As the global population continues to age, there is a noticeable yearly rise in the incidence of hernias. Simultaneously, smoking, a widespread addictive behavior and a significant contributor to mortality, has evolved into a pervasive public health concern. Existing literature has already established a connection between smoking and an increased risk of postoperative recurrence and postoperative infections following hernia surgery. However, there remains a dearth of research exploring the association between smoking and hernia morbidity. In this study, our objective is to systematically evaluate the causal relationship between cigarette smoking behaviors and hernia morbidity using a Mendelian randomization (MR) approach. Hernia-related data were sourced from the FinnGen Biobank database, while cigarette smoking behavior data were gathered from the GWAS and Sequencing Consortium of Alcohol and Nicotine Use. To assess the causal relationship, we employed five methods: the weighted median, the weighted mode the inverse variance weighted (IVW), MR-Egger, and the simple mode. Sensitivity analysis was conducted, incorporating Cochran's Q test, the MR-Egger intercept test, leave-one-out analysis, and funnel plot. The presentation of the causal relationship is expressed as an odds ratio (OR) along with their corresponding 95

减重与代谢外科手术后由于体重下降所导致相对皮肤过多可给病人带来严重的外观、生理与心理困扰,腹壁是受此影响的最主要部位,实施包括腹壁塑形术在内的二期手术为此问题提供了重要的解决方案.了解减重与代谢外科手术对腹壁的影响并进行准确评估,选择合适的手术时机,在进行充分术前准备基础上规范实施腹壁塑形术对于进一步提高减重与代谢外科手术效果以及降低塑形手术并发症的发生具有重大意义.

1单吻合口胃旁路术 单吻合口 胃旁路术(one anastomosis gastric bypass,OAGB)是在 Roux-en-Y 胃旁路术(Roux-en-Y gastric by-pass,RYGB)基础上简化的术式,通过建立狭长的胃囊及旷置十二指肠与部分空肠达到减重目的.此术式仅建立一个胃空肠吻合口,手术时间与学习曲线短,操作简捷易于掌握.

背景与目的:闭孔疝是临床较为罕见的腹外疝,老年女性由于盆底松弛等特点,易罹患此病.由于闭孔疝的疝环狭小缺乏弹性,患者多因嵌顿造成的急腹症就诊,一般在肠梗阻手术时发现.彻底缝闭半坚硬的疝环有一定困难,故疝易复发,再手术率高,使用修补材料可有效降低复发率.本文中笔者通过回顾收治的闭孔疝病例,分析总结闭孔疝的疾病特点及临床诊治方面经验体会,以期为该病的临床诊治提供参考. 方法:回顾性总结2019年6月-2021年6月复旦大学附属华东医院和郑州大学附属郑州中心医院胃肠、疝和腹壁外科收治的10例闭孔疝患者的相关临床资料. 结果:10例患者均为女性,年龄48～86岁,中位年龄(70.7±11.8)岁.所有患者术前接受腹盆腔CT扫描检查,发现2例左侧闭孔疝,8例右侧闭孔疝.术中证实嵌顿疝内容物中肠管8例,大网膜1例,腹膜外脂肪1例.全组病例中未有无张力修补的绝对禁忌患者,结合腹腔污染情况,2例使用生物补片,其余8例患者使用聚丙烯补片.6例完全在腔镜下完成,1例在腔镜下疝修补完成后观察肠管活力恢复欠佳中转开腹行肠切除,1例腔镜探查后中转开腹行肠切除及疝修补,2例患者腔镜不耐受直接行开腹探查并无张力修补术.手术时间50～120min,平均75.5 min.术后1例患者死于围术期内科疾病合并症,其余患者顺利出院,住院时间3～28d.术后6、12、18个月随访,均无复发及补片相关感染. 结论:闭孔疝发病率低,起病隐匿容易发生嵌顿.腹盆腔CT扫描对此病诊断有较高价值.使用补片修补并恰当地固定有助于降低复发率.腹腔污染的情况下使用合成补片一期修补具有可行性,污染较重时生物补片更具优势.修补区域严重感染,应放弃使用补片修补.

Complex systems science (CSS) is an evaluation system that integrates the overall system and draws multilateral conclusions in the form of dynamic and reasonable interpreta-tion. Evaluation of modern hernia and abdominal wall surgery by CSS includes the application of artificial intelligence, data analysis and other methods. It implements the value oriented clinical quality improvement principle in the overall treatment cycle through the measurement of value, combined cost, quality evaluation and patient perspective. Finally, CSS will realize the sustainable development of hernia and abdominal wall surgical diagnosis and treatment system of medical care system.

随着我国生活和物质条件的极大改善,肥胖症合并疝与腹壁外科疾病越来越多见.而肥胖症及合并的代谢性疾病具有特殊性,由肥胖引起的机体一系列病理生理改变会显著影响疝与腹壁外科疾病的治疗效果.笔者认为:准确判断肥胖症及合并代谢性疾病的状态与严重程度并进行有效控制是确定手术时机与制订手术规划的重要前提,对于肥胖症患者采取各种减重措施行术前减重是其治疗的基本原则,对不同疝与腹壁外科疾病患者采用同期或分期针对性个体化手术方案是其治疗成功的保障.

目的 比较腹腔镜下应用生物材料补片和合成材料补片对老年腹股沟疝修补术后患者血清肿发生率的影响.方法 采用前瞻性对照临床研究方法,纳入华东医院普外科2021年6月—2021年12月收治的单侧老年腹股沟疝患者30例,采用数字表法随机分为生物材料组(n=15)和合成材料组(n=15).所有患者均由同一组医师进行经腹腔腹膜前修补术(TAPP),术后1个月、3个月、6个月随访进行体格检查及彩色多普勒超声检查.观察并比较2组术后彩超下血清肿情况、其他并发症和随访情况.结果 术后1个月彩超诊断生物材料组血清肿发生率高于合成材料组(66.7％vs 13.3％,P<0.05);术后3个月生物材料组彩超诊断血清肿发生率高于合成材料组,但差异无统计学意义(6.67％vs 0％,P>0.05);术后6个月2组均未发现血清肿.生物材料组术后平均体温明显高于合成材料组(37.2℃vs 36.7℃,P<0.05);2组术后静息、咳嗽疼痛评分差异均无统计学意义(P>0.05);2组随访期间均未出现复发和感染等其他并发症.结论 TAPP术后第1个月生物材料的血清肿发生率高于合成材料,术后随访需要密切关注.

造口旁疝是疝与腹壁外科领域较为棘手的疾病之一,目前我国造口旁疝的流行病学资料仍不完善.通过查询结直肠肿瘤相关流行病学资料及国内几家大型结直肠外科中心的数据,粗略的对我国造口旁疝发生率进行估计分析.虽然我国接受永久性造口的病人数量相对不多,但造口旁疝的发生率很高,可达到＞80％.造口旁疝修补手术复杂,影响手术的因素很多,治疗效果并不理想,复发率高,甚至在一段时间后产生严重的并发症.因此,目前仍然建议严格掌握手术指征.同时,应充分发挥腹腔镜技术的优势,在多种术式中Sugarbaker手术效果相对更好.另外,随着补片材料的不断改进,预防性造口旁疝补片修补术将会有很好的临床应用前景.

目的:探讨联合应用生长激素和谷氨酰胺对短肠大鼠小肠粘膜上皮细胞凋亡发生分布的影响.材料和方法:选用40只手术成功的SD短肠大鼠,按2×2析因实验设计随机分为四组,分别给予常规全肠外营养(STD组,n=10)、附加谷氨酰胺(Gln组,n=10)、附加生长激素(GH组,n=10)及附加谷氨酰胺和生长激素全肠外营养(GG组,n=10),持续6天,取8只正常大鼠模拟手术后第一天处死,作为基础对照组(Control组,n=8).应用原位末端标记方法对比观察残留小肠粘膜上皮细胞凋亡的发生和分布.结果:凋亡细胞主要位于肠绒毛的顶部.STD组小肠粘膜上皮细胞凋亡指数较对照组明显高增高(P＜0.01);GH组和Gln组凋亡指数明显低于STD组(P＜0.01);而GG组凋亡指数又显著低于GH组和GLN组(P＜0.01).结论:联合应用生长激素和谷氨酰胺能够减少小肠粘膜上皮细胞的凋亡,从而防止小肠粘膜萎缩的发生.

目的:探讨联合应用生长激素和谷氨酰胺对小肠粘膜的营养作用.材料和方法:研究选用40只手术成功的SD短肠大鼠,按2×2析因实验设计随机分为四组,分别给予常规全肠外营养、附加谷氨酰胺、附加生长激素及附加谷氨酰胺和生长激素全肠外营养,持续6天.应用光镜和电镜技术对残留小肠进行形态学对比研究.结果:单用谷氨酰胺和生长激素均可不同程度增加小肠粘膜的粘膜厚度、肠腺深度、绒毛高度和表面积(P＜0.01),维持肠粘膜上皮吸收细胞超微结构的正常形态,但联用谷氨酰胺和生长激素的效果优于各自单独使用(P＜0.01).结论:研究表明联合应用谷氨酰胺和生长激素能够更有效的防止小肠粘膜萎缩,维持其上皮吸收细胞超微结构的正常形态和结构完整性,为临床谷氨酰胺和生长激素的联合应用提供实验依据.

目的:探讨联合应用生长激素和谷氨酰胺对短肠大鼠小肠粘膜吸收功能的影响.材料和方法:研究选用40只手术成功的SD短肠大鼠,按2×2析因实验设计随机分为四组,分别给予常规全肠外营养、附加谷氨酰胺、附加生长激素及附加谷氨酰胺和生长激素全肠外营养,持续6天.应用生化酶学的方法测定各组小肠粘膜上皮Na+,K+-ATPase的活性.结果:谷氨酰胺组小肠粘膜Na+,K+-ATPase的活性较常规组明显增高;生长激素组Na+,K+-ATPase的活性无明显增高;而联合应用谷氨酰胺和生长激素组小肠粘膜上皮Na+,K+-ATPase的活性较常规组亦有显著性增高.结论:研究表明联合应用谷氨酰胺和生长激素能够有效的增加小肠粘膜上皮Na+,K+-ATPase的活性,从而提高其吸收功能.

OBJECTIVE: To study the effects and the underlying mechanism of recombinant human growth hormone (rhGH) and glutamine (Gln) on the adaptation of the remnant small intestine in parenterally nourished, short bowel syndrome (SBS) rats. METHOD: Four parenteral nutrition (PN) treatment groups of SBS rats were randomly arranged in a 2 × 2 factorial design as follows: (i) STD (standard PN) group (–rhGH, –Gln); (ii) Gln group (–rhGH, +Gln); (iii) rhGH group (+rhGH, –Gln); and (iv) rhGH + Gln group (+rhGH, +Gln). Morphological changes of the intestinal mucosa were investigated and the expression of proliferating cell nuclear antigen (PCNA) and the occurrence of apoptosis were observed by immunohistochemical staining and terminal deoxynucleotidyl transfer‐mediated dUTP‐biotin nick end‐labeling (TUNEL) methods. The level of intestinal insulin‐like growth factor‐1 (IGF‐1) mRNA was determined by northern blotting. RESULTS: The mucosal thickness, villous height, crypt depth and villous surface area of the remnant small intestine in the rhGH + Gln group were increased significantly as compared with the other three experimental groups, and there were synergistic effects between rhGH and Gln (P < 0.01). The expression of PCNA was higher in the rhGH + Gln group than in the rhGH, Gln and STD groups (24.95 ± 3.93 vs 19.28 ± 3.25, 17.27 ± 3.38, and 8.37 ± 2.23 positive cells per crypt of Lieberkuhn, respectively; P < 0.01) but the rate of apoptosis was lower in the rhGH + Gln group than in the rhGH, Gln and STD groups (5.68 ± 2.07 vs 8.06 ± 2.33, 10.00 ± 2.24 and 22.32 ± 3.84 positive cells per 100 cells, respectively; P < 0.01). The intestinal IGF‐1 mRNA was also expressed at a higher level in the rhGH + Gln group than in the rhGH, Gln and STD groups (0.73 ± 0.05 vs 0.62 ± 0.04 vs 0.51 ± 0.04 and 0.41 ± 0.22, respectively; P < 0.05). CONCLUSION: The synergistic combination of rhGH and Gln can significantly improve the adaptation of the remnant small intestine in parenterally fed SBS rats. An increase in cell proliferation and a decrease in cell apoptosis are both responsible for the intestinal adaptation. An increase in local IGF‐1 plays an important role in this process.

Objective To understand the potential synergisite effects of rhGH and Gln on postresectional adaptation of the remnant small intestine in parentera fed, short bowel rats. Methods Four PN treatment groups of SBS rat were randomized arranged in a 2 × 2 factorial design as follows: STD group (-rhGH,-Gln),Gin group (-rhGH, +Gln), rhGH group (+rhGH, -Gln) and GG group (+rhGH, +Gin). The morphological changes of the intestinal mucosal epithelia were determined; The expression of PCNA and the occurrence of the apoptosis were observed by immunohistochemical staining and TUNEL methods. The intestinal mucosal bcl-2 and bax mRNA were determined by RT-PCR methods; Intestinal IGF-1 mRNA were determined by Northern blot assays. Results Mucosal thickness, villous height, crypt depth and villous surface of the remnant small intestine in GG group were increased significantly compared to other 3 groups; The expression of PCNA was increased but the rate of apoptosis was decreased significantly; The expression of bcl-2 mRNA was increased accordingly, and bax mRNA was just on the contrary, P<0.01. There are synergistic effects between rhGH and Gin statiticaUy. The expression of the intestinal IGF-1 mRNA was higher in rhGH and Gin groups than STE) group, and was highest in GG group, P<0.05. Conelasions The combination of rhGH and Gin can significantly improve the adaptation of the remnant small intestine in parenterally fed, SBS rats, there are synergistic effects between them; The increase of proliferation and the decrease of apoptosis in the remnant intestinal epithelial cells are involved in this process; The intestinal IGF-I p; ays an important role in the intestinal adaptation. Our findings support the concept that specific gut-trophic nutrients and growth factors may combined to enhance the intestinal adaptation and reduce the severity of short bowel syndrome.

研究添加生长激素(rhGH)及谷氨酰胺(Gln)的肠外营养(PN)对短肠大鼠残留小肠代偿的作用及作用机制.将SD大鼠按2×2析因设计方案随机分成STD、rhGH、Gln及GG四组,建立PN短肠大鼠动物模型.

前瞻性地研究术后短期应用不含脂肪乳剂的肠外营养(PN)与含10%及20%脂肪乳剂的PN对行中等以上普外科手术患者血脂代谢的影响.将56例患者随机分成对照组(n＝18)、10% Intralipid组(n＝19)及20% Intralipid组(n＝19),于术后接受5天PN支持.结果:术后10%组血总胆固醇(Tcho)及低密度脂蛋白胆固醇(LDL-ch)明显高于20%组及对照组,增加的胆固醇以游离胆固醇(Fcho)为主;异常脂蛋白(LPX)及磷脂也均高于20%组及对照组.本实验结果提示:脂肪乳剂中磷脂/甘油三酯(PL/TG)比值过高所产生的过剩磷脂是导致术后短期PN血Tcho蓄积的主要原因,其中LPX的形成起了重要的作用.与10% Intralipid相比,20% Intralipid对机体脂代谢影响较小,更适合于临床使用.