慢性放射性肠炎并发小肠梗阻的外科治疗

目的：探讨慢性放射性肠炎并发小肠梗阻的外科治疗方法。方法：回顾分析4例结直肠癌术后辅助放疗后并发慢性放射性肠炎、小肠梗阻的外科治疗结果和手术失败的原因。结果：2例直肠癌和2例乙状结肠癌病人术后放疗后(间隔3．5～11个月)因慢性放射性肠炎并发小肠梗阻而接受手术治疗。手术方法均采用了短路吻合法。即将梗阻段小肠的远近端肠管侧侧吻合。2例直肠癌病人术后恢复顺利。1例乙状结肠癌病人术后早期并发旷置段小肠肠外瘘。另1例乙状结肠癌病人术后4个月并发旷置小肠肠外瘘。2例病人并发肠瘘后均发现存在降结肠梗阻。结论：慢性放射性肠炎病人并发小肠梗阻时，可能同时合并有结肠梗阻。术前需要了解有无合并结肠梗阻并同时解决结肠梗阻。短路吻合术治疗后旷置的病变小肠有并发肠穿孔、肠瘘可能，首次手术治疗宜尽量切除梗阻段病变肠管，如不能切除，应尽量将病变肠管与消化道完全隔离。

Surgical management of small bowel obstruction from chronic radiation injury

Objective: To explore appropriate surgical management of small bowel obstruction arising from chronic radiation injury. Methods: The surgical results of 4 colorectal cancer patients admitted for chronic enteritis complicated with small bowel obstruction and the reasons for management failure were analyzed retrospectively. Results: Four male patients, 2 with rectal cancer and 2 with sigmoid colon cancer, presented with small bowel obstruction resulted from the chronic radiation injury of postoperative adjunctive radiation therapy, which was delivered from 3.5 to 11 months before admission. All 4 patients received bypass operation, namely the proximal intestinal segments from the obstructions were anastomosed side-side with the distal segments. Two rectal cancer patients recovered without major complication. One sigmoid colon cancer patient developed enterocutaneous fistula arising from the bypassed intestinal segment during the early postoperative period. Another sigmoid colon cancer patient experienced an eventless early postoperative period, however, he developed enterocutaneous fistula located also in the bypassed small bowel segment 4 months later. Descending colon radiogenic obstruction was identified in both patients after the presence of intestinal fistula. Conclusions: Concurrent radiogenic colon obstruction may occur in chronic radiation enteritis patients presented with small bowel obstruction. It is very important to determine preoperatively whether colon obstruction concurs with small bowel obstruction in any chronic radiation enteritis patient, and if so the colon obstruction should be treated synchronously. After bypass procedure, the bypassed small bowel loop carries considerable risk of developing intestinal perforation or fistula. On the first operation, the obstructed segment should be resected as possible. If safe resection is impossible, it is preferred to isolate the bypassed loop from the rest of the gastrointestinal tract.