Long-axis rotational volvulus in an ileal J-pouch anal anastomosis: A preventable rare complication

Puropose: This study was designed to report a very rare long-term complication of ileal-Jpouch anal anastomosis: An 180 degree longaxial rotational volvulus causing J pouch obstruction. Methods: An Ovid and Medline search using the following keywords was performed: J pouch ileoanal anastomosis, J-pouch ileoanal anastomosis complications, J-pouch volvulus, J-pouch complications, restorative proctocolectomy complications, and restorative proctocolectomy volvulus. One J-pouch ileoanal anastomosis 180° volvulus report was found [1]. Result: We describe a long-axis 180° rotational volvulus complication of a J-pouch ileoanal anastomosis. The J pouch was performed three years prior after the laparoscopic total proctocolectomy for chronic ulcerative colitis. Pouch excision and new ileoanal J-pouch surgery were then performed along with pexy using alloderm mesh placement with excellent outcomes. Conclusion: Long-axis 180° rotational volvulus is a rare complication of a J-pouch ileoanal anastomosis. Pouch dysfunction after a long-axis rotational volvulus is an uncommon cause of acute abdomen. Lack of adhesions and pouch size are risk factors for the pouch torsion. Prompt diagnosis and treatment are essential for the pouch salvage. Simple abdominal x-ray, barium enema and CT scan represent important tools for diagnosis. Salvage surgery should be performed even if detorsion and decompression of the affected bowel are achieved. Surgery has excellent outcomes if performed after the prompt diagnosis. Pouch pexy should be done to prevent recurrent volvulus.

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis:A narrative review

Restorative proctocolectomy with ileal pouch-anal anastomosis(RP-IPAA) is the gold standard surgical treatment for ulcerative colitis.However,despite the widespread use of RP-IPAA,many aspects of this treatment still remain controversial,such as the approach(open or laparoscopic),number of stages in the surgery,type of pouch,and construction type(hand-sewn or stapled ileal pouch-anal anastomosis).The present narrative review aims to discuss current evidence on the short-,mid-,and long-term results of each of these technical alternatives as well as their benefits and disadvantages.A review of the MEDLINE,EMBASE,and Ovid databases was performed to identify studies published through March 2016.Few large,randomized,controlled studies have been conducted,which limits the conclusions that can be drawn regarding controversial issues.The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases.Regarding 2- and 3-stage RP-IPAA,patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables,making any comparisons extremely difficult.The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly,although the J pouch is generally preferred by surgeons.Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages,and there is no clear benefit of one technique over the other.

Complications after ileal pouch-anal anastomosis in Korean patients with ulcerative colitis

AIM: To investigate the outcomes of treatments for complications after ileal pouch-anal anastomosis (IPAA) in Korean patients with ulcerative colitis.

Eviendep~ reduces number and size of duodenal polyps in familial adenomatous polyposis patients with ileal pouchanal anastomosis

AIM:To evaluate if 3 mo oral supplementation with Eviendep was able to reduce the number of duodenal polyps in familial adenomatous polyposis(FAP)patients with ileal pouch-anal anastomosis(IPAA).METHODS:Eleven FAP patients with IPAA and duodenal polyps were enrolled.They underwent upper gastrointestinal(GI)endoscopy at the baseline and after 3 mo of treatment.Each patient received 5 mg Eviendep twice a day,at breakfast and dinner time,for3 mo.Two endoscopists evaluated in a blinded manner the number and size of duodenal polyps.Upper GI endoscopies with biopsies were performed at the baseline(T0)with the assessment of the Spigelman score.Polyps>10 mm were removed during endoscopy and at the end of the procedure a new Spigelman score was determined(T1).The procedure was repeated 3 mo after the baseline(T2).Four photograms were examined for each patient,at T1 and T2.The examined area was divided into 3 segments:duodenal bulb,second and third portion duodenum.Biopsy specimens were taken from all polyps>10 mm and from all suspicious ones,defined by the presence of a central depression,irregular surface,or irregular vascular pattern.Histology was classified according to the updated Vienna criteria.RESULTS:At baseline the mean number of duodenal detected polyps was 27.7 and mean sizes were 15.8mm;the mean Spigelman score was 7.1.After polypectomy the mean number of duodenal detected polyps was 25.7 and mean sizes were 7.6 mm;the mean Spigelman score was 6.4.After 3 mo of Eviendep bid,all patients showed a reduction of number and size of duodenal polyps.The mean number of duodenal polyps was 8(P=0.021)and mean size was 4.4 mm;the mean Spigelman score was 6.6.Interrater agreement was measured.Lesions>1 cm found a very good degree of concordance(kappa 0.851)and a good concordance was as well encountered for smaller lesions(kappa 0.641).CONCLUSION:Our study demonstrated that shortterm(90 d)supplementation with Eviendep in FAP patients with IPAA and with recurrent adenomas in the duodenal mucosa,resulted effective in reducing polyps number of 32%and size of 51%.

Laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for Peutz-Jeghers syndrome with synchronous rectal cancer

We report on a patient diagnosed with PeutzJeghers syndrome(PJS) with synchronous rectal cancer who was treated with laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA). PJS is an autosomal dominant syndrome characterized by multiple hamartomatous polyps in the gastrointestinal tract, mucocutaneous pigmentation, and increased risks of gastrointestinal and nongastrointestinal cancer. This report presents a patient with a 20-year history of intermittent bloody stool, mucocutaneous pigmentation and a family history of PJS, which together led to a diagnosis of PJS. Moreover, colonoscopy and biopsy revealed the presence of multiple serried giant pedunculated polyps and rectal adenocarcinoma. Currently, few options exist for the therapeutic management of PJS with synchronous rectal cancer. For this case, we adopted an unconventional surgical strategy and ultimately performed laparoscopic restorative proctocolectomy with IPAA. This procedure is widely considered to be the first-line treatment option for patients with ulcerative colitis or familial adenomatous polyposis. However, there are no previous reports of treating PJS patients with laparoscopic IPAA. Since the operation, the patient has experienced no further episodes of gastrointestinal bleeding and has demonstrated satisfactory bowel control. Laparoscopic restorative proctocolectomy with IPAA may be a safe and effective treatment for patients with PJS with synchronous rectal cancer.

Ileal pouch anal anastomosis with modified double-stapled mucosectomy-the experience in China

AIM:To investigate the feasibility and long-term functional outcome of ileal pouch-anal anastomosis with modified double-stapled mucosectomy.METHODS:From January 2002 to March 2011,fourtyfive patients underwent ileal pouch anal anastomosis with modified double-stapled mucosectomy technique and the clinical data obtained for these patients were reviewed.RESULTS:Patients with ulcerative colitis(n = 29) and familial adenomatous polyposis(n = 16) underwent ileal pouch-anal anastomosis with modified doublestapled mucosectomy.Twenty-eight patients underwent one-stage restorative proctocolectomy,ileal pouch anal anastomosis,protective ileostomy and the ileostomy was closed 4-12 mo postoperatively.Two-stage procedures were performed in seventeen urgent patients,proctectomy and ileal pouch anal anastomosis were completed after previous colectomy with ileostomy.Morbidity within the first 30 d of surgery occurred in 10(22.2%) patients,all of them could be treated conservatively.During the median follow-up of 65 mo,mild to moderate anastomotic narrowing was occurred in 4 patients,one patient developed persistent anastomotic stricture and need surgical intervention.Thirtyfive percent of patients developed at least 1 episode of pouchitis.There was no incontinence in our patients,the median functional Oresland score was 6,3 and 2 after 1 year,2.5 years and 5 years respectively.Nearly half patients(44.4%) reported "moderate functioning",37.7% reported "good functioning",whereas in 17.7% of patients "poor functioning" was observed after 1 year.Five years later,79.2% of patients with good function,16.7% with moderate function,only 4.2% of patients with poor function.CONCLUSION:The results of ileal pouch anal anastomosis with modified double-stapled mucosectomy technique are promising,with a low complication rate and good long-term functional results.

Management of pouch related symptoms in patients who underwent ileal pouch anal anastomosis surgery for adenomatous polyposis

BACKGROUND Adenomatous polyposis syndromes(APS)patients with ileal pouch anal anastomosis(IPAA)suffer frequent symptoms with scarce signs of inflammation,distinct from ulcerative colitis patients.While the management of pouchitis in ulcerative colitis patients is well established,data regarding response to treatment modalities targeting pouch-related disorders in APS patient population is scarce.AIM To assess clinical,endoscopic and histologic response to various treatment modalities employed in the therapy of pouch related disorders.METHODS APS patients who underwent IPAA between 1987-2019 were followed every 6-12 mo and pouch-related symptoms were recorded at every visit.Lower endoscopy was performed annually,recording features of the pouch,cuff and terminal ileum.A dedicated gastrointestinal pathologist reviewed biopsies for signs and severity of inflammation.At current study,files were retrospectively reviewed for initiation and response to various treatment modalities between 2015-2019.Therapies included dietary modifications,probiotics,loperamide,antibiotics,bismuth subsalicylate,mebeverine hydrochloride,5-aminosalicylic acid compounds and topical rectal steroids.Symptoms and endoscopic and histologic signs of inflammation before and after treatment were assessed.Pouchitis disease activity index(PDAI)and its subscores was calculated.Change of variables before and after therapy was assessed using Wilcoxon signed rank test for continuous variables and using McNemar's test for categorical variables.RESULTS Thirty-three APS patients after IPAA were identified.Before treatment,16 patients(48.4%)suffered from abdominal pain and 3(9.1%)from bloody stools.Mean number of daily bowel movement was 10.3.Only 4 patients(12.1%)had a PDAI≥7.Mean baseline PDAI was 2.5±2.3.Overall,intervention was associated with symptomatic relief,mainly decreasing abdominal pain(from 48.4%to 27.2%of patients,P=0.016).Daily bowel movements decreased from a mean of 10.3 to 9.3(P=0.003).Mean overall and clinical PDAI scores decreased from 2.58 to 1.94(P=0.016)and from 1.3 to 0.87(P=0.004),respectively.Analyzing each treatment modality separately,we observed that dietary modifications decreased abdominal pain(from 41.9%of patients to 19.35%,P=0.016),daily bowel movements(from 10.5 to 9.3,P=0.003),overall PDAI(from 2.46 to 2.03,P=0.04)and clinical PDAI(1.33 to 0.86,P=0.004).Probiotics effectively decreased daily bowel movements(from 10.2 to 8.8,P=0.007),overall and clinical PDAI(from 2.9 to 2.1 and from 1.38 to 0.8,P=0.032 and 0.01,respectively).While other therapies had minimal or no effects.No significant changes in endoscopic or histologic scores were seen with any therapy.CONCLUSION APS patients benefit from dietary modifications and probiotics that improve their pouch-related symptoms but respond minimally to anti-inflammatory and antibiotic treatments.These results suggest a functional rather than inflammatory disorder.

Lactobacillus acidophilus alleviates pouchitis after ileal pouch-anal anastomosis in rats

AIM To assess the therapeutic potential of Lactobacillus acidophilus(LA) for the treatment of pouchitis in a rat model.METHODS Sprague Dawley rats underwent proctocolectomy and ileal pouch-anal anastomosis followed by administration of dextran sulfate sodium(DSS) to induce pouchitis. Rats with pouchitis were randomly divided into three groups: no intervention(NI), normal saline(NS, 3 m L/d normal saline for 7 d), and LA(3 m L/d LA at 1× 1010 colony-forming units for 7 d). General body condition was recorded and pouch specimens were obtained for histological examination. m RNA expression levels of interleukin(IL)-1β, IL-6, IL-10, and tumor necrosis factor-α were determined by RT-PCR. Zonula occludens protein 1(ZO-1) levels were measured by immunohistochemistry. RESULTS LA reduced weight loss associated with pouchitis(P < 0.05) and improved the symptoms of pouchitis in rats. Compared with the NI and NS groups, rats in the LAgroup showed earlier disappearance of hematochezia(6.17 ± 0.75, 6.50 ± 0.55, 3.17 ± 0.75, P < 0.05) and higher fecal scores(2.67 ± 0.48, 2.50 ± 0.51, 4.42 ± 0.50, respectively, P < 0.05). Histological scores were also lower in the LA group compared with the other two groups(7.17 ± 0.98, 8.00 ± 0.89, 4.00 ± 0.89, respectively, P < 0.05). m RNA expression levels of IL-1β, IL-6, and tumor necrosis factor-α were significantly reduced, while IL-10 m RNA levels were significantly increased in the LA group(P < 0.05, respectively). ZO-1 protein levels were also significantly increased after administration of LA(P < 0.05). CONCLUSION LA alleviates pouchitis induced by DSS after ileal pouchanal anastomosis by decreasing pro-inflammatory factors and increasing anti-inflammatory factors, and restoring ZO-1 expression in the mucosa.

Ileal pouch surgery for ulcerative colitis

Ulcerative colitis (UC) is a relapsing and remitting disease characterised by chronic mucosal and submucosal inflammation of the colon and rectum. Treatment may vary depending upon the extent and severity of inflammation. Broadly speaking medical treatments aim to induce and then maintain remission. Surgery is indicated for inflammatory disease that is refractory to medical treatment or in cases of neoplastic transformation. Approximately 25% of patients with UC ultimately require colectomy. Ileal pouch-anal anastomosis (IPAA) has become the standard of care for patients with ulcerative colitis who ultimately require colectomy. This review will examine indications for IPAA, patient selection, technical aspects of surgery, management of complications and long term outcome following this procedure.

Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis

Restorative proctocolectomy is the most common surgical option for patients with familial adenomatous polyposis(FAP). However,adenomas may develop in the ileal pouch mucosa over time,and even carcinoma in the pouch has been reported. We therefore reviewed the prevalence,nature,and treatment of adenomas and carcinoma that develop after proctocolectomy in the ileal pouch mucosa in patients with FAP. In 25 reports that were reviewed,the incidence of adenomas in the ileal pouch varied from 6.7% to 73.9%. Several potential factors that favor the development of pouch polyposis have been investigated,but many remain controversial. Nevertheless,it seems certain that the age of the pouch is important. The risk appears to be 7%to 16% after 5 years,35% to 42% after 10 years,and75% after 15 years. On the other hand,only 21 cases of ileal pouch carcinoma have been recorded in the literature to date. The diagnosis of pouch carcinoma was made between 3 to 20 years(median,10 years) after pouch construction. Although the risk of malignant transformation in ileal pouches is probably low,it is not negligible,and the long-term risk cannot presently be well quantified. Regular endoscopic surveillance,especially using chromoendoscopy,is recommended.

Clinical outcome of ileal pouch-anal anastomosis for chronic ulcerative colitis in China

Background The incidence of chronic ulcerative colitis （CUC） in China is remarkably increasing, while little information on surgical treatment has been reported. This study aimed to completely describe and analyze the clinical outcome of restorative proctocolectomy with ileal pouch-anal anastomosis （IPAA）for CUC in China. Methods Ninety-five consecutive patients, who suffered CUC and had surgical indications, were carefully selected. All patients underwent IPAA. Data on patient characteristics, surgical indications, surgical details, postoperative complications, functional outcome, and quality of life were collected. Results The mean patient age at the time of the operation was 32 years. Twenty-nine （31%） patients underwent an emergency operation, and 66 （69%） underwent elective procedures. Four patients with severe dysplasia underwent operations, but no carcinoma was histologically confirmed. A two-stage operation was performed in 87 （92%） patients, and a hand-sewn technique was applied in 88 （93%） patients. Sixteen patients （17.0%） experienced early complications, and there was a significant difference between the emergency surgery group and the elective group （31.0% vs. 10.6%, respectively; P 〈0.01）. Five （5.3%） patients developed pouchitis as a late complication. The mean stool frequency after the operation was 4.6 （2-11） during the first 24 hours and 1.5 （0-4） overnight. According to the Kirwan grading scale, 87 （91.8%） patients showed satisfactory anal continence function. The quality of life improved significantly from a preoperative mean value of 0.28-0.61 before ileostomy closure to 0.78 after ileostomy closure （P 〈0.01） according to the Cleveland Global Quality of Life index. Conclusions IPAA is an effective and safe surgical procedure for patients with CUC in China. However, some characteristics, such as the low incidence of pouchitis, require further study.

Volvulus of the ileal pouch-anal anastomosis:a meta-narrative systematic review of frequency,diagnosis,and treatment outcomes

Background:Proctocolectomy with ileal pouch–anal anastomosis(IPAA)is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis.While rare,a pouch volvulus can occur.We aimed to determine the frequency,presentation,and management approach of pouch volvulus in patients with IPAA.Methods:A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications,extracted data,and assessed the methodological quality based on a validated tool.A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018.Results:The frequency of pouch volvulus from one large published study reporting long-termoutcomes of IPAA was 0.18%(3/1,700).A total of 22 patients(18 ulcerative colitis)were included(median age 32 years,73%females).Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours.Abdominal pain was the most commonly reported symptom(76%).The diagnosis was made primarily by abdominal computed tomography(13/17 patients,76%).Endoscopic treatment was successful in 1 of 11 patients(9%).Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations.A redo IPAA was performed in five patients(25%).Conclusion:Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms.Endoscopic treatment often fails and surgery is effective when performed early.

回肠储袋肛管吻合术后排便生理改变及储袋功能评价

对于内科难治性溃疡性结肠炎以及家族性腺瘤性息肉病病人,回肠储袋肛管吻合术(ileal pouch-anal anastomosis,IPAA)是首选的手术方式。尽管关于储袋术后结构性和炎性并发症(包括储袋炎)已有较多文献报道,但功能性储袋疾病仍了解甚少。其复杂之处在于IPAA术后储袋功能结果变量定义的可变性,以及缺乏症状报告的标准化。部分病人的储袋功能较差,这可能是由于储袋生理未达最佳或病人特定因素(年龄、性别、体重指数和饮食习惯)所致。因此,探讨储袋正常的生理功能,进一步研究储袋功能性并发症,对于改善IPAA病人术后生活质量至关重要。

家族性腺瘤性息肉病的外科治疗

为了提高家族性腺瘤性息肉病（ＦＡＰ）的外科治疗效果，对１６例ＦＡＰ患者的外科治疗情况进行了回顾性总结。１６例中除１例行全结肠直肠切除、回肠造口外，其余１５例均行全结肠直肠切除、回肠贮袋肛管吻合术。贮袋式中Ｊ型３例、Ｈ型１例，Ｓ型１１例，术后全部患者获１～５年随访，随访结果表明，病人排便功能均较满意，其中以Ｓ型贮袋者为好。笔者认为全结肠直肠切除是治疗ＦＡＰ唯一彻底有效的方法，而回肠贮袋肛管吻合则是减少术后排便次数、提高术后生活质量的良好术式，并讨论了手术方式的选择。

家族性腺瘤性息肉病行腹腔镜下全结直肠切除回肠储袋肛管吻合术的护理

目的总结家族性腺瘤性息肉病患者行腹腔镜下全结直肠切除回肠储袋肛管吻合术的围手术期护理措施。方法对6例行腹腔镜下全结直肠切除回肠储袋肛管吻合术的家族性息肉病患者进行回顾性分析。结果 6例行腹腔镜下全结直肠切除回肠储袋肛管吻合术,其中有1例患者出现吻合口瘘,经禁食、营养支持、抗炎、冲洗低负压吸引、生长抑素应用,加强管道护理,瘘口愈合。1例术后腹泻严重,平均每日大便次数10余次,经饮食管理,药物应用,肛周皮肤护理,无护理并发症发生,大便次数减少到3~4次/d,肛门功能恢复较满意。结论家族性腺瘤性息肉病患者行腹腔镜下全结直肠切除回肠储袋肛管吻合术,手术及护理难度大,加强围手术期护理,可减少并发症的发生,提高患者的生活质量。

家族性腺瘤性息肉病患者结直肠癌变的外科预防

目的探讨家族性腺瘤性息肉病(FAP)患者结直肠癌变外科预防的手术时机和术式选择。方法回顾性分析我院近年来连续诊治的43例FAP患者结直肠癌的发病状况及预防性手术治疗的疗效。结果未经手术干预的FAP患者,20岁、25岁、30岁、35岁、40岁、45岁、50岁时的累积结直肠癌变风险分别约为0、10.4%、25.3%、32.4%、63.0%、76.9%、86.2%;发生结直肠癌变的病例中有84.6%发生直肠癌变。11例患者在我院接受了预防性手术治疗,无手术死亡,3例全结直肠切除、回肠J-Pouch肛管手工吻合术患者术后并发吻合口瘘。1例结肠次全切除的患者于术后13年直肠癌变。3例回肠J-Pouch肛管吻合患者无肛门失禁,每日排便4～6次。结论FAP患者预防性手术治疗时机应在20岁之前,最迟不超过25岁,全结直肠切除、回肠J-Pouch肛管吻合器吻合术预防结直肠癌变安全有效,适合作为预防性手术的首选术式。

双吻合器法回肠储袋肛管吻合治疗溃疡性结肠炎的临床效果分析

目的:分析双吻合器法回肠储袋肛管吻合治疗溃疡性结肠炎的临床效果。方法:本实验研究对象为2005-07～2012-06于我院治疗的121例溃疡性结肠炎病人。按照随机数字表法分为观察组(双吻合器法回肠储袋肛管吻合治疗组)60例,对照组(回肠储袋肛管吻合治疗组)61例,比较两组手术时间、术后并发症、术后排便功能、术中输血量、术后住院时间等。结果:观察组平均手术时间为3.7±11.3h、术中输血量平均为504.2±103.6mL、平均住院时间为14.8±8.4d、术后排便功能评分平均为2.3±3.1分、并发症发生率为10%,均明显低于对照组,差异明显,P<0.05。结论:双吻合器法应用于溃疡性结肠炎病人回肠储袋肛管吻合术中能够显著缩短手术时间及住院、降低术中输血量、减少并发症的发生、提高术后排便能力。

回肠袋肛门吻合术治疗不确定性结肠炎的远期随访研究

目的探究回肠袋肛门吻合术对不确定性结肠炎的近期疗效及远期生存率的影响。方法回顾性分析2013年7月至2015年7月于上海中医药大学附属曙光医院确诊并治疗的不确定结肠炎82例,其中46例行回肠袋肛门吻合术治疗的患者作为研究组,36例行常规外科手术治疗的患者作为对照组。获取2组患者2年完整随访资料,收集其手术相关指标(手术时间、术中出血量、排气时间、导管置留时间、住院时间)、随访指标(术后并发症发生率、肛门功能、生活质量、总生存率);随访结束时根据患者生存情况将患者分为存活组和死亡组,比较2组患者临床资料并采用多因素分析其死亡危险因素。结果围手术期2组患者均无死亡;研究组手术时间、术中出血量、排气时间、导管置留时间、住院时间少于对照组,差异均有统计学意义(P<0.05)。研究组患者短期总有效率为86.96%,高于对照组(66.67%),差异有统计学意义(P<0.05)。研究组患者并发症发生率43.48%,低于对照组(66.67%),差异有统计学意义(P<0.05)。术后2组患者肛门功能及生活质量均逐渐改善,且研究组术后3、12个月24 h便次、夜间便次、克利夫兰生活质量量表(CGQL)评分、Kirwan分级均优于对照组,差异均有统计学意义(P<0.05)。研究组2年总生存率为84.78%,高于对照组(69.44%),差异有统计学意义(P<0.05)。重症型疾病、常规手术治疗方式是患者死亡危险因素(P<0.05),且手术方式相对危险比最大。结论回肠袋肛门吻合术对不确定性结肠炎治疗效果好。

经肛微创手术在直肠良性疾病中的应用

经肛微创手术(trans-anal minimally invasive surgery,TAMIS)是指利用经肛门手术平台,采用"由下而上"的操作路径实施的经肛门微创手术。它结合了经肛门内镜微创手术(trans-anal endoscopic microsurgery,TEM)和单孔腹腔镜技术,用更常规的单孔腹腔镜器械取代了直肠镜。结合了单孔腹腔镜的优势,使得组装时间大大减少,手术时间减少,以及费用降低等。随着技术的发展,除了经肛全直肠系膜切除(trans-anal total mesorectal excision,TaTME)手术外,TAMIS主要可以应用于全结肠直肠切除、回肠储袋肛管吻合术(ileal pouch-anal anastomosis,IPAA);储袋再手术;直肠切除术后吻合口瘘;以及克罗恩病直肠切除、超低位Hartmann造口还纳、直肠阴道瘘、直肠尿道瘘,吻合口修补等其他疾病。随着针对该术式的相应器械和操作平台的研究和改进,以及临床经验的积累和手术方案的规范化,TAMIS手术必将在中低位直肠良性疾病中占据越来越重要的治疗地位。但作为一种全新的直肠外科治疗思路和微创新技术,TAMIS手术的开展仍需要更加规范化以及更多的临床研究。

溃疡性结肠炎回肠储袋术后排便功能与生活质量影响因素分析

目的探讨溃疡性结肠炎(ulcerative colitis,UC)病人行全结直肠切除-回肠储袋肛管吻合术(total proctocolectomy with ileal pouch-anal anastomosis,TPC-IPAA)术后排便功能情况与长期生活质量,初步分析其影响因素,为制定有效的措施、改善其生活质量提供依据。方法回顾性收集2008年2月至2017年12月期间于上海交通大学医学院附属新华医院接受TPC-IPAA的UC病人的临床资料与术后随访信息,通过克利夫兰生活质量评分量表(Cleveland Global Quality of Life,CGQL)评估病人术后远期生活质量,采用Wexner和Vaizey评分法评估术后排便功能。基于术后CGQL评分提高50%,以及Wexner/Vaizey评分均值为截断值,分别将病人不同分组统计,进一步分析TPC-IPAA术后排便功能与生活质量的影响因素。结果 (1)治疗及随访情况:研究共纳入61例病人,中位随访时间为85.7个月(IQR45.2-105.8个月),TPC-IPAA术后CGQL评分较术前显著提高(0.732±0.148比0.420±0.173,P<0.001)。(2)TPC-IPAA术后并发症发生情况:共发生早期储袋手术相关并发症31例次(储袋术后30 d内发生),其中肠梗阻8例次(25.8%),储袋及吻合口出血8例次(25.8%),切口感染8例次(25.8%),储袋相关瘘发生共有3例次(8.7%)。发生远期并发症35例次,以储袋炎、肠梗阻较为常见。储袋失败3例(8.6%)。(3)TPC-IPAA术后排便功能与生活质量影响因素分析:术后早期并发症(OR:3.50;95%CI:1.078~11.361)、手术时年龄(OR:0.950;95%CI:0.908~0.995)是影响长期生活质量的独立危险因素。术后早期并发症与储袋术后排便功能相关(P=0.031)。结论 TPC-IPAA治疗重度(难治性)UC安全有效,早期并发症的发生与储袋病人远期生活质量有关。选择微创精细的手术操作,合理规避防治储袋手术早期并发症,有助于进一步提高UC病人术后的排便功能与远期生活质量。