胃大部切除术后腹内疝继发胰腺炎一例并文献复习

Pancreatitis secondary to intra-abdominal hernia after subtotal gastrectomy:a case report and literature review

目的探讨胃切除术后腹内疝的发病原因、临床特点、诊断思路及治疗方法,提高对本病的认识。方法 2018年3月9日吉林大学中日联谊医院收治1例75岁的男性病人,以腹痛、腹胀伴恶心、呕吐为主要症状,曾于当地医院行保守治疗无明显好转,病人20年前因胃溃疡穿孔行胃大部切除术,BillrothⅡ式吻合,本次入院后行腹部CT检查,考虑腹内疝可能,同时继发胰腺炎。急诊行剖腹探查术,术中诊断为彼得森疝,行疝复位、彼得森间隙关闭术。结果手术过程顺利,病人术后恢复良好,术后7 d行消化道造影检查,见胃肠道蠕动良好,造影剂通过顺利,病人于术后10 d出院。结论胃切除术后腹内疝的发病率较低,胃切除术后腹内疝继发胰腺炎的发病率更低。腹腔镜手术、体重减轻、Roux-en-Y重建、胆胰支过长及未关闭肠系膜间隙是腹内疝发生的危险因素。腹部CT是诊断腹内疝的重要手段,对于怀疑腹内疝的病人,应积极手术治疗。胃切除术后行结肠前消化道重建及关闭肠系膜间隙可以降低术后腹内疝的发生率。

Objective To investigate the causes, clinical characteristics, diagnosis and treatment of intra-abdominal hernia after gastrectomy, and to improve the understanding of this disease. Methods A 75-year-old male patient was admitted to China-Japan Union Hospital of Jilin University on March 9,2018 with abdominal pain, abdominal distention, nausea and vomiting as the main symptom. The patient had received conservative treatment from the local hospital, but there was no significant improvement. The patient underwent subtotal gastrectomy and Billroth Ⅱ anastomosis for gastric ulcer perforation 20 years ago. The patient underwent abdominal CT examination after admission, and results indicated the possibility of internal hernia and subsequent pancreatitis. An emergency laparotomy was performed and Petersen's hernia was diagnosed intraoperatively. The reduction of the hernia and the closure of Pedersen space were performed. Results The operation was successful and the patient recovered well. Digestive tract radiograph was performed 7 days after surgery, and it was found that gastrointestinal peristalsis was good and contrast agents passed smoothly. The patient was discharged 10 days after surgery. Conclusion The incidence of abdominal internal hernia after gastrectomy is relatively low, but the incidence is increasing in recent years. Laparoscopic surgery, weight loss, roux-en-y reconstruction, long biliary and pancreatic branches, and unclosed mesenteric space are risk factors for internal hernia. Abdominal CT is an important means to diagnose internal hernia. For patients suspected of internal hernia, active surgery should be performed. The antecolic reconstruction and the closure of the mesenteric space can reduce the incidence of abdominal internal hernia after gastrectomy.