克罗恩病外科治疗85例分析

目的总结分析肠道克罗恩病（CD）的外科治疗策略。方法对1980—2005年收治的85例CD病人资料进行回顾性分析。结果近年来CD病人呈增多趋势，术前确诊率为23．53％。肠梗阻（25．88％）、右下腹包块（回盲部肿物，10．59％）、盲肠癌（12．94％）、急性阑尾炎（4．71％）是术前误诊的几大主要原因。手术方式以右半结肠切除术（37．65％），小肠部分切除（21．18％）为主，内、外瘘及肛周CD行外科处理预后良好。结论手术仍是目前肠道CD的重要治疗手段；手术方式依病变部位和并发症类型不同而有差异，术式选择和规范化手术操作是亟待解决的问题。     

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肛瘘是克罗恩病(Crohn’s disease,CD)的常见症状之一,5%~10%的克罗恩病病人首先表现为肛瘘而无其他临床表现,且多为复杂性肛瘘。CD合并肛瘘尤其是复杂性肛瘘时严重影响病人生活质量,治疗困难。对于复杂性肛瘘,应在多学科协作团队(multiple disciplinary team,MDT)共同讨论的基础上,结合病情及药物治疗效果等制定合理可行的个体化治疗方案。     

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??Objective:To investigate the role of arachidonic acid metabolism in Crohn’s disease complicated by intestinal fistula. Methods:By immunohistochemical methods, we examined the expression pattern of major arachidonic acid metabolizing enzymes in 17 samples of Crohn;s disease with associated intestinal fistula. Results:Arachidonic acid metabolizing enzymes were universally present in Crohn’s disease intestines,and the spatial distribution of cyclooxygenase??2,5??lipoxygenase and 15??lipoxygenase??1 expression followed sequential arrangement in Crohn’s ulcer. Conclusion:The regulated distribution of these enzymes indicated protective roles for cyclooxygenase 2 and 15??lipoxygenase??1 and deleterious roles for 5??lipoxygenase in Crohn’s disease.     

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??Laparoscopic surgery for Crohn’s disease: current perspectives GONG Jian-feng. Center for Inflammatory Bowel Diseases, Department of General Surgery, General Hospital of Nanjing Military Command of PLA; Nanjing Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
Abstract Laparoscopic surgery is currently routinely performed in colorectal resections. However??Crohn’s disease??CD??represented a specific cohort due to disease related characteristics such as intestinal stricture?? fistula?? abscess?? malnutrition?? previous laparotomy?? and use of immunosuppressive agents. In non-complex CD?? laparoscopic ileocolic resection has been proven by emerging evidence to be safe and feasible?? and is associated with decreased postoperative morbidity and length of hospital stay. In complex diseases?? such as penetrating and recurrent disease?? laparoscopic resection also confers to beneficial effects in selected patients. Full preoperative evaluation and optimization are important to improve the success rate and to reduce conversion rate of laparoscopic surgery in CD patients.     

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??Diagnosis and treatment of acute lower gastrointestinal hemorrhage in Crohn’s disease: A report of 73 cases LI Guan-wei??REN Jian-an??WANG Ge-fei??et al. Department of General Surgery??Nanjing General Hospital of Nanjing Command??Nanjing 210002??China
Corresponding author??REN Jian-an??E-mail??jan@medmail.com.cn
Abstract Objective To investigate the risk factors for Crohn’s disease (CD)-associated acute lower gastrointestinal hemorrhage (ALGIH) and evaluate its outcome following treatments. Methods The clinical and follow-up data of 73 cases of CD patients suffering from ALGIH admitted from January 2007 to June 2013 in Jinling Hospital were analyzed retrospectively. Results A total of 1374 cases of CD were admitted in Jinling Hospital. The proportion of cases affected by ALGIH was 5.3%. In the multivariate logistic regression analysis??left colon involvement and previous hemorrhage history were significant factors that independently impacted the frequency of ALGIH. Eight cases abandoning therapy or with death were excluded. Thirty-six cases successfully stopped ALGIH by medical treatment while 29 cases underwent surgery. During the follow-up??ALGIH recurred in 17 cases with conservative therapy, compared with only 6 cases after surgery. The cumulative probability of rebleeding in those had surgical intervention was lower than those receiving conservative therapy. Conclusion Left colon involvement and previous hemorrhage history were independent risk factors affecting ALGIH in CD. The rebleeding is common.Thus further investigations are warranted to discover the optimum treatment.     

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??Surgical strategy for colonic Crohn’s disease ZHU Yi-lian, DU Peng, CUI Long. Department of Colorectal and Anal Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200092,China
Corresponding author??CUI Long??E-mail??longcuidr@126.com
Abstract Clinical manifestations of Crohn’s disease(CD) varies from person to person. No curative treatment is available yet. CD occurs at any site of the GI tract. As the disease evolves, complications such as stricture, obstruction, malignant transformation, penetration and fistulas eventually occur, and surgery is demanded accordingly. With specific clinical features and prognosis of colonic CD, the therapeutic strategy is different from CD of other sites. Patients benefit more when pros and cons of the surgery are carefully weighed and when the surgery is performed in the appropriate approach at the right moment along with personalized therapy with multidisciplinary cooperation.     

克罗恩病的诊断治疗:附30例报告

目的 探讨克罗恩病的诊断及治疗方法.方法 回顾性分析13年间经病理确诊为克罗恩病30例的临床资料.26例获随访.结果 30例患者,经手术病理诊断17例(56.7%),结肠镜活检诊断13例(43.3%).17例手术患者中,术前诊断急腹症6例.肠梗阻4例,消化道大出血3例,结肠癌2例.胰头占位病变1例,肠痿1例.随访26例患者中,15例接受过外科治疗,复发5例,21例有服用药物治疗史,治疗总有效率73.1%.近1个月病情缓解患者13例(13/23,56.5%).结论 克罗恩病病情迁延,诊断困难,多因误诊或并发症手术,术后易复发,生活质量低,应对该类患者提高警惕,以早期诊断,并加强随访和指导治疗.     

A case report of retroperitoneal Castleman disease

Castleman disease (CD) is an uncommon lymphoproliferative disorder and is especially rare in the retroperitoneum or perirenal area. We report the case of a 42-year-old woman in whom we found on routine physical examination a mass localized in the right abdomen without clinically important constitutional symptoms for 30 days. Abdominal ultrasound, magnetic resonance images and computed tomography scans revealed a solid mass localized just below the right kidney in the retroperitoneum. The patient subsequently underwent an exploratory laparotomy. Pathological examination revealed a right retroperitoneal mass of CD (hyaline vascular type). The patient completely recovered after surgery. Castleman disease is commonly misdiagnosed as malignant lymphoma, lymphadenitis or ectopic thymoma. So far, its diagnosis is mainly achieved via histopathological examination of surgically obtained tissue. After removal of the lesion, local CD has a good prognosis.     

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目的探讨肠内营养治疗对克罗恩病并发管状外瘘的临床效果。方法回顾性分析2007年5月至2011年12月南京军区南京总医院普通外科收治的克罗恩病并发管状外瘘43例病人,应用半要素肠内营养治疗3个月的临床资料。记录经肠内营养治疗后肠瘘是否愈合、愈合时间,以及治疗前后的炎症指标C反应蛋白(CRP)、血沉(ESR)、血小板(Plt),营养指标体重、身体质量指数(BMI)、血红蛋白(Hb)、白蛋白、前白蛋白、总蛋白等指标,以观察肠内营养对克罗恩病并发肠外瘘的治疗效果。病人肠瘘愈合后随访时间至少半年。结果 43例病人经过肠内营养治疗后,27例病人肠瘘得到愈合,平均愈合时间为(32.6±9.2)d。经治疗后所有病人的克罗恩病炎症指标血沉、CRP、Plt计数均较治疗前显著改善(P<0.05),愈合组、未愈组炎症指标改善均有显著意义(P<0.05),但两组间差异无统计学意义(P>0.05)。治疗后的营养指标如体重、BMI、Hb、白蛋白、前白蛋白、总蛋白均较治疗前显著改善(P<0.05),其中愈合组白蛋白、前白蛋白的改善情况明显优于未愈组(P<0.05)。结论克罗恩病并发管状外瘘的病人应用肠内营养治疗后,可诱导克罗恩病缓解,减轻病人的炎症反应,改善营养状态,使部分病人的肠外瘘达到临床愈合,避免了再次手术对病人的打击。     

腹腔镜在外科急腹症中的应用价值

目的：探讨腹腔镜在外科急腹症中的应用价值和操作特点。方法：对我科2000年9月～2003年9月间应用腹腔镜诊治的134例急腹症做回顾性分析。结果：本组134例外科急腹症中。130例运用腹腔镜治疗成功(97％)，4例中转开腹手术(3％)。本组无手术死亡，无术后腹腔残余脓肿及胃肠瘘，无粘连性肠梗阻及伤口感染，平均手术时间45min，平均住院时间为5d。结论腹腔镜在外科急腹症中有应用价值。不但具有诊断及治疗的双重作用，且具有损伤小，痛苦轻，术后恢复快和并发症少等优点。