Trends and Predictors for Vagotomy When Performing Oversew of Acute Bleeding Duodenal Ulcer in the United States

Background In the era of Helicobacter pylori treatment, the role of vagotomy in bleeding duodenal ulcers is debatable. National outcomes were evaluated to determine the current surgical treatment and use of vagotomy for bleeding duodenal ulcers. Methods Data from the Nationwide Inpatient Sample (NIS) were used from years 1999 to 2003. Patients were selected using diagnostic codes for acute duodenal ulcer bleed and procedure codes for simple oversew of a bleeding ulcer and vagotomy. Data were analyzed using multiple linear and logistic regression. Results Between 1999 and 2003, 100,931 patients with an acute bleeding duodenal ulcer were identified. Over time, there was a decrease in the number of acute bleeding ulcers (p = 0.027) and a decrease in the number of vagotomies (p = 0.027). A high co-morbidity index [odds ratio (OR), 0.60, p = 0.017], operation in the Midwest (OR 0.50, p < 0.001) and operation in the West (OR 0.68, p = 0.034) were predictive of no vagotomy during surgery for a bleeding duodenal ulcer. Conclusions A vagotomy is not commonly performed during surgical treatment of an acute bleeding duodenal ulcer. This variation in practice was not fully explained by patient characteristics. We must seek new evidence to determine the safety of combined medical and surgical management of this clinical problem. Presented at DDW/SSAT May 20–24, Los Angeles, California.     

An Unusual Complication of Gastric Bypass: Perforated Duodenal Ulcer

Peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in only 17 cases.We report a 54-year-old woman with a perforated duodenal ulcer, who had undergone laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity 15 months previously. She was successfully treated by a laparoscopic repair of the perforated duodenal ulcer.     

Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer

Background and aims The aim of this study is to evaluate the predictive accuracy of different scoring systems on surgery for perforated peptic ulcer referred to an academic department of general surgery in a tertiary reference center. Patients and methods Seventy-five consecutive patients (Male/female ratio = 64:11; mean age, 44 years; range, 16–85) with perforated peptic ulcer disease were investigated. Disease severity scores and mortality predictions were calculated using the collected data during admission. Discrimination and calibration characteristics of each system, namely, the acute physiology and chronic health evaluation II and III, the simplified acute physiology score II, and the mortality probability models (MPM) II, were determined by using the area under receiver operating characteristics curve and the Hosmer–Lemeshow goodness-of-fit test, respectively. Results Among the 75 patients included, there were eight (10.6%) mortalities. All systems had a reliable power of discrimination and calibration. Among the systems tested, MPM II was the best performing as far as discrimination and calibration characteristics were considered. The parameters of MPM II system that were related to systemic perfusion of the patient were significantly positive in patients who died compared to those who survived. Conclusions MPM II that predicted mortality at admission is better than the other systems in predicting mortality. Results also indicate the importance of maintenance of systemic perfusion of the patient at the early phases of peptic ulcer perforation.     

重型颅脑损伤后应激性溃疡防治与胃肠道感染的相关性及对策

目的探讨重型颅脑损伤患者应用洛赛克对应激性溃疡进行防治与胃肠道感染几率增加之间的关系及治疗对策。方法回顾近3年来我院收治的重型颅脑损伤并存活30 d以上病人176例,测定不同时间胃液pH值并分析防治应激性溃疡与发生胃肠道感染的相关性以及相应对策。结果在126例持续应用洛赛克的患者中,持续应用＞7 d的患者胃肠道感染发生率明显高于持续应用≤7 d的病人。其余50例间隔应用洛赛克患者与126例持续应用洛赛克患者相比,应激性溃疡发生率无明显差别,但间隔应用洛赛克患者胃肠道感染发生率较持续应用洛赛克＞7 d的患者明显下降。结论重型颅脑损伤患者应激性溃疡防治＞7 d者,由于胃酸分泌严重抑制,增加胃肠道感染发生率。间隔性应用洛赛克治疗在抑制胃酸分泌,减少应激性溃疡发生的同时,可明显减少胃肠道感染的发生。     

自体骨髓单个核细胞移植治疗下肢慢性静脉溃疡的初步研究

目的探讨自体骨髓单个核细胞移植治疗下肢慢性静脉溃疡的疗效。方法 2009年5月-2010年9月,在采用大隐静脉剥脱术基础上,对17例下肢慢性静脉溃疡患者采用自体骨髓单个核细胞移植治疗(移植组),并与同期未采用细胞移植治疗的10例患者(对照组)比较疗效。移植组:男9例,女8例;年龄(33.3±6.1)岁。单纯大隐静脉曲张慢性溃疡11例,单纯深静脉瓣膜功能不全慢性溃疡6例。溃疡面积(4.39±2.46)cm2。病程3个月～6年。对照组:男4例,女6例;年龄(39.2±10.3)岁。单纯大隐静脉曲张慢性溃疡7例,单纯深静脉瓣膜功能不全慢性溃疡3例。溃疡面积(5.51±2.63)cm2。病程3个月～2年。两组按照临床病因解剖病理学分级(CEAP)均为C6级。两组患者一般资料比较差异均无统计学意义(P>0.05),有可比性。观察术后溃疡愈合情况;移植组于术前及术后3 d分别切取溃疡面肉芽组织行常规HE染色,免疫组织化学染色观察VEGF表达和微血管密度(microvessel density,MVD)。结果移植组患者溃疡愈合较快,其中15例愈合,1例好转,1例未愈合,中位愈合时间为22 d,四分位数间距为15 d;对照组溃疡愈合缓慢,其中7例愈合,3例未愈合,中位愈合时间57.5 d,四分位数间距为40 d。两组溃疡愈合时间比较差异有统计学意义(Z=0.001 4,P=0.002 7)。移植组HE染色显示,细胞移植后溃疡肉芽组织有丰富毛细血管结构;免疫组织化学染色示移植后MVD为(32.1±12.8)个,较移植前(22.1±6.7)个显著增加,差异有统计学意义(t=3.120,P=0.008);移植后VEGF表达阳性细胞百分比为8.05%±5.10%,较移植前(6.13%±4.20%)升高,但差异无统计学意义(t=1.150,P=0.268)。结论自体骨髓单个核细胞移植可以促进下肢慢性静脉溃疡肉芽组织增生,加速溃疡愈合。     

腔镜在下肢静脉性溃疡治疗中的应用

目的探讨腔镜在下肢慢性静脉功能不全(CVI)并发静脉性溃疡中的临床治疗经验与疗效。方法回顾性分析2004年5月至2011年4月期间我院应用腔镜治疗78例(88条患肢)下肢CVI并发静脉性溃疡患者的临床资料,患者均行大隐静脉高位结扎+腔内激光治疗(EVLT)+腔镜深筋膜下交通静脉离断术(SEPS)。结果所有患者手术顺利。SEPS手术时间15～30min,平均20min;术中出血量1～5ml,平均2ml;术后住院时间2～8d,平均5d。术后肢体酸胀感和曲张浅静脉消失,色素沉着区缩小。术后筋膜下血肿3例,皮下气肿2例,小腿胫前区及足靴区麻木感3例。所有患者4～6周溃疡愈合,随访0.5～5年,平均3.5年,仅1例复发,是由于足靴区交通静脉残留。结论 SEPS是治疗CVI并发静脉性溃疡的首选方法,具有创伤小、出血少、手术时间短、恢复快、并发症少、疗效显著等特点。     

大鼠慢性皮肤溃疡创面愈合中转化生长因子-β1、胶原Ⅰ、胶原Ⅲ的蛋白表达

目的 观察大鼠慢性皮肤溃疡创面愈合过程中转化生长因子-β1( TGF-β1)、胶原Ⅰ和胶原Ⅲ的蛋白表达。方法 将24只8周龄雌性Wister大鼠分为单纯创面组(A组)和皮瓣+创面组即缺血模型组(B组),每组各12只;苏木素-伊红(HE)染色法观察创面1、3、7、10d上皮化率、收缩率及中性粒细胞;采用酶联免疫吸附试验(ELISA)方法测定创面1、3、7、10 d TGF-β1、Ⅰ型和Ⅲ型胶原的蛋白表达。结果 A组上皮化率在各个时间段均高于B组,且在第7天差异有统计学意义(P＜0.05)。A组收缩率明显低于B组。A组中性粒细胞第1、3天逐渐增加,第3天增加到最多,随后逐渐减少;B组在1、3、7d出现增加趋势,第7天增加到最多,第10天减少。TGF-31含量A组于术后1、3、7、10d呈曲线上升趋势,B组在术后1、3、7d逐渐减低,10 d较7d略有回升,且在第1天两组差异有统计学意义(P＜0.05)。胶原Ⅰ蛋白的含量两组随着术后时间的延长均呈减少趋势,在第10天两组差异有统计学意义(P＜0.05)。胶原Ⅲ蛋白的含量两组随术后时间的延长也呈减少的趋势,但在第3天A组比B组明显增加,差异有统计学意义(P＜0.05)。结论 在缺血的干预因素作用下TGF-β1、Ⅰ型和Ⅲ型胶原蛋白表达的减少可能延迟了慢性创伤的正常愈合。     

聚维酮碘联合云南白药治疗迁延性伤口效果观察

目的观察聚维酮碘敷料联合云南白药治疗老年患者迁延性伤口的效果。方法将60例发生压疮导致迁延性伤口的老年患者按时间顺序分为对照组和观察组各30例。两组常规清创后,均使用聚维酮碘敷料贴于疮面,观察组在此基础上,至疮面缩小至1cm×1cm时,用云南白药外敷。结果两组治疗效果比较,差异无统计学意义(P>0.05);观察组治愈时间显著短于对照组(P<0.05)。结论聚维酮碘敷料联合云南白药能缩短迁延性伤口治疗时间。     

胃十二指肠溃疡大出血的外科手术疗效

目的观察外科手术治疗胃十二指肠溃疡大出血的临床疗效。方法根据58例胃十二指肠溃疡大出血患者的临床表现及身体状况选择适宜的时机行急诊手术或择期手术治疗。结果本组58例患者中行急诊胃大部切除术治疗者37例,行择期胃大部切除术者21例。术后57例患者痊愈出院,痊愈率达98.28%;死亡1例,占1.72%。有3出例患者术后出现了并发症,并发症发生率5.26%。结论对于胃十二指肠溃疡大出血患者在手术治疗时应严格把握手术适应证,并选择适宜的手术时机和手术方式进行治疗能迅速止血,提高其痊愈率。     

改良间歇负压封闭引流治疗压疮疗效观察

目的克服负压封闭引流(VSD)治疗压疮的不足,提供高质量的压疮治疗方法。方法将87例Ⅱ~Ⅳ期压疮患者按分层随机抽样法分为三组。对照组(22例)处理创面后,喷撒利福平粉剂;VSD组(35例)创面应用VSD持续负压吸引;改良VSD组(30例)在常规VSD治疗的基础上,将1个厌氧包压在VSD敷料上,同时每日夜间停止负压吸引12 h。结果三组压疮治疗效果及治愈时间比较,差异有统计学意义(均P<0.01);改良VSD组和VSD组比较,差异无统计学意义(均P>0.05);改良VSD组、VSD组治疗效果均显著高于对照组,治愈时间显著短于对照组(均P<0.05)。改良VSD组匹兹堡睡眠指数量表(PSQI)测评结果除睡眠时间外,其余6个成分及总分显著低于VSD组(均P<0.01)。结论改良间歇VSD治疗在保证与常规VSD治疗同等疗效的前提下,避免了持续吸引带来的噪声、影响睡眠质量、被动体位等不良影响。