改良预防性回肠造口术在中低位直肠癌经自然腔道取标本手术中的应用

Modified Prophylactic Ileostomy in Natural Orifice Specimen Extraction Surgery for Mid-low Rectal Cancer

目的探讨改良预防性回肠造口术在中低位直肠癌经自然腔道取标本手术(natural orifice specimen extraction surgery,NOSES)中的应用价值。方法回顾性分析2017年9月~2023年5月我院63例中低位直肠癌NOSES行预防性回肠造口术,根据造口方式的不同,分为观察组(改良回肠造口术,n=31)和对照组(常规襻式回肠造口,n=32),比较2组造口时间、造口还纳手术时间、术后造口早期并发症(造口渗漏、周围皮炎、疼痛、周围trocar孔感染、出血、缺血坏死、水肿、周围皮肤黏膜分离及近端肠梗阻)和远期并发症(造口狭窄、回缩、脱垂、旁疝)、肿瘤复发及死亡情况。结果63例均顺利完成预防性回肠造口术及造口还纳手术。观察组造口手术时间中位数7(6,8)min,明显短于对照组23(21,24)min(Z=-6.853,P=0.000);观察组造口还纳手术时间(63.2±5.7)min,明显短于对照组(93.5±4.7)min(t=-23.109,P=0.000)。2组均无造口出血、坏死。观察组造口疼痛发生率明显低于对照组[6.4%(2/31)vs.65.6%(21/32),χ^(2)=21.766,P=0.000];观察组造口周围trocar孔感染发生率显著低于对照组[0%(0/31)vs.53.1%(17/32),P=0.000]。2组均无造口狭窄发生;造口旁疝3例,其中观察组1例,对照组2例,2组发生率差异无统计学意义(P=1.000);对照组1例造口回缩,1例造口脱垂。5例并发症均在二次还纳手术中得到及时治疗。63例随访6~60个月,均无肿瘤复发或死亡。结论中低位直肠癌NOSES中应用改良预防性回肠造口术安全、可行,操作简便,有一定的实用性及推广价值。

Objective To explore the application value of modified prophylactic ileostomy in natural orifice specimen extraction surgery(NOSES)for patients with mid-low rectal cancer.Methods We retrospectively analyzed 63 patients who received prophylactic ileostomy in NOSES for mid-low rectal cancer in our hospital from September 2017 to May 2023.The patients were divided into the observation group(those who received modified ileostomy,n=31)and the control group(those who received conventional loop ileostomy,n=32)according to different ostomy methods.The operation time of ostomy,operation time of ostomy reversal surgery,early-stage complications(stoma leakage,peristomal dermatitis,stoma pain,peristomal trocar hole infection,stoma bleeding,stoma ischaemic necrosis,stoma oedema,peristoma skin-mucosal separation and stoma proximal bowel obstruction)and long-stage complications(stoma stenosis,stoma retraction,stoma prolapse,parastomal hernia),tumor recurrence and death of the two groups were compared and analyzed.Results Both prophylactic ileostomy and ostomy reversal surgery were successfully completed in all the 63 cases.The operation time of ostomy in the observation group was 7(6-8)min,which was significantly shorter than that of 23(21-24)min in the control group(Z=-6.853,P=0.000),and the operation time of ostomy reversal surgery in the observation group was(63.2±5.7)min,which was significantly shorter than(93.5±4.7)min in the control group(t=-23.109,P=0.000).Neither stoma bleeding nor stoma ischaemic necrosis were observed in both groups.The incidence of stoma pain in the observation group was lower than that in the control group[6.4%(2/31)vs.65.6%(21/32),χ^(2)=21.766,P=0.000].The incidence of peristomal incision infection in the observation group was lower than that in the control group[0%(0/31)vs.53.1%(17/32),P=0.000].There was no stoma stenosis in both groups.There were 3 cases of parastomal hernia,1 case in the observation group and 2 cases in the control group,the difference of the incidence being not statistically significant(P=1.000).There was 1 case of stoma retraction and 1 case of stoma prolapse in the control group.All the 5 cases with complications received prompt treatment in the second ostomy reversal surgery.Follow-up visits for 6-60 months in the 63 cases showed no tumor recurrence or death.Conclusion Modified prophylactic ileostomy in NOSES for patients with mid-low rectal cancer is safe,feasible,and easy to operate,having certain practicality and promotion value.