胆道镜探讨胆肠吻合术后肝胆管结石复发的成因

目的 通过术后胆道镜的观察,了解胆肠吻合术中的人工乳头瓣膜的防反流效果,探讨胆肠吻合术及人工乳头瓣膜的可行性及其对肝胆管结石复发干预的有效性.方法 44例肝胆管结石行胆肠Roux-en-Y吻合术的病例,术中均在空肠输出袢行人工乳头瓣膜防反流,术后胆道镜通过T管窦道进入肝胆管,观察肝内外胆道、胆肠吻合口及其反流情况.对于复发的2例通过穿刺置管建立通道,应用胆道镜进行观察和治疗.结果 术后32例发生胆肠反流;2例术后结石复发通过胆道镜诊治,其中1例结石松软,内以食物渣、纤维素为主,另1例为松散的食物团絮.结论 胆肠Roux-en-Y吻合术、空肠输出袢行人工乳头瓣膜防反流并未有效地解决胆肠反流的弊端,复发的结石与术后反流及胆管狭窄有关.     

抗返流式间置空肠肝管十二指肠吻合术在肝胆管结石伴狭窄治疗中的应用

目的 探讨抗返流式间置空肠肝管十二指肠吻合术治疗肝胆管结石伴狭窄的效果。方法 平舆县中医院采用此术式,在间置的空肠段上做一抗返流套选瓣,空肠、十二指肠采用端侧半侧吻合加行同步缝合的术式治疗高位肝胆管结石伴狭窄病人36例。术后用消化道钡餐造影的方法观察了术后近期(术后14d),及远期(术后3个月～1a)间置空肠的抗返流效果,并对31例病人进行了8个月～6.5a的随访。结果 93％的病人无胆道返流症状,或虽有但症状较轻。结论 说明该术式对预防胆道返流有较好效果。     

对大口径胆肠吻合术的再认识(附63例分析)

目的 总结分析大口径胆肠吻合术的手术治疗方法及效果.方法 回顾性分析用胆总管或肝总管斜面与肠管侧壁大口径吻合行胆道内引流术63例患者的资料,总结临床经验教训.其中53例行胆管空肠端侧Roux-en-y吻合术,10例行胆管十二指肠端侧吻合术.结果 本组63例中,围手术期无胆漏发生,无死亡.随访60例,随访率95.2%,随访时间0.5～10.0 年,有11例术后死于肿瘤复发,其中最短的1例术后生存11个月.结论 术后胆管壁的弹性回缩是胆肠吻合口狭窄的重要原因,纵行切开胆管壁扩大吻合口是预防吻合口术后狭窄简单、有效的方法.     

对大口径胆肠吻合术的再认识（附63例分析）

目的总结分析大口径胆肠吻合术的手术治疗方法及效果。方法回顾性分析用胆总管或肝总管斜面与肠管侧壁大口径吻合行胆道内引流术63例患者的资料，总结临床经验教训。其中53例行胆管空肠端侧Roux—en—Y吻合术，10例行胆管十二指肠端侧吻合术。结果本组63例中，围手术期无胆漏发生，无死亡。随访60例，随访率95．2％，随访时间0．5～10．0年，有11例术后死于肿瘤复发，其中最短的1例术后生存11个月。结论术后胆管壁的弹性回缩是胆肠吻合口狭窄的重要原因，纵行切开胆管壁扩大吻合口是预防吻合口术后狭窄简单、有效的方法。     

胆肠吻合术式与逆行胆道感染的发生相关性临床观察

胆肠吻合术是对胆囊、胆管及周围组织病变切除后修复胆道损伤和重建胆道常用的手术方式,主要包括胆管、胆囊空肠吻合,胆管、胆囊十二指肠吻合。术后逆行胆道感染发生率高,约为22.5%～45.3%,是常见的并发症,对患者预后及生活质量造成严重影响,甚至需要二次手术,加重患者负担。本文回归分析106例胆肠吻合术患者逆行胆管感染的发生率与吻合方式之间的关系,为临床手术方案选择提供参考。1资料与方法1.1一般资料2002年2月—2011年3年在我院行胆肠吻合术的患者     

保留Oddis括约肌、空肠皮下盲袢型胆肠吻合术治疗肝内胆管结石

目的 总结保留Oddis括约肌、空肠皮下盲袢治疗肝内胆管结石的经验及治疗效果.方法 肝内胆管多发结石6例,采取保留Oddis括约肌、皮下盲袢型胆肠吻合.结果 术后未发生近期并发症,远期并发症1例为反流性慢性胆管炎,术后经皮下盲袢行胆道镜取石4例.结论 保留Oddis括约肌、空肠皮下盲袢是治疗肝内胆管结石的有效手段.     

胆总管十二指肠后低位内引流治疗胆道结石合并胆总管远端狭窄32例分析

传统的胆总管十二指肠吻合术，容易造成术后胆肠返流、盲端综合症、吻合口狭窄及反复发作的难治性胆管炎。本文从1973-10～2000-12采用胆总管十二指肠后低位内引流术，治疗胆道结石合并胆总管远端狭窄32例急诊病人取得了较好疗效，现报告如下。     

两种胆肠内引流术与胆道逆行感染的实验研究

目的比较不离断空肠的胆肠吻合术与传统的Roux-en-Y胆肠吻合术预防胆道逆行感染的效果。方法16只Begle犬随机分成两组,分别行不离断空肠的胆囊空肠吻合(不离断空肠组)和Roux-en-Y胆囊空肠吻合(离断空肠组)。检测术前肠襻和术后12周胆支肠襻内细菌的类别以及吻合口的胆道压力。分析手术前后两组肠襻内细菌类别的变化和术后两组间细菌类别、吻合口胆道压力的变化。结果术前革兰氏阴性需氧菌、厌氧菌的检出率为37.50%、6.25%;不离断空肠组术后为62.50%、12.50%,离断空肠组术后为87.50%、75.00%;不离断空肠组与术前比较,差异无显著性差异(p=0.390,1.000);离断空肠组术后明显高于术前,其差异有显著性差异(p=0.033,0.001);离断空肠组术后厌氧菌的检出率明显高于不离断空肠组(p=0.041)。离断空肠组吻合口胆道压力明显高于不离断组(p<0.001)。结论不离断空肠的胆肠吻合术能更有效的抗胆道逆行感染。     

近端胃癌术后重建方式与术后反流发生的关系探讨

目的通过对近端胃癌术后五种重建方式与反流发生的临床资料进行回顾性分析,探讨全胃切除术后更加符合生理的消化道重建方式。方法选择2007年1月～2009年1月平顶山市第一人民医院胃肠外科行全胃切除术的患者46例,近端胃癌根治术20例,分别采用功能性间置空肠代胃术,间置空肠代胃,P型间置空肠代胃术,Roux-en-Y吻合术式,食管残胃后壁吻合,随访其发生反流性食管炎的比例与严重程度。结果返流性食管炎发生率分别为12.5%,0.0%,25.0%,68.2%,和86.7%;其中行食管残胃吻合术式的4例发生严重的反流,营养不良,生活质量极差。结论功能性间置空肠代胃术和间置空肠代胃对于减少近端胃癌术后反流、提高生存质量有重要意义,是近端胃癌根治术后理想的重建术式。     

医源性胆管损伤的原因及对策

目的　探讨医源性胆管损伤的原因及对策。方法　对 4 7例医源性胆管损伤病例的临床资料进行回顾性分析。结果　对术中及术后不同时期发现的胆管损伤 ,分别行胆道修复、引流及胆肠吻合等不同方法处理 ,经 1～ 10年随访 ,效果优良率达 85 .4 %。结论　 (1)加强技术培训和规范的技术管理是减少医源性胆管损伤的保证。 (2 )术前、术中全面细致检查 ,充分运用各种影像学及造影检查 ,详细了解胆道系统情况 ,选择合理的术式。 (3)根据胆管损伤类型 ,合理把握初次手术时机 ,胆管成形空肠Roux -en -Y吻合术是胆道重建术的最佳选择     

上消化道重建术后肠腔菌群的改变

目的:探讨上消化道重建术后空肠上段肠道菌群的种类、数量与感染并发症的关系。方法:前瞻性观察上消化道手术病人52例。分别于术中、术后第2天和第5天抽取病人空肠上段肠液,测定肠液菌群种类和菌落计数,同时检测病人血浆内毒素水平。结果:术中、术后第2和第5天无明显菌群失调及细菌移位发生(各菌种之间细菌菌落数比较,P>0.05)。术中、术后第2和第5天血浆内毒素水平无显著性差异(P>0.05)。结论:上消化道重建术后,无明显肠道菌群紊乱。     

Placement of nasoenteral feeding tubes using external magnetic guidance

BACKGROUND: Enteral feeding is preferred over parenteral methods, and feeding into the duodenum is preferred over gastric feeding in certain groups of critically ill patients. However, with current techniques, feeding tubes often coil in the stomach, exposing patients to the risk of aspiration. This study investigated whether a nasoenteral feeding tube can be guided beyond the pyloric sphincter, using external magnetic guidance. METHODS: This is a case series of 288 critically ill patients who needed placement of an enteral feeding tube, carried out in the intensive care units and wards of a university-affiliated community hospital. A 12-French polyurethane nasoduodenal feeding tube was modified by placing a small magnet in the distal tip. After inserting the tube through the nares into the esophagus, an external magnet was used to draw the tube tip beyond the pyloric sphincter and further into the duodenum or jejunum. Placement was verified by plain abdominal x-ray, and the depth of insertion (stomach, proximal duodenum, distal duodenum, or jejunum) was recorded. RESULTS: Three hundred twenty-nine intubations were performed in 288 patients (mean procedure time 15 minutes). In 293 cases (89.1%), the tube was placed beyond the pyloric sphincter. In 139 insertions (42.2%), the tube tip was in the distal portion of the duodenum or the jejunum. There were no significant complications. CONCLUSIONS: This case series demonstrates that external magnetic guidance achieves transpyloric placement of an enteral feeding tube in 89.1% of cases. This reliable bedside technique is superior to other methods described in the literature.     

7 g weighted versus unweighted polyurethane nasoenteral tubes--spontaneous transpyloric passage and clinical performance: a controlled randomised trial

A proportion of patients requiring enteral nutrition is at increased risk of regurgitation or pulmonary aspiration of enteral diet as a result of gastric atony or paresis. The positioning of the distal end of an enteral feeding tube beyond the pylorus into duodenum or jejunum may reduce this risk. It has been postulated that by suitable lengthening of feeding tubes and by altering the distal end tip profile or by the addition of a weight, spontaneous passage of a tube through the pylorus after pernasal insertion may be achieved. In a recent controlled trial we were unable to demonstrate any advantage to a) modifying the tip profile or b) the addition of a 2.4 g weight. This prospective controlled clinical study examined the difference between an unweighted polyurethane tube which had performed optimally in the previous study and a new 7 g weighted tube similar in all other respects. In both cases less than 50% of tubes had passed spontaneously through the pylorus when assessed at 24 h, with no significant difference in performance (p = 0.38). When comparing overall length of time that each tube remained in situ, there was similarly no significant difference between the 7 g weighted and unweighted tubes (p = 0.277). We conclude that the addition of a 7 g weight to a suitably lengthened enteral feeding tube confers no advantage on either incidence of spontaneous transpyloric passage or in prolonging tube usage. If post-pyloric feeding is indicated for a patient, positioning by either fluoroscopic or endoscopic techniques should be undertaken.     

Primary colon carcinoma in a colon interposition graft after oesophageal resection

A 79-year-old man presented with a massive subcutaneous swelling due to extreme dilatation ofa subcutaneously interposed right-sided hemicolon; 7 years earlier he had undergone oesophageal resection and gastric tube reconstruction for a poorly differentiated adenocarcinoma of the distal oesophagus. The procedure was complicated by gastric tube necrosis, and the tube was removed. One year later the continuity of the gastrointestinal tract was restored by a right-sided isoperistaltic colon graft: the terminal ileum, including the ileocecal valve, was anastomosed to the pre-existing cervical portion of the oesophagus. The dilatation was caused by an obstructive adenocarcinoma located in the distal part of the interposed colon in combination with an intact ileocecal valve in the neck. The tumour was a primary colon carcinoma with no evidence of further dissemination. The colon graft was removed, and the patient received a definitive salivary fistula placed in the neck and permanent feeding tube by jejunostomy. Development of primary colon carcinoma in a colon graft is rare; 7 cases have been reported in the literature so far. Routine endoscopic follow-up of a graft does not appear to be warranted, but endoscopy should be performed if symptoms arise.     

胆管空肠Roux-Y吻合术后胆道感染相关因素分析

目的探讨胆管空肠Roux-Y吻合术后胆道感染的危险因素。方法回顾性分析2006年1月-2010年10月行胆管空肠Roux-Y吻合术87例的病例资料,对胆道感染相关因素进行logistic回归分析。结果 87例中有12例占13.79%术后出现胆道感染;单因素分析表明,术前黄疸减退、吻合口直径、胆管空肠吻合术式与术后胆道感染有显著相关性(P<0.05);而年龄、性别、术前黄疸持续时间、术前胆红素水平、术中抗菌药物应用、术中输血量、手术时间与胆道感染无明显相关(P>0.05);多因素分析表明,吻合口直径(OR=0.226,P=0.023)、胆管空肠吻合术式(OR=9.628,P=0.039)为影响胆道感染的危险因素。结论吻合口直径≤2.0 cm,胆管空肠侧吻合为Roux-Y吻合术后胆道感染发生的独立危险因素。     

Nutrition entérale à domicile en site jéjunal

Jejunal nutrition has developed nowadays, especially for patients with swallowing disorders, severe gastro-oesophageal reflux disease or previous history of aspiration pneumonia, and obstruction of the upper GI tract. Access to the jejunum is no longer restricted to surgery thanks to the development of tube feeding insertions radiological and endoscopic techniques. This clinical case of a stroke patient underlines the clinical indications of these recent radiology or endoscopy-guided jejunostomies and gastrojejunostomies. They are suitable for home nutrition support as they could avoid surgical laparotomy or laparoscopy or even, parenteral nutrition.     

胆囊管变异与胆囊切除术

胆囊切除术是腹部外科的常见手术之一,胆囊管的处理是胆囊切除术的关键步骤,胆囊管的变异可造成手术的困难,也是胆道医源性损伤的一个主要原因。方法：回顾性分析我院２０年来在胆囊切除术中发现的１２５例胆囊管变异,对其病理分型及术中的处理方法作一探讨。结果：术中胆总管损伤８例,胆囊管处理不当致术后形成胆汁性腹膜炎４例,全组无死亡。结论：胆囊管的变异是造成胆囊切除术中胆道医源性损伤的主要原因,术中应根据胆囊管的变异情况作不同的处理。     

肝胆外科T管引流并发症的原因及护理体会

目的分析肝胆外科T管引流并发症的原因,并总结临床护理措施。方法收集肝胆外科T管引流患者648例,分析其并发症情况,并总结其护理措施。结果本组共11例患者出现并发症,发生率为1.7%。其中,4例T管脱落,3例T管堵塞,2例胆道感染,1例胆漏,1例胆管十二指肠瘘,均经对症处理后好转。结论 T管引流可促进肝胆外科患者的康复,但容易发生各类并发症,在护理过程中应提高并发症预见性,并积极采取针对性的防控措施,以提高护理质量。     

A new self-propelling nasoenteric feeding tube

A new fine-bore nasoenteric feeding tube was tested in 19 post-operative patients. It is a silicone rubber tube, which at its distal end has 5 loops with a diameter of approximately 4 cm. The loops are easily straightened during insertion into the stomach, but ease transpyloric passage after removal of the guidewire. 4 h after insertion, 18 tubes had reached the duodenum or upper part of the jejunum. In only 1 patient was there regurgitation of the tube into the stomach after insertion.