低位直肠癌术后造口相关并发症的防治
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_jpg/gsCSOksyaNLiauo82Vmn4gdCWFsfAgLu4lvPWSictbj8F4JR6ibYdKGJfOaDdImqsCSNkNicqtDmvKibUp6zY8mrfMA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">作者</span><span style="color: black;">：</span><span style="color: black;">顾晋, 杨勇</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">文案</span><span style="color: black;">源自</span>：中华胃肠外科杂志, 2022, 25(11) </span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">摘要</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">肠造口的<span style="color: black;">关联</span>技术是结直肠外科<span style="color: black;">大夫</span><span style="color: black;">必要</span><span style="color: black;">把握</span>的专业技能，预防低位直肠癌术后肠造口<span style="color: black;">关联</span>并发症的<span style="color: black;">出现</span>，<span style="color: black;">针对</span><span style="color: black;">病人</span>的预后<span style="color: black;">拥有</span><span style="color: black;">要紧</span>的临床<span style="color: black;">道理</span>。肠造口的<span style="color: black;">初期</span>并发症<span style="color: black;">包含</span>造口回缩、造口缺血坏死、造口水肿和<span style="color: black;">周边</span>皮肤炎等；远期并发症<span style="color: black;">包含</span>造口旁疝、造口狭窄和造口脱垂等。<span style="color: black;">另一</span>，少见<span style="color: black;">或</span>容易<span style="color: black;">忽略</span>的造口癌、造口还纳困难和社会心理<span style="color: black;">阻碍</span>等<span style="color: black;">关联</span>并发症<span style="color: black;">亦</span>应该<span style="color: black;">导致</span>外科<span style="color: black;">大夫</span><span style="color: black;">注意</span>。有效减少肠造口并发症，可使<span style="color: black;">病人</span><span style="color: black;">得到</span>更好的生活质量，<span style="color: black;">亦</span>是结直肠外科<span style="color: black;">大夫</span>对“以<span style="color: black;">病人</span>为中心”治疗理念的最佳诠释。</span></p><span style="color: black;">直肠癌是<span style="color: black;">平常</span>的恶性肿瘤。以手术为主的综合治疗仍然是直肠癌的<span style="color: black;">重点</span>治疗<span style="color: black;">办法</span>。在低位直肠癌的治疗中，腹会阴联合切除术（abdominal- perineal resection，APR）是直肠癌的标准手术治疗<span style="color: black;">办法</span>之一。近年来，术前新辅助放化疗可使20%的局部<span style="color: black;">发展</span>期直肠癌<span style="color: black;">病人</span><span style="color: black;">得到</span>临床完全缓解，但仍有很大一部分<span style="color: black;">病人</span>仍<span style="color: black;">不可</span>避免APR手术。<span style="color: black;">针对</span>APR手术，尽管其能够取得根治性切除，但<span style="color: black;">因为</span><span style="color: black;">没</span>法<span style="color: black;">保存</span>肛门的正常功能，术中需同期行乙状结肠永久性造口，替代原有会阴部肛门的排粪功能；<span style="color: black;">针对</span>低位前切除（low anterior resection，LAR）手术，<span style="color: black;">思虑</span>术后吻合口供血不足及术前接受过新辅助放化疗等<span style="color: black;">原因</span>，术中需行临时性回肠或横结肠造口；还有部分低位直肠癌<span style="color: black;">病人</span><span style="color: black;">因为</span>肠梗阻、穿孔等并发症，急诊手术需行乙状结肠临时造口。</span><span style="color: black;">在美国，每年大<span style="color: black;">大概</span>15万台肠造口手术，广泛用于结直肠癌、溃疡性结肠炎、克罗恩病、憩室炎、化学性结肠炎、辐射<span style="color: black;">损害</span>以及排粪失禁等手术。国内造口<span style="color: black;">关联</span><span style="color: black;">科研</span>结果<span style="color: black;">表示</span>，其并发症<span style="color: black;">出现</span>率为21%~70%。肠造口的<span style="color: black;">初期</span>并发症<span style="color: black;">包含</span>造口回缩、造口缺血坏死和造口水肿以及<span style="color: black;">周边</span>皮肤炎等，远期并发症<span style="color: black;">包含</span>造口旁疝、造口狭窄和造口脱垂等。<span style="color: black;">另一</span>，少见<span style="color: black;">或</span>容易<span style="color: black;">忽略</span>的造口癌、造口还纳困难和社会心理<span style="color: black;">阻碍</span>等<span style="color: black;">关联</span>并发症<span style="color: black;">亦</span>应该<span style="color: black;">导致</span>外科<span style="color: black;">大夫</span><span style="color: black;">注意</span>。造口并发症的<span style="color: black;">出现</span>率和整体功能<span style="color: black;">重点</span>取决于造口的适应证，对术后造口<span style="color: black;">关联</span>并发症进行<span style="color: black;">恰当</span>的防治，能<span style="color: black;">明显</span><span style="color: black;">加强</span><span style="color: black;">病人</span>的生活质量。本文将对<span style="color: black;">平常</span>的低位直肠癌术后造口<span style="color: black;">关联</span>并发症的特征和处理原则进行总结，以期为同道<span style="color: black;">供给</span>参考。</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">1、</span><span style="color: black;">初期</span>并发症</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1.造口回缩：造口回缩缺乏被<span style="color: black;">广泛</span>接受的定义，其<span style="color: black;">出现</span><span style="color: black;">原由</span><span style="color: black;">重点</span>有两种观点：一种是造口<span style="color: black;">小于</span><span style="color: black;">周边</span>皮肤水平，另一种则是造口<span style="color: black;">小于</span><span style="color: black;">周边</span>皮肤水平0.5cm以上。造口回缩大部分<span style="color: black;">出现</span>在造口术后<span style="color: black;">初期</span>，有2%~13%的结肠造口以及11%~24%的回肠造口术后会<span style="color: black;">出现</span>回缩。<span style="color: black;">初期</span>的造口回缩通常是<span style="color: black;">因为</span>肠段过度紧张<span style="color: black;">导致</span>，还有<span style="color: black;">肥壮</span>等<span style="color: black;">原因</span><span style="color: black;">引起</span>肠系膜过短而与肠管<span style="color: black;">必要</span><span style="color: black;">经过</span>的腹壁厚度不匹配，或<span style="color: black;">运用</span>糖皮质激素以及营养不良<span style="color: black;">引起</span>的伤口愈合不良；远期造口回缩则多由体质量<span style="color: black;">增多</span><span style="color: black;">或</span>外置肠段长度较短<span style="color: black;">导致</span>。回缩的造口所排出的粪便刺激造口<span style="color: black;">周边</span>皮肤，<span style="color: black;">引起</span>造口<span style="color: black;">更易</span><span style="color: black;">出现</span>渗漏；<span style="color: black;">初期</span>造口的急性回缩<span style="color: black;">乃至</span>会<span style="color: black;">引起</span>黏膜皮肤连接处裂开，<span style="color: black;">从而</span><span style="color: black;">导致</span>腹膜内污染。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">造口回缩<span style="color: black;">出现</span>后，<span style="color: black;">能够</span><span style="color: black;">经过</span><span style="color: black;">运用</span>特殊的造口<span style="color: black;">工具</span>以减少渗漏的<span style="color: black;">出现</span>。肠段过度紧张<span style="color: black;">一般</span><span style="color: black;">是由于</span>血供不良<span style="color: black;">导致</span>，而局部修复并<span style="color: black;">不可</span>达到目的，<span style="color: black;">一般</span><span style="color: black;">必须</span>开腹手术以获取更长的肠段并以<span style="color: black;">没</span>张力的方式修复造口。造口横杆<span style="color: black;">能够</span>减小造口回缩的<span style="color: black;">危害</span>。然而，一项荟萃分析<span style="color: black;">表示</span>，与不<span style="color: black;">运用</span>造口横杆组相比，<span style="color: black;">运用</span>造口横杆并<span style="color: black;">不可</span>显著降低造口回缩率（2.28%比3.45%，95%CI：0.32~1.54），反而会<span style="color: black;">明显</span><span style="color: black;">增多</span>造口<span style="color: black;">周边</span>皮炎（29.86%比16.00%）和坏死（7.00%比1.15%）的<span style="color: black;">出现</span>率。<span style="color: black;">因此呢</span>，不<span style="color: black;">举荐</span>常规<span style="color: black;">运用</span>造口横杆进行袢式造口术。<span style="color: black;">日前</span>认为，防止造口回缩的最佳<span style="color: black;">办法</span>，是<span style="color: black;">保证</span>肠道<span style="color: black;">拥有</span>足够的运动范围和良好的血液供应，并制造足够大的筋膜孔以促进造口更好地连接至皮肤。<span style="color: black;">针对</span>末端结肠造口术，造口易被肠系膜下动脉蒂牵拉，将肠系膜下动脉根部结扎，<span style="color: black;">能够</span><span style="color: black;">明显</span>减少因血管牵拉<span style="color: black;">导致</span>的造口回缩。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2.造口缺血坏死：造口缺血坏死<span style="color: black;">一般</span><span style="color: black;">出现</span>在肠系膜对侧近造口处，多为局限性，<span style="color: black;">平常</span>于<span style="color: black;">肥壮</span><span style="color: black;">病人</span>和紧急造口后，是造口术后严重的<span style="color: black;">初期</span>并发症，其<span style="color: black;">出现</span>率为2.3%~17.0%，常<span style="color: black;">出现</span>于术后48h内。造口缺血坏死临床表现为造口外观局部或完全变暗紫色，若<span style="color: black;">即时</span>适当处理，大<span style="color: black;">都数</span>造口缺血可恢复正常。若未<span style="color: black;">即时</span>处理，则造口可能缺血加重，肠管变黑，黏膜及肠段坏死，<span style="color: black;">乃至</span><span style="color: black;">导致</span>腹膜炎和腹腔感染。慢性造口缺血坏死的临床表现为肠造口黏膜干燥、苍白，<span style="color: black;">逐步</span>变成灰褐色，<span style="color: black;">最后</span>发展为坏死。常见<span style="color: black;">原由</span>有：（1）肠系膜张力过大，术中肠系膜离断<span style="color: black;">太多</span>；（2）<span style="color: black;">损害</span>造口肠段边缘血管，<span style="color: black;">引起</span>造口血供<span style="color: black;">欠好</span>；（3）腹壁造口过小及缝合过紧等<span style="color: black;">引起</span>造口处肠段压力大；（4）严重的动脉硬化、或肠梗阻过久<span style="color: black;">引起</span>肠壁<span style="color: black;">长时间</span>缺氧、肠造口<span style="color: black;">关联</span>肠系膜过紧等。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">万德森将造口坏死分为三度：（1）轻度：造口坏死不超过造口黏膜外1/3，造口皮肤正常，<span style="color: black;">没</span>分泌物<span style="color: black;">增加</span>或<span style="color: black;">反常</span>臭味。其处理<span style="color: black;">办法</span>为解除所有压迫造口的碘纺纱布等物品，外用呋喃西林溶液或生理盐水清洗。（2）中度：造口黏膜外中2/3呈紫黑色，有分泌物<span style="color: black;">增加</span>和<span style="color: black;">反常</span>臭味，<span style="color: black;">然则</span>造口中央黏膜仍呈淡红色，用力摩擦可见黏膜<span style="color: black;">流血</span>。解除压迫处理同前，待坏死部分与正常组织<span style="color: black;">显现</span><span style="color: black;">知道</span>界线后，清除坏死组织。（3）重度：造口坏死，黏膜<span style="color: black;">所有</span>呈漆黑色，有<span style="color: black;">海量</span><span style="color: black;">反常</span>臭味的分泌物，坏死深入筋膜面，<span style="color: black;">必须</span>紧急重建造口，仔细<span style="color: black;">检测</span>坏死界限并切除坏死部分。腹壁造口直径<span style="color: black;">通常</span>为3 cm，以防术后挤压造口<span style="color: black;">引起</span>缺血。积极治疗<span style="color: black;">导致</span><span style="color: black;">病人</span>腹内压<span style="color: black;">升高</span>的<span style="color: black;">疾患</span>，<span style="color: black;">选取</span>经腹直肌造口，术中术后防止造口<span style="color: black;">周边</span>感染，能够<span style="color: black;">明显</span>降低造口缺血坏死的<span style="color: black;">出现</span>率。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3.造口水肿和<span style="color: black;">周边</span>皮肤炎：造口水肿常<span style="color: black;">出现</span>于造口术后<span style="color: black;">初期</span>，<span style="color: black;">重点</span>是<span style="color: black;">因为</span>腹壁开口过小<span style="color: black;">或</span>造口袋底盘开口过小，使造口肠管的血液、淋巴液回流受阻所<span style="color: black;">导致</span>。<span style="color: black;">针对</span>轻度造口水肿，<span style="color: black;">通常</span><span style="color: black;">没</span>需特殊处理；若造口水肿程度较重或较<span style="color: black;">长期</span>仍不缓解，则需解除肠管受压<span style="color: black;">原因</span>，<span style="color: black;">同期</span>应用高渗盐水湿敷肠管以减轻水肿。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">造口<span style="color: black;">周边</span>皮肤炎常表现为造口<span style="color: black;">周边</span>皮肤红肿、瘙痒、<span style="color: black;">病痛</span>，严重者可<span style="color: black;">显现</span>溃烂。造口<span style="color: black;">周边</span>皮肤炎<span style="color: black;">重点</span>是<span style="color: black;">因为</span><span style="color: black;">拥有</span>刺激性的造口流出物<span style="color: black;">长期</span>接触造口<span style="color: black;">周边</span>皮肤而<span style="color: black;">导致</span>。手术中应<span style="color: black;">选取</span>合适的造口位置，避开皮肤皱褶，以预防造口<span style="color: black;">周边</span>皮肤炎的<span style="color: black;">出现</span>。有<span style="color: black;">科研</span><span style="color: black;">发掘</span>，造口<span style="color: black;">周边</span>存在皮肤皱褶是<span style="color: black;">出现</span>造口<span style="color: black;">周边</span>皮肤炎的危险<span style="color: black;">原因</span>。术后应<span style="color: black;">指点</span><span style="color: black;">病人</span><span style="color: black;">选择</span>能够有效防止粪水渗漏的造口用品，加强对造口<span style="color: black;">周边</span>皮肤的护理，保持造口<span style="color: black;">周边</span>皮肤清洁，以及适当应用氧化锌软膏等皮肤<span style="color: black;">守护</span>剂。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">2、</span>远期并发症</strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1.造口旁疝：是<span style="color: black;">平常</span>的远期造口<span style="color: black;">关联</span>并发症之一，表现为造口<span style="color: black;">周边</span>的<span style="color: black;">反常</span><span style="color: black;">凸出</span>，是<span style="color: black;">因为</span>腹腔内容物经由造口旁的腹壁<span style="color: black;">缺失</span>处<span style="color: black;">明显</span><span style="color: black;">导致</span>。据欧洲疝学会<span style="color: black;">报告</span>，造口旁疝的<span style="color: black;">出现</span>率在随访12个月时超过30%，在随访更<span style="color: black;">长期</span>时达到50%或更高。<span style="color: black;">出现</span>造口旁疝的危险<span style="color: black;">原因</span><span style="color: black;">包含</span><span style="color: black;">病人</span><span style="color: black;">关联</span><span style="color: black;">原因</span>如<span style="color: black;">肥壮</span>、慢性咳嗽和慢性阻塞性肺<span style="color: black;">疾患</span>等，以及手术<span style="color: black;">关联</span><span style="color: black;">原因</span>如经腹膜造口或造<span style="color: black;">口味</span>染等。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">日前</span>，造口旁疝的预防<span style="color: black;">办法</span><span style="color: black;">重点</span><span style="color: black;">包含</span>：（1）经腹膜外途径造口。两项荟萃分析提示，在进行永久性结肠造口时，经腹膜外途径造口相较于经腹膜内途径造口，其造口旁疝的<span style="color: black;">出现</span>率较低。（2）造口时预防性<span style="color: black;">安置</span>补片。据一项纳入10项随机对照<span style="color: black;">实验</span>的荟萃分析<span style="color: black;">报告</span>，在进行造口时，预防性<span style="color: black;">运用</span>人工补片加固可降低造口旁疝的<span style="color: black;">出现</span>率。（3）适当<span style="color: black;">掌控</span><span style="color: black;">肥壮</span><span style="color: black;">病人</span>的体质量，积极治疗慢性咳嗽等<span style="color: black;">升高</span>腹内压的<span style="color: black;">疾患</span>，加强对营养不良<span style="color: black;">病人</span>的支持治疗，预防切<span style="color: black;">口味</span>染和切口愈合不良以及术后避免提举重物等<span style="color: black;">增多</span>腹内压的活动。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">症状轻微者或不能耐受手术者，可应用造口专用腹带进行局部压迫，阻止其进一步发展。疝过大或有嵌顿、绞窄等<span style="color: black;">危害</span>者应接受手术治疗。<span style="color: black;">包含</span>疝原位修补和造口移位。两篇纳入多项回顾性<span style="color: black;">科研</span>的系统<span style="color: black;">评估</span>指出，直接缝合修补腹壁<span style="color: black;">缺失</span><span style="color: black;">拥有</span>高复发率，而应用合成补片或生物补片进行修补的复发率较低。造口移位即在新的部位重新<span style="color: black;">安顿</span>造口，<span style="color: black;">因为</span>造口移位后，在先前造口部位存在切口疝<span style="color: black;">危害</span>以及在新造口部位存在<span style="color: black;">出现</span>造口旁疝的可能，<span style="color: black;">因此呢</span><span style="color: black;">日前</span>不<span style="color: black;">意见</span>采用造口移位。</span></p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;">★</strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><a style="color: black;">低位直肠癌术后造口<span style="color: black;">关联</span>并发症的防治</a></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">参考文献【略】</strong></span></p>
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