胰十二指肠切除术后严重并发症的防治

目的 探讨胰十二指肠切除术（pancreaticoduodenectomy,PD）后严重并发症发生后的防治方法.方法 回顾性分析了2004年1月至2009年12月实施PD手术65例的临床资料.结果 术后16例患者出现术后并发症28例次,并发症发生率24.6％.术后死亡2例,围手术期死亡率为3.0％.结论 采取适当的手术方法可以预防术后胰漏及出血,发生胰漏及出血后采取适当的处理措施可以降低术后死亡率.     

胰十二指肠切除术后上消化道出血

目的 探讨胰十二指肠切除术后上消化道出血。方法 回顾性研究我院自1983年1月至1997年12月间施行胰十二指肠切除术(PD)共115例的并发症。结果 PD术后并发症41例(35．7％)，死亡7例(61％)；并发症中以上消化道出血(UGIB)为最多，共21例(18.3％)。按并发UGIB与否分为UGIB和非UGIB两组，UGIB组的PD术中估计失血量、输血量多于非UGIB组；UGIB组的死亡率为23．8％，高于非UGIB组的死亡率21％(P<0．05)：UGIB组死亡5例，均合并其他严重的并发症。出血的主要原因为应激性溃疡8例(38．1％)，胃空肠吻合口出血6例(28．6％)，胆道出血3例(14．3％)，原因不明10例(47．6％)；其中吻合口出血均伴不同程度的应激性溃疡。出血后的处理以保守治疗为主，手术止血6例(28．6％)，保守治疗15例(71．4％)，止血术后死亡3例，非手术治疗死亡2例。结论 上消化道出血是PD术后常见的严重并发症，应积极防治。     

胰十二指肠切除术132例严重并发症的防治

目的总结胰十二指肠切除术(PD)严重并发症的防治经验。方法回顾性分析我院1997年1月至2009年10月间胰十二指肠切除术132例的临床资料,其中经典胰十二指肠切除术91例,保留幽门的胰十二指肠切除术(PPPD)25例,保留幽门和十二指肠升部的胰十二指肠切除术16例,联合门静脉部分切除1例,捆绑式胰肠吻合术28例。全组患者均放置胰管支撑引流,103例肝总管放置T管引流。结果术后胰瘘2例(1.52%),多系统器官功能衰竭死亡1例(0.76%),吻合口出血3例(2.27%),胆瘘2例(1.52%)。其他切口感染6例,胃排空延迟2例,肺部感染1例,腹腔脓肿1例。总体并发症发生率为13.6%。结论胰管内支架安放和肝总管T管引流是预防PD术后严重并发症的关键。及时有效的处理出血、胰瘘、胆瘘可最大限度地降低围手术期死亡率。     

再手术在胰十二指肠切除术后并发症处理中的疗效评价

目的探讨再手术在胰十二指肠切除（PD）术后并发症处理中的疗效。方法回顾性分析1986年1月至2005年12月间我院施行的392例PD术后并发症及再手术的原因、诊断、处理方式及疗效。结果PD术后并发症133例（33．9％），死亡14例（3．6％）。其中22例再手术，再手术的死亡3例，再手术死亡率13．6％。结论导致PD术后再手术主要并发症有出血、胰瘘和切口裂开等。再手术是处理PD术后并发症的一个有效手段且不增加手术死亡率。     

Whipple术后胰瘘的若干认识

胰十二指肠切除术（pancreaticoduodenectomy,PD）是治疗胰头癌、壶腹周围癌、十二指肠癌的主要术式。1935年Whipple首先施行PD手术成功,故大家又称PD为Whipple手术。Whipple手术的特点：复杂、费时、术后并发症多、死亡率高。而胰瘘是Whipple术后常见而严重的并发症,其发生率是15％～20％,它亦是术后引起腹腔感染、腹腔大出血等其它严重并发症的主要原因．同时也是术后早期致死的主要原因。     

老年人胰十二指肠切除术后并发症的临床分析

目的 探讨老年人胰十二指肠切除术(PD)后主要的并发症及防治方法.方法 回顾性分析我院采用PD术治疗的61例老年人胰胆管疾病患者的临床资料.结果 术后并发症发生率为29.51％( 18/61),死亡率为3.28％( 2/61).主要并发症为胰瘘2例(3.28％),上消化道出血3例(4.92％),腹腔内感染10例(16....     

胰十二指肠切除术后胰漏的危险因素

随着医疗技术的进步，胰十二指肠切除术（pancreatoduodenectomy，PD）的病死率已经明显下降。JohnsHopkins医院的资料显示，自1981～2002年共施行1891例PD术，术后死亡率1．6％，而并发症发生率仍高达40％（371例），其中胰漏发生率11．4％（216例），可见胰漏仍是PD术后最主要的并发症之一。为了进一步减少胰漏的发生，本文对PD术后胰漏相关的危险因素作一综述。     

单中心胰十二指肠切除术经验分析:附543例报告

目的探讨单中心胰十二指肠切除术的围手术并发症的经验分析方法回顾性分析自2014年1月至2018年12月期间由同一团队开展的胰十二指肠切除术的围手术期资料和随访期间手术疗效,分析其围手术期并发症以及标准化处理方法。结果自2014年1月1日至2018年12月31日期间中科大附属第一医院胆胰外科收治并行PD患者543例,其中LPD手术114例,其中PD术429例,共有280例患者共发生并发症604次,总并发症发生率51.5%(280/543),其中胰瘘发生率17.3%(B级胰瘘发生率3.6%、C级胰瘘发生率1.8%)、胆瘘发生率4.60%,胃排空延迟发生率38.1%,围手术期死亡率为2.58%。结论高手术量的胰腺外科中心行PD手术时需要有标准化流程,这样可以最大程度的降低术后并发症的发生,减少围手术期死亡率。     

502例胰十二指肠切除术后主要并发症的临床分析

目的 总结胰十二指肠切除术(PD)的主要并发症的原因和防治措施.方法 回顾性分析1986年1月至2007年12月南京医科大学第一附属医院施行的502例PD,其中保留幽门的胰十二指肠切除术(PPPD)87例,联合切除19例.结果 术后近期并发症的发生率为31.5%(158/502),手术死亡率为3.2%(16/502),因并发症而再手术32例,再手术死亡率9.4%(3/32).以1999年为界将PD手术病人分为两个阶段进行对照,结果 显示:第一、二阶段的手术并发症分别为33.7%(56/166)、30.4%(102/336),死亡率分别为4.2%(7/166)、2.4%(8/336),无显著差异.结论 消化道和腹腔出血、胰瘘、多器官功能衰竭、腹腔感染等是PD病人死亡的主要原因.适当的围手术期处理和熟练的外科操作技术是降低手术并发症和死亡率的重要因素.     

胰十二指肠切除术胰肠吻合口漏的防治措施

胰十二指肠切除术(pancreaticoduodenectomy，PD)是治疗胰腺和壶腹周围恶性肿瘤的主要方法，手术复杂，创伤大，并发症多，死亡率高。随着胰腺癌手术切除率的提高，进一步降低手术并发症及死亡率，是胰腺外科必然面对的问题，其中胰漏是胰十二指肠切除术后并发症与手术死亡原因中的主要元凶，一旦发生，死亡率极高。文献报道，PD术后胰漏发生率在5％     

胰十二指肠切除术后主要并发症分析：附442例报告

目的:探讨胰十二指肠切除术(PD)后主要并发症发生情况与防治措施。方法:回顾性分析1994年8月—2010年12月442例PD术后并发症发生情况。按不同年代和不同胰肠吻合方式分组:1998年12月以前采用单纯胰-肠套入吻合(32例)为A组;此后的胰管空肠黏膜端侧吻合(305例)为B组;套入加捆绑式吻合(105例)为C组。分析各组手术直接相关和间接相关并发症的发生情况及病死率。结果:全组总并发症发生率为29.9%,总病死率为2.3%。3组间比较,B,C组各项指标均明显优于A组(均P<0.01),但B,C组间差异均无统计学意义(均P>0.05)。A,B,C组手术直接相关并发症分别为43.8%,6.6%,6.7%(其中胰瘘发生率分别为28.1%,3.6%,2.9%);间接相关并发症分别为59.4%,17.0%,19.0%;病死率分别为21.9%,0.7%,1.0%。结论:胰瘘的发生与采用何种胰肠吻合方式有关;熟练的手术技巧、仔细严密的吻合以及加强术前术后防范措施是降低PD术后并发症和病死率的重要因素。     

Surgical complications following pancreaticoduodenectomy: results of a single center experience

Pancreaticoduodenectomy represents the only therapeutic option for cefalo-pancreatic and periampullary cancers. Surgical and anaesthesiological techniques development over the last twenty years has granted an operative mortality decrease. However, surgical morbidity is still high, with an incidence of 30-50%. A 20 year experience of a single Centre is examined retrospectively: 121 patients underwent pancreatic resection with radical intent. Type of operation or re-operation, operative mortality within 30 days, general and surgical morbidity, postoperative hospital stay were analysed. Average recovery time was 24 days (range 12-65); operative mortality was 5.8% (7/121); general morbidity, including medical and surgical complications, was observed in 47 patients (38.8%). Pancreatic fistula occurred in 16 patients (13.2%); ten of these underwent a second operation. Patients who underwent pancreaticoduodenctomy were divided as follows: 76 pts. received a pylours-preserving pancreaticoduodenectomy and 45 a Whipple's resection. Neither surgical complications incidence nor mortality rate were significantly different between the two groups. Postoperative complications following pancreaticoduodenectomy are still frequent and severe. In particular, pancreatic fistula represents the most relevant complication following pancreaticoduodenectomy. The Authors suggest that standard and meticulous surgical procedures together with continued efforts to improve postoperative follow-up, support early detection of complications and improvement of results in most patients.     

Perforated duodenal ulcer in elderly patients

To examine the mortality and morbidity associated with perforated duodenal ulcer in patients 70 years or older a review of those admitted between 1978 and 1987 was undertaken. There were 33 patients, three in whom the diagnosis was made at post-mortem examination. Two patients were considered unfit for surgery and were treated conservatively while 28 were treated by operation. There were three postoperative deaths giving an operative mortality rate of 11.7%. Overall mortality rate from perforated duodenal ulcer in the series was 24%. Serious postoperative morbidity occurred in 72% of patients surviving operation. The occurrence of morbidity correlated positively with the time interval between symptoms of perforation and surgery although statistical significance was not shown. Perforated duodenal ulcer is associated with a high mortality and morbidity in the elderly. Efforts to reduce mortality and morbidity should be aimed at accurate diagnosis and early surgical intervention.     

食管癌术后再入重症监护病房患者的严重并发症特征分析

目的探讨食管癌术后严重并发症的特征及其变化特点。 方法2009年1月至2013年12月在华西医院胸外科接受食管癌切除术患者共3171例,其中因术后严重并发症再次转入重症监护病房(ICU)的患者153例,再入率为4.8%。收集153例患者的基本信息、并发症情况以及治疗结局,并进行回顾性分析。同时通过计算机系统检索有关食管癌术后并发症的临床研究,检索时间截至2014年1月。 结果153例再入ICU患者中死亡68例。肺部并发症、吻合口和心血管并发症是最常见的致死性并发症,发生率分别为2.7%(85/3171)、0.9%(29/3171)和0.3%(10/3171),病死率分别为1.1%(35/3171)、0.5%(15/3171)和0.2%(5/3171)。ICU获得性肺炎会增加死亡风险。多因素回归分析显示,患者再入ICU的时间间隔是死亡的独立危险因素(P＝0.044,OR＝2.151,95% CI为1.022～4.528)。分析总结相关文献,食管癌术后严重并发症根据年代可分为3个特征性时间段：1950年之前,顺序为休克、外科感染;1950至1980年间,顺序为吻合口瘘、肺部并发症;而1980年后,常见严重并发症顺序为肺部并发症、吻合口并发症和心血管并发症。 结论食管癌切除术仍具有较高的风险,再入ICU可以成为反映其严重程度的标准。目前,肺部并发症已成为食管癌术后最主要的致死性并发症,其次为吻合口并发症和心血管并发症。     

Feeding jejunostomy during Whipple is associated with increased morbidity

Background

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

Materials and methods

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

Results

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis.

Conclusion

Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.     

Prediction of risk in noncardiac operations after cardiac operations

To determine the preoperative variables affecting the mortality rate and the development of severe complications in patients who have had myocardial revascularization or a valve replacement and who then undergo a noncardiac operation, we retrospectively studied data from 120 such patients over the 5 years from 1982 through 1986. Thirty-six percent of patients had a noncardiac operation during the first month after the cardiac operation. The mortality rate was 11%, and the morbidity rate was 56%. The statistical comparison of the predictive accuracy of postoperative complications of three simple, widely used classifications (American Society of Anesthesiologists physical status, New York Heart Association classification, Massachusetts General Hospital cardiac risk index) demonstrated the superiority of the simplified three-class cardiac risk index (Massachusetts General Hospital-cardiac risk index; predictive accuracy of 84%). In a multivariate discriminant analysis of 21 variables in this population, five variables (myocardial infarction in previous 6 months, S3 gallop or jugular vein distention, arrhythmia on last preoperative electrocardiogram, emergency operation, delay between cardiac and noncardiac operation) were identified as being the most predictive of a postoperative complication. When these variables were used in the function (DF3) obtained by linear discriminant analysis, the prediction accuracy of a postoperative complication reached 83%. Performance of the new models in a prospective validation population remained satisfactory (75% for Massachusetts General Hospital-cardiac risk index three-class index and 72% for DF3). Extensive statistical analysis of our data tested by a validation study provided simple predictive models based on clinical variables easily available even in emergency situations.     

胰十二指肠切除术后并发症危险因素分析及治疗策略

目的探讨胰十二指肠切除术（PD）后并发症危险因素分析及相关并发症治疗策略。 方法选取2014年1月至2015年11月收治148例行PD术患者的完整资料,记录术后并发症发生情况,并采用单因素分析及Logistic回归方法进行危险因素分析。 结果患者行PD术后1个月并发症发生率为33.8%（50/148）,死亡4例（2.7%）。单因素分析显示：（1）黄疸持续时间、血总胆红素水平、手术时间及凝血原酶时间是影响术后出血的独立高危因素;（2）黄疸持续时间、血红蛋白和术中出血量是影响术后PF的独立高危因素;（3）血红蛋白和胆总管直径是影响术后BF的独立高危因素;（4）年龄和手术时间是影响术后肺部感染的独立高危因素;（5）术后出血、术后胰瘘和手术时间是影响术后腹腔感染的独立高危因素;（6）黄疸持续时间和糖尿病是影响术后胃排空障碍的独立高危因素,以上差异均有统计学意义（P<0.05）。Logistic多因素回归分析显示血总胆红素水平、黄疸持续时间、术中失血量及手术时间是影响PD术后主要的高危因素,差异均有统计学意义（P=0.042、0.031、0.047、0.019）。 结论总胆红素、黄疸持续时间、术中失血量及手术时间是影响PD术预后的主要高危因素,应规范化进行PD手术治疗,加强围手术期临床干预,以预防PD术后并发症发生。     

Whipple胰十二指肠切除术后早期移除鼻胃管的可行性分析

目的探讨经典Whipple胰十二指肠切除术后早期移除鼻胃管引流管的安全性。方法回顾性分析2008年1月至2013年3月期间我院收治的310例Whipple胰十二指肠切除术患者的临床资料。根据术后鼻胃管引流管移除时间分为早期（≤24 h）移除鼻胃管组和晚期（〉24 h）移除鼻胃管组,主要分析指标为鼻胃管重置率、固体饮食耐受时间、术后住院时间、死亡率及胰十二指肠切除术后的主要相关并发症。结果 1 2组患者术前基本信息及合并症比较差异无统计学意义（P〉0.05）。2 2组患者的鼻胃管重置率比较差异无统计学意义（P=0.450）。3 2组患者术后主要相关并发症和死亡率比较,差异均无统计学意义（P〉0.05）;但经多因素分析,晚期移除鼻胃管组的术后总并发症发生率明显高于早期移除鼻胃管组（P=0.014）。4早期移除鼻胃管组患者的平均固体饮食耐受时间（P=0.013）和术后平均住院时间（P〈0.001）均较晚期移除鼻胃管组明显缩短,差异有统计学意义。结论若患者术前无明显胃排空梗阻症状,Whipple胰十二指肠切除术后可尽早拔除鼻胃管,增加患者舒适度。     

Thoracic aortic operations in patients aged 70 years or older.

Thirty-one patients over the age of 70 years (group A) and 72 patients less than 69 years (group B) underwent a variety of thoracic aortic surgical procedures. Early and long-term results and cerebral function were compared between the two groups. Preoperative and postoperative cerebral function was evaluated using mini mental state-Himeji and Wechsler adult intelligence scale tests. The operative mortality of groups A and B was 12.9% and 11.1%, respectively (not significant). There were no significant differences in postoperative complications between the two groups. The late mortality rates of groups A and B were 11.1% and 9.3%, respectively (not significant). There were no significant differences between the two groups in the mini mental state-Himeji test, digit symbol, vocabulary, and total Wechsler adult intelligence scale scores before and after operation. We conclude that thoracic aortic surgical procedures in patients over 70 years of age can be performed with acceptable mortality and morbidity risks. Most patients showed symptomatic improvement.