预防性手术治疗结直肠克罗恩病7例

为探讨预防性手术治疗结直肠克罗恩病的疗效，回顾分析7例结直肠克罗恩病患者的资料。结果显示，7例患者手术治疗共23次，手术方式以肠段切除吻合术最多（21／23，91．3％）；肠段切除范围在保证血运通畅的条件下尽量多地保留肉眼可见的正常肠段；手术后复发率为69．6％（16／23）；切缘阳性的复发率为75．0％（9／12），切缘阴性的复发率为63．6％（7／11），组间差异无统计学意义（P〉0．05）。结果表明，结直肠克罗恩病肠管切除范围及切缘有无病变残留不影响术后复发率；预防性手术是其一种有效的治疗方法，可以减少并发症的发生，提高患者生活质量，但不能改变其基本病程进展。     

Analysis of surgical treatments for acute abdomen caused by Crohn's disease:A report of 16 cases

目的 探讨克罗恩病引起的外科急腹症的临床诊治特点.方法 回顾性分析2000年1月至2011年6月因外科急腹症接受手术治疗的16例克罗恩病例,总结其临床治疗特点.结果 16例中术前确诊8例,误诊率50.0％.本组病人表现以腹痛、腹泻和恶心呕吐为主,分别占81.3％、43.8％、37.5％.16例全部行手术治疗,手术原因以肠梗阻最多,手术方法以肠部分切除吻合术最多.术后出现并发症4例,复发2例.结论 克罗恩病临床表现多样化,术前误诊率高,可根据术中所见做出判断;克罗恩病急腹症内科治疗无效并有外科手术指征时可选择合理的手术方式进行干预.     

26例克罗恩病患者外科手术病例分析

目的 探讨克罗恩病的临床表现及外科治疗方法.方法 回顾性分析1997年8月至2010年8月外科治疗的26例克罗恩病患者的临床资料,随访时间1～13年.结果 术前确诊克罗恩病患者11例,误诊率57.7%.临床表现以肠梗阻为主占57.7%,其次消化道穿孔和消化道出血分别占26.9%和15.4%.以急腹症表现23例,占88.5%;全组均经手术治疗,其中小肠部分切除10例,回盲部切除4例,右半结肠切除7例,左半结肠切除4例,回肠结肠短路术1例.7例出现术后并发症,死亡1例.18例患者获得随访,随访率69.2%.16.7%(3/18)患者死亡,27.8%(5/18)患者明确复发,55.6%(10/18)患者无克罗恩病复发症状.结论 克罗恩病临床表现多样,外科手术病例多以肠梗阻、出血等急腹症为主,术式选择和规范化手术方式是治疗成功的关键.     

克罗恩病的诊断治疗:附30例报告

目的 探讨克罗恩病的诊断及治疗方法.方法 回顾性分析13年间经病理确诊为克罗恩病30例的临床资料.26例获随访.结果 30例患者,经手术病理诊断17例(56.7%),结肠镜活检诊断13例(43.3%).17例手术患者中,术前诊断急腹症6例.肠梗阻4例,消化道大出血3例,结肠癌2例.胰头占位病变1例,肠痿1例.随访26例患者中,15例接受过外科治疗,复发5例,21例有服用药物治疗史,治疗总有效率73.1%.近1个月病情缓解患者13例(13/23,56.5%).结论 克罗恩病病情迁延,诊断困难,多因误诊或并发症手术,术后易复发,生活质量低,应对该类患者提高警惕,以早期诊断,并加强随访和指导治疗.     

克罗恩病并发症的手术治疗

目的总结克罗恩病并发症的临床特点及外科治疗方法。方法对2010年1月~2012年7月北京协和医院外科手术治疗的36例合并并发症的克罗恩病患者临床资料进行回顾性分析。结果本组36例克罗恩病患者并发症包括肠梗阻27例,肠瘘6例,急性肠穿孔4例,消化道出血5例。手术方式:小肠部分切除吻合术12例,腹腔镜右半结肠切除+回结肠吻合术11例,右半结肠切除+回肠造口术2例,回盲部切除、回结肠吻合术3例,小肠部分切除+结肠部分切除肠吻合术6例,回结肠吻合口切除重建术1例,以及其他1例。11例患者出现术后并发症,包括切口感染5例,腹腔感染2例,消化道出血3例,下肢深静脉血栓、肺栓塞1例。其中2例死亡。结论克罗恩病并发症以肠梗阻及肠瘘多见,手术是目前克罗恩病治疗的重要手段。     

努力促进腹腔镜胃肠手术向深入发展

腹腔镜胃肠手术是继腹腔镜胆囊切除手术之后开展较早、病种较多、随访时间较长的一组微创手术。在腹腔镜胃肠手术发展的初期，仅做一些良性病变切除手术，如阑尾切除、消化性溃疡穿孔修补手术、胃良性肿瘤切除手术、胃底折叠手术、肠憩室切除手术、结肠息肉的部分肠段切除术、溃疡性结肠炎和克罗恩（Crohn）病的病变肠段切除手术以及肠梗阻的松解手术等。随着技术的熟练和水平的提高，     

克罗恩病肠梗阻的外科治疗

克罗恩病是一种需用内科药物控制的疾病,病变肠壁长期炎症反应并纤维化导致肠梗阻是克罗恩病最常见的手术原因.近年来克罗恩病的相关基础研究、诊断与治疗都取得了巨大进步.外科医师应与胃肠内科、内镜、影像科、病理科等多学科医师合作,严格把握克罗恩病肠梗阻的手术适应证和手术时机,熟悉其外科治疗原则,积极应用损伤控制外科、快速康复外科和腹腔镜手术等新理念、新原则和新技术,对提高克罗恩病肠梗阻的外科治疗效果十分重要.     

手术治疗克罗恩病82例的临床分析

目的探讨克罗恩病的临床表现类型与治疗方法。方法回顾性分析近30年经外科治疗的82例克罗恩病患者的临床资料。结果本组患者术前确诊38例,误诊率53.7%。发病类型以腹痛、腹泻和腹部肿块为主,分别占96.3%、89.0%和28.0%;其他还有瘘管形成、肠出血、肛门直肠周围病变,甚至肠外表现如口腔溃疡、鹅口疮性口腔炎。全组均经手术治疗,其中小肠部分切除术57例,结肠部分切除造口术4例,回肠部分切除造口术2例,小肠结肠短路手术3例,内瘘者行小肠及结肠部分切除、吻合术3例,回肠穿孔修补术2例,肠粘连松解术6例,腹腔脓肿引流术并小肠造口术3例,结肠癌变行根治术2例。手术缓解(或有效)73例(89.0%),9例出现术后并发症,死亡2例。结论克罗恩病临床类型多种多样,采用相应的手术方式是手术成功的关键。     

克罗恩病的肠狭窄与梗阻的处理

克罗恩病是一种肠管慢性炎症,可累及整个消化道,常见病变部位在末端回肠和右半结肠。约三分之一的克罗恩病患者在病程中出现肠狭窄及肠梗阻。本文综述了手术、内镜球囊扩张和肠道内支架术及腹腔镜技术在处理克罗恩病肠狭窄与梗阻中的进展。     

克罗恩病的发病机理与治疗

克罗恩病 (Ｃｒｏｈｎｄｉｓｅａｓｅ ,ＣＤ)是一种全胃肠道炎性疾病 ,它与溃疡性结肠炎 (ＵＣ)同属炎症性肠病。常累及从口腔到肛门的任何部位 ,多伴有肠外表现。疾病似乎呈终生复发性 ,即使手术切除病变肠段后也不例外 ,术后 3年肠镜下复发率达 75 % ,所以手术不是ＣＤ的理想治疗方法。外科手术只是在内科治疗失败或出现如穿孔、大出血、肠狭窄梗阻、肠瘘、腹腔脓肿、或无法与其它腹内炎症鉴别的急腹症、腹部包块及重要肠外并发症时 ,才不得而为之的对症治疗。要真正改善炎性肠病的现状 ,必须抓住病因学研究 ,弄清其发病学的基础、致病环…     

克罗恩病外科治疗85例分析

目的总结分析肠道克罗恩病（CD）的外科治疗策略。方法对1980—2005年收治的85例CD病人资料进行回顾性分析。结果近年来CD病人呈增多趋势，术前确诊率为23．53％。肠梗阻（25．88％）、右下腹包块（回盲部肿物，10．59％）、盲肠癌（12．94％）、急性阑尾炎（4．71％）是术前误诊的几大主要原因。手术方式以右半结肠切除术（37．65％），小肠部分切除（21．18％）为主，内、外瘘及肛周CD行外科处理预后良好。结论手术仍是目前肠道CD的重要治疗手段；手术方式依病变部位和并发症类型不同而有差异，术式选择和规范化手术操作是亟待解决的问题。     

Surgery for hemoptysis in various pulmonary tuberculous lesions: a prospective study

Hemoptysis due to pulmonary tuberculous lesions is a common cause of morbidity, and occasionally mortality. The aim of this study is to evaluate the surgical outcome of hemoptysis in patients with various tuberculous pulmonary lesions. A total of 45 cases who underwent surgical procedures for various pulmonary tuberculous lesions with hemoptysis were included in this study. Sixteen patients underwent surgical management within one week of the attack of hemoptysis (group A), the other 29 patients underwent surgery one week after the attack (group B). Hemoptysis was classified into minor, major and massive hemoptysis. Major and massive hemoptysis were the common presentation of group A and tuberculous cavities were the most common lung lesions in both groups (37.7%). Lobectomy was the main surgical procedure performed in both groups (51.1%). Bronchopleural fistula occurred in one case in each group after right pneumonectomy. There was one case (6.2%) of mortality in group A. Tuberculous cavity is the common pulmonary lesion which can result in major and massive hemoptysis, therefore, we recommend early surgical resection of tuberculous cavities to avoid life-threatening hemoptysis. Limited resection should be avoided to prevent recurrence.     

克罗恩病术后复发行再次手术的危险因素分析

目的 探讨克罗恩病术后复发行再次手术的危险因素.方法 回顾性分析2004年3月至2013年9月中国医学科学院北京协和医院收治的108例克罗恩病行肠切除术患者的临床资料.其中82例患者行单次手术,26例行再次手术.分析可能影响克罗恩病患者术后复发行再次手术的25项因素,包括患者性别、年龄、血型、术前WBC、术前中性粒细胞、术前淋巴细胞、术前Hb、术前Alb、术前前白蛋白、超敏C-反应蛋白（hs-CRP）水平、抗酿酒酵母抗体（ASCA）表达、中性粒细胞胞质抗体（ANCA）表达、病变原发部位、疾病类型、肠外表现、肛周病变、吸烟史、阑尾手术史、初次手术前病程、初次手术前1年内使用免疫抑制剂、初次手术前BMI、术前小野寺预后营养指数（OPNI）、初次手术前应用肠内营养、是否急诊手术、初次术后并发症情况.单因素分析采用x2检验或Fisher确切概率法,多因素分析采用Logistic回归模型.结果 单因素分析结果表明：术前前白蛋白、hs-CRP、病变原发部位、疾病类型、吸烟史、初次手术前1年内使用免疫抑制剂及初次手术前应用肠内营养是克罗恩病患者术后复发行再次手术的危险因素（x2=5.928,4.805,7.491,12.363,5.229,9.026,16.506,P＜0.05）.多因素分析结果表明：病变原发部位为回结肠型（L3型）、初次手术前1年内使用免疫抑制剂及初次手术前应用肠内营养制剂提供热量＜500 kcal/d是克罗恩病患者术后复发行再次手术治疗的独立危险因素（OR=1.908,3.535,5.489,95％可信区间：1.035～3.518,1.087 ～ 11.494,1.816 ～ 16.590,P＜0.05）.结论 克罗恩病病变部位为回结肠型（L3型）、初次手术前1年内行免疫抑制剂治疗及初次手术前2周内每日肠内营养制剂提供热量＜ 500 kcal的患者有较高的复发再次手术风险.     

120例直肠疾病患者经肛门括约肌路径手术的临床疗效

目的探讨经肛门括约肌路径的手术（Mason手术）在直肠外科中的应用。方法回顾分析1990年8月至2005年8月同120例中下段直肠疾病患者施行Mason手术的临床资料。结果全组直肠绒毛状腺瘤61例。其中伴癌变者26例；直肠癌25例；直肠黏膜下结节17例；直肠阴道瘘13例；直肠尿道瘘1例；直肠良性狭窄3例。103例直肠肿物中行直肠部分切除术98例，直肠节段切除术5例。术后伤口感染2例（1．7％），直肠。皮肤瘘4例（3．3％）。肿瘤局部复发3例（2．9％）。全组术后无发生肛门失禁者。确诊直肠癌的51例患者术后存活逾5年者达90．2％。结论Mason手术具有手术径路直达、术野表浅和显露良好的优势。适用于可行局部手术治疗的中下段直肠良、恶性疾病。     

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??Objective:To analyze the surgical treatment of Crohn’s disease (CD). Methods:The clinical data of 85 cases of Crohn’s disease admitted between 1980 and 2005 were analyzed retrospectively. Results:The number of inpatient with CD increased significantly in recent years.The rate of pre??operation diagnosis was 23.53%.Ileus (25.88%),mass in the right abdomen (10.59%),cecum cancer (12.94%) and acute appendicitis (4.71%) were the most common causes of misdiagnosis before operation.The most surgical procedure was the right half colon resection??37.65%??.The second was partial enterectomy (21.18%).The prognosis of enteral and external fistula and perianal CD were satisfactory. Conclusion:Surgical treatment is an important means to treat CD.The timely diagnosis and reasonable medical management are helpful to decrease the chance of operation when the lesion is active.It can improve the prognosis significantly.The main surgical signs of CD include obstruction,abdomen mass,fistula,acute perforation,hemorrhage and perianal lesions,etc.The surgical patterns are related to the location of lesion and type of the complication.The research of surgical patterns and standardization is the clinical issue to be resolved urgently.     

Arthroscopic debridement of glenoid labral tears in athletes

This is a retrospective study of 46 patients who underwent arthroscopic glenoid labral debridement from June 1988 to June 1990. All patients complained of pain in the involved shoulder and all were active in sports involving overhead use of the shoulder, including 30 baseball players (16 professional, 14 collegiate/high school). The average age was 22 years (range 16 to 45) and the average follow-up was 2.7 years (range 18 to 50 months). At operation, 35 patients had posterior glenoid lesions, 9 had anterior-superior lesions, and 2 had anterior-inferior lesions. The posterior lesions were further divided into those that involved a horizontal flap tear (n = 19), and those that involved fraying (n = 16). Overall, at an average of 31 months follow-up, 54% (25 of 46) of patients had good to excellent results. Professional baseball players had a statistically significant enhanced outcome with 75% (12 of 16) good-excellent compared with the remaining nonprofessional group, with 43% (13 of 30) good-excellent results. Outcome did not correlate with shoulder laxity, labral lesion location, mechanism of injury, or the presence of a rotator cuff lesion. Conclusions: Arthroscopic debridement of glenoid labral lesions does not yield consistent long-term results. Aggressive, supervised physical therapy in highly motivated individuals may be the most important factors in influencing outcome in patients having arthroscopic labral debridement in the absence of overt shoulder instability.     

Recurrence of Crohn's disease after surgery--causes and risks

BACKGROUND: In spite of the important role of conservative treatment, up to 90 % of all patients with Crohn's disease will undergo an operation during the course of their illness. Up to 50 % even need a second operation or further surgical procedures - with an increasing risk for perioperative complications. This study was designed to identify the risk factors for recurrence in patients with Crohn's disease and the influence of the primary operation. METHODS: Between 1986 and 2004, 412 patients with Crohn's disease required operative treatment. 218 underwent a primary procedure and 194 needed a reoperation. In particular, the indications for surgical treatment, the surgical procedures and the perioperative complications were registered and evaluated in the context of a possible recurrence of Crohn's disease. In this study, "recurrence" is defined as a reoperation because of Crohn's disease after a primary operation. RESULTS: The most common indications for a surgical treatment were stenosis (58.4 %) and fistulas (38.5 %). As the most frequent procedures, the ileocoecal resection and the partial resection of the small bowel were performed. Altogether, the complication rate was 11.5 %. The primary procedures (6.52 %) had less complications than the operations for a recurrence of Crohn's disease (17.70 %). The rate for the recurrence of Crohn's disease was 17.4 % after 5 years, 36.7 % after 10 years and 52.8 % after 15 years. Patients with fistulas as the indication for primary operation had the highest rate of recurrence (45 %). Patients with an isolated Crohn's lesion of the small intestine had a significantly higher risk for recurrence (59.5 %) than patients with lesions in the ileocoecal region or the colon. The anastomosis region (73 %) was the most common localisation for recurrence. CONCLUSION: On the basis of defined risk factors, patients with a high risk for recurrence can be identified. This is very important because of the higher risk for complications caused by reoperations compared to primary procedures. That is why interdisciplinary cooperation including postoperative care and optimal conservative treatment are absolutely essential.     

骨盆和骶骨骨巨细胞瘤的治疗策略

目的 探讨骨盆和骶骨骨巨细胞瘤(GCT)外科治疗的手术方法、局部复发率、并发症.方法 1997年12月至2005年12月我院共收治骶骨、骨盆GCT 46例,其中男性25例,女性21例.年龄17～64岁,平均32岁.骶骨GCT 24例、骨盆GCT 22例.骨盆Ⅰ区GCT(髂骨)8例,Ⅱ区(髋臼)10例,Ⅲ区(坐骨耻骨)4例.S1-5 GCT 2例,S1-4 4例,S1-3 12例,S1-2 5例,S3-5 1例.手术方法:行3次手术者2例,行2次手术者7例.骶骨GCT患者的治疗方式包括19例患者进行了病灶内边缘切除术,2例患者同时进行了病灶内边缘切除术和放疗,3例患者进行了广泛边缘切除术.骨盆22例GCT患者中,除2例坐骨及1例髂骨GCT患者采用刮除术外,其余19例均行大块切除术.结果 1例患者在外院手术后复发,肿瘤巨大、表面溃烂,再次手术后2周死于严重感染.余45例患者,随访时间12个月至8年,平均随访时间37个月.2例患者1年后死亡.1例骶骨GCT患者术后2年出现肺转移,化疗1周期,随访1年,肺部病灶无明显增大.1例髋臼部GCT患者刮除术后2年出现肺转移、局部复发,行肺部照射、髋臼部肿瘤广泛切除、人工半骨盆置换术,肺部病灶随访1年,控制良好.局部复发:骶骨:9/24(37.5%),其中复发2次的患者2例,复发1次的患者7例;骨盆:2/22(9.1%),2例坐骨GCT刮除后均局部复发;行大块切除的19例GCT均未复发.结论 对于骶骨GCT,由于刮除术后局部复发率高,治疗应该更具侵袭性.肿瘤广泛边缘切除术可能会引起骶神经损害,但由于局部复发率降低,所以仍为治疗的最佳选择.     

阴茎疣状癌误诊分析

目的探讨阴茎鳞状细胞癌的特殊类型疣状癌误诊的原因和治疗方法。方法回顾分析9例阴茎疣状癌患者的诊治资料,患者平均年龄49岁,肿瘤呈菜花样生长。瘤体病现活检6例误诊。4例患者肿瘤局限于阴茎头者行肿瘤局部切除术,其余5例均行阴茎部分切除术。结果病理检查见肿瘤细胞分化良好,手术标本切缘未见肿瘤细胞。病理诊断均为“高分化鳞状细胞癌”。随访2-6年,平均3．8年,无1例肿瘤复发或转移。结论阴茎疣状癌细胞分化好,组织活检易误诊。由于其生物学行为以局部侵袭性生长为主,手术治疗预后好。     

Residual tumor discovered in routine second transurethral resection in patients with stage T1 transitional cell carcinoma of the bladder.

When a second transurethral resection was routinely performed 8 to 14 days after the initial transurethral resection in 46 patients for stage T1 bladder tumors residual disease was found in 20 despite the surgical report of complete resection in 40. In only 13 patients was residual tumor noted at repeat resection by the senior urologist performing the operation and residual tumor was confirmed histologically in 10 of them. The extent of the lesion is easily misjudged even by experienced surgeons. Early cystoscopy cannot exclude residual tumor. Residual tumor is an important cause of early recurrence and repeat resection of stage T1 lesions is recommended.