腹腔镜Parks手术治疗慢性放射性直肠损伤的可行性和安全性  

Feasibility and safety of laparoscopic Parks procedure for chronic radiation proctopathy

作　　者：钟清华[1] 黄小艳 李杨 何炎炯 秦启元 王怀明[1] 陈代词 王辉[1] 马腾辉[1] Zhong Qinghua;Huang Xiaoyan;Li Yang;He Yanjiong;Qin Qiyuan;Wang Huaiming;Chen Daici;Wang Hui;Ma Tenghui(Department of Colorectal Surgery,the Sixth Affiliated Hospital,Sun Yat-sen University,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases,Guangdong Institute of Gastroenterology,Guangzhou,Guangdong 510655,China)

机构地区：[1]中山大学附属第六医院结直肠肛门外科,放射性肠病专科,广东省结直肠盆底疾病研究重点实验室,广东省胃肠病学研究所,广州510655

出　　处：《中华胃肠外科杂志》2020年第8期745-751,共7页Chinese Journal of Gastrointestinal Surgery

基　　金：国家自然科学基金面上项目(31970703);国家自然科学基金青年科学基金项目(81803163)。

摘　　要：目的放射性直肠损伤(RP)是盆腔放疗最常见并发症之一。当RP出现梗阻、穿孔、瘘、顽固性直肠出血等严重晚期并发症时,需要手术治疗。由于放疗后腹盆腔可能广泛粘连,解剖层次消失,手术难度大,目前病变肠管切除术(尤其是腹腔镜下)在慢性RP(CRP)中的应用仍缺乏经验借鉴。本研究初步探讨腹腔镜Parks手术治疗CRP的可行性和安全性。方法采用描述性病例系列研究方法,回顾性分析中山大学附属第六医院2013年7月至2019年3月期间,因CRP晚期并发症行腹腔镜Parks手术的19例患者的临床及随访资料。病例纳入标准:(1)盆腔放疗后出现CRP严重晚期并发症,包括:重度顽固性便血(血红蛋白<70 g/L)、重度顽固性肛门疼痛(疼痛数字评分>7分)、直肠狭窄、直肠穿孔和直肠瘘;(2)术前行结肠镜、盆腔MRI和(或)胸腹盆CT等影像学检查明确病变。排除标准:(1)术前或术中诊断肿瘤复发;(2)腹腔镜探查后仅行造口术;(3)直肠癌新辅助放疗后;(4)病历资料不完整。Parks手术步骤:(1)腹腔镜探查:排除肿瘤复发,明确放射性损伤肠管范围,于肉眼判断近端无明显水肿增厚、无放射性损伤改变的近端乙状结肠处做标记。(2)腹部操作:打开乙状结肠直肠右侧系膜,离断肠系膜下动、静脉,向内侧头侧拓展Toldt间隙,游离左半结肠外侧,打开胃结肠韧带,充分游离脾曲,从后方、两侧及前方分离直肠至最低点,转会阴部操作。(3)会阴部操作:于病变下缘1 cm全层切开直肠壁,充分分离直肠周围间隙至与腹腔相通,将直肠及乙状结肠经肛门拖出,于肉眼评估正常肠管处切断,移除病变肠管,行结肠肛管吻合。(4)行保护性造口。对入组病例总结手术、并发症以及症状缓解情况。采用描述性统计学方法,计量资料用±s或M(P25,P75)表示。结果全组19例患者均为女性,中位年龄53(50,56)岁,18例患者原发肿瘤为宫颈癌。因放疗致直肠�Objective To preliminarily evaluate the feasibility and safety of laparoscopic Parks procedure for chronic radiation proctopathy(CRP).Methods A descriptive cohort study was carried out.The clinical and follow-up data of 19 patients who received laparoscopic Parks procedure due to CRP in the Sixth Affiliated Hospital of Sun Yat-sen University from July 2013 to March 2019 were retrospectively analyzed.Inclusion criteria:(1)serious late complications occurred after pelvic radiotherapy,e.g.serious intractable hematochezia(hemoglobin<70 g/L),intractable anal pain(numerical rating scale>7),rectostenosis,perforation,and fistula.(2)imaging examinations including colonoscopy,pelvic MRI and/or chest,abdomen and pelvic CT were performed before surgery to confirm the lesions.Exclusion criteria:(1)preoperative or intraoperative diagnosis of tumor recurrence;(2)only ostomy was performed after laparoscopic exploration;(3)after neoadjuvant radiotherapy for rectal cancer;(4)incomplete medical records.Surgical procedures:(1)Laparoscopic exploration:tumor recurrence was excluded,and the range of radioactive damage in the intestine was determined.Marks were made on the proximal sigmoid colon without grossly obvious edema,thickening or radioactive injuries.(2)Abdominal operation:the right mesentery of sigmoid colon and rectum was opened,inferior mesenteric vein and inferior mesenteric artery were divided and the Toldt gap was expanded inwards and cephalad.The outside of left hemicolon was freed,the gastrocolic ligament was opened,the splenic flexure was fully mobilized,and the rectum was separated from the rear,side and front to the lowest point.Then perineal operation was performed.(3)Perineal operation:the whole layer of rectum wall was cut thoroughly at 1cm below the lesion's lower margin,the space around the rectum was fully separated,the rectum and sigmoid colon was pulled out through the anus and cut off at the site of the grossly normal intestine,the diseased bowel was removed and a coloanal anastomosis was made.(4)A protectiv

关 键 词：放射性直肠损伤 慢性 微创外科 PARKS手术 

分 类 号：R730.55[医药卫生—肿瘤]