肝移植术后胃肠道穿孔的处理

目的总结肝移植术后胃肠道穿孔的治疗经验。方法回顾性分析1999年12月至2014年10月共完成的424例肝移植中7例移植术后出现胃肠道穿孔病人的临床资料,其中男性5例,女性2例,年龄21~63岁,中位年龄43岁。包括胃穿孔3例,空肠穿孔1例,横结肠穿孔3例。其中4例胃肠道穿孔病人肝移植前曾有过腹部手术史。3例胃穿孔中,2例行单纯局部冲洗引流,1例内镜下钛夹+尼龙圈夹闭;1例空肠穿孔行手术切除瘘肠管,空肠-空肠吻合;3例结肠穿孔中,1例单纯局部冲洗引流,2例先行回肠造瘘,3个月后1例行单纯回肠关瘘,1例行横结肠切除+结肠结肠吻合+回肠关瘘。本组所有病例均给予充分的营养支持,适当减少免疫抑制剂的用量,加强抗感染等治疗。结果本组胃肠道穿孔发生率为1.6%(7/424),1例胃穿孔因未及时发现,在引流过程中出现腹腔感染、移植肝功能不良、多器官功能障碍综合征(MODS)死亡,死亡率为14.3%(1/7);1例横结肠穿孔行回肠造瘘,3个月后行回肠关瘘后1周再次于原穿孔处出现结肠瘘,经局部冲洗引流2周后治愈。其余5例经过综合治疗后均康复出院,目前已随访4~96个月。结论胃肠道穿孔是肝移植术后较少见的并发症,治疗复杂,若发现不及时,容易因腹腔感染致移植失败。既往腹部手术史、术中医源性损伤可能是其发生的主要原因。以减少免疫抑制剂用量、控制感染、营养支持为基础的综合治疗是治愈的关键。     

乙状结肠镜检查造成直肠穿孔的教训

1978年3月至1982年10月我科共收治3例因乙状结肠镜检查而致肠穿孔的病人,报道如下: 例1,男,39岁。因大便次数多、腹痛两个月行乙状结肠镜检查。检查后出现腹痛并逐渐加重,伴有恶心,发热。第2天来院复诊,见急性病容,腹胀,全腹有明显压痛及反跳痛,肠鸣音微弱。腹部X线透视,双膈下可见游离气体。诊断:急性腹膜炎,消化道穿孔。急诊开腹探查,发现有肠内容及脓液,并见在乙状结肠与直肠移行处前壁有一直径1cm的穿孔,周围肠壁复有脓苔。于肠壁穿孔清创后行肠修补术,清洗腹腔,经左下腹壁在盆腔放置引流管。术后应用     

十二指肠损伤10例分析

我院于1991～2006年期间手术治疗十二指肠损伤患者10例,男9例,女1例; 年龄9～55岁.患者受伤后均立即出现腹部剧痛、腹胀、呕吐.损伤后就诊时间5～25 h,伤后5 h内确诊为十二指肠损伤者2例,伤后5～20 h确诊者3例,伤后20～25 h确诊者5例.术前均进行B超、X线片、CT等检查,其中3例诊断为肠穿孔,经剖腹才得以明确诊断.本组7例十二指肠降部破裂伤均行双层内翻缝合修补,清除裂口周围及腹腔积血、积液后,将胃肠减压管置入十二指肠修补处以远,术后进行持续胃肠减压,使十二指肠处于空虚状态.2例十二指肠全段血肿,经切开浆膜清除血肿后,缝合浆膜,与十二指肠降部破裂伤修补病例一样,持续胃肠减压,腹腔引流,有效抗感染、禁食、静脉营养,术后2例并发十二指肠瘘,经再次修补扩大引流,修补后再次并发肠瘘1例,第3次剖腹修补、引流治愈.院外转来1例,因十二指肠降部损伤术后发生肠瘘,经第2次修补加引流,虽经多种综合治疗,终因腹腔感染、全身衰竭,于伤后第35天死亡.     

成人肝移植术后早期并发急性阑尾炎的诊断和治疗分析

目的探讨肝移植患者术后早期并发急性阑尾炎的临床特点及诊疗经验。方法 7年间笔者单位共实施817例成人尸肝移植,4例术后早期并发急性阑尾炎。笔者回顾性分析该4例患者以及误诊为阑尾炎的另4例患者的临床资料。结果肝移植术后早期急性阑尾炎的发生率为0.49%(4/817)。该4例患者分别于肝移植术后8,13,11,9 d出现急性阑尾炎症状,包括右下腹阵发性疼痛,发热,右下腹压痛、反跳痛,白细胞升高;2例于出现症状当天,2例于症状出现后第2天急诊行阑尾切除术。无阑尾穿孔者。术后病理提示2例为单纯性阑尾炎,2例为化脓性阑尾炎。阑尾炎发病及治疗过程中,未调整免疫抑制剂,肝功能无不良影响。4例术后均顺利恢复,迄今肝移植术后分别存活84,62,40,29个月。其余4例误诊为急性阑尾炎的患者1例为术后9 d十二指肠憩室并穿孔,1例为术后10 d空肠穿孔(术后15 d死亡);2例分别为术后8 d及11 d发生胆瘘,后者术后4个月死亡。结论肝移植术后阑尾炎的患病率低,需与胆瘘、消化道穿孔等并发症鉴别;对于确诊患者应尽早行阑     

自发性大肠穿孔诊治体会：附9例报告

目的:探讨自发性大肠穿孔的诊治。方法:回顾性分析1994年以来收治的9例自发性大肠穿孔患者的临床资料。结果:9例均为60岁以上的老年患者，缺乏特异性临床表现，术前均未能明确诊断。既往有长期高血压、动脉硬化史4例，有习惯性便秘史6例。穿孔位于横结肠1例，降结肠1例，乙状结肠3例，直肠上段4例。治疗采用穿孔修补、肠管外置4例，穿孔修补加近段结肠造瘘5例。术后1例出现心律失常，2例肺部感染，1例切口感染，均经处理后恢复顺利而痊愈出院。结论:自发性大肠穿孔多见于老年患者；好发部位在直肠和乙状结肠；术前易误诊，应尽早剖腹探查；手术宜简单化，应加强术后管理。     

Crohn病并发多处肠穿孔2例

Crohn病是一种非特异性肠道炎性疾病。现将我院2例并发多处肠穿孔Crohn病报道如下。患者女性,41岁,因突发性全腹痛4h入院。既往有长期腹部隐痛病史,曾行胃镜、肠镜检查,胃、十二指肠、结肠未见异常。查体:腹部呈“板状腹”,全腹肌紧张,压痛及反跳痛,肝浊音界下降,无移动性浊音,肠鸣音消失。腹部X片:两侧膈下见游离气体。入院诊断:急性弥漫性腹膜炎,消化道穿孔。给予禁食、持续胃肠减压、补液、抗感染等非手术治疗,疼痛仍不缓解,出现发热,体温38.3℃,体征进一步加重,急诊行剖腹探查术。术中见腹腔有较多肠内容物及渗液,距回盲部约60cm开始…     

腹腔镜修补术在医源性结肠镜肠穿孔治疗中的应用体会（附7例报告）

目的：探讨腹腔镜修补术治疗医源性结肠镜肠穿孔的可行性及手术技巧,以期建立合理的诊疗方案。方法：回顾分析2006年2月至2012年12月为7例因结肠镜诊治并发肠穿孔患者行腹腔镜修补术的临床资料,其中治疗性穿孔3例,诊断性穿孔4例。结果：7例患者均顺利完成腹腔镜修补术,无一例中转开腹。手术时间50～100min,术后48～72h恢复胃肠功能并拔除胃管进食。术后均无切口感染、肠梗阻、肠漏、腹腔脓肿等并发症发生,5～8d顺利出院。结论：腹腔镜修补术应用于医源性结肠镜肠穿孔是安全、有效的,具有手术时间短、患者创伤小、术后肠道功能恢复快、住院时间短、并发症少等优点,值得临床推广应用,但需经验丰富的腹腔镜外科医生及早介入。     

食管自发性破裂误诊为上消化道穿孔一例

食管自发性破裂临床较少见。我们将此病误诊为上消化道穿孔1例。现报告如下:一、临床资料患者,男,66岁,以突发性上腹痛2ｈ为主诉就诊。患者发病前2ｈ进食中突感上腹部刀割样疼痛,后呈持续性,伴恶心、未呕吐。既往有“胃病”史,经常反酸及胸骨后烧灼感。查体:板状腹,满腹压痛、反跳痛(±)。肝浊音界似缩小。胸腹联透示右肋膈角变钝,膈下未见明显游离气体。心电图未见异常。随以上消化道穿孔行剖腹探查。术中腹腔干净,未发现穿孔灶及其他脏器病变。术后呼吸困难进行性加重。复查胸透示右侧液气胸。行胸腔闭式引流,引流出淡黄、微浊液约2000ｍ…     

自发性结肠穿孔14例临床分析

目的探讨自发性结肠穿孔的发病原因及诊治方法。方法回顾性分析14例自发性结肠穿孔病例的临床资料,术前1例确诊,余13例均误诊。行Hartmann结肠造瘘术5例,穿孔修补外置术5例,穿孔Ⅰ期修补近端结肠造瘘2例,穿孔Ⅰ期单纯修补和穿孔结肠外置造瘘术各1例。结果穿孔位于直肠乙状结肠交界处6例,乙状结肠4例,降结肠2例,横结肠1例,升结肠1例。术后创缘病检均为炎症,死亡2例,其余12例痊愈出院。结论自发性结肠穿孔主要发病原因为习惯性便秘及动脉硬化,好发部位在乙状结肠,术前误诊率高,及时准确的手术治疗及完善的围手术期处理是挽救病人生命的关键;肠管修补外置术及Hartmann结肠造瘘术是两种较好的手术方式。     

伤寒肠穿孔的护理

伤寒肠穿孔是伤寒病的严重并发症。我院1975年1月至1990年12月共收治47例,均进行了手术治疗,现将护理体会介绍如下。一、临床资料本组男35例,女12例,年龄7～63岁。入院前穿孔41例,入院后穿孔6例。穿孔诱因饮食不当16例,腹泻及服用泻药后6例,腹胀4例,严重肠出血、咳嗽及呕吐各2例,用力排便1例。37例行肠穿孔修补术,6例行肠切除术,3例行肠修补加肠造瘘术,1例行肠外置术。术后并发切口感染19例,腹腔或盆腔脓肿5例,肠瘘4例,死亡6例。二、术前观察及护理     

腹腔镜在胃肠道穿孔手术中的应用体会(附20例报告)

目的:总结腹腔镜手术治疗胃肠道穿孔的手术方法及应用价值。方法:回顾分析为20例胃肠道穿孔患者行腹腔镜手术的临床资料。术中探查腹腔,吸净腹腔积液,行穿孔修补术。结果:19例顺利完成腹腔镜手术,1例胃穿孔患者术中见胃壁僵硬发白,冰冻检查确诊为胃癌,遂中转开腹行胃癌根治术(D1)。手术时间60～120 min,平均90 min;术后48～96 h恢复胃肠蠕动后拔除胃管、引流管、尿管,开始进流质饮食,并逐渐恢复正常饮食。术后无并发症发生。术后3个月行胃镜、结肠镜检查及全消化道钡餐透视,随访6～12个月,无一例复发或明显异常。结论:腹腔镜胃肠道穿孔修补术操作简单、安全、效果确切,不受患者肥胖因素影响,可充分吸净腹腔内积液,减少了术后腹腔、盆腔脓肿的发生,对腹腔脏器干扰小,术后粘连性肠梗阻发生率低;同时可明确诊断,避免了盲目开腹手术切口相关并发症的发生,较传统开腹手术更具优越性,值得临床推广。     

腹腔镜技术在外科急腹症中的应用

目的探讨腹腔镜技术在外科急腹症中的应用价值。方法2002年3月～2007年3月,行306例急诊腹腔镜手术探查与相应治疗。术前诊断急性阑尾炎105例,腹痛原因待查34例,急性胆囊炎、胆囊结石64例,消化道穿孔51例,胆总管结石、急性胆管炎5例,肠梗阻33例,有明确外伤史9例,重症急性胰腺炎5例。结果本组306例全部术中明确诊断,腹腔镜手术成功275例,其中阑尾切除术123例,胆囊切除术57例,消化道穿孔修补术48例,22例肠梗阻中行肠粘连松解13例、小肠复位联合斜疝修补4例、腹腔镜辅助下乙状结肠癌根治直肠前吻合4例、小切口小肠肠段切除端端吻合术1例,胆总管切开取石T管引流术3例,右叶肝破裂修补术2例,脾破裂止血3例,重症急性胰腺炎清创冲洗引流术5例,腹腔镜探查12例（肠系膜挫裂伤2例,腹壁刀刺伤伴大网膜挫伤1例,原发性腹膜炎8例,过敏性紫癜腹型1例）;余31例腹腔镜完成困难而中转开腹。306例随访1～18个月,无术中、术后并发症。结论急诊腹腔镜探查术不仅可以对病因不明的急腹症做出准确诊断,且可同时行腹腔镜手术治疗。即使腹腔镜下不能完成的手术,也可以指导及时开腹,以及采取较为合适的手术切口。     

Malignant lymphoma incidentally diagnosed due to the perforation of the small intestine caused by a fish bone: A case report

IntroductionThe ingestion of a foreign body is relatively common. However, it rarely results in the perforation of gastrointestinal tract. We herein report an unusual case of malignant lymphoma incidentally diagnosed after the perforation of the small intestine by a fish bone.Presentation of caseA 90-year-old woman was admitted to our hospital because of abdominal pain and vomiting. Abdominal computed tomography demonstrated free air and ascites in the abdominal cavity. In the pelvic cavity, a radiopaque linear shadow about 35 mm in diameter was shown in the small intestine, and the stricture was exposed to the abdominal cavity. Therefore, a diagnosis of perforation of the small intestine due to ingestion of a foreign body and panperitonitis was made. Emergent laparotomy was performed. The intraoperative findings revealed perforation of the small intestine with a fish bone in the jejunum. Local inflammation at the perforation site was seen, and circulated wall thickness was observed at the distal side of the jejunum. Partial resection of the jejunum and anastomosis of jejuno-jejunostomy was performed. A pathological examination and immunohistochemical study of the resected specimen resulted in a diagnosis of malignant lymphoma of follicular lymphoma Grade 1.DiscussionIt is very difficult to identify the existence malignancy accompanied with gastrointestinal perforation with ingestion of a foreign body.ConclusionIn cases suspected of involving malignancy, careful observation during surgery is needed in order to avoid missing the accompanying malignancy.     

提高原位肝移植术后长期生存率的临床研究

目的 探讨提高原位肝移植术后长期生存率的临床措施。方法 回顾性分析我科3年多来所施行的72例原位肝移植病人术后生存情况、并发症发生的种类及数量，以及诊治处理方法，以探讨成功及失败原因。结果 72例肝移植病人中，原发病为良性疾病50例(其中终末期乙肝肝硬化34例)；恶性疾病22例(其中HCC19例)。术后发生并发症54例次，含因凝血功能紊乱致术后腹腔内继发性出血4例，术前腹水感染未能控制，致术后腹水严重感染2例，激素用量过大致应激性溃疡出血、穿孔1例，胆瘘6例，肺部感染21例，肠道真菌感染5例。全组无原发性肝无功能及血管并发症，随访2～41个月，无远期胆道并发症及慢排发生。住院期死亡6例，随访期死亡6例，目前生存60例，总生存率为83．33％，存活超过1年者32例，最长已3年5个月。结论 ①术中技术的改进及新技术的应用；②采用个体化的免疫抑制方案；③加强术后感染预防与治疗；④加强乙肝复发的预防和治疗；⑤预防肿瘤复发的系列措施，是提高肝移植术后生存率的关键。     

Jejunal gastric heterotopia presenting as perforation peritonitis in a middle-aged adult: A case report

IntroductionGastric heterotopia rarely occurs in the small intestine beyond ligament of Treitz. Most cases of jejunal gastric heterotopia have been reported in children and young adults. Herein we report a case of jejunal gastric heterotopia presenting as a perforation peritonitis in a middle-aged adult.Presentation of caseA 51-year-old male presented with abrupt onset abdominal pain of 1 day duration. Physical examination revealed abdominal tenderness and rebound tenderness as well as costovertebral angle tenderness. Abdominal computed tomography revealed pneumoperitoneum, suggestive of hollow viscus perforation. At emergency laparotomy, a perforation site was discovered in the jejunum 100 cm distal to the ligament of Treitz. On macroscopic examination, the mucosa contained a 3 × 4 cm ill-defined, shallow ulceration next to the perforation site. Microscopically, the mucosa surrounding the perforation site revealed gastric heterotopia which consisted of gastric foveolar epithelium along with abundant pyloric glands and a few fundic glands.DiscussionTo the best of our knowledge, this case is the presumed oldest jejunal gastric heterotopia patient presenting with perforation peritonitis ever reported.ConclusionJejunal gastric heterotopia should also be considered in the differential diagnosis of perforation peritonitis in adults.     

肾移植术后并发肠穿孔的诊断和治疗体会

目的 总结肾移植术后并发肠穿孔的诊断和治疗体会.方法 回顾性分析8例肾移植术后并发生肠穿孔患者的资料.8例均为首次肾移植,术后采用环孢素A(或他克莫司)、霉酚酸酯及甲泼尼龙预防排斥反应.8例患者中,1例肾移植术前有胃大部切除手术史,其余7例术前无胃肠道病变.1例于肾移植术中切除了双侧多囊肾.1例在发生肠穿孔前因急性排斥反应而接受甲泼尼龙冲击治疗.8例患者均接受了剖腹探查术,同时减少免疫抑制剂的用量.结果 肠穿孔发生于肾移植术后3～18 d.5例患者表现为突发性腹部绞痛,不同程度的急性腹膜炎体征;3例急性腹膜炎体征不明显.患者体温为36.5～38.4℃.腹部X线检查显示,5例右侧或双侧膈下出现游离气体,3例出现肠管扩张及肠梗阻征象.诊断肠穿孔后3～96 h患者接受了剖腹探查.术中证实,7例为同肠穿孔,1例为降结肠穿孔.剖腹探查的同时,3例接受了小肠穿孔修补术,4例接受了部分小肠切除吻合术,1例接受了部分结肠切除吻合术.经手术治疗,5例患者痊愈出院.随访0.5～3.5年,肾功能良好,未再发生肠穿孔;3例患者分别于肾移植术后30～108 d因肠穿孔并发症死亡.结论 肠穿孔是肾移植术后少见而严重的并发症,其临床症状不典型,腹部X线检查结果对早期诊断具有较大意义,早期诊断和手术治疗是改善患者预后的关键.     

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.     

A report of an atypical case of Degos' disease with multiple perforations of the stomach and small intestine

A 47-year old male complaining of severe abdominal pain associated with distention was admitted to our department on August 5, 1986. His first admission to our hospital was 18 days previously for leg pain and fever. He underwent emergency operation with a preoperative diagnosis of acute peritonitis due to perforation of gastric ulcer. Operative findings showed one perforation of the stomach and two of the ileum. Distal gastrectomy, enterectomy and peritoneal drainage were carried out. Resected specimen revealed six ulcers, two of them in the stomach, four in the ileum. Microscopic examination disclosed intimal proliferations of small arteries in the mucosal layer. The vessels near the ulcers were most severely involved but the same changes were also found in the subserous layer and mesentery. It was suggested that the multiple ulcers were secondary to vascular lesions identical to the gastrointestinal lesion of Degos' disease. Postoperative examinations revealed one ulcer in the jejunum and another in the descending colon. Ten months after operation he lives with no complaint on the gastrointestinal tract. Only 80 cases of Degos' disease have been reported in the western countries and 10 cases in Japan. In those atypical cases of Degos' disease without papulosis were only Manuel's and ours.     

肝移植术后消化道出血的原因及处理

目的 探讨肝移植术后消化道出血的原因和处理方法.方法 对中山大学附属第一医院2000年1月至2006年12月施行的776例同种原位肝移植（OLT）患者的临床资料进行回顾性分析,总结原位肝移植术后消化道出血的诊治经验.结果 776例肝移植患者中共发生术后消化道出血18例（2.3%）.其中消化性溃疡出血8例（44.5%）,胃底食管静脉曲张急性出血3例（16.7%）,胃十二指肠炎出血3例（16.7%）,胆道出血3例（16.7%）,空肠憩室出血伴穿孔1例（5.6%）.分别采取积极的非手术治疗和经内镜直视下局部止血治疗、血管栓塞治疗和手术探查等措施,除死亡5例（27.8%）外,13例患者临床治愈,术后平均随访3.5年,除1例于术后2年死于移植肝癌复发外,其余均健康存活.结论 OLT术后可能出现不同部位的消化道出血,病死率较高：一旦发生,应尽快寻找出血部位并及时做出正确的治疗选择.     

胆道闭锁婴儿亲属活体肝移植术后空肠穿孔四例

目的 分析胆道闭锁婴儿亲属活体肝移植术后空肠穿孔的原因,总结治疗经验.方法 胆道闭锁婴儿行亲属活体肝移植者28例,术后应用环孢素A、糖皮质激素预防排斥反应,部分患儿加用吗替麦考酚酯.结果28例中4例(14.3%)发生空肠穿孔,共发生7次,发生时间平均为术后11 d(8～13 d).4例的穿孔部位均在空肠,其中3例在肠吻合口丝线缝合线脚处,1例在肠袢臂固定丝线线头处.肠吻合口丝线缝合线脚处穿孔的3例经丝线缝合修补穿孔后,其中2例(67%)再次出现穿孔,用prolene线修补后愈合.无患儿因空肠穿孔而死亡.结论 胆道闭锁婴儿行亲属活体肝移植后发生空肠穿孔可能与用丝线吻合肠道有关,可换用Prolene线吻合肠道或修补穿孔.早期诊断和早期剖腹探查对空肠穿孔的治疗至关重要.

Abstract：

Objective To investigate the cause of jejunum perforation after infantile livingrelated liver transplantation (ILRLT) and summarize the experience of treatment. Methods The clinical data of 28 infants with biliary atresia who underwent ILRLT were analyzed and 4 of 28 infantile recipients (14. 3%) developed jejunum perforation after ILDLT. Results Four patients had 7 episodes of jejunum perforation after transplantation among 28 infantile recipients who underwent ILRLT because of biliary atresia. The median time between transplantation and perforation was 11 days.Perforation occurred at the point of silk in jejunum stoma (n = 3) and the Roux-en-Y limb (n = 1 ).None had a history of prior operation including Kasai in 4 patients. Clinical manifestation included fever, increased heart rate, abdominal distention, leukocytosis, and no free air on abdominal roentgenograrns. A simple repair was performed in three infants with silk: two developed recurrent perforation (67%) and underwent a re-exploration,and another had a third perforation and underwent a third repair because of re-perforation. Another child underwent a simple repair with prolene, and there was no recurrence. None died from the perforation in our study. Conclusion The occurrence and location of jejunum perforation after ILDLT suggests that the cause of the perforation is related to the jejunal anastomosis with silk, and the jejunum perforation may be avoided in the jejunal anastomosis with prolene. Early diagnosis and exploration may ensure better survival.