管状吻合器使用不当致吻合口梗阻35例临床分析

Anastomotic obstruction caused by incorrect use of circular stapler:An analysis of 35 cases

目的探讨管状吻合器在胃肠外科应用中致吻合口梗阻的原因及其预防和治疗方法。方法回顾性分析2003年7月至2014年12月东南大学附属中大医院普外科使用管状吻合器发生吻合口梗阻的35例病人的临床资料。从吻合口类型、发生部位、梗阻类型、发现梗阻时间等方面进行分析。结果 (1)吻合口的类型:小肠端对侧吻合口29例(82.9%),食管空肠端对侧吻合口2例(5.7%),回肠结肠侧对端吻合口2例(5.7%),结肠直肠侧对端吻合口2例(5.7%)。(2)吻合口梗阻发生在小肠33例(94.3%),梗阻发生在结肠2例(5.7%)。(3)吻合口梗阻类型:完全梗阻32例(91.4%)、部分梗阻3例(8.6%)。(4)吻合口梗阻发现的时间:术中即刻发现吻合口梗阻31例(88.6%),术后因吻合口梗阻再次手术时发现4例(11.4%)。对于术中发现的吻合口梗阻,及时重新吻合;对于术中未发现的吻合口梗阻,须再次手术,重新吻合。结论管状吻合器使用不当可导致肠管的黏膜和黏膜下层滑动,对侧的黏膜和黏膜下层被钉入吻合口,最终导致吻合口梗阻;术中选择合适的吻合器、精湛的吻合技术和吻合后常规检测吻合口,可有效避免吻合器使用不当而导致的吻合口梗阻。

Objective To explore the mechanisms of end-to-side anastomotic obstruction and how to prevent and treat anastomotic obstruction made by circular stapler. Methods The clinical data of 35 cases of anastomotic obstruction resulting from end-to-side anastomosis made by circular stapler performed between July 2003 and December 2014 in Department of General Surgery, Zhongda Hospital of Southeast University were analyzed retrospectively. The type of the stoma, the site of obstruction,the form of obstruction and the therapy method were analyzed respectively. Results （1） According to the type of end-to-side stoma, 29 cases （82.9%） of small intestinal anastomosis, 2 cases （5.7%） of esophagojejunal anastomosis, 2 cases （5.7%） of ileocolie anastomosis and 2 cases （5.7%） of colonic anastomosis were found. （2） The sites of obstruction were analysised, which included 33 eases （94.3%）of anastomotie obstruction in bowel, and 2 eases （5.7%） in colon. （3） Thirty-two eases （91.4%） of complete obstruction and 3 eases （8.6%） of incomplete anastomotie obstruction were observed in 35 eases. （4） Thirty-one eases （88.6%）were detected intraoperatively and the anastomoses were reconstructed immediately. Four eases （21.1%） were not detected in the operation and developed bowel obstruction after operation. Relaparotomies and reanastomoses should be undertaken. Conclusion The mueosa and submueosa in intestine were pushed forward by the circular stapling device and accumulated around the anastomosis. When the stapler was fired, the mueosa and submucosa were stitched into the stoma and caused the anastomotie obstruction. Proper stapler, excellent technique and careful examination after completing the anastomosis may avoid the anastomotie obstruction.