低位直肠癌手术中使用双吻合器吻合口瘘的原因与处理

目的探讨低位直肠癌双吻合器吻合吻合口瘘发生的原因、预防及处理方法。方法回顾性分析我院2000年6月至2005年12月应用双吻合器进行Dixon术的86例病例的临床资料。结果12例发生吻合口瘘,7例经保守治疗治愈,5例手术治疗治愈。2例出现吻合口狭窄,排便不畅,经定期扩肛而治愈。结论吻合口瘘是低位直肠癌双吻合器前切除术后常见的并发症,小的瘘口可经保守治疗治愈,大的瘘口则需结肠造口以转流粪便,待瘘口封闭后再次手术还纳造口。     

直肠癌术后直肠阴道瘘的危险因素分析

目的 探讨直肠癌术后直肠阴道瘘的危险因素与临床对策.方法 回顾分析1997～2008年1123例女性直肠癌手术患者的临床资料,应用SPSS软件对数据进行统计处理,采用X2检验.结果 34例(3.03%,34/1123)术后出现直肠阴道瘘.直肠阴道瘘发生与患者有无绝经、肿瘤距肛缘的距离、肿瘤位于直肠壁的部位、吻合方式密切相关(P<0.05),而与患者年龄、肿瘤T分期、术前放疗、预防性造口等无明显相关.34例患者中12例经保守治疗后自愈,余22例患者均在瘘后3月局部炎症消退后行修补术,在修补直肠阴道瘘的同时行近端肠造口使粪便转流.结论 直肠癌术后直肠阴道瘘与患者有无绝经、肿瘤距肛缘的距离、肿瘤位于直肠壁的部位、吻合方式密切相关.熟悉其病因,加强围手术前准备,选择正确的手术时机和手术方式可降低直肠阴道瘘的发生率.     

直肠脱出技术在腹腔镜低位直肠前切除术中的应用

目的探讨直肠脱出技术在腹腔镜低位直肠前切除术中应用可行性与治疗效果。方法回顾性分析2005年10月至2007年3月上海微创外科临床医学中心为9例低位直肠肿瘤病人运用直肠脱出技术行腹腔镜低位直肠前切除术的临床资料，研究其手术操作、术后恢复、肿瘤根治性效果及随访结果。结果男6例，女3例，平均年龄58（40～75）岁。腺瘤2例，Ⅰ期病例6例，Ⅱ期1例。所有病例无术中严重并发症和手术死亡，无中转开腹手术；平均手术时间195（150～232）min、平均术中出血55（25～100）ml，病人术后排气时间、留置导尿管时间和术后住院天数分别为2（1～4）d，7（5—10）d和11（7～20）d。清扫淋巴结总数12（9～20）枚，肿瘤距下切缘距离为1．6（1．0～3．8）cm。无严重术后并发症。随访12（4—21）个月，无局部复发和远处转移，排便功能恢复较满意。结论直肠脱出技术运用于腹腔镜低位直肠前切除术安全有效，符合肿瘤根治原则，且能获得较满意的排便功能恢复。     

Rectovaginal fistula after low anterior resection for rectal cancer healed by nonoperative treatment

BackgroundRectovaginal fistula (RVF) is a serious complication after colorectal anastomosis using a double-stapling technique. RVF following this procedure has been considered to be refractory to conservative treatment.Case presentationA 75-year-old woman who underwent laparoscopy-assisted low anterior resection for early rectal cancer developed RVF on the 12th postoperative day. Conservative treatment was chosen and was successful. She was discharged from the hospital after 3 weeks with a normal oral diet. Colonoscopy on the 50th postoperative day showed that the RVF was closed.ConclusionConservative treatment may be effective for RVF after colorectal anastomosis using a double-stapling technique when there is no evidence of defecation through the vagina.     

Redo coloanal anastomosis for anastomotic leakage after low anterior resection for rectal cancer: an analysis of 59 cases

Aim

The construction of a new coloanal anastomosis (CAA) following anastomotic leakage after low anterior resection (LAR) is challenging. The available literature on this topic is scarce. The aim of this two‐centre study was to determine the clinical success and morbidity after redo CAA.

Method

This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short‐ and long‐term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow‐up.

Results

A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years (SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range (IQR) 8–27]. The median duration of follow‐up was 27 months (IQR 17–36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions (IQR 2–4) per patient. At the end of follow‐up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma (OR 0.022; 95% CI 0.004–0.122).

Conclusion

Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates.     

Functional outcome after low anterior resection for rectal cancer using the colonic J-pouch

The functional outcome after low anterior resection (LAR) using the colonic J-pouch was compared with that after LAR using straight anastomosis. Colonic J-pouch construction was performed in 58 patients who underwent resection of tumors located 5–10 cm from the anal verge (J-pouch group). Functional assessment was performed 1 year postoperatively. Clinical function was evaluated using a scoring system, while physiologic sphincter and reservoir function were evaluated by anorectal manometry. The historical control group consisted of 20 patients who underwent LAR with straight anastomoses (straight group). The functional score of the J-pouch group was significantly better than that of the straight group. Although sphincter function was similar in the two groups, reservoir function was significantly better in the J-pouch group than in the straight group. These results demonstrated that the functional outcome following LAR for rectal cancer is improved by the colonic J-pouch construction.     

An improved technique for low anterior resection using a PDS endoloop

We describe herein the results of performing a new technique of low anterior resection of the rectum using a PDS endoloop, on ten patients with rectal cancer. This technique involves first preparing the rectosigmoid colon with an anvil as in the conventional low anterior resection; then, after the stapler is inserted transanally, two endoloops are slid over the colon and rectum. The rectum is ligated by pushing the knot of the endoloop and a second knot is applied 2 cm proximal to the first. Finally, the rectum is cut and the stapler is closed and fired to make a circular end-to-end anastomosis. The level of the anastomosis ranged from 2.5 to 6 cm with a mean of 4.7 cm in the ten patients, only one of whom developed a minor anastomotic leakage postoperatively. Moreover, no patient has developed local recurrence or distant metastasis to date. In summary, this technique offers certain advantages that allow the operation to be done with more skill and safety in a narrow pelvis.     

Kumacone II: An adapter to aid in the placement of a purse-string suture in very low anterior rectal resection

We have designed an adapter called the Kumacone II, being a bottle-shaped rubber device which greatly aids in placing a purse-string suture, even at the lowest level near the anorectal junction of the rectum. When this adapter is used, performing the anastomosis is much less time-consuming and not as much training is needed as for low anterior resection using conventional manual suturing. In a clinical study, the incidence of leakage and incontinence was nil in five out of five patients.     

直肠癌前切除、结肠“J”型储袋对术后排便功能的影响

目的为探讨直肠癌行低位前切除术后应用结肠“J”型储袋行直肠或肛管吻合能否改善患者的排便功能。方法对2000年1月至2001年1月间连续行低位前切除术的72例中、下段直肠癌患者行回顾性分析。根据吻合方式分为两组：“J”型储袋组,共33例;直接吻合组,共37例。分别于术后1、3、6及12个月,对手术并发症及排便功能行比较性研究。结果发现两组均无手术死亡及术后出血病例。直吻组发生吻合口瘘2例;储袋组及直肠组术后吻合口狭窄分别为2例及1例;局部复发者各为3例;肝转移分别为2例及3例。“J”型储袋组较直接吻合组患者术后6个月及12个月之日排便次数及夜间排便人数比率均明显减少（7次vs3次,P〈0．05;3次VS1次,P〈0．05）,（64％VS31％,P〈0．05;30％VS3．9％,P〈0．05）。前者大便失禁综合评分显著优于后者（8VS2,P〈0．05;5．2VSL5,P〈0．05）。结论结果表明直肠癌行低位前切除术后,应用“J”型储袋行直肠或肛管吻合,不增加手术并发症,且在术后1年内,可以在某些方面改善患者排便功能。     

Survival and recurrence after low anterior resection and abdominoperineal resection for rectal cancer: The results of a long-term study with a review of the literature

Morbidity, survival, and recurrence in 203 patients treated with curative low anterior resection (LAR) were compared with those in 100 patients treated with curative abdominoperineal resection (APR). The overall 5-year survival figures for the total number of, LAR and APR patients were 75.6±5.7%, 79.8±6.4% and 67.7±9.6%, respectively. The prognosis for cancers situated low enough in the rectum to involve the anal canal was poor even when managed by APR, as evidenced by a low survival at 5 years of 59.0±9.6% and a high pelvic recurrence rate of 34%. For all except these tumors, LAR proved at least equal to, or better than APR as a curative surgical method for middle and low rectal cancers, on the basis of 5-year survival being 79.8±6.4% vs 78.7±5.2%, operative mortality being 1.5% vs 1.0%, morbidity being 39.4% vs 59.0%, and the incidence of pelvic recurrence being 8.9% vs 13.5%. When deciding upon the most appropriate surgical procedure for rectal cancer, especially for middle or low rectal lesions, the patient should not simply be condemned to a permanent colostomy. Thus, we first attempt LAR for every lesion except those which are very advanced or those with anal canal involvement, if technically feasible and suitable for the individual patient.     

Laparoscopic resection of high rectovaginal fistula with intracorporeal colorectal anastomosis and omentoplasty

A 46-year-old Caucasian female underwent vaginal hysterectomy for myoma in another hospital and developed a high rectovaginal fistula 6 weeks later. A diverting-loop colostomy of the sigmoid colon was performed 2 months later. The patient was admitted to our service with persistent high rectovaginal fistula 6 months later. We resected the sigmoid colon and two-thirds of the rectum including the fistula tract using laparoscopic techniques. An intracorporeal anastomosis was accomplished using a double-stapling technique. An omental flap was mobilized and placed between the colorectal anastomosis and the vagina. Except for a subcutaneous wound infection at the former colostomy site, the postoperative course was uneventful. The patient was discharged at the 7th postoperative day and remained free of symptoms. We conclude that laparoscopic resection of high rectovaginal fistula with primary intracorporeal anastomosis is feasible and should be considered in selected cases as an alternative ``minimal-invasive' approach to this disease. Received: 4 December 1995/Accepted: 23 March 1996     

Anorectal dysfunction following low anterior resection for rectal carcinoma: a comparison between handsewn and stapled anastomosis

Sphincter-saving resection for rectal carcinoma is frequently accompanied by anorectal dysfunction (increased stool frequency and varying degrees of faecal incontinence). Although numerous reports regarding this dysfunction have been published, the exact mechanism is still controversial. The purpose of the present study was to compare the functional results of low anterior resection (LAR) for rectal carcinoma following handsewn and stapled anastomosis. The patients with rectal carcinoma were divided into two groups: LAR with handsewn anastomosis (HS) ( n  = 15), and LAR with stapled EEA (U.S. Surgical Corporation) anastomosis (EEA) ( n  = 16; four with 28 mm stapler, 12 with 31 mm stapler). Sixteen patients with carcinoma of sigmoid colon who received high anterior resection (HAR) were taken as the control group. Anorectal functional study was performed preoperatively and post-operatively at 1 week and another after 6 months, whereas routine clinical assessment was carried out preoperatively and 6 months post-operatively. The post-operative maximal resting pressure was significantly reduced in both HS and EEA groups, while a tendency to recovery was observed in the HS and 28 mm stapler group 6 months later. A significant decrease in rectal capacity was noted in the EEA group. The return of rectoanal inhibitory reflex was observed in 67% of the HS group and 37.5% of the EEA group. Although clinically increased stool frequency was experienced in both HS and EEA groups, continence was significantly worse in the EEA group. LAR for rectal carcinoma results in impaired anorectal function, which might present clinically with increased stool frequency and minor faecal soiling. The former may be due partially to reduced neorectal capacity, while the latter may be due to internal anal sphincter dysfunction, possibly because of damage to innervation.     

低位直肠癌前切除术后吻合口瘘的原因及防治的研究

低位直肠癌行保肛手术,可以使患者的生活质量有很大的提高,但是术后吻合口瘘仍是其主要的并发症,其发生可导致围手术期病死率上升,住院时间延长,费用增加,给患者造成了极大的痛苦.本文就低位直肠癌术后吻合口瘘发生的原因及防治措施的研究现状做一综述.     

The impact of the anastomotic configuration on low anterior resection syndrome 3 years after total mesorectal excision for rectal cancer: a national cohort study

Aim

After low anterior resection, the bowel can be anastomosed in different ways. It is not clear which configuration is optimal from a functional and complication point of view. The primary aim was to investigate the impact of the anastomotic configuration on bowel function evaluated by the low anterior resection syndrome (LARS) score. Secondarily, the impact on postoperative complications was evaluated.

Method

All patients who had undergone low anterior resection from 2015 to 2017 were identified in the Swedish Colorectal Cancer Registry. Three years after surgery, patients were sent an extensive questionnaire and were analysed based on anastomotic configuration (‘J-pouch/side-to-end anastomosis’ or ‘straight anastomosis’). Inverse probability weighting by propensity score was used to adjust for confounding factors.

Results

Among 892 patients, 574 (64%) responded, of whom 494 patients were analysed. After weighting, the anastomotic configuration had no significant impact on the LARS score (J-pouch/side-to-end OR 1.05, 95% confidence interval [CI] 0.82–1.34). The J-pouch/side-to-end anastomosis was significantly associated with overall postoperative complications (OR 1.43, 95% CI 1.06–1.95). No significant difference was seen regarding surgical complications (OR 1.14, 95% CI 0.78–1.66).

Conclusion

This is the first study investigating the impact of the anastomotic configuration on long-term bowel function, evaluated by the LARS score, in an unselected national cohort. Our results suggested no benefit for J-pouch/side-to-end anastomosis on long-term bowel function and postoperative complication rates. The anastomotic strategy may be based upon the anatomical conditions of the patient and surgical preference.     

直肠癌术后低位前切除综合征的评估与治疗进展

目的了解目前直肠癌术后低位前切除综合征(LARS)的评估方法以及治疗进展。方法复习近年来关于直肠癌术后LARS相关研究的文献并加以综述。结果 LARS的发生机制与手术前肛门功能状态、手术中对肛门直肠周围神经、肌肉损伤以及新建直肠容积、顺应性等均有密切关系。针对LARS的症状群,临床现有主观、客观等多种评估办法,包括多种生活质量评分量表、大便失禁相关量表、LARS评分量表、肛管直肠测压、肛门括约肌影像学检查等手段。治疗包括经肛门灌洗、综合康复训练、骶神经刺激、中医疗法等多种治疗方法。结论术前、术中、术后多重因素影响LARS的发生,详尽的评估、规范的手术及治疗以及有效的患者教育都可以预防或减轻LARS,提升患者术后生活质量。