十二指肠腺瘤性息肉10例诊治体会

目的:总结十二指肠腺瘤性息肉的诊断与治疗体会。方法:对10例十二指肠腺瘤性息肉的临床资料进行回顾分析,其中通过胃镜检查、上消化道造影及术中快速病理检查确诊,内窥镜切除1例;十二指肠切开局部切除7例;空肠、胆管内引流1例;胰头十二指肠切除1例。结果:十二指肠腺瘤性息肉早期多无症状,随着肿瘤的增长可并发梗阻、肿瘤溃疡、恶变或出血等临床症状,症状、体征和放射学检查多缺乏特异性,胃活检及术中快速病理检查可以确诊;经内窥镜或手术是其主要的治疗方法。结论:十二指肠腺瘤性息肉应尽早采取胃活检及术中快速病理检查可以确诊,经内窥镜或手术进行治疗。     

胃十二指肠后壁穿孔的临床诊治分析

回顾性分析13例胃十二指肠后壁穿孔患者的临床资料。术前仅1例明确诊断, 1例术中胃镜诊断, 其余均为术中探查诊断。所有患者均行急诊手术治疗, 并根据术中探查情况实施不同术式。术后并发十二指肠瘘1例, 多器官功能衰竭1例, 胃造瘘口瘘1例, 胸腔积液和肺部感染各1例, 其余患者均恢复顺利。胃十二指肠后壁穿孔临床症状较隐匿, 腹部体征多不典型, 对怀疑或考虑该疾病时, 应尽快手术探查及合理选择手术方式。     

十二指肠间质瘤39例临床分析

目的 探讨十二指肠间质瘤的临床表现及外科治疗经验.方法 回顾性分析中国医科大学附属第一医院1992年1月至2010年12月收治的39例十二指肠间质瘤的临床资料.结果 本组十二指肠间质瘤的最常见症状为上消化道出血,占46％(18/39).增强CT是有效的诊断方法,准确率为69％(22/32),十二指肠镜检查的准确率为83％ (15/18).发病部位以十二指肠降部多见,占69％(27/39).39例均行手术治疗,R0切除34例,其中十二指肠部分切除术16例,胰十二指肠切除术12例,十二指肠节段切除术及胃大部切除术各3例,另有转流或探查手术5例.围手术期死亡1例,有9例出现术后并发症,均行非手术治疗治愈.R0切除术后患者1、3、5年生存率分别为90％、72％、41％.结论 腹部增强CT和十二指肠镜检查是诊断十二指肠间质瘤的有效方法.根据十二指肠间质瘤的大小和位置采取不同的手术方式以达到R0切除,而十二指肠部分切除术应该是首选术式.对于中、高危险度的患者,术后应给予伊马替尼辅助治疗.     

胃十二指肠溃疡并发急性出血137例临床分析

目的 总结胃十二指肠溃疡并发急性出血的临床诊断和治疗方式.方法 回顾分析2000年1月至2010年1月收治的胃十二指肠溃疡并发急性出血137例的临床资料.结果 全部病例均经胃镜、钡餐、手术及术后病理检查确诊.其中采取非手术治疗78例,手术治疗59例;自动出院9例,死亡5例,治愈123例.结论 胃十二指肠溃疡并发急性出血...     

胃大部切除术后早期出血的治疗分析

目的 分析胃大部切除术后早期出血行再手术的原因及有效治疗.方法 回顾性分析13例胃大部切除术后早期出血行再手术的临床资料.结果 再手术中发现吻合口出血7例,旷置溃疡出血2例,胃小弯闭锁区出血3例,十二指肠溃疡遗留病灶1例;经切除原吻合口和溃疡旷置,重新胃空肠吻合,仔细缝扎止血等手术,出血停止,13例全部治愈,无术后并发症,随访6个月至3年无再出血.结论 胃大部切除术后早期出血应尽早查明出血原因,再手术为治疗术后出血的有效方法.     

保留幽门胰胃吻合胰十二指肠切除术的临床应用

目的 探讨保留幽门胰胃吻合式胰十二指肠切除术的临床应用价值。方法 对36例壶腹周围癌患者在证实胃幽门，幽门上，下淋巴结及十二指肠球部未受侵犯的情况下，施行保留幽门胰胃吻合的胰十二指肠切除术，术后观察治疗效果。并进行随访。结果 本组无手术死亡，胆胰瘘，出血等并发症发生，5例术后短期内有胃排空延迟症状，经处理后缓解，无吻合口溃疡和胆道返流症状，1、3、5年累计生存率分别为61.1%,25.0%和13.9%。结论 本术式可降低胰十二指肠切除术的死亡率和并发症，1、3、5年生存率与Whipple手术相比无差异。     

十二指肠胃肠道间质瘤外科治疗与预后因素分析

目的:探讨十二指肠胃肠道间质瘤的诊断、手术方式和预后因素。方法:回顾性分析18例经病理证实的十二指肠胃肠道间质瘤的临床资料,包括临床症状、诊断方法、病灶部位、手术方式、病理结果和预后等。结果:18例均行手术切除治疗,11例行十二指肠肿瘤局部切除术,3例行胰十二指肠切除术(Child术),2例行肠段切除术,2例行胃大部切除术;经24个月到7年随访,5例死于转移和复发,其余13例生存,生活质量良好。随访资料显示性别、年龄、肿瘤大小和手术方法与病人的复发和死亡率无关;导致病人复发和死亡唯一危险因素是肿瘤的危险度分级。结论:上消化道出血是十二指肠胃肠道间质瘤最为常见的症状。多因素分析显示,高危分级是十二指肠胃肠道间质瘤的独立预后因素;根据肿瘤部位和大小来决定手术方式。     

胃十二指肠溃疡急性穿孔1226例临床分析

目的探讨急性胃十二指肠溃疡穿孔的诊断和治疗方法。方法对1980年至2002年期间，我院外科收治的1226例急性胃十二指肠穿孔病人的临床资料进行了回顾性的分析。结果122例保守治疗成功。1104例行手术治疗，其中行单纯穿孔修补术393例，围手术死亡率6．9％。行胃大部切除术和溃疡病局部切除术711例，围手术死亡率0．72％。结论胃大部切除术是胃十二指肠溃疡急性穿孔的主要治疗方法。在保守治疗过程中，应该掌握外科的手术适应证，以便提高治愈率，降低手术死亡率。     

急性胰腺炎并发十二指肠梗阻的外科治疗

目的 探讨急性胰腺炎并发十二指肠梗阻的诊断及治疗。方法 对6例急性胰腺炎并发十指肠梗阻病人的临床资料进行回顾性分析。结果 2例病人施行胃空肠吻合加迷走神经干切断术，无手术并发症，1例施行胃大部切除术，术后发生十二指肠残端瘘；1例行胃空肠吻合术，因同时伴有胆总管下段坏死，术后并发十二指肠瘘及胆汁瘘，经非手术治疗痊愈，2例非手术治疗痊愈。结论 要提高对急性胰腺炎并发十二指肠梗阻的认识。及时诊断，如需手术治疗，以行迷走神经干切断加胃空肠吻合为宜。     

壶腹部局部切除术治疗壶腹与十二指肠乳头部肿瘤

目的:探讨壶腹部局部切除术对壶腹与十二指肠乳头部肿瘤的治疗作用.方法:对2例病人施行壶腹部局部切除术,就手术的背景、适应证、手术方法、手术合并症及处理办法进行论述.结果:1例病人术前十二指肠镜为乳头状瘤,行壶腹部局部切除术,术后合并胃排空障碍和消化道出血,经治痊愈;1例病人术前影像学诊断为壶腹癌,因经济问题行壶腹部局部切除术,术后恢复顺利.结论:选择恰当的适应证,壶腹部局部切除术可用于治疗壶腹与十二指肠乳头部肿瘤.     

腹腔镜手术、开腹手术及保守治疗胃十二指肠溃疡穿孔的对比研究

目的:探讨腹腔镜手术、开腹手术及保守治疗胃十二指肠溃疡穿孔的特点与临床疗效。方法:回顾分析2005年1月至2012年12月237例胃十二指肠溃疡穿孔患者的临床资料,其中56例行腹腔镜手术,147例行传统开腹手术,34例采用非手术治疗,对比3组患者全身炎症反应综合征(systemic inflammatory response syndrome,SIRS)症状改善时间、手术时间、肠蠕动恢复时间、并发症、住院时间、住院花费等指标。结果:腹腔镜组在SIRS症状改善时间、肠蠕动恢复时间、腹腔脓肿与胸腔积液例数、住院时间方面明显优于非手术组与开腹手术组(P<0.05);术中出血量、切口感染例数、术后镇痛次数、术后粘连性肠梗阻发生例数明显少于开腹手术组(P<0.05);手术时间与开腹手术组相比差异无统计学意义(P>0.05);3组患者住院花费差异无统计学意义(P>0.05)。结论:腹腔镜胃十二指肠溃疡穿孔修补术具有患者创伤小、并发症少、疗效显著等优点,体现了微创手术的优越性,是目前治疗胃十二指肠溃疡穿孔的理想方法。     

Laparoscopic bowel injury: incidence and clinical presentation

PURPOSE: Bowel injury is a potential complication of any abdominal or retroperitoneal surgical procedure. We determine the incidence and assess the sequelae of laparoscopic bowel injury, and identify signs and symptoms of an unrecognized injury. MATERIALS AND METHODS: Between July 1991 and June 1998 laparoscopic urological procedures were performed in 915 patients, of whom 8 had intraoperative bowel perforation or abrasion injuries. In addition, 2 cases of unrecognized bowel perforation referred from elsewhere were reviewed. A survey of the surgical and gynecological literature revealed 266 laparoscopic bowel perforation injuries in 205,969 laparoscopic cases. RESULTS: In our series laparoscopic bowel perforation occurred in 0.2% of cases (2) and bowel abrasion occurred in 0.6% (6). The 6 bowel abrasion injuries were recognized intraoperatively and 5 were repaired immediately. In 4 cases, including 2 referred from elsewhere, perforation injuries were not recognized intraoperatively and they had an unusual presentation postoperatively. These patients had severe, single trocar site pain, abdominal distention, diarrhea and leukopenia followed by acute cardiopulmonary collapse secondary to sepsis within 96 hours of surgery. The combined incidence of bowel complications in the literature was 1.3/1,000 cases. Most injuries (69%) were not recognized at surgery. Of the injuries 58% were of small bowel, 32% were of colon and 50% were caused by electrocautery. Of the patients 80% required laparotomy to repair the bowel injuries. CONCLUSIONS: Bowel injury following laparoscopic surgery is a rare complication that may have an unusual presentation and devastating sequelae. Any bowel injury, including serosal abrasions, should be treated at the time of recognition. Persistent focal pain in a trocar site with abdominal distention, diarrhea and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury.     

腹腔镜与开腹手术治疗老年消化性溃疡急性穿孔的对比研究

目的:比较腹腔镜与开腹手术治疗老年患者消化性溃疡急性穿孔的临床效果。方法:比较腹腔镜与开腹两种手术治疗52例老年患者消化性溃疡穿孔的疗效,两种术式的手术时间、术后下床活动时间、术后排气时间、术后止痛药使用率、术后并发症发生率、住院时间等影响因素。结果:两种手术的各项指标均有显著差异(P<0.05或P<0.01)。结论:腹腔镜手术修补具有患者创伤小、康复快、并发症少、住院时间短等优点,是治疗老年消化性溃疡急性穿孔较为理想的手术方式。     

肾移植术后并发肠穿孔的诊断和治疗体会

目的 总结肾移植术后并发肠穿孔的诊断和治疗体会.方法 回顾性分析8例肾移植术后并发生肠穿孔患者的资料.8例均为首次肾移植,术后采用环孢素A(或他克莫司)、霉酚酸酯及甲泼尼龙预防排斥反应.8例患者中,1例肾移植术前有胃大部切除手术史,其余7例术前无胃肠道病变.1例于肾移植术中切除了双侧多囊肾.1例在发生肠穿孔前因急性排斥反应而接受甲泼尼龙冲击治疗.8例患者均接受了剖腹探查术,同时减少免疫抑制剂的用量.结果 肠穿孔发生于肾移植术后3～18 d.5例患者表现为突发性腹部绞痛,不同程度的急性腹膜炎体征;3例急性腹膜炎体征不明显.患者体温为36.5～38.4℃.腹部X线检查显示,5例右侧或双侧膈下出现游离气体,3例出现肠管扩张及肠梗阻征象.诊断肠穿孔后3～96 h患者接受了剖腹探查.术中证实,7例为同肠穿孔,1例为降结肠穿孔.剖腹探查的同时,3例接受了小肠穿孔修补术,4例接受了部分小肠切除吻合术,1例接受了部分结肠切除吻合术.经手术治疗,5例患者痊愈出院.随访0.5～3.5年,肾功能良好,未再发生肠穿孔;3例患者分别于肾移植术后30～108 d因肠穿孔并发症死亡.结论 肠穿孔是肾移植术后少见而严重的并发症,其临床症状不典型,腹部X线检查结果对早期诊断具有较大意义,早期诊断和手术治疗是改善患者预后的关键.     

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目的 总结小肠憩室病的临床、病理特点和诊治体会。方法 对33例小肠憩室病例的临床和病理进行回顾性分析。结果（1）术前5例十二指肠憩室4例确诊，28例空回肠憩室仅1例确诊。（2）不肠憩室的临床并发症有小肠梗阻9例，憩室出血6例，余有憩室穿孔，憩室结石等。（3）术后32例痊愈，1例死于多器官功能障碍综合征（MODS）。（4）组织病理学特点：有并发症的憩室都有炎症表现，3例有溃疡。在切除有并发症的Meckel憩室（MD）标本中，43%含有异位组织。结论 小肠憩室可成为腹部严重并发症的病因。MD并发症与憩室粘膜异位组织的类型有关。MD最常见的并发症为肠梗阻，且最多为肠套叠引起。     

Colon perforation after kidney transplantation.

Between 1962 and 1977 approximately 2% of Denver kidney transplant patients developed colon perforation. The single commonest cause was diverticulitis of the left colon (6/13 cases). In spite of drastic reduction or discontinuation of immunosuppression, only 5/13 patients survived for more than 90 days after operation. Analysis of this experience suggests that the high mortality rate associated with this complication can be reduced by early operation which removes the perforation from the peritoneal cavity (either exteriorization or resection) without primary intestinal reanastomosis. We believe that candidates for kidney transplantation with a history of previously symptomatic diverticulosis coli should have elective colon resection prior to transplantation. Any kidney transplant patient with lower abdominal signs should be investigated and treated aggressively.     

Unsuspected perforation in bleeding duodenal ulcers

A combination of bleeding and perforation rarely occurs simultaneously in peptic ulcer disease. The charts of 127 patients undergoing surgery for either complication were reviewed (bleeding, 91; perforation, 36). Nine of 91 (9.9%) patients in the bleeding group were found at operation to have a unsuspected perforated duodenal ulcer. The operative mortality in the patients with the combined complications (44%, 4/9) was significantly higher than that in patients with bleeding alone (8/82, 9.8, P less than 0.001) or those with perforation alone (4/36, 11.00, P less than 0.025). The mean age of nonsurvivors was significantly higher than that of the survivors (74 +/- 8.01 vs 50.4 +/- 5.65 years, P less than 0.005). The duration of symptoms until operation was longer in patients who died (63 +/- 12.7 hours) than in survivors (40.2 +/- 6.02 hours, P = NS). All patients who died, and three of five survivors, had preoperative fever (greater than 99.0 F), leukocytosis (greater than 12,000/mm3), and persistent tachycardia despite adequate hydration and blood replacement. Perforation in bleeding peptic ulcers is not an uncommon finding, and was present in 9.9 per cent of patients. The presenting symptom of bleeding may obscure signs of perforation, delay surgery, and contribute to the higher mortality rate. The presence of fever, leukocytosis, and tachycardia despite adequate fluid and blood replacement warrants a suspicion of perforation in patients with bleeding peptic ulcer.     

结直肠腺瘤性息肉和早期癌的内镜治疗

目的 评价结直肠腺瘤性息肉和早期癌的内镜治疗效果.方法 自2006年1月至2007年10月对245例肠镜发现的腺瘤性息肉,局限于黏膜层、抬举征(+)的早期癌患者分别进行息肉圈套切除术、内镜黏膜切除术、内镜分片黏膜切除术和内镜黏膜下剥离术.结果 253枚病变,大小0.5～8.5 cm(平均2.3 cm),其中<2 cm 157枚,>2 cm 96枚.内镜下成功切除249枚,内镜切除成功率98.4%(249/253).内镜治疗中未出现无法控制的创面大出血,2例术后出现迟发出血.1例长蒂息肉治疗后出现少量膈下游离气体,2例直肠病变剥离治疗后出现皮下气肿,保守治疗后气肿减退;4例病变剥离过程中创面见裂口,3例金属夹成功缝合;1例治疗后出现腹胀和腹腔大量游离气体,急诊开腹手术修补创面.总的并发症发生率3.6%(9/253).内镜治疗后8例接受外科手术(病变局部抬举不良4例,分化不良腺癌1例,高级别瘤变2例,穿孔1例).术后随访231例,随访期3～22个月(平均14.3个月),内镜黏膜下剥离术后巨大人工溃疡创面3个月基本愈合;3例分片黏膜切除术后复发.结论 内镜治疗可以有效切除结直肠腺瘤性息肉和早期癌,提供准确的病理诊断资料,内镜治疗并发症发生率有待进一步降低.     

腹腔镜与开腹对胃十二指肠溃疡急性穿孔治疗的临床疗效分析

目的探讨腹腔镜与开腹手术治疗胃十二指肠溃疡急性穿孔的疗效。方法将2015年1月至2016年9月我院收治的80例胃十二指肠溃疡急性穿孔患者作为研究对象进行前瞻性研究。根据随机数字法分为腹腔镜组和开腹组,各40例患者,开腹组采取传统的开腹手术修补穿孔治疗,腹腔镜组采取腹腔镜手术修补穿孔治疗,应用SPSS 22.0统计学软件进行统计学处理,术中及术后相关指标以均数±标准差(x珋±s)表示,组间比较采用独立t检验;术后并发症的发生率及复发率采用卡方(χ2)检验,以P0.05表示差异具有统计学意义。结果与开腹组相比,腹腔镜组的手术时间、切口长度、术后下床活动时间、肛门排气时间和住院时间均显著缩短,术中出血量显著降低,差异具有统计学意义(P0.05);腹腔镜组术后并发症的发生率和复发率分别为5例(12.5%)和1例(2.5%),开腹组分别为13例(32.5%)和6例(15.0%),差异具有统计学意义(P0.05)。结论腹腔镜手术治疗胃十二指肠溃疡急性穿孔患者具有损伤小、手术时间短、恢复快、安全性高等特点,临床上应大力推广应用。     

Intra-abdominal complications after cardiac surgery.

Gastrointestinal complications such as peptic ulcer disease, pancreatitis, acute cholecystitis, bowel ischaemia, and diverticulitis are rare after cardiac surgery (< 1%), but are associated with high morbidity and mortality (about 30%). Hypoperfusion during cardiopulmonary bypass seems a possible aetiological factor. As many patients may be mechanically ventilated and sedated, the usual symptoms and signs of an abdominal complication may be masked. It is necessary to keep this possibility in mind in patients with abdominal pain or tenderness, and the usual diagnostic measures should be undertaken if time permits. Initial treatment is usually conservative, but when it fails, prompt intervention is obligatory. Unfortunately surgeons are often reluctant to submit patients to major abdominal operations immediately after cardiac surgery. However, effective and timely intervention may be life-saving in patients who are poorly able to compensate for the major haemodynamic disturbances of the untreated serious bleeding or sepsis. Although the cardiac condition must be taken into consideration, most patients' cardiac function will have improved since their open-heart surgery and they should be able to withstand general anaesthesia and most operations.