目的 评价股薄肌转移及双套管冲洗对复杂直肠阴道瘘治疗效果.方法 收集2013年5月至2017年5月在北京世纪坛医院行股薄肌转移治疗的40例直肠阴道瘘患者的临床资料,术后早期漏患者行双套管冲洗处理.记录手术成功率及术后并发症,比较术前及术后6个月SF-36生活质量评分及Wexner肛门失禁评分.结果 29例患者术后直肠阴道瘘顺利愈合,初始愈合率72.5％;11例患者术后早期漏行双套管冲洗治疗,9例愈合,2例失败,失败患者予以粪便转流.平均随访18个月,直肠阴道瘘修补成功率为95.0％,并发症发生率为17.5％,术后SF-36生活质量评分及Wexner肛门失禁评分明显改善(P<0.05).结论 股薄肌转移联合双套管冲洗是复杂直肠阴道瘘的有效治疗手段.

探讨改良教具在外科总论实习课中的应用效果.方法总结带教临床医学五年制本科生外科总论实习课经验,改良体表肿物切除术、外科清创术和肠吻合术3种外科总论实习课教具,并应用到2018、2019级医学本科生教学中,通过期末临床技能大赛评价教学效果.结果与传统教具比较,改良教具更加接近于临床实际,可操作性更强;在期末临床技能大赛中,使用改良教具后,外科操作水平明显提高,合格率提高16.7％(100％vs 83.3％,P=0.013);平均分提高15.8分(88.5 vs 72.7,P=0.000).结论改良教具教学效果良好,值得推广应用.

住院医师规范化培训改革后,对医学硕士研究生进行住院医师规范化培训是研究生培养阶段的重要组成部分.肿瘤外科是外科学的基础,做好肿瘤外科培训是整个外科学临床培训的关键.因此住院医师规范化培训改革后,对于肿瘤外科带教老师和研究生都提出了非常高的要求.本文总结我科多年来的临床教学体会,探讨肿瘤外科住院医师培训的新思路,以提高住院医师在肿瘤外科规范化培训阶段的教学质量.

Objective To investigate the clinical curative effect of Milligan‐Morgan and Ligasure blood vessels closed system for conducting mixed hemorrhoidectomy under local anesthesia .Methods 68 inpatients with mixed hemorrhoid in the general sur‐gery department of our hospital from April 2009 to April 2012 were selected and randomly divided into the Ligasure group (observa‐tion group ,34 cases) and the Milligan‐Morgan group (control group ,34 cases) .The operation adopted the local infiltration anesthe‐sia .The postoperative followed up lasted for 6‐36 months .The operation time ,intraoperative blood loss ,total hospitalization cost , postoperative hospital stay time ,postoperative pain degree and the postoperative complications were compared between the two groups .Results The average operation time in the control group and the observation group was (32 .35 ± 10 .24)min and (20 .29 ± 7 .88) min(P=0 .000) ,the average intraoperative blood loss was (29 .71 ± 14 .67)mL and (4 .97 ± 2 .89) mL(P=0 .000) ,the aver‐age postoperative pain score was (5 .88 ± 1 .12) points and (3 .47 ± 0 .83) points(P=0 .000) ,the average postoperative hospital stay time was (7 .97 ± 2 .55) d and (2 .29 ± 1 .17) d(P=0 .000) ,and the average hospitalization expense was (1 541 .32 ± 205 .91) Yuan and (2 872 .32 ± 652 .30) Yuan ,respectively ,the differences between the two groups were statistically significant (P=0 .000) .Dur‐ing the hospitalization period and follow‐up ,the anal exudation rate and the average postoperative pain score in the control group were higher than those in the observation group(P=0 .000) ,the occurrence rate of other complications had no statistically signifi‐cant differences between the two groups .Conclusion The Ligasure operation mode has less intraoperative blood loss ,shorter opera‐tion time and shorter postoperative hospital stay time .

目的 分析腹膜后肿瘤术后发生尿瘘的危险因素并总结尿瘘的处理经验.方法 回顾性分析2009-04-2014-04首都医科大学附属北京世纪坛医院普通外科行腹膜后肿瘤手术的530例患者,术后随访2～6个月,期间发生尿瘘29例,对其危险因素进行Logistic多因素分析,进而总结预防和处理尿瘘并发症的经验.结果 530例患者中有29例发生尿瘘,其中输尿管瘘25例,膀胱瘘4例,经Logistic回归分析发现,发生尿瘘并发症的相关因素中术区放疗史是最大的危险因素(OR=80.973),其次是肿瘤最大直径(OR=58.258);术前血白蛋白水平(OR=0.021)是最大的保护因素,其次是输尿管支架置入术(OR=0.054).25例输尿管瘘患者均先行超声引导下肾盂造瘘术,充分转流尿液.有5例经肾盂造瘘引流术后自愈,2例引流随访期间肿瘤复发死亡,8例输尿管瘘再行经皮下隧道肾盂膀胱导管引流术后治愈,其余10例输尿管瘘患者接受再次开腹部手术治疗后愈合.4例膀胱瘘患者行留置尿管及膀胱冲洗治疗,其中3例自行愈合,1例再行膀胱造瘘术后自行愈合.结论 腹膜后肿瘤手术患者,因术区放疗史、肿瘤较大、术前血白蛋白水平低和未放置输尿管支架者,易发生尿瘘;发生尿瘘患者经肾盂造瘘、膀胱造瘘、留置尿管以及皮下隧道肾孟膀胱导管引流术和开腹手术,均可获得治愈.

目的 探讨腹膜后肿瘤的临床病理特点,总结腹膜后肿瘤诊治经验.方法 回顾性分析了1975年9月-2014年12月间收集的687例腹膜后肿瘤患者资料,并进行临床病理特征及术后复发影响因素的分析.结果 687例腹膜后肿瘤患者中,良性173例(25.2％),交界性44例(6.4％),恶性470例(68.4％).原发性腹膜后恶性肿瘤中常见的为脂肪肉瘤、平滑肌肉瘤、恶性纤维组织细胞瘤,分别占全部腹膜后肿瘤11.6％、8.7％、4.4％.良性肿瘤常见的为畸胎瘤,占全部肿瘤5％.原发性肿瘤592例,占86.2％.继发性肿瘤95例,占13.8％.腹膜后肿瘤临床表现多样,术中出血多,术中联合脏器切除的概率高.肿瘤性质、肿瘤切除程度、肿瘤分化程度是腹膜后肿瘤术后复发的主要影响因素(P＜0.05).肿瘤切除愈彻底,复发时间愈晚.结论 提高腹膜后恶性肿瘤的完全切除率,降低腹膜后肿瘤术后复发,是治疗腹膜后肿瘤的关键措施.

AIM To evaluate the efficacy of gracilis muscle transposition and postoperative salvage irrigation-suction in the treatment of complex rectovaginal fistulas (RVFs) and rectourethral fistulas (RUFs). METHODS Between May 2009 and March 2012, 11 female patients with complex RVFs and 8 male patients with RUFs were prospectively enrolled. Gracilis muscle transposition was undertaken in all patients and postoperative wound irrigation-suction was performed in patients with early leakage. Efficacy was assessed in terms of the success rate and surgical complications. SF-36 quality of life (QOL) scores and Wexner fecal incontinence scores were compared before and after surgery. RESULTS The fistulas healed in 14 patients after gracilis muscle transposition; the initial healing rate was 73.7%. Postoperative leakage occurred and continuous irrigation-suction of wounds was undertaken in 5 patients: 4 healed and 1 failed, and postoperative fecal diversions were performed for the patient whose treatment failed. At a median follow-up of 17 mo, the overall healing rate was 94.7%. Postoperative complications occurred in 4 cases. Significant improvement was observed in the quality outcomes framework scores (P < 0.001) and Wexner fecal incontinence scores (P = 0.002) after the successful healing of complex RVFs or RUFs. There was no significant difference in SF-36 QOL scores between the initial healing group and irrigation-suction-assisted healing group. CONCLUSION Gracilis muscle transposition and postoperative salvage wound irrigation-suction gained a high success rate in the treatment of complex RVFs and RUFs. QOL and fecal incontinence were significantly improved after the successful healing of RVFs and RUFs.

目的:研究直肠癌患者行Dixon手术后发生吻合口瘘的相关因素.方法:回顾性分析2009-04/2013-04我院收治的289例行Dixon手术直肠癌患者的性别、年龄、伴有糖尿病、TNM分期、营养指标和吻合口距肛缘距离的情况,统计吻合口瘘的发生情况,并进行Logistic回归分析.结果:直肠癌Dixon手术后吻合口瘘的相关因素中,相对危险度最大的是TNM分期（OR=2.165）,相对危险度最小的是吻合口距肛缘距离（OR=0.194）.结论:直肠癌Dixon手术后吻合口瘘的相关因素中TNM分期是最大的危险因素,吻合口距肛缘距离是最大的保护因素.

Objective To investigate the surgical operation method and its clinical efficacy for leiomyosarcoma of the inferior vena cava.Method The clinical data of 5 tumor patients were reviewed retrospectively,and historical surgical experiences of retroperitoneal tumor and comprehensive literature were combined to seek the curative measures of leiomyosarcoma of the inferior vena cava.Result Of the 5 cases,3 cases of leiomyosarcoma originated from the middle of the inferior vena cava,and 1 case each in upper and lower segments.4 cases had undergone surgical resection as planned,in which2 cases achieved RO resection,and were recurrence-free in more than 20 months of follow up;And 1 cases reached Rl resection,but developed postoperative recurrence and received reoperation after 6 months,with no recurrence during 24-month follow up;1 patient had liver metastases thus received R2 resection,gaining 8-month survival;1 case was found during operation that the tumor had extended to right atrium and blood vessels were infiltrated,and only got biopsy performed,obtaining just 2-month survival.No IVC reconstruction were undergone in 3 cases of inferior vena cava resection,and no serious complication occurred,e.g.,renal failure.Conclusion Preoperative CT/MRI examination is applied primarily on locating tumor and assessing the possibility of surgical resection,while angiography identifies the path,blood flow and collateral circulation of inferior vena cava,thus helps to reduce blood loss in probing surgery and assists in decision making of IVC reconstruction;RO radical resection is the major factor in reducing recurrence and prolonging survival;patients who developed postoperative transient renal insufficiency may recover rapidly via blood filtration;and reoperation may prolong survival time for patients with postoperative local recurrence.

OBJECTIVETo assess the efficacy and experience of gracilis muscle transposition for complex rectovaginal fistula (RVF) and rectourethral fistula (RUF).METHODSNineteen patients underwent gracilis muscle transposition for complex RVF and RUF from May 2009 to November 2011 in the Beijing Shijitan Hospital and the clinical data were prospectively collected. The success rate and complications were recorded. SF-36 quality of life score, Wexner fecal incontinence score, and female sexual function score before surgery and 6 months after surgery were recorded.RESULTSIn 19 patients, there were 8 males (RUF) and 11 females (RUF). The times of failed attempt repair preoperatively ranged from 0-3 (mean, 1.0). The diameter of the fistula ranged from 0.5-3.0 cm (mean, 1.6), and all fistulas located above the sphincter. The operative time ranged from 145-400 minutes (median, 240). The postoperative hospital stay ranged from 10-39 days (median 21). Early postoperative complications included thigh pain and numbness in 2 cases, leg numbness in 2 cases. No long-term complications were noticed. The follow-up period ranged from 6-35 months (median, 18). The gracilis muscle transposition had a healing rate of 94.7% (18/19). As compared with the preoperative level, Wexner score decreased from 10.0±8.8 to 2.9±5.8, and the continence function improved significantly (P=0.002). Sexual function score of 11 female patients increased from 1.0±1.8 to 4.0±4.0, and the sexual function had a significant improvement after surgery (P=0.022). SF-36 quality of life scores improved significantly (P<0.001).CONCLUSIONSGracilis muscle transposition for complex rectovaginal fistula and rectourethral fistula has high success rate with mild and rare complications.

Objective To investigate the clinical significance of Tokyo Guidelines for acute cholangitis(AC). Methods 223 patients involved in the study, following the diagnositic criteria and severity assessment and strategy of treatments, were analyzed retrospectively from Oct. in 2006 to Oct. in 2012 in our hospital. Results (1) Following the traditional criteria of Charcot's trid, only 64.1%(143/223) of AC got definite diagnosis at the first time, whereas that was 86.09%(192/223) following the Tokyo Guidelines criteria, but 7.85%of non-AC were misdiagnosed as AC. (2) To assess the severity of AC suggested by Tokyo Guidelines, there were 30.49%(68/223) of mild (gradeⅠ), 55.6% (124/223) of moderate (grade Ⅱ) and 13.9% (31/223) of severe (grade Ⅲ), while only 7.6%(17/223) satisfied sever AC according to Reynold’s Pentad. (3) choledocholithiasis or malignant tumors were the common etiologies, 81.17%(181/223) or 10.77% (24/223), respectively. 95.96%of patients had biliary obstruction, while other 4.14% (9/223) had not biliary dilatation but "accumulative gas sign". (4) Biliary drainage was performed in 63.23% (141/223) of patients. The effective rate of ENBD and PTCD was about 70.45% (62/88). (5) Total mortality was 5.38% (12/223), and 58.33% (7/12) of death were simultaneously concomitant with serious disease in other organs or systems. Conclusion It is more precise to diagnose and evaluate the severity of AC that employing the criteria of Tokyo Guidelines. Furthermore, the strategy of the treatments is very normative and practical. The mortality can be obviously reduced on account of following the recommendations of Tokyo Guidelines. However, it maybe misdiagnose because of false positive.

目的探讨便秘的有效手术治疗方法。方法不同类型的便秘患者40例,其中13例慢传输型便秘患者及3例混合型便秘患者行全结肠切除术;1例耻骨直肠肌痉挛行耻骨直肠肌部分离断术;4例直肠黏膜脱垂、3例直肠黏膜脱垂伴混合痔及3例混合痔患者行吻合器痔上黏膜环切术(PPH);3例直肠前膨出合并直肠黏膜脱垂患者行STARR手术;9例直肠前膨出患者行经阴道修补术;6例乙状结肠脱垂患者行部分直乙状结肠切除术,其中3例合并盆底疝者加行盆底重建术。观察治疗效果。结果 30例患者便秘症状完全消失,8例患者症状明显好转,1例患者诉排气障碍(患者术后证实有抑郁症),1例诉便秘症状无好转(考虑粘连性肠梗阻)。结论对于各种不同病因的便秘要采取不同的手术治疗方式,严格掌握手术适应证。

OBJECTIVE:To evaluate the differences in clinicopathological characteristics and severity between American and Chinese patients with colorectal Crohn disease(CD).METHODS:Between March 1985 and September 2004, 68 patients with colorectal CD in Cleveland Clinic Florida (America) and 85 patients with colorectal CD in the 301 Hospital(China) were enrolled in the study. Data of two groups,including demographics, clinical characteristics, extraintestinal manifestations, presenting symptoms, location and pathological characteristics,were compared.RESULTS:60.3% of American patients and 36.5% of Chinese patients were female(P=0.003). 11.8% of American patients and 1.2% of Chinese patients had a family history of CD(P=0.016). American patients had a significantly higher rate of extraintestinal disease (39.7% vs 20.0%), abscess(19.0% vs 0), and anorectal fistulas(51.5% vs 0). American patients had significantly more extensive disease than Chinese patients(pancolitis: 44.1% vs 4.7%, P<0.01). American patients had a significantly higher rate of disease involving the ascending colon, transverse colon, descending colon, sigmoid colon, anorectal area compared with Chinese patients(all P<0.05).CONCLUSIONS:American patients with colorectal Crohn disease seem to have a female predominance, a higher rate of CD family history, to involve the distal intestinal tract more often, and have more severe clinical manifestation and pathological process, as compared with Chinese patients.