上腹部正中切口作胆道手术的临床体会

我院自1995年1月～1998年4月间以上腹部正中切口进行胆道手术86例,均取得良好的效果。现探讨其临床实用价值。 一、资料与方法 临床资料:本组共86例,其中男性35例,女性51例。年龄10岁～84岁,平均为50.71岁。选择病例主要为胆囊炎,胆囊结石,胆囊息肉,胆总管结石。手术前均经多次B超或CT检查证实。本组中行单纯胆囊切除术56例,胆囊切除加胆总管探查术27例,胆囊切除加胃空肠吻合术,胆囊空肠吻合,空肠侧侧合术和胆囊切     

胃低分化内分泌肿瘤伴微灶状黏液细胞癌一例

患者男,63岁.因间断性黑便1个月于2010年1月以上消化道出血收入本院.体检:腹部平坦,上腹轻度压痛,肝脾肋下未触及.实验室检查:血红蛋白 82 g/L,红细胞3.82×1012/L,余无特殊.内窥镜下贲门黏膜充血、水肿,胃底后壁、胃体小弯侧及后壁并大弯侧溃疡,表面被覆陈旧血及污秽苔,周边不规则隆起.胃角、胃窦黏膜略粗糙,局部水肿,黏液附着,并见稀疏分布的过生结节.幽门通畅.考虑胃癌合并慢性浅表-萎缩性炎,取活检组织6块.切片报告低分化黏液腺癌,行全胃切除、食管空肠Roux-en-Y吻合术.术中探查肠系膜根部无肿大淋巴结,肝脏、盆腔未见转移结节,壁层腹膜光滑.术后恢复良好,排气和排便正常出院.     

上消化道穿孔手术后的护理及并发症

急性穿孔是胃十二指肠溃疡常见的严重并发症．十二指肠溃疡穿孔远较胃溃疡穿孔多见，穿孔的部位常在十二指肠球部前壁偏小弯侧和近幽门的胃前壁，多数穿孔直径小于0．5cm，胃溃疡穿孔一般较十二指肠穿孔为大。     

腹腔镜胆总管探查术

腹腔镜胆总管探查术能使胆总管结石的病人减少手术后不适,缩短住院时间并迅速恢复体力和工作。手术方法:全麻下人工气腹后,分别在脐、右腋前线、右锁骨中线及剑突下造孔进腹腔。先通过剑突下孔用钩形电凝和解剖钳解剖出胆囊动脉和胆囊管。胆囊动脉近端双重结扎。     

腹腔镜胆总管探查手术技巧

胆总管探查是普通外科常见手术 ,实践证明腹腔镜胆总管探查比传统的手术损伤小、病人痛苦轻、并发症少、适应范围广 ,受到病人欢迎 .1995年 4月～ 2 0 0 2年 8月 ,我们经腹腔镜胆总管探查治疗肝内外胆管结石共 2 15例 .本文重点介绍手术方法、手术技巧 .1　临床资料本组 (包括广州、佛山、深圳、惠州、英德等地手术的病例 ) 2 15例 ,其中男 82例 ,女 133例 ,年龄 6～82岁 ,平均 4 9岁 .黄疸并胆管炎者 36例 .有上腹部手术史者 2 8例 ,其中有胃穿孔修补术史者 3例、胃大部分切除术史者 15例、肠硬阻肠部分切除术史者1例、传统胆囊切除术史者 …     

胆道术后胆瘘临床分析

目的探讨胆道术后胆瘘的原因、预防及处理。方法回顾性分析了21例胆道术后合并胆瘘患者的临床资料。结果单纯胆囊切除术后13例,胆总管探查术后6例,胆肠吻合术后2例。全组首选手术治疗4例,3例治愈,1例拒绝手术死亡;首选非手术治疗17例,后中转手术2例,1例放弃治疗。非手术治愈率66.7%（14/21）,总治愈率90.5%（19/21）。结论胆瘘多发生于单纯胆囊切除术后或胆总管探查术后,与解剖变异、组织炎症、水肿、粘连、术者经验、患者全身情况等因素有关。应从熟悉解剖、规范操作、妥善引流、加强围手术期管理等方面加以预防。治疗方法应个体化,大部分病人可通过非术手治疗方法治愈。     

经脐单孔腹腔镜胆囊切除围手术期护理

经自然腔道内镜手术(natural orifice transluminal endoscopic surgery, NOTES )是通过病人胃、阴道、膀胱、肚脐、肛门等脏器进入腹腔和胸腔进行手术,最大的优点是没有可见疤痕、减少了外伤的疼痛和感染的机会[1].单孔腹腔镜胆囊切除术是经自然腔道内镜手术术式之一.我科自2009年2月至2009年4月共实施了6例单孔腹腔镜胆囊切除术,效果理想.现将护理体会报告如下.     

经胆囊管胆道探查取石的手术技巧和临床体会

目的：总结经胆囊管行胆总管探查取石的手术技巧及临床体会。方法：2010年1月至2011年12月我院收治胆总管结石患者23例，均采用经胆囊管行胆总管探查取石术治疗，对其临床资料进行回顾分析。结果：本组23例，19例成功经胆囊管取出结石，1例因镜下取石困难、1例因胆总管撕裂中转行胆总管切开取石，2例探查阴性。术中患者取出结石数1～5枚，直径约3～5mm。23例患者术后恢复顺利，无并发症发生。17例获随访5-7个月，平均6个月。术后1周、3个月均行肝胆超声检查，无一例发现残余结石，胆管内径均在正常范围，无胆管扩张及狭窄。结论：经胆囊管探查取石术，不切开乳头括约肌和胆总管，保护了括约肌的功能和胆管壁的完整性，术后不带T管，避免了T管相关并发症的发生，具有易操作、创伤小及恢复快等优点。     

胃小弯侧动脉的应用解剖

目的 解剖观察胃小弯侧的动脉供应及其变异,为临床上腹部手术、胃癌介入治疗提供解剖学依据.方法 随机收集经福尔马林处理过的74具成年尸体,观察胃动脉的起源、行径及其分支分布范围,并进行统计学处理.结果 在本组标本中,胃左动脉起源于腹腔干者72例,占97.3％;起于肝左动脉者2例,占2.7％.胃左动脉发出副肝左动脉者4例,占5.4％;发出替代性肝左动脉者4例,占5.4％.另有4例其变异更为特殊,占5.4％,其中有2例,替代性肝左动脉直接由腹腔干发出,后者再发出3支胃动脉,供应食管下部、胃的贲门部和胃体前壁小弯侧的部分;1例胃左动脉的前、后支直接由腹腔干发出;另1例除拥有常规的胃的动脉来源外,腹腔干还直接发出1支粗大的胃动脉供应贲门部的右上份.胃右动脉起源于肝固有动脉者48例,占64.8％;起于肝总动脉者10例,占13.5％;起于肝左动脉者9例,占12.2％;起源于胃十二指肠动脉者7例,占9.5％.结论 胃小弯侧动脉变异率较高,掌握其变化规律,对临床医生具有十分重要的意义.     

胃炎性纤维性息肉合并胃壁间质瘤1例

正患者女性,67岁,因间歇性嗳气,腹胀3个月余,黑便2周入院。胃镜检查示胃窦幽门前区可见一息肉样隆起性病变,表面光滑,色泽如常,有长蒂,为防止病灶出血,故未行活检。上腹部CT平扫示胃窦腔内可见一类圆形软组织密度影,CT值27~31 HU,病变与胃窦大弯侧胃壁相连,局部胃壁稍厚,胃周及腹膜后未见肿大淋巴结影。术中所见:切除约2/3胃,于胃窦大弯近幽门管处可见一大小4 cm×4 cm×     

Hyperplastic polyps of the gastric mucosa adjacent to gastroenterostomy stomas.

In two patients with functionally active, nonatrophic oxyntic gastric mucosa, hyperplastic polyps developed on the gastric side of Billroth II and Billroth I anastomoses. The polyp associated with the Billroth II procedure was almost circumferential, sparing only the lesser curvature. That associated with the Billroth I operation was on the anterior wall from lesser to greater curvature. The operations had been performed 11 years and ten years earlier for peptic ulcers of the gastroduodenal junction. The sites of polyp formation resembled those of experimental cancers in rats with Billroth I and Billroth II anastomoses, and of human cancer occurring 20 or more years after gastrojejunostomy for benign disease. This suggests that stomal carcinomas and hyperplastic polyps each result from the reflux of enteric contents into the stomach remnant.     

A型肉毒毒素降低大鼠胃平滑肌收缩及P物质含量

目的：在胃窦前壁注射A型肉毒毒素( BTX-A)后观察局部P物质（substance P）含量和分布的变化及其胃平滑肌收缩的变化，揭示两者之间的关系。 方法： 健康Wistar大鼠30只（普通级），体重260-300 g，雌雄不限。随机分为BTX-A组（B group）及对照组(A group)，在胃体前壁与幽门部交界线中点平滑肌内分别注射0.3 mL BTX-A (20 U/kg)，或0.9 % 氯化钠溶液0.3 mL； 记录胃肌电24 min后，切取局部胃前壁组织行放射免疫测定和免疫组化。结果： ① 放射免疫检测结果提示胃前壁组织中BTX-A组SP平均含量较对照组低28%（P＜0.01），免疫组化结果显示BTX-A组SP免疫反应阳性产物含量较对照组低11%（P＜0.05）；②注射BTX-A 12 min，24 min后， BTX-A组胃肌电的各项指标除24 min后峰电位发生率无显著差异(P＞0.05)外，其它均低于对照组（P＜0.05）。结论： BTX-A可以减少局部SP的含量，这种减少导致了胃肠平滑肌收缩功能的抑制。     

Bronchogenic cyst of the stomach masquerading as benign stromal tumor

Gastric bronchogenic cyst is an extremely rare lesion. A 62-year-old Korean woman presented with an incidentally found perigastric nodule. An abdominal ultrasonogram and computed tomography showed a 1.5 cm solid, homogeneous, low-density nodule in the hepatogastric ligament near the gastric lesser curvature. At the time of surgery, a soft 1.7 cm nodule was found in the lesser curvature side just below the gastroesophageal junction, and a gelatinous mass was protruded from the nodule during the resection. Microscopically, the gastric subserosa showed cystic structures lined by pseudostratified ciliated columnar epithelium, seromucinous gland, connective tissue and complete layers of smooth muscle bundles. Neither cartilage nor gastrointestinal epithelium was identified. A mucocele was found near the cyst and foamy cells and faintly bluish mucinous substances were found near the cystic structures. All the mucinous substances were stained by alcian blue at pH 2.5 with varying degrees of staining intensity. The present case is the smallest reported cyst among the gastric bronchogenic cysts, and these lesions are unusually located at the lesser curvature side of the stomach. Although these lesions are very rare, gastric bronchogenic cyst should be included in the differential diagnosis of gastric wall mass.     

A case of gastroenteritis associated with gastric trichuriasis

A rare human case of gastroenteritis and eosinophilic ascites associated with gastric trichuriasis is described. The patient was a 32-yr-old woman who was working in a farm near Pohang, Korea. She complained of abdominal pain, diarrhea, and vomiting. Endoscopic examination found focal linear hyperemia on the mucosa of the stomach antrum, and endoscopic biopsy confirmed eosinophilic inflammation of the mucosa and submucosa of the stomach, terminal ileum, and cecum. The biopsy specimen of the stomach included a female Trichuris trichiura which was covered by many inflammatory cells on its surface. Ascites and intestinal wall thickening was found by CT scan, and Douglas pouch centesis aspirated bloody ascites which included many eosinophils. She was medicated with prednisolone and albendazole and cured. She is the first case of eosinophilic inflammation of the gastrointestinal tract and ascites associated with trichuriasis in the stomach.     

Foregut duplication cyst of the stomach with pseudostratified columnar ciliated epithelium

Duplication cyst of the stomach with pseudostratified columnar ciliated epithelium is extremely rare. A 72-year-old Japanese woman visited Oomoto Hospital for examination of the stomach. Gastroendoscopy indicated a slightly depressed gastric cancer in the anterior wall of the middle third of the stomach. Adenocarcinoma was confirmed on endoscopic biopsy. Preoperative CT indicated a subserosal cystic lesion 2 cm in diameter on the lesser curvature of the stomach. The cystic lesion was resected through distal gastrectomy and systematic lymph node dissection. Histopathology showed that the cyst did not communicate with the gastric lumen, had pseudostratified columnar ciliated epithelium with circular muscle layers, and did not have gastric epithelium or cartilaginous tissue. The gastric cancer consisted of moderately differentiated adenocarcinoma with submucosal invasion and lymph node metastasis. Consequently, the present patient was diagnosed as having foregut duplication cyst of the stomach.     

In patients with Helicobacter pylori gastritis and functional dyspepsia, a biopsy from the incisura angularis provides useful diagnostic information

The aim of this study was to assess whether the taking of an additional biopsy from the incisura angularis increases the chance of detecting maximal degrees of atrophy and intestinal metaplasia (IM) in patients with Helicobacter pylori gastritis and functional dyspepsia. At entry into a randomised trial, biopsies were taken from 328 patients (mean age 48 years), two from both the gastric antrum and corpus, and one from the incisura angularis, and comparative grading of gastritis variables was carried out. Biopsy material from the gastric antrum, corpus, and the incisura angularis revealed no notable differences in atrophy or an incidence of IM and mucosa-associated lymphatic tissue. However, when the incisura biopsies were classified histologically, 58% contained antral mucosa (AM), 18% corpus mucosa (CM), and 24% intermediate zone mucosa. AM at the incisura was associated with considerably more severe gastritis in both the incisura and antrum (14% atrophy, 20% IM) than in CM of incisura (2% atrophy, 6% IM). Corpus atrophy and IM were rare in the AM group and absent from the CM group. Incisura angularis biopsy in patients with H. pylori gastritis and functional dyspepsia does give additional information regarding the severity of gastritis expected in the corpus and antrum. Antral-type mucosa in the incisura angularis region seems to indicate an increased risk for the development of atrophy and/or IM.     

经外侧裂入路行基底节区高血压脑出血手术的解剖和技巧

目的:为经外侧裂行基底节区高血压手术提供显微外科解剖学基础和手术技巧。方法:15例头颅湿标本,模拟手术入路观察外侧裂区解剖结构和相互毗邻关系并进行手术入路研究。结果:视辐射分前、中、后3束,前束覆盖颞角前尖端顶壁和侧壁,中束在颞角上壁和侧壁,前束和后束从外侧膝状体发出后向前卷曲,而后束离开外侧膝状体后终止于距状沟上岸没有向前的卷曲,后束走行于侧脑室下角的外侧壁,这样视辐射纤维存在于脑侧面的颞角的顶壁和中后及侧壁,颞角下壁没有视辐射纤维;经外侧裂、梨状皮质和钩的入路行基底节区高血压手术时,可以不损伤视辐射和钩束。结论:手术入路经外侧裂通过钩前面和上面的梨状皮质能安全进入基底节区而不损伤视辐射和钩束的主要部分。     

Torus Hyperplasia of the Pyloric Antrum

Primary or idiopathic hypertrophy of the pyloric muscle in adult, so called torus hyperplasia, is an infrequent but an established entity. It is caused by a circular muscle hypertrophy affecting the lesser curvature near the pylorus. Since most of the lesions are difficult to differentiate from tumor, distal gastrectomy is usually preformed to rule out most causes of pyloric lesions including neoplastic ones through a pathological study. A 56-yr-old man with a family history of gastric cancer presented with abdominal discomfort of 1 month duration. Upper gastrointestinal endoscopy showed a 1.0 cm sized irregular submucosal lesion proximal to the pylorus to the distal antrum on the lesser curvature. On colonoscopy examination, a 1.5 cm sized protruding mass was noticed on the appendiceal orifice. Gastrectomy and cecectomy were done, and histological section revealed marked hypertrophy of the distal circular pyloric musculature and an appendiceal mucocele. To the best of our knowledge, this is the first case of torus hyperplasia with appendiceal mucocele which is found incidentally.     

Foregut duplication cyst of the stomach

Foregut duplication cyst of the stomach is an extremely rare disease entity. A 35-year-old Korean man presented with epigastric pain. An abdominal cystic mass, measuring 7 x 6 x 5 cm, was found in the lesser curvature of the stomach. The cyst was unilocular with a grey-white, rubbery wall. Microscopically, the cyst wall was lined by pseudostratified ciliated, columnar epithelium and gastric mucosa with a complete lining of smooth muscle bundles. Although the origin of this lesion remains uncertain, this case suggests that the gastric cyst arose from the embryonic foregut and showed differentiation toward respiratory and gastric structures.     

Effects of blood flow and vessel geometry on wall stress and rupture risk of abdominal aortic aneurysms

Sudden rupture of abdominal aortic aneurysm (AAA), often without prior medical warning, is the 13th leading cause of mortality in the US. The local rupture is triggered when the elusive maximum local wall stress exceeds the patient's yield stress. Employing a validated fluid – structure interaction code, the coupled blood flow and AAA wall dynamics were simulated and analysed for two representative asymmetric AAAs with different neck angles and iliac bifurcations. It turned out that the AAA morphology plays an important role in wall deformation and stress distribution, and hence possible rupture. The neck angle substantially impacts flow fields. A large neck angle may cause strong irregular vortices in the AAA cavity and may influence the wall stress distribution remarkably. The rupture risk of lateral asymmetric AAAs is higher than for the anterior – posterior asymmetric types. The most likely rupture site is located near the anterior distal side for the anterior – posterior asymmetric AAA and the left distal side in the lateral asymmetric AAA.