27. Postoperative Syndrome an Gallenwegen und Pankreas aus der Sicht des Chirurgen

Zusammenfassung Im Bereich der Gallenwege gibt es das seltene akute Okklusions-Syndrom, häufiger das sog. Postcholecystektomie-Syndrom, mit seinen vielfältigen Ursachen. Schilderung der Krankheitsbilder, speziellen chirurgischen Diagnostik und Therapie von Residualund Rezidivsteinen, Papillenstenose, Strikturen, Cysticusstumpf-Syndrom und Blindsack-Syndrom. Darstellung der aktuellen Operationsprinzipien. Am Pankreas können akute Pankreatitis, biliäre Pankreatitis, Pankreasfisteln sowie Folgeerscheinungen einer exokrinen bzw. endokrinen Insuffizienz auftreten. Besprechung von Prophylaxe und eventueller chirurgischer Behandlung.     

胰十二指肠切除术后出血34例临床分析

目的 探讨胰十二指肠切除术(pancreaticoduodenectomy,PD)后出血的原因和防治措施.方法 回顾性分析2000年1月至2012年1月接受PD的422例患者的临床资料.结果 PD术后出血34例,发生率8.1％;死亡7例,死亡率20.6％.其中,早期出血19例,晚期出血15例;腹腔出血20例,消化道出血14例.再手术19例中死亡3例(15.8％).早期出血的死亡率低于晚期出血(P＜0.05).结论 术中精细操作、确切止血,术后预防胰瘘、胆瘘及胰肠或胆肠吻合口周围积液是减少术后出血的关键.及时果断的再手术止血是治疗术后出血的重要手段.     

衰弱对老年患者手术后认知功能影响的研究进展

衰弱是身体机能、认知、心理衰退的一种多维综合征。衰弱可增加机体对应激的易损性,并导致患者术后并发症增加、住院时间延长、甚至死亡率上升。随着人口老龄化进程不断加快,越来越多的老年患者需接受手术治疗,而该类患者手术后容易发生认知功能障碍。衰弱是老年患者常见的合并状态,但衰弱对老年患者手术后认知功能的影响尚未完全明确。本文就衰弱与老年患者术后谵妄、术后认知功能障碍及术后认知功能改善相关研究做出综述,为临床开展衰弱与术后认知研究提供参考。     

49. Das akute postoperative Nierenversagen

Zusammenfassung Die Letalität beim akuten Nierenversagen (ANV) ist trotz verbesserter Dialyse- und Intensivtherapie noch hoch. Anhand der Verläufe von 11474 Patienten unserer Intensivstation wird die enge Relation zwischen Schwere der Grunderkrankung, weiterer Komplikationen und der Prognose des ANV und die zu empfehlende Therapie dargestellt. Bei steigender Frequenz des ANV sank die Letalität von 80 % bis 1972 auf jetzt 50 %. Dies ließ sich wesentlich auf eine bessere konservative Therapie zurückführen; die Dialysether war nur im Einzelfall erfolgreich (13 von 98 Patienten).     

Cuidados postoperatorios incluyendo tratamiento del dolor. Recomendaciones para la elaboración de un protocolo

The main objective of postoperative care is the prompt identification and treatment of the possible complications of surgery and/or anesthesia. In the last few years, several scientific societies have published clinical practice guidelines to guarantee high-quality postoperative care and optimize patient safety. Advances in the knowledge of the physiopathology of pain, regional techniques and new analgesic modalities have also been included in guidelines for the treatment of acute postoperative pain. This review discusses the most important aspects of postoperative care, including the treatment of pain, by evaluating these clinical practice guidelines and suggesting recommendations for each of the topics studied.     

芬太尼静脉镇痛对血浆胃动素的影响

目的　研究芬太尼静脉镇痛对血浆胃动素水平的影响。方法　接受矫形外科手术的ASAI～II级患者 5 0例 ,随机分为哌替啶镇痛组 (P组即对照组 ,n =2 0 )和芬太尼静脉镇痛组(F组 ,n =30 )。镇痛方式 :F组采用病人自控静脉镇痛 (PCIA) ,配方 :芬太尼 1 2mg、氟哌利多 5mg,加生理盐水至 10 0ml。背景流量 2ml/h ,自控剂量 0 5ml,锁定时间 15min。P组采用肌注哌替啶镇痛。分别于手术当天、术后第 1、2和 3天晨抽取空腹静脉血 2ml,放免法测定胃动素含量。观察指标 :镇痛评分、恶心呕吐评分和镇痛药用量。结果　F组镇痛效果显著优于P组 (P <0 0 1)。术后第 1天两组血浆胃动素水平均显著下降 (P <0 0 1) ,但两组间比较无显著差异 (P >0 0 5 )。F组第 2天胃动素水平显著上升 (与基础值相比 ,P <0 0 1;与P组相比 ,P <0 0 1) ,第 3天逐渐下降。有 11例患者发生恶心呕吐。P组第 2、3天胃动素水平逐渐上升 ,接近术前水平 ,3例患者出现恶心呕吐。结论　芬太尼静脉镇痛升高血浆胃动素水平 ,可能是芬太尼静脉镇痛增加术后恶心呕吐的机制     

Influence of Postoperative Hypertension on the Development of Spinal Epidural Hematoma

Spinal epidural hematoma (SEH) is a rare postoperative complication but can result in catastrophic neurological deficits requiring immediate surgical evacuation of the hematoma. Knowing the risk factors for postoperative SEH can help surgeons stratify patients. Therefore, to identify possible risk factors for postoperative SEH, we reviewed 6 clinical cases and examined the relation between postoperative hypertension and the risk of developing SEH. A retrospective review was conducted of 1282 consecutive patients who underwent spinal surgery at a single institution between 2010 and 2015. Of this cohort, 6 patients developed symptomatic SEH and underwent emergency hematoma evacuation. The 6 SEH patients were evaluated for previously described risk factors of postoperative hematoma formation. In particular, postoperative blood pressure measurements were reviewed. The incidence of postoperative symptomatic SEH was 0.468%. Two patients developed SEH secondary to a nonfunctional surgical drain in the early postoperative period (5 or 12 h post‐surgery). Preoperative and postoperative hypertension was observed in 4 patients who developed SEH at greater than or equal to 48 h following surgery. Our findings suggest that rigorous postoperative blood pressure control may decrease the risk of SEH.     

不同镇痛方法对老年食管癌患者术后疼痛及早期认知功能的影响

目的探讨不同镇痛方法对老年食管癌患者术后疼痛及认知功能的影响。方法选择拟行左进胸食管癌根治术患者60例,男31例,女29例,年龄65~80岁,ASAⅠ或Ⅱ级,随机分为A、B两组,每组30例。A组:关胸前予以0.375%罗哌卡因行肋间神经阻滞后接静脉镇痛泵,配方为舒芬太尼3μg/kg+氟比洛芬酯100mg,泵速2ml/h,自控镇痛0.5ml/按压,锁定时间15min。B组:关胸前予以舒芬太尼10μg+氟比洛芬酯50mg为负荷量后接静脉镇痛泵,配方同A组。观察两组患者术前1d、术后3、5、7d内简易精神状态量表(MMSE)评分,术后苏醒时、苏醒后4、8、12、24、48h视觉模拟疼痛(静息及运动时VAS)评分、BCS舒适评分、术后镇痛泵有效按压次数及术后认知功能障碍(POCD)的发生率。结果与B组比较,A组术后苏醒时、苏醒后4、8、12、24、48h静息及运动时VAS评分均明显降低(P0.05或P0.01);苏醒后4、8、12、24、48h的BCS评分明显升高、有效按压次数明显降低(P0.05);术后3、5、7d的MMSE评分明显升高(P0.05);术后3、5、7d的POCD发生率降低,但差异无统计学意义。结论开胸手术围术期应用肋间神经阻滞复合静脉镇痛可有效缓解患者术后疼痛,降低术后POCD的发生率,提高术后患者舒适度,有利于术后患者的快速康复。     

Management of pleural injuries during retroperitoneal surgical procedures

Purpose The necessity of a postoperative chest tube for the treatment of pneumothorax after a radical nephrectomy is controversial. Materials and methods A five-year retrospective study was performed on 91 patients, having undergone a radical nephrectomy. We examined the existence and length of a pleural rent, presence of a postoperative thoracostomy tube, postoperative pneumothorax, postoperative pneumonia, postoperative atelectasis, pain scores, hemoglobin saturation, and length of hospital stay with univariate and multivariate analysis. Results Incidence of a pleural rent occurred in 29 (36%) of open radical nephrectomy cases; 4 of the 29 cases had a postoperative thoracostomy tube. There was no significant difference in hemoglobin saturation levels between cases that had no pleural rent, a pleural rent without a thoracostomy tube, and a pleural rent with a postoperative thoracostomy tube. A pleural rent without a postoperative chest tube had significantly lower rates of pain score, atelectasis, pneumonia, pleural effusion, and length of hospital stay compared to individuals with a postoperative chest tube. Patients with a chest tube had a significantly higher incidence of pain, atelectasis, pneumonia, effusion, and length of hospital stay. Conclusion Iatrogenic pleural rents treated without a postoperative chest tube show a significant decrease in postoperative complications of pneumonia and atelectasis, pain score and length of hospital stay. These patients show no significant increases in postoperative complications; therefore, it appears that postoperative chest tube placement after a pleural injury occurs is of no advantage.     

A randomized double-blinded study to determine the effectiveness of utilizing intraperitoneal bupivacaine: Does it reduce post-operative opioid use following laparoscopic appendectomy?

Background

Improving postoperative pain control may lead to improved outcomes including decreased opioid use, shorter hospital stays, and improved patient satisfaction. This study examined the effects of instilling intraperitoneal bupivacaine following laparoscopic appendectomy.

椎弓椎体截骨矫正脊柱后凸畸形手术并发症分析

作者对６７例在椎弓椎体截骨矫正脊柱后凸畸形术中及术后发生手术并发症者进行分析。其中过量失血２例,脊椎滑脱６例,脊髓受压致瘫５例,神经根性疼痛６例,截骨角度丢失２６例,脑脊液漏及皮下蓄积５例,切口皮缘坏死１６例,鲁氏棒撬起穿破皮肤１例。作者分析了各种并发症发生原因、治疗结果及预防措施。作者认为,强直性脊柱炎患者应在病情稳定后手术,一个平面截骨角度不要过大。     

Postoperative retrograde intussusception in an infant: a rare occurrence

Retrograde intussusception is a rare postoperative complication, most commonly after gastric resection or gastrojejunostomy. This report describes a case of retrograde jejunojejunal intussusception after duodenal atresia repair.     

22. Einführung

Zusammenfassung Postoperative Syndrome in der Gastroenterologie können auftreten trotz perfekter Technik and trotz regelrechter Anzeigenstellung. Dieser Umstand gibt dem Syndrom eine wichtige chirurgische and interdisciplinary Bedeutung. Durch richtige Verfahrenswahl sollte es vermeidbar sein.     

Evaluation of an Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system to predict postoperative risk: a multicenter prospective study

We previously reported generating a scoring system termed E-PASS that predicted postsurgical risk. This study was undertaken to evaluate the usefulness of this system. A consecutive series of 902 patients who underwent elective gastrointestinal operations in six national hospitals in Japan were prospectively assessed for a comprehensive risk score (CRS) of the E-PASS, which was compared with their postoperative course. The postoperative morbidity rates linearly increased as the CRS increased. The postoperative mortality rate was only 0.13%, when the CRS was below 0.5; however, it increased to 9.7% when the CRS ranged from 0.5 to <1.0, and to 26.9% when the CRS was ≥1.0. The CRS correlated significantly with the severity of postoperative complications (r _s = 0.527, P < 0.0001) and the costs of hospital stay (r _s = 0.810, P < 0.0001). When the CRS-adjusted mortality rate at the CRS of ≥0.5 was compared among the hospitals, it was related to the hospital volume of operations, being 44.2% at the volume of <100 cases per year, 20.6% at the range of 100–199 cases, and 8.6% at the volume of ≥200 cases. These results suggest that E-PASS may be useful for predicting postsurgical risk, estimating medical expense, and comparing surgical quality. Received: June 12, 2000 / Accepted: November 20, 2000     

甲状腺术后出血的原因及处理：附8例临床分析

目的:探讨甲状腺术后出血的临床特征及处理措施。方法:回顾郑州大学第一附属医院自2014年4月—2015年5月共3417例甲状腺手术患者的临床资料,对其中8例发生术后出血的患者进行临床分析。结果:8例患者中有2例为皮瓣出血,2例为颈前静脉的出血,2例为甲状腺上动脉的出血,1例为甲状腺下动脉的出血,1例为颈前肌肉出血。8例患者均给予相应的处理措施,均未出现窒息等严重后果,切口甲级愈合出院。结论:早期明确诊断并积极处理是减少术后出血并发症的关键,不能忽略传统丝线的结扎或缝扎。