溃疡性结直肠炎的外科治疗

目的 介绍一种全大肠切除回肠与肛营一期吻合治疗溃疡性结直肠炎的方法。方法 本术要求在直肠游离达肛提肌水平后继续推进于直肠内外括约肌之间。使直肠从肛管内翻拖出后。皮肤、齿状线及直肠粘膜成同一平面．其间无间沟及反折。在齿缘水平回肠与肛管于肛外行一期吻合。结果 本组16例。主要表现为严重便血、腹泻贫血及营养不良。均经过长期的内科治疗。癌变的两例病史分别为7年、17年。术后一个月内每周排便6～12次，3个月后正常，16例中随访6个月～5年，均获治愈。结论 因其结直肠切除彻底故而无复发．回肠肛管血运极其丰富，吻合易于成功。     

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.     

支撑捆扎法回肠Pouch-直肠肌鞘内肛管一期吻合术

目的 探讨用肛门支撑吻合管支撑捆扎法进行回肠囊袋（Pouch）－直肠肌鞘内肛管一期吻合术，并分析该术式对结、直肠息肉病、溃疡性结炎治疗的价值。方法 对结、直肠息肉病行全结肠及上段直肠切除，保留齿状线上4－6cm直肠。距齿状线处2cm剥离直肠粘膜。回肠“J”型、“S”型、“W”型Pouch内置入肛门支撑吻合管8cm，结扎－缝扎、固定。距直肠粘膜残端1cm处用2号肠线全层内荷包缝合一周，在直肠肌鞘套内回肠Pouch与外科肛管吻合。溃疡性结肠炎直肠肌鞘内与解剖肛管吻合。结果 一期完成手术，吻合口愈合良好。无肌间血肿，无吻合口漏及吻合口狭窄。术后6个月排便功能优良率达88.8%，随访1－5年未发现息肉复发。结论 全结肠及部分直肠切除后用支撑捆扎法行一期手术即可完成回肠Pouch-直肠肌鞘内肛管吻合术，保留肛管直肠移行区的回肠Pouch外科肛管吻合术优于回肠Pouch解剖肛管吻合术。     

溃疡性结肠炎病人的超声直肠粘膜切除术(英)

作者对28例需行回肠肛管吻合术的溃疡性结肠炎病人用超声破碎法进行了直肠粘膜切除术.年龄17～62岁,平均30岁.术前有症状时间平均6年(6个月到24年).女12例,男16例.23例因症状重经内科治疗无效而施行手术.另5例因出现癌前征状而手术.6例行全结肠切除、直肠粘膜切除、一期回肠肛管吻合术.22例先行结肠次全切除、回肠造瘘术,3个月后再行直肠粘膜切除、回肠肛管吻合术.有严重直肠出血、营养不良和类固醇中毒的病人应分期手术.     

用肛门支撑吻合管一期回肠Pouch套入式肛管吻合术（附7例报告）

目的：分析评价全结肠部分直肠切除,直肠粘膜剥脱,用肛门支撑吻合管一期回肠Ｐｏｕｃｈ经直肠肌鞘肛管吻合术。方法：对ＵＣ和ＦＡＣ行全结肠切除部分直肠切除,肛缘６ｃｍ处直肠粘膜剥脱４例,保留齿状线上２ｃｍ粘膜,用肛门支撑吻合管经肛门外拖环扎式回肠“Ｓ”“Ｗ”－Ｐｏｕｃｈ,经直肠肌鞘外科肛管套入式吻合术４例,解剖肛管吻合术３例,肛门支撑吻合管１０ｄ拔除,切除外拖回肠,一期完成手术,不做回肠造瘘。术后药物性控制排便。结果：一期完成手术,吻合术愈合良好,无吻合口瘘,吻合口狭窄２例,扩肛治愈,肛周皮肤损害３例,术后半年排例功能评价,优良率１００％。结论：肛门支撑吻合管经肛门外拖式吻合可以一期完成手术,是一种安全手术方法,保留齿状线上２ｃｍ（外科肛管）与回肠囊吻合,排便功能明显优于回肠囊－肝管吻合术。     

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。     

结肠次全切除治疗梗阻性乙状结肠癌16例临床分析

目的:探讨一期结肠次全切除,回肠乙状结肠或回肠直肠吻合术,治疗梗阻性乙状结肠癌的效果。方法:在收治的急性梗阻性乙状结肠癌病人中,选择行一期结肠次全切除、回肠乙状结肠或回肠直肠吻合术的16例患者的临床资料进行回顾性分析。结果:在全麻下行剖腹探查证实乙状结肠癌,行一期结肠次全切除回肠与乙状结肠吻合12例,回肠与直肠吻合4例。4例术后发生排便次数增加3～6次/d,经调节饮食和口服易蒙停等3个月治愈。切口脂肪液化感染2例,经换药处理治愈。其余均顺利康复出院,未发生吻合口瘘。结论:达到解除梗阻,根治性切除肿瘤,一期吻合重建肠道,减少吻合口瘘的发生,是治疗梗阻性乙状结肠癌安全和有效术式。     

腹腔镜下低位直肠癌保肛术中支撑吻合管的应用价值

【摘要】〓目的〓探讨腹腔镜下低位直肠癌保肛术中支撑吻合管的应用价值。方法〓腹腔镜下对14例低位直肠癌病人实施全直肠系膜切除(TME)根治性切除,用支撑吻合管完成超低位结直肠-肛管吻合术。结果〓超低位结直肠-肛管吻合成功14例,吻合时间l5~30 min,直肠系膜均完整切除,其中结肠与外科肛管吻合8例,结肠与解剖肛管吻合6例。术后病人肛门括约肌功能、排尿功能良好,未发生吻合口狭窄与吻合口瘘者。术后6个月排便功能优良率为85.71%(12/14)。寿命表法计算5年生存率和局部复发率分别为78.57%(11/14)及7.14%(1/14)。结论〓腹腔镜下低位直肠癌保肛术中支撑吻合管的应用是安全可行的。     

家族性腺癌性息肉病的手术选择(摘要)

家族性腺瘤性息肉病(FAP)是常染色体显性遗传性疾病,如不手术治疗终将发生癌变,本文报告23例,男12例,女11例,年龄19~62岁,35岁以下10例,有家族史13例,手术时有8例癌变。最小癌变年龄23岁。治疗:行全结肠直肠切除回肠造口术1例,只适用于中低位直肠有恶变或全结肠切除回肠直肠吻合术后直肠发生癌变无法保留肛门括约肌者。行全结肠切除回肠直肠吻合术12例,保留段直肠为6~8cm便于术后复查直肠。适应证为直肠下段腺瘤少并能长期随访。行升结肠切除升结肠直肠吻合术1例。行全结肠切除,直肠部分切除,直肠粘膜剥除共9例,其中回肠末端直接与肛管吻合4例,J—pouch肛管吻合4例,S-pouch肛管吻合1例。随访1~18年,平均97个月,脾曲癌变1例术后3年死亡。回肠直肠吻合术12例中有4例直肠腺瘤再发多次手术切除,其中1例直肠腺瘤第3次再发未接受手术切除而致癌变,经局部切除。术后近期排便功能回肠直肠吻合组优于直肠粘膜剥除组。回肠贮袋有无远期排便功能无差别。作者认为应根据病变的范围、程度、有无恶变、能否长期随访、医生的经验等选择手术治疗方法。只要适应证选择合适即能取得良好的疗效。     

结直肠全切除回肠J形储袋肛管吻合术治疗慢传输型便秘

目的 探讨结直肠全切除回肠J形储袋肛管吻合术治疗慢传输型便秘的疗效.方法 对我科收治的慢传输型便秘患者8例,均行结直肠全切除回肠J形储袋肛管吻合术治疗的临床资料作回顾性分析.结果 8例患者术后1个月平均每天大便次数为5.7次(3~10次),呈稀糊状大便.术后6个月平均每天大便次数为3.4次(1.2~4.3次),成形软便.术后1年平均大便次数为1.6次(0.8~3.2次),成形软便.结果 8例患者术后生活质量均得到明显改善.术后1例患者发生储袋炎,经治疗缓解,其余患者未发生严重并发症.结论 结直肠全切除回肠J形储袋肛管吻合术能有效的治疗慢传输型便秘,改善患者生活质量.     

Anal sphincter-saving operations for chronic ulcerative colitis.

Three anal sphincter-saving operations--ileorectostomy, ileal pouch-anal anastomosis, and ileal pouch-distal rectal anastomosis--are currently being used in the surgical treatment of chronic ulcerative colitis. All three operations remove the disease, or most of it, and yet they maintain transanal defecation, reasonable fecal continence, and a satisfactory quality of life. All three avoid permanent abdominal ileostomy. Ileorectostomy is the easiest to perform, but it leaves residual disease in the remaining rectum and proximal anal canal that may cause symptoms and that may predispose the patient to cancer. In contrast, ileal pouch-anal anastomosis, although a more technically demanding procedure, totally eradicates the colitis. Its main drawbacks--frequent stooling, nocturnal fecal spotting, and pouchitis--are usually satisfactorily treated with loperamide hydrochloride and metronidazole. Ileal pouch-distal rectal anastomosis is somewhat easier to perform than ileal pouch-anal anastomosis and may result in less nocturnal fecal spotting. Like ileorectostomy, however, the operation leaves residual disease in the distal rectum and proximal anal canal. Considering all of these factors, the ileal pouch-anal operation is preferred today for most patients who require surgery for chronic ulcerative colitis.     

Preventive Turnbull ileostomy

Turnbull soprovozhdaetsia khoroshimi rezul'tatami. Preventive Turnbull ileostomy was made in 28 patients. There were 19 male and 9 female patients aged from 18 to 77 years (mean age -- 46 years). Fifteen patients underwent reconstructive proctocolectomy with anastomosis between anal canal and J-shape ileac reservoir. Ten of them had familial polyposis, 5 patients had ulcerative colitis 3 had rectal cancer. Total mesorectumectomy with anastomosis between anal canal and J-shape colic reservoir was performed in 7 patients with cancer of middle and lower part of the rectum. Partial mesorectumectomy was performed in 4 patients with cancer of upper part of the rectum. Low anterior resection of the rectum with anastomosis between anal canal and J-shape colic reservoir was performed in 2 patients with villous adenoma. There were no specific complications. Following ileostomy closure was carried out in 25 of 28 patients. Wound infection was seen in 1 patient. It is concluded that preventive Turnbull ileostomy performed after lower colorectal, coloanal and ileonal anastomosis produces good results.     

New rectum and new anal canal: two cases of ileal reservoir-cutaneous anastomosis

Two patients who had total proctocolectomy for ulcerative colitis 4 and 10 years ago respectively have each been given a new rectum and anal canal, the lower end of a J ileal reservoir being brought through the pelvic floor muscles and joined to a skin wound made in the perineum.     

Anal canal mucosa in restorative proctocolectomy for ulcerative colitis

In an attempt to improve continence after restorative proctocolectomy, ileal reservoir-anal anastomosis at the level of the anorectal junction has been advocated. This procedure preserves the entire mucosa of the anal canal. The histological appearances of the anal mucosa have been examined in 16 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis. In 14 patients there was chronic inflammation characteristic of ulcerative colitis. Four patients had moderate dysplasia and in one of these patients an unsuspected adenocarcinoma of the anal canal extending down to the level of the dentate line was present. We believe that the anal mucosa should always be removed down to the level of the dentate line in restorative proctocolectomy for ulcerative colitis.     

Conservative proctocolectomy: a dubious option in ulcerative colitis

Conservative proctocolectomy was performed for ulcerative colitis in 19 patients, Crohn's disease in three and familial adenomatous polyposis in one. Healing was uncomplicated in only three patients (13 per cent). Eleven developed an anal discharge and nine an infected pelvic haematoma despite peranal drainage. Fourteen patients developed pelvic sepsis and, despite surgical curettage in 11, none healed. Six of these patients have had the anal sphincter divided, with healing in only one, and the anal canal has been excised in two. Eleven patients have ultimately healed at a median time of 28 months and eight have persistent sepsis after a median period of 45 months. Two patients with sepsis have had a successful ileoanal anastomosis. Conservative proctocolectomy cannot be recommended as a definitive operation for ulcerative colitis even though it may permit a subsequent restorative procedure.     

An alternative conversion technique for salvaging a failed ileal J-pouch-anal anastomosis to a modified H-pouch

Ileal J-pouch-anal anastomosis is a commonly accepted surgical treatment for patients with ulcerative colitis. However, making a J-pouch anal anastomosis can be difficult due to anatomical variations of patients. We experienced an informative case of ulcerative colitis in which the ileal pouch was damaged when it was pulled down into the anal canal because of a fatty short mesentery. To preserve intestinal consistency and functioning fecal continence, a modified H-pouch was converted from a damaged J-pouch and anastomosed to the dentate line. This operation achieved a satisfactory functional result and, we believe, presents an option for reconstructing ileal J-pouch-anal anastomosis.     

Surgical policy in nonspecific ulcerative colitis

Results of surgical treatment of 101 patients with nonspecific ulcerative colitis are analyzed. In 73 (72.3%) patients variants of abdomino-anal coloproctectomy were performed, 22 of them underwent total coloproctectomy with terminal ileo- or colostoma creation. In 21 (20.8%) patients who had no inflammatory-ulcerative process in the rectum resection of the affected part of the colon with ileo--or colorectal anastomosis was performed, in 8 cases suturing device AKA-2 was used. In 7 (6.9%) patients who had undergone total coloproctectomy S-type intestinal reservoir and reservoir-anal anastomosis were created. Rate of postoperative complications was 16.8%, lethality--3.0%. 6 months after creation of reservoir-anal anastomosis nearly complete recovery of anal sphincter function was seen that permits to regard this surgery as a method of choice in the treatment of patients with total ulcerative colitis.     

The J-pouch Swenson procedure for ulcerative colitis and familial polyposis.

Total colectomy with mucosal proctectomy and ileal pouch-anal anastomosis has proven to be a favorable option in the treatment of ulcerative colitis and familial polyposis coli. The main advantages of this procedure are that it obviates the need for a permanent stoma, it preserves anal continence, and it removes all disease-prone mucosa. As an alternative to this procedure, the authors have found success with the Swenson pull-through following proctocolectomy in children. This technique involves resection of the rectum at the dentate line, thus, eliminating the need for mucosal proctectomy. This may be particularly advantageous in patients with severely diseased rectal mucosa. Ileoanal anastomosis is performed after creation of an ileal J-pouch using the terminal ileum. The procedure has been used in two children with familial polyposis coli and in three with ulcerative colitis. Median follow-up after closure of the diverting ileostomy is 13 months (5-33 months). Continence has been preserved in all five patients. There have been no complications involving bladder or sexual dysfunction. This technique provides a reliable alternative for the definitive treatment of ulcerative colitis and familial polyposis coli.     

Mucosal proctectomy and colo-anal anastomosis for distal ulcerative proctocolitis

Four patients with long-standing symptomatic ulcerative colitis confined to the left colon and rectum were treated by resection, mucosal proctectomy and colo-anal sleeve anastomosis. There was no operative mortality or anastomotic leakage. Follow-up has ranged from 12 to 66 months (mean 52 months). Loose bowel motions with urgency and frequency of defaecation were troublesome postoperative symptoms. Recurrence of the colitis in the neorectum with extension into the proximal colon occurred in all patients within 3 to 11 months (mean 6 months) of operation. This necessitated total proctocolectomy with ileostomy in three patients (mean 18 months postoperatively). In the fourth patient the recurrence is medically controlled without a stoma more than 5 years after operation. This operation is unsuitable for the treatment of segmental ulcerative proctocolitis.