结直肠疾病开腹手术中合理应用电刀防治腹部切口并发症探讨

目的探讨合理应用电刀在防治结直肠疾病开腹手术后切口皮下脂肪液化、积液及切口感染的临床效果。方法对436例结直肠疾病患者行开腹手术时,腹壁切口除皮肤表层外均使用电刀,进行有张力切割,止血采用点凝,观察其术后切口皮下脂肪液化、积液及切口感染情况。结果结直肠疾病开腹手术436例,术后其中32例（7.34%）局部皮下脂肪液化、积液少许,接近Ⅰ期愈合;24例（5.50%）切口感染,加强换药渐自行愈合;14例（3.21%）切口感染裂开,Ⅱ期缝合。结论结直肠疾病开腹手术中,腹壁切口除皮肤表层外均使用电刀,进行有张力切割,止血采用点凝,是减少术后切口皮下脂肪液化、积液及切口感染的理想方法。     

结直肠肿瘤根治术后腹腔乳糜漏的诊治

目的 总结结直肠肿瘤根治术后腹腔乳糜漏的诊治及预防经验.方法 比较1259例不同术式（开腹与腹腔镜）、不同部位（右半、左半结肠与直肠）结直肠肿瘤根治术后腹腔乳糜漏的发生率.结果 本组46例患者（3.6%）术后发生腹腔乳糜漏,开腹组与腹腔镜组的发生率分别为3.2%（18/570）和4.1%（28/689）,差异无统计学意义（P＞0.05） 右半结肠根治术后腹腔乳糜漏的发生率为9.6%（16/167）,显著高于左半结肠的2.6%（7/268）和直肠的2.8%（23/824）（P＜0.05）.45例患者经保守治疗（治疗措施包括禁食、肠外营养、静脉使用生长抑素和延缓拔除腹腔引流管）治愈,1例经行腹腔淋巴管漏口结扎术并局部喷洒医用胶治愈,无死亡病例.结论 根治性右半结肠切除是术后发生乳糜漏的高危因素 术后腹腔乳糜漏保守治疗有效.     

腹腔镜结直肠癌术后切口感染的影响因素分析

目的：探讨结直肠癌腹腔镜手术后切口感染的影响因素。 方法：回顾性分析中国医科大学附属盛京医院结肠直肠肿瘤外科697例结直肠癌手术患者的临床资料,对可能影响切口感染的相关因素进行单因素与多因素分析。 结果：697例手术中有43例出现切口感染43/697（6.17%）,单因素分析显示,结直肠癌手术切口感染与性别、年龄、手术时间、手术方式、是否合并基础疾病有关（均P<0.05）;Logistic回归显示,手术方式、年龄及手术时间为切口感染的独立影响因素（均P<0.05）。 结论：手术方式、年龄及手术时间是腹腔镜结直肠癌手术术后患者切口感染的独立影响因素。如病情允许,结直肠癌腹腔镜手术应作为减少术后切口感染率的首选手术术式。     

高龄结肠直肠癌合并急性肠梗阻的外科治疗

目的：探讨老年结肠直肠癌合并急性肠梗阻的外科诊断和治疗的有关问题。方法：89例老年结肠直肠癌并急性肠梗阻：行一期切除吻合69例,Hartmamm手术10例,回肠-乙状结肠或回肠-直肠捷径吻合手术5例,肿瘤切除、近端肠管造口、二期恢复肠道连续5例。结果：术后出现切口感染、腹腔脓肿和肠瘘等并发症14例（15.7%）,其中死亡2例,87例（97.8%）痊愈出院。结论：老年大肠癌合并急性肠梗阻一经确诊,应积极争取手术,术式选择应根据患者具体病情决定。     

老年结直肠癌并发肠梗阻患者42例临床分析

目的总结老年结直肠癌合并肠梗阻患者的手术效果。方法对42例老年结直肠癌合并肠梗阻患者实施行Ⅰ期肠吻合根治及肿瘤远端闭合、近端肠管于腹壁切口造瘘等手术。观察治疗效果及术后并发症发生率。结果 42例患者住院时间10~31 d。发生术后并发症5例(11.90%),其中切口感染2例,腹腔感染1例,心肌梗死1例和吻合瘘1例。死亡2例,死亡原因:并发心肌梗死和感染性休克引起多脏器功能衰竭各1例。余40例痊愈出院。结论老年结直肠癌合并肠梗阻患者,在严格掌握适应证的前提下,行Ⅰ期根治术,可减少二次手术率,术后并发症少,值得临床应用。     

内镜下全层切除术治疗结直肠黏膜下肿瘤的价值

目的探讨内镜下全层切除术（EFTR）治疗结直肠黏膜下肿瘤（SMT）的可行性和安全性。方法回顾性分析2009年9月至2012年3月间复旦大学附属中山医院内镜中心实施EPTR切除的4例结直肠SMT患者的临床资料。结果4例患者中男性1例,女性3例,年龄33。78岁;肿瘤位于上段直肠2例,升结肠1例．降结肠1例。4例EFTR手术均获成功并完整切除肿瘤．手术时间24-80（平均48．0）min,切除肿瘤最大径为0.8．2．0（平均1．45）cm。术后病理结果提示分别为神经鞘瘤、囊样积气症、子宫内膜异位症和黏膜肌层平滑肌轻度增生。术中及术后均未出现出血和穿孔,有2例患者术后出现腹痛、发热,其中1例出现局限性腹膜炎体征,均经禁食、静脉抗炎补液等保守治疗后好转,未行外科干预。术后随访1-30个月,未发现肿瘤残留或复发。结论EPTR治疗结直肠SMT安全、有效。     

PPH术后合并直肠口袋征的防治（附2例报告）

目的探讨PPH术治疗脱垂痔术后合并直肠口袋征的原因和处理。方法回顾性分析2例PPH术后合并直肠憩室患者的临床资料,总结手术并发症的发生原因及处理措施。结果 1例（男性）PPH术后肛门局部肿物脱出,伴出血及低热,1例（女性）术后排脓血黏液便伴低热,均经直肠指诊发现及肛镜诊断吻合口局部形成直肠口袋征。其中男性患者经保守治疗治愈,女性患者出现间断性肛周肿痛感染,行脓肿切开引流及开放＂口袋＂后治愈。结论荷包缝合不当可导致PPH术后发生直肠口袋征,开放引流疗效确切。     

腹腔镜辅助结肠全（次全）切除术150例

目的探讨腹腔镜辅助结肠全（次全）切除术（LAC）的技术特点和安全性。方法总结2005年6月至2008年5月问开展的150例LAC手术病例的临床资料。结果本组患者LAC联合改良Duhamel手术治疗重度功能性便秘126例,LAC联合回肠直肠吻合治疗家族性息肉病11例、溃疡性结肠炎8例和结直肠多发肿瘤5例。147例完成LAC,3例中转开腹。腹腔镜下手术时间（76．0±23．5）min,术中出血（35．4±10．9）ml,辅助切口长（5．2±1．1）cm。术后肠道功能恢复时间（42．5±12．6）h,无切口感染、吻合口瘘等并发症。术后1周内．2例出现严重腹泻．2例出现不完全性小肠梗阻,经保守治疗缓解。无并发症者术后住院时间（7．2±1．5）d。116例患者术后获1年以上随访,胃肠生活质量指数为（110．3±20．7）分,与术前的（90．1±23．8）分比较,差异有统计学意义（P〈0．05）。105例重度功能性便秘患者症状均得到缓解;3例结直肠多发肿瘤、5例家族性息肉病和3例溃疡性结肠炎患者均未见复发、转移。结论LAC更好地体现了腹腔镜手术微创的优点．是治疗累及全结肠疾病的合理术式选择。     

结直肠梗阻支架植入后腹腔镜手术的临床疗效

目的探讨结直肠肿瘤致结肠梗阻支架植入治疗后再行腹腔镜结直肠癌根治术的可行性。方法回顾性分析2009年10月至2011年11月上海市第十人民医院收治的行支架植入治疗的21例结直肠肿瘤致急性梗阻患者的临床资料。对支架植入情况、肠梗阻症状、相关疾病缓解情况、腹腔镜手术结果等进行分析,计数资料采用Fisher确切概率法检验。结果21例左半结肠梗阻患者中17例支架植入成功;支架植入后肠梗阻症状均在24h内得到缓解。支架植入后患者Alb、Hb获得明显改善,酸碱失衡、水电解质紊乱获得纠正,高血压、糖尿病、心肌缺血、肺部感染均有明显改善,麻醉风险明显降低（P〈0．05）。心律失常、慢性阻塞性肺病等内科疾病则改善不明显（P〉0．05）。4例支架植入治疗失败患者,1例支架导致结肠穿孔,3例因完全梗阻未能植入,均行急诊Ha~mann手术。所有肠梗阻症状缓解患者顺利行腹腔镜结直肠癌根治术。腹腔镜手术时间为（142±38）min,出血量为（29±11）mL,远切缘距肿瘤距离为（3．8±0．3）em,左髂区斜切口长度为（6．2±2．8）cm。术后无吻合口瘘发生,排气时间为（2．4±0．6）d,进食时间为（3．8±1．6）d,术后住院时间为（17±4）d。21例患者随访6个月至2年,1例术后1年因脑血管意外死亡;2例发生肿瘤肝转移,目前仍在维持化疗中。其余18例患者均无瘤生存。结论肿瘤导致的结直肠梗阻经支架植入治疗使肠梗阻缓解后再行腹腔镜结直肠癌根治术是可行的。     

腹腔镜联合辅助化疗及内镜治疗进展期结直肠癌合并腺瘤的应用研究

目的：探讨腹腔镜结直肠癌切除术加辅助化疗加二期内镜下治疗结直肠癌合并根治术切除范围外结直肠腺瘤的临床应用价值。方法：2005年1月-2010年6月对54例进展期结直肠癌合并根治术切除范围外结直肠腺瘤（〉1．0cm）的患者（研究组）行腹腔镜结直肠癌切除术加辅助化疗（FOLFOX4方案）加二期内镜下腺瘤切除的综合治疗,对同期396例单发进展期结直肠癌患者（对照组）行腹腔镜结直肠癌切除术加辅助化疗（FOLFOX4方案）。通过并发症发生率、长期随访等评价治疗效果。结果：2组患者在年龄、性别、手术方式、手术时间、术中出血量、并发症发生率、平均住院时间、肿瘤大小、淋巴结转移、TNM分期及1、3和5年存活率差异无统计学意义（P〉O．05）。研究组辅助化疗后对合并腺瘤进行内镜下切除治疗,4例出血经保守治疗后成功止血,未发生穿孔、狭窄等严重并发症;3例患者术后病理组织学检查为腺瘤癌变,其中2例癌变局限于腺瘤中,1例癌细胞侵犯达黏膜下层,该例患者再次行腹腔镜下切除,术后随访无复发。结论：腹腔镜联合辅助化疗及内镜为合并结直肠癌根治术切除范围外腺瘤的患者提供了一种安全有效的微创治疗方法,值得临床推厂和应用。     

Experience of sternal secondary closure by means of a titanium fixation system after transverse thoracosternotomy

Sternal dehiscence is a common complication after transverse thoracosternotomy in patients undergoing bilateral sequential lung transplantation (BSLT). These patients can be treated with conservative therapy, but severe dehiscence requires surgical reapproximation and secondary closure of the sternum. Seventy-one cases of patients who underwent BSLT between January 2007 and May 2009 were reviewed retrospectively. Out of 71 patients, the sternum was intact in two cases due to the use of bilateral anterolateral thoracotomy, and a clamshell incision had been utilized in 69 patients. Four patients (6.8%) presented with persistent chest pain with severe sternal dehiscence diagnosed by chest X-ray and/or chest computed tomography, and underwent sternal reapproximation using the Synthes Titanium Sternal Fixation System for longitudinal sternal plating. All four patients had successful sternal realignment and resolution of their preoperative clinical symptoms. No perioperative or postoperative complications were observed. The Synthes Titanium Sternal Fixation System is an appropriate and effective method for internal fixation of the sternum when used for symptomatic severe sternal dehiscence after sequential BSLT via transverse thoracosternotomy.     

老年人胃癌的围手术期处理（附181例报告）

目的探讨老年胃癌患者的围术期处理经验。方法回顾性分析1996年7月至2007年6月181例60岁以上接受手术治疗的胃癌病例。结果181例患者中合并糖尿病27例，慢性支气管炎37例，阻塞性通气障碍12例，贫血79例，低蛋白血症28例，高血压病63例，冠心病72例。无术前死亡病例，术后出现并发症147例次：胰漏1例，腹水形成13例，伤口裂开1例，伤口感染3例，心衰2例，心绞痛3例，血压升高79例，心律失常57例，血糖升高34例，肺部感染18例，急性胰腺炎1例；死亡3例（1．66％）。结论术前合并症增加了手术的风险性，但术前全面了解病情，加强对其围手术期处理可提高手术的安全性，降低手术死亡率和并发症发生率。     

乳腺癌乳房部分切除术后即刻背阔肌肌皮瓣重建乳房的临床应用

目的探讨Ⅱ期和Ⅲ期乳腺癌新辅助化疗后行乳房部分切除术,并转移同侧背阔肌肌皮瓣（latissimus dorsal myocutaneous flap,LDM皮瓣）进行即刻重建乳房的临床应用及效果。方法18例经粗针抽吸病理组织证实的Ⅱ期和Ⅲ期乳腺癌,经新辅助化疗后进行乳房部分切除术,并转移同侧LDM皮瓣进行重建乳房。术后1个月及放疗完成后1个月对重建乳房外形评分,取平均值为最后分值。采用Kaplan-Meier方法进行生存分析。结果肿瘤经新辅助化疗最大直径由30～55mm缩小至25～45mm。乳房切除标本平均重量为140g（90～220g）。重建乳房93．33％（16／18）评分3分以上。5例背部供区皮下积液（27．78％）,2例背部切口裂开（11．11％）。平均随访22个月无局部复发,1例（5．55％）远位转移（骨转移）,Kaplan-Meier生存曲线与同期根治术比较无差异。结论联合新辅助化疗的Ⅱ期和Ⅲ期乳腺癌部分乳房切除术后转移LDM皮瓣重建乳房,可提高乳房外形的满意度。     

Pyogenic spondylitis in the elderly: a report from Japan with the most aging society

Pyogenic spondylitis can be life-threatening for elderly patients. To discuss the characteristics of the disease in the elderly, medical records of 103 consecutive cases of pyogenic spondylitis were reviewed. Of these, 45 cases were 65 years of age or older, and these 45 cases were enrolled into further study. In this study, the proportion of elderly patients among the total number with pyogenic spondylitis was 43.7%, and this figure has increased with the passing of time as follows: 37.5% (1988–1993), 44.4% (1994–1999), and 55.5% (2000–2005). The microorganisms were isolated in 16 cases: Staphylococcus aureus in 13 cases (including methicillin-resistant Staphylococcus aureus in nine) and others in three. Twenty-five patients had associated diseases: diabetes in 18 patients and malignant tumors in seven. Thirty patients were treated conservatively, and 15 patients underwent surgery. Twenty-six patients had paralysis. All 15 patients treated surgically, and eight of the 11 patients treated conservatively showed improvement in paralysis. Bone union was achieved in all cases except one. Our results indicate that a good outcome can be expected from conservative treatment in elderly patients as well as the young.     

肛提肌外腹会阴联合切除术后并发症的原因与防治(附18例报告)

目的探讨肛提肌外腹会阴联合切除术后并发症的原因与防治。方法回顾性分析2012年1月至2013年12月,18例接受肛提肌外腹会阴联合切除术的直肠癌患者临床资料。结果发生性功能障碍5例,尿潴留4例,会阴部切口并发症4例(会阴部切口血肿或伴感染2例、会阴部疝1例、切口裂开1例),骶尾部慢性疼痛2例,以上并发症均经保守方式或再次手术处理后治愈或改善。结论肛提肌外腹会阴联合切除术后并发症的发生与较晚的肿瘤分期和较大的手术创伤有关,严格掌握手术适应证、精细术中操作(个体化手术、会阴神经保护和盆底重建)以及加强围手术期管理,可能有助于减少并发症的发生。     

老年男性腹股沟嵌顿疝导致急腹症35例临床分析

目的 探讨老年腹股沟嵌顿疝导致急腹症的治疗方法和临床结局,为老年腹股沟嵌顿疝的诊治提供参考.方法 回顾性分析201 1年1月-2016年1月北大医疗鲁中医院35例经手法无法复位的老年男性(年龄≥60岁)腹股沟嵌顿疝患者,急症诊接受手术治疗的临床资料,总结其有无合并症、手术方式、手术时间、并发症、住院时间及随访情况.结果 35例老年男性腹股沟嵌顿疝(嵌顿的时间2～48 h,肿块无法手法还纳)患者均顺利完成手术,其中行单纯疝囊高位结扎者18例(其中1例行乙状结肠双腔造瘘术),传统疝修补术者10例,无张力疝修补术者7例;手术时间为60 ～140 min,平均85 min;术后共有5例患者发生并发症,其中1例嵌顿疝患者自行还纳导致乙状结肠破裂合并感染性休克,导致患者多器官功能衰竭,3d后经抢救无效死亡;住院时间为3～13d,平均7d;手术后出现切口液化、感染2例,阴囊血肿1例,不全肠梗阻1例,经相应处理后患者均恢复良好;随访6个月以上,有2例患者腹股沟疝复发,其余患者未出现不适症状.结论 对老年男性腹股沟疝嵌顿导致急腹症的患者应优先处理急腹症,采取及时的手术治疗,降低急腹症的合并症和并发症,如减少肠管坏死、腹腔感染、疝复发等.     

高龄梗阻性结肠癌的外科治疗和围手术期处理(附112例报告)

目的 探讨高龄梗阻性结肠癌的临床特点、外科治疗策略,提高围手术期处理水平.方法 对我院自1997年1月至2007年1月收治的112例70岁以上经手术治疗的梗阻性结肠癌病例的临床资料进行回顾性分析.结果 入院前误诊47例(42.0%);急性梗阻72例(64.3%),慢性梗阻40例(35.7%);Dukes C期82例(73.2%),Dukes D期30例(26.8%);根治性切除70例(62.5%),姑息性切除32例(28.6%),结肠造口4例(3.6%),捷径手术6例(5.4%);一期切除吻合69例(61.6%);伴发其他疾病103例(92.0%);发生并发症34例(30.4%);围手术期死亡4例(3.6%);平均生存期23.4个月.结论 高龄结肠癌误诊率高,手术切除仍是主要的治疗手段.选择"个体化"治疗方案、积极处理伴发病和加强围手术期营养支持治疗是改善其预后的关键.     

A study of bleeding peptic ulcer in the elderly in the view of risk factors

We treated 448 patients for peptic ulcer from 1970 to 1988. Among them, 52 cases were bleeding peptic ulcer in the elderly. 32 cases (61.6%) had a duration of illness of less than 3 months, and the most common symptom was abdominal pain (51.9%). 22 cases (44.0%) were in shock and 32 cases (62.7%) had accessory diseases. Twelve cases were treated medically, while 40 cases were treated surgically. Elective operations were performed in 15 cases, and their mortality was 6.7%. Emergent operations were performed in 25 cases, and their mortality was 28.0%. The mortality of of cases involving both shock and accessory diseases was 57.1%, and of this group, all 3 cases treated medically died. When bleeding exceeded 2000cc was the mortality 46.7%. Regarding cases of emergent operation involving shock or accessory diseases, the mortality was 18.2% in the cases treated medically for less than 4 days and had the episodes of massive bleeding less than 3 times, but 62.5% in other cases. The results of this study suggest that aggressive surgical treatment in an early stage may reduce the mortality in elderly patients with peptic ulcer.     

Diagnosis and treatment of the cruciate ligament injury of knee joint

During 1959 to 1986, 62 Cases with cruciate ligament injury of the knee joint were treated in our hospital. Thirty of these cases were anterior cruciate ligament injuries and 32 cases were posterior The diagnosis of the cruciate ligament injuries was made by stability tests of the cruciate ligament. When the knee was greatly swollen with multiple ligament injuries, a series of X-ray films should be taken to test the knee stability under local or nerve block anesthesia. Fresh tear of the cruciate ligament (33 cases) was treated with immediate surgical repair except in one. Old ligament injuries (28 cases) were treated by conservative method (10 cases) or surgical reconstruction (18 cases). All patients were followed for 2 to 18 years (mean 6 years). The results showed that the fresh tear of the cruciate ligament treated surgically had excellent and good rates in 87.9% (29/33). In the conservative treatment group, only 27.3% (3/11) obtained good result, and most of them were complicated with meniscal lesions and osteoarthritis. Eighteen cases treated by ligament reconstruction gave 34.5% (8/18) good result.     

Surgical management of duplex ureteroceles.

We reviewed the cases of 95 children with duplex ureteroceles treated in this department over an 18-year period. There were 101 ureteroceles (6 bilateral). Diagnosis and treatment were analyzed. Special attention was paid to newborns screened in utero. We always strove to preserve functional renal tissue whenever possible. In keeping with this goal, three surgical techniques were used: (1) upper pole heminephrectomy; (2) ureterocele excision, bladder neck reconstruction, and ureter reimplantation with or without cutaneous ureterostomy of the upper pole ureter; and (3) endoscopic ureterocele incision. Follow-up studies using x-ray and radionuclide imaging demonstrated satisfactory renal function in 86.6% of patients. These findings support a conservative approach to ureteroceles using endoscopic ureterocele incision as the primary treatment. Lower urinary tract reconstruction may be associated in cases involving urinary tract infection, obstruction or incontinence. Upper pole heminephrectomy should be performed only after functional evaluation following ureterocele incision or cutaneous ureterostomy.