肠瘘治疗普外科学习（学习资料）课件

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1、EntericFistulas:PrinciplesofManagement泌尿外科吴振旺2012-05-28historicalperspectiveLillienthal(in1901)andvonCackovic(6yearslater)reportedtheirexperiencewithsurgicalmanagementofECF,withfataloutcomesinallcases.Even20yearslater,thereportedoverallmortalityremained81%.his

2、toricalperspectiveTheintroductionofantibioticsinthemid-20thcenturydidnotimprovemortalityfromECF.Themajorbreakthroughcamewiththeintroductionoftotalparenteralnutrition(TPN)DefinitionsAfistulaisanabnormalcommunicationbetweentwoepithelializedsurfacesAnECFisanabnor

3、malcommunicationbetweenthebowellumenandskin.EtiologicclassificationIatrogenicOperationPercutaneousdrainageTraumaForeignbodyCrohndiseaseInfectiousdiseaseTuberculosisActinomycosisMalignancyPhysiologicclassificationLowoutput<200ml/dModerate200ml/d

4、tput>500ml/dCurrentmanagementofECF1.recognitionandstabilization2.anatomicaldefinitionanddecision3.definitiveoperationPart1:recognitionandstabilizationfourlifethreateningfocusofclinicalattention1.fluidandelectrolyteimbalance2.sepsis3.nutrition4.skincarefluidand

5、electrolyteimbalanceHypokalemiaisbyfarthemostcommonelectrolyteabnormalityControloftheeffluentVacuum-assistedwoundmanagementSomatostatinandoctreotideIntraabdominalinfectionabscess---drainedpercutaneouslyunderCTguidancePeritonitis---laparotomytoachievesourcecont

6、rolEffectivenutritionalsupportBaselinenutritionalrequirements:Caloric20kcal/kg/d,protein0.8g/kg/dHighoutputfistulas:30kcal/kg/d1.5to2.5g/kg/d,EffectivenutritionalsupportTPN----ENRelativemeritsofenteralversusparenteralfeedinginpatientswithentericfistulasareacti

7、velydebatedTPNhasbeenshowntoimprovethespontaneousclosureratesofentericfistulasPhase2:anatomicaldefinitionanddecisionpurpose--todevelopenoughimaginginformationtoassessthelikelihoodofspontaneousclosure.FistulogramsCTscansPhase2:anatomicaldefinitionanddecisiongen

8、eralprinciplereconstructiveoperationsshouldbedelayediffistulaoutputisgraduallydecreasingandthewound(ortract)showssignsofhealing.generallyacceptedECFisassociatedwithobliterativeperi