关于结直肠癌梗阻患者肠道吻合研究进展

我国结直肠癌发病率呈逐年上升趋势,而原发性结直肠癌患者中有大约15%～20%并发肠梗阻,伴随着大肠癌发病率的不断增加,由肿瘤所致肠梗阻的病例也逐渐增多。对于肠梗阻患者的治疗方式虽然在不断研究与改进的同时还存在着争议,说明无论在治疗观念或治疗技术上都存在着许多需要进一步解决的问题     

胃肠道肿瘤术后肠梗阻诊治分析

目的探讨胃肠道肿瘤术后肠梗阻的诊断、治疗及预后。方法回顾性分析江苏省中医院2011年1月至2013年1月期间58例胃肠癌术后肠梗阻患者的临床资料。结果 58例患者中不全性肠梗阻46例,完全性梗阻12例。17例行保守治疗;41例行剖腹探查术,其中探查发现嵌顿性腹内疝4例,肠扭转4例,粪石性梗阻1例,肠套叠2例,粘连性肠梗阻9例,肿瘤复发者21例。术前肿瘤标志物高于正常者32例,其中肿瘤复发者19例。PET-CT提示无明显肿瘤病灶但探查发现复发转移者14例。结论胃肠道肿瘤术后反复发作的肠梗阻多为肿瘤复发,提示预后不良。及早剖腹探查可改善患者预后及生活质量;肿瘤标志物的升高与肿瘤复发有一定的联系;PET-CT对于多发性结节性转移灶的检测并不敏感。     

经鼻型肠梗阻导管在肠梗阻治疗中的作用(附58例报道)

目的 探讨经鼻型肠梗阻导管在肠梗阻治疗中的作用及临床疗效.方法 回顾我院2014年1月至2015年2月期间使用经鼻型肠梗阻导管治疗肠梗阻的病人58例,总结分析其临床治疗效果.结果 所有病人经过3～25 d的肠梗阻导管治疗,共42例病人梗阻症状完全缓解;8例病人因肿瘤梗阻行手术治疗;5例因保守治疗后效果不佳行手术治疗;3例因症状完全缓解后带管进食后又再次出现肠梗阻症状行手术治疗.结论 经鼻型肠梗阻导管对于小肠梗阻及右半结肠梗阻的病人可以起到较好的减压作用,值得推荐使用.     

慢性放射性肠炎并发肠梗阻的治疗

目的探讨放射性肠炎并发肠梗阻的治疗方法及临床效果。方法对2001年8月至2006年12月间收治的51例慢性放射性肠炎并发肠梗阻患者的临床资料进行总结。结果本组患者放射性肠炎并发肠梗阻均为肿瘤切除后盆腔、腹腔接受放射治疗所致,从放疗结束到肠梗阻症状出现的时间为(11.9±22.6)个月。分别采用了保守治疗(方案包括禁食、胃肠减压、抑制消化液分泌、营养支持、灌肠、补液、对症等,对于有感染征象的患者选用敏感的抗生素)、肠切除吻合术、肠造口术及短路手术。2例患者因肿瘤广泛转移未行有效手术治疗,1例患者术后因腹腔出血死亡,48例患者得到治愈,治愈率达94.1%。结论慢性放射性肠炎并发肠梗阻的治疗方案应该根据患者的营养状况及肠管损伤情况进行选择。     

胃肠道肿瘤术后早期炎性肠梗阻的诊治(附18例报道)

目的 探讨胃肠道肿瘤术后早期炎性肠梗阻的临床特点、诊断和治疗措施.方法 回顾性分析18例胃肠道肿瘤术后早期炎性肠梗阻患者的临床资料.结果 18例患者,其中1例症状缓解后再次梗阻,均经非手术治疗痊愈,恢复时间为12～37d,平均15d,均无肠瘘、肠坏死和腹腔严重感染等并发症发生.结论 CT有利于鉴别诊断胃肠道肿瘤术后早期炎性肠梗阻,确诊后应采取非手术治疗,疗效良好.     

左半结肠癌致肠梗阻的外科处理

大肠癌在发达国家中是最常见的恶性肿瘤之一 ,居第二位。在我国大肠癌占恶性肿瘤的第三位 ,仅次于肺癌及胃癌。且近年其发病率和死亡率都有上升趋势。大肠癌伴肠梗阻尤其是左半结肠癌伴肠阻的治疗成了近年临床医生关注的热点。本文就国外文献报道的大肠癌致肠梗阻的外科治疗方法及效果加以综述。1　姑息性肠减压术　　肠梗阻的病人有严重的水电失衡 ,加上肿瘤慢性消耗 ,解除梗阻 ,恢复正常生理通道 ,争取肿瘤切除时机是左半结肠癌致肠梗阻患者急需解决的问题。1 .1　盲肠造瘘术 :是一种古老的手术方式。手术简便安全 ,死亡率低。适用于急诊…     

成人机械性肠梗阻手术治疗预测因素的探讨

目的:探讨成人机械性肠梗阻手术治疗的预测因素及中西医结合非手术治疗的疗效.方法:回顾性分析住院治疗的机械性肠梗阻患者,病人分为非手术治疗组和手术治疗组,临床指标、实验室检查、影像学检查作为手术治疗的预测因素采用logistic多因素回归分析,并分析中西医结合非手术治疗的疗效.结果:根据logistic多因素回归分析得出腹部包块、肠鸣音减弱、腹痛进行性加重、白细胞计数、腹部立位X线平片示梗阻肠襻固定且扩张加重5 项指标可以预测机械性肠梗阻患者是否需手术治疗.结论:患者入院或住院期间,腹部包块、肠鸣音减弱、腹痛进行性加重、白细胞计数增高、腹部立位X线平片示梗阻肠襻固定且扩张加重可能是机械性肠梗阻患者需手术治疗的预测因素.中药治疗能有效治疗腹腔粘连、复发或转移性肿瘤所致机械性肠梗阻.     

肠梗阻导管联合大承气汤在肠道肿瘤术后粘连性肠梗阻中的应用

探讨肠梗阻导管联合大承气汤在肠道肿瘤术后粘连性肠梗阻治疗中的应用价值。回顾性分析2014年1月—2018年1月在我科治疗的肠道肿瘤术后粘连性肠梗阻45例患者的临床资料,根据治疗方法分为3组:鼻胃管组、肠梗阻导管组、肠梗阻导管+大承气汤组,均为15例,比较3组的临床疗效。与鼻胃管组相比,肠梗阻导管组、肠梗阻导管+大承气汤组在腹痛腹胀缓解时间、排气排便时间、气液平面消失时间、住院时间、临床有效率等方面差异有统计学意义(P0.05);肠梗阻导管+大承气汤组在排气排便时间、气液平面消失时间、住院时间方面优于肠梗阻导管组,差异有统计学意义(P0.05)。肠梗阻导管联合中药大承气汤治疗肠道肿瘤术后粘连性肠梗阻具有症状缓解快、住院时间短、临床有效率高、费用低等优势,对腹部肿瘤晚期术后的中低位肠梗阻患者以及体质差、合并疾病多、不能耐受手术的患者,是比较理想的选择。     

经肛型肠梗阻导管置入联合限期手术治疗结直肠癌伴肠梗阻的价值研究

目的分析经肛型肠梗阻导管置入联合限期手术治疗结直肠癌伴肠梗阻患者的临床价值。方法在本院接受治疗的结直肠癌伴肠梗阻患者40例,随机分为单纯接受手术治疗的对照组及接受手术联合经肛型肠梗阻导管置入的观察组,比较其肛管引流相关情况、内毒素及肿瘤坏死因子水平、术后并发症发生情况等差异。结果 1观察组患者接受治疗后,其腹围、胃管引流量及近端肠管最大横截均明显小于接受常规术前准备的对照组患者(P<0.05);2观察组患者术后4d及7d的内毒素及肿瘤坏死因子水平均显著低于对照组患者(P<0.05);3观察组患者术后各项并发症发生率均明显低于对照组(P<0.05)。结论经肛型肠梗阻导管置入联合限期手术可以有效解除直肠癌伴肠梗阻患者的梗阻症状,降低术后内毒素及肿瘤坏死因子水平,减少术后并发症发生。     

梗阻性结肠癌的术式选择（附75例临床分析）

目的 探讨结肠癌并急性肠梗阻的手术方式.方法 回顾性分析我院自2000年至2012年收治的75例结肠癌并急性肠梗阻病例的临床资料,评价其手术方式.结果 75例患者均经手术治疗,出现并发症10例;死亡3例,病死率为4.0％,其余均痊愈出院.结论 结肠癌并急性结肠梗阻的处理要根据患者的全身情况和肿瘤的局部情况来进行综合判定,掌握适应证,一期肿瘤切除吻合加预防性造口术是安全的.     

Outcome of palliative operations for malignant bowel obstruction in patients with peritoneal carcinomatosis from nongynecological cancer

Background:Malignant bowel obstruction (MBO) secondary to peritoneal carcinomatosis carries a grave prognosis. We evaluated clinicopathologic factors that predict outcomes after palliative operations for MBO.Methods:Data on patients undergoing laparotomy for palliation of gastrointestinal MBO at City of Hope between 1995 and 2000 were retrospectively collected. Successful palliation was defined as the ability to tolerate solid food (TSF).Results:Sixty-three patients underwent operative treatment. In 20 patients, MBO was the first presentation of disease; for others, the median disease-free interval was 15 months. The complication rate was 44%, and postoperative mortality was 15%. The median length of stay was 12 days. Twenty-nine patients (45%) were discharged from the hospital on a regular diet; 22 (76%) continued to eat until their last follow-up. Median survival was 90 days. Univariate factors for longer survival were TSF on discharge, colorectal primary, and nonmetastatic status at first diagnosis. Patients with ascites and whose cancer first presented with MBO had an inferior survival. Noncolorectal primary remained a multivariate predictor for decreased survival. TSF was predicted by the absence of ascites, an obstruction not involving the small bowel, and a preoperative albumin of >3.0 mg/dl. Multiple logistic regression analysis yielded presence of ascites and small-bowel obstruction as predictors of inability to TSF.Conclusions:Only one third of patients with MBO from peritoneal carcinomatosis will have prolonged postoperative palliation with significant, but acceptable, treatment-related morbidity. TSF at discharge is a useful predictor of continued palliation for most patients. Patients with colorectal cancer may have superior survival outcome and better palliation; others are at risk for poor outcomes, especially in the presence of ascites and MBO of small bowel. In these patients, highly selective use of laparotomy is recommended.     

奥曲肽在胃肠道肿瘤所致恶性肠梗阻治疗中的应用

目的探讨生长抑素类似物——奥曲肽治疗胃肠道肿瘤所致恶性肠梗阻的临床效果。方法回顾性分析2006年1月～2008年2月我院42例恶性肠梗阻的临床资料,分为奥曲肽组23例和对照组19例,比较2组患者在治疗后腹痛、腹胀症状变化,肛门恢复排气排便时间,胃肠减压量,中转手术率和住院时间。结果奥曲肽组腹胀、腹痛缓解率78.3%（18/23）较常规组36.8%（7/19）有明显改善（χ2=7.409,P=0.006）;奥曲肽组胃肠引流量（409.1±32.4）ml显著少于常规组（605.7±45.9）ml（t=-16.237,P=0.000）;奥曲肽组中转手术率21.7%（5/23）显著低于常规组63.2%（12/19）（χ2=7.409,P=0.006）;治疗后肛门开始排气时间奥曲肽组（4.1±1.3）d显著短于常规组（6.5±2.7）d（t=3.773,P=0.000）;治疗后奥曲肽组生活质量明显改善,KPS评分为（61.2±7.2）分,显著高于常规组（45.1±7.8）分（t=4.910,P=0.000）。结论在常规治疗基础上加用生长抑素类似物奥曲肽能改善胃肠道肿瘤所致肠梗阻患者的临床症状,降低中转手术率,改善患者生活质量。     

Obstruction-Free Survival Following Operative Intervention for Malignant Bowel Obstruction in Appendiceal Cancer

Annals of Surgical Oncology - Patients with peritoneal metastases from appendiceal cancer are at high risk of malignant bowel obstruction (MBO), which is associated with significant morbidity and...     

醋酸奥曲肽在恶性肿瘤肠梗阻中的应用

目的探讨醋酸奥曲肽对恶性肿瘤致肠梗阻的治疗价值。方法回顾总结1996年8月至2004年6月间收治的51例恶性肿瘤并发不全肠梗阻患者的治疗结果。结果常规治疗组19例，予以禁食、胃肠减压、灌肠、肛管排气、营养支持和纠正水电解质失衡等治疗。醋酸奥曲肽联合常规治疗组（联合治疗组）32例，予以醋酸奥曲肽0．1mg，皮下注射，1次／8h；合并上述常规治疗。对比临床症状改善情况、胃肠减压量、胃管是否拔除以及不同梗阻部位对醋酸奥曲肽疗效的影响等指标。联合治疗组症状缓解20例（63．1％），常规治疗组仅4例（21．1％），两组比较，差异有统计学意义（P〈0.01）。联合治疗组胃肠减压量（398±152）ml／d，常规治疗组（834±306）ml／d，两组比较，差异也有统计学意义（P〈0.05）。结论醋酸奥曲肽对恶性肿瘤合并肠梗阻的患者，可明显缓解肠梗阻，减少胃肠减压量。     

恶性肠梗阻的治疗进展

[摘要] 恶性肠梗阻是指由恶性肿瘤引起的肠梗阻,通常是结直肠癌以及妇科恶性肿瘤晚期并发症。患者预后较差,平均生存期只有4～9个月。目前治疗恶性肠梗阻包括手术、置入可扩式支架、药物治疗,以及经皮内镜下胃造口和鼻胃管引流。除此之外,由于患者一般体质较差,还可给予肠外营养支持,不过该治疗效果存在争议。本文就目前恶性肠梗阻的多种治疗方案进行综合分析,并作一定的评估。     

Surgery as a Bridge to Palliative Chemotherapy in Patients with Malignant Bowel Obstruction from Colorectal Cancer

Background Malignant bowel obstruction (MBO) is a feature of the clinical course of 10–28% of colorectal cancer (CRC) patients and is associated with a poor prognosis. Recent advancements in palliative chemotherapy regimens have prolonged survival in patients with stage IV CRC. Few reports exist that describe outcomes in patients who have had surgery for MBO and subsequent chemotherapy as part of their treatment. The objective of this study was to review surgical outcomes in patients with MBO for CRC and to evaluate the extent to which surgery can serve as a bridge to palliative chemotherapy. Methods Patients who presented with MBO and had surgical treatment were identified from a prospectively kept database at a single tertiary care center between 09/99 and 08/04. Charts were retrospectively reviewed and clinical and outcomes data were abstracted. Results Forty-seven patients were identified who had surgery as part of the treatment for MBO from CRC. Operations included resections, bypasses and stoma creation. Overall, 80% of patients were able to tolerate solid food post-operatively and return home. The median survival for the entire cohort was 3.5 months. Seven patients died within 30 days of surgery. Of the remainder, 24 patients were palliated with surgery alone and 16 patients ultimately received palliative chemotherapy. Survival in the final cohort was significantly prolonged (P < 0.001). Conclusion Surgery can adequately palliate a substantial proportion of patients with MBO from CRC with acceptable morbidity and mortality. In addition, in a subset of patients it can facilitate palliative chemotherapy that is associated with improved overall survival. Dr. Calvin Law is a Career Scientist of the Ontario Ministry of Health and Long Term Care and is supported through a Health Research Personnel Development—Career Scientist Award.     

The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer

BACKGROUND: This study was designed to investigate the early outcomes after surgical treatment of malignant large bowel obstruction (MBO) and to identify risk factors affecting operative mortality. METHODS: Data were prospectively collected from 1046 patients with MBO by 294 surgeons in 148 UK hospitals during a 12-month period from April 1998. A predictive model of in-hospital mortality was developed using a 3-level Bayesian logistic regression analysis. RESULTS: The median age of patients was 73 years (interquartile range 64-80). Of the 989 patients having surgery, 91.7% underwent bowel resection with an overall mortality of 15.7%. The multilevel model used the following independent risk factors to predict mortality: age (odds ratio [OR] 1.85 per 10 year increase), American Society of Anesthesiologists grade (OR for American Society of Anesthesiologists grade I versus II,III,IV-V = 3.3,11.7,22.2), Dukes' staging (OR for Dukes' A versus B,C,D = 2.0, 2.1, 6.0), and mode of surgery (OR for scheduled versus urgent, emergency = 1.6, 2.3). A significant interhospital variability in operative mortality was evident with increasing age (variance = 0.004, SE = 0.001, P < 0.001). No detectable caseload effect was demonstrated between specialist colorectal and other general surgeons. CONCLUSIONS: Using prognostic models, it was possible to develop a risk-stratification index that accurately predicted survival in patients presenting with malignant large bowel obstruction. The methodology and model for risk adjusted survival can set the reference point for more accurate and reliable comparative analysis and be used as an adjunct to the process of informed consent.     

Surgical management of malignant bowel obstruction in recurrent pancreatic cancer

IntroductionMalignant bowel obstruction (MBO) is harrowing complication of gastrointestinal cancers. Only a few studies have reported on the surgical roles of bowel obstruction from recurrent pancreatic cancer. We report successfully management for malignant bowel obstruction by palliative surgery for relief of symptoms.Presentation of caseA 43 year old man was diagnosed with pancreatic tail cancer. After distal pancreatectomy, he underwent six cycle of adjuvant chemotherapy. 10 months later, he had suffered from small bowel obstruction by seeding metastases. We performed segmental small bowel resection. This patient had good recovery and continued to receive palliative chemotherapy. A 78 year old man was diagnosed with unresectable, huge pancreatic cancer. He had recurrent obstructive symptoms and periumbilical pain. We decided palliative surgery of wide excision of umbilical abdominal mass for pain control. 3 weeks later, he presented with recurrent symptoms in previous op site. We planned 2nd operation for relief of symptoms. He underwent surgery to resect abdominal wall mass and small bowel due to 2 cm sized mass in terminal ileum. After 2nd surgery, he received consistently palliative chemotherapy with good clinical condition.Discussion and conclusionPalliative surgery improves quality of life in recurrent pancreatic cancer patients and can continue patient’s palliative management. In selected patients, palliative surgery may effective management for progress of survival and quality of life.     

Palliative Venting Gastrostomy in Patients with Malignant Bowel Obstruction and Ascites

Background

Fluoroscopic-guided placement of a percutaneous decompression gastrostomy tube (PDGT) is used to palliate patients with malignant bowel obstruction (MBO). We report our clinical experience in cases of MBO and ascites that were known to be technically difficult and at increased risk for complications after PDGT placement.

Methods

Between October 2005 and April 2010, a total of 89 consecutive oncology patients with MBO and ascites underwent at least one attempt at PDGT placement. We retrospectively reviewed the electronic medical record to collect demographic details, procedure information, and morbidity and mortality data. Kaplan–Meier curves were used to calculate median survival after PDGT.

Results

Ninety-three new gastrostomy encounters occurred in 89 patients. The primary and secondary technical success rates were 72 % (67 of 93) and 77.4 % (72 of 93), respectively. Inadequate gastric distention was the reason for failure in 84.6 % (22 of 26) of the cases in which the initial PDGT attempt was unsuccessful. For ascites management, 13 patients underwent paracentesis and 78 patients underwent placement of an intraperitoneal catheter. The overall complication rate in successful placements was 13.9 %, with a major complication rate of 9.7 %. After PDGT, the median overall survival rate was 28.5 days (95 % confidence interval 20–42).

Conclusions

PDGT is feasible in the majority of patients with MBO and ascites, although there is an inherent risk of major complications. An intraperitoneal catheter can be used to manage ascites to facilitate PDGT.     

胆道支架介入治疗恶性胆道梗阻136例临床分析

目的探讨胆道支架(金属支架、塑料支架)介入治疗恶性胆道梗阻的应用价值。方法2005年8月～2008年5月,对136例不宜行手术治疗的恶性胆道梗阻患者,通过内镜途径或经皮经肝途径行胆道支架置入术。结果内镜成功128例,不成功的8例行经皮经肝穿刺。放置金属支架71例,塑料支架65例。放置胆道内支架1周后,血清总胆红素、ALT、AST均明显下降(P0.01),临床症状显著改善。71例放置胆道金属支架者中,11例术后2个月内支架阻塞,再次放置塑料支架后引流通畅;余60例支架通畅时间270～286d,平均275d。65例放置塑料内支架者中,9例术后1～4周支架移位和梗阻,重新置入塑料支架;余56例支架通畅时间110～128d,平均118d。经皮经肝途径术后发生胆汁性腹膜炎1例,经保守治疗治愈。其余病例无严重并发症。随访生存时间1.5～28个月,存活3个月以上者92例。结论胆道支架介入治疗恶性胆道梗阻疗效确切,适用于不宜手术者,对于解除晚期恶性胆道梗阻性黄疸、缓解症状、提高患者生存质量具有满意效果。估计生存期3个月者,宜选择金属支架;估计生存期3个月或经济条件不充许者,可选用塑料支架。