结肠内旁路在中低位直肠癌保肛手术中的应用

Clinical application of intracolonic bypass in sphincter preserving surgery for middle and low rectal cancer

目的介绍结肠内旁路技术在中低位直肠癌保肛术中的应用方法并评价其临床意义。方法 148例中低位直肠癌患者随机分成两组:一组为研究组(78例),在行直肠癌低位前切除的基础上,用生物可降解吻合环及避孕套在吻合口上方5cm处做成结肠内旁路以保护吻合口;一组为对照组(70例),在行直肠癌低位前切除术的基础上,附加预防性末端回肠造口。观察两组治疗结果。结果两组患者在性别、年龄、肿瘤位置、肿瘤大小、吻合口距肛缘距离等生理、病理因素方面差异无统计学意义(P>0.05)。两组术后肠功能恢复时间均为2～5天(P>0.05)。研究组吻合口瘘发生率6.4%(5/78),吻合环自然排出时间为术后14～23天(平均17天),无引流管相关并发症,术后6个月内有5.1%(4/78)的病例出现轻度吻合口狭窄,吻合口瘘者漏后引流时间平均7.1天;对照组吻合口瘘发生率10.0%(7/70),37.1%(26/70)的病例伴有造口相关并发症,6个月后有30%(21/70)的病例出现吻合口轻度狭窄,5.7%(4/70)的病例出现吻合口重度狭窄,需进行松解治疗,吻合口瘘后引流时间平均18.2天。两组吻合口瘘发生率差异无统计学意义(P>0.05)。但在吻合口瘘后骶前引流管引流时间及术后6个月吻合口狭窄方面两组差异有统计学意义(P<0.05)。结论与预防性回肠末端造口相比,结肠内旁路技术简单,安全,可有效保护吻合口,降低了吻合口瘘带来的风险,减少了吻合口狭窄的发生率。

Objective To introduce the technique of intracolonic bypass in sphincter preserving surgery for middle and low rectal cancer,and to evaluate its clinical significance.Methods 148 patients with middle and low rectal cancer were randomly assigned to study group（n=78） and control group（n=70）.The study group was added with intracolonic bypass which was made by biofragmentable anastomosis ring（BAR） and a latex condom 5 cm above the anastomotic stoma during the low anterior resection of rectal cancer.The control group was added with protective ileostomy during the operation.The results of surgery in the two groups were observed.Results There were no significant differences in physiopathological factors such as sex,age,location of tumor,size of tumor,site of anastomotic stoma between two groups（P0.05）.All the patients had bowel movement in 2锝？ days after operation（P0.05）.In the study group,the anastomotic leakage rate was 6.4%（5/78）,the BAR and condom were expelled naturally from anus at 14锝？3 days after operation.There were no bypass related complications.Light anastomotic stenosis occurred in 4 cases（5.1%） 6 month after operation.In the cases with anastomotic leakage,the time of abdominal drainage after leakage was 7.1 days.In the control group,anastomotic leakage rate was 10.0%（7/70）.Six months after operation,stoma related complications occurred in 26 cases（37.1%）,light anastomtic stenosis occurred in 21 cases（30%）,and severe anastomotic stenosis occurred in 4 cases（5.7%）.In the cases with anastomotic leakage,the time of abdominal drainage after leakage was 18.2 days.There was no significant difference in the rate of anastomotic leakage between two groups（P0.05）.But there were significant differences in the time of abdominal drainage after leakage and anstomotic stenosis 6 months after operation（P0.01）.Conclusion Compared with protective ileostomy,intracolonic bypass is a simple,safe and effective method.It can effectively protect anastomotic stoma,reduce the hazard induced by anastomotic leak,and reduce the incidence of anastomotic stenosis.