Roux-en-Y吻合术后肠系膜性腹内疝的临床研究进展

Clinical research progress of mesenteric internal hernia after Roux-en-Y reconstruction

手术后腹内疝是临床少见的并发症，多发生于消化道重建手术后。Roux—en-Y是常用的消化道重建术式。Roux-en—Y吻合术后腹内疝主要发生于消化道重建时肠系膜切口间隙未闭或闭合不良所形成的系膜缺损处，我们将其系统地称为Roux—en—Y吻合术后肠系膜性腹内疝。根据系膜缺损构成方式的不同，又可将此类腹内疝分为空肠一空肠吻合系膜缺损型（J型）、上提空肠一横结肠系膜缺损型或彼得森型（P型）和横结肠系膜缺损型（M型）。由于病例数量和随访时间上存在较大差异，现有研究报道腹腔镜Roux-en—Y胃旁路术（LRYGB）术后腹内疝的发病率波动范围较大，在0．2％～9．0％之间。Roux—en-Y吻合术后肠系膜性腹内疝一旦诊治延误，可造成肠坏死等灾难性的后果。腹内疝的临床表现各异，轻者可无症状，重者出现急性肠梗阻症状；腹痛是腹内疝的常见表现。腹内疝一经诊断，均建议手术治疗，选择从远端正常空虚的肠管人手，逆向追寻至疝环口，能更快辨清疝环及疝人行径，使得嵌顿疝复位更加安全可行。Roux-en—Y吻合术后肠系膜性腹内疝的预防与初始手术方式和肠系膜关闭技术有关，腹腔镜下Roux-en—Y吻合时是否关闭系膜缺损仍存在较大争议。本文结合近年来Roux—en—Y式消化道重建手术后因肠系膜缺损而导致腹内疝的部分报道和研究作一综述，以提高对此类腹内疝的认识和重视，并建议在涉及消化道重建手术中采取更为积极的预防举措。

Postoperative internal hernia is a rare clinical complication which often occurs after digestive tract reconstruction. Roux-en-Y anastomosis is a common type of digestive tract reconstruction. Internal hernia after Roux-en-Y reconstruction, which occurs mainly in the mesenteric defect caused by incomplete closure of mesenteric gaps in the process of digestive tract reconstruction, is systematically called, in our research, as mesenteric internal hernia after Roux-en-Y reconstruction. Such internal hernia can be divided, according to the different structures of mesentric defect, into 3 types： the type of mesenteric defect at the jejunojejunostomy （J type）, the type of Petersen＇s defect （P type）, and the type of mesenteric defect in the transverse mesocolon （M type）. Because of huge differences in the number of cases and follow- up time among existing research reports, the morbidity of internal hernia after LRYGB fluctuates wildly between 0.2% and 9.0%. Delayed diagnosis and treatment of mesenteric internal hernia after Roux- en-Y reconstruction may result in disastrous consequences such as intestinal necrosis. Clinical manifestations of internal hernia vary from person to person： some, in mild cases, may have no symptoms at all while others in severe cases may experience acute intestinal obstruction. Despite the difference, one common manifestation of internal hernia is abdominal pain. Surgical treatment should be recommended for those diagnosed as internal hernia. A safer and more feasible way to conduct the manual reduction of the incarcerated hernia is to start from the distal normal empty bowel and trace back to the hernia ring mouth, enabling a faster identification of hernia ring and its track. The prevention of mesenteric internal hernia after Roux-en-Y reconstruction is related to the initial surgical approach and the technique of mesenteric closure. Significant controversy remains on whether or not the mesenteric defect should be closed in laparoscopic Roux-en-Y anastomosis. This article is to review the reports and researches on internal hernia resulting from the mesenteric defect after Roux-en-Y digestive tract reconstruction in recent years, so as to promote understanding and attention on this disease. And more active preventive measures are strongly suggested to be taken in operations where digestive tract reconstruction is involved.