混合痔术后口服迈之灵对并发症和疗程影响的临床观察

目的:混合痔术后口服迈之灵对术后水肿、出血、疼痛以及疗程等情况的观察.方法:采用随机对照的方法,治疗组48例患者在术前术后常规治疗的基础上,自手术当天开始连服迈之灵300 mg,每天2次,共10 d.对照组50例患者给予术前术后常规的治疗.术后4 d观察两组患者肛门水肿、出血、疼痛的情况及疗程时间.结果:两组患者术后水肿、出血、疼痛比较,治疗组优于对照组(P＜0.05).结论:混合痔术后口服迈之灵可有效缓解水肿、出血、疼痛等症状及缩短了疗程.     

显微外科技术在肛瘘切除缝合术中的应用

肛瘘的常规治疗是肛瘘切开术和肛瘘挂线术，创口需肉芽增生来填充，愈合缓慢，挂线疗法的过程尤其冗长。为了缩短疗程，笔者将显微外科技术应用于肛瘘的治疗，有效解决了上述不足之处，现报道如下。     

表皮生长因子受体表达及其下游基因突变与结直肠癌细胞放射敏感性的关系

目的探讨表皮生长因子受体（EGFR）表达及其下游基因K-ras、B-rM和PIK3CA突变对结直肠癌细胞放射敏感性的影响。方法对9株人结直肠癌细胞株应用实时定量RT-PCR检测EGFR表达,并检测K-ras、B—raf和PIK3CA基因的突变状态;对各细胞株行梯度剂量射线照射后,行克隆形成实验明确其放射敏感性、行Hoechst33258染色凋亡形态学观察和流式细胞术检查细胞凋亡及细胞周期。结果人结直肠癌细胞株EGFR表达与放疗抵抗呈正相关（r=O．717．P=0．030）,~K3CA突变与放疗敏感性有关（t=2．401,P=0．047）,K—ras和B．raf突变与放疗敏感性无关（均P〉O．05）。放疗敏感细胞株（HCTll6）总凋亡率在低放射剂量（2Gy）时即显著增加,并随放射剂量增加而继续增加（P〈0．05）,而放疗抵抗细胞株（HT29）总凋亡率只有放射剂量较大时（6Gy）才明显增加。G1／G。期HCTll6细胞株比例随放疗剂量增加显著降低（P〈0．05）,而HT29细胞株G1／G。期比例在放疗剂量增加时无明显变化（P〉0．05）。结论EGFR通路中多个位点同时参与了结直肠癌细胞的放疗抵抗或敏感作用,EGFR高表达与放疗抵抗相关,PIK3CA突变与放疗敏感有关,放疗抵抗机制可能与抑制细胞凋亡和增加细胞在G1／Go期停顿相关。     

吻合器痔上粘膜环切术对肛肠动力学影响的临床研究

目的：比较吻合器痔上粘膜环切术（PPH手术）与传统痔外剥内扎术对肛门直肠动力学影响的差异。方法：采用瑞典生产的肛肠测压仪测量PPH术和传统常规手术术前及术后3月患者的肛管静息压（RASP）、肛管收缩压（MASP）、直肠感知阈值（RSTV）、直肠最大容量阈值（RMTV）的变化，切除标本送病理检查，观察有无肌肉组织和痔组织。结果：PPH术后肛管RASP较术前明显降低（P〈0．01），肛管MASP、直肠RSTV、直肠RMTV较术前有轻微降低但无显著性差异（P〉0．05），肛管RASP在PPH手术组恢复至正常水平，而在传统手术组肛管MASP、直肠RSTV、直肠RMTV较术前和正常值均有显著性降低。病理检查切除标本中无肌肉组织，仅含少量痔组织。结论：PPH手术使重度痔患者的肛管高压明显改变，使肛垫得到保护，而对直肠功能影响较小，使直肠功能得到最大保护。     

高位肛瘘显微切除术的手术配合及护理

高位肛瘘指瘘管在外括约肌1／2以上穿过外括约肌或肛提肌的一类肛瘘，包括高位经括约肌肛瘘、括约肌上瘘和括约肌外瘘。治疗高位肛瘘的常规方法是挂线疗法，但挂线疗法治疗过程漫长而痛苦，并可使50％的患者遗留不同程度的肛门失禁。因此，至今高位肛瘘的治疗仍是肛肠外科的一个难题。为了改善高位肛瘘的治疗效果，我院肛肠外科将显微外科技术应用于高位肛瘘的手术治疗，使得高位肛瘘可以被一期切除，同时保留了肛门括约肌的正常功能，极大地缩短了高位肛瘘的治疗时间，取得了良好的治疗效果。现将手术配合及护理要点报告如下。     

腹腔镜全直肠系膜切除联合经肛内括约肌切除保肛治疗超低位直肠癌

目的 探讨腹腔镜全直肠系膜切除（TME）联合经肛内括约肌切除（ISR）保肛治疗超低位直肠癌的可行性.方法 对13例超低位直肠癌（肿瘤距肛缘2.0～5.0cm）患者采用腹腔镜TME联合经肛ISR治疗.结果 13例患者无中转开腹或改行腹腔镜Miles术,行部分ISR 7例,次全ISR 4例,完全ISR 2例.6例同时行回肠造口术,术后未发生吻合口瘘;7例未行回肠造口术,术后发生吻合口瘘2例,加行回肠造口术及充分引流后痊愈.全组无围手术期死亡,无腹腔出血等并发症,1例患者术后阴茎勃起硬度下降.术后平均随访16个月,无复发及转移.术后早期肛门经常粪污,每日排便3～10次.术后1年控便时间可达5min以上,排便次数减为每日1～4次.绝大多数患者能控便,但内括约肌全切除患者腹泻时仍有粪污.结论 选择合适的的超低位直肠癌,特别是没有侵犯外括约肌的早期患者,采用腹腔镜TME联合经肛ISR是可行的,能体现根治、保肛、微创和经济的优点.回肠造口术能有效预防吻合口瘘的发生.但如何理想地解决早期排便功能障碍仍需进一步研究;肿瘤的复发和转移问题仍需长期随访.     

经肛内括约肌切除术联合经腹全系膜切除术对超低位直肠肿瘤保肛的应用探讨

Objective To study the combination of trans-anal intersphincteric resection and trans- abdominal total mesorectal excision for anus-retained ultra-low rectal tumors. Methods Clinical data of 34 ultra-low rectal tumor patients without external anal sphincter involved, who underwent the combination surgery, were retrospectively analyzed Results The distance from the distal incisal margin of the rectum to the inferior margin of the tumor ranged from 1.8 cm to 3.0 cm on an average of 2. 1 cm. For pathological types, there were 23 cases of adenocarcinoma (9 well differentiated and 14 moderately differentiated), 1 papillary carcinoma, 2 rectal stromal tumor, 5 rectal villous adenoma with canceration and 3 giant villous adenoma. For pathological stages, there were 18 eases at stage pTNM Ⅰ , 5 at Ⅱ A, 1 at Ⅱ B, 4 at ⅢA, 1 at ⅢB and for T grading, there were 15 cases at stage T1, 5 at T2, 8 at T3, 1 at T4. In these 34 patients, there were 3 cases with postoperative anastomotic stenosis, 2 with postoperative anastomotic rupture, 2 with rectovaginal fistula and no operative death. Because of the dysfunction of bowel control, bowel frequency varied from 3 to 12 in the early stage after operation, but with the recovery of anus function, bowel frequency decreased and ranged form 1 to 5 times a day and the time of formed bowel control could be more than 5 min in 6-12 months after operation. However, patients underwent total resection of internal anal sphincter still suffered from incontinence of loose stool after 1 year. After operation, anastomotic recurrence was found in 1 case in 5 months, liver metastasis in 1 case in 10 months and 28 months respectively, cardiac sudden death in 1 case in 26 months. Conclusion The combination of trans-anal ISR and trans-abdominal TME for anus-retained ultra low rectal tumor is not only coincident with radical tumor principle but also retains the function of anus, on the premise of the strict indication.     

经肛内括约肌切除术联合经腹全系膜切除术对超低位直肠肿瘤保肛的应用探讨

Objective To study the combination of trans-anal intersphincteric resection and trans- abdominal total mesorectal excision for anus-retained ultra-low rectal tumors. Methods Clinical data of 34 ultra-low rectal tumor patients without external anal sphincter involved, who underwent the combination surgery, were retrospectively analyzed Results The distance from the distal incisal margin of the rectum to the inferior margin of the tumor ranged from 1.8 cm to 3.0 cm on an average of 2. 1 cm. For pathological types, there were 23 cases of adenocarcinoma (9 well differentiated and 14 moderately differentiated), 1 papillary carcinoma, 2 rectal stromal tumor, 5 rectal villous adenoma with canceration and 3 giant villous adenoma. For pathological stages, there were 18 eases at stage pTNM Ⅰ , 5 at Ⅱ A, 1 at Ⅱ B, 4 at ⅢA, 1 at ⅢB and for T grading, there were 15 cases at stage T1, 5 at T2, 8 at T3, 1 at T4. In these 34 patients, there were 3 cases with postoperative anastomotic stenosis, 2 with postoperative anastomotic rupture, 2 with rectovaginal fistula and no operative death. Because of the dysfunction of bowel control, bowel frequency varied from 3 to 12 in the early stage after operation, but with the recovery of anus function, bowel frequency decreased and ranged form 1 to 5 times a day and the time of formed bowel control could be more than 5 min in 6-12 months after operation. However, patients underwent total resection of internal anal sphincter still suffered from incontinence of loose stool after 1 year. After operation, anastomotic recurrence was found in 1 case in 5 months, liver metastasis in 1 case in 10 months and 28 months respectively, cardiac sudden death in 1 case in 26 months. Conclusion The combination of trans-anal ISR and trans-abdominal TME for anus-retained ultra low rectal tumor is not only coincident with radical tumor principle but also retains the function of anus, on the premise of the strict indication.     

经肛内括约肌切除术联合经腹全系膜切除术对超低位直肠肿瘤保肛的应用探讨

Objective To study the combination of trans-anal intersphincteric resection and trans- abdominal total mesorectal excision for anus-retained ultra-low rectal tumors. Methods Clinical data of 34 ultra-low rectal tumor patients without external anal sphincter involved, who underwent the combination surgery, were retrospectively analyzed Results The distance from the distal incisal margin of the rectum to the inferior margin of the tumor ranged from 1.8 cm to 3.0 cm on an average of 2. 1 cm. For pathological types, there were 23 cases of adenocarcinoma (9 well differentiated and 14 moderately differentiated), 1 papillary carcinoma, 2 rectal stromal tumor, 5 rectal villous adenoma with canceration and 3 giant villous adenoma. For pathological stages, there were 18 eases at stage pTNM Ⅰ , 5 at Ⅱ A, 1 at Ⅱ B, 4 at ⅢA, 1 at ⅢB and for T grading, there were 15 cases at stage T1, 5 at T2, 8 at T3, 1 at T4. In these 34 patients, there were 3 cases with postoperative anastomotic stenosis, 2 with postoperative anastomotic rupture, 2 with rectovaginal fistula and no operative death. Because of the dysfunction of bowel control, bowel frequency varied from 3 to 12 in the early stage after operation, but with the recovery of anus function, bowel frequency decreased and ranged form 1 to 5 times a day and the time of formed bowel control could be more than 5 min in 6-12 months after operation. However, patients underwent total resection of internal anal sphincter still suffered from incontinence of loose stool after 1 year. After operation, anastomotic recurrence was found in 1 case in 5 months, liver metastasis in 1 case in 10 months and 28 months respectively, cardiac sudden death in 1 case in 26 months. Conclusion The combination of trans-anal ISR and trans-abdominal TME for anus-retained ultra low rectal tumor is not only coincident with radical tumor principle but also retains the function of anus, on the premise of the strict indication.     

术前放化疗对中低位直肠癌患者手术及术后并发症的影响

目的探讨术前放化疗对中低位直肠癌患者手术及术后并发症的影响。方法回顾性分析2009年1月至2010年12月间第二军医大学长海医院肛肠外科收治的174例T3～T4期中低位进展期直肠癌患者的临床资料,其中接受术前放化疗者加手术治疗者81例（放化疗组）,直接行手术治疗者93例（对照组）。结果术前放化疗组和对照组患者的手术切除率分别为100％（81／81）和94．6％（88／93）,差异无统计学意义（P〉O．05）;保肛率分别为86.4％（70／81）和73．1％（68／93）,差异有统计学意义（P=0．039）。两组手术时间分别为（130±15）min和（125±20）min,术中出血量分别为（100±15）ml和（95±10）ml,差异均无统计学意义（P〉0．05）。两组术后并发症发生率分别为9．9％（8／81）和9．7％（9／93）,差异无统计学意义（P〉0．05）。结论术前放化疗能够显著提高中低位直肠癌患者的保肛率。且并不会增加手术难度和术后并发症的发生率。