低位直肠癌保肛手术中回肠襻式造口与改良自闭式造口的对比研究

目的探讨低位直肠癌保肛手术中应用改良自闭式造口的安全性和有效性,比较采用改良自闭式造口与回肠襻式造口两种造口方式的临床疗效。 方法回顾性分析苏北人民医院胃肠外科2016年9月~2018年8月期间60例行低位直肠癌保肛手术患者的临床资料,根据预防性造口实施方式的不同分为：改良自闭式造口组25例,回肠襻式造口组35例。分析指标包括：一般资料及病理资料、术中及术后恢复情况、术后并发症及随访情况。 结果两组患者均未发生吻合口漏,改良自闭式造口组患者术后总住院时间为（8.68±0.95）天,回肠襻式造口组患者术后总住院时间为（14.46±1.20）天,两组比较差异具有统计学意义（t=13.00,P<0.01）,包括行一期造口及二期还纳手术的时间。改良自闭式造口组患者在院总花费为（59 284.52±5 712.63）元,回肠襻式造口组为（75 128.77±10 238.05）元,两组比较差异具有统计学意义（t=6.99,P<0.01）。 结论相比回肠末端襻式造口,改良自闭式造口住院时间少、住院费用低,避免了造口旁疝及造口脱垂等造口相关并发症的出现,是低位直肠癌保肛术中可供选择的预造口方式。     

低位直肠癌前切除术后预防性回肠造口方式对转流性结肠炎发病及转归的影响

目的 比较行预防性回肠单腔或双腔造口术对低位直肠癌前切除术后转流性结肠炎发病及转归的影响.方法 回顾性分析2015年1月至2019年9月于空军军医大学唐都医院接受腹腔镜低位直肠癌前切除术+预防性回肠造口术的147例患者的病例资料.按入排标准从中选取68例,根据造口方式不同分为单腔组(31例)和双腔组(37例),收集两组...     

老年直肠癌Dixon术后吻合口漏159例临床分析

目的 探讨老年直肠癌Dixon术后吻合口漏的发生率、危险因素和治疗方法.方法 回顾性分析159例直肠癌行Dixon术患者的临床资料.结果 年龄、肿瘤距肛缘距离、糖尿病、术前低蛋白、术前合并肠梗阻、切口感染与吻合口漏的发生密切相关,而性别与吻合口漏的发生无关.结论 吻合口漏是直肠癌Dixon术后一种常见并发症,低位直肠癌行保肛手术增加吻合口漏发生率,大部分吻合口漏经单纯引流管冲洗可治愈,少数病例需行剖腹探查肠造瘘术.     

预防性末端回肠造瘘在超低位直肠癌保肛手术中的应用探讨

目的探讨预防性末端回肠造瘘在超低位直肠癌保肛手术中的应用效果。方法将收治并行超低位直肠癌保肛手术治疗的72例患者随机分为观察组和对照组各36例。两组患者均施行超低位直肠癌保肛手术治疗,术中严格遵循全直肠系膜切除(TME)原则。观察组在此基础上行预防性末端回肠造瘘。比较两组患者术后排气时间、拔除引流管时间、住院时间及吻合口瘘发生率等。结果观察组术后排气时间、拔除引流管时间、住院时间均明显短于对照组(P 0. 05)。观察组术后吻合口瘘发生率低于对照组,但差异无统计学意义(P 0. 05)。结论超低位直肠癌保肛手术患者术后行预防性末端回肠造瘘可促进肠道功能早期恢复、缩短住院时间,并有降低术后吻合口瘘发生率的优势。     

中下段直肠癌保肛术并TME术后吻合口瘘的危险因素分析(附156例报告)

分析156例中下段直肠癌患者行保肛术并直肠全系膜切除（TME）术后吻合口瘘的影响因素。吻合口距肛缘平均3.6cm（1-5cm），吻合口瘘发生率10．3％。女性、行近段肠造口者吻合口瘘发生率低（P均〈0．01），未行近段肠造口的男性患者吻合瘘发生率较高。行近段肠造口发生吻合口瘘者无1例需再次手术。认为应用保肛术并TME术治疗中低位直肠癌时，为了预防吻合口瘘的发生，对男性患者应常规行近段肠造口术；女性患者可不需要，只有在吻合技术不理想时选择近段肠造口术。     

吻合环及传统末端吻合用于直肠癌保护性回肠造口术对患者术后恢复的影响

目的研究吻合环及传统末端吻合用于直肠癌保护性回肠造口术对患者术后恢复的影响。方法纳入2017年3月至2019年3月于空军军医大学西京医院收治的124例直肠癌患者为对象,按照抽签随机方法分为两组,各62例。其中对照组行传统保护性末端回肠造口术,观察组实施吻合环复合装置保护性回肠造口术。观察两组手术相关指标(包括手术操作时间、住院时间),分析两组手术并发症发生情况(包括吻合口瘘、造口相关并发症),并分析对照组患者术后还纳情况。结果两组所有患者均顺利完成造口手术。观察组手术操作时间显著长于对照组(P 0. 05),但住院时间较对照组比较差异无统计学意义(P 0. 05)。观察组造口相关并发症发生率为29. 03%,显著低于对照组的61. 29%(P 0. 05);观察组吻合口瘘发生率为8. 06%,对照组吻合口瘘发生率为6. 45%,差异无统计学意义(P 0. 05)。术后所有患者均随访6个月,随访期间无失访病例。对照组患者中,第1次术后3月还纳者占32. 26%,术后6月还纳者占61. 29%,未还纳者占6. 45%。结论与传统保护性末端回肠造口术比较,采用吻合环复合装置保护性回肠造口术更利于直肠癌患者术后早期康复,造口相关并发症少,无需二次还纳,临床应引起足够重视。     

腹腔镜辅助直肠癌前切除术后吻合口狭窄的危险因素分析

[目的]分析影响腹腔镜辅助直肠癌前切除术后发生吻合口狭窄的危险因素。[方法]收集行直肠癌根治术的108例患者的临床资料,采用单因素分析及Logistic多因素回归分析研究直肠癌术后发生吻合口狭窄的危险因素。[结果]单因素分析结果显示,新辅助放疗、预防性末端回肠造口、不保留左结肠血管、吻合口漏是直肠癌术后吻合口狭窄的相关因素,多因素分析结果显示,新辅助放疗和吻合口漏是术后吻合口狭窄的独立危险因素。[结论]对于术前接受放疗和术后发生吻合口漏的直肠癌手术患者应重点随访,预防吻合口狭窄的发生。     

预防性回肠与结肠造口预防吻合口漏的应用对比及预防吻合口漏技术的进展

吻合口漏是结直肠术后常见并且严重的并发症之一,预防性回肠及结肠襻式造口被用来应对结直肠术后吻合口漏。每种造口方式都有其优缺点,这篇综述结合当下最新研究结果来探究是否其中一种方式优于另一种。同时对当下预防吻合口漏的策略进行了汇总,主要有经肛肠减压术、盲肠置管造口术、经肛肠腔减压术、管腔内旁路技术、无需回纳预防性造瘘术、带蒂大网膜包裹吻合口术,临床实践中选择何种方式预防吻合口漏需要综合各种情况决定。     

回肠双腔造口对中低位直肠癌前切除术后转流性结肠炎的发生及疾病转归的影响

目的 探究回肠双腔造口对中低位直肠癌前切除术后转流性结肠炎的发生及疾病转归的影响。方法 回顾性分析223例2011年6月至2021年6月就诊于铜陵市人民医院胃肠外科接受预防性回肠造口和中低位直肠癌切除术的老年患者病例资料。根据造口方式分为单腔造口组(101例)和双腔造口组(122例),收集分析两组临床资料，分析造口后3～4个月和造口还纳术后6个月结肠镜结果及临床症状资料。采用Logistic回归分析影响转流性结肠炎的危险因素。结果 单腔造口组肠道恢复时间和术后并发症发生率显著高于双腔造口组(P<0.05);造口术后3～4个月，单腔造口组转流性结肠炎中、重度及临床症状发生率均显著高于双腔造口组(P<0.05);造口还纳术6个月后，单腔造口组转流性结肠炎严重程度、临床症状发生率均显著高于双腔造口组(P<0.05);Logistic回归分析显示，造口方式的不同是影响回肠造口术后发生转流性结肠炎及转归的危险因素。结论 回肠双腔造口能够降低中低位直肠癌前切除术后转流性结肠炎的发生率，并促进转流性结肠炎的转归。     

两种乙状结肠造口术并发症发生情况的比较

虽然直肠癌保肛术式临床应用逐渐增多,但Miles术仍是低位直肠癌和肛管癌的根治标准术式,乙状结肠造口是其重要的组成部分,造口质量的优劣将影响患者一生的生活质量,因此如何减少造口并发症一直是乙状结肠造口术研究的重点。1996年10月～2004年10月,我院在直肠癌手术中行腹膜外隧道式乙状结肠造口一期成形术90例,行传统的腹膜内乙状结肠造口术83例。现对两种造口术并发症的发生情况进行比较。     

Quality of Life after Low Anterior Resection and Temporary Loop Ileostomy

Purpose Low anterior resection has become the operation of choice for mid rectal or low rectal cancer. A defunctioning stoma is routinely created at some centers to decrease the risk of leakage requiring surgical intervention. This study was designed to evaluate the quality of life in patients undergoing low anterior resection with a temporary ileostomy. Methods A prospective longitudinal study was conducted in 22 patients with rectal cancer who underwent low anterior resection with a loop ileostomy. Quality of life was assessed by using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires. Twenty-five patients who underwent high anterior resection for rectosigmoid cancer were studied concurrently to evaluate the impact of major colorectal resection without a stoma. Results Patients’ scores on the quality of life questionnaires generally improved after high anterior resection; however, for patients who underwent low anterior resection, the scores for physical and role functioning before ileostomy closure were worse than the preoperative values. The scores on the quality of life questionnaires generally improved after ileostomy closure. Ileostomy closure required a short hospital stay and was rarely associated with complications. Conclusion Patients who underwent low anterior resection with ileostomy had significant reductions in physical and role functioning, which apparently improved after ileostomy closure. Similar declines in these quality of life variables were not found in patients who underwent high anterior resection. A temporary ileostomy should be created in selected patients with the highest risk of anastomotic leakage. Increased resources for not only surgical care but also for stoma therapy are necessary for patients who undergo low anterior resection with a temporary ileostomy. Presented at the meeting of The Japan Society of Coloproctology, Tokyo, Japan, November 2 to 3, 2007.     

Virtual ileostomy following TME and primary sphincter-saving reconstruction for rectal cancer

Surgical management of rectal cancer has undergone a significant change during the past two decades. Low anterior resection (LAR) with total mesorectal excision (TME) is, at the moment, the "gold standard" for carcinoma of the mid or lower rectum. Because the most specific complication following rectal resection with anastomosis is symptomatic leakage, which is associated with 18% mortality rate, routine formation of a temporary stoma is suitable after sphincter-saving resection for anastomoses situated at or less than 5cm from the anal verge. Actually the preferred modes of fecal diversion following LAR with TME are loop ileostomy or loop transverse colostomy. Low anastomosis, preoperative radiation or chemoradiation, presence of intraoperative adverse events and male gender are independent risk factors for symptomatic anastomotic leakage. A defunctioning loop ileostomy or the classical "protective" colostomy requires subsequent reconstructive surgery with a significant postoperative morbidity. For these reasons we use an alternative to protect a high risk anastomosis with fashioning a proximal intraabdominal closed loop ileostomy called "virtual ileostomy". In a seven-year period from 1999 to 2005 a total of 107 patients underwent elective anterior resection of the rectum for carcinoma, in all cases was fashioned a virtual ileostomy. The incidence of symptomatic clinically evident anastomotic leakage was 13%; in all the cases (14 pts) the closed loop ileostomy was opened with a reduction of the originally planned number of ileostomies by over 80%. The procedure is easy to perform and well accepted by the patients. It avoids a second operation.     

Anastomotic leakage following low anterior resection: results of a standardized diagnostic and therapeutic approach

BACKGROUND AND AIMS: This study analyzed the results of a standardized approach in anastomotic leakage following low anterior resection for rectal cancer without performance of a protective ileostomy during the primary operation. PATIENTS AND METHODS: The study included all 306 patients with rectal cancer electively undergoing low anterior resection with retroperitonealization of the anastomosis over 9 years. The diagnostic procedure for anastomotic leakage included serum laboratory investigations and abdominal CT together with contrast enema. Minor leakages, i.e., small leakages and pelvic abscess, were treated with rectoscopic lavage and/or CT-guided drainage of the abscess, respectively. Major leakage was defined as broad insufficiency with or without septicemia. Nonseptic patients were treated by ileostomy and rectoscopic treatment. In septic patients a revision of the anastomosis with loop ileostomy was performed. RESULTS: Anastomotic leakage was diagnosed in 30 patients (overall 9.8%; 12 major, 18 minor leakages). Common clinical signs were pelvic pain and fever. No patient developed a peritonitis. The most accurate diagnostic instrument was CT (96.7%). CONCLUSION: Retroperitonealization appears to prevent peritonitis in patients with anastomotic leakage following low anterior resection. A differential treatment leads to good results in terms of mortality and anorectal function.     

Morbidity related to defunctioning loop ileostomy in low anterior resection

Aim

A defunctioning loop ileostomy in low anterior resection reduces the incidence and morbidity of an anastomotic leakage, but complications related to the stoma may occur. We explored stoma-associated complications during the stoma period and after stoma reversal.

Methods

A retrospective analysis of rectal cancer patients operated with low anterior resection and a defunctioning loop ileostomy at Helsingborg Hospital and Malm? University Hospital from January 2007 to June 2009 was undertaken.

Results

Ninety-two patients were included, of whom 82 (89?%) underwent stoma reversal. The median stoma period was 6.2?±?3.2?months. Sixty-six percent of the patients suffered from minor or major stoma-associated morbidity. The complication rate was significantly related to the stoma time (p?<?0.01). Twenty-nine percent (27/92) had at least one episode of dehydration, leading to readmittance in half of the cases. Elderly patients were more prone to develop dehydration. Dehydration most commonly occurred early in the postoperative period (mean, 5.8?weeks). The mean hospital stay for stoma reversal was 6.5?±?4.0?days. Forty percent (33/82) had some complication associated with the reversal.

Conclusion

This study indicates high morbidity associated with defunctioning loop ileostomy. Our data suggest that the stoma time should be limited to reduce complications. Monitoring and early stoma reversal should be considered in elderly patients. Furthermore, stoma reversal is not uneventful, and more studies are needed to address how to minimize complications.     

The true cost of protective loop colostomy

Transverse loop colostomies are commonly used to "protect" low colorectal anastomoses after anterior resection for rectal carcinoma. However, anastomotic leaks occur despite proximal decompression. We studied 61 consecutive patients who underwent anterior resection to evaluate the cost of loop colostomy as reflected by morbidity, mortality, and length of post-operative hospital stay. Colostomy patients had significantly greater blood loss (736 vs. 500 ml, p = 0.004), more blood transfusions (1.55 units vs. 0.41 units, p less than 0.001), and longer operations (238 vs. 193 min, p = 0.005). They were also older (68 vs. 65, p = 0.13), had lesions closer to the anal verge (10.2 vs. 11.4 cm, p = 0.07), and had more infectious complications (13.6% vs. 2.6%, 0.05 less than p less than 0.1) than patients without colostomies. Colostomy was not related to sex or stage. There were no anastomotic leaks among those with colostomies and only one among those without colostomies; there were no associated mortalities. Patients with colostomies stayed an additional 10 days, on average, when readmitted for colostomy closure. The 22 patients who received loop colostomies had postoperative stays averaging one-third longer than patients without colostomies (16 vs. 12 days, p = 0.004). In both groups, the 8th postoperative day was the mean for resumption of a regular diet; all patients were eating a regular diet by the 12th postoperative day. The delay in discharging colostomy patients was due to the additional time necessary for patients to learn to change their appliance and irrigate their stoma. Proximal diverting colostomies may more than double the total dollar cost of anterior resection, although DRG reimbursement is the same with or without a colostomy. This additional cost could be reduced by initiating ostomy teaching in the preoperative period and by reducing the use of unnecessary colostomies.     

Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients

In restorative proctocolectomy the use of a stapling technique to construct an ileal pouch with anal anastomosis offers an alternative to the hand-sewn technique following mucosectomy; a temporary defunctioning loop ileostomy may reduce the consequences of an anastomotic leakage, however it may entail discomfort for the patient, an additional operation, possible complications, and longer total hospital stay. This prospective study evaluated the peri- and postoperative courses in 86 consecutive, referred patients receiving ileal pouch-anal anastomosis using the stapling technique to construct the ileal pouch and ileoanal anastomosis, omitting the defunctioning loop ileostomy except in cases of increased risk of ileoanal anastomotic insufficiency according to defined criteria. Follow-up time was 36-96 months. Patients undergoing primary loop ileostomy stayed a median of 19 days in hospital, as opposed to a median of 9 days in those who did not. Eight patients developed pelvic sepsis that demanded a secondary defunctioning loop ileostomy, and five showed symptoms arising from relapsing inflammation in residual rectal mucosa; in three of these, a secondary transanal mucosectomy covered by a loop ileostomy was necessary. During the follow-up period ten patients had bowel obstructions that demanded surgery; two developed late pouch-vaginal fistulas, and one a fistula from the J-limb to the abdominal scar. There was one case of pouch procidentia. At 12-month follow-up the median evacuation frequency was 6 per 24 h, the incidence of minor incontinence was about 10%, and urgency to evacuate occurred in about 10%. None of the patients experienced any major incontinence. The stapling technique and omission of the defunctioning loop ileostomy in restorative proctocolectomy were thus a comparatively reliable and time-saving method with short total hospital stay. In patients at increased risk of anastomotic complications, however, a defunctioning loop ileostomy is recommended. We believe it is important to perform an exact dissection into the anal canal to avoid a residual rectal mucosa that may be inflamed or even become dysplastic.     

Use of Intracolonic Bypass Secured by a Biodegradable Anastomotic Ring to Protect the Low Rectal Anastomosis

Purpose Because of the relatively high morbidity and mortality of anastomotic leakage in patients with low rectal cancer who receive an anterior resection, many fecal diverting methods have been introduced. This study was designed to assess the efficacy and safety of the Valtrac™-secured intracolonic bypass in protecting low rectal anastomosis and to compare the efficacy and complications of Valtrac™-secured intracolonic bypass with those of loop ileostomy. Methods From January 2002 to April 2006, 83 patients with rectal cancer who underwent elective low anterior resection received intracolonic bypass or ileostomy. Demographics, clinical features, and operative data were recorded. Results Forty-four patients (53 percent) received a Valtrac™-secured intracolonic bypass and 39 patients (47 percent) a loop ileostomy. The demographics and clinical features of the groups were similar. None of the patients developed clinical anastomotic leakage. Longer overall postoperative hospital stay (21.3 ± 5.8 days) and higher costs incurred (3.1 ± 0.9 × $1,000 U.S. dollars) were observed in the ileostomy group than in the intracolonic bypass group (12.5 ± 6.3 days, 4.4 ± 1.2 × $1,000 U.S. dollars; P < 0.05). Stoma-related complications in the ileostomy group included dermatitis (12.8 percent), bleeding (2.6 percent), and intestinal obstruction after stoma closure (5.1 percent). No complications were observed in the intracolonic bypass group except for the Valtrac™ ring discharging en bloc, which compromised fecal evacuation in two cases (4.5 percent). Conclusions The Valtrac™-secured intracolonic bypass procedure is a safe, effective, but time-limited, diverting technique to protect an elective low colorectal anastomosis. Valtrac™-secured intracolonic bypass, in contrast to loop ileostomy, avoids stoma-related complications or readmission for closure and is associated with decreased hospital time and cost. Presented at the First National Conference on Colorectal Surgery, Zhu Hai, Guang Dong, China, November 2 to 5, 2006. Reprints are not available.     

直肠癌前切除术后预置回肠造口与袢式回肠造口的对比研究

目的评估预置回肠造口（末段回肠预置于腹壁下）对比袢式回肠造口在腹腔镜直肠癌前切除术中的优势。 方法进行前瞻性研究,纳入2020年1月至2021年12月甘肃省人民医院肛肠科收治的行腹腔镜直肠癌前切除术的患者,分为预置回肠造口组及袢式回肠造口组。主要的研究终点：首次住院以及术后3个月总体并发症指数（CCI）;次要研究终点：术后吻合口漏发生率、肠梗阻发生率、手术时间、住院时间、住院费用、并发症Clavien-Dindo分级、术后3个月再次住院率以及肛门直肠功能（Wexner评分）;其他研究终点：术后通气时间、首次进食时间、术后腹泻、手术时间＞3 h、切缘阳性率以及术后病理pTNM分期。 结果预置回肠造口组对比袢式回肠造口组的首次住院总体并发症评分（CCI评分）为（25.3±7.1 vs. 26.4±5.7）,差异无统计学意义（t=0.456,P=0.067）,而预置回肠造口组对比袢式回肠造口组术后3个月的CCI评分为（26.2±6.2 vs. 31.7±9.1）,差异有统计学意义（t=0.283,P=0.041）。此外,预置回肠造口组患者对比袢式回肠造口组患者在手术时间（Z=-2.646,P=0.008）、住院时间（Z=-3.564,P=0.034）、住院费用（Z=-5.118,P=0.021）、术后3个月再次住院率（χ²=25.652,P=0.001）、术后3个月肛门直肠功能（t=-3.128,P=0.003）以及并发症Clavien-Dindo分级（χ²=9.692,P=0.021）等方面差异均具有统计学意义。 结论预置回肠造口相对于袢式回肠造口是一种安全可行且经济有效的术式,但仅限于中低危吻合口漏患者。此外,本研究样本量较少且随访时间短,仍需后续试验加以验证。