经腹腔途径腹腔镜前列腺癌根治术并发症的预防及处理

前列腺癌是西方国家发病率最高的肿瘤,也是男性患者致死率第二位的肿瘤.在中国,前列腺癌的发病率和死亡率也逐年上升.腹腔镜前列腺癌根治术已经成为治疗局限性前列腺癌的标准治疗方案之一.该手术的主要并发症包括:血管损伤、直肠损伤、吻合口瘘、吻合口狭窄、性功能障碍等.本文分享我们在经腹腔途径腹腔镜前列腺癌根治术的经验,探讨该术式相关并发症的预防和处理.     

Anterior resection for adenocarcinoma. Lahey Clinic experience from 1963 through 1969.

The results of anterior resection for adenocarcinoma of the rectum and rectosigmoid are reported with respect to survival rates and complications. Anastomotic recurrence is related to low lying, ulcerated, and less well differentiated tumors that have penetrated the bowel wall. The incidence of recurrent disease at the anastomosis increases with decreases in the margin of resection. Distal margins of at least 6 cm offer significant protection from recurrence. This study shows that anastomotic septic and fistulous complications are related to advanced age, diabetes, anemia, atherosclerotic disease, construction of the anastomosis below the peritoneal reflection, perforated bowel, obstructed bowel, and the use of drains. The determination of those factors that correlate with the development of anastomotic complications can be accomplished with pre- and intraoperative examinations. The role of these factors in operative decision-making and patient management is emphasized.     

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目的 探讨内镜治疗在肝移植术后胆道并发症中的地位和作用。方法 对1993年4月至2002年12月实施的210例肝移植病人临床资料进行回顾性分析。结果 共确诊29例肝移植术后胆道并发症。胆道并发症发生率为13．8％，与胆道并发症相关的病死率为1．4％。内镜治疗占53．3％(24／45)。结论 内镜下逆行胰胆管造影(ERCP)对胆道并发症既能准确诊断，又能提供有效的介入治疗手段。ERCP治疗吻合口漏、吻合口狭窄和胆总管结石的疗效理想，对缺血性胆管病变的诊断作用大于治疗作用。     

Management of biliary tract complications after orthotopic liver transplantation

INTRODUCTION: Despite improved survival, biliary complications remain a significant cause of morbidity following orthotopic liver transplantation. The aim of this study was to review the incidence, treatment and optimum management pathway of biliary complications at the Scottish Liver Transplant Unit. MATERIALS AND METHODS: All patient data were collected prospectively onto a database at the Scottish Liver Transplant Unit with review of hospital records for validation. RESULTS: A total of 379 consecutive orthotopic liver transplants were performed in 333 adult patients between November 1992 and September 2001. Biliary complications occurred in 55 grafts (51 patients) (14.6%) and their incidence decreased with time. Biliary complications occurred in 29 (10.9%) of the 265 choledocho-choledochostomies compared with 14 (25%) of the 56 with T-tubes. Twenty-eight biliary leaks occurred, 22 of which were anastomotic. Seventeen anastomotic leaks were successfully treated non-operatively. Eight patients with biliary leaks subsequently developed an anastomotic stricture. Of the 30 anastomotic strictures, stent insertion was successful in resolving six of 14 (42%) early anastomotic strictures compared with one of 12 (8%) late anastomotic strictures (p = 0.0479). Six (38%) of the 16 early anastomotic strictures required surgery for complete resolution, compared with 12 (86%) of the 14 late anastomotic strictures (p = 0.0106). CONCLUSION: The incidence of biliary complications has decreased with time. The abandonment of choledocho-choledochostomy over a T-tube has been justified. A combination of conservative, endoscopic, and radiological management has been effective in treating biliary leaks and early anastomotic stricture. However endoscopic or radiological stenting was ineffective in the management of late anastomotic strictures, which were best treated by surgical intervention.     

Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Roux-en-Y hepaticojejunostomy biliary reconstruction

BACKGROUND: The aim of this study was to compare the incidence of biliary complications after adult living donor liver transplantation (ALDLT) with Roux-en-Y hepaticojejunostomy (R-Y HJ) or duct-to-duct hepaticocholedochostomy (D-D HC). METHODS: Biliary complications were reviewed in 20 consecutive ALDLT recipients surviving more than 1 month, including 10 patients who underwent R-Y HJ and 10 patients who underwent D-D HC reconstructions. RESULTS: Ten biliary complications were seen in 8 patients (40%) from the study group. Specifically, 1 case of biliary leakage and 1 case of biliary hemorrhage were observed in the R-Y HJ group (20%), and 2 biliary leakages, 4 biliary strictures, and 2 C-tube related biliary leakages were seen in 6 patients from the D-D HC group (60%). Three of the 5 patients (60%) who underwent right lobe graft ALDLTs experienced biliary stricture. All cases of biliary leakage and biliary hemorrhage were stopped spontaneously by continuous drainage. Three patients in the D-D HC group with anastomotic strictures were successfully treated with percutaneous interventions. Only 1 patient with anastomotic stricture in the D-D HC group with left lobe graft required intrahepatic R-Y HJ reanastomosis. Two cases of C-tube related biliary leakages were treated with endoscopic management. CONCLUSIONS: Biliary complications such as anastomotic strictures were common in the D-D HC group rather than in the R-Y HJ group. D-D HC reconstruction should be applied cautiously, especially in the right lobe graft ALDLT cases.     

Papel de la cirugía en el manejo de las complicaciones biliares tras el trasplante hepático

Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years. The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000 LT; and to study the management of patients with anastomotic strictures (AS).ResultsThe incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications.Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs. radiological: 20 (32%); p=0.2 and mortality: surgical: 0% vs. radiological: 8 (11%); p=0.23).Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%).ConclusionsSurgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures.     

Endoscopic management of airway complications after lung transplantation.

Airway complications remain a source of significant morbidity after lung transplantation. The current incidence of such complications is 12% to 15%. The associated mortality is 2% to 3%. Extensive necrosis and anastomotic dehiscence have become rare, but granulation tissue accumulation, stenosis, and bronchomalacia persist. The major factors that increase the risk for such complications are those that aggravate anastomotic ischemia. Because blood flow to the donor main-stem bronchus is derived from collateral circulation from the pulmonary arteries, minimizing pulmonary inflammation, optimizing pulmonary blood flow, and limiting exposure to positive pressure ventilation are important considerations. Attention to organ preservation techniques and perioperative management is critically important. Controversy remains regarding the optimal anastomotic technique, but properly done, end-to-end anastomosis is readily reproducible and is associated with a low incidence of complications. Attempts to restore the bronchial circulation surgically are not associated with significant reductions in airway complications. Similarly, the routine use of vascularized soft tissue reinforcement no longer seems justified. Most complications can be managed readily with a combination of endoscopic techniques, including débridement (with or without laser or cryotherapy), dilation, and stent placement. Resective procedures rarely are indicated, and retransplantation should be reserved for exceptional cases.     

Anastomotic leak after esophagectomy

Anastomotic leaks continue to be a source of considerable morbidity and mortality after esophageal resection. Careful attention to the contributing factors to the development of a leak, particularly conduit ischemia and anastomotic technique, can reduce the incidence of anastomotic complications postoperatively. Selective management of leaks, including non-operative treatment when indicated, will maximize the chance for a successful outcome.     

Complications of endoscopic extraperitoneal radical prostatectomy (EERPE): prevention and management

Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimal invasive surgery as it overcomes the limitations of laparoscopic (transperitoneal) RPE by the strictly extraperitoneal route of access combining the advantages of minimal invasive surgery with the advantages of an extraperitoneal procedure. Endoscopic extraperitoneal radical prostatectomy has many advantages but is not without complications. The aim of this review article is to describe the most common complications of this procedure. Complications associated with endoscopic extraperitoneal radical prostatectomy are: vascular injury—bleeding—haematoma, bowel injury, lymphocele, injury to the bladder—ureter, port site hernia, anastomotic leakage—stricture, obturator nerve injury—paralysis, gas embolism, catheter blockage, and miscellaneous like perineal pain, pubic osteitis, infection- urosepsis. The present review paper focuses on the identification and management of these complications The incidence of most complications directly correlates with the surgeons’ experience, and the various complications are related to technical errors rather than to the technique itself. The laparoscopist performing endoscopic/ laparoscopic radical prostatectomy should be aware of all these complications. He should be able to recognise promptly, treat efficiently, and ideally prevent these complications.     

直肠癌根治术后吻合口出血的原因和处理

近年来,我国直肠癌的发病率逐渐升高,外科手术切除是治愈直肠癌的唯一方法,全直肠系膜切除术是国际上直肠癌手术的“金标准”。在外科治疗直肠癌的过程中,术后并发症是困扰外科医生的难题之一,其中术后吻合口出血是较为严重的并发症,如患者持续出血且临床未观察到或未及时处理,患者可出现失血性休克的表现,严重时甚至危及生命。本文针对直肠癌根治术后吻合口出血的原因进行归纳总结,并讨论了各原因的预防措施和治疗手段。     

直肠癌保肛术后吻合口瘘发生因素分析

目的分析直肠癌保肛术后吻合口瘘的发生因素。方法选择2012年1月至2019年12月在成都市第三人民医院接受保肛术治疗的直肠癌病人1594例进行回顾性分析。收集病人性别、年龄、术式、吻合口瘘发生率等资料,分析术式等不同因素对吻合口瘘发生率的影响。单因素分析行χ^2检验,多因素分析采用二元Logistic回归分析。结果1594例病人中术后出现并发症者372例(23.34%),其中吻合口瘘186例(11.67%),占所有并发症的50.00%。单因素基础上多因素分析结果显示直肠癌保肛术后吻合口瘘的危险因素为:体质量指数(BMI)≥25.0 kg/m2[OR=1.539,95%CI(1.164,2.093)],糖尿病[OR=1.612,95%CI(1.188,2.117)];保护因素为:血清白蛋白≥35.0 g/L[OR=0.672,95%CI(0.283,0.841)],吻合口肛缘距离≥5.0 cm[OR=0.605,95%CI(0.237,0.894)];手术方式非直肠癌术后吻合口瘘独立性影响因素(P>0.05)。结论直肠癌保肛术后吻合口瘘发生率较高,其发生与BMI、糖尿病、血清白蛋白及吻合口肛缘距离有关,临床上可注意对上述因素进行干预以降低吻合口瘘发生率。     

The incidence and management of biliary complications following liver transplantation in children

Biliary complications following liver transplantation are a cause of significant morbidity and mortality. During the period 1988–1993 ten cases of biliary complications occurred after 98 transplantations in 78 children. The complications were four bile leaks, three intrahepatic biliary strictures (one with recurrent cholangitis), two anastomotic biliary strictures (one with recurrent cholangitis) and one recurrent cholangitis. All leaks occurred within 6 weeks of transplantation whereas all strictures and cholangitic episodes occurred after 3 months. Two biliary complications (20%) — one intrahepatic and one anastomotic stricture — developed secondary to hepatic artery thrombosis. The incidence of biliary complications was 13.2% with whole liver grafts as compared to 6.7% with partial liver grafts and it was 4.3% with duct-to-duct anastomosis as compared to 12.0% with Roux-en-Y hepatico-jejunostomy. Seven children required intervention for management of biliary complications and three were managed conservatively. There were no deaths related to the biliary complications.     

降低直肠癌根治术后吻合口漏发生率对策

吻合口漏是直肠癌术后与吻合口相关的常见并发症之一。随着手术技术和质控要求的提高,手术器械和设备不断发展,使得直肠癌手术越来越微创、精细和精准,低位直肠癌病人保肛率得以提高,但吻合口漏的发生率却并没有显著下降。究其原因,可能是由于吻合口漏的危险因素众多有关,单独去强调预防某一个或某一些危险因素并不能很好的改善和降低吻合口漏发生率。因此,全面的掌握与吻合口漏相关的术前、术中、术后的危险因素,针对性的对每位病人的危险因素采取个体化的预防策略至关重要。术前积极纠正和改善低蛋白血症、贫血、高血糖等一般状况,严格戒烟戒酒,术中规范做好全直肠系膜切除手术操作,根据肿瘤位置、是否做过新辅助治疗等实际情况选择合适的预防性保护措施。术后防止长期低氧血症,纠正早期腹泻,加强监测和观察,争取早诊断早治疗。对直肠癌吻合口漏的预防策略应贯穿围手术期始终,只有综合预防和个体化治疗才能更好的降低吻合后漏的发生率。     

结直肠癌术后吻合口漏预测因素研究进展

吻合口漏是结直肠癌术后严重的并发症之一,危险因素众多且发生隐匿,极大地影响患者术后疗效和生活质量。探寻有效的影响因素以提前预测吻合口漏的发生并给予相应处理对降低其发病率以期改善患者不良预后具有重要临床意义。本文将从围手术期相关因素和生物学标记物两个方面综述结直肠癌术后吻合口漏的危险因素,目的为预测吻合口漏的发生及改善吻合口漏的治疗提供理论依据。     

Anastomosis dehiscence in anterior resection of the rectum with total excision of the mesorectum

Anterior rectal resection with total mesorectal excision is currently regarded as the operation of choice in patients with neoplasms of the extraperitoneal rectum. This operation is associated with a significant incidence of anastomotic dehiscence. Some authors, therefore, advise the execution of a protective stoma. From 1987 to 2000, 241 patients with rectal neoplasma were submitted to radical surgery: 183 to anterior rectal resection (extraperitoneal neoplasms in 129 cases and intraperitoneal neoplasms in 54) and 58 to a Miles operation. The total incidence of anastomotic complications was 8.1% (15 patients). In 12 cases (6.5%) a clinical dehiscence was observed, while in 3 patients (1.6%) an asymptomatic fistula was present. In the patients with symptomatic dehiscence a colostomy was performed in 5 cases (42%), while in 7 cases (58%) a conservative approach was adopted (total parenteral nutrition and antibiotic therapy), with complete healing of the fistula. The incidence of anastomotic complications was 9.3% in extraperitoneal neoplasms and 5.6% in intraperitoneal localizations. In relation to the anastomotic technique adopted, the incidence of dehiscences was 25% after 8 Knight-Griffen anastomoses, 16% after 12 manual anastomoses and 7.3% after 163 end-to-end mechanical anastomoses (P = NS). The percentage of anastomotic complications was greater in the period from 1995 to 1997, compared to the period from 1987 to 1994 (12.6% vs 3.8%, P = NS), due to the routine execution of rectal resection in conjunction with total mesorectal excision, particularly at the beginning of the experience, in 1995. In the last 36 cases from 1998 on the incidence of anastomotic complications was reduced to 8.3%, after the learning phase. No related mortality was observed. On the basis of our experience and the evidence reported in the international literature we do not think the execution of a protective stoma is justified after low and ultra-low colorectal anastomosis, except in selected cases.     

持续低氧血症对食管重建术后吻合口狭窄的影响

目的分析食管重建术后吻合口瘢痕狭窄的相关因素，尤其相关的全身性因素。方法回顾性分析中山大学附属肿瘤医院收治的1111例食管癌切除、消化道重建术患者的病例资料，对可能导致吻合口瘢痕狭窄的全身及局部因素进行logistic单因素、多因素回归分析，并对筛选出的因素进行相关分析。结果单因素回归分析显示：术后持续低氧血症（P=0．003）、胸部并发症（P=0．000）、吻合口瘘（P=0．000）、糖尿病史（P=0．019）、慢性阻塞性肺病病史（P=0．046）和心血管并发症（P=0．015）6项因素有统计学意义；而多因素回归分析则显示仅持续低氧血症（P=0．044）、胸部并发症（P=0．009）、吻合口瘘（P=0．001）和糖尿病史（P=0．036）4项因素有统计学意义：相关分析显示：持续低氧血症与胸部并发症及吻合口瘘三者之间呈正相关。结论持续低氧血症是食管重建术后吻合口瘢痕狭窄的重要全身性因素。     

Late complications after aortic surgery

The incidence of false aneurysms, anastomotic stenoses, and ureteric obstruction is reported to be low in patients who have undergone aortic surgery. The use of intravenous peripheral digital subtraction angiography (IVDSA) with completion excretory urography (CEU) may provide a more sensitive means of long-term detection of these complications. The aim of this study was to (1) establish the incidence of anastomotic aneurysms, anastomotic stenoses, and ureteric obstruction after aortic surgery; (2) identify local and systemic factors that predispose to these complications; and (3) evaluate IVDSA as a single radiologic investigation to diagnose these complications. Forty-four patients who had undergone aortic surgery 1 to 12.3 years previously agreed to undergo IVDSA and CEU. False aneurysms were found at 10 distal anastomoses (none at the aorta), for an anastomotic incidence of 11.2% and a patient incidence of 15.9%. Endarterectomy and the femoral artery as a site of distal anastomosis were important factors in the development of anastomotic aneurysms, as were detected radiologi cally at eight aortic anastomosis (18%). There were no distal anastomotic stenoses. Hyper cholesterolemia was more common in this group (62.5%) than in the overall group (21.2%). Three asymptomatic ureteric obstructions were diagnosed in two patients, both of whom had emergency surgery for ruptured aortic aneurysms. The higher incidence of anastomotic aneurysms, anastomotic stenoses, and asymptomatic ureteric obstruction sound merits careful follow-up. IVDSA with CEU may be a simple and effective method of detection.Presented at the Fourth Biennial Congress of the Vascular Society of Southern Africa, Durban, South Africa, June 26–28, 1991.     

Anastomotic Leaks after Laparoscopic Gastric Bypass

The gastrojejunostomy may be the most technically challenging step when performing laparoscopic Roux-en-Y gastric bypass. Patients who develop anastomotic leaks have increased morbidity and mortality rates. Difficulty in diagnosis is related to nonspecific systemic symptoms and limitations in most radiological studies. Our aim is to evaluate the incidence, etiology, diagnosis, management, and prevention of anastomotic leaks occurring in patients undergoing laparoscopic Roux-en-Y gastric bypass.     

胰十二指肠切除术后并发症

１９８５年１月～１９９５年１２月，我院行胰十二指肠切除术１１５例，术后死亡率７０％（８例）。并发症发病率为３７４％（４３例），包括胃排空延迟１９１％（２２例），胰空肠吻合口漏７８％（９例），腹腔脓肿７０％（８例），胆肠吻合口漏６１％（７例），应激性溃疡８７％（１０例）和腹腔内出血７０％（８例）。并发症与高龄，手术时间长和术中大量出血有关，大多数以非手术治疗而愈。当需再次手术，死亡率增加。术后并发症的处理以简单和保守为原则。     

Hepatic artery reconstruction and biliary stricture formation after living donor adult liver transplantation using the left lobe

Biliary complications, including bile leak, biliary stricture, and cholangitis, are seen in 15% to 29% of all cases after living related liver transplantation. We investigate risk factors and discuss the management of biliary complications after living related liver transplantation in adults using left-lobe grafts. We studied 37 adult patients who underwent living related liver transplantation using left-lobe grafts. Perioperative variables were evaluated as risk factors for biliary strictures. The overall incidence of biliary complications was 43.2% (16 of 37 patients). Anastomotic strictures occurred in 8 patients, whereas bile leaks and cholangitis occurred in 9 and 8 patients, respectively. Anastomotic stricture was strongly related to a partial artery reconstruction (P < .02) and cholangitis (P < .01). Anastomotic biliary stricture was not associated with bile leak, acute cellular rejection, or infection. Our results suggest that an important risk factor for biliary anastomotic biliary strictures is a partial artery reconstruction. To minimize the risk for biliary anastomotic strictures, we will reconstruct both the middle and left hepatic artery. (Liver Transpl 2002;8:495-495.)