Turnbull-Blowhole结肠造口治疗妊娠中毒性溃疡性结肠炎(2例报道)

溃疡性结肠炎可影响各年龄女性 ,高峰在生育期 ,生育力不受影响。妊娠期结肠切除术有 60 %诱发自发性流产的危险 ,母亲和胎儿发病率、死亡率均高。本文阐述了通过Turnbull Blowhole结肠造口治疗妊娠期溃疡性结肠炎的并发症 :中毒性巨结肠 ,可降低母子死亡率。方法　回顾 2例中毒性溃疡性结肠炎的妊娠女性。例 1 :2 5岁初孕女性 ,妊娠 1 6周患难治性中毒性溃疡性结肠炎 ,重症监护并静脉激素治疗 60小时无改善 ,横结肠扩张直径达 8cm。例 2 :2 6岁初孕女性 ,妊娠 1 0周患难治性中毒性溃疡性结肠炎。结果　急诊行Turnbull Blowhole如鲸鱼鼻孔…     

溃疡性结肠炎术后早期并发症的预防及处理

目的总结分析溃疡性结肠炎外科治疗术后并发症的发生原因及处理经验。方法回顾性分析1995年1月至2005年12月手术治疗26例溃疡性结肠炎的临床资料。因结肠出血、肠穿孔、中毒性巨结肠和吻合口瘘等并发症入院病人19例，内科治疗无效而无并发症入院病人7例。其中急诊手术12例，择期手术14例；全结肠直肠切除术11例，结肠部分切除和结肠单纯造口术15例。结果11例（18例次）病人术后出现并发症，并发症发生率为42．3％，急诊手术后并发症发生率较高，主要为切口并发症和吻合口瘘。4例吻合口瘘病人2例保守治疗痊愈，2例再次手术，共有2例病人死亡。结论全结肠直肠切除术是治疗溃疡性结肠炎的有效手段，合理掌握手术时机和采取合理的手术方式能够降低术后并发症的发生率。对于常见的吻合口瘘并发症，通过持续骶前灌洗、通畅引流以及有效的贮袋引流减压等保守治疗，可使吻合口瘘闭合。     

腹腔镜辅助Soave根治术治疗新生儿先天性巨结肠(附73例报告)

目的:探讨腹腔镜辅助Soave根治术治疗新生儿先天性巨结肠的临床疗效及安全性。方法:回顾分析2002~2010年应用腹腔镜辅助Soave根治术治疗73例新生儿先天性巨结肠的临床资料。结果:73例手术均获成功,患儿腹胀、便秘等临床症状消失,大便每天5~19次,腹部切口均愈合良好。术后小肠结肠炎6例,肛周皮炎23例,污粪5例,无复发、肠粘连、吻合口瘘、结肠回缩等并发症发生。术后随访,随小儿年龄增长,大便次数逐渐减少,术后3个月大便呈糊状,6~12个月后大便接近正常,排便功能优良率98%。结论:腹腔镜辅助Soave根治术治疗新生儿先天性巨结肠具有患儿创伤小、操作简单、安全、有效、并发症少等优点,特别是对长段型巨结肠、全结肠型巨结肠优势明显。     

抗生素相关性肠炎合并中毒性巨结肠6例

为探讨抗生素相关性肠炎合并中毒性巨结肠的诊治,回顾性分析6例抗生素相关性肠炎合并中毒性巨结肠的临床资料。3例治愈患者中有2例经大剂量生长抑素治疗,3例治疗无效行手术治疗,其中1例行坏死结肠切除,2例行结肠造口,均死亡。结果表明,大剂量生长抑素治疗抗生素相关性肠炎合并中毒性巨结肠有效,手术治疗死亡率较高。     

成人特发性巨结肠手术治疗体会

病例资料笔者所在医院2004年3月至2012年1月期间共收治特发性巨结肠患者5例,均行手术治疗,效果较好。男4例,女1例;年龄18～58岁,平均36岁;临床表现:5例均有不同程度的便秘、腹胀、腹痛,尤以便秘、腹胀为主;2例有在慢性肠梗阻的基础上并发急性梗阻,在外院行结肠切开减压手术。病程5～36个月,平均14个月。4例     

套袖式带蒂浆肌瓣覆盖结肠吻合口效果观察

1.对象与方法:患者18例,其中男8例,女10例,年龄42～63岁.溃疡性结肠炎4例,乙状结肠癌6例其中并发梗阻4例,降结肠癌8例其中并发梗阻6例.手术行结肠一期切除吻合,结肠吻合口覆盖套袖式带蒂浆肌瓣.手术方法:手术按常规结肠手术方法进行,在进行结肠吻合前,制作套袖式带蒂浆肌瓣.取切除病变肠管后的近端结肠,距结肠断端5cm切断肠管,保留系膜血管,使之成带蒂肠管,将肠管粘膜翻外,将结肠粘膜去掉.剥离方法,可用剪刀锐性分离,也可用手指     

巨结肠根治术后便秘复发的原因探讨

目的 探讨巨结肠根治术后便秘复发的原因,以提高手术效果.方法 总结1995年至2005年在我院行手术治疗的巨结肠病例392例,其中32例因便秘复发再次手术,分析复发病例的手术时间、方式、病理结果、肠炎发生情况及排便功能.结果 巨结肠根治术便秘复发率为4.5%,左半结肠切除术后复发率为16.0%(26/162),明显高于结肠次全切除术的复发率2.1%(4/189) (P<0.01).32例复发病例中,巨结肠同源病(HAD)及先天性巨结肠(HD)合并同源病共26例.复发的原因主要有近端HAD肠管切除不够或继发HAD改变,HD肠管切除不完全;远端切除不够,吻合口过高;吻合口狭窄、肛门狭窄及失弛缓等.复发病例的肠炎发生率明显高于无复发病例(P<0.05).结论 HAD较HD更易便秘复发,彻底切除近远端病变肠管,吻合口尽可能做到后壁距肛门缘1.5cm处,对小肠结肠炎早期诊断、早期治疗,术后置肛管以及术后复诊,一旦发现吻合口狭窄,及时扩肛等措施可降低巨结肠术后便秘的复发率.     

自制中药灌肠液治疗溃疡性结肠炎

溃疡性结肠炎亦称慢性、非特异性、溃疡性结肠炎,是一种原因不明的主要发生在结肠粘膜层的炎症性病变,多因情绪激动,饮食不节或劳倦等反复发作。患者以腹痛,里急后重,持续腹泻、粘液脓血便,体重减轻为主要临床特征,属于中医“泄泻”范畴。2003 年 1~12 月,我科对 10 例溃疡性结肠炎患者采用自制中药灌肠液保留灌肠,取得了满意效果,报告如下。1　临床资料10例患者中,男6例、女4 例,年龄 25~55(33 1±4 2)岁。病程5~10年,其中湿热型 6 例,虚寒型 4 例;均经结肠纤维镜检,确诊为溃疡性结肠炎。临床表现腹痛 7 例,腹泻10例,粘液血便5例。治疗…     

阿米巴痢疾误诊原因分析及避免误诊的措施

肠阿米巴病又称阿米巴痢疾是由溶组织内阿米巴原虫寄生于结肠引起的疾病，主要病变部位在近端结肠和盲肠，亦可侵袭全结肠，典型的临床表现有腹痛、腹泻、黏液血便、果酱样大便等症状。由于本病与溃疡性结肠炎临床症状尤为相似，均有腹痛、腹泻、黏液血便等症状，较易误诊。因此，提高阿米巴痢疾的检出率，亦可明显提高溃疡性结肠炎的确诊率及治愈率。     

1005例回肠袋肛管吻合术后的并发症和功能分析

自1978年以来,溃疡性结肠炎和家族性腺瘤性息肉病已用直肠全结肠切除和回肠袋肛管吻合(IPAA)治疗,其回肠装有两肠襻(J)、三肠襻(S)或四肠襻(W)型之分,而以1型回肠袋最为常用.近期对手术已作了改进,在某些病例省略了暂时性回肠造口术,缩短了住院日期.IPAA术后肛管排便功能如何和回肠袋有什么并发症,均是临床上关注的问题.美俄亥俄州Cleveland临床基金会肛肠外科自1983～1993年共施行直肠全结肠切除和IPAA手术1005例,其中455例为女性.术前诊断为溃疡性结肠炎858例(854%)、家族性腺瘤性息肉病62例(6.2%)、病因尚未确定的结肠炎75例(7.5%),其余有TNM2期结肠直肠癌4例、幼年型息肉瘤4例以及结肠直肠多发性海绵状血管瘤和巨结肠各1例.平均随访35个月(1～125个月).术后病理学诊断确定术前诊断的46例溃疡性结肠炎和21例诊断未定的病例均为克隆病.分析手术指征计内科治疗失败422例、组织发育不良104例、癌肿23例、中毒症21例、出血29例、失禁或便急40例、预防癌变18例、结肠直肠狭窄11例和便秘1例.另296例在完全切除了直肠后仍有结肠病变.349例原已施行各种结肠等手术,如结肠切除和回肠直肠吻合术,部分结肠切除和回肠造口术(达280例)、结肠直肠切除和回肠造口术、直接回肠肛管吻合和IPAA吻合术等.     

Decompressive colonoscopy with intracolonic vancomycin administration for the treatment of severe pseudomembranous colitis

Background: We explored the potential of early decompressive colonoscopy with intracolonic vancomycin administration as an adjunctive therapy for severe pseudomembranous Clostridium difficile colitis with ileus and toxic megacolon. Methods: We reviewed the symptoms, signs, laboratory tests, radiographic findings, and outcomes from the medical records of seven patients who experienced eight episodes of severe pseudomembranous colitis with ileus and toxic megacolon. All seven patients underwent decompressive colonoscopy with intracolonic perfusion of vancomycin. Results: Fever, abdominal pain, diarrhea, abdominal distention, and tenderness were present in all patients. Five of seven patients were comatose, obtunded, or confused, and six of the seven required ventilatory support. The white blood cell count was greater than 16,000 in seven cases (six patients). Colonoscopy showed left-side pseudomembranous colitis in one patient, right-side colitis in one patient, and diffuse pseudomembranous pancolitis in five patients. Two patients were discharged with improvement. Five patients had numerous medical problems leading to their death. Complete resolution of pseudomembranous colitis occurred in four patients. One patient had a partial response, and two patients failed therapy. Conclusion: Colonoscopic decompression and intracolonic vancomycin administration in the management of severe, acute, pseudomembranous colitis associated with ileus and toxic megacolon is feasible, safe, and effective in approximately 57% to 71% of cases. apd: 7 May 2001     

Toxic megacolon: Ultimate fate of patients after successful medical management

The clinical course and ultimate outcome in 38 patients with toxic megacolon who were successfully treated nonoperatively has been reviewed. Thirty-two patients had ulcerative colitis and 6 had Crohn's disease. Follow-up was complete and ranged from 3 to 22 years (average 13 years). Eleven of 38 patients (29 percent) eventually suffered second episode of fulminant acute colitis or recurrent toxic megacolon. Ultimately, a total of 18 patients (47 percent) underwent colon resection, which was performed on an emergency or urgent basis in 15 patients. A modified Visick classification was employed to assess the long-term results of medical therapy in the entire group, in patients showing improvement within 48 or 72 hours, in patients 30 years or younger, in patients whose initial presentation of inflammatory bowel disease was toxic megacolon, and in patients with ulcerative colitis as opposed to Crohn's disease. The results were equally poor for all subgroups, and they have strengthened our opinion that medical management of toxic megacolon should be regarded almost exclusively as preparation for imminent surgery.     

Surgical management of pseudomembranous colitis

The authors recently studied two cases of pseudomembranous colitis (PMC) that required surgery and combined them with previously reported cases in the literature, which required surgery to propose guidelines for the surgical management of PMC. A total of 21 patients were studied. Indications for surgery included refractory disease in seven patients, toxic megacolon in 12 patients, and perforation in two patients. Operative management ranged from decompressive cecostomy to total proctocolectomy. The best results were obtained with subtotal colectomy and ileostomy. It is concluded that PMC should be managed surgically in a manner analogous to ulcerative colitis. If there is no improvement after 7 days of aggressive medical management, surgical intervention, ileostomy with subtotal colectomy is indicated to prevent complications. Complications of PMC, toxic megacolon and perforation, should also be managed with ileostomy and subtotal colectomy as simple decompression or segmental resection does nothing to alter the underlying disease process.     

Management of severe hemorrhage in ulcerative colitis

Twenty-five patients with ulcerative colitis were treated between 1959 and 1986 at the Mount Sinai Hospital, with severe gastrointestinal hemorrhage as their major complaint. Twenty-two patients required operation, while three patients were treated medically. Total proctocolectomy with ileostomy was carried out in 5 patients, and subtotal colectomy accompanied by mucous fistula (14), Hartmann closure (2), or ileosigmoidostomy (1) was performed in 17 patients. Eleven of the patients who underwent operation had emergency colectomies, while the remaining 11 had semielective procedures. Subtotal colectomy was performed in 10 of the 11 emergency cases. Indications for emergency surgery were massive hemorrhage alone in seven patients and severe hemorrhage complicated by toxic megacolon in four patients. One patient died postoperatively of a perforated duodenal ulcer following emergency subtotal colectomy. There were two late deaths from leukemia in one surgically treated patient and one medically treated patient at 9 and 18 months, respectively. All 4 of the 25 patients with remaining intact rectums were alive and well at 3- to 12-year follow-up. Subtotal colectomy can be undertaken in patients with massive hemorrhage from ulcerative colitis for whom subsequent ileoanal anastomosis is planned, provided that one recognizes and is prepared for the approximately 12% risk of continued rectal hemorrhage.     

Surgical treatment of toxic megacolon and proposal for a program of therapy

Experience with 12 patients with toxic megacolon that required surgical intervention is described and analyzed. Ten patients had ulcerative colitis and 2 had Crohn's colitis; 9 were treated with corticosteroids before operation. The diagnosis was established by radiologic studies, operative findings and examination of the surgical specimens. The operations performed in these patients were proctocolectomy and ileostomy in five, abdominal colectomy and ileostomy with preservation of the rectum in five, and loop ileostomy and colonic venting in two. All patients had prolonged and complicated recovery periods; 1 died in the postoperative period and 10 reassumed their pre-illness activities. A highly specific therapy program is proposed for managing patients with toxic megacolon.     

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中毒性巨结肠(toxic megacolon,TMC)是各种炎症性肠病、细菌性肠病和病毒性肠病等的一种致命并发症,常见于溃疡性结肠炎病人。该病通常发生于急性重症溃疡性结肠炎或慢性溃疡性结肠炎急性发作阶段。某些具有麻醉作用的药物如鸦片类、抗胆碱酯类和止泻药以及某些不适宜的医疗操作(如结肠镜检查)等可诱发其发作,一旦确立诊断,应立即进行挽救性治疗。为降低手术风险,提高手术成功率,对于病情危急的TMC病人,应遵循三期手术原则进行外科治疗。     

Free colonic perforation without dilatation in ulcerative colitis

Free perforation occurred in only 7 of 702 patients with ulcerative colitis (1 percent) without toxic dilatation seen at The Mount Sinai Hospital from 1960 to 1981; however, these seven patients represented 30 percent (7 of 23) of all colonic perforations seen in patients with ulcerative colitis in our institution during the same period. Classic physical signs of peritonitis (silent, rigid abdomen and rebound tenderness) were absent in six of the seven patients, but all had a marked deterioration in general condition after perforation. Other signs included a sudden increase in severity of abdominal pain (three patients), marked abdominal distention (four patients), and a sharp decrease in frequency of bowel movements (six patients). Mortality was high (four of seven patients, 57 percent) and characterized by comparatively longer patient histories of colitis, longer current attacks, slightly greater delays between presumed perforation and operation, much higher transfusion requirements, and a 100 percent incidence of coagulopathy (thrombocytopenia and increased prothrombin time in three of four patients, and increased partial thromboplastin time in all four patients). The possibility of free perforation in ulcerative colitis must be considered in fulminating cases, even in the absence of colonic dilatation. Careful clinical monitoring and early surgical intervention may be the keys to reducing mortality.     

Emergency surgery in inflammatory bowel disease. Experience in 26 cases

BACKGROUND: The emergency surgical treatment of inflammatory chronic bowel diseases is closely related to the classification of patients according to their symptoms and clinical conditions, as well as possible surgical options. In our study, an actual set of criteria is proposed for the classification of the degree of seriousness of symptoms, related to patient conditions, and applicable surgical strategies. METHODS: Retrospectively evaluation of the outcome of the disease has been performed over 26 patients undergoing emergency treatment in our Hospital, and with at least 5 years of follow-up. Fourteen patients were affected by ulcerative rectocolitis and 11 underwent subtotal colectomy with ileostomy; the remaining 12 were affected by Crohn's disease and were treated with colic or ileal local resection. RESULTS: Among 11 operated patients with RCU, 6 toxic megacolon, 4 severe colitis and one perforation (postoperative death) have been diagnosed. Recanalization was possible in 8 patients. On the other hand proctectomy was necessary in the remaining 3 patients as final operation. In MC patients 6 occlusions, 4 severe colitis, one multiple perineal fistulization and one perforation of occult right colon tumor have been diagnosed. We performed 5 right colectomy, 4 jejuno-ileal resections, one Hartmann's operation, one colostomy in emergency and one multiple bypass. Because of recurrence, one right colectomy needed following total colectomy and two jejuno-ileal resections needed right colectomy soon after. Three jejuno-ileal resections were performed with a conservative purpose in patients treated by right colectomy. CONCLUSIONS: It has resulted that in ulcerative rectocolitis total colectomy actually permits an adequate control of the disease, as well as a satisfactory therapy of the rectal stump, with subsequent recanalization in the majority of cases, whereas in Crohn's disease the frequency of recidive is higher and it seems more advisable to opt for a radical resection treatment (chiefly right colectomy), but with a conservative purpose.     

Clinical features and management of pouchitis in Japanese ulcerative colitis patients

Purpose

Pouchitis frequently occurs after restorative proctocolectomy for ulcerative colitis. This study evaluated the incidence and treatment of pouchitis in Japanese ulcerative colitis patients.

Method

This study reviewed the clinical data from 772 patients with pouch surgery between January 2000 and December 2010. Pouchitis was classified as acute or chronic pouchitis. The potential preoperative risk factors for overall and chronic pouchitis were analyzed using a logistic regression analysis.

Result

The incidence of overall pouchitis and the cumulative risk of developing overall pouchitis were 10.0 % (77/772) and 10.7 % after 10 years, respectively. In addition, 74.0 % of all patients who developed overall pouchitis did so within 2 years after surgery. Chronic pouchitis occurred in 37.7 %. Although no independent risk factor for overall pouchitis was found, age at the onset of ulcerative colitis <26 years and surgical indications of toxic megacolon were found to be risk factors for chronic pouchitis and surgical indications of cancer/dysplasia were significantly associated with a low risk of overall pouchitis and patients with cancer/dysplasia were older than patients with other surgical indications (p < 0.01).

Conclusion

Immune abnormalities in younger onset patients or toxic megacolon may be more significant than surgical indications of cancer/dysplasia in elderly patients. Fundamental immune abnormalities may remain even after proctocolectomy.