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(2006 - 06 - 18收稿 )
国外医学文摘
低位直肠癌内括约肌切除技术和远期效果
Ruololf S, et al. D is Colon Rectum, 2005, 48 (10) : 1858 - 1867
低位直肠癌内括约肌切除是将直肠切除扩大至内括约
肌间隙的一种术式 ,该手术是在腹会阴切除、直肠系膜切
除、全部或部分内括约肌切除下同时进行。该研究对此手
术的远期效果以及排便节制功能做一评估。
方法 : 1984 - 2000年共对 121例低位直肠癌施行内括
约肌切除 ,手术按照以下
: a. 肿瘤位于直肠下段和肛
管。b. 术前磁共振 (MR I)或肛内超声证实肿瘤局部转移局
限于直肠壁或内括约肌。 c. 肿瘤直径 > 1cm。 d. 术前通过
活检进行组织学分类 ( GⅠ - Ⅱ)。 e. 通过直肠指检和肛管
测压评估括约肌功能。 f. 胸部 X线和腹部超声证实无远处
转移。g. 病人在侧卧下采用乙状结肠硬镜测量肛缘至肿瘤
距离。
结果 :直肠癌 117例 ,异常绒毛腺瘤 2例 ,内癌瘤 2例。
行根治性切除 117例 ,姑息性切除 4例。肿瘤按照 Dukes
分期 ,A期 49例 (41% ) ,B期 33例 (28% ) , C期 37例 (31% )
肿瘤距肛缘平均距离 3cm (1~5cm )。术后并发症 :根治性
切除术后 30d并发症发生率为 717% ( n = 9 ) ,病死率
018%。因肺梗死死亡 1例 ,发生吻合口漏 6例 (511% ) ,因
膀胱尿道漏再次手术 1例 ,肠梗阻 1例以及腹内出血和小
肠漏 1例需再次手术 ,保护性结肠造口关闭后发生漏 1例 ,
结肠肛管吻合口狭窄 11例 ( 914% )。平均随访 94个月
(24~185个月 ) ,局部复发 6例 ( 513% ) ,按照肛管节制功
能评分 ,节制功能正常 101例 (8613% ) ,仅固体便节制功能
正常 16例 (1317% ) ,排便失禁 1例 (018% )。每天平均排
便次数为 2124次 (1~9次 )。
结论 :对于保护括约肌的直肠手术 ,采用内括约肌切除
是可行的。研究显示 ,该手术远期效果和功能满意 ,重要的
必备条件是术前通过 MR I对肿瘤扩散进行仔细评估 ,排除
外括约肌浸润。
(龚 苏 摘译 喻德洪 审校 )
·256· 中国实用外科杂志 2006年 9月 第 26卷 第 9期