Altemeier术和Delorme术治疗直肠脱垂的疗效分析

Efficacy analysis of Altemeier and Delorme procedures for the rectal prolapse

目的比较Altemeier术与Delorme术治疗直肠脱垂后对患者术后生活质量的影响。方法采用回顾性队列研究方法,分析2013年2月至2018年1月期间,中山大学附属第六医院收治并行手术治疗的直肠脱垂患者资料,剔除术前影像学资料欠缺、直肠内套叠以及未行Altemeier术或Delorme术的患者,67例入组,其中男性32例,中位年龄20.5(13,34)岁;女性35例,中位年龄65.0(50,77)岁。按所实施手术方式不同分为Altemeier组(48例)和Delorme组(19例),两组分别行规范的Altemeier和Delorme手术。比较两组患者术前蹲位最大脱垂长度和手术前后Longo便秘评分、Wexner失禁评分以及ED-5Q-5L生活质量自主评分的变化,并比较两组术后并发症发生率及术后复发率等疗效的差异。结果术前Altemeier组和Delorme组蹲位最大脱垂长度分别为(7.3±3.3)cm和(4.9±2.1)cm,差异有统计学意义(t=2.907,P=0.005)。两组患者均顺利完成手术。Altemeier组手术时间(112.3±47.0)min,术后住院时间(11.3±5.0)d,均长于Delorme组的(80.7±35.4)min(t=2.637,P=0.010)和(8.6±3.0)d(t=2.177,P=0.033),差异均有统计学意义。中位随访26(13,45)个月,与术前比较,Altemeier组术后末次随访时的Longo便秘评分[9.0(6.0,14.0)分比4.0(1.0,6.5)分,Z=-4.989,P<0.001]、Wexner失禁评分[0(0,5.5)分比0(0,2.0)分,Z=-3.325,P<0.001]和EQ-5D-5L评分[45.0(40.0,57.5)分比80.0(70.0,87.5)分,Z=-5.587,P<0.001]均明显改善;Delorme组术后末次随访时Longo便秘评分[6.0(5.0,14.0)分比3.0(1.0,7.0)分,Z=-2.186,P=0.029]、Wexner失禁评分[0(0,12.0)分比0(0,4.0)分,Z=-2.325,P=0.020]和EQ-5D-5L评分[50.0(35.0,60.0)分比75.0(65.0,90.0)分,Z=-3.360,P=0.001]也均明显改善。术后Altemeier组与Delorme组的并发症发生率差异无统计学意义[10例(20.8%)比4例(21.1%),χ2=0.049,P=0.826]。术后随访期间共有16例(28.0%)复发,其中Altemeier组10例,Delorme组6例,两组差异无统计学意义(P=0.134)。结论Altemeier术和Delorme术均是治疗直肠脱垂的有效手段;对于脱垂程度较轻的患者,Delorme术式具有手术时间短、术后恢复快等优势。

Objective To evaluate the quality of life after Altemeier and Delorme procedures for rectal prolapse patients.Methods A retrospective cohort study was performed.Clinical data of patients with full-thickness rectal prolapse undergoing surgical treatment in the Sixth Affiliated Hospital,Sun Yat-sen University from February 2013 to January 2018 were retrospectively analyzed.Patients who had no preoperative imaging data,who suffered from internal rectal intussusception,or who did not undergo Altemeier and Delorme operations were excluded.Sixty-seven patients were enrolled,including 32 males with median age of 20.5(13,34)years and 35 females with median age of 65.0(50,77)years.According to different procedures,patients were divided into the Altemeier group(48 cases)and the Delorme group(19 cases),who received standard Altemeier and Delorme operations respectively.The maximal prolapse length of preoperative squat position,the Longo constipation score,Wexner incontinence score,EQ-5D-5L score,postoperative complications and recurrence rate were analyzed and compared between two groups.Results The maximal prolapse length of preoperative squat position in Altemeier group and Delorme group was(7.3±3.3)cm and(4.9±2.1)cm respectively with significant difference(t=2.907,P=0.005).The operations in both groups were successfully completed.The operation time and postoperative hospital stay of Altemeier group were longer than those of Delorme group[(112.3±47.0)minutes vs.(80.7±35.4)minutes,t=2.637,P=0.010;(11.3±5.0)days vs.(8.6±3.0)days,t=2.177,P=0.033].The median follow-up period was 26(13,45)months.In the last follow-up,compared to pre-operation,the Longo constipation score[9.0(6.0,14.0)vs 4.0(1.0,6.5),Z=-4.989,P<0.001],Wexner incontinence score[0(0,5.5)vs.0(0,2.0),Z=-3.325,P<0.001]and EQ-5D-5L score[45.0(40.0,57.5)vs.80.0(70.0,87.5),Z=-5.587,P<0.001]were all improved obviously in the Altemeier group,meanwhile Longo constipation score[6.0(5.0,14.0)vs.3.0(1.0,7.0),Z=-2.186,P=0.029],Wexner incontinence score[0(0,12.0)vs.0(0,4.0),Z=-2.325,P=0.020]and EQ-5D-5L score[50.0(35.0,60.0)vs.75.0(65.0,90.0),Z=-3.360,P=0.001]in the Delorme group were all improved obviously as well.The postoperative morbidity of complication between the two groups was not significantly different[10/48(20.8%)vs.4/19(21.1%),χ2=0.049,P=0.826].Sixteen patients(28.0%)relapsed after operation,including 10 patients in the Altemeier group and 6 patients in the Delorme group,without statistically significant difference(P=0.134).Conclusions Both the Altemeier and Delorme procedures are effective treatments for rectal prolapse,which can improve the postoperative quality of life.Delorme procedure has the advantages of shorter operation time and faster postoperative recovery in patients with mild prolapse.