快速康复流程在梗阻型大肠癌一期吻合中的应用

快速康复流程（fast track programmes,FT）由于能缩短住院时间,减少术后并发症的发生,节约患者住院费用,现在逐渐在国内推广[1],多学科协助诊治模式下的结直肠外科FT已得到广泛认可。     

乙状结肠癌肠道支架移位后一期切除吻合1例报告

应用自膨式金属支架(self-expanding metal-lic stent,SEMS)可使部分结直肠癌病人缓解梗阻症状,将部分急诊手术转变为择期手术,从而使外科医生可以全面评估和稳定病人的病情及生理状态,采取最佳的个体化治疗方案,最终提高一期吻合率,降低永久性造口率,降低围手术期并发症发生率及死亡风险.然而,SE...     

46例大肠癌致肠梗阻手术一期切除吻合分析

目的探讨大肠癌致肠梗阻一期切除吻合的可行性。方法回顾性分析46例大肠癌引起肠梗阻患者行一期吻合的临床资料。结果一期切除吻合43例,各种捷径吻合3例。44例吻合口愈合良好,2例出现吻合口瘘,经保守治疗,吻合口瘘愈合。结论大肠癌致肠梗阻能行一期吻合者,尽量采用一期手术,使患者免受二次手术痛苦,并能缩短住院时间、减少治疗费用。     

一期切除吻合治疗左半结肠癌性梗阻

目的：总结一期切除吻合治疗左半结肠癌性梗阻的方法和体会,介绍预防吻合口漏的措施。方法：本组一期切除吻合治疗左半结肠癌性梗阻１６例,梗阻时间１．５～６天,按改良Ｄｕｃｋｅ＇ｓ分型,Ｂ期２例,Ｃ１期８例,Ｃ２期６例。结果：术后１５例伤口一期愈合,伤口感染１例,平均住院２５天,无吻合口漏发生。结论：此法优于分期手术,但要掌握适应证,术中防止吻合口漏发生,术中减压和结肠灌洗,术后应用抗生素等,可促进结肠愈合。     

肠道支架植入术在梗阻性结肠肿瘤中的应用

肠道支架植入术是近年来出现的治疗梗阻性结直肠肿瘤的新方法。国内外文献报道肠道支架植入术的近期并发症发生率较低、造口率低、住院时间较短,尤其是在外科手术序贯治疗中的作用,明显地增加了一期吻合率。就支架治疗梗阻性结肠肿瘤的治疗优势、远期疗效、并发症和外科手术中的作用进行综述。     

肠道支架序贯腹腔镜手术在左半结肠恶性梗阻中的临床应用

目的:评估肠道支架序贯腹腔镜手术在左半结肠恶性梗阻中的临床应用疗效。方法:回顾性收集2015年1月至2022年9月我院收治的符合条件的127例左半结肠恶性梗阻患者的临床资料。根据治疗方式的不同,将患者分为序贯组(41例,先行支架置入术再行腹腔镜手术)和常规组(86例,未行支架置入术,直接手术)。比较2组患者术前检查、术中情况及术后近期疗效。结果:置入支架后Hb<90 g/L、WBC>10×10⁹/L、Alb<35 g/L、Na⁺<135 mmol/L、K⁺<3.5 mmol/L、Ca²⁺<2.1 mmol/L者比例明显低于未置入支架者,P<0.05。序贯组支架置入成功率为92.7%,并发症发生率为7.3%,穿孔率为4.9%。与常规组相比,序贯组腹腔镜手术率、一期切除吻合率更高,淋巴结清扫数更多,造口率更低,术后住院时间、引流量更少,P<0.05。2组手术时间、术中出血量、术后排气排便时间、术后并发症、标本病理特征、住院总费用方面比较差异均无统计学意义,...     

支架植入一期吻合术在左侧结直肠癌合并肠梗阻中的应用

目的对比研究左侧结肠癌合并肠梗阻患者支架植入一期吻合术和传统Hartmann术的优劣势。方法对武汉协和医院2005年1月—2009年1月收治的62例左侧结肠癌合并肠梗阻患者的临床资料进行回顾性分析。A组32例中有29例成功植入支架后行手术切除一期吻合;B组30例均行标准Hartmann术。比较两组患者肠道功能恢复时间、术后并发症发生率、总住院时间、总住院费用、临床受益反应、复发转移率和随访期存活率等。采用χ2检验和Log-rank检验对数据进行分析。结果 A组32例中有3例结肠癌患者于肠道支架植入术后4～5 d内出现肠道穿孔致弥漫性腹膜炎,余29例均顺利完成一期手术治疗,术后10～18 d痊愈出院。B组与A组间肠道功能恢复时间和术后并发症发生率无统计学差异(P>0.05);B组总住院时间、总住院费用、临床受益反应、复发转移率、随访存活率与A组比较,均有统计学意义(P<0.05)。结论肠道支架减压在治疗左侧结直肠癌合并肠梗阻患者与传统Hartmann手术相比,短期优势明显,远期并无优势。     

一期切除吻合应用于中上段直肠癌急性梗阻

目的：探讨无周围器官浸润的中上段直肠癌所致急性肠梗阻应用一期切除吻合术的安全性。方法：回顾1996～2003年间17例行一期切除吻合的无周围器官浸润的中上段直肠癌致急性梗阻病例。平均年龄64．2岁,均行术中顺行结肠灌洗。结果：术后切口感染3例(17．6％),肺部感染1例(5．9％)并致呼吸衰竭死亡,吻合口瘘2例(11．7％),1例保守治疗治愈,另一例切开预防性造口后痊愈。结论：对无周围器官浸润的中上段直肠癌所致急性肠梗阻应争取实施一期切除吻合术;在术中顺行结肠灌洗等措施下,手术的安全性是有保障的。     

结肠癌急性梗阻一期切除吻合的肠减压方法

目的 介绍一种彻底快速而毫不污染手术野的术中肠减压方法。以便提高手术的安全性。方法 游离系膜后，钳夹下将切除肠段的下端先切断，将其近侧端置入并固定于粘附在手术床边的塑料袋中；松开肠钳，肠内容物自由流入袋内；双手交替推挤膨胀的肠段，由近而远，由小肠至 大肠，直至大，小肠的内容物彻底排空，钳夹下切除上端，移除切下的肠段和充满粪便的塑料袋。结果 使用本法行肠减压术，一期切除的左半经肠癌和各类小肠急性梗阻，均未发生吻合口漏和腹腔污染，结论 本法可推荐为术中肠减压的首选方法。     

结肠癌急性梗阻一期切除吻合的肠减压方法

目的 介绍一种彻底快速而毫不污染手术野的术中肠减压方法,以便提高手术的安全性。方法 游离系膜后,钳夹下将切除肠段的下端先切断,将其近侧端置入并固定于粘附在手术床边的塑料袋中;松开肠钳,肠内容物自由流入袋内;双手交替推挤膨胀的肠段,由近而远,由小肠至大肠,直至大、小肠的内容物彻底排空。钳夹下切除上端,移除切下的肠段和充满粪便的塑料袋。结果 使用本法行肠减压术,一期切除的左半结肠癌和各类小肠急性梗阻,均未发生吻合口漏和腹腔污染。结论 本法可推荐为术中肠减压的首选方法。     

经肛型肠梗阻导管置入联合外科手术治疗急性左半结直肠恶性梗阻

正结直肠癌是胃肠道常见恶性肿瘤。为减少结直肠癌患者术后吻合口瘘的发生,外科手术治疗多先行一期肿瘤切除、结肠造瘘术,再择期行二期肠吻合术,增加了患者痛苦及住院费用。本院采用经肛型肠梗阻导管置入联合外科手术治疗急性左半结直肠恶性梗阻患者36例,疗效显著,现报道如下。1资料与方法1.1一般资料收集2009年1月—2017年6月在我     

经肛肠梗阻导管联合腹腔镜手术治疗结直肠恶性梗阻

目的 评价经肛肠梗阻减压导管联合腹腔镜手术在结直肠恶性梗阻治疗中的应用价值.方法 2007年3月至2010年10月37例急性完全性结直肠恶性梗阻患者经肛置入肠梗阻导管至梗阻近端肠管,冲洗引流4～10 d后行腹腔镜探查并一期切除吻合.结果 37例患者中34例成功置入导管,导管引流时间为4～10 d,平均(5.8±1.6)d.置入肠梗阻导管后(3.8±1.3)d(1～7 d)患者腹痛、腹胀症状消失.与入院时腹围(92 4±7)cm相比,手术时腹围(84±6)cm,明显缩小(P=0.013).其中31例患者减压后完成腹腔镜一期根治切除吻合,术后患者恢复顺利,无严重并发症.结论 经肛型肠梗阻减压导管联合腹腔镜手术治疗急性结直肠梗阻安全、有效,可将急诊手术转为限期手术,在适当的肠道准备后腹腔镜下根治手术并一期吻合是可行的.

Abstract：

Objective To evaluate the safety and efficacy of transanal drainage tube followed by laparoscopic surgery in management of malignant colorectal obstruction. Methods From March 2007 to October 2010, 37 patients with colorectal cancer manifesting acute complete mechanical obstruction were treated by ileus tube drainage. After irrigation and drainage ranging from 4 to 10 days, the radical operations and anastomosis were performed by laparoscopy. Results The drainage tubes were successfully implanted in 34 patients. The decompression time of patients was (5. 8 ±1.6) d, ranging from 4 to 10 d. The abdominal pain and bloating symptoms were faded away after (3. 8 ±1.3) d (1 to 7 d) drainage. And comparing to that of patients when admission, abdominal circumference significantly reduced from ( 92 ± 7 ) cm to (84 ±6)cm(P =0. 013) before surgery. Thirty-one cases were performed radical resection and anastomosis by laparoscopy after decompression. Postoperative recovery was smooth, and there was no serious complication. Conclusions Laparoscopic surgery followed decompression by transanal ileus tube is effective and safe for acute lower colorectal obstruction. Emergency surgery may be converted to limit surgery by this method. After appropriate bowel preparation, laparoscopic radical surgery and anastomosis is feasible.     

术前腔内支架与急诊手术治疗左半结肠和直肠癌肠梗阻的安全性与有效性Meta分析

目的评价术前腔内支架治疗左半结肠和直肠癌肠梗阻的安全性与有效性。方法利用CENTRAL、PubMed、EMBASE、Medline、OvidLww等英文数据库和CMB、CNKI、万方等中文数据库．全面检索术前腔内支架与急诊手术治疗左半结肠和直肠癌肠梗阻的比较研究的中英文随机对照试验和回顾性分析文献．利用RevMan5．1软件对两种治疗方法的安全性和有效性指标进行Meta分析。结果最终纳入14篇文献共1083例患者,其中随机对照研究5篇,回顾性分析9篇。与急诊手术相比,术前腔内支架组围手术期死亡率（RR：O．52;95％CI：0．30-0．93。P〈0．05）和总并发症发生率降低（RR=0．46,95％U：0．31-0．70,P〈0．01）,手术切除率提高（RR：1．90,95％U：1．33-2．70,P〈0．01）,手术时间（MD=-59．77,95％CI：-87．51-32．04．P〈0．01）和术后排气时间缩短（MD=一10．78,95％CI：-16．67-4．90,P〈0．01）：两种方法的永久造瘘率和住院时间的差异则无统计学意义（均P〉0．05）。结论术前腔内支架治疗左半结肠和直肠癌肠梗阻的安全性和有效性均优于急诊手术。     

Non-centralised service for palliative stenting of malignant gastric outlet obstruction

IntroductionMalignant gastric outlet obstruction (GOO) is a common, debilitating and frequently pre-terminal symptom of intra-abdominal malignancies. Traditional ‘gold standard’ treatment has been palliative surgical gastro-enterostomy. Over the past two decades, use of self-expanding metallic stents (SEMSs) to relieve malignant GOO has become first-line treatment. We present the results from a single district general hospital in the UK in which malignant GOO was treated with SEMSs over a six-year period.MethodsAll patients who underwent palliative stenting for malignant gastro-duodenal tumours in our centre for six years up to January 2013 were assessed retrospectively. Outcomes were assessed with regard to: technical and clinical success; return to oral nutrition; prevalence of complications and re-intervention; and overall survival.ResultsThirty-two stents were implanted in 29 patients. Technical success was 100%. Clinical success and return to oral nutrition were both 91%. The prevalence of complications was 16%. The prevalence of re-intervention was 13%. Mean survival was 91 (range, 5–392) days. Median wait from decision to implant a stent to stent implantation was 1 (range, 0–14) day. Overall, 25 covered and nine uncovered stents were implanted.ConclusionStent implantation for GOO in this patient group is an established and preferable alternative to surgical intervention. Much of the treatment for malignancies of the upper gastrointestinal tract has now been centralised. Our data showed comparable results with published data for these procedures, with a high prevalence of success and low prevalence of major complications. It is of considerable benefit to these patients not to have to travel to a regional centre for stent implantation.     

Bowel function following insertion of self-expanding metallic stents for palliation of colorectal cancer

Objective Self‐expanding metallic stents (SEMS) are an important addition to the treatment of large bowel obstruction. The aim of this study was firstly to assess bowel function following SEMS placement and secondly to identify any potential factors which might aid in the prediction of technical failure of stent insertion. Methods A review of all patients undergoing attempted SEMS placement for palliation of malignant left‐sided colorectal obstruction over a four‐year period (1st May 2000–30th April 2004) was performed. Results Twenty‐one patients (12 male) with a median age of 76 years (range 48–92 years) were included, 11 with metastatic disease and 10 severe comorbidity. SEMS insertion was technically successful in 16 (76%) of 21 cases. Contrast successfully passed through the obstructing lesion in all 16 cases where SEMS placement was technically successful. It only passed through 1 of 5 cases where stenting was not possible (P = 0.0008, Fisher's Exact test). Complications included colonic perforation (1 case), stent migration (1 case) and tumour ingrowth requiring a second stent (1 case). Median survival after SEMS was 12 months (range 1–30 months), and 9 patients died during follow‐up. Median bowel frequency following SEMS was 3.5 times per day (range 1–7). Eight patients always passed a liquid stool, 3 others regularly required laxatives and one further patient with poor function after stenting requested a defunctioning stoma. Conclusion Failure of contrast to pass through the obstructing lesion may predict those cases where stenting will not be technically possible. Median survival following SEMS insertion is encouraging in this series, but bowel function is often poor. Expected bowel function should be discussed fully when consenting patients for a SEMS, particularly those with metastatic disease who are otherwise fit for resectional surgery.     

支架植入治疗左半结肠直肠癌所致的急性梗阻

目的：探讨肠道支架放置对左半结肠直肠癌所致的急性梗阻之治疗效果和安全性。方法：对2000年5月～2006年6月收治的42例左半结肠直肠癌所致的急性梗阻进行临时性或姑息性支架放置：观察支架植入后梗阻缓解情况和并发症。结果：42例中34例支架植入成功（81．0％）．24h内的临床梗阻缓解率为94．1％（32／34）．全组无死亡发生。术后并发结肠穿孔和食物残渣堵塞支架各1例，均改作Hartmann手术；支架移位和肛门疼痛各2例。18例经过肠道准备和全身支持治疗后再行根治性手术；另14例支架植入属永久性姑息性治疗。结论：肠道支架植入对左半结肠、直肠癌所致的急性梗阻是一种安全有效的临时过渡性或永久性姑息性治疗手段，可借以免除急诊结肠造瘘术。     

经内镜支架置入联合腹腔镜手术治疗左侧大肠癌性梗阻的临床价值

目的:探讨经内镜支架置入术联合腹腔镜手术治疗左侧大肠癌性梗阻的临床价值。方法:回顾分析2010年3月至2015年3月收治的44例左侧大肠癌并急性肠梗阻患者的临床资料,其中观察组(n=18)经内镜联合X光置入结肠金属支架,缓解肠梗阻后择期行腹腔镜手术,对照组(n=26)则行术中结肠灌洗、Ⅰ期根治性切除吻合术。对比分析两组手术时间、术中出血量、术后肛门排气时间、手术并发症、住院时间、住院费用等。结果:观察组手术时间、术中出血量、术后肛门排气时间、住院时间明显优于对照组(P0.01),而住院费用则高于对照组(P0.01);对照组术后并发症发生率明显高于观察组(P0.05)。结论:结肠支架置入术可有效解除左侧大肠癌急性肠梗阻,支架置入术后择期行腹腔镜手术安全、可行,患者创伤小,术后康复快,并发症少,是安全有效的治疗手段。     

Treatment of acute malignant colorectal obstruction with self-expandable metallic stents

Background: Malignant left‐sided large bowel obstruction from intraluminal and extrinsic causes constitutes a surgical emergency. When conservative measures fail, emergent surgery is usually required, which carries increased morbidity and mortality compared with elective resections. In many situations, a stoma is created and further surgery may be required later to re‐establish bowel continuity. We present an initial series of patients in whom self‐expandable metallic stents (SEMS) were deployed to allow bowel decompression in place of emergency surgery for acute left‐sided colorectal obstruction. Methods: From April 1999 to January 2001, patients who were admitted to the colorectal unit with clinical and radiological features of intestinal obstruction were considered for endolumenal stenting. Stenting was performed under radiological guidance. Results: Sixteen patients underwent endolumenal stenting (age range: 23?90 years, eight men and eight women). There were two technical failures, two delayed perforations and one sealed perforation related to the stent. Three patients underwent elective resection and anastomosis after successful bowel decompression and mechanical bowel preparation. Eight patients with advanced malignancy or multiple medical disease had good bowel decompression after stent deployment and did not undergo any surgery. Conclusion: SEMS is a useful alternative in the management of acute left‐sided colorectal obstruction for a select group of patients. An algorithm for management of acute left‐sided large bowel obstruction incorporating the use of SEMS is proposed.     

结直肠癌伴急性肠梗阻的术式选择

目的探讨结直肠癌伴急性肠梗阻的外科处理方法。方法回顾性分析2002年1月至2008年6月手术治疗的结直肠癌伴急性肠梗阻31例的临床资料。结果31例均经手术治疗。右半结肠癌伴梗阻13例,其中12例行右半结肠一期切除,无吻合口漏发生,另1例癌肿不能切除行捷径手术;横结肠切除一期吻合2例;一期左半结肠切除肠吻合术7例,术后发生吻合口漏1例,其中2例乙状结肠癌伴梗阻行金属内支架置入,解除梗阻后3周行一期肿瘤切除肠吻合;Hartmann手术5例,术后恢复顺利,造口排便通畅,3～6个月后均进行了顺利关瘘手术;肿瘤无法切除行单纯结肠造口4例。结论重视围手术的处理,根据急性梗阻性结直肠癌病人全身情况和局部条件合理选择手术方式。