早期确定性手术治疗小肠瘘

目的:探讨早期确定性手术治疗小肠瘘的可行性及方法。方法:11例小肠瘘患者,在肠瘘发生后48 h内剖腹探查,行确定性手术,术后使用生长抑素、生长激素及胃肠外营养支持等治疗。结果:11例患者中10例治愈,1例再次发生肠瘘,保守治疗后治愈。总治愈率100%。结论:早期确定性手术治疗小肠瘘安全可行,大大缩短患者住院时间,减少患者负担。     

肠外瘘早中期确定性外科处理的临床研究

目的探讨肠外瘘早中期确定性处理方法。方法对３１例肠外瘘病人的治疗经验进行分析。在重视综合措施的前提下,对无法确定可否自愈的２８例病人,应经过必要准备后,争取早期手术治疗,并根据术中发现的情况,采用不同手术方法。另３例瘘口较小者采用非手术症法。结果３例非手术治疗者均自愈。可２８例手术治疗者中,治愈２６例（９３６％）,死亡２例（６４５％）。平均住院日期３６２２ｄ。结论在大多数肠瘘病人,采取早期手术治疗肠外瘘,可取得缩短病程,降低死亡率的好效果     

胆石性肠梗阻的诊断与治疗

目的：探讨胆石性肠梗阻的诊断与治疗,提高对胆石性肠梗阻的认识。方法 ：回顾性分析2014年1月至2019年12月江苏省苏北人民医院收治12例胆石性肠梗阻病人的临床资料,包括临床表现、影像学特征和治疗。结果：12例均出现腹痛、腹胀、恶心、呕吐。术前确诊胆石性肠梗阻6例,其中5例为CT检查确诊,1例为MRI检查确诊。11例行手术治疗,1例保守治疗。其中6例一期行肠切开取石+胆囊切除+胆肠瘘修补术,平均手术时间（167.5±23.2） min,术后平均住院时间（15.5±3.2） d。5例单纯行肠切开取石术,平均手术时间（96.2±31.1） min,术后平均住院时间（16.25±2.7） d。单纯行肠切开取石组病人的手术时间短于一期联合胆囊切除+胆肠瘘修补术组（P<0.05）,但两组术后住院时间比较,差异无统计学意义（P>0.05）。1例保守治疗排石,1年后行胆囊切除、胆肠瘘修补。结论：胆石性肠梗阻临床症状不典型,易漏诊。腹部CT检查有助于诊断,手术为主要治疗方法。     

腹腔镜在胆瘘或肠瘘诊治中的应用体会（附12例报道）

目的探讨腹腔镜在胆瘘或肠瘘诊治中的应用价值。方法回顾性分析2008年11月至2013年4月期间广西壮族自治区桂东人民医院和广西壮族自治区民族医院收治的应用腹腔镜诊治的12例胆瘘或肠瘘患者的临床资料。结果12例患者中胆瘘7例，肠瘘5例，均在手术后发生，均经腹腔镜探查后确诊。12例患者均在腹腔镜下行再次置管引流、缝闭迷走胆管或肠瘘管等处理。手术时间60-170min、（90±19）min，住院时间3-7d、（4±1）d，术中出血量20-150mL、（70±12）mL，术后均顺利康复出院。术后12例患者均获访，随访时间为1个月-5年，平均随访时间为36个月，未发现胆瘘或肠瘘复发者。结论腹腔镜探查有助于胆瘘或肠瘘的诊断，并可达到微创手术治疗的目的。     

食管癌和贲门癌术后胸内吻合口瘘诊治分析

目的 探讨食管癌及贲门癌术后胸内吻合口瘘的诊断及治疗方法.方法 分析我院2001年1 月至2010年12月2583例行食管癌、贲门癌术后发生胸内吻合口瘘19例患者的临床资料.结果 本组吻合口瘘发生率为0.74%,死亡率15.8%.确诊时间平均术后10d.接受手术治疗9例(治愈6例),保守治疗10例(治愈8例).手术治疗组平均住院时间79.4d,保守治疗组为70.5 d.手术治疗组与保守治疗组在治愈率和平均住院时间方面差异均无统计学意义(P=0.09,P=0.63).结论胸内吻合口瘘有较高死亡率.一旦确诊或高度怀疑吻合口瘘发生,应积极根据患者情况个体化选择合理的治疗方法.无论是手术治疗还是保守治疗,充分引流、有效冲洗和营养支持治疗均很重要.     

首次发作原发自发性气胸的治疗方案探讨

目的：探讨首次发作的原发自发性气胸最佳治疗方案。方法分析我院2008年1月－2011年1月期间首次发作的原发自发性气胸患者76例,其中保守治疗组共42例,VATS 手术组共34例。比较二组患者临床特征及治疗的指标。结果二组患者中性别、年龄、气胸部位及吸烟均无统计学差异,保守治疗无效而行 VATS 手术者14例（33．3％）,其中肺部持续漏气9例（21．4％）,肺膨胀不全5例（11．9％）。VATS 组气胸的范围（56．91±15．52）％,与保守治疗组（48．57±19．36）％比较差异有统计学意义（P ＝0．045）。VATS 组无中转开胸,二组中均未出现肺炎、脓胸、血胸等并发症。行 VATS 手术患者,术中发现明确肺大疱共30例（88．2％）,VATS 组与保守治疗组在止痛药的应用时间[（3．35±0．65）d vs （1．04±0．89）d,P ＜0．05]及拔除胸引管的时间[（4．82±0．58）d vs （4．09±0．76）d,P ＜0．05]方面比较差异有统计学意义。经过平均28．4个月的随访, VATS 组与保守治疗组气胸的复发[1例（2．9％）vs 16例（38．1％）,P ＜0．05]。平均住院日期 VATS组与保守治疗组[（7．74±0．86）d vs （5．29±1．04）d,P ＜0．05]。结论与保守治疗相比,VATS 能明显降低首次发作的自发性气胸复发率,在特定的患者中,该术式值得推荐。     

III型胆石性胰腺炎治疗过程中的护理配合

目的 探讨III型胆石性胰腺炎治疗过程中的护理配合策略。方法 回顾性分析温州医科大学附属第一医院2006年1月至2016年12月期间收治的59例III型胆石性胰腺炎患者的临床资料。患者分为两组。早期手术组（n=29）：行早期手术解除胆道梗阻,其中行ERCP+EST 17例,开腹或腔镜下手术12例;结合护理配合策略包括胰腺炎常规护理操作+充分的术前准备+完备的术后护理。保守治疗组（n=30）：行传统保守治疗,包括禁食、抑酸、抑酶、补液等;护理策略仅行胰腺炎的常规护理操作。比较两组患者的基线资料、护理满意度、住院时间、住院费用、并发症发生率、病死率等指标。结果 两组患者的护理满意度无统计学差异[93.10%（27/29）vs 83.33%（25/30）,P=0.449];早期手术组的住院时间短于保守治疗组[（14.48±7.01）d vs（22.80±15.58）d,P=0.011];两组患者的住院费用无统计学差异[（54 969.22±10 844.51）元 vs（88 210.55±14 838.98）元,P=0.076];早期手术组的局部并发症发生率明显低于保守治疗组[0 vs 20%（6/30）,P=0.035];早期手术组死亡1例,保守治疗组死亡4例,两组差异无统计学意义[3.45%（1/29）vs 13.33%（4/30）,P=0.449]。结论 III型胆石性胰腺炎应采取手术或ERCP+EST的方法早期解除胆道梗阻;相应地,其护理配合策略除做好常规护理外,还应尽早进行充分术前准备,并做好完备的术后护理。     

创伤性连枷胸保守治疗与手术治疗的效果比较

目的 比较手术内固定治疗与保守治疗在治疗创伤性连枷胸患者中的疗效.方法回顾性分析2005年5月至2010年5月我院收治的90例创伤性连枷胸患者的临床资料,比较手术治疗组（手术内固定治疗,52例）和保守治疗组（非手术外固定治疗,38例）患者的临床疗效.结果 （1）手术治疗组与保守治疗组损伤严重程度评分值分别为（26.7±6.7）、（29.8±8.6）,双侧肋骨骨折数分别为（10.9±3.4）、（10.1±2.1）,差异无统计学意义（P〉0.05）.（2）手术治疗组患者平均住院时间、平均ICU时间和平均机械通气时间均显著短于非手术组（P〈0.05 ）.（3）呼吸系统并发症及胸廓畸形发生率手术治疗组显著低于保守治疗组（15.4% vs 78.9%,3.8% vs 92.1%）（P〈0.01）.（4）术后3个月后用力肺活量、第一秒肺活量、最大通气量肺功能值手术治疗组较保守治疗组有明显改善,差异有统计学意义（P〈0.05）.结论对于创伤性连枷胸手术可迅速稳定胸壁、减少连枷胸引起的并发症,改善连枷胸对呼吸功能的影响,明显优于保守治疗组.     

术后早期肠梗阻的诊断和治疗 （附23例临床分析）

目的　探讨术后早期肠梗阻的诊断及治疗原则。方法　分析 2 3例术后早期肠梗阻临床特点及治疗方法。结果　 2 3例术后早期肠梗阻中 2 0例为早期炎性肠梗阻 ,18例肠梗阻发生时间在术后 1周内。腹胀 ,肛门停止排气、排便为主要症状 ,腹痛相对较轻。有 5例手术治疗 ,其中 3例为肠扭转 ,内疝等机械性因素所致 ,手术治愈 ;2例为早期炎性肠梗阻 ,术后再次发生炎性肠梗阻。术后早期炎性肠梗阻行保守治疗者 ,缓解时间为 4～ 2 6d ,平均为 11.2d。结论　术后早期机械性肠梗阻中约有 10 %为肠扭转 ,内疝等所致 ,诊断明确后应尽快手术 ,有 90 %为早期炎性肠梗阻 ,应先行 2～ 4周保守治疗 ,过期无缓解再行手术 ,这样可避免不必要的手术并减少术后并发症。     

阑尾脓肿Ⅰ期手术治疗与保守治疗的临床疗效比较分析

目的通过分别对阑尾脓肿行Ⅰ期手术治疗和保守治疗,比较两种方法的临床效果。方法选择2010年6月至2014年4月在本院就诊的阑尾脓肿患者164例,按照手术方法不同分为手术组和非手术组,平均每组82例。手术组患者行Ⅰ期手术切除治疗,非手术组患者行抗生素药物及彩超定位下经皮穿刺腹腔脓液治疗。通过随访比较两组患者住院时间、阑尾脓肿治愈率、并发症发生情况进行比较分析。结果所有患者均行随访,随访时间12-36个月,平均23.68±5.27个月。手术组82例住院期间全部治愈,治愈率100%。住院时间6-13天,平均（10.43±1.29）天。术后1个月内并发症发生情况,3例切口感染,2例发生黏连性肠梗阻,3例发生阑尾残株炎,没有患者发生粪瘘、肠漏、弥漫性腹膜炎等并发症。非手术组患者住院时间9-21天,平均（14.53±3.41）天。67例患者治愈,术后1个月内5例并发化脓性门静脉炎,4例并发盆腔脓肿,4例并发膈下脓肿,5例并发粘连性肠梗阻,3例患者并发粪瘘或肠漏。15例经再次保守治疗后,9例患者并发症无改善并行手术治疗。随访期间无患者死亡,并发症患者经再次治疗后无再发生。手术组并发症发生率为9.76%;非手术组并发症发生率为25.61%。手术组患者住院时间、住院费用、治愈率、并发症发生率明显低于非手术组。结论对于阑尾脓肿行Ⅰ期手术治疗效果较好,优势显著,值得临床广泛推广应用,提高阑尾脓肿患者的生活质量。     

Alternative surgical treatment for complex enterocutaneous fistula.

A retrospective analysis on the clinical-surgical handling of patients with enterocutaneous fistula (ECF) was performed, where an alternative surgical technique was discussed: intestinal bypass. Fistula with draining over 500 ml/24 h, which were present in 13 patients, were classified as high debit. We defined as complex, the fistula with multiple orifices, high defect of the abdominal wall or through the mesh. The population studied consisted of 25 patients, 11 male, in a total of 34 ECF and mean age of 41.9 years. At clinical treatment with TPN for high debit ECF, 2 patients (16.6%) were cured, another 2 died and 8 (66.8%) needed surgical treatment. The surgery cured 7 patients (77.7%) with high debit ECF but 2 (22.3%) died. In the patients with low debit ECF, TPN cured 2 patients (40%) but failed in another 3 (60%). All patients with low debit ECF resolved with surgical treatment.     

Management of enterocutaneous fistulae: A 10 years experience

AIM: To compare the outcomes of conservative vs surgical treatment of enterocutaneous fistulae (ECF) in a community teaching hospital over a decade.METHODS: All cases of ECF between 1997 and 2007 were reviewed for management strategy.RESULTS: Of the 83 patients with ECF, 60 (72%) were postoperative. Sixty-six patients (79.5%) were treated initially with conservative measures. Eighteen patients failed to respond to conservative treatment and required later (secondary) exploration; this group consisted of an equal number of low vs high output fistulae. Seventeen (20.5%) patients underwent initial (primary) definitive-surgery secondary to anastomotic leak and peritonitis. Surgical procedures included resection of ECF with anastomosis (24), exclusion (6) and direct-drainage (4). No significant difference was seen in the recurrence rate for conservative (10%) vs operative-treatment (20%).CONCLUSION: Conservative treatment plays a pivotal role as an initial management in both low and high output fistulae. In selective cases only, early primary exploration is recommended.     

Factors Predictive of Recurrence and Mortality after Surgical Repair of Enterocutaneous Fistula

Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17–81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.     

围手术期化疗加外科手术治疗晚期胃癌

目的 探讨围手术期化疗加外科手术治疗晚期胃癌的效果.方法 2006年3月到2009年9月共24例晚期胃癌患者入组,其中ⅣM0期14例,Ⅳ M1期10例;其中包括肝转移5例,腹膜种植转移4例,肺转移1例.予紫杉醇+顺铂+5-氟尿嘧啶(PCF)或表阿霉素+顺铂+5-氟尿嘧啶(ECF)方案化疗2～4疗程,然后手术治疗,手术后继续术前方案化疗2～4疗程.结果 本组中7例未进行手术治疗,其中4例因疾病进展放弃手术,另外3例因其他原因自动放弃手术治疗;17例进行手术治疗,其中16例达到R0切除,R0切除率为94%;完成术前化疗的病例中总临床反应率为75%,病理总反应率为82%;59%(10例)患者血清CEA和CA199水平恢复至正常;71%(12/17)病例术后病理分期明显下降;患者Ⅲ～Ⅳ级粒细胞减少、血小板减少、贫血的发生率分别为79%、8%、13%,2例Ⅲ～Ⅳ级粒细胞减少伴发热,Ⅲ～Ⅳ级恶心、呕吐发生率为54%;无治疗相关的死亡病例.结论 对部分晚期胃癌可考虑行术前化疗及有计划的外科手术治疗.     

全胸腔镜单向式肺叶切除在Ⅰ／Ⅱ期非小细胞肺癌治疗中的临床应用

目的探讨完全胸腔镜单向式肺叶切除＋淋巴结清扫术在I／Ⅱ期非小细胞肺癌切除中的优越性及临床应用价值。方法选取2010年3月至2011年6月140例胸外科I、Ⅱ期非小细胞肺癌患者进行回顾性研究。电视辅助胸腔镜手术（VATS）组：70例采用不撑开肋骨,完全在电视胸腔镜下完成单向式肺叶切除＋淋巴结清扫术,其中左肺上叶15例,下叶18例;右肺上叶10例,中叶10例,下叶17例。术后病理：鳞癌29例,腺癌41例。常规开胸（对照）组：70例采用常规后外侧切口进胸,行肺叶切除术＋淋巴结清扫,其中左肺上叶14例,下叶20例;右肺上叶10例,中叶11例,下叶15例。术后病理：鳞癌30例,腺癌40例。观察两种手术方式的切口长度、手术时间、术中出血量、胸腔引流管留置时间、术后胸腔总引流量、切除淋巴结的数目、术后住院时间。结果VATS组手术时间85—200min,平均131．9min;手术出血量10—300ml,平均98．4ml;切除淋巴结5—31枚,平均17．4枚;胸腔引流管引流时间3～20d,平均6．0d;术后总引流量220～4710ml,平均1417．8ml;术后住院天数为7。17d,平均11．2d。常规开胸手术组手术时间106～210min,平均162．1min;手术出血量80～500ml,平均178．9ml;切除淋巴结10～22枚,平均17．0枚;胸腔引流管留置时间4—14d,平均7．2d;术后总引流量910～3500ml,平均1620．4ml;术后住院时间9—26d,平均为14．6d。结论全胸腔镜单向式肺叶切除术对于可切除的Ⅰ／Ⅱ期非小细胞肺癌的治疗是一种安全、可行的手术方式,此术式能减少术中出血量,缩短术后胸腔引流时间及平均住院时间,且不增加术后并发症的发生率,能够完成纵隔及肺门淋巴结的清扫,值得在临床上推广应用。     

低出生体重儿及早产儿心脏手术的早期疗效分析

目的分析60例先天性心脏病(先心病)低出生体重儿(low birth weight infant)和早产儿行外科手术治疗的早期疗效。方法回顾性分析自2003年5月至2011年10月广东省心血管病研究所60例患先天性心脏病的低出生体重儿(体重2 500 g)和早产儿施行心脏手术治疗的临床资料,其中男43例,女17例;年龄4～55(24.9±12.5)d;孕周26～42(33.5±4.1)周,其中47例为早产儿;出生时体重640～2 500(1 729.3±522.5)g,手术时体重650～2 712(1 953.2±463.6)g。术前所有患者均在新生儿重症监护病房(NICU)接受治疗,在全身麻醉下行先心病矫治手术,其中行非体外循环手术29例,体外循环手术31例。术后住NICU进行监护治疗,并观察并发症发生情况和死亡情况。结果住院期间共死亡13例,总病死率为21.7%(13/60)。其中术中死亡4例,术后早期(72 h内)死亡6例,放弃治疗3例。体外循环时间(121.0±74.7)min,升主动脉阻断时间(74.8±44.7)min,术后呼吸机辅助呼吸时间(136.9±138.1)h。术后延期关胸13例,床旁开胸探查止血8例,发生重症肺炎10例,肺动脉高压危象2例,低心排血量综合征8例,均经相应的治疗治愈或好转。随访47例,随访时间2～12个月,患者均生存。结论对危重先心病低出生体重儿或早产儿早期施行外科手术治疗是安全、有效的。     

Effect of essential amino acid supplementation in acute renal failure

The effect of intravenous (i.v.) essential amino acids (EAA) in the treatment of acute renal failure was evaluated in 50 patients. Thirty patients (Group A) received daily 13.4 g of i.v. EAA solution [Nephramine^® (Don Baxter, McGraw) 250 ml/d]+dopamine i.v. 2 μg/kg/min+20% hypertonic glucose solution 500 ml/d as dompared with twenty patients (Group B) who received dopamine i. v. 2 μg/kg/min+20% hypertonic glucose solution 500 ml/d. In Group A patients showed lower daily increase in blood urea nitrogen (BUN) (p<0.05), higher serum total protein and albumin levels on the 15th day of the posttherapy period (p<0.001), lower complication rate (p<0.005), lower mortality rate (p<0.005) and a reverse relation between serum total protein concentration, duration of oliguria and age (p<0.01, r²=0.26; p<0.001, r²=0.32). These data suggest that treatment of such patients with i.v. EAA solutions significantly improves survival.     

Management of enterocutaneous fistulas using negative-pressure dressings

Fifteen patients with enterocutaneous fistulas (ECFs) not amenable to surgical treatment were treated with negative-pressure dressings over the abdominal wound and ECF. Closure of the ECF and time to closure were examined. In 11 patients who had no visible intestinal mucosa on examination, the closure rate was 100%, with a mean time to closure of 14 days. In 4 patients who did have grossly visible intestinal mucosa, no closure occurred. This represents an overall closure rate of 73%. Fistula output rate did not have a significant effect on outcome. These results confirm the efficacy of negative-pressure dressings in the closure of ECFs. Presence or absence of visible intestinal mucosa is the single most important clinical factor when considering the use of a negative-pressure dressing in the management of a patient with ECF.     

不同手术方案在高危前列腺增生患者中的疗效对比

【摘要】 目的 总结探讨经尿道前列腺剜除术(TUEP)在治疗高危良性前列腺增生症患者的经验,探讨其优势并比较经尿道前列腺电切术(TURP)的临床效果。方法〓选取2012年2月~2015年2月我科收治的高危良性前列腺增生症患者80例,根据手术方式分为TUEP组、TURP组,每组各40例,观察两组患者疗效及并发症发生情况。结果〓TUEP组患者手术时间、术中失血量、术后留置导尿管时间与TURP组相比显著减少(55.4±6.8 min vs 72.5±7.2 min,195.4±17.3 mL vs 253.7±26.8 mL,5.2±1.4 d vs 7.3±2.1 d),前列腺切除重量显著大于TURP组(69.4±4.2 g vs 55.4±3.7 g),差异具有统计学意义(P<0.05);术后两组患者IPSS、Qmax、PV较术前均有显著改善,差异具有统计学意义(所有P<0.05);组间比较,TUEP组IPSS、Qmax、PV指标改善较TURP组更为显著(5.4±1.2 vs 8.9±2.0,22.7±2.3 mL/s vs 17.9±1.8 mL/s,10.3±2.1 mL vs 16.7±2.3 mL),差异具有统计学意义(所有P<0.05);TUEP组患者尿失禁、继发出血等并发症发生情况也显著低于TURP组(5.0% vs 17.5%,2.5% vs 15.0%),差异具有统计学意义(所有P<0.05)。结论〓与传统TURP相比,采取TUEP治疗高危良性前列腺增生症患者,可获得更好的优势,符合相关文献报道。     

Interactions of preoperative erythromycin administration with general anaesthesia

Previous reports have demonstrated a gastric emptying effect of erythromycin due to a motilin-like mechanism. We studied 50 patients, scheduled for daycase laparoscopy, randomly assigned to one of two groups: Group P patients received 30 min before induction of anaesthesia, in a double-blind manner an infusion of 250 ml dextrose 5% while patients in Group E (n = 25) received 500 mg of erythromycin diluted in 250 ml dextrose 5%. An orogastric tube was inserted to measure both gastric pH using a pHmeter and residual gastric volume (RG V) using the phenol red dilutional technique. Six patients were excluded for surgical reasons. More patients in Group P (6/22) than in Group E (0/22) had RGV > 25 ml and more patients in Group P (17/22) presented with a gastric pH < 2.5 than in Group E (5/22), P < 0.05. Since coma and respiratory depression have been reported recently after midazolam and alfentanil administration in patients having received erythromycin, recovery conditions were assessed and were found to be comparable between groups. In conclusion, the administration of iv erythromycin before outpatient laparoscopy decreased residual gastric volume and increased gastric pH without affecting recovery from general anaesthesia.