关键词:

text-indent:0pt, vertical-align:middle, "> 器官移植, 小肠, 胰腺肿瘤, 随访

Abstract:

Objective To establish a follow-up system for postoperative patients of pancreatic cancer undergoing radical resection combined with intestinal autotransplantation，in order to provide reference for standardizing hospital follow-up management，improving follow-up efficiency，and promoting self-management of patients at home. Methods Establish an integrated follow-up team of medical care，the construction of a three-dimensional structured follow-up list of "physiology—psychology—behavior"，and the establishment of an information-based follow-up platform based on patient-reported outcomes，the follow-up files of patients'continuous care were improved，and the standardized follow-up after discharge was implemented. Results From November2024 to August 2025，a total of 178 systematic follow-up visits were completed for 27 patients，and the followup compliance was 100%. Patients received 234 adjuvant treatments，and the treatment compliance was 99.6 %. The follow-up team solved 33 difficult problems and needs of patients，and the average score of patient satisfaction evaluation was 98.3 points. Conclusion This system base on collaborative healthcare partnerships，uses a unified follow-up checklist to ensure the comprehensiveness and scientific nature of the content. The information-basedfollow-up platform built by integrating patient report outcomes can provide patients with individualized symptom intervention，psychological support and rehabilitation guidance，tracking to improve postoperative survival，followup efficiency and continuous care level.

Key words:

text-indent:0pt, vertical-align:middle, "> Organ transplantation, Small bowel, Pancreatic neoplasms, Follow up