婴幼儿先天性胆总管囊肿自发穿孔的诊治

目的探讨先天性胆总管囊肿自发性穿孔的诊断和治疗。方法回顾性分析11例婴幼儿先天性胆总管囊肿自发性穿孔患儿的临床资料。结果本组8例经术前腹腔穿刺确诊胆道自发性穿孔,其中5例经B超或CT诊断胆总管囊肿。3例行一期胆总管囊肿切除加胆道重建术(胆总管空肠Roux-Y吻合术);6例行胆道外引流加腹腔引流术,2例行胆囊置管引流加腹腔引流术,3~6个月后行胆总管囊肿切除加胆道重建术。11例患儿治疗后均恢复良好。结论婴幼儿胆总管囊肿自发穿孔容易误诊,掌握其临床特点、提高诊断意识以及根据患儿具体情况选择合理的手术方式是提高术前诊断率和减少术后并发症的关键。     

小儿先天性胆总管囊肿自发性穿孔的临床分析

目的：探讨先天性胆总管囊肿自发性穿孔的诊断方法和手术方式。方法：回顾性分析16例先天性胆总管囊肿自发性穿孔患儿的临床资料。结果：本组16例患儿年龄均小于4岁，平均年龄23个月。临床表现为胆胀，腹痛，呕吐及发热，同时有全腹压痛，10例术前经腹腔穿刺明确胆道自发性穿孔的诊断，其中5例经B超或CT检查证实有胆总管囊肿，采用囊肿外引流加腹腔引流治疗。16例患儿术后均恢复良好，3个月左右再地囊肿切除加胆道重建。结论：先天性胆总管囊肿穿孔与胆道梗阻有关，对小婴儿有腹膜炎表现，全腹压痛并以右上腹为著者，应常规行腹腔穿刺检查，急诊治疗宜选择囊肿外引流术，而后再行囊肿切除和胆道重建。     

腹腔镜治疗小儿胆道穿孔12例临床体会

目的:总结腹腔镜手术治疗小儿胆道穿孔的临床体会。方法:2008年12月至2015年12月收治12例胆道穿孔患儿,均经腹腔镜探查证实为胆道穿孔,根据病情分别行胆总管囊肿T管引流+腹腔引流、胆囊造瘘术+腹腔引流、单纯腹腔引流。结果:12例患儿均成功完成手术,术后未出现胆道出血、胆漏等并发症。胆汁引流及腹腔引流24~72 h后,临床症状缓解,腹痛显著减轻,体温降至正常,黄疸逐步消退。8例胆总管囊肿穿孔患者术后6个月行二期胆总管囊肿切除、肝总管空肠Roux-Y吻合术,其中5例在腹腔镜下完成二期手术,3例因胆总管周围粘连重、分离困难中转开腹。结论:腹腔镜用于小儿自发性胆道穿孔的诊断与治疗避免了盲目开腹探查的缺点,创伤小,手术视野广,对腹腔及肠管干扰小,手术时间短,胆总管囊肿穿孔不影响二次腹腔镜手术。     

胆总管外T形管引流治疗婴幼儿胆总管自发性穿孔

胆总管外Ｔ形管引流治疗婴幼儿胆总管自发性穿孔陈平成志芳孙玉振胆总管自发性穿孔临床上极为少见［１］，治疗方法有单纯性腹腔引流，Ｔ形管引流，穿孔缝合及各种内引流［２］。笔者对２例胆总管细小、管壁水肿炎症较重、胆总管内放置Ｔ形管引流困难者，采用胆总管外Ｔ形...     

儿童自发性胆道穿孔诊治经验

目的 探讨儿童自发性胆道穿孔（spontaneous perforation of the bile duct,SPBD）的临床特点、诊断及治疗。方法 回顾性分析首都医科大学附属北京儿童医院2007年6月至2020年8月收治的36例SPBD患儿的临床资料,评价腹部超声和腹腔穿刺的诊断价值,比较胆囊置管引流、穿孔部位置管引流和胆总管囊肿切开置管引流3种主要手术方式的治疗效果。结果 本研究中患儿中位年龄为1.68（1.11,3.04）岁,其中男14例,女22例,男女比例1:1.57。腹部超声对本病的诊断敏感度为61.8%（21/34）;20例行诊断性腹腔穿刺穿刺液为胆汁样腹水的患儿,后续手术证实均为胆道穿孔,诊断特异度为100%。首次治疗：6例非手术治疗,30例手术治疗。3种手术方式：胆囊置管+腹腔引流（13例）,穿孔部位置管+腹腔引流（8例）,胆总管囊肿切开置管+腹腔引流（3例）。术后症状缓解时间3组无统计学差异（P＞0.05）,但穿孔部位置管+腹腔引流术组术后腹腔引流管的拔管时间[（6.60±1.67）d]显著短于胆囊置管+腹腔引流术组[（11.22±3.77）d,P＜0.05],胆总管囊肿切开置管+腹腔引流术组和穿孔部位置管+腹腔引流组的术后住院时间[（8.00±2.65）d和（10.14±2.15）d]显著短于胆囊置管+腹腔引流术组[（15.08±5.50）d,P＜0.05]。随访发现,31例患儿合并胆总管囊肿,行胆总管囊肿根治手术（其中2例为外院手术）;胆总管囊肿根治术距前次胆道穿孔引流手术或保守治疗时间间隔1～19个月。结论 腹部超声检查和诊断性腹腔穿刺目前是儿童SPBD的主要诊断方法。虽然部分病例可以通过保守治疗痊愈,但联合胆道引流的腹腔引流术仍是SPBD重要的治疗手段。     

老年人自发性乙状结肠穿孔：附21例报告

目的：探讨老年人自发性乙状结肠穿孔的病因、临床表现及处理原则。方法：回顾性分析2007年11月—2012年10月诊断明确的21例老年人自发性乙状结肠穿孔的临床资料。结果：全组男12例,女9例;平均年龄67（62~73）岁。多数患者以突发性急性腹痛就诊,患者均有不同程度的习惯性便秘史,术前出现感染性休克3例。全组中术前诊断为乙状结肠穿孔仅4例,误诊率为80.95%。21例患者均行Hartmann术,术后仍出现感染性休克3例,经过积极抗休克及抗感染治疗后好转;术后发生切口感染8例,肺部感染6例,经抗感染对症治疗治愈;并发多器官功能障碍综合征（MODS）3例,经过积极抢救及相应处理后治愈1例,死亡2例均为紧贴后腹膜乙状结肠后壁穿孔。19例治愈出院且于术后3~6个月行乙状结肠造瘘口还纳术。结论：老年人自发性乙状结肠穿孔缺乏特异性的临床表现,行腹腔穿刺及腹部X线、肛肠指诊对诊断有所帮助。早诊断、早期积极抗休克、抗感染、维持水电解质及酸碱平衡、尽早手术及行对症处理,预防并发症是保证患者康复的关键。

     

胆总管囊肿自发性破裂

日本Nagoya大学医院外科在过去24年中共收治123例胆总管囊肿,其中5例(4.1%)发生自发性穿孔,病因不清,可能与胆道内蛋白塞子和胰胆管连接异常有关.该5例的年龄为9月～8岁,均有腹胀、疼痛、恶心和呕吐症状,4例有发热,2例有黄疸,均未能扪及胆总管囊肿的块物.术前化验检查示血清胆红素值增高5例、血清淀粉酶增高1例、GOT增高3例和GPT增高1例.术前确诊3例,依据腹腔穿刺所得的胆汁和超声扫描提示胆总管扩张的结果.均行急症剖腹探查,见穿孔均在胆总管与胆囊管交接处的前方,穿孔自针尖至6mm直径不等,在穿孔处置入T管,并作腹腔引流.胆总管均呈梭形,伴胆胰管连接异常.术后恢复顺利.第一次术后1～4月再施行根治术,切除扩张的胆总管以及胰内狭窄的胆管远端,作空肠肝管Roux-Y型吻合,术后良好.组织学检查示胆总管穿孔壁增厚,复盖有肉芽组织,后者的范围局限,穿孔处以外的胆管粘膜完整良好,近穿孔处的纤维肌层含有大而活跃核的成纤维细胞,血管丰富.讨论 1932年Dijkstra报道首例胆管自发性穿孔,此后陆续有病案报道.病理机制不明,推测可能与胆管壁先天性薄弱、胆管壁存有憩室或异常腺体,胆管内反流的胰液刺激其粘膜以及胆管病毒感染有关.胆管自发性穿孔与穿孔性胆总管囊肿是不同的疾     

胆总管囊肿穿孔的手术治疗

目的 探讨先天性胆总管囊肿穿孔的诊断及治疗方法。方法 对10例胆总管囊肿穿孔的临床资料进行回顾性分析。结果 男6例,女4例。平均年龄4．5岁。病程＜12h者4例,12－72h者3例,＞72h者3例。2例穿孔前合并感染,8例穿孔前无明显不适。7例行一期囊肿切除、胆道重建术,5例术后恢复顺利,2例发生吻合口漏,其中1例穿孔前合并感染,1例病程＞72h;3例先行外引流,3个月后行囊肿切除、胆道重建术。结论 胆总管囊肿穿孔如为早期且治疗及时,可一期行囊肿切除、胆道重建术。     

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印度医生Ｋｕｍａｒ(Ｓｕｒｇｅｒｙ ,1998,12 4:92 4)曾发表了一篇题目为“胆总管自发性穿孔”的个案报道 ,文章说 :非医源性成人胆总管穿孔 ,就他自己所知 ,尚未见报道。Ｓｕｒｇｅｒｙ 1999年第 7期同时刊登了 2篇来信 ,香港Ｎｇ博士总结了从 195 1～ 1996年 18篇关于胆总管自发穿孔的论文 ,其中绝大多数发表在世界著名的外科学杂志上 ,累计病例 3 8例。而ＮｅｗＹｏｒｋＭｅｔｈｏｄｉｓｔＨｏｓｐｉｔａｌ的Ｐａｌａｄｕｇｕ博士在来信中指出 :通过复习文献 ,我们收集了远较胆总管自发穿孔罕见的成人肝总管穿孔 2 7例 ,迄今为止 ,文献…     

自发性系膜缘结肠穿孔7例临床诊治分析

目的探讨自发性系膜缘结肠穿孔的临床特点、诊治方法及转归。方法对我科1998年8月至2012年2月收治的自发性系膜缘结肠穿孔的相关资料进行回顾性分析。结果 4例初诊"机械性肠梗阻"予对症保守治疗24～48h无好转而行剖腹探查,3例因有先前经验或腹部CT提示而直接行剖腹探查,证实系膜缘结肠穿孔。结论自发性系膜缘结肠穿孔临床少见,容易误诊漏诊,CT能提高诊断率,剖腹手术能确诊并能治愈。     

股骨颈骨折后股骨头ECT血流动态观察

股骨颈骨折后，常发生股骨头缺血坏死，原因是由于股骨颈部动脉损伤还是静脉郁血仍不清楚，本文对２７例不同时间的头下型股骨颈骨折进行ＥＣＴ血流动态观察，认为股骨头坏死，主要是由于静脉瘀血所致。     

NEUROMUSCULAR EFFECTS OF I.A. INFUSION OF LIGNOCAINE IN MAN

Neuromuscular effects of lignocaine during and after i.a. infusionwere studied in healthy adult patients, using evoked electromyography.Supramaximal, paired stimuli were applied to the ulnar nervewith variable intervals between the two stimuli. The amplitudeof the hypothenar muscle action potential to the second componentof the paired stimulus (test response) was compared with thatevoked by the first component (conditioning response). Duringand after i.a. infusion of lignocaine, there were marked decreasesof the test response at intervals from 7 to 100 ms after theconditioning stimulus, although the decreases of the conditioningresponse were slight or negligible. The finding of decreasedtest responses coincided with the results obtained with tetanicstimulation such as pronounced fade and only slight post-tetanicpotentiation. Differences between these findings and those foundwith muscle relaxants were compared, and it was concluded thatthe mechanism responsible for these results might be attributedto an effect of lignocaine on the motor nerve terminal.     

A TECHNIQUE FOR THE LABORATORY EVALUATION OF THE SPEED OF ONSET OF I.V. ANAESTHESIA

A method is described for the evaluation of the speed of onsetof i.v. anaesthesia in mice. The technique involves (a) determinationof the median hypnotic dose (HD50) by plotting the probit valueof the percentage of mice sleeping, against dose on a logarithmicscale, (b) plotting mean induction time over a range of dosesagainst the logarithm of the dose and (c) comparison of inductiontimes at 1.25 HD50. All doses were given over 1 s or 10 s. A1–s injection was thought to be of most value in the evaluationof structure activity effects whereas the 10–s injectionproduced results similar to those which have been reported inman. With this technique, and using 1–s injection times,induction times were found to be similar with thiopentone andAlthesin. Those following methohexitone, etomidate and propanididwere marginally longer whereas ketamine and pentobarbitone wereobviously slower in onset.     

PHARMACOKINETICS OF I.M. GLYCOPYRRONIUM

A sensitive radioreceptor assay was used to determine the pharmacokineticsof glyco-pyrronium following a single i.m. injection of 8 ugkg^–1 in nine surgical patients. Rapid absorption was found,with a mean peak plasma concentration after 16.1 min and meanelimination half-life of 75.4 min. Almost half (49.3%) of thedrug was excreted in pharmacologically active form in the urinewithin 3 h. A significant increase in heart rate (P < 0.05)occurred in 15 min, lasting up to 60 min, and an antisialagogueeffect in 10 min, lasting up to 8 h (P < 0.05). There wasno measurable glycopyrronium in lumbar cerebrospinal fluid samples(n = 9) taken 40 min after administration of drug.     

DOUBLE-BLIND COMPARISON OF THE MORPHINE SPARING EFFECT OF CONTINUOUS AND INTERMITTENT I.M. ADMINISTRATION OF KETOROLAC

The morphine sparing effect of ketorolac 10 mg administered4-hourly by intermittent i.m. injection was compared with acontinuous i.m. infusion in a double-blind, placebo-controlledtrial in patients undergoing upper abdominal surgery. Duringthe 48-h postoperative period, each patient was provided witha patientcontrolled analgesia (PCA) system which delivered bolusdoses of morphine and administered the intermittent i.m. dosesautomatically via a computer controlled pump. In the first 24h after surgery, there was a significant reduction in morphinedemanded by both groups receiving ketorolac compared with placebo.Patients who received a continuous infusion of ketorolac afterabdominal surgery required a median dose of morphine by PCAwhich was 49% less than controls. In the second 24 h and overthe entire 48 h of the study, patients in the continuous grouprequired significantly less morphine than those in the placebogroup. The intermittent group used less than the placebo group,but this was not significant.     

EFFECT OF PREOPERATIVE I. M. ADMINISTRATION OF DICLOFENAC ON SUXAMETHONIUM-INDUCED MYALGIA

We have studied the effects of preoperative administration ofdiclofenac on suxamethonium-induced myalgia, plasma met-enkephalin-likeactivity (ELA), prostaglandin E₂-like activity (PGE₂-LA), leukotrieneC₄-like activity (LTC₄-LA), and histamine-like activity (H-LA).Thirty-four ASA I patients undergoing elective ophthalmic surgerywere allocated randomly to two groups to receive either salineplacebo or diclofenac 75 mg i.m. 20 min before operation, ina double-blind design. Anaesthesia was induced with thiopentone5–7 mg kg^–1 followed by suxamethonium 1.5mg kg^–1and maintained with 67% nitrous oxide and halothane in oxygen.Plasma PGE₂-LA, LTC₄-LA, H-LA and E-LA were measured beforepremedication, 1 min after the administration of suxamethoniumand 24 h after operation. Muscle fasciculations, intubationconditions and postoperative myalgia were graded numerically.Postoperative myalgia in the diclofenac group was significantly(P<0.05) less (47.1 %) than in the control group (76.5%).Postsuxamethonium and 24-h concentrations of plasma PGE₂-LAand LTC₄ were also significantly (P<0.05) greater than baselinein the control group. Plasma H-LA was increased in both groupsafter suxamethonium and this increase was significant (P<0.05)in the control group. We conclude that diclofenac reduces significantlythe incidence and intensity of suxamethonium-induced myalgia.     

WORK LOADS OF A SAMPLE OF GENERAL SURGEONS IN N.S.W

The work loads of 34 general surgeons in New South Wales during a six week period in 1977 have been determined. Data was obtained on the number of elective, emergency and supervised procedures, and of elective and emergency first consultations. The operative work loads were assessed by a simple grading system, and also by the “hernia-equivalent” method which relates the work involved in a given operation to that for an adult unilateral inguinal herniorrhaphy. The latter is arbitrarily given a score of one. The hernia-equivalent scores for academics, country and city surgeons were similar. The mean hernia-equivalent rating for the 2,321 operations assessed was 1.1; thus, the “typical” operation was equivalent to a herniorrhaphy. The mean number of operations per week was 11.4, or 12.6 hernia- equivalents. Assuming a 48-week working year, these figures represent an annual work load of 547 operations, or 605 hernia-equivalents. Comparison of these results with those obtained in the U.S.A. (the “SOSSUS” report) indicates that these work loads are almost three times those found for board-certified general surgeons in the U.S.A.     

COMPARISON OF THE EFFICAY OF CHLORMETHIAZOLE AND DIAZEPAM AS I.V.SEDATIVES FOR SUPPLEMENTATION OF EXTRADURAL ANAESTHESIA

The clinical efficacy of two sedative agents was compared in21 young healthy patients undergoing surgery under extraduralblockade. A state of sedation and amnesia in which patientslapsed into a sleep-like state when left undisturbed, yet spontaneouslyopened their eyes to make comments and co-operate with verbalcommands, was sought. This was achieved readily by careful titrationof responses and required a diazepam loading dose of 20 (±15) mg given at a rate of 1 mg min^-1 or 0.8% chlormethiazoleedisylate infusion 10 ml min^-1 given over 16 (±6) min.Control of this state was easier with chlormethiazole (by varyingthe rate of infusion) than by giving repeated doses of diazepam.Both agents provided good anterograde amnesia; there was noretrograde amnesia. Considerable postoperative somnolence witha high incidence of relapse into amnesic and sedated stateswere noted with both agents. However, if the total volume ofchlormethiazole infused was less than 300 ml, then ±adistinct advantage of abrupt and lucid recovery was apparent.Blood concentrations producing the desired clinical state weremore variable for diazepam than for chlormethiazole.