自发性结肠穿孔14例临床分析

目的探讨自发性结肠穿孔的发病原因及诊治方法。方法回顾性分析14例自发性结肠穿孔病例的临床资料,术前1例确诊,余13例均误诊。行Hartmann结肠造瘘术5例,穿孔修补外置术5例,穿孔Ⅰ期修补近端结肠造瘘2例,穿孔Ⅰ期单纯修补和穿孔结肠外置造瘘术各1例。结果穿孔位于直肠乙状结肠交界处6例,乙状结肠4例,降结肠2例,横结肠1例,升结肠1例。术后创缘病检均为炎症,死亡2例,其余12例痊愈出院。结论自发性结肠穿孔主要发病原因为习惯性便秘及动脉硬化,好发部位在乙状结肠,术前误诊率高,及时准确的手术治疗及完善的围手术期处理是挽救病人生命的关键;肠管修补外置术及Hartmann结肠造瘘术是两种较好的手术方式。     

自发性大肠穿孔诊治体会：附9例报告

目的:探讨自发性大肠穿孔的诊治。方法:回顾性分析1994年以来收治的9例自发性大肠穿孔患者的临床资料。结果:9例均为60岁以上的老年患者，缺乏特异性临床表现，术前均未能明确诊断。既往有长期高血压、动脉硬化史4例，有习惯性便秘史6例。穿孔位于横结肠1例，降结肠1例，乙状结肠3例，直肠上段4例。治疗采用穿孔修补、肠管外置4例，穿孔修补加近段结肠造瘘5例。术后1例出现心律失常，2例肺部感染，1例切口感染，均经处理后恢复顺利而痊愈出院。结论:自发性大肠穿孔多见于老年患者；好发部位在直肠和乙状结肠；术前易误诊，应尽早剖腹探查；手术宜简单化，应加强术后管理。     

结肠穿孔的手术治疗：附18例报告

为探讨急诊手术治疗不同病因致结肠穿孔的手术方式及治疗方法。笔者对18例不同原因的结肠穿孔手术病人的临床资料进行回顾分析。18例中2例自发性升结肠穿孔，全身情况差，全腹弥漫性腹膜炎，腹腔污染严重，行冲洗腹腔，修补穿孔，穿孔近端造瘘。术后均出现不可逆性休克，治疗无效死亡。２例纤维结肠镜检致乙状结肠穿孔，行肠破裂修补术；13例癌性结肠穿孔，1例乙状结肠扭转肠坏死穿孔，腹腔污染严重，病情严重，分期手术，治愈出院。 提示结肠穿孔的手术方式是决定预后的关健，治疗应当个体化，根据患者全身情况，腹腔污染程度，致穿孔病因来决定手术方式：纤维肠镜检查所致结肠穿孔，可实施一期修补手术。癌性溃疡致结肠穿孔宜采取分期手术的方式；自发性结肠穿孔应根据情况采用一期或分期手术。手术治疗应与综合治疗并重。     

非创伤性乙状结肠穿孔18例分析

笔者回顾性分析近8年间收治的非外伤性乙状结肠穿孔18例的临床资料。全组18例均急诊行剖腹探查，其中自发性穿孔8例，结肠癌性穿孔5例，乙状结肠扭转坏死穿孔2例，乙状结肠憩室穿孔和甲鱼骨致乙状结肠穿孔及炎性肠病穿孔各1例;行病灶Ⅰ期吻合10例，Hartmann术6例，穿孔修补、乙状结肠襻式造瘘2例。术后切口感染、切口裂开、肺部感染等并发症6例，死亡3例。自发性结肠穿孔和癌性穿孔是乙状结肠穿孔的重要原因，手术方式应根据不同病因、穿孔时间、腹腔污染情况及全身情况而定，早期诊断和手术是降低病死率的关键。     

自发性直肠乙状结肠穿孔16例诊治分析

目的 探讨自发性直肠、乙状结肠穿孔病因和诊疗策略,缩短术中寻找穿孔部位时间.方法回顾分析16例自发性直肠、乙状结肠穿孔患者临床资料.结果 16例自发性直肠、乙状结肠穿孔患者穿孔直径大于1.5cm 有9例,小于1.5cm 有7例,其中4例小穿孔,穿孔部位难以发现.全部病人治愈.结论对直肠、乙状结肠穿孔小,时间长,在寻找穿孔部位有困难时及时使用补胎法,提高术中确诊率.及时急诊手术,选用Hartmann术或肠穿孔修补,远端关闭加近端结肠造瘘术两种术式为宜.     

乙状结肠自发性穿孔临床分析（附10例报告）

目的探讨乙状结肠自发性穿孔的病因、临床特点及处理原则。方法对10例经手术和病理检查证实为乙状结肠白发性穿孔病例的l临床资料进行回顾性分析。结果10例平均年龄为66岁,均有习惯性便秘史,主要临床表现为腹痛、腹胀及腹膜刺激征,腹穿抽到粪性液体,X线显示膈下游离气体。所有患者均予手术治疗,10例中术前误诊8例。6例行病变肠段切除、Hartman造瘘术,行穿孔修补近端结肠造瘘、穿孔肠段外置双腔造瘘术各1例,单纯穿孔修补术2例。8例痊愈,2例死亡,均死于感染中毒性休克继发多器官功能衰竭。结论乙状结肠自发性穿孔多见于老年人,术前诊断较困难,患者通常有便秘史及腹压增加诱因,局部解剖因素是发病的基础原因。该病缺乏特征性的临床表现,腹部X线及腹穿对诊断有帮助。提高确诊率关键在于对本病的认识,早期正确诊断、及时合理的外科治疗是救治成功的关键。     

老年人自发性乙状结肠穿孔9例诊治体会

目的探讨老年人自发性乙状结肠穿孔的病因、诊断及治疗方法。方法对四川大学华西医院胃肠外科中心2009～2011年期间收治的9例自发性乙状结肠穿孔老年患者的临床资料进行回顾性分析。结果 9例患者中7例有长期便秘史,术前均诊断为"全腹膜炎、腹腔脏器穿孔"而行急诊手术。术中见穿孔位于直乙交界处6例,乙状结肠中上段3例,均在系膜对侧缘。3例行病变处肠段切除加远端封闭、近端造瘘术(Hartmann术),4例行乙状结肠部分切除吻合、横结肠双腔造瘘术,1例行穿孔修补术,1例行穿孔修补加横结肠造瘘术。8例患者治愈出院,1例患者因经济原因放弃治疗。结论老年人自发性乙状结肠穿孔临床上较少见,其发病与解剖学因素、病理学因素密切相关,便秘等是其重要诱因。及时手术、选择适宜的手术方式以及彻底清除腹腔污染是治疗成功与否的关键。     

手术治疗老年人自发性乙状结肠穿孔39例

目的：探讨老年人自发性乙状结肠穿孔的病因、临床特点和手术治疗方法。方法：完善术前准备剖腹探查,术中快速病理检查。根据病灶位置、大小及腹腔污染情况,行病变肠段切除远端关闭加近段结肠造瘘或穿孔修补加近段结肠双腔造瘘或穿孔段乙状结肠外置造痿。结果：行穿孔段乙状结肠外置造瘘1例,穿孔修补加近段结肠双腔造瘘3例,病变肠段切除远端关闭加近段结肠造瘘：35例。行切口减张缝合30例。术后发生切口感染18例,切口裂开再手术2例,死亡16例。结论：便秘是老年人自发性乙状结肠穿孔主要病因,泛影葡胺灌肠造影有利定性和定位诊断,及时手术是提高疗效的关健,手术方式应以病变肠段切除远端关闭加近段结肠造瘘为首选。     

老年非外伤性结肠穿孔23例

目的：提高老年非外伤性结肠穿孔的临床特征和治疗方法进行分析和探讨。方法：回顾性分析23例老年非外伤性结肠穿孔患者的临床资料,分析总结治疗方法及治疗效果,观察病因、年龄、腹腔污染程度、全身情况、基础疾病等因素对术式选择和预后的影响。结果：23例均以急性腹膜炎为第一诊断,其中自发性穿孔8例,癌性穿孔8例,乙状结肠扭转致肠绞窄坏死穿孔3例,乙状结肠憩室穿孔2例,炎性肠病和鱼骨致结肠穿孔各1例。23例均行急诊手术治疗。其中12例行病灶Ⅰ期切除吻合术,6例行病灶切除近端肠管造口、远端关闭术,2例行Hartmann术,2例行单纯修补术,1例行穿孔修补加乙状结肠襻式造口术。20例治愈,3例感染性休克死亡。结论：结肠原发性病变是老年患者非外伤性结肠穿孔的主要原因,尽早手术,手术以简单为宜,有利于减少术后并发症,降低病死率。     

自发性结肠破裂32例临床分析及诊疗策略

目的总结自发性结肠破裂的病因和发病机制、好发部位、诊疗策略及预防措施。方法回顾性分析32例自发性结肠破裂患者的临床资料,有慢性便秘史21例,冠心病、动脉粥样硬化病史12例,有肠内压增高诱因16例,术前均摄腹部平片,示膈下游离气体19例;行泛影葡胺灌肠造影12例,10例示左半结肠穿孔;腹穿阳性者14例。术前仅3例确诊。行一期修补6例,穿孔段结肠外置造瘘8例,穿孔修补加近段结肠造瘘8例,病变段结肠切除加近段结肠造瘘10例。结果手术证实穿孔部位:乙状结肠10例,直肠乙状结肠交界处11例,降结肠6例,横结肠4例,盲肠1例。治愈19例(59.4%),死亡13例(40.6%)。结论自发性结肠破裂缺乏特异的临床表现,术前不易确诊;本病好发于乙状结肠及直肠乙状结肠交界处;对本病有充分认识及术前泛影葡胺灌肠造影有利于术前诊断;依患者全身及腹部情况选择一期或二期手术。     

Sigmoid colon exteriorization after ruptured abdominal aortic aneurysm

A 74-year-old man in shock was transferred to our hospital. A ruptured abdominal aortic aneurysm was diagnosed by computed tomography and an emergency operation was thereafter performed. At operation, a massive hematoma was encountered in the retroperitoneal space and a standard aneurysmectomy with bifurcated graft replacement was carried out. At the end of the operation, signs of sigmoid colonic ischemia were recognized, including mild discoloration and bowel spasm. After considering the recovery or deterioration from colonic ischemia, we chose to exteriorize the sigmoid colon. On the 4th postoperative day, patchy ischemic areas of an elevated sigmoid colon were noticed to worsen and as a result, we were forced to perform a sigmoid colectomy with end colostomy. Thereafter, the patient developed multisystem organ failure, but he recovered gradually. The patient was discharged from the hospital 3 months after the initial operation. As a complication after surgery for abdominal aortic aneurysms, colonic ischemia remains a serious problem, especially in cases of ruptured AAA. It is generally better to avoid an operation for both abdominal aortic aneurysms and a colon resection at the same time. In this case, an exteriorization of the sigmoid colon was selected for the 1st operation in order to treat a ruptured abdominal aortic aneurysm. This surgical modality was found to be useful for making a correct diagnosis of colonic ischemia before the perforation, while a 2nd look operation for colonic ischemia could thus be performed under conditions of a reduced risk of infection to the prosthetic graft. These operative procedures were considered to be important factors in saving the patient's life.     

慢性假性结肠梗阻的诊断治疗：附17例报告

目的:探讨慢性假性结肠梗阻的诊断与治疗方法。方法:回顾性分析17例慢性假性结肠梗阻患者的临床资料。结果:所有患者均行手术治疗，5例右半结肠加横结肠切除，8例右半结肠加横结肠加降结肠切除，1例乙状结肠切除，1例乙状结肠造瘘，2例肠减压术。术后2例切口感染和1例左膈下脓肿，经处置后痊愈;1例术后胃瘫，保守治疗30 d治愈，1例肠减压术患者，术后19 d因脓毒症，感染性休克死亡。2例乙状结肠切除及1例肠减压患者，术后症状均无缓解。其余患者腹胀消失，排气、排便正常而获痊愈。结论:慢性假性结肠梗阻是一种少见疾病，切除全部扩张的、无功能肠段可使大多数患者的症状缓解。     

Stercoral perforation of the colon in sigmoid colostomy patients: Two case reports

INTRODUCTIONStercoral perforation of the colon has rarely been reported. Only 3 cases of stercoral perforation of the colon proximal to an end colostomy have been reported. We present two cases of stercoral perforation of the colon in end colostomy patients.PRESENTATION OF CASEA 70-year-old man who had undergone abdomino-perineal excision for anal cancer was referred for left lower quadrant pain and fever. Stercoral perforation was discovered along the distal descending colon, proximal to the end sigmoid colostomy. The patient underwent segmental resection of the colon and revision of the stoma and was discharged on postoperative day 32. A 71-year-old woman who had undergone abdomino-perineal excision for distal rectal cancer with preoperative chemoradiation presented fever with 2 days of low abdominal pain. The patient had sacral bone and lung metastases from rectal cancer and suffered from chronic constipation. Stercoral perforation was found around the sigmoid colon, just proximal to the end sigmoid colostomy. The patient underwent simple repair of the perforated colon through the parastomal incision. On postoperative day 8, leakage occurred at the repair site. Segmental resection of the colon and revision of the stoma were performed. She was discharged 44 days after the initial surgery.DISCUSSIONSegmental resection of the perforated colon, rather than simple repair, appears to improve postoperative outcomes.CONCLUSIONAs the number of cancer survivors increases, appropriate management of constipation is important to prevent stercoral perforation during follow-up.     

Stercoral perforation of the colon. Concepts of operative management

Stercoral perforation of the colon is a direct result of ischemic pressure necrosis by a stercoraceous mass. In over 90 per cent of cases, the perforation will involve either the sigmoid or rectosigmoid colon and is consistently centrally located within a region of mucosal ulceration of varying diameter and magnitude. A review of 33 surgically treated cases from the literature along with four cases presented here, support resection, end colostomy, and either mucous fistula or Hartmann's procedure as the operation of choice with the lowest operative mortality (23%) when compared to those patients treated by either loop colostomy or exteriorization (71%) or proximal colostomy with plication of the perforation (44%). Irrigation of the distal rectal segment as that for penetrating rectal injury is also recommended.     

升结肠回盲部肿瘤侵犯乙状结肠22例治疗体会

目的总结升结肠回盲部肿瘤侵犯乙状结肠的治疗经验。方法升结肠回盲部肿瘤侵犯乙状结肠22例,术前诊断明确7例,其余均为术中明确诊断,急诊手术11例(占50.0%),均行多发结肠肿瘤肠段切除术,其中一期吻合5例,预防性小肠造口11例,降结肠造口6例,包括右侧输尿管部分切除5例,肉眼达到R0根治性切除21例,1例因右侧髂内血管侵犯行姑息性肿瘤切除。结果术后患者恢复好,无死亡患者,无肠漏及吻合口漏。预防性小肠造口患者于术后1个月余行造口还纳手术,3例降结肠造口患者于术后半年行造口还纳术,另有3例随访无异常。结论升结肠回盲部肿瘤侵犯乙状结肠患者行根治性肿瘤切除,可提高患者生存率及生活质量,采用多肠段切除一期吻合或预防性小肠造口是一种合理的手术方式,如必须行结肠造口术时,需为二次手术创造条件。     

老年人自发性乙状结肠穿孔：附21例报告

目的：探讨老年人自发性乙状结肠穿孔的病因、临床表现及处理原则。方法：回顾性分析2007年11月—2012年10月诊断明确的21例老年人自发性乙状结肠穿孔的临床资料。结果：全组男12例,女9例;平均年龄67（62~73）岁。多数患者以突发性急性腹痛就诊,患者均有不同程度的习惯性便秘史,术前出现感染性休克3例。全组中术前诊断为乙状结肠穿孔仅4例,误诊率为80.95%。21例患者均行Hartmann术,术后仍出现感染性休克3例,经过积极抗休克及抗感染治疗后好转;术后发生切口感染8例,肺部感染6例,经抗感染对症治疗治愈;并发多器官功能障碍综合征（MODS）3例,经过积极抢救及相应处理后治愈1例,死亡2例均为紧贴后腹膜乙状结肠后壁穿孔。19例治愈出院且于术后3~6个月行乙状结肠造瘘口还纳术。结论：老年人自发性乙状结肠穿孔缺乏特异性的临床表现,行腹腔穿刺及腹部X线、肛肠指诊对诊断有所帮助。早诊断、早期积极抗休克、抗感染、维持水电解质及酸碱平衡、尽早手术及行对症处理,预防并发症是保证患者康复的关键。

     

Antiperistaltic transverse colostomy for massive bowel necrosis following surgery for an abdominal aortic aneurysm: Report of a case

We herein report the findings of a 72-year-old man with gangrenous multivisceral necrosis following an operation for abdominal aortic aneurysm. The region of necrosis, which accompanied infarction of the left kidney, included the entire ileum and the ascending, descending, and sigmoid colon. An end ileostomy and transverse colostomy were performed subsequent to massive bowel resection in a second operation. After the second operation, he was managed with total parenteral nutrition and recovered uneventfully except for end-jejunostomy syndrome. A third operation was performed to reconstruct the interrupted bowel. To minimize abandoned bowel, antiperistaltic transverse colostomy was used for jejunocolonal reconstruction. The antiperistaltic colostomy improved the symptoms of end-jejunostomy syndrome and normalized the patient's vitamin B₁₂ and bile acid levels. An antiperistaltic colostomy is thus considered to be useful for preventing short bowel syndrome after a massive bowel resection.     

A novel mutation in the vascular Ehlers-Danlos syndrome: a case presenting with colonic perforations

A 15-year-old girl who had chronic constipation presented with peritonitis caused by sigmoid colon perforation. After her sigmoid colon was resected and an end colostomy performed, as there were no apparent causes for perforation, she was followed-up. After the second colonic perforation proximal to the end colostomy, as the pathologic findings revealed myopathic changes, the connective tissue disorders were evaluated. Her molecular biology studies revealed an undefined missense mutation in the COL3A1 gene, confirming the diagnosis of vascular Ehlers-Danlos syndrome (EDS). As she refused a permanent stoma, total colectomy and ileorectal anastomosis were performed, but the postoperative complications resulted in a fatal progression.The typical progression of vascular EDS will be discussed with the presented case by means of a review of the English medical literature on children diagnosed with vascular EDS.