闭合性腹部空腔脏器损伤21例诊治体会

目的 探讨闭合性腹部空腔脏器损伤的临床特点，指导临床诊治和提高疗效。方法 对1998年6月～2002年6月收治的21例闭合性腹部空腔脏器损伤病例的临床资料进行回顾性分析。结果 本组治愈20例，死亡1例。结论 选择合理的手术方式是治疗腹部空腔脏器损伤的主要措施，早期诊断、早期手术、有效胃肠减压、腹腔引流和术后早期应用静脉营养药物，是影响预后的主要因素。     

腹腔再次手术切口选择探讨：附313例再次手术入路分析

１９７５年－１９９５年作者单位腹腔再次手术３１３例，约占同期外科手术的２．１％。其中近期再次手术５２例，中期再次手术６７例，后期再次手术１９４例。作者根据再次手术所见，按照创口愈合的不同时期提出腹腔再次手术时其切口选择，除再次手术的目的，诊断的准确性，手术种类大小及难易，病情的缓急，患者的体态，腹壁厚薄，更应注意距上次手术的时间，创口感染情况及疤痕大小，并估计腹腔内的粘连程度来决定。     

腹部创伤时缩小手术的理论基础与实施方案

关于严重腹部创伤病人的救治在近二十年来获得了重要进展.当代高能量伤多见的伤情特点导致了大量病人出现严重的多器官损伤,院前救治与复苏水平的进步又使得严重创伤病人的早期存活成为可能.但人们意识到伤后早期的初次手术虽然可以做到伤情的精确控制与修复,多发伤病人仍可能死于术中的代谢衰竭,而不是不完整的手术修复;损伤控制性外科(damage control surgery,DCS)应运而生,主要是为救治严重创伤病人,改变以往在早期进行复杂、完整手术的策略,而采用快捷、简单的缩小手术,但又能控制伤情的进一步恶化,保留进一步处理的条件,使病人获得复苏的时间,有机会再进行完整、合理的再次或分期手术.近年来,旨在损伤控制的缩小手术在腹部创伤救治中获得高度关注,从理论到实践均有重要进展.     

腹部创伤术后近期再手术临床分析

本文报道了本院近年收治的27例腹部创伤术后早期再手术病例，重点对近期再手术的原因进行了分析、讨论。认为再手术原因除了病情本身复杂外，还与术前未能详细了解受伤史和全面体检、术者经验不足或麻痹大意发麻醉选择不当有关，尤其是对腹膜后脏器损伤、胰腺损伤、隔肌穿孔伤的诊断、处理及预防措施提出了见解。     

空腔脏器损伤52例诊治体会

我们自1992年以来共收治空腔脏器损伤病人52例,现就其诊疗体会报告如下。     

损伤控制性手术在严重腹部创伤中的应用

创伤是当今人类死亡的主要原因之一,创伤救治是创伤外科研究的核心内容之一.严重的腹部创伤、出血,尤其是合并低温、凝血功能障碍及代谢性酸中毒时,患者往往难以承受较长时间的手术,但患者又存在必须手术处理的情况,损伤控制性手术(damage control surgery,DCS)应运而生.近年来,DCS理念在严重腹部创伤的治疗中日益受到各国学者重视.本文就近年来DCS在严重腹部创伤中的应用进行综述.     

腹部闭合性损伤剖腹探查术后再次手术分析

目的 分析了腹部闭合性损伤剖腹探查术后12例再次手术的病因分析及预防措施。方法 对腹部闭合性损伤病人256例及9例术后自基层医院转入的病人临床资料进行回顾性分析。结果 行剖腹探查术的246例中术后有3例进行了再次手术（1．2％），其余9例均为基层医院转入我院治疗。本组10例经再次手术而痊愈出院，2例死亡（16．67％）。结论 对腹部闭合性损伤剖腹探查术中，术中探查一定要全面、彻底；正确处理腹膜后血肿是降低死亡率的主要措施之一。术后一旦发生漏诊漏治，易并发多脏器功能衰竭，治疗困难，死亡率高。因此，应引起高度警惕，重在预防。     

腹部创伤早期再手术分析

腹部创伤病情危重，首次手术往往实施非计划性手术。再手术病情复杂而危重。手术难度大，并发症多，死亡率高。本院1995年6月至2007年12月共行腹部创伤早期再手术13例，占同期腹部创伤手术的7．6％，后果严重。现就其原因加以分析讨论．旨在提高腹部创伤手术质量。     

腹部创伤急诊科围手术期处理体会

急诊是医院的重要窗口,急诊救治水平的高低则直接关系到急诊病员的安危[1].本院1998年至2002年,抢救腹部闭合性损伤病人108例,经急诊科围手术期处理后直接送手术室手术,治愈102例,死亡6例,本文结合文献,谈谈对腹部闭合性损伤的急诊围手术期抢救处理体会.     

������������������43������

目的 探讨腹部创伤再手术的原因和预防。方法 回顾分析14年间43例腹部创伤早期再手术病人的资料。结果 再手术病例占同期1126例创伤剖腹术病人的3.8%。钝性伤31例，穿透性伤12例。再手术原因主要为首次手术漏诊（13例）、处置失误（12例）、并发症（15例）、阴性再手术（3例）。43例病人共行再手术50例次，其中2例经受4次手术。病死率为11.6%(5/43），主要死因为再手术后消耗性凝血病或（和）严重感染并发症诱发多器官功能障碍综合征（MODS）。结论 剖腹术时坚持全面探查，正确掌握手术操作技术和重视腹部创伤的充分引流，是减少再手术的关键。     

355例以腹部损伤为主的严重创伤救治分析

【摘要】〓目的〓探讨腹部损伤为主的严重创伤的诊断及救治措施。方法〓对1999年9月~2012年9月救治的355例以腹部损伤为主的严重创伤进行分析总结。结果〓本组急诊腹部手术319例/次,其中103例/次在一次麻醉下分组同台完成了两个以上部位的手术。重症监护病房(ICU)平均住院日28.6±10.8天。临床治愈237例(66.8%),致残78例(22.0%),死亡40例(11.2%)。结论〓病史和体格检查应同抢救治疗同步(如维持呼吸道通畅、止血措施,抗休克等);应积极采用诊断性腹腔穿刺、B超、CT等比较简洁和敏感的快速诊断方法;手术顺序应按受损器官的重要性和损伤的严重程度决定,尽可能在一次麻醉下分组同台处理不同部位的损伤;主动采用损伤控制性外科(DCS)策略,可有效降低死亡率。严重多发伤病人术后均应进入ICU监护和治疗。     

颅脑对冲伤与冲击伤再手术病例诊治探讨

目的探讨颅脑对冲伤与冲击伤患者需再次手术的原因与处理方法。方法回顾性分析2010-01—2014-01受伤机制为对冲伤与冲击伤的需再次开颅手术的24例患者的病例资料。结果本组再次开颅病例术后随访3~6个月,按格拉斯哥预后评分(GOS)判定预后,恢复良好12例(50%),重残2例,植物生存2例,死亡8例(33%)。结论颅脑创伤需手术患者术前应仔细研究患者的受伤机制,分析影像学资料,及时诊断并处理对侧迟发性颅内血肿和扩大的脑挫裂伤灶,能提高其治愈率,减少死残率,改善患者预后。     

腹腔填塞在非创伤性腹腔大出血中的应用

目的:探讨腹腔填塞在非创伤性腹腔大出血患者中的应用价值.方法:收集2002年2月至2007年2月应用纱布填塞控制非创伤性腹腔大出血患者的资料.回顾性分析患者的生理学参数、手术指征及操作、输血输液量、ICU及住院时间、并发症及病死率.将实际病死率分别与计数死亡率和发病率的生理学和手术严重性评分(POSSUM)和Portsmouth计数病死率和发病率的生理学和手术严重性评分(P-POSSUM)预计病死率进行比较.结果:本组患者共26例,平均年龄(42.6±15.8)岁(18～72岁).与腹腔大出血相关的常见病因为坏死性胰腺炎(11例)、肠瘘(5例)和肿瘤(4例).24例(92.4%)患者单纯填塞获得止血,1例联合血管造影栓寨获得止血,1例止血失败.术中平均出血虽为1253.8 ml.经ICU复温复苏后生理学参数明显改善的有:体温、收缩压、心率、动脉血pH、碱剩余、血红蛋白、红细胞压积、凝血酶原时间及国际标准化比率.平均填塞时间(4.3±2.4)d.平均住ICU时间和住院时间分别为(40.5±41.5)d和(67.4±51.0)d.死亡7例(26.9%),实际病死率显著低于POSSUM(77.7%,P=0.001)和P-POSSUM(63.4%,P=0.025)预计病死率.最常见的并发症包括肺炎15例(57.7%)、菌血症13例(50.0%)和再出血7例(26.9%).结论:腹腔填塞是控制非创伤性腹腔大出血的有效手段,可阻断患者向以低体温、凝血障碍及酸中毒为特征的"致死三联征"发展,对经严格选择的患者使用该策略可降低病死率.     

腹部外伤术后近期再手术38例

目的探讨腹部外伤术后近期再手术的原因、预防及处理措施。方法回顾性分析1999年3月至2009年10月收治的38例腹部外伤术后近期因不同原因非计划性再手术病人的临床资料。结果再手术38例中,腹腔大出血9例,消化道瘘8例,胰瘘4例,胆漏3例,腹腔脓肿5例,肠梗阻4例,小肠坏死1例,切口裂开2例,阴性再手术1例,肝脓肿1例。再次手术后死亡4例(10.5%),余痊愈。结论术中探查仔细,操作精细,加强术后观察,提高首次手术质量,是提高腹部外伤疗效的关键;而合理掌握再手术指征、实施及时有效的再次手术可避免疾病进一步恶化。     

腹部外伤再手术20例临床分析

目的探讨腹部外伤再手术的原因及其预防措施。方法对我科1992年1月~2004年8月收治的20例腹部外伤早期再手术病人的临床资料进行回顾性分析。结果本组20例共行再手术23次,其中,有3例行再手术2次。经再手术后治愈18例,死亡2例。结论行剖腹术时坚持全面探查、正确掌握手术操作技术、重视腹部创伤的充分引流是减少腹部外伤再手术的关键。     

Damage Control Surgery: An Alternative Approach for the Management of Critically Injured Patients

Over the past 20 years, it has gradually become apparent that the results of prolonged and extensive surgical procedures performed on critically injured patients are often poor, even in experienced hands. The triad of hypothermia, coagulopathy, and metabolic acidosis effectively marks the limit of the patient's ability to cope with the physiological consequences of injury, and crossing this limit will frustrate even the most technically successful repair. These observations have led to the development of a new surgical strategy that sacrifices the completeness of immediate repair in order to adequately address the combined physiological impact of trauma and surgery. This approach is unfolded in three phases. During the initial operation, the surgeon carries out only the absolute minimum necessary to rapidly control exsanguination and prevent the spillage of intestinal contents and urine into the peritoneal cavity. Packing represents the traditional method for the management of major liver injuries. The second phase consists of secondary resuscitation in the intensive care unit, characterized by maximization of hemodynamics, correction of coagulopathy, rewarming, and complete ventilatory support. During the third phase, the intra-abdominal packing is removed and definitive repair of abdominal injuries is performed. The "damage control" concept has been shown to increase overall survival and is likely to modify the management of the critically injured patient. Received: March 12, 2001 / Accepted: September 11, 2001     

Risk factors for abdominal reoperations in bariatric patients

BackgroundWith a growing bariatric population, a better understanding of the patient and health provider-related factors associated with later reoperations could help providers enhance follow-up and develop reliable benchmarking targets.ObjectivesTo investigate the patient and provider-related risk factors associated with abdominal reoperations in bariatric patients.SettingThis is a cohort study using data from a large clinical registry of Ontario bariatric patients between 2010 and 2016.MethodsA multilevel mixed effect logistic regression model using hospital and surgeon identifiers as random effects was performed to adjust for clustering of patients. The primary outcome was any abdominal operation performed within 2 years of primary bariatric surgery.ResultsAmong a cohort of 10,946 bariatric patients (86.6% receiving gastric bypass surgery), 15.8% underwent an abdominal operation within 2 years and about a third of these were urgent. The multilevel analysis demonstrated that 98% of patient variation among reoperations was a result of patient characteristics rather than disparities between surgeons or center experience. Type of procedure was not a significant factor after adjustment for surgeon and hospital level experience (OR [odds ratio] .85, 95% CI [confidence interval] .70–1.03). Concurrent abdominal wall (OR 2.40, 95% CI 1.26–4.59), hiatal hernia repairs (OR 1.29, 95% CI 1.02–1.62), and previously higher health care users (OR 1.30, 95% CI 1.15–1.46) were most significantly associated with reoperations.ConclusionReoperations are significantly more common among certain bariatric patients, especially those undergoing concurrent hernia procedures. Reoperations were not associated with provider-related factors and may not be a suitable target for health provider benchmarking.     

右美托咪定对老年糖尿病患者腹部肿瘤根治术后心肌损伤的影响

目的 探讨右美托咪定对老年糖尿病患者腹部肿瘤根治术后心肌损伤的影响。
方法 选择择期行腹部肿瘤根治术的2型糖尿病患者92例,男50例,女42例,年龄≥65岁,BMI 18～28 kg/m²,ASA Ⅱ或Ⅲ级。将患者随机分为两组：右美托咪定组（D组）和对照组（C组）。D组于麻醉诱导前静脉泵注右美托咪定1 μg/kg,给药时间为10～15 min,随后以0.5 μg·kg^-1·h^-1的速度静脉泵注至手术结束前30 min;C组给予等量生理盐水。记录入室时、术毕即刻、术后6、24 h时血浆肌酸激酶同工酶（CK-MB）、肌钙蛋白I（cTnI）、丙二醛（MDA）、超氧化物歧化酶（SOD）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）和白细胞介素-10（IL-10）的浓度、HR和MAP。记录术中不良事件（低血压、心动过缓以及心动过速）的发生情况。记录入PACU 10 min时、出PACU时、术后6、24 h的疼痛数字评价量表（NRS）评分。记录术后拔管时间、PACU停留时间、苏醒期躁动、术后心血管事件（低血压、心动过缓、室性早搏、心肌缺血）的发生情况。
结果 与入室时比较,术毕即刻、术后6、24 h 两组CK-MB、cTnI、MDA、TNF-α、IL-6、IL-10浓度明显升高（P＜0.05）,SOD浓度明显降低（P＜0.05）,术毕即刻两组MAP明显降低（P＜0.05）,C组HR明显减慢（P＜0.05）。与C组比较,术毕即刻、术后6、24 h D组CK-MB、cTnI、MDA、TNF-α、IL-6浓度明显降低（P＜0.05）,SOD、IL-10浓度明显升高（P＜0.05）,术毕即刻HR明显增快（P＜0.05）,MAP明显升高（P＜0.05）,术中低血压、心动过速、入PACU 10 min和出PACU NRS评分以及苏醒期躁动、术后低血压、心动过缓的发生率明显降低（P＜0.05）。
结论 右美托咪定可改善老年糖尿病患者腹部肿瘤根治术后的氧化应激及炎症反应,减轻术后心肌损伤。     

Impact of self-inflicted injury on nontherapeutic laparotomy in patients with abdominal stab wounds

IntroductionBecause Japan has high suicide rates and low violent crime rates, it is likely that most abdominal stab wounds (ASWs) in Japan are self-inflicted. Although physical examination is one of the most important factors in surgical decision making, such evaluations can be difficult in patients with self-inflicted ASWs due to patient agitation and uncooperative behavior. Therefore, the self-inflicted nature of an injury may strongly affect clinical practice, particularly in Japan, but its influence remains uncertain. We hypothesized that the rates of exploratory laparotomy and nontherapeutic laparotomy (NTL) would be higher in self-inflicted patients.MethodsWe reviewed ASW patients from 2004 to 2014 in the Japan Trauma Data Bank. The rates of exploratory laparotomy and NTL were compared between self-inflicted and non-self-inflicted ASWs.ResultsOf the 1705 eligible patients, 1302 patients (76.4%) had self-inflicted ASWs, and 403 patients (23.6%) had non-self-inflicted ASWs. Self-inflicted patients had a significantly higher rate of psychiatric history, but lower injury severity. The in-hospital mortality rate was similar between the two groups (4.5% vs. 5.2%, p = 0.576). Self-inflicted patients had significantly higher rates of exploratory laparotomy and NTL (69.1% vs. 56.7%, p < 0.001, 22.5% vs. 13.6%, p = 0.03, respectively). Self-inflicted patients were also associated with significantly longer hospital stays (10.0 [5.0–21.0] vs. 9.0 [4.0–18.0] days, P = 0.045). In a multivariable analysis, self-inflicted patients were independently associated with exploratory laparotomy (odds ratio [OR], 2.05; 95% confidence interval [CI]: 1.55–2.72) and NTL (OR, 1.61; 95% CI: 1.01–2.56).ConclusionASWs in Japan were predominantly self-inflicted. The clinical patterns of self-inflicted ASWs had some unique features. Patients with self-inflicted ASWs had higher rates of laparotomy and NTL. Further studies are needed to develop a useful protocol specific to self-inflicted ASWs.