损伤控制性理念用于急性梗阻性化脓性胆管炎中的外科处理

目的探讨损伤控制性外科（DCS）理念应用于急性梗阻性化脓性胆管炎（AOSC）的治疗经验和效果。方法回顾性分析大连大学附属中山医院胆道微创外科2009年1月至10月收治的24例AOSC患者的损伤控制性手术和后续治疗情况。结果23例患者经DCS治疗，12例患者痊愈，死亡1例，2例带塑料胆道内置管出院未行再次手术，8例接受再次确定性手术（7例治愈，1例放弃继续治疗）。再次手术术后2例（25％）出现切口感染，1例（12．5％）胆漏，经保守治疗痊愈。结论DCS联合再次确定性手术是治疗AOSC的一种安全、有效的方法。     

损伤控制技术在急性化脓性梗阻性胆管炎中的应用

目的 探讨损伤控制性外科（DCS）技术治疗急性化脓性梗阻性胆管炎（AOSC）的方法和疗效.方法 回顾性分析我们2001年10月至2008年10月收治的72例AOSC患者的控制性手术和后续治疗的情况.结果 72例患者均经DCS治疗.经外科重症监护病房（SICU）复苏后,20例患者痊愈,49例接受再次确定性手术.全组痊愈67例（93.1％）,再次确定性手术后胆肠吻合口漏1例（1.4％）,胆道出血2例（2.8％）,肝断面及膈下感染3例（4.2％）,均经相应治疗痊愈;放弃后续治疗3例（4.2％）,死亡2例（2.8％）.结论 对AOSC患者应根据不同的病因,选择适当的DCS术式和再次确定性手术,其疗效是满意的.     

损伤控制性手术治疗严重肝脏创伤(附32例回顾性分析)

目的探讨损伤控制性手术（DCS）治疗严重肝脏创伤的临床价值，以总结手术经验。方法回顾性分析1999年8月至2006年8月，采用DCS原则治疗32例严重肝脏创伤的手术资料和后续治疗的情况。结果32例病人均经损伤控制性手术治疗：SICU复苏后，所有病人均接受相应形式的再次确定性手术。治愈28例（87．5％），再次手术术后出现肝脓肿、胆瘘各1例（各为3．1％），经保守治疗痊愈；死亡4例（12．5％），死亡原因与手术无关。结论符合DCS指征的严重肝脏创伤的病人，应积极选择适宜的手术治疗方式，并应根据损伤的不同部位和程度，分次手术治疗。     

损伤控制外科理念应用于胰十二指肠损伤的处理

目的探讨损伤控制外科（DCS）理念在处理危重胰十二指肠损伤时的应用价值。方法回顾性分析2005年3月至2013年1月问在温州市中西医结合医院和温州医学院附属第一医院接受DCS理念处理的19例胰十二指肠损伤患者的临床资料。结果3例经损伤控制性手术及重症监护复苏处理,未再行确定性手术,康复出院。12例经损伤控制性手术及重症监护复苏处理后行确定性手术（远端胰腺空肠Roux-en—Y吻合术、近端十二指肠空肠Roux—en-Y吻合术或胰十二指肠切除术）,康复出院。4例（21．1％）在损伤控制性手术后因多器官功能障碍综合征死亡。结论应用DCS理念处理胰十二指肠损伤能获得较满意的临床转归。     

老年梗阻性直肠癌处理方式探讨

目的 在损伤控制性外科理念指导下,探讨老年梗阻性直肠癌的合理处理方式。方法 山西省人民医院结直肠肛门外科2006年1月至2009年6月收治老年梗阻性直肠癌病人20例,在损伤控制性外科理念的指导下,回顾性分析病人分阶段、分步骤处理的临床资料。结果 18例经过分阶段、分步骤的围手术期处理,肠梗阻症状缓解,并进行了限期确定性手术治疗。2例病人急诊手术造口。确定性手术后痊愈17例,1例发生吻合口瘘,经回肠末端造口后治愈。 结论 对于老年梗阻性直肠癌的病人,在损伤控制性外科理念的指导下,术前暂时缓解肠梗阻症状,变急诊手术为限期手术,可以提高一期手术成功率,明显改善病人预后。     

损伤控制急救严重腹部创伤192例

目的：探讨损伤控制（DC）急救在严重腹部创伤中的应用效果。方法：回顾性分析将损伤控制急救应用于192例严重腹部创伤患者的救治情况和治疗效果。结果：192例患者均完成院前急救,186例完成损伤控制性手术（DCO）救治,184例进入外科重症监护病房（SICU）复苏,177例接受不同方式的再次确定性手术治疗。急救过程中,各项异常指标在DCO后72h内逐渐恢复正常。治愈出院174例（90.6%）,其中再次手术术后出现并发症4例（2.3%）,经保守治疗痊愈;死亡12例（6.2%）,死亡原因与损伤控制急救技术无关。结论：符合指征的严重腹部创伤的患者,应积极选择适宜的损伤控制急救方式,并应根据损伤的不同部位和程度,分步骤治疗。     

严重肝外伤的损伤控制性手术治疗

目的 探讨严重肝外伤的治疗及损伤控制性手术理念(damage control surgery,DCS)在治疗过程中的应用价值.方法 回顾性分析我院2004年4月-2008年10月17例严重肝外伤患者手术治疗的临床资料及损伤控制性手术的应用情况.结果 17例患者均经损伤控制性手术治疗,其中痊愈14例(占82.4%),死亡3例(占18%).术后并发症6例(占43%).结论 符合DCS指征的严重肝外伤患者,应积极实施DCS,提高综合治疗水平,根据损伤的不同部位和程度,分次手术治疗,可有效地降低严重肝外伤死亡率.     

胰腺损伤的诊断与外科治疗探讨

目的:探讨胰腺损伤的诊断与外科治疗原则。方法:回顾性分析我院2002年2月至2012年10月收治的39例胰腺损伤病人的临床资料,总结胰腺损伤的诊断与外科治疗方法。本研究胰腺损伤程度分级标准采用Lucas4型分级标准。结果:本研究病人均行手术治疗并确诊,单纯胰腺损伤11例(28.2%),合并其他脏器损伤28例(71.8%)。治愈31例,术后早期死亡3例,死于多器官合并伤;后期死亡5例,死于严重的胰腺坏死、胰漏和感染所致的多器官功能衰竭,病死率为20.5%。对Ⅳ级严重胰腺损伤的4例病人先行控制性手术,后行确定性手术,获得成功。结论:MRCP适合于胰管损伤的诊断,主胰管断裂的识别和定位也是治疗成功的关键,对Ⅳ级严重胰腺损伤病人先行控制性手术,后行确定性手术,以提高治愈率。     

34例严重胰腺损伤的损伤控制性外科治疗

目的 分析损伤控制外科技术(DCS)在胰腺损伤急救中的应用效果.方法 回顾性分析我院急救中心2005年1月至2009年10月期间符合DCS纳入标准的34例严重胰腺损伤患者的临床资料.结果 34例严重胰腺损伤患者应用包括迅速控制出血和污染、临时关闭腹腔等简单快速手术,经ICU复苏待生命体征稳定后再实施确定性手术,31例(91.2%)痊愈出院,3例(8.8%)患者死于多器官功能衰竭.并发胰瘘8例(23.5%),通过引流、对症、支持治疗后均治愈.结论 对于符合DCS纳入标准的严重胰腺损伤患者应积极按照DCS原则,选用合适的手术方式处理,以达到提高存活率和减少并发症的目的 .     

早期确定性肠吻合治疗急性肠系膜血管缺血的可行性探讨

目的 探讨急性肠系膜血管缺血（acute mesenteric ischemia,AMI）的早期确定性手术治疗的可行性。 方法 回顾性总结南京军区南京总医院全军普通外科研究所2008年1月至2009年9月行早期确定性恢复肠道连续性治疗的10例AMI病人的临床资料,血管造影和(或)CT证实为AMI,剖腹探查术后5~8（5.6±2.3）d内行再次剖腹探查及恢复肠道连续性,所有病人均在门诊随访6个月以上。结果 10例病人均顺利完成早期确定性手术,其中3例行取栓治疗,发生吻合口瘘的4例病人经非手术方法治愈,随访半年,所有病人均脱离肠外营养,9例病人脱离肠内营养。结论 初步研究结果表明,早期确定性恢复肠道连续性手术治疗AMI病人符合目前损伤控制性外科的理念,存活率高,但吻合口瘘发生率较高,需要较长时间的营养支持。     

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??Damage control surgery (DCS)for acute obstructive suppurative cholangitis(AOSC): a retrospective analysis of 69 cases DAI Rui-wu, TIAN Fu-zhou, WANG Yu, et al. The PLA Center of General Surgery, Chengdu Army General Hospital of PLA, Chengdu 610083,China Corresponding author: TIAN Fu-zhou, E-mail:rwdai@163.com Abstract Objective To explore the current management strategy and effect of damage control surgery (DCS)for acute obstructive suppurative cholangitis(AOSC). Methods The clinical data of 69 AOSC patients who admitted in our center from Sep.2001 to Dec.2007 were selected as the object of this study. A retrospective analysis was done on preference of DCS methods and perioperative therapies. Results DCS was performed in all 69 patients. Then 18 patients were healed, 47 patients were performed reoperations after SICU resuscitation.The cure rate was 94.2% with 65 cases, The incidence of choleintestinal anastomotic stoma fistula(1 cases) or hemobilia(1 cases) was as low as 2.1% after reoperations, and all healed by corresponding treatments. Two cases abandoned treatment. Mortality rate was 2.9% with 2 cases, and the causes were irrespective with DCS. Conclusion Consideration for DCS should be made positively under indications to AOSC patients. According to the difference of etiopathogenesis, choosing eligible DCS and reoperations methods is the key management.     

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??Treatment of complicated intrahepatic stones accompanied with biliary stricture by limited hepatectomy and balloon dilatation TIAN Fu-zhou, LUO Zhu-lin, TANG Li-jun, et al. PLA General Surgery Center,Chengdu General Military Hospital,Chengdu 610083,China. Corresponding author: TIAN Fu-zhou, E-mail??tfz30061@yahoo.com.cn Abstract Objective To summarize the treatment experience of the patients suffered the complicated intrahepatic stones accompanied with biliary stricture in our hospital in the recent 6 years. Methods From 76 patients with complicated intrahepatic stones accompanied with biliary stricture between march, 2002 and march, 2008, 34 patients (male 16 and female 18), of mean age 46 (range 27~65) years, were selected and divided equally into two groups which underwent traditional surgery and progressive balloon dilatation, respectively. The follow-up was carried out after the treatment. Results After the follow-up of mean 2.8 (range 1~7) years, 12 cases were cured, 2 were improved, 1 was aggravated and 2 were dead in the traditional surgery group. In contrast, 10 cases were cured, 7 got improvements, and only 1 had complications. There were no aggravated or dead case in this group. Conclusion the risk of trauma in surgery can be diminished by limited hepatectomy.the treatment of progressive balloon dilatation,as well as hepatectomy and hepatic portal plasty, exhibit good safety and efficiency in the treatment of complicated intrahepatic stones accompanied with biliary stricture.     

Endoscopic management strategies in relation to the severity of acute cholangitis

BACKGROUND AND STUDY AIMS: Acute cholangitis (AC) and especially suppurative cholangitis due to biliary lithiasis is an emergency situation that requires urgent biliary decompression. The aim of the study is to present our policy for the treatment of AC due to choledocholithiasis, endoscopically. METHODS: In a 4-year period, 71 patients presenting AC, due to lithiasis, underwent endoscopic retrograde cholangio-pancreatography and endoscopic sphincterotomy (ES). All patients had fever, jaundice, abdominal pain, and in case of suppurative cholangitis hemodynamic instability. Most of them seemed to be high-risk candidates for surgery. RESULTS: Forty-nine patients had AC and 22 patients had acute obstructive suppurative cholangitis (AOSC). ES (conventional or needle-knife biliary fistulotomy) was successful in 69 out of 71 (97%) patients. Two patients were eventually operated and were excluded from statistical analysis. Fifty of the 69 patients (72%) had a complete bile duct clearance in 1 session. Conventional ES, complete bile duct clearance, and other endoscopic maneuvers (balloon, basket, lithotripsy) were significantly more frequent in the AC group (P<0.001). Needle-knife biliary fistulotomy, and stent insertion were significantly more frequent in the AOSC group (P<0.001). Endoscopical treatment had low morbidity and total hospital stay time. CONCLUSIONS: ES is the procedure of choice for the treatment of AC offering definite treatment with low morbidity and short hospitalization. Urgent biliary decompression with minimal endoscopic maneuvers is crucial for the outcome of patients having AOSC.     

限量肝切除加球囊扩张治疗复杂性肝胆管结石并狭窄疗效分析

目的 探讨复杂性肝胆管结石并狭窄的有效治疗方法。方法 在成都军区总医院2002年3月至2008年3月收治的复杂肝胆管结石并狭窄76例病人中,选择出34例分为传统手术组和球囊扩张组（各17例）,男16例,女18例。平均年龄为46（27~65）岁。分别进行传统手术方法和球囊渐进扩张法治疗复杂肝胆管结石并狭窄,术后长期随访观察。结果 34例病人均完成手术,术后随访1～7年,平均2.8年。传统手术组治愈12例,好转2例,加重1例,死亡2例,其中出现并发症5例;球囊扩张组治愈10例,好转7例,出现并发症1例,无加重或死亡病例。结论 限量肝切除可以减少肝切除术给病人带来的直接损伤和危险,而球囊渐进扩张分期取石是除肝切除和肝门整形以外,另一种治疗复杂肝胆管结石并狭窄的较为安全可靠的方法。     

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??Association of gallbladder carcinoma and anomalous pancreaticobiliary ductal junction TIAN Fu-zhou, LUO Zhu-lin, ZHANG Bing-yin??et al. PLA General Surgery Center, Chengdu General Military Hospital, Chengdu 610083, China
Corresponding author: TIAN Fu-zhou, E-mail: tfz30061@yahoo.com.cn
Abstract Incidence of gallbladder carcinoma in patient with anomalous pancreaticobiliary ductal junction ??APBD??has been noted as high as 50% or more. The patients with APBD have an earlier age of onset comparing with the “normal people”. It found the similar result in 694 pancreaticobiliary ductal image materials admitted between 1995—2007 at PLA General Surgery Center of Chengdu General Military Hospital. Incidence of gallbladder carcinoma in patients with APBD was 21.8%. It is noteworthy that the length of common channel (CC) more than 15 mm is considered as the gold standard for the diagnosis of APBD in the world. The literature about characteristics of gallbladder carcinoma in “normal people” with the length of CC less than 15mm is rare. All the “normal people” were divided into short CC group and long CC group except for 28 patients with APBD in 694 pancreaticobiliary ductal image materials. Incidence of the latter was 10 times higher than that of the former. The concentration of amylase in bile in long CC group was higher than that in short CC group. The mechanism of the high incidence of gallbladder carcinoma may the reflux of the pancreatic juice into the bile duct. Measuring the length of CC and detecting the concentration of amylase in bile might be a method for predicting the onset risk of gallbladder carcinoma.     

急性梗阻性化脓性胆管炎合并糖尿病引发严重腹腔感染的治疗

急性梗阻性化脓性胆管炎（AOSC）是临床中凶险的急腹症之一,又称为急性重症胆管炎.若该病合并糖尿病,其发生腹腔感染的危险性大大增加,并进一步引发胆汁漏、肠瘘等,导致生命危险.而腹腔感染的处置得当与否对患者预后非常关键.2013年5-7月解放军第四二五医院收治1例AOSC合并糖尿病患者,因家属早期拒绝手术、手术前后血糖控制不严格致反复腹腔感染、脓肿形成,引发胆汁漏、肠瘘等严重并发症.患者经3次手术、禁食、胃肠减压、肠外营养及应用生长抑素、加强抗感染等治疗后痊愈出院.     

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??Treatment of pancreatic and peripancreatic infections secondary to severe acute pancreatitis by ultrasound-guided puncture & catheterization and debridement under choledochoscope??an analysis of 22 cases TANG Li-jun, WANG Tao, TIAN Fu-zhou, et al. Center of General Surgery, Chengdu General Hospital of PLA Chengdu Command, Chengdu 610083, China Corresponding author: TANG Li-jun, E-mail: whjtlj@yahoo.com.cn Abstract Objective To introduce and summarize a new method in treatment of pancreatic and peripancreatic infections secondary to severe acute pancreatitis. Methods The treatments of 22 cases of pancreatic and peripancreatic infections secondary to severe acute pancreatitis admitted between 2004 and 2007 at Chengdu General Hospital of PLA Chengdu Command were analyzed. The treatment procedure included as following: puncturing and placing a catheter through B-ultrasonic guidance for drainage of pancreatic and peripancreatic infections, and then removing the catheter after 3-5 days, expanding the sinus tract of the catheter with a skin expander, and then placing a large-diameter tube for drainage, removing the large-diameter tube and debriding under a choledochoscope in the next week. Results Of all the 22 cases treated by the above method, pancreatic and peripancreatic infections were effectively drained or removed. Among them, 15 cases were relieved of pancreatic and peripancreatic infections completely. Four cases underwent open-abdominal surgery for drainage as the residual abscess was located in the hilus lienis or iliac fossa difficult to debride under choledochoscope. Three cases underwent cysto-jejunostomy due to formation of pancreatic pseudocyst. Conclusion Ultrasound-guided puncture & catheterization and debridement under choledochoscope is a simply, safe and reliable treatment method for pancreatic and peripancreatic infections secondary to severe acute pancreatitis.     

置管引流并胆道镜清创治疗重症急性胰腺炎继发的胰腺及胰周感染22例体会

目的 介绍并总结一种治疗重症急性胰腺炎（SAP）继发的胰腺及胰周感染的新方法。方法 对2004年1月至2007年4月成都军区总医院收治的22例SAP继发的胰腺及胰周感染病人的治疗过程进行分析。在B超引导下穿刺置管引流,3～5d后拔除引流管,采用扩皮器将其窦道适当扩开后,再放置一粗引流管进行引流。1周后,拔除粗引流管,应用胆道镜在感染灶内进行清创。结果 通过上述方法治疗22例病人,胰腺及胰周感染的坏死组织及积液均达到有效的引流或清创。其中,15例胰腺及胰周感染灶完全消失;4例因残余脓肿位于脾门或髂窝,胆道镜难以安全清创,于后期行开腹脓肿引流手术;3例形成胰腺假性囊肿择期施行囊肿空肠吻合。结论 采用超声引导穿刺置管引流并胆道镜清创治疗SAP继发的胰腺及胰周感染,方法简单、安全,临床效果可靠。