肝癌合并下腔静脉与肝静脉癌栓的围手术期护理体会

目的探讨原发性肝癌合并下腔静脉与肝静脉癌栓的围手术期护理方法及其价值。方法回顾性分析和总结15例原发性肝癌合并下腔静脉与肝静脉癌栓的围手术期护理经过。包括术前加强病人的心理护理及做好充分术前准备;术后密切观察生命体征,切实做好引流管护理,重点是术后并发症（大出血、肝功能衰竭、胆漏、腹水）观察及护理。结果 15例患者均康复出院。其中7例术后未出现明显并发症,术后10天出院。1例出现肝功能衰竭,予对症支持治疗,积极护理后2个月后康复出院。其余7例出现不同程度的胆漏和出血并发症,予积极处理后1月内康复出院。结论加强围手术期护理,尤其是术前术后对可能出现并发症的积极护理,在原发性肝癌合并下腔静脉与肝静脉癌栓整个治疗过程中起着十分重要的作用。     

消化性溃疡穿孔的临床治疗分析

目的观察消化性溃疡穿孔的手术治疗效果,评价临床价值。方法 80例消化性溃疡穿孔患者采用穿孔修补术治疗,对临床资料进行回顾性总结。结果 80例中痊愈76例,占95%,术后坚持正规内科治疗,随访1～3a,无溃疡复发。4例术后穿孔未愈合,经手术引流,营养支持和内科治疗后痊愈。结论穿孔修补术治疗消化性溃疡穿孔疗效肯定、操作简单、并发症少,适于在基层医院开展。     

360例下肢静脉性溃疡个体化治疗的临床分析

目的探讨下肢静脉性溃疡个体化治疗的临床效果和可行性。方法回顾性分析2012年2月至2014年2月期间我院采用个体化治疗的下肢静脉性溃疡患者360例(共421条肢体),其中男126例,女234例;年龄45~78岁,中位年龄53岁;位于左下肢176例,右下肢123例,双下肢61例。所有患者依据术前彩色多普勒超声定位、标记进行个体化治疗方案选择,对功能不全的交通静脉予以结扎,术后穿着弹力袜等。临床观察指标为患者术后恢复正常活动时间、疼痛程度VAS评分、围手术期并发症发生情况,随访溃疡愈合及复发情况。结果所有患者均按计划完成手术,手术时间平均35 min。术后8 h VAS评分平均2.6分,24 h时VAS评分平均为1.5分,疼痛基本消失。术后完全恢复正常活动平均为3 d。围手术期发生术后切口出血5例,溃疡周围切口感染32条肢体。术后随访12~24个月,溃疡均愈合,复发9例。结论个体化治疗下肢静脉性溃疡具有安全、有效、并发症少、溃疡愈合速度快、患者术后疼痛轻的优点。     

肝移植治疗原发性肝癌切除术后肝内复发七例

目的 探讨对原发性肝癌切除术后肝内复发患者进行肝移植手术的适应证和围手术期的治疗经验.方法 回顾性分析2000年9月至2005年9月间7例原发性肝癌切除术后肝内复发的患者接受原位肝移植治疗的临床资料,其中男性6例,女性1例,平均年龄43.7岁,肝移植术前均经病理学检查确诊为原发性肝癌,肿瘤组织学分级为高、中分化,肝癌切除术后无瘤期为6～31个月,均未发生肿瘤细胞侵犯大血管和肝外转移.所有患者均采用改良背驮式肝移植术.术后采用他克莫司(或西罗莫司)+霉酚酸酯+激素的三联免疫抑制方案.观察肝移植术后受者并发症及存活率情况.总结肝移植治疗原发性肝癌切除术后肝内复发的经验.结果 所有受者肝移植手术过程顺利,围手术期无死亡.1例术后22 h发生腹腔出血,1例术后13 d发生腹腔感染,1例术后4个月发生门静脉血栓,其余未发生严重并发症,7例受者均顺利出院.有3例受者分别于移植术后9、13及19个月时,因肿瘤复发而死亡,其余4例均长期无瘤存活,最长已达52个月.受者的1、2年存活率分别为85.7%和57.1%.结论 肝移植能有效治疗原发性肝癌切除术后肝内复发,受者适应证的选择和围手术期的辅助治疗非常关键.     

肝癌切除联合脾切除贲门周围血管离断术的临床应用

随着术前肝储备功能的预测、手术方法的改进及围手术期处理等环节的进步,医生在治疗肝癌的同时亦能顾及门静脉高压症的处理.对术式选择应既能根治或控制肝癌发展,又能有效控制消化道出血、防止再出血,在积极处理肝癌病灶的同时,采取适当的针对门静脉高压症的治疗措施对于提高原发性肝癌的总体疗效意义重大[1].     

肝癌切除联合脾切除贲门周围血管离断术的临床应用

随着术前肝储备功能的预测、手术方法的改进及围手术期处理等环节的进步,医生在治疗肝癌的同时亦能顾及门静脉高压症的处理.对术式选择应既能根治或控制肝癌发展,又能有效控制消化道出血、防止再出血,在积极处理肝癌病灶的同时,采取适当的针对门静脉高压症的治疗措施对于提高原发性肝癌的总体疗效意义重大[1].     

肝癌切除联合脾切除贲门周围血管离断术的临床应用

随着术前肝储备功能的预测、手术方法的改进及围手术期处理等环节的进步,医生在治疗肝癌的同时亦能顾及门静脉高压症的处理.对术式选择应既能根治或控制肝癌发展,又能有效控制消化道出血、防止再出血,在积极处理肝癌病灶的同时,采取适当的针对门静脉高压症的治疗措施对于提高原发性肝癌的总体疗效意义重大[1].     

肝癌切除联合脾切除贲门周围血管离断术的临床应用

随着术前肝储备功能的预测、手术方法的改进及围手术期处理等环节的进步,医生在治疗肝癌的同时亦能顾及门静脉高压症的处理.对术式选择应既能根治或控制肝癌发展,又能有效控制消化道出血、防止再出血,在积极处理肝癌病灶的同时,采取适当的针对门静脉高压症的治疗措施对于提高原发性肝癌的总体疗效意义重大[1].     

肝癌切除联合脾切除贲门周围血管离断术的临床应用

随着术前肝储备功能的预测、手术方法的改进及围手术期处理等环节的进步,医生在治疗肝癌的同时亦能顾及门静脉高压症的处理.对术式选择应既能根治或控制肝癌发展,又能有效控制消化道出血、防止再出血,在积极处理肝癌病灶的同时,采取适当的针对门静脉高压症的治疗措施对于提高原发性肝癌的总体疗效意义重大[1].     

肝癌切除联合脾切除贲门周围血管离断术的临床应用

随着术前肝储备功能的预测、手术方法的改进及围手术期处理等环节的进步,医生在治疗肝癌的同时亦能顾及门静脉高压症的处理.对术式选择应既能根治或控制肝癌发展,又能有效控制消化道出血、防止再出血,在积极处理肝癌病灶的同时,采取适当的针对门静脉高压症的治疗措施对于提高原发性肝癌的总体疗效意义重大[1].     

THORACOSCOPIC VAGOTOMY FOR RECURRENT ULCER AFTER PREVIOUS GASTRIC OPERATION

Background : Recurrent peptic ulcer after previous gastric operation is a difficult surgical problem and abdominal re-operation is associated with significant morbidity, mortality and recurrence rate. Methods : The authors report on five patients with recurrent ulcers who, after previous gastric operation, were treated with thoracoscopic vagotomy. Results : All patients tolerated the procedure well without complications, and the median hospital stay was 5 days. Endoscopy confirmed healing of the ulcers in all patients. Pre-operative and postoperative gastric acid studies showed a significant postoperative reduction in both basal and maximal acid output (P < 0.05). In a follow-up period of 18–33 months, one patient had a recurrent ulcer presenting with bleeding. Gastric biopsy revealed presence of Helicobacter pylori and repeated gastroscopy after a course of H. pylori eradication treatment showed a healed ulcer. The other four patients were asymptomatic. Conclusions : We conclude that thoracoscopic vagotomy is a simple and safe procedure for the treatment of recurrent ulcers after previous gastric operation, but the long-term results need further assessment.     

Control of acute gastroduodenal hemorrhage with cimetidine.

Thirty-four patients with acute gastroduodenal hemorrhage were treated with intravenous Cimetidine. Preliminary endoscopy was done at the onset of bleeding to determine the source of bleeding and to rule out the presence of a brisk arterial bleeding site that would require immediate operation for control. Sixteen of the patients had primary peptic ulcer disease and 18 patients had "stress ulcer" syndrome. The bleeding stopped following Cimetidine administration in 14 of the 16 peptic ulcer patients (88%) and in 13 of 18 stress ulcer patients (72%). There was no subsequent rebleeding. The data suggest that Cimetidine is of value in the immediate nonoperative management of acute gastroduodenal hemorrhage. Further, the availability of Cimetidine for postoperative use may modify the surgical approach to stress ulcer bleeding.     

Acute Surgical Treatment of Complicated Peptic Ulcers with Special Reference to the Elderly

The results of 136 consecutive patients treated surgically for the acute complications of peptic ulcers between 1990 and 1993 are reviewed. All patients required emergency operation. Among 136 patients, 91 had perforations, 42 hemorrhage, and 3 a penetrated peptic ulcer. The median age was 77 years; 65% were women; and 83% were more than 60 years old. Concurrent disease requiring medical treatment were present in 92 patients; 79 patients (58%) were currently or recently taking antiinflammatory drugs at the time of admission; 66% of the patients had duodenal ulcer. Only 46 patients (34%) had no postoperative complications; pneumonia, arrhythmia, bleeding, and septic complications were the most frequent. The overall mortality was 30%. Sepsis and multiple organ failure was the leading cause of death in most of the patients. It was concluded that elderly individuals using two or more antiinflammatory drugs should be considered potential peptic ulcer patients and should be treated prophylactically with ulcer-healing drugs.     

消化性溃疡合并上消化道出血影响因素分析

目的探讨消化性溃疡合并上消化道出血的影响因素。方法收集笔者所在医院315例消化性溃疡合并上消化道出血患者为研究组;同期门诊选取656例消化性溃疡无上消化道出血并发症的患者为对照组。再根据研究组中HP阳性者根除HP后随访2年,观察上消化道再出血情况。所有入选患者均统计幽门螺杆菌检测结果、NSAIDs服用、性别、年龄、饮酒史、血小板计数等情况。结果 NSAIDs对消化性溃疡合并上消化道出血的差异有统计学意义（P〈0.05）;年龄对消化性溃疡合并上消化道出血的差异有统计学意义（P〈0.01）;合用不同种类NSAIDs对消化性溃疡合并上消化道出血的差异有统计学意义（P〈0.05）。结论 NSAIDs增加消化性溃疡合并上消化道出血的风险;年龄与消化性溃疡合并上消化道出血相关,大于60岁的老龄消化性溃疡患者更易合并上消化道出血;合用不同种类NSAIDs较单用NSAIDs者消化性溃疡更易合并上消化道出血。     

Treatment of perforated gastroduodenal ulcer by simple suture followed by Helicobacter pylori eradication

AIMS OF THE STUDY: To determine the prevalence of Helicobacter pylori (HP) infection in Vietnam in case of perforated gastro-duodenal ulcer and to evaluate efficiency of medical treatment to obtain eradication of HP and ulcer healing. PATIENTS AND METHODS: One hundred and eleven patients with perforated gastro-duodenal ulcer underwent surgical suture. HP infection was diagnosed by urease test and pathologic examination of peroperative antral biopsies, and by postoperative detection of HP-specific immunoglobulins G. HP infection was defined by positivity of at least one test. Medical treatment included omeprazole, clarithromycin, and amoxicillin for 7 days followed by omeprazole for 3 weeks for duodenal ulcer and 5 weeks for gastric ulcer. Follow-up endoscopy with biopsies was performed 4 to 6 weeks after treatment cessation. RESULTS: Among 111 patients, 107 (96%) were infected by HP. The 4 patients non-infected by HP were treated by omeprazole alone and excluded from the study. Ulcer healed in 99 patients (93%). HP eradication was obtained in 102 patients (95%). The 8 patients with a non-healed ulcer and the 5 patients in whom HP eradication was not obtained at the first endoscopic control received additional medical treatment. Ultimately HP eradication and ulcer healing were obtained in all cases. CONCLUSION: In a country in which prevalence of HP infection is high, acid-reduction surgery is unnecessary in case of perforated gastro-duodenal ulcer treated by simple surgical closure.     

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial

OBJECTIVE: In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer. BACKGROUND DATA: Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation. METHODS: Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year. RESULTS: Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%). CONCLUSIONS: Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.     

Perforated peptic ulcer following gastric bypass for obesity

Peptic ulcer in the excluded segment of a gastric bypass performed in the management of morbid obesity has only rarely been reported in the literature. The purpose of this study is to review our experience with the condition in a series of 4300 patients who underwent gastric-restrictive surgery between 1978 and 1997. Eleven patients presented with acute perforation of a peptic ulcer in the excluded gastric segment. Nine ulcers were duodenal, one was gastric, and one patient had both gastric and duodenal perforations. The time between primary gastric-restrictive surgery and ulcer perforation varied from 20 days to 12 years. All patients presented with upper abdominal pain. The classical radiological sign of perforated peptic ulcer, free air under the diaphragm, did not occur in any patient. Nine patients were initially treated by primary closure of the perforation with subsequent definitive ulcer therapy by vagotomy, pyloroplasty, or gastrectomy. One case, initially treated elsewhere, was managed by placement of a Malecot catheter through the duodenal perforation, gastrostomy, and peritoneal drainage. One recent case remains symptom-free on H2 blockers after simple closure. There was no mortality. Six cases were previously reported in the literature with a 33 per cent mortality rate.     

Perforated gastroduodenal ulcer. I. postoperative mortality and late results following simple suturing

Following the introduction of H2-blockers in the treatment of gastroduodenal ulcer disease, there has not been a change in the incidence of perforated peptic ulcer. By the diagnosis of perforated peptic ulcer the indication for an emergency operation is shown in generally. The postoperative mortality amount now as before 10% and the ulcer relapse rate behave less or more high, dependent on operative procedures, which optical choice is open. Therefore the perforated gastroduodenal ulcer has not lost any actuality. The following paper takes into account the informations of 245 patients from 1970 to 1988, which perforation of peptic ulcer were treated only with simple suture. The collection of data was retrospective till 1985 and since then prospective. Beside analysis of postoperative mortality, reasons of death, complications during healing and preoperative false diagnosis we have done a follow up of operated patients till 1987 (n = 232). On the basis of the results a statement was given for the therapeutical management of ulcer perforations.     

Peptic ulcer hemorrhage: Local injection of fibrin sealant—Experimental and clinical data

This study was undertaken to assess the role of fibrin sealant in achieving early hemostasis and wound healing following endoscopic injection in peptic ulcer hemorrhage. In an experimental study in Wistar-rats we looked at the healing rate and histological changes of laser-induced acute gastric ulcers and acetic acid-induced chronic gastric ulcers following injection of standard sclerosants as well as fibrin sealant. A statistically favourable result was observed in the fibrin treated group. We also treated 127 patients suffering from bleeding peptic ulcers with local injection of fibrin sealant (33 Forrest stage la, 40 Forrest lb, 54 Forrest Ila) in a prospective clinical trial during the period of 1. February 1988 to 31. January 1991. A primary recurrence was noticed in 19 (14.9%) patients. With a 2. injection the hemostasis was definite in 116 of 127 patients (91.3%). Only 11 patients (8.6%) needed surgery for hemostasis. The mortality was 6.3% (8 patients).     

Enhanced postoperative recovery pathways in emergency surgery: a randomised controlled clinical trial

Background

Enhanced recovery pathways are now widely used in elective surgical procedures. The feasibility of enhanced postoperative recovery pathways in emergency surgery for perforated peptic ulcer disease was investigated in this randomized controlled clinical trial.

Methods

Patients with perforated peptic ulcer disease who underwent laparoscopic repair were randomized into 2 groups. Group 1 patients were managed with standard postoperative care and group 2 patients with enhanced postoperative recovery pathways. The primary endpoints were the length of hospital stay and morbidity and mortality.

Results

Forty-seven patients were included in the study. There were 26 patients in group 1 and 21 in group 2. There were no significant differences in the morbidity and mortality rates, whereas the length of hospital stay was significantly shorter in group 2.

Conclusions

The application of enhanced postoperative recovery pathways in selected patients with perforated peptic ulcer disease who undergo laparoscopic Graham patch repair seems feasible.