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。     

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。     

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。     

粪块性结肠穿孔的诊断与治疗(附32例报告)

目的探讨粪块性结肠穿孔的诊断与治疗。方法对1990～2002年收治的粪块性结肠穿孔的32例临床资料进行回顾性分析。术前明确诊断17例,误诊为上消化道穿孔剖腹探查15例。全部病例均行急诊手术,病变结肠Ⅰ期切除吻合7例,穿孔段结肠切除、远端关闭、近端结肠造瘘15例,穿孔结肠拖出双腔造瘘6例,穿孔修补+乙状结肠造瘘4例。结果治愈24例,死亡8例,并发伤口感染6例。结论粪块性结肠穿孔的误诊率高(47.1%),预后差,改善本病治疗效果的关键在早诊断和早治疗。     

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。     

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.     

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。     

老年自发性乙状结肠穿孔28例临床分析

目的探讨老年自发性乙状结肠穿孔患者的诊治方法及效果。方法回顾性分析卢氏县第三人民医院2008-02—2018-02间收治的28例老年自发性乙状结肠穿孔患者的临床资料。结果 13例采取穿孔区域肠段切除Hartmann术,9例采取穿孔修补术联合近端结肠双腔造口术,6例采取穿孔肠段直接外置双腔造口术。20例(71. 4%)痊愈出院,8例(28. 6%)死亡。结论加强对老年自发性乙状结肠穿孔患者的病史询问、体格检查和病情观察,采取相应的影像学检查和治疗措施,能有效提高治愈率。     

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.     

新式保护性肠造口在急诊结肠手术中的应用价值

目的 探讨新式保护性肠造口在急诊结肠手术中的应用价值.方法 回顾性分析16例急诊结肠一期切除吻合术中应用新式保护性肠造口患者的临床资料:回盲部癌合并阑尾穿孔2例;自发性乙状结肠穿孔3例;闭合性腹部外伤致降结肠、乙状结肠广泛挫裂4例;左半结肠癌、乙状结肠癌伴肠梗阻7例.造口方法:回盲部癌伴阑尾穿孔患者,切除末段回肠、部分...     

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。     

Colon perforation in Ehlers-Danlos syndrome: Report of two cases and review of the literature

Two cases of spontaneous perforation of the colon in Ehlers-Danlos syndrome type IV are reported, and eight cases previously reported in the English literature are reviewed. Emergency surgery for acute free colon perforation in patients with Ehlers-Danlos syndrome should be carried out in the following standard manner: exteriorization of the perforation or resection of the involved colon with end colostomy, and either closure of the rectal stump (Hartmann procedure) or distal mucous colostomy. The reported experience although small, indicates that a high incidence of recurrent perforation can be expected if bowel continuity is reestablished. Permanent colostomy status, therefore, appears advisable, despite the young ages of most of the patients.     

Spontaneous rupture and stercoral perforation of the colon. A case report

A case of ruptured colon and massive faecal contamination of the peritoneal cavity after a difficult bowel movement is presented. A perforated peptic ulcer was suspected but a rupture of the rectosigmoid colon was found at operation. Surgical management included resection of the affected colon, proximal colostomy and closure of the distal end of the bowel. Definitions of spontaneous rupture and stercoral perforation of the colon are given, and the possible aetiological factors in and management of these rare cases are discussed.     

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。

     

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.     

Resection of the perforated segment : A significant advance in treatment of diverticulitis with free perforation or abscess

As a result of improved medical management of chronic diverticular disease, perforation has become the most common indication for surgical intervention. During the past five years sixty-three patients underwent operation for colonic diverticular disease, of which forty-six were for perforation (generalized peritonitis in 8, abscess in 30, and fistula in 8). The eight patients with generalized peritonitis underwent emergency exploration for spreading peritoneal signs and were managed by resection of the perforated segment, end colostomy, and mucous fistula or Hartmann's pouch. Treatment of thirty-eight patients with abscess or fistula has also stressed primary resection of the perforated segment of colon. Resection and end colostomy without anastomosis was performed in three. Primary anastomosis with proximal diverting colostomy was performed in four. Primary anastomosis alone was done in thirty-one patients. There were no deaths. These results support primary resection of the involved colon with immediate or delayed anastomosis in the operative management of perforated diverticular disease.