外科决定

In managing their patients,surgeons have to make clinical decisions.Looking back,some decisions are correct,while others are incorrect.Does making a wrong clinical decision by a surgeon constitute prof...     

数字化技术助力外科新发展

The in-depth development of digital technologies has brought new changes to surgery.In the new era,surgeons need to know not only the operating skills of the scalpel,but also the manipulation of new di...     

消化外科医师的必备素质

消化外科医师的成长与发展应该是双向的,即自己的主观努力和上级医师的指导、培养。该过程不变的核心概括为“3N”：即Never ignore responsibility（千万不要忽视自己的责任）,Never too old and too much to learn（千万不要终止不断学习）,Never forget the past,otherwise,would be condemned（千万不要忘记思考总结经验教训）。     

胰腺神经内分泌肿瘤的外科治疗

Pancreatic neuroendocrine tumor (pNET) accounts for about 2％ of all malignant pancreatic tumors.According to presence or absence of specific hormone related symptoms,pNET is classified as functional an...     

外科今日:从烙铁到计算机

The reform of medical concepts,development of medical knowledge and innovation of medical techniques bring surgeons from the era of soldering iron to the digital era.In the 21st century,the demand for ...     

精准肝脏外科的现代理念与临床实践

The principles of “precise liver surgery”include to absolutely clearing target lesions,ensuring structural　integrity of residual liver,maximizing the volume of remnant　liver,controlling bleed as well a...     

“外科格言与引语”集萃(一)

Every operation in surgery is an experiment in bacteriology.外科的每一次手术都是一次细菌学实验。——Berkeley Moynihan 1865—1936。As long as surgical infections exist,surgeons must make never-ending efforts to control them.It may be described as a time when science and art can absolutely prevent bacteria from gaining a foothold in the human body and can abruptly terminate their activity,if they have already become established.只要存在外科感染,外科医师控制感染的努力就永无终结。可以说,这是一个科学和技术可以绝对阻止细菌在人体立足的时代,即使它们已经人侵也可即刻令其失去活力。——Frank L Meleney,1889—1963。     

加速康复外科技术对肝肿瘤患者术后恢复的影响

Objective To investigate the effects of fast-track surgery on postoperative rehabilitation of patients with liver cancer. Methods Forty-one patients with liver cancer who had been admitted to Zhongshan Hospital of Fudan University from 9 to 30 in July 2008 were randomly divided into fast-track surgery group (n =20) and routine treatment group (n =21) according to the random number table. Patients in fast-track surgery group were preoperatively educated in order to lessen their anxiety. Bowel preparation was not applied before operation, and they were orally administered with 1000 ml of enteral nutrition emulsion (1300 kcal), then they were fasted for 4 hours before operation. Urethral catheter and gastric tube were removed after operation. They were orally administered with 1000 ml of enteral nutrition emulsion on postoperative day 2, and were encouraged to partake in off-bed activity shortly after the operation. The off-bed time, anus exhaust time, postoperative complica-tions, hospitalization time, expense, nutritional and metabolic indexes on postoperative day 1, 3 and 5, hepatic and renal function, immune and stress indexes between the 2 groups were compared by t test and chi-square test. Results There were significant differences in off-bed time, anus exhaust time, patients' weight, expense, total bilirubin level on postoperative day 1, 3 and 5, and level of serum TNF-α on postoperative day 3 between the 2 groups (t =7.065, 5.483, 3.754, 2.291,2.289, 3.218, 3.192, 2.434, 2.089, P <0.05). Conclusions Fast-track surgery can accelerate the postoperative rehabilitation of patients with liver cancer.     

21例距骨骨折脱位的外科治疗

目的探讨分析急诊外科治疗距骨骨折脱位的疗效.方法回顾分析武汉大学人民医院自2004年1月-2010年1月收治的21例距骨骨折伴脱位患者,均急诊切开复位,松质骨螺钉固定,术后中立位管形石膏固定、保持患肢不负重,视复查X片情况进行功能锻炼.结果 21例患者经急诊手术治疗后随访6个月～3.8年,根据美国足踝外科医师协会(AOFAS)踝-后足评分标准进行评估,优良率为61.91%.结论距骨骨折脱位经急诊手术、解剖复位、有效内固定、术后不负重管形石膏固定等治疗,效果优良,并发症发病率低.

Abstract：

Objective To evaluate the surgical therapy on dislocated fracture of talus. Methods Retrospective analysis was mode in 21 patients with dislocated fracture of talus collected from Jan. 2004 to Jan.2010, which were treated with open reduction, cannulated screw fixation, and kept neutral position plaster fixation with no weight loading, to do functional exercise depending on the Ⅹ film demonstrations. Results All the patients were followed up from 6 months to 3.8 years post-operation, and according to the evaluation standard by American Foot-Ankle Surgery Society, good rate was 61.91%. Conclusion Treating dislocated fracture of talus with emergency operation, anatomical reduction, valid internal fixation and no weight loading plaster fixation post-operation, shows good effect with low rate of complication.     

中晚期胆囊癌的外科治疗策略:附17例报告

目的 探讨中晚期胆囊癌(NevinⅢ～Ⅴ期)的外科治疗方法,进一步提高患者存活时间.方法 结合文献,联系17例中晚期胆囊癌的围手术期临床资料及随访数据,着重从患者术前诊断、手术治疗策略、术后并发症及存活时间等方面进行探讨.结果 通过术前多种影像学资料相互印证,可以诊断中晚期胆囊癌并对分期做出判断,但是不能避免误诊;手术治疗中晚期胆囊癌的要点在于手术范围的确定,特别是淋巴结彻底清扫的程度,本组13a淋巴结阳性率35.3%;8淋巴结阳性率23.5%,说明为了尽量保证肿瘤无残留必要时可适当扩大手术范围;手术后并发症主要包括腹腔感染、胆瘘和麻痹性肠梗阻.结论 中晚期胆囊癌外科治疗需要适当手术范围,术中肿瘤无残留可以使患者存活较长时间.

Abstract：

Objective To explore the optimal surgical treatment strategy of advanced gallbladder carcinoma (Nevin Ⅲ - Ⅴ ), with an aim to prolong patients' overall survival. Methods 17 patients with advanced gallbladder carcinoma were reviewed. Their preoperative diagnosis, surgical treatment, complications and survival time were studied. Results The diagnosis of advanced gallbladder carcinoma was done using different medical imaging techniques, but incorrect diagnosis still happened. There is a wide range of surgical treatment for advanced gallbladder carcinoma. Controversy still exists as whether lymph node resection should be done. In our patients, 35.3% of the 13a lymph nodes and 23. 5% of the 8 lymph nodes were positive for metastasis, which showed that lymph node resection should be carried out. Extended surgery was sometime required to ensure a R0 resection.The main complications of surgery were intraabdominal infection, bile leakage and paralytic ileus.Conclusion An aggressive surgical approach for advanced gallbladder carcinoma is required to ensure a R0 resection, which contributed to better overall survival.     

Reoperative surgery in cholelithiasis

From 1965 to 1980, reoperations for residual or recurrent stones were performed on 78 out of 962 Japanese patients with cholelithiasis. The majority of patients who required reoperation had intrahepatic stones. Most of the causes of reoperation were residual stones due to incomplete removal or the non-detection of intrahepatic stones at the previous surgery. Very careful examination of the intrahepatic biliary trees should be done in patients with biliary tract diseases, because in many, the first operation was done during their youth. To remove the intrahepatic calculi completely, hepatic lobectomy should be considered as a final procedure. The causes of reoperation of common duct stones were residual in 60 per cent and recurrent in 40 per cent. Definitive surgery should be done at the first or at least the second operation to avoid irreversible hepatic disorders which have untoward effects on the prognosis. It is important not only to remove the stones but also to relieve the bile stasis in the biliary tract.     

微创技术在胆道外科应用的现状

Minimally invasive biliary surgery developed rapidly and laparoscopic cholecystectomy has become the"gold standard"for the treatment of benign gallbladder disease.Combined application of endoscopic and ultrasonic technology improved the diagnosis of biliary diseases.Endoscopic balloon dilation or sphincterotomy of duodenal papilla to remove connon bile duct stones and internal biliary stent placement under ERCP for obstructive jaundice caused by biliary tumors provided safe and satisfactory therapeutic effect.However,in the laparoscopic era,minimally invasive techniques should still be used in conjunction with traditional biliary surgery.Meanwhile,strict indication should be emphasized to avoid the occurrence of complications.     

Surgical treatment of choledochal cysts

Biliary cystic disease is uncommon in Asia and very rare in Europe and the Americas. Patients with biliary cysts may present as infants, children, or adults. When patients present as adults, they are more likely to have stones in the gallbladder, common duct, or intrahepatic ducts and to present with biliary colic, acute cholecystitis, cholangitis, or gallstone pancreatitis. With increasing age at presentation, the risks of intrahepatic strictures and stones, segmented hepatic atrophy/hypertrophy, secondary biliary cirrhosis, portal hypertension, and biliary malignancy all increase significantly. Factors to be considered when performing surgery on patients with biliary cystic disease include: (1) age, (2) presenting symptoms, (3) cyst type, (4) associated biliary stones, (5) prior biliary surgery, (6) intrahepatic strictures, (7) hepatic atrophy/hypertrophy, (8) biliary cirrhosis, (9) portal hypertension, and (10) associated biliary malignancy. In general, regardless of age, presenting symptoms, biliary stones, prior surgery or other secondary problems, surgery should include cholecystectomy and excision of extrahepatic cyst(s). With respect to the distal bile duct, the surgical principle should be excision of a portion of the intrapancreatic bile duct with care to not injure the pancreatic duct or a long common channel. Resection of the pancreatic head should be reserved for patients with an established malignancy. With respect to the intrahepatic ducts, surgery should be individualized depending on whether (1) both lobes are involved, (2) strictures and stones are present, (3) cirrhosis has developed, or (4) an associated malignancy is localized or metastatic. When the liver is not cirrhotic, hepatic parenchyma should be preserved even when strictures and stones are present. If cirrhosis is advanced, hepatic transplantation may be indicated, but this sequence of events is unusual. If a malignancy has developed, oncologic principles should be followed. Whenever possible, resection of a localized tumor including adjacent hepatic parenchyma and regional lymph nodes should be performed.     

Early surgery for biliary pancreatitis

Herein, we documented our successful experience in performing definitive biliary tract surgery on patients with biliary pancreatitis as soon as the diagnosis was made and within 48 hours of admission. Early surgery reduced the length of hospital stay and did not result in associated morbidity, death, or complications of acute pancreatitis. The results of the study support the concept that removing obstruction of the pancreatic duct prevents progression of edematous pancreatitis to hemorrhagic pancreatitis. We conclude that patients with acute pancreatitis should be evaluated urgently for the presence of biliary tract stone disease and should be operated on as soon as the diagnosis of biliary pancreatitis is made, that early definitive surgery can be performed safely on patients with biliary pancreatitis, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary should be performed in all patients, and that length of stay for patients with biliary pancreatitis is reduced and morbidity and mortality possibly may be reduced by early surgery as compared with delayed surgery.     

复杂性肝内胆管结石的外科治疗

目的　总结复杂性肝内胆管结石的外科治疗方法及效果。 方法　 总结分析１９９２ ～１９９８ 年外科治疗复杂性肝内多段胆管结石并多处胆管狭窄３５ 例的手术方法,总结显露与切开肝内狭窄段胆管、取出结石、解除狭窄的经验和体会。 结果　３５ 例无手术死亡,术后近期并发感染、胆漏、肝功能不全或消化道出血共７ 例,均治愈;残留结石９ 例,术后经胆道镜取净结石７ 例。随访６ 个月至５ 年６ 个月２４ 例,优良２１ 例（８８ ％ ） ,好转２ 例（８ ％ ） ,无效１ 例（４ ％ ） 。 结论　复杂肝内胆管结石外科治疗的关键是显露和切开肝内各叶段胆管的狭窄段,取出结石、建立通畅的胆流通道。经肝门区或肝方叶可以显露和切开肝门胆管、左右肝管和左内叶、右前叶胆管,经肝膈面切开肝实质进路,可以显露和切开右肝内各叶段胆管。     

肝胆管外科入路的应用解剖

目的探讨在不同肝门解剖结构条件下，肝内及肝门胆管的暴露途径。方法选用成人肝脏标本３０例，沿肝十二指肠韧带向肝门及肝内解剖，观察肝内外胆管的行径特点及其毗邻关系。结果肝管汇合的常见方式有３型，本组左右肝管正常汇合型１８例、二级肝管直接汇合型和右侧胆管变异支异常汇合型分别为６例。肝管行出肝门的水平有较大差异。肝门区管道结构的相互毗邻关系及Ｇｌｉｓｏｎ束在肝内的行径相对恒定。结论在正常的肝门解剖结构条件下，通过解剖肝门的方法可以暴露肝总管及左右肝管，在解剖变异或需要暴露更高位胆管时，可以借助肝正中裂切开法或肝方叶切开法达到暴露目的。     

我国胆道外科发展现状及专科医师管理培训的意义

我国是一个胆道疾病高发的国家，随着时代发展，胆道外科疾病的结构发生了明显变化，胆囊结石、胆道恶性肿瘤发生率明显上升；科学技术的发展给胆道外科带来了新的气象，腹腔镜技术、内镜微创技术、机器人辅助外科系统的应用及三维影像重建技术等影像学的发展，使胆道外科手术方式出现了巨大变化，胆道疾病外科诊治观念面临着更新和拓展。因此，胆道外科专科医师的规范化管理培训显得格外重要。     

Recurrent cholangitis after biliary surgery

After a biliary-enteric anastomosis, the development of cholangitis is usually assumed to be due to obstruction of the stoma. Six patients in whom this was not the case are described. Achlorhydria, duodenal diverticula, and foreign bodies are important predisposing factors. When bacterial contamination is severe in an abnormal intrahepatic biliary tree, especially that which follows long-standing intermittent common duct obstruction, symptomatic biliary infection may occur in the absence of extrahepatic biliary obstruction.     

肝外胆道腔镜手术中胆道造影术的临床意义

通过腹腔镜微创技术不断的发展及完善,腹腔镜胆道外科技术体系已进入精准时代,朝着更安全、高效、微创的方向发展。随着腹腔镜技术的推广,胆道术后并发症发生率有所上升,如何预防其发生是关键所在。目前,常应用术中胆道造影及吲哚菁绿荧光胆道造影技术于腹腔镜胆道术中以预防胆管损伤,明确术中有无结石遗漏及胰胆管变异,了解术中胆总管通畅程度及Oddis括约肌的功能状态。     

带蒂胆囊瓣修复胆管缺损的临床应用

胆管缺损的修复是胆道外科的一个难题。报道了5例带蒂胆囊瓣修复胆管缺损的经验,认为在oddi氏括约肌功能正常,肝内外胆管病变能充分纠正、局部胆管炎症不重等情况下,应用胆囊瓣修复胆管缺损较用其它非胆系材料更符合生理,在条件允许时应努力争取。