PERINEAL PROCTECTOMY FOR RECTAL PROLAPSE IN ELDERLY AND DEBILITATED PATIENTS

This paper details the indications, operative technique and results of perineal proctectomy in the management of complete rectal prolapse in a high risk, elderly and debilitated group of patients. Eighteen procedures were performed by one surgeon (A.L.P.) on 16 consecutive patients over a 5 year period. Data collection was via: (i) retrospective analysis of hospital and office records; and (ii) response to a postal questionnaire by the patient, a relative or attending nursing staff. There were 14 females and two males with a mean age of 81 years. All patients had significant associated medical conditions. The interval from the time of a surgical procedure until review varied from 3 to 37 months with a mean follow-up period of 16 months. Total hospital stay varied between 6 and 20 days with a mean of 7 days. Eleven procedures were performed under general anaesthesia and seven under spinal anaesthesia. There was no postoperative mortality. One patient suffered an anastomotic haemorrhage that required operative intervention and another patient suffered a rectal stricture that necessitated dilatation. Two patients were re-operated for recurrent symptomatic prolapse at 34 and 36 months after the initial procedure. Continence improved in seven patients, worsened in one and was unchanged in the remaining patients. Fifteen of 16 patients were considered to have had a successful result from the operation with satisfactory control of the symptom of rectal prolapse. Perineal proctectomy is a low risk operative procedure for the elderly and debilitated group of patients in controlling complete rectal prolapse. If the condition recurs, the procedure can be repeated with equally low morbidity.     

经腹肛拖出式直肠癌切除术治疗早、中期低位直肠癌21例分析

目的 探讨早、中期低位直肠癌保留肛门括约肌功能的理想手术方式。方法 采用经腹肛拖出式直肠癌切除术治疗早、中期低位直肠癌21例。结果 全组无手术死亡，术后1例发生肛门外拉出肠管部分坏死。骶前感染1例，无肠回缩、吻合口瘘。平均随访 28（6-50）个月，无局部复发。术后18个月发现肝脏转移灶1例，现仍无癌生存20例，吻合口狭窄2例。本组术后2周拉出肠段修整后排便次数较多。1月后控制大便能力明显改善。大便3-5次/d,3月后大便基本正常。1-2次/d。结论 在严格掌握手术适应证的条件下，经腹肛拖出式直肠癌切除术可作为治疗早、中期低位直肠癌并保留肛门功能的一种可靠术式。     

Combined endoscopic trans-anal rectal mucosal ablation and laparoscopic partial proctectomy for ulcerative colitis--a new procedure

A case is reported in which endoscopic trans-anal rectal mucosal ablation (ETARMA) was employed in combination with laparoscopic partial proctectomy in order to decrease complications associated with open surgery.     

低位直肠癌低位前切除的合理性及技巧

1992年7月至1996年8月对19例低位直肠癌施行低位Diton术，其中属超低位吻合者8例，除2例使用EEA吻合器外，其余6例均经手法缝合获得成功．全组无手术死亡和术后并发症，随访1年以上者8例．其中3例已超过3年，未发现复发或转移，排便功能基本良好．结果表明，低位直肠癌施行低位、超低位Dixon术是合理的．可行的．选择合适病例．注重手术技巧以及辅以必要综合治疗，是低位、超低位直肠前切除端端吻合术(Dixon术)取得成功的关键所在。     

Hybrid laparoscopic flexure takedown and open procedure for rectal resection is associated with significantly shorter length of stay than equivalent open resection

PURPOSE: Laparoscopic-assisted, sphincter-saving resection (largest incision <7 cm) of the middle and distal rectum is technically very difficult and, with regard to cancers, has not been demonstrated to be oncologically safe. The hypothesis of this retrospective study is that a hybrid operation that combines laparoscopic and open methods would be associated with short-term outcome benefits compared with open surgery results for patients undergoing sphincter-saving proctectomy. METHODS: A total of 31 hybrid and 25 fully open rectal resection patients were compared in this retrospective review. All patients had splenic flexure takedown and rectal anastomosis. The hybrid approach consisted of laparoscopic splenic flexure takedown (with or without partial rectal mobilization and devascularization) followed by completion of the procedurevia infraumbilical midline laparotomy. The indication was neoplasm in 87 percent of hybrid patients and in 68 percent of open patients. The majority of tumors were located between 4 and 10 cm from the dentate line. RESULTS: Fifty-eight percent of hybrid and 68 percent of open patients had low anterior or coloanal resections, and 48 percent of hybrid and 64 percent of open patients underwent temporary diversionvia ileostomy. The mean hybrid midline incision length was 11 cm compared with 24 cm for open patients (P <0.0001). The neoplastic specimens were similar with regard to margins and lymph node harvest. Similar complication rates were noted in both groups. Nonsignificant benefits for hybrid patients (0.9–1.2 days) were seen with regard to length of time until toleration of liquid or solid diet and first flatus. Hybrid patients experienced their first bowel movements 4.1 daysvs. 5.7 days for the open group (P=0.03). Mean length of stay was significantly shorter for hybrid patients (6.1. days) than for open patients (11.1 days;P=0.0006). CONCLUSION: This preliminary retrospective study suggests that a combined hybrid laparoscopic and open approach to sphincter-saving proctectomy permits a similar resection as open methods and may be associated with a length-of-stay benefit and more rapid return of bowel function. Prospective studies will be needed before any firm conclusions can be drawn.Presented at the meeting of the American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.     

腹腔镜直肠癌根治性切除术对中性粒细胞呼吸暴发功能的影响

目的探讨腹腔镜及开腹手术后,二者中性粒细胞呼吸暴发(respiratory burst)功能的变化,了解腹腔镜手术对中性粒细胞杀菌功能的影响.方法选取"直肠恶性肿瘤"患者20例,随机分为两组各10例,腹腔镜组(Laparoscopy)行经腹腔镜直肠癌根治性切除术,开腹组(Open)行开腹直肠癌根治性切除术作为对照.于术前、术后即刻、术后24h及72 h,抽取外周静脉血,行血常规检查,并分离中性粒细胞,经佛波酯(PMA)刺激后,用流式细胞仪检测呼吸暴发强度.结果腹腔镜直肠癌根治性切除术后,患者白细胞总数及中性粒细胞升高幅度及呼吸暴发强度在术后24及72 h明显低于开腹直肠癌根治性切除术后(P＜0.05).结论腹腔镜直肠癌根治性切除术后,中性粒细胞杀菌功能低于开腹直肠癌根治性切除术后.     

保留回盲瓣之盲肠经直肠肌鞘肛管吻合术在结直肠良性病变中的应用

目的 探讨保留回盲瓣之全结肠切除、直肠粘膜剥除,盲肠经直肠肌鞘肛管吻合术在溃疡性结肠炎、家族性腺瘤性息肉病患者中的应用及效果.方法 回顾性总结1990年以来进行的8例保留回盲瓣之全结肠切除、直肠粘膜剥除,盲肠经直肠肌鞘肛管吻合患者,其中溃疡性结肠炎患者5例,家族性腺瘤性息肉病患者3例.结果 随访5～10年无1例复发,无伤口感染、肛瘘形成,排尿及性功能无影响,8～10周排便次数恢复到3～5次/d,3～4月恢复正常(1～3次/d).结论 保留回盲瓣之全结肠切除、盲肠经直肠肌鞘肛管吻合术治疗重症溃疡性结肠炎、家族性腺瘤性息肉病初步结果满意.