肠瘘继发坏死性筋膜炎病例的临床资料分析及死亡危险因素筛查

赵陈雨瑶; 张玉珅; 杨占杰; 王明青; 薛文君; 霍然; 赵冉

doi:10.3760/cma.j.cn501225-20230923-00088

肠瘘继发坏死性筋膜炎病例的临床资料分析及死亡危险因素筛查

doi: 10.3760/cma.j.cn501225-20230923-00088

山东第一医科大学附属省立医院烧伤整形外科，济南　　250021

基金项目:

山东省自然科学基金 ZR2021MH103

详细信息

通讯作者:
赵冉，Email：zhaoran@sdfmu.edu.cn

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出版历程
- 收稿日期: 2023-09-23

Analysis of clinical data of necrotizing fasciitis secondary to intestinal fistulas and screening the mortality risk factors

Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China

Funds:

Natural Science Foundation of Shandong Province of China ZR2021MH103

More Information

Corresponding author: Zhao Ran, Email: zhaoran@sdfmu.edu.cn

摘要

摘要: 目的分析肠瘘继发坏死性筋膜炎（NF）病例的临床资料，并筛查这些病例的死亡危险因素。方法该研究为回顾性观察性研究。检索2000年1月—2023年10月入住山东第一医科大学附属省立医院（以下简称本单位）且符合入选标准的所有肠瘘继发NF病例的资料，在PubMed、Web of Science、Scopus、中国知网、中华医学期刊网数据库内检索建库至2023年10月符合入选标准的所有肠瘘继发NF病例的资料并进行筛检。按照临床结局，将有效病例纳入存活组（男47例、女24例）和死亡组（男16例、女7例）并计算病死率。对比分析2组病例的临床资料，包括年龄、基础疾病（与NF最相关的病种）、就诊前症状持续时间、白细胞计数、NF原因、腹膜炎体征、NF累及范围、肠道处理措施和创面处理措施，筛选94例肠瘘继发NF患者死亡的危险因素。结果共纳入有效病例为94例，包括文献报告90例、本单位收治病例4例，病死率为24.5%（23/94）。单因素分析结果显示，2组患者年龄、基础疾病、就诊前症状持续时间、白细胞计数、NF原因、腹膜炎体征和NF累及范围比较，差异均无统计学意义（ P>0.05）；2组患者肠道处理措施和创面处理措施比较，差异均有统计学意义（ χ ²值分别为17.97、8.33， P<0.05）。多因素logistic回归分析显示，肠道处理措施和创面处理措施均是94例肠瘘继发NF患者死亡的独立危险因素，其中Ⅰ期造瘘+后期重建和负压治疗均具有更高的保护效应（比值比分别为0.05、0.27，95%置信区间为0.01~0.33、0.08~0.88， P<0.05）。结论肠瘘继发NF患者的死亡风险高，在综合治疗的基础上，行积极的肠道和创面处理或许是避免患者死亡的关键，其中Ⅰ期造瘘+后期重建和负压治疗具有更高的保护效应。
- 筋膜炎，坏死性 /
- Fournier坏疽 /
- 肠瘘 /
- 肠穿孔
Abstract: Objective To analyze the clinical data and to screen the mortality risk factors of necrotizing fasciitis (NF) secondary to intestinal fistulas (NFsIF). Methods This study was a retrospective observational study. The data of all NFsIF cases who met the inclusion criteria and were admitted into Shandong Provincial Hospital Affiliated to Shandong First Medical University (hereinafter referred to as our unit) from January 2000 to October 2023, and in PubMed, Web of Science, Scopus, China National Knowledge Infrastructure, and Chinese Medical Journal Network databases from its establishment to October 2023 were retrieved and screened. Based on clinical outcomes, the cases were divided into survival group (47 males and 24 females) and death group (16 males and 7 females), and the mortality rate was calculated. Clinical data of patients in the two groups including age, underlying diseases (most related to NF), symptom duration before presentation, white blood cell count, causes of NF, signs of peritonitis, scope of NF involvement, and intestinal management and wound management measures were compared and analyzed to screen the risk factors of death in 94 patients with NFsIF. Results A total of 94 valid cases were collected, including 90 patients reported in the literature and 4 patients admitted to our unit, with the mortality rate of patients being 24.5% (23/94). Univariate analysis showed that there were no statistically significant differences in age, underlying diseases, symptom duration before presentation, white blood cell count, causes of NF, signs of peritonitis, scope of NF involvement between patients in the two groups ( P>0.05); there were statistically significant differences in intestinal treatment and wound treatment between the two groups (with χ ² values of 17.97 and 8.33, respectively, P<0.05). Multivariate logistic regression analysis showed that both intestinal treatment measures and wound treatments measures were independent risk factors for death in 94 NFsIF patients, among which first-stage colostomy+late-stage reconstruction and negative presssure therapy had higher protective effects (with odds ratios of 0.05 and 0.27, respectively, 95% confidence intervals of 0.01-0.33 and 0.08-0.88, respectively, P<0.05). Conclusions The mortality risk of patients with NFsIF is high. Based on comprehensive treatments, active intestinal and wound treatment may be the key to avoid death, with first-stage colostomy+late-stage reconstruction and negative pressure therapy having higher protective effects.
- Fasciitis, necrotizing /
- Fournier gangrene /
- Intestinal fistula /
- Intestinal perforation
赵陈雨瑶、张玉珅：检索文献、双盲校对、分析数据；杨占杰、王明青、薛文君、霍然：病例诊治、研究设计及指导、论文审阅并修改；赵冉：数据处理、统计分析、论文撰写、经费支持

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1 直肠瘘继发右下肢坏死性筋膜炎例1患者诊断过程。1A.入院时CT示盆腔及右侧皮下多发游离气体；1B.入院3 h急诊探查见右下肢后内侧切开后皮下及肌间隙广泛筋膜坏死，大量脓性及粪便样物质积聚；1C.入院5 d肠镜示直肠下段巨大瘘口；1D.入院35 d引流管逆行碘造影CT扫描+三维重建示腹膜后脓腔与盆底脓腔贯通

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2 回肠瘘继发右大腿坏死性筋膜炎例2患者的诊断过程。2A.入院时右侧臀部肌肉间隙内可见游离气体（上侧图），右大腿上段后侧可见肌肉深部巨大腔隙伴内侧软组织坏死液化缺损（下侧图）；2B.入院3 d后，消化道碘水造影显示回肠-盆腔瘘（见红色椭圆标记）

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表1 2组肠瘘继发NF患者临床资料比较

表1. Comparison of the clinical data of two groups of patients with necrotizing fasciitis secondary to intestinal fistulas

组别	例数	年龄（岁， x ¯ ± s ）	基础疾病 ^a（例）						NF原因（例）
组别	例数	年龄（岁， x ¯ ± s ）	无	肠道肿瘤	肠道溃疡或慢性炎症 ^b	肠道急性炎症或嵌顿 ^c	外伤或操作损伤 ^d	全身性疾病 ^e	直肠穿孔	结肠穿孔	盲肠穿孔	阑尾穿孔	回肠穿孔	十二指肠穿孔	胆囊穿孔
存活组	71	58±16	12	25	13	6	4	11	18	21	8	11	9	2	2
死亡组	23	62±17	1	11	0	4	3	4	6	4	2	5	3	3	0
统计量值		t=-1.15	—						—
P值		0.254	0.052						0.528
注：NF为坏死性筋膜炎； ^a指与本次NF最相关的基础疾病， ^b包括克罗恩病、憩室炎、胃十二指肠溃疡和结核性肠炎， ^c包括阑尾炎和嵌顿疝， ^d包括骨盆骨折、腹部撞击、脊髓损伤以及抽脂术、结肠镜检查和顽固性便秘造成的损伤， ^e包括2型糖尿病、甲亢、心脏病和高血压等， ^f可包括会阴区； ^g可包括会阴区及腹部， ^h可包括会阴区、腹部、腰背部及大腿， ⁱ包括Ⅰ期肠壁修补术和Ⅰ期肠穿孔切除吻合术， ^j包括负压治疗后自行愈合、局部缝合、皮片或皮瓣修复；“—”表示无此统计量值

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表2 94例肠瘘继发坏死性筋膜炎患者死亡的多因素logistic回归分析结果

表2. Multivariate logistic regression analysis results of 94 patients with necrotizing fasciitis secondary to intestinal fistulas

变量	回归系数	标准误	Wald χ ²值	比值比	95%置信区间	P值
肠道处理措施
Ⅰ期造瘘+后期重建	-2.99	0.96	9.78	0.05	0.01~0.33	0.002
Ⅰ期肠道修复术 ^a	-1.73	0.93	3.42	0.18	0.03~1.11	0.065
创面处理措施
负压治疗 ^b	-1.31	0.60	4.69	0.27	0.08~0.88	0.030
常量	1.50	0.88	2.94	—	—	0.087
注：肠道处理措施以无处理为参照，创面处理措施以仅清创换药为参照； ^a包括Ⅰ期肠壁修补术和Ⅰ期肠穿孔切除吻合术， ^b包括负压治疗后自行愈合、局部缝合、皮片或皮瓣修复；“—”表示无此统计量值