163例高龄结直肠癌合并糖尿病患者的围手术处理体会

目的 探讨高龄结直肠癌合并糖尿病患者的围手术处理。方法 对1994-2004年围手术处理的163例高龄（年龄大于印岁）结直肠癌合并糖尿病患者作回顾性分析。结果 163例病人均作结直肠癌择期手术,术后并发症发生率39．9％,其中切口感染19．6％（32／163）,肺部感染12．3％（20／163）,吻合口漏占3．7％（6／163）,泌尿系感染为2．5％（4／163）,高渗性昏迷1．2％（2／163）,死亡0．6％（1／163）。术后平均住院20天。结论 如能做到控制血糖、选择合理的术式和手术时机,高龄结直肠癌并糖尿病患者可顺利度过围手术期,并取得良好的手术疗效。     

结肠直肠手术部位感染的手术技术因素及其预防

手术部位感染（surgical site infection，SSI）是外科手术的并发症之一，不仅影响病人的预后，甚至导致死亡。美国CDC国家医院感染监视系统资料显示SSI是第3位常见的院内感染．占住院病人院内感染的14％～16％，其中结肠直肠外科手术的SSI发生概率较高，为8．6％～9．7％。美国医院感染控制委员会颁布的SSI预防指南指出．除外术中环境因素、无菌材料、无菌术等，手术技术和操作对SSI的防治具重要意义口。SSI其诊断标准已达成共识，包括切口浅部感染、切口深部感染、器官或腔隙感染等。现就结肠直肠外科SSI相关手术技术及其预防作一概述和分析。     

结直肠癌术后切口感染危险因素的Logistic回归分析

目的研究和分析结直肠癌术后切口感染的危险因素,为有效降低结直肠癌术后感染风险提供参考依据。方法回顾性分析本院2016年1月~2017年12月期间203例行结直肠癌手术患者的临床资料,采用Logistic回归模型分析术后切口感染的独立危险因素。结果 203例患者中,发生术后切口感染者30例,切口感染发生率为14.778%。经Logistic单因素分析结果显示,术后切口感染与患者手术部位、切口类型、急诊手术、麻醉评分分级、手术风险分级、住院时间和合并糖尿病有关(均P0.05);Logistic多因素分析结果显示,切口类型、住院时间和合并糖尿病为术后切口感染的独立危险因素(均P0.05)。结论手术切口类型、住院时间和合并糖尿病为结直肠癌术后切口感染的独立危险因素,在临床工作中应加强对风险因素的评估和干预,使患者更好的恢复。     

围手术期预防应用抗菌药物指南

感染是最常见的手术后并发症,抗菌药物在围手术期的正确预防性应用有助于减少手术部位的感染。 一、手术部位感染（surgical site infection。SSI）的定义及诊断标准 （一）SSI的定义 SSI是指围手术期（个别情况在围手术期以后）发生在切口或手术深部器官或腔隙的感染,如切口感染、脑脓肿、腹膜炎等。SSI约占全部医院感染的15％,占外科患者医院感染的35％～40％。     

基于预测评分系统的高龄结直肠癌患者术后并发症的预防策略

目的探讨高龄结直肠癌患者术后并发症发生的危险因素和预防策略。方法收集2006年1月至2009年12月间北京大学人民医院胃肠外科收治并行手术治疗的107例高龄结直肠癌患者（75岁以上）的临床资料。应用POSSUM、E．POSSUM评分系统预测术后并发症发生率,并用ROC曲线及实际例数／预测例数（O／E）比值评估其效度：采用Logistic回归分析影响并发症发生的独立危险因素。结果E．POSSUM和POSSUM评分系统预测术后并发症发生率分别为13．9％。86．6％（平均32．7％）和19．1％～99．1％（平均55．5％）,E—POSSUM评分系统优于POSSUM评分系统[ROC曲线下面积（AUC值）：0．862比0．576];O／E：0．771比0．454,更加接近于实际并发症发生率（25．2％,27／107）。术前合并糖尿病（P=0．019）和发病部位为直肠（P=0．005）是手术相关并发症的独立危险因素：吻合口瘘为最常见的手术相关并发症;术前合并慢性阻塞性肺病（P=0．026）、术前ASA分级（P_0．025）、术前肠梗阻（P=0．037）及术前肠穿孔（P=0．001）是非手术相关并发症的独立危险因素：肺部感染是最常见的非手术相关并发症。结论术前应用E—POSSUM评分系统可对高龄结直肠癌患者术后并发症发生率进行较为准确的预测：对于并发症发生高危患者术前应积极干预高危因素．以预防术后并发症的发生。     

人类免疫缺陷病毒/获得性免疫缺陷综合征患者骨科手术部位感染的影响因素

目的研究人类免疫缺陷病毒（HIV）/获得性免疫缺陷综合征（AIDS）患者骨科手术后发生手术部位感染（SSI）的危险因素以及预防策略。 方法回顾性分析2010年1月至2018年1月于首都医科大学附属北京地坛医院住院行骨科手术的HIV/AIDS患者共79例，根据是否发生手术部位感染将其分为手术切口感染组（21例）和非感染组（58例）。分析两组患者SSI发生率，筛选SSI影响因素，并经Logistic回归分析确定独立危险因素。 结果79例行骨科手术的HIV/AIDS患者中发生SSI者共21例（26.58%），其中13例为切口浅部感染，5例为深部感染，3例为腔隙感染。感染组和非感染组患者年龄基础疾病（糖尿病）、合并疾病（结核）、术前HIV RNA载量、术后1周红细胞沉降率（ESR）、术后1周C-反应蛋白（CRP）、手术时程、住院时间、腰部及下肢手术部位、BMI指数、CD4⁺ T计数、CD8⁺ T计数、CD4⁺/CD8⁺ T、白细胞（WBC）和血红蛋白（HGB）差异均有统计学意义（P均< 0.05）。将临床中及以往文献报道的SSI相关因素均纳入多因素Logistic回归分析，结果显示：年龄、ALB、BMI、CD4⁺ T计数、HGB、WBC、合并疾病（结核）、手术类型、手术部位、手术时程、切口类型、麻醉类型和术中出血量均为HIV/AIDS患者骨科相关手术部位感染的独立危险因素（P均< 0.05）。 结论行骨科手术的HIV/AIDS患者为SSI高危人群，应针对其危险因素采取有效措施干预，积极治疗基础疾病，纠正贫血、低蛋白血症，合理围手术期用药包括高效联合抗反转录病毒治疗（HAART）进行免疫重建、应用抗菌药物以预防性抗感染治疗；尽量控制术中出血量，减少手术时间，术中严格执行无菌操作，尽可能降低手术切口感染。     

脊柱手术部位感染的危险因素及预防措施研究进展

随着医疗技术的不断发展,人们对生活质量要求的提高,越来越多的脊柱疾病可以通过外科手术治疗,同时手术所带来的并发症也不容忽视。手术部位感染（surgical site infection,SSI）是脊柱术后常见的并发症之一,它是指无置入物手术30d内、有内置物（如椎弓根螺钉、椎体间融合器、人工椎间盘等）手术后1年内发生的与手术相关感染,包括浅表切口感染、深部切口感染以及器官/组织间隙感染。脊柱术后感染的危险因素很多,包括年龄、美国麻醉医师协会评分（ASA score）、肥胖、糖尿病、吸烟,此外手术入路、内置物、骨移植、手术时间及输血都被认为是SSI的危险因素。脊柱术后SSI发生率在0.7%～12%之间,近些年发病率呈增高趋势,延长了治疗时间,增加了治疗费用,甚至增加了死亡率[1],预防脊柱手术感染,确保医疗安全意义重大。笔者对脊柱手术部位感染的危险因素及预防措施综述如下。     

膀胱癌根治术后早期并发症及其危险因素分析

目的:探讨膀胱癌根治术(RC)后早期并发症发病特点及常见并发症相关危险因素。方法:收集2009年10月~2014年1月我院行根治性全膀胱切除手术且随访资料完整的患者共294例,收集患者相关信息及术中、术后资料,统计患者术后90天内早期并发症,并应用二元逻辑回归统计方法探讨术后常见并发症的危险因素。结果:术后并发症发生发生率38.7%(114/294),其中Clavien分级1级25例,2级74例,3级13例,5级2例。术后并发症以感染、肠梗阻、切口脂肪液化常见;老年(65岁)及肥胖(BMI25kg/m2)是术后肠梗阻发生的危险因素;开放式RC及糖尿病则是术后切口脂肪液化的危险因素。结论:RC术后并发症发生率较高,对于有发生肠梗阻或切口脂肪液化危险因素的患者,RC术前及术后应采取积极措施预防其发生。     

腹腔镜阑尾切除与开腹阑尾切除术疗效比较

探讨腹腔镜阑尾切除术与开腹阑尾切除手术治疗急性阑尾炎的疗效。回顾分析急性阑尾炎患者769例,分为实验组(腹腔镜阑尾切除术)432例和对照组(开腹阑尾切除术)324例,观察两组手术时间、术中出血量、术后疼痛程度、肛门排气时间、切口感染、切口脂肪液化情况。结果显示,实验组术中出血量、术后疼痛程度、肛门排气时间、住院天数优于对照组,肥胖与切口感染、切口脂肪液化相关。结果表明,腹腔镜阑尾切除术能降低手术切口相关并发症发生,对肥胖患者更具优势。     

腹腔镜结直肠癌术后切口感染的影响因素分析

目的：探讨结直肠癌腹腔镜手术后切口感染的影响因素。 方法：回顾性分析中国医科大学附属盛京医院结肠直肠肿瘤外科697例结直肠癌手术患者的临床资料,对可能影响切口感染的相关因素进行单因素与多因素分析。 结果：697例手术中有43例出现切口感染43/697（6.17%）,单因素分析显示,结直肠癌手术切口感染与性别、年龄、手术时间、手术方式、是否合并基础疾病有关（均P<0.05）;Logistic回归显示,手术方式、年龄及手术时间为切口感染的独立影响因素（均P<0.05）。 结论：手术方式、年龄及手术时间是腹腔镜结直肠癌手术术后患者切口感染的独立影响因素。如病情允许,结直肠癌腹腔镜手术应作为减少术后切口感染率的首选手术术式。     

梗阻性结直肠癌导管减压后3D腹腔镜与开腹手术的疗效比较

目的:比较梗阻性结直肠癌导管减压后行3D腹腔镜与开腹根治术的疗效。方法:回顾性分析2011年5月—2013年6月96例行手术治疗的梗阻性结直肠癌患者资料,所有患者术前均行肠梗阻导管置入减压,然后50例行3D腹腔镜下行结直肠癌根治术3D(腹腔镜手术组),46例行传统开腹结直肠癌根治手术(开腹手术组),比较两组患者的相关临床指标。结果:两组患者术前资料具有可比性;腹腔镜手术组平均手术时间长于开腹手术组(5.9 h vs.5.2 h,P0.05),平均总住院费用高于开腹手术组(3.3万元vs.2.7万元,P0.05),但平均术后排气时间(2.4 d vs.3.0 d,P0.05)、留置尿管时间(2.7 d vs.3.9 d,P0.05)、住院时间(15.2 d vs.23.8 d,P0.05)均明显短于开腹手术组;两组患者术后吻合口瘘、切口感染、腹腔脓肿和肠梗阻发生率差异均无统计学差异(均P0.05);两组患者3年无瘤生存率无统计学差异(80.0%vs.82.6%,P=0.744)。结论:3D腹腔镜手术治疗导管减压后梗阻性结直肠癌术后恢复快,且围手术期并发症与预后方面与开腹手术相似,可作为梗阻性结直肠癌治疗的手术方式。     

Surgical Site Infections Following Colorectal Surgery in Patients with Diabetes: Association with Postoperative Hyperglycemia

Introduction  Postoperative glycemic control reduces sternal infections following cardiac surgery in patients with diabetes mellitus (DM). The objective of this study was to examine the relationship between postoperative glycemic control and surgical site infections (SSI) in patients with DM undergoing colorectal resection. Discussion  A cohort of patients with DM who underwent colorectal resection (April 2001–May 2006) at our institution were reviewed. SSI were defined by Centers for Disease Control criteria. From a study cohort of 149 patients, 24% had poor postoperative glycemic control (defined as a mean 48-h postoperative capillary glucose (MCG) >11.0 mmol/L or 200 mg/dL), and these patients developed SSI at a significantly higher rate than those with a 48-h MCG ≤11.0 mmol/L (29.7% vs. 14.3%; odds ratio (OR) 2.5, p = 0.03). On multivariate logistic regression, 48-h MCG >11.0 mmol/L was significantly associated with SSI (OR 3.6, p = 0.02), independent of the dose and regimen of postoperative insulin administration. In conclusion, 48-h MCG >11.0 mmol/L (200 mg/dL) was independently associated with increased SSI following colorectal resection in patients with DM. Prospective studies are required to validate this relationship, address the role of preoperative glycemic control, and examine strategies to improve glycemic control following colorectal resection. Meeting presentation: Canadian Association of General Surgery, Canadian Surgery Forum, September 8, 2007, Toronto, Ontario, Canada     

糖尿病与结直肠癌临床病理因素及预后的相关性研究

目的 探讨糖尿病对结直肠癌临床病理因素及预后的影响.方法 采用回顾性研究的方法,将2000年1月至2007年6月收治的共计599例结直肠痛患者分为糖尿病组(DM组)和非糖尿病组(NDM组),比较两组性别、年龄等一般情况及临床病理因素的差异并作Logistic多因素同归分析;并对直接接受根治手术的402例患者进行预后影响凶素的Cox回归分析.结果 本组患者中共58例(9.7%)罹患糖尿病,糖尿病组与非糖尿病组患者在体质量、年龄、是否合并高血压方面差异均有统计学意义(P<0.05);两组在肿瘤组织学分级、浸润、淋巴转移、TNM分期及脉管癌栓方面差异均无统计学意义(P>0.05).Logistic多因素回归分析显示糖尿病与结直肠癌的病理因素无相关性(P>0.05).直接接受根治手术的患者生存分析显示:术后3年的转移复发Kaplan-meier曲线及生存曲线有、无糖尿病的两组间差异均无统计学意义(P=0.521、0.909);多因素Cox回归分析未提示糖尿病与结直肠癌患者预后相关(P=0.991).结论 在接受了外科手术的结直肠癌患者中,糖尿病与结直肠癌的临床病理因素无相关性;罹患糖尿病并不改变结直肠癌患者的预后,糖尿病在结直肠癌发展与转归的作用尚需进一步研究.     

Surgical site infections: reanalysis of risk factors

BACKGROUND: Surgical site infections (SSI) are the most common nosocomial infection in surgical patients, accounting for 38% of all such infections, and are a significant source of postoperative morbidity resulting in increased hospital length of stay and increased cost. During 1986-1996 the Center for Disease Control and Prevention's National Nosocomial Infections Surveillance system reported 15,523 SSI following 593,344 operations (2.6%). Previous studies have documented patient characteristics associated with an increased risk of SSI, including diabetes, tobacco or steroid use, obesity, malnutrition, and perioperative blood transfusion. In this study we sought to reevaluate risk factors for SSI in a large cohort of noncardiac surgical patients. METHODS: Prospective data (NSQIP) were collected on 5031 noncardiac surgical patients at the Veteran's Administration Maryland Healthcare System from 1995 to 2000. All preoperative risk factors were evaluated as independent predictors of surgical site infection. RESULTS: The mean age of the study cohort was 61 plus minus 13. SSI occurred in 162 patients, comprising 3.2% of the study cohort. Gram-positive organisms were the most common bacterial etiology. Multiple logistic regression analysis documented that diabetes (insulin- and non-insulin-dependent), low postoperative hematocrit, weight loss (within 6 months), and ascites were significantly associated with increased SSI. Tobacco use, steroid use, and chronic obstructive pulmonary disease (COPD) were not predictors for SSI. CONCLUSION: This study confirms that diabetes and malnutrition (defined as significant weight loss 6 months prior to surgery) are significant preoperative risk factors for SSI. Postoperative anemia is a significant risk factor for SSI. In contrast to prior analyses, this study has documented that tobacco use, steroid use, and COPD are not independent predictors of SSI. Future SSI studies should target early preoperative intervention and optimization of patients with diabetes and malnutrition.     

Diabetes is associated with increased perioperative mortality but equivalent long-term outcome after hepatic resection for colorectal cancer

Diabetes is associated with alterations in liver metabolism and immune response that may influence post-operative recovery and long-term survival after hepatectomy for cancer. Patients with type I or type II diabetes mellitus submitted to a potentially curative hepatic resection for metastatic colorectal cancer were identified from the prospective database, and compared with patients with hepatic colorectal metastases submitted to resection during the same time interval, but without diabetes mellitus. Data on operative morbidity and mortality and long-term survival were analyzed. Between December 1990 and July 1999, a total of 727 patients underwent hepatic resection, 61 of whom (8.1%) had type I and type II diabetes mellitus. Operative mortality in the diabetic patients was significantly greater than in nondiabetic patients (8% vs. 2%, P < 0.02). Among patients with diabetes mellitus, four of the five perioperative deaths were due to liver failure after major hepatic resection (lobectomy or greater). All four of these patients had significant parenchymal abnormality (three with steatosis). Long-term survival was identical to that in nondiabetic control subjects. We conclude that the presence of diabetes is associated with a higher incidence of perioperative mortality. In patients with diabetes mellitus and parenchymal steatosis, major hepatic resection should be undertaken with caution. Supported in part by grants RO1 CA 75416, RO1 CA 72632, and RO1 CA 61524 (Y.F.) from the National Institutes of Health, grant MBC-99366 (Y.F.) from the American Cancer Society, and the St. Andrews Society of New York (S.A.L.).     

免疫微生态肠内营养在合并糖尿病的胃肠道肿瘤患者中的应用

目的探讨由益生菌、谷氨酰氨、深海鱼油和短肽肠内营养组成的免疫微生态肠内营养制剂对合并糖尿病的胃肠道肿瘤患者术后恢复的影响。方法将2007年1月至2010年10月期间山东省聊城市人民医院收治的67例合并糖尿病的胃肠道肿瘤患者,按随机数字表法分为治疗组（33例．添加益生菌、谷氨酰胺和深海鱼油的免疫微生态肠内营养制剂）和对照组（34例,普通肠内营养）。分别于术前、术后3d和术后7d检测空腹血糖、空腹胰岛素（FINS）、胰岛素抵抗指数（InHOMA．IR）、T淋巴细胞亚群水平（CD3＋、CD4＋、CD8＋、CD4／CD8）及自然杀伤（NK）细胞计数,并观察院内感染发生率、肠功能恢复时间和住院时间。结果术后7d,治疗组空腹胰岛素和InHOMA．IR明显低于对照组,分别为（8．4±3．7）mU／L比（13．7±5．4）mU／L（P〈0．05）和1．1±0．2比1．7±0．4（P〈0．05）;治疗组CD4＋[（45．2±5．4）％]、CD4／CD8（2．1±0．3）及NK细胞计数[（19．5±6．6）％]明显高于对照组[（38．1±2．9）％、1．6±0．2及（15．4±5．6）％,均P〈0．05]。两组患者院内感染发生率[6．1％（2／33）比17．6％（6／34）,P〉0．05]和肠功能恢复时间[（69．3±9．5）h比（70．1±11．6）h,P〉0．05]的差异无统计学意义,但住院时间治疗组明显短于对照组[（17±3．8）d比（21±4．2）d,P〈0．05]。结论对合并糖尿病的胃肠道肿瘤患者。应用免疫微生态肠内营养能降低胰岛素抵抗,改善免疫状态,促进患者术后恢复。     

糖尿病与结直肠癌及其生物学行为的关系

目的探讨糖尿病与结直肠癌发生及生物学行为的关系。方法对2006—2009年南方医科大学附属南海人民医院486例结直肠癌患者（结直肠癌组）与533例同期收治的非结直肠癌患者（对照组）进行病例对照研究,比较两组患者糖尿病并发情况及糖尿病病程对结直肠癌发生的影响。并对结直肠癌组患者中合并糖尿病对肿瘤生物学行为的影响进行分析。结果结直肠癌组和对照组的糖尿病并发率分别为12．1％（59／486）和7．1％（38／533）,差异有统计学意义（P〈0．01）;进一步经多因素分析结果显示．糖尿病是结直肠癌发生的独立危险因素（OR=1．886,95％CI：1．450．3．571）。糖尿病病程5。20年者结直肠癌发生危险性显著升高（P〈0．05）．而病程5年以内或超过20年者,其结直肠癌发生风险未见增高（P〉0．05）。结直肠癌患者是否并发糖尿病对肿瘤分化程度、浸润深度、淋巴结转移、远处转移及脉管栓塞均无明显影响（P〉0．05）。结论糖尿病患者罹患结直肠癌的风险增高．但并发糖尿病并不会改变结直肠癌的肿瘤生物学行为。     

Risk factors for and effect of a one-year surveillance program on surgical site infection at a university hospital in Turkey

BACKGROUND: Surveillance of surgical site infection (SSI) is one of the most effective methods for decreasing the incidence. We determined the risk factors for SSI and the effect of a one-year surveillance program on the rate at a tertiary-care center. METHODS: The annual SSI rate before the study period was determined in a preliminary study. Risk factors related to SSI, the bacteria cultured from infected sites, and the effect of surveillance were then analyzed prospectively. Risk factors were determined by logistic regression analysis, and 95% confidence intervals were calculated. RESULTS: The incidence of SSI decreased from 12.8% before the study to 8.8% at the end of the surveillance period. There were 90 SSIs (8.8%) in 1,017 procedures during the study period, most of which (77; 69%) were detected during the hospital stay. The distribution of superficial incisional, deep incisional, and organ/space SSI was 61.1%, 33.4%, and 5.5%, respectively. Prolonged preoperative hospital stay (>8 days), abdominal incision, early preoperative hair removal, inappropriate antimicrobial prophylaxis, whole blood transfusion, famotidine treatment, repair with mesh, age >75 years, wound contamination, high American Society of Anesthesiologists score, malnutrition, diabetes mellitus, emergency surgery, obesity, and coexistent infection proved to be independent risk factors for SSI, whereas the skin closure technique, patient sex, presence of malignancy, smoking history, and duration of operation were not. Staphylococcus aureus and Escherichia coli were the bacteria isolated most frequently. Six infected patients (5.4%) died, four because of SSI. Development of SSI increased hospital expenses by around 600 US dollars per patient. CONCLUSION: Surveillance even for one year decreases the incidence of SSI.     

腹腔镜结直肠癌根治术与开腹手术近远期疗效的比较

目的 比较腹腔镜结直肠癌根治术与开腹手术的近远期临床疗效.方法 回顾性分析1998 年1月至2008 年12 月在本院行结直肠癌根治性手术的375例患者的临床病理资料,根据其手术方式分为腹腔镜手术组（72例）和开腹手术组（303例）,比较两组的一般资料、手术时间、出血量、淋巴结数目、肛门排气时间、术后住院时间、术后并发症及术后无瘤生存率.结果 腹腔镜组和开腹手术组资料具有可比性,在出血量（121.81 ml vs 160.41 ml）、肛门排气时间（3.03 d vs 3.90 d）、术后住院时间（12.03 d vs 15.69 d）腹腔镜组优于开腹手术组（P均 〈 0.05）,两组手术时间（209.79 min vs 198.50 min）、淋巴结数目（10.82 vs 9.48）及术后并发症发生率（23.61% vs 26.07%）差异无统计学意义,腹腔镜组术后3、5年无瘤生存率分别为67.7%、60.3%,开腹手术组分别为66.8%、53.5%,两组比较差异无统计学意义,按病理分期分层分析两组的术后无瘤生存率仍差异无统计学意义.结论 腹腔镜结直肠癌根治术近期疗效优于开腹手术,远期疗效与开腹手术相当,腹腔镜结直肠癌根治术具有可行性.