腹腔镜直肠前切除术的双吻合技巧

直肠双吻合技术（DST）给直肠癌切除手术带来了革命性的改变．其克服了因盆腔手术空间狭小而导致的手工肠吻合操作困难等缺点．缩短了手术时间,提高了保且T率．并降低了吻合口瘘等风险。本文结合自身开展腹腔镜结直肠切除手术10年的临床经验．从直肠的吻合方式到吻合操作技巧．阐述了腹腔镜下直肠双吻合技术的操作要点。     

凯途双吻合器对直肠癌低前切除术吻合口的影响

目的 探讨凯途双吻合器吻合法对直肠癌低前切除术吻合口的影响.方法 回顾性分析总结122例直肠癌行直肠前切除并采用双吻合器重建肠道连续性的病例资料.结果 122例直肠癌患者中未行保护性转流造口,发生吻合器穿破闭合的远端直肠而以手工吻合2例;吻合口距齿状线距离为0.5～4 cm,平均2.5 cm.手术时间为185～260 min;术中出血量(327±53)mL.平均随访时间为13个月,发生吻合口漏2例(1.67%),经保守治疗好转.无吻合口狭窄、出血及吻合口周围感染发生,随访期内无局部复发.结论 在低位直肠癌行直肠前切除术中采用凯途双吻合器吻合,吻合口漏及吻合口狭窄发生率低,与手工缝合、荷包钳缝合相比可以缩短手术时间,减少术中出血量,达到超低位保肛,较直线型吻合器使用更方便,值得进一步推广应用.     

Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection

Background Rectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed. Methods The important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon. Results Seventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%). Conclusions Our standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).     

直肠前切除术中单吻合器的应用

目的：为了克服直肠前切除术中应用双吻合器方法的缺点。方法：采用单吻合器加手缝法治疗52例直肠中段癌病人。结果：无吻合口漏,无死亡,同期用国产吻合器荷包缝合法治疗41例,4例瘘,无死亡,两组比较,经卡方检验X^2＝3．962,P＜0．05。结论：单吻合器方法具有更低位的直肠切除,由于直肠系膜的厚度大大超过吻合器钉脚的长度,因此手法缝合粘膜肌层制成直肠盲袋更为安全,吻合无瘘,同时可节省经费。     

直肠癌低位前切除术吻合方式优化对肛门功能保护研究进展

外科手术是治疗直肠癌的重要方式。直肠癌低位前切除术常规端端（SCA）吻合方式有80%～90%的患者术后出现不同程度的排便功能障碍,这些症状会长期存在或术后需要较长时间恢复,严重影响患者生活质量,统称为低位前切除术后综合征（LARS）。为了改善LARS,临床提出了三种优化吻合方式：结肠J型储袋吻合术（CJP）、结肠成形术（TCP）、端侧吻合术（SEA）。目前关于吻合方式对患者术后肛门功能影响的争议尚未消除,近年来一些关于优化吻合方式的研究结果已显现出优势,为直肠癌术后患者提供更好的功能保护,改善生活质量。     

经前会阴超低位直肠前切除术的临床应用

目的总结经前会阴超低位直肠前切除术（APPEAR）治疗低位直肠癌的临床经验。方法回顾性分析2009年9月至2011年8月间在北京协和医院基本外科施行APPEAR手术的26例低位直肠癌患者的临床和随访资料。结果26例患者中男19例,女7例,年龄（63．4±9．5）岁。术前检查见肿瘤距肛缘距离（4．6±0．7）cm。14例患者术前接受新辅助放化疗。26例患者均顺利保肛,手术时间（170±21）min,术中出血量（140±69）ml。术中发生直肠破损1例,术后发生会阴切口感染4例。术后病理：高中分化腺癌10例,中分化腺癌伴部分黏液腺癌7例,低分化腺癌1例,绒毛状腺瘤高级别上皮内瘤变1例．直肠绒毛状腺瘤1例,标本未找到癌细胞6例。术后全组均获随访,随访时间（11．4±5．6）个月,随访期间未出现泌尿功能障碍和肿瘤复发。18例患者于术后6个月行横结肠造口还纳术,术后wexner控粪功能评分平均为5．5分。肛门直肠功能测压显示,肛门括约肌最大主动收缩压为（224．0±59.3）mmHg,肛门括约肌最大静息压为（42．5±11．8）mmHg,直肠最大耐受量为（120．0±27．4）m1,直肠肛门抑制反射均存在。结论经前会阴超低位直肠前切除术适用于部分保留肛门的低位直肠癌手术．并能取得较为满意的肛门排粪功能。     

经前会阴平面超低位直肠前切除技术在腹腔镜直肠癌根治术中的应用

The introduction of stapling instruments and improved understanding of pathology has resulted in a greater proportion of low rectal cancer patients undergoing sphincter-preserving resection.A variety o...     

Local recurrence after curative anterior resection for carcinoma of the rectum

From 1972 to 1985, 60 patients with rectal carcinoma underwent curative anterior resections. There was a local recurrence in three (5 per cent). Pelvic recurrence was seen in two patients and a there was suture line recurrence in one. The length of the distal margin of the normal bowel or lymph node involvement did not appear to be a significant determining factor of the local recurrence. As for the factor responsible for the recurrence, tumor implantation into the pelvic cavity or into the suture line was suspected. Care should be taken to avoid implantion of tumor cells during operative procedures. There were no local recurrences in patients with lower rectal carcinoma. This finding might be related to the selection of patients with carcinoma of stage I and II.     

The incidence and causes of permanent stoma after anterior resection

Aims Defunctioning stomas are used following anterior resection to guard against the serious consequences of anastomotic leak such as pelvic sepsis and generalized peritonitis. This study aims to determine what proportion of patients undergoing anterior resection have a defunctioning stoma, how many of these patients do not have their stoma closed, and the reasons for this. Methods All patients undergoing a resection for rectal cancer in our institution in a five year period (January 1995 to December 1999) are included in the study. Anterior resection was performed on 154 patients, divided into 76 anterior resections (AR) and 78 low anterior resections (defined as the anastomosis within 6 cm of the anal verge). The data from these patients were analysed retrospectively. Results Of the total of 154 patients undergoing anterior resection, 59 (38%) were defunctioned, divided into 33 with loop ileostomy and 26 with loop colostomy. Five of these patients had not had their stoma closed at a median follow up of four years (range 1.5–6.5 years). The reasons for non closure were anastomotic stricture (2), metastatic disease (2), and patient choice (1). When comparing AR and LAR, 16% of patients had a defunctioning stoma after AR, compared with 60% after LAR (P < 0.01). Conclusion Anterior resection is being performed for very low rectal tumours in order to avoid a permanent stoma. However we have found that 8% of patients who are defunctioned with a stoma at anterior resection will not have their stoma closed, and conclude that patients should be warned of this pre‐operatively.     

腹腔镜直肠前切除术后吻合口出血研究进展

随着双吻合技术的广泛应用,使低位或超低位直肠癌保肛手术成为可能,直肠前切除术的适应证逐步扩大。尤其是腹腔镜手术,因其视野好、骶前解剖结构暴露清楚,对低位或超低位直肠癌也可在达到根治效果的同时保留肛门．提高了病人术后的生活质量。然而,直肠前切除术后并发症是影响腹腔镜手术术后恢复的重要因素．其中吻合口出血是术后早期严重并发症之一．     

直肠癌前切除术后吻合口漏的危险因素分析

目的探讨直肠癌前切除术后吻合口漏发生的危险因素。方法对我院从2005年1月到2007年12月三年间114例直肠癌前切除术后发生吻合口漏11例的临床资料进行回顾性分析。结果11例确诊发生吻合口漏,总发生率为9.65%（11/114）吻合口漏发生在术后第6～10天。其中男性患者8例（11.76%,8/68）、年龄〉60岁者9例（14.52%,9/62）、肿瘤距肛缘距离≤6cm者6例（14.63%,6/41）、术前有糖尿病者3例（17.65%,3/17）、术前有贫血或低蛋白血症者2例（20%,2/10）、术前伴有肠梗阻者2例（22.22%,2/9）、行全直肠系膜切除者5例（13.89%,5/36）。结论男性患者、年龄〉60岁、肿瘤距肛缘距离≤6cm、术前合并糖尿病、贫血或低蛋白、伴有肠梗阻及全系膜切除者,是术后吻合口漏发生的危险因素。     

结肠J型贮袋在低位直肠癌吻合术32例中的应用

目的探讨结肠J型贮袋在低位直肠癌手术中的应用。方法对我科2001年~2004年实施的直肠癌结肠J型贮袋肛管(直肠)吻合术32例的临床资料进行回顾性分析。结果全组无术中意外损伤及大出血病例。无死亡病例。发生吻合口狭窄1例。无吻合口漏及便秘。病人术后1年内排便状况满意。结论低位直肠癌行结肠J型贮袋肛管(直肠)吻合术具有操作方便、易于观察、容易推广等特点,有明显改善排便功能的作用,可显著提高病人术后的生活质量。     

Colorectal stapled anastomosis: results after anterior resection of the rectum for cancer

OBJECTIVE: Stapled end to end anastomosis makes the restoration of digestive continuity at the level of lower pelvis easier, but carries a certain risk. The aim of this report was to evaluate this risk in terms of immediate results and tumor recurrence after surgery for rectal cancer. PATIENTS AND METHODS: The data of 301 patients operated on following this technique between 1980 and 2000 have been reviewed in order to analyse the tumor characteristics, the operation and associated complications, the immediate postoperative complications and recurrence rate. RESULTS: Among the 301 patients (192 males and 109 females) with median age of 66 years, 19 (6.3%) received an emergency operation due to bowel obstruction. The rectal adenocarcinoma was located in the upper rectum in 132 cases (43.8%), in the middle rectum in 141 cases (46.8%) and in the lower rectum in 19 cases (9.4%). Preoperative radiotherapy was carried out in 148 cases (49%): between 1987 and 1996 with a dose of 30 Grays (Gy), later increased to 39 Gy and 45 Gy in 12 cases. From 1990, 113 patients have received adjuvant chemotherapy for stage III and IV tumors and in some position cases for stage II tumor. The excision left a safety margin under the tumor of less than 2 cm in 59 cases (19.6%), and the anastomosis was located at 5 cm or less from the anal verge in 178 cases (59%). Primary defunctioning stoma was formed in 39 cases (13%). An anastomotic defect was observed during the operation in 18 cases (6%) and 26 fistulas occured postoperatively (7.6%), significantly related to the location of the anastomosis with regard to the anal verge (P = 0.0009). The hospital mortality was 8 cases (2.6%). Cases of stenosis were uncommon : 11 cases (3.6%), significantly associated with preoperative radiotherapy (P =0.02). The local recurrence rate was 12% (37 cases) in a median time delay of 16 months, essentially related to the tumor stage (P = 0.004) and the considered period (P = 0.001). CONCLUSION: Stapled end-to-end colorectal anastomosis after excision of rectum for cancer is a reliable technique with a low rate of complication and tumor recurrence, when the surgical procedure is included in the curative therapy management of cancer.     

Risk factors for anastomotic leakage after anterior resection of the rectum

Objective Surgical technique and peri‐operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re‐operations in relation to anastomotic leakage. Patients and methods In a nine‐year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient‐ and surgery‐related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients. Results The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30‐day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (≤ 6 cm), pre‐operative radiation, presence of intra‐operative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients without leakage was 10 days (range 5–61 days) and for patients with leakage 22 days (3–110 days). Conclusion In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30‐day mortality was 2.1%. Low anastomosis, pre‐operative radiation, presence of intra‐operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.     

直肠癌Miles术后影响会阴部切口愈合的多因素分析

目的 对直肠癌行Miles手术可能影响会阴部切口愈合的多种因素进行分析,为合理处理各影响因素提供理论依据.方法 回顾性分析176例低位直肠癌行Miles手术的患者,采用SPSS For Windows 13.0统计分析,单因素分析用χ2检验或Fisher's确切概率法,将12个因素数量化后构建Logistic回归模型进行多因素分析,P＜0.05为差异有统计学意义.结果 直肠癌Miles术后会阴部切口一期愈合率为70.5%,29.5%的患者发生会阴部切口愈合不良.术前行放疗的患者会阴部切口一期愈合率与未行放疗者相比P=0.014,有统计学意义.Logistic回归分析显示:只有术前放疗的卡方值0.906＞0,P=0.012,OR为2.475.结论 直肠癌患者Miles手术前,行局部放疗的患者比未行放疗的患者更容易发生会阴部切口愈合不良,前者发生会阴切口愈合不良的危险是后者的2.475倍.     

超低位直肠前切除术中会阴前平面的应用解剖研究

目的 对超低位直肠前切除术涉及的会阴前平面及相邻组织结构进行局部解剖研究.方法 对16具带下肢的男性半骨盆矢状位标本进行解剖,测量并记录直肠前壁与尿道膜部距离、会阴体头侧宽度、会阴体尾侧宽度、会阴体厚度、耻骨直肠肌厚度、直肠前壁处及后壁处耻骨直肠肌上缘与齿状线距离以及盆膈裂孔宽度等8项指标.结果 在16具标本中均可清晰找到会阴前平面.直肠前壁与尿道膜部距离(rectum-urethra,R-U)的中位数为14(10～17)mm.会阴体轮廓呈梯形,头侧窄,尾侧宽,头侧宽度(width of cranial perineal body)的中位数为8(6～9)mm,尾侧宽度(width of caudal perineal body)的中位数为21(18～23)mm.会阴体厚度(thickness of perineal body)的中位数为20.5(17～23)mm.耻骨直肠肌厚度(thickness of puborectalis)的中位数为12(10～16)mm.直肠前壁处耻骨直肠肌上缘与齿状线距离[puborectalis-dental line(anterior wall of rectum)]的中位数为25(21～27)mm,直肠后壁处耻骨直肠肌上缘与齿状线距离[puborectalis-dental line(posterior wall of rectum)]的中位数为20(16～23)mm.盆膈裂孔的宽度(width of pelvic diaphragm)的中位数为8(6～10)mm.结论 会阴前平面清晰存在,经此平面可以利用长约20 mm的最远端直肠,提高低位直肠癌手术的保肛率.     

Methods of anastomosis in anterior resection of the rectum]

For the second row of anastomosis sutures in anterior resection the authors employed the technic of "enlarging rectosigmoid anastomosis", which is formed by two running sutures. The second row of sutures is put prior to the withdrawal of the apparatus KTs-28, which is used for pulling the stoma into the wound and turning of both anastomosed intestines to provide an adequate access to the anastomotic line. The experience with the initial II operations seems to be fairly promising. No stricture of the anastomosis develops while using this technic. Indications to the anterior resection of the rectum for cancer are discussed.     

直肠癌前切除术后早期吻合口出血的临床分析

目的:探讨直肠癌前切除术后早期吻合口出血的危险因素及处理方法。方法:回顾分析2011年1月至2016年6月512例行直肠癌根治术患者的临床资料。结果:术后16例早期发生严重吻合口出血,发生率3.13%,多因素分析显示,肿瘤下缘距肛门的距离、男性是吻合口出血的独立危险因素。16例出血患者均行结肠镜检查并止血,15例止血成功,1例因内镜下止血失败行外科手术治疗,内镜下止血成功率为93.75%(15/16)。结论:吻合口位置、男性是吻合口出血的危险因素。对于吻合口位置较低的男性患者,尤其要警惕,需从手术技巧、器械使用及术后检查监测等方面全面注意,防范其发生,一旦出现明显的出血,内镜可作为处理吻合口出血的第一选择。     

Single incision vs conventional laparoscopic anterior resection for sigmoid colon cancer: a case-matched study

Background

The purpose of the study was to evaluate the safety and effects of single-incision laparoscopic anterior resection (SILAR) for sigmoid colon cancer by comparing it with conventional laparoscopic anterior resection (CLAR).

Methods

Twenty-four patients who underwent SILAR between April 2010 and July 2011 were case matched 1:2 with patients who underwent CLAR, with respect to age, sex, body mass index, tumor location, and history of abdominal surgery.

Results

Two patients in the SILAR group and 1 patient in the CLAR group experienced anastomotic leakage. The operative time was longer in the SILAR group than in the CLAR group (251 ± 50 vs 237 ± 49 minutes; P = .253). The number of harvested lymph nodes (19.6 ± 10.7 vs 20.8 ± 7.7; P = .630) was not different. The postoperative hospital stay was shorter in the SILAR group (7.1 ± 3.4 days) than in the CLAR group (8.1 ± 3.5 days) (P = .234).

Conclusions

On the basis of the early outcomes, we conclude that SILAR is feasible and safe. Moreover, the adequate lymph node harvest and free margins support the use of this procedure.     

直肠癌前切除术后吻合口漏的影响因素分析

目的 探讨直肠癌全直肠系膜切除术后吻合口漏的相关影响因素.方法 对2005年1月至2007年12月施行直肠癌前切除手术的738例连续患者的临床资料行回顾性研究.分析影响吻合口漏发生的相关因素.结果 单因素分析显示低位直肠癌(肿瘤距肛缘≤7cm)、非结直肠专科术者和放置肛管与吻合口漏发生率相关.低位直肠癌的吻合口漏发生率显著高于高位直肠癌(5.9%vs.0.9%.P=0.003).结直肠专科术者手术吻合口漏发生率显著低于非专科术者(3.9%vs.11.3%.P=0.031).结直肠专科术者手术的患者中低位直肠癌比例也明显高于非专科术者(72.1%vs.52.8%,P=0.003).放置肛管组的吻合口漏发生率反而明显高于未放置组(14.5%vs.3.6%.P<0.001).多因素分析显示除低位直肠癌、非结直肠专科术者和放置肛管外,糖尿病(P=0.027)、远端切缘肿瘤距离<1 cm(P=0.009)和预防性造口(P=0.031)也与吻合口漏的发生相关.在522例低位直肠癌中进一步分析发现,预防性造口组的吻合口漏发生率明显低于未造口组(2.9%vs.8.5%,P=0.007);而由于保护作用较差及选择偏倚存在,肛管放置组的吻合口漏发生率仍显著高于未放置组(15.1%vs.4.9%,P=0.008).结论 低位直肠癌、非结直肠专科术者以及糖尿病是直肠癌术后吻合口漏的危险因素,而预防性造口能有效预防低位直肠癌术后吻合口漏的发生.