慢性放射性直肠病单中心十年系列研究荟萃

lO-year series studies of chronic radiation proctopathy from The Sixth Affiliated Hospital of Sun Yat-sen University

慢性放射性直肠病（CRP）是指盆腹腔恶性肿瘤接受放疗后出现的迟发的迁延反复的放射性直肠损伤．以进行性的组织纤维化为特征，其症状具有多样性及非特异性．临床诊疗迁延，易出现严重并发症。患者生活质量受到极大影响。目前国内外尚未形成规范的诊疗指南。总结中山大学附属第六医院CRP的10年诊治经验：（1）直肠放射性损伤区域除存在血管病变、间质纤维化、黏膜溃疡、水肿及炎性细胞浸润外，其黏膜下层微血管计数明显减少。该区域血管抑素表达量显著增加，进而导致了黏膜层的代偿性毛细血管扩张及间质纤维化的不断发展；（2）国际上首次将直肠超声检查用于CRP的诊断，根据直肠壁的分层增厚改变及血流信号增加，对CRP患者进行疾病活动严重程度评估，具有良好的诊断价值；（3）以轻中度直肠出血、中重度出血、重度顽固性出血分别采用以黏膜保护剂为基础的复方制剂保留灌肠、改良的甲醛局部灌注止血法及近端结肠造口术，取得了满意的治疗效果；（4）对于出现晚期并发症的CRP患者，推荐行改良Parks手术；（5）对于接受新辅助放化疗的直肠癌患者，创新性采用“近侧扩大切除术”（天河术）以减少术后吻合口并发症的发生风险。

Chronic radiation proctopathy （CRP） is the delayed adverse effect after radiotherapy for pelvic malignancies. It is characterized as progressive fibrosis in pathology. The symptoms are usually unspecific which include rectal bleeding, perianal pain, tenesmus, stool frequencies and so on. The course of CRP can present from months to years after radiation. Severe complications can occur in the late stage and will greatly affect the quality of life. Currently, there is no standard guides for diagnosis and treatment of CRP. For advancing the knowledge and proposing new treatment modalities of CRP, this article summarizes our 10- year experience as follows： （1） Except the existence of vessel damage, interstitial fibrosis, mucous ulcer, edema and inflammatory cell infiltration in the radiation-injury area, the capillary count was obviously reduced in mucous substratum and angiostatin expression up-regulated remarkably in above area, resulting in the continuous development of compensatory capillary expansion and interstitial fibrosis in mucous layer. （2） Rectal ultrasound examination was used the first time to diagnose CRP. According to thickness change of rectal wall layer and increase of blood signal, severity of CRP activity was evaluated with good diagnostic value. （3） For slight- moderate rectal bleeding, moderate-heavy bleeding and heavy bleeding, application of retention enema with compound preparation based on mucoproteetive agents, regional perfusion hemostasis with formaldehyde and proximal eolostomy gained satisfactory efficacy. （4） Improved Parks operation should be recommended for CRP patients with advanced complications. （ 5 ） For rectal cancer patients receiving neoadjuvant chemoradiotherapy, ＂proximal extended excision＂ should be performed innovatively to decrease the risk of anastomotic complications （Tianhe Procedure）.