小儿肠套叠（图文演示）

10.肠套叠还原
•肠套叠还原
•原则

用两个手术步骤肠套叠还原：
-使用肺切开术游离两个圆柱
-减少肠套叠的症状点

•肺切开术

在套入部的颈部，从肠套叠的鞘部剥离肠套叠；二氧化碳自发性的渗入套入部的颈部，避免干扰导致扩大。

•症状点肠套叠还原


可用肠道钳或者无创伤抓取器减少肠套叠的症状点，在肠道末端道套入部的地方维持牵开。
肠套叠温和的牵开可以帮助完成。

•肠道撕裂

当温和的牵开近端肠道时，远端肠道会有强烈阻抗性，而导致肠道撕裂。

•困难的案例

腹腔镜方式在某些阻塞式肠套叠可能相当困难，当小肠膨胀时会导致手术空间减小。
如果是梅克尔氏憩室症，肿瘤或长期站立姿势，肠套叠会难以察觉，可能需要改为使用腹腔镜方式。

•肠道切开

以下几点难以评价：
-已还原肠道的活性
-短暂改变肠道状况
-继发于肠道分开的坏死或穿孔风险
难以从腔内血肿分辨坏死区，若是下腹部进行性紫癜病例就更加困难，必须在下腹部由腹腔镜引导的情况下，透过一个低水平的小切口进行转换，有主要的困难。

11.开腹方法


在肚脐或稍往下一点处进行水平皮肤切开，由于McBurney’s切口可能不适合（万一发生肠套叠症状点远端恶化）或太低（万一盲肠较高），之后最好进行Jalaguier-Buck’s切口（如前面所介绍）。
Jalaguier-Buck方法让肠套叠还原，必要时进行肠切除，可以常规进行阑尾切除手术，复发率很低（2%）；有阻塞风险：5%的阻塞案例归因于一种自1972年以来曾在我们医院用来治疗的绷带（Becmeur等人，1997）。

12.术后处理
介入放射学后
小孩可在液压静力完成后立即恢复进食，如果特别脱水且疲累，静脉注射液体维持到术后几个小时。
如果临床检查和超声波检视都令人满意，小孩可在术后24到48小时内出院。
约有5%案例发生立即复发。
为了更了解肠套叠的病因，在小孩住院期间需进行临床评价与病史调查。

腹腔镜手术之后
如果未切除肠道，小孩可以在术后隔天渐渐恢复饮食，且维持静脉输液直到水分与电解质恢复平衡；小孩可在住院48小时内出院。
如果有切除肠道，小孩可在肠道运输重建后立即恢复饮食，术后的前几天需开立止痛药。

13.Reference
Adejuyigbe O, Odesanmi WO. Intrauterine intussusception causing intestinal atresia. J Pediatr Surg
1990;25:562-3.
Becmeur F, Ringenbach P, Schwaab C, Tucella M, Carrenard G. Occlusions sur brides en chirurgie
pédiatrique. Annales de Pédiatrie 1997;44:463-8.
Bowerman RA, Silver TM, Jaffe MH. Real-time ultrasound diagnosis of intussusception in children.
Radiology 1982;143:527-9.
Bramson RT, Blickman JG. Perforation during hydrostatic reduction of intussusception: proposed
mechanism and review of the literature. J Pediatr Surg 1992;27:589-91.
Chan KL, Saing H, Peh WC, Mya GH, Cheng W, Khong PL et al. Childhood intussusception:
ultrasound-guided Hartmann's solution hydrostatic reduction or barium enema reduction? J Pediatr
Surg 1997;32:3-6.
Choi SO, Park WH, Woo SK. Ultrasound-guided water enema: an alternative method of nonoperative
treatment for childhood intussusception. J Pediatr Surg 1994;29:498-500.
Chung JL, Kong MS, Lin JN, Wang KL, Lou CC, Wong HF. Intussusception in infants and children: risk
factors leading to surgical reduction. J Formos Med Assoc 1994;93:481-5.
Cuckow PM, Slater RD, Najmaldin AS. Intussusception treated laparoscopically after failed air enema
reduction. Surg Endosc 1996;10:671-2.
Daneman A, Alton DJ, Ein S, Wesson D, Superina R, Thorner P. Perforation during attempted
intussusception reduction in children--a comparison of perforation with barium and air. Pediatr Radiol
1995;25:81-8.
Ein SH, Mercer S, Humphry A, Macdonald P. Colon perforation during attempted barium enema
reduction of intussusception. J Pediatr Surg 1981;16:313-5.
Eklof O, Hartelius H. Reliability of the abdominal plain film diagnosis in pediatric patients with
suspected intussusception. Pediatr Radiol 1980;9:199-206.
Galatioto C, Angrisano C, Blois M, Goletti O, Buccianti P, Lorenzetti L et al. Laparoscopic treatment of
appendico-cecal intussusception. Surg Laparosc Endosc Percutan Tech 1999;9:362-4.
Goetting MG, Tiznado-Garcia E, Bakdash TF. Intussusception encephalopathy: an underrecognized
cause of coma in children. Pediatr Neurol 1990;6:419-21.
Gorenstein A, Raucher A, Serour F, Witzling M, Katz R. Intussusception in children: reduction with
repeated, delayed air enema. Radiology 1998;206:721-4.
Gorgen-Pauly U, Schultz C, Kohl M, Sigge W, Moller J, Gortner L. Intussusception in preterm infants:
case report and literature review. Eur J Pediatr 1999;158:830-2.
Gu L, Zhu H, Wang S, Han Y, Wu X, Miao H. Sonographic guidance of air enema for intussusception
reduction in children. Pediatr Radiol 2000;30:339-42.
Hadidi AT, El Shal N. Childhood intussusception: a comparative study of nonsurgical management. J
Pediatr Surg 1999;34:304-7.
REFERENCES 01/10/2001
- 2 -
Lai IR, Huang MT, Lee WJ. Mini-laparoscopic reduction of intussusception for children. J Formos Med
Assoc 2000;99:510-2.
Lee JM, Kim H, Byun JY, Lee HG, Kim CY, Shinn KS et al. Intussusception: characteristic
radiolucencies on the abdominal radiograph. Pediatr Radiol 1994;24:293-5.
Ong NT, Beasley SW. Progression of intussusception. J Pediatr Surg 1990;25:644-6.
Palder SB, Ein SH, Stringer DA, Alton D. Intussusception: barium or air? J Pediatr Surg 1991;26:271-
4; discussion 274-5.
Pierro A, Donnell SC, Paraskevopoulou C, Carty H, Lloyd DA. Indications for laparotomy after
hydrostatic reduction for intussusception. J Pediatr Surg 1993;28:1154-7.
Poddoubnyi IV, Dronov AF, Blinnikov OI, Smirnov AN, Darenkov IA, Dedov KA. Laparoscopy in the
treatment of intussusception in children. J Pediatr Surg 1998;33:1194-7.
Pracros JP, Tran-Minh VA, Morin de Finfe CH, Deffrenne-Pracros P, Louis D, Basset T. Acute
intestinal intussusception in children. Contribution of ultrasonography (145 cases). Ann Radiol
1987;30:525-30.
Ratcliffe JF, Fong S, Cheong I, O'Connell P. The plain abdominal film in intussusception: the accuracy
and incidence of radiographic signs. Pediatr Radiol 1992;22:110-1.
Riebel TW, Nasir R, Weber K. US-guided hydrostatic reduction of intussusception in children.
Radiology 1993;188:513-6.
Rohrschneider WK, Troger J. Hydrostatic reduction of intussusception under US guidance. Pediatr
Radiol 1995;25:530-4.
Schier F. Experience with laparoscopy in the treatment of intussusception. J Pediatr Surg
1997;32:1713-4.
Schmit P, Rohrschneider WK, Christmann D. Intestinal intussusception survey about diagnostic and
nonsurgical therapeutic procedures. Pediatr Radiol 1999;29:752-61.
Shanbhogue RL, Hussain SM, Meradji M, Robben SG, Vernooij JE, Molenaar JC. Ultrasonography is
accurate enough for the diagnosis of intussusception. J Pediatr Surg 1994;29:324-7; discussion 327-8.
Shehata S, El Kholi N, Sultan A, El Sahwi E. Hydrostatic reduction of intussusception: barium, air, or
saline? Pediatr Surg Int 2000;16:380-2.
Shiels WE, 2nd, Kirks DR, Keller GL, Ryckman FR, Daugherty CC, Specker BL et al. John Caffey
Award. Colonic perforation by air and liquid enemas: comparison study in young pigs. AJR Am J
Roentgenol 1993;160:931-5.
Stanley A, Logan H, Bate TW, Nicholson AJ. Ultrasound in the diagnosis and exclusion of
intussusception. Ir Med J 1997;90:64-5.
Stringer MD, Pledger G, Drake DP. Childhood deaths from intussusception in England and Wales,
1984-9. BMJ 1992;304:737-9.
Wang GD, Liu SJ. Enema reduction of intussusception by hydrostatic pressure under ultrasound
guidance: a report of 377 cases. J Pediatr Surg 1988;23:814-8.
Wood SK, Kim JS, Suh SJ, Paik TW, Choi SO. Childhood intussusception: US-guided hydrostatic
reduction. Radiology 1992;182:77-80.

好得很

学习学习