尿粪分流手术在治疗膀胱全切Sigma直肠膀胱术后严重代谢紊乱中的应用价值

Value of urine excrement shunt surgery for the treatment of severe metabolic disorders after Sigma rectum pouch of bladder cancer

目的 探讨尿粪分流手术在治疗膀胱癌膀胱全切Sigma直肠膀胱术后严重代谢紊乱中的应用价值. 方法 2011年7月至2013年12月收治4例因膀胱癌行根治性膀胱切除＋Sigma直肠膀胱术的术后严重代谢紊乱患者,均为男性,年龄58- 82岁,平均（72±10）岁.4例患者术后1-4年反复出现乏力、纳差,甚至意识障碍,经血气分析和血生化检验均诊断为高氯性代谢性酸中毒和低钾血症,伴有肾功能损害.尿粪分流手术前1周查血pH 7.15±0.08,碳酸氢盐（7.8±4.7）mmol/L,钾（3.1 ±0.2） mmol/L,氯（110.3±4.7） mmol/L,肌酐（314.8±66.4） μmol/L.本组4例均于全麻下行储尿囊腹壁造口＋乙状结肠直肠吻合术.由下腹正中原切口进入,游离储尿囊、乙状结肠和直肠,于乙状结肠和储尿囊交界处用直线切割闭合器横断肠管,于输尿管与结肠储尿囊吻合口下方用弧形切割闭合器横断直肠,用一次性管型吻合器将乙状结肠和直肠于储尿囊左侧端端吻合,浆肌层缝合加固.切开储尿囊,并从切口拉出做腹壁造口.比较手术前后患者的动脉血气分析、血清电解质和肾功能指标.结果 本组4例手术时间（256.3±26.9） min,出血量（147.5±111.2） ml,未出现手术相关并发症.术后1周复查血碳酸氢盐（19.1±4.8） mmol/L,与术前比较差异有统计学意义（P＜0.05）.术后1个月复查血pH 7.38±0.05,血钾（3.9±0.3） mmol/L,肌酐（208.8±50.8） μmol/L,与术前比较差异均有统计学意义（P＜0.05）.术后6个月复查血氯（102.4±5.8） mmol/L,与术前比较差异有统计学意义（P＜0.05）.随访6-36个月,4例均未发生严重酸中毒和电解质紊乱. 结论 储尿囊腹壁造口＋乙状结肠直肠吻合术可有效纠正根治性膀胱切除＋Sigma直肠膀胱术后患者的酸中毒和电解质紊乱,是处理此类严重并发症可选择的治疗方法.

Objective To investigate the application value of urine excrement shunt surgery for the treatment of severe metabolic disorders after Sigma rectum pouch of bladder cancer.Methods From July 2011 to December 2013,4 male patients （mean age 72±10 years old,ranged from 58-82 years old）,who received radical cystectomy and Sigma rectum pouch due to bladder cancer,were admitted in our hospital.Within four years after the operation,all patients complained about the recurrent fatigue,anorexia and even unconsciousness.The hyperchloremic metabolic acidosis,hypokalemia and renal dysfunction were diagnosed by blood gas analysis and biochemical tests.One week before urine excrement shunt operation,the arterial blood pH,HCO3-,serum potassium,chloride and creatinine were （7.15±0.08）,（7.8±4.7）mmol/L,（3.1 ±0.2） mmol/L,（110.3±4.7） mmol/L,（314.8±66.4） μmol/L,respectively.They received urine excrement shunt surgery.The lower abdominal mid-line incision was made and the pouch was isolated from intestinal tract.The abdomen ostomy was made and the sigmoid colon and rectum were re-coincided in order to recover the intestinal continuity.The results of blood gas analysis,electrolytes and renal function after surgery were compared with those before surgery.Results The average operation time was （256.3±26.9） min and the mean volume of bleeding was （147.5±111.2） ml.There was no surgery related complication.Blood bicarbonate was （19.1±4.8） mmol/L one week after surgery,which was significantly improved than that before operation （P〈0.05）.One month later,blood pH level descended to （7.38±0.05）,potassium level was （3.9±0.3） mmol/L,creatinine was （208.8±50.8） umol/L.All of them were significantly improved,compared with those results before surgery （P〈0.05）.Blood chloride was significantly reduced to （102.4±5.8） mmol/L （P〈0.05） after 6 months of operation.Nobody developed severe acidosis and electrolyte disturbances during 6 months to 3 years＆#39; follow-up.Conclusions Urine excrement shunt surgery can effectively corrected the acidosis and electrolyte disturbances due to the radical cystectomy and Sigma rectum pouch.It might be a alternative method to treat such kind of severe complications.