克罗恩病并发十二指肠内瘘的外科治疗

谢之豪; 郭栋; 顾立立; 龚剑峰; 朱维铭; 李宁; 黎介寿

doi:10.3760/cma.j.issn.1673-9752.2014.08.003

克罗恩病并发十二指肠内瘘的外科治疗

Surgical management of Crohn′s disease complicated with duodenal fistula

摘要

摘要: 目的:探讨克罗恩病并发十二指肠内瘘的外科治疗方法。
方法:回顾性分析2002年1月至2014年1月南京军区南京总医院收治的1 012例克罗恩病患者的临床资料，其中22例并发十二指肠内瘘。22例患者中12例十二指肠回结肠吻合口瘘，7例十二指肠-横结肠瘘，2例十二指肠-乙状结肠瘘，1例十二指肠-小肠瘘。通过放置鼻肠管越过十二指肠内瘘行肠内营养支持，待营养状况及BMI、Alb、C反应蛋白、红细胞沉降率、克罗恩病活动指数评分等指标恢复正常或显著改善后行手术治疗。手术方式为十二指肠瘘修补术+原发病灶肠管切除术。通过门诊、电话及网络形式随访，随访时间截至2014年5月。营养支持治疗前后比较采用t检验，非正态数据采用Mann Whitney u检验。
结果:2例患者因腹腔感染、1例患者因消化道出血行急诊手术，其余19例患者均先建立肠内营养途径。3例急诊手术患者行肠造口术，术后2例出现十二指肠修补处瘘(1例经肠内营养+冲洗引流12 d后愈合、1例再次手术治疗后痊愈)。19例患者经营养支持治疗肠内营养能量供应为(25.3±2.1)cal/g、肠内肠外营养能量供应为(28.5±3.2)cal/g，营养支持治疗时间为(31±5)d，C反应蛋白、克罗恩病活动指数评分由入院前25 mg/L、(207±111)分降至2 mg/L、(117±71)分，治疗前后比较，差异有统计学意义(u=53.000，t=0.942，P<0.05)。BMI、Alb、红细胞沉降率治疗前分别为(17.0±2.1)kg/m 2、(35±5)g/L、26 mm/h，治疗后为(17.9±2.8)kg/m 2、(38±5)g/L、23 mm/h，治疗前后比较，差异无统计学意义(t=0.482，1.170，u=67.500，P>0.05)。19例患者中1例经肠内营养治疗后内瘘消失，避免了手术；其余18例患者中5例行肠造口术，13例行肠吻合术。22例患者均获得随访。平均随访时间为13.4个月(4.0～37.0)个月，1例患者术后6个月吻合口复发致十二指肠回结肠吻合口瘘，再次行手术治疗，其余均未出现十二指肠修补处瘘等并发症。结论:克罗恩病并发十二指肠内瘘患者尽量争取择期手术，围手术期处理首选肠内营养治疗，纠正营养不良并诱导活动期克罗恩病缓解后，择期切除病变肠管，行十二指肠瘘修补术可以获得满意的疗效。

Abstract: Objective:To investigate the surgical management of Crohn′s disease complicated with duodenal fistula.
Methods:The clinical data of 1 012 patients with Crohn′s disease who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2002 to January 2014 were retrospectively analyzed. Of the 1 012 patients, 22 were complicated with duodenal fistula, including 12 with ileocolonic anastomosisduodenal fistula, 7 with coloduodenal fistula, 2 with sigmoidoduodenal fistula and 1 with duodenoenteric fistula. All patients received duodenal fistula repair+resection of diseased intestine. Patients were followed up via outpatient examination, phone call and email till May 2014. The condition of patients before and after enteral nutrition support was compared using the t test. Nonnormal data were analyzed using the MannWhitney u test.
Results Two patients with abdominal infection and 1 with gastrointestinal bleeding received emergent operation, and the other 19 patients received enteral nutrition support prior to operation. Three patients received emergent colostomy. Two patients had fistula at the duodenal anastomosis, and 1 patient was cured by enteral nutrition support+drainage for 12 days and the other 1 received reoperation. The energies provided by enteral nutrition and enteral+parenteral nutrition were (25.3±2.1)cal/g and (28.5±3.2)cal/g, respectively, and the time for nutrition support was (31±5)days. The level of Creaction protein and Crohn′s disease activity index were decreased from 25 mg/L and 207±111 before treatment to 2 mg/L and 117±71 after treatment, with significant difference (u=53.000, t=0.942, P<0.05). The levels of body mass index, albumin and blood sedimentation rate were (17.0±2.1)kg/m 2, (35±5)g/L and 26 mm/h before treatment, and (17.9±2.8)kg/m 2, (38±5)g/L and 23 mm/h after treatment, with no significant differences (t=0.482, 1.170, u=67.500, P>0.05). One patient was cured by enternal nutrition. Five patients received intestinal stoma and the other 13 patients received intestinal anastomosis. Twentytwo patients were followed up with the median time of 13.4 months (range, 4.0-37.0 months). One patient had recurrence of ileocolonic anastomosisduodenal fistula and received reoperation, and complications were not observed in the other 21 patients.
Conclusion:Selective operation is recommended for patients with Crohn′s disease complicated with duodenal fistula. Enteral nutrition support is the first choice during the interoperative management. Resection of diseased intestine combined with repair of duodenal fistula after alleviation of Crohn′s disease and malnutrition could achieve satisfactory effect.

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