腹腔双套管持续冲洗负压引流技术在腹部外科的临床应用

目的 观察持续冲洗负压引流技术在腹部外科应用的临床效果.方法 回顾性分析2006年1月至2011年3月期间我院将自制双套管实施持续冲洗负压引流技术应用于172例腹部外科患者的临床资料.结果 全部患者的消化道瘘均治愈,瘘道愈合的平均时间为36 d.治疗过程中,1例患者出现上消化道出血,另1例出现腹腔出血,无腹腔感染、皮肤破溃感染、脓毒症等并发症.结论 采用持续冲洗负压引流的双套管制作简单,经济有效,在腹部外科中对术后肠瘘、出血、胆汁漏及感染的防治具有重要临床意义.     

持续腹腔冲洗治疗胰十二指肠切除术后吻合口瘘患者的护理

目的 探讨持续腹腔冲洗引流治疗胰十二指肠切除术后吻合口瘘患者的护理方法.方法 对20例胰十二指肠切除术后发生胰肠吻合口瘘患者给予持续腹腔冲洗引流治疗,给予保持腹腔引流管通畅与正常引流、引流管周围皮肤的护理,以及防止引流管脱出等护理.结果 20例胰肠吻合口瘘全部自行愈合,未发生出血及腹腔感染.结论 持续腹腔冲洗是一种简单、有效的治疗方法,做好引流管冲洗护理是胰十二指肠切除术后治疗吻合口瘘的关键.     

腹腔持续冲洗引流治疗肠瘘合并腹腔感染的临床疗效观察

目的探讨腹腔持续冲洗引流治疗肠瘘合并腹腔感染的临床疗效及其应用价值。方法回顾性分析解放军兰州总医院普外科于2012年3月至2017年3月期间收治的62例行急诊手术的肠瘘合并腹腔感染患者的临床资料,所有患者行急诊手术后进行腹腔持续冲洗引流治疗。总结患者的持续腹腔冲洗时间、抗生素使用时间、血象恢复时间、瘘口愈合时间和总住院时间。结果 62例患者的手术救治均获成功,无死亡及感染性休克病例。术后出现腹腔脓肿6例,切口感染5例,胸腔积液5例,肺部感染2例,且患者均有不同程度的低蛋白血症。62例患者的持续腹腔冲洗引流时间为(45±21)d,抗生素使用时间为(14±7)d,血象恢复时间为(16±8)d,瘘口愈合时间为(47±24)d,总住院时间为(56±27)d。其中49例肠瘘经持续腹腔冲洗引流治愈,13例肠瘘经腹腔持续冲洗引流未治愈,行二期手术治愈。结论腹腔持续冲洗引流治疗肠瘘合并腹腔感染的疗效确切,治愈率较高,并发症少,冲洗设备简单,技术难度不高,经济实惠,冲洗设备护理方便,可为复杂性或难治性肠瘘患者再次手术创造良好的条件,有较高的临床应用价值。     

保留十二指肠胰头切除术后并发症的防治体会

目的 探讨保留十二指肠胰头切除术后并发症的防治措施.方法 回顾性分析2003-2008年期间武汉协和医院胰腺中心行保留十二指肠胰头切除术56例病人的临床诊疗经过.结果 术后发生并发症13例(23.2%),包括胰瘘7例(12.5%),十二指肠瘘2例(5.4%);胆瘘1例(2.8%);腹膜后积液和感染2例(5.4%);腹腔大出血1例(2.8%).消化道瘘经支持治疗和维持通畅引流等治疗而痊愈,腹膜后积液和感染病人在B超引导下置管引流治愈,腹腔大出血者急诊选择性腹腔动脉造影显示胃十二指肠动脉分支破裂出血,经明胶海绵和不锈钢圈栓塞后治愈.结论 胰瘘、十二指肠瘘、胆瘘、腹腔感染和出血等是DPPHR术后主要并发症,严格掌握手术适应证,术中仔细操作,尽量保留十二指肠的血液供应是减少DPPHR术后并发症和提高手术成功率的关键,一旦出现并发症应采用正确的治疗方法 .     

肠外瘘并腹腔感染的临床诊治（附86例报道）

目的 探讨肠外瘘并腹腔感染的诊治.方法 回顾性分析我院2002年1月至2007年12月期间收治的86例肠外瘘并腹腔感染患者的临床资料.结果 所有肠瘘多在术后1～2周发生,经口服或引流管注入60%泛影葡胺60～100 ml造影后明确诊断,均行腹腔引流液细菌培养,加强抗感染.20例患者行腹腔冲洗引流,62例在B型超声定位下穿刺引流,4例急诊行剖腹冲洗引流,其中2例行降结肠造瘘.2例合并糖尿病的患者因全身感染严重且反复发作,出现多器官功能衰竭,分别于术后第15 天和第28 天死亡.其余84例住院治疗时间平均12 d,均顺利出院.结论 对肠外瘘并腹腔感染的患者,早期彻底的腹腔冲洗及有效的腹腔和脓肿引流,是控制感染、治愈肠外瘘的关键.     

肠瘘并发腹腔感染的治疗分析

目的探讨肠外瘘并发腹腔感染的治疗方法和效果。方法回顾性分析2005年1月至2010年1月我院普外科收治的肠外瘘并发腹腔感染患者的临床资料。结果本组病人治愈出院18例（81.3%）,死亡3例,自动出院1例。结论有效的腹腔冲洗、脓肿引流、抗生素治疗以及积极支持疗法,是治愈肠外瘘并腹腔感染的关键。     

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目的探讨引起胰腺术后腹腔感染的主要致病菌以及腹腔感染与术后胰瘘的关系。方法分析北京协和医院2005年8月至2006年6月收冶的60例胰腺疾病病人临床资料。术后通过取样导管收集腹腔内手术区域的引流液，进行细菌学培养及鉴定，用以分析腹腔引流液细菌培养结果。分析临床腹腔感染与胰瘘之间的关系。结果60例胰腺疾病术后病人中，腹腔引流液细菌培养的阳性率在术后2h、1d、3d、7d和14d分别为2．7％（1／37）、27．3％（15／55）、45．8％（27／59）、70．3％（26／37）和87．5％（14／16）。60例病人手术区域引流液共进行了204次培养，获得67株细菌，最常见的为MRSCoN（耐甲氧西林凝固酶阴性葡萄球菌）16．4％，其次为粪肠球菌14．9％和MRSA（耐甲氧西林金黄色葡萄球菌）11．9％。17例在术后10d内发生临床腹腔感染，22例发生胰瘘。利用χ^2检验和Logistic回归分析发现：术后胰瘘发生与术后第1、3天腹腔引流液细菌培养阳性不相关；而与10d内临床腹腔感染相关。结论胰腺术后腹腔引流液细菌培养阳性率随引流时间延长而迅速上升，培养中无专性厌氧菌。术后胰瘘与术后引流液细菌培养结果不相关，而与术后临床腹腔感染相关。     

自制双套管持续冲洗负压引流治疗术后胰瘘的临床效果

目的探讨自制双套管持续冲洗负压引流治疗胰腺术后胰瘘的效果。方法回顾性分析2008年8月至2014年3月期间于笔者所在医院接受自制双套管持续冲洗负压引流治疗的12例胰瘘患者的临床资料,总结效果。结果 12例患者均接受双套管持续冲洗负压引流治疗,治疗期间引流管若有堵塞,可拔出体外清理。所有患者均于拔管后治愈。更换双套管早期(1~3 d)患者发热等感染症状明显缓解,引流10~22 d后引流量逐渐减少。出院后所有患者均获访6个月,患者恢复良好,胰瘘部位包裹吸收,无并发症发生。结论自制双套管持续冲洗负压引流治疗胰腺术后胰瘘的效果满意,安全可行。     

肝移植术后胃肠道穿孔的处理

目的总结肝移植术后胃肠道穿孔的治疗经验。方法回顾性分析1999年12月至2014年10月共完成的424例肝移植中7例移植术后出现胃肠道穿孔病人的临床资料,其中男性5例,女性2例,年龄21~63岁,中位年龄43岁。包括胃穿孔3例,空肠穿孔1例,横结肠穿孔3例。其中4例胃肠道穿孔病人肝移植前曾有过腹部手术史。3例胃穿孔中,2例行单纯局部冲洗引流,1例内镜下钛夹+尼龙圈夹闭;1例空肠穿孔行手术切除瘘肠管,空肠-空肠吻合;3例结肠穿孔中,1例单纯局部冲洗引流,2例先行回肠造瘘,3个月后1例行单纯回肠关瘘,1例行横结肠切除+结肠结肠吻合+回肠关瘘。本组所有病例均给予充分的营养支持,适当减少免疫抑制剂的用量,加强抗感染等治疗。结果本组胃肠道穿孔发生率为1.6%(7/424),1例胃穿孔因未及时发现,在引流过程中出现腹腔感染、移植肝功能不良、多器官功能障碍综合征(MODS)死亡,死亡率为14.3%(1/7);1例横结肠穿孔行回肠造瘘,3个月后行回肠关瘘后1周再次于原穿孔处出现结肠瘘,经局部冲洗引流2周后治愈。其余5例经过综合治疗后均康复出院,目前已随访4~96个月。结论胃肠道穿孔是肝移植术后较少见的并发症,治疗复杂,若发现不及时,容易因腹腔感染致移植失败。既往腹部手术史、术中医源性损伤可能是其发生的主要原因。以减少免疫抑制剂用量、控制感染、营养支持为基础的综合治疗是治愈的关键。     

经侧腹路腹膜后切开引流术治疗重症急性胰腺炎的体会

目的:探讨经侧腹路腹膜后切开引流术治疗重症急性胰腺炎（SAP）合并腹腔感染的可行性。方法:笔者对4例SAP合并腹腔感染患者在超声定位下经侧腹壁切开进行腹膜后坏死组织及脓肿清除、引流术。结果:4例均治愈出院。合并结肠瘘1例，持续引流治愈;合并腹腔出血1例，消化道出血1例，均采用非手术治疗痊愈。结论:笔者体会经侧腹路腹膜后切开引流治疗SAP合并腹腔感染是一种操作简便、创伤小、确实有效的手术方法。     

黎氏引流管腹腔灌洗引流治疗肠瘘20例

目的探讨黎氏引流管腹腔持续灌洗引流治疗肠瘘的效果。方法我院2005年12月～2007年2月采用黎氏引流管腹腔持续灌洗引流治疗肠瘘20例,总结分析其疗效。结果14例(70%)未经手术获得自愈,3例经手术获得治愈,2例死亡,1例放弃治疗。住院费用平均2.3万元。住院时间平均16.8d。结论黎氏引流管腹腔持续灌洗引流治疗肠瘘有自愈率高、安全、不增加住院费用和住院时间的优点,值得临床推广。     

腹腔镜治疗小儿胆道穿孔12例临床体会

目的:总结腹腔镜手术治疗小儿胆道穿孔的临床体会。方法:2008年12月至2015年12月收治12例胆道穿孔患儿,均经腹腔镜探查证实为胆道穿孔,根据病情分别行胆总管囊肿T管引流+腹腔引流、胆囊造瘘术+腹腔引流、单纯腹腔引流。结果:12例患儿均成功完成手术,术后未出现胆道出血、胆漏等并发症。胆汁引流及腹腔引流24~72 h后,临床症状缓解,腹痛显著减轻,体温降至正常,黄疸逐步消退。8例胆总管囊肿穿孔患者术后6个月行二期胆总管囊肿切除、肝总管空肠Roux-Y吻合术,其中5例在腹腔镜下完成二期手术,3例因胆总管周围粘连重、分离困难中转开腹。结论:腹腔镜用于小儿自发性胆道穿孔的诊断与治疗避免了盲目开腹探查的缺点,创伤小,手术视野广,对腹腔及肠管干扰小,手术时间短,胆总管囊肿穿孔不影响二次腹腔镜手术。     

Refractory abdominal-cutaneous fistulas or leaks: percutaneous management with a collagen plug

BACKGROUND: We report the results of abdominal-cutaneous fistula tract occlusion with a collagen plug in a series of patients with fistulas or leaks refractory to conservative therapy. STUDY DESIGN: Seven patients were found to have persistent fistula or leak after percutaneous drainage of abdominal pelvic fluid collections. All patients but one were refractory to surgical or percutaneous drainage. Under fluoroscopic guidance, modified Vasoseal (Datascope Inc, Montvale, NJ) collagen plugs were deployed into the fistulas using catheter-directed techniques. The plugs were split longitudinally to fit into an 8F or 9F peel-away sheath, placed into the fistula, and deployed. Results were tabulated and patients were followed up. RESULTS: Six of seven patients undergoing fluoroscopically guided, catheter-directed tract occlusion had resolution of the fistula, with no evidence of fistula or abscess recurrence from 30 to 180 days after closure. There were no procedural complications. The technique was unsuccessful in dosing a gastrocutaneous fistula after removal of a large-bore gastrostomy tube; this failure was believed to be secondary to the short length and large caliber of the tract in a patient with hypercortisolemia. CONCLUSIONS: Closure of abdominal-cutaneous fistula tracts by occlusion with a modified Vasoseal collagen plug shows promise in the management of fistulas refractory to catheter drainage.     

消化道瘘62例临床分析

目的　为探讨术后消化道瘘发生的病因 ,寻找诊断及治疗方法。方法　以术后消化道瘘 6 2例 ,对其发生率、发生时间、临床表现及原因进行分析。结果　发生率占同期消化系手术的0 .4 9% ,术后至发生消化道瘘的时间平均 4 .6d。 6 9.4 %是由医源性损伤所造成的 ,再次手术 2 3例 ,占 37.1% ,全组死亡 19例 ,死亡率 30 .7%。老年人术后消化道瘘发生率显著高于成年人 (P <0 .0 1)。结论　加强责任感 ,是预防消化道瘘的关键。加强围手术期营养支持 ,控制血糖 ,及时、彻底的引流是降低死亡率的关键     

Spontaneous cholecystocutaneous fistula draining from an abdominal scar from previous surgical drainage

We present a rare case of cholecystocutaneous fistula draining from an old surgical scar in the right upper abdominal quadrant following chronic calculous cholecystitis. A 71 year old male presented to the emergency department with a persistent bilious drainage from an old surgical scare, from surgical drainage, of the right upper abdominal quadrant for about a week. Cultures from the draining fluid grew Staphylococcus hominis, Escherichia coli and Klebsilla pneumoniae and tigecycline 50 mg twice a day was administrated intravenously to the patient according to sensitivity results. An abdominal US revealed the presence the gallbladder with calculi in a superficial position and the fistulogram revealed a cholecystocytaneous fistula arising from the fundus of the gallbladder. At laparotomy a fistula track was found connecting the gallbladder fundus to the skin, which was dissected and a cholecystectomy was performed. Spontaneous cholecystocutaneous fistula is rarely observed today, mostly as a complication of chronic calculous cholecystitis. Most often it arises from the gallbladder fundus and the clinical presentation is that of a painless draining sinus tract in the right upper quadrant. Diagnosis is aided by abdominal CT scan and ultrasound and treatment is with elective cholecystectomy and excision of the fistula.     

肠瘘并腹腔感染16例诊治体会

目的　探讨肠瘘并腹腔感染的早期诊断及治疗。方法　对 1 6例肠瘘并腹腔感染的诊断及治疗进行回顾性分析。结果　本组死亡 1例 ,1 5例早期明确腹腔感染存在后及时作有效彻底的腹腔冲洗及引流 ,而使腹腔感染得到有效的控制。结论　对肠瘘并腹腔感染的病人 ,首先明确是否存在腹腔感染 ,早期彻底的腹腔冲洗及通畅有效的腹腔及脓肿引流 ,是控制感染治愈肠瘘的关键     

全胃切除术后Roux-en-Y和储袋吻合的近期疗效

目的探讨全胃切除术中采用Roux-en-Y＋储袋吻合进行消化道重建的近期疗效。方法回顾性分析2013年7月至2013年11月四川大学华西医院收治的7例食管胃结合部腺癌、3例胃体癌患者的临床资料。患者采用全胃切除＋D：淋巴结清扫术,消化道重建采用横结肠前Roux-ell-Y十储袋吻合。采用门诊或电话进行随访,了解患者术后恢复情况,随访时间截至2013年11月。分析患者手术时间、术中出血量、术后住院时间、术后并发症发生率及病死率等手术疗效指标。结果10例患者中,5例采用经腹路径,5例采用经食管裂孔路径。手术时间为（266±23）rain,出血量为（143±40）mL,术后住院时间为（9．3±0．5）d。1例患者术后发生腹腔感染、弥漫性腹膜炎（非吻合口漏导致）,经腹腔冲洗引流治疗后痊愈。无吻合口漏、吻合口出血、腹腔出血等手术并发症发生,无手术死亡。所有患者达到Rn切除,淋巴结清扫数目为（45±18）枚（26～90枚）,阳性淋巴结数目为0～72枚。10例患者获得随访,短期内无明显烧心症状,进食量及进餐数均自觉满意。结论全胃切除术后采用Roux-elq-Y＋储袋吻合进行消化道重建安全可行,近期疗效满意。     

Digestive system fistula: a problem still relevant today

Digestive system fistula originates most frequently as a complication after surgical procedures, less often occurs in the course of inflammatory diseases, but it can also result from neoplasm and injuries. THE AIM OF THE STUDY was to analyze the causes and retrospectively assess the perioperative procedures as well as the results of digestive system fistula treatment. MATERIAL AND METHODS. Own experience in digestive system fistula treatment was presented. The subject group consisted of 32 patients treated at the General Surgery, Oncology and Endocrinology Clinical Department between 01.05.2005 and 30.04.2010 due to different digestive tract diseases. The causes of the occurrence of digestive system fistula, methods and results of treatment were analyzed. RESULTS. The analysis covered 32 patients with digestive system fistula, among them 15 men and 17 women. Average age for men was 57 years (20-78), and for women 61 years (24-88). In 11 patients idiopathic fistula causally connected with primary inflammatory disease (7 cases) and with neoplasm (4 cases) was diagnosed, in 19 patients fistula was the result of complications after surgery, in 2 - after abdominal cavity injury. Recovery from fistula was achieved in 23 patients (72%) with the use of individually planned conservative therapy (TPN, EN, antibiotics, drainage, and others) and surgery, depending on the needs of individual patient. 5 patients (16%) died, whereas in 4 left (12%) recovery wasn't achieved (fistula in palliative patients, with advanced stages of neoplasm - bronchoesophageal fistula, the recurrence of uterine carcinoma). CONCLUSIONS. Recently the results of digestive system fistula treatment showed an improvement which manifests itself in mortality decrease and shortening of fistula healing time. Yet, digestive system fistula as a serious complication still poses a very difficult surgical problem.     

Evaluation of somatostatin or octreotide efficacy in the treatment of external pancreatic fistulas

AIM OF THE STUDY: To evaluate the prevalence of pancreatic pseudocyst after persistent fistula closure with somatostatin or octreotide. To compare the patient characteristics according to the subsequent presence or absence of pseudocyst. PATIENTS AND METHODS: This retrospective study from January 1994 to August 1999 included 15 patients with an external pancreatic fistula. Fistula closure was observed for all patients with somatostatin or octreotide. CT scan was performed 66 +/- 34 days after the end of this treatment. RESULTS: CT scan was normal in 9 patients (favorable group) and showed pancreatic pseudocyst (failure group) in 6 patients. Pancreatic fistula etiologies were different between the two groups. The 5 patients presenting pancreatic fistula after duodenopancreatectomy belonged to the favorable group. Six of the 10 patients presenting pancreatic fistula after pseudocyst drainage belonged to the failure group. There were no other differences between the two groups. CONCLUSION: Persistent pancreatic fistula can be cured with somatostatin or octreotide. However, fistulas occurring after duodenopancreatectomy are more easily cured with somatostatin or octreotide than fistulas occurring after external pseudocyst drainage. Somatostatin or octreotide cannot be considered to be an effective treatment for pancreatic fistula occurring after pseudocyst drainage, despite the fact that 40% of them were permanently cured.     

胰腺空肠端侧套入式胰管空肠黏膜吻合200例经验

目的探讨胰肠端侧套入式胰管空肠黏膜吻合术的临床效果。方法回顾性分析笔者所在医院基本外科2005年8月至2012年12月期间200例行胰十二指肠切除术患者的临床资料。采用Child法重建消化道,胰肠吻合施行胰肠端侧套入式胰管空肠黏膜吻合术,采用3层缝合结构（胰腺与空肠浆肌层、胰腺切缘与空肠浆肌层切缘以及胰管与空肠黏膜）,胰管内置入硅胶管并引至空肠内。吻合口周围覆盖部分大网膜,并于吻合口下方放置引流管。结果全部患者手术均顺利,未出现围手术期死亡者。手术时间为（298±77）min、280～420 min。胰瘘发生率为11%（22/200例）,A级17例、B级2例、C级3例;其中16例合并腹腔感染,1例合并脾静脉腐蚀大出血,1例合并胆肠吻合口假性动脉瘤破裂大出血,1例合并腹腔脓肿。3例C级胰瘘患者经二次手术治愈,其余19例均经保守治疗痊愈。结论胰肠端侧套入式胰管空肠黏膜吻合术操作简便,适用范围广,安全性高,可有效降低胰瘘发生率。吻合口覆盖大网膜可限制外漏胰液的扩散,减少胰瘘导致的严重并发症。