经肛门耻骨直肠肌部分切断术治疗耻骨直肠肌肥厚型便秘28例

2000年3月-2004年4月,我们采用经肛门耻骨直肠肌部分切断术治疗耻骨直肠肌肥厚型便秘28例,疗效满意,现报告如下.     

结肠部分切除治疗冗长结肠208例疗效观察

采用结肠部分切除，缩短肠内容物在大肠内的通过及停留时间，恢复肠道正常生理功能，治疗冗长结肠２０８例，治愈率９３．８％，总有效率９８．６％。结果证明，该方法术式简单、安全，疗效可靠，易于操作，恢复快，患者乐于接受。     

腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术治疗成人完全性直肠脱垂的疗效

目的探讨腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术治疗成人完全性直肠脱垂的疗效。方法对2010年5月至2013年5月期间笔者所在医院科室收治的32例成人完全性直肠脱垂患者行腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术,总结手术疗效。结果32例患者的手术过程均顺利,无一例中转开腹手术。平均手术时间为114．7min（95～167min）,平均术中出血量为80mL（55～150mL）,术后平均住院时间为9．8d（6～14d）,均全部治愈出院。术后32例患者获访3个月～4年（平均25．6个月）,均无脱垂症状,肛门功能恢复良好,无术后并发症及复发。结论腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术治疗成人完全性直肠脱垂的疗效良好,具有创伤小、恢复快、复发率低等优点,是一种具有较高临床应用价值的术式。     

低位直肠肌层内拖出术治疗先天性巨结肠的评价

Ｓｗｅｎｓｏｎ和Ｂｉｌｌ在 194 8年首先报道了经肛门拖出术治疗本病。196 4年 ,Ｓｏａｖｅ报道了直肠内拖出术 ,后来Ｂｏｌｅｙ对此手术方法进行了改进 ,成为现在临床常用的Ｓｏａｖｅ术 ,但仍存在某些情况下直肠粘膜剥离困难 ,保留过多肌套可能会出现某些机能障碍。1992年以来 ,我们针对这些问题改进手术方法 ,缩短了保留的肌套 ,同时也减少了术中出血 ,缩短了手术时间 ,并取得了初步满意的效果。临床资料1.一般资料 :1992年以来我们共收治先天性巨结肠4 6例 ,男 2 8例 ,女 18例 ;年龄 7ｄ～ 8岁 ,其中小于 1个月的17例 ,4岁以上的 4例。…     

经会阴直肠乙状结肠部分切除术联合肛门环缩术治疗老年直肠脱垂16例

长期的直肠脱垂会导致会阴部神经损伤,产生肛门失禁,甚至狭窄和坏死的危险,外科手术为其主要手术方式,但疗效不佳。老年人由于其特殊的生理条件,传统的经腹手术患者很难耐受。会阴直肠乙状结肠部分切除术（Altemeie术）为经会阴切除直肠全层和部分乙状结肠,再经肛手工缝合或用吻合器行结肠肛管吻合术,由Mikulicz在1889年首次报道。本研究回顾性分析自2010年4月至2013年1月6家医院的16例行Altmeier术联合肛门环缩术的60岁以上老年直肠脱垂患者临床资料,探讨该术式在老年直肠脱垂患者治疗中的疗效。     

耻骨直肠肌部分松解术治疗耻骨直肠肌综合征62例

为探讨耻骨直肠肌部分松解术治疗耻骨直肠肌综合征所致便秘的临床疗效,对62例经症状、体征及相关检查确诊为耻骨直肠肌综合征所致便秘患者采用耻骨直肠肌部分松解术治疗,观察治疗后临床疗效及随访3个月疗效。结果显示,62例患者治疗后总有效率为96．7％,随访3个月疗效为95．2％。结果表明,耻骨直肠肌部分松解术治疗耻骨直肠肌综合征所致便秘安全有效。     

腹腔镜直肠乙状结肠部分切除联合直肠前突缝合 术治疗重度出口梗阻型便秘的临床效果

目的:评价腹腔镜直肠乙状结肠部分切除联合直肠前突缝合术治疗重度出口梗阻型便秘的临床效果。方法:将2014年1月至2018年3月120例确诊为重度出口梗阻型便秘的患者分为两组,实验组(n=60)行腹腔镜直肠乙状结肠部分切除联合直肠前突纵行柱状缝合术,对照组(n=60)行吻合器痔上黏膜环切术联合直肠前突纵行柱状缝合术,分析围手术期数据及手术疗效。结果:实验组患者均顺利完成手术,术中、术后无严重并发症发生,手术时间[(100.5±27.2)min vs.(52.4±18.3)min]、术后住院时间[(6.4±1.1)d vs.(2.4±0.7)d]长于对照组(P0.05),术后排气时间、围手术期并发症两组差异无统计学意义(P0.05)。随访1年,对照组患者术后出现肛门下坠感及吻合口狭窄的趋势更明显,实验组Wexner评分[(4.5±1.6) vs.(7.2±2.1),P0.05]低于对照组,便秘改善优于对照组。结论:腹腔镜直肠乙状结肠部分切除联合直肠前突纵行柱状缝合术治疗重度出口梗阻型便秘安全、可靠,效果良好,值得临床推广。     

结肠切除治疗慢传输型便秘疗效回顾与分析

报告30例结肠慢传输型便秘，其中结肠部分切除9例，次全切除19例。全结肠切除2例。术前均经传输试验、钡灌肠造影以及排粪造影证实结肠慢传输，并排除其它原因的便秘。结肠部分切除远期复发5例，复发率55％，次全结肠切除无复发。术后一年内腹痛，腹胀7例，长期大便不成形，日排便6次以上1例。远期疗效：结肠部分切除，术后并发症少，恢复快，症状在第一次排便后消失，但部分病例在1－2年后大便次数减少而再复发，但间隔时间及痛苦均轻于术前。5例再手术。次全切除或全切除远期疗效可靠，因腹腔创伤面大，以及术后水分吸收功能降低，近期肠粘连等并发症及大便次数多将不可避免。次全切除疗效满意，并发症少，优于部分切除或全切除（回直吻合）。     

改良耻直肌松解术治疗耻骨直肠肌肥厚性便秘：附56例报告

耻骨直肠肌肥厚性便秘占我院功能性出口梗阻性便秘的1/5,如果仅通过非手术治疗往往不能取得明显的疗效,然而,通常使用的经尾骶部耻直肌松解手术,术后容易并发感染,而且复发率较高。1995年起,我们设计了经肛管直肠内切口入路的改良耻骨直肠肌松解方法,治疗了因耻骨直肠肌肥厚而便秘的患者56例,均取得了显著疗效,现报告如下。1　资料和方法11　一般资料　56例中,男23例,女33例,年龄26～57岁,平均3206±571岁,病程05～30年,平均568±720年。全部病例符合1992年第7次全国肛肠学术会议拟定的耻骨直肠肌肥厚的诊断标准。12　治疗方法　腰俞穴麻醉…     

肛提肌标识在直肠癌腹会阴联合切除术中的作用

目的 探讨肛提肌标识在直肠癌腹会阴联合切除术中的作用.方法 回顾性分析2001年1月至2008年1月南京医科大学第一附属医院收治的109例直肠癌患者的临床资料,其中55例采用传统方法手术（传统法组）,54例采用肛提肌标识法进行手术（肛提肌标识法组）.手术遵循直肠癌全系膜切除术原则,锐性分离直肠系膜,整块切除.两组患者术前肠道准备、麻醉选择、患者体位、腹部切口、会阴部切口、会阴部缝合与Miles术相同.传统法组用电刀或超声刀切开会阴部脂肪组织,自尾骨的前方进入盆腔,与腹部手术医师会合,靠近盆壁切断两侧肛提肌未进行标识则进行后续手术操作.肛提肌标识法组采用电刀切开肛门周围间隙脂肪组织,分离两侧坐骨肛管间隙脂肪组织,切断后方肛尾韧带,直达肛提肌平面,标识肛提肌后进行后续手术操作.术后病理检查为Ⅰ期者进行随访观察;术后病理检查为Ⅱ期者,如组织学分化差、T4期、血管淋巴管浸润、检出淋巴结数目＜12枚,则行辅助化疗,如无则进行随访观察;术后病理检查为Ⅲ、Ⅳ期者,行术后化疗.术后第1年,每3个月复查1次血常规、肝肾功能、胸部X线片和肝胆B超.1年后每6个月复查1次上述检查;每年复查1次CT和肠镜检查.随访时间截至2012年12月.计数资料采用x2检验,计量资料采用t检验,Kaplan-Meier法绘制生存曲线,生存率比较采用Log-rank检验.结果 两组患者顺利完成手术,传统法组患者和肛提肌标识法组患者的会阴手术时间分别为（60±15） min和（30±10） min,术中出血量分别为（300 ±60） mL和（30±20） mL,两组比较,差异有统计学意义（t=3.936,5.687,P＜0.05）.传统法组患者中,3例直肠破损,2例尿道（阴道）破损,10例切口感染;而肛提肌标识法组患者中,只有9例切口感染.109例患者中,术后化疗周期少于12个疗程者30例,6个疗程及以上者41例.中位随访时?     

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 ±75 mg/dl vs. 231 ±24 mg/dl; P<0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient’s life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2l–24, 2000.     

腹腔镜联合部分内括约肌切除在低位直肠癌保肛根治术中的应用

目的评价低位直肠癌患者行腹腔镜辅助部分内括约肌切除保肛根治术的安全性和可行性。 方法回顾性分析2011年1月至2014年12月60例在汕头大学医学院第二附属医院行腹腔镜辅助低位直肠癌保肛术患者的资料,其中30例行部分内括约肌切除术(pISR组),30例行全内括约肌切除保肛术(tISR组),两组进行肿瘤安全性、术后肛门控制功能等方面的比较。 结果pISR组与tISR组在肿瘤安全性比较,差异无统计学意义(P>0.05);术后plSR组肛门功能良好率高于tISR组,术后分期比较,差异有统计学意义[(20、24、26例) vs (17、20、21例),(10、6、4例) vs (13、10、9例),P < 0.05]。 结论腹腔镜联合部分内括约肌切除行低位直肠癌保肛根治术是安全可行的,能更好地保留肛门控制排便功能。     

先天性巨结肠术后便秘复发再手术37例临床分析

目的总结先天性巨结肠术后便秘复发的原因及再手术的治疗经验。方法分析37例先天性巨结肠术后便秘复发再手术患儿的临床资料。结果37例患儿术后便秘复发的主要原因为肠管切除不足14例,合并肠神经发育不良6例,闸门综合征5例,其他原因12例。再手术后无1例死亡;31例(83.8%)获6个月至11年的随访。术后15例排便1～2次/d,7例1次/2d,6例1次/3d;1例Rehbein术者(该术式本身保留了过多的病变直肠)和1例Soaves术者(再手术后未及时行肛管扩张)每周排便1～2次,仍间断使用缓泻剂;1例Soaves术者术后有粪液污裤现象。均无大便失禁者。结论先天性巨结肠便秘复发的主要原因为肠管切除不足;复发后再手术效果良好。     

Laparoscopic versus robotic rectal resection for rectal cancer in a veteran population

Background

Robotic rectal cancer resection remains controversial. We compared the safety and efficacy of laparoscopic vs robotic rectal cancer resection in a high-risk Veterans Health Administration population.

Methods

Patients who underwent minimally invasive rectal cancer resection were identified from an institutional colorectal cancer database. Baseline characteristics and outcomes were compared between robotic and laparoscopic groups.

Results

The robotic group (n = 13) did not differ significantly from the laparoscopic group (n = 59) with respect to baseline characteristics except for a higher rate of previous abdominal surgery. Robotic patients had significantly lower tumors, more advanced disease, a higher rate of preoperative chemoradiation, and were more likely to undergo abdominoperineal resection. Robotic rectal resection was associated with longer operative time. There were no differences in blood loss, conversion rates, postoperative morbidity, lymph nodes harvested, margin positivity, or specimen quality between groups.

Conclusions

The robotic approach for rectal cancer resection is safe with similar postoperative and oncologic outcomes compared with laparoscopy.     

Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach

Aim Laparoscopic sphincter‐saving surgery has been investigated for rectal cancer but not for tumours of the lower third. We evaluated the feasibility and efficacy of laparoscopic intersphincteric resection for low rectal cancer. Method From 1990 to 2007, patients with rectal tumour below 6 cm from the anal verge and treated by open or laparoscopic curative intersphincteric resection were included in a retrospective comparative study. Surgery included total mesorectal excision with internal sphincter excision and protected low coloanal anastomosis. Neoadjuvant treatment was given to patients with T3 or N+ tumours. Recurrence and survival were evaluated by the Kaplan–Meier method and compared using the Logrank test. Function was assessed using the Wexner continence score. Results Intersphincteric resection was performed in 175 patients with low rectal cancer: 110 had laparoscopy and 65 had open surgery. The two groups were similar according to age, sex, body mass index, ASA score, tumour stage and preoperative radiotherapy. Postoperative mortality (zero) and morbidity (23%vs 28%; P = 0.410) were similar in both groups. There was no difference in 5‐year local recurrence (5%vs 2%; P = 0.349) and 5‐year disease‐free survival (70%vs 71%; P = 0.862). Function and continence scores (11 vs 12; P = 0.675) were similar in both groups. Conclusion Intersphincteric resection did not alter long‐term tumour control of low rectal cancer. The safety and efficacy of the laparoscopic approach for intersphincteric resection are suggested by a similar short‐ and long‐term outcome as obtained by open surgery.     

Transanal rectosigmoid resection for severe intractable idiopathic constipation

Introduction

Idiopathic constipation is a source of significant morbidity in children. A subset of patients is refractory to medical therapy and requires surgical intervention. We present a novel surgical technique for the management of these patients.

Methods

We reviewed the records of 288 patients with severe idiopathic constipation and soiling. Patients who were refractory to medical management and had a megarectosigmoid underwent a transanal full-thickness rectosigmoid resection with a primary colo-anal anastomosis.

Results

Fifteen patients underwent a transanal rectosigmoid resection. The preoperative contrast enema demonstrated an enormously dilated rectosigmoid in 14. An average of 43 cm (range, 8-98 cm) of rectosigmoid was resected. Of 14 patients with more than 3 months of follow-up, the preoperative laxative dose was 68 mg of senna/d (range, 52-95 mg), which decreased to 8.6 mg postoperatively (P < .001). Nine patients are clean without soiling, 1 is more prone to diarrhea, but is clean. Two patients soil occasionally, but are noncompliant, and 2 were lost to follow-up.

Conclusion

Transanal rectosigmoid resection for medically intractable idiopathic constipation resulted in a dramatic reduction or elimination in laxatives use while preserving continence. It is a useful alternative to surgical options such as other colonic resections, antegrade enemas, and stomas.     

腹骶联合直肠癌切除术的临床应用

目的探讨腹骶联合切除术治疗低位进展期直肠癌的可行性和安全性。方法前瞻性人组2010年6月至2012年1月间兰州军区兰州总医院收治的可行局部根治性切除但又难以保留肛门的97例低位进展期直肠癌患者,按人院顺序交替分为腹会阴组（49例,行腹会阴联合切除术）和腹骶组（48例,行腹骶联合切除术）。比较两组患者的术中及术后情况。结果两组患者手术顺利,无围手术期死亡。与腹会阴组相比,腹骶组手术时间（包括第2次调整体位的时间）明显延长[（188±45）min比（143±48）min,P=0．000],非计划性前列腺或阴道损伤发生率降低[0比14．3％（7／49）,P=0．032],会阴部切口感染率降低[2．1％（1／48）比18．4％（9／49）,P=0．040]。结论腹骶联合切除术应用于中低位直肠癌患者安全、可行。     

内括约肌切除术治疗超低位直肠肿瘤26例

目的 总结用肛门内括约肌切除术治疗超低位直肠肿瘤的临床经验.方法 对26例无外括约肌受侵的低位直肠肿瘤患者行全直肠系膜切除加经肛内括约肌切除术的临床资料进行回顾性分析.对肿瘤下缘距齿状线 2 cm者,行内括约肌部分切除;肿瘤下缘距齿状线 1.0 cm、<2.0 cm者,行内括约肌次全切除;肿瘤距齿状线<1.0 cm或侵及齿状线者,行内括约肌全切除,结肠肛管行端端吻合.结果 26例患者肿瘤下缘距齿状线距离为0～3 cm.病理类型:高分化腺癌6例,中分化腺癌16例.乳头状癌1例,绒毛状腺瘤癌变1例.巨大绒毛状腺瘤2例.病理分期:pTNM Ⅰ期11例,ⅡA期8例,ⅢA期4例,ⅢB期1例;T分级:T1 8例,T2 15例,13 1例.全组无手术死亡;无吻合口瘘;发生吻合口狭窄2例.术后早期肛门经常粪污,每日大便3～10次.术后1年控便时间可达5 min以上,患者排便次数减少,最少为每日1次,或每日2～4次.但内括约肌全切除者仍偶然粪污.术后平均随访时间28个月,术后5个月吻合口肿瘤复发1例,术后10个月肝转移1例,术后26个月心源性猝死1例.结论 对于癌灶局限于直肠壁内的超低位直肠癌,采用肛门内括约肌切除术可以达到根治效果,并保留肛门功能.     

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。