我国炎症性肠病多学科综合治疗现状

炎症性肠病虽然是内科疾病,但多数病人病情复杂且需药物长期维持和手术治疗,其治疗方案须个体化。因此,术前应高度重视多学科综合治疗协作组的作用,充分发挥消化内科、结直肠外科、营养科甚至心理科等多个专科的力量,进行充分的围手术期处理,并准确把握内科治疗和外科治疗的指征。在选择外科治疗方式时,强调在合适的时机,以最小的创伤和风险解除症状,进而减少术后并发症,提高病人生活质量。     

克罗恩病肠梗阻的外科治疗

克罗恩病是一种需用内科药物控制的疾病,病变肠壁长期炎症反应并纤维化导致肠梗阻是克罗恩病最常见的手术原因.近年来克罗恩病的相关基础研究、诊断与治疗都取得了巨大进步.外科医师应与胃肠内科、内镜、影像科、病理科等多学科医师合作,严格把握克罗恩病肠梗阻的手术适应证和手术时机,熟悉其外科治疗原则,积极应用损伤控制外科、快速康复外科和腹腔镜手术等新理念、新原则和新技术,对提高克罗恩病肠梗阻的外科治疗效果十分重要.     

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重症急性胰腺炎(severe acute pancreatitis,SAP)是一种外科急重症,病情凶险,病死率高,一直以来都是急性胰腺炎(acute pancreatitis,AP)中治疗的难题和焦点。本文仅就其外科干预时机的选择及多学科协作阐述如下。1外科干预在SAP治疗中的价值随着对SAP的认识越来越深入,对本病的治疗理念也经历了数次转变,最初以内科治疗为主,逐渐转变到外科治疗为主,再到现在的理念,即在非手术治疗基础上进行适时的必要的外科干预治疗。     

克罗恩病外科治疗27例临床体会

目的 总结克罗恩病外科治疗的临床体会.方法 自2000年1月至2012年6月共收治27例克罗恩病患者,均行手术治疗和病理确诊.结果 本组病例均经病理证实为克罗恩病.术后随访8个月至6年,根据克罗恩病简化CDAI评分标准判断疗效.复发9例中,再次手术5例,其他4例转内科药物治疗症状缓解,复发时间6个月至5年,平均21个月.结论 对克罗恩病无论是外科治疗,还是内科治疗均无法达到治愈,仅是对症治疗.手术治疗克罗恩病,其复发率及再手术率高是外科治疗的重点.     

克罗恩病合并肛瘘的综合治疗

目的 探讨克罗恩病合并肛瘘的合理治疗方法.方法 回顾性分析2007年6月至2011年4月中山大学附属第六医院收治的33例克罗恩病合并肛瘘或肛周脓肿患者的临床资料.根据克罗恩病合并肛瘘的活动程度及病变范围,本研究采用外科治疗、内科治疗以及外科联合内科治疗.外科治疗方式包括肛瘘挂线术、肛瘘切除术、肛周脓肿切开引流术以及肠造口术.针对克罗恩病患者肠道病变选用5-氨基水杨酸类药物、免疫抑制剂、糖皮质激素治疗、TNF单克隆抗体等药物进行内科治疗.治疗后采用门诊治疗和电话方式随访至2012年8月.术前及术后克罗恩病活动指数(CDAI)、肛周克罗恩病活动指数(PDAI)采用独立样本t检验比较.结果 33例患者中,22例行外科联合内科治疗,7例行单纯外科治疗,4例行单纯内科治疗.首次治疗后18例患者肛瘘瘘口愈合(其中3例行单纯内科治疗),愈合时间为(3.2±2.6)个月(1 ～12个月),其中8例瘘管减少、症状改善;4例瘘口持续未闭;6例出现肛瘘复发或再发,复发或再发时间为首次治疗后(35±56)个月(5～ 148个月).33例患者术前CDAI和PDAI评分分别为(166±100)分(7～ 361分)和(9.2±2.6)分(5～16)分,经治疗后(包括手术及药物治疗)CDAI和PDAI评分分别为(83±53)分(0 ～212分)和(2.7±3.1)分(0～11分),患者治疗前后CDAI和PDAI评分比较,差异有统计学意义(t=4.20,8.92,P＜0.05).12例首次治疗肛瘘未愈合患者再次治疗后,3例愈合,9例未愈合.6例患者出现复发或再发,其中5例接受再次手术治疗(4例愈合、1例症状改善),1例仅接受内科治疗瘘口未愈合.直至随访结束,30例患者中20例肛瘘愈合,10例肛瘘未愈合.结论 目前尚无统一的克罗恩病合并肛瘘治疗标准,外科联合内科治疗克罗恩病合并肛瘘疗效较好,手术方式需根据患者具体情况慎重选择.     

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Ｃｒｏｈｎ病 (ＣＤ)是一原因不明的节段性慢性炎性肠病 ,可发生于消化道的任何部位 ,其中回盲部占 4 1%～ 5 5 % ,小肠占 30 %～ 4 0 % ,结肠占 14 %～ 2 6 %。ＣＤ在我国的发病率较低 ,约为 (6～ 10 ) / 10万人 ,欧美国家约为 (5 0～10 0 ) / 10万人。ＣＤ是慢性反复发作性终身疾病 ,不论是内科或外科治疗都不能治愈。但临床治疗上仍以内科药物治疗为主[1] ,70 %的病人在病程中至少接受一次手术治疗。通过手术治疗 ,可以消除或缓解症状 ,改善病情 ,从而提高病人的生活质量。因此 ,在适当的情况选择外科治疗是一种迅速、安全 ,也是最有效的…     

Crohn病合并肠梗阻的诊治（附6例报告）

目的Crohn病合并肠梗阻的外科治疗手术方式及效果。方法本科1998--2006年共治疗6例Crohn病合并肠梗阻。4例手术，其中，病变切除肠吻合3例，结肠造漏1例。保守治疗2例。结果随访12～24个月，手术4例患者：3例腹痛、腹胀、腹泻消失；1例存在慢性腹泻，经内科保守治疗病情平稳，无急性肠梗阻发生。结论对有手术指征的Crohn病合并肠梗阻患者，经充分准备，积极手术治疗有好的疗效。     

合理把握炎性肠病手术时机

炎性肠病以往被定义为“内科病”，外科手术往往是在内科治疗无效、或是患者出现严重并发症时才实施的手段。随着治疗理念的进步，外科手术在炎性肠病治疗中的价值被重新认识，目前更加强调外科积极与合理地介入以及多学科协作的综合治疗。本期“炎性肠病”重点期将围绕炎性肠病的外科手术时机选择及综合治疗等问题进行探讨。     

肠道炎性疾病的外科治疗

肠道炎性疾病（ＩＢＤ）主要是指溃疡性结肠炎（ＵＣ）和克隆病（ＣＤ）,基本属于内科治疗疾病,但有不少患者因内科治疗难以控制病情的发展或出现并发症而需要外科处理。在什么情况下需要手术,Ｔｒｕｅｌｏｎｅ提出意见可供参考：（１）出现急症需手术挽救生命;（２）内科治疗难以控制并发症和多次复发;（３）防治癌变而切除肠段。近１０多年来,由于外科技术和设备的不断发展和完善,尤其是腹腔镜和吻合器的广泛应用,ＩＢＤ外科治疗有较大发展,在治疗观念上有较多的更新。结直肠全切除、回肠袋肛管吻合术（ｉｌｅａｌｐｏｕｃｈａ…     

炎性肠病手术时机的选择

炎性肠病虽然是以内科治疗为主的疾病．但外科处理是不可缺少的治疗手段。对于有手术适应证的患者．应及时进行外科治疗。回避外科治疗，企网采用药物治疗代替手术不但达不到治疗效果．而且由于拖延了治疗时机，显著增加手术风险。迄今已明确。无效的内科治疗、使用糖皮质激素、营养不良和合并感染均是手术的危险因素，急诊手术和活动期手术也增加手术风险。内科医生应该准确把握手术时机，为具有手术指征的患者创造手术条件。     

Treatment of severe and fulminant inflammatory bowel disease colitis

Despite dramatic advances in medical treatment of inflammatory colitis, a substantial proportion of patients with ulcerative colitis (UC) and isolated Crohn's disease (CD) colitis will acutely develop severe disease requiring hospitalization and surgery. It is imperative that surgeons understand the multidisciplinary nuances at the intersection between medical and surgical management. It is important that the surgeon be able to evaluate and stratify the severity of inflammatory bowel disease (IBD) colitis, understand medical treatment options, monitor responses to medical therapy, and ultimately execute timely and appropriate surgery for these often-ill patients.     

Pharmacotherapy of inflammatory bowel disease

Inflammatory bowel disease (IBD) encompasses ulcerative colitis and Crohn's disease. Since the etiology of both diseases, is undetermined the causal therapy do not exist. Medical treatment has focused on nonspecific suppressions of the inflammatory process. There are four groups of IBD drugs: anti-inflammatory medicaments, immunomodulators, antidiarrheal agents, and biologic therapy. In a last year immunosuppressives become the very essential IBD drugs. Azathioprine is drug of choice for chronically active Crohn's disease; methotrexate become the second line immunosuppressive drug. It appears that anti-TNG monoclonal antibodies, cA2 (infliximab) may produce rapid control of active Crohn's disease and achieve tissue healing. Topically acting glucocorticosteroids are a safer than standard glicocorticosteroids in ileocolonic Crohn's disease. Cyclosporin is becoming a drug of choice in severely active ulcerative colitis. Anti-inflammatory agents, sulfasalazine and 5-ASA drugs are recommended in treatment mild and moderately active IBD and as maintenance treatment in ulcerative colitis. Corticosteroids still have the main role in the treatment of active IBD. There is no convincing data for efficacy of corticosteroids as maintenance therapy.     

Idiopathic inflammatory bowel disease

IBD (Crohn's disease, ulcerative colitis) present a great challenge to medical sciences because of many secrets which still hidden their real nature. Modern sophisticated digestive surgery occupies very important place in the treatment of IBD, owing to bravurous surgical skill and in a great dill to logistic support of different medical disciplines. Historical evaluation of scientific knowledge and pathways of therapeutic approaches are described. Contemporary principles and method of treatment are particularly stressed, especially on the surgical field.     

The long-term benefit of surgery on health-related quality of life in patients with inflammatory bowel disease

HYPOTHESES: Health-related quality of life (HRQL) has been shown to improve dramatically shortly after surgery in patients with inflammatory bowel disease (IBD). Our hypotheses were that (1) improved HRQL would be maintained long term in patients after surgery for ulcerative colitis and (2) the improved HRQL in patients with Crohn disease would decline with long-term follow-up. DESIGN: Consecutive series of patients undergoing surgery for IBD between June 1994 and January 2000 prospectively investigated as a cohort outcomes study. PATIENTS: Data were obtained in 139 patients. The diagnoses were Crohn disease (n = 56) and ulcerative colitis (n = 83). INTERVENTION: Patients with Crohn disease underwent resections with or without stricturoplasties; all but 5 patients with ulcerative colitis underwent ileal pouch-anal anastomoses. MAIN OUTCOME MEASURE: Health status was measured using the Health Status Questionnaire (HSQ) preoperatively and then every 3 months postoperatively. RESULTS: Preoperative HSQ scores were very low in all 8 scales of the HSQ. Postoperatively, HRQL measures improved significantly (P<.05) both in patients with Crohn disease and ulcerative colitis, with scores equal to or better than published scores in the general population. In patients with Crohn disease, the scores improved significantly after surgical resection and steadily increased despite disease recurrence and reoperations. The HRQL at last follow-up was equivalent to the general population. The improvements were statistically significant in patients followed up for more than 1 year in 7 of 8 scales of the HSQ. CONCLUSIONS: These results confirm that HRQL is poor in patients with IBD referred for possible operation. Surgical resection resulted in significant improvement in HRQL. More important, the results were durable. With follow-up up to 6 years, the HRQL in this cohort was equal to or better than norms for the general population both in patients with ulcerative colitis and with Crohn disease. We believe these data justify aggressive surgical intervention in many patients with IBD and support the prospective study of HRQL by surgeons treating patients with chronic diseases.     

Clinical characteristics and validation of diagnosis in individuals with Hirschsprung disease and inflammatory bowel disease

Background/purposeHirschsprung disease has previously been reported to be associated with inflammatory bowel disease (IBD). The aim was to clinically confirm the diagnosis and to describe characteristics among individuals with both conditions in a national populationbased cohort.MethodsNationwide, population-based cohort study, including all individuals with a Hirschsprung disease diagnosis and an IBD diagnosis registered between 1964 and 2016, in which clinical data were collected from the medical records of 18 validated cases with both Hirschsprung disease and IBD. The medical record of each individual in the study cohort was reviewed for age at IBD diagnosis, type of aganglionosis, type of surgical treatment, subtype of IBD, and treatment for IBD.ResultsMedian age at follow up was 34 years (range 19–66), and 3 of 18 indivduals (17%) were females. Median age at first diagnosis of IBD was 21 years (range 10–46). Six patients had ulcerative colitis, ten had Crohn's disease and two had unclassified IBD. Most of the patients had pharmacological treatment for IBD and 5 (28%) individuals had surgical treatment.ConclusionHirschsprung disease and IBD was clinically confirmed in 18 cases. Age at IBD onset and subtype of IBD is similar to IBD patients without Hirschsprung disease. Five individuals had undergone surgical treatment for IBD.     

Management of Crohn’s disease and ulcerative colitis

Crohn’s disease and ulcerative colitis (UC) are complex, contrasting disease processes that require multidisciplinary team management. The treatment modalities in inflammatory bowel disease are varied and the indications and threshold for surgery quite different in patients with UC compared with Crohn’s disease. We discuss the panoply of surgical techniques available to the surgeon and IBD patient while highlighting the potential sequelae, complimentary medical therapies, nutritional considerations and innovative techniques for reconstruction of the gastrointestinal tract.     

炎性肠道疾病与营养支持

概述了炎性肠道疾病（Inflammatory Bowel Disease,IBD）的病理生理和临床表现及由此导致营养不良的原因,尽管IBD的病因不明,但据推测与自身免疫和变态反应,甚至遗传因素有关,由于炎症活动,应激和瘘或穿孔,慢性失血和蛋白质的流失,都导致体重下降和营养不良,基于“让肠道休息”的观点,营养支持已作为IBD治疗措施之一,肠内营养与肠外营养支持对缓解临床症状同样有效,而且,对Crohn‘s病的缓解作用优于溃疡性结肠炎。尽管营养支持能改善和纠正营养不良、降低术后并发症发生率,但不能代替传统的IBD治疗方法和手术处理。     

炎性肠病肠道免疫学的研究进展

目的总结有关炎性肠病肠道免疫学领域的最新进展。方法采用文献复习的方法,对炎性肠病包括溃疡性结肠炎及克罗恩病免疫学领域的相关文献进行综述。结果溃疡性结肠炎和克罗恩病是炎性肠病的两种主要类型,两者的临床和病理特征既有重叠又有区别。免疫学的研究表明,易感个体对肠道微生物"过激"的炎症反应以及机体与微生物之间的相互作用在炎性肠病发生、发展中发挥重要作用。这一领域的突出成果包括发现了核苷酸结合寡聚化结构域2(NOD2)基因、自体吞噬基因、微RNA、白细胞介素23/Th17通路等。肠道细菌、肠上皮、肠道免疫细胞以及肠道微血管的功能异常在炎性肠病的病程进展中起关键作用。目前一些单克隆抗体已被用来治疗炎性肠病,并取得良好效果。结论对炎性肠病发病过程中肠道黏膜免疫基础和分子网络调控的研究,将为炎性肠病的防治提供理论依据;对炎性肠病相关基因的研究,又可为炎性肠病治疗提供更多的基因治疗靶点。     

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??Choice and key points of emergency surgical procedure for inflammatory bowel disease WU Xiao-ting, XIA Lin. Department of Gastrointestinal Surgery, West China Hospital, Sichuan University??Chengdu 610041??China
Corresponding author??WU Xiao-ting, E-mail??wxt1@medmail.com.cn
Abstract Emergency surgery of inflammatory bowel disease (IBD) is always the implementation in the case of poor efficacy of medical treatment, and the choice of surgical procedure is based on pathological diagnosis of IBD. Generally we prefer colectomy (or subtotal colectomy) with ileostomy for ulcerative colitis. But in Crohn's disease, surgeons need only to deal with the complete obstruction, bleeding and perforation??then perform double barrel enterostomy or intestinal anastomosis depending on the patient's general condition. In the procedures, to retain the intestine is important. In addition??for undiagnosed IBD we should not only to deal with the lesion by staging surgery treatment??but also to confirm the diagnosis in the surgical procedure.     

Drug therapy for inflammatory bowel disease: Part II.

Part II of this two-part article (See The American Journal of Surgery 1992; 164: 85-9) reviews the current definition of the role of immunosuppressive therapy in inflammatory bowel disease (IBD) and the use of antibiotics in IBD, as well as summarizes the uses of the new agents on the horizon for the treatment of IBD. Azathioprine and 6-mercaptopurine have steroid-sparing effects in patients with refractory Crohn's disease and ulcerative colitis, treat Crohn's disease-associated fistulas, and are the first agents to demonstrate efficacy in the prophylaxis of Crohn's disease. Their low risk for the development of lymphoreticular malignancy remains a factor in decisions regarding their long-term use. Cyclosporine is steroid sparing in active chronic Crohn's disease and, given intravenously, may help treat severe, refractory ulcerative colitis. Antibiotics have expanding roles: metronidazole is effective for the primary treatment of Crohn's disease, fistulas, abscess, bacterial overgrowth, and pouchitis (after ileoanal anastomosis). Other potential agents show promise in pilot studies but await controlled trials.