婴幼儿结肠狭窄7例诊疗及近期随访结局分析
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摘要
目的探讨婴幼儿结肠狭窄的临床特点及诊疗经验,并对近期随访结局进行初步分析。方法回顾性分析2012年1月至2017年12月湖南省儿童医院普外科收治的3月龄以上的结肠狭窄患儿资料,共纳入结肠狭窄病例7例,其中男童5例,女童2例,月龄3～12个月,中位月龄7个月。结肠狭窄部位:升结肠1例,降结肠3例,乙状结肠3例。患儿均有不同程度、不同持续时间的腹胀表现,均接受手术治疗。术前1例通过肠镜检查,1例通过钡剂灌肠造影明确诊断后手术,1例术前误诊为先天性巨结肠,4例因病情紧急行剖腹探查术。术中6例发现结肠狭窄,其中4例行狭窄部位切除、肠吻合术,2例行肠造瘘术,术后3个月关瘘。1例因急诊术中漏诊,术后腹胀加重再次探查发现乙状结肠狭窄行肠造瘘术。结果 7例患儿中,1例因遗漏乙状结肠狭窄再次行肠造瘘术,最后因多器官功能衰竭死亡;其余6例随访1年均预后良好,无肠瘘、粘连性肠梗阻、肠狭窄等并发症发生。术后7例病理结果均提示狭窄段肠壁出现慢性炎症改变,2例合并肠壁黏膜组织息肉样增生,1例缩窄处肠壁肌间可见异位的肠黏膜腺体结构,1例狭窄段肠壁肌层部分缺失,浆膜层脂肪组织及毛细血管显著增生,所有病例病理检查结果均排除先天性巨结肠。结论婴幼儿结肠狭窄临床上相对罕见,多由各种因素引起的炎症导致,常诊断困难,易发生误诊、漏诊造成严重后果。术中应细心观察,在探查未发现问题或发现的问题不能解释患儿病情时应及时扩大探查范围。结肠狭窄行一期狭窄段切除肠吻合基本安全可行,但如合并多发肠道畸形或腹腔炎症明显则建议行肠造瘘术。
Objective To explore the clinical features,diagnosis and treatment of colonic stenosis in infants and young toddlers and conduct a preliminary analysis of the outcomes of immediate follow-ups.Methods A retrospective analysis was conducted for all operated children with colonic stenosis aged above 3 months from January 2012 to December 2017.A total of 7 cases of infantile colon stenosis were included.There were 5 boys and 2 girls with a median monthly age of 7(3-12) months.The sites of colonic stenosis were ascending colon(n = 1),descending colon(n = 3) and sigmoid colon(n = 3).All children had abdominal distensions of varying degrees and durations.One patient underwent preoperative colonoscopy and another was postoperatively diagnosed by barium enema angiography.One patient was misdiagnosed preoperatively as congenital megacolon and four others underwent emergency exploratory laparotomy because of acute illness.Six cases of colonic stenosis were detected intraoperatively.Stenosis & intestinal anastomosis(n = 4) and enterostomy with closure at 3 months(n = 2) were performed.One case was missed during an emergency operation.Postoperative abdominal distension became aggravated and enterostomy was performed for sigmoid colonic stenosis.Results One case of enterodenectomy due to missing sigmoid stenosis finally died of multiple organ failure.During a 1-year followup period,the remaining 6 patients healed well without any onset of intestinal fistula,adhesive intestinal obstruction or intestinal stenosis.Postoperative pathological results indicated chronic inflammatory changes in stenotic intestinal wall,polypoid hyperplasia of intestinal wall mucosa(n = 2),ectopic intestinal mucosal gland formation in stenotic intestinal wall(n = 1) and stenosis(n = 1).Muscle layer of segmental wall was partially missing and adipose tissue and serosal capillary significantly proliferated.The pathological results of all cases excluded congenital megacolon.Postoperative pathological results showed chronic inflammatory changes in stenotic intestinal wall(n = 7),polypoid hyperplasia of intestinal wall mucosa(n = 2),ectopic intestinal mucosal gland formation in stenotic intestinal wall(n = 1) and stenosis(n = 1).Muscle layer of segmental wall was partially missing and adipose tissue and serosal capillary significantly proliferated.The pathological results of all cases excluded the congenital megacolon.Conclusion Rare in infants and young children,colonic stenosis is caused by various inflammatory factors.It is often difficult to diagnose and its misdiagnosis and underdiagnosis have serious consequences.Careful intraoperative observations should be made and the scope of exploration expanded when a problem is not discovered or it fails to explain the disease condition of a child.Colonic stenosis is both safe and feasible for first-stage stenosis and anostomotic resection.However,if multiple intestinal malformations or abdominal inflammation is present,enterostomy is recommended.
Objective To explore the clinical features,diagnosis and treatment of colonic stenosis in infants and young toddlers and conduct a preliminary analysis of the outcomes of immediate follow-ups.Methods A retrospective analysis was conducted for all operated children with colonic stenosis aged above 3 months from January 2012 to December 2017.A total of 7 cases of infantile colon stenosis were included.There were 5 boys and 2 girls with a median monthly age of 7(3-12) months.The sites of colonic stenosis were ascending colon(n = 1),descending colon(n = 3) and sigmoid colon(n = 3).All children had abdominal distensions of varying degrees and durations.One patient underwent preoperative colonoscopy and another was postoperatively diagnosed by barium enema angiography.One patient was misdiagnosed preoperatively as congenital megacolon and four others underwent emergency exploratory laparotomy because of acute illness.Six cases of colonic stenosis were detected intraoperatively.Stenosis & intestinal anastomosis(n = 4) and enterostomy with closure at 3 months(n = 2) were performed.One case was missed during an emergency operation.Postoperative abdominal distension became aggravated and enterostomy was performed for sigmoid colonic stenosis.Results One case of enterodenectomy due to missing sigmoid stenosis finally died of multiple organ failure.During a 1-year followup period,the remaining 6 patients healed well without any onset of intestinal fistula,adhesive intestinal obstruction or intestinal stenosis.Postoperative pathological results indicated chronic inflammatory changes in stenotic intestinal wall,polypoid hyperplasia of intestinal wall mucosa(n = 2),ectopic intestinal mucosal gland formation in stenotic intestinal wall(n = 1) and stenosis(n = 1).Muscle layer of segmental wall was partially missing and adipose tissue and serosal capillary significantly proliferated.The pathological results of all cases excluded congenital megacolon.Postoperative pathological results showed chronic inflammatory changes in stenotic intestinal wall(n = 7),polypoid hyperplasia of intestinal wall mucosa(n = 2),ectopic intestinal mucosal gland formation in stenotic intestinal wall(n = 1) and stenosis(n = 1).Muscle layer of segmental wall was partially missing and adipose tissue and serosal capillary significantly proliferated.The pathological results of all cases excluded the congenital megacolon.Conclusion Rare in infants and young children,colonic stenosis is caused by various inflammatory factors.It is often difficult to diagnose and its misdiagnosis and underdiagnosis have serious consequences.Careful intraoperative observations should be made and the scope of exploration expanded when a problem is not discovered or it fails to explain the disease condition of a child.Colonic stenosis is both safe and feasible for first-stage stenosis and anostomotic resection.However,if multiple intestinal malformations or abdominal inflammation is present,enterostomy is recommended.
引文
1 Vecchia LKD,Grosfeld JL,West KW,et al.Intestinal atresia and stenosis:a 25 year experience with 277 cases[J].Arch Surg,1998,133(5):490-496.
2 Mirza B,Iqbal S,Ijaz L.Colonic atresia and stenosis:our experience[J].J Neonat Surg,2012,1(1):4.
3 Singh V,Pathak M.Congenital neonatal intestinal obstruction:Retrospective analysis at tertiary care hospital[J].JNeonat Surg.2016,5(1):49.DOI:10.21699/jns.v5i4.393.
4 Yeh TC,Chang JH,Kao HA,et al.Necrotizing enterocolitis in infants:clinical outcome and influence on growth and neurodevelopment[J].J Formos Med Assoc,2004,103(10):761-766.
5 Ekema G,Pedersini P,Milianti S,et al.Colonic stricture mimicking Hirschsprung's disease:a localized cytomegalovirus infection[J].J Pediatr Surg,2006,41(4):850-852.DOI:10.1016/j.jpedsurg.2005.12.029.
6 Marseglia L,Manti S,D'Angelo G,et al.Colonic stenosis post-necrotizing enterocolitis in term newborn with acquired cytomegalovirus infection[J].Chirurgia(Bucur),2015,110(2):175-178.
7 Pelizzo G,Nakib G,Goruppi I,et al.Isolated colon ischemia with norovirus infection in preterm babies:a case series[J].J Med Case Rep,2013,7(1):108.DOI:10.1186/1752-1947-7-108.
8 Xie X,Xiang B,Wu Y,et al.Infant progressive colonic stenosis caused by antibiotic-related Clostridium difficile colitisa case report and literature review[J].BMC Pediatr,2018,18(1):320.DOI:10.1186/s12887-018-1302-9.
9 Pérez Sánchez LE,Hernández Barroso M,Hernández Hernández G.Rectal inflammatory stenosis secondary to Chlamydia trachomatis:a case report[J].Rev Esp Enferm Dig,2017,109(9):668.DOI:10.17235/reed.2017.4917/2017.
10余克驰,吴晓娟,冯杰雄,等.小儿继发性肠狭窄及闭锁诊疗分析[J].中华小儿外科杂志,2015,(3):211-214.DOI:10.3760/cma.j.issn.0253-3006.2015.03.012.Yu KC,Wu XJ,Feng JX,et al.Analysis of diagnosis and treatment of secondary intestinal stenosis and atresia in children[J].Chinese Journal of Pediatric Surgery,2015,(3):211-214.DOI:10.3760/cma.j.issn.0253-3006.2015.03.012.
11 CH Houben,AW I Lo,SY Tsui,et al.Under pressure:a contribution to the pathogenesis of acquired ileal atresia[J].BMJ Case Reports,2013,2013(now 12,1).DOI:10.1136/bcr-2013-201505.
12孙建中,王桐德,张立根.婴幼儿先天性结肠狭窄(附3例报告)[J].中华小儿外科杂志,1984,(1):33-34.DOI:10.3760/cma.j.issn.0253-3006.1984.01.015.Sun JZ,Wang TD,Zhang LG.Congenital colonic stenosis in infants and young children:a report of 3 cases[J].Chinese Journal of Pediatric Surgery,1984,(1):33-34.DOI:10.3760/cma.j.issn.0253-3006.1984.01.015.
13 Haxhija Emir Q,Schalamon Johannes,H?llwarth Michael E.Management of isolated and associated colonic atresia[J].Pediatr Surg Int.2011,27(4):411-416.DOI:10.1007/s00383-010-2802-3.
14 Cox SG,Numanoglu A,Millar AJ,et al.Colonic atresia:spectrum of presentation and pitfalls in management.A review of 14 cases[J].Pediatr Surg Int,2005,21(10):813-818.DOI:10.1007/s00383-005-1488-4.
15彭荣,杨星海,张伊凡,等.先天性肠闭锁352例诊治体会[J].临床小儿外科杂志,2012,(1):45-46.DOI:10.3969/j.issn.1671-6353.2012.01.020.Peng R,Yang XH,Zhang Yifan,et al.Diagnosis and treatment of 352 cases of congenital intestinal atresia[J].Journal of Clinical Pediatric Surgery,2012,(1):45-46.DOI:10.3969/j.issn.1671-6353.2012.01.020.
2 Mirza B,Iqbal S,Ijaz L.Colonic atresia and stenosis:our experience[J].J Neonat Surg,2012,1(1):4.
3 Singh V,Pathak M.Congenital neonatal intestinal obstruction:Retrospective analysis at tertiary care hospital[J].JNeonat Surg.2016,5(1):49.DOI:10.21699/jns.v5i4.393.
4 Yeh TC,Chang JH,Kao HA,et al.Necrotizing enterocolitis in infants:clinical outcome and influence on growth and neurodevelopment[J].J Formos Med Assoc,2004,103(10):761-766.
5 Ekema G,Pedersini P,Milianti S,et al.Colonic stricture mimicking Hirschsprung's disease:a localized cytomegalovirus infection[J].J Pediatr Surg,2006,41(4):850-852.DOI:10.1016/j.jpedsurg.2005.12.029.
6 Marseglia L,Manti S,D'Angelo G,et al.Colonic stenosis post-necrotizing enterocolitis in term newborn with acquired cytomegalovirus infection[J].Chirurgia(Bucur),2015,110(2):175-178.
7 Pelizzo G,Nakib G,Goruppi I,et al.Isolated colon ischemia with norovirus infection in preterm babies:a case series[J].J Med Case Rep,2013,7(1):108.DOI:10.1186/1752-1947-7-108.
8 Xie X,Xiang B,Wu Y,et al.Infant progressive colonic stenosis caused by antibiotic-related Clostridium difficile colitisa case report and literature review[J].BMC Pediatr,2018,18(1):320.DOI:10.1186/s12887-018-1302-9.
9 Pérez Sánchez LE,Hernández Barroso M,Hernández Hernández G.Rectal inflammatory stenosis secondary to Chlamydia trachomatis:a case report[J].Rev Esp Enferm Dig,2017,109(9):668.DOI:10.17235/reed.2017.4917/2017.
10余克驰,吴晓娟,冯杰雄,等.小儿继发性肠狭窄及闭锁诊疗分析[J].中华小儿外科杂志,2015,(3):211-214.DOI:10.3760/cma.j.issn.0253-3006.2015.03.012.Yu KC,Wu XJ,Feng JX,et al.Analysis of diagnosis and treatment of secondary intestinal stenosis and atresia in children[J].Chinese Journal of Pediatric Surgery,2015,(3):211-214.DOI:10.3760/cma.j.issn.0253-3006.2015.03.012.
11 CH Houben,AW I Lo,SY Tsui,et al.Under pressure:a contribution to the pathogenesis of acquired ileal atresia[J].BMJ Case Reports,2013,2013(now 12,1).DOI:10.1136/bcr-2013-201505.
12孙建中,王桐德,张立根.婴幼儿先天性结肠狭窄(附3例报告)[J].中华小儿外科杂志,1984,(1):33-34.DOI:10.3760/cma.j.issn.0253-3006.1984.01.015.Sun JZ,Wang TD,Zhang LG.Congenital colonic stenosis in infants and young children:a report of 3 cases[J].Chinese Journal of Pediatric Surgery,1984,(1):33-34.DOI:10.3760/cma.j.issn.0253-3006.1984.01.015.
13 Haxhija Emir Q,Schalamon Johannes,H?llwarth Michael E.Management of isolated and associated colonic atresia[J].Pediatr Surg Int.2011,27(4):411-416.DOI:10.1007/s00383-010-2802-3.
14 Cox SG,Numanoglu A,Millar AJ,et al.Colonic atresia:spectrum of presentation and pitfalls in management.A review of 14 cases[J].Pediatr Surg Int,2005,21(10):813-818.DOI:10.1007/s00383-005-1488-4.
15彭荣,杨星海,张伊凡,等.先天性肠闭锁352例诊治体会[J].临床小儿外科杂志,2012,(1):45-46.DOI:10.3969/j.issn.1671-6353.2012.01.020.Peng R,Yang XH,Zhang Yifan,et al.Diagnosis and treatment of 352 cases of congenital intestinal atresia[J].Journal of Clinical Pediatric Surgery,2012,(1):45-46.DOI:10.3969/j.issn.1671-6353.2012.01.020.