不同保肛术式对低位直肠癌术后排粪功能的影响

Influence of different sphincter-preserving surgeries on postoperative defecation function

随着外科技术的进步和治疗方式的发展,越来越多的低位直肠癌患者在不牺牲生存期的前提下实现了保留肛门的目的。但是低位直肠癌患者术后常出现排气排粪失禁、排粪频繁、排粪聚集和排粪急迫等功能障碍。低位直肠癌保肛手术的主要术式包括低位直肠前切除术(LAR)、经括约肌间切除术(ISR)和结肠肛管吻合术(Parks术)等。低位直肠癌行LAR的患者术后重度低位前切除综合征(LARS)的发生率高达84.6%。ISR术后排粪功能劣于LAR术,且ISR手术范围越大,术后功能更差。关于Parks术的排粪功能研究较少,目前证据显示,术后短期排粪功能劣于LAR,但是随着时间延长,功能可逐步恢复。结直肠外科医师尝试通过改变肠道重建方式改善患者术后排粪功能,但是目前证据表明,在LAR术中使用J型储袋或端侧吻合并未降低排粪障碍的发生率;ISR术中重建储袋也不能降低重度LARS的发生率。总而言之,低位直肠癌患者术后排粪功能的保护,任重而道远。

Advances in surgical techniques and treatment concept have allowed more patients with low rectal cancer to preserve sphincter without sacrificing survival benefit.However,postoperative dysfunctions such as fecal incontinence,frequency,urgency,and clustering often occur in patients with low rectal cancer.The main surgical procedures for low rectal cancer include low anterior rectum resection(LAR),intersphincteric resection(ISR),coloanal anastomosis(Parks)and so on.The incidence of major LARS after LAR is up to 84.6%.The postoperative function of ISR is even worse than LAR.Moreover,the greater the extent of resection ISR surgery,the worse the postoperative function.There are few studies on the function of Parks procedure.Current evidence suggests that the short-term function of Parks procedure is inferior to LAR,but function can gradually recovered over time.Colorectal surgeons have attempted to improve postoperative defecation by modifying bowel reconstructions.Current evidence suggests that J pouch or end-to-side anastomosis during LAR does not reduce the incidence of defecation disorders.Pouch reconstruction during ISR cannot reduce the incidence of severe LARS either.In general,the protection of postoperative defecation function in patients with low rectal cancer still has a long way to go.