外科治疗狭窄型克罗恩病的临床疗效

Clinical effect of surgical treatment of stricturing Crohn＇s disease

目的探讨外科治疗狭窄型克罗恩病的临床疗效。方法采用回顾性横断面研究方法。收集2013年6月至2016年4月浙江大学医学院附属第一医院收治的28例狭窄型克罗恩病患者的临床资料。术前采取对应措施改善患者营养状况和优化并发症的风险因素后，依据自身情况实施个体化治疗方案，引起症状的克罗恩病狭窄部位施行肠切除一期吻合或造口术，轻度狭窄部位暂不予处理或施行狭窄成形术。术后定期门诊复查，根据患者个体情况，应用药物预防复发。观察指标：手术方式（开腹手术或腹腔镜手术）、手术时间、术中出血量、术中输血例数、切除肠管长度、吻合方式、狭窄成形术、术后住院时间、术后并发症、随访情况。采用门诊、电话及微信方式进行随访，随访内容为腹痛、腹泻等临床复发症状和内镜下复发情况。随访时间截至2016年7月。结果28例狭窄型克罗恩病患者均行择期手术，其中8例行腹腔镜手术（3例中转开腹）；20例行开腹手术。28例患者中，行高位空肠部分切除2例、行末端回肠部分切除10例、行右半结肠切除15例、行结肠切除1例。28例患者手术时间为33—288min，平均为122min；术中出血量为50～650mL，平均为200mL；术中输血1例。28例患者切除肠管长度为10～150cm，平均为54cm；切除病变小肠、结肠肠管累计约1510cm。28例患者中，26例行直线闭合器侧侧吻合术（1例行管状吻合器端侧吻合术，1例结肠多发病变合并直肠阴道瘘行病变结肠肠管切除＋回肠造口术）；2例多发小肠狭窄行肠切除联合3处狭窄成形术。28例患者术后住院时间为7～45d，平均15d，无手术死亡病例。术后3例患者发生并发症，分别为切口感染、切口疝、吻合口漏各1例。21例患者获得随访，随访时间为3个月至2年，中位随访时间为11个月，随访期间未发现患者复发。结论有症状和内科治疗无效的慢性纤维性狭窄型克罗恩病和吻合口狭窄患者需行外科手术治疗，手术应遵循“微创”原则；术前对并发症高危因素采取优化措施是预防术后并发症发生的关键，其手术治疗临床疗效满意。

Objective To explore the clinical effect of surgical treatment of stricturing Crohn＇s disease （CD）. Methods The retrospective cross-sectional study was conducted. The clinical data of 28 patients with strieturing CD who were admitted to the First Affiliated Hospital of Zhejiang University School of Medicine between June 2013 and April 2016 were collected. After improving the patients＇ nutritional status by preoperative corresponding treatment and optimizing the risk factors of complications, patients received individualized therapy according to their conditions. The intestinal one-stage resection and anastomosis or ostomy were performed at the stenotic locus causing sypmtoms, and no treatamnt or angioplasty for stenosis was performed at the gentle stenotic locus. Patients received regularly postoperative outpatient reexaminations. The medication was used to prevent recurrence according to the individual conditions. Observation indicators： surgical procedures （open or laparoscopic surgery）, operation time, volume of intraoperative blood loss, number of patients with intraoperative blood transfusion, length of intestine resected, anastomosis methods, angioplasty for stenosis, duration of postoperative hospital stay, postoperative complications and follow-up. Follow-up using outpatient examination, telephone interview and wechat was performed to detect the abdominal pain, diarrhea, symptoms of clinical recurrence and endoscopic recurrence situations up to July 2016. Results All the 28 patients with stricturing CD underwent the selective operations, including 8 undergoing laparoscopic surgery （3 receiving conversion to open surgery） and 20 undergoing open surgery. Of 28 patients, 2 underwent partial upper jejunum resection, 10 underwent partial terminal ileum resection, 15 underwent right hemicolectomy and 1 underwent colectomy.Operation time and volume of intraoperative blood loss were 33-288 minutes with an average time of 122 minutes and 50-650 mL with an average volume of 200 mL, respectively. One patient had intraoperative blood transfusion. Length of intestine resected of 28 patients was 10-150 em, with an average of 54 cm and a total length of 1 510 era. Of 28 patients, 26 received the side-to-side anastomosis using linear closures （1 received the end-to-side anastomosis using pipe stapler, 1 with multiple lesions and reetovaginal fistula received coleetomy and ileostomy）. Two patients with multiple stenosis of the small intestine underwent intestinal resection combined with angioplasty for stenosis in 3 loci. Duration of postoperative hospital stay was 7-45 days, with an average duration of 15 days. No patient died of surgery. Three patients had postoperative complications, including wound infection, incisional hernia and anastomotie leakage. Twenty-one patients were followed up for 3 months to 2 years, with a median time of 11 months, and there was no recurrence during the follow-up. Conclusions Surgical treatment should be performed to the patients with non-symptom, chronic and fibrous stricturing CD and anastomotic stenosis after ineffective medical treatment, with a satisfactory outcome. Meanwhile, it need follow the principle of ＂minimally invasive＂. And optimizing high risk factors of complications before operation is a key point for preventing postoperative complications.