结肠镜检查治疗后肠穿孔高危因素及治疗方案对比分析

Comparison of risk factors and treatments for intestinal perforation after colonoscopic treatment

背景近年来,结肠镜检查作为结直肠疾病最重要的诊疗手段被广泛运用于临床中,但其具有一定的侵入性,可能导致消化道出血、穿孔等一系列严重并发症.其中,消化道穿孔如不能及时发现并处理可引起感染性休克,甚至危及生命.目的分析可能导致结肠镜穿孔的危险因素,探索穿孔患者的合理治疗方案.方法统计2012-01/2020-12在我院行纤维电子结肠镜检查患者共41642例,回顾患者一般资料(性别、年龄、既往史、体重指数、是否麻醉、肠道清洁程度、操作时间、穿孔部位等),分析结肠镜穿孔的高危因素;穿孔患者均行肠穿孔修补术,根据手术方式分为腹腔镜组(laparoscopic surgery,LS)和开放手术组(open surgery,OS),对比分析两种不同术式的临床疗效及预后.结果发生肠穿孔患者共21例(0.05%),其中肠镜检查导致穿孔13例,治疗(包括圈套息肉切除术、内镜下黏膜切除术、球囊扩张等有创操作)导致穿孔8例,穿孔部位多见于乙状结肠(47.6%)及直肠(28.6%).腹腔镜手术13例,开放手术7例,保守治疗1例,有3例同时行肠造瘘术.Logistic回归分析提示肠道清洁程度、有无麻醉、腹部手术史为导致肠镜穿孔的危险因素(P<0.05),与患者性别、年龄、体重指数、操作时间、是否为检查或治疗无明显相关性(P>0.05).LS组术后住院时间、术后疼痛评分、伤口感染率、住院费用较OS组有显著统计学差异.结论结肠镜穿孔易发于乙状结肠及直肠,操作过程粗暴、局部肠壁薄弱及解剖结构异常是导致肠穿孔的三大重要因素;肠道清洁程度、无痛麻醉、腹部手术史为肠镜穿孔发生的危险因素,而与患者性别、年龄、体重指数、操作时间、是否为检查或治疗无关.肠镜穿孔治疗的基本原则是早期发现、积极手术,避免腹腔感染弥散.腹腔镜下肠穿孔修补术与开放手术对比具有疼痛轻、恢复快、伤口感染率低等优势,可作为首选方案.如肠道准备好,大部分肠镜穿孔患者不做预防性肠造瘘是安全可行的.

BACKGROUND In recent years,colonoscopy,as the most important tool for the diagnosis and treatment of colorectal diseases,has been widely used in clinical practice,but it is somewhat invasive and may lead to a series of serious complications such as gastrointestinal bleeding and perforation.Among them,gastrointestinal perforation,if not detected and treated timely,can cause septic shock,and even endanger life.AIM To analyze the risk factors that may lead to colonoscopy-related perforation and explore the reasonable treatment for patients with perforation.METHODS A total of 41642 patients who underwent electronic colonoscopy at our hospital from January 2012 to December 2020 were statistically analyzed.The general information of the patients(gender,age,past history,body mass index,anesthesia,intestinal cleanliness,operating time,perforation site,etc.)was reviewed,and the risk factors for colonoscopy-related perforation were analyzed.The clinical efficacy and prognosis were compared between laparoscopic surgery(LS)and open surgery(OS).RESULTS Intestinal perforation occurred in 21(0.05%)patients,including 13 cases of perforation caused by colonoscopy and 8 cases caused by treatment(including entrapment polypectomy,endoscopic mucosal resection,balloon dilation,and other invasive procedures).The most common perforation sites were the sigmoid colon(47.6%)and rectum(28.6%).Laparoscopic surgery was performed in 13 cases,open surgery in 7,conservative treatment in 1,and enterostomy in 3.Logistic regression analysis indicated that intestinal cleanliness,anesthesia,and abdominal operation history were the risk factors for colonoscopy-related perforation(P<0.05),while gender,age,body mass index,examination,and treatment were not(P<0.05).The postoperative length of stay,postoperative pain score,wound infection rate,and hospitalization cost in the LS group were significantly different from those in the OS group.CONCLUSION Colonoscopy-related perforation more commonly occurs in the sigmoid colon and rectum.Roughness of operation,weak local intestinal wall,and abnormal anatomical structure are three important factors leading to intestinal perforation.Poor intestinal cleanliness and previous history of abdominal surgery are high risk factors for perforation,while early detection and active surgery are the basic principles for the treatment of intestinal perforation,and laparoscopic perforation repair is the first choice.If bowel preparation is ready,it is safe and feasible to avoid a prophylactic enterostomy in most patients with colonoscopy perforation.