直肠癌术后并发急性坏死性筋膜炎及脓毒性休克诊治体会

摘要

目的 探讨直肠癌术后并发急性坏死性筋膜炎的危险因素、临床特征及诊治特点.方法 回顾性分析2013年1月—2015年12月解放军总医院重症医学科收治的直肠癌术后并发急性坏死性筋膜炎及脓毒性休克7例的临床资料.结果 本组中位年龄53岁,3例有糖尿病病史,3例术前曾接受全身化学治疗.7例均在直肠癌术后24 h内出现发热及会阴、腹股沟部红肿、疼痛等症状,48 h内出现乳酸酸中毒、系统及器官功能衰竭、不同程度意识障碍.清创前序贯器官衰竭估计评分(12.29±4.54)分,急性生理学及慢性健康评定标准Ⅱ评分(25.86±9.70)分,动脉血乳酸(13.59±5.47)mmol/L.所有患者均给予综合支持治疗维持脏器功能,其中1例未行外科清创,病情迅速恶化,于直肠癌术后第3天死亡;6例均在发病48~96 h行外科清创治疗,休克及酸中毒情况迅速改善,病情逐渐好转,组织培养提示均为混合感染,病理检查证实为坏死性筋膜炎.结论 直肠癌术后并发急性坏死性筋膜炎常迅速出现脓毒性休克、乳酸酸中毒和多脏器功能衰竭;早期诊断及外科清创引流是其治疗成功的关键.%Objective To investigate risk factors, clinical characteristics, key points of diagnosis and treatment of post-operative combination of acute necrotizing fasciitis and severe septic shock after operation for rectal cancer. Methods Clinical data of 7 patients with combination of acute necrotizing fasciitis and severe septic shock after operation for rectal cancer admitted during January 2013 and December 2015 was retrospectively analyzed. Results The median age of patients was 53 years old, and 3 patients had the history of diabetes, and 3 patients underwent systemic chemotherapy before the operation. Symptoms such as fever, swelling in perinea and groin and pain were found in the 7 patients within 24 h after the operation, and then lactate aci-dosis, system and organ nonfunction and consciousness disorders in different degrees were found within 48 h after the operation. Before debridement, sequential organ failure assessment (SOFA) score was(12. 29 ± 4. 54) score, and acute physiology and chronic health evaluation Ⅱ (Apache Ⅱ) score was(25. 86 ± 9. 70) score, and level of arterial blood lactic acid was 6. 2-23. 0 (13. 59 ± 5. 47) mmol/L. All patients received comprehensively support treatments to keep the function of organs. Among the 7 patients, 1 patient without debridement died on the 3rd d after the rectal surgery because of quickly worse condition, and other 6 patients received surgical debridement within 48-96 h after the onset, and symptoms of shock and acidosis were improved imme-diately. Tissue cultures showed mixed bacterial infections, and pathological examination showed necrotizing fasciitis. Conclu-sion Highly risk factors of postoperative necrotizing fasciitis are complicated with quickly septic shock, lactate acidosis and multiple organ failure in patients with acute necrotizing fasciitis after rectal surgery, diabetes, hypoimmunity and poor prepara-tion before operation, and therefore early diagnosis and surgical debridement is the key to successful treatment.