【作者】 张龙；

【导师】 范恩学；

【作者基本信息】 吉林大学 ， 临床医学， 2011， 硕士

【摘要】 直肠前突(rectocele RC)又称直肠前膨出,是出口梗阻型便秘的常见病因之一,是肛肠外科常见的疾病,多见于经产妇女。目前,我国直肠前突所致便秘患者日益增多。很多专家学者应用各种不同手术方式予以治疗,亦均取得不同效果。但是,直肠前突手术的时机把握、术式的选择目前在临床上尚有很大的争议,另外患者术后便秘症状不缓解或缓解后又复发者仍有一定比率。因此,本文结合临床,总结了直肠前突的手术适应证,并且着重观察了直肠粘膜柱状缝合加PPH术治疗直肠前突的术后近远期疗效。希望通过此临床观察研究,能够进一步把握直肠前突型便秘的手术适应证,提高术后疗效,从近远期效果上降低术后复发率,以提高患者生活质量。1.直肠前突病因及手术适应证的选择女性直肠前壁由直肠阴道膈支持,该膈主要为骨盆筋膜构成,内由肛提肌中线交叉纤维构成。鉴于直肠前壁薄弱,加之长期在排便时粪便的压迫、或产伤(特别对于经产妇),使直肠阴道隔松弛,向阴道凸出引起便秘。排便困难、里急后重感为本病的突出症状。多与局部发育及长期不良排便习惯有关；男性偶发,多见于前列腺手术摘除者。综合上述情况,我们总结为其手术适应证应包含以下几点：(1)病史长于0.5年,且经保守治疗半年症状无明显好转,甚至有加重者。(2)排便困难、肛门处梗阻感,肛门及会阴部坠胀,排便不尽感等临床症状明显者。便秘严重影响生活,强烈要求手术治疗者。(3)排粪造影结果显示直肠前突Ⅱ、Ⅲ度,可同时合并有直肠粘膜内套叠及内痔患者(4)通过相关术前常规检查及辅助检查,排除严重心肺功能疾病,肠道器质性病变等疾病。2.一般资料及随机分组入选62例直肠前突患者。均为女性,年龄37-65岁(平均年龄45岁)。经产妇55例,占88.71%(55/62)。全部患者便秘史均在0.5-25年。随机将62例患者分成治疗组及对照组。观察组行直肠前突Block术联合PPH术,对照组行经肛门直肠前突Block术。分组后两组在平均年龄、Longo Ods评分、排粪造影指标上统计学处理均无统计学差异(p>0.05),符合统计学原则。3.手术方法治疗组：麻醉方式均采用腰硬联合麻醉。患者取截石位,待麻醉生效后,常规消毒术野及阴道腔、直肠腔,并铺无菌单。麻醉松弛下再次行肛门指检,确认无占位病变后,缓慢扩肛,至容3示指,持续5min。将肛管扩张器(CAD33)涂少许润滑剂缓慢插入肛管,忌暴力,取出内栓,于距肛缘3厘米左右肛周皮肤处3、6、9、12点分别缝线固定肛管扩张器。充分暴露术野。用示指在阴道里将直肠前突囊带前壁向直肠内顶起,艾里斯钳起前突薄弱区直肠粘膜,大弯钳纵行夹持直肠粘膜,范围在齿线上直前突上2.5厘米左右,用3-0羊肠线在弯钳下行连续锁边缝合,深达肌层,缝合后撤掉弯钳,结扎线结,缝合时注意保持缝合粘膜下宽上窄,呈塔形,以防止直肠上端形成人为粘膜瓣。将小圆针带3-0微乔线,分别在齿状线上约3.0厘米和4.0厘米处、3点和9点进针,做粘膜及粘膜下层做双荷包缝合,双荷包之间距离在0.5-1cm,3、9点牵出引线,将吻合器钉座置入到双荷包缝线的上方,收紧荷包缝线,注意先结扎直肠近端荷包线,再结扎远端荷包线。用带线器(ST 100)将两侧微乔线通过吻合器侧孔分别牵出,止血钳夹持荷包线断端,适当保持一定张力,确认切除粘膜已经进入吻合器套管端,此时注意食指于阴道处探查,确认未将阴道粘膜带入吻合器吻合范围,收紧吻合器并快速击发,持续30秒以上,以防止吻合口出血。吻合器逆行旋转3圈半、小心取出,观察吻合器切除粘膜是否完整,检查吻合口是否有活动性出血,如有出血,用可吸收缝线“8”字缝合止血。确定手术区域无活动性出血后,用油纱包裹胶状引流管一枚,置入肛门,引流管近端超过吻合口,以便观察出血情况,清点器械,术毕。对照组：患者取截石位,待麻醉生效后,常规消毒术野及阴道腔、直肠腔,并铺无菌单。麻醉松弛下再次行肛门指检,确认无占位病变后,缓慢扩肛,至容4示指,持续5min。将肛管扩张器(CAD33)涂少许润滑剂缓慢插入肛管,忌暴力,取出内栓,于距肛缘3厘米左右肛周皮肤处3、6、9、12点分别缝线固定肛管扩张器。充分暴露术野。用示指在阴道里将直肠前突囊带前壁向直肠内顶起,艾里斯钳起前突薄弱区直肠粘膜,大弯钳纵行夹持直肠粘膜,范围在齿线上直前突上2.5厘米左右,用3-0羊肠线在弯钳下行连续锁边缝合,深达肌层,缝合后撤掉弯钳,结扎线结,缝合时注意保持缝合粘膜下宽上窄,呈塔形,以防止直肠上端形成人为粘膜瓣。确定手术区域无活动性出血后,用油纱包裹胶状引流管一枚,置入肛门,引流管近端超过吻合口,以便观察出血情况,清点器械,术毕。4.观察指标记录术后第1次排便时间、术后1周、1个月、3个月排便情况的,对手术近远期疗效进行对比。同时观察术后相关并发症及住院时间。5.结果(1)组内对比：各组内术后1个月、3个月Longo Ods评分相比较,治疗组显示排便困难症状差异较小,对照组排便困难症状有有较大变动。(2)两组间对比：术前分组患者Longo Ods评分相近；术后1个月两组Longo Ods评分差异不明显；手术后3个月治疗组效果明显优于对照组。治疗组平均住院时间8.72天,对照组平均住院时间8.95天。6.讨论1.该术式可显著改善便秘患者术后排便情况,提高患者生活质量。2.该术式在治疗重度直肠前突的患者较单纯行Block术效果更好,从远期疗效来看,该术式复发率低,优于单纯经肛门直肠前突柱状缝合(Block术)。3.由于PPH吻合器的应用,在治疗合并有内痔或直肠粘膜脱垂者效果更佳。更多还原

【Abstract】 1. Rectocele(RC), also known as prominent rectum wall, as one of the common reasons of outlet obstruction constipations, is usually diagnosed in anus bowel surgery. It occurred more frequently among multipara. So far, an increasing number of patients are diagnosed of rectocele in our country. Although there are many surgical treatments available for rectocele, the symptom of constipation is not mitigated or alleviated postoperatively so there is a very high recurrence rate. Therefore, we put forward rectocele surgical indications, and focused on observing the short-term and long-term effect of the rectocele repair surgery plus PPH. Hope that, through clinical observation of this study we can improve the diagnosis of rectocele rate, standardized rectocele surgery indications, improve surgery effect and reduce postoperative relapse rate.improve The quality of the patients lives.2. Rectocele etiology and surgical indications for the rectocele.Female anterior rectal wall is supported by the rectovaginal septum.which is mainly composed of fascia pelvis,the inner part of the septum is levator ani muscle from the midline crossing fibers.In view of the rectal wall is weak, coupled with long-term oppression of feces in the defecation, or birth trauma (especially for the multipra), the relaxation of rectovaginal septum, protruding to the vagina results in constipation. Constipation and tenesmus are main prominent symptoms of the disease. The disease is associated with the regional development and long-term adverse bowel habits; male sporadic, more common in surgical removal of the prostate.Therefore, we summarize the indications for surgery should include the following:(1) a history of longer than half a year, six months after conservative treatment with no significant improvement of the symptoms, even those who deteriorate. (2)constipation,obstruction of the anus, anus and perineum bulge, poor stool and other clinical symptoms were. Constipation seriously affects life, strong demand surgical treatment form the patients. (3) defecography showed rectocele II, III degree, which is complicated with a set of overlapping and rectal mucosa in patients with hemorrhoids (4) preoperative routine examination and laboratory examinations rule out serious cardiovascular disease, intestinal organic disease and other diseases.3. The general data and randomizationObserve 62 cases of patients with rectocele. They were all women, aged 37-65 years (median age 45 years).55 cases of maternal were multipara, accounting for 88.71 (55/62).All patients’history of constipation is between 0.5-25 years.62 patients were divided into 2 groups,31 cases of treatment group,31 cases of the control group. After grouping the two groups had no statistically significant difference (p> 0.05)in average age, history of constipation, Longo Ods score, defecography as well as II degree internal hemorrhoids with or rectal prolapse. Therefore, these 2 groups are randomized.4. Surgical treatmentTreatment groups:Patients were placed in lithotomy position under combined spinal-epidural anesthesia, after the commencement of anesthesia, routine disinfection of the operative field and the vaginal cavity, rectal cavity, and display drapes. Under anesthesia rectal examination, confirmed that no occupying lesions, expand the anal to 3 index fingers slowing for 5mins. The anal dilator (CAD33) coated with a little lubricant were inserted into the anal canal, avoid violence, and remove the bolt, at about 3 cm from the anal margin of perianal skin, the device was sutured at 3,6,9,12 point of the anal. Fully exposing operative field, inserted the Index finger into the vagina,pressed the anterior capsule of the rectocele to the rectum,clamping the protrusion from the weak zone mucosausing allis tissue forceps, using the great curved forceps grip rectal mucosa longitudinally in the range of tooth protrusion2.5cm above the straight line, continuous suture under the curved forceps with a 3-0 catgut deep into muscle, removed forceps after the suture, ligature knot, suture closure to make sure the mucous membrane is in the shape of tower, wide at the bottom and narrow at the top, preventing the formation of artificial rectal mucosal flap. Using small round needle with a 3-0 VICRYL, suture at dentate line at about 3.0 cm and 4.0 cm,3 and 9 o’clock of the line, making the mucosa and submucosa double ring suture, the distance between the double purse was 0.5-1cm, pulling line at 3,9 points, rectal anastomat will be stapled into the top pocket stitching to tighten the purse suture, pay attention to proximal ligation of rectal purse line firstly, and then ligated distal purse line. Using thread (ST 100) pulled the VICRYL from both sides of the anastomat,using haemostat hold purse line to maintain a certain tension, after confirming removal of mucosa into the stapler, at this time put the index finger in the vagina to confirm that the vaginal mucous membrane is not brought into the stapling range, and quickly tighten the stapler firing for more than 30 seconds in order to prevent anastomotic bleeding. Retrograde rotation stapler 3 and a half, carefully observing mucosal resection anastomosis is complete, check whether there is active anastomotic bleeding, if there was bleeding, "8" suture to stop bleeding with absorbable suture. Make sure the surgical field is has no active bleeding, then wrap the drain tube with oil package, inserted the tube into the anus, drainage tube above the proximal anastomosis in order to observe the bleeding, inventory of equipment, completion of surgery.Control group:Patients were placed in lithotomy position under combined spinal-epidural anesthesia, after the commencement of anesthesia, routine disinfection of the operative field and the vaginal cavity, retal cavity, and display drapes. Under anesthesia rectal examination, confirmed that no occupying lesions, expand the anal to 3 index fingers slowing for 5mins. The anal dilator (CAD33) coated with a little lubricant were inserted into the anal canal, avoid violence, and remove the bolt, at about 3 cm from the anal margin of perianal skin, the device was sutured at 3.6.9,12 point of the anal. Fully exposing operative field, inserted the Index finger into the vagina,pressed the anterior capsule of the rectocele to the rectum, clamping the protrusion from the weak zone mucosausing allis tissue forceps, using the great curved forceps grip rectal mucosa longitudinally in the range of tooth protrusion2.5cm above the straight line, continuous suture under the curved forceps with a 3-0 catgut deep into muscle, removed forceps after the suture, ligature knot, suture closure to make sure the mucous membrane is in the shape of tower, wide at the bottom and narrow at the top, preventing the formation of artificial rectal mucosal flap. Make sure the surgical field is has no active bleeding, then wrap the drain tube with oil package, inserted the tube into the anus, drainage tube above the proximal anastomosis in order to observe the bleeding, inventory of equipment, completion of surgery.5. Observation dataRecord target situation first post-operation defecation, after 1 week,1 month,3 months of the bowel, at the same time, Score the short-term and the long-term efficacy of surgery. At the same time also observe the complications, and length of stay in hospital.6. Results(1) Group comparison:2 Groups are all more significant improved compare with the preoperative. One month compared with three month, the efficacy has no significant difference between the treatment group, there is significant difference in the control group.(2) Inter-group comparison:Treatment group and control group have no significant difference at the post-operation defecation time, the first one week, the first month. At 3 months after the operation there is significant difference between the treatment group and the control group.In the treatment group the average length of stay is 8.72 days, as in the control group the average length of stay is 8.95 days.7. Conclusion (1) The procedure can improve the situation of patients with defecation.(2)The procedure more appropriately applies to the treatment of gradeⅡ. Judging from the long-term efficacy of the procedure with lower relapse rates, it is better than Columnar Suture (Block)(3)The procedure used in the treatment of rectal prolapse combined with hemorrhoids and rectum prolapse were to obtain better results.更多还原