腹腔镜、十二指肠镜及腹腔镜术中超声联合治疗胆囊结石合并胆总管结石

目的:探讨腹腔镜、十二指肠镜联合腹腔镜术中超声治疗胆总管结石的应用价值.方法:2005年5月至2010年12月共纳入病例85例,78例术前确诊为胆囊结石并胆总管结石,腹腔镜胆囊切除术中超声发现7例合并胆总管结石,序贯行腹腔镜、十二指肠镜联合治疗.结果:腹腔镜联合十二指肠镜成功72例,13例因结石巨大或十二指肠憩室内乳头...     

腹腔镜联合纤维胆道镜经胆囊管治疗胆囊结石合并胆总管结石

目的探讨胆囊结石合并胆总管结石病例用腹腔镜与纤维胆道镜联合治疗的可行性。方法 2006年9月至2009年12月共35例胆囊结石合并有胆总管结石,术前经B超或磁共振检查确诊,采用腹腔镜下经胆囊管纤维胆道镜胆总管取石、胆囊切除术。结果 35例胆总管结石均经腹腔镜下纤维胆道镜经胆囊管取石成功,无一例发生严重并发症和残余结石。35例胆总管均未放置T管。结论腹腔镜联合纤维胆道镜治疗胆囊结石合并胆总管结石是安全有效的微创手术方式,值得推广。     

同期腹腔镜、胆管镜、十二指肠镜多入路治疗胆囊结石合并细径胆总管结石71例

目的总结运用同期三镜（腹腔镜、胆管镜、十二指肠镜）多入路手术治疗胆囊结石合并细径胆总管结石的临床经验。方法回顾性分析我院2001年2月至2013年12月期间施行腹腔镜胆囊切除（LC）＋术中胆管镜下取石术及液电碎石术＋术中十二指肠镜下乳头切开术治疗71例胆囊结石合并细径胆总管结石患者的临床资料。首先完成LC后,经胆囊管残端切口插入输尿管导管或斑马导丝并经胆总管下端进入十二指肠腔。在输尿管导管指引下,经胆囊管残端扩张、经汇合处切口、经胆囊管与胆总管联合切口或经胆总管直接切口,插入胆管镜进入胆总管腔内用取石网取石或液电碎石。然后,经口插入十二指肠镜至十二指肠乳头,针刀在输尿管导管指引下对乳头施行切开术,继续用十二指肠镜取石网取石。结果同期三镜治疗胆囊结石合并细径胆总管结石71例,胆总管内径为4～8 mm。经胆囊管途径延长切口放置导管59例,经胆总管切口途径放置导管22例（其中10例因经胆囊管途径插入输尿管导管能够成功进入胆总管末端或十二指肠腔,但不能引导进入十二指肠上段胆总管腔内而失败,从而改为从十二指肠上段胆总管前壁另做一条纵行切口进入胆总管腔内）。经胆管镜下取净胆总管结石64例,联合十二指肠镜下取净胆总管结石7例。71例均取净胆总管结石。无中转开腹。术后发生胆汁漏5例,轻症胰腺炎1例。无胆管残留结石,无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症,无死亡。结论只要病例选择合适,同期三镜多入路手术治疗胆囊结石合并细径胆总管结石可行、有效和安全。     

三镜联合在胆囊结石合并胆总管结石治疗中的应用

目的 探讨腹腔镜、十二指肠镜、胆道镜在胆囊结石合并胆总管结石治疗中的作用及最优选择.方法 对2003年8月至2006年11月间我院收治的52例胆囊结石合并胆总管结石患者进行腹腔镜、十二指肠镜、胆道镜联合治疗,分析微创手术的疗效及安全性.结果 2005年12月以前患者23例,均行腹腔镜胆囊切除+胆总管切开胆道镜取石,均放置T管引流.1例术后1 d T管脱出行腹腔镜T管放置术,另有1例术后3个月拔除T管时出现胆漏而行腹腔引流术.2006年1月以后患者29例,根据术前检查发现胆总管结石大小决定是否术前行十二指肠镜治疗.其中6例胆总管结石≥12 mm者直接行腹腔镜胆囊切除+胆总管切开胆道镜检查取石,2例放置T管引流;23例行术前乳头括约肌切开(endoscopic sphinctemtomy,EST),成功取石16例(69.6%),随后行腹腔镜胆囊切除;7例取石失败后行腹腔镜胆囊切除+胆总管切开胆道镜取石,1例放置T管引流;未放置T管引流者共10例均行胆总管一期缝合.术后未出现胆漏、胆管狭窄以及胆总管残余结石等并发症.结论 ①腹腔镜、十二指肠镜、胆道镜联合是治疗胆囊结石合并胆总管结石的趋势,具有创伤小、恢复快及并发症少的优点.②腹腔镜手术前是否行十二指肠镜取石应按胆总管结石大小来确定,对于胆总管结石超过12 mm或十二指肠镜取石失败的病例选择腹腔镜联合胆道镜治疗.③腹腔镜下胆总管切开一期缝合是安全的,并可避免T管相关并发症.     

腹腔镜联合内镜治疗胆囊结石合并胆总管结石的体会

目的探讨腹腔镜联合内镜治疗胆囊结石合并胆总管结石的手术方式及年龄的关系。方法利用腹腔镜联合十二指肠镜,碎石网篮来治疗胆囊结石合并胆总管结石。结果207例术前诊断胆总管结石先行十二指肠乳头切开取石再行LC;23例LC术后发现胆总管结石行EST。全部病例治愈。无严重并发症。结论胆囊结石合并胆总管结石先行十二指肠乳头切开取石再行LC,具有明显的优势,无明显年龄限制。     

内镜十二指肠乳头切开联合腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石

目的 :探讨胆囊结石合并胆总管结石的微创术式及几种术式的优缺点。方法 :回顾总结采用十二指肠乳头切开取石 ,再行腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石 32例的治疗经验 ,分析该术式的优点。结果 :32例中 2例行十二指肠乳头切开取石失败 ,行开腹胆囊切除术加胆总管探查取石、十二指肠乳头成形术。余者均采用内镜十二指肠乳头切开取石后腹腔镜胆囊切除术方法治愈 ,均取得良好疗效 ,无 1例出现胆囊结石脱落致胆总管结石复发。结论 :绝大多数胆囊结石合并胆总管结石病例适用于此术式。比先行腹腔镜胆囊切除再行内镜十二指肠乳头切开取石更为安全可靠。     

腹腔镜联合术中胆道镜、十二指肠镜治疗胆囊结石并胆总管结石

目的总结腹腔镜联合术中胆道镜、十二指肠镜治疗胆囊结石并胆总管结石的方法及临床意义。方法我院2007年1月至2008年12月期间采用腹腔镜联合术中胆道镜、十二指肠镜治疗胆囊结石并胆总管结石患者42例,在全麻下行腹腔镜胆囊切除并切开胆总管前壁,以术中胆道镜联合十二指肠镜取净胆总管结石,一期缝合胆总管,并放置鼻胆管引流。结果本组42例患者中1例中转开腹手术,41例成功,术后5～7d拔管出院,无手术死亡病例,无术后漏胆、上消化道出血、穿孔及急性胰腺炎发生。结论腹腔镜联合术中胆道镜、十二指肠镜治疗胆囊结石并胆总管结石,是一种创伤小、恢复快及安全可靠的方法。     

腹腔镜联合十二指肠镜一期治疗胆囊结石合并胆总管结石

目的探讨腹腔镜联合十二指肠镜一期治疗胆囊结石合并胆总管结石的可行性及优点。方法 2009年6月～2011年6月,采用腹腔镜联合十二指肠镜一期治疗90例胆囊结石合并胆总管结石。胆总管单发或多发结石,结石直径≤20 mm。第1例先行十二指肠镜手术,以后89例先行腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）,LC术后变换体位为俯卧或侧俯卧位行十二指肠镜手术。术后常规放置鼻胆管引流。结果手术均获成功,90例均取尽结石,无并发症发生。住院5～9 d,平均7 d。随访1～23个月,其中54例〉12个月。无结石复发和胆道狭窄、胰腺炎、逆行胆道感染等并发症。结论在已开展腹腔镜和十二指肠镜手术,同时手术室具备胆道造影条件的单位,开展腹腔镜联合十二指肠镜一期治疗胆囊结石合并胆总管结石,是一种较好的选择。     

急性胆囊炎腹腔镜切除术：附58例报告

目的 探讨胆囊管结石的治疗方法。方法回顾性分析近6年来收治的158例胆囊管结石病例的临床资料。结果 97例胆囊管结石行开腹手术取出结石；61例胆囊管结石行腹腔镜胆囊切除手术，其中49例于术中切除胆囊时一并取出结石，12例于术后经十二指肠镜取出结石。结论 胆囊管结石尽可能于术中切除胆囊时一并处理，如结石或结石碎片掉入胆总管，除开腹手术时可切开胆总管取出结石外，行LC者于术后经十二指肠镜处理，不失为一种创伤小、恢复快、疗效肯定的治疗方法。     

腹腔镜胆囊切除术术中联合十二指肠镜治疗正常直径胆总管结石158例

目的探讨腹腔镜胆囊切除术术中联合十二指肠镜下乳头切开取石术治疗胆囊结石继发细径胆总管结石的手术方法和适应证。方法腹腔镜胆囊切除术术中联合十二指肠镜治疗158例正常直径胆总管结石,完成腹腔镜胆囊切除后,经胆囊管残端插入输尿管导管至十二指肠肠腔,经口插入十二指肠镜至十二指肠乳头,针式刀在输尿管导管引导下施行乳头切开术,用十二指肠镜取石网或球囊取石。结果 158例患者中,行乳头切开取石140例,乳头切开排石15例,中转为其他术式3例。术后轻症胰腺炎9例,胆管残留结石3例。无肠穿孔、胆管穿孔、胆漏、大出血、重症胰腺炎等并发症发生,无死亡病例。结论只要选择合适的病例,腹腔镜胆囊切除术术中联合十二指肠镜下乳头切开取石术治疗胆囊结石继发细径胆总管结石是可行、有效和安全的。     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.