促进化脓性腹膜炎肠吻合愈合的临床研究

Clinical Study of Measures Promote Healing of Intestinal Anastomosis in Severe Purulent Peritonitis

目的探索在急性化脓性腹膜炎条件下促进肠吻合或缝合口愈合的措施。方法于1998～2004年选择性地对47例外伤性肠损破或手术后吻合破裂伴有急性化脓性腹膜炎且延误处理48h以上的病人,在剖腹探查、引流的同时,行肠切除吻合或缝合术,辅以大量等渗盐水冲洗腹腔,吻合或缝合口涂喷纤维蛋白胶,放置多根腹腔负压引流管。术后24～48h开始给予重组人生长激素与相应的术后处理。结果术后2例发生吻合口破裂,1例经非手术治疗后愈合;另1例系胃癌术后胃肠吻合口破裂,再次手术后未应用生长激素,非手术治疗无效。全组病人术后除均继续表现有脓毒症外,并发肝功能损害23例(48.9%),肺部感染或急性呼吸窘迫综合征(ARDS)16例(34.0%),肾功能障碍6例(12.8%),除1例死亡外,余均治愈。结论营养支持,感染控制措施的进步,纤维蛋白胶与生长激素的应用,加上术后细致的处理、有效地防治并发症,在急性化脓性腹膜炎条件下肠切除吻合或缝合仍能获得成功。

Objective To investigate the effective measures to promote the healing of intestinal anastomosis in severe purulent peritonitis. Methods From 1998 to 2004,47 cases of severe purulent peritonitis due to delay diagnosed traumatic perforation or anastomotic leak of intestine were enrolled into study. Resection and anastomosis or suture of damaged intestinal segment was performed during laparotomy for drainage of purulent peritonitis. The peritoneal cavity irrigated with large volume of isotonic saline（ about 10000mL） at the beginning and the end of operation respectively. Fibrin glue used to seal the anastomosis. Multiple double-lumen sump drainage tubes were insearted in the subhepatic, paracolonic peritoneal potential space or iliad： fossa for drainage of peritoneal residual fluid. Recombinant human growth hormone administrated at 2nd or 3rd postoperative day for 5 - 7 days. Results Disruption of intestinal anastomosis was occurred in 2 cases postoperatively,one cured after conservative treatment. Another one is a case of gastric cancer with gastroenteric fistula, rhGH not administrated after reoperation, fail to response subsequent treatment. Thus, the cure rate of 47 cases is 95. 7%, and the fail rate of operation is 2. 1%. Some postoperative complications were developed in this group of patients such as hepatic dysfuntion （23 cases,48. 9% ） ,renal dysfunction （6 cases, 12.8% ） and ARDS（ 16 cases,34.0% ）. The complications were successfully treated in all patients except one case died of severe sepsis, the total mortality is 2. 1%. Conclusion The combination of peritoneal lavage,effective drainage and application of fibrin glue and rhGH have the benefit to promote healing of intestinal anastomosis in severe purulent peritonitis. In addition, well control of sepsis, excellent nutrition support and meticulous postoperative intensive care are important accessory management to provide success.