Célicout B, Levard H, Hay J, Msika S, Fingerhut A, Pelissier E
Clinique des Presles, Epinay-sur-Seine, France.
Dig Surg. 1998;15(6):697-702. doi: 10.1159/000018681.
To propose guidelines for treatment based on the study of early and late outcome after various surgical procedures for sclerosing encapsulating peritonitis (SEP). PRIMARY BACKGROUND DATA: SEP is rare. The main complication is intestinal obstruction. Ideal treatment is resection of the membrane, whenever possible. Mortality and morbidity, however, have not been well analyzed.
The case records and histopathological reports of 32 operated cases of SEP (18 centers during 16 years) were retrospectively studied. Patients underwent four types of procedures: group 1 (n = 5), membrane resection; group 2 (n = 12), enterolysis with partial excision of the membrane; group 3 (n = 7), intestinal resection, and group 4 (n = 8), exploratory laparotomy only. Five cases were considered as idiopathic. Medical and surgical antecedent history for the 27 other cases (6 patients had associations) included laparotomy for carcinoma (n = 14) or benign disorders (n = 5), beta-blocker treatment (n = 4), cirrhotic ascites (n = 4), generalized peritonitis (n = 3) and continuous ambulatory peritoneal dialysis (n = 3). Indications for operation included subacute (n = 22) or acute intestinal obstruction (n = 6), abdominal mass (n = 8), other clinical presentations (n = 4) and asymptomatic SEP discovered during surgery for portacaval shunt (n = 1). Seven patients had two associated clinical presentations. All cirrhotic patients with ascites and the asymptomatic patient were in group 4. None of the imaging techniques (plain radiograms, barium follow-through, sonograms and CT scans) were formally contributive to the preoperative diagnosis of SEP.
In group 1, both complicated patients, one with an inadvertent intraoperative intestinal wound, the other with a postoperative intestinal leak, healed uneventfully. In group 2, 4 inadvertent intraoperative intestinal wounds led to 4 postoperative leaks with 3 consequent deaths. One further patient died of persistent intestinal obstruction. In group 3, 1 inadvertent intestinal intraoperative wound healed uneventfully and 2 deaths, one due to persistent intestinal obstruction associated with anastomotic leakage and the other due to ventricular fibrillation, were noted. In group 4, there were no intraoperative wounds, no postoperative morbidity or deaths. The median follow-up was 49.5 months (range 4-142 months). Seven patients (1 or 2 in each group) experienced transient episodes of subacute intestinal obstruction between 1 month and 6 years after discharge, none of which required a repeat operation. Eight patients (in all groups) died of their initial cancer between 4 and 75 months after discharge.
Our results suggest that: (1) resection of the membrane should be attempted when feasible; (2) in case of inadvertent intestinal wound(s), the most proximal one should be brought out as a stoma, and partial resections should not be anastomosed primarily, but (3) no surgical treatment is required in ascites, asymptomatic SEP or subacute intestinal obstruction.
基于对硬化性包裹性腹膜炎（SEP）各种手术方法的早期和晚期结果的研究，提出治疗指南。主要背景数据：SEP较为罕见。主要并发症是肠梗阻。理想的治疗方法是尽可能切除包膜。然而，死亡率和发病率尚未得到充分分析。
回顾性研究32例SEP手术病例（16年间来自18个中心）的病例记录和组织病理学报告。患者接受了四种手术方式：第1组（n = 5），包膜切除术；第2组（n = 12），肠粘连松解术并部分切除包膜；第3组（n = 7），肠切除术；第4组（n = 8），仅行剖腹探查术。5例被认为是特发性的。其他27例患者（6例有相关疾病）的内科和外科既往史包括因癌症行剖腹手术（n = 14）或良性疾病（n = 5）、β受体阻滞剂治疗（n = 4）、肝硬化腹水（n = 4）、弥漫性腹膜炎（n = 3）和持续性非卧床腹膜透析（n = 3）。手术指征包括亚急性肠梗阻（n = 22）或急性肠梗阻（n = 6）、腹部肿块（n = 8）、其他临床表现（n = 4）以及在门腔分流手术中发现的无症状SEP（n = 1）。7例患者有两种相关临床表现。所有肝硬化腹水患者和无症状患者均在第4组。所有影像学检查（平片、钡剂造影、超声和CT扫描）均未对SEP的术前诊断有明确帮助。
在第1组中，2例复杂患者，1例术中意外肠损伤，另1例术后肠漏，均顺利愈合。在第2组中，4例术中意外肠损伤导致4例术后肠漏，其中3例死亡。另有1例患者死于持续性肠梗阻。在第3组中，1例术中意外肠损伤顺利愈合，2例死亡，1例死于与吻合口漏相关的持续性肠梗阻，另1例死于心室颤动。在第4组中，无术中损伤，无术后发病或死亡。中位随访时间为49.5个月（范围4 - 142个月）。7例患者（每组1或2例）在出院后1个月至6年期间经历了亚急性肠梗阻的短暂发作，均无需再次手术。8例患者（所有组）在出院后4至75个月死于原发性癌症。
我们的结果表明：（1）可行时应尝试切除包膜；（2）如发生意外肠损伤，最近端损伤应外置造口，部分切除不应一期吻合；（3）腹水、无症状SEP或亚急性肠梗阻无需手术治疗。
