新型早产猪短肠综合征模型的建立

目的探讨新的早产猪短肠综合征模型的建立方法。方法将32头早产猪按随机号码表法分成空肠回肠吻合组、空肠结肠吻合组、假手术组及空白对照组4组,每组8头小猪。空肠回肠吻合组:切除75%的小肠,保留近端空肠(占总小肠长度的10%)和远端回肠(占总小肠长度的15%),并行空肠回肠吻合;空肠结肠吻合组:切除75%的小肠,包括远端空肠(占总小肠长度的25%)、全部回肠(占总小肠长度的50%)、回盲瓣和回盲瓣以远5 cm的结肠,保留近端空肠(占总小肠长度的25%),行空肠结肠吻合;假手术组:在距回盲瓣以近25 cm处行回肠完全横断并重新吻合;空白对照组:未行手术。比较4组小猪的术后第1次排便时间、腹泻时间、PN时间、小肠长度、小肠重量、结肠重量、空肠绒毛高度和陷窝深度以及回肠绒毛高度和陷窝深度。结果与假手术组和空白对照组比较,空肠回肠吻合组及空肠结肠吻合组术后21 d的空肠和回肠绒毛高度及陷窝深度均较长(P0.050),显示了充足的肠适应的解剖学证据;但空肠结肠吻合组术后依赖PN时间较空肠回肠吻合组长(P0.050),且术后21 d时,空肠结肠吻合组的小肠长度、重量以及结肠的重量均较空肠回肠吻合组低(P0.050),提示空肠结肠吻合组小肠的肠适应能力较空肠回肠吻合组低。结论空肠回肠吻合和空肠结肠吻合法建立早产猪短肠综合征模型有着不同的肠适应程度和生长情况,可用于短肠综合征的实验研究,其中以空肠回肠吻合法较为理想。     

短肠综合征及术式探讨 短肠综合征及其治疗问题

外科手术切除小肠的70％以上,或切除小肠的50％和回盲瓣后,导致了腹泻、脂肪痢、营养不良,严重者甚至死亡,即谓“短肠综合征”。在新生儿,小肠切除后剩留小肠短于75cm者,即为小肠广泛切除。肠系膜上动脉或肠系膜上静脉血栓形成,内疝、粘连性肠梗阻、腹部损伤等,都可导致小肠广泛切除。而肠闭锁、肠扭转、脐膨出、坏死性小肠结肠炎、腹裂及广泛的无神经节细胞症等,则是导致新生儿小肠广泛切除的常见原因。     

上消化道手术后肠内、肠外营养支持前后血浆抗氧化维生素的变化

目的 了解胃肠手术患者术后接受肠内营养(EN)和肠外营养(PN)时血清抗氧化维生素的变化情况,以指导临床营养补充.方法 对笔者2所医院接受上消化道肿瘤手术的120名患者随机平均分组为EN组和PN组,检测两组手术前、EN或PN前后的维生素A(VA)和维生素E(VE)及β-胡萝卜素的水平.结果 患者术后血浆VA和β-胡萝卜素显著下降(P=0.03,P=0.01);营养辅助治疗10周后,两组VE水平显著下降,且EN组VE水平低于PN组(P<0.01),而VA和VE在营养辅助前后水平无显著变化(P>0.05).结论 手术应激可引起外周血VA和β-胡萝卜素水平下降,VE则在术后发生持续下降,EN或PN均无法避免,需予以积极补充.     

短肠综合征的外科治疗——160例患者的治疗经验

本文报道1980～1994年Nebraska大学医学中心48例成人和112例儿童短肠综合征患者的治疗经验,在此基础上确定短肠综合征外科治疗的方法.48例成人患者中15例残存小肠短于60cm,13例为60～120cm,20例为120～180cm.年龄小于16岁的112例患儿中43例残存小肠短于30cm,23例为30～60cm,46例长于60cm.短肠综合征的外科治疗包括:沿对系膜缘将多余小肠壁切除或折叠的小肠管壁缩窄术;缩窄肠段的狭窄成形术;节段肠袢倒置术;系膜缘及对系膜缘间肠壁纵向横断再吻合的小肠延长术;包括单独小肠移植和肝肠联合移植的小肠移植术.结果160例患者中71例(44%)残存小肠充分适应,肠内营养(PN)支持即可满足患者营养需求,44例(28%)长期行PN支持而未进行手术治疗,45例(28%)接受49次手术治疗.手术选择:残存小肠长度足够而肠腔过度扩张致功能损害的4例成人患者(残存小肠>120cm)和11例患儿分别接受狭窄成形术和小肠管壁缩窄术,其中13例(87%)临床症状改善,2例患儿因再次发生肠吸收不良而行小肠延长术;残有小肠90～120cm而食物转运过快的3例患者中,2例接受人工瓣膜成形术,1例施行肠袢倒置术,这3例患者中2例疗效佳,1例施行肠袢倒置术的患者疗效明显,但因持续恶心,呕吐再次施行矫正手术;扩张的残存小肠短于90cm的14例患者接受小肠延长术,其     

广泛小肠切除后短肠综合征的治疗

短肠综合征引起严重的营养代谢障碍,治疗比较棘手。本院自1970年6月至1981年6月行广泛小肠切除术共52例,报告如下。临床资料一般资料:本组年龄最大者86岁,最小3岁。首次手术坏死小肠长达400～600cm者8例,其余均在200～350cm之间。剩余小肠最短者仅5cm(2例),多数在100～150cm之间。剩余小肠以空肠为主者较多,共38例,以回肠为主者较少,仅7侧。5例剩余空肠和回肠大致相等,2例几乎仅剩十二指肠。治疗和随访情况:52例手术关闭回盲部,行小肠一横结肠端侧吻合术9例,小肠逆蠕动吻合术2例,其余均行端端吻合。术后短期内死亡12例,占23.1%,     

回盲瓣替代术

由于麻醉、手术技术,重点监护和胃肠外全营养的进步,新生儿施行广泛小肠切除术后早期大多能够存活,但能否长期存活则与其它因素有关,例如残留小肠的长度和是否保留回盲瓣。为了延长小肠的输送时间和促进小肠吸收曾提出无数方法,包括迷走神经切断术,肠道再循环,倒置肠段,肠袋形成,人工括约肌以及小肠延长术等,所有的实验均在大动物中进行,作者报道在大鼠中施行回盲瓣替代术治疗短肠综合征取得较好疗效。     

活体小肠移植术后慢性排斥反应一例

患者 男,18岁,因短肠综合征于2002年1月3日入院。患者曾于2001年9月因肠扭转坏死行小肠切除术,残余小肠为距Treitz韧带10cm、长约30cm的空肠,回盲瓣完整存在;患者当时体质量仅30kg。患者入院后经积极术前准备,于2002年2月15日行活体小肠移植术。供体为患者父亲,供体和受体的ABO血型均匹配,HLA和DA为半相符。     

近回盲瓣回肠吻合应用于新生儿和婴儿急症的探讨

目的 探讨近回盲瓣回肠端端吻合术应用于新生儿和婴儿急症的可行性和安全性.方法 对2003-2006年行近回盲瓣回肠(末端回肠距回盲瓣10 cm以内)端端吻合术的15例新生儿和婴儿急症患者的临床资料进行回顾性分析.结果 本组15例中回肠吻合口距回盲瓣均在10 cm以内,其中5 cm以内9例.1例残留小肠约40 cm者术后当日即自动出院,另14例均痊愈出院,平均住院10.5 d.仅1例发生切口感染,未发生吻合口漏等并发症.结论对新生儿和婴儿具有重要功能的尚未被病变累及的回盲部可采用近回盲瓣回肠端端吻合术,辅助肠减压手术多无必要.     

短肠综合征及其处理

短肠综合征 (SBS)是消化、吸收不良所致的营养不良综合病征。因病使残留小肠不足6 0 cm或 <1cm/ kg,易致本病。影响 SBS代偿的因素有年龄、摄食情况、回盲瓣和结肠是否完整等。肠外营养和肠内营养已可能使 SBS者得以长期生存。谷氨酰胺、生长激素及膳食纤维的联合应用可促使 SBS者之代偿     

在短肠综合征病人中间置逆蠕动小肠段可替代肠移植

广泛小肠切除后发生的短肠综合征具有腹泻和吸收不良等症状，如残留小肠不足1m者常需胃肠外营养（PN）支持，长期家庭PN可获75％5年生存串，但其费用及并发症串需要人们寻找外科替代治疗。目引进新免疫抑制剂FK506以来，小肠移植又引起临床注意，病人和供体的2年生存率分别为60％和50％，仍是一大问回。在众多的代偿性手术（如小肠延长术、小肠人工问澳构造以及结肠间登术等）中，间置逆蠕动小肠里（SRSB）不失为替代肠移植的理想手术。作者于1985～1995年省行8例SRSB术，计男5例，女3例，平均年龄58±16岁。7例依靠家庭PN每周7天，…     

Long-Term Outcomes of Short Bowel Syndrome Requiring Long-Term/Home Intravenous Nutrition Compared in Children With Gastroschisis and Those With Volvulus

Introduction

Short bowel syndrome (SBS) is a malabsorptive state that occurs following extensive small intestinal resection. The most severely affected children require intravenous feeding/parenteral nutrition (PN). Two common causes in infancy/early childhood are intestinal resection for volvulus and resection of necrotic small intestine in infants with gastroschisis. The aim of this study was to review the long-term outcomes of children with severe intestinal failure who remained dependent on PN for many months or years. We evaluated the outcomes among gastroschisis cases versus those following resection of mid-gut volvulus or congenital short gut.

Methods

We reviewed the case records over a 10-year period from 1997 of children presenting by 5 years of age with volvulus and/or congenital short gut or gastroschisis and who were dependent on long-term/home PN. We obtained data regarding the diagnosis, the small intestinal length, the presence of the ileo-cecal valve, the survivals, and the incidences of weaning from PN.

Results

Six children underwent resection following volvulus or congenital short gut syndromes and 7 had gastroschisis. Ten of the 13 children underwent surgery as neonates and 3 from 2-5 years of age. The residual small intestinal length was <10 cm in 1, 10-25 cm in 4, 25-50 cm in 5, 50-100 cm in 2, and >100 cm in 1 case. The ileo-cecal valve was removed in 8 children. All children were treated with PN after surgery for at least 7 months. All 7 children with gastroschisis and 1 with <10 cm small intestine after intestinal resection for volvulus still required PN after 14-120 months. Three with gastroschisis died. All 5 children with volvulus and >10 cm small intestine were weaned from PN, thriving at our review 7 months-7 years later.

Conclusions

Infants and young children with short gut and >10 cm small intestine gain intestinal autonomy. In contrast, those with gastroschisis have poor outcomes and should be referred for intestinal transplantation assessment more readily than those with after intestinal resection for volvulus short gut.     

Long term prognosis after massive small bowel resection in children

Eight survivors after massive small bowel resection were reviewed for a period of 2 to 19 years to assess the long term prognosis of patients. The primary diseases of short bowel syndrome were congenital intestinal atresia (6) and midgut volvulus (2). The length of the residual small intestine ranged between 27 and 75 cm and ileocecal valve was also resected in 3 cases. All cases had been already weaned from parenteral nutrition and six children tolerate normal meals and two have still enteral formula at home now. Near normal somatic growth was achieved in cases which received intensive nutritional supports after operation. The D-Xylose absorption test revealed gradual improvement except one with the shortest intestine (27 cm) and fat absorption was disturbed in patients who had less than 45 cm residual intestine. Late metabolic complications, such as renal calculus, cholelithiasis and pathologic fractures were encountered in three cases.     

Hydrostatic characteristics of the ileocolic valve and intussuscepted nipple valves: an animal model.

The ileocolic valve, in the dog, decelerates the passage of stools and prevents fecal reflux. A loss of anterograde resistance worsens the symptoms of short bowel syndrome. The absence of fecal reflux control enhances the risk of recurrence of Crohn's disease. The aim of the present study was to examine what length of intussusception-like nipple valve (INV) should be constructed in order to restore the hydrostatic characteristics of the normal ileocecal valve. The anterograde and retrograde hydrostatic resistances of INVs of different lengths (4, 5, 6, or 7 cm) were compared with those of the normal ileocolic valve by using a contrast enema and x-ray monitoring in a canine model. It was found that the 4-cm-long INV may be sufficient to achieve an appropriate antireflux efficacy (59.60 +/- 4.26 cm H(2)O) versus the ileocolic valve (25.80 +/- 4.92 cm H(2)O), but this does not furnish an anterograde resistance comparable to that of the normal ileocolic valve (10.70 +/- 1.15 cm H(2)O vs. 21.60 +/- 3.96 cm H(2)O). We found that the appropriate length of the INV with which the anterograde resistance of the ileocolic valve could be attained in our model was between 6 and 7 cm. Thus, the shortest possible constructed INV should be effective in clinical conditions such as Crohn's disease, but the recommended length in short bowel syndrome should be greater than this.     

LONG TERM NUTRITIONAL EFFECTS OF EXTENSIVE RESECTION OF THE SMALL INTESTINE

A nutritional study was carried out on 36 patients several years after major resection of the small intestine (100 to 330 cm). Thirty one of these resections had been performed for Crohn's disease and only patients who had been clinically free of disease for more than one year were studied. The group of patients were 15% below their ideal weight. Total body fat was 24% below the predicted normal value and total body protein was 10% below. Although deficiencies of iron, vitamin B₁₂ and folic acid were frequently found, only six patients were anaemic. Other vitamin and mineral deficiencies were common. Despite these abnormalities, two thirds of the patients were engaged in their normal occupation full time and were subjectively well. The others who did not regain their normal capacity for work, had a greater nutritional deficit and a shorter length of remaining small intestine. It is concluded that nutritional deficiencies are common following extensive small bowel resection and all patients need regular follow up and appropriate vitamin and mineral supplementation. However, major disturbances of body composition and severe protein energy malnutrition with a reduced capacity for work are restricted to a small number of patients with very short lengths of remaining small intestine.     

Surgical approach to short-bowel syndrome. Experience in a population of 160 patients.

OBJECTIVE: The authors reviewed their experience with short-bowel syndrome to define the surgical approach to this problem in 160 patients. METHODS: Forty-eight adults and 112 children were evaluated over a 15-year period. RESULTS: Seventy-one patients (44%) adapted to resection and took enteral nutrition alone. Forty-four patients (28%) were supported by parenteral nutrition (PN). Forty-five patients (28%) have had 49 surgical procedures. Fifteen patients with adequate intestinal length (> 120 cm in adults) but dilated dysfunctional bowel underwent stricturoplasty (n = 4) or tapering (n = 11). Thirteen patients (87%) demonstrated clinical improvement. Fourteen patients with shorter remnants (90-120 cm) and rapid transit time received an artificial valve (n = 2) or a reversed segment (n = 1). All patients' conditions improved initially, but the reversed segment was revised or taken down. Fourteen patients with short remnants and dilated bowel underwent intestinal lengthening. Twelve patients' conditions improved (86%), one underwent transplantation, and one died. Sixteen patients with very short remnants (< 60 cm) and complications of PN underwent solitary intestine (n = 4) or combined liver-intestinal transplantation (n = 13). One-year graft survival was 65%. There have been five deaths. CONCLUSIONS: The surgical approach to short-bowel syndrome depends on the patient's age, remnant length and caliber, intestinal function, and PN-related complications. Nontransplant procedures have a role in the treatment of selected patients. Intestinal transplantation is emerging as a potential therapy for patients with significant PN-related complications.     

Massive small bowel resection in neonates—Is weaning from parenteral nutrition the final goal?

Eight surviving cases from an original 15 pediatric patients who underwent massive small bowel resection during their neonatal period were reviewed for a period of 2–19 years to assess long-term prognosis. the primary diseases were congenital intestinal atresia in 6 cases and midgut volvulus in 2. The length of the residual small intestine ranged from 27–75 cm and the ileocaecal valve had been resected in 3 cases. All cases were able to be weaned from parenteral nutrition and at present, 6 of the children can tolerate normal meals but 2 are still receiving enteral nutrition, in the form of a low residue diet at home. Near normal somatic growth was achieved in the most recent 5 cases who received intensive nutritional treatment in the immediate postoperative period, whereas 3 who did not receive nutritional management exhibited growth retardation. The D-Xylose absorption test revealed gradual improvement and finally normal absorption in all except one case with the shortest remaining intestine (27 cm). However, the fat absorption test revealed abnormal absorption in cases with a residual intestine of less than 45 cm. Late metabolic complications such as renal calculi, cholelithiasis and pathologic fractures were encoutered in 3 cases.     

Problems and difficulties in adapting period in infants and children after massive intestinal resection

In the period of intestinal adaptation following massive resection of intestine, patients have several difficulties and problems. This study was done in 17 survivals of 31 infants and children received massive intestinal resection (residual intestine; less than 75 cm) between 1966-1987 to define these problems and difficulties. 1) Postoperative hepatic dysfunction occurred in 11 of the 17 survivals. The relationship between relapsing frequency of hepatic dysfunction and length of remaining ileal segment suggested that the reduced ileal length may be one of the etiologic factors of the hepatic dysfunction. 2) Evaluation of serum bile acid levels suggested that the disturbance of bile acid reabsorption and its rapid turn over might still remain even after catch-up growth of these patients. 3) Abnormal levels of serum minerals (Ca, InP, Mg, Zn and Cu) were observed in 4 cases during TPN, and these abnormalities disappeared by discontinuation of parenteral nutrition and beginning of oral feeding. 4) Serum vitamin levels (Vit.A, Vit.E, 25-OH-D3, and Vit.B12) still remained in abnormal even after the patients reached school age. These results suggested that very long-term nutritional cares, especially in lipid and vitamin nutrition, are necessary for the children with massive intestinal resection.     

Importance of Ileum and Colon in Children with Short Bowel Syndrome

BackgroundIt is well known that small bowel length is a dominant prognostic indicator in patients with short bowel syndrome (SBS). The relative importance of jejunum, ileum, and colon is less well defined in children with SBS. Here we review the outcome of children with SBS with respect to the type of remnant intestine.MethodsA retrospective review of 51 children with SBS was conducted at a single institution. The duration of parenteral nutrition use was the main outcome variable. The length of the remaining intestine as well as the type of intestine were recorded for each patient. Kaplan–Meier analyses were conducted to compare the subgroups.ResultsChildren with greater than 10% expected small bowel length or more than 30 cm of small bowel achieved enteral autonomy faster than those with less. The presence of ileocecal valve enhanced the ability to wean from parenteral nutrition. The presence of ileum significantly enhanced the ability to wean from parenteral nutrition. Patients with the entire colon also achieved enteral autonomy sooner than those with partial colon.ConclusionsThe preservation of ileum and colon is important in patients with SBS. Approaches to preserve or lengthen ileum and colon may be beneficial for these patients.Level of evidenceIV.     

Nutritional condition and absorptive capacity of 14 infants with short bowel syndrome

We examined the absorptive capacity and the nutritional condition of 14 infants with short bowel syndrome, whose residual small intestine was 90 cm or less. Their age ranged from 1 year to 18 years. Examined items were body weight, height, serum albumin, total cholesterol, triglyceride, fat soluble vitamins, trace elements and rapid turn over protein as markers of the nutritional condition. Fecal fat, fecal bile acid, d-xylose absorption test, sugar-, amino acid-evoked potential difference in the small intestine and disaccharidase activity of the mucosa were examined as markers of the absorptive capacity. Our results showed that the body weight was below the normal range in the patients with small intestine of less than 50 cm. Most nutritional markers were within normal range, however, cholesterol and vitamin D were low in the patients with fat malabsorption, especially in patients with less than 50 cm of small intestine. Fecal bile acid was higher than the normal range in all the patients. Potential difference was in normal range or slightly lower than normal in all the patients. We concluded that infants with less than 50 cm of small intestine had malabsorption of sugar, protein and fat. Therefore, prolonged nutrient support, especially fat, is necessary.     

Nutrition assessment in children with short bowel syndrome weaned off parenteral nutrition: a long-term follow-up study

Purpose

The purpose of the study was to assess long-term growth and nutrition status of children with neonatal short bowel syndrome (SBS) after weaning off parenteral nutrition (PN).

Methods

Eight children with neonatal SBS weaned from PN therapy for more than 2 years were studied. Medical records were reviewed; anthropometric measurements and blood test (hemoglobin, albumin and prealbumin, immunoglobulin, electrolytes, trace elements, and fat-soluble vitamins) were assayed during follow-up.

Results

Anthropometric measurements, weight for age, and height for age were normal in all children; one child was found to be overweight according to weight for height z score. No children were found to have anemia, although one presented with macrocytosis and another had microcytosis. Low serum concentrations of zinc in 3 cases and iron in 1 case were detected. Immunoglobulin levels of all children were within the reference value. Low plasma levels of vitamin A in 2 cases, vitamin E in 4 cases, and β-carotene in 2 cases were found; one of them had obviously low levels of the 3 fat-soluble vitamins.

Conclusion

Children with SBS are still at risk for different nutrient malabsorption even after weaning off PN for a long time. Therefore, they need long-term, regular monitoring and intensive nutritional care to prevent various nutrient deficiencies.