经皮肾镜手术导致结肠穿孔的系统评价

Colonic perforation during percutaneous nephrolithotomy:a systematic review

目的通过分析文献总结经皮肾镜手术导致的结肠穿孔的诊断方法、治疗策略及预防措施。方法用"percutaneous nephrolithotomy"和"colon"为关键词,检索1985年1月至2015年6月PubMed数据库中的英文文献,将检索的原始文献中对结肠穿孔的例数、左右、危险因素、手术体位、穿刺盏、诊断时间、诊断方法、损伤的分型、治疗方法和预后等有表述的进行统计和分析。结果检索到8篇对经皮肾镜手术导致结肠穿孔的诊疗有较为详细描述的原始文献,共报道经皮肾镜手术19 500例(其中1篇文献未提及总数),经皮肾镜手术导致结肠穿孔共63例,结肠穿孔的发生率0.3%(58/19 500),其中左侧41例、右侧20例(有2例作者未提及左右)。63例结肠穿孔患者中,作者直接描述危险因素的有23例,包括同侧肾和胃肠道有手术史者11例、马蹄肾4例、结肠疾病2例、肾后型结肠4例。大多数患者为俯卧手术(48例),仰卧位15例。术中穿刺的目标盏为下盏者57例,中上盏4例,2例未提及。在术中确诊结肠穿孔18例,术后确诊的45例。结肠穿孔为腹膜内型9例,腹膜外型54例。腹膜内型结肠穿孔均通过开放手术治疗,其中8例治愈、1例死亡。腹膜外型损伤中有45例通过保守治疗治愈,9例通过开放手术治愈。结论结肠穿孔是一种罕见而严重的经皮肾镜手术并发症。术前了解可能导致结肠穿孔的危险因素并行CT检查是很好的预防措施。术中术后仔细观察和及时CT或造影检查可明确诊断,延误诊断可能带来严重的后果,并可能导致腹膜外型结肠穿孔需要开放手术治疗。及时的诊断和适当治疗大多可有较好的转归。

Objective To summarize the diagnostic and therapeutic strategies and risk factors of colonic injury during percutaneous nephrolithotomy （PCNL）. Methods A literature review was conducted for the studies published in the English language in the databases of PubMed during July 1985 and June 2015. The key words for digital literature search were ＂percuta- neous nephrolithotomy AND colon＂. Results A total of 8 articles involving 19 500 patients were included. Colonic perfora- tion occurred in 63 （0.3%） cases, including 41 cases in the left side, 20 in the right side （2 cases were not mentioned）. The risk factors were described in 23 of the 63 cases, including history of renal and gastrointestinal tract operation of the same side in 11 cases, horseshoe kidney in 4 cases, colonic diseases in 2 cases, and post-renal colon in 4 cases. The prone position was adopted in 48 cases and the supine position in 15 cases. The target of puncture was lower calyx in 57 cases, upper and middle calyx in 4 cases, not mentioned in 2 cases. Colonic perforation was confirmed in 18 cases during operation and in 45 cases after operation. The perforation was intraperitonea[ in 9 cases and extraperitoneal in 54 cases. Of the 9 cases of intraperitoneal perforation treated with open surgery, 8 were cured and 1 died. Of the 5% cases of extraperitoneal perforation, 45 were cured with conser- vative treatment and 9 were cured with open surgery. Conclusions Colon perforation is a rare but serious complication of PCNL. Meticulous evaluation of the risk factors preoperatively is the initial step in the prevention of colon perforation. Ab- dominal CT is the best diagnostic tool. Timely diagnosis plays an essential role in the management of this PCNL complication. Although extraperitoneal colon perforation may be managed conservatively, surgery is required for intraperitoneal colon perfo- ration. Delayed diagnosis may lead to serious consequences, and surgical management is the mandatory treatment with extrap- eritoneal colon perforation.