Dionigi G, Dionigi R, Rovera F, Boni L, Padalino P, Minoja G, Cuffari S, Carrafiello G
Department of Surgical Sciences, University of Insubria, Viale Borri 57, 21100 Varese, Italy.
Int J Surg. 2008 Feb;6(1):51-6. doi: 10.1016/j.ijsu.2007.07.006. Epub 2007 Aug 2.
Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects.
Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present.
All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800ml/day (range 400-1600ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20-2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis.
After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.
肠瘘是根据其起源部位、连通情况和流量来定义的。我们评估了患有巨大腹壁缺损的复杂性肠-皮肤瘘患者的治疗情况。
对意大利瓦雷泽市因苏布里亚大学外科学系治疗的19例患者（15例男性，中位年龄46岁）进行回顾性病例记录分析。这些患者的特点是存在多个/广泛的胃肠道瘘口，肠管完全中断。瘘口未被腹壁覆盖，从而出现巨大腹壁缺损。一旦患者营养状况良好，便计划进行手术。
所有瘘均由既往手术引起，其中7例（37%）为炎症性肠病，4例（21%）为腹部创伤，3例（16%）为急性坏死性感染性胰腺炎，3例（16%）为腹内恶性肿瘤，2例（10%）为憩室病。最常见的瘘管出现部位是回肠（80%）。瘘管每日平均排出量为800毫升（范围400 - 1600毫升/天）。塞尔策预后指数显示，70%的患者在就诊时存在营养不良。从瘘管形成到择期手术治疗的平均时间为184天（范围20 - 2190天）。最后7例患者在术前使用了VAC系统，6例术后腹部伤口裂开且无法立即缝合、有愈合并发症高风险的患者也使用了该系统。VAC治疗未出现并发症。69%的病例手术成功。死亡率为21%。与死亡相关的因素包括持续性恶性肿瘤、营养不良和脓毒症。
在优化营养状况后，采用瘘管整块切除手术可取得最佳效果。在本系列研究中，癌症和脓毒症是影响预后的不利因素。这些瘘管可通过多学科方法成功治疗。
