腹腔镜下结肠次全切联合改良Duhamel术治疗顽固性混合型便秘临床分析
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摘要
目的探讨腹腔镜下结肠次全切联合改良Duhamel术治疗顽固性混合型便秘的临床疗效与安全性。方法回顾性分析2015年1月至2017年3月在同济大学附属杨浦医院行腹腔镜下结肠次全切联合改良Duhamel术治疗的10例经保守治疗无效的顽固性混合型便秘患者的临床资料,观察术中情况、术后恢复情况和术后9个月随访结果。结果所有患者均顺利完成腹腔镜下手术,无中转开腹,无预防性造口,平均手术时间(273±46) min,术中出血量(136±68) ml,术后肛门排气时间(4. 7±1. 1) d,术后下床活动时间(4. 3±0. 8) d,术后住院时间(12±2. 1) d。1例患者术后8 d出现肠梗阻症状,行经鼻肠梗阻导管置入治疗后痊愈,无吻合口瘘、腹腔出血等并发症,无死亡病例。术后随访9个月,Wexner便秘评分由术前的(22. 6±4. 1)分降至术后9个月的(5. 4±1. 7)分,差异有统计学意义(P <0. 001);术前和术后9个月的Wexner肛门失禁评分分别为(1. 3±1. 0)和(2. 1±1. 2)分,差异无统计学意义(P=0. 074);胃肠道生活质量评分(GIQLI)由术前的(65. 6±13. 7)分升至术后9个月的(97. 5±11. 4)分,差异有统计学意义(P <0. 001);术后9个月患者总体排便满意度为80%,无便秘复发。2例出现长期腹泻,在给予止泻剂和肠道菌群调节剂治疗后好转。结论腹腔镜下结肠次全切联合改良Duhamel术治疗顽固性混合型便秘安全、可行,可有效改善患者的便秘症状和生活质量。
Objective To explore the efficacy and safety of laparoscopy-assisted subtotal colectomy combined with modified Duhamel procedure in treatment of patients with intractable mixed constipation. Methods The clinical data of 10 patients with refractory mixed constipation undergoing laparoscopy-assisted subtotal colectomy combined with modified Duhamel procedure in Shanghai Yangpu Hospital during January 2015 to March 2017 were retrospectively studied. The intraoperative conditions and postoperative recovery were observed,and they were followed-up for 9 months after the operation. Results All these patients were successfully completed laparoscopic surgery without conversion to open surgery. No defunctioning stoma was constructed. The mean operating time was 273 ± 46 min and intraoperative blood loss was 136 ± 68 ml. The mean duration for postoperative anal exhaust,postoperative ambulation and postoperative hospital stay were( 4. 7 ± 1. 1) d,( 4. 3 ± 0. 8) d and( 12 ± 2. 1) d,respectively. One patient suffered with intestinal obstruction on 8 th day after the operation,and no other complication occurred. There was no death related to the procedure. All patients were followed up by clinical assessment in 9 months after surgery. The Wexner scores of constipation were significantly descended from preoperation to follow up period [( 22. 6 ± 4. 1) vs.( 5. 4 ± 1. 7) ],P < 0. 001,and the Gastrointestinal Quality of Life Index( GIQLI) scores were significantly from preoperation to follow up period [( 65. 6 ± 13. 7) vs.( 97. 5 ± 11. 4),P < 0. 001]. There was no statistical difference observed between preoperative and postoperative Wexner scores of fecal incontinence [( 1. 3 ± 1. 0) vs.( 2. 1 ± 1. 2),P = 0. 074]. The satisfactory rate in 9-month follow up period was 80%,and no constipation reocurred. Two patients suffered with persistent diarrhea after the surgery and they had been improved with medication. Conclusion Laparoscopy-assisted subtotal colectomy combined with modified Duhamel procedure provides a safe and effective surgical treatment for mixed refractory constipation,which achieved good bowel function and a satisfactory quality of life.
Objective To explore the efficacy and safety of laparoscopy-assisted subtotal colectomy combined with modified Duhamel procedure in treatment of patients with intractable mixed constipation. Methods The clinical data of 10 patients with refractory mixed constipation undergoing laparoscopy-assisted subtotal colectomy combined with modified Duhamel procedure in Shanghai Yangpu Hospital during January 2015 to March 2017 were retrospectively studied. The intraoperative conditions and postoperative recovery were observed,and they were followed-up for 9 months after the operation. Results All these patients were successfully completed laparoscopic surgery without conversion to open surgery. No defunctioning stoma was constructed. The mean operating time was 273 ± 46 min and intraoperative blood loss was 136 ± 68 ml. The mean duration for postoperative anal exhaust,postoperative ambulation and postoperative hospital stay were( 4. 7 ± 1. 1) d,( 4. 3 ± 0. 8) d and( 12 ± 2. 1) d,respectively. One patient suffered with intestinal obstruction on 8 th day after the operation,and no other complication occurred. There was no death related to the procedure. All patients were followed up by clinical assessment in 9 months after surgery. The Wexner scores of constipation were significantly descended from preoperation to follow up period [( 22. 6 ± 4. 1) vs.( 5. 4 ± 1. 7) ],P < 0. 001,and the Gastrointestinal Quality of Life Index( GIQLI) scores were significantly from preoperation to follow up period [( 65. 6 ± 13. 7) vs.( 97. 5 ± 11. 4),P < 0. 001]. There was no statistical difference observed between preoperative and postoperative Wexner scores of fecal incontinence [( 1. 3 ± 1. 0) vs.( 2. 1 ± 1. 2),P = 0. 074]. The satisfactory rate in 9-month follow up period was 80%,and no constipation reocurred. Two patients suffered with persistent diarrhea after the surgery and they had been improved with medication. Conclusion Laparoscopy-assisted subtotal colectomy combined with modified Duhamel procedure provides a safe and effective surgical treatment for mixed refractory constipation,which achieved good bowel function and a satisfactory quality of life.
引文
[1] Sbahi H,Cash BD. Chronic Constipation:a Review of Current Literature[J]. Curr Gastroenterol Rep,2015,17(12):47.
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[3] Chu H,Zhong L,Li H,et al. Epidemiology characteristics of constipation for general population,pediatric population,and elderly population in china[J]. Gastroenterol Res Pract,2014,2014:532734.
[4]孙威,陈爱山,闫兆鹏,等.腹腔镜辅助下结肠次全切除联合改良Duhamel手术治疗重度功能性便秘[J].中国普外基础与临床杂志,2013,20(2):169-173.
[5] Bassotti G,Blandizzi C. Understanding and treating refractory constipation[J]. World J Gastrointest Pharmacol Ther,2014,5(2):77-85.
[6]范朝刚,朱维铭,李宁,等.改良Duhamel手术联合结肠部分切除术治疗难治性便秘[J].中国实用外科杂志,2004,24(9):562-563.
[7] Longstreth GF,Thompson WG,Chey WD. Functional Bowel Disorders.In:Drossman DA. RomeⅢ:the functional gastroinestinal disorders[M]. Mclean:Degnon Associates,2016:487-555.
[8]中华医学会消化病学分会胃肠动力学组中华医学会外科学分会结直肠肛门外科学组.中国慢性便秘诊治指南(2013,武汉)[J].胃肠病学,2013,18(10):605-612.
[9]姜军,陈启仪,冯啸波,等.金陵术治疗顽固性便秘1100例疗效分析[J].中华外科杂志,2016,54(1):13-20.
[10]姜军,丁威威,王林,等.行金陵术治疗多次手术治疗无效顽固性混合型便秘135例分析[J].中国实用外科杂志,2012,32(9):767-770.
[11] Junjun W,Yiyi Z,Xiaozhuan L,et al. The in vivo oxidized LDL to LDL-cholesterol ratio is correlated with lipid content of LDL[J]. Atherosclerosis,2000,149(1):217-218.
[12]童卫东.成人便秘的外科治疗[J/CD].中华结直肠疾病电子杂志,2015,4(2):122-124.
[13] Li N,Jiang J,Feng X,et al. Long-term follow-up of the Jinling procedure for combined slow-transit constipation and obstructive defecation[J]. Dis Colon Rectum,2013,56(1):103-112.
[14] Riss S,Herbst F,Birsan T,et al. Postoperative course and long term follow up after colectomy for slow transit constipation--is surgery an appropriate approach[J]? Colorectal Dis,2009,11(3):302-307.
[15] Fitz Harris GP,Garcia-Aguilar J,Parker SC,et al. Quality of life after subtotal colectomy for slow-transit constipation:both quality and quantity count[J]. Dis Colon Rectum,2003,46(4):433-440.
[2] Amir AA. Etiological factors of constipation in the elderly,with emphasis on functional causes[J]. East Mediterr Health J,2011,17(8):708-711.
[3] Chu H,Zhong L,Li H,et al. Epidemiology characteristics of constipation for general population,pediatric population,and elderly population in china[J]. Gastroenterol Res Pract,2014,2014:532734.
[4]孙威,陈爱山,闫兆鹏,等.腹腔镜辅助下结肠次全切除联合改良Duhamel手术治疗重度功能性便秘[J].中国普外基础与临床杂志,2013,20(2):169-173.
[5] Bassotti G,Blandizzi C. Understanding and treating refractory constipation[J]. World J Gastrointest Pharmacol Ther,2014,5(2):77-85.
[6]范朝刚,朱维铭,李宁,等.改良Duhamel手术联合结肠部分切除术治疗难治性便秘[J].中国实用外科杂志,2004,24(9):562-563.
[7] Longstreth GF,Thompson WG,Chey WD. Functional Bowel Disorders.In:Drossman DA. RomeⅢ:the functional gastroinestinal disorders[M]. Mclean:Degnon Associates,2016:487-555.
[8]中华医学会消化病学分会胃肠动力学组中华医学会外科学分会结直肠肛门外科学组.中国慢性便秘诊治指南(2013,武汉)[J].胃肠病学,2013,18(10):605-612.
[9]姜军,陈启仪,冯啸波,等.金陵术治疗顽固性便秘1100例疗效分析[J].中华外科杂志,2016,54(1):13-20.
[10]姜军,丁威威,王林,等.行金陵术治疗多次手术治疗无效顽固性混合型便秘135例分析[J].中国实用外科杂志,2012,32(9):767-770.
[11] Junjun W,Yiyi Z,Xiaozhuan L,et al. The in vivo oxidized LDL to LDL-cholesterol ratio is correlated with lipid content of LDL[J]. Atherosclerosis,2000,149(1):217-218.
[12]童卫东.成人便秘的外科治疗[J/CD].中华结直肠疾病电子杂志,2015,4(2):122-124.
[13] Li N,Jiang J,Feng X,et al. Long-term follow-up of the Jinling procedure for combined slow-transit constipation and obstructive defecation[J]. Dis Colon Rectum,2013,56(1):103-112.
[14] Riss S,Herbst F,Birsan T,et al. Postoperative course and long term follow up after colectomy for slow transit constipation--is surgery an appropriate approach[J]? Colorectal Dis,2009,11(3):302-307.
[15] Fitz Harris GP,Garcia-Aguilar J,Parker SC,et al. Quality of life after subtotal colectomy for slow-transit constipation:both quality and quantity count[J]. Dis Colon Rectum,2003,46(4):433-440.