摘要
目的探讨小肠最小化切除策略对预防慢性放射性肠损伤(CRE)术后吻合口漏和短肠综合征等并发症的效果。方法采用回顾性队列研究方法。合并肠狭窄和肠梗阻的小肠CRE可分为以下两种分型:(1)Ⅰ型:回肠末端病变,但在回肠病变与回盲部之间始终存在2~20 cm的正常回肠段;(2)Ⅱ型:病灶位于距离回盲部较远的小肠,病灶外的肠段通常广泛受损。最小化肠切除术适应证:Ⅰ型小肠CRE、直肠乙状结肠无放射性损伤、无结肠梗阻。禁忌证包括各种原因导致的盲肠远端狭窄性或穿透性病变、急诊手术、恶性肿瘤复发或复发性恶性肿瘤的放疗史、放疗与手术时间间隔<6个月、术前小肠切除史或腹腔化疗史。根据上述指征,回顾性分析2017年4月至2019年12月期间,接受最小化肠切除术策略治疗的40例Ⅰ型CRE患者病例资料(最小化肠切除组,其中东部战区总医院13例,上海交通大学医学院附属第九人民医院16例,徐州医科大学附属医院11例);同时纳入2015年10月至2017年3月期间,40例接受切除肠狭窄病变及回盲部的Ⅰ型CRE患者作为历史对照(传统肠切除组,均来自东部战区总医院)。最小化肠切除组采用小肠最小化切除策略,即一期回肠部分切除+回肠-回肠吻合术+保护性小肠造口术。传统肠切除组采用回盲部切除+回肠升结肠吻合术。观察两组手术情况、术后并发症的发生情况、术后恢复情况和手术前后生活质量变化。术后并发症严重程度采用Clavien-Dindo和综合并发症指数(CCI)评估。采用卡氏评分(KPS)对两组患者术前和术后的生活质量进行评价,得分越高,表示生活质量越好。结果两组基线资料比较,差异无统计学意义(均P>0.05)。与传统肠切除组相比,最小化肠切除组的小肠切除长度[51(20~200)cm比91(60~200)cm,Z=5.653,P<0.001]、术后全肠内营养时间[9(3~18)d比12(4~50)d,Z=2.172,P=0.030]和术后住院时间[17(9~24)d比29(13~57)d,Z=6.424,P<0.001]均更短,差异有统计学意义。最小化肠切除组术后并发症发生率低于传统肠切除组[20.0%(8/40)比28/40(70.0%),χ^(2)=19.967,P<0.001],其中短肠综合征[5.0%(2/40)比25.0%(10/40),χ^(2)=6.274,P=0.012]、吻合口漏或瘘[2.5%(1/40)比22.5%(9/40),χ^(2)=7.314,P=0.014]和胸腔积液的发生率[7.5%(3/40)比25.0%(10/40),χ^(2)=4.500,P=0.034]均低于传统肠切除组。最小化肠切除组CCI指数也低于传统肠切除组[CCI>40:2.5%(1/40)比12.5%(5/40),Z=18.451,P<0.001]。最小化肠切除组术后1个月和3个月的KPS评分均高于术前1 d[(79.9±4.7)分比(75.3±4.1)分,(86.2±4.8)分比(75.3±4.1)分,均P<0.05]。在最小化肠切除组中,7例患者对目前的生活质量满意,随访时拒绝接受肠造口还纳手术;1例患者由于直肠出血暂缓造口还纳;其余32例于术后3~12个月行造口还纳术,其中26例行回肠-回肠吻合术,余6例切除造口至回盲部肠段,行回肠-升结肠吻合术。结论小肠最小化切除策略可以减少切除小肠的长度,降低术后并发症的风险和严重程度,对改善放射性肠损伤患者的预后和生活质量具有积极意义。
Objective To investigate the efficacy of strategies for minimizing small bowel resection during surgery for pelvic radiation-induced terminal small intestinal stenosis in preventing postoperative complications such as anastomotic leakage and short bowel syndrome.Methods This was a retrospective cohort study.There are two subtypes of chronic radiation enteritis(CRE)with combined intestinal stenosis and intestinal obstruction:(1)Type I:terminal ileal lesions with a normal ileal segment of 2–20 cm between the ileal lesion and ileocecal junction;and(2)Type II:the lesion is located in the small bowel at a distance from the ileocecal region,usually accompanied by extensive damage to the bowel segments outside the lesion.The indications for minimal bowel resection are as follows:(1)diagnosis of Type I small bowel CRE;(2)absence of radiological evidence of rectosigmoid damage;and(3)absence of colonic obstruction.The contraindications are:(1)stenotic,penetrating lesions of the distal cecum;(2)emergency surgery;(3)recurrence of malignant tumor or history of radiotherapy for recurrent malignant tumor;(4)interval between radiotherapy and surgery<6 months;and(5)history of preoperative small bowel resection or abdominal chemotherapy.Case data of 40 patients with Type I CRE who met the above criteria and had undergone minimal bowel resection between April 2017 and December 2019 were retrospectively analyzed(minimal bowel resection group;including 13 patients from Jinling Hospital,16 from the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,and 11 from the Affiliated Hospital of Xuzhou Medical University).Forty patients with Type I CRE who had undergone resection of intestinal stenosis lesions and the ileocecal region between October 2015 and March 2017 were included as historical controls(conventional resection group;all from Jinling Hospital).The specific strategy for minimal bowel resection was one-stage partial ileal resection+ileo anastomosis+protective small bowel stoma.In contrast,conventional resection comprised ileocecal resection+ileocecal-ascending colon anastomosis.Postoperative complications,intraoperative and postoperative recovery,and changes in postoperative quality of life were analyzed in both groups.The severity of postoperative complications was assessed by Clavien-Dindo and the Comprehensive Complication Index(CCI).Karnofsky performance scores(KPS)were used to evaluate the quality of life of patients in the two groups preoperatively and postoperatively.The higher the KPS score,the better the quality of life.Results Baseline patient characteristics did not differ significantly between the two groups(P>0.05).Compared with the conventional resection group,the length of small bowel resected in the minimal bowel resection group(51[20–200]cm vs.91[60–200]cm,Z=5.653,P<0.001),duration of postoperative total enteral nutrition[9(3–18)days vs.12(4–50)days,Z=2.172,P=0.030],and duration of postoperative hospital stay[17(9–24)days vs 29(13–57)days,Z=6.424,P<0.001]were shorter;all of these differences are statistically significant.The overall incidence of postoperative complications was lower in the minimal bowel resection group than in the conventional resection group[20.0%(8/40)vs.70.0%(28/40),χ2=19.967,P<0.001],These comprised short bowel syndrome[5.0%(2/40)vs.25.0%(10/40),χ2=6.274,P=0.012],anastomotic leakage or fistula[2.5%(1/40)vs.22.5%(9/40),χ2=7.314,P=0.014],and pleural effusion[7.5%(3/40)vs.25.0%(10/40),χ2=4.500,P=0.034],all of which occurred less often in the minimal bowel resection than conventional resection group.The CCI index was also lower in the minimal bowel resection group than in the conventional resection group[CCI>40:2.5%(1/40)vs.12.5%(5/40),Z=18.451,P<0.001].KPS scores were higher in the minimal bowel resection group 1 and 3 months postoperatively than they had been 1 day preoperatively(79.9±4.7 vs.75.3±4.1,86.2±4.8 vs.75.3±4.1,both P<0.05).In the minimal bowel resection group,seven patients were satisfied with their current quality of life and refused to undergo stoma reduction at follow-up and one deferred stoma reduction because of rectal bleeding.The remaining 32 patients underwent stoma reduction 3 to 12 months after surgery,26 of whom underwent ileo-cecal anastomosis.The remaining six underwent resection of the stoma and anastomosis of the ileum to the ascending colon.Conclusions The strategy of minimal small bowel resection in patients with radiation-induced bowel injuries reduces the length of resected small bowel,decreases the risk and severity of postoperative complications,and is associated with a better prognosis and quality of life than conventional resection.
作者
王凯
倪小冬
卞邦健
张轩
付海啸
李腾腾
刘浩
符炜
宋军
王剑
Wang Kai;Ni Xiaodong;Bian Bangjian;Zhang Xuan;Fu Haixiao;Li Tengteng;Liu Hao;Fu Wei;Song Jun;Wang Jian(Department of Gastrointestinal Surgery,the Affiliated Hospital of Xuzhou Medical University,Xuzhou 221000,China;Department of General Surgery,Jinling Hospital,Medical School of Nanjing University,Nanjing 210002,China;Department of General Surgery,the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China;Department of General Surgery,the Fouth Affiliated Hospital of Nanjing Medical University,Nanjing 210031,China)
出处
《中华胃肠外科杂志》
CSCD
北大核心
2023年第10期947-954,共8页
Chinese Journal of Gastrointestinal Surgery
基金
国家自然科学基金(82073133)
白求恩-爱惜康卓越外科基金项目(HZB-20181119-50)
徐州医科大学附属医院青苗人才计划项目(XYFY20210220)。
关键词
放射性肠炎
小肠狭窄
吻合口漏
短肠综合征
保护性小肠造口
小肠最小化切除策略
Radiation enteritis
Small intestinal stenosis
Anastomotic leakage
Short bowel syndrome
Protective enterostomy
Minimizing intestinal resection strategy
