淋巴管造影剂进入肠管二例

患者1 女性,28岁.主因间歇性乏力、水肿、腹泻2年,于2000年10月6日入院.实验室检查:血浆总蛋白37 g/L,清蛋白17 g/L,血淋巴细胞0.3×10~9/L.胃镜:十二指肠黏膜密集白色斑点;胃镜活检:黏膜下淋巴管扩张.淋巴管造影:腹膜后淋巴管扩张,在荧光屏监视下造影剂进入十二指肠降部,经过横部进入空肠,胸导管末端回流不畅.诊断:原发性小肠淋巴管扩张症,十二指肠淋巴瘘.于2000年11月19日行胸导管颈外静脉吻合术,后行保守治疗包括间断全肠外营养5年多无效,于2006年5月30日入院.     

肠段切除治疗小肠淋巴管扩张症三例

小肠淋巴管扩张症（intestina lymphangieetasia,IL）为少见病，诊断易被忽视，治疗效果不确切，手术治疗少见报道，1998年以来我院行肠段切除治疗原发性IL3例，结果满意，报告如下。     

新分型对胆管囊状扩张症治疗方式的指导价值

目的 探讨董家鸿等提出的新分型(以下简称“新分型”)对胆管囊状扩张症治疗方式选择的指导价值.方法 回顾性分析1968年9月至2013年7月北京协和医院收治的213例参照Todani 2003分型原则选择治疗方式的胆管囊状扩张症患者的临床资料,采用2013年董家鸿等提出的新分型对213例患者重新分析,评价其对术式选择的指导作用.通过门诊、电话等方式随访,随访时间截至2013年8月.结果 213例患者中,Todani Ⅰ型139例(新分型为C型);Todani Ⅱ型3例(新分型为C1型);Todani Ⅲ型1例(新分型为E型);TodaniⅣa型52例(新分型为D1型35例、D2型17例);TodaniⅣb型1例(新分型为C型);Todani Ⅴ-Ⅰ型8例(新分型为B1型5例、B2型3例);Todani Ⅴ-Ⅱ型9例(新分型为A1型5例、2型4例).18例患者未行手术治疗.195例手术患者中,C型和D型患者占多数.型患者主要采用胆囊切除、胆管囊肿切除、胆肠吻合术、内引流术.D型患者采用肝外胆管切除、胆肠吻合术,对于肝内病变严重的D1型患者同时行左半肝切除或胰十二指肠切除术.A1型行右半肝切除,A2型外院行劈离式肝移植后保守治疗,B1型行左半肝切除、胆肠吻合,B2型行胆管取石.E型施行胆管囊肿部分切除,胆管成型术.74患者术后出现胰瘘、胆瘘、反流性胆管炎、胆管炎以及吻合口狭窄等并发症,经保守治疗或取石后恢复良好.187例患者获得随访,中位随访时间85个月(1～432个月).175例患者恢复良好,发生胆管系统癌变的患者中12例于随访1～282个月后因肿瘤全身播散死亡.结论 新分型方法简化了肝外胆管囊状扩张的分型,细化了肝内胆管囊状扩张的分型,对治疗方式的选择具有重要指导价值.     

小儿结肠系膜淋巴管瘤5例临床分析

目的探讨小儿结肠系膜淋巴管瘤的诊断与治疗方法。方法回顾性分析我院2006年1月至2011年12月期间手术治疗的5例小儿结肠系膜淋巴管瘤的临床资料。结果 3例诊断为腹腔包块性质待查的患儿,术中发现腹腔肿块来源于乙状结肠系膜,其中1例肿块侵犯到降结肠系膜达结肠脾曲而行左半结肠切除＋肠吻合术,另外2例行乙状结肠系膜淋巴管瘤切除＋部分乙状结肠切除＋肠吻合术;1例患儿诊断为急性化脓性阑尾炎合并乙状结肠系膜淋巴管瘤,行阑尾切除＋乙状结肠系膜淋巴管瘤切除＋肠吻合术,1例患儿诊断为乙状结肠系膜淋巴管瘤破裂并弥漫性腹膜炎,行乙状结肠系膜淋巴管瘤切除＋乙状结肠造瘘术,术后6个月后再行二期手术。5例患儿手术后恢复良好,未发生吻合口漏等并发症。术后随访5个月～5年,（2.3±1.1）年,1例失访,余均存活,仍在随访中,所有病例均未复发。结论日常行阑尾手术中,应常规探查小肠、结肠;未进行肠道准备的结肠一期吻合手术中结肠灌洗可减少吻合口漏等并发症的发生率;腹腔感染严重的患儿结肠一期吻合不可取,结肠造瘘安全;小儿结肠系膜淋巴管瘤术前确诊困难,反复出现腹痛、腹部包块的患儿应想到结肠系膜淋巴管瘤的可能性,行充分的肠道准备后择期手术,手术是肠系膜淋巴管瘤唯一的治疗方法。     

胰十二指肠切除术肠胰吻合术式的探讨

目的探讨胰十二指肠切除后的肠胰吻合的合理术式.方法回顾分析1996年1月-2003年12月施行的108例胰十二指肠切除手术行套入捆绑式肠胰吻合者的临床资料.结果手术时间为3.5～4.5h.无围手术期死亡.无胰瘘发生;1例糖尿病患者术后第8天发生胆瘘经引流自愈;切口裂开2例,经行切口减张缝合后愈合;2例术后发生胃瘫,经保守治疗治愈.结论套入捆绑式肠胰吻合手术方式能够较好的预防胰瘘,且手术时间明显缩短.     

原发性小肠淋巴管扩张症一例分析

小肠淋巴管扩张症(intestinal lymphangiectasia,IL)是一种少见病,以小肠黏膜、黏膜下、浆膜层的淋巴管扩张及肠腔淋巴液丢失为特征,由Waldmann等[1]在1961年首次报道.近年来,随着胶囊内镜检查技术的开展,IL的诊断率有所提高,国内共报道该病20余例,原发性小肠淋巴管扩张症全球报道不足200例[2],且国内外对该病报道多为以内科治疗的病例报道为主,少有详尽外科治疗病例报道.本文报道小肠部分切除成功治疗原发性小肠淋巴管扩张症1例并进行分析.     

胆肠吻合术后再次手术原因分析及处理

目的探讨胆肠吻合术后再次手术的原因及处理方式。方法对22例院内外行Roux-Y胆肠吻合病人进行回顾性分析。结果肝内胆管结石伴扩张12例,肝内胆管结石伴吻合口狭窄5例,吻合口狭窄3例,慢性胰腺炎1例,胆管癌1例。再次手术行吻合口扩张整形后重新吻合13例,行肝叶切除术并取石3例,行空肠袢切开取石3例,行肝叶切除加吻合口扩张整形重新吻合2例,胆肠侧侧吻合改为端侧吻合1例,胆道下端通畅拆除胆肠吻合1例。12例随访,2例间断发生胆管炎。结论肝内胆管残留病变和吻合口狭窄是再次手术的主要原因。胆肠吻合手术选择应慎重、治疗应彻底。     

先天性胆管囊状扩张症术后胆肠吻合口狭窄再次手术分析

目的分析先天性胆管囊状扩张症术后胆肠吻合口狭窄的原因。方法回顾性分析2014年1月至2018年6月湖南省人民医院肝胆外科收治的先天性胆管囊状扩张症术后胆肠吻合口狭窄的28例患者的临床及随访资料。该组患者吻合口狭窄距上次手术0.2～25年, 平均15年。结果 26例为良性狭窄, 2例癌变。26例重新行胆管空肠Roux-en-Y吻合, 其中合并肝叶切除8例。2例因吻合口癌变仅行胆道外引流术。无住院死亡, 无严重并发症。术后随访时间6～67个月, 2例肿瘤患者于半年内死亡, 其余患者均未发生远期并发症。结论胆肠吻合口狭窄是先天性胆管囊状扩张症术后远期严重的并发症之一, 宽敞、无张力的胆肠吻合可能有助于减少远期吻合口狭窄。     

炎性肠病45例手术治疗及疗效评价

目的 探讨炎性肠病的手术治疗方法 及疗效评估.方法 回顾性分析近6年经外科手术治疗的45例炎性肠病患者的临床资料.结果 急诊手术16例,Crohn病9例,溃疡性结肠炎(UC)7例.择期手术29例,Crohn病4例,UC 25例.其中13例Crohn病患者行小肠部分切除6例,内瘘者行小肠及结肠部分切除、吻合术1例,回肠穿...     

腹腔镜治疗放射性肠损伤12例

目的总结腹腔镜手术用于放射性肠损伤外科治疗技术的初步经验。方法回顾性分析2012年1月至2013年1月收治的采用腹腔镜手术治疗的12例放射性肠损伤患者的临床资料。结果12例患者中,2例中转剖腹,其中1例因为广泛全腹腔粘连,另1例因为无法排除肿瘤复发;其余10例均在腹腔镜下顺利完成手术。2例肠梗阻患者行小肠造口,1例患者因消化道出血行横结肠造口术;行肠切除吻合的7例患者中,先期进行的2例在腹腔镜下分离后经小的辅助切口行肠吻合,后期进行的5例行完全腹腔镜下的分离和吻合。术后1例发生回肠结肠吻合口瘘,经双套管持续冲洗后生物蛋白胶封堵愈合,其余患者无明显腹部并发症。结论腹腔镜手术可以安全用于放射性肠损伤患者,能够避免切口不愈合等并发症。     

孤立性肠系膜上动脉夹层的治疗选择：单中心经验

目的 孤立性肠系膜上动脉夹层（ISMAD）是相对罕见的一类疾病,其最佳治疗方式仍然未能确定,本研究拟总结本中心治疗ISMAD的临床结果和经验。方法 回顾性收集和分析2014年4月至2020年6月期间在我院诊断为ISMAD患者的临床资料和随访资料。结果 共有29名患者纳入本研究,其中28名患者为男性,1名患者为女性。有腹痛症状症16例。平均年龄为56.9±10.2岁。按照Yun分型,本研究包含12例Ⅰ型病变,8例Ⅱa型,8例Ⅱb型和1例Ⅲ型病变。共有13例接受观察治疗,5例行保守治疗,11例行腔内治疗。其中,1例接受腔内治疗者仍表现为腹膜炎,遂行开放手术。对于I型病变,均采取了观察治疗;对于Ⅱ型病变,采用保守治疗或者腔内治疗,对于Ⅲ型病变,采用腔内治疗基础上行坏死肠管切除。术后无腔内相关并发症。中位随访时间12（1~48）月,4例接受观察治疗的患者失访。接受肠切除的病例,有反复的出血的表现,遂停用抗凝,其随访4年的计算机断层扫描血管造影（CTA）结果显示,植入的支架通畅在位。余植入的支架通畅。未植入支架的病例,未见病变进展。结论 观察治疗适用于无症状的ISMAD患者,保守治疗和腔内治疗适用于有症状ISMAD患者,开放手术适用于有肠坏死的患者。Yun分型可用于指导治疗方式的选择。     

Role of CT scan in diagnosis of renal lymphangiectasia: our single-center experience

Background: Renal lymphangiectasia is rarely reported benign renal disorder of lymphatic malformation. Though found incidentally; it presents with nonspecific symptoms and shows characteristic findings in radiological imaging studies.

Aim: Here, we report eight patients with symptoms, laboratory and imaging findings compatible with renal lymphangiectasia. This report describes clinical and laboratory characteristics, treatment, Imaging findings and outcome of a series of patients with renal lymphangiectasia and reviews the literature.

Methods and material: Eight patients (mean age 45?years, male:female ratio 3:1) from 1st January 2011 to 30th June 2016; showing renal lymphangiectasia as incidental finding on CT IVP were included in the series. Imaging and laboratory findings were reviewed. Two out of eight patients (25%) underwent aspiration of collection and laboratory findings confirmed the diagnosis of renal lymphangiectasia. Four out of eight patients (50%) did not undergo aspiration of fluid and were offered conservative treatment. Two out of eight patients (25%) were donors for renal transplantation who were managed conservatively.

Results: Renal lymphangiectasia was diagnosed on CT IVP. In each case, where aspiration of collection fluid was offered, the laboratory diagnosis of renal lymphangiectasia was confirmed and patients were managed conservatively. However, large collection in one patient was relieved by percutaneous aspiration.

Conclusions: Renal lymphangiectasia can be diagnosed with CT scan and confirmed by laboratory tests. As it may be confused with other cystic lesions of kidney; proper diagnosis and exclusion of other differentials can be effectively offered by CT scan IVP, which can avoid unnecessary invasive treatment options.     

Solitary Fibrous Tumor of the Pleura: An Analysis of 13 Cases

BACKGROUND: Solitary fibrous tumor of the pleura is a rare soft-tissue tumor. In search of appropriate diagnosis and treatment methods, we present our experience with 13 patients. METHODS: The medical charts of 13 patients treated during the last 5 years were reviewed, as well as pathological records, including immunohistochemical stains. Follow-up data were obtained. In addition, a literature review with regard to treatment and clinical outcome was performed. RESULTS: Our series consisted of four men and nine women with a mean age of 47 years. Two were diagnosed before operation with ultrasonography-guided core needle biopsy. All patients underwent primary surgical treatment, and four of them were resected by video-assisted thoracic surgery. Seven tumors were malignant and the other six were benign. Immunohistochemical staining showed nestin was positive in three malignant solitary fibrous tumors of pleura (3/7), which were negative for CD34. Except for one, all patients were followed-up for 3 to 35 (mean, 14.5) months. Among them, one patient experienced a recurrence and one patient died of brain metastasis. CONCLUSION: Ultrasonography-guided core needle biopsy combined with immunohistochemical analysis might be a safe and rapid method to provide a confirmatory diagnosis before resection. For smaller, pedunculated tumors, video-assisted thoracic surgery could be a powerful and useful approach. We speculate that CD34-negative and nestin-positive might be a malignant marker for solitary fibrous tumor of pleura.     

膀胱肠瘘诊断治疗12例报告

目的探讨膀胱肠瘘的诊断与治疗方法。方法回顾性分析12例膀胱肠瘘患者的临床资料。男10例，女2例。平均年龄57岁。膀胱回肠瘘3例、膀胱结肠瘘7例、膀胱直肠瘘2例。病因为肠道恶性肿瘤7例、Crohn病3例、膀胱癌和肠道憩室炎各1例。临床表现粪尿10例、反复尿路感染6例、腹痛4例、气尿3例。CT确诊5例（5／9）、膀胱镜确诊3例（3／6）、膀胱造影确诊2例（2／5）、钡剂灌肠确诊1例（1／5）。行手术治疗10例，其中病变肠段切除一期吻合加膀胱部分切除术4例，病变肠段切除一期吻合加瘘修补术或单纯膀胱引流术各1例，一期横结肠造口、二期结肠癌根治加膀胱部分切除术1例，姑息性近端结肠造口术3例。保守治疗2例。结果1例于入院后第10天死于感染性休克。9例随访3个月～16年，平均6．5年。肠瘘1例复发，再次手术后治愈；1例保守治疗者及1例姑息性手术者死于肿瘤转移，1例术后2年死于脑血管意外，此前随访肠瘘无复发；余5例手术治疗者生存良好，无明显术后并发症。结论膀胱肠瘘多继发于肠道恶性肿瘤，主要临床表现为粪尿和反复尿路感染，CT和膀胱镜为首选的检查方法，治疗以手术为主。     

Transplantation for the treatment of intra-abdominal fibromatosis

MATERIALS AND METHODS: During the last 9 years we treated 14 patients with a diagnosis of intra-abdominal fibromatosis. The 11 patients who received an intestinal allograft included isolated intestine (n = 6), liver-intestine (n = 1), intestine-kidney (n = 1), multivisceral (n = 1), multivisceral-kidney (n = 1), multivisceral-no liver (n = 1). Three patients received an intestinal autograft after partial abdominal evisceration and ex vivo tumor resection. Three patients additionally underwent an abdominal wall allograft. RESULTS: At follow-up until August 2004, all autotransplant patients are alive. Four intestinal transplant patients died within the first postoperative month. There were three graft losses. A patient who lost his graft early postoperatively was retransplanted but died of sepsis shortly there after. Two more patients lost their graft due to severe rejection and were retransplanted successfully. Two patients developed desmoid tumor recurrence in their abdominal or thoracic wall. Ten patients are alive 1 to 9 years posttransplantation. Nine have fully functioning grafts and one patient requires TPN supplementation at night due to dysmotility of her autograft. CONCLUSION: Intestinal allo-, or autotransplantation combined with transplantation of the abdominal wall can be lifesaving for patients suffering from extensive intra-abdominal fibromatosis.     

Treatment of symptomatic primary chylous disorders.

PURPOSE: Primary chylous disorders (PCDs) are rare. Rupture of dilated lymph vessels (lymphangiectasia) may result in chylous ascites, chylothorax, or leakage of chyle through chylocutanous fistulas in the lower limbs or genitalia. Chyle may reflux through incompetent lymphatics, causing lymphedema. To assess the efficacy of surgical treatment, we reviewed our experience. METHODS: The clinical data of 35 patients with PCDs treated between January 1, 1976, and August 31, 2000, were reviewed retrospectively. RESULTS: Fifteen men and 20 women (mean age, 29 years; range, 1 day-81 years) presented with PCDs. Sixteen (46%) patients had chylous ascites, and 19 (54%) had chylothorax (20 patients), and of these, 10 (29%) had both. In 16 patients, reflux of chyle into the pelvic or lower limb lymphatics caused lymphedema (14, 88%) or lymphatic leak through cutaneous fistulae (11, 69%). Presenting symptoms included lower-limb edema (19, 54%), dyspnea (17, 49%), scrotal or labial edema (15, 43%), or abdominal distention (13, 37%). Primary lymphangiectasia presented alone in 23 patients (66%), and it was associated with clinical syndromes or additional pathologic findings in 12 (yellow nail syndrome in 4, lymphangiomyomatosis in 3, unknown in 3, Prasad syndrome (hypogammaglobulinemia, lymphadenopathy, and pulmonary insufficiency) in 1, and thoracic duct cyst in 1). Twenty-one (60%) patients underwent 26 surgical procedures. Preoperative imaging included computed tomography scan in 15 patients, magnetic resonance imaging in 3, lymphoscintigraphy in 12, and lymphangiography in 14. Fifteen patients underwent 18 procedures for chylous ascites or pelvic reflux. Ten (56%) procedures were resection of retroperitoneal/mesenteric lymphatics with or without sclerotherapy of lymphatics, 4 (22%) were lymphovenous anastomoses or grafts, 3 (17%) were peritoneovenous shunts, and 1 (6%) patient had a hysterectomy. Six patients underwent eight procedures for chylothorax, including thoracotomy with decortication and pleurodesis (4 procedures), thoracoscopic decortication (1 patient), ligation of thoracic duct (2 procedures), and resection of thoracic duct cyst (1 patient). Postoperative mean follow-up was 54 months (range, 0.3-276). Early complications included wound infections in 3 patients, elevated liver enzymes in 1, and peritoneovenous shunt occlusion with innominate vein occlusion in 1. All patients improved initially, but four (19%) had recurrence of symptoms at a mean of 25 months (range, 1-43). Three patients had postoperative lymphoscintigraphy confirming improved lymphatic transport and diminished reflux. One patient died 12 years postoperatively, from causes unrelated to PCD. CONCLUSIONS: More than half of the patients with PCDs require surgical treatment, and surgery should be considered in patients with significant symptoms of PCD. Lymphangiography is recommended to determine anatomy and the site of the lymphatic leak, especially if lymphovenous grafting is planned. All patients had initial benefit postoperatively and two thirds of patients demonstrated durable clinical improvement after surgical treatment.     

Teaching students to break bad news

BACKGROUND: Mesenteric vein thrombosis (MVT) is an uncommon type of intestinal ischemia associated with significant mortality and morbidity because of its delay in diagnosis. METHODS: A retrospective analysis of 9 patients treated surgically for MVT during 1982 to 1997 was performed. RESULTS: Nine patients underwent surgical therapy for intestinal ischemia due to MVT. The most common presenting symptom was abdominal pain with bloody diarrhea in 3 patients; preoperative diagnosis of MVT was suspected in 2. Radiologic tests included plain roentgenograms, computed axial tomography, and ultrasound. Time to surgery ranged from 3 hours to 7 days after admission. All patients underwent resection of infarcted bowel with primary anastomosis and immediate postoperative anticoagulation. No patient underwent a second-look operation. The postoperative morbidity and mortality rates were 55% and 11%, respectively. CONCLUSION: Diagnosis of intestinal ischemia from MVT is often delayed, and strong clinical suspicion and aggressive treatment are necessary in its management.     

胆管内乳头状黏液性肿瘤21例临床分析

目的 探讨胆管内乳头状黏液性肿瘤（intraductal papillary mucinous neoplasm of the bile tract， IPMN-B）的临床特点及诊治方法。方法 回顾性分析郴州市第一人民医院2012年1月至2019年6月收治 的21例IPMN-B患者临床资料。结果 21例患者中男4例，女17例，平均年龄（63.0±7.5）岁。临床表现： 腹痛19例，黄疸10例，畏寒发热7例；既往有胆道手术史13例；合并胆管结石14例。患者CA19-9阳性率 38.1%（8/21）， CEA阳性率28.6%（6/21）；术前诊断率33.3%（7/21）。肿瘤位置：位于左肝19例，右肝及胆 总管各1例。手术方式：肝部分切除+胆道探查术18例，肿瘤活检+胆道探查术2例，胰十二指肠切除术1例。 术后病理诊断：腺癌11例，腺瘤10例。本组死亡4例，其中1例因术后1个月并发肝功能衰竭死亡； 2例术 后病情进展，分别于术后8个月及10个月死亡； 1例术后2年复发并发消化道出血死亡。术后复发3例，其 中1例再次手术，2例保守治疗，其余患者顺利康复。结论 IPMN-B患者以老年女性为主，多数合并有胆 道手术史、胆管结石，好发于左肝，术前诊断率低，手术切除是主要治疗手段，预后较好。     

胸椎骨折39例治疗分析

目的探讨胸椎骨折的损伤特点及治疗。方法对39例胸椎骨折患者的临床资料作回顾性分析。稳定压缩骨折10例单纯保守治疗,不稳定压缩骨折15例行后路减压植骨融合加椎弓根螺钉内固定,爆裂骨折10例行前路减压植骨融合Z-plate前路钢板内固定;骨折脱位3例及爆裂脱位1例采用前后联合入路。结果全部病例均获随访,时间6~24个月,平均12个月。神经功能明显改善,术后6个月植骨融合率达100%,未见内植物松动及断裂现象。结论胸椎骨折的治疗应根据骨折的类型及稳定性,对于不稳定骨折应行融合及内固定手术,合并有不完全性脊髓损伤者还应同时行减压手术。     

Strictureplasty and intestinal resection: different options in complicated pediatric-onset Crohn disease

Background/PurposeSurgical resection or strictureplasty (SP) are different options for intestinal Crohn disease (CD) strictures. The aim of this article is evaluation of long-term outcome of SP and resection.MethodsFrom 1996 to 2011, 39 patients (23 male, 16 female) with symptomatic ileal and ileocolonic CD strictures resistant to medical/nutritional therapy and treated with surgery in 2 different surgical units were reviewed. The mean age at diagnosis was 11.82 years (range, 4-17 years). Mean age at surgery was 15.94 years (range, 4-24 years). Mean follow-up was 6.88 years (range, 0.5-15 years). Patients underwent resection (group A) or different SP techniques (group B).ResultsTwenty patients underwent intestinal resection (ileal or ileocolonic resection), and 19 patients underwent SP (jejunal, ileal, or ileocolic). Early postsurgical complications were observed in 2 patients of group A. Follow-up of group A patients revealed that 1 patient needed emergency treatment after 8 months surgery because of adhesions and 1 patient developed recurrence treated with medical therapy. In the follow-up group B, 3 patients experienced disease recurrence, 2 of them at the site of previous surgery.ConclusionsAt long-term follow-up, no significant difference in relapsing rate was observed between the 2 groups. Strictureplasty and resection represent an effective treatment of pediatric CD strictures. Strictureplasty could represent the first option for intestinal preservation.