陆金根运用拖线法治疗肛瘘经验探讨

介绍陆金根教授运用现代技术诊断肛瘘瘘管的走向、拖线的设置及术后创面的处理等临床经验。     

Clinical application of gastrointestinal decompression in anastomotic fistula after McKeown esophagectomy for esophageal cancer

AbstractCervical anastomotic fistula is one of the most common complications after McKeown esophagectomy for esophageal cancer, leading to septic shock and even death. It is therefore very important to provide effective symptom management after diagnosis of anastomotic fistula. Placing the gastrointestinal decompression tube beside the anastomotic site and connecting the tube to a gastrointestinal decompression disk could support the prevention and treatment of anastomotic fistula after surgical treatment of esophageal cancer.Thirty-eight patients with anastomotic fistula after undergoing McKeown esophagectomy for esophageal cancer in our hospital from April 2017 to January 2021 were divided equally into control and observation groups according to the gastrointestinal decompression method used. Gastrointestinal decompression tubes were placed 45 to 50 cm from the incisors in the control group or 25 to 30 cm from the incisors in the observation group. The treatment efficacy was compared between the 2 groups.The drainage time, length of hospital stay after anastomotic fistula detection, and fistula healing time in the observation group were significantly shorter than those in the control group (P < .05 for all).Placing the gastrointestinal decompression tube connected to a gastrointestinal decompression disk next to the anastomotic site is a simple procedure and may significantly improve the drainage time, length of hospital stay, and fistula healing time of patients who develop anastomotic fistula resulting from McKeown esophagectomy for esophageal cancer.     

改良双套管持续冲洗负压吸引在肠瘘治疗中的临床分析

目的 探讨改良双套管持续冲洗负压吸引方法治疗肠瘘的临床效果。方法 回顾性分析2003年2月~2013年9月在本科住院治疗肠瘘患者的临床资料,其中A组27例采用自制双套管连接低负压持续引流,B组24例采用传统单腔引流管,分析和比较两组的住院天数、最高体温、引流液量、吻合口狭窄发生率、再手术率及痊愈时间。结果 A组住院天数、痊愈时间短于B组,引流液量少于B组,吻合口狭窄发生率、再手术率低于B组,两组比较差异有统计学意义（P〈0.05）。结论 术后发生肠瘘应立即采用自制双套管及持续低负压冲洗,较传统治疗方式能取得更好的治疗效果。     

眼眶瘘管的特点及治疗分析

目的 探讨不同病因眼眶瘘管的特点及治疗方法.方法 回顾性分析1980年1月至2007年7月就诊的眼眶瘘管患者37例.结果 37例中异物引发的21例.眼眶囊肿引发的9例.眼眶感染性炎症引发的6例.嗜酸性肉芽肿1例,如瘘管可排出脓液、豆渣样物及澄清液体,分别提示感染性炎症、皮样囊肿及非感染性因素.结论 眼眶瘘管形成的常见原因是异物存留、皮样囊肿(包括表皮样囊肿)和骨髓炎.     

Esophageal atresia: critical review of 10 years' experience

From January 1976 to October 1986, 107 cases of esophageal atresia (EA) were admitted to the Neonatal Surgical Unit of the Bambino Gesú Hospital of Rome; 86% of the children had a type III EA. Associated anomalies were present in 47%; they were multiple in 18%. Cardiological malformations were the most frequent followed by digestive, skeletal, urological, and chromosomal aberrations. Surgical treatment was attempted in all children except 3, who died before surgical correction, in an effort to perform an end-to-end anastomosis in a single layer through a transpleural approach. According to the results, children were divided into two groups of 50 patients each: group 1 (1976–1981); and group 2 (1981–1986). Anastomosis was possible in 69% of children (68.7% in group 1, 69.3% in group 2). After 1983, gastrostomy fell into gradual disrepute and a transanastomotic tube was used. Immediate complications were seen in 36.6% of cases; in no case did recurrence of the tracheoesophageal fistula occur. The overall mortality decreased from 50% (group 1) to 30% (group 2). In the two periods considered, the mortality according to Waterston's risk classes was 28.5% 5,8% (class A), 42.1% 11.7% (class B), 82.3% 68.7% (class C). Of a total of 41 deaths, 47% were due to severe associated malformations: bronchopneumopathy or prematurity seemed to have less importance in establishing the prognosis.Offprint requests to: P. Bagolan     

消化管唇状瘘外堵法的临床应用研究

目的 探讨消化管唇状瘘棉球外堵法的临床意义.方法 采用前瞻性随机对照研究的方法,将2001年1月～2007年11月收治的消化管唇状瘘患者分为实验组(15例)和对照组(15例),对照组采用传统的瘘口持续引流、禁食或部分肠内营养加肠外营养支持处理方法,实验组采用瘘口棉球外堵法处理,控制外溢肠液,恢复正常进食及活动.比较两组患者一般临床资料、瘘口大小、流量、体重、白蛋白、确定性手术时间、术后并发症、住院天数、费用等.结果 实验组与对照组相比,瘘口缩小、流量减少、体重白蛋白上升、手术时间提前、术后并发症减少、住院时间缩短、费用减少等差异均有统计学意义.结论 消化管唇状瘘棉球外堵法安全有效,可显著缩短患者病程、减少费用及其痛苦、迅速改善其营养状况.     

Magnetic resonance imaging and hysteroscopy to diagnose colo-uterine fistula: a rare complication of diverticulitis

Colo-uterine fistula of diverticular origin is an extremely rare disease due to the resistance of uterine tissue. Methods for diagnosis remain to be established. Non-invasive imaging like magnetic resonance imaging (MRI) may help to establish a proper diagnosis, but confirmation may be reached by diagnostic hysteroscopy or even surgical exploration. We report a 78-year-old female who presented with continuous dull aching pain associated with increasing constipation. MRI suspected a fistula between the posterior aspect of the uterine body and the sigmoid colon which contained extensive diverticulosis. Hysteroscopy confirmed the fistulous opening, but colonoscopy confirmed diverticular disease with no evidence of malignancy. The patient had en block surgical treatment of the uterus and the adjacent colon, followed by an uneventful recovery. The sensitivity and specificity of non-invasive imaging procedures to diagnose such cases remain to be established. As imaging procedures cannot rule out neoplasia, endoscopic procedures need to be added.     

Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasound

Objective  To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter.
Design  A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed.
Methods  To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans.
Main outcome measures  Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A–E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations.
Conclusions  LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms.     

The circumferential obstetric fistula: characteristics, management and outcomes

Obstetric vesicovaginal fistula is a tragic injury that is widespread in any country where access to emergency obstetric care is limited. More and more people are now interested in treating and caring for these women, but little is known about surgical management, and most operators have developed their own methods through years of experience. One of the more challenging cases to get a functional repair is in those women who have a circumferential defect in the bladder/urethra. This article analyses a series of 77 consecutive circumferential obstetric fistula cases operated in the Barhirdar Hamlin Fistula Centre by the author.     

食管癌、贲门癌切除术后食管胃器械吻合术213例临床观察

目的：探讨器械吻合器在治疗食管癌、贲门癌中的临床价值。方法：通过回顾分析，将213例食管癌、贲门癌切除术行器械吻合器吻合作为观察组，将同期208例食管癌、贲门癌切除术行传统手工吻合作为对照组，并将两组进行比较分析，观察两组术后吻合口瘘、吻合口狭窄及吻合口出血的发生率。结果：观察组中无吻合口瘘发生，发生率0．00％，对照组中有8例并发吻合口瘘，发生率3．85％，两组比较有统计学差异（P＜0．05）；观察组中仅有1例并发吻合口狭窄，发生率0．47％，对照组中有11例并发吻合口狭窄，发生率5．29％，两组比较有统计学差异（P＜0．01）；观察组中有1例并发吻合口出血，发生率0．47％，对照组2例吻合口出血，发生率0．96％，两组比较无统计学差异（P＞0．05）。结论：食管癌、贲门癌切除术应用器械吻合器进行食管胃听合术后吻合口瘘和吻合口狭窄的发生率低，吻合效果满意，临床应用价值乐观。