胰腺外伤40例的个体化诊治

目的探讨胰腺外伤的个体化处理措施。方法回顾性分析我院近10年来收治的40例胰腺外伤患者的资料。结果40例患者中12例行保守治疗,28例行手术治疗。其中行单纯手术引流6例,清创修补引流术11例,B超引导经皮穿刺置管引流3例,行胰尾或胰体尾切除术4例,右半肝＋远端胰腺＋脾切除1例,远端胰腺胃吻合＋空肠造瘘1例,胰十二指肠切除1例,肝、胆总管、十二指肠、胰修补＋胃及空肠造瘘1例。治愈38例,死亡2例,发生胰瘘4例,十二指肠漏1例。结论根据胰腺外伤的位置和程度,选择个体化的治疗方法是提高胰腺外伤治愈率的关键。B超引导下穿刺置管引流及胰胃吻合等方法提供了一种新的治疗思路。     

经皮胃镜胃造瘘空肠置管术在重型颅脑损伤昏迷患者中的应用研究

目的探讨经皮胃镜胃造瘘空肠置管术在重型颅脑损伤昏迷患者中的应用。方法选取本院于2015年7月至2017年6月间收治重型颅脑外伤昏迷患者60例,随机分为经鼻空肠置管术组、经皮胃造瘘空肠置管术组,比较两组病人在肺部感染、消化道出血、低蛋白血症、1个月后营养指数。结果经皮胃造瘘空肠置管术组患者在肺部感染、消化道出血、低蛋白血症发生率明显低于经鼻空肠置管术组(P0.05)。结论胃造瘘空肠置管术组应用于重型颅脑损伤昏迷患者中可降低肺部感染、消化道出血、低蛋白血症发生率,改善患者营养状态。     

自制二用管在胰十二指肠切除术后患者早期治疗中的应用

目的总结分析自制胃造瘘、空肠营养管（简称“二用管”）在胰十二指肠切除术后患者早期治疗中的应用,改善患者营养状况,降低医疗费用。方法总结2006年7月～2009年2月实施的10例胰十二指肠切除术临床资料,术中采用自制“二用管”行胃造瘘、空肠内置营养管,术后24h开始由导管输注回收胆汁及营养液,观察患者恢复情况及并发症发生率。结果9例术后吻合口愈合良好,未出现胰瘘、胆瘘、肠瘘等并发症,肠道功能均在3～5天内恢复。1例出现胰瘘,考虑胰腺钩突残余胰腺断面胰瘘所致,术后20余天胰瘘愈合;1例拔除“二用管”后该处瘘管6个月后愈合。所有患者术后精神营养均恢复良好。结论应用自制胃造瘘、空肠营养管（简称“二用管”）在胰十二指肠切除术后患者行早期肠内营养,可以改善患者营养、预防呼吸道并发症,减轻患者的经济负担。     

胰腺外伤的处理经验——附45例报告

【摘要】 目的 探讨胰腺损伤的处理经验。方法 回顾性分析我院及佛山市第一人民医院近10年来收治的45例胰腺外伤患者的临床资料,其中对12例Ⅰ级损伤患者行保守治疗,4例Ⅰ级损伤患者行介入超声治疗;另外29例患者则选择外科手术治疗,其中行单纯手术引流6例,清创修补引流11例,胰尾或胰体尾切除术4例,右半肝联合远端胰腺加脾切除1例,近端胰腺关闭、远端胰腺行胰胃吻合2例,胰十二指肠切除4例,肝、胆总管、十二指肠、胰修补加胃及空肠造瘘1例。结果 全组治愈43例,2例死与多脏器功能衰竭,胰瘘4例,12指肠瘘1例,均经保守治疗后痊愈。结论 根据胰腺外伤的不同位置和程度,选择合适的处理方法有利于提高胰腺外伤的治愈率,减少并发症的发生率。     

单纯及复合型胰腺外伤的诊断与个体化手术体会

目的:探讨单纯及复合型胰腺外伤的诊断及个体化手术治疗方法;方法:回顾分析大庆油田总医院2005年1月至2011年12月急诊收治的42例胰腺外伤患者的临床资料;结果:术前确诊22例,其余均经术中探查确诊,治疗均采用手术治疗,Ⅰ、Ⅱ级胰腺损伤18例,其中单纯行胰周引流3例,清除胰周坏死组织、缝合止血、外引流1 3例,腹腔镜下胰周引流2例;Ⅲ级胰腺损伤15例,其中胰腺远端、脾联合切除,胰腺近端结节缝合9例,胰腺远端与空肠吻合术近端结节或褥氏缝合缝合4例,胰腺遗端胃吻合加空肠造瘘术2例,Ⅳ级胰腺损伤7例,给予行胰头坏死组织彻底清除、近侧断端缝合、远侧断端与空肠吻合、彻底引流,Ⅴ级损伤2例,行胰十二指肠切除术及改良十二指肠憩室化手术;结论:联合应用影像学及生化检查可提高术前胰腺损伤患者的诊断率,术中认真细致探查是防止遗漏胰腺损伤的重要措施,根据患者胰腺损伤级别给予个体化手术方式可提高胰腺损伤的治愈率.     

三孔法完全腹腔镜胃/空肠造瘘术

目的：总结三孔法完全腹腔镜胃/空肠造瘘术的初步经验。方法：回顾分析2007年10月至2009年11月采用三孔法行完全腹腔镜胃/空肠造瘘术放置永久性胃/空肠造瘘管10例的临床资料,其中晚期食管癌1例,晚期贲门癌2例,晚期胃癌7例,均完全或几乎不能经口进食,行三孔法完全腹腔镜胃造瘘术3例,三孔法完全腹腔镜空肠造瘘术7例。结果：本组手术均获成功,无中转开放,手术时间45~110min,平均60min,术中出血5~15ml,平均8.5ml,术后住院5~11d,平均7.2d。术后均无并发症发生,造瘘管均顺利开放并维持正常肠内营养。结论：三孔法完全腹腔镜胃/空肠造瘘术放置胃/空肠造瘘管具有患者创伤小、康复快、启用造瘘管早等特点,临床效果满意,值得推广。     

Whipple术中应用改良式胃造瘘术的临床研究

目的探讨Whipple术中应用改良式胃造瘘术的临床意义。方法总结2004年11月至2006年12月收治的36例Whipple术中行改良式胃造瘘术加空肠造瘘术（治疗组）患者的临床资料,并与24例同期Whipple术中行传统胃造瘘术加空肠造瘘术（对照1组）及22例同期行Whipple术加空肠造瘘术（对照2组）的患者进行对照研究。对3组患者的手术时间,术后开始行肠内营养时间,术后留置鼻胃引流管时间以及术后胃瘫、胰瘘、胆瘘、腹腔感染等并发症的发生率进行统计学分析。结果治疗组及对照2组术后胃瘫发生率明显低于对照1组（P〈0．05）;治疗组术后留置鼻胃引流管时间明显短于对照2组（P〈0．01）;3组的手术时间、术后开始行肠内营养时间、胰瘘、胆瘘及腹腔感染发生率的差异无统计学意义（P〉0．05）。结论Whipple术中行改良式胃造瘘术安全、可靠,可以明显缩短术后鼻胃引流管留置时间;与传统胃造瘘方法相比,可明显降低术后胃瘫的发生率。     

胰腺手术后胃瘫13例诊治分析

目的探讨胰腺手术后胃瘫的病因、诊断和治疗。方法回顾性分析我院1986年～2004年571例胰腺手术后发生胃瘫的13例病人的临床资料。结果所有病人均经中西医结合保守疗法治愈。结论胰腺术后胃瘫多发生于病情复杂、手术创伤大、手术时间长的病人。预防胰腺术后胃瘫,需要术前消除病人顾虑、加强营养、控制感染;术中操作要轻柔,手术创面尽量要小。治疗胃瘫,应该是以肠内营养(EN)为主的中西医结合的综合疗法。对那些病情重、体质差、精神紧张,手术时间长、创伤大的病人,术中空肠营养造瘘、术后适时置放鼻肠管是防治胃瘫有效的措施。     

胰腺手术后胃瘫13例诊治分析

目的探讨胰腺手术后胃瘫的病因、诊断和治疗。方法回顾性分析我院1986年～2004年571例胰腺手术后发生胃瘫的13例病人的临床资料。结果所有病人均经中西医结合保守疗法治愈。结论胰腺术后胃瘫多发生于病情复杂、手术创伤大、手术时间长的病人。预防胰腺术后胃瘫，需要术前消除病人顾虑、加强营养、控制感染；术中操作要轻柔，手术创面尽量要小。治疗胃瘫，应该是以肠内营养(EN)为主的中西医结合的综合疗法。对那些病情重、体质差、精神紧张，手术时间长、创伤大的病人，术中空肠营养造瘘、术后适时置放鼻肠管是防治胃瘫有效的措施。     

空肠双腔造瘘治疗食管癌术后难治性胃瘫8例

胃瘫是食管癌切除术后一种少见并发症.2002年2月至2006年8月,我们手术治疗食管癌2460例,术后并发胃瘫17例,对其中保守治疗超过15 d、胃排空功能未恢复、并且胃镜下未能成功置入十二指肠营养管的8例胃瘫病人,进行剖腹探查空肠双腔造瘘,治疗效果满意,现总结如下.     

胆总管下端术后十二指肠瘘19例治疗分析

目的：了解胆总管下端手术后十二指肠瘘发生的原因及处理。方法：回顾性分析1975－2002年收治的19例胆总管下端手术后十二指肠瘘发生的原因，诊断和治疗。十二指肠瘘经确诊后均经手术治疗。治疗方式：脓肿引流13例，十二指肠修补5例，胃大部切除幽门旷置胃空肠吻合，空肠造口1例。结果：十二指肠瘘治愈15例，死亡4例，死亡原因：消化道大出血2例，腹膜后严重感染1例，并发重症胰腺炎1例。结论：行胆总管下端探查操作时应谨慎，避免发生医源性损伤。十二指肠后早期诊断尤为重要，十二指肠瘘手术以引流为主，并予以充分的肠内营养支持。     

经皮内镜空肠造瘘术置管行早期肠内营养对重症急性胰腺炎的疗效

目的探讨经皮内镜空肠造瘘(PEG/J)术置管行早期肠内营养(EN)对重症急性胰腺炎(SAP)的治疗效果。方法回顾性分析了90例SAP患者的治疗情况,其中45例行PEG/J术置管早期肠内营养治疗(PEG/J组),45例行常规治疗(对照组)。90例患者于入院后1、12和18 d分别采集空腹外周静脉血,用酶联免疫吸附法测定白细胞介素-6(IL-6)及肿瘤坏死因子-α(TNF-α);三肽偶氮显色法测定内毒素含量,异硫氰酸荧光素(FITC)标记间接免疫荧光染色法测定CD4/CD8。结果入院后12和18 d PEG/J组患者血浆中IL-6、TNF-α及内毒素含量显著低于对照组(P<0.01),而CD4/CD8比值高于对照组(P<0.01),入院1 d PEG/J组IL-6、TNF-α、内毒素及CD4/CD8比值与对照组比较差异均无统计学意义(P>0.05)。对照组平均13.5 d体温恢复正常;并发上消化道出血2例,假性囊肿形成4例,二重感染2例;平均住院时间为33.5 d。PEG/J组平均10.5 d体温恢复正常;无并发上消化道出血及二重感染的病例,并发假性囊肿形成2例;平均住院时间为28 d。结论 PEG/J术置管行早期EN治疗SAP,疗效满意。     

Surgical intervention in acute necrotizing pancreatitis

Thirty-eight patients with acute pancreatitis were treated with an operation that included cholecystostomy, gastrostomy, feeding jejunostomy, and sump drainage of the peripancreatic lesser sac. Of eleven patients judged to be dying of fulminant pancreatitis in the first forty-eight hours of treatment, nine improved immediately and seven survived. Of eighteen patients who underwent operation because of persistent or increased signs of inflammation two weeks after admission, seven had an immediate favorable response, mainly due to drainage of abscesses, necrotic pancreas, or pseudocysts, and twelve survived. Nine patients with pancreatitis of lesser severity received no apparent benefit from the operation.Gastrostomy and jejunostomy were used for prolonged treatment of intestinal dysfunction in nine patients. In six patients the cholecystostomy helped to control bacterial cholangitis. In seven patients the peripancreatic sumps provided tracts for the late drainage of abscesses, pancreatic fistulas, and sloughed pancreas.The major problem after surgery was the development of intra-abdominal abscesses in sixteen patients. Of the thirteen deaths, ten were directly related to these abscesses. An aggressive approach to re-exploration and drainage of late pancreatic abscesses in patients with necrotizing pancreatitis should improve still further the survival rate of patients.The survival of patients with severe pancreatitis resistant to standard medical measures appears to be improved by this operative approach.     

Surgical treatment and outcome after delayed diagnosis of blunt duodenal injury.

OBJECTIVE: To review our experience of 18 patients with duodenal injuries after blunt trauma, the diagnosis of which had been delayed for more than 24 hours. DESIGN: Retrospective study. SETTING: Teaching hospital, Taiwan, R.O.C. SUBJECTS: 18 patients who presented with duodenal injuries between January 1986 and December 1995. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The reasons for the delay were: injuries not found during the first operation (n = 6), patients had not sought medical help (n = 6), and injuries treated conservatively at local hospitals (n = 5). There was one delay in our department because the patient lost consciousness. 12 patients were treated by pyloric exclusion with no deaths and four complications (one duodenal fistula and 3 retroperitoneal abscesses). The other 6 had various operations including pancreaticoduodenectomy, jejunostomy, and gastrostomy, with six complications and one death, giving an overall mortality of 6% and morbidity of 50%. Three patients developed delayed extensive retroperitoneal abscesses and all three were treated successfully by laparostomy. 16 of the 18 patients required enteral feeding through a jejunostomy. CONCLUSIONS: Though the complication rate was high, the use of pyloric exclusion and a feeding jejunostomy kept the mortality low. Enteral nutrition should be started early. Laparostomy is a good way to manage retroperitoneal abscesses. To avoid delay, patients at risk of duodenal injuries should be evaluated early by experienced trauma surgeons and any central retroperitoneal haematoma should be explored during the initial laparotomy.     

Changing trends in the management of pancreatic trauma

Forty-four patients were operated on for pancreatic trauma during the past three years. Twenty-one patients (48%) were treated by drainage alone, nine (21%) by distal resection, eight (19%) by duodenal diversion, and one (2%) by pancreatoduodenectomy. Active sump drainage was used in 27 patients (71%) and early enteral feeding by needle catheter jejunostomy in 24 (63%) postoperatively. Of the 38 patients who survived the initial operation, two (5%) died postoperatively. Pancreas-related complications occurred in 13 patients (34%). Comparison with earlier findings from our institution reveals (1) more frequent use of active sump drainage, (2) continued use of distal resection for suspected ductal injuries of the body or tail, (3) earlier postoperative nutrition by needle catheter jejunostomy, and (4) increased use of duodenal diversion for concurrent pancreatic and duodenal trauma.     

Percutaneous approaches to enteral alimentation

Feeding gastrostomy and jejunostomy provide effective access for long-term enteral nutrition. Traditional operative techniques for the performance of these procedures requires laparotomy and often, general anesthesia. This report describes our experience with two relatively new methods, percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy. Results of percutaneous gastrostomy and jejunostomy to date in 323 cases include a morbidity of 5.9 percent and a 0.3 percent operative mortality. Percutaneous endoscopic gastrostomy and jejunostomy should become the procedures of choice for the establishment of enteral access in patients requiring long-term enteral alimentation.     

Esophagocutaneous drainage to treat late and complicated esophageal perforation.

Five patients with complicated esophageal perforation--three with spontaneous rupture, one with dehiscence after resection of a diverticulum, and one with an iatrogenic lesion--were successfully treated by esophagocutaneous drainage of the esophageal perforation. At thoracotomy, after careful debridement and cleaning of the mediastinum and pleura, a T-tube drain was placed in the esophagus through the perforation in addition to pleural drains. A feeding jejunostomy and a gastrostomy was carried out via a separate laparatomy in 4 cases. Postoperatively the patients were managed according to a protocol with subsequent removal of pleural drains, esophageal T-tube and, after esophageal healing, gastrostomy and feeding jejunostomy. Broad-spectrum antibiotics were given initially. Healing was slow but progressive and without major problems. The healing process was followed by repeated contrast swallows. In all cases the esophagus healed without residual stenosis within 8-12 weeks. This method seems to be a way to save the life and the esophagus of patients with esophageal perforations complicated by late discovery or failure of primary repair.     

Trauma care construction under the guidance of county-level trauma centers

Severe trauma has the characteristics of complicated condition, multiple organs involved, limited auxiliary examinations, and difficulty in treatment. Most of the trauma patients were sent to primary hospitals to receive treatments. But the traditional mode of separate discipline management can easily lead to delayed treatment, missed or wrong diagnosis and high disability, which causes a high mortality in severe trauma patients. Therefore, if the primary hospitals, especially county-level hospitals (usually the top general hospital within the administrative region of a county), can establish a scientific and comprehensive trauma care system, the success rate of trauma rescue in this region can be greatly improved. On March 1st, 2013, Tiantai People's Hospital of Zhejiang Province, China set up a trauma care center, which integrated the pre-hospital and in-hospital trauma treatment procedures, and has achieved good economic and social benefits. Till March 1st, 2017, 1265 severe trauma patients (injury severity score >16) have been treated in this trauma center. The rescue success rate reached 95% and the delayed and/or missed diagnosis rate was less than 5%. Totally 86 severe cases of pelvic fractures with unstable hemodynamics were treated, and the success rate was 92%. The in-hospital emergency rescue response time is less than 3 min, and the time from definite diagnosis to surgery is within 35 min.