肠外瘘早期确定性手术的临床研究

摘要

目的研究在肠外瘘发生早期，一期切除肠外瘘肠段，并进行肠吻合以消除瘘的手术效果。方法本组患者男18例，平均(31.5±16.5)岁；女8例，平均(38.4±22.4)岁。26例患者中，重症胰腺炎并发肠外瘘2例，腹部创伤并发肠外瘘11例，妇产科手术因术中损伤肠道并发肠外瘘3例，肠道炎性疾病、肠梗阻和肠套叠等小肠良性疾病术后并发肠外瘘10例。26例患者中十二指肠瘘2个，小肠瘘及小肠吻合口瘘18个，回结肠吻合口瘘5个，结肠瘘4个。本组患者2例合并胆瘘，1例合并胰空肠吻合口瘘，2例为多发瘘。小肠部分切除吻合术18例次，结肠部分切除吻合术3例次，回结肠吻合口切除再吻合术5例。在术后72 h使用重组人生长激素。结果 26例患者无死亡。18例需机械辅助呼吸，平均支持时间(3.0±2.4) d。早期确定性手术距前次致瘘手术或腹膜炎发生平均(8.9±4.6) d，距发现瘘的时间为(4.0±2.6) d。恢复肠内营养的时间为(9.7±3.1) d。完全经口饮食平均为(18.7±8.1) d。术后生长激素平均使用(8.9±2.8) d。结论在肠外瘘早期行确定性手术，并在术后适时加用生长激素可促进吻合口的愈合；进一步提高肠外瘘的治愈率，缩短治疗时间。%Objective　To study the possibility and effect of early definitive surgery in enterocutaneous fistula (EF) patients with intra-abdominal sepsis. Early definitive surgery was defined as early resection of EF and reanastomosis of the bowel within 14 days after operation or injury caused EF.　Methods　26 patients with EF comprised 18 males (mean age 31.5±16.5 years) and 8 females (mean 38.4±22.4 years). Enterocutaneous fistulas included 2 from the duodenum, 18 from the small bowel, 4 from the colon, and 5 from the ileocolic anastomotic dehiscence. Among them, 2 were complicated by biliary fistula, one patient had pancreatic fistula and two had multiple orifices fistulas. Etiological factors of EF were severe pancreatitis (2 patients), abdominal trauma (11), anastomotic dehiscence of the small bowel (10), and injuries in gynecological procedures (3). All patients underwent resection of EF, anastomosis by using stapling devices and copious peritoneal lavage. Recombinant growth hormone (rhGH, 0.16 U*kg－1*d－1) was given within 3 days after operation, and all the patients had prophylactic antibiotic coverage.　Results　No death was observed in these patients and the morbility reduced significantly after early definitive surgery. Complications included immediate postoperative anastomotic leakage cured spontaneously within three days (3 patients) and acute respiratory insufficiency that needed （3.0±2.4）days of mechanical ventilation (18). The time between definitive surgery and previous operation or trauma induced EF was (8.9±4.6) days. Enteral feeding and total oral feeding were restored after (9.7±3.1) and (18.7±8.1)days accordingly after reoperation. The average length of rhGH treatment was (8.9±2.8)days.　Conclusions　With improved surgical techniques, nutrition support, organ function support, appropriate antibiotics use and rhGH treatment, early resection-anastomosis can be performed safely and effectively for EF patients even with severe intra-abdominal sepsis.