胰十二指肠切除术后围手术期死亡原因分析

目的分析胰十二指肠切除术后围手术期死亡的常见原因和探讨降低其死亡率的防治措施.方法回顾性分析我院1961年6月至2002年6月胰十二指肠切除术后死亡病例资料.结果共有307例患者施行了胰十二指肠切除术,术后有21例患者死亡,死亡率为6.8%.以1986年为界将行胰十二指肠切除术患者分为2个阶段,手术死亡率第1阶段为14.7%(11/75),第2阶段为4.3%(10/232)(P<0.01).死亡原因为消化道出血 (5例)、腹腔内出血(5例)、胰瘘(4例)、多器官功能衰竭 (3例),ARDS(2例),腹腔感染(1例)及胆瘘 (1例).结论胰十二指肠切除术后围手术期死亡的主要原因是消化道或腹腔内出血、胰瘘、多器官功能衰竭等.加强围手术期处理,术前进行重要脏器功能的合理评估,配备具有丰富经验的专科医生和完善外科操作技术,提高严重并发症的处理水平,可显著降低胰十二指肠切除术的围手术期死亡率.     

胰十二指肠切除术后胰肠吻合口瘘临床分析

目的：回顾分析胰十二指肠切除术后发生胰肠吻合口瘘病例以减少手术并发症。方法：对1986年1月－2001年6月62例胰十二指肠切除术病例资料行回顾性分析。结果：62例中，发生胰肠吻合口瘘9例，发生率14．5％，其中1986年1月－1991年12月发生胰肠吻合口瘘5例，发生率62．5％（5／8）；1992年1月－2001年6月发生胰肠吻合口瘘4例，发生率7．4％（4／54）。围手术期死亡2例，死亡率3．2％，占胰瘘的22．2％。死因为胰瘘致全身衰竭。结论：要降低胰肠吻合口瘘的发生率，重点在于手术技巧及方式的改进。手术前后的支持治疗、应用生长抑制、控制感染、有效的胃肠减压是必须的。一旦发生胰瘘，若早期诊断，及时采取综合治疗，可以使绝大部分的胰肠吻合口瘘得到治愈。     

胰十二指肠切除术围手术期并发症分析

目的：探讨5年来实施的50例胰十二指肠切除术围手术期并发症。方法：应用胰十二指肠切除术治疗壶腹周围癌患者50例。结果：全组围手术期死亡率0％，并发症发生率26％（13／50），并发症中以切口感染发生率最高10％（5／50），严重并发症为多脏器功能衰竭（MOF），成人呼吸窘迫综合征（ARDS）等。结论：虽然胰十二指肠切除术术后并发症发生率仍然较高，如对解剖结构熟悉，提高手术技巧及熟练程度，应用胰腺导管引流、TPN及重症监护呼吸机等新技术，可减少其严重并发症。     

胰十二指肠切除术并发症的防治

胰十二指肠切除术（ＰＤ）是治疗Ｖａｔｅｒｓ壶腹癌、十二指肠乳头癌、胆总管下端癌及胰头癌的经典术式。ＰＤ切除范围广、创伤大、时间长、出血多,对患者侵袭较大,术后易发生出血、腹腔感染、胆瘘、胰瘘等并发症,其中以出血（腹腔内手术野出血或消化道出血）和胰瘘为多。因此,降低胰十二指肠切除术的并发症对提高疗效十分重要。１腹腔出血 防止腹腔出血包括两方面：①术前纠正凝血功能异常 施行胰十二指肠切除术的患者,术前多有黄疸、肝功能不全、凝血机制不良。因此,术前最好行经十二指肠镜鼻胆管引流或经皮肝穿刺胆管引流（ＰＴＣ…     

胰十二指肠切除术中并发症预防措施的效果评价

目的 评价胰十二指肠切除术（PD）中实施并发症预防措施的临床效果。方法 回顾性分析69例行PD患者的临床资料，根据手术人员是否固定及术中是否采取预防措施分为两组，比较两组的并发症发生率和手术死亡率。结果 手术人员不固定和未实施预防措施组发生胆瘘、出血、多器官功能衰竭等并发症9例，死亡5例；手术人员固定和采取预防措施组发生并发症3例，死亡2例。两组术后并发症发生率差异显著（P〈0．05），手术死亡率差异无显著性（P〉0．05）。结论 PD术中实施并发症预防措施可明显减少PD术后并发症的发生。     

胰十二指肠切除术后胰肠吻合口瘘临床分析

目的回顾分析胰十二指肠切除术后发生胰肠吻合口瘘病例以减少手术并发症.方法对1986年1月～2001年6月62例胰十二指肠切除术病例资料行回顾性分析.结果 62例中,发生胰肠吻合口瘘9例,发生率14.5%,其中1986年1月～1991年12月发生胰肠吻合口瘘5例,发生率62.5%(5/8);1992年1月～2001年6月发生胰肠吻合口瘘4例,发生率7.4%(4/54).围手术期死亡2例,死亡率3.2%,占胰瘘的22.2%.死因为胰瘘致全身衰竭.结论要降低胰肠吻合口瘘的发生率,重点在于手术技巧及方式的改进.手术前后的支持治疗、应用生长抑素、控制感染、有效的胃肠减压是必须的.一旦发生胰瘘,若早期诊断,及时采取综合治疗,可以使绝大部分的胰肠吻合口瘘得到治愈.     

老年消化道疾病患者围手术期死亡病例分析

目的分析老年消化道疾病患者围手术期死亡的主要原因，探讨降低病死率的方法。方法回顾性总结1990至2003年2891例老年消化道患者的临床资料，对其中61例围手术期死亡患者进行分析。用Logisitic回归方法分析患者的血红蛋白、白蛋白、血压、心脏病、糖尿病等与围手术期病死率的关系。结果在2891例中，并存心血管疾病者1338例（46．2％），呼吸系统疾病813例（28．1％），糖尿病449例（15．5％），肾功能不全348例（12．1％），贫血（血红蛋白低于110g／L）796例（26．2％），低蛋白血症（白蛋白低于35g／L）442例（22．2％），围手术期死亡61例（2．1％），死亡的主要原因为心血管系统并发症、呼吸系统并发症和肾功能衰竭等。Logisitic回归分析结果显示：术前心血管疾病、低蛋白血症与围手术期病死率明显相关。结论加强老年消化道患者围手术期的处理对降低病死率有重要意义。     

胰瘘的原因与防治（附24例报告）

胰瘘不是一种独立的疾病，而是胰腺疾病手术或创伤后的并发症，它在胰腺外科病人中的发生率为8％～25％。胰瘘病例虽不多见，但其危害性常很严重，是腹腔脓肿形成、腹腔内大出血等并发症的始动因素，也是胰腺外科病人死亡的主要原因。我们收集了自1990年以来因胰十二指肠切除术(PD)后、胰腺损伤及急性坏死胰腺炎(ANP)病人行手术治疗后发生的胰瘘24例，总结分析胰瘘发生的原因及防治体会，现报告如下。     

老年胰十二指肠切除术36例临床分析

目的探讨老年人胰十二指肠切除术指征,提高手术切除率及减少术后并发症的发生。方法回顾性总结2004～2010年间我院收治的36例≥65岁老年胰十二指肠切除术病例的临床资料,采用闭锁式胰腺套入吻合Child术式进行手术,使用术前＂减黄＂等措施减少手术并发症。结果 36例行胰十二指肠切除术患者中全部为恶性。胰瘘发生率为2.7%,36例患者中35例痊愈,死亡1例（死于肝衰竭）。结论可靠的诊断及合适的探查和适应证的严格把控能提高手术切除率。对老年人而言,完善的围手术期准备和精湛的手术技巧对提高胰十二指肠切除手术安全性、降低并发症尤为重要。     

胰十二指肠切除术并发胰瘘的原因及预防

目的探讨胰十二指肠切除术并发胰瘘的原因及其预防方法。方法回顾性分析25例胰十二指肠切除术患者的临床资料。结果术后并发胰瘘4例（4/25）,其中行胰空肠端侧吻合3例（3/8）,空肠套入捆绑式吻合1例（1/17）。结论胰十二指肠切除术后胰瘘的发生与手术方式相关,捆绑式胰肠吻合发生胰瘘的几率较小。胰管内放置引流管能减少胰瘘的发生。     

血液透析和腹膜透析患者死亡原因分析及比较

目的:分析血液净化患者的死亡原因,并比较血液透析(HD)和腹膜透析(PD)患者的死因差异.方法:纳入2005-01-01至2008-12-31期间新进入透析的患者,随访至2009-03-31.结果:460例透析患者中,247例起始采用HD治疗,213例起始采用PD治疗.HD组男性比例和血肌酐显著较高,而PD组基础疾病为高血压肾病比例显著较高,其余基线资料包括透始年龄、体重指数、透析前已知的肾功能不全病程、首次透析治疗前eGFR、平均动脉压、心脑血管事件、Charlson并发症指数等两组间均无明显统计学差异.共87例死亡患者,其中HD患者40例,PD患者47例.HD总体死亡率低于PD患者(0.102和0.171/患者年,P＜0.01).HD 1年死亡率与PD患者无显著差异(0.133和0.196/患者年,P＞0.05),HD 2年死亡率低于PD患者(0.101和0.170/患者年,P＜0.05),HD 3年死亡率低于PD患者(0.101和0.165/患者年,P＜0.05).透析患者的主要死亡原因为心血管疾病(31.0%)、脑血管疾病(21.8%)、感染(16.1%).PD患者心血管病因死亡率显著高于HD患者(0.064和0.022/患者年,P＜0.01),而两组的脑血管疾病、感染、多脏器衰竭和恶性肿瘤导致的死亡率均无显著差异.年龄＜65岁患者中,HD总体死亡率与PD无显著差异,两组患者的心血管疾病、脑血管疾病、感染、多脏器衰竭和恶性肿瘤死亡率均无显著差异.年龄≥65岁患者中,HD总体死亡率低于PD(0.179和0.378/患者年,P＜0.05),PD患者心血管疾病死亡率高于HD患者(0.164和0.004/患者年,P＜0.05),两组患者的脑血管疾病、感染、多脏器衰竭和恶性肿瘤死亡率均尤显著差异.透析龄≤1年患者中,HD总体死亡率与PD患者无显著差异;PD患者多脏器衰竭导致的死亡率显著高于HD患者(0.082和0.000/患者年,P＜0.05),而两组的心血管疾病、脑血管疾病、感染和恶性肿瘤导致的死亡率均无显著差异.透析龄＞1年患者中,HD总体死亡率与PD患者无显著差异;PD患者心血管病因死亡率高于HD患者(0.026和0.006/患者年,P＜0.05),感染导致的死亡率显著高于HD患者(0.013和0.000/患者年,P＜0.05),两组的脑血管疾病、多脏器衰竭、恶性肿瘤导致的死亡率均无显著差异.结论:透析患者最主要的死因为心、脑血管疾病和感染.HD总体死亡率可能低于PD,尤其是心血管疾病和感染导致的死亡率.应该强调透析患者的心脑血管并发症和感染的防治,以提高透析质量,改善长期预后.     

单中心九年冠状动脉介入治疗围术期患者死亡原因的探讨

目的探讨PCI围术期患者死亡的原因。方法选择2002年1月～2010年12月行PCI患者5225例,记录围术期死亡患者的基线临床资料、冠状动脉病变特点、死亡时间及死亡原因。结果围术期患者共死亡54例,病死率1.03%,54例死亡患者中,单支病变13例,双支病变11例,3支病变30例;19例(35.2%)死于术后第1天、20例(37.0%)死于术后2～8d;有18例(33.3%)死于心源性休克、9例(16.7%)死于支架内血栓形成、7例(12.9%)死于严重左心衰竭。结论 PCI围术期死亡发生率低,且多发生在急诊PCI、老年、多支病变患者。引起死亡原因多为心源性休克、支架内血栓形成、严重左心衰竭等。     

Significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy

BACKGROUND/AIMS: The significance of pancreatic exocrine function in the perioperative management of pancreatoduodenectomy (PD) has not been well understood. The aim of this study was to clarify this issue. METHODOLOGY: Clinical records of 60 Japanese patients who underwent PD were reviewed retrospectively. Patients were divided into two groups, normal (n=33) and low (n=27) pancreatic exocrine function, according to the preoperative value of N-benzoyl-L-tyrosyl-p-aminobenzoic acid excretion test (normal value >70%). We compared the perioperative events and nutritional status between the two groups. RESULTS: The preoperative and operative characteristics between the two groups were not significantly different. Postoperative pancreatic juice output from the remnant pancreas during the initial 7 days after PD was greater (1145 +/- 618 vs. 741 +/-612mL, P=0.02), and the prevalence of pancreatic anastomotic leakage was higher (10/23, 30% vs. 1/27, 4%, P=0.008) in the group with normal pancreatic exocrine function than that in the insufficient group. Perioperative body mass index and serum albumin concentration, which reflect the nutritional status of patients, were significantly lower in the group with low pancreatic exocrine function (P=0.007 and 0.04, respectively). CONCLUSIONS: Surgeons should pay more attention to pancreatic anastomotic leakage in patients with normal pancreatic exocrine function after PD. On the other hand, in patients with insufficient exocrine function, perioperative nutritional support should be considered.     

Clinical outcome of diabetic peritoneal dialysis patients and evaluation of factors affecting mortality: a single centre's experience from Turkey

The purpose of this study is to analyse the outcome of the diabetic peritoneal dialysis (PD) patients and compare the findings of those remaining on treatment with those who withdrew from treatment. Participants were 61 patients starting PD between 2001 and 2009, data were evaluated retrospectively. PD treatment was withdrawn in 48 patients forming Group 1 = drop-out; 26 F, mean age 59 ± 13 years; 13 patients in Group 2 = treatment; 4 F, mean age 50 ± 10 years, still receiving PD therapy. Demographics, laboratory and blood pressure data were compared in both groups. The causes for withdrawal were: death (54%), transfer to HD (33%), other causes (13%). Most frequent cause of death: cardiac events (57.7%), peritonitis and/or sepsis (38,4%). Transfer to HD - peritonitis (50%), insufficient PD (50%). Most frequent cause of peritonitis was Staph. Aureus in 42 instances in Group 1. We found positive correlation between mortality and age (p:0.008, r:0,345) and negative correlation between mortality and follow-up time, pretreatment albumin, calcium and PTH, systolic and diastolic BP in the last follow-up appointment. Cardiovascular events and peritonitis were the most important causes of withdrawal of patients. The presence of hypo-parathyroidaemia, hypocalcaemia and hypo-albuminaemia were associated with mortality.     

Candidemia in patients with diabetes mellitus: epidemiology and predictors of mortality

Candidemia is the fourth most frequent nosocomial bloodstream infection in the US. The clinical characteristics and outcome of candidemia in adult patients with diabetes mellitus (DM) have not been reported in the literature. The objective of the study was to determine the epidemiology and determinants of mortality in diabetic patients with candidemia. A retrospective cohort study among diabetic patients with candidemia was carried out at 2 medical centers. The primary outcome was death from any cause after the onset of candidemia until discharge from the hospital. A stepwise logistic regression analysis was performed to determine the predictors of mortality. From June 1995 to June 2003, 87 patients with both DM and candidemia were studied. Candida albicans was the most common (48/87, 55%) and Candida glabrata the second most common isolate of candidemia (18/87, 21%). Overall hospital mortality was 39% (34/87). Logistic regression analysis identified 3 independent determinants of death; Apache II score > or =23 (OR 8.3, 95% CI{2.7, 25.4}, p =0.0002), nosocomial candidemia (OR 10.2, 95% CI{1.1, 97.9}, p = 0.04), and mechanical ventilation (OR 3.6, 95% CI{1.1, 11.2}, p = 0.03). The study demonstrates the emergence of non-albicans species of Candida as major causes of candidemia among diabetic patients. The severity of illness reflected by Apache II was the most significant predictor of mortality among diabetic patients with candidemia.     

Liver resection: 10-year experience from a single institution

BACKGROUND: Liver resection constitutes the main treatment of most liver primary neoplasms and selected cases of metastatic tumors. However, this procedure is associated with significant morbidity and mortality rates. AIM: To analyze our experience with liver resections over a period of 10 years to determine the morbidity, mortality and risk factors of hepatectomy. PATIENTS AND METHODS: Retrospective review of medical records of patients who underwent liver resection from January 1994 to March 2003. RESULTS: Eighty-three (41 women and 42 men) patients underwent liver resection during the study period, with a mean age of 52.7 years (range 13-82 years). Metastatic colorectal carcinoma and hepatocellular carcinoma were the main indications for hepatic resection, with 36 and 19 patients, respectively. Extended and major resections were performed in 20.4% and 40.9% of the patients, respectively. Blood transfusion was needed in 38.5% of the operations. Overall morbidity was 44.5%. Life-threatening complications occurred in 22.8% of cases and the most common were pneumonia, hepatic failure, intraabdominal collection and intraabdominal bleeding. Among minor complications (30%), the most common were biliary leakage and pleural effusion. Size of the tumor and blood transfusion were associated with major complications (P = 0.0185 and P = 0.0141, respectively). Operative mortality was 8.4% and risk factors related to mortality were increased age and use of vascular exclusion (P = 0.0395 and P = 0.0404, respectively). Median hospital stay was 6.7 days. CONCLUSION: Liver resections can be performed with low mortality and acceptable morbidity rates. Blood transfusion may be reduced by employing meticulous technique and, whenever indicated, vascular exclusion.     

Causes of late deaths after pediatric cardiac surgery: a population-based study.

OBJECTIVES: We examined the causes and modes of late death after pediatric cardiac surgery. BACKGROUND: The late mortality of patients operated on for congenital heart defect (CHD) is comprehensively unexamined. In this study, the causes of death were examined to obtain further knowledge of the morbidity of the patients. METHODS: We studied all late deaths of patients operated on for CHD in Finland during the years 1953 to 1989. We calculated the survival of patients, identified the causes of deaths from death certificates, and examined the modes of CHD-related deaths. We compared the survival and the causes of non-CHD-related deaths to those of the general population. RESULTS: Of the 6,024 patients who survived their first operation, 592 (9%) died during the 45-year follow-up period. The progress of treatment was seen in the survival of the patients operated on in different decades. The cause of death was confirmed with postmortem examination in 474 (81%) cases. The majority of patients (397, 67%) died owing to the CHD. Furthermore, non-CHD-related mortality was twice as high (risk ratio 1.9, 95% confidence interval 1.5 to 2.4) as expected. The main mode for CHD-related death was heart failure (40%). Other modes included perioperative (26%), sudden (22%), and cardiovascular (12%) deaths. The number of deaths caused by neurological and respiratory diseases was higher and the number of accidental deaths was lower than expected. CONCLUSIONS: The survival of patients was lower than that of the general population (relative 45-year survival 89%). Most patients died owing to CHDs, but non-CHD-related mortality was also high.     

Continuous suture of the pancreatic stump and Braun enteroenterostomy in pancreaticoduodenectomy

AIM:To investigate a new modification of pancreaticoduodenectomy(PD)-a mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy.METHODS:Two hundred and three patients underwent PD from 2009 to 2014 and were classified into two groups:Group A(98 patients),who received PD with a mesh-like running suturing for the pancreatic remnant,and Braun’s enteroenterostomy; and Group B(105 patients),who received standard PD.Demographic data,intraoperative findings,postoperative morbidity and perioperative mortality between the two groups were compared by univariate and multivariate analysis.RESULTS:Demographic characteristics between Group A and Group B were comparable.There were no significant differences between the two groups concerning perioperative mortality,and operative blood loss,as well as the incidence of the postoperative morbidity,including reoperation,bile leakage,intraabdominal fluid collection or infection,and postoperative bleeding.Clinically relevant postoperative pancreatic fistula(POPF) and delayed gastric emptying(DGE) were identified more frequently in Group B than in Group A.Technique A(PD with a mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy) was independently associated with decreased clinicallyrelevant POPF and DGE,with an odds ratio of 0.266(95%CI:0.109-0.654,P =0.004) for clinically relevant POPF and 0.073(95%CI:0.010-0.578,P =0.013) for clinically relevant DGE.CONCLUSION:An additional mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy during PD decreases the incidence of postoperative complications and is beneficial for patients.     

Risk factors of pancreatic leakage after pancreaticoduodenectomy

AIM: To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage. METHODS: Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage. RESULTS: Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) developed postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical significance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy. CONCLUSION: Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.