【摘要】：目的:結(jié)直腸癌病人呈逐年增加的趨勢(shì),其中低位直腸癌占有較高比例。對(duì)于低位直腸癌及肛管癌患者目前的標(biāo)準(zhǔn)術(shù)式仍然是Miles術(shù)(腹會(huì)陰聯(lián)合直腸癌根治術(shù)),也幾乎是唯一能夠獲得根治的治療手段。此種術(shù)式的最大特點(diǎn)是在患者腹壁建立人工肛門(mén)。雖然患者壽命延長(zhǎng),但造瘺口的出現(xiàn)也帶來(lái)一系列術(shù)后并發(fā)癥,如出血、壞死、感染、梗阻、狹窄及造口旁疝等。而造口旁疝是結(jié)腸造口術(shù)后常見(jiàn)并發(fā)癥,并且嚴(yán)重降低了患者術(shù)后生活質(zhì)量。由于造口旁疝的高發(fā)病率(高達(dá)50%)和外科手術(shù)修補(bǔ)的復(fù)雜性,如何預(yù)防造口旁疝的形成變得非常重要。影響造口旁疝發(fā)生的因素有很多,病人自身相關(guān)的因素如高齡、性別、肥胖、營(yíng)養(yǎng)不良、慢性咳嗽等;和手術(shù)相關(guān)的因素有:造口部位、造口大小及造口方式等。盡管外科醫(yī)生做了大量的工作來(lái)預(yù)防造口旁疝的發(fā)生,但是其發(fā)病率并居高不下。近期國(guó)外研究報(bào)道在結(jié)腸造口時(shí)通過(guò)植入疝補(bǔ)片來(lái)加強(qiáng)造口周?chē)贡趶?qiáng)度可有效預(yù)防造口旁疝的發(fā)生。本研究在低位直腸癌患者中施行Miles術(shù)并術(shù)中乙狀結(jié)腸造口處使用IPOM法(即腹膜內(nèi)固定法)預(yù)置Bard CK疝補(bǔ)片,探究預(yù)置疝補(bǔ)片對(duì)預(yù)防造口旁疝的作用。方法:選取我科于2014年6月至2015年6月期間行低位直腸癌Miles手術(shù)且經(jīng)腹直肌乙狀結(jié)腸造口患者50名,隨機(jī)分成兩組,每組25名,試驗(yàn)組使用IPOM法在腹壁造口旁預(yù)置Bard CK專業(yè)造口疝補(bǔ)片,對(duì)照組直接在腹壁完成造口制作。試驗(yàn)組手術(shù)的25名患者中,男性14例,女性11例,年齡在45-69歲之間,平均年齡56.2歲;對(duì)照組手術(shù)的25名患者中,男性13例,女性12例,年齡在46-72歲之間,平均年齡在57.4歲。術(shù)前由造口治療師和醫(yī)生共同選定造口位置,并標(biāo)記。術(shù)后造口由造口治療師觀察記錄并維護(hù)。術(shù)后使用造口腹帶固定3月,期間避免大笑及高強(qiáng)度體力勞動(dòng)。術(shù)后隨訪患者,并行腹部CT掃描確認(rèn)有無(wú)造口旁疝的發(fā)生。結(jié)果:50名患者,隨訪周期為18-30個(gè)月,平均26.8個(gè)月。試驗(yàn)組中有2位患者出現(xiàn)腹壁異物感及局部刺痛,術(shù)后1月內(nèi)都好轉(zhuǎn)消失。1位患者出現(xiàn)造口周?chē)つw炎,對(duì)癥治療后痊愈。其余患者均無(wú)造口出血、感染、皮炎、壞死等并發(fā)癥出現(xiàn)。對(duì)照組中有術(shù)后出現(xiàn)2位造口周?chē)?對(duì)癥處理后痊愈。兩組術(shù)后總并發(fā)癥發(fā)生率比較,P0.05。所有患者均行體格檢查,追問(wèn)患者出院后情況,門(mén)診腹部CT掃描。對(duì)照組中有6位患者經(jīng)CT掃描確認(rèn)發(fā)生造口旁疝,而試驗(yàn)組未有出現(xiàn),P0.05。結(jié)論:在低位直腸癌患者行Miles術(shù)時(shí)行IPOM法預(yù)置Bard CK疝補(bǔ)片可預(yù)防造口旁疝的發(fā)生,且并不增加總并發(fā)癥的發(fā)生率。預(yù)置造口疝補(bǔ)片技術(shù)具有很大的應(yīng)用前景。國(guó)內(nèi)需要多進(jìn)行多中心、大樣本的前瞻性隨機(jī)對(duì)照研究,積累研究數(shù)據(jù),爭(zhēng)取早日將技術(shù)推廣,讓患者獲得更好的預(yù)后及生活質(zhì)量。
[Abstract]:Objective: colorectal cancer patients are increasing year by year, in which low rectal cancer accounts for a high proportion. The current standard procedure for patients with low rectal and anal cancer is still Miles (abdominal perineum combined with rectal cancer radical resection) and is almost the only treatment that can be cured. The most important feature of this procedure is the establishment of artificial anus in the abdominal wall of the patient. Although the patient's life span is longer, the appearance of the fistula also brings a series of postoperative complications, such as bleeding, necrosis, infection, obstruction, stenosis and paracentesis hernia. Paracostomy hernia is a common complication after colostomy, and seriously reduces the postoperative quality of life. Because of the high incidence (up to 50%) of parastatal hernia and the complexity of surgical repair, it is very important to prevent the formation of paracentotomy hernia. There are many factors that affect the occurrence of paracentesis hernia, such as age, sex, obesity, malnutrition, chronic cough and so on. Although surgeons do a lot of work to prevent paracentesis hernia, its incidence remains high. Recent foreign studies have reported that strengthening the strength of abdominal wall around colostomy by implanting herniation patch can effectively prevent the occurrence of para-stomal hernia. In this study, Miles was performed in patients with low rectal cancer and Bard CK herniation patch was prepositioned at sigmoidostomy with IPOM method (peritoneal internal fixation) to explore the effect of preimplantation hernia patch on prevention of paracostomal hernia. Methods: from June 2014 to June 2015, 50 patients with low rectal cancer underwent Miles operation and underwent rectus sigmoidostomy from June 2014 to June 2015 were randomly divided into two groups, 25 patients in each group. IPOM method was used in the experimental group to preposition Bard CK professional herniation patch beside the abdominal wall orifice, while the control group finished the orifice making directly in the abdominal wall. There were 14 males and 11 females, aged 45-69 years, with an average age of 56.2 years, while in the control group, there were 13 males and 12 females, aged between 46 and 72 years, with an average age of 57.4 years. The site was selected and marked by the surgeon and the surgeon before operation. The postoperative opening was recorded and maintained by the orthopedic therapist. After operation, the abdominal band was fixed for 3 months, during which laughter and high-intensity manual labor were avoided. Postoperative follow-up, abdominal CT scan to confirm the occurrence of parastatal hernia. Results 50 patients were followed up for 18-30 months with an average of 26.8 months. There were 2 patients in the test group with abdominal wall foreign body sensation and local prickly pain. 1. 1 patients had peristomal dermatitis and recovered after symptomatic treatment. The other patients had no complications such as bleeding, infection, dermatitis and necrosis. In the control group, there were 2 cases of peristomal inflammation after operation, and recovered after symptomatic treatment. The incidence of postoperative complications in the two groups was significantly higher than that in the control group (P 0.05). All the patients underwent physical examination, asked about the condition after discharge, and CT scan of the outpatient abdomen. Six patients in the control group were confirmed to have parastotomy hernia by CT scan, but no P0.05 was found in the trial group. Conclusion: IPOM preplacement of Bard CK hernia patch during Miles in patients with low rectal cancer can prevent the occurrence of perioperative hernia and does not increase the incidence of total complications. The technique of preimplantation hernia patch has great application prospect. It is necessary to carry out multi-center, large sample prospective randomized controlled studies in China, accumulate research data, and strive to promote the technology as soon as possible, so that patients can obtain better prognosis and quality of life.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R735.37

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