甲状腺术后并发症分析

目的　探讨甲状腺术后并发症与甲状腺原发疾病、手术方式以及手术操作的关系。方法　分析我院 1990～ 2 0 0 1年间收治的 180 5例甲状腺手术患者的临床资料。结果　 180 5例共发生各种术后并发症 67例 (3 .7% )。桥本病和甲状腺癌术后并发症分别为 6例 (16.2 % )和 2 7例(12 .2 % ) ,明显高于其他原发病 (P <0 .0 1,P <0 .0 5 )。初次手术行甲状腺全切术 (包括单侧和双侧 )者术后并发症 3 5例 (4 .2 % ) ,高于未行全切术者 (2 .1% ) (P <0 .0 5 ) ;初次手术操作行囊内结扎处理甲状腺下动脉分支者术后发生并发症 16例 (1.5 % ) ,低于包膜主干结扎者 (5 .9% ) (P <0 .0 1) ;保留后被膜者术后并发症 2 6例 (1.7% ) ,低于于未保留者 (16.7% ) (P <0 .0 1) ;再次手术者术后并发症 14例 (14 .6% ) ,明显高于首次手术者 (3 .1% ) (P <0 .0 1)。结论　手术治疗甲状腺疾病是安全、有效、合理可行的。提高术者素质、遵循精确的手术操作是减少并发症的关键     

几丁糖对大鼠术后腹腔粘连的预防作用

目的　探讨几丁糖对术后腹腔粘连的预防作用。方法　将 45只大鼠随机分为对照组 (A组 ) ,右旋糖酐组 (B组 ) ,几丁糖组 (C组 ) ,于腹腔内浆膜损伤部位分别注入 1%乳酸液 ,3 2 %右旋糖酐 -70液 ,2 %几丁糖乳酸液各 2ml ,术后 14d处死动物 ,观察各组腹腔粘连状况并送病理检查。结果　 3组粘连分级有显著性差异 (P <0 .0 1) ;C组粘连发生率较另 2组为低 ,有显著性差异 (P <0 .0 5 )。光镜下C组炎症反应轻微 ,纤维增生不明显 ;电镜下C组纤维细胞分泌胶原能力弱 ,间皮细胞增生活跃。结论　几丁糖可有效地降低大鼠术后腹腔粘连的发生和粘连程度 ,其作用优于右旋糖酐 -70 ,且不影响切口的愈合。     

善得定对预防大鼠腹部手术后肠粘连的研究

目的 评价腹腔注射善得定对大鼠腹部手术后肠粘连的预防作用。方法 将50只SD大鼠随机分为5组：Ⅰ组,对照组;Ⅱ组,腹腔内注射善得定20μg/kg;Ⅲ组,腹腔内注射善得定40μg/kg,腹腔内注射得定60μg/kg;V组,腹腔内注射透明质酸钠。各组动物均于定40μg/kg;Ⅳ组,腹腔内注射善得定60μg/kg;Ⅴ组,腹腔内注射透明质酸钠。各组动物均于术后14d处死,肉眼评价粘连程度,并取粘连的肠段测羟脯氨酸（OHP）。结果 Ⅱ,Ⅲ,Ⅳ,Ⅴ组之粘连程度明显低于Ⅰ组（P＜0．05）;Ⅱ,Ⅲ,Ⅳ组粘连肠段的OHP明显低于I组和V组（P＜0．05）;Ⅱ,Ⅲ,Ⅳ组间粘连程度及粘连肠段的OHP无明显差异（P＞0．05）。结论 腹腔注射善得定对预防腹部手术后肠粘连有一定作用。     

Peptic Ulcer/Stricture After Gastric Bypass: A Comparison of Technique and Acid Suppression Variables

Background: Mason's original animal experiments on the gastric bypass (GBP) showed little acid production in the gastric pouch, a finding confirmed in humans. Despite this, GBP in humans is associated with an incidence of ulcer/stricture (U/S) at the gastrojejunostomy of 3 to 20%, with both acid secretion and staple-line dehiscence considered important risk factors or etiologies. Our series of GBP patients was reviewed to determine what technical or management factors, if any, were associated with U/S. Methods: All patients undergoing first time GBP at Dartmouth-Hitchcock Medical Center by one surgeon from June 1991 until June 2000 were reviewed. The incidence of U/S as confirmed on upper endoscopy was determined by retrospective chart review. The technique of surgery, frequency of acid suppressive therapy at discharge, postoperative day of U/S diagnosis by endoscopy, length of follow-up with a member of the multidisciplinary bariatric team, and incidence of staple-line dehiscence were tabulated. Results: 158 patients (72% female, mean BMI 53, mean age 42) underwent GBP.Two gastric stapling methods were used to create the gastric pouch: 4-rows (136 patients) and 8-rows (22 patients). No other technical feature was adjusted in the series. The two patient groups were similar in gender, age, and BMI. Acid suppressive therapy at the time of discharge was similar in each group with U/S (4-rows 64% and 8-rows 50%, p=0.5). U/S developed in 12 (55%) of the 8-row group and in 14 (10%) of the 4-row group (p < 0.001). U/S typically occurred within the first 2 months postoperatively (mean 48 days, SD 40). No patients in our series developed a staple-line dehiscence. Conclusion: U/S occur in the first few months following GBP.Twice the number of gastric staple-lines is associated with over five times the incidence of U/S, whereas post-discharge acid suppressive therapy is not predictive of U/S. Thus, a technique performed to decrease the risk of staple-line breakdown was associated with a much higher incidence of U/S. Staple-line dehiscence is not the etiology of this condition.Therefore, U/S after GBP does not appear to be explained by acid injury. We speculate that local, tissue injury related factors may be more responsible, a speculation that invokes a novel pathophysiologic mechanism for U/S formation following gastrojejunostomy.     

Continuous Spinal Anesthesia/Analgesia for Perioperative Management of Morbidly Obese Patients Undergoing Laparotomy for Gastroplastic Surgery

Background: The authors determined prospectively the safety of continuous spinal anesthesia combined with general anesthesia and the efficacy of postoperative pain relief with continuous spinal analgesia for morbidly obese patients undergoing vertical banded gastroplasty. Methods: 27 patients (13 men, 14 women) with a mean body mass index (BMI) of 50.4 ± 7.8 and several co-morbidities were studied. All patients were anesthetized with the same anesthetic regimen, which included midazolam, fentanyl, propofol, muscle relaxants, N₂O, isoflurane and intrathecal bupivacaine. Postoperative pain relief was provided for 5 days and all patients received the same regimen, which included intrathecal bupivacaine, fentanyl and intravenous tenoxicam. The intrathecal analgesic regimen was administered continuously through a pump which had the facility of providing bolus doses when requested in predetermined lockout intervals. Intra-operative monitoring included hemodynamic and respiratory parameters. Additional postoperative monitoring included respiratory rate, degree of sedation, sensory level of anesthesia, motor response and intensity of pain. Results: Intraoperative anesthetic technique was safe and provided satisfactory results in the immediate postoperative period. Furthermore, the postoperative analgesia regimen provided effective analgesia in all patients.The mean doses of fentanyl and bupivacaine infused intrathecally for the first 24 postoperative hours were 14.1 ± 2.0 μg.h^-1 and 0.7 ± 0.1 mg.h^-1 respectively, while the requirements of anal gesia decreased progressively with time. The technique provided effective analgesia with low pain scores, which was reflected by ease in mobilizing and performing physical exercises with the physiotherapist. Only minor complications related to anesthesia and analgesia were encountered. Conclusion: To our knowledge, this technique of anesthesia and postoperative analgesia has not been described before in morbidly obese patients. This regimen merits further controlled trials to establish its place in the perioperative management of morbidly obese patients.     

Impact of Patient Follow-Up on Weight Loss after Bariatric Surgery

Background: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass.We reviewed all patients at 1 year after these two operations. Methods: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months.The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. Results: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). Conclusion: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.     

Leptin in Morbidly Obese Patients: No Role for Treatment of Morbid Obesity but Important in the Postoperative Immune Response

Despite the current opinion that leptin can no longer be seen as a hormone which could be used therapeutically to prevent an energy surplus (it rather protects the organism for an energy deficit), leptin may still have an impact in clinical medicine. Leptin was shown to have several important functions. The pleiotropic properties of leptin include a regulatory function in the immune system. Reviewing the effects of leptin on different parts of the immune system reveals that the immune system is deregulated in an environment low in leptin. A strong reduction in leptin levels occurs in situations of starvation as seen after bariatric surgery. We postulate the hypothesis that the starvation-induced postoperative decrease of leptin is causative of the more serious course of complications observed after bariatric surgery.     

两种肝门胆管成形胆道重建手术疗效的对比

目的 探讨肝门部胆管炎症性狭窄的有效治疗方法。方法 回顾性分析近10年间因肝内胆管结石行带血管蒂胆囊瓣肝门胆管成形术(PHBDS)及胆管空肠Roux-en-Y吻合术(RYCJ)治疗的肝门胆管炎症性狭窄患者的临床资料。观察围下术期的情况和术后胆管炎发生率、结石复发率。结果 两组间围手术期胆漏、炎性肠梗阻的发生率无统计学意义，PHBDS组与RYCJ组术后胆管炎发生率分别为5．66％和21．88％(P=0.010)。胆管结石发生率分别为3．77％和16．67％(P=0．021)。结论 PHBDS手术操作简单安全，保留了Oddi括约肌功能，防止了胆肠反流的发生，治疗效果优于RYCJ组。     

痔外剥内扎术后肛门疼痛时间分布特点的纵向研究

[目的]探讨混合痔外剥内扎术后肛门疼痛的时间分布特点.[方法]运用描述性研究的方法,采用视觉模拟评分法(VAS)和肢体活动评分法(BRS),对300例患者进行多时点、多因素观察术后肛门疼痛的变化,纵向探讨其时间分布特点.[结果]痔外剥内扎术后患者多在2～4h开始出现肛门疼痛,多数(89％)在术后6～10 h内处于疼痛的...