内镜下乳头肌切开术后迟发性胆道出血的治疗观察

目的:探讨内镜下乳头肌切开术(EST)后并发迟发性胆道出血的原因和治疗方案。方法:回顾分析3000例确诊为胆总管结石患者且结石直径3.5 cm,既往未行EST的患者,行常规ERCP及EST术后出现迟发性胆道出血的发生率、出血发现时间和治疗情况。结果:共有20例患者术后并发胆道出血,占0.6%,20例均及时发现出血并经积极止血治疗后最终全部康复出院,无1例死亡。结论:早期及时发现迟发性胆道出血并积极采取治疗方案对预后起着重要的作用。     

组织黏合剂对内镜黏膜下剥离术难治性出血的临床疗效

目的研究组织黏合剂对治疗内镜下黏膜剥离术（ESD）中难治性出血及预防迟发性出血的疗效。方法上海复旦大学附属中山医院内镜中心自2006年9月至2013年8月在对9874例胃肠道黏膜或黏膜下肿瘤的患者行ESD治疗中,发生5例难治性出血（0．05％）,在其他止血方法无效的情况下,运用注射和喷洒组织黏合剂的方法进行止血,观察其疗效及其并发症。结果5例患者运用组织黏合剂后均止血成功,且未发生迟发性出血及穿孔。内镜随访2个月后,见创面愈合并瘢痕形成。结论组织黏合剂对治疗ESD难治性出血快速、有效并安全。     

全覆膜金属支架治疗内镜乳头括约肌切开术后出血的疗效

EST是ERCP检查中常用的诊断与治疗操作,EST术后乳头切缘出血发生率为2％～9％[1-2].内镜下止血是其首选治疗方案.如内镜下治疗不能控制出血,则需行动脉栓塞和外科开腹手术治疗,增加了患者创伤和经济负担.目前临床上常用的内镜下控制EST术后出血的方法是金属夹夹闭出血灶和黏膜下注射肾上腺素[3-4].但这两种治疗方法均难以控制EST术后活动性出血,因此,临床上需要更简便有效的内镜下止血措施.近年来,笔者应用全覆膜自膨式金属支架（full covered self-expandable metal stents,FCSEMS）控制EST术后出血,取得了一定的效果.本研究回顾性分析2012年1月至2013年2月成都军区总医院应用FCSEMS治疗4例EST术后出血患者的临床资料,探讨EST术后出血治疗的新方法.     

十二指肠镜联合腹腔镜治疗胆囊结石并肝外胆管结石

目的探讨镜下十二指肠乳头括约肌切开(endoscop ic sph incterotomy,EST)胆道取石联合腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)治疗胆囊结石、肝外胆管结石的价值。方法回顾性分析2002年8月~2004年10月我院行EST及LC联合治疗胆囊结石、肝外胆管结石的临床资料。结果十二指肠镜下行逆行胰胆管造影(endoscop icretrograde cholangiopancreatography,ERCP)成功53例,其中51例(94.4%)完成EST与LC联合治疗,2例EST后未取净结石,行开腹手术。1例内镜治疗未成功,行开腹胆囊切除、胆肠吻合术。2例EST后迟发性创面出血再次内镜治疗止血成功。LC无并发症。51例平均住院时间(10.3±2.1)d。结论EST联合LC是微创治疗胆囊并肝外胆管结石病较为理想的方法。     

止血夹预防高危出血患者ERCP术后迟发性出血的临床效果

目的 探讨出血高危患者在内镜下逆行胰胆管造影（endoscopic retrograde cholangio pancreatography,ERCP）术中即刻留置止血夹对预防术后迟发性出血的临床作用。方法 收集2016年8月至2019年9月来院行ERCP的1 854 例患者,其中符合纳入标准的出血高危患者493 例,包括止血夹组215 例、常规对照组278 例,回顾性分析两组患者术后并发症包括出血、胰腺炎、穿孔,以及操作时间、住院时间和住院费用等指标。结果 止血夹组术后出血发生率低于常规对照组[1.4%（3/215） vs 4.7%（13/278）,P＜0.05],两组在性别、年龄、疾病构成、术后胰腺炎和穿孔、操作时间、取石方式、住院费用等指标上无统计学差异（P＞0.05）。结论 ERCP术中针对出血高危患者预防性实施止血夹,可以显著降低术后迟发性出血发生率,且不额外增加患者费用,是一种安全便捷、值得推广的技术。     

ERCP联合LC治疗胆囊结石合并胆总管结石的临床分析

目的探讨经内镜逆行胰胆管造影术(ERCP)、内镜十二指肠乳头括约肌切开术(EST)联合腹腔镜胆囊切除术(LC)治疗胆囊结石合并胆总管结石的临床疗效。方法回顾性分析采用ERCP/EST联合LC方法治疗的40例胆囊结石合并胆总管结石的患者的临床资料。结果 ERCP/EST手术成功率97.5%(39/40),1例插管失败,LC手术成功率97.4%(38/39),1例中转开腹手术,8例(20.5%)患者ERCP/EST术后出现高淀粉酶血症,无出血、胆瘘、十二指肠瘘、胆管损伤及胆道结石残留等并发症发生。61.5%(24/39)患者ERCP/EST术后2~5天行LC术,38.5%(15/39)患者ERCP/EST术后6~14天行LC术,前者在住院时间及住院费用上明显低于后者。结论 ERCP/EST联合LC治疗胆囊结石合并胆总管结石安全可行,具有患者创伤小、康复快、并发症少等优点,ERCP术后尽早施行LC可减少患者住院天数及住院费用。     

胰十二指肠切除术后出血12例临床分析

目的总结胰十二指肠切除术后出血的诊疗经验。方法回顾性分析行胰十二指肠切除手术且术后合并出血的12例患者的临床资料。结果 12例患者中早发性出血2例,迟发性出血10例。按出血部位分为消化道出血9例,腹腔内出血3例。死亡3例,死亡率25%。7例患者行保守治疗,成功止血5例,死亡2例;2例行手术止血,成功1例,死亡1例;3例患者行内镜下止血治疗,其中1例止血成功、1例内镜止血失败后行介入栓塞治疗止血成功、1例内镜止血成功后再发出血,行手术治疗止血成功。结论术前充分评估、术中精细操作和术后规范治疗是减少术后出血发生的关键。出血发生后,应该根据出血部位、出血量、患者生命体征是否平稳等因素,个体化地采取相应的治疗措施。     

LC术前及术后联合应用ERCP和EST的体会

目的探讨行内镜逆行胰胆管造影(ERCP)和内镜乳头括约肌切开术(EST)在腹腔镜胆囊切除术(LC)术前、术后的应用体会。方法回顾性分析选择性进行LC术前、术后ERCP及内镜治疗102例(包括EST,ENBD和网篮取石术等)的经验体会。结果术前行ERCP94例中,胆管显影89例,显影率94.6%,发现胆总管结石41例,乳头炎性狭窄21例,阳性发现率约65%,取石38例,成功率92.6%;术后行ERCP8例,胆管均显影,术后阳性发现8例,阳性率100%。其中2例胆漏、3例胆总管残石、3例乳头炎性狭窄,内镜治疗成功100%。对胆总管结石,无论术前、术后,内镜取石治疗成功率93%。ERCP并发症3例(2.8%)1例乳头出血,2例高淀粉酶血症,均用非手术治疗痊愈。结论ERCP和EST的应用是当前LC手术前、后诊断和治疗胆囊结石合并胆总管结石的最佳手段,对提高LC的成功率和减少LC的并发症,降低胆总管结石开腹手术的比率,均具有重要的作用。     

内镜逆行胰胆管造影、内镜十二指肠乳头括约肌切开术并发症的分析及防治(附475例报告)

目的:探讨内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)、内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)的并发症及预防措施。方法:回顾分析2005年1月至2009年4月475例患者行ERCP、EST的临床资料,分析各种并发症的发生原因、伴随症状及防治措施。结果:109例发生并发症,其中ERCP 36例,EST73例,发生急性高淀粉酶血症和急性胰腺炎66例(13.9%),胆管感染34例(7.16%),出血5例(1.05%),网篮嵌顿2例(0.42%),肠穿孔1例(0.21%),死亡1例。结论:术前准备不足、术中操作粗暴、胰管反复显影等是ERCP,EST发生并发症的主要原因。严格掌握ERCP、EST的治疗指征,技术熟练与细致的围手术期处理是防治并发症的关键。     

远端胃癌根治术后迟发性出血原因与处理

目的 分析远端胃癌根治术后迟发性腹腔出血的病因、诊断及治疗方案.方法 对广州市第一人民医院2008年1月-2013年6月远端胃癌根治术后发生出血的45例患者进行回顾性研究.结果 45例患者中有13例发生迟发性腹腔性出血,出血时间为术后1～4周.其中5例为术后1周以后出现间歇性出血,经CT、DSA诊断为胃十二指肠动脉假性动脉瘤破裂出血,经DSA栓塞止血后治愈;8例术后3～4周出现反复呕血,经胃镜检查后明确诊断为吻合溃疡出血,在内镜下止血成功.结论 远端胃癌根治术后迟发性腹腔出血病因复杂,CT、DSA及胃镜检查可帮助明确诊断,DSA及内镜具有较高的治疗价值,可避免再次开腹手术.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.