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《中华消化外科杂志》2018年9月第17卷第9期论著

腹腔镜与开腹全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎的临床疗效分析

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引用本文:
骆洋,俞旻皓,陈建军,等.腹腔镜与开腹全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎的临床疗效分析[J].中华消化外科杂志,2018,17(9):929-934.DOI:10.3760/cma.j.issn.1673-9752.2018.09.011.
【摘要】

目的:比较腹腔镜与开腹全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎的临床疗效。
方法:采用回顾性队列研究方法。收集2003年1月至2016年12月上海交通大学医学院附属仁济医院收治的150例行全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎患者的临床资料。150例患者中,87例行腹腔镜全结直肠切除回肠储袋肛管吻合术,设为腹腔镜组;63例行开腹全结直肠切除回肠储袋肛管吻合术,设为开腹组。观察指标:(1)术中及术后情况。(2)术后并发症情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者术后恢复及术后并发症情况。随访时间截至2017年12月。正态分布的计量资料以±s表示,组间比较采用t检验;计数资料组间比较采用x2检验。
结果:(1)术中及术后情况:腹腔镜组患者手术时间为(306±3)min,术中出血量为(197±12)mL,术后小肠造口首次通气时间为(62.1±1.8)h,术后住院时间为(8.2±0.4)d;开腹组患者分别为(224±4)min、(308±24)mL、(75.6±2.0)h和(10.1±0.6)d,两组患者上述指标比较,差异均有统计学意义(t=16.23,4.33,5.03,2.61,P<0.05)。150例患者术后均顺利出院。150例患者术后3~12个月均行回肠造口回纳术,其中腹腔镜组为术后(6.0±5.6)个月,开腹组为术后(6.0±4.6)个月,两组比较,差异无统计学意义(t=0.01,P>0.05)。(2)术后并发症情况:腹腔镜组患者中,术后切口感染、尿潴留、排便次数>4次/d分别为2、8、21例;开腹组患者分别为8、15、29例,两组患者上述指标比较,差异均有统计学意义(x2=5.25,4.37,0.96,P<0.05)。腹腔镜组患者中,术后肠梗阻、吻合口漏、盆腔感染、储袋炎、储袋克罗恩病、回肠储袋异常增生分别为3、10、5、23、2、1例;开腹组患者分别为8、7、4、24、1、0例,两组患者上述指标比较,差异均无统计学意义(x2=3.65,0.11,0.01,0.96,0.17,0.82,P>0.05)。术后发生并发症的患者经抑酸、禁食、抗感染、补液等对症支持治疗后均好转。(3)随访情况:150例患者均获得随访,随访时间为12~60个月,中位随访时间为48个月。比较患者术前及术后 5年肠镜检查结果,术后吻合口和肠黏膜无异常。随访期间50例行转流性小肠造口回纳术患者,术后3年仍有大便不成形、排便不规律(排便次数>4次/d)情况,其中腹腔镜组21例,开腹组29例,两组比较,差异有统计学意义(x2=4.72,P<0.05)。术后5年腹腔镜组和开腹组仍各有11例和10例患者出现大便不成形和排便习惯改变,但症状较术前均有所好转,两组比较,差异无统计学意义(x2=0.32,P>0.05)。
结论:腹腔镜全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎可获得与传统开腹手术同等的安全性,且近期和中期疗效优于开腹组。

【Abstract】

Objective: To compare the short-term and long-term outcomes between laparoscopic and open total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC).
Methods:The retrospective cohort study was conducted. The clinical data of 150 UC patients who underwent total proctocolectomy with IPAA in the Renji Hospital of Shanghai Jiaotong University between January 2003 and December 2016 were collected. Among 150 patients, 87 undergoing laparoscopic total proctocolectomy with IPAA and 63 undergoing open total proctocolectomy with IPAA were respectively allocated into the laparoscopy group and open group. Observation indicators: (1) comparisons of intra-and post-operative situations; (2) postoperative complications; (3) follow-up situation. Follow-up using outpatient examination and telephone interview was performed to detect postoperative recovery and complications up to December 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Comparison between groups of count data was analyzed using the chi-square test.
Results:(1) Comparisons of intra-and post-operative situations: operation time, volume of intraoperative blood loss, time of initial intestinal stoma exsufflation and duration of hospital stay were respectively (306±3)minutes, (197±12)mL, (62.1± 1.8)hours, (8.2±0.4)days in the laparoscopy group and (224±4)minutes, (308±24)mL, (75.6±2.0)hours, (10.1±0.6)days in the open group, with statistically significant difference between groups (t=16.23, 4.33, 5.03, 2.61, P<0.05). All patients discharged successfully from hospital. All the 150 patients underwent stoma reversion of ileum at 3- 12 months postoperatively, and the average time in the laparoscopy group and open group was respectively (6.0±5.6)months and (6.0±4.6)months, with no statistically significant difference between groups (t=0.01, P>0.05). (2) Postoperative complications: cases with postoperative wound infection, retention of urine and frequency of defecation > 4 times / day were respectively 2, 8, 21 in the laparoscopy group and 8, 15, 29 in the open group, with statistically significant differences between groups (x2=5.25, 4.37, 0.96, P<0.05). The cases with postoperative intestinal obstruction, anastomotic leakage, pelvic infection, pouch infection, pouch-related Crohn′s disease and hyperplasia of ileal pouch were respectively 3, 10, 5, 23, 2, 1 in the laparoscopy group and 8, 7, 4, 24, 1, 0 in the open group, with no statistically significant differences between groups (x2=3.65, 0.11, 0.01, 0.96, 0.17, 0.82, P>0.05). Patients with postoperative complications were improved by acid suppression, fasting, anti-infection and fluid infusion. (3) Follow-up situation: 150 patients were followed up for 12- 60 months, with a median time of 48 months. There was no abnormality of postoperative anastomotic stoma and intestinal mucosa through comparison of colonoscopy results between pre-operation and 5 year postoperatively. During the follow-up, 50 patients had shapeless stool and irregular defecation (times > 4 times / day) at 3 years after stoma reversion of small intestine bypass, including 21 in the laparoscopy group and 29 in the open group, with a statistically significant differences between groups (x2=4.72, P<0.05). Eleven and 10 patients in the laparoscopy group and open group had shapeless stool and irregular defecation at 5 years postoperatively, but status were improved compared with the preoperative status, with no statistically significant difference between groups (x2=0.32, P>0.05).
Conclusion:The security of laparoscopic total proctocolectomy with IPAA for UC is equivalent to that of open total proctocolectomy, with the better short-term and long-term outcomes.

DOI:10.3760/cma.j.issn.1673-9752.2018.09.011
基金项目:国家自然科学基金面上项目(81873555、81672347);上海市卫生和计划委员会重点项目(201540031)
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