全大肠切除回肠贮袋肛管吻合术治疗家族性腺瘤性息肉病45例分析

目的探讨全大肠切除回肠贮袋肛管吻合术在治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)中的价值。方法回顾性分析1995—2005年45例FAP患者行全大肠切除回肠贮袋肛管吻合术的手术方式、并发症以及结肠镜、肛肠测压等随访资料。结果45例中发生吻合口漏1例;术后平均排便频率:3个月内每日9次,6个月后每日5次,12个月后每日4次;术后平均肛管慢波静息压为5 cm H_2O,频率为13次/min,肛管收缩压平均180 cm H_2O。37例术后结肠镜随访发现,14例有贮袋息肉(14/37,38%);4例术后发生小肠系膜硬纤维瘤。结论全大肠切除回肠贮袋肛管吻合术是FAP理想的外科手术方式,回肠"J"型贮袋患者控便功能良好,术后应密切随访,预防发生大肠外肿瘤。     

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.     

回肠贮袋肛管吻合术改进方案探讨及对术后肛门远期功能影响

目的对传统回肠贮袋肛管吻合术进行一定改进,探讨该改进术式对溃疡性结肠炎(ulcerative colitis,UC)或家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)术后肛门远期功能的保护作用。方法对2000年1月至2011年1月我院收治的行回肠贮袋肛管吻合术治疗的64例UC或FAP患者的治疗资料进行回顾性分析。按术式分组,观察组38例均接受改进术式治疗,直肠经肛门拖出切除,同时辅助应用双吻合器,对照组26例均接受常规手术。行5~15年的院外随访,对比术后肛门远期功能。结果观察组未见死亡病例,随访期间出现4例并发症,随访5年、10年、15年时有效随访人数分别为38例、22例、18例,Kirwan评分良好者分别占60.5%、59.1%、55.6%,Oresland评分中位数分别为3分、5分、5分;对照组3例恶性FAP患者、1例UC患者术后3年内死亡,其余患者共出现9例并发症,随访5年、10年、15年时有效随访人数分别为22例、17例、13例,Kirwan评分良好者分别占68.2%、35.3%和30.8%,Oresland评分中位数分别为3分、6分、8分。两组术后10年、15年Kirwan评分及Oresland评分差异显著,均有统计学意义(P0.05)。结论经肛门拖出切除直肠、双吻合器技术对保护回肠贮袋肛管吻合术患者远期肛门功能有一定价值。     

全结肠切除回肠"S"型储袋肛管吻合术治疗家族性腺瘤性息肉病

目的:探讨全结肠切除回肠“S“型储袋肛管吻合术治疗FAP的效果.方法:回顾分析1995至2005年进行的33例FAP全结肠切除术,对治疗效果进行分析.结果:33例患者中良性21例,癌变12例.全部患者均施行了全结肠切除,27例回肠“S“型储袋肛管吻合术,6例永久性回肠造口术; 手术后无严重并发症发生.33例均得到随访1～10年, 5例癌变病人因肿瘤复发、肝转移死亡.余者术后生存质量满意,排便功能良好. 结论:全结肠切除回肠“S“型储袋肛管吻合术治疗FAP息肉切除彻底、术后控便能力理想,该术式是治疗FAP较为理想的手术方式.     

回肠新直肠吻合

回肠新直肠吻合术(INRA)是治疗溃疡性结肠炎(UC)和家族性多发性腺瘤性息肉病(FAP)的一种新方法,它摒弃了回肠肛管囊袋,而保留了直肠储存粪便的功能。对UC和FAP来说,其本身是粘膜疾患,外科处理UC和FAP的目的就是切除结肠病变粘膜并保留直肠储存粪便和排粪功能,去除直肠肌层事实上毫无必要。回肠囊袋肛管吻合术(IPAA)能实现该目的,但有着15%～35%的并发症,10%的失败率以及不能预测术后功能的缺陷;而INRA术式正好符合这些要求,它切除了直肠粘膜并以有血供的回肠粘膜来替代。本文观察INRA术式的早期结果,共11例(6男5女)患者施行了I…     

腹腔镜辅助下全大肠切除、回肠储袋与直肠肌管吻合术治疗家族性腺瘤性息肉病

目的 探讨腹腔镜辅助下全大肠切除、回肠储袋与直肠肌管吻合术在治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)中的价值.方法 回顾性统计分析7例FAP患者行腹腔镜辅助下全大肠切除、回肠储袋与直肠肌管吻合术的手术、术后恢复情况及随访资料,并与同期开腹手术患者相比较.结果 腹腔镜手术患者手术切口平均长度为4.32 cm,明显短于开腹手术,差异有统计学意义;术后排气时间平均为1.45 d,短于开腹患者,两组间差异无统计学意义;住院时间平均为11.95d,明显短于开腹手术患者,差异有统计学意义.术后6个月随访资料显示回肠储袋与直肠肌管吻合术安全可靠,较回肠储袋肛管吻合术后患者排便次数明显减少,肛管静息压和最大收缩压明显增高.结论 与原有回肠储袋肛管吻合术相比,腹腔镜辅助全大肠切除、回肠储袋直肠肌管吻合术不仅手术创伤小,手术方式简单,手术难度低,而且减少了可能发生的盆底肌肉和肛门括约肌损伤,更好地保留患者控排便功能.     

离断肠系膜上动、静脉,全直肠肌鞘内回肠袋一肛管吻合术治疗家族性结肠息肉病

目的 探讨全结肠及低位直肠黏膜切除,离断肠系膜上动、静脉,全直肠肌鞘内回肠贮袋-肛管吻合术治疗家族性结肠息肉病的临床价值.方法 对6例家族性结肠息肉病患者采用离断肠系膜上动、静脉以松解小肠系膜,全直肠肌鞘内回肠袋一肛管吻合术,并随访4个月至17年,评价术后近期及远期效果.结果 术后3～7 d,患者即可区分肠内气体与粪便;术后7～10 d,大便转为成形.5例随访3～17年,大便1次/d,无夜便粪污,小便正常;1例随访4个月,大便2次/d,无夜便.6例患者大、小便均正常,植物神经功能和性功能正常,6例均无感染和息肉复发.结论 离断肠系膜上动、静脉后肠系膜可获充分松解,再行全直肠肌鞘内回肠袋一肛管吻合术对家族性结肠息肉病治疗效果是满意的.     

腹腔镜手术治疗家族性腺瘤性息肉病临床分析

目的探讨家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)的微创外科治疗疗效与安全。 方法回顾性分析2010年2月至2017年3月于北京协和医院行腹腔镜手术治疗的16例FAP患者的病例资料。 结果16例患者均完成腹腔镜手术,其中行全结直肠切除、回肠储袋肛管吻合术6例,全结肠直肠切除、回肠端式造口5例,全结肠切除、回肠直肠吻合术5例;无中转开腹,手术时间(227.9±52.7)min,平均术中出血量(98.1±90.7)ml。5例(31.2%)发生腺瘤癌变,4例(25.0%)伴高级别上皮内瘤变。14例患者获得长期随访,其中4例患者残余直肠新发息肉、3例患者术后发生腹腔硬纤维瘤。1例FAP合并肠癌患者术后1.5年因肝转移死亡。 结论腹腔镜手术治疗FAP安全可行;FAP患者术后需定期复查。     

腹腔镜辅助全结直肠切除、回肠J型储袋与肛管吻合治疗家族性腺瘤性息肉病

目的探讨腹腔镜辅助全结直肠切除、回肠J型储袋与肛管吻合治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)的疗效。方法 2013年1月～2017年12月对15例FAP施行全结直肠切除、回肠J型储袋与肛管吻合术。先行腔镜下全结直肠的游离,离断直肠,然后将回肠断端构建J形储袋,经肛门放置直线管状吻合器,拉下回肠,完成贮袋肛管吻合。结果 15例均顺利完成腹腔镜辅助下全结直肠切除术、回肠J型储袋与肛管吻合。手术时间(112. 4±32. 3) min,术后住院时间(9. 9±2. 5) d。术后病理4例息肉恶变。术后1例出现盆腔感染,穿刺引流后好转。15例平均随访28个月(3～60个月),术后随访1年时,大便次数(3. 3±1. 4)次/d,基本成形,无肿瘤复发及死亡。结论腹腔镜辅助全结直肠切除、回肠J型储袋与肛管吻合是治疗FAP的有效手术方式。     

应用吻合器法改进回肠贮袋肛管吻合术的初步研究

全结肠、部分直肠切除、直肠黏膜剥除、回肠贮袋肛管手法吻合术（ileal pouch-anal anastomosis,IPAA）已成为治疗家族性腺瘤性息肉病（familial adenomatous polyposis,FAP）和溃疡性结肠炎（ulcerative colitis,UC）的标准术式,约50%的患者术后出现夜间的粪污。近年采用不剥离直肠黏膜、直接采用吻合器行保留肛门移行区（anal transitional zone,ATZ）的回肠贮袋肛管吻合术（ileal pouch anal canal anastomosis，IACA），明显提高了术后的控便功能。     

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.     

Ileal pouch-anal anastomoses complications and function in 1005 patients.

BACKGROUND: Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become an established surgery for patients with chronic ulcerative colitis and familial adenomatous polyposis. PURPOSE: The authors report the results of an 11-year experience of restorative proctocolectomy and IPAA at a tertiary referral center. METHODS: Chart review was performed for 1005 patients undergoing IPAA from 1983 through 1993. Preoperative histopathologic diagnoses were ulcerative colitis (n = 858), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 75), and miscellaneous (n = 10). Information was obtained regarding patient demographics, type and duration of diseases, previous operations, and indications for surgery. Data were collected on surgical procedure and postoperative pathologic diagnosis. Early (within 30 days after surgery) and late complications were noted. Follow-up included an annual function and quality-of-life questionnaire, physical examination, and biopsies of the pouch and anal transitional zone. RESULTS: Of the 1005 patients (455 women), postoperative histopathologic diagnoses were as follows: ulcerative colitis (n = 812), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 54), Crohn's disease (n = 67), and miscellaneous (n = 10). During a mean follow-up time of 35 months (range 1-125 months), histopathologic diagnoses were changed for 25 patients. The overall mortality rate was 1% (n = 10 patients, early = 4, late = 6); one death (0.1%) was related to pouch necrosis and sepsis. The overall morbidity rate was 62.7% (1218 complications in 630 patients; early, n = 27.5%; late, n = 50.5%). Septic complication and reoperation rates were 6.8% and 24%, respectively. The ileal pouch was removed in 34 patients (3.4%), and it is nonfunctional in 11 (1%). Functional results and quality of life were good to excellent in 93% of the patients with complete data (n = 645) and are similar for patients with ulcerative colitis, familial adenomatous polyposis, indeterminate colitis, and Crohn's disease. Patients who underwent operations from 1983 through 1988 have similar functional results and quality of life compared with patients who underwent operations after 1988. CONCLUSION: Restorative proctocolectomy with an IPAA is a safe procedure, with low mortality and major morbidity rates. Although total morbidity rate is appreciable, functional results generally are good and patient satisfaction is high.     

Laparoscope-Assisted Versus Conventional Restorative Proctocolectomy with Rectal Mucosectomy

To assess the advantages of a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis compared with conventional procedures, we retrospectively analyzed the results of the two procedures as follows: Eleven patients including five patients with familial adenomatous polyposis (FAP) and six with ulcerative colitis (UC) underwent a laparoscope-assisted proctocolectomy and hand-sewn ileal J-pouch anal anastomosis at our department from June 1997 to November 1999. This laparoscope-assisted colectomy (LAC) group was then compared with a group of 13 patients who had undergone conventional ileal pouch anal anastomosis using a standard laparotomy from 1986 to 1997. The median operative time of the LAC group was 8 h 23 min, which was 81 min longer than that of the standard colectomy (SC) group. The number of days during which eating was prohibited were similar in the two groups but the median postoperative hospital stay was significantly shorter in the LAC group (24.1 days). In the LAC group, the small incisions showed better cosmetic results and there was also a remarkable reduction in the degree of postoperative pain. In conclusion, a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis can be employed widely in patients with FAP and also in selected patients with UC. Received: April 17, 2000 / Accepted: September 26, 2000     

Rare complication after ileal pouch–anal anastomosis: Bilateral ureteral obstruction due to pelvic sepsis and retroperitoneal fibrosis

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the procedure of choice for the majority of patients who require surgery for ulcerative colitis, and the preferred operation for patients with familial adenomatous polyposis. Complications of IPAA are common, including septic, inflammatory, functional, neoplastic and metabolic complications. When early postoperative sepsis develops, subsequent failure over time is approximately five times the rate for the whole pouch population. The objective of this study was to report an uncommon complication of IPAA. We reported a case of a patient who developed bilateral ureteral obstruction due to retroperitoneal fibrosis secondary to pelvic sepsis after a pouch–anal anastomosis leak. To the best of our knowledge, no such case has ever been reported.     

Anatomic and functional characteristics of the rat ileal pouch

BACKGROUND: The definitive operation for chronic ulcerative colitis (UC) and familial adenomatous polyposis is total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Mild inflammation (pouchitis) is omnipresent in pouches and becomes severe in 50% of UC patients with IPAA. The etiology of pouchitis is likely due to combined genetic, microbial, and immunologic factors. Epithelial cell exposure to surgical trauma and/or to changes in intestinal bacterial composition may account for the inflammatory infiltrate. Progress in understanding pouchitis is restricted by the lack of suitable animal models. METHODS: An ileal pouch-rectal anastomosis [IPRA] in rats was developed to reproduce a model of human IPAA and clinical, gross and histologic criteria were determined. RESULTS: Many shared features with human ileal pouch were observed. CONCLUSION: IPRA is an important in vivo model to study mechanisms of repair, defense and immunity that may contribute to pouchitis.     

Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients

OBJECTIVE: To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. BACKGROUND: IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence. METHODS: A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n > or = 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval. RESULTS: The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. CONCLUSIONS: Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures.     

Ileal pouch-anal canal anastomosis for familial adenomatous polyposis: early and late results.

OBJECTIVE: The objective was to review the early and late results of ileal pouch-anal anastomosis (IPAA) done for patients with familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA: Patients with FAP will have colorectal adenomas develop and die of colorectal cancer if left untreated. Ileal pouch-anal anastomosis removes all disease-bearing mucosa while preserving transanal passage of stools. METHODS: Between 1981 and 1994, 187 patients with FAP, 11 to 59 years of age with a mean follow-up of 60 months (range, 5-170 months) had proctocolectomy and IPAA at Mayo Medical Center in Rochester, Minnesota. All patients had a proximal anal canal mucosal excision and a hand-sewn anastomosis of the pouch to the anal canal at the dentate line. A temporary ileostomy was used in 85% of the patients. RESULTS: No early postoperative deaths occurred, although two patients died later of metastatic colorectal carcinoma present at their initial operation. More important, no patient had a new cancer develop after IPAA. The overall morbidity after operation was 24%, with small bowel obstruction being the most common complication (13%). Patients had four bowel movements/24 hours and good fecal control, which continued during follow-up. CONCLUSIONS: The IPAA eradicates the risk of colorectal cancer in patients with FAP. It can be performed with low mortality, acceptable morbidity, and good functional results over the long term.     

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     

Immediate and long-term results in ileoanastomosis with reservoir in 335 consecutive cases

Restorative proctocolectomy with ileal pouch anal anastomosis is the first choice procedure for the treatment of ulcerative colitis and familial adenomatous polyposis. The introduction of the stapled technique has shortened the duration of the procedure and reduced the complication rates. Data on 335 consecutive patients undergoing ileal pouch anal anastomosis for ulcerative colitis (277 pts), Indeterminate colitis (20 pts) and familial adenomatous polyposis (38 pts) between 1984 and 1998 were prospectively collected. Parameters evaluated included diagnosis, surgical technique, functional outcome, early and late complications and their management and results. Twenty-nine patients (8.6%) presented with pelvic sepsis. Twelve patients (3.5%) experienced late perianal fistulas. The pouch failure rate was 3.4%. Six patients required a re-do pouch procedure, with 75.9% preservation of sphincter function. No correlation was found between complication rates and diagnosis. The mean number of stools was 5.2/24 h. The study confirmed the safety and effectiveness of the procedure. In particular, morbidity rates are comparable to those of major abdominal procedures and the long-term functional results are satisfactory. However, a number of technical aspects, such as the anastomosis technique, the need for temporary ileostomy and the treatment of indeterminate colitis, still remain controversial.     

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.