腹腔镜与开腹胃癌切除的疗效比较

目的:比较腹腔镜手术与传统开腹手术治疗胃癌的效果。方法:回顾腹腔镜胃癌根治术与传统开腹胃癌根治术的病历资料,通过手术时间、术中出血量、淋巴结清除数目,胃肠道功能恢复时间和术后住院时间,分析腹腔镜胃癌根治术与传统开腹胃癌根治术的疗效。结果:腹腔镜组术中出血量指标优于传统开腹组,而腹腔镜组手术时间长于传统开腹组。淋巴结清除数目两组没有显著性差别。腹腔镜组的胃肠道功能恢复时间和术后住院时间短于传统开腹组。结论:腹腔镜胃癌切除术在技术上是可行和安全的,而且具有微创、术后康复快等优点。     

加速康复外科护理在老年胃癌患者腹腔镜根治术中的应用效果评价

目的探讨加速康复外科(ERAS)护理在老年胃癌患者腹腔镜根治术中的应用效果。方法根据随机数字表达法将148例接受腹腔镜胃癌根治术治疗的胃癌患者分为实验组和对照组,各74例,实验组采用ERAS理念的综合护理,对照组采用常规护理,护理结束后比较两组患者的护理效果进行评价。结果 (1)实验组术前饥饿评分、术日术后7d疼痛评分、术前术后1dNVDS、术后7d腹胀评分均明显低于对照组(P0.05);(2)实验组疼痛、恶心呕吐及腹胀控制满意度和总体满意度评分均明显高于对照组(P0.05)。结论加速康复外科护理可有效减轻腹腔镜胃癌根治术围手术期患者的腹胀、恶心呕吐等临床症状,减轻患者的疼痛,促进患者生活能力的恢复,有实际推广意义。     

老年胃癌的外科特点分析

目的分析和总结老年胃癌的外科特点和治疗方式。方法回顾性分析250例大于60岁的老年胃癌患者临床资料。结果老年人胃癌术前多数伴随有其它疾病。手术证实多数为中晚期胃癌,行根治性胃切除占30.8%,姑息性胃切除占48%。术后并发症增加,其中泌尿系并发症58例占23.3%,肺部感染53例占21.1%,切口感染38例占15.2%。结论应重视老年胃癌的外科治疗特点,积极做好围手术期的处理,选择合理的术式,以减少并发症和死亡率,提高治疗效果。     

重庆地区376例胃癌手术病例分布特征及手术疗效比较

目的分析重庆地区胃癌住院患者的分布特征,比较腹腔镜与开腹手术的疗效,为完善胃癌防治策略提供科学依据。方法收集第三军医大学附属西南医院2005年1月-2010年12月收治的全部胃癌患者病历资料,以病人ID号码采集病人个人特征、临床特征和手术治疗选择等信息,并进行流行病学分布特征描述;根据手术方式的不同进行围手术期疗效指标的比较。结果患者来源于重庆市区及周边地区,共计64个区县,其中沙坪坝区最多;男女比例2．24：1,51—60岁胃窦癌发病率最高;腹腔镜手术和开腹手术比较,前者术中出血量少,但手术时间会延长。结论重庆市胃癌住院病例在病例来源、发病部位等方面具有一定的分布规律,腹腔镜相比开腹手术有优势,可作为临床优先选择的术式。     

李勇:做一本小而精的手术笔记

专家简介:李勇( 图1),中山医科大学微创外科硕士,肿瘤学博士,广东省人民医院胃肠外科主任.曾师从我国著名微创外科、肿瘤外科专家,经过腹腔镜手术、肿瘤规范化治疗严格训练.主持广东省科技厅课题一项,参与多项胃癌、结直肠癌的国家级和省级研究课题,获卫生部二等奖一项.《腹腔镜胃肠手术笔记》主编.     

腹腔镜、胆道镜和十二指肠镜微创技术联合应用治疗肝内外胆管结石

目的探讨运用多种微创外科技术在腹腔镜胆总管探查术中的联合应用价值. 方法在腹腔镜超声和术中胆道造影指导下,联合应用腹腔镜、十二指肠镜、胆道镜,对120例肝内外胆管结石病人进行微创外科治疗. 结果 120例手术均获成功,无中转开腹或严重并发症发生.术后住院时间明显缩短,而手术时间并无延长.部分残留结石病人经术后胆道镜取净结石,随访2年未见远期并发症. 结论多种微创外科技术联合应用治疗胆石症安全可靠、切实可行,可望成为肝内外胆管结石微创化治疗的有效新途径.     

腹腔镜胃癌D2根治术和开腹胃癌D2根治术中患者炎症反应比较

目的：比较腹腔镜胃癌D2根治术和开腹胃癌D2根治术对患者炎症因子的影响。方法：选取96例胃癌患者随机分为腹腔镜组和开腹组,腹腔镜组采用腹腔镜胃癌D2根治术治疗,开腹组采用开腹D2根治术治疗,比较两组术前及术后CRP、IL-6、TNF-α及IL-10水平。结果：腹腔镜组术中出血量明显少于开腹组,手术时间、术后排气时间及术后下床活动时间少于开腹组,差异比较有统计学意义(P<0.05);两组术后1 d CRP、IL-6、TNF-α及IL-10水平较术前明显升高,差异比较有统计学意义(P<0.05);腹腔镜组术后CRP、IL-6、TNF-α水平明显低于开腹组,IL-10水平高于开腹组,差异比较有统计学意义(P<0.05)。结论：腹腔镜胃癌D2根治术较开腹胃癌D2根治术炎症反应轻,创伤小,可在临床上推广。     

谈谈如何学好手术学的基本操作技术

外科在医学发展史上出现较早。它的特点是以手的操作为主要治疗手段,诸如换药、手法、手术等。外科不等于手术。外科是基础理论、临床实践,实验探索三者的结合。 学手术不应只限于学基本技术操作,它应包括手术指征、术前准备、术式选择、术后处理、并发症的预防和处理等多项内容。今天我仅就学习手术操作技术谈谈本     

腹腔镜外科的临床研究进展

微创外科一词是在腹腔镜外科发展之后提出的 ,它的定义至今尚未明确 ,一般认为应包括腹腔镜外科、内镜外科、介入放射治疗和介入超声治疗等 .这些微创方法治疗的病种过去是用开腹手术或开胸手术治疗 ,而这些微创方法的治疗结果等于或好于传统手术方法 ,对病人机体的创伤与传统手术方法相比经统计学分析其差异有显著性 .在这些方法中 ,腹腔镜外科的应用范围广泛 ,已经取代了部分传统手术 ;其他方法都是传统外科手术的补充方法 .故判断这些方法的微创意义 ,仍以腹腔镜外科的效果为主 .近几年微创外科的临床研究进展有以下几点 :①腹腔镜手术的…     

腹腔镜辅助与开腹行远端胃癌D2根治术的护理对照

目的 从护理的角度探讨腹腔镜辅助远端胃癌D2根治术与传统开腹远端胃癌D2根治术的优劣.方法 我科于2006年11月～2007年9月将同期救治的远端胃癌需手术治疗病人随机分为腹腔镜组和开腹组,对两组手术病人术后的直接护理时间、下床活动时间、肛门排气时间、胃管拔除时间、进食流质时间、术后住院天数以及术后并发症发生率和术后疼痛药物的使用进行对比分析.结果 腹腔镜组每天所需的直接护理时间和术后住院天数明显比开腹组少;腹腔镜组下床活动时间、肛门排气时间、胃管拔除时间以及进食时间少于开腹组;术后腹腔镜组运用止痛药物的例数比开腹组少;腹腔镜组术后并发症发生率低于开腹组.结论 腹腔镜辅助远端胃癌D2根治术与传统开腹远端胃癌D2根治术相比较,减轻了病人的痛苦,术后恢复快,并发症少,减少了护理工作量,值得临床推广应用.     

解剖定位标志在腹腔镜远端胃癌D2根治术中的应用体会

目的：探讨解剖定位标志在腹腔镜远端胃癌根治术中的意义,以及利用解剖定位标志在腹腔镜下实施胃癌根治术的正确方法和技巧。方法：通过对6具成人尸体标本进行腹腔镜胃癌根治模拟手术及解剖,观察远端胃癌D2根治术中可供利用的镜下解剖学定位标志;对20例病人行腹腔镜远端胃癌根治术治疗。结果：解剖观察发现,胰腺、结肠中血管、胃左血管、肝胰襞位置恒定而突出,在腔镜下易于识别,可作为腹腔镜下手术的定位标志。20例在腹腔镜下完成D2根治手术,手术清扫的淋巴结数目为11—32个。结论：借助于镜下可利用的解剖定位标志进行胃癌根治手术,可引导手术在正确的位置和层面进行解剖分离,更符合安全性的原则和肿瘤根治的规范。     

The roles of surgical oncologists in the new era: minimally invasive surgery for early gastric cancer and adjuvant surgery for metastatic gastric cancer

In the new era of technical development in surgery, operative devices, molecular targeting and chemotherapeutic agents, surgical oncologists have two main roles in the treatment of gastric cancer. One is to provide patients with minimally invasive surgery, including laparoscopy- or robot-assisted surgery in early gastric cancer patients, and the new concept of surgical intervention toward advanced and metastatic disease. Since recently, laparoscopy-assisted distal gastrectomy has become prevalent in Japan as a surgery which is minimally invasive for the patients and provides them with a good quality of life afterwards. However, the provision of advanced surgical techniques, including lymph node dissection and reconstruction, is more important for patient survival. The second role of surgical oncologists is to evaluate the significant values of the aggressive treatment which we term 'adjuvant surgery' for stage IV gastric cancer patients who have successfully responded to initial chemotherapy for curative intent. Stage IV gastric cancer patients are now being informed about the possibility of longer survival with the new chemotherapeutic and surgical strategic approach.     

腹腔镜下手术治疗卵巢巧克力囊肿研究

腹腔镜手术近年来已经成为临床妇科手术治疗的一个重要的发展方向,传统的手术治疗模式正在被其逐步的取代。与临床以往应用的传统开腹手术方式相比较,腹腔镜手术主要具有对机体造成创伤,术后的恢复速度快,不会对美观造成妨碍等几大基本的优点,目前在临床上已经成为对妇科疾病特别是卵巢囊肿进行治疗的首选。本文主要通过卵巢巧克力囊肿概述、腹腔镜治疗适应症、手术方式选择等几个方面,对腹腔镜下手术治疗卵巢巧克力囊肿的研究情况进行综述。     

Recent advances in bariatric/metabolic surgery:appraisal of clinical evidence

Obesity and associated type 2 diabetes mellitus(T2DM) are becoming a serious medical issue worldwide.Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients.Increasing data indicates bariatric surgery as metabolic surgery is an effective and novel therapy for not well controlled obese T2 DM patients.The review of recent developments in bariatric/metabolic surgery covers 4major fields.1) Improvement of safety:recent advances in laparoscopic/metabolic surgery has made this minimal invasive surgery more than ten times safer than a decade ago.The safety profile of laparoscopic/metabolic surgery is compatible with that of laparoscopic cholecystectomy now.2) New bariatric/metabolic surgery:laparoscopic sleeve gastrectomy(LSG) is becoming the leading bariatric surgery because of its simplicity and efficacy.Other new procedures,such as gastric plication,banded plication,single anastomosis(mini) gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for bariatric/metabolic surgery.3)Mechanism of bariatric/metabolic surgery:Restriction is the most important mechanism for bariatric surgery.Weight regain after bariatric surgery is usually associated with loss of restriction.Recent studies demonstrated that gut hormone,microbiota and bile acid changes after bariatric surgery may play an important role in durable weight loss as well as in T2 DM remission.However,weight loss is still the cornerstone of T2 DM remission after metabolic surgery.4) Patient selection:patients who may benefit most from bariatric surgery was found to be patients with insulin resistance.For Asian T2 DM patients,the indication of metabolic surgery has been set to those with not well2controlled(Hb A1 c.7.5%) disease and with their BMI.27.5 Kg/m.A novel diabetes surgical score,ABCD score,is a simple system for predicting the success of surgical therapy for T2 DM.     

Diagnosis and management of organic ovarian cysts: indications and procedures for laparoscopy

In the field of gynaecological surgery, the past few years have been significant due to the development of operative laparoscopy. Originally recommended for the diagnosis of female infertility, over the past 15 years laparoscopy has acquired the standing of a surgical discipline in its own right. Laparoscopic surgical treatment of ovarian cysts, whether conservative or radical, has now been completely standardized. The aim of this work is to specify the indications, procedures and risks involved with this surgery as applied to organic ovarian cysts. Only benign ovarian cysts are suitable for treatment by laparoscopic surgery; ovarian cancer must always be handled by classic surgery using a mid-line laparotomy. Given that clinical and other pre-operative investigations can give only an indication, ovarian lesions require surgical investigation to diagnose the histological type. Laparoscopy appears to be as reliable as laparotomy when assessing whether an ovarian tumour is malignant. The risk of parietal contamination and peritoneal dissemination if a malignancy is not recognized means that, if there are no signs of extra-ovarian extension, adnexectomy is mandatory whenever there is the slightest doubt. This adnexectomy must obey two important rules: it must be accomplished without rupturing the cyst, and the cyst must be placed, intact, inside an endoscopic bag before being extracted. Provided that all stages of the procedure, from pre-operative work-up to the initial diagnostic phase of the laparoscopy, are carried out meticulously, laparoscopic surgery is reliable for both the diagnosis and the management of benign organic-ovarian cysts.     

腹腔镜下远端胃癌根治术中胃背系膜及系膜间隙的解剖形态特点

目的:探讨腹腔镜胃癌根治术中相关系膜及系膜间隙的镜下解剖学特点,为腹腔镜下解剖定位和操作入路提供解剖学依据。方法:通过大体解剖观察并在腹腔镜下于新鲜尸体标本上模拟进展期胃癌根治术,对胚胎期胃背系膜形成的胰腺筋膜、胃脾韧带和腹后壁筋膜间隙在腹腔镜下的解剖层次和形态特点进行观察和描述。结果:胃背系膜后层衍化形成的胃脾韧带、胰腺筋膜、胰十二指肠筋膜和横结肠系膜前叶是相互延续的一个整体;胰腺前筋膜形成的胃胰襞和肝胰襞是镜下确定胃左血管根部和肝总动脉的解剖标志;胰腺后筋膜与肾前筋膜之间的融合筋膜间隙是进行胰后淋巴结清扫的安全平面,而肾前筋膜是确保安全操作平面的后界。结论:(1)胚胎时期由于肠管旋转形成胃周广泛存在的筋膜和筋膜间隙,是腹腔镜胃癌根治术中进行解剖定位、系膜游离和淋巴结清扫的关键;(2)循筋膜间隙进行分离有助于提高腹腔镜下操作的安全性和根治的彻底性;建立腹腔镜下筋膜层次解剖的整体观念可为腹腔镜手术的设计和规范提供形态学依据。     

Patient perception of natural orifice transluminal endoscopic surgery in an endoscopy screening program in Korea

Purpose: Natural orifice transluminal endoscopic surgery (NOTES) is a new method of accessing intracavitary organs in order to minimize pain by avoiding incisions in the body wall. The aim of this study is to determine patients' acceptance of NOTES in Korea and to compare their views about laparoscopic surgery and NOTES for benign and malignant diseases. Materials and Methods: The target number of total subjects was calculated to be 540. The subjects were classified into 18 sub-groups based on age groups, gender, and history of prior surgery. The questionnaire elicited information about demographic characteristics, medical check-ups, diseases, endoscopic and surgical histories, marital status and childbirth, the acceptance of NOTES, and the preferred routes for NOTES. In addition, the subjects chose laparoscopic surgery or NOTES for a hypothetical cholecystectomy and rectal cancer surgery, and responded to questions regarding the acceptable complication rate of NOTES, the appropriate cost of NOTES, and the reason(s) why they did not select NOTES. Results: 486 of 540 patients (90.0%) who agreed to participate in this study completed the questionnaire. NOTES was preferred by the following patients: elderly; a history of treatment due to a disease; having regular check-ups; and a history of an endoscopic procedure (p<0.05). The most preferred route for NOTES was the stomach (67.1%). Eighty-four percent of the patients choosing NOTES responded that the complication rate of the new surgical method should be the same or lower than laparoscopic surgery. Vague anxiety over a new surgical method was the most common reason why NOTES was not selected in benign and malignant diseases (64% and 73%), respectively. Conclusion: Patients appear to be interested in the potential benefits of NOTES and would embrace it if their concerns about safety are met. We believe that qualified surgical endoscopists can meet these safety concerns, and that NOTES development has the potential to flourish.     

腹腔镜uncut Roux-en-Y吻合与传统吻合方式的研究进展

随着胃癌患者术后5年生存率的提高,患者对获得更好的术后生活质量的要求也不断提高,这与手术中消化道重建的方式有关,目前腹腔镜手术的应用已被多数普外科医生接受,但消化道重建的选择方式尚未统一。传统的3种吻合方式各有其优缺点,但共同弊端是会影响患者术后的生存质量。Uncut Roux-en-Y吻合术能够阻断肠道消化液返流,同时保持完整的肠道电生理,患者术后并发症少,将可能成为最理想的消化道重建方式。现就腹腔镜uncut Roux-en-Y吻合与传统吻合方式对胃癌患者术后生活质量的影响进行综述,分析各种吻合方式的优缺点。