目的 探討直腸癌低位、超低位前切除并行橫結腸預防性造口術后其并發癥的護理對策。 方法 對2011年12月－2012年5月收治的43例低位直腸癌行預防性橫結腸造口患者的臨床資料進行回顧性分析，并就其發生并發癥的原因及護理方法予以總結。 結果 43例患者均在直腸癌前切除術后行預防性橫結腸袢式造口術。術后拔管時間2～5 d，造口排氣時間19～73 h，均未出現吻合口瘺，但發生造口脫垂1例，造口回縮1例，造口周圍皮膚疾病2例，經積極治療護理后均痊愈出院。 結論 術后精心護理對降低橫結腸造口術后并發癥，提高患者生活質量，改善預后十分重要。
ObjectiveTo explore the causes of colon-anal anastomotic stenosis in patients with low rectal cancer after prophylactic ileostomy under complete laparoscopy. MethodsA total of 194 patients with low rectal cancer who received complete laparoscopic radical resection of rectal cancer combined with preventive ileostomy in our hospital from January 2020 to December 2020 were selected as the study objects, and were divided into non-stenosis group (n=136) and stenosis group (n=58) according to postoperative colon-anal anastomosis stenosis. The clinical data of the two groups were compared. Univariate and multivariate logistic regression were used to analyze the factors affecting postoperative colon-anal anastomotic stenosis, and stepwise regression was used to evaluate the importance of each factor. The risk prediction model of postoperative colon-anal anastomotic stenosis was constructed and evaluated. ResultsIn the stenosis group, the proportion of males, tumor diameter ＞3 cm, NRS2002 score >3 points, manual anastomosis, left colic artery not preserved, anastomotic leakage, pelvic infection and patients undergoing neoadjuvant radiotherapy and neoadjuvant chemotherapy were higher than those in the non-stenosis group (P<0.05). The results of univariate logistic analysis showed that female and preserving the left colonic artery were the protective factors for postoperative colon-anal anastomotic stenosis (P<0.05), and the tumor diameter >3 cm, NRS2002 score >3 points, manual anastomosis, anastomotic leakage, pelvic infection, neoadjuvant radiotherapy and neoadjuvant chemotherapy were the risk factors for postoperative colon-anal anastomotic stenosis (P<0.05). Multivariate logistic regression analysis showed that gender, tumor diameter, NRS 2002 score, anastomotic mode, anastomotic leakage, and pelvic infection were independent influencing factors for postoperative colon-anal anastomotic stenosis (P<0.05). Stepwise regression analysis showed that the top three factors affecting postoperative colon-anal anastomotic stenosis were NRS 2002 score, gender and anastomotic leakage. Multivariate Cox risk proportional model analysis showed that the multivariate model composed of NRS 2002 score, gender and anastomotic leakage had a good consistency in the risk assessment of postoperative colon-anal anastomotic stenosis. Based on this, a risk prediction model for postoperative colon-anal anastomotic stenosis was constructed. The results of strong influence point analysis show that there are no data points in the modeling data that have a strong influence on the model parameter estimation (Cook distance <1). Receiver operating characteristic curve results showed that the model had good differentiation ability, the area under curve was 0.917, 95%CI was (0.891, 0.942). The calibration curve was approximately a diagonal line, showing that the model has good predictive power (Brier value was 0.097). The results of the clinical decision curve showed that better clinical benefits can be obtained by using the predictive model to identify the corresponding risk population and implement clinical intervention. ConclusionThe prediction model based on NRS 2002 score, gender and anastomotic fistula can effectively evaluate the risk of colon-anal anastomotic stenosis after preventive ileostomy in patients with low rectal cancer under complete laparoscopy.
Objective?To investigate the procedure and the effectiveness of modified Sublay-Keyhole technique for repair in situ of parastomal hernia.?Methods?Between October 2007 and March 2010, 11 patients with parastomal hernia underwent modified Sublay-Keyhole technique for repair in situ. There were 5 males and 6 females with an average age of 63 years (range, 55-72 years). The average body mass index was 28.2 (range, 23.5-32.5). All stomas in patients were permanent, including 6 end colostomies caused by abdominal perineal resection for rectal cancer, 2 end ileostomies secondary to total colon resection for ulcerative colitis, and 3 end ileostomies following ileal conduit for bladder resection. One patient underwent previous prothetic repair with polypropylene mesh. The average time from last operation to admission was 2.5 years (range, 1-4.5 years). According to classification criteria of George Eliot hospital, 3 cases were classified as grade 2b, 2 as grade 3a, 5 as grade 3b, and 1 as grade 4. The average longest diameter of hernia ring was 9.5 cm (range, 6-12cm).?Results Reconstructions of abdominal wall in all patients were performed successfully through modified Sublay-Keyhole technique. The average size of hernia ring was 75.5 cm2 (range, 30-112cm2), and the average size of polypropylene mesh was 280.5 cm2 (range, 175-360 cm2). The average operative time was 165 minutes (range, 120-195 minutes) and the average postoperative hospitalization days were 11 days (range, 9-14 days). All patients achieved healing of incision by first intention with no abdominal wall infection. Seroma and hematoma occurred in 2 patients and 1 patient, respectively, and were cured by needle aspiration and pressure bandaging. All patients were followed up 26.3 months on average (range, 10-39 months). One case suffered from parastomal hernia recurrence at 11 months postoperatively because of suture loosening and too wide aperture in mesh; and re-sutures in both mesh aperture and myofascial dehiscence were given and no recurrence was observed during additional follow-up of 15 months. No parastomal hernia recurrence or incisional hernia occurred in the other 10 patients.Conclusion?Modified Sublay-Keyhole technique is an effective procedure for reconstruction of abdominal wall in patients with parastomal hernia for low recurrence incidence and less complications. But the long-term effectiveness needs further follow-up
目的 探討盲腸管道式造口持續減壓方法防治直腸癌低位前切除術后吻合口漏的臨床價值。方法 選擇120例擬行直腸癌低位前切除手術患者，按機械抽樣法隨機分成2組，60例為盲腸管道式造口減壓組（盲腸減壓組），另外60例行常規手術作為對照。分析2組患者術后吻合口漏、消化道反應、呼吸系統感染及腹腔感染發生的差異及出現吻合口漏后的住院時間、開始進食時間和住院總費用。結果 盲腸減壓組與常規手術組相比，發生吻合口漏〔(5.0%（3例）比13.3%（8例）〕、消化道反應〔15.0%（9例）比48.3%（29例）〕、呼吸系統感染〔11.7%（7例）比26.7%（16例）〕及腹腔感染〔11.7%（7例）比21.7%（13例）〕者均明顯減少(Plt;0.05)。盲腸減壓組中發生吻合口漏的患者與常規手術組中發生吻合口漏的患者相比，漏后住院時間〔（39±3） d比（53±4） d〕更短，進食〔（14±2） d比（25±3） d〕更早，住院總費用〔（39 620±2 033）元比（46 750±2 131）元〕降低，差異均有統計學意義(Plt;0.05)。結論 盲腸管道式造口持續減壓能有效降低直腸癌低位前切除術后吻合口漏的發生率。