Böckler D, Hyhlik-Dürr A, Hakimi M, Brenner T, Ulrich A, Hofer S
Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
Klinik für Anästhesie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
Chirurg. 2016 Feb;87(2):119-27. doi: 10.1007/s00104-015-0142-5.
Bleeding and vascular infections are serious potential complications during abdominal general surgery. The management of bleeding depends on the extent and localization and can range from the application of hemostatics to vascular sutures, interpositioning and ligatures. The use of prosthetic biomaterials implanted endoluminally or during open reconstruction permits palliation of potentially fatal conditions. The overall incidence of infections involving vascular prostheses is relatively low because of routine antibiotic prophylaxis prior to surgery, refinements in sterilization and packaging of devices and careful adherence to aseptic procedural and surgical techniques. When infections occur detection and definitive therapy of the vascular prosthesis are often delayed and the management is complex and tedious. Infections involving vascular prostheses are difficult to eradicate and in general, surgical therapy is required often coupled with excision of the prosthesis. Keys to success include accurate diagnostics to identify the organism and extent of graft infections, specific long-term antibiotic therapy and well-planned surgical interventions to excise and replace the infected graft and sterilize the local tissue. Regardless of the technique used to eradicate graft infections, success is measured by patient survival, freedom from recurrent infection and patency of revascularization. Even when treatment is successful, the morbidity associated with vascular graft infections is considerable. Aortoenteric fistulas (AEF) are a rare (incidence < 1.5 %) but often fatal complication. Primary diagnosis of AEF remains difficult. Computed tomography (CT) and fluorodeoxyglucose positron emission tomography CT (FDG-PET-CT) are the diagnostic tools of choice. Therapy consists of an urgent individualized interdisciplinary surgical approach with primary axillofemoral bypass and secondary prosthesis explantation or in situ replacement and subsequent bowel resection. Endovascular aortic repair (EVAR) is reserved for primary aortoenteric fistulas in patients with no signs of infection or in emergency cases as a bridging method.
出血和血管感染是腹部普通外科手术中严重的潜在并发症。出血的处理取决于出血程度和部位，范围从应用止血剂到血管缝合、血管间置和结扎。腔内植入或开放重建时使用人工生物材料可缓解潜在的致命状况。由于术前常规使用抗生素预防、器械灭菌和包装的改进以及严格遵守无菌操作和手术技术，涉及血管假体的感染总体发生率相对较低。当发生感染时，血管假体的检测和确定性治疗往往会延迟，且处理复杂繁琐。涉及血管假体的感染难以根除，一般需要手术治疗，通常还需切除假体。成功的关键包括准确诊断以确定移植物感染的病原体和范围、特定的长期抗生素治疗以及精心规划的手术干预，以切除和更换感染的移植物并对局部组织进行消毒。无论采用何种技术根除移植物感染，成功的衡量标准是患者存活、无复发性感染以及血管再通。即使治疗成功，与血管移植物感染相关的发病率仍然很高。主动脉肠瘘（AEF）是一种罕见（发病率<1.5%）但往往致命的并发症。AEF的初步诊断仍然困难。计算机断层扫描（CT）和氟脱氧葡萄糖正电子发射断层扫描CT（FDG-PET-CT）是首选的诊断工具。治疗包括紧急个体化的多学科手术方法，先行腋股旁路手术，二期切除假体或原位置换，随后进行肠切除。血管腔内主动脉修复术（EVAR）适用于无感染迹象的原发性主动脉肠瘘患者或作为紧急情况下的桥接方法。
