结、直肠损伤26例诊治分析

目的探讨结、直肠损伤的诊治经验。方法对26例结、直肠损伤患者的病例资料进行回顾性分析。结果26例均予以手术治疗,行一期单纯修补、"V"型切除或切除吻合术者22例(占87%,22/26),无肠瘘发生。二期肠造瘘或肠外置3例(占12%,3/26),两类手术酌情放或不放腹腔引流。死亡1例,死亡主要原因为失血性休克、严重多发伤。结论结、直肠损伤大部分一期手术是安全的;二期手术仅适用于结、直肠损伤严重、腹腔污染重、全身情况差和腹膜返折以下的直肠损伤。     

结直肠损伤104例手术治疗分析

目的探讨结直肠损伤的手术治疗方法。方法对104例结直肠损伤患者的临床资料进行回顾性分析。结果104例结直肠损伤患者均经手术治疗,一期单纯修补或切除吻合91例（80％）;二期肠造口或外置术13例（20％）,死亡2例,均为多脏器功能衰竭及脑挫裂伤。结论结直肠损伤一期手术是首选的,二期手术适用于结肠重度损伤、腹腔重度污染、全身病情严重及腹膜返折以下的直肠损伤者。     

医源性结直肠损伤的诊治分析

探讨医源性结直肠损伤科学、合理的处理方案。回顾性分析2004年1月—2012年12月收治的19例医源性结直肠损伤的病例资料。19例患者均行手术治疗,一期手术切除或修补17例(89.47%),其中2例(11.76%)发生切口感染,2例(11.76%)发生肠瘘,均为Ⅱ级损伤引起;二期乙状结肠造瘘及造瘘还纳术2例(10.53%)。所有患者均痊愈出院。重视医源性结直肠损伤的处理,严格掌握其适应证,对早期发现、污染轻的医源性结直肠损伤可行I期手术;发现较晚或污染较重的则考虑行结肠造瘘及II期造瘘还纳术。     

结直肠损伤的手术治疗：附125例报告

目的:探讨结直肠损伤的手术治疗和围手术期处理。 方法:回顾性分析19年间收治的125例结直肠损伤患者的临床资料。结果:结肠和腹膜内直肠破裂69例中，初期缝合或切除吻合56例（81.16 %），行造口术11例，“损伤控制外科”术式2例。腹膜外直肠破裂18例中，14例行乙状结肠近端造口并骶前引流，4例一期修补未造口;其余38例非全层损伤患者，均做简单修补。全组死亡8例（6.40 %），6例术中、1例术后死于失血性休克，1例术后5 d死于胸腔感染。术后并发症包括局部感染6例、粘连性肠梗阻1例，均治愈。 结论:多数结肠和腹膜内直肠损伤可一期手术，应配合围手术期正确使用抗生素尤其甲硝唑。腹膜外直肠伤应分期手术，为阻断远端污染，应行乙状结肠近端造口而不选择襻式造口。     

结直肠损伤的特点和处理

目的 探讨结直肠损伤的特点和结肠损伤Ⅰ期修复的适应证以及直肠损伤和医源性结直肠损伤处理的特殊性。方法 总结分析1989年1月～2000年12月收治的结直肠损伤41例临床资料。结果 38例行急诊手术,术中出现并发症11例,占26.8％,2例术中损伤未发现以致形成直肠阴道瘘和腹膜后脓肿,1例结肠镜下息肉切除造成小穿孔在镜下用钛夹修补治愈。本组治愈39例,死亡2例,均死于严重的并发症。结论 了解结直肠损伤的特点,提高结直肠损伤的认识,掌握好结肠Ⅰ期修复手术的适应证、直肠损伤及医源性损伤处理的特殊性是减少结直肠损伤并发症,提高外科治疗效果的关键。     

全结肠灌洗在结直肠损伤一期修复术中的应用

结直肠损伤的处理至今仍比较棘手。是一期修复还是先行肠造瘘、外置、再二期修复,仍众说纷云。开展一期手术采用的方法也各异。笔者主要阐述全结肠灌洗在结直肠损伤一期修复术中的应用和体会。 临床资料 本组男9例,女3例,年龄23～69岁,平均40.4岁。结直肠损伤原因:穿透伤6例,钝性伤3例,医源性损伤2例(腹部手术误伤1例,乙状结肠镜检查致肠穿孔1例),结肠内鱼骨刺致肠破裂1例。损伤部位:横结肠3例,降结肠5例,乙状结肠3例,直肠(腹膜返折线以上)1例。损伤创口大小:最小0.5cm×0.8cm,最大为肠管周径之2/3。腹内粪便污染情况:轻者9例,较重者3例。从损伤至手术时间:1例达11h,其余均在5h之内。合并伤:脾破裂1例,结肠旁、后腹膜外血肿2例,小肠损伤2例,骨盆骨折1例。本组病人均作肠管破裂口清创后丝线全层间断一层缝合,其中1例作部分横结肠切除、吻合,彻底的清洗腹腔后即行全结肠灌洗。具体方法如下:切除阑尾,于阑尾残端插入气囊导尿管人盲肠(也可经回肠末端戳孔插入导尿管通过回盲瓣入盲肠),丝线缚扎固定后向气囊     

创伤性结肠损伤的特点及诊治体会

目的探讨创伤性结肠损伤的特点和救治体会。方法回顾分析我院1995年1月~2003年12月结肠外伤48例的临床资料。结果结肠损伤中刀刺伤占71%,腹部钝性伤占25%,火器伤4%。合并多发伤或多脏器伤35例,一期修补或切除吻合46例,结肠局部切除 近端造口2例,手术死亡1例,十二指肠损伤漏诊1例,术后死亡3例,切口感染及脂肪液化7例,严重腹腔感染3例。结论结肠损伤以开放性穿透性损伤为多见,常伴有其他脏器伤,且结肠损伤具有一定的隐匿性,易误诊、漏诊,引起严重感染,影响愈合。治疗上强调尽早手术,术中探查应全面仔细,谨防遗漏,一期修补或切除吻合对绝大多数结肠损伤是安全可靠的。     

结直肠癌性梗阻的外科治疗: 附108例报告

目的　探讨结直肠癌性梗阻的治疗原则。方法　回顾性分析 10年间我院收治的 10 8例结肠梗阻患者的临床资料和治疗方法 :右半结肠癌 3 0例中 2 8例行一期切除吻合 ,1例行姑息性手术 ,1例未手术。左半结肠和直肠癌 78例中行一期切除 ( 5 6例 ) (Ⅰ期或Ⅱ期吻合分别 3 2 ,2 4例 )或二期切除11例 ,6例行姑息性手术 ,5例未手术。结果　伴结肠梗阻的结直肠癌多见于Duke′sC和D期 ( 5 9例 )的中、低分化腺癌 ( 65例 )。手术并发症发生率为 2 7.3 % ( 2 6例 46例次 ) ,以感染性并发症为主 ( 3 5 /46) ,吻合口漏 4例。围手术期死亡率为 7.8%。手术治疗患者的 5年生存率为 2 8.4% ,未手术者 5年生存率为 0 % (P <0 .0 1)。肿瘤I期 ,II期切除 5年生存率分别为 3 3 .3 % ,9.0 % (P <0 .0 5 )。肿瘤一期切除后行一期 ,二期吻合手术的 5年生存率无显著性差异 (P >0 .0 5 )。结论　对伴结肠梗阻的结直肠癌 ,手术应及时并遵循个体化原则 ,创造条件 ,要力争一期手术切除肿瘤 ,解除梗阻 ,但切除后行I期或II期吻合对预后无影响。     

中国结直肠外科医师执业现状及观念调查报告

目的调查中国结直肠外科医师的执业现状及观念。方法自2014年1月至2015年1月,对北京大学人民医院、北京大学肿瘤医院、同济大学附属东方医院、复旦大学附属中山医院、浙江大学医学院附属第二医院、中山大学附属第六医院、山东省立医院、兰州大学第二医院、中南大学湘雅医院、中国医学科学院肿瘤医院等105家医院的结直肠外科医师发放统一的调查表。结果回收有效调查表共660份。(1)一般状况:被调查者95.3%为男性,年龄30岁者占91.2%,最高学历为博士研究生者占26.5%,三级医院执业者占76.7%,结直肠外科执业年限5年者占72.7%。(2)执业现状:调查医师所在科室总床位数的中位数为52张,其中收治结直肠疾病病人的床位数为30张;科室年中位手术量900例,结直肠疾病手术200例;科室手术医师数量的中位数为8名,结直肠专业手术医师6名。调查医师每年中位手术量250例,结直肠疾病手术80例;调查医师年结肠疾病手术量的中位数为50例,其中开放手术62.5%、腹腔镜手术31.3%;调查医师年直肠疾病手术量的中位数为40例,其中开放手术50.0%、腹腔镜手术47.5%。(3)执业观念:有76.6%的结直肠外科医师认为有必要掌握内镜技术,然而只有26.3%的结直肠外科医师掌握软式结肠镜检查技术,11.4%掌握内镜手术(内镜下黏膜切除术或内镜下黏膜剥离术)技术。对于早期结直肠癌、局部进展期结直肠癌、可切除的结直肠癌肝转移、不可切除的结直肠癌肝转移病人,分别有19.7%、33.8%、46.2%、59.1%的结直肠外科医师认为治疗决策权属于多学科综合治疗协作组(multidiciplinary team,MDT)。结论我国结直肠外科医师专业化程度尚需提高;新的诊疗手段及观念如微创技术、内镜技术及MDT观念仍须进一步推广和加强。     

腹腔镜联合结肠镜手术治疗结直肠小占位(≤3cm)病变

目的探讨腹腔镜联合结肠镜治疗结直肠小占位(≤3 cm)病变的临床效果。方法 2010年1月~2015年1月我院采用腹腔镜联合结肠镜手术治疗小占位结直肠肿瘤41例,结肠镜进行全结直肠内探查,在结肠镜下注射亚甲蓝进行染色,腹腔镜下进行局部钛夹定位,退出结肠镜,术中根据快速冰冻病理结果选择在腹腔镜下肠管切除、结直肠根治术等相应手术。结果 41例均顺利完成腹腔镜联合结肠镜手术,无中转开腹。9例术前诊断为癌前病变,术中及术后病理诊断为结肠上皮内瘤变6例,Tis期腺癌3例。32例术前诊断为0~Ⅰ期结直肠癌者,术中及术后诊断Ⅰ期29例,其中T_1N_0M_0期腺癌23例,T_2N_0M_0期腺癌6例;Ⅲ期3例,均为T_2N_1M_0期腺癌。多发病灶2例。结肠上皮内瘤变及Tis期结直肠肠癌行病变肠管切除,T_1~T_2期结直肠癌均行结直肠癌根治术。2例结肠上皮瘤变分别在术后9、12个月随访无复发。其余39例随访24~49个月,中位时间38.6月,35例结直肠癌中,1例T_2N_1M_0即Ⅲ期腺癌术后34个月结肠镜复查局部复发,所有患者均无转移。结论腹腔镜联合结肠镜治疗≤3 cm良性及Tis~T_2期恶性结直肠肿瘤,可发挥双镜优势,尤其适用于单镜难以定位或完全切除的病变,可提高定位精确性及手术安全性。     

COLORECTAL INJURY: WHERE DO WE STAND WITH REPAIR?

Background: The chief danger of colonic injury is sepsis resulting from faecal spill. Primary repair is now well established in the USA, particularly for penetrating injuries, in up to 81% of patients. However, in Australia, highly destructive blunt trauma forms a larger proportion of injuries, and the purpose of this study was to determine if there are any contrasts in the management of these patients. Method: A retrospective survey was undertaken over the past 20 years of all of the patients with full-thickness colorectal injuries presenting at the three major hospitals which receive multi-trauma patients in Brisbane. Results: Of 112 patients 114 sustained full-thickness colorectal injuries. Forty patients had penetrating injuries, 41 had blunt injuries and 33 had iatrogenic injuries. Primary repair or resection and anastomosis was performed in 39% of patients with colonic injuries and the leak rate was 8%. Exteriorized repairs had a 67% leak rate. A colostomy was used in 58% of patients. The mortality for penetrating injuries was zero. The mortality for blunt colonic injuries was 17% and for iatrogenic injuries was 7% but for blunt rectal injuries was 50%. The overall mortality was 10%. Colostomy closure had a 20% morbidity but no mortality. Conclusions: In the absence of shock, associated injuries, or gross faecal soiling primary repair or resection with anastomosis may be considered. For blunt injury, colostomy is still usually indicated, often with resection. For iatrogenic injury, when seen early, primary repair can be performed. We do not recommend exteriorized repair. Extraperitoneal rectal injuries require proximal colostomy and distal washout, with drainage where appropriate. Blunt devitalizing injury is relatively more common in Australia than in the USA and therefore there is less indication here for primary repair. Colostomy remains an important consideration in operative management.     

严重骨盆骨折合并毗邻脏器损伤的救治

目的探讨严重骨盆骨折合并毗邻脏器损伤的急诊处理方法。方法对14年中收治的79例严重骨盆骨折合并毗邻脏器损伤患者的资料做回顾性分析。结果骨盆大出血行髂内动脉结扎术33例、栓塞术8例;膀胱造口和后期尿道重建35例、尿道会师术7例;腹膜外直肠伤做结肠造口并骶前引流13例、一期修补4例;腹膜内结直肠伤一期手术19例、结肠造口3例。死亡率9％(7／79),主要死于休克和合并伤。共发生并发症7例：直肠膀胱瘘4例、右髂总动脉血栓形成1例、胸伤后急性呼吸窘迫综合征(ARDS)1例、截瘫1例,除截瘫均治愈。结论迅速准确的诊断治疗是成功的关键。髂内动脉断血术配合骨盆外固定支架的使用、膀胱造口和乙状结肠近端造口,是危重患者急诊治疗时常采用的有效方法。     

Primary repair of the colon: when is it a safe alternative?

Management of civilian colon injuries has clearly departed from the military directive advocating mandatory colostomy. The treatment of 228 colon injuries at the Denver General Hospital was reviewed to elucidate risk factors for colon-related complications and quantify the morbidity of available surgical treatment options. In our population, 68% of patients sustained gunshot wounds with a high percentage of severe colon injuries and associated abdominal organ damage. Primary repair was accomplished in 49% with 17% septic morbidity and 1% septic mortality rates. Colostomy was required in 36% with a cumulative septic morbidity of 48% and 2% septic mortality. The most common complications were abdominal abscess (12%), wound infection (7%), and fecal fistula (4%). Analysis of risk factors for colon-related morbidity showed that the Abdominal Trauma Index (ATI), colon injury severity, preoperative shock, and peritoneal contamination were most important. Synthesis of the treatment outcome and risk factor data yields a proposed management scheme for colon injuries that is based on the patient's hemodynamic status, colon injury severity, and ATI scores. Primary repair by either debridement and simple closure or resection with primary anastomosis is advocated for colon injuries in patients who are hemodynamically stable with an ATI score less than 25.     

Management of severe pelvic fracture associated with injuries of adjacent viscera

everepelvicfractureassociatedwithinjuriesofadjacentviscerahasahighmortality .Thefirst”goldenhour”aftertraumashouldbegrasped ,sincethemanagementinthishourcandeterminegreatlywhetherthecritically injuredvictimcouldsurvive .Inthispaper ,theexperienceintheemergencymanagementofsuch patientsisreviewedinordertoimprovethetherapeuticoutcome .METHODSSeventyninepatientswithseverepelvicfractureassociatedwithinjuriesofadjacentvisceratreatedinourDepartmentfromJanuary 1990toDecember 2 0 0 3werereviewedr…     

Penetrierende Kriegsverletzungen der Colorectalregion

INTRODUCTION: Colorectal war injuries can be treated with primary repair or by colostomy. We report our experience with both treatments. METHODS: During the Croatian war from July 1991 to March 1994, 155 patients with colorectal injuries were treated at the Surgical Clinic, University Hospital Split. This group represents 7% of all patients (n = 2220) with gunshot and shrapnel wounds treated in this period at our clinic. The median patient age was 24.7 years (range 14-70 years). The majority of the patients (96.7%) were male. Concomitant injuries of the colon (83.7%) and rectum (69%) were found more frequently than isolated ones. 50 patients were operated on as emergencies in our clinic, while 105 were operated on in field hospitals. In 28 patients primary repair of the colorectal injury was performed (without derivation), whereas 127 patients were treated by colostomy. In those patients 106 wounds were closed electively during a second operation. The average in hospital stay was 32.3 days (range 10-65 days). RESULTS: Using PATI and FCIS scores for colorectal injuries, 80% of our patients had life-threatening injuries. In the cases with primary repair the percentage of complications was high (92%). In the cases with the diverting colostomy it was only 34%. The high complication rate in the cases with primary repair was directly related to the presence of the anastomotic leaks and subsequent peritonitis. Explorative laparotomy was an effective diagnostic tool especially in the field hospitals. The overall mortality rate was 3.2%. CONCLUSION: In our operative strategy we preferred derivation operations in order to decrease major complications due to anastomotic leakage or peritonitis.     

Blunt colonic injury--a multicenter review.

During the past decade there has been a shift in the management of injuries of the colon to primary repair without a protective diverting colostomy. Unfortunately, reports concerning this practice contain relatively few patients with blunt trauma and it is unclear whether the principles established for penetrating injury should be applied in the setting of blunt colon injury. A retrospective review of 54,361 major blunt trauma patients admitted to nine regional trauma centers from January 1, 1986, through December 31, 1990, was conducted. Statistical analysis of the data collected regarding 286 (0.5%) of these patients who suffered colonic injury revealed: (1) injury to the colon is found in more than 10% of patients undergoing laparotomy following blunt trauma; (2) available diagnostic modalities are unreliable in detecting isolated colonic pathology; (3) primary repair of full-thickness injuries or resection and anastomosis may be safely performed without diversion; (4) gross fecal contamination is the strongest contraindication to primary repair. Further, delay of surgery, shock, and the timing of antibiotic administration were not associated with significantly increased morbidity.     

Management of penetrating colon injuries. A prospective randomized trial.

Fifty-six patients with penetrating colon injuries were entered into a randomized prospective study. Management of the colon injury was not dependent on the number of associated injuries, amount of fecal contamination, shock, or blood requirements. Twenty-eight patients were treated with primary repair or resection and anastomosis and 28 patients were treated by diversion (24 colostomy, 3 ileostomy, 1 jejunostomy). The average Penetrating Abdominal Trauma Index score was 23.9 for the diversion group and 26 for the primary repair group. There were five (17.9%) septic-related complications in the diversion group. This included four intra-abdominal abscesses and one subcutaneous wound infection. There were six (21.4%) septic-related complications in the primary repair group. This included one wound infection, two positive blood cultures, and three intra-abdominal abscesses. There were no episodes of suture line failure in the primary repair/anastomosis group. The authors conclude that, independent of associated risk factors, primary repair or resection and anastomosis should be considered for treatment of all patients in the civilian population with penetrating colon wounds.     

A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy

BACKGROUND: Current management of extraperitoneal rectal injuries involves a laparotomy and diversion of the fecal stream. In this study, we review our experience with laparoscopy and diverting loop sigmoid colostomy without laparotomy in the management of these injuries. METHODS: All patients admitted to the trauma unit at Groote Schuur Hospital between January 1995 and May 2000 with a rectal injury were evaluated. The presence of a rectal injury was confirmed by rectal examination and proctosigmoidoscopy. Intraperitoneal injuries were excluded by laparoscopy. Only patients who did not have intraperitoneal injuries were included in the study. The patients were then managed with a diverting loop sigmoid colostomy created through an abdominal wall trephine without laparotomy. RESULTS: Ten patients were included in the study. In eight patients, laparoscopy excluded intraperitoneal injuries. All 10 patients had a diverting loop sigmoid colostomy fashioned. There were no complications related to either the rectal injury or colostomy. Nine stomas have since been closed. CONCLUSION: In patients with isolated extraperitoneal rectal injuries, laparoscopic exclusion of intraperitoneal injuries, followed by a diverting loop sigmoid colostomy, is a feasible option.     

Palliation for rectal cancer. Resection? Anastomosis?

There is no agreement regarding the proper management of patients with advanced carcinoma of the rectum. We performed a study to clarify whether palliative resection with or without primary anastomosis is worthwhile and safe. Among 679 patients managed for cancer of the rectum, 125 were considered incurable and underwent palliative procedures. High and low anterior resections were performed in nine and 57 cases, respectively, abdominoperineal resection in 26, Hartmann's procedure in three, simple diverting colostomy in 17, and transanal excision in 13. The overall postoperative mortality rate was 0.8%. Postoperative morbidity was 18% in abdominal operations and none in local excisions. Among patients treated by abdominal resections, only one required subsequent reoperation for colonic obstruction secondary to local recurrence. The median survival was 6.4 months for patients treated by diverting colostomy, 14.8 months for abdominally resected cases, and 14.7 months for transanal excisions. We conclude that palliative resection, often with primary anastomosis or local transanal excision, can be done safely in patients with incurable rectal cancer. We believe this approach improves the quality of the remaining life for these patients.