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

摘要：

目的 构建联合自体小肠移植的胰腺癌根治术后患者随访体系，旨在为规范随访管理，提高随访效率，促进患者居家自我管理提供借鉴。 方法 组建医护一体化随访团队，构建“生理—心理—行为”三维度结构化随访清单，基于患者报告结局建立信息化随访平台，健全患者延续性照护随访档案，并落实出院后规范化随访。 结果 2024 年11月至2025 年8 月，完成27 例患者共178 次的体系化随访，随访依从性为100 %，患者接受辅助治疗共234 次，治疗依从性为99 .6 %，随访团队解决患者疑难问题及需求33 项，患者满意度评价平均得分为98 .3 分。 结论 该随访体系基于医护合作，采用标准化随访清单确保了随访内容的全面性和科学性。整合患者报告结局构建的信息化随访平台在实现规范化随访的基础上，能够为患者提供个体化的症状干预、心理支持和康复指导，持续追踪改善患者术后生存质量，有效提高了随访效率和延续性照护水平。

关键词:

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