腹腔镜下直肠脱垂悬吊固定治疗直肠全层脱垂32例临床疗效分析

doi:10.3877/cma.j.issn.2095-3224.2019.06.012

目的

探讨腹腔镜下经腹直肠脱垂悬吊固定治疗直肠全层脱垂的临床疗效。

方法

回顾性分析南京中医药大学附属南京中医院肛肠科从2010年6月至2018年3月采用腹腔镜下经腹直肠脱垂悬吊固定术治疗中重度直肠全层脱垂32例患者的资料。采用肛门直肠压力测定、Wexner便秘评分及Wexner肛门失禁评分指标评价术前、术后1个月、3个月及随访期间患者的肛门功能。

结果

32例直肠全层脱垂患者均在全麻下顺利完成腹腔镜下经腹直肠脱垂悬吊固定手术，无中转开腹。手术时间平均（115.94±23.34）min；术中出血量平均（20.16±10.74）mL。住院时间平均（12.84±2.10）天。术后当天的VAS评分平均（4.56±1.08）分。32例患者腹部切口愈合良好，无肠梗阻、腹腔感染等并发症。32例患者中成功随访31例，随访成功率96.97%（31/32），随访时间为平均（47.56±31.29）个月。31例患者，在术后6个月以上的痊愈率为90.32%（28/31）。患者术后1个月、3个月及随访期Wexner便秘评分（t=6.135，10.448，10.348；均P<0.05）和患者术后1个月、3个月及随访期Wexner肛门失禁评分（t=7.211，7.789，10.089；均P<0.05）均较术前改善。12例直肠脱垂合并肛门失禁患者术后3月肛管静息压（t=-3.477，P<0.05）和肛管最大收缩压（t=-2.311，P<0.05）均高于术前。

结论

腹腔镜下经腹直肠脱垂悬吊固定治疗直肠全层脱垂术后肛门直肠功能改善显著。

关键词: 直肠, 腹腔镜, 直肠全层脱垂, 肛门功能, Wexner便秘评分, Wexner肛门失禁评分

Objective

To evaluate the clinical efficacy of laparoscopic transabdominal rectal prolapse and suspension for the treatment of rectal full-thickness prolapse.

Methods

Aretrospective analysis was performed on the data of 32 patients with moderate and severe rectal full-thickness prolapse who underwent laparoscopic transabdominal rectal prolapse and suture fixation from June 2010 to March 2018 in Nanjing Department of Anorectal Surgery, Nanjing University of Traditional Chinese Medicine. Anal rectal pressure measurements, Wexner constipation scores, and Wexner anal incontinence scores were used to evaluate anal function in patients before, 1 month, 3 months, and during follow-up.

Results

Thirty-two patients with full-thickness rectal prolapse underwent laparoscopic transabdominal rectal prolapse and suture fixation under general anesthesia without conversion to open surgery. The operation time was (115.94±23.34) min; the intraoperative blood loss was (20.16±10.74) mL. The hospital stay was (12.84±2.10) d. The VAS score on the day after surgery was (4.56±1.08) points. Thirty-two patients had a good abdominal incision and no complications such as intestinal obstruction and abdominal infection. Of the 32 patients, Thirty-one were successful followed up. The successful rate of follow-up was 96.97% (31/32), and the follow-up time was (47.56±31.29) months. In 31 patients, the cure rate was 90.32% (28/31) after 6 months of surgery. Wexner constipation scores (t=6.135, 10.448, 10.348; all P<0.05) at 1 month, 3 months, and follow-up, and Wexner anal incontinence scores at 1 month, 3 months, and follow-up (t=7.211, 7.789, 10.089; all P<0.05) were all improved compared with preoperative. Twelve patients with rectal prolapse and anal incontinence were more likely to have anal canal pressure (t=-3.477, P<0.05) and anal canal systolic pressure (t=-2.311, P<0.05).

Conclusion

Laparoscopic transrectal rectal prolapse and suspension fixation for the treatment of rectal full-thickness prolapse is significantly improved.

Key words: Rectum, Laparoscopes, Full-thickness rectal prolapse, Anal function, Wexner constipation scores, Wexner anal incontinence scores

图1 腹腔镜下经腹直肠脱垂悬吊固定治疗。1A：手术前，患者肛门肿物反复脱出10余年，长约8 cm；1B：显露及保护下腹下神经丛；1C：用倒刺线将生物疝补片材料与右侧的分离的腹膜翼并固定在骶骨岬上；1D：缝合另外一侧的腹膜翼；1E：继续缝合并关闭腹膜；1F：患者痊愈，无肿物脱出

表1 Wexner肛门失禁评分

失禁情况	频率
失禁情况	从不	很少	有时	常常	总是
干便	0	1	2	3	4
稀便	0	1	2	3	4
气体	0	1	2	3	4
需要衬垫	0	1	2	3	4
生活方式改变	0	1	2	3	4

表1 Wexner肛门失禁评分

失禁情况	频率
失禁情况	从不	很少	有时	常常	总是
干便	0	1	2	3	4
稀便	0	1	2	3	4
气体	0	1	2	3	4
需要衬垫	0	1	2	3	4
生活方式改变	0	1	2	3	4

表2 直肠脱垂患者的痊愈率（n=31）

随访时间	痊愈［n（%）］	好转［n（%）］	无效［n（%）］
1个月	31（100）	0	0
3个月	30（96.77）	1（3.23）	0
术后6个月及以上	28（90.32）	2（6.45）	1（3.23）

表2 直肠脱垂患者的痊愈率（n=31）

随访时间	痊愈［n（%）］	好转［n（%）］	无效［n（%）］
1个月	31（100）	0	0
3个月	30（96.77）	1（3.23）	0
术后6个月及以上	28（90.32）	2（6.45）	1（3.23）

表3 直肠脱垂合并便秘、肛门失禁患者治疗前后Wexner评分

项目	例数	术前	术后1个月	术后3个月	随访期
WCS	16/16	16.25±4.42	13.44±3.63*	6.00±1.26*^△	6.19±1.68*^△▼
WFIS	12/13	12.17±3.21	10.08±2.78*	6.67±1.97*^△	3.08±1.98*^△▲

表3 直肠脱垂合并便秘、肛门失禁患者治疗前后Wexner评分

项目	例数	术前	术后1个月	术后3个月	随访期
WCS	16/16	16.25±4.42	13.44±3.63*	6.00±1.26*^△	6.19±1.68*^△▼
WFIS	12/13	12.17±3.21	10.08±2.78*	6.67±1.97*^△	3.08±1.98*^△▲

表4 患者术前、术后3个月肛管压力变化

组别	时间	ARP（mmHg）	AMCP（mmHg）
直肠脱垂合并便秘（16/16）	术前	59.04±18.52	113.59±50.31
直肠脱垂合并便秘（16/16）	术后3个月	-	-
直肠脱垂合并肛门失禁（12/13）	术前	7.65±2.28	46.63±20.27
直肠脱垂合并肛门失禁（12/13）	术后3个月	14.96±6.79	67.65±23.84
t值	?	-3.477	-2.311
P值	?	0.005	0.041

表4 患者术前、术后3个月肛管压力变化

组别	时间	ARP（mmHg）	AMCP（mmHg）
直肠脱垂合并便秘（16/16）	术前	59.04±18.52	113.59±50.31
直肠脱垂合并便秘（16/16）	术后3个月	-	-
直肠脱垂合并肛门失禁（12/13）	术前	7.65±2.28	46.63±20.27
直肠脱垂合并肛门失禁（12/13）	术后3个月	14.96±6.79	67.65±23.84
t值	?	-3.477	-2.311
P值	?	0.005	0.041

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Laparoscopic rectal prolapse and suspension for the treatment of 32 cases of rectal full-thickness prolapse

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Laparoscopic rectal prolapse and suspension for the treatment of 32 cases of rectal full-thickness prolapse