常順伍,呂云福
(海南省人民醫(yī)院胃腸外一科,海南 海口 570311)
擴(kuò)大右半結(jié)腸切除術(shù)在梗阻性結(jié)腸脾曲腫瘤中的應(yīng)用
常順伍,呂云福
(海南省人民醫(yī)院胃腸外一科,海南 海口 570311)
目的 探討擴(kuò)大右半結(jié)腸切除術(shù)治療結(jié)腸脾曲腫瘤并急性梗阻的臨床療效。方法回顧性分析我院2005年6月至2014年11月期間由同一術(shù)者實(shí)施的11例梗阻性結(jié)腸脾曲腫瘤行擴(kuò)大右半結(jié)腸切除手術(shù)患者的臨床資料,針對(duì)患者的手術(shù)時(shí)間、術(shù)中出血量、術(shù)后排氣時(shí)間、住院時(shí)間、淋巴結(jié)清掃數(shù)目及術(shù)后吻合口瘺的發(fā)生率等方面進(jìn)行觀察。結(jié)果本組均除外Ⅳ期患者。11例患者TNM分期中ⅡC期2例,ⅢB期4例,ⅢC期5例。平均手術(shù)時(shí)間(195.7±17.1)min,平均術(shù)中出血量(272.6±54.8)ml,平均術(shù)后排氣時(shí)間(4.2±2.6)d,平均住院時(shí)間(11.5±6.8)d,術(shù)后3個(gè)月平均每日排便次數(shù)為3.5次/d。淋巴結(jié)的中位清掃數(shù)為13.8枚,淋巴結(jié)陽(yáng)性比例為44%。3例患者淋巴結(jié)清掃數(shù)不足12枚(27.3%)。11例患者手術(shù)切緣均為腫瘤陰性。術(shù)后無(wú)一例患者發(fā)生吻合口瘺。結(jié)論在充分掌握適應(yīng)證的情況下,結(jié)腸脾曲腫瘤并急性梗阻行擴(kuò)大右半結(jié)腸切除一期吻合術(shù)安全可行。
擴(kuò)大右半結(jié)腸切除術(shù);結(jié)腸脾曲腫瘤;腸梗阻
結(jié)腸脾曲腫瘤在結(jié)腸癌中相對(duì)少見(jiàn),在手術(shù)治療的結(jié)腸癌中僅占2%~8%[1],癥狀多表現(xiàn)為梗阻且處于進(jìn)展期,較左半結(jié)腸其他部位的腫瘤預(yù)后差[2]。結(jié)腸脾曲腫瘤急性梗阻有兩種最常用的術(shù)式:(1)擴(kuò)大右半結(jié)腸切除術(shù);(2)左半結(jié)腸切除加橫結(jié)腸造瘺或術(shù)中結(jié)腸灌洗一期吻合術(shù)。結(jié)腸脾曲的位置定義相對(duì)模糊,手術(shù)術(shù)式也仍然存在著爭(zhēng)論[3]。目前,具體選擇何種術(shù)式及相應(yīng)術(shù)式的優(yōu)缺點(diǎn),文獻(xiàn)仍鮮有報(bào)道。筆者通過(guò)對(duì)我院2005年6月至2014年11月期間由同一術(shù)者實(shí)施的11例結(jié)腸脾曲腫瘤并急性梗阻行擴(kuò)大右半結(jié)腸切除手術(shù)病例進(jìn)行回顧性分析,探討和評(píng)價(jià)其術(shù)后的近期效果。
1.1 一般資料 本組11例患者中,男性8例,女性3例,年齡54~78歲,平均67.5歲,臨床表現(xiàn)為腹痛、腹脹及肛門(mén)停止排氣排便等腸梗阻癥狀,根據(jù)術(shù)前腹部平片、CT和腸鏡結(jié)果證實(shí)為降結(jié)腸或脾曲腫瘤占位,經(jīng)手術(shù)和術(shù)后病理診斷,腫瘤位于脾曲5例,左側(cè)橫結(jié)腸近脾曲2例,降結(jié)腸近脾曲4例。術(shù)后病理診斷為低分化腺癌2例,中分化腺癌5例,中、低分化腺癌1例,高分化腺癌3例。TNM分期:ⅡC期2例,ⅢB期4例,ⅢC期5例,均行擴(kuò)大右半結(jié)腸切除一期吻合術(shù)。
1.2 手術(shù)方法 所有患者的手術(shù)均由我院同一手術(shù)組外科醫(yī)生完成。均為急診開(kāi)腹手術(shù),急診手術(shù)定義為入院后72 h內(nèi)。所有患者術(shù)前均給予禁食、胃腸減壓、灌腸、抗炎、營(yíng)養(yǎng)支持、糾正電解質(zhì)及酸堿平衡紊亂等治療。擴(kuò)大右半結(jié)腸切除術(shù)定義為右半及橫結(jié)腸切除,同時(shí)還切除部分降結(jié)腸,以保證遠(yuǎn)端切除距離腫瘤至少5 cm。腹部正中切口,進(jìn)入腹腔后,游離回盲部并提出腹腔外,盲腸外側(cè)壁開(kāi)口行減壓術(shù);縫合開(kāi)口,游離右半結(jié)腸及其系膜,打開(kāi)胃結(jié)腸韌帶,游離橫結(jié)腸及結(jié)腸脾曲,根部結(jié)扎結(jié)腸中動(dòng)脈,回結(jié)腸動(dòng)脈、右結(jié)腸動(dòng)脈(如存在)于中央部位結(jié)扎;游離左半結(jié)腸及系膜,如腫瘤位置在降結(jié)腸近端,需結(jié)扎左結(jié)腸動(dòng)脈根部,保留乙狀結(jié)腸動(dòng)脈;充分游離降結(jié)腸及乙狀結(jié)腸系膜,并與回腸斷端行側(cè)側(cè)吻合術(shù),將小腸推向右側(cè)腹腔,閉合系膜裂孔。
11例患者手術(shù)過(guò)程順利。平均術(shù)中出血量(272.6±54.8)ml,平均手術(shù)時(shí)間(195.7±17.1)min,平均術(shù)后排氣時(shí)間(4.2±2.6)d,平均住院時(shí)間(11.5±6.8)d。淋巴結(jié)的中位清掃數(shù)為13.8枚,淋巴結(jié)陽(yáng)性比例為44%,3例患者淋巴結(jié)清掃數(shù)不足12枚(27.3%)。11例患者手術(shù)切緣均為腫瘤陰性,均達(dá)到腫瘤完全切除(R0)。術(shù)后無(wú)一例患者發(fā)生吻合口瘺。術(shù)后3個(gè)月隨訪,平均排便次數(shù)為3.5次/d。
結(jié)腸脾曲的位置定義相對(duì)模糊,其血供和淋巴回流也存在明顯異質(zhì)性[4]。因此,手術(shù)切除的范圍更多是基于外科醫(yī)生自身的選擇。擴(kuò)大右半結(jié)腸切除在絕大多數(shù)情況下可以滿足回腸-結(jié)腸的無(wú)張力吻合,并且保證吻合口較好的血供[5];左半結(jié)腸切除為高位結(jié)扎腸系膜下動(dòng)脈、結(jié)腸中動(dòng)脈左側(cè)分支,行橫結(jié)腸造瘺術(shù),或術(shù)中結(jié)腸灌洗后行橫結(jié)腸-直腸吻合,或選擇性結(jié)扎左結(jié)腸動(dòng)脈,行橫結(jié)腸-乙狀結(jié)腸吻合[6]。然而,左半結(jié)腸切除術(shù)有時(shí)需要游離部分右半結(jié)腸以達(dá)到無(wú)張力吻合[7]。目前,具體選擇何種術(shù)式及相應(yīng)術(shù)式的優(yōu)缺點(diǎn),文獻(xiàn)仍鮮有報(bào)道。
Nakagoe等[8]研究發(fā)現(xiàn),結(jié)腸脾曲腫瘤患者行左半結(jié)腸切除術(shù)與擴(kuò)大右半結(jié)腸切除術(shù),其短期療效及總生存率方面并無(wú)明顯統(tǒng)計(jì)學(xué)差異。在淋巴結(jié)清掃方面,一項(xiàng)大型研究顯示,在結(jié)腸腫瘤切除標(biāo)本中,僅37%達(dá)到了12個(gè)及12個(gè)以上的淋巴結(jié)清掃數(shù)[9]。本研究中,淋巴結(jié)的中位清掃數(shù)為13.8枚,淋巴結(jié)陽(yáng)性比例為44%,3例患者淋巴結(jié)清掃數(shù)不足12枚(27.3%),高于上述的研究結(jié)果。淋巴結(jié)清掃數(shù)和生存率是否存在確切的相關(guān)性,目前仍存爭(zhēng)議[10]。由于切除了中結(jié)腸動(dòng)脈,擴(kuò)大右半結(jié)腸切除術(shù)更加徹底,12個(gè)以上淋巴結(jié)清掃數(shù)的比例更高[11]。淋巴結(jié)清掃數(shù)是否與外科醫(yī)生的手術(shù)操作或病理科醫(yī)生的清掃技術(shù)不足有關(guān),目前仍不清楚。然而,更多的研究發(fā)現(xiàn),病理科醫(yī)生的操作水平較手術(shù)本身對(duì)淋巴結(jié)清掃數(shù)的影響更大[12]。
本組患者切緣均為腫瘤陰性,均達(dá)到腫瘤完全切除(R0),反映出擴(kuò)大右半結(jié)腸切除術(shù)是一種更為徹底的術(shù)式,更能有效切除橫結(jié)腸及其血管蒂。結(jié)腸脾曲腫瘤并急性梗阻行急診擴(kuò)大右半結(jié)腸切除加回結(jié)腸一期吻合術(shù)更少發(fā)生灌注不足或張力過(guò)大的問(wèn)題。左半結(jié)腸腫瘤并急性梗阻,多數(shù)情況下需行橫結(jié)腸造瘺術(shù),待二期行閉瘺手術(shù),直接行腸管吻合在急診手術(shù)中較為少見(jiàn)[13]。本組病例均行一期吻合術(shù),術(shù)后無(wú)1例患者出現(xiàn)吻合口瘺。結(jié)腸脾曲腫瘤并急性梗阻開(kāi)腹手術(shù)暴露困難,如行左半結(jié)腸切除術(shù),吻合方面存在著張力大的風(fēng)險(xiǎn),即使行術(shù)中腸道灌洗,仍需切除相對(duì)較短的腸管,以避免出現(xiàn)吻合困難的問(wèn)題。即使是腔鏡下結(jié)腸脾曲腫瘤的手術(shù)亦是結(jié)腸手術(shù)的難點(diǎn),游離面廣,特別是擴(kuò)大左半結(jié)腸切除的同時(shí),還要游離降結(jié)腸及乙狀結(jié)腸,以方便吻合。結(jié)腸中動(dòng)脈的保留可以最大限度地避免吻合口張力的問(wèn)題,但有可能導(dǎo)致中結(jié)腸動(dòng)脈根部淋巴結(jié)清掃不徹底。研究表明,局部復(fù)發(fā)與較長(zhǎng)淋巴結(jié)回流的中央血管蒂遺留有關(guān)[14]。
長(zhǎng)期療效方面,Slim等[15]發(fā)現(xiàn),急診手術(shù)與年齡是結(jié)直腸癌術(shù)后死亡率增高的重要預(yù)測(cè)指標(biāo)。結(jié)腸脾曲腫瘤的預(yù)后較結(jié)腸其他部位差可能與其常表現(xiàn)為腫瘤進(jìn)展期并伴有急性梗阻有關(guān)[16]。Hohenberger等[17]報(bào)道,血管的高位結(jié)扎和淋巴結(jié)的廣泛清掃有利于控制復(fù)發(fā)率和提高生存率。
總之,結(jié)腸脾曲腫瘤并急性梗阻行擴(kuò)大右半結(jié)腸切除術(shù)安全可行,避免了橫結(jié)腸造瘺,具有吻合口安全性高、切除更徹底等優(yōu)點(diǎn);缺點(diǎn)是切除了較多的結(jié)腸,容易導(dǎo)致術(shù)后患者大便次數(shù)增多。術(shù)中結(jié)腸灌洗并一期吻合術(shù)雖然避免了行結(jié)腸造瘺術(shù),但Kazuhito等[18]報(bào)道,左半結(jié)腸癌合并急性腸梗阻一期切除結(jié)腸吻合后吻合口瘺的病死率高達(dá)25%~45%,因此筆者認(rèn)為,梗阻時(shí)間長(zhǎng)、近端高度擴(kuò)張的結(jié)腸不宜行一期結(jié)腸吻合術(shù),為避免行結(jié)腸造瘺術(shù),可考慮行擴(kuò)大右半結(jié)腸切除術(shù)。
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Application of extended right colectomy in the treatment of obstructive splenic flexure tumours.
CHANG Shun-wu, LV Yun-fu.Department of Ggastrointestinal Surgery,People's Hospital of Hainan Province,Haikou 570311,Hainan,CHINA
Objective To evaluate the clinical efficacy of extended right colectomy in treating obstructive splenic flexure tumour.MethodsThe clinical and follow-up data of 11 patients who underwent extended right colectomy from June 2005 to november 2014 in our hospital were retrospectively analyzed.The operation time,intraoperative blood loss, postoperative exhausting time,length of hospital stay,number of lymph nodes dissected and incidence of postoperative anastomotic fistula were analyzed.ResultsAccording to the TNM staging,there were 2 phaseⅡC cases,4 phaseⅢB cases,and 5 phaseⅢC cases.The mean operation time was(195.7±17.1)min,intraoperative blood loss was (272.6.0±54.8)ml,postoperative exhausting time was(6.2±2.3)d,length of hospital stay was(11.5±6.8)d,and stool frequency was 3.5 times per day 3 months after the surgery.The median number of dissected lymph nodes was 13.8,with positive lymph nodes in 44%of patients.The proportion of patients with<12 dissected lymph nodes was 27.3%.All patients had negative resection margins.And postoperative anastomotic fistula developed in no patients.ConclusionExtended right colectomy for patients with obstructive splenic flexure tumours is feasible and safe.
Extended right colectomy;Splenic flexure tumour;Intestinal obstruction
R656.9
A
1003—6350(2015)18—2755—03
10.3969/j.issn.1003-6350.2015.18.1002
2015-05-12)
國(guó)家臨床重點(diǎn)專(zhuān)科建設(shè)項(xiàng)目經(jīng)費(fèi)資助(編號(hào):2012-649)
呂云福。E-mail:yunfu_lv@126.com