上消化道大出血术后再出血的教训和治疗体会（附56例报告）

目的 探讨上消化道大出血术后再出血应吸取的教训和处理对策。方法 对56例上消化道大出血术后再出血的原因进行分析。结果 再次手术37例，治愈33例(89.2％)，死亡4例(10．8％)；经腹腔内动脉插管介入治疗2例，止血成功1例，另1例再手术治愈；非手术治疗18例，治愈10例(55．6％)．死亡8例(44．4％)。12例死亡病人再次出血距首次手术时间均在48小时内。结论 对该类病人采取再手术与否．关键是看再出血的部位和原因以及非手术疗法止血的效果，应掌握好再手术的时机和正确的探盘方法。     

上消化道大出血行胃大部切除术后再出血临床分析

目的探讨上消化道大出血行胃大部切除手术再出血的相关原因,并提出相应的预防措施。方法选取上消化道大出血行胃大部切除术后再出血患者22例,对术后再出血的原因进行分析,并提出相应预防策略。结果 22例患者均于术后72 h内再次出血,引起术后再出血的原因:吻合口缝合不严10例(45.45%),旷置溃疡出血7例(31.82%),应激性溃疡出血3例(13.64%),无明显原因2例(9.09%)。经治疗后22例患者痊愈12例,好转8例,死亡2例。结论借助内镜进行诊治、严格掌握手术指征、正确选择手术方式、规范进行手术操作,可有效减少上消化道大出血术后再次出血发生。     

老年人上消化道大出血的临床特征与治疗体会(附11 6例报告)

目的:探讨老年人上消化道大出血的特点和治疗应注意的问题.方法:对116例老年人上消化道大出血行胃镜及手术探查,发现出血病因101例,原因不明15例.结果:80例行急诊手术,治愈68例(85%),死亡12例(15%);择期手术33例,治愈30例(90.9%),死亡3例(9.1%);3例胃粘膜病变行非手术治愈.术后出现并发症35例(30.9%).结论:老年人上消化道大出血,不易非手术止血;若非手术和内镜下不能止血,应果断采取手术治疗,术前应注意防治休克和并存的心肺肾等器官的病变,以提高抢救的成功率.     

门静脉高压断流术后再出血的治疗

目的探讨和分析门静脉高压断流术后再出血的治疗措施。方法对武汉大学中南医院自2013年1月至2015年6月收治门静脉高压断流术后再出血病人60例的临床治疗进行回顾性分析。60例病人中,25例病人采用内镜下套扎止血,20例病人行经颈静脉肝内门静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS),10例病人行肝移植,5例复发重度食管静脉曲张行再次断流术。结果内镜套扎组8例病人因再次出血行第2次内镜下套扎,其中1例病人再次大出血死亡;行TIPS组2例发生间断性肝性脑病,其中1例发生再次出血行内镜下套扎治疗;肝移植组术后恢复较好;再次行断流手术组,1例病人因出血无法控制死亡。结论对门静脉高压断流术后再出血的病人以上方法均有效,其中最有效的治疗方法是肝移植,对肝衰竭以及顽固性食管胃底静脉曲张上消化道出血的病人疗效好;肝功能较好且无肝性脑病者,或断流术后效果欠佳反复消化道出血病人可考虑行TIPS术;肝功能较差者,或病人急性消化道大出血身体状况较差者可选择内镜下套扎止血;再次手术难度大,风险高,再次行断流手术需慎重。     

胃切除术后近期上消化道大出血再手术治疗临床分析(附14例报告)

目的 探讨胃切除术后近期上消化道大出血的原因及再手术治疗。方法 对我院1986～2002年间收治的14例胃切除术后近期(24～72h内)上消化道大出血行再手术治疗的病例资料进行回顾性分析。结果 本组14例，术后吻合口出血4例，残胃粘膜损伤出血2例．残胃肠套叠出血2例．十二指肠残端出血1例．遗漏十二指肠球后溃疡及贲门粘膜撕裂出血各1例．原因不明出血3例，均经再次手术治疗后痊愈。结论 胃切除术后近期上消化道大出血原因多为操作不当及病灶遗漏所致，出血灶直视下缝扎为有效止血方法。     

急诊手术治疗门静脉高压症并上消化道大出血手术疗效评价

目的探讨急诊手术在治疗门静脉高压症并上消化道大出血中的效果和意义。方法对我院近5年内151例门静脉高压症并上消化道大出血患者行急诊手术的疗效和并发症发生率进行回顾性研究,其中肝功能ChildA级72例,B级58例,C级21例。结果总体出血有效控制率95.3%,断流术死亡率为7.7%(10/130),死亡的主要原因为腹腔内出血、上消化道出血和肝肾综合征,分流术死亡率为38.1%(8/21),死亡的主要原因为肝肾功能衰竭。术后1年生存率为97.7%,3年生存率为94.2%,5年生存率为86.8%。术后1年再出血率为1.5%(2/133),3年再出血率为5.7%(4/70),5年再出血率为7.9%。结论在当今条件下贲门周围血管离断术仍是挽救门静脉高压症并发不可内科控制的上消化道大出血患者生命的主要急诊手段,肝内型门静脉高压急诊手术最好不选择分流手术。     

急性上消化道大出血盲目胃切除14例疗效分析

年９８０年１月至１９９６年１月１我院收治的急性上消化道大出血作急诊手术１３６例，其中出血“原因未明”有１４例施行盲目胃切除，术后近期再出血３例，其中死亡２例，再次手术探查止血治愈１例。本文就出血“原因未明”盲目胃切除和再出血的看法，并要重视术前检查等问题进行了讨论。     

精准断流术治疗门静脉高压症上消化道出血疗效分析

目的探讨精准断流术治疗门静脉高压症上消化道出血的疗效。方法回顾性分析2005~2012年期间施行精准断流术治疗门静脉高压症上消化道出血病人43例,观察该组病人手术前后血象、肝功能、并发症等指标,术后对病人进行长期随访,观察再出血率和生存情况。结果手术止血率为100%,围手术期无再出血及死亡病例。围手术期术后脾功能亢进得到有效治疗(P0.05);术后发生胃潴留2例(3.7%),手术创面渗血2例(3.7%),均经保守治疗后痊愈;术后门静脉超声检查均未发现门静脉血栓形成。43例病人全部顺利出院,术后住院时间为7~34 d,平均(11.2±5.7)d。43例中有40例获得随访,随访率为93.0%,随访时间为8~73个月,平均(49.2±10.5)月。其中1年再出血率为2.5%(1/40),1年死亡率为5.0%(2/40)。总体再出血率为17.5%(7/40),总体死亡率为22.5%(9/40),死亡原因为上消化道出血2例、肝衰竭7例,其中合并肝细胞肝癌2例。结论精准断流术是治疗门静脉高压症上消化道出血的一种有效术式。     

胰十二指肠切除术后腹腔迟发性大出血因素分析与处理

目的探讨胰十二指肠切除术(PD)后腹腔迟发性大出血因素分析与处理。方法回顾性分析138例病人行胰腺十二指肠切除术诊治过程及体会。结果 138例病人中术后发生胰漏并大出血者11例,发生率为7.97%(11/138),11例出血病人中,因大出血经DSA介入治疗4例,发生率2.89%(4/138),因大出血再次手术止血7例,发生率5.07%(7/138),再次手术后死亡3例,病死率27.27%(3/11),出血主要原因为胰漏腐蚀腹腔动静脉血管引起大出血。结论胰十二指肠切除术后腹腔迟发性大出血主要是胰漏腐蚀胰肠吻合口周围血管出血所致。介入治疗和手术治疗是PD术后胰漏合并迟发性腹腔出血的重要手段。     

门静脉高压症断流术后上消化道再出血诊治体会

目的 探讨门静脉高压症断流术后上消化道再出血的原因及防治措施。方法 对近8年解放军第302医院肝胆外科收治的因门静脉高压症行脾切除、贲门周围血管离断术后发生上消化道再出血的15例患者的临床资料进行回顾性分析。结果 15例术后消化道再次出血患者中，因急性胃黏膜病变出血9例，残留食管胃底曲张静脉再次破裂大出血5例，围手术期门静脉、脾静脉及肠系膜上静脉血栓形成并呕血1例。围手术期再出血并死亡2例，通过保守或手术治疗治愈13例。结论 断流术是治疗门静脉高压症引起上消化道大出血的良好术式，术后再出血是断流术后常见并发症之一，完善的手术操作、适时祛聚抗凝减少门静脉系统血栓形成可减少断流术后再出血的发生或减轻其症状。     

上消化道出血行胃大部切除术后再出血

目的 探讨上消化道出大出血胃大部分 切除术后近期再出血原因、预防及处理。方法 对１９８５～１９９８年收治的３２全一再出血病例的临床资料进行回顾性分析。结果 男２８例，妇４例，平均年龄３７．５，２１例再次手术，治愈１５例，６例术后再出血，死亡１例。非手术治疗１１例，死亡２例。结论 原发病灶存在和胃肠吻合口出血是主要原因，作者提倡术前术中应用内窥镜以帮助诊断，强调不能切除的十二指肠疡用Ｎｉｓｓｅｎ法溃     

Reoperation of postoperative rebleeding in patients with portal hypertension

Since 1970, reoperation was performed on 84 cases with postoperative rebleeding gastroesophageal varices. The operative mortality was 15.5%. Of the 71 patients discharged from the hospital 67 were followed up. The five year survival rate after the operation was 66.1%. Seven of 43 cases treated by portoazygos disconnection died of bleeding varices after the surgery. Among the 32 cases undergoing portal systemic shunt, one died of rebleeding. Shunt operation plus portoazygos disconnection was performed on 5 cases without postoperative rebleeding death. Three of four patients treated by incomplete portoazygos disconnection died of postoperative rebleeding. Our results showed that shunt operation alone or added with portoazygos disconnection have the advantage over portoazygos disconnection in preventing postoperative bleeding, and should be the procedure of choice in treating rebleeding patients.     

门静脉高压症复发性上消化道出血的腹腔镜手术治疗

目的探讨应用腹腔镜脾切除术(LS)及门奇断流术治疗门静脉高压症复发性上消化道出血的手术技巧及临床应用的安全性。 方法回顾性分析2010年5月至2015年4月对56例门静脉高压症复发性上消化道出血患者采用腹腔镜手术治疗的临床资料。 结果56例患者中,51例患者完成LS及门奇断流术,其中采用一级脾蒂离断法13例,采用二级脾蒂离断法38例;手术时间(2.8±0.5)h、术中出血量(156.8±33.5)ml、术后肛门排气时间(3.1±1.3)d、术后住院时间(6.1±1.3)d;术后胸腔积液2例,轻度腹腔积液1例;有2例发生轻度胰漏,经腹腔引流后痊愈。全组无围手术期死亡。因术中出血,2例改为手助腹腔镜手术,3例完全中转开腹手术;非完全腹腔镜手术中转率为8.9%。随访1年内再出血3例,再出血率5.4%。术后1、3、5年生存率分别为96.4%(54/56)、87.5%(28/32)、75.0%(15/20)。 结论应用LS及门奇断流术治疗门静脉高压症复发性上消化道出血,具有创伤小、出血少、恢复快、并发症发生率低的优点。只要严格掌握适应证,术前精确评估,术中精细操作并做好中转应急处理,术后精心管理,该术式是安全可行的,其远期疗效也是肯定的。     

Management of recurrent hemorrhage in portal hypertension

123 cases of recurrent hemorrhage were studied. It was found that the rebleeding rate differed with different original operations. Those with unsatisfactory portal decompression or persistence of varices were prone to rebleeding. Rebleeding within one year occurred in 47.96%, and in late stage in 52.04%. Early postoperative rebleeding should be treated conservatively with intensive circulatory resuscitation. Repeated rebleeding occurred in 89% of the patients, reoperation should be carried out with definite indications. Emergency surgery was usually not recommended. On the operation, portal vein thrombosis was found in 58.8% of the patients, and dilatation of the superior mesenteric vein in 82.9%. Of the fifty six rebleeding cases treated surgically, 21.4% died of further bleeding in 5 years compared with 50.7% treated conservatively. Rebleeding occurred in 62.5% of disconnection cases and in 31.2% of shunt cases. The authors performed mesocaval side-to-side anastomosis in those with enlarged superior mesenteric vein, and restricted portocaval shunt in those without portal thrombosis. Rebleeding patients with regional portal hypertension were better treated with devascularization.     

Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated?

BACKGROUND: This study analyzed presentation and management of hemorrhage after pancreaticoduodenectomy (PD) to determine the respective role of surgery and embolization. METHODS: From January 1992 to March 2005, 411 patients underwent PD and were analyzed with regard to postoperative hemorrhage. RESULTS: Hemorrhage occurred in 27 patients (7%), either within the first 3 postoperative days ("early" hemorrhage, n = 11) or after day 8 ("delayed" hemorrhage, n = 16, including 4 with "sentinel" bleeding). At the time of bleeding, 12 patients (44%) (all with delayed hemorrhage) had associated abdominal complications. Two patients had successful conservative treatment. Two stable patients with pseudoaneurysm, diagnosed by computed tomography scan, underwent successful embolization. Four patients with active bleeding underwent unsuccessful angiography. Overall, 23 patients were reoperated on without any completion pancreatectomy, 3 rebled, and 3 (11%) died (including 2 with delayed hemorrhage). CONCLUSIONS: Both embolization and surgery have a role in the management of hemorrhage after PD. For early hemorrhage, reoperation is appropriate. In case of sentinel bleeding, pseudoaneurysms can be detected by computed tomography scan and treated by embolization. For delayed active hemorrhage, reoperation is still indicated.     

胃切除术后上消化道大出血的再手术治疗

目的：探讨和总结胃切除术后上消化道大出血的原因及再手术方法。方法：回顾性分析1986年8月－2000年6月间我院收治11例胃切除术后上消化道大出血再手术病人的临床资料。结果：吻合口出血5例,残胃粘膜损伤出血3例,旷置溃疡出血2例,遗漏病灶出血1例,均再手术治疗痊愈。结论：预防再出血是关键,正确估计再出血病情,把握再手术时机及再手术方式十分重要。     

Overall results in 304 consecutive patients with acute spontaneous subarachnoid hemorrhage

The results obtained in 304 consecutive patients with spontaneous subarachnoid hemorrhage are described, the majority of whom (86%) were admitted while in acute condition. Only 46% of the patients in this series were in good condition at admission. The initial management was standardized for all patients, but the protocol of "delayed surgery" was applied to patients with subarachnoid hemorrhage from aneurysmal rupture. Two hundred and twenty-two patients (73%) had intracranial aneurysms. Of these, 20 (9%) were moribund and died shortly after admission; nine (4%) underwent emergency surgery due to the coexistence of a life-threatening cerebral hematoma; seven (3%) were operated upon within 3 days of admission; 78 (35%) died after rebleeding or after steady deterioration of the patient's condition due to vasospasm while awaiting surgery. Of the remaining 108 patients ready for delayed surgery, 12 (11%) (operation refused, elderly patients in poor general condition, spontaneous thrombosis of the aneurysm) were treated conservatively, and 96 (89%), who were in various clinical conditions, were actually operated on. Of these 96 patients, 79 (82%) exhibited excellent or good results, 5 (5%) were disabled, and 12 (12%) died. In the authors' experience, the overall management of intracranial aneurysms in unselected patients according to the protocol of delayed surgery results in significant loss of patients awaiting surgery, and good surgical results in the survivors.     

门静脉高压断流术后上消化道再出血的治疗策略：附56例报告

目的：探讨门静脉高压断流术后上消化道再出血的原因及分流术的治疗作用。方法：回顾性分析10年间收治的门静脉高压断流术后上消化道再出血56例患者的临床资料。其中54例再次行分流手术，其中急诊手术5例，择期手术49例，包括肠系膜上静脉－下腔静脉人工血管反C型分流术(肠腔分流术)45例，门静脉－下腔静脉分流术5例，肠系膜下静脉－下腔静脉人工血管分流术4例。结果：54例手术治疗者术后出现乳糜漏13例，均治愈;肝性脑病5例，治疗好转4例，死亡1例;术后3d，死于肝衰竭1例。另非手术治疗2例中1例死于肝衰竭;1例死于失血性休克。随访52例，随访时间6个月至9年;随访期间无上消化道再出血病例;死亡7例，其中2死于原发性肝癌，3例死于肝衰竭、肝性脑病，2例死于非相关性疾病。结论：对于门静脉高压断流术后上消化道再出血患者首先采取积极的非手术治疗，然后行择期手术;积极非手术治疗48h无效者，应急诊手术治疗。手术方式首选肠系膜上静脉－下腔静脉人工血管反C型分流术(肠腔分流术)，尤其对伴有门静脉血栓、门脉高压性胃病患者。     

脾腔分流加断流术治疗门静脉高压症上消化道出血

目的　观察脾腔分流加断流联合手术治疗门静脉高压症上消化道出血的疗效。方法　回顾性总结此术式治疗门静脉高压症上消化道出血56例的疗效。结果　手术死亡率为36%,术后近期无出血。远期再出血率41%。肝性脑病发生率为20%。术后1,3,5,10年生存率分别为981%,939%,825%,667%。结论　脾腔分流加断流术,既保留了断流术的优点,又降低了门静脉压力,特别对门静脉高压性胃病出血有较好疗效,并能保持一定量的门静脉向肝血流,有利于肝功能的恢复。     

False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage

OBJECTIVE: Patients with subarachnoid hemorrhage and multiple intracranial aneurysms present a unique challenge to the neurosurgeon. Unless all aneurysms can be clipped through a single craniotomy, the surgeon must accurately determine which aneurysm has ruptured. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true ruptured lesion. We assessed the risk of false localization of the rupture site and subsequent rebleeding and documented the problems in predicting the true rupture site when patients have multiple intracranial aneurysms. METHOD: We reviewed the records of a consecutive series of 93 patients treated over a period of 12 years who presented with their first subarachnoid hemorrhage and who had multiple intracranial aneurysms. The rupture site was determined on the basis of computed tomographic and angiographic findings, and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage in each patient. Additional aneurysms that could not be accessed in the same surgical session were operated on at a later stage. All patients' records were reviewed, and all computed tomographic scans and angiograms, including repeat studies performed in some patients, were retrospectively reevaluated by the authors, who had no knowledge of the patients' clinical information. RESULTS: The location of the aneurysm that ruptured was verified at the time of surgery or during the autopsy in 76 patients (82%). The aneurysm that ruptured was the one predicted as ruptured by the surgeon before surgery in 69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 patients in whom the ruptured aneurysm was not correctly identified were thought to have only a single aneurysm. Four patients rebled after surgery, and 2 patients died as a result of the rebleeding. CONCLUSION: In the reported series, the most common cause of rebleeding soon after aneurysm surgery was failure to obliterate the ruptured aneurysm, usually because it was missed on the initial angiogram. The results support not only meticulous radiological investigation of all intracranial arteries before surgery but also thorough surgical inspection of the target aneurysm in all cases of subarachnoid hemorrhage even after one candidate lesion has been discovered.