腹腔镜与开腹胃癌根治术疗效对比分析

目的探讨腹腔镜与开腹胃癌根治术治疗胃癌的疗效对比分析。 方法回顾性分析2012年3月至2017年3月收治的胃癌患者98例,根据手术方法不同分为开腹组和腹腔镜组,每组49例。数据统计分析采用SPSS19.0进行处理,术中术后指标采用( ±s)进行统计描述,组间比较采用独立t检验;并发症等计数资料采用χ²检验,P<0.05表示差异具有统计学意义。 结果腹腔镜组患者手术切口长度、肛门排气时间、下床时间、引流管拔除时间及住院时间均短于开腹组,术中出血量和使用止痛药次数少于开腹组,但手术时间长于开腹组(P<0.05)。两组患者清扫淋巴结数及近、远切端距肿瘤距离比较差异无统计学意义(P>0.05)。两组患者术后3 d时CRP、TNF－α及IL－6水平较术前上升,腹腔镜组患者3个指标水平均低于开腹组患者(P<0.05)。开腹组患者术后3 d时NO和ET水平高于术前和腹腔镜组患者(P<0.05)。腹腔镜组患者NO和ET水平与术前比较差异无统计学意义(P>0.05)。腹腔镜组患者术后并发症率为6.12%低于开腹组患者18.4%(P<0.05)。 结论腹腔镜胃癌根治术具有手术时间短、切口小,应激反应小,恢复快的特点,同时对机体的免疫功能影响较小。     

三孔法腹腔镜直肠癌根治术的临床研究

目的:探讨三孔法腹腔镜直肠癌根治术的可行性及近期临床效果,对三孔法腹腔镜直肠癌根治术的临床应用价值进行前瞻性研究分析。方法:根据严格的入组标准将2004年6月至2009年12月在我科收治的符合入组条件的直肠癌病人700例分成三孔法腹腔镜组(n=345)和传统开腹手术组(n=355)。比较两组病人的术中及术后一般情况、手术相关病理学因素、术后并发症及1～5年随访资料等。结果:对比开腹手术组,三孔法腹腔镜组病人术中出血量少;术后下床时间早,排气快,但平均手术时间更长。在并发症发生率、切除标本中淋巴结个数、下切缘距肿瘤距离及随访效果方面两组无统计学差异。结论:三孔法腹腔镜直肠癌根治术对腹腔镜技术要求较高,但安全可行,具有传统开腹手术相同的根治效果及更好的近期疗效。     

The role of laparotomy for intestinal perforation in very low birth weight infants

Background/Purpose

The management of intestinal perforation in very low birth weight (VLBW) infants (less than 1500 g) is controversial. Current practice favors peritoneal drainage (PD) with or without a delayed laparotomy over primary laparotomy (PL). We compared the outcomes of PD ± delayed laparotomy vs PL in VLBW infants using the Score for Neonatal Acute Physiology with Perinatal Extension (SNAPPE-II) as a validated predictor of mortality.

Methods

A retrospective analysis (1998-2003) of VLBW infants with intestinal perforation at 2 pediatric centers was undertaken. Data retrieval included neonatal demographics and parameters for SNAPPE-II calculation. The primary end point was 30-day mortality. Other outcome measures included in-hospital mortality, days fasting, days to extubation, and length of stay. Statistical analysis was performed with either Student's t test or χ² analysis. Subgroup and multivariate analyses were also performed. P values < .05 were considered significant.

Results

Fifty-two neonates (25 PD, 27 PL) were reviewed. Overall, 10 (19.2%) infants died. Observed 30-day mortality rates in PD and PL groups were 32% and 7.4% (P = .028), respectively. Average SNAPPE-II scores for PD (42.5 ± 20.8) and PL (25.1 ± 14.6) groups yielded predicted mortality rates of 15.7% and 4.9% (P = .001), respectively. PD group 30-day mortality far exceeded the rate predicted by the SNAPPE-II score. Days fasting (13.7 vs 20.4; P = .0001), days to extubation (26.7 vs 51.5; P = .014), and length of stay (56.1 vs 83.6; P = .031) all favored the PL group despite incorporating SNAPPE-II score as a covariate into the multivariate analysis. Of the 25 patients receiving drainage, 9 underwent PD alone (SNAPPE-II = 46.6 ± 27.9), whereas 16 patients underwent delayed laparotomy (SNAPPE-II = 37.8 ± 17.6). The PD-only group had a greatly elevated mortality rate (77.8% vs 15.7% predicted), whereas the delayed laparotomy group had a reduced mortality rate (6.3% vs 9.3% predicted).

Conclusion

Our data suggest that laparotomy, either alone or after PD, provides an improved outcome in VLBW infants with intestinal perforation. PD should be used as a temporizing measure until laparotomy can be performed.     

Laparoscopic management of surgical complications after a recent laparotomy

Background The use of laparoscopy in the scarred abdomen is now well established. However, recent laparotomy and the presence of a fresh abdominal wound usually preclude laparoscopic intervention. Thus, early postlaparotomy complications, which mandate surgical interventions, are usually treated by a second laparotomy. We report our experience with the use of laparoscopy for the treatment of postoperative complications, after open abdominal procedures.Methods Fourteen patients were operated for a variety of conditions, and postoperative complications, such as bowel obstruction, intraabdominal infection, or anastomotic insufficiency, were handled laparoscopically.Results Eleven patients recovered from the acute condition. One patient died from sepsis, one retroperitoneal abscess was missed and later drained percutaneously, and one conversion to open surgery was necessary because of adhesions and lack of working space.Conclusions We conclude that a recent laparotomy is not a contraindication for laparoscopic management of acute abdominal conditions. Postlaparotomy complications can be successfully treated by laparoscopy. Avoiding the reopening of the abdominal wound and a second laparotomy may reduce the additional surgical trauma, and thus result in easier recovery.     

Laparotomy or laparoscopic surgery? Factors affecting the surgeons choice for the treatment of ectopic pregnancy

Purpose:In this study, we aim to compare the surgeons’ choice on the ectopic pregnancy cases during the last four years. The differences between laparoscopy and laparotomy cases and the factors which directed the surgeon to choose either of the surgical methods were evaluated. Methods:Our study comprises 135 patients who were diagnosed as ectopic pregnancy and were hospitalized in the Gynecology Department of Istanbul Medical Faculty during 1996–1999. Results: During 1996–1999 a total of 118 cases had been diagnosed as tubal ectopic pregnancy and had been treated surgically. Seventy three patients (62%) had been treated with laparotomy while the rest 45(38%) had been treated laparoscopically. When compared, the amount of intraabdominal free blood volume was significantly higher in laparotomy group [270.45±466.72 mL laparoscopy group – 889.75±714 mL laparotomy group, (p=0.0001)]. When we considered haemoperitoneum amount according to the patients’ parity, intraabdominal blood volume was interestingly higher in multiparas [507±599.32 mL nulliparas vs. 768.68±749.15 mL mulltiparas, (p=0.044)]. The percent of cases with ruptured tubes was 64% for the laparotomy and 38% the laparoscopic cases; and the difference between two groups was significant (p=0.0013). Conclusion: Our study implied that haemodynamic stability and less intraabdominal free blood affect the surgeons’ decision between laparotomy and laparoscopy. Fewer multiparous patients are suitable for these criteria which leads to less laparoscopic surgery. These findings, which need to be clarified, lead to the idea of human factor affecting the surgeons’ choice indirectly. Received: 20 February 2001 / Accepted: 28 March 2001     

Abdominal trauma

Summary While a great part of the Anglo-American medical literature addresses the topic of penetrating trauma the German spreaking countries rather publish on blunt abdominal injury. The presented paper discusses the strategic principles of acute clinical management of abdominal trauma on the combined basis of own research results and a comprehensive review of the literature. Blunt abdominal injuries in most cases from a part in the pattern of multiple trauma. The early, first-hours mortality is most often caused by severe traumatic brain injury or abdominal trauma with massive hemorrhage. The prehospital management of penetrating injuries is characterized rather by the concept of ’load and go', whereas the on-scene stabilization of the patient with blunt abdominal injury should precede transport to the adequate hospital. On arrival in the accident and emergency room an immediate blood transfusion is recommended for hemodynamically unstable patients. If then a stabilization is not achieved, an emergency laparotomy should follow. Abdominal stab injuries should be explored by laparoscopy if an intraperitoneal lesion is suspected. If then the possibility of an intestinal lesion is present a laparotomy should be performed directly thereafter. Firearm injuries require open revision in almost all cases. The standard diagnostic technique in blunt abdominal trauma is sonography, assisted by computed tomography and, if indicated, angiography in hemodynamically stable patients. Isolated abdominal injuries without hemodynamic or coagulation disorders allow conservative treatment in the intensive care setting. In severe multiple trauma as well as in manifest shock even the smallest fluid detection should lead to laparotomy. The surgical treatment of splenic rupture is still a matter of discussion. Splenectomy is indicated in patients with severe concomitating injuries or shock whereas in the remainder of cases the total or partial preservation of the spleen should be pursued. Hepatic injuries offer a broad spectrum of operative interventions, ranging from superficial hemostatic measures over compression techniques like ’packing' and ’mesh-wrapping' to atypical and anatomical resections and to liver transplantation in exceptional cases. Lesions of tubular organs and the pancreas pose especially difficult diagnostical problems but regularly allow a rather easy operative treatment.      

Hemobilia — successful treatment by angiographic embolization

Summary Hemobilia after major liver trauma is a difficult problem to manage. We report a case of an 18-year-old male who sustained major liver trauma. Bleeding was controlled at laparotomy. Seventeen days after surgery hematemesis and intermittent bleeding from the drain occurred. Hepatic artery angiography demonstrated a pseudoaneurysm of one of the branches. Gelfoam embolization successfully controlled the bleeding. Review of the literature reveals that hemobilia has been treated by a conservative means as well as by surgery. Hepatic angiography to localize the site of bleeding and then embolization to control the hemorrhage now constitute the preferred method of treatment.     

An initial comparative study of two techniques of laparoscopic colonic anastomosis and mesenteric defect closure

Laparoscopic colon and rectal surgery is still in its nascent stages of development. The ease, efficacy, and safety of intracorporeal mechanical colonic anastomosis are contingent upon expensive stapling devices. Although mobilization and mesenteric division are feasible, a method of inexpensive rapid anastomosis is not. A single inexpensive multifire stapler which could be used both to fashion the anastomosis and to close the mesenteric defect would be ideal. Therefore, this prospective randomized study was undertaken to compare the clinical and functional results of laparoscopic colotomy closure performed using the Endopath EMS hernia stapler (EMS; Ethicon Endosurgery Inc., Cincinnati, OH) to results of using standard two-layer hand suturing (HS). Both the colotomy itself and the mesenteric defect closure sites were included in the randomization and analysis. The abdominal cavity was assessed for evidence of anastomotic leakage, abscess, and adhesion formation. In addition, radiographic luminal diameter, bursting strength, and histology were evaluated. Eight healthy pigs were randomized to either the EMS (N=4) or HS (N=4). There was no evidence of leakage, abscesses, or adhesion formation in either group; however, the mesenteric defect revealed more scarring in the HS than in the EMS animals. There were no significant differences in either luminal diameter (HS: mean=0.92 cm; EMS: mean=0.91 cm) or bursting strength (HS: mean=171 mm Hg; EMS: mean=157 mm Hg) (P>0.05). Histologic analysis also demonstrated no difference in inflammation, necrosis, or fibrosis. This study suggests that this technique can be safely applied to both colotomy closure and mesenteric defect repair. Clinical, histopathologic, and functional results after EMS closure are comparable to standard (HS) closure. Reproduction of this inexpensive means of safe, cost-effective, intracorporeal anastomosis and mesenteric closure should be pursued in human clinical trials.     

Laparoskopie versus laparotomie

Zusammenfassung An Hunden wurden laparoskopisch (n = 7) bzw. per Laparotomie (n = 7) nach Exploration des Dünndarms eine Zäkalpolresektion mit Endo-GIA bzw. TA-30 durchgeführt, 2 cm² der lateralen Bauchwand deserosiert und ein Netzzipfel reseziert. Am B. postoperativen Tag wurden alle Tiere relaparotomiert und die entstandenen Adhäsionen rechnergestützt vermessen. Das Ausmaß der Adhäsionen nach laparoskopischen Eingriffen war signifikant (P < 0,01) geringer. Ausgedehnte Adhäsionen zur Laparotomiewunde und zwischen den Darmschlingen bedingten größere Adhäsionsflächen nach Laparotomie. Konglomeratadhäsionen, adhäsionsbedingte Darmabknickungen und Briden fanden sich häufiger nach konventionellen Operationen. Identische Manipulationen wie Zäkalresektion und Deserosierung der lateralen Bauchwand führten nach laparoskopischen und konventionellen Eingriffen zum gleichen Adhäsionsausmaß. Aufgrund unserer Ergebnisse ist das Risiko adhäsionsbedingter Komplikationen nach laparoskopischen Operationen insgesamt geringer als nach identischen konventionellen Eingriffen einzuschätzen.

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Laparoscopy versus laparotomy. An experimental study comparing formation of adhesions in dogs

We performed laparoscopy (n = 7) or laparotomy (n = 7) for exploration of the small intestine, cecal resection with Endo-GIA or TA-30, deserosation of 2 cm² of the abdominal wall and resection of the omenturn majus in dogs. After 8 days all dogs were re-examined and the adhesions were quantified by computer-aided measurement. Laparoscopic operations were followed by significantly (P < 0.001) fewer adhesions. After conventional operations extensive adhesions to the abdominal incision and interenteric adhesions were found, together with frequent conglomerates of adhesions, intestinal kinkings or adhesive bands. Identical manipulations, such as cecal resection or deserosation of the lateral abdominal wall, led to the same frequency and severity of adhesions in both groups. Based on our results, the risk of adhesion-related complications may be reduced by the laparoscopic approach.