目的:评价双吻合器技术在超低位直肠癌保肛术中的实用性。方法:回顾分析我院2006年1月至2009年11月60例超低位直肠癌应用双吻合器技术保肛的临床资料。结果:本组手术中结直肠56例吻合顺利,术后1例吻合口瘘及无出血病例发生,吻合口狭窄2例(333％),无手术死亡病例。结论:应用双吻合器技术可极大提高超低位直肠癌保肛率且并发症少,值得推广。
直肠癌是临床常见的恶性肿瘤之一，手术切除仍是目前治疗直肠癌的重要手段，Miles手术经历近100年的历史，已成为治疗直肠癌的金标准。当Miles手术推行半个世纪以后，人们开始对该手术需做永久性腹部结肠造口，给患者带来精神上的负担、生活和社交上的不便而引起重视。近年来，随着国民经济的发展和人民生活水平的不断提高，人们越来越重视在保住生命的同时，更要求有良好的生活质量。随着对直肠癌的解剖、病理、生物学特性及淋巴结转移规律的深入研究和探索，提出了新的概念、新的理论、新的观点和新的术式，使保留肛门括约肌功能的直肠癌根治术逐年增多，约占直肠癌外科手术的70%。保肛术式的发展逐渐取代了Miles手术，可显著提高患者的生活质量。目前直肠癌的外科治疗在知识创新和技术创新的推动下已进入一个蓬勃发展的阶段。
Seven hundred and eighty three cases of rectal carcinoma were treated in this hospital Jan. 1986 to Dec. 1994. There were 552 cases(70.5%)in which the tumor located in the middle and lower portion of the rectum. Of this group, 201 cases were treated with the operations of preservation of sphincter ani. The operations included transabdomino-sacral resection(5 cases), transpubic resection(5 cases), Dixon’s operation(67 cases), perineal pull through anastomosis(44 cases), Welch’s operation(68 cases), and local resection(12 cases). The 3-year survival rate was 90.9%. We consider that anal sphincter preservation is rational in the treatment of rectal cancer of middle and lower segment, As often os the radical resection and maintenauce of normal defecation is concerned, it is suitable for rectal carcinomas in Duke’s A and B1 stages. Combined treatment is necessary to prevent the recurrence and increase the survival rate.
目的:探讨保留肛门外括约肌低位直肠癌保肛手术的应用。方法: 在全直肠系膜切除的基础上,应用国产一次性管状吻合器,对32例低位直肠癌行保留肛门外括约肌超低位结肛吻合,随访12～36个月。回顾性分析其根治性、术后排便功能、手术并发症、局部复发率。结果: 全组病例术后病理检查无切端癌残留,无大便失禁,无吻合口漏;全组无手术死亡;肿瘤局部复发率9.4%(3/32)。结论: 低位直肠癌保留肛门外括约肌保肛手术,遵循肿瘤根治的原则下,能保留患者正常的肛门排便功能,明显改善该类患者的生活质量。
Objective To compare the outcomes of low/ultra-low anterior rectal resection and valgus resection in elder patients with rectal or anal cancer. Methods The clinical data of 184 patients with rectal or anal cancer， who were treated with extreme sphincter preserving surgery in West China Hospital from January 2009 to December 2011， were collected and analyzed retrospectively. The intraoperative and postoperative indexes between low/ultra-low anterior rectal resection group and valgus resection group were compared. Results ①There were no significant differences in the age，body mass index， gender， diameter of tumor， TNM stage， degree of differentiation， histological type， gross type， and complications before operation， such as hypertension， chronic obstructive pulmonary disease， cardiovascular diseases， diabetes， renal disease， and hypoproteinemia in two groups （P＞0.05）. ②Compared with the low/ultra-low anterior rectal resection group， the distance from the anal verge to the tumor was shorter （P＜0.05） and the distance of distal resec-tion margin of tumor was longer （P＜0.05） in the valgus resection group. ③There were no significant differences in the operation time， blood loss， ASA grade， and the postoperative complications in two groups （P＞0.05）. ④There were no significant differences in the duration of pulling out nasogastric tube， urinary catheter， and drainage tube， the duration of first passing flatus， first defecation， first oral intake， and first ambulation， and hospitalization cost （P＞0.05）. But the postoperative hospital stay and total hospital stay in the valgus resection group were significantly longer than those in the low/ultra-low anterior rectal resection group （P＜0.05）. ⑤All the patients were followed-up for 6-24 months （average 13 months）. During the following-up， only 1 case suffered local tumor recurrence in the valgus resection group. One case suffered distant metastases in the ultra-low anterior rectal resection and valgus resection group， respectively. Eight cases （4.35%） died， of which 4 cases （4.04%） in the low/ultra-low anterior rectal group and 4 cases （4.71%） in the valgus resection group. All the patients were in functional recovery of anal control after operation. Conclusions As the extreme sphincter preserving surgery for elder patients with rectal or anal cancer， the low or ultra-low anterior rectal resection and valgus resection could both be used for elder patients with extreme-low rectal or anal cancer. However， valgus resection results in longer distal surgical margin than that low/ultra-low anterior rectal resection， and it is suitable for the patients with shorter distances from the anal verge to the tumor.
目的 评价超低位直肠癌保肛手术的安全性和疗效。方法 回顾性分析笔者所在医院2004年10月至2010年12月期间收治的48例行管扎式结肠肛管吻合术的超低位直肠癌患者的临床资料。结果 48例患者手术均获成功，手术时间120～221min，（178±37） min； 术中出血量70～210mL，（167±38） mL； 术后排气时间2～5d，（3.1±1.2） d； 术后排便时间8～11d，（9.1±1.4） d。保留完整齿状线者27例，保留齿状线≥1/2者14例，保留齿状线＜1/2者7例。所有患者均获随访，随访时间1～7年，平均32个月。术后有3例患者发生吻合口狭窄，无吻合口漏发生。术后1年有25例患者的肛门括约肌功能达优，其中保留完整齿状线者18例，保留齿状线≥1/2者7例； 良好16例，其中保留完整齿状线者9例，保留齿状线≥1/2者7例； 一般7例，均为保留齿状线＜1/2的患者，优良率为85.4%（41/48）。随访期间，2例患者分别于术后9个月和13个月直肠癌局部复发，其中1例于术后23个月死亡。结论 超低位直肠癌保肛手术是一种安全的、可行的手术方式，可以在根治的前提下达到保肛的目的。