应用吻合器行回肠双腔造瘘术30例

目的 探讨应用管状吻合器实施回肠双腔造瘘术的临床价值.方法 2005年3月至2012年3月间应用管状吻合器施行回肠双腔造瘘术30例,其中结肠癌伴急性完全性肠梗阻13例,外伤性结肠破裂17例.取同期进行手工空肠双腔造瘘术38例作为对照组,进行统计学处理.结果 应用吻合器组造瘘相关并发症的发生率为16.7%（5/30）,低于手工造口组的36.8%（14/38）,P＜0.05.应用吻合器组造瘘还纳术后相关并发症的发生率为10.0%（3/30）,亦低于手工造口组的28.9%（11/38）,P＜0.05.结论 应用管状吻合器进行回肠双腔造瘘术,具有操作简便、手术时间明显减少,造瘘口形态一致,手术并发症少等优点.     

管型吻合器在肠造口术的应用 (附48例临床报告)

目的：探讨管型吻合器在乙状结肠造口术中的应用。方法：对48例采用直管型吻合器行乙状结肠造口术的患者进行回顾性分析和随访。结果：Miles手术37例，Hartmann手术11例，无手术死亡，术中结肠造口轻度出血2例，吻合不完全2例；术后随访1－30个月，造口皮肤瘢痕狭窄1例，结论：使用管型吻合器所作的人工肛门，美观大方，制作简单，术后恢复快，护理方使以及并发症少，值得临床推广应用。     

腹腔镜下腹会阴切除术两种结肠造口方式的比较

目的探讨腹腔镜下腹会阴切除术（LAPR）乙状结肠单腔造口的手术方式，以减少造口并发症的发生。方法63例患者中，低位直肠癌53例，直肠肛管癌10例。有61例用圆形吻合器行乙状结肠与腹壁皮肤吻合造口，2例手工缝合乙状结肠造口。腹腔内腹直肌型结肠造口37例（A组）；腹膜外隧道腹直肌型结肠造口26例（B组）。结果全组在腹腔镜下完成降结肠、乙状结肠和直肠的分离以及会阴部的直肠肛门开放性切除。无中转开腹，无手术死亡。两组的平均手术时间差异无统计学意义（P〉0．05）；而术后人工肛门排气时间[A组（2．4±1．1）d与B组（1．9±0．8）d比较，P〈0．05]、术后平均住院日[A组（19．9±7．8）d与B组（14．5±3．9）d比较，P〈0．01]及造口相关并发症的发生率（A组29．4％，B组4．0％；两组比较P〈0．05）差异均有统计学意义；B组患者术后平均住院日较A组短，造口相关并发症低于A组。结论LAPR手术中。采用圆形吻合器经腹膜外隧道和腹直肌行乙状结肠单腔造口，可有效地减少造口并发症的发生和缩短手术后的住院时间。     

管形吻合器在乙状结肠单腔造瘘术中应用的对比研究

目的探讨管形吻合器在乙状结肠单腔造瘘术中的应用价值。方法 2008年1月~2009年12月,行腹腔镜低位直肠癌Miles手术42例,按手术组不同和患者要求采用管形吻合器行乙状结肠单腔造瘘20例（吻合器组）,采用传统的手工缝合造瘘22例（手工缝合组）,对2组手术成功率、术后并发症发生率、手术总时间、住院时间和住院总费用进行统计学分析。结果 2组手术均成功。2组术中出血量、清扫淋巴结个数、造瘘口并发症发生率差异无显著性（P〉0.05）。手工缝合组术后出现并发症4例,分别为造瘘口坏死2例、造瘘口旁疝2例,均再次手术治愈,吻合器组未出现并发症。吻合器组手术时间短[（165.0±16.3）min vs.（221.0±20.2）min,t=-9.734,P=0.000],肠功能恢复快[（43.8±3.5）h vs.（52.5±2.6）h,t=-9.081,P=0.000],术后住院时间短[（12.7±2.9）d vs.（15.7±2.1）d,t=-4.009,P=0.000],需要镇痛者少（8例vs.21例,χ2=15.074,P=0.000）,但住院总费用高[（2.30±0.11）万元vs.（2.16±0.24）万元,t=4.009,P=0.000]。结论吻合器在乙状结肠单腔造瘘术中的运用使手术时间明显缩短,术后并发症减少,在技术上是安全、可靠的,具有手术创伤小、术后疼痛轻、易护理的特点,值得推广。     

4例肠道内瘘患者行转流治疗的临床分析

目的探讨转流手术在肠道内瘘治疗中的应用价值。方法回顾性分析2016年在北京大学第三医院行转流手术治疗的4例肠道内瘘患者的临床资料。结果病例1,直肠癌术后出现右侧输尿管瘘,先于膀胱镜下行右侧输尿管支架置入术,术后症状短暂缓解,后肛门溢液再次出现,且逐渐发展为右肾积水,3个月后又行右侧经皮肾造瘘术。病例2,直肠癌术后出现尿道瘘,行腹腔镜横结肠双腔造瘘术。病例3,乙状结肠憩室炎导致结肠膀胱瘘,行腹腔镜探查、开腹膀胱后壁分离、膀胱瘘修补、结肠修补及末端回肠双腔造瘘术。病例4,盆腔肿瘤复发导致小肠阴道瘘,行腹腔镜末端回肠双腔造瘘术。4例患者术后1周内原有症状消失,手术效果良好。术后随访3个月~1年,病例1和病例4肿瘤原位复发;病例2于术后6个月行经肛门尿道修补手术成功;病例3于术后6个月时瘘口愈合,行造瘘口还纳术。结论转流手术治疗肠道内瘘具有重要价值,但应严格把握适应证,并重视术后随访。     

应用双吻合器低位直肠癌保肛术后吻合口大出血病因及防治分析

目的探讨低位直肠癌应用双吻合器保肛术后,吻合口大出血的原因及防治方法。方法回顾性分析2003年1月—2011年3月间收治的低位直肠癌患者,经双吻合器保肛术后发生吻合口大出血8例的临床资料。结果患者均为男性,吻合口出血时间术后6～16 d,出血量均在1 000 mL以上,5例有出血性休克表现,其中5例有吻合口瘘。4例经二次手术横结肠造瘘好转,2例经肛门放置直肠支撑管压迫止血成功,1例经非手术治疗痊愈,1例死亡。结论男性低位直肠癌患者是双吻合器保肛术后吻合口大出血的高危因素;预防性结肠造瘘术可能是防治该并发症的有效手段。     

结肠造口还纳术后并发症的分析

目的分析结肠造1：3还纳术后并发症的发生情况。方法回顾性分析2006年至2008年间44例行结肠造口还纳手术患者的临床资料。结果44例中．术后总并发症发生牢59．1％;其中手术切口感染26例（59．1％）．大便失禁5例（11．4％）．吻合口瘘2例（4．5％）,切口疝2例（4．5％）,直肠膀胱瘘1例（2．3％）。术后吻合口瘘及直肠膀胱瘘者,行再次结肠造口;其余并发症经引流、局部换药、生物反馈及手术治疗后均获得好转。结论结肠造口还纳术后并发症发生率较高。     

管型吻合器固定预置补片在永久性肠造口中的应用(附11例报告)

目的探讨管型吻合器在永久性肠造口预置补片中的临床应用价值。方法回顾性分析2011年3月~2015年12月我院老年外科应用管型吻合器固定预置补片的11例肠造口患者的术后并发症及随访情况。结果术后伤口感染3例,未影响造口及置入的补片。术后均随访2年以上,未出现造口旁疝,有2例直肠癌患者2年后出现远处转移。结论永久性肠造口时使用管状吻合器固定预置人工补片,方法简捷,固定可靠。     

低位直肠癌手术中使用双吻合器吻合口瘘的原因与处理

目的探讨低位直肠癌双吻合器吻合吻合口瘘发生的原因、预防及处理方法。方法回顾性分析我院2000年6月至2005年12月应用双吻合器进行Dixon术的86例病例的临床资料。结果12例发生吻合口瘘，7例经保守治疗治愈，5例手术治疗治愈。2例出现吻合口狭窄，排便不畅，经定期扩肛而治愈。结论吻合口瘘是低位直肠癌双吻合器前切除术后常见的并发症，小的瘘口可经保守治疗治愈，大的瘘口则需结肠造口以转流粪便，待瘘口封闭后再次手术还纳造口。     

腹腔镜乙状结肠癌根治术15例

目的探讨腹腔镜乙状结肠癌根治术的临床价值。方法回顾性分析2008年5月至2013年5月腹腔镜下乙状结肠癌根治术15例的临床资料。结果全组15例均在腹腔镜下完成手术,其中9例经体外行端端吻合,5例经肛门行直肠-乙状结肠端端吻合,1例行降结肠端造瘘。术后无吻合口瘘、吻合口出血等并发症发生,手术时间（192．8±33．5）min,平均186．8min,术中出血量（68．5±14．6）ml,平均59．6ml,术后住院时间（8．6±2．5）d,平均9．1d。结论腹腔镜乙状结肠癌根治术手术创伤小、术后恢复快,是治疗乙状结肠癌安全、可行的方法,但术者需有丰富的腹腔镜手术和结肠外科手术经验。     

吻闭合器在结直肠癌手术中的应用

为探讨吻闭合器在结直肠癌手术中的应用价值,自2003年6月至2007年3月,应用吻闭合器行回结肠端侧、直结肠端端、端侧及结肠端端、端侧吻合治疗94例结直肠癌患者,对治疗结果进行总结。结果显示,94例患者中,根治性切除81例,姑息性切除13例。术后随访,1年生存率93．6％（88／94）,2年生存率8d．0％（79／94）。行根治性切除的81例患者中,盆腔复发4例,吻合口狭窄2例,吻合口漏1例。结果表明,采用吻闭合器行回结肠端侧、直结肠端端、端侧技结肠端端、端侧吻合治疗结直肠癌,具有创伤小、操作简单、吻合成功率高、并发症少等优点,值得临床推广。     

The double-staple technique in colorectal anastomoses: a critical review.

The widespread availability and use of stapling devices have changed colorectal surgery. In 1980, Knight and Griffen developed the "double-staple" technique, using a circular stapler to transect a linear rectal staple line. This eliminated the need for a hand-sewn, distal purse string, which was sometimes difficult or even impossible to accurately place low in the pelvis. To evaluate this procedure, the authors have reviewed their results with the double-staple technique over the past 5 years. One hundred four patients underwent this procedure between 1985 and 1990 at Thomas Jefferson University Hospital (Philadelphia, PA). There were 60 men and 44 women, with a mean age of 62.4 years. Seventy-two patients underwent operation for carcinoma of the rectum or sigmoid. Thirty-five of these had preoperative radiation therapy. Other diagnoses included 1) diverticular disease, 2) rectal prolapse, 3) villous adenoma, 4) endometrial carcinoma, 5) fistula, 6) stricture, 7) Crohn's disease, 8) colonic endometriosis, 9) lymphoma, 10) ovarian carcinoma, and 11) ulcerative colitis. Incomplete "donuts" were observed in 5 patients. Diverting colostomies were performed in 23 patients, ileostomies in 3. Postoperative complications relating to the double-staple technique itself included a rectovaginal fistula in 1 patient. There were 3 clinical leaks (2.8%), all treated nonoperatively. No strictures were observed. As previously observed, the authors believe the double-staple technique offers certain advantages over traditional, hand-sewn and stapled anastomoses, for instance: 1) there is significantly less contamination, 2) the anastomosis is technically easier, and 3) bowel segments of different diameters can be easily anastomosed.     

Low anterior resection of the rectum using a double stapling technique

Using a double stapling technique in 30 patients, anterior resection of the rectum was attempted for low rectal carcinoma (n = 28), giant rectal adenoma (n = 1) and radiation-induced rectal stricture (n = 1). There were three emergency operations. The rectum was stapled transversely more than 3 cm below the tumour using the adjustable-angle linear stapler (Roticulator). Colorectal or coloanal anastomoses were constructed using the EEA circular stapler introduced per anum through the anorectal stump staple line. Ten coloanal and 19 low rectal anastomoses were achieved. A protecting transverse loop colostomy was fashioned in one patient with coloanal anastomosis who developed a vaginal tear during the procedure. In one patient technical failure necessitated conversion to abdominoperineal excision of the rectum. All staple rings and resection margins were intact and free from tumour. There were two clinical anastomotic leaks, both treated successfully with a defunctioning transverse loop colostomy. One patient developed a small infective pelvic haematoma 2 weeks after surgery which required drainage. Hospital stay ranged from 6 to 15 days (mean 8 days). Continence was normal in all patients at 8 weeks. One soft coloanal anastomotic stricture required dilatation. No recurrences have been detected during a follow-up of between 10 and 22 months.     

Feasibility of single-stage resection and primary anastomosis in patients with acute noncomplicated sigmoid volvulus

BACKGROUND: The management of sigmoid volvulus remains controversial. The aim of this study was to evaluate the feasibility of treating sigmoid volvulus by using a single-stage resection and anastomosis versus a 2-stage approach. METHODS: A total of 136 patients with noncomplicated sigmoid volvulus who had undergone emergency surgery within the last 15 years were evaluated retrospectively. Sigmoid resection plus Hartmann colostomy was performed in 45 patients, and sigmoid resection plus primary anastomosis was performed in 91 patients. In 40 of the patients who underwent a Hartmann procedure, we performed a second operation for colostomy closure (HC&CC group). RESULTS: There were no significant differences among the groups with regard to age, sex, morbidity, reoperation because of complications, mortality rates, and duration of intensive care unit stay (P > .05). The duration of hospital stay was significantly longer in the HC&CC group than in the other groups (P < .001). CONCLUSIONS: In cases without the complications of perforation or gangrene, sigmoid resection with immediate anastomosis was feasible. Single-stage operations did not increase morbidity or mortality rates, and patients required a shorter hospital stay than those who had undergone 2-stage operations.     

结直肠损伤的手术治疗：附125例报告

目的:探讨结直肠损伤的手术治疗和围手术期处理。 方法:回顾性分析19年间收治的125例结直肠损伤患者的临床资料。结果:结肠和腹膜内直肠破裂69例中，初期缝合或切除吻合56例（81.16 %），行造口术11例，“损伤控制外科”术式2例。腹膜外直肠破裂18例中，14例行乙状结肠近端造口并骶前引流，4例一期修补未造口;其余38例非全层损伤患者，均做简单修补。全组死亡8例（6.40 %），6例术中、1例术后死于失血性休克，1例术后5 d死于胸腔感染。术后并发症包括局部感染6例、粘连性肠梗阻1例，均治愈。 结论:多数结肠和腹膜内直肠损伤可一期手术，应配合围手术期正确使用抗生素尤其甲硝唑。腹膜外直肠伤应分期手术，为阻断远端污染，应行乙状结肠近端造口而不选择襻式造口。     

Safety of laparoscopic intracorporeal rectal transection with double-stapling technique anastomosis

To assess the feasibility and analyze the short-term outcomes of laparoscopic intracorporeal rectal transection with double-stapling technique anastomosis, a review was performed of a prospective registry of 67 patients who underwent laparoscopic sigmoidectomy and anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis between July 2001 and January 2004. Patients were divided into 3 groups: sigmoid colon/rectosigmoid carcinoma, upper rectal carcinoma, and middle/lower rectal carcinoma. A comparison was made of the short-term outcomes among the groups. The number of cartridges required in bowel transection was significantly increased in patients with middle/lower rectal carcinoma, and significant differences were observed in the length of the first stapler cartridge fired for rectal transection. Furthermore, mean operative time and blood loss were also significantly greater in the middle/lower rectum group; however, complication rates and postoperative course were similar among the 3 groups. No anastomotic leakage was observed. Laparoscopic intracorporeal rectal transection with double-stapling technique anastomosis can be performed safely without increased morbidity or mortality.     

贲门癌根治术术中管状吻合器的使用优点及技巧探讨

目的 探讨贲门癌根治术(食管空肠吻合及残胃食管吻合)术中管状吻合器的使用优点及技巧.方法 1998年～2007年本院753例贲门癌根治术行食管空肠吻合或残胃食管吻合重建消化管,术中均使用一次性管状吻合器.结果 本组753例,无手术死亡,行胸腹联合手术6例(0.80%),无吻合口漏发生,吻合器切割不全2例(0.26%),发生吻合口狭窄4例(0.53%),腹腔感染1例(0.13%),膈疝1例(0.13%),术后标本病理检查上切缘癌累及1例,下切缘均未累及.结论 在贲门癌根治术中,管状吻合器的运用简化了手工操作程序,可靠、安全、省时,降低贲门癌进胸手术比例,手术创伤小,恢复快,能有效地预防吻合口瘘和狭窄.但吻合器吻合也不是绝对安全的,吻合口瘘、出血、狭窄等并发症仍有一定的发生率,术中技巧值得在今后的工作中进一步总结、探讨.     

Stapled anastomoses in colorectal surgery

The purpose of this paper was to analyze the advantages, indications and results of stapled circular anastomoses in colorectal surgery. In the last four years (1995-1998), fifteen patients underwent stapled anastomoses after Dixon's anterior rectal resection for cancers of upper and midrectum (11 patients), total colectomy with ileorectal anastomosis for malignant familial polyposis (1 patient), segmental colectomy of transverse and descending colon (1 patient with synchronous colic and rectal cancers, having concomitant rectal resection for cancer), previous Hartmann's resection for perforated upper rectal cancer (1 patient) or distal sigmoid diverticulitis (1 patient). The anastomoses have been performed in end-to-end fashion (11 patients), according to the Knight's technique (2 cases) or in side-to-end fashion (2 patients). As most frequent associated technique with stapled anastomoses, anterior rectal resection for cancer was performed with 2 cm of clearance beyond the macroscopic margin of tumor. Distal margin of resection was histologically verified and it proved to be free of tumor cells. There was no operative mortality. Anastomotic leakage occurred in three patients because of imperfection of stapled anastomosis (2 cases) or after local irradiation (1 case). Spontaneous closure was seen in one patients. The other two patients needed reoperation for suture or colostomy. Late clinical, endoscopic and X-ray controls did not discover local recurrences. Functional results were good in terms of stool frequency and continence. In conclusion, stapled fashioned anastomoses have the main indication in sphincter saving Dixon's and Hartmann's procedures. In these cases, stapled anastomoses are easier than manual technique, reduce operative time and improve suture reliability.     

Laparoscopic disk resection for bowel endometriosis using a circular stapler and a new endoscopic method to control postoperative bleeding from the stapler line

BACKGROUND: Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required. STUDY DESIGN: Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally. RESULTS: The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management. CONCLUSIONS: In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.