全肺切除术后并发症的预防与护理

目的探讨全肺切除术后并发症的预防与护理方法。方法对32例原发性肺癌行全肺切除术患者,术前、术中采取积极有效措施预防心律失常、血胸、急性肺水肿、支气管胸膜瘘、呼吸衰竭等并发症;术后密切观察病情变化,采取针对性措施,杜绝并发症发生。结果患者均顺利完成手术,术后发生心律失常1例,血胸3例,急性肺水肿2例,支气管胸膜瘘1例;并发症发生率为21.9%,均治愈。结论有效预防和精心护理可防止原发性支气管肺癌全肺切除术后并发症发生,提高手术效果。     

全肺切除术后并发症的预防与护理

目的 探讨全肺切除术后并发症的预防与护理方法.方法 对32例原发性肺癌行全肺切除术患者,术前、术中采取积极有效措施预防心律失常、血胸、急性肺水肿、支气管胸膜瘘、呼吸衰竭等并发症;术后密切观察病情变化,采取针对性措施,杜绝并发症发生.结果 患者均顺利完成手术,术后发生心律失常1例,血胸3例,急性肺水肿2例,支气管胸膜瘘1例;并发症发生率为21.9%,均治愈.结论 有效预防和精心护理可防止原发性支气管肺癌全肺切除术后并发症发生,提高手术效果.     

原发性主动脉消化道瘘并出血(附9例报告)

目的为提高临床罕见的、死亡率高的主动脉消化道瘘的诊治水平和术后存活率。方法报告主动脉消化道瘘9例,作回顾性临床分析,并结合文献对该病的流行病学特征、临床诊治进行探讨。结果主动脉消化道瘘发生率占同期收治消化道出血的0.072%(9/12431),占同期胸腹主动脉瘤的3.4%(9/262)。9例均有“herald”出血特征和腹部搏动性包块,6例出现腹痛,所有特殊检查未能诊断主动脉消化道瘘。9例中7例死亡,2例存活。3例经主动脉瘤及肠瘘手术,其中原位人工血管置换术2例存活。结论临床对具有“herald”出血、腹痛、腹部搏动性包块三联征,影像学检查患有胸腹主动脉瘤者,应高度怀疑主动脉消化道瘘可能。迅速积极的手术是抢救生命唯一有效的治疗方法。主动脉瘤切除,原位人工血管置换,肠瘘封闭是可取的手术方式。     

Whipple手术死亡原因分析

目的分析Whipple手术死亡原因,探讨降低手术病死率的方法和手段.方法回顾1980年初至1999年底20年间425例Whipple手术,对其中28例手术死亡病例的术前高危因素、术中情况、术后处理等因素进行分析探讨,提出防治严重并发症发生的方法.结果425例手术中共死亡28例,手术病死率6.6%.死亡的28例中,男性16例,女性12例;年龄30～81岁;良性病变4例,恶性病变24例;术前24例患者合并有高危因素,其中合并二种以上高危因素的20例(71%);专业手术组手术病死率4.8%(16/331),非专业手术组手术病死率12.8%(12/94);手术时间4.5～17.0 h,平均(7.8+2.6)h;术中出血量800～12 000 ml(2 330±2 220)m1;术后严重并发症中,手术并发症包括消化道瘘、消化道出血、腹腔出血、腹腔严重感染等;非手术并发症包括心、肺、肝、肾等重要脏器功能衰竭以及严重代谢障碍等.19例患者因手术并发症而直接导致死亡,其中消化道瘘9例、腹腔出血4例、消化道出血3例、腹腔严重感染3例;9例患者由于非手术并发症死亡.结论Whipple手术死亡率受多方面因素影响;手术的专业化、规范化,术前重要脏器功能的合理评估,减少手术并发症的发生,提高严重并发症的处理水平,对降低手术病死率至关重要.     

原发性主动脉消化道瘘并出血（附9例报告）

目的 为提高临床罕见的、死亡率高的主动脉消化道瘘的诊治水平和术后存活率。方法 报告主动脉消化道瘘9例，作回顾性临床分析，并结合献对该病的流行病学特征、临床诊治进行探讨。结果 主动脉消化道痿发生率占同期收治消化道出血的0．072％(9／12431)，占同期胸腹主动脉瘤的3．4％(9／262)。9例均有“herald'’出血特征和腹部搏动性包块，6例出现腹痛，所有特殊检查未能诊断主动脉消化道瘘。9例中7例死亡，2例存活。3例经主动脉瘤及肠瘘手术，其中原位人工血管置换术2例存活。结论 临床对具有“herald”出血、腹痛、腹部搏动性包块三联征，影像学检查患有胸腹主动脉瘤，应高度怀疑主动脉消化道痿可能。迅速积极的手术是抢救生命唯一有效的治疗方法。主动脉瘤切除，原位人工血管置换，肠瘘封闭是可取的手术方式。     

动静脉内瘘手术患者的护理体会

目的总结动静脉内瘘手术患者的术前及术后护理措施及体会。方法分析50例尿毒症患者前臂自体动静脉内瘘手术的临床资料。术前及术后对患者实施相应的护理干预,观察患者术后的手术成功率及并发症情况。结果患者手术全部成功,无严重并发症发生。结论对动静脉内瘘手术患者实施正确的术前、术后护理干预,可提高手术成功率和降低术后并发症的发生。     

胸主动脉瘤不同手术方式的护理配合

对11例实施不同手术的胸主动脉瘤患者给予充分的术前准备和科学的术中护理.结果11例中1例因术后渗血不止死亡,其余手术均取得满意效果.胸主动脉瘤手术复杂,危险性高,术前充分的心理和物质准备是手术成功的基础,术中的医护默契配合是手术成功的重要环节.     

胸主动脉瘤不同手术方式的护理配合

对11例实施不同手术的胸主动脉瘤患者给予充分的术前准备和科学的术中护理。结果11例中1例因术后渗血不止死亡，其余手术均取得满意效果。胸主动脉瘤手术复杂，危险性高，术前充分的心理和物质准备是手术成功的基础，术中的医护默契配合是手术成功的重要环节。     

腹腔镜下胰体尾部切除术并发胰瘘的护理体会

目的探讨腹腔镜下胰体尾部切除术并发胰瘘患者的护理措施。方法对4例腹腔镜下胰体尾部切除并发胰瘘的患者进行常规病情观察、用药护理、引流管护理、营养护理、基础和心理护理等。结果本组患者术后2~3月胰瘘治愈,无出血、多器官功能衰竭等严重并发症发生,无病例死亡。结论良好的术后护理能明显改善腹腔镜下胰体尾部切除术后并发胰瘘患者的预后,提高手术效果。     

僵硬性脊柱侧凸的护理

[目的]总结9例僵硬性脊柱侧凸的护理。[方法]对9例患者进行术前心理护理，肺功能训练轴向翻身及术后体位护理、病情观察、指导饮食和功能锻炼等综合护理。[结果]9例患者术前术后疗效满意，无1例因护理不当出现并发症。[结论]通过术前术后的精心护理，保证了手术的成功，实现了病人的满意。     

Improved outcomes in the recent management of secondary aortoenteric fistula

OBJECTIVE: We reviewed the presentation, management, and late events in a recent experience with aortic graft-enteric communications (secondary aortoenteric fistula) to identify variables associated with poor outcomes. METHODS: Since 1991, 29 patients (19 men, 10 women; mean age, 70) presented with a secondary aortoenteric fistula. The duration from aortic graft implantation to aortoenteric fistula development ranged from 8 months to 180 months (mean, 47 months). Presenting symptoms included gastrointestinal bleeding (n = 25), sepsis and retroperitoneal abscess (n = 3), and ruptured para-anastomotic aneurysm (n = 1). One third (10/29) of patients were hypotensive at presentation. Repair was accomplished by graft excision with axillobifemoral bypass (17 simultaneous, 8 staged), graft excision with in situ deep vein replacement (n = 2), or graft excision with rifampin-treated prosthetic replacement (n = 2). Mean follow-up was 51 months, and the incidence of late events was reported by life table methods. RESULTS: The operative (< or = 30-day) mortality rate was 21%, with shock at presentation (P < .01), the need for preoperative transfusion (P < .01), and use of suprarenal aortic clamping during aortoenteric fistula repair (P = .03) associated with lethal outcome. Cumulative mortality related to aortoenteric fistula management was only 24% within an overall 5-year survival rate of 61%. Freedom from recurrent infection or amputation was 86% and 88% at 5 years, respectively, and assisted graft patency was 79%. Presence of staphylococcal species in 22% of patients and occasional operative findings of adjacent perigraft "biofilm" suggests that underlying indolent graft infection may contribute to the development of aortoenteric fistula in some cases. CONCLUSION: Outcomes associated with aortoenteric fistula repair were surprisingly favorable in the absence of preoperative hemodynamic instability.     

腹主动脉重建后肠出血的诊断和治疗

目的探讨腹主动脉重建后肠出血的诊断和治疗方法。方法回顾分析6例患者的临床资料，总结其病因、临床表现、影像学资料、诊断和手术中的情况。结果6例均在全身麻醉下剖腹探查，术中见均为腹主动脉一小肠瘘所致肠出血。在瘘口上下方阻断主动脉，控制出血后行动脉瘘口修复、肠瘘口周围小肠部分切除术。1例术后11d死于多器官功能衰竭；5例获得临床治愈。随访1～10年，1例手术后1年死于脑出血，1例肿瘤复发再次术后1年5个月死于急性心肌梗塞，余3例随访5年以上均健康存活。结论主动脉重建后消化道出血的原因均为主动脉-肠瘘，结合影像学检查可得出正确诊断，手术修复主动脉和肠道瘘口是治疗该病可靠的治疗方法。     

Aortoenteric fistula. A 7 year urban experience

In this 7 year review of the operative records of a single city's teaching hospitals, we found 28 patients with aortoenteric fistulas. Among 25 patients with secondary aortoenteric fistulas, 80 percent presented with a herald bleed. Sepsis was rare. Most diagnostic maneuvers, with the possible exception of upper gastrointestinal tract endoscopy, computerized axial tomography, or ultrasonography, were unhelpful. As noted by others, graft excision, aortic ligature, and extraanatomic bypass is the only predictably useful operative therapy. Initial hospital survival was 60 percent, but this decreased to 36 percent because recurrent aortic complications developed in more than half the initial survivors, 75 percent of whom died. Although the pathogenesis of aortoenteric fistulas remains obscure, our study demonstrates that patients who have previously undergone complicated, repeated, or emergency aortic operations, including previous repair of an aortoenteric fistula, are at high risk for the development of another aortoenteric fistula. Serial screening by noninvasive imaging techniques, such as ultrasonography or computerized axial tomography, may be warranted in these patients.     

Primary aortoduodenal fistula including the afferent loop of a Billroth II anastomosis. A case report

Primary aortoenteric fistula is a very rare consequence of the evolution of an abdominal aortic aneurysm (AAA). The 3rd and 4th portion of the duodenum are involved in up to 80% of all cases. Frequently, gastrointestinal bleeding represents the first symptom, and diagnosis is difficult because of the aspecific clinical presentation and course, characterized by alternating remission and relapse; this is the reason why surgical treatment is usually delayed and therefore such events are managed as emergencies with a preoperative and intraoperative high death rate. We report the case of a 76-year-old man with a primary aortoduodenal fistula, who was submitted to gastric resection according to Billroth II 20 years before. This case could be interesting for its anatomical peculiarities favourable to the formation of the fistula.     

Aortic sepsis: is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.     

In Situ Repair of a Secondary Aortoappendiceal Fistula with a Rifampin-Bonded Dacron Graft

Secondary aortoenteric fistulas remain challenging diagnostic and therapeutic problems. Although the duodenum is most frequently involved, other intestinal segments are possible sites for fistulization. We report here a case of graft-appendiceal fistula revealed by recurrent gastrointestinal bleeding 11 years after abdominal aortic aneurysm replacement. The preoperative diagnosis was not achieved by endoscopy or imaging assessment. Despite recommended principles of total graft excision and extraanatomic bypass, appendectomy and in situ rifampin-bonded graft reconstruction were performed because of the advanced age and poor arterial runoff. The postoperative course was uneventful and the patient remains well 17 months after operation.     

基层医院肝切除治疗原发性肝癌35例分析

目的探讨肝切除治疗原发性肝癌的临床疗效。方法回顾性分析我院2003年4月至2005年4月35例原发性肝癌的手术治疗及随诊情况。其中右半肝切除6例,左半肝切除16例,肝中叶切除3例,单纯肝肿瘤切除10例。结果术后病理证实为肝细胞癌30例,胆管细胞癌5例。术后出血4例,再次手术出血1例,胆瘘1例,手术死亡1例,术后住院死亡1例,半年内死亡2例,1年内死亡6例,25例存活至今。结论严格掌握原发性肝癌切除手术指征及肝切除量,减少术中出血,正确处理肝创面及降低术后并发症发生率,才能保证提高手术治疗的效果。     

Ⅲ型肝门部胆管癌的治疗策略及疗效分析

目的 探讨Ⅲ型肝门部胆管癌的治疗策略及效果.方法 回顾性分析解放军总医院2009年1月-12月收治的32例Ⅲ型肝门部胆管癌患者的临床资料,总结其手术情况及预后.结果 32例患者中,27例行手术切除治疗,5例行姑息性减黄治疗;10例联合门静脉受侵部分切除重建,4例联合门静脉及肝动脉切除重建.手术切除率为84.3％,根治性切除率达34.4％.6例术后出现胆瘘,4例出现胆瘘合并腹腔内感染,1例出现肠瘘,2例出现上消化道出血,1例术后出现腹腔出血,均经治疗后痊愈.无围手术期死亡病例.术后并发症发病率为43.7％.R0切除组患者术后1、3、5年生存率分别为81.8％、45.5％、27.3％;R1/R2切除组则分别为66.7％、14.3％、0.结论 对于Ⅲ型肝门部胆管癌,行联合半肝和（或）尾状叶,甚至联合肝门部血管切除重建的根治性手术,不会增加患者术后并发症发病率及围手术期病死率,可大大提高手术的根治性切除率及远期生存率.     

�������������������������

??Surgical treatment of aortoenteric fistula LIU Bing, HUANG Ren-ping. Department of Vascular Surgery, the First Affiliated Hospital of Harbin Medical University, Harbin 150001 , China
Corresponding author: HUANG Ren-ping,E-mail: cup521@163.com
Abstract An aortoenteric fistula (AEF) is a rare but life-threatening cause of gastrointestinal (GI) bleeding. Two major concerns for the treatment of AEF are bleeding control at the time of the initial presentation and the prevention of late complications associated with bleeding or infection. Immediate recognition and prompt surgical treatment are essential for reducing the risk of a massive GI hemorrhage. In order to reduce the incidence of postoperative infectious complications, the optimal surgical treatment should be chosen. The most appropriate surgical procedure may be selected based on the surgical findings, underlying cause of the AEF and patients’ status.     

32例Oddi括约肌成形术及其严重并发症分析

目的　探讨Oddi括约肌成形术临床疗效及其严重并发症的防治。方法　观察 32例十二指肠乳头良性狭窄行Oddi括约肌成形术患者术后并发症、临床症状改善情况。结果　 2 7例术后无任何并发症发生 ,除 1例长期慢性胰腺炎症状外 ,其余临床症状消失 ,有效率 81 .3 %。 5例 (1 5 % )并发症中 ,严重者 4例 ;急性胰腺炎 1例 ,十二指肠瘘 2例 ,十二指肠梗阻 1例 ,死亡 2例。另外 1例并发轻微上消化道出血 ,经保守治疗痊愈。结论　严格掌握Oddi括约肌成形术的手术适应证 ,其疗效良好 ;术中精细操作可以预防严重并发症发生 ;及早诊治并发症可减低死亡率