顽固性溃疡性结肠炎的外科治疗

Surgical treatment of refractory ulcerative colitis, report of 60 cases

目的评价顽固性溃疡性结肠炎（ulcerativecolitis，UC）患者采用全结直肠切除、回肠贮袋肛管吻合手术（ilealpouch-analanastomosis，IPAA）治疗的临床效果和应用价值。方法对1990－2010年60例符合手术指征的顽固性UC患者行IPAA治疗，观察分析其术后近期、远期并发症，评价肛门自制功能及术后粪便性状分类，采用克利夫兰生活质量量表（ClevendGlobalQualityofLifeindex，CGQL）进行手术前后生活质量评估对比，采用单因素方差方法进行统计分析。结果60例术后随访均2年以上。术后近期并发症发生率为15％（9／60），包括腹腔、盆腔感染、贮袋吻合口漏、贮袋出血、贮袋阴道瘘和肠梗阻等，远期并发症发生率12％（7／60），包括贮袋炎、肠梗阻和男性性功能障碍等。术后12个月的24h和夜间大便次数分别为（3．5±1．3）次和（1．4±0．6）次。气便分辨能力良好者93％（56／60），需要日常戴垫者3％（2／60）。Kirwan分级评价肛门自制功能结果为I级者54例（90％），Ⅱ级者4例（7％），Ⅲ级者2例（3％）。Bristol粪便分类评价结果为Ⅳ类者31例（52％），V类者25例（42％），Ⅵ类者4例（6％）。CGQL量表法评价IPAA手术前后生活质量，术后较术前明显改善（F＝12．368，P〈0．05）。结论顽固性UC具备外科治疗指征，IPAA是首选术式，临床应用安全．疗效满意，生活质量明显改善。

Objective To evaluate the clinical effect of restorative proctocolectomy with ileal pouch-anal anastomosis （IPAA） for refractory ulcerative colitis （UC）. Methods In this study 60 refractory UC patients received IPAA operation during the period of 1990 to 2010. Data were collected regarding early and late postoperation complications, anal continence function, and characteristics of feces. The patients＇ quality of life was objectively accessed using the Clevend Global Quality of Life （CGQL） index. One-way analysis of variance was used. Results Mean follow-up period was 2 years. Early postoperative complication rate developed in 15% （9/60）, including abdominal or pelvic infection, anastomotic leak, pouch bleeding, pouch-vaginal fistula, and intestinal obstruction. Late postoperative complication rate was 12% （7/60）, including pouchitis, intestinal obstruction, and male sexual dysfunction. Stool frequency per 24 hours and that at night was 3.5 ：t： 1.3 and 1.4 ：l： 0. 6. 93% （56/60） patients differentiated gas and feces well and 3 % （2/60） needed daily pads. According to Kirwan Grading Scale, anal function outcomes were Grade Ⅰ ： 54 （90%）, Grade Ⅱ ： 4 （7%）, and Grade Ⅲ ： 2 （3%）. According to Bristol Stool Form Scale, characteristics of feces were Grade Ⅳ： 31 （52%）, Grade V ： 25 （42%）, and Grade Ⅵ： 4 （6%）. Postoperative CGQL result showed a much better quality of life than preoperative CGQL （ F = 12. 368, P 〈 0. 05 ）. Conclusions Refractory UC is surgically indicated and IPAA is the ooeration of choice with safety, satisfactory long-term outcome and improved quality of life.