Murray J J, Schoetz D J, Nugent F W, Coller J A, Veidenheimer M C
Am J Surg. 1984 Jan;147(1):58-65. doi: 10.1016/0002-9610(84)90035-7.
The experience with 25 patients who required operation for Crohn's disease involving the duodenum is reviewed. Two distinct patterns of duodenal involvement are apparent. Intrinsic duodenal Crohn's disease has a characteristic clinical presentation that is distinct from the symptoms seen in patients with involvement of other portions of the gastrointestinal tract. Among 70 patients with duodenal Crohn's disease seen over a 30 year period, 22 required surgical intervention at the Lahey Clinic. Although hemorrhage and intractable pain were associated problems in several of these patients, unrelenting duodenal obstruction remained the primary indication for operation. Of patients who underwent operative bypass, 78 percent had a good result with a median follow-up period of 12.3 years. The presence of associated gastric Crohn's disease did not influence long-term results. A third of the patients required reoperation for duodenal disease. Marginal ulceration and recurrent gastroduodenal obstruction have been the primary reasons for reoperation. Although the addition of vagotomy to operative bypass has not helped to protect against subsequent marginal ulceration, the absence of appreciable morbidity associated with vagotomy in our series and the high incidence of marginal ulcers reported with gastroenterostomy in other clinical settings lead us to recommend gastroenterostomy with vagotomy as the procedure of choice for duodenal Crohn's disease. Proceeding with vagotomy in persons who have had previous ileocecal or extensive small bowel resection should not be undertaken without careful consideration. Similar caution should also be used in patients who are already troubled with poorly controlled diarrhea. The duodenum may also be involved by duodenoenteric fistulas which represent a complication of Crohn's disease involving other portions of the gastrointestinal tract. Most frequently this occurs in patients with Crohn's colitis who have no evidence of intrinsic duodenal disease. Management of the internal fistula requires resection of the involved colon and closure of the duodenal defect. Three patients with duodenocolic fistula have been so treated.
回顾了25例因克罗恩病累及十二指肠而需手术治疗的患者的经验。十二指肠受累有两种明显不同的模式。十二指肠原发性克罗恩病有其特征性临床表现，与胃肠道其他部位受累患者的症状不同。在30年期间诊治的70例十二指肠克罗恩病患者中，22例在拉希诊所需要手术干预。虽然其中一些患者伴有出血和顽固性疼痛，但持续的十二指肠梗阻仍是手术的主要指征。接受手术旁路术的患者中，78%效果良好，中位随访期为12.3年。合并胃克罗恩病并不影响长期疗效。三分之一的患者因十二指肠疾病需要再次手术。边缘性溃疡和复发性胃十二指肠梗阻是再次手术的主要原因。虽然在手术旁路术中加做迷走神经切断术无助于预防随后的边缘性溃疡，但在我们的系列研究中迷走神经切断术相关的明显并发症较少，而在其他临床情况下胃空肠吻合术报道的边缘性溃疡发生率较高，这使我们建议对十二指肠克罗恩病选择胃空肠吻合术加迷走神经切断术作为手术方式。对于既往有回盲部或广泛小肠切除术的患者，在未仔细考虑的情况下不应进行迷走神经切断术。对于已有控制不佳的腹泻困扰的患者也应同样谨慎。十二指肠也可能因十二指肠肠瘘而受累，这是克罗恩病累及胃肠道其他部位的一种并发症。最常见于无十二指肠原发性疾病证据的克罗恩结肠炎患者。内瘘的处理需要切除受累结肠并闭合十二指肠缺损。3例十二指肠结肠瘘患者已接受此治疗。
