三孔法完全腹腔镜永久性粘膜管道式胃造口术

目的:总结三孔法完全腹腔镜永久性粘膜管道式胃造口术的手术经验与技巧。方法:回顾分析2010年8月至2012年10月为11例患者行三孔法完全腹腔镜永久性粘膜管道式胃造口术的临床资料,其中晚期食管癌9例,晚期贲门癌2例,均完全或几乎不能经口进食。结果:本组手术均获成功,无一例中转开腹;手术时间50～120 min,平均(55.0±22.5)min;术中出血量5～30 ml,平均(10.0±7.4)ml;术后住院3～9.5 d,平均(6.0±1.6)d。术后均无并发症发生,胃造口术后顺利开放并维持正常肠内营养。结论:三孔法完全腹腔镜永久性粘膜管道式胃造口术具有操作简便、微创、患者疼痛轻、康复快、启用造口早、安全可靠及舒适等优点,疗效满意,值得推广应用。     

经皮内镜胃联合空肠造瘘在普通外科疾病中的应用(附12例报告)

目的:探讨经皮内镜胃造瘘(percutaneous endoscopic gastrostomy,PEG)联合经皮内镜空肠造瘘(percutaneous endoscopic jejunostomy,PEJ)用于治疗普通外科多种疾病的价值。方法:2003年10月至2008年6月我院为12例普通外科疾病患者行PEG联合PEJ治疗,其中术后胃瘫2例,胆汁回输4例,胰头癌致胃十二指肠不全梗阻6例。结果:12例PEG及PEJ均一次性完成,手术成功率100%。2例造瘘管周围感染,患者PEG/J管发挥作用后逐步停用原有鼻胃(肠)管,改静脉营养补液为肠内营养补液,患者病情明显好转,9例带管出院,3例病情恢复后拔除PEG/J管,瘘口愈合,起到了替代原有鼻胃(肠)管的治疗作用;患者带管期间原有的咽喉部不适等症状消失,满意度高于传统的经鼻胃(肠)管。结论:PEG/J管是建立胃(肠)腔与外界通道的一种非常微创、有效和安全的方法,PEG置管可替代普通外科中大部分较长期的经鼻置胃(肠)管和手术胃(肠)造瘘置管,值得推广。     

完全腹腔镜肝总管-空肠吻合术的临床应用

目的 探讨完全腹腔镜肝总管-空肠吻合术的临床疗效.方法 回顾性分析2011年10月至2013年6月间37例接受腹腔镜肝总管空肠Roux-en-Y吻合术患者的临床资料.观察手术时间、术中出血量、切口长度、术后住院时间、术后胃肠功能恢复时间、切口感染率以及术后胆瘘发生率.结果 37例均完成腹腔镜肝总管空肠Roux-en-Y吻合术,手术时间为（275.4±12.3） min,术中出血量为（83.1±6.3） ml,切口长度为（5.8±0.7） cm,术后胃肠道恢复时间为（43.3±3.2） h,术后住院时间为（12.6±2.2） d.患者切口感染发生率、胆瘘发生率均为5.4%.结论完全腹腔镜肝总管-空肠吻合术安全有效,创伤较小,术后并发症少,适合临床推广应用.     

腹腔镜胃切除后食管残胃和食管空肠吻合新技术

目的 探讨经口腔放置倾斜的圆形抵钉座(OrVilTM装置)进行腹腔镜胃切除后食管残胃和食管空肠吻合的疗效.方法 回顾性分析2009年7月至2011年2月第二军医大学附属长海医院收治的接受OrVilTM装置在腹腔镜下进行消化道重建的34例胃肿瘤患者的临床资料.手术采用4孔法,在完成淋巴结清扫以及食管游离后,先横断食管;然后在食管断端开口,将含OrVilTM装置的胃管从该开口穿出,并将抵钉座带人腹腔;最后在腹腔镜监视下,在体内完成食管残胃或食管空肠吻合.结果 34例患者手术顺利,无中转开腹.其中32例经口腔放置OrVilTM装置顺利;2例经口腔放置OrVilTM装置困难,经放掉患者气管插管气囊内的气体并将其头部后仰后顺利放置.34例患者平均手术时间为175 min(90～240 min);术中平均出血量为196 ml(50～800 ml);术后平均住院时间为7.6 d(5～14 d);术后胃肠功能平均恢复时间为3 d(2～6 d),并开始进食流质饮食和下床活动.术后未出现吻合口漏.33例患者获得随访,平均随访时间为(10±6)个月(2～20个月),无肿瘤复发和转移发生.结论 OrVilTM装置改变了以往抵钉座的置入方向,这一技术可以避免开胸手术,降低腹腔镜下消化道重建的操作难度,缩短手术时问.

Abstract：

Objective To investigate the efficacy of transorally inserted anvil system(OrVilTM)in esophagogastrostomy and esophagojejunostomy after laparoscopic gastrectomy.Methods The clinical data of 34 patients with gastric neoplasms who were installed OrVilTM for esophagogastrostomy or esophagojejunostomy at the Changhai Hospital from July 2009 to February 2011 were retrospectively analyzed.After radical dissection of lymph nodes and full mobilization of esophagus,the esophagus was transected and the anvil was then transorally inserted into the esophagus by using the OrVilTB system.Double-stapling esophagogastrustomy or esophagojejunostomy with a circular stapler Was performed intracorporeally under direct laparuscopic view.Results The surgery was success fully completed in all the 34 patients with no conversion to open surgery.Two patients had difficulty in placing OrVilTM system.and the condition Was alleviated by reducing tension in the cuff and tilting the head back.The mean operation time,volume of blood loss,duration of postoperative hospital stay and time to gastrointestinal function recovery were 175 minutes(range,90-240 minutes),196 ml(range,50-800 ml),7.6 days(range,5-14 days)and 3 days(range,2-6 days).No postoperative anastomotic leakage Was detected.Thirty-three patients were followed up for 2-20 months with a mean time of(10±6)months,and no tumor recurrence or metastasis occurred.Conclusion OrVilTM system changes insert direction of the anvil,which significantly reduces the difficulty of laparoscopic operation,shortens the operation time and avoids the thoracotomy.     

腹腔镜胃旁路术结肠前与结肠后胃空肠吻合术的前瞻性比较研究

目的比较腹腔镜Roux-en—Y胃旁路术（LRYGB）治疗肥胖症术中结肠前与结肠后两种胃空肠吻合术式的疗效差异。方法前瞻性地将2008年3月至2010年7月暨南大学附属第一医院收治的40例肥胖症患者按随机数字表法分为结肠前组（20例）和结肠后组（20例）。比较两种术式术中、术后恢复情况及短期消化道症状。结果所有病例均顺利完成手术。两组术中失血量、术后排气时间、进食半流时间及术后住院时间方面的差异均无统计学意义（均P〉0．05）;但结肠后组手术时间明显长于结肠前组[（163．4±28．1）min比（131．8±22．7）min,P〈0．05]。两组均未出现腹内疝及吻合口瘘等并发症;术后3个月,两组患者消化道症状的差异亦无统计学意义（P〉0．05）。结论尽管LRYGB结肠后胃空肠吻合更加符合生理结构．但在术后短期疗效上结肠前与结肠后吻合术相当．其远期效果有待进一步研究证实。     

完全腹腔镜根治性全胃切除术后食管空肠三角吻合的近期疗效

目的探讨完全腹腔镜根治性全胃切除术中采用食管空肠三角吻合进行消化道重建的近期疗效。方法回顾性分析2013年7月至10月上海交通大学医学院附属瑞金医院收治的5例食管胃结合部腺癌和2例胃体癌患者的临床资料。7例患者进行术前评估后施行腹腔镜根治性全胃切除术,消化道重建采用完全腹腔镜下食管空肠三角吻合。术后每月门诊或电话随访,随访了解进食情况和有无胸骨后烧灼感等,随访时间截至2013年11月。结果7例患者均顺利完成完全腹腔镜根治性全胃切除和消化道重建。手术时间为（234±23）min,其中食管空肠三角吻合时间为（34±7）min,术中出血量为（153±32）mL,平均清扫淋巴结数目为（36±4）枚;术中用60mm钉仓7个。前3例患者消化道重建完成后行术中胃镜检查,吻合口通畅。7例患者术后恢复良好,术后第1天拔除胃管,术后肛门排气时间、进食流质时间以及半流质时间分别为（2．4±0．5）d、（4．0±0．6）d、（5．3±0．5）d,术后无吻合口出血、吻合口漏、吻合口狭窄、腹腔感染等手术相关并发症,无围手术期死亡。前3例患者术后第5天行上消化道造影,造影剂通过顺畅。术后病理分期：IA期3例、IB期2例、ⅡA期1例、ⅡB期1例。术后住院时间为（9．7±1．4）d。患者中位随访时间为3个月,一般情况良好,均可进食软性普通食物,无体质量减轻,无进食哽噎感和胸骨后烧灼感等症状。结论在腹腔镜胃癌根治术中进行食管空肠三角吻合安全可行。该术式吻合口大小不受食管和空肠内径限制,近期疗效满意。     

透视下经皮穿刺胃空肠造瘘术的初步探讨

经皮穿刺胃空肠造瘘术 (percutaneousgastrojejunostomy ,PGJ)在国外已有报道[1] 。笔者自 1997年始开展本研究 ,现报告如下。资料与方法1.一般资料 :本组 13例患者 ,男 9例 ,女 4例 ;年龄 5 4～72岁 ,平均 6 1岁。上段食管癌 6例 ,咽部癌 2例 ,插入鼻饲管不成功。球麻痹 2例 ,脑转移瘤 3例 (肺癌 1例 ,鼻咽癌2例 ) ,不能自主经口进食。鼻饲管置入成功后 ,经鼻饲营养10～ 30d ,平均 12d。2 .方法 :采用美国Cook公司生产的Carey Alzate CoonsPGJ套装。器材主要有 :18G穿刺针、饲管 (10 .2F ,长10 0cm)、扩张器、导引导管、可撕脱鞘、超…     

空肠造瘘术改进

我院自 1995年至今应用胃管行空肠造瘘术 ,并对传统肠造瘘方法进行了改进 ,进行肠内营养 5 0例 ,效果满意。现报告如下。1　方法双荷包缝合 :于空肠造瘘处肠壁行浆肌层双荷包缝合。第一荷包直径 0 5ｃｍ ,第二个荷包位于第一个荷包外 0 3～0 5ｃｍ。于荷包中心切开肠壁 ,插入胃管 ,收紧第一个荷包缝合线。充气 :于荷包处近端肠管 5～ 10ｃｍ、远端肠管 4 0ｃｍ(估计造瘘管插入肠腔内远端处 )各上一把肠钳夹闭肠腔 ,用注射器通过空肠造瘘管充气使肠管膨胀后将胃管下插 4 0ｃｍ。排出肠腔内气体 ,收紧结扎荷包缝合线。固定 :将胃管从腹壁戳…     

胃空肠结肠瘘1例

患者　男 ,30岁。 2 0 0 2年 7月 4日入我院。 6年前因上消化道大出血在当地医院急诊行幽门窦旷置大部切除术(Ｂａｎｃｒｏｆｔ术 ) ,术后恢复顺利。术后第 3年出现腹泻 ,每天 3次左右 ,为稀便 ,量不多 ,含不消化食物 ,多次作钡灌肠检查未发现明显异常 ,按结肠炎治疗 ,无效。 1年前腹泻加重 ,每天 5～ 8次 ,为水样便 ,仍含不消化食物 ,钡灌肠检查未发现异常 ,仍按结肠炎治疗 ,无效 ,逐渐消瘦 ,并出现双下肢水肿。体检 :血压 95/ 55ｍｍＨｇ ,消瘦 ,贫血貌 ,肠鸣音活跃 ,双侧踝部、胫前可凹性水肿。血红蛋白 82 .5ｇ/Ｌ ,血清白蛋白 /球蛋白…     

超声引导下经皮胃腔穿刺充气术在经皮胃造瘘术中的应用

正经皮胃造瘘术主要用于吞咽困难、需长期肠内营养支持的患者,其引导方式主要为胃镜引导(percutaneous endoscopy gastrostomy,PEG)、透视引导(percutaneous radiologic gastrostomy,PRG)及透视联合CT引导。经皮胃造瘘术操作简单、费用低廉,已成为临床建立肠内营养通道的首选方法[1-4];但对于食管严重狭窄、闭塞患者,因胃镜或导管不能通过梗阻段、不能用气体充盈胃     

经皮内镜胃造瘘和小肠造瘘术的临床应用价值

目的 探讨经皮内镜胃造瘘术（PEG）和经皮内镜小肠造瘘术（PEJ）的临床应用价值。方法 总结分析1996年6月至2005年4月121例患者予以PEG和PEJ治疗的临床资料。结果 121例患者共行PEG、PEG加PEJ 134例次，其中90例（103例次）PEG胃肠营养（13例行造瘘管置换）；31例行PEG胃肠减压加PEJ小肠内营养；手术成功率100％。所有患者造瘘管置入后营养迅速恢复，停止静脉补液。4例患者出现造瘘管周围皮下感染。平均随访10个月无严重并发症发生。结论 PEG和PEJ是作为胃肠减压和肠内营养替代鼻饲的一种新的治疗方法，具有安全、并发症少的优点，如有条件应当选用。     

经皮内镜下胃造口、空肠造口及十二指肠造口120例临床分析

目的　探讨经皮内镜下胃造口、空肠造口及十二指肠造口的技术操作及适应证。方法2 0 0 1年 5月— 2 0 0 4年 4月间 ,共行 12 0例经皮内镜下胃肠造口 ,其中 75例经皮内镜下胃造口 (PEG) ,4 2例经皮内镜下空肠造口 (PEJ) ,2例经皮内镜下十二指肠造口 (PED) ,1例直接法经皮内镜下空肠造口(DPEJ)。操作均采用经典经腹壁拉出法技术。结果　采用上述方法共行长期肠内营养 88例 ;胃肠减压 2 5例 ;肠内营养联合胆汁回输 5例 ;围手术期应用PEG 2例 ,术前行胃肠减压 ,术后行长期肠内营养。PEG操作时间平均 (9± 4 )min ,PEJ平均 (17± 6 )min ,DPEJ为 2 0min ,2例PED分别为 10和 12min。技术成功率 98 4 % (12 0 / 12 2 )。严重并发症发生率为 0 8% (1/ 12 0 ) ,轻微并发症发生率为 7 5 %(9/ 12 0 )。结论　经皮内镜下胃肠造口操作简便、有效 ,并发症少。     

PEG/J技术与鼻空肠管在重症急性胰腺炎患者营养支持治疗中的比较

目的:比较经皮内镜引导下胃空肠造瘘(PEG/J)术置管与鼻空肠管行肠内营养(EN)治疗重症急性胰腺炎(SAP)的治疗效果。方法:回顾性分析61例SAP患者的治疗情况,其中15例采用PEG/J术置管行EN治疗(PEG/J组),46例行采用鼻空肠管行EN治疗(鼻空肠管组),比较两组之间的操作时间、患者恢复排便时间、患者血象降至正常所需时间、导管相关肺部感染率、营养管平均留置时间和患者自感舒适度。结果:PEG/J组的操作时间较长,但是恢复排便时间要快于鼻空肠管组,且血象降到正常所需的时间也明显比鼻空肠管组短(均P<0.05);PEG/J组要比鼻空肠管组的留管时间长,但是导管相关肺部感染率要明显低于鼻空肠管组,且PEG/J组患者自感舒适度好于鼻空肠管组(均P<0.05)。结论:早期EN治疗SAP时,PEG/J术置管要比鼻空肠管效果好,而且其并发症少,特别有利于SAP的后期营养支持治疗和病情恢复。     

Single site laparoscopic gastrostomy with a 4-mm bronchoscopic optical grasper

Percutaneous endoscopic gastrostomy (PEG) is a common technique for gastrostomy placement. However, certain children may not be candidates for PEG, such as those with craniofacial or foregut anomalies and prior surgery. Laparoscopic gastrostomy has also gained popularity, but this requires 2 or 3 trocar sites. The use of a larger single operating laparoscope or multiple-port laparoscopic techniques may not be practical in small children and infants. We describe a simple technique for gastrostomy tube placement in infants using a 4-mm operative bronchoscope.A 1.4-kg infant with a cleft palate and hypotonia underwent general anesthesia. A 5-mm laparoscopic port was placed in the left upper quadrant at the site of the intended gastrostomy. Following pneumoperitoneum, a 4-mm bronchoscopic optical grasper was inserted into the abdomen via the single port. The stomach was grasped and pulled out through the port site. The extracorporeal portion of stomach was matured as a gastrostomy. A low-profile gastrostomy button was placed.Proper position of the gastrostomy device was verified intraoperatively using dye. At 2 months follow-up, the child and gastrostomy are without complication.This technique is minimally invasive and provides direct visualization through one 5-mm abdominal port without the requirement of endoscopy and blind percutaneous entrance into the abdominal cavity. This single-site laparoscopic gastrostomy may be a practical alternative for infants who may not be candidates for PEG or larger single-port operating systems.     

First results of laparoscopic gastrostomy

Background: Laparoscopic gastrostomy as an alternative to open gastrostomy was introduced with various technical variants 5 years ago. However, long-term results of these new methods are still lacking. Methods: From 4/1993 to 2/1996, laparoscopic gastrostomies were performed on 42 patients (50.9 ± 15.6 [24–71] years) with esophageal stenosis in locally advanced hypopharyngeal (17 patients) or oropharyngeal (nine patients) carcinoma, incurable esophageal carcinoma (13 patients) and cerebral dyspagia (three patients). Operating time was 38 ± 11 min [15–65 min]. Procedure-related mortality was 0%. Major complications occurred in 2/42 (4.7%) patients; minor complications were found in 4/42 (9.4%) patients. During a total usage time of 427 months, 14 stoma infections occurred (0.11 infections/100 days). Conclusion: Laparoscopic gastrostomy allows a safe, fast, and cheap reestablishment of enteral nutrition. The procedure is minimally invasive and can also be performed under local anesthesia. It has become our method of choice in patients with malignant, nonresectable subtotal stenosis of the hypopharynx or esophagus. Received: 5 March 1996/Accepted: 31 July 1996     

A comparison of techniques for laparoscopic gastrostomy placement in children

Background

The insertion of gastrostomy tube (GT) for children is typically accomplished using a minimally invasive approach. There is considerable variability in the technical details of this operation, depending on how much of the procedure is performed intracorporeal. The purpose of this study is to compare the outcomes and resource utilization of two differing techniques for laparoscopic GT insertion in the pediatric population.

Materials and methods

A single-center retrospective review of all patients who underwent a laparoscopic GT insertion from 2001–2011 was conducted and analyzed based on technique of insertion. This was laparoscopy plus either an intracorporeal Seldinger technique, or an extracorporeal insertion approach, (mini-open technique; [MOT]). Outcomes investigated included short-term complications within the first mo (dislodgement, infection), long-term complications (infection, need for revision, dislodgement), and measures of resource utilization (operative time, material cost, and GT-related hospital visits).

Results

A total of 129 insertions were performed; 87 (67.4%) done using the Seldinger technique, and 42 underwent MOT. Overall, complication rates did not differ between the two groups. Of all patients who underwent a GT placement, 38% were treated for granulation tissue, 27.1% experienced dislodgement, and 23.3% were reported to have a GT-related infection. The MOT approach was associated with a 29% reduction in disposable operating room costs and a 57% reduction in emergency department visits (P < 0.05).

Conclusions

Pediatric patients undergoing laparoscopic gastrostomy tube insertion via the Seldinger or MOT method have similar morbidity risks, although MOT was associated with less overall resource utilization in this study.     

Laparoscopic gastrostomy using T-fasteners as retractors and anchors

Summary Most feeding or venting gastrostomies can be placed percutaneously via gastroscopy. Laparotomy is required if gastroscopy is not possible—for example, in patients with esophageal strictures or large tumors. We have developed a new technique of laparoscopic gastrostomy, and used it successfully in three patients. The key to this technique is the T-fastener, a nylon suture attached to a metal T-bar, which is introduced via a slotted needle percutaneously and dislodged inside the stomach lumen. Four T-fasteners secure the stomach wall to the anterior abdomen. A balloon catheter gastrostomy tube is then placed over a J-wire through the center of these T-fasteners. This technique requires no gastroscopy or intracorporeal suturing and needs only one port for the laparoscope. It is safe and simple and can be used for patients who require a gastrostomy in whom gastroscopy is not possible or is risky.