严重肠系膜上动脉损伤后的损伤控制性外科研究  

Damage control surgery after severe superior mesenteric artery injury

作　　者：丁威威 吴性江 李宁 黎介寿 

机构地区：[1]南京军区南京总医院,南京大学医学院附属金陵医院,全军普通外科研究所,210002

出　　处：《中华创伤杂志》2014年第1期62-66,共5页Chinese Journal of Trauma

基　　金：国家自然科学基金青年基金资助项目（81300278）;南京军区医学科技创新课题面上资助项目（12NA081）;江苏省临床医学科技专项资助项目（B12012006）

摘　　要：目的通过比较不同手术方式对肠系膜上动脉（superiormesentericartery，SMA）损伤后的血流动力学、全身主要脏器损伤和存活率的影响，探索一种符合损伤控制性外科（damagecontrolsurgery，DCS）的简便措施。方法本地杂种猪共30只，游离SMA，用无损伤血管钳阻断SMA血流后，按随机数字表法分为对照组、I期血管吻合组（吻合组）、暂时血管腔内分流管（tem-poraryintravascularshunt，TIVS）组，TIVS组又分为3个亚组：血管腔内分流管放置6h（TIVS-6h）组、9h（TIVS-9h）组和12h（TIVS-12h）组，行血管造影评价分流管的通畅程度，检测各时相点血流动力学指标，取各时相点末端回肠和SMA行病理学检查。结果各组均表现出危重的生理状态：低体温、严重酸中毒、低血压、低心输出量和氧供。与吻合组比较，TIVS-6h组和TIVS-9h组需要更少的复苏液体量即可更快恢复SMA血流速度，较早清除血清乳酸，减轻肠道缺血再灌注损伤，提高早期存活率。TIVS-6h、TIVS-9h、TIVS-12h组分别保持100％、50％和0％的通畅率。肠道病理结果提示：TIVS-12h组出现广泛肠坏死，TIVS-6h组和TIVS-9h组肠缺血再灌注损伤为可逆性损伤。结论在血流动力学严重紊乱、濒危情况下的SMA损伤，与I期血管吻合术比较，TIVS能缩短肠道缺血时间、维持全身血流动力学稳定、减轻肠道损伤、提高早期存活率，能有效维持较长的通畅时间。Objective To determine the effect of different surgical modalities on hemodynamics, systemic major organ injury and survival rate following superior mesenteric artery （SMA） injury in an at- tempt to search a modality that conforms to principles of damage control surgery （ DCS）. Methods SMA was exposed in 30 domestic hybrid pigs, leaving the blood flow blocked using non-invasive ves- sel forceps. The animals were divided into control group, primary anastomosis group （ anastomosis group） and temporary intravascular shunt （TIVS） group according to random number table. TIVS group was further divided into three subgroups： shunting for 6 hours group （TIVS-6 h group） , 9 hours group （TIVS-9 h group） and 12 hours group （TIVS-12 h group）. At each time point, the angiography was performed for evaluation of shunt patency; hemodynamic parameters were detected, terminal ileum and SMA samples were harvested for pathological analysis. Results All groups suffered extreme physiological conditions including hypothermia, severe acidosis, hypotension, low cardiac output and low oxygen sup- ply. Less requirement of resuscitation fluid, faster restoration of SMA blood flow, earlier clearance of lactate, milder intestinal ischemia-reperfusion injury and higher survival rate were observed in TIVS-6 h and TIVS-9 h groups, compared with anastomosis group. Patency rate in T1VS-6 h, 9 h and 12 h groups was 100% , 50% and 0% respectively. Pathologic outcome of intestine revealed diffuse intestinal necro- sis in TIVS-12 h group and reversible intestinal ischemia-reperfusion injury in TIVS-6 h and 9 h groups. Conclusion For SMA injury in severe hemodynamic disarrangement and jeopardized condition, TIVS shortens intestinal ischemia time, maintains systemic hemodynamic stability, relieves intestinal injury, improves early survival rate and keeps long-term intestine patency when compared with primary vascular anastomosis.

关 键 词：休克 肠系膜上动脉 损伤控制性外科 

分 类 号：R657.2[医药卫生—外科学]