Analysis of clinical characteristics and treatment of patients with perianal necrotizing fasciitis
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摘要:
目的 探讨肛周坏死性筋膜炎患者的临床特征及治疗情况。 方法 该研究为回顾性队列研究。2013年8月—2023年9月,广西医科大学第一附属医院烧伤整形外科（以下简称本科室）收治20例符合入选标准的肛周坏死性筋膜炎患者,其中男19例、女1例,年龄24~74（56±11）岁。根据肛周感染向下腹部扩散的路径,将患者分为肛周-腹股沟-下腹壁组（12例）和肛周-盆腔-腹膜后组（8例）。比较2组患者基本资料,包括性别、年龄、合并基础疾病情况,转入本科室时的血糖水平、急性生理学和慢性健康状况评价Ⅱ（APACHEⅡ）评分,转入本科室时及14 d的坏死性筋膜炎实验室风险指数（LRINEC）评分；转入本科室时感染指标,包括C反应蛋白水平、白细胞计数、淋巴细胞计数、降钙素原水平、乳酸水平；临床结局相关指标,包括发病到明确感染范围的时间、手术次数、重症监护病房（ICU）治疗情况、住院时长、治疗结局及随访时坏死性筋膜炎复发情况；转入本科室时创面坏死组织标本病原菌检出情况及细菌耐药情况。 结果 与肛周-腹股沟-下腹壁组比较,肛周-盆腔-腹膜后组患者转入本科室时APACHEⅡ评分和乳酸水平、转入本科室14 d的LRINEC评分（t值分别为-5.98、-5.01、-2.86,P<0.05）及ICU治疗比例（P<0.05）均明显升高,发病到明确感染范围的时间明显延长（Z=-3.75,P<0.05）,手术次数明显增多（Z=2.80,P<0.05）。2组患者其余资料比较,差异均无统计学意义（P>0.05）。最终18例患者治愈。随访6个月,18例治愈患者肛周坏死性筋膜炎均无复发。2组患者转入本科室时创面坏死组织标本检出的细菌主要为大肠埃希菌、肺炎克雷伯菌,真菌为曲霉菌和白色念珠菌。肛周-盆腔-腹膜后组患者转入本科室时创面坏死组织标本细菌多重耐药比例明显高于肛周-腹股沟-下腹壁组（P<0.05）。 结论 肛周坏死性筋膜炎可通过肛周-腹股沟-下腹壁及肛周-盆腔-腹膜后2种路径向下腹部扩散,后者病情进展较为隐蔽、治疗难度更大。建立多学科团队诊疗机制可实现肛周坏死性筋膜炎的早期诊断和精准治疗的目标。 Abstract:Objective To investigate the clinical characteristics and treatment of patients with perianal necrotizing fasciitis. Methods This study was a retrospective cohort study. Twenty patients with perianal necrotizing fasciitis who met the inclusion criteria were admitted to the Department of Burn and Plastic Surgery of the First Affiliated Hospital of Guangxi Medical University (hereinafter referred to as our department) from August 2013 to September 2023, including 19 males and 1 female, aged 24-74 (56±11) years. Based on the spreading route of perianal infection to the lower abdomen, the patients were divided into perianal-inguinal-lower abdominal wall group (12 cases) and perianal-pelvic cavity-retroperitoneal group (8 cases). The following clinical data were compared between the two groups of patients: general data, including gender, age, combined underlying diseases, blood glucose level and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score when admitted to our department, and laboratory risk indicator for necrotizing fasciitis (LRINEC) score when admitted to our department and at 14 d after admitted to our department; infection indicators when admitted to our department, including C-reactive protein level, white blood cell count, lymphocyte count, procalcitonin level, and lactic acid level; clinical outcome-related indicators, including time from onset to definite infection range, number of surgery, treatment in intensive care unit (ICU), length of hospital stay, treatment outcome, and recurrence of necrotizing fasciitis during follow-up; detection of pathogen and bacterial drug resistance in wound necrotic tissue specimen when admitted to our department. Results Compared with those in perianal-inguinal-lower abdominal wall group, the APACHE Ⅱ score and lactic acid level when admitted to our department and LRINEC score at 14 d after admitted to our department (with t values of -5.98, -5.01, and -2.86, respectively, P<0.05) and ICU treatment ratio (P<0.05) were significantly increased, the time from onset to definite infection range was significantly prolonged (Z=-3.75, P<0.05), and the number of surgery was significantly increased (Z=2.80, P<0.05) in patients in perianal-pelvic cavity-retroperitoneal group. There were no statistically significant differences in other data between the two groups of patients (P>0.05). Eighteen patients were cured, and no recurrence of perianal necrotizing fasciitis was observed during follow-up of 6 months in 18 cured patients. The main bacteria were Escherichia coli and Klebsiella pneumoniae, and the fungui were Aspergillus and Candida albicans detected in wound necrotic tissue specimens in two groups of patients when admitted to our department. The ratio of multiple drug resistance of bacteria in wound necrotic tissue specimens in perianal-pelvic cavity-retroperitoneal group of patients was significantly higher than that in perianal-inguinal-lower abdominal wall group (P<0.05). Conclusions Perianal necrotizing fasciitis can spread to the lower abdomen through two routes: the perianal-inguinal-lower abdominal wall route and the perianal-pelvic cavity-retroperitoneal route. The latter is more insidious in disease progression and more challenging in treatment. Establishing a mechanism of multi-disciplinary team diagnosis and treatment can achieve the goal of early diagnosis and precise treatment of perianal necrotizing fasciitis. -
参考文献
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图 1 肛周-腹股沟-下腹壁组肛周坏死性筋膜炎例1患者的临床特征及治疗效果。1A、1B.分别为发病后10 d CT显示肛周、左下腹壁软组织积气、积液；1C.发病后10 d CT显示两侧腹膜后软组织无积气、积液；1D.入院后6 d,行肛周脓肿切开挂线引流术后,阴囊出现肿胀；1E.行肛周脓肿切开挂线引流术后5 d,阴囊阴茎皮肤软组织坏死；1F.转入烧伤整形外科后,第1清创术中,可见腹股沟及筋膜组织广泛坏死；1G.转入烧伤整形外科后,第2次清创术中,左腹股沟可见大量液化坏死组织；1H.转入烧伤整形外科后,第5次手术中,可见肛周-会阴部创面肉芽组织生长良好；1I.转入烧伤整形外科后,第6次手术中,移植大腿中厚皮修复阴茎创面,将会阴部其他创面拉拢缝合后；1J.行中厚皮移植修复阴茎创面后1周,皮片成活,会阴部缝合口完全愈合
图 2 肛周-盆腔-腹膜后组肛周坏死性筋膜炎例2患者的临床特征及治疗效果。2A、2B、2C.分别为发病后11 d CT显示肛周、两侧盆壁、两侧腹膜后肾周间隙软组织积气、积液；2D.转入烧伤整形外科时,肛周创面见少量坏死组织；2E.转入烧伤整形外科后,第2次切开清创术中,右下腹深及腹膜后可见大量液化坏死筋膜组织；2F、2G.分别为转入烧伤整形外科后,第4次手术中,见创面肉芽组织生长良好及将下腹部创面拉拢缝合后即刻；2H.转入烧伤整形外科后,第6次手术后即刻,肛周-会阴部创面完全封闭
Table 1. 2组肛周坏死性筋膜炎患者基本资料比较
组别 例数 性别（例） 年龄（岁, 合并基础疾病（例） LRINEC评分（分, 转入烧伤整形外科时APACHE Ⅱ评分（分, 转入烧伤整形外科时血糖[mmol/L,M（min,max）] 男 女 糖尿病 肝硬化 直肠癌 转入烧伤整形外科时 转入烧伤整形外科14 d 肛周-腹股沟-下腹壁组 12 12 0 55±13 9 1 0 10.1±2.6 5.2±1.3 6.9±2.6 9.50（4.13,15.32） 肛周-盆腔-腹膜后组 8 7 1 57±10 5 1 2 9.5±2.3 7.1±1.7 14.8±3.2 8.17（7.31,16.40） 统计量值 — t=-0.35 — — — t=0.51 t=-2.86 t=-5.98 Z=-0.57 P值 0.400 0.730 0.642 1.000 0.147 0.616 0.010 <0.001 0.578 注：2组组名对应肛周感染向下腹部扩散的路径；LRINEC为坏死性筋膜炎实验室风险指数,APACHEⅡ为急性生理学和慢性健康状况评价Ⅱ；“—”表示无此统计量值 
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Table 2. 2组肛周坏死性筋膜炎患者转入烧伤整形外科时感染指标及临床结局相关指标比较
组别 例数 C反应蛋白（mg/L, 白细胞计数（×109/L, 降钙素原（ng/mL, 乳酸（mmol/L, 淋巴细胞计数（×109/L, 发病到明确感染范围的时间[d, M（min,max）] 手术次数[M（min,max）] ICU治疗（例） 死亡（例） 住院时长[d,M（min,max）] 肛周-腹股沟-下腹壁组 12 155±29 15±6 8±4 1.6±0.4 1.2±0.4 2（1,6） 3.0（2.0,9.0） 1 0 37.0（23.0,61.0） 肛周-盆腔-腹膜后组 8 163±28 16±7 12±6 2.9±0.7 1.1±0.7 14（9,17） 5.5（4.0,9.0） 5 2 42.5（30.0,70.0） 统计量值 t=-0.56 t=-0.28 t=-2.01 t=-5.01 t=-1.10 Z=-3.75 Z=2.80 — — Z=0.42 P值 0.581 0.781 0.050 <0.001 0.280 <0.001 0.004 0.018 0.147 0.678 注：2组组名对应肛周感染向下腹部扩散的路径；手术次数指清创及创面修复手术次数；ICU为重症监护病房；“—”表示无此统计量值
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Table 3. 2组肛周坏死性筋膜炎患者转入烧伤整形外科时创面坏死组织标本病原菌检出情况（株）
组别 例数 细菌 真菌 大肠埃希菌 肺炎克雷伯菌 铜绿假单胞菌 金黄色葡萄球菌 鲍曼不动杆菌 克氏柠檬酸杆菌 曲霉菌 白色念珠菌 肛周-腹股沟-下腹壁组 12 8 2 4 0 0 0 1 6 肛周-盆腔-腹膜后组 8 2 4 0 1 2 1 0 4 注：2组组名对应肛周感染向下腹部扩散的路径
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Table 4. 2组肛周坏死性筋膜炎患者转入烧伤整形外科时创面坏死组织标本细菌多重耐药情况（例）
组别 例数 肺炎克雷伯菌 鲍曼不动杆菌 金黄色葡萄球菌 大肠埃希菌 肛周-腹股沟-下腹壁组 12 1 0 0 0 肛周-盆腔-腹膜后组 8 3 2 1 1 注：2组组名对应肛周感染向下腹部扩散的路径
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