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目的 总结6例短肠综合征病人肠管倒置手术失败的教训，强调合理选择手术适应证的重要性和必要性，提出短肠综合征合理的治疗策略，方法 回顾性分析6例短肠综合征病人，均在外院接受肠管倒置手术，除1例为结肠倒置外，其余均为小肠倒置，倒置肠管长度从10～50cm不等，5例小肠倒置手术均在广泛肠切除的同时进行，术后1例出现吻合口瘘，4例出现肠梗阻。结果 1例病人因肝功能衰竭于术后5年死亡，1例病人放弃治疗，1例行肠瘘及倒置小肠切除治愈，2例行倒置肠管切除治愈，1例行倒置肠管复位治愈。治愈病人依靠普通饮食和部分肠内营养支持维持正常营养状况。结论 短肠综合征病人应首选肠康复治疗和小肠移植。只有极少数病人适宜进行肠倒置手术，手术时倒置肠管不应超过10cm，手术时机应在广泛肠切除2年以后进行．手术时应注意倒置肠管的血液供应，避免肠缺血。     

腹腔镜下胆总管囊肿的手术治疗

目的 探讨在腹腔镜下胆总管囊肿切除、空肠切断及肠肠吻合、胆总管空肠Roux-en-Y吻合的可行性、安全性、技术特点及优势.方法 自2008年6月至2013年2月期间,对24例胆管囊肿行腹腔镜下病变胆管切除、空肠切断及肠肠吻合、胆总管空肠Roux-en-Y吻合.结果 24例患者均顺利完成手术.手术时间168 ～216 min,平均（168±24） min.术中出血40～ 120 ml,平均（60±33）ml.术后出现胆漏1例,无肠漏、无出血等.结论 腹腔镜下病变胆管切除、肠管切断及肠肠吻合、胆总管空肠Roux-en-Y吻合是安全、可行的,与开腹手术相比,有明显优势.     

Ghrelin受体表达对大鼠胃肠手术后小肠动力不足的影响

目的探讨ghrelin受体变化对大鼠术后小肠动力不足的影响。方法采用体外肌条实验观察在卡巴胆碱（10nmol／L）存在和缺乏时,不同浓度的ghrelin（0、0．01、0．1、0．5、1．0μmol／L）对肌条收缩力的影响。采用免疫组织化学方法和Westemblot技术检测行端侧肠吻合的实验组大鼠和行假手术的对照组大鼠小肠肌层ghrelin受体（GHS—R1a）的表达情况。结果在体外,卡巴胆碱存在时,ghrelin能够增强小肠平滑肌肌条的收缩,不同浓度的ghrelin（0．1、0．5、1．0la,mol／L）引起的收缩力差异具有统计学意义[（223±18）％、（245±22）％、（264±25）％,P〈0．01]。免疫组化染色显示．GHS—R1a主要分布于小肠肌层．实验组大鼠小肠环形肌和纵行肌中GHS—R1a表达均弱于对照组。Westernblot结果显示,实验组小肠ghrelin受体表达量（0．51±0．02）明显低于对照组（0．71±0．01,P〈0．01）。结论术后小肠肌层ghrelin受体表达下调所导致的ghrelin效应减弱可能参与术后小肠动力不足的发生。     

袖带胃减容手术

袖带胃减容术起源于胆胰转流手术（biliopancreatic diversion，BPD）的改良术式，Scopinaro等首先报道BPD手术，但BPD存在腹泻严重、吻合口溃疡、营养不良等缺点。1993年，Marceau等在BPD基础上设计了胆胰转流合并十二指肠开关术（biliopancreatic diversion with duodenal switch，BPD—DS）：行胃袖带切除，保留幽门，在十二指肠处切断，将十二指肠近端与距回盲瓣上方250cm切断的小肠的远端吻合，十二指肠远端用吻合器闭合，切断的小肠近端则与距回盲瓣上方100cm处的回肠作端侧吻合，形成100cm共同通道。     

短肠综合征康复治疗的实验与临床研究

目的 研究生长激素对大部小肠切除后残存小肠粘膜增殖活性的影响;评价短肠康复治疗的临床疗效。方法 利用病理图象分析、流式细胞分析、免疫组化法和ＲＴ－ＰＣＲ法观察比较对照组（假手术组）、短肠组（８０％小肠切除）和生长激素组（８０％小肠切除加１Ｕ．ｋｇ＾－１．ｄ＾－１生长激素皮下注射２８ｄ）ＳＤ大鼠小肠粘膜的增殖状况。观察肠康复治疗（肌注生长激素８～１２Ｕ．ｄ＾－１加静脉滴注加谷氨酰胺０．６ｇ．ｋｇ＾－     

先天性小肠闭锁25例诊治体会

目的:探讨先天性小肠闭锁的诊断及治疗。方法:对25例先天性小肠闭锁的临床资料进行回顾性总结。结果:全组病人均以呕吐为首发症状,2例生后排出少量胎粪。成活18例,治愈率72％;肠造瘘疗效差,单层粘膜外缝合肠管斜行吻合术治愈率达91.7％;肠切除肠吻合术治愈率60％。结论:肠闭锁患者应尽量切除闭锁盲端改变明显的肠管,单层粘膜外缝合肠管斜形吻合术尤适用于先天性小肠闭锁手术。     

大鼠异位节段小肠移植模型的建立

目的建立大鼠异位节段小肠移植模型。方法对100只雄性SD大鼠施行50次异位节段小肠移植，采用肠系膜上动脉-腹主动脉端侧吻合以及门静脉-左肾静脉套管吻合重建供肠血管，远端肠管腹壁造瘘。结果预实验阶段移植25只，存活3只，成功率12％；正式实验阶段25次手术，成功21次，成功率84％；供体手术时间（60±5）min，移植肠修整时间（15±5）min，受体手术时间（100±10）min。结论大鼠小肠移植中注重手术操作中的细节问题是建立稳定模型的关键。     

小肠重复畸形二例并文献复习

例1：女患，14岁。主因“便血5d”入院。查体：轻度贫血貌，心肺阴性，腹部无阳性体征。辅助检查：腹部B超、纤维结肠镜未发现异常，^99Tc^m扫描见有异位胃牯膜，考虑肠重复畸形。于2004年11月20日在硬膜外麻醉下剖腹探查，距回盲部18．0cm处见两条小肠共同开口于回肠。重复肠管长约30．0cm。重复回肠近端盲端，远端开口于回肠，正常回肠到屈氏韧带未见异常。行重复肠管及系膜连同部分正常回肠切除，回肠端端吻合。病理检查：肠重复（回肠），小肠慢性溃疡，系膜淋巴结反应性增生。病人康复出院，随访半年无不适。     

直肠低位吻合辅助器的应用

最近我们设计了直肠低位吻合辅助器 ,对距肛门 4cm以上的中低位直肠癌采用了一种新的保肛手术获得成功 ,并取得良好的近期效果。该术式使直肠超低位吻合变得简单容易 ,明显降低了手术难度。适用于低位直肠结肠吻合以及结肠肛管吻合和回肠肛管吻合。病人取截石位 ,手术按Dixon术要求进行。在距肿瘤上方 10cm以上处切断乙状结肠 ,同时保证将肿瘤和有侵犯及转移的肠管和系膜完全切除。手术中尽可能多保留一些乙状结肠 ,以保证其有足够长度从肛门拉出吻合。肿瘤下切缘要保证 >3cm。如肿瘤至盆底已无 3cm间距 ,可在肿瘤下 1～ 2cm切断直肠 ,待肠…     

医源性回肠末端坏死2例教训分析

例1.女,7岁。于1979年12月5日以肠梗阻手术。术中见回肠顺时针扭转480°。复位后发现距回盲部15cm处有一段5cm长的肠管发黑塌陷,肠管边缘动脉搏动消失。V形切断肠系膜后切除坏死肠管端端吻合。术后第7天患儿出现持续性腹痛,以右下腹为重,并有压痛、反跳痛。腹腔穿刺抽出含肠内容物液     

Effect of sex and sex hormones on structural intestinal adaptation after massive small bowel resection in rats

Purpose

The gonadal steroids play a major role in the regulation of many functions. The purpose of the current study was to evaluate the effect of sex and sex hormones on intestinal adaptation in a rat model of short bowel syndrome (SBS).

Methods

In the first experiment, male and female Sprague-Dawley rats underwent bowel transection and re-anastomosis (sham group) or 75% small bowel resection and anastomosis (SBS group). Relative changes in parameters of intestinal adaptation (overall bowel and mucosal weight, mucosal DNA and protein, villus height, and crypt depth) were measured on day 15 and were compared with respect to sex. In the second experiment, male rats were divided into 4 experimental groups: SBS rats, SBS castrated rats, SBS castrated rats treated with testosterone, and SBS castrated rats treated with estradiol. Parameters of intestinal adaptation were compared with respect to hormonal treatment. Statistical significance was determined by Student's t test and analysis of variance with P < .05 considered significant.

Results

Sex had minimal effects on intestinal adaptation. Both male and female rats showed a comparable increase in all parameters of intestinal adaptation. In the second experiment, castration led to significant decrease in bowel and mucosal weight, mucosal DNA and protein in both jejunum and ileum compared with SBS animals. Castrated rats also had lower jejunal villus height and crypt depth compared with SBS animals. Testosterone attenuated this negative effect of castration on bowel regrowth. Rats treated with testosterone showed a significant increase in bowel and mucosal weight, mucosal protein in both jejunum and ileum, mucosal DNA, villus height, and crypt depth in jejunum compared with castrated nontreated animals. Treatment with estradiol after resection and castration had minimal effect on bowel regrowth.

Conclusions

Bowel regrowth after massive small bowel resection is not sex-related. Depletion of androgens by castration inhibited intestinal adaptation. Testosterone has shown a strong stimulating effect on bowel regrowth.     

可分解吻合环和手工缝合在肠道吻合中的应用对照研究

目的 比较可分解吻合环（BAR）与常规手工缝合在肠道吻合手术中的应用价值。方法 对我院2001年12月至2007年12月收治行肠切除并吻和180例病例采用两种手术方法并分为两组,其中吻合环组（BAR组）92例,手工缝合组88例。术后分别记录肠道功能恢复时间,与吻合口有关的并发症发生等情况。结果 BAR组死亡1例,但与手术无关。BAR组有1例发生术后吻合口瘘,手工缝合组2例,BAR组发生不完全性吻合口梗阻7例。手工缝合组2例,两组间有显著性差异（P〈0．05）。术后肠道功能恢复时间分别为BAR组27．2±5．6h,手工缝合组49．6±8．7h,两组间存在显著性差异（P〈0．01）。吻合口炎症发生情况BAR组1例,手工缝合组11例。两组间有显著性差异（P〈0．01）。结论 BAR是一种安全有效,可标准化的肠道吻合方法,特别是对急诊的高危病例。     

改良胆肠襻式吻合与Roux-en-Y吻合治疗胆道梗阻的临床对比研究

目的:比较胆道梗阻性疾病胆肠吻合应用改良胆肠襻式吻合术式和Roux-en-Y吻合术式的临床疗效。方法:回顾性分析72例行胆肠吻合术患者的临床资料,其中行改良胆肠襻式吻合36例(改良组),行胆肠Roux-en-Y吻合术36例(对照组)。比较两组患者吻合手术时间、肠鸣音出现、肛门排气及住院时间,观察胆汁漏发生、总胆红素下降指标、胆肠吻合口狭窄、胆汁反流情况。结果:改良组吻合手术时间较对照组明显缩短(0.9±0.4 h vs 1.4±0.6 h,P<0.05);术后肠鸣音出现时间较对照组早(2.3±4.0h vs 60.2±5.2 h,P<0.05),肛门排气时间较对照组提前(70.2±5.3 h vs 88.1±6.5 h,P<0.05),住院时间较对照组少(10.0±1.9 d vs 12.0±3.0 d,P<0.05)。术后对照组发生1例胆汁漏(5.6%);术后2周总胆红素下降指标>50%比率,改良组优于对照组(91.7%vs 83.3%);胆肠吻合口狭窄情况改良组优于对照组(2.8%vs 5.6%);术后胆汁反流情况改良组优于对照组(2.8%vs 8.3%)。结论:改良胆肠襻式吻合术较传统胆肠Roux-en-Y吻合术,能缩短手术时间、肠道功能恢复快、改善术后肝功能,术后胆汁反流发生率低、手术操作简单方便,尤其适用于基层县级医院,但仍存在捆扎肠襻再通可能,需进一步改进。     

生长因子及其在短肠综合征中的应用

目的探讨生长因子促进大量肠切除后肠道代偿的作用与机制,并了解其在短肠综合征营养支持治疗中的研究进展。方法对介绍生长因子促进肠切除后肠道代偿以及其在短肠综合征患者的应用的有关文献进行综述。结果不同种类的生长因子对促进肠切除后肠道代偿产生着不同的效应,可根据短肠综合征患者的具体情况合理选择外源性生长因子,以缩短残留小肠代偿时间,改善患者的营养状况。结论生长因子能够在一定意义上促进肠切除后肠道代偿,但不同种类的生长因子有各自的作用效应,将对短肠综合征患者尽早摆脱完全肠外营养有帮助,但仍需进一步的研究。     

结肠成型袋对改善中低位直肠癌术后排便功能的作用

目的：探讨结肠成型袋对改善中低位直肠癌术后排便功能的作用。方法：将62例中下段直肠癌患者根据消化道重建方法分为两组,32例行传统的结肠断端与直肠肛管直接端端吻合（CAA组）,30例断端结肠先行结肠成型术制成结肠贮袋再与直肠肛管行端端吻合（TCP组）。分别于术后1、3、6、9个月和1年、1年半对排便功能进行评估,比较两组的手术并发症和排便功能指标。结果：CAA组和TCP组平均大便次数：术后6个月分别为5次和2次（P〈0.001）,术后1年分别为3次和1次（P〈0.05）,术后1年半均为2次（P〉0.05）。TCP组定性排便控制能力近期优于CAA组。结论：中下段直肠癌低位前切除结肠成型术后直肠肛管吻合不增加手术并发症,在术后第1年内有明显改善排便功能的作用。     

Intestinal adaptation in short bowel syndrome

Regaining enteral autonomy after extensive small bowel resection is dependent on intestinal adaptation. This adaptational process is characterized by hyperplastic growth of the remaining gut, which is accompanied by both an increase of cell division at the level of the crypt cells and by an increased rate of programmed cell death (apoptosis). Apart from the absorptive function, the small bowel also has a barrier function and plays an important role in interorgan metabolism. Also, these functions are greatly affected by a massive intestinal resection and subsequent recovery by intestinal adaptation. This review aims to give an overview of the debilitating effects of massive intestinal resection on gut function and subsequently discusses intestinal adaptation and possible factors stimulating adaptation.     

Effect of transforming growth factor-alpha on intestinal adaptation in a rat model of short bowel syndrome

OBJECTIVE: TGF-alpha has recently been shown to stimulate enterocyte proliferation. In the present study we investigated the effect of TGF-alpha on enterocyte proliferation and loss via apoptosis and its effects on intestinal adaptation in a rat following massive bowel resection. METHODS: Male Sprague-Dawley rats underwent bowel transection and reanastomosis (sham group) or 75% small bowel resection and anastomosis (SBS group) and were treated with intraperitoneal TGF-alpha (75 microg/kg) from the ninth postoperative day (SBS-TGF-alpha group). Parameters of intestinal adaptation (overall bowel and mucosal weight, mucosal DNA and protein, villus height, and crypt depth), enterocyte proliferation, and apoptosis were determined on day 15. Statistical significance was determined by ANOVA with a P < 0.05 considered significant. RESULTS: SBS-TGF-alpha rats demonstrated a significant increase (vs SBS) in duodenal, jejunal, and ileal overall bowel and mucosal weights; ileal mucosal DNA and protein; and jejunal and ileal villus height. SBS-TGF-alpha rats also showed an increased cell proliferation index in jejunum (704 +/- 43 vs 499 +/- 63 BrdU-positive cells/10 crypts, P < 0.05) and ileum (715 +/- 84 vs 529 +/- 40 BrdU-positive cells/10 crypts, P < 0.05) and decreased apoptotic index in ileum (8.7 +/- 1.1 vs 21.8 +/- 3.2 apoptotic cells/1,000 villus cells, P < 0.05) compared to SBS animals. CONCLUSIONS: In a rat model of SBS, TGF-alpha enhances intestinal adaptation. Possible mechanisms may include increased cell proliferation and decreased enterocyte loss via apoptosis.     

克罗恩病肠切除术后吻合口瘘的危险因素分析

目的探讨克罗恩病肠切除术后吻合口瘘的危险因素及防治措施。方法回顾性分析1990--2010年间91例克罗恩病肠切除患者的临床资料,采用Logistic回归模型分析术后吻合口瘘发生的危险因素。结果91例患者共进行120例次肠切除肠吻合术,其中有14例（11．7％）发生吻合口瘘。单因素分析显示,手术时机（急诊或择期手术）、吻合方式（侧侧吻合或端端吻合,端侧吻合）、吻合方法（吻合器或手工缝合）和手术时间（3h以上或不足3h）是吻合口瘘的危险因素（均P〈0．05）。多因素分析显示,急诊手术（OR=3．891,95％C1：1．332～13．692）、端侧吻合或端端吻合（OR=3．236,95％CI：1．165～11．950）和手工缝合（OR=5．715,95％CI：1．454～17．328）是吻合口瘘发生的独立危险因素。结论克罗恩病行肠切除时应避免急诊手术,采用侧侧吻合和应用吻合器可降低吻合口瘘的发生风险。     

Does L-arginine induce intestinal adaptation by epithelial growth factor?

BACKGROUND: To evaluate whether L-Arginine has an effect on endogenous epidermal growth factor secretion and intestinal adaptation in massive small bowel resection an experimental study was performed. METHODS: Fourteen albino Wistar rats weighing 250-300 g were used for the study. After performing 50% small bowel resection and anastomosis the rats were randomly divided into two groups. The first group received 500 mg/kg/day of L-Arginine intraperitoneally for 14 days just after the surgical procedure. The control group received isotonic saline instead. Body weight measurement was preformed daily. At the end of the second postoperative week all rats underwent relaparotomy. Small bowel was resected for histopathological examination. Levels of epidermal growth factor were measured by enzyme-linked immunosorbent assay in serum, saliva, and urine at the end of second postoperative week in both groups. RESULTS: The weight gain was higher in the L-Arginine treated group (P < 0.05). Serum, saliva and urinary epidermal growth factor levels were significantly higher at the end of the second week compared to the control group (P < 0.05). The villus height was higher on histopathological examination in L-Arginine treated group compared to the control group (P < 0.05). CONCLUSION: L-Arginine resulted in a better intestinal adaptation after massive bowel resection. The high levels of epidermal growth factor in body fluids of L-Arginine treated rats could be the explanation for this effect.     

盲肠插管造瘘术预防结直肠术后吻合口漏的应用

目的探讨盲肠插管造瘘术在预防结直肠术后吻合口漏的作用。方法采用病例对照研究,研究组73例,其中因直肠癌行前切除术41例,乙状结肠癌并慢性不全性梗阻20例,均行乙状结肠癌根治性Ⅰ期切除吻合,因左半结肠癌合并急性梗阻行Ⅰ期切除吻合10例,成人巨结肠并梗阻2例,均行Ⅰ期切除吻合;对照组87例,其中因直肠癌行前切除56例,乙状结肠癌并慢性不全性梗阻31例,均行乙状结肠癌根治性Ⅰ期切除吻合。研究组均行经阑尾残端盲肠造瘘;对照组未予预防性插管。结果研究组术后进食时间和住院时间分别为(3.3±0.4)d和(20.2±4.0)d,均明显短于对照组的(4.6±0.9)d和(29.1±5.5)d,两组比较差异显著(P0.05)。研究组术后发生吻合口漏1例(1.4%);对照组发生10例(11.5%),两组比较有统计学差异(P0.05)。结论盲肠插管造瘘术在预防结直肠手术后吻合口漏方面具有简单、方便、有效、可行的优势。