损伤控制性手术

损伤控制性手术(dam age control surgery,DCS)主要是指在救治严重创伤病人时改变以往早期进行复杂、完整手术的策略,而采用快捷、简单的操作,及时控制伤情的进一步恶化,保留进一步处理的条件,使病人获得复苏的时间,有机会再进行完整、合理的再次或分期手术。其病理生理基础在于病人出现"致死三联征",即低体温、酸中毒和凝血功能障碍时不能耐受长时间手术。正确且熟练掌握DCS适应证是成功应用这项技术的关键。DCS主要包括三个步骤:初步复苏的同时进行止血和污染控制手术、在ICU继续复苏以及计划性再手术。     

医源性胆总管远段损伤的临床分析

目的探讨医源性胆总管远段损伤早期诊断及腹膜后严重感染的预防。方法 回顾分析1990年至2004年间处理的17例医源性胆总管远段损伤患者的临床资料。结果 17例患者中,15例为术中损伤,2例为ERCP切开取石所致。术中发现胆管损伤14例,术中未及时发现者1例。胆管损伤前行B超检查16例,MRCP检查2例,6例在胆道探查后行胆道镜检查。10例行胆总管穿孔修补加T管引流,2例行Oddi括约肌切开成形术,2例行胆肠吻合术,1例行十二指肠及胆管修补腹膜后引流术。胆管损伤后术中表现为胆道探子异位于胆管壁外,胆道镜见到胆管远段有2个或多个孔隙,经T管注水见腹膜后水肿和积液,注入美蓝出现腹膜后蓝染。损伤后临床表现为腹胀、发热、腰背胀痛、休克等。治愈13例,术后并发症包括十二指肠瘘1例,切口感染1例,死亡4例,其中3例死于感染性休克,1例死于胃切除术后再出血。结论 胆道远段损伤术后表现缺乏特异性,对可疑患者应作CT检查,早期诊断胆总管下段损伤并进行及时治疗可以取得较好效果。术前完善的影像学检查及在胆道探查前进行胆道镜检查有可能减少胆总管远段损伤。     

损伤控制性手术在胃肠外科中的应用

损伤控制性手术（damage control surgery,DCS）的概念由Stone首先于1983年提出,具体为：早期简化手术、复苏和二期确定性手术三个阶段。随着社会的发展,在交通伤等各种复杂致伤因素的作用下,临床上多发伤合并腹部损伤的病例越来越多。因此在创伤早期采用各种手术干预,患者容易发生多器官功能衰竭。因此在创伤早期综合治疗过程中,既要有效控制原发损伤,又要积极预防继发性损伤,是外科医生必须面对的重要问题。     

直肠癌手术输尿管损伤原因及处理

直肠癌是最常见的恶性肿瘤之一,由于直肠与输尿管解剖上的毗邻,直肠癌手术中输尿管损伤不可避免。局部进展期直肠癌侵犯输尿管、术前新辅助放化疗导致盆腔粘连水肿、直肠癌复发需要二次手术,以及外科医生对输尿管解剖不熟悉,术中操作不当均可导致输尿管损伤。术中及时发现,立即修复,预后良好。术后超过48 h发现尿瘘应在保护肾脏功能的同时,2～3个月后再手术修补,留置双J管防止局部狭窄。严格遵守TME原则、在骶生殖襞内侧操作,术前放置双J管等可有效预防输尿管的损伤。     

损伤控制性手术在严重腹部创伤中的应用

创伤是当今人类死亡的主要原因之一,创伤救治是创伤外科研究的核心内容之一.严重的腹部创伤、出血,尤其是合并低温、凝血功能障碍及代谢性酸中毒时,患者往往难以承受较长时间的手术,但患者又存在必须手术处理的情况,损伤控制性手术(damage control surgery,DCS)应运而生.近年来,DCS理念在严重腹部创伤的治疗中日益受到各国学者重视.本文就近年来DCS在严重腹部创伤中的应用进行综述.     

上肢挤压伤后神经损伤机制分析与临床治疗

目的 报告上肢挤压伤后神经损伤机制和治疗方法.方法 对2003年3月至2009年5月收治的17例上肢挤压伤后神经损伤患者进行综合性治疗.结果 治疗3周后部分轻症患者受压部位肌群肌张力开始恢复,肌力恢复至M2～M3.6周后,大部分患者受压部位以远肌群肌力逐渐恢复至M3～M4.11例获得6个月至2年的随访,6例失访.11例患肢感觉功能完全恢复.7例患肢功能恢复良好;2例遗留轻度手功能障碍,手指总主动活动度(TAM)较健侧减少20.,肌力M4;2例并发一氧化碳中毒后迟发性脑病的患者,遗留明显的功能障碍,但手部感觉和肌张力恢复良好.按中华医学会手外科学会上肢部分功能评定试用标准评定:优7例,良2例,差2例.结论 上肢挤压伤后神经损伤具有明显的特殊性,应针对其损伤机制予以积极治疗.     

46例次医源性胆管损伤诊治中损伤控制应用分析

目的探讨医源性胆管损伤诊治中损伤控制应用的意义。方法回顾分析我们手术修复的46例次医源性胆管损伤病例,根据疗效情况分为优良组（n=41）及差组（n=5）,分析其疗效与既往修复史及病理分型的关系,并进一步分析其既往修复技术正当性与疗效的关系。统计软件采用SPSS13．0软件包,方法采用χ^2检验Fisher确切概率法。结果共有5例次疗效差,病理分型均为Bismuth分型的Ⅲ型或Ⅳ型,其中4例次具有修复史,似乎疗效差组具有更高比例的修复史,但统计学分析差异无统计学意义（P=0．357,P〉0．05）。无修复史的21例均为直接接受本次专科修复,其中20例疗效优良。对有修复史的25例次的前次修复的专科属性与技术正当性的评判结果提示,多数的非专科修复技术运用不当（14／21）,差异有统计学意义（P=0．026,P〈0．05）。结论规范内镜治疗,避免非专科确定性修复,防范修复过程中的新损伤,作为医源性胆管损伤诊治中损伤控制的重要内容,对改善预后具有重要价值。     

损伤控制性手术在胰腺外伤中的应用研究

目的探讨损伤控制外科在胰腺损伤病人治疗中的临床应用效果。方法回顾分析2006年2月至2016年2月收治的40例胰腺外伤病人的临床资料。40例病人中,男性30例,女性10例;年龄14~60岁,平均34岁;损伤的类型:闭合性胰腺损伤30例(75.0%),开放性胰腺损伤10例(25.0%)。按即胰腺损伤分级标准,Ⅰ级损伤10例(25.0%),Ⅱ级损伤11例(27.5%),工、Ⅱ级均无主胰管损伤;Ⅲ级损伤12例(30%),Ⅳ级为近侧胰腺横断伤或累及壶腹部的裂伤4例(10.0%),V级为胰头毁损伤3例(7.5%)。本组所有病例在积极抗休克的同时均行急诊剖腹探查术,术中均证实为胰腺损伤。结果 39例治愈出院(97.5%),死亡1例(2.5%);因合并脾蒂撕裂致腹腔大出血术中死亡;围术期发生并发症10例,并发症发生率为25.0%,并发症有胰瘘5例,肠瘘3例,腹腔脓肿及假性胰腺囊肿各1例,经手术或保守治疗痊愈。结论胰腺外伤并发症多,病死率高,选择合理的手术时机及手术方法并且严格掌握损伤控制原则是降低胰腺外伤病人的病死率和并发症发生率的关键。     

损伤控制性手术在胰腺外伤中的应用

损伤控制性手术（damage control surgery，DCS）是近年来倍受关注的外科治疗原则，是一种复杂外科问题应急分期处理的理念。临床实践业已证明，DCS的合理应用可以有效降低复杂创伤病人的病死率。本文就近年来国内外相关进展结合笔者的临床实践，对DCS在胰腺外伤中的应用作一介绍。     

上肢高位撕脱离断伤的围手术期注意事项

目的探讨上肢高位撕脱离断伤的围手术期处理方法。方法回顾性分析2006年6月～2010年10月我院收治的5例上肢高位撕脱离断病例的手术处理情况及术后恢复情况。其中肩胛带离断伤3例,肱骨外科颈处撕脱离断2例。结果 1例肩胛带离断伤患者死亡;剩余4例中1例肩胛带离断伤患者行肩部残端修整,另1例肩胛带离断和2例肱骨外科颈处离断伤患者均行断肢再植术。术后平均随访18（10～27）个月,肢体不同程度获得功能恢复。结论上肢高位撕脱离断伤的病人应严格把握手术适应证,在保全生命的前提下采取再植手术,再植成功后的综合治疗使患肢功能得到更好的恢复。     

伤害控制骨科原则治疗骨盆型严重多发伤

目的：探讨伤害控制骨科原则在救治骨盆型严重多发伤中的作用并总结其经验。方法：系统回顾2005年9月至2009年3月运用伤害控制骨科原则治疗的以骨盆骨折为主的严重多发伤患者31例,男22例,女9例;年龄17～63岁,平均30.5岁;ISS平均32.7分。结果：所有病例均成功复苏,无死亡病例,术后外固定架针道浅表感染2例,深部伤口感染2例,下肢深静脉血栓1例,肺部感染1例,褥疮1例。31例患者均获得随访,时间3～29个月,平均10个月。按Matta等评价标准：优12例,良11例,可7例,差2例。结论：合理应用伤害控制骨科原则治疗骨科严重多发创伤患者,可降低早期手术规模及手术治疗风险,提高临床效果,是一种安全有效的治疗方式。     

Application of damage control orthopedics in 41 patients with severe multiple injuries

Objective： To probe the feasibility and efficacy of damage control orthopedics （DCO） in treating severe multiple injuries. Methods： A retrospective analysis was made on the clinical data of 41 patients （31 males and 10 females, aged 18-71 years, mean： 36.4） with multiple injuries admitted to our department and treated by DCO from January 1995 to December 2005.
Results： As a first-stage therapy, devascularization of internal iliac arteries was performed in 29 patients with pelvic fractures combined with massive bleeding, including ligation of bilateral internal iliac arteries in 21 patients and embolization of bilateral internal iliac arteries in 8. And early external fixation of pelvis was performed in 10 patients. Ten patients with severe multiple injuries combined with femoral fractures were managed with primary debridement and temporal external fixation and 2 patients with spinal fractures combined with spinal cord compression received simple laminectomy. Thirty-one patients received definite internal fixation after resuscitation in intensive care unit. The overall mortality rate was 12.1% （5/41） with an average injury severity score of 41.4. The main causes of death were hemorrhagic shock and associated injuries. Complications occurred in 7 patients including acute respiratory distress syndrome in 3 cases, thrombosis of right common iliac artery in 1, subphernic abscess in 2 and infection of deep wound in lower extremity in 1. After treatment, all the patients got cured.
Conclusions： Prompt diagnosis and integrated treatment are keys to higher survival rate in patients with severe multiple injuries. In this condition, DCO is an effective and safe option.     

严重创伤患者血浆细胞因子变化及其与器官功能损害的关系

作者通过观察１７例严重创伤患者血浆肿瘤坏死因子（ＴＮＦ）、白介素－６（ＩＬ－６）和白介素－８（ＩＬ－８）水平的变化及其与内脏功能损害和内毒素血症的关系,旨在阐明细胞因子在创伤后器官功能损害中的作用及其产生机制。结果显示,严重创伤后患者血浆细胞因子水平可相继明显升高,其中ＴＮＦ升高较早,其变化分别与伤情记分（ＩＳＳ）、心肝酶谱、肾功能指标以及血浆内毒素水平呈显著正相关。提示ＴＮＦ、ＩＬ－６和ＩＬ－８参与了严重创伤后器官功能损害的发生发展过程,创伤后细胞因子释放与创伤早期内毒素大量侵入体内有一定关系。     

Hospital management of abdominal trauma in Tehran, Iran: a review of 228 patients

Objective: Today, trauma is a major public health problem in some countries. Abdominal trauma is the source of significant mortality and morbidity with both blunt and penetrating injuries. We performed an epidemiological study of abdominal trauma (AT) in Tehran, Iran. We used all our sources to describe the epidemiology and outcome of patients with AT.Methods: This study was done in Tehran. The study population included trauma patients admitted to the emergency department of six general hospitals in Tehran during one year. The data were collected through a questionnaire that was completed by a trained physician at the trauma center. The statistical analysis was performed using the SPSS software (version 11.5 for Windows). The statistical analysis was conducted using the chi-square and P＜0.05 was accepted as being statistically significant.Results: Two hundred and twenty-eight (2.8%) out of 8 000 patients were referred to the above mentioned centers with abdominal trauma. One hundred and twenty-five (54.9%)of the patients were in their 2nd and 3rd decades of life and 189 (83%) of our patients were male. Road traffic accidents (RTA) were the leading cause of AT with 119 (52.2%) patients. Spleen was the commonly injured organ with 51 cases. Following the analysis of injury severity, 159 (69.7%) patients had mild injuries (ISS＜16) and 69 (30.3%) patients had severe injuries (ISS= 16). The overall mortality rate was 46 (20.2%).Conclusions: Blunt abdominal trauma is more common than penetrating abdominal trauma. Road traffic accidents and stab wound are the most common causes of blunt and penetrating trauma, respectively. Spleen is the most commonly injured organ in these patients. The mortality rate is higher in blunt trauma than penetrating one.     

“损伤控制骨科”救治严重下肢多发伤合并休克患者的护理

不恰当的骨折治疗,会对严重创伤患者构成二次伤害,引发过度全身炎症反应综合征,增加病死率[1]。损伤控制骨科（damage control orthopedics,DCO）,强调严重多发骨折早期采用快速临时控制措施,     

损害控制救治平时和地震时严重多发伤的比较研究

目的：探讨损害控制在平时和地震时救治严重多发伤的作用。方法：回顾性对比研究损害控制技术救治平时骨关节型严重多发伤26例和汶川地震时骨关节型严重多发伤24例，评估两组伤员的病情特点、损害控制救治方法及临床效果。结果：平时组26例全部存活，19例返回原工作岗位，7例生活自理，其中3例需继续治疗。地震组24例全部存活，4例重要器官衰竭者已脱离危险，3例尚需进一步的清创和植皮手术，其他伤员均已完成确定性手术并顺利康复之中。损害控制技术救治平时组和地震组严重多发伤，两者救治效果差异没有统计学意义（P〉0．05）。结论：骨科损害控制技术救治平时和地震时严重多发伤均可取得理想效果。     

新型冠状病毒肺炎疫情期间急诊创伤骨科患者特点和处理策略

目的探讨新型冠状病毒肺炎(COVID-19)疫情期间急诊创伤患者的损伤特点和处理策略。方法回顾性分析2020年1月20日至2月26日期间南方医科大学南方医院骨科收治的22例创伤急症住院患者资料。男18例,女4例;年龄4~66岁,平均年龄35岁。致伤原因:交通伤11例,锐器切割伤(含菜刀切伤)6例,重物压砸伤1例,机器碾压伤1例,跌倒摔伤2例,机器绞伤1例;损伤类型:高能量损伤13例,低能量损伤9例;损伤部位:上肢7例,下肢15例。医护人员诊疗过程中对于无新型冠状病毒(2019-nCoV)核酸筛查结果的1例患者采用二级防护,其余21例患者采用一级防护。记录患者和医务人员感染2019-nCoV的情况,总结疫情期间创伤急症的处理措施和经验。结果在诊治22例创伤急症患者期间,无一例医务人员和患者确诊COVID-19。紧急入院未做筛查的1例患者按疑似COVID-19病例对待,采用二级防护,术后排除COVID-19。结论COVID-19疫情期间,处理创伤急症的一线医务人员接诊过程均面临较高感染风险。创伤骨科急诊患者主要是交通伤和机器伤,老年患者主要由锐器切割及跌倒引起。通过完善院前筛查、选择合适的麻醉及手术方式、做好围手术期医护人员的防护及合理的术后病房管理和患者心理疏导,可降低院内COVID-19感染发生率。     

Hospital management of abdominal trauma in Tehran, Iran: a review of 228 patients

Objective: Today, trauma is a major public health problem in some countries. Abdominal trauma is the source of significant mortality and morbidity with both blunt and penetrating injuries. We performed an epidemiological study of abdominal trauma (AT) in Tehran, Iran. We used all our sources to describe the epidemiology and outcome of patients with AT.Methods: This study was done in Tehran. The study population included trauma patients admitted to the emergency department of six general hospitals in Tehran during one year. The data were collected through a questionnaire that was completed by a trained physician at the trauma center. The statistical analysis was performed using the SPSS software (version 11.5 for Windows). The statistical analysis was conducted using the chi-square and P＜0.05 was accepted as being statistically significant.Results: Two hundred and twenty-eight (2.8%) out of 8 000 patients were referred to the above mentioned centers with abdominal trauma. One hundred and twenty-five (54.9%)of the patients were in their 2nd and 3rd decades of life and 189 (83%) of our patients were male. Road traffic accidents (RTA) were the leading cause of AT with 119 (52.2%) patients. Spleen was the commonly injured organ with 51 cases. Following the analysis of injury severity, 159 (69.7%) patients had mild injuries (ISS＜16) and 69 (30.3%) patients had severe injuries (ISS= 16). The overall mortality rate was 46 (20.2%).Conclusions: Blunt abdominal trauma is more common than penetrating abdominal trauma. Road traffic accidents and stab wound are the most common causes of blunt and penetrating trauma, respectively. Spleen is the most commonly injured organ in these patients. The mortality rate is higher in blunt trauma than penetrating one.     

主动脉创伤腔内修复术后的影像学随访

目的 分析主动脉腔内修复术救治的主动脉创伤伤员的影像学随访资料,探讨预防主动脉腔内修复术后出现并发症的措施.方法 回顾性分析2006年1月-2014年9月因主动脉创伤在广州军区武汉总医院心胸外科行主动脉腔内修复术的伤员影像学随访资料,要求术后至少有2次CTA检查,且最后一次检查需离手术至少3个月.结果 检索出符合条件的病例23例,CTA显示主动脉内血管支架无移位、严重内漏,伤员无严重并发症的临床症状.11例伤员出现主动脉血管内支架在病变部位凸出,其中3例明显致使邻近食管管腔狭窄.结论 主动脉腔内修复术是主动脉创伤的一种快速、有效的救治方式,术后的一些特殊类型的并发症应在手术前进行评估.