1 病例介绍 患者女,71 岁,农民.因"体检发现肝脏占位10 d"于2021年4月17日入院.查体:生命体征平稳,双侧锁骨上无肿大淋巴结,心肺无明显异常.腹部膨隆,腹肌软.剑突下可扪及一巨大肿块,质软,边界不清,上缘不可触及.腹部无压痛及反跳痛,肝肾区无叩痛,无移动性浊音,肠鸣音正常.入院后完善各项实验室检查.血红蛋白98 g/L;肝功能:碱性磷酸酶225 IU/L,γ-谷氨酰转肽酶207 IU/L,胆碱酯酶3931 IU/L.肾功能、AFP、CEA、CA199及感染性疾病筛查均正常.

Objective To investigate the effect of different pneumoperitoneal pressures on liver and intestinal function after laparoscopic cholecystectomy for cholecystolithiasis. Methods A total of 88 patients with cholecystolithiasis from January 2019 to December 2021 were selected and then divided into hypobaric group（44 cases） and hyperbaric group（44 cases） by random number table. The patients in the hypobaric group were maintained at a CO 2 pneumoperitoneal pressure of 8-12 mmHg during the operation, while the patients in the hyperbaric group were maintained at a CO 2 pneumoperitoneal pressure of 13-15mmHg during operation. The intestinal function, pain and liver function indexes on the 1st day and the 3rd day after surgery were compared between the two groups. Results After surgery, the VAS scores of the two groups on the 1st day after surgery were significantly higher than those before surgery（P＜0.05）, but the VAS scores began to decrease on the 2nd day after surgery, which were significantly lower than those on the 1st day after surgery（P＜0.05）. The VAS scores on the 3rd day after surgery were significantly lower than those on the 1st and 3rd day after surgery（P＜0.05）. The VAS scores of the patients in the hypobaric group were significantly lower than those in the hyperbaric group（P＜0.05）. There was no significant difference in ALT or AST between the two groups（P＞0.05）. On the 1st day after the operation, the ALT and AST of the two groups were significantly higher than those before the operation（P＜0.05）, and those in the hypobaric group were significantly lower than those in the hyperbaric group（P＜0.05）. On the 3rd day after surgery, there was no significant difference in ALT and AST between the two groups or compared with those before surgery（P＞0.05）. The time to first defecation in the hypobaric group was significantly shorter than that in the hyperbaric group（P＜0.05）. There was no complications such as gas embolism and hypercapnia in both groups. Conclusion Pneumoperitoneal pressure maintained at 8-12 mmHg during laparoscopic cholecystectomy surgery is helpful for the operation of patients, not only can reduce the impact on intestinal function and liver function, but also reduce the incidence of pain in patients, especially shoulder pain.

Objective:To investigate the postoperative recovery of patients undergoing laparoscopic upper gastrointestinal perforation repair under different pneumoperitoneum pressures.Methods:According to the principle of prospective study, 50 patients with upper gastrointestinal perforation who were admitted to Anqing Hospital Affiliated to Anhui Medical University from June 2019 to June 2021 were selected and randomly divided into two groups: the observation group (24 cases, pneumoperitoneal pressure 8-12 mmHg, i.e. 1.064-1.596 kPa) and the control group (26 cases, pneumoperitoneum pressure 13-15 mmHg, i.e. 1.729-1.996 kPa). The patients in the two groups underwent laparoscopic exploration + ulcer perforation repair. The postoperative recovery process, complications, and the changes of inflammatory indexes (leukocyte count, C-reactive protein and procalcitonin) at one hour before operation and on the first and fourth day after operation were compared between the two groups.Results:Both groups successfully completed the operation, and there was no significant difference in operation time between the two groups. The postoperative anal recovery time, length of hospital stay, and total hospitalization expenses in the observation group were less than those in the control group (t=-3.006, -2.514, -7.012; all P<0.05); the incidence of postoperative complications in the observation group was lower than that in the control group, but the difference was not statistically significant (χ2=2.427, P=0.119). There were no significant differences in inflammatory indexes between the two groups one hour before operation, but the indexes in the control group was significantly higher than those in the observation group on the first and fourth day after operation (all P<0.05).Conclusion:During laparoscopic repair of upper gastrointestinal perforation, controlling the pneumoperitoneum pressure at 8-12 mmHg dose not affect the operation, which can reduce the impact on the recovery of gastrointestinal function and toxin absorption.

目的 探讨上消化道穿孔术后早期序贯性肠内营养支持的疗效.方法 选取安徽医科大学附属安庆医院普外科2017年1月-2019年4月收治的上消化道穿孔患者71例.将按随机数字表法分为两组,观察组36例,对照组35例.观察组术前留置液囊空肠营养管,术后经空肠营养管进行序贯性肠内营养支持治疗;对照组术前留置普通胃管,术后给予全肠外营养支持治疗.于术前和术后第7天检测两组患者的体质量指数、前白蛋白、血清白蛋白、术后肛门排气时间、体质量下降情况、住院时间、住院总费用及禁食期每日补液量.结果 两组患者的性别、年龄、体质量指数及穿孔部位差异无统计学意义(P均>0.05).术后第7天两组患者的各营养指标较术前均有所升高(P<0.05);观察组体质量指数、血清白蛋白及前白蛋白的升高幅度显著高于对照组(P<0.05).两组患者术后肛门排气时间[(3.0±0.8)dvs(3.6±0.7)d]、术后住院时间[(5.2±2.3)dvs(7.3±2.6)d]、住院总费用[(12905±2723)元vs(15251±2742)元]及禁食期补液量[(2063±241)ml vs(2224±264)ml]比较,观察组均明显低于对照组,差异有统计学意义(P均<0.05).观察组并发症发生率低于对照组(22.2％vs 31.4％),但差异无统计学意义(P>0.05).结论 上消化道穿孔术后患者早期应用序贯性肠内营养支持能更好地改善营养状况,加速术后的康复.

Objective To evaluate the effect of early enteral nutrition (EEN) supplemented with glutamine (Gln) for patients with severe acute pancreatitis (SAP) on systemic inflammatory response and immune function. Methods Forty-nine SAP patients admitted to the General Surgery of Anqing Hospital Affiliated to Anhui Medical University from Oct. 2015 to May. 2017 were randomly divided into the experimental group (24 cases) and the control group (25 cases). EEN combined with Gln was used in the experimental group and only EEN was used in the control group. Blood samples from all the patients were collected for analysis of inflammatory markers [C-Reactive protein (CRP), procalcitonin (PCT), Interleukin-6 (IL-6), Interleukin-8 (IL-8), tumor necrosis factor-α (TNF-α)] and immune indices (CD3+, CD4+, CD4+/CD8+) on the day l, 6 and 11 after admission, and their differences were compared between the two groups. Results (1) On the first day after admission,compared with the control group, there was no significant difference of systemic inflammation markers (including CRP, PCT, IL-6, IL-8, TNF-α) and immune parameters (CD3+, CD4+, CD4+/CD8+) in the experimental group. (2) On day 6, the levels of inflammatory markers CRP [(56.31±18.04) mg/L vs (98.12±11.54) mg/L, P=0.037], IL-6 [(45.87±10.99) pg/mL vs (54.72±4.77) mg/L, P=0.026), IL-8 [(45.15±9.27) ng/mL vs (59.03±4.87) ng/mL, P=0.013], TNF-α [(24.35±7.15) pg/mL vs (32.41±4.22) pg/mL, P=0.010] and PCT [(1.11±0.49) ng/mL vs (1.50±0.30) mg/L, P=0.024] in the experimental group were significantly lower than those in the control group. In addition, levels of immune indices CD3+ [(63.42±2.86)％ vs (54.67±1.76)％, P=0.035], CD4+ [(43.69±1.83)％ vs (40.08±1.08)％, P=0.014] and CD4+/CD8+ [(2.25±0.39) vs (1.87±0.22), P=0.006] were significantly higher in the experimental group. (3) On day 11, the levels of CRP [(16.81±7.56) mg/L vs (43.01±2.74) mg/L, P=0.009], IL-6 [(29.39±7.92) pg/mL vs (38.29±5.33) pg/mL, P=0.020], IL-8 [(30.73±9.26) ng/mL vs (39.69±5.26) ng/mL, P=0.018], TNF-α [(13.87±5.67) pg/mL vs (20.35±3.82) pg/mL, P=0.019] and PCT [(0.34±0.11) ng/mL vs (0.95± 0.29) ng/mL, P=0.035] in the experimental group were also significantly lower than those in the control group. And the levels of CD3+ [(69.68±1.87)％ vs (61.14±1.21)％, P=0.017], CD4+ [(54.27±3.23)％ vs (45.30±1.59)％, P=0.007] and CD4+/CD8+ [(2.98±0.51) vs (2.01±0.28), P=0.012] in the experimental group were also significantly higher.Conclusion For patients with severe acute pancreatitis, EEN combined with Gln is superior to EEN alone in reducing systemic inflammatory response and improving immune function.

目的 观察并分析腹腔镜肝切除联合胆道镜治疗肝内外胆管结石手术的安全性、有效性.方法 选取我院自2014年1月至2017年9月期间收治的40例肝内外胆管结石患者资料,根据手术方法不同入组,20例进行腹腔镜肝切除联合胆道镜探查的患者纳入观察组,20例进行开腹肝切除联合胆道镜探查的患者纳入对照组.针对两组患者的各项临床资料,分析其差异有无统计学意义.结果 在手术时间、术中出血量方面,两组病例间的差异无统计学意义.两组患者术后第3天生化指标中,总胆红素的差异无统计学意义,谷丙转氨酶、前白蛋白、C-反应蛋白的差异有统计学意义.在术后住院时间、术后通气时间、术后第1天疼痛评分、术后第3天疼痛评分方面,两组患者间的差异有统计学意义.在并发症发生率、复发率方面,两组患者间的差异无统计学意义.结论 治疗肝内外胆管结石,腹腔镜肝切除联合胆道镜是一种安全有效的手术方式,值得临床推广.

目的 分析早期梗阻型急性胆源性胰腺炎(ABP)患者应用不同治疗方法治疗的效果.方法 回顾性分析安徽医科大学附属安庆医院2013年7月至2015年1月收治的60例梗阻型ABP患者临床资料,根据不同治疗方法分为非手术治疗组、开腹手术组和内镜下十二指肠乳头括约肌切开术(EST)治疗组,每组20例;依据Ranson标准及APACHEⅡ评分,将患者分为轻型组(34例)及重型组(26例).对比各组患者住院时间、腹痛缓解时间、血淀粉酶恢复时间、病死率、半年内胰腺炎复发率及胰腺炎并发症发生情况.结果 轻型组患者比较:非手术治疗组住院时间、腹痛缓解时间及血淀粉酶恢复时间均长于开腹手术组、EST治疗组(P均＜0.05),而开腹手术组和EST治疗组比较差异无统计学意义(P均＞0.05).重型组患者比较:非手术治疗组住院时间、腹痛缓解时间及血淀粉酶恢复时间均长于开腹手术组、EST治疗组(P均＜0.05),且开腹手术组均长于EST治疗组(P均＜0.05).非手术治疗组患者死亡率为15.0％,开腹手术组为5.0％,EST治疗组为5.0％,3组患者死亡率比较差异无统计学意义(P＞0.05).开腹手术组患者并发症发生率、胰腺炎复发率均低于非手术治疗组(P均＜0.05);EST治疗组并发症发病率、胰腺炎复发率均低于非手术治疗组,均高于开腹手术组,但差异均无统计学意义(P均＞0.05).结论 梗阻型ABP患者非手术治疗后,须早期行开腹手术或EST解决胆道梗阻.同时,对于早期胆道手术方式的选择,需根据患者实际疾病及机体应激状态、年龄等综合因素做出科学选择,以便进行针对性治疗,促进患者预后康复.

目的：探讨谷氨酰胺联合肠内营养对胃癌患者术后血清C反应蛋白（CRP）及免疫功能的影响。方法将行胃癌根治术患者共42例随机化分为谷氨酰胺联合肠内营养组（A组）和肠内营养组（B组），分别于术前第1天，术后第1、7天晨同一时间空腹抽取外周静脉血分别检测血清CRP、IgA、IgM、IgG、T淋巴细胞亚群（CD4＋、CD8＋、CD4＋／CD8＋值）。结果术后第1天两组的免疫指标都比术前第1天降低，术后第7天回升。血清CRP较术前第1天明显上升，术后第7天明显下降。术后第7天，谷氨酰胺联合肠内营养组IgG、CD4＋、CD4＋／CD8＋均比肠内营养组显著升高（P＜0．05）；谷氨酰胺联合肠内营养组患者术后血清CRP水平比肠内营养组显著偏低（P＜0．05）。两组感染并发症差异无统计学意义（P＞0．05）。结论谷氨酰胺联合肠内营养能够有效的改善胃癌患者术后免疫功能，减少术后炎症反应，促进术后快速康复。

目的 探讨胆汁回输联合早期肠内营养(early enteral nutrition,EEN)对良性梗阻性黄疸患者术后血清C反应蛋白(C-reactive protein,CRP)及免疫功能的影响.方法 将57例术后行胆汁外引流的良性梗阻性黄疸患者随机分为胆汁回输组(A组)、EEN组(B组)、胆汁回输联合早期肠内营养组(联合组,C组),分别于术前1 d,术后第1、3、7天晨同一时间空腹抽取外周静脉血10 mL,测定CRP、C3、C4、IgA、IgM、IgG、T淋巴细胞亚群(CD3+,CD4+,CD8+,CD4+/CD8+值).观察患者病情转归情况,统计术后感染发生率.结果 联合组患者术后血清CRP水平低于EEN组及胆汁回输组(P＜0.05).联合组与EEN组相比较,其T淋巴细胞功能恢复更迅速、恢复程度更高(P＜ 0.05),免疫球蛋白及补体系统术后恢复较快(P＜0.05);联合组与单纯胆汁回输组比较,两组术后免疫球蛋白及补体系统的恢复,在速度和程度上的差异不具有统计学意义(P＞ 0.05).联合组术后感染发生率低于EEN组及胆汁回输组(P＜ 0.05).结论 胆汁回输联合早期肠内营养能有效改善良性梗阻性黄疸患者的体液及细胞免疫功能,减轻术后炎症反应,降低术后感染发生率,促进术后快速康复.

十二指肠间质瘤是起源于十二指肠间叶组织的非定向分化性肿瘤,占小肠间质瘤的10％～20％,临床报道较少;而十二指肠间质瘤合并主胰管变异的病例则更为罕见,我院收治1例十二指肠间质瘤合并主胰管变异患者,现报道如下. 病例 患者,男,74岁,因“呕血黑便五小时”入院.体检:皮肤巩膜无黄染,体表未扪及肿大淋巴结.心肺无明显异常.腹部平软,未扪及肿块,腹部无压痛及反跳痛,肝脾肋下未及,Murphy征阴性,无移动性浊音,肠鸣音活跃.实验室检查:血白细胞8.8×109/L,血红蛋白64 g/L,血小板120×109/L,肝功能:总胆红素8.1 μmol/L,白蛋白32.5g/L,胆碱酯酶4 503 IU/L.腹部MRI:十二指肠占位性病变(图1A、1B),MRCP:主胰管开口位于胆总管上方,考虑主胰管经副乳头开口(图1C).

目的 研究早期肠内营养(EEN)对重症急性胰腺炎(SAP)患者血清C反应蛋白(CRP)及T淋巴细胞亚群的影响.方法 将45例SAP患者随机分为实验组(22例)和对照组(23例).实验组给予EEN,对照组给予肠外营养(PN),待患者排气排便后给予EN(通常于入院后5～7d).于入院后第1、5、7、11天,检测两组患者血清CRP及T淋巴细胞亚群(CD3、CD4+、CD4+/CD8+值).结果 除3例排除实验,余42例SAP患者治愈.平均住院日及住院费用,实验组低于对照组(P＜0.05).两组间比较,血清CRP、T淋巴细胞亚群,在第1天的差异无统计学意义(P＞0.05)；第5、7、11天血清CRP水平,实验组低于对照组(P＜0.05),T淋巴细胞亚群(CD3、CD4+、CD4+/CD8+值)水平实验组高于对照组(P＜ 0.05).结论 给予EEN能更好地降低SAP患者急性反应期炎症反应,提高免疫功能.

目的探讨胆汁回输在低体重患者胆道术后行肠内营养支持治疗的临床应用价值。方法将62例低体重胆道疾病手术患者随机分为胆汁回输组(32例)和对照组(30例),于术前、术后第7天检测两组患者肝功能、营养指标,并观察两组患者术后的胃肠功能恢复时间、体重下降、切口愈合情况、住院时间、住院费用及禁食期每日输液量。结果术后两组患者肝功能指标总胆红素(TBIL)、谷丙转氨酶(ALT)、谷草转氨酶(AST)与术前相比均有显著下降(P<0.05);两组患者术后血清白蛋白(ALB)、前白蛋白(PRE)与术前比较均有显著上升(P<0.05);胆汁回输组患者术后TBIL、ALT下降幅度和血清ALB、PRE升高幅度均较对照组明显,差异有统计学意义(P<0.05);术后两组AST差异无统计学意义,且两组患者术后体重与术前相比均下降,差异有统计学意义(P<0.05);对照组下降较胆汁回输组明显,差异有统计学意义(P<0.05)。胆汁回输组胃肠功能恢复时间、切口愈合情况、住院时间、住院费用及禁食期每日输液量低于对照组。结论低体重患者胆道术后行胆汁回输有利于改善患者的营养状况,降低并发症发生率,减少住院费用。

Aim To explore the effects of mannitol on adhesive intestinal obstruction by ileus tube.Methods A total of 40 Adhesive intestinal obstruction patients were randomly divided into control group and experimental group.Patients in the control group were treated with routine therapy including fasting,nutritional support,maintaining electrolyte and acid-base balance,using somatostatin and ileus tube decompression.Patients in the experimental group received mannitol based on routine therapy.Results Experimental group had a better outcome as compared with control group,including a quick recovery of flatus and stool[95% and 35.2±1.4 h vs 75% and 43.0±3.9 h](P0.05),decreased degree of abdominal circumference[15.0±1.5 cm vs 13.2±1.4cm](P0.05),the disappearing time of gas-liquid and hospitalization time was shorter than the control group[41.7±7.0 h and 8.9±1.3 d vs 53.3±9.2 h and 13.2±1.4 d](P0.05).The rate of transferring to operation in experimental group(5%)was significantly lower than that in the control group(25%).Conclusion Using mannitol by ileus tube plus routine treatment is an effective method to treat adhesive intestinal obstruction by significantly improving clinical symptoms,increasing non-surgical cure ativerate,decreasing the rate of transferring to operation and shorten hospital stay.