16例腹主动脉瘤合并消化系统疾病的手术治疗

摘要 目的:探讨腹主动脉瘤合并需外科手术的消化系统疾病的外科治疗方法。方法:回顾性分析16例腹主动脉瘤合并消化系统疾病在我科进行手术治疗病人的临床资料,总结处理经验。腹主动脉瘤与消化系统疾病同期手术12例(同时行胆囊切除术5例,结肠癌根治术7例),腹主动脉瘤腔内治疗后行结肠癌根治

正文

摘要 目的:探讨腹主动脉瘤合并需外科手术的消化系统疾病的外科治疗方法。方法:回顾性分析16例腹主动脉瘤合并消化系统疾病在我科进行手术治疗病人的临床资料,总结处理经验。腹主动脉瘤与消化系统疾病同期手术12例(同时行胆囊切除术5例,结肠癌根治术7例),腹主动脉瘤腔内治疗后行结肠癌根治术2例、食道下段癌根治术1例,先行胃癌根治术后再行腹主动脉瘤手术1例。结果:发生食道胃吻合口瘘1例,术后第2 d死亡。胃瘫1例,经保守治疗30 d 后恢复。14例存活8~60个月,无人工血管感染,无血管支架内漏,无肿瘤复发。结论:腹主动脉瘤与消化系统疾病并存,只要全身和局部情况允许,应争取同期手术,反之应分期手术,合适病例在腹主动脉瘤腔内治疗后,再行消化系统疾病手术是一种安全、有效的方法。

关键词:主动脉瘤 消化系统疾病

Clinical Analysis of patients with abdominal aortic aneurysm and concomitant digestive system disease: report of 16 cases

SU XU LI Bin CHEN Fuzhen . (Vascular Hepatic Biliary Pancreatic Surgery, Xiamen First Hospital, Fujian Medical University, Xiamen 361003, China)

Abstract Objective: To approach the surgical treatment strategy of patients with abdominal aortic aneurysm and concomitant digestive system disease. Methods: Analyze retrospectively of the clinical data of 16 cases with abdominal aortic aneurysm and concomitant digestive system surgical disease and summarize our treatment experience. There were 12 one-stage operation cases of abdominal aortic aneurysm and concomitant digestive system disease (5 cases of cholecystectomy and 7 cases of radical resection of colon cancer), 2 cases of radical resection of colon cancer after intracavitary therapy of abdominal aortic aneurysm, 1 case of radical resection of low esophageal, and 1 case of abdominal aortic aneurysm surgery after radical resection of gastric cancer. Results: There occurred 1 case of esophagus and stomach anastomotic fistula, died the next day after surgery, and 1 case of gastric paralysis recovered after 30 days’ conservative therapy. Another 14 cases survived 8-60 months without infection of artificial vascular, endoleak of vascular stents, and cancer recurrent. Conclusions: One-stage operation should be carried out in the patients with abdominal aortic aneurysm and concomitant digestive system surgical disease while the whole and local conditions of the patients permitted. Otherwise, staging surgery should be considered. It is safe and in effect to do the digestive system diseases operation after intracavitary therapy of abdominal aortic aneurysm.

Key Words aortic aneurysm , digestive system disease

患腹主动脉瘤的病人常患有需要外科手术的胃肠道、肝、胆道等消化系统疾病,其中合并消化系统肿瘤发病率约0.5%~13.4%[1,2],如何处理此类疾病尚存在争议[3],我们从1999年3月至2008年2月收治16例,报道如下。

1资料与方法:

1.1 临床资料 本组16例,均为男性,年龄65~80岁,平均74.5岁,肾下型腹主动脉瘤直径4.8 cm ~11cm,平均7.0 cm。合并慢性胆囊炎、胆囊结石5例,结肠癌9例,食道下段癌1例,胃癌1例。术前腹主动脉瘤均经彩超、SCTA、MRA、或DSA证实,消化系统疾病均经彩超、胃镜、肠镜确诊。

1.2 手术方式

1.2.1 同时手术 采用腹主动脉瘤切除+人工血管移植术(PTFE分叉型或直型人工血管),同时行胆囊切除术5例,结肠癌根治术7例。手术探查结肠癌无肝转移、无腹腔内种植转移,把肿瘤与腹主动脉瘤隔开后,常规方法行腹主动脉瘤切除+人工血管移植术,人工血管以动脉瘤壁及后腹膜双层缝合包埋后,再行规范的胆囊切除术或结肠癌根治术。手术时间3.0~4.5 h,平均4 h,出血量200~1800 ml,平均400 ml。

1.2.2 先行消化系统疾病手术 1例因胃癌、幽门梗阻、全身情况差,腹主动脉瘤直径5 cm,先行胃癌根治术,术后1年发生腹主动脉瘤破裂出血行急诊手术。

1.2.3 行腹主动脉瘤腔内治疗后,短期内再行消化系统疾病手术3例。1例因合并冠心病、高血压,在腔内治疗后13 d行食道下段癌根治术,2例在腔内治疗后第2 d 行结肠癌根治术。

2 结果

本组1例在腹主动脉瘤腔内治疗术后第2 d行结肠癌根治术,术后出现胃瘫,经保守治疗30 d后胃功能恢复。1例在腹主动脉瘤腔内治疗后13d行食道下段癌根治术,术后第1 d出现吻合口瘘,病人自动出院后死亡。腹主动脉瘤切除+人工血管移植术同时行胆囊切除术5例,结肠癌根治术7例。 1例胃癌根治术后行腹主动脉瘤手术。随诊8-60个月,平均32个月,人工血管通畅,无人工血管感染,无血管支架内漏发生,无肿瘤复发、转移。

3 讨论

腹主动脉瘤病人常患有需要外科手术的胃肠道、肝、胆道等消化系统疾病,是同期手术或分期手术,常使外科医生感到为难。如果先做腹主动脉瘤手术,尚待治疗的腹内消化系统疾病可能发展成为手术禁忌症;而如先行治疗消化系统疾病,因腹腔松动、腹内压增高等因素术后可能引发腹主动脉瘤的急性破裂,导致病人死亡;如果同期手术,则因腹主动脉瘤施行的为无菌手术,消化系统的手术系污染手术,移植的人工血管感染的危险性增加。对腹主动脉瘤合并消化系统恶性肿瘤者, Lobbato调查美国46位教授的意见:在23位普外科教授中,7位主张先行消化道肿瘤手术,另7位主张先行腹主动脉瘤手术,8位要等剖腹探查术中决定,仅1位主张同时手术处理;在16位血管外科教授中,5位主张先行消化道肿瘤手术, 7位主张先行腹主动脉瘤手术,4位主张术中探查决定;7位科主任中,主张先行消化道肿瘤手术或先行腹主动脉瘤手术或术中探查决定各2位,仅1位主张同时手术。主张先行消化道肿瘤切除术者认为,腹主动脉瘤不大,消化道肿瘤较大可有压迫症状;主张先行腹主动脉瘤手术手术者认为腹主动脉瘤较大,消化道肿瘤不大;主张同时手术者不多。

随着手术和麻醉技术的进步及抗生素的发展,对腹主动脉瘤合并需要外科手术的消化系统疾病患者,主张一期手术的报道日趋增多,综合考虑利弊关系,只要患者全身及局部情况允许,主张一期切除两种病变,术后严重并发症、移植物感染及死亡率并不增加[4-10]。Bachoo[4]等报道5例腹主动脉瘤合并结肠癌一期手术,术后随诊6个月至6年未见人工血管感染,无肿瘤复发。Tsuji等提出腹主动脉瘤合并恶性肿瘤者先切除腹主动脉瘤,人工血管移植后用原动脉瘤壁覆盖人工血管,游离大网膜固定,并用浸有利福平的明胶封闭移植部位行恶性肿瘤切除术。

1991年阿根廷医生Parodi等首次报道经血管腔内治疗腹主动脉瘤,经过十几年的快速发展,该技术的有效性和微创性得到肯定,尤其适用于合并重要脏器功能不全的高危患者。对合并需要外科手术的消化系统疾病的腹主动脉瘤患者,可在血管腔内治疗后择期利用腹腔镜或开放手术切除消化系统病灶,可基本避免人工血管感染的危险,同时大大减小手术创伤,利于病人恢复[11-12]。

结合本组临床资料分析,我们有限经验认为:① 对腹主动脉瘤病人,术前全面检查如彩超、SCT, MRI等,确定有无合并需要外科手术的消化系统疾病,同时了解病人全身情况,包括心肺、脑、肝肾等重要脏器功能,判定病人能否耐受两种手术。② 对可耐受同期手术病人,首选同期修复腹主动脉瘤并切除消化系统病变,术中注意无菌操作,减少污染,加强预防性抗生素应用,但对合并如急性胆囊炎、急性阑尾炎、或消化道肿瘤急性梗阻、穿孔者,禁忌同时手术。③ 对全身情况较差,合并消化道恶性肿瘤,判定不能耐受同时手术者,如腹主动脉瘤直径< 6 cm,无腹主动脉瘤破裂或濒临破裂者,应先行消化道恶性肿瘤根治术,腹主动脉瘤择期再做处理。④ 对血管条件、经济条件适合者,可先行腹主动脉瘤腔内治疗,此后根据病人恢复情况限期行消化系统病变切除术,这对高危病人尤其适合。本组有3例腹主动脉瘤腔内治疗后行消化系统恶性肿瘤根治术。⑤ 对肿瘤晚期,或伴转移病人,一般无法再耐受腹主动脉瘤手术,特别是复杂的腹主动脉瘤手术,除非腹主动脉瘤破裂,不宜行腹主动脉瘤手术治疗。总之,对腹主动脉瘤病人合并需要外科手术的消化系统疾病,治疗上应充分考虑同时手术的必要性与可能性,个体化选择,最大程度保证治疗的有效性与安全性。

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