腹部术后吻合口瘘14例治疗体会

肠外瘘是腹部外科常见的一种严重并发症，发生于手术后者约占80％。我科于1998～2004年共施行腹部手术328例，发生吻合口瘘14例，均经非手术治愈，现报告如下。     

上消化道重建围术期吻合口出血10例诊治分析

回顾性分析2008年7月—2013年5月10例上消化道重建手术患者围术期吻合口出血的临床资料。10例患者吻合口出血发生在上消化道重建手术后2 h~9 d,分别为胃空肠吻合口出血3例,胰肠吻合口出血4例,胆肠吻合口出血1例,空肠与空肠吻合口出血2例。经剖腹探查或导管介入术确诊,其中7例经导管介入栓塞后止血,3例经开腹二次手术止血,无死亡病例,术后康复出院。导管介入术可用于上消化道重建手术围术期吻合口出血的诊断和治疗,有助于二次开腹手术止血寻找确切出血部位。     

胃肠机械吻合与传统吻合术后并发症的比较(附932例报告)

目的　比较胃肠机械吻合与传统手工吻合对术后并发症的影响 ,探讨机械吻合的安全性问题。方法　对我院 1999年 1月至 2 0 0 3年 12月期间收治的 932例行BillrothⅡ式胃肠吻合术患者的资料进行回顾性分析 ,了解其术后并发症的发生情况。结果　行机械吻合的 392例中出现术后并发症 8例 (吻合口漏 7例 ,梗阻 1例 ) ,其发生率为 2 .0 4 % ;而使用传统手工吻合的 5 4 0例中出现术后并发症 4 4例 (吻合口漏 2 8例 ,出血 4例 ,梗阻12例 ) ,其发生率为 8.15 % ,明显高于前者 (P<0 .0 1)。结论　胃肠机械吻合较传统手工吻合更为安全。     

残胃开放吻合对预胃大部切除术后胃肠吻合口出血的探讨

统计分析我院１９８１年８月对１９９５年８月５８６例做胃大部分切除术的病人，在残胃钳夹与开放两种状态下胃大部分切除术，观察术后胃肠吻合口出血的并发症。胃肠钳夹吻合法４０２例，６例发生胃肠吻合口出血。残胃开放组１８４例，无一例发生术后吻合口出血。说明残胃开放吻合对预防胃大部切除术后胃肠吻俣口出血是一种简便、有效的手术方法。     

上消化道大出血术后再出血的教训和治疗体会(附56例报告)

目的探讨上消化道大出血术后再出血应吸取的教训和处理对策。方法对56例上消化道大出血术后再出血的原因进行分析。结果再次手术37例,治愈33例(89.2%),死亡4例(10.8%);经腹腔内动脉插管介入治疗2例,止血成功1例,另1例再手术治愈;非手术治疗18例,治愈10例(55.6%),死亡8例(44.4%)。12例死亡病人再次出血距首次手术时间均在48小时内。结论对该类病人采取再手术与否,关键是看再出血的部位和原因以及非手术疗法止血的效果,应掌握好再手术的时机和正确的探查方法。     

上消化道大出血术后再出血的教训和治疗体会（附56例报告）

目的 探讨上消化道大出血术后再出血应吸取的教训和处理对策。方法 对56例上消化道大出血术后再出血的原因进行分析。结果 再次手术37例，治愈33例(89.2％)，死亡4例(10．8％)；经腹腔内动脉插管介入治疗2例，止血成功1例，另1例再手术治愈；非手术治疗18例，治愈10例(55．6％)．死亡8例(44．4％)。12例死亡病人再次出血距首次手术时间均在48小时内。结论 对该类病人采取再手术与否．关键是看再出血的部位和原因以及非手术疗法止血的效果，应掌握好再手术的时机和正确的探盘方法。     

胃肠外静脉营养应用在胃肠吻合口瘘的疗效观察

目的探讨胃肠外静脉营养（PN）在腹部外科术后胃肠吻合口瘘的临床应用价值。方法64例胃肠吻合口瘘患者分成两组，胃肠外静脉营养（PN）为治疗组32例，另未采用PN32例为对照组，进行对比分析。结果两组在治愈率、愈合时间、体重、上臂肌围、血清自蛋白、总淋巴细胞计数等存在显著差异（P〈0．05）。结论在胃肠吻合口瘘临床处理中及时应用胃肠外静脉营养（PN）支持有助于改善愈后。     

电镊治疗PPH吻合口出血的临床观察

为探讨电镊治疗吻合器痔上黏膜环切术（PPH）吻合口出血的效果,我们对PPH吻合口出血行电镊止血治疗的87例患者病例资料进行回顾性分析。结果显示,87例患者共127处吻合口有明显渗血或搏动性射血,仅6处需“8”字缝扎止血,其余均用电镊一次性止血成功。术后电凝处钛钉自然脱落时致大出血1例,“8”字缝扎止血处因线头反应致大出血1例。结果表明,电镊治疗PPH吻合口出血简捷实用、安全性好、疗效可靠。     

消化道机械吻合术后早期吻合口出血的内镜治疗

目的 探讨内镜下止血治疗消化道机械吻合术后早期吻合口出血的疗效.方法 回顾性分析2005年1月至2010年6月间在复旦大学附属中山医院内镜中心接受内镜下止血的消化道机械吻合术后早期吻合口出血的14例患者的临床资料.结果 男性9例,女性5例,中位年龄57.5岁(26～74岁).术后出血时间6 h至14 d,出血量500～1500 ml.内镜下发现吻合口出血灶后,采取硬化剂注射、电凝止血或金属夹夹闭的方法 进行止血.所有患者均一次止血成功,术后均未出现吻合口瘘等严重并发症.随访至今,未见再次出血.结论 内镜下治疗消化道机械性吻合术后早期吻合口出血操作简单、安全、有效,可作为首选方法 在临床上推广应用.

Abstract：

Objective The study aimed to evaluate the efficacy of endoscopic therapy for early postoperative anastomotic hemorrhage. Methods Fourteen patients experienced an episode of early postoperative anastomotic hemorrhage and were treated endoscopically from January 2005 to June 2010. The clinical data was analyzed retrospectively. Results Fourteen patients (9 males and 5 females, median age 57.5 years,range 26-74 years) were diagnosed with postoperative hemorrhage between 6 hours to 14 days after surgery. The blood loss ranged from 500 to 1500 ml. Sclerosing agent injection, electrocoagulation, and hemoclips were attempted to control the bleeding. Endoscopic approach to control early postoperative anastomotic hemorrhage was successful in all the patients. No recurrent bleeding was observed during the follow-up. No complications associated with endoscopic therapy. Conclusion Endoscopic approach for the management of early postoperative anastomotic hemorrhage is feasible with high success rate and associated with no complications.     

食管癌术后胸内吻合口瘘九例治疗体会

胸内食管胃吻合口瘘是食管癌术后严重并发症。我院于1995年2月至2006年1月间，共施行食管癌手术462例．发生吻合口瘘12例（2．5％），其中9例在第2次手术时．采取瘘口内放置T型管引流同时结合应川胸腔闭式引流及空肠造瘘肠道内营养等综合治疗，效果满意，现报道如下。     

Surgical Treatment Concepts for Acute Lower Gastrointestinal Bleeding

Background and purpose  To this day, the diagnostic and therapeutic strategy for acute lower gastrointestinal hemorrhage requiring transfusion varies among different hospitals. The purpose of this paper was to evaluate our own data on the group of patients presented and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years. Methods  Following prospective data collection on 63 patients of a university hospital (40 male, 23 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion, we retrospectively analyzed the data. After a medical history had been taken, all patients underwent clinical examination, including digital palpation; 62 patients underwent procto-rectoscopy, 38 gastroscopy and colonoscopy, 52 patients colonoscopy only, and 45 patients gastroscopy only. Angiography was applied in 14 cases and scintigraphy in 20 cases. Results  Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%. Conclusions  Examination and stabilization of the patient is directly followed by diagnostic localization. Today, we primarily rely on nonsurgical control of hemorrhage by endoscopy or angiography; the indication for surgery is mainly limited to peracute, uncontrollable, and recurrent forms. In the case of surgery, intestinal segmental resection is recommended after identification of the lesion; if the localization of colonic hemorrhage is uncertain, subtotal resection is the method of choice. For stable patients with unverifiable small-bowel hemorrhage we recommend regular re-evaluation.     

Abernethy畸形致下消化道出血的诊治

目的探讨Abernethy畸形致下消化道出血的诊断及治疗方法。方法回顾1例Abernethy畸形患者的诊治情况,并结合相关文献进行分析。结果血管造影确诊后经积极术前准备,行剖腹探查、乙状结肠造瘘术,术后3周开始给予中药保留灌肠至术后7周,6个月关闭造瘘,3周后继续辅以中药保留灌肠4周。患者顺利恢复出院,随访9个月未再次出血。结论正确的诊断及合理的治疗方案是救治的关键。     

应激性溃疡大出血的治疗体会

目的 总结外科手术后应激性溃疡大出血的临床特点和治疗经验。方法 回顾分析1997～2003年期间我院治疗的32例应激性溃疡大出血患者的临床资料。结果 28例患者采用非手术治疗，其中12例患者接受急诊胃镜检查；手术治疗4例。奉组患者总的治愈率为87．50％．死亡率为15．62％。结论 急诊胃镜检查有助于明确诊断及止血治疗，应激性溃疡大出血首选非手术治疗，无效者可选择于术治疗。     

门脉高压症上消化道大出血急诊手术治疗体会

目的探讨门脉高压症食管胃底静脉曲张破裂出血急诊手术时机和疗效。方法2002年1月~2007年4月48例肝硬化门脉高压症上消化道大出血患者行急诊选择性贲门周围血管离断,其中18例加行改良Sugiura术。结果45例获随访,平均18(3~24)个月,无术后死亡,无吻合口瘘和肝性脑病,无术后再出血的发生。结论选择性贲门周围血管离断和条件允许情况下的改良Sugiura术能有效地治疗门脉高压症食管胃底静脉曲张破裂出血,降低术后再出血率和并发症发生率。     

生长抑素及生长激素预防胰十二指肠切除术后并发症发生的临床应用

目的　探讨生长抑素 14肽与生长激素联合应用在预防胰十二指肠切除术后并发症发生中的作用。方法　我院 1995年 3月至 2 0 0 3年 3月共收治因胆总管下段癌、十二指肠乳头癌及胰头癌行胰十二指肠切除术患者 4 8例 ,对其中 2 6例 (治疗组 )应用生长抑素 14肽 6mg/d(持续微量泵泵入 )及生长激素 8U/d(分两次肌注 )治疗 ,余 2 2例为对照组 ,术后常规应用全肠外营养及抗生素治疗 ,比较两组的治疗结果。结果　术后发生并发症对照组 17例 (77.3% ) ,治疗组 5例 (19.2 % ) ,两组比较差异有显著性意义 (P<0 .0 5 )。治疗组胰液量及胰周引流液中淀粉酶的含量明显低于对照组 (P<0 .0 5 ) ,两组术前、术后蛋白质指标 ,治疗组于术后第 7天基本恢复到术前水平 ,而对照组第 10天才达到术前水平。结论　联合应用生长抑素及生长激素能有效降低胰十二指肠切除术后并发症的发生率     

胃肠道浆肌层吻合、黏膜外吻合、一层吻合和二层吻合的实验比较研究

目的比较胃肠道浆肌层吻合、黏膜外吻合、一层吻合和二层吻合对吻合愈合的影响。方法家兔分成4组,即浆肌层吻合组、二层吻合组、一层吻合组和黏膜外吻合组。每组10只,每只动物行1个胃十二指肠侧侧吻合、2个回肠端端吻合和2个结肠端端吻合。术后第3和7d,每组分别各取5只动物,测定吻合破裂压（ABP）、组织羟脯氨酸（HP）含量并做病理检查。结果术后第3d,各组ABP间差异无统计学意义（P〉0.05）。术后第7d,二层吻合、一层吻合和黏膜外吻合的ABP间差异无统计学意义（P〉0.05）;胃十二指肠浆肌层吻合的ABP高于二层吻合和一层吻合（P〈0.05）;回肠浆肌层吻合的ABP高于二层吻合（P〈0.01）;结肠浆肌层吻合的ABP高于二层吻合、一层吻合和黏膜外吻合（P〈0.05）。术后第3d,胃十二指肠和回肠吻合的各组HP含量无明显差异,结肠二层吻合HP含量高于一层吻合（P〈0.05）;术后第7d回肠、结肠吻合的各组HP含量差异无统计学意义（P〉0.05）,胃十二指肠浆肌层吻合HP含量高于二层吻合（P〈0.025）。术后第3d,胃十二指肠和回肠吻合的各组炎症程度相似,结肠黏膜外吻合的炎症反应轻于二层吻合（P〈0.05）;术后第7d,胃十二指肠和结肠吻合的各组炎症程度相似,回肠浆肌层吻合炎症反应轻于二层吻合（P〈0.05）。术后第7d,胃肠道吻合各组黏膜愈合指数差异无统计学意义（P〉0.05）。结论胃肠道浆肌层吻合和其他手工吻合一样安全可靠,但更加简便。     

Age-related changes in Serum Growth Hormone,Insulin-like Growth Factor-1 and Somatostatin in System Lupus Erythematosus

Background

Systemic lupus erythematosus is an age- and gender-associated autoimmune disorder. Previous studies suggested that defects in the hypothalamic/pituitary axis contributed to systemic lupus erythematosus disease progression which could also involve growth hormone, insulin-like growth factor-1 and somatostatin function. This study was designed to compare basal serum growth hormone, insulin-like growth factor-1 and somatostatin levels in female systemic lupus erythematosus patients to a group of normal female subjects.

Methods

Basal serum growth hormone, insulin-like growth factor-1 and somatostatin levels were measured by standard radioimmunoassay.

Results

Serum growth hormone levels failed to correlate with age (r² = 3.03) in the entire group of normal subjects (i.e. 20 – 80 years). In contrast, serum insulin-like growth factor-1 levels were inversely correlated with age (adjusted r² = 0.092). Of note, serum growth hormone was positively correlated with age (adjusted r² = 0.269) in the 20 – 46 year range which overlapped with the age range of patients in the systemic lupus erythematosus group. In that regard, serum growth hormone levels were not significantly higher compared to either the entire group of normal subjects (20 – 80 yrs) or to normal subjects age-matched to the systemic lupus erythematosus patients. Serum insulin-like growth factor-1 levels were significantly elevated (p < 0.001) in systemic lupus erythematosus patients, but only when compared to the entire group of normal subjects. Serum somatostatin levels differed from normal subjects only in older (i.e. >55 yrs) systemic lupus erythematosus patients.

Conclusions

These results indicated that systemic lupus erythematosus was not characterized by a modulation of the growth hormone/insulin-like growth factor-1 paracrine axis when serum samples from systemic lupus erythematosus patients were compared to age- matched normal female subjects. These results in systemic lupus erythematosus differ from those previously reported in other musculoskeletal disorders such as rheumatoid arthritis, osteoarthritis, fibromyalgia, diffuse idiopathic skeletal hyperostosis and hypermobility syndrome where significantly higher serum growth hormone levels were found. Somatostatin levels in elderly systemic lupus erythematosus patients may provide a clinical marker of disease activity in these patients.