【作者】 张冰；

【导师】 张海山；

【作者基本信息】 吉林大学 ， 外科学， 2013， 硕士

【摘要】 背景：直肠脱垂（Ｒectal prolapse）完全性直肠脱垂是指直肠全层从肛门脱出，其发生频率多与肛门失禁（５０％～７０％）有关，或与便秘有关，后者比较少见。长期的完全性直肠脱垂将会导致会阴部神经损伤进而产生肛门失禁、出血、狭窄及坏死等症状，除幼儿可用非手术方法治愈外，需要手术治疗。治疗成人直肠脱垂手术治疗的历史悠久,种类繁多,根据手术入路可以分为经腹部和经会阴部手术方式两组。而经腹部常用术式为经腹直肠悬吊固定术、随着对盆底解剖研究认识的深入，手术器械的改进以及修补材料的应用,涌现出了许多新的手术方式,这些新的手术方式重建了盆底的解剖结构,改善了盆底的功能,降低了术后复发率,如改良直肠后悬吊固定术。目的：评价改良直肠后悬吊固定术治疗直肠完全脱垂脱垂的有效性,为进行临床推广提供充足的临床循证医学证据。资料与方法：1、研究对象:为2008年6月至2012年11月间在吉林大学中日医院行经腹部手术治疗完全直肠脱垂的患者的11例。患者年龄26~65岁,平均45岁,无合并心脑血管、肾等系统严重危及生命的原发性疾病或不宜手术者。2、术前查体:常规的体格检查,结肠镜、直肠肛管测验、全身重要脏器功能检查如血常规，凝血常规、心电图、胸片等。3、手术相关情况:记录所有术中参数如术中出血量、手术时间、有无脏器损伤等记录术后恢复情况：保留尿管时间、均住院时间及并发症等。4、随访:术后第一年每3个月进行随访,术后第二年起每半年进行随访,内容主要包括有无复发、排便困难、肛门失禁、便血等症状。结果：11例患者手术均顺利完成，平均手术时间65.5（60~90）min，出血量75（20~30）ml，术后3d以内基本恢复肛门通气，3.5d后拔除尿管。本组无手术死亡发生，无切口感染、补片感染、无新发便秘出现、男性患者未见性功能障碍出现。术前患者MRP为20~30（26.6±2.40）mmHg，术后MRP为2~60（32.5±2.23）mmHg，术前MSP为8~152（69.3±6.50）mmHg，术后MSP为35~158（79.5±4.18）mmHg。患者术前伴随的直肠脱垂的相关症状，接受经腹直肠后悬吊固定术后除1例大便失禁未改善症状，余下患者术前直肠脱垂便随相关症状全部消失，嘱大便失禁未改善患者出院继续练习提肛运动。术后3-24个月随访，所有患者均获随访，无复发及直肠脱垂相关症状出现，给予复查直肠肛管测压较术前明显提高，术后仍伴有大便失禁患者给予练习提肛运动后，肛门控便能力有所提高。结论：1.改良直肠后悬吊固定术能有效改善直肠完全脱垂患者的脱垂、肛门失禁、肛门潮湿等伴随的相关症状，是较为理想的治疗直肠脱垂的手术方法。2.改良直肠后悬吊固定术能明显改善患者肛门括约肌的功能；3.改良直肠后悬吊固定术治疗直肠完全脱垂复发率低；4.改良直肠后悬吊固定术是一种安全可靠、疗效确切的治疗直肠完全脱垂的方法；5.改良直肠后悬吊固定术作为一种新术式,能更好地修补缺陷,重建盆底结构,恢复盆底功能,值得临床推广。更多还原

【Abstract】 background:Rectal prolapse (Rectal prolapse), completeness refers to rectalfull-thickness rectum prolapse from anal prolapse, its frequency is associatedwith anal incontinence (50%~70%), or associated with constipation, the latterare relatively rare. Will lead to long-term complete rectal prolapse pudendalnerve damage resulting anal incontinence, ulcers, bleeding, narrow, and thesymptom such as necrosis, in addition to the baby cured by non-operativemethods, need operation treatment. Treatment of surgical treatment of rectalprolapse adult has a long history, sort is various, according to the surgicalapproach can be divided into the abdominal and perineal surgery two groups.After abdominal operation is commonly used for abdominal rectal suspensionfixation, with the deepening of the understanding of pelvic floor anatomy study,the improvement of surgical instruments, and the application of repair materials,emerged many new operation method, the new way of surgical reconstructionof the pelvic floor anatomy, improved the function of the pelvic floor, reducethe postoperative recurrence rate, such as modified rectal suspension afterfixation.Objective:Evaluation modified rectal suspension fixation after the effectiveness of thetreatment of rectal prolapse prolapse completely, for the purpose of clinicalpromotion provide sufficient clinical evidence of evidence-based medicine.Results:11patients were successfully completed surgery, average operation time of65.5min (60~90),75(20~30ml) blood loss, postoperative basic recoveryanus ventilation within3d,3.5d after remoal of ureter. Our group no operative death occurred, no incision infection, infection of the patch, no newconstipation appear, not seen men with sexual dysfunction.Preoperativepatients with MRP for20~30mmHg (26.6±2.40), postoperative MRP for2~60mmHg (32.5±2.23), preoperative MSP for8~152mmHg (69.3±6.50), postoperative MSP for35~158mmHg (79.5±4.18). Patients withprolapse of the rectum with preoperative symptoms, accept after abdominalrectal suspension fixed except1case of fecal incontinence after surgery fails toimprove symptoms, and the remaining patients with preoperative rectalprolapse symptoms disappear, instruct patients with fecal incontinence did notimprove the hospital continue to practice the anus movement. Postoperative3to24months follow-up, all patients were follow-up, no recurrence and rectalprolapse symptoms appear, gives review of rectal pressure compared withpreoperative, postoperative still associated with fecal incontinence patientsgiven anus movement after exercise, the anus control ability has improved.Conclusion:1. Modified rectal suspension and fixation can effectively improve theprolapse of rectum prolapse patients completely, along with related symptomssuch as anal incontinence, anal wet, is the ideal surgical treatment for rectalprolapse.2. The modified rectal suspension fixation can significantly improvepatients with anal sphincter function;3. The modified rectal suspension fixation for treatment of rectal prolapsecompletely the recurrence rate is low;4. Modified rectal suspension fixation is a safe, reliable, the curative effectof treatment of rectal prolapse completely method;5. As a kind of new and modified rectal suspension fixation operation, better able to repair the defects and reconstruction of pelvic floor structures,restore your pelvic floor function, worth clinical promotion.更多还原