Analysis of clinical data of necrotizing fasciitis secondary to intestinal fistulas and screening the mortality risk factors
-
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。 -
关键词:
- 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. -
Key words:
- Fasciitis, necrotizing /
- Fournier gangrene /
- Intestinal fistula /
- Intestinal perforation
-
(1)较早地在烧伤领域提出持续炎症-免疫抑制-分解代谢综合征（PICS）这一概念。
持续炎症-免疫抑制-分解代谢综合征（persistent inflammation-immunosuppression-catabolism syndrome，PICS）是在全身性感染或非感染如烧创伤等进入慢性危重症（chronic critical illness，CCI）阶段时，出现的以持续性炎症、免疫抑制及蛋白质高分解代谢为特征的临床综合征。PICS防治困难、发病率高，是导致重症患者长期生活质量低下及远期死亡的重要原因，已成为重症患者治疗的新挑战 ［ 1, 2］ 。
大面积烧伤是一个累及全身的严重创伤事件，其病理生理学过程及临床表现与PICS类似，但目前关于大面积烧伤患者并发PICS的临床研究甚少。本研究总结大面积烧伤患者继发PICS的临床特征，对大面积烧伤患者继发PICS的影响因素进行多元回归分析，以期有助于临床早期识别、阻止或逆转可能的高危因素，进而改善大面积烧伤患者的预后。
1. 对象与方法
本回顾性病例系列研究符合《赫尔辛基宣言》的基本原则，根据暨南大学附属广州红十字会医院（以下简称本单位）伦理委员会政策，可以在不泄露患者身份信息的前提下对其临床资料进行分析、使用。
1.1 入选标准
纳入标准：（1）烧伤总面积≥30%TBSA；（2）年龄≥18岁，性别不限；（3）住院天数>14 d。排除标准：病历资料不完整者。
1.2 PICS诊断标准
（1）住院天数>14 d；（2）持续性的炎症反应：C反应蛋白>150 mg/L；（3）免疫抑制：淋巴细胞计数<0.8×10 9/L；（4）分解代谢综合征：血清白蛋白<30 g/L。
1.3 临床资料与分组
2017年1月—2021年12月，本单位烧伤ICU（BICU）收治220例符合入选标准的大面积成年烧伤患者，其中男168例、女52例，年龄18~84（43±14）岁。通过查询本单位的电子病历系统和重症护理系统，按照PICS发生情况将患者分为PICS组（84例）和非PICS组（136例）。
1.4 统计指标
1.4.1 一般资料
性别、年龄（分层：<65岁、≥65岁）、入院时合并基础疾病（糖尿病、高血压）情况和急性生理学和慢性健康状况评价Ⅱ（APACHEⅡ）评分、入院时和入院14 d脓毒症相关性器官功能衰竭评价（SOFA）评分、治疗期间行机械通气超过48 h比例。
1.4.2 专科情况
烧伤总面积、Ⅲ度烧伤面积、伤后48 h内入院比例、伤后30 d深度创面暴露面积（包括未行手术治疗的深Ⅱ度和Ⅲ度烧伤创面、暴露的肉芽组织创面、植皮区/供皮区感染创面面积）。
1.4.3 结局指标
住院天数、住院总费用、手术次数以及死亡情况。
1.5 统计学处理
采用SPSS 22.0统计软件进行数据分析。符合正态分布的计量资料数据以
2. 结果
2.1 一般资料
PICS组患者入院时APACHEⅡ评分和SOFA评分、治疗期间行机械通气超过48 h比例均明显高于非PICS组（ P<0.05），2组患者其余一般资料均相近（ P>0.05）。见 表1。
表1 2组大面积烧伤患者一般资料比较组别 例数 性别［例（%）］ 年龄［例（%）］ 入院时合并基础疾病［例（%）］ 入院时APACHEⅡ评分（分， 入院时SOFA评分［分， M（ Q 1， Q 3）］ 入院14 d SOFA评分［分， M（ Q 1， Q 3）］ 治疗期间行机械通气超过48 h［例（%）］ 男 女 <65岁 ≥65岁 糖尿病 高血压 PICS组 84 65（77.4） 19（22.6） 80（95.2） 4（4.8） 3（3.6） 10（11.9） 11±5 4（3，5） 3（2，4） 46（54.8） 非PICS组 136 103（75.7） 33（24.3） 128（94.1） 8（5.9） 4（2.9） 8（5.9） 7±4 2（1，3） 2（1，3） 54（39.7） 统计量值 χ 2=0.08 χ 2<0.01 χ 2<0.01 χ 2=2.50 t=6.78 Z=-4.75 Z=-1.90 χ 2=4.74 P值 0.780 0.960 1.000 0.113 <0.001 <0.001 0.057 0.029 注：PICS为持续炎症-免疫抑制-分解代谢综合征，APACHEⅡ为急性生理学和慢性健康状况评价Ⅱ，SOFA为脓毒症相关性器官功能衰竭评价 2.2 专科情况
PICS组患者烧伤总面积、Ⅲ度烧伤面积、伤后30 d深度创面暴露面积均明显大于非PICS组（ P<0.05），但伤后48 h内入院比例明显低于非PICS组（ P<0.05）。见 表2。
表2 2组大面积烧伤患者专科情况比较组别 例数 烧伤总面积（%TBSA， Ⅲ度烧伤面积［%TBSA， M（ Q 1， Q 3）］ 伤后48 h内入院［例（%）］ 伤后30 d深度创面暴露面积［%TBSA， M（ Q 1， Q 3）］ PICS组 84 73±20 56（36，80） 57（67.9） 25（15，35） 非PICS组 136 55±20 29（6，43） 112（82.4） 8（0，13） 统计量值 t=6.29 Z=-7.25 χ 2=6.13 Z=-8.73 P值 <0.001 <0.001 0.013 <0.001 注：PICS为持续炎症-免疫抑制-分解代谢综合征，TBSA为体表总面积；深度创面暴露面积包括未行手术治疗的深Ⅱ度和Ⅲ度烧伤创面、暴露的肉芽组织创面、植皮区/供皮区感染创面面积 2.3 结局指标
PICS组患者住院天数、住院总费用、手术次数均明显多于非PICS组（ P<0.05），但2组患者死亡情况相近（ P>0.05）。见 表3。
表3 2组大面积烧伤患者结局指标比较组别 例数 住院天数［d， M（ Q 1， Q 3）］ 住院总费用［万元， M（ Q 1， Q 3）］ 手术次数［次， M（ Q 1， Q 3）］ 死亡［例（%）］ PICS组 84 66（42，86） 85.3（48.1，110.6） 5（3，7） 2（2.4） 非PICS组 136 40（26，48） 35.7（13.0，47.8） 2（1，4） 3（2.2） 统计量值 Z=-7.12 Z=-8.48 Z=-6.87 χ 2<0.01 P值 <0.001 <0.001 <0.001 0.633 注：PICS为持续炎症-免疫抑制-分解代谢综合征 2.4 多因素logistic回归分析结果
以继发PICS的情况（PICS=1，非PICS=0）为因变量，将单因素分析中差异具有统计学意义的指标作为自变量，将烧伤总面积、Ⅲ度烧伤面积、伤后30 d深度创面暴露面积、入院时APACHEⅡ评分、入院时SOFA评分以原始值代入，伤后48 h内是否入院赋值（是=1，否=2）、治疗期间行机械通气是否超过48 h赋值（是=1，否=2），进行多因素logistic回归分析。结果显示，入院时APACHEⅡ评分、伤后30 d深度创面暴露面积均为大面积烧伤患者继发PICS的独立危险因素（ P<0.05）。见 表4。
表4 影响220例大面积烧伤患者继发PICS的多因素logistic回归分析阳性结果因素 回归系数 标准误 比值比 95%置信区间 P值 入院时APACHEⅡ评分（分） 0.14 12.13 1.15 1.06~1.25 <0.001 伤后30 d深度创面暴露面积（%TBSA） 0.07 30.07 1.07 1.05~1.10 <0.001 注：PICS为持续炎症-免疫抑制-分解代谢综合征，APACHEⅡ为急性生理学和慢性健康状况评价Ⅱ，TBSA为体表总面积；深度创面暴露面积包括未行手术治疗的深Ⅱ度和Ⅲ度烧伤创面、暴露的肉芽组织创面、植皮区/供皮区感染创面面积 3. 讨论
近年来，随着重症器官支持治疗理念和技术的发展，越来越多的重症患者从MODS早期死亡高峰阶段幸存下来，成为CCI患者。2012年，Gentile等 ［ 3］ 提出PICS的新概念。PICS提供了一个理解长期住院CCI患者病理生理状态的新视角。该概念被提出后，其合理性逐渐被接受。在脓毒症、多发伤、严重创伤等患者中的研究显示，PICS患者住院天数多、医疗资源消耗巨大、长期生活质量低下、中远期病死率高，值得临床医师高度重视。
大面积烧伤患者的病程中，存在典型的持续炎症反应、免疫抑制以及高分解代谢状态。大面积烧伤患者是否存在PICS，其发生、发展的特点如何，是本研究团队开展这一回顾性病例系列研究的目的。
本单位收治的220例符合入选标准的大面积成年烧伤患者中有84例符合PICS诊断标准，PICS的发病率为38.18%，高于在多发伤患者中的11.7% ［ 4］ ，与老年脓毒症患者中的37.1%相近 ［ 5］ 。一般情况下，年龄≥65岁、合并基础疾病是重症患者继发PICS的危险因素。本研究显示，PICS组与非PICS组大面积烧伤患者在年龄、入院时合并基础疾病（糖尿病、高血压）方面的差异均无统计学意义（ P>0.05），可能与本单位BICU收治的烧伤患者普遍较年轻，大部分为从事体力劳动的青壮年，基础疾病较少有关。
本研究中，PICS组患者烧伤总面积、Ⅲ度烧伤面积均明显大于非PICS组。烧伤面积与深度基本决定了烧伤的严重程度，大面积烧伤将导致大量促炎性细胞因子释放，进而触发和增强炎症反应与高分解代谢，推测其可能促成了PICS的发生。
有文献指出，烧伤后最初阶段的复苏不全往往是导致SIRS持续或全身状态恶化的重要因素 ［ 6, 7］ 。与PICS组相比，非PICS组伤后48 h内入院的患者占比较高。一般情况下，伤后48 h内入院的患者通常能接受较规范的液体复苏以及后续治疗。本研究中，伤后48 h后入院的患者，一部分是受伤地点离本单位较远，长途转运或多方辗转后才到达本单位接受治疗；一部分是在外院治疗了一段时间，创面处理不恰当，患者出现了一系列并发症后转入本单位的，因此PICS的发病率也高。不合适的创面处理通常会造成创面的感染、暴露，影响后续创面处理的效果，增加了创面封闭的难度，因此手术次数也会相应增多。推测此为本研究中PICS组患者的手术次数较非PICS组多的主要原因。
本研究中PICS组治疗期间行机械通气超过48 h的患者比例明显高于非PICS组，这与许多关于PICS的研究结果 ［ 8, 9］ 一致。有研究显示，SOFA评分对烧伤患者的预后有较好的预测价值 ［ 10］ 。在本研究中，2组患者仅入院时这个时间点的SOFA评分比较差异有统计学意义（ P<0.05），且SOFA评分非大面积烧伤患者继发PICS的独立危险因素。SOFA评分由氧合指数、血小板计数、胆红素水平、血管活性药物使用情况、格拉斯哥昏迷量表（GCS）评分等组成，其中的胆红素水平、GCS评分对于烧伤患者早期的评估，特异度并不高 ［ 10］ 。有学者指出，由于烧伤患者脓毒症休克出现迅速，但胆红素指标对于肝脏功能变化反应较慢，并且胆红素水平非烧伤患者的常规检测项目，因此认为，应将其从对烧伤及烧伤脓毒症休克患者的评分中剔除 ［ 11］ 。而包含血糖水平、将镇静与非镇静患者分别评估（镇静患者评估肠内营养耐受情况，非镇静患者评估意识状态）的“烧伤SOFA”评分，可能更适合重症烧伤患者。
进一步的多因素logistic回归分析结果显示，入院时APACHEⅡ评分、伤后30 d深度创面暴露面积是大面积烧伤患者继发PICS的独立危险因素。APACHEⅡ评分是目前临床危重症患者病情评估的主要评分系统，由急性生理学评分、年龄评分、慢性健康状况评分三部分组成，得分越高表示病情越重。本研究中，PICS组患者病情更严重、伤后48 h内入院的患者比例更低，可能是导致入院时APACHEⅡ评分更高的原因。而此评分包括了本研究纳入的如年龄、合并基础疾病等诸多影响因素，较全面地反映了患者的病情，可能是其成为大面积烧伤患者继发PICS独立危险因素的重要原因。同样，在对脓毒症、创伤等的研究中观察到，APACHEⅡ评分高的患者更易出现PICS ［ 4， 8］ ，与本研究结果一致。然而入院时病情严重程度是否与后期出现的PICS直接相关？伤后48 h后入院的已经出现并发症的患者，入院时的APACHEⅡ评分是否能反映其病情的严重程度？这需要大样本、更细的分层研究来证实。
本研究中2组患者烧伤总面积和Ⅲ度烧伤面积有明显差异，但这2个指标不是大面积烧伤患者继发PICS的独立危险因素，而伤后30 d深度创面暴露面积是大面积烧伤患者继发PICS的独立危险因素。大面积深度创面的长时间暴露对烧伤患者内环境的稳态、代谢、免疫等带来深远的影响。而创面坏死组织的去除，自体皮或皮肤替代物覆盖创面不仅可以减少炎症因子的释放以及其带来的全身炎症反应、免疫抑制，亦可以通过恢复体温调节、减少热量损失和水分蒸发等减轻高代谢反应，是打断烧伤后持续炎症反应-免疫抑制-高分解代谢这一循环的有效手段 ［ 12, 13］ 。
为了缩短大面积烧伤患者创面暴露时间，减少并发症的发生。本单位自2007年开始，对重症烧伤患者实行统一管理，伤后5 d左右为患者行第1次切削痂手术，对同一深度烧伤面积区间的患者实施统一手术方案；同时，结合深Ⅱ度创面愈合后作为供皮区，头部、阴囊反复供皮，以及控制手术出血及损伤等方法，分次分批手术覆盖创面。对于外院转入、创面处理不及时或不恰当且已经出现并发症的患者，亦在维护脏器功能的同时，积极进行手术干预，尽量减少创面暴露的时间和面积。既往研究显示，本单位BICU治疗的烧伤总面积<50%TBSA、51%~80%TBSA、>80%TBSA的患者，平均创面愈合时间分别为36、43、79 d ［ 14］ 。
持续炎症-免疫抑制-高分解代谢多层面与多环节的恶性循环，最终影响了PICS患者的结局。目前，针对PICS的治疗，包括抗感染治疗、免疫治疗、物理治疗、营养治疗等，但PICS是由一系列的介质引起的，介质相互关联和依存，存在多层面、多环节的恶性循环，目前许多关键节点或环路尚不清楚，因此治疗棘手。大面积烧伤的患者病死率与感染以及全身炎症反应等导致的脏器功能损伤有关，其中PICS一般与创面暴露导致的全身炎症反应相关。本研究结果显示，虽然PICS在大面积烧伤患者中发病率不低，但经过积极的手术治疗，结合重症患者脏器功能支持技术，总体预后良好，2组患者病死率相近。这也提示，无论是对于烧伤本身的治疗还是对于烧伤后并发症的治疗，都不能忽略对创面本身的处理。
另外，本研究也显示，PICS组患者手术次数、住院天数、住院总费用均明显多于非PICS组，提示继发PICS的患者，需要更多的手术干预和住院天数以及更高的住院费用。因此，尽管PICS预后良好，但其仍会给患者以及医院带来巨大负担。
综上所述，本研究中，大面积烧伤患者继发PICS的发病率较高，入院时APACHEⅡ评分以及伤后30 d深度创面暴露面积为大面积烧伤患者继发PICS的独立危险因素，说明入院时病情严重的患者更易出现PICS，提示深度创面处理对于阻断大面积烧伤患者持续炎症-免疫抑制-高分解代谢这一恶性循环的重要性。然而本研究属于单中心回顾性研究，样本量小，可能造成选择性偏倚，需要大样本多中心的研究完善其结果。同时，PICS诊断标准仍有争议，涉及PICS诊断的指标，例如血清白蛋白水平、C反应蛋白等是否能较好地体现烧伤患者的代谢、炎症反应情况，仍值得商榷；烧伤患者继发PICS是否对其瘢痕的形成、远期生活质量以及生存产生影响，也仍需要进一步研究。
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、经费支持所有作者均声明不存在利益冲突 -
参考文献
(101) [1] PelletierJ, GottliebM, LongB, et al. Necrotizing soft tissue infections (NSTI): pearls and pitfalls for the emergency clinician[J]. J Emerg Med, 2022,62(4):480-491. DOI: 10.1016/j.jemermed.2021.12.012. [2] ChenLL, FasolkaB, TreacyC. Necrotizing fasciitis: a comprehensive review[J]. Nursing, 2020,50(9):34-40. DOI: 10.1097/01.NURSE.0000694752.85118.62. [3] 孔祥力,石凯,薛岩,等. Fournier坏疽的研究进展[J]. 中华烧伤杂志,2020,36(1):70-76.DOI: 10.3760/cma.j.issn.1009-2587.2020.01.014. [4] BonneSL, KadriSS. Evaluation and management of necrotizing soft tissue infections[J]. Infect Dis Clin North Am, 2017,31(3):497-511. DOI: 10.1016/j.idc.2017.05.011. [5] 冉瑞军, 张国如. 阑尾炎穿孔继发腹壁坏死性筋膜炎1例[J].现代医药卫生,2023,39(14):2509-2513. DOI: 10.3969/j.issn.1009-5519.2023.14.038. [6] SatheakeerthyS, TangH, ArafatY, et al. Perineal necrotizing soft tissue infection secondary to rectal perforation from a large fish bone -a painful lesion not to be missed[J]. Radiol Case Rep, 2023,18(5):2011-2013. DOI: 10.1016/j.radcr.2023.03.011. [7] KhefachaF, FatmaA, ChangalA, et al. Necrotizing fasciitis of the thigh due to a secondary aortoduodenal fistula[J]. Radiol Case Rep, 2023,18(1):169-172. DOI: 10.1016/j.radcr.2022.09.086. [8] GanesanS. Necrotising fasciitis secondary to a perforated hepatic flexure tumour - a case report[J]. Int J Surg Case Rep, 2023,109:108619. DOI: 10.1016/j.ijscr.2023.108619. [9] FalconiS, WilhelmC, LoewenJ, et al. Necrotizing fasciitis of the abdominal wall secondary to complicated appendicitis: a case report[J]. Cureus, 2023,15(5):e39635. DOI: 10.7759/cureus.39635. [10] SuleimanovV, AlhanabiFH, Al SaeedFH, et al. A rare complication of perforated appendicitis: a case of necrotizing fasciitis[J]. Cureus, 2022,14(9):e29679. DOI: 10.7759/cureus.29679. [11] SmithMJ, LimR, MuhlmannMD. Abdominal wall necrotising fasciitis with colonic fistula[J]. ANZ J Surg, 2022,92(12):3387-3388. DOI: 10.1111/ans.17726. [12] SabloneS, LagouvardouE, CazzatoG, et al. Necrotizing fasciitis of the thigh as unusual colonoscopic polypectomy complication: review of the literature with case presentation[J]. Medicina (Kaunas), 2022,58(1):131. DOI: 10.3390/medicina58010131. [13] RadhiMA, ClementsJ. Necrotising myofasciitis of the lower limb secondary to extra-peritoneal rectal perforation[J]. Cureus, 2022,14(9):e28939. DOI: 10.7759/cureus.28939. [14] WynnM, GibsonR, GoldsmithP. Multidisciplinary management of a complex abdominal wound post necrotising fasciitis: a case study[J]. J Wound Care, 2022,31(11):924-929. DOI: 10.12968/jowc.2022.31.11.924. [15] BergeronE, BureL. Necrotizing fasciitis of the back originating from a perforated appendicitis: a case report[J]. Int J Surg Case Rep, 2022,99:107656. DOI: 10.1016/j.ijscr.2022.107656. [16] AltomareM, BenuzziL, MolteniM, et al. Negative pressure wound therapy for the treatment of Fournier's gangrene: a rare case with rectal fistula and systematic review of the literature[J]. J Pers Med, 2022,12 (10):1695. DOI: 10.3390/jpm12101695. [17] YamakawaS, FujiokaM, FukuiK, et al. Fournier's gangrene with subcutaneous emphysema of the thigh caused by air inflow associated with a rectovaginal fistula: a case report of pseudo-gas gangrene[J]. Wounds, 2021,33(1):E10-E13. [18] TosiM, Al-AwaA, RaeymaeckersS, et al. Subcutaneous emphysema of the extremities: be wary of necrotizing fasciitis, but also consider occult rupture or perforation[J]. Clin Case Rep, 2021,9(9):e04831. DOI: 10.1002/ccr3.4831. [19] ShuteL, PiduttiJ, TrepmanE, et al. Rectal perforation by an intrauterine device leading to fatal intra-abdominal sepsis and necrotizing fasciitis[J]. J Obstet Gynaecol Can, 2021,43(6):760-762. DOI: 10.1016/j.jogc.2020.09.015. [20] OhJ. Acute perforated appendicitis complicated by necrotizing fasciitis and bladder perforation[J]. Cureus, 2021,13(1):e12764. DOI: 10.7759/cureus.12764. [21] ElahabadiI, BazmandeganG, SalehiH, et al. Fournier's gangrene after missed acute perforated appendicitis: a case report[J]. Clin Case Rep, 2021,9(10):e04989. DOI: 10.1002/ccr3.4989. [22] CelikSU, SenocakR. Necrotizing fasciitis of the lower extremity secondary to a perforated rectosigmoid tumor[J]. Indian J Cancer, 2021,58(4):603-607. DOI: 10.4103/ijc.IJC_670_20. [23] BahlN, LongAS, VemuriA, et al. A case of necrotizing soft tissue infection secondary to perforated colon cancer[J]. Cureus, 2021,13(9):e17663. DOI: 10.7759/cureus.17663. [24] SaleemN, DevanWJ, PittsDR, et al. Unusual cause of Fournier's gangrene: colorectal-genitourinary tract fistulae status post brachytherapy[J]. BMJ Case Rep, 2020,13(10):e235903. DOI: 10.1136/bcr-2020-235903. [25] De la FuenteJ, FerdinandA, DybasM, et al. Necrotizing soft tissue infection and perforated viscus after suction-assisted lipectomy[J]. Cureus, 2020,12(6):e8617. DOI: 10.7759/cureus.8617. [26] ImaokaK, YanoT, ChodaY, et al. Successful use of negative pressure wound therapy for abdominal wall necrosis caused by a perforated ascending colon using the ABThera system[J]. Case Rep Surg, 2020,2020:8833566. DOI: 10.1155/2020/8833566. [27] KaramC, KozmanMA, FewtrellM, et al. Perforated descending colon adenocarcinoma manifesting as necrotizing fasciitis[J]. ANZ J Surg, 2020,90(11):E100-E102. DOI: 10.1111/ans.15812. [28] BegA, QureshiOA, SiddiquiF, et al. Retroperitoneal necrotizing fasciitis in a 42-year-old male patient: a case report[J]. J Pak Med Assoc, 2020,70(10):1857-1859. DOI: 10.47391/JPMA.647. [29] YangYC, LeeKH, HsuCW, et al. Acute onset of a swollen leg with crepitus: a complication with rectal perforation[J]. J Acute Med, 2019,9(1):29-33. DOI: 10.6705/j.jacme.201903_9(1).0005. [30] SoinS, RanganSV, AliFS, et al. Not your usual hip pain: necrotising fasciitis secondary to sigmoid perforation[J]. BMJ Case Rep, 2019,12(3):e228985. DOI: 10.1136/bcr-2018-228985. [31] OkkabazN, TurgutMA. Necrotising fasciitis of the thigh caused by duodenum invasion of renal cell carcinoma: a case report[J]. Int Wound J, 2019,16(5):1195-1198. DOI: 10.1111/iwj.13186. [32] NadeemK, ThomasS. Uncommon presentation of a common condition: necrotizing fasciitis caused by diverticular mircroperforation[J]. ANZ J Surg, 2020,90(3):371-373. DOI: 10.1111/ans.15240. [33] LeeA, JiangW, ArachchiA, et al. Amyand's hernia with perforated appendix complicated by necrotizing fasciitis[J]. ANZ J Surg, 2020,90(7/8):1524-1525. DOI: 10.1111/ans.15624. [34] DownieE, BhamidipatyM, LiR, et al. Surgical management of a perforated caecal carcinoma presenting as abdominal wall necrotizing fasciitis[J]. ANZ J Surg, 2020,90(3):370-371. DOI: 10.1111/ans.15108. [35] DellièreV, BertheuilN, HarnoisY, et al. Multiple bowel perforation and necrotising fasciitis secondary to abdominal liposuction in a patient with bilateral lumbar hernia[J]. Indian J Plast Surg, 2014,47(3):436-440. DOI: 10.4103/0970-0358.146650. [36] RuppM, KnappG, WeisweilerD, et al. Intestinal perforation by a toothpick as reason for necrotizing fasciitis[J]. J Bone Jt Infect, 2018,3(4):226-229. DOI: 10.7150/jbji.29065. [37] RebaiL, DaghmouriA, BoussaidiI. Necrotizing fasciitis of chest and right abdominal wall caused by acute perforated appendicitis: Case report[J]. Int J Surg Case Rep, 2018,53:32-34. DOI: 10.1016/j.ijscr.2018.09.036. [38] PatelL, TeklayS, WallaceD, et al. Perforated caecal carcinoma masquerading as lower limb necrotising fasciitis: lessons learnt[J]. BMJ Case Rep, 2018, 2018:bcr2017219412. DOI: 10.1136/bcr-2017-219412. [39] KumarD, Cortés-PenfieldNW, El-HaddadH, et al. Bowel perforation resulting in necrotizing soft-tissue infection of the abdomen, flank, and lower extremities[J]. Surg Infect (Larchmt), 2018,19(5):467-472. DOI: 10.1089/sur.2018.022. [40] KröpflV, TremlB, ScheidlS, et al. Necrotizing fasciitis of the lower extremity caused by perforated sigmoid diverticulitis-a case report[J]. J Surg Case Rep, 2018,2018(8):rjy198. DOI: 10.1093/jscr/rjy198. [41] PourikiS, SkalistirM, ZoumpouliC, et al. Necrotising fasciitis of the left leg caused by perforated caecal adenocarcinoma[J]. Ann R Coll Surg Engl, 2017,99(8):e223-e224. DOI: 10.1308/rcsann.2017.0138. [42] HuJ, GoekjianS, StoneN, et al. Negative pressure wound therapy for a giant wound secondary to malignancy-induced necrotizing fasciitis: case report and review of the literature[J]. Wounds, 2017,29(8):E55-E60. [43] BocchiottiMA, BogettiP, ParisiA, et al. Management of Fournier's gangrene non-healing wounds by autologous skin micrograft biotechnology: a new technique[J]. J Wound Care, 2017,26(6):314-317. DOI: 10.12968/jowc.2017.26.6.314. [44] WanisM, NafieS, MellonJK. A case of Fournier's gangrene in a young immunocompetent male patient resulting from a delayed diagnosis of appendicitis[J]. J Surg Case Rep, 2016,2016(4):rjw058. DOI: 10.1093/jscr/rjw058. [45] RajaguruK, Tan Ee LeeD. Amyand's hernia with appendicitis masquerading as Fournier's gangrene: a case report and review of the literature[J]. J Med Case Rep, 2016,10(1):263. DOI: 10.1186/s13256-016-1046-9. [46] SmithNE, McKenneyM. Acute sigmoid diverticulitis presenting as necrotizing fasciitis of the thigh and retroperitoneum[J]. Am Surg, 2016,82(11):301-302. [47] HusnooN, PatilS, JacksonA, et al. Necrotising fasciitis secondary to a colocutaneous fistula[J]. Ann R Coll Surg Engl, 2016,98(7):e130-e132. DOI: 10.1308/rcsann.2016.0177. [48] ConnorMJ, ThomsonAR, GrangeS, et al. Necrotizing fasciitis of the thigh and calf: a reminder to exclude a perforated intra-abdominal viscus: a case report[J]. JBJS Case Connect, 2016,6(2):e44. DOI: 10.2106/JBJS.CC.15.00217. [49] WeissA, SandlerB. Lower extremity necrotizing fasciitis: a unique initial presentation of Crohn's disease[J]. Ann Med Surg (Lond), 2015,4(3):215-216. DOI: 10.1016/j.amsu.2015.05.007. [50] PapadimitriouG, KoukoulakiM, VardasK, et al. Fournier's gangrene due to perioperative iatrogenic colon perforation in a renal transplant recipient[J]. Saudi J Kidney Dis Transpl, 2015,26(6):1257-1261. DOI: 10.4103/1319-2442.168665. [51] OssibiPE, SouikiT, Ibn MajdoubK, et al. Fournier gangrene: rare complication of rectal cancer[J]. Pan Afr Med J, 2015,20:288. DOI: 10.11604/pamj.2015.20.288.5506. [52] LoST, LeungSL, TangCN. Abdominal wall necrotising fasciitis secondary to fish bone ingestion[J]. J Surg Case Rep, 2015,2015 (7):rjv078. DOI: 10.1093/jscr/rjv078. [53] KimKY, ParkWC. Necrotizing fasciitis arising from an enterocutaneous fistula in a case of an appendiceal mucocele[J]. Ann Coloproctol, 2015,31(6):246-250. DOI: 10.3393/ac.2015.31.6.246. [54] EvansWD, WintersC, AminE. Necrotising fasciitis secondary to perforated rectal adenocarcinoma presenting as a thigh swelling[J]. BMJ Case Rep, 2015,2015:bcr2014208312. DOI: 10.1136/bcr-2014-208312. [55] BouassidaM, HamzaouiL, MrouaB, et al. Retroperitoneal necrotizing fasciitis with gas gangrene, caused by perforated caecal diverticulitis[J]. Int J Colorectal Dis, 2015,30(12):1739-1740. DOI: 10.1007/s00384-015-2150-9. [56] TaifS, AlrawiA. Missed acute appendicitis presenting as necrotising fasciitis of the thigh[J]. BMJ Case Rep, 2014,2014:bcr2014204247. DOI: 10.1136/bcr-2014-204247. [57] PecicV, NestorovicM, KovacevicP, et al. Catastrophic necrotizing fasciitis after blunt abdominal trauma with delayed recognition of the coecal rupture--case report[J]. Ulus Travma Acil Cerrahi Derg, 2014,20(2):143-146. DOI: 10.5505/tjtes.2014.64249. [58] GuGL, WangL, WeiXM, et al. Necrotizing fasciitis secondary to enterocutaneous fistula: three case reports[J]. World J Gastroenterol, 2014,20(24):7988-7992. DOI: 10.3748/wjg.v20.i24.7988. [59] ShrivastavaA, GuptaA, GuptaA, et al. Erosion of small intestine with necrotising fasciitis of over lying abdominal wall after expanded poly-tetrafluoroethylene mesh implantation: a rare complication after laparoscopic incisional hernia repair[J]. J Minim Access Surg, 2013,9(3):138-140. DOI: 10.4103/0972-9941.115381. [60] MichalopoulosN, ArampatziS, PapavramidisTS, et al. Necrotizing cellulitis of the abdominal wall, caused by Pediococcus sp., due to rupture of a retroperitoneal stromal cell tumor[J]. Int J Surg Case Rep, 2013,4(3):286-289. DOI: 10.1016/j.ijscr.2012.12.008. [61] HaemersK, PetersR, BraakS, et al. Necrotising fasciitis of the thigh[J]. BMJ Case Rep, 2013,2013:bcr2013009331. DOI: 10.1136/bcr-2013-009331. [62] ChanCC, WilliamsM. Fournier gangrene as a manifestation of undiagnosed metastatic perforated colorectal cancer[J]. Int Surg, 2013,98(1):43-48. DOI: 10.9738/CC168.1. [63] WibergA, CarapetiE, GreigA. Necrotising fasciitis of the thigh secondary to colonic perforation: the femoral canal as a route for infective spread[J]. J Plast Reconstr Aesthet Surg, 2012,65(12):1731-1733. DOI: 10.1016/j.bjps.2012.04.006. [64] TakedaM, HigashiY, ShojiT, et al. Necrotizing fasciitis caused by a primary appendicocutaneous fistula[J]. Surg Today, 2012,42(8):781-784. DOI: 10.1007/s00595-012-0140-x. [65] Ruiz-LopezM, MeraS, Gonzalez-PovedaI, et al. Fournier's gangrene: a complication of surgical glue treatment for a rectourethral fistula in a patient with human immunodeficiency virus infection[J]. Colorectal Dis, 2012,14(4):e203. DOI: 10.1111/j.1463-1318.2011.02822.x. [66] ParkSH, ChoiJR, SongJY, et al. Necrotizing fasciitis of the thigh secondary to radiation colitis in a rectal cancer patient[J]. J Korean Soc Coloproctol, 2012,28(6):325-329. DOI: 10.3393/jksc.2012.28.6.325. [67] RojeZ, RojeZ, MatićD, et al. Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs[J]. World J Emerg Surg, 2011,6(1):46. DOI: 10.1186/1749-7922-6-46. [68] RajendranS, KhanA, MurphyM, et al. Rectocutaneous fistula with Fournier's gangrene, a rare presentation of rectal cancer[J]. BMJ Case Rep, 2011,2011:bcr0620114372.DOI: 10.1136/bcr.06.2011.4372. [69] LeeIH, ChiuYH, HowCK, et al. Right hip necrotizing fasciitis[J]. Am J Med Sci, 2011,341(6):499. DOI: 10.1097/MAJ.0b013e3181f3cc12. [70] SalduaNS, FellarsTA, CoveyDC. Case report: bowel perforation presenting as subcutaneous emphysema of the thigh[J]. Clin Orthop Relat Res, 2010,468(2):619-623. DOI: 10.1007/s11999-009-1015-3. [71] KhalilH, TsilividisB, SchwarzL, et al. Necrotizing fasciitis of the thigh should raise suspicion of a rectal cancer[J]. J Visc Surg, 2010,147(3):e187-e189. DOI: 10.1016/j.jviscsurg.2010.07.003. [72] Georgiev-HristovT, Álvarez-GallegoM, JuliáJB, et al. Necrotising fasciitis of the lower limb due to perforated inguinal hernia[J]. Hernia, 2011,15(5):571-573. DOI: 10.1007/s10029-010-0688-6. [73] AgabaEA, KandelAR, AgabaPO, et al. Subcutaneous emphysema, muscular necrosis, and necrotizing fasciitis: an unusual presentation of perforated sigmoid diverticulitis[J]. South Med J, 2010,103(4):350-352. DOI: 10.1097/SMJ.0b013e3181c1a899. [74] FuWP, QuahHM, EuKW. Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb[J]. Singapore Med J, 2009,50(8):e270-e273. [75] UnderwoodTJ, SouthgateJ, TalbotR, et al. Perforated diverticulitis presenting as necrotising fasciitis of the leg[J]. World J Emerg Surg, 2008,3:10. DOI: 10.1186/1749-7922-3-10. [76] OkadaK, ShatariT, YamamotoT, et al. Necrotizing fasciitis secondary to carcinoma of the gallbladder with perforation[J]. J Hepatobiliary Pancreat Surg, 2007,14(3):336-339. DOI: 10.1007/s00534-006-1185-2. [77] LiuSY, NgSS, LeeJF. Multi-limb necrotizing fasciitis in a patient with rectal cancer[J]. World J Gastroenterol, 2006,12(32):5256-5258. DOI: 10.3748/wjg.v12.i32.5256. [78] SharmaD, DalencourtG, BitterlyT, et al. Small intestinal perforation and necrotizing fasciitis after abdominal liposuction[J]. Aesthetic Plast Surg, 2006,30(6):712-716. DOI: 10.1007/s00266-006-0078-8. [79] PenningaL, WettergrenA. Perforated appendicitis during near-term pregnancy causing necrotizing fasciitis of the lower extremity: a rare complication of a common disease[J]. Acta Obstet Gynecol Scand, 2006,85(9):1150-1151. DOI: 10.1080/00016340600613816. [80] MarronCD, McArdleGT, RaoM, et al. Perforated carcinoma of the caecum presenting as necrotising fasciitis of the abdominal wall, the key to early diagnosis and management[J]. BMC Surg, 2006,6:11. DOI: 10.1186/1471-2482-6-11. [81] RozeboomAL, SteenvoordeP, HartgrinkHH, et al. Necrotising fasciitis of the leg following a simple pelvic fracture: case report and literature review[J]. J Wound Care, 2006,15(3):117-120. DOI: 10.12968/jowc.2006.15.3.26875. [82] TandonT, MossMC, ShaikM, et al. Perforated colonic diverticulum presenting as necrotizing fasciitis of the thigh[J]. J Orthop Sci, 2005,10(5):534-536. DOI: 10.1007/s00776-005-0926-4. [83] AshL, HaleJ. CT findings of perforated rectal carcinoma presenting as Fournier's gangrene in the emergency department[J]. Emerg Radiol, 2005,11(5):295-297. DOI: 10.1007/s10140-005-0417-0. [84] NabhaKS, BadwanK, KerfootBP. Fournier's gangrene as a complication of steroid enema use for treatment of radiation proctitis[J]. Urology, 2004,64(3):587-588. DOI: 10.1016/j.urology.2004.05.034. [85] MahlerCW, BoermeesterMA, BuschOR. Acute diverticulitis mimicking necrotizing fasciitis[J]. J Am Coll Surg, 2003,197(3):517. DOI: 10.1016/S1072-7515(03)00536-2. [86] LeeYC, YangWH, WuWJ, et al. Perforated duodenum--an unusual etiology of Fournier's disease: a case report[J]. Kaohsiung J Med Sci, 2003,19(12):635-638. DOI: 10.1016/S1607-551X(09)70518-2. [87] 吴胜东,蔡秀军,Fandrich.胃穿孔术后并发坏死性筋膜炎一例[J].临床外科杂志, 2002, 10(5):297-297.DOI: 10.3969/j.issn.1005-6483.2002.05.050. [88] GrothD, HendersonSO. Necrotizing fasciitis due to appendicitis[J]. Am J Emerg Med, 1999,17(6):594-596. DOI: 10.1016/s0735-6757(99)90205-x. [89] GamagamiRA, MostafaviM, GamagamiA, et al. Fournier's gangrene: an unusual presentation for rectal carcinoma[J]. Am J Gastroenterol, 1998,93(4):657-658. DOI: 10.1111/j.1572-0241.1998.189_b.x. [90] RehmanA, WalkerM, KubbaH, et al. Necrotizing fasciitis following gall-bladder perforation[J]. J R Coll Surg Edinb, 1998,43(5):357. [91] GouldSW, BanwellP, GlazerG. Perforated colonic carcinoma presenting as epididymo-orchitis and Fournier's gangrene[J]. Eur J Surg Oncol, 1997,23(4):367-368. DOI: 10.1016/s0748-7983(97)91020-9. [92] GaetaM, VoltaS, MinutoliA, et al. Fournier gangrene caused by a perforated retroperitoneal appendix: CT demonstration[J]. AJR Am J Roentgenol, 1991,156(2):341-342. DOI: 10.2214/ajr.156.2.1898809. [93] HarrisonBJ. Perforated sigmoid diverticulum with necrotizing fasciitis of the abdominal wall[J]. J R Soc Med, 1981,74(8):625-626. DOI: 10.1177/014107688107400815. [94] MoreiraCA, WongpakdeeS, GennaroAR. A foreign body (chicken bone) in the rectum causing extensive perirectal and scrotal abscess: report of a case[J]. Dis Colon Rectum, 1975,18(5):407-409. DOI: 10.1007/BF02587433. [95] UstinJS, MalangoniMA. Necrotizing soft-tissue infections[J]. Crit Care Med, 2011,39(9):2156-2162. DOI: 10.1097/CCM.0b013e31821cb246. [96] WongCH, KhinLW, HengKS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections[J]. Crit Care Med, 2004,32(7):1535-1541. DOI: 10.1097/01.ccm.0000129486.35458.7d. [97] KiranRP. Fournier's gangrene: a review of 1726 cases[J]. Br J Surg, 2000,87(11):1596. DOI: 10.1046/j.1365-2168.2000.01679-9.x. [98] El-QushayriAE, KhalafKM, DahyA, et al. Fournier's gangrene mortality: a 17-year systematic review and meta-analysis[J]. Int J Infect Dis, 2020,92:218-225. DOI: 10.1016/j.ijid.2019.12.030. [99] PeetermansM, de ProstN, EckmannC, et al. Necrotizing skin and soft-tissue infections in the intensive care unit[J]. Clin Microbiol Infect, 2020,26(1):8-17. DOI: 10.1016/j.cmi.2019.06.031. [100] BhamaAR. Evaluation and management of enterocutaneous fistula[J]. Dis Colon Rectum, 2019,62(8):906-910. DOI: 10.1097/DCR.0000000000001424. [101] HagedornJC, WesselIsH. A contemporary update on Fournier's gangrene[J]. Nat Rev Urol, 2017,14(4):205-214. DOI: 10.1038/nrurol.2016.243. -
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
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）
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， 基础疾病 a（例） NF原因（例） 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 
下载: 导出CSV
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
下载: 导出CSV
-
下载:
计量
- 文章访问数: 1424
- HTML全文浏览量: 124
- PDF下载量: 28
- 被引次数: 0
