全结直肠切除并回肠储袋-肛管吻合术治疗溃疡性结肠炎

目的　探讨全结直肠切除、回肠储袋肛管吻合术治疗溃疡性结肠炎的疗效。方法　对１９８４ ～１９９８ 年间进行的９ 例全结直肠切除、回肠储袋肛管吻合的溃疡性结肠炎患者作回顾性总结。结果　“Ｓ”形储袋６ 例,“Ｊ”形储袋３ 例。９ 例均存活。手术后发生粘连性肠梗阻１ 例,经非手术治疗后缓解;１ 例发生储袋瘘导致盆腔感染,最终切除储袋,行回肠造瘘;伤口感染１ 例;切口疝１ 例。随访８ 例,随访时间１ ～１３ 年。排便次数中位数为５ 次／２４ 小时（４～１０ 次／２４ 小时） 。对排尿和性功能无影响。结论　全结直肠切除、回肠储袋肛管吻合手术治疗溃疡性结肠炎患者的初步结果基本满意。     

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中毒性巨结肠(toxic megacolon,TMC)是各种炎症性肠病、细菌性肠病和病毒性肠病等的一种致命并发症,常见于溃疡性结肠炎病人。该病通常发生于急性重症溃疡性结肠炎或慢性溃疡性结肠炎急性发作阶段。某些具有麻醉作用的药物如鸦片类、抗胆碱酯类和止泻药以及某些不适宜的医疗操作(如结肠镜检查)等可诱发其发作,一旦确立诊断,应立即进行挽救性治疗。为降低手术风险,提高手术成功率,对于病情危急的TMC病人,应遵循三期手术原则进行外科治疗。     

全结直肠切除环扎式回肠贮袋肛管吻合治疗溃疡性结肠炎

我们自 1994年 5月开始 ,对 5例全结肠直肠切除的溃疡性结肠炎病例 ,应用自制支撑吻合管行环扎式回肠Ｓ贮存袋肛管吻合术 ,获得满意疗效 ,报告如下。一、材料与方法1.临床资料 :本组患者 5例 ,其中男 2例 ,女 3例 ,年龄2 4～ 5 3岁 ,病期 2～ 11年。术前均经纤维结肠镜和钡剂灌肠检查确诊 ,且经手术后病理证实。 5例均为慢性重型患者 ,经过内科正规治疗无效 ,病情反复长期发作。2 .手术方法 :(1)全结直肠切除 :常规游离全结肠直肠后 ,于齿状线上 1ｃｍ切断直肠 ,将全结肠直肠完整切除。因齿状线上的Ｍｏｒｇａｇｎｉ直肠柱为立方上皮 ,并非…     

全结直肠切除并回肠储袋-肛管吻合术治疗溃疡性结肠炎

目的 探讨全结直肠切除、回肠储袋-肛管吻合术治疗溃疡性结肠炎的疗效。方法 对1984～1998年间进行的9例全结直肠切除、回肠储袋-肛管吻合的溃疡性结肠炎患作回顾性总结。结果 “S”形储袋6例,“J”形储袋3例。9例均存活。手术后发生粘连性肠梗阻1例．经非手术冶疗后缓解;1例发生储袋瘘导致盆腔感染,最终切除储袋,行回肠造瘘：伤口感染1例：切口疝1例。随访8例,随访时间1～13年。排便次数中位数为5次／24小时(4～10次／24小时)对排尿和性功能无影响．结论 全结直肠切除、回肠储袋．肛管吻合手术治疗溃疡性结肠炎患的初步结果基本满意。     

全结直肠切除回肠贮袋肛管手缝吻合术在溃疡性结肠炎治疗中的临床价值

目的 评价全结直肠切除回肠贮袋肛管手缝吻合术（HIPAA）治疗溃疡性结肠炎的临床价值.方法 回顾性分析1989年1月至2013年12月天津医科大学总医院收治的191例溃疡性结肠炎患者的临床资料,采用开腹和腹腔镜辅助手术行HIPAA.末次手术后3个月和12个月进行问卷调查,依据24h和夜间排便次数、Bristol粪便分类表和Kirwan分级评价贮袋肛门功能.依据克利夫兰生命质量表评价生命质量;依据贮袋炎活动指数诊断贮袋炎.随访时间截至2014年4月.独立样本比较采用t检验,多组比较采用方差分析,两两比较采用LSD-t检验,计数资料比较采用x2检验.结果 191例患者中有180例行开腹手术,11例行腹腔镜手术.175例行二期手术,9例行一期手术,7例行三期手术.181例采用J型贮袋,9例采用H型贮袋,1例采用W型贮袋.患者无围手术期死亡,术后早期8例患者腹腔感染,7例切口感染,应用抗生素后治愈.术后1～2周发生贮袋吻合口出血4例,吻合口漏4例,给予止血处理后治愈.6例患者术后出现高位肠梗阻,经对应处理后缓解.8例患者发生贮袋炎,经饮食调节或抗生素治疗后缓解.2例患者发生性功能障碍.所有患者获得随访,随访时间1～25年.术后贮袋肛门功能不断改善,术后3个月24 h和夜间排便次数、Bristol粪便分类和Kirwan分级分别为（6.5±2.8）次,（2.9±1.5）次,Ⅳ类86例、Ⅴ类89例、Ⅵ类16例,Ⅰ级160例、Ⅱ级19例、Ⅲ级12例;术后12个月分别为（3.7±1.4）次,（1.3±0.5）次,Ⅳ类107例、Ⅴ类76例、Ⅵ类8例,Ⅰ级177、Ⅱ级8例、Ⅲ级6例,两者比较,差异有统计学意义（=12.36,3.98,x2=7.76,29.27,P＜0.05）.克利夫兰生命质量表评分：术前为（0.37±0.19）分,术后3个月为（0.67±0.16）分,术后12个月为（0.82±0.13）分,3者比较,差异有统计学意义（F=6.011,P＜0.05）.术后3个月与术前和术后12个月比较,差异有统计学意义（t=16.69,10.06,P＜0.05）;术后12?     

赋能干预对溃疡性结肠炎术后疗效影响研究

目的 探讨赋能干预对溃疡性结肠炎（UC）病人全结直肠切除回肠贮袋肛管吻合术（IPAA）后肛门功能及生活质量影响。方法 选取2010年1月至2014年9月天津医科大学总医院普外科收治的行IPAA的UC病人60例,采用随机数字表法将病人分为干预组（30例）和对照组（30例）,分别接受赋能干预和传统健康指导。干预6个月后,以24 h和夜间便次及Kirwan分级评价术后肛门自制功能,Bristol粪便分类法评定粪便性状;于干预前及干预6个月后,采用血浆中血清总蛋白（TP）、前白蛋白（PA）、白蛋白（ALB）及转铁蛋白（TRF）的水平评估病人的营养状况,采用IBDQ问卷评估生活质量。结果 赋能6个月后,干预组病人24 h和夜间便次均优于对照组,差异有统计学意义［24 h：（4.3±1.5）次 vs. （5.9±2.4）次;夜间：（1.6±0.7）次 vs. （2.3±1.3）次,均P<0.05］。干预组Kirwan 分级Ⅰ级21例、Ⅱ级7例、Ⅲ级2例,对照组Ⅰ级14例、Ⅱ级12例、Ⅲ级4例,差异无统计学意义（χ2=3.380,P>0.05）。干预组病人Bristol大便分类4类20例、5类6例、6类4例,对照组4类11例、5类17例、6类2例,差异有统计学意义（χ2=8.540,P<0.05）。营养状况方面,干预组病人ALB水平高于对照组［（47.4±5.8）g/L vs. （43.3±6.5）g/L,P<0.05）］;IBDQ问卷得分方面,干预组在肠道症状、全身症状等维度均高于对照组,差异有统计学意义（均P<0.05）。结论 赋能干预可以改善UC病人IPAA后肛门功能及粪便性状,提高其生活质量。     

手辅助腹腔镜与开腹全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎的对比研究

目的比较手辅助腹腔镜技术（HALS）与开腹全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎的应用效果。方法回顾性分析上海交通大学医学院附属新华医院肛肠外科同一组医师自2009年1月至2011年6月期间对溃疡性结肠炎分别采用HALS技术（HALS组．36例）和传统开腹手术（开腹组,42例）完成的全结直肠切除回肠储袋肛管吻合术患者的临床资料．对比其手术安全性、术后恢复情况和并发症。结果HALS组与开腹组的手术时间分别为（300．3±56．4）min和（227．2±34．0）min（P=0．001）;术中出血量分别为（150．2±42．2）ml和（213．5±61．0）ml（P=0．043）：术后排气时间分别为（2．4±0．9）d和（3．1±1．2）d（P=0．026）;进食流质时间分别为（3．7±1．0）d及（4．6±1．7）d（P=0．004）;术后住院时间分别为（9．3±2．6）d及（11．6±3．4）d（P=0．039）：除手术时间稍长外,HALS组均优于开腹手术组。HLAS组术后吻合口瘘、吻合口出血、伤口感染、盆腔脓肿和肠梗阻等手术并发症与开腹组差异无统计学意义（均P〉0．05）。结论手辅助腹腔镜技术在全结直肠切除回肠储袋肛管吻合术中可获得与传统开腹手术同等的安全性．近期疗效优于开腹手术。     

溃疡性结肠炎的手术治疗

尽管溃疡性结肠炎的内科治疗已经取得了很大的进步．仍有相当一部分患者需要手术治疗。回肠储袋肛管吻合术（IPAA）在目前西方国家最为常用：回直肠吻合（IRA）仍有一定的临床应用价值。临床上对于手术方式的选择往往需要根据具体的临床情况、在患者充分知情同意后决定。     

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。     

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…     

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.     

Pouch outcomes among children with ulcerative colitis treated with calcineurin inhibitors before ileal pouch anal anastomosis surgery

Purpose

The purpose of this article is to describe the outcomes of the pouches of 14 children with ulcerative colitis (UC) who were pretreated with calcineurin inhibitors before they underwent their ileal pouch anal anastomosis (IPAA) surgery.

Methods

An institutional review board-approved retrospective review of the charts of consecutive patients with UC treated with calcineurin inhibitors before undergoing IPAA surgery at a tertiary pediatric center between 1998 and 2003 was performed. The primary endpoint was pouch outcome after at least 2 years of follow-up (healthy pouch, acute pouchitis, chronic refractory pouchitis, or pouch failure); the secondary endpoints were early postoperative complications, number of stages, and time between stages.

Results

Fourteen of 53 consecutive patients who underwent IPAA for UC were treated with calcineurin inhibitors before their surgery (26%; 6 with cyclosporine and 8 with tacrolimus). All 14 patients were concomitantly treated with systemic steroids. Ten patients (71%) were also taking 6-mercaptopurine or azathioprine, and 9 (64%) were also taking mesalamine. Three patients (21%) had healthy pouches with no clinical evidence of pouchitis, 6 (43%) had at least one episode of acute pouchitis (average of 2 episodes per year), 3 (21%) had chronic relapsing pouchitis, and 2 (14%) were later determined to have Crohn's disease. There was no pouch failure. Two patients (14%) had an early postoperative complication (intraabdominal abscess, anastomotic stricture). Five patients (36%) had a 2-staged procedure, and 8 (64%) had a 3-staged procedure. For the 2-staged procedures, the mean time between the first and second stages was 3.14 months (range, 3-4 months). For the 3-staged procedures, the mean time between the first and second stages was 4.25 months (range, 2-6 months) and that between the second and third stages was 4 months (range, 2.5-6 months).

Conclusions

In this series, chronic pouchitis was an infrequent complication among children who were pretreated with calcineurin inhibitors. Calcineurin inhibitor use did not lead to or portend increased early postoperative complications or affect the number or duration of surgical stages. Further studies are required to determine if preoperative calcineurin inhibitors improve pouch outcomes or facilitate the performance of 2-staged procedures.     

Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultrasonic Surgical Aspirator®

This is a report of adenocarcinoma arising in an ileal pouch after restorative proctocolectomy (RPC) with rectal mucosal stripping performed by Cavitron Ultrasonic Surgical Aspirator (CUSA®) for ulcerative colitis. The CUSA® was introduced to simplify and optimize ileal pouch–anal anastomosis with mucosectomy and has been shown to shorten the operative time and reduce blood loss. Its use however, may increase the number of pathology specimens made uninterpretable on account of tissue ablation. In the present case, even though preoperative colonoscopy had clearly shown dysplasia, the surgical pathology report could not detect any neoplasia in the specimen; hence, the patient was not surveyed for pouch cancer. Six years later, the patient presented with intestinal obstruction caused by cancer. While protocols for universal pouch surveillance remain somewhat controversial, we conclude on the basis of this case and a review of the literature that in RPC with mucosectomy performed by CUSA®, pouch cancer surveillance is particularly important because remnants of rectal epithelium may have been left behind and tissue ablation may have made the surgical pathology report uninterpretable.     

Chronic pouchitis after ileal pouch-anal anastomosis for ulcerative colitis: effect on quality of life

Chronic pouchitis can be observed in up to 30% of patients after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). It remains a poorly understood complication and often requires chronic antibiotic and antidiarrheal treatment. We hypothesized that its occurrence can be predicted by distinct clinical parameters and that it adversely affects quality of life. Sixty-eight of 129 consecutive UC patients who underwent IPAA over a 10-year period were evaluated by Cleveland Clinic Global Quality of Life questionnaires, telephone interviews, and by chart review. Using bivariate comparison, clinical predictors for the occurrence of chronic pouchitis were sought, and postoperative data analyzed with regard to functional results and quality of life. Nineteen of 68 patients (28%) experienced chronic pouchitis, but its occurrence could not be predicted by any variable assessed. Patients with chronic pouchitis complained of more frequent fecal incontinence (32% vs. 4% in controls; P < 0.01), of more frequent bowel movements (7.7/day vs. 6.2/day; P < 0.05), and experienced severe abdominal pain more often (P < 0.05). Overall quality of life and satisfaction with surgery, as well as subjective health and energy levels were lower in patients with chronic pouchitis (P < 0.01); however, greater than 80% of these patients would consider undergoing the same procedure again. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–19, 2005 (poster presentation). Supported in part by the Digestive Health Center, University of Louisville Hospital, Louisville, Kentucky.     

Factors affecting the bowel function after proctocolectomy and ileal J pouch-anal anastomosis for ulcerative colitis

The aim was to study determinants of postoperative bowel function after restorative proctocolectomy for ulcerative colitis. Medical records of patients who underwent proctocolectomy with ileal J pouch-anal anastomosis (IPAA) in two- or three-stage operations and whose status of defecation was known via a questionnaire were retrospectively reviewed. Bowel function, including stool frequency, stool consistency, and degree of nighttime soiling, was correlated with age at the time of surgery, time after ileostomy closure, mean resting anal pressure, longitudinal length of ileal J pouch, and duration of fecal diversion by using univariate and multivariate analyses. Stool frequency decreased significantly with time after ileostomy closure in both univariate and multivariate analyses. Stool frequency tended to be less in patients having a long J pouch, but the correlation was not significant (P=0.071) in univariate analysis. Nighttime soiling ameliorated with time after ileostomy closure in multivariate, but not univariate, analysis. Deterioration of nighttime soiling was seen in patients whose duration for fecal diversion was long, both in univariate (P=0.068) and multivariate (P=0.052) analyses. Stool consistency was related to none of the five factors investigated. These results indicate that as the time after surgery increases, stool frequency decreases and nighttime soiling ameliorates. Delaying ileostomy closure because of anticipated postoperative incontinence does not significantly alter postoperative continence.     

Acute histologic inflammatory activity and postoperative outcomes in pediatric patients with ulcerative colitis

BackgroundThe aim of this study was to determine whether acute histologic inflammatory activity at the rectal margin predicts postoperative complications in children with ulcerative colitis following ileal pouch-anal anastomoses (IPAA).MethodsPatients who underwent IPAA following previous total abdominal colectomy for ulcerative colitis between 2006 and 2014 were included. Data collected included demographics, operative and postoperative data, histologic grading of the rectal margin at time of IPAA, and stooling outcomes at one, six and 12 months following ileostomy closure.ResultsTwenty-seven patients were included. Acute inflammation scores ranged between 2 and 13. Unadjusted and adjusted models showed no statistically significant relationship between inflammation and presence of any postoperative complications, number of daily stools, nighttime stooling, soiling, or stool-altering medication usage.ConclusionAcute histologic inflammatory activity at the rectal margin is not associated with increased rates of postoperative complications following IPAA creation in children, nor with poorer continence outcomes following ileostomy closure.     

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis:A narrative review

Restorative proctocolectomy with ileal pouch-anal anastomosis(RP-IPAA) is the gold standard surgical treatment for ulcerative colitis.However,despite the widespread use of RP-IPAA,many aspects of this treatment still remain controversial,such as the approach(open or laparoscopic),number of stages in the surgery,type of pouch,and construction type(hand-sewn or stapled ileal pouch-anal anastomosis).The present narrative review aims to discuss current evidence on the short-,mid-,and long-term results of each of these technical alternatives as well as their benefits and disadvantages.A review of the MEDLINE,EMBASE,and Ovid databases was performed to identify studies published through March 2016.Few large,randomized,controlled studies have been conducted,which limits the conclusions that can be drawn regarding controversial issues.The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases.Regarding 2- and 3-stage RP-IPAA,patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables,making any comparisons extremely difficult.The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly,although the J pouch is generally preferred by surgeons.Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages,and there is no clear benefit of one technique over the other.     

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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。