移植肾活组织检查在急性排斥反应预后判断上的价值

报告我院经肾活组织检查 (肾活检 )病理学诊断急性排斥反应 3 2例 ,并将急性排斥反应近期转归与肾活检病理学改变参数作相关性回顾分析 ,探讨肾活检在移植肾急性排斥反应预后判断上的价值。一、临床资料1988～ 1999年我院共行尸体肾移植术 4 0 0余例 ,经肾活检诊断急性排斥反应3 2例 ,其中男性 2 8例 ,女性 4例。年龄( 3 7± 7)岁。肾移植术后给予泼尼松、硫唑嘌呤和环孢素Ａ三联免疫抑制剂治疗 ,少数早期病例仅以前二者联合抗排斥。确诊急性排斥反应者给予甲泼尼龙0 .5～ 1.0 ｇ/ｄ静脉滴注 ,连续冲击 3ｄ ,酌情给 1～ 3个疗程 ,合用透析疗…     

血浆置换治疗肾移植术后急性排斥反应

肾移植术后的急性排斥反应,常规治疗几乎都是增加糖皮质激素用量,仍有一部分病例排斥反应不能逆转。我们应用血浆置换治疗肾移植术后急性排斥反应,现将结果报告如下。一、资料与方法对11例同种异体肾移植术后出现急性排斥反应、经用糖皮质激素冲击治疗无效的患者行血浆置换治疗,其中男8例,女3例,年龄26～52岁,平均45岁。肾移植术后免疫抑制剂的用法为:环孢素Ａ10ｍｇ·ｋｇ-1·ｄ-1,分次口服;甲泼尼龙于术日至术后2ｄ500ｍｇ/ｄ静脉滴注,以后改为泼尼松2ｍｇ·ｋｇ-1·ｄ-1,开始每日递减5～10ｍｇ,至30ｍｇ/ｄ口服维持;硫唑嘌呤2ｍｇ·ｋｇ-…     

肾移植后血清白细胞介素2、可溶性白细胞介素2受体和白细胞介素6的监测

动态监测６０例肾移植患者术后２个月内血清白细胞介素２（ＩＬ－２）、可溶性ＩＬ－２受体（ｓＩＬ－２Ｒ）和白细胞介素６（ＩＬ－６）的变化。结果发现发生急性排斥反应时，上述细胞因子的升高较临床诊断提早数天，并且显著高于环孢素Ａ肾中毒组；对甲泼尼龙敏感的排斥反应，抗排斥治疗数天后上述因子下降到排斥前水平。提示肾移植术后动态监测患者血清ＩＬ－２、ｓＩＬ－２Ｒ和ＩＬ－６有助于急性排斥反应的早期诊断、鉴别诊断、及时治疗和甲泼尼龙抗排斥的疗效评价。     

肾移植术后并发多灶性结核性肠坏死穿孔一例

患者，男性，30岁。1993年1月8日行尸体肾移植术，术后移植肾功能良好，给予环抱素A、硫咄瞟吟和泼尼松三联抗排斥治疗，1993年7月ZO日因持续高热伴脐周痛一周入院。入院后考虑激素所致消化道应激性溃疡，将泼尼松用量减至IOmg川，并输往氨等青霉素8．Og／d和甲氰咪派0．sg／d，体温渐降至正常，但仍有济周压痛。1993年8月8日突发剧烈腹痛，呈板状腹，腹部透视可见隔下游离气体，诊断消化道穿孔急性腹膜炎行剖腹探查，术中见回肠末端IOOcm范围内约1．scmXI．scm～3‘OcmX3．Ocm灶性坏死8处，其中一处约1．scmXI．scm穿孔，切除回肠末…     

肾移植术后泌尿系恶性肿瘤11例报告

我院于 1 977～ 1 999年的 2 2年中共行同种肾移植术 1 1 32例 ( 1 2 86例次 ) ,术后共发生泌尿系肿瘤 1 1例 ,现报告如下。1　临床资料本组 1 1例 ,男 4例 ,女 7例 ,年龄 2 9～ 60岁 ,平均 47岁。其中一次肾移植 1 0例 ,二次肾移植 1例。肾移植病因分别为慢性肾小球肾炎尿毒症 8例 ,慢性肾盂肾炎 3例。术前均行血液透析 ,时间 2～ 1 5个月 ,平均 4个月 ,肾移植术后所有患者肾功能均恢复正常 ( 1例第一次移植发生急性排斥反应1 2 d后切除移植肾除外 )。9例患者接受环孢素 A、硫唑嘌呤、泼尼松治疗 ,2例患者接受环孢素 A、雷公藤多甙、泼尼…     

外伤性肠穿孔诊治临床分析

目的总结外伤性肠穿孔的诊治方法及经验。方法对我院1997年1月～2004年12月外伤性肠穿孔40例患者进行回顾性分析。结果40例患者均进行剖腹探查，进行一期肠修补32例，肠部分切除肠吻合术6例，肠吻合外置2例。术后一期愈合36例，切口感染3例，死亡1例；未发生腹腔脓肿、肠瘘。结论早期诊断、早期手术、正确的手术方式、有效胃肠减压、腹腔引流、术后早期应用抗生素、静脉营养药物，是影响肠穿孔治疗效果的主要因素。     

肾移植术后小肠梗阻的诊断和治疗

目的 探讨肾移植术后小肠梗阻的诊断和治疗。方法 收集和分析6例肾移植术后小肠梗阻的病例资料。结果 6例患出现肠梗阻症状的时间为肾移植术后0．5～46个月。4例在肾移植手术前后有腹部手术史。腹痛、腹胀和肛门停止排气、排便为主要临床表现。腹部X线明确诊断后，2例予禁食、胃肠减压等非手术治疗症状缓解；但其中1例缓解后发作急性排斥反应，予甲基强的松龙(MP)冲击治疗后好转。4例在非手术治疗无效后行手术治疗，分别行小肠粘连松解、粘连部分空肠切除术、端端吻合术和回肠部分切除术、端端吻合术，3例患肠梗阻症状消失，1例术后死于腹腔感染。结论早期诊断和正确及时的处理是改善肾移植术后小肠梗阻预后的关键。     

成人先天性肠系膜裂孔疝的诊断与外科治疗

目的 总结成人先天性肠系膜裂孔疝（ACMH）的诊治经验.方法 回顾性分析1975-2007年间行外科手术治疗的19例ACMH患者的临床资料.结果 本组患者中14例根据临床表现特点及腹部X线立位平片影像检查,术前均未明确诊断;5例根据腹部超声、选择性血管造影、腹部CT多平面重建检查,术前均得以明确诊断.本组患者均予以剖腹探查术,其中10例行肠绞窄坏死小肠切除、对端吻合术;6例疝入小肠复位后生机良好;3例因移动盲肠症并慢性阑尾炎急性发作、剖腹术中意外发现系膜裂孔.手术顺利,2例患者因肠坏死并脓毒性休克于围手术期死亡,1例患者因心肌梗塞死于术后第9年,余16例患者均长期存活.结论 腹部B超、选择性血管造影、腹部CT多平面重建是诊断ACMH的重要手段.早期手术和术中对肠管生机的判断是ACMH外科治疗的关键.     

肠系膜静脉血管血栓形成

8例肠系膜静脉血管血栓形成(MVT),术前无1例第一诊断是该病,均以肠梗阻、腹膜炎等剖腹探查。肠坏死从110cm至全部小肠。7例肠切除、肠吻合,其中3例行广泛肠切除(≥5/6小肠),1例仅作剖腹探查。术后4例抗凝治疗。1例血栓复发。5例治愈,3例分别死于毒血症、腹腔感染及休克。     

肾移植术后皮肤血管角质瘤一例

患者 ,男性 ,4 6岁。于 2 0 0 1年 1月 4日因慢性肾小球肾炎、慢性肾功能衰竭尿毒症期在我院行同种异体肾移植术。术后肾功能恢复良好 ,常规服用泼尼松、霉酚酸酯和环孢素三联免疫抑制剂抗排斥。患者分别于术后 2 0 0 1年 8月、2 0 0 2年 8月 ,发生急性排斥反应而返院 ,接受甲泼尼龙冲击治疗后肾功能恢复。半年前患者不慎烫伤右小腿内踝方 ,经治疗后伤口愈合。 5个月前因又发生移植肾急性排斥反应 ,再次使用甲泼尼龙冲击治疗。右小腿原来伤口处出现溃破且红肿 ,皮损迅速向四周蔓延并波及足、大腿 ,同时发现右腹股沟淋巴结肿大。分别取右内踝…     

Colon perforation after kidney transplantation.

Between 1962 and 1977 approximately 2% of Denver kidney transplant patients developed colon perforation. The single commonest cause was diverticulitis of the left colon (6/13 cases). In spite of drastic reduction or discontinuation of immunosuppression, only 5/13 patients survived for more than 90 days after operation. Analysis of this experience suggests that the high mortality rate associated with this complication can be reduced by early operation which removes the perforation from the peritoneal cavity (either exteriorization or resection) without primary intestinal reanastomosis. We believe that candidates for kidney transplantation with a history of previously symptomatic diverticulosis coli should have elective colon resection prior to transplantation. Any kidney transplant patient with lower abdominal signs should be investigated and treated aggressively.     

肝移植术后并发消化道穿孔六例报告

目的总结肝移植术后并发消化道穿孔的临床特点及诊疗体会。方法6例肝移植患者术后并发消化道穿孔,其中4例既往有腹部手术史。穿孔诊断时间在肝移植后7～12 d,确诊前2～4 d均有突发性腹部疼痛,但均能耐受,仅有1例腹痛较明显,上中腹压痛及反跳痛,其余5例腹肌不紧张,反跳痛不明显,6例均无明显的寒战及高热,5例的引流物细菌培养发现屎肠球菌感染,另1例未行引流物细菌培养。诊断明确后在全身麻醉下施行剖腹探查及穿孔修补术。结果3例(1例横结肠穿孔,1例胃壁、空肠穿孔,1例空肠憩室穿孔)穿孔直径较大,腹腔污染严重,手术过程中均出现感染性休克症状,分别于修补术后第2、9、33天死于多器官功能衰竭,另外3例(1例为回肠穿孔,1例为胃壁穿孔,1例为横结肠穿孔)的腹腔污染较轻,经穿孔修补术及营养支持治疗后痊愈。结论既往腹部手术史、医源性损伤及大剂量激素的应用,是导致肝移植后并发消化道穿孔的重要原因,而激素的应用使得患者的临床症状不明显,早期诊断、及时处理是治疗成功的关键。     

Tuberculous enteritis and peritonitis

In Turkey, diseases associated with Mycobacterium tuberculosis are common. Intestinal tuberculosis has generally been a complication of pulmonary tuberculosis, but recently there has been an increase in the frequency of intestinal tuberculosis without the pulmonary form. The authors present their experience over 8 years in 41 patients (aged 15 to 56 years) who underwent surgery for tuberculous enteritis (14), peritonitis (13), a combination of the two (5), genital tuberculosis and peritonitis (5) and tuberculous mesenteric lymphadenitis (4). Of these, 29 had no associated pulmonary tuberculosis. Eighteen of the 41 patients had complications of their disease-bowel obstruction in 13, intestinal perforation in 2, intestinal bleeding in 2 and enterocutaneous fistula in 1. The diagnosis was established at operation and by the appearance of caseating granuloma on histologic examination and isolation of the causative organism. Twenty-four patients required emergency surgery; 2 who had bowel perforation died. Operative procedures included laparotomy with biopsy (17), resection of intestine (10), division of adhesions (7), evacuation of mesenteric abscesses (4) and bypass (3). There were seven (17%) operative deaths. The authors recommend that noninvasive procedures be used for the diagnosis of intestinal tuberculosis, but if these fail, surgery is indicated.     

Recurrent complicated colon diverticulitis in renal transplanted patient

Colon perforation due to diverticulitis is a life-threatening complication in the postoperative course of kidney transplantation. In the immunocompromised patient a diagnosis of diverticulitis is difficult to make. We report a 53-year-old woman being kidney transplanted 14 years ago with known diverticulosis. She was admitted with acute severe pain in the lower left abdomen. Abdominal computed tomography (CT) scan indicated a diagnosis of intestinal abscess in the small pelvis. Laparotomy showed a covered sigma perforation with abscess located in the small pelvis (Hinchey-I). Because of the immunocompromised situation of the patient we performed a Hartmann procedure. Her postoperative course was uneventful. In a 6-month interval the intestinal continuity restoration was performed. Twelve days after discharge the patient was readmitted with reduced renal function and increased infection parameters. During physical examination the abdomen was tender. The patient complained of abdominal pain in the left upper abdomen and additional pain in the left shoulder. An antibiotic therapy using ciprofloxacin was already initiated owing to a urinary tract infection. An abdominal CT scan was performed and indicated an intestinal abscess in the left upper abdomen. Laparotomy showed an abscess involving transverse colon, distal jejunum, and proximal ileum (Hinchey-II). Segmental resection of the left colonic flexure, proximal jejunum, and ileum was performed. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. The present casuistry emphasizes that the immunocompromised patient can undergo diverticulitis twice, and that primary anastomosis is a feasible option for patients with localized peritonitis due to complicated diverticulitis.     

Jejunal perforation by a fish bone diagnosed by CT-Scan: report of two cases

The authors relate two cases of peritonitis secondary to jejunal perforation by a fish bone. Clinically, the first patient presented signs and symptoms of acute diverticulitis and the second had signs of duodenal perforation. In both cases, the diagnosis was made by the CT-scan revealing a linear radio-opaque object suggestive of a fish bone perforating the jejunum. At laparotomy of the first case, we found a perforation located above several loops of small bowel densely adhered to the nonabsorbable intra-abdominal mesh. Removal of the fish bone, suture of the jejunal perforation, washing and drainage of the abdominal cavity were performed. The mesh was removed and replaced by a polyglycolic acid mesh. In the second case, jejunal perforation occurred in an unaltered small bowel loop and a short intestinal resection was performed. The postoperative course was uneventful for both patients. These clinical cases allow us to discuss the several fish bone perforation site and our patients precipitating factors.     

Cytomegalovirus infection and colonic perforation in renal transplant patients

Cytomegalovirus (CMV) infection in immunocompromised patients is a major cause of morbidity and mortality. A well-documented manifestation of gastrointestinal CMV infection is gastrointestinal haemorrhage. In contrast, CMV-associated intestinal perforation has rarely been reported after transplantation, although it is well documented in AIDS patients. Three patients are reported who received their first cadaveric renal transplant in 1994 and subsequently developed CMV disease. During the course of their CMV illness, which was treated with ganciclovir, each presented with clinical suspicion of peritonitis and proceeded to laparotomy. All three were found to have sigmoid colon perforations with histological evidence of CMV infection. Following bowel resection and defunctioning, two patients made an uneventful recovery and have had the continuity of their bowel restored, but one died of overwhelming sepsis within hours of surgery. The explanation for the apparent clustering of this rare condition in transplant patients is uncertain.     

结肠腹膜内穿孔26例诊治体会

目的总结结肠腹膜内穿孔的诊治经验。方法回顾分析我院2005年1月至2015年10月收治的26例结肠破裂患者临床资料。结果 26例结肠破裂患者中,由于结肠肿瘤性穿孔9例、肠镜检查导致结肠穿孔6例、外伤性结肠穿孔2例、炎性肠病导致穿孔3例、粪性肠穿孔2例、自发性结肠穿孔2例、结肠憩室2例;以急性腹膜炎主要表现的患者为17例、以局限性腹膜炎者7例、以腹部炎性包块者2例;有慢性便秘病史17例、合并糖尿病、动脉硬化合并脑梗塞、冠心病、慢性咳嗽等内科基础病13例;术前摄腹部平片示膈下游离气体12例、通过泛影葡胺灌肠造影确诊4例、手术确诊10例;降结肠穿孔9例、乙状结肠穿孔6例、横结肠穿孔2例、升结肠穿孔8例、盲肠穿孔1例;腹腔穿刺阳性11例。术前误诊8例,包括误诊为上消化道穿孔6例,阑尾穿孔2例。所有患者均行手术治疗,治愈21例,死亡5例。结论结肠穿孔有时术前确诊不易,只要可疑且有手术指征,应及早手术。     

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目的 探讨针对争性肠系膜静脉血栓形成不同程度肠缺血病变的最佳手术治疗方式。方法 6例急腹症经影像学检查术前诊断为急性肠系膜静脉血栓形成。所有病人手术探查,依肠管不同缺血程度,对淤血性病变和坏死性病变各3例,分别实行肠系膜务栓除术和肠切除术,围手术期抗凝治疗。结果 3例肠切除者治愈;3例肠系膜静脉血栓切除者2例治愈,1例结肠受累者因结肠动力性肠阻、穿孔而再作右半结肠切除术治愈。随访8个月至6年无复发。结论 以血栓切除术和肠切除手术分别治疗急性肠系膜静脉血栓形成所致的肠淤血和肠坏死。并辅以抗凝治疗是提高生存率、降低病死率的合理而有效方案。     

Transverse Colonic Perforation in Renal Transplant Recipients During the Early Postoperative Period: A Case Series

There are very few cases of nondiverticulitis episodes of colonic perforation in the acute postoperative period following kidney transplantation described in the literature. Various nondiverticular causes of colonic perforations include ischemia, malignancy, cytomegalovirus (CMV) enterocolitis, and nonobstructive colonic dilatation. Immunosuppressive medication can contribute to colonic perforation, placing kidney recipients at risk for these complications. Since 2011, there have been 2 cases of transverse colonic perforation in the early postoperative period following renal transplantation at our institution. Both patients underwent urgent exploratory laparotomy with resection of perforated transverse colon and creation of a proximal colostomy. The aim of this study is to review the cases of colonic perforation following renal transplantation to gain a greater understanding of this rare occurrence. Despite the lack of a clear cause of perforation, it is imperative to have a high index of suspicion for colonic perforations in these immunocompromised patients to provide prompt surgical management and improved outcomes.     

Experience in surgery of diastatic ruptures of the colon

An experience with treatment of 58 patients operated upon for carcinoma of the colon complicated by acute intestinal obstruction and diastatic perforation has been analyzed, 13 patients had incomplete diastatic ruptures (tears) of the colon. In 23 patients the IV stage of the tumor process (remote metastases) were found and the other 35 patients had the III stage. In early terms after operation 37 (63.8%) patients out of 58 patients died. Lethality after incomplete diastatic ruptures of the colon made up 53.8%, and after diastatic perforation - 67.7%. The main cause of lethal outcomes was polyorganic insufficiency against the background of intoxication of mixed genesis (cancerous + endogenous). Ablation of colonic tumor is justified in cases of local peritonitis. Hemicolectomy with ablation of the diastatic rupture is indicated for the right-side localization of the tumor Obstructive resection is expedient for left-side localization of the tumor and rupture, the diastatic ruptures should be sutured or extraperitonized with application of cecostoma. Subtotal colectomy is possible for left-side localization of the tumor and diastatic ruptures of the right half of the colon. Symptomatic operations are indicated for canceromatosis of the peritoneum, terminal phase of peritonitis or infectious-toxic shock.