摘要目的 总结腹腔镜经括约肌间切除术(LapISR)治疗低位直肠癌的围手术期和术后并发症发生情况及其临床处理措施.方法 2011年6月至2016年2月期间火箭军总医院结直肠肛门外科采用LapISR治疗了73例低位直肠癌患者,对该组患者的临床资料进行回顾性分析.定义术后3个月内发生的并发症为围手术期并发症,术后3个月至随访终点(2016年6月30日)发生的并发症为术后并发症;总结分析围手术期和术后并发症的发生情况及处理措施.结果 全组73例患者中,男49例(67.1％),女24例(32.9％);中位年龄61(25～79)岁,肿瘤下极距肛缘的中位距离为4.0(1.0 ～ 5.5) cm;中位手术时间为195(120 ～ 360) min,中位出血量100(20 ～ 300) ml.所有患者均常规行预防性末端回肠袢式造口.全组患者无中转开腹及死亡病例.R0切除率98.6％(72/73),肿瘤远切缘均为阴性,中位清扫淋巴结数14(3 ～ 31)枚/例.围手术期,有21例(28.8％)出现34例次并发症,其中7例次(20.6％)为Dindo Ⅲ～Ⅳ级;以吻合口相关并发症为多(16.4％,12/73),其中吻合口周围黏膜缺血9例(12.3％,9/73);吻合口狭窄7例(9.6％,7/73),有4例为吻合口周围黏膜坏死脱落后继发狭窄,予扩肛对症处理;A级吻合口瘘3例(4.1％,3/73),予保守治疗;吻合口及近端肠管缺血坏死1例(1.4％,1/73),行永久性造口.术后中位随访时间为21(3～ 60)月,共12例(16.4％)患者出现16例次术后并发症,包括术后吻合口狭窄6例(8.2％),A级与B级狭窄各3例;其中2例A级狭窄患者经肛切除吻合口瘢痕后好转,1例B级狭窄经肛切除瘢痕后症状无明显改善,其余3例予扩肛、灌肠或泻剂辅助排粪.4例(5.5％)男性患者发生吻合口近端肠管狭窄,其中1例因不全性肠梗阻反复发作行永久性造口;1例辅助放疗后出现吻合口近端肠管纤维瘢痕样狭窄,予扩肛、灌肠保守治疗;1例黏膜缺血坏死后经内镜及消化道造影证实吻合口近端肠管发生节段性狭窄;另1例经内镜切除狭窄瘢痕后好转.此外,1例直肠阴道瘘与1例不全性肠梗阻保守治疗后好转;1例直肠黏膜脱垂患者于术后31个月经肛手术切除;1例辅助放疗后出现吻合口部分裂开及吻合口瘘.共计6例(8.2％)患者因并发症需再次手术干预.结论 LapISR治疗低位直肠癌围手术期和随访期术后并发症以吻合口相关并发症为多,需积极应对、采用合适的方式来处理.

abstractsObjective To summarize the perioperative and postoperative complications follow laparoscopic intersphincteric resection (LapISR) in the treatment of low rectal cancer and their management.Methods An observational study was conducted in 73 consecutive patients who underwent LapISR for low rectal cancer between June 2011 and February 2016 in our hospital.The clinicopathological parameters,perioperative and postoperative complications,and clinical outcomes were collected from a prospectively maintained database.Perioperative and postoperative complications were defined as any complication occurring within or more than 3 months after the primary operation,respectively.Results Forty-nine(67.1％) cases were male and 24(32.9％) were female with a median age of 61 (25 to 79) years.The median distance from distal tumor margin to anal verge was 4.0(1.0 to 5.5) cm.The median operative time was 195 (120 to 360) min,median intra operative blood loss was 100 (20 to 300) ml,median number of harvested lymph nodes was 14 (3 to 31) per case.All the patients underwent preventive terminal ileum loop stoma.No conversion or hospital mortality was presented.The R0 resection rate was 98.6％ with totally negative distal resection margin.A total of 34 complication episodes were recorded in 21 (28.8％) patients during perioperative period,and among which 20.6％(7/34) was grade Ⅲ-Ⅳ according to Dindo system.Anastomosis-associated morbidity (16.4％,12/73) was the most common after LapISR,including mucosa ischemia in 9 cases(12.3％),stricture in 7 cases (9.6％,4 cases secondary to mucosa necrosis receiving anal dilation),grade A fistula in 3 cases (4.1％) receiving conservative treatment and necrosis in 1 case (1.4％) receiving permanent stoma.After a median follow up of 21 (3 to 60) months,postoperative complications were recorded in 12 patients (16.4％) with 16 episodes,including anastomotic stenosis (8.2％),rectum segmental stricture (5.5％),ileus (2.7％),partial anastomotic dehiscence (1.4％),anastomotic fistula (1.4％),rectovaginal fistula (1.4％) and mucosal prolapse (1.4％).These patients received corresponding treatments,such as endoscopic transanal resection,anal dilation,enema,purgative,permanent stoma,etc.according to the lesions.Six patients (8.2％) required re-operation intervention due to postoperative complications.Conclusion Anastomosis-associated morbidity is the most common after LapISR in the treatment of low rectal cancer in perioperative and postoperative periods,which must be strictly managed with suitable methods.