161例肾损伤的处理

目的探讨严重肾损伤的概念及治疗方案。方法对１９６５至１９９６年收治的１６１例严重肾损伤病例资料进行回顾分析。结果１６１例病人,伴有合并伤１１６例（７２．０％）。保守治疗７７例,发生并发症６例,治愈率９２．２％;手术治疗７３例,其中肾切除３２例,切肾率１９．９％;选择性肾动脉栓塞治疗１１例,治愈率１００．０％;死亡１５例,死亡率为９．３％。结论（１）强调手术治疗与非手术治疗的指征。（２）对有合并伤者,应全面、准确、及时的进行伤情评估。（３）对疑有内脏损伤者,应仔细探查,发现损伤应一并处理。     

脾切除后存活至少一年的病人死亡原因

脾切除后的凶险性脓毒症是一不常见的并发症，作者利用瑞典住院病人登记电脑联网、总人口登记和全国死亡原因登记资料，分析以人口为基础的脾切除后死亡率。初步评估脾切除后第一年内的危机，包括1297例外伤行脾切除和991例手术治疗邻近器官非恶性病并已存活1年者的死亡数和标准死亡比率（SMR），取瑞典总人口作为比较。结果外伤脾切除组病人较年轻，18．8％不足匕岁，60．9％在手术时为30岁以下；而非恶性病脾切除组病人仅0．4％不足15岁，37％系刀岁以下。鉴于性别差别很小，故将男女组合并计算。脾切除后第1年内，外伤组病人的死亡率比…     

血液病患者脾切除同时行消化道或胆道手术的危险

作者回顾性分析了207例因血液系统疾病行脾切除患者，比较了单纯脾切除与同时行消化道或胆道手术者术后并发症与死亡率的区别。病人分为两组，组1，19例，于脾切除同时接受消化道或胆道手术；组2，188例，行单纯脾切除术。两组患病情况及手术指征相同，所患疾病为原发性血小板减少性紫癜，何杰金氏病，骨髓纤维化，非何杰金淋巴瘤，白血病等。多数病人因脾功能亢进行脾切除手术治疗。结果显示：组1的19例中发生腹腔感染4例，其发生率明显高干组2（3／188例），P=0．002，消化道手术方式为胆囊切除与小肠或结肠手术。总死亡11例（组1=3，组2…     

特大肝癌的手术切除：附86例报告

目的 通过８６例特大原发性肝癌的临床追踪分析,以探讨其手术切除指征和疗效。方法 １９８５年１月至１９９６年６月,共采用手术切除治疗特大原发性肝癌８６例,其中规则性肝叶切除４６例,不规则肝叶切除４０例。统计术中出、输血量。术后观察腹腔引流量、补液天数、住院天数,随访并发症发生率及生存时间。结果 手术死亡率３．４８％,术后并发症的发生率为３１．４％。手术死亡率和术后并发症发生率与术前白蛋白较低或γ－球     

外伤性脾破裂的修补术及脾部分切除术(综述)

自1893年Riegues首创用脾切除治疗外伤性脾破裂以后,许多年来一直认为脾破裂后,脾切除是唯一可行的手术方法,且认为脾脏切除后对人体生理无不良反应。1952年King等总结脾切除100例的经验,认为切脾后的小儿感染的发病率较高,并发症及死亡率也高。1973年,Singer广泛复习文献,收集脾切除病共2,796例,发现脾切除后暴发性脓毒症的发病率为4.25％死亡率为2.52％,较正常儿童脓毒症发病率高58倍,在这些严重感染的病人中死亡率达58％。感染可发生于手术后任何时间,易发于3岁以内的婴儿。     

肝脏恶性肿瘤切除后肝内复发的综合处理

近8年来我们共收治32例肝脏恶性肿瘤切除后肝内复发患者。采用以手术切除为主的综合治疗措施，其中再次手术切除14例（43．75％），经随访术后1、2、3年生存率分别为91．7％，66．8％．33．3％，其中5例现尚存活。在再次手术切除中，应注意麻醉、切口、手术技巧、切肝量等方面的问题．才能降低手术死亡率，减少手术并发症，提高术后生存率。     

肝海绵状血管瘤:规则切除与摘除术的比较

本研究旨在探讨肝海绵状血管瘤（Cavemoushe－mansiomaoftheliver,CHL）手术方式对病人治疗效果和水后腹腔内并发症的影响。方法研究者分析了．1987年12月1日～1997年12月1日之间采用肝切除或摘除术的CHL病人28例。手术指征为：腹疼、肿瘤增大、诊断不明或自发破裂。用多变量分析的方法评价CHL的切除方式、住院病程以及出现腹腔内并发症等情况,以确定影响术后并发症的独立因素。结果24例女病人,4例男病人,年龄47．5土12．4岁。有腹疼症状的16例（57％）,腹疼伴肿瘤增大的3例（％）,诊断不明7例（2％）,自发破裂2例（7％）。23例…     

上尿路结石肾切除原因及降低切肾率的探讨

为降低上尿路结石肾切除率，总结分析自１９７５～１９９５年手术治疗上尿路结石６７３例资料。结果：６７３例中行肾切除６５例，占９．６％。分析其原因认为掌握以下几点可降低切肾率：（１）正确掌握上尿路结石手术与非手术治疗的指征界限，（２）严格控制积水的切肾指征，（３）避免取石时肾脏大出血，（４）尽可能减少残余结石，（５）加强手术前后抗感染治疗。     

胃癌根治性手术联合脾切除必要性的Meta分析

目的评价胃癌根治手术联合脾切除的必要性。方法以Medline、the Cochrane Library数据库作为已发表国外文献的主要来源．以万方数据知识服务平台及中国知网数据出版平台作为已发表国内文献的主要来源：检索时间：2010年10月12日。收集1990-2010年公开发表的有关胃癌根治性手术切除与保留脾脏两种术式疗效的中文和英文文献．对切脾组和保脾组术后并发症发生率及5年生存率进行Meta分析。结果筛选出符合纳入标准的研究12项（2628例）。切脾组900例,保脾组1728例。两组术后并发症发生率的差异有统计学意义（DR=1．91,95％CI：1．28～2．87,P〈0．05）;5年生存率的差异无统计学意义（HR=0．90,95％CI：0．73。1．11．P〉0．05）。结论联合脾切除的胃癌根治性手术不能改善胃癌患者的预后．且使胃癌患者的术后并发症增多。     

小儿脾切除指征、合併症及外伤性脾破裂之处理(综述)

切脾指征【先天性球形溶血性贫血】为最常见的小儿切脾指征。此病有家族倾向、脾切除可治愈。本病出现危像时血胆红质升高、血色素及血球容积下降。术前需作胆囊造影、手术中对胆道应仔细扪诊以除外胆道结石。在美国儿科学会儿外组统计的1413例小儿脾切除、及匹茨堡儿童医院309例脾切除中,此病为切牌指     

Splenectomy for splenomegaly of more than 1000 grams. A retrospective study of 36 patients

Splenectomy for massive splenomegaly is frequently performed for hematologic disorders for diagnostic and therapeutic indications. The role of splenectomy is complex and controversial. The aims of our retrospective study were to focus on postoperative complications and advantages of splenectomy for massive splenomegaly. Thirty six patients with splenomegaly weighing 1000 g or more, underwent splenectomy at Centre Hospitalier Universitaire Lyon Sud, from January 1st, 1982, to December 31, 1995. Thirty-one (85%) of these patients had hematologic malignancy and more than half of them were older than sixty years. The main indications for splenectomy were hypersplenism (18 patients) and diagnosis (14). Preliminary ligation of the splenic artery was performed in 25 patients (42%). All patients had drainage. The mortality and morbidity rates were 5.5% and 20%, respectively. No major septic or thromboembolic complications occurred. There was only one major bleeding complication. The advantages of splenectomy included histopathological diagnosis in 13 of 14 patients with splenomegaly of unknown origin, permanent pain relief in all cases, and immediate correction of hematological cytopenia in 27 cases (75%). We conclude that the large weight of the spleen does not constitute a contraindication to splenectomy, but indications must be carefully selected, and the operative and perioperative management, must be appropriate.     

Predictors for morbidity and mortality following non-traumatic splenectomy at the University Hospital, Jeddah, Saudi Arabia

OBJECTIVE: To determine the pre-operative predictors of morbidity and mortality of patients undergoing elective splenectomy for non-trauma indications. METHODS: Analysis of 123 patients who underwent splenectomy at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between 1986-1996. Data collected included patients' demographic data, indication for splenectomy, laboratory data, details of operative procedure and postoperative events for morbidity and mortality. Statistical analysis was carried out using the Chi-square test. RESULTS: Of the patients, 69% were males and 31% females with ages ranging from 13-72 years (mean 39 years). Portal hypertension constituted 55% of the indications and benign hematological conditions 26%. The morbidity rate was 27.6% and the commonest complication was chest and wound infection in 6.6% and 5.7%, respectively. Age of >50 years, pre- and postoperative haematocrit of <33%, thoraco-abdominal approach and operative time of >120 min had P values of < 0.05, <0.002, <0.03 and <0.03, respectively for postsplenectomy mortality. CONCLUSIONS: According to this study, age of >50 years is a significant predictor for morbidity following splenectomy, whereas age >50 years, pre- and postoperative haematocrit of <33%, thoraco-abdominal approach and operative duration >120 min were significant predictors of postsplenectomy mortality.     

Indications for splenectomy in the surgical treatment of gastric cancer

The extent of lymphadenectomy in the treatment of gastric cancer is still a matter of debate. Splenectomy, which has to be performed using the common surgical techniques to remove the lymph nodes of the splenic hilus, is part of this problem. The indications for splenectomy in the treatment of gastric cancer are examined, considering the results in terms of operative mortality and morbidity and long term survival. The Authors analyze a consecutive series of 129 patients who underwent total gastrectomy with D2 or D3 lymphadenectomy for gastric cancer. Forty-seven splenectomies were performed among 79 patients submitted to total gastrectomy. Splenectomy did not influence the perioperative mortality. Morbidity was higher in the patients who underwent splenectomy (33.3%) than in the patients without splenectomy (28.12%). This difference was not statistically significant. Five-year survival was higher in the group that did not undergo splenectomy (37.6% vs 27%) without any significant difference. Also considering the results in literature, splenectomy is associated with an increase in morbidity, and, for some authors, also in mortality, without any significant improvement in long-term survival. The indication for splenectomy in gastric cancer is based on an accurate evaluation of the localization and the depth of the parietal infiltration of the tumor.     

Results of laparoscopic and open splenectomy for nontraumatic diseases

The medical records of patients who had undergone splenectomy for nontraumatic diseases of the spleen between 1997 and 2000 were reviewed. The aim of the study was to evaluate the short-term outcomes of open and laparoscopic splenectomies and to determine whether some well-known benefits of laparoscopic surgery could be observed in patients who underwent laparoscopic splenectomy for nontraumatic splenic diseases. The data of 44 patients were available for analysis and included 20 patients (45.5%) who underwent laparoscopic splenectomy and 24 patients (54.5%) who underwent open splenectomy. Various parameters were reported for open and laparoscopic procedures separately, including associated surgical procedures, spleen weight, postoperative mortality and morbidity rates, perioperative blood transfusions, use and length of abdominal drainage, accessory spleen removal, operative times, length of hospital recovery, and hematologic parameters on admission to and discharge from the hospital. Laparoscopic splenectomy was successfully completed in all 20 considered patients with no conversion to open splenectomy. The supine position and four trocars were adopted in all patients. Accessory spleens were found in four (9.0%) patients: two (4.5%) during open splenectomy and two (4.5%) during laparoscopic splenectomy. The postoperative mortality rate was 2.7% (a case of myocardial infarction). The morbidity rate was 9% (four patients), but no postoperative complications occurred after laparoscopic splenectomy. A significant statistical difference was shown by the increase in platelet counts after open versus laparoscopic splenectomy. The open and laparoscopic mean operative times (73.70 +/- 13.42 minutes and 78.42 +/- 14.63 minutes, respectively) were comparable. These times were comparable also considering patients who underwent only splenectomy. Mean recovery time was shorter after laparoscopic splenectomy (3.95 +/- 0.60 days) than after open splenectomy (7.0 +/- 1.68 days). After open procedures, however, the mean recovery time was shorter in uncomplicated cases (6.68 +/- 1.49 days) than in the open group as a whole. Authors conclude that many well-known advantages of the laparoscopic approach. especially those related to its low invasiveness, can be observed in patients requesting splenectomy for nontraumatic diseases of the spleen, without lowering the efficacy of this operation. They suggest that such advantages can be entirely displayed when selection criteria of the patients are applied.     

Splenectomy for the massively enlarged spleen

The experience at the National Cancer Institute from 1955 to 1988 with 46 cases of splenectomy for massive splenomegaly (greater than or equal to 1,500 grams) was reviewed to assess the indications, pathology, operative, and postoperative course for this procedure. The median age was 51 years. Thirty-one splenectomies (67.4%) were performed for malignancy (chronic lymphocytic leukemia, 11; chronic myelogenous leukemia, 10; lymphoma, 9; hairy cell leukemia, 1), 11 for myeloid metaplasia, and four for other nonmalignant conditions. Indications for splenectomy included hypersplenism (32 patients), symptoms (6), diagnosis (3), and splenic rupture (3). A midline incision (30 patients) was most commonly used. Median operative time was 2 hours, 50 minutes. Median operative blood loss was 1,300 ml (range, 100 ml-60 units). The splenic artery was ligated initially in 16 patients (34.8%) but did not correlate with blood loss or operating time. The median splenic weight was 2,030 grams (range, 1500-5320 gm). The postoperative complication rate was 39.1 per cent (21 complications in 18 patients). This included infection in 10 patients, bleeding in six patients. Six patients required reoperation (bleeding, 4; abscess, 1; small bowel obstruction, 1 patient). The 30-day operative mortality was 19.6 per cent (9 patients). Excluding operative deaths, 35 patients were available for follow-up evaluation. Twenty-nine patients had improvement in parameters for which splenectomy was indicated. Six patients had no change in their course after splenectomy. These findings indicate that many patients with massive splenomegaly benefit from splenectomy, however, the procedure is associated with a high risk for postoperative morbidity and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of splenic injuries. Retrospective study of 101 cases

101 patients with splenic trauma were treated during the period 1978 to 1988. They included 76 men and 25 women aged between 16 and 85 years, with a mean age of 38 years 6 months. Exclusively splenic lesions were present in 33 cases (32.67%) and bony or visceral lesions were also present in 68 cases (67.33%). 61 cases (60.39%) suffered from multiple trauma. 97 patients underwent laparotomy, 86 (85.1%) subsequently underwent total splenectomy and 11 (10.8%) conservative surgical treatment (10 partial splenectomies and 1 splenorrhaphy). Four patients did not undergo surgery and were kept under surveillance in a surgical ward for 3 weeks. The majority of partial splenectomies were carried out after 1985 though the first was performed in 1981. There was no operative mortality and post-operative mortality was 9.9% (10 deaths). The overall mean duration of hospitalisation was 20.2 days: 15.6 days for patients who underwent partial splenectomy, 19.6 days for patients who underwent total splenectomy and 21 days for cases involving simple surveillance. Operative complications occurred in 28 patients who underwent laparotomy. Complications did not occur in the 4 patients who received simple surveillance. The most frequent complications were sepsis, pneumonia, thrombo-embolic complications and four patients required reoperation for hemoperitoneum. Conservative surgical treatment is increasingly being used in splenic trauma. The criteria for avoidance of surgical intervention remain difficult to define at the present time.     

Hand-assisted laparoscopic splenectomy vs conventional laparoscopic splenectomy in cases of splenomegaly

HYPOTHESIS: Laparoscopic splenectomy (LS) is the procedure of choice for elective splenectomy. Splenomegaly may preclude safe mobilization and hilar control using conventional laparoscopic techniques. Hand-assisted LS (HALS) may offer the same benefits of minimally invasive surgery for splenomegaly while allowing safe manipulation and splenic dissection. DESIGN: A retrospective review of patients with splenomegaly undergoing conventional LS or HALS was performed. SETTING: Tertiary care referral center. PATIENTS: Hand-assisted LS was performed at the start of the operation for patients with splenomegaly; splenomegaly was determined by palpation of the splenic tip extending to the midline or the iliac crest, or by a craniocaudal splenic length of greater than 22 cm. Splenomegaly was defined as a splenic weight of greater than 700 g after morcellation. MAIN OUTCOME MEASURES: Patient demographic characteristics, operative indications, splenic weight after morcellation, morbidity, mortality, and clinical outcomes were evaluated. RESULTS: Forty-five patients with splenomegaly were identified: 31 underwent standard LS and 14 underwent HALS. The HALS group had significantly larger spleens than the conventional LS group (mean weight, 1516 vs 1031 g; P =.02). Mean operative time (177 vs 186 minutes; P =.89), estimated blood loss (602 vs 376 mL; P =.17), and length of hospital stay (5.4 vs 4.2 days; P =.24) and complication rates (5 [36%] of 14 vs 5 [16%] of 31; P =.70) were similar between the HALS and the standard LS groups. No perioperative mortality occurred. CONCLUSIONS: Hand-assisted LS is a safe and efficacious procedure for these extremely difficult cases. Hand-assisted LS provides the benefits of a minimally invasive approach in cases of splenomegaly.     

Postoperative mortality and morbidity of patients in their late eighties]

During the 12 year period, 1978-1989, 555 operations were performed at the Department of Clinica Chirurgica III of the University of Bologna, on 530 patients greater than 80 years old at the time of surgery. These were the indications for surgical procedure in these patients: malignant neoplasm of digestive system (243), other diseases of the digestive system (111), abdominal wall hernia (74), biliary disease (77), miscellaneous (50). The purpose of this paper is to define the role of surgery in patients over 80 years old. An acute complication required an emergency operation in 295 cases (53%). In all the other cases (260, 47%) an elective operation was performed. There were 63 deaths with an operative mortality rate of 11%. Among the patients who underwent elective surgery there were 11 deaths (4%); in the emergency group there were 52 deaths (17.6%). These rates were found to be statistically significant. The overall morbidity rate was 37.6% in the elective group and 49% in the emergency group. Also these rates were found to have a statistic significance. Then we have compared morbidity and operative mortality of over-eighty years old patients with the ones of two younger groups of patients: I group (age greater than 80 years), II group (age 65-80 years), III group (age less than 65 years). Patients of the three groups had undergone identical surgical operations for the same pathology. The operative mortality was 11% in the I group, 5.2% in the II group and 1.4% in the III group. The morbidity was 46%, 30% and 17% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Splenectomy in the treatment of idiopathic thrombopenic purpura in adults. Apropos of 43 cases

Case reports of 43 patients with idiopathic thrombocytopenic purpura (ITP) operated upon from 1975 up to the present were analyzed. After revision of therapeutic indications the predictive prognostic factors for splenectomy, essentially the initial response to corticotherapy, were studied. Findings indicated that splenectomy is effective treatment for ITP since permanent total remissions were obtained in 76% with a morbidity of 16% and a mortality of 2%. Emphasis is placed on the need for minute pre-, intra- and post-operative precautions.     

老年闭合性腹部损伤的早期诊断与处理

目的总结老年性腹部损伤的早期诊断与处理要点。方法回顾性分析120例闭合性腹部损伤的临床资料。120例全部接受手术治疗。肝修补29例,肝叶切除5例,脾切除44例,脾修补6例,肠切除5例,肠修补16例,胰腺修补4例,膈修补6例,结肠造瘘6例。结果手术治愈率90%,死亡12例,死亡率10%,术中死亡3例,术后死亡9例。结论早期诊断、早期手术、综合治疗,是降低病死率,提高生存质量的重要因素。