腹腔镜技术在急性肠系膜血管缺血性疾病诊断中的应用
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摘要
目的探讨腹腔镜技术在急性肠系膜血管缺血性疾病(acute mesenteric ischemia,AMI)诊断中的应用价值。方法回顾性分析我院2006年8月～2018年1月11例术前检查不能明确的可疑AMI患者资料,均行腹腔镜探查。结果8例(72. 7%)术中证实为急性肠缺血坏死,均中转开腹手术切除坏死段肠管,其中7例行Ⅰ期吻合,1例因缺血坏死肠管广泛,结肠内容物较多,腹腔污染严重而行远段小肠造瘘术,术后2天因腹痛剧烈不缓解再次行腹腔镜探查,发现部分残余小肠肠管呈渐进性缺血坏死,再次行坏死小肠切除+小肠造瘘术,平均手术时间110 min(78～185 min),平均出血量95 ml (40～210 ml),平均住院时间11 d(7～28 d),8例均痊愈出院,术后均于门诊定期复诊6个月,未再次出现明显腹痛、腹胀等症状,进食正常,大便良好,其中二次手术者术后3个月行小肠造瘘还纳,术后恢复良好。另3例探查术中见肠管远端存在不同程度粘连,血运、蠕动正常,无明显出血、坏死表现,行肠粘连松解术。结论对于腹部症状和体征不相符,伴有急性肠梗阻的可疑AMI患者,在严格掌握探查指征以及手术时机情况下,腹腔镜技术可有效地用于AMI的诊断。
Objective To investigate clinical value of laparoscopy in the early diagnosis of acute mesenteric ischemia( AMI). Methods A total of 11 cases with suspected AMI who were not definitively diagnosed by preoperative workup in our hospital from August 2006 to January 2018 were reviewed. They underwent laparoscopic exploration. Their clinical data were analyzed retrospectively. Results Among the 11 patients who underwent laparoscopic exploration because of unclear preoperative diagnosis,8( 72. 7%) were definitely diagnosed and proved to be acute intestinal ischemic necrosis during operation. All of them were converted to open surgery to resect necrotic intestinal canal,including 7 cases of stage Ⅰ anastomosis and 1 case of distal enterostomy because of extensive ischemic necrosis of intestinal canal,large amount of colonic contents and severe peritoneal contamination. Because of severe abdominal pain without relief,a laparoscopic re-exploration was performed on the second day after the first operation. It was found that part of the residual small intestine showed progressive ischemic necrosis. Necrotized small intestine resection and enterostomy were performed once again. The mean operation time was 110 minutes( range,78-185 minutes); the mean bleeding volume was 95 ml( range,40-210 m1); the mean hospitalization time was 11 days( range,7-28 days). All the 8 cases with AMI were cured and discharged from hospital. The follow-ups lasted for 6 months. No obvious abdominal pain or distension occurred again. The patients had good appetite and normal stool. The case with laparoscopic second operation underwent return of enterostomy 3 months later and recovered well. In another 3 cases,the distal intestinal tract with adhesion was found to have normal blood supply and peristalsis,without obvious hemorrhage or necrosis,and intestinal adhesiolysis was performed. Conclusions Suspicious AMI patients with inconsistent abdominal symptoms and signs are often accompanied by acute intestinal obstruction. Laparoscopic exploration can be effectively applied for the diagnosis of AMI under strict surgical indications and proper operative opportunity.
Objective To investigate clinical value of laparoscopy in the early diagnosis of acute mesenteric ischemia( AMI). Methods A total of 11 cases with suspected AMI who were not definitively diagnosed by preoperative workup in our hospital from August 2006 to January 2018 were reviewed. They underwent laparoscopic exploration. Their clinical data were analyzed retrospectively. Results Among the 11 patients who underwent laparoscopic exploration because of unclear preoperative diagnosis,8( 72. 7%) were definitely diagnosed and proved to be acute intestinal ischemic necrosis during operation. All of them were converted to open surgery to resect necrotic intestinal canal,including 7 cases of stage Ⅰ anastomosis and 1 case of distal enterostomy because of extensive ischemic necrosis of intestinal canal,large amount of colonic contents and severe peritoneal contamination. Because of severe abdominal pain without relief,a laparoscopic re-exploration was performed on the second day after the first operation. It was found that part of the residual small intestine showed progressive ischemic necrosis. Necrotized small intestine resection and enterostomy were performed once again. The mean operation time was 110 minutes( range,78-185 minutes); the mean bleeding volume was 95 ml( range,40-210 m1); the mean hospitalization time was 11 days( range,7-28 days). All the 8 cases with AMI were cured and discharged from hospital. The follow-ups lasted for 6 months. No obvious abdominal pain or distension occurred again. The patients had good appetite and normal stool. The case with laparoscopic second operation underwent return of enterostomy 3 months later and recovered well. In another 3 cases,the distal intestinal tract with adhesion was found to have normal blood supply and peristalsis,without obvious hemorrhage or necrosis,and intestinal adhesiolysis was performed. Conclusions Suspicious AMI patients with inconsistent abdominal symptoms and signs are often accompanied by acute intestinal obstruction. Laparoscopic exploration can be effectively applied for the diagnosis of AMI under strict surgical indications and proper operative opportunity.
引文
1辛世杰,李禄增.急性肠道血管源性缺血的腔内治疗.中国微创外科杂志,2013,13(9):769-771.
2张健,陈亮,何青青,等.急性肠系膜动静脉缺血性疾病的临床特征分析.中国医药,2016,11(12):1808-1810.
3秦耿,赵洪川.缺血性肠病的诊治现状及进展.中日友好医院学报,2012,26(2):112-114.
4张昭,李国逊,王西墨,等.急性肠系膜缺血性疾病42例临床分析.中华外科杂志,2012,50(12):1068-1071.
5魏志成,王春喜,张薇薇,等.急性肠系膜血管缺血性疾病肠切除的手术时机探讨.解放军医学院学报,2014,35(5):424-426.
6冯丽光,刘习红,段进东,等.腹腔镜在急腹症诊治中的应用.腹腔镜外科杂志,2012,17(4):308-310.
7廖松林.缺血性肠病的病理学.诊断病理学杂志,1996,3(3):160-163.
8 Aouini F,Bouhaffa A,Baazaoui J,et al.Acute mesenteric ischemia:study of predictive factors of mortality.Tunis Med,2012,90(7):533-536.
9 Acosta S,Ogren M,Sternby NH,et al.Incidence of acute thromboembolic occlusion of the superior mesenteric artery-a populationbased study.Eur J Vasc Endovas Surg,2004,27(2):145-150.
10杨艳丽,李铭,任庆国,等.急性肠系膜缺血的诊断和治疗进展.中华消化杂志,2012,32(12):876-878.
11刘斯,陈旭岩,印建中,等.急性肠系膜血管缺血性疾病的诊断与治疗(附67例报告).中国急救医学,2014,34(3):216-220.
12檀薇薇,张玫.D-二聚体对缺血性肠病及其严重程度的临床早期诊断价值.检验医学与临床,2016,13(11):1497-1498.
13朱辉超,廖立安,陈楷.血浆D-二聚体早期诊断急性肠系膜缺血性疾病的价值研究.中国实用医药,2017,12(12):32-33.
14 Matsumoto S,Sekine K,Funaoka H,et al.Diagnostic performance of plasma biomarkers in patients with acute intestinal ischaemia.Br JSurg,2014,101:232-238.
15刘凯,丁威威,吴性江,等.血清学指标在早期诊断急性肠系膜缺血性疾病的研究进展.中华胃肠外科杂志,2015,18(10):1068-1070.
16 Chiu YH,Huang MK,How CK,et al.D-dimer in patients with suspected acute mesenteric ischemia.Am J Emerg Med,2009,27:975-979.
17张健.肠系膜静脉血栓形成的诊断和治疗.临床外科杂志,2015,23(8):574-576.
18李水连,郭永飞,余水全,等.急性缺血性肠病应首选多排螺旋CT检查.中国临床医学影像杂志,2013,24(9):665-667.
19贾中芝,黄渊全,王凯,等.肠系膜上动脉栓塞的MSCT诊断.中华普通外科杂志,2014,29(9):727-728.
20 Alemanno G,Somigli R,Prosperi P,et al.Combination of diagnostic laparoscopy and intraoperative indocyanine green fluorescence angiography for the early detection of intestinal ischemia not detectable at CT scan.Int J Surg Case Rep,2016,26:77-80.
21 Klar E,Rahmanian PB,Bucker A,et al.Acute mesenteric ischemia:a vascular emergency.Dtsch Arztebl Int,2012,109:249-256.
22李宇罡,辛世杰.急性肠系膜缺血性疾病的诊治进展.中国血管外科杂志(电子版),2015,7(4):214-216.
23 Gonenc M,Dural CA,Kocatas A,et al.The impact of early diagnostic laparoscopy on the prognosis of patients with suspected acute mesenteric ischemia.Eur J Trauma Emerg Surg,2013,39(2):185-189.
2张健,陈亮,何青青,等.急性肠系膜动静脉缺血性疾病的临床特征分析.中国医药,2016,11(12):1808-1810.
3秦耿,赵洪川.缺血性肠病的诊治现状及进展.中日友好医院学报,2012,26(2):112-114.
4张昭,李国逊,王西墨,等.急性肠系膜缺血性疾病42例临床分析.中华外科杂志,2012,50(12):1068-1071.
5魏志成,王春喜,张薇薇,等.急性肠系膜血管缺血性疾病肠切除的手术时机探讨.解放军医学院学报,2014,35(5):424-426.
6冯丽光,刘习红,段进东,等.腹腔镜在急腹症诊治中的应用.腹腔镜外科杂志,2012,17(4):308-310.
7廖松林.缺血性肠病的病理学.诊断病理学杂志,1996,3(3):160-163.
8 Aouini F,Bouhaffa A,Baazaoui J,et al.Acute mesenteric ischemia:study of predictive factors of mortality.Tunis Med,2012,90(7):533-536.
9 Acosta S,Ogren M,Sternby NH,et al.Incidence of acute thromboembolic occlusion of the superior mesenteric artery-a populationbased study.Eur J Vasc Endovas Surg,2004,27(2):145-150.
10杨艳丽,李铭,任庆国,等.急性肠系膜缺血的诊断和治疗进展.中华消化杂志,2012,32(12):876-878.
11刘斯,陈旭岩,印建中,等.急性肠系膜血管缺血性疾病的诊断与治疗(附67例报告).中国急救医学,2014,34(3):216-220.
12檀薇薇,张玫.D-二聚体对缺血性肠病及其严重程度的临床早期诊断价值.检验医学与临床,2016,13(11):1497-1498.
13朱辉超,廖立安,陈楷.血浆D-二聚体早期诊断急性肠系膜缺血性疾病的价值研究.中国实用医药,2017,12(12):32-33.
14 Matsumoto S,Sekine K,Funaoka H,et al.Diagnostic performance of plasma biomarkers in patients with acute intestinal ischaemia.Br JSurg,2014,101:232-238.
15刘凯,丁威威,吴性江,等.血清学指标在早期诊断急性肠系膜缺血性疾病的研究进展.中华胃肠外科杂志,2015,18(10):1068-1070.
16 Chiu YH,Huang MK,How CK,et al.D-dimer in patients with suspected acute mesenteric ischemia.Am J Emerg Med,2009,27:975-979.
17张健.肠系膜静脉血栓形成的诊断和治疗.临床外科杂志,2015,23(8):574-576.
18李水连,郭永飞,余水全,等.急性缺血性肠病应首选多排螺旋CT检查.中国临床医学影像杂志,2013,24(9):665-667.
19贾中芝,黄渊全,王凯,等.肠系膜上动脉栓塞的MSCT诊断.中华普通外科杂志,2014,29(9):727-728.
20 Alemanno G,Somigli R,Prosperi P,et al.Combination of diagnostic laparoscopy and intraoperative indocyanine green fluorescence angiography for the early detection of intestinal ischemia not detectable at CT scan.Int J Surg Case Rep,2016,26:77-80.
21 Klar E,Rahmanian PB,Bucker A,et al.Acute mesenteric ischemia:a vascular emergency.Dtsch Arztebl Int,2012,109:249-256.
22李宇罡,辛世杰.急性肠系膜缺血性疾病的诊治进展.中国血管外科杂志(电子版),2015,7(4):214-216.
23 Gonenc M,Dural CA,Kocatas A,et al.The impact of early diagnostic laparoscopy on the prognosis of patients with suspected acute mesenteric ischemia.Eur J Trauma Emerg Surg,2013,39(2):185-189.