大网膜在外科临床中的应用

目的 探讨大网膜在外科临床中的应用及方法。方法 收集胸腹部外科手术时曾附加大网膜进行治疗的病例共92例,分析其附加治疗的原因及疗效。结果 本组应用大网膜在腹部手术90例,胸部手术2例;术中均采用附加大网膜进行治疗。92例患者全部治愈出院。手术后无大出血、胃肠穿孔,吻合瘘,严重腹腔感染及切口肿瘤种植等并发症。结论 大网膜应用于临床外科,在治疗胸腹腔软组织缺损及预防手术后并发症可以取得良好效果。     

导致腹股沟疝临床路径负性变异的影响因素分析

目的 分析导致腹股沟疝临床路径负性变异的影响因素.方法 选择2012年6月-2014年12月收治的腹股沟疝临床路径病例160例,进行回顾性调查,对可能导致腹股沟疝临床路径负性变异的主要影响因素进行统计分析.结果 单因素分析显示,年龄(P =0.021)、病程(P =0.034)、治疗组(P=0.008)、疝分类(P=0.035)、围术期并发症(P =0.048)、术后住院天数(P=0.000)、术前合并症(P=0.001)与腹股沟疝临床路径负性变异有关(均P＜0.05).Logistic回归分析表明,腹股沟疝临床路径负性变异的危险因素为围术期并发症(OR=15.291,P=0.010)和术前合并症(OR=5.320,P=0.010).结论 术前合并症、围术期并发症是导致腹股沟疝临床路径负性变异发生的主要影响因素.     

快速康复外科——优化的临床路径

快速康复外科是将围手术期有循证医学证据的措施整合在一起,将麻醉、护理和外科等学科的最新研究证据完美结合的概念,需有严格的临床路径来保证实施才能发挥其真正的优势。文章探讨了临床推广应用为什么不够令人满意的原因和主要困难。     

Enhanced recovery after surgery pathways benefit patients with soft pancreatic texture following pancreaticoduodenectomy

BackgroundWe aimed to compare the enhanced recovery after surgery pathway with the standard perioperative care protocol concerning complications, postoperative length of stay and 1-year survival rate.MethodsUsing a before–after cohort study design, data from patients with pancreatic head cancer, who consecutively underwent pancreaticoduodenectomy, were retrospectively collected.ResultsCompared to the control group, patients with soft pancreas in the enhanced recovery after surgery group had a lower incidence of delayed gastric emptying (36.7% vs 13.3%, P = 0.026) and respiratory complications (46.7% vs 20.0%, P = 0.028), and shorter postoperative length of stay (All: 10.9 ± 3.4 d vs13.5 ± 3.8 d, P = 0.002; Soft: 11.2 ± 3.8 d vs14.0 ± 4.5 d, P = 0.001). The 1-year survival rates were similar between the groups.ConclusionThe enhanced recovery after surgery pathways can significantly reduce the incidence of certain surgical complications and decrease the postoperative length of stay. It does not affect 1-year survival.     

减重与代谢外科临床数据规范化管理与实践

标准化的临床数据是开展高质量临床与基础研究的重要基础,是提升临床诊疗水平的有力保障,是临床决策和医疗政策制定的依据来源,而规范化临床数据库的构建及临床资料管理可提高临床数据质量。本文基于大中华减重与代谢外科数据库,围绕数据库建立的目的和意义、临床数据库的建设方案、临床数据的质量控制、临床数据的保护及成果展望五个方面,重点阐述临床数据库的建立流程及实践经验,以实现对减重与代谢外科临床资料的规范化管理与分析,积极推动高质量临床研究及临床实践。     

Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients

Background Context

Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin (Hb) trigger—defined as an intraoperative Hb level of ≥10?g/dL, a postoperative level of ≥8?g/dL, or a whole hospital nadir between 8 and 10?g/dL—and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study.

Evidence that cyclosporin A prevents clinical cardiac allograft rejection by blocking both direct and indirect antigen presentation pathways

Abstract  Monitoring for the re sponses to alloantigens presented either by the direct or the indirect presentation pathway have been re ported to be of clinical value after kidney transplantation. Amongst others, the level of these responses may be dependent on the immuno-suppressive treatment. We studied both presentation routes in periph eral blood mononuclear cells (PBMC) of cardiac transplant pa tients, who experienced episodes of rejection, and related them to the in vivo cyclosporin A (CsA) levels in plasma. PBMC of the recipients were stimulated with irradiated do nor cells to determine the direct presentation pathway. As a method for the activation of the immune re sponse via the indirect pathway, PBMC were stimulated with tetanus toxoid. Both immune responses in creased when CsA levels inadver tently decreased to inadequate con centrations and histological rejec tion was diagnosed. After clinical heart transplantation, CsA may pre vent rejection by blocking both the direct and the indirect antigen pre sentation pathway.     

简化的快速康复外科策略与传统临床路径在胃手术中应用的前瞻性队列研究

目的 探讨简化的快速康复外科策略在胃手术中应用的安全性及可行性.方法 按纳入、排除及剔除标准,选取2010年3月-2011年12月连续的非急症胃部手术病例,以“信封法”随机分为快速康复外科组及传统临床路径组.对比两组的人口统计学数据、手术相关数据(手术时间、术中失血量及胃切除范围)及术后相关数据(手术后恢复情况及并发症)的差异.结果 快速康复外科组(n=149)与传统临床路径组(n=154)比较,在人口统计学及手术相关数据上两组差异无统计学意义(P＞0.05).两组在肠功能恢复时间[肠鸣音出现时间分别为(1.95 ±0.54)d,(2.46 ±0.93)d,P=0.032]、开始摄食时间[进食流质时间分别为(1.95±0.54)d,(3.53 ±0.61)d,P=0.013]及术后住院时间[分别为(9.63 ±2.14)d,(11.08±4.51)d,P=0.019]方面比较,快速康复外科组优于传统临床路径组(P＜0.05).术后各种并发症比较(分别为吻合口出血3例 vs 5例,吻合口漏5例 vs 4例,切口感染4例 vs 3例,肺部感染9例 vs 9例,再手术0例 vs 2例,死亡1例 vs 0例),差异无统计学意义(P＞0.05).结论 简化的快速康复外科策略在胃部手术围手术处理中较传统临床路径具有在不增加术后并发症的基础上加快术后患者恢复的优势,临床应用安全、可行.     

重症急性胰腺炎临床路径探讨

临床路径作为一种规范化的医疗管理模式,应用于临床已30年,其意义在于维持或改进医疗品质的基础上缩短住院日数、减少医疗费用。就某种疾病而言,大多数病人可以施行临床路径,少部分则须用个案管理来处理。重症急性胰腺炎是普通外科常见的严重急腹症,该疾病病情凶险,复杂多变,治疗过程中个体化差异较大,故在临床工作中,应结合病人实际情况合理应用临床路径。     

Applying evidence-based surgery in daily clinical routine: a feasibility study

Background: Although the word evidence-based medicine (EBM) has gained wide popularity, only a few studies have evaluated how EBM works in clinical practice. Methods: We have prospectively evaluated the feasibility of evidence-based trauma surgery. Orthopaedic trauma surgeons were asked to produce clinical questions related to the treatment of current patients. An informaticist searched the literature (Medline, Cochrane Library, practice guidelines and textbooks) and reported the findings on every following day. The study’s main endpoints were the rate of questions for which relevant evidence (>level V) was available and the time necessary to find and critically appraise medical evidence. Results: In total, 44 EBM questions were formulated, mainly concerning treatment options. PubMed was searched for 39 questions, textbooks for 14, the Cochrane Library for 11, online guidelines for 9 and other sources were used for 4 questions. On average, 157 text items (three per questions) were identified as potentially relevant. Journal articles predominated (83%) over textbooks (10%). Sixty-eight percent of the questions (30 of 44) were answered, either on the basis level 1 (n=13 questions), level 2 (n=6), or level 4 evidence (n=14). Trying to answer a question required 53 min on average, split up between 39 min of database searches and 25 min of obtaining full text articles. In four cases, the evidence suggested a change in clinical management. The physicians were very appreciative of our project and found the provided evidence very helpful for their clinical decisions. Conclusions: Time will be the main barrier against the introduction of clinical EBM. It is likely that clinicians reduce EBM to those situations where evidence is likely to be found. Although the impact of EBM on patient-care was limited, the concept of EBM was successfully implemented.     

巨脾型晚期血吸虫病临床路径探讨

参考国外最新临床指南,结合笔者多年的实践经验,制定巨脾型晚期血吸虫病的临床路径。路径包括诊断、药物治疗、内镜治疗、介入治疗、手术适应证、手术方式、围手术期处理、总体住院时间以及出院后治疗、护理、随访等,从而为晚期血吸虫病的外科治疗建立一套标准化流程、路线。     

腹股沟斜疝手术患者应用临床护理路径的护理效果分析

目的探讨腹股沟斜疝手术患者应用临床护理路径的临床效果。方法收集2013年1月～2014年4月来我院进行腹股沟斜疝手术的患者81例,根据护理方法分为研究组41例,对照组40例。比较住院时间、住院总费用、疾病知识掌握程度及护理满意度。结果与对照组比较,研究组住院时间较短,住院总费用较低,疾病知识掌握程度优良率、护理满意度较高（P〈0.05）。结论在腹股沟斜疝手术患者中实施临床护理路径护理效果显著,能使患者的住院时间缩短、住院总费用降低,疾病知识掌握程度优良率及护理满意度提高。     

胃癌外科临床数据挖掘系统的构建与实现

目的 开发一款符合国际标准和临床应用习惯、适合回顾性及前瞻性临床研究、科学合理地进行肿瘤外科临床数据管理并能进行临床数据挖掘的软件系统,以满足胃癌外科多中心、大样本临床数据分析需要.方法 结合日本胃癌规约（JGCA）第13、14版及UICC分期系统,确定临床核心数据项目,根据数据挖掘理论和临床工作思路合理设计数据结构和控制逻辑,采用Microsoft Visual Basic、Vista DB等进行编程.结果 历时近1年的开发和完善,南方医科大学南方医院使用该软件系统回顾性录入600余例胃癌临床数据资料,建立起包含近4000项临床指标的、内置数据挖掘功能的数据库系统,各项功能指标经实践检验达到设计要求.该软件作为中国腹腔镜胃癌外科研究组的数据平台,已在全国内地和香港地区30家医院参与的第一期临床研究项目＂腹腔镜胃癌手术可行性的回顾性多中心研究＂中成功运行.数据挖掘功能达到预期目标,能可视化地进行复杂搜索,统计分析功能可对数据进行描述性分析.记录和数据的导入、导出满足了进行交流的需要,导出数据格式与所有统计软件兼容,无数据传输错误.结论 本软件系统在胃癌外科临床研究领域具有广泛的应用前景和网络化升级扩展的潜能.     

重症胰腺炎手术时机和手术方式的选择

目的探讨重症胰腺炎（ＳＡＰ）最佳手术时机和手术方式。方法对１９８５年～１９９４年间收治的５０例ＳＡＰ患者手术时机、术式及病死率进行回顾性分析。结果（１）手术病死率为１４％,其中８５．７％为４０～６０岁年龄段患者。性别及病因分类无差异。（２）随手术距发病时间延长,病死率逐渐降低,但差异无显著性（Ｐ＞０．０５）。（３）随手术距入院时间延长,病死率明显降低,入院１２小时内手术者病死率显著高于其他时间组（Ｐ＜０．０１）。（４）随胰坏死程度及胰外器官受累个数增加,手术病死率显著增加（Ｐ＜０．０１及Ｐ＜０．０５）。（５）休克、胰坏死及多脏器功能衰竭（ＭＯＦ）的相关病死率分别为３１．８％、３１．６％和２８．０％（Ｐ均＜０．０５）。（６）术式以胆胰联合手术及单纯胰病灶清除引流为主。结论ＳＡＰ手术时机是影响手术病死率的重要因素,最佳时机的选择应与ＳＡＰ自然病程相适应,避免在发病后１～７天,尤其在入院１２小时内手术。强调术前给予至少２４小时支持治疗。术式选择应以简单有效,充分引流,清除病灶,去除病因为基本原则。     

Cost effectiveness of lumbar disc surgery and of a preventive treatment for peridural fibrosis

Study design: This study used a retrospective modeling approach to predict the sequelae, treatment patterns, and economic outcomes that patients treated or not treated with ADCON^®-L Anti-Adhesion Barrier Gel can experience over a 1-year period following first-time surgery for herniated lumbar disc. The study was designed for and carried out in the Netherlands. Objectives: The study was carried out to investigate the economic impact of ADCON-L application in lumbar disc surgery. Summary of background data: Patients with a poor outcome following primary lumbar disc surgery represent a medical challenge to physicians and an economic concern, as they often experience long-term sequelae. Patients who have failed to benefit adequately from primary surgery tend to be very expensive patients, receiving a costly array of conservative therapies, diagnostic measures and, sometimes, repeat surgery. Methods: A Markov model was constructed to integrate the retrospectively assessed treatment patterns, economic outcomes, and costs of Dutch lumbar disc patients with the analysis of the benefits of ADCON-L as shown in a clinical study population derived from the preliminary results of a multicenter, randomized clinical trial of ADCON-L in Europe. Results: Use of ADCON-L can recoup 20% of its proposed initial cost of NLG 1000 in direct health care savings during the first year after primary surgery. When indirect/societal as well as direct costs are considered, for every Dutch guilder invested in ADCON-L treatment, savings of NLG 1.8 are achieved. Conclusions: In patients treated with ADCON-L during lumbar discectomy, the quality of surgical outcome improves while cost per successful outcome is reduced.This study was supported by a grant from Gliatech Inc., Cleveland, Ohio, USA     

基于临床数据挖掘技术的腹腔镜结直肠癌手术评估体系的构建及应用

目的 整合优势科研资源,搭建良好的科研平台,开展单（多）中心临床试验,以中国人的临床数据科学地评价腹腔镜结直肠癌手术目前仍存在争议的问题.方法 以南方医院2008年10月自主开发的一款专门以腹腔镜结直肠癌手术为数据架构,同时适合于回顾性和前瞻性临床研究,既能科学管理和深度分析临床数据,又能满足多单位合作需要的数据挖掘系统软件为数据平台,构建腹腔镜结直肠癌手术评估体系,开展单（多）中心腹腔镜结直肠癌手术研究.结果 历时1年多的开发和完善,南方医院已经使用该软件系统按照标准回顾性录入1200余例临床资料,构建了单中心腹腔镜结直肠癌手术评估体系.同时该软件系统作为＂中国南方腹腔镜结直肠外科研究组（SCLCSG）＂的数据平台,已在第1期临床研究项目＂腹腔镜与开腹结直肠癌手术的回顾性多中心对比研究＂中成功运行,迄今已录入8200余例病例数据.以南方医院数据完成＂腹腔镜与同期开腹直肠癌根治术后肿瘤学结果对比研究（单中心）＂,结果显示,腹腔镜直肠癌根治术的远期复发和生存并不劣于开腹手术,甚至优于开腹手术的肿瘤学结果.结论 该手术评估体系和临床数据挖掘软件设计达到预定目标,在腹腔镜结直肠癌手术领域具有广泛的应用前景和网络化升级扩展的潜能,值得推广.     

临床路径在基层医院腹股沟疝治疗中的应用

目的探讨临床路径在基层医院腹股沟疝手术中的应用价值。方法回顾分析我院2009年未执行临床路径及2010年执行临床路径行腹股沟疝手术在手术费用、平均住院天数、术后并发症等方面的差异。结果两组患者无切口感染、血肿及其他与手术有关的并发症。2009年平均费用（5348±312）元。平均住院天数（10．5±0．5）d。抗生素使用天数（6．0±1．0）d；2010年平均费用（4298±256）元。平均住院天数（6．5±0．5）d。在平均费用及平均住院天数方面2组差异有统计学意义（P〈0．05）。结论临床路径在基层医院是可行的，医院和患者均可获益、值得推广。     

Impact of clinical pathways on hospital costs and early outcome after major vascular surgery

Purpose: The purpose of this study was to determine whether major vascular surgery could be performed safely and with significant hospital cost savings by decreasing length of stay and implementation of vascular clinical pathways.Methods: Morbidity, mortality, readmission rates, same-day admissions, length of stay, and hospital costs were compared between patients who were electively admitted between September 1, 1992, and August 30, 1993 (group 1), and January 1 to December 31, 1994 (group 2), for extracranial, infrarenal abdominal aortic, and lower extremity arterial surgery. For group 2 patients, vascular critical pathways were instituted, a dedicated vascular ward was established, and outpatient preoperative arteriography and anesthesiology-cardiology evaluations were performed. Length-of-stay goals were 1 day for extracranial, 5 days for aortic, and 2 to 5 days for lower extremity surgery. Emergency admissions, inpatients referred for vascular surgery, patients transferred from other hospitals, and patients who required prolonged preoperative treatment were excluded.Results: With this strategy same-day admissions were significantly increased (80% [145/177] vs 6.2% [9/145]) (p < 0.0001), and average length of stay was significantly decreased (3.8 vs 8.8 days) (p < 0.0001) in group 2 versus group 1, respectively. There were no significant differences between group 1 and group 2 in terms of overall mortality rate (2.1% [3/145] vs 2.3% [4/177]), cardiac (3.4% [5/145] vs 4.0% [7/177]), pulmonary (4.1% [6/145] vs 1.7% [3/177]), or neurologic (1.4% [2/145] vs 0% [0/177]) complications, or readmission within 30 days (11.3% [16/142] vs 9.2% [16/173]) (p > 0.05). There were also no differences in morbidity or mortality rates when each type of surgery was compared. Annual hospital cost savings totalled $1,267,445.Conclusion: Same-day admission and early hospital discharge for patients undergoing elective major vascular surgery can result in significant hospital cost savings without apparent increase in morbidity or mortality rates. (J VASC SURG 1995;22:649-60.)     

Ten- to 15-year outcome of surgery for lumbar disc herniation: radiographic instability and clinical findings

The most appropriate treatment for radiculopathy associated with disc pathology is still controversial. Since 1934, surgical treatment has consisted of hemilaminectomy and removal of the herniated material. Many authors believe that these procedures may cause degenerative spondylosis and vertebral instability. Several surgical methods have been proposed, but the long-term effects are still being debated. In addition there appear to be few well-designed outcome studies on the management of this disease. In the present study, 150 patients were selected for surgery with strict criteria and all treated with the standard technique. The series was evaluated by subjective analyses (Roland questionnaire; 120 patients), objective examinations (68 patients – 56.6%) and radiographic studies including dynamic views (analyzed by the Taillard and Boxall methods) to establish the presence of vertebral instability (50 patients – 41.6%). The subjective and objective analyses showed a high rate of good results. Radiographic studies showed vertebral instability in 30 cases, but only 9 were symptomatic. Recurrences were not observed and only a few patients suffered from leg pain. The standard procedure for lumbar disc herniation showed good results at 10- and 15-year follow-up. Received: 25 June 1998 Revised: 1 October 1998 Accepted: 19 October 1998     

腹腔镜胆囊切除术与开腹胆囊切除术的临床特征及住院费用的对比

目的 对腹腔镜胆囊切除术的安全性，临床及经济价值作出评估。方法 对行ＬＣ的２７８例患者与开腹胆囊切除术的２３４例患者进行对比调查。结果 ＬＣ与ＯＣ具有相同的安全性；ＬＣ患者术后总的疼痛时间与严重疼痛时间，住院及出院后恢复工作的时间均明显短于ＯＣ患者；