老年肠外瘘患者早期手术治疗的可行性分析

肠外瘘是一种严重的腹部外科疾病,多见于各种急腹症术后、开放性腹部外伤、炎症性肠病穿孔等,目前其死亡率仍较高,据报道在15%～20%[1].治疗肠外瘘的有效方法包括腹腔引流、抗感染、肠外及肠内营养支持、药物治疗、手术治疗等综合治疗手段.老年肠外瘘患者多合并全身系统性疾病,脏器功能储备不足,对手术治疗耐受力较差,以往的治疗多以长期的营养支持和药物治疗等非手术措施为主,在付出心理和经济负担的同时治愈率却未见提高.本文对我科2006年7月至2010年10月收治的16例老年肠外瘘患者的临床资料进行回顾性分析,旨在探讨对老年肠外瘘患者早期手术干预的可行性.     

手术后肠外瘘的原因及预防

2000年1月至2002年6月，我们收治手术后肠外瘘患者34例。现将肠外瘘原因进行分析，并探讨预防或降低肠外瘘的有效措施。     

肠外瘘临床综合诊治的探讨

目的探讨肠外瘘的综合诊断与治疗的方法与效果。方法回顾性分析该院2013-06~2017-01收治的149例肠外瘘(由外院转入119例)的临床治疗结果。结果 149例肠外瘘患者经治疗后顺利出院129例(86.58%),放弃治疗自动出院13例(8.72%),死亡7例(4.70%),主要死于严重感染及多器官功能衰竭。其中腹部外伤致肠外瘘18例(12.08%),其余多为腹部外科手术后1~2周出现肠外瘘,经通畅引流、抗感染、营养支持等治疗后大部分肠外瘘患者好转或治愈。而其中8例结直肠外瘘早期行回肠造瘘术或结肠造瘘术,12例肠外瘘患者行二期闭瘘术或二期肠瘘切除术+消化道重建术。结论该组肠外瘘患者取得治疗成功的关键是早期通畅有效的腹腔冲洗引流,同时强力有效的抗感染、营养支持与生命器官的监测是成功的基础。     

重组生长激素与谷氨酰胺协同促进短肠大鼠小肠的代偿

目的　研究添加生长激素(rhGH)及谷氨酰胺(Gln)的肠外营养(PN)对短肠大鼠残存小肠代偿的作用及机制。方法　按2×2析因实验方案,将SD大鼠随机分成STD、Gln、rhGH及rhGH+Gln组,建立PN短肠动物模型。PN6d后行小肠黏膜形态学检查,并行细胞增殖核心抗原(PCNA)测定、原位末端标记(TUNEL)染色及胰岛素样生长因子-1(IGF-1)mRNA的Northernb1ot测定。结果　rhGH+Gln组残余小肠黏膜形态学上呈显著代偿表现。析因分析表明,rhGH与Gln间存在协同作用(P＜0.01)。其PCNA表达显著高于rhGH、Gln与STD组,分别为24.95±3.93、19.28±3.25、17.27±3.38与8.37±2.23(P＜0.01);凋亡指数显著降低,分别为5.68±2.07、8.06±2.33、10.00±2.24及22.32±3.84(P＜0.01);小肠IGF-1mRNA表达在rhGH+Gln组显著高于rhGH、Gln及STD组,分别为0.73±0.05、0.62±0.04、0.51±0.04及0.41±0.22(P＜0.05)。结论　rhGH与Gln通过促进肠黏膜上皮细胞增生与抑制其凋亡,协同促进短肠大鼠残存小肠代偿,小肠IGF-1在二者协同作用的发挥中起重要的介导作用。     

肠外营养支持辅助治疗老年性肺炎22例报告

老年性肺炎起病急骤，病情重，病后大多食欲不振，日久则因营养不良而发生全身衰竭，是其死亡率高的一个重要原因。应用肠外营养（ｐａｒｅｎｔｅｒａｌｎｕｔｒｉｔｉｏｎ，ＰＮ）支持辅助治疗老年性肺炎，可获得满意的疗效，介绍如下。１资料与方法１．１病例选择老年性...     

老年胃肠道手术后患者早期肠内肠外营养支持与肠外营养支持的疗效比较

目的探讨早期肠内肠外营养支持疗法(EEN+PN)与肠外营养支持(PN)对老年胃肠道手术后患者的疗效。方法将106例行胃肠道手术的老年患者随机分为EEN+PN组(n=53)和PN组(n=53),分别于术前1 d和术后第7天测定其相关营养、生化、免疫及炎症指标,比较两组患者胃肠道恢复、住院时间、营养相关费用及术后并发症情况。结果术后第7天EEN+PN组血清白蛋白(ALB)与前白蛋白(PA)水平均明显高于PN组(均P0.05);术后第7天EEN+PN组C反应蛋白(CRP)明显高于PN组,而淋巴细胞计数(LYM)明显低于PN组(均P0.05);EEN+PN组术后首次排气时间、住院时间及营养支持费用均明显低于PN组(均P0.05),EEN+PN组中有5例发生腹泻、腹胀及恶心等并术后发症,PN组3例。结论早期EEN+PN较PN可更有效改善机体营养状况,保护机体免疫能力及胃肠道功能,有助于患者术后恢复,缩短其住院时间,减少营养支持费用。     

食管癌术后患者早期肠内、全肠外营养对比观察

目的比较食管癌术后早期肠内营养（EEN）支持与全肠外营养（TPN）支持的效果。方法将93例行开胸探查食管癌切除手术患者随机分为EEN组（47例）和TPN组（46例）,术后分别给予EEN支持、TPN支持,检测手术前后营养、肠屏障功能、炎性及免疫指标,观察并发症、肠功能恢复时间、术后住院时间、住院费用。结果与同组术前比较,两组术后第1天ALB、TFN、PA、CD4／CD8、NK水平降低,I-FABP、ET、D—Lac、CRP、TNF-α水平升高;术后第7天TFS、MAC、ALB、TFN、PA、CD4／CD8、NK水平降低,I-FABP、ET、D—Lac、CRP、TNF—α水平升高（P均〈0．05）。与TPN组比较,EEN组术后第7天TFN、PA、CD4／CD8、NK水平升高,I-FABP、ET、D—Lac、CRP、TNF—α水平降低（P均〈0．05）。EEN组、TPN组并发症发生率分别为36．2％、78．3％,肠功能恢复时间分别为（43．2±5．6）、（82．4±16．7）h,术后住院时间分别为（15．3±3．2）、（22．7±5．5）d,住院费用分别为（64669±7150）、（77923±8990）元,两组比较P均〈0．05。结论食管癌术后EEN支持在改善患者营养状况、细胞免疫功能、保护肠黏膜屏障功能等方面较TPN支持具有明显优势。     

以腰部脓肿为主要表现的肠外瘘1例

患者男 ,38岁 ,因右腰背部肿痛 12天、破溃流脓 4天入院。既往无盗汗、咳血、消瘦 ,无腹痛、腹胀、恶心呕吐等 ,大小便正常。 1个月前曾不明原因腹痛 ,对症治疗后缓解。查体见右腰背部髂嵴上距中线约 10 cm有一直径 8cm的红肿压痛区 ,中央破溃 ,有稀薄粪臭味脓液溢出 ,余未发现异常。诊断为腰部脓肿。在局麻下切开脓肿 ,引流脓液 2 0 0 ml,取出长 8cm的死亡蛔虫 1条。化验检查脓液中含粪便成份 ,细菌培养为大肠杆菌生长。全消化道钡透检查示脓腔与回盲部相通。纠正诊断为盲肠外瘘。经抗炎输液治疗后脓腔缩小 ,后在硬膜外麻醉下行剖腹探查术…     

肠外营养支持在老年胃肠道肿瘤病人围手术期中的应用

老年人患胃肠道肿瘤的围手术期营养支持,是老年外科手术治疗中一个极易被忽视而又十分重要的问题。自１９９３年６月以来,我们在对２０例老年胃肠道肿瘤病人的手术治疗中。实施围手术期肠外营养支持（Ａ组）,与同期２０例未进行围手术期肠外营养支持的同类病人（Ｂ组）...     

腹部手术后肠外瘘42例临床分析

目的 探讨腹部手术后肠外瘘病人的病因及诊疗方法。方法 回顾性分析42例腹部手术后肠外瘘病人产生原因、诊疗情况。结果42例病人产生的局部原因中,吻合口、残端及病理性胃、肠穿孔修补术后愈合不良22例,占52．38％,手术误伤15例,占35．71％,切口感染、裂开时,对腹内肠管保护不当3例,占7．14％,腹内脓肿及引流管压迫2例,占4．76％。全组治愈34例,占80．95％,死亡6例,占14．29％,因经济原因未愈要求出院2例,占4．76％。结论手术后肠外瘘产生的主要因素是局部原因,重在预防;其治疗原则包括维持内环境稳定、营养支持、抗感染并建立有效通畅的引流、应用生长抑素和生长激素、确定性手术治疗及维护重要器官功能。肠外瘘是腹部外科手术中最严重并合症之一,住院时间长、经济费阁大、死亡率较高;自20世纪70年代开始,应用肠外营养及对肠外瘘病理生理的进一步认识,80年代生长抑素的应用,肠外瘘的死亡率明显下降,自愈率不断提高;但是,肠外瘘目前仍然是腹部外科手术中相当棘手的问题：作对本组42例腹部手术后肠外瘘病人的临床资料进行分析,并对其产生的局部原因及诊治方法进行了总结和讨论。     

Reduction of the closure time of postoperative enterocutaneous fistulas with fibrin sealant

AIM: To assess whether the use of fibrin sealantshortens the closure time of postoperative enterocutaneous fistulas (ECFs). METHODS: The prospective case-control study included 70 patients with postoperative ECFs with an output of < 500 mL/d, a fistulous tract of > 2 cm and without any local complication. They were divided into study (n = 23) and control groups (n = 47). Esophageal, gastric and colocutaneous fistulas were monitored under endoscopic visualization, which also allowed fibrin glue application d...     

Treatment of enterocutaneous and colocutaneous fistulas with early surgery or somatostatin analog

Standard therapy of enterocutaneous (ECF) and colocutaneous (CCF) fistulas consists of conservative management, with surgery reserved for failures of maximal medical treatment. We conducted a five-year retrospective review of 28 patients with low-output ECF and CCF to determine the outcome of early surgical and nonsurgical treatment of these conditions. Twelve men and 16 women with a mean age of 60 years presented with 22 ECF and 6 CCF. Six patients had early operative intervention in an attempt to close their fistulas, while the remaining 22 patients were treated without surgery. In addition, four of the nonsurgical group received parenteral somatostatin analog (SA). None of the surgical patients was septic preoperatively (mean WBC=9.7), the mean preoperative hospital stay was 11 days, and no patients required a proximal diverting stoma. All of the surgical group resumed normal gastrointestinal function within two weeks, and seven of the nine (78 percent) demonstrated no recurrence of the fistula at a mean follow-up of 8.3 months. Of the 22 medically treated patients, three of the four who received SA healed their fistulas within two weeks. Only two of the other 13 medically treated patients (15 percent) healed their fistulas. Early surgery or the use of SA should be considered in the treatment of patients with low-output intestinal fistulas.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Polymorphism of heat shock protein 70-2 and enterocutaneous fistula in Chinese population

AIM: To investigate whether the heat shock protein 70-2 (HSP70-2) polymorphism is associated with enterocutaneous fistulas in a Chinese population.METHODS: This study included 131 patients with enterocutaneous/enteroatmospheric fistulas. Patients with inflammatory bowel disease or other autoimmune diseases were excluded from this study. All patients with enterocutaneous/enteroatmospheric fistulas were followed up for three months to observe disease recurrence. In addition, a total of 140 healthy controls were also recruited from the Jinling Hospital, matched according to the sex and age of the patient population. Genomic DNA was extracted from peripheral blood from each participant. The HSP70-2 restriction fragment length polymorphism related to the polymorphic PstI site at position 1267 was characterized by polymerase chain reaction (PCR). First PCR amplification was carried out, and then PCR products were digested with PstI restriction enzyme. The DNA lacking the polymorphic PstI site within HSP70-2 generates a product of 1117 bp in size (allele A), whereas the HSP70-2 PstI polymorphism produces two fragments of 936 bp and 181 bp in size (allele B).RESULTS: The frequency of the HSP70-2 PstI polymorphism did not differ between patients and controls; however, the A allele was more predominant in patients with enterocutaneous fistulas than in controls (60.7% vs 51.4%, P = 0.038, OR = 1.425, 95%CI: 1.019-1.994). Sixty-one patients were cured by a definitive operation, drainage operation, or percutaneous drainage while 52 patients were cured by nonsurgical treatment. There was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who had surgery compared to those who did not (P = 0.437, OR = 1.237, 95%CI: 0.723-2.117). Moreover, 11 patients refused any treatment for economic reasons or tumor burden, and 7 patients with enterocutaneous fistulas (5.8%) died during the follow-up period. However, there was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who survived compared to those who died (P = 0.403, OR = 0.604, 95%CI: 0.184-1.986).CONCLUSION: The A allele of the HSP70-2 PstI polymorphism was associated with enterocutaneous fistulas in this Chinese population.     

良性食管气管瘘的治疗经验

目的总结良性食管气管瘘的治疗经验。方法我科收治的食管气管瘘患者13例,食管烧伤造成9例,先天性食管气管瘘3例,原因不明的食管气管重复瘘1例。采用结肠或胃代食管术治疗10例,行瘘口修补术3例。结果术后吻合口瘘发生4例,经保守治疗痊愈,术后吻合口狭窄1例,经扩张治疗痊愈。术后患者进食情况良好,无围手术期死亡。结论良性食管气管瘘应及时恢复消化道的连续性,先天性和获得性食管气管瘘诊断和治疗有明显差别。     

Hydrogen peroxide enhanced ultrasound- fistulography in the assessment of enterocutaneous fistulas complicating Crohn's disease

BACKGROUND/AIMS: Proper management of enterocutaneous fistulas complicating Crohn's disease largely depends on the anatomical characteristics of the sinus tracks as well as the coexistence of complications such as abscesses and distal bowel stenosis. The aim of this prospective study was to evaluate the accuracy of a new technique (hydrogen peroxide enhanced ultrasound (US)-fistulography) compared with conventional x ray fistulogram and/or surgical findings in the detection of Crohn's disease associated enterocutaneous fistulas. METHODS: Patients with known Crohn's disease and a suspicion of enterocutaneous fistulas were prospectively studied with this novel technique, conventional x ray fistulogram, and barium radiography as well as with computed tomography whenever an abdominal abscess was suspected at US. In those undergoing surgery, intraoperative findings were also compared. RESULTS: Seventeen of 502 (3.4%) consecutive patients with Crohn's disease seen over a ten month period had associated enterocutaneous fistulas and were enrolled. Hydrogen peroxide enhanced US-fistulography visualised the extent and configuration of fistula in all cases: 13 patients had a fistula arising from the ileum and two from the sigmoid colon, whereas in two there was no evidence of communication with intestinal loops; in contrast, conventional x ray fistulography missed a correct definition of the fistulous branches or communication with intestinal loops in 50% (4/8) and 36% (4/11) of patients respectively; barium radiography showed fistulas in two cases only. The presence of abscesses along or close to the sinus track, as well as the coexistence of intestinal stenosis, was correctly detected at US in all patients. CONCLUSIONS: Hydrogen peroxide enhanced US-fistulography could be considered the diagnostic procedure of choice in Crohn's disease associated enterocutaneous fistulas, as it is at least as accurate, simple, and safe as conventional x ray fistulogram, does not miss coexisting abdominal complications, and also provides information on the diseased bowel segments. In addition, it can be easily repeated over time in order to monitor the course of fistulas undergoing conservative treatment.     

Effects of recombinant human growth hormone on enterocutaneous fistula patients

AIM： To explore the effects of recombinant human growth hormone （rhGH） on intestinal mucosal epithelial cell proliferation and nutritional status in patients with enterocutaneous fistula. METHODS： Eight patients with enterocutaneous fistulas received recombinant human growth hormone （10 ug/d） for 7 d. Image analysis and immunohistochemical techniques were used to analyse the expression of proliferating cell nuclear antigen （PCNA） in intestinal mucosal epithelial cells in biopsy samples from the patients who had undergone an endoscopic biopsy through the fistula at day 0, 4 and 7. Body weights, nitrogen excretion, serum levels of total proteins, albumin, prealbumin, transferrin and fibronectin were measured at day 0, 4 and 7. RESULTS： Significant improvements occurred in the expression of PCNA in the intestinal mucosal epithelial cells at day 4 and 7 compared to day 0 （24.93 ± 3.41%, 30.46 ± 5.24% vs 12.92 ± 4.20%, p 〈 0.01）. These changes were accompanied by the significant improvement of villus height （500.54 ± 53.79 um, 459.03 ± 88.98um vs 210.94 ± 49.16 um, P 〈 0.01）, serum levels of total proteins （70.52 ± 5.13 g/L, 74.89 ± 5.16 g/L vs 63.51 ± 2.47 g/L, P 〈 0.01）, albumin （39.44 ± 1.18 g/L, 42.39 ± 1.68 g/L vs 35.74 ± 1.75 g/L, P 〈 0.01） and fibronectin （236.3 4- 16.5 mg/L, 275.8± 16.9 mg/L vs 172.5 ± 21.4 mg/L, P 〈 0.01） at day 4 and 7, and prealbumin （286.38 ± 65.61 mg/L vs 180.88 ± 48.28 mg/L, P 〈 0.05）, transferrin （2.61 ± 0.12 g/L vs 2.41 ±0.14 g/L, P 〈 0.05） at day 7. Nitrogen excretion was significantly decreased at day 7 （3.40 ± 1.65 g/d vs 7.25 ± 3.92 g/d, P 〈 0.05）. No change was observed in the body weight. CONCLUSION： Recombinant human growth hormone could promote intestinal mucosal epithelial cell proliferation and protein synthesis in patients with enterocutaneous fistula.     

Salvage surgery after definitive chemoradiotherapy for esophageal cancer

Background Definitive chemoradiotherapy has been performed as a first-line treatment for esophageal cancer, whereas salvage surgery might be the only reliable treatment for patients with recurrence after definitive chemoradiotherapy.Methods We reviewed 38 patients with squamous cell carcinoma who underwent esophagectomy and 6 patients who underwent lymphadenectomy after definitive chemoradiotherapy (≥50 Gy).Results The median survival time and 5-year survival rate after salvage esophagectomy were 16 months and 27%, respectively. Three of the 7 patients who had cervical esophageal cancer underwent cervical esophagectomy with laryngeal preservation. Two patients (5.2%) who underwent salvage esophagectomy with three-field lymphadenectomy before 1997 died of postoperative complications, but no patient died of complications thereafter. Although the overall survival after salvage esophagectomy was correlated with residual tumor (R) (P = 0.0097), the median survival time of 7 patients with residual tumors (R₂) was 7 months. Overall postoperative survival was closely correlated with the response to chemoradiotherapy (P < 0.0001) but was not associated with histologic effects on resected specimens. Survival was significantly correlated with the depth of viable tumor invasion (pT) (P = 0.0013) and with lymph node metastasis (pN) (P < 0.0001). Long-term survival was achieved in 5 of the 6 patients who underwent salvage lymphadenectomy.Conclusions Salvage surgery should be considered for patients with recurrence after definitive chemoradiotherapy. Salvage lymphadenectomy may be useful for recurrence confined to the lymph nodes whereas postoperative complications of salvage esophagectomy should be warranted.     

Early rehabilitation programs after laparoscopic colorectal surgery:Evidence and criticism

During the past several decades,early rehabilitation programs for the care of patients with colorectal surgery have gained popularity.Several randomized controlled trials and meta-analyses have confirmed that the implementation of these evidence-based detailed perioperative care protocols is useful for early recovery of patients after colorectal resection.Patients cared for based on these protocols had a rapid recovery of bowel movement,shortened length of hospital stay,and fewer complications compared with traditional care programs.However,most of the previous evidence was obtained from studies of early rehabilitation programs adapted to open colonic resection.Currently,limited evidence exists on the effects of early rehabilitation after laparoscopic rectal resection,although this procedure seems to be associated with a higher morbidity than that reported with traditional care.In this article,we review previous studies and guidelines on early rehabilitation programs in patients undergoing rectal surgery.We investigated the status of early rehabilitation programs in rectal surgery and analyzed the limitations of these studies.We also summarized indications and detailed protocol components of current early rehabilitation programs after rectal surgery,focusing on laparoscopic resection.     

监测下麻醉部分下尿路腔镜手术禁食与早期肠内营养

目的:探讨监测下麻醉部分下尿路腔镜手术缩短禁食时间与术后早期肠内营养安全性.方法:选择监测下麻醉部分下尿路腔镜手术46例,与同期传统方法50例进行比较.禁食时间研究组>1h、腰麻组>4 h;麻醉前测定血糖、酮体.记录三个时段(手术区间前、中、后1/3时间点)平均呼吸频率和心率.术后1 h进食,观察有无消化道反应(上腹部饱胀、恶心或/和呕吐).结果:研究组46例,血糖5.3467±0.9762 mmol/ L、血酮体1.1933±0.4876 mmol/L、平均呼吸频率19.73±2.02次/分和心率76.8±19.6次/分.术后6例(13%)有消化道反应.腰麻组50例,血糖4.8765±1.2390 mmol/L、血酮体1.568l±1.0368 mmol/L、平均呼吸频率20.53±3.26次/min和心率80.2±21.4次/min.术后36例(72%)有消化道反应.统计分析禁食时,两组血糖和酮体有显著差异(P<0.05),而术中平均呼吸频率和心率无显著区别(P>0.05).早期肠内营养项目组间比较有显著差异(P<0.05).结论:监测下麻醉部分下尿路腔镜手术缩短禁食是安全的,术后早期肠内营养也是安全可行的.