带系膜去黏膜小肠片修复全层腹壁缺损可行性的初步研究

目的 为克服人工材料在腹壁缺损修复中的缺点,设计以动物自体带系膜去黏膜小肠片修复腹壁缺损的实验研究.方法 健康普通雌性家猪25头.取20头行一般观察,随机分为空肠组和回肠组,每组10头.切除10cm×7cm皮肤至腹膜的腹壁组织制备全层腹壁缺损模型,分别以自体带系膜去黏膜空肠、回肠片修复腹壁缺损,再行一期断层皮片移植覆盖.术后30d观察两组动物一般情况,并在体检测修复腹壁的抗张强度.另5头同法制备全层腹壁缺损模型,以中段小肠的带系膜去黏膜小肠片修复腹壁缺损,再行一期断层皮片移植覆盖.术后30d整块切取修复腹壁,观察修复腹壁缺损前后带系膜去黏膜小肠片、断层皮片及修复腹壁的组织学变化,测量各部分组织的相对厚度.结果 动物手术均成功.带系膜去黏膜空肠、回肠片与剩余腹壁边缘均Ⅰ期愈合,无感染及裂开.术后无肠梗阻及肠吻合口瘘发生.断层皮片移植均成活,移植皮片与缺损腹壁边缘缝合处均有可自行愈合的局灶性坏死.空肠组2头动物及回肠组1头动物出现移植皮片引流戳孔处肠黏膜组织再生,经再次刮除黏膜组织并将移植皮片戳孔缝合后愈合.自由活动状态下腹壁外观正常,无复发性疝形成.在体检测修复腹壁抗疝形成的抗张强度空肠组和回肠组分别为(24.8±3.4)kPa和(21.3±2.8)kPa,二者差异有统计学意义(P<0.01),两组修复腹壁均可承受40kPa腹腔内压力.修复腹壁缺损前,带系膜去黏膜小肠片表面有少量黏膜层组织残留,修复腹壁缺损后30d,修复腹壁各部分组织均有明显增生、增厚,原去黏膜小肠片表面残留的黏膜层组织完全消失.结论 带系膜去黏膜小肠片修复全层腹壁缺损操作简便,成功率高,无重要并发症,修复效果好,修复腹壁抗张强度高,无需使用假体材料,具有较高的可行性.     

右半结肠癌切除合并十二指肠缺损的处理

目的探讨右半结肠癌切除十二指肠缺损的外科处理方法。方法1990年1月~2004年1月收治右半结肠癌切除合并十二指肠缺损10例,根据缺损的程度总结为局部小缺损、巨大缺损和内瘘型缺损三种类型。采用局部切除间断缝合十二指肠局部小缺损4例;带蒂末端回肠补片修补十二指肠巨大缺损2例;内瘘型的4例分别行局部修补、十二指肠引流1例,带蒂胃壁浆肌层补片修补、十二指肠造口1例,右半结肠切除后加行胰十二指肠切除2例。结果内瘘型缺损中,行带蒂胃壁浆肌层补片修补、十二指肠造口的1例术后并发胃梗阻,2周后加作胃空肠吻合后恢复出院,行十二指肠引流的1例术后出现十二指肠漏,后因病情恶化出院,其余8例无围手术期并发症,顺利恢复。结论根据右半结肠癌切除十二指肠缺损的不同特点,积极合理的手术抉择和外科处理将有助于改善预后和减少手术风险。     

右半结肠肿瘤侵犯十二指肠的外科治疗

目的探讨右半结肠肿瘤侵犯十二指肠的外科处理方法及疗效。方法右半结肠肿瘤侵犯十二指肠患者26例,根据肿瘤浸润十二指肠程度,行十二指肠局部切除后直接修补6例、带蒂补片十二指肠浆肌层修补7例、扩大胰头十二指肠联合切除5例和姑息性手术8例。结果 6例十二指肠局部切除后直接修补者,1例术后发生修补处狭窄;7例带蒂补片修补十二指肠缺损者中,6例采用带蒂回肠瓣修补,1例采用胃浆肌层瓣修补,其中1例带蒂回肠瓣修补患者术后发生十二指肠修补处漏,经充分引流后痊愈,1例胃浆肌层瓣修补患者术后发生胃梗阻,2周后加作胃空肠吻合后康复;5例扩大胰头十二指肠联合切除者,1例围手术期因呼吸衰竭死亡;8例姑息性手术包括4例回肠横结肠侧侧吻合和4例十二指肠浸润旷置的结肠姑息性切除。结论合理的术式选择和积极的外科处理将有助于改善结肠肿瘤侵犯十二指肠患者的症状和预后。     

带蒂全层回肠片修补十二指肠局部缺损

2006年8月—2009年10月我科在手术中用带蒂全层回肠片修补十二指肠局部缺损6例,总结报道如下。     

带蒂空肠片或段修复十二指肠大缺损

十二指肠的大部分紧贴在后腹壁，比较固定、无系膜、降部有胰胆管开口、血供较其他小肠差，当有缺损、特别是大缺损时，直接修补和愈合均较困难。我院自1991年1月至2003年12月，采用带蒂空肠片或段修复十二指肠大缺损7例。现报告如下。     

带蒂末端回肠瓣修补右半结肠癌切除术后的十二指肠缺损

目的 探讨右半结肠癌切除术所致十二指肠缺损的修补方法.方法 对5例右半结肠癌根治术后遗留的十二指肠巨大缺损采用了带蒂末端回肠瓣修补,附加减压、引流术.结果 5例均一期恢复,无围手术期死亡,术后未发生十二指肠瘘和十二指肠狭窄,术后上消化道造影显示十二指肠蠕动和排空正常.结论 带蒂末端回肠瓣修补右半结肠癌术后的十二指肠巨大缺损安全可靠.     

胃回肠瓣在十二指肠修复中的应用二例

十二指肠因溃疡或肿瘤浸润局部切除后，较大缺损的修补是外科手术上比较难以处理的问题。我们应用带血管蒂胃大弯胃瓣修补十二指肠降部溃疡切除处；回肠瓣修补结肠癌浸润十二指肠切除处，取得较好效果。     

外伤性十二指肠损伤治疗对策探讨

外伤性十二指肠损伤的治疗仍是外科治疗中棘手的问题。本文回顾性分析24例不同部位、不同程度的外伤性十二指肠损伤的治疗，其中包括：单纯十二指肠修补加胃管行十二指肠减压；单纯十二指肠修补加十二指肠造口术；十二指肠端端吻合术加胆总管造口术；带血管蒂空肠片转位修补十二指肠缺损；十二指肠修补加憩室化。除1例因急性肾功能衰竭，ARDS死亡外，其余23例均痊愈，全组无十二指肠瘘发生。认为单纯十二指肠修补加十二指肠减压对大多数外伤性十二指肠损伤来说，是一个首选的术式，只有少数患者才有行更为复杂的手术的必要。     

胆道修复手术在Mirizzi综合征大范围胆管缺损中的应用

目的 探讨修复手术在伴有大范围胆管缺损Mirizzi综合征中的应用.方法 回顾分析2008年7月至2011年11月作者所在单位采用带血管蒂胃瓣修补治疗的3例伴有大范围胆管缺损者的Mirizzi综合征患者的临床资料.检索国内2001年1月至2011年1月,10年间有关修复方法治疗Mirizzi综合征的报道5篇,对检出的159例病例资料按Csendes分类,对其外科治疗方法进行统计分析.结果 3例胃瓣修复病例中,CsendesⅢ型2例,Ⅳ型1例.手术过程顺利.术后分别随访2年、3年、1年,平均随访2.5年,无胆管狭窄及胆管炎症等并发症发生.国内文献检索159例中,CsendesⅠ型93例,采用单纯胆囊切除58例,胆囊大部切除+剩余黏膜电凝消融35例;Ⅱ型40例,瘘口直接修补29例,带血管蒂胆囊瓣修补9例,脐静脉瓣修补2例;Ⅲ型20例,带血管蒂胆囊瓣修补9例,脐静脉瓣修补1例,带血管蒂胃瓣修补3例,胆管空肠Roux -en-Y吻合7例:Ⅳ型5例,均采用胆管空肠Roux-en-Y吻合,术后胆瘘1例,消化道出血1例,胆管狭窄1例,均治愈.结论 对于存在胆囊胆管内瘘的Mirizzi综合征患者,应根据瘘口大小及修复材料,进行个体化的修复治疗.对于伴有较大缺损的胆管损伤,采用带血管蒂胃瓣修复胆道疗效确切,宜作为首选.     

带蒂全层小肠段修补十二指肠巨大缺损(附7例报告)

目的 探讨十二指肠巨大缺损外科处理的有效方法,以提高手术效果,方法 近１０年来对十二指肠外伤及右半结肠癌根治造成的７例十二指肠巨大缺损,采用了带蒂全层小肠片修补附加减压,引流手术。结果 ７例病人术后均一期愈合,未发生十二指肠瘘,并恢复正常饮食。钡餐检查示十二指肠蠕动,排空正常。结论 不论是外伤还是腹部手术所致的十二指肠巨大缺损,本术式可推荐为首选方法。     

十二指肠损伤35例外科治疗体会

目的：探讨十二指肠损伤的外科治疗手术方式及效果。方法：回顾分析1998年3月—2008年3月手术治疗的35例十二指肠损伤患者的临床资料。结果：十二指肠损伤术前诊断率低,为17.1%（6/35）;合并其他脏器损伤率高,占71.4%（25/35）。手术方式：单纯修补造瘘10例,端端吻合或与空肠侧侧吻合3例,十二指肠空肠Roux-en-Y吻合3例,浆膜覆盖及带蒂空肠片移植修补8例,十二指肠憩室化手术8例,胰十二指肠切除3例。十二肠损伤术后并发症发生率及死亡率较高,本组死亡5例（14.3%）。结论：十二指肠损伤的外科处理关键应根据其损伤情况综合判断,选择合理术式及治疗策略。     

Stromal tumors of the small intestine. Retrospective analysis of 9 cases surgically treated

The authors report on their experience with 9 patients with small bowel stromal tumours who underwent surgical treatment over the period 1974-2001. Seven were males and 2 females, with an average age of 63.1 years (range: 49-72 years). Histologically, 4 tumours showed evidence of differentiation towards smooth muscle elements (1 benign and 3 malignant), 4 towards neural elements (all malignant) and 1 lacked differentiation towards either cell type. Five tumours were located in the ileum, 3 in the jejunum and 1 in the duodenum. The main symptoms were abdominal pain and an abdominal mass, and the most sensitive diagnostic technique was abdominal CT scan. In the 8 jejunal or ileal stromal tumours we performed a typical intestinal resection, while undifferentiated duodenal stromal tumours were managed by pancreaticoduodenectomy. The diagnosis was only histological. There was no operative mortality, while 2 postoperative complications (1 pancreatic fistula and 1 myocardial infarction) occurred. The patient with jejunal benign muscular stromal tumour is still alive and in good health 73 months after the operation. Of the 3 patients with malignant muscular ileal stroma tumours, 1 is alive and free from disease 63 months after the operation, while the other 2 died of metastatic disease 39 and 29 months after surgery. Of the 4 patients with malignant neural stromal tumours (2 jejunal and 2 ileal) 1 with jejunal and 1 with ileal tumour were lost to follow-up, while 1 is still alive and in good health 101 months postoperatively; the 4th patient, with jejunal disease, developed liver metastasis 14 months after small bowel resection and died 12 months later. The patient with undifferentiated duodenal stromal tumour died of liver metastases 38 months after pancreaticoduodenectomy. Small bowel stromal tumours are more often than not malignant. The most frequent symptoms are abdominal pain and a palpable mass, but no specific signs have been detected. Abdominal CT scan is the most sensitive diagnostic technique in the evaluation of the location, size, invasion of adjacent organs and metastases. The treatment must be intestinal resection, and prognostic prediction on the basis of histological findings is difficult.     

Beneficial effects of oral insulin on intestinal recovery following ischemia-reperfusion injury in rat

BACKGROUND: It has been reported that oral insulin has a trophic effect on intestinal mucosa, but the precise mechanism of its action is still unclear. The purpose of the present study was to investigate the effect of oral insulin on ischemia-reperfusion (IR) intestinal mucosal injury in rat. MATERIALS AND METHODS: Male Sprague-Dawley rats underwent laparotomy (Sham) or IR-intestinal damage by clamping both the superior mesenteric artery and the portal vein for 30 min followed by 24 h reperfusion. IR-INS rats were treated with oral insulin given in drinking water (1U/ml) 48 h before and after IR. Intestinal structural changes, enterocyte proliferation, and enterocyte apoptosis were determined 24 h after IR. Park's score was used for the quantitative assessment of histological change. A non-parametric Kruskal-Wallis ANOVA test was used for statistical analysis with P less than 0.05 considered statistically significant. RESULTS: IR-injury resulted in a significant decrease in bowel weight in jejunum, mucosal weight in jejunum and ileum, villus height in jejunum and ileum, cell proliferation index in jejunum, and ileum compared to sham animals. IR-INS animals demonstrated greater duodenal and jejunal bowel weight, duodenal, jejunal and ileal mucosal weight, jejunal mucosal DNA, jejunal and ileal mucosal protein, jejunal and ileal villus height and crypt depth, jejunal and ileal proliferation index compared to IR-animals. Oral insulin administration induced also a significant decrease in apoptotic index in ileum (1.2 +/- 0.4 versus 2.8 +/- 0.7 TUNEL positive cells/10 villi, P < 0.05) compared to IR-untreated animals. CONCLUSIONS: Oral insulin improves intestinal recovery after IR- injury in rat.     

Acute malignant intestinal obstruction accompanied by synchronous multifocal intestinal cancer in Peutz–Jeghers syndrome: report of a case

Acute mechanical intestinal obstruction is one of the most common modes of presentation in patients with Peutz–Jeghers syndrome (PJS). This report presents a case of PJS with malignant acute jejunal obstruction accompanied by synchronous foci of duodenal, jejunal, and ileal cancer originated from hamartomatous polyps. The follow-up endoscopic findings of the patient also revealed severe polyposis of the entire gastrointestinal tract, including the stomach and colon, in addition to the small intestine. Very few cases of multifocal synchronous small intestinal cancer in PJS patients have been reported in the previous literature.     

Leptin increases small intestinal response to cholecystokinin in leptin-deficient obese mice

INTRODUCTION: Leptin receptors are present in the jejunum, ileum, and vagal neurons. Leptin increases duodenal secretion of cholecystokinin (CCK) and acts with CCK on vagal mechanoreceptors in the regulation of small intestinal motility. We have demonstrated that leptin-deficient (Lepob) obese mice have increased jejunal and normal ileal responses to CCK. Therefore, we hypothesized that leptin administration alters small intestinal motility observed in leptin-deficient obese mice. MATERIALS AND METHODS: Twelve-week-old female leptin-deficient (Lepob) obese mice received either saline (n=12) or 5 microg/g leptin ip (n=12) injections daily. After 4 weeks, jejunal and ileal segments were harvested, mounted in an organ bath, and reacted with acetylcholine (ACh, 10(-5)M) and CCK (10(-8,-7,-6)M). Data were expressed as N/cm2 and compared by ANOVA and Student's t test. RESULTS: The average body weights in the leptin-treated group were significantly decreased compared to those of the saline-treated group (34 versus 49 g, P <0.01). Jejunal responses to ACh within each group were significantly decreased (P <0.05) when compared to ileal responses. No significant differences in responses to ACh were observed between groups. Jejunal responses to 10(-7,-6)M CCK in the leptin-treated group were significantly greater than those in the saline-treated group. Ileal responses in the leptin group were similarly increased at all CCK concentrations. CONCLUSIONS: These data suggest that daily leptin administration for 4 weeks in leptin-deficient (Lepob) obese mice increases jejunal and ileal responses to CCK and does not alter responses to ACh. Therefore, we conclude that regulation of small intestinal motility may be influenced by synergistic action of cholecystokinin and leptin.     

Reparation of the parcel defect of duodenum with pediculated jejunal patch by laparoscopy. Experimental study

The objectives were to evaluate the intraoperative aspects of the repairing by laparoscopy of a parcel duodenal defect, using a pediculated jejunal patch and to emphasize the intraoperative complications. The research has been made on 6 pigs. The pediculated jejunal patch was been achieved by excluding from the intestinal tract of a 2-4 cm segment with nutritional pedicle and the cut of intestinal tube on the anti-mesenteric border. The suture of the duodenal defect has been accomplished in one layer manner. The animals were followed 2 hours, under anesthesia. There was not intraoperative mortality, wether conversion to laparotomy. There was been a good cover of the defect, without any leakage. We did not notice intraperitoneal blood or bile. The duodenoplasty with pediculated jejunal patch is effective. The laparoscopic accomplishing of this procedure has no complications and it can be applied in clinical activity for selected cases.     

眼轮匝肌蒂颞部皮瓣修复颜面部软组织缺损

目的探讨用眼轮匝肌蒂颞部岛状皮瓣修复颜面部、鼻部及下睑小面积软组织缺损的方法及效果.方法1994年～1999年设计以眼轮匝肌为蒂,以同侧颞区无毛发区为供区,皮瓣最大范围3cm×5cm.皮瓣带蒂岛状移位至颜面部创面,共修复下睑外翻、鼻部、面部瘢痕及色素痣切除后的组织缺损12例.结果术后12例皮瓣完全成活,随访2年,疗效良好.皮瓣宽在3cm以下时供区均可直接缝合,术后较少遗留瘢痕及继发畸形.结论眼轮匝肌是一个多元血管供血的肌肉,以其眶部肌肉为蒂的同侧颞部无毛区岛状小皮瓣是修复颜面部小面积软组织缺损的一个可行方法.但颜面部组织缺损面积较大时,供区缝合困难,应慎用.     

Experimental reconstruction of the trachea with free jejunal graft

To evaluate experimentally the usefulness of the jejunum in the correction of extensive tracheal defect, circumferential tracheal defect was surgically created in 31 mongrel dogs and primarily reconstructed with microsurgical free tissue transfer of autogenous jejunal segment. A silicone T tube was inserted to maintain the lumen of the grafted jejunal segment. First, defect of 7 cervical tracheal rings was repaired with untreated 5 cm free jejunal segment in 12 dogs (group 1). Next, a pilot experiment to examine the quantity of intestinal juices from jejunal segments revealed that abrasion and cauterization of the mucosal surface decreased the secretion of intestinal juices, so defect of 7 cervical tracheal rings was repaired with 5 cm free jejunal segment the surface of whose mucosa was abraded and cauterized in 11 dogs (group 2). In all the dogs except two, primary healing was accomplished without air leakage or infection, and gross pathological examination of the trachea and graft revealed no evidence of disruption, infection or granulation. In group 1, 6 of the 12 dogs died of pneumonia or air way obstruction caused by intestinal juices from free jejunal segment within 20 days after the operation. On the other hand, only one of the 11 dogs died of pneumonia at 9 days in group 2. One of the dogs died of air way obstruction caused by mucus at 3 months. Three dogs died of filariasis at 4 weeks, 3 and 7 months, and 5 dogs were sacrificed at 2, 4, 8 weeks and 3 months. Microscopic examination of the graft demonstrated thin jejunal mucosa. The anastomosis was already covered with epithelium by the end of 2 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)