胃肠肿瘤病人围手术期应用加速康复外科理念的实践

目的:观察快速康复外科(FTS)治疗在胃肠癌手术病人中的安全性和有效性。方法:30例胃肠癌病人行根治切除手术治疗,围手术期按FTS要求管理,主要措施包括缩短病人术前的禁食时间、术前口服含糖类的液体、术中高位硬膜外加全身麻醉、术后早期肠内营养、加强术后止痛和尽早下床活动等。对照组62例围手术期按传统方法管理。观察比较两组病人手术和术后住院时间、肠道功能恢复时间、并发症发生情况。结果:FTS组与对照组相比,术后住院时间缩短,术后肠排气时间提前,停止静脉输液时间提前,手术后体重下降减少。FTS组病人术后并发症的发生率并未增加。结论:胃肠癌病人围手术期按FTS理念管理,治疗过程安全、有效,可以缩短住院时间,从而加速病人的康复。     

单孔腹腔镜阑尾切除术脐部切口感染的预防策略

目的探讨预防单孔腹腔镜阑尾切除术脐部切口感染的策略。方法通过围术期合理使用抗菌药物、彻底清洁脐部切口、切口保护及改良式缝合、加强术后切口管理等措施,回顾性分析2009年1月-2010年10月,进行单孔腹腔镜阑尾切除的50例患者脐部切口感染的发生率。结果 50例患者中,无1例发生脐部切口感染,1例因缝线反应出现切口红肿,拆除缝线经换药后切口痊愈,术后平均住院时间3d。结论单孔腹腔镜阑尾切除过程中,通过实施各项管理措施,可减少术后脐部切口感染的发生。     

新营养管理模式在胃肠手术快速康复中的应用

目的:应用新的营养管理模式,观察胃肠癌手术病人的恢复情况。方法:将80例胃肠癌病人随机分为传统营养组和新营养管理组。新营养管理组主要采用改变流质膳食的时间和品质。比较两组病人术后的恢复情况。结果:采用新营养管理模式的病人,术后住院天数、首次肛门排气时间、体重下降以及停止静脉输液时间等有显著性差异(P<0.05)。结论:改变营养管理模式有利于加快胃肠手术病人术后的康复。     

经脐单孔腹腔镜阑尾切除术10例

目的探讨经脐单孔腹腔镜阑尾切除术的安全性、可行性及临床应用价值。方法回顾分析10例急性阑尾炎患者施行经脐单孔腹腔镜阑尾切除术的临床资料。结果本组手术时间50~110 min,平均70min。术后24 h恢复流质饮食,术后3~5 d出院,无术后出血、肠漏、切口感染等并发症。术后复查切口瘢痕较隐蔽不易察觉,患者对美容效果满意。结论初步的临床经验表明经脐单孔腹腔镜阑尾切除术安全可行,该技术易学习掌握,不受新器械设备的限制,亦不明显增加费用,具有明显的美容效果。     

自制简易单孔腹腔镜装置经脐胆囊、阑尾联合切除20例

目的 通过自制简易单孔腹腔镜装置,成功进行胆囊、阑尾联合切除.方法 回顾性分析20例采用自制简易单孔腹腔镜装置经脐胆囊、阑尾联合切除患者临床资料.结果 20例手术切口约3 cm,愈合佳,平均手术时间60(45～ 90) rin,术后第1天均下床活动,饮温水,术后第2天恢复半流质低脂饮食,平均住院时间3.5(3～5)d.结论 单孔腹腔镜装置成本小,易制作,适用于胆囊、阑尾疾病手术,该方法切实可行,便于开展.     

经脐单孔法行腹腔镜阑尾切除术和开腹阑尾切除术治疗阑尾炎疗效对比

目的：研究经脐单孔法行腹腔镜阑尾切除术和开腹阑尾切除术治疗阑尾炎疗效的差异。方法：回顾性分析137例阑尾炎患者的临床资料,分析比较此两种手术方式对阑尾炎患者的手术时间、平均住院总时间和平均完全康复时间是否存在差异。结果：经脐单孔法行腹腔镜阑尾切除术患者的手术时间大于开腹阑尾切除术的患者（t=168.58,P〈0.001）,但术后平均住院总时间和平均完全康复时间前者短于后者（t=-50.02,P〈0.001;t=-947.67,P〈0.001）。结论：经脐单孔法行腹腔镜阑尾切除术治疗阑尾炎的临床效果优于开腹阑尾切除术,这有助于提高对经脐单孔法行腹腔镜阑尾切除术和开腹阑尾切除术治疗阑尾炎的认识,指导临床手术治疗。     

胃癌病人围手术期的观察与护理体会

总结胃癌根治术病人的围术期,即术前做好准备、营养支持,术后严密观察病情,做好胃肠减压、胃肠内营养等护理,可提高手术成功率、减少并发症、促进病人康复,病人均病情恢复良好。     

经皮内镜下胃造口在放射性肠炎病人围手术期的应用

目的:报道经皮内镜下胃造口(PEG)在2例放射性肠炎手术病人围手术期的应用经验.方法:2例放射性肠炎病人,术前因肠梗阻需肠外营养支持及长期胃肠减压,手术时切除大段小肠导致术后发生短肠综合征,需长期肠内营养支持.2例病人均行PEG治疗,术前通过PEG进行胃肠减压,术后通过PEG进行长期肠内营养支持.结果:术前通过PEG引流胃肠液500～1 000 ml/d,术后通过PEG输入肠内营养,能量为2 092～5 020.8 kJ/d.结论:PEG在一些特殊病人的围手术期应用,可以同时发挥胃肠减压和长期肠内营养的作用.     

腹腔镜辅助缝合钩针经脐单孔胃十二指肠溃疡穿孔修补术的应用分析

目的探讨应用腹腔镜辅助缝合钩针经脐单孔胃、十二指肠溃疡穿孔修补术的临床价值及疗效。方法选取2012年4月——2013年11月间我院外科收治的40例胃、十二指肠溃疡穿孔患者,随机分为观察组（20例）,和对照组（20例）。对照组给予3孔法腹腔镜胃、十二指肠溃疡穿孔修补术;观察组给予腹腔镜辅助缝合钩针经脐单孔胃、十二指肠溃疡穿孔修补术。比较两组疗效。结果观察组平均手术时间少于对照组（P〈0.01）、术后切口感染率及镇痛剂使用率均少于对照组（P〈0.05）差异具有统计学意义。术中出血量,术后下床活动时间,住院时间以及术后腹腔并发症的发生率两组差异无统计学意义（P〉0.05）。结论腹腔镜辅助缝合钩针经脐单孔胃、十二指肠溃疡穿孔修补术较传统腹腔镜穿孔修补术,具有手术切口美观、手术时间更短、创伤更小、术后疼痛更轻、操作简便易学的特点,值得临床推广。     

经脐单孔法免钛夹腹腔镜阑尾切除术204例分析

目的探讨经脐单孔法免钛夹成人腹腔镜阑尾切除术的优缺点及其临床应用价值。方法回顾性分析204例成人阑尾炎患者施行经脐单孔法腹腔镜免钛夹阑尾切除术的临床资料。结果204例均顺利施行单孔法免钛夹腹腔镜阑尾切除术,手术时间（28±13．5）min,术后24h内均能恢复肠蠕动,无切口感染,无术中并发症。术后住院（2．5±1．5）d。结论经脐单孔法腹腔镜免钛夹阑尾切除术联合了开腹手术和腹腔镜辅助手术的优点,创伤小,成功率高,并发症少,恢复快,是一种安全有效的方法。     

肠康复治疗用于缺血性肠功能障碍

目的:总结肠康复治疗用于急性肠系膜缺血所致肠功能障碍的经验.方法:对2例急性肠系膜缺血病人,在早期治疗中保留生机不确定的肠管,设法尽早恢复肠道血供,术后肠功能障碍给予肠外、肠内营养支持 谷氨酰胺 生长激素 膳食纤维行肠康复治疗.结果:肠康复治疗结束后,肠功能恢复,饮食正常.结论:急性肠系膜缺血所致肠功能障碍应尽早进行肠康复治疗.     

Audit of nutritional guidelines for head and neck cancer patients undergoing radiotherapy

BACKGROUND: Head and neck cancer patients being treated with radiotherapy are at an increased risk of malnutrition due to the severe side-effects, e.g. mucositis, odynophagia and xerostomia, impacting on the ability to eat and drink. Effective dietetic management involves identifying those patients malnourished or at risk of becoming so and incorporating nutritional intervention into their treatment plan. The use of gastrostomy tubes in this patient group has been shown to be acceptable. By placing them prophylactically, the aim is to prevent a disruption to treatment and avoid an unnecessary admission for feeding. This audit was carried out to determine whether the implementation of locally produced nutritional guidelines improved the dietetic management of this patient group. METHOD: A prospective audit tool was used to collect data on 32 head and neck cancer patients undergoing radiotherapy. Data was collected weekly during the course of treatment and compared with data from previous audits. Weight change was the nutritional outcome measured. RESULTS: More patients underwent combined treatment (radiotherapy postoperatively or with concurrent weekly chemotherapy) when compared with previous audits. However, implementation of the guidelines appeared to contribute to an improvement in dietetic management, as fewer patients lost weight over the course of radiotherapy and there were no admissions for feeding. The presence of a dietitian at the multidisciplinary head and neck clinic improved access and communication and this is also likely to have contributed to the improved management. CONCLUSIONS: Implementation of the guidelines led to an improvement in the nutritional management of this patient group. Implementation may be more likely if a dietitian is present at the combined head and neck clinic.     

A Canadian survey of prophylactic antibiotic use among hip-fracture patients.

OBJECTIVE: To study how surgical prophylactic antibiotics (SPAs) were utilized in the perioperative management of surgery for hip fractures. DESIGN: Retrospective chart review of randomly selected medical records. SETTING: Twenty-two hospitals (teaching, nonteaching, community, and large urban referral centers) from across Canada. PATIENTS: Patients admitted in 1990 with a diagnosis of hip fracture. METHODS: Complete medical records of 438 patients were examined; 352 cases who underwent surgical repair of a fractured hip with insertion of prosthetic material were included in analysis. Perioperative SPA use was assessed by abstracting the agent(s) chosen, dosages, time given with respect to the incision, and duration of postoperative use. Fourteen patient and process-of-care variables related to SPA were examined. RESULTS: 247 (70%) of 352 cases did not receive a dose of SPA 2 hours preoperatively. Ten percent of preoperative SPA was administered either too early or during the procedure. In 91 (39%) of 231 cases receiving SPA, the first dose was not administered until the end of the procedure. Preoperative SPA consisted of a parenteral first-generation cephalosporin for 94% of cases. SPAs were continued more than 24 hours postoperatively in 78% of cases. Lack of a written order for SPA, being a nonteaching hospital, and shorter duration of surgical procedure were predictive of failure to receive SPA in an effective manner. CONCLUSIONS: Most hip-fracture-surgery patients did not receive effective antibiotic prophylaxis as required to prevent serious wound infections. This important variable can be included for surveillance, so that corrective measures can be taken to assure effective prophylactic antibiotic administration.     

围手术期营养支持对蛋白质-热能营养不良患者的影响

目的探讨围手术期营养支持对蛋白质-热能营养不良患者的影响。方法选择2009年3月～2010年10月本院外科住院的营养不良病人,分成对照组和营养治疗组,对照组采用自主配餐的形式进行膳食补充,营养治疗组由营养医生制订营养支持方案进行营养支持。结果营养治疗组在患者体重、血红蛋白、术后感染率、住院时间、住院费用等方面比对照组均有明显改善,p<0.05。结论对PEM患者进行围手术期的营养支持可以增加患者的体重和Hb,同时缩短住院时间和住院费用。     

北京地区消化道恶性肿瘤患者术前营养状态及营养支持应用的回顾性分析

目的调查消化道恶性肿瘤患者术前营养状态及营养支持的应用情况.方法采用回顾性研究,调查2009年4月至12月在北京协和医院接受手术治疗的336例消化道恶性肿瘤患者营养状态和营养支持的应用情况.结果 胃癌患者营养不良发生率最高(34.6％),结直肠癌次之(23.8％),食管贲门癌最低(23％).术前营养状态越差的患者,营养支持使用时间越长,摄入能量越高.结论消化道恶性肿瘤患者存在营养状态下降,目前营养支持的使用不甚合理.     

低压辅助悬吊式经脐入路腹腔镜胆囊切除11例报告

目的研究低CO2气腹压辅助腹壁悬吊经脐入路行腹腔镜胆囊切除术可行性和临床安全性。方法辅助6mmHgCO2气腹,腹壁悬吊经脐入路建立操作空间及通道,常规腹腔镜胆囊切除,标本从脐部取出,检查无出血及胆漏,未放置引流管,缝合切口恢复脐部正常形态。结果11例患者中除1例术中钛夹滑脱致胆囊动脉出血,气腹压增大至14mmHg成功止血完成手术外,余10例均顺利完成手术,胆囊切除时间36～48min,平均42min,术中出血10-30ml,平均18ml。术后无出血、胆漏、邻近脏器损伤等并发症发生,未用止痛药物,腹壁无明显手术瘢痕,术后3～5d痊愈出院。结论该项技术安全可行,更具微创美容优势,值得临床进一步探索。     

Prise en charge nutritionnelle préopératoire

Undernutrition is an independent factor of postoperative morbidity and mortality. The aim of a preoperative nutritional support is to enhance immune, muscular and cognitive functions, and to support wound healing. This nutritional support (e.g. dietary management, enteral or parenteral nutrition) should be limited to high-risk situations with a beneficial effect of nutrition for the patient: undernutrition, major surgery and elderly. Preoperative nutritional support should be scheduled for at least 7 to 10 days before the surgery. During the preoperative period, the type and route of an eventual postoperative nutritional assistance should be anticipated. In the case of emergency surgery, nutritional assessment of the patient should be done as soon as possible before surgery or in the 48-h postoperative period. Finally, in elective surgery, preoperative fasting should be limited to 2–3 hours for clear liquids and 6 hours for solids.     

Preliminary results of patient satisfaction with nutrition handouts versus dietetic consultation in oncology outpatients receiving chemotherapy

Aim:  To determine patient satisfaction with nutrition interventions in outpatients receiving chemotherapy identified as at nutritional risk.
Methods:  An observational, cross-sectional study was conducted at an Australian public hospital in 61 oncology outpatients receiving chemotherapy. A simple malnutrition screening tool was used to identify nutritional risk. Patients identified as moderate risk were triaged to receive nutrition handouts on increasing energy and protein intake. Those at high risk received nutrition counselling and support by a dietitian. Patient satisfaction was assessed using a modification of a valid and reliable satisfaction with nutrition services questionnaire.
Results:  Sixty-one patients entered the study and one-third (20/61) were at nutritional risk. Seven patients were at high risk, and received dietetic review while 13 patients were at moderate risk and received nutrition handouts. Patients identified as at nutritional risk (n = 20) were approached to complete the satisfaction with nutrition services questionnaire. Eighteen patients completed the questionnaire (n = 7: dietetic review; and n = 11: nutrition handout). Nutrition information/advice was rated as helpful (n = 15), met patient expectations (n = 16) and overall patient satisfaction was rated highly. Patients who had received a dietitian review recorded a clinically but not statistically higher overall satisfaction with nutrition services than those patients receiving the nutrition handout.
Conclusion:  The high patient satisfaction helps support nutrition intervention at the chemotherapy unit. A prospective trial is required to determine the benefits of this triage and nutrition intervention on nutrition-related outcomes.     

慢性放射性肠损伤病人的围手术期营养支持

目的:探讨慢性放射性肠损伤(CRII)病人围手术期营养支持情况。方法:采用主观全面评价(SGA)系统回顾性总结206例CRII病人围手术期营养支持情况,并对CRII病人的营养状况进行评估。结果:206例CRII病人接受手术229例次,86.16%的病人入院时有营养不良。经围手术期营养支持和手术治疗后,病人的营养状况得到了明显改善,但营养不良发生率仍然较高。结论:CRII病人的营养不良发生率甚高,围手术期营养支持时间较长,围手术期营养支持和手术能明显改善病人的营养状况。     

消化道恶性肿瘤化疗病人营养状况现况调查和影响因素分析

目的:通过调查消化道恶性肿瘤单纯行化疗病人的营养状态及支持的现况,并分析相关影响因素,为后期制定针对性的营养支持护理方案提供理论依据。方法:选取2019年1月~2019年9月上海长海医院757例消化道恶性肿瘤单纯行化疗的病人为调查对象,运用营养风险筛查2002(NRS 2002)评分表和病人主观整体营养状况评估量表(PG-SGA)进行营养不良分级,对相关影响因素进行分析。结果:757例消化道肿瘤病人中存在营养风险的占35.4%,其中可疑营养不良占19.4%,中度营养不良占54.8%,重度营养不良占25.7%。最近2周体质量变化、有无"无食欲"、"呕吐"、"腹泻"、"疼痛"等症状以及年龄≥65岁是消化道肿瘤化疗病人营养不良的主要影响因素。营养支持现状:87.3%的病人接受营养教育,66.4%接受营养支持,营养支持并发症发生率高。结论:单纯化疗的消化道肿瘤病人营养不良发生率高,化疗后胃肠道不良反应的发生以及营养支持并发症的发生是影响营养状况的主要原因,做好症状管理以及规范营养支持是改善该类病人营养状况的主要方向。