腹腔镜胆囊切除术围手术期死亡原因的分析及对策

目的:分析腹腔镜胆囊切除术(LC)围手术期非手术并发症死亡原因,探讨降低LC围手术期病死率的对策。方法:回顾分析3 543例LC 5例非手术并发症死亡患者的术前、术中情况,手术后处理以及死亡原因等。结果:本组LC围手术期非手术因素死亡5例,其中2例死于急性心肌梗死,1例死于脑梗死,1例死于严重心律失常,1例疑死于急性肺栓塞,均死于非手术并发症。结论:在重视避免手术严重并发症的同时,需重视术前对患者重要脏器功能及全身情况的合理评估和改善,减少手术过程对重要脏器的影响,加强术后重要脏器功能的监测,这对降低LC围手术期病死率有重要意义。     

老年腹腔镜胆囊切除术围手术期处理

目的探讨老年腹腔镜胆囊切除术（LC）的围手术期处理方法.方法：回顾分析105例老年LC患者的临床资料,分析围手术期对内科疾病的治疗.结果：105例中103例手术成功,2例中转开腹,术中出现严重心律失常1例,术后发生脑梗塞1例,心绞痛2例,肺部感染2例,并发胆漏2例.结论：老年患者行LC难度大,风险高,只要重视围手术期的处理,还是安全、可行的.     

高龄进展期直肠癌的外科治疗

目的：探讨高龄进展期直肠癌患者的外科治疗。方法：回顾性分析1996年1月至2003年6月收治的52例70岁以上进展期直肠癌患者的外科治疗资料。结果：52例患者全部经手术治疗．并在围手术期加强对并存病的处理，术后出现粘连性肠梗阻1例，伤口裂开1例，伤口感染4例，2例因并存病导致术后死亡。结论：高龄进展期直肠癌并存病多，手术风险大．但手术仍然是最好的治疗方法，在围手术期加强对并存病的处理，也对提高手术成功率．降低死亡率和并发症的发生率有积极的意义。     

老年腹部手术病人的围手术期处理

为探讨如何作好老年人腹部手术的围手术期处理，以减少并发症，提高疗效，对３０７例老年腹部手术病人临床资料进行了回顾性分析。围手术期处理包括术前全面查体及辅助检查、营养支持、重要脏器的功能维护、并存病的处理及特殊病例手术时机、麻醉方法的选择与术中监护、并发症的防治。结果显示：３０７例中，术后发生各种并发症５６例（１８．２％）死于并发症７例（２．３％）。提示加强围手术期处理对减少并发症，提高疗效，具有重     

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目的探讨高龄结、直肠癌病人并存病的围手术期处理。方法回顾性分析1996年1月至2000年7月间收治65例70岁以上有并存病的结、直肠癌病人的外科治疗？结果并存心脏病40例，高血压17例，糖尿病13例，呼吸系统疾病13例，贫血26例，低蛋白血症41例。术后并发症有肠瘘2例，伤口裂开2例、伤口感染8例，肺部感染3例，心功能不全1例。围手术期死亡2例。结论虽然并存病增加了手术风险，但术前全面了解病情，加强并存病的围手术期处理可大大提高手术成功率，降低手术死亡率和并发症发生率。     

老年急性胆囊炎病人并存病的围手术期处理

目的 探讨老年急性胆囊炎病人并存病的围手术期处理。方法 回顾分析2000年2月～2004年2月收治的97例有并存病的老年急性胆囊炎病人的围手术期处理。结果 本组中并存高血压47例，心脏病2例，慢性支气管炎、肺气肿20例，肝功能异常16例，黄疸4例，糖尿病16例，贫血8例，低蛋白血症3例。术后并发症发生率9％，无死亡病例。结论 术前全面了解病情，正确的围手术期处理，能大大提高手术成功率，降低并发症发生率。     

70岁以上直肠癌患者术前并存病的围手术期治疗

目的:探讨70岁以上直肠癌患者并存病的围手术期处理.方法:回顾性分析2002年1月至-2012年10月间收治121例70岁以上有并存病的直肠癌患者的外科治疗资料.结果:并存心脏病11例(9.1％),高血压17例(14.0％),糖尿病33例(27.3％),呼吸系统疾病11例(9.1％),肝功能异常10例(8.3％),贫血26例(21.5％),低蛋白血症31例(25.6％).术后并发症有肠瘘2例(1.7％),伤口裂开4例(3.3％),伤口感染11例(9.1％),肺部感染3例(2.5％),心功能不全1例(0.8％).围手术期死亡2例(16.5％).结论:虽然并存病增加了手术风险,但术前全面了解病情,加强并存病的围手术期处理可大大提高手术成功率,降低手术病死率和并发症发生率.     

并存糖尿病的腹部外科手术30例围术期处理

目的探讨30例并存糖尿病的腹部外科手术病人的围术期处理情况。方法入院后控制饮食,应用胰岛素控制血糖,作好围术期监测。结果30例病人中切口感染2例,肺部感染1例,电解质紊乱1例,死亡2例,均为急症手术。1例死于肺功能不全,1例死于严重电解质紊乱。结论腹部外科手术合并糖尿病,应积极术前准备,控制血糖在安全水平,加强营养支持及应用有效抗生素,必能减少并发症及病死率。     

消化道肿瘤病人并存糖尿病的围术期处理

目的探讨消化道肿瘤病人并存糖尿病的围术期处理。方法回顾性分析1999年1月~2005年12月间收治283例消化道肿瘤病人,47例并存糖尿病病人的围术期处理方法。结果并存糖尿病47例,合并心肌供血不足、高血压等33例,其中术后切口感染1例、呼吸道感染2例,经治疗全部治愈,无其他严重并发症。结论糖尿病增加了手术风险,术前全面了解病情,严格控制血糖,可极大提高手术成功率,降低并发症发生率。     

围手术期处理措施在胆管损伤治疗中的作用

目的探讨围手术期处理措施在胆管损伤(BDI)治疗中的作用。方法分析我院1990年7月至2008年7月期间46例BDI患者的临床资料。结果46例BDI患者术中发现32例,术后发现13例,1例外伤所致。2例BDI患者行二期胆管修复术后,死于漏胆引起的弥漫性腹膜炎及全身衰竭,1例十二指肠降部憩室手术胆胰管损伤死于并发症,2例胆肠吻合因反复胆管炎死于全身衰竭。结论除手术措施外,围手术期处理措施对BDI预后有重要影响。应及时发现并处理BDI,术中胆管造影对诊断和治疗有指导意义,术后发现BDI并严重腹腔感染者,围手术期应选择恰当的非手术处理措施有效控制病情后决定手术时机。     

Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis

HYPOTHESIS: Tube cholecystostomy followed by interval laparoscopic cholecystectomy is a sale and efficacious treatment option in critically ill patients with acute cholecystitis. DESIGN: Retrospective cohort study within a 4 1/2%-year period. SETTING: University hospital. PATIENTS: Of 324 patients who underwent laparoscopic cholecystectomy, 65 (20%) had acute cholecystitis; 15 of these 65 patients (mean age, 75 years) underwent tube cholecystostomy. INTERVENTION: Thirteen patients at high risk for general anesthesia because of underlying medical conditions underwent percutaneous tube cholecystostomy with local anesthesia. Laparoscopic tube cholecystostomy was performed on 2 patients during attempted laparoscopic cholecystectomy because of severe inflammation. Interval laparoscopic cholecystectomy was attempted after an average of 12 weeks. MAIN OUTCOME MEASURES: Technical details and clinical outcome. RESULTS: Prompt clinical response was observed in 13 (87%) of the patients after tube cholecystostomy. Twelve patients (80%) underwent interval cholecystectomy. Laparoscopic cholecystectomy was attempted in 11 patients and was successful in 10 (91%), with 1 conversion to open cholecystectomy. One patient had interval open cholecystectomy during definitive operation for esophageal cancer and another had emergency open cholecystectomy due to tube dislodgment. Two patients (13%) had complications related to tube cholecystostomy and 2 patients died from sepsis before interval operation. One patient died from sepsis after combined esophagectomy and cholecystectomy. Postoperative minor complications developed in 2 patients. At a mean follow-up of 16.7 months (range, 0.5-53 months), all patients were free of biliary symptoms. CONCLUSIONS: Tube cholecystostomy allowed for resolution of sepsis and delay of definitive surgery in selected patients. Interval laparoscopic cholecystectomy was safely performed once sepsis and acute infection had resolved in this patient group at high risk for general anesthesia and conversion to open cholecystectomy. Just as catheter drainage of acute infection with interval appendectomy is accepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy should have a role in the management of selected patients with acute cholecystitis.     

The efficacy of laparoscopy in acute cholecystitis.

OBJECTIVE: To evaluate the role of laparoscopic cholecystectomy in acute cholecystitis and establish the outcomes of this treatment modality at North Oakland Medical Centers. METHODS: This was a retrospective analysis over a three-year period (January 1, 1994 to December 31, 1996), performed at a University-affiliated urban teaching hospital, North Oakland Medical Centers, Pontiac, Michigan. Five hundred and fifty-seven patients underwent surgical treatment for gallbladder disease; 88 patients had acute cholecystitis, and 469 patients had chronic cholecystitis. Acute cholecystitis patients underwent surgery within 72 hours of the onset of symptoms; the patient's selection for laparoscopic cholecystectomy or open cholecystectomy depended on severity of disease, co-morbid factors and surgeon's preference. The parameters of age, gender, operating (OR) time, length of stay, complications, conversion rates from laparoscopic cholecystectomy to open cholecystectomy, and cost were compared in patients who underwent laparoscopic cholecystectomy and/or open cholecystectomy. RESULTS: Patients chosen to undergo laparoscopic cholecystectomy for acute cholecystitis tended to be younger females. Patients treated with laparoscopic cholecystectomy for acute cholecystitis had shorter OR times and LOS compared to patients treated with open cholecystectomy for acute cholecystitis. Conversion rates (CR) were 22% in acute cholecystitis and 5.5% in chronic cholecystitis during the study period; CR diminished considerably between the first and third year. Complications were also lower in patients who underwent laparoscopic cholecystectomy vs. open cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a reliable, safe, and cost-effective treatment modality for acute cholecystitis; however, the surgical approach should be cautionary because of the spectrum of potential technical hazards. CR is improving as surgeons gain experience.     

2mm无鞘针形器械在隐瘢痕腹腔镜胆囊切除术中的应用:一种无瘢痕手术新思路

目的:探讨隐瘢痕腹腔镜胆囊切除术的手术方法及应用价值。方法:选择2011年1月至2011年6月60例无严重胆囊炎症的胆囊息肉或胆囊结石患者,随机分为2组,新方法组行隐瘢痕腹腔镜胆囊切除术,单孔组行常规单孔腹腔镜胆囊切除术,对比分析两组患者手术时间、术后切口疼痛程度、术后切口满意程度及中转率。结果:新方法组均顺利完成手术;单孔组28例顺利完成手术,2例中转常规腹腔镜胆囊切除术。新方法组与单孔组手术时间平均(14.17±3.51)min和(24.67±4.12)min,新方法组明显优于单孔组(P<0.01);术后切口疼痛程度轻于单孔组,但差异无统计学意义(P>0.05);术后患者对切口满意程度优于单孔组,差异有统计学意义(P<0.01)。两组均无出血、胆漏、胆管损伤等并发症发生。结论:隐瘢痕腹腔镜胆囊切除术安全、可行,术后瘢痕不明显且隐蔽,相对单孔腹腔镜胆囊切除术,手术时间缩短,手术难度及中转率降低,术后患者切口满意度高,为腹腔镜手术的更微创化发展提供了新的可行途径及思路。     

Laparoscopic and open cholecystectomy in New York State: mortality, complications, and choice of procedure

BACKGROUND: With the advent of laparoscopic cholecystectomy patient outcomes and choice of procedure (laparoscopic vs open) are of vital interest. The purpose of this study was to examine the mortality and complication rates for patients undergoing laparoscopic and open cholecystectomy in New York State and to test for differences among hospital peer groups and regions of the state in the tendency to use the laparoscopic approach. METHODS: A population-based, retrospective cohort study of laparoscopic and open cholecystectomy was conducted in which data were analyzed on all 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996. RESULTS: A total of 78.7% of the 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996 underwent laparoscopic cholecystectomy. The mortality rate was lower for laparoscopic cholecystectomy than for the open procedure (0.23% vs 1.90%, P < .0001) and remained significantly lower after patient characteristics related to patient survival (odds ratio 0.34, P < .0001) were controlled for. The prevalence rate of the 8 most common complications among cholecystectomy patients was also much lower among patients undergoing laparoscopic cholecystectomy. Patients undergoing cholecystectomy in public hospitals, Bronx County, and Kings County were found to be significantly less likely to have laparoscopic procedures, and patients undergoing cholecystectomy on Long Island were found to be significantly more likely to have laparoscopic procedures than were other patients in the state. CONCLUSIONS: There are reasonably large differences among hospitals, hospital groups, and regions of the state in the type of cholecystectomy used, even after adjustment for differences in patient comorbidities and indications for type of procedure.     

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

BACKGROUND: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. METHODS: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. RESULTS: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. CONCLUSIONS: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.     

Mirizzi综合征的腹腔镜诊治体会

目的:探讨Mirizzi综合征患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的特点及处理措施。方法:回顾分析7例Mirizzi综合征患者行LC的临床资料。结果:5例中转开腹置T管引流,2例顺利完成腹腔镜手术,无严重并发症发生。结论:Mirizzi综合征I型行LC、II型行胆总管T管引流+保留部分胆囊壁缝合瘘口的手术安全可行。     

腹腔镜技术诊治Mirizzi综合征(附28例报告)

目的:探讨Mirizzi综合征的腹腔镜手术技巧.方法:回顾分析为28例Mirizzi综合征患者施行腹腔镜手术的临床资料.结果:28例中,Ⅰ型21例,均成功地实施了腹腔镜胆囊切除术;Ⅱ型5例,均于腹腔镜下行一期缝合术修复瘘口;Ⅲ型2例,均因Calot三角致密粘连而中转开腹,用部分胆囊壁缝合覆盖于瘘口,放置T管支撑引流.术...     

胆囊结石并糖尿病患者腹腔镜胆囊切除术围手术期及主要并发症的处理

目的:探讨为胆囊结石合并糖尿病患者施行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)围手术期及主要并发症的处理.方法:回顾分析为560例胆囊结石合并糖尿病患者施行LC围手术期及主要并发症的处理方法.结果:术前口服降糖药或用胰岛素治疗,血糖控制在理想范围.术后发生并发症16例,15例治...     

完全经脐单孔腹腔镜胆囊切除术的手术方法及技术改进

目的:探讨完全经脐单孔腹腔镜胆囊切除术(1aparoscopic cholecystectomy,LC)的手术方法及技术改进.方法:回顾分析在钟世镇院士提出的胆囊替代定位点理论指导下,开展完全经脐LC94例的手术方法及技术改进,并复习总结国內相关文献.结果:94例患者中1例因可疑胆囊癌中转开腹,3例因腹腔粘连、肥胖等因...     

Laparoscopic cholecystectomy in the transplant population

Background: The results of laparoscopic cholecystectomy in a group of transplant recipients were reviewed to determine the safety and efficacy of the procedure in the setting of immunosuppression. Methods: All solid-organ-transplant recipients who underwent laparoscopic cholecystectomy over a 3-year period were reviewed. Indication for operation, conversion to open procedure, length of stay, and complications were characterized. These results were compared to the registry data of all laparoscopic cholecystectomies performed at the same institution. Results: There were 26 transplant patients who underwent laparoscopic cholecystectomy including renal, heart, double lung, and heart-lung recipients. The mean age was 47 years. Symptomatic cholelithiasis was the most common indication in 73% of patients followed by acute cholecystitis in 11%. Seven patients (27%) underwent conversion to an open procedure. Three patients (11.5%) experienced a minor complication in hospital. Median length of stay was 2.5 days. One patient died during a subsequent unrelated operation. These results compared favorably to the registry experience at the same institution where the mean age was 49 years, 24% of cases were performed for acute cholecystitis, there was a 10% complication rate, median length of stay was 2 days, and 3 deaths occurred in hospital. The only statistically significant difference was a lower conversion rate (11% vs 27%) in the registry vs transplant group. Conclusions: This experience confirms that laparoscopic cholecystectomy is as safe in the transplant population as the general population. Despite a slightly higher conversion rate to an open procedure, the advantages of short hospital stay, low morbidity, and early return to preoperative routines remain equivalent.Presented as a poster presentation at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995