【临床报告】朱金浩, 王铮, 张锋敏, 等. 精细功能保肛术联合结肠J型储袋(PPS-CJP)在超低位直肠癌中的应用体会
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGg7U3oNu99qRnD2GoOhnSMQkfSuicUFYXJseBGYUjwlx2b26kjZsbAWQg/640?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;"><strong style="color: blue;"><span style="color: black;">临床<span style="color: black;">报告</span></span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgk6XQNu000GAjJZUGQt7Dg4nbhXMiancHxtnQoWpu5hCjkibkXQBoo57w/640?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;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgiaE4qOFibYZsia4yWBDpgN33fjOVksdJ1f9MAZE5gicbxa7CLAZuRvTjFQ/640?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;"><strong style="color: blue;"><span style="color: black;">引用信息</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">朱金浩, 王铮, 张锋敏, 等. <span style="color: black;">精细</span>功能保肛术联合结肠J型储袋(PPS-CJP)在超低位直肠癌中的应用体会. 结直肠肛门外科, 2023, 29(5): 513-517.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgkAPC4lxzCGoDV0uHyLiaPVokNTsV2kX875IqPgVfkalicVYHPGC4xckQ/640?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;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgiaK7LdHQkDsOlpkdKsR2MAd9ASjlumhfPTPb4laqkMKVonnAvGvS3ibA/640?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;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">精细</span>功能保肛术联合结肠J型储袋（PPS-CJP）在超低位直肠癌中的应用体会</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">朱金浩，王铮，张锋敏，张现中，吴浩凡，庄成乐△，刘忠臣△</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">同济大学<span style="color: black;">附庸</span>第十人民医院（上海市第十人民医院）胃肠外科 上海 200072</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">△通信作者，E-mail：13860184888@163.com（刘忠臣）；zhuangchengle@tongji.edu.cn（庄成乐</span>）</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgVX1KicAUXTialhkpoqiaPricoFNIxwicc3B1eQhrI4IItwCWic7tf1rNkE1g/640?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;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;">刘忠臣</strong><span style="color: black;">专家</span>医师，教授，肿瘤外科博士、博士后，同济大学<span style="color: black;">附庸</span>第十人民医院（上海市第十人民医院）胃肠外科<span style="color: black;">专家</span>。<span style="color: black;">日前</span>担任中国NOSES<span style="color: black;">科研</span>协作组PPS分会理事长，中国医师协会结直肠肿瘤专业委员会<span style="color: black;">第1</span>届委员会常务委员兼腹腔镜专业委员会副<span style="color: black;">专家</span>委员，中国抗癌协会大肠癌专业委员会腹腔镜学组委员，大中华结直肠腹腔镜外科学院特聘教授讲师。是《实用肿瘤学杂志》《中华胃肠外科杂志》等杂志编委及审稿人。<span style="color: black;">得到</span>国内外发明专利及<span style="color: black;">运用</span>新型专利30余项，<span style="color: black;">发布</span>国内外专业论文20余篇。</span></span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgiaE4qOFibYZsia4yWBDpgN33fjOVksdJ1f9MAZE5gicbxa7CLAZuRvTjFQ/640?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;"><strong style="color: blue;"><span style="color: black;">摘要</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">结直肠癌<span style="color: black;">已然</span><span style="color: black;">作为</span>我国第二大<span style="color: black;">平常</span>癌症，直肠癌占结直肠癌的57.6%，而直肠癌又以中低位多见。在直肠癌诊疗过程中，三个问题备受术者及<span style="color: black;">病人</span>的关注，<span style="color: black;">包含</span>能否<span style="color: black;">保存</span>肛门、保肛手术后的并发症及术后肛门功能<span style="color: black;">状况</span>。超低位直肠癌保肛手术是世界性<span style="color: black;">困难</span>，本团队前期系列<span style="color: black;">科研</span>证实<span style="color: black;">精细</span>功能保肛术可<span style="color: black;">明显</span><span style="color: black;">加强</span>超低位直肠癌保肛率；<span style="color: black;">日前</span>认为，结肠J型储袋可<span style="color: black;">经过</span><span style="color: black;">增多</span>的肠道容积、转变的肠道运动等改善中低位直肠癌术后肛门功能，<span style="color: black;">同期</span>还可<span style="color: black;">经过</span><span style="color: black;">增多</span>吻合口处血供、减少盆腔间隙等降低吻合口漏的<span style="color: black;">出现</span>率。本文分享笔者科室3例应用<span style="color: black;">精细</span>功能保肛术联合结肠J型储袋治疗的超低位直肠癌<span style="color: black;">病人</span>的治疗经过，分析围手术期<span style="color: black;">关联</span>指标、术后并发症<span style="color: black;">状况</span>及术后1个月肛门功能，探讨<span style="color: black;">精细</span>功能保肛术联合结肠J型储袋在超低位直肠癌中的应用价值。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgkAPC4lxzCGoDV0uHyLiaPVokNTsV2kX875IqPgVfkalicVYHPGC4xckQ/640?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;"><span style="color: black;">按照</span>2023年</span><span style="color: black;">中国国家癌症中心<span style="color: black;">颁布</span>的统计数据，结直肠癌已<span style="color: black;">作为</span>我国第二大<span style="color: black;">平常</span>癌症，在2000—2016年<span style="color: black;">时期</span>，结直肠癌的发病率和死亡率都<span style="color: black;">显著</span><span style="color: black;">提升</span></span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。在结直肠癌<span style="color: black;">病人</span>中，直肠癌占57.6%，而直肠癌中又以中低位多见</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。现<span style="color: black;">周期</span>在直肠癌的诊疗过程中，<span style="color: black;">病人</span>的关注点<span style="color: black;">再也不</span>仅是肿瘤的根治，<span style="color: black;">她们</span>对能否<span style="color: black;">保存</span>肛门以及<span style="color: black;">保存</span>肛门后功能<span style="color: black;">状况</span><span style="color: black;">一样</span>较为关注</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。随着系统的刘氏三步吻合法【<span style="color: black;">详细</span><span style="color: black;">包含</span>：（1）近端肠管与盆底肌减张缝合；（2）<span style="color: black;">精细</span>吻合器介导的器械吻合；（3）手工缝合加固吻合口】被提出，学者们<span style="color: black;">发掘</span>基于<span style="color: black;">精细</span>吻合器和刘氏吻合三步法的<span style="color: black;">精细</span>功能保肛术（precision func⁃tional sphincter-preserving surgery，PPS）克服了<span style="color: black;">因为</span>肿瘤位置低，骨盆深部视野狭窄等<span style="color: black;">困难</span></span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。但随着术后随访例数<span style="color: black;">增加</span>，跟踪随访<span style="color: black;">发掘</span>超低位直肠癌PPS术后，可能<span style="color: black;">因为</span>直肠顺应性和直肠储器功能下降、复合运动<span style="color: black;">增多</span>等<span style="color: black;">原因</span></span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">，<span style="color: black;">病人</span>在短期内会<span style="color: black;">显现</span>排粪频率<span style="color: black;">增多</span>的<span style="color: black;">状况</span>，即低位前切除<span style="color: black;">综合症</span>（low anterior resection syndrome，LARS）</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。同济大学<span style="color: black;">附庸</span>第十人民医院（上海市第十人民医院）刘忠臣教授及其团队创新性地提出将结肠J型储袋（Colonic J-Pouch，CJP）应用于超低位直肠癌PPS，采用CJP—直肠／肛管吻合术替代既往结直肠／肛管直接吻合。该术式一方面可<span style="color: black;">明显</span>降低预防性造口比例和吻合口漏<span style="color: black;">危害</span>；另一方面J型储袋使肠管容量增大、储袋肠管的动力学改变，储袋及其系膜使盆腔死腔减小，<span style="color: black;">同期</span>吻合的储袋顶端的血液循环<span style="color: black;">通常</span><span style="color: black;">保留</span>良好，<span style="color: black;">拥有</span>更好的血供</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。本文分享笔者科室3例应用PPS-CJP治疗的超低位直肠癌<span style="color: black;">病人</span>的治疗经过，分析围手术期<span style="color: black;">关联</span>指标、术后并发症<span style="color: black;">状况</span>及术后1个月肛门功能，探讨PPS-CJP在超低位直肠癌中的应用价值，以期为临床<span style="color: black;">供给</span>参考。</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;">1 病例资料</span></strong></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;">1.1 病例1</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（1）<span style="color: black;">通常</span>资料：<span style="color: black;">病人</span>男性，术时年龄为67岁，BMI 20.83 <span style="color: black;">公斤</span>/m2，因“间断便血1月余”就诊，结肠镜<span style="color: black;">检测</span>提示：距肛门4 cm于直肠有一肿块，<span style="color: black;">体积</span>约3 cm×4 cm，质韧，边界清，占<span style="color: black;">全部</span>肠腔的1/2周，管腔狭窄，内镜能<span style="color: black;">经过</span>。内镜诊断：直肠恶性肿瘤。肠镜病理：（直肠）低—中分化腺癌。直肠MRI：下段直肠癌，mrT3N0M0，MRF（-），EMVI（-）。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（2）手术治疗：手术前一晚进行机械性肠道准备。气管插管全麻成功后，<span style="color: black;">病人</span>取改良截石位，会阴部术野消毒，铺<span style="color: black;">没</span>菌巾单。在脐上1 cm处作1 cm小切口，置入10 mm Trocar，接CO2气腹，维持腹腔CO2灌注压8~10 mmHg。<span style="color: black;">创立</span>观察孔后常规探查腹腔，再次确认有<span style="color: black;">没</span>远处转移。再分别于右侧腹直肌旁，右下腹、左侧腹直肌外侧肋缘下、左下腹分别作三处5 mm及一处12 mm小切口（主操作孔<span style="color: black;">位置于</span>右下腹）分别置入Trocar。仔细分离系膜粘连，显露肠系膜下血管根部及左结肠动脉，距血管根部约1.5 cm用Hem-o-lok夹闭离断，<span style="color: black;">保存</span>左结肠动脉。分离乙状结肠外侧系膜，并向上直至分离显露降结肠脾曲。沿Toldts间隙分离，<span style="color: black;">重视</span><span style="color: black;">守护</span>左侧输尿管及左侧生殖血管，直至将乙状结肠及降结肠完全游离。继续沿Toldts间隙分离骶前及直肠两侧间隙，直至显露盆底肌，修剪直肠及乙状系膜。肛指<span style="color: black;">检测</span>分离超过肿瘤位置后，终止腹部手术，转为经肛手术。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">经肛手术操作时（图1），<span style="color: black;">选取</span>合适型号的自制新型透明螺纹扩肛器，石蜡油润滑后螺旋<span style="color: black;">插进</span>肛门进行扩肛（图1A），充分扩肛后卸下内芯，经透明螺纹扩肛器在开放直视下进行操作（图1B）。确认肿瘤下缘距肛缘及齿状线的距离（图1C），用电刀进行初步定位，在距肿瘤下缘约1 cm处<span style="color: black;">精细</span>地用超声刀环形全层切开直肠壁。中低位直肠癌<span style="color: black;">病人</span>的远端切缘（distal resection margin，DRM）<1 cm的组织学切除边缘与DRM>1 cm的临床结果相当</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。经肛门拉出后，取少量下切缘组织送术中冰冻。切除距肿瘤上缘约10 cm肠管后移除标本（图1D），在根治性切除的前提下<span style="color: black;">保存</span><span style="color: black;">尽可能</span>多的肠管。移除肿瘤后，于肠管切缘上方5~6 cm处切开肠壁，将肠管折叠后伸入直线切割闭合器，将肠管行侧侧吻合，完成结肠J型储袋（图1E），再用可吸收线加固缝合吻合口。有<span style="color: black;">科研</span>证实，长度为5~6 cm的结肠J型储袋可<span style="color: black;">得到</span>较佳功能效果。在肠腔开口处行荷包缝合，肠管置入吻合器底钉座（图1F）；将近端直肠送回腹腔。可吸收线将近端肠管固定于盆腔。直视下连续缝合远端切缘肠壁全层后，置入柱状垫圈，将吻合器底钉座穿入垫圈，收紧线束将垫圈捆扎固定（图1G）。<span style="color: black;">插进</span>吻合器，<span style="color: black;">检测</span>肠管<span style="color: black;">没</span>扭转，吻合器击发将近远端肠管端侧吻合（图1H）。再用可吸收线间断缝合加固吻合口1周，<span style="color: black;">同期</span>加固吻合口交角。重建气腹，<span style="color: black;">检测</span>吻合口完整，腹腔内<span style="color: black;">没</span>活动性<span style="color: black;">流血</span>，继续常规完成其他操作。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgfkALpO3HlBjdmbBC0KSVYLNL25EPYl9mmgUZS8MCALBdwPD42p8LDg/640?tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（3）术后恢复<span style="color: black;">状况</span>（采用Wexner肛门失禁评分、Vaizey评分及LARS评分来<span style="color: black;">评估</span><span style="color: black;">病人</span>的术后肛门功能，其中Wexner肛门失禁评分总分20分，0分<span style="color: black;">暗示</span><span style="color: black;">没</span>肛门失禁，20分<span style="color: black;">暗示</span>完全肛门失禁；Vaizey评分总分24分，分值越高<span style="color: black;">表率</span>肛门功能越差；LARS评分总分42分，0~20分则<span style="color: black;">不可</span>诊断LARS，21~29分为轻度LARS，30~42分为重度LARS）：手术顺利，未行预防性造口；手术时间253 min，术中<span style="color: black;">流血</span>量120 mL，术后住院时间8 d；病理结果提示中低分化腺癌（印戒细胞癌），分期T3N2aM0；<span style="color: black;">没</span>术后并发症<span style="color: black;">出现</span>。术后1个月进行<span style="color: black;">tel</span>随访，LARS评分为27分（轻度LARS），Wexner肛门失禁评分为4分，Vaizey评分为8分；平均每日排粪次数为4次，夜间排粪次数0次，未<span style="color: black;">吃下</span>止泻或通便的<span style="color: black;">药品</span>。</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;">1.2 病例2</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（1）<span style="color: black;">通常</span>资料：<span style="color: black;">病人</span>女性，术时年龄58岁，BMI 23.01 <span style="color: black;">公斤</span>/m2，因“排粪次数<span style="color: black;">增加</span>、里急后重近半年”就诊。结肠镜<span style="color: black;">检测</span>提示：距肛门4 cm处可见新生物生长，占据管腔2/3，表面高低不平，质地脆，触之易<span style="color: black;">流血</span>。肠镜病理提示：直肠中分化腺癌。直肠指诊提示：截石位直肠后壁距离肛门4 cm处触及肿块，直径约4 cm。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（2）手术治疗：手术操作<span style="color: black;">过程</span>基本同病例1，<span style="color: black;">没</span>特殊处理。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（3）术后恢复<span style="color: black;">状况</span>：手术顺利，未行预防性造口；手术时间186 min，术中<span style="color: black;">流血</span>量112 mL，术后住院时间7 d；病理结果提示中分化腺癌（浸润型），分期T3N1M0；<span style="color: black;">没</span>术后并发症<span style="color: black;">出现</span>。术后1个月进行<span style="color: black;">tel</span>随访，LARS评分为28分（轻度LARS），Wexner肛门失禁评分为5分，Vaizey评分为9分；平均每日排粪次数为5次，夜间排粪次数0次，未<span style="color: black;">吃下</span>止泻或通便的<span style="color: black;">药品</span>。</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;">1.3 病例3</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（1）<span style="color: black;">通常</span>资料：<span style="color: black;">病人</span>女性，术时年龄为56岁，BMI 25.78 <span style="color: black;">公斤</span>/m2，因“里急后重20余天”就诊，结肠镜<span style="color: black;">检测</span>提示：距肛门4 cm于直肠有一隆起型肿块，<span style="color: black;">体积</span>约3 cm×3 cm，质韧，占<span style="color: black;">全部</span>肠腔的1/3周，管腔狭窄，内镜能<span style="color: black;">经过</span>。内镜诊断：直肠恶性肿瘤。肠镜病理提示：直肠中分化腺癌。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（2）手术治疗：手术操作<span style="color: black;">过程</span>基本同病例1，<span style="color: black;">没</span>特殊处理。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">（3）术后恢复<span style="color: black;">状况</span>：手术顺利，未行预防性造口；手术时间193 min，术中<span style="color: black;">流血</span>量109 mL，术后住院时间7 d；病理结果提示中低分化腺癌，分期T3N0M0；<span style="color: black;">没</span>术后并发症<span style="color: black;">出现</span>。术后1个月进行<span style="color: black;">tel</span>随访，LARS评分为25分（轻度LARS），Wexner肛门失禁评分为2分，Vaizey评分为5分；平均每日排粪次数为2次，夜间排粪次数0次，未<span style="color: black;">吃下</span>止泻或通便的<span style="color: black;">药品</span>。</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 讨论</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">我国结直肠癌的统计发病率<span style="color: black;">已然</span>从第3位<span style="color: black;">提升</span>至第2位，仅次于肺癌</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。直肠肿瘤下缘距肛缘<5 cm或距齿状线<3 cm为超低位直肠癌</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">，超低位直肠癌PPS的<span style="color: black;">显现</span>使部分<span style="color: black;">必须</span>行Miles术的<span style="color: black;">病人</span>有了保肛的<span style="color: black;">选取</span>。PPS<span style="color: black;">重点</span>分为两个<span style="color: black;">重点</span>部分，<span style="color: black;">首要</span>在腹腔镜下常规游离肠段至肿瘤下方；其次转为经肛手术，<span style="color: black;">运用</span>新型透明螺纹扩肛器扩张肛管后，术者在开阔清晰的视野下<span style="color: black;">精细</span>适形离断肠管，可最大程度<span style="color: black;">保存</span>健康的肠段。经新型透明螺纹扩肛器直视下手工褥式吻合使得吻合口更加<span style="color: black;">牢靠</span>。文中所纳入的3个病例，肿瘤下缘距肛缘均<5 cm，均未行预防性造口，术后均未<span style="color: black;">出现</span>并发症；术后1个月随访，患者均未<span style="color: black;">显现</span>重度LARS，每日排粪次数得到有效<span style="color: black;">掌控</span>。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">PPS的<span style="color: black;">显现</span>很好地回答了<span style="color: black;">病人</span>关注能否<span style="color: black;">保存</span>肛门、保肛手术后的并发症<span style="color: black;">状况</span>的问题。但在PPS术后跟踪随访中，<span style="color: black;">病人</span><span style="color: black;">显现</span>了与Dixon术后类似的排粪频繁、控便能力差的<span style="color: black;">状况</span>。2012年，Bryant等</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">首次提出了LARS。新近的一项国际专家共识<span style="color: black;">知道</span>LARS诊断标准为：直肠前切除或保肛术后<span style="color: black;">显现</span><span style="color: black;">最少</span>1种临床<span style="color: black;">关联</span>症状（肠道功能难以预测、排空困难、便急、大便次数<span style="color: black;">增多</span>、失禁、便秘等）并<span style="color: black;">引起</span><span style="color: black;">最少</span>1种临床<span style="color: black;">关联</span><span style="color: black;">结果</span>（厕所依赖、心理健康、专注于排粪、<span style="color: black;">平常</span>活动受影响等）</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。而高达18%~56%的保肛手术<span style="color: black;">病人</span>术后会<span style="color: black;">显现</span>较为严重的失禁、紧急排粪、便秘等肠道功能的改变</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。LARS<span style="color: black;">没</span>法治愈，治疗的目的是减少症状</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">，<span style="color: black;">因此呢</span>完善手术对减少LARS的<span style="color: black;">出现</span>至关<span style="color: black;">要紧</span>。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">既往有<span style="color: black;">科研</span><span style="color: black;">报告</span>应用直肠储袋<span style="color: black;">增多</span>直肠容积，以达到改善直肠肿瘤术后肛门功能的目的</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。相比直接吻合，储袋吻合<span style="color: black;">病人</span>的排粪<span style="color: black;">状况</span><span style="color: black;">显著</span>改善</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">，虽然这两种吻合方式<span style="color: black;">病人</span>的术后排粪<span style="color: black;">状况</span>会在1~2年趋于一致，但储袋吻合<span style="color: black;">病人</span>的直肠生理功能<span style="color: black;">能够</span>更早恢复</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。多普勒超声<span style="color: black;">影像</span><span style="color: black;">表示</span>，与直肠吻合相比，储袋吻合处储袋顶端血运更加丰富；<span style="color: black;">同期</span>，垂坠下来的储袋结构<span style="color: black;">亦</span>使得盆腔空隙减少，术后吻合口漏的<span style="color: black;">出现</span>率<span style="color: black;">亦</span><span style="color: black;">因此呢</span><span style="color: black;">明显</span>降低</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。然而，<span style="color: black;">以上</span><span style="color: black;">科研</span>均基于肿瘤下缘距肛缘≥5 cm的<span style="color: black;">状况</span>，<span style="color: black;">日前</span>鲜有CJP应用于超低位直肠癌（肿瘤下缘距肛缘<5 cm）的<span style="color: black;">报告</span></span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">有<span style="color: black;">科研</span>指出，当吻合口距肛缘<4 cm时，储袋组术后直肠功能<span style="color: black;">明显</span>优于直接吻合组</span><span style="color: black;"><span style="color: black;"></span></span><span style="color: black;">，而中低位直肠肿瘤（肿瘤下缘距肛缘≥5 cm）手术吻合口<span style="color: black;">通常</span>距肛缘≥4 cm。由此猜测，储袋结构在中低位直肠癌治疗中并<span style="color: black;">无</span>完全发挥效益，根治手术后残留的健康直肠的功能效果并不亚于额外构建的储袋结构，储袋结构可能仅是术后残留直肠功能未完全恢复时的替代品，当残留直肠功能渐渐恢复后，储袋的<span style="color: black;">功效</span>效果<span style="color: black;">亦</span>就<span style="color: black;">再也不</span><span style="color: black;">显著</span>。但超低位直肠癌的保肛手术从解剖学上<span style="color: black;">已然</span>决定了损失<span style="color: black;">更加多</span>的直肠肠段的问题，术后残存的健康直肠完全恢复后所起到的<span style="color: black;">功效</span>将<span style="color: black;">显著</span><span style="color: black;">少于</span>储袋所发挥的<span style="color: black;">功效</span>。<span style="color: black;">因此呢</span>在超低位直肠癌保肛手术中，<span style="color: black;">咱们</span>推测CJP所带来的肛门功能恢复<span style="color: black;">优良</span>将是<span style="color: black;">连续</span>存在的。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">超低位直肠癌<span style="color: black;">病人</span>肿瘤位置靠近齿状线，传统Dixon术常难以<span style="color: black;">保存</span>肛门。超低位直肠癌PPS依赖自制的透明螺纹扩肛器等器械，实现了肿瘤下缘的<span style="color: black;">精细</span>切除，<span style="color: black;">明显</span><span style="color: black;">加强</span>了超低位直肠癌手术的保肛率。PPS-CJP在PPS的<span style="color: black;">基本</span>上对游离的结肠段行侧侧吻合，构建CJP，再行远端肠管端侧吻合。在<span style="color: black;">保存</span>肛门解剖结构和生理功能的<span style="color: black;">基本</span>上，储袋吻合将进一步促进PPS术后肛门功能的恢复，本文3例病例的随访结果<span style="color: black;">亦</span>验证了<span style="color: black;">咱们</span>的想法。<span style="color: black;">因此呢</span>，基于Dixon术联合储袋的部分<span style="color: black;">科研</span>结果不完全适用于PPS联合储袋，<span style="color: black;">咱们</span>推测PPS联合储袋<span style="color: black;">得到</span>的治疗效益要好于<span style="color: black;">日前</span><span style="color: black;">科研</span>较多的Dixon术联合储袋。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">综上所述，CJP应用于超低位直肠癌PPS，重建了一个假性直肠壶腹部，<span style="color: black;">能够</span>有效地<span style="color: black;">帮忙</span><span style="color: black;">病人</span>降低直肠保肛术后吻合口漏等并发症<span style="color: black;">危害</span>、减轻排粪频繁等直肠刺激症状，<span style="color: black;">同期</span><span style="color: black;">亦</span>为直肠生理功能的恢复争取了时间。但<span style="color: black;">以上</span>结论仍需前瞻性、大样本临床<span style="color: black;">科研</span>进一步验证。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">利益冲突声明</span></strong><span style="color: black;"> 全体作者均声明不存在与本文<span style="color: black;">关联</span>的利益冲突。</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGg7HAiaD1woc8rUHq2OXUy7RBuduWbPlmdYyhDf2KEMkRKKpjpibZrvBlA/640?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;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgiaE4qOFibYZsia4yWBDpgN33fjOVksdJ1f9MAZE5gicbxa7CLAZuRvTjFQ/640?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;"><strong style="color: blue;"><span style="color: black;">滑动查看参考文献</span></strong></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"> ZHENG R S, ZHANG S W, ZENG H M, et al. Cancer incidence and mortality in China, 2016. Journal of the National Cancer Center, 2022, 2(1): 1-9.</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> SHI J F, WANG L, RAN J C, et al. Clinical characteristics, medical service utilization, and expenditure for colorectal cancer in China, 2005 to 2014: overall design and results from a multicenter retrospective epidemiologic survey. Cancer, 2021, 127(11): 1880-1893.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> WRENN S M, CEPEDA-BENITO A, RAMOS-VALADEZ D I, et al. Patient perceptions and quality of life after colon and rectal surgery: what do patients really want?. Diseases of the Colon and Rectum, 2018, 61(8): 971-978.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 庄成乐, 张现中, 刘骞, 等. 基于一种螺纹扩肛器的超低位直肠癌<span style="color: black;">精细</span>保肛(PPS)手术. 中华结直肠<span style="color: black;">疾患</span>电子杂志, 2019, 8(5): 509-512.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> 庄成乐, 刘正, 张锋敏, 等. 基于<span style="color: black;">精细</span>吻合器和刘氏吻合三步法的改良PPS术与传统PPS术治疗超低位直肠癌的非随机病例对照临床<span style="color: black;">科研</span>. 中华结直肠<span style="color: black;">疾患</span>电子杂志, 2022, 11(1): 30-35.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> SAKR A, SAURI F, ALESSA M, et al. Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chinese Medical Journal, 2020, 133(15): 1824-1833.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> KEANE C, FEARNHEAD N S, BORDEIANOU L, et al. International consensus definition of low anterior resection syndrome. Colorectal Disease, 2020, 22(3): 331-341.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> HALLB??K O, JOHANSSON K, SJ?DAHL R. Laser Doppler blood flow measurement in rectal resection for carcinoma — comparison between the straight and colonic J pouch reconstruction. British Journal of Surgery, 2005, 83(3): 389-392.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> ZENG W G, LIU M J, ZHOU Z X, et al. A distal resection margin of ≤1 mm and rectal cancer recurrence after sphincter-preserving surgery: the role of a positive distal margin in rectal cancer surgery. Diseases of the Colon and Rectum, 2017, 60(11): 1175-1183.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> LAZORTHES F, CHIOTASSO P, GAMAGAMI R A, et al. Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis: colonic J pouch versus straight coloanal anastomosis. British Journal of Surgery, 1997, 84(10): 1449-1451.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> HIDA J, YASUTOMI M, FUJIMOTO K, et al. Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch: prospective randomized study for determination of optimum pouch size. Diseases of the Colon and Rectum, 1996, 39(9): 986-991.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> CHEN W Q, SUN K X, ZHENG R S, et al. Cancer incidence and mortality in China, 2014. Chinese Journal of Cancer Research, 2018, 30(1): 1-12.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> TYTHERLEIGH M G, MORTENSEN N J M. Options for sphincter preservation in surgery for low rectal cancer. British Journal of Surgery, 2003, 90(8): 922-933.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> BRYANT C L C, LUNNISS P J, KNOWLES C H, et al. Anterior resection syndrome. The Lancet. Oncology, 2012, 13(9): e403-408.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> CROESE A D, LONIE J M, TROLLOPE A F, et al. A meta-analysis of the prevalence of low anterior resection syndrome and systematic review of risk factors. International Journal of Surgery, 2018, 56: 234-241.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> LAZORTHES F, FAGES P, CHIOTASSO P, et al. Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. British Journal of Surgery, 2005, 73(2): 136-138.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> PARC R, TIRET E, FRILEUX P, et al. Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma. British Journal of Surgery, 2005, 73(2): 139-141.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> HALLB??K O, P?HLMAN L, KROG M, et al. Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Annals of Surgery, 1996, 224(1): 58-65.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> FüRST A, BURGHOFER K, HUTZEL L, et al. Neorectal reservoir is not the functional principle of the colonic J-pouch: the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. Diseases of the Colon and Rectum, 2002, 45(5): 660-667.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> HO Y H, TAN M, SEOW-CHOEN F. Prospective randomized controlled study of clinical function and anorectal physiology after low anterior resection: comparison of straight and colonic J pouch anastomoses. British Journal of Surgery, 2005, 83(7): 978-980.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> SAILER M, FUCHS K H, FEIN M, et al. Randomized clinical trial comparing quality of life after straight and pouch coloanal reconstruction. British Journal of Surgery, 2002, 89(9): 1108-1117.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> ZAMAN S, PETERKNECHT E, BHATTACHARYA P, et al. Comparison of the colonic J-pouch versus side-to-end anastomosis following low anterior resection: a systematic review and meta-analysis. The American SurgeonTM, 2023. doi:10.1177/00031348231191769.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"> HIDA J, YASUTOMI M, MARUYAMA T, et al. Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer: determining the optimum level of anastomosis. Diseases of the Colon and Rectum, 1998, 41(5): 558-563.</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgmIHPLybHl9Jl67e8OSkw8ABofUTQTuiaAXV3xE0ebZ2OA56etFWZgBQ/640?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;"><a style="color: black;">点击此处下载原文</a></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgt8RlBicKY9w82APPjjia48Jeicpuh2HgIYCTkGT8emF6DcaPq4mEJjRlA/640?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;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgppesRZI85fb2FWvesKwLgdqJnaAkUunyZq3AicHtJ4hk8jJ67M5ZdJA/640?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;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGgULj6G5CMq2nNkiaFzZrI8R02uk7sTh5iaKBokRBrsAsrSQDbYmTRdkjg/640?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;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/VzVSsuHk4TmaMzcvWmHRPXp7Zfg5wKGglJUs8d41EFNKShjUBCovkA2ZUU1adHxVXKGOIUoNozbnbia5JY5Kslw/640?tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">◆ <a style="color: black;">《结直肠肛门外科》杂志2023年第5期内容通告</a></span></p><span style="color: black;">◆ <a style="color: black;">【专题述评】王玉柳明.王贵玉. 《中国肿瘤整合诊治技术指南（CACA）· NOSES技术》要点介绍及<span style="color: black;">诠释</span></a></span><span style="color: black;">◆<a style="color: black;">【专题述评】谭嘉男, 韩方海. 胃癌NOSES的<span style="color: black;">状况</span>与展望</a></span><span style="color: black;">◆<a style="color: black;">【专题述评】徐兴远，田野，王丹波. 谈经自然腔道取标本手术的发展与应用：从经阴道取标本手术与妇科肿瘤治疗的<span style="color: black;">方向</span></a></span><span style="color: black;"><span style="color: black;">◆<a style="color: black;">【专题述评】高云浩, 赵钦欣, 韩苏军, 等.经阴道取标本手术（Tv-NOSES）在泌尿系统肿瘤手术中的应用</a></span></span><span style="color: black;"><span style="color: black;">◆<a style="color: black;">【专题论著】张鑫,</a> 王玉柳明, 金英虎, 等. 经自然腔道取标本手术与常规腹腔镜手术在右半结肠癌中的疗效对比</span></span><a style="color: black;"><strong style="color: blue;"><span style="color: black;">◆</span></strong>【专题论著】白峻阁, 王哲学, 杨明, 等. 腹腔镜直肠癌低位前切除术经预防性回肠造口部位取标本的可行性及对造口还纳的影响</a> <span style="color: black;">◆ <a style="color: black;">【专题论著】罗军, 王刚, 刘勇, 等. 51例结直肠癌经自然腔道取标本手术<span style="color: black;">病人</span>的临</a>床资料分析</span><a style="color: black;"><span style="color: black;">◆ </span>【东林笔谈】魏建灿, 苏丹, 任东林, 等. 1例骶前成熟囊性畸胎瘤病理<span style="color: black;">成份</span>见胰腺组织的病例报告</a>
感谢楼主的分享！我学到了很多。 感谢你的精彩评论，带给我新的思考角度。 谢谢、感谢、感恩、辛苦了、有你真好等。
页:
[1]