胃空肠结肠瘘1例

患者　男 ,5 3岁。 2年前因十二指肠球部溃疡并出血行胃大部切除、溃疡旷置、结肠前胃空肠吻合术 ,术后半年起常感上腹部隐痛 ,并偶解柏油样黑便 ,经内科治疗症状有缓解。 1个月前腹痛加重 ,伴腹泻 ,为黄色稀水样便 ,便中有不消化食物 ,10次 /d以上 ,同时感乏力、纳差、消瘦、嗳气有粪臭味 ,体重下降约 2 0kg。体查 :轻度贫血貌 ,重度营养不良 (体重 42kg) ,舟状腹 ,全腹无压痛 ,未触及包块 ,移动性浊音阴性 ,双下肢凹陷性水肿。血红蛋白 87g/L ,红细胞 3 .0 7× 10 1 2 /L ,血清总蛋白5 0 .7g/L ,白蛋白 2 0 .9g/L ,球蛋白2 9 .8g/L ,白 …     

胃空肠结肠瘘1例报告

患者,男,31岁。因十二指肠球部溃疡,幽门梗阻于1980年行胃大部切除,胃空肠吻合术(毕氏Ⅱ式,结肠前)。术后3年又出现上腹部疼痛,给予对症处理。1987年因腹痛,疑肠梗阻在外院行剖腹探查并行空肠Roux-Y式吻合。术后1年出现慢性腹泻,每日5～10次,为糊状不消化食物,消瘦,体力下降,多次到内科门诊对症治疗,症状无改善。经钡灌肠,纤维结肠镜检查确诊为胃空肠结肠瘘转外科治疗。查体:T36.5,P78次,BP16/14kPa。发育正常,营养不良,消瘦明显,皮肤弹性差,心肺阴性。腹部平坦,上腹正中见手术疤痕,腹软,肝脾未及,无包块,肠鸣音活跃。实验室检查:血红蛋白129g/L,红细胞4.52×10~(12)/L,白细胞6.3×10~9/     

吻合口溃疡四例报道

临床资料 :例 1 ,男 ,39岁。 2年前因十二指肠球部溃疡穿孔于本院行胃大部切除术 ,结肠前胃空肠吻合。 1 990年6月再以消化道穿孔入院 ,术中见吻合口前壁空肠侧穿孔 ,直径 1cm。行胃次全切除 ,结肠前胃空肠吻合。病理报告 :空肠前壁溃疡穿孔。例 2 ,男 ,6 2岁。 3年前因十二指肠球部穿孔于某院行胃大部切除术 ,结肠近端对大弯胃空肠吻合。1 990年 7月再以消化道穿孔入我院 ,术中见吻合口前壁空肠侧穿孔 ,直径 1 .5cm ,局部有瘢痕 ,行胃次全切除 ,结肠前胃空肠吻合。病理报告 :空肠前壁溃疡穿孔。例 3,男 ,73岁。 5年前因十二指肠球部前壁溃…     

肿瘤相关的胃结肠瘘的诊疗方式的探讨（附4例病例报告）

目的 探讨关于肿瘤相关胃结肠瘘的诊断及治疗.方法 回顾性分析2008年8月-2014年2月首都医科大学附属北京友谊医院普外科诊治的4例肿瘤相关胃结肠瘘患者的临床资料.其中3例患者为女性,1例患者为男性,平均年龄61岁,4例术后病理证实为腺癌所致的胃结肠瘘.主要临床症状有腹泻3例、粪样呕吐3例、体重下降4例、腹痛4例.术前诊断胃结肠瘘的方法包括胃镜3例、结肠镜1例、钡灌肠1例、上消化道造影2例.结果 4例患者均施行了肿瘤及胃结肠瘘切除手术,2例根治性切除,2例姑息性切除.术后病理均提示低分化腺癌,3例患者进行了CDX-2,CK20免疫组化检查辅助判断肿瘤来源.术后1例患者出现胃排空障碍,DIC,心功能衰竭并死亡,2例出现吻合口瘘,存活患者均接受卡培他滨、奥沙利铂联合化疗.结论 内镜检查及消化道造影是胃结肠瘘诊断主要依据,胃结肠瘘区域应完整切除,一期肠造口可能更加安全,但这一结论还需进一步研究.根据病理特点、免疫组化CDX-2 、CK20染色推断肿瘤来源,并进行辅助化疗.     

胃大部切除术后输入袢结肠瘘一例

患者男,46岁。因腹泻、排大便为所进食物原型2月余,体重下降17kg,于2003年6月2日入院。15年前曾因十二指肠球部溃疡行胃大部切除;5年前因肠穿孔行穿孔修补术,均痊愈出院。入院查体所见:腹凹陷,右侧腹见一长约15cm的纵行手术瘢痕,肠鸣音活跃,其余无异常。胃镜检查:空肠鞍部慢性溃疡。结肠镜:距肛门40cm见一瘘口,黏膜充血糜烂,可见胆汁排出。拟诊胃结肠瘘于6月6日全麻下行剖腹探查术。术中见:胃已部分切除(毕Ⅱ式)。胃结肠无瘘口;横结肠中段与空肠输入袢(距胃肠吻合口约3cm)紧密粘连,横结肠近端扩张,肠壁水肿严重;分离粘连后,发现为结肠空肠瘘…     

胃空肠吻合口内瘘2例

1　病例报告　例 1　男 ,42岁。 1 999年 7月入院。患者 1 0年前曾因“胃穿孔”行胃大部切除术。近 3年来反复上腹疼痛 ,腹泻 ,大便为未消化食物。体查 :极度消瘦 ,站立及行走不便。上腹部切口瘢痕 ,舟状腹 ,上腹压痛 ,未触及包块。血红蛋白 92 ｇ/Ｌ ,总蛋白 62ｇ/Ｌ ,钡餐、钡灌肠及胃镜均提示胃空肠横结肠瘘。术中发现胃空肠吻合口骑跨于横结肠 ,并形成内瘘 ,予以切除原吻合口及瘘管、行空肠空肠、横结肠横结肠及结肠后胃空肠吻合口术。术后痊愈出院。病理检查 :胃空肠吻合口溃疡。例 2　男 ,57岁。 1 999年 1 2月入院。 2 0年前曾行胃大…     

胃空肠结肠瘘的诊断和外科治疗

胃空肠结肠瘘为溃疡病行胃大部切除术后晚期一种罕见而严重的并发症。因对其认识不足，临床上极易误诊。我们对1970年8月至2004年12月收治的11例胃空肠结肠瘘患者的临床资料进行回顾性分析，报告如下。     

胃空肠袢吻合术疗效探讨

目的探讨胃空肠袢吻合术的近远期疗效。方法统计1983～2000年传统Ⅱ式、Roux-en-Y式、胃空肠袢吻合术3种术式治疗十二指肠球部溃疡共451例的早期并发症,并随访10年以上病例3组共136例,按Visick分级对比、     

十二指肠球部—横结肠瘘二例报告

十二指肠球部溃疡很少穿透至肝、胆及横结肠内。作者曾经治2例十二指肠球部溃疡穿透横结肠形成十二指肠球部——横结肠瘘,现报道如下。临床病例例1.男,42岁。反复胃痛10余年,住内科治疗期间胃病加重,出现无规律性呕吐,吐出物为胃内容,时有粪臭味。大便呈水样,每日3～5次。疑为胃癌并幽门不全梗阻转入外科治疗。术中发现十二指肠球部溃疡穿入横结肠,瘘口约黄豆粒大。行胃大部切除,胃空肠吻合术,修剪球部溃疡瘘口疤痕并予内翻缝合修     

急诊胃次全切除术后胃空肠采用一针一线吻合的体会

目的 介绍对急诊胃次全切除术后胃空肠丝线一针一线缝合的体会。方法 对20例胃十二指肠溃疡并发大出血，急性穿孔急诊采用胃大部分切除，胃空肠丝线一针一线吻合。结果 成功率达100%。缩短了手术的时间。结论 本法减少了患者再次手术的痛苦及医务人员处理上的困难。     

Gastrocolic fistulas

Sixteen patients were treated for gastrocolic fistula arising as a complication of peptic ulcer (11 cases), colonic perforation (2), gastric cancer (1), colonic cancer (1) or pancreatitis (1). The predominant symptoms were diarrhoea, weight loss and abdominal pain. Barium meal and barium enema were the most reliable means of diagnosis, and no fistula was gastroscopically demonstrable. A one-stage en bloc resection of the involved gastrocolic region was performed in eight cases. Other operations were simple excision (3), gastric resection with closure of the colonic wall (2) and colectomy with closure of the gastric wall (2). In one case cure was achieved with cimetidine, without surgical intervention. Four patients died postoperatively and two had recurrence of fistula.     

成人结肠冗长症的诊治(附42例分析)

目的：探讨成人结肠冗长症的诊断与围手术期处理经验，提高对该病的诊治水平。方法：回顾性分析42例成人结肠冗长症的临床资料，并作了随访观察。结果：32例患者（75．7％）有顽固性便秘，18例患者（42．9％）存在反复不完全肠梗阻，16例患者（38．1％）便秘与腹泻交替出现，以便秘为主。39例经X线钡剂灌肠透视确诊。急诊手术3例，择期手术39例。41例（97．6％）病理检查于镜下可见典型改变。42例均行不同长度的肠段切除，4例加行乙状结肠固定术。术后随访率为83．3％（35／42），28例症状消失，4例仍有症状，保守治疗有效果，3例再次手术，术后症状消失。结论：典型的病史和X线钡剂灌肠可确诊成人结肠冗长症，外科手术是治疗本病的最终有效措施。     

儿童特发性便秘的诊断(86例临床分析)

目的：探讨儿童特发性便秘的诊断。方法：对2000年6月至2002年10月经结肠造影和肛门直肠测压诊断的86例特发性便秘的临床资料进行分析。结果：男44例，女42例，婴儿期9例，幼儿期66例，学龄期11例。结肠造影检查86例，其中未见异常75例，直肠扩张5例，乙状结肠冗长3例，直肠扩张合并乙状结肠冗长3例；肛门直肠测压44例，其中未见异常16例，排便弛缓反射异常12例，直肠肛门抑制反射(RAIR)异常22例，感觉功能障碍10例。获得随访68例，其中痊愈47例(69．1％)，好转11例(16．2％)，无效10例(14．7％)。结论：结肠造影结合肛门直肠测压检查可提高儿童特发性便秘的诊断。     

原发性十二指肠肿瘤的诊断和治疗

目的 探讨原发性十二指肠肿瘤的诊断和术式选择.方法 回顾性分析中国医科大学附属第一医院2001-2007年间124例原发性十二指肠肿瘤患者的临床资料,其中良性肿瘤10例,恶性肿瘤114例.结果 本组原发性十二指肠肿瘤常见的临床表现有上腹痛、黄疸、体重下降以及纳差等.肿瘤位于十二指肠球部9例(7.3%),降部107例(86.3%),水平部7例(5.7%),升部1例(0.8%).术前纤维内镜确诊率为90.5%,ERCP确诊率为94.1%,超声内镜确诊率为100%,胃肠气钡双重造影发现率为78.6%,MRI发现率为80.5%,CT发现率为75.7%,B超发现率为40.6%.10例原发性十二指肠良性肿瘤中5例行肿瘤局部切除术,2例行标准胰十二指肠切除术,1例行十二指肠节段切除术,2例未手术,5年生存率为100%;114例原发性十二指肠恶性肿瘤中47例行标准胰十二指肠切除术,3例行保留幽门的胰十二指肠切除术,5年生存率为35.8%;6例行局部肿瘤切除术,12例行十二指肠节段切除术,5年生存率为16.7%;22例行旁路手术,均死于术后5～16个月;2例行支架介入术,2例行经皮肝胆道穿刺引流术,死于术后3～11个月;其余未手术,死于术后1～11个月.结论 原发性十二指肠肿瘤缺乏特异性临床表现,经内镜、超声内镜以及ERCP等联合检查可提高术前诊断率.对良性肿瘤可行局部肿瘤切除术或十二指肠节段切除术,对恶性肿瘤首选胰十二指肠切除术,对晚期肿瘤患者可采用旁路手术以提高生存率及生存质量.     

Intussusception: barium or air?

At The Hospital For Sick Children, the use of air has recently replaced the use of barium in the reduction of intussusceptions. The purpose of this study was to review the results from 200 consecutive patients with intussusceptions, 100 patients treated with barium enema and 100 patients treated with air enema. The groups were similar with regard to sex, average and median ages, and presenting symptoms and signs. Successful reduction was achieved in 75% of episodes of intussusception treated with barium enema and 76% treated with air enema. Failure of either modality showed a high association with the presence of either a lead point or an ileoileal or ileoileocolic intussusception. Among those cases of unsuccessful reduction, operation was performed in all 59 cases; resection in 30 cases, manual reduction in 19, and spontaneous reduction was found in 10. There were three perforations during attempted reduction with barium and two with air. All perforations were treated by resection and primary anastomosis. There were 18 recurrent intussusceptions following barium enema reduction and nine following air enema reduction. Therefore, with the lower absorption of x-rays by air and the relatively inert nature of air (compared with barium in the event of a perforation), we feel that air enema is the treatment of choice in the initial management of intussusception.     

The treatment of high and intermediate anorectal malformations: one stage or three procedures?

Background/Purpose

The aim of this study was to examine the safety, feasibility, and the long-term outcome of complete 1-stage repair of high and intermediate anorectal malformation using posterior sagittal anorectoplasty (PSARP) in a neonate.

Methods

One hundred thirteen patients with high-type and intermediate-type anorectal malformations (ARM) underwent follow-up. Of 113 cases, 48 cases entailed a divided colostomy, definitive operation, and colostomy closure (group I); the other 65 patients underwent 1-stage PSARP (group II). Anorectal function was measured by the modified Wingspread scoring, including “excellent,” “good,” “fair,” and “poor.” In barium enema studies, anorectal angulation was judged as “clear,” “unclear,” and “not present,” and leakage of barium was observed in the meantime. For anorectal manometric studies, anal resting pressure (ARP), anal squeezing pressure (ASP), and positive anorectal reflex (PAR) were measured.

Results

In group I, the rate of excellent and good scores was 58.3% (28 of 48). In the barium enema examination, 85.4% (41 of 48) was clear and 14.6%(7 of 48) unclear or not present. The rate of barium leakage was 10.4% (5 of 48). In group II, the rate of excellent and good was 53.8% (35 of 65). Anorectal angulations were clear in 83.1% of patients (54 of 65). Barium leakage happened in 7.69% of patients (5 of 65). Early operative complications occurred in 56.3% (27 of 48) of patients in group I and 29.2% (19 of 65) in group II. The incidence of colostomy complications in group I was 39.6% (19 of 48). Soiling and constipation were the major complications after the PSARP operation. The respective rates of constipation in the 2 groups were 47.9% (23 of 48) and 44.6% (29 of 65), and the respective rates of soiling were 47.9% (23 of 48) and 50.8% (33 of 65). There was no significant difference in the mean ARP between the 2 groups.

Conclusions

The 1-stage PSARP procedure in the neonate not only achieves the same long-term outcome as the conventional PSARP procedure but also involves fewer short-term complications. Complete 1-stage repair using the PSARP to treat high-type and intermediate-type anorectal malformations is safe and feasible.     

Why barium enemas fail to identify colorectal cancers

Background: The aim of the present study was to determine the cause and clinicopathological factors associated with the failure of barium enemas to detect colorectal cancers. Methods: A histopathological database was used to identify all patients with a diagnosis of colorectal cancer between 1991 and 1995. These records were matched with the records from patients who underwent barium enema examinations between 1990 and 1995. Those patients who had a colorectal cancer histologically diagnosed within 24 months of a barium enema in which no car­cinoma was seen, were identified. Where possible the radiology was reviewed. Failure to identify a carcinoma was then attributed to either simple failure, technical, interpretive or perceptive difficulties. Results: There were 967 patients with colorectal cancers treated in Christchurch Hospital during the study period 1991–1995. Matching of these patient details with all barium enema records revealed 313 patients who had barium enemas and histologically proven colorectal cancer. There were 21 (6.7%) patients in whom a carcinoma was missed. Of these, 18 had a barium enema within 8 months of surgery, and three were performed outside this timespan (15, 18 and 28 months, respectively). On review, 11 carcinomas could not be identified (nine due to technical error: poor coating (n = 1), overlapping loops (n = 3), single‐contrast enema (n = 4), faecal residue (n = 1)); and seven could be seen on review of the films (two interpretation errors, one technical and perceptive error, and four perceptive errors). In three cases films could not be found for review. In 16 of the 21 missed lesions the patient had a double‐contrast barium enema (DCBE) while five patients had single‐contrast barium enema (SCBE). The site and stage of missed tumours is presented. Conclusions: The most common reason for missed tumours was technical. The percentage of missed tumours in each region of the bowel correlates with the known incidence of tumours in each region and with a normal Dukes stage distribution, except in the caecum where the number of missed lesions was higher than expected.     

Tumor Localization for Laparoscopic Colorectal Surgery

Background Because palpating colonic tumors during laparoscopy is impossible, the precise location of a tumor must be identified before operation. The aim of this study was to evaluate the accuracy of various diagnostic methods that are used to localize colorectal tumors and to propose an adequate localization protocol for laparoscopic colorectal surgery. Methods A total of 310 patients underwent laparoscopy-assisted colectomy between April 2000 and March 2006. We investigated if the locations of the tumors that were estimated preoperatively were consistent with the actual locations according to the operation. Results All the tumors were correctly localized and resected. Altogether, 203 patients had complete endoscopic reports available. Colonoscopy was inaccurate for tumor localization in 23 cases (11.3%). In total, 104 patients (33.5%) underwent barium enema; five tumors (4.8%) were not visualized, and three tumors were incorrectly localized. Another group of 94 patients (30.3%) underwent computed tomography (CT) colonography, which identified 91 of 94 lesions (96.8%). Finally, 96 patients (31.0%) underwent endoscopic tattooing; 2 patients (2.1%) did not have tattoos visualized laparoscopically and required intraoperative colonoscopy to localize their lesions during resection. Dye spillage was found in six patients intraoperatively, but only one patient experienced clinical symptoms. Intraoperative colonoscopy was performed in four patients; two of the four were followed by endoscopic tattooing, and the other two underwent intraoperative colonoscopy for localization. All lesions were correctly localized by intraoperative colonoscopy. The accuracy of tumor localization was as follows: colonoscopy (180/203, 88.7%), barium enema (97/104, 93.3%), CT colonography (89/94, 94.7%), endoscopic tattooing (94/96, 97.9%), and intraoperative colonoscopy (4/4, 100%). Conclusions With a combination of methods, localization of tumors for laparoscopic surgery did not seem very different from that during open surgery. Preoperative endoscopic tattooing is a safe, highly effective method for localization. In the case of tattoo failure, intraoperative colonoscopy can be used for accurate localization.     

肠结核的诊断及外科治疗37例报告

目的探讨肠结核诊断及内、外科治疗方法。方法回顾性病例分析及文献综述。结果我院１９８３～１９９７年共收治３７例肠结核病例,其中２６例行钡餐阳性率１００％（２６／２６）、钡灌肠２４例阳性率１００％（２４／２４）和纤维结肠镜１７例阳性率９４１％（１６／１７）。单纯内科治疗２１例,１６例因并发症或误诊接受外科治疗,１３例切除病变肠管,３例行开腹活检或穿孔修补术。内科治疗组,抗结核时间２０个月,复发４例;切除病变肠管的１３例患者平均抗结核时间１０个月,没有复发;行开腹活检或穿孔修补的３例患者抗结核时间１９个月,１例复发。结论钡餐、钡灌肠、纤维结肠镜是较为有效的检查方法,对于伴有腹部并发症的患者及早积极采用外科手术治疗切除病变肠管及术后抗结核治疗,从治疗时间、治疗复发等方面可能优于单纯内科保守治疗。