急性肠缺血治疗策略探讨

目的探讨急性肠缺血的病因、诊断和治疗方法的选择。方法对2008年1月～2011年7月本科室收治的21例急性肠缺血患者的临床资料进行回顾性分析。肠系膜上动脉(SMA)血栓性闭塞16例,其中中心型9例,周围型2例,混合型5例,合并SMA硬化斑块7例;孤立性SMA夹层5例。结果中心型9例:5例行取栓,其中2例行小肠部分切除;导管溶栓4例,溶栓后支架置入3例,死亡1例,因小肠系膜缘出血行小肠部分切除1例。混合型5例:行剖腹探查肠切除3例,死亡1例,术后发生短肠综合征1例;2例行导管溶栓,其中1例死于心肌梗死,另1例辅以支架置入。周围型2例:药物溶栓1例,导管溶栓、碎栓1例,均成功。孤立性SMA夹层支架治疗3例,保守治疗成功2例。结论 SMA主干夹层病变首选保守治疗,如果症状不缓解,应积极治疗,以腔内治疗为主;急性肠缺血SMA主干栓塞,首选手术取栓;有时短段主干血栓形成或栓塞,也可以采用导管溶栓,必要时辅以支架。     

Chronic intestinal ischemia: diagnosis and therapy

Splanchnic arteriosclerosis is common among the elderly population, but intestinal angina is distinctly a rare entity. Extensive and efficient mesenteric collateral pathways make development of intestinal angina unlikely unless at least two major vessels exhibit hemodynamically important stenoses. Herein we describe the surgical management of 17 patients with chronic intestinal ischemia. The patients most commonly had postprandial pain and lost significant weight; angiography, including lateral aortography, confirmed the diagnosis. An average of 2.5 vessels in these 17 patients were arteriosclerotically involved. These 17 patients underwent 20 major splanchnic artery reconstructions altogether (average, 1.2 vessels per patient) for relief of symptomatic intestinal ischemia. Arterial reconstructions (16 bypass procedures and 4 endarterectomies) were undertaken with either autogenous saphenous vein (10 vessels) or Dacron prosthetics (6 vessels). Revascularizations involved the superior mesenteric artery (six patients), hepatic artery (three patients), splenic artery (seven patients), and inferior mesenteric artery (four patients). Five deaths occurred after operation, two early and three late, all from myocardial infarctions. All patients who survived have been relieved of their pain, and there has been no recurrence. The average length of follow-up has been 60.9 months and repeat angiography in six patients at intervals of up to 5 years has shown no evidence of revascularization occlusion.     

Recent trends in the diagnosis and management of chronic intestinal ischemia

This paper reviews the operative management over the past 27 years of 102 patients with chronic mesenteric ischemia, and summarizes recent clinical trends and ongoing research in this area. The most important trends in the diagnosis and management of chronic intestinal ischemia include: (1) increasing use of duplex ultrasound scanning in the initial evaluation of patients with possible intestinal angina; (2) rapidly evolving noninvasive clinical tests to assess mucosal perfusion (reflectance spectrophotometry, laser Doppler flow analysis, and tonometry); and (3) preferential use of antegrade mesenteric grafts or transaortic endarterectomy for mesenteric atherosclerotic occlusive disease. Surgical revascularization continues to provide excellent early relief of symptoms (93%) and a low late recurrence rate (10%). New noninvasive diagnostic tests for chronic intestinal ischemia and excellent results of surgical revascularization support a continued aggressive approach to the early recognition and treatment of patients with chronic intestinal angina. With the aging population, we anticipate that the number of patients with chronic intestinal ischemia will increase.Presented at the Meeting of the French Society of Vascular Surgery, Strasbourg, France, June 22–25, 1989.     

肛门直肠重建的解剖学基础

低位直肠癌的传统术式是Mile手术，因术后必须做腹壁人工肛门，常使患者难以接受，甚至延误或拒绝治疗。因此，在根治癌肿的基础上，肛门直肠重建术日益引起人们的兴趣。本文就若干重建术与解剖学的关系讨论如下。     

肛门直肠重建的解剖学基础

低位直肠癌的传统术式是Mile手术,因术后必须做腹壁人工肛门,常使患者难以接受,甚至延误或拒绝治疗。因此,在根治癌肿的基础上,肛门直肠重建术日益引起人们的兴趣。本文就若干重建术与解剖学的关系讨论如下。一、括约肌复合体(sphincter complex,SC)近年来,随着MRI和超声内镜等影像技术的进步,在活体上直接获得了与传统观念完全不同的括约肌形态学征象,2002年Fritsch等[1]首次提出SC的新概念。正确认识SC,对科学地设计保肛术式并获得最佳手术效果具有重要意义。1.SC的形态学特征:SC是指肛提肌和外括约肌(ES)之间包绕肛直肠的全部纤维…     

Anatomic basis of hepatic surgery

Modern hepatic surgery is based on precise anatomic foundations. The importance of this information applies to all levels of the diagnostic and therapeutic chain. Modern methods of imaging--CT scanning, MR imaging, and preoperative sonography--help physicians to detect variations and plan surgical excision.     

Mesenteric angioplasty in the treatment of chronic intestinal ischemia

Purpose: This study was undertaken to determine the safety and efficacy of percutaneous transluminal angioplasty (PTA) in the treatment of chronic mesenteric ischemia (CMI) in very high-risk surgical patients.Methods: Twenty-four focal mesenteric stenoses treated from 1984 to 1994 by PTA in 19 patients with CMI were reviewed. All 19 patients were considered poor surgical candidates. Seventeen patients had classic symptoms of CMI, and two patients had atypical abdominal complaints. Vessels dilated included the superior mesenteric artery (18), celiac artery (3), inferior mesenteric artery (1), aorta superior mesenteric artery vein graft (1), and aorta splenic artery vein graft (1). Complete follow-up was possible in all patients, with the exception of one patient who had no symptoms when last seen 17 months after the procedure.Results: PTA was technically successful in 18 of 19 patients (95%) and 23 of 24 stenoses (96%). The lone technical failure resulted in superior mesenteric artery dissection with thrombosis and bowel infarction; the patient died despite emergent laparotomy and revascularization (mortality rate, 5%). Complete symptomatic relief was attained in 15 patients (79%), with follow-up showing continued relief of symptoms for a mean of 39 months (range, 4 to 101 months). Partial symptomatic relief was attained in three patients. Recurrent symptoms developed in three patients (20%) at a mean interval of 28 months (range, 9 to 43 months). Repeat PTA performed in two patients provided good technical results and relief from clinical symptoms. One patient had a symptomatic axillary sheath hematoma that required surgical decompression.Conclusions: Mesenteric PTA is a valuable treatment option in patients who have CMI and are considered very high operative risks. The initial technical success rate is excellent, with the majority of patients having complete symptomatic improvement and continued relief of symptoms at short-term follow-up. (J Vasc Surg 1996;24:415-23.)     

Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia

OBJECTIVE: Complete revascularization is recommended by many authors for treatment of intestinal ischemia. The observation that postprandial intestinal hyperemia is limited to the superior mesenteric artery (SMA) has suggested to us that SMA revascularization alone should be adequate treatment. We preferentially manage intestinal ischemia with a single bypass graft to the SMA and herein update our results using this approach. METHODS: Patients were identified from a prospectively established vascular surgical registry. Each patient was assessed for acute versus chronic intestinal ischemia, preoperative angiographic findings, operation used, perioperative morbidity and mortality, late symptomatic relief, cause of death, and life table-determined survival and graft patency. Graft patency was determined by follow-up angiography or duplex scanning. RESULTS: Fifty bypass grafts to the SMA alone were performed in 49 patients (31 women, 18 men; mean age, 62 years) for treatment of intestinal ischemia. In all patients additional splanchnic arteries were available for bypass grafting. Operative indications were acute symptoms in 21 patients, 14 of whom had bowel infarction; chronic symptoms in 26 patients; and prophylaxis in conjunction with infrarenal aortic surgery in 3 patients. Thirty-two grafts originated from the aorta or an iliac artery, and 18 originated from an aortic graft. There were 40 prosthetic and 10 autogenous conduits. Perioperative mortality was 3% in patients with chronic symptoms and 12% overall. All survivors were symptomatically improved. Mean follow-up was 44 months. Nine-year assisted primary graft patency was 79%, and 5-year patient survival was 61%. Two late deaths occurred in patients with recurrent intestinal ischemia resulting from graft occlusions. CONCLUSIONS: Bypass grafting to the SMA alone appears to be both an effective and durable procedure for treatment of intestinal ischemia. Our results appear equal to those reported for "complete" revascularization for intestinal ischemia. When the SMA is a suitable recipient vessel, multiple bypass grafts to other splanchnic vessels are unnecessary in the treatment of intestinal ischemia.     

Radiology in intestinal ischemia. Angiographic diagnosis and management.

Angiography is an essential component of the diagnosis and treatment of patients with acute and chronic intestinal ischemia. Aortography and selective angiography permit identification of the cause and precise anatomy of intestinal ischemic syndromes, and also help plan their potential correction. Direct intra-arterial infusion of pharmacologic agents into splanchnic vessels has now become part of the therapy of these conditions. This article reviews angiographic techniques and their applications in the management of intestinal ischemic syndromes.     

Anatomic basis of the harvest of abdominal organs for organ transplants

The abdominal organs removals, with a view to transplants, are complex surgical operations which require a perfect knowledge of visceral vascular anatomy. The common point of these removals is the "birenal en bloc excision", whose we have codified the development. This removal has induced us to revise many points of surgical anatomy and particulary: the connections between the liver and the right kidney; the importance of the mesoduodenum; the relative orientations of the portal vein and inferior vena cava axis; the ureteral vascularisation; the topography and the number of renal arteries; the connections between renal arteries orifices and superior mesenteric arterial orifice. When we have to remove, besides the kidneys, the liver or the pancreas or even the small intestine, surgical problems are the same, but then, the dissections concern also the celiac axis and the superior mesenteric artery. These multiple removals raise also many questions to the anatomist, the most interesting concerning: the multiple hepatic arteries; the connections between celiac branches of the abdominal aorta. All these notions are envisaged not only by the light of the anatomical preparations but also by reference to the clinical experience of the authors.     

Laparoscopic diagnosis and treatment of intestinal obstruction

Background: Intestinal obstruction is a common reason for general surgical referral. The traditional approach has been conservative management, followed by laparotomy if conservative measures are unsuccessful. However, with the advent of minimally invasive surgery, the need for laparotomy for this common problem is being challenged.Methods: From May 1991 to April 2001, 167 patients underwent laparoscopy for diagnosis and/or treatment of intestinal obstruction. Average patient age was 62 years (range, 21–98). The site of obstruction was the stomach in seven patients, small bowel in 116 patients, and colon in 44 patients.Results: Laparoscopy successfully diagnosed the site of obstruction in all patients. In addition, 154 patients (92.2%) were successfully treated laparoscopically without conversion to laparotomy. Both intraoperative and postoperative complication rates were low (3.5 and 18.6%, respectively) and compared favorably with those of published reports.Conclusions: Intestinal obstruction can be approached safely and effectively by laparoscopy with the intent not only to correctly diagnose the patient but also to render treatment.     

肠结核的诊治体会

目的　总结肠结核的诊治经验。方法　回顾性分析华山医院１９７５ 年至１９９７ 年收治的３９ 例肠结核患者诊治情况。结果　临床表现以慢性腹痛和低热为主,分别占９２－３％ 和８４－６％ ;有排便习惯改变者占６４－１％ ;Ｘ线检查和／ 或纤维结肠镜确诊者占８１－８ ％ ;２５ 例经非手术治疗治愈,１４ 例因完全性肠梗阻、肠穿孔、腹块、肠瘘等并发症而行手术治疗。结论　凡遇慢性腹痛和低热者应排除肠结核的可能,仅在出现并发症时才考虑手术。     

低位直肠癌保功能手术的解剖学基础

尽管全直肠系膜切除术（TME）是直肠癌根治术的金标准．但术后有一定的泌尿生殖功能障碍发生率。我们通过盆腔筋膜的解削研究明确了TME正确的手术层次,并进一步界定了手术层次与盆腔神经的关系．以期减少术巾神经损伤。值得注意的是,盆丛存在两种形态。如果盆丛为弥散状,完整的切除直肠系膜将不可避免地损伤盆丛,因而需通过深入的研究明确盆丛不同的功能单位。