一期肠切除肠吻合术治疗新生儿坏死性小肠结肠炎后肠狭窄

目的总结一期肠切除肠吻合术治疗新生儿坏死性小肠结肠炎(necrotizing enterocolitis,NEC)后肠狭窄的经验。方法回顾性分析2012年6月至2019年6月上海市儿童医院普外科行一期肠切除肠吻合术治疗的18例NEC后肠狭窄患儿临床资料(包括确诊NEC后至肠狭窄的时间、手术年龄、狭窄部位、术后并发症等)并进行经验总结。结果18例确诊NEC后至肠狭窄的平均时间为45.7天;手术时平均日龄73.8天。狭窄部位仅1处者14例:7例位于回肠末端,5例位于升结肠,2例位于降结肠;多发狭窄者4例,其中1例位于回盲部和降结肠乙状结肠交界部,1例位于回肠末端和降结肠乙状结肠交界部,1例位于升结肠和横结肠中段,1例位于结肠肝曲和脾曲。5例出现术后并发症,其中4例再次行肠造瘘术,原因分别为:2例吻合口漏、1例吻合口狭窄、1例吻合口近端肠粘连扭转坏死;另1例再发回盲部狭窄,再行肠切除肠吻合术。18例均获随访,预后良好,4例肠造瘘者已关瘘3例,无其他并发症。结论一期肠切除肠吻合术治疗NEC后肠狭窄效果整体良好,狭窄常发于末端回肠和升结肠。诊断需综合临床表现及消化道造影结果,术中需对可疑肠管注水充盈以排除多发狭窄。NEC后肠狭窄有一定的发病形成时间,需把握一期手术时机并保证剩余肠管质量,避免发生术后再发狭窄或其他并发症。     

先天性高位肛门直肠畸形不同结肠造瘘方式的对比研究

目的比较先天性高位肛门直肠畸形新生儿期结肠袢式造瘘术、乙状结肠分离式造瘘术及其改良术式的优缺点。方法回顾性分析复旦大学附属儿科医院2007年6月至2017年6月收治的148例先天性高位肛门直肠畸形肠造瘘患儿的临床资料,其中男童115例,女童33例,平均出生体重为(3 240±572)g,平均胎龄(38.07±1.1)周,根据造瘘方式分为3组:A组采取结肠袢式造瘘(A1组:横结肠袢式造瘘术;A2组:乙状结肠袢式造瘘术);B组采取乙状结肠分离、远端缩窄式造瘘;C组采取单纯乙状结肠分离式造瘘。对各组手术时间、造瘘口脱垂、造瘘口内陷、远端粪石残留、Ⅱ期术前评估及手术难易等资料进行总结。结果 3组患儿出生体重、胎龄、手术时间比较差异无统计学意义(P0.05)。A1组术前行远端肠造影成功仅3例(20.0%),A2组术前远端造影成功4例(66.7%),B组术前行远端肠造影成功46例(79.3%),C组术前行远端肠造影成功20例(62.5%),差异有统计学意义(χ~2=18.834,P0.001)。B组出现远端造瘘口闭塞3例,A、C组未出现远端闭塞病例。所有患儿于二期肛门成形术中发现直肠盲端积粪扩张16例,其中A1组13例,A2组3例;B组和C组均未发现直肠盲端积粪扩张,3组远端肠管积粪扩张发生率比较差异有统计学意义(χ~2=45.276,P0.05)。A组中有5例发生腹壁伤口感染,而B、C组各有1例发生腹壁伤口感染,3组腹壁伤口感染率比较,差异有统计学意义(χ~2=6.745,P0.05)。A组有1例出现造瘘口肠管脱垂,该例无肠管内陷;B组有3例出现造瘘口肠管脱垂,脱垂肠管为近端;C组有2例出现造瘘口肠管脱垂,均为造瘘近端肠管。3组肠管脱垂发生率比较差异无统计学意义(χ~2=0.426,P=0.808)。结论新生儿期先天性肛门闭锁单纯乙状结肠分离式造瘘效果优于结肠袢式造瘘及乙状结肠分离远端缩窄的造瘘方式。乙状结肠近降结肠处造瘘,可降低二期手术难度。     

先天性结肠闭锁18例诊治分析

目的：探讨结肠闭锁的病因、分类、临床表现、外科治疗及预后。方法收集本院2004年10月至2013年10月收治的18例结肠闭锁患儿临床资料,总结我们在诊疗方面的经验。结果18例患儿中,外院造瘘1例,本院急诊手术17例,均在入院后8～20 h内手术。闭锁部位发生在横结肠8例,升结肠3例,降结肠2例,结肠肝曲2例,结肠脾曲2例,乙状结肠1例。Ⅲ型14例,Ⅰ型2例,Ⅱ型2例。14例行一期肠吻合术,3例行乙状结肠造瘘,1例术中放弃治疗。全组有2例死亡。结论当闭锁发生在近端结肠时应选择回结肠吻合;当闭锁盲端在脾区以远,可以保留回盲部及部分近端结肠行结结肠吻合;如果闭锁盲端超过乙状结肠或患儿一般情况较差时,应先行肠造瘘。     

小儿结肠狭窄三例并文献复习

目的 探讨小儿结肠狭窄可行且实用的诊治方法。方法 回顾性分析2008年7月至2018年7月收治的3例乙状结肠狭窄患儿的临床资料。其中,男2例,女1例;年龄9个月至2岁1个月。通过Pubmed数据库、万方医学网及申请文献传递等方式收集并详细分析小儿结肠狭窄并手术治疗的文献资料。本次检索的关键词为结肠狭窄(Colonic stenosis及Colonic stricture)和小儿(Child)。文献的发表时间范围为1968年1月至2018年11月。结果 本组中1例有新生儿坏死性小肠结肠炎(NEC)病史,合并回肠末端狭窄。另2例为先天性乙状结肠狭窄,其中1例合并凝血系列异常。3例均导致急性肠梗阻并手术,1例行狭窄结肠切除,端端吻合术;2例行一期狭窄段切除加近端肠造瘘,二期关瘘手术。3例术后均恢复良好,随访至今无并发症。将检索到的文献分为先天性结肠狭窄组及继发性结肠狭窄组。其中,先天性结肠狭窄组共检索到19篇文献22例,行一期狭窄结肠切除并吻合术9例(41%),二期狭窄结肠切除并近端肠造瘘分期手术4例(18%),余者不详。继发性结肠狭窄组检索到31篇文献共180例;以NEC继发结肠狭窄为主要...     

疑似全结肠巨结肠回肠造瘘术后的二期手术策略

目的：探讨疑似全结肠巨结肠病例行急诊回肠造瘘术后二期手术的诊疗流程及手术方案。方法对本院2012年1月至2013年6月收治的22例回肠造瘘术后的疑似全结肠巨结肠患儿进行回顾性分析。患儿手术年龄3～13个月,平均年龄5．8个月。经下消化道造影后24 h复查腹平片及直肠测压检查。均行术中回结肠多处活检,冰冻病理检查。根据检查结果决定下一步手术方案。结果11例诊断为全结肠巨结肠,行经腹部切口辅助经肛门巨结肠根治术（全结肠切除回肠肛门吻合术）。2例确诊为长段型巨结肠,1例确诊为常见型巨结肠,行巨结肠根治术。8例排除巨结肠及巨结肠同源病,行关瘘术。术后患儿恢复可。结论对于因疑全结肠巨结肠而行回肠造瘘的患儿,二期手术前可行下消化道造影,造影后24 h复查腹平片以评估远端肠管排钡功能。术中行回结肠多处浆肌层活检快速冰冻病理检查可以明确诊断及病变范围,从而指导二期手术方案的选择,是一种可靠、可行、简便快捷的方法。     

节段性阑尾无神经节细胞症

作者报告了一3kg体重的患儿,年龄1个月,因食欲低下,便秘,体重增长极缓慢被收入院。钡灌肠示先天性短结肠,并疑全结肠无神经节细胞症。予以行直肠抽吸活检,示神经节细胞缺如,剖腹检查,从乙状结肠及横结肠近端行浆肌层活检,均未见神经节细胞,同时可见回肠远端肠管直径大小有明显差异,扩张段活检可见神经节细胞。予以行回肠远端造瘘,术后患儿生长发育良好。21个月后,行巨结肠根治术,术中见横结肠近端肠管直径大小不同,行结肠肝曲浆膜     

Management of intestinal strictures after necrotizing enterocolitis: retrospective study of 14 cases

目的 探讨新生儿坏死性小肠结肠炎(NEC)后肠狭窄临床特点和诊治经验.方法 对我院自2005年1月至2010年12月收治的14例NEC后肠狭窄临床资料进行回顾性分析.14例Bell分期Ⅰ期2例,Ⅱ期9例,Ⅲ期3例.临床表现为喂养不耐受、胃潴留、呕吐、腹胀等,出现症状的平均时间为发生NEC后29.7 d.11例腹部正侧位片均提示有固定扩张的肠袢；9例消化道造影,仅3例提示肠狭窄.术中发现狭窄部位:末端回肠8处、降结肠4处、结肠肝曲2处、结肠脾曲2处、升结肠1处、空肠中下段1处；其中4例为多发肠狭窄.14例中除1例放弃治疗均接受手术,8例Ⅰ期肠狭窄切除肠吻合术,其余分期手术.结果 术后均治愈出院.9例获随访,除1例因并发粘连性肠梗阻再次手术治疗外均获满意效果.结论 临床上NEC后反复喂养不耐受、腹胀应警惕肠狭窄发生.狭窄常发于结肠和末端回肠,必要时予以剖腹探查所有肠段,避免多发肠狭窄,多数Ⅰ期狭窄段切除肠吻合术效果良好.     

先天性肠闭锁／狭窄病变部位与预后关系的探讨

目的探讨特殊部位的肠闭锁／狭窄手术方法与预后的关系。方法回顾性分析本院自2006年6月至2011年6月收治的145例因肠闭锁／狭窄而行手术治疗的患儿临床资料,其中十二指肠闭锁／狭窄36例,空肠闭锁／狭窄46例,回肠闭锁／狭窄59例,结肠闭锁／狭窄4例。145例中,距屈氏韧带约20cm以内的肠闭锁／狭窄3l例,距回盲部20am以内的回肠闭锁／狭窄19例。结果总病死率为12．41％,术后并发症的总发生率为21．13％。距回盲部20cm以内的回肠闭锁／狭窄患儿术后并发症的发生率明显高于术后并发症的总发生率（P〈0．05）。结论末端回肠和结肠闭锁术后并发症的发生率高,先天性肠闭锁／狭窄的治疗强调围手术期的正确处理。     

新生儿胎粪性肠梗阻21例诊治分析

目的：探讨新生儿胎粪性肠梗阻的诊疗经验,提高新生儿外科医师对该病的认识。方法回顾性分析本院2002年至2012年收治的21例胎粪性肠梗阻患儿临床资料。结果21例中,17例为单纯型,4例为复杂型;20例行稀释泛影葡胺灌肠造影,依靠该检查明确诊断5例,其中3例经非手术治疗痊愈。18例手术患儿中,14例单纯型行急诊手术治疗,其中10例采用肠管切开灌洗＋肠造瘘术（7例采用回肠双腔造瘘术,3例采用回肠Bishop-Koop造瘘术）,4例采用阑尾切除、肠内灌洗术（3例留置阑尾造瘘管）。4例复杂型均行急诊手术,2例采用回肠双腔造瘘术,2例术中放弃治疗。18例手术患儿中,16例术后恢复良好,10例造瘘患儿术后7～16周行造瘘还纳术。结论稀释泛影葡胺灌肠造影既能有效协助诊断,又能使少部分患儿治愈;Bishop-Koop造瘘术为首选术式;胎粪较易排出的患儿可选用阑尾切除、肠内灌洗术。     

新生儿巨结肠类缘病

目的探讨新生儿期先天性巨结肠类缘病(HAD)的临床和病理特征及恰当的处理方式。方法回顾性总结1990～2004年间手术治疗的HD患儿315例，重新复习术后病理切片(HE染色)。发现新生儿HAD17例。其中14例表现为腹胀、便秘、呕吐；3例表现为肠穿孔的症状。病理分型混合型11例：HD IND3例、HD 节细胞减少症1例、HD 节细胞未成熟7例；单纯型6例：IND3例、肠神经元发育异常3例。经历的手术方式：单纯肠造瘘；小肠部分切除 肠吻合或造瘘；右半结肠切除；巨结肠根治术；造瘘口关闭术；肠粘连松解术等。6例行过2次手术；10例曾行3次(包括3次)以上手术；1例行回肠造瘘。13例已行巨结肠根治术。结果2例死于多次手术导致的肠功能异常、营养不良、感染等；2例需经常回流洗肠协助排便；1例回肠造瘘后4月在观察中；2例失访；其余随年龄增长肠道功能逐渐恢复正常。结论HAD的存在应引起临床医生足够的重视，疑似HD的患儿术前应尽量做到诊断明确，以便施以正确的术式，避免多次手术。按HD根治术后效果不满意者，应再复习病理切片，防止遗漏HAD的诊断。     

Differences in the clinical and radiologic patterns of rotavirus and non-rotavirus necrotizing enterocolitis

We analyzed retrospectively 32 successive infants who developed necrotizing enterocolitis (NEC), 13 with rotavirus (RV) infection (RV+) and 19 RV-negative (RV-). All patients showed at least pneumatosis intestinalis. All patients except one had risk factors for perinatal asphyxia. Our study demonstrated significant differences between RV+ NEC and RV- NEC cases: RV+ NEC infants had a higher birth weight and were born at a later gestational age. Oral feeding was started earlier and symptoms developed later and more insidiously in RV+ patients than in RV- NEC babies. Radiology revealed a less severe and more distal colon involvement in RV+ NEC infants, whereas the RV- NEC patients mostly had small intestinal or ileocecal changes and more frequent complications of pneumoportogram and intestinal perforations. These latter infants often had a rapidly deteriorating clinical course; 84% needed surgical treatment. In conclusion RV may be a cause of NEC in susceptible infants. Historic and clinical data and a more distal colonic pneumatosis allow a differentiation of RV+ NEC from other forms of NEC.     

Perforated enterocyst: a late complication of neonatal necrotizing enterocolitis

Infants with necrotizing enterocolitis (NEC) may develop late sequelae including intestinal stenoses, enteric fistulae, abscess formation, recurrent NEC, cholestasis, malabsorption, short gut syndrome, and enterocyst formation [4]. A case is reported where a child developed an enterocyst arising from the proximal aspect of a defunctionalized Hartmann's pouch 2 years after ileostomy and near-total colectomy. The patient presented with fever and abdominal pain and distension, and was successfully treated by excision of the perforated enterocyst. This rare complication demonstrates that problems may develop in a defunctionalized bowel segment long after primary therapy for NEC.     

Paneth cell hyperplasia and metaplasia in necrotizing enterocolitis

Paneth cell dysfunction has been suggested in necrotizing enterocolitis (NEC). The aim of this study was to i) study Paneth cell presence, protein expression, and developmental changes in preterm infants with NEC and ii) determine Paneth cell products and antimicrobial capacity in ileostomy outflow fluid. Intestinal tissue from NEC patients (n = 55), preterm control infants (n = 22), and term controls (n = 7) was obtained during surgical resection and at stoma closure after recovery. Paneth cell abundance and protein expression were analyzed by immunohistochemistry. RNA levels of Paneth cell proteins were determined by real-time quantitative RT-PCR. In ileostomy outflow fluid, Paneth cell products were quantified, and antimicrobial activity was measured in vitro. In acute NEC, Paneth cell abundance in small intestinal tissue was not significantly different from preterm controls. After recovery from NEC, Paneth cell hyperplasia was observed in the small intestine concomitant with elevated human alpha-defensin 5 mRNA levels. In the colon, metaplastic Paneth cells were observed. Ileostomy fluid contained Paneth cell proteins and inhibited bacterial growth. In conjunction, these data suggest an important role of Paneth cells and their products in various phases of NEC.     

1型和2型黏蛋白在新生儿坏死性小肠结肠炎患儿肠组织中的表达变化

目的观察新生儿坏死性小肠结肠炎（NEC）患儿肠黏膜屏障中1型和2型黏蛋白（MUC1和MUC2）的表达变化。方法病例对照研究。NEC组为重庆医科大学附属儿童医院病理科NEC患儿手术肠组织病理切片中随机选取10份，并查阅住院病历收集一般临床资料；对照组为重庆医科大学附属儿童医院病理科先天性肠闭锁病理切片，以选取的NEC患儿的胎龄、发病日龄行1∶1匹配，利用HE染色对NEC组肠组织结构变化进行研究，以免疫组织化学方法对肠组织样本中MUC1及MUC2的表达变化进行分析。结果NEC组及对照组肠组织在结构上有明显差异，NEC组患儿肠组织结构的完整性破坏甚至消失，表现为大量绒毛脱落、坏死，黏膜下层及肌层水肿，毛细血管扩张充血，样本肠壁层炎性细胞浸润，肠组织杯状细胞及隐窝减少；NEC患儿肠组织MUC1及MUC2表达均明显低于对照组（以累计光密度值统计，MUC1中位数：NEC组780 455.5 vs 对照组19 175 070.4，P=0.004；MUC2中位数：NEC组3 039 120 vs 对照组45 750 707.5，P=0.001）。结论NEC患儿肠黏膜屏障中MUC1及MUC2表达显著降低，可能参与了NEC的发病过程。     

Problems of ileostomy in necrotizing enterocolitis

Exteriorization of the intestine and resection of the gangrenous bowel are major therapeutic regimens for necrotizing enterocolitis (NEC). Ileostomy associated complications are well known, therefore the time of ileostomy closure is a matter for discussion. Between 1975 and 1992, 84 patients with NEC were treated surgically. Ileostomies were performed in 37 children (44%). Of these 37 neonates, 9 (7M, 2F) died. In the remaining 28 patients (16M, 12F) with a mean gestational age of 35.8 weeks and a mean birth weight of 2412 g, ileostomies were performed between the 2nd and 11th days after birth. On average, the stomies were in function for 91 days, and within this period the average weekly weight gain was 153 g. Nineteen patients of this group did not show any problems attributable to the ileostomy. In 9 patients (32%) complications occurred, requiring a preplanned closure of the stoma. Postinflammatory strictures of bowel were diagnosed in 9 patients and resection of the stenotic intestine was performed at the same time as stoma closure. In conclusion, an appropriate weight gain can be achieved in patients with an ileostomy with an adequate feeding regimen. In otherwise uncomplicated cases, ileostomy closure can be delayed by up to 10 weeks when simultaneous surgical correction of additional intestinal strictures is possible. In one-third of patients with an ileostomy, however, complications may occur and urge a preplanned closure of the stoma.     

Necrotizing enterocolitis. Results of surgery

From 1975 to 1991, 132 patients with necrotizing enterocolitis (NEC) were treated at the Department of Pediatric Surgery in Graz. Two of 49 conservatively treated patients died (4%), 1 of these was not operated upon due to complex additional malformations, and the other, a baby with 860 g birth weight (BW), could not be resuscitated sucessfully. Eighty-three patients were treated operatively, 78% with intestinal resection and exteriorization of the bowel. The mean gestational age (GA) was 36 weeks, the mean BW 2,400 g. Nearly all the patients had a medical history of one or more of the well-known predisposing risk factors; 65% had an intestinal perforation at laparotomy, 25% a transmural intestinal necrosis, and 10% pneumatosis or hemorrhagic inflammation of the intestine. Overall mortality in operated patients was 21.7% (n = 18), including 4 deaths in patients with total intestinal necrosis. There were 12 operative deaths, mainly due to progressive septicemia or total intestinal necrosis, and 6 late deaths due to infection, congenital heart disease, or cerebral disease. The mortality declined from 34% before 1985 to 7.7% after 1985 and 6.3% in the last 5 years of this study. Thirty operative complications consisted chiefly of late stenoses, ileus, or late anastomotic complications. Among these patients, only 1 with septicemia after ileostomy closure died. In contrast, all major nonoperative complications caused death, primarily due to infectious problems with septicemia. Mature granulocytes at admission were significantly higher among operated survivors (42.9% vs 23.0%) and represented a valuable predictor of patient survival. In conclusion, despite some differences in this population group with respect to the literature (higher GA and BW), the results show a definite increase in survival, reaching more than 90% of operated patients with NEC. Correspondence to: M. E. Höllwarth     

新生儿坏死性小肠结肠炎手术介入治疗的临床分析

目的：评价新生儿坏死性小肠结肠炎（NEC）手术介入治疗的高危因素、预后因素及手术时机。方法：选取2001年10月至2011年10月10年间入住新生儿重症监护室的62例NEC早产儿患者。根据患儿是否需要手术治疗分为手术组（n=20）和非手术组（n=42）。比较两组患儿的一般资料、合并症、临床症状、实验室检查、治疗方法、预后等各因素。结果：呼吸窘迫综合征发生率、肠鸣音消失比例、CRP及血小板水平、血培养阳性比例、X线表现为气腹和固定肠绊及机械通气比例在两组间差异有统计学意义（P<0.05）。手术组患儿预后因素分析显示治愈患儿多处穿孔率及循环衰竭率显著低于死亡患儿,差异有统计学意义（P<0.05）。手术组20例患儿中,19例（95％）在NEC诊断后1周进行手术,15例顺利完成手术。结论：NEC手术介入治疗的高危因素是多因素的;手术的预后与肠道病变及是否循环衰竭有关。NEC手术时间一般在NEC诊断后1周内。     

早产儿坏死性小肠结肠炎临床流行病学特点

目的 对上海市早产儿中心近10年间NEC临床流行病学特点进行分析，旨在加强对本病的进一步认识，早期诊断，早期干预，进一步提高早产儿存活率。方法 调查1993年1月1日-2002年12月31日出生的1869例早产儿，对确诊NEC的59例临床资料进行比较分析，寻找引起。NEC可能的相关因素。结果 早产儿NEC发生率为3．16％。胎龄小、体重低、胃肠道动力功能差及局部免疫应答能力低下、感染仍是NEC发病重要的影响因素。临床分度与预后密切相关。结论 减少早产儿发生率是降低NEC发病率的最好办法。加强早产儿的护理，实施正确喂养方案，促进胃肠蠕动功能，及时发现和控制感染是十分重要的预防措施。何时恢复喂养需谨慎判断。     

Necrotizing enterocolitis in infants with esophageal atresia awaiting delayed primary repair

Of 149 infants with esophageal atresia treated during a 13-year period, 5 (3%) developed postoperative necrotizing enterocolitis (NEC). Four of the 5 were premature with birth weights below 1.8 kg (Waterston group C), and all were from a group of 17 awaiting delayed primary esophageal anastomosis. In each case, NEC occurred suddenly and death ensued within 5 days. NEC should be included in the list of complications resulting from, or associated with, delayed primary repair of esophageal atresia.     

Intestinal obstruction following necrotizing enterocolitis (author's transl)

The increase in survival from necrotizing enterocolitis results in an increased rate of late sequelae. We would like to take the opportunity to emphasize these new complications by a review of our patient material. 11 (23.9%) patients from a total number of 46 showed signs and symptoms of intestinal obstruction at different points in the course of the disease. In two surviving patients out of this group of 11, a resection of postinflammatory gut stenosis had to be performed within the first year. In the 9 children who died, particular emphasis is being paid in the autopsy reports to obstructive lesions in the gastrointestinal tract. Due to this rather frequent event (23.9%) of postinflammatory formation of strictures and stenoses in the recovery from NEC a functional radiographic study of the intestinal patency seems mandatory before discharge of any patient with NEC with operative or conservative treatment.