生长抑素与生长激素促进肠外瘘自愈的机理与临床研究

目的　探索促进肠外瘘自愈的方法。　方法　用 90只雄性SD大鼠进行动物实验 ,研究生长激素对肉芽组织及肠粘膜上皮细胞的作用 ;观察 2 9例肠外瘘患者临床联合应用生长抑素、生长激素与营养支持治疗的效果 ,并与 5 8例用生长抑素加营养支持组对比。　结果　生长激素可促使肉芽组织的羟脯氨酸和纤维母细胞含量增加 ,促进肠粘膜上皮细胞增长。临床联合用药组的自愈率为 96 5 % (2 8/ 2 9) ,明显高于生长抑素组的 6 8 4% (39/ 5 8) ,差异有显著性意义 (P <0 0 1)。　结论　生长抑素加生长激素可促进肠外瘘的自愈 ,是一新的治疗方法。     

肠外瘘早期确定性手术的临床研究

目的研究在肠外瘘发生早期,一期切除肠外瘘肠段,并进行肠吻合以消除瘘的手术效果。方法本组患者男18例,平均(31.5±16.5)岁;女8例,平均(38.4±22.4)岁。26例患者中,重症胰腺炎并发肠外瘘2例,腹部创伤并发肠外瘘11例,妇产科手术因术中损伤肠道并发肠外瘘3例,肠道炎性疾病、肠梗阻和肠套叠等小肠良性疾病术后并发肠外瘘10例。26例患者中十二指肠瘘2个,小肠瘘及小肠吻合口瘘18个,回结肠吻合口瘘5个,结肠瘘4个。本组患者2例合并胆瘘,1例合并胰空肠吻合口瘘,2例为多发瘘。小肠部分切除吻合术18例次,结肠部分切除吻合术3例次,回结肠吻合口切除再吻合术5例。在术后72h使用重组人生长激素。结果26例患者无死亡。18例需机械辅助呼吸,平均支持时间(3.0±2.4)d。早期确定性手术距前次致瘘手术或腹膜炎发生平均(8.9±4.6)d,距发现瘘的时间为(4.0±2.6)d。恢复肠内营养的时间为(9.7±3.1)d。完全经口饮食平均为(18.7±8.1)d。术后生长激素平均使用(8.9±2.8)d。结论在肠外瘘早期行确定性手术,并在术后适时加用生长激素可促进吻合口的愈合;进一步提高肠外瘘的治愈率,缩短治疗时间。     

肠外瘘早中期确定性外科处理的临床研究

目的探讨肠外瘘早中期确定性处理方法。方法对３１例肠外瘘病人的治疗经验进行分析。在重视综合措施的前提下,对无法确定可否自愈的２８例病人,应经过必要准备后,争取早期手术治疗,并根据术中发现的情况,采用不同手术方法。另３例瘘口较小者采用非手术症法。结果３例非手术治疗者均自愈。可２８例手术治疗者中,治愈２６例（９３６％）,死亡２例（６４５％）。平均住院日期３６２２ｄ。结论在大多数肠瘘病人,采取早期手术治疗肠外瘘,可取得缩短病程,降低死亡率的好效果     

双套管引流配合早期口服饮食治疗非高流量肠外瘘

目的总结双套管引流配合早期正常口服饮食在非高流量肠外瘘病人中的治疗作用。方法胃肠手术后非高流量肠外瘘病人82例,其中治疗组39例,采用双套管引流配合早期口服饮食治疗;对照组43例,采用双套管引流配合全程使用肠内营养制剂治疗。比较两组病人治疗后肠瘘是否愈合、愈合时间以及治疗前后的炎症指标、营养指标改善情况。结果治疗组39例病人愈合33例,瘘口自愈率为84.6%,对照组自愈率为86.0%,两组比较差异无统计学意义(P0.05)。对照组和治疗组愈合时间分别为(14.7±6.7)天和(16.4±7.2)天,差异有统计学意义(P0.05)。其中治疗组中,低位瘘自愈率和愈合时间分别为93.1%和15.8天,高位瘘分别为60.0%和19.8天,两组比较差异有统计学意义(P0.05)。治疗后所有病人肿瘤坏死因子、白细胞介素-6、血浆内毒素、C反应蛋白水平均较治疗前显著改善(P0.05)。治愈后的营养指标(血红蛋白、血清总蛋白、白蛋白、转铁蛋白、前白蛋白和视黄醇结合蛋白)均增高,其中前白蛋白和视黄醇结合蛋白比对照组高(P0.05)。结论非高流量肠外瘘病人经双套管引流,早期过渡到正常口服饮食安全有效,而且在低位肠瘘治疗中更有优势。它可减轻病人的炎症反应,改善营养状态,使大部分病人的肠外瘘达到临床愈合,避免再次手术。     

生长抑素和生长激素在肠外瘘治疗中的应用

生长抑素在８０年代中期即应用在肠外瘘的治疗,我科早年亦有报道。近年来,我们根据多年来治疗肠外瘘的经验,针对肠外瘘的病理生理和生长激素的作用特点,创造性提出营养支持联合生长抑素和生长激素促进肠外瘘自愈。并进一步将生长激素应用在肠外瘘治疗的多个方面［１,...     

胃癌切除术后十二指肠残端瘘的营养支持

目的总结胃癌切除术后十二指肠残端瘘的营养支持经验，以提高对十二指肠残端瘘的治疗水平。方法对1997年1月至2006年12月间收治的18例胃癌切除术后十二指肠残端瘘患者的临床资料进行回顾性分析。结果18例患者均予以加强十二指肠残端瘘处的引流、采用持续胃肠减压、肠外营养结合肠内营养支持的治疗手段；16例强化予以谷氨酰胺．12例使用了生长抑素，8例加用了生长激素。在首次胃癌切除术后，5例在21．30d内瘘口自愈，12例30．72d瘘口愈合，1例因并发腹腔内出血和上消化道出血于首次胃癌切除术后62d死亡。结论保证腹腔引流的通畅和持续胃肠减压，采用肠外结合肠内营养支持、强化谷氨酰胺、生长抑素、生长激素等措施，是促进十二指肠残端瘘愈合的重要手段。     

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目的　总结长期禁食的肠外瘘病人在使用肠内营养 (EN)早期出现并发症的特点与规律 ,并探讨其治疗方法。方法　连续收集 2 0 0 1年 4月至 2 0 0 2年 7月治愈的肠外瘘病人 10 0例。收集肠内营养开始前的禁食时间 ;肠内营养实施前、实施后 1、3、5、10、15天肝功、生化和营养指标。收集大便次数、体温、心率和呼吸次数并进行全身炎症反应综合征 (SIRS)评分。所有病人均选用短肽类制剂。结果　 10 0例肠外瘘病人均为成功治愈病例 ,其中择期手术 5 6例 ,早期手术 15例 ,自行愈合 2 9例。AKP在EN前为 (181 5± 12 7 5 )U ,在EN后第 3天显著升高为 (2 4 3 0± 12 1 6 ) ;γ -GT在EN前为 (118 4± 94 2 )U ,EN后第 1和第 3天显著升高 ,分别为 (14 9 6±92 1)U ,(177 2± 10 9 9)U。以后各指标渐降低。出现淤胆性胆囊炎 3例。大便次数超过 3次的在肠内营养实施后第 1、3、5、10和 15天分别为 31例 ,2 6例 ,12例 ,13例和 7例。SIRS评分在EN后第 1天 (1 0 5± 1 0 8)和第3天 (0 96± 1 11)均显著高于EN前 (0 72± 0 84 ) ;在EN第 5天逐渐降低 (0 83± 0 91) ;SIRS评分在EN第 10天 (0 4 9± 0 73)和第 15天 (0 32± 0 6 0 )显著低于EN前。结论　肠内营养再灌食综合征的出现与胃肠道长期缺乏腔内营养所致     

谷氨酰胺和生长激素联合应用对大鼠氨基酸水平的影响

本文对化疗后大鼠肠外补充谷氨酰胺和生长激素 ,研究血浆和组织 (肌肉和小肠 )中游离氨基酸的变化 ,探讨谷氨酰胺和生长激素联合应用对氨基酸代谢的影响。材料与方法1.研究方法5 0只雄性Ｗｉｓｔａｒ大鼠平均体重 184ｇ± 12 .4ｇ。在手术日晨行中心静脉插管 ,随机分为 5组 ,每组 10只 :Ａ组普通饮食 (Ｃｈｏｗ) ;Ｂ组肠外营养 (ＰＮ) ;Ｃ组肠外营养加甘氨酰-谷氨酰胺双肽 (Ｇｌｙ -Ｇｌｎ) ;Ｄ组肠外营养加生长激素(ＧＨ) ;Ｅ组肠外营养加谷氨酰胺双肽和生长激素 (Ｇｌｎ加ＧＨ)。Ａ组提供普通饮食 ,其它组给予等氮 2 .5ｇ/ (ｋｇ·ｄ)、等…     

纤维蛋白胶封堵法治疗肠外瘘32例报告

目的探讨纤维蛋白胶封堵法治疗肠外瘘临床应用价值。方法2003年2月至2006年2月第二军医大学附属长海医院对32例术后肠外瘘病人应用纤维蛋白胶封堵法治疗肠外瘘,观察其临床疗效。结果31例获得愈合,封堵开始至愈合平均时间(8.9±3.6)d,平均封堵次数(2.3±1.3)次,其中1次者11例,2次者9例,3次及以上者12例,成功率为96.9%。结论纤维蛋白胶能有效地促进肠外瘘愈合。     

胃癌切除术后胃肠道瘘的治疗

目的 总结胃癌切除术后胃肠道瘘的治疗经验,以提高对胃癌切除术后胃肠道瘘的治疗水平.方法 对1997年1月至2006年12月在北京解放军总医院治疗的胃癌切除术后19例吻合El瘘和18例十二指肠残端瘘共37例胃肠道瘘患者进行回顾性分析.结果 本组37例均加强了瘘口附近的腹腔引流,采用了持续胃肠减压,先给予肠外营养支持、然后从肠外营养支持逐步过渡到肠内营养支持的治疗手段.32例在肠外营养液中强化了谷氨酰胺,31例使用了生长抑素,13例在吻合口瘘愈合期加用了生长激素.9例瘘口于术后21-30d自愈,24例于30-60d内愈合,2例于60.81 d内愈合.2例死亡,其中1例食管空肠吻合口瘘因严重的左侧胸腔、肺部感染及腹腔感染于术后42 d死亡.另1例十二指肠残端瘘因瘘口周围严重感染和急性腹腔内出血于术后62 d死亡.结论 保证腹腔引流的通畅、持续胃肠减压,特别是肠外结合肠内营养支持、强化谷氨酰胺、生长抑素及生长激素等措施,是促进胃癌切除术后胃肠道瘘愈合的重要手段.     

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.