Laparoscopic harvesting of small bowel graft for small bowel transplantation

Background: Small bowel transplantation represents a valid therapeutic option for patients with intestinal failure, obviating the need for long-term total parenteral nutrition. Recently, reports have shown the feasibility of performing living related intestinal transplantation using segmental small bowel grafts. The limitations of this technique include inadequate harvested small bowel lengths, as compared with the lengths obtained in cadaveric small bowel harvests, and large incisions for the donor. In this pilot study, we evaluated the feasibility of laparoscopically harvesting long segments of proximal jejunum for small bowel transplantation using a porcine model. The results can be used to evaluate the potential for applying this technique in human cases. Methods: For this study 10 yorkshire pigs were used. Under general anesthesia, each pig underwent laparoscopic segmental resection of 200 cm of proximal jejunum on a vascular pedicle. The harvested graft then was autoreimplanted using an open technique by anastomosing the vascular pedicle to the superior mesenteric vessels. Success was determined 2 hours after anastomosis by visually identifying a pink graft with viable-appearing mucosa, an artery with a strong thrill, and palpable venous flow. The animals were then sacrificed. Results: The mean operation time required to laparoscopically harvest the small bowel graft was 80 min (range, 35–120 min), and the mean length of harvested graft was 220 cm (range, 200–260 cm). The mean length of the graft's vascular pedicle was 4.5 cm (range, 4–5 cm). All 10 grafts were successfully harvested laparoscopically and then reimplanted using an open technique. All the grafts maintained good vascular flow, and showed no evidence of mucosal necrosis at necropsy. Obviously, further studies would be required to examine the long-term results of reimplanting a laparoscopically harvested small bowel graft, but proposals for such studies is beyond the scope of this report. Conclusion: Minimally invasive techniques can be used to harvest proximal small bowel grafts for living related small bowel transplantation.     

Extensive small bowel resections

Bowel resections of at least 70% of the total length give rise to nutritional and metabolic disorders. The consequences are also related to the site of the resection itself, to the causative disease and thus to the patient's morphological and functional adaptation capacity. Over the past 20 years we have operated on 32 patients for vascular disorders, Crohn's disease, intestinal volvulus, actinic enteritis, and ileo-caecal carcinoma. In all patients total parenteral nutrition was started and followed by enteral nutrition and oral feeding after variable periods of time. The postoperative course, in terms of adaptation and stabilisation, was regular on most cases: only in the patients operated on for Crohn's disease was symptom and nutritional remission belated or incomplete. The perioperative mortality was 34% (11 patients). The extent of the resection was often conditioned by the topography of irreversible anatomico-pathological lesions and only in one case did a colic resection prove necessary. In more extensive resections, involving a longer adaptation time, enteral nutrition was supplemented with total parenteral nutrition for lengthier periods.     

原发性小肠肿瘤

原发性小肠肿瘤是少见疾病，发病率低，误诊率高，早期缺乏典型的症状和体征，迄今尚无特异性诊断方法，应引起临床重视。     

腹腔镜小肠切除术的临床应用

目的探讨腹腔镜小肠切除术的治疗价值。方法总结分析1993年3月至2000年12月施行的腹腔镜小肠切除术31例患者的临床资料。结果术式包括:腹腔镜辅助下小肠切除术25例;全腹腔镜下小肠切除术6例。25例腹腔镜辅助下小肠切除术平均手术时间(101.9±32.8)min;术中平均出血(65.3±28.5)ml;平均住院(5.5±1.6)d。6例全腹腔镜下小肠切除术平均手术时间(97.2±28.1)min;术中平均出血(59.6±22.1)ml;平均住院(5.1±1.3)d。两组各指标比较,差异均无显著性意义(P>0.05)。所有患者均在术后48d内恢复胃肠功能,并开始下床活动。仅3例术后使用止痛剂。全组手术无病灶遗漏,也无并发症、中转开腹和手术死亡发生。结论腹腔镜小肠切除术具有良好的治疗效果,器械的更新和经验的积累将使这项技术日臻完善。     

Primary small bowel malignancies

Fifty-five patients with primary small bowel malignancies were evaluated from 1955 to 1983. Twenty-seven patients (49%) had carcinoid tumors, 16 (29%) had adenocarcinomas, and 12 (22%) had leiomyosarcomas. The average age at presentation was 68 years (range: carcinoids, 27-82; leiomyosarcomas, 36-75; adenocarcinomas, 40-83). Carcinoids and leiomyosarcomas were 1.7 and 2.0 times, respectively, more common in men; adenocarcinomas showed no sex predominance. Eighty-nine per cent of all patients had symptoms: abdominal pain in 65 per cent, obstruction in 23 per cent, bleeding in 8 per cent, and palpable mass in 5 per cent. Although 27 per cent of carcinoid patients were asymptomatic, 40 per cent exhibited the carcinoid syndrome. Symptoms were longstanding in the majority of cases, and, at the time of diagnosis, 49 per cent of the carcinomas were metastatic. Fifty-five per cent of the tumors were in the ileum, 24 per cent in the jejunum, and 21 per cent in the duodenum. Fifty-five patients (89%) underwent resection for palliation or cure. Five adenocarcinoma patients (32%) survived 1 year, and one (6%) lived 10 years. Twenty-five per cent of leiomyosarcoma patients survived for 10 years. Eighty-seven per cent of patients with carcinoids survived for 1 year, 39 per cent for 5 years, and 22 per cent for 10 years. Previous reports have documented the difficulty of diagnosing these lesions, as does the present study. A higher degree of physician awareness and a more aggressive investigation of referable symptoms should lead to earlier treatment and better long-term results.     

亲缘性活体部分小肠移植术

目的 介绍我国首例亲缘性活体部分小肠移植术的临床处理体会。方法 受体为男性,18岁,因短肠综合征而接受小肠移植。供体,男性,44岁,为受体之父。取供体回肠末段150cm,移植给患者,术后给予抗免疫排斥、抗感染、抗凝及营养支持等治疗。结果 目前,患者已健康生存19个月,移植肠功能恢复良好。结论 亲缘性活体部分小肠移植术是治疗短肠综合征的有效手段,良好的术后管理是确保活体小肠移植手术成功的关键。     

Primary small bowel lymphoma

We present four patients with non-Hodgkin's lymphoma of the small bowel. Three of the patients were men. Two patients presented with acute abdomen due to tumoral perforation and the remaining 2 presented with abdominal pain and other effects of the mass. The tumors were located in the ileum (1 patient), jejunum (2 patients) and jejunoileum (1 patient). All patients underwent resection of the affected segment. Three patients had large B-cell lymphomas and the remaining patient had a T-cell lymphoma associated with celiac disease. Different combinations of chemotherapy were administered. Only the patient with T-cell lymphoma died due to disease progression. Clinical aspects and the therapeutic strategy used in these tumors are discussed.     

Cholelithic small bowel obstruction

Results of treatment of 18 patients with cholelithic small bowel obstruction are analyzed. All of them were female aged 62 to 84 years with severe concomitant diseases. Different variants of clinical manifestation of small bowel obstruction, significance of diagnostic methods, the causes of delayed hospitalization and operation are analyzed in details. Fourteen patients have been operated with diagnosis of intestinal obstruction but only at 3 of them the true cause of disease has been assumed before surgery. Enterolithotomy was performed at 15 patients, resection of small intestine together with gallstone - at 3 patients. Recurrence of cholelithic obstruction was seen at one patient on 8th day after surgery. Postoperative lethality was 27.7%, but only at one case the purulent complications and multiple organ failure was the cause of lethality. Recommendations for improvement of treatment results and prophylaxis of cholelithic small bowel obstruction are given.     

Postlaparoscopic small bowel obstruction

Background: Patients with early postoperative small bowel obstruction (SBO) are usually managed nonoperatively with nasogastric suction, intravenous fluids, and observation. The majority of early postoperative SBO resolve without an operation. Methods: We performed a retrospective review of patients who had been diagnosed with postlaparoscopic SBO at three Chicago area teaching hospitals. Results: The patients were initially managed nonoperatively for up to 7 days. However, all of them subsequently required an operation. In every case, the postlaparoscopic SBO was caused by the small bowel being incarcerated in a peritoneal defect created either by trocar placement or peritoneal incision for herniorrhaphy. Conclusion: In contradistinction to the approach used for early SBO after laparotomy, prompt operative intervention for postlaparoscopic SBO is recommended.     

小肠肿瘤并发症的诊断和治疗

目的：探讨小肠肿瘤并发症的发生及其诊治。方法：回顾性分析1980年1月至2001年6月间收治的47例有并发症的小肠肿瘤的临床资料。结果：47例中恶性肿瘤33例（70％）。并发症包括出血17例、穿孔8例、肠套叠11例、肠梗阻8例、肠扭转1例、腹内疝1例、肠扭转加肠套叠1例。腹痛为主要症状。X线检查是主要诊断手段，B超、CT、MRI也有助于诊断。良性肿瘤行局部肠段切除，恶性肿瘤25例行根治性切除，7例行姑息性切除。2例死于术后全身衰竭。结论：小肠肿瘤早期诊断困难，多数因并发症就诊，外科手术是主要的治疗方法。     

Leiomyomas of small bowel]

The analysis of our own country and foreign literature, devoted to the problems of clinical aspects, diagnosis and treatment of leiomyomas of the small bowel for the last 48 years has been carried out. The authors present their personal experience in follow-up of 6 cases of the small bowel leiomyomas, the main clinical manifestations of which being recurrent intestinal bleedings and in lesser degree--small bowel obstruction. The results of preoperative examination evidence that besides thorough physical, endoscopical and ultrasound examination the necessity may arise to use for diagnosis angiographic and computed-tomographic methods. The subject of special attention of each clinical physician should be the danger of malignant transformation of benign leiomyomatous neoplasms of the small bowel, which the authors encountered in 2 patients.