中低位直肠癌保肛术后大便失禁的诊治进展  

Evaluation and Treatment for Fecal Incontinence after Sphincter-Preserving Operation for Middle and Low Rectal Cancer

作　　者：皮艳娜[1] 肖毅[2] 方秀才[1] 

机构地区：[1]中国医学科学院北京协和医学院北京协和医院消化内科,北京100730 [2]中国医学科学院北京协和医学院北京协和医院基本外科,北京100730

出　　处：《中国普外基础与临床杂志》2014年第5期641-645,共5页Chinese Journal of Bases and Clinics In General Surgery

基　　金：863计划课题(编号:2010AA023007);"十一五"国家科技支撑计划资助项目(编号:2007BAI04B01)~~

摘　　要：目的了解中低位直肠癌根治保肛术后大便失禁的发生率、影响其发生和转归的因素、症状与肛门直肠功能的关系及治疗现状。方法对中低位直肠癌根治保肛术后大便失禁的相关文献进行综述。结果大便失禁是中低位直肠癌根治保肛术后最常见的一种排便功能障碍,发生率约为35.3%。评估大便失禁严重程度的方法以Wexner大便失禁评分的临床有效性和实用性较高,Wexner评分与大便失禁生活质量量表得分相关,当Wexner评分≥9分时患者生活质量严重受损。直肠癌根治术后吻合口距肛缘距离与大便失禁发生和恢复显著相关,吻合口距肛缘越近,术后越易出现大便失禁且程度越重。当肿瘤位置极低时,在保证肿瘤根治的基础上,可考虑通过手术方式来弥补术后肛门直肠功能的下降。放化疗对大便失禁的影响的结论不一。年龄本身是发生大便失禁的危险因素,对超高龄低位直肠癌患者行根治性保肛手术仍需慎重。直肠癌根治术后患者是否出现大便失禁及其发展、转归与肛门直肠功能间的关系尚不完全明确。术中肛门内括约肌神经功能测定可预测术后是否出现神经源性大便失禁。直肠冲洗能改善直肠癌根治术后患者的生活质量。小样本研究证实骶神经电刺激治疗大便失禁有效,但仍需大样本研究来证实。生物反馈可显著改善直肠癌根治术后大便失禁的评分。结论需进一步规范评估大便失禁严重程度的客观标准,需更多前瞻性研究来分析影响大便失禁发生的因素并进一步采取有效的方法进行防治。Objective To understand the incidence of fecal incontinence after sphincter-preserving operation for middle and low rectal cancer, the factors influencing fecal incontinence, the relationship of fecal incontinence to anorectal manometry, and treatment. Method The literatures about fecal incontinence after sphincter-preserving operation for middle and low rectal cancer were reviewed. Results The incidence of fecal incontinence after sphincter-preserving operation for middle and low rectal cancer was about 35.3%. Wexner fecal incontinence score was the most popular scale in assessing the severity of fecal incontinence, which had high validity and utility. When Wexner score I〉 9, the fecal incontinence-related quality of life was seriously damaged. Closer the anastomosis to the anal margin, the fecal incon- tinence was more likely to happen and much severer if it appeared. Surgeon could improve the anorectal function through some kinds of surgeries, like ultralow anterior resection with levator-sphincter reinforcement when the tumor site was rather low. The effect of chemoradiotherapy on fecal incontinence was uncertain now. Age itself was a risk factor for fecal incontinence, for elderly patients underwent sphincter-preserving operation needed to be careful. The relationship of fecal incontinence to anorectal function was not completely clear. The anal sphincter nerve function was a predicting factor whether neurogenic fecal incontinence was going to happen or not. Even though the retrograde colonic irrigation, sacral nerve stimulation, and biofeedback therapy had been proved to alleviate the symptoms and improve the qualityof life after sphincter-preserving operation, much more prospective and controlled studies were needed to validate their efficacy and explore other new solutions. Conclusions We still need to come up with the objective criterion to assess fecal incontinence. Much more prospective studies are needed to analyze the influencing factors and to find effective prevention and treatment.

关 键 词：直肠癌 大便失禁 肛门直肠功能 治疗 

分 类 号：R657.1[医药卫生—外科学]