直肠癌导致低位肠梗阻的病理机制、精准诊疗与个体化的外科治疗策略

Pathological Mechanisms, Precision Diagnosis and Treatment, and Individualized Surgical Strategies for Low Intestinal Obstruction Caused by Rectal Cancer

摘要: 尽管目前消化系统疾病的早期诊断水平不断提升，肠梗阻是外科最常见的急腹症之一，以腹胀、肛门停止排气排便为主要表现。而肠梗阻最常见的病因除了各种原因引起的肠道粘连之外，另一个主要因素为肿瘤引发，当以急性肠梗阻来院就诊时，经检查多提示肿瘤已进入进展期阶段。直肠癌合并低位肠梗阻并非简单的机械性肠梗阻，而是由解剖狭窄、肠壁动力学异常、黏膜屏障破坏、细菌易位、感染中毒症及全身代谢紊乱共同驱动的多级联病理生理过程，当肠梗阻形成闭袢时，肠缺血或穿孔等并发症发生的概率也会随之升高。近年来，随着腹部CT、高分辨率直肠MRI、急诊内镜介入、微创外科技术及加速康复外科(ERAS)理念的普及，该病诊疗模式已从传统急诊剖腹探查，转向精准评估、紧急复苏过渡治疗、个体化手术、围手术期精细化管理的成体系治疗方案。本文基于循证医学证据与最新临床进展，系统阐述直肠癌导致低位肠梗阻的流行病学特点、病理生理机制、精准诊断体系、个体化外科治疗、围术期并发症处理及远期预后优化方案，为临床医生对其诊疗提供参考。

Abstract: Although the level of early diagnosis of digestive system diseases is constantly improving at present, intestinal obstruction is one of the most common acute abdomens in surgery, with abdominal distension and anus stopping to exhaust and defecate as the main manifestations. The most common cause of intestinal obstruction is not only intestinal adhesion caused by various reasons, but also tumor. When the patient comes to the hospital with acute intestinal obstruction, the examination indicates that the tumor has entered the advanced stage. Rectal cancer complicated with low intestinal obstruction is not a simple mechanical intestinal obstruction, but a multi-stage pathophysiological process driven by anatomical stenosis, abnormal intestinal wall dynamics, mucosal barrier destruction, bacterial translocation, infection poisoning and systemic metabolic disorder. When intestinal obstruction forms a closed loop, the probability of complications such as intestinal ischemia or perforation will also increase. In recent years, with the popularization of abdominal CT, high-resolution rectal MRI, emergency endoscopic intervention, minimally invasive surgery and the concept of accelerated rehabilitation surgery (ERAS), the diagnosis and treatment mode of this disease has changed from traditional emergency laparotomy to a systematic treatment scheme of accurate evaluation, emergency resuscitation transitional treatment, individualized surgery and meticulous perioperative management. Based on the evidence of evidence-based medicine and the latest clinical progress, this paper systematically expounds the epidemiological characteristics, pathophysiological mechanism, accurate diagnosis system, individualized surgical treatment, perioperative complications management and long-term prognosis optimization scheme of low intestinal obstruction caused by rectal cancer, so as to provide reference for clinicians in their diagnosis and treatment.