克罗恩病并发十二指肠内瘘的外科治疗

目的 探讨克罗恩病并发十二指肠内瘘的外科治疗方法.方法 回顾性分析2002年1月至2014年1月南京军区南京总医院收治的1 012例克罗恩病患者的临床资料,其中22例并发十二指肠内瘘.22例患者中12例十二指肠-回结肠吻合口瘘,7例十二指肠-横结肠瘘,2例十二指肠-乙状结肠瘘,1例十二指肠-小肠瘘.通过放置鼻肠管越过十二指肠内瘘行肠内营养支持,待营养状况及BMI、Alb、C反应蛋白、红细胞沉降率、克罗恩病活动指数评分等指标恢复正常或显著改善后行手术治疗.手术方式为十二指肠瘘修补术＋原发病灶肠管切除术.通过门诊、电话及网络形式随访,随访时间截至2014年5月.营养支持治疗前后比较采用t检验,非正态数据采用Mann-Whitney u检验.结果 2例患者因腹腔感染、1例患者因消化道出血行急诊手术,其余19例患者均先建立肠内营养途径.3例急诊手术患者行肠造口术,术后2例出现十二指肠修补处瘘（1例经肠内营养＋冲洗引流12d后愈合、1例再次手术治疗后痊愈）.19例患者经营养支持治疗肠内营养能量供应为（25.3 ±2.1）cal/g、肠内肠外营养能量供应为（28.5±3.2） cal/g,营养支持治疗时间为（31±5）d,C反应蛋白、克罗恩病活动指数评分由入院前25 mg/L、（207±111）分降至2 mg/L、（117 ±71）分,治疗前后比较,差异有统计学意义（u=53.000,t=0.942,P＜0.05）.BMI、Alb、红细胞沉降率治疗前分别为（17.0 ±2.1）kg/m2、（35±5） g/L、26 mm/h,治疗后为（17.9±2.8）kg/m2、（38±5）g/L、23 mm/h,治疗前后比较,差异无统计学意义（t=0.482,1.170,u=67.500,P＞0.05）.19例患者中1例经肠内营养治疗后内瘘消失,避免了手术;其余18例患者中5例行肠造口术,13例行肠吻合术.22例患者均获得随访.平均随访时间为13.4个月（4.0～37.0）个月,1例患者术后6个月吻合口复发致十二指肠-回结肠吻合口瘘,再次行手术治疗,其余均?     

克罗恩病并发肠梗阻外科治疗的术式选择

克罗恩病（Crohn’s disease,CD）常与溃疡性结肠炎统称为炎症性肠病。CD的病理特征为非连续性（跳跃性）、透壁性炎症,以淋巴细胞聚集、非干酪样肉芽肿为主要特征,在内镜下典型的表现为鹅卵石样改变,阿弗他溃疡常位于肠壁的系膜侧并与肠壁纵轴平行。     

克罗恩病合并瘘手术治疗 24例

目的 总结分析外科手术治疗克罗恩病（CD）合并瘘的疗效和临床意义。方法对1980年1月至2005年4月期间收治的CD合并急性穿孔和瘘的手术病例进行回顾性分析。结果25年间确诊CD的181例中，合并瘘或穿孔病例24例（13．3％）。8例患者（33．3％）穿孔前明确使用过类固醇药物，9例无激素治疗史，其余7例情况不明。单一穿孔18例，2处游离穿孔4例，3处以上腹壁外瘘2例。急诊手术8例，择期手术16例；有20例在病变肠段切除的基础上，分别采取阴道或膀胱瘘口修补术4例，瘘管一期扩创切除12例，腹壁瘘管搔刮术4例；还有4例采取乙状结肠单腔造瘘加肛瘘切开术。术后5例患者（20．8％）出现并发症，其中切口感染2例，腹腔脓肿2例，吻合IEl瘘1例：均经外科引流、抗感染等保守措施治愈。死亡3例（12．5％），2例死于出血和持续高热；1例为感染合并多器官功能衰竭并造瘘口出血死亡。其余病例均痊愈出院。18例获6个月至18年的随访，5年瘘的复发率为16．7％，10年再手术率为33．3％。结论激素的应用并非构成CD合并瘘的主要因素，CD合并瘘应成为手术的明确指征。     

克罗恩病的流行病学及外科治疗

克罗恩病（Crohn disease，CD）是一种不明原因的、可累及全消化道的慢性复发性肉芽肿性炎症。其在我国乃至全世界范围内的发病率尚不甚清晰，在外科治疗的许多问题上也没有达成共识。     

克罗恩病并发腹腔脓肿的外科治疗策略

克罗恩病（Crohn’s disease,CD）是以消化道病变为主的一种免疫相关性疾病,目前发病率有显著增加趋势,近年相关基础研究与临床治疗进展很快。     

克罗恩病外科治疗进展

克罗恩病(Crohn's disease,CD)属于炎性肠病(inflammatory bowel disease,IBD)的一种,是一组病因尚不十分清楚的慢性特异性肠道炎症性疾病。近年来全球CD发病率呈上升趋势,国内报道也逐渐增多。CD可累及胃肠道各部位,以末段回肠及其邻近结肠为主,为一种累及肠壁全层的慢性肉芽肿性炎症。对CD主要采取内科治疗,近年来不断有新的药物应用于临床,取得了更好的疗效,但对药物治疗反应差或伴有严重并发症的病人仍需外科治疗。微创外科技术、快速康复外科及损伤控制性手术的理念也逐渐被     

克罗恩病外科治疗的特点

克罗恩病（CD）是炎性肠病（IBD）之一，在1761年为Morgagni所描述，1932年Crohn等著文详加叙述后，始被命名为Crohn disease。但至今仍不清楚致病因素。该病多发于北美、北欧等地区的青年人，且有家族性的可能，但世界各地也都有发生。我国也有此类病人，且近年来虽无流行病学的调查，但临床诊治的数量为之增加，可能是诊治水平提高，认识意向有所加强的缘故，生活环境的改变也可能促使此病的增多。CD虽为炎性肠病，以药物治疗为主，但也常涉及外科治疗。据统计，CD患病20年以上的病人中有78％须接受外科治疗。因此，腹部外科医生需要了解这一疾病有关特性。由于CD的病因不明，故尚无针对性很强的药物或外科手术治疗方法，所有治疗均只能是症状控制性治疗，延长缓解期，减轻发作期的症状。手术治疗是针对它的并发症，如梗阻、出血、穿孔、脓肿、炎性肿块、肠内外瘘等。这些并发症施行的手术术式虽与其他原因所致的类似情况相似，主要是切除并发症的肠段或对侵蚀成瘘的器官（膀胱、阴道等）进行修复，但需要了解它的一些特点给予相应的处理。     

克罗恩病并发直肠尿道瘘、肛周脓肿1例

1一般情况 患者男，25岁，因“肛周肿痛20d伴肛门漏尿半年”于2004年12月28日入院。患者诉1999年起出现腹泻伴发热，在职工医院对症治疗，效果差，后行大肠镜检查发现全结肠黏膜糜烂，即转入湖南医科大学附属湘雅医院，行电子肠镜，全消化道造影等检查，诊断为克罗恩病，给予对症治疗，效果较好。2004年初因精神刺激病情反复再次入住湘雅医院治疗，住院期间出现肛门部漏尿，行膀胱镜检查，     

腹腔镜外科治疗在克罗恩病中的应用

正炎症性肠病是一种以非可控性炎症反应为特点的肠道自身免疫性疾病。我国国民生活环境的改变特别是饮食结构和生活习惯的变化,导致近20年来克罗恩病的发病率逐渐上升。炎症性肠病已成为我国疾病负担最重的胃肠道疾病之一[1]。外科治疗是炎症性肠病的重要治疗方式之一,克罗恩病病人因肠腔狭窄、腹腔脓肿、肠瘘、消化道出血等并发症需手术治疗[2]。克罗恩病病人手术后恢复往往较慢,部分病人常需行二次手术。腹腔镜具有创伤小、疼     

克罗恩病的外科治疗分析

目的探讨外科治疗克罗恩病的手术时机及手术方式。方法回顾性分析了1998～2012年期间笔者所在医院收治的13例克罗恩病手术患者的临床资料。结果 13例患者中行急诊手术6例,择期手术7例;行左半结肠切除术2例,回盲部并小肠切除术4例,部分小肠切除术4例,右半结肠切除术2例,全结肠切除回肠造口术1例。本组仅7例获随访,随访时间12～48个月,平均38个月,有2例患者分别于术后16个月和31个月死亡,死亡原因为营养不良,消化道出血,多脏器功能衰竭;另外5例预后良好。结论对克罗恩病正确把握手术时机及选择手术方式,围手术期结合激素及免疫抑制剂治疗是取得满意治疗效果的关键。     

Surgical and metabolic management of patients with external fistulas of the small intestine associated with Crohn's disease

In order to define more clearly the principles of surgical and metabolic management of patients with external small bowel fistulas in association with Crohn's disease, a consecutive series of 85 patients (26 with Crohn's disease) was studied. The patients were all managed by one surgeon and, in the last 60 patients, management was according to a standard protocol. In 19 cases, detailed metabolic studies (body composition, plasma proteins, and total energy expenditure) were conducted at intervals during the period of treatment. In 69 (82%) of the 85 patients, successful closure of the fistula was achieved (36 spontaneously, and 33 surgically), and the mortality rate was 16%. The overall results were similar for the Crohn's patients, except that spontaneous closure occurred significantly less often (in 4 of 26 patients). Two distinct types of Crohn's fistula were observed. In 10 patients, the fistula arose in the early postoperative period and was not associated with residual Crohn's disease. The pattern of behavior and overall results of treatment of these patients were the same as for non-Crohn's patients. In 16 patients whose fistula arose from an area of Crohn's disease (6 postoperatively, 10 spontaneously after discharge of an abscess), spontaneous closure was not observed. Surgery was undertaken in 15 of these patients, and was successful in 14; one patient died. Studies of body stores of protein showed that massive losses (2% per day) occurred in patients in whom sepsis was uncontrolled, in spite of intravenous nutrition (IVN). Although the total energy expenditure of Crohn's patients was no different from that of non-Crohn's patients (45 kcal/kg per day), studies of total body protein while the patients were being given IVN showed that, when active Crohn's disease remained in situ, the expected increase in body protein stores of about 1 kg did not occur. It is concluded that fistulas unassociated with residual Crohn's disease should be managed along conventional lines. Those fistulas arising from diseased small intestine all require surgery. This is performed after sepsis has been drained, metabolic deficits (but not necessarily deficits of body protein) have been corrected, and the anatomy of the fistula has been defined. The surgical procedure is a radical one involving complete dissection of the entire small intestine, resection of the bowel involved, and performance of a primary anastomosis.

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Resumen Con el objeto de définir mejor los principios del manejo quirÚrgico y metabólico de pacientes con fistulas externas del intestino delgado asociadas con enfermedad de Crohn, se estudió una serie de 85 pacientes consecutivos, 26 de ellos con enfermedad de Crohn. Todos los pacientes fueron manejados por un solo cirujano, los Últimos 60 pacientes de acuerdo a un protocolo estándar. Se realizaron estudios metabólicos (composición corporal, proteínas plasmáticas, y gasto energético total) en 19 casos en el curso del tratamiento.El cierre exitoso de la fístula fue logrado en 69 (82%) de los 85 pacientes (espontáneamente en 36 y por intervención quirÚrgica en 33), y la mortalidad fue de 16%. Los resultados globales aparecieron similares en los pacientes con enfermedad de Crohn, excepto que el cierre espontáneo ocurrió con frecuencia significativamente menor (4 de 26 pacientes). Dos tipos bien definidos de fistula de Crohn fueron observados. En 10 pacientes la fistula apareció en el período postoperatorio temprano, sin estar asociada con enfermedad de Crohn residual; la evolución clínica y los resultados del tratamiento en estos pacientes fueron iguales a los de los pacientes sin enfermedad de Crohn. En 16 pacientes cuya fístula se originó en un área de enfermedad de Crohn (6 fístulas postoperatorias y 10 fistulas a raíz del drenaje de un absceso) no hubo cierre espontáneo; en 15 de ellos se realizó intervención quirÚrgica, con éxito en 14; un paciente murió.Los estudios de depósitos corporales de proteína mostraron pérdidas masivas (2% por día) en los pacientes con sepsis no controlada, a pesar de nutrición intravenosa. Aunque el gasto energético total de los pacientes con Crohn no fue diferente del de los pacientes sin enfermedad de Crohn (45 kcal/kg por día), los estudios de proteína corporal total en el curso de la nutrición intravenosa mostraron que mientras se mantuvo la enfermedad de Crohn in situ, no se logró el esperado aumento de 1 kg en los depósitos corporales de proteína.La conclusión es que las fistulas no asociadas con enfermedad de Crohn deben ser manejadas en forma convencional. Todas aquellas que se originan en el intestino delgado afectado requieren cirugía. La operación debe ser realizada una vez drenado el foco séptico, cuando los déficits metabólicos (pero no necesariamente los déficits de proteína corporal) estén corregidos y la fístula haya sido bien definida. El procedimiento quirÚrgico debe ser radical, incluyendo la disección completa del intestino delgado, la resección del segmento afectado, y la realización de una anastomosis primaria.

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Résumé Pour définir avec précision les principes du traitement chirurgical et métabolique des malades présentant une fistule externe de l'intestin grÊle associée parfois à une maladie de Crohn, une série de 85 cas (26 cas de maladie de Crohn) a été étudiée. Tous les malades ont été traités par le mÊme chirurgien et les 60 derniers selon un protocole standard. Dans 19 cas des études métaboliques détaillées (composition corporelle, protéine plasmatique, consommation totale d'énergie) ont été pratiquées.Dans 69 (82%) cas sur 85 la cicatrisation de la fistule fut obtenue (36 fois spontanément et 33 fois après intervention chirurgicale). Les résultats globaux furent identiques chez les malades atteints de maladie de Crohn ou non, bien que la cicatrisation spontanée fut peu fréquente (4 fois sur 26 en cas de Crohn). Deux types différents de fistules sur maladie de Crohn ont été observées. Chez 10 opérés la fistule se manifesta précocemment après l'intervention alors mÊme qu'il n'y avait pas trace de lésion résiduelle de Crohn. Le comportement et les résultats globaux furent alors identiques à ceux constatés chez les malades qui ne présentaient pas de maladie de Crohn. Chez 16 autres malades dont la fistule trouvait son origine au niveau d'une zone intéressée par l'affection (6 après intervention, 10 après évacuation spontanée d'un abcès) la cicatrisation spontanée fit défaut. Chez 15 d'entre eux il fut nécessaire d'intervenir: 14 fois avec succès alors qu'un opéré décéda.Les études des réserves protéiques mirent en évidence des pertes massives (2% par jour) chez les malades présentant une infection incontrÔlée, et ce, malgré l'alimentation parentérale. Bien que la consommation énergétique totale chez les malades atteints de maladie de Crohn ne fut pas différente de celle des malades indemnes de cette affection (45 Kcal/kg/jour), les études de la réserve protéique totale, alors que les malades étaient soumis à l'alimentation parentérale, montrèrent que l'augmentation escomptée des réserves protéiques ne se manifesta pas dès lors que les lésions actives du Crohn restaient in situ.On peut conclure de ces faits que les fistules, en l'absence de maladie de Crohn résiduelle, peuvent Être traitées de faÇon conventionnelle. Dès lors qu'elles se manifestent sur intestin altéré, il est nécessaire d'avoir recours à la chirurgie. L'intervention doit Être pratiquée après drainage de l'abcès, correction des déficits métaboliques (pas nécessairement les déficits protéiques) et définition correcte de l'anatomie de la fistule. L'intervention radicale comporte la dissection complète de l'intestin grÊle, la résection du segment intestinal intéressé, et la réalisation immédiate de l'anastomose intestinale.

     

Surgical management of perforated Crohn's disease

The records of 102 patients operated on by one of the authors for Crohn's disease during the past 15 years were reviewed. Twenty-seven patients with confined (abscess present) or free perforation were evaluated. The average age was 31 years and the mean duration of disease was four years. Only two of the 27 patients had had previous surgery. All patients presented with a combination of pain, weight loss, and diarrhea. Twenty-three patients were afebrile, 17 had abdominal tenderness, and 6 had an abdominal mass. The average serum albumin was 3.7, the average hematocrit was 35 per cent and the average WBC was 13,000. Radiologic tests were abnormal in 23 of the 27 patients. All patients had been on medical treatment for Crohn's disease, and 19 of 27 were on high-dose steroids at the time of surgery. Ten of the 27 had a bowel prep before surgery and all had preoperative and postoperative antibiotics. All patients were surgically managed by resection and primary anastomosis without proximal diversion or delayed reconstruction. Drains were used in one third of the patients. Intraoperative cultures revealed gram-negative rods with Escherichia coli, enterococcus, and Enterobacter the most common. One enterocutaneous fistula, two superficial wound infections, and one death were recorded. Based on these results, the authors believe that an aggressive one-stage surgical approach for these complicated problems can be recommended. The low morbidity and mortality justifies this approach that results in considerable improvement in lost work time, length of hospital stay, number of readmissions, and significant cost control.     

Vesicorectal fistula associated with Crohn's disease: a case report

A 41-year-old man was hospitalized, complaining of fecaluria and right lower abdominal pain. He was diagnosed to have vesicorectal fistula. Wedge resection of bladder and rectum, and partial resection of ileocecal legion were performed. Pathological diagnosis was Crohn's disease. Postoperative course was uneventful and no recurrence was observed. Including our case, 32 cases of enterovesical fistula due to Crohn's disease have been reported in the Japanese literature.     

Surgical management of ulcerative colitis and Crohn's disease

The term inflammatory bowel disease is used to describe two conditions ‒ ulcerative colitis and Crohn's disease. Due to the complex nature of the disease, the treatment can be varied from each case to case and is usually approached by multidisciplinary team management. In this article, we focus on the surgical treatment options for inflammatory disease especially relating to basic principles.     

Surgical management of Crohn's disease in children.

Crohn's disease is more common in children than has generally been appreciated. Based on a 12 year review of cases from the UCLA Hospital, approximately 57 per cent of children with this disease require operation for the management of its complications.In 28 of 50 children undergoing operation, the disease was confined to the terminal ileum and ascending colon. Each of these patients underwent localized resection with ileocolostomy, although two children had preliminary cutaneous ileostomy; 25 per cent had mild recurrence within 5 years but only two required reoperation. Obstruction is the major symptom in this group, whereas perianal fistulas and abscesses are uncommon.Approximately one third of the patients (17 of 50) had primary Crohn's disease of the colon and rectum. Diarrhea and growth failure are common with this form of the disease. Eighty-two per cent had anal fistulas and abscesses requiring surgical treatment. Although intestinal diversion or intestinal resection, or both, with reanastomosis were tried in the majority of these patients, 14 of the 17 eventually required proctocolectomy for relief of severe symptoms. Recurrent disease in the terminal ileum occurred in 64 per cent of these patients.Only a rare patient with granulomatous disease of the small intestine alone will benefit from surgical resection.Bowel rest and total parenteral nutrition before and after resectional surgery appear to minimize the likelihood of postoperative obstruction or anastomotic leak and also to reduce the length of intestine required for resection.     

Surgical management of perianal lesions in Crohn's disease

Perianal lesions associated with Crohn's disease are often intractable and require surgical intervention. Among 28 patients surgically treated in our department, 16 patients manifested perianal complications consisted of four periproctal abscesses, eight anal fistulas, three skin tags and one anal fissure. The incidence of perianal lesions was higher in ileocolic type than in colic and ileal type. In half of our patients perianal lesions preceded the diagnosis of Crohn's disease, and they often gave the important clue for the diagnosis. The perianal lesions seemed to be independent of the activity of the intestinal lesions. The surgical treatments for the perianal lesions were performed on 13 patients and the results were satisfactory in most cases. But the results were very poor in four patients with rectal involvement. Two of them were obliged to undergo proctectomy because of the severely diseased anorectal lesions. Therefore radical surgery should be considered in patients whose perianal lesions are quiescent, and the severity of the rectal lesion was considered to be the major factor which decides the prognosis of the patients.     

Surgical management and strategy in classical Crohn's disease.

Surgical treatment for Crohn's disease of the small bowel or ileocecal region consists of resection. Surgery is not for cure but rather to relieve symptoms. In this respect resectional surgery has proved to be superior to present day medical management. The main arguments against resectional surgery are that it causes a fair amount of operative morbidity and mortality. However, these hazards can be reduced by recommending surgery at an earlier stage of the disease before the onset of complications. Furthermore it should be followed by a high incidence of recurrence of the disease, amounting to about 50% by 10 years. However, recurrences can be excised with no increased likelihood of further recurrence, and by a combination of resection and reresection as required, most patients can be afforded prolonged periods of symptomatic relief; limited resections are recommended with removal of macroscopically diseased bowel. And last that intestinal absorption is grossly impaired, especially after major or repeated resections of the small bowel. However, ileal resection causes a characteristic malabsorption pattern, qualitatively and quantitatively related to the extent of resection. The consequences such as diarrhea and possible hematological and nutritional disturbances and a predisposition to the formation of biliary and urinary calculi can be successfully prevented and/or managed by medical support and dietary restrictions. Even a loss of up to 50% of the entire small intestine is often compatible with a reasonably good state of general health, particularly if most of the colon has been preserved. Fortunately, such extensive intestinal losses are rare, even after 2 or 3 resections.