腹会阴联合直肠癌根治术后发生造口旁疝的影响因素

目的探讨腹会阴联合直肠癌根治术(Miles术)后造口旁疝形成的相关危险因素,为造口旁疝的预防提供科学依据。方法回顾性分析2011年5月至2015年5月期间在徐州医科大学附属医院普外科行直肠癌Miles术的218例患者的临床资料,收集15项可能影响造口旁疝发生的因素,采用单因素分析和非条件二分类logistic回归分析方法探索它们对造口旁疝发生的影响。结果 218例患者随访期间发生造口旁疝55例,造口旁疝的发生率为25.23%。单因素分析结果显示:年龄、腹部皮下脂肪厚度、体质量指数(BMI)、造口途径及合并高血压情况均与术后造口旁疝的形成有关(P0.05);非条件二分类logistic回归分析结果显示:高龄、腹部皮下脂肪厚度厚、超重肥胖及经腹膜造口均是Miles术后造口旁疝形成的独立危险因素(P0.05)。结论对于存在危险因素的患者,在行直肠癌Miles术时需选择合理的造口途径,以预防造口旁疝的发生。     

直肠癌患者Miles术后发生造口旁疝的影响因素分析

目的探索直肠癌患者Miles术后发生造口旁疝的相关影响因素。 方法回顾性调查分析2016年1月至2019年1月在安徽医科大学第一附属医院胃肠外科行Miles术的84例直肠癌患者的病案资料,采用单因素分析和二分类Logistic回归分析发生造口旁疝的相关影响因素。 结果84例患者中,有16例患者在随访期间发生了造口旁疝,发生率为19%。单因素分析显示：造口旁疝组和非造口旁疝组患者组间的体质量指数（BMI）、甲胎蛋白水平比较,差异有统计学意义（P<0.05）;2组患者组间的有无疾病合并症、Tumor分期及术后有无发生低蛋白血症比较,差异均接近显著性水平（0.0525 kg/m²）是发生造口旁疝的重要影响因素[OR=6.784,β=1.915,95% CI（1.979～23.263）,P=0.002];此外,术后低蛋白血症是发生造口旁疝的可能影响因素[OR=3.501,β=1.253,95% CI（0.989～12.388）,P=0.052]。 结论对于超重肥胖患者（BMI>25 kg/m²）在术前应合理控制体重,与此同时,针对术后发生营养风险的患者应积极改善营养状况,从而以降低造口旁疝的发生风险。     

直肠癌Miles术后结肠造口旁疝的预防

目的探讨直肠癌Miles手术后结肠造口旁疝的预防方法。方法对123例直肠癌患者结肠造口的临床资料进行回顾性分析,其中行腹直肌旁造口74例,经腹直肌造口49例。结果 74例经腹直肌旁造口患者中,有14例(18.9%)发生造口旁疝;49例经腹直肌造口患者中,有2例(4.1%)发生造口旁疝;两组比较差异显著(P0.05)。结论为减少术后结肠造口旁疝的发生,Miles手术应尽量选择经腹直肌乙状结肠造口。     

直肠癌Miles术中预防结肠造口旁疝的体会

目的探讨直肠癌Miles术中结肠造口旁疝的预防。方法采取左下腹经腹直肌或经腹直肌旁造口位置，留取适当乙状结肠肠段，减少乙状结肠系膜脂肪，分层缝合方法行乙状结肠单腔永久性造口。结果在20例经腹直肌结肠造口患者中，无结肠造口旁疝发生；26例经腹直肌旁结肠造口患者中，有2例发生造口旁疝。结论为预防结肠造口旁疝的发生，手术中应选择经腹直肌造口，避免造口段肠管过长，肠系膜脂肪保留过多；合理选择腹壁造口直径；实行分层缝合方法。     

应用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定对造口旁疝的预防

目的 评估应用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定预防造口旁疝的结果。方法2003年1月至2005年1月间中山大学附属第一医院需行腹会阴联合切除直肠肿瘤（Miles术）手术的60例患者按信封法随机分成两组,每组30例。对照组行经腹膜经腹直肌乳头型造口,试验组加用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定．观察造口并发症及随访造口旁疝发生情况。结果对照组有8例（26．7％）出现造口旁疝;观察组患者无造口旁疝发生。结论使用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定可预防造口旁疝的发生。     

Miles手术结肠造口术的改进

自1908年Miles施行第1例腹会阴联合切除直肠癌手术（Miles术）以来,世界各地有关造口并发症的报道显示其总发生率高达21%～71%。为了防止造口旁疝的发生,对结肠造口术的改进,一直是外科医生探索的课题。本文作者采用将造口处腹膜拖至造口真皮层缝合固定,使外翻的腹膜与造口结肠的浆膜层容易粘连愈合,减少造口旁疝、造口脱垂及造口旁感染的发生率。手术方式的设计有科学性,有新意。但对肥胖、腹壁很厚的患者,要将造口的腹膜拖至真皮层缝合不太可能。另外,作者这一改进的结肠造口术还未能从根本上解决结肠造口旁疝发生的原因。如因造口周围肌肉的萎缩,或因造口周围肌肉向远离造口方向的收缩致造口肠壁周围肌肉的间隙不断增宽等。用补片预防Miles术后人造肛旁疝的发生,是当前外科医生普遍认为较好的方法。随着各种新型补片的出现,手术方法也将不断更新,关于预防Miles术后结肠造口并发症的工作,还需要外科界同僚共同努力。[编者按]     

腹膜外结肠造口术后造口旁疝病因的病例-对照研究

目的:探讨经腹膜外结肠造口术后发生造口旁疝的原因。方法:并随访2006年1月至2009年12月在我院普外科行永久性经腹膜外结肠造口术的164例病人,对其资料进行回顾分析。确诊有造口旁疝的病人9例,作为病例组;按1∶2比例匹配同样手术而未并发造口旁疝者18例作为对照组;按文献报道中的10项引起造口旁疝的危险因素,进行回顾性病例组与对照组的对照研究。结果:本研究病人的随访率为87.2%,造口旁疝的发生率为6.3%(9/143);其中2/3的病例发生于术后2年内。腹压升高、造口过大(直径2.5 cm)、术前未行造口定位、未经腹直肌造口及病人肥胖(体质量指数≥26)等5个危险因素有统计学意义,相对危险度(RR)依次分别为16.0、12.2、10.0、9.1和7.0。既往有腹部手术史者发生造口旁疝的RR为8.5,但尚无统计学意义(P0.05)。结论:经腹膜外结肠造口术后的造口旁疝发病率较低;腹压升高、造口过大、术前未行造口定位、未经腹直肌造口和病人肥胖是引起经腹膜外结肠造口术后发生造口旁疝的主要原因。     

Miles术后造口旁疝发生的原因分析及处理

目的分析Miles术后造口旁疝发生的原因及处理方法。方法回顾性分析2007年1月至2013年5月,郑州大学附属肿瘤医院行Miles术158例患者资料,其中经腹直肌旁造口46例,经腹直肌造口83例,经腹膜外造口29例;16例术后出现造口旁疝,其中经腹直肌旁11例,经腹直肌5例;对造口旁疝发生的原因进行分析总结。结果10例经无张力疝修补手术后痊愈,6例经保守治疗后痊愈,未出现复发病例;1例发生切口感染,经换药和充分引流、抗感染后痊愈;1例慢性疼痛,给予对症治疗;未出现严重的补片相关并发症。结论本组患者造日旁疝的发生与造口方式、手术操作、腹压增加有关,根据病情采用保守或手术治疗。     

应用生物补片预防造口旁疝二例

自1908年Miles施行第1例腹会阴联合直肠癌根治术以来,结肠造口后发生造口旁疝一直是降低患者、尤其是长期生存患者生存质量的难题。随着现代外科技术迅猛发展,国内外学者针对降低造口旁疝的发生率、治疗造口旁疝进行了大量的研究,已有应用合成补片预防造口旁疝、应用生物补片治疗造口旁疝的报道,均取得了良好的效果。我们受此启发,设计结肠造口时一期腹腔内植人生物补片以预防造口旁疝。     

应用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定对造口旁疝的预防

目的 评估应用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定预防造口旁疝的结果.方法 2003年1月至2005年1月间中山大学附属第一医院需行腹会阴联合切除直肠肿瘤(Miles术)手术的60例患者按信封法随机分成两组,每组30例.对照组行经腹膜经腹直肌乳头型造口,试验组加用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定,观察造口并发症及随访造口旁疝发生情况.结果 对照组有8例(26.7%)出现造口旁疝;观察组患者无造口旁疝发生.结论 使用膨体聚四氟乙烯补片行乙状结肠造口腹膜内固定可预防造口旁疝的发生.     

Effects of Abdominal Fat Distribution Parameters on Severity of Acute Pancreatitis

Background

Obesity is a well-established risk factor for acute pancreatitis. Increased visceral fat has been shown to exacerbate the pro-inflammatory milieu experienced by patients. This study aimed to investigate the relationship between the severity of acute pancreatitis and abdominal fat distribution parameters measured on computed tomography (CT) scan.

Methods

Consecutive patients admitted to Cork University Hospital with acute pancreatitis between January 2005 and December 2010 were evaluated for inclusion in the study. An open source image analysis software (Osirix, v 3.9) was used to calculate individual abdominal fat distribution parameters from CT scans by segmentation of abdominal tissues.

Results

A total of 214 patients were admitted with pancreatitis between January 2005 and December 2010. Sixty-two of these patients underwent a CT scan and were thus eligible for inclusion. Visceral fat volume was the volumetric fat parameter that had the most significant association with severe acute pancreatitis (P?=?0.003). There was a significant association between visceral fat volume and subsequent development of systemic complications of severe acute pancreatitis (P?=?0.003). There was a strong association between mortality and visceral fat volume (P?=?0.019). Multivariate regression analysis, adjusted for gender, did not identify any individual abdominal fat distribution index as an independent risk factor for severe acute pancreatitis.

Conclusions

Overall, estimation of abdominal fat distribution parameters from CT scans performed on patients with acute pancreatitis indicates a strong association between visceral fat, severe acute pancreatitis, and the subsequent development of systemic complications. These data suggest that visceral fat volume should be incorporated into future predictive scoring systems.     

Association of age with muscle mass, fat mass and fat distribution in non-diabetic haemodialysis patients.

BACKGROUND: In the general population, aging induces changes in body composition, such as sarcopenia or a relative increase in visceral fat, but it remains unclear if similar changes occur in elderly haemodialysis (HD) patients. METHODS: Age-related changes in muscle and fat mass and fat distribution in the thigh and abdomen were cross-sectionally investigated in Japanese HD patients. The thigh muscle area (TMA), thigh intermuscular fat area (IMFA), thigh subcutaneous fat area (TSFA), abdominal muscle area (AMA), abdominal visceral fat area (AVFA) and abdominal subcutaneous fat area (ASFA) were measured by computed tomography in 134 non-diabetic patients between 21 and 82 years on HD. AMA, AVFA and ASFA were also measured in 70 age-matched controls. RESULTS: Muscle mass, fat mass and fat distribution differed significantly with age in both HD patients and controls, without significant differences in BMI. In both male and female HD patients, TMA and AMA showed significant negative correlations with age. All measures of subcutaneous fat-including TSFA, ASFA and the triceps skinfold thickness, were inversely associated with age in the female patients. In contrast, both IMFA and AVFA showed significant positive correlations with age in both male and female patients. The increase in the AVFA/ASFA ratio with age suggests progression of visceral fat accumulation in the elderly HD patients. Controls showed similar relationships between age and muscle mass and visceral fat accumulation. CONCLUSIONS: We found an association between age and decrease in muscle mass as well as increase in visceral and intermuscular fat in non-diabetic HD patients. Such changes may be associated with the metabolic abnormalities and increased mortality in elderly HD patients.     

Dysregulation of the peripheral and adipose tissue endocannabinoid system in human abdominal obesity

The endocannabinoid system has been suspected to contribute to the association of visceral fat accumulation with metabolic diseases. We determined whether circulating endocannabinoids are related to visceral adipose tissue mass in lean, subcutaneous obese, and visceral obese subjects (10 men and 10 women in each group). We further measured expression of the cannabinoid type 1 (CB(1)) receptor and fatty acid amide hydrolase (FAAH) genes in paired samples of subcutaneous and visceral adipose tissue in all 60 subjects. Circulating 2-arachidonoyl glycerol (2-AG) was significantly correlated with body fat (r = 0.45, P = 0.03), visceral fat mass (r = 0.44, P = 0.003), and fasting plasma insulin concentrations (r = 0.41, P = 0.001) but negatively correlated to glucose infusion rate during clamp (r = 0.39, P = 0.009). In visceral adipose tissue, CB(1) mRNA expression was negatively correlated with visceral fat mass (r = 0.32, P = 0.01), fasting insulin (r = 0.48, P < 0.001), and circulating 2-AG (r = 0.5, P < 0.001), whereas FAAH gene expression was negatively correlated with visceral fat mass (r = 0.39, P = 0.01) and circulating 2-AG (r = 0.77, P < 0.001). Our findings suggest that abdominal fat accumulation is a critical correlate of the dysregulation of the peripheral endocannabinoid system in human obesity. Thus, the endocannabinoid system may represent a primary target for the treatment of abdominal obesity and associated metabolic changes.     

Human body tolerance to high energy trauma: influence of subcutaneous and visceral fat

Every year in the US, over 40,000 individuals are killed and more than 3 million others injured as a result of motor vehicle collisions (MVCs). The economic cost of crash injuries each year is greater than $230 billion. In order to improve vehicle safety, a better understanding of the mechanism by which injuries are caused in current crashes as well as the human factors that affect injury tolerance is required. Biomechanical studies using cadavers suggest that factors such as bone density, muscle mass and body geometry influence the body’s ability to tolerate injurious forces. We hypothesized that fat in both the subcutaneous and visceral compartments may act as an energy absorbing material and affect injury patterns in MVCs. This study examined the relationship between the severity of the injuries sustained in MVCs and that occupant’s subcutaneous and visceral fat volumes as measured by CT. 139 adults MVC occupants were studied. Field and vehicle inspection was performed to determine crash configuration, crash severity and restraint use. All of the patients received CT evaluation of their abdomen and pelvis as part of their trauma workup. A three-dimensional image of the abdomen was reconstructed and volumetric measurement of both the subcutaneous and visceral fat were performed on a two-inch slab at the level of the third lumbar vertebra. The results showed that increased volume of either subcutaneous or visceral fat correlated with a significant decrease in the overall Injury Severity Score (ISS) (p < 0.02). Increased subcutaneous fat was associated with significantly decreased injury severity to the head (p = 0.001) and abdominal (p = 0.02) regions, but significantly worse injury severity to the lower extremities (p < 0.0001). Subcutaneous fat volume was found to have greater influence on injury severity than occupant age, restraint status or crash severity.     

Recurrent stone‐forming patients have high visceral fat ratio based on computed tomography images compared to first‐time stone‐forming patients

Objectives

To compare various fat parameters based on computed tomography images between recurrent stone‐forming patients and patients forming stones for the first time.

Methods

Included in the present study were 300 patients with upper urinary tract calculi who had undergone active stone removal in our hospital. Using pretreatment computed tomography images, we measured visceral fat area and volume, subcutaneous fat area and volume, visceral fat area ratio and visceral fat volume ratio. We compared patient backgrounds and these fat parameters between those who recurrently formed stones and those who formed stones for the first time. We also performed logistic regression analysis to identify factors that contribute to severe stones.

Results

A total of 148 (49.3%) patients were recurrent stone‐forming patients. Recurrent stone‐forming patients were statistically significantly younger (P < 0.01) and there were more male patients (P < 0.01). In addition, visceral fat area ratio and visceral fat volume ratio in recurrent stone‐forming patients were significantly higher than those in first‐time stone‐forming patients (P = 0.03 and P = 0.01, respectively). On the other hand, there was no significant difference in visceral fat area (P = 0.32), subcutaneous fat area (P = 0.36), visceral fat volume (P = 0.38) or subcutaneous fat volume (P = 0.23). Receiver operating characteristics analysis showed that area under the curve of visceral fat volume ratio (0.583) for recurrent stones was larger than that of visceral fat area ratio (0.571). In multivariate analysis, increasing visceral fat volume ratio was an independent significant predictor of recurrent stones (P = 0.04).

Conclusions

Recurrent stone‐forming patients have high visceral fat ratios compared to first‐time stone‐forming patients, shown here for the first time.

     

Altered myocellular and abdominal fat partitioning predict disturbance in insulin action in HIV protease inhibitor-related lipodystrophy

HIV protease inhibitor-related lipodystrophy is characterized by peripheral fat loss, hyperlipidemia, and insulin resistance. Increased availability of lipid to muscle may be one of the mechanisms that induce insulin resistance. Regional fat, intramyocellular lipid (by (1)H-magnetic resonance spectroscopy), serum lipids, and insulin-stimulated glucose disposal (by hyperinsulinemic-euglycemic clamp) were quantified in 10 men who had HIV-1 infection with moderate to severe lipodystrophy and a control group of 10 nonlipodystrophic men who had HIV-1 infection and were na?ve to protease inhibitors to examine the effects of lipodystrophy on glucose and lipid metabolism. Lipodystrophic subjects showed lower insulin-stimulated glucose disposal than control subjects (P = 0.001) and had increased serum triglycerides (P = 0.03), less limb fat (P = 0.02), increased visceral fat as a proportion of total abdominal fat (P = 0.003), and increased intramyocellular lipid (1.90 +/- 0.15 vs. 1.23 +/- 0.16% of water resonance peak area; P = 0.007). In both groups combined, visceral fat related strongly to intramyocellular lipid (r = 0.83, P < 0.0001) and intramyocellular lipid related negatively to insulin-stimulated glucose disposal (r = -0.71, P = 0.0005). Fasting serum cholesterol and triglycerides related positively to intramyocellular lipid and visceral fat in lipodystrophic subjects only. The data indicate that lipodystrophy is associated with increased lipid content in muscle accompanying impaired insulin action. The results do not establish causation but emphasize the interrelationships among visceral fat, myocyte lipid, and insulin action.     

Altered abdominal fat distribution and its association with the serum lipid profile in non-diabetic haemodialysis patients.

BACKGROUND: Disturbances of lipid and carbohydrate metabolism may be associated with the distribution of abdominal adiposity. However, little is known about the alteration of abdominal adiposity and its association with the serum lipid profile in haemodialysis patients. METHODS: We evaluated the distribution of abdominal adiposity by using computed tomography and examined its relationship with the serum lipid profile in 92 non-diabetic haemodialysis patients and 80 control subjects with normal renal function. Since the mean body mass index (BMI) and total body fat mass were significantly lower in the haemodialysis patients than in the control subjects, the subcutaneous abdominal fat area and the visceral fat area were standardized by body mass index and compared between the haemodialysis patients and the control subjects. RESULTS: Mean subcutaneous fat area/body mass index (SFA/BMI) was significantly lower, and mean visceral fat area/body mass index (VFA/BMI) was significantly higher in the haemodialysis patients (SFA/BMI, 2.40+/-0.12; VFA/BMI, 2.28+/-0.15) than in the control subjects (SFA/BMI, 3.75+/-0.21, P<0.01; VFA/BMI, 1.65+/-0.15, P<0.01). Consequently, visceral fat area/ subcutaneous fat area ratio was significantly higher in the haemodialysis patients (1.05+/-0.07) than in the control subjects (0.46+/-0.04, P<0.01). A scattered plot of visceral fat area relative to BMI revealed that visceral fat area was higher in the haemodialysis patients than in the control subjects at any BMI level. A simple regression analysis showed that BMI, total body fat mass, subcutaneous fat area and visceral fat area were all associated with serum triglycerides and the atherogenic index, (total cholesterol-HDL cholesterol)/HDL cholesterol. Furthermore, a multiple regression analysis indicated that the visceral fat area was the best predictor for either the atherogenic index or triglycerides among these fat components. CONCLUSIONS: These data indicate that haemodialysis patients exhibited a visceral fat accumulation irrespective of BMI, and this shift of abdominal adiposity might be associated with disturbance of the serum lipid profile in non-diabetic haemodialysis patients.     

远端胰腺切除术后发生胰瘘的危险因素分析

目的 探讨远端胰腺切除术（distal pancreatectomy,DP）后发生术后胰瘘（postoperative pancreatic fistula,POPF）的危险因素。方法 回顾性分析2014年1月至2018年10月在西南医科大学附属医院肝 胆外科接受诊治的81例胰腺远端肿瘤性病变行DP的临床资料,对可能导致POPF的相关因素进行单因素 分析和Logistic回归分析。结果 81例患者DP术后发生生化漏13例,B级胰瘘9例,C级胰瘘3例。单因 素分析显示POPF可能与手术时间、术中失血量及内脏脂肪面积有关（P＜0.05）;Logistic回归分析显示, 手术时间（OR 1.060,95%CI 1.021～1.102,P=0.003）及内脏脂肪面积（OR 1.116,95%CI 1.046～1.190, P=0.001）是 POPF的独立危险因素。结论 手术时间和内脏脂肪面积是DP术后发生临床胰瘘的独立危险 因素。对内脏脂肪面积较大的患者需采取积极预防措施。     

Use of a prosthetic mesh to prevent parastomal hernia during laparoscopic abdominoperineal resection: a randomized controlled trial

Purpose

Prevention of parastomal hernia represents an important aim when a permanent stoma is necessary. The objective of this work is to assess whether implantation of a prophylactic prosthetic mesh during laparoscopic abdominoperineal resection contributed to reduce the incidence of parastomal hernia.

Methods

Rectal cancer patients undergoing elective laparoscopic abdominoperineal resection with permanent colostomy were randomized to placement of a large-pore lightweight mesh in the intraperitoneal/onlay position by the laparoscopic approach (study group) or to the control group (no mesh). Parastomal hernia was defined radiologically by a CT scan performed after 12 months of surgery. The usefulness of subcutaneous fat thickness measured by CT to discriminate patients at risk of parastomal hernia was assessed by ROC curve analysis.

Results

Thirty-six patients were randomized, 19 to the mesh group and 17 to the control group. Parastomal hernia was detected in 50?% of patients in the mesh group and in 93.8?% of patients in the control group (P?=?0.008). The AUC for thickness of the subcutaneous abdominal was 0.819 (P?=?0.004) and the optimal threshold 23?mm. Subcutaneous fat thickness ??23?mm was a significant predictor of parastomal hernia (odds ratio 15.7, P?=?0.010), whereas insertion of a mesh was a protective factor (odds ratio 0.06, P?=?0.031).

Conclusions

Use of prophylactic large-pore lightweight mesh in the intraperitoneal/onlay position by a purely laparoscopic approach reduced the incidence of parastomal hernia formation. Subcutaneous fat thickness ??23?mm measured by CT was an independent predictor of parastomal hernia.