结直肠切除术的应用体会

目的：探讨全结肠直肠切除术在家族性腺瘤性鼻肉病（ＦＡＰ）、溃疡性结肠炎（ＵＣ）及结肠克隆病（ＣＣ）外科治疗中的应用。方法：对２２例ＦＡＰ,３例ＵＣ及２例ＣＣ病人施行全结肠直肠切除术,其中回肠贮袋肛管吻合（ＩＰＡＡ）２２例、回肠造口５例。在ＩＰＡＡ中,Ｊ型贮袋３例,Ｈ型贮袋２例,Ｓ型贮袋１７例,就手术适应证、手术操作、术后处理等进行讨论。结果：回肠造口中以加部分倒置者效果较好,ＩＰＡＡ术后排便功能较     

家族性腺瘤性息肉瘤的外科治疗

为了提高家族性腺瘤性息肉瘤的外科治疗效果，对１６例ＦＡＰ患者的外科治疗情况进行了回顾性总结。１６例中除１例行全结肠直肠切除，回肠造口外，其余１５例均行全结肠直遥切除、回肠贮袋代管吻合术。     

外科治疗15例溃疡性结肠炎的临床体会

目的:探讨溃疡性结肠炎的外科治疗体会,提高对本病救治水平。方法:对15例外科治疗的溃疡性结肠炎的临床资料进行回顾性分析。结果:本组15例患者中,行全结直肠切除、回肠造口术4例;全结肠切除、回肠直肠吻合术4例;全结肠直肠切除、回肠贮袋肛管吻合术7例。结论:全结肠切除、回肠造口术治疗较彻底,全结肠直肠切除、回肠贮袋肛管吻合术可改善排便控制功能但吻合口溃疡发生率高。对于常见的吻合口瘘并发症,通过持续骶前引流等保守治疗,可使吻合口瘘闭合。"J"型全结肠直肠切除、回肠贮袋肛管吻合术是目前治疗溃疡性结肠炎较好的手术方法。     

溃疡性结肠炎18例外科治疗体会

目的探讨溃疡性结肠炎的外科治疗。方法对18例外科手术治疗的溃疡性结肠炎的临床治疗进行回顾性分析。结果全组均经手术治疗，无围术期死亡，术后无主要并发症。结论全结肠切除、回肠造口术治疗较彻底，全结肠直肠切除，回肠贮袋肛管吻合术可以改善排便控制功能，是目前治疗溃疡性结肠炎较好的手术方式。     

回肠贮袋的作用是否能持久?

对于需行全结肠、直肠切除术的病人 ,回肠贮袋术可避免永久性的回肠造口。有报道贮袋功能的短期效果令人满意 ,但长期作用尚无法肯定 ,需长期随访观察。有研究认为贮袋术后控便功能的减退与年龄、贮袋炎、吻合口狭窄、括约肌功能失常、原发病及手术技巧有关。目前贮袋术后随访时间超过 10年以上的报道少见。ＢｕｌｌａｒｄＫＭ等对 1992年随访的 2 3 5例因炎性肠病 (溃疡性结肠炎、克罗恩病 )或ＦＡＰ行全结肠、直肠切除术、回肠贮袋术的病人再次进行排便功能的随访调查。其中有效的随访 15 4例 (60 % ) ,平均年龄 47(2 5 72 )岁 ,平均随访…     

家族性结直肠腺瘤样息肉病58例报告

目的 总结家族性结直肠腺瘤样息肉病(FAP)的最佳手术方式及临床效果.方法 对58例FAP患者的临床资料进行总结.结果 58例中良性45例,癌变13例.全部患者均施行了全结肠切除,采用回肠造口8例,部分直肠切除和回直肠吻合16例,直肠切除、回肠贮袋肛管吻合4例,直肠切除、直肠黏膜剥脱经直肠肌鞘内回肠J形贮袋肛管吻合30例(随访1～5年,大便次数2～4次/d,肛门有控便能力,无息肉复发、癌变,均能参加重体力劳动).本组严重并发症5例.随访6个月～8年,良性患者术后均存活,6例术后5～7年发生癌变而再次行手术.13例癌变者中,4例术后6～13个月因肿瘤广泛转移死亡,另9例仍存活.排便功能以回肠造口术较差,保留直肠的术式较好.结论 治疗FAP,选择全结肠切除、保留直肠肌鞘、回肠贮袋、回肠肛管吻合术较合适.     

家族性腺癌性息肉病的手术选择(摘要)

家族性腺瘤性息肉病(FAP)是常染色体显性遗传性疾病,如不手术治疗终将发生癌变,本文报告23例,男12例,女11例,年龄19~62岁,35岁以下10例,有家族史13例,手术时有8例癌变。最小癌变年龄23岁。治疗:行全结肠直肠切除回肠造口术1例,只适用于中低位直肠有恶变或全结肠切除回肠直肠吻合术后直肠发生癌变无法保留肛门括约肌者。行全结肠切除回肠直肠吻合术12例,保留段直肠为6~8cm便于术后复查直肠。适应证为直肠下段腺瘤少并能长期随访。行升结肠切除升结肠直肠吻合术1例。行全结肠切除,直肠部分切除,直肠粘膜剥除共9例,其中回肠末端直接与肛管吻合4例,J—pouch肛管吻合4例,S-pouch肛管吻合1例。随访1~18年,平均97个月,脾曲癌变1例术后3年死亡。回肠直肠吻合术12例中有4例直肠腺瘤再发多次手术切除,其中1例直肠腺瘤第3次再发未接受手术切除而致癌变,经局部切除。术后近期排便功能回肠直肠吻合组优于直肠粘膜剥除组。回肠贮袋有无远期排便功能无差别。作者认为应根据病变的范围、程度、有无恶变、能否长期随访、医生的经验等选择手术治疗方法。只要适应证选择合适即能取得良好的疗效。     

溃疡性结肠炎的外科治疗16例分析

目的探讨溃疡性结肠炎的外科治疗方式。方法对16例行外科手术治疗的溃疡性结肠炎的临床资料进行回顾性分析。结果本组16例行外科手术治疗，占全部收治患者的20．5％（16／78）。手术原因包括保守治疗无效10例，肠梗阻3例，合并息肉可疑癌变3例。行全结直肠切除、回肠造口术8例，全结直肠全切除、回肠肛管吻合术4例，结肠全切除、回直肠吻合术2例，结肠部分切除2例。结论溃疡性结肠炎主要手术指征为内科治疗无效或合并肠梗阻及并发息肉可疑癌变者。全结肠切除、回肠造口术治疗较彻底，全结直肠切除、回肠贮袋肛管吻合术可改善排便控制功能，但吻合口溃疡发生率高。     

家族性腺瘤性息肉病外科手术方式的选择

探讨家族性腺瘤性息肉病手术方式的选择和效果,方法对１７例ＦＡＰ的临床资料进行回顾性分析。结果１７例病人中良性１３例,癌变４例。全部病人均施行了全结肠切除,采用回肠造口１例,回直肠吻合２例,直肠切除、回肠肛管吻龠中回肠储袋、回肠肛管吻合７例,部分直肠切除、直肠粘膜剥脱经直肠肌鞘回肠肛管吻合７例。     

全结肠直肠切除回肠贮袋肛管吻合术的手术配合

全结肠直肠切除术适合于结肠多发性家庭性息肉病,溃疡性结肠炎非手术治疗无效,且直肠病变较轻者.以往在全结肠直肠切除后,行回肠造口,但永久性的回肠造口术后给病人带来诸多的不便,生活质量下降,病人要承受较大的精神压力及一定的社会压力.近年来,出现了多种全结肠直肠切除,回肠贮袋肛管吻合术式.自1994年以来,我院肛肠外科完成全结肠直肠切除,回肠贮袋肛管吻合术20例,取得了满意效果.现就将手术配合体会介绍如下.     

家族性腺瘤性息肉病两种术式的对比研究

目的探讨家族性腺瘤性息肉病采用回肠贮袋肛管吻合术与回肠直肠吻合术两种术式的手术效果。方法回顾性分析两组在手术结果、术后排便功能和生活质量的差异。结果30例患者中行回肠直肠吻合术12例,贮袋吻合术18例,术后无死亡,无吻合口瘘等严重并发症,均无膀胱和性功能障碍。平均住院时间、手术时间和失血量直接吻合组优于贮袋组(P<0 01),在并发症发生率、术后排气排便时间和肠蠕动次数两组相似(P>0 05)。随访时间最短6个月,最长16年。3例(25% )直接吻合者术后直肠息肉癌变需切除直肠。两种术式的术后排便功能相似,仅在白天排便次数和肛周刺激方面IRA组优于IPAA组(P<0 05)。结论两组患者术后排便功能和术后生活质量相似,但回肠贮袋肛管吻合术可减少术后残留的直肠黏膜癌变机会,因而是较理想的手术方式。     

直肠手术各种储袋的应用与评价

结肠储袋能改善低位直肠切除保肛术后早期控制排粪功能障碍,但其对患者术后远期（2年以上）控制排粪功能方面不具有优势。同时,随着时间的延长,排空障碍的发生率将逐渐提高,很多患者出现排粪困难,需要长期应用栓剂和灌肠。而储袋的制作延长了手术时间,增加了治疗费用。所以,低位直肠切除术后结肠储袋的价值正在遭受质疑,它的应用也变得越来越少。在溃疡性结肠炎（UC）和家族性腺瘤性息肉病（FAP）行全结肠切除术后,如果行回肠储袋肛管吻合（IPAA）,可通过增加新建直肠的容积并改变肠管的生理学动力,使排粪次数减少;且术后短期和长期控制排粪功能更好,生活质量更高。所以,IPAA是手术治疗UC和FAP的首选。     

Pouch reconstruction in the pelvis

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.     

The ileo-anal pouch procedure: Complications, quality of life, and long-term results

The ileo-anal pouch procedure: Complications, quality of life, and long-term results. Restorative proctocolectomy with construction of an ileal pouch-anal anastomosis (IPAA) has evolved as the surgical therapy of choice for patients with ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). 662 patients (493 UC, 169 FAP) consecutively received IPAA. Marked differences were observed between UC and FAP patients regarding the rates of overall complications (33.1 % vs. 12.5 %), pouchitis (29 % vs. 2 %), and pouch extirpation (3.2 % vs. 0.6 %). Pouchitis occurred as primary (79 %) and secundary (21 %) form, with acute (67.2 %) or chronic (32.8 %) course. Each form and course required specific therapy. Chronic pouchitis implies the risk of malignant transformation of the pouch mucosa. Quality of life improves significantly after IPAA in patients with UC and is equal to that in normal individuals, in UC and FAP, if postoperative complications are either prevented or under control.     

RESTORATIVE PROCTOCOLECTOMY WITH ILEAL POUCH–ANAL ANASTOMOSIS IN 203 PATIENTS: THE AUCKLAND EXPERIENCE

Background : Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become an established operation for patients with ulcerative colitis and familial adenomatous polyposis (FAP). The results of a 15-year experience with IPAA are reported. Methods : Between September 1982 and June 1997, 203 patients had IPAA surgery. From a review of the charts, data were collected on the surgical procedure, the diagnosis and early and late complications. Pouch function was assessed by means of a postal questionnaire. Results : Of the 201 patients (median age of 32 years; 89 women) with complete records, 122 had J pouches, 65 had W pouches and 14 S pouches were constructed. The pre-operative diagnosis in 88% was ulcerative colitis and in 10% it was FAP. During a median follow-up time of 6.1 years the diagnoses were changed for 8% of the patients; in 4% the diagnosis was changed to Crohn’s disease. The overall mortality was 1.5% (early = 2, late = 1) The overall morbidity was 62% (early = 17%, late = 52%). The pouch was removed or was non-functional in 9%. All patients with a final diagnosis of Crohn’s disease have had their pouch excised. The median stool frequency was 4.0 (range 1.3–8.7) during the day, and 0.7 (range 0–2.1) during the night. The fewer night-time stools (J = 1.0 ± 0.6; W = 0.4 ± 0.5 P < 0.0001) and the reduced requirement of the W-pouch patients for anti-diarrhoeals (P = 0.004) were offset by the need for two W-pouch patients to pass a catheter to empty their pouches. Conclusions : The type of patients who present for IPAA surgery and the outcomes observed in this series of Auckland patients are similar to those reported from major centres elsewhere.     

家族性腺瘤性息肉病的外科治疗

目的：分析大肠家族性腺瘤性息肉病（FAP）的临床特点，探讨其手术治疗方法。 方法 ： 回顾性分析近14年多来收治的28例大肠FAP患者的临床特点和治疗方法。28例中20例有家族史，6例已发生癌变。结果： 28例均行手术治疗，行全结肠切除直肠黏膜剥除回肠造袋肛门吻合术25例（89.3％），其他术式3例。手术后无严重并发症发生。术后辅以非甾体类抗炎药，或他莫西酚治疗。28例均得到随访2~14年，4例死亡（14.3％）。余者术后生存质量满意，排便功能良好。未发现回肠粪袋息肉形成。结论 ：手术是治疗家族性腺瘤性息肉病的主要方法，它可预防肠息肉癌变。术后使用非甾体类抗炎药，或他莫西酚治疗对家族性腺瘤性息肉病的复发有预防作用。     

Ileal pouch anal anastomosis in pediatric familial adenomatous polyposis: A 24-year review of operative technique and patient outcomes

Background

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is the operative procedure of choice for familial adenomatous polyposis (FAP) patients. We review 24 years of operative experience and outcomes in pediatric patients with FAP.

Methods

Patients with FAP, age < 20 years, presenting to a single institution between 1987 and 2011 were included. Operative technique and outcomes were reviewed retrospectively. Primary outcomes included postoperative complications (30 days), long-term bowel function, and polyp recurrence at the anal anastomosis.

Results

95 patients with FAP underwent IPAA. Mean age at IPAA was 15.5 years with a mean follow-up of 7.6 years. 29 patients underwent 1-stage IPAA, 65 patients had a two-stage IPAA, and 1 patient underwent a 3-stage procedure. 67 patients had an open procedure, 25 underwent a laparoscopic approach, and more recently 3 patients underwent single incision laparoscopic IPAA. Patients with 1-stage IPAA demonstrate better long term bowel control vs. 2-stage IPAA patients (10.7% vs. 36.0% occasional incontinence, p = 0.018). However, 1-stage IPAA patients suffered increased short-term complications, such as anastomotic leak (17.2% vs. 0%, p = 0.002) and reoperation (20.7% vs. 4.6%, p = 0.02) compared to 2-stage IPAA. Anal anastomosis polyp recurrence occurred in 22.7% of 1-stage patients and 10.0% of 2-stage patients. Short-term complications, polyp recurrence, or long-term continence were equivalent between open and laparoscopic cases.

Conclusion

Single-stage IPAA in children with FAP is associated with better bowel control but increased anastomotic leak, reoperative rate, and polyp recurrence. In experienced hands, laparoscopic IPAA is equivocal to open IPAA.     

全大肠切除回肠贮袋肛管吻合术的远期疗效评价

目的　探讨全大肠切除回肠贮袋肛管吻合术治疗溃疡性结肠炎 (UC)和家族性腺瘤性息肉病 (FAP)的远期疗效。方法　 1985～ 2 0 0 2年间共对 6 1例患者行全结肠直肠切除回肠贮袋肛管吻合术 ,其中UC 2 5例、FAP 34例、其他 2例 ,应用S袋 2 5例、S J袋 13例、J袋 17例以及W袋 6例 ,术后随诊 1～ 18年、平均 8年 ,比较分析术后控便功能及并发症。结果　全部患者存活。并发症发生率为 16 % ( 10 / 6 1) ,其中UC患者 ( 2 4 % ,6 / 2 5 )高于FAP患者 ( 12 % ,4 / 34) ,W袋高于其他各袋 ,手法吻合 ( 2 0 % ,8/ 4 1)高于吻合器吻合 ( 10 % ,2 / 2 0 ) ,但差异均无显著性 (P >0 0 5 )。术后 2 4h大便次数平均为 4 2次。日间 84 % ( 4 3/ 5 1)、夜间 75 % ( 38/ 5 1)的患者排便能自控 ,6 % ( 3/ 5 1)的患者有明显的大便失禁。大部分患者对目前的生活质量表示满意。结论　全大肠切除回肠贮袋肛管吻合术治疗可维持UC与FAP患者肛管自控功能和可接受的大便次数 ,术后并发症较少 ,是较为理想的手术方式     

Prevalence and risk factors for adenomas in the ileal pouch and the afferent loop after restorative proctocolectomy for patients with familial adenomatous polyposis

Background

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become the treatment of choice in familial adenomatous polyposis (FAP) to prevent the risk of colorectal cancer. However, it currently is recognized that adenomas may develop in the ileal pouch. The risk of adenoma occurring in the afferent ileal loop above the pouch is less clearly identified. This study aimed to evaluate the difference in prevalence of adenomas between the ileal pouch and the afferent ileum after IPAA in FAP.

Methods

The study analyzed 442 endoscopies performed between 2003 and 2008 for 139 FAP patients. The patients had undergone an IPAA in 118 cases, an ileorectal anastomosis in 13 cases, or an ileostomy in 8 cases.

Results

Among the 118 IPAA patients, 57 (48.3 %) had pouch adenomas a median of 15 years after surgery. The risk factors for pouch adenomas were delay since pouch construction [odds ratio (OR), 1.11; p = 0.016] and presence of advanced duodenal adenomas (OR, 4.35; p = 0.011). Seven patients had pouch adenomas with high-grade dysplasia. Only nine patients had afferent ileal loop adenomas (6.5 %). The only significant risk factor for ileal adenomas was the presence of pouch adenomas (OR, 2.16; p = 0.007).

Conclusion

After restorative proctocolectomy in FAP, adenoma recurrence is frequent in the pouch, with a higher risk for patients with advanced duodenal adenomas and an increasing risk over time, whereas adenomas are rarely found in the afferent ileal loop. This finding may help to propose redo ileal pouch anal anastomosis if required.