胰腺损伤的术式选择及并发症防治

目的：探讨治疗胰腺损伤的术式选择及危险并发症的防治。方法：71例中29例行胰腺清创缝合引流术,17例行胰体尾切除、脾切除术,4例行胰体尾切除术,17例行胰体尾空肠Roux-Y式吻合术,2例行胰管吻合术。结果：71例中62例治愈,9例死亡（12.7％）。结论：Ⅲ～IV级胰腺损伤术后的严重并发症主要是胰肠吻合瘘,在术式上应选择切除远端胰腺及脾脏,避免胰肠Roux-Y式吻合术及胰管吻合。     

Procedures under tourniquet

Limb tourniquets are commonly used to help facilitate surgery by producing less blood in the surgical field. This may also shorten operative time and reduce intraoperative blood loss. These advantages need to be weighed against potential complications such as post-tourniquet syndrome, skin damage, deep vein thrombosis, rhabdomyolysis and ischaemic pain. Physiological changes in the cardiovascular, respiratory, metabolic, haematological and neurological systems also occur.     

Procedures under tourniquet

Limb tourniquets are commonly used to help facilitate surgery by producing less blood in the surgical field. This may also shorten operative time and reduce intraoperative blood loss. These advantages need to be weighed against potential complications such as post-tourniquet syndrome, skin damage, deep vein thrombosis, rhabdomyolysis and ischaemic pain. Physiological changes in the cardiovascular, respiratory, metabolic, haematological and neurological systems also occur.     

Suture Injury to the Urinary Tract in Urethral Suspension Procedures for Stress Incontinence

The case histories of women attending the Urogynecology Department at the Royal Women’s Hospital and Mercy Hospital for Women were reviewed between 1986 and 1998 to determine the incidence and postoperative morbidity caused by suture injury to the urinary tract following urethral suspension surgery for stress incontinence. In our department 1103 Burch colposuspensions and 61 Stamey urethral suspensions have been performed. Intraoperative cystourethroscopy was performed routinely for the early detection and treatment of urinary tract injury. Intravesical sutures were found by routine intraoperative cystoscopy in 1 Stamey suspension, 1 open Burch colposuspension and 3 laparoscopic Burch colposuspensions. Ureteric suture ligation was diagnosed in 2 women intraoperatively and 1 woman postoperatively after laparoscopic Burch colposuspension. Two women presented with late complications from intravesical sutures following open Burch colposuspension. A further 7 women referred with urinary symptoms were found to have intravesical sutures, 2 following Burch colposuspension, 4 following Stamey urethral suspension and 1 following the Marshall–Marchetti–Kranz procedure. Seven of the 9 women diagnosed with intravesical sutures presented with bladder or pelvic pain, frequency or urinary tract infection. Two women had recurrent stress incontinence and were found to have a intravesical suture on routine cystoscopy at the time of stress incontinence surgery. Suture removal, with any accompanying calculus, was achieved cystoscopically with almost immediate resolution of symptoms without loss of urinary control in all cases. Non-absorbable intravesical sutures occurring as a result of suture misplacement or erosion is an infrequent but important complication of stress incontinence surgery, but should be suspected if pain and irritative bladder symptoms or recurrent urinary infection occur postoperatively. Cystourethroscopy performed intraoperatively or postoperatively is essential for early diagnosis and treatment.     

Procedures under tourniquet

The pneumatic tourniquet is used widely in operations involving the limbs. However, despite its everyday use, a clinician’s knowledge of this instrument is often limited to the pressure and time limit. Although the principle behind the tourniquet is simple, anaesthetists and surgeons should appreciate the effects of the tourniquet as well as the various complications associated with its use. Safe use of the tourniquet starts from the point of setting up the pneumatic machine. It is important to choose the appropriate pressure. Overinflation can lead to nerve damage. On the other hand, underinflation will lead to a bloody surgical field and unnecessary blood loss. The tourniquet should be applied with care to avoid local damage to the skin. Pathophysiological effects of the tourniquet can vary from a simple tachycardia and increase in systolic pressure to fatal events such as large pulmonary embolus and cardiac arrest. Prolonged use of the tourniquet can lead to a phenomenon known as tourniquet pain. Other complications associated with the use of the tourniquet include nerve and vascular damage and muscle contracture. In the past, the use of the tourniquet was avoided in patients with sickle cell disease for fear of triggering a sickle cell crisis. However, it has been shown that by creating the optimum conditions – sufficient hydration, good oxygenation, warmth and mild hyperventilation – this group of patients should not be deprived of the choice of having their limb operations with a tourniquet.