损伤控制理念下结肠损伤的处理方式  

Management of colonic injuries in the setting of damage control surgery

作　　者：叶志强[1] 杨跃武[2] 罗刚健[3] 黄勇[4] 

机构地区：[1]中山大学附属第三医院急诊科,广州510630 [2]中山大学附属第三医院中医科,广州510630 [3]中山大学附属第三医院麻醉科,广州510630 [4]中山大学附属第三医院胃肠外科,广州510630

出　　处：《中华胃肠外科杂志》2014年第11期1125-1129,共5页Chinese Journal of Gastrointestinal Surgery

基　　金：广东省科技计划项目（20108060900024）

摘　　要：目的 比较损伤控制手术（DCS）处理严重结肠损伤时,二期确定性手术肠切除肠吻合与肠造口两种结肠修补方式的安全性.方法 回顾性分析2005-2013年间在中山大学附属第三医院接受DCS处理的67例严重结肠损伤患者的临床资料,按二次确定性手术中结肠修补方式,分为吻合组（40例,单纯肠缝合修补术,或肠切除肠吻合术）和造口组（27例,肠切除肠吻合加近端预防性肠造口）,比较两组患者术后并发症发生情况,并对术后结肠吻合口瘘的危险因素进行分析.结果 吻合组与造口组患者一般资料、损伤程度、入院时生理状态及初次手术处理（包括输血）的差异均无统计学意义（P＞0.05）.确定性手术后,两组患者吻合口瘘、腹腔脓肿、肠外瘘及切口感染等并发症发生率的差异均无统计学意义（P＞0.05）.吻合组和造口组分别有6例（15.0％）和3例（1 1.1％）患者出现结肠吻合口瘘（P＞0.05）.在9例结肠吻合口瘘患者中有7例（7/9）出现左半结肠损伤,明显高于其在无吻合口瘘者中的比例（41.4％,24/58） （P＜0.05）;腹膜关闭中位时间为10d,较无吻合口瘘患者（2 d）明显延迟（P＜0.05）.结论 在严重结肠损伤的DCS处理中,肠造口术不宜优先考虑;尽早关闭腹膜或有助于降低结肠吻合口瘘的发生概率。Objective To compare the safety of anastomosis and ostomy following 2-stage definitive colonic resection when severe colonic injuries treated in the setting of damage control surgery （DCS）.Methods Clinical data of 67 patients with severely traumatic colonic injuries undergoing DCS at the Third Affiliated Hospital of Sun Yat-sen University between 2005 and 2013 were analyzed retrospectively.Patients were divided into the anastomosis group undergoing colonic resection and anastomosis （n=40）,and the ostomy group undergoing anastomosis with a protecting proximal ostomy （n=27）.Postoperative complications were compared between these two groups.The risk factors of colonic anastomosis leakage were analyzed.Results Demographics,injury severity,physiological imbalance on admission,transfusion during the first operative procedure were similar in the two groups （all P 〉0.05）.Rates of anastomotic leakage,intra-abdominal abscess,enterocutaneous fistula,and would infection after definitive resection were not statistically different between the two groups （all P〉 0.05）.Colonic anasomotic leakage rates were 15.0%（6/40） in anastomosis group and 11.1%（3/27） in ostomy group without significant difference （P〉0.05）.Left-sided colon injuries occurred in 7 out of 9 patients with anatomotic leakage,whose proportion was significantly higher than that in those without anastomotic leakage（7/9 vs.24/58,77.8% vs.41.4%,P〈0.05）.A prolonged peritoneal closure was also observed in patients with anastomotic leakage （median,10 days vs.2 days,P〈0.05）.Conclusions A strategy of diverting ostomy is not the first choice for patients sufering from severe colonic injuries in the setting of DCS.Peritoneal closure at early stage may decrease the risk of colonic anastomotic leakage.

关 键 词：结肠损伤 损伤控制手术 肠吻合术 肠造口术 吻合口瘘 

分 类 号：R656.9[医药卫生—外科学]