腹部大手术后早期肠内营养的免疫学研究

目的：研究早期肠内营养支持对腹部大手术患者对机体免疫的影响。方法：37例腹部大手术患者,术后第1天即由鼻肠管进行肠内营养支持（EN组）,同时取另外37例行肠外营养（PN）组的腹部大手术患者,对营养指标和体液免疫指标进行检测。结果：EN组患者均能良好耐受早期肠内营养支持,肠内营养开始后第15天的血红蛋白、清蛋白、转铁蛋白均比PN组升高（P〈0.05）,第15天IgG较PN组升高（P〈0.05）,第3天IgA较PN组下降（P〈0.05）,第15天IgA下降更明显（P〈0.05）,第15天IgM变化与PN组差异无统计学意义（P〉0.05）。结论：手术后早期肠内营养的施行能够明显改善患者腹部大手术后的营养状况,不损害机体的体液免疫机制,安全有效,是较理想的营养支持措施之一。     

腹部外科手术后肠内与肠外营养的选择

腹部外科患者因消化系统的病变多会影响机体对营养物质的吸收和代谢。术后由于创伤应激,机体产生一系列代谢改变,处于高分解代谢状态、合成代谢受限、免疫功能低下,加上早期胃肠道功能未能恢复,摄入热量及蛋白质量的不足,此时机体往往处于营养不良状态。如果得不到及时、足够的营养补充,就会出现不同程度的蛋白质消耗,影响手术创伤的愈合及术后恢复,严重者会对机体其他器官结构和功能产生影响,从而影响临床治疗效果。     

腹部手术后肠外瘘27例分析

总结近十年来收治腹部手术后肠外瘘患27例,经治疗后16例瘘口自愈,2例手术术后治愈。全组死亡5例,死亡率为18．52％。认为提高肠外瘘治疗效果,应去除原发病灶,控制感染源。强调早期进行有效的引流,重视对器官功能的监测与维护,对各种并发症的处理以及营养支持治疗（包括肠外营养和肠内营养）。对于瘘口不能自愈,应手术治疗。     

不同途径早期营养支持对腹部手术后代谢反应的影响

１７例腹部手术患者随机分为肠内（ＥＮ）和肠外（ＰＮ）营养二组。自术后第１天起，给予等氮等热卡的营养支持，连续８天。监测营养支持过程中体温、血浆蛋白、体重、氮平衡和与应激相关的激素变化。结果显示体温、血浆蛋白和体重变化两组间差异不明显，ＥＮ组术后第２天氮平衡明显优于ＰＮ组（３．２±２．６ｖｓ．－１．０±３．１ｇ，Ｐ＜０．０５），ＥＮ组累积氮平衡虽亦优于ＰＮ组，但差异不显著。ＥＮ组术后第３天和第９天血胰高血糖素明显高于ＰＮ组（１８３±５９ｖｓ．１０８±５０和１５８±７４ｖｓ．１００±１７ｐｇ／ｍｌ，Ｐ值均小于０．０５），但皮质醇和胰岛素水平在两组间无差异。说明早期肠内营养和肠外营养相比，并不能减轻腹部手术后的应激反应和蛋白质分解代谢。     

肠外,肠内阶段性营养支持在腹部外科的应用

肠外、肠内阶段性营养支持”（StagenutritionalsupportofPN、EN）是据疾病的不同阶段、胃肠功能状况和／或代谢特征，依次阶段性地施行肠外、肠内营养支持，其中主要指由TPN逐渐过渡为空肠喂养（Je－junalfeeding）的营养支持。这种营养支持方式在腹部外科具有广泛而重要的应用价值。具体地说，在腹部外科某些疾病或为其施行腹腔手术时，于空肠上段施行空肠营养造口备用。术后待病人全身状况稳定（约48～72h），开始施行TPN。一旦全身状况进一步稳定，胃肠功能恢复，肛门排气，及早地过渡为空肠喂养，直至病人能完全经口进食为止。其…     

老年病人腹部大手术后的营养支持

１７例６０岁以上腹部大手术的老年病人，沐中附加空肠营养造瘘，术后病情稳定先行肠外营养，肠道功能恢复即逐渐转为经空肠造瘘肠内营养。全组病人无死亡，术后体重稳定，术后一周达到基本氮平衡，白蛋白术后二周明显高于术前（Ｐ〈０．０５）。说明老年病人腹部大手术后由肠外营养逐渐过渡到经空肠造瘘喂饲肠内营养是一种简便易行、安全有效的营养支持方法。     

生长抑素对腹部手术后早期肠内营养支持影响的临床观察

目的 探讨各种腹部大、中型手术后早期肠内营养支持(Early Enteral Nutrition,EEN)与生长抑素(Somatostatin,SS)联合应用的效果与可行性.方法 将100例接受各种腹部大、中型择期手术的住院病人随机分为两组(n=50例),两组均于手术后6 h起给予相同方式的早期肠内营养支持,连续5～7 d,实验组同时应用生长抑素.对照组未予.比较两组病人手术后48 h腹痛腹胀的发生率、胃肠减压量以及手术后3 d、7 d血常规和肝肾功能及血糖、电解质等指标.结果 与对照组比较,实验组腹痛腹胀发生率(P=0.041)及胃肠减压量(P=0.001)降低,差异有统计学显著性.手术后3 d、7 d,两组间血常规、肝肾功能、血糖和电解质结果 比较差异无统计学显著性.结论 各种腹部大、中型手术后早期肠内营养支持与生长抑素联合应用是安全、合理、切实可行的围手术期治疗措施.     

手术后短期胃肠内、外营养支持效果比较

作者比较研究了手术后短期胃肠内、外营养支持的效果，探讨了不同途径营养支持的优缺点。将手术后患者２０例随机分为两组（每组各１０例）：胃肠内营养组（ＥＮ组）和胃肠外营养组（ＰＮ组）。术后第１天起两组分别接受等热卡营养支持１０天，ＥＮ组和ＰＮ组非蛋白质热卡／Ｎ分别为１２８：１和１３１：１。营养支持前后分别测体重；营养支持期间每日计算氮平衡；术前及营养支持３、７、１０天后分别测血清ＧＰＴ、直间接胆红素、ＡＫＰ、白蛋白水平；术前及营养支持５、１０天后分别测定血清总铁结合力（ＴＩＢＣ）水平。结果表明：ＰＮ组营养支持第五天达到正氮平衡，ＥＮ组第六天达到正氮平衡，但两组间累积氮平衡无统计学差异；营养支持１０天后ＰＮ组ＴＩＢＣ水平显著（ｐ＜０．０１）高于ＥＮ组；两组间其它指标无显著差异。结论是：两种营养方式对于手术后短期营养支持的效果均较满意，而以胃肠外营养支持更好；术后早期开始胃肠内营养可促进患者胃肠功能的恢复。     

应用重组人生长激素对肝胆胰外科患者术后氮平衡及营养状况的影响

目的　探讨肝胆胰外科患者术后联合使用重组人生长激素 (rhGH )和TPN对其氮平衡及营养状况的影响。方法　选择 45例接受肝胆胰大手术和完全胃肠外营养的患者 ,随机分为实验组 (rhGH TPN ,30例 )和对照组(TPN ,15例 ) ,分别于术后连续 7天 ,每天皮下注射重组人生长激素 4u或生理盐水 2ml。结果　术后氮平衡的恢复、血浆白蛋白和转铁蛋白水平的提高、体重和肌酐 /身高指数的增加及降低血尿素氮的作用 ,实验组明显优于对照组 (P <0 .0 1) ,但对肱三头肌皮皱厚度的改变两组间差异无统计学意义。结论　术后给予药理剂量的重组人生长激素能提高肝胆胰外科患者术后肠外营养的疗效。     

THE EFFECT OF RECOMBINANT GROWTH HORMONE ON NITROGEN BALANCE IN MALNOURISHED PATIENTS AFTER MAJOR ABDOMINAL SURGERY

The effect of recombinant growth hormone (rGH) on nitrogen balance was studied in malnourished patients receiving total parenteral nutrition after major abdominal surgery. Fifteen patients were randomized to receive either subcutaneous rGH (0.2 iu/kg) or placebo (saline) injection daily for seven days after surgery. Positive nitrogen balance was achieved throughout the treatment period with rGH administration and was significant on days 3 and 6. This was associated with increase in mid-arm muscle circumference and significant weight gain. Plasma insulin-like growth factor-1 (IGF-1) concentration was significantly raised in the rGH group at day 7, suggesting its role in the anabolic effect of growth hormone. Plasma pre-albumin and retinol-binding protein concentrations were raised in both the rGH and control groups, indicating improvement in the nutritional status. We conclude that the postoperative catabolic response can be attenuated using recombinant growth hormone.     

QUALITY OF LIFE AFTER EMERGENCY ABDOMINAL AORTIC ANEURYSM REPAIR

Background : Quality of life issues following surgical procedures, especially those with high mortality, should be of prime importance. There have been few studies on the quality of life of patients following emergency abdominal aortic aneurysm repairs. The decision to continue to offer surgery to these patients, especially with present monetary constraints, should rely heavily on quality of life issues. Audits of major surgical procedures should be undertaken and quality of life included. Methods : All patients in the Hawkes Bay area who had undergone emergency abdominal aortic aneurysm repairs since 1981 were identified and their quality of life assessed by means of the short form-36 (SF-36) questionnaire. Results : One hundred and fifteen patients were identified as having had an abdominal aortic aneurysm repaired as an emergency. Sixty patients died peri-operatively and 19 subsequently. There were 28 patients available to complete the questionnaire, of whom 75% rated their global quality of life as good to excellent. Using the SF-36 questionnaire, there was no statistically significant difference between those patients who had undergone surgery (whether proven leak or not) and the age-matched healthy population. Conclusions : Quality of life remains good to excellent in the majority of patients following emergency abdominal aortic aneurysm repairs. This may help justify surgery being offered to patients with this condition. Quality of life should be considered as an important outcome rather than mortality only.     

腹部择期手术前后电解质变化及术后早期补钾对胃肠功能的影响

为观察腹部择期手术前后电解质变化及早期补钾对胃肠功能恢复的影响,对６９例患者术前和术后电解质水平进行了测定,并观察了术后不同时间补钾者的胃肠功能恢复情况。结果：术后血Ｋ＋、Ｎａ＋、Ｃｌ－水平均较术前有明显降低（Ｐ＜０．０５）,但仍在正常值范围,而血Ｃａ２＋及血Ｍｇ２＋手术前后无显著变化;术中输血量与血Ｋ＋变化无明显相关性;术后早期补钾者胃肠功能恢复快。本组资料结果提示：只要肾功能正常,术中输血不会引起高血钾,因此术后第１天可开始见尿补钾     

AUSTRALIAN NATIONAL DIAGNOSIS RELATED GROUPS AND ABDOMINAL SURGERY

This study compares the declared splits for abdominal surgery within the Australian National Diagnosis Related Groups (AN-DRG) with age-based strata. Data were derived from two clinical trials involving 2114 adults. The patients tended to be elderly (25% > 71 years) and had significant co-morbidity, that is, 57% with an American Society of Anesthesia (ASA) classification > 1. Adverse events after surgery included pulmonary complications (16%), urinary tract infections (10%), wound infection (6%), and death (4.5%). Only 27% of the patients could be classified into a ‘non-complicated’ AN-DRG partition; these patients had a median age of 25 years and 88% had either appendicectomy or cholecystectomy. In contrast, analysis of six age-based strata revealed a stepwise increase in the incidence of adverse events after surgery (Friedman anova P < 0.001). It might therefore be wise to consider the inclusion of age-strata in the abdominal surgery component of the AN-DRG. Failure to do so may result in financial penalties for hospitals that care for patients at high risk of an adverse outcome after abdominal surgery.     

不同切口人工膝关节置换术后的早期并发症比较

目的 比较小切口与常规切口人工膝关节置换术(total knee arthroplasty,TKA)术后早期并发症,评估小切口技术在TKA中的应用价值.方法 2004年5月-2005年7月,对38例(46膝)患者行小切口TKA(小切口组),同期对43例(54膝)患者行常规切口TKA(常规切口组).小切口组:男12例12膝,女26例34膝;年龄52～76岁.骨性关节炎24例28膝,类风湿性关节炎14例18膝.膝内翻30例34膝,膝外翻8例12膝.根据美国膝关节协会评分标准(American Knee Socitety Score,AKSS)评分为(37.5±12.6)分.病程(7.5±2.3)年.常规切口组;男15例19膝,女28例35膝;年龄55～82岁.骨性关节炎32例37膝,类风湿性关节炎11例17膝.膝内翻34例41膝,膝外翻9例13膝.AKSS评分为(31.1±10.2)分.病程(10.1±4.2)年.两组一般资料差异无统计学意义(P>0.05).结果 小切口组切口长度、手术时间及术后引流量分别为(12.6±1.2)cm、(95±15)min、(650.1±10.0)mL;常规切口组分别为(18.7±2.3)cm、(63±11)min、(300.0±20.0)mL:两组比较差异均有统计学意义(P<0.05).小切口组术后出现早期及晚期关节感染各2例2膝,均经对症处理后愈合:术后第3天出现1例下肢深静脉栓塞,经溶栓治疗后愈合:术后第7天和第9天分别出现1例皮缘部分坏死,采用局部换药后愈合;术后12个月1例因摔跤导致股骨髀上骨折,但假体稳定,行钢板内固定术后骨折临床愈合.常规切口组中术后第10天1例1膝出现关节感染,对症治疗后愈合;无术后骨折、皮缘坏死、下肢深静脉血栓等并发症发生.术后患者均获随访,小切口组随访时间为(3.7±0.4)年,常规切口组为(3.9±0.6)年.末次随访时小切口组AKSS评分为(78.2±6.7)分,常规切口组为(81.2±7.3)分;两组与术前比较差异均有统计学意义(P<0.05),两组间差异无统计学意义(P>0.05).结论 与常规切口相比,采用小切口技术行TKA术后早期并发症较多,严格的手术适应证选择、熟练的人工膝关节置换技术、更合理的手术器械、细致入微的围手术期管理是取得手术成功的关键.     

MORBIDITY AND MORTALITY AFTER ABDOMINAL AORTIC SURGERY IN A POPULATION OF PATIENTS WITH HIGH CARDIOVASCULAR RISK

Postoperative myocardial infarction is a major risk factor in patients undergoing abdominal aortic surgery. Correction of cardiac ischaemia prior to abdominal aortic surgery improves outcome. The morbidity and mortality of 639 consecutive patients were reviewed from an area with poor access to cardiac surgery, operated upon in a single tertiary referral hospital for aortic aneurysm or aortobifemoral grafting. A total of 101 patients with ruptured aortic aneurysm who survived to reach the intensive care unit experienced a hospital mortality of 29%. Multiorgan failure was the cause of death in 48% and postoperative myocardial infarction in 31%. Of the 253 patients with intact aortic aneurysm, which included elective and urgent resection, the mortality was 9%. There was a high incidence of uncorrected pre-operative ischaemic heart disease and myocardial infarction was the major cause of death (62%). Pre-operative myocardial infarction was predictive of postoperative cardiac morbidity and mortality. Of the 285 patients undergoing aortobifemoral grafting the mortality was 3% despite a high incidence of pre-operative ischaemic heart disease. Further reductions in postoperative death from ruptured aortic aneurysm must await improved screening to diagnose and treat the aneurysm before rupture. In patients operated upon electively, improved pre-operative cardiac screening and coronary bypass grafting where appropriate, especially for patients with aortic aneurysm and previous myocardial infarction, may further reduce pen-operative mortality.     

INFLUENCE OF TIMING ON THE EFFECT OF CONTINUOUS EXTRADURAL ANALGESIA WITH BUPIVACAINE AND MORPHINE AFTER MAJOR ABDOMINAL SURGERY

We have studied the effect of continuous extradural analgesiawith bupivacaine and morphine, initiated before or after colonicsurgery, in a double-blind, randomized study. Thirty-two patientswere allocated randomly to receive an identical extradural blockinitiated 40 min before surgical incision (n = 16) or at closureof the surgical wound (n = 16). The extradural regimen consistedof a bolus of 7 ml of plain bupivacaine 7.5 mg ml^–1 plusmorphine 2 mg and continuous extradural infusion of a mixtureof bupivacaine 7.5mg ml^–1 plus morphine 0.05 mg ml^–1,4 ml h^–1 for 2 h, followed by a continuous extraduralinfusion of a mixture of bupivacaine 2.5mgml^–1 plus morphine0.05 mg ml^–1, 4 ml^–1 h^–1, continued for 72h after operation. In addition, all patients received similargeneral anaesthesia. There was no significant difference inrequest for additional morphine and no significant differencesbetween the groups in pain scores (visual analogue scale orverbal) during rest or ambulation at any time of measurement.These results do not suggest that timing of analgesia with aconventional extradural regimen is of major clinical importancein patients undergoing colonic surgery     

纳米仿生组织工程血管兔腹主动脉置换术后体内演化的实验研究

目的 兔自体种子细胞构建的纳米仿生组织工程血管(nano-biomimetie tissue engineered bloodvessel,NBTEBV)移植置换兔腹主动脉,观察NBTEBV在兔体内降解和重塑演化过程,检测NBTEBV的组织相容性. 方法 6月龄新西兰大白兔20只,雌雄不限,体重2～3 kg.取兔自体种了细胞体外构建NBTEBV.取新两兰大白兔,游离.肾下腹主动脉结扎其分支,剪下长约10mm腹主动脉,采用同体种子细胞来源的NBTEBV置换兔腹主动脉,吻合口置钛夹标记.观察NBTEBV在兔体内降解及重塑演化过程:术后第12周行DSA检查及彩色多普勒检查;术后第1、4、12周,取移植血管行大体及组织学观察,并行移植血管14C标记的PLGA X射线电子能谱检测. 结果 17只兔移植NBTEBV在观察期内保持通畅,3只兔分别于术后36、72 h死于移植段腹主动脉闭寒.术后第12周DSA检查示移植血管显影良好,彩色多普勒检查示移植血管通畅,血流为层流,血流速度末见异常,无血管扩张.术后第1周移植血管腔被覆单层内皮细胞,管壁平滑肌细胞分布层次欠清晰,周围较多仿ECM夹杂未降解的黑色PLGA;术后第4周管壁平滑肌细胞分层,ECM开始形成,仿ECM成分部分降解,PLGA含量明显减少,颜色减淡;术后第12周管壁分层更清晰,ECM已形成,仿ECM成分完全降解,几乎无PLGA,血管形态近似自体血管.14C标记的PLGA射线电子能谱检测示14C能量峰值逐周递减. 结论 构建的NBTEBV有较好的手术操作性,同体移植术后具备良好组织相容性,在动物体内的自然重塑演化过程符合组织工程技术要求,电纺构建NBTEBV是可行的.     

胆道术后肝脓肿的原因分析及诊治

目的 探讨胆道系统术后并发肝脓肿的原因和治疗.方法 9例肝内外胆管结石病人经各种胆道手术后肝脏内形成脓肿;明确诊断后,在B超引导下经皮肝穿刺引流和对脓腔进行抗菌素灌洗,2例行手术治疗.结果 5例患者脓肿愈合,2例脓腔明显缩小,另2例行手术治疗病人已治愈.结论 分析肝内脓肿形成的主要原因为(1)胆道损伤;(2)肝内胆管结石残余;(3)十二指肠液返流;(4)T管引流不畅,胆道梗阻,胆汁滞留.在B超引导下经皮肝穿刺脓肿引流及选用敏感抗菌素对脓腔进行灌洗是治疗胆道术后并发肝脓肿的有效手段.但脓液引流不畅病人应及时作有效的手术引流,并同时去除病因.