肠袢圈式吻合与重叠式肠管倒置术治疗短肠综合征

本文报告9例小肠广泛切除术后不同手术处理的随访结果。9例中行小肠—小肠端端吻合术3例,均于术后6月内死亡。肠袢圈式吻合4例,1例于术后2年死亡,3例现已分别生存13年、8年和7年。重叠式肠管倒置术2例,已分别生存12年和10年。作者认为肠袢圈循环式吻合或重叠式肠管倒置术操作并不复杂,即使在急症手术时也能较快完成,它对治疗短肠综合征效果满意,是值得采用的手术方法。     

急性肠系膜上动脉栓塞小肠广泛坏死七例治疗经验

目的 总结急性肠系膜上动脉栓塞小肠广泛坏死的治疗经验。方法 对1991-1999年收治的急性肠系膜上动脉栓塞小肠广泛坏死7例的临床资料进行回顾性分析。结果 7例术后剩留小肠28-30cm的3例,70-90cm的4例。本组2例术后死于感染中毒性休克;5例发生短肠或超短肠综合征,经静脉营养与经口进食等综合治疗全部治愈,本组随访18个月4例,36个月1例,均健在,结论 及时诊断和早期手术是提高治愈率的关键,尽可能保留有生机的肠段,对术后剩留小肠在28-90cm的短肠和超短肠综合征,采取静脉营养和经口进食并举的综合治疗,可以较快恢复肠管的消化吸收功能。     

益气生津法结合胃肠外营养治疗短肠综合征2例

益气生津法结合胃肠外营养治疗短肠综合征２例张静吉吉朱培庭沈平刘铭升王伟良上海中医药大学龙华医院（上海２０００３２）短肠综合征是指小肠广泛切除（小肠切除量超过７０％或残留肠管长度少于１００ｃｍ）术后出现严重的消化道吸收和全身营养障碍的临床综合征〔１，２...     

肠道非移植手术治疗短肠综合征最新进展

短肠综合征是各种原因导致小肠广泛切除后，残留功能性小肠过少而出现的临床症候群，治疗难度大，预后较差。多数病人需长期依赖肠外营养提供能量。作为短肠综合征治疗的重要组成部分，肠道非移植手术已有术式的适应证不断被探讨、临床效果不断被验证及新的术式不断被发掘。实践证明，以“小肠倒置术”为代表的“增加食物转运时间”的手术成功率低，改善营养水平有限，已不做推荐。以“缩窄肠管直径、增加残余小肠长度及吸收面积”为核心理念设计的术式如小肠缩窄延长术（LILT）、连续横向肠管成形术（STEP），效果较为确切，是目前应用最多的术式。作为LILT、STEP适应证补充的螺旋延长缩窄术（SILT）是一种最新手术方式，其临床效果仍需进一步验证。     

短肠综合征治疗进展一例报道

短肠综合症 (shortbowelsyndromeSBS)指医源性切除小肠超过 75 %或剩余小肠长度小于 6 0～ 1 0 0cm ,无法满足消化吸收功能的吸收不良综合征。本例术中切除小肠仅 80cm ,但由于术中将近端空肠约 6 0cm与回肠末端短路吻合 ,使大段的剩余小肠功能废用出现SBS的表现。经综合治疗治愈。临床资料 :病人 ,女性 ,6 3岁。有阑尾切除及胆囊切除史 ,行直肠癌Mile’s手术 ,术后放疗出现不完全肠梗阻 ,重度营养不良。转我院手术探查 ,发现小肠结肠紧密成角粘连 ,切除小肠约 80cm ,保留近端距屈氏韧带 6 0cm ,与回肠末端吻合。远端小肠严重粘连 ,为免…     

急性肠系膜血管闭塞时肠道的处理

目的总结肠缺血和淤血时肠道的处理经验和教训。方法回顾性分析2001—2006年收治的5例肠系膜血管闭塞的诊治过程，重点探讨不同情况下如何缩小肠管的切除范围，减少并发症的发生。结果5例病人中，3例病人处理得当，结果满意。l例病人初次处理不当，再次行肠切除，病人治愈。1例转当地医院后行造口还纳术，1周后因小肠大出血而死亡。结论对于受累肠管范围较小的病例，应将受累肠管切除。保证吻合口愈合良好；对于肠管累及范围较大的病例，应尽可能保留生机可能恢复的肠管，采用肠造口的方法观察肠管活力。适时进行造口还纳。在处理肠管的同时，对肠系膜血栓的病人应进行取栓，术后抗凝治疗，避免血栓蔓延和复发。     

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     

急性肠系膜上静脉血栓形成18例诊治体会

目的总结急性肠系膜上静脉血栓形成(superiormesentericvenousthrombosis,SMVT)的诊治经验。方法18例急性SMVT患者,6例行抗凝、溶栓治疗(其中1例中转手术),另12例行手术治疗,切除坏死肠管及含有静脉血栓的全部肠系膜。结果6例抗凝、溶栓治疗患者中顺利溶栓、症状体征消失者5例(83.3%);另1例患者于非手术治疗17h后出现明显的腹膜炎体征而中转手术。13例开腹探查的患者中治愈9例(69.2%),死亡4例(30.8%),死于小肠广泛坏死短肠综合征、多系统器官功能衰竭各2例。结论早期诊断及抗凝、溶栓治疗使非手术疗法成为首选,但对于已出现腹膜炎、穿孔等肠缺血坏死征象的患者则应考虑手术治疗。     

短肠综合征并肠外瘘的诊治(附32例分析)

目的研究短肠综合征合并肠外瘘的诊断与治疗方法的特点与规律。方法1995~2005年共收治剩余小肠<100 cm的肠外瘘病人32例,就肠外瘘发生原因、部位、治疗方法和肠康复方法进行分析。结果治愈20例,死亡6例,6例好转后中断治疗出院。病人残存的肠管平均(58.03±28.30)cm。28例接受了肠内营养,其中9例未进行肠康复治疗,肠管平均长度为(52.8±31.5)cm,肠内营养平均恢复时间为(129.6±89.8)d;19例接受了肠康复治疗,肠管平均长度(64.1±19.2)cm,肠内营养平均恢复时间为(61.8±54.0)d。结论短肠综合征合并肠外瘘的主要疾病为肠扭转,部位多在吻合口,原因是坏死范围较大,切除界限不易判断。早期使用生长抑素有减少肠液分泌的作用,还可减少短肠综合征急性期的腹泻症状。后期使用生长激素有促进肠外瘘自愈和肠康复的双重作用。     

大鼠广泛肠切除后小肠组织miR-125a和Mcl-1的表达及意义

目的：探讨广泛肠切除后miR-125a和抗凋亡蛋白（Mcl-1）在肠上皮细胞中表达的变化及其在短肠综合征剩余肠管适应性变化过程中的意义。方法选取8周龄的SD雄性大鼠54只,分为实验组（18只,进行70％的大范围小肠切除,距回盲部近端15 cm和Treitz韧带远端10 cm处分别切断小肠,然后行空回肠端端吻合）、肠切除对照组（18只,在距回盲部近端15 cm处切断肠管然后再吻合）和手术对照组（18只,仅行开关腹手术）。术后1周在距吻合口远端1 cm处取材,采用免疫组织化学方法和实时荧光定量 PCR检测各组大鼠小肠组织中 Mcl-1和 miR-125a 表达。结果实验组大鼠肠组织中Mcl-1阳性表达率为18．8％（3／16）,明显低于手术对照组（76．5％,13／17）和肠切除对照组（83．3％,15／18）（均P＜0．01）;miR-125a相对表达量为1.92,明显高于肠切除对照组（1.01）和手术对照组（1.05）（均P＜0．01）。结论 miR-125a和Mcl-1在广泛肠切除诱导的肠道适应过程中发挥重要作用,二者之间通过一定的机制相互调节。     

Segmental reversal of the small bowel as an alternative to intestinal transplantation in patients with short bowel syndrome.

OBJECTIVE: This article reports the results of segmental reversal of the small bowel on parenteral nutrition dependency in patients with very short bowel syndrome. SUMMARY BACKGROUND DATA: Segmental reversal of the small bowel could be seen as an acceptable alternative to intestinal transplantation in patients with very short bowel syndrome deemed to be dependent on home parenteral nutrition. METHODS: Eight patients with short bowel syndrome underwent, at the time of intestinal continuity restoration, a segmental reversal of the distal (n = 7) or proximal (n = 1) small bowel. The median length of the remnant small bowel was 40 cm (range, 25 to 70 cm), including a median length of reversed segment of 12 cm (range, 8 to 15 cm). Five patients presented with jejunotransverse anastomosis, and one each with jejunorectal, jejuno left colonic, or jejunocaecal anastomosis with left colostomy. RESULTS: There were no postoperative deaths. Three patients were reoperated early for wound dehiscence, acute cholecystitis, and sepsis of unknown origin. Three patients experienced transient intestinal obstruction, which was treated conservatively. Median follow-up was 35 months (range, 2 to 108 months). One patient died of pulmonary embolism 7 months postoperatively. By the end of follow-up, three patients were on 100% oral nutrition, one had fluid and electrolyte infusions only, and, in the four other patients, parenteral nutrition regimen was reduced to four (range of 3 to 5) cyclic nocturnal infusions per week. Parenteral nutrition cessation was obtained in 3 of 5 patients at 1 years and in 3 of 3 patients at 4 years. CONCLUSION: Segmental reversal of the small bowel could be proposed as an alternative to intestinal transplantation in patients with short bowel syndrome before the possible occurrence of parenteral nutrition-related complications, because weaning for parenteral nutrition (four patients) or reduction of the frequency of infusions (four patients) was observed in the current study.     

An experimental evaluation of segmental reversal after massive small bowel resection.

The technique of reversal of a distal segment of residual small intestine was applied to the management of massive resection. A controlled evaluation was carried out in dogs into the effects of segmental reversal on the proximal remnant after the distal 75 per cent of the small bowel had been resected. The variables studied were survival, body weight, glyceryl tri(palmitate-1-14C) absorption and mouth-to-caecum transit time. Animals subjected to resection alone had accelerated intestinal transit, poor absorption, serious weight loss and a high early mortality. It was clearly demonstrated that segmental reversal after resection produced marked and progressive delay in transit time from mouth to caecum, sustained improvement in fat absorption and body weight and enhanced survival.     

生长因子及其在短肠综合征中的应用

目的探讨生长因子促进大量肠切除后肠道代偿的作用与机制,并了解其在短肠综合征营养支持治疗中的研究进展。方法对介绍生长因子促进肠切除后肠道代偿以及其在短肠综合征患者的应用的有关文献进行综述。结果不同种类的生长因子对促进肠切除后肠道代偿产生着不同的效应,可根据短肠综合征患者的具体情况合理选择外源性生长因子,以缩短残留小肠代偿时间,改善患者的营养状况。结论生长因子能够在一定意义上促进肠切除后肠道代偿,但不同种类的生长因子有各自的作用效应,将对短肠综合征患者尽早摆脱完全肠外营养有帮助,但仍需进一步的研究。     

小肠内支撑排列术治疗多次术后广泛粘连性肠梗阻

目的总结小肠内支撑排列术治疗多次术后广泛粘连性肠梗阻的临床经验与疗效。方法回顾分析1995～2003年间采用小肠内支撑排列术治疗多次术后广泛粘连性肠梗阻21例患者的临床资料。结果20例患者术后无并发症发生,顺利康复。1例肠坏死肠切除病例术后发生肠瘘,经内支撑管持续低负压引流后迅速痊愈。19例患者经1～7年随访,均未出现肠粘连和肠梗阻。结论对多次手术(2次以上)后出现广泛粘连性肠梗阻患者,小肠内支撑排列术是一种操作简单、安全而有效的术式。     

Short Bowel Syndrome

Abstract The short bowel syndrome is a symptom complex that occurs in adults who have less than 200 cm of jejunum-ileum remaining after intestinal resection. Similar symptoms are observed in infants and children following massive bowel resection or congenital anomalies and in individuals with longer segments of intestine with severe mucosal disease. Initial care should focus on a thorough excision of nonviable bowel, an exact measurement of the remaining viable bowel, placing all intestine in continuity at the initial or subsequent operation, and controlling initial food intake. With time, adaptation of the remnant intestine occurs, and absorptive function may be maximized by enhancing the enteral diet and minimizing parenteral nutrition. Growth factors and specialized nutrients may also enhance this process. Intestinal transplantation should be considered in selected individuals with the short bowel syndrome who fail intestinal rehabilitation protocols. E-pub: 31 October 2000     

Segmental Intestinal Preservation and Enteral Nutrition Help to Maintain the Intestinal Function After a Massive Intestinal Resection: Report of a Case

We report a case in which both segmental intestinal preservation and enteral nutrition helped to maintain the intestinal function after a massive bowel resection for superior mesenteric artery (SMA) thrombosis. A 53-year-old Japanese man was admitted to our hospital with acute abdomen. Extensive necrosis of the small intestine was found during the operation; however, a loop of the ileum appeared to be viable. A massive resection of the small intestine which preserved a 50-cm length of the viable ileum loop was thus performed. However, diffuse stenosis of the remaining ileum was found after surgery. An end-to-end anastomosis of the distal end of the preserved ileum loop and the terminal ileum was made in the second operation, and enteral nutrition was infused to improve the remnant intestinal function. A jejunoileostomy was performed in the final operation. An X-ray study after the final operation showed the stenosis of the remaining ileum to have improved. The patient therefore did not need any nutritional support after being discharged. Received: December 5, 2000 / Accepted: May 15, 2001     

Surgical therapy for the short bowel syndrome

The introduction of total parenteral nutrition has resulted in more patients surviving massive intestinal resection. Long-term parenteral nutrition is expensive, has potential complications, and causes inconvenience for the patient. Therefore, interest persists in surgical therapy for the short bowel syndrome. The goals of surgical therapy in the short bowel syndrome are to slow intestinal transit, increase the area of absorption, and reduce gastric hyperacidity. Patients with sufficient absorptive area, but rapid intestinal transit, benefit from antiperistaltic segments or colon interposition. Intestinal valves yield inconsistent results. Recirculating loops are associated with prohibitive morbidity and mortality. Experience with intestinal pacing is limited. Patients with dilated bowel segments may benefit from intestinal tapering or lengthening. Growing neomucosa holds promise but has not been evaluated clinically. Recent improvement in the results of intestinal transplantation in animals may warrant clinical trials. The efficacy of H2 receptor antagonists makes procedures for reducing gastric hyperacidity less necessary. None of the operations to treat the short bowel syndrome are sufficiently safe and effective to recommend their routine use. Operations should be performed only on selected patients to achieve specific goals. Although investigation continues, our emphasis should continue to be conservation of as much of the intestine as possible when massive resection is necessary.     

临床同种活体部分小肠移植：附1例报告

目的：探讨临床同种活体小肠移植治疗短肠综合征的效果。方法：对1例因小肠扭转而切除大部分小肠和右半结肠，残留小肠仅20cm的超短肠综合征男性患者，行亲属活体同种部分小肠移植。供体为患者之母。受体术前行供体特异性输血，50mL/周，共8周。供受体巨细胞病毒感染状态均为阴性。移植肠长约160cm。移植肠的回结肠动静脉分别与受体肾下腹主动脉和下腔静脉端侧吻合，移植肠末端造口。术后给予抗排斥、抗感染、抗凝及营养支持治疗。结果：供体术后恢复顺利，无并发症。受体已健康存活31周，无感染和排斥反应。术后8周脱离肠外营养治疗，口服低脂饮食，D－木糖吸收试验结果接近正常。结论：同种活体部分小肠移植是治疗短肠综合征的有效措施。     

小肠移植术后慢性移植物失功1例报道及文献复习

目的探讨小肠移植术后慢性移植物失功(chronic graft dysfunction,CGD)的诊断及治疗。方法报道国内首例同种异体小肠移植患者术后CGD的临床资料,复习相关文献。结果患者因"门静脉血栓、脾静脉血栓致肠系膜血栓"切除了大部分小肠,后行同种异体小肠移植术。术后长期服用他克莫司(FK506),屡次发生排斥反应。术后3次因"小肠狭窄、不全性肠梗阻"行"小肠节段切除吻合术"。其中术后576d第3次出现肠梗阻,予经皮内镜下胃空肠造瘘术胃肠减压等治疗,确定移植肠不可逆性失功后行移植小肠切除术。结论 CGD治疗困难,预后不佳,预防胜于治疗。在确诊CGD不可逆后应尽快切除移植小肠,挽救患者生命,有条件应尽快安排再次移植。