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随着吻合器应用的推广,吻合器相关的并发症也随之出现。上消化道重建器械吻合失败包括两种情况,一种是术中即发现吻合失败;另一种是术后发现的吻合失败。前者应在术中即刻处理、术后严密观察。后者中吻合口狭窄应以先行胃镜下球囊扩张,如无效,则行二次手术;吻合口漏和出血应先行保守治疗,再根据情况选择二次手术。     

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在肠道部分切除之后，重建肠道的连续性是一常规的手术步骤。利用机械进行消化道吻合重建的这一思想几乎与手术历史本身一样古老。1826年Lembert提出的重建消化道应浆膜化，即浆膜对浆膜进行吻合的基本原则，一直延用至今。许多吻合器的发展也都遵循这一原则。     

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虽然上消化道重建方式多种多样,但目前尚无被公认的最佳重建方式。上消化道重建后,一方面必须控制好并发症的发生率;另一方面要保证病人有满意的营养状态和良好的生存质量。胃癌根治术后的重建方式也是专家们一直讨论和研究的热点,一直受到大家的重视。全胃切除术后,Roux-en-Y吻合是一种简单、并发症少,又能满足功能要求的重建方式。对病期晚、预后差的进展期胃癌病人,Roux-en-Y吻合时不建议附加贮袋,对于良性肿瘤或者早期胃癌,可以附加重建贮袋,以期提高生存质量。远端胃大部切除术后,相对于BillrothⅠ式吻合来说,BillrothⅡ式或Roux-en-Y吻合重建术并发症少、肿瘤复发率低。BillrothⅠ式吻合重建的适用范围较为有限。近端胃大部切除术后,采用食管残胃(管状胃)吻合是较为常见的重建方式。幽门重建的作用还存在一定争议,有待进一步研究。     

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尽管外科手术一直都是治疗直肠癌的主要手段,但单纯的手术疗法效果不尽人意。近年来,术前放、化疗在中低位直肠癌治疗中的作用已经在越来越多的临床实践中得到验证。新辅助疗法的引入,在降低肿瘤局部复发率、提高保肛率、延长病人的生存时间等方面均取得了明显进步。1术前放化疗方案术前化疗还没有统一方案,目前多数临床研究是以5-氟脲嘧啶(5-FU)为基础联合化疗方案。有研究表明,联合用药可以提高完全缓解率。联合应用较多的有甲酰四氢叶酸(LV)。近年,不少新药应用于直肠癌治疗,取得了良好的效果,如卡培他滨、雷替曲塞、奥沙利铂和伊立替…     

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中低位直肠癌最主要的治疗手段目前仍然是手术根治性切除,但近10余年间治疗策略发生了很大的变化。以往,术前诊断的重点是定性诊断,强调的是手术的根治性或能否保肛。当前,直肠癌术前分期诊断受到重视,针对不同分期选择治疗方式及术式,使病人最大限度的收益。对于不伴有不良预后因素的T1N0M0期早期直肠癌可以慎重选择局部切除术;对于局部中晚期直肠癌[T3~4期和(或)伴有区域性淋巴结转移]推荐术前放化疗然后再行手术;而对于伴有肝、肺等远处转移的直肠癌病人,根据情况决定原发病灶是否需要切除。     

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??iagnosis and treatment of local recurrent mid-lower rectal cancer WANG Zhen-jun. Department of General Surgery, Beijing Chaoyang Hospital,Capital Medical University, Beijing 100020,China Abstract Local recurrence of mid-lower rectal cancer persistently constitutes a challenging clinical problem. Recurrent lesion often located in anastomosis, perineum, osteal pelvis and adjacent organs in the pelvis. Clinical manifestation of local recurrent rectal cancer (LRRC) patients include blood stool, perineal pain, pelvic and presacral lump, et al. Regular postoperative physical examination, CT, MRI as well as tumor markers are important methods for diagnosis of LRRC. The treatment choice include excision as the main part of multimodality treatment or palliative radiochemotherapy on comprehensive analysis of type of recurrence, cancer biological features and involvement extent of recurrent cancer.     

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198 5年 5月至 1998年 12月我科对 5 6例直肠癌病人施行Dixon手术 ,取得了良好的效果。现报道如下。1　资料与方法本组 5 6例 ,男 3 8例 ,女 18例。年龄 2 2 72岁。肿瘤下缘距肛缘的距离 68cm 3 6例 ,910cm 2 0例 ,平均 8cm。Dukes分期为A期 8例 ,B期 3 8例 ,C期 10例。病理诊断高、中分化腺癌 3 7例 ,粘液腺癌 8例 ,低分化腺癌 9例 ,未分化癌 2例。所有病例探查肿瘤位于盆底腹膜返折水平或以下 ,无远处转移病灶 ,按直肠癌根治原则行全直肠系膜切除(TME) ,直视下在骶前间隙进行锐性分离 ,保持包裹直肠系膜的盆筋膜脏层的完整无损 ,以防…     

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??Standard of pathological evaluation for mid-low rectal cancer YAO Hong-wei*??LI Wen-di??TIAN Mao-lin??et al. *Department of General Surgery??Peking University Third Hospital??Beijing100191, China
Corresponding author: SHI Xue-ying??E-mail??zhsh6812@aliyun.com??LIU Yin-hua??E-mail??liuyinhua@medmail.com.cn
Abstract Pathological examination plays a core role in the multi-disciplinary diagnosis and treatment of rectal cancer. It can evaluate the effect of neoadjuvant therapy and operation??can assist postoperative adjuvant therapy??and can even predict cancer recurrence and risk degree of patient's prognosis. Anatomy and TNM staging are the basis of pathological assessment of mid-low rectal cancer. Standardized evaluation of routine pathology includes resection range??tumor site??tumor size??gross type??distance between tumor and bowel margin??grade of cancer??depth of invasion (T staging)??number of lymph nodes evaluated and number positive (N staging)??status of proximal and distal margin??circumferential resection margin??response of neoadjuvant therapy??lymphovascular invasion??perineural invasion??and tumor deposition. Molecular pathological diagnosis plays more and more prominent role in the choice of drug and prognosis assessment.     

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??Diagnosis and treatment of medium low rectal cancer in the status quo and outlook WANG Jian-ping. Department of Gastrointestinal Surgery, the Sixth Affiliated (Gastrointestinal and Anal Hospital) of Sun Yat-sen University, Guangzhou 510655, China Abstract Middle-low rectal cancer is a common disease with high morbidity. It is of vital importance for early detection and early treatment, which results in high survival rate. In addition, it is becoming routine to provide prognostic and predictive factors for treatment selection and prognosis when diagnosing. The progress in image methods has made reliable information for pre-treatment diagnosis and staging, which helps to make treatment strategy. Multi-disciplinary treatment and individual treatment are two major principles when treating middle-low rectal cancer. More and more studies are carried on to find the best combination of operation, radiation and chemotherapy. The aims of treatment are to improve survival rate as well as to maintain the function of anus and pelvic automatic nerve. Quality of life is the crucial focus during the whole process of treating patients with middle-low rectal cancer.     

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??Selective lateral pelvic lymph node dissection for mid-low rectal cancer WEI Ming-tian??WANG Zi-qiang. Department of Gastrointestinal Surgery??West China Hospital??Chengdu 610041??China
Corresponding author??WANG Zi-qiang??E-mail??wangzqzyh@163.com
Abstract Lateral pelvic lymph node metastasis is not uncommon in patients with advanced mid-low rectal cancer??and is also the cause of lateral recurrence. The latter has been indicated to be the most common kind of local recurrences in Asian reports. Presence of enlarged lateral lymph nodes at presentation is an independent risk factor for lateral pelvic recurrence after chemoradiotherapy (CRT) and total mesorectal excision. Controversy exists between Asian and western countries with respect to the use of CRT and lateral lymph node dissection (LLND) in the management of mid-low advanced rectal cancer. Primary reports indicated that thecombination of CRT and LLND was likely to be superior to either of the two strategies and provided more favourable local control and survival. So far??there is no consensus on the criteria to diagnose lateral lymph node metastases (LLNM) and the indication for selective LLND. More multicenter prospective cohort studies are warrant to address the issues, before we can provide better health care to the patients to improve their survival??as well as to avoid unnecessary LLND??which has been associated with more surgical complications and poorer quality of life.     

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与结肠癌相比,直肠癌尤其是中低位直肠癌在解剖和治疗学上有许多不同之处。首先大多数中低位直肠癌病人面临着是进行传统的经腹会阴联合切除,还是进行保留括约肌的保肛手术的问题。其次,虽然近年来随着手术技术的不断改进,尤其是在全直肠系膜切除(TME)技术得到推广以后,病人的保肛率、长期生存率得到明显的提高,但是术后局部复发仍然是直肠癌手术失败的重要原因之一,尤其是直肠癌侵犯深达全层以上、淋巴结有转移或周边切缘肿瘤阳性的病人,盆腔或局部复发的机会仍然比较高,即使采用TME技术,仍然可达5%～40%。另外,由于直肠位于狭小的盆腔…     

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??Pathology of the mid-lower rectal carcinoma ZHU Xiong-zeng. Department of Patholgy, Cancer Hospital, Fudan University, Shanghai 200032, China Abstract The rectum is the most common site of the large bowel carcinoma. In rectal carcinoma, about 70% cases are located in the mid-lower rectum. Also some issues have been mantioned at histopathological diagnosis, including (1) the concept of the intraepithelial neoplasia (I N) and the relationship with surgical treatment, especially introducing the Vinna classification of gastronitesinal epithelial neoplasia and clinical management. (2) the prognostic paremeters determined by histopathology, such as resected margins, extent of extracolorectal invasion, reginal nodal metastases, vascular and perineural invasion, and (3) genetics of the large bowel cancers, mainly about hereditary nonpolyposis colorectal cancer(HNPCC) and familial adenomatous polyposis(FAP).     

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Ｍｉｌｅｓ手术是治疗直肠癌的经典术式 ,但所造成的腹壁永久性人工肛门给病人带来痛苦和生活不便 ,生存质量下降 ,病人难以接受。近几十年来关于直肠癌的病理和免疫等各方面的研究进展以及手术操作的熟练 ,尤其是端端吻合 (ＥＥＡ)吻合器的应用 ,使一部分直肠中低位的癌肿应用前切除术 (Ｄｉｘｏｎｓ手术 )既免受人工肛门之苦 ,又能获得较满意的疗效。本文对 1 992～ 1 997年我们医院收治的 2 8例距肛缘 6～ 8ｃｍ的中低位直肠癌应用改进的ＥＥＡ吻合器吻合方法行低位前切除术进行研究分析并就相关的问题进行探讨。1　临床资料1 1　一般…     

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目的研究胰腺肿瘤不同手术方式对病人糖代谢内环境稳态和胰岛素分泌的影响。方法对第二军医大学附属长海医院胰腺外科2009-2010年手术治疗的120例胰腺肿瘤病人进行前瞻性研究,其中胰腺癌76例,胰腺良性肿瘤44例。64例行胰十二指肠切除术,56例胰体尾切除术。全部病人术前及术后第1、3、5、7、30天测定血浆空腹血糖、胰岛素、C-肽及糖化血红蛋白浓度。结果胰腺部分切除导致了病人胰岛素释放的减少,无论是胰十二指肠切除术还是胰体尾切除术,病人术后基础胰岛素分泌水平较术前降低了40%左右(P<0.05)。不过,行胰十二指肠切除术的胰腺癌病人术后空腹血糖水平得到了明显改善,特别是胰腺癌合并糖尿病病人更加显著;而行胰体尾切除的良性胰腺肿瘤病人术后空腹血糖明显恶化(P<0.05)。结论不同术式对胰腺肿瘤病人糖代谢呈现不同的影响,胰十二指肠切除术可以改善胰腺癌病人血糖水平,特别是胰腺癌合并糖尿病病人更加明显。     

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??Metabolic changes and nutrition support management in surgical critically ill patients WANG Xin-ying.Department of General Surgery, Jinling Hospital, Medical School, Nanjing University, Nanjing 210002, China
Abstract Surgical critically ill patients are hypermetabolic, accompanying with the system inflammation response and increased nutrient requirement. Nutrition support is now considered as an important part of therapy for critically ill patients. Rational nutrition support implement should be based on the overall consideration of organ function and enteral nutrition tolerability in surgical critically ill patients, including the appropriate substrate, timing, route and monitoring. Clinical studies also demonstrate that some new formulae enriched with specific nutrients may improve the organ and immune function, decrease the incidence of morbidity and mortality, and shorten the hospital stay in critically ill patients.     

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??The effect of restrictive and non-restrictive fluid therapy on the postoperative hemodynamics and tissue oxygenation in major abdominal surgery SI Xiang, WU Jian-feng, CHEN Juan, et al. Department of Surgical Intensive Care Unit ,First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080,China.
Corresponding author:GUAN Xiang-dong,E-mail:carlg@163.net
Abstract Objective To discuss the effect of restrictive and non-restrictive fluid therapy on the postoperative hemodynamics and tissue oxygenation in major abdominal surgery. Methods The postoperative patient who received major abdominal surgery and admitted to surgical intensive care unit of the First Affiliated Hospital of Sun Yat-Sen University from April 2011 to February 2014 were analyzed retrospectively. The patient was divided into restrictive infusion group??<-10%??95 cases??and non-restrictive infusion group (≥-10%??42 cases) comparing with standard fluid therapy according to that textbook opinion. The effect of restrictive and non-restrictive fluid therapy on the postoperative hemodynamics and tissue oxygenation was investigated. Results There were 71 patients (74.7%) with SVV>10% in the restrictive group and 18 patients(42.8%) in the non-restrictive group??the hypovolemic incidence in the restrictive group was significantly higher than the non-restrictive group (P<0.05). The mean arterial pressure ??(96.9±14.0)mmHg vs. (82.3±14.8)mmHg??P=0.003??, systolic blood pressure ??(139.0±16.3) mmHg vs. (118.8±24.2) mmHg??P=0.007??, diastolic blood pressure ??(74.1±12.4) mmHg vs. (63.7±12.6) mmHg??P=0.014??, cardiac index ??3.8±1.3 vs. 3.1±0.9??P=0.035?? and stroke volume index ??51.8±19.3 vs. 41.3±14.3??P=0.047?? ??base excess??BEecf??(-1.8±4.2)mmol/L vs. (1.3±4.1)mmol/L??P=0.024??BEb??(-1.4±3.9) mmol/L vs (1.4±3.6) mmol/L??P=0.028?? was significantly higher in the non-restrictive group than in the restrictive group??the difference was statistically significant (P<0.05). The other indicators were not statistically significant. Conclusion For the major abdominal surgery patients??it was more prone to postoperative hypovolemia??tissue hypoperfusion and tissue hypoxia with restrictive infusion during the operation, while the hymodynamics was more stable for the patients in the non-restrictive group.