嵌顿疝并肠坏死的系统评价在实验和临床中的建立及应用研究

发布时间：2018-05-19 04:11

本文选题：嵌顿疝 + 肠坏死　；参考：《山东大学》2014年博士论文

【摘要】：第一部分嵌顿疝动物模型的建立与肠坏死程度系统评价研究背景及目的肠坏死可表现为早期的非特异性症状和晚期延迟性特异性症状。临床中各种原因导致的肠缺血性疾病均可导致肠坏死,而嵌顿疝作为常见的导致肠缺血疾病之一,如不能及时解除嵌顿,可以导致肠绞窄坏死,最终导致局部及全身严重的临床后果。就单纯评价肠管坏死程度而言,肠管壁可以由粘膜、肌层到透壁性全层梗死过渡,但作为人体系统而言,嵌顿疝所导致的肠坏死除肠管组织形态学改变外,可导致局部炎症(红肿,甚至蜂窝织炎、肠外瘘)、肠梗阻、腹膜炎、感染性休克等局部及全身的表现。究其原因是随着坏死时间的延长肠坏死程度是不同的,所导致的临床后果不同,同时处理方式及预后不同。目前的实验室检查因为缺乏特异性,尚没有一种快速且可靠的检测指标来预测肠缺血并判定肠坏死时间,临床中更没有一种系统来评判肠坏死的程度。因为嵌顿疝导致的肠坏死与其他原因导致的肠坏死临床表现不同,比较适合建立一种系统来评价肠坏死的程度并体现该病的进展过程。本研究的目的为建立一种大鼠腹壁嵌顿疝模型,模拟肠绞窄坏死的过程,观察肠坏死后局部及全身表现并系统赋分,为临床中嵌顿疝肠坏死程度分级的建立提供实验依据。方法选取成年健康雄性Wistar大鼠,制作腹壁嵌顿疝动物模型。根据肠管嵌顿时间的增加,依次将模型分为12组,嵌顿时间自2h起,分别于2h、4h、6h、8h、12h、16h、20h、24h、28h、32h、36h、36h作为时间节点处死大鼠,依据不同时间节点的坏死肠管形态及组织学观察、局部炎症及全身表现等对肠管坏死的程度进行系统赋分,比较与对照组及各组之间肠管坏死程度的差异。结果 1.肠管损伤在嵌顿时间4-6h实现组织学全层坏死,腹部可出现肠梗阻体征。嵌顿时间16h,肠管可破溃,局部呈炎症表现并查见细菌,腹部可有腹膜炎表现。嵌顿时间超过32h嵌顿肠管形态消失,局部可呈蜂窝织炎,至72h左右大鼠逐步休克死亡。 2.与对照组比较,各实验组肠管坏死系统评分依嵌顿时间递增排序,至嵌顿时间超过36h直至大鼠死亡,系统评分达最高值。各实验组间,嵌顿时间相差8h及以上者,系统评分存在明显的差异；且嵌顿4-6h组间、16-20h组间、32-36h组间系统评分有显著性差异,P值均小于0.05。结论 1.本实验制备的大鼠腹壁嵌顿疝模型较好地模拟了肠管绞窄到坏死的过程,同时呈现了该过程中临床表现及最终结局。 2.随着嵌顿时间的延长,肠坏死系统评分呈现出较明显的时间相关性,肠坏死系统评分可以客观反映嵌顿疝肠坏死的病情进展。第二部分嵌顿疝肠坏死程度临床分级的建立与患者临床特点的关系研究背景及目的临床中嵌顿疝需要紧急的外科干预治疗,但是非择期情况下其手术的并发症及死亡率增加。腹股沟疝嵌顿后作为常见外科急腹症能显著增加肠梗阻及肠绞窄风险。大约15%的腹股沟嵌顿疝患者可发展为肠坏死而不得不行肠切除,其死亡率达5%。虽然嵌顿疝绞窄后的最终结局是肠坏死,但随着坏死时间的延长,其局部及全身症状及体征是不同的。坏死早期,绞窄的肠管虽然已部分或全层坏死,但尚未发生穿孔,手术区域和腹腔也未受到明确或明显的污染,局部及全身症状较轻。但是在坏死后期,肠管可以形态消失或穿孔,局部可表现为蜂窝织炎,创面属于明确污染或感染伤口；腹部可表现为肠梗阻、腹膜炎；全身可表现为感染性休克甚至死亡。所以作为系统而言,嵌顿疝肠坏死程度是不同的,相应的临床结局及处理方式不同。但目前临床中尚无对肠坏死程度的系统定义。在之前的研究中我们通过动物实验对大鼠腹壁嵌顿疝肠坏死病情进展进行初步观察与系统评价分析。本研究是在临床中通过对腹股沟嵌顿疝并发肠坏死患者肠管形态学、局部及全身症状及体征的临床观察,目的建立一种肠坏死分级系统来客观反映肠坏死的程度,分析肠坏死分级与患者临床特点关系,尤其是与患者预后的关系。研究方法对2003年1月至2013年1月期间的所有急症入院并手术治疗的成人嵌顿疝患者进行前瞻性并排除性研究,对符合纳入研究标准的腹股沟嵌顿疝并发肠坏死患者的局部及全身表现进行系统观察,根据嵌顿时间、肠管坏死后形态、疝囊的完整性及疝外被盖组织的炎症程度、疝内容物性状,有无肠梗阻、腹膜炎及休克体征等,对肠坏死程度进行临床分级,分析影响肠坏死分级的临床因素以及肠坏死分级与患者预后的关系。结果 1.共有68例患者纳入本研究并据其建立3级肠坏死分级系统,共有49例(72.1%)Ⅰ级坏死患者,14例(20.1%)Ⅱ级坏死患者,5例(7.4%)Ⅲ级坏死患者。术后并发症及死亡率分别为32.4%和7.4%。 2.年龄≥65岁(P=0.035)、伴随疾病(P=0.008)和高ASA评分(P=0.014)是导致肠坏死程度加重而影响肠坏死分级的因素。 3.随着肠坏死分级的提高,其全身并发症(5.9%、35.7%和60.0%)及腹部和伤口并发症(6.1%、28.6%和60.0%)相应增加,同时死亡率增加(2.0%、14.3%和40.0%),各组之间均有显著性差异(P0.05)。结论 1.肠坏死分级能够客观反映肠坏死后肠管损伤的程度及其相应的患者预后,尤其是有合并症的高龄、高ASA评分患者。 2.肠坏死分级能够指导临床及时干预治疗并预测和提高预后；外科应尽早干预以避免肠坏死发生或坏死程度加重从而影响患者预后。第三部分嵌顿疝肠坏死和预后影响因素与肠坏死指数的建立研究背景及目的目前关于导致嵌顿疝肠坏死的因素以及影响嵌顿疝患者预后因素的研究报道较少。毫无疑问,嵌顿时间的长短是导致(或影响)肠坏死的主要因素,而其他因素,如年龄、性别、合并症、疝类型是否是影响肠坏死的因素结果差异较大。大部分研究表明肠坏死后肠切除是影响预后的主要因素,但其他因素,如年龄、有无合并症、能否耐受手术等因素在预后中亦扮演重要角色,但各研究结果差异较大。再者嵌顿疝,尤其是合并肠坏死者应用补片修补是否可行争议更大。本研究的目的是在通过对嵌顿疝患者临床资料回顾性分析,目的分析导致嵌顿疝患者肠坏死并肠切除的危险因素,以及影响嵌顿疝患者预后的因素,尤其是探讨肠坏死和修补方式与患者预后的关系。同时依据引起肠坏死的因素和加重肠坏死的因素,建立肠坏死指数以客观判断肠坏死及其程度来指导临床预测肠管绞窄发生和肠坏死程度分级,最终指导临床预后判断。研究方法对2003年1月至2013年12月1168例急症手术治疗的成人嵌顿性腹股沟疝患者的临床资料进行回顾性分析,采用单变量及多变量统计方法分析导致肠坏死并肠切除的危险因素以及影响嵌顿疝患者预后的因素,探讨修补方式与预后的关系。对于有意义的导致肠坏死的因素,结合第二部分研究结果中影响肠坏死程度的因素,作为危险因素赋分并制定肠坏死指数,划定赋分范围确定肠坏死的有无及坏死程度分级。结果 1.所有患者均急症手术并疝修补,共有1147例患者纳入本研究,其中195例(17%)患者因肠坏死而行肠切除,952例(83%)无肠坏死患者。术后并发症及死亡率分别为16.9%和5.1%。 2.肠坏死患者和非肠坏死患者两组在年龄、性别、有无伴随疾病、疝类型、嵌顿时间、有无肠梗阻及腹膜炎等各因素之间均有显著性差别(P0.05)。Logistic回归多因素分析显示,嵌顿时间≥6h(OR=8.32, P0.001)、股疝(OR=10.47, P=0.018)和腹膜炎(OR=4.79,P=0.005)是导致肠坏死并肠切除的独立危险因素。 3.嵌顿疝肠坏死指数5-10分无肠坏死,11～18分Ⅰ级肠坏死,19～26分Ⅱ级肠坏死,26分Ⅲ级肠坏死。 4.单变量分析显示伴随疾病、ASA评分、麻醉类型、修补方式和肠坏死与患者并发症有关(P0.05)；而年龄、伴随疾病、ASA评分和肠坏死与患者病死率有关(P0.05)。但Logistic回归显示只有肠坏死是影响预后(并发症和病死率)的独立危险因素(P0.01)。 5.嵌顿疝并肠坏死患者补片修补的总体并发症大于一期缝合修补患者(P0.05),但对于Ⅰ级坏死患者应用补片修补的伤口感染率与一期缝合没有差别(P0.05),多变量分析显示补片的应用不是影响预后的危险因素(p0.05)。结论 1.嵌顿时间大于6h、疝类型为股疝和腹膜炎是嵌顿疝肠坏死并肠切除的独立危险因素,而肠坏死后肠切除是影响嵌顿疝患者预后的独立因素。 2.嵌顿疝肠坏死指数的建立能够指导临床客观评判肠坏死的有无以及预测肠坏死的分级,结合肠坏死分级更能提前预测和提高预后。 3.补片的应用能增加术后总体并发症的发生,尤其是Ⅱ、Ⅲ级坏死患者伤口并发症的发生,但不是影响预后的独立因素。第四部分腹股沟嵌顿疝并肠坏死的一期无张力疝修补研究背景及目的嵌顿疝并发肠坏死能否一期无张力疝修补有争议。传统的观点认为行肠切除后创面污染,容易导致切口感染从而导致修补失败而最终不得不取出补片。也有入认为嵌顿疝绞窄后肠管虽然已坏死,但如尚未发生穿孔,手术区域也未受到明确或明显的污染,使用补片修补是可行的。也有研究发现切口的感染与是否应用补片无关。对于择期无张力疝修补,创面属于清洁伤口,手术可行毋庸置疑。对于并发肠坏死患者,虽然临床上有许多一期无张力疝修补的成功报告,但不是所有的肠管坏死后一期无张力疝修补是可行的。因为随着坏死时间的延长,创面由污染到感染过渡。早期坏死创面属于污染或潜在污染伤口,而后期可以明显的坏死化脓,创面属于明确污染或感染伤口,显然不能修补。此条件下勉强修补只能导致手术失败。根据创面的污染情况来决定是否应用补片修补是首先考虑的,但患者的一般状况在决定手术的成功与否中亦非常关键。而术中如何避免或减少污染及术后的综合治疗在手术的成功中亦扮演重要角色。在之前的研究中我们通过动物实验及临床观察首次对肠坏死程度进行分级,并且研究表明肠坏死程度与患者年龄及伴随疾病以及ASA评分有关,并影响患者预后,且证实肠坏死是影响预后的独立因素。同时研究表明对于Ⅰ级坏死患者,补片的应用没有增加伤口等并发症发生。本研究的目的为探索不同坏死分级下结合患者一般状况行一期无张力疝修补的可行性,总结一期无张力疝修补的成功经验。研究方法对2005年1月至2013年6月40例腹股沟嵌顿疝并发肠坏死患者,依据肠坏死分级标准对肠坏死程度进行分级,对其中一般状况较好(ASAⅠ、Ⅱ)的21例Ⅰ级坏死、4例Ⅱ级坏死患者根据个体化原则的综合治疗下行肠切除吻合并一期无张力疝修补,对其余一般状况较差(ASAⅢ、Ⅳ)或(和)坏死程度较重的7例Ⅰ级坏死、5例Ⅱ级坏死和3例Ⅲ级坏死患者行单纯缝合修补。记录术后并发症并分析坏死等级与ASA评分和术后并发症的关系。结果选择性25例一期无张力疝修补患者没有死亡病例,其余患者死亡4例。全部患者术后血肿5例；切口感染8例,其中Ⅰ级坏死补片修补患者1例,为皮下感染,经换药未除去网片痊愈,Ⅱ级坏死患者4例,其中补片修补2例,1例因深部组织感染(合并补片感染)而不得不取出补片。术后随访6月以上补片修补患者无排异反应发生。术后复发4例,其中1例为Ⅱ级坏死感染后取出补片患者。统计分析示肠坏死分级与ASA评分相关(r=0.388,P=0.018),随者坏死程度加重和ASA评分增加,术后并发症逐步增加(P0.05)。结论 1.对于肠坏死程度Ⅰ级、ASA评分Ⅰ、Ⅱ的患者,一期无张力疝修补可以取得成功,是可行的。 2.正确评价肠坏死的程度,结合患者的一般状况来选择性一期无张力疝修补是嵌顿疝并发肠坏死手术的合理选择。
[Abstract]:Part I establishment of incarcerated hernia animal model and systematic evaluation of intestinal necrosis degree
Background and purpose of research
Intestinal necrosis may be shown as an early non specific symptom and late delayed specific symptoms. Intestinal ischemic disease caused by various causes in the clinic can cause intestinal necrosis, and incarcerated hernia is one of the common causes of intestinal ischemia. If incarcerated incarcerated in time, it can lead to intestinal strangulation and necrosis, eventually leading to local and systemic severity. Clinical consequences.
As far as the degree of intestinal necrosis is evaluated, the bowel wall can be transferred from the mucosa, the myometrium to the permeable full layer infarction, but as the human system, the intestinal necrosis caused by incarcerated hernia can lead to local inflammation (swelling, even cellulitis, even cellulitis, intestinal fistula), intestinal obstruction, peritonitis, infectious shock and other parts. The reason is that the extent of intestinal necrosis is different with the prolongation of necrotic time, and the clinical consequences are different, and the methods and prognosis are different at the same time.
There is no rapid and reliable indicator to predict intestinal ischemia and to determine the time of intestinal necrosis. There is no system to judge the extent of intestinal necrosis in the clinic, because the intestinal necrosis caused by incarcerated hernia is different from other causes of intestinal necrosis and is more suitable for establishing one. The purpose of this study is to establish a rat model of incarcerated hernia of abdominal wall, to simulate the process of intestinal strangulation and to observe the local and systemic manifestations of intestinal necrosis and to provide an experimental basis for the establishment of the classification of incarcerated hernia intestinal necrosis.
An animal model of incarcerated hernia of abdominal wall was made in adult healthy male Wistar rats. According to the increase of incarceration time, the model was divided into 12 groups, and the incarceration time was from 2H, respectively, in 2H, 4h, 6h, 8h, 12h, 16h, 20h, 24h, 28h, 32H, as a time node, and the morphological and histological observation of necrotic intestines in different time nodes. The degree of intestinal necrosis was systematically assessed by local inflammation and systemic performance, and the difference of intestinal necrosis between the control group and the control group was compared.
Result
1. intestinal canal injury in the time of incarceration 4-6h to realize full layer necrosis of histology, abdomen can appear intestinal obstruction signs. Incarcerated time 16h, intestinal tube can break, local inflammation and examination of bacteria, abdomen can have peritonitis appearance. Incarceration time more than the 32H incarcerated intestinal tube form disappeared, local cellulitis, to 72h rats gradually shock death.
2. compared with the control group, the score of the intestinal necrosis system in each experimental group was increased according to the incarceration time, and the time of incarceration was more than 36h until the rat died, and the system score was the highest. There was a significant difference in the system score between the experimental groups, the difference in the system score of incarcerated time of 8h and above, and the system score between the group of incarcerated 4-6h and the group 16-20h, the scores of the system among the 32-36h groups were Significant differences, P values are less than 0.05.
conclusion
1. the rats' abdominal wall incarcerated hernia model prepared by this experiment is a good simulation of the process of intestinal strangulation to necrosis, and the clinical manifestation and final outcome in the process are presented.
2. with the prolongation of the incarceration time, the score of the intestinal necrosis system showed a more obvious time correlation. The score of the intestinal necrosis system could objectively reflect the progression of the incarcerated hernia intestinal necrosis.
The second part is about the relationship between the clinical grading of incarcerated hernia and the clinical characteristics of patients.
Incarcerated hernia in the clinic requires urgent surgical intervention, but the complications and mortality of the operation are increased in non elective cases. As a common surgical emergency after inguinal hernia incarceration, it can significantly increase the risk of intestinal obstruction and intestinal strangulation. About 15% of the inguinal incarcerated hernia can develop intestinal necrosis and have to be excised. The rate is up to 5%.
Although the final outcome of the incarcerated hernia is intestinal necrosis, the local and systemic symptoms and signs are different with the prolongation of the necrotic time. In the early stages of the necrosis, the strangulated intestine has been partially or completely necrotic, but has not yet been perforated, and the surgical area and abdominal cavity have not been clearly or obviously polluted, but the local and systemic symptoms are lighter. It is in the late stage of necrosis that the bowel can disappear or perforate the shape of the intestine, and the local may be phcellulitis. The wound belongs to the clear pollution or infection of the wound; the abdomen can be manifested by intestinal obstruction and peritonitis; the whole body can be characterized by septic shock and even death. As a system, the degree of incarcerated hernia bowel necrosis is different, corresponding clinical outcome and However, there is no systematic definition of the degree of intestinal necrosis.
In the previous study, we conducted a preliminary observation and systematic evaluation of the progression of incarcerated hernia and intestinal necrosis in the abdominal wall of rats. This study was to establish a classification of intestinal necrosis by clinical observation of intestinal morphology, local and systemic symptoms and signs in patients with inguinal incarcerated hernia complicated with intestinal necrosis. The objective of the system is to objectively reflect the degree of intestinal necrosis, and to analyze the relationship between the grading of intestinal necrosis and the clinical characteristics of patients, especially the relationship with the prognosis of patients.
A prospective and exclusionary study of all acute adult incarcerated hernia patients during the period from January 2003 to January 2013 was conducted to observe the local and systemic manifestations of patients with inguinal incarcerated hernia complicated with enteronecrosis, according to the incarceration time, the shape of the necrotic intestine and the integrity of the hernia sac. The degree of intestinal necrosis and the relationship between the classification of intestinal necrosis and the relationship between the classification of intestinal necrosis and the prognosis of the patients were analyzed.
1. a total of 68 patients were included in this study and the 3 grade intestinal necrosis classification system was established. There were 49 (72.1%) class I necrosis patients, 14 (20.1%) class II necrosis patients and 5 (7.4%) stage III necrosis patients. The postoperative complications and mortality were 32.4% and 7.4%., respectively.
2. age over 65 years (P=0.035), accompanied by disease (P=0.008) and high ASA score (P=0.014) were the factors that aggravated intestinal necrosis and affected the grading of intestinal necrosis.
3. with the improvement of intestinal necrosis, its systemic complications (5.9%, 35.7% and 60%) and abdominal and wound complications (6.1%, 28.6% and 60%) increased correspondingly, and the mortality increased (2%, 14.3% and 40%), and there were significant differences between each group (P0.05).
conclusion
1. the grading of intestinal necrosis can objectively reflect the degree of intestinal injury after intestinal necrosis and the prognosis of the patients, especially in the elderly with high complication and ASA score.
2. intestinal necrosis classification can guide the clinical intervention and predict and improve the prognosis in time. Surgery should intervene early to avoid the severity of necrosis or necrosis of intestinal necrosis and affect the prognosis of the patients.
The third part is incarcerated hernia intestinal necrosis and prognostic factors and establishment of intestinal necrosis index.
Background and purpose of research
There are few reports on the factors that lead to incarcerated hernia and the factors affecting the prognosis of incarcerated hernia. There is no doubt that the length of incarceration time is the main factor leading to (or affecting) intestinal necrosis. Other factors, such as age, sex, complication, and type of hernia are the major factors that affect intestinal necrosis. Studies have shown that enterecrosis after intestinal necrosis is a major prognostic factor, but other factors, such as age, absence of complications, and tolerance to surgery also play an important role in prognosis, but the results vary greatly.
The purpose of this study was to review the clinical data of patients with incarcerated hernia and to analyze the risk factors leading to intestinal necrosis and intestinal resection in patients with incarcerated hernia, as well as factors affecting the prognosis of patients with incarcerated hernia, especially to explore the relationship between intestinal necrosis and repair methods and the prognosis of patients. The factor of intestinal necrosis, the establishment of the intestinal necrosis index to objectively judge the intestinal necrosis and its degree to guide the clinical prediction of intestinal strangulation and the degree of intestinal necrosis, and ultimately guide the clinical prognosis.
The clinical data of 1168 cases of adult incarcerated inguinal hernia treated by emergency surgery from January 2003 to December 2013 were retrospectively analyzed. A single variable and multivariate statistical method was used to analyze the risk factors leading to intestinal necrosis and intestinal resection, as well as the factors affecting the prognosis of incarcerated hernia patients, and the relationship between the repair mode and the prognosis was discussed. Factors contributing to intestinal necrosis, combined with the factors that affect the degree of intestinal necrosis in the second part of the study, are assigned as risk factors, and the intestinal necrosis index is established, and the classification of the extent of the necrosis of intestinal necrosis is defined to determine the extent of the necrosis of the intestinal necrosis.
Result
1. all patients underwent emergency surgery and herniorrhaphy. A total of 1147 patients were included in this study, of which 195 cases (17%) underwent enteronecrosis with intestinal necrosis and 952 (83%) patients with no intestinal necrosis. The postoperative complications and mortality were 16.9% and 5.1%., respectively.
There were significant differences in age, sex, unaccompanied disease, type of hernia, incarceration, intestinal obstruction and peritonitis between the two groups of 2. enteronecrosis patients and non enteronecrosis patients (P0.05).Logistic regression multivariate analysis showed that the incarceration time was more than 6h (OR= 8.32, P0.001), OR=10.47, P=0.018, and peritonitis (OR=4.79, P=0.0) 05) is an independent risk factor for intestinal necrosis and bowel resection.
3. the incarcerated hernia had an intestinal necrosis index of 5-10 points without intestinal necrosis, 11~18 grade I intestinal necrosis, 19~26 grade II intestinal necrosis, and 26 grade III intestinal necrosis.
4. univariate analysis showed that the associated disease, ASA score, type of anesthesia, patching and intestinal necrosis were associated with patient complications (P0.05); age, associated disease, ASA score, and intestinal necrosis were associated with patient mortality (P0.05). But Logistic regression showed that only intestinal necrosis was an independent risk factor for prognosis (complications and mortality) (P0.01).
The total complication of patch repair in patients with 5. incarcerated hernia and intestinal necrosis was greater than that of one stage suture repair (P0.05), but there was no difference between the wound infection rate of patch repair and primary suture in patients with stage I necrosis (P0.05). Multivariate analysis showed that the application of patch was not a risk factor for prognosis (P0.05).
conclusion
1. incarceration time is greater than 6h, hernia type and peritonitis are independent risk factors for incarcerated hernia intestinal necrosis and intestinal resection, and intestinal resection is an independent factor affecting the prognosis of patients with incarcerated hernia.
The establishment of 2. incarcerated hernia intestinal necrosis index can guide the clinical evaluation of intestinal necrosis or predict the classification of intestinal necrosis. Combined with the classification of intestinal necrosis, the prognosis can be predicted and improved in advance.
The application of 3. patch can increase the incidence of postoperative complications, especially the occurrence of wound complications in patients with grade II and III necrosis, but it is not an independent prognostic factor.
The fourth part of inguinal incarcerated hernia with intestinal necrosis one stage tension free hernia repair.
Background and purpose of research
It is controversial whether incarcerated hernia and enteronecrosis are tension-free herniorrhaphy. Patch repair is feasible for definite or apparent contamination. Studies have also found that infection of incisions is not related to patch application.
For selected tension-free herniorrhaphy, the wound is a clean wound, and the operation is unquestionable. For patients with complicated intestinal necrosis, although there are many successful reports of tension free herniorrhaphy in the clinic, it is not all tension free hernia repair after necrosis of the intestine. As the time of necrosis is prolonged, the wound is contaminated to the sense of the wound. The early necrotic wound is contaminated or submersible
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R656.2

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