肠系膜缺血性疾病的临床诊断

早期诊断和及时治疗，对降低肠系膜缺血性疾病的并发症发生率和病死率至关重要，但由于肠系膜缺血性疾病缺乏特异的临床表现，鉴别诊断也比较困难。因此，基于临床表现的早期诊断一直是非常困难的课题。     

急慢性肠系膜缺血的诊治

肠系膜缺血性疾病具有发病率低,诊治难度大,并发症发生率和死亡率高的特点。因此,对于血管外科或普通外科医生来说都具有很大的挑战性。欧洲血管外科协会（ESVS）和美国血管外科协会（SVS）分别于2017年和2020年发布了关于肠系膜缺血疾病和慢性肠系膜缺血疾病的指南。本文将两个协会指南及最新研究数据结合笔者临床经验,对急慢...     

肠缺血性疾病诊治——急性肠系膜缺血

急性肠系膜缺血(acute mewsenteric ischemia，AMI)是常见的血管性急症，它是由肠管动脉血供或静脉血流障碍引起的严重缺血性损伤所致，表现为肠管坏疽和穿孔或是肠管狭窄和肠梗阻。AMI多累及小肠，大肠缺血多可自发性消除而很少留后遗症。尽管近年来诊断技术和治疗方法有不少进展，但AMI的医院内病死率仍很高，为59％-93％。动脉所致的AMI更为常见，     

肠系膜血管性疾病——肠系膜缺血性疾病的临床病理生理

肠系膜缺血性疾病是一类疾病的总称，是由各种原因引起肠道急性或慢性血流灌注不足或回流受阻所致的肠壁缺血坏死和肠管运动功能障碍的一种综合征。凡全身血液循环动力异常、肠系膜血管病变以及其他全身或局部疾病引起的肠壁缺血，均可引发本病。此病可累及全消化道。但以左半结肠较为常见。尤以结肠脾曲多见。这是由于结肠脾曲是由肠系膜上、下动脉末梢吻合部供血，对抗缺血的能力最弱，易于发生供血不足。肠系膜缺血性疾病发生后，肠管局部和全身将出现一系列复杂的病理生理变化。现分述如下。     

急性肠系膜静脉血栓形成的治疗

急性肠系膜静脉血栓形成（mesenteric venous thrombosis,MVT）是一种发病率较低、误诊率和死亡率较高的肠缺血性疾病，早期由于对急性MVT认识不足,手术曾经被做为治疗本病的惟一方法,目前认为在本病的早期阶段,尚未出现肠坏死时可进行保守治疗。     

急性肠系膜血管缺血性疾病的早期诊断和治疗（附14例报告）

目的 探讨急性肠系膜缺血性疾病的早期诊断和治疗方法。方法 分析1987年1月－2001年12月急性肠系膜缺血性疾病14例临床资料。结果 急性肠系膜上动脉栓塞6例，急性肠系膜上动脉血栓形成3例，急性肠系膜上静脉血栓形成4例，非血管阻塞性急性肠缺血1例，均经病理证实。10例有与腹部体征不相符的剧烈腹痛，6例存在慢性肠缺血表现。选择性肠系膜动脉造影确诊1例，CT确诊2例，11例为术中发现。14例均行手术治疗，术后均行溶栓，抗凝治疗，9例治愈，5例死亡。结论 （1）器质性心脏病，动脉硬化，血栓等病史伴与腹部不相符的剧烈腹痛是急性肠系膜缺血性疾病的重要临床特征；（2）选择性动脉造影和CT是最有价值的诊断方法；（3）血管的再管化，必要的肠切除和术前，后抗凝及溶栓是提高疗效的重要保证；（4）出现慢性肠缺血再表现时，预防性抗凝可能是降低死亡率的有效方法。     

急性肠系膜缺血笔谈

急性肠系膜缺血（AMI）是指由于小肠供血中断而引起的急腹症,如未及时治疗将迅速进展为肠坏死,从而危及生命。AMI常被认为是一种罕见病,而随着增强CT的普及,诊出率越来越高。不同类型的AMI有各自的特点,鉴别各类型AMI有利于治疗的选择。早期血运重建对AMI的预后至关重要,血管腔内治疗及开放手术治疗应个体化选择。     

急性肠系膜缺血性疾病诊治现代策略

急性肠系膜缺血性疾病是血管外科的急症之一,也是外科最为凶险的急腹症之一。其原因来源于肠系膜动脉或静脉发生阻塞,导致血液供应或回流突然中断,肠管出现营养不良与障碍,最终发生肠管功能丧失、坏死。该病起病隐匿、进展快、危害大、后果严重。CT血管成像（CTA）是当前被推荐的首选诊断方法。早期诊断、复苏、抗凝、恢复肠系膜的血液供应、切除无生机的肠管、维持水盐电解质平衡以及静脉高营养是成功诊治该病的重要支柱。     

慢性肠系膜缺血13例手术治疗经验

慢性肠系膜缺血（chronic mesenteric ischemia，CMI）主要是由于肠系膜上动脉狭窄或闭塞引起。采用何种术式恢复其血供是目前临床研究的重点。天津医科大学总医院普通外科在2004-2012年间收疗CMI患者13例。采用动脉取栓及内膜剥脱术、主动脉旁路术、腔内治疗和杂交手术等不同术式治疗，效果满意。现报告如下。     

41例急性肠系膜上动脉缺血性疾病的临床诊治经验

目的总结急性肠系膜上动脉缺血性疾病的外科治疗经验。方法对黄石市中心医院2002年1月至2013年6月期间收治的41例急性肠系膜上动脉缺血性疾病患者的临床资料进行回顾性分析。结果41例急性肠系膜上动脉缺血性疾病患者中,行手术治疗40例（术中死亡2例）,行介入溶栓治疗1例。术后出现短肠综合征9例,死亡19例。出院后27例患者获访,随访时间为1周-2年（平均随访时间为1．4年）。随访期间,因家属放弃治疗而于家中死亡7例,转院后于他院死亡4例,3例未愈或复发,13例痊愈（1例行介入溶栓治疗）。结论急性肠系膜上动脉缺血性疾病的不同进展阶段其临床特征有所差异,术前CT血管造影（CTA）检查的意义重大。早期诊断、早期治疗、根据病情不同阶段选择合适的治疗方案（手术、介入治疗、药物治疗等）是降低死亡率的关键。     

Surgical therapy for acute superior mesenteric artery embolism

BACKGROUND: Acute mesenteric artery embolism has a high rate of morbidity and mortality. Early diagnosis and appropriate treatment are the most important factors associated with morbidity and mortality. METHODS: During the period between 1997 and 2002, 24 patients underwent superior mesenteric artery embolectomy. The patients were divided into three groups according to the onset of symptoms and operation time. Group I (n = 12) patients were operated on in the first 6 hours after onset of symptoms; group II (n = 9) patients were operated on between 6 and 12 hours after onset; and group III (n = 3) patients underwent embolectomy after 12 hours. Low-dose (5 to 10 mg) local tissue-type plasminogen activator (t-PA) administration directly into the superior mesenteric artery was an additional procedure with the embolectomy in all patients. RESULTS: The macroscopic view of the intestine was normal in 15 patients (12 patients in group I and 3 patients in group II) 30 minutes after the administration of local t-PA. Segmental resection was necessary in 4 patients in group II. Extended resection was necessary in 2 patients in group II and 3 patients in group III, and all of the patients died during the early postoperative period. CONCLUSIONS: We suggest that explorative laparotomy should be done in patients with sudden abdominal pain, nausea, vomiting, mild leukocytosis, and metabolic acidosis who have previous valvular heart disease or atrial fibrillation. Ultimately, selective low dose t-PA (5 to 10 mg) administration reduces the length of intestinal portion to be resected.     

Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience

INTRODUCTION: Endovascular therapy (percutaneous transluminal angioplasty [PTA] with stenting) has been increasingly applied in patients with chronic mesenteric ischemia (CMI) to avoid morbidities associated with open repair (OR). The purpose of this study was to compare outcomes of PTA/Stent vs OR in patients with symptomatic CMI. METHODS: During the interval of January 1991 to December 2005, 80 consecutive patients presenting with symptomatic CMI underwent elective revascularization. Patients with acute mesenteric ischemia or those with mesenteric revascularization performed as part of complex aneurysm repair were excluded. PTA/Stent (with stenting in 87%) was the initial procedure in 31 patients (42 vessels). OR was performed in 49 patients (88 vessels) and consisted of bypass grafting in 31 (63%), transaortic endarterectomy in 7 (14%), patch angioplasty in 4 (8%), or combined in 7 (15%). Mean follow-up was 15 months in the PTA/Stent group and 42 months in the OR cohort. Study end points included perioperative morbidity, mortality, late survival (Kaplan-Meier), and symptomatic and radiographic recurrence. RESULTS: Baseline comorbidities, with the exception of heart disease (P=.025) and serum albumin<3.5 g/dL (P=.025), were similar between PTA/Stent and OR patients. The PTA/Stent group had fewer vessels revascularized (1.5 vs 1.8 vessels, P=.001). Hospital length of stay was less for the PTA/Stent group (5.6 vs 16.7 days, P=.001). No difference was noted in in-hospital major morbidity (4/31 vs 2/49, P=.23) or mortality (1/31 vs 1/49, P=.74). Actuarial survival at 2 years was similar between the groups (88% PTA/Stent vs 74% OR, P=.28). There was no difference in the incidence of symptomatic (7/31 [23%] vs 11/49 [22%], P=.98) or radiographic recurrence (10/31 [32%] vs 18/49 [37%], P=.40) between the two groups. Radiographic primary patency (58% vs 90%, P=.001) and primary assisted patency (65% vs 96%, P<.001) at 1 year were lower in the PTA/Stent group compared with OR. Five (16%) of 31 PTA/Stent patients compared with 11 (22%) of 49 OR patients required a second intervention on at least one index vessel at any time (P=.49). CONCLUSIONS: Symptomatic recurrence requiring reintervention is common (overall 16/80 [20%]) after open and endovascular treatment for CMI. PTA/Stent was associated with decreased primary patency, primary assisted patency, and the need for earlier reintervention. In-hospital mortality or major morbidity were similar in patients undergoing PTA/Stent and OR. These findings suggest that OR and PTA/Stent should be applied selectively in CMI patients in accordance with individual patient anatomic and comorbidity considerations.     

急性肠系膜上静脉血栓形成的手术及介入治疗

目的 探讨急性肠系膜上静脉血栓形成的治疗方法.方法 2006年10月至2012年2月共收治31例急性肠系膜上静脉血栓形成的患者,分别做了坏死小肠切除及肠系膜上静脉切开取栓或经肠系膜上动脉置管间接肠系膜上静脉溶栓治疗,分析2种治疗方式的疗效及适应证.结果 外科手术治疗9例,其中6例术后痊愈,3例因消化道出血无法抗凝、溶栓,术后仍有腹胀,造影可见肠系膜上静脉内血栓残留;介入治疗22例中有17例术后72h内症状明显改善,其余症状改善时间为术后5～7d.2例置管溶栓过程中并发少量消化道出血,终止溶栓治疗;1例置管溶栓48 h后腹痛症状加重,中转开腹手术.本组随访25例(81％),随访时间5 ～35个月,平均(19±5)个月.20例无腹胀、腹痛,3例有饱食后腹部胀满感.结论 合理选择急性肠系膜上静脉血栓治疗适应证是取得良好疗效的关键,肠系膜上动脉置管间接肠系膜上静脉溶栓是一种操作简单、风险较小、疗效确切的方法.     

Surgical therapy of mesenteric infarct

Acute mesenteric infarction represents less than 1-2% of all surgical emergencies but is responsible for many lethal events. A successful management requires very efficient diagnostic and therapeutic measures. Cases with established bowel infarction are associated with a mortality rate of 80-90% since years. In the last 10 years some hospitals offering an aggressive pre-, per- and postoperative multimodal therapy could reduce the mortality in selected series to 50-60%. One of the most important factors to reduce the mortality is beneath early diagnosis the emergency angiography and the angiography-associated treatment like intraarterial application of vasodilators, even in occlusive forms of mesenteric infarction. But this concept is seldom applicable to small hospitals because of the partially lacking availability of angiography. We present a concept of treatment taking into account this fact. Generous indication for emergency laparotomy in patients suspect of acute mesenteric ischemia is the central pillar of our concept. We also plea for a very restraint indication in biologically old multimorbid patients presenting a sum of negative prognostic factors and consider in these cases the reluctant attitude as an ethically and medically positive behaviour.     

肠系膜缺血性疾病的临床病理生理

肠系膜缺血性疾病是一类疾病的总称,是由各种原因引起肠道急性或慢性血流灌注不足或回流受阻所致的肠壁缺血坏死和肠管运动功能障碍的一种综合征。凡全身血液循环动力异常、肠系膜血管病变以及其他全身或局部疾病引起的肠壁缺血,均可引发本病。此病可累及全消化道,但以左半结肠较为常见,尤以结肠脾曲多见。这是由于结肠脾曲是由肠系膜上、下动脉末梢吻合部供血,对抗缺血的能力最弱,易于发生供血不足。肠系膜缺血性疾病发生后,肠管局部和全身将出现一系列复杂的病理生理变化。现分述如下。1肠管本身的改变1.1肠管缺血性改变肠道绒毛内血管为…     

急性肠系膜血管缺血疾病的诊治

急性肠系膜血管缺血（acute mesenteric ischemia,AMI）是一种少见的死亡率极高的腹部急症。随着人类年龄结构及饮食习惯等方面的改变,其发病率有逐年增多的趋势,给人类健康带来了巨大危害。近年来损伤控制性外科理念在严重创伤患者治疗中的作用逐渐为人们所认识,并在急性肠系膜缺血等非创伤性的严重外科疾病的处理中也得到了广泛应用。血管造影检查时行分流手术或血管内溶栓治疗、急诊手术切除梗死肠管后不一期吻合、