Maghsoudi Robab, Etemadian Massoud, Kashi Amir H, Mehravaran Kaveh
Hasheminejad Kidney Centre, Iran University of Medical Sciences , Tehran, Iran .
J Endourol. 2017 Oct;31(10):1032-1036. doi: 10.1089/end.2017.0379.
The management protocol for colon perforation during percutaneous nephrolithotomy (PCNL) is controversial because of the scarcity of reported cases and their management diversity. We present our management experience of colon perforation during PCNL.
All PCNL operations between April 2004 and September 2016 in our center (N = 11,376) were reviewed for the occurrence and management of colon perforation. We typically performed PCNL with insertion of nephrostomy tube before mid-2007. After mid-2007, we typically performed tubeless PCNL and inspected access tract for evidence of organ injury especially colon perforation during nephroscope removal.
Seventeen colon perforations happened during the study period. The first three cases were diagnosed postoperatively and in two patients open surgery was employed for treatment. The next 14 cases were diagnosed intraoperatively (n = 12) or in the early postoperative period (n = 2) and were managed by broad spectrum antibiotics, bowel rest, and urinary Double-J and Foley's catheter insertion. Percutaneous retroperitoneal drain was inserted for only one patient after intraoperative diagnosis of colon perforation. The other 13 patients were managed without insertion of such drains. For one patient, postoperative insertion of retroperitoneal drain was attempted because of collection of urine. In other patients (n = 12), the management was effective with no need for an operation. Complications according to Clavien-Dindo grade in these 17 patients were grades II, IIIa, and IIIb in 13, 1, and 3 patients, respectively.
Colon perforation during PCNL that is diagnosed intraoperatively or in the early postoperative period can be managed conservatively. It seems possible not to insert colostomy or retroperitoneal drains in stable patients with early or intraoperative diagnosis. In cases of delayed diagnosis, or deterioration of the patient on tubeless management, the standard protocol should be performed including insertion of colonic or retroperitoneal drain or surgery especially in patients with signs or symptoms of peritonitis or persistent fever.
经皮肾镜取石术（PCNL）期间结肠穿孔的处理方案存在争议，因为报道的病例较少且处理方式多样。我们介绍我们在PCNL期间结肠穿孔的处理经验。
回顾了2004年4月至2016年9月在我们中心进行的所有PCNL手术（N = 11376例），以了解结肠穿孔的发生情况及处理方式。2007年年中之前，我们通常在插入肾造瘘管后进行PCNL。2007年年中之后，我们通常进行无管PCNL，并在取出肾镜时检查通道有无器官损伤，尤其是结肠穿孔。
研究期间发生了17例结肠穿孔。前三例在术后确诊，其中两例患者接受了开放手术治疗。接下来的14例在术中（n = 12）或术后早期（n = 2）确诊，并采用广谱抗生素、肠道休息、留置输尿管双J管和 Foley 导尿管进行处理。仅1例患者在术中诊断为结肠穿孔后插入了经皮腹膜后引流管。其他13例患者未插入此类引流管进行处理。1例患者因尿液积聚术后尝试插入腹膜后引流管。其他患者（n = 12）处理有效，无需手术。这17例患者根据Clavien-Dindo分级的并发症分别为13例II级、1例IIIa级和3例IIIb级。
PCNL期间术中或术后早期诊断出的结肠穿孔可保守处理。对于早期或术中诊断的稳定患者，似乎无需插入结肠造口或腹膜后引流管。在延迟诊断或无管处理患者病情恶化的情况下，应执行标准方案，包括插入结肠或腹膜后引流管或手术，尤其是在有腹膜炎体征或症状或持续发热的患者中。
