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。     

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.     

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。     

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目的 探讨溃疡性结肠炎及其并发症的治疗方式。方法 回顾性分析108例溃疡性结肠炎病人的临床资料。结果 轻、中型溃疡性结肠炎采用药物保留灌肠和口服药物治疗,缓解率达88.9%,但73.1%的病例呈周期性发作,并发症的治疗包括;息肉电凝摘除。结肠大部分切除,回肠造口,全结肠直肠切除,回肠造口,全结肠直肠切除,回肠贮袋肛管吻合（IPAA）等术式,全组病例无严重并发症和死亡,效果良好。结论 轻、中型溃疡性结肠炎应以药治疗为主,其并发症的治疗应采用外科治疗。全结肠切除,回肠造口术及结肠大部分切除。回肠造口术仍为较安全的手术方式,但亦给病人带来生活上的不便。故保肛手术应受推崇。     

全毕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 1 994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 2 0例 ,取得了满意效果。现就将手术配合体会介绍如下。1　临床资料　　本组 2 0例病人。男 1 8例、女 2例。年龄 1 5～61岁 ,平均年龄 32 .5岁。其中家庭性息肉…     

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结直肠切除术(proctocolectomy)指切除全部的结肠以及直肠或直肠黏膜，行末端回肠造口或回肠肛管吻合术。主要用于累及整个大肠而又需要手术处理的病变，如溃疡性结肠炎、大肠家族性息肉病、克罗恩病、多源发大肠癌、先天性巨结肠等。结直肠切除术后消化道重建有多种方式，如末端回肠造口术、可控性回肠造口术、回肠肛管直接吻合术以及回肠贮袋肛管吻合术等。     

13例溃疡性结肠炎外科治疗的体会

目的探讨溃疡性结肠炎的外科治疗方法。方法对13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13例患者中,6例全结直肠切除、回肠贮袋肛管吻合术（IPAA）,4例全结直肠切除、回肠肛管吻合术,3例全结直肠切除术、回肠造瘘术。结论积极早期的手术治疗能够根除疾病并消除癌变可能,IPAA是目前UC择期手术的患者较好的手术方式。     

1005例回肠袋肛管吻合术后的并发症和功能分析

自1978年以来,溃疡性结肠炎和家族性腺瘤性息肉病已用直肠全结肠切除和回肠袋肛管吻合(IPAA)治疗,其回肠装有两肠襻(J)、三肠襻(S)或四肠襻(W)型之分,而以1型回肠袋最为常用.近期对手术已作了改进,在某些病例省略了暂时性回肠造口术,缩短了住院日期.IPAA术后肛管排便功能如何和回肠袋有什么并发症,均是临床上关注的问题.美俄亥俄州Cleveland临床基金会肛肠外科自1983～1993年共施行直肠全结肠切除和IPAA手术1005例,其中455例为女性.术前诊断为溃疡性结肠炎858例(854%)、家族性腺瘤性息肉病62例(6.2%)、病因尚未确定的结肠炎75例(7.5%),其余有TNM2期结肠直肠癌4例、幼年型息肉瘤4例以及结肠直肠多发性海绵状血管瘤和巨结肠各1例.平均随访35个月(1～125个月).术后病理学诊断确定术前诊断的46例溃疡性结肠炎和21例诊断未定的病例均为克隆病.分析手术指征计内科治疗失败422例、组织发育不良104例、癌肿23例、中毒症21例、出血29例、失禁或便急40例、预防癌变18例、结肠直肠狭窄11例和便秘1例.另296例在完全切除了直肠后仍有结肠病变.349例原已施行各种结肠等手术,如结肠切除和回肠直肠吻合术,部分结肠切除和回肠造口术(达280例)、结肠直肠切除和回肠造口术、直接回肠肛管吻合和IPAA吻合术等.     

203例直肠结肠切除后回肠贮袋肛管吻合术

直肠结肠切除回肠贮袋肛管吻合术(IPAA）现普遍被用来治疗溃疡性结肠炎和家族性腺瘤性息肉,从而代替全结肠直肠切除回肠造瘘。由于并发症发生率高和功能方面的问题．限制了一些外科医生的使用,且各种贮袋结构的潜在优点仍有争议,本对手术经验,尤其是手术并发症进行了总结,并比较不同贮袋结构的功能。     

203例直肠结肠切除后回肠贮袋肛管吻合术

直肠结肠切除回肠贮袋肛管吻合术(IPAA)现普遍被用来治疗溃疡性结肠炎和家族性腺瘤性息肉,从而代替全结肠直肠切除回肠造瘘.由于并发症发生率高和功能方面的问题,限制了一些外科医生的使用,且各种贮袋结构的潜在优点仍有争议.本文对手术经验,尤其是手术并发症进行了总结,并比较不同贮袋结构的功能.     

Surgical treatment in ulcerative rectocolitis . Analysis of a 24 years experience of 50 patients

Ulcerative colitis (UC) is an inflammatory bowel disease that may be cured by surgery being indicated for emergency situations resulting from complications of fulminant disease and for elective indications. We analyzed the last 24 years experience regarding 50 patients surgically treated for ulcerative colitis in the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute. The indications for surgery were: failure of medical treatment in 22 patients, acute disease with complications in 20, chronic complications in 8 cases. We used the following surgical procedures: total proctocolectomy in all 2 cases with associated rectal cancer, total colectomy with ileo-rectal anastomosis (one staged or two staged procedures) in 31, and restorative proctocolectomy in 17 cases (in all cases as a 2 or 3 staged procedure). In acute disease with complications we have performed total colectomy with terminal ileostomy, closure of the rectal stump, or exteriorization of the sigmoid stump in a mucous fistula. The gravity of acute complications does not justify the use of palliative procedures such as ileostomy, colostomy or Hartmann procedure because the mortality rate of these operations is higher than the postoperative mortality rate of total colectomy performed in emergency. Even in the elective surgery, when the patients are in a poor condition, nutritionally depleted, taking large doses of steroids or immunosuppressive drugs, we prefer the staged procedure. Total proctocolectomy is performed only in the cases of ulcerative colitis associated with rectal cancer, severe perianal disease, sphincter incontinence. Total colectomy with ileo-rectal anastomosis is indicated when the rectal stump has minimal inflammatory lesions. Restorative proctocolectomy is the surgery of choice for UC, the functional results being comparable with those of total colectomy with ileo-rectal anastomosis, but having the advantage of curing the disease. The global mortality rate was 12% (6 patients).     

Surgical treatment of hemorrhagic proctocolitis]

Surgical treatment of chronic ulcerative colitis requires restorative proctocolectomy with ilial pouch-anal anastomosis to remove all the disease bowel and provide cure. A one-stage or two-stage procedure can be performed after subtotal colectomy with ileostomy and colostomy. Restorative proctocolectomy is not advised for very old patients or patients with anal sphincter insufficiency. In such cases, total colectomy with ileo-rectal anastomosis is proposed. The rectal stump must be examined regularly by rectoscopy because of the risk of cancer. A proctocolectomy with definitive ileostomy is proposed after pouch-anal excision for pelvic septic complications (5% of ileal pouch-anal anastomoses). Surgical treatment of chronic ulcerative colitis is indicated when medical treatment fails, at onset of fulminant acute colitis, or because of colorectal dysplasia.     

重症溃疡性结肠炎手术治疗分析

目的 评价不同手术方式治疗重症溃疡性结肠炎（UC）的治疗效果.方法 收集1996年1月至2008年12月间华西医院收治的29例重症UC手术病例的临床资料,除2例部分结肠切除外,其余27例按不同的切除方式分为全结肠切除（TC组,7例）和全结直肠切除（TPC组,20例）;按不同的吻合方式分为回肠储袋肛管吻合（IPAA组,8例）、回肠直肠（IRA）或同肠肛管（IAA）吻合（直接吻合组,14例）和回肠造口（造口组,5例）.采用CGQL量表法进行术后生活质量（QOL）评估.结果 TPC组和TC组术后并发症的发生率分别为60.0%和57.1%,差异无统计学意义（P＞0.05）;复发率分别为15.0%和57.1%,差异有统计学意义（P＜0.05）.IPAA组和直接吻合组术后并发症的发生率分别为6/8和50.0%,差异无统计学意义（P＞0.05）;术后1年排便次数分别为（5.6±1.7）次/d和（9.1±2.9）次/d,差异有统计学意义（P＜0.05）;两组术后QOL均较术前明显改善（P＜0.01）,但两组之间差异并无统计学意义（P＞0.05）.结论 TPC-IPAA是目前治疗重症UC较为理想的手术方式;TC-IRA则是对有生育要求患者的首选术式,但术后需严格内镜随访、监测复发及恶变情况.     

炎性肠病45例手术治疗及疗效评价

目的 探讨炎性肠病的手术治疗方法 及疗效评估.方法 回顾性分析近6年经外科手术治疗的45例炎性肠病患者的临床资料.结果 急诊手术16例,Crohn病9例,溃疡性结肠炎(UC)7例.择期手术29例,Crohn病4例,UC 25例.其中13例Crohn病患者行小肠部分切除6例,内瘘者行小肠及结肠部分切除、吻合术1例,回肠穿...     

腹腔镜手术治疗溃疡性结直肠炎

目的探讨腹腔镜手术治疗溃疡性结直肠炎的可行性和安全性。方法对腹腔镜手术治疗溃疡性结直肠炎5例患者的临床资料进行回顾性分析。结果5例均在腹腔镜下完成手术,其中4例行全结-直肠切除,回肠储袋-肛管吻合术(total proctocolectomy and ileal pouch-anal anastomosis,IPAA),1例行结肠次全-全直肠切除,盲肠-肛管吻合术。中位手术时间7.5(6.5～9)h,中位出血量250(150～400)mL,中位术后进半流食时间62(60～86)h,中位术后住院时间12(10～14)d。术后发生盆腔感染1例,粘连性肠梗阻1例。随访中位时间22(10～34)个月,大便平均每天6.5(4～10)次。日常生活自理,工作正常,无复发。结论腹腔镜下溃疡性结直肠炎手术,创伤小,恢复快,安全可靠,但尚需进一步积累临床资料。     

Laparoscopic total proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis: initial experience in Mexico

Background Since the introduction of laparoscopic colectomy in 1991, experience in laparoscopic bowel surgery has gradually increased. Several reports from specialized centers have demonstrated that laparoscopic colorectal resections are feasible and safe, providing an acceptable alternative to laparotomy for a variety of diseases. Some studies have shown the feasibility, safety, and good functional outcome of the minimally invasive procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). No known studies have investigated laparoscopic proctocolectomy in México. This report aims to describe the first laparoscopic proctocolectomies with ileal pouch anal anastomosis (IPAA) performed at the Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubirán (INCMNSZ). Methods All the patients in the authors’ institution who underwent a one- or two-stage laparoscopic total proctocolectomy with IPAA between June 2005 and December 2006 were included in the study. All the operations were performed by the same surgeon, who had already completed the learning curve for colorectal laparoscopic procedures. Results For the study, 10 patients underwent a laparoscopic proctocolectomy with IPAA by a single surgeon. Eight of the patients underwent a one-stage procedure, whereas two patients with severe colitis underwent a two-step procedure. All the cases were managed with a diverting loop ileostomy. Six patients underwent a standard double-stapled IPAA anastomosis, and two patients with FAP underwent a mucosectomy with a manual IPAA anastomosis. The mean operative time was 187 min, and the mean blood loss was 46 ml. There were two postoperative complications. One patient presented with an early small bowel obstruction due to an internal hernia, which required reoperation. The other complication was a wound infection. The mean return to oral intake was 1.5 days, and the mean length of hospital stay was 3.4 days. Conclusion Although this was not a comparative study and although sample size imposed limitations, with this preliminary data, we conclude that the laparoscopic approach to UC and FAP at our institution is safe, feasible, and effective. However, to achieve the benefits in postoperative outcome, this procedure should be performed only by experienced laparoscopic surgeons.     

Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses

INTRODUCTION

Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch.

PRESENTATION OF CASE

A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done.

DISCUSSION

The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients.

CONCLUSION

The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.     

Emergency total proctocolectomy in an uninsured patient with Familial Adenomatous Polyposis Syndrome and acute lower gastrointestinal hemorrhage in a community hospital: A case report

IntroductionRectal bleeding is the most common symptom of Familial Adenomatous Polyposis (FAP). This case investigates the efficacy of emergency surgery for FAP with total proctocolectomy end ileostomy for recurrent lower gastrointestinal (GI) hemorrhage in an uninsured patient in a 266-bed community hospital. The optimal treatment for FAP with acute lower GI hemorrhage and hemodynamic compromise unresponsive to conservative management is unclear.Presentation of caseA 41-year-old uninsured African American man with no past medical or family history presented to the emergency department with hematochezia lasting three days. A clinical diagnosis of FAP made on colonoscopy with biopsies revealed villous and tubulovillous adenomas without dysplasia. After blood products resuscitation, an emergency total proctocolectomy with end ileostomy was performed. A staged ileal J pouch to anal anastomosis and creation of protective loop ileostomy was performed months later after securing state funding. A final loop ileostomy reversal occurred six weeks later. His self reported quality of life is improved.DiscussionLower GI hemorrhage from FAP unresponsive to blood products may require emergency total proctocolectomy and end ileostomy with a staged ileal J pouch to anal anastomosis, which can be done in a community acute care hospital for an uninsured patient.ConclusionA total proctocolectomy is feasible in the emergency setting in an uninsured patient with lower GI bleeding and FAP. A staged ileal J pouch-anal anastomosis is easier to justify to the hospital compared to a staged completion colectomy with proctectomy. It is essential to monitor the ileo-anal anastomosis with anoscopy.     

Changes in Intestinal Transit Time after Proctocolectomy Assessed by the Lactulose Breath Test

After proctocolectomy with ileal pouch-anal anastomosis (IPAA) patients have increased stool frequency and intermittently use antidiarrheal medication. In addition to other factors, gastrointestinal transit time (MTT) could influence stool frequency. The aim of this study was to investigate how MTT changes after IPAA and to study whether MTT has an influence on daily stool frequency. In a prospective trial MTT was investigated with the lactulose breath test in 12 patients undergoing surgery for chronic ulcerative colitis (CUC) or familial adenomatous polyposis coli (FAPC) at different stages: before proctocolectomy, after IPAA with loop ileostomy, and 3 months and 1 year after ileostomy closure. MTT was also measured in 12 patients with IPAA, 12 patients with subtotal colectomy and ileorectal anastomosis (IRA), and 8 patients with conventional proctocolectomy and Brooke ileostomy (CPC) several years after surgery. Twelve healthy volunteers served as controls. Before IPAA, MTT was prolonged in CUC versus FAPC and controls. After restoration of gut continuity MTT was markedly accelerated. After 1 year MTT was slowed again, though values before proctocolectomy and those in controls were not reached. Several years after surgery MTT was significantly prolonged in IPAA and IRA versus controls. In CPC, MTT could not be determined by lactulose breath test. Stool frequency showed an inverse correlation to MTT in IPAA. In conclusion, this study shows that orocecal and oropouch transit are accelerated in the early postoperative period after (procto)colectomy but prolonged in the long-term course. Adaptation of the small bowel takes longer than 1 year. Impairment of stool frequency may be partly due to this adaptation.