重视肠瘘的早期诊断与快速治疗

Early diagnosis and rapid treatments of gastrointestinal fistula

腹部外科手术后发生肠瘘，尤如大江决堤，令人见之“色变”。紧随肠瘘之后就是感染、出血和水电解质失衡。感染和出血失控又会进一步加重脏器功能损害，导致多脏器功能障碍。整个病程中患者能量与蛋白质的摄入、消化与吸收均会不同程度地受到影响，营养不良随之发生。诸多并发症相继出现并相互影响，形成恶性循环，病程迁延，最终引起一个或多个脏器功能的衰竭，导致治疗失败。

Traditional treatments of gastrointestinal fistula include early drainage, maintaining nutrition and then resection of fistula at the proper time, which usually take throe to four months or even longer. Rapid treatments of gastrointestinal fistula mean promoting rapid spontaneous closure of tract fistula and early primary resection of fistula within two weeks after fistula occurrence. Early diagnosis is the premise of early management, and fistulography and abdominal CT scan are important early diagnostic methods. Most of fistula could close spontaneously in the maintaining stage. To promote the rapid closure, however, special measures including sufficient drainage, somatostatin and total parenteral nutrition in the early stage should be implemented to avoid intra-abdominal collection of intestinal fluid and infection, control further leakage of intestinal fluid and improve nutritional status. In the late stage, when leakage of intestinal fluid could be controlled, recombine human growth hormone （rhGH） and enteral nutrition should be administered in place of somatostatin and total paronteral nutrition respectively. The fistula can reach rapid spontaneous closure in both stages. Fibrin glue and rhGH used at the same time can improve the curative rate and shorten the treatment time even more. In the 1960s and 1970s, early primary resection of the fistula and re-anastomosis often resulted in anastomosis failure. The reasons for this included poor nutritional status, uncontrolled secretion of intestinal fluid, severe intra-abdominal infection and multiorgan dysfunction syndrome. Such stage management policy has been proposed, developed and persisted since late 1960s. Nowadays, the advance of medical science provided the possibility to change or improve the current policy. Our research proved that early resection of the primary fistula and re-anastomosis of the small bowel could be performed successfully in some selected patients whose general conditions are good and intestinal adhesion were not severe within ten to fourteen days after fistula occurrence. More studies are still needed to define the indications and contradictions for early resection of the primary gastrointestinal fistla, and prove the feasibility and rationality of rapid treatments of gastrointestinal fistula.