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。     

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。     

直肠肌鞘内拖出术治疗结肠息肉病的体会

我科自1989～1995年以来,用直肠肌鞘内拖出术治疗结肠息肉病22例。其中施行全结肠切除、直肠部分切除、回肠直肠肌鞘内拖出、回肠肛管吻合术20例;乙状结肠切除、直肠部分切除、结肠直肠肌鞘内拖出、结肠肛管吻合术2例。远期效果满意,现将诊治体会报告如下。     

离断肠系膜上动、静脉,全直肠肌鞘内回肠袋一肛管吻合术治疗家族性结肠息肉病

目的 探讨全结肠及低位直肠黏膜切除,离断肠系膜上动、静脉,全直肠肌鞘内回肠贮袋-肛管吻合术治疗家族性结肠息肉病的临床价值.方法 对6例家族性结肠息肉病患者采用离断肠系膜上动、静脉以松解小肠系膜,全直肠肌鞘内回肠袋一肛管吻合术,并随访4个月至17年,评价术后近期及远期效果.结果 术后3～7 d,患者即可区分肠内气体与粪便;术后7～10 d,大便转为成形.5例随访3～17年,大便1次/d,无夜便粪污,小便正常;1例随访4个月,大便2次/d,无夜便.6例患者大、小便均正常,植物神经功能和性功能正常,6例均无感染和息肉复发.结论 离断肠系膜上动、静脉后肠系膜可获充分松解,再行全直肠肌鞘内回肠袋一肛管吻合术对家族性结肠息肉病治疗效果是满意的.     

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。     

全结肠或全结直肠切除、回肠J-袋直肠或肛管吻合术

目的　评估全结肠或结直肠切除 (TC或PC)后 ,回肠J -袋直肠或肛管吻合术的效果。方法　回顾性总结分析 12例全结肠或结直肠切除后J -袋直肠或肛管吻合术的临床资料。结果　男性 5例 ,女性 7例手术经过顺利 ,除一例于术后第一天有肛门出血外 ,其余均顺利恢复 ,无手术死亡。肛门排便功能随时间推移 ,经三个月逐步改善 ,六个月后随访 ,大便多已成形 ,每天平均 3 -5次。有 2例加作短段回肠倒置术 ,术后第一个月不需口服肠蠕动抑制药 ,每天排便亦仅 4-6次。结论　该手术能保持良好的排便功能 ,病人生活质量感到满意 ,是全结肠或结直肠切除后的一种有效而理想的肠道重建方式 ,若再加作回肠倒置术效果更好     

全结肠或全结直肠切除、回肠J-袋直肠或肛管吻合术

目的评估全结肠或结直肠切除(TC或PC)后，回肠J-袋直肠或肛管吻合术的效果。方法回顾性总结分析12例全结肠或结直肠切除后J-袋直肠或肛管吻合术的临床资料。结果男性5例，女性7例手术经过顺利，除一例于术后第一天有肛门出血外，其余均顺利恢复，无手术死亡。肛门排便功能随时问推移，经三个月逐步改善，六个月后随访，大便多已成形，每天平均3—5次。有2例加作短段回肠倒置术，术后第一个月不需口服肠蠕动抑制药，每天排便亦仅4—6次。结论该手术能保持良好的排便功能，病人生活质量感到满意，是全结肠或结直肠切除后的一种有效而理想的肠道重建方式，若再加作回肠倒置术效果更好。     

家族性腺瘤性息肉病的外科治疗

为了提高家族性腺瘤性息肉病（ＦＡＰ）的外科治疗效果，对１６例ＦＡＰ患者的外科治疗情况进行了回顾性总结。１６例中除１例行全结肠直肠切除、回肠造口外，其余１５例均行全结肠直肠切除、回肠贮袋肛管吻合术。贮袋式中Ｊ型３例、Ｈ型１例，Ｓ型１１例，术后全部患者获１～５年随访，随访结果表明，病人排便功能均较满意，其中以Ｓ型贮袋者为好。笔者认为全结肠直肠切除是治疗ＦＡＰ唯一彻底有效的方法，而回肠贮袋肛管吻合则是减少术后排便次数、提高术后生活质量的良好术式，并讨论了手术方式的选择、手术操作等     

腹腔镜全结肠切除治疗家族性腺瘤性息肉病12例

目的探讨腹腔镜全结肠切除术治疗家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)的可行性及安全性。方法回顾性分析2015年6月～2018年12月腹腔镜全结肠切除术治疗12例FAP的临床资料,4例癌变者行腹腔镜全结肠直肠切除、末段回肠造口术,6例直肠下段未扪及明显息肉者行腹腔镜全结肠切除、直肠次全切除、回肠J形储袋直肠吻合术,2例直肠下段有少量息肉者行腹腔镜全结肠切除及直肠次全切除、残留直肠黏膜剥脱、经直肠肌鞘内回肠肛管吻合术。结果 12例均顺利完成手术,无中转开腹,术后2～3天肛门排气,住院时间8～12 d。随访3～24(13±3)月,无近期并发症发生,除回肠造口4例外,其余8例术后控便较好,3个月后大便能控制在3～6次/日。结论腹腔镜全结肠切除术治疗FAP创伤小,恢复快,安全,有效。     

Ileorectal anastomosis for ulcerative and Crohn's colitis

Except in the presence of severe perineal suppuration or sphincter damage by previous surgery for fistulas, the rectum was preserved in all patients considered candidates for surgery for inflammatory disease of the bowel. A primary anastomosis with a single-layer 5-0 monofilament stainless steel wire was carried out when a relatively healthy rectum with erythema and granularity presented. For patients with more severe disease of the rectum, a two-stage operation with intensive interval treatment of the rectum stump with topical corticosteroids was carried out. Of a total of eighty-six patients with involvement of the colon and rectum with either Crohn's disease or chronic ulcerative colitis, fifty-six patients were treated by local abdominal colectomy and ileorectal anastomosis. Twenty-four had primary anastomosis and thiry-two had a two-stage operation. One anastomotic dehiscence developed. A mean follow-up of 8.4 years (6 months to 20 years) has been satisfactory. Only three anastomoses have been taken down for unsatisfactory results. With the proper selection of patients and with appropriate treatment of the diseased rectal segment, a large majority of patients with inflammatory disease of the bowel can have long-term salutory results after colectomy and ileorectal anastomosis.     

保留扩张而不肥厚结肠的腹腔镜辅助小儿先天性巨结肠根治术

目的探讨保留扩张而不肥厚结肠的腹腔镜辅助下小儿先天性巨结肠根治术的疗效。方法 2006年5月～2008年11月15例先天性巨结肠小儿接受腹腔镜手术治疗,其中常见型13例,短段型2例。脐部、右上腹和右下腹各切口置5mmtrocar,腹腔镜辅助下用腔镜器械,腹腔内游离病变结肠,保留扩张而不肥厚结肠,然后经直肠将病变结肠拖出肛门外切除,将近端扩张而不肥厚的结肠断端与齿状线上直肠黏膜切缘处吻合。结果 15例患儿均经腹腔镜顺利完成手术,无中转开腹。手术时间100～180min,平均130.4min;术中出血量20～50ml。术后1～2d排气,术后第3天进食,7～9d出院。切除结肠组织病理诊断显示扩张但不肥厚或轻度肥厚的结肠含正常神经节细胞。15例随访6～12个月,平均9.5月,患儿6个月后每日大便1～2次,无便秘复发、污粪、狭窄,12例术后3～6个月复查钡灌肠显示扩张的肠管恢复正常。结论腹腔镜辅助下保留扩张但不肥厚或扩张伴轻度肥厚结肠的巨结肠根治术创伤小,安全、有效、可行。     

腹腔镜微创治疗高龄完全性直肠脱垂

目的探讨腹腔镜微创治疗高龄完全性直肠脱垂的手术方法,总结手术操作体会及临床治疗经验。方法总结2012年6月~2017年6月收治的22例完全性直肠脱垂患者的临床资料,患者年龄67~79岁,均在腹腔镜下行悬吊固定。结肠造影和术中均可见明显增厚且冗长的乙状结肠,直肠周围组织宽松,膀胱直肠窝或子宫直肠窝之间脂肪结缔组织明显增厚,尤其是直肠前壁。术中切除直肠周围增厚的脂肪结缔组织,切除冗长的乙状结肠和直肠上端,行结肠直肠吻合。结果所有患者手术顺利,无中转开腹。手术时间平均(86.59±14.84)min,出血量平均(63.41±23.67)ml,术后住院时间平均(10.01±1.57)d。无吻合口出血、感染、肠瘘等并发症发生,无术中死亡或术后2周内死亡病例。22患者均获得临床治愈,随访2~4年,平均(2.81±0.91)年,患者排便次数1~2次/d,肛门功能正常,无复发。结论腹腔镜下微创切除直肠周围增厚的结缔组织、切除冗长的乙状结肠和直肠上端,是一种较好的微创治疗高龄直肠脱垂的方法。     

Mortality and quality of life after total abdominal colectomy

We have reviewed the results of 107 consecutive total abdominal colectomies performed at our institutions during the past 10 years. Indications for surgery were carcinoma of the colon (60), multiple polyps (nine), diverticular disease (31), and other conditions (seven). Seven (6.5%) were emergency operations. All patients had anastomosis of the terminal ileum into the lower rectum or distal sigmoid colon no more than 25 cm above the anus. Thirty days after surgery, two patients (1.8%) had died of complications of anastomotic leaks. Both were poor candidates for primary reanastomosis. Morbidity was low, occurring in 11 patients (10.3%). Follow-up evaluation of bowel function revealed satisfactory results in 102 patients (95%). Five patients (5%) had experienced chronic debilitating diarrhea. Unfavorable results were more common with diverticular disease than with neoplasia.     

经阴道后壁直肠和阴道双重修补法治疗单纯直肠前突67例分析

目的：观察经阴道后壁直肠和阴道双重修补法治疗单纯直肠前突的效果。方法：67例单纯直肠前突患者。采用经阴道后壁切开。直肠前壁行柱状缝扎，阴道后壁修补的方法。结果：67例单纯直肠前突患者，术后64例(95．5％)便秘症状得以完全缓解，其中1例仍有轻度腹胀，但较术前明显减轻，随访6～24个月，无症状复发；2例(3．O％)仍感排便困难。但术前需依赖手法排便，术后可自排便；1例(1．5％)无明显效果。无切口感染、直肠瘘发生。所有病例术后复查排粪造影均显示直肠前突明显改善或消失。结论：经阴道壁直肠和阴道双重修补法治疗单纯直肠前突操作简单、疗效确切。     

Primary diffuse large B-cell lymphoma of the sigmoid colon

IntroductionExtranodal lymphomas are commonly encountered in the gastrointestinal tract but lymphomas of colon and rectum are rare. Non-Hodgkin lymphoma is the most common type of colonic lymphoma and represents less than 0.5% of colorectal neoplasms. Chemotherapeutical agents are gateway to disease remission and sometimes cure in most patients but surgery may be necessary in emergent situations.Case presentationA 77-year-old male patient presented with abdominal discomfort, constipation, and obstructive defecation symptoms. Radiological imaging revealed a mass in the sigmoid colon extending towards the rectum. Colonoscopy was performed and biopsy of a nearly 10 cm ulcerovegetative lesion was obtained. Histological examination following biopsy revealed it to be a diffuse large B-cell lymphoma of the sigmoid colon. There was no indication for surgery and the patient was referred to medical oncology clinic for chemotherapy treatment.DiscussionNon-Hodgkin lymphoma is a lymphoproliferative disorder with the diffuse large B cell lymphoma (DLBCL) being the most common subtype. The DLBCL subtype is rarely observed in the colon and rectum. Chromosomal abnormalities are involved in the pathophysiology and gene rearrangements lead to adjustments in lymphocyte function and differentiation.ConclusionIn this case report, we present a rare presentation of a Non-Hodgkin lymphoma presenting in the sigmoid colon. The disease can present with nonspecific symptoms and various imaging modalities along with histopathological evaluation is necessary for the correct subtyping of lymphoma. Chemoradiotherapy is key for treatment, and surgery is usually reserved for cases of obstruction, perforation, or bleeding.     

Rectum resection with colonic J reservoir and coloanal anastomosis for rectal cancer

A low anterior resection of the rectum followed by a colo-rectal or a straight colo-anal anastomosis often leads to poor functional results (increased frequency and urgency of defecation) due to the loss of the reservoir function of the rectum. In order to improve the functional results the authors performed in 7 patients colo-anal anastomosis with a J shaped colonic pouch. In all the cases a temporary diverting loop ileostomy was performed. This ileostomy was closed 4-5 weeks after the first operation. There was no operative mortality. After stoma closure, the functional results were improved during the first week. A colo-anal anastomosis with a colonic reservoir appears to be an optimal solution comparing with a very low colorectal or a straight colon-anal anastomosis.     

直肠癌患者三种肠道重建术对肛门功能的影响比较

目的探讨不同肠道重建术对低位直肠癌患者肛门功能的影响。方法将120例低位直肠癌患者随机分为吻合组(行直接吻合术)、结袋组(行结肠成形袋术)、J型袋组(行J型贮袋术)各40例,随访12个月后比较三组患者的肛门功能。结果吻合组、结袋组、J袋组成功率分别为95.0%、97.0%、95.0%,组间比较差异无统计学意义(P0.05);术后6、12个月结袋组和J型袋组患者肛门功能主观感受评分均高于吻合组患者;术后3、6、12个月吻合组患者24h排便次数、不能区分排便与排气率均高于结袋组和J型袋组患者;术后12个月吻合组患者最大收缩压、直肠顺应性均显著低于结袋组和J型袋组患者;术后3、6、12个月吻合组患者最大耐受量、静息压均显著低于结袋组和J型袋组患者,以上差异均有统计学意义(P0.05)。结论低位直肠癌患者行全直肠结肠系膜切除术后,直接吻合术对患者肛门功能的影响最大,J型贮袋术、结肠成形袋术对患者肛门功能影响接近,可以根据患者的生理类型行肠道重建术治疗,以最大程度保留患者肛门功能。     

左半结肠癌肠梗阻术中排便一期切除吻合术的应用

目的 探讨术中排便一期切除吻合在左半结肠癌肠梗阻中的应用价值.方法 回顾分析我院2000年1月至2008年1月收治的39例左半结肠癌合并肠梗阻行术中排便一期切除吻合患者的临床资料.结果 39例患者中男性25例,女性14例,年龄57～78岁,平均年龄68.5岁.肿瘤位于结肠脾曲3例(7.7%),降结肠8例(20.5%),乙状结肠15例(38.5%),直肠、乙状结肠交界8例(20.5%),直肠上段5例(12.8%).全部行术中排便一期切除吻合,左半结肠切除18例,乙状结肠切除13例,骶前切除8例.术后切口感染4例,其中1例切口裂开;肺部感染5例.1例吻合口瘘并发腹腔脓肿,二次手术后死于肿瘤转移.1例患者死于肺部感染呼吸衰竭.并发症和病死率分别为25.6%和5.1%.结论 术中排便一期切除吻合术是左半结肠癌肠梗阻可行的手术方式,效果满意.