填塞手套并预置缝线法处理65例Miles术会阴部切口疗效观察

腹会阴联合直肠癌根治术（Miles术）会阴部伤口的处理通常采用会阴部皮肤拉拢直接缝合、     

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.     

直肠癌Miles术后会阴切口一期缝合引流方法的选择

目的:探讨直肠癌Miles术后会阴切口一期缝合不同引流方法对会阴部切口愈合的影响。方法:将近3年来收治的100例行直肠癌Miles术的患者随机分成对照组和观察组,每组50例。对照组在Miles术后会阴切口一期缝合仅行骶前负压管经腹部切口引流,会阴部未置引流;观察组则除在骶前间隙采用经腹部切口引流外,还在会阴部行单管负压引流。比较两组的引流量、引流时间、一期愈合率、创口感染率、残腔消失时间以及皮肤切口愈合时间。结果:观察组的引流量显著多于对照组,且引流时间显著短于对照组(均P<0.05);观察组的一期愈合率显著高于对照组,而创口感染率显著低于对照组(均P<0.05);观察组的残腔消失时间和皮肤切口愈合时间均显著短于对照组(均P<0.05)。结论:直肠癌Miles术后会阴切口一期缝合采用骶前间隙单管引流和会阴部单管负压引流的方法对会阴部切口愈合效果优于仅行髋前负压管经腹部切口引流的方法。     

Miles术后骶前持续灌洗预防会阴切口感染

作者自１９８５年以来，对１０６例直肠癌Ｍｉｌｅｓ术后采用骶前持续灌洗预防会阴切口感染。在术中无直肠或／和阴道破损的９２例中，会阴切口一期愈合者８９例（９６．７％）。术中有直肠或／和阴道破损的１４例中，会阴切口一期愈合１０例（７１．４％）。全组会阴切口的一期愈合口率为９３．３％。文中对目前处理会阴切口的几种方法进行了归纳和比较，产骶前持续灌洗在预防会阴切口感染中的作用进行了讨论。     

直肠癌Miles术后会阴部不同引流方式效果比较

目的探讨直肠癌Miles术后会阴部切口I期缝合后不同引流方式对切口愈合的影响。方法将90例接受直肠癌Miles手术的患者随机分为观察组(n=46)和对照组(n=44)。均I期缝合会阴部切口,观察组使用骶前间隙经左下腹引出接负压引流,同时会阴部进行单管负压引流。而对照组仅行骶前间隙经左下腹引出负压引流。比较2组日均引流量、拔管时间、切口感染率、切口愈合时间及手术至出院时间。结果观察组日均引流量多于对照组,切口感染率低于对照组,拔管时间、皮肤愈合时间及出院时间均明显短于对照组(P0.05)。结论直肠癌Miles术后双管负压引流较单管更利于会阴部切口愈合。     

低位直肠癌腹会阴联合切除术后会阴切口愈合延迟危险因素分析

目的 探讨低位直肠癌腹会阴联合切除(APR)术后会阴切口愈合延迟的危险因素.方法 2008年7月～2020年6月行APR的低位直肠癌病人172例,根据术后会阴切口愈合情况,将其分为切口愈合延迟组(42例)和切口正常愈合组(130例).对两组性别、年龄、体质量指数(BMI)、糖尿病、美国麻醉医师协会评分、术前血红蛋白、术...     

直肠癌Miles术后会阴部复发的诊治

目的:探讨直肠癌Miles手术后会阴部复发的合理治疗方法。方法:回顾性分析行直肠癌Miles手术86例,其中术后复发16例。将16例为A、B二组(各8例),A组手术切除,B组以手术为主联合放化疗,对其治疗及疗效进行分析。结果:再复发率A组75％,B组12.5％,平均手术时间A组3.6h,B组1.2h;平均出血量A组960ml,B组60ml,并发症发生率A组高于B组(均P<0.01)。结论:鉴于再复发率、手术时间、出血量、并发症发生率,A、B二组间有显著性差异,我们认为;直肠癌行Miles术后会阴部复发,B组治疗方式优于A组。     

经腹会阴联合直肠切除术后会阴切口处理的随机对照研究

目的 对比研究经腹会阴联合直肠切除术(Miles术)后骶前腔隙的自然引流或持续灌洗对会阴切口愈合的影响.方法 对2004年10月至2009年8月实施Miles术的74例患者进行前瞻性研究,术后3 d将患者随机分为骶前持续灌洗组和骶前自然引流组,观察比较两组患者会阴部切口感染、积液、延迟愈合等情况.将会阴切口愈合情况分为甲级、乙级和丙级愈合三种.结果 共74例患者纳入本研究.随机入组持续灌洗组37例(含术前放疗12例),入组自然引流组37例(含术前放疗10例).持续灌洗组会阴切口出现丙级愈合2例,乙级愈合3例,甲级愈合32例;自然引流组则分别为8例,3例,26例;两组间丙级愈合率差异有统计学意义(5.4%比21.6%,P=0.042).本研究中行术前放疗者22例,3例会阴切口丙级愈合,4例乙级愈合,15例甲级愈合;直接手术患者52例,7例会阴切口丙级愈合,2例乙级愈合,43例甲级愈合,两组间乙级愈合率差异有统计学意义(18.2%比3.9%,P=0.039).结论 持续骶前灌洗明显改善经腹会阴联合直肠切除术后会阴切口的愈合情况,术前50 Gy的长程放疗可明显提高会阴切口乙级愈合的比例.     

新辅助治疗对低位直肠癌患者经腹会阴联合直肠切除术后会阴切口愈合的影响

目的探讨新辅助治疗对于低位直肠癌经腹会阴联合直肠切除术（APR）后会阴切口愈合的影响。方法回顾性分析北京协和医院基本外科2005年1月至2009年1月实施APR术的93例直肠癌患者的临床资料．其中29例行术前新辅助治疗（新辅助治疗组）．64例直接手术（直接手术组）。将会阴伤口愈合情况分为甲、乙、丙级。对比观察两组患者会阴切口愈合情况。结果新辅助治疗组29例术前行局部放疗（50Gv,25次／5周）并同步联合化疗,采用FOLFOX4方案（氟尿嘧啶、奥沙利铂）;APR术后会阴伤口甲级愈合18例（62．1％）,乙级愈合6例（20．7％）,丙级愈合5例（17．2％）：直接手术组会阴伤口甲级愈合41例（64．1％）,乙级愈合15例（23．4％）,丙级愈合8例（12．5％）;两组间伤口感染（丙级愈合）发生率差异无统计学意义（P=0．773）。结论术前新辅助治疗尤其是50Gv的长程放疗不增加APR术后会阴伤口的感染发生率。     

封闭式高压负压吸引对直肠肿瘤腹会阴联合切除会阴切口愈合的促进作用

目的探讨封闭式高压负压吸引对直肠肿瘤腹会阴联合切除术（APR）后会阴切口一期愈合的影响。方法按随机数字表法．将2009年1月至2011年1月间武汉同济医院胃肠外科中心收治并行APR手术的120例直肠肿瘤患者．随机分为试验组（61例,行封闭式高压负压吸引）和对照组（59例,行骶前引流）。比较两组术后会阴切口引流量、一期愈合率及愈合时间。结果试验组和对照组术后前3d会阴切口引流量分别为（448．1±142．9）ml和（548．3±190．6）ml,第3天引流量分别为（28．1±12．7）ml和（125．9±84．3）ml,一期愈合率分别为93．4％（57／61）和74．6％（44／59）,愈合时间分别为（13．5±3．5）d和（20．1±5．1）d,差异均有统计学意义（均P〈0．01）。结论封闭式高压负压吸引能促进APR手术后会阴切口的一期愈合。     

Risk factors for impaired healing of the perineal wound after abdominoperineal resection of rectum for carcinoma

OBJECTIVE: Nonhealing perineal wound is an unpleasant complication of surgical excision of the rectum and anus. The aim of the study was to evaluate the risk factors for impaired perineal wound healing after abdominoperineal resection (APR) of rectum for adenocarcinoma, particularly with the increasing use of neo-adjuvant chemoradiation. METHOD: The study included 38 consecutive patients (29 men, nine women; median age 66 years, range: 43-86), who underwent surgical excision of rectum and anus for adenocarcinoma from 1999 to 2004. Thirty-seven patients underwent APR of rectum and one patient, who developed carcinoma in the background of chronic ulcerative colitis, had panproctocolectomy. Associations between the failure of the perineal wound to heal and a number of patient, tumour and treatment-related variables were evaluated by Pearson chi-square test or Fisher's exact test, as appropriate. A P-value of <0.05 was considered significant. Multivariate statistical technique of principal component analysis was also used to identify risk factors and their relative contribution to impaired healing. RESULTS: Impaired healing of the perineal wound was observed in 10 (26%) of 38 patients. In four of them (11%) the wound remained nonhealed in 1 year after surgery. Preoperative radiotherapy, delayed primary closure of the wound and alcohol consumption in excess of 28 units/week was statistically significantly associated with impaired wound healing. Principal component analysis identified the following seven factors that cumulatively contributed to 96% of impaired healing: (i) distant metastases, (ii) preoperative radiotherapy, (iii) T-stage of the tumour, (iv) smoking, (v) perioperative blood transfusion, (vi) preoperative chemotherapy and (vii) development of side effects of preoperative chemoradiation. CONCLUSION: Patients who undergo APR of rectum are prone to impaired healing of the perineal wound if radiotherapy is used to treat malignancy prior to surgery and wound closure is delayed. In addition, the wound may not heal in patients with distant metastases, excessive alcohol consumption, present and past smokers and those who suffer adverse effects of preoperative chemoradiation and require blood transfusion.     

Long-term comorbidity of diabetes mellitus is a risk factor for perineal wound complications after an abdominoperineal resection

Background  This report is an attempt to clarify the effect of diabetes mellitus on perineal wound complications including infectious entities and delayed wound healing after abdominoperineal resection and also tried to show the risk factors for perineal wound complications. Material and methods  The data of 80 patients who underwent an abdominoperineal resection were reviewed from April 1996 to March 2006. Results  The rate of perineal wound complications is higher in diabetics (67%) than in nondiabetics (18%, p = 0.005). In a multivariate analysis, diabetes mellitus and operation time (≥420 min) were the risk factors for perineal wound complications (p = 0.040, p = 0.027, respectively). Infectious perineal wound complication was associated with diabetes mellitus (p < 0.001) but not with the operation time (p = 0.097). Furthermore, a longer comorbid duration of diabetes (≥10 years) was a significant predictor for perineal wound complications (p = 0.008). Conclusion  This study demonstrated diabetes mellitus to be independently associated with perineal wound complications, and when the patients have diabetes mellitus, especially with a longer comorbid duration and longer operation time, the clinical path should be changed to reduce perineal wound complications.     

低位直肠癌行腹腔镜腹会阴联合切除术临床分析

目的探讨腹腔镜直肠癌腹会阴联合切除术手术方法、技巧及临床应用价值。方法回顾性分析2003年7月至2010年6月30例行腹腔镜直肠癌腹会阴联合切除术（Miles术）患者（腹腔镜组）的围手术期情况,并按年龄、性别、肿块下缘距肛门距离、Dukes分期等匹配条件从同期开腹直肠癌手术（Miles术）中抽取30例（开腹组）作为参照,并对两组肿瘤手术情况、术后恢复情况、并发症发生率、随访结果等进行分析比较。结果腹腔镜组手术时间略多于开腹组,两组术中平均出血量、肠道功能恢复时间比较,差异有统计学意义（P〈0.005）。两组肠段切除长度、清扫淋巴结数目、术后并发症发生率、局部复发率比较,差异无统计学意义。腹腔镜组除1例中转开腹手术外,其余29例均在腹腔镜下完成手术,手术时间平均（185±30）min,术中出血量平均（80.0±30.5）ml,术后肠蠕动恢复时间平均为（30±10）h。1例术后并发肠梗阻,1例并发造瘘口肠管缺血坏死,无死亡病例。结论低位直肠癌更加适合在腹腔镜下进行手术切除,视野暴露充分,安全可靠,出血量少,肠道功能恢复快,具备操作安全、精细,术后恢复快的优点。     

腹腔镜腹会阴联合切除术治疗低位直肠癌疗效评价

目的前瞻性评估腹腔镜直肠癌腹会阴联合切除术的临床优劣性。方法将2003年7月至2006年4月收治的低位直肠癌患者随机分为两组，37例行腹腔镜腹会阴联合切除术（腹腔镜组），另37例常规开腹行腹会阴联合切除术（开腹组）；比较两组的手术时间、清除淋巴结数目和腹部出血量、术后排气时间、起床活动时间、住院时间、并发症发生率和复发转移率及卫生经济学情况。结果腹腔镜全组患者均顺利完成手术，无中转开腹者；手术时间两组比较差异无统计学意义（P〉0．05），但前10例手术时间比开腹组长（P〈0．01）；腹部出血量少于开腹组（P〈0．01）．但前10例较开腹组多（P〈0．01）；术后肛门排气时间两组差异无统计学意义（P〉0．05）；起床活动时间腹腔镜组早于开腹组（P〈0．01）；住院时间长短两组无差异，但腹腔镜会阴闭合较开腹组早：腹腔镜组腹部创口相关并发症明显少于开腹组（P〈O．05）；两组的清除淋巴结枚数、局部复发及远处早期复发率差异无统计学意义（P〉0．05）；手术费用腹腔镜组明显高于开腹组，但医疗总费用两组差异无统计学意义（P〉0．05）。结论腹腔镜直肠癌腹会阴联合切除术不仅创口小、术中出血少、与腹部创口相关并发症少、术后恢复快，且其手术时间、医疗总费用和肿瘤根治性与开腹手术无差异。     

腹腔镜下腹-会阴联合直肠癌切除术(附9例长期随访报告)

目的 探讨腹腔镜下腹--会阴联合直肠癌切除术的围手术期过程、肿瘤状态与预后。方法 对腹腔镜下腹--会阴联合直肠癌切除术后5年以上(1993年12月—1996年2月)的9例患进行回顾性随访。结果随访时间中位数80m(40m-90m)。患年龄中位数50岁(30岁—67岁)。腹腔镜下完成腹部操作8例，小切口辅助下完成腹部操作l例，均进行了标准的根治性切除。手术时间中位数6h(4．5h—7．5h)。术中、后发生并发症4例，其中皮下气肿、尿潞留l例，髂静脉损伤l例，下肢深静脉血栓形成、造瘘口部分粘膜坏死l例，会阴部伤口感染l例。术后标本检测淋巴结数目的中位数为13个(4个—25个)。6例存活，3例死亡，5年生存率为77．8％。结论腹腔镜下腹--会阴联合直肠癌切除术安全可行，能够满足开腹手术所要求的肿瘤切除原则。     

Ileal strangulation by a secondary perineal hernia after laparoscopic abdominoperineal rectal resection: A case report

IntroducitonWe report a recent case of strangulated bowel obstruction due to an incarcerated secondary perineal hernia that developed after laparoscopic rectal resection.Presentation of caseA 75-year-old man undergoing treatment for alcoholic cirrhosis underwent laparoscopic abdominoperineal resection of the rectum (APR) for lower rectal cancer after preoperative chemoradiotherapy. Lung metastases were diagnosed 2 months postoperatively. Ten days after chemotherapy initiation, the patient was hospitalized on an emergency basis due to hepatic encephalopathy. Ten days thereafter, we observed perineal skin protrusion. Moreover, the skin disintegrated spontaneously, resulting in ascetic fluid outflow. Pain and fever developed, with inflammatory reactions. Contrast-enhanced computed tomography showed strangulated small bowel obstruction due to perineal hernia. We performed an emergency surgery, during which we found small intestine wall incarcerated in the pelvic dead space, with thickening and edema; no necrosis or perforation was observed. We performed internal fixation by introducing an ileus tube into the ileocecum and fixing its balloon at the cecal terminus.DiscussionSecondary perineal hernia is rare and can develop after APR. Its prevalence is likely to increase in future because of the increasing ubiquity of laparoscopic APR, in which no repair of peritoneal stretching to the pelvic floor is performed. However, only two case of secondary perineal hernia causing strangulated bowel obstruction has been reported in the literature. The follow-up evaluation of our procedures and future accumulation of cases will be important in raising awareness of this clinical entity.ConclusionWe suggest that the pelvic floor and the peritoneum should be repaired.