腹主动脉瘤破裂急诊手术与非破裂择期手术对比分析

目的总结腹主动脉瘤破裂（ruptured abdominal aortic aneurysm，RAAA）急诊手术的治疗经验。方法回顾性分析25例RAAA急诊救治过程，并与同期完成的48例择期腹主动脉瘤（abdominal aortic aneurysm，AAA）切除术在输血量、ICU住院天数、瘤体最大直径和死亡率等指标分别进行统计分析比较。结果RAAA急诊手术与择期AAA切除术患者比较，围手术期输血量（2980±2712）ml和（580±314）ml；ICU住院天数（6．8±5．7）d和（2．5±1．5）d；手术死亡率32％（8／25）和2．1％（1／48），差异均有统计学意义（P〈0．01）；瘤体直径（5．9±1．4）cm和（5．3±1．4）cm者差异无统计学意义（P〉0．05）；术后并发症有：脑卒中、肾功能衰竭、成人呼吸窘迫综合征和消化道出血。结论AAA一经发现，应选择尽早择期手术，合理的抢救措施有助于降低RAAA手术死亡率。     

破裂腹主动脉瘤的外科治疗及预后

目的探讨破裂腹主动脉瘤的诊断、治疗方法及影响预后的因素。方法回顾性分析1999年4月至2005年12月期间我院收治的23例肾动脉下破裂腹主动脉瘤患者的临床资料，其中男15例，女8例；年龄35～78岁，平均65岁。自知有腹主动脉瘤者7例，有腹部搏动性包块者6例，术前行急诊彩超和（或）CT检查确诊15例。所有患者均行急诊手术治疗。根据术中情况采取肾动脉下腹主动脉钳夹阻断或腹主动脉腔内球囊阻断，控制出血后行人造血管移植术。结果手术后30d内死亡9例（39％），死亡原因为出血性休克所致的急性肾功能衰竭4例、多器官功能衰竭3例、呼吸循环衰竭2例。结论手术治疗是对破裂腹主动脉瘤的有效治疗，根据术中情况采取不同的方法阻断破裂口近端腹主动脉以控制出血是手术的关键。急性心脑血管疾病、急性肾功能衰竭及肺部并发症是术后的主要并发症及死亡原因。     

3D影像融合技术用于腔内介入治疗主动脉病变

目的 分析3D影像融合技术用于腔内介入治疗主动脉病变的价值。方法 回顾性分析18例接受3D影像融合引导腔内介入治疗主动脉病变患者。于Siemens Artis Pheno工作站以Syngo-X-workshop软件将术前主动脉CT血管造影（CTA）与术中锥形束CT （CBCT）图像进行融合,分别于T10~L3椎体水平进行冠状位、矢状位及轴位3个维度的配对融合,将最终形成的3D融合影像投射至实时数字减影血管造影（DSA）影像中,用于导引主动脉腔内介入操作。记录治疗用时、碘对比剂用量及射线剂量等。结果 18例中,腹主动脉瘤7例、主动脉穿透性溃疡5例、胸主动脉夹层4例、胸主动脉瘤2例;对11例行腹主动脉瘤腔内修复术（EVAR）、7例行胸主动脉腔内修复术（TEVAR）,均获得成功,技术成功率100%;治疗用时（124.28±55.95） min,碘对比剂用量（178.89±37.87） ml,辐照时间（20.21±13.20） min,CBCT辐射剂量（225.17±60.10） mGy,总辐射剂量（815.68±439.10） mGy。7例术前合并肾功能不全,术后24 h、出院前及术后1、3个月血肌酐值与术前比较差异均无统计学意义（P均>0.05）。结论 3D影像融合技术用于腔内介入治疗主动脉病变安全、可行。     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

腹主动脉瘤破裂18例救治体会

１８例腹主动脉瘤破裂，１６例经手术治疗。手术方法主要为腹主动脉瘤切除人造血管植入术，围手术期死亡６例（３７５％）。为提高病人生存率，一旦腹主动脉瘤诊断成立，应积极行择期手术治疗。腹主动脉瘤破裂后，正确及时的诊断尤为重要。手术时应注意阻断腹主动脉的方法以及防止术后下肢缺血     

肺动脉发育不良的法洛四联症分期手术37例

目的探讨肺动脉发育不良的法洛四联症分期手术的临床效果。方法1996年6月至2006年6月，治疗37例法洛四联症病儿男26例，女11例。年龄5个月-17岁，平均3．6岁；体重4．6-38．0kg。均明确诊断为法洛四联症伴肺动脉发育不良。术前动脉血氧饱和度（SatO2）平均为0．68±0．07；McGoon比值0．81-1．17，平均0．95±0．26；Nakata指数为71．6-97．5mm^3/m^2，平均（82．7±21．6）mm^3／m^2。一期手术行升主动脉-主肺动脉中央分流术17例，左侧改良Blalock-Taussig术13例，右侧7例。结果37例一期分流术无早、晚期死亡，5例术后出现胸腔积液。分流术后，SatO2提高至0．91±0．10（P〈0．01），血红蛋白由术前的（15．6±2．7）g／L降至（12．5±2．2）g／L（P〈0．05）。全组均于分流术后6-31个月（平均10．7个月）行二期法洛四联症根治术。其时McGoon比1．82±0．43，较一期术前显著升高（P〈0．01），Nakata指数176．8±46．8，显著高于一期术前（P〈0．01）。二期根治手术后早期死亡1例（2．7％），无晚期死亡。结论法洛四联症伴肺动脉发育不良病儿，分期手术可改善缺氧状况，促进肺动脉发育，提高二期根治手术的成功率。     

腺病毒介导TIMP-2基因转染抑制大鼠腹主动脉细胞外基质降解的实验研究

目的利用大鼠腹主动脉瘤模型，在腹主动脉局部灌注携载基质金属蛋白酶组织抑制剂-2（TIMP-2）基因的腺病毒溶液，应用形态学及组织病理学手段评价其对血管壁基质降解的影响。方法建立大鼠腹主动脉瘤弹力蛋白酶灌注模型，将通过基因重组技术构建成功的腺病毒质粒AdTIMP-2灌注至主动脉局部。2周后处死大鼠，取动脉标本行多聚甲醛灌注固定，常规石蜡包埋，对标本进行大体观察、组织病理学常规及特殊染色观察。结果灌注后14d AdCMV组和PBS组腹主动脉直径分别为（3．52±0．11）mm和（3．43±0．09）mm，明显大于AdTIMP-2组的（2．33±0．06）mm，P〈0．05；腹主动脉直径增加百分比AdTIMP-2组为（48±4）％，明显低于AdCMV组的（120±6）％和PBS组的（118±5）％，P〈0．05；AdTIMP-2组的8只大鼠均未见腹主动脉瘤形成，而AdCMV组和PBS组8只大鼠均见主动脉形成瘤样扩张；AdTIMP-2组中层弹力纤维及胶原纤维保存较完整，破坏较轻，在动脉外膜可见炎症细胞浸润。结论腺病毒介导的TIMP-2基因转染可以恢复由蛋白溶解酶引起的细胞外基质降解，阻止动脉瘤的形成，为治疗腹主动脉瘤提供了新的策略。     

表现为急性胆囊炎的胆囊癌25例分析

目的：探讨老年人胆囊癌的临床特点，避免表现为急性胆囊炎的老年人胆囊癌行腹腔镜胆囊切除术。方法：回顾分析1995年1月-2005年12月表现为急性胆囊炎的老年患者（≥60岁）109例，其中术中或术后发现胆囊癌25例（均经病理证实），将此组患者与其余非肿瘤患者的术前临床资料包括术前肝功能等进行统计分析。结果：胆囊癌组25例，12例行剖腹探查，13例行腹腔镜手术。14例术中行快速冰冻切片示恶性而扩大手术或中转开腹，其余11例术后病理证实恶性肿瘤。非肿瘤组84例，34例行开腹手术，50例行腹腔镜手术，14例中转开腹。术前肿瘤组与非肿瘤组的肝功能变化有显著差异，主要为总胆红素TBil（83．4±131．2）μmol／L和（20．6±13．9）μmol／L，（P〈0．05）；直接胆红素DBil（55．1±77．4）tunol／L和（7．3±5．2）μmol／L，（P〈0．05）；AST（96．1±89．7）IU／L和（44．3±29．1）IU／L，（P〈0．05）；GGTP（512．1±871．8）IU／L和（99．8±101．3）IU／L，（P〈0．05）；AKP（433．7±272．5）IU／L和（98．7±47．4）IU／L，（P〈0．01）。结论：对于某些肝酶标异常的老年人急性胆囊炎，有胆囊癌可能。应进一步完善影像学检查，手术以直接开腹为宜。     

冠状动脉旁路移植手术方式对甲状腺激素代谢的影响

目的观察体外循环（on-pump）心脏停跳下和非体外循环（off-pump）心脏不停跳冠状动脉旁路移植手术围术期甲状腺激素的变化规律。方法冠脉旁路手术病人40例，分为Off-pump组和Onpump组，每组20例，分别测定围术期甲状腺功能指标。结果术前两组病例甲状腺功能指标均在正常值范围内。Off-pump组T3和FT3术后显著下降，术后第1d降至最低[（T3：（39．7±6．2）ng，dl对（78．6±12．1）mg/dl，P〈0．01；FT3（1．6±0．5）pg/ml对（2．4±0．6）pg/ml，P〈0．05]；T4在正常值范围内变化，术后第1d降至最低[（5．3±0．8）μg/dl对（7．2±0．7）μg/dl，P〈0．05]；FT4在正常值范围内波动，各阶段检测值与术前差异无统计学意义（P〉0．05）；rT3术后逐渐升高，术后第3d达高峰[（82．1±26．8）ng/dl对（42．3±15．6）ng/dl，P〈0．01]；TSH术中逐渐下降，术后第1d降至最低[（0．4±0．2）tdU／ml对（1．3±0．6）μIU／ml，P〈0．01]，术后第7d恢复术前水平。围术期两组病例甲状腺功能指标变化趋势相似，差异无统计学意义（P〉0．05）。结论On-pump与Off-pump下冠状动脉旁路移植手术均影响甲状腺激素代谢，两组病人术后均存在低B综合征。     

再次肝移植的临床经验和体会

目的总结再次肝移植的临床经验，提高再次肝移植患者的存活率。方法14例再次肝移植患者，其再次肝移植的原因分别为缺血性胆道并发症（9例）、急性肝动脉血栓形成（2例）、慢性排斥反应（2例）及重度药物性肝损害（1例）。再次肝移植均采用改良背驮式，供、受者的门静脉均采用端端吻合；8例供、受者的肝动脉仍行端端吻合，6例供肝动脉经搭桥与受者的腹主动脉吻合；2例的供肝胆管与受者的空肠行Roux-en-Y吻合，12例的胆管行端端吻合。结果14例患者首次和再次肝移植术前终末期肝病模型评分分别为16．4±7．2和22．5±7．9（P〈0．05），手术耗时分别为（553．3±85．4）min和（796．4±125．2）min（P〈0．05），无肝期时间分别为（63．4±29．6）min和（102±32．8）min（P〈0．05），术中出血量分别为（1537．3±348．3）ml和（2589．3±429．7）ml（P〈0．05）。14例中，死亡4例，均为MELD评分≥25分者。结论术前科学评估患者的病情、把握手术时机、提高手术技巧及防治术后感染是提高再次肝移植成功率的关键。     

Ruptured abdominal aortic aneurysm: a novel method of outcome prediction using neural network technology.

BACKGROUND: reported survival following emergency surgery for ruptured abdominal aortic aneurysm (RAAA) varies widely between institutions. This is largely attributable to differences in case mix. The aim of this study was to identify and evaluate a set of prognostic variables that would accurately predict outcome for individual patients from perioperative indices. METHODS: perioperative factors associated with subsequent mortality at our institution were identified by retrospective review of 102 consecutive operations for RAAA over a 7-year period (January 1990 to January 1997). Logistic regression analysis was used to select the most significant variables associated with subsequent mortality. These were used to construct, train, and validate a neural network designed to predict survival from surgery in individual cases on a prospective basis. RESULTS: the 30-day mortality rate was 53%. Multivariate analysis identified four highly significant independent predictors of mortality; preoperative hypotension, intraperitoneal rupture, preoperative coagulopathy, and preoperative cardiac arrest. Using these inputs, the neural network correctly predicted outcome in 82.5% of individual cases. CONCLUSION: a neural network based on just four perioperative variables can accurately predict outcome of RAAA. Prognostic variables should be reported in studies as a measure of the effect of case mix on survival data. Neural networks have potential to aid decision-making relating to outcome for individual cases.     

院内发生的腹主动脉瘤破裂诊治

目的 总结5例院内发生的腹主动脉瘤破裂的救治经验.方法 对2006年1月～2009年12月我院5例院内发生的腹主动脉瘤破裂患者的临床资料进行回顾性分析.结果 1例因出血性休克所致急性呼吸循环衰竭死亡;其余4例患者采用开腹手术救治,行肾动脉下腹主动脉阻断,采用自体血液回输,行急诊腹主动脉瘤切除人造血管移植术,4例手术成功,随访6～38个月,无并发症发生.结论 手术治疗腹主动脉瘤破裂是有效治疗方法,对于非腹部疾病引起的住院腹主动脉瘤患者特别是有明确诱因患者,采取术前降低血压并紧急外科手术治疗是降低破裂腹主动脉瘤死亡率的关键.     

Survival of ruptured abdominal aortic aneurysms in the west of Ireland: do prognostic indicators of outcome exist?

Ruptured abdominal aortic aneurysm (RAAA) is a demanding vascular surgical problem and the cause of significant morbidity and mortality. The aim of this study was to identify prognostic factors that influence outcome. Over 6 years, 42 ruptured abdominal aortic aneurysms were operated on with a mean diameter of 7.2 cm. RAAA was defined as free intraperitoneal rupture. Data were collected retrospectively from hospital medical records. The male: female ratio was 8:1 and the mean age was 74 years (range 55-89). Fifteen were in hypovolemic shock and 27 patients were clinically stable. The perioperative mortality rate for the 15 shocked patients was 60% (9 patients) and the 1-year cumulative survival rate was 33%. The perioperative mortality rate for the 27 clinically stable patients was 40% (11 patients) and the 1-year cumulative survival rate was 56%. Survival curves were constructed for these groups to compare male versus female, age >/= 70 versus age < 70, shocked versus stable, and preoperative hemoglobin (Hb) 10. No patient with preoperative cardiac arrest survived more than 24 hours. With VassarStats, the confidence interval for age, gender, hemodynamic status, and preoperative Hb were calculated. The standard weighted mean analysis by ANOVA gave a p value of < 0.001. The overall 30-day mortality rate was 47% (20 of 42) and the 1-year mortality rate was 52% (22 of 42). Male patients over 70 years with RAAA in hypovolemic shock with low Hb have a higher 30-day mortality rate and few survive more than 1 year. The study suggests that each of these 4 parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.     

Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.     

破裂性腹主动脉瘤的治疗

目的探讨破裂性腹主动脉瘤急诊救治的治疗经验。方法回顾性研究2002年5月-2013年7月救治的36例破裂性腹主动脉瘤患者的临床资料。其中25例合并高血压病,21例合并慢性阻塞性肺疾病。33例采取急诊开腹主动脉人工血管置换术;3例采取主动脉覆膜支架腔内修复术,其中1例中转开腹手术治疗。结果术后33例存活,另外3例死亡,死亡原因包括1例失血性休克和心功能衰竭,1例术中心跳骤停,1例术后多器官功能衰竭,围手术期病死率为8．3％。术后随访3～61个月,未发生人工血管感染等手术相关并发症及死亡病例。结论积极的手术治疗是提高破裂性腹主动脉瘤患者救治成功率的关键,早期明确诊断,手术中快速有效控制近端瘤颈血流,完善围手术期治疗能有效降低病死率。     

A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm.

OBJECTIVES: The purpose of this study was to perform the first statewide, population-based, time-series analysis of the frequency of ruptured abdominal aortic aneurysm (RAAA), to determine the outcomes of RAAA, and to assess the association of patient, physician, and hospital factors with survival after RAAA. The hypotheses of the study were as follows: 1) the rate of RAAA would increase over time and 2) patient, surgeon, and hospital factors would be associated with survival. BACKGROUND: Ruptured abdominal aortic aneurysm is a life-threatening emergency that presents the surgeon with a technically demanding challenge that must be met and surmounted in a short time if the patient is to survive. METHODS: Data were obtained from the following four separate data sources: 1) the North Carolina Hospital Discharge database, 2) the North Carolina American Hospital Association database, 3) the North Carolina State Medical Examiner's database, and 4) the Area Resource File. All patients with the diagnosis of an abdominal aortic aneurysm (AAA) were selected for initial assessment. Patients were grouped into those with and those without rupture of the abdominal aneurysm. RESULTS: During the 6 years of the study, 14,138 patients were admitted with a diagnosis of AAA. Of these, 1480 (10%) had an RAAA. The yearly number of patients with elective AAAs increased 33% from 1889 in 1988 to 2518 in 1993. The yearly number of RAAAs increased 27% from 203 to 258. The mortality rate for AAA was 5%, as compared with 54% in RAAA patients. The patient's age was found to be the most powerful predictor of survival. Univariate logistic regression analyses demonstrated an association of the surgeon's experience with RAAA and patient survival after RAAA. Analysis of the survival rates of board-certified and nonboard-certified surgeons demonstrated that patients with RAAAs who were treated by board-certified surgeons had significantly better survival. When the survival was compared in small (less than 100 beds) and large (more than 100 beds) hospitals, survival was significantly better in the larger hospitals. CONCLUSIONS: Ruptured abdominal aortic aneurysm remains a highly lethal lesion, even in the best of hands. Despite the many improvements in the care of seriously ill patients, there was no significant improvement in the survival of RAAA during this study. This suggests that early diagnosis is the best hope of survival in these patients. The study demonstrated that survival after RAAA was related most strongly to patient age at the time of the RAAA. The physician's and the hospital's experience with RAAA, the physician's background as measured by board certification, and the type of hospital at which the operation was performed (small vs. large) also may be associated with survival. These findings may have important implications for the regionalization of care and the education and credentialling of physicians. Given the lack of recent progress of improving the outcome of RAAA, aggressive efforts to treat patients before rupture are appropriate.     

九例腹主动脉瘤破裂死亡原因分析

目的分析总结腹主动脉瘤破裂的死亡原因与救治经验。方法回顾性分析2001-2005年23例腹主动脉瘤破裂手术治疗后9例死亡病例的临床资料。结果23例中死亡9例,术前均伴有休克,总死亡率约39．1％。术前伴发高血压7例、COPD 1例、慢性肾功不全1例。其破裂类型包括向前壁开放性破裂5例;向脊柱左侧方破裂3例;向后方破裂1例。破裂部位分别为肾动脉3例、肾下腹主动脉领域6例。术后分别死于ARDS 4例、急性肾衰2例、人工血管感染2例、DIC 1例。结论死亡率与就诊时的休克状态、破裂部位和类型、术后并发症、人工血管感染密切相关,及时正确地诊断救治、加强围手术期监护有利于降低死亡率。     

Abdominal aortic aneurysm surgery in a district general hospital: a 15-years experience

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.