分期回肠造口与还纳手术治疗慢性放射性肠损伤21例  

Treatment of 21 cases of chronic radiation intestinal injury by staging ileostomy and closure operation

作　　者：李顾楠 程康文 赵振国 王剑 朱维铭 黎介寿 Li Gunan;Cheng Kangwen;Zhao Zhenguo;Wang Jian;Zhu Weiming;Li Jieshou(Department of General Surgery, Jinling Hospital, Nanjing 210002, China;Changzhou Tumor Hospital Affiliated to Soochow University)

机构地区：[1]解放军南京总医院普通外科,210002 [2]苏州大学附属常州肿瘤医院胃肠外科

出　　处：《中华胃肠外科杂志》2018年第7期772-778,共7页Chinese Journal of Gastrointestinal Surgery

基　　金：国家自然科学基金（81200327）;江苏省自然科学基金（BK2011415）

摘　　要：目的总结分期回肠造口与造口还纳手术联合营养支持治疗在慢性放射性肠损伤（CRII）中的应用。方法回顾分析2012年1月至2016年12月解放军南京总医院普通外科收治有放射治疗史及术后病理确诊为CRII患者的临床资料，剔除术中或术后病理证实肿瘤复发者，纳入所有一期回肠造口、二期造口还纳联合营养支持治疗的患者进行病例系列研究。一期回肠造口术具体方案及治疗时间由患者的临床症状和营养状况确定，在行回肠造口的同时根据其肠损伤范围和程度决定是否切除病变肠管，术后予以营养支持治疗和其他对症治疗。根据患者营养状况选择二期造口还纳手术时机，术中先判断剩余肠管病变，进行必要的肠管切除和回肠造口还纳。按本中心提出的放射性肠损伤粘连分级（5级）方法评估肠管病变的程度和范围：0级为病变肠袢与周围脏器之间无粘连；1级为粘连和纤维化局限于右侧盆腔；2级为粘连包括整个盆腔，粘连往往为重度，难以分离；3级为2级粘连向前延伸，病变肠袢与前盆壁粘连；4级为3级粘连向上延伸，病变肠袢与前腹壁粘连。术后并发症采用Clavien-Dindo分级（级别越低症状越轻）并通过在线程序（http：//www.assessurgery.com）计算并发症综合指数（CCI，指数越低症状越轻）。比较患者一期回肠造口和二期造口还纳两次手术中切除肠管的长度、放射性肠损伤粘连分级、术后并发症发生情况及先后两次手术后恢复完全胃肠内营养（TEN）的时间和营养状况（体质指数和血清白蛋白）。结果21例患者纳入研究，其中男性2例，女性19例。原发肿瘤为宫颈癌14例，直肠癌3例，子宫内膜癌1例，卵巢癌1例，精原细胞瘤1例，混合性生殖细胞瘤1例。放疗结束至发生放射性肠损伤中位时间间隔为7（2-91）月；发生放射性肠损伤至行回肠造口术中位时Objective To summarize the application of staged ileostomy and closure operation combined with nutritional support therapy in the treatment of chronic radiation intestinal injury（CRII）. Methods Clinical data of patients with definite radiation history and pathological diagnosis of CRII receiving treatment at Department of General Surgery, Jinling Hospital from January 2012 to December 2016 were retrospectively analyzed. Patients who were diagnosed with tumor recurrence during operation or by postoperative pathology were excluded. Patients undergoing stage I ileostomy and stage ]I closure operation combined with nutrition support therapy were enrolled to the cohort. Detailed scheme of stage I ileostomy and therapeutic time were determined by clinical symptoms and nutritional status. While performing ileostomy, the removal of intestinal lesions depended on range and degree of intestinal injury. Nutritional support therapy and other symptom-relieving therapy were offered after surgery. Timing for stage II closure operation was decided according to nutritional status of patients. Lesions of remaining intestine were determined during operation, then necessary intestinal resection and closure operation were performed. Adhesion classification of radiation intestinal injury （total five levels） proposed by our center was adopted to evaluate the level and range of intestinal lesions. Level 0 indicated no adhesion between injured intestinal loop and surrounding organs; level 1 indicated that the adhesion and fibrosis were limited to right pelvis; level 2 indicated that the adhesion included all pelvis and the adhesion was severe and difficult to divide; level 3 was the forward extension of level 2 adhesion, which was between injured intestinal loop and anterior pelvic wall; level 4 was the upward extension of level 3 adhesion, which was between injured intestinal loop and anterior abdominal wall. Clavien-Dindo classification （lower level means milder symptom） and complication comprehensive index （CCI, lower CC

关 键 词：慢性放射性肠损伤 回肠造口术 造口还纳术 营养支持治疗 

分 类 号：R730.55[医药卫生—肿瘤]