质控篇-肠漏的预测和对策课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,胃肠吻合口瘘,预测和对策,鸣谢,中国抗癌协会胃癌专业委员会,中华医学会外科学分会胃肠外科学组,中国抗癌协会大肠癌专业委员会,中国医师协会外科医师分会肿瘤外科委员会,中国实用外科杂志,胃癌手术消化道重建机械吻合专家共识,编写委员会,消化道重建专家共识,编写委员会,吻合口并发症管理项目愿景,搭建覆盖全国的并发症管理专家网络，交流手术经验，降低手术并发症,，,推动,规范化诊疗，,提升医疗质量和患者预后！,调研,全国消化道肿瘤诊疗数据，,推动信息交流,，帮助完善,共识,和循证依据，,提升国际影响！,4,吻合口瘘,术后死亡的独立预测因素,住院患者术后死亡者,39.3%,发生瘘,7%,未发生漏,一,.,吻合口瘘高危因素？,5,吻合口瘘危险因素分为三类,可控因素：,1,、张力,2,、丰富的血供,3,、转流性肠造口,4,、瘘口检测,部分可控因素：,1,、手术时机,2,、手术时血液流失,3,、病人营养状况,不可控因素：,1,、紧急病例,2,、病程,3,、发病部位,4,、病人体重指数,/,年龄,/ASA,评分,肠吻合瘘是一复杂过程,手术,患者,疾病,患者,因素,（,1,）,肥胖？,当,BMI,大于,30,时，瘘发生率增加：,结肠直肠吻合,急诊手术,再次手术,腹腔镜下肠吻合术,Am J Surg.2000;179:275-281,Dis Colon Rectum 2005;48:2272-2280,Dis Colon Rectum 2003,46:653-660,Ann Surg 2008;248:259-265,肥胖与右半结肠手术,右半结肠切除肥胖与非肥胖者相同,瘘,腹腔积液,腹腔脓肿,死亡率,9,肥胖与左半结肠手术,肥胖,正常体重,吻合口瘘,16%,6%,腹腔积液,10%,2%,死亡率,5%,0.5%,10,Am J Surg,.,2000 Apr;179(4):275-81,11,肥胖与直肠手术,直肠切除,+,预防性造瘘：,糖尿病,ASA status 2,谈论是否需要自体血回输,60 years old,ASA status 2.,Am J Surg,.,2000 Apr;179(4):275-81,12,A Systematic Review and Meta-analysis,（纳入,1700,病人）,饮酒不是独立危险因素,戒酒干预措施，不影响外科结局,J Gastrointest Surg.2013 Jul 9.,患者,因素,（,2,）嗜酒？,13,A Systematic Review and Meta-analysis:,107 studies,9354 pati.were included,general morbidity(,RR=1.52,95%CI:1.33-1.74),wound complications(,RR=2.15,95%CI:1.87-2.49),general infections(,RR=1.54,95%CI:1.32-1.79),pulmonary complications(,RR=1.73,95%CI:1.35-2.23),neurological complications(,RR=1.38,95%CI:1.01-1.88),admission to ICU(,RR=1.60,95%CI:1.14-2.25).,Ann Surg.,2014 Jan;259(1):52-71,患者,因素,-,（,3,）吸烟,患者自身其他危险因素,1.,年迈,70,岁,2.ASA,评分,高于,3,、,4,分,3.,使用糖皮质激素,超过三个月,4.,吸烟,J Am Coll Surg 1997;184:364-372,Ann Sur.1991;213(1):37-42,Colorectal,Dis.,2010 Jan;12(1):37-43.1463-1318,疾病因素,-,（,1,）,病变部位？,瘘的几率,腹膜外吻合口远远大于腹膜内吻合,肛缘,5cm,以下较,5cm,以上,6.5,倍,Ann Surg.2007;245(2):254-258,Dis Colon Rectum 2006;49:1719-1725,Br J Surg 85:355-358,疾病因素,-,（,2,）,病理？,炎症性肠病,憩室疾病,外伤,肿瘤,克罗恩病,瘘的危险因素？,低白蛋白血症,白蛋白低于,30g/L,围手术期应用糖皮质激素,超过,3,个月,术前有腹腔脓肿和瘘存在,多次手术,Dis Colon Rectum.2000 Aug;43(8):1141-5,Dis Colon Rectum.2007 Mar;50(3):331-6,10,克罗恩病,瘘的危险因素？,风险,术前营养不良,6.23,(1.75-22.52),术前有腹腔脓肿存在,7.47,(1.5-37.69),术前用激素,三个月,5.95,(1.04-34.1),克罗恩病复发,1.38,(1.03-1.9),Dis Colon Rectum.2000 Aug;43(8):1141-5,Dis Colon Rectum.2007 Mar;50(3):331-6,手术因素,术中失血,200 ml,术中术后需要输血,手术时间延长,200 minutes,Arch Surg.2010,145(4):371-376,Dis Colon Rectum 2006;49:1719-1725,J Am Coll Surg 1997;184:364-372,二 如何预测术后瘘？,（客观指标）,20,1,检验指标,CRP,预判吻合口瘘？,173,病人，,24,发生瘘,CRP,早起持续升高是预测指标,cut-off value140mg/L,术后第三天,sensitivity 78%,Specificity 86%,21,Int J Surg.2012;10(2):87-9,1,检验指标,腹腔引流液检测细菌菌落和细胞因子水平,瘘的患者：显著升高,有助于更早明确吻合瘘诊断,22,J Gastrointest Surg.2011 Jan;15(1):137-44,2,术中检测,（,1,）漏气检测有必要吗？,825,例行漏气检测的左半结肠吻合,8%,检测结果阳性,发生术后吻合口漏：,漏气检测阳性发生瘘,7.7%,漏气检测阴性发生瘘,3.8%,没进行漏气检测的吻合口瘘几率,8.1%,Ricciardo et al.Arch Surg.2009;144(5):407-11,2,术中检测,（,2,）,可,见光谱观察微循环？,Anastomotic leakage occurred in 14(18%)patients.When compared with a leaking anastomosis,normal anastomoses showed rising O(2)values during the operation,mean StO,2,瘘的患者,=72.19.0 -76.78.0,未瘘患者,=73.97.9 -73.17.4,(P 0.05),24,Colorectal Dis.2010 Oct;12(10),:1018-25,（,3,）中近红外线成像？,经肛门成像，了解吻合口血供,外周静脉注射,ICG,染料,经肛门内镜观察微循环情况,20,例患者，,4,例异常者,2,例发生楼,25,Colorectal Dis.2013 Jan;15,26,Neoadjuvant therapy,No,0,Radiotherapy,1,Chemoradiation,2,Emergency surgery,No,0,Bleeding,2,Obstruction,3,Perforation,4,Distance of anast to anal (cm),10,0,510,3,5,6,Additional procedures,No,0,Yes,1,Blood loss(cc)transfusion,2000,6,Duration of operation(h:min),2:00,0,2:002:59,1,3:003:59,2,4:00,4,3,瘘风险评分系统,J Surg Res.,2011 Mar;166(1),27,Score,Age(y),30/5 kg/6 mo),3,Intoxication,No,0,Smoking(any),1,Alcohol(3 U/d),1,Steroids(present use,excluding inhalers,4,3,瘘风险评分系统,J Surg Res.,2011 Mar;166(1),3,瘘风险评分系统,结论：,CLS,可预测左结肠瘘发生风险,需进一步应用和改进,有望帮助制定个体化治疗，吻合 或 预防性造瘘,28,J Surg Res.,2011 Mar;166(1),三 预防瘘的对策,术前措施,手术措施,材料器械改进,29,30,机械准备,n=670,非机械准备,n=684,P,值,吻合口瘘,32(48%),37(54%),069,伤口感染,90(134%),96(140%),082,伤口裂开,19(28%),16(23%),069,尿路感染,71(106%),70(102%),090,肺炎,39(58%),51(75%),027,腹腔脓肿,15(22%),32(47%),002,死亡,20(30%),26(38%),050,1,术前干预,肠道准备降低风险？,Lancet 2007 Dec 22;370(9605):2112-7,2,粪便转流,有必要吗？,Huser et al.Ann Surg.2008 Jul;248(1):52-60,结直肠吻合口瘘,Meta,分析,纳入,358,例,结论，可降低瘘发生率,预防性造瘘,832,例结直肠手术,246,例预防性造瘘,590,例未预防性造瘘,降低瘘相关并发症（,0.8%vs 5.1%,）,造瘘口并发症增加,32,Ann Coloproctol.2013 Apr;29(2):66-71,3,盆腔引流有用吗？,Surgery.1999 May;125(5):529-35.,引流组（,n=248,）,未引流组,(n=246),死亡率,8(3.2%),10(4%),肠瘘致死,3,2,再次手术,11,4,瘘发生率,6.3%,6.1%,盆腔引流,Cochrane Database Syst Rev.2004 Oct 18;(4),引流组,n=573,非引流组,n=567,P,死亡率,18(3%),25(4%),吻合口瘘,11(2%),7(1%),伤口感染,29(5%),28(5%),二次手术,34(6%),28(5%),腹部以外并发症,34(7%),32(6%),盆腔引流能否预防瘘？,meta-analysis.,8,项研究,2277,例患者,reduces the leakage,（,OR=0.51,）,reduces reintervention(,OR=0.29,),35,Colorectal Dis.2014 Feb;16(2):O35-42.,4,吻合口大网膜包裹？,Ann Surg.1998:227(2);