管型消化道吻合器在胆肠吻合术中的应用

目的探讨管型消化道吻合器在胆肠吻合术中应用的价值及经验。方法对我院2010年1月～2010年3月应用管型消化道吻合器实施胆肠吻合术的31例的临床资料进行回顾性分析。结果手术时间70～128min,平均90min;吻合时间13～25min,平均18min。未发生吻合器吻合导致的肝动脉、门静脉损伤,术后无吻合口漏、出血、狭窄等并发症,无围手术期死亡病例。结论管型消化道吻合器应用于胆肠吻合术,手术时间短,吻合安全可靠,操作简单易行,具有较高的临床应用价值。     

一种新的胃十二指肠吻合方法:“三枪法”胃十二指肠同步切除吻合术

目的探讨一种新的胃十二指肠切除吻合方法在远端胃癌根治术中的可行性和临床疗效。方法回顾性分析2015年1-6月沈阳军区总医院普通外科实施的13例胃远端癌根治术,应用"三枪法"胃十二指肠同步切除吻合术患者的临床资料。其中,8例采用开腹手术,5例采用腹腔镜下手术。该吻合方法利用三枚直线切割闭合器一次性完成胃和十二指的切除及吻合。结果所有13例患者均顺利完成手术,开腹手术吻合平均时间为(11.2±8.5)min,完全腹腔镜下完成平均时间为(20.2±11.5)min,术后首次下床活动时间(1.7±0.8)d,肛门排气时间(3.4±1.5)d,术后住院时间(8.2±2.7)d。术后患者均顺利出院,无吻合口出血、吻合口高张力、吻合口狭窄等并发症。结论 "三枪法"胃十二指肠同步切除吻合术应用于远端癌根治术是安全可行的,近期疗效满意。     

吻合器在胃癌经腹全胃切除术中的应用与评价

目的 评价吻合器在胃癌经腹全胃切狳术中应用的临床效果。方法 回顾性分析148例胃癌、贲门癌患者行全胃切除、管状吻合器消化道重建术的临床资料。结果 本组148例手术均采用管状吻合器完成食管空肠吻合术,一次性吻合成功率100％,发生吻合口漏1例(0.68％),狭窄2例(1.4％),无手术后出血,无手术死亡。吻合口漏1例,经引流等保守治疗后治愈,吻合口狭窄2例,经扩张后治愈,进食状态良好。结论 全胃切除术中使用吻合器有以下优点:简化深部操作,省时省力,具有更大的安全性,降低吻合口漏、出血、吻合口狭窄等并发症发生率。     

消化道重建术后吻合口残端漏微创治疗的护理

吻合口漏是胃肠道术后一种常见和高危手术并发症,一旦发生,可造成腹腔严重感染,继发性腹膜炎。预后差,死亡率高。本科自2003年5月~2006年5月进行胃肠消化道重建术共823例,出现吻合口残端漏12例(占1.46%),其中10例予以微创处理在B超引导下穿刺引流(占83.33%),取得良好的治疗效果。现报道如下:1临床资料与方法1.1一般资料本组10例中,男6例,女4例,年龄52~85岁。其中十二指肠残端漏2例,胃空肠吻合口漏1例,结肠吻合口或残端漏5例,直肠癌骶前吻合口漏2例。早期症状均以腹痛为主,呈进行性加重,其中8例患者疼痛难以忍受,2例患者疼痛可以忍受;早期39…     

食管,贲门癌11例吻合器吻合失败原因分析

1993～1997年,我们在食管、贲门癌根治术中用吻合器吻合464例,其中失败11例(2.4%),现将失败原因分析如下。1　临床资料1.1　一般情况　11例中,男10例,女1例;年龄42～71岁,平均62岁。其中食管中段癌6例,下段癌3例,贲门癌2例。根治术后作胸顶吻合3例,弓上吻合4例,弓下吻合4例。1.2　失败原因　钉合不全4例,其中2例术后发生吻合口漏,1例术后5d死亡。主要原因为抵钉座与机身间距稍大,吻合部钉合过松,造成吻合钉不能充分屈曲为B形。其中2例术中见吻合口钉合不全,改为手工缝合;另2例术后第2天吻合口裂开,出现吻合口漏。手术探查见吻合钉均呈垂直,…     

直肠癌全系膜切除及双吻合器术后吻合口瘘的相关因素分析与防治对策

目的探讨直肠癌行全系膜切除及双吻合器手术切除后吻合口瘘的相关原因及预防、诊断、治疗措施。方法回顾性分析我院2001年1月—2009年6月252例(男159例,女93例)直肠癌患者,行直肠全系膜切除及双吻合器术后吻合口瘘的发生率及治疗情况。结果 该组病例吻合口瘘的发生率为5.6%(14/252);确诊吻合口瘘发生时间为4~9 d,平均为6.8 d。其中8例高流量瘘采用早期横结肠造瘘与腹腔冲洗引流手术;6例低流量瘘采用非手术治疗,骶前双腔管冲洗与肛管固定引流术。2次治疗至出院时间为28~80 d,平均为48.6 d。术后吻合口瘘发生与患者的全身情况、吻合技术、吻合口位置,肿瘤Dukes分期、术前放化疗、是否行预防性造瘘等有相关性。结论术前充分的评估,术中细致的操作及选择性预防性造瘘的应用和围术期合理的处理是预防术后吻合口瘘的关键;术后及时正确的判断,恰当的手术时机的把握,充分的引流、营养支持等综合性措施是治疗吻合口瘘的必要手段。     

器械吻合术后早期胸内食管胃吻合口裂开的诊治

目的总结食管癌、贲门癌切除、器械吻合术后早期胸内食管胃吻合口裂开的原因,探讨预防及诊治方法。方法对6例器械吻合术后早期胸内食管胃吻合口裂开患者再次行开胸手术。结果 5例吻合口裂开发生在2003年以前,2003年后1例,所有患者均在术后24 h内发现,平均为术后18 h。其中5例发现吻合口裂开24 h内行手术治疗,1例于裂开后40 h行吻合口修补;5例术后痊愈出院,1例出现再次吻合口瘘死亡;手术成功率83.3%。结论早期胸内食管胃吻合口裂开与早期吻合器使用技术不熟练有密切关系;及时发现、迅速确诊、果断采取手术修补或重新吻合,可取得较好的治疗效果。术中重视吻合口检查,可避免早期胸内食管胃吻合口瘘的发生。     

男性创伤性复杂性后尿道狭窄的手术治疗

目的 探讨男性创伤性复杂性后尿道狭窄的手术治疗效果.方法 回顾性分析479例诊断为创伤性复杂性后尿道狭窄患者的临床资料.其中422例Ⅰ期行尿道狭窄段切除+端端吻合术,57例行带血管蒂阴囊皮瓣后尿道成形术.结果 手术时间平均115 min(90～140 min),术中平均出血量225 ml(100～300 ml).无一例需术中输血.术后平均随访15个月(12 ～24个月),422例行尿道吻合术的患者中,386例排尿通畅,36例排尿不畅的患者中,再次行排泄性尿道造影提示21例是因为吻合口瓣膜形成,15例因局部存在狭窄环,行尿道瓣膜切除或狭窄环内切开术,术后恢复良好.57例行后尿道成形术患者中,45例排尿通畅;9例患者出现前尿道与皮管吻合口狭窄,其中4例行尿道扩张后好转,5例行尿道狭窄内切开术后好转;3例出现皮管与后尿道或膀胱颈吻合口狭窄,其中1例经尿道扩张后好转,2例行尿道狭窄内切开术后好转.结论 Ⅰ期尿道狭窄段切除+端端吻合术是治疗创伤性复杂性后尿道狭窄的主要方法,病情不允许时可行后尿道成形术.     

尿道带管造影的临床应用价值

目的 探讨尿道带管造影在尿道狭窄(闭锁)手术后的应用价值.方法 男性尿道狭窄(闭锁)患者62例,年龄18～49岁,平均32岁.其中,44例行尿道端端吻合术,18例行黏膜替代尿道成形术.所有患者术后行尿道带管造影.如造影片提示尿道吻合口愈合良好.则拔除导尿管;如造影片提示尿道吻合口愈合不良,则继续留置导尿管,直到尿道带管造影片提示尿道吻合口愈合良好.结果 93.2%的尿道端端吻合术患者术后2～3周拔除导尿管.88.9%的黏膜替代尿道成形术患者术后2～3周拔除导尿管.尿道端端吻合术的手术成功率为88.6%,黏膜替代尿道成形术的手术成功率为83.3%.结论 尿道带管造影可以准确检测尿道狭窄(闭锁)患者手术后尿道吻合口愈合情况,在术后拔除导尿管时间的选择上有重要的指导意义.     

先天性巨结肠28例一期切除吻合临床疗效

目的:探讨双吻合器用于先天性巨结肠一期切除吻合的临床疗效.方法:回顾性分析总结2003年6月～2008年6月用双吻合器在28例先天性巨结肠实施一期根治性切除吻合治疗的情况.结果:28例手术均获成功,无手术死亡.平均手术时间120 min,吻合器所切下的结、直肠组织中,病理检查均找到神经节细胞.并发吻合口瘘2例,均采用非手术治愈;切口裂开1例,腹部感染2例,均治愈.全组病例均治愈出院,平均住院8 d,平均随访18个月;术后排便次数(2～3)次/d,腹胀消失,进食情况良好.结论:双吻合器用于先天性巨结肠一期根治切除吻合术,操作简单,术时短,恢复快,并发症发生率低,临床疗效满意.     

Over-utilisation of radiography in the assessment of stapled colonic anastomoses

We have reviewed the radiological studies in 31 patients who underwent stapled colorectal anastomoses using the EEA staple gun. In 10 patients there was clinical evidence to suggest anastomotic dehiscence. Nine of these patients had a disrupted staple ring on plain abdominal radiograph. In these days of audit and financial constraint, we suggest that radiological investigation should be reversed for those patients with questionable clinical evidence of an anastomotic leak.     

晚期贲门癌切除后食管胃隧道吻合术加胸膜包盖18例

目的探讨晚期贲门癌根治术后预防吻合口瘘及吻合口狭窄的方法。方法对晚期贲门癌根治术后采用隧道式吻合加壁层胸膜包盖。结果1998年1月—2004年8月对18例III期贲门癌根治术患者采用此方法,无吻合瘘、吻合口狭窄及手术死亡者。结论这种吻合方法具有以下优点:(1)壁层胸膜粘连愈合力强;(2)对吻合口包盖严密可靠;(3)壁层胸膜可紧贴在吻合口上,不留残腔,可促进粘连。(4)壁层胸膜取材方便。     

CT assessment of anastomotic bowel leak

AIM: To evaluate the predictors of clinically important gastrointestinal anastomotic leaks using multidetector computed tomography (CT). SUBJECTS AND METHODS: Ninety-nine patients, 73 with clinical suspicion of anastomotic bowel leak and 26 non-bowel surgery controls underwent CT to investigate postoperative sepsis. Fifty patients had undergone large bowel and 23 small bowel anastomoses. The time interval from surgery was 3-30 days (mean 10+/-5.9 SD) for the anastomotic group and 3-40 days (mean 14+/-11 SD) for the control group (p=0.3). Two radiologists blinded to the final results reviewed the CT examinations in consensus and recorded the presence of peri-anastomotic air, fluid or combination of the two; distant loculated fluid or combination of fluid and air; free air or fluid; and intestinal contrast leak. Final diagnosis of clinically important anastomotic leak (CIAL) was confirmed at surgery or by chart review of predetermined clinical and laboratory criteria. RESULTS: The prevalence of CIAL in the group undergoing CT was 31.5% (23/73). The CT examinations with documented leak were performed 5-28 (mean; 11.4+/-6 SD) days after surgery. Nine patients required repeat operation, 10 percutaneous abscess drainage, two percutaneous drainage followed by surgery, and two prolonged antibiotic treatment and total parenteral nutrition (TPN). Of the CT features examined, only peri-anastomotic loculated fluid containing air was more frequently seen in the CIAL group as opposed to the no leak group (p=0.04). There was no intestinal contrast leakage in this cohort. Free air was present up to 9 days and loculated air up to 26 days without CIAL. CONCLUSION: Most postoperative CT features overlap between patients with and without CIAL. The only feature seen statistically more frequently with CIAL is peri-anastomotic loculated fluid containing air.     

Anastomotic strictures of the upper gastrointestinal tract: results of balloon dilation

Enteroenteric anastomotic strictures of the upper gastrointestinal tract are common and require treatment if significant obstruction occurs. The authors performed 44 fluoroscopically guided balloon dilations in 19 patients with symptomatic anastomotic strictures. The anastomoses were esophagoesophageal (n = 5), esophagogastric (n = 8), esophagoileocolonic (n = 4), and gastrojejunal (n = 2). Nine patients required only one balloon dilation for stricture lysis and relief of clinical symptoms. Recurrent symptoms developed in the remaining ten patients, who required two to eight dilations. Radiographically, stenoses made up 40%-90% of the anastomotic lumen before dilation (mean, 72%). Complete resolution of the stricture was achieved during the procedure in 24 instances. Residual stenosis in 18 instances varied from 7% to 45% (mean, 21%). Two complications, a mucosal tear and a perforation, were immediately recognized and successfully treated non-operatively. The authors conclude that fluoroscopically guided balloon dilation has an important role in the treatment of anastomotic strictures of the upper gastrointestinal tract.     

Sonography accurately detects biliary obstruction in patients with surgically created biliary-enteric anastomosis

The use of sonography to determine the patency of surgically created biliary-enteric anastomoses has been questioned by authors who favor use of cholescintigraphy and percutaneous transhepatic cholangiography for this purpose. We retrospectively reviewed the sonographic findings in 35 patients with such anastomoses: 16 choledochojejunostomies, 11 choledochoduodenostomies, five intrahepatic cholangiojejunostomies, and three cholecystoenterostomies. The anastomosis was patent in 25 patients, completely obstructed in four, and partially obstructed in six. Five of the 25 patients with patent anastomoses had nonanastomotic complications with biliary stasis and cholangitis. In the 20 patients with patent anastomoses and no complication, sonography showed bile ducts ranging from 2 to 9 mm in diameter filled with bile (six), gas (two), or both (12). No patient with a normally functioning anastomosis had evidence of a dilated bile-filled duct in the upright position. In four patients with complete obstruction of the anastomosis, sonography showed dilated, bile-filled ducts ranging from 6 to 14 mm in diameter proximal to the anastomosis. Sonograms in all six patients with partial obstruction showed both gas and bile in dilated bile ducts with superficial gas-filled ducts and dependent bile-filled ducts creating gas/fluid interfaces, which were persistent in the upright position. The 15 patients with anastomotic obstruction or other complication had confirmatory percutaneous transhepatic cholangiography (nine patients), scintigraphy (five patients), CT (four patients), and surgery (eight patients). Our experience suggests that sonography can be used to accurately assess surgically created biliary-enteric anastomoses for both anastomotic patency and for other complications.     

Transverse anastomoses of the veins at the base of the brain

Summary Venous anastomoses at the base of the brain are represented by the anterior and posterior communicating veins. The anterior communicating vein anastomoses with the anterior cerebral veins. The posterioir communicating veins join the basal veins through the interpenduncular veins. The functional value of these venous anastomoses is less important than that of the arterial polygon of Willis. This anastomotic function depends on anatomical constancy and on the calibre of these transverse veins. Under certain pathological conditions the variations of intracranial pressure result in contralateral venous drainage through these anterior and posterior anastomotic veins.Presented at the 5th Congress of the European Society of Neuroradiology-GEILO (Norway), 4–6 September 1975.     

The double wire technique: an improved method for treating challenging ureteroileal anastomotic strictures and occlusions

Up to 10% of patients who undergo ileal conduit urinary diversion may go on to develop ureteroileal anastomotic stenosis (UIAS); this can lead to recurrent urinary tract infections and deterioration in renal function. Classical management has been open revision of the anastomosis. We describe a novel technique that allows balloon dilatation and ureteral stent placement in a retrograde fashion. All patients in this study had undergone radical cystectomy and ileal conduit formation with Wallace type end-to-end refluxing uretero-intestinal anastomosis. After initial retrograde loopogram, a 6F MPA-1 catheter and an 0.035 inch extra stiff guide was passed to the distal ostium. Subsequently, a customised 8F bright tip MPA-1 guiding catheter was advanced over the guide wire which allowed effective splinting of the equipment to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastomosis. Results show that a total of ten anastomoses were treated; nine anastomoses were successfully treated with a primary retrograde approach with no intra or post-procedural complications. After a mean follow-up of 19 months (5-33 months), as assessed by ascending loopograms, all anastomoses remained open. In conclusion, morbidity of open surgery has resulted in the popularization of endourological techniques in treating anastomotic stenoses. However, key to these endourological techniques is access to the anastomosis; typically, this has been via a percutaneously placed nephrostomy. The ideal route to the anastomosis is via a retrograde approach; we have illustrated a safe and successful novel technique that utilized two guidewires and a guiding catheter, allowing retrograde ureteral access.     

Postoperative radiologic follow-up of rectocolonic anastomoses. The visualization of fistulous passages after evacuation

The early postoperative study of colo-rectal anastomoses is a common diagnostic procedure with symptomatic patients which is extended to asymptomatic patients by some authors. Eighty-eight anastomotic fistulas were early diagnosed after intervention in 316 patients who underwent a water-soluble contrast enema. Four out of these fistulas (4.5%) could not be demonstrated at complete filling on X-ray, but were only opacified on radiographs taken after the spontaneous evacuation of contrast medium. The increase in endoluminal pressure due to the evacuation and the lack of balloon catheter probably play a role in allowing these fistulas to be visualized.     

65岁以上老年人腹部手术并发症分析

目的 探讨65岁以上老年人腹部手术术后并发症的特点及预防措施,提高外科治疗水平.方法 回顾性分析我院2006年10月-2009年10月间256例65岁以上老年患者腹部手术的临床资料.结果 术后并发症：术后早期肠梗阻12例,吻合口漏14例,腹腔感染8例,猝死6例,肺部感染6例,心功能不全15例,下肢深静脉血栓形成7例,切口感染、裂开16例,死亡10例.结论 65岁以上行腹部手术的老年患者常合并心脏病、肺部疾病、糖尿病等疾病,术后并发症较多,加强围手术期处理仍可使老年患者耐受腹部手术,降低病死率和并发症的发生率.     

Temporary Placement of Stent Grafts in Postsurgical Benign Biliary Strictures: a Single Center Experience

Objective

To evaluate the effect of temporary stent graft placement in the treatment of benign anastomotic biliary strictures.

Materials and Methods

Nine patients, five women and four men, 22-64 years old (mean, 47.5 years), with chronic benign biliary anastomotic strictures, refractory to repeated balloon dilations, were treated by prolonged, temporary placement of stent-grafts. Four patients had strictures following a liver transplantation; three of them in bilio-enteric anastomoses and one in a choledocho-choledochostomy. Four of the other five patients had strictures at bilio-enteric anastomoses, which developed after complications following laparoscopic cholecystectomies and in one after a Whipple procedure for duodenal carcinoma. In eight patients, balloon-expandable stent-grafts were placed and one patient was treated by insertion of a self-expanding stent-graft.

Results

In the transplant group, treatment of patients with bilio-enteric anastomoses was unsuccessful (mean stent duration, 30 days). The patient treated for stenosis in the choledocho-choledochostomy responded well to consecutive self-expanding stent-graft placement (total placement duration, 112 days). All patients with bilio-enteric anastomoses in the non-transplant group were treated successfully with stent-grafts (mean placement duration, 37 days).

Conclusion

Treatment of benign biliary strictures with temporary placement of stent-grafts has a positive effect, but is less successful in patients with strictures developed following a liver transplant.