超声引导经皮穿刺置管引流治疗细菌性肝脓肿疗效分析(发表于中国实用外科杂志)赵宇1 ,王墨飞(通讯作者)1 ,张远石1 ,徐玲劼2 ,王卓2 ,梁健1中图分类号:R6 文献标志码: A[关键词] 肝脓肿; 穿刺; 引流术Keywords hepatapostema; puncture;..; drainage 2004年7月至2009年6月,本院采用超声引导下经皮肝穿刺置管引流治疗细菌性肝脓肿36例,效果良好,分析报道如下。1 资料与方法1.1一般资料 本组36例中男20例,女16例。年龄 32~81岁,平均57岁。脓腔长径3.6~12.7cm,平均5.8cm。主要症状为寒战、高热、肝区持续疼痛和肝脏肿大。白细胞计数升高31例。肝右叶27例,肝左叶4例,双叶均受累5例。其中单发肝脓肿28例,多发肝脓肿8例。术前由超声及CT检查证实诊断。1.2穿刺置管与治疗方法 病人取平卧位或左侧卧位,常规消毒铺巾,1%利多卡因局部浸润麻醉,以18 G PTC针在超声直视下穿刺插入脓腔,抽吸出脓液证实穿刺准确后,退出针筒,脓液送菌培养,自穿刺针置入导丝后退出针芯。以刀尖于穿刺部做2mm左右小切口,导丝引导下7F、12F介入扩管顺次扩张穿刺针道,用改良同轴导管技术将一次性塑料吸痰管送入脓腔:适当型号的扩管插入透明塑料管内以起支撑作用,两者相当于同轴导管的内外导管,顺导丝一起插入脓腔后,退出扩管而将塑料管留置于脓腔内完成操作(原同轴导管技术是借助外导管的支撑作用向体内更深部送入更细小的内导管)。置管后尽量抽尽脓液,以生理盐水、庆大霉素液、0.5%甲硝唑冲洗脓腔后导管外接引流袋。术后卧床休息,根据细菌学培养结果及时调整抗生素,反复冲洗保持引流通畅,注意观察引流物的量及性质,如脓液较稠难以抽出,可注入适量的α-糜蛋白酶,促进液化。如体温正常,症状、体征明显好转,超声检查脓肿消失或直径<2cm,引流液变清亮,<10 mL/d时拔除引流管。1.3结果 本组36例,共40个脓腔,脓液培养32例阳性,其中肺炎克雷伯菌17例,大肠埃希菌13例,金黄色葡萄球菌2例。平均置引流管7.5d,所有病例置管后均引流通畅,临床症状明显改善,体温多在2~3d内降至正常。无出血、胆瘘及弥漫性腹腔感染等并发症。2 讨论 经皮肝脓肿穿刺以其操作方法简便易行、病人痛苦少、成功率高、治疗费用低廉而广泛应用于肝脓肿的治疗,而置管引流同单纯穿刺抽吸治疗相比治愈率明显提高,是肝脓肿治疗的首选方法。目前,国内外多采用向脓腔内置入多侧孔8~10F猪尾管,由于导管过细常致使引流不畅,因此,达不到理想的引流效果。我们参照彭贵祖等[1]报道的方法,采用改良同轴导管技术将足够粗大的塑料管引入脓腔从而达到引流通畅的效果,克服了单纯Seldinner技术只能引入较小导管难以满足引流通畅的缺点。 过去认为多房性肝脓肿不宜行经皮肝穿刺置管引流,而Liu等[2]报告脓腔内的分隔不是穿刺引流术的禁忌证。本组8例多房性肝脓肿经穿刺引流取得良好效果。我们认为多数多房性肝脓肿之间可相通,不宜各个分别穿刺,反复冲洗即可获得良好引流效果。但对于多房分隔、脓腔较大、互不交通的脓肿,治疗效果较差,应考虑手术引流。针对不同肝叶的多发性肝脓肿,我们选择较大的两个脓腔分别进行穿刺置管,较小的脓腔单纯穿刺抽脓冲洗,结合应用有效抗生素,多能取得较好疗效。Ferraioli等[3]对比穿刺置管与手术引流治疗效果,证实两种方法在治疗细菌性肝脓肿方面均可取得相似效果,而在住院时间、治疗费用及并发症发生率等方面,穿刺组明显优于手术组。Tan等[4]报告直径>5cm的脓肿,手术引流总有效率优于穿刺引流。本组17例脓肿直径>5cm,且伴有高血压、糖尿病等疾病行穿刺置管引流也获得良好效果。 经皮肝穿脓腔置管引流的并发症多由操作失误引起,多可避免。我们体会操作过程中需注意以下问题:(1)脓肿穿刺时机:一旦确诊为肝脓肿,在应用有效抗菌药物治疗的同时,应尽早穿刺置管引流。对于高热、中毒症状较重者,有人主张先用3~7d抗生素,控制毒血症后再作引流。本组21例入院时毒血症严重,在输入大量抗生素的同时立即行此治疗,2~3d后体温很快下降,肝区疼痛缓解,中毒症状消失。说明对毒血症较重的病人早期施行经皮肝穿脓腔置管引流是适宜的,可尽早去除病灶,减少脓毒素的吸收。(2)穿刺技术:超声引导下直视穿刺的穿刺点一般在腋中线,以保证平卧位时引流管在最低位,保持引流通畅。要求穿刺处与脓肿间要有相当厚度的肝组织,不宜选择脓肿突出于肝脏表面处。穿刺针进入腹腔后进针要缓慢,如有落空感并见到脓液溢出证实穿刺成功,此时应尽量抽尽脓液并注生理盐水、庆大霉素液、0.5%甲硝唑冲洗脓腔,且将引流管在超声引导下置于脓肿最深处,选择引流管要足够粗,避免引流不畅。本组36例均一次穿刺成功,置管顺利。(3)术后处理及拔管时机:术后应每日用生理水或加入庆大霉素液、甲硝唑冲洗脓腔,以保持引流通畅,继续静脉应用抗生素治疗,如脓液较稠难以抽出,可注入适量的a-糜蛋白酶,促进脓液液化,必要时更换引流管。部分病例引流后仍有少许渗液,可经引流管向脓腔内注射少量10%氯化钠溶液,促进脓腔壁坏死。一般体温正常,症状、体征明显好转,超声检查脓肿消失或直径<2cm,引流液变清亮,引流量<10 mL/d时,可拔除引流管。本组病人经超声复查证实引流7~10d后脓腔均闭合。参考文献[1]彭贵祖,万仁华,张永模.改良同轴导管技术经皮经肝穿刺置管引流治疗细菌性肝脓肿38例[J].中华普通外科杂志,2001,16(8):504.[2]Liu CH,Gervais DA,Hahn PF,et al.Percutaneous hepatic abscess drainage:do multiple abscesses or multiloculated abscesses preclude drainage or affect outcome? [J].J Vasc Interv Radiol,2009,20(8):1059-1065.[3]Ferraioli G,Garlaschelli A, Zanaboni D,et al.Percutaneous and surgical treatment of pyogenic liver abscesses:observation over a 21-year period in 148 patients[J].Dig Liver Dis,2008,40(8):697-698.[4]Tan YM,Chung AY,Clow PK,et al. An appraisal of surgical and percutaneous drainage for pyogenic liver abscesses larger than 5 cm[J].Ann surg,2005,241(3):485-490.
腹腔镜和开腹结肠癌根治术远期疗效分析(发表于中国现代普通外科进展杂志)王墨飞1 李春雨1 胡祥2 李震1 张健2 金俊哲1 【摘要】 目的 评价腹腔镜和开腹结肠癌根治术在远期疗效方面的差异。方法 2003年10月至2009年6月,由同一手术组医生行结肠癌根治术183例,其中腹腔镜下完成81例,开腹完成102例,依据分期对比两组患者术后远期并发症,局部复发、远处转移及5年生存率。结果 两组在性别,年龄,病理类型及肿瘤位置等方面差异无统计学意义 (P>0.05);除术后粘连性肠梗阻发生率腹腔镜组少于开腹组外(Ⅰ/Ⅱ期 P=0.036, Ⅲ期 P= 0.042),切口疝、种植率,局部复发及远处转移两组比较差异均无统计学意义(P>0.05); 5年累计生存率,Ⅰ/Ⅱ期腹腔镜组77.4%,开腹组75.7%,差异无统计学意义(P= 0.626), Ⅲ期腹腔镜组71.8%,开腹组65.6%,差异无统计学意义(P = 0.517)。结论 腹腔镜结肠癌根治术远期疗效与开腹手术相似,但术后远期并发症少,值得推广。【关键词】 结肠肿瘤 腹腔镜 结肠外科 并发症Analysis on long-term results of laparoscopic surgery versus open surgery for colon cancer Wang Mo-fei1,Hu Xiang2,Zhang Jian2,Li Yong-shuang1,Jin Jun-zhe1.1.Department of Anorectal Surgery,The 4th Affiliated Hospital of China Medical University.Shenyang 110032,China;2.Department of Gernral surgery,The First Affiliated Hospital of Dalian Medical University.Dalian 116011,China.【Abstract】 Objective To evaluate the long-term results of laparoscopic (LP) and open (OP) radical resection for colon cancer. Methods 183 patients with colon cancer from October 2003 to June 2009 were divided into laparoscopic groups(81cases) and open operation groups (102 cases). Long-term postoperative complications,local recurrence,distant metastasis and 5-year survival rate were compared between the two groups by stage. Results There were no statistical differences in sex,age,pathology type and tumor location between the two groups( P>0. 05 ) . The incidence of postoperative adhesive intestinal obstruction was significantly lower in LP group than that in OP group(P=0.036 in stageⅠ/Ⅱ, P= 0.042 in stage Ⅲ), There were no significant differences in the incidences of incision hernia,incision seeding,local recurrence and distant metastasis for each stage between the two groups( P>0.05). The 5-year survival rates were, respectively 77.4% in LP group and 75.7% in OP group for stage Ⅰ/Ⅱ(P= 0.626),and 71.8% and 65.6% for stage III (P = 0.517). Conclusion Long-term results of laparoscopic resection are similar to those of open resection for colon cancer,but laparoscopic surgery has less long-term complications.【Key words】 Colon neoplasms Laparoscopy Colon surgery Complication
直肠类癌29例的临床分析(发表于中华普通外科杂志)王墨飞1 胡祥2 李震1 张德巍1 张健2 谢强1 【摘要】目的 探讨直肠类癌的临床、病理及影响预后的因素。方法 回顾性分析两间医院29例直肠类癌患者的临床资料。所有病例均经手术和病理证实,其中内镜粘膜下切除5例,经肛局部切除14例、局部扩大切除6例,经骶尾直肠部分切除2例,根治性切除4例。结果 年龄32~71(54.5±10.6)岁,随访时间3个月至10年,平均60±5.2个月,随访率为75.9﹪(22/29)。随防期内,小于1cm的13例手术切除后无复发,1~2cm的5例复发1例,大于2cm的4例中3例因类癌肝转移死亡。5,10年特异性生存率87.3%, 80.2%。结论 手术治疗是本病的最佳治疗方法,手术切除范围取决于原发肿瘤的大小,浸润程度,淋巴结受累及肝转移等情况。【关键词】 直肠肿瘤 类癌 病理 外科手术Clinical analysis of 29 cases of rectal carcinoid Wang Mofei1, Hu-Xiang2, Li-Zhen1 Zhang Dewei1,Zhang-Jian2, Xie-Qiang1(1. Department of Anorectal surgery,The Fourth Affiliated Hospital,China Medical University. Shenyang 110032,China;2.Department of General surgery,The First Affiliated Hospital,Dalian Medical University. Dalian 116011,China.【Abstract】Objective To investigate the clinical and patholonical features of rectal carcinoid and factors influencing the pronnosis.Methods Clinical data of 29 cases with postoperative pathologic diagnosis from May 1998 to May 2008 in two hospital were retrospectively reviewed.Among 29 cases Endoscopic submucosal resection was conducted in 5 cases,local resection in 14 cases,expensively local resection in 6 cases,transsacral local wide resection in 2 cases,radical operation in 4 cases.Results Median age at treatment was 54.5±10.6 (32~71)years. Median follow-up was 60±5.2 months (3 months-10 years) , follow-up rate was 75.9﹪(22/29).During a follow-up, there were no cases with recurrence among the 13 patients with tumor size<1cm. The 5-,10-year disease-specific survival rates were 87.3%, 80.2%. Conclusions The operative treatment is the best therapy to this kind of disease,the choice of operative mode must be made accordinn to the size,infiltration of the tumor,the condition of infiltrated lymph node and hepatic metastasis.【Key words】 Rectal neoplasms Carcinoid tumor Patholony Surgical procedures
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