慢性肠系膜缺血的治疗方法选择

Choice of treatment methods for chronic mesenteric ischemia

目的总结慢性肠系膜缺血(CMI)的外科治疗方法。方法回顾性分析2004～2018年天津医科大学总医院治疗的36例CMI患者的临床资料,其中13例患者伴腹腔动脉(CA)和/或肠系膜下动脉(IMA)狭窄或闭塞。结果本组36例患者中35例肠系膜上动脉(SMA)获得再通,1例CA获得再通。35例通过数字减影血管造影证实SMA病变后行手术治疗,其中23例成功开通SMA。12例未开通SMA的患者中,1例开通CA,3例行SMA取栓及内膜剥脱术,5例行顺行主动脉旁路术,3例行复合手术。1例未行DSA直接开腹行逆行主动脉旁路术。无手术死亡病例,进食后腹痛症状均消失。2例顺行主动脉旁路术患者出现淋巴漏,1例逆行主动脉旁路术者出现粘连性肠梗阻。结论腔内治疗是治疗CMI的微创手段,可作为首选的治疗方法。腔内治疗困难者可考虑复合手术,该术式结合开放手术及腔内治疗优势,成功率高、创伤较开放手术低。开放性旁路手术及内膜剥脱术作为传统方法,创伤大,并发症发生率高,可作为特殊情况下的备选方法。

Objective To summarize the surgical treatment of chronic mesenteric ischemia(CMI).Methods The clinical data of 36 patients with CMI treated in our hospital from 2004 to 2018 were retrospectively analyzed.Thirteen patients had stenosis or occlusion of the celiac artery(CA)and/or the inferior mesenteric artery(IMA).Results Of the 36 patients in this group,35 had SMA recanalization and 1 CA was recanalized.Thirty-five patients underwent DSA to confirm the superior mesenteric artery(SMA)lesions,of which 23 patients successfully opened SMA;of the 12 patients who did not open SMA,1 patient opened CA,3 patients accepted SMA thrombectomy and endarterectomy,5 patients performed antegrade aortic bypass and 3 cases accepted hybrid surgery.One patient underwent open surgery for retrograde aortic bypass.There was no surgical death,the symptoms of abdominal pain disappeared after eating either.Lymphatic fistula occurred in 2 patients with antegrade aortic bypass.One patient with retrograde aortic bypass developed adhesive intestinal obstruction.Conclusions Endovascular treatment is a minimally invasive method for the treatment of CMI and can be used as the preferred treatment.Patients difficult for intraluminal treatment may consider hybrid surgery,which combines the advantages of open surgery and endovascular treatment,carries higher success rate and lower trauma compared with open surgery.Open bypass surgery and endarterectomy as a traditional method,carry large trauma and high complication rates,can be used as an alternative method in special cases.