自闭式插管造瘘在低位直肠癌保肛手术的临床应用研究

背景低位直肠癌保肛手术在临床上越来越常见,人工造瘘术是直肠癌手术的常见辅助技术,传统人工造瘘术手术创伤较大,肠道功能恢复后需要再次手术封闭瘘口,操作繁琐且成本较高,遂对新式自闭式插管造瘘展开研究.目的观察低位直肠癌保肛手术应用自闭式插管造瘘的临床效果.方法选择2016-07/2018-07在我院消化外科行低位直肠癌保肛手术治疗的120例患者作为研究对象,按随机数表法分两组组,每组60例,均行直肠癌低位前切除术,对照组在术中行常规回肠保护性造口技术,观察组行自闭式插管造瘘技术,比较两组手术指标、并发症及生活质量.结果观察组带管时间26.59 d±3.81 d、住院时间12.01d±3.56 d相比对照组短,且造口袋更换次数1.09次/wk±0.30次/wk比对照组少(P0.05);观察组并发症6.67%相比对照组26.67%更低(P0.05);观察组术后躯体功能(92.41分±10.21分)、生理职能(76.82分±14.15分)、机体疼痛(90.11分±10.63分)等评分相比对照组高(P0.05).结论低位直肠癌保肛手术应用自闭式插管造瘘能保护吻合口,减少造口并发症,缩短造口期,减少造口袋更换次数,效果良好.     

低位直肠癌保肛手术42例应用观察

目的观察低位直肠癌保肛手术的临床疗效。方法对42例低位直肠癌采用保肛手术治疗。结果本组均顺利实施手术,仅1例转为传统Miles手术;术后随访1～24个月,局部复发2例,远处转移2例,死亡3例;患者对手术的总体满意度为83．33％。治疗后在患者SCL-90量表评分低于治疗前,P〈0．05。结论低位直肠癌保肛手术安全有效,可明显改善患者的生活质量。     

双钉吻合器在低位直肠癌保肛手术中的应用

双钉吻合器可解决低位直肠癌盆腔深部吻合困难的问题,具有手术省时、安全、吻合口瘘发生率低等优点.2001年11月～2006年11月,我院采用双钉吻合法行低位直肠癌保肛手术27例.现报告如下.     

中低位直肠癌保肛手术67例体会

1991年 1月至 1 999年 1 2月 ,我院共行直肠癌手术 1 67例 ,保肛手术 67例 ,现报告如下。1　资料与方法本组男 39例 ,女 2 8例 ;年龄 2 3～ 79岁 ,平均 61岁。肿瘤下缘距肛缘 4～ 5cm1 5例 ,6～ 7cm46例 ,7cm以上 6例。Ducks分期 A期 7例、B期 50例、C期 1 0例。病理分型腺癌 59例 ,粘液腺癌 8例。手术方法 :Dixon手术 8例 (其中利用吻合器低位吻合 3例 ) ,Bacon手术 1 1例 ,改良 Bacon手术 37例 ,Parks手术1 1例。均按向上、向两侧清扫淋巴结 ,手术标本均于术中行快速冰冻病理切片 ,以保证远端及周围无残存肿瘤组织、细胞。术后用顺铂…     

低位直肠癌保肛治疗围手术期护理

2001年5月至2003年6月，我们采用吻合器保肛手术治疗低体位直肠癌患者22例，取得了满意效果。现将围手术期护理体会总结如下。     

中低位直肠癌行保肛手术184例临床分析

自1908年Miles术式创建以来。为众多中低位直肠癌患义带来了生存的希望，但术后终生的膨壁造口又使大部分患痛苦不堪。自1986年以来，我们对184例中低位直肠癌患有选择的施行了保肛手术，经2年以上的随访，效果满意，报告如下：     

套袖式吻合技术在腹腔镜超低位直肠癌保肛手术中的应用

目的探讨套袖式吻合技术在腹腔镜超低位直肠癌保肛手术的安全性、有效性及近期疗效。 方法回顾性分析中国医学科学院北京协和医学院肿瘤医院2018年4月至2019年2月采用套袖式吻合技术完成的腹腔镜超低位直肠癌保肛手术患者的临床资料,统计并分析患者的临床特征、病理特征、手术和术后恢复情况、围手术期并发症及术后肛门功能等资料。 结果共有40例患者成功完成应用套袖式吻合技术的腹腔镜超低位直肠癌保肛手术,2例患者术中因结肠残端血供较差行预防性回肠造口,其中21例（52.5%）患者术前行新辅助治疗,肿瘤距肛缘中位距离为4 cm,中位手术时间为166.5 min,中位术中出血量为20.0 mL。肿瘤中位长径为2.5 cm,中位近端切缘长度为10.3 cm,中位远端切缘长度为1.0 cm,中位淋巴结检出数目为13.10枚。患者术后中位下地时间、进食时间、排气时间和住院时间分别为19.0 h、12.5 h、20.5 h和6.0 d,中位住院费用为47 646.0元。随访过程中,结肠残端回缩入盆腔的中位时间为12.0 d,其中4例（10%）患者术后出现吻合口漏,行临时性肠造口手术后逐渐好转,1例（2.5%）患者术后出现结肠残端出血,4例（10%）患者术后出现肛周粪水性皮炎,2例（5%）患者术后出现肛周疼痛,均予对症止处理后好转。术后3个月采用低前切除综合征（LARS）评分量表评估肛门功能,其中,8例（20%）无LARS,23例（57.5%）轻度LARS,9例（22.5%）重度LARS。随访期间无患者肿瘤复发或者转移。 结论应用套袖式吻合技术的腹腔镜超低位直肠癌保肛手术安全可行,避免了常规预防性造口,近期疗效较为满意,其远期疗效待进一步随访观察。     

吻合器用于中低位直肠癌保肛手术66例治疗体会

1997～ 2 0 0 1年 ,我院对 6 6例中低位直肠癌患者实施Dixon手术 ,采用吻合器完成骶前吻合 ,术后发生吻合口瘘 3例。现报告如下。临床资料 :本组男 41例 ,女 2 5例 ;年龄 2 7～ 75岁 ,平均5 5 .8岁。肿瘤下缘距肛缘 5～ 8cm,肛诊均能触及肿瘤 ,术前活检诊断为腺癌 5 0例 ,粘液腺癌 11例 ,低分化腺癌 2例 ,息肉恶变 2例 ,印戒细胞癌 1例。 Dukes分期为 A期 2例 ,B期2 4例 ,C期 37例 ,D期 3例。手术方法 :使用 34号 GF- 1型直式管道吻合器 ,肿瘤切除及淋巴结清除范围同 Miles'手术 ,肿瘤远端切除均超过2 .5 cm。充分游离直肠系膜及周围脂…     

保肛手术治疗低位直肠癌142例分析

1998年以来 ,我院收治低位直肠癌 14 2例。现就直肠低位吻合保肛手术的有关问题分析如下。临床资料 :低位直肠癌 (距肛缘 7～ 4 cm) 14 2例 ,男 94例 ,女 4 8例 ;年龄 2 8～ 74岁。低位吻合术 10 2例 ,拖出式手术4 0例。就诊症状为便形变细、粘液脓血便、大便次数增多、消瘦等。直肠指诊触及菜花状或溃疡型肿物 ,纤维结肠镜活检病理确诊 ,腔内超声检查示癌肿均未侵透肌层 ,CT检查示直肠周围无浸润及远处转移。病理组织学分型为高分化腺癌 4 2例 ,中分化腺癌 6 0例 ,低分化腺癌 2 8例 ,粘液腺癌 12例。治疗方法 :1术前准备 :术前 3天口服庆…     

一针法预防性回肠造口在直肠癌低位前切除手术中的应用

目的探讨一针法回肠造口方法在直肠癌低位前切除手术中的技术优势。 方法前瞻性分析2016年1月至2019年1月河南省肿瘤医院普外科连续80例行直肠癌低位前切除并预防性回肠造口手术的患者,按随机表法分为一针法回肠造口组（观察组）和传统方法造口组（对照组）,对比两组造口手术操作时间、造口皮肤黏膜分离、粪水性皮炎、造口旁疝、造口脱垂、造口回缩等相关造口并发症指标的发生率。 结果两组患者的基线资料比较差异无统计学意义（均P>0.05）,观察组手术操作时间短于对照组［（2.1±0.9）min vs.（15.2±4.6）min］（t=-17.510,P<0.05）,造口皮肤黏膜分离、粪水性皮炎、造口回缩等发生率与传统方法组比较差异均有统计学意义（观察组造口皮肤黏膜分离患者1例,对照组15例;观察组粪水性皮炎患者3例,对照组32例;观察组造口回缩患者0例,对照组8例）（χ²=15.313,42.717,8.889;P均<0.05）,在造口旁疝、造口脱垂两方面差异无统计学意义（观察组造口旁疝患者2例,对照组6例;观察组造口脱垂患者2例,对照组3例）（χ²=2.222,0.213;P均>0.05）。 结论一针法回肠造口在直肠癌低位前切除术中较传统方法更具操作优势,而且可减少相关造口并发症的发生。     

A new ultimate anus-preserving operation for extremely low rectal cancer and for anal canal cancer

Abstract. To avoid permanent colostomy, we perform a new ultimate anus preserving operation for extremely low rectal cancer or for anal canal cancer. According to our pathologic study, two different removal methods of anal canal were theoretically considered. One is internal sphincter resection (ISR method), and the other is both deep-superficial external sphincter and internal sphincter resection (ESR method). Six patients received ISR and ten patients ESR. No severe intraoperative complications occurred and the postoperative course was uneventful. All patients receiving ISR had excellent anal function without soiling. Some patients receiving ESR sometimes complained of night soiling but satisfied the anus preservation. The median follow-up was 15 months, (range, 3–28 months). We had recurrences in two female patients receiving ISR. One had para-aortic and lateral lymph node recurrences without anastomotic recurrence. She underwent lateral and para-aortic lymphadenectomy, but died of lung metastasis, regardless of intensive chemotherapy. Another had pelvic recurrence with abdominal dissemination. She underwent abdominoperineal resection and is alive with pelvic re-recurrence. ISR and ESR are excellent procedures for anus preservation, but ISR needs a strict indication.     

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。     

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。     

Clinical outcome of intersphincteric resection for ultra-low rectal cancer

AIM:To analyze oncological outcome of intersphinctericresection(ISR)in ultra-low rectal cancer with intent tospare colostoma.METHODS:From 1995 to 1998,patients with a non-fixed rectal adenocarcinoma(tumor stage T2)preserving thelower margin at 1-3 cm above the dentate line withoutdistant metastasis was enrolled(period Ⅰ).ISR was prac-ticed in eight patients,and their postoperative follow-up was at least 5 years.In addition,from 1999 to 2003,another 10 patients having the same tumor locationas period Ⅰ underwent ISR(period Ⅱ).Among those,6patients with T3-4-staged tumor received preoperativechemoradiotherapy.RESULTS:All patients received ISR with curative inten-tion and no postoperative mortality.In these case seriesat period Ⅰ,local recurrence rate was 12.5% and me-tastasis rate 25.0%;the 5-year survival rate was 87.5%and disease-free survival rate 75.0%.There was no localrecurrence or distant metastases in 10 patients with amedian follow-up of 30(range,18-47)mo at period Ⅱ.CONCLUSION:As to ultra-low rectal cancer,inter-sphincteric resection could provide acceptable localcontrol and cancer-related survival with no permanentstoma in early-staged tumor(tumor stage T2);more-over,preoperative concurrent chemoradiotherapy wouldmake ISR feasible with surgical curative intent in moreadvanced tumors(tumor stages T3-4).     

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.     

Review of the pull-through operation for rectal cancer

Conclusions The pull-through operation is a good operative means of treating rectal cancer, and it will not be entirely discarded even with the development of methods of extremely low anastomoses. This has been a recital of “ancient” surgical history in some respects, because today a fair number of these patients would have had anterior resections or the Miles procedure. Furthermore, the radicality of this operation may be open to question: because the inferior mesenteric artery is not ligated at its origin, some of the sigmoidal mesentery remains. In 5 per cent of cases, however, the marginal artery of Drummond does not supply enough blood to the pulled-through segment when the inferior mesenteric artery is ligated at its origin. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978.