手术治疗腹主动脉瘤205例远期疗效分析

目的评价手术治疗肾下型腹主动脉瘤的围手术期和远期效果。方法回顾性分析205例肾下型腹主动脉瘤切除术的临床资料,总结围手术期并发症和远期生存率,评价手术治疗腹主动脉瘤的安全性和远期疗效。结果30 d围手术期死亡率为1．0％;手术时间3-6 h,平均(3．8±1．4)h;ICU恢复时间中位数为16 h。围术期主要并发症包括心功能不全18例,呼吸功能不全10例,急性心肌梗塞2例,急性脑梗塞2例,急性肾功能衰竭4例;寿命表分析1、3、5年生存率分别为96．2％,83．1％,75．8％,随访中未发现与人工血管移植有关的死亡病例和并发症。结论手术仍是腹主动脉瘤的标准治疗方法。术前全身系统风险的评估和围手术期的谨慎管理在提高手术治疗效果中起重要作用。     

外科手术在肾下腹主动脉瘤治疗中的地位(附187例手术经验)

目的：就肾下型腹主动脉瘤的治疗经验，讨论外科手术的实用性和前途。方法：回顾分析1992年1月至2004年2月择期行肾下型腹主动脉瘤切除术187例，将其结果与经腔内治疗者作比较。结果：围手术期死亡1例(0．54％)，死亡原因是术后6h出现频发室性早搏、室颤，诱发大面积心肌梗死。手术时间平均为3．8h；出血量平均470ml．输血量445ml。ICU内恢复时间为12～24h。围手术期并发症包括心力衰竭17例，呼吸衰竭8例，急性心肌梗死2例，急性脑梗死1例，急性肾功能衰竭3例，无术后严重出血或失血性休克发生，也无下肢动脉栓塞发生。术后1、3、5年生存率分别为97．0％、84．6％及78.3％，随访期间病人死亡者的原因与腹主动脉瘤和手术无关。经腔内治疗手术目前仍有较高的中、远期并发症。结论：瘤体直径不能作为手术适应证的唯一指标。术前同时应确切评价全身重要脏器功能。影响腹主动脉瘤手术的危险因素主要是高龄、严重心、肺疾患及肾功能不全等。迄今，经腹手术仍是治疗腹主动脉瘤的主要方法。     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

肾下型腹主动脉瘤的外科治疗

目的总结26例肾下型腹主动脉瘤的手术治疗经验。方法回顾性分析近5年多来手术治疗26例肾下型腹主动脉瘤的临床资料，全组26例，术前均经影像检查证实诊断。行择期手术21例，破裂型腹主动脉瘤急诊手术5例。26例均行腹主动脉瘤切除，人工血管重建术。结果围手术期死亡2例，均为急症手术患者，总病死率7．7％，急诊手术病死率40．0％。随访时间1-5年。术后1，3，5年生存率分别为96％，88％，75％。死亡原因均与腹主动脉瘤和手术无关。结论CTA检查是诊断腹主动脉瘤的可靠方法。手术治疗仍是治疗腹主动脉瘤的重要方法。瘤体直径不是决定手术的唯一指征。影响手术的危险因素主要是高龄、严重的心肺疾病和肾功能不全。     

腹腔镜与开放性肾切除术的比较:549例良性肾脏疾病非随机对照研究10年结果

1993至 2 0 0 2年对良性肾脏疾病行肾切除 5 4 9例。A组 :开放手术 2 36例 ,年龄 8～ 89岁 ,平均 5 8.5岁。B组 :腹腔镜手术 313例 ,年龄 16～ 37岁 ,平均4 0岁。A组包括萎缩肾 15 2例 ,症状性肾积水 6 6例 ,其他 18例 ;B组萎缩肾192例 ,症状性肾积水 97例 ,其他 2 4例。B组 91.0 %为经腹进路。结果 :A组手术时间 30～ 2 4 0min ,平均 90min ;B组 4 1～ 2 10min ,平均 90min。A组失血量 5 0～ 180 0ml,平均 2 5 0ml;B组 4 0～75 0ml,平均 2 0 0ml,P =0 .0 0 1。B组中转开放手术 16例 (5 .1% )。A组输血者为 18.6 % ,B组为 9.9% ,P <0 …     

活体亲属肾移植手术的17例报告

目的总结活体亲属肾移植的临床经验。方法对供、受者进行全面的免疫学检查，对供者行IVU检查了解分侧肾功能，行DSA或MRA、螺旋CT血管三维成像检查了解血管的变异情况之后，开放式手术摘取供肾13例，经后腹腔镜活体供肾摘取4例，按常规方法移植给受者。免疫抑制方案为环孢素A（或FK506）、霉酚酸酯（或硫唑嘌呤、雷帕鸣）、强的松三联免疫抑制剂。结果13例开放式手术时间1．5～3．0h，平均2．0h；热缺血时间1．0～1．5min，平均1．2min；术中出血量60～200ml，平均140ml，术中及术后均未输血；术后住院7～10d，平均8d。4例后腹腔镜手术时间3．0～4．5h，平均3．5h；热缺血时间2．5～3．5min，平均2．8min；术中出血量60～100ml，平均75ml，术中及术后均未输血；术后3～5d出院。移植肾血液循环恢复后10～40s泌尿，平均20s。1例受者术后45d发生轻微的急性排斥反应，应用激素冲击3d后逆转，其余受者均无并发症。随访4～60个月，人／肾存活率为100％，移植肾功能良好。结论活体亲属肾移植安全可行，取左肾尽量靠近腹主动脉壁切断肾动脉，取右肾切取少许下腔静脉片。     

破裂腹主动脉瘤的外科救治体会

目的 探讨破裂腹主动脉瘤(RAAA)外科救治经验.方法 回顾性分析1999年4月至2008年12月救治的38例RAAA患者的临床资料,根据病史、体征、急诊彩超和CT快速诊断,行急诊腹主动脉瘤切除人造血管移植手术.结果 均行急诊RAAA切除人造血管移植手术,围手术期死亡10例(26.3%),其中出血性休克昕致急性肾功能衰竭4例,多器官功能衰竭4例,呼吸循环衰竭2例;其他28例患者经治疗后均痊愈出院.结论 快速早期确定RAAA诊断,紧急外科手术治疗,尽快纠正失血昕致内环境紊乱是提高RAAA救治成功的关键.     

局部切除与胰十二指肠切除治疗Vater壶腹癌的临床对比研究

目的 为治疗Vater壶腹癌提供一种简单、实用的新方法。方法 应用局部切除与胰十二指肠切除两种不同的方法治疗Vater壶腹癌,判定Vater壶腹癌局部切除的可靠性。结果 Vater壶腹癌局部切除组21例,平均住院14d。发生手术并发症1例,无围手术期死亡,1年、3年、5年生存率分别为95％、69.7％、38.7%。胰十二指肠切除组16例,平均住院21d,发生手术并发症7例,围手术期死亡2例,1年、3年、5年生存率分别为86.7%、68.9%、36.8%。手术并发症两种方法有非常显著差别（P＜0.01）,围手术期死亡及1年、3年、5年生存率无显著差别（P＞0.05）。结论 Vater壶腹癌局部切除是一种合理治疗Vater壶腹癌的手术方法。     

小肾癌选择性保肾手术治疗体会

目的探讨小肾癌选择性保肾手术的临床价值。方法回顾性分析1999年12月～2001年12月采用局部低温、保留肾单位手术治疗小肾癌16例。所有病例对侧肾功能正常，肿瘤直径平均2．4(1．5～3．0)cm，均为RobsonⅠ期。结果16例手术均获成功，平均手术时间1．2(1．0～1．5)h，平均输血400(100～800)ml。术中损伤肾盏6例，以4-0的Dexon线修补，无术后出血、肾功能衰竭、感染、尿瘘等并发症。术后平均随访26(3～57)个月，未见并发症及肿瘤局部复发及转移。结论保留肾单位手术治疗小肾癌安全有效，对肿瘤体积小、位置适宜、年轻患者可考虑行保留肾单位手术。     

腹腔镜下保留肾单位手术治疗T1肾癌

目的 探讨腹腔镜下保留肾单位手术治疗T1肾癌的方法和疗效. 方法 肾癌患者32例.男24例,女8例.年龄31～72岁,平均49岁.均经B超、CT或MRI检查确诊为T1N0M0肾癌.肿瘤位于左肾21例,右肾11例;肾上极10例,下极13例,肾脏中部5例,近肾盂部位4例;偏背侧18例,腹侧14例.肿瘤平均直径(2.8±0.8)cm.25例行后腹腔途经,肿瘤位于偏腹侧者7例行经腹途径腹腔镜下保留肾单位术,均沿瘤体边缘外0.5 cm处分离切除肿瘤.手术前后行肾核素扫描(ECT)检测分肾功能. 结果 31例完成腹腔镜下保留肾单位手术,1例因缝合后肾脏渗血明显,中转开放手术.32例阻断肾蒂时间平均(24±4)min.3例开放血流后有明显渗血,均有2次阻断肾蒂史,阻断血管时间>30 min.31例平均手术时间(105±15)min,平均出血量(120±22)ml,6例术中输血400 ml.5例肿瘤位于肾脏中部者术前放置双J管.3例切除肿瘤后暴露肾盏,于术后当日通过膀胱镜放置双J管引流,其中2例于术后2～3 d发生漏尿,引流量200～300 ml,分别于术后15、21 d引流液<20 ml后拔出负压引流管后愈合.术后复查SCr、BUN均正常.术后住院时间平均(9±2)d.术后病理报告切缘均未见肿瘤残留.平均随访(23±5)个月,肿瘤无复发.术后1个月B超和CT复查发现患侧肾手术部位局部血肿3例,术后3个月血肿吸收.术后15 d复查双肾ECT,9例患侧肾血流较术前下降10%～15%,3例下降20%;术后1个月复查,7例患侧肾血流较术前下降10%～15%,术后(23±5)个月复查.仍有3例患侧肾血流较术前下降10%～15%. 结论 腹腔镜下保留肾单位手术安全可行.     

Acute renal failure after endovascular vs open repair of abdominal aortic aneurysm

OBJECTIVE: Endovascular aneurysm repair (EVAR) is an increasingly used alternative to open surgical repair of unruptured abdominal aortic aneurysms (AAAs). The effect of EVAR on postprocedure acute renal failure has not been determined. We hypothesized that EVAR would be associated with a lower risk of acute renal failure and acute renal failure requiring hemodialysis. METHODS: A retrospective cohort study was conducted of the 2002 Nationwide Inpatient Sample, the largest all-payer inpatient care database in the United States, reflecting discharges from a representative sample of United States hospitals. We identified 6614 discharges with a primary diagnosis of unruptured AAA and a primary procedure code for open AAA repair or EVAR. We excluded 56 patients with end-stage renal disease and 42 patients who underwent concomitant aortorenal bypass. We compared EVAR vs open repair in this cohort. The main outcome measures were acute renal failure and acute renal failure requiring dialysis. RESULTS: A total of 6516 patient discharges met the inclusion criteria for the study, and postprocedure acute renal failure developed in 439 (6.7%). EVAR was associated with lower odds of acute renal failure (adjusted odds ratio, 0.42; 95% confidence interval, 0.33 to 0.53) and acute renal failure requiring dialysis (adjusted odds ratio, 0.30, 95% confidence interval, 0.15 to 0.63). Results were similar when EVAR and open AAA repair were compared within quintiles of the propensity score for the receipt of EVAR. CONCLUSIONS: Compared with open AAA repair, EVAR is associated with a lower risk of postprocedure acute renal failure.     

Management of synchronous renal neoplasm and abdominal aortic aneurysm

OBJECTIVES: Renal neoplasm (RN) and abdominal aortic aneurysm (AAA) are occasionally discovered concurrently. The approach to synchronous malignancy and aortic aneurysm is controversial. METHODS: Between 1981 and 1999, concurrent RN and AAA were diagnosed in 50 patients at the Cleveland Clinic Foundation. Twenty-three patients were managed conservatively because of small asymptomatic AAA or metastatic disease; these patients were excluded from the study. The remaining 27 patients underwent operative management of both entities with a staged or simultaneous approach, and they form the basis of this article. RESULTS: AAA diameter ranged from 4.8 to 13 cm (mean, 6.0+/-1.8 cm). RNs were managed with radical nephrectomy in 11 patients (41%), partial nephrectomy in 10 patients (37%), or both in 6 patients with bilateral renal tumors (22%). The AAA repair was performed at the time of the urologic procedure in 11 patients (41%), before the urologic procedure in 13 patients (48%), or after the urologic procedure in 3 patients (11%). The AAA was addressed with open surgical repair in 24 patients (89%); recently, three patients (11%) underwent endovascular repair of the aneurysm and staged partial nephrectomy. The incidence of major perioperative complications was 23% (6 patients). Acute renal failure was the most common complication (3 [11%]) followed by acute respiratory failure (2 [7.4%]), pulmonary embolism (1 [3.7%]), and stroke (1 [3.7%]). At the mean follow-up of 57 months, there were no graft infections reported. The 5-year overall and cancer-specific survival rates were 62% and 81%, respectively. There was a significant difference in 5-year cancer-specific survival when comparing patients managed simultaneously versus staged (80% versus 35%, P =.007). CONCLUSIONS: The concurrent presentation of RN and AAA should not discourage one from treating both entities simultaneously because long-term survival is common. Endovascular repair of AAA holds promise as an attractive strategy in these complex patients.     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

Endovascular repair of ruptured aneurysms of the infrarenal abdominal aorta: feasibility and results

AIM: Endovascular repair may represent an interesting alternative to open surgery for ruptured abdominal aortic aneurysms (AAA). This study evaluated the feasibility and short-term results of endovascular repair of ruptured AAA at our center. METHODS: Between April 2004 and December 2005, all patients admitted to our center for a ruptured AAA were considered for endovascular repair. Patients whose hemodynamic status was too unstable to permit a preoperative CT scan and patients with an unfavorable anatomy for endovascular repair underwent open surgery. Endovascular repair consisted in emergency placement of an aorto-uni-iliac endograft associated with a crossover femoro-femoral bypass and deployment of an occluder in the contralateral common iliac artery. Follow-up postoperative CT scans were obtained 1, 6, 12 and 18 months after intervention and then annually. Data concerning diagnosis, the operative risk, treatment, and follow-up were collated prospectively in a registry and were analyzed on an intention-to-treat basis. RESULTS: Between April 2004 and December 2005, 17 patients were admitted to our Department for a ruptured AAA. Ten patients (59 %) underwent emergency endovascular repair and were included in this study (8 men and 2 women, mean age 81 years, range 51-97). The mean duration of the operation was 167 +/- 37 min. The mean blood transfusion volume was 3 700 +/- 1 400 mL. The mean duration of hospitalization was 19 days (range: 9-60). Mortality at day 30 was 20% (2 patients): one death occurred on day 2 due to multi-organ failure in an 80-year-old patient and another death occurred on day 2 owing to myocardial infarction in an 87-year-old patient. Mean follow-up was 6 months. Late mortality occurred in 2 cases. No endoleaks were observed during follow-up. CONCLUSION: Our initial results using endografts for the repair of ruptured AAA were satisfactory, with a feasibility of 59% and an operative mortality of 20%. Randomized studies are necessary to determine the true value of endovascular repair of ruptured AAA compared to conventional open repair.     

腹主动脉瘤96例的诊断与手术治疗

摘要：目的 探讨腹主动脉瘤(AAA)的诊断、手术方式的选择及并发症的防治。方法 回顾性分析14年余收治的96例AAA的诊断和手术治疗的临床资料。对82例肾动脉水平以下型AAA行动脉瘤切除人工血管置换术，12例肾下型行涤纶片动脉瘤体包裹术，2例肾动脉上型腹主动脉假性动脉瘤行側壁瘤体切除修补术。结果 主动脉造影、MRA或EBT可确定动脉瘤上界与肾动脉间的距离。93例获得临床治愈。手术死亡3例，手术病死率3.1%(3/96)；其中急诊手术病死率50.0%(2/4)，限期手术病死率1.1%(1/92)，两者差异显著（P<0.05）。6例术后出现乙状结肠缺血症状，2例肢体远端有缺血症状，2例急性肾功能不全，均经非手术治疗痊愈。手术并发症发生率21.3％。82例获随访，随访时间6个月至15年。术后5年生存率为81.7%。 结论 AAA切除人工血管置换术是治疗AAA的基本方法。     

Ruptured inflammatory abdominal aortic aneurysm: insights in clinical management and outcome

BACKGROUND: Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment. METHODS: Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay. RESULTS: Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy. CONCLUSIONS: Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.