手术探查和高温灌肠联合治疗老年自发结肠穿孔20例临床观察

摘 要 目的:探讨手术探查联合高温灌肠治疗老年自发性结肠穿孔的临床治疗效果。方法:自发性结肠穿孔患者39例,按照住院床位单双号法随机分为两组,治疗组20例,采用手术探查、结肠穿孔修补术联合灌肠治疗;对照组19例,仅采用手术探查治疗、结肠穿孔修补术。比较两组临床疗效。结果:治疗组显效12例,有效6例,无效1例,总有效率90.0%;对照组分别为8例、6例、3例,总有效率为73.7%;治疗组疗效优于对照组,差异有统计学意义(P

关键词 自发性结肠穿孔 老年 手术探查 高温灌肠

doi:10.3969/j.issn.1007-614x.2010.23.086

Abstract Object:To research into the clinical treatment effects of treating spontaneous colonic perforation in elderly patients with a combination of operations research and high-temperature enema.Method:Select 39 cases of spontaneous colonic perforation patients.Divide them into 2 groups randomly by odd numbers and even numbers of their in-patient bed numbers,20 cases as treatment group to be treated by a combination of operations research,colonic perforation neoplasty and enema treatment;19 cases as comparison group using only operations research and colonic perforation neoplasty.The clinical treatment effects of the two groups were compared.Results:In the treatment group 12 cases had distinctive effects,6 were effective and 1 was ineffective.The total effective rate was 90.0%.In the comparison group,the se figures were respectively 8 cases,6 cases,3 cases and 73.7%.The treatment effects in the treatment group were obviously better than that of the comparison group.The difference had statistical significance(P

KeyWordsSpontaneous Colonic Perforation;Elderly;Operations Research;High-temperature Enema

自发性结肠穿孔是临床上较为少见的急腹症,是指结肠本身无任何病变或无外伤原因而引起的急性结肠穿孔,常发生于老年人。因起病突然,缺乏特异性临床表现,加是老年患者感知力减弱,容易误诊而危及患者的生命,死亡率极高[1]。2003年1月～2009年12月收治老年自发性结肠穿孔患者39例,其中20例采用手术探查联合高温灌肠治疗取得较好效果。现将临床治疗观察总结如下。

资料与方法

一般资料:老年自发性结肠穿孔患者39例,发病前均有不同程度的慢性习惯性便秘史,慢性肠脱垂8例,痔疮25例;伴有高血压20例,冠心病13例,糖尿病9例。所有病例临床表现见腹部压痛、反跳痛等弥漫性腹膜炎症状,出现时间长短不一。其中全腹部压痛患者27例,局限于下腹部压痛患者12例;有反跳痛患者10例,板状腹患者7例,肠鸣音减弱患者36例;腹腔穿刺患者18例,均出现脓性液体或含粪性液体,伴恶臭。且35例有腹胀,19例伴有黏液血便,3例伴发热,7例伴有感染性休克。影像学检查:腹透见膈下游离气体,腹部B超或彩超见肠间积液、盆腔积液,腹部CT扫描见结肠占位,腹腔积液。所有患者发病至入院时间为2～7小时;按照住院床位单双号法随机分为两组,治疗组20例,男11例,女9例,年龄59～78岁,平均67.8岁,对照组19例,男12例,女7例,年龄60～80岁,平均69.1岁。两组患者性别、年龄、病程、病情等方面比较,差异无统计学意义(P>0.05),具有可比性。

治疗方法:两组均选用剖腹探查手术治疗。入院后及时补液,纠正酸中毒等治疗,并完善各项检查,症状有所缓解后立即在硬膜外麻醉下行剖腹探查术。术中可见腹腔内有暗黄色液体及粪液和没有消化的食物残渣300～1500ml,穿孔处有并伴有大量脓苔覆盖,降结肠和乙状结肠有扩张,穿孔均位于结肠系膜对侧缘,其中结肠脾曲3例,乙状结肠8例,直肠乙状结肠交界处28例。穿孔大小为0.5～1.5cm,穿孔处肠壁变黑、变薄,酷似坏疽样;穿孔周围无肿块或裂伤,管壁水肿不明显,探查肝、胆、胰、小肠等未见异常情况。术中用0.9%生理盐水1000～5000ml冲洗腹腔直到干净,行穿孔修补术,如结肠穿孔较大,腹腔感染严重,则切除穿孔处近肠约5cm后再端端或端侧吻合术,术中从插入肛管,用盐水分段结直肠灌洗,清除结直肠内粪便,最后温盐水灌肠明确修补口或吻合口无渗漏,在穿孔口旁,结肠旁沟和盆腔内放置引流管各1根,以便于腹腔内液体的流出,治疗组从置入硅胶管并超过结肠穿孔口约10cm,留置。术后观察患者的腹痛腹胀、排便、排气及腹腔引流情况。治疗组在上述治疗的基础上加用高温灌肠治疗:用45℃高温盐水从留置的硅胶管进行低压灌肠,每次500～1500ml,使患者自觉不能耐受想要排便为止,嘱患者夹闭,尽可能的保留灌肠再排出,直至排出物清亮。均于术后6小时内进行,每天2次,连续7天。