食管胃器械吻合后吻合口出血的原因及防治

食管吻合器的问世，缩短了手术时间，有效地降低了食管胃吻合口瘘的发生率。随着此技术的普及，在大宗病例的使用中，也出现较为罕见的吻合口出血。现探讨管形吻合器行食管胃吻合后出现出血的原因及防治措施。     

食管胃器械吻合术后吻合口瘘原因分析

1995年6月至2005年6月，我们行食管癌贲门癌切除、应用器械行胃食管吻合412例，发生吻合口瘘13例，占3．16％，发生率较高，现总结分析原因报道如下。[第一段]     

胸内食管胃吻合口狭窄再手术

食管胃吻合口严重狭窄是食管癌、贲门癌术后严重并发症之一；通常采用内窥镜下食管扩张术或再次开胸手术治疗。我们报道１０例手术切除狭窄吻合口，原位食管胃端端吻合。无吻合口漏或手术死亡。随访１年５年，无吻合口再狭窄。现就再手术的适应证、术前准备和手术方法进行讨论并提出看法。     

吻合口胃侧荷包缝合在食管胃胸内器械吻合术中的应用

目的 探讨吻合口胃侧荷包缝合在食管胃胸内器械吻合术中的安全性和有效性.方法 回顾性分析2008年1月至2011年12月四川省人民医院收治的行食管胃胸内器械吻合术治疗的238例胸段食管癌和24例食管胃结合部癌患者的临床资料,其中122例吻合口按常规方法处理(常规组),140例改进了处理方法,吻合前在吻合口胃侧吻合器中心杆处予以1号丝线作浆肌层荷包缝合并结扎(改进组),比较两组患者吻合口瘘和吻合口狭窄发生率等临床指标.计量资料比较采用￡检验,计数资料比较采用x2检验或者Fisher确切概率法.结果 两组患者手术时间、术中出血量、术后24 h胸腔积液引流量、术后住院时间和术后pTNM分期比较,差异无统计学意义(t=0.410,0.798,0.634,0.362,x2=0.605,P＞0.05);两组患者吻合器使用类型、吻合口位置、吻合器食管端组织质量比较,差异无统计学意义(x2 =0.118,0.221,t=0.459,P＞0.05);两组患者术后肺部并发症、心律失常等并发症的发生率以及病死率比较,差异无统计学意义(P＞0.05);但改进组吻合器胃端组织质量大于常规组,差异有统计学意义(t=13.856,P＜0.05);改进组术后吻合口瘘、吻合口狭窄的发生率均低于常规组,差异有统计学意义(P＜0.05).结论 吻合口胃侧荷包缝合操作简单、安全,不延长手术时间和住院时间,可以有效减少食管胃胸内器械吻合术后吻合口瘘和吻合口狭窄的发生.     

纤维内窥镜扩张治疗食管胃吻合口狭窄66例经验

纤维内窥镜扩张治疗食管胃吻合口狭窄６６例经验王厚峋，库尔班，方公贤，余养生，张铸，严宏吻合口狭窄是食管癌和贲门癌切除术后常见的并发症之一，文献报告其发生率为０．３９－９．５％，并且随着吻合器的广泛应用而有所增加［１－３］。从１９８４年１０月起，我们在...     

不同平面吻合加盖大网膜或下肺韧带预防食管、胃吻合口瘘及狭窄

目的改进食管胃吻合方式，降低吻合口瘘及狭窄的发生率。方法将５５２例食管、贲门癌患者随机分为３组，分别采用荷包式吻合；食管胃分层吻合；食管胃不同平面吻合，吻合口加盖大网膜或下肺韧带三种不同的吻合方式，比较各组吻合口瘘及狭窄的发生率。结果吻合口瘘发生率分别为：３．７５％，１．０９％和０；狭窄的发生率分别为：８．１％，３．２５％和０．９６％。三组结果有显著性差异。结论食管胃不同平面吻合，吻合口加盖大网膜或下肺韧带可有效预防食管胃吻合口瘘及狭窄的发生。     

食管贲门癌术后吻合口瘘的原因及预防

胃底贲门癌根治性切除术与经左开胸食管癌根治术,常需吻合器吻合。随着新型吻合器的应用,术后并发症发生率大大下降。但因操作不当等原因,会出现吻合口瘘等并发症。现将吻合口瘘的原因及预防进行总结。     

优质护理在不对称双眼皮整形修复术患者中的应用效果

目的 分析在不对称双眼皮整形修复术患者中开展优质护理的效果。方法 选取2022年5月-2023年 11月于我院接受不对称双眼皮整形修复术的100例患者为研究对象,随机分为对照组和研究组,每组50例。 对照组给予常规护理,研究组在对照组基础上给予优质护理,比较两组满意度、焦虑情绪、眼部功能恢复情 况、住院时间、术后康复时间及并发症发生情况。结果 研究组护理后满意度评分高于对照组,差异有统计 学意义（P ＜0.05）;研究组护理后焦虑评分低于对照组,差异有统计学意义（P ＜0.05）;研究组护理后 眼部功能恢复评分高于对照组,差异有统计学意义（P＜0.05）;研究组住院时间及术后康复时间均短于对 照组,差异有统计学意义（P ＜0.05）;研究组并发症发生率为4.00%,低于对照组的28.00%,差异有统计 学意义（P ＜0.05）。结论 优质护理在不对称双眼皮整形修复术患者中的应用效果确切,可提高患者满意 程度,减轻患者的焦虑情绪,有利于促进眼部功能恢复,对于缩短住院时间及术后康复时间、降低术后并 发症发生几率均具有积极意义。     

X射线激发Cu-Cy介导的光动力对人结肠癌细胞的杀伤作用研究

目的:探讨X射线激发Cu-Cy介导的光动力对人结肠癌SW620细胞的体外杀伤效应及其作用机制。方法:用不同浓度(0~100 mg/L)Cu-Cy联合或不联合低剂量X线照射处理SW620细胞后,采用CCK8法检测并光镜观察细胞的生长活性;JC-1染色检测线粒体膜电位;Annexin V FIFC/PI双染法检测细胞的凋亡率;Western blot检测凋亡相关蛋白Bax、Bcl-2及自噬相关蛋白LC3B、P62的表达;透射电镜观察细胞的超微结构。结果:与空白对照SW620细胞(0 mg/L Cu-Cy,无X线照射),Cu-Cy联合X线照射处理的SW620细胞生长活性明显降低,并呈一定的浓度依赖性(部分P0.05),且细胞凋亡率明显升高、线粒体膜电位下降细胞的比例明显增加、Bax与LC3B-II蛋白表达明显升高,Bcl-2与P62蛋白表达明显降低(均P0.05)、细胞内自噬体增多;单纯X射线照射和单加Cu-Cy处理的SW620细胞以上指标均无明显改变。结论:X线激发Cu-Cy介导的光动力能有效抑制人结肠癌SW620细胞体外生长活性,机制可能与其诱导细胞凋亡和自噬有关。     

不同剂量阿芬太尼复合丙泊酚在无痛膀胱镜检查中的临床应用效果

目的：研究不同剂量阿芬太尼复合丙泊酚在无痛膀胱镜检查术中的临床应用效果。方法：选取2021年1月—2021年12月在我院行静脉全麻下膀胱镜检查的患者105例，采用随机数字表法将患者随机分为A组、B组和C组，分别采用阿芬太尼5μg/kg、7.5μg/kg和10μg/kg复合丙泊酚麻醉，目标镇静深度为改良警觉/镇静评分(MOAA/S)≤2分。记录膀胱镜检查中检查时间、低氧血症发生率、不自主体动事件、低血压、心动过缓、术后恶心、头晕发生率、术后尿路刺激征发生率、中重度尿路刺激征发生率、镇静成功率、丙泊酚用量、血管活性药物使用人数、诱导时间、苏醒时间及满意度评分。结果：C组患者术中低氧血症发生率明显高于B组(25.0%vs 3.2%,P<0.05);A组低血压发生率显著高于B组(32.4%vs 9.7%,P<0.05),A组心动过缓发生率（35.3%）显著高于B组（12.9%）、C组（12.5%），差异有统计学意义；A组尿路刺激征发生率（67.6%）显著高于B组（35.5%）、C组（25.0%），差异有统计学意义。A组丙泊酚用量、血管活性药人数及苏醒时长均显著高于B、C组，差异有统...     

食管癌术后食管胃吻合口狭窄的危险因素及对策

目的分析食管胃吻合术后吻合口狭窄的危险因素,并提出预防措施。 方法以2014年6月—2016年6月在川北医学院附属医院胸外科内镜室因吻合口狭窄行吻合口扩张术的食管癌术后患者为实验组(n＝138),以1∶2比例随机抽取同期能进食固体食物的食管癌术后患者为对照组(n＝276)。通过单因素和多因素分析了解术前体重指数、术前吞咽情况、术前影像学检查有无狭窄、病变位置、手术方式、吻合口位置、吻合方式、肿瘤直径、病理分型、病理分期、术后是否发生吻合口瘘等因素对术后吻合口狭窄的影响。 结果单因素分析显示：病理分期和术后吻合口瘘差异均有统计学意义(P<0.05);吻合方式和吻合口位置差异均无统计学意义(P>0.05)。将吞咽困难(P＝0.05)、肿瘤直径(P ＝0.1)、病理分期(P ＝0.04)、吻合口瘘(P<0.01)纳入Logistic多因素回归分析显示：术后吻合口瘘(OR＝5.87,95% CI：2.65～13.01;P<0.01)、肿瘤直径<3 cm(OR＝1.65,95% CI：1.01～2.67;P ＝0.04)是吻合口狭窄发生的影响因素;术前吞咽情况亦是吻合口狭窄的影响因素,其中半流质患者相对于流质患者更易发生吻合口狭窄(OR＝2.13,95% CI：1.32～3.45;P<0.01)。 结论吻合口瘘是食管癌患者术后吻合口狭窄的独立危险因素,早期预防性食管扩张对预防吻合口狭窄非常重要。术前吞咽困难相对较轻、肿瘤直径相对较短及病理分期相对较早的患者更容易发生吻合狭窄,对于这部分患者应采取侧侧吻合,以减少术后吻合口狭窄。     

Jejunal pouch to avoid stricture after esophagojejunostomy with circular stapler.

BACKGROUND: Anastomotic stricture is one of the most common problems in esophagojejunostomy using the end-to-end anastomosing (EEA) instrument (Auto Suture Co, Norwalk, CT) after total gastrectomy. To alleviate the stricture, several methods, such as incision to the scar, balloon dilatation, and steroid injection are available. To avoid stricture, the jejunal pouch may allow use of a larger EEA than Roux-en-Y (ReY) reconstruction does. STUDY DESIGN: A total of 45 patients underwent curative total gastrectomy and esophagojejunostomy with jejunal pouch construction (27 patients) or ReY (18 patients), using the EEA. The effects of jejunal pouch construction with a large EEA on avoidance of stricture and benefit to nutritional status were investigated by comparing it with the ReY in terms of postoperative morbidity, postprandial symptoms, and nutritional parameters (serum protein, serum albumin, body weight). RESULTS: EEA28 or larger could be used in 25 patients in the pouch group and 8 patients in the ReY group (p < 0.05). Stricture developed in one patient in the pouch group and in four patients in the ReY group (p < 0.05). Postprandial symptoms were experienced less frequently (p < 0.05) in the pouch group than in the ReY group. When stricture and symptoms were analyzed according to the size of EEA, they occurred more frequently (p < 0.05) in the patients with EEA25 than those with EEA28 or EEA31. No significant differences were evident in nutritional parameters. CONCLUSIONS: The choice of jejunal pouch technique allowed the use of a larger EEA than that of ReY reconstruction, resulting in avoidance of anastomotic stricture and postprandial symptoms, though little benefit in nutritional status was evident to the patients after total gastrectomy.     

尿道端端吻合术后狭窄复发的危险因素分析

目的分析尿道狭窄患者行尿道端端吻合术(excision and primary anastomotic urethroplasty,EPA)后狭窄复发的危险因素。方法回顾性分析2017年1月至2018年12月上海交通大学附属第六人民医院收治的209例尿道狭窄患者的临床资料。年龄42.1(5~78)岁。肥胖(体质指数>28 kg/m2)25例(12.0%)。既往有糖尿病史12例(5.7%),术前3个月吸烟史103例(49.3%)。术前未行尿道扩张127例(60.8%),尿道扩张1~2次42例(20.1%),尿道扩张≥3次40例(19.1%)。术前有尿道内切开术史56例(26.8%)。术前无尿道成形术史157例(75.1%),尿道成形术1次38例(18.2%),尿道成形术≥2次14例(6.7%)。术前行膀胱造瘘201例(96.2%),未行膀胱造瘘8例(3.8%)。后尿道狭窄183例,球部尿道狭窄26例。狭窄时间35.1(1~360)个月。狭窄段长度(3.19±0.65)cm。病因为外伤190例,医源性损伤12例,炎性狭窄2例,其他5例。患者均行EPA治疗,69例(33.0%)术中行耻骨下缘切除。术后复发标准:拔除导尿管后出现排尿困难,经尿道镜或尿道造影检查提示手术部位尿道狭窄。对可能导致狭窄复发的因素采用Cox比例风险回归模型进行单因素和多因素分析。结果本组209例术后随访18.8(3~32)个月。31例(14.8%)出现狭窄复发,复发时间(5.3±5.6)个月。单因素分析结果显示,狭窄时间(HR=1.007,P<0.001),狭窄段长度(HR=5.334,P<0.001),尿道内切开术史(HR=2.901,P=0.003),尿道扩张≥3次(HR=6.214,P<0.001),尿道成形术1次、≥2次(HR=4.175,P=0.001、HR=9.885,P<0.001),术前3个月吸烟史(HR=2.605,P=0.016),膀胱造瘘(HR=0.231,P=0.006),耻骨下缘切除(HR=6.603,P<0.001)与狭窄复发有相关性。多因素分析结果显示狭窄段长度(HR=4.911,P<0.001),尿道成形术1次、≥2次(HR=2.387,P=0.045、HR=3.688,P=0.015),术前3个月吸烟史(HR=2.730,P=0.030)是狭窄复发的独立危险因素。结论EPA术后尿道狭窄复发多集中在术后6个月内,患者尿道狭段窄长度、尿道成形术史、术前3个月吸烟史是狭窄复发的独立危险因素。     

Esophagogastric anastomosis performed with a stapler: the occurrence of leakage and stricture

The circular stapler has lowered the leakage rate of an esophageal anastomosis to a level hitherto achieved by only a few surgeons performing hand anastomosis on selected patients with carcinoma of the esophagus. However, the esophageal anastomosis performed with a stapler is also associated with a high stricture rate. Our prospective study was conducted to determine the leakage rate and the incidence of stricture after esophagogastric anastomosis was performed with a stapler, the relationship of stricture to the size of the stapler, and the risk of stricture in relation to time. In a group of 174 patients with carcinoma of the thoracic esophagus, resection was performed, and a one-stage esophagogastric anastomosis was constructed. There were 33 hand anastomoses, 64 anastomoses with an EEA stapler (U.S. Surgical Corp., Norwalk, Conn.), and 77 anastomoses with an ILS stapler (Ethicon Ltd., Edinburgh, U.K.). The anastomotic leakage rate was 3.4% (6/174); 3% with the hand technique and 3.5% with the stapler technique (4.7% for the EEA and 2.6% for the ILS). After leakages and hospital deaths were excluded, 133 discharged patients were evaluated for the occurrence of anastomotic strictures. Only those who complained of dysphagia were investigated. The incidence of stricture for hand anastomosis was 8.7%-EEA 20% and ILS 10%; the overall incidence of anastomoses with a stapler was 14.5%. The true incidence would probably be higher if all patients were assessed by endoscopic or radiologic examination after operation. All three sizes of EEA staplers had a high incidence of stricture. For the ILS stapler the 25 mm size had the highest stricture rate (28.6%) of all groups, but for the 29 and 33 mm sizes, the incidences were 5.3% and 0%, respectively. Actuarial analysis showed an increasing risk of stricture with a reduction in the size of stapler used and was 32.5% and 35%, respectively, for the ILS 25 mm and EEA 25 mm staplers at 131/2 months. The risk of stricture occurrence was highest in the first 4 months. Treatment by bougienage was satisfactory. In conclusion, esophagogastric anastomosis performed with a stapler is a very safe procedure with respect to leakage but is associated with a high risk of stricture, except when the largest ILS staplers are used. However, dilatation readily overcomes the stricture occurrence and adequately compensates for the reduced leakage rate and its attendant serious consequences.     

胃次全切除后圆形吻合器完成残胃-空肠端侧吻合的实验与临床应用研究

目的探讨胃次全切除后采用圆形吻合器行残胃．空肠端侧吻合的实验与临床可行性。方法Beagle＇s犬12条，随机分成A、B两组，在胃窦切除后分别以器械或手工行残胃-十二指肠端侧吻合术。3个月后，以器械行残胃-十二指肠侧侧吻合术。测量残胃十二指肠侧侧吻合处及邻近的十二指肠周长；并观察残胃空肠端侧吻合口直径及愈合情况。选择163例远端胃癌患者，随机分成C、D两组，C组89例，D组74例。胃次全切除后，分别以器械或手工行残胃-空肠端侧吻合术，手术后观察吻合口漏、狭窄等并发症，1年后行稀钡上消化道造影，观察吻合口钡剂通过和2h后残胃钡剂残留情况。结果手术后12条Beagle＇s犬术后均恢复良好，残胃十二指肠侧侧吻合处及邻近的十二指肠周长分别是（6．46±0．06）cm，（7．26±0．12）cm。残胃空肠端侧吻合口及小弯侧三角处愈合均良好，A、B两组吻合口直径分别为（1．18±0．13）cm和（1．20±0．09）cm。两组比较差异无显著性意义（t=0．255，P=0．804）。163例患者均顺利完成手术，术后未出现吻合口漏、狭窄等并发症，术后1年，2组分别行上消化道稀钡造影，均显示吻合口无明显狭窄，钡剂通过顺利，2h后残胃仅见少量钡剂残留。结论胃次全切除后应用器械行残胃-空肠端侧吻合能够在残胃的原位完成消化道重建，降低吻合难度，方法可行。     

胃次全切除后残胃-空肠端侧器械吻合的临床和实验研究

目的 总结胃次全切除后采用弧形切割吻合器行残胃-空肠端侧吻合的临床和实验体会.方法 Beagle犬12条,随机分成A、B两组,在胃窦切除后分别以器械或手工行残胃-十二指肠端侧吻合术;3个月后,以器械行残胃-十二指肠侧侧吻合术;测量残胃十二指肠侧侧吻合处及邻近的十二指肠周长,并观察残胃-空肠端侧吻合口直径及愈合情况.选择145例远端胃癌患者,随机分成A、B两组:A组71例,B组74例.胃次全切除后,分别以器械或手工行残胃-空肠端侧吻合术,手术后观察吻合口瘘、狭窄等并发症;1年后行上消化道造影,观察吻合口钡剂通过和2 h后残胃钡剂残留情况.结果 12条Beagle犬术后均恢复良好,残胃十二指肠侧侧吻合处及邻近的十二指肠周长分别是(6.46±0.06)cm和(7.26±0.12)am;残胃空肠端侧吻合口及小弯侧三角处愈合均良好,A、B两组吻合口直径分别为(1.18±0.13)cm和(1.20±0.09)cm;两组比较差异无统计学意义(t=0.255,P=0.804).145例患者均顺利完成手术,术后未出现吻合口瘘、狭窄等并发症;术后1年,两组分别行上消化道稀钡造影,均显示吻合口无明显狭窄,钡剂通过顺利,2 h后残胃仅见少量钡剂残留.结论 胃次全切除后应用器械行残胃-空肠端侧吻合能够在残胃的原位完成消化道重建,降低吻合难度,确保足够的胃切除,避免撕裂脾脏和脾周血管.     

Transanal treatment of strictured rectal anastomosis with a circular stapler device: simple and safe

BACKGROUND: Several methods of treatment for benign anastomotic strictures after low anterior resection have been described. We report and illustrate a simple, safe, and effective method for treating benign rectal anastomotic strictures by means of a transanal circular stapling device. METHODS: Three patients with a clinically significant rectal stricture underwent transanal resection of the fibrous stenosis by a circular stapler device (CEEA stapler 29 or 31 mm calibre; Tyco Co., USA). RESULTS: No complications occurred. Patients were discharged from the hospital on the first postoperative day. After a follow-up period of 8, 12 and 14 months respectively, no recurrence of the stricture was observed. The stool habits of all 3 patients were normal with 1-3 formed, asymptomatic fecal passages per day. CONCLUSION: Transanal reanastomosis by means of a circular stapler device is a simple and effective method. However, a larger number of patients need to be treated with this relatively new method to draw further conclusions.