پديد آورندگان :
سروش، احمدرضا دانشگاه علوم پزشكي تهران - بيمارستان دكتر شريعتي - بخش جراحي عمومي - گروه جراحي عمومي , خورگامي، ژامك دانشگاه علوم پزشكي تهران - بيمارستان دكتر شريعتي - بخش جراحي عمومي - گروه جراحي عمومي , حكيميان، محمدرضا دانشگاه علوم پزشكي تهران - بيمارستان دكتر شريعتي - بخش جراحي عمومي - گروه جراحي عمومي , احتشامي، ندا , آقاجاني، مطهره
چكيده فارسي :
ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﭘﺮﻓـﻮراﺳﻴﻮن دﺳﺘﮕﺎه ﮔﻮارش از ﻋﻠﻞ ﻣﻬـﻢ ﺟﺮاﺣﻲ ﻫﺎي اورژاﻧﺲ در ﺑﺨﺶ ﻫﺎي ﺟـﺮاﺣﻲ ﻣﻲ ﺑﺎﺷـﺪ. از ﻃﺮﻓﻲ، ﺑﻪ ﻋﻠﺖ ﺑﻴﻤـﺎري ﻫﺎي زﻣﻴﻨﻪ اي و ﺗﺄﺧﻴـﺮ در ﺗﺸﺨﻴﺺ، ﻣﺮگ و ﻣﻴـﺮ در اﻳﻦ دﺳﺘﻪ از ﺑﻴﻤﺎري ﻫﺎ ﻗـﺎﺑﻞ ﺗﻮﺟﻪ اﺳﺖ. ﺑﻨﺎﺑـﺮاﻳﻦ ﺑﺮرﺳﻲ اﻳﻦ ﺑﻴﻤﺎري ﺑﻪ وﻳﮋه در ﻳﻚ ﻣـﺮﻛﺰ ارﺟـﺎﻋﻲ ﺳﻄـﺢ ﺳﻮم، در درﻣﺎن ﺑﻬﺘـﺮ و ﻛﺎﻫﺶ ﻋﻮارض و ﻣـﺮگ و ﻣﻴـﺮ راﻫﮕﺸﺎ ﺧﻮاﻫـﺪ ﺑﻮد. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: در ﻃﻲ ﻳﻚ دوره ﭘﻨﺞ ﺳﺎﻟﻪ از ﺳﺎل 1381 اﻟﻲ 1385 ﻣـﺪارك ﺑﺎﻟﻴﻨﻲ ﺑﻴﻤـﺎران ﻣﺒﺘﻼ ﺑﻪ ﭘﺮﻓﻮراﺳﻴﻮن دﺳﺘﮕﺎه ﮔﻮارش از ﻣﺮي ﺗﺎ رﻛﺘﻮم )ﺑﻪ ﻏﻴﺮ از آﭘﺎﻧﺪﻳﺴﻴﺖ ﭘﺮﻓﻮره( ﻣﻮرد ﺑﺮرﺳﻲ ﻗـﺮار ﮔﺮﻓﺖ و اﻃﻼﻋﺎت دﻣﻮﮔـﺮاﻓﻴﻚ، ﺑﻴﻤﺎري ﻫﺎي زﻣﻴﻨﻪ اي، ﻣﺤﻞ و ﻋﻠﺖ ﭘﺮﻓﻮراﺳﻴﻮن و ﭘﻴﺎﻣﺪ ﺑﻴﻤﺎران اﺳﺘﺨﺮاج و ﺗﺤﻠﻴﻞ ﺷﺪ. ﻳﺎﻓﺘﻪ ﻫﺎ: در ﻣﺠﻤﻮع 80 ﺑﻴﻤﺎر، 60 ﻧﻔﺮ زن ﺑﻮدﻧﺪ. ﻣﺘﻮﺳﻂ ﺳﻦ ﺑﻴﻤﺎران 51+19 ﺳﺎل ﺑﻮد. ﺷﺎﻳﻌﺘﺮﻳﻦ ﻋﻠﻞ ﭘﺮﻓﻮراﺳﻴﻮن ﺑﻪ ﺗﺮﺗﻴﺐ ﻋﺒﺎرت ﺑﻮدﻧﺪ از زﺧﻢ ﻫﺎي ﭘﭙﺘﻴﻚ )36%(، ﺗﺮوﻣﺎ )17%(، ﺑﺪﺧﻴﻤﻲ )15%( و ﻳﺎﺗﺮوژﻧﻴﻚ در زﻣﻴﻨﻪ آﻧﺪوﺳﻜﻮﭘﻲ ﻫﺎي ﺗﺸﺨﻴﺼﻲ و درﻣﺎﻧﻲ 12/5 در ﮔﺮوه زﺧﻢ ﻫﺎي ﭘﭙﺘﻴﻚ، ﻣﺘﻮﺳﻂ ﺳﻦ ﺑﻴﻤﺎران 52/6 ﺳﺎل ﺑﻮد. ﺗﻌﺪاد 24 ﻧﻔﺮ 82/8 از ﺑﻴﻤﺎران ﻣﺮد و 5 ﻧﻔﺮ زن ﺑﻮدﻧﺪ. از ﻧﻈﺮ ﻓﺼﻞ و ﻣﺎه ﺑﺴﺘـﺮي در ﺑﻴﻦ اﻳﻦ ﮔـﺮوه از ﺑﻴﻤﺎران ﺗﻔﺎوت آﻣﺎري وﺟﻮد ﻧﺪاﺷﺖ. ﻣﺤﻞ ﭘﺮﻓﻮراﺳﻴﻮن در 19 ﻣﻮرد )65/5 ﻣﻌـﺪه و در 10 ﻣـﻮرد )34/5 دﺋﻮدﻧﻮم ﺑﻮد. ﺗﻌﺪاد 7 ﻣـﻮرد از اﻳﻦ ﺑﻴﻤـﺎران ﻓـﻮت ﻛﺮدﻧﺪ. ﻣـﺮگ و ﻣﻴـﺮ در اﻳﻦ ﺑﻴﻤﺎران ﺑﺎ ﺳﺎﺑﻘﺔ ﺑﻴﻤـﺎري ﮔـﻮارش، ﺳﻴﮕﺎر، اﻟﻜﻞ، ﻣﺼﺮف اﭘﻴـﻮم، ﻣﺼﺮف داروﻫﺎي ﺿﺪ اﻟﺘﻬﺎﺑﻲ ﻏﻴﺮ اﺳﺘﺮوﺋﻴﺪي، ﻣﺼﺮف ﻛﻮرﺗﻴﻜﻮاﺳﺘﺮوﺋﻴﺪ ﻳﺎ ﻣﺸﻜﻼت زﻣﻴﻨﻪ اي ﻗﻠﺒـﻲ ﺑﻪ ﺗﻨﻬﺎﻳﻲ ارﺗﺒـﺎط آﻣﺎري ﻣﻌﻨﻲ دار ﻧﺸﺎن ﻧﺪاد. ﻫﻤﭽﻨﻴﻦ ارﺗﺒﺎﻃﻲ ﺑﻴﻦ ﻣﺮگ و ﻣﻴـﺮ ﺑﻴﻤﺎران و ﺗﻌﺪاد ﻟﻜﻮﺳﻴﺖ ﻫﺎي ﺧﻮن، اﻧﺪازه ﭘﺮﻓـﻮراﺳﻴﻮن، ﻃﻮل زﻣﺎن ﺑﻴﻦ ﻋﻼﻣﺖ دار ﺷﺪن ﺗﺎ ﺟﺮاﺣﻲ ﻳﺎﻓﺖ ﻧﺸﺪ. وﻟﻲ ﻣـﺮگ و ﻣﻴﺮ ﺑﻪ ﻃﻮر ﻣﻌﻨﻲ داري ﺑﺎ وﺟـﻮد ﺑﻴﻤﺎري زﻣﻴﻨﻪ اي ارﺗﺒﺎط داﺷﺖ )P=0.041( و ﺑﻴﻤـﺎران ﺑﺎ ﺑﻴﻤـﺎري زﻣﻴﻨﻪ اي ﺳﻦ ﺑﺎﻻﺗـﺮي داﺷﺘﻨﺪ )P<0.005(. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﺷﺎﻳﻌﺘﺮﻳﻦ ﻋﻠﺖ ﭘﺮﻓﻮراﺳﻴﻮن در دﺳﺘﮕﺎه ﮔﻮارش )ﺑﺎ ﺣﺬف ﻛﺮدن ﭘﺮﻓﻮراﺳﻴﻮن آﭘﺎﻧﺪﻳﺲ(، زﺧﻢ ﭘﭙﺘﻴﻚ ﭘﺮﻓﻮره اﺳﺖ. اﻳﻦ ﺑﻴﻤﺎري ﺷﻴﻮع ﺑﻴﺸﺘﺮي در ﻣﺮدان دارد و ﻣﻬﻤﺘﺮﻳﻦ ﻓﺎﻛﺘﻮري ﻛﻪ ﺑﺎ ﻣﺮگ و ﻣﻴﺮ ارﺗﺒﺎط دارد، وﺟﻮد ﺑﻴﻤﺎري زﻣﻴﻨﻪ اي اﺳﺖ ﻛﻪ در ﺑﻴﻤﺎران ﻣﺴﻦ ﺑﻴﺸﺘﺮ اﺳﺖ. اﻳﻦ ﻣﻄﻠﺐ، اﻫﻤﻴﺖ در ﻧﻈﺮ داﺷﺘﻦ اﻳﻦ ﺗﺸﺨﻴﺺ در اﻓﺮاد ﻣﺴﻦ و اﻗﺪام درﻣﺎﻧﻲ زودرس در آﻧﻬﺎ را روﺷﻦ ﻣﻲ ﻧﻤﺎﻳﺪ. ﻧﺘﺎﻳﺞ اﻳﻦ ﺑﺮرﺳﻲ ﻧﺸﺎن داد ﻛﻪ در ﻣﺮاﻛﺰي ﻛﻪ اﻗﺪاﻣﺎت ﺗﺸﺨﻴﺼﻲ و درﻣﺎﻧﻲ آﻧﺪوﺳﻜﻮﭘﻴﻚ ﺑﻪ ﻃﻮر ﺷﺎﻳﻊ اﻧﺠﺎم ﻣﻲ ﺷﻮد، ﻳﻜﻲ از ﻋﻠﻞ ﺷﺎﻳﻊ ﭘﺮﻓﻮراﺳﻴﻮن دﺳﺘﮕﺎه ﮔﻮارش، اﻗﺪاﻣﺎت ﻣﺬﻛﻮر ﺧﻮاﻫﻨﺪ ﺑﻮد.
چكيده لاتين :
Introduction & Objective: Gastrointestinal perforation is one of the most important causes of emergent surgeries in surgery wards. On the other hand, mortality is high in this group because of underlying diseases and delay in diagnosis. Assessment of these patients is helpful especially in a tertiary care center.
Materials & Methods: In a five-year period from 2002 to 2007, we reviewed clinical records of patients with gastrointestinal perforations from esophagus to rectum (excluding perforated appendicitis). Demographic data, underlying diseases, location, and causes of perforation and outcome of patients extracted and analyzed.
Results: From 80 patients, 60 (75%) were male and 20 (25%) were female. Mean age was 51+19 years old. The most common causes of perforation were peptic ulcers (36%), trauma (17%), malignancy (15%), and iatrogenic due to endoscopic procedures (12.5%). In peptic ulcer subgroup, mean age was 52.6 year. Twenty two patients (81.5%) were male and five (18.5%) were female. There was no statistical difference in admission month and season in this subgroup. Site of perforation was stomach in 19 (65.5%) and duodenum in 10 (34.5%). Seven patient (24%) with perforated peptic ulcer expired. Mortality was not related with history of gastrointestinal disease, smoking, alcohol consumption, opium addiction, NSAID or corticosteroid use, and ischemic heart disease. There was no association between mortality and leukocyte count, perforation size, and time from symptoms to surgery; but mortality was significantly associated to underlying disease (P-Value = 0.041) and patients with underlying disease were older than others (P<0.005).
Conclusions: The most common cause of gastrointestinal perforation (excluding perforated appendicitis) is peptic ulcer disease, which is more common in males. The most related factors with mortality was the presence of underlying disorders which are more in the older. This shows importance of proper diagnosis in geriatric patients. In centers with frequent diagnostic and therapeutic endoscopic procedures, iatrogenic gastrointestinal perforation is among common causes of perforation.
