急性肠系膜上动脉栓塞小肠广泛坏死七例治疗经验

目的 总结急性肠系膜上动脉栓塞小肠广泛坏死的治疗经验。方法 对1991-1999年收治的急性肠系膜上动脉栓塞小肠广泛坏死7例的临床资料进行回顾性分析。结果 7例术后剩留小肠28-30cm的3例,70-90cm的4例。本组2例术后死于感染中毒性休克;5例发生短肠或超短肠综合征,经静脉营养与经口进食等综合治疗全部治愈,本组随访18个月4例,36个月1例,均健在,结论 及时诊断和早期手术是提高治愈率的关键,尽可能保留有生机的肠段,对术后剩留小肠在28-90cm的短肠和超短肠综合征,采取静脉营养和经口进食并举的综合治疗,可以较快恢复肠管的消化吸收功能。     

术后短肠综合征与长期家庭肠外营养

术后短肠综合征与长期家庭肠外营养上海医科大学中山医院外科（２０００３２）吴肇汉短肠综合征（ｓｈｏｒｔｂｏｗｅｌｓｙｎｄｒｏｍｅ，ＳＢＳ）是小肠广泛切除后产生的严重消化吸收功能障碍和营养不良等一系列的临床综合病征。ＳＢＳ在临床上并不少见，其最常见的病因...     

短肠综合征及其处理

小肠广泛切除后所导致的严重营养消化吸收障碍(短肠综合征)一直是临床处理的一大难题,多数病例最终难免死亡。我科自1963～1983年,因各种肠疾患行广泛小肠切除12例(残留小肠在80cm以内),其中死亡8例。近年自临床应用全胃肠外营养(TPN)和要素饮食(ED)以来,提高了抢救成活率,兹对几个主要问题讨论如下。     

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短肠综合征 (以下简称短肠 )是指因各种原因引起广泛小肠切除 ,造成剩余的功能性小肠过短而导致水、电解质代谢紊乱以及各种营养物质吸收不良的综合征。肠道的代偿能力甚强 ,切除 50 %的小肠并不引起症状 ;切除 75%以上可因吸收面积减少而出现严重腹泻、吸收不良 ,水、电解质紊乱 ,代谢障碍和进行性营养不良。肠外营养问世以前 ,造成短肠病人死亡的主要原因是原发病本身 (如广泛的血管病变或肿瘤 )、肠道吸收功能障碍导致的营养不良和肠外营养及其并发症所造成的感染和肝肾功能损害。随着肠外营养技术的进步以及对短肠综合征病理生理过程和…     

短肠吻合术

短肠系指小肠大部分切除后,成人保留的小肠少于100cm而言。短肠病人可发生短肠吸收不良综合征。若保留的小肠少于50～60cm,如果不采取吻合技术上的补救措施,则病人可因腹泻、水电解质平衡紊乱、酸碱平衡紊乱、低蛋白血症,贫血等,最终将使病人不能生存。短肠吻合术的术式较多,其目的均为延长食糜在短肠内停留时间,增加小肠吸收或增加食糜在短肠内重复循环、重复吸收,以维持人体的基本营养吸收及水电解质平衡和酸、碱平衡。现分别讨论如下: 一、短肠双口循环式吻合术(图1,2):短肠吻合时,先将近端小肠断端吻合于距断端16cm处近端肠壁上(端侧吻合)制成d型,然后将远端肠断端     

肠功能障碍的营养支持

肠道是维持人体营养、生存的重要器官之一。长期以来，人们对肠功能的认识偏重于营养物质的消化、吸收。通常所谓的“肠衰竭（intestinalfailure）”是指患者丧失了小肠这一器官或小肠的功能，不能通过消化吸收来维持机体最低营养需要量、甚至水与电解质的平衡。在日常临床实践     

临床同种活体部分小肠移植：附1例报告

目的：探讨临床同种活体小肠移植治疗短肠综合征的效果。方法：对1例因小肠扭转而切除大部分小肠和右半结肠，残留小肠仅20cm的超短肠综合征男性患者，行亲属活体同种部分小肠移植。供体为患者之母。受体术前行供体特异性输血，50mL/周，共8周。供受体巨细胞病毒感染状态均为阴性。移植肠长约160cm。移植肠的回结肠动静脉分别与受体肾下腹主动脉和下腔静脉端侧吻合，移植肠末端造口。术后给予抗排斥、抗感染、抗凝及营养支持治疗。结果：供体术后恢复顺利，无并发症。受体已健康存活31周，无感染和排斥反应。术后8周脱离肠外营养治疗，口服低脂饮食，D－木糖吸收试验结果接近正常。结论：同种活体部分小肠移植是治疗短肠综合征的有效措施。     

母子亲体小肠移植治疗小肠衰竭的方法及疗效探讨：附1例报告

目的：探讨母子亲体小肠移植的方法及其对短肠综合征所致小肠衰竭的疗效。方法：为1名15岁短肠综合征（仅残留小肠8cm）致小肠衰竭的男患者行小肠移植术。供体为患者母亲。取供体带血管蒂回肠中下段1.2m移植于受体腹腔，两端分别造瘘及作人工肛。二期手术于6个月后施行，将受体残余肠中部横断，上下端分别与供肠近、远段行端侧吻合。结果：供、受体手术顺利。受体一期手术后曾发生感染及排斥，经治疗后痊愈。二次术后随访8个月，受体小肠功能逐渐恢复，患者体重明显增加，一般情况好，进食半流质，生活能自理。结论：亲体小肠移植是治疗短肠综合征肠衰竭的有效方法。排斥和感染是威胁小肠移植安全的主要因素。     

成人短肠综合征的治疗现状

短肠综合征（short bowel syndrome，SBS）是由于大量小肠切除后,机体不能吸收足够的营养以维持生理代谢的需要．而导致整个机体处于营养不足的状况，继而出现器官功能衰退，代谢功能障碍，免疫功能下降，由此而产生的一系列综合征。成人短肠综合征可由于小肠因反复发作性疾病如克罗恩病或反复发作的肠梗阻、肠外瘘而多次被切除所致．也可因血管疾病如肠系膜血管发生梗塞，肠扭转血运障碍而坏死。或是外伤性血管破裂、中断，大量小肠因缺血坏死而被切除所导致。     

短肠综合征的外科治疗——160例患者的治疗经验

本文报道1980～1994年Nebraska大学医学中心48例成人和112例儿童短肠综合征患者的治疗经验,在此基础上确定短肠综合征外科治疗的方法.48例成人患者中15例残存小肠短于60cm,13例为60～120cm,20例为120～180cm.年龄小于16岁的112例患儿中43例残存小肠短于30cm,23例为30～60cm,46例长于60cm.短肠综合征的外科治疗包括:沿对系膜缘将多余小肠壁切除或折叠的小肠管壁缩窄术;缩窄肠段的狭窄成形术;节段肠袢倒置术;系膜缘及对系膜缘间肠壁纵向横断再吻合的小肠延长术;包括单独小肠移植和肝肠联合移植的小肠移植术.结果160例患者中71例(44%)残存小肠充分适应,肠内营养(PN)支持即可满足患者营养需求,44例(28%)长期行PN支持而未进行手术治疗,45例(28%)接受49次手术治疗.手术选择:残存小肠长度足够而肠腔过度扩张致功能损害的4例成人患者(残存小肠>120cm)和11例患儿分别接受狭窄成形术和小肠管壁缩窄术,其中13例(87%)临床症状改善,2例患儿因再次发生肠吸收不良而行小肠延长术;残有小肠90～120cm而食物转运过快的3例患者中,2例接受人工瓣膜成形术,1例施行肠袢倒置术,这3例患者中2例疗效佳,1例施行肠袢倒置术的患者疗效明显,但因持续恶心,呕吐再次施行矫正手术;扩张的残存小肠短于90cm的14例患者接受小肠延长术,其     

Laparoscopically assisted bowel surgery for inflammatory bowel disease

Background: Laparoscopic bowel surgery was evaluated in 44 consecutive patients who underwent surgery for inflammatory bowel disease (IBD). We studied feasibility, results, and final outcome. Methods: At two academic institutes, 44 laparoscopically assisted colectomies and laparoscopic ileostomies or colostomies were attempted. All patients had histologically proven IBD and no prior surgery for IBD. Loop ileostomy (n= 4), end colostomy (n= 1), ileocecal resection (n= 26) and (procto)colectomy (n= 13) were performed. All resections were laparoscopically assisted with extracorporal resection and anastomosis. Results: Only in two patients (ileocecal resection in both) was conversion to open surgery necessary. Two patients with laparoscopic ileocolic resection had intra-abdominal abscesses, which were drained percutaneously in both. One patient in the laparoscopically assisted colectomy group had a subphrenic abscess that was drained percutaneously, and one patient had a generalized candidiasis. Conclusions: Laparoscopically assisted colectomies can be performed safely in treating IBD. The laparoscopic method with use of a small vertical umbilical or Pfannenstiel's incision seems acceptable with regard to operating time and overall costs, also allowing superior cosmesis to be maintained. Received: 12 August 1998/Accepted: 13 January 1999     

Isoperistaltic bowel lengthening for short bowel syndrome in children

BACKGROUND: Short bowel syndrome, secondary to a variety of causes, can be lethal in infancy and childhood. Isoperistaltic bowel lengthening, performed by longitudinal division of dilated small bowel with end-to-end anastomosis, has shown early promise but long-term outcome is unknown. METHODS: Sixteen infants and children (aged 3 months to 14 years) had short bowel syndrome from necrotizing enterocolitis (8), gastroschisis (4), atresia (2), and volvulus (2). All of these patients were partially or totally dependent on parenteral nutrition and have undergone isoperistaltic bowel lengthening for short bowel syndrome (length <100 cm). Bowel length was increased by 22% to 85% (mean 42%) with the procedure. Studies of intestinal function were performed preoperatively and postoperatively. RESULTS: Isoperistaltic bowel lengthening resulted in significant improvement in stool counts, intestinal transmit time, intestinal clearance of barium, D-xylose absorption, and fat absorption at 6 months and 12 months postoperatively. Fourteen of 16 patients (88%) have been weaned from parenteral nutrition. CONCLUSIONS: These data show that isoperistaltic bowel lengthening can be an effective operation for short bowel syndrome in children, improving absorption and motility, and allowing weaning from parenteral nutrition.     

Smoking in inflammatory bowel disease and the irritable bowel syndrome

The smoking habits of 145 patients with irritable bowel syndrome (IBS) were compared with those of 63 patients with ulcerative colitis and 25 patients with Crohn's disease. Patients with IBS and ulcerative colitis smoked significantly less than those with Crohn's disease. There was no significant difference in the smoking prevalence between ulcerative colitis and IBS patients. There were significantly more ex-smokers in the ulcerative colitis group and two-thirds of these patients developed their colitis within a year of stopping smoking. It is suggested that any protective role postulated for smoking in the pathogenesis of ulcerative colitis should also be considered for IBS.     

Massive small bowel resection during pregnancy causing short bowel syndrome

Massive small bowel infarction in pregnancy is rare but has devastating complications. Diagnosis is difficult because pregnancy masks the symptoms. Our aim was to assess risk factors and outcomes of massive resection associated with pregnancy. We conducted a review of nine patients with short bowel syndrome (SBS) secondary to massive bowel resection during pregnancy. The most common cause of bowel resection was midgut volvulus in seven patients. Four of these also had malrotation. Three others had previous abdominal operations, including gastric bypass. The two remaining patients had vascular insufficiency. Five of the nine patients presented after a cesarean delivery. There were three fetal deaths. Resulting small bowel length was less than 60 cm in all but one patient. All patients required parenteral nutrition (PN). Seven patients developed significant complications related to SBS and long-term PN. Four patients underwent transplantation. Massive small bowel resection during pregnancy is a devastating complication, which requires a high degree of suspicion to diagnose. Most patients have risk factors, which include previous surgery, congenital malrotation, and a hypercoagulable state. Surviving patients usually need long-term PN or transplantation.     

Laparoscopic harvesting of small bowel graft for small bowel transplantation

Background: Small bowel transplantation represents a valid therapeutic option for patients with intestinal failure, obviating the need for long-term total parenteral nutrition. Recently, reports have shown the feasibility of performing living related intestinal transplantation using segmental small bowel grafts. The limitations of this technique include inadequate harvested small bowel lengths, as compared with the lengths obtained in cadaveric small bowel harvests, and large incisions for the donor. In this pilot study, we evaluated the feasibility of laparoscopically harvesting long segments of proximal jejunum for small bowel transplantation using a porcine model. The results can be used to evaluate the potential for applying this technique in human cases. Methods: For this study 10 yorkshire pigs were used. Under general anesthesia, each pig underwent laparoscopic segmental resection of 200 cm of proximal jejunum on a vascular pedicle. The harvested graft then was autoreimplanted using an open technique by anastomosing the vascular pedicle to the superior mesenteric vessels. Success was determined 2 hours after anastomosis by visually identifying a pink graft with viable-appearing mucosa, an artery with a strong thrill, and palpable venous flow. The animals were then sacrificed. Results: The mean operation time required to laparoscopically harvest the small bowel graft was 80 min (range, 35–120 min), and the mean length of harvested graft was 220 cm (range, 200–260 cm). The mean length of the graft's vascular pedicle was 4.5 cm (range, 4–5 cm). All 10 grafts were successfully harvested laparoscopically and then reimplanted using an open technique. All the grafts maintained good vascular flow, and showed no evidence of mucosal necrosis at necropsy. Obviously, further studies would be required to examine the long-term results of reimplanting a laparoscopically harvested small bowel graft, but proposals for such studies is beyond the scope of this report. Conclusion: Minimally invasive techniques can be used to harvest proximal small bowel grafts for living related small bowel transplantation.     

Malignant bowel obstructions

Malignant large bowel obstructions (LBO) present a unique and often challenging problem that requires thoughtful consideration of both short and long-term outcomes. Presentations can vary, but the patient will often need urgent or emergent intervention. Primary colorectal cancer accounts for the majority of malignant LBOs making this topic particularly important for the colon and rectal surgeon. Currently there are 3 main treatment strategies for potentially curable disease: Fecal diversion, primary resection with or without diversion, or colonic stent placement followed by elective resection. Stenting is also being used in palliative circumstances. The following chapter outlines the latest literature in malignant LBOs and provides algorithms for both emergent and elective cases.     

Small bowel imaging

There is a variety of options available to image the small bowel depending on the clinical scenario. This article describes multiple imaging options and focuses on several clinical scenarios common to general surgeons.