直肠癌前切除术后预置回肠造口与袢式回肠造口的对比研究

目的评估预置回肠造口（末段回肠预置于腹壁下）对比袢式回肠造口在腹腔镜直肠癌前切除术中的优势。 方法进行前瞻性研究,纳入2020年1月至2021年12月甘肃省人民医院肛肠科收治的行腹腔镜直肠癌前切除术的患者,分为预置回肠造口组及袢式回肠造口组。主要的研究终点：首次住院以及术后3个月总体并发症指数（CCI）;次要研究终点：术后吻合口漏发生率、肠梗阻发生率、手术时间、住院时间、住院费用、并发症Clavien-Dindo分级、术后3个月再次住院率以及肛门直肠功能（Wexner评分）;其他研究终点：术后通气时间、首次进食时间、术后腹泻、手术时间＞3 h、切缘阳性率以及术后病理pTNM分期。 结果预置回肠造口组对比袢式回肠造口组的首次住院总体并发症评分（CCI评分）为（25.3±7.1 vs. 26.4±5.7）,差异无统计学意义（t=0.456,P=0.067）,而预置回肠造口组对比袢式回肠造口组术后3个月的CCI评分为（26.2±6.2 vs. 31.7±9.1）,差异有统计学意义（t=0.283,P=0.041）。此外,预置回肠造口组患者对比袢式回肠造口组患者在手术时间（Z=-2.646,P=0.008）、住院时间（Z=-3.564,P=0.034）、住院费用（Z=-5.118,P=0.021）、术后3个月再次住院率（χ²=25.652,P=0.001）、术后3个月肛门直肠功能（t=-3.128,P=0.003）以及并发症Clavien-Dindo分级（χ²=9.692,P=0.021）等方面差异均具有统计学意义。 结论预置回肠造口相对于袢式回肠造口是一种安全可行且经济有效的术式,但仅限于中低危吻合口漏患者。此外,本研究样本量较少且随访时间短,仍需后续试验加以验证。     

三种食管胃吻合法的临床比较

目的：探讨预防食管胃吻合口瘘和吻合口狭窄的方法。方法 156例病人采用一层间断缝合法(A组)(：38例病人采用一层连续缝合法(B组);86例病人使用吻合器行食管胃吻合(C组)。结果 吻合口瘘和吻合口狭窄总的发生率：A组7．62％;B组5．26％;C组1．16％。三比较有显性差异。结论 一层连续缝合法显优于一层间断缝合法。在胸内吻合,吻合器机械吻合显优于手工吻合。     

管状吻合并全层间断减张缝合术可以降低食管癌术后颈部吻合口瘘

背景吻合口瘘是食管癌术后最常见的严重并发症.本研究回顾性分析我科食管癌根治术患者的临床资料,分析筛选出吻合口瘘发生的相关危险因素,同时就本治疗组为降低吻合口瘘采用的管状吻合并全层间断减张缝合术做一报道.目的分析影响食管癌术后颈部吻合口瘘发生的相关危险因素,同时探究管状吻合并全层间断减张缝合术对预防吻合口瘘的安全性及有效性.方法回顾性分析安阳市肿瘤医院胸外五科2014-05/2018-12行根治性手术治疗的544例食管鳞癌患者的临床资料,选取与颈部吻合口瘘发生相关的可能因素,进行临床单因素及多因素Logistic回归分析,确定与颈部吻合口瘘发生的独立危险因素.结果患者年龄、糖尿病史、手术时间长短(是否300 min)、管状吻合后全层间断减张缝合与否是术后吻合口瘘发生的独立危险因素.其中管状吻合并全层间断减张缝合术有利于降低术后颈部吻合口瘘的发生率(6.1%vs13.1%, P 0.05).结论采用管状吻合并全层间断减张缝合术对预防颈部吻合口瘘的发生安全有效,值得临床推广.     

梗阻性左半结直肠癌术前支架减压与急诊手术248例

目的:评价梗阻性结直肠癌支架置入的安全性,比较支架减压后手术与急诊手术的短、长期效果.方法:回顾性分析2000-10/2008-02我院248例梗阻性左半结直肠癌手术患者的临床资料,按支架与否分为两组,统计结肠镜下留置结肠腔内支架本身的成功率及并发症情况.比较两组Ⅰ期切除吻合例数、吻合口漏、切口感染、脾撕裂、腹腔脓肿等短期并发症、住院期间死亡率及两组生存曲线.结果:内镜下留置结肠腔内镍钛记忆合金支架成功率98.4%,总的并发症发生率14.5%,其中严重并发症(穿孔、支架移位)发生率4.8%.Ⅰ期吻合支架组明显高于急诊手术组(87.1%vs 34.4%,P=0.001).总的并发症支架组明显低于急诊手术组(17.7% vs 47.3%,P=0.000).两组患者2年生存曲线几乎重叠,之后支架组生存率略高于急诊手术组,但两组生存曲线比较无统计学差异(P=0.497).结论:对于梗阻性左半结直肠癌患者.结肠镜下留置结肠腔内支架术前减压是一种比较理想的辅助方法,增加I期切除吻合机会,避免造口,降低短期并发症,长期生存率也较急诊手术有一定的提高.     

直肠癌前切除手术术后吻合口漏的风险因素分析

目的:探讨直肠癌前切除手术术后吻合口漏的发生率和危险因素.方法:回顾性分析1998-02/2007-05我院行直肠癌前切除手术患者518例的病例资料,探讨直肠癌前切除手术术后吻合口漏发生率的危险因素.结果:518例直肠癌前切除术后共发生吻合口漏48例,发生率9.2%(48/518).患者年龄>65岁、术前血清白蛋白<35 g/L、术前有糖尿病病史、术中没有行保护性近端肠造瘘、肿瘤病灶直径>30 mm是患者术后发生吻合口漏的危险因素.结论:对于存在上述吻合口漏风险因素的患者,行保护性近端肠造瘘能够减低了吻合口漏的发生率.     

老年直肠癌Dixon术后吻合口漏159例临床分析

目的 探讨老年直肠癌Dixon术后吻合口漏的发生率、危险因素和治疗方法.方法 回顾性分析159例直肠癌行Dixon术患者的临床资料.结果 年龄、肿瘤距肛缘距离、糖尿病、术前低蛋白、术前合并肠梗阻、切口感染与吻合口漏的发生密切相关,而性别与吻合口漏的发生无关.结论 吻合口漏是直肠癌Dixon术后一种常见并发症,低位直肠癌行保肛手术增加吻合口漏发生率,大部分吻合口漏经单纯引流管冲洗可治愈,少数病例需行剖腹探查肠造瘘术.     

影响直肠癌术后吻合口漏的因素分析

目的探讨直肠癌保肛手术后发生吻合口漏的影响因素。 方法回顾性收集2015年10月~2018年10月间中山大学附属孙逸仙纪念医院和青岛市第八人民医院普外科行直肠癌保肛手术的患者216例。应用SPSS 20.0统计软件对NRS2002、吻合口距齿状线距离、肿瘤TNM分期、肿瘤最大直径、肿瘤环周度、年龄、肠梗阻等因素进行分析。 结果χ²检验显示NRS2002评分≥3分、吻合口距齿状线距离≤5 cm、肿瘤TNM分期Ⅲ期、肿瘤最大直径≥5 cm、肿瘤环周度≥3/4环、年龄≥60岁、肠梗阻等是影响吻合口漏的因素;应用Logistic回归分析显示NRS2002评分≥3分、吻合口距齿状线距离≤5 cm是影响吻合口漏的独立因素。 结论吻合口距齿状线距离≤5 cm、NRS2002评分≥3分的患者,应该警惕直肠癌保肛术后吻合口漏的发生。     

预防性回肠与结肠造口预防吻合口漏的应用对比及预防吻合口漏技术的进展

吻合口漏是结直肠术后常见并且严重的并发症之一,预防性回肠及结肠襻式造口被用来应对结直肠术后吻合口漏。每种造口方式都有其优缺点,这篇综述结合当下最新研究结果来探究是否其中一种方式优于另一种。同时对当下预防吻合口漏的策略进行了汇总,主要有经肛肠减压术、盲肠置管造口术、经肛肠腔减压术、管腔内旁路技术、无需回纳预防性造瘘术、带蒂大网膜包裹吻合口术,临床实践中选择何种方式预防吻合口漏需要综合各种情况决定。     

腹腔植入化疗对大鼠结肠吻合口愈合影响的实验研究

目的探讨术中中人氟安腹腔化疗对大鼠生理指标和结肠吻合口愈合的影响。方法将60只雄性大鼠随机分为A、B、C组,每组再随机分两个亚组。术后A组和B组分别腹腔注入生理盐水（NS）20ml／（kg·d）和5．氟尿嘧啶（5-ru）20ml／（kg·d）＋NS20mr／（kg·d）,1次／24h、连用5次;C组术中植入中人氟安20mg／（kg·d）。术后第7天和第14天分别进行吻合口评分,血常规（Rt）和肝、肾功能检测,吻合口破裂压（ABP）和羟脯氨酸（HYP）含量测定及病理组织学检查。结果术后A组无死亡,B死亡8只,C组死亡4只;术后吻合口评分分别为3、12、5分,B组均高于A、C组;术后第7天,B组Rt、ABP和HYP含量均低于A、C组（P〈0．01）;术后第14天,除白细胞外各组相应指标均无统计学差异（P〉0．05）。结论中人氟安腹腔化疗全身不良反应小,对大鼠结肠吻合口愈合的影响较小。     

生物降解吻合环在肠吻合术中的应用观察

目的观察生物降解吻合环在肠吻合术中的应用效果。方法将203例拟行手术治疗的肠道疾病患者随机分为观察组138例和对照组65例,观察组肠吻合时使用生物降解吻合环,对照组采行手工肠吻合,比较两组术后肠功能恢复时间和并发症发生率。结果观察组肠功能恢复时间为（64.8±3.6）h,吻合口瘘及出血的发生率均为0,吻合口梗阻发生率0.72%（1/138）;对照组肠功能恢复时间为（65.7±6.2）h,吻合口瘘及出血的发生率均为6.15%（4/65）,吻合口梗阻发生率3.08%（2/65）。两组相比,吻合口瘘及出血的发生率比较,P均〈0.05。结论生物降解吻合环用于肠吻合术,能避免吻合口瘘及出血的发生。     

保留左结肠动脉在腹腔镜直肠癌前切除术中的临床应用和疗效观察

目的探讨腹腔镜直肠癌前切除术中保留左结肠动脉(LCA)与否对临床疗效的影响。方法回顾分析2015年7月至2018年7月山西省肿瘤医院结直肠肛门外科收治的行腹腔镜直肠癌前切除术病例的临床资料,共186例,其中保留LCA组80例(观察组),不保留LCA组106例(对照组)。比较两组患者手术相关指标,包括手术时间、术中出血量...     

The healing process of anastomoses of the colon

In spite of modern suture materials and different techniques in colonic anastomoses after resection, leakage is still the most feared complication in colonic surgery. In female pigs of Swedish land breed, standardized 5-cm long colonic resection was performed 10 cm above the peritoneal deflection, usign either a single layer of Gambee-stitches (n=6, Vicryl^® 4-0), two-layer interrupted stitches (n=6, Vicryl^® 4-0) or the intraluminal stapling device (n=6, ILS Ethicon^®). After one week, the animals were sacrificed and an anastomotic index was calculated usingin vitro x-ray. Also, anastomotic circulation (calculated by the microsphere technique), breaking strength, and histologic evaluation were performed. All animals survived and no leakage was observed. The time to perform, the anastomosis was significantly shorter (P<0.05) for the stapling device compared with the manual techniques used. The anastomotic index was lower (P<0.05) for two rows (0.24) compared with Gambee-stitches (0.38) or stapler anastomoses (0.37). There were no differences in blood flow among the three groups and no differences in breaking strength. Macroscopic investigation revealed mucosal defects in two of the stapled anastomoses and histologic investigation showed small areas of necrosis. The stapling device did not induce any inflammatory reaction. On the other hand, a severe inflammatory reaction was seen when using conventional suture materials. In conclusion, this study shows that a single row of Gambee-stitches is equal to the ILS stapling device when performing colonic anastomoses and these two methods seem to be superior to the two-layer technique.     

氩离子凝固术在Barrett食管中治疗效果及安全性分析

目的探讨氩离子凝固术（APC）在Barrett食管中治疗效果和安全性。 方法选取2016年1月至2017年2月新疆维吾尔自治区人民医院诊治Barrett食管患者83例临床资料行回顾性分析,根据患者治疗方案分为干预组（APC＋埃索拉唑、莫沙必利治疗,52例）和常规组（埃索拉唑、莫沙必利治疗,31例）,比较2组患者症状改善情况、疗效及不良反应发生率。 结果干预组和常规组治疗前反酸、胸骨后疼痛、腹胀评分比较：（5.5±1.1）分vs （5.4±1.3）分,（5.1±1.2）分vs （5.0±1.1）分,（4.9±1.3）分vs （4.7±1.5）分,t=0.3606、0.3635、0.6165,P=0.7194、0.7172、0.5394。干预组和常规组治疗3月反酸、胸骨后疼痛、腹胀评分比较：（2.2±0.3）分vs （2.3±0.5）分,（2.0±0.4）分vs （2.2±0.5）分,（2.1± 0.6）分vs （2.0±0.4）分,t=1.1056、1.9339、0.7881,P=0.2724、0.0569、0.4331。治疗后3月,干预组反酸、胸骨后疼痛、腹胀评分与治疗前比较：（2.2±0.3）分vs （5.5±1.1）分,（2.0±0.4）分vs （5.1± 1.2）分,（2.1±0.6）分vs （4.9±1.3）分;t=20.4657、17.3295、13.8282,P=0.0000。治疗后3月,常规组反酸、胸骨后疼痛、腹胀评分与治疗前比较：（2.3±0.5）分vs （5.4±1.3）分,（2.2±0.5）分vs （5.0± 1.1）分,（2.0±0.4）分vs （4.7±1.5）分;t=11.7771、12.2620、9.2031,P=0.0000。干预组患者治疗总有效率显著于常规组［95.83% vs 70.37%,χ²=7.6172,P=0.0058］。干预组患者和常规组患者不良反应总发生率比较无统计学意义［12.50% vs 14.81% ,χ²=0.0050,P=0.9436］。 结论APC治疗Barrett食管可改善患者病变,具有显著疗效和较高治疗安全性。     

机器人和腹腔镜治疗中低位直肠癌对照研究

目的对比机器人和腹腔镜治疗中低位直肠癌的近期疗效。 方法自2017年3月18日至2017年10月25日,共有56例中低位直肠癌患者在解放军总医院普通外二科接受直肠癌根治术,患者被随机分组接受机器人或腹腔镜手术,对两组的临床资料进行了比较。 结果最终机器人组27例,腹腔镜组29例。机器人组较腹腔镜组在手术时间、术后镇痛时间、排气时间、恢复饮食时间、导尿管留置时间、住院日和淋巴结清扫数目方面差异均无统计学意义（均P>0.05）。机器人组术中失血量比腹腔镜少［（77.0±50.0）mL vs.（121.0±129.8）mL］,但差异无统计学意义（Z=-1.825,P=0.068）。机器人组术后有1例吻合口漏和1例肠梗阻,腹腔镜组术后有1例吻合口出血和1例肺部感染,术后并发症发生率方面差异无统计学意义（7.4% vs. 6.9%,χ²=0.006,P=1.000）。 结论机器人和腹腔镜直肠癌根治术围术期效果相当,远期功能学和肿瘤学效果有待进一步随访。     

Albert-Lembert versus hybrid-layered suture in hand sewn end-to-end cervical esophagogastric anastomosis after esophageal squamous cell carcinoma resection

Background

Hand sewn cervical esophagogastric anastomosis (CEGA) is regarded as preferred technique by surgeons after esophagectomy. However, considering the anastomotic leakage and stricture, the optimal technique for performing this anastomosis is still under debate.

Methods

Between November 2010 and September 2012, 230 patients who underwent esophagectomy with hand sewn end-to-end (ETE) CEGA for esophageal squamous cell carcinoma (ESCC) were analyzed retrospectively, including 111 patients underwent Albert-Lembert suture anastomosis and 119 patients underwent hybrid-layered suture anastomosis. Anastomosis construction time was recorded during operation. Anastomotic leakage was recorded through upper gastrointestinal water-soluble contrast examination. Anastomotic stricture was recorded during follow up.

Results

The hybrid-layered suture was faster than Albert-Lembert suture (29.40±1.24 min vs. 33.83±1.41 min, P=0.02). The overall anastomotic leak rate was 7.82%, the leak rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (3.36% vs. 12.61%, P=0.01). The overall anastomotic stricture rate was 9.13%, the stricture rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (5.04% vs. 13.51%, P=0.04).

Conclusions

Hand sewn ETE CEGA with hybrid-layered suture is associated with lower anastomotic leakage and stricture rate compared to hand sewn ETE CEGA with Albert-Lembert suture.     

Biliary reconstruction with wide-interval interrupted suture to prevent biliary complications in pediatric living-donor liver transplantation

Background/Purpose

Liver transplantation is an established therapy for children with end-stage chronic liver disease or acute liver failure. However, despite refinements of surgical techniques for liver transplantation, the incidence of biliary tract complications has remained high in recent years. Therefore, we suggest our anastomotic technique with wide-interval interrupted suture to prevent biliary complications in pediatric living-donor liver transplantation (LDLT).

Methods

Forty-nine LDLTs were performed on 49 pediatric recipients with end-stage liver disease. Biliary reconstruction was performed using a 2.5× magnifying surgical loupe, via end bile duct to side Roux-en-Y hepaticojejunostomy (n?=?47) and duct-to-duct choledochocholedochostomy (n?=?2) with an external stent. A stay suture with 6-0 absorbable materials was placed at each end of the anastomotic orifice. Two interrupted sutures of the posterior row were performed. After completion of the suture of the posterior row, an external transanastomotic stent tube was inserted into the intrahepatic bile duct and was fixed with posterior row material. Finally, two interrupted sutures of the anterior wall were performed, totaling six stitches. The transanastomotic stent tube emerging out of the blind end of the Roux-en-Y limb was covered with a round ligament and was usually left in place for 1?month after the operation.

Results

The median follow-up period was 58.0?months (range 8?C135?months). In 33 recipients, the bile duct was used to perform the reconstruction with a single lumen. In 5 cases, there were 2 bile ducts that were formed to enable a single anastomosis. In 10 cases, there were 2 separated ducts and each duct was anastomosed with the recipient jejunum. In one case, there were 3 ducts that were formed to enable two anastomoses. Twenty-two percent of the living-donor grafts required 2 biliary anastomoses. Forty-four patients (89.8%) are alive (ranging from 8?months to 11?years), and 5 patients have died. Two patients had biliary complications, an anastomotic stricture in one (2.0%) and bile leakage in one. There were no complications due to anastomotic tubes.

Conclusions

Biliary reconstruction with wide-interval interrupted suture prevents anastomotic strictures and bile leakage in pediatric LDLT.     

Laparoscopic colonic anastomosis using a degradable stent in a porcine model

AIM: To explore the feasibility and safety of laparoscopic colonic anastomosis using a degradable stent in a porcine model.METHODS: Twenty Bama mini-pigs were randomly assigned to a stent group(n = 10) and control group(hand-sewn anastomosis, n = 10). The anastomotic completion and operation times were recorded, along with histological examination, postoperative general condition, complications, mortality, bursting pressure, and the average anastomotic circumference(AC).RESULTS: All pigs survived postoperatively except for one in the stent group that died from ileus at 11 wk postoperatively. The operation and anastomotic completion times of the stent group were significantly shorter than those of the control group(P = 0.004 and P = 0.001, respectively). There were no significant differences in bursting pressure between the groups(P = 0.751). No obvious difference was found between the AC and normal circumference in the stent group, but AC was significantly less than normal circumferencein the control group(P = 0.047, P 0.05). No intestinal leakage and luminal stenosis occurred in the stent group. Histological examination revealed that the stent group presented with lower general inflammation and better healing.CONCLUSION: Laparoscopic colonic anastomosis with a degradable stent is a simple, rapid, and safe procedure in this porcine model.     

以家庭为中心的护理模式对胃食管反流病合并支气管哮喘患儿的影响

目的探讨以家庭为中心的护理模式对胃食管反流病（GERD）合并支气管哮喘患儿的影响。 方法选取2016年4月至2017年5月新疆维吾尔自治区人民医院收治的GERD合并支气管哮喘患儿58例,随机均分为研究组和对照组2组,每组各29例。治疗期间对照组患儿给予常规护理模式,研究组患儿则实施以家庭为中心的护理模式。比较2种护理模式对患儿的影响。 结果研究组患儿喘息、咳嗽及肺部哮鸣音等症状消失时间、出院时间均短于对照组患儿［（3.6±1.5）d vs （5.8±2.2）d,（3.4±1.7）d vs （5.0±2.8）d,（4.0±0.9）vs （6.1±2.1）d,（5.0±2.2）d vs （9.0±3.5）d］,且差异均有统计学意义（t=4.579,P<0.001;t=2.670,P=0.010;t=5.102,P<0.001;t=5.226,P< 0.001）。研究组患儿护理满意度及出院后1、3、6个月生活质量评分均高于对照组患儿［93.1% （27/29）vs 72.4% （21/29）,（70.3 ± 5.5）分vs （60.1 ± 4.8）分,（82.1 ± 4.9）分vs （71.3 ± 3.8）分,（90.1±3.7）分vs （79.8±4.2）分］,且差异均有统计学意义（χ²=4.350,P=0.037;t=7.563、9.457、9.814,P均<0.001）。 结论GERD合并支气管哮喘患儿实施以家庭为中心的护理模式,可有效提升治疗效果,缩短患儿症状消失时间和康复出院时间,提升其后期生活质量,具有推广价值。     

使用下腹部陈旧手术切口做直肠癌标本取出和预防性造口的可行性研究

目的探讨使用下腹部陈旧手术切口做直肠癌标本取出和预防性造口的可行性。 方法回顾性分析解放军总医院第七医学中心普通外科2017年1月~2019年6月间收治的中低位直肠癌腹腔镜保肛手术后行末端回肠双腔造口的患者的临床资料,其中22例应用了既往下腹部及盆腔脏器手术切口取出标本和预防性造口（观察组）;选取同期情况相近的经左侧腹直肌切口取标本,经右下腹行预防性造口的直肠癌患者40例作为对照组。比较两组患者的一般资料和造口及造口还纳相关并发症的发生情况,疼痛情况采用视觉模拟评分法（VAS）比较,出院时采用功能状态（Karnofsky）评分评价患者功能状态。 结果两组患者手术时间、术中出血量、术后进食时间、造口袋首次渗漏时间、结直肠吻合口漏发生率相比较差异均无统计学意义（t=2.539、0.879、0.866、0.774,χ²=6.508;P>0.05）。观察组术后各时间点患者疼痛情况评分分值均显著低于对照组（t=5.695,7.614,6.677;P<0.05）,术后使用镇痛药物人次显著下降（χ²=5.213,P<0.05）。两组患者造口相关并发症发生率、造口还纳相关并发症的发生率相比较差异均无统计学意义（P>0.05）。观察组Karnofsky功能状态评分为（83.7±5.6）分,显著高于对照组（78.4±5.2）分（t=2.906,P<0.05）。 结论对于中低位直肠癌保肛手术后行末端回肠双腔造口的患者,使用下腹部陈旧手术切口做标本取出和预防性造口是安全可行的,患者术后恢复较快,值得临床应用。