医源性结肠镜穿孔的诊治

Diagnosis and treatment of iatrogenic colonoscopic perforation

目的总结医源性结肠镜穿孔（ICP）的诊断及治疗选择。 方法回顾性分析海军军医大学附属长海医院肛肠外科结肠镜检查及治疗后发生穿孔的17例患者临床资料、治疗及其结果。 结果2000年1月至2013年12月间，共计施行结肠镜检查及治疗患者累计为127 106例，其中发生ICP有17例（占0.013%）。男性8例，女性9例。平均年龄65.2（32~85）岁。ICP发生至被临床诊断为ICP的间隔时间为当时至术后6 d。有8例为结肠镜下操作包括单纯结肠息肉摘除术、内镜下黏膜切除术（EMR）和内镜黏膜剥离术（ESD）后发生的穿孔，9例单纯结肠镜检查后发生穿孔。除1例患者为操作时发现＂视野内可见黄色类似脂肪组织＂而当即诊断ICP外，7例前期患者，采取腹部X线拍片检查进行诊断；9例后期患者均通过腹部CT检查确诊。穿孔部位：乙状结肠5例，盲肠和降结肠各3例，降乙交界2例，回肠、结肠脾曲、直乙交界和直肠各1例。1例因盲肠侧方生长型息肉行ESD治疗术后发生ICP者，采取禁食、胃肠减压、补液、抗感染、营养支持等保守治疗成功；1例结肠镜操作当时发现ICP者，立即给予结肠镜下钛夹夹闭并辅以抗感染等保守治疗成功；15例患者手术治疗，其中8例患者施行一期肠穿孔修补术、4例施行一期切除相关肠段并行吻合术、2例施行一期切除相关肠段并行造口术以及1例施行一期穿孔修补并行造口术。术后出现腹部切口感染4例，肺部感染1例，切口感染合并心血管事件、尿路感染各1例，均予以对症治疗后恢复。17例患者住院时间平均18.6（3~45）d。 结论ICP发生后，应尽快通过查体及影像学检查等进行诊断；对于结肠镜操作时发生的穿孔，部分可以采用钛夹夹闭的方式；穿孔修补术仍是ICP主要的治疗方式，必要时可以选择部分肠段切除吻合术及造口术等。

ObjectiveTo summarize the diagnosis and treatment of iatrogenic colonoscopic perforation （ICP） . MethodsClinical data, treatment course and outcome of 17 patients who developed ICP following colonoscopic examination or operation at Department of Colorectal Surgery, Changhai Hospital from January 2000 to December 2013 were retrospectively analyzed. ResultsDuring above 13 years, a total of 127 106 patients underwent colonoscopic examination or operation, of whom 17 cases （0.013%） had ICP. There were 8 males and 9 females with an average age of 65.2 （32-85） years. The interval between the onset of ICP and clinically diagnosed ICP was 0 to 6 days after performance. ICP occurred in 8 patients following colonoscopy operations, including simple colonic polyp excision, endoscopic mucosal resection （EMR） and endoscopic submucosal dissection （ESD） , while in 9 patients following simple colonoscopy examination. Except for one patient who was immediately diagnosed with ICP through the finding of ＂yellow adipose tissue visible in the vision field＂ during operation, 7 early cases （41.2%） were diagnosed by abdominal X-ray examination, and 9 later cases were confirmed by abdominal CT examination. The perforation sites included sigmoid colon in 5 cases, caecum in 3 cases, descending colon in 3 cases, descending and sigmoid junction in 2 cases, ileum in 1 case, splenic flexure in 1 case, sigmoid and rectum junction in 1 case, retum in 1 case. One case with ICP following ESD after resection of polyp in caecum was cured successfully with conservative treatment, including fasting, gastrointestinal decompression, fluid infusion, anti-infection and nutritional support. One case with ICP, which was found during colonoscopic operation and the perforation was immediately closed with titanium clip, received conservative treatment, including anti-infection and then was cured. Fifteen patients underwent surgery, including 8 patients with primary intention intestinal perforation repair, 4 patients with primary intention resection of associated intestine and anastomosis, 2 patients with primary intention resection of associated intestine and ostomy, 1 patient with primary intention intestinal perforation repair and ostomy. Postoperative abdominal incision infection occurred in 4 cases, pulmonary infection in 1 case, incision infection with cardiovascular event or urinary tract infection in 1 case each. All the patients were cured and discharged. Average hospital stay was 18.6 （3-45） days. ConclusionsICP should be diagnosed by physical examination and imaging examination as soon as possible. For perforation during colonoscopic performance, colonoscopic titanium clip can be used for closure. Perforation repair is still the main procedure for ICP. If necessary, partial intestinal resection and anastomosis or ostomy can be selected.