直肠癌全直肠系膜切除术后直肠阴道瘘原因与防治(附18例报告)

The cause,prevention and treatment of rectovaginal fistula following total mesorectal excision in rectal cancer:Report of 18 cases

目的探讨直肠癌全直肠系膜切除术后直肠阴道瘘发生的原因以及防治方法。方法回顾分析近5年来我院18例女性直肠癌全直肠系膜切除术后直肠阴道瘘的临床资料。结果发现直肠阴道瘘多发生于中低位直肠癌行全直肠系膜切除保肛手术的患者。瘘的发生与肿瘤的位置、肿瘤的分期、肿瘤距肛门口的距离,以及手术技巧、手术难度、引流方法有关,而与是否进行预防性造口,以及是否采用腹腔镜手术无关。预防上强调应重视术中直肠前壁的锐性分离、结肠直肠吻合以及术后盆腔的负压引流。治疗上应首先进行保守治疗,即肠内营养、阴道冲洗、早期配合肠外营养及全身或局部抗炎治疗,保守治疗无效时考虑结肠或末端回肠造口。结论大部分直肠阴道瘘通过保守治疗可以治愈,若长期不愈应考虑吻合口肿瘤复发的可能。

Objective To observe the cause, prevention and treatment of rectovaginal fistula following total mesorectal excision （TME） in rectal cancer. Methods Data of 18 patients with rectovaginal fistula following total TME in rectal cancer in our hospital were retrospectively analysed. Results It was found that rectovaginal fistula often occurred in patients with middle and low rectal cancer after total mesoreetal excision. The cases of rectovaginal fistula were related to tumor site, tumor stage, distance of tumor to anal, the skill of operation, the degree of operation difficulty and method of drain. But there were no associations between rectovaginal fistula and the diverting ostomy established atthe initial operation or laparoscopic operation. In order to prevent rectovaginal fistula, sharp dissection between rectrum and vagina, the vacunm-assisted closure in pelvis and the coloanal or colorectal anastomosis technique should be stressed. In the treatment of rectovaginal fistula, conservative treatments should be first performed, they included enteral nutrition, vaginal washing, and loeal or systemic anti-inflammatory treatment in the early stage. Only unrecovering patients should undergo diverting ostomy. Conclusion Most of patients with rectovagianl fistula can be cured. If rectovaginal fistula is hard to be healed for a long time after conservative treatments, the local recurrence of rectal cancer shall be considered.