Successful use of the “patch, drain, and wait” laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered “good angiogenesis” involved?
Successful use of the “patch, drain, and wait” laparotomy approach to perforated necrotizing enterocolitis: is hypoxia-triggered “good angiogenesis” involved?
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成功使用“修补、引流和等待”剖腹手术方法治疗穿孔坏死性小肠结肠炎：是否涉及缺氧引发的“良好血管生成”？
DOI：
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发表时间：
2000
期刊：
影响因子：
--
通讯作者：
T. C. Moore
中科院分区：
文献类型：
--
作者：
T. C. Moore
穿孔性坏死性小肠结肠炎（NEC）的传统手术方法，即开腹手术和肠切除并建立肠造口，具有不可接受的高死亡率和高并发症（败血症、短肠综合征、狭窄、长期全胃肠外营养（TPN）、多次手术的长期和昂贵的住院治疗，在大约10%的剖腹手术病例中，不可避免的用于“无望的”广泛肠缺血的开闭手术等）。使用剖腹手术“补片，引流，等待”（PD&W）的方法来处理这一严重的NEC并发症提供了一个简单，直接和有效的手段来处理这个问题。基本原则是不切除肠道，不做肠造口术。这里介绍了详细信息以及多种类型的“修补”和使用广泛直视引流的重要性，双侧小Penrose引流管从两个横膈膜下表面进入骨盆，出口部位在两个下象限。正确有效的修补和引流不能盲目进行，而需要直视（剖腹手术或腹腔镜）。强调了“等待”的关键组成部分和时机，包括在引流后7- 14天内严格避免早期引流后剖腹手术的至关重要性（无论引流是经皮、开腹PD&W还是腹腔镜PD&W），由于早期，此时发生的危及生命的结束性血管过多，如果不受干扰，将有益地起到挽救生命和肠道的“良好血管生成”的作用。双侧Penrose引流管捕获粪瘘，并作为事实上的肠造口发挥很好的作用，因为腹膜腔被粘连和大规模、丰富的血管增生/肠道缺氧迅速闭塞，引发了“良好的血管生成”（无腹膜腔，无腹膜炎）。广谱三联抗生素和常规使用TPN有助于良好的结果。在仅有胎粪性腹膜炎且无梗阻（“自动吻合术”）的偶尔病例中，在患有中肠闭锁和显著肠道存活水平的新生儿中遇到的自然经验教训/实验在此是相关的，因为PD&W的TPN通过母体-胎盘循环在闭锁中提供，并且闭锁的无菌腹膜腔通过抗生素和腹膜腔闭塞的组合来模拟。挽救生命和肠道的“良好血管生成”在这两种情况下都是常见的。本文报告了23例穿孔NEC患者采用PD&W剖腹术治疗的15年个人经验，术后最初60天内无死亡率，无严重并发症，70%的病例（自发性“自动吻合”）无需二次手术。所有患有广泛肠道缺血/坏死（NEC totalis）的婴儿，否则将被归类为“无望”，只能通过开放和关闭进行治疗，在此经验中，PD&W成功地进行了治疗，保留了生命和足够的肠道，尽管这些病例需要进行第二次手术以重建肠道连续性。一个特别引人注目的观察结果是，这些婴儿在开始PD&W后的几个小时内从严重疾病迅速转变为接近正常--就像伴随着兰辛疖子或脓肿的快速临床变化一样。缺氧诱导的“良好的血管生成”与显着的血管过多和涉及分子，基因和缺氧诱导的血管生成分子的血管内皮生长因子家族的受体的参与被推测后，和临床研究，以记录这些推测建议，以及研究评估腹腔镜PD&W的潜力。阿盖尔胸管在结肠“补丁”区上方经肛门“排气”和“支架”的有效性（2例）值得进一步研究和应用。
Abstract The traditional and most frequently employed surgical approach to perforated necrotizing enterocolitis (NEC), laparotomy and bowel resection with enterostomy creation, has been associated with an unacceptably high mortality and major morbidity (sepsis, short-gut syndrome, strictures, long-term total parenteral nutrition (TPN), prolonged and costly hospitalizations with multiple operations, the inevitable open-and-close procedure for “hopeless” extensive gut ischemia in approximately 10% of laparotomy cases, etc.). The use of the laparotomy “patch, drain, and wait” (PD&W) approach to this serious of NEC complication has provided a simple, direct, and effective means of dealing with this problem. The basic principle is to resect no gut and do no enterostomies. The details are presented here as well as the multiple types of “patching” and the importance of use of extensive direct-vision draining with bilateral small Penrose drains from the undersurfaces of both diaphragms into the pelvis with exit sites in both lower quadrants. Proper and effective patching and draining cannot be done blindly, but requires direct vision (laparotomy or laparoscopy). The critical components and timing of the “waiting” are emphasized, including the vital importance of strict avoidance of early post-drainage laparotomy in the 7- to 14-day post-drainage period (whether the drainage is percutaneous, laparotomy PD&W, or laparoscopy PD&W) due to the early, life-threatening-ending hypervascularity that occurs at this time and if left unmolested will function beneficially as life- and gut-saving “good angiogenesis”. The bilateral Penrose drains capture fecal fistulas and function quite well as de-facto enterostomies as the peritoneal cavity is rapidly obliterated by adhesions and massive, florid hypervascularity/gut hypoxia triggered “good angiogenesis” (no peritoneal cavity, no peritonitis). Broad-spectrum triple antibiotics and the routine use of TPN contribute to favorable results. The lessons/experiments of nature encountered in newborns with midgut atresia(s) and remarkable levels of gut survival, in the occasional case with only meconium peritonitis and no obstruction (“auto-anastomosis”) are pertinent here as the TPN of PD&W is provided in atresia(s) by the maternal-placental circulation and the sterile peritoneal cavity of atresia(s) is simulated by the combination of antibiotics and peritoneal-cavity obliteration. Life- and gut-saving “good angiogenesis” is common to both situations. A 15-year personal experience with the PD&W laparotomy approach to perforated NEC in 23 cases is reported here with no mortality in the initial 60 postoperative days, no major morbidity, and no second operation required in 70% (spontaneous “auto-anastomosis”) of cases. All infants with extensive gut ischemia/necrosis (NEC totalis) who would otherwise be classified as “hopeless” and managed by open-and-close only were managed in this experience successfully by PD&W with preservation of both life and an adequate amount of gut, although a second operation was required in these cases to re-establish intestinal continuity. A particularly striking observation was the rapid transition of these infants from profound illness to near-normalcy in a matter of hours after the initiation of PD&W – much like the rapid clinical changes accompanying the lancing of a boil or an abscess. An involvement of hypoxia-induced “good angiogenesis” with marked hypervascularity and involving molecules, genes, and receptors of the vascular endothelial growth factor family of hypoxia-induced angiogenesis molecules is speculated upon, and clinical studies to document these speculations are suggested as well as studies evaluating the potential of laparoscopic PD&W. The usefulness of Argyle chest-tube “venting” and “stenting” by trans-anal passage above colonic “patched” areas as seen in 2 cases is worthy of further study and use.
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影响因子：
37.8
作者：
E. Brogi;Tian-gen Wu;A. Namiki;J. Isner
通讯作者：
E. Brogi;Tian-gen Wu;A. Namiki;J. Isner
DOI：
10.1073/pnas.91.10.4190
发表时间：
1994-05-10
影响因子：
11.1
作者：
LEIBOVICH, SJ;POLVERINI, PJ;KOCH, AE
通讯作者：
KOCH, AE
培养物中牛肺动脉内皮细胞对血清素的摄取。
DOI：
10.1152/ajpcell.1986.250.5.c766
发表时间：
1986
期刊：
The American journal of physiology
影响因子：
--
作者：
Lee,SL;Fanburg,BL
通讯作者：
Fanburg,BL
影响因子：
15.9
作者：
Brogi, E;Schatteman, G;Isner, JM
通讯作者：
Isner, JM