Diagnosis and treatment of abdominal cocoon: a report of 24 cases

Background

Abdominal cocoon (AC) is a rare disease characterized by total or partial encasement of the small bowel by a thick, fibrous membrane. Twenty-four cases are reported in this article. Our aim was to investigate the methods of diagnosis and treatment for AC.

Methods

The clinical manifestations, diagnoses, surgical treatments, and follow-up results of 24 cases of AC in the Department of General Surgery of the Third Affiliated Hospital of Sun Yat-sen University between January 1997 and September 2007 were retrospectively analyzed.

Results

Main clinical manifestations were partial or complete intestinal obstruction (87.5%) and abdominal mass (54.2%). Three cases were preoperatively diagnosed by computed axial tomography and 1 case by barium x-ray examination. The other 20 cases were diagnosed by laparotomy. All of the patients underwent surgery. In all cases, we found that part of or the entire small bowel was encapsulated in a dense, white, fibrous, cocoon-like membrane. During surgery, excision of the thick membrane and lysis of adhesions were carefully performed to release the small intestine. Postsurgical recovery in most cases was smooth, and there was no recurrence during a follow-up period of 3 months to 9 years (mean 37 months).

Conclusion

The clinical manifestation of AC is nonspecific; therefore, preoperative diagnosis is difficult. However, its manifestations on barium x-ray and contrast computed axial tomography scan are characteristic, and aggregate analysis of the clinic and radiologic data can increase preoperative diagnosis. The main treatment of AC is surgery, and the overall prognosis of these patients is satisfactory.     

16层螺旋CT在腹主动脉瘤诊断中的应用

目的讨论16层螺旋CT血管造影在腹主动脉瘤诊断中的应用价值。方法20例腹主动脉瘤患者行16层螺旋CT血管造影（15例DSA证实,5例手术证实）,采用多平面重组（muhiplanar reformation,MPR）、最大密度投影（maximal intensity projevtion,MIP）、容积再现（volume rendering,VR）。结果20例中肾下型16例,近肾型2例,肾上型2例。瘤体近端最大瘤径8—57mm,最小瘤径6—15mm;最大直径55—75mm,最小直径31—38mm,瘤体最长118mm。15例伴瘤体内附壁血栓（1例合并主动脉夹层,2例合并髂总动脉瘤）,其中囊状扩张4例,梭状扩张11例,囊梭状混合型5例;真性动脉瘤19例,假性动脉瘤1例。结论MSCTA可以快速、准确、无创诊断腹主动脉瘤,是最理想的检查方法之一。     

The Current Status of Laparoscopic Sacrocolpopexy: A Review

Context

Pelvic organ prolapse (POP) is a common problem in women that causes morbidity and a decreased quality of life. Sacrocolpopexy can treat women with vaginal vault prolapse (VVP), multicompartmental POP, and/or a history of failed prolapse procedures. Abdominal sacrocolpopexy (ASC) is the gold standard for VVP and is superior to vaginal sacrocolpopexy, with fewer recurrent prolapses and less dyspareunia. Vaginal prolapse repairs, however, are often faster and offer patients a shorter recovery time. Laparoscopic sacrocolpopexy (LSC) aims to bridge this gap and to provide the outcomes of ASC with decreased morbidity.

Objective

This review evaluates the recent literature on LSC as a therapy for POP.

Evidence acquisition

A PubMed search of the available English literature on LSC was performed. The reference lists of selected articles were reviewed, and additional on-topic articles were included. Some 50 articles were screened, 22 articles were selected, and the reported outcomes from 11 series are presented in this review.

Evidence synthesis

Laparoscopic experience with POP has advanced tremendously, and LSC results from >1000 patients in 11 series support this. Conversion rates and operative times have decreased with increased experience. Mean operative time was 158 min (range: 96–286 min) with a 2.7% conversion rate (range: 0–11%) and a 1.6% early reoperation rate (range: 0–3.9%). With a mean follow-up of 24.6 mo (range: 11.4–66 mo), there was, on average, a 94.4% satisfaction rate, a 6.2% prolapse reoperation rate, and a 2.7% mesh erosion rate. Several centers have demonstrated that excellent outcomes with LSC are reproducible in terms of operative parameters, durable results, minimal complications, and high levels of patient satisfaction.

Conclusions

LSC upholds the outcomes of the gold standard ASC with minimal morbidity. Longer prospective and randomized trials are needed to confirm these results.     

急性ITP患儿外周PPAR-γ mRNA表达变化及与IL-18水平的相关性

目的 检测急性特发性血小板减少性紫癜(idiopathic thrombocytopenic purpura,ITP)惠儿外周血浆中IL-18对血淋巴细胞PPAR-γ mRNA表达变化影响.方法 序贯收集符合试验入选标准的急性ITP患儿53例,同时收集相匹配的同期体检儿童50例作为对照.将血液标本平均分为5份,在取样1、24、48、72 h后,分别采用RT-PCR法检测ITP患儿外周血淋巴细胞PPAR-γ mRNA的表达,蛋白免疫印迹(western blot)检测PPAR-γ蛋白的含量,ELISA法检测血浆中IL-18水平.结果 急性ITP组白细胞表达PPAR-γ蛋白在1、24、48、72 h与对照组PPAR-γ蛋白分别相比均明显增强,差异有显著性(t_1=7.52,t_(24)=16.38,t_(48)=9.65,t_(72)=12.34,均P<0.05);急性ITP患儿在不同的时间点测定的PPAR-γ mRNA表达水平明显均高于正常对照组(t_1=9.25,t_(24)=14.24,t_(48):8.69,t_(72)=16.14,均P<0.05),同样发现急性ITP患儿血浆IL-18水平均显低于正常对照组(t_1=6.38,t_(24):9.65,t_(48)=8.91,t_(72)=7.19,均P<0.05);血浆IL-18水平与PPAR-γ mRNA表达呈负相关(r=-0.89,P<0.05).结论 血浆中IL-18生成量的减少可能导致了急性ITP患儿外周血淋巴细胞PPAR-γ表达的增加,调控Th1/Th2细胞分化功能出现障碍,使有效的免疫抑制作用降低,导致自身反应性T细胞激活增多、凋亡减少,使得浆细胞产生抗血小板抗体增多,促进了血小板的破坏.     

外伤性小肠破裂的诊治

目的探讨外伤性小肠破裂的早期诊断及治疗方法。方法对288例外伤性小肠破裂病人的临床资料进行回顾性分析。结果典型腹膜炎表现者209例（72．6％）;腹腔穿刺198例,阳性175例（88．4％）;腹腔灌洗28例,阳性22例（78．6％）;B型超声检查214例,阳性177例（82．7％）;288例KUB平片,发现膈下游离气体143例（49．7％）;CT检查65例,阳性43例（66．2％）。治愈280例（97．2％）,死亡8例。结论重视外伤性小肠破裂常见症状和体征,积极应用各种腹腔穿刺技术,并结合血常规、X线、B型超声、CT等辅助检查,早期诊断,避免漏诊误诊,尽早手术探查,选择合理术式可明显提高治愈率及病人生活质量。     

多层螺旋CT显示肝圆韧带的初步研究

目的：探讨肝圆韧带的多层螺旋CT表现及其临床意义。方法：对130例无肝脏疾病的患者行16层CT腹部平扫及增强扫描,采用多平面重组（MPR）、层块最大密度投影（slab-MIP）和层块容积再现（slab-VR）等后处理技术重点观测肝圆韧带。结果：在斜矢状位MPR,slab-MIP,slab-VR图像上肝圆韧带表现为符合其解剖走行特点的密度稍高的光滑条索灶,显示率为90.8%（118/130）。裂隙段中点处直径为(5.44±0.96)mm（3.2～7.2 mm）,游离段中点处直径为(3.43±0.91)mm（1.6～6.0 mm）。结论：多层螺旋CT能清晰显示肝圆韧带,可为以肝圆韧带为自体修复材料的上腹部手术提供较为可靠的术前影像学判断。     

Effects of CO2 pneumoperitoneum on blood flow vol-ume of abdominal organs of rabbits with controlled hem-orrhagic shock and liver impact injuries

Objective: To investigate the effects of CO2 pneumo-peritoneum on blood flow volume of abdominal organs of rabbits with controlled hemorrhagic shock model and liver impact injuries.Methods: After controlled hemorrhagic shock and liver impact injuries, the rabbit model was established. Eighteen rabbits subjected to hemorrhagic shock and liver impact inju-ries were divided into 3 groups randomly according to the volume of lost blood: light hemorrhagic shock (blood loss volume was 10%, 6 ml/kg), moderate hemorrhagic shock (20%, 12 ml/kg) and severe hemorrhagic shock (40%, 22 ml/kg). Intraabdominal pressures of CO2 pneumoperitoneum was 10 mmHg. Color-labeled microspheres were used to mea-sure the blood flow volume of the liver, kidney and stomach before pneumoperitoneum at 30 minutes and 2 hours after pneumoperitoneum and 30 minutes after deflation. And the mortality and hepatic traumatic condition of rabbits were recorded.Results: Of the 18 rabbits, there were 9 with liver impact injuries at Grade Ⅰ, 8 at Grade Ⅱ and Ⅰ at Grade Ⅲ (according to AIS-2005). The mortality rate in light hemorrhagic shock group was 33.33%, and that in moderate or severe hemor-rhagic shock group was 100% within 30 minutes and 2 hours after pneumoperitoneum, respectively. The blood flow vol-ume in the organs detected decreased at 30 minutes under pneumoperitoneum in light and moderate hemorrhagic shock groups. At the same time, the blood flow volume of the liver in moderate hemorrhagic shock group decreased more sig-nificantly than that in light hemorrhagic shock group.Conclusions: The blood flow volume of abdominal organs in rabbits is decreased obviously under CO2 pneumoperitoneum, with fairly high mortality rate. It is be-lieved that CO2 pneumoperitoneum should cautiously be used in abdominal injury accompanied with hemorrhagic shock, especially under non-resuscitation conditions.     

ITP血小板特异性自身抗体（GPⅡb/Ⅲa和GPIbα）与糖皮质激素和静脉丙种球蛋白临床疗效的关系

目的检测特发性血小板减少性紫癜（ITP）患者体内的抗血小板膜糖蛋白（GPⅡb/Ⅲa和GPIbα）特异性自身抗体,并探讨特异性自身抗体与糖皮质激素和静脉丙种球蛋白（静丙）治疗的临床疗效是否存在针对性,以便得到更经济和个体化的治疗方案,为ITP提出新的分型依据。方法应用改良的单克隆抗体特异性俘获血小板抗原（MAIPA）法检测抗GPⅡb/ⅡIa,GPIbα特异性自身抗体。结果双抗体阳性组与单一抗GPIbα抗体阳性组总疗效比较,差异无显著性（χ^2=0.995,P〉0.05）双抗体阳性组与单一抗GPⅡb/ⅡIa抗体阳性组总疗效比较,差异有显著性（χ^2=17.439,P〈0.01）,后者优于前者;单一抗GPⅡb/ⅡIa抗体阳性组,双抗体阳性组,双抗体阴性组,糖皮质激素治疗与糖皮质激素联合静丙治疗比较,差异无显著性（P〉0.05）。结论血小板特异性自身抗体种类（GPⅡb/Ⅲa和GPIbα）及种类数目与ITP的临床疗效（糖皮质激素、静丙）有一定关系,对临床治疗方案的选择有一定意义。以抗血小板膜糖蛋白（GPⅡb/Ⅲa和GPIbα）特异性自身抗体为ITP进行新的分型依据尚不足,需扩大样本量进一步研究。     

尿系列蛋白对早期诊断过敏性紫癜肾损害的临床价值探讨

目的：探讨尿微量蛋白检测对过敏性紫癜肾损害的早期诊断价值。方法：采用放射免疫分析分别检测25例单纯性过敏性紫癜（AP）、27例紫癜性肾炎（PN）患儿和32例正常儿童（对照组）尿微量白蛋白（Alb）、免疫球蛋白G（IgG）、β2微球蛋白（β2-m）含量,并同期检测常规肾功能指标。结果：正常对照组与AP组、PN组的尿系列蛋白含量比较差异均有统计学意义（P〈0.01）,AP组与PN组比较差异亦有统计学意义（P〈0.01）,而三组BUN、Cr均在正常值范围。结论：尿微量蛋白在过敏性紫癜肾功能受损时较肾功能指标BUN、Cr改变出现早,可作为早期诊断肾功能损害的敏感指标。     

Acquired Omental Cystic Lymphangioma after Subtotal Gastrectomy: A Case Report

We herein describe a case of cystic lymphangioma in the greater omentum of the remnant stomach, which is thought it to be related with subtotal gastrectomy 10 yr ago for early gastric cancer. A 76-yr-old man was admitted to our department with postprandial abdominal discomfort and bowel habit change. Intraabdominal multilocular cystic mass was detected by ultrasonography and computed tomography. We performed a complete En-bloc tumor resection including spleen and distal pancreas, and histological examination confirmed cystic lymphangioma originated from the greater omentum of the remnant stomach. Although the etiology of omental lymphangioma remains largely unclear, these findings suggested strongly that obstruction of the lymphatic vessels after gastric resection for gastric carcinoma might be the most plausible cause. The surgical extirpation with resection of organs involved appears to be a treatment of choice for such unusual case.