小儿继发性肠狭窄及闭锁诊疗分析

Experiences of managing children with acquired intestinal stenosis and atresia

目的 探讨小儿继发性肠狭窄及闭锁的临床特点及诊治经验,分析其发病原因.方法 回顾性分析2010年2月至2013年2月间接受手术治疗的继发性肠狭窄及肠闭锁11例的临床资料.其中,男8例,女3例；手术年龄3.0～12.7个月,平均7.1个月.本组原发病分别为：坏死性小肠结肠炎4例,胎粪性腹膜炎2例,肠套叠3例,腹部手术2例.临床表现主要为：呕吐、排便次数及量减少、腹胀等.症状发生于原发病治愈后40 d～12个月不等,平均5.4个月.有6例腹部X线正侧位片提示有固定扩张的肠袢,5例提示腹部多发液气平并远端肠管正常积气减少；6例行消化道碘水造影提示末端回肠梗阻.术中发现肠狭窄或闭锁均位于回肠及其末端（7例严重的肠狭窄,3例发生肠闭锁,1例末端回肠闭锁合并毗邻肠管狭窄）,其中2例有2处肠狭窄.所有患儿均行一期肠狭窄或闭锁肠管切除肠吻合术.病理检查报告除1例异位胰腺和1例梅克尔憩室外,其余均呈非特异性慢性炎症改变.术后对痊愈出院患儿进行随访,随访内容包括饮食、排便、有无腹胀.结果 除1例3个月大肠狭窄的患儿术后第4天因吻合口瘘行回肠造瘘术,后因伤口反复裂开家属放弃治疗,余10例治愈出院.痊愈患儿获随访6个月～3年,肠梗阻症状消失,无腹胀,饮食及排便恢复正常.结论 继发性肠狭窄及闭锁具体发病机制尚不能明确,机械压力、肠道缺血及炎症是其易感因素,消化道造影检查对其诊断有重要意义.对有上述既往病史治愈后出现肠梗阻患儿需警惕继发性肠狭窄及肠闭锁的发生,病变好发于末端回肠,且有多发狭窄或闭锁可能,一期行病变肠管切除肠吻合可取得良好效果.

Objective To explore the clinical features and treatment experiences of children with acquired intestinal stenosis and atresia and elucidate its pathogenesis.Methods The clinical data were retrospectively analyzed for 11 surgical cases with acquired intestinal stenosis and atresia at our department.There were 8 males and 3 females with a mean age of 7.1 （3.0-12.7） months.The primary causes were necrotizing enterocolitis （NEC,n =4）,meconium peritonitis （n =2）,ileocolic intussusception （n =3） and laparotomy （n =2）.The major symptoms of intestinal obstruction were vomiting,infrequent defecation and abdominal distension.The median time was 5.4 months （40 days to 12 months） between recovery from primary disease and a diagnosis of acquired intestinal stenosis or atresia.Radiology showed a fixed and expanded intestinal loop （n =6） and multiple gas fluid level （n =5）.Six patients underwent gastrointestinal contrast study showing terminal ileum obstruction.All lesions were found in ileum （intestinal stenosis,n =7; intestinal atresia,n =4） and 3 patients had multiple strictures or atresia.All patients underwent primary end-to-end anastomosis.And the postoperative pathological diagnosis showed heterotopic pancreas （n =1）,Meckel＆#39;s diverticulum （n =1） and non-specific inflammatory lesions （n =9）.Their diet,defecation and abdominal distension were evaluated during the follow-ups.Results One case of anastomotic leakage underwent ileum colostomy at Day 4 after the first operation and gave up treatment after repeated wound dehiscence.And the remainder was all cured.During a follow-up period of 6 months to 3 years,the symptoms of ileus disappeared and they resumed normal diet and defecation.Conclusions Although the pathogenesis of acquired intestinal stenosis and atresia is still illusive,mechanical stress,intestinal ischemia and inflammation are the causative factors.Digital gastrointestinal contrast radiography may aid its diagnosis.And the possibility of intestinal stenosis or atresia should raise a high alert after various primary diseases are cured.An optimal prognosis may achieved with primary end-to-end anastomosis.