全盆腔脏器切除治疗盆腔放射性损伤晚期并发症的初步经验  

Pelvic exenteration for late complications of radiation-induced pelvic injury:a preliminary study

作　　者：何炎炯 周佐霖 秦启元 黄斌杰[1] 黄小艳 李嘉敏 朱苗苗 尧冰 王德娟 邱剑光 王辉[1] 马腾辉[1,4] He Yanjiong;Zhou Zuolin;Qin Qiyuan;Huang Binjie;Huang Xiaoyan;Li Jiamin;Zhu Miaomiao;Yao Bing;Wang Dejuan;Qiu Jianguang;Wang Hui;Ma Tenghui(Department of General Surgery(Colorectal Surgery),The Sixth Affiliated Hospital,Sun Yat-sen University Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases,The Sixth Affiliated Hospital,Sun Yat-sen University Biomedical Innovation Center,The Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China;Department of Pharmacy,The Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China;Department of Urology,The Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China;Biomedical Innovation Center,The Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China Department of Clinical Nutrition and Microecology,The Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China)

机构地区：[1]中山大学附属第六医院普通外科(结直肠外科、放射性肠损伤中心)广东省结直肠盆底疾病研究重点实验室广州市黄埔区中六生物医学创新研究院,广州510655 [2]中山大学附属第六医院药学部,广州510655 [3]中山大学附属第六医院泌尿外科,广州510655 [4]中山大学附属第六医院临床营养与微生态科,广州510655

出　　处：《中华胃肠外科杂志》2023年第10期940-946,共7页Chinese Journal of Gastrointestinal Surgery

基　　金：国家临床重点专科广东省消化系统疾病临床医学研究中心项目(2020B1111170004);中山大学附属第六医院“1010”计划(1010CG(2022)-09)。

摘　　要：目的初步探讨全盆腔脏器切除(TPE)治疗盆腔放射性损伤晚期并发症的安全性及有效性。方法采用观察性研究的方法,纳入标准:(1)盆腔恶性肿瘤放疗后确诊为盆腔放射性损伤;(2)盆腔放射性损伤晚期并发症(包括出血、穿孔、瘘及梗阻等),合并复杂盆腔瘘并累及盆腔多器官;(3)多学科团队会诊评估认为TPE手术可达到R0切除,建议进行TPE手术;(4)患者术前状态良好,可以耐受TPE手术;(5)患者手术意愿强烈,充分接受手术风险。排除标准:(1)术前或术中诊断肿瘤复发或转移;(2)腹腔镜探查后仅行转流或短路等姑息性手术;(3)临床资料不完整。根据上述标准,回顾性纳入中山大学附属第六医院放射性肠损伤数据库中2020年3月至2022年9月期间,因盆腔放射性损伤晚期并发症接受TPE或扩大TPE(合并其他脏器)手术患者的临床及随访资料。观察手术和术后恢复情况,记录术后并发症发生情况、围手术期死亡情况和术后1年生活质量情况。结果本研究共纳入14例患者,均为女性患者,包括9例直肠-阴道-膀胱瘘、2例膀胱阴道瘘、1例回肠-膀胱瘘+直肠坏死、1例回肠-膀胱瘘+直肠阴道瘘和1例直肠溃疡+双侧输尿管狭窄。手术时间为(592.1±167.6)min,中位出血量为550(100~6000)ml,10例进行了肠道重建,4例接受了Hartmann手术;10例采用Bricker手术进行泌尿系重建;7例接受盆底重建。术后住院天数为(23.6±14.9)d。7例(7/14)患者在围手术期出现Clavien-DindoⅢa~Ⅳb级并发症,包括手术部位感染8例次、腹盆腔脓肿5例次、肺部感染5例次、肠梗阻4例次及回肠膀胱瘘2例次。5例患者诊断空盆腔综合征(EPS),均为未进行盆底重建的患者,未进行盆底重建患者EPS发生比例为5/7;进行盆底重建的患者均未发生EPS。1例EPS患者因盆腔脓肿、盆腔出血和肠梗阻,需要二次手术。无围手术期死亡。随访(18.9±10.1)个月,3例患者死亡,其中2例死亡�Objective To investigate the safety and efficacy of total pelvic exenteration(TPE)for treating late complications of radiation-induced pelvic injury.Methods This was a descriptive case series study.The inclusion criteria were as follows:(1)confirmed radiation-induced pelvic injury after radiotherapy for pelvic malignancies;(2)late complications of radiation-induced pelvic injury,such as bleeding,perforation,fistula,and obstruction,involving multiple pelvic organs;(3)TPE recommended by a multidisciplinary team;(4)patient in good preoperative condition and considered fit enough to tolerate TPE;and(5)patient extremely willing to undergo the procedure and accept the associated risks.The exclusion criteria were as follows:(1)preoperative or intraoperative diagnosis of tumor recurrence or metastasis;(2)had only undergone diversion or bypass surgery after laparoscopic exploration;and(3)incomplete medical records.Clinical and follow-up data of patients who had undergone TPE for late complications of radiation-induced pelvic injury between March 2020 and September 2022 at the Sixth Affiliated Hospital of Sun Yat-sen University were analyzed.Perioperative recovery,postoperative complications,perioperative deaths,and quality of life 1 year postoperatively were recorded.Results The study cohort comprised 14 women,nine of whom had recto-vagino-vesical fistulas,two vesicovaginal fistulas,one ileo-vesical fistula and rectal necrosis,one ileo-vesical and rectovaginal fistulas,and one rectal ulcer and bilateral ureteral stenosis.The mean duration of surgery was 592.1±167.6 minutes and the median blood loss 550(100–6000)mL.Ten patients underwent intestinal reconstruction,and four the Hartmann procedure.Ten patients underwent urinary reconstruction using Bricker's procedure and 7 underwent pelvic floor reconstruction.The mean postoperative hospital stay was 23.6±14.9 days.Seven patients(7/14)had serious postoperative complications(Clavien-Dindo IIIa to IVb),including surgical site infections in eight,abdominopelvic abscesses in

关 键 词：全盆腔脏器联合切除 盆腔放射性损伤 晚期并发症 直肠-阴道-膀胱瘘 

分 类 号：R730.55[医药卫生—肿瘤]