腹腔内感染病原菌的耐药特点与对策

外科感染是危及外科患者健康并引起死亡的常见原因．腹腔内感染在外科感染中最常见,也是院内感染较常见的疾病之一。胃肠外科的感染包括急性阑尾炎、结肠炎、坏死性小肠炎及盲肠炎等。腹腔内感染常用的治疗方法包括外科手段和抗菌药物的应用．而后者是治疗中的重要一环。抗菌药物合理应用的前提条件是熟悉腹腔内感染的病原学特点及病原体对抗菌药物的敏感性。不能及早做出正确的病原学诊断．     

179例坏疽穿孔阑尾炎术后无切口感染的体会

目的探讨预防坏疽穿孔阑尾炎术后切口感染的方法。方法 2009年6月至2011年8月本院外科治疗179例坏疽穿孔阑尾炎,术中采用局部腹腔及切口内冲洗并留置抗菌药物,改变传统单一静脉滴注大量抗菌药物的方法。结果全部患者切口均为Ⅰ期愈合,无切口红肿、化脓及裂开等征象,亦无腹腔脓肿形成。结论在坏疽穿孔阑尾炎手术中采用局部腹腔及切口内冲洗并留置抗菌药物基本达到了预防切口感染的目的。     

胆道感染抗菌药物临床抉择的焦点问题

胆道感染是临床常见的腹腔感染性疾病,常合并多种病原菌感染,如不及时有效控制,可继发化脓性胆管炎、脓毒血症,甚至感染性休克,危及病人生命。抗菌药物的合理应用在胆道感染的治疗中发挥着重要作用。该文就胆道感染的诊断标准及严重程度评估,胆道感染细菌谱及药物敏感性监测,病原学诊断,抗菌药物的给药时机、用药时长及给药方式,抗菌药物的胆汁排泄特点等临床应用的焦点问题进行了综述。     

急性弥漫性腹膜炎对全身免疫功能的影响

消化道急性穿孔、吻合口瘘、胆道感染等均可导致急性弥漫性腹膜炎,从而发生腹腔内感染甚至导致脓毒症(sepsis)和多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS).     

消化道穿孔致腹腔感染的外科手术治疗

消化道穿孔致腹腔感染是急诊手术常见原因, 大部分情况下需行病变肠段切除, 切除后行一期吻合还是造口, 是困扰临床医生的关键。随着外科技术不断进步, 患者改善生活质量的需求增加, 一期切除吻合术成为最为理想的手术方式。但由于对术后吻合口漏的担忧, 临床实际中术后造口率仍居高不下。本文对近年来有关胃肠道穿孔致腹腔感染外科手术治疗进行综述, 就穿孔位置、病因等问题, 探讨了最佳手术方案。对并对一期吻合后吻合口漏的多种预防手段进行探讨, 包括围手术期管理、胃肠道吻合和肠道灌洗减压等技术, 以期提高肠切除术后一期吻合率, 为消化道穿孔致腹腔感染的外科手术治疗提供参考, 对改善患者生活质量、减轻医疗负担具有重要意义。     

克林霉素在治疗腹腔内感染中的应用

腹腔内感染为常见的外科感染 ,其处理原则为外科治疗及合理应用抗生素。Ｗｉｌｓｏｎ和Ｆａｕｌｋｎｅｒ[1] 依据腹腔内感染的发生部位及病因将其分为三类 :(1)上消化道疾病所致腹腔内感染 (ｕｐｐｅｒｇａｓｔｒｏｉｎｔｅｓｔｉｎａｌｔｒａｃｔｉｎｆｅｃｔｉｏｎ ,ＵＧＩ) ,其中包括胆囊炎、胆管炎、胃及十二指肠溃疡穿孔、膈下脓肿、非特异性腹膜炎等。(2 )各种类型的阑尾炎 (ｃｏｍｐｌｉｃａｔｅｄａｐ ｐｅｎｄｉｃｉｔｉｓ,ＣＡＰＰＸ) ,其中包括坏疽性阑尾炎、阑尾穿孔、阑尾炎性腹膜炎、阑尾脓肿等。 (3)下消化道疾病所致腹腔内…     

血尿淀粉酶正常的重症急性胰腺炎误诊12例分析

目的：探讨血尿淀粉酶正常重症急性胰腺炎的诊断及误诊原因。方法：回顾分析12例血尿淀粉酶正常的重症急性胰腺炎患者误诊的临床资料。结果：12例中误诊为肠梗阻5例,胆石症4例,消化道溃疡并穿孔2例,急性阑尾炎伴穿孔1例。6例经CT确诊;2例经腹腔穿刺确诊,4例经手术确诊。结论：详细、全面询问病史,对可疑患者行CT及腹腔穿刺检查,是预防重症急性胰腺炎误诊的关键。

     

重视重症急性胰腺炎后期并发症的防治

随着对重症急性胰腺炎 (SAP)发病及其进展机制认识的深化 ,针对性的临床治疗策略亦随之发生了相应的转变 ,例如在发病早期即全身性炎性反应期注意多脏器功能的保护 ,包括呼吸机正压反比通气 (PPRV )、间歇短时血滤 (ISHF)、持续血液透析(CRRT)等 ,使SAP早期并发多脏器功能衰竭(MOF)的防治水平提高 ,死亡率下降。相对而言 ,SAP的后期并发症诸如感染、出血、消化道漏 (瘘 )的致死率则无明显降低。统计表明 ,SAP后期继发腹腔和腹膜后感染的发生率为 15 %～ 4 0 % ,并发出血者为 10 % ,并发消化道瘘亦很常见 ,其中并发腹腔内大出血的…     

当前提高腹部外伤和腹腔感染疗效的进展

腹部外伤和腹腔感染是腹部外科常见的急症。随着外科手术和重症监护技术的不断进步,其死亡率在逐年下降。但是,严重腹部外伤,尤其是严重多发性损伤,以及重症腹腔感染的死亡率仍然居高不下。进一步提高临床诊治水平,降低严重腹部外伤和重症腹腔感染的死亡率,是我们需要不断努力的方向。一、腹部外伤和腹腔感染诊治的标准化问题1.腹部外伤和腹腔感染的评分系统:用评分方法评估腹部外伤和腹腔感染的严重程度,不仅有助于准确、客观地判断病情和预测预后,有助于治疗方式的选择,还有利于不同资料的横向交流和对比。临床上应用最多的是APACHEⅡ…     

中国腹腔感染诊治指南（2019版）

腹腔感染(intra-abdominal infection,IAI)是腹部外科常见病,可继发于消化道的穿孔、坏死与坏疽,如胃十二指肠消化性溃疡穿孔、W肠道肿瘤因梗阻和放化疗合并的穿孔;化脓性阑尾炎与阑尾穿孔、肠梗阻与肠坏死也会引起IAL 1AI也是腹部外科手术的常见并发症1,如胃肠道肿瘤手术后并发的肠外瘘。作为住院病人中第二高发的感染性疾病[2],IAI病人的病死率可达20%,严重影响公共卫生安全。     

Management of severe sepsis of abdominal origin.

Severe sepsis is a life-threatening condition that may occur as a sequela of intra-abdominal infections (IAIs) of all types. Diagnosis of IAIs is predicated upon the combination of physical examination and imaging techniques. Diffuse peritonitis usually requires urgent surgical intervention. In the absence of diffuse peritonitis, abdominal computed tomography remains the most useful test for the diagnosis of IAIs, and is essential to both guide therapeutic interventions and evaluate suspected treatment failure in the critically ill patient. Parameters most consistently associated with poor outcomes in patients with IAIs include increased illness severity, failed source control, inadequate empiric antimicrobial therapy, and healthcare-acquired, as opposed to community-acquired infection. Whereas community-acquired IAI is characterized predominantly by enteric gram-negative bacilli and anaerobes that are susceptible to narrow-spectrum agents, healthcare-acquired IAI (e.g., anastomotic dehiscence, postoperative organ-space surgical site infection) frequently involves at least one multi-drug resistant pathogen, necessitating broad-spectrum therapy guided by both culture results and local antibiograms. The cornerstone of effective treatment for abdominal sepsis is early and adequate source control, which is supplemented by antibiotic therapy, restoration of a functional gastrointestinal tract (if possible), and support of organ dysfunction. Furthermore, mitigation of deranged immune and coagulation responses via therapy with recombinant human activated protein C may improve survival significantly in severe cases complicated by septic shock and multiple organ dysfunction syndrome.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.     

急性胆源性胰腺炎41例外科治疗临床体会

目的探讨急性胆源性胰腺炎(acute biliary pancreatitis ABP)外科治疗的时机与方法。方法 41例ABP患者均采用外科手术治疗。结果本组41例患者均获治愈。结论对ABP的治疗应根据其病情与类型而定,对伴有胆总管下端梗阻或胆道感染的重症ABP应急诊或早期(72 h)手术,对不伴胆道完全梗阻、胆管炎的重症ABP患者,早期采取保守治疗,手术尽量延至病情稳定后。对急性水肿性ABP可经保守治疗,病情稳定后2～4周行胆道手术,但保守治疗期间若出现胆管炎、胆囊坏疽或穿孔应急诊手术。     

重症急性胰腺炎术后并发十二指肠瘘

目的　探讨重症急性胰腺炎 (SAP)术后并发十二指肠瘘的原因及防治方法。方法　对 2 2例SAP术后并发十二指肠瘘患者的临床资料进行回顾性分析。结果　 184例手术治疗的SAP发生十二指肠瘘 2 2例 ,15例出现在术后 2周。 18例非手术治疗自行愈合 ,4例再次手术治愈。结论　SAP早期手术、胰周感染、手术时引流管放置不当或时间过长与十二肠瘘发生有关。保持瘘口周围引流通畅 ,积极控制胰周感染 ,抑制胃肠道分泌 ,加强营养支持 ,多数十二指肠瘘可自行愈合     

Epidemiological study of community- and hospital-acquired intraabdominal infections

Purpose: To investigate and analyze the clinical and etiological characteristics of community-acquired intraabdominal infections (CIAIs) and hospital-acquired or nosocomial intraabdominal infections (NIAIs) in a comprehensive hospital, to understand the characteristics, pathogen composition, and drug resistance of CIAIs as well as NIAIs, and to provide a reference for clinical treatment. Methods: We collected the clinical data of patients with intraabdominal infections admitted to our hospital from June 2013 to June 2014. In vitro drug sensitivity tests were conducted to separate pathogens, and the data were analyzed using the WHONET 5.4 software and SPSS 13.0 software. Results: A total of 221 patients were enrolled in the study, including 144 with CIAIs (55 mild-moderate and 89 severe) and 77 with NIAIs. We isolated 322 pathogenic strains, including 234 strains of gramnegative bacteria, 82 strains of gram-positive bacteria, and 6 strains of fungi. Based on clinical features, NIAIs and severe CIAIs presented significantly higher values in age, length of hospital stay, mortality, and the incidence of severe intra-abdominal infection than mild-moderate CIAIs (p < 0.05). There was no significant difference in the prognosis between NIAIs and severe CIAIs. Primary diseases leading to CIAIs and NIAIs mostly were hepatobiliary diseases and gastrointestinal diseases respectively. Bacteria isolated from various types of IAIs mainly were Enterobacteriaceae; mild-moderate CIAIs mostly were mono-infection of gram-negative bacteria; NIAIs mostly were mixed infections of gram-negative and gram-positive bacteria; and severe CIAIs were from either type of infection. The rate of Extended Spectrum b-Lactamase-producing Escherichia coli and Klebsiella pneumoniae was much higher in NIAIs than in CIAIs (p < 0.05). The antimicrobial drug sensitivity of gram-negative bacteria isolated from NIAIs was significantly lower than that of CIAIs. Conclusion: CIAIs and NIAIs have their own unique clinical features and epidemiological features of pathogens which should be considered during the initial empiric therapy for the rational use of antimicrobial drugs. Regional IAIs pathogenic bacteria have their own features in drug resistance, slightly different from some recommendations of 2010 Infectious Diseases Society of America guidelines.     

Surgical management of severe secondary peritonitis

BACKGROUND: Despite advances in diagnosis, surgery, antimicrobial therapy and intensive care support, the mortality rate associated with severe secondary peritonitis remains unacceptably high. This article presents various surgical treatment strategies for severe secondary peritonitis, emphasizing the role of open management of the abdomen and planned relaparotomies. METHODS: Material was identified from previous review articles, references cited in original papers and a Medline search of the literature. RESULTS AND CONCLUSION: Surgical treatment of severe secondary peritonitis is highly demanding and very complex. The combination of improved surgical techniques, antimicrobial therapy and intensive care support has improved the outcome of such peritonitis following perforation or anastomotic disruption of the digestive tract, or infected necrotizing pancreatitis. However, aggressive surgical treatment strategies, such as open management of the abdomen and planned relaparotomies, may have reached their limits.     

First case report of spontaneous perinatal gastric perforation in premature neonate with potter sequence and syndrome

Introduction and importanceThe Potter sequence is defined as a series of congenital defects related to severe oligohydramnios, associated with polycystic kidney disease, bilateral renal agenesis, pulmonary hypoplasia, obstructive uropathy and premature rupture of membrane, which compromises the life of the neonate sometime after birth. Within the evidence published so far, which is very little, no perforation of the gastrointestinal tract has been reported as a complication of this condition.Case presentationMale neonate born preterm with prenatal diagnosis of pulmonary hypoplasia, polycystic renal dysplasia and severe oligohydramnios (Potter sequence), presented acute respiratory distress syndrome 10 min after birth, requiring mechanical ventilation and admission to the intensive care unit. During her stay in intensive care, he developed abdominal distension and presence of biliary content in the nasogastric tube. An abdominal X-ray was performed and showed signs of pneumoperitoneum, evidencing gastric perforation on exploratory laparotomy.Clinical discussionGastric perforation in neonates is a condition that causes high health costs, morbidity, high risk of mortality and disability, regardless of the cause. The management of gastric perforation in Potter syndrome, as well as any other complication, represents a challenge due to the prognosis of these patients. Renal failure and acute respiratory distress syndrome are disorders that compromise the function of various structures and organs such as the heart and brain.ConclusionGastric perforation is a possible complication of the Potter sequence or syndrome. In addition, there is no literature describing the benefits or disadvantages of specific surgical techniques in the resolution of perforation.     

胆道结石并胆道感染的临床分型及手术时机

目的：探讨胆道结石并胆道感染的临床分型及手术时机。方法从2011年5月至2013年5月收治的胆道结石并胆道感染患者中随机选择100例进行研究,经分型,5例为确诊型急性重症胆道感染（ACST）（确诊型ACST组）,85例为轻症胆道感染（轻症胆道感染组）,10例为先兆型急性重型胆道感染（先兆型ACST组）。采用SPSS 15．0统计软件进行分析,组间比较采用单因素方差分析,数据经检验方差不齐,选择多个独立样本比较的Kruskal-Wallis H检验,以P＜0．05为差异有统计学意义。结果经治疗,仅有1例患者死亡,为确诊型胆囊炎穿孔患者。比较各组的术后残石率可得,确诊型ACST组（25．0％）和先兆型ACST组（20．0％）的术后残石率显著高于轻症胆道感染组（6．0％）,差异有统计学意义（χ2＝5．16, P＜0．05）;但先兆型ACST组和确诊型ACST组之间进行比较,无显著差异（P＞0．05）。三组患者之中,确诊型ACST组患者术后的住院天数、术后住ICU天数最长,显著长于其他两组（t＝11．12, t＝3．85, P＜0．05）。术后随访3～6个月,患者进行影像学检查,所有患者均未出现复发。结论临床治疗胆道结石合并胆道感染患者的时候,若患者无禁忌证,则需要对先兆型急性重型胆道感染患者进行诊断和治疗,轻症者予以彻底手术治疗,先兆型急性重型者按照实际情况给予及时的手术治疗。     

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对于急性胆源性胰腺炎,内镜治疗具有重要的地位。行内镜逆行胰胆管造影术(ERCP)及内镜超声检查可明确诊断,指导进一步治疗。早期行经内镜鼻胆管引流(ENBD)、经内镜乳头括约肌切开术(EST)、胰管支架置入可及时解除梗阻,降低胆管、胰管压力,引流胆汁及胰液,缓解胰腺炎,降低并发症的发生率。内镜治疗可能导致出血、穿孔、胰腺炎加重、腹膜后感染等严重并发症,因此应严格掌握适应证,对于伴有急性胆管炎的急性胆源性胰腺炎,早期内镜治疗是绝对适应证;对于不伴有急性胆管炎的重症急性胰腺炎,应严密观察,除留置空肠营养管之外的早期内镜治疗并没有明显益处。     

Bacillus anthracis as an agent of bioterrorism: a review emphasizing surgical treatment

OBJECTIVE: To familiarize surgeons with the specific complications of cutaneous, gastrointestinal, inhalation, and systemic infection with Bacillus Anthracis, which may require surgical treatment. SUMMARY BACKGROUND DATA: The recent cases of intentional exposure to Bacillus Anthracis in the United States make familiarity with the basic microbiology, clinical manifestations, diagnosis, treatment, and control of this disease essential if mortality and morbidity is to be minimized, particularly following mass exposure. Although the treatment of Bacillus Anthracis infection is primarily medical, there are specific surgical complications with which the surgeon should be familiar. METHODS: A review of the literature was undertaken, utilizing electronic databases on infection with Bacillus Anthracis, as well as consultation with experts in this field. Emphasis was placed on the diagnosis and treatment of complications of infection that might require surgical intervention. RESULTS: Cutaneous anthrax infection results in eschar formation and massive soft tissue edema. When involving the extremities, increased compartment pressure requiring fasciotomy may result. Primary infection of the gastrointestinal tract may result in oropharyngeal edema and respiratory compromise requiring a surgical airway. Direct involvement of the lower gastrointestinal tract can result in intestinal ulceration, necrosis, bleeding, and perforation, which would require surgical exploration and resection of affected segments. Systemic sepsis, most often associated with inhalation anthrax, can cause massive ascites, electrolyte derangements, and profound shock requiring aggressive fluid resuscitation and careful hemodynamic monitoring and respiratory support. Systemic anthrax infection can also lead to gastrointestinal involvement by hematogenous dissemination, resulting in complications and requiring surgical management similar to direct gastrointestinal infection. CONCLUSIONS: Cutaneous, gastrointestinal, inhalation and systemic infection with Bacillus Anthracis can result in complications which would require familiarity with the pathogenesis and manifestations of this disease in order to recognize and treat promptly and successfully by surgical intervention.