overall operative, in-hospital mortality rate was 52% (75% in patients operated on within the first week and 16% if time from infarct to surgery was >3 weeks). Time from AMI to surgery and time from hospital admission to operation were significantly shorter in non-survivors (p=0.003 and 0.012, respectively). Other pre-operative variables significantly associated with mortality were: cardiogenic shock, pulmonary pressure, VSD diameter.In conclusion, time from AMI to operation appears to be a very important prognostic factor. However, size of VSD and hemodynamic conditions significantly influence the mortality. Moreover, concomitant procedures of revascularization can be safely performed, when required, as actually occurs in most cases.