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中华结直肠疾病电子杂志 ›› 2019, Vol. 08 ›› Issue (03) : 221 -226. doi: 10.3877/cma.j.issn.2095-3224.2019.03.002

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低位直肠癌切除术后影响功能因素分析及对策
朱晓明1, 张卫1,()   
  1. 1. 200433 上海,第二军医大学附属长海医院肛肠外科
  • 收稿日期:2018-11-19 出版日期:2019-06-25
  • 通信作者: 张卫
  • 基金资助:
    上海市科委医学引导项目(No.134119a3800); 上海申康医院发展中心临床科技创新项目(No.SHDC12016122)

The analysis of factors on anal function and its countermeasure after sphincter-preserving surgery in low rectal cancer

Xiaoming Zhu1, Wei Zhang1,()   

  1. 1. The Colorectal Surgery Department, Changhai Hospital Affiliated to the Second Military Medical University, Shanghai 200433, China
  • Received:2018-11-19 Published:2019-06-25
  • Corresponding author: Wei Zhang
  • About author:
    Corresponding author: Zhang Wei, Email:
引用本文:

朱晓明, 张卫. 低位直肠癌切除术后影响功能因素分析及对策[J/OL]. 中华结直肠疾病电子杂志, 2019, 08(03): 221-226.

Xiaoming Zhu, Wei Zhang. The analysis of factors on anal function and its countermeasure after sphincter-preserving surgery in low rectal cancer[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2019, 08(03): 221-226.

直肠癌是常见的消化道恶性肿瘤,在我国多数是位于腹膜返折以下的低位直肠癌。近年来,随着直肠癌理论研究的深入和手术技术的提高,低位直肠癌保肛手术率在逐年上升。目前临床上常用的保肛术式有低位前切除术(LAR)、经括约肌间切除术(ISR)等,但保肛术后出现的各种肛门功能问题一直困扰着患者和医生。笔者通过回顾文献并结合自身经验就低位直肠癌保肛术后影响肛门功能的因素及处理对策进行探讨。

Rectal cancer is a common intestinal malignant tumor in China and most of them are low rectal cancer which located under the peritoneal reflection. For the past few years, the rate of sphincter-saving is increased significantly due to the development of theory and surgical skill. At present, the low anterior resection and the intersphincter resection are widely used as the sphincter-preserving surgery. However, a variety of problems in anal function perplex patients and surgeons. In this article, we will investigate the factors on anal function and its countermeasure after sphincter-preserving surgery based on literature review and our experience.

图1 Rullier低位直肠癌外科学分型。1A:Ⅰ型:肿瘤下缘距肛管直肠环>1 cm;1B:Ⅱ型:肿瘤下缘距肛管直肠环<1 cm;1C:Ⅲ型:肿瘤侵犯肛门内括约肌;1D:Ⅳ型:肿瘤侵犯肛门外括约肌或肛提肌
图2 极低位直肠癌拖出式适形切除示意图。2A:将肠管翻出肛门,在直视下保证肿瘤远切缘至少1 cm,根据肿瘤位置设计斜行切除线,总体是从肿瘤侧斜行向上到达对侧,使对侧远端保留更多的括约肌和齿状线。2B:间断缝合残端。2C:吻合时,将近端结肠吻合在直肠保留较多的一侧,使吻合口尽量远离齿状线
图3 直肠前间隙。打开腹膜返折后,可见位于覆盖在直肠表面的直肠固有筋膜和其前方的Denonvilliers筋膜,两者之间是一无血管神经的"裸区"(直肠前间隙),是行TME时应走行的平面。1:直肠固有筋膜;2:Denonvilliers筋膜;3:精囊腺;4:腹膜返折;5:髂内动脉前干分支血管;6:闭孔动脉分支;7:来自盆丛的神经纤维。5、6、7共同构成位于前列腺后外侧、直肠系膜前外侧的神经血管束
图4 Denonvilliers筋膜前方的神经交通支。在前方移除精囊腺和部分前列腺后,可见来自盆丛神经在Denonvilliers筋膜前方发出分支支配前列腺和精囊腺,并有着细小的交通支。1:前列腺;2:两侧盆丛;3:Denonvilliers筋膜;4:位于Denonvilliers筋膜前方的神经交通支
图5 新辅助治疗组与对照组EAS的超微结构观察。新辅助治疗组中可见:5A:大片肌纤维、肌节、线粒体溶解,糖原颗粒分布不均(×2 000);5B:肌节排列紊乱,线粒体嵴消失(×3 000);5C:Z线、M线、A带、I带消失(×3 000);5D:肌纤维和肌节坏死后被胶原纤维填充(×5 000),对照组则未见上述改变;5E:肌纤维、肌节排列整齐(×1 000);5F:Z线、M线、A带、Ⅰ带清晰可见(×3 000);5G-H:糖原分布均匀,线粒体嵴及外膜完整(×5 000)
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