结肠镜术并发肠穿孔的诊断与处理

结肠镜已成为目前诊治结直肠疾病最常用的方法.尽管肠穿孔与医源性因素及患者某些高危因素有关,发生率较低,但被认为是结肠镜术严重的并发症之一,病死率高.根据结肠镜术中或术后患者的临床表现,早期发现肠穿孔是成功治疗的前提,也是降低病死率的关键.在治疗上有保守治疗、开腹手术、腹腔镜手术及内镜夹等多种方法.临床上应具体分析和准确判断病情,不能一概而论,根据患者的临床表现、穿孔大小、肠道准备情况、确诊时间、结肠原发病变等具体临床条件选择合理有效的治疗方案.     

腹腔镜治疗上消化道溃疡穿孔的应用体会

目的:探讨腹腔镜治疗上消化道溃疡穿孔的应用价值及优越性。方法:回顾分析2005年1月至2008年12月我院应用腹腔镜手术治疗上消化道穿孔30例患者的临床资料。结果:30例中胃十二指肠溃疡穿孔28例,胃癌穿孔2例。28例腹腔镜手术成功,2例胃癌穿孔患者中转开腹。手术时间60～80min,平均(68.2±15.5)min。术后住院4～10d,平均6.2d。本组无并发症发生及死亡病例。结论:腹腔镜手术治疗上消化道溃疡穿孔具有患者痛苦小、损伤轻、康复快、并发症少、住院时间短等优点,疗效满意,值得临床推广应用。     

Laparoscopic repair of a colonoscopic perforation

We report a case of laparoscopic repair of a diagnostic colonoscopic perforation. No other such reports were noted in the literature. The management of colonoscopic perforations has become controversial. Operative vs nonoperative treatment is continually debated. The morbidity of operative management is significant. Colostomy is often performed. Laparoscopy should allow early evaluation of operative patients and primary repair of those with minimal contamination and no residual pathology. The benefits of minimally invasive surgery, such as shortened hospitalization and rapid return to full activities, including work, were realized in our patient. Laparoscopy should be considered in the selective management of colonoscopic perforations. Received: 15 September 1995/Accepted: 16 January 1996     

Promptness of diagnosis is the main prognostic factor after colonoscopic perforation

Aim The authors present their experience of colonoscopic perforation and its management, with an analysis of factors affecting outcome. Method During the last 10 years, 22 cases of colonoscopic perforation (CP) were identified in two different institutions. Multiple logistic regression analysis was used to identify significant predictors of morbidity and mortality. Results Morbidity and mortality rates were 31% and 13.6%, respectively. Prompt diagnosis was the most powerful predictor of outcome of CP. Multiple logistic regression analysis showed that morbidity and mortality were significantly related to a delay in diagnosis of more than 24 h (P = 0.03 and P = 0.04). Conclusion The results emphasize the importance of prompt assessment of a patient who develops symptoms after colonoscopy.     

颈椎前路手术并发食管瘘的治疗

目的 :探讨颈椎前路手术并发食管瘘的治疗措施及其效果。方法 :回顾性分析2006年9月~2016年7月颈椎前路手术并发食管瘘的8例患者资料,其中男6例,女2例;年龄31~71岁(52.32±13.05岁)。外伤性颈椎骨折4例(其中强直性脊柱炎2例),颈椎病2例,颈椎结核1例,颈椎畸形1例。术中发现食管瘘1例,当即给予修补;术后早发性(1个月内)食管瘘6例,其中2例经呋喃西林纱布条换药处理,2例行清创探查引流术并在术中给予修补,1例清创探查术后给予胸锁乳突肌瓣填塞,1例因脓毒血症死亡;迟发性(1个月后)食管瘘1例,行内固定取出清创探查,并肌瓣填塞。同时所有患者行伤口细菌培养,应用敏感抗生素,鼻饲饮食加强营养等治疗。结果:1例强直性脊柱炎合并颈椎骨折脱位患者,于术后第4天出现食管瘘,术后第7天因脓毒血症死亡;其余7例食管瘘口均愈合,愈合时间为2周~2.5个月;随访1~5年(2.86±1.36年),7例均无复发,且吞咽功能良好。结论:依据食管瘘发生的时间,结合其大小和污染程度采取不同的治疗方案,可取得较好的疗效。     

腹腔镜辅助胃肠穿孔修补术

目的 :探讨腹腔镜辅助胃肠穿孔修补术的手术方法。方法 :对 1 3例十二指肠球部穿孔 ,1例胃窦部穿孔 ,3例小肠穿孔患者实施腹腔镜辅助下微小创口胃肠穿孔修补术 ,手术在直视下进行。结果 :患者手术均获成功 ,预后良好 ,无任何并发症发生 ,均在 7d内出院。结论 :腹腔镜辅助微小创口胃肠穿孔修补术具备腹腔镜手术患者损伤小、康复快及传统手术直观、易操作的特点     

Management of colonoscopic perforations: A systematic review

Background

Perforation during colonoscopy is a rare but well recognized complication with significant morbidity and mortality. We aim to systematically review the currently available literature concerning care and outcomes of colonic perforation. An algorithm is created to guide the practitioner in management of this challenging clinical scenario.

Surgical site infections in plastic surgery: an italian multicenter study

BACKGROUND: Plastic surgery interventions have increased in terms of frequency, complexity of surgical procedures, and postoperative complications, particularly surgical site infections (SSIs). The aim of the present study was to assess the SSI frequency in plastic and reconstructive surgery settings in Italy and to evaluate the associated risk factors. METHODS: From June 2004 to June 2005, a prospective multicenter study including 2806 consecutive patients was conducted in 23 Italian plastic and reconstructive units. To assess potential risk factors for surgical site infection, a conditional logistic regression model was used and results were exposed in terms of odds ratio (OR) with their respective 95% confidence interval (CI). RESULTS: SSIs occurred in 85/2806 (3%) patients. Sixty (70.6%), 24 (28.2%), and 1 (1.2%) SSIs were classified as superficial, deep, and organ/space, respectively. Sixty-six percent of the SSIs were diagnosed during postdischarge surveillance. At multivariate analysis, diabetes mellitus, chronic obstructive pulmonary disease, preoperative radiotherapy, and use of surgical drains were significantly associated with the occurrence of SSI. CONCLUSIONS: Our findings, based on a large population including all types of plastic and reconstructive interventions, provided consistent information on potential risk factors for SSI in this surgical setting. Moreover, the high rate of SSI found during the postdischarge surveillance underlines the need for improving active surveillance methodologies in this surgical setting.     

Predictors of surgical site infection in dirty urological surgery

Objectives:   Risk factors for surgical site infection (SSI) following urologic dirty operations have not been clearly identified. This study was conducted to describe incidence, potential risk factors and common causative pathogens of the SSI in such operations.
Methods:   Medical records of patients who had undergone simple nephrectomy or lumbotomy for suppurative renal infection at our institutions from 1999 to 2006 were retrospectively evaluated. The following data were retrieved: presence of SSI, demographic data, laboratory findings, comorbidities, microbiological data, type of renal suppuration, type of urological surgery and antibiotic regimen. Risk factors for SSI were evaluated using the multiple logistic regression model.
Results:   Sixty-five patients (mean age 55.6 ± 13.1 years) were eligible for data analysis. In 20 of them (30.8%) a SSI was identified. The most common isolated pathogens were gram-negative bacteria. At univariate logistic regression analysis risk factors significantly associated with SSI included: presence of emphysematous infection, hypoalbuminemia, number of predisposing conditions, emergency operations, isolation of Enterobacteriaceae, positive pus culture. The use of trimethoprim/sulfamethoxazole was associated with a decreased risk for SSI. Multiple logistic model identified only the emergency operations and isolated Enterobacteriaceae as independent predictors of SSI (odds ratio [OR] = 11.1) (95% confidence interval [CI] = 3.0–40.8) and OR = 3.9 (1.0–14.8), respectively.
Conclusions:   Patients with suppurative renal infections are submitted to life-saving emergency surgery. Urological surgeons should keep in mind that this carries a high risk for subsequent SSI. Effective preventive measures in these circumstance cannot be identified. Further research in this area is necessary to clarify this issue.     

Oesophageal perforation after anterior cervical surgery: management in four patients

Background  Oesophageal perforation related to anterior cervical surgery is an uncommon but well recognised and potentially life-threatening complication with an incidence of 0–3.4%. Our experience with this complication and a review of the literature are presented. Method  We retrospectively reviewed our clinical experience over 10 years and found four patients in whom an oesophageal perforation was recognised after anterior surgery for cervical spine trauma. In three patients the perforation was noticed in the early post-operative period and the other had a delayed presentation. In all patients, the hardware was removed, long-term intravenous antibiotics were administered and parenteral nutrition was instituted. In two patients a primary suture of the perforation was performed and in one of these an additional sternocleidomastoid myoplasty was carried out as well. One patient had conservative treatment and one died before closure of the perforation could be performed. Findings  The two patients, in whom surgical repair of the perforation was performed, recovered well with residual neurological deficits as expected due to the cervical trauma. In the patient in whom conservative treatment was instituted, healing of the perforation occurred. One patient died due to systemic complications, indirectly related to the perforation. Conclusions  Although not very frequent and sometimes difficult to diagnose, oesophageal perforations after anterior cervical surgery constitute a potentially life-threatening complication. Diagnosis is made by imaging or endoscopic studies, but clinical suspicion is most important. Basic treatment consists of surgery with removal of hardware, drainage of abscesses, primary closure of the perforation if possible, parenteral nutrition and antibiotic therapy. Residual instability should be recognised in time and may be anticipated in patients in whom there has been little time for solid bony fusion. Successful management depends on early diagnosis and immediate institution of treatment.     

Laparoscopic repair of a colonic perforation sustained during colonoscopy

A patient who sustained a colonic perforation during therapeutic colonoscopy was treated successfully by laparoscopic repair. Laparoscopy was performed 5 h after polypectomy. Fecal matter was not identified in the peritoneal cavity. Local peritonitis was mild. The laceration was oversewn with five sutures using the extracorporeal endoscopic knot technique. The appendix epiploica was then anchored over the lesion. The postoperative recovery was rapid and uneventful. Laparoscopic surgery may become a useful tool for the safe, effective, and minimally invasive management of iatrogenic colonic perforation.     

加速康复外科在腹腔镜治疗胃十二指肠穿孔中的应用

目的本研究旨在探讨围手术期采用加速康复外科(ERAS)理念在腹腔镜治疗胃十二指肠穿孔中的有效性及安全性。方法回顾性分析2014年1月至2016年5月收治的腹腔镜下治疗胃十二指肠穿孔的患者,将患者根据围手术期处理方法的不同分为2组:ERAS组(42例)和传统组(46例)。分析比较两组患者术后并发症、胃肠功能恢复、住院时间、住院费用及满意程度。结果两组患者在一般临床资料和手术时间比较无统计学差异。ERAS组和传统组患者在术后并发症发生率比较方面亦未见统计学差异(分别为9.5%和10.9%,P=0.835)。ERAS组的患者术后胃肠功能恢复时间较快,如首次肛门排气时间(分别为1.8天和2.0天,P=0.011),首次肛门排便时间(分别为2.2天和2.5天,P=0.011)。ERAS组和传统组的术后住院时间存在显著差异,分别为6.9天和7.8天(P=0.003)。研究发现ERAS组可显著降低总体的费用(8661.4元和9325.7元,P=0.044)。此外ERAS组患者术后停留胃管、腹腔引流管和尿管的时间亦明显缩短(P0.05)。结论本研究的结果显示ERAS概念在胃十二指肠穿孔行腹腔镜治疗的患者中是安全、有效的。ERAS概念可加快术后康复、缩短住院时间、减少手术费用。     

Postoperative hyperbilirubinemia after surgery for gastrointestinal perforation

Abstract. Purpose: The aim of this study was to evaluate the risk factors and outcome of patients with hyperbilirubinemia after surgery for generalized peritonitis. Methods: We retrospectively analyzed data from 229 patients with generalized peritonitis caused by gastrointestinal (GI) perforations. Results: Postoperative hyperbilirubinemia defined as a value of ≧5 mg/dl, within 1 month, developed in 39 patients. Postoperative hyperbilirubinemia was related to age (P= 0.0102), poor nutritional status (P= 0.0388), decreased base excess (P= 0.0037), delay until surgery (P= 0.0276), preoperative serum bilirubin (P= 0.0321) and postoperative persistent infection (P < 0.0001). Higher mortality was seen in patients with hyperbilirubinemia (59%) than in those without hyperbilirubinemia (4%). The patients with hyperbilirubinemia who survived had decreased serum bilirubin levels after 3–5 postoperative days whereas a continuous increase was seen in the patients who ultimately died. Preoperative shock (P= 0.0003), a decreased preoperative platelet count (P= 0.0152), postoperative infection (P= 0.0050), and postoperative hyperbilirubinemia (P < 0.0001) were risk factors for overall mortality. Conclusion: These results indicate that postoperative hyperbilirubinemia in patients with GI perforation is related to persistent postoperative infection and associated with poor prognosis. Received: July 19, 2001 / Accepted: January 8, 2002     

Esophagus perforation complicating anterior cervical spine surgery

Purpose  

To study the diagnosis and treatment strategy of esophagus perforation complicating anterior cervical spine surgery.     

Oesophageal perforation following cervical spinal surgery with instrumentation: A case report on primary repair with pedicled sternocleidomastoid muscle flap reinforcement and review of the literature

Anterior cervical spine fusion and stabilisation is an entrenched procedure for managing traumatic spinal fracture. Oesophageal perforation by spinal hardware after cervical spinal fusion surgery is a rare complication that can be life-threatening. We present a case with a complication of oesophageal perforation following anterior and posterior spinal fusion with instrumentation performed 7 years ago with a review of literature.     

A management algorithm for esophageal perforation

Despite the prolonged morbidity caused by a major surgery and the high occurrence of continued leakage, primary repair has been the standard treatment for esophageal perforations. We believe that management using removable esophageal stents is both simpler and more effective. Over the past 3 years, we have treated 14 patients using esophageal stents, and the procedure was successful in all patients. Because of the shorter bed rest that follows endoscopic Polyflex stent (Rush, Inc; Teleflex Medical, Duluth, GA) placement, it is very likely that the care of patients with esophageal perforation will be changed over time.     

Incidence rate and risk factors of surgical wound infection in general surgery patients: A cross-sectional study

Hospital-acquired infections (HAIs) are considered a major challenge in health care systems. One of the main HAIs, playing an important role in increased morbidity and mortality, is surgical wound infection. Therefore, this study aimed to determine the incidence rate and risk factors of surgical wound infection in general surgery patients. This cross-sectional study was performed on 506 patients undergoing general surgery at Razi hospital in Rasht from 2019 to 2020. Bacterial isolates, antibiotic susceptibility pattern, antibiotic administration, and its type, operation duration and shift, the urgency of surgery, people involved in changing dressings, length of hospitalisation, and levels of haemoglobin, albumin, and white blood cells after surgery were assessed. The frequency of surgical wound infection and its association with patient characteristics and laboratory results were evaluated. The SPSS software package (version 16.0, SPSS Inc., Chicago, IL, USA) was used to analyse the data. Quantitative and qualitative variables were presented using mean (standard deviation) and number (percentage). The Shapiro–Wilk test was used to evaluate the normality of the data in this study. The data did not have a normal distribution. Hence, χ² and Fisher's exact tests were used to evaluate the relationship between variables. Surgical wound infection occurred in 4.7% (24 cases) of patients with a mean age of 59.34 (SD = 14.61) years. Preoperative (>3 days) and postoperative (>7 days) hospitalisation, history of immunodeficiency (P < 0.001), and interns responsible for changing dressings (P = 0.021) were associated with surgical wound infection incidence. About 9.5% and 4.4% of surgical wound infection cases were significantly associated with pre- and postoperative antibiotic use. Gram-positive cocci were the most prevalent strains isolated from 24 surgical wound infection cases (15/24, 62.5%). Among these, Staphylococcus aureus was the predominant species, followed by coagulase-negative staphylococci. In addition, the most common Gram-negative isolates identified were Escherichia coli bacteria. Overall, administration of antibiotics, emergency surgery, surgery duration, and levels of white blood cells and creatinine were identified as surgical wound infection-associated risk factors. Identifying important risk factors could help control or prevent surgical wound infections.