胃肠术后肠瘘31例分析

目的:对手术后肠瘘原因进行分析,为其诊治提供参考。方法:对我院2000/2008年收治的手术后肠瘘31例临床资料进行分析。结果:术中误伤、胃肠管吻合技术欠佳、保留无生机肠管、阑尾处理不当、术前贫血、糖尿病和低蛋白血症等,是导致术后肠瘘的危险因素。而胃肠术后肠瘘的预后的影响因素主要是高位瘘、高流量瘘、有无合并腹腔脓肿、有无合并其他系统感染和有无M ODS。结论:胃肠术后并发肠瘘预后严重,注意危险因素,预防肠瘘发生,提高肠瘘治愈率。     

胃肠手术后肠瘘治疗时机及方式的选择

目的对胃肠手术后发生肠瘘患者的治疗、转归进行总结分析,探讨治疗时机及治疗方式的合理性,寻求治疗肠瘘的最佳途径。方法回顾性总结首都医科大学附属北京同仁医院普外科2006年7月至2013年6月胃肠道手术共967例,40例于术后发生肠瘘,对该40例患者的治疗方案、治疗时机及治疗方式的选择、预后等方面进行总结分析。结果40例中21例为小肠瘘,均行早期手术干预,15例行小肠部分切除、肠吻合术,14例治愈。19例为结直肠瘘,15例行非手术治疗,11例自愈,另外8例半年后行确定性手术,6例治愈。结论对于胃肠手术后的小肠瘘,早期肠切除肠吻合加充分腹腔冲洗引流术安全有效,并能有效缩短病程。对于结直肠瘘,首先行非手术治疗,强调充分引流的重要性,自愈率较高,当合并全身炎症反应加重时,早期行腹腔冲洗引流、肠转流等控制性手术,待全身状况及腹部炎症缓解后行确定性手术。     

阑尾切除术后粪瘘19例分析

目的：探讨阑尾切除术后发生粪瘘的原因与预防对策。方法：回顾性分析我院1996—01／2006—12行阑尾切除术后发生粪瘘19例的临床资料。结果：19例均予局部通畅引流、应用抗菌药物、支持治疗，其中17例于4～8周痊愈，另外2例保守治疗5个月未愈，均手术治疗后痊愈出院。结论：术前、术中误诊、术中处理欠妥是导致肠瘘的重要原因。针对阑尾切除术后并发肠瘘原因，采取不同的预防与治疗措施。     

闭合性十二指肠损伤21例

目的总结闭合性十二指肠损伤的诊断和治疗体会。方法对我院1997年至2006年收治21例(男16例,女5例)闭合性十二指肠损伤的诊断、治疗进行回顾性总结分析。结果21例中17例治愈,3例术后出现肠瘘胰瘘并发多器官功能衰竭(MOF)死亡;1例术后出现肠瘘胰瘘,转上级医院经多次手术后痊愈。结论早诊断,早手术,十二指肠肠腔有效减压、腹腔引流和术后肠内营养,是预防十二指肠瘘的关键,可有效提高治愈率。     

PCT联合腹腔引流液淀粉酶检测在肠瘘早期诊断和预后评估中的临床应用

目的研究血清降钙素原(PCT)和腹腔引流液淀粉酶检测在早期诊断肠瘘、预后评估中的可行性。方法选取该院胃肠外科2014年1月至2016年12月收治的180例胃肠道手术患者为研究对象,通过术后检测分析血清PCT和腹腔引流液淀粉酶水平与术后肠瘘的关系。结果 180例患者中确诊为肠瘘者17例(9.4%),确诊肠瘘的时间为(6.35±3.04)d,术后3、5、7d血清PCT和腹腔引流液淀粉酶水平明显高于非肠瘘者,差异有统计学意义(P0.05)。对17例肠瘘患者依据腹腔感染程度分为微瘘组和非微瘘组,其中微瘘组6例,非微瘘组11例,微瘘组术后3、5、7d的PCT和腹腔引流液淀粉酶水平明显低于非微瘘组,差异有统计学意义(P0.05)。结论 PCT联合腹腔引流液淀粉酶检测能早期发现肠瘘,而PCT能预测腹腔感染的程度。     

肠外瘘23例诊治体会

肠外瘘是普外科中危重病症之一 ,创伤、腹腔感染、胃肠手术后愈合不良及Crohn病等是其主要原因。肠外瘘病情复杂、病程长、严重者可致死亡 ,我院自 1 997年 5月至 2 0 0 2年 3月共收治肠外瘘病人2 3例 ,现总结如下。1　临床资料本组 2 3例病人中 ,男 1 6例 ,女 7例 ,年龄 1 9～62岁 ,平均 3 6岁。腹部创伤术后致小肠瘘 4例、小肠吻合口瘘 6例 ,乙状结肠瘘 1例 ,肠梗阻术后并发小肠瘘 3例、小肠吻合口瘘 2例 ,晚期结肠癌并肠梗阻行捷径手术致小肠吻合口瘘 1例 ,回结肠吻合口瘘 1例 ,胃癌术后十二指肠残端瘘 2例 ,胆道手术意外损伤致十二指肠…     

胃十二指肠手术后致十二指肠瘘22例临床分析

目的 研究胃、十二指肠外科手术后致肠瘘的处理经验.方法 收集1985-09～2009-05北京安贞医院外科因胃、十二指肠手术后发生十二指肠瘘的病例22例,对其发生原因、并发症、治疗方法和经验、死亡原因进行回顾性研究分析.结果 十二指肠瘘发生后患者分别有1～5个并发症,主要为腹腔感染和由感染引起的心、肺、肝、肾、肠道功能衰竭及胰腺炎、胰瘘和结肠瘘.本组患者平均住院69 d,接受23～238 d(平均69 d)营养支持治疗.其中单纯肠外营养(PN)3例,单纯肠内营养(EN)3例,16例行PN+EN联合支持.22例中治愈16例,瘘口自然愈合14例,2例后期经手术愈合.6例死于感染导致的感染性休克、多脏器功能衰竭、消化道出血和急性肝衰竭.结论 胃、十二指肠手术后发生的十二指肠瘘主要发生于十二指肠残端处理或穿孔修补不当,急诊手术后易于发生.控制瘘后腹腔感染和适当的营养支持是主要的治疗手段,严重感染造成的脏器功能衰竭是致死的主要原因.     

十二指肠损伤术后肠瘘4例教训分析

目的：探讨十二指肠损伤术后肠瘘的原因及预防和处理方法。方法：结合文献回顾分析了作者经治的4例十二指肠损伤术后肠瘘的诊治经过。结果：4例病人中1例因术前诊断不清延误手术时机出现肠瘘，2例因术中漏诊出现肠瘘，1例因合并伤较重二次手术出现肠瘘。4例病人除1例因引流管放置不当死于消化道出血、感染性休克外，另3例经充分引流、空肠造瘘营养、消化液回输、生长抑素使用及分期手术后治愈。结论：及时手术，减少术中漏诊，合理选择手术方式是预防十二指肠损伤术后肠瘘的关键。肠瘘后充分的引流、空肠造瘘营养、消化液回输、生长抑素使用及选择合理的手术方式和手术时机对肠瘘的治愈非常重要。     

1例腹腔双套管联合临床营养治疗术后肠瘘的护理

正肠瘘是腹部外科手术后严重的并发症之一。一旦发生肠瘘,大量刺激性的消化液、肠液会从瘘口流出,从而导致患者全身病理生理变化,给患者带来非常大的痛苦,严重降低患者的生活质量,情况较为严重的患者甚至会威胁其生命健康[1]。由于肠瘘特殊的病理过程,一旦发生,及时建立通畅有效的引流十分关键[2]。我科收治1例复杂胃肠手术患者,术后发生肠瘘,通过腹腔双套管联合临床营养治疗,患者康复出院,现将护理经验报道如下。     

治疗胃肠瘘44例体会

病员一旦发生胃肠瘘,由于大量消化液和营养物质的耗损,病员常迅速消耗死。它的妥善处理和预防,对于提高治愈率,减少死亡具有重要意义。我院从1958～1985年处理胃肠瘘44例非手术治愈15例,死亡10例,延期手术治愈16例(16/19),死亡3例(3/19),总的病死率为29.5%(13/44)。体会诊断:手术后胃肠瘘的诊断一般并不困难,在腹部手术应用引流的病例,如术后病人感觉引流口烧灼痛,并自引流口流出脓液,继之流出混有胆汁样液,则使人容易想到胃肠瘘的存在,给病人服美蓝、骨炭等,     

Case Report: Aortoenteric Fistula Presenting as Repeated Hematochezia

Background: Aortoenteric fistula (AEF) is a rare but life-threatening condition in which expedient diagnosis is often difficult. It arises from erosion of a segment of aorta, usually an abdominal aortic aneurysm, into an adjacent portion of the gastrointestinal tract or between a vascular graft of the aorta and an adjacent portion of the gastrointestinal tract. It can present as life-threatening upper or lower gastrointestinal bleeding and is a surgical emergency that requires rapid assessment, emergency resuscitation, and definitive treatment. Case Report: To present the case of an 87-year-old man diagnosed with AEF in the emergency department. A review of the literature follows the case report. Conclusions: Aortoenteric fistula is a rare diagnosis that can cause sudden life-threatening gastrointestinal bleeding.     

胆内瘘31例诊治分析

目的：总结胆内瘘的临床特征和诊治经验。方法：回顾分析31例自发性胆内瘘患者的临床资料。结果：术前经B超、CT、消化道造影、磁共振胰胆管造影（magnetic resnancect cholangiopancreatography,MRCP）等检查确诊胆内瘘8例,术前疑诊胆内瘘7例。术中证实胆囊十二指肠瘘23例,胆囊结肠瘘4例,胆囊胆总管瘘4例。除2例胆囊癌晚期外均切除胆囊后,行十二指肠瘘修补术18例,胆总管切开T管外引流＋胃空肠吻合术2例,结肠瘘修补术3例,横结肠癌根治术1例,胆总管修补＋T管引流术4例,另有3例行回肠切开取石。结论：胆内瘘患者常无特殊临床症状,结合B超、CT、消化道造影、MRCP等检查有助于术前诊断胆内瘘,治疗原则仍是切除病变胆囊和瘘管、修补瘘口、解除消化道梗阻。     

Aortoenteric Fistula in A 25-Year-Old Man

Background

Aortoenteric fistula (AEF) is a rare diagnosis that is often considered only in older patients with histories of abdominal aortic aneurysm.

Objectives

To remind emergency physicians that traumatic injury and repair put patients at risk for formation of AEF.

Case Report

We discuss the case of a 25-year-old man who developed an aortoduodenal fistula weeks after a stab wound to the abdomen. AEF can occur anywhere along the gastrointestinal tract and can therefore present as either upper or lower tract bleeding. The expected triad of pain, pulsatile mass, and gastrointestinal bleeding is unfortunately rarely present, making diagnosis difficult. Patients often present with a self-limited herald bleed that precedes the fatal exsanguination by hours to days. Diagnosing the fistula at the time of the herald bleed can be difficult but lifesaving. Imaging studies are often misleading and only delay definitive operative treatment. Even with prompt diagnosis and treatment, mortality is high; without repair, it is 100%.

Conclusion

This case highlights the importance of suspecting and quickly recognizing AEF based on history and physical examination alone. After extensive preoperative imaging to confirm the diagnosis, this patient nearly died in the operating room as surgeons took down adhesions trying to reach the fistula to repair it.     

改良无辅助切口完全腹腔镜直肠癌全直肠系膜切除术的临床研究

目的研究改良无辅助切口完全腹腔镜直肠癌全直肠系膜切除术(TME)在直肠癌治疗中的临床效果。方法回顾性总结2007年5月~2010年6月在本院接受改良无辅助切口完全腹腔镜直肠癌TME术治疗的23例患者的临床资料。结果 23例均获成功,平均手术时间242.5 min,术中平均出血量52.6 mL。术后病理证实远近切缘均无癌残留。术后平均胃肠功能恢复时间51.7 h,术后平均住院时间5.4 d。无吻合口瘘及出血、腹腔出血及感染等术后并发症。随访12~18个月,未发现肿瘤局部复发。结论改良无辅助切口完全腹腔镜直肠癌TME术具有手术损伤小、出血少、无腹壁辅助切口、恢复快等优点,是真正意义上的全腹腔镜下直肠癌微创手术,值得临床推广应用。     

Laparoscopic surgery for sigmoidocutaneous fistula due to diverticulitis: A case report

Sigmoidocutaneous fistulas due to sigmoid colon diverticulitis are very rare. Here we report a case in which laparoscopic sigmoidectomy was used to successfully treat a sigmoidocutaneous fistula due to diverticulitis. A 41‐year‐old man was admitted to our hospital because of redness and swelling of the left inguinal skin. Enhanced abdominal CT revealed a subcutaneous abscess in the left lower abdomen. Percutaneous drainage was performed, and fistulography revealed a fistula between the sigmoid colon and left inguinal skin. Therefore, a sigmoidocutaneous fistula was diagnosed, and laparoscopic sigmoidectomy and fistulectomy were performed. The sigmoid colon had several diverticula, and a pathological examination revealed that the sigmoidocutaneous fistula was due to diverticulitis. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. In cases of sigmoidocutaneous fistula, laparoscopic treatment can be safely performed.     

A complicated case of aortoduodenal fistula

Aortoduodenal fistula may occur primarily as a complication of abdominal aortic aneurysm or secondarily after reconstructive surgery of the abdominal aorta. The clinical presentation may be occult, with the classic triad of mass, pain, and bleeding inapparent or overshadowed by signs of infection. A high index of clinical suspicion combined with radiographic and endoscopic examinations will establish the diagnosis.     

Aortoenteric fistula

A fistula between the aorta and the gastrointestinal (GI) tract is a relatively uncommon and often lethal cause of GI bleeding. This report describes a patient with massive upper GI bleeding due to an aortoduodenal fistula. Such fistulae arise because of a combination of mechanical factors and local infection; the varied clinical presentations can be explained by the pathogenesis of the disease entity. These clinical presentations are reviewed, and a suggested approach to the diagnosis and management is presented.     

尿毒症上臂动静脉内瘘术后淋巴瘘一例

动静脉内瘘是尿毒症患者长期维持血液透析治疗的血管通路,术后并发淋巴瘘少见。淋巴瘘是淋巴管受损引起的淋巴液外流,临床表现为术后早期伤口出现不能解释的包块或溢液。淋巴瘘常用的治疗方法为局部填塞、加压包扎,对于渗液量较大、压迫治疗无效的患者,可行手术治疗。该文报道了1例上臂动静脉内瘘术后并发淋巴瘘的尿毒症患者的诊治经过,该例经临床表现、体征结合漏液乳糜试验诊断为淋巴瘘。开始行淋巴瘘清创引流术,用局部加压包扎,效果欠佳,遂再行局部淋巴瘘腔探查引流术并局部使用50％葡萄糖液浸泡冲洗,术后予加压气囊加压包扎,同时联合阿托品肌内注射治疗,创面愈合,随访情况良好。     

Rare sigmoid abdominal wall fistula after appendectomy: a case report

An extraintestinal fistula is a rare complication after appendectomy. To our knowledge, this study is the first to report a case of sigmoid abdominal wall fistula after appendectomy in a 45-year-old male patient who underwent appendectomy due to acute appendicitis. Purulent discharge was noted at the abdominal wall incision wound for more than 1 year postoperatively. The patient''s clinical manifestation, medical history, physical examination, and auxiliary examination all suggested the formation of an abdominal sinus. After exploratory laparotomy at the Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, a diagnosis of sigmoid abdominal wall fistula was confirmed, and the fistula was cured after complete fistula resection. The reporting of this rare and atypical case may provide useful reference information for diagnosing and treating future cases of enterocutaneous fistula.     

食管癌及贲门癌术后防治吻合口瘘的护理

[目的]探讨防治食管癌及贲门癌术后吻合口瘘的护理干预措施.[方法]回顾性分析26例食管癌及贲门癌手术病人防治术后发生吻合口瘘护理措施.[结果326例病人手术后发生吻合口瘘3例,1例吻合口瘘并发严重肺部感染、营养不良行再次吻合、胸廓改型、空肠造瘘手术后治愈出院,2例经保守治疗治愈出院.[结论]针对食管癌及贲门癌术后吻合口瘘可能出现的原因,采取正确的护理措施加以预防和处理,能有效降低吻合口瘘的发生率.