十二指肠、小肠闭锁及合并畸形的术式选择（附3例报告）

十二指肠、小肠闭锁是小儿外科少见的先天性发育畸形，也是新生儿肠梗阻的重要病因之一，常合并其它发育异常。正确的外科术式选辑与患儿生存率的提高密切相关。作等自1994年9月至1997年3月收活3例，手术效果满意。笔等认为对于十二指肠、小肠闭锁的治疗，在明确其诊断的基础上，要善于发现或排除其它发育不良的存在，针对各种发育异常进行综合评价，作出准确的术式选择，才能提高患儿生存率。     

新生儿小肠闭锁8例诊治体会

目的 探讨新生儿小肠闭锁的诊断及手术治疗方法.方法 总结分析收治的8例新生儿小肠闭锁相关的诊断及手术方式资料.结果 8例其中十二指肠降段闭锁3例,空肠闭锁5例.均行手术治疗,其中3例术后5～6 d 2次手术.8例患儿术后恢复良好,随诊2～5 a效果良好,发育均正常.结论 新生儿小肠闭锁是新生儿常见的消化道畸形,早期诊断...     

先天性小肠闭锁治疗体会

目的:进一步探讨先天性小肠闭锁的术式及围术期治疗原则。方法:系统回顾我院近两年间收治的小肠闭锁患儿68例,手术采用闭锁两断肠切除,端端斜形单层一期吻合术,围术期辅以周围静脉径路全静脉营养,术后4天对28例肠功能恢复不良患儿鼻饲中药复方大承气汤。结果:本组患儿术后存活56例,治愈率82.35％,疗效满意。结论:先天性小肠闭锁治疗的关键在于选择适当的手术方式以保障吻合口通畅和良好的愈合;围术期护理和治疗是决定手术成败的关键,周围静脉径路全静脉营养即便于操作和护理,又能基本上满足患儿机体营养发育的需要,是一种既安全又有效的治疗措施。中药复方大承气汤应用于术后肠功能恢复不良患儿,对闭锁远端肠功能的恢复具有帮助。     

术中门静脉测压对胆道闭锁患儿Kasai术后的预后评估

目的采用术中门静脉压力测定对胆道闭锁患儿Kasai术后的预后评估。方法1990年1月至1996年12月,法国巴黎Bic毢tre医院儿外科共对127例胆道闭锁患儿行Kasai手术或其变异术式,其中113例术中脐静脉插管行门静脉压力测定,术后平均随访9年。分别计算患儿带自体肝生存率和带自体肝且无门静脉高压生存率,进行比较;依据患儿手术时的年龄,胆道闭锁的类型,手术方式,有无polysplenia综合征以及术时门静脉压力对生存率进行评估。结果术中门脉压力正常患儿带自体肝5年和10年生存率较门静脉压力升高组显著延长。门静脉压力升高组5年带自体肝且无门静脉高压表现的生存率显著低于门静脉压力正常组。胆道闭锁的类型和门静脉压力改变较其他指标更显著反映对Kasai术后预后影响。结论术前门静脉压力改变对Kasai术后的预后有显著性指导意义,并且优于其他指标。     

先天性小肠闭锁的外科手术治疗

新生儿小肠闭锁为新生儿外科常见急诊,发病率报道由1/330～1/1500不等.小肠闭锁根据闭锁部位可分为十二指肠闭锁、空肠闭锁和回肠闭锁,本文重点阐述空肠、回肠闭锁.目前,小肠闭锁的病因研究中,宫内肠系膜血管受损导致受累肠管坏死是最为接受的理论.最近的肠闭锁小鼠模型研究提示一部分的肠闭锁是遗传性的,小肠在由纤维细胞生长因子调节的小肠发育中,出现了细胞增殖及分化障碍,临床上遗传性、多发性肠闭锁为一种特殊类型的肠闭锁,诊断上与一般肠闭锁并无特异性,但预后极差.     

Ladd术加十二指肠大部切除术治疗儿童巨十二指肠症一例

患儿,女,2岁7个月.因腹胀、呕吐半个月于2007年4月入住我科.上消化道造影示十二指肠显著扩张,最大直径达8cm,扩展范围达空肠近端.考虑患儿十二指肠远端存在梗阻因素,遂决定剖腹探查.术中见十二指肠降部明显扩张,内有较多食物积存.Treitz韧带远端5cm空肠明显变细,考虑此处为梗阻部位.由于十二指肠全程显著扩张,决定行Ladd术,即松解Treitz韧带,游离结肠,顺时针旋转小肠,将全部小肠置于右侧腹,结肠置于左侧腹,十二指肠拉直,整个消化道处于旋转前状态.剖开狭窄断空肠,发现肠腔内存在一有孔隔膜,诊断为空肠有孔膜状闭锁.十二指肠内积存大量未消化的菠萝片.     

先天性肠闭锁和肠狭窄的诊治现状

先天性肠闭锁和肠狭窄指从十二指肠到直肠间发生的肠道先天性闭塞和变窄,是新生儿外科中较常见的消化道畸形,发生率约1／5000,男女发病率接近。肠闭锁中按发生率高低依次为小肠闭锁、十二指肠闭锁、结肠闭锁。以前该病死亡率较高,但近年来,随着麻醉和手术技术的改进、术后营养支持和监护水平的提高,存活率已显著提高,目前一般国内外文献报告先天性肠闭锁和肠狭窄的治愈率为80％～95％。本文就目前国内外先天性肠闭锁和肠狭窄的诊治有关问题进行简要讨论。     

胆道闭锁患儿Kasai手术年龄选择与预后关系的研究进展

Kasai手术是胆道闭锁的首选治疗方法, 手术年龄是影响患儿预后、避免肝移植的重要因素。选择合适手术年龄、解除胆道梗阻恢复胆汁引流、提高自体肝生存时间、避免过早行肝移植是临床医师共同努力的方向。Kasai手术年龄与黄疸清除率、自体肝生存率及术后胆管炎发生率均存在相关性。本文系统综述了胆道闭锁Kasai手术年龄选择的相关研究进展, 旨在为探索最佳Kasai手术年龄提供参考。     

126例胰十二指肠切除术的经验

目的　介绍提高胰十二指肠切除术 (PD )的手术质量和疗效经验。方法　回顾性分析我院 1973～ 2 0 0 0年间采用PD传统Child术式 (4 1例 )和闭锁式胰腺套入吻合Child术式 (85例 )两组的术后并发症和手术死亡率。结果　闭锁式胰腺套入吻合Child手术组术后胰瘘发生率、手术死亡率分别为 2 .4%和 4.7% ,较传统Child术式组有显著降低 (P <0 .0 1)。结论　闭锁式胰腺套入child术式是安全、合理而实用的术式。     

先天性食管闭锁术后近期/远期并发症的预防和处理

食管闭锁伴或不伴食管气管瘘是严重的新生儿发育畸形,随着新生儿外科技术的提高和围术期监护的完善,国外总体生存率已达90%以上[1-2],包括极低出生体重儿和伴发心脏畸形的患儿[3],仅在一些伴随严重畸形患儿仍有较高的死亡率.我国一些较大的临床中心报道食管闭锁生存率约为91.4%[4],但其中多数为足月产儿和不伴有心脏畸形的患儿.半个多世纪以来,食管闭锁的治疗经历了很大的变化,但是其术后的各种并发症仍然是临床上非常棘手的问题,也是影响生存质量的重要因素.本文着重叙述先天性食管闭锁术后近远期并发症的预防和处理.     

纤维胆道镜在肝胆管结石治疗中的价值

目的 探讨手术和纤胆镜联合治疗肝胆管结石的应用价值。方法 回顾分析1998年9月～2003年6月共380例手术和纤胆镜联合治疗肝胆管结石病人的临床资料。结果 380例肝胆管结石病人术中应用纤胆镜技术后。残留结石率由38％降到12．9％,132例术中纤胆镜发现合并肝内胆管狭窄，其中30例为假性狭窄，经纤胆镜扩张后治愈，其余采用了相应的手术方式。49例残留结石的病人术后均采用纤胆镜取石，残留结石率为1．9％，4例因多次取石费用高而放弃，3例因胆道出血而放弃。结论 肝胆管结石的手术中联合应用纤胆镜可使肝内结石的诊断更明确、取石更有效，并对手术方式的选择有指导意义，术后经T管窦道纤胆镜取石是治疗肝H日管残留结石的的主要手段.     

Congenital diaphragmatic hernia: improved surgical results should influence abortion decision making.

AIMS: To compare surgical results for congenital diaphragmatic hernia (CDH) in two Scandinavian university hospitals and to evaluate the effects of abortions on the clinical profile of CDH in Iceland. METHODS: A retrospective study including all CDH-cases in Iceland 1983-2002 and children referred to Lund University Hospital 1993-2002. Aborted fetuses with CDH from a nation-wide Icelandic abort-registry were also included. RESULTS: In Iceland, 19 out of 23 children with CDH were diagnosed < 24 hours from delivery, one with associated anomalies. Eight fetuses were diagnosed prenatally and seven of them aborted, three having isolated CDH at autopsy. In Iceland, 15 of 18 children operated on survived surgery (83% operative survival). In Lund 28 children were treated with surgery, 23 of them diagnosed early after birth or prenatally. Four children did not survive surgery (86% operative survival) and 9 (31%) had associated anomalies. All the discharged children treated in Iceland and Lund are alive, 3-22 years postoperatively. CONCLUSION: CDH is a serious anomaly where morbidity and mortality is directly related to other associated anomalies and pulmonary hypoplasia. However, majority of CDH patients do not have other associated anomalies. In spite of improved surgical results (operative mortality < 20%), a large proportion of pregnancies complicated with CDH are terminated. We conclude that the improved survival rate after corrective surgery must be emphasized when giving information to parents regarding abortion of fetuses with a prenatally diagnosed CDH.     

Benefit of operative mortality reduction on colorectal cancer survival

BACKGROUND: The aim of this study was to determine trends in operative mortality after colorectal cancer surgery over a 20-year period in a well defined population, and consequences on overall survival. METHODS: Some 4745 new cases of colorectal adenocarcinoma were registered between 1976 and 1995 in a French region containing 500 000 people. Among these, 84.3 per cent were operated on, of whom 78.1 per cent were resected. RESULTS: The overall operative mortality rate decreased from 17.7 to 8.1 per cent between 1976-1979 and 1992-1995. Corresponding rates after curative surgery were 12.6 and 6.2 per cent respectively. Period of diagnosis, age and subsite were factors independently associated with operative mortality. Applying the operative mortality rates for the interval 1976-1979 to the 1992-1995 cohort, the expected 5-year survival rate after curative surgery would have been 40.0 per cent, compared with an observed rate of 51.0 per cent. This corresponds to a 27.5 per cent improvement in 5-year overall survival. Applying this result to the French population as a whole, it was estimated that almost 3000 deaths are avoided each year in France as a result of the reduction in operative mortality. CONCLUSION: Operative mortality decreased dramatically over the 20 years of the study. It was associated with a significant improvement in survival after surgery for cure.     

肝门部胆管癌根治性切除手术技巧

肝门部胆管癌是具有挑战性的疑难病症,其根治性切除一直是外科医生不断追求的目标之一.围手术期治疗策略的优化,影像学技术的提高,特别是手术器械的改进为肝门部胆管癌治疗的发展起到了重要的推动作用[1].肝门部胆管癌手术策略的制定以及规范化操作是获得满意远期疗效的基础.     

肝门部胆管癌根治性切除手术技巧

Hilar cholangiocarcinoma remains a formi-dable challenge to hepatopancreatobiliary surgeons since the reported resection of a primary cancer originating at the hepatic duct confluence by Brown and Myers in 1954. Emerging evidence has indicated that aggressive surgery with a curative resection offers a better option for long-term survival compared with conservative therapy. Liver transplantation has also been considered as a management opportunity for the treatment of cholangiocarcinoma. However, the survival rate has been poor due to the high proportion of disease recurrence. This review highlights recent techniques in hilar cholangiocarcinoma resec-tion, with special attention to the management of the resection margin, clinical skills of liver resection, lymph node clearance, and portal vein or hepatic artery resection or reconstruction. In addition, technical advances have been proposed in hepatopan-creatoduodenectomy and liver transplantation for hilar cholangio-carcinoma treatment. In the current hepatic procedures, promis-ing survival outcomes have been obtained in patients with hilar cholangiocarcinoma, exhibiting a decreased operative mortality and a steady improvement in long-term survival. Overall, the correct clinical strategy and appropriate surgical techniques may provide an increased chance to cure patients with hilar cholan-giocarcinoma.     

肝门部胆管癌根治性切除手术技巧

肝门部胆管癌是具有挑战性的疑难病症,其根治性切除一直是外科医生不断追求的目标之一.围手术期治疗策略的优化,影像学技术的提高,特别是手术器械的改进为肝门部胆管癌治疗的发展起到了重要的推动作用[1].肝门部胆管癌手术策略的制定以及规范化操作是获得满意远期疗效的基础.     

肾部分切除术治疗肾肿瘤的安全性及疗效分析

目的 评价肾部分切除术治疗肾肿瘤的安全性及有效性.方法 回顾性分析56例行肾部分切除术患者的临床资料.术中肾动脉阻断时间≤30 min者28例.＞30 min者28例.采用99Tcm-DTPA肾核素扫描检测术前术后分肾的肾小球滤过率(GFR),比较两组患者术中出血量、手术时间、术后住院日、并发症发生率以及术前、术后1周和术后6个月的GFR值,明确肾热缺血安全时限,并随访远期生存情况.结果 术后随访30～48个月,平均36个月,总体生存率和肿瘤无复发生存率分别为100%和98%.阻断时间≤30 min和＞30 min组患者术中失血量、手术时间、术后住院日及并发症比较,差异均无统计学意义(P＞0.05).两组术前患肾GFR分别为(42.9±4.9)、(42.8±5.6)ml/min,术后1周为(34.2±4.9)和(30.4±5.2)ml/min,前者GFR降低程度低于后者,差异有统计学意义(p=0.007).术后6个月时肾热缺血时间≤30 min组患肾GFR为(41.2±4.3)ml/min,与术前相比,差异无统计学意义(P＞0.05);＞30 min组GFR为(38.1±5.0)ml/min,仍明显低于术前水平(P=0.001).结论 肾部分切除术治疗肾肿瘤局部复发率低,远期生存率高,并发症发生率低,而且能最大限度地保留功能性肾单位,安全有效.术中阻断肾血管可以有效减少术中失血,将热缺血时间控制在30 min内,对肾功能影响较小,安全可行.

Abstract：

Objective To report the safety and efficacy of partial nephrectomy (PN) in 56 patients with renal tumors. Methods A retrospective analysis was performed for 56 patients who were treated with PN.Patients were divided into two groups according to the occlusion time.The occlusion time for Group 1 was≤30 min in 28 cases,and Group 2＞30 min in 28 cases.All patients underwent pre-and post-operation 99Tcm-diethylenetriamine pentoacetic acid renal scintigraphy, to determine the renal glomerular filtration rate (GFR).The GFR values, amount of blood loss during operation,operative time,postoperative hospital stay and the complications rate were compared between the two groups prior to surgery and one week and six months post-surgery.All patients were followed-up.Results The average follow-up time was 36 (30-48) months.The overall survival rate and tumor recurrence-free survival rate were 100% and 98%.There was no significant difference between vessel clamp time≤30 min and＞30 min in the amount of intraoperative blood loss,operative time,postoperative hospital stay and complications rate,P values were 0.266,0.487,0.879 and 1.000.The preoperative and 1 week postoperative GFR values of the two groups were (42.9±4.9) and (34.2±4.9),(42.8±5.6) and (30.4±5.2) ml/min.The difference was significant(P=0.007).The GFR values were (41.2±4.3)ml/min at 6 months after surgery for Group 1,compared with that before surgery,but the difference was not significant (P＞0.05).While the GFR values were (38.1±5.0) ml/min for Group 2,and the GFR for Group 2 did not recover to the preoperative level (P=0.001). Conelusions PN for renal tumors could be a safe and effective treatment option.The damage on renal function could be minimal when the renal artery clamping time is controlled to within 30 min.     

Improved Results of Liver Resection for Hepatocellular Carcinoma on Cirrhosis Give the Procedure Added Value

OBJECTIVE: To review a single-center experience to update the performance indexes of liver resection (LR). SUMMARY BACKGROUND DATA: Several therapies have been proposed in the treatment of hepatocellular carcinoma (HCC) on cirrhosis, although LR was the first to be widely applied. METHODS: Of 408 patients with cirrhosis admitted for HCC in the period 1983 to 1998, 264 had a LR. Patient selection, surgical technique, 30-day deaths, long-term survival, recurrence rate, and recurrence treatment were reviewed after stratifying patients according to the year of surgery. Mean follow-up was 34.5 +/- 29.1 months. RESULTS: The number of Child A patients who underwent surgery after the discovery of the tumor at routine evaluation increased significantly from 64.5% to 87.9% during the study period. Procedures carried out without blood transfusions increased from 31.4% to 76.9%. The overall operative death rate was 4.9%. Actuarial survival rates were 63.1% and 41.1% after 3 and 5 years, respectively; actuarial tumor-free survival rates were 49.3% and 27.9% at the same intervals. After 1992, surgical deaths decreased from 9.3% to 1.3%. Actuarial survival rates increased from 52.9% and 32.3% to 71.7% and 49.4% after 3 and 5 years, respectively. There was no difference in the actuarial recurrence rate between the two periods, but the chance to treat recurrence increased over time from 22.4% to 53.7% with a concomitant, significant improvement in survival. CONCLUSIONS: LR represents a well-established therapy for HCC on cirrhosis. It remains one of the fundamentals in the multidisciplinary approach to this tumor and should be considered as the first option for patients with preserved hepatic function and limited disease. Today, LR should offer a surgical death rate of less than 1.5%, a 5-year survival rate of approximately 50%, and a 5-year tumor-free survival rate of 28% when performed in specialized centers.     

What is the probability that coronary artery surgery prolongs life?

Two-hundred and nine male patients who had coronary artery surgery from 1972 to 1974 at the Marshfield Clinic (MC) were compared with Veterans Administration (VA) coronary patients to determine the probability of coronary surgery prolonging life. The survival data includes operative and late cardiac and noncardiac deaths. Including the MC operative mortality rates but considering late noncardiac deaths withdrawn as alive at the time of death, the MC cumulative 5-year surgical survival rate is 93%. This is identical to predicted 93% 5-year survival rate for any man of 54.5 years, the average age of MC patients living in this geographic locale in 1973. Annual attrition rates, including the noncardiac deaths, are 1.4% for any man 1.5% per year for MC patients, based on MC 5-year survival data. It is probable that coronary surgery prolongs life by sharply reducing late cardiac deaths.     

黄色肉芽肿性胆囊炎74例诊治分析

目的 探讨黄色肉芽肿性胆囊炎（XGC）的外科治疗方法。方法 回顾分析上海交通大学医学院附属瑞金医院1996年5月至2006年2月治疗XGC74例的临床资料，比较腹腔镜与开腹手术在手术时间、术后住院天数方面的差别。结果 74例中47例行腹腔镜手术（腹腔镜组），27例行传统开腹手术（开腹组）。开腹组的平均手术时间为113．9min，腹腔镜组的平均手术时间为69．4min，腹腔镜组的手术时间明显短于开腹组（P〈0．01）。开腹组的术后平均住院天数为18．3d；腹腔镜组的术后平均住院天数为8．7d，明显短于开腹组（P〈0．01）。腹腔镜组的手术中转率为10．6％。结论 手术是治疗XGC最有效可行的方法，腹腔镜手术因其在手术时间和术后住院时间上存在明显优势，可以作为治疗XGC的首选方法。