IPOM法预置疝补片对Miles术后造口旁疝的预防作用

发布时间：2018-10-05 15:18

【摘要】：目的:结直肠癌病人呈逐年增加的趋势,其中低位直肠癌占有较高比例。对于低位直肠癌及肛管癌患者目前的标准术式仍然是Miles术(腹会阴联合直肠癌根治术),也几乎是唯一能够获得根治的治疗手段。此种术式的最大特点是在患者腹壁建立人工肛门。虽然患者寿命延长,但造瘘口的出现也带来一系列术后并发症,如出血、坏死、感染、梗阻、狭窄及造口旁疝等。而造口旁疝是结肠造口术后常见并发症,并且严重降低了患者术后生活质量。由于造口旁疝的高发病率(高达50%)和外科手术修补的复杂性,如何预防造口旁疝的形成变得非常重要。影响造口旁疝发生的因素有很多,病人自身相关的因素如高龄、性别、肥胖、营养不良、慢性咳嗽等;和手术相关的因素有:造口部位、造口大小及造口方式等。尽管外科医生做了大量的工作来预防造口旁疝的发生,但是其发病率并居高不下。近期国外研究报道在结肠造口时通过植入疝补片来加强造口周围腹壁强度可有效预防造口旁疝的发生。本研究在低位直肠癌患者中施行Miles术并术中乙状结肠造口处使用IPOM法(即腹膜内固定法)预置Bard CK疝补片,探究预置疝补片对预防造口旁疝的作用。方法:选取我科于2014年6月至2015年6月期间行低位直肠癌Miles手术且经腹直肌乙状结肠造口患者50名,随机分成两组,每组25名,试验组使用IPOM法在腹壁造口旁预置Bard CK专业造口疝补片,对照组直接在腹壁完成造口制作。试验组手术的25名患者中,男性14例,女性11例,年龄在45-69岁之间,平均年龄56.2岁;对照组手术的25名患者中,男性13例,女性12例,年龄在46-72岁之间,平均年龄在57.4岁。术前由造口治疗师和医生共同选定造口位置,并标记。术后造口由造口治疗师观察记录并维护。术后使用造口腹带固定3月,期间避免大笑及高强度体力劳动。术后随访患者,并行腹部CT扫描确认有无造口旁疝的发生。结果:50名患者,随访周期为18-30个月,平均26.8个月。试验组中有2位患者出现腹壁异物感及局部刺痛,术后1月内都好转消失。1位患者出现造口周围皮肤炎,对症治疗后痊愈。其余患者均无造口出血、感染、皮炎、坏死等并发症出现。对照组中有术后出现2位造口周围炎,对症处理后痊愈。两组术后总并发症发生率比较,P0.05。所有患者均行体格检查,追问患者出院后情况,门诊腹部CT扫描。对照组中有6位患者经CT扫描确认发生造口旁疝,而试验组未有出现,P0.05。结论:在低位直肠癌患者行Miles术时行IPOM法预置Bard CK疝补片可预防造口旁疝的发生,且并不增加总并发症的发生率。预置造口疝补片技术具有很大的应用前景。国内需要多进行多中心、大样本的前瞻性随机对照研究,积累研究数据,争取早日将技术推广,让患者获得更好的预后及生活质量。
[Abstract]:Objective: colorectal cancer patients are increasing year by year, in which low rectal cancer accounts for a high proportion. The current standard procedure for patients with low rectal and anal cancer is still Miles (abdominal perineum combined with rectal cancer radical resection) and is almost the only treatment that can be cured. The most important feature of this procedure is the establishment of artificial anus in the abdominal wall of the patient. Although the patient's life span is longer, the appearance of the fistula also brings a series of postoperative complications, such as bleeding, necrosis, infection, obstruction, stenosis and paracentesis hernia. Paracostomy hernia is a common complication after colostomy, and seriously reduces the postoperative quality of life. Because of the high incidence (up to 50%) of parastatal hernia and the complexity of surgical repair, it is very important to prevent the formation of paracentotomy hernia. There are many factors that affect the occurrence of paracentesis hernia, such as age, sex, obesity, malnutrition, chronic cough and so on. Although surgeons do a lot of work to prevent paracentesis hernia, its incidence remains high. Recent foreign studies have reported that strengthening the strength of abdominal wall around colostomy by implanting herniation patch can effectively prevent the occurrence of para-stomal hernia. In this study, Miles was performed in patients with low rectal cancer and Bard CK herniation patch was prepositioned at sigmoidostomy with IPOM method (peritoneal internal fixation) to explore the effect of preimplantation hernia patch on prevention of paracostomal hernia. Methods: from June 2014 to June 2015, 50 patients with low rectal cancer underwent Miles operation and underwent rectus sigmoidostomy from June 2014 to June 2015 were randomly divided into two groups, 25 patients in each group. IPOM method was used in the experimental group to preposition Bard CK professional herniation patch beside the abdominal wall orifice, while the control group finished the orifice making directly in the abdominal wall. There were 14 males and 11 females, aged 45-69 years, with an average age of 56.2 years, while in the control group, there were 13 males and 12 females, aged between 46 and 72 years, with an average age of 57.4 years. The site was selected and marked by the surgeon and the surgeon before operation. The postoperative opening was recorded and maintained by the orthopedic therapist. After operation, the abdominal band was fixed for 3 months, during which laughter and high-intensity manual labor were avoided. Postoperative follow-up, abdominal CT scan to confirm the occurrence of parastatal hernia. Results 50 patients were followed up for 18-30 months with an average of 26.8 months. There were 2 patients in the test group with abdominal wall foreign body sensation and local prickly pain. 1. 1 patients had peristomal dermatitis and recovered after symptomatic treatment. The other patients had no complications such as bleeding, infection, dermatitis and necrosis. In the control group, there were 2 cases of peristomal inflammation after operation, and recovered after symptomatic treatment. The incidence of postoperative complications in the two groups was significantly higher than that in the control group (P 0.05). All the patients underwent physical examination, asked about the condition after discharge, and CT scan of the outpatient abdomen. Six patients in the control group were confirmed to have parastotomy hernia by CT scan, but no P0.05 was found in the trial group. Conclusion: IPOM preplacement of Bard CK hernia patch during Miles in patients with low rectal cancer can prevent the occurrence of perioperative hernia and does not increase the incidence of total complications. The technique of preimplantation hernia patch has great application prospect. It is necessary to carry out multi-center, large sample prospective randomized controlled studies in China, accumulate research data, and strive to promote the technology as soon as possible, so that patients can obtain better prognosis and quality of life.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.37

【相似文献】