膀胱肠瘘诊断治疗12例报告

目的探讨膀胱肠瘘的诊断与治疗方法。方法回顾性分析12例膀胱肠瘘患者的临床资料。男10例，女2例。平均年龄57岁。膀胱回肠瘘3例、膀胱结肠瘘7例、膀胱直肠瘘2例。病因为肠道恶性肿瘤7例、Crohn病3例、膀胱癌和肠道憩室炎各1例。临床表现粪尿10例、反复尿路感染6例、腹痛4例、气尿3例。CT确诊5例（5／9）、膀胱镜确诊3例（3／6）、膀胱造影确诊2例（2／5）、钡剂灌肠确诊1例（1／5）。行手术治疗10例，其中病变肠段切除一期吻合加膀胱部分切除术4例，病变肠段切除一期吻合加瘘修补术或单纯膀胱引流术各1例，一期横结肠造口、二期结肠癌根治加膀胱部分切除术1例，姑息性近端结肠造口术3例。保守治疗2例。结果1例于入院后第10天死于感染性休克。9例随访3个月～16年，平均6．5年。肠瘘1例复发，再次手术后治愈；1例保守治疗者及1例姑息性手术者死于肿瘤转移，1例术后2年死于脑血管意外，此前随访肠瘘无复发；余5例手术治疗者生存良好，无明显术后并发症。结论膀胱肠瘘多继发于肠道恶性肿瘤，主要临床表现为粪尿和反复尿路感染，CT和膀胱镜为首选的检查方法，治疗以手术为主。     

肠伤寒穿孔的诊治（附30例报告）

目的 探讨肠伤寒穿孔的诊断及治疗方法。方法 对1978－1998年收治的30例肠伤寒穿孔病人的临床资料进行回顾性分析。结果 30例均行急诊剖腹探查,穿孔修补16例,肠切除、肠吻合术9例,肠外置术5例。术后切口感染裂开2例,肺部感染1例,中毒性心肌炎1例,肠瘘4例。治愈26例,死亡4例,死于脓毒性休克1例,肠瘘全身衰竭3例。结论 强调早期诊断,早期手术及选择恰当的术式是降低肠伤寒穿孔的病死率的关键。     

胆总管下端术后十二指肠瘘19例治疗分析

目的：了解胆总管下端手术后十二指肠瘘发生的原因及处理。方法：回顾性分析1975－2002年收治的19例胆总管下端手术后十二指肠瘘发生的原因，诊断和治疗。十二指肠瘘经确诊后均经手术治疗。治疗方式：脓肿引流13例，十二指肠修补5例，胃大部切除幽门旷置胃空肠吻合，空肠造口1例。结果：十二指肠瘘治愈15例，死亡4例，死亡原因：消化道大出血2例，腹膜后严重感染1例，并发重症胰腺炎1例。结论：行胆总管下端探查操作时应谨慎，避免发生医源性损伤。十二指肠后早期诊断尤为重要，十二指肠瘘手术以引流为主，并予以充分的肠内营养支持。     

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。     

炎性肠病45例手术治疗及疗效评价

目的 探讨炎性肠病的手术治疗方法 及疗效评估.方法 回顾性分析近6年经外科手术治疗的45例炎性肠病患者的临床资料.结果 急诊手术16例,Crohn病9例,溃疡性结肠炎(UC)7例.择期手术29例,Crohn病4例,UC 25例.其中13例Crohn病患者行小肠部分切除6例,内瘘者行小肠及结肠部分切除、吻合术1例,回肠穿...     

腹腔镜膀胱癌根治加回肠膀胱术

目的:总结腹腔镜下膀胱癌根治加回肠膀胱术的手术方法及临床疗效。方法:2003年6月～2007年5月共行25例腹腔镜下根治性全膀胱切除、双侧盆腔淋巴结清扫加回肠膀胱术,患者平均年龄68岁,全膀胱切除和盆腔淋巴结清扫均在腹腔镜下完成,标本自下腹部小切口取出后,体外切取末端回肠10～15cm,近端闭合并与双侧输尿管吻合,远端造口于右下腹壁。结果:所有手术均顺利完成,手术时间210～320min,平均270min。术中出血220～1000ml,平均460ml。平均每例清扫淋巴结数10个,淋巴结阳性率16.2%,手术切缘均阴性。术后3～5天肠道功能恢复,1例因粘连性肠梗阻于术后1周再行手术探查松解粘连。术后2～3周拔除单J管,无肠漏及尿漏并发症发生。随访2～30个月,1例死于原发病转移,无腹壁造口狭窄发生,3例术后B超或造影显示单侧轻度肾积水和轻度输尿管扩张。结论:腹腔镜膀胱癌根治术具有创伤小,恢复快等优点,但手术难度较大,手术技术要求较高。回肠膀胱术手术操作相对简单,并发症少,可作为腹腔镜膀胱癌根治术后尿流改道可选方式之一。     

Transvaginal pelvic organ prolapse repair of anterior enterocele following cystectomy in females

This study aims to highlight pelvic organ prolapse (POP) in females following radical cystectomy and to describe our experiences with their management. This is a retrospective case series of five women who had symptomatic POP following radical cystectomy and ileal conduit urinary diversion. All patients presented with a midline anterior enterocele with atrophic ulcerated vaginal skin. One patient presented with small bowel evisceration and required an emergency surgical repair. The average time for presentation was 10.6 ± 6.5 months after cystectomy. In all cases, repair was done via a transvaginal approach. Three patients underwent fascial repair, one colpocleisis, and one bilateral iliococcygeal repair. In three cases, we had to use mesh for reinforcement. Two patients underwent ancillary procedures because of POP recurrence. Surgical repair of POP in women following radical cystectomy is challenging especially if vaginal length is to be maintained. Transvaginal repair is feasible and using synthetic mesh may be necessary.     

Management of enterovesical fistula in patients with Crohn's disease

PURPOSE: Enterovesical fistula in patients with Crohn's disease is intractable. Although there are some reports that the enterovesical fistula were successfully treated conservatively, closure of the fistula cannot always be achieved and surgical intervention may required for those patients. Since surgical closure of entero-entero fistula has a high risk of relapse, the strategy for treating enterovesical fistula has not been established. We evaluated the clinical findings especially in management of enterovesical fistula in Crohn's disease. PATIENTS AND METHODS: Two hundred two patients (mean age was 28.4 year old, range 12-69; 152 men and 50 women) were diagnosed as Crohn's disease during a period of 15 years between 1986 and 2000 in our institute. The incidence and the clinical results regarding the diagnosis and the treatment of enterovesical fistula in these patients were retrospectively evaluated. RESULTS: Seven in 202 patients were diagnosed to have an enterovesical fistula (3.5%, 6 men and 1 woman). The period from the initial diagnosis of Crohn's disease to the recognition of the enterovesical fistula was 11 to 204 months (mean 92.1 months). Enterovesical fistula was revealed and/or visualized by radiological enterography in 6, cystography in 2, cystoscopy in 6, and CT in 4 patients. Surgical interventions were finally conducted in all 7 patients after the failure of conservative treatment for 10 to 146 days (mean 68.2 days). Surgical procedures performed for closing the enterovesical fistula were partial cystectomy with fistulectomy in 5, fistulectomy with bladder wall overlay-suture in 2, and bladder wall overlay-suture alone in 1. No relapse of enterovesical fistula was recognized in any patient in the average observation of 41.6 months. CONCLUSION: Although the treatment of Crohn's disease has been advanced, enterovesical fistula is shown to be resistant to conservative treatment options and it makes patients in unfavorable status for relatively long duration. Our evaluation shown here demonstrated the sufficient surgical results on the closure of enterovesical fistula without any relapse, and was different from the high relapse rate after the surgical management of entero-entero fistula in similar observation period. Surgical interventions of enterovesical fistula caused by Crohn's disease might have an advantage to make diseased patients improved in shorter duration.     

Roboterassistierte laparoskopische radikale Zystektomie

Recent reports have demonstrated that robot-assisted laparoscopic cystectomy is technically feasible. However, wide-spread acceptance of this promising technique is limited due to long operating times and lacking long-term data especially on oncological outcome. After establishing robot-assisted laparoscopic prostatectomy (n=250) we report technical and functional results of a large series of patients undergoing laparoscopic cystectomy with the da Vinci surgical system (DVSS). 27 patients (24 males) underwent laparoscopic radical cystectomy with the DVSS (Intuitive Surgical) between Jan 2004 and Dec 2006. Indications for cystectomy were muscle-invasive transitional cell carcinoma (TCC) or leiomyosarcoma of the urinary bladder (n=24) and bladder shrinking following prior radiotherapy for TCC (n=3). A pelvic lymphadenectomy was routine part of the procedure. Urinary diversions were ilieal conduits (n=19) and ileal neobladders (n=8). Mean operating time was 340 minutes (range 150–450) with a mean blood loss of 301 mL (range 50–550). The mean number of lymph nodes retrieved during lymphadenectomy was 23. Surgical margins were negative except in one case. After a mean follow-up of 10.2 months, 2 perioperative (anastomotic leakage, adhesions) and 3 postoperative complications (ileus, intestinal fistula) occurred. 6/7 patients reported satisfying erectile function following nerve-sparing surgery. Day-time continence was completely restored after a mean 3.5 months in 7/8 patients. Robot-assisted laparoscopic cystectomy is a safe procedure. Satisfying functional and oncological short-term results can be achieved within acceptable operating time limits.     

18例先天性冠状动脉瘘手术治疗体会

目的 总结先天性冠状动脉瘘(coronary artery fistula,CAF)的手术治疗方法及预后。方法 回顾分析2011-01-2015-01间手术治疗的18例先天性冠状动脉瘘患者的临床资料、手术方法及预后。结果 15例在体外循环下行经心腔瘘口关闭术,2例在非体外循环下行冠状动脉下切线褥式缝合,1例在体外循环下行冠状动脉切开修补术。术后随访6个月~3 a,效果良好。所有患者在随访期间症状消失,心功能恢复Ⅰ级,心胸比例趋于正常,心电图改善,能正常工作、生活。结论 冠状动脉瘘手术治疗安全有效,远期效果好。     

Robot-assisted laparoscopic radical cystectomy

Recent reports have demonstrated that robot-assisted laparoscopic cystectomy is technically feasible. However, wide-spread acceptance of this promising technique is limited due to long operating times and lacking long-term data especially on oncological outcome. After establishing robot-assisted laparoscopic prostatectomy (n=250) we report technical and functional results of a large series of patients undergoing laparoscopic cystectomy with the da Vinci surgical system (DVSS).27 patients (24 males) underwent laparoscopic radical cystectomy with the DVSS (Intuitive Surgical) between Jan 2004 and Dec 2006. Indications for cystectomy were muscle-invasive transitional cell carcinoma (TCC) or leiomyosarcoma of the urinary bladder (n=24) and bladder shrinking following prior radiotherapy for TCC (n=3). A pelvic lymphadenectomy was routine part of the procedure. Urinary diversions were ilieal conduits (n=19) and ileal neobladders (n=8).Mean operating time was 340 minutes (range 150-450) with a mean blood loss of 301 mL (range 50-550). The mean number of lymph nodes retrieved during lymphadenectomy was 23. Surgical margins were negative except in one case. After a mean follow-up of 10.2 months, 2 perioperative (anastomotic leakage, adhesions) and 3 postoperative complications (ileus, intestinal fistula) occurred. 6/7 patients reported satisfying erectile function following nerve-sparing surgery. Day-time continence was completely restored after a mean 3.5 months in 7/8 patients.Robot-assisted laparoscopic cystectomy is a safe procedure. Satisfying functional and oncological short-term results can be achieved within acceptable operating time limits.     

腹主动脉重建后肠出血的诊断和治疗

目的探讨腹主动脉重建后肠出血的诊断和治疗方法。方法回顾分析6例患者的临床资料，总结其病因、临床表现、影像学资料、诊断和手术中的情况。结果6例均在全身麻醉下剖腹探查，术中见均为腹主动脉一小肠瘘所致肠出血。在瘘口上下方阻断主动脉，控制出血后行动脉瘘口修复、肠瘘口周围小肠部分切除术。1例术后11d死于多器官功能衰竭；5例获得临床治愈。随访1～10年，1例手术后1年死于脑出血，1例肿瘤复发再次术后1年5个月死于急性心肌梗塞，余3例随访5年以上均健康存活。结论主动脉重建后消化道出血的原因均为主动脉-肠瘘，结合影像学检查可得出正确诊断，手术修复主动脉和肠道瘘口是治疗该病可靠的治疗方法。     

先天性胆总管囊肿62例诊治体会

目的探讨先天性胆总管囊肿的临床特点,并比较先天性胆总管囊肿不同手术方式的治疗效果。方法对62例先天性胆总管囊肿的手术方式及疗效回顾性进行分析。结果本组62例中,获得随访占42例,随访率为74．2％,随访时间自术后3个月。9年。本组无手术死亡病例发生。手术后并发症是胆漏3例和伤口感染5例。在15例囊肿内引流中,随访7例,疗效优良者3例。囊肿部分切除,残余囊肿空肠吻合术12例,随访11例,疗效优良者7例。囊肿完全切除,肝总管空肠吻合术31例,随访24例,疗效优良者22例。以上3种术式的癌变率分别为28．6％,18．2％和8．3％。结论外引流术适用于危急、重症患者不能耐受其他手术方式时,为第二次手术做准备;囊肿完全切除,胆总管空肠Roux-en-Y吻合术是治疗先天性胆总管囊肿的最佳术式。     

不同分期胆囊癌的外科术式选择

目的探讨不同分期胆囊癌的外科治疗方式及其疗效。方法74例手术治疗胆囊癌患者根据不同TNM分期采取相应的手术方式：7例Ⅱ、Ⅲ期病例行单纯胆囊切除;24例Ⅲ期患者行胆囊癌根治术;35例ⅣA、ⅣB期病例行胆囊癌扩大切除术;另8例Ⅳ期胆囊癌因肝门部骨化合并梗阻性黄疸行IVb段肝切除＋胆囊切除＋胆肠吻合。其中10例ⅣB期病例附加腹腔动脉、胰头周围淋巴结酒精注射,9例ⅣB期病例附加I131粒子植入;35例胆囊癌扩大切除患者均附加肝段切除术;3例附加横结肠切除吻合;2例附加门静脉部分切除,4例附加肝右动脉切除。结果围手术期死亡1例;发生胆漏3例,腹腔感染9例;糖尿病酮症酸中毒1例。术后住院时间平均15．2（10～25）d。随访34例,平均11．2（1～31）月,3例术后1年内死亡,7例术后1～2年死亡,25例局部复发。最长生存29月。结论绝大部分胆囊癌发现时处于晚期;针对不同分期和部位选择合适的外科手术治疗手段可以有效延长患者寿命、改善症状、提高生存质量。     

保留尿道板手术修复尿道下裂术后尿瘘

目的 总结保留尿道板手术修复尿道下裂术后尿瘘的l临床经验.方法 尿道下裂术后尿瘘患儿224例.患儿术后时间均>6个月,尿瘘瘘口直径>1.0 cm.应用尿道板切开卷管尿道成形术(Snodgrass)102例,年龄2～16岁,平均3.7岁;Duplay尿道成形手术86例,年龄2～14岁,平均3.5岁;Onlay岛状包皮瓣尿道成形术修复20例;尿道口基底皮瓣法(Flip-Flap)修复16例.结果 224例术后随访均≥6个月.Snodgrass手术102例,成功86例(84.3%),发生尿道狭窄3例,尿瘘复发13例;Duplay手术86例,成功75例(87.2%),发生尿道狭窄2例,尿瘘复发9例.2组手术疗效比较差异无统计学意义(P>0.05).Onlay手术20例,成功19例,尿瘘复发1例.Flip-Flap手术16例,成功14例,尿瘘复发2例.结论 尿道下裂术后尿瘘修补方法应根据患儿的具体条件选择.Snodgrass尿道成形术成功率与Duplay手术相当,可以更多应用,保证阴茎外观满意.     

膀胱非上皮性肿瘤的诊治

目的 总结膀胱非上皮性肿瘤的诊治经验。方法 对1953～2002年收治的28例膀胱非上皮性肿瘤患者的诊治情况进行总结、分析。结果 膀胱非上皮性肿瘤的主要临床表现为血尿、盆腔肿块、尿频、排尿困难等症状。主要辅助检查为B超、CT、膀胱镜检查及镜下活检。本组28例中,经术后病理检查,恶性肿瘤17例(占61．7％),有7种病理类型,分别为膀胱横纹肌肉瘤、膀胱小细胞癌、膀胱平滑肌肉瘤、膀胱恶性淋巴瘤、膀胱恶性纤维组织细胞瘤、膀胱脂肪肉瘤、膀胱黑色素瘤;良性11例(占39．3％),有4种病理类型,分别为膀胱海绵状血管瘤、膀胱壁纤维瘤、膀胱平滑肌瘤、膀胱嗜铬细胞瘤。11例良性肿瘤均完整切除或电灼、电切。17例恶性肿瘤中,膀胱部分切除术7例、膀胱全切除术9例、无法切除1例,有7例恶性肿瘤因复发多次行手术切除。17例恶性肿瘤患者均获随访,3年存活率47．0％(8／17)。结论 膀胱非上皮性肿瘤临床少见,病理类型复杂,恶性居多且预后较差,良性肿瘤预后较好。术前诊断率低,膀胱镜下深部活检可提高诊断率。手术是该病的主要治疗方法。良性肿瘤应完整切除,恶性肿瘤应争取广泛切除,结合其病理特点辅助放化疗可能提高疗效。     

Hydatic cyst of the liver. Considerations on 337 cases

Hydatid disease of the liver is still endemic in certain parts of the world. The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy. Surgery is still the treatment of choice and can be performed by the conventional or laparoscopic approach. The aim of the study is to analyze the results of the surgical treatment in hydatid disease of the liver in First Surgical Clinic, Ia?i. The study concerned a period of 12.5 years (1992 - 31.07.2004) and it included 337 cases. There were performed radical procedures (ideal cystectomy - 17 cases - 5.04%, hepatic segmentectomy - 8 cases - 1.48%, atypical hepatectomy - 10 cases - 2.96%) or conservative procedures (de-roofing - 37 cases - 10.97%, subtotal pericystectomy - 34 cases -10.80%, total pericystectomy - 19 cases - 5.63%, partial pericystectomy - 212 cases -62.90%). In 35 cases (10.38%) the operation was started laparoscopically and 12 cases needed conversion. Postoperative course was complicated in 112 cases (33.32%) (external biliary fistula, cavity suppuration, residual cavity hydatid relapse). Radical methods constituted operations that had excellent results, but they are feasible in few cases. Conservative procedures, relatively simple and still accepted, have a higher rate of morbidity. The laparoscopic approach is more and more used, with good results.     

Meckel's diverticulum in laparoscopic era

A recent case of a Meckel's diverticulum diagnosed and successfully laparoscopically treated, triggered off a retrospective study on a series of 34 cases with Meckel's diverticulum admitted to the First Surgical Clinic between 1990-2003. We encountered 12 uncomplicated cases and 22 cases with a large panel of complications: 11 intestinal obstructions (volvulus 9, intussusceptions on a tumor-2), 9 cases with diverticulitis, 1 gastrointestinal bleeding and 1 case with Littre's inguinal hernia. Positive diagnosis was established intraoperatively and the surgical treatment was adapted according to the local situation (excision of the diverticulum or enterectomy). Out of 12 patients with uncomplicated Meckel's diverticulum 8 were subjected to prophylactic excision of the diverticulum. In 6 of these microscopic examinations were inclusions of gastric mucosa. Laparoscopy is safe, relatively inexpensive and efficient in the diagnosis and treatment of Meckel's diverticulum.     

尿道下裂成形术后尿瘘的修补术改进

目的 探讨通过改进手术方法、手术技巧、尿道支架引流等方式,提高尿道下裂成形术后尿瘘修补的成功率.方法 分析、总结11例尿道下裂成形术及感染后20个瘘口患者的临床资料,小瘘口(直径小于3mm)17例、其中大瘘口(直径大于3 mm)3例.年龄4～42岁,平均15岁,其中瘘口位于冠状沟处3例,阴茎体部14例,阴茎阴囊交界处3例,采用改进补方法.结果 19个瘘口一次修复成功,一次修补成功率达95%.有1例术后发生漏尿,但瘘口比术前缩小.随访3个月-2年,均排尿正常,尿线有力,阴茎外观满意.结论 采用改进修补术,用于治疗尿瘘修复,操作简单,疗效确切.     

尿道下裂成形术后尿瘘的修补术改进

目的 探讨通过改进手术方法、手术技巧、尿道支架引流等方式,提高尿道下裂成形术后尿瘘修补的成功率.方法 分析、总结11例尿道下裂成形术及感染后20个瘘口患者的临床资料,小瘘口(直径小于3mm)17例、其中大瘘口(直径大于3 mm)3例.年龄4～42岁,平均15岁,其中瘘口位于冠状沟处3例,阴茎体部14例,阴茎阴囊交界处3例,采用改进补方法.结果 19个瘘口一次修复成功,一次修补成功率达95%.有1例术后发生漏尿,但瘘口比术前缩小.随访3个月-2年,均排尿正常,尿线有力,阴茎外观满意.结论 采用改进修补术,用于治疗尿瘘修复,操作简单,疗效确切.