双吻合器在全直肠系膜切除低位直肠癌保肛手术中应用的探讨

目的 探讨双吻合器在全直肠系膜切除低位直肠癌保肛手术中的应用方法、并发症及临床效果.方法 回顾性分析在全直肠系膜切除的基础上,应用双器械吻合技术,对48例中低位直肠癌行低位或超低位吻合的保肛手术方法,观察其术后并发症,以及术后排便功能,局部复发率.结果 随访1～4年,低位吻合44例,超低位吻合4例.15例6个月内大便次数每天多于5次,6个月后大便次数均在每天3次以下,无大便失禁.吻合口漏1例,吻合口狭窄1例,吻合口出血3例,吻合口复发1例,全组无手术死亡.结论 双吻合器能简化手术操作,维持正常排便功能,提高了生活质量.     

直肠癌TME术围手术期处理体会

目的探讨直肠癌全直肠系膜切除(TME)低位结肠、直肠或肛管吻合术围手术期的处理方法.方法对239例直肠癌TME患者术前给予口服无渣肠内营养制剂、缓泻剂进行肠道准备;术后保持肛门清洁、调节饮食,指导坐浴和缩肛运动.结果本组患者手术顺利,术后吻合口瘘发生2例,吻合口狭窄发生1例,无张力膀胱3例,均经治疗缓解.患者术后肛门括约肌收缩功能存在,控便功能良好,临床疗效满意.结论加强直肠癌TME患者围手术期处理,定期观察盆腔外引流物的色泽、性质对及早发现术后并发症、改善患者的预后发生有重要意义.     

直肠癌TME术围手术期处理体会

目的探讨直肠癌全直肠系膜切除(TME)低位结肠、直肠或肛管吻合术围手术期的处理方法.方法对239例直肠癌TME患者术前给予口服无渣肠内营养制剂、缓泻剂进行肠道准备;术后保持肛门清洁、调节饮食,指导坐浴和缩肛运动.结果本组患者手术顺利,术后吻合口瘘发生2例,吻合口狭窄发生1例,无张力膀胱3例,均经治疗缓解.患者术后肛门括约肌收缩功能存在,控便功能良好,临床疗效满意.结论加强直肠癌TME患者围手术期处理,定期观察盆腔外引流物的色泽、性质对及早发现术后并发症、改善患者的预后发生有重要意义.     

86例超低位直肠癌保肛手术的临床分析

目的探讨超低位直肠癌保肛手术的临床疗效。方法回顾性分析我院2003年9月至2009年9月86例超低位直肠癌保肛手术的临床资料,对手术方法、术后并发症、术后肛门功能恢复情况等进行评价。结果 86例保肛手术均成功完成,术后吻合口漏2例,吻合口狭窄3例,术后1年控便能力均达优良级,随访时间为12~84个月,平均42个月,1例患者出现局部复发,1例患者出现肝转移。结论超低位直肠癌保肛手术避免了永久性的造口,患者生活质量得到明显改善,根治性高,安全性好,并发症低,值得推广。     

低位直肠癌切除后重建肛门内括约肌的解剖学基础

目的：为低位直肠癌切除后肛门内括约肌重建术提供解剖学依据。方法：应用游标卡尺、读数显微镜、量角器等测量工具在30例经防腐处理的盆腔标本上观测了肛管、肛门外括约肌各部、肛门内括约与齿状线的位置关系、齿状线平面与水平面的位置关系以及肛周间隙。结果：1.肛管（盆隔至齿状线段）的长度为41.97±3.57mm。2.肛门外托约肌皮下部全部位于线下;浅部位于线以上、线以下约占一半;深部均在线上方。3.肛门内括约肌在齿状线上、下所占比例平均为2：1。4.齿状线约呈前高后低位,与水平面的夹角平均为30.07±2.96度。结论：由于在齿状线上切断直肠,部分外括约肌的浅部、外括约肌的深部及2/3内括约肌被切除,肛门直肠环受到破坏,所以沿齿状线离断肛管切除直肠癌并行结肠齿状线吻合后,必须再行肛门内括约肌重建,方可使患在术后基本保证正常的排便功能。     

全直肠系膜切除联合双吻合技术在低位直肠癌保肛手术中的应用

目的探讨全直肠系膜切除联合双吻合技术在基层医院低位直肠癌保肛手术应用的可行性及并发症的防治。方法对已经行低位前切除术的121例低位直肠癌患者作了回顾性分析。结果全组患者手术顺利，无手术死亡。术后都发生了不同程度的排便功能障碍，1年后患者排便功能基本正常。术后发生吻合口瘘3例（9．38％），吻合口狭窄4例（12．5％），局部复发2例（6．25％），无排尿功能障碍；有性生活70例，其中3例有障碍。结论只要合理选择手术适应证，全直肠系膜切除联合双吻合技术对治疗低位直肠癌是一种较安全、有效术式，能够提高低位直肠癌保肛手术成功率及生活质量。     

腹腔镜下经腹或经肛门内括约肌切除术治疗低位直肠癌疗效对比

目的 比较腹腔镜下全直肠系膜间切除术(LA-TME)联合经腹或经肛门内括约肌切除术(ISR)治疗低位直肠癌的疗效。方法 回顾性分析2009年1月至2016年8月江苏大学附属第一人民医院胃肠外科收治的经电子肠镜检查及病理组织学检查确诊为低位直肠癌的28例患者的临床资料,按照手术方式将其分为经肛ISR组(接受LA-TME联合经肛门内ISR治疗,18例)和经腹ISR组(接受LA-TME联合经腹ISR治疗,10例)。对比分析2组患者的术中情况、术后的病理资料、并发症、肛门功能和预后情况。结果 患者手术时间、术中失血量、预防性造口比例、术后住院时间、术后复发率和肛门功能恢复方面组间比较,2组差异无统计学意义(P 0. 05)。结论 LA-TME联合经腹或经肛门内ISR对低位直肠癌的临床治疗效果相当,均可以作为腹腔镜辅助下ISR治疗低位直肠癌的术式。     

双吻合器在低位直肠癌根治术中的应用

目的：探讨双吻合器在低位直肠癌行Dixon保肛手术中应用的安全性和实用性。方法：自1998年1月-2002年12月采用双吻合器技术行低位直肠癌直肠前切除术治疗低位直肠癌39例，并对其临床资料进行回顾分析。结果：所有肿瘤均完整切除。术后吻合口漏1例，术后6个月复发1例，无吻合口狭窄及伤口感染。39例术后均有不同程度的排便习惯改变。结论：对低位直肠癌行Dixon保肛手术，采用双吻合器是安全可靠、省时、实用的。     

超低位直肠癌切除双吻合器结肠直肠吻合16例分析

目的 探讨超低位直肠癌使用双吻合器保肛手术的可行性、手术方式及其并发症处理.方法 对我院2006年1月至2011年3月收治的超低位直肠癌16例的临床病理特点、吻合方式、术后肛门功能、并发症及其预后情况进行回顾性分析.结果 本组术后发生吻合口瘘2例;局部复发2例;其中DukesB期1例、C期1例;本组5年生存率为62.5%,DukesA、B、C期的5年生存率分别为69%、50%、0%;病人术后1月内排便功能普遍较差,6个月后趋于正常,无1例大便失禁.结论 对于肿瘤局限、分化良好的、身体情况良好的超低位直肠癌病人可以采用双吻合器行保肛手术,达到根治目的,并发症少,提高病人生存质量.     

保肛手术在低位直肠癌根治术中的应用

低位直肠癌传统采用Miles经腹会阴切除和人工肛门造口术,术后给病人的生活带来不便和痛苦,因而保留肛门改善患者的术后生活质量已成为当今肛肠外科非常重视的研究课题。当今人们一直在追求进一步提高治愈率,另一方面也要求尽量避免永久性腹部结肠造口。本科在1996年1月～1998年12月近三年时间内采用保肛手术治疗21例低位直肠癌,取得良好的疗效,现报告如下。 1 临床资料 1.1 一般资料:本组21例,其中男12例,女9例;年龄26～73岁,平均57岁。癌肿距肛缘7cm(8例)、6cm(9例)、5cm(4例)。癌肿侵犯粘膜层,粘膜下层各1例,侵犯肌层15例,侵犯全层4例。 1.2 手术方法:低位前切除术6例应用进口双吻合器吻合,经腹直肠切除保留肛门结肠拖出术13例,经肛门直肠癌局部切除术2例。     

自体肌肉移植重建人工肛门括约肌

背景：有效的人工肛门括约肌重建能够改善肛门失禁患者的生存能力和生活质量。 目的：评价自体肌肉移植重建人工肛门括约肌的效果。 方法：分析自体臀大肌和股薄肌移植重建人工肛门括约肌的解剖学基础,并对应用自体臀大肌和股薄肌移植重建人工肛门括约肌的患者进行随访观察,通过评估人工肛门控便功能恢复情况以及相关并发症发生情况,明确自体臀大肌和股薄肌移植重建人工肛门括约肌的应用效果。 结果与结论：臀大肌和股薄肌均有丰富的血液供应,并且营养肌肉的动脉均有相应静脉和神经伴行。对应用自体臀大肌和股薄肌移植重建人工肛门括约肌的患者随访观察发现,患者多为直肠癌或者肛管癌,经过自体肌肉移植重建人工肛门括约肌后,均能获得较好的肛门排控便功能,较少发生肛门狭窄、肛周感染等并发症,无机体排斥反应的发生。     

The morphological differentiation of the internal sphincter muscle of the anus in the human embryo and fetus (26.01.1990)

Conclusion The opening of the anal canal appears to be the factor which initiated the differentiation of the sphincter apparatus.The internal sphincter m. of the anus is entirely composed of smooth muscle as distinct from the striated fibers of the m. puborectalis, and the external sphincter which is a mixture of smooth and striated fibers (of skeletal type). It develops in the terminal part of the internal circular layer of the rectal m., outside which are longitudinal fibers which descend early to form the external sphincter (beginning around the third month).This study shows that the internal sphincter is scarcely evident before 12 SA. Thus continence between 10 and 12 SA (after the closure of the anal membrane) is closely related to the other components of the sphincter apparatus. On the other hand, the internal sphincter has become well formed after 28 to 30 SA and then plays a direct role in maintaining continence.     

Fecal incontinence. Studies on physiology,pathophysiology and surgical treatment

The thesis consists of ten previously published studies and a review. The physiological and pathophysiological mechanisms in fecal incontinence has been studied by anal manometry, both by standard static anal manometry and by a new method, dynamic anal manometry, where anal sphincter pressure can be measured during simultaneous opening and closing of the anal canal. Patients with fecal incontinence showed abnormal sphincter pressures more frequently when dynamic anal manometry was used compared to standard anal manometry. The physiology and pathophysiology of the rectum was studied using rectal compliance measurements. Patients with normal anorectal function had a large variation in rectal compliance. Patients with fecal incontinence had as a group, lower rectal compliance than continent patients. This may lead to increased frequency of incontinence episodes in patients with fecal incontinence. The relationship between idiopathic fecal incontinence and pudendal nerve terminal latency was studied in 178 patients. The far majority of patients had normal latencies, and there was no correlation between latency and anal manometry. In contrast to previous suggestions, idiopathic fecal incontinence does not seem to be caused by pudendal nerve damage. Reconstruction of the external anal sphincter in patients with fecal incontinence due to obstetric sphincter lesion showed a poorer functional result among patients older than forty years compared to younger. This indicates that the general muscular weakening with age contribute to the incontinence in these patients. The treatment of more complicated forms of fecal incontinence consists of, apart from conservative treatment or colostomi, mainly in muscle transpositions or artificial anal sphincter. Transposition of the distal part of the gluteus maximus muscle to encircle the anal canal, did not lead to acceptable continence in any of the patients studied. Transposition of the gracilis muscle lead to acceptable continence in half the patients. Patients where the transposed muscle were stimulated by a neurostimulator had satisfactory continence in most cases. However, with this method several re-operations were necessary in some patients. In addition, some patients developed severe evacuation difficulties. Implantation of an artificial sphincter resulted in long-term improvement of continence in that half of patients in whom the artificial sphincter remained implanted. The other half of the patients had the artificial sphincter explanted due to various reasons, most frequently due to infection around the device. In selected patients with more complicated fecal incontinence, stimulated gracilis transposition or implantation of an artificial anal sphincter may be offered as an alternative to colostomy. Sacral nerve stimulation is a new method which seems to provide the best results among the more advanced procedures. Its minimally invasive character also contribute to the increasing use of this method in the last few years. Evaluation and treatment of fecal incontinence is presently in a state of rapid change with focus on more elaborate investigative methods and more diversified treatment.     

Studies on the integrated extrinsic nervous control of rectal motility in the cat

The effect of sympathetic nervous activity on rectal motility induced by pelvic nerve stimulation (PNS) was studied in anaesthetized cats. Division of the sympathetic lumbar colonic and hypogastric nerves or alpha-adrenoreceptor blockade, both of which reduced rectal tone, also reversed a predominantly relaxatory pelvic nerve response into a pure contraction. Contractions to pelvic nerve stimulation were reduced by simultaneous lumbar colonic nerve stimulation. This lumbar colonic nerve-induced inhibition was augmented by alpha-adrenoceptor blockade and abolished by beta-blockade. Close intra-arterial injection of a beta-adrenergic agonist reduced contractions to PNS, while an alpha-adrenergic agonist had no effect. Stimulation of the hypogastric nerves enhanced rectal contractions to simultaneous PNS. The apparent similarity with the arrangement of extrinsic nervous control of the internal anal sphincter suggests that the rectum is functionally involved in continence mechanisms.     

Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex

Chronic anal fissure is a painful disorder caused by linear ulcers in the distal anal mucosa. Even though it counts as one of the most common benign anorectal disorders, its precise etiology and pathophysiology remains unclear. Current thinking is that anal fissures are caused by anal trauma and pain, which leads to internal anal sphincter hypertonia. Increased anal basal pressure leads to diminished anodermal blood flow and local ischemia, which delays healing and leads to chronic anal fissure. The current treatment of choice for chronic anal fissure is either lateral internal sphincterotomy or botulinum toxin injections.In contrast to current thinking, we hypothesize that the external, rather than the internal, anal sphincter is responsible for increased anal basal pressure in patients suffering from chronic anal fissure. We think that damage to the anal mucosa leads to hypersensitivity of the contact receptors of the anal-external sphincter continence reflex, resulting in overreaction of the reflex. Overreaction causes spasm of the external anal sphincter. This in turn leads to increased anal basal pressure, diminished anodermal blood flow, and ischemia. Ischemia, finally, prevents the anal fissure from healing.Our hypothesis is supported by two findings. The first concerned a chronic anal fissure patient with increased anal basal pressure (170 mmHg) who had undergone lateral sphincterotomy. Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80 mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125 mmHg, even though the internal anal sphincter could no longer be responsible for the increase. Second, in contrast to previous studies, recent studies demonstrated that botulinum toxin influences external anal sphincter activity and, because it is a striated muscle relaxant, it seems reasonable to presume that it affects the striated external anal sphincter, rather than the smooth internal anal sphincter.If our hypothesis is proved correct, the treatment option of lateral internal sphincterotomy should be abandoned in patients suffering from chronic anal fissures, since it fails to eliminate the cause of high anal basal pressure. Additionally, lateral internal sphincterotomy may cause damage to the anal-external sphincter continence reflex, resulting in fecal incontinence. Instead, higher doses of botulinum toxin should be administered to those patients suffering from chronic anal fissure who appeared unresponsive to lower doses.     

中低位直肠癌患者低位前切除术对肛门直肠功能影响研究

目的：研究中低位直肠癌患者手术对肛门直肠功能的影响。方法：选择2012年1月至2015年1月在我院就诊的中低位直肠癌患者100例,患者肿瘤远侧缘距肛缘距离≤5 cm为低位组,肿瘤远侧缘距肛缘距离5~10 cm为中位组,低位组、中位组患者各50例,所有患者均采用低位前切除术,采用Hida肛门直肠临床功能评分系统对两组患者的肛门直肠功能进行评分,观察患者排便情况,采用肛门直肠功能压力检测仪对患者进行检测。结果：术后低位组患者每日出现便失控、每周出现便失控、排气失控、排液性便失控、排固性便失控等发生率均显著高于中位组,中位组中偶尔便失控、排便功能正常发生率高于低位组,低位组患者排便功能较中位组差,差异有统计学意义(P<0.05),术前两组患者的肛门直肠临床功能评分比较差异无统计学意义(P>0.05),术后3、6、12个月时,低位组患者的肛门直肠临床功能评分较中位组高,差异有统计学意义(P<0.05);术后,中位组患者肛管最大收缩压、肛管静息压、肛管最大收缩时间、直肠肛门抑制反射压力下降等均显著高于低位组,低位组患者肛门直肠测压较中位组差,差异有统计学意义(P<0.05)。结论：低位直肠癌患者手术后肛门直肠功能障碍较中位直肠癌患者显著,在中低位直肠癌患者治疗时,应全面评估患者肛门直肠功能,争取保留患者肛门功能。     

The role of the longitudinal muscle in the anal sphincter complex

Intersphincteric resection (ISR) enables radical sphincter-preserving surgery in a subset of low rectal tumors impinging on the anal sphincter complex (ASC). Excellent anatomical knowledge is essential for optimal ISR. This study describes the role of the longitudinal muscle (LM) in the ASC and implications for ISR and other low rectal and anal pathologies. Six human adult en bloc cadaveric specimens (three males, three females) were obtained from the University of Leeds GIFT Research Tissue Programme. Paraffin-embedded mega blocks containing the ASC were produced and serially sectioned at 250 μm intervals. Whole mount microscopic sections were histologically stained and digitally scanned. The intersphincteric plane was shown to be potentially very variable. In some places adipose tissue is located between the external anal sphincter (EAS) and internal anal sphincter (IAS), whereas in others the LM interdigitates to obliterate the plane. Elsewhere the LM is (partly) absent with the intersphincteric plane lying on the IAS. The LM gave rise to the formation of the submucosae and corrugator ani muscles by penetrating the IAS and EAS. In four of six specimens, striated muscle fibers from the EAS curled around the distal IAS reaching the anal submucosa. The ASC formed a complex structure, varying between individuals with an inconstant LM affecting the potential location of the intersphincteric plane as well as a high degree of intermingling striated and smooth muscle fibers potentially further disrupting the plane. The complexity of identifying the correct pathological staging of low rectal cancer is also demonstrated. Clin. Anat. 33:567–577, 2020. © 2019 Wiley Periodicals, Inc.     

Internal anal sphincter: an anatomic study

The anatomy of the internal anal sphincter and surrounding structures was investigated in 24 cadavers using a surgical microscope (6-25 x magnification). An understanding of the anatomy of the internal anal sphincter is helpful in avoiding complications during surgical procedures in the anorectal region. The external anal sphincter was composed of three ellipsoid rings of skeletal muscle (subcutaneous, superficial, and deep) that encircle the anal canal; in contrast, we found that the internal anal sphincter was composed of flat rings of smooth muscle bundles stacked one on top of the other, like the slats of a Venetian blind. In each anal canal, the average number of ring-like slats observed was 26.33 +/- 2.93 (range = 20-30) and each was covered by its own fascia. The smooth muscle fibers and fascia coalesced at three equidistant points around the anal canal to form three columns that extended distally into the lumen and differed in form from the other anal columns. When viewed from an anterior position, the columns were located anteriorly at the observer's right (5 o'clock position), posteriorly at the right (1 o'clock position), and laterally at the left (9 o'clock position). This heretofore unreported anatomy of the internal anal sphincter may play an important role in closing off the lumen of the anal canal and maintaining bowel continence.     

Study on reconstruction of rectal sensation based on wavelet packet analysis and SVM strategy

To control anal incontinence, we have developed an artificial anal sphincter system with sensor feedback. The artificial anal sphincter system is a novel hydraulic-electric muscle which mainly comprises an artificial anal sphincter, a wireless power supply subsystem, and a rectal sensation reconstruction subsystem. To investigate the features of the patients’ rectal sensation, we have developed an in vitro experimental platform of artificial anal sphincter. In vitro experiments have been performed, and demonstrate that the traditional threshold method is not suitable for predicting the time for defecation. The traditional threshold method only uses single-dimensional pressure time series which may contain a few interdependent components simultaneously. A wavelet packet analysis algorithm is employed to extract the feature vector of the rectal pressure signal, then the rectal sensation prediction model is constructed based on a support vector machine for defecation pattern recognition. The results show that the proposed method is an effective approach for the reconstruction of patients’ rectal sensation.     

Efferent sympathetic nervous control of rectal motility in the cat

The sympathetic nervous control of rectal motility was studied in anesthetized cats. Division of the sympathetic nerves, i.e. the hypogastric nerves and the lumbar colonic nerves and alpha-adrenergic blockade reduced rectal tone indicating that these nerves are tonically active. Efferent electrical stimulation of the nerves at high intensities caused an immediate and sustained contraction which was inhibited after phentolamine but unaffected by hexamethonium suggesting a direct alpha-adrenergic effect on the rectal smooth muscle. However when prevailing rectal tone was high beta-adrenergic inhibitory responses unaffected by hexamethonium were observed. In addition the hypogastric nerves seem to convey cholinergic excitatory fibres to the rectum. The results imply that the sympathetic nerves are integrated in the nervous regulation of rectal motility in a fashion similar to the nervous control of the internal anal sphincter.