经骶尾部入路手术治疗骶前肿物33例临床分析

Clinical analysis of treating presacral masses by posterior approach in 33 patients

目的:探讨骶前肿物的临床特点及经骶尾部入路手术的治疗经验。方法:收集2008年6月至2017年6月诊治的33例骶前肿物患者的临床资料并结合文献分析。结果:45.5%的患者无症状,部分患者表现为肛门部肿痛(27.3%)、坠胀(21.2%)、排便困难(3.0%)、尿频(3.0%)等。75.8%的患者直肠指检可触及肿物。在诊断骶前肿物的性质方面盆腔MRI检查的准确率为69.7%。本组患者均经骶尾入路手术,术中见36%的患者骶前肿物与直肠致密粘连。术后病理证实骶前先天性囊肿18例(表皮样囊肿7例,皮样囊肿2例,尾肠囊肿6例,骶前囊肿3例),畸胎瘤3例,恶性肿瘤3例(黏液腺癌2例,转移腺癌1例),交界性肿瘤2例(黏液性肿瘤1例,囊腺瘤1例),脂肪瘤、神经鞘瘤、神经内分泌肿瘤、错构瘤、孤立性胶原瘤、肌纤维母细胞瘤样增生、吻合器痔上黏膜环切术后异位肠壁各1例。全组患者无术中大出血、围手术期死亡、肛门失禁等并发症发生。术后出现直肠阴道瘘1例,行乙状结肠单腔造口,术后1周患者出院。出现切口感染2例,经外科引流、换药后痊愈。结论:骶前肿物临床表现多样,直肠指检和盆腔MRI检查是病情评估的重要手段。经骶尾部入路手术治疗低位骶前肿物,手术创伤小,术后并发症发生率低,是一种安全有效的手术方式。

Objective： To explore the clinical characteristics and treatment experience of presacral masses by posterior approach. Methods： 33 cases of presacral masses（ from 2008 to 2017） were analyzed retrospectively combined with literature review. Results： Within all patients enrolled in the group,45%（ 15/33） were asymptomatic and were discovered incidentally,27. 3%（ 9/33） had sacral or rectal pain,21. 2%（ 7/33） had the sensation of rectal tenesmus,3. 0%（ 1/33） had difficult defecation,and 3. 0%（ 1/33） had frequent urination. 75. 8%（ 25/33） of patients had a palpable mass on digital rectal examination. The diagnostic accuracy of pelvic MRI in patients with presacral masses was 69. 7%. All patients underwent resection of presacral masses by posterior approach and36%（ 12/33） among them were found to have dense adhesion between rectal and presacral masses. Of the 33 patients,there were 18 cases of congenital cyst,3 of teratoma,3 of adenocarcinoma,2 of borderline tumor,1 of lipoma,1 of schwannoma,1 of neuroendocrine neoplasm,1 of hamartoma,1 of isolated collagenoma,1 of myofibroblastic hyperplasia,and 1 of ectopic bowel wall after the procedure for prolapse and hemorrhoids. No complication occurred during the operation. There was no operative mortality and no postoperative faecal incontinence. Rectovaginal fistula occurred in 1 patient,and recovered by sigmoidostomy. 2 cases with incision infection were recovered through conservative therapy. Conclusions： The clinical manifestations of presacral masses are varied,digital rectal examination and pelvic MRI plays an important role in the diagnosis of these masses. Trans-sacral approach is a safe and effective surgical procedure for the treatment of low presacral masse for its small surgical trauma and low incidence of complications.