腹腔镜联合胆道镜在小肠出血手术中的应用

目的探讨腹腔镜联合胆道镜在小肠出血手术中的应用。方法回顾性分析笔者所在医院2003年1月至2015年12月期间收治的21例小肠出血患者经腹腔镜联合胆道镜探查的临床资料。结果本组21例小肠出血患者均顺利完成腹腔镜探查,5例直接发现病灶,联合应用胆道镜检查发现病灶16例。病变部位位于空肠15例,其中肿瘤9例,憩室2例,血管病变4例;回肠5例,其中肿瘤3例,憩室1例,血管病变1例;多部位病变1例,为憩室。病理报告显示平滑肌瘤6例,腺瘤3例,平滑肌肉瘤1例,恶性间质瘤2例,Meckel憩室炎伴出血4例,血管畸形3例,黏膜下血管瘤2例。恶性肿瘤3例均位于空肠。术后患者复查大便隐血均阴性。恢复良好,随访未再发消化道出血。结论腹腔镜联合胆道镜检查对常规检查无法明确病因的小肠出血有较好的诊断价值,该技术方法操作简便、创伤小、病变诊断准确性高,在基层医院有较好的临床应用价值。     

36例小肠出血的外科手术治疗分析

分析外科手术在小肠出血中的诊断及治疗价值,并通过术后病理分析小肠出血的病因。纳入2014年至今于新疆医科大学第一附属医院就诊的不明原因消化道出血并手术治疗后明确为小肠出血的患者,对其临床资料进行回顾性分析。本研究共纳入小肠出血患者36例,手术成功35例,术后死亡1例,手术中均找到出血点。术前明确诊断5例,诊断明确的形式为增强CT、介入血管造影、胶囊镜。手术方式为开腹探查及开腹探查联合术中肠镜探查。小肠出血病例的病因依次为憩室(14例)、间质瘤(7例)、溃疡炎症性病变(6例)、异位胰腺(3例)、血管瘤血管畸形(3例)、淋巴瘤(2例)、腺癌(1例)。出血好发部位依次是空肠(25例)、回肠(11例);均为单发出血灶。术后随访时间为6~24个月,术后均未出现再出血情况。手术常见并发症主要为手术后切口感染共2例、术后吻合口狭窄1例。憩室与间质瘤是小肠出血的主要病因,术前小肠出血诊断率较低,开腹探查联合术中肠镜检查可提高诊断率。外科手术在小肠出血的诊断及治疗中有较大意义。     

腹腔镜辅助下小肠部分切除术应用探讨

目的探讨腹腔镜辅助下小肠部分切除术的方法和治疗价值。方法回顾性分析我院2001年1月至2006年6月施行的腹腔镜辅助下小肠部分切除术42例患者的临床资料。结果42例手术均在腹腔镜辅助下顺利完成。平均手术时间95min（65～150min），术中平均出血65ml（40～160ml），术后平均排气时间42h，平均住院7．5d（5～11d）。术后病理诊断为小肠间质瘤20例，小肠恶性淋巴瘤6例，原发性小肠腺癌5例，小肠多发转移癌1例，小肠憩室5例，小肠结核3例，小肠系膜炎性肿块2例。所有患者无病灶遗漏，无手术并发症，均痊愈出院，随访4～65个月未见复发。结论腹腔镜辅助下小肠部分切除术创伤小，操作简便，治疗效果满意。     

腹腔镜技术在小肠疾病诊治中的应用

目的 探讨腹腔镜技术在小肠疾病诊治中的应用。方法总结分析2000年5月至2004年2月解放军总医院收治的33例小肠疾病患者行腹腔镜探查和手术治疗的效果。结果33例患者手术均顺利完成，平均手术时间65min，术中出血量平均30ml。术后疼痛轻微，排便、排气时间平均32h，平均住院时间7d。术后病理检查诊断为小肠间质瘤24例（其中6例为低度恶性间质瘤），美克尔憩室5例，小肠恶性淋巴瘤4例。所有患者均痊愈出院，随访10-36个月未见复发。结论腹腔镜技术在小肠疾病诊治中具有良好效果，腹腔镜小肠手术是一种安全、有效的微创手术方法，值得临床推广应用。     

双气囊小肠镜对小肠出血部位的诊断价值

目的探讨双气囊小肠镜对小肠出血手术定位的临床应用价值。方法回顾性分析2003年6月至2005年12月间行双气囊小肠镜检查并行手术探查的56例小肠出血患者的临床资料。将术前小肠镜诊断结果与术中检查所见加以比较,并随访手术治疗的效果。结果54例(96%)经术前双气囊小肠镜检查发现出血病灶,其中53例(95%)术前的病灶定位与术中发现的病变部位基本一致,4例定性诊断不一致,1例手术探查未发现病灶。间质瘤是本组患者中导致小肠出血的最常见病因。结论双气囊小肠镜对小肠出血术前定位具有可靠的临床价值。     

小肠间质瘤的诊治

目的 探讨小肠间质瘤的诊断和治疗方法.方法 回顾性分析32例空回肠间质瘤患者的临床资料.结果 32例患者平均发病年龄52.8岁,病程10h至5年.主要临床表现为黑便、腹痛、腹部肿块、腹胀不适、发热、乏力、贫血、体重下降等.发生部位:窄肠26例,回肠5例,空回肠多原发性1例.B超检查12例提示腹腔肿块,其中4例提示来源于肠道,5例小能提示来源,3例误诊为卵巢肿瘤.4例行消化道造影,均阴性.20例行CT检查,均发现肿瘤或转移病灶,阳性发现率100%,其中15例定位于肠道肿瘤(75.0%).8例行数字减影血管造影(DSA),6例提爪小肠肿瘤.5例行小肠镜检查,均明确诊断小肠肿瘤.所有患者均手术治疗.术后经病理及免疫组化证实为间质瘤.4例肝转移患者口服格列卫治疗.22例获得0.5～5年的随访,术后复发4例,肝转移2例,死亡2例.结论 空回肠间质瘤缺乏特征性临床表现,CT和DSA对诊断有帮助,小肠镜诊断率高,手术及分子靶向治疗是其有效治疗方式.     

小肠间质瘤21例临床分析

目的：探讨小肠间质瘤的临床表现、诊断及治疗方法。 方法：回顾性分析收治的21例小肠间质瘤的临床资料。 结果：肿瘤位于十二指肠3例,空肠12例,回肠6例。主要临床表现为黑便、腹痛、腹部肿块、腹部不适、贫血等。术前确诊14例。本组均手术治疗,行胰十二指肠切除1例,小肠部分切除18例,小肠部分切除加肝部分切除2例。术后复发3例,1例腹腔广泛转移,1例局部复发并肝转移,再次行复发灶及肝转移灶切除,1例术后1.2年死亡,1例术后3年,仍存活。 结论：小肠间质瘤缺乏特异性临床表现,空回肠肿瘤缺乏特异性检查手段,容易误诊,手术是最有效的治疗方法。     

小肠间质瘤相关临床特征分析

目的 总结小肠间质瘤相关临床特征.方法 回顾性分析我科自2007年至2012年收治的31例小肠间质瘤患者的临床资料及随访资料.以腹部隐痛不适表现者7例,肠梗阻表现者8例,腹部包块表现着3例,消化道出血者11例,2例表现为纳差乏力等全身症状;术前行CT检查20例,11例诊断间质瘤,B超诊断9例,未能作出间质瘤诊断,上消化道造影3例,1例做出间质瘤诊断,内镜检查8例,4例做出间质瘤诊断;术后均行免疫组织化学检测：按照NIH分级：低风险度9例,中风险度5例,高风险度17例.结果 术后随访,复发10例,复发时间最短1个月,最长3年,中位时间18个月,复发后出现肝转移及网膜转移患者7例.结论 小肠间质瘤起病隐匿,缺乏临床特异性,术前诊断困难,术后更易复发.     

小肠、阑尾

克罗恩病102例临床分型及术式选择；成人美克尔憩室致肠梗阻的诊治；腹腔镜联合双气囊小肠镜在小肠出血中的诊断和治疗；小肠出血的诊断和治疗（附76例报告）[编者按]     

内镜联合腹腔镜切除胃肠道间质瘤可行性研究

目的研究内镜联合腹腔镜对胃肠道间质瘤进行切除的可行性及其临床疗效。方法选择2008年4月至2012年4月间诊治的102例胃肠道间质瘤患者，其中男性60例，女性42例；年龄在20~79岁，平均为（57．8±6．7）岁。62例为胃间质瘤，行腹腔镜联合胃镜治疗；40例为肠道间质瘤，运用腹腔镜联合肠镜进行治疗。所有患者围手术期均行胃肠减压、补充液体、营养支持以及预防性应用抗生素。待肠道功能恢复后，拔除胃管。短期内进行流质饮食，逐步过渡到正常饮食。对所有患者进行半年以上的随访观察。结果所有患者均成功实施手术，病变部位定位准确，手术过程所需时间为40-80min，术中出血量在5-30ml，无中转开腹手术的患者；术后无吻合口出血及吻合口漏等并发症。所有患者随访半年，均无肿瘤复发。结论两镜联合治疗胃肠道间质瘤，疗效明确，手术的安全性高，同时降低了开腹手术给患者带来的痛苦和损伤，是目前治疗胃肠道间质瘤的较为理想的一种方法。     

Laparoscopically assisted bowel surgery in an era of double-balloon enteroscopy: from inside to outside

Background  This report describes an integrated therapeutic method of double-balloon enteroscopy (DBE) and laparoscopically assisted bowel surgery (LABS) for small bowel diseases. Methods  In this study, 34 patients with obscure gastrointestinal bleeding (OGIB, n = 25) and abdominal pain (n = 9) who underwent DBE and LABS were analyzed. Demographics, patient characteristics, diagnostic tests, DBE and LABS findings, surgical results, and long-term outcome were reviewed. Results  All 34 patients underwent DBE without significant complications. Biopsy was performed for 16 patients, ink mark for 25 patients, and temporary homeostasis during DBE for 5 patients. Laparoscopically assisted bowel resection was performed for 27 patients, converted laparotomy for 6 patients, and laparoscopic diagnosis alone for 1 patient. The pathologic diagnoses included gastrointestinal stromal tumor (GIST) for eight patients, primary adenocarcinoma for three patients, lymphoma for three patients, Meckel’s diverticulum for three patients, angiodysplasia for three patients, ulcer for two patients, lipoma for four patients, metastasis for three patients, jejunal diverticulosis for two patients, and tuberculosis ileitis, ileal varix, and lymphangioma for one patient each. No surgical mortalities or significant morbidities were noted. After a follow-up period of 14 ± 3 months, 29 patients were well without disease recurrence. Two patients had symptomatic recurrence, and three patients died of cancerous progression. Conclusions  The combination of DBE and LABS represents an ideal therapeutic method, especially for OGIB caused by small bleeding neoplasms or vascular lesions.     

Diagnosis of small-bowel metastasis of hepatocellular carcinoma by double-balloon enteroscopy

INTRODUCTIONHepatocellular carcinoma (HCC) is a major cause of cancer-related deaths around the world. Nearly half of patients with HCC display metastatic disease at the time of initial diagnosis, frequently involving the liver, bone, brain, lungs, and adrenal glands, but gastrointestinal involvement is rare. Melena occurring secondary to a metastatic tumor from HCC is particularly rare. Herein, we present a case of melena secondary to metastatic HCC after chemoradiation to lung and brain metastases from HCC, diagnosed preoperatively by double-balloon enteroscopy. To the best of our knowledge, this represents the first such case to be reported.PRESENTATION OF CASE60-Year-old man had been diagnosed with hepatitis B virus-associated hepatocellular carcinoma (HCC). He was readmitted for investigation of general fatigue and iron-deficiency anemia. Esophagogastroduodenoscopy, total colonoscopy, and CT failed to identify any cause for gastrointestinal bleeding. Double-balloon enteroscopy, however, revealed small bowel metastasis from HCC preoperatively. After 5 days of conservative management, segmental small bowel resection and end-to-end anastomosis were performed. The histological appearances were considered typical for moderately differentiated HCC.DISSCUSSIONEndoscopic findings of gastrointestinal metastasis from HCC vary, such as raised and centrally ulcerated lesions, polypoid tumors, or submucosal tumors. Immunohistochemical findings are thus key to differentiating HCC from adenocarcinoma in the diagnosis of GIT metastasis. Some patients with gastrointestinal bleeding remain undiagnosed even after upper endoscopy and total colonoscopy, and most such patients will display bleeding sites in the small bowel. Video capsule endoscopy and DBE have been introduced recently for the evaluation of the small bowel. DBE, which was developed by Yamamoto et al.,⁵ allowed us to obtain biopsy specimens, circumventing one limitation of capsule endoscopy. In this case, DBE contributed significantly to diagnosis and treatment.CONCLUSIONDBE thus seems to represent a valuable method, particularly in the preoperative setting, due to the possibility of precisely identifying the tumor site and achieving preoperative diagnosis.     

Laparoscopy-assisted exploration of obscure gastrointestinal bleeding after capsule endoscopy: the Korean experience

BACKGROUND: Obscure gastrointestinal bleeding (OGB) is generally defined as recurrent acute or chronic bleeding for which no source has been identified by routine radiologic and endoscopic examination. The aim of this study was to report our early experiences detecting small bowel bleeding by capsule endoscopy (CE) and the results of laparoscopy assisted surgery for OGB. MATERIALS AND METHODS: Seventy-five patients with OGB were examined by CE. Twelve of 24 patients in the active bleeding group underwent laparoscopic or laparoscopy assisted surgery and we carried out intraoperative enteroscopy to find the focus of the bleeding. RESULTS: Laparoscopic localization of the lesion was successful for 4 patients-those with Meckel's diverticulum, gastrointestinal stromal tumor, lymphoma, and ischemic necrosis. In 3 cases in which there was no natural passage of the capsule endoscope, lesions were identified by small bowel exploration through simple palpation by hand. Intraoperative enteroscopy was performed extracorporeally in 5 cases through a minilaparotomy window using an extended incision of a port site less than 7 cm in length. The lesions that were identified by CE preoperatively were resected successfully, via laparoscopic or laparoscopy-assisted surgery. The gastrointestinal bleeding has not recurred during the postoperative follow-up period (mean, 10.6 months). CONCLUSION: The laparoscopic approach can be chosen for surgical management of OGB patients with active bleeding whose lesions have been identified by CE. This approach allows minimally invasive surgical treatment for ongoing OGB.     

小肠出血的诊断和治疗(附76例报告)

目的探讨小肠出血的病因、诊断和治疗措施。方法对我院近8年收治的病因明确的76例小肠出血病人的临床资料进行回顾性分析。结果本组小肠出血病人肿瘤占首位(37/76),其中包括小肠间质瘤32例,其余依次为美克尔憩室(21/76)、血管病变(15/76)及异位胰腺(3/76)。经数字减影血管造影诊断21例,小肠气钡双重对比造影诊断13例,腹腔核素扫描诊断11例,小肠镜检查诊断6例,腹腔镜探查诊断21例,剖腹探查诊断4例。全组病人均经手术治疗,手术方式以包括病变在内的小肠部分切除术为主(68/76)。随访时间6月～5年,临床疗效满意。结论气钡双重对比造影、核素扫描、数字减影血管造影、腹腔镜探查及剖腹探查是诊断小肠出血的主要手段。包括病变在内的小肠部分切除术是治疗小肠出血最有效方法。     

Results of a single-center experience with resection and ablation for sarcoma metastatic to the liver

HYPOTHESIS: A subset of patients with sarcoma liver metastasis may benefit from hepatic resection and/or ablation. DESIGN: Retrospective review of prospectively collected cancer center database records. PATIENTS AND METHODS: Sixty-six patients who underwent hepatic resection and/or open radiofrequency ablation of metastatic sarcoma between July 1, 1996, and April 30, 2005, were identified from the database. Clinicopathologic, operative, recurrence, and long-term survival data were analyzed. RESULTS: The primary sarcoma site was the abdomen or retroperitoneum (n = 22), stomach (n = 18), small or large bowel (n = 17), pelvis (n = 4), uterus (n = 3), or other (n = 2). Tumor pathologic types included gastrointestinal stromal tumor (n = 36), leiomyosarcoma (n = 18), and sarcoma not otherwise classified (n = 12). Thirty-five patients underwent resection, 18 underwent resection plus radiofrequency ablation, and 13 underwent radiofrequency ablation only. With a median follow-up of 35.8 months, 44 patients (66.7%) had recurrence (intrahepatic only, n = 16; extrahepatic only, n = 11; both, n = 17). Treatment with radiofrequency ablation (either alone or combined with resection) (P = .002) and lack of adjuvant chemotherapy (P = .01) predicted shorter disease-free survival. The 1-, 3-, and 5-year overall survival rates were 91.2%, 65.4%, and 27.1%, respectively. Patients with gastrointestinal stromal tumor who were treated with adjuvant imatinib mesylate had the longest median survival (not reached) (P = .003). CONCLUSIONS: Long-term survival can be achieved following surgical treatment of sarcoma liver metastasis, especially in patients with gastrointestinal stromal tumor. Patients with sarcoma liver metastasis should be evaluated by a multidisciplinary team, as recurrence is common and adjuvant therapy may prolong survival.     

腹腔镜诊治儿童美克尔憩室出血

目的研究腹腔镜在儿童Meckel憩室出血诊断和治疗中的应用。方法分析近年来采用腹腔镜治疗的Meckel憩室出血病例31例,男19例,女12例。结果腹腔镜治疗31例Meckel憩室中1例因粘连广泛改行开腹手术,合并肠重复畸形1例,肠套叠2例。其中楔形切除吻合12例,肠切除端-端吻合18例。同时进行了3例阑尾及4例斜疝的联合手术。结论腹腔镜的应用为儿童Meckel憩室出血的诊断和治疗提供了一条极好的途径,具有诊断和治疗的双重作用。提高了疾病的诊断率,减少了并发症的发生率,降低了医疗费用。     

Perforation through small bowel malignant tumors

Data on 19 patients (6 women and 13 men) with malignancy perforation through small bowel tissue were retrospectively reviewed. The median patient age was 57 years (range, 41–81 years). The histopathology included lymphoma (seven patients), leiomyosarcoma (two patients), gastrointestinal stromal tumor (one patient), adenocarcinoma (one patient), metastatic carcinomas with unknown primary tumor (four patients), metastatic adenocarcinoma from the lung (one patient), and metastatic carcinomas from the hypopharynx (one patient), cervix (one patient), and lung (one patient). Resection of a segment of perforated bowel with primary anastomosis was performed in 16 patients, wedge resection of perforated lesion with plication in two patients, and loop ileostomy in one patient. Postoperative deaths occurred in 10 (52.6%) patients, owing to sepsis and organ functional failure. Seven patients died from the primary malignancy at a median follow-up of 6.5 months (range, 5 months to 1 year 9 months) after surgery. Moreover, two patients with small bowel lymphoma were alive with disease at 4 years 8 months and 7 years 1 month after surgery. In conclusion, perforation through small bowel malignant tumors had a high postoperative mortality rate. High index of suspicion of the disease with early surgical treatment may improve treatment outcomes. Supported by Chang Gung Memorial Hospital, Taiwan, under contract No. BMRP072.     

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目的探讨胃肠道恶性间质瘤的临床诊断与治疗。方法回顾性分析1993～1999年22例胃肠道恶性间质瘤病人的临床资料。结果胃部肿瘤14例，小肠肿瘤8例。其中5例高度恶性，17例低度恶性1例广泛转移行肝结节活检，术后4个月死亡、4例行姑息切除，1例复发。其余行根治术，无病生存最长达5年。结论要提高对胃肠道恶性间质瘤的认识，加强免疫组化检查，确定良恶性及恶性程度，根治性手术对预后及防止复发有一定意义。     

Small Bowell Malignant Melanoma-Report of Three Cases and Review of Literature

Malignant melanomas have a predilection to metastasize to the small bowel. Three patients with malignant melanoma involving the small bowel are reported. Two patients were operated on for small bowel obstruction and the third for gastrointestinal bleeding with anemia. Two patients remained well 6 month and 2 years, respectively, after surgery. One patient died of metastatic cerebral melanoma 6 months postoperatively.

One should suspect small bowel metastasis in every patient with malignant melanoma in his past medical history, who presents with recent changes in bowel habits, intestinal obstruction or gastrointestinal bleeding. Preoperative assessment can only raise the suspicion, even with advanced imaging methods: capsule endoscopy, enteroscopy, CT or PET-CT. The only therapeutic procedure is surgical resection, offering both short term survival as well as an improvement in the quality of life. Although prognosis is dismal there are factors associated with prolonged survival: complete surgical resection with no residual primary or metastatic tumor, so-called primary small bowel tumors in patients aged more then 60 years, LDH < 200 U/L, lack of tumor spread in mesenteric lymph nodes.