“带蒂回肠袖带”在直肠癌手术中的应用

目的观察"带蒂回肠袖带"预防瘘及狭窄效果。方法随机将我院外科1985年2月～2008年4月收治的379例中、上段直肠癌前切除术患者分为两组。治疗组268例,行直肠癌前切除、结、直肠端端直褥式单层吻合后,将"带蒂回肠袖带"缝在吻合口周围。对照组111例,行直肠癌前切除后,仍用传统吻合法,即结肠、直肠端端全层间断缝合,再做浆肌层缝合加固,观察两组术后并发症。结果对照组术后结、直肠吻合口瘘发生率明显增高,占6.3%(7/111),治疗组术后结、直肠吻合口瘘发生率明显下降,占0.37%(1/268)(P<0.01);对照组术后结、直肠吻合口狭窄率明显增加,占5.4%(6/111),治疗组术后结、直肠吻合口狭窄率明显下降,占0.37%(1/268)(P<0.01);对照组术后盆腔感染率明显增高,占7.2%(8/111),治疗组术后盆腔感染率明显降低,占0.75%(2/268)(P<0.01),两组之间差异有显著性意义。结论"带蒂回肠袖带"围缝在结、直肠吻合口周围,增加了吻合口血供,加快了吻合口的愈合,明显降低了结、直肠吻合口瘘、狭窄和盆腔感染的发生率。

Factors determining delay in relaparotomy for anastomotic leakage after colorectal resection

AIM： To analyze the time interval （‘delay＇） between the first occurrence of clinical parameters associated with anastomotic leakage alter colorectal resection and subsequent relaparotomy. METHODS： In 36 out of 289 consecutive patients with colorectal anastomosis, leakage was confirmed at relaparotomy. The medical records of these patients were retrospectively analysed and type and time of appearance of clinical parameters suggestive of anastomotic leakage were recorded. These parameters included heart rate, body temperature, local or generalized peritoneal reaction, leucocytosis, ileus and delayed gastric emptying. Factors influencing delay of relaparotomy and consequences of delayed recognition and treatment were determined. RESULTS： First documentation of at least one of the predefined parameters for anastomotic leakage was alter a median interval of 4 ± 1.7 d alter the operation. The median number of days between first parameter（s） associated with leakage and relaparotomy was 3.5 ± 5.7 d. The time interval between the first signs of leakage and relaparotomy was significantly longer when a weekend was included （4.2 d vs 2.4 d, P = 0.021） or radiological evaluation proved to be false-negative （8.1 d vs 3.5 d, P = 0.007）. No significant association between delay and number of additional relaparotomies, hospital stay or mortality could be demonstrated.CONCLUSION： An intervening weekend and negative diagnostic imaging reports may contribute to a delay in diagnosis and relaparotomy for anastomotic leakage. That delay was more than two days in two-thirds of the patients.

Long-term results of subtotal colectomy with cecorectal anastomosis for isolated colonic inertia

AIM： To evaluate the results of sub total colectomy withI cecorectal anastomosis （STC-CRA） for isolated colonicinertia （CI）. METHODS： Fourteen patients （mean age 57.5±16.5 year） underwent surgery for isolated CI between January 1986 and December 2002. The mean frequency of bowel motions with the aid of laxatives was 1.2±0.6 per week. All subjects underwent colonoscopy, anorectal manometry, cinedefaecography and colonic transit time （CTF）. CI was defined as diffuse markers delay on CTF without evidence of pelvic floor dysfunction. All patients underwent STC-CRA. Long-term follow-up was obtained prospectively by clinical visits between October 2005 and February 2006 at a mean of 10.5 ＋ 3.6 years （range 5-16 years） during which we considered the number of stool emissions, the presence of abdominal pain or digitations, the use of pain killers, laxatives and/or fibers. Patients were also asked if they were satisfied with the surgery. RESULTS： There was no postoperative mortality Postoperative complications occurred in 21.4% （3/14）. At the end of follow-up, bowel frequency was significantly （P〈0.05）increased to a mean of 4.8±7.5 per day （range 1-30）. One patient reported disabling diarrhea. Two patients used laxatives less than three times per month without complaining of what they called constipation Overall, 78.5% of patients would have chosen surgery again if necessary. CONCLUSION： STC-CRA is feasible and safe in patients with CI achieving 79% of success at a mean follow-up of 10.5 years. A prospective controlled evaluation is warranted to verify the advantages of this surgical approach in patients with CI.

Possible role of human cytomegalovirus in pouchitis after proctocolectomy with ileal pouch-anal anastomosis in patients with ulcerative colitis

AIM: To detect the presence of human cytomegalovirus (HCMV) proteins and genes on the ileal pouch of patients with ulcerative colitis who have undergone proctocolectomy with ileal pouch-anal anastomosis (iPAA). METHODS: immunohistochemistry, polymerase chain reaction (PCR) and PCR sequencing methods were utilized to test the presence of HCMV in pouch specimens taken from 34 patients in 86 endoscopies. RESULTS: HCMV genes and proteins were detected in samples from 12 (35.2%) patients. The rate of detection was significant in the endoscopies from patients diagnosed with pouchitis (5 of 12, 41.6%), according to the Japanese classification of pouchitis, in comparison to patients with normal pouch (7 of 62, 11.2%; P = 0.021). in all patients with pouchitis in which the HCMV was detected, it was the first episode of pouchitis. The virus was not detected in previous biopsies taken in normal endoscopies of these patients. During the follow- up, HCMV was detected in one patient with recurrent pouchitis and in 3 patients whose pouchitis episodes improved but whose positive endoscopic findings persisted. CONCLUSION: HCMV can take part in the inflammatory process of the pouch in some patients with ulcerative colitis who have undergone proctocolectomy with iPAA.