腹腔镜下与传统开腹松解术治疗粘连性肠阻梗的效果与安全性对比

目的探讨腹腔镜下与传统开腹松解术治疗粘连性肠阻梗的临床效果及其安全性。方法 132例粘连性肠阻梗患者按照手术方式的不同分成观察组(腹腔镜下松解术)与对照组(传统开腹松解术),比较两组手术指标、不良反应和复发情况。结果两组术中出血量、手术时间、术后排气时间、术后胃肠功能恢复时间以及住院时间差异均有统计学意义(均P<0.05);两组不良反应发生情况及复发率差异均有统计学意义(均P<0.05)。结论腹腔镜下松解术治疗粘连性肠阻梗手术具有创伤小、术后恢复快、不良反应发生率及复发率低等优点,值得临床推广使用。

多排螺旋CT诊断肠梗阻的临床价值

目的探讨多排螺旋CT(MDCT)诊断肠梗阻的临床价值。方法回顾性分析2010年4月到2011年4月期间于我院接受肠梗阻治疗的36例患者的MDCT资料,与手术治疗结果相对照。结果经手术治疗的28例患者的手术确诊结果与MDCT诊断结果比较得出,梗阻部位符合26例(92.9%),病因符合27例(96.4%)。结论 MDCT对肠梗阻的部位、病因的诊断率很高,且对血供情况的了解在显示上具有很大的优势,是作为肠梗阻的首选检查方法之一。

食管裂孔结肠疝并发肠梗阻3例X线分析

<正> 食管裂孔结肠疝并发肠梗阻较少见,X线检查是诊断本病的主要手段之一.我们收集3例经X线检查、手术证实的病例,就X线表现作一分析.病例介绍例1:男55岁,心窝部持续性隐痛7天,伴反酸、呕吐,以“胃炎”入院.经对症治疗未见好转,症状进行性加剧,且停止排便、排气4天.检查:左下肺呼吸音减低,叩诊呈鼓音.腹部压痛明显,肠呜音亢进.血白细胞9.5×10~9/L,中性0.82,淋巴0.18.X线检查:左上腹及右下腹肠管扩张,并可见2～3cm长液平面.左中下肺野见宽达13cm的透亮区,其内见条纹状影,服少量泛影葡胺通过食管下段缓慢,但未见梗阻,胃形态、位置无异常改变.手术所见:隔肌食管裂孔有约3cm宽疝口,结肠疝人胸腔.

腹腔镜联合肠梗阻导管治疗复杂性粘连性肠梗阻的可行性分析

目的:探讨腹腔镜联合经鼻肠梗阻导管治疗复杂性粘连性肠梗阻的可行性及潜在优势。方法:回顾性收集符合复杂性粘连性肠梗阻纳入标准、经鼻肠梗阻导管治疗后梗阻未缓解并行手术治疗者65例,随机分为腹腔镜治疗组31例,开腹手术治疗组34例。比较两组围手术期安全性及治疗效果间差异。结果:两组患者年龄、性别、ASA评分及手术史等一般资料比较差异均无统计学意义。31例腹腔镜探查患者共中转5例,34例行开腹手术治疗。在术后并发症率、排气时间、进食时间及术后住院时间方面,腹腔镜组优于开腹组,存在统计学差异(P<0.05)。腹腔镜组患者术后随访复发率(7.7%)低于开腹组(14.7%),具备统计学差异。结论:腹腔镜联合肠梗阻导管治疗复杂性粘连性肠梗阻安全、微创、效果可靠,可显著减低术后复发率,可作为复杂性肠梗阻的有效治疗方式。

Security Assurance for One-stage Resection of Left Colon Cancer with Acute Obstruction—Thorough and Prompt Enteral Decompression without Contamination

Objective: Thorough, prompt enteral decompression technique without contamination was de- veloped to ensure safety for emergent colon resection and primary anastomosis. Methods: After isolating the mesentery, the “to be resected colon segment” was cut at its lower end, then the proximal cut end was put into a plastic bag which was adhered to one side of the operating table. After releasing the clamp, the content could ?ow into this bag. The operator could squeeze the bowel with two hands by turns, from proximal to farness, and from small bowel to large bowel, until the entire bowel content was fully discharged. Then the upper end of this “to be resected colon segment” was cut, and was removed together with the plastic bag. Results: 31 cases of left colon cancer with acute obstruction were decompressed with this technique. They all recovered smoothly, without anastomosis ?stula. Another 6 cases of hepatic seg- mentectomy with incidental colonectomy were decompressed with this technique and had the same results. This technique was also used in di?erent kinds of acute small intestinal obstruction and gained satisfactory results. Conclusion: This technique could be considered as the preferable choice for intraoperative enteral decompression.

Generalized megaviscera of lupus:Refractory intestinal pseudo-obstruction,ureterohydronephrosis and megacholedochus

Dilated dysfunction involving multiple visceral organs has been reported in patients with systemic lupus erythematosus （SLE）. Chronic intestinal pseudoobstruction （CIPO） resulting from intestinal smooth muscle damage has presented in conjunction with ureterohydronephrosis and, more rarely, biliary dilatation （megacholedochus）. While the molecular pathogenesis is largely unknown, observed histopathologic features include widespread myositis, myocyte necrosis in the intestinal muscularis propria with subsequent atrophy and fibrosis, preserved myenteric innervations and little vasculitis. High dose immunosuppression usually results in resolution of symptoms with recovery of smooth muscle function, indicative of an autoimmune etiology. We report a patient with SLE who presented with intestinal pseudo-obstruction, ureterohydronephrosis and megacholedochus, and present images that illustrate megaviscera simultaneously involving all 3 visceral organs. Since the co-manifestation of all 3 is unusual and has been reported only once previously, we have termed this rare clinical syndrome generalized megaviscera of lupus （GML）. Although the SLE disease-activity parameters responded to aggressive immunomodulative therapy in our patient, clinical evidence of peristaltic dysfunction persisted in all involved viscera. This is a variation from the favorable outcomes reported previously in SLE patients with GML and we attribute this poor clinical outcome to disease severity and, most importantly, delayed clinical presentation. Since inflammation followed by atrophy and fibrosis are key aspects in the pathogenesis and natural history of GML, the poor response in our patient who presented late in the clinical course may be the result of ＇burnt out＇ inflammation with irreversible end-stage fibrosis. Thus, early recognition and timely initiation of treatment may be the key to recover visceral peristaltic function in patients with GML.

Recent trends in the surgical management of inflammatory bowel disease

Surgery is required in the vast majority of patients with Crohn’s disease (CD) and in approximately one-third of patients with ulcerative colitis (UC). Similar to medical treatments for IBD, significant advances have occurred in surgery. Advances in CD include an emphasis upon conservatism as exemplified by more limited resections, strictureplasties, and laparoscopic resections. The use of probiotics in selected patients has improved the outcome in patients with pouchitis following restorative proctocolectomy for UC. It is anticipated that ongoing discoveries in the molecular basis of IBD will in turn identify those patients who will best respond to surgery.

Decompression of the small bowel by endoscopic long-tube placement

AIM:To investigate and compare the decompression effect on small bowel obstruction of a long tube inserted using either endoscopic or fluoroscopic placement.METHODS:Seventy-eight patients with small bowel obstruction requiring decompression were enrolled in the study and divided into two groups.Intubation of a long tube was guided by fluoroscopy in one group and by endoscopy in the other.The duration of the procedure and the success rate for each group were evaluated.RESULTS:A statistically significant difference in the mean duration of the procedure was found between the fluoroscopic group(32.6±14.6 min)and the endoscopic group(16.5±7.8 min)among the cases classified as successful(P<0.05).The success rate was significantly different between the groups:88.6%in the fluoroscopic group and 100%in the endoscopic group(P <0.05).CONCLUSION:For patients with adhesive small bowel obstruction,long-tube decompression is recommended and long-tube insertion by endoscopy was superior to fluoroscopic placement.

Acute small bowel obstruction caused by endometriosis:A case report and review of the literature

Gastrointestinal involvement of endometriosis has been found in 3%-37% of menstruating women and exclusive localization on the ileum is very rare(1%-7%).Endometriosis of the distal ileum is an infrequent cause of intestinal obstruction,ranging from 7% to 23% of all cases with intestinal involvement.We report a case in which endometrial infiltration of the small bowel caused acute obstruction requiring emergency surgery,in a woman whose symptoms were not related to menses.Histology of the resected specimen showed that endometriosis was mainly prevalent in the muscularis propria and submucosa and that the mucosa was not ulcerated but had inflammation and glandular alteration.Endometrial lymph node involvement,with a cystic glandular pattern was also detected.

Endoscopic stenting-Where are we now and where can we go?

Self expanding metal stents (SEMS) play an important role in the management of malignant obstructing lesions in the gastrointestinal tract. Traditionally,they have been used for palliation in malignant gastric outlet and colonic obstruction and esophageal malignancy. The development of the polyflex stent,which is a removable self expanding plastic stent,allows temporary stent insertion for benign esophageal disease and possibly for patients undergoing neoadjuvant chemotherapy prior to esophagectomy. Potential complications of SEMS insertion include perforation,tumour overgrowth or ingrowth,and stent migration. Newer stents are being developed with the aim of increasing technical and clinical success rates,while reducing complication rates. Other areas of development include biodegradable stents for benign disease and radioactive or drug-eluting stents for malignant disease. It is hoped that,in the future,newer stents will improve our management of these diffi cult conditions and,possibly,provide prognostic as well as symptomatic benefi t in the setting of malignant obstruction.

Eosinophilic gastroenteritis presenting as small bowel obstruction: A case report and review of the literature

Eosinophilic gastroenteritis is a rare disease of unknown etiology. It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with gastrointestinal tract. Recently, the authors experienced a case of eosinophilic gastroenteritis presenting as small bowel obstruction. A 51-year old woman was admitted to our hospital complaining of abdominal pain and vomiting. Physical examination revealed a distended abdomen with diffuse tenderness. Complete blood count showed mild leukocytosis without eosinophilia. Computed tomography confirmed a dilatation of the small intestine with ascites. An emergency laparotomy was performed for a diagnosis of peritonitis due to intestinal obstruction. Segmental resection of the ileum and end to end anastomosis were performed. Histologically, there was a dense infiltration of eosinophils throughout the entire thickness of ileal wall and eosinophilic enteritis was diagnosed. The patient recovered well, and was free from gastrointestinal symptoms at the time when we reported her disease.

Recent advances in the management of radiation colitis

Radiation colitis, an insidious, progressive disease of increasing frequency, develops 6 mo to 5 years after regional radiotherapy for malignancy, owing to the deleterious effects of the latter on the colon and the small intestine. When dealing with radiation colitis and its complications, the most conservative modality should be employed because the areas of intestinal injury do not tend to heal. Acute radiation colitis is mostly self-limited, and usually, only supportive management is required. Chronic radiation colitis, a poorly predictable progressive disease, is considered as a precancerous lesion; radiation-associated malignancy has a tendency to be diagnosed at an advanced stage and to bear a dismal prognosis. Therefore, management of chronic radiation colitis remains a major challenge owing to the progressive evolution of the disease, including development of fibrosis, endarteritis, edema, fragility, perforation, partial obstruction, and cancer. Patients are commonly managed conservatively. Surgical intervention is difficult to perform because of the extension of fibrosis and alterations in the gut and mesentery, and should be reserved for intestinal obstruction, perforation, fistulas, and severe bleeding. Owing to the difficulty in managing the complications of acute and chronic radiation colitis, particular attention should be focused onto the prevention strategies. Uncovering the fibrosis mechanisms and the molecular events underlying radiation bowel disease could lead to the introduction of new therapeutic and/or preventive approaches. A variety of novel, mostly experimental, agents have been used mainly as a prophylaxis, and improvements have been made in radiotherapy delivery, including techniques toreduce the amount of exposed intestine in the radiation field, as a critical strategy for prevention.

Definitive palliation for neoplastic colonic obstruction using enteral stents:Personal case-series with literature review

Acute colonic obstruction due to malignancies is an emergency that requires surgical treatment.Elderly patients or inoperable tumors require intestinal decompression that is a simple colostomy in almost all cases.This“manoeuvre” leads the patient to a percentage of moRality/morbidity and to a bad quality of life due to acceptance of stoma.The introduction of enteral metal stent inserted endoscopically has,in our opinion,provided a new way to obtaining the definitive palliation of inoperable colo-rectal cancer with a simple method.We reported our case-series and we analyzed the current literature and costs of treatments.

Review:Mechanism of acute pancreatitis complicated with injury of intestinal mucosa barrier

Acute pancreatitis (AP) is a common acute abdomen in clinic with a rapid onset and dangerous pathogenetic condition. AP can cause an injury of intestinal mucosa barrier, leading to translocation of bacteria or endotoxin through multiple routes, bacterial translocation (BT), gutorigin endotoxaemia, and secondary infection of pancreatic tissue, and then cause systemic in- flammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS), which are important factors influencing AP’s severity and mortality. Meanwhile, the injury of intestinal mucosa barrier plays a key role in AP’s process. Therefore, it is clinically important to study the relationship between the injury of intestinal mucosa barrier and AP. In addition, many factors such as microcirculation disturbance, ischemical reperfusion injury, excessive release of inflammatory mediators and apoptosis may also play important roles in the damage of intestinal mucosa barrier. In this review, we summarize studies on mechanisms of AP.

Value of CT in the diagnosis and management of gallstone ileus

AIM:To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy. METHODS: Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient's final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course. RESULTS: The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis. CONCLUSION: Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.

A prospective randomized trial of transnasal ileus tube vs nasogastric tube for adhesive small bowel obstruction

AIM:To study the therapeutic efficacy of a new transnasal ileus tube advanced endoscopically for adhesive small bowel obstruction.METHODS:A total of 186 patients with adhesive small bowel obstruction treated from September 2007 to February 2011 were enrolled into this prospective randomized controlled study.The endoscopically advanced new ileus tube was used for gastrointestinal decompression in 96 patients and ordinary nasogastric tube(NGT) was used in 90 patients.The therapeutic efficacy was compared between the two groups.RESULTS:Compared with the NGT group,the ileus tube group experienced significantly shorter time for relief of clinical symptoms and improvement in the findings of abdominal radiograph(4.1 ± 2.3 d vs 8.5 ± 5.0 d) and laboratory tests(P < 0.01).The overall effectiveness rate was up to 89.6% in the ileus tube group and 46.7% in the NGT group(P < 0.01).And 10.4% of the patients in the ileus tube group and 53.3% of the NGT group underwent surgery.For recurrent adhesive bowel obstruction,ileus tube was also significantly more effective than NGT(95.8% vs 31.6%).In the ileus tube group,the drainage output on the first day and the length of hospital stay were significantly different depending on the treatment success or failure(P < 0.05).The abdominal radiographic improvement was correlated with whether or not the patient underwent surgery.CONCLUSION:Ileus tube can be used for adhesive small bowel obstruction.Endoscopic placement of the ileus tube is convenient and worthy to be promoted despite the potential risks.

Clinical considerations and therapeutic strategy for sigmoid volvulus in the elderly:A study of 33 cases

AIM： To evaluate different types of treatment for sigmoid volvulus and clarify the role of endoscopic intervention versus surgery. METHODS： A retrospective review of the clinical presentation and imaging characteristics of 33 sigrnoid volvulus patients was presented, as well as their diagnosis and treatment, in combination with a literature review. RESULTS： In 26 patients endoscopic detorsion was achieved after the first attempt and one patient died because of uncontrollable sepsis despite prompt operative treatment. Seven patients had unsuccessful endoscopic derotation and were operated on. On two patients with gangrenous sigrnoid, Hartmann＇s procedure was performed. In five patients with viable colon, a sigmoid resection and primary anastomosis was carried out. Three patients had a lavage ＂on table＂ prior to anastomosis, while in the remaining 2 patients a diverting stoma was performed according to the procedure of the first author. Ten patients were operated on during their first hospital stay （3 to 8 d after the deflation）. All patients had viable colon; 7 patients had a sigmoid resection and primary anastomosis, 2 patients had sigrnoidopexy and one patient underwent a near-total colectomy. Two .patients （sigmoidectomy- sigmoidopexy） had recurrences of volvulus 43 and 28 mo after the initial surgery. Among 15 patients who were discharged from the hospital after non-operative deflation, 3 patients were lost to follow-up. Of the remaining 12 patients, 5 had a recurrence of volvulus at a time in between 23 d and 14 mo. All the five patients had been operated on and in four a gangrenous sigmoid was found. Three patients died during the 30 d postoperative course. The remaining seven patients were admitted to our department for elective surgery. In these patients, 2 subtotal colectomies, 3 sigmoid resections and 2 sigmoidopexies were carried out. One patient with subtotal colectomy died. Taken together of the results, it is evident that after 17 elective operations we had only one death （5.9%）, whereas after 15 emergency operations 6 patients died, which means a mortality rate of 40%. CONCLUSION： Although sigmoid volvulus causing intestinal obstruction is frequently successfully encountered by endoscopic decompression, however, the principal therapy of this condition is surgery. Only occasionally in patients with advanced age, lack of bowel symptoms and multiple co-morbidities might surgical repair not be considered.

Gallstone ileus:Report of two cases and review of the literature

Gallstone ileus is a rare disease and accounts for 1%-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We report two cases of gallstone ileus. The first was a 78-year old woman who had a 2-d history of vomiting and epigastralgia. Plain abdominal film suggested small bowel obstruction clinically attributed to adhesions. Later on, gallstone ileus was diagnosed by abdominal computed tomography (CT) based on the presence of pneumobilia, bowel obstruction, and an ectopic stone within the jejunum. She underwent emergent laparotomy with a one-stage procedure of enterolithotomy, cholecystectomy and fistula repair. The second case was a 76-year old man with a 1-wk history of epigastralgia. Plain abdominal film showed two round calcified stones in the right upper quadrant. Fistulography confirmed the presence of a cholecystoduodenal fistula and gallstone ileus was also diagnosed by abdominal CT. We attempted to remove the stones endoscopically, but failed leading to an emergent laparotomy and the same one-stage procedure as for the first case. The postoperative courses of the two cases were uneventful. Inspired by these 2 cases we reviewed the literature on the cause, diagnosis and treatment of gallstone ileus.

Heterotopic pancreas in the gastrointestinal tract

Heterotopic pancreas is defined as pancreatic tissue found outside the usual anatomical location of the pancreas. It is often an incidental finding and can be found at different sites in the gastrointestinal tract. It may become clinically evident when complicated by pathological changes such as inflammation, bleeding, obstruction, and malignant transformation. In this report, a 60-year-old man with carcinoid syndrome caused by heterotopic pancreatic tissue in the duodenum is described, along with a 62-year-old man with abdominal pain caused by heterotopic pancreatic tissue in the gastric antrum. The difficulty of making an accurate diagnosis is highlighted. The patients remain healthy and symptom-free after follow-up of 1 year. Frozen sections may help in deciding the extent of resection intraoperatively. Although heterotopic pancreas is rare, it should be considered in the differential diagnosis of gastrointestinal stromal tumor.

Chronic intestinal pseudo-obstruction

Chronic intestinal pseudo-obstruction (CIPO) is a se- vere digestive syndrome characterized by derangement of gut propulsive motility which resembles mechanical obstruction, in the absence of any obstructive process. Although uncommon in clinical practice, this syndrome represents one of the main causes of intestinal failure and is characterized by high morbidity and mortality. It may be idiopathic or secondary to a variety of diseases. Most cases are sporadic, even though familial forms with either dominant or recessive autosomal inheritance have been described. Based on histological features in- testinal pseudo-obstruction can be classified into three main categories:neuropathies, mesenchymopathies, and myopathies, according on the predominant involvement of enteric neurones, interstitial cells of Cajal or smooth muscle cells, respectively. Treatment of intestinal pseu- do-obstruction involves nutritional, pharmacological and surgical therapies, but it is often unsatisfactory and the long-term outcome is generally poor in the majority of cases.