CAJ | 학술논문

背景与目的：中低位直肠癌根治术中行直肠低位双吻合，术后易发生吻合口瘘及“直肠低位前切除术后综合征”等并发症，如何降低这些并发症的发生，目前临床仍处于探索之中。本研究的目的是观察、探讨腹腔镜下垂直切割闭合直肠远端在改进直肠低位双吻合中的作用和意义。方法：将2010年2月—2014年6月在苏州大学附属第一医院普外科完成腹腔镜下直肠癌根治术的120例中低位直肠癌患者，随机分为A、B两组。以性别、年龄、肿瘤大小、下缘离齿状线距离及肿瘤分期等为指标，逐一配对。其中A组(观察组)55例，在进行“第一吻合”时，将常规的直肠远端切割闭合，由水平方向改为垂直方向；行“第二吻合”时，行肠-肠“端-角”吻合，去除直肠远侧闭合线上端角部(“狗耳”)；血管夹夹闭去除下端“狗耳”；加强缝合“端-角”吻合后形成的一处钉合线“T”形交汇处(“危险三角”)。B组(对照组)65例，按直肠低位双吻合常规操作完成手术，两只“狗耳”及两处“危险三角”不作任何处理。将两组患者进行对比分析。结果：A组在垂直切割闭合直肠远端后，“狗耳”及“危险三角”均位于同一垂直线上，便于观察和处理。“端-角”吻合后远近端肠管轴线形成一定交角，远端直肠腔形成类似“壶腹”样膨隆；无“狗耳”存在，一处“危险三角”得以缝合加强。B组完成“端-端”吻合后远近端肠管在同一轴线上，留有两只“狗耳”及两处“危险三角”。两组患者的一般临床资料差异无统计学意义(P>0.05)。两组患者术中出血量、术后引流量、术后吻合口出血、肛门排气时间和住院时间差异无统计学意义(P>0.05)。手术耗时、术后吻合口瘘的发生数、排便次数、里急后重、术后再次手术造瘘差异有统计学意义(P<0.05)。结论：直肠低位双吻合时垂直切割闭合远侧直肠，使双吻合后肠管的走行和形态更接近直肠的生理弯曲和形态；同时方便了术中去除“狗耳”和“危险三角”的加强缝合；术后并发症发生率显著降低。揹景與目的：中低位直腸癌根治術中行直腸低位雙吻閤，術後易髮生吻閤口瘺及“直腸低位前切除術後綜閤徵”等併髮癥，如何降低這些併髮癥的髮生，目前臨床仍處于探索之中。本研究的目的是觀察、探討腹腔鏡下垂直切割閉閤直腸遠耑在改進直腸低位雙吻閤中的作用和意義。方法：將2010年2月—2014年6月在囌州大學附屬第一醫院普外科完成腹腔鏡下直腸癌根治術的120例中低位直腸癌患者，隨機分為A、B兩組。以性彆、年齡、腫瘤大小、下緣離齒狀線距離及腫瘤分期等為指標，逐一配對。其中A組(觀察組)55例，在進行“第一吻閤”時，將常規的直腸遠耑切割閉閤，由水平方嚮改為垂直方嚮；行“第二吻閤”時，行腸-腸“耑-角”吻閤，去除直腸遠側閉閤線上耑角部(“狗耳”)；血管夾夾閉去除下耑“狗耳”；加彊縫閤“耑-角”吻閤後形成的一處釘閤線“T”形交彙處(“危險三角”)。B組(對照組)65例，按直腸低位雙吻閤常規操作完成手術，兩隻“狗耳”及兩處“危險三角”不作任何處理。將兩組患者進行對比分析。結果：A組在垂直切割閉閤直腸遠耑後，“狗耳”及“危險三角”均位于同一垂直線上，便于觀察和處理。“耑-角”吻閤後遠近耑腸管軸線形成一定交角，遠耑直腸腔形成類似“壺腹”樣膨隆；無“狗耳”存在，一處“危險三角”得以縫閤加彊。B組完成“耑-耑”吻閤後遠近耑腸管在同一軸線上，留有兩隻“狗耳”及兩處“危險三角”。兩組患者的一般臨床資料差異無統計學意義(P>0.05)。兩組患者術中齣血量、術後引流量、術後吻閤口齣血、肛門排氣時間和住院時間差異無統計學意義(P>0.05)。手術耗時、術後吻閤口瘺的髮生數、排便次數、裏急後重、術後再次手術造瘺差異有統計學意義(P<0.05)。結論：直腸低位雙吻閤時垂直切割閉閤遠側直腸，使雙吻閤後腸管的走行和形態更接近直腸的生理彎麯和形態；同時方便瞭術中去除“狗耳”和“危險三角”的加彊縫閤；術後併髮癥髮生率顯著降低。
배경여목적：중저위직장암근치술중행직장저위쌍문합，술후역발생문합구루급“직장저위전절제술후종합정”등병발증，여하강저저사병발증적발생，목전림상잉처우탐색지중。본연구적목적시관찰、탐토복강경하수직절할폐합직장원단재개진직장저위쌍문합중적작용화의의。방법：장2010년2월—2014년6월재소주대학부속제일의원보외과완성복강경하직장암근치술적120례중저위직장암환자，수궤분위A、B량조。이성별、년령、종류대소、하연리치상선거리급종류분기등위지표，축일배대。기중A조(관찰조)55례，재진행“제일문합”시，장상규적직장원단절할폐합，유수평방향개위수직방향；행“제이문합”시，행장-장“단-각”문합，거제직장원측폐합선상단각부(“구이”)；혈관협협폐거제하단“구이”；가강봉합“단-각”문합후형성적일처정합선“T”형교회처(“위험삼각”)。B조(대조조)65례，안직장저위쌍문합상규조작완성수술，량지“구이”급량처“위험삼각”불작임하처리。장량조환자진행대비분석。결과：A조재수직절할폐합직장원단후，“구이”급“위험삼각”균위우동일수직선상，편우관찰화처리。“단-각”문합후원근단장관축선형성일정교각，원단직장강형성유사“호복”양팽륭；무“구이”존재，일처“위험삼각”득이봉합가강。B조완성“단-단”문합후원근단장관재동일축선상，류유량지“구이”급량처“위험삼각”。량조환자적일반림상자료차이무통계학의의(P>0.05)。량조환자술중출혈량、술후인류량、술후문합구출혈、항문배기시간화주원시간차이무통계학의의(P>0.05)。수술모시、술후문합구루적발생수、배편차수、리급후중、술후재차수술조루차이유통계학의의(P<0.05)。결론：직장저위쌍문합시수직절할폐합원측직장，사쌍문합후장관적주행화형태경접근직장적생리만곡화형태；동시방편료술중거제“구이”화“위험삼각”적가강봉합；술후병발증발생솔현저강저。
Background and purpose:Anastomotic leakage and low anterior resection syndrome(LARS) are both common complications in dual-anastomosis for patients with low rectal cancer. The aim of this study was to observe and explore the signiifcance and role of vertical cutting of the closed distal rectum in dual-anastomosis for patients with low rectal cancer.Methods:A total number of 120 patients with mid-low rectal cancer who admitted to and completed laparoscopic rectal cancer resection in the Department of General Surgery, the First Afifliated Hospital of Soochow University from Feb. 2010 to Jun. 2014 were pair-matched into Groups A and B based on their gender,age, tumor size, the distance of lower edge to the dentate line and tumor staging, etc. For the 55 patients in Group A (observation group), the rectum distal end was closed vertically instead of horizontally while disposing “the ifrst intestinal anastomosis”, intestine-intestine anastomosis was conducted in an “end-corner” approach when dealing with “the second intestinal anastomosis”, upper corner (“dog ear”) of the closed line in the distal end of the rectum was removed, the lower corner (“dog ear”) of the closed line in the distal end of the rectum was removed using vascular occlusion clamp method, and the T-shaped interchanges (“dangerous triangle”) of stapled sutures formed after anastomosis were strengthened with absorbable suture. For the 65 patients in Group B (control group), laparoscopic dual anastomosis was conducted using conventional method, and the two “dog-ears” and “dangerous triangles” were kept without any treatment. The clinical outcomes of the two groups of patients were analyzed retrospectively. Results:In group A, It was convenient to complete the operation when the “dog ears” and “dangerous triangle” on the vertical line after cutting the closed distal rectum vertically by “end-corner” anastomosis. The axis of intestine formed a certain angle making the closed distal rectum into “ampulla” sample without “dog ears”. the “dangerous triangle” were strengthened with absorbable suture. In group B, The distal and proximal intestine located on the same axis after intestine-intestine anastomosis leaving two “dog ears” and a “dangerous triangle”. The general clinical data of patients in the two groups were comparable and not signiifcantly different (P>0.05). The two groups of patients showed no signiifcant differences in blood loss, postoperative drainage, postoperative anastomotic bleeding, anal exhaust time, and length of hospital stay (P>0.05). However, the operation time as well as the numbers of anastomotic ifstula occurrence, defecation, tenesmus and post-operation re-ostomy differed significantly (P<0.05).Conclusion:Vertical cutting of the closed distal rectum with dual anastomosis made the “new” intestine closer to the physiological bending and morphology of the rectum, meanwhile, it simpliifed the approach of removing “dog ear” and strengthening “dangerous triangle”, ifnally it signiifcantly reduced the incidence of post-surgical complications.