结直肠吻合的预防性造口术——袢式横结肠造口与袢式回肠造口的比较

作为结直肠吻合口的预防性造口,袢式回肠造口与横结肠造口均可有效地转流粪便,减少吻合口漏所带来的危害,适用于具有高吻合口漏风险的低位、超低位直肠癌切除患者,特别是接受新辅助治疗者。两种造口各有利弊。本文总结了关于这两种造口的大部分对照研究,结果显示袢式横结肠造口术后的并发症率相对较高,主要包括造口脱垂、旁疝、伤口感染、还纳术后切口疝等。袢式回肠造口的主要缺点是造口高排便量、脱水以及术后肠梗阻风险。另一方面,由于部位等原因,袢式横结肠造口可以更为有效地进行结直肠减压,更适用于无法进行肠道准备如急诊手术等情况。通过手术技术的改进,或可有效地减少造口脱垂等并发症,充分发挥袢式横结肠造口的优势。     

临时性袢式造口患者钡灌肠检查失误的原因分析（附7例报告）

目的探讨临时性袢式造口患者钡灌肠检查失误的原因。方法对我科行临时性横结肠袢式造口和回肠袢式造口7例患者进行造口关闭术前钡灌肠检查吻合口愈合情况发生失误的临床资料进行回顾性分析。结果主要原因有肠道准备差、检查结果有误、钡剂无法灌入、护士无法找到造口远端开口等。结论临床护士必须为患者做好肠道的清洁;加强钡灌肠室护士的培训和制定造口患者钡灌肠检查的操作方法、步骤和注意事项才能更好确保造口患者钡灌肠检查准确顺利进行。     

胃切除术后并发输入空肠袢内疝二例

我院近期遇到胃切除术后并发输入空肠袢内疝2例,报道如下。例1.男,42岁。因十二指肠溃疡行胃大部切除术(毕罗Ⅱ式结肠前)。术后78天晚餐后,突然持续性剧烈腹痛,阵发性加剧,伴恶心呕吐,但吐物不含胆汁。检查:腹软,上腹正中压痛明显,无肌卫和反跳痛,肠鸣音稍亢进。腹透两次见胃泡大小正常,膈下无游离气体,右下腹小肠有积气但未见液平,考虑高位肠梗阻荐行剖腹探查。术中见大网膜与原切口和吻合口粘连,输入空肠袢约15cm疝入并嵌顿于横结肠下方空肠系膜与横结肠系膜间隙中,输入空肠袢充血肿胀,遂行还纳,并行输入输出空肠袢侧侧吻合,术后经过良好,痊愈出院。例2.男,29岁。因十二指肠球部溃疡在我院行胃大部切除术(毕罗Ⅱ式结肠前),术后74天早餐后,     

肠袢式断端结肠造口术——一种结肠造口的新技术

永久性结肠造口术后,部分患者可出现末端结肠坏疽、造口结肠旁内疝、造口狭窄、粘膜脱出或结肠断端缩进腹腔等并发症。土耳其安卡拉大学医学院Bumin等设计了一种结肠造口新技术。具体步骤如下:近断端结肠末端双层关闭。按常规方法在拟造口处腹壁作圆形切口。妥善游离近断端结肠袢,使其侧壁靠近腹壁圆形切口,特别注意肠袢前法结带要与圆孔对正。自腹壁外将肠袢前结肠带两端缝合固定于腹壁圆形切口上。从腹腔内将肠袢结肠带处浆肌层缝合于腹横筋膜上,长约5～7cm,关腹。再从腹壁外面将造口肠袢的浆肌层缝至腹外斜肌腱膜上。切开已固定好的肠袢侧壁,将其全层缝合于皮肤上。     

暂时性造口患者的生活质量:回肠造口与结肠造口比较

在讨论不同造口优缺点时,更多强调造口技巧和并发症,而造口对日常生活影响很少讨论并常常被低估.本文报告造口对患者日常生活的影响与造口护理问题和并发症的关系.方法： !"# a !"@年X3.D' @家教学医院进行了=A例择期或急诊需失功能性造口的结直肠手术,对这%=例袢式回肠造口和%"例袢式横结肠造口的并发症和生活质量进行随机分组比较的前瞻性临床研究.根据社交限制的程度进行分类, !度是社交限制少于!次b周, "度是社交限制等于或超过!次b周, #度是完全的社交孤立.造口护理问题包括造口漏、造口周围皮肤刺激、需要更换造口用品和因造口需…     

肠道暂时性造口与还纳方式及适应证选择90例分析

目的探讨肠造口方式对还纳手术的影响及造口还纳手术适应证的把握。方法选择2004年1月至2010年12月肠造口还纳手术的患者90例,统计分析造口原因、造口肠段和方法、造口方式、还纳时间、手术方式、手术时间、术后并发症及住院时间等。结果端式造口59例(其中单腔造口39例,双腔造口20例),袢式造口31例(其中改进式袢式造口18例),端式造口还纳手术时间显著长于袢式造口还纳手术(P<0.05)。手法吻合72例,吻合器吻合18例;端端吻合50例,端侧吻合40例;共发生近期并发症8例,发生率为8.9%,是否使用器械与使用不同吻合方式其并发症发生率无差别。结论暂时性肠造口应尽量选择袢式造口,尤其是改进式袢式造口;肠造口还纳术前应充分检查排除远端肠道狭窄或损伤处未愈合,造口术后3～6个月可行还纳手术,可以根据需要选择端端或端侧吻合、手法或吻合器吻合。     

自体带蒂皮瓣支撑在末端回肠襻式造口中的应用

对91例低位直肠癌患者行直肠癌根治联合末端回肠保护性造口手术中采用皮瓣支撑和支撑棒支撑两种方式,比较两组患者术前、术中和术后情况。皮瓣支撑组与支撑棒支撑组的手术时间、出血量、造口旁疝及BMI≤24 kg/m 2患者造口渗漏次数相比差异均无统计学意义(均 P>0.05);两组开腹切口感染率、造口周围皮...     

Hartmann术及回肠袢式造口术治疗老年梗阻性肠癌的疗效分析

目的:分析结肠造口术(Hartmann术)及回肠袢式造口术治疗老年梗阻性乙状结肠癌和高位直肠癌的临床效果。方法:回顾性分析经术后病理确诊为梗阻性乙状结肠癌和高位直肠癌患者137例,其中61例患者采用Hartmann术(Hartmann组),66例患者采用回肠袢式造口术(回肠袢式造口组)。对比分析两组患者一、二期手术的围手术期指标和手术并发症差异。结果:Hartmann组与回肠袢式造口组的手术时间、住院时间差异无统计学意义(P0.05);回肠袢式造口组的肛门排气时间、禁食时间显著的短于Hartmann组(P0.05)。一期手术时,Hartmann组和回肠袢式造口组的并发症率分别为6.56%、7.58%,组间无统计学差异(P0.05);二期手术时,回肠袢式造口组的手术时间、肛门排气时间、禁食时间、住院时间显著的短于Hartmann组(P0.05);二期手术时,回肠袢式造口组并发症率为6.06%明显低于Hartmann组的18.03%(P0.05);回肠袢式造口组和Hartmann组的WHOQOL-BREF总分、生理、心理、社会关系及环境四个领域评分差异均无统计学意义(均P0.05)。结论:Hartmann手术与回肠袢式造口手术的效果相当,但相对术后恢复时间较长,II期手术后并发症率较高。     

两种袢式肠造口术并发症发生情况的比较

目的 比较传统肠袢式造口术和改良肠袢式造口术的并发症发生情况.方法 对2000年9月到2011年9月本院进行的29例传统肠袢式造口术(传统组)和33例改良袢式造口术(改良组)并发症发生情况进行比较.结果 改良组在造口旁皮炎、造口粪便转流不全方面明显低于传统组(P＜0.05).结论 改良袢式造口术术后与造口有关的并发症发生率低,易于患者术后对肠造口的管理,且该手术操作较为简单,值得临床推广应用.     

皮桥袢式回肠造口在腹腔镜低位直肠前切除术中应用价值研究

目的 探讨皮桥袢式回肠造口方法在腹腔镜低位直肠前切除术中的应用价值.方法 回顾性分析2015年1月至2019年6月在长江大学附属荆州医院结直肠肛门外科因低位直肠癌行腹腔镜低位直肠前切除术联合回肠造口80例病人资料.根据回肠造口方式不同分为皮桥袢式回肠造口组(40例)和传统袢式回肠造口组(40例).比较两组病人术后造口相...     

Divided loop colostomy that does not prolapse

A loop colostomy in infants and children is usually temporary, made through a small abdominal incision, and frequently prolapses its distal limb within months of its construction. Once this prolapse occurs, its permanent reduction is hardly ever achieved. On the other hand, the colostomy that is made at the time of a major laparotomy and the colostomy whose limbs are brought out through separate abdominal wall openings, rarely prolapse. The advantage of the loop colostomy over the latter two types is that it is easier to make and easier to close. Within the last 3 years, 13 infants and children received a form of loop colostomy that way easy to construct, easy to close, and did not prolapse between these two procedures. The loop colostomy (right transverse in all instances) was brought out through a small right upper quadrant transverse rectus cutting incision, and after the fascia was closed on either side of the colon loop, the latter was divided with the distal stoma tunnelled under the skin about 2.5 cm to the left and sutured to a second skin opening with interrupted 4-0 Dexon sutures. The proximal stoma was sutured to the original skin incision in a similar fashion. Function of this modified loop colostomy was no different, and neither the stomal therapist nor the parents had any trouble caring for this double type of colostomy opening. The closure was not any more difficult. Both stomas were mobilized through one longer than usual transverse incision, trimmed off, and the usual end-to-end colostomy anastomosis was made either extraperitoneal or intraperitoneal.     

Penetrating colon injuries: exteriorized repair vs. loop colostomy

Eighty-five patients with penetrating colon injuries, treated either by exteriorized repair (39) or loop colostomy (46), were analyzed. Missile wounds accounted for 75.3% of the injuries. The Penetrating Abdominal Trauma Index (PATI) was the scoring method employed to assess quantitatively the severity of injuries in each patient. Of 21 patients with right colon injuries, eight were treated by exteriorized repair and the remainder by loop colostomy. PATI and other variables were comparable in both groups. Suture line leaks occurred in two patients (25%) with exteriorized repair. The morbidity was similar in both groups. In left colon trauma, exteriorized repair was employed in 31 patients and 33 underwent loop colostomy. The injury severity indices, clinical status, and time lapse to laparotomy were similar in both groups. Colostomy was avoided in 67.7% (21 of 31) patients with exteriorized repair. The incidence of abscesses was significantly higher in the colostomy group compared to the group treated by exteriorized repair (24.2% and 6.4%, respectively; p less than 0.05). The length of hospital stay was shorter after exteriorized repair (17.2 days vs. 23.2 days; p less than 0.05). All three mortalities (3.5%) were related to associated injuries. We conclude that exteriorized repair is a safe and superior alternative to loop colostomy in penetrating colon trauma.     

Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision

BACKGROUND: The aim of this study was to compare loop ileostomy and loop transverse colostomy as the preferred mode of faecal diversion following low anterior resection with total mesorectal excision for rectal cancer. METHODS: Patients who required proximal diversion after low anterior resection with total mesorectal excision were randomized to have either a loop ileostomy or a loop transverse colostomy. Postoperative morbidity, stoma-related problems and morbidity following closure were compared. RESULTS: From April 1999 to November 2000, 42 patients had a loop ileostomy and 38 had a loop transverse colostomy constructed following low anterior resection. Postoperative intestinal obstruction and prolonged ileus occurred more commonly in patients with an ileostomy (P = 0.037). There was no difference in time to resumption of diet, length of hospital stay following stoma closure and incidence of stoma-related complications after discharge from hospital. A total of seven patients had intestinal obstruction from the time of stoma creation to stoma closure (six following ileostomy and one following colostomy; P = 0.01). CONCLUSION: Intestinal obstruction and ileus are more common after loop ileostomy than loop colostomy. Loop transverse colostomy should be recommended as the preferred method of proximal faecal diversion.     

Evolution of the treatment of the injured colon in the 1980s

During the past 10 years, 1006 patients with colon injuries were treated in an urban trauma center. Primary repair, including suture repair and resection with anastomosis, was performed in 614 patients (61%), colostomy in 284 patients (28%), and exteriorized repairs in 83 patients (8.3%). In the remaining 25 patients (2.5%) who were exsanguinating, the colon injuries were ligated. Independent risk factors for adverse outcomes (defined as a fecal fistula, abdominal abscess, stomal complication, or death from multisystem failure) were identified using multiple logistic regression analysis. These factors were used to match patients at similar risk within different treatment groups, and odds ratios for each treatment were calculated. The odds ratios for primary repair, colostomy, and exteriorized repair were 1.0, 1.9, and 2.0, respectively. Therefore, the chance of an adverse outcome was twice as great for both exteriorized repair or colostomy as for primary repair. It is concluded that further increases in the use of primary repair are warranted.     

Early closure of transverse loop colostomies.

A transverse loop colostomy was constructed in 60 patients at the time of primary elective surgery and the stoma was then resected within one month under antibiotic cover. There was a single death unrelated to operation. Four patients developed faecal leakage, 1 became obstructed, and 6 had infected wounds. With the exception of colostomy closure following sutured coloanal anastomosis a transverse loop colostomy can be closed within one month of construction with acceptable morbidity.     

Colostomy complications in infants and children.

Seventy-seven colostomies were performed in 74 patients: 35 for high anorectal agenesis, 34 for Hirschsprung's disease, 2 for necrotizing enterocolitis, 2 for small left colon syndrome, and 1 for volvulus neonatorum with perforation. There were 55 boys and 19 girls with a mean age of 0.8 years. The different types of colostomies performed were: transverse loop in 48, sigmoid loop in 21, transverse end in 4, descending end in 2, sigmoid end in 1, and transverse double barrel in 1. Forty-seven patients developed stomal complications (74.6%). Eleven patients died, but only in 2 (2.7%) were the deaths directly related to colostomy formation. Five patients required stomal revision (6.8%). The incidence of complications was neither related to the age nor to the primary indication for the colostomy, but sigmoid colostomy was associated with a lower complication rate compared to transverse colostomy (52% versus 81% 0.02 greater than p greater than 0.01). A sigmoid loop colostomy should be used whenever possible.     

Role of protective colostomy in colorectal surgery. Apropos of 68 cases

A retrospective study was made from the records of 68 patients who had temporary loop colostomy with left colectomy between 1975 and 1985. Six fecal fistula occurred. Two of these patients died in spite of the colostomy. The colostomy closure was complicated by six leakages and four wound infections. The results are compared with those from literature. Finally loop colostomy for protecting an anastomosis keeps good indications with sub-obstructions and acute obstructions without large colectasia, infections without abscess, bowels no or bad prepared, and some low colo-rectal anastomosis. Large bowel obstruction with megacolon, and peritonitis avoid all kind of anastomosis. The colostomy closure is a high colonic surgery procedure. It must occur three months after its formation. A barium enema is necessary before loop colostomy closure.     

Wounds of the colon and rectum

The mortality from wounds of the large bowel and rectum will be less in World War II than in World War I, due to the better nutritional state of our soldiers, blood and plasma infusions, chemotherapy and early surgery.The best method of treating wounds of the colon is by exteriorization, when possible. If exteriorization is not possible, the wounds of the colon should be sutured and a proximal colostomy performed. Resection is rarely indicated.When colostomy is performed as in exteriorization or as a colostomy proximal to a wound in the distal bowel or as a colostomy proximal to a resected and sutured colon, the colon should be completely transected and the two ends of the bowel brought out on the abdominal wall at different sites. This procedure prevents spillage of fecal material into the distal loop, prevents intestinal obstruction, prevents interposition of a loop of small bowel in a septum, and after proper irrigation of the proximal and distal loops permits end-to-end anastomosis with ease.Mikulicz colostomy was commonly used in the earlier stages of the war. In our forty cases, one developed intestinal obstruction and in eighty per cent, it was feasible to clamp the spur and close the colostomy. In twenty per cent it was necessary to mobilize the colostomy, dissect the wedge and perform an end-to-end anastomosis, intraperitoneally.Devine colostomy avoids the difficulties presented by Mikulicz procedure but is more time consuming.Edema of the colostomy has been frequently met and may be the cause annoying delay in closure of the colostomy. The edema may be satisfactorily treated by reducing the colostomy into the lumen, applying a firm tight abdominal binder, and by having the patient lie prone most of the day.A colostomy should not be made through the exploratory incision because of the great incidence of sepsis and dehiscence. A separate stab wound is made for a colostomy.With injuries of the colon and rectum in which the wounds were not sutured and with combined wounds of the rectum and bladder, where a proximal colostomy was performed, a special problem is presented. Before closing the colostomy it is necessary to wait six months or until the wound of the bowel has been proven healed by proctoscopy or barium enema, and to prove that there is no communication between the exterior wound and the lumen of the bowel by lipiodol injection. Otherwise a recurrence of the fecal fistula may be met.Cases are presented which show how wounds of every part of the colon and rectum and their complications have been handled at different echelons.     

A simplified method of diverting colostomy

The diversion of the fecal stream is necessary in some situations, to protect lower anastomosis, or in emergency operations on the colon. Several techniques of colostomy were described, in order to improve the sustaining bridge to the skin level, for the immediate placement of a colostomy bag. A simplified method of diverting colostomy is presented: a plastic tube bridge is passed subcutaneously, extraperitoneally, under the colon loop, permitting an immediate opening of the loop and the placement of the colostomy bag.     

Unopened colostomy in colorectal surgery: a renewal interest?

INTRODUCTION: Anastomotic leak or disruption is a grave complication of colorectal surgery. Protection of an at-risk anastomosis by an upstream open diverting colostomy (OC) reduces this gravity. An unopened upstream loop colostomy is a surgical alternative which may diminish the unpleasant consequences of an open colostomy while maintaining the option of diversion in case of need. The aim of this study is to report the results of this approach and to define its indications. MATERIAL [corrected] AND METHODS: We report a retrospective series of 34 cases of unopened diverting loop colostomy to protect an at-risk colorectal anastomosis. Indications for this procedure were stool-laden bowel (59%), low serum albumin (11.5%), local inflammation (11.5%), and very low placed anastomosis (17.5%). RESULTS: The loop colostomy was eventually opened after surgery in six cases because of anastomotic leakage diagnosed clinically and/or detected by water soluble contrast opacification which was performed routinely on the sixth post-operative day. In all six cases, there was no need for an urgent surgical intervention. In 28 cases, the anastomosis healed without complication and the exteriorized loop was returned to the abdominal cavity seven days after the initial surgery. This was a short, simple procedure with an average operating time of ten minutes. Average hospital stay after returning the unopened colostomy to the abdomen was two days. CONCLUSION: Unopened loop colostomy offers the advantages of protection of a colorectal anastomosis without proper morbidity or mortality, shorter hospitalization, and improved psychological comfort for the patient. It's principal indication is to minimize the risks related to leakage from an at-risk colorectal anastomosis.