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肠瘘治疗--普外科学习.ppt
Enteric Fistulas: Principles of Management 泌尿外科 吴振旺 2012-05-28 historical perspective Lillienthal (in 1901) and von Cackovic (6 years later) reported their experience with surgical management of ECF, with fatal outcomes in all cases. Even 20 years later, the reported overall mortality remained 81%. historical perspective The introduction of antibiotics in the mid-20th century did not improve mortality from ECF. The major breakthrough came with the introduction of total parenteral nutrition (TPN) Definitions A fistula is an abnormal communication between two epithelialized surfaces An ECF is an abnormal communication between the bowel lumen and skin. Etiologic classification Iatrogenic Operation Percutaneous drainage Trauma Foreign body Crohn disease Infectious disease Tuberculosis Actinomycosis Malignancy Physiologic classification Low output 200ml/d Moderate 200ml/dx500ml/d High output 500ml/d Current management of ECF 1. recognition and stabilization 2. anatomical definition and decision 3. definitive operation Part1:recognition and stabilization four lifethreatening focus of clinical attention 1. fluid and electrolyte imbalance 2. sepsis 3. nutrition 4. skin care fluid and electrolyte imbalance Hypokalemia is by far the most common electrolyte abnormality Control of the effluent Vacuum-assisted wound management Somatostatin and octreotide Intraabdominal infection abscess ---drained percutaneously under CT guidance Peritonitis---laparotomy to achieve source control Effective nutritional support Baseline nutritional requirements : Caloric 20 kcal/kg/d , protein 0.8 g/kg/d High output fistulas: 30 kcal/kg/d 1.5 to 2.5 g/kg/d, Effective nutritional support TPN----EN Relative merits of enteral versus parenteral feeding in patients with enteric fistulas are actively debated TPN has been shown to improve the spontaneous closure rates of enteric fistulas Phase 2: anatomical defin
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