急性梗阻性左侧结直肠癌的手术方式选择与预防性肠造口

Surgical Treatment and Prophylactic Bowel Stoma for Acute Obstruction of Left Colorectal Carcinoma

摘要: 目的：探讨左侧结直肠癌并发急性肠梗阻外科治疗的手术方式选择与预防性肠造口的必要性。方法：回顾性分析15年间外科治疗的278例左侧结直肠癌并发急性肠梗阻病人的临床资料。结果：本组包括无肠吻合病例59例及一期切除肠吻合219例，其中一期切除吻合病例中有66例行预防性肠造口术，手术方式分别是左半结肠切除术24例、乙状结肠切除术20例、结肠次全切除1例、Dixon手术13例、ISR手术8例。另外，本组有5例用可扩张金属内支架解除肠梗阻后一期切除吻合。本组一期切除吻合病例术后吻合口瘘发生率为6.4% (14/219)，但术中肠道减压灌洗(5.6%, 3/54)与不灌洗病例(6.1%, 10/165)之间的差异不大(P > 0.05)，且加预防性肠造口的一期吻合病例中后无吻合口瘘发生。结论：手术方式选择原则是解除梗阻、力争根治肿瘤、一期吻合，必要时可加预防性肠造口。但对于年老体弱、一般状况差者应采取侵袭小的手术，如近端结肠造瘘或Hartmann手术来解除梗阻。

Abstract: Objective: To investigate the selection of surgical treatment for left colorectal carcinoma with acute obstruction and feasibility of prophylactic bowel stoma. Methods: The data of 278 left colon carcinoma patients with acute obstruction (LCCPAO) treated surgically during 15 years were analyzed retrospectively. Results: In this study, there were 59 cases of LCCPAO underwent resection without intestinal anastomosis, and 219 cases of one-stage underwent one-stage resection with intestinal anastomosis. Among the latter cases, 66 underwent one-stage underwent one-stage resection with enteral anastomosis plus prophylactic colostomy. The procedures were left colectomy in 24 cases, sigmoid colectomy in 20 cases, subtotal colectomy in 1 case, Dixon’s operation in 13 cases, and intersphincteric resection (ISR) in 8 cases. In addition, 5 cases were treated with expandable metal stent for relieving intestinal obstruction before operation and followed by one-stage resection and anastomosis. The anastomotic leakage rate in patients with one-stage resection and intestinal anastomosis was 6.4% (14/219 cases), and no significant difference was found between the patients with (5.6%, 3/54 cases) or without (6.1%, 10/165) intraoperative irrigation (P > 0.05), and no anastomostic leakage was found in the cases with one-stage anastomosis plus prophylactic bowel stoma. Conclusion: The principle of surgical treatment is to resolve intestinal obstruction, resect tumor with radical and one-stage intestinal anastomosis, and prophylactic bowel stoma is added, if necessary. But in case of the old patients with poor general condition, the proximal colon stoma and Hartmann’s operation is indicated for relief of intestinal obstruction.